Aaos2008 PDF

Celebrate with your Academy:
Learn, interact and enjoy the 75th Anniversary projects!
75th Annual Meeting Proceedings

Moscone North
View a historical film - the 75th Anniversary
historical film Moving Pictures reflects on the last
75 years of orthopaedic innovation and development
by researchers, surgeons, industry, and happenstance.
The story is conveyed largely through the personal
stories of orthopaedic surgeons and patients.
Take in a three-dimensional art exhibit - this stunning,

5-foot by 7.5-foot piece of three-dimensional art is
made up of actual and miniaturized pieces of the
Academy’s history that will take your breath away.
Travel the Digital Timeline - this must-see Digital

Timeline takes viewers on an interactive, historical
adventure where they can view more than 1,500
events that have taken place over the history of
orthopaedics.
Moscone West
Check out the traveling exhibit - stroll through
the traveling exhibit and watch the history of
Deborah Williams, oil on can- orthopaedics unfold before your eyes. Major
vas, 8 x 16 in. subject areas include Academy history, the New
Century, the War Years, Polio, Scoliosis, Industry,
Joint Replacement, Specialties, the Future, and more.
Enjoy the eMotion Pictures art show - admire the

more than 200 artworks that sometimes humorously,
sometimes poignantly, portray the patient and physi-
cian perspective of our orthopaedic specialty.
Flip through a commemorative coffee table book -

rich with images, personal stories, and timelines not-
ing significant events in the history of orthopaedics,
the coffee table book, Moving Stories: Seventy-five
2008 San Francisco, CA

Years of Orthopaedic Surgery, commemorates the
Academy’s Diamond Jubilee.
“Get it Straight” with a historical reference book -

this ambitious text, Getting it Straight: A History of Volume 9
American Orthopaedics, documents the development
of the specialty, historical markers, and medical
advances in areas such as fracture care, manipulation,
and surgery, in addition to the history of AAOS and
other orthopaedic societies.
Visit the Celebratory Web site - everything the 75th

Anniversary has to offer can be experienced by
visiting the new site at www.aaos.org/75years.
75th Annual Meeting
San Francisco, California
March 5–9, 2008
Call For
Abstracts
Proceedings Applications to submit a poster presentation,
Symposia Handouts podium presentation, scientific exhibit or multimedia
Abstracts of: education presentation are available on-line at
Podium Presentations,
Poster Presentations, www.aaos.org/abstracts
Scientific Exhibits, and
Submission deadline is June 2, 2008
Multimedia Education
Submission deadline for multimedia education
presentation is July 15, 2008
Board of Directors
James H. Beaty, MD Thomas C. Barber, MD William J. Robb, III, MD
President
Kevin J. Bozic, MD, MBA Matthew S. Shapiro, MD
E. Anthony Rankin, MD John T. Gill, MD James P. Tasto, MD
First Vice President
Christopher D. Harner, MD George Zachary Wilhoit, MS, MBA
Joseph D. Zuckerman, MD
Richard F. Kyle, MD Ken Yamaguchi, MD
Second Vice President
William L. Healy, MD
Joseph C. McCarthy, MD Karen L. Hackett, FACHE, CAE 2009 Annual Meeting
Norman Y. Otsuka, MD Chief Executive Officer
Treasurer February 25 – March 1
Las Vegas, Nevada
75th Annual Meeting
San Francisco, California
March 5–9, 2008
Call For
Abstracts
Proceedings Applications to submit a poster presentation,
Symposia Handouts podium presentation, scientific exhibit or multimedia
Abstracts of: education presentation are available on-line at
Podium Presentations,
Poster Presentations, www.aaos.org/abstracts
Scientific Exhibits, and
Multimedia Education
Board of Directors
James H. Beaty, MD Thomas C. Barber, MD William J. Robb, III, MD
President
Kevin J. Bozic, MD, MBA Matthew S. Shapiro, MD
E. Anthony Rankin, MD John T. Gill, MD James P. Tasto, MD
First Vice President
Christopher D. Harner, MD George Zachary Wilhoit, MS, MBA
Joseph D. Zuckerman, MD
Richard F. Kyle, MD Ken Yamaguchi, MD
Second Vice President
Joseph C. McCarthy, MD Karen L. Hackett, FACHE, CAE 2009 Annual Meeting
Norman Y. Otsuka, MD Chief Executive Officer
Treasurer February 25 – March 1
Las Vegas, Nevada
75th Annual Meeting Proceedings

Moscone North


events that have taken place over the history of
orthopaedics.
Moscone West
the traveling exhibit and watch the history of
Deborah Williams, oil on can- orthopaedics unfold before your eyes. Major
Enjoy the eMotion Pictures art show - admire the

more than 200 artworks that sometimes humorously,
Flip through a commemorative coffee table book -

rich with images, personal stories, and timelines not-
ing significant events in the history of orthopaedics,
the coffee table book, Moving Stories: Seventy-five
2008 San Francisco, CA

Years of Orthopaedic Surgery, commemorates the

this ambitious text, Getting it Straight: A History of Volume 9
of the specialty, historical markers, and medical
advances in areas such as fracture care, manipulation,

01 FRONT MATTER 08:Layout 1 1/28/08 6:42 PM Page 1
6300 North River Road

Rosemont, Illinois 60018
P. 847.823.7186
F. 847.823.8125
www.aaos.org
Dear Colleagues:
Welcome to the AAOS 75th Annual Meeting! In a collaborative effort, the Central Program Committee,
Exhibits Committee and Multimedia Education Center Subcommittee have combined the abstracts from
selected scientific portions of the Annual Meeting.
The Proceedings Book and CD-ROM are divided into sections which include symposia handouts, podium
and poster abstracts, scientific exhibit abstracts, and multimedia education abstracts. Each section is
classified by subspecialty.
We have also included:

• the subspecialty guide to the Annual Meeting (which separates presentations by subspecialty)
• an author index
• a key word index
These compiled materials comprise some of the most exciting topics presented at the 75th Annual
Meeting. We hope that you find this book and CD-ROM useful now and in the future.
Sincerely,
Daniel J. Berry, MD Lynn A. Crosby, MD Gene R. Barrett, MD

Chair, Program Committee Chair, Exhibits Committee Chair, Multimedia Education
Center Subcommittee
1
DISCLAIMER FDA STATEMENT

The material presented at the Annual Meeting has been made Some drugs or medical devices demonstrated at the Annual
available by the American Academy of Orthopaedic Surgeons Meeting have not been cleared by the FDA or have been
for educational purposes only. This material is not intended cleared by the FDA for specific purposes only. The FDA has
to represent the only, nor necessarily best, method or stated that it is the responsibility of the physician to determine
procedure appropriate for the medical situations discussed, the FDA clearance status of each drug or medical devices he
but rather is intended to present an approach, view, statement or she wishes to use in clinical practice.
or opinion of the faculty which may be helpful to others who
face similar situations. Academy policy provides that “off label” uses of a drug or
medical device may be described in the Academy’s CME
The AAOS disclaims any and all liability for injury or other activities so long as the “off label” use of the drug or medical
damages resulting to any individuals attending a session for device is also specifically disclosed (i.e. it must be disclosed
all claims, which may arise out of the use of the techniques that the FDA has not cleared the drug or device for the
demonstrated therein by such individuals, whether these described purpose). Any drug or medical device is being used
claims shall be asserted by a physician or any other person. “off label” if the described use is not set forth on the products
approval label.
No reproductions of any kind, including still photography,
audiotapes and videotapes, may be made of the presentation
at the Academy’s Annual Meeting. The Academy reserves all
of its rights to such material, and commercial reproduction is Product Code # 02965
specifically prohibited.
Printed in the United States of America
DISCLOSURE
Each participant in the Annual Meeting has been asked to
disclose if he or she has received something of value from a
commercial company or institution, which relates directly or
indirectly to the subject of their presentation. The Academy
has identified the options to disclose as follows:
a. Research or institutional support has been received;
b. Miscellaneous non-income support (e.g. equipment or

services);
c. Royalties;
d. Stock or stock options; or
e. Consultant or employee
n. Disclosed nothing of value received
The Academy does not view the existence of these disclosed

interests or commitments as necessarily implying bias or
decreasing the value of the author’s participation in the
meeting.
The alphabetical disclosure list begins on page 18.
2
TA B L E O F C O N T E N T S
Subspecialty Guide to the Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Symposia Handouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Abstracts of Podium Presentations, Poster Presentations, and Scientific Exhibits . . . . . . . . 373
Abstracts of Multimedia Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
Key Word Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809

TABLE OF CONTENTS
Subspecialty Guide to the Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Symposia Handouts
Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Foot and Ankle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
General. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Practice Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Sports Medicine and Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Abstracts of Podium Presentations, Poster Presentations, and Scientific Exhibits

AAOS Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
Basic Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Foot and Ankle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
Practice Management/Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . 563
Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 576
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 617
Sports Medicine and Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 659
Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696
Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
Allied Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 768
Abstracts of Multimedia Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
Author Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776
Key Word Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
3
WEDNESDAY, MARCH 5
4
8:00 - 10:00 AM 8:00 - 11:00 AM 10:30 AM - 12:30 PM 1:30 - 3:30 PM 1:30 - 4:30 PM 4:00 - 6:00 PM
ADULT RECONSTRUCTION HIP AND KNEE
Instructional Courses 101, 102 121, 122 141, 142 184 161, 162, 163
Scientific Exhibits 7:00 AM-6:00 PM Hip: SE01-SE24 Knee: SE25-SE38
Adult Hip II: Hip Resurfacing,
Adult Hip I: Bearing Surfaces, Papers 046-060 Room 3002 West Adult Knee II: Complications,
Scientific Papers Papers 016-030 Adult Knee I: Surgical Technique and Peri- Papers 091-105
01 FRONT MATTER 08:Layout 1
Room 3014 West operative Management, Room 3002 West

Papers 061-075 Room 3014 West
Scientific Posters 7:00 AM-6:00 PM Hip P001-P110 Knee P111-P205
The Latest Information on Total Hip Arthro- Technical Tips and Innovation for
plasty Bearing Surfaces: Presentation, Analysis Total Knee Arthroplasty (C)
1/28/08
Symposia and Critique of the Latest Data Gateway Ballroom

from Around the World (A) Hip Resurfacing: Art and Science as of 2008
Gateway Ballroom (AAOS/ORS II) Room 3002 West
BASIC RESEARCH
6:42 PM
Instructional Courses 125

Scientific Exhibits 7:00 AM-6:00 PM SE39-SE42
FOOT AND ANKLE
Page 4
Instructional Course 104 181 144 164
Scientific Posters 7:00 AM-6:00 PM P206-P225

GENERAL
Instructional Courses 123 143
Biologic Strategies to Grow Bone in Difficult Clinical
Symposia Situations (AAOS/ORS I) Rm 3002 West
HAND AND WRIST
Instructional Courses 106 126 146
PEDIATRICS
Instructional Courses 1SK, 107 127 147 167, 169
PRACTICE MANAGEMENT/NON-CLINICAL
Instructional Courses 105 182 124 145 170
Scientific Exhibits 7:00 AM-6:00 PM SE54
SUBSPECIALTY GUIDE TO ANNUAL MEETING
Current State of Fellowship Employment:

Symposia Is a Universal Match Necessary?
Is it Possible? (F) Room 307
REHABILITATION MEDICINE
SHOULDER AND ELBOW
Instructional Courses 2SK, 108 128 148 3SK 168

Shoulder and Elbow I: Arthroplasty, Reverse Shoulder and Elbow II:
Scientific Papers and Total Shoulder Replacement, Rotator Cuff, Papers 151-165
Papers 001-015 Room 307 Room 250
1/28/08
Trends and Controversies in the Management

of Elbow Trauma and Posttraumatic Elbow Recon-
Symposia struction: From Arthroscopy
to Arthroplasty (B) Room 2005 West
6:42 PM
SPINE
Instructional Course 109 131 152 171
Spine I: BMP, Grafting, and Fusion,
Page 5
Scientific Papers
Papers 076-090 Room 250

SPORTS MEDICINE AND ARTHROSCOPY
Instructional Courses 110 130 150, 151 165
Sports Medicine and Arthroscopy I: Sports Medicine and Arthroscopy II: Car-
Scientific Papers Anterior Cruciate Ligament I, tilage, Meniscal and Articular, Papers
Papers 031-045 Room 250 121-135 Room 307
Doc, When Can He Go Back in
Symposia the Game? (E) Room 2005 West
TRAUMA
Instructional Courses 103, 112 129 149 185 166
Trauma I: Polytrauma and
Scientific Papers General Trauma, Papers 136-150
Room 3014 West
Pearls for Common Fracture Treatment (D)
Symposia Room 2005 West
TUMOR AND METABOLIC DISEASE
Tumor/Metabolic Disease I: Metabolic
Scientific Papers Bone Disease and Osteonecrosis,
5
THURSDAY, MARCH 6
6
8:00 - 10:00 AM 8:00 - 11:00 AM 10:30 AM - 12:30 PM 1:30 - 3:30 PM 1:30 - 4:30 PM 4:00 - 6:00 PM
Instructional Courses 5SK, 201 221, 222 241, 242 6SK 261, 262
Adult Knee III: Alignment, Kinematics Adult Hip III: Non-Arthroplasty, Adult Knee IV: Outcomes I, Adult Hip IV:
Scientific Papers and Computer Assisted Surgery, Papers 226-240 Papers 286-300 Revision and Infection,
Papers 196-210 Room 3014 West Room 3002 West Room 3014 West Papers 346-360 Room 250
Techniques and Technical Tips in Choices and Compromises for

1/28/08
the Treatment of Knee Arthritis in

Symposia Hip Surgery (J) the Baby Boomer (M)
Gateway Ballroom Gateway Ballroom
BASIC RESEARCH
6:42 PM

FOOT AND ANKLE
Page 6

Foot and Ankle I: Arthroplasty and
Scientific Papers Arthrodesis, Papers 256-270 Room 250
GENERAL
The Value of National Registries: Has the Findings
Symposia Changed Practice? (H) Room 2005 West
HAND AND WRIST

Instructional Courses 206 228, 233 246 285 266
PEDIATRICS
Instructional Courses 207 247 7SK 267
Pediatrics I: General, Upper Extremity, and
Scientific Papers Spine, Papers 181-195 Room 307
Spine Problems in Young Athletes (N)
Instructional Courses 209 223, 229 244 264
Practice Management/Rehabilitation, Pa-
Scientific Papers
pers 211-225 Room 250

New Devices and Techniques: The Need for Orthopaedic Advocacy: The 2008 Election,
Symposia the Evidence is Real (L) Room 2005 West the AAOS, and You (O) Room 2005 West
SHOULDER AND ELBOW
Instructional Courses 4SK, 203, 208 227, 230 248 284 268

Shoulder and Elbow III: Instability, Pa- Shoulder and Elbow IV:
Trauma, Fractures and Soft Tissue,
Scientific Papers pers 241-255 Papers 331-345
Room 3014 West Room 3014 West
1/28/08
SPINE
6:42 PM
Scientific Papers Spine II: Deformity and Trauma, Spine III: Cervical Spine,
Papers 166-180 Room 3002 West Papers 271-285 Room 307
Controversies in Cervical Disc Arthro-
Page 7
Symposia
plasty (I) Room 307
Instructional Courses 210, 213 282 232 250 265
Sports Medicine and Arthroscopy III: Shoulder,
Scientific Papers Hip, and Elbow, Papers 301-315 Room 250
Decision-Making and Effective Arthroscopic
Symposia Techniques in the Management of
Shoulder Instability (G) Room 2005 West
TRAUMA
Trauma II: Fracture Healing and
Scientific Papers Upper Extremity Fractures, Papers
316-330 Room 307
Orthopaedic War Injuries: New
Symposia Developments in Treatment and Research
Room 2016 West
Scientific Posters 7:00 AM-6:00 PM P521-P545 All Scientific Exhibits and
AAOS sessions will
Evaluation of Bone and Soft Tissue Lesions be held at The Poster Presentations will
Symposia for Non Tumor Surgeons: How to Stay Out Moscone Center. be held at The Moscone
of Trouble! (K) Room 3002 West Center, West, Level 1.
7
8
FRIDAY, MARCH 7
8:00 - 10:00 AM 8:00 - 11:00 AM 10:30 AM - 12:30 PM 1:30 - 3:30 PM 1:30 - 4:30 PM 4:00 - 6:00 PM
Instructional Courses
8SK, 301, 302, 303 383 321, 322 341, 342 384 361, 362, 363

Adult Knee V: Outcomes II, Adult Hip V: General Topics in THA, Pa- Adult Hip VI: Osteonecrosis and General
Scientific Papers Papers 436-450 Room 3014 West pers 511-525 Room 250 Topics in THA Room 250

1/28/08
BASIC RESEARCH
6:42 PM
FOOT AND ANKLE

Foot and Ankle II: Fractures and Ten- Foot and Ankle III:
Page 8
Scientific Papers don/Ligament Reconstruction, Papers Bunions and Miscellaneous,

361-375 Room 307 Papers 481-495 Room 307
Sports Injuries of the Foot and Ankle (R)
GENERAL
HAND AND WRIST
Hand and Wrist I: The Wrist and Hand and Wrist II: Soft Tissue Repair and
Scientific Papers Trauma, Papers 391-405 Outcome Assessment, Papers 466-480
Room 250 Room 3002 West
Scaphoid Fractures and Nonunions: What's Hot,
Symposia What's Not (V) Room 2005 West
PEDIATRICS
Instructional Courses 307 327 347, 351 367
Scientific Papers Pediatrics II: Hip and Lower Extremity,
Papers 406-420 Room 3002 West
Deformities of the Child's Foot: Evaluation
Symposia and Principles-Based Management (Q)
Room 2005 West
Instructional Courses 305, 313 325, 333 343, 345
The Evolving Orthopaedic Surgeon – “Stark” The Law, The Exceptions, and
How to Make It Work for your Practice
Symposia Industry Relationship (CC) Without Going “Stark” Raving Mad (T)
Gateway Ballroom Room 2005 West

1/28/08
SHOULDER AND ELBOW

Instructional Courses 308, 311 328 348 10SK 368
Scientific Posters 7:00 AM-6:00 PM P286-345
6:42 PM
Controversial Decision-Making in Shoul-

Symposia der Arthroplasty (S)
Gateway Ballroom
SPINE
Page 9
Instructional Courses 312 324, 332 346 385

Spine IV: Lumbar Spine, Papers 526-540
Scientific Papers Room 3002 West
Novel Technology for the Treatment of Spinal
Symposia Disorders and the Effect on Orthopaedic Sur-
geons (P) Room 3002 West
Sports Medicine IV: Anterior Cruciate Ligament II,
Scientific Papers Papers 556-570 Room 3014 West
TRAUMA
Instructional Courses 9SK, 309 382 329 352 369
Trauma III: Hip Fractures, Trauma IV: Pelvic Ring, Acetabular, Trauma V: Tibia and Lower Extremity
Scientific Papers Papers 376-390 and Femur Fractures, Papers 421-435 Fractures, Papers 496-510
Room 3014 West Room 307 Room 3014 West
Managing Hip Fractures in the Osteoporotic
Symposia Patient: What is the Evidence? (U)
Gateway Ballroom
Instructional Courses 331 386 364, 371
9
Tumor II: General Topics, Tumor III: Sarcomas and Surgical Reconstruction
Scientific Papers Papers 541-555 Room 307
10
SATURDAY, MARCH 8
7:00 AM - 5:30 PM Specialty Day – Times Vary (See Below)
Hip Society/AAHKS 8:00 AM - 5:20 PM
SFM, Yerba Buena Salon 9
Knee Society/AAHKS 8:00 AM - 5:00 PM
Specialty Day Program SFM, Yerba Buena Salons 7-8

LLRS 8:00 AM - 5:30 PM
TMC, West, Room 2024
Scientific Exhibits 7:00 AM - 5:30 PM Hip: SE01-SE24 Knee: SE25-SE38
Scientific Posters 7:00 AM - 5:30 PM Hip P001-P110 Knee P111-P205
1/28/08
BASIC RESEARCH
Scientific Exhibits 7:00 AM - 5:30 PM SE39-SE42

6:42 PM
FOOT AND ANKLE

AOFAS 7:00 AM - 5:00 PM
Specialty Day Program TMC, West, Room 3002, 04, 06, 08
Page 10
Scientific Posters 7:00 AM - 5:30 PM P206-P225
HAND AND WRIST

ASSH/AAHS 8:00 AM - 5:00 PM
Specialty Day Program
TMC, West, Room 2005, 07, 09, 11
PEDIATRICS
POSNA 8:00 AM - 5:00 PM
Specialty Day Program TMC, West, Room 2020, 22

Scientific Exhibits 7:00 AM - 5:30 PM SE54

Specialty Day Program ORA 7:00 AM - 4:00 PM TMC, West, Room 3000
1/28/08
SHOULDER AND ELBOW

ASES 7:30 AM - 5:05 PM
TMC, Room 301, 03, 05
6:42 PM
SPINE
Page 11
FOSA 7:55 AM - 5:00 PM

TMC, West, Room 3020, 22, 24

AANA 7:50 AM - 5:20 PM
TMC, Gateway Ballroom
AOSSM 7:55 AM - 5:20 PM
TMC, Room 307, 08, 09, 10
TRAUMA
OTA 8:00 AM - 5:30 PM
TMC, West, Room 3001, 03, 05, 07

Specialty Day Program MSTS 7:00 AM - 5:00 PM
TMC, West, Room 2016, 18
11
Specialty Day will be held at The Moscone Center (TMC) and the San Francisco Marriott (SFM).
12
SUNDAY, MARCH 9
8:00 - 10:00 AM 8:00 - 11:00 AM 10:30 AM - 12:30 PM
Instructional Courses 401, 402, 409 421
The Young Patient with Hip Pain:

Unicompartmental Knee Replacement: Indi- Nonsurgical Management to Arthroplasty:
Symposia cations and Technique (X) A Worldwide Perspective (Y)
Room 301 Room 307
1/28/08
BASIC RESEARCH
FOOT AND ANKLE

6:42 PM

Page 12
HAND AND WRIST

Osteoporosis and the Myth of Colles:

Symposia Do They All Do Well? (W)
Room 307
PEDIATRICS


Scientific Posters 7:00 AM-12:30 PM

1/28/08
SHOULDER AND ELBOW

Instructional Courses 404, 408 425
6:42 PM
Fractures of the Clavicle-Contemporary Contro-

Symposia
versies (Z) Room 301
SPINE
Page 13

Current Trends in Sports Medicine:
Symposia An International Perspective (AA)
Room 301
TRAUMA

The Business of Orthopaedic
Symposia Trauma Care (BB)
Room 2005 West

13
Call For
Abstracts
Applications to submit a poster presentation,
podium presentation, scientific exhibit or multimedia
education presentation are available on-line at
www.aaos.org/abstracts
2009 Annual Meeting

February 25 – March 1
Las Vegas, Nevada

Moscone North


events that have taken place over the history of or-
thopaedics.
Moscone West
the traveling exhibit and watch the history of or-
Deborah Williams, oil on can- thopaedics unfold before your eyes. Major
Enjoy the eMotion Pictures art show - admire the more

than 200 artworks that sometimes humorously,
Flip through a commemorative coffee table book - rich

with images, personal stories, and timelines noting
significant events in the history of orthopaedics, the
coffee table book, Moving Stories: Seventy-five Years
of Orthopaedic Surgery, commemorates the

this ambitious text, Getting it Straight: A History of
of the specialty, historical markers, and medical ad-
vances in areas such as fracture care, manipulation,

2008 ANNUAL MEETING COMMITTEES

The following AAOS Committees are responsible for the scientific program, the scientific exhibits and the
multimedia education program. They grade abstracts, suggest moderators, identify hot topics and evaluate
sessions all in an effort to bring you an exciting and innovative program.
COMMITTEE MEMBERS
EXHIBITS COMMITTEE MULTIMEDIA EDUCATION CENTRAL PROGRAM

CENTER SUBCOMMITTEE COMMITTEE
Lynn A. Crosby, MD, Chair,
Dayton, OH Gene R. Barrett, MD, Chair, Daniel J. Berry, MD, Chair
Jackson, MS Rochester, MN
J. David Blaha, MD, Ann Arbor, MI
Nicholas A. Abidi, MD, Santa Cruz, CA Scott D. Boden, MD, Atlanta, GA
A. Seth Greenwald, D. Phil (Oxon),
Cleveland, OH Animesh Agarwal, MD, Joseph A. Bosco, III, MD,
San Antonio, TX New York, NY
Michael H. Huo, MD, Dallas, TX
Richard E. Bowen, MD, William J. Maloney, MD, Stanford, CA
Alfonso Mejia, MD, Chicago, IL
Los Angeles, CA Andrew H. Schmidt, MD,
Michael P. Mott, MD,
Ty Henry Goletz, MD, San Antonio, TX Plymouth, MN
Grand Rapids, MI
Todd Kevin Gothelf, MD, Arlen D. Hanssen, MD,
David L.Nelson, MD, Greenbrae, CA
New South Wales, Australia Rochester, MN, BOS Representative
Martin Plotkin, MD, St. Charles, IL
Spero G. Karas, MD, Atlanta, GA
William H. Seitz, Jr., MD,
Kevin D. Plancher, MD, New York, NY
Cleveland, OH
Richard Uhl, MD, Albany, NY
Jeffrey L. Visotsky, MD,
Des Plaines, IL Steven T. Woolson, MD, Palo Alto, CA
CENTRAL PROGRAM SUBCOMMITTEE MEMBERS

ADULT RECONSTRUCTION HIP HAND AND WRIST SPINE
William A. Jiranek, MD, Richmond, VA, Richard A. Berger, MD, Rochester, MN, Howard S. An, MD Chicago, IL, Chair
Chair Chair Christian Ivan Fras, MD,
Ronald E. Delanois, MD, David L. Cannon, MD, Chesapeake, VA Philadelphia, PA
Chesapeake, VA Matthew D. Putnam, MD, Bryan A. Gunnoe, MD, Phoenix, AZ
William J. Hozack, MD, Minneapolis, MN William J. Richardson, MD, Durham, NC
Philadelphia, PA Thomas E. Trumble, MD, Seattle, WA Vincent J. Silvaggio, MD, Pittsburgh, PA
Jay D. Mabrey, MD, Dallas, TX Andrew V. Slucky, MD, Oakland, CA
Thomas A. Malvitz, MD, PEDIATRICS Susan E. Stephens, MD, Cleveland, OH
Grand Rapids, MI Lori A. Karol, MD, Dallas, TX, Chair
Charles L. Nelson, MD, Voorhees, NJ Frances A. Farley MD, Ann Arbor, MI SPORTS MEDICINE/ARTHROSCOPY
Michael L. Parks, MD, New York, NY Martin J. Herman, MD, Philadelphia, PA Ronald M. Selby, MD, New York, NY,
Michael D Ries, MD, San Francisco, CA Chair
PRACTICE MANAGEMENT/REHABILITATION Diane L. Dahm, MD, Rochester, MN
ADULT RECONSTRUCTION KNEE Ty Henry Goletz, MD, San Antonio, TX Mark T. Galloway, MD, Cincinnati, OH
Robert T. Trousdale, MD, Rochester, Shawn Patrick Granger, MD, Mark J. Lemos, MD, Rye, NH
MN, Chair Leesville, LA Ronald A. Navarro, MD,
Craig H. Bennett, MD, Timonium, MD Rolling Hills, CA
Henry D. Clarke, MD, New York, NY SHOULDER AND ELBOW Lawrence Wells, MD, Philadelphia, PA
Andrew A. Freiberg, MD, Boston, MA Marc Safran, MD, San Francisco, CA,
Terence J. Gioe, MD, Apple Valley, MN Chair TRAUMA
Michael A. Kelly, MD, Hackensack, NJ Carl J. Basamania, MD, Durham, NC Kenneth J. Koval, MD, Lebanon, NH,
William M. Mihalko, MD, Norman D. Boardman, III MD, Chair
Charlottesville, VA Richmond, VA Animesh Agarwal, MD, San Antonio, TX
David A. Detrisac, MD, Okemos, MI Andrew N. Pollak, MD, Baltimore, MD
FOOT AND ANKLE Laurence D. Higgins, MD, Boston, MA Henry C. Sagi, MD, Tampa, FL
John S. Gould, MD, Birmingham, AL, R. Kumar Kadiyala, MD, Philip P. Wolinsky, MD, Sacramento, CA
Chair Miami Beach, FL Bruce Ziran, MD Youngstown, OH
Paul T. Fortin, MD, Royal Oak, MI
Steven L. Haddad, MD, Glenview, IL TUMOR & METABOLIC DISEASE
Norman S. Turner, III, MD, Kristy L. Weber, MD, Baltimore, MD,
Rochester, MN Chair
R. Lor Randall, MD, Salt Lake City, UT
John E. Ready, MD, Boston, MA
16
02 DISC 08:Layout 1 1/28/08 6:39 PM Page 1
This Proceedings Book is divided into three sections, Symposia Scientific Exhibits have been grouped in the following categories:
handouts and then Podium Presentations, Poster Presentations,
Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE01 – SE24
and Scientific Exhibits by classification and finally Multimedia
Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE25 – SE38
Education.
Basic Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE39 – SE42
Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE43 – SE47
PODIUM PRESENTATIONS Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE48 – SE49
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE52 – SE53
The Scientific Program features 585 podium presentations. All Practice Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE54
podium presentations are six minutes in groups of three Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE55 – SE57
followed by an open floor discussion moderated by chosen Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE58 – SE65
Academy members. The Scientific Program takes place at The Sports Medicine and Arthroscopy . . . . . . . . . . . . . . . . . . .SE66 – SE73
Moscone Center at various times and locations, please see the Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE50 – SE51
SYMPOSIA
final program for the schedule. Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE74 – SE75
AAOS Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE76 – SE84
BOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SE85 – SE88
POSTER PRESENTATIONS
Five hundred and seventy Poster Presentations will be
exhibited during the Annual Meeting. All Poster Presentations
MULTIMEDIA EDUCATION
will be displayed the entire five days of the meeting. Included Orthopaedic education benefits greatly from visual examples.
in these are Board of Specilaty Societies (BOS) posters. The This is the place to learn by example and to prepare for your
BOS posters will be indicated by their Society’s name or the future. Select from dozens of surgical technique videos and
name of their presentation. The Program also features selected multimedia programs and enjoy them at your convenience.
posters from the Orthopaedic Research Society. We hope that Learn more about leading edge technologies and techniques in
you spend time visiting the poster presentations and discussing minimally invasive surgery. Strengthen your knowledge of
the information with the presenters who will be at their display surgical anatomy, exposures, and more.
from 11:30 AM until 12:30 PM Wednesday through Friday in We are deeply indebted to our program authors. Without their
The Moscone Center, West, Level 1. voluntary contributions of know-how, time, and talent, the
The Scientific Program Committee is very appreciative of the Multimedia Education Center would not be possible.
effort extended by all the presenters and wishes to congratulate Video and multimedia programs are group by area of anatomy:
them on the high quality of the abstracts that were submitted
for evaluation. Award Winners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Stations 1 – 4
Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Stations 5 – 10
Poster awards will be presented on Friday morning, March 7 Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Stations 11 – 16
beginning at 7:00 AM. Awards will be given to the highest Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Station 17
rated poster in each of the 12 classifications and from them Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . .Stations 18 – 21
one overall winner will be chosen. Sports Medicine and Arthroscopy . . . . . . . . . . . . . . . .Stations 22 – 26
Adult Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P001 – P110 Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Station 27
Adult Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P111 – P205 Encore Presentations . . . . . . . . . . . . . . . . . . . . . . . . .Stations 28 – 32
Foot and Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P206 – P225
Hand and Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P226 – P240
Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P241 – P260
Practice Management/Rehabilitation . . . . . . . . . . . . . . . .P261 – P285
POSTERS, SCIENTIFIC EXHIBITS,
Shoulder and Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P286 – P345
Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P346 – P405
AND THE MULTIMEDIA
Sports Medicine and Arthroscopy . . . . . . . . . . . . . . . . . . .P406 – P455 EDUCATION CENTER ARE
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P456 – P520
Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P521 – P545 LOCATED IN THE MOSCONE
Best of ORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P546 – P555
Allied Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P556 – P559 CENTER, WEST, LEVEL 1
SCIENTIFIC EXHIBITS POSTER AND SCIENTIFIC EXHIBIT HOURS:
The Scientific Exhibit format is used to graphically illustrate a
study or a complex procedure. It differentiates itself from a Wednesday- Friday, March 5 – 7 . . . . . . . . .7:00 AM – 6:00 PM
poster presentation in the amount of material that is presented Saturday, March 8 . . . . . . . . . . . . . . . . . . . .7:00 AM – 5:30 PM
and uses audiovisual, interactive demonstration, or some other
Sunday, March 9 . . . . . . . . . . . . . . . . . . . .7:00 AM – 12:30 PM
type of enhancement in its presentation. The Scientific
Exhibits are located on Level 1 of The Moscone Center, West
and open at 7:00 AM, Wednesday through Sunday, to allow
MULTIMEDIA EDUCATION CENTER HOURS:
you to view the exhibits before the scientific program sessions. Wednesday- Friday, March 5 – 7 . . . . . . . . .7:30 AM – 6:00 PM
The authors of the exhibits are requested to be present daily
between 11:30 AM and 12:30 PM to discuss their ideas and Saturday, March 8 . . . . . . . . . . . . . . . . . . . .7:30 AM – 5:30 PM
presentation. The names of the authors presenting the Sunday, March 9 . . . . . . . . . . . . . . . . . . . .7:30 AM – 12:30 PM
Scientific Exhibits are printed in boldface.
17
Why Disclosure? The AAOS disclosure policy requires that faculty submit all
As an accredited provider of continuing medical education financial relationships occurring within the past 12 months
(CME) the Academy is required by the Accreditation Council that create a potential conflict.
for Continuing Medical Education (ACCME) to obtain and Each participant in the Annual Meeting has been asked to
share with participants of any AAOS CME activity any poten- disclose if he or she has received something of value from a
tial conflicts of interest by faculty, program developers, and commercial company or institution, which relates directly or
CME planners. indirectly to the subject of their presentation. The Academy
The ACCME Standards of Commercial Support, Standard 2 has identified the options to disclose as follows:
states the requirements: a. Research or institutional support has been received;
2.1 The provider must be able to show that everyone who b. Miscellaneous non-income support (e.g. equipment
is in a position to control the content of an education or services);
activity has disclosed all relevant financial relation- c. Royalties;
ships with any commercial interest to the provider. d. Stock or stock options; or
e. Consultant or employee
2.2 An individual who refuses to disclose relevant finan-
n. Disclosed nothing of value received
cial relationships will be disqualified from being a
planning committee member, a teacher, or an author The Academy does not view the existence of these disclosed
of CME, and cannot have control of, or responsibility interests or commitments as necessarily implying bias or
for, the development, management, presentation or decreasing the value of the author’s participation in the
evaluation of the CME activity. meeting.
NAME DISCLOSURE NAME DISCLOSURE
BOARD OF DIRECTORS Edward Akelman, MD, Member . . . . a – Auxillium Pharmaceuticals,,

James H Beaty, MD, President . . . . . . a – DePuy, A Johnson & Johnson Company, Biomimetic, DePuy, A Johnson & Johnson
Smith & Nephew, Synthes Company, National Institutes of Health
E Anthony Rankin, MD,. . . . . . . . . . . n (NIAMS & NICHD), Stryker, Synthes,
1st Vice President Tornier, b – Auxillium Pharmaceuticals,
Joseph D Zuckerman, MD, . . . . . . . . b, c – Exactech, Inc, e – Biomimetic, Smith & c – KMI, d – Biomimetic, Johnson &
2nd Vice President Nephew, Progenics Johnson, Pfizer, e – Auxillium
William L Healy, MD, Treasurer . . . . . a, b, e – DePuy, A Johnson & Johnson Pharmaceuticals, GLG Consultants,
Company Biomimetic
Richard F Kyle, MD, Past President. . . . a, c – DePuy, A Johnson & Johnson Stephen A Albanese, MD, . . . . . . . . . a – Stryker, Synthes, Zimmer, Biometric,
Company, c – Encore Medical, Smith & Member at Large Abbott Spine, Exactech, Inc, Crosstrees
Nephew, Zimmer Medical, Pioneer Surgical Technology,
Matthew S Shapiro, MD, . . . . . . . . . . c – Hely-Weber Corporation Ouroboros, d – Eli Lilly, Schering Plough,
Chair BOC Bristol-Myers Squib, Procter & Gamble
John T Gill, MD, Chair-Elect BOC. . . . n Miguel E Cabanela, MD, Member . . . a, b, c, e – Stryker
Thomas C Barber, MD . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, John J Callaghan, MD,. . . . . . . . . . . . a – Smith & Nephew, DePuy, A Johnson &
Secretary BOC Smith & Nephew, Zimmer Member at Large Johnson Company, EBI, Arthrex, Inc,
Joseph C McCarthy, MD, . . . . . . . . . a – Biomet, Zimmer, b – Vindico, c – Arthrex, b – DePuy, A Johnson & Johnson Company,
Chair BOS Inc, Innomed, Stryker, e – Stryker Zimmer, c, e – DePuy, A Johnson & Johnson
James P Tasto, MD, . . . . . . . . . . . . . . a, b, e – Arthrocare, Smith & Nephew, Company
Chair-Elect BOS c – Arthrocare, CONMED Linvatec, Barbara Jean Campbell, MD, . . . . . . b – Norvartis, GlaxoSmithKline
d – Pegasus Member
William J Robb III, MD . . . . . . . . . . . a – Brainlab, b, e – Brainlab, Smith & Nephew, Eric Ward Carson, MD, Member . . . . b – KFx San Diego CA
Secretary BOS c – Innomed, d – Medtronic, Stryker William P Cooney, III MD, . . . . . . . . b – Small Bone Innovations, c – Aircast(DJ),
George Zachary Wilhoit, MS, MBA, . d – Amgen Co, Pfizer Member Small Bone Innovations, d, e – Small Bone
DISCLOSURE
Lay Member Innovations

Kevin John Bozic, MD, MBA, . . . . . . a – Zimmer, b – Wright Medical Technology, Frances A Farley, MD, Member. . . . . . a, d – Medtronic
Member at Large Inc., Zimmer Evan L Flatow, MD, Member . . . . . . . a – Zimmer, c – Innomed, Zimmer,
Christopher D Harner, MD, . . . . . . . c – Biomet e – Wyeth
Member at Large Steven L Frick, MD, Member . . . . . . . a – Zimmer, Synthes
Norman Yoshinobu Otsuka, MD, . . a – National Institutes of Health (NIAMS & William A Grana, MD, MPH, . . . . . . a – Arthrex, Inc, Arthrocare, Breg, DePuy, A
Member at Large NICHD), Shriners Hospitals for Children Member Johnson & Johnson Company,
Clinical Outcomes Studies Advisory Board Musculoskeletal Transplant Foundation,
Ken Yamaguchi, MD, . . . . . . . . . . . . . c – Arthrex, Inc National Institutes of Health (NIAMS &
Member at Large NICHD), Smith & Nephew, Stryker,
Karen L Hackett, FACHE, CAE, . . . . . n Synthes, Surgical Acuity, Inc., Hanger,
Ex-Officio e – Synergy Medical Education, Scientific
Advisory Board for Orthopaedic Surgery of
COUN CIL ON EDUCATIO N UnitedHealthcare
Alan Marc Levine, MD, Chair . . . . . . a – Accuray, Medtronic Sofamor Danek, Letha Y Griffin, MD, Member . . . . . . . n
b – Accuray, c – US Spine, e – LRV David G Lewallen, MD, Member . . . . a – DePuy, A Johnson & Johnson Company,
Arlen D Hanssen, MD,. . . . . . . . . . . . a – Biomet, DePuy, A Johnson & Johnson Stryker, Zimmer, b, c – Zimmer,
Representative of BOS Company, Implex, Stryker, Tornier, Zimmer, e – Orthosonics, Zimmer, Bristol-Myers Squib
c – Stryker, Orthopaedic Development Stephen Paul Makk, MD, MBA, . . . . b – Biomet, DePuy, A Johnson & Johnson
Corp., e – Stryker Member Company, d – Retirement has some pharma
stocks that I don't control, Schering Plough,
options in Pradama, e – Pradama, 3DR,
Kentucky Seed Fund, Metacyte Business
Incubator, Healthcoast
John Lawrence Marsh, MD,. . . . . . . . a, b – Smith & Nephew, c – Biomet
Member
18

Colin F Moseley, MD, Member . . . . . n Scott D Boden, MD, Member . . . . . . . a – Synthes, National Institutes of Health
Charles T Price, MD,. . . . . . . . . . . . . . a, c – Biomet, e – Hanger Orthotics and (NIAMS & NICHD), Medtronic Sofamor
Member at Large Prosthetics Danek, Linvatec, Johnson & Johnson,
Michael F Schafer, MD, Member . . . . n DePuy, A Johnson & Johnson Company,
Matthew S Shapiro, MD, Member . . . c – Hely-Weber Corporation Abbott, b – Osteotech, Medtronic Sofamor
John R Tongue, MD,. . . . . . . . . . . . . . n Danek, c – Medtronic Sofamor Danek,
Member at Large Osteotech, e – Medtronic Sofamor Danek
Joseph D Zuckerman, MD, . . . . . . . . b, c – Exactech, Inc, e – Biomimetic, Smith & Joseph A Bosco, III MD, Member. . . . a – DePuy, A Johnson & Johnson Company,
Member Nephew, Progenics Mitek, Smith & Nephew, Stryker, Synthes
Mark Wieting, Staff Liaison . . . . . . . . d – GE Healthcare, Medtronic, e – Medtronic Arlen D Hanssen, MD, Member. . . . . a – Biomet, DePuy, A Johnson & Johnson
Company, Implex, Stryker, Tornier, Zimmer,
ANNUAL MEET ING COMMITT EE c – Stryker, Orthopaedic Development
Colin F Moseley, MD, Chair . . . . . . . n Corp., e – Stryker
Frederick M Azar, MD, Member . . . . . a – DePuy, A Johnson & Johnson Company, William J Maloney MD, Member. . . . a – DePuy, A Johnson & Johnson Company,
Smith & Nephew, Synthes, c – Elseiver for Medtronic, Synthes, Zimmer, c – Zimmer,
Campbell's Operative Orthopaedics Wright Medical Technology, Inc., e – Wright
Daniel J Berry, MD, Member . . . . . . . a – DePuy, A Johnson & Johnson Company, Medical Technology, Inc.
Smith & Nephew, Stryker, Zimmer, Andrew H Schmidt, MD, Member. . . a – Synthes, Smith & Nephew, Twin Star
b – DePuy, A Johnson & Johnson Company Medical, b – AGA FH Orthopedics,
but turned over to Mayo Clinic, c – Thieme, Inc, d – Twin Star Medical,
c, e – DePuy, A Johnson & Johnson e – Smith & Nephew, Twin Star Medical,
Company Millenium Medical Technologies, DePuy,
Scott D Boden, MD, Member . . . . . . . a – Synthes, National Institutes of Health A Johnson & Johnson Company
(NIAMS & NICHD), Medtronic Sofamor Kathie Niesen, Staff Liaison . . . . . . . . n
Danek, Linvatec, Johnson & Johnson,
DePuy, A Johnson & Johnson Company, E X H I BI T S C O M M I T T E E
Abbott, b – Osteotech, Medtronic Sofamor Lynn A Crosby, MD, Chair. . . . . . . . . a – Exactech, Inc, Smith & Nephew, Synthes,
Danek, c – Medtronic Sofamor Danek, b – DePuy, A Johnson & Johnson Company,
Osteotech, e – Medtronic Sofamor Danek Exactech, Inc, c, d, e – Exactech, Inc
Lynn A Crosby, MD, Member. . . . . . . a – Exactech, Inc, Smith & Nephew, Synthes, J David Blaha, MD, Member . . . . . . . a – Wright Medical Technology, Inc., Stryker,
b – DePuy, A Johnson & Johnson Company, c, e – Wright Medical Technology, Inc.,
Exactech, Inc, c, d, e – Exactech, Inc. d – Wright Medical Technology, Inc.,
Dennis Paul Grogan, MD, Member . n Abbott, Amgen Co, Bristol-Myers Squibb,
Robert F McLain, MD, . . . . . . . . . . . . a – Abbott, Blackstone Medical, DePuy, A GlaxoSmithKline, Norvartis, Procter &
Member at Large Johnson & Johnson Company, EBI, Stryker, Gamble, Roche, Sanofli, Teva,
Synthes, Zimmer, e – Blackstone Medical, A Seth Greenwald, DPhil Oxon . . . . a – Aesculap/B.Braun, AxioMed, Biomet,
Stryker Member Cervitech, DePuy, A Johnson & Johnson
Raffy Mirzayan, MD, Member . . . . . . c – Lippincott, Thieme Company, Encore Medical, Finsbury, Link
Mary I O'Connor, MD, Member . . . . a – DePuy, A Johnson & Johnson Company, Orthopaedics, Wright Medical Technology,
c – DePuy, A Johnson & Johnson Company, Inc., Amedica, OrthoDevelopment, Theken,
Zimmer b – Biomet, e – DePuy, A Johnson &
Ghazi M Rayan, MD, Member . . . . . n Johnson Company, Medtronic, Smith &
Randy N Rosier, MD, PhD, . . . . . . . . a – Aircast(DJ), AO, Eli Lilly, Merck, Nephew, Link Orthopaedics, Wright
Member Musculoskeletal Transplant Foundation, Medical Technology, Inc.
National Institutes of Health (NIAMS & Michael H Huo, MD, Member . . . . . . b – Sanofi-Aventis, Boehringer-Ingelheim,
NICHD), Zimmer, b – Synthes, d – Amgen Portola, e – Stryker, Zimmer, Boehringer-
Co, Medtronic Ingelheim, Portola
H Del Schutte Jr, MD, Member . . . . . a, b, e – DePuy, A Johnson & Johnson Alfonso Mejia, MD, Member . . . . . . . a – Acumed, LLC, DePuy, A Johnson &
Company, Stryker Johnson Company, Smith & Nephew,
Robert T Trousdale, MD, . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Synthes, Zimmer, d – Eli Lilly, Merck, Pfizer
Member at Large Stryker, Zimmer, b, c – DePuy, A Johnson & Michael P Mott, MD, Member . . . . . . d – Johnson & Johnson
Johnson Company, e – DePuy, A Johnson & David L Nelson, MD, Member . . . . . . b – Pfizer, Synthes, Orthofix, Inc., Biomet,
Johnson Company, Wright Medical DePuy, A Johnson & Johnson Company,
Technology, Inc. EBI, Hand Innovations, KMI, Orthofix, Inc.,
Philip R Wolinsky, MD, . . . . . . . . . . . a – Zimmer Stryker, Synthes, Trimed, Wright Medical
Member at Large Technology, Inc., Zimmer, c – Orthofix, Inc.,
Pietro M Tonino, MD, Ex-Officio. . . . d – Regeneration Technologies, Inc. Stryker, d, e – Orthofix, Inc.
DISCLOSURE
Susan A McSorley, Staff Liaison . . . . . n Martin Plotkin, MD, Member. . . . . . . b – HeelUSA (Homotoxicology Company)
William H Seitz Jr, MD, Member . . . . a – ArthroCare, b – Pfizer, e – Stryker, Small
INST RUCTION AL CO URSE COMMITTEE Bone Innovation, Kapp Surgical Instrument
Frederick M Azar, MD, Chair . . . . . . . a – DePuy, A Johnson & Johnson Company, Jeffrey L Visotsky, MD, Member . . . . . b – DePuy, A Johnson & Johnson Company,
Smith & Nephew, Synthes, c – Elseiver for Pfizer, d – Pegasus, DePuy, A Johnson &
Campbell's Operative Orthopaedics Johnson Company, e – DePuy, A Johnson &
Paul J Duwelius, MD, Member. . . . . . a, b, c – Zimmer, e – Zimmer, GE Johnson Company
Healthcare, Medtronic, Synthes Pat Whitaker, Staff Liaison . . . . . . . . . n
Kenneth A Egol, MD, Member . . . . . . a – Biomet, Smith & Nephew, Stryker,
Synthes, b – Biomet, d – Johnson & Johnson MULTIMEDIA EDUCATION CENTE R SUBCOMMIT TEE
J Lawrence Marsh, MD, . . . . . . . . . . . a, b – Smith & Nephew, c – Biomet Gene R Barrett, MD, Chair . . . . . . . . . n
Member Nicholas A Abidi, MD, Member. . . . . n
Mary I O’Connor, MD, Member . . . . a – DePuy, A Johnson & Johnson Company, Animesh Agarwal, MD, Member . . . . a – DePuy, A Johnson & Johnson Company,
c – DePuy, A Johnson & Johnson Company, KCI, Smith & Nephew, Stryker, Synthes,
Zimmer b – KCI, Smith & Nephew, Synthes,
James D Heckman, MD, Ex-Officio. . n e – Synthes
Dempsey S Springfield, MD, . . . . . . a – Stryker, Zimmer, d – Johnson & Johnson Richard E Bowen, MD, Member. . . . . e – Abbott
Ex-Officio Ty Henry Goletz, MD, Member . . . . . b – DePuy, A Johnson & Johnson Company
Kathie Niesen, Staff Liaison . . . . . . . . n Todd Kevin Gothelf, MD, Member. . . n
Spero G Karas, MD, Member . . . . . . . a – Linvatec, Stryker, Encore Medical,
CENTRAL P ROGRAM COMMITTE E b – Encore Medical, Linvatec, e – Encore
Daniel J Berry, MD, Chair . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Medical
Smith & Nephew, Stryker, Zimmer, Kevin D Plancher, MD, Member . . . . n
b – DePuy, A Johnson & Johnson Company Richard Uhl, MD, Member. . . . . . . . . n
but turned over to Mayo Clinic, c, e – DePuy,
A Johnson & Johnson Company
The codes after the name are identified as a – research or institutional support, b – miscellaneous funding, c – royalties, d – stock options, e – consultant or employee, and n – no conflicts disclosed.
For full information refer to page 18. 19

Steven T Woolson, MD, Member . . . . a – DePuy, A Johnson & Johnson Company, Practice Management Subcommittee
Zimmer, b, e – DePuy, A Johnson & Ty Henry Goletz, MD, Member . . . . . b – DePuy, A Johnson & Johnson Company
Johnson Company Shawn Patrick Granger, MD, . . . . . . . n
Reid L Stanton, Staff Liaison. . . . . . . . d – Pfizer, Johnson and Johnson, Abbott, Member
Bristol-Myers Squib
Shoulder and Elbow Program Subcommittee
ANNUAL MEET ING EDUCATION SUBCO MMIT TEES Marc Safran, MD, Chair . . . . . . . . . . . a – Zimmer, Smith & Nephew, DJ
Orthopaedics, d, e – Cool Systems, Inc.
Adult Hip Program Subcommittee Carl J Basamania, MD, Member. . . . . e – DePuy, A Johnson & Johnson Company
William A Jiranek, MD, Chair . . . . . . a, c – DePuy, A Johnson & Johnson Norman Douglas Boardman, . . . . . . a – Biomet, Acumed, LLC, DePuy, A Johnson
Company, d – DePuy, A Johnson & Johnson III, MD, Member & Johnson Company, b – Biomet, DePuy,
Company, Zimmer, Bristol-Myers Squib, GE A Johnson & Johnson Company,
Healthcare, Genzyme, Merck, Pfizer, Procter GlaxoSmithKline, Merck, e – DePuy,
& Gamble, Sanofi-Aventis, e – DePuy, A A Johnson & Johnson Company
Johnson & Johnson Company, Zimmer, David Arthur Detrisac, MD, Member. . n
Lifenet Laurence D Higgins, MD, Member. . . a – Zimmer, DePuy, A Johnson & Johnson
Ronald E. Delanois, MD, Member. . . a – Stryker, Wright Medical Technology, Inc. Company, DJ Orthopaedics, b – DePuy, A
William J Hozack, MD, Member . . . . a, c, e – Stryker Johnson & Johnson Company, c – Zimmer,
Jay D Mabrey, MD, Member . . . . . . . . a – Synthes, e – Exactech, Inc e – DePuy, A Johnson & Johnson Company
Thomas A Malvitz, MD, Member. . . . a – DePuy, A Johnson & Johnson Company R Kumar Kadiyala, MD, PhD, . . . . . . e – EBI
Charles L Nelson, MD, Member . . . . a – DePuy, A Johnson & Johnson Company, Member
b, e – Zimmer, c – Exactech, Inc
Michael Lloyd Parks, MD, . . . . . . . . . a – Zimmer, Stryker, Procter & Gamble, Spine Subcommittee
Member Pfizer, b – Zimmer, d – Johnson & Johnson, Howard S An MD, Chair . . . . . . . . . . a – Zimmer, Stryker, Medtronic Sofamor
Merck, Zimmer, Pfizer, Procter & Gamble, Danek, Johnson & Johnson, b – Stryker,
e – Zimmer c – U & I Inc., e – Zimmer, Stryker, Johnson
Michael D Ries, MD, Member . . . . . . a – Smith & Nephew, Zimmer, c – Smith & & Johnson
Nephew Christian Ivan Fras, MD, Member . . . n
Bryan A Gunnoe, MD, Member . . . . . d – Nuvasive
Adult Knee Program Subcommittee William J Richardson, MD, Member. . a – EBI, DePuy, A Johnson & Johnson
Robert T Trousdale, MD, Chair . . . . . a – DePuy, A Johnson & Johnson Company, Company
Stryker, Zimmer, b, c – DePuy, A Johnson & Vincent J Silvaggio, MD, Member . . . c – Globus Medical, d – Amgen Co, Globus
Johnson Company, e – DePuy, A Johnson & Medical, Johnson & Johnson, Merck, Pfizer,
Johnson Company, Wright Medical e – Globus Medical
Technology, Inc. Andrew V Slucky, MD, Member . . . . . a – Spinal Motion, b – AO
Craig Howard Bennett, MD, . . . . . . . n Susan E Stephens, MD, Member . . . . n
Member
Henry D Clarke, MD, Member . . . . . . a – Stryker, b – DePuy, A Johnson & Johnson Sports Medicine/Arthroscopy Program Subcommittee
Company, Zimmer, Stryker, e – Zimmer, Ronald M Selby, MD, Chair . . . . . . . . n
DePuy, A Johnson & Johnson Company Diane Lynn Dahm, MD, Member . . . n
Andrew A Freiberg, MD, Member . . . a – Zimmer, Biomet, c, e – Zimmer Marc T Galloway, MD, Member . . . . . a – Arthrocare, e – Wyeth
Terence J Gioe, MD, Member . . . . . . . a – DePuy, A Johnson & Johnson Company, Mark J Lemos, MD, Member . . . . . . . a – DePuy, A Johnson & Johnson Company,
Stryker, Zimmer, b – DePuy, A Johnson & e – Smith & Nephew
Johnson Company, d – Johnson & Johnson Ronald Anthony Navarro, MD, . . . . n
Michael A Kelly, MD, Member . . . . . . b – Zimmer, c – Zimmer Faziomed, Member
d – Abbott, Bristol-Myers Squib, Pfizer, Lawrence Wells, MD, Member . . . . . . n
e – Zimmer
William Michael Mihalko, MD, PhD. . a – Smith & Nephew, b – Smith & Nephew, Trauma Program Subcommittee
Stryker, Ethicon, e – Smith & Nephew, Kenneth J Koval, MD, Chair. . . . . . . . b, e – Biomet, Stryker, c – Biomet
Stryker, Ethicon Animesh Agarwal, MD, Member . . . . a – DePuy, A Johnson & Johnson Company,
KCI, Smith & Nephew, Stryker, Synthes,
Foot and Ankle Program b – KCI, Smith & Nephew, Synthes,
John S Gould, MD, Chair. . . . . . . . . . a – Biomimetic, DePuy, A Johnson & e – Synthes
Johnson Company, e – DePuy, A Johnson & Andrew N Pollak, MD, Member . . . . a – Synthes, Stryker, Smith & Nephew,
Johnson Company, Zimmer Zimmer, Wyeth, e – KCI
Paul T Fortin, MD, Member . . . . . . . . n Henry Claude Sagi, MD, Member . . . a – Smith & Nephew, Synthes, b – Stryker,
Steven L Haddad, MD, Member. . . . . a – Biomimetic, DePuy, A Johnson & Smith & Nephew, AO, c – Smith & Nephew,
Johnson Company, b – DePuy, A Johnson & e – Smith & Nephew, Synthes, Stryker
DISCLOSURE
Johnson Company, Nexa Orthopaedics, Philip R Wolinsky, MD, Member . . . . a – Zimmer

Stryker, e – DePuy, A Johnson & Johnson Bruce Ziran, MD, Member . . . . . . . . . a – Medtronic, b – Stryker, AO, e – Stryker,
Company, Stryker Synthes
Norman S Turner III, MD, Member. . n
Tumor/Metabolic Disease Program Subcommittee
Hand and Wrist Program Subcommittee Kristy L Weber, MD, Chair . . . . . . . . . a – Zimmer
Richard A Berger, MD, PhD, Chair . . c – Small Bone Innovations R Lor Randall, MD, Member. . . . . . . . a – Biomet
David L Cannon, MD, Member . . . . . n John E Ready, MD, Member . . . . . . . . b – Smith & Nephew, e – Stryker, Smith &
Matthew D Putnam, MD, Member. . . a – Biomet, Aircast(DJ), AO, DePuy, A Nephew
Johnson & Johnson Company, Medtronic
Sofamor Danek, Wright Medical
Technology, Inc., c – Wright Medical
Technology, Inc., Small Bone Innovations,
d – Amgen Co, GE Healthcare, Johnson &
Johnson, BoundaryMedical, Anchor Inc.,
e – Small Bone Innovations, Stryker, Wright
Medical Technology, Inc., BoundaryMedical
Thomas E Trumble, MD, Member . . . n
Pediatrics Subcommittee
Lori A Karol, MD, Chair . . . . . . . . . . . n
Frances A Farley, MD, Member. . . . . . a, d – Medtronic
Martin Joseph Herman, MD, . . . . . . n
Member
20 For full information refer to page 18.
FACULTY NAME DISCLOSURE

NAME DISCLOSURE
Amenabar, Pedro Pablo . . . . . . . . . . . n
Abbot, Amy E . . . . . . . . . . . . . . . . . . . e – DePuy Amendola, Annunziato . . . . . . . . . . . a, d, e – Arthrosurface, b – Genzyme,
Abboud, Joseph Albert. . . . . . . . . . . . n Musculoskeletal Transplant Foundation,
Abell, Brian . . . . . . . . . . . . . . . . . . . . . n c, e – Arthrex, Inc, e – Link Orthopaedics
Abjornson, Celeste . . . . . . . . . . . . . . . e – Synthes Spine Amendola, Luca . . . . . . . . . . . . . . . . . n
Aboulafia, Albert J . . . . . . . . . . . . . . . n Ames, James . . . . . . . . . . . . . . . . . . . . n
Abrams, Jeffrey S. . . . . . . . . . . . . . . . . b – Orthopaedic Scientific Research Amirault, John David. . . . . . . . . . . . . n
Foundation, c, e – CONMED Linvatec, Amirouche, Farid . . . . . . . . . . . . . . . . n
d, e – Arthrocare, e – Wright Medical Ammendolia, Antonio. . . . . . . . . . . . n
Technology, Inc. Amrami, Kimberly K . . . . . . . . . . . . . n
Accousti, Kenneth. . . . . . . . . . . . . . . . n Amstutz, Harlan C . . . . . . . . . . . . . . . a, e – Wright Medical Technology, Inc.
Ackroyd, Christopher . . . . . . . . . . . . . a, b, c – Stryker Howmedica An, Howard S . . . . . . . . . . . . . . . . . . . a, b, e – Stryker, a, e – Zimmer, Johnson &
Adam, John . . . . . . . . . . . . . . . . . . . . . n Johnson, a – Medtronic Sofamor Danek,
Adamczyk, Mark J. . . . . . . . . . . . . . . . n c – U & I Inc.
Adams, Chris S . . . . . . . . . . . . . . . . . . a – Smith & Nephew An, Kai-Nan. . . . . . . . . . . . . . . . . . . . . n
Adams, Christopher S . . . . . . . . . . . . n An, Young Hee . . . . . . . . . . . . . . . . . . n
Adams, Joanne B. . . . . . . . . . . . . . . . . a – Biomet An, Yuehuei H. . . . . . . . . . . . . . . . . . . a – Ceremed, Inc.
Adams, Julie E . . . . . . . . . . . . . . . . . . . n Anderle, Matthew . . . . . . . . . . . . . . . . a – Archus Orthopedics, DePuy
Adams, Mary Jo. . . . . . . . . . . . . . . . . . a – DePuy Andermahr, Jonas. . . . . . . . . . . . . . . . n
Adams, Robert A . . . . . . . . . . . . . . . . . n Anderson, Allen F . . . . . . . . . . . . . . . . e – Genzyme
Adeyemo, Foley . . . . . . . . . . . . . . . . . a – Stryker Howmedica, DePuy, Intavent Anderson, D Ron . . . . . . . . . . . . . . . . a – DePuy, Zimmer, Smith & Nephew
Orthofix Anderson, Donald D . . . . . . . . . . . . . n
Adler, Ronald S . . . . . . . . . . . . . . . . . . n Anderson, Jodi N . . . . . . . . . . . . . . . . n
Aebi, Jurg . . . . . . . . . . . . . . . . . . . . . . . e – Zimmer Anderson, John G. . . . . . . . . . . . . . . . a, b, e – Zimmer, b – Arthrex, Inc,
Affonso, Jesse . . . . . . . . . . . . . . . . . . . n d – Merck, Pfizer
Agarwal, Animesh. . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Anderson, John Anthony. . . . . . . . . . n
KCI, Smith & Nephew, Stryker, Synthes, Anderson, Lucas . . . . . . . . . . . . . . . . . n
b – KCI, Smith & Nephew, Synthes, Anderson, Martin R . . . . . . . . . . . . . . n
e – Synthes Anderson, Michael J . . . . . . . . . . . . . . c, e – Wright Medical Technolgy, e – Zimmer
Agarwal, Sanjeev . . . . . . . . . . . . . . . . . n Anderson, Paul A . . . . . . . . . . . . . . . . a, b, c, e – Medtronic
Agarwalla, Anant . . . . . . . . . . . . . . . . n Anderson, Robert B . . . . . . . . . . . . . . a, b, c, d, e – Wright Medical Technology,
Agel, Julie. . . . . . . . . . . . . . . . . . . . . . . n Inc., a, b, c, d – DJ Orthopaedics
Ageno, Walter . . . . . . . . . . . . . . . . . . . e – Bayer Health Care AG Anderson, Sarah . . . . . . . . . . . . . . . . . n
Aggarwal, Ajay. . . . . . . . . . . . . . . . . . . n Anderson, Stephan . . . . . . . . . . . . . . . n
Aghayev, Emin . . . . . . . . . . . . . . . . . . n Andreassen, Geir. . . . . . . . . . . . . . . . . a – Inion
Agnew, Samuel G . . . . . . . . . . . . . . . . e – Zimmer Andrew, J Glynne . . . . . . . . . . . . . . . . a – Stryker
Agudelo, Juan Fernando . . . . . . . . . . n Andrews, Amanda L . . . . . . . . . . . . . . n
Ahmad, Christopher S . . . . . . . . . . . . a, b – Arthrex, Inc Andriacchi, Thomas P . . . . . . . . . . . . n
Ahmad, Jamal . . . . . . . . . . . . . . . . . . . n Andrish, Jack T . . . . . . . . . . . . . . . . . . a – Arthrex, Smith & Nephew
Ahn, Jaimo . . . . . . . . . . . . . . . . . . . . . n Andtbacka, Robert . . . . . . . . . . . . . . . n
Ahn, Nicholas Utchan . . . . . . . . . . . . n Angelo, Richard L . . . . . . . . . . . . . . . . b, e – Mitek, d – Johnson & Johnson
Aibinder, William . . . . . . . . . . . . . . . . n Angibaud, Laurent . . . . . . . . . . . . . . . e – Exactech
Aihara, Masaharu . . . . . . . . . . . . . . . . n Anglen, Jeffrey. . . . . . . . . . . . . . . . . . . a – Multiple companies support our
Ajibade, David . . . . . . . . . . . . . . . . . . n educational program, c – Biomet, e – Stryker
Akbar, Michael . . . . . . . . . . . . . . . . . . n Anis, Aslam . . . . . . . . . . . . . . . . . . . . . n
Akbarnia, Behrooz A . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson Ankem, Hari . . . . . . . . . . . . . . . . . . . . n
Company, a, b, d, e – Nuvasive, Anract, Philippe . . . . . . . . . . . . . . . . . n
a – Medtronic Sofamor Danek, b – Stryker, Anthony, Shawn . . . . . . . . . . . . . . . . . n
e – Vertech, K2M Antoci Jr Valentin . . . . . . . . . . . . . . . . a – Smith & Nephew
Akelina, Yelena . . . . . . . . . . . . . . . . . . n Antonacci, M Darryl. . . . . . . . . . . . . . n
Akgun, Karli Isik . . . . . . . . . . . . . . . . . n Ao, Masakazu . . . . . . . . . . . . . . . . . . . n
Akindolire, Jason . . . . . . . . . . . . . . . . n Aono, Kiyoshi . . . . . . . . . . . . . . . . . . . n
Akira, Goto . . . . . . . . . . . . . . . . . . . . . n Apker, Kimberly . . . . . . . . . . . . . . . . . n
Akira, Takahashi . . . . . . . . . . . . . . . . . n Appleyard, Richard Charles. . . . . . . . n
Alaee, Farhang. . . . . . . . . . . . . . . . . . . n Apyan, Paul M. . . . . . . . . . . . . . . . . . . n
Alavi, Abass . . . . . . . . . . . . . . . . . . . . . n Arai, Kenichiro . . . . . . . . . . . . . . . . . . n
Albert, Todd J . . . . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson Arakaki, Kazunobu. . . . . . . . . . . . . . . n
DISCLOSURE
Company, d – K2M, Axiamed, Gentis Aratake, Masato . . . . . . . . . . . . . . . . . n
Alberta, Francis G . . . . . . . . . . . . . . . . b, e – Arthrex Archbold, Pooler H A. . . . . . . . . . . . . n
Alcock, Chris . . . . . . . . . . . . . . . . . . . . n Arciero, Robert A. . . . . . . . . . . . . . . . . a, b – Arthrex, Inc, a – Mitek, Smith &
Aldinger, Peter R . . . . . . . . . . . . . . . . . n Nephew
Aldridge, Julian M. . . . . . . . . . . . . . . . n Arendt, Elizabeth A . . . . . . . . . . . . . . a – Ferring Pharmaceuticals, Biomet,
Alexander, A Herbert . . . . . . . . . . . . . b – Synthes Linvatec, Medtronic Sofamor Danek,
Alexander, Jerry W . . . . . . . . . . . . . . . n Wright Medical Technology, Inc.
Alexander, Marcus . . . . . . . . . . . . . . . a – Small Bone Innovations, Wright Medical Argarwal, Suresh . . . . . . . . . . . . . . . . . n
Technology, Inc. Argenson, Jean-Noel A. . . . . . . . . . . . a, c, e – Zimmer
Al-Hakim, Ramsey A . . . . . . . . . . . . . n Argento, Giuseppe . . . . . . . . . . . . . . . n
Ali, Mir H . . . . . . . . . . . . . . . . . . . . . . n Arias Pesantex, Carlos Fernando. . . . n
Allami, Mark . . . . . . . . . . . . . . . . . . . . n Ariizumi, Takashi . . . . . . . . . . . . . . . . n
Allan, D B . . . . . . . . . . . . . . . . . . . . . . n Arimizu, Jun . . . . . . . . . . . . . . . . . . . . n
Allen, Answorth Anthony . . . . . . . . . n Ariumi, Akihior. . . . . . . . . . . . . . . . . . n
Allen, Bryce . . . . . . . . . . . . . . . . . . . . . n Arizono, Takeshi. . . . . . . . . . . . . . . . . n
Allen, Wesley. . . . . . . . . . . . . . . . . . . . n Armitage, Andrew. . . . . . . . . . . . . . . . n
Allende, Bartolome T . . . . . . . . . . . . . n Armstrong, Douglas G . . . . . . . . . . . . n
Allende, Christian. . . . . . . . . . . . . . . . n Armstrong, Johnathan K . . . . . . . . . . d – Ceremed, Inc.
Almeida, Fernando Souza . . . . . . . . . n Arnold, Kali Danielle . . . . . . . . . . . . . n
Alonso, Jorge E . . . . . . . . . . . . . . . . . . a – Synthes Arrington, Terry Lee . . . . . . . . . . . . . . n
Altchek, David W . . . . . . . . . . . . . . . . n Asaumi, Koji . . . . . . . . . . . . . . . . . . . . n
Altman, Daniel T . . . . . . . . . . . . . . . . n Asavamongkolkul, Apichat . . . . . . . . n
Al-Turki, Abdullah . . . . . . . . . . . . . . . n Asghar, Jahangir . . . . . . . . . . . . . . . . . n
Amadio, Peter C . . . . . . . . . . . . . . . . . n Ashby, Elizabeth . . . . . . . . . . . . . . . . . n
Ameen, Debbie. . . . . . . . . . . . . . . . . . n Asheld, John . . . . . . . . . . . . . . . . . . . . n

Ashish, Joshi . . . . . . . . . . . . . . . . . . . . n Barnes, Keith . . . . . . . . . . . . . . . . . . . . n
Ashraf, Mujeeb . . . . . . . . . . . . . . . . . . n Barnett, Ted Marcus . . . . . . . . . . . . . . n
Ashton, Roger . . . . . . . . . . . . . . . . . . . e – Smith & Nephew Baronetti, Marco. . . . . . . . . . . . . . . . . n
Ashwin, Nathan . . . . . . . . . . . . . . . . . n Barrack, Robert L. . . . . . . . . . . . . . . . . a, c, e – Smith & Nephew, a – Zimmer,
Asnis, Peter D . . . . . . . . . . . . . . . . . . . n Wright Medical Technology, Inc., Medtronic
Aston, William . . . . . . . . . . . . . . . . . . n Barrera, O Andres . . . . . . . . . . . . . . . . a – Biomet
Athanasian, Edward A . . . . . . . . . . . . n Barrett, William P . . . . . . . . . . . . . . . . a, c, e – DePuy
Athanasou, N.A. . . . . . . . . . . . . . . . . . n Barrette-Grischow, Mary Kate . . . . . . a – Ohio Department of Public Safety,
Athwal, George . . . . . . . . . . . . . . . . . . a – Wright Medical Technology, Inc., Tornier Emergency Medical Services Grant
Atsuta, Yuji . . . . . . . . . . . . . . . . . . . . . n Barron, O Alton . . . . . . . . . . . . . . . . . n
Atsuya, Watanabe . . . . . . . . . . . . . . . . n Bartlett, Craig Scott. . . . . . . . . . . . . . . d – Merck Dow
Atwood, Sara A . . . . . . . . . . . . . . . . . . n Bartol, Stephen . . . . . . . . . . . . . . . . . . n
Aubaniac, Jean-Manuel . . . . . . . . . . . a, c – Zimmer Barz, Thomas . . . . . . . . . . . . . . . . . . . n
Audige, Laurent. . . . . . . . . . . . . . . . . . e – AO Foundation Basad, Erhan . . . . . . . . . . . . . . . . . . . . n
Auerbach, Andrew . . . . . . . . . . . . . . . n Bastrom, Tracey. . . . . . . . . . . . . . . . . . a – DePuy Spine
Auerbach, Joshua D . . . . . . . . . . . . . . a – Synthes Spine Bathis, Holger . . . . . . . . . . . . . . . . . . . n
Augustini, Bengt G . . . . . . . . . . . . . . . n Bauer, R David . . . . . . . . . . . . . . . . . . e – Biomet
Austin, Mathew. . . . . . . . . . . . . . . . . . n Baum, Jeffrey A . . . . . . . . . . . . . . . . . . d – Bristol-Myers Squib, Johnson and
Austin, Matthew . . . . . . . . . . . . . . . . . a, b – Stryker Johnson
Auw Yang, Gie Kiem. . . . . . . . . . . . . . n Bauman, Jean . . . . . . . . . . . . . . . . . . . n
Awan, Hisham . . . . . . . . . . . . . . . . . . n Baumgaertner, Michael R. . . . . . . . . . a, b – Synthes, e – Smith & Nephew
Axe, Michael J . . . . . . . . . . . . . . . . . . . e – Sanofi Aventis Baumgarten, Keith Michael . . . . . . . . a – OREF
Axelrod, Terry S. . . . . . . . . . . . . . . . . . a – Synthes, Zimmer Baumhauer, Judith F . . . . . . . . . . . . . a – Biomimetics, Donjoy, Carticept;
Ayerza, Miguel Angel . . . . . . . . . . . . . n e – Zimmer
Azad, Hussain . . . . . . . . . . . . . . . . . . . e – Smith & Nephew Bayeff-Filoff, Michael . . . . . . . . . . . . . n
Azad, Vikrant . . . . . . . . . . . . . . . . . . . n Bayers-Thering, Mary T . . . . . . . . . . . n
Aziz, Jorge . . . . . . . . . . . . . . . . . . . . . . b – Biomet Bayley, J I L . . . . . . . . . . . . . . . . . . . . . n
Azuma, Takashi. . . . . . . . . . . . . . . . . . n Bayne, Christopher. . . . . . . . . . . . . . . n
Azuma, Yoshiaki . . . . . . . . . . . . . . . . . e – Teijin Phramaceutical Bayrakci, Kenan . . . . . . . . . . . . . . . . . n
Babbitt, Ann . . . . . . . . . . . . . . . . . . . . b – Merck, Lilly, Aventis, Roche, Novartis, Beach, William R . . . . . . . . . . . . . . . . e – Arthrex, Inc, Reed Smith
Kyphon Beals, Timothy C. . . . . . . . . . . . . . . . . n
Babis, George . . . . . . . . . . . . . . . . . . . n Beard, David J . . . . . . . . . . . . . . . . . . . a, b – Stryker Howmedica, Biomet
Babu, Rajendra . . . . . . . . . . . . . . . . . . n Beatty, Karen Tania . . . . . . . . . . . . . . . a – Stryker, Smith & Nephew, EBI, Biomet,
Bach Jr Bernard R . . . . . . . . . . . . . . . . a – Smith & Nephew, DJ Orthopaedics, Zimmer
Miomed, Athletico Beaty, James H . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Bach, Joel M . . . . . . . . . . . . . . . . . . . . a, e – Stryker Howmedica Smith & Nephew, Synthes
Bacher, Thomas . . . . . . . . . . . . . . . . . n Beaule, Paul E . . . . . . . . . . . . . . . . . . . a, b, e – Wright Medical Technology, Inc.,
Bachus, Kent N . . . . . . . . . . . . . . . . . . n a – Stryker, Zimmer, e – Brainlab, Getinge
Backstein, David . . . . . . . . . . . . . . . . . e – Zimmer USA
Backus, Sherry I. . . . . . . . . . . . . . . . . . n Becher, Christoph . . . . . . . . . . . . . . . . b – Arthrosurface Inc.
Badarudeen, Sameer. . . . . . . . . . . . . . n Bechtold, Joan E . . . . . . . . . . . . . . . . . n
Bader, Joseph Scott . . . . . . . . . . . . . . . n Beck, Markus. . . . . . . . . . . . . . . . . . . . n
Bader, Joseph S . . . . . . . . . . . . . . . . . . n Beck, Preston. . . . . . . . . . . . . . . . . . . . n
Badhwar, Amit . . . . . . . . . . . . . . . . . . n Becker, Roland . . . . . . . . . . . . . . . . . . n
Badman, Brian . . . . . . . . . . . . . . . . . . b – Encore Medical Beebe, Kathleen . . . . . . . . . . . . . . . . . a – Biomet, Musculoskeletal Transplant
Bado, Federico . . . . . . . . . . . . . . . . . . n Foundation
Bae, Ki-Cheol . . . . . . . . . . . . . . . . . . . n Beischer, Andrew D . . . . . . . . . . . . . . a – Medical Research Foundation for
Baechler, Maj Martin F . . . . . . . . . . . . n Women and Babies
Baek, Seung Hun . . . . . . . . . . . . . . . . n Bejui-Hugues, Jacques . . . . . . . . . . . . c – Amplitude
Baez, Norberto . . . . . . . . . . . . . . . . . . n Bekler, Halil Ibrahim . . . . . . . . . . . . . n
Bagheri, Ramin . . . . . . . . . . . . . . . . . . n Belangero, William. . . . . . . . . . . . . . . n
Bagley, Anita . . . . . . . . . . . . . . . . . . . . n Belkoff, Stephen . . . . . . . . . . . . . . . . . a – Zimmer, Stryker
Bailie, David S. . . . . . . . . . . . . . . . . . . a, b, e – Biomet Orthopedics Bellapianta, Joseph. . . . . . . . . . . . . . . n
Bailleul, Francois . . . . . . . . . . . . . . . . e – Genzyme Bellemans, Johan . . . . . . . . . . . . . . . . n
Bain, Lisa M. . . . . . . . . . . . . . . . . . . . . n Bellotte, Brad. . . . . . . . . . . . . . . . . . . . e – DePuy Spine
Bajares, Guillermo . . . . . . . . . . . . . . . a – Archus Orthopedics Belthur, Mohan. . . . . . . . . . . . . . . . . . n
Baker, Brendon M. . . . . . . . . . . . . . . . n Bembom, Oliver . . . . . . . . . . . . . . . . . n
DISCLOSURE
Bal, B Sonny . . . . . . . . . . . . . . . . . . . . a – Zimmer, b – DePuy, A Johnson & Benevenia, Joseph. . . . . . . . . . . . . . . . a – Biomet, Musculoskeletal Transplant
Johnson Company, d – AMEDICA, Foundation
e – Zimmer, AMEDICA Benhaim, Prosper . . . . . . . . . . . . . . . . n
Baldini, Todd H . . . . . . . . . . . . . . . . . n Bennell, Kim . . . . . . . . . . . . . . . . . . . . n
Balg, Frederic. . . . . . . . . . . . . . . . . . . . n Bennett, Craig Howard . . . . . . . . . . . n
Balian, Gary. . . . . . . . . . . . . . . . . . . . . n Bennett, James B. . . . . . . . . . . . . . . . . a – Arthrex, Inc, b – SBI
Ball, Scott T . . . . . . . . . . . . . . . . . . . . . n Bennett, James Michael . . . . . . . . . . . a – Smith & Nephew
Ballmer, Peter . . . . . . . . . . . . . . . . . . . n Bennett, James T . . . . . . . . . . . . . . . . . n
Balthrop, Paul Matthew. . . . . . . . . . . n Bennett, William F . . . . . . . . . . . . . . . b – Genzyme, Encore, Zimmer, Tornier
Banco, Robert J . . . . . . . . . . . . . . . . . . d – Medtronic, e – DePuy, A Johnson & Benzel, Edward . . . . . . . . . . . . . . . . . . n
Johnson Company, Medtronic Sofamor Beppu, Moroe . . . . . . . . . . . . . . . . . . . n
Danek, Stryker, Impliant, Surgicraft Berberian, Wayne Sarkis. . . . . . . . . . . n
Band, Tim . . . . . . . . . . . . . . . . . . . . . . e – Smith & Nephew Bercik, Michael . . . . . . . . . . . . . . . . . . n
Bandel, Tiemo-Joerg. . . . . . . . . . . . . . e – Bayer Health Care AG Bercovy, Michel. . . . . . . . . . . . . . . . . . c – Biomet
Bandiera, Stefano . . . . . . . . . . . . . . . . n Berend, Keith R . . . . . . . . . . . . . . . . . . a, c, e – Biomet
Baque, Francois. . . . . . . . . . . . . . . . . . n Berend, Michael E. . . . . . . . . . . . . . . . a, b, c, e – Biomet, a – DePuy, A Johnson &
Barber, F Alan . . . . . . . . . . . . . . . . . . . a – Wright Medical Technology Johnson Company, Zimmer, Stryker
Barber, Thomas C . . . . . . . . . . . . . . . . b – Zimmer Berg, Per. . . . . . . . . . . . . . . . . . . . . . . . n
Barei, David. . . . . . . . . . . . . . . . . . . . . a – Synthes, Zimmer, b – AO, Smith & Berg, Robert. . . . . . . . . . . . . . . . . . . . . n
Nephew, Synthes, Zimmer Berger, Richard A . . . . . . . . . . . . . . . . c – Small Bone Innovations
Barg, Alexej . . . . . . . . . . . . . . . . . . . . . n Berger, Richard A . . . . . . . . . . . . . . . . a, b, c, e – Zimmer, a – Wright Medical
Barkan, Howard . . . . . . . . . . . . . . . . . n Technology, Inc., Smith & Nephew,
Barker, Joseph . . . . . . . . . . . . . . . . . . . n b – Biomet, e – TissueLink
Barnes, C Lowry . . . . . . . . . . . . . . . . . a, b, c, e – Stryker Orthopaedics, Wright Beris, Alexandros . . . . . . . . . . . . . . . . n
Medical, a – Johnson & Johnson, c – Biomet Berland, Kimberly A. . . . . . . . . . . . . . n

Bernasek, Thomas L . . . . . . . . . . . . . . a – DePuy Orthopaedics, c – DePuy Boese, Clifford K. . . . . . . . . . . . . . . . . a, e – DePuy
Orthopaedics Bogoch, Earl R. . . . . . . . . . . . . . . . . . . a, e – Procter & Gamble Pharmaceuticals,
Berry, Daniel J . . . . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson a – Merck Frosst Canada Inc., Novartis
Company, a – Smith & Nephew, Stryker, Pharmaceuticals Canada Inc., DePuy
Zimmer Orthopaedics Inc., A Johnson & Johnson
Bert, Jack M . . . . . . . . . . . . . . . . . . . . . e – Exactech, Inc Company, Wright Medical Technology
Bertani, Antoine . . . . . . . . . . . . . . . . . a – Zimmer Bohay, Donald R. . . . . . . . . . . . . . . . . b, e – Zimmer
Bertolusso, Roberto . . . . . . . . . . . . . . n Bohlman, Henry H. . . . . . . . . . . . . . . n
Berven, Sigurd H. . . . . . . . . . . . . . . . . a, b, e – Medtronic Sofamor Danek, Bohsali, Kamal I . . . . . . . . . . . . . . . . . n
b, e – DePuy, Stryker, b – Kyphon Boileau, Pascal . . . . . . . . . . . . . . . . . . c, e – Tornier, e – Mitek
Besjakov, Jack . . . . . . . . . . . . . . . . . . . n Boland, Michael R . . . . . . . . . . . . . . . a – Acumed
Best, Thomas M . . . . . . . . . . . . . . . . . n Boland, Patrick J . . . . . . . . . . . . . . . . . n
Betz, Randal R. . . . . . . . . . . . . . . . . . . a, b, c, e – DePuy Spine, Synthes, Bolling, William Seth. . . . . . . . . . . . . n
b, c, e – Medtronic, Spine Medica, Osteotech Bolognesi, Michael P . . . . . . . . . . . . . a, b, d, e – Orthosoft, a, b, e – DePuy,
Bevoni, Roberto . . . . . . . . . . . . . . . . . n A Johnson & Johnson Company, Zimmer,
Beykirch, Sarah . . . . . . . . . . . . . . . . . . a – Inova Health System d, e – Amedica
Bezwada, Hari. . . . . . . . . . . . . . . . . . . n Bonar, Fiona . . . . . . . . . . . . . . . . . . . . n
Bhan, Surya . . . . . . . . . . . . . . . . . . . . . n Bond, James L . . . . . . . . . . . . . . . . . . . n
Bhandari, Mohit . . . . . . . . . . . . . . . . . a – Canadian Institutes of Health Research Bondi, Aniello. . . . . . . . . . . . . . . . . . . n
(CIHR), Canadian Orthopedic Foundation Bone, Lawrence B . . . . . . . . . . . . . . . . e – Synthes
Bianchi, Guiseppe . . . . . . . . . . . . . . . n Bonnin, Michel. . . . . . . . . . . . . . . . . . c – Tornier
Bianchi, Loris . . . . . . . . . . . . . . . . . . . n Bono, Christopher M . . . . . . . . . . . . . a, b, e – DePuy Spine, Medtronic Sofamor
Biau, David Jean . . . . . . . . . . . . . . . . . n Danek, a – Synthes Spine, b, e – Stryker
Bibbo, Christopher. . . . . . . . . . . . . . . a – Biomimetic, e – Orthofix, Wright Spine, c, d, e – LifeSpine, e – Kyphon
Medical, Medtronic Bono, James V. . . . . . . . . . . . . . . . . . . c, e – Sectra, e – Stryker
Bicknell, Ryan T . . . . . . . . . . . . . . . . . n Bontempo, Nicholas . . . . . . . . . . . . . n
Biechteler, Andrea. . . . . . . . . . . . . . . . n Bonutti, Peter M . . . . . . . . . . . . . . . . . b, c, e – Stryker
Bielema, David J . . . . . . . . . . . . . . . . . n Bonvallet, Todd C. . . . . . . . . . . . . . . . n
Biemesch, Claire . . . . . . . . . . . . . . . . . n Boonen, Steven. . . . . . . . . . . . . . . . . . a – Amgen, Eli Lilly, Novartis, Pfizer, Procter
Biermann, Janet Sybil. . . . . . . . . . . . . n & Gamble, Sanofi-Aventis, and Roche
Biette, Gregory . . . . . . . . . . . . . . . . . . n GlaxoSmithKline, e – Amgen, Eli Lilly,
Bigliani, Louis U . . . . . . . . . . . . . . . . . n Merck, Novartis, Procter & Gamble, Sanofi-
Bignozzi, Simone . . . . . . . . . . . . . . . . n Aventis, and Servier
Bihari, Aurelia . . . . . . . . . . . . . . . . . . . n Boorman, Richard Stuart . . . . . . . . . . n
Bilgili, Mustafa Gokhan. . . . . . . . . . . n Booth Jr Robert E . . . . . . . . . . . . . . . . b, c, e – Zimmer
Billante, Mark J . . . . . . . . . . . . . . . . . . n Boraiah, Sreevathsa . . . . . . . . . . . . . . n
Biltoft, Emily C . . . . . . . . . . . . . . . . . . n Borg, Tomas . . . . . . . . . . . . . . . . . . . . n
Bin, Sung Woo . . . . . . . . . . . . . . . . . . n Boriani, Luca . . . . . . . . . . . . . . . . . . . . n
Binazzi, Roberto . . . . . . . . . . . . . . . . . e – Lima Borisova, Tatyana . . . . . . . . . . . . . . . . n
Birch, John G . . . . . . . . . . . . . . . . . . . c – Orthofix, Inc. Borkhuu, Battugs . . . . . . . . . . . . . . . . n
Biring, Gurdeep S . . . . . . . . . . . . . . . . n Born, Christopher T . . . . . . . . . . . . . . a – Foundation for Orthopaedic Trauma,
Birkedal, John P . . . . . . . . . . . . . . . . . n AO Foundation, b – Stryker, d – Illuminoss,
Birmingham, Trevor B . . . . . . . . . . . . a – Arthrex e – Stryker, Smith & Nephew, Illuminoss
Birnbaum, Mark A . . . . . . . . . . . . . . . n Borowski, Andrzej . . . . . . . . . . . . . . . n
Bishop, Allen T . . . . . . . . . . . . . . . . . . n Borrelli Jr Joseph. . . . . . . . . . . . . . . . . e – Medtronic, Wright
Bissell, Scott . . . . . . . . . . . . . . . . . . . . n Borris, Lars Carl . . . . . . . . . . . . . . . . . e – Bayer Health Care AG
Bito, Haruhiko . . . . . . . . . . . . . . . . . . n Bortier, Hilde. . . . . . . . . . . . . . . . . . . . n
Biyani, Ashok B. . . . . . . . . . . . . . . . . . e – DePuy Spine Boscainos, Petros J . . . . . . . . . . . . . . . n
Black, James C. . . . . . . . . . . . . . . . . . . n Boschin, Leonardo . . . . . . . . . . . . . . . n
Black, Molly D . . . . . . . . . . . . . . . . . . a – Stryker Orthopaedics Bosco III Joseph A . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Blaha, J David . . . . . . . . . . . . . . . . . . . a, c, d, e – Wright Medical Technology, Inc., Mitek, Smith & Nephew, Stryker, Synthes
a – Stryker, d – Abbott, Amgen Co, Bristol- Bosse, Michael J . . . . . . . . . . . . . . . . . a – AO, Synthes, Zimmer, e – KCI,
Myers Squibb, GlaxoSmithKline, Norvartis, Medtronic
Procter & Gamble, Roche, Sanofli, Teva Botto-van Bemden, Angie L. . . . . . . . n
Blaine, Theodore A . . . . . . . . . . . . . . . a – Zimmer, Pfizer, Sanofi-Aventis, Bouchard, Kimberely . . . . . . . . . . . . . n
b – Zimmer, Sanofi-Aventis, e – Zimmer Boucher, Henry Robert. . . . . . . . . . . . a – Zimmer, e – Aesculap/B.Braun
Blakemore, Laurel C. . . . . . . . . . . . . . b – Medtronic Bourne, Robert Barry . . . . . . . . . . . . . a – Johnson & Johnson, Smith & Nephew,
DISCLOSURE
Blasier, R Dale . . . . . . . . . . . . . . . . . . . a, b – Synthes Stryker, Zimmer, c, e – Smith & Nephew
Blazar, Philip E . . . . . . . . . . . . . . . . . . a – Biomet, DePuy, A Johnson & Johnson Bouvenot, Julien . . . . . . . . . . . . . . . . . n
Company, Wright Medical Technology, Inc. Bowen, Ashlea. . . . . . . . . . . . . . . . . . . e – Corin
Blood, Emily . . . . . . . . . . . . . . . . . . . . n Bowen, J Richard . . . . . . . . . . . . . . . . n
Bloom, Tamir . . . . . . . . . . . . . . . . . . . a – Rady Childrens Hospital Orthopedic Bowers, Andrea Legath. . . . . . . . . . . . n
Research and Education Fund Boyd, Joel L . . . . . . . . . . . . . . . . . . . . . e – Zimmer, e – RTI
Blum, Yossef C . . . . . . . . . . . . . . . . . . n Boyer, Martin I . . . . . . . . . . . . . . . . . . b, d, e – OrthoHelix Inc., b – Pfizer, Synthes
Blunn, Gordon W. . . . . . . . . . . . . . . . n USA, d, e – MiMedX Inc.
Boachie-Adjei, Oheneba . . . . . . . . . . b, c, d, e – K2Medical, b, e – DePuy, A Boyer, Patrick J . . . . . . . . . . . . . . . . . . n
Johnson & Johnson Company, Osteotech Bozic, Kevin John . . . . . . . . . . . . . . . . a, b – Zimmer, b – Wright Medical
Boardman III Norman Douglas . . . . a – Biomet, Acumed, LLC, DePuy, Technology, Inc.
A Johnson & Johnson Company, Bradbury Jr Thomas L . . . . . . . . . . . . a – DePuy
b – Biomet, DePuy, A Johnson & Johnson Bradford, David S . . . . . . . . . . . . . . . . e – United Health care
Company, GlaxoSmithKline, Merck, Bradley, Gary Worthington . . . . . . . . e – PLUS Orthopedics
e – DePuy, A Johnson & Johnson Company Bradley, James P . . . . . . . . . . . . . . . . . a, c, d, e – Arthrex, Inc.
Boateng, Henry A . . . . . . . . . . . . . . . . n Bradley, Timothy . . . . . . . . . . . . . . . . n
Bocquet, Donatien . . . . . . . . . . . . . . . n Braeutigam, Heike . . . . . . . . . . . . . . . n
Boden, Scott D . . . . . . . . . . . . . . . . . . a, b, c, e – Medtronic Sofamor Danek, Brandalise, Silvia R . . . . . . . . . . . . . . . n
a – Synthes, National Institutes of Health Brandt, Jan Mels B . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company
(NIAMS & NICHD), Linvatec, Johnson & Branfoot, Toby . . . . . . . . . . . . . . . . . . n
Johnson, DePuy, A Johnson & Johnson Branson, Jill. . . . . . . . . . . . . . . . . . . . . n
Company, Abbott, b, c – Osteotech Branstetter, Joanna . . . . . . . . . . . . . . . b – Smith & Nephew
Bodenstab, Alex B. . . . . . . . . . . . . . . . n Brassart, Nicholas . . . . . . . . . . . . . . . . n
Boehm, Cynthia A . . . . . . . . . . . . . . . n Bratcher, Kelly R . . . . . . . . . . . . . . . . . n
Boehm, Stephanie . . . . . . . . . . . . . . . n Brauer, Carmen. . . . . . . . . . . . . . . . . . n

Bray, Timothy James. . . . . . . . . . . . . . n Bynum Jr Donald K . . . . . . . . . . . . . . n
Brazil, Declan . . . . . . . . . . . . . . . . . . . a – GOT Byrd, J W Thomas. . . . . . . . . . . . . . . . a, e – Smith & Nephew
Breen, Christopher M. . . . . . . . . . . . . n Cabrita, Henrique Berwanger . . . . . . n
Breidenbach, Warren C . . . . . . . . . . . n Cadossi, Matteo . . . . . . . . . . . . . . . . . a – Smith & Nephew
Breitbart, Eric . . . . . . . . . . . . . . . . . . . n Caesar, Benjamin C . . . . . . . . . . . . . . n
Breivis, James S . . . . . . . . . . . . . . . . . . e – Lewin Cain, Jr, E Lyle. . . . . . . . . . . . . . . . . . . n
Brennan, L. . . . . . . . . . . . . . . . . . . . . . n Caldwell III Paul E . . . . . . . . . . . . . . . a – Arthex, DePuy Mitek, Arthrocare
Brennan, Sarah . . . . . . . . . . . . . . . . . . n Callaci, John . . . . . . . . . . . . . . . . . . . . n
Brenner, Eric . . . . . . . . . . . . . . . . . . . . a – NIH Grant, Stryker Callaghan, John J . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Brenner, Mark E . . . . . . . . . . . . . . . . . a, b – Accuray Company, a – Smith & Nephew, EBI,
Brezis, Mayer . . . . . . . . . . . . . . . . . . . . n Arthrex, Inc, b – Zimmer
Bridwell, Keith H . . . . . . . . . . . . . . . . a, e – Medtronic Sofamor Danek, e – DePuy, Caltoum, Christine B . . . . . . . . . . . . . a – DePuy Spine
A Johnson & Johnson Company Calvert, George . . . . . . . . . . . . . . . . . . a – Biomet, Pfizer
Briem, Kristin . . . . . . . . . . . . . . . . . . . n Camargo, Olavo Pires . . . . . . . . . . . . n
Briggs, Karen K . . . . . . . . . . . . . . . . . . a – Smith & Nephew, Ossur, Genzyme, Campanacci, Laura. . . . . . . . . . . . . . . n
e – IBalance, Regen Biologics Campbell, Barbara Jean . . . . . . . . . . . n
Briggs, Tim. . . . . . . . . . . . . . . . . . . . . . n Campbell, David Neil . . . . . . . . . . . . n
Brink, Ole . . . . . . . . . . . . . . . . . . . . . . a – Inion Campbell, Mitchell J . . . . . . . . . . . . . a, c, e – Medtronic Sofamor Danek
Brislin, Brian . . . . . . . . . . . . . . . . . . . . n Campbell, Patricia A . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Britten, Simon. . . . . . . . . . . . . . . . . . . n Smith & Nephew, Wright Medical
Brock, Dylan C . . . . . . . . . . . . . . . . . . n Technology, Inc.
Brockmeier, Stephen . . . . . . . . . . . . . n Campbell Jr Robert Murray . . . . . . . . b, c – Synthes
Brodersen, Mark Preston . . . . . . . . . . n Canale, S Terry . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Brodke, Darrel S . . . . . . . . . . . . . . . . . e – Amedica, DePuy EBI, Medtronic Sofamor Danek, Smith &
Bronstein, Robert D . . . . . . . . . . . . . . n Nephew, Synthes, Wright Medical
Brooks, Adam . . . . . . . . . . . . . . . . . . . n Technology, Inc., Zimmer, e – Benchmark
Brooks, Adam . . . . . . . . . . . . . . . . . . . n Athletic Shoes
Brooks, Adam . . . . . . . . . . . . . . . . . . . n Canbridge, John . . . . . . . . . . . . . . . . . d – Ceremed, Inc.
Brooks, Darlene . . . . . . . . . . . . . . . . . n Cannada, Lisa K . . . . . . . . . . . . . . . . . a – Zimmer, Wyeth, b, e – Medtronic
Brophy, Robert . . . . . . . . . . . . . . . . . . a – Orteq, Ltd. Sofamor Danek, b – Smith & Nephew,
Brown, Barrett S . . . . . . . . . . . . . . . . . d – GE Healthcare, Pfizer, Procter & Gamble Stryker
Brown, Gabriel D . . . . . . . . . . . . . . . . n Cannon, David L . . . . . . . . . . . . . . . . n
Brown, Gregory Alexander . . . . . . . . n Cannon, Stephen R . . . . . . . . . . . . . . n
Brown, Stephen L . . . . . . . . . . . . . . . . n Cannon, Steven . . . . . . . . . . . . . . . . . n
Brown, Thomas D . . . . . . . . . . . . . . . a – NIH Cannon-Albright, Lisa . . . . . . . . . . . . n
Browne, James Andrew . . . . . . . . . . . n Capo, John T. . . . . . . . . . . . . . . . . . . . a, c, e – Wright Medical Technology, Inc.,
Browne, Jon E . . . . . . . . . . . . . . . . . . . e – Genzyme a – Synthes, b – Stryker
Browne, Richard H . . . . . . . . . . . . . . . n Capponcelli, Silvia . . . . . . . . . . . . . . . n
Brownhill, James . . . . . . . . . . . . . . . . n Caputo, Andrew E . . . . . . . . . . . . . . . n
Brox, William Timothy . . . . . . . . . . . n Carandang, Gerard . . . . . . . . . . . . . . . a – Synthes Spine
Brubaker, Scott A . . . . . . . . . . . . . . . . e – American Association of Tissue Banks Caraway, Megan L. . . . . . . . . . . . . . . . a – Sanofi Aventis, Genzyme
Brubaker, Shawn. . . . . . . . . . . . . . . . . n Cardoz, Hiran . . . . . . . . . . . . . . . . . . . n
Bruce, Robert W . . . . . . . . . . . . . . . . . a – Medtronic Carlisle, John. . . . . . . . . . . . . . . . . . . . n
Brucker, Peter . . . . . . . . . . . . . . . . . . . n Carlston, Cory V . . . . . . . . . . . . . . . . . n
Bruinsma, David R . . . . . . . . . . . . . . . n Carney, Brian T . . . . . . . . . . . . . . . . . . n
Brunson, Matt . . . . . . . . . . . . . . . . . . . n Carney, Joseph R. . . . . . . . . . . . . . . . . a – Synthes USA, Arthrex
Bryant, Dianne . . . . . . . . . . . . . . . . . . n Carolan, Gregory F . . . . . . . . . . . . . . . n
Bryk, Eli . . . . . . . . . . . . . . . . . . . . . . . . n Caron, Christine . . . . . . . . . . . . . . . . . n
Bryne, C . . . . . . . . . . . . . . . . . . . . . . . . n Caron, Jason Joseph . . . . . . . . . . . . . . n
Buch, Barbara . . . . . . . . . . . . . . . . . . . n Carr, Andrew J. . . . . . . . . . . . . . . . . . . n
Buchko, Greg . . . . . . . . . . . . . . . . . . . a – Breg Carr, Diana D . . . . . . . . . . . . . . . . . . . n
Buchner, Matthias. . . . . . . . . . . . . . . . n Carragee, Eugene . . . . . . . . . . . . . . . . a – US Army, Synthes, DePuy, d – Simpiria
Buckler, Michael C . . . . . . . . . . . . . . . n Spine, e – Orthokinematics
Buckley, Christine A . . . . . . . . . . . . . . n Carreon, Leah Yacat . . . . . . . . . . . . . . n
Buckley, Richard E . . . . . . . . . . . . . . . a – Synthes Carroll, Michael E. . . . . . . . . . . . . . . . e – Wright Medical Technology, Inc.
Buda, Roberto . . . . . . . . . . . . . . . . . . . n Carson, Eric Ward. . . . . . . . . . . . . . . . n
Buddu, Reddi . . . . . . . . . . . . . . . . . . . n Carter, Cordelia Wheeler . . . . . . . . . . n
DISCLOSURE
Buehler, Knute C. . . . . . . . . . . . . . . . . a – MCI Cartner, Jacob . . . . . . . . . . . . . . . . . . . e – Smith & Nephew

Buford, William L. . . . . . . . . . . . . . . . n Carvalho, Fabio Veiga . . . . . . . . . . . . n
Buijze, Geert . . . . . . . . . . . . . . . . . . . . n Cascio, Brett . . . . . . . . . . . . . . . . . . . . d, e – Cartilix, Inc
Bukczynski, Jacob. . . . . . . . . . . . . . . . n Casey, David . . . . . . . . . . . . . . . . . . . . n
Bull, Jenni . . . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew Cason, Garrick Wayne . . . . . . . . . . . . n
Burghardt, Rolf D . . . . . . . . . . . . . . . . n Cass, Joseph Ralph . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Burgoyne, Chadler . . . . . . . . . . . . . . . n Stryker, Zimmer, d – K2M
Burgueno, Jorge E . . . . . . . . . . . . . . . . n Cassinelli, Ezequiel . . . . . . . . . . . . . . n
Burke, Dennis W. . . . . . . . . . . . . . . . . n Castelli, Jennifer . . . . . . . . . . . . . . . . . n
Burke, Peter . . . . . . . . . . . . . . . . . . . . . n Castilleja, Amanda . . . . . . . . . . . . . . . n
Burkett, Benjamin. . . . . . . . . . . . . . . . a – Stryker, Zimmer Castillo, Renan C . . . . . . . . . . . . . . . . n
Burkhart, Stephen S . . . . . . . . . . . . . . b, c, e – Arthrex, Inc Castoldi, Filippo. . . . . . . . . . . . . . . . . n
Burkhead Jr Wayne Z . . . . . . . . . . . . . a – Mitek, b, c, e – Tornier, b, c – Wright Castro-Aragon, Oscar . . . . . . . . . . . . . n
Medical Technology, Inc., c – Linvatec Castropil, Wagner . . . . . . . . . . . . . . . . n
Burks, Robert T . . . . . . . . . . . . . . . . . . a – Stryker, b – Mitek, c – Arthrex, Inc Catani, Fabio. . . . . . . . . . . . . . . . . . . . c – Finsbury
Burkus, J Kenneth . . . . . . . . . . . . . . . . a, b, e – Medtronic Sofamor Danek Cates Jr Harold E . . . . . . . . . . . . . . . . a – Zimmer
Burnett, Robert Stephen. . . . . . . . . . . a – Smith & Nephew Catonne, Yves . . . . . . . . . . . . . . . . . . . n
Burns, Erica M. . . . . . . . . . . . . . . . . . . n Cauthen, Joseph C . . . . . . . . . . . . . . . n
Burns, Joseph P. . . . . . . . . . . . . . . . . . n Cervinka, Tony . . . . . . . . . . . . . . . . . . n
Busconi, Brian. . . . . . . . . . . . . . . . . . . e – DePuy Cerynik, Doug. . . . . . . . . . . . . . . . . . . n
Busey, Terri . . . . . . . . . . . . . . . . . . . . . a – Sanofi Aventis, Genzyme Chafik, Dara . . . . . . . . . . . . . . . . . . . . n
Bushnell, Brandon D . . . . . . . . . . . . . n Chalmers, Peter. . . . . . . . . . . . . . . . . . n
Butler, Joseph S . . . . . . . . . . . . . . . . . . n Chaminade, Bruno. . . . . . . . . . . . . . . n
Butt, David . . . . . . . . . . . . . . . . . . . . . n Chan, Denise S . . . . . . . . . . . . . . . . . . n
Buttaro, Martin . . . . . . . . . . . . . . . . . . n Chan, Jacqueline . . . . . . . . . . . . . . . . a – NIH

Chana, Gursharan . . . . . . . . . . . . . . . n Ciccone II William J . . . . . . . . . . . . . . a – Storz, Sanofi Aventis, Genzyme,
Chana Rodriguez, Francisco . . . . . . . n b – Mitek
Chang, Bong-Soon . . . . . . . . . . . . . . . n Ciccotti, Michael G. . . . . . . . . . . . . . . a, b, e – Stryker, b, e – Genzyme,
Chang, Charles . . . . . . . . . . . . . . . . . . n Regeneration Technologies, Inc.
Chang, Chong Bum . . . . . . . . . . . . . . a – Smith & Nephew Ciccotti, Michael C . . . . . . . . . . . . . . . n
Chang, Paul. . . . . . . . . . . . . . . . . . . . . n Cil, Akin . . . . . . . . . . . . . . . . . . . . . . . n
Chang, Seong-Sil . . . . . . . . . . . . . . . . a – Stryker Howmedica Cillo, Yolanda A . . . . . . . . . . . . . . . . . e – Medtronic
Chang, Tai-Li. . . . . . . . . . . . . . . . . . . . d – Merck Ciobanu, Eugene . . . . . . . . . . . . . . . . n
Chapman, Jens R . . . . . . . . . . . . . . . . a, b, e – AO, Stryker, Synthes, Ciotti, Mauro . . . . . . . . . . . . . . . . . . . n
a, b – Medtronic Sofamor Danek, Cipriano, Cara A. . . . . . . . . . . . . . . . . n
a, e – DePuy, A Johnson & Johnson Company Citak, Musa . . . . . . . . . . . . . . . . . . . . . n
Chaput, Christopher D . . . . . . . . . . . n Clanton, Thomas O . . . . . . . . . . . . . . a, b, e – Arthrex, Inc, a, e – Link
Charles, Gina . . . . . . . . . . . . . . . . . . . n Orthopaedics, a – Biomet, Stryker, Zimmer,
Charron, Kory . . . . . . . . . . . . . . . . . . . n Pharmacia Corporation, National Institutes
Chatzisymeon, Apostolos Simeon . . n of Health (NIH), b, e – Wright Medical
Chau, R . . . . . . . . . . . . . . . . . . . . . . . . a – Biomet Technology, Inc.
Chen, Andrew L . . . . . . . . . . . . . . . . . a – Smith & Nephew, Genzyme, EBI Clark, Christopher C . . . . . . . . . . . . . n
Chen, Chih-Yu . . . . . . . . . . . . . . . . . . n Clark, Christopher . . . . . . . . . . . . . . . n
Chen, CT Christopher . . . . . . . . . . . . n Clarke, Henry D . . . . . . . . . . . . . . . . . a – Stryker, b – DePuy, A Johnson &
Chen, Hsiang-Ho . . . . . . . . . . . . . . . . n Johnson Company, Zimmer, Stryker,
Chen, Lei . . . . . . . . . . . . . . . . . . . . . . . n e – Zimmer, DePuy, A Johnson & Johnson
Chen, Peter C . . . . . . . . . . . . . . . . . . . n Company
Chen, Po Quang . . . . . . . . . . . . . . . . . n Clarke, Ian C . . . . . . . . . . . . . . . . . . . . n
Chen, Ryan . . . . . . . . . . . . . . . . . . . . . n Clatworthy, Mark . . . . . . . . . . . . . . . . a, e – DePuy
Chen, Tina. . . . . . . . . . . . . . . . . . . . . . n Clayton, Robert Anthony Emilius. . . n
Chen, Tong Yi . . . . . . . . . . . . . . . . . . . a – National Natural Science Foundation of Clements III David H. . . . . . . . . . . . . a, c, e – DePuy Spine
People's Republic of China Clifford, Paul D . . . . . . . . . . . . . . . . . n
Chen, Xinqian. . . . . . . . . . . . . . . . . . . n Clinton, Jeremiah . . . . . . . . . . . . . . . . n
Chen, Zhong Wei . . . . . . . . . . . . . . . . a – National Natural Science Foundation of Clohisy, Denis R . . . . . . . . . . . . . . . . . n
People's Republic of China Clohisy, John C. . . . . . . . . . . . . . . . . . a, b, e – Zimmer, a – Wright Medical
Cheney, Robert Alan. . . . . . . . . . . . . . n Technology, Inc., b – Smith & Nephew
Cheng, Joseph S . . . . . . . . . . . . . . . . . n Clovis, Nina B . . . . . . . . . . . . . . . . . . . a – Orthopaedic Trauma Association,
Cheng, Richard . . . . . . . . . . . . . . . . . . n Orthopaedic Research and Education
Chepalli, Reddy . . . . . . . . . . . . . . . . . n Foundation
Chertoff, Jason L. . . . . . . . . . . . . . . . . n Clyburn, Terry A . . . . . . . . . . . . . . . . . b – Biomet, Encore
Chess, David Gordon. . . . . . . . . . . . . a – Zimmer Coathup, Melanie. . . . . . . . . . . . . . . . n
Chester, Rachel . . . . . . . . . . . . . . . . . . n Cobb, Tyson K . . . . . . . . . . . . . . . . . . n
Chetty, Yudash . . . . . . . . . . . . . . . . . . n Cobelli, Neil . . . . . . . . . . . . . . . . . . . . n
Cheung, Sunny . . . . . . . . . . . . . . . . . . n Cockrell, Jacqueline . . . . . . . . . . . . . . a – Stryker Howmedica, Synthes
Cheung, Therma WC . . . . . . . . . . . . . n Codsi, Michael J . . . . . . . . . . . . . . . . . a – NIH
Chevalier, Xavier . . . . . . . . . . . . . . . . . a – Genzyme Coetzee, J Chris. . . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Chevillotte, Christophe J . . . . . . . . . . n Company, a – Zimmer, b, c – Arthrex, Inc,
Chhabra, Abhinav Bobby . . . . . . . . . n e – Nexa Orthopaedics
Chiang, Chien-chung. . . . . . . . . . . . . n Cofer, Barry R . . . . . . . . . . . . . . . . . . . n
Chiarello, E . . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew Coffin, Cheryl . . . . . . . . . . . . . . . . . . . n
Chiba, Ko . . . . . . . . . . . . . . . . . . . . . . n Cofield, Robert H . . . . . . . . . . . . . . . . c – Smith & Nephew
Chidambaram, Ramiah . . . . . . . . . . . n Cohen, Russell Glen. . . . . . . . . . . . . . a, b, c, e – Zimmer
Childress, Lorenzo . . . . . . . . . . . . . . . n Cohen, Steven B . . . . . . . . . . . . . . . . . n
Chillemi, Claudio. . . . . . . . . . . . . . . . n Colangeli, Marco . . . . . . . . . . . . . . . . n
Chiodo, Christopher P. . . . . . . . . . . . a – DePuy, Biomet, a, c – DJ ORtho, Colangeli, Simone . . . . . . . . . . . . . . . n
e – Zimmer, c – Arthrex Cole, Brian J . . . . . . . . . . . . . . . . . . . . a, c, e – Arthrex, Inc, a, b, e – Genzyme,
Chirumamilla, Vasu . . . . . . . . . . . . . . n a, e – Zimmer
Chiu, Mark Hsien Nien . . . . . . . . . . . n Coleman, Cardella . . . . . . . . . . . . . . . a, b – Accuray
Cho, Byoung-ki. . . . . . . . . . . . . . . . . . n Coleman-Wood, Krista . . . . . . . . . . . n
Cho, Byoung-ki. . . . . . . . . . . . . . . . . . n Colford, John . . . . . . . . . . . . . . . . . . . n
Cho, Chul-Hyun. . . . . . . . . . . . . . . . . n Collier, John P. . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Cho, Kyu Jung. . . . . . . . . . . . . . . . . . . n Zimmer, d – Stryker, e – DePuy, A Johnson
DISCLOSURE
Cho, Robert Hyun . . . . . . . . . . . . . . . n & Johnson Company
Cho, Samuel Kang-Wook . . . . . . . . . a – Stryker Howmedica Collinge, Cory Alan . . . . . . . . . . . . . . b – Stryker, c, e – Smith & Nephew
Cho, Sang Gwon . . . . . . . . . . . . . . . . n c – Biomet
Cho, Seong-Beom . . . . . . . . . . . . . . . n Collins, David N. . . . . . . . . . . . . . . . . e – DePuy, A Johnson & Johnson Company
Cho, Woojin . . . . . . . . . . . . . . . . . . . . n Colombet, Philippe . . . . . . . . . . . . . . a, b, e – Smith & Nephew, b – Smith &
Cho, Yong Jin . . . . . . . . . . . . . . . . . . . n Nephew, c – PRAXIM Grenoble France
Cho, Young-Jin . . . . . . . . . . . . . . . . . . n Colombier, Jean-Alain . . . . . . . . . . . . c – Tornier
Choi, Gene . . . . . . . . . . . . . . . . . . . . . n Colon-Emeric, Cathleen . . . . . . . . . . a – Novartis, a – The Alliance for Better
Choi, Min-Sun . . . . . . . . . . . . . . . . . . n Bone Health, e – Novartis
Choi, Paul . . . . . . . . . . . . . . . . . . . . . . n Colton, Anne E . . . . . . . . . . . . . . . . . . n
Choi, Yoowang . . . . . . . . . . . . . . . . . . n Colwell Jr Clifford W . . . . . . . . . . . . . a – The Knee Society, MCI
Chow, Bettina Ann . . . . . . . . . . . . . . . n Comba, Fernando Martin . . . . . . . . . n
Christensen, Christian P . . . . . . . . . . a, b, e – Biomet, a – Smith & Nephew Combes, Antoine . . . . . . . . . . . . . . . . n
Christie, Michael J . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson Componovo, Roger M . . . . . . . . . . . . n
Company, c – Zimmer, d – Exactech, Inc Compson, Jonathan Paul . . . . . . . . . n
Chryssikos, Timothy. . . . . . . . . . . . . . n Conca, Marco . . . . . . . . . . . . . . . . . . . n
Chu, Constance R. . . . . . . . . . . . . . . . n Conditt, Michael A . . . . . . . . . . . . . . . n
Chuinard, Christopher. . . . . . . . . . . . n Connor, Patrick Michael . . . . . . . . . . c, e – Arthrotek, e – Zimmer
Chung, Byung June . . . . . . . . . . . . . . n Conrad III Ernest U . . . . . . . . . . . . . . a – Stryker Howmedica, Zimmer
Chung, Christine . . . . . . . . . . . . . . . . n Conteduca, Fabio . . . . . . . . . . . . . . . . n
Chung, Jae Yoon . . . . . . . . . . . . . . . . . n Contereas, Juan Salvador. . . . . . . . . . n
Chung, May. . . . . . . . . . . . . . . . . . . . . n Conway, Janet Donohue . . . . . . . . . . c – Quantum Medical Concepts, e – Smith
Church, Chris . . . . . . . . . . . . . . . . . . . n & Nephew
Ciampi, Pietro. . . . . . . . . . . . . . . . . . . n Conway, John E . . . . . . . . . . . . . . . . . n
Cook, Chad. . . . . . . . . . . . . . . . . . . . . n

Cook, Stephen D . . . . . . . . . . . . . . . . a,e – Biomet David, Lee . . . . . . . . . . . . . . . . . . . . . . n
Coolican, Myles Raphael . . . . . . . . . . a – Biomet, EBI, Genzyme, Smith & Davids, Jon R . . . . . . . . . . . . . . . . . . . n
Nephew, Stryker, Zimmer Davidson, Darin . . . . . . . . . . . . . . . . . a, b – Synthes, Zimmer
Coon, Thomas M . . . . . . . . . . . . . . . . b, c, d, e – Zimmer, c, e – Innovative Davidson, Helen M . . . . . . . . . . . . . . n
Medical Products, c – NEmco Medical, Davies, Malcolm J. . . . . . . . . . . . . . . . n
e – MAKO surgical Davies, Michael. . . . . . . . . . . . . . . . . . n
Cooney, A . . . . . . . . . . . . . . . . . . . . . . n Davis, Benjamin . . . . . . . . . . . . . . . . . n
Cooper, Andrew J . . . . . . . . . . . . . . . . n Davis, Edward T . . . . . . . . . . . . . . . . . n
Cooper, Daniel E . . . . . . . . . . . . . . . . c – Linvatec, e – Stryker Davis, JT. . . . . . . . . . . . . . . . . . . . . . . . n
Cooper, Lane J. . . . . . . . . . . . . . . . . . . n Davis, Mark . . . . . . . . . . . . . . . . . . . . . n
Copay, Anne G . . . . . . . . . . . . . . . . . . b – Medtronic Sofamor Danek Dawson-Bowling, Sebastian . . . . . . . n
Copeland, Carol E . . . . . . . . . . . . . . . a – Synthes, Stryker, Smith & Nephew, Day, Charles S . . . . . . . . . . . . . . . . . . . a, b – Small Bone Innovations, Wright
Wyeth Medical Technologies, c – AM surgical
Copeland, Stephen A . . . . . . . . . . . . . n De Boer, Peter . . . . . . . . . . . . . . . . . . . e – AO Foundation
Cordasco, Frank A . . . . . . . . . . . . . . . n De Chiara, Raffaele. . . . . . . . . . . . . . . n
Coric, Domagoj . . . . . . . . . . . . . . . . . n de Haan, R. . . . . . . . . . . . . . . . . . . . . . b – Wright Medical
Cormicam, Martin . . . . . . . . . . . . . . . n De Jager, Caroline. . . . . . . . . . . . . . . . n
Cornelius, Jonathan P . . . . . . . . . . . . n De la Fuente, Elena. . . . . . . . . . . . . . . n
Cornett, M B . . . . . . . . . . . . . . . . . . . . n De La Torre, Basilio . . . . . . . . . . . . . . n
Corrales, Luis . . . . . . . . . . . . . . . . . . . a – Doris Duke Clinical Research Fellowship De Palma, Luigi . . . . . . . . . . . . . . . . . n
Costa, Matthew L . . . . . . . . . . . . . . . . a – Wright Medical Technology, Inc., Corin De Peretti, Frederic . . . . . . . . . . . . . . . n
U.S.A. De Smet, Koen Aime . . . . . . . . . . . . . a – Biomet, DePuy, Stryker, Smith &
Costantini, Julian . . . . . . . . . . . . . . . . n Nephew, Wright Medical Zimmer, b – Smith
Costa-Paz, Matias . . . . . . . . . . . . . . . . n & Nephew, Wright Medical, c – Wright
Costic, Ryan . . . . . . . . . . . . . . . . . . . . n Medical, e – Smith & Nephew, Wright
Cottam, Howard. . . . . . . . . . . . . . . . . n Medical
Cottrell, Jocelyn . . . . . . . . . . . . . . . . . a – Orteq, Ltd. De Steiger, Richard . . . . . . . . . . . . . . . a – Medical Research Foundation for
Courpied, Jean-Pierre. . . . . . . . . . . . . n Women and Babies
Court-Brown, Charles M . . . . . . . . . . n DeAngelis, Joseph. . . . . . . . . . . . . . . . n
Courville, Xan . . . . . . . . . . . . . . . . . . . n Debnath, Ujjwal . . . . . . . . . . . . . . . . . e – SpR, Nevill Hall Hospital, Abergavenny
Coutinho, Etevaldo . . . . . . . . . . . . . . n DeBoer, David Kent . . . . . . . . . . . . . . n
Covey, Dana C . . . . . . . . . . . . . . . . . . n DeBruhl, Kathleen L. . . . . . . . . . . . . . n
Cowan, James . . . . . . . . . . . . . . . . . . . n DeCarli, Angelo . . . . . . . . . . . . . . . . . n
Cowie, Andy . . . . . . . . . . . . . . . . . . . . n Dedhia, Sunil . . . . . . . . . . . . . . . . . . . d – Pfizer
Craig, Edward V . . . . . . . . . . . . . . . . . e – Biomet Dee, Debra O . . . . . . . . . . . . . . . . . . . a – DePuy, Zimmer, Smith & Nephew
Crawford, Alvin Howell. . . . . . . . . . . a, c, e – DePuy, A Johnson & Johnson DeFrate, Louis E . . . . . . . . . . . . . . . . . n
Company DeHaven, Kenneth E . . . . . . . . . . . . . n
Crawford, Eileen A . . . . . . . . . . . . . . . a – Stryker Howmedica Del Gaizo, Daniel. . . . . . . . . . . . . . . . n
Creighton, Robert Alexander. . . . . . . n Del Piccolo, Nicolandrea. . . . . . . . . . n
Crepeau, Allison . . . . . . . . . . . . . . . . . n Delamarter, Rick B . . . . . . . . . . . . . . . a – Abbott, Medtronic, Stryker, Synthes,
Crim, Julia . . . . . . . . . . . . . . . . . . . . . . n Zimmer, c – Stryker, Synthes, Zimmer,
Crisco, Joseph . . . . . . . . . . . . . . . . . . . a – Praxim e – Zimmer, Synthes
Crist, Martha . . . . . . . . . . . . . . . . . . . . n Deland, Jonathan T . . . . . . . . . . . . . . n
Croci, Alberto Tesconi . . . . . . . . . . . . n Delanois, Ronald Emilio . . . . . . . . . . a – Stryker, Wright Medical Technology, Inc.
Crofoot, Carmen . . . . . . . . . . . . . . . . n DeLaTorre, Katrina . . . . . . . . . . . . . . . n
Cronen, Geoffrey A . . . . . . . . . . . . . . n Delialioglu, Onder M. . . . . . . . . . . . . n
Crook, Julia . . . . . . . . . . . . . . . . . . . . . n Dell, Richard M. . . . . . . . . . . . . . . . . . n
Crowninshield, Roy D . . . . . . . . . . . . c – Zimmer Della Valle, Craig J . . . . . . . . . . . . . . . a, b, e – Zimmer, b – Stryker, Smith &
Cuckler, John M . . . . . . . . . . . . . . . . . b, c, e – Biomet Nephew, Ortho Biotech
Cui, Quanjun . . . . . . . . . . . . . . . . . . . a – Smith & Nephew DeMarco, James Robert . . . . . . . . . . . n
Cullen, Aaron B . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Denaro, Vicenzo . . . . . . . . . . . . . . . . . n
Stryker Denda, Hiroshi . . . . . . . . . . . . . . . . . . n
Cummings Jr Robert Jay. . . . . . . . . . . a – Nemours Foundation Deneno, Bianca . . . . . . . . . . . . . . . . . n
Cuomo, Frances . . . . . . . . . . . . . . . . . n Deng, Wen You . . . . . . . . . . . . . . . . . . n
Currey, Thomas W . . . . . . . . . . . . . . . n Deng, Xiang-Hua . . . . . . . . . . . . . . . . a – Orteq, Ltd.
Currier, Barbara H . . . . . . . . . . . . . . . a – DePuy, Zimmer Denneen, John . . . . . . . . . . . . . . . . . . n
Currier, John H . . . . . . . . . . . . . . . . . . a – DePuy, Zimmer Dennis, Douglas A . . . . . . . . . . . . . . . a, b c, e – DePuy, A Johnson & Johnson
DISCLOSURE
Curtis, Alan S . . . . . . . . . . . . . . . . . . . b, c – Arthrex, Donjoy, Stryker Howmedica Company, a, b – Zimmer

Curtis, M J . . . . . . . . . . . . . . . . . . . . . . n Dennison, Michael. . . . . . . . . . . . . . . n
Czerwein, John K . . . . . . . . . . . . . . . . n Derham, D . . . . . . . . . . . . . . . . . . . . . n
Dabney, Kirk W. . . . . . . . . . . . . . . . . . n DeRosa, G Paul . . . . . . . . . . . . . . . . . . n
Daglar, Bulent . . . . . . . . . . . . . . . . . . . n Desai, Shaunak S . . . . . . . . . . . . . . . . n
Dahl, Brian . . . . . . . . . . . . . . . . . . . . . n Deschamps, Gerard . . . . . . . . . . . . . . n
Dahm, Diane Lynn. . . . . . . . . . . . . . . n DeSmet, Koen Aime. . . . . . . . . . . . . . a, c – Wright Medical Technology, Inc.,
Dahners, Laurence E. . . . . . . . . . . . . . n e – Wright Medical Technology, Inc., Finsbury
Dainty, Katie . . . . . . . . . . . . . . . . . . . . n Dethmers, Daniel A . . . . . . . . . . . . . . e – Stryker Howmedica
Dajani, Khlaed . . . . . . . . . . . . . . . . . . n Detrisac, David Arthur . . . . . . . . . . . . n
Dakhakhn, Hatem E . . . . . . . . . . . . . a – Zimmer Dettoni, Federico . . . . . . . . . . . . . . . . n
Dalen, Tore . . . . . . . . . . . . . . . . . . . . . n Deutsch, Allen A . . . . . . . . . . . . . . . . . a – Arthrex
D’Alessandro, Donald F. . . . . . . . . . . e – Biomet Sports Medicine Dev, Parvati . . . . . . . . . . . . . . . . . . . . . n
Dallari, Dante . . . . . . . . . . . . . . . . . . . n Devendra, A . . . . . . . . . . . . . . . . . . . . n
Dalury, David F. . . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson Devers, Brandon N . . . . . . . . . . . . . . . n
Company Devitt, Aiden. . . . . . . . . . . . . . . . . . . . n
Daniel, Joseph . . . . . . . . . . . . . . . . . . a, b, e – Smith & Nephew Dhar, Sunil . . . . . . . . . . . . . . . . . . . . . n
Daniels, Stephen. . . . . . . . . . . . . . . . . n Dheenadhayalan, Jayarama Raju . . . n
D’Antonio, James A . . . . . . . . . . . . . . a, b, c, e – Stryker Dhert, W.JA.. . . . . . . . . . . . . . . . . . . . . n
Dantuluri, Phani K . . . . . . . . . . . . . . . n Di Caprio, Francesco . . . . . . . . . . . . . n
Dapuzzo, Michele R. . . . . . . . . . . . . . n Di Cesare, Paul E . . . . . . . . . . . . . . . . a, e – Stryker
Darabos, Nikica . . . . . . . . . . . . . . . . . n Di Gennaro, Gianluigi . . . . . . . . . . . . n
DaRin, Ferdinando. . . . . . . . . . . . . . . n Diab, Mohammad . . . . . . . . . . . . . . . a – Medtronic
D'Arrigo, Carmelo . . . . . . . . . . . . . . . n Diab, Mohammed Atef . . . . . . . . . . . n
Dastane, Manish. . . . . . . . . . . . . . . . . n Dial, Julie. . . . . . . . . . . . . . . . . . . . . . . n

Diaz Jr Luis A . . . . . . . . . . . . . . . . . . . n Duncan, Clive P . . . . . . . . . . . . . . . . . a, b, c, e – Zimmer, a – DePuy, A Johnson &
DiBella, Claudia . . . . . . . . . . . . . . . . . n Johnson Company, Stryker
DiCarlo, Edward F . . . . . . . . . . . . . . . e – Regeneration Biologics Dunn, Warren . . . . . . . . . . . . . . . . . . . a – NIH, NFL Charities, AOSSM, Arthrex,
DiCesare, Paul E . . . . . . . . . . . . . . . . . a – Smith & Nephew, e – Stryker Pfizer, Smith & Nephew, b – Arthrex
Dicintio, Martin . . . . . . . . . . . . . . . . . n Duquin, Thomas . . . . . . . . . . . . . . . . n
Dickson, Kyle F . . . . . . . . . . . . . . . . . . n Durieux, Marcel . . . . . . . . . . . . . . . . . n
Diduch, David R. . . . . . . . . . . . . . . . . n Durr, H R . . . . . . . . . . . . . . . . . . . . . . . n
Dierking, Kurt . . . . . . . . . . . . . . . . . . . n Durrani, Abubakar Atiq . . . . . . . . . . . n
Diesfeld, Paul . . . . . . . . . . . . . . . . . . . a – Biomet, Pfizer Duwelius, Paul J . . . . . . . . . . . . . . . . . a, b, c, e – Zimmer, e – GE Healthcare,
Dietrich, Mark. . . . . . . . . . . . . . . . . . . n Medtronic, Synthes
Dietz, Jeffrey . . . . . . . . . . . . . . . . . . . . n Dy, Christopher J . . . . . . . . . . . . . . . . n
Digennaro, Vitantonio. . . . . . . . . . . . n Dye, Scott F . . . . . . . . . . . . . . . . . . . . . n
DiGioia III Anthony M . . . . . . . . . . . n Dykes, Daryll C. . . . . . . . . . . . . . . . . . a – Medtronic
DiGiovanni, Christopher W . . . . . . . a, d, e – Biomimetics; e – Integra Eachempati, Krishna Kiran . . . . . . . . n
DiMaio, Frank R . . . . . . . . . . . . . . . . . e – Zimmer Eary, Janet F. . . . . . . . . . . . . . . . . . . . . a – NIH/NCI
Dimar II John R . . . . . . . . . . . . . . . . . a, c, e – Medtronic Sofamor Danek Easley, Mark E . . . . . . . . . . . . . . . . . . . a – Orthofix, Inc., Arthrex, Inc, DePuy,
Dimitriou, Christos . . . . . . . . . . . . . . n A Johnson & Johnson Company, Wright
Dimitriou, Rozalia I . . . . . . . . . . . . . . n Medical Technology, Inc., b – Orthofix, Inc.,
Dines, David M. . . . . . . . . . . . . . . . . . a, b, c, e – Biomet, a, c, e – Biomimetic e – Wright Medical Technology, Inc.
Dines, Joshua . . . . . . . . . . . . . . . . . . . n Eastwood, Deborah . . . . . . . . . . . . . . n
Ding, Anthony . . . . . . . . . . . . . . . . . . n Eberhardt, Alan. . . . . . . . . . . . . . . . . . a – Stryker, Zimmer
Dingeldein, Margaret Anne . . . . . . . . n Eberle, Robert W . . . . . . . . . . . . . . . . . e – Zimmer
Djurasovic, Mladen . . . . . . . . . . . . . . a, c, e – Medtronic Sofamor Danek Ebert, Frank R . . . . . . . . . . . . . . . . . . . a, b, c, e – Zimmer, c – Biomet
D'Lima, Darryl D . . . . . . . . . . . . . . . . a – NIH, OREF Ebneter, Lukas. . . . . . . . . . . . . . . . . . . n
Dobbin, Gwendolyn . . . . . . . . . . . . . n Ebramzadeh, Edward . . . . . . . . . . . . . n
Dobbs, Matthew Barrett. . . . . . . . . . . n Eckardt, Jeffrey John. . . . . . . . . . . . . . n
Dobson, Michael . . . . . . . . . . . . . . . . n Ecker, Timo M. . . . . . . . . . . . . . . . . . . n
Dodd, Christopher A F. . . . . . . . . . . . a – Biomet, Smith & Nephew, Stryker, Eckman, Kort, . . . . . . . . . . . . . . . . . . n
Wright Medical Technology, Inc., Edobor-Osula, Folorunsho . . . . . . . . n
b, c, e – Biomet Edwards Jr Peter H . . . . . . . . . . . . . . . n
Dodds, Matthew . . . . . . . . . . . . . . . . . n Egawa, Hiroshi . . . . . . . . . . . . . . . . . . a – Inova Health System, DePuy
Dodds, Michael K. . . . . . . . . . . . . . . . n Egol, Kenneth A . . . . . . . . . . . . . . . . . a, b – Biomet, a – Smith & Nephew, Stryker,
Dodge, Larry D . . . . . . . . . . . . . . . . . . n Synthes, d – Johnson & Johnson
Dodge, Lindsey . . . . . . . . . . . . . . . . . . n Ehrlich, Michael G . . . . . . . . . . . . . . . a, b, d, e – BioMimetic Therapeutics, Inc.
Domb, Benjamin . . . . . . . . . . . . . . . . n Eiji, Kondo . . . . . . . . . . . . . . . . . . . . . n
Donati, Davide . . . . . . . . . . . . . . . . . . n Ejerhed, Lars . . . . . . . . . . . . . . . . . . . . n
Donell, Simon Thomas . . . . . . . . . . . n Ekdahl, Max . . . . . . . . . . . . . . . . . . . . n
Donley, Brian Gerard . . . . . . . . . . . . . e – Tornier, Wright Medical Technology, Inc. Ekelund, Anders L . . . . . . . . . . . . . . . b, c, e – DePuy, A Johnson & Johnson
Donnan, Leo. . . . . . . . . . . . . . . . . . . . a – Medical Research Foundation for Company, b – MSD
Women and Babies ElAttrache, Neal S . . . . . . . . . . . . . . . . a, b, c, e – Arthrex, Inc, b, e – Acumed, LLC
Donohoo, Shane . . . . . . . . . . . . . . . . a – Stryker, Ceramtec Eldridge, Jonathan DJ . . . . . . . . . . . . a – Stryker, Smith & Nephew, b – Stryker
Donthineni, Rakesh . . . . . . . . . . . . . . n Howmedica
Doornberg, Job N. . . . . . . . . . . . . . . . a – Annafonds, Joint Active Systems, Wright Eleftheriou, Kyriacos . . . . . . . . . . . . . n
Medical, Stichting Wetenschappelijk Elias, Ilan. . . . . . . . . . . . . . . . . . . . . . . a – Synthes
Onderzoek Orthopaedische Chirurgie, Elias, John J . . . . . . . . . . . . . . . . . . . . . a – Donjoy, Storz, Sanofi Aventis, Genzyme
Fulbright Program Ellenbecker, Todd . . . . . . . . . . . . . . . . e – Stryker Physiotherapy
Doran, Peter P. . . . . . . . . . . . . . . . . . . n Ellingsen, Elisabeth . . . . . . . . . . . . . . a – Synthes
Dordelly, Luis . . . . . . . . . . . . . . . . . . . n Ellingson, Christopher I. . . . . . . . . . . n
Dorey, Frederick . . . . . . . . . . . . . . . . . a – Wright Medical Technology, Inc., Smith Elliot-Gibson, Victoria . . . . . . . . . . . . n
& Nephey, DePuy, Zimmer, Biomet Elliott, Alan . . . . . . . . . . . . . . . . . . . . . n
Dorr, Lawrence D . . . . . . . . . . . . . . . . a, b, c, e – Zimmer Elliott, Andrew J . . . . . . . . . . . . . . . . . n
Doski, John J. . . . . . . . . . . . . . . . . . . . n Elliott, Kirsten G . . . . . . . . . . . . . . . . . n
Dougherty, Paul J . . . . . . . . . . . . . . . . n Ellis, Andrew R . . . . . . . . . . . . . . . . . . n
Douglas, Lonnie . . . . . . . . . . . . . . . . . n Ellis, Scott . . . . . . . . . . . . . . . . . . . . . . n
Doulgerakis, Christos. . . . . . . . . . . . . n Ellison, Brad . . . . . . . . . . . . . . . . . . . . a – The Ohio State University, Dept. of
Dow, Kyle . . . . . . . . . . . . . . . . . . . . . . n Orthopaedics
Dowd, James E . . . . . . . . . . . . . . . . . . c – DePuy Elmaraghy, Amr . . . . . . . . . . . . . . . . . n
DISCLOSURE
Draeger, Reid W . . . . . . . . . . . . . . . . . a – Holderness Distinguished Medical Elmlund, Anna . . . . . . . . . . . . . . . . . . n
Scholars Program, Alpha Omega Alpha Elting, James J . . . . . . . . . . . . . . . . . . . c – Zimmer, e – Smith & Nephew
Carolyn L. Kuckein Student Research El-Zaim, Haissam S . . . . . . . . . . . . . . Zimmer
Fellowship Emam, Abdel Fatah . . . . . . . . . . . . . . a – Zimmer
Dragoo, Jason L . . . . . . . . . . . . . . . . . e – Genzyme, iBalance Emans, John B . . . . . . . . . . . . . . . . . . a, e – Synthes, Medtronic Sofamor Danek,
Drake, Gregory N . . . . . . . . . . . . . . . . n a – Stryker
Drake, Thurston . . . . . . . . . . . . . . . . . n Emerson Jr Roger H . . . . . . . . . . . . . . a, b, c, e – Biomet, a – Johnson & Johnson,
Drenos, Fotios. . . . . . . . . . . . . . . . . . . n Kendle International, Boehringer-
Drescher, Wolf . . . . . . . . . . . . . . . . . . n Ingelheim, OrthoMcNeil, AstraZeneca
Drewniak, Elizabeth. . . . . . . . . . . . . . n Emery, Sanford E . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Driscoll, Matthew D. . . . . . . . . . . . . . n Medtronic Sofamor Danek, Zimmer
Driscoll, Matthew David . . . . . . . . . . n Emond, Christopher . . . . . . . . . . . . . n
Drosdowech, Darren Sean. . . . . . . . . n Empson, Janene A . . . . . . . . . . . . . . . a – DePuy
Drummond, Denis S . . . . . . . . . . . . . n Endo, Hirooki. . . . . . . . . . . . . . . . . . . n
Dua, Aman . . . . . . . . . . . . . . . . . . . . . n Endo, Hirosuke. . . . . . . . . . . . . . . . . . n
Dubey, Ashok . . . . . . . . . . . . . . . . . . . n Endo, Naoto . . . . . . . . . . . . . . . . . . . . n
Dudley, Thomas E . . . . . . . . . . . . . . . n Endo, Toru. . . . . . . . . . . . . . . . . . . . . . n
Duell, Tobias. . . . . . . . . . . . . . . . . . . . n Endres, Terrence J . . . . . . . . . . . . . . . . n
Duerr, Hans R . . . . . . . . . . . . . . . . . . . n Engebretsen, Lars . . . . . . . . . . . . . . . . d – ABS, iBalance
Duffield, Beverly. . . . . . . . . . . . . . . . . n Engh, Jr, C Anderson . . . . . . . . . . . . . a – INOVA Health System, c, e – DePuy,
Duffy, Michael . . . . . . . . . . . . . . . . . . n e – Lifenet
Duke, Justin. . . . . . . . . . . . . . . . . . . . . n Engh, Sr, Charles A . . . . . . . . . . . . . . . a – Inova Health System, c, d – DePuy
Dumonski, Mark L . . . . . . . . . . . . . . . a – Medtronic
Dumont, Clemens . . . . . . . . . . . . . . . n
Dunbar, Michael. . . . . . . . . . . . . . . . . a, e – Stryker, Zimmer, b, d – Zimmer

Engh, Gerard Anderson . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Fisher, David A . . . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Smith & Nephew, Wright Medical Company, b – DVO, Tornier,
Technology, Inc., b – Biomet, Smith & e – Orthopediatrics
Nephew, Inova Health Care Services, Fisher, John . . . . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
c – DePuy, A Johnson & Johnson Company, Finsbury, Smith & Nephew, Synthes,
Innomed, d – Alexandria Research Zimmer, b, c, e – DePuy, A Johnson &
Technologies, e – Smith & Nephew, Johnson Company, d – BITECIC, Tissue
Alexandria Research Technologies Regenix,
Enna, Matthew Joseph . . . . . . . . . . . . n Fisher, Timothy C . . . . . . . . . . . . . . . . d – Ceremed, Inc.
Enomoto, Hiroshi . . . . . . . . . . . . . . . n Fithian, Donald C. . . . . . . . . . . . . . . . a – Zimmer, DePuy, Smith & Nephew
Enomoto, Hiroyuki . . . . . . . . . . . . . . n Fitts, Stephanie M. . . . . . . . . . . . . . . . e – Stryker Howmedica
Erak, Sani. . . . . . . . . . . . . . . . . . . . . . . n Fitz, Wolfgang . . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Erdos, Jennifer. . . . . . . . . . . . . . . . . . . n c, d – Conformis Inc.
Erggelet, Christoph. . . . . . . . . . . . . . . e – Genzyme Fitzgerald, Brian T. . . . . . . . . . . . . . . . n
Erhart, Jennifer . . . . . . . . . . . . . . . . . . n Fitzpatrick, Michael Joseph . . . . . . . . n
Erickson, Ben . . . . . . . . . . . . . . . . . . . n Fjelsgaad, Knut . . . . . . . . . . . . . . . . . . n
Erickson, Jill . . . . . . . . . . . . . . . . . . . . a – Biomet Flanagan, Adrienne . . . . . . . . . . . . . . n
Erickson, Mark A . . . . . . . . . . . . . . . . a – Medtronic Flanigan, David. . . . . . . . . . . . . . . . . . a – Arthrex, Smith & Nephew
Eriksen, Erik . . . . . . . . . . . . . . . . . . . . d, e – Novartis Flatow, Evan L . . . . . . . . . . . . . . . . . . . a, c – Zimmer, c – Innomed, e – Wyeth
Eriksson, Bengt E . . . . . . . . . . . . . . . . n Flecher, Xavier . . . . . . . . . . . . . . . . . . . a – Zimmer
Ernst, Judith . . . . . . . . . . . . . . . . . . . . n Fleischli, James E . . . . . . . . . . . . . . . . n
Erol, Bulent . . . . . . . . . . . . . . . . . . . . . n Fleming, Braden C . . . . . . . . . . . . . . . n
Erpenbach, John . . . . . . . . . . . . . . . . . n Flemister Jr Adolph Samuel. . . . . . . . a – Aircast(DJ), e – Biomimetic
Ervin, Timothy B. . . . . . . . . . . . . . . . . n Fletcher, Joel G . . . . . . . . . . . . . . . . . . b – Siemens Medical Solutions
Esch, James C . . . . . . . . . . . . . . . . . . . b, e – Smith & Nephew, c – Breg, d, e – KFx Flint, Michael . . . . . . . . . . . . . . . . . . . n
Medical, e – Wright Medical Technology, Inc. Flurin, Pierre-Henri . . . . . . . . . . . . . . e – Exactech
Escott, Benjamin. . . . . . . . . . . . . . . . . n Flynn, John M. . . . . . . . . . . . . . . . . . . a – Synthes, b, e – DePuy, A Johnson &
Eskelinen, Antti. . . . . . . . . . . . . . . . . . n Johnson Company, c, e – Biomet
Eslam Pour, Aidin. . . . . . . . . . . . . . . . n Fordyce, Michael. . . . . . . . . . . . . . . . . n
Esler, Colin . . . . . . . . . . . . . . . . . . . . . n Forman, Rachel. . . . . . . . . . . . . . . . . . n
Espinoza-Ervin, Christopher . . . . . . . n Forssblad, Magnus . . . . . . . . . . . . . . . n
Estok II Daniel M . . . . . . . . . . . . . . . . b, e – Zimmer Forsythe, Brian . . . . . . . . . . . . . . . . . . n
Estreicher, Michael B . . . . . . . . . . . . . n Forthman, Christopher L. . . . . . . . . . a – Synthes
Evangelista, Peter . . . . . . . . . . . . . . . . e – Biomimetics Fortin, Paul T. . . . . . . . . . . . . . . . . . . . n
Evans, Christopher H . . . . . . . . . . . . . n Foss, Catherine A . . . . . . . . . . . . . . . . n
Evans, Richard Parker. . . . . . . . . . . . . a – Biomet, Smith & Nephew, b – 3M, Fowler, Peter J . . . . . . . . . . . . . . . . . . . a – Aircast, Physician Services Inc.
Cubist Fox, Edward J . . . . . . . . . . . . . . . . . . . a – Stryker Howmedica
Even, Tirtza . . . . . . . . . . . . . . . . . . . . . n Fox, Joel . . . . . . . . . . . . . . . . . . . . . . . . n
Evenski, Andrea . . . . . . . . . . . . . . . . . n Fox, Maya . . . . . . . . . . . . . . . . . . . . . . n
Fabbri, Nicola . . . . . . . . . . . . . . . . . . . n Fracchia, Michael J . . . . . . . . . . . . . . . b, c, e – Aesculap/B.Braun
Faber, Ken . . . . . . . . . . . . . . . . . . . . . . n Fragomen, Austin . . . . . . . . . . . . . . . . a – Smith & Nephew, Biomet
Faldini, Cesare . . . . . . . . . . . . . . . . . . a – Smith & Nephew Franceschi, F . . . . . . . . . . . . . . . . . . . . n
Farfalli, German Luis . . . . . . . . . . . . . n Francis, David O . . . . . . . . . . . . . . . . . n
Faris, Philip M. . . . . . . . . . . . . . . . . . . a – Stryker, Zimmer, Biomet Frank, Darren . . . . . . . . . . . . . . . . . . . n
Farjoodi, Payam . . . . . . . . . . . . . . . . . n Frank, Joshua B. . . . . . . . . . . . . . . . . . n
Farley, Frances A . . . . . . . . . . . . . . . . . a, d – Medtronic Frankle, Mark A. . . . . . . . . . . . . . . . . . a, b, c, e – Encore Medical, d – Arthrocare
Farr II Jack . . . . . . . . . . . . . . . . . . . . . . n Franklin, Betty E . . . . . . . . . . . . . . . . . n
Farris, Rory C. . . . . . . . . . . . . . . . . . . . n Franko, Orrin I . . . . . . . . . . . . . . . . . . a, b – Small Bone Innovations, Wright
Faucett, Scott C . . . . . . . . . . . . . . . . . . n Medical Technologies, c – AM surgical
Favajee, Marein . . . . . . . . . . . . . . . . . . n Franta, Amy Katherine . . . . . . . . . . . . n
Fayssoux, Reginald Scott . . . . . . . . . . n Fras, Christian Ivan. . . . . . . . . . . . . . . n
Fealy, Stephen . . . . . . . . . . . . . . . . . . . n Fraschini, Gianfranco. . . . . . . . . . . . . n
Fedder, Keith . . . . . . . . . . . . . . . . . . . . n Fraser, Matthew H . . . . . . . . . . . . . . . n
Feeley, Brian . . . . . . . . . . . . . . . . . . . . n Frassica, Frank J. . . . . . . . . . . . . . . . . . a, d – Zimmer, b, e – Stryker
Fehring, Thomas K . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson Fredin, Hans O . . . . . . . . . . . . . . . . . . n
Company Freeman, Katherine . . . . . . . . . . . . . . n
Fehringer, Edward V . . . . . . . . . . . . . . a – DVO Freeman, Mark . . . . . . . . . . . . . . . . . . n
DISCLOSURE
Feinglass, Neil . . . . . . . . . . . . . . . . . . . n Freeman, Theresa . . . . . . . . . . . . . . . . a – Smith & Nephew

Feldman, David S . . . . . . . . . . . . . . . . a, e – EBI, Smith & Nephew, Stryker Freemont, Anthony . . . . . . . . . . . . . . n
Feller, Julian . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew Freiberg, Andrew A. . . . . . . . . . . . . . . a, c, e – Zimmer, a – Biomet
Fern, Darren . . . . . . . . . . . . . . . . . . . . b – Corin, Zimmer, DePuy, Smith & Freitas, Andre M . . . . . . . . . . . . . . . . . n
Nephew, Finsbury, Wright Medical, Biomet Frenkel, Sally R . . . . . . . . . . . . . . . . . . a – DePuy-Mitek
Fernandez, Leonor . . . . . . . . . . . . . . . n Frey, Carol C . . . . . . . . . . . . . . . . . . . . n
Fernandez, Nicholas. . . . . . . . . . . . . . n Frick, Steven L . . . . . . . . . . . . . . . . . . . a – Zimmer, Synthes
Fernando, Clington . . . . . . . . . . . . . . n Friedl, Gerald . . . . . . . . . . . . . . . . . . . n
Ferreira, Louis . . . . . . . . . . . . . . . . . . . n Friedman, Darren . . . . . . . . . . . . . . . . n
Ferretti, Andrea . . . . . . . . . . . . . . . . . . n Friedman, Richard J . . . . . . . . . . . . . . a, e – Bayer, a – Bristol-Myers Squib, Pfizer,
Ferretti, Mario . . . . . . . . . . . . . . . . . . . n b, e – Sanofi-Aventis, c, e – Encore Medical,
Ferruzzi, Alberto . . . . . . . . . . . . . . . . . n d – Zimmer, Johnson & Johnson,
Fessler, Richard G . . . . . . . . . . . . . . . . d, e, b – Medtronic e – Boehringer Ingelheim
Festa, Anthony . . . . . . . . . . . . . . . . . . n Frigg, Arno Martin . . . . . . . . . . . . . . . n
Fetzer, Gary B . . . . . . . . . . . . . . . . . . . n Frisella, William . . . . . . . . . . . . . . . . . n
Field, Larry D . . . . . . . . . . . . . . . . . . . e – Smith & Nephew Froimson, Mark I . . . . . . . . . . . . . . . . a – MCI
Fillingim, Roger . . . . . . . . . . . . . . . . . n Fu, Freddie H . . . . . . . . . . . . . . . . . . . a, e – Smith & Nephew, a – Biomet, Breg
Finegold, David N . . . . . . . . . . . . . . . n Fuchs, Susanne . . . . . . . . . . . . . . . . . . n
Finerty, Eileen . . . . . . . . . . . . . . . . . . . n Fugl-Meyer, Kerstin. . . . . . . . . . . . . . . n
Fink, Barbara. . . . . . . . . . . . . . . . . . . . n Fujii, Tadashi. . . . . . . . . . . . . . . . . . . . n
Fink, Howard . . . . . . . . . . . . . . . . . . . n Fujimoto, Yoshinori . . . . . . . . . . . . . . n
Finn, Michael A. . . . . . . . . . . . . . . . . . n Fujita, Hiroshi. . . . . . . . . . . . . . . . . . . n
Fischer, David A . . . . . . . . . . . . . . . . . c – Johnson & Johnson Fujita, Koji. . . . . . . . . . . . . . . . . . . . . . n
Fish, Mark . . . . . . . . . . . . . . . . . . . . . . n Fujiwara, Kazuo . . . . . . . . . . . . . . . . . n
Fukubayashi, Toru . . . . . . . . . . . . . . . n

Fukuda, Tomiko . . . . . . . . . . . . . . . . . b – DePuy, Synthes Gill, Harinderjit Singh . . . . . . . . . . . . a – Biomet, Plus, Stryker, Smith & Nephew,
Fukuhara, Testsutaro . . . . . . . . . . . . . n Wright Medical, Zimmer, b – Wright
Fukunaga, Kenji . . . . . . . . . . . . . . . . . n Medical, e – Biomet, Wright Medical
Fukunishi, Kunimoto. . . . . . . . . . . . . n Gill, Inder . . . . . . . . . . . . . . . . . . . . . . n
Fulkerson, John P . . . . . . . . . . . . . . . . c, d, e, – DJ Orthopaedics, c – Arthrex, Inc, Gill, J Brian . . . . . . . . . . . . . . . . . . . . . n
Lippincott, e – Musculoskeletal Transplant Gill, John T . . . . . . . . . . . . . . . . . . . . . n
Foundation Gill, Richie H S . . . . . . . . . . . . . . . . . . n
Funayama, Atsushi . . . . . . . . . . . . . . . n Gill, Thomas J . . . . . . . . . . . . . . . . . . . n
Furey, Andrew . . . . . . . . . . . . . . . . . . . n Gilley, Robert S . . . . . . . . . . . . . . . . . . n
Furey, Christopher George. . . . . . . . . n Gillies, Ronald M . . . . . . . . . . . . . . . . a – Stryker, Ceramtec
Furmanski, Jevan . . . . . . . . . . . . . . . . n Gilligan, Brendan . . . . . . . . . . . . . . . . n
Furnes, Ove Nord . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Gioe, Terence J . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Smith & Nephew Stryker, Zimmer, b – DePuy, A Johnson &
Gajjar, Aakash . . . . . . . . . . . . . . . . . . . n Johnson Company, d – Johnson & Johnson
Galacteros, Frederic . . . . . . . . . . . . . . n Giori, Nicholas John . . . . . . . . . . . . . n
Galanakis, Spiros . . . . . . . . . . . . . . . . n Girard, Julien . . . . . . . . . . . . . . . . . . . n
Galante, Jorge O . . . . . . . . . . . . . . . . . a, b, c, e – Zimmer Giraud, Marc . . . . . . . . . . . . . . . . . . . . e – Zimmer
Galatz, Leesa M. . . . . . . . . . . . . . . . . . e – Biomimetic, Wyeth Giuffre, Bruno. . . . . . . . . . . . . . . . . . . n
Galinat, Brian J . . . . . . . . . . . . . . . . . . n Giuffrida, A Ylenia . . . . . . . . . . . . . . . n
Gallego, David . . . . . . . . . . . . . . . . . . n Giunti, Armando . . . . . . . . . . . . . . . . n
Galloway, Marc T . . . . . . . . . . . . . . . . a – Arthrocare, e – Wyeth Giustini, Dean . . . . . . . . . . . . . . . . . . n
Gambardella, Ralph A . . . . . . . . . . . . n Giveans, M. Russell. . . . . . . . . . . . . . . a – Arthrex, Biomet, Zimmer, Omeros
Gamradt, Seth C . . . . . . . . . . . . . . . . . n Corporation, b – Smith & Nephew
Ganapathi, Muthu . . . . . . . . . . . . . . . n Gladstone, James N . . . . . . . . . . . . . . n
Ganga, Sarat . . . . . . . . . . . . . . . . . . . . n Glaser, Diana A . . . . . . . . . . . . . . . . . . a – Zimmer
Ganley, Theodore J . . . . . . . . . . . . . . . n Glassman, Rebecca D . . . . . . . . . . . . . a – Genzyme, Smith & Nephew
Ganz, Reinhold. . . . . . . . . . . . . . . . . . a – Smith & Nephew Glassman, Steven D . . . . . . . . . . . . . . a, c, e – Medtronic Sofamor Danek
Garavaglia, Guido. . . . . . . . . . . . . . . . n Glazebrook, Mark. . . . . . . . . . . . . . . . a – Smith & Nephew, Arthrex, Inc, DePuy,
Garbuz, Donald S. . . . . . . . . . . . . . . . a, e – Zimmer A Johnson & Johnson Company,
Garcia, Ryan . . . . . . . . . . . . . . . . . . . . n d – Stryker, Wright Medical Technology, Inc.
Gardiner, Aaron . . . . . . . . . . . . . . . . . n Glousman, Ronald E . . . . . . . . . . . . . n
Gardner, Michael J . . . . . . . . . . . . . . . n Glowacki, Julianne . . . . . . . . . . . . . . . n
Gardner, Thomas R . . . . . . . . . . . . . . a – Stryker Howmedica Glyn-Jones, Sion. . . . . . . . . . . . . . . . . n
Garellick, Goran . . . . . . . . . . . . . . . . . n Gobezie, Reuben. . . . . . . . . . . . . . . . . n
Garg, Sumeet. . . . . . . . . . . . . . . . . . . . n Godsiff, Steven . . . . . . . . . . . . . . . . . . n
Garges, Kim Jeffrey . . . . . . . . . . . . . . . n Goebel, Jennifer . . . . . . . . . . . . . . . . . n
Garino, Jonathan P. . . . . . . . . . . . . . . c – DePuy, A Johnson & Johnson Company, Goel, S.C.. . . . . . . . . . . . . . . . . . . . . . . n
Smith & Nephew, e – Ceramtec Goetz, Devon D . . . . . . . . . . . . . . . . . a, e – DePuy
Garrigues, Grant Edward . . . . . . . . . . n Goetz, Thomas . . . . . . . . . . . . . . . . . . n
Garrison, Glenn W . . . . . . . . . . . . . . . n Goh, Seo Kiat . . . . . . . . . . . . . . . . . . . n
Garutti-Martinez, Ignacio . . . . . . . . . n Goitz, Robert Joseph . . . . . . . . . . . . . n
Garvey, Timothy A . . . . . . . . . . . . . . . a – Medtronic Gokasian, Zia . . . . . . . . . . . . . . . . . . . a – Synthes, DePuy Spine, b – AO North
Garvin, Kevin L . . . . . . . . . . . . . . . . . . a, b, c – Biomet, a – Stryker, b – Smith & America, AO Foundation, d – Spinal
Nephew Kinetics, US Spine
Gaston, Mark . . . . . . . . . . . . . . . . . . . n Gold, Jonathan . . . . . . . . . . . . . . . . . . n
Gates, Philip E. . . . . . . . . . . . . . . . . . . a – United Cerebral Palsy and Shriners Gold, Rachel . . . . . . . . . . . . . . . . . . . . n
Hospitals Clinical Outcomes Studies Goldberg, Michael J . . . . . . . . . . . . . . n
Advisory Board Goldberg, Victor . . . . . . . . . . . . . . . . . a, b – Ferring Pharmaceuticals, Sanofi-
Gatto, Giacomo . . . . . . . . . . . . . . . . . n Aventis, c, e – Zimmer, Wright Medical
Gauvin, Jean . . . . . . . . . . . . . . . . . . . . n Technology, Inc.
Gawande, Atul . . . . . . . . . . . . . . . . . . n Goldstein, Daniel . . . . . . . . . . . . . . . . n
Gay, David. . . . . . . . . . . . . . . . . . . . . . n Goldstein, Rachel Y . . . . . . . . . . . . . . n
Gebauer, Gregory . . . . . . . . . . . . . . . . n Goldstein, Steven A . . . . . . . . . . . . . . a – Biomet, DePuy, A Johnson & Johnson
Gehlert, Rick J . . . . . . . . . . . . . . . . . . . n Company, Medtronic Sofamor Danek,
Gehrig, Laura M . . . . . . . . . . . . . . . . . n National Institutes of Health (NIAMS &
Geissler, William Bennett . . . . . . . . . e – Acumed, LLC NICHD), Stryker, Wright Medical
Geller, Jeffrey A . . . . . . . . . . . . . . . . . . n Technology, Inc., Synvasive, Aastrom,
DISCLOSURE
Generelli, Julie . . . . . . . . . . . . . . . . . . d, e – Osteotech Department of Defense, Department of
Genuario, James . . . . . . . . . . . . . . . . . n Energy, c – Zimmer, d – Amgen Co
George, Steven . . . . . . . . . . . . . . . . . . n Goldstein, Wayne M. . . . . . . . . . . . . . a, b, c, e – DePuy, b, c, e – Smith & Nephew,
Gerber, Christian . . . . . . . . . . . . . . . . a, c – Zimmer, a – Medacta, e – Storz c – Innomed
Gerdesmeyer, Ludger . . . . . . . . . . . . . e – Electro Medical Systems Goletz, Ty Henry. . . . . . . . . . . . . . . . . b – DePuy, A Johnson & Johnson Company
Gerlach, David . . . . . . . . . . . . . . . . . . n Golladay, Gregory. . . . . . . . . . . . . . . . e – Zimmer
Geula, Danielle. . . . . . . . . . . . . . . . . . a – Medtronic Gomberawalla, Mufaddal M . . . . . . . n
Ghanayem, Alexander J . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Gomez, Jaime A . . . . . . . . . . . . . . . . . n
Medtronic, Synthes Goncalves, Jose Cb . . . . . . . . . . . . . . . n
Ghanem, Elie S . . . . . . . . . . . . . . . . . . a – Stryker Gondusky, Joseph S . . . . . . . . . . . . . . a – Synthes USA
Gharzeddine, Ihab . . . . . . . . . . . . . . . n Gong, Hyun Sik . . . . . . . . . . . . . . . . . n
Ghatan, Christine . . . . . . . . . . . . . . . . n Gong, Il-Gyu . . . . . . . . . . . . . . . . . . . . n
Ghodadra, Neil S . . . . . . . . . . . . . . . . n Gonzales, Ricardo. . . . . . . . . . . . . . . . n
Gholve, Purushottam Arjun . . . . . . . n Gonzalez, Mark H . . . . . . . . . . . . . . . c – DePuy, a – Zimmer
Ghoz, Ali . . . . . . . . . . . . . . . . . . . . . . . n Gonzalez, Ruben . . . . . . . . . . . . . . . . n
Giannini, Sandro . . . . . . . . . . . . . . . . a – Smith & Nephew, c – Finsbury Gonzalez-Lomas, Guillem. . . . . . . . . n
Giannoudis, Peter. . . . . . . . . . . . . . . . a – AO, GlaxoSmithKline, Smith & Nephew, Good, Christopher . . . . . . . . . . . . . . . b – Cannuflow
Stryker, Synthes, b – DePuy, A Johnson & Goodman, Stuart Barry . . . . . . . . . . . a – Zimmer, e – NIAMS, Biomimedica,
Johnson Company, AO, Stryker Zimmer, NIH
Gibbons, Max . . . . . . . . . . . . . . . . . . . n Goodstadt, Noel . . . . . . . . . . . . . . . . . n
Gibson, Peter H . . . . . . . . . . . . . . . . . n Gorantla, Vijay . . . . . . . . . . . . . . . . . . n
Gierer, Philip. . . . . . . . . . . . . . . . . . . . n Gordon, Alexander C . . . . . . . . . . . . . a, e – DePuy
Giffin, Robert . . . . . . . . . . . . . . . . . . . a – Aircast, Arthrex, Physician Services Inc. Goroku, Takahiro . . . . . . . . . . . . . . . . n
Gikas, Panagiotis . . . . . . . . . . . . . . . . a – Stryker Howmedica Gosling, Thomas . . . . . . . . . . . . . . . . n
Gilbert, Alan . . . . . . . . . . . . . . . . . . . . n Goswami, Anukul Kumar Deb . . . . . n

Gott, Michael . . . . . . . . . . . . . . . . . . . n Guyer, Richard D . . . . . . . . . . . . . . . . a – Abbott, DePuy, A Johnson & Johnson
Gould, John . . . . . . . . . . . . . . . . . . . . a, e – DePuy, A Johnson & Johnson Company, Synthes, Medtronic Neuro,
Company, a – Biometric, d – Pfizer b – DePuy, A Johnson & Johnson Company,
Gousias, Konstantinos . . . . . . . . . . . . n Synthes, c – Abbott, d – K2M, e – DePuy,
Govaers, Kristoffei . . . . . . . . . . . . . . . b – Smith & Nephew A Johnson & Johnson Company, Synthes,
Gradl, Georg . . . . . . . . . . . . . . . . . . . . n Spinal Motion
Graham, Issac . . . . . . . . . . . . . . . . . . . e – DePuy Guyton, James L . . . . . . . . . . . . . . . . . n
Graham, William C . . . . . . . . . . . . . . n Ha, Chul Won. . . . . . . . . . . . . . . . . . . n
Granan, Lars-Petter. . . . . . . . . . . . . . . n Haag, Manuel . . . . . . . . . . . . . . . . . . . n
Granchi, Carrine . . . . . . . . . . . . . . . . . e – Praxim Haasters, Joerg . . . . . . . . . . . . . . . . . . n
Grande, Daniel A . . . . . . . . . . . . . . . . n Habaguchi, Tatsuya . . . . . . . . . . . . . . n
Grandi, Gian Luca . . . . . . . . . . . . . . . n Hacker, Rovert J. . . . . . . . . . . . . . . . . . n
Granger, Shawn Patrick . . . . . . . . . . . n Haddad, Fares Sami . . . . . . . . . . . . . . a,c,e – Smith & Nephew, a – Stryker
Grauer, Jonathan N . . . . . . . . . . . . . . e – Stryker, a – Medtronic Haddad, Steven L . . . . . . . . . . . . . . . . a, b, e – DePuy, A Johnson & Johnson
Gravare Silbernagel, Karin . . . . . . . . . n Company, a – Biomimetic, b, e – Stryker,
Graves, Matthew L . . . . . . . . . . . . . . . n b – Nexa Orthopaedics
Graves, Stephen . . . . . . . . . . . . . . . . . n Hadzic, Admir. . . . . . . . . . . . . . . . . . . n
Green, Andrew . . . . . . . . . . . . . . . . . . a, b, c, e – Tornier, a – Arthrex, Inc, Haentjens, Patrick. . . . . . . . . . . . . . . . n
CONMED Linvatec, Mitek, d – Biogen, Inc, Haggard, Warren. . . . . . . . . . . . . . . . . n
IlluminOs Hahne, Jochen . . . . . . . . . . . . . . . . . . n
Greene, Denise . . . . . . . . . . . . . . . . . . a – Merck Haider, Hani . . . . . . . . . . . . . . . . . . . . a – Biomet
Greene, Johnny . . . . . . . . . . . . . . . . . . n Haidukewych, George John. . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Greenwald, A Seth . . . . . . . . . . . . . . . a, b – Biomet, a, e – DePuy, A Johnson & Company, c – Zimmer, d, e – Surmodics
Johnson Company, Wright Medical Hakki, Sam . . . . . . . . . . . . . . . . . . . . . b, e – Aesculap/B.Braun, e – OrthoVita
Technology, Inc., Link Orthopaedics, Hall, Deborah J. . . . . . . . . . . . . . . . . . a – Wright Medical Technology, Inc.
a – Aesculap/B.Braun, AxioMed, Cervitech, Hall, Jeremy . . . . . . . . . . . . . . . . . . . . n
Encore Medical, Finsbury, Amedica, Halley, David K. . . . . . . . . . . . . . . . . . e – Zimmer, Exactech
OrthoDevelopment, Theken, e – Medtronic, Halliday, D . . . . . . . . . . . . . . . . . . . . . n
Smith & Nephew Hallock, Amy . . . . . . . . . . . . . . . . . . . n
Greenwald, Jonathan F.I. . . . . . . . . . . a – Portland Orthopaedics, DePuy Hallows, Rhett . . . . . . . . . . . . . . . . . . n
Gregory, Thomas . . . . . . . . . . . . . . . . n Halsey, David A. . . . . . . . . . . . . . . . . . n
Gregush, Ronald V . . . . . . . . . . . . . . . n Hamada, Takahiro . . . . . . . . . . . . . . . n
Greis, Patrick . . . . . . . . . . . . . . . . . . . . a – Stryker Hamada, Yoshiki . . . . . . . . . . . . . . . . n
Greisberg, Justin K . . . . . . . . . . . . . . . n Hamadouche, Moussa . . . . . . . . . . . . n
Grewal, Ruby. . . . . . . . . . . . . . . . . . . . n Hamasaki, Takahiko. . . . . . . . . . . . . . n
Griffin, Sharon . . . . . . . . . . . . . . . . . . n Hamer, Andrew J . . . . . . . . . . . . . . . . a – Stryker
Griffin, William L . . . . . . . . . . . . . . . . a, b, c, e – DePuy Hamilton, Christopher D . . . . . . . . . a – Mitek, Smith & Nephew, b – Arthrex, Inc
Griffith, Matthew . . . . . . . . . . . . . . . . n Hamilton, William G. . . . . . . . . . . . . a – INOVA Health System, e – DePuy, Lifenet
Grifka, Joachim. . . . . . . . . . . . . . . . . . a – Brainlab Han, Hyuk Soo . . . . . . . . . . . . . . . . . . n
Grigolo, Brunella . . . . . . . . . . . . . . . . n Han, Ilkyu . . . . . . . . . . . . . . . . . . . . . . n
Grillo, Jean-Charles . . . . . . . . . . . . . . n Han, Seung Beom. . . . . . . . . . . . . . . . n
Grindel, Steven I . . . . . . . . . . . . . . . . . n Hanada, Hirofumi . . . . . . . . . . . . . . . n
Grissom, Leslie . . . . . . . . . . . . . . . . . . n Hananouchi, Takehito . . . . . . . . . . . . n
Groh, Gordon I. . . . . . . . . . . . . . . . . . n Handa, Akiyoshi . . . . . . . . . . . . . . . . . n
Grohman, Charmaine . . . . . . . . . . . . n Hanel, Douglas P . . . . . . . . . . . . . . . . a, b – AO, Biomet, Trimed, Zimmer,
Grosjean, Guillaume . . . . . . . . . . . . . n a – Arthrex, Inc, DePuy, A Johnson &
Gross, Allan E . . . . . . . . . . . . . . . . . . . c, e – zimmer Johnson Company, Johnson & Johnson,
Gross, Michael . . . . . . . . . . . . . . . . . . a, c, e – Wright Medical Sawbones/Pacific Research Laboratories,
Gross, Thomas P. . . . . . . . . . . . . . . . . a – Corin, e – Biomet Smith & Nephew, Stryker, Synthes,
Gruen, Thomas A . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson b – Small Bone Innovations
Company Hangasaphuk, Naraphong . . . . . . . . n
Grunwald, Zvi. . . . . . . . . . . . . . . . . . . n Hankemeier, Stefan . . . . . . . . . . . . . . n
Grupp, Thomas. . . . . . . . . . . . . . . . . . e – Braun Aesculap Hanley, Cheryl . . . . . . . . . . . . . . . . . . n
Gruson, Konrad . . . . . . . . . . . . . . . . . n Hanna, Sammy A . . . . . . . . . . . . . . . . n
Guala, Agustin Jose . . . . . . . . . . . . . . n Hannah, Sami. . . . . . . . . . . . . . . . . . . n
Guanche, Carlos . . . . . . . . . . . . . . . . . b, d, e – Arthrosurface, Inc, b, e – Zimmer, Hansen, Laura. . . . . . . . . . . . . . . . . . . n
c, d, e – Arthrex, Inc Hanson, Beate. . . . . . . . . . . . . . . . . . . e – AO Foundation
DISCLOSURE
Guettler, Joseph . . . . . . . . . . . . . . . . . a – Stryker, Mitek, b – Genzyme, Mitek, Hanson, Chad M . . . . . . . . . . . . . . . . n

Arthrex Hanssen, Arlen D . . . . . . . . . . . . . . . . a, c, e – Stryker, a – Biomet, DePuy,
Gugala, Zbigniew . . . . . . . . . . . . . . . . n A Johnson & Johnson Company, Implex,
Guille, James T . . . . . . . . . . . . . . . . . . n Tornier, Zimmer, c – Orthopaedic
Guillo, Stephane. . . . . . . . . . . . . . . . . n Development Corp.
Gulati, A . . . . . . . . . . . . . . . . . . . . . . . n Hara, Michiya . . . . . . . . . . . . . . . . . . . n
Gullung, Gregory . . . . . . . . . . . . . . . . n Hara, Yasushi . . . . . . . . . . . . . . . . . . . n
Gulotta, Lawrence. . . . . . . . . . . . . . . . n Harada, Mikio. . . . . . . . . . . . . . . . . . . n
Gundle, Roger . . . . . . . . . . . . . . . . . . . n Harada, Yoshitada . . . . . . . . . . . . . . . n
Gunel, Ugur . . . . . . . . . . . . . . . . . . . . n Hardacker, James W . . . . . . . . . . . . . . a, e – Medtronic Sofamor Danek
Gungor, Ertugrul. . . . . . . . . . . . . . . . . n Hardy, Daniel . . . . . . . . . . . . . . . . . . . n
Gunnoe, Bryan A . . . . . . . . . . . . . . . . d – Nuvasive Harilainen, Arsi T . . . . . . . . . . . . . . . . n
Gupta, Ajay . . . . . . . . . . . . . . . . . . . . . n Haritidis, John . . . . . . . . . . . . . . . . . . n
Gurbani, Narendra G . . . . . . . . . . . . . n Harner, Christopher D . . . . . . . . . . . . c – Biomet
Gurgel, Henrique . . . . . . . . . . . . . . . . n Haro, Hirotaka . . . . . . . . . . . . . . . . . . n
Guss, Daniel . . . . . . . . . . . . . . . . . . . . n Harper, William . . . . . . . . . . . . . . . . . n
Gutierrez, Berenice . . . . . . . . . . . . . . . n Harrasser, Norbert . . . . . . . . . . . . . . . n
Gutierrez, Juan C . . . . . . . . . . . . . . . . n Harris, Colin . . . . . . . . . . . . . . . . . . . . n
Guyatt, Gordon. . . . . . . . . . . . . . . . . . a – NIH, CIHR, OREF Harris, David John . . . . . . . . . . . . . . . n
Guyen, Olivier . . . . . . . . . . . . . . . . . . b – Amplitude Harris, Mitchel B. . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Synthes, Zimmer, e – Globus Medical
Harris, William H . . . . . . . . . . . . . . . . a, c – Zimmer, a – Smith & Nephew, Biomet
Harrison, Bradley K . . . . . . . . . . . . . . n
Harrison, John Meredith . . . . . . . . . . n
Harrison, Robert M . . . . . . . . . . . . . . n

Hart, Alister . . . . . . . . . . . . . . . . . . . . . a – Furlong Charitable Research Foundation Hicks, Benjamin Matthew . . . . . . . . . a, e – Medtronic
Hart, Charlie . . . . . . . . . . . . . . . . . . . . d, e – BioMimetic Therapeutics, Inc. Hickson, Gerald B . . . . . . . . . . . . . . . n
Hart, Jennifer . . . . . . . . . . . . . . . . . . . n Hida, Shinichi. . . . . . . . . . . . . . . . . . . n
Hart, Joseph . . . . . . . . . . . . . . . . . . . . n Hidalgo, Ignacio Alonso . . . . . . . . . . n
Hart, Robert A . . . . . . . . . . . . . . . . . . . n Hideki, Yoshikawa . . . . . . . . . . . . . . . n
Hartigan, Brian J . . . . . . . . . . . . . . . . . b – Hand Innovations, DePuy, A Johnson & Hiemstra, Laurie . . . . . . . . . . . . . . . . . a – Breg, b, e – CONMED Linvatec
Johnson Company, e – DePuy, A Johnson & Higashino, Kosaku . . . . . . . . . . . . . . . n
Johnson Company Higgins, Jason A . . . . . . . . . . . . . . . . . n
Hartman, Jodi . . . . . . . . . . . . . . . . . . . n Higgins, Laurence D. . . . . . . . . . . . . . a, b, e – DePuy, A Johnson & Johnson
Hartzband, Mark A. . . . . . . . . . . . . . . a, b, c, e – Zimmer Company, a, c – Zimmer, a – DJ
Hase, Hitoshi . . . . . . . . . . . . . . . . . . . n Orthopaedics
Hasegawa, Atsushi . . . . . . . . . . . . . . . n Higuchi, Hiroshi. . . . . . . . . . . . . . . . . n
Hasenboehler, Erik A . . . . . . . . . . . . . n Hilibrand, Alan S . . . . . . . . . . . . . . . . a, c – Stryker, a – Medtronic, DePuy,
Hashimoto, Tomoyuki. . . . . . . . . . . . n A Johnson & Johnson Company, Osteotech,
Haslam, Paul Gregory . . . . . . . . . . . . n Synthes, c – Biomet, Zimmer,
Haspl, Miroslav. . . . . . . . . . . . . . . . . . n Aesculap/B.Braun, d – Amedica
Hassenpflug, Joachim . . . . . . . . . . . . n Hill, Genevieve A . . . . . . . . . . . . . . . . n
Hatori, Masahito . . . . . . . . . . . . . . . . n Hill, J David . . . . . . . . . . . . . . . . . . . . n
Hauptmann, Sandra M . . . . . . . . . . . a – Stryker Howmedica Hill, Robert A . . . . . . . . . . . . . . . . . . . n
Hausdorf, Joerg. . . . . . . . . . . . . . . . . . n Hillstrom, Howard . . . . . . . . . . . . . . . n
Havey, Robert . . . . . . . . . . . . . . . . . . . a – Synthes Spine Hilstrom, Howard . . . . . . . . . . . . . . . n
Hawkins, Nathaniel . . . . . . . . . . . . . . e – Biomet Hinkle, Sarah . . . . . . . . . . . . . . . . . . . n
Hayakawa, Keiko . . . . . . . . . . . . . . . . n Hinojosa, Lauren . . . . . . . . . . . . . . . . n
Hayashi, Masayuki . . . . . . . . . . . . . . . n Hintermann, Beat. . . . . . . . . . . . . . . . a – Stryker, Zimmer, a, c, d – New Deal
Hayashi, Riku . . . . . . . . . . . . . . . . . . . n Integra
Hayden, Dallas . . . . . . . . . . . . . . . . . . n Hipp, John . . . . . . . . . . . . . . . . . . . . . n
Hayden, Shawn A . . . . . . . . . . . . . . . . n Hirakawa, Kazuo . . . . . . . . . . . . . . . . n
Haydon, Chris. . . . . . . . . . . . . . . . . . . n Hirano, Takaaki . . . . . . . . . . . . . . . . . n
Haytmanek, Craig T . . . . . . . . . . . . . . n Hirohashi, Nori . . . . . . . . . . . . . . . . . n
Healey, John H . . . . . . . . . . . . . . . . . . a, b – Biomet, e – Biomet, Musculoskeletal Hirose, Toshiaki . . . . . . . . . . . . . . . . . n
Transplant Foundation Hirota, Shigeaki . . . . . . . . . . . . . . . . . n
Healthy, Desai. . . . . . . . . . . . . . . . . . . n Hishmeh, Shuriz. . . . . . . . . . . . . . . . . n
Healy, Michael T . . . . . . . . . . . . . . . . . n Hitachi, Shin . . . . . . . . . . . . . . . . . . . . n
Healy, William L . . . . . . . . . . . . . . . . . a, b, e – DePuy, A Johnson & Johnson Ho, Yvette . . . . . . . . . . . . . . . . . . . . . . n
Company Hoang, Mike . . . . . . . . . . . . . . . . . . . . n
Heard, Mark . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew, Lifemark Health, Breg Hoang-Kim, Amy . . . . . . . . . . . . . . . . a – Smith & Nephew
Heckman, James D. . . . . . . . . . . . . . . n Hoballah, Jamal . . . . . . . . . . . . . . . . . n
Heflin, John Alexander . . . . . . . . . . . n Hobeika, Paul E . . . . . . . . . . . . . . . . . n
Heim, Christine S . . . . . . . . . . . . . . . . n Hobson, Sally . . . . . . . . . . . . . . . . . . . n
Heiner, John P . . . . . . . . . . . . . . . . . . a, b, e – Zimmer Hodrick, Jeffrey Thomas . . . . . . . . . . n
Helfet, David Leonard . . . . . . . . . . . . a, d – Synthes Hoffman, Michael V. . . . . . . . . . . . . . n
Helgeson, Melvin D . . . . . . . . . . . . . . n Hoffmeyer, Pierre J . . . . . . . . . . . . . . . a – Zimmer
Heller, John G . . . . . . . . . . . . . . . . . . . a – Abbott, Medtronic, Synthes, b – Abbott, Hofmann, Aaron Adam. . . . . . . . . . . e – Zimmer
Medtronic, c, d – Medtronic, e – Abbott, Hofmeister, Eric P. . . . . . . . . . . . . . . . n
Medtronic, BioCure Hogan, Christopher James . . . . . . . . n
Henderson, Jennifer . . . . . . . . . . . . . . n Hogan, MaCalus. . . . . . . . . . . . . . . . . a – NIH
Hendrix, Mike. . . . . . . . . . . . . . . . . . . n Hojo, Tatsuya . . . . . . . . . . . . . . . . . . . n
Henket, Marjolijn . . . . . . . . . . . . . . . . n Hollins, Anthony M . . . . . . . . . . . . . . n
Henley, M Bradford . . . . . . . . . . . . . . a, b, e – Proliance Surgeons, Synthes, Hollis, Ronald. . . . . . . . . . . . . . . . . . . n
a – Amgen Co, Arthrex, Inc, Biomet, Holloway, Ian Paul . . . . . . . . . . . . . . . a – DePuy, Stryker
Cerapedics, DePuy, A Johnson & Johnson Holmes, James R. . . . . . . . . . . . . . . . . n
Company, Johnson & Johnson, Pfizer, Holmes, Tara. . . . . . . . . . . . . . . . . . . . a – Arthrex, NFL Charities, b – Arthrex
Wright Medical Technology, Inc., AO North Holt, Ginger E. . . . . . . . . . . . . . . . . . . b, e – Zimmer
America, AO Spine North America, AO Holthusen, Scott Myron . . . . . . . . . . n
Stiftung-ASIF Foundation, Bank of America Holtom, Paul D . . . . . . . . . . . . . . . . . n
Foundation, Bearly Inc., Pacific Medical, The Honda, Masahito . . . . . . . . . . . . . . . . n
Seattle Foundation, Silicon Valley Hong, Jung Woo. . . . . . . . . . . . . . . . . n
DISCLOSURE
Community Foundation, SpineVision, Hong, Ki-Sook . . . . . . . . . . . . . . . . . . n
Synthes Spine, T&P LLC, Trimed, BioAxone Hongo, Michio . . . . . . . . . . . . . . . . . . n
Therapeutique, Integra Lifesciences, Kythera Honkamp, Nicholas J . . . . . . . . . . . . n
Biopharmaceuticals, Ostex International, Hooper, Gary J . . . . . . . . . . . . . . . . . . n
Boeing, Zymogenetics, b, e – Smith & Hopfenmueller, Werner . . . . . . . . . . . n
Nephew, Stryker, Zimmer, b – Virgina Hopper, Robert . . . . . . . . . . . . . . . . . . a – Inova Health System
Mason, e – Milliman and Robertson, MBH Horan, Marilee P . . . . . . . . . . . . . . . . n
Consulting, Gerson Lehrman Group Horibe, Shuji. . . . . . . . . . . . . . . . . . . . n
Hennigar, Allan. . . . . . . . . . . . . . . . . . n Horie, Osamu . . . . . . . . . . . . . . . . . . . e – Medtronic
Henning, Jeffrey A . . . . . . . . . . . . . . . n Horigome, Keiko . . . . . . . . . . . . . . . . n
Henrique, Alexandre . . . . . . . . . . . . . n Horio, Michiko . . . . . . . . . . . . . . . . . . n
Henshaw, Robert Mikael . . . . . . . . . . n Hornbuckle, Hilary F . . . . . . . . . . . . . n
Hepinstall, Matthew. . . . . . . . . . . . . . n Hornung, Phillip . . . . . . . . . . . . . . . . e – Stryker
Herbert, Morley A. . . . . . . . . . . . . . . . a – Wright Medical Technology Hosaka, Masami . . . . . . . . . . . . . . . . . n
Herman, Martin Joseph . . . . . . . . . . . n Hosaka, Noboru . . . . . . . . . . . . . . . . . n
Herndon, James H . . . . . . . . . . . . . . . n Hosalkar, Harish Sadanand. . . . . . . . n
Hernigou, Philippe. . . . . . . . . . . . . . . n Hoshino, Makiko . . . . . . . . . . . . . . . . n
Herrera-Soto, Jose A . . . . . . . . . . . . . . n Hosogane, Naobumi . . . . . . . . . . . . . n
Herring, Marion McBride . . . . . . . . . n Hosono, Kozo. . . . . . . . . . . . . . . . . . . n
Herzberg, Wolfgang . . . . . . . . . . . . . . n Hospodar, Paul P . . . . . . . . . . . . . . . . n
Herzenberg, John E . . . . . . . . . . . . . . a – Orthofix, Inc., Smith & Nephew, Hotta, Tetsuo. . . . . . . . . . . . . . . . . . . . n
b, e – Biomet Hou, Sheng-Mou . . . . . . . . . . . . . . . . n
Heyde, Christoph . . . . . . . . . . . . . . . . n Hovelius, Lennart . . . . . . . . . . . . . . . . n
Hickman, Jenifer K . . . . . . . . . . . . . . . n Howe, Tet Sen . . . . . . . . . . . . . . . . . . . n
Hickok, Noreen J . . . . . . . . . . . . . . . . n Howell, Stephen M. . . . . . . . . . . . . . . c – Biomet, e – Biomet, OtisMed, Inc

Howells, Nick . . . . . . . . . . . . . . . . . . . n Iwasaki, Junichi. . . . . . . . . . . . . . . . . . n
Hoyen, Harry A. . . . . . . . . . . . . . . . . . n Iwasaki, Kiyoshi . . . . . . . . . . . . . . . . . n
Hozack, William J. . . . . . . . . . . . . . . . a, c, e – Stryker Iwase, Takenobu . . . . . . . . . . . . . . . . . n
Hsiao, Andrew . . . . . . . . . . . . . . . . . . n Iwinski, Henry J . . . . . . . . . . . . . . . . . n
Hsu, Chi-Shiung . . . . . . . . . . . . . . . . . n Izumi, Tomohiro . . . . . . . . . . . . . . . . n
Hsu, Victor . . . . . . . . . . . . . . . . . . . . . n Jaberi, Fereidoon M . . . . . . . . . . . . . . n
Hsu, Wellington . . . . . . . . . . . . . . . . . n Jackson, Ben . . . . . . . . . . . . . . . . . . . . n
Hu, Ming-Hsiao . . . . . . . . . . . . . . . . . n Jackson, C . . . . . . . . . . . . . . . . . . . . . . n
Huang, Chung Cheng . . . . . . . . . . . . n Jacobs, Benjamin . . . . . . . . . . . . . . . . n
Huang, Deqing . . . . . . . . . . . . . . . . . . n Jacobs, Cale . . . . . . . . . . . . . . . . . . . . . a – Biomet, Smith & Nephew
Huang, Hsuan-Ying . . . . . . . . . . . . . . n Jacobs, Joshua J. . . . . . . . . . . . . . . . . . a, b, e – Zimmer, a, e – Advanced Spine
Huang, James L. . . . . . . . . . . . . . . . . . n Technologies, Wright Medical Technology,
Huang, Jerry . . . . . . . . . . . . . . . . . . . . n Inc., Arcus, Medtronic Sofamor Danek,
Huang, Michael . . . . . . . . . . . . . . . . . a – Genzyme, Smith & Nephew Spinal Motion, e – IsoTis Orthobiologics
Huard, Johnny . . . . . . . . . . . . . . . . . . a, e – Cook Myosite, b – Wyeth Jacquet, Robin. . . . . . . . . . . . . . . . . . . n
Hubbard, David F. . . . . . . . . . . . . . . . a – Orthopaedic Trauma Association, Jaffe, William L . . . . . . . . . . . . . . . . . . e – Stryker Howmedica
Orthopaedic Research and Education Jaggi, Shuchie . . . . . . . . . . . . . . . . . . . n
Foundation Jagiello, Jake . . . . . . . . . . . . . . . . . . . . n
Huber, Roland. . . . . . . . . . . . . . . . . . . n Jagodzinski, Michael . . . . . . . . . . . . . n
Huddleston III James I. . . . . . . . . . . . n Jahangir, Amir A . . . . . . . . . . . . . . . . . n
Huffman, G Russell . . . . . . . . . . . . . . n Jain, Viral. . . . . . . . . . . . . . . . . . . . . . . n
Hufner, Tobias . . . . . . . . . . . . . . . . . . n Jaiswal, Ashish . . . . . . . . . . . . . . . . . . n
Hughes, Jeffery S. . . . . . . . . . . . . . . . . a, e – Zimmer Jamali, Amir A . . . . . . . . . . . . . . . . . . n
Hughes, Josh . . . . . . . . . . . . . . . . . . . . a – DePuy James, Laurence Edward . . . . . . . . . . n
Hughes, Jr, Thomas B. . . . . . . . . . . . . a – Zimmer James, Michelle A . . . . . . . . . . . . . . . . n
Hughlock, Mariah K. . . . . . . . . . . . . . a – DePuy, Zimmer James, Roshan. . . . . . . . . . . . . . . . . . . n
Hull, Thomas F. . . . . . . . . . . . . . . . . . a – Ohio Department of Public Safety, Jameson, Simon . . . . . . . . . . . . . . . . . a, b – DePuy
Emergency Medical Services Grant Janowitz, Ira . . . . . . . . . . . . . . . . . . . . a – NIH
Hungerford, Marc Wilson . . . . . . . . . e – Zimmer Janssen, Michael E . . . . . . . . . . . . . . . n
Hunt, David . . . . . . . . . . . . . . . . . . . . n Jansson, Volkmar . . . . . . . . . . . . . . . . a – Stryker Howmedica, Braun Aesculap,
Hunt, Devyani . . . . . . . . . . . . . . . . . . n b, c – Braun Aesculap
Hunt, Kenneth John. . . . . . . . . . . . . . n Jantho, Erica . . . . . . . . . . . . . . . . . . . . n
Hunter, Robert E. . . . . . . . . . . . . . . . . a, b, e – Smith & Nephew, a, b – Breg, Jaramaz, Branislav . . . . . . . . . . . . . . . n
a – DJ Orthopaedics, e – DePuy, A Johnson Jarit, Gregg. . . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew
& Johnson Company Jarmon, Nicholas . . . . . . . . . . . . . . . . n
Hunuo, Nicolas . . . . . . . . . . . . . . . . . n Jarrett Jr Joe Nelson . . . . . . . . . . . . . . e – DePuy
Hur, Chang-Ich . . . . . . . . . . . . . . . . . . n Jawa, Andrew . . . . . . . . . . . . . . . . . . . a – Synthes, b – Respironics
Hurd, Jason . . . . . . . . . . . . . . . . . . . . . n Jazrawi, Laith M . . . . . . . . . . . . . . . . . e – Xylos, Mitek
Hurson, Conor . . . . . . . . . . . . . . . . . . n Jean, Ronald P. . . . . . . . . . . . . . . . . . . n
Hurwitz, Shepard R . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Jelinek, James . . . . . . . . . . . . . . . . . . . n
Exactech, e – Amgen Co Jenis, Louis George . . . . . . . . . . . . . . . e – Apatech, Stryker, DePuy Spine,
Husain, Sohail . . . . . . . . . . . . . . . . . . n Medtronic
Hyman, Joshua E . . . . . . . . . . . . . . . . n Jenkins, Paul John . . . . . . . . . . . . . . . n
Hynes, Darragh. . . . . . . . . . . . . . . . . . n Jenny, Jean-Yves . . . . . . . . . . . . . . . . . n
Iannotti, Joseph P. . . . . . . . . . . . . . . . c – DePuy Jeon, Dae-Geun . . . . . . . . . . . . . . . . . n
Ianuzzi, Allyson . . . . . . . . . . . . . . . . . n Jeong, Kwang-Cheul. . . . . . . . . . . . . . n
Idemmili, Christopher. . . . . . . . . . . . n Jepson, Eric K . . . . . . . . . . . . . . . . . . . n
Ikebuchi, Mitsuhiko. . . . . . . . . . . . . . n Jerosch, Joerg. . . . . . . . . . . . . . . . . . . . a – Genzyme
Ikeda, Takumi . . . . . . . . . . . . . . . . . . . n Jessel, Rebecca. . . . . . . . . . . . . . . . . . . n
Ikoma, Kazuya . . . . . . . . . . . . . . . . . . n Jessup, Nennette . . . . . . . . . . . . . . . . . n
Ilizarova, Svetlana. . . . . . . . . . . . . . . . a – Smith & Nephew, Biomet Ji, Jong Hun. . . . . . . . . . . . . . . . . . . . . n
Illingworth, Kenneth . . . . . . . . . . . . . n Jia, Xiaofeng . . . . . . . . . . . . . . . . . . . . a – National Natural Science Foundation of
Imai, Mitsuru . . . . . . . . . . . . . . . . . . . n People's Republic of China
Imbriglia, Joseph E . . . . . . . . . . . . . . . n Jia, Xiaofeng . . . . . . . . . . . . . . . . . . . . n
Imhauser, Carl W . . . . . . . . . . . . . . . . n Jibodh, Stefan R . . . . . . . . . . . . . . . . . n
Imura, Kenji . . . . . . . . . . . . . . . . . . . . n Jin, Xiaolong . . . . . . . . . . . . . . . . . . . . n
In, Yong . . . . . . . . . . . . . . . . . . . . . . . . n Jindal, Gaurav . . . . . . . . . . . . . . . . . . . n
DISCLOSURE
Inacio, Maria Carolina Secorun . . . . a – Zimmer, DePuy, Smith & Nephew Jiranek, William A . . . . . . . . . . . . . . . a, c, d, e – DePuy, A Johnson & Johnson
Ingallina, Antonello . . . . . . . . . . . . . . n Company, d – Zimmer, Bristol-Myers Squib,
Ingham, Eileen . . . . . . . . . . . . . . . . . . n GE Healthcare, Genzyme, Merck, Pfizer,
Ingham, Sheila Jean McNeill. . . . . . . n Procter & Gamble, Sanofi-Aventis,
Inori, Fumiaki. . . . . . . . . . . . . . . . . . . n e – Zimmer, Lifenet
Inoue, Masahiro . . . . . . . . . . . . . . . . . n Jo, Ki Hyun . . . . . . . . . . . . . . . . . . . . . n
Inscore, Stephen C . . . . . . . . . . . . . . . n Jobe, Frank W . . . . . . . . . . . . . . . . . . . n
Insogna, Karl . . . . . . . . . . . . . . . . . . . . n John, Thilo . . . . . . . . . . . . . . . . . . . . . b – Mathys Medical
Iorio, Richard . . . . . . . . . . . . . . . . . . . a – DePuy Johnsen, S Paaske . . . . . . . . . . . . . . . . n
Isabell Jr Gene Paul . . . . . . . . . . . . . . n Johnson, Anne Holland. . . . . . . . . . . n
Ishak, Charbel. . . . . . . . . . . . . . . . . . . n Johnson, Darren L . . . . . . . . . . . . . . . e – Smith & Nephew
Ishida, Yoichiro. . . . . . . . . . . . . . . . . . n Johnson, James A . . . . . . . . . . . . . . . . n
Ishigaki, Takayuki . . . . . . . . . . . . . . . . n Johnson, Geoffrey V . . . . . . . . . . . . . . n
Ishiguro, Naoki. . . . . . . . . . . . . . . . . . n Johnston II Charles Eugene. . . . . . . . a, b, c, e – Medtronic
Ishii, Yoshinori . . . . . . . . . . . . . . . . . . n Johnston, James D . . . . . . . . . . . . . . . a – Lawson Health Research Institute
Isler, Balz . . . . . . . . . . . . . . . . . . . . . . . n Johnstone, Alan J . . . . . . . . . . . . . . . . n
Ismaily, Sabir. . . . . . . . . . . . . . . . . . . . n Jones, Alan L . . . . . . . . . . . . . . . . . . . . a – Synthes
Isogai, Noritaka . . . . . . . . . . . . . . . . . n Jones, Bob . . . . . . . . . . . . . . . . . . . . . . e – Smith & Nephew
Isomoto, Shinji. . . . . . . . . . . . . . . . . . n Jones, Clifford B . . . . . . . . . . . . . . . . . a, b, e – Zimmer, a – Medtronic Sofamor
Ito, Takui . . . . . . . . . . . . . . . . . . . . . . . n Danek, b – AO
Itoi, Eiji . . . . . . . . . . . . . . . . . . . . . . . . n Jones, Clifford. . . . . . . . . . . . . . . . . . . e – Zimmer
Iwahashi, Takeshi . . . . . . . . . . . . . . . . n Jones, David . . . . . . . . . . . . . . . . . . . . n
Iwaki, Hiroyoshi . . . . . . . . . . . . . . . . . a – DePuy, Wright Medical, Zimmer Jones, Ian. . . . . . . . . . . . . . . . . . . . . . . n
Iwakiri, Kentarou . . . . . . . . . . . . . . . . n Jones, Jackson . . . . . . . . . . . . . . . . . . . n
Iwamoto, Yukihide. . . . . . . . . . . . . . . n Jones, Lynne C . . . . . . . . . . . . . . . . . . a – Stryker Howmedica, Zimmer

Jones, Morgan H. . . . . . . . . . . . . . . . . a – Arthrex, Smith & Nephew Kashiwaguchi, Shinji . . . . . . . . . . . . . n
Jones, Neil F . . . . . . . . . . . . . . . . . . . . n Kasow, Douglas. . . . . . . . . . . . . . . . . . n
Jones, Rhidian Morgan . . . . . . . . . . . n Kasser, James R . . . . . . . . . . . . . . . . . . n
Jones, Teresa L. . . . . . . . . . . . . . . . . . . a – Stryker Spine, Synthes Spine Kasugi, Shinichi . . . . . . . . . . . . . . . . . n
Joseph, Jeffrey I . . . . . . . . . . . . . . . . . . n Kataoka, Hiroyuki . . . . . . . . . . . . . . . n
Josse, Robert . . . . . . . . . . . . . . . . . . . . a, b – Procter & Gamble Pharmaceuticals, Kateros, Konstantinos . . . . . . . . . . . . n
Sanofi Aventis, Novartis Pharmaceuticals Kato, Hideteru . . . . . . . . . . . . . . . . . . n
Canada Inc., Merck Frosst Canada Inc., Kato, Sadatoshi . . . . . . . . . . . . . . . . . . n
a – Servier Canada Inc., b – Eli Lilly Canada Kato, Tsuyoshi. . . . . . . . . . . . . . . . . . . n
Inc., AstraZenica Katoh, Shinsuke . . . . . . . . . . . . . . . . . n
Jotoku, Tsuyoshi . . . . . . . . . . . . . . . . . n Katsura, Taro . . . . . . . . . . . . . . . . . . . . n
Joyce, Michael J . . . . . . . . . . . . . . . . . . e – Medical Board of Trustees, Katz, Jeffrey N . . . . . . . . . . . . . . . . . . . n
Musculoskeletal Tranplant Foundation Katz, Jonathan . . . . . . . . . . . . . . . . . . n
Judet, Thierry. . . . . . . . . . . . . . . . . . . . c – Tornier Kaufman, Christina . . . . . . . . . . . . . . n
Judex, Stefan . . . . . . . . . . . . . . . . . . . . n Kaufman, Kenton R . . . . . . . . . . . . . . n
Jung, Sung Taek. . . . . . . . . . . . . . . . . . n Kaufman, Robert P . . . . . . . . . . . . . . . n
Junichiro, Hamada. . . . . . . . . . . . . . . n Kavanaugh, Eoin C. . . . . . . . . . . . . . . e – Osteotech
Junji, Wasa. . . . . . . . . . . . . . . . . . . . . . n Kawahara, Ikuo. . . . . . . . . . . . . . . . . . n
Jupiter, Jesse B . . . . . . . . . . . . . . . . . . . a, e – Synthes, a – Aircast(DJ), Biomet, Kawashima, Hiroyuki. . . . . . . . . . . . . n
Hand Innovations, Linvatec, Mitek, SBI, Kawasoe, Yasuomi . . . . . . . . . . . . . . . n
Wright Medical Technology, Inc., Zimmer, Kawate, Kenji. . . . . . . . . . . . . . . . . . . . n
e – Amgen Co, Wyeth Kay, Robert Michael . . . . . . . . . . . . . . n
Jurgensmeier, Darin . . . . . . . . . . . . . . n Kaya, Mitsunori. . . . . . . . . . . . . . . . . . n
Jurist, Kenneth A. . . . . . . . . . . . . . . . . a – Stryker, Mitek, b – Genzyme, Mitek, Kaynak, Gokhan . . . . . . . . . . . . . . . . . n
Arthrex Kean, Crystal . . . . . . . . . . . . . . . . . . . . n
Jurrens, Traci L . . . . . . . . . . . . . . . . . . n Keating, E Michael . . . . . . . . . . . . . . . a – Stryker, Zimmer, Biomet
Kaar, K . . . . . . . . . . . . . . . . . . . . . . . . . n Keaveny, Tony . . . . . . . . . . . . . . . . . . . d, e – O.N. Diagnostics
Kadiyala, R Kumar . . . . . . . . . . . . . . . e – EBI Kedgley, Angela E . . . . . . . . . . . . . . . . n
Kadoya, Yoshinori . . . . . . . . . . . . . . . a – Biomet Keefer, Jennifer . . . . . . . . . . . . . . . . . . n
Kaeaeb, Max J . . . . . . . . . . . . . . . . . . . b – Mathys Keeler, Kathryn A . . . . . . . . . . . . . . . . n
Kaeding, Christopher C . . . . . . . . . . . a – Arthrex, Smith & Nephew Keenan, Mary Ann E. . . . . . . . . . . . . . n
Kahler, David M . . . . . . . . . . . . . . . . . e – Brainlab Keggi, John M . . . . . . . . . . . . . . . . . . . a, c, d, e – OmniLife Science, a – Smith &
Kainonen, Terho . . . . . . . . . . . . . . . . . a – Inion Nephew, b – TissueLink
Kakar, Sanjeev . . . . . . . . . . . . . . . . . . . n Kellam, James F . . . . . . . . . . . . . . . . . a – Synthes, Zimmer, AO Foundation,
Kakarala, Gopikrishna . . . . . . . . . . . . n e – Lifenet
Kalandiak, Steven P . . . . . . . . . . . . . . n Kellett, Catherine . . . . . . . . . . . . . . . . n
Kalberer, Fabian . . . . . . . . . . . . . . . . . n Kelley, Scott S . . . . . . . . . . . . . . . . . . . n
Kalia, P. . . . . . . . . . . . . . . . . . . . . . . . . n Kelly, Bryan T . . . . . . . . . . . . . . . . . . . n
Kallina IV Charles F . . . . . . . . . . . . . . n Kelly, Cynthia M . . . . . . . . . . . . . . . . . n
Kalteis, Thomas. . . . . . . . . . . . . . . . . . a – Brainlab Kelly II James D . . . . . . . . . . . . . . . . . n
Kaltsas, Dimitris . . . . . . . . . . . . . . . . . n Kelly IV John D. . . . . . . . . . . . . . . . . . n
Kam, Check C . . . . . . . . . . . . . . . . . . . n Kelly, Michael A . . . . . . . . . . . . . . . . . b, c, e – Zimmer, c – Faziomed, d – Abbott,
Kam, Galen . . . . . . . . . . . . . . . . . . . . . n Bristol-Myers Squib, Pfizer
Kamada, Satoshi . . . . . . . . . . . . . . . . . n Kenandis, Efstathios . . . . . . . . . . . . . . n
Kamali, Amir. . . . . . . . . . . . . . . . . . . . e – Smith & Nephew Kendoff, Daniel . . . . . . . . . . . . . . . . . n
Kamata, Satoshi . . . . . . . . . . . . . . . . . n Kenmoku, Tomonori . . . . . . . . . . . . . n
Kamath, Atul F . . . . . . . . . . . . . . . . . . a – Wright Medical Technology, Inc., SBI Kennedy, John G. . . . . . . . . . . . . . . . . n
Kamath, Ganesh V . . . . . . . . . . . . . . . n Kennedy, William R . . . . . . . . . . . . . . a – Corin USA
Kamath, Vijay . . . . . . . . . . . . . . . . . . . n Kennon, Robert Edward. . . . . . . . . . . n
Kamegaya, Makoto. . . . . . . . . . . . . . . n Kent, David . . . . . . . . . . . . . . . . . . . . . a – Pfizer
Kamikawa, Koya . . . . . . . . . . . . . . . . . n Keppler, Louis . . . . . . . . . . . . . . . . . . . n
Kamineni, Srinath . . . . . . . . . . . . . . . n Ker, Andrew. . . . . . . . . . . . . . . . . . . . . n
Kanakaris, Nikolaos K . . . . . . . . . . . . n Kerber, Richard . . . . . . . . . . . . . . . . . . n
Kanamiya, Takeshi . . . . . . . . . . . . . . . n Kerboull, Luc. . . . . . . . . . . . . . . . . . . . n
Kanamori, Akihiro . . . . . . . . . . . . . . . n Kerboull, Marcel . . . . . . . . . . . . . . . . . n
Kanayama, Masahiro . . . . . . . . . . . . . n Kercher, James. . . . . . . . . . . . . . . . . . . n
Kandel, Leonid Arieh . . . . . . . . . . . . . n Kerker, Jordan Todd . . . . . . . . . . . . . . n
DISCLOSURE
Kaneda, Kiyoshi . . . . . . . . . . . . . . . . . n Kesturu, Girish . . . . . . . . . . . . . . . . . . n
Kaneshiro, Yasunori . . . . . . . . . . . . . . n Ketonis, Constantinos . . . . . . . . . . . . n
Kang, James. . . . . . . . . . . . . . . . . . . . . a – Johnson & Johnson, Stryker, Medtronic Khan, Fazel . . . . . . . . . . . . . . . . . . . . . n
Sofamor Danek, Osteotech Khan, Sami O . . . . . . . . . . . . . . . . . . . n
Kang, Joon Soon. . . . . . . . . . . . . . . . . c, e – Zimmer Khan, Yusuf. . . . . . . . . . . . . . . . . . . . . n
Kang, Kyung-Joong. . . . . . . . . . . . . . . n Khanna, A Jay . . . . . . . . . . . . . . . . . . . a – Blackstone, b – AO Spine North
Kang, Lana. . . . . . . . . . . . . . . . . . . . . . n America, Medical Education and Research
Kang, Seung Baik . . . . . . . . . . . . . . . . n Center, Vindico Medical Education,
Kang, Suk Bong. . . . . . . . . . . . . . . . . . n e – Kyphon, Blackstone Medical,
Kanwar, Rajdeep . . . . . . . . . . . . . . . . . n Zimmer Spine
Kapetanos, George A . . . . . . . . . . . . . n Khanuja, Harpal Singh. . . . . . . . . . . . e – Zimmer
Kaplan, Kevin . . . . . . . . . . . . . . . . . . . n Kheirelseid, El Rashied Ahmed . . . . . n
Kapoor, Sandeep. . . . . . . . . . . . . . . . . n Khoury, Joseph G . . . . . . . . . . . . . . . . n
Karam, Maroun. . . . . . . . . . . . . . . . . . n Kibler, W Benjamin . . . . . . . . . . . . . . a, d, e – Alignmed
Karashima, Daisetsu. . . . . . . . . . . . . . n Kiernan Jr Howard A . . . . . . . . . . . . . n
Karashima, Hirotaka . . . . . . . . . . . . . n Kilian, Pascal. . . . . . . . . . . . . . . . . . . . n
Karastinos, Anastassios . . . . . . . . . . . n Kilian, Pascal. . . . . . . . . . . . . . . . . . . . a – Zimmer
Karlsson, Jon . . . . . . . . . . . . . . . . . . . . n Killeen, Kathleen . . . . . . . . . . . . . . . . n
Karlsson, Magnus . . . . . . . . . . . . . . . . n Kilma, Stefan. . . . . . . . . . . . . . . . . . . . e – Stryker Howmedica
Karol, Lori A . . . . . . . . . . . . . . . . . . . . n Kim, Do-Gyoon . . . . . . . . . . . . . . . . . n
Karrholm, Johan Nils. . . . . . . . . . . . . a – Biomet, Zimmer, b – Link Orthopaedics, Kim, Han-Soo . . . . . . . . . . . . . . . . . . . n
d, e – RSA Biomedical Kim, Hubert T. . . . . . . . . . . . . . . . . . . n
Kartus, Catarina . . . . . . . . . . . . . . . . . n Kim, Hye Mi . . . . . . . . . . . . . . . . . . . . n
Kartus, Juri. . . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew Kim, Hye Ran . . . . . . . . . . . . . . . . . . . n
Kaseje, Neema. . . . . . . . . . . . . . . . . . . n Kim, Hyun Min . . . . . . . . . . . . . . . . . n

Kim, Hyun-Jong . . . . . . . . . . . . . . . . . n Komistek, Richard D . . . . . . . . . . . . . a – Zimmer, Tornier, Archus Orthopedics,
Kim, Jin Hyok . . . . . . . . . . . . . . . . . . . n DePuy, Smith & Nephew, Biomet
Kim, Jong-Hak . . . . . . . . . . . . . . . . . . n Komiya, Koichiro . . . . . . . . . . . . . . . . n
Kim, Joon-Woo. . . . . . . . . . . . . . . . . . n Komiya, Stesuro . . . . . . . . . . . . . . . . . n
Kim, Jun Shik . . . . . . . . . . . . . . . . . . . n Komori, Hiromichi . . . . . . . . . . . . . . n
Kim, Ki-Hyeong . . . . . . . . . . . . . . . . . n Konan, Sujith . . . . . . . . . . . . . . . . . . . n
Kim, Myung-Sun . . . . . . . . . . . . . . . . n Kondo, Eiji . . . . . . . . . . . . . . . . . . . . . n
Kim, Paul R . . . . . . . . . . . . . . . . . . . . . a, c, e – Wright Medical Technology Kondo, Makoto. . . . . . . . . . . . . . . . . . n
Kim, Poong-Taek . . . . . . . . . . . . . . . . n Koniaris, Leonidas G . . . . . . . . . . . . . n
Kim, Sae Hoon . . . . . . . . . . . . . . . . . . n Kontogeorgakos, Vasileios . . . . . . . . . n
Kim, Sang D . . . . . . . . . . . . . . . . . . . . n Koo, Samuel . . . . . . . . . . . . . . . . . . . . n
Kim, Shin-Yoon . . . . . . . . . . . . . . . . . n Koob, Trevor W. . . . . . . . . . . . . . . . . . n
Kim, Sun Jin . . . . . . . . . . . . . . . . . . . . n Kopf, Sebastian . . . . . . . . . . . . . . . . . . n
Kim, Tae Kyun. . . . . . . . . . . . . . . . . . . a – Smith & Nephew, b – Braun Aesculap Korotkova, Tatiana . . . . . . . . . . . . . . . n
Kim, Yongjung J . . . . . . . . . . . . . . . . . n Kosashvili, Yona . . . . . . . . . . . . . . . . . n
Kim, Yoon Taek. . . . . . . . . . . . . . . . . . n Koshima, Isao . . . . . . . . . . . . . . . . . . . n
Kim, Young-Bae . . . . . . . . . . . . . . . . . n Koskinen, Esa . . . . . . . . . . . . . . . . . . . n
Kim, Young-Hoo . . . . . . . . . . . . . . . . n Kostamo, Timothy . . . . . . . . . . . . . . . n
Kim, Young-Jin . . . . . . . . . . . . . . . . . . n Kou, Joseph Xavier . . . . . . . . . . . . . . . n
Kim, Young-Jo. . . . . . . . . . . . . . . . . . . a – OREF, Siemens Koulouvaris, PanaGiotis S . . . . . . . . . n
Kim, Youn-Jin . . . . . . . . . . . . . . . . . . . n Kovacevic, David. . . . . . . . . . . . . . . . . n
Kimata, Yoshihiro. . . . . . . . . . . . . . . . n Koval, Kenneth J . . . . . . . . . . . . . . . . . b, c, e – Biomet, b, e – Stryker
Kimura, Masashi. . . . . . . . . . . . . . . . . n Koyuncu, Lutfu Ozgur . . . . . . . . . . . . n
Kimura, Shinji. . . . . . . . . . . . . . . . . . . a – The General Insurance Association of Kraay, Matthew J. . . . . . . . . . . . . . . . . a – Zimmer, Sulzer, NIH Grant
Japan Krackow, Kenneth A . . . . . . . . . . . . . . a, b, c, d, e – Stryker, c – Smith & Nephew
Kinchelow, Tosca . . . . . . . . . . . . . . . . n Krantz, Lars . . . . . . . . . . . . . . . . . . . . . n
Kindsfater, Kirk . . . . . . . . . . . . . . . . . . c – DePuy Krasinski, Kevin . . . . . . . . . . . . . . . . . n
Kiner, Dirk W . . . . . . . . . . . . . . . . . . . a – AO, DePuy, A Johnson & Johnson Kregor, Philip James . . . . . . . . . . . . . . a – A.O. Foundation, Synthes
Company, Pfizer, Smith & Nephew, Stryker, Krenek, Lucie. . . . . . . . . . . . . . . . . . . . n
Synthes, Zimmer Krettek, Christian . . . . . . . . . . . . . . . . a – Stryker
King, David J . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew, Genzyme, EBI Kreuzer, Stefan . . . . . . . . . . . . . . . . . . b, e – Stryker Orthopaedics
King, Graham J W. . . . . . . . . . . . . . . . a, b, c – Wright Medical Technology, Inc., Krishnan, Sumant G. . . . . . . . . . . . . . a, b, e – Mitek, Tornier, c – Innovation
c – Tornier, Tenet Medical Sports, d – Johnson & Johnson, Pfizer,
King III Joseph John. . . . . . . . . . . . . . a – Stryker Howmedica Merck
Kinoshita, Mitsuo . . . . . . . . . . . . . . . . n Krismer, Martin. . . . . . . . . . . . . . . . . . a – Stryker Orthopaedics
Kinsey, Tracy . . . . . . . . . . . . . . . . . . . . a, e – Stryker Orthopedics Krosin, Michael Tyler . . . . . . . . . . . . . n
Kinzler, Kenneth W . . . . . . . . . . . . . . n Krupat, Edward. . . . . . . . . . . . . . . . . . n
Kippe, Matthew. . . . . . . . . . . . . . . . . . n Kua, Jade PH . . . . . . . . . . . . . . . . . . . . n
Kircher, Michelle. . . . . . . . . . . . . . . . . n Kubo, Tadahiko . . . . . . . . . . . . . . . . . n
Kirk, Jessica . . . . . . . . . . . . . . . . . . . . . n Kubo, Takahiro . . . . . . . . . . . . . . . . . . n
Kirkos, John Margaritis . . . . . . . . . . . n Kubo, Toshikazu. . . . . . . . . . . . . . . . . n
Kirkpatrick, John S . . . . . . . . . . . . . . . a – Biomet, Synthes, d – Johnson & Kubota, Atsushi. . . . . . . . . . . . . . . . . . n
Johnson, Bristol-Myers Squib, Pfizer, Procter Kuhn, John E. . . . . . . . . . . . . . . . . . . . a, b, e – Arthrex, Inc, a – DJ Orthopaedics,
& Gamble, Zimmer Smith & Nephew, d – Pfizer
Kishan, Shyam . . . . . . . . . . . . . . . . . . n Kuhn, Michael J . . . . . . . . . . . . . . . . . n
Kishida, Shunji . . . . . . . . . . . . . . . . . . n Kuiper, Jan Herman . . . . . . . . . . . . . . n
Kitagawa, Hiroshi . . . . . . . . . . . . . . . . n Kuklo, Timothy R . . . . . . . . . . . . . . . . a, b, c, d, e – Medtronic Sofamor Danek,
Kitamura, Nobuto . . . . . . . . . . . . . . . n a – Zimmer, Arthrex, Inc, c – Mitek
Kitaoka, Harold B. . . . . . . . . . . . . . . . n Kulkarni, Mahesh . . . . . . . . . . . . . . . . n
Kiyama, Takahiko . . . . . . . . . . . . . . . . n Kumai, Tsukasa. . . . . . . . . . . . . . . . . . n
Kleweno, Conor P . . . . . . . . . . . . . . . n Kumar, Deepak . . . . . . . . . . . . . . . . . . n
Klineberg, Eric. . . . . . . . . . . . . . . . . . . n Kumar, Kapil . . . . . . . . . . . . . . . . . . . . n
Kloen, Peter. . . . . . . . . . . . . . . . . . . . . n Kummer, Fredrick J. . . . . . . . . . . . . . . a – Smith & Nephew
Klug, Raymond . . . . . . . . . . . . . . . . . . n Kunihiro, Oka. . . . . . . . . . . . . . . . . . . n
Knapp Jr D Raymond. . . . . . . . . . . . . n Kunisada, Toshiyuki . . . . . . . . . . . . . . n
Knierim, Annie . . . . . . . . . . . . . . . . . . n Kuo, Yur-Ren . . . . . . . . . . . . . . . . . . . . n
Knight, Trevor B . . . . . . . . . . . . . . . . . n Kuppersmith, David. . . . . . . . . . . . . . n
DISCLOSURE
Knupp, Markus . . . . . . . . . . . . . . . . . . n Kuramochi, Rieko. . . . . . . . . . . . . . . . n

Ko, Clifford . . . . . . . . . . . . . . . . . . . . . n Kurd, Mark F . . . . . . . . . . . . . . . . . . . . n
Kobayashi, Akio . . . . . . . . . . . . . . . . . a – Zimmer, Japan Medical Materials Kuremsky, Marshall . . . . . . . . . . . . . . n
Kobayashi, Hiroto . . . . . . . . . . . . . . . a – OsteoLign Inc Kuribayashi, So . . . . . . . . . . . . . . . . . . n
Kobayashi, Tetsuya . . . . . . . . . . . . . . . n Kurkinen, Merja . . . . . . . . . . . . . . . . . e – Inion
Kobayashi, Tsutomu. . . . . . . . . . . . . . n Kurtz, Steven M. . . . . . . . . . . . . . . . . . a – Kyphon Inc., Medtronic, Synthes,
Kobbe, Philipp . . . . . . . . . . . . . . . . . . n Johnson & Johnson, Stryker, DePuy Spine,
Koch, Peter . . . . . . . . . . . . . . . . . . . . . n Archus Orthopaedics, Zimmer
Kocher, Mininder S. . . . . . . . . . . . . . . e – Smith & Nephew, CONMED Linvatec, Kusuzaki, Katsuyuki . . . . . . . . . . . . . . n
Biomet, Regen Biologics, Scandius Kwek, Ernest Beng Kee . . . . . . . . . . . . n
Biomedical Kwon, Michael Soon . . . . . . . . . . . . . n
Kochlar, Tony . . . . . . . . . . . . . . . . . . . n Kwon, Oh-Ryong . . . . . . . . . . . . . . . . n
Kodali, Pradeep. . . . . . . . . . . . . . . . . . n Kwon, Sae Kwang . . . . . . . . . . . . . . . . n
Koenig, Matthew A. . . . . . . . . . . . . . . n Kwon, Yong . . . . . . . . . . . . . . . . . . . . . n
Koenig, Scott J. . . . . . . . . . . . . . . . . . . n Kwon, Yoon Joo . . . . . . . . . . . . . . . . . n
Koh, Jason L . . . . . . . . . . . . . . . . . . . . a – Aesculap/B.Braun, Arthrex, Inc, Enturia, Kwon, Young W . . . . . . . . . . . . . . . . . e – Exactech, Inc, Smith & Nephew
b, e – Aesculap/B.Braun, Arthrex, Inc Kyle, Richard F . . . . . . . . . . . . . . . . . . a, c – DePuy, A Johnson & Johnson
Koh, Joyce Suang Bee . . . . . . . . . . . . . n Company, a – Encore Medical, Smith &
Koike, Yoichi . . . . . . . . . . . . . . . . . . . . n Nephew, Zimmer
Koizumi, Wataru. . . . . . . . . . . . . . . . . n Kyrkos, Margaritis J. . . . . . . . . . . . . . . n
Kolimarala, V . . . . . . . . . . . . . . . . . . . n Kyung, Hee Soo . . . . . . . . . . . . . . . . . n
Kolisek, Frank R . . . . . . . . . . . . . . . . . a, c, e – Stryker Orthopaedics La Russa, Massimo . . . . . . . . . . . . . . . n
Koman, L Andrew. . . . . . . . . . . . . . . . a, b – Allergan Labbe, Marc R . . . . . . . . . . . . . . . . . . . a, e – Wright Medical Technology
Komatsuda, Tatsuro . . . . . . . . . . . . . . n Labianca, Luca . . . . . . . . . . . . . . . . . . n
Labib, Sameh A. . . . . . . . . . . . . . . . . . n

Lachiewicz, Paul F . . . . . . . . . . . . . . . a, e – Zimmer, e – Endo Lee, Sang Hyoup. . . . . . . . . . . . . . . . . b – DePuy
Lackman, Richard D. . . . . . . . . . . . . . a, e – Stryker Lee, Sang-Hoon . . . . . . . . . . . . . . . . . n
Ladd, Amy L . . . . . . . . . . . . . . . . . . . . b – Orthohelix, c – Skeletal Kinetics Lee, Seung-Bak . . . . . . . . . . . . . . . . . . n
Laffargue, Philippe . . . . . . . . . . . . . . . e – Tornier Lee, Steve K . . . . . . . . . . . . . . . . . . . . . n
Laffenetre, Olivier. . . . . . . . . . . . . . . . a – Biomimetic, c – Integra New Deal / FH Lee, Thay Q . . . . . . . . . . . . . . . . . . . . . n
Orthopedics / Donjoy, e – FH Orthopedics Lee, Yong-Seuk . . . . . . . . . . . . . . . . . . n
Lafosse, Laurent . . . . . . . . . . . . . . . . . n Leeson, Mark C . . . . . . . . . . . . . . . . . . n
Lahad, Amnon . . . . . . . . . . . . . . . . . . n Lefevre, Nicolas. . . . . . . . . . . . . . . . . . n
Lajtai, George . . . . . . . . . . . . . . . . . . . c, e – Karl Storz Germany Legedza, Anna T R . . . . . . . . . . . . . . . n
Lal, Shalini . . . . . . . . . . . . . . . . . . . . . a – Wright Medical Technologies, b – Small Lehman, Wallace B. . . . . . . . . . . . . . . n
Bone Innovations, c – AM Surgical Leighton, Ross K . . . . . . . . . . . . . . . . . a, e – DePuy
Lalliss, Steven J . . . . . . . . . . . . . . . . . . b – Smith & Nephew LeMarr, Angela . . . . . . . . . . . . . . . . . . a – Biomet, Pfizer
Lambert, Simon . . . . . . . . . . . . . . . . . n Lemons, Jack E . . . . . . . . . . . . . . . . . . a – Biomet, Smith & Nephew, Synthes,
Lamm, Bradley M . . . . . . . . . . . . . . . . a – Smith & Nephew Stryker, Zimmer, e – Biomet
Lamprecht, Derek E . . . . . . . . . . . . . . n Lemos, Mark J . . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Landa, Joshua . . . . . . . . . . . . . . . . . . . n e – Smith & Nephew
Landis, William J . . . . . . . . . . . . . . . . n Lenart, Brett. . . . . . . . . . . . . . . . . . . . . n
Lane, Joseph M . . . . . . . . . . . . . . . . . . b, e – Orthovita, Osteotech, Lenke, Lawrence G . . . . . . . . . . . . . . . a, b, c, e – Medtronic, a, c – DePuy,
b – GlaxoSmithKline, Eli Lilly, Procter & A Johnson & Johnson Company
Gamble, Sanofi-Aventis, e – Biomimetic, Lennon, Nancy . . . . . . . . . . . . . . . . . . n
Zimmer Leo, Andrew . . . . . . . . . . . . . . . . . . . . n
Lang, Jason Edward . . . . . . . . . . . . . . n Leonardsson, Olof . . . . . . . . . . . . . . . n
Langer, Phillip Raymond . . . . . . . . . . n Leone, Bruce . . . . . . . . . . . . . . . . . . . . n
Langford, Joshua. . . . . . . . . . . . . . . . . n Leonetti, Danilo . . . . . . . . . . . . . . . . . n
Langkamer, VG . . . . . . . . . . . . . . . . . . a – Surgical Innovations Leontaritis, Nikoletta M. . . . . . . . . . . n
Laor, Tal . . . . . . . . . . . . . . . . . . . . . . . . n Lesieur-Brooks, Anne M. . . . . . . . . . . n
Laor, Tal . . . . . . . . . . . . . . . . . . . . . . . . n Lessnick, Stephen . . . . . . . . . . . . . . . . n
Laoruengthana, Artit . . . . . . . . . . . . . n Leszko, Filip . . . . . . . . . . . . . . . . . . . . a – Tornier, Zimmer
LaPrade, Robert F . . . . . . . . . . . . . . . . n Letko, Lynn Juliana . . . . . . . . . . . . . . a – DePuy Spine
Larsen, Mitchell W . . . . . . . . . . . . . . . n Leumann, Andre. . . . . . . . . . . . . . . . . n
Larson, Annalise N . . . . . . . . . . . . . . . n Leunig, Michael . . . . . . . . . . . . . . . . . a – Zimmer, d – Pivot, e – Plus Orthopedics
Larson, Christopher . . . . . . . . . . . . . . a – Biomet, Omeros Corporation, Arthrex, Lev, Ishay . . . . . . . . . . . . . . . . . . . . . . . n
Inc, Zimmer, b – Smith & Nephew Leventhal, Evan. . . . . . . . . . . . . . . . . . a – Praxim
Larsson, Sune . . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Levi, Gabriel . . . . . . . . . . . . . . . . . . . . n
Kyphon Inc., b – Acumed, LLC, Stryker, Levin, L Scott. . . . . . . . . . . . . . . . . . . . n
Synthes, Smith & Nephew, e – Norvartis Levine, Alan Marc . . . . . . . . . . . . . . . . a, b – Accuray, a – Medtronic Sofamor
Laskin, Richard Sheldon . . . . . . . . . . a, b, c, d, e – Smith & Nephew, Danek, c – US Spine, e – LRV
b, c, e – TissueLink Levine, William N. . . . . . . . . . . . . . . . n
Lassen, Michael Rud. . . . . . . . . . . . . . e – Bristol-Myers Squibb, GlaxoSmithKline, Levy, Bruce A . . . . . . . . . . . . . . . . . . . . n
DaiichiSankyo inc, Bayer, Astellas, Levy, Ofer . . . . . . . . . . . . . . . . . . . . . . n
Boehringer Ingelheim Lew MS William D . . . . . . . . . . . . . . . a – Stryker Biotech, Medtronic Sofamor
LaTouche, Aurelien. . . . . . . . . . . . . . . n Danek, Midwest Orthopaedic Research
Lau, Edmund . . . . . . . . . . . . . . . . . . . a – Stryker Foundation
Laufer, Amanda. . . . . . . . . . . . . . . . . . n Lewallen, David G . . . . . . . . . . . . . . . a, b, c, e – Zimmer, a – DePuy, A Johnson &
Laughlin, Richard T . . . . . . . . . . . . . . a – Synthes, Smith & Nephew Johnson Company, Stryker, e – Orthosonics,
Laval, Georges . . . . . . . . . . . . . . . . . . . n Bristol-Myers Squib
Lavelle, William Francis . . . . . . . . . . . n Lewis, Paul B . . . . . . . . . . . . . . . . . . . . n
Lavernia, Carlos J . . . . . . . . . . . . . . . . c – Zimmer, d – Johnson & Johnson Lewis, Valerae O . . . . . . . . . . . . . . . . . a – Stryker
Lavigne, Martin . . . . . . . . . . . . . . . . . . a, e – Zimmer, a – Stryker Howmedica, Lhamby, Juliano Tozzo . . . . . . . . . . . n
Biomet, DePuy, Smith & Nephew Li, Chenxi . . . . . . . . . . . . . . . . . . . . . . e – Smith & Nephew
Lawrence, James . . . . . . . . . . . . . . . . . n Li, Esther . . . . . . . . . . . . . . . . . . . . . . . a – Wright Medical
Lawrence, John F. . . . . . . . . . . . . . . . . b – Occidental Oil Li, Gang . . . . . . . . . . . . . . . . . . . . . . . . n
Lazennec, Jean Yves . . . . . . . . . . . . . . n Li, Guoan. . . . . . . . . . . . . . . . . . . . . . . n
Le, Dana. . . . . . . . . . . . . . . . . . . . . . . . n Li, Ru . . . . . . . . . . . . . . . . . . . . . . . . . . n
Le Duff, Michel Jean. . . . . . . . . . . . . . n Li, Sayori . . . . . . . . . . . . . . . . . . . . . . . n
Leardini, Alberto. . . . . . . . . . . . . . . . . c – Finsbury Li, Xinning. . . . . . . . . . . . . . . . . . . . . . n
LeBa, Thu-Ba . . . . . . . . . . . . . . . . . . . . n Liang, Sherri . . . . . . . . . . . . . . . . . . . . n
DISCLOSURE
Lebel, Benoit P . . . . . . . . . . . . . . . . . . n Liaw, Chen-Kun . . . . . . . . . . . . . . . . . n
Ledet, Eric H . . . . . . . . . . . . . . . . . . . . n Liddington, Mark . . . . . . . . . . . . . . . . n
Ledingham, W M . . . . . . . . . . . . . . . . n Liden, Mattias . . . . . . . . . . . . . . . . . . . n
Leduc, Stephane . . . . . . . . . . . . . . . . . n Lieberman, Jay R. . . . . . . . . . . . . . . . . a, b, e – DePuy, A Johnson & Johnson
Lee, Ben . . . . . . . . . . . . . . . . . . . . . . . . n Company, a – Arthrex, Inc, Tornier, Medarhs
Lee, C. Marcus. . . . . . . . . . . . . . . . . . . n Inc, b, e – Boehringer Ingelheim, Bayer
Lee, Choon-Ki . . . . . . . . . . . . . . . . . . . n Health Care.com, e – Scios
Lee, Dam-Seon . . . . . . . . . . . . . . . . . . n Liebs, Thoralf R. . . . . . . . . . . . . . . . . . n
Lee, Dam-Sum . . . . . . . . . . . . . . . . . . n Lim, Boon Whatt . . . . . . . . . . . . . . . . n
Lee, Daniel . . . . . . . . . . . . . . . . . . . . . e – Wright Medical Lim, Gerald . . . . . . . . . . . . . . . . . . . . . n
Lee, David . . . . . . . . . . . . . . . . . . . . . . n Lim, Kyung Su. . . . . . . . . . . . . . . . . . . n
Lee, Donald H. . . . . . . . . . . . . . . . . . . a, b, c, e – Biomet Lim, Moe R-P . . . . . . . . . . . . . . . . . . . n
Lee, Dong Joo . . . . . . . . . . . . . . . . . . . b – DePuy Lima, Ana Lucia . . . . . . . . . . . . . . . . . n
Lee, Francis Young-In . . . . . . . . . . . . . n Limpaphayom, Noppachart . . . . . . . n
Lee, Ho Gyu . . . . . . . . . . . . . . . . . . . . n Lin, Cindy . . . . . . . . . . . . . . . . . . . . . . n
Lee, Jae Joon . . . . . . . . . . . . . . . . . . . . n Lin, Eric . . . . . . . . . . . . . . . . . . . . . . . . n
Lee, Jin-Ho. . . . . . . . . . . . . . . . . . . . . . n Lin, Kenneth C . . . . . . . . . . . . . . . . . . n
Lee, Joon Yung . . . . . . . . . . . . . . . . . . n Lin, Sheldon S. . . . . . . . . . . . . . . . . . . a – Biomimetic, Medtronics Sofomor
Lee, Keun Bae . . . . . . . . . . . . . . . . . . . n Danek, e – Tissue Gene, Tornier
Lee, Kyung-Jae. . . . . . . . . . . . . . . . . . . n Lin, Wei-Hsin . . . . . . . . . . . . . . . . . . . n
Lee, Michael . . . . . . . . . . . . . . . . . . . . n Lincoln, Maximillian . . . . . . . . . . . . . n
Lee, Mija . . . . . . . . . . . . . . . . . . . . . . . n Lindemann, Jessica. . . . . . . . . . . . . . . n
Lee, Myung Chul . . . . . . . . . . . . . . . . n
Lee, Rushyuan . . . . . . . . . . . . . . . . . . . n
Lee, Sahnghoon . . . . . . . . . . . . . . . . . n

Lindenhovius, Anneluuk L . . . . . . . . a – Small Bone Innovations, Wright Maben, Catherine. . . . . . . . . . . . . . . . a – Stryker Spine, Synthes Spine
Medical, Smith & Nephew, Tornier, Mabilleau, Guillaume . . . . . . . . . . . . n
Acumed, Biomet, Joint Active Systems, AO- Mabrey, Jay D . . . . . . . . . . . . . . . . . . . a – Synthes, e – Exactech, Inc
CID, Annafonds, Stichting Professor Macaulay, William B . . . . . . . . . . . . . a – Zimmer, Smith & Nephew, b, e – Smith
Michael van Vloten Fonds, Stichting & Nephew, Wright Medical Technology, Inc.
Wetenschappelijk Onderzoek MacDermid, Joy C . . . . . . . . . . . . . . . n
Orthopaedische Chirurgie MacDonald, Daniel . . . . . . . . . . . . . . a – NIH Grant, a – Stryker
Lindsay, Adam . . . . . . . . . . . . . . . . . . n MacDonald, Steven J . . . . . . . . . . . . . a, e – DePuy, A Johnson & Johnson
Lindsey, Brock A . . . . . . . . . . . . . . . . . a – Orthopaedic Trauma Association, Company, a – Smith & Nephew, Stryker
Orthopaedic Research and Education MacGillivray, John Dougald . . . . . . . n
Foundation MacGregor, Michael . . . . . . . . . . . . . . n
Lindsey, Derek P . . . . . . . . . . . . . . . . . n Macheras, George A . . . . . . . . . . . . . . n
Lindsey, Ronald W . . . . . . . . . . . . . . . n Maciolek, Lawrence John. . . . . . . . . . n
Lindskog, Dieter . . . . . . . . . . . . . . . . . a – Smith & Nephew, Stryker, Synthes, Mack, Christopher D . . . . . . . . . . . . . n
e – Arthrocare MacKenzie, John D. . . . . . . . . . . . . . . n
Link, Allison . . . . . . . . . . . . . . . . . . . . n MacLean, Catherine . . . . . . . . . . . . . . n
Linklater, James. . . . . . . . . . . . . . . . . . n Macleod, Alan. . . . . . . . . . . . . . . . . . . b – Smith & Nephew
Lino Jr Waldo . . . . . . . . . . . . . . . . . . . n MacMillan, K. . . . . . . . . . . . . . . . . . . . n
Lipman, Joseph D. . . . . . . . . . . . . . . . n Madan, Sanjeev. . . . . . . . . . . . . . . . . . n
Lipton, Glenn E . . . . . . . . . . . . . . . . . n Maderazo, Alex . . . . . . . . . . . . . . . . . . n
Litchfield, Robert B. . . . . . . . . . . . . . . n Maeno, Shinichi . . . . . . . . . . . . . . . . . n
Little, Chris . . . . . . . . . . . . . . . . . . . . . n Maeyama, Akira . . . . . . . . . . . . . . . . . n
Little, Chris D . . . . . . . . . . . . . . . . . . . a – DePuy Maffulli, Nicola. . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company
Littleton, Aaron. . . . . . . . . . . . . . . . . . n Magaziner, Jay. . . . . . . . . . . . . . . . . . . a – Novartis and Merck, e – Amgen, Merck,
Liu, Fei . . . . . . . . . . . . . . . . . . . . . . . . . n Aventis, GTx, Merck and Pfizer
Liu, Gabriel . . . . . . . . . . . . . . . . . . . . . n Magerkurth, Olaf . . . . . . . . . . . . . . . . n
Liu, Hwa-Chang . . . . . . . . . . . . . . . . . n Magit, David . . . . . . . . . . . . . . . . . . . . n
Liu, Nancy Q. . . . . . . . . . . . . . . . . . . . n Mahar, Andrew . . . . . . . . . . . . . . . . . . a – Rady Childrens Hospital Orthopedic
Liu, Rue-Tsan. . . . . . . . . . . . . . . . . . . . n Research and Education Fund
Liu, Steve S . . . . . . . . . . . . . . . . . . . . . n Maher, Suzanne A. . . . . . . . . . . . . . . . a – Orteq, Ltd.
Livani, Bruno . . . . . . . . . . . . . . . . . . . n Maheshwari, Rajshri. . . . . . . . . . . . . . n
Llinas, Paulo . . . . . . . . . . . . . . . . . . . . n Mahfouz, Mohamed . . . . . . . . . . . . . a – Zimmer, Tornier, Archus Orthopedics,
Lo, Ian . . . . . . . . . . . . . . . . . . . . . . . . . a, b, c, e – Arthrex, Inc, b, c, e – Lippincott DePuy, Smith & Nephew, Biomet,
Loeffler, Bryan. . . . . . . . . . . . . . . . . . . n e – Zimmer
Loeven, Michael . . . . . . . . . . . . . . . . . n Mahoney, Craig Robert . . . . . . . . . . . n
Loew, Markus . . . . . . . . . . . . . . . . . . . n Mahoney, Ormonde M . . . . . . . . . . . a, b, c, e – Stryker
Lombardi Jr Adolph V . . . . . . . . . . . . a, b, c, e – Biomet, b – DJ Orthopaedics, Mahran, Mahmoud . . . . . . . . . . . . . . b – Smith & Nephew
Innomed, Medtronic, Medtronic Sofamor Mai, Kenny . . . . . . . . . . . . . . . . . . . . . n
Danek, Osteosolutions, Pfizer, Smith & Maier, Markus . . . . . . . . . . . . . . . . . . . n
Nephew, Stryker, Zimmer Mainine, Sergio. . . . . . . . . . . . . . . . . . n
Long, William T . . . . . . . . . . . . . . . . . e – Zimmer Mair, Jeffrey J. . . . . . . . . . . . . . . . . . . . n
Long, William . . . . . . . . . . . . . . . . . . . n Maistrelli, Gianni L. . . . . . . . . . . . . . . n
Longo, Umile Guiseppe. . . . . . . . . . . n Majid, Adnan . . . . . . . . . . . . . . . . . . . n
Lonner, Baron . . . . . . . . . . . . . . . . . . . a, b, e – DePuy Majima, Tokifumi. . . . . . . . . . . . . . . . n
Lonner, Jess H . . . . . . . . . . . . . . . . . . . a, b, c, e – Zimmer, e – MAKO surgical Major, Nancy M . . . . . . . . . . . . . . . . . n
Looney, Colin Guy . . . . . . . . . . . . . . . n Makela, Keijo . . . . . . . . . . . . . . . . . . . n
Lopes, Ademar . . . . . . . . . . . . . . . . . . n Makhni, Eric . . . . . . . . . . . . . . . . . . . . a – Small Bone Innovations, Wright Medical
Lopez Ovenza, Juan Manuel . . . . . . . n Technology, Inc.
Lopomo, Nicola . . . . . . . . . . . . . . . . . n Makino, Arturo Roberto. . . . . . . . . . . n
Lorang, Douglas . . . . . . . . . . . . . . . . . e – OsteoLign Inc Malawer, Martin M . . . . . . . . . . . . . . . a, c, e – Stryker Howmedica
Loree, Robert . . . . . . . . . . . . . . . . . . . . n Malchau, Henrik. . . . . . . . . . . . . . . . . a – Zimmer, Smith & Nephew, Biomet,
Lorich, Dean G . . . . . . . . . . . . . . . . . . n e – Smith & Nephew
Lott, Patricia . . . . . . . . . . . . . . . . . . . . n Malek, Farbod. . . . . . . . . . . . . . . . . . . n
Loveless, Eric A . . . . . . . . . . . . . . . . . . n Malhotra, Rajesh. . . . . . . . . . . . . . . . . n
Lovett, David. . . . . . . . . . . . . . . . . . . . n Malin, Andrew S . . . . . . . . . . . . . . . . . n
Low, Richard . . . . . . . . . . . . . . . . . . . . n Malizak, Robert A . . . . . . . . . . . . . . . . a – Stryker, Zimmer, Biomet
Lowder, Elizabeth . . . . . . . . . . . . . . . . n Malkani, Arthur L . . . . . . . . . . . . . . . . n
DISCLOSURE
Lowe, Thomas. . . . . . . . . . . . . . . . . . . a, c – DePuy Spine, c – Medtronic Mallory, Thomas H . . . . . . . . . . . . . . c, e – Biomet

Lowe, Walter R . . . . . . . . . . . . . . . . . . a – Stryker Howmedica Malone, Alex . . . . . . . . . . . . . . . . . . . . n
Lozano-Calderon, Santiago A . . . . . . n Maloney, William J. . . . . . . . . . . . . . . a, c – Zimmer, a – DePuy, A Johnson &
Lu, Yan. . . . . . . . . . . . . . . . . . . . . . . . . a – OsteoLign Inc Johnson Company, Medtronic, Synthes,
Lubbeke-Wolff, Anne . . . . . . . . . . . . . n c, e – Wright Medical Technology, Inc.
Lubowicki, Anne. . . . . . . . . . . . . . . . . n Malvitz, Thomas A . . . . . . . . . . . . . . . a – DePuy
Lucarini, Silvia . . . . . . . . . . . . . . . . . . n Maly, Pavel . . . . . . . . . . . . . . . . . . . . . n
Luft, Hal. . . . . . . . . . . . . . . . . . . . . . . . n Manaswi, Abhijit . . . . . . . . . . . . . . . . n
Lumawig, Jose Miguel Tanedo . . . . . n Manca, Aniello . . . . . . . . . . . . . . . . . . n
Lundberg, Hannah . . . . . . . . . . . . . . . a – NIH, NSF Mandelbaum, Bert . . . . . . . . . . . . . . . a, e – DePuy, A Johnson & Johnson
Luo, Zong-Ping . . . . . . . . . . . . . . . . . . n Company, Genzyme, Inc., Smith & Nephew,
Luria, Shai . . . . . . . . . . . . . . . . . . . . . . b – Arthrex b – Tigenix, Arthrex, Inc, d, e – Scandius,
Lurie, Jon D . . . . . . . . . . . . . . . . . . . . . e – Pacific Business Group on Health ONI, e – Regeneration Technologies, Inc.,
Luring, Christian. . . . . . . . . . . . . . . . . n Stryker, Zimmer, Tigenix
Lusignan, Daniel . . . . . . . . . . . . . . . . a, e – Zimmer, a – DePuy, Biomet, Smith & Mangla, Jimmi . . . . . . . . . . . . . . . . . . n
Nephew Manigrasso, Michaele B . . . . . . . . . . . n
Lusty, Patrick J . . . . . . . . . . . . . . . . . . . a – DePuy, Stryker Manjoo, Ajay. . . . . . . . . . . . . . . . . . . . n
Lv, Hua Guo . . . . . . . . . . . . . . . . . . . . n Manley, Michael T . . . . . . . . . . . . . . . e – Stryker
Lyford, Kimberly A . . . . . . . . . . . . . . . a – DePuy, Zimmer Mann, Frederick . . . . . . . . . . . . . . . . . n
Lyles, Kenneth. . . . . . . . . . . . . . . . . . . a – Novartis, Sanofi-Aventis, Procter & Manohar, Leslie . . . . . . . . . . . . . . . . . n
Gamble, Amgen, e – Novartis, Procter & Manoucis, Grigorios. . . . . . . . . . . . . . n
Gamble, Merck, Amgen, GTx, Manson, Theodore T . . . . . . . . . . . . . a – Synthes
GlaxoSmithKline, Eli Lilly, Bone Medical Mansour, Youseffi. . . . . . . . . . . . . . . . a – Smith & Nephew
Lyman, Stephen . . . . . . . . . . . . . . . . . a – Sanofi-Aventis Manteghi, Alexander . . . . . . . . . . . . . n
Ma, Jianjun . . . . . . . . . . . . . . . . . . . . . a – Allergan Manternach, Alison . . . . . . . . . . . . . . a – AORN, MVH Foundation

Manvar, Sheetal. . . . . . . . . . . . . . . . . . n Matsen, III, Frederick A . . . . . . . . . . . . a – Alaska Orthopaedic Specialists, AO
Marangoz, Salih . . . . . . . . . . . . . . . . . n North America, AO Spine North America,
Marcacci, Maurilio . . . . . . . . . . . . . . . n AO-Stiftung-ASIF Foundation, Bank of
Marchant Jr Milford H . . . . . . . . . . . . n America Foundation, Bearly, Inc., Helena
Marchesi, Stephanie . . . . . . . . . . . . . . n Orthopaedic Clinic, Illinois Orthopaedic &
Marchetti, Emmanuel . . . . . . . . . . . . n Hand, JMS Hand Associates, Northwest
Marcini, Amy . . . . . . . . . . . . . . . . . . . n Biomet, Inc., Orthopedic Surgeons, Pacific
Marcos, Lucas E. . . . . . . . . . . . . . . . . . n Medical, Inc, Pfizer, Inc., Proliance Surgeons,
Marcus, Randall Evan. . . . . . . . . . . . . a, b, d, e – Zimmer, a – AO, DePuy, Inc.,The Seattle Foundation, Seattle Hand
A Johnson & Johnson Company, EBI, Surgery Group, Silicon Valley Community
Medtronic Sofamor Danek, Musculoskeletal Foundation, Simonian Sports Medicine
Transplant Foundation, Ortho Biotech, Clinic, SpineVision, Inc., Synthes Spine, T&P,
Stryker, Synthes, Wright Medical LLC, Trimed, Inc., Washington Orthopaedic
Technology, Inc. Center, Washington State Orthopaedic
Marent, Marta . . . . . . . . . . . . . . . . . . . e – AO CID Association, Wright Medical Technology,
Marinelli, Mario . . . . . . . . . . . . . . . . . n National Institutes of Health (NIH),
Marinozzi, Andrea . . . . . . . . . . . . . . . n Veterans Affairs Rehabilitation Research and
Marin-Pena, Oliver . . . . . . . . . . . . . . . n Development Service, Orthopaedic Research
Marion, Chad . . . . . . . . . . . . . . . . . . . n and Education Foundation (OREF), A.O.
Markel, Mark D. . . . . . . . . . . . . . . . . . a – OsteoLign Inc North America, Amgen, Inc., Arthrex, Inc.,
Marker, David R . . . . . . . . . . . . . . . . . n BioAxone Therapeutique, Inc., CeraPedics,
Markert, Ronald L. . . . . . . . . . . . . . . . n LLC, Christopher Reeve Paralysis
Markowicz, Daniel . . . . . . . . . . . . . . . n Foundation, Foundation for Orthopedic
Marks, Barbara . . . . . . . . . . . . . . . . . . n Trauma, Integra Lifesciences Corporation,
Marks, Michelle . . . . . . . . . . . . . . . . . a – DePuy Spine Johnson & Johnson, nc., Kythera
Marra, Guido . . . . . . . . . . . . . . . . . . . a, b, e – Zimmer Biopharmaceuticals, Inc., National Science
Marsh, John Lawrence . . . . . . . . . . . . a, b – Smith & Nephew, c – Biomet Foundation , Ostex International, Inc.,
Marshall, Amanda . . . . . . . . . . . . . . . a – DePuy Orthopaedic Trauma Association, Synthes
Martell, John M . . . . . . . . . . . . . . . . . e – Stryker Spine Co., The Boeing Company, US Army
Martelli, Sandra . . . . . . . . . . . . . . . . . n Research Office, US Department of
Martimbianco, Ana L . . . . . . . . . . . . . n Education, Zymogenetics, Inc.
Martin, Elizabeth . . . . . . . . . . . . . . . . n Matsuda, Shuichi . . . . . . . . . . . . . . . . n
Martin, Krismer. . . . . . . . . . . . . . . . . . a – Stryker Matsueda, Mumenori. . . . . . . . . . . . . n
Martin, Robroy Lee. . . . . . . . . . . . . . . n Matsuki, Keisuke. . . . . . . . . . . . . . . . . n
Martin, Scott David . . . . . . . . . . . . . . n Matsumoto, Hideo. . . . . . . . . . . . . . . n
Martin, Shelden L . . . . . . . . . . . . . . . . a – Synthes Spine Matsumoto, Hiroko . . . . . . . . . . . . . . n
Martineau, Paul . . . . . . . . . . . . . . . . . b – Arthrex Matsuno, Shigeo. . . . . . . . . . . . . . . . . n
Marx, Robert G . . . . . . . . . . . . . . . . . . a – Arthrex, Smith & Nephew Matsuno, Takeo . . . . . . . . . . . . . . . . . n
Masada, Toshiaki . . . . . . . . . . . . . . . . n Matsuo, Toshihiro . . . . . . . . . . . . . . . n
Maselli, Judy . . . . . . . . . . . . . . . . . . . . n Matsuura, Tetsuya. . . . . . . . . . . . . . . . n
Mashru, Rakesh Pravinkumar . . . . . . n Matta, Joel Michael. . . . . . . . . . . . . . . b – DePuy, A Johnson & Johnson Company,
Mason, J Bohannon . . . . . . . . . . . . . . a, b, e – DePuy, A Johnson & Johnson c – OSI, e – DePuy, A Johnson & Johnson
Company, a – Zimmer, Wright Medical Company, Stryker
Technology, Inc. Mattan, Yoav . . . . . . . . . . . . . . . . . . . . a – Zimmer
Masonis, John Leander . . . . . . . . . . . a, b, e – Smith & Nephew Mattern, Christopher . . . . . . . . . . . . . n
Masri, Bassam A . . . . . . . . . . . . . . . . . a, b, e – Zimmer, d – Medtronic Mauck, Robert. . . . . . . . . . . . . . . . . . . n
Masse, Vincent . . . . . . . . . . . . . . . . . . n Mauffrey, Cyril . . . . . . . . . . . . . . . . . . n
Massin, Philippe. . . . . . . . . . . . . . . . . a – Zimmer Mavrogenis, Andreas . . . . . . . . . . . . . n
Matar, Wadih. . . . . . . . . . . . . . . . . . . . n Mavropoulos, John. . . . . . . . . . . . . . . n
Matava, Matthew J . . . . . . . . . . . . . . . a – Breg, b – Pfizer, e – ISTO Technologies Maxwell, Brian . . . . . . . . . . . . . . . . . . n
Matero, Catherine. . . . . . . . . . . . . . . . n May, Olivier. . . . . . . . . . . . . . . . . . . . . n
Matheney, Travis. . . . . . . . . . . . . . . . . n Mayerson, Joel . . . . . . . . . . . . . . . . . . a – Orthovita
Matheny, Lauren M . . . . . . . . . . . . . . a – Smith & Nephew, Genzyme, EBI Mayor, Michael B . . . . . . . . . . . . . . . . a, c, e – DePuy, a – Zimmer
Mathis, John M . . . . . . . . . . . . . . . . . . e – Stryker Mayr, Eckart. . . . . . . . . . . . . . . . . . . . . a – Stryker
Mathis, Kenneth B . . . . . . . . . . . . . . . e – Zimmer Mazur, John M . . . . . . . . . . . . . . . . . . n
Matschke, Stefan. . . . . . . . . . . . . . . . . a – AO CID Mazurek, Michael T . . . . . . . . . . . . . . n
Mazzocca, Augustus D . . . . . . . . . . . . a – Arthrex
DISCLOSURE
McAlister, Deborah M . . . . . . . . . . . . n
McAllister, Craig M. . . . . . . . . . . . . . . a, b, e – Stryker
McAuley, James P . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Company, a – Canadian Institutes of Health
Research (CIHR), Inova Health Care
Services, Johnson & Johnson, Smith &
Nephew, Zimmer
McCaffrey, Michael. . . . . . . . . . . . . . . n
McCalden, Richard W . . . . . . . . . . . . a, e – Smith & Nephew, a – DePuy,
A Johnson & Johnson Company, e – Stryker
McCann, Peter D . . . . . . . . . . . . . . . . e – Conmed, DePuy
McCarthy, James J. . . . . . . . . . . . . . . . a, b – EBI, Biomet, a – DePuy, A Johnson &
Johnson Company, Shriners Hospitals for
Children Clinical Outcomes Studies
Advisory Board, Synthes
McCarthy, Joseph C . . . . . . . . . . . . . . a – Biomet, Zimmer, b – Vindico,
c, e – Stryker, c – Arthrex, Inc, Innomed
McCarthy, Richard E. . . . . . . . . . . . . . a – Medtronic
McCarthy, Tom . . . . . . . . . . . . . . . . . . n
McCarty, Eric Cleveland. . . . . . . . . . . a – Arthrex, Smith & Nephew, Stryker
Howmedica
McClelland, Jodie A . . . . . . . . . . . . . . a – Smith & Nephew
McClelland Jr Walter B. . . . . . . . . . . . n
McClung, Anna. . . . . . . . . . . . . . . . . . n
McCollough, Cynthia H . . . . . . . . . . b – Siemens Medical Solutions

McConnell, Sharon . . . . . . . . . . . . . . n Mighell, Mark A . . . . . . . . . . . . . . . . . e – DePuy
McCormack, Damian. . . . . . . . . . . . . n Mihalko, William Michael. . . . . . . . . a, b, e – Smith & Nephew, b, e – Stryker,
McCormack, Robert G . . . . . . . . . . . . a – Stryker Howmedica, Synthes, Trimed, Ethicon
Zimmer Mihata, Teruhisa . . . . . . . . . . . . . . . . . n
McCullough, Matthew . . . . . . . . . . . . n Mik, Gokce . . . . . . . . . . . . . . . . . . . . . n
McDaniel, Candice O. . . . . . . . . . . . . n Mikami, Yasuo . . . . . . . . . . . . . . . . . . n
McEachern, Edward . . . . . . . . . . . . . . n Miki, Roberto . . . . . . . . . . . . . . . . . . . n
McElwain, John . . . . . . . . . . . . . . . . . n Mikolyzk, David K . . . . . . . . . . . . . . . n
McEvoy, Fiona. . . . . . . . . . . . . . . . . . . n Milbrandt, Todd A . . . . . . . . . . . . . . . n
McFarland, Edward G . . . . . . . . . . . . a, b, e – DePuy, A Johnson & Johnson Milet, Alexandre . . . . . . . . . . . . . . . . . n
Company, Stryker, a – Encore Medical Mileti, Joseph . . . . . . . . . . . . . . . . . . . n
McGarry, John. . . . . . . . . . . . . . . . . . . n Millar, Neal L . . . . . . . . . . . . . . . . . . . n
McGarry, Michelle H . . . . . . . . . . . . . n Miller, Christopher P . . . . . . . . . . . . . n
McGee-Brown, Jeanie. . . . . . . . . . . . . n Miller, Derek W. . . . . . . . . . . . . . . . . . n
McGrath, Anthony F . . . . . . . . . . . . . n Miller, Freeman. . . . . . . . . . . . . . . . . . n
McGrory, Brian Joseph. . . . . . . . . . . . n Miller, Gavin . . . . . . . . . . . . . . . . . . . . n
McGwin Jr Gerald. . . . . . . . . . . . . . . . n Miller, Mark D . . . . . . . . . . . . . . . . . . n
McHugh, P . . . . . . . . . . . . . . . . . . . . . n Miller, Suzanne L . . . . . . . . . . . . . . . . n
McIntosh, Amy L . . . . . . . . . . . . . . . . n Millett, Peter J . . . . . . . . . . . . . . . . . . . a, c, e – Arthrex, Inc, a – Genzyme, Smith &
McKee, Michael D. . . . . . . . . . . . . . . . a – Zimmer, b – Stryker Biotech Nephew
McKee, Travis R . . . . . . . . . . . . . . . . . . e – Biomet Millis, Michael B. . . . . . . . . . . . . . . . . n
McKinney, Bart . . . . . . . . . . . . . . . . . . n Millman, Jennifer E . . . . . . . . . . . . . . n
McLain, Robert F. . . . . . . . . . . . . . . . . a – Abbott, Blackstone Medical, DePuy, Milos, Steven. . . . . . . . . . . . . . . . . . . . a – Arthrex, Inc
A Johnson & Johnson Company, EBI, Min, Byung Woo. . . . . . . . . . . . . . . . . n
Stryker, Synthes, Zimmer, e – Blackstone Minami, Akio . . . . . . . . . . . . . . . . . . . n
Medical, Stryker Minami, Michio . . . . . . . . . . . . . . . . . n
McLardy-Smith, Peter. . . . . . . . . . . . . e – Wright Medical Technology Mine, Ryoko . . . . . . . . . . . . . . . . . . . . n
McLaughlin, Joseph S. . . . . . . . . . . . . n Mineta, Mitsuyoshi. . . . . . . . . . . . . . . n
McLaurin, Toni M. . . . . . . . . . . . . . . . b – Zimmer Miniaci, Anthony . . . . . . . . . . . . . . . . a, b, e – Stryker, a, c – Zimmer, a – Arthrex,
McLean, Alan N . . . . . . . . . . . . . . . . . n Inc, DJ Orthopaedics, c, d – Arthrosurface,
McMahon, Margot . . . . . . . . . . . . . . . n c – Tenet
McMinn, Derek James Wallace . . . . . a, b, c, d, e – Smith & Nephew Minoda, Yukihide. . . . . . . . . . . . . . . . a – DePuy, Wright Medical, Zimmer
McNulty, Donald . . . . . . . . . . . . . . . . e – DePuy Minola, Riccardo . . . . . . . . . . . . . . . . n
McPherson, Edward J . . . . . . . . . . . . . a, c, e – Biomet Minter, Christin . . . . . . . . . . . . . . . . . n
McQueen, David A. . . . . . . . . . . . . . . a, e – Stryker Orthopaedics, e – Howmedica Mintz, Douglas N . . . . . . . . . . . . . . . . n
McQueen, Margaret M . . . . . . . . . . . . n Miranda, Michael Anthony . . . . . . . . n
McTighe, Timothy . . . . . . . . . . . . . . . a – JISRF, GOT, OMNI Life, Encore Mirza, Sohail K . . . . . . . . . . . . . . . . . . n
Meadows, James R . . . . . . . . . . . . . . . n Miscione, Maria Teresa. . . . . . . . . . . . n
Mears, Simon . . . . . . . . . . . . . . . . . . . a – Zimmer Misselwitz, Frank . . . . . . . . . . . . . . . . e – Bayer Health Care AG
Meding, John B. . . . . . . . . . . . . . . . . . a – Stryker, Zimmer, Biomet Mitani, Shigeru . . . . . . . . . . . . . . . . . . n
Medley, John B . . . . . . . . . . . . . . . . . . a – Canadian Arthitis Network, Mittlmeier, Thomas W F . . . . . . . . . . b – Braun-Aesculap
e – Medtronic, a – DePuy Miura, Hiromasa . . . . . . . . . . . . . . . . n
Meehan, John Patrick. . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Miyasaka, Takeshi. . . . . . . . . . . . . . . . n
Stryker, b – DePuy, A Johnson & Johnson Miyatake, Shin . . . . . . . . . . . . . . . . . . n
Company Mizel, Mark S . . . . . . . . . . . . . . . . . . . n
Meermans, Geert . . . . . . . . . . . . . . . . b – Smith & Nephew Mizner, Ryan L . . . . . . . . . . . . . . . . . . n
Mehbod, Amir A. . . . . . . . . . . . . . . . . a – Medtronic, Stryker Mizuuchi, Hideki . . . . . . . . . . . . . . . . n
Mehle, Susan Clay . . . . . . . . . . . . . . . n Moazzaz, Payam . . . . . . . . . . . . . . . . . n
Mehlhoff, Thomas L. . . . . . . . . . . . . . n Mochida, Joji. . . . . . . . . . . . . . . . . . . . n
Mehlman, Charles T. . . . . . . . . . . . . . a – NIH, d – Eli Lilly Modi, Chetan S. . . . . . . . . . . . . . . . . . n
Meininger, Alexander . . . . . . . . . . . . . n Moed, Berton R. . . . . . . . . . . . . . . . . . a, c – DePuy, A Johnson & Johnson
Melkerson, Mark. . . . . . . . . . . . . . . . . n Company, a, e – Stryker, a – Smith &
Meller, Rupert . . . . . . . . . . . . . . . . . . . n Nephew, Synthes, Zimmer
Melloh, Markus . . . . . . . . . . . . . . . . . n Moeller, Amy Teresa . . . . . . . . . . . . . . n
Melvin III James Stuart. . . . . . . . . . . . n Moen, Kathleen Y . . . . . . . . . . . . . . . . n
Melzer, Christian . . . . . . . . . . . . . . . . n Moezzi, Darius M . . . . . . . . . . . . . . . . n
Mendez, Kirk. . . . . . . . . . . . . . . . . . . . n Mohan, Arvind . . . . . . . . . . . . . . . . . . n
DISCLOSURE
Meneghini, Robert Michael . . . . . . . . a, e – Stryker Mohan, Vivek . . . . . . . . . . . . . . . . . . . n

Menetrey, Jacques . . . . . . . . . . . . . . . . a – Zimmer, DePuy, A Johnson & Johnson Mohr, Karen J . . . . . . . . . . . . . . . . . . . n
Company, Synthes, Medacta, Storz Mohtadi, Nick G. . . . . . . . . . . . . . . . . n
Mercuri, Mario . . . . . . . . . . . . . . . . . . n Moindreau, Marie. . . . . . . . . . . . . . . . n
Merk, Bradley Robert . . . . . . . . . . . . . a – Synthes, b – Stryker Mok, Daniel . . . . . . . . . . . . . . . . . . . . a – Biomet Sports Medicine
Merk, James C. . . . . . . . . . . . . . . . . . . n Moller, Anders . . . . . . . . . . . . . . . . . . n
Merkl, Brandon Cole . . . . . . . . . . . . . n Molloy, Tim. . . . . . . . . . . . . . . . . . . . . n
Mesenbrink, Peter. . . . . . . . . . . . . . . . d, e – Novartis Mologne, Timothy Scott . . . . . . . . . . n
Messerschmitt, Patrick . . . . . . . . . . . . n Mommsen, Philipp . . . . . . . . . . . . . . n
Metcalf, Ben . . . . . . . . . . . . . . . . . . . . n Momonoi, Yoshitaka . . . . . . . . . . . . . n
Meuffels, Duncan . . . . . . . . . . . . . . . . n Monaco, Edoardo. . . . . . . . . . . . . . . . n
Meyer, Christiane . . . . . . . . . . . . . . . . n Monden, Satoshi . . . . . . . . . . . . . . . . n
Meyer, Christopher L . . . . . . . . . . . . . n Monson, David K . . . . . . . . . . . . . . . . n
Meyer, Dominik Christoph . . . . . . . . n Mont, Michael A. . . . . . . . . . . . . . . . . a, e – Wright Medical Technology, Inc.,
Meyer, Nicholas J . . . . . . . . . . . . . . . . n Stryker, a – Brainlab
Michael, John . . . . . . . . . . . . . . . . . . . n Monteleone, Brad . . . . . . . . . . . . . . . . a – LifeMark Health, Breg
Micheli, Lyle J . . . . . . . . . . . . . . . . . . . a – Genzyme Corp. Board Montgomery, Christopher. . . . . . . . . n
Miclau, Theodore . . . . . . . . . . . . . . . . a, e – AO, DePuy, A Johnson & Johnson Montgomery, Hugh . . . . . . . . . . . . . . n
Company, Musculoskeletal Transplant Montgomery, R J. . . . . . . . . . . . . . . . . n
Foundation, a – Brainlab, National Moon, Eun-Sun . . . . . . . . . . . . . . . . . n
Institutes of Health (NIAMS & NICHD), Moon, Kyoung Ho . . . . . . . . . . . . . . . b – DePuy
Stryker, Synthes, Zimmer, d – Johnson & Moon, Randall T. . . . . . . . . . . . . . . . . n
Johnson, Merck, Pfizer, e – Amgen Co Mooney III James F . . . . . . . . . . . . . . n
Middleton, William D . . . . . . . . . . . . n Moons, Carl . . . . . . . . . . . . . . . . . . . . n
Migaud, Henri. . . . . . . . . . . . . . . . . . . e – Tornier Moore, Douglas C . . . . . . . . . . . . . . . n

Moore, K David. . . . . . . . . . . . . . . . . . a, b – Biomet, Smith & Nephew Nada, Atif M . . . . . . . . . . . . . . . . . . . . e – Nevill Hall Hospital
Moore, Thomas J . . . . . . . . . . . . . . . . a – Kinetic Concepts Inc. Nadzadi, Mark . . . . . . . . . . . . . . . . . . e – Smith & Nephew
Mootoo, Nicola M . . . . . . . . . . . . . . . a – DePuy, Zimmer Nagamachi, Akihiro . . . . . . . . . . . . . . n
Moquin, Ross . . . . . . . . . . . . . . . . . . . n Naganuma, Yasushi . . . . . . . . . . . . . . n
Morag, Guy . . . . . . . . . . . . . . . . . . . . . n Nagoya, Satoshi . . . . . . . . . . . . . . . . . n
Moran, Steven L . . . . . . . . . . . . . . . . . n Naito, Masatoshi . . . . . . . . . . . . . . . . n
Morandi, Massimo Max. . . . . . . . . . . n Nakajima, Takayuki . . . . . . . . . . . . . . n
Morgan, Steven J. . . . . . . . . . . . . . . . . a, b – AO, Smith & Nephew, Stryker, Nakamura, Hiroyuki . . . . . . . . . . . . . n
Synthes, a, d – Johnson & Johnson, Nakamura, Junichi . . . . . . . . . . . . . . . n
a, e – Biomet Nakamura, Norimasa. . . . . . . . . . . . . n
Moriishi, Joji . . . . . . . . . . . . . . . . . . . . n Nakanishi, Kazuyoshi . . . . . . . . . . . . n
Morimoto, Yuki . . . . . . . . . . . . . . . . . n Nakano, Shunji. . . . . . . . . . . . . . . . . . n
Moritomo, Hisao . . . . . . . . . . . . . . . . n Nakashima, Hiroatsu . . . . . . . . . . . . . n
Morishita, Yuichiro. . . . . . . . . . . . . . . n Nakata, Katsuya . . . . . . . . . . . . . . . . . n
Moritz IV Burt E . . . . . . . . . . . . . . . . . a – Arthrex Nakata, Ken. . . . . . . . . . . . . . . . . . . . . n
Morley, John R . . . . . . . . . . . . . . . . . . n Namba, Robert S . . . . . . . . . . . . . . . . c – Innomed
Moroni, Antonio . . . . . . . . . . . . . . . . a – Orthofix, Inc., Smith & Nephew, Active Namdari, Surena . . . . . . . . . . . . . . . . n
Implants, b – Stryker, Smith & Nephew, JRI Nana, Arvind D. . . . . . . . . . . . . . . . . . n
Morra, Edward . . . . . . . . . . . . . . . . . . a – Finsbury, DePuy Nanni, Mateo . . . . . . . . . . . . . . . . . . . n
Morrey, Bernard F . . . . . . . . . . . . . . . . c – Aircast(DJ), SBI, Stryker, Zimmer Nantel, Julie . . . . . . . . . . . . . . . . . . . . a – Zimmer
Morris, Carol D. . . . . . . . . . . . . . . . . . n Naresh Babu, J . . . . . . . . . . . . . . . . . . n
Morscher, Melanie . . . . . . . . . . . . . . . n Nargol, Antoni . . . . . . . . . . . . . . . . . . a, b – DePuy
Morshed, Saam. . . . . . . . . . . . . . . . . . n Narikawa, Kouichi . . . . . . . . . . . . . . . n
Morton, David . . . . . . . . . . . . . . . . . . n Narvez, Fernando . . . . . . . . . . . . . . . . n
Mosca, Vincent Stephen. . . . . . . . . . . n Nascone, Jason Warren . . . . . . . . . . . a, e – Synthes
Moseley, Bruce . . . . . . . . . . . . . . . . . . n Nash, Michael. . . . . . . . . . . . . . . . . . . n
Moseley, Jon . . . . . . . . . . . . . . . . . . . . e – Wright Medical Technology, Inc. Nasser, Ahmad Bin. . . . . . . . . . . . . . . n
Moser, Carsten . . . . . . . . . . . . . . . . . . n Nasser, Philip . . . . . . . . . . . . . . . . . . . n
Moser, Michael William. . . . . . . . . . . n Nathwani, Dinesh K. . . . . . . . . . . . . . n
Moser, Micheal T . . . . . . . . . . . . . . . . n Natividad, Toribio T . . . . . . . . . . . . . . n
Moskowitz, Alan. . . . . . . . . . . . . . . . . a – Stryker Spine, Synthes Spine, e – Stryker Naudie, Doug . . . . . . . . . . . . . . . . . . . a, b – DePuy, A Johnson & Johnson
Spine Company, Smith & Nephew, e – Smith &
Mosqueda, Teresa V . . . . . . . . . . . . . . n Nephew
Mottard, Sophie . . . . . . . . . . . . . . . . . n Naughton, Marybeth . . . . . . . . . . . . . e – Stryker Howmedica
Mounce, R Douglas . . . . . . . . . . . . . . n Navarro, Ronald Anthony . . . . . . . . . n
Mprilakis, Manolis . . . . . . . . . . . . . . . n Naylor, Malcolm G. . . . . . . . . . . . . . . e – Biomet
Mraovic, Boris . . . . . . . . . . . . . . . . . . . n Nazarian, David George . . . . . . . . . . a, c, e – Zimmer
Mruyama, Kazuo . . . . . . . . . . . . . . . . n Nazarian, Levon N . . . . . . . . . . . . . . . n
Mudgal, Chaitanya S . . . . . . . . . . . . . a – Small Bone Innovations, Wright Nebelung, Wolfgang. . . . . . . . . . . . . . n
Medical, Smith & Nephew, Tournier, Nedeman, Vered . . . . . . . . . . . . . . . . . n
Acumed, Biomet, Joint Active Systems, AO- Nellans, Kate W . . . . . . . . . . . . . . . . . n
CID Nelson, Bradley James . . . . . . . . . . . . n
Mueller, Michael. . . . . . . . . . . . . . . . . n Nelson, Charles L . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Mueller, Peter E. . . . . . . . . . . . . . . . . . n b – Zimmer, c – Exactech, Inc, e – Zimmer
Muirhead-Allwood, Sarah . . . . . . . . . e – DePuy, Smith & Nephew, Zimmer Nemke, Brett . . . . . . . . . . . . . . . . . . . . a – OsteoLign Inc
Mulcahey, Mary Jane . . . . . . . . . . . . . n Nepola, James V . . . . . . . . . . . . . . . . . n
Mulcahey-Hershey, Mary Jane. . . . . . n Nepple, Jeffrey. . . . . . . . . . . . . . . . . . . n
Mulconrey, Daniel . . . . . . . . . . . . . . . n Nestor, Bryan J . . . . . . . . . . . . . . . . . . a – Knee Society
Muldoon, Michael P . . . . . . . . . . . . . e – Plus Neumann, Wolfram . . . . . . . . . . . . . . n
Muldrew, Kenneth . . . . . . . . . . . . . . . n Neviaser, Andrew . . . . . . . . . . . . . . . . n
Mulhall, Kevin James . . . . . . . . . . . . . n Newberg, Andrew. . . . . . . . . . . . . . . . n
Mulieri, Philip. . . . . . . . . . . . . . . . . . . n Newcomb, William A. . . . . . . . . . . . . n
Muller, Christoph . . . . . . . . . . . . . . . . a – Plus Orthopedics (Smith & Nephew) Newman, Joel S . . . . . . . . . . . . . . . . . e – ONI Medical Systems
Muller, Mathias. . . . . . . . . . . . . . . . . . e – AO Foundation Newman, John . . . . . . . . . . . . . . . . . . a – Stryker, Smith & Nephew, Corin,
Muller, Peter . . . . . . . . . . . . . . . . . . . . n b – Stryker Howmedica, c – Smith &
Mulliken, Brian D. . . . . . . . . . . . . . . . n Nephew, Corin
Mulpuri, Kishore . . . . . . . . . . . . . . . . n Newman, June . . . . . . . . . . . . . . . . . . a – Biomimetics
DISCLOSURE
Murakami, Hideki . . . . . . . . . . . . . . . n Newman, Justin T. . . . . . . . . . . . . . . . n
Murase, Tsuyoshi . . . . . . . . . . . . . . . . n Newton, Peter O . . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Muriuki, Mituri. . . . . . . . . . . . . . . . . . n Company
Murphy, Jeffrey A . . . . . . . . . . . . . . . . e – DePuy Ng, Aaron . . . . . . . . . . . . . . . . . . . . . . n
Murphy, Stephen B. . . . . . . . . . . . . . . a, c, e – Wright Medical Technology, Inc., Ngarmukos, Srihatach . . . . . . . . . . . . n
e – Brainlab, Smith & Nephew Nho, Shane . . . . . . . . . . . . . . . . . . . . . n
Murray, Barbara E . . . . . . . . . . . . . . . . n Nicholson, Gregory P. . . . . . . . . . . . . a – EBI, c, d, e – Zimmer c – Innomed
Murray, David W . . . . . . . . . . . . . . . . a – Biomet, Stryker, Smith & Nephew, Niederle, Muriel . . . . . . . . . . . . . . . . . n
Wright Medical Technology, Inc., Zimmer, Nielsen, Jonathan. . . . . . . . . . . . . . . . e – Smith & Nephew
c, e – Biomet Niki, Hisateru . . . . . . . . . . . . . . . . . . . n
Murrell, George A C . . . . . . . . . . . . . . n Niki, Yasuo . . . . . . . . . . . . . . . . . . . . . n
Murthi, Anand M . . . . . . . . . . . . . . . . a – Arthrex, Inc, DePuy, A Johnson & Nilsson, Katarina . . . . . . . . . . . . . . . . n
Johnson Company, Synthes, b, e – Zimmer Nilsson, Kjell G. . . . . . . . . . . . . . . . . . a – Smith & Nephew, Zimmer
Murugan, Subramaniam . . . . . . . . . . n Ninh, Christopher Cao . . . . . . . . . . . n
Muschler, George F. . . . . . . . . . . . . . . a – Procter & Gamble, Stryker, Synthes, Nishida, Hideji . . . . . . . . . . . . . . . . . . n
b – DePuy, A Johnson & Johnson Company, Nishida, Jun . . . . . . . . . . . . . . . . . . . . a – Iwate Medical University
Therics, Inc, c – DePuy, A Johnson & Nishida, Yoshihiro . . . . . . . . . . . . . . . n
Johnson Company, d – Cleveland BioLabs, Nishii, Takashi . . . . . . . . . . . . . . . . . . n
Inc (CBLI), e – DePuy, A Johnson & Nishiike, Osamu. . . . . . . . . . . . . . . . . n
Johnson Company, Stryker Nishikawa, Koichiro. . . . . . . . . . . . . . n
Muscolo, Domingo Luis . . . . . . . . . . n Nishikawa, Masataka . . . . . . . . . . . . . n
Myerson, Mark S. . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson Nishio, Yasuhiko . . . . . . . . . . . . . . . . n
Company, a, c, e – Biomet, e – Hand Nizard, Remi S . . . . . . . . . . . . . . . . . . n
Innovations Noble, Philip C. . . . . . . . . . . . . . . . . . a – Stryker Howmedica, e – Zimmer
Nace, Lesley. . . . . . . . . . . . . . . . . . . . . n Nogler, Michael M . . . . . . . . . . . . . . . e – Stryker Howmedica

Noguchi, Hideo . . . . . . . . . . . . . . . . . n Olsen, Michael . . . . . . . . . . . . . . . . . . n
Noguchi, Hideo . . . . . . . . . . . . . . . . . n Olsewski, John M . . . . . . . . . . . . . . . . n
Noguchi, Hideo . . . . . . . . . . . . . . . . . n Olson, Steven A . . . . . . . . . . . . . . . . . n
Noiseux, Nicolas. . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company O’Mahony, David . . . . . . . . . . . . . . . . n
Nolan, John . . . . . . . . . . . . . . . . . . . . a – Stryker O’Malley, Martin J . . . . . . . . . . . . . . . n
Nonaka, Shinsuke . . . . . . . . . . . . . . . n Omata, Junichi . . . . . . . . . . . . . . . . . . n
Noonan, Kenneth J. . . . . . . . . . . . . . . n O’Neill, Brian . . . . . . . . . . . . . . . . . . . n
Noorani, Ali M . . . . . . . . . . . . . . . . . . n O’Neill, Michelle Elyse. . . . . . . . . . . . n
Norberg, Alonna. . . . . . . . . . . . . . . . . n Ong, Kevin . . . . . . . . . . . . . . . . . . . . . a – Zimmer, Stryker, Medtronic Sofamor
Norberg, John . . . . . . . . . . . . . . . . . . . n Danek, Kyphon Inc., e – Stryker
Nord, Russell. . . . . . . . . . . . . . . . . . . . n Ono, Seiichi . . . . . . . . . . . . . . . . . . . . n
Nordsletten, Lars . . . . . . . . . . . . . . . . a – Biomet, e – Novartis, DePuy, Wyeth O’Rourke, Kieran S . . . . . . . . . . . . . . . n
Nork, Sean E . . . . . . . . . . . . . . . . . . . . a – Zimmer, Synthes, EBI, Stryker O’Rourke, Michael R . . . . . . . . . . . . . b, e – DePuy, A Johnson & Johnson
Norris, Tom R . . . . . . . . . . . . . . . . . . . a, c, e – Tornier Company
Norton, H James. . . . . . . . . . . . . . . . . n Osaki, Makoto . . . . . . . . . . . . . . . . . . n
Norton, Knight Martin Tonebridge . . n Osawa, Toshihisa . . . . . . . . . . . . . . . . n
Norton, Mark . . . . . . . . . . . . . . . . . . . e – Corin, Bone and Joint Solutions LLP, Oskouei, Shervin V. . . . . . . . . . . . . . . n
Trust Health Limited Ostermeier, Sven. . . . . . . . . . . . . . . . . n
Nousiainen, Markku . . . . . . . . . . . . . n O’Sullivan, Kathleen . . . . . . . . . . . . . n
Novak, Erik J . . . . . . . . . . . . . . . . . . . . a – Medtronic Oswald, Timothy Stephen . . . . . . . . . n
Novicoff, Wendy. . . . . . . . . . . . . . . . . a – Smith & Nephew Otani, Toshiro. . . . . . . . . . . . . . . . . . . n
Nunley, II, James Albert . . . . . . . . . . . a – Piedmont Orthopaedic Society Otoi, Takeshige . . . . . . . . . . . . . . . . . . n
Nunley, Ryan. . . . . . . . . . . . . . . . . . . . a – Smith & Nephew O’Toole, Robert V . . . . . . . . . . . . . . . . a – Smith & Nephew, Synthes, Stryker,
Nyffeler, Richard W . . . . . . . . . . . . . . n e – Synthes
Obata, Masanori. . . . . . . . . . . . . . . . . n Otsuka, Norman Yoshinobu . . . . . . . a – National Institutes of Health (NIAMS &
Obert, Richard . . . . . . . . . . . . . . . . . . e – Wright Medical Technology, Inc. NICHD), Shriners Hospitals for Children
Obopilwe, Elifho . . . . . . . . . . . . . . . . n Clinical Outcomes Studies Advisory Board
Obremskey, William . . . . . . . . . . . . . a – Synthes, e – Medtronic, Osteogenix Ouellette, Elizabeth A . . . . . . . . . . . . n
Obremsky, William T . . . . . . . . . . . . . a – Kinetic Concepts Inc. Oussedik, Sam . . . . . . . . . . . . . . . . . . n
O’Brien, Michael J . . . . . . . . . . . . . . . n Overgard, Soren . . . . . . . . . . . . . . . . . n
O’Brien, Stephen J . . . . . . . . . . . . . . . n Owashi, Kazuya . . . . . . . . . . . . . . . . . n
O’Brien, Timothy S. . . . . . . . . . . . . . . a – Sanofi Aventis, Genzyme Owens, Joshua Burk . . . . . . . . . . . . . . n
O’Byrne, John Martin. . . . . . . . . . . . . n Oyama, Kori . . . . . . . . . . . . . . . . . . . . n
Ochi, Mitsuo . . . . . . . . . . . . . . . . . . . . a – Alcare, Smith & Nephew, Stryker, Ozaki, Toshifumi . . . . . . . . . . . . . . . . n
Zimmer, b, e – Smith & Nephew Ozawa, Tomoyuki . . . . . . . . . . . . . . . n
Ochoa, Jorge A . . . . . . . . . . . . . . . . . . e – Archus Orthopedics Ozer, Kagan. . . . . . . . . . . . . . . . . . . . . n
O’Connor, J Patrick . . . . . . . . . . . . . . d – Avelalox Inc. Ozgen, Zerrin . . . . . . . . . . . . . . . . . . . n
O’Connor, James Patrick . . . . . . . . . . a – Wyeth Corp. Paavolainen, Pekka. . . . . . . . . . . . . . . n
O’Connor, Mary I . . . . . . . . . . . . . . . . a, c – DePuy, A Johnson & Johnson Pacifici, Maurizio . . . . . . . . . . . . . . . . n
Company, c – Zimmer Pack, Bryan . . . . . . . . . . . . . . . . . . . . . n
Oda, Hiromi . . . . . . . . . . . . . . . . . . . . n Packham, Iain . . . . . . . . . . . . . . . . . . . n
Oda, Ryo . . . . . . . . . . . . . . . . . . . . . . . n Paczas, Michael. . . . . . . . . . . . . . . . . . n
Oda, Yutaka. . . . . . . . . . . . . . . . . . . . . n Padgett, Douglas E . . . . . . . . . . . . . . . a – MCI
Odebiyi, Daniel O . . . . . . . . . . . . . . . n Paessler, Hans H . . . . . . . . . . . . . . . . . n
O’Driscoll, Shawn W . . . . . . . . . . . . . b, c – Acumed, LLC, c – Aircast(DJ), Tornier Pagenstert, Geert. . . . . . . . . . . . . . . . . a – Zimmer, Stryker
Odum, Susan Marie . . . . . . . . . . . . . . a – DePuy, Smith & Nephew Pagkrati, Stavroula . . . . . . . . . . . . . . . n
Oduwole, Kayode . . . . . . . . . . . . . . . . n Pagnani, Michael J . . . . . . . . . . . . . . . n
Oetgen, Matthew . . . . . . . . . . . . . . . . n Pagnano, Mark W. . . . . . . . . . . . . . . . a, c – DePuy, A Johnson & Johnson
Ofluoglu, Onder. . . . . . . . . . . . . . . . . n Company, Zimmer, a – Musculoskeletal
Ogilvie, Christian M. . . . . . . . . . . . . . a – Stryker Howmedica Transplant Foundation, National Institutes
Ogose, Akira . . . . . . . . . . . . . . . . . . . . n of Health (NIAMS & NICHD), Stryker
Ogut, Tahir . . . . . . . . . . . . . . . . . . . . . n Pahk, Brian . . . . . . . . . . . . . . . . . . . . . n
Oh, Chang-Wug . . . . . . . . . . . . . . . . . a – Kyungpook National University Pakos, Aimilios . . . . . . . . . . . . . . . . . . n
Oh, Chung Hee . . . . . . . . . . . . . . . . . n Paksima, Nader. . . . . . . . . . . . . . . . . . a, e – Stryker Howmedica
Oh, Joo Han . . . . . . . . . . . . . . . . . . . . n Palan, Jeya . . . . . . . . . . . . . . . . . . . . . . a, b – Stryker Howmedica
Oha, Fumihiro . . . . . . . . . . . . . . . . . . n Paley, Dror. . . . . . . . . . . . . . . . . . . . . . a, b, e – Orthofix, a, e – Smith & Nephew
Ohashi, Hirotsugu . . . . . . . . . . . . . . . n Paller, David . . . . . . . . . . . . . . . . . . . . n
DISCLOSURE
Ohata, Norihide . . . . . . . . . . . . . . . . . n Palti, Ram . . . . . . . . . . . . . . . . . . . . . . n

Ohgushi, Hajime . . . . . . . . . . . . . . . . n Panagiotopoulos, Kostas . . . . . . . . . . n
Ohlin, Acke . . . . . . . . . . . . . . . . . . . . . n Panchbhavi, Vinod Kumar . . . . . . . . n
Ohnmeiss, Donna D . . . . . . . . . . . . . n Pandit, Hemant G . . . . . . . . . . . . . . . a – Biomet
Ohta, Yoichi . . . . . . . . . . . . . . . . . . . . n Pantazopoulos, Christina . . . . . . . . . n
Ohzono, Kenji . . . . . . . . . . . . . . . . . . n Paoletta, Ruben. . . . . . . . . . . . . . . . . . n
Oinuma, Kazuhiro . . . . . . . . . . . . . . . n Papadopoulos, Stephen . . . . . . . . . . . c, d, e – Medtronic
Oka, Richard . . . . . . . . . . . . . . . . . . . . n Papagelopoulos, Panayiotis J . . . . . . n
Okada, Hirokazu . . . . . . . . . . . . . . . . n Papavasiliou, Kyriakos Athanasios . . n
Okamura, Kenji . . . . . . . . . . . . . . . . . n Pape, Hans-Christoph . . . . . . . . . . . . a – Synthes, Stryker, Zimmer
Okano, Kunihiko . . . . . . . . . . . . . . . . n Pappannagari, Ramprasad. . . . . . . . . n
Okazaki, Hroyuki . . . . . . . . . . . . . . . . n Pappas, Peter . . . . . . . . . . . . . . . . . . . . n
Okazaki, Ken. . . . . . . . . . . . . . . . . . . . n Paprosky, Wayne Gregory . . . . . . . . . a, b, c, e – Zimmer
O'Keefe, Thomas Joseph . . . . . . . . . . a, e – Zimmer Parameswaran, Angelo D. . . . . . . . . . n
Okike, Kanu M . . . . . . . . . . . . . . . . . . n Paredes Nunez, Marco . . . . . . . . . . . . n
Okonkwo, Ugochuku . . . . . . . . . . . . n Parekh, Anand A. . . . . . . . . . . . . . . . . n
Okubadejo, Gbolahan . . . . . . . . . . . . n Parekh, Selene G. . . . . . . . . . . . . . . . . n
Okuda, Ryuzo . . . . . . . . . . . . . . . . . . . n Parikh, Viraj K . . . . . . . . . . . . . . . . . . . n
Ole, Voges . . . . . . . . . . . . . . . . . . . . . . n Park, Brandon . . . . . . . . . . . . . . . . . . . n
Oliva, Alejandro . . . . . . . . . . . . . . . . . a – Archus Orthopedics Park, Byung Chul . . . . . . . . . . . . . . . . n
Oliveira, Gustavo . . . . . . . . . . . . . . . . n Park, Hyeoung-Won. . . . . . . . . . . . . . n
Oliveira, J Daniel . . . . . . . . . . . . . . . . n Park, Il Hyung. . . . . . . . . . . . . . . . . . . n
Oliveira, Leonardo . . . . . . . . . . . . . . . n Park, Ju-Kwon . . . . . . . . . . . . . . . . . . . n
Olney, Robert C . . . . . . . . . . . . . . . . . a – Nemours Foundation Park, Kun-woo . . . . . . . . . . . . . . . . . . n
O’Loughlin, Padhraig F . . . . . . . . . . . n Park, Kwan Kyu. . . . . . . . . . . . . . . . . . n

Park, Sang Jin . . . . . . . . . . . . . . . . . . . n Perl, II, John . . . . . . . . . . . . . . . . . . . . n
Park, Sang-Hyun. . . . . . . . . . . . . . . . . n Perlick, Lars . . . . . . . . . . . . . . . . . . . . . n
Park, Se-Jun . . . . . . . . . . . . . . . . . . . . . n Perumal, Ramesh . . . . . . . . . . . . . . . . n
Park, Seungrim . . . . . . . . . . . . . . . . . . n Pesantez Reinoso, Rodrigo . . . . . . . . b – AOLAT
Park, Yong-Cheol . . . . . . . . . . . . . . . . n Pessach, Ilias . . . . . . . . . . . . . . . . . . . . n
Park, Young-Churl . . . . . . . . . . . . . . . n Petcharaporn, Maty . . . . . . . . . . . . . . a – DePuy Spine
Parker, David. . . . . . . . . . . . . . . . . . . . a, e – Stryker, a – Smith & Nephew, EBI, Peters, Christopher L . . . . . . . . . . . . . a, c, e – Biomet
Biomet, Zimmer Peters, Paul . . . . . . . . . . . . . . . . . . . . . n
Parker, Richard D . . . . . . . . . . . . . . . . a, b, e – Sanofi-Aventis, Smith & Nephew, Petersen, Donald W . . . . . . . . . . . . . . n
a, e – DJ Orthopaedics, a – Aircast(DJ), Petersilge, Cheryl . . . . . . . . . . . . . . . . n
Arthrex, Inc, Biomet, Breg, DePuy, A Peterson, Donald R . . . . . . . . . . . . . . e – Biological Inovations
Johnson & Johnson Company, Johnson & Peterson, Margaret G E. . . . . . . . . . . . n
Johnson, National Institutes of Health Peterson, Steve . . . . . . . . . . . . . . . . . . n
(NIAMS & NICHD), Orthopaedic Scientific Petit, Charles J. . . . . . . . . . . . . . . . . . . n
Research Foundation, Stryker, Zimmer, Petrisor, Brad. . . . . . . . . . . . . . . . . . . . n
b – Musculoskeletal Transplant Foundation Petterson, Stephanie C. . . . . . . . . . . . n
Parks, Michael Lloyd . . . . . . . . . . . . . a – Zimmer, Stryker, Procter & Gamble, Pfizer, Pezzotti, Giuseppe . . . . . . . . . . . . . . . n
b, e – Zimmer, d – Johnson & Johnson, Pfaeffle, Jamie . . . . . . . . . . . . . . . . . . . n
Merck, Zimmer, Pfizer, Procter & Gamble Pfander, Gregoire . . . . . . . . . . . . . . . . n
Parratte, Sebastian . . . . . . . . . . . . . . . n Pfeifer, Bernard Andrew. . . . . . . . . . . n
Parsley, Brian S . . . . . . . . . . . . . . . . . . a – DePuy Pfeifer, Bernard Andrew. . . . . . . . . . . n
Parsons, Bradford . . . . . . . . . . . . . . . . n Pfirrmann, Christian . . . . . . . . . . . . . n
Parsons III Theodore W . . . . . . . . . . . a, b – Biomet, a – Smith & Nephew, Tornier, Philippon, Marc J . . . . . . . . . . . . . . . . a, b, c, e – Smith & Nephew
Synthes, Zimmer, Medtronic, DePuy, A Phillips, Frank M . . . . . . . . . . . . . . . . a, c, d – Nuvasive, a – Cervitech, Stryker,
Johnson & Johnson Company c, e – DePuy, A Johnson & Johnson
Partal, George N . . . . . . . . . . . . . . . . . n – Synthes, Stryker, Zimmer Company, d,e – Arcus, AxioMed,
Parvataneni, Hari . . . . . . . . . . . . . . . . n d – Alphatec Spine, Spinal Motion,
Parvizi, Javad. . . . . . . . . . . . . . . . . . . . a, e – Stryker, b – Johnson & Johnson, e – Kyphon Inc., TissueLink
e – Smith & Nephew Phillips, Jonathan H. . . . . . . . . . . . . . n
Pascual, Cristina . . . . . . . . . . . . . . . . . n Phillips, Matthew J . . . . . . . . . . . . . . . a, e – Stryker Howmedica
Pate, Graham C. . . . . . . . . . . . . . . . . . n Piasecki, Dana. . . . . . . . . . . . . . . . . . . n
Pateder, Dhruv . . . . . . . . . . . . . . . . . . n Pibarot, Vincent . . . . . . . . . . . . . . . . . c – Amplitude
Patel, Minoo Keki . . . . . . . . . . . . . . . . b – Smith & Nephew Piccaluga, Francisco . . . . . . . . . . . . . . n
Patel, Pile. . . . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew Picci, Piero. . . . . . . . . . . . . . . . . . . . . . n
Patel, Vipul . . . . . . . . . . . . . . . . . . . . . n Pichard, Carmen P . . . . . . . . . . . . . . . n
Patel, Vishal A . . . . . . . . . . . . . . . . . . . n Pichert, James W. . . . . . . . . . . . . . . . . n
Patil, Sanjeev R . . . . . . . . . . . . . . . . . . n Picinic, Betty . . . . . . . . . . . . . . . . . . . . n
Patil, Shantanu . . . . . . . . . . . . . . . . . . n Pick, Andrew Glen . . . . . . . . . . . . . . . n
Patron, Laura P . . . . . . . . . . . . . . . . . . n Pienkowski, David . . . . . . . . . . . . . . . n
Patt, Joshua . . . . . . . . . . . . . . . . . . . . . n Pieper, Carl . . . . . . . . . . . . . . . . . . . . . a – Novartis
Patterson, Francis Robert . . . . . . . . . . a – Biomet, MTF Pietri, Mirco . . . . . . . . . . . . . . . . . . . . n
Patterson, J Megan M . . . . . . . . . . . . . n Pietrobon, Ricardo . . . . . . . . . . . . . . . n
Patterson, Jennifer . . . . . . . . . . . . . . . n Pietschmann, Matthias . . . . . . . . . . . n
Patterson, Rita. . . . . . . . . . . . . . . . . . . n Pike, Leah M . . . . . . . . . . . . . . . . . . . . a – Nemours Foundation
Patton, Joanna . . . . . . . . . . . . . . . . . . n Pill, Stephan Geoffrey . . . . . . . . . . . . n
Patwardhan, Avinash G . . . . . . . . . . . a – Synthes Spine Pillai, Gita . . . . . . . . . . . . . . . . . . . . . . n
Patzakis, Michael J . . . . . . . . . . . . . . . a – Synthes Pimenta, Luiz . . . . . . . . . . . . . . . . . . . e – Nuvasive Inc.
Paulos, Lonnie E. . . . . . . . . . . . . . . . . a, c – DJ Orthopaedics, b – Mitek, Pinczewski, Leo A . . . . . . . . . . . . . . . . a, b, c, e – Smith & Nephew, a – DePuy,
c, e – Stryker, c – CONMED Linvatec, Smith A Johnson & Johnson Company, Linvatec,
& Nephew, e – Wright Medical Technology, Stryker, Surgical Synergies, Smith &
Inc. Nephew, Zimmer
Pauly, Vanessa . . . . . . . . . . . . . . . . . . . n Pino, Alfonso E. . . . . . . . . . . . . . . . . . n
Pauyo, Thierry. . . . . . . . . . . . . . . . . . . a – Small Bone Innovations, Wright Medical Pinoit, Yannick . . . . . . . . . . . . . . . . . . n
Technology, Inc. Piper, Michael S . . . . . . . . . . . . . . . . . a – Stryker Howmedica, Synthes, Trimed,
Pavelka, Karel . . . . . . . . . . . . . . . . . . . a – Genzyme Zimmer
Pavlov, Helene . . . . . . . . . . . . . . . . . . n Piper, Samantha L. . . . . . . . . . . . . . . . n
Pawelek, Jeff . . . . . . . . . . . . . . . . . . . . a – DePuy Spine Piriou, Philippe . . . . . . . . . . . . . . . . . n
DISCLOSURE
Paxton, Liz. . . . . . . . . . . . . . . . . . . . . . a – Zimmer, DePuy, Smith & Nephew Pittoors, Kathleen . . . . . . . . . . . . . . . . n
Payne, John . . . . . . . . . . . . . . . . . . . . . n Pizzutillo, Peter D. . . . . . . . . . . . . . . . a – Stryker
Peabody, Terrance D. . . . . . . . . . . . . . a – Biomet Plaskos, Christopher . . . . . . . . . . . . . e – Praxim
Pearl, Michael L . . . . . . . . . . . . . . . . . c, e – Zimmer Plitz, Wolfgang . . . . . . . . . . . . . . . . . . n
Pearson, Adam . . . . . . . . . . . . . . . . . . n Plotkine, Olivier . . . . . . . . . . . . . . . . . n
Pearson, Sara E . . . . . . . . . . . . . . . . . . a – Arthex, DePuy Mitek, Arthrocare Png, Meng Ai. . . . . . . . . . . . . . . . . . . . n
Peckett, William Robert Charles . . . . n Podeszwa, David A. . . . . . . . . . . . . . . n
Pedersen, Alma Becic . . . . . . . . . . . . . n Poe-Kochert, Connie . . . . . . . . . . . . . n
Pedersen, Douglas R. . . . . . . . . . . . . . e – NIH Poggie, Robert A . . . . . . . . . . . . . . . . . d, e – Zimmer
Pedowitz, Robert A . . . . . . . . . . . . . . . a, e – Stryker, a – Arthrex, Inc, GE Poignard, Alexandre. . . . . . . . . . . . . . n
Healthcare, Regeneration Technologies, Inc., Poitras, Philippe . . . . . . . . . . . . . . . . . n
Smith & Nephew, Stryker, DJ Orthopaedics, Pollak, Andrew N . . . . . . . . . . . . . . . . a – Synthes, Stryker, Smith & Nephew,
c – Lippincott Zimmer, Wyeth, e – KCI
Pedrini, Elena . . . . . . . . . . . . . . . . . . . n Pollock, David Carl . . . . . . . . . . . . . . e – DePuy
Pedrotty, Dawn . . . . . . . . . . . . . . . . . . n Pollock, JW . . . . . . . . . . . . . . . . . . . . . n
Pelegri, Cedric . . . . . . . . . . . . . . . . . . . n Polly Jr David W . . . . . . . . . . . . . . . . . b, e – Medtronic Sofamor Danek
Penenberg, Brad L. . . . . . . . . . . . . . . . a, c – Wright Medical Technology Pomeroy, Donald L . . . . . . . . . . . . . . a, b – DePuy
Peng, Benedict . . . . . . . . . . . . . . . . . . n Pomper, Martin G. . . . . . . . . . . . . . . . n
Penna, James. . . . . . . . . . . . . . . . . . . . n Ponce, Brent A. . . . . . . . . . . . . . . . . . . n
Pennell, Dudley . . . . . . . . . . . . . . . . . n Ponce, Caroline. . . . . . . . . . . . . . . . . . n
Penner, Murray J . . . . . . . . . . . . . . . . . a – Zimmer Poore, Tim P . . . . . . . . . . . . . . . . . . . . a – Tornier
Pereira, David S. . . . . . . . . . . . . . . . . . n Porcher, Raphael. . . . . . . . . . . . . . . . . n
Perey, Bertrand . . . . . . . . . . . . . . . . . . a – Stryker Howmedica, Synthes, Trimed, Porter, Kristina . . . . . . . . . . . . . . . . . . n
Zimmer Porter, Scott E . . . . . . . . . . . . . . . . . . . n
Perez, Edward . . . . . . . . . . . . . . . . . . . n Portugal, Denise . . . . . . . . . . . . . . . . . n

Postak, Paul D. . . . . . . . . . . . . . . . . . . a – Portland Orthopaedics, DePuy, Zimmer, Ranawat, Anil . . . . . . . . . . . . . . . . . . . n
Link Orthopaedics Ranawat, Chitranjan S . . . . . . . . . . . . e – DePuy, A Johnson & Johnson Company
Potocki, Jason John . . . . . . . . . . . . . . n Randall, Craig J . . . . . . . . . . . . . . . . . . n
Potoupnis, Michael Emilios . . . . . . . n Randall, Kyle L . . . . . . . . . . . . . . . . . . n
Potter, Hollis . . . . . . . . . . . . . . . . . . . . a – GE Healthcare, e – Histogenics Randall, R Lor . . . . . . . . . . . . . . . . . . . a – Biomet
Corporation Rani, Nicola. . . . . . . . . . . . . . . . . . . . . n
Poupon, J. . . . . . . . . . . . . . . . . . . . . . . n Rankin, John . . . . . . . . . . . . . . . . . . . . n
Powers, Cara . . . . . . . . . . . . . . . . . . . . a – Inova Health System Rao, Shashibhushan. . . . . . . . . . . . . . n
Poynton, Ashley R . . . . . . . . . . . . . . . n Raphael, Bradley . . . . . . . . . . . . . . . . . n
Pradhan, Chandra . . . . . . . . . . . . . . . a, b, e – Smith & Nephew Rasmussen, G Lynn . . . . . . . . . . . . . . e – Wright Medical Technology, Inc.
Prasad, P S . . . . . . . . . . . . . . . . . . . . . . n Rasquinha, Vijay J. . . . . . . . . . . . . . . . e – Stryker
Prasarn, Mark L. . . . . . . . . . . . . . . . . . n Rathjen, Karl E . . . . . . . . . . . . . . . . . . n
Prather, Heidi . . . . . . . . . . . . . . . . . . . n Rattner, Jerome B . . . . . . . . . . . . . . . . n
Prayson, Michael J . . . . . . . . . . . . . . . a – Synthes, Smith & Nephew, I-Flow, Ravaud, Phillipe . . . . . . . . . . . . . . . . . n
Canica, Biomet Rawlins, Bernard A . . . . . . . . . . . . . . . n
Price, Andrew J . . . . . . . . . . . . . . . . . . n Ray, Ruth . . . . . . . . . . . . . . . . . . . . . . . n
Price, Andrew . . . . . . . . . . . . . . . . . . . a – Genzyme Razzano, Pasquale . . . . . . . . . . . . . . . n
Price, Charles T . . . . . . . . . . . . . . . . . . a, c – Biomet, e – Hanger Orthotics and Reach, John S . . . . . . . . . . . . . . . . . . . a – Piedmont Orthopaedic Society
Prosthetics Ready, John E . . . . . . . . . . . . . . . . . . . b, e – Smith & Nephew
Priebat, Dennis . . . . . . . . . . . . . . . . . . n Reardon, Gerald Peter . . . . . . . . . . . . n
Primak, Andrew . . . . . . . . . . . . . . . . . b – Siemens Medical Solutions Reed, Jeremy . . . . . . . . . . . . . . . . . . . . a – Breg
Prince, Edward J . . . . . . . . . . . . . . . . . n Reedy, Mary E . . . . . . . . . . . . . . . . . . . a – Biomet, Pfizer
Prince, Francois. . . . . . . . . . . . . . . . . . a – Zimmer Rees, Jonathan . . . . . . . . . . . . . . . . . . n
Pring, Maya . . . . . . . . . . . . . . . . . . . . . a – Rady Children's Hospital Orthopedic Reese, Keri A . . . . . . . . . . . . . . . . . . . . n
Research and Education Fund Regenbrecht, Bertram. . . . . . . . . . . . . n
Probe, Robert A. . . . . . . . . . . . . . . . . . a – Stryker, Blackstone Medical, Cervitech, Register, Brad. . . . . . . . . . . . . . . . . . . . n
DePuy, A Johnson & Johnson Company, Rehak, Peter. . . . . . . . . . . . . . . . . . . . . n
Pfizer, b – AO, Smith & Nephew, Stryker, , Reichmann, William Michael . . . . . . n
e – Stryker Reijman, Max . . . . . . . . . . . . . . . . . . . n
Provelengios, Stefanos . . . . . . . . . . . . n Reilly, Mark C . . . . . . . . . . . . . . . . . . . a, e – Stryker, Synthes, a – Biomet, EBI,
Provencher, Matthew T . . . . . . . . . . . n Musculoskeletal Transplant Foundation,
Provus, Jason Daniel . . . . . . . . . . . . . n Smith & Nephew, Wright Medical
Pruett, Arianna . . . . . . . . . . . . . . . . . . n Technology, Inc., Zimmer
Pruitt, Lisa . . . . . . . . . . . . . . . . . . . . . . n Reinhold, Johansson Henning . . . . . n
Pryor, Philip Warren. . . . . . . . . . . . . . a, e – Medtronic Sofamor Danek Reinke, Markus . . . . . . . . . . . . . . . . . . n
Puget, Jean L . . . . . . . . . . . . . . . . . . . . e – Tornier Reis, Abilio Antunes . . . . . . . . . . . . . . n
Puigdevall, Miguel . . . . . . . . . . . . . . . n Reiter, Mitchell Forest. . . . . . . . . . . . . n
Pulido, Luis . . . . . . . . . . . . . . . . . . . . . n Relwani, Jai . . . . . . . . . . . . . . . . . . . . . n
Pulkkinen, P . . . . . . . . . . . . . . . . . . . . n Remes, Ville M . . . . . . . . . . . . . . . . . . b – Zimmer, Stryker, Biomet, Smith &
Puno, Rolando M . . . . . . . . . . . . . . . . a, c, e – Medtronic Sofamor Danek Nephew, DePuy
Punwar, Shah . . . . . . . . . . . . . . . . . . . n Remia, Leonard. . . . . . . . . . . . . . . . . . b, e – Encore Medical
Purohit, Govind J . . . . . . . . . . . . . . . . n Rempel, David . . . . . . . . . . . . . . . . . . a – NIH
Purtill, James J. . . . . . . . . . . . . . . . . . . a – Stryker Ren, Yupeng . . . . . . . . . . . . . . . . . . . . n
Puskas, Brian. . . . . . . . . . . . . . . . . . . . n Renkawitz, Tobias. . . . . . . . . . . . . . . . a – Brainlab
Putnam, Matthew D. . . . . . . . . . . . . . a – Biomet, , Aircast(DJ), AO, DePuy, Renner, Susan . . . . . . . . . . . . . . . . . . . a – Synthes Spine
A Johnson & Johnson Company, Medtronic Repicci, John A . . . . . . . . . . . . . . . . . . b, c, d – Biomet, e – Mako
Sofamor Danek, Wright Medical Resnick, Donald . . . . . . . . . . . . . . . . . n
Technology, Inc., c – Wright Medical Rhee, John JM . . . . . . . . . . . . . . . . . . . n
Technology, Inc., Small Bone Innovations, Rhoades, Charles Edward . . . . . . . . . n
d – Amgen Co, GE Healthcare, Johnson & Rhue, John P . . . . . . . . . . . . . . . . . . . . n
Johnson, BoundaryMedical, Anchor Inc., Ribas Fernandez, Manel. . . . . . . . . . . n
e – Small Bone Innovations, Stryker, Wright Ricchetti, Eric T . . . . . . . . . . . . . . . . . . n
Medical Technology, Inc., Boundary Medical Ricci, William Michael. . . . . . . . . . . . a, b, c, e – Smith & Nephew, a, b – AO,
Puttler, Eric G . . . . . . . . . . . . . . . . . . . n a – Synthes, b, e – Wright Medical
Pydisetty, Ravikumar . . . . . . . . . . . . . n Technology, Inc., b – Synthes, e – OrthoVita
Qaisi, Yaqdan . . . . . . . . . . . . . . . . . . . n Rice, Robert S . . . . . . . . . . . . . . . . . . . n
Qin, Zhen . . . . . . . . . . . . . . . . . . . . . . n Richard, Alexandre . . . . . . . . . . . . . . . n
DISCLOSURE
Quach, Tony . . . . . . . . . . . . . . . . . . . . n Richards, Andrew M. . . . . . . . . . . . . . n

Quigley, Laura R . . . . . . . . . . . . . . . . . a, b – Zimmer Richardson, James . . . . . . . . . . . . . . . a, e – Smith & Nephew, b – Biocomposites
Quinn, Robert H. . . . . . . . . . . . . . . . . n Richardson, Mark W . . . . . . . . . . . . . a – Stryker
Raab, Gregory Ernest . . . . . . . . . . . . . a – DePuy Richardson, Martin. . . . . . . . . . . . . . . n
Rachala, Sridhar . . . . . . . . . . . . . . . . . n Richardson, William J . . . . . . . . . . . . a – EBI, DePuy, A Johnson & Johnson
Radl, Roman . . . . . . . . . . . . . . . . . . . . n Company
Raijmakers, Natasja . . . . . . . . . . . . . . n Richmond, John C . . . . . . . . . . . . . . . e – DePuy-Mitek, Axya Medical, Lifenet,
Raikin, Steven M . . . . . . . . . . . . . . . . . a – Synthes Tissue Regeneration
Raisis, Leo W . . . . . . . . . . . . . . . . . . . . n Ries, Michael D. . . . . . . . . . . . . . . . . . a – Smith & Nephew, Zimmer, c – Smith &
Raiss, Patric . . . . . . . . . . . . . . . . . . . . . n Nephew
Raja Sabapathy, S . . . . . . . . . . . . . . . . n Riew, K Daniel . . . . . . . . . . . . . . . . . . a – Medtronic Sofamor Danek, c – Biomet,
Rajagopal, Trichy Srinivasarangan . . n d – Osprey, Spine Medica, e – Interpore-
Rajan, Daniel . . . . . . . . . . . . . . . . . . . n Cross, Spineology
Rajasekaran, S . . . . . . . . . . . . . . . . . . . n Rihn, Jeffrey. . . . . . . . . . . . . . . . . . . . . n
Rakebrand, Elmar . . . . . . . . . . . . . . . . e – Stryker Howmedica Rijk, Paul . . . . . . . . . . . . . . . . . . . . . . . n
Ralston, Stuart H. . . . . . . . . . . . . . . . . e – Proctor & Gamble, Sanofi Aventis, Riley III Lee H . . . . . . . . . . . . . . . . . . . a – DePuy Spine, Blackstone, b – AOSNA,
Novartis Lifenet, d – Spinal Kinetics
Ramakrishnan, Rama . . . . . . . . . . . . . e – Stryker Howmedica Riley, Patrick M . . . . . . . . . . . . . . . . . . n
Ramesh, Palanisamy . . . . . . . . . . . . . n Rimnac, Clare M. . . . . . . . . . . . . . . . . a – NIH Grant, Zimmer, Sulzer, Wibert J.
Ramirez, Miguel Angel Zuqui . . . . . . n Austin Professor of Engineering Chair
Ramon, Jose G . . . . . . . . . . . . . . . . . . n Rincon, Lina M . . . . . . . . . . . . . . . . . . n
Ramsey, Matthew Lee. . . . . . . . . . . . . e – Zimmer
Ranade, Avinash B . . . . . . . . . . . . . . . n
Ranawat, Amar S. . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Company, Stryker

Ring, David C . . . . . . . . . . . . . . . . . . . a – Acumed, LLC, Biomet, Joint Active Rothman, Richard H . . . . . . . . . . . . . a, b, c, e – Stryker
Systems, Small Bone Innovations, Smith & Rothrock, Corey . . . . . . . . . . . . . . . . . n
Nephew, Wright Medical Technology, Inc., Rotstein, Jason . . . . . . . . . . . . . . . . . . n
Tornier, b – Small Bone Innovations, Smith Rouard, Helene. . . . . . . . . . . . . . . . . . n
& Nephew, Wright Medical Technology, Inc., Rouben, David P. . . . . . . . . . . . . . . . . n
AO, c – Hand Innovations, d – Illuminos, Rousseau, Marc Antoine . . . . . . . . . . n
Inc., Mimedex, Inc., e – Acumed, LLC, Routt Jr Milton L. . . . . . . . . . . . . . . . . a – Synthes, Zimmer, b – Synthes
Smith & Nephew, Wright Medical Roy, Alain . . . . . . . . . . . . . . . . . . . . . . a – Stryker Howmedica, Biomet, DePuy,
Technology, Inc., Tornier Smith & Nephew, a, e – Zimmer
Ringler, James R . . . . . . . . . . . . . . . . . n Royalty, Rob . . . . . . . . . . . . . . . . . . . . n
Rios, Antonio . . . . . . . . . . . . . . . . . . . n Royce, Bryan . . . . . . . . . . . . . . . . . . . . a – Zimmer
Rispoli, Damian Mark . . . . . . . . . . . . b – Synthes Roye Jr David Price . . . . . . . . . . . . . . . n
Ritacco, Lucas . . . . . . . . . . . . . . . . . . . n Royston, Simon . . . . . . . . . . . . . . . . . n
Ritter, Merrill A . . . . . . . . . . . . . . . . . . a – Biomet, DePuy, Zimmer, Stryker, MCI; Rozbruch, S Robert. . . . . . . . . . . . . . . a – Smith & Nephew, Biomet
e – Biomet Rubash, Harry E . . . . . . . . . . . . . . . . . a, c – Zimmer
Ritz, Beate . . . . . . . . . . . . . . . . . . . . . . a – NIH Rudd, Joseph. . . . . . . . . . . . . . . . . . . . n
Rixen, Dieter . . . . . . . . . . . . . . . . . . . . n Rudert, Lindsay . . . . . . . . . . . . . . . . . . n
Rizzello, Giacomo . . . . . . . . . . . . . . . n Rudzki, Jonas R. . . . . . . . . . . . . . . . . . n
Roach, John B . . . . . . . . . . . . . . . . . . . n Rue, John-Paul H . . . . . . . . . . . . . . . . n
Robb, III, William J. . . . . . . . . . . . . . . a, b – Brainlab, b – Smith & Nephew, Rufo-Smith, Candace . . . . . . . . . . . . . n
c – Innomed, d – Medtronic, Stryker, Rugo, Eric . . . . . . . . . . . . . . . . . . . . . . e – Stryker Orthopaedics
e – Brainlab, Smith & Nephew Ruland, Robert Thomas . . . . . . . . . . . n
Roberts, Craig S. . . . . . . . . . . . . . . . . . a – Stryker, Synthes Russell Jr George V . . . . . . . . . . . . . . . n
Roberts, P. . . . . . . . . . . . . . . . . . . . . . . n Russell, Thomas A . . . . . . . . . . . . . . . a, b, c, e – Smith & Nephew, a – Eli Lilly,
Roberts, Veronica . . . . . . . . . . . . . . . . n Merck, Pfizer, Synthes, Wright Medical
Robertson, Claire . . . . . . . . . . . . . . . . a – Rady Children's Hospital Orthopedic Technology, Inc., b, d – Etex
Research and Education Fund Russlies, Martin. . . . . . . . . . . . . . . . . . n
Robertson, Douglas D . . . . . . . . . . . . e – Zimmer Rust, Luke . . . . . . . . . . . . . . . . . . . . . . n
Robertson, William . . . . . . . . . . . . . . n Ruther, Wolfgang . . . . . . . . . . . . . . . . n
Robertsson, Otto. . . . . . . . . . . . . . . . . n Ruzzini, Laura . . . . . . . . . . . . . . . . . . . n
Robinson, Andrew H . . . . . . . . . . . . . n Ryge, Camilla . . . . . . . . . . . . . . . . . . . a – GlaxoSmithKline, e – Pfizer, Bristol-
Robinson, Christopher M . . . . . . . . . n Myers Squibb
Robinson, Eric Vinton . . . . . . . . . . . . a – Smith & Nephew Ryssman, Daniel B . . . . . . . . . . . . . . . n
Robinson, Yohan . . . . . . . . . . . . . . . . n Ryu, Richard K N . . . . . . . . . . . . . . . . b – Mitek, Stryker, d – KFx
Roche, Christopher. . . . . . . . . . . . . . . e – Exactech Saag, Kenneth . . . . . . . . . . . . . . . . . . . n
Roche, Martin William. . . . . . . . . . . . a, b, d, e – MAKO Surgical, a, b, e – DePuy, Sabesan, Vani Janaki. . . . . . . . . . . . . . n
A Johnson & Johnson Company Sabharwal, Sanjeev. . . . . . . . . . . . . . . a – Smith & Nephew
Rockwood Jr Charles A . . . . . . . . . . . c – DePuy, A Johnson & Johnson Company, Sabokbar, Afsaneh . . . . . . . . . . . . . . . n
d – Zimmer Sadri, Hassan . . . . . . . . . . . . . . . . . . . n
Rodeo, Scott Alan . . . . . . . . . . . . . . . . a, e – Wyeth, d – Cayenne Medical Saeboe, Modolv . . . . . . . . . . . . . . . . . n
Rodkey, William G . . . . . . . . . . . . . . . a – Smith & Nephew, Ossur, Saeki, Kazuhiko . . . . . . . . . . . . . . . . . n
a, b, d, e, – Regen Biologics Safir, Oleg . . . . . . . . . . . . . . . . . . . . . . n
Rodrigo, Juan J . . . . . . . . . . . . . . . . . . a, b – Orthopaedic Research Foundation of Safran, Marc . . . . . . . . . . . . . . . . . . . . a – Zimmer, Smith & Nephew, DJ
the Carolinas Orthopaedics, d, e – Cool Systems, Inc.
Rodriguez, Jose A . . . . . . . . . . . . . . . . e – Stryker, Howmedica, e – DePuy, Safren, Steve . . . . . . . . . . . . . . . . . . . . n
e – Exactech Sagi, Henry Claude. . . . . . . . . . . . . . . a, b, c, e – Smith & Nephew, a, e – Synthes,
Rodriguez-Huerta, Ana . . . . . . . . . . . n b, e – Stryker, b – AO
Rodway, Ian. . . . . . . . . . . . . . . . . . . . . n Sah, Alexander P. . . . . . . . . . . . . . . . . n
Roeder, Christoph P . . . . . . . . . . . . . . n Sahar, Tali . . . . . . . . . . . . . . . . . . . . . . n
Roehrig, Gregory. . . . . . . . . . . . . . . . . n Sairyo, Koichi . . . . . . . . . . . . . . . . . . . n
Roel, Trip . . . . . . . . . . . . . . . . . . . . . . . e – OsteoLign Inc Saisu, Takashi . . . . . . . . . . . . . . . . . . . n
Roepke, Martin . . . . . . . . . . . . . . . . . . n Saito, Izumi. . . . . . . . . . . . . . . . . . . . . n
Rogers, Benedict . . . . . . . . . . . . . . . . . n Saito, Tomoyuki . . . . . . . . . . . . . . . . . n
Rogers, Caroline . . . . . . . . . . . . . . . . . e – Nevill Hall Hospital Sajovic, Matjaz . . . . . . . . . . . . . . . . . . n
Rogmark, Cecilia. . . . . . . . . . . . . . . . . n Sakai, Takashi . . . . . . . . . . . . . . . . . . . n
Roh, Jeffrey . . . . . . . . . . . . . . . . . . . . . n Sakai, Toshinori . . . . . . . . . . . . . . . . . n
Rokito, Andrew S . . . . . . . . . . . . . . . . n Sakamoto, Taiji . . . . . . . . . . . . . . . . . . n
DISCLOSURE
Romagnoli, Matteo. . . . . . . . . . . . . . . a – Smith & Nephew Sakayama, Kenshi. . . . . . . . . . . . . . . . n
Romagnoli, Sergio . . . . . . . . . . . . . . . a, c – Zimmer Sakellariou, Vasilios I . . . . . . . . . . . . . n
Romas, Keren . . . . . . . . . . . . . . . . . . . n Sakuraba, Keishoku . . . . . . . . . . . . . . n
Romeo, Anthony A. . . . . . . . . . . . . . . a, b, c, d, e – Arthrex, Inc Sala, Debra Anne . . . . . . . . . . . . . . . . n
Romness, Mark J . . . . . . . . . . . . . . . . . n Saleh, Khaled J . . . . . . . . . . . . . . . . . . a, b, e – Aesculap/B.Braun, Stryker,
Ronald, Kara . . . . . . . . . . . . . . . . . . . . n a, c – Smith & Nephew a – Johnson &
Root, Leon. . . . . . . . . . . . . . . . . . . . . . n Johnson, b, e – Genzyme, Innomed,
Rorabeck, Cecil H . . . . . . . . . . . . . . . . a, b, c, e – Smith & Nephew Kinamed, Zimmer
Rosca, Mircea . . . . . . . . . . . . . . . . . . . a – Portland Orthopaedics, DePuy, Zimmer Salihu, Sydha . . . . . . . . . . . . . . . . . . . a – Orthopaedic Trauma Association,
Rose, Peter S . . . . . . . . . . . . . . . . . . . . n Orthopaedic Research and Education
Rosen, Jeffrey E . . . . . . . . . . . . . . . . . . a – DePuy-Mitek Foundation
Rosenberg, Aaron Glen . . . . . . . . . . . a, b, c, d, e – Zimmer, c – TissueLink Salin, Jeffrey W . . . . . . . . . . . . . . . . . . n
Rosenberg, Andrew D . . . . . . . . . . . . n Salkeld, Samantha L. . . . . . . . . . . . . . a – Biomet Medtronic
Rosencher, Nadia . . . . . . . . . . . . . . . . e – Bayer Health Care AG Salmon, Lucy J . . . . . . . . . . . . . . . . . . a – DePuy, Johnson & Johnson, Linvatec,
Rosenfeld, Scott B. . . . . . . . . . . . . . . . n Stryker, Surgical Synergies, Zimmer, Smith &
Rosenstein, Alexander . . . . . . . . . . . . n Nephew
Rosenstock, Jeffrey . . . . . . . . . . . . . . . n Salomone, Matthew . . . . . . . . . . . . . . n
Rosenwasser, Melvin Paul . . . . . . . . . c, e – Biomet, e – Stryker Saltzman, Charles L . . . . . . . . . . . . . . a – Biomet, DePuy, A Johnson and Johnson
Rosenzweig, Seth . . . . . . . . . . . . . . . . n Company, Zimmer, c – Nexa Orthopaedics,
Rosner, Michael . . . . . . . . . . . . . . . . . n d – Tornier, e – Link Orthopaedics, Nexa
Ross, Steven Douglas K . . . . . . . . . . . a – Synthes Orthopaedics, Zimmer
Rossi, Mark . . . . . . . . . . . . . . . . . . . . . n Salyapongse, Aaron K. . . . . . . . . . . . . e – Wright
Rossi, Paolo. . . . . . . . . . . . . . . . . . . . . n Samarji, R . . . . . . . . . . . . . . . . . . . . . . n
Rossi, Roberto . . . . . . . . . . . . . . . . . . . n Samdani, Amer . . . . . . . . . . . . . . . . . . n
Rosson, John . . . . . . . . . . . . . . . . . . . . n Sampsel, Sarah . . . . . . . . . . . . . . . . . . n

Sanchez, Anthony. . . . . . . . . . . . . . . . e – Mitek Schon, Lew C . . . . . . . . . . . . . . . . . . . a, b, c, d, e – Tornier, Nexa Orthopaedics,
Sanchez-Sotelo, Joaquin . . . . . . . . . . a, e – Stryker, a – DePuy, A Johnson & a, b, c, e – Zimmer, a, b, c – Arthrex, Inc,
Johnson Company, Zimmer a, b, e – DePuy, A Johnson & Johnson
Sanders, David . . . . . . . . . . . . . . . . . . a – NIH, CIHR, OREF Company, Biomet, a, c – Aircast(DJ),
Sanders, James O . . . . . . . . . . . . . . . . a – Scoliosis Research Society a, d – Royer Biomedical, Inc., a – Synthes,
Sanders, Samuel . . . . . . . . . . . . . . . . . n EBI, KMI/Integra, Stryker, Allosource,
Sandhu, Harvinder S . . . . . . . . . . . . . a – Support to Hospital for Special Surgery, Medtronic, Biomimetic, c – Darco,
Numerous, b, c, e – Kyphon Inc., e – The Snyder Center of Pain Pharmacology
b – Orthovita, Bio-Imaging, Schousboe, John. . . . . . . . . . . . . . . . . b – Hologic, e – Merck, Amgen
c, d, e – Spinewave, c, d – Amedica, Schreck, Barbara . . . . . . . . . . . . . . . . . n
c, e – Aesculap/B. Braun, d – Simpirica, Schreurs, Berend Willem . . . . . . . . . . n
Columna, Paradigm Spine, K2 Medical, Schroder, Steven . . . . . . . . . . . . . . . . . n
Osteotech Schroeder, David W . . . . . . . . . . . . . . e – Biomet
Sandstrom, Bjorn . . . . . . . . . . . . . . . . n Schroer, William C . . . . . . . . . . . . . . . a, e – Biomet, a – Pfizer
Sanfilippo, James . . . . . . . . . . . . . . . . n Schulman, Jeff E . . . . . . . . . . . . . . . . . a – Synthes
Sangiorgi, Luca . . . . . . . . . . . . . . . . . . n Schurman, David J . . . . . . . . . . . . . . . n
SanGiovanni, Thomas P . . . . . . . . . . n Schwartsmann, Carlos Roberto. . . . . n
Sano, Hirotaka . . . . . . . . . . . . . . . . . . n Schwartz, Herbert S . . . . . . . . . . . . . . a – Musculoskeletal Transplant Foundation,
Santini Araujo, Maria G . . . . . . . . . . . n Stryker, Synthes, Zimmer
Santore, Richard F. . . . . . . . . . . . . . . . a – Zimmer, b, c, e – Plus Orthopedics, Schweizer, Elizabeth. . . . . . . . . . . . . . n
b, d – Merck, Pfizer, b,e – Smith & Nephew, Schwend, Richard M . . . . . . . . . . . . . n
b – AO, Sanofi-Aventis, Synthes, Orthovita, Sciadini, Marcus F. . . . . . . . . . . . . . . . e – Stryker, a – Synthes
d – Biomet, Johnson & Johnson, Abbott Sciascia, Aaron D . . . . . . . . . . . . . . . . n
Sanz, L . . . . . . . . . . . . . . . . . . . . . . . . . n Sciore, Paul . . . . . . . . . . . . . . . . . . . . . n
Sargent, Mary Catherine . . . . . . . . . . n Sciubba, Daniel . . . . . . . . . . . . . . . . . n
Saris, Daniel B F . . . . . . . . . . . . . . . . . n Scott, Richard D . . . . . . . . . . . . . . . . . c, d, e – DePuy, A Johnson & Johnson
Sarris, Ioannis . . . . . . . . . . . . . . . . . . . n Company
Sarti, Daniele. . . . . . . . . . . . . . . . . . . . n Scotti, Celeste, . . . . . . . . . . . . . . . . . . n
Sarwark, John F. . . . . . . . . . . . . . . . . . n Scuderi, Giles R. . . . . . . . . . . . . . . . . . b, c, d, e – Zimmer
Sasaki, Mikito . . . . . . . . . . . . . . . . . . . n Sculco, Peter . . . . . . . . . . . . . . . . . . . . n
Sasaki, Shin . . . . . . . . . . . . . . . . . . . . . n Sculco, Thomas P . . . . . . . . . . . . . . . . a – Exactech, Inc, Smith & Nephew, Zimmer
Sasso, Rick C . . . . . . . . . . . . . . . . . . . . a, c, e – Medtronic Sofamor Danek, Scully, Sean P . . . . . . . . . . . . . . . . . . . n
a – AO, Cerapedics, Eli Lilly, Stryker, Seeley, Mark . . . . . . . . . . . . . . . . . . . . n
b – Ono Pharmaceutical, d – Biomet Segal, Lee S . . . . . . . . . . . . . . . . . . . . . n
Sasyniuk, Treny M . . . . . . . . . . . . . . . a, e – Zimmer, Breg Segalman, Keith A . . . . . . . . . . . . . . . a – Synthes
Sathy, Ashoke K . . . . . . . . . . . . . . . . . n Sehat, Khosrow. . . . . . . . . . . . . . . . . . n
Sato, Kazuhiro . . . . . . . . . . . . . . . . . . n Sekiya, Jon K . . . . . . . . . . . . . . . . . . . . a, c – Arthrex, Inc, c, e – OrthoDynamix, LLC
Satoshi, Iida . . . . . . . . . . . . . . . . . . . . n Selby, Ronald M . . . . . . . . . . . . . . . . . n
Savoie III Felix H. . . . . . . . . . . . . . . . . b – Mitek Seligson, David . . . . . . . . . . . . . . . . . . a, b, e – Stryker, a – Zimmer
Sawaguchi, Naohiro . . . . . . . . . . . . . . n Sems, Stephen A . . . . . . . . . . . . . . . . . e – DePuy
Sawakami, Kimihiko . . . . . . . . . . . . . n Sendtner, Ernst . . . . . . . . . . . . . . . . . . a – Brainlab
Sawaki, Keisuke. . . . . . . . . . . . . . . . . . n Sendtner, Ernst . . . . . . . . . . . . . . . . . . a – Brainlab
Sawyer, Aenor J . . . . . . . . . . . . . . . . . . n Sennerby, Ulf C. . . . . . . . . . . . . . . . . . n
Sayana, Murali Krishna . . . . . . . . . . . n Sennett, Brian J . . . . . . . . . . . . . . . . . . n
Sayegh, Fares . . . . . . . . . . . . . . . . . . . . n Senoo, Issei . . . . . . . . . . . . . . . . . . . . . n
Sayuri, Arimitsu . . . . . . . . . . . . . . . . . n Seo, Jai Gon. . . . . . . . . . . . . . . . . . . . . n
Scaife, Courtney . . . . . . . . . . . . . . . . . n Seo, Sung Wook . . . . . . . . . . . . . . . . . a – Stryker Howmedica
Scannell, Brian . . . . . . . . . . . . . . . . . . n Seon, Jong – Keun . . . . . . . . . . . . . . . n
Schaaf, Adam . . . . . . . . . . . . . . . . . . . n Seong, Sang Cheol . . . . . . . . . . . . . . . n
Schachter, Aaron. . . . . . . . . . . . . . . . . a – DePuy-Mitek Sernert, Ninni . . . . . . . . . . . . . . . . . . . n
Schaefer, Sarah . . . . . . . . . . . . . . . . . . a – Sanofi-Aventis Seshadri, Roopa . . . . . . . . . . . . . . . . . n
Schafer, Michael F. . . . . . . . . . . . . . . . n Severini, Gariele . . . . . . . . . . . . . . . . . n
Schelkun, Steven Ross . . . . . . . . . . . . n Severson, Erik P . . . . . . . . . . . . . . . . . n
Schemitsch, Emil H . . . . . . . . . . . . . . a, b, e – Stryker, a, b – Smith & Nephew, Sewhoy, Robert P . . . . . . . . . . . . . . . . a – DePuy, Stryker
a – Biomimetic, Synthes, Zimmer, e – Pfizer Seyahi, Aksel . . . . . . . . . . . . . . . . . . . . n
Schenkengel, Jan-Peter. . . . . . . . . . . . n Seyler, Thorsten M . . . . . . . . . . . . . . . a – Musculoskeletal Transplant Foundation,
Schepers, Anton . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Smith & Nephew, Stryker, Wright Medical
DISCLOSURE
Smith & Nephew, Technology, Inc., Zimmer, Ossacur,

Schepsis, Anthony Alberto. . . . . . . . . a, b, e – Arthrosurface e – Ossacur
Scherl, Susan A . . . . . . . . . . . . . . . . . . a – Biomet, DePuy, A Johnson & Johnson Shaffer, Benjamin . . . . . . . . . . . . . . . . d – Scandius, e – Arthrex, Inc
Company, Stryker, Zimmer Shafi, Shahid. . . . . . . . . . . . . . . . . . . . n
Schiltenwolf, Marcus . . . . . . . . . . . . . n Shah, Suken A. . . . . . . . . . . . . . . . . . . a, e – DePuy Spine
Schinsky, Mark F. . . . . . . . . . . . . . . . . n Shah, Swapnil B . . . . . . . . . . . . . . . . . n
Schleck, Cathy D. . . . . . . . . . . . . . . . . n Shamie, Arya Nick . . . . . . . . . . . . . . . a, e – Biomet
Schmalzried, Thomas P . . . . . . . . . . . a, b, c, d, e – Stryker, a, b, c, d – DePuy, Shaneyfelt, Steven. . . . . . . . . . . . . . . . n
A Johnson & Johnson Company, a – Corin Shapiro, Irving M . . . . . . . . . . . . . . . . a – Smith & Nephew
U.S.A., Wright Medical Technology, Inc., Sharkey, Peter F. . . . . . . . . . . . . . . . . . a, c, e – Stryker, a – Surgical Monitoring
b, d – Zimmer, b – Smith & Nephew, Associates, Inc.
d – Biomet, Bristol-Myers Squib, Pfizer Sharma, Adrija . . . . . . . . . . . . . . . . . . a – DePuy, Zimmer
Schmidt, Andrew H . . . . . . . . . . . . . . a, d, e – Twin Star Medical, a, e – Smith & Sharma, Vineet . . . . . . . . . . . . . . . . . . n
Nephew, a – Synthes, b – AGA, FH Sharma, Vivek . . . . . . . . . . . . . . . . . . . n
Orthopedics, c – Thieme, Inc, e – Millenium Sharma, Vivek . . . . . . . . . . . . . . . . . . . n
Medical Technologies, DePuy, A Johnson & Sharp, Richard . . . . . . . . . . . . . . . . . . a – Corin USA
Johnson Company Sharrock, Nigel E . . . . . . . . . . . . . . . . n
Schmidt, Bernhard . . . . . . . . . . . . . . . e – Siemens Medical Solutions Shay, Jerry W . . . . . . . . . . . . . . . . . . . . n
Schmidt, Josh . . . . . . . . . . . . . . . . . . . n Sheffler, Lindsey C . . . . . . . . . . . . . . . n
Schmidt, Robert H . . . . . . . . . . . . . . . b, c – Wright Medical Shelbourne, K Donald . . . . . . . . . . . . c – Aircast(DJ)
Schmier, Jordana K. . . . . . . . . . . . . . . e – Exponent Shelton, Walter R . . . . . . . . . . . . . . . . n
Schneiderbauer, Michaela Maria. . . . n Shen, Hong – Xing . . . . . . . . . . . . . . . n
Schoenecker, Perry L. . . . . . . . . . . . . . n Shen, Jian . . . . . . . . . . . . . . . . . . . . . . a – Allergan
Schoenfeld, Andrew . . . . . . . . . . . . . . a – OREF Shen, Wei. . . . . . . . . . . . . . . . . . . . . . . n
Scholvin, Dirk. . . . . . . . . . . . . . . . . . . e – Wright Medical Technology, Inc. Shepstone, Lee . . . . . . . . . . . . . . . . . . n

Sheth, Neil P . . . . . . . . . . . . . . . . . . . . n Slobogean, Gerard . . . . . . . . . . . . . . . n
Shetty, Ajoy Prasad . . . . . . . . . . . . . . . n Slomczykowski, Mike, (B)
Shewman, Elizabeth. . . . . . . . . . . . . . n Slover, James D . . . . . . . . . . . . . . . . . . n
Shi, Lewis L . . . . . . . . . . . . . . . . . . . . . n Slucky, Andrew V . . . . . . . . . . . . . . . . a – Spine Motion, b – AO
Shia, Derek S. . . . . . . . . . . . . . . . . . . . n Small, Scott R . . . . . . . . . . . . . . . . . . . a – Biomet, DePuy, Zimmer, Stryker
Shida, Junichi . . . . . . . . . . . . . . . . . . . n Smeltzer, Mark S . . . . . . . . . . . . . . . . . n
Shido, Yoji . . . . . . . . . . . . . . . . . . . . . . n Smith, Amanda. . . . . . . . . . . . . . . . . . n
Shigenobu, Keiichi . . . . . . . . . . . . . . . n Smith, Angela D . . . . . . . . . . . . . . . . . n
Shima, Hiraoka. . . . . . . . . . . . . . . . . . n Smith, Beth P . . . . . . . . . . . . . . . . . . . a – Allergan
Shimada, Kozo . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company, Smith, Eric Louis. . . . . . . . . . . . . . . . . n
GlaxoSmithKline, Sanofi – Aventis, Smith & Smith, Harvey . . . . . . . . . . . . . . . . . . . b – Medtronic
Nephew, Stryker, Zimmer Smith, James . . . . . . . . . . . . . . . . . . . . n
Shimamura, Tadashi . . . . . . . . . . . . . a – Iwate Medical University Smith, Langan. . . . . . . . . . . . . . . . . . . n
Shimizu, Koh . . . . . . . . . . . . . . . . . . . n Smith, Lindsay . . . . . . . . . . . . . . . . . . a – Surgical Innovations
Shimizu, Sara . . . . . . . . . . . . . . . . . . . n Smith, Melvin D . . . . . . . . . . . . . . . . . n
Shimmin, Andrew John. . . . . . . . . . . e – Stryker, Finsbury Smith, Suzanne. . . . . . . . . . . . . . . . . . a – Orthopaedic Trauma Association,
Shimose, Shoji . . . . . . . . . . . . . . . . . . n Orthopaedic Research and Education
Shin, Alexander Yong Shik . . . . . . . . a – DePuy, A Johnson & Johnson Company, Foundation
Stryker, Trimed, Ascension, Mayo Smith, Tom . . . . . . . . . . . . . . . . . . . . . a – Allergan
Foundation Smith, Wade Russell. . . . . . . . . . . . . . a, b, e – AO, Stryker, Synthes,
Shindle, Michael Kenneth . . . . . . . . . n a, b – Exactech, Inc
Shindo, Hiroyuki . . . . . . . . . . . . . . . . n Smith, Wade . . . . . . . . . . . . . . . . . . . . n
Shino, Konsei . . . . . . . . . . . . . . . . . . . n Snider, Matt. . . . . . . . . . . . . . . . . . . . . n
Shinoda, Tsuyoshi . . . . . . . . . . . . . . . n Snyder, Stephen J . . . . . . . . . . . . . . . . a, c, d, e – Wright Medical Technology, Inc.,
Shinomiya, Kenichi . . . . . . . . . . . . . . n CONMED Linvatec, a, c, e – Smith &
Shirai, Toshiharu . . . . . . . . . . . . . . . . n Nephew, a, c – DJ Orthopaedics,
Shirai, Chikashi . . . . . . . . . . . . . . . . . n Sawbones/Pacific Research Laboratories,
Shiraishi, Hideo . . . . . . . . . . . . . . . . . a – Iwate Medical University a – DePuy, A Johnson & Johnson Company,
Shiramizu, Kei . . . . . . . . . . . . . . . . . . n c – Arthrex, Inc, Lippincott, Stryker
Shitama, Hiroshi . . . . . . . . . . . . . . . . n Snyder-Mackler, Lynn. . . . . . . . . . . . . a – NIH
Shitara, Hitoshi. . . . . . . . . . . . . . . . . . n Soballe, Kjeld . . . . . . . . . . . . . . . . . . . n
Shmookler, Barry M . . . . . . . . . . . . . . n Soenen, Marc . . . . . . . . . . . . . . . . . . . n
Shoji, Hiromu. . . . . . . . . . . . . . . . . . . n Sofianos, Ioannis . . . . . . . . . . . . . . . . n
Shore, Ben . . . . . . . . . . . . . . . . . . . . . . a – Linvatec Soileau, Elizabeth S . . . . . . . . . . . . . . e – Zimmer
Shufflebarger, Harry L . . . . . . . . . . . . a, e – DePuy Spine, Inc. Sokolowski, Margaret S . . . . . . . . . . . n
Shukla, Divyang . . . . . . . . . . . . . . . . . b – Smith & Nephew Sokolowski, Mark . . . . . . . . . . . . . . . . n
Shuler, Michael S . . . . . . . . . . . . . . . . n Solgaard, Soren. . . . . . . . . . . . . . . . . . n
Siddeshwar, Patil . . . . . . . . . . . . . . . . n Solomon, Daniel . . . . . . . . . . . . . . . . n
Siddharth, Srivastava . . . . . . . . . . . . . n Sommer, Kirsten . . . . . . . . . . . . . . . . . n
Siddiqui, Mashfiqul Arafin . . . . . . . . n Song, Eun Kyoo . . . . . . . . . . . . . . . . . a, b, c, e – Aesculap/B.Braun
Sides, Steven Douglas. . . . . . . . . . . . . n Song, Hae Ryong . . . . . . . . . . . . . . . . n
Siebenrock, Klaus . . . . . . . . . . . . . . . . a – Mathys Ltd, Synthes, Zimmer Song, Kwang Soon . . . . . . . . . . . . . . . n
Siegel, Jodi. . . . . . . . . . . . . . . . . . . . . . n Son-Hing, Jochen Paul. . . . . . . . . . . . n
Siegler, Sorin . . . . . . . . . . . . . . . . . . . . n Sonne-Holm, Stig . . . . . . . . . . . . . . . . n
Siegmeth, Alexander Walter. . . . . . . . n Sonoda, Shozo . . . . . . . . . . . . . . . . . . n
Sierra, Rafael J . . . . . . . . . . . . . . . . . . . n SooHoo, Nelson Fong . . . . . . . . . . . . n
Sietsema, Debra . . . . . . . . . . . . . . . . . n Soojian, Michael G. . . . . . . . . . . . . . . n
Sikka, Robbi . . . . . . . . . . . . . . . . . . . . n Soto, Jorge . . . . . . . . . . . . . . . . . . . . . . n
Silverstein, Marc D . . . . . . . . . . . . . . . a – Medtronic Soucacos, Panayotis N . . . . . . . . . . . . n
Silverstone, Elizabeth . . . . . . . . . . . . . n Souer, John S. . . . . . . . . . . . . . . . . . . . a – Small Bone Innovations, Wright
Silvestri, Linda S . . . . . . . . . . . . . . . . . a – Ohio Department of Public Safety, Medical, Smith & Nephew, Tournier,
Emergency Medical Services Grant Acumed, Biomet, Joint Active Systems, AO-
Silvestri, Lorenzo . . . . . . . . . . . . . . . . n CID, Annafonds, Stichting Professor
Sim, Franklin H . . . . . . . . . . . . . . . . . n Michael van Vloten Fonds
Sim, Lynette . . . . . . . . . . . . . . . . . . . . n Southworth, Carleton . . . . . . . . . . . . e – DePuy
Simcock, Xavier C. . . . . . . . . . . . . . . . n Souza, Eduardo. . . . . . . . . . . . . . . . . . n
Simmons, Barry P. . . . . . . . . . . . . . . . n Specht, Lawrence . . . . . . . . . . . . . . . . a – DePuy
DISCLOSURE
Simmons, Christopher. . . . . . . . . . . . n Specht, Stacy C . . . . . . . . . . . . . . . . . . n
Simmons III James Walter . . . . . . . . . n Spencer, Samantha . . . . . . . . . . . . . . . n
Simon, David Andrew . . . . . . . . . . . . n Spengler, Dan M . . . . . . . . . . . . . . . . . n
Simon, Josef B. . . . . . . . . . . . . . . . . . . n Speranza, Attilio . . . . . . . . . . . . . . . . . n
Simpson, Andrew K . . . . . . . . . . . . . . n Sperling, John William . . . . . . . . . . . e – Biomet
Simpson, D . . . . . . . . . . . . . . . . . . . . . n Spiegel, David Andrew. . . . . . . . . . . . n
Simpson, Kathy J . . . . . . . . . . . . . . . . a – Stryker Orthopedics Spindler, Kurt P. . . . . . . . . . . . . . . . . . a – Arthrex, Smith & Nephew
Sims, Stephen H . . . . . . . . . . . . . . . . . n Spinner, Robert Jay . . . . . . . . . . . . . . . e – Mayo Medical Ventures
Sinclair, Marc F . . . . . . . . . . . . . . . . . . n Sponseller, Paul D . . . . . . . . . . . . . . . n
Singanamala, Naveen. . . . . . . . . . . . . a – Arthex, DePuy Mitek, Arthrocare Sporer, Scott M . . . . . . . . . . . . . . . . . . a, b, c, e – Zimmer
Singh, Aulakh Tajeshwar . . . . . . . . . . a – Smith & Nephew Spouge, A. . . . . . . . . . . . . . . . . . . . . . . c – Taylor and Francis, LLC
Singh, Bikramjit . . . . . . . . . . . . . . . . . n Spratt, Kevin F. . . . . . . . . . . . . . . . . . . n
Singh, Kern . . . . . . . . . . . . . . . . . . . . . a – Medtronic Springer, Bryan Donald . . . . . . . . . . . a – DePuy, Smith & Nephew
Singhal, Manuj Chandra . . . . . . . . . . n Srivastava, Rajeshwar Nath . . . . . . . . n
Sinner, Penny . . . . . . . . . . . . . . . . . . . n Srivastava, Siddharth . . . . . . . . . . . . . n
Sirkin, Michael Saul . . . . . . . . . . . . . . a, c, e – Biomet, a – Synthes, Smith & Staddon, Arthur P. . . . . . . . . . . . . . . . n
Nephew, Wright Medical Technology, Inc., Staehler, Michael . . . . . . . . . . . . . . . . n
Musculoskeletal Transplant Foundation Stafylas, Kosmas . . . . . . . . . . . . . . . . . n
Skaggs, David Lee . . . . . . . . . . . . . . . . a, b, e – Medtronic Sofamor Danek, Stryker Stagni, Cesare . . . . . . . . . . . . . . . . . . . n
Skinner, John . . . . . . . . . . . . . . . . . . . n Stahel, Philip Frank . . . . . . . . . . . . . . n
Skoglund, Ulf I P . . . . . . . . . . . . . . . . n Stalnikowicz, Ruth . . . . . . . . . . . . . . . n
Skolasky, Richard L. . . . . . . . . . . . . . . n Standard, Shawn C. . . . . . . . . . . . . . . a – Smith & Nephew
Skrbensky, Gobert . . . . . . . . . . . . . . . n Stanley, Tom D . . . . . . . . . . . . . . . . . . a – Medtronic
Slade III Joseph F . . . . . . . . . . . . . . . . b, e – Acumed, LLC Stannard, James P. . . . . . . . . . . . . . . . a – Kinetic Concepts, Inc., a, b – Medtronic,
Slobogean, Bronwyn LT . . . . . . . . . . . n Smith & Nephew, Synthes

Stark, John Gregory . . . . . . . . . . . . . . a – Medtronic Sullivan, Nicholas. . . . . . . . . . . . . . . . n
Starnes, Trevor. . . . . . . . . . . . . . . . . . . a – NIH Summers, Erik C. . . . . . . . . . . . . . . . . n
Starr, Adam Jennings . . . . . . . . . . . . . b – Smith & Nephew Sun, Junfeng . . . . . . . . . . . . . . . . . . . . n
Staub, Lukas P. . . . . . . . . . . . . . . . . . . n Sun, Yi-Chin . . . . . . . . . . . . . . . . . . . . n
Stauff, Michael Paul . . . . . . . . . . . . . . n Sung, Ki Sun . . . . . . . . . . . . . . . . . . . . n
Steadman, J Richard . . . . . . . . . . . . . . a – Smith & Nephew, Ossur, b, c – Linvatec, Suratwala, Sanjeev J . . . . . . . . . . . . . . a – Orthopaedic Research and Education
a, b, d, e – ReGen Biologics, Inc. Foundation
Stedtfeld, Hans-Werner . . . . . . . . . . . b – B. Braun-Aesculap Susman, Jeffrey . . . . . . . . . . . . . . . . . . n
Steffen, Robert T . . . . . . . . . . . . . . . . . a – BUPA Foundation, Smith & Nephew, Suto, Morimichi . . . . . . . . . . . . . . . . . n
b – Oxfordshire Health Services Research Suzme, Rafi . . . . . . . . . . . . . . . . . . . . . n
Committee Suzue, Naoto. . . . . . . . . . . . . . . . . . . . n
Steger-May, Karen . . . . . . . . . . . . . . . . n Suzuki, Chiho . . . . . . . . . . . . . . . . . . . n
Stegmann, Jens-Ulrich . . . . . . . . . . . . e – Grunenthal GmbH Suzuki, Ryo . . . . . . . . . . . . . . . . . . . . . n
Steinbrecher, Jill . . . . . . . . . . . . . . . . . n Suzuki, Hideki . . . . . . . . . . . . . . . . . . n
Steiner, Mark E . . . . . . . . . . . . . . . . . . n Suzuki, Tomoyuki. . . . . . . . . . . . . . . . n
Steinmann, Scott P . . . . . . . . . . . . . . . a – Wright Medical Technology, Inc., Suzuki, Yoshitaka . . . . . . . . . . . . . . . . n
e – Arthrex, Inc Swan, Kenneth . . . . . . . . . . . . . . . . . . a, b – Stryker Howmedica
Steklov, Nick . . . . . . . . . . . . . . . . . . . . n Swanik, C. Buz . . . . . . . . . . . . . . . . . . n
Stengel, Dirk . . . . . . . . . . . . . . . . . . . . a, b, e – AO Foundation, a – DePuy Swanik, Kathleen . . . . . . . . . . . . . . . . n
Stepanian, Jeff . . . . . . . . . . . . . . . . . . . n Swank, Michael L . . . . . . . . . . . . . . . . a, e – Brainlab, DePuy, A Johnson &
Stephen, David J . . . . . . . . . . . . . . . . . n Johnson Company, d – Alexandria Research
Stephens, Susan E. . . . . . . . . . . . . . . . n Technologies
Stephenson, Lindsay P . . . . . . . . . . . . n Swanson, Megan A . . . . . . . . . . . . . . . n
Steppacher, Simon D . . . . . . . . . . . . . a – National Center for Competence in Sward, Leif. . . . . . . . . . . . . . . . . . . . . . n
Research of the Swiss National Science Swaringen, Jennifer C. . . . . . . . . . . . . n
Foundation Sweitzer, Brett Alan. . . . . . . . . . . . . . . n
Sterba, William Robert. . . . . . . . . . . . n Swenson, Jeffrey R . . . . . . . . . . . . . . . n
Sterbank, Patrick. . . . . . . . . . . . . . . . . n Swiontkowski, Marc F . . . . . . . . . . . . a, e – Medtronic, a – AO, Biomet,
Sterett, William I. . . . . . . . . . . . . . . . . a – Smith & Nephew, Genzyme, a, c, e, – EBI CONMED Linvatec, DePuy, A Johnson &
Stern, Peter J . . . . . . . . . . . . . . . . . . . . a – Stryker Johnson Company, EBI, Genzyme, Johnson
Sternheim, Amir . . . . . . . . . . . . . . . . . n & Johnson, Medtronic Sofamor Danek,
Stevens, Jennifer E . . . . . . . . . . . . . . . n Merck, Musculoskeletal Transplant
Stevens, Peter M . . . . . . . . . . . . . . . . . a, e – GE Healthcare, a – AO, Biomet, Foundation, National Institutes of Health
Medtronic, Medtronic Sofamor Danek, (NIAMS & NICHD), Orthofix, Inc., Plus
Shriners Hospitals for Children Clinical Orthopedics, Pfizer, Smith & Nephew,
Outcomes Studies Advisory Board, Smith & Synthes, Tornier, e – Eli Lilly, Wyeth
Nephew, Stryker, Synthes, Wright Medical Switzer, Julie A . . . . . . . . . . . . . . . . . . n
Technology, Inc., Zimmer, b, c, e – Orthofix Swope, Steve . . . . . . . . . . . . . . . . . . . . e – DePuy
Stewart, Duncan J . . . . . . . . . . . . . . . . n Szalantzy, Melinda . . . . . . . . . . . . . . . n
Stewart, Rena. . . . . . . . . . . . . . . . . . . . a – Kinetic Concepts Inc., Synthes Tabata, Shiro . . . . . . . . . . . . . . . . . . . . n
Stiehl, James B . . . . . . . . . . . . . . . . . . a, b, c, e – Zimmer, a, d, e – Praxim/ Tabutin, Jacques . . . . . . . . . . . . . . . . . e – Tornier
Medivision, e – Implex Tadross, Ramon . . . . . . . . . . . . . . . . . a – Zimmer
Stienstra, John J . . . . . . . . . . . . . . . . . n Taguchi, Toshihiko . . . . . . . . . . . . . . . n
Stihsen, Christoph . . . . . . . . . . . . . . . n Tai, Chen chin. . . . . . . . . . . . . . . . . . . a – DePuy, Stryker
Stock, Thomas. . . . . . . . . . . . . . . . . . . e – Stryker Howmedica Takagishi, Kenji. . . . . . . . . . . . . . . . . . n
Stocks, Gregory William . . . . . . . . . . n Takahashi, Norimasa . . . . . . . . . . . . . n
Stojimirovic, Dragan . . . . . . . . . . . . . n Takakura, Yoshinori . . . . . . . . . . . . . . n
Stott, Tonya . . . . . . . . . . . . . . . . . . . . . a, b – Orthopaedic Research Foundation of Takamori, Yoshihiro. . . . . . . . . . . . . . n
the Carolinas Takano, Yuichi . . . . . . . . . . . . . . . . . . n
Strauch, Robert J . . . . . . . . . . . . . . . . . n Takao, Masaki . . . . . . . . . . . . . . . . . . . n
Strauss, Elton. . . . . . . . . . . . . . . . . . . . a – Medtronic, b, e – Stryker, b – AO, Takaoka, Kunio. . . . . . . . . . . . . . . . . . n
e – Synthes Takatori, Ryota . . . . . . . . . . . . . . . . . . n
Strauss, Eric . . . . . . . . . . . . . . . . . . . . . a – DePuy Mitek, Smith & Nephew Takeda, Atsushi . . . . . . . . . . . . . . . . . . n
Strebe, Sara . . . . . . . . . . . . . . . . . . . . . n Takeda, Mitsuhiro. . . . . . . . . . . . . . . . n
Strickland, Justin P . . . . . . . . . . . . . . . n Takeuchi, Akihiko. . . . . . . . . . . . . . . . n
Stuart, Michael J . . . . . . . . . . . . . . . . . n Takeuchi, Ryohei. . . . . . . . . . . . . . . . . n
Stubbs, Allston J . . . . . . . . . . . . . . . . . n Takeyama, Akinori . . . . . . . . . . . . . . . n
DISCLOSURE
Stuchin, Steven Andrew . . . . . . . . . . . n Takiuchi, Toshiro . . . . . . . . . . . . . . . . n

Stulberg, Bernard N . . . . . . . . . . . . . . a – Stryker Howmedica, Corin, e – Stryker Talmo, Carl T . . . . . . . . . . . . . . . . . . . n
Howmedica, Corin, Exactech Talwalkar, Vishwas R . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Stulberg, S David . . . . . . . . . . . . . . . . a, c, e – Aesculap/B.Braun, c – Innomed, Shriners Hospitals for Children Clinical
d – Smith & Nephew, Stryker, Johnson and Outcomes Studies Advisory Board, Synthes,
Johnson, e – Brainlab Smith & Nephew, Zimmer, Stryker, Kyphon
Sturm, Patrick D . . . . . . . . . . . . . . . . . n Inc.
Stuyck, Jose A . . . . . . . . . . . . . . . . . . . n Tamai, Katsuya . . . . . . . . . . . . . . . . . . n
Suarez, Juan C. . . . . . . . . . . . . . . . . . . a – DePuy Tammachote, Nattapol . . . . . . . . . . . a – Smith & Nephew , DePuy
Subach, Brian R . . . . . . . . . . . . . . . . . b, e – Medtronic Sofamor Danek Tamura, Shigenori . . . . . . . . . . . . . . . n
Sucato, Daniel J . . . . . . . . . . . . . . . . . a, b, c – Medtronic Tan, Carol . . . . . . . . . . . . . . . . . . . . . . n
Suda, Kota . . . . . . . . . . . . . . . . . . . . . . n Tan, Seang Beng . . . . . . . . . . . . . . . . . n
Suda, Yasunori . . . . . . . . . . . . . . . . . . n Tan, Virak . . . . . . . . . . . . . . . . . . . . . . a – Wyeth Corp, c,e – Wright Medical
Suero, Eduardo M. . . . . . . . . . . . . . . . n Technology
Sugama, Ryo . . . . . . . . . . . . . . . . . . . . n Tanaka, Minoru . . . . . . . . . . . . . . . . . n
Sugamoto, Kazuomi. . . . . . . . . . . . . . n Tanaka, Nobuhiro . . . . . . . . . . . . . . . n
Sugano, Nobuhiko. . . . . . . . . . . . . . . n Tanaka, Tadashi . . . . . . . . . . . . . . . . . n
Suganuma, Katsuyoshi. . . . . . . . . . . . n Tanaka, Tatsuaki . . . . . . . . . . . . . . . . . n
Sugawara, Hirobumi . . . . . . . . . . . . . n Tanaka, Yasuhito. . . . . . . . . . . . . . . . . n
Sugaya, Hiroyuki . . . . . . . . . . . . . . . . n Tanaka, Yoshinari . . . . . . . . . . . . . . . . n
Sugimoto, Kazuya. . . . . . . . . . . . . . . . n Tanavalee, Aree . . . . . . . . . . . . . . . . . . n
Sugita, Takashi . . . . . . . . . . . . . . . . . . n Tang, Peter . . . . . . . . . . . . . . . . . . . . . . n
Sugiura, Hideshi . . . . . . . . . . . . . . . . . n Tanifuji, Osamu . . . . . . . . . . . . . . . . . n
Suk, Se-Il . . . . . . . . . . . . . . . . . . . . . . . n Taniguchi, Akira . . . . . . . . . . . . . . . . . n
Sukthankar, Atul . . . . . . . . . . . . . . . . . n Taniguchi, Daigo . . . . . . . . . . . . . . . . n

Tannast, Moritz. . . . . . . . . . . . . . . . . . a – National Center for Competence in Toth, Alison P . . . . . . . . . . . . . . . . . . . n
Research Co-Me of the Swiss National Toulson, Charles. . . . . . . . . . . . . . . . . n
Science Foundation Toy, Jason H . . . . . . . . . . . . . . . . . . . . n
Tannenbaum, Allen R . . . . . . . . . . . . n Toyone, Tomoaki . . . . . . . . . . . . . . . . n
Taras, John S . . . . . . . . . . . . . . . . . . . . a, b – Integra Life Sciences Tracy, Jeremiah . . . . . . . . . . . . . . . . . . n
Tasbas, Bulent Adil . . . . . . . . . . . . . . . n Trampuz, Andrej. . . . . . . . . . . . . . . . . n
Tashiro, Shigeyoshi. . . . . . . . . . . . . . . n Transfeldt, Ensor E . . . . . . . . . . . . . . . a – Medtronic, Stryker
Tashjian, Robert . . . . . . . . . . . . . . . . . n Trask, Kelly . . . . . . . . . . . . . . . . . . . . . n
Tatanu, Robyn. . . . . . . . . . . . . . . . . . . n Treme, Gehron P. . . . . . . . . . . . . . . . . n
Tateda, Kenji . . . . . . . . . . . . . . . . . . . . n Tressel, William . . . . . . . . . . . . . . . . . n
Taunton, Michael J . . . . . . . . . . . . . . . n Tria Jr Alfred J . . . . . . . . . . . . . . . . . . . c – Zimmer, e – Smith & Nephew, IMP
Tay, Shian Chao . . . . . . . . . . . . . . . . . a – National Medical Research Council, Trier, Kathy . . . . . . . . . . . . . . . . . . . . . e – Corin
Mayo Foundation Trikha, Paul Sanjay . . . . . . . . . . . . . . . n
Teefey, Sharlene A . . . . . . . . . . . . . . . . n Tripuraneni, Krishna Raj . . . . . . . . . . n
Teeny, Steven M . . . . . . . . . . . . . . . . . n Trojani, Christophe . . . . . . . . . . . . . . n
Tejwani, Nirmal C . . . . . . . . . . . . . . . a, b – Biomet, b – Stryker, Zimmer Trousdale, Robert T. . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Tellisi, Nazzar . . . . . . . . . . . . . . . . . . . n Company, a – Stryker, Zimmer, e – Wright
Teloken, Marco A . . . . . . . . . . . . . . . . n Medical Technology, Inc.
Templeman, David C . . . . . . . . . . . . . a – Smith & Nephew, b, c, e – Zimmer, Trumble, Thomas E . . . . . . . . . . . . . . n
b, e – Stryker, d – Pfizer, e – SIGN, Tsai, Wen-chi. . . . . . . . . . . . . . . . . . . . n
MSF/Doctors Without Borders Tsuchiya, Hiroyuki . . . . . . . . . . . . . . . n
Tengrootenhuysen, Mike . . . . . . . . . . n Tsukamoto, Mikiko . . . . . . . . . . . . . . n
Teochi, Luiz Fernando . . . . . . . . . . . . n Tsukamoto, Riichiro. . . . . . . . . . . . . . n
Teratani, Takeshi . . . . . . . . . . . . . . . . . n Tsukayama, Dean T . . . . . . . . . . . . . . n
Terauchi, Masanori. . . . . . . . . . . . . . . n Tsukushi, Satoshi . . . . . . . . . . . . . . . . n
Terrell, Daria Brooks. . . . . . . . . . . . . . n Tsunekawa, Hiromi . . . . . . . . . . . . . . n
Tesei, Federico. . . . . . . . . . . . . . . . . . . a – Smith & Nephew Tsung-Yu, Lan . . . . . . . . . . . . . . . . . . . n
Thabet, Ahmed Mohamed . . . . . . . . n Tsutsui, Shunji . . . . . . . . . . . . . . . . . . a – DePuy Spine
Thacker, Mihir. . . . . . . . . . . . . . . . . . . n Tuke, Michael A . . . . . . . . . . . . . . . . . e – Finsbury
Thakral, Rishi . . . . . . . . . . . . . . . . . . . n Tuohy, Christopher . . . . . . . . . . . . . . n
Thawrani, Dinesh . . . . . . . . . . . . . . . . n Turcotte, Robert Emile . . . . . . . . . . . . n
Theilman, Diogo . . . . . . . . . . . . . . . . n Turen, Clifford H . . . . . . . . . . . . . . . . a – Synthes
Theis, Jean-Claude . . . . . . . . . . . . . . . n Turkelson, Charles . . . . . . . . . . . . . . . n
Thermann, Hajo . . . . . . . . . . . . . . . . . n Turnbull, Allen . . . . . . . . . . . . . . . . . . n
Thillemann, Theis Muncholm . . . . . n Turner III Norman S. . . . . . . . . . . . . . n
Thomas, Stephen John. . . . . . . . . . . . n Turner, Thomas M . . . . . . . . . . . . . . . a – Wright Medical Technology, Inc.
Thomas, Thad . . . . . . . . . . . . . . . . . . . n Turpie, Alexander G . . . . . . . . . . . . . . e – Bayer Health Care AG
Thompson, Abigail E . . . . . . . . . . . . . n Tuson, Kenneth. . . . . . . . . . . . . . . . . . n
Thompson, Charles . . . . . . . . . . . . . . a – OTA, Zimmer Tuttle, Robert W . . . . . . . . . . . . . . . . . n
Thompson, George H . . . . . . . . . . . . a – Medtronic Sofamor Danek, Zimmer, Tuy, Benjamin E . . . . . . . . . . . . . . . . . a – Biomet, Musculoskeletal Transplant
b – DePuy, A Johnson & Johnson Company, Foundation
Synthes, e – DePuy, A Johnson & Johnson Twigg, Stacy L . . . . . . . . . . . . . . . . . . . n
Company, Synthes Tyler, Jennifer . . . . . . . . . . . . . . . . . . . n
Thompson, Kevin J. . . . . . . . . . . . . . . n Tyler, Michael . . . . . . . . . . . . . . . . . . . n
Thompson, Matthew . . . . . . . . . . . . . n Tzermiadianos, Michail . . . . . . . . . . . a – Synthes Spine
Thompson, Michael A . . . . . . . . . . . . n Tzioupis, Christopher Harry . . . . . . . n
Thonse, Raghuram . . . . . . . . . . . . . . . n Uchiyama, Yohsiyasu . . . . . . . . . . . . . n
Thornhill, Thomas S . . . . . . . . . . . . . n Udupa, Jayaram . . . . . . . . . . . . . . . . . n
Thornton, Gail M . . . . . . . . . . . . . . . . n Ueda, Takafumi . . . . . . . . . . . . . . . . . n
Throckmorton, Thomas. . . . . . . . . . . a – Mid-American Orthopaedic Association Ueha, Tomoyuki . . . . . . . . . . . . . . . . . n
Tibesku, Carsten Oliver . . . . . . . . . . . n Ueno, Shigekazu. . . . . . . . . . . . . . . . . n
Tibone, James E . . . . . . . . . . . . . . . . . n Ueno, Yoshinori . . . . . . . . . . . . . . . . . n
Tieszer, Christina . . . . . . . . . . . . . . . . n Uglialoro, Anthony . . . . . . . . . . . . . . n
Tillander, Bo . . . . . . . . . . . . . . . . . . . . n Uhl, Richard . . . . . . . . . . . . . . . . . . . . n
Tilzey, John F. . . . . . . . . . . . . . . . . . . . a – DePuy Uhl, Timothy L . . . . . . . . . . . . . . . . . . n
Timothy, Daniel Jasper. . . . . . . . . . . . a – Smith & Nephew Ulmer Jr William H . . . . . . . . . . . . . . n
Tingart, Markus. . . . . . . . . . . . . . . . . . n Ulrich, Slif D . . . . . . . . . . . . . . . . . . . . n
DISCLOSURE
Tjoumakaris, Fotios P. . . . . . . . . . . . . n Umansakar, S . . . . . . . . . . . . . . . . . . . n
Togawa, Daisuke. . . . . . . . . . . . . . . . . n Umeda, Naoya . . . . . . . . . . . . . . . . . . n
Tohyama, Harukazu. . . . . . . . . . . . . . n Umi, Yumi. . . . . . . . . . . . . . . . . . . . . . n
Tojo, Yuichi . . . . . . . . . . . . . . . . . . . . . n Unlu, Mehmetcan . . . . . . . . . . . . . . . n
Tokish, John Michael . . . . . . . . . . . . . n Upasani, Vidyadhar V . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company
Tokish, Leonard J . . . . . . . . . . . . . . . . e – Archus Orthopedics Upmalis, David. . . . . . . . . . . . . . . . . . b, e – Johnson & Johnson Pharmaceutical
Tokuhara, Yoshio . . . . . . . . . . . . . . . . n Research and Development, d – Johnson &
Tokunaga, Daisaku. . . . . . . . . . . . . . . n Johnson
Tolo, Eric Thorpe . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company Urban, Robert M. . . . . . . . . . . . . . . . . a – Wright Medical Technology, Inc.
Tom, James A . . . . . . . . . . . . . . . . . . . n Urband, Christopher E. . . . . . . . . . . . a – Exactech, Inc.
Toman, Jared A . . . . . . . . . . . . . . . . . . n Urbaniak, James R . . . . . . . . . . . . . . . n
Tomek, Ivan M . . . . . . . . . . . . . . . . . . n Usrey, Molly M . . . . . . . . . . . . . . . . . . n
Tomita, Katsuro . . . . . . . . . . . . . . . . . n Utsumi, Hideaki . . . . . . . . . . . . . . . . . n
Tomita, Masuhiro . . . . . . . . . . . . . . . . n Uzun, Ibrahim . . . . . . . . . . . . . . . . . . n
Tompkins, Bryan. . . . . . . . . . . . . . . . . n Vaccaro, Alexander . . . . . . . . . . . . . . . a, c, e – DePuy, A Johnson & Johnson
Tongue, John R . . . . . . . . . . . . . . . . . . n Company, Medtronic Sofamor Danek,
Tonino, Pietro M . . . . . . . . . . . . . . . . d – Regeneration Technologies, Inc. Stryker, a – AO, Synthes, c, d – Globus
Tontz Jr William . . . . . . . . . . . . . . . . . n Medical, c, e – Biomet, c – Aesculap/
Tonussi, Maria. . . . . . . . . . . . . . . . . . . n B.Braun, EBI, Lippincott, d – Spinal Motion,
Topliss, Claire J . . . . . . . . . . . . . . . . . . a, e – Zimmer, a – Biomimetrics Zygoloc, Vertebron, Progressive Spinal
Torchia, Michael E . . . . . . . . . . . . . . . n Technologies, Computational Biodynamics,
Tornetta III Paul . . . . . . . . . . . . . . . . . a, c, e – Smith & Nephew, c – Lippincott Stout Medical, Paradigm Spine, K-2,
Toscano, Angelo . . . . . . . . . . . . . . . . . n Replication Medica, Spinology, Osteotech,
Tosi, Laura Lowe . . . . . . . . . . . . . . . . . a – Zimmer, b, e – Merck e – Orthofix, Inc.
Tosteson, Anna . . . . . . . . . . . . . . . . . . n Vadala, Antonio . . . . . . . . . . . . . . . . . n

Vaidya, Rahul . . . . . . . . . . . . . . . . . . . n Vigorita, Vincent J. . . . . . . . . . . . . . . . e – Regeneration Biologics
Vail, Thomas Parker. . . . . . . . . . . . . . . a – Brainlab, Johnson & Johnson, Vilarrubias Guillamet, Jose M G . . . . n
Medtronic, Musculoskeletal Transplant Villamil-Wiscovitch, Fernando . . . . . n
Foundation, National Institutes of Health Villanueva, Manuel . . . . . . . . . . . . . . n
(NIAMS & NICHD), Zimmer AIOD-Assn Villarraga, Marta . . . . . . . . . . . . . . . . . n
Intl l'Osteosynthese Dynamique, Aleeva Vince, Kelly . . . . . . . . . . . . . . . . . . . . . a, b, c, e – Zimmer
Medical, Inc., American College of Sports Vincent, Maria. . . . . . . . . . . . . . . . . . . n
Medicine Fdn, American Orthopaedic Soc Virkus, Walter W . . . . . . . . . . . . . . . . . a, b, d, e – Stryker
for Sports Med, AO Foundation, Arthritis Virshup, David . . . . . . . . . . . . . . . . . . n
Foundation, Arthrocare Corporation, Vissers, Maaike . . . . . . . . . . . . . . . . . . n
Arthroscopy Association of North America, Vitale, Michael G . . . . . . . . . . . . . . . . n
Canadian Academy of Sports Medicine, Vittetoe, David . . . . . . . . . . . . . . . . . . e – Zimmer
Columbia University, Deafness Research Vives, Michael . . . . . . . . . . . . . . . . . . . n
Foundation, DePuy Inc., a Johnson & Vlastou, Catherine . . . . . . . . . . . . . . . n
Johnson Company, Hacettepe University, Vogelstein, Bert . . . . . . . . . . . . . . . . . . n
Harold K. L. Castle Foundation, Histogenics Voigt, Clifford . . . . . . . . . . . . . . . . . . . n
Corporation, Intl Spinal Injection Society, Volgas, David A. . . . . . . . . . . . . . . . . . a – Synthes, Pfizer, Kinetic Concepts, Inc.
ISTO Technologies, Inc., March of Dimes Von Schroeder, Herbert P. . . . . . . . . . n
Birth Defects Foundation, NIH Natl Inst Von Tscharmer, Vinzenz. . . . . . . . . . . n
Arthr, Musculoskel & Skin, NIH Natl Inst Voos, James . . . . . . . . . . . . . . . . . . . . . n
Dental & Craniofacial Res., North American Voronov, Leonard . . . . . . . . . . . . . . . . a – Synthes Spine
Spine Society, North Shore-Long Island Voulgaris, Spyridon . . . . . . . . . . . . . . n
Jewish Hlth Sys, Novo Nordisk, Orthologic Vrahas, Mark S . . . . . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Corporation, Orthopaedic Research and d – Angstrom Medica, e – Synthes
Education Fdn., Orthopaedic Trauma Vranceanu, Ana-Maria . . . . . . . . . . . . n
Association, Scios, Inc., a Johnson & Vrouvas, John . . . . . . . . . . . . . . . . . . . n
Johnson Co., Scoliosis Research Society, Wada, Takuro . . . . . . . . . . . . . . . . . . . n
Spinal Kinetics, Inc., SpinalMotion, Inc., Wada, Yuichi . . . . . . . . . . . . . . . . . . . . n
Spine Solutions, Inc., Stryker Corporation, Wada, Yuichi . . . . . . . . . . . . . . . . . . . . n
Stryker Howmedica Osteonics, Synthes USA, Waddell, David D . . . . . . . . . . . . . . . . e – Wright Medical Technology, Inc.
TissueLink Medical, Inc., TranS1, Inc., UC Waddell, James P . . . . . . . . . . . . . . . . n
Berkeley, United Health Group Company, Wade, Roger . . . . . . . . . . . . . . . . . . . . n
University of Minnesota, University of Texas Wadey, Veronica Marie Rita . . . . . . . . n
at Dallas, Wisconsin Alumni Research Wagner, Susanne. . . . . . . . . . . . . . . . . n
Foundation, Zimmer, Inc., b, c, e – DePuy, Wai, Eugene. . . . . . . . . . . . . . . . . . . . . n
A Johnson & Johnson Company Waitayawinyu, Thanapong . . . . . . . . b – Arthrex
Valderrabano, Victor. . . . . . . . . . . . . . n Waked, Walid . . . . . . . . . . . . . . . . . . . n
Valles, Alfonso. . . . . . . . . . . . . . . . . . . n Walch, Gilles . . . . . . . . . . . . . . . . . . . . b, c, e – Tornier
Vallier, Heather A . . . . . . . . . . . . . . . . n Walcott-Sapp, Sarah . . . . . . . . . . . . . . a – Sanofi-Aventis
Vallurupalli, Santaram . . . . . . . . . . . . n Walker, Decker . . . . . . . . . . . . . . . . . . n
Van Arkel, Ewout . . . . . . . . . . . . . . . . n Walker, Janet . . . . . . . . . . . . . . . . . . . . n
Van Bosse, Harold J P . . . . . . . . . . . . . n Walker, Peter S . . . . . . . . . . . . . . . . . . n
Van Citters, Douglas. . . . . . . . . . . . . . a – Zimmer, a, e – DePuy Wall, Bradford A . . . . . . . . . . . . . . . . . a – Stryker Spine, Synthes Spine
van Dam, Bruce E . . . . . . . . . . . . . . . . n Wall, Eric . . . . . . . . . . . . . . . . . . . . . . . n
Van Damme, Geert . . . . . . . . . . . . . . . n Wallace, Henry . . . . . . . . . . . . . . . . . . n
Van De Luijtgaarden, Koen . . . . . . . . n Wallace, Margaret . . . . . . . . . . . . . . . . n
Van de Velde, Samuel K . . . . . . . . . . . n Walsh, Eric Ferguson . . . . . . . . . . . . . a, b – Praxim
Van Der Pol, G Jerry . . . . . . . . . . . . . . n Walsh, Michael . . . . . . . . . . . . . . . . . . n
van Dijk, C N . . . . . . . . . . . . . . . . . . . n Walsh, Nicola A . . . . . . . . . . . . . . . . . n
Van Griensven, Martijn . . . . . . . . . . . n Walter, Frank L . . . . . . . . . . . . . . . . . . n
van Loon, Corne JM . . . . . . . . . . . . . . n Walter, William Keith. . . . . . . . . . . . . a, c – DePuy, Stryker
Van Tongel, Alexander . . . . . . . . . . . . n Walter, William Lindsay. . . . . . . . . . . a, c, e – DePuy, A Johnson & Johnson
Vandeneucker, Hilde . . . . . . . . . . . . . n Company, a, e – Ceramtec,
Vanderhave, Kelly L . . . . . . . . . . . . . . n a, b, c, e – Stryker, e – Finsbury
Vannini, Francesca . . . . . . . . . . . . . . . n Wambolt, Elizabeth . . . . . . . . . . . . . . n
Vanoeveren, Lucas S . . . . . . . . . . . . . . n Wan, Zhinian . . . . . . . . . . . . . . . . . . . n
Varecka, Thomas F . . . . . . . . . . . . . . . a, c – Zimmer, a – Synthes Wanderer, Jonathan . . . . . . . . . . . . . . n
DISCLOSURE
Varma, Amit . . . . . . . . . . . . . . . . . . . . n Wang, Bing Qiang . . . . . . . . . . . . . . . n

Vaughn, Zackary D . . . . . . . . . . . . . . . n Wang, Ching-Jen. . . . . . . . . . . . . . . . . n
Vaz, Gualter. . . . . . . . . . . . . . . . . . . . . n Wang, David William. . . . . . . . . . . . . n
Veillette, Christian . . . . . . . . . . . . . . . n Wang, Edward D. . . . . . . . . . . . . . . . . n
Velkeniers, Brigitte . . . . . . . . . . . . . . . n Wang, Feng-Sheng . . . . . . . . . . . . . . . n
Velpula, Jagan Mohana Reddy . . . . . n Wang, Hali . . . . . . . . . . . . . . . . . . . . . n
Vendittoli, Pascal-Andre. . . . . . . . . . . a, e – Zimmer, a – Stryker Howmedica, Wang, Jeffrey C . . . . . . . . . . . . . . . . . . a, b, c, e – Biomet, Medtronic Sofamor
Biomet, DePuy, Smith & Nephew Danek, b, e – Stryker, b – AO, c, e – DePuy,
Verde, Francesco . . . . . . . . . . . . . . . . . n A Johnson & Johnson Company, Zimmer,
Verdonk, Rene. . . . . . . . . . . . . . . . . . . a – Biomet, EBI, DePuy, A Johnson & c – Aesculap/B.Braun, seaspine, e – Synthes,
Johnson Company, Stryker, Synthes, Musculoskeletal Transplant Foundation
Tornier, b, c, e – Medacta, Orteq Wang, Pin-Chieh . . . . . . . . . . . . . . . . a – NIH
Vereeke West, Robin . . . . . . . . . . . . . . n Wang, Robert. . . . . . . . . . . . . . . . . . . . n
Verhaar, Jan . . . . . . . . . . . . . . . . . . . . . n Wang, Yun . . . . . . . . . . . . . . . . . . . . . . n
Verhagen, Cees . . . . . . . . . . . . . . . . . . n Wanich, Tony . . . . . . . . . . . . . . . . . . . n
Verma, Ashim . . . . . . . . . . . . . . . . . . . n Warner Jr William C . . . . . . . . . . . . . . a – DePuy, A Johnson & Johnson Company,
Verma, Nikhil N . . . . . . . . . . . . . . . . . n Smith & Nephew
Verstreken, Frederik . . . . . . . . . . . . . . b – Smith & Nephew Warren, R E . . . . . . . . . . . . . . . . . . . . . n
Verzier, Nancy . . . . . . . . . . . . . . . . . . . n Warren, Russell F . . . . . . . . . . . . . . . . a – Smith & Nephew, c – Biomet, Smith &
Vianello, Roberto . . . . . . . . . . . . . . . . n Nephew, d – Zimmer, e – KFX
Victor, Jan MK . . . . . . . . . . . . . . . . . . . n Warth, Lucian Craig . . . . . . . . . . . . . . n
Vidal, Armando F . . . . . . . . . . . . . . . . a – Arthrex, Smith & Nephew Wasa, Junji. . . . . . . . . . . . . . . . . . . . . . n
Vidyahara, S . . . . . . . . . . . . . . . . . . . . n Waseem, Mohammed . . . . . . . . . . . . n
Viens, Nicholas Adam . . . . . . . . . . . . n Wasielewski, Ray C . . . . . . . . . . . . . . . a, c, e – Zimmer
Vigler, Mordechai . . . . . . . . . . . . . . . . n Wasserman, Bruce A. . . . . . . . . . . . . . n

Watanabe, Atsuyi . . . . . . . . . . . . . . . . n Williams Jr Gerald R. . . . . . . . . . . . . . a – Arthrex, Inc, National Institutes of
Watanabe, Chisato . . . . . . . . . . . . . . . n Health (NIAMS & NICHD), Stryker,
Watanabe, Kei . . . . . . . . . . . . . . . . . . . n Synthes, b, c, e – DePuy, A Johnson &
Watanabe, Takuya. . . . . . . . . . . . . . . . n Johnson Company, e – Mitek
Watanabe, Tetsu . . . . . . . . . . . . . . . . . a – Stryker Orthopedics Williams, Heidi A . . . . . . . . . . . . . . . . a – DePuy, Johnson & Johnson, Linvatec,
Waters, Tim S . . . . . . . . . . . . . . . . . . . a – DePuy, Stryker Stryker, Surgical Synergies, Zimmer, Smith &
Watnabe, Gen . . . . . . . . . . . . . . . . . . . n Nephew
Watson, Alex . . . . . . . . . . . . . . . . . . . . n Williams, Kathy . . . . . . . . . . . . . . . . . n
Watson, J Tracy . . . . . . . . . . . . . . . . . . a, c – Smith & Nephew, DePuy, A Johnson Williams, Riley Joseph . . . . . . . . . . . . n
& Johnson Company, a – Zimmer, Williams, Sophie . . . . . . . . . . . . . . . . e – DePuy
e – Wright Medical Technology, Inc. Willis, R Baxter . . . . . . . . . . . . . . . . . . n
Watson, Jeffry T. . . . . . . . . . . . . . . . . . a – Biomet Willits, Kevin. . . . . . . . . . . . . . . . . . . . a – Aircast, Physician Services Inc.
Watters, III, William Charles . . . . . . . e – Stryker, Intrinsic Therapeutics, MeKessen Wills, Nicholas Joseph . . . . . . . . . . . . n
Health Care Solutions Willsey, Daniel S. . . . . . . . . . . . . . . . . n
Watts, Hugh Godfrey . . . . . . . . . . . . . n Wilson, APR . . . . . . . . . . . . . . . . . . . . n
Weaver, Rachel . . . . . . . . . . . . . . . . . . n Wilson, Charles . . . . . . . . . . . . . . . . . n
Weber, Elizabeth West . . . . . . . . . . . . n Wilson, David . . . . . . . . . . . . . . . . . . . n
Weber, Horst . . . . . . . . . . . . . . . . . . . . e – Grunenthal GmbH Wilson, Michael G . . . . . . . . . . . . . . . a, e – DePuy, a – Biomet, DJ ORtho
Weber, Kristy L . . . . . . . . . . . . . . . . . . a – Zimmer Winberg, Tierney . . . . . . . . . . . . . . . . n
Weber, Patrick . . . . . . . . . . . . . . . . . . . n Winberg, Tierney J . . . . . . . . . . . . . . . n
Webster, Kate. . . . . . . . . . . . . . . . . . . . n Windhager, Reinhard . . . . . . . . . . . . . n
Weeden, Steven H. . . . . . . . . . . . . . . . a, b, c, e – Zimmer Windsor, Russell E . . . . . . . . . . . . . . . c, e – Zimmer
Wei, Ai Qun . . . . . . . . . . . . . . . . . . . . n Wing, Kevin J . . . . . . . . . . . . . . . . . . . a – Zimmer
Wei, Anthony Shen-Yuan. . . . . . . . . . n Wingerter, Scott A . . . . . . . . . . . . . . . . n
Weikert, Douglas . . . . . . . . . . . . . . . . a – Biomet Winquist, Robert A . . . . . . . . . . . . . . . b, c, e – Zimmer
Weil, Lowell Scott . . . . . . . . . . . . . . . . n Winston, Kim . . . . . . . . . . . . . . . . . . . n
Weiner, Dennis S . . . . . . . . . . . . . . . . n Winter, Matthias . . . . . . . . . . . . . . . . . n
Weiner, Scott D . . . . . . . . . . . . . . . . . . n Winter, Suzanne . . . . . . . . . . . . . . . . . a – Zimmer
Weinfeld, Steven Bennett . . . . . . . . . a – Zimmer Wirth, Michael A. . . . . . . . . . . . . . . . . a, b, c, e – DePuy, A Johnson & Johnson
Weinstein, David . . . . . . . . . . . . . . . . a – DePuy Mitek, Sanofi Aventis, Genzyme, Company, a – Smith & Nephew, Stryker,
b – DePuy Mitek d – Tornier
Weinstein, James N . . . . . . . . . . . . . . n Wiss, Donald A . . . . . . . . . . . . . . . . . . a – Arthrex, Inc, Linvatec, Smith & Nephew,
Weisenburger, Joel N . . . . . . . . . . . . . a – Biomet b – Stryker, Synthes
Weiskopf, Joanne . . . . . . . . . . . . . . . . n Wixted, John J . . . . . . . . . . . . . . . . . . . a – Synthes, Merck
Weiss, Brian. . . . . . . . . . . . . . . . . . . . . n Wojewnick, Bartosz . . . . . . . . . . . . . . n
Weiss, Jennifer M . . . . . . . . . . . . . . . . n Wolcott, Michelle . . . . . . . . . . . . . . . . a – Arthrex, Smith & Nephew
Wellisz, Tadeusz . . . . . . . . . . . . . . . . . d – Ceremed, Inc. Wolf, Brian R. . . . . . . . . . . . . . . . . . . . a – Arthrex, Smith & Nephew
Wellman, Samuel Secord. . . . . . . . . . n Wolf, Bryce T . . . . . . . . . . . . . . . . . . . . n
Wells, Chris . . . . . . . . . . . . . . . . . . . . . n Wolfe, Scott W. . . . . . . . . . . . . . . . . . . b, c, e – Trimed, c – Small Bone Innovations
Wells, Lawrence. . . . . . . . . . . . . . . . . . n Wolinsky, Philip R . . . . . . . . . . . . . . . a – Zimmer
Welsch, Matthew David . . . . . . . . . . . b – Medtronic Won, Man Hee . . . . . . . . . . . . . . . . . . n
Wen, Zuejun . . . . . . . . . . . . . . . . . . . . a – Ceremed, Inc. Wong, David Alan . . . . . . . . . . . . . . . a – Abbott, Arcus, Cervitech, Stryker,
Wenda, Klaus . . . . . . . . . . . . . . . . . . . n Zimmer, b – Cervitech, Stryker, Zimmer,
Wendt, Martina. . . . . . . . . . . . . . . . . . n Anulex, e – Stryker, Zimmer, Anulex
Wenger, Dennis R . . . . . . . . . . . . . . . . n Wood, Billy . . . . . . . . . . . . . . . . . . . . . n
Wenke, Joseph C. . . . . . . . . . . . . . . . . b – Smith & Nephew Wood, David. . . . . . . . . . . . . . . . . . . . n
Werner, Clement. . . . . . . . . . . . . . . . . n Wood, Gavin. . . . . . . . . . . . . . . . . . . . n
West, Hugh . . . . . . . . . . . . . . . . . . . . . c – Linvatec Wood, II, George William . . . . . . . . . n
Westrich, Geoffrey H . . . . . . . . . . . . . a, e – DJ Orthopaedics, Exactech, Inc, Wood, Kirkham B. . . . . . . . . . . . . . . . a – Blackstone Medical, DePuy, A Johnson
Stryker, a – Sanofi-Aventis & Johnson Company, Medtronic Sofamor
Weyer, Reinhard . . . . . . . . . . . . . . . . . n Danek, Synthes, b – DePuy, A Johnson &
Wezeman, Frederick H. . . . . . . . . . . . n Johnson Company, d – TranS1, Inion Inc.,
Whang, Peter G. . . . . . . . . . . . . . . . . . a – Medtronic Sofamor Danek, e – Inion, Inc.
e – Paradigm Spine Woodall, Jr, James. . . . . . . . . . . . . . . . n
Whelan, Daniel. . . . . . . . . . . . . . . . . . n Woodgate, Ian G. . . . . . . . . . . . . . . . . n
Whiddon, David Richmond . . . . . . . n World, Michael . . . . . . . . . . . . . . . . . . n
Whitaker, Mark Camden . . . . . . . . . . a, b – Stryker Spine, Synthes Spine, Wredmark, Torsten . . . . . . . . . . . . . . . n
DISCLOSURE
e – Stryker Spine Wright, James G . . . . . . . . . . . . . . . . . a – Synthes
White, Augustus A . . . . . . . . . . . . . . . n Wright, Judy L . . . . . . . . . . . . . . . . . . . n
White, Brian . . . . . . . . . . . . . . . . . . . . n Wright, Michelle L . . . . . . . . . . . . . . . n
White, Lanya W. . . . . . . . . . . . . . . . . . n Wright, Rick W . . . . . . . . . . . . . . . . . . a – Arthrex, Inc, Smith & Nephew,
White, Timothy O. . . . . . . . . . . . . . . . n d – Wright Medical Technology, Inc.
Whiteside, Leo A. . . . . . . . . . . . . . . . . b, c – Smith & Nephew, d – Signal Medical Wright, Thomas W . . . . . . . . . . . . . . . a, c, d, e – Exactech
Whitwell, Duncan . . . . . . . . . . . . . . . n Wright, Timothy M. . . . . . . . . . . . . . . a – Zimmer, Exatech, Synthes Spine, Orteq,
Wickiewicz, Thomas L . . . . . . . . . . . . e – Mako Surgical Ltd.
Widmann, Roger F . . . . . . . . . . . . . . . n Wright, Vonda. . . . . . . . . . . . . . . . . . . n
Widmer, Andreas . . . . . . . . . . . . . . . . n Wright, Woodring E . . . . . . . . . . . . . . n
Wiebking, Ulrich . . . . . . . . . . . . . . . . n Wrigley, Tim . . . . . . . . . . . . . . . . . . . . n
Wieners, Gero . . . . . . . . . . . . . . . . . . . n Wu, Karl. . . . . . . . . . . . . . . . . . . . . . . . n
Wierks, Carl. . . . . . . . . . . . . . . . . . . . . n Wu, Karl. . . . . . . . . . . . . . . . . . . . . . . . n
Wijkstrom, Martin . . . . . . . . . . . . . . . n Wu, Tuoh. . . . . . . . . . . . . . . . . . . . . . . n
Wild, Lisa M . . . . . . . . . . . . . . . . . . . . a – OTA, Zimmer, Wright Medical Wu, Wei Ping . . . . . . . . . . . . . . . . . . . a – GOT
Wildstein, Michael S . . . . . . . . . . . . . e – Kyphon Wu, Xiao . . . . . . . . . . . . . . . . . . . . . . . n
Will, Elizabeth M . . . . . . . . . . . . . . . . n Wuerz, Thomas H. . . . . . . . . . . . . . . . n
Willems, K . . . . . . . . . . . . . . . . . . . . . . n Wulf, Corey A . . . . . . . . . . . . . . . . . . . n
Willems, W Jaap . . . . . . . . . . . . . . . . . n Wybo, Christopher D. . . . . . . . . . . . . n
Williams, Allison E. . . . . . . . . . . . . . . n Xenakis, Theodoros . . . . . . . . . . . . . . n
Williams, Dan. . . . . . . . . . . . . . . . . . . a – Surgical Innovations Xenos, John S . . . . . . . . . . . . . . . . . . . a – Sanofi Aventis, Genzyme
Williams, Denis A. . . . . . . . . . . . . . . . n Xerogeanes, John W . . . . . . . . . . . . . . n
Xiaohui, Niu . . . . . . . . . . . . . . . . . . . . n
Yajima, Hiroshi. . . . . . . . . . . . . . . . . . n
Yakkanti, Madhusudhan Reddy . . . . n

Yalamanchili, Praveen . . . . . . . . . . . . n Zawadsky, Mark W . . . . . . . . . . . . . . . n
Yamada, Kiyotaka . . . . . . . . . . . . . . . . n Zdeblick, Thomas A . . . . . . . . . . . . . . a, c, e – Medtronic, a, c – EBI, Zimmer,
Yamada, Yoshihisa . . . . . . . . . . . . . . . n d, e – Anulex
Yamada, Yuzo . . . . . . . . . . . . . . . . . . . n Zebala, Lukas . . . . . . . . . . . . . . . . . . . n
Yamagata, Masahiro . . . . . . . . . . . . . . n Zeichen, Johannes . . . . . . . . . . . . . . . n
Yamaguchi, Ai . . . . . . . . . . . . . . . . . . . n Zeiders, Gregory . . . . . . . . . . . . . . . . . a, b – Smith & Nephew, b – Synthes
Yamaguchi, Ken . . . . . . . . . . . . . . . . . c – Arthrex, Inc Zembo, Michele M . . . . . . . . . . . . . . . a – Medtronic Sofamor Danek, d – Merck
Yamamoto, Atsushi . . . . . . . . . . . . . . n Zha, Kristin . . . . . . . . . . . . . . . . . . . . . n
Yamamoto, Kengo . . . . . . . . . . . . . . . n Zhang, Jian . . . . . . . . . . . . . . . . . . . . . a – National Natural Science Foundation of
Yamamoto, Koji . . . . . . . . . . . . . . . . . n Peoples Republic of China
Yamamoto, Norio. . . . . . . . . . . . . . . . n Zhang, Jing Fan. . . . . . . . . . . . . . . . . . n
Yamamoto, Shinji. . . . . . . . . . . . . . . . n Zhang, Li-Qun . . . . . . . . . . . . . . . . . . n
Yamane, Shigeru . . . . . . . . . . . . . . . . . n Zhao, Chunfeng . . . . . . . . . . . . . . . . . n
Yamashita, Keishi . . . . . . . . . . . . . . . . n Zhao, Kristin D . . . . . . . . . . . . . . . . . . n
Yamashita, Takeshi . . . . . . . . . . . . . . . n Zhao, Lin . . . . . . . . . . . . . . . . . . . . . . . n
Yamashita, Toshihiko. . . . . . . . . . . . . n Zhao, Meijuan . . . . . . . . . . . . . . . . . . n
Yamasita, Takeshi . . . . . . . . . . . . . . . . n Zhen, Gehua . . . . . . . . . . . . . . . . . . . . n
Yamauchi, Kensuke . . . . . . . . . . . . . . n Zheng, Yanming . . . . . . . . . . . . . . . . . e – Smith & Nephew
Yamazaki, Akiyoski. . . . . . . . . . . . . . . n Zhongmin, Jin . . . . . . . . . . . . . . . . . . n
Yamazaki, Ken. . . . . . . . . . . . . . . . . . . n Zhou, Weiping . . . . . . . . . . . . . . . . . . n
Yamazaki, Takaharu . . . . . . . . . . . . . . a – Stryker Orthopedics Zhu, Jinjun . . . . . . . . . . . . . . . . . . . . . n
Yang, Edward C. . . . . . . . . . . . . . . . . . n Zhuang, Harry. . . . . . . . . . . . . . . . . . . n
Yang, Jinping. . . . . . . . . . . . . . . . . . . . n Ziaee, Hena . . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew
Yang, Kuender D. . . . . . . . . . . . . . . . . n Zicat, Bernard A . . . . . . . . . . . . . . . . . a, c – DePuy, c – Zimmer
Yang, Rong-Sen . . . . . . . . . . . . . . . . . . n Ziegler, Dean W . . . . . . . . . . . . . . . . . n
Yang, Ya-Ju. . . . . . . . . . . . . . . . . . . . . . n Ziegler, Jessica . . . . . . . . . . . . . . . . . . . n
Yasko, Alan W . . . . . . . . . . . . . . . . . . . a – Musculoskeletal Transplant Foundation, Zigler, Jack E . . . . . . . . . . . . . . . . . . . . n
Synthes, DePuy, A Johnson & Johnson Zijl, Jacco . . . . . . . . . . . . . . . . . . . . . . . n
Company, Medtronic Zilber, Sebastian . . . . . . . . . . . . . . . . . n
Yasuda, Kazunori . . . . . . . . . . . . . . . . n Zilkens, Christoph . . . . . . . . . . . . . . . n
Yasuda, Toshito. . . . . . . . . . . . . . . . . . n Zingde, Sumesh M . . . . . . . . . . . . . . . a – Archus Orthopedics, DePuy, Zimmer
Yasui, Kenji . . . . . . . . . . . . . . . . . . . . . n Zingg, Patrick Oliver. . . . . . . . . . . . . . n
Yasui, Natsuo . . . . . . . . . . . . . . . . . . . n Zingmond, David. . . . . . . . . . . . . . . . n
Yasunaga, Yuji . . . . . . . . . . . . . . . . . . . n Ziran, Bruce. . . . . . . . . . . . . . . . . . . . . a – Medtronic, b, e – Stryker, b – AO,
Yaszemski, Michael J . . . . . . . . . . . . . a, e – National Institutes of Health (NIAMS e – Synthes
& NICHD), a – Health and Human Services, Zlowodzki, Michael Pawel. . . . . . . . . a – Osteosynthesis and Trauma Care
e – IsoTis Orthobiologics, Osteotech, Foundation, AO North America
Wyeth, BonWRX Zobitz, Mark E . . . . . . . . . . . . . . . . . . n
Yeager, Keith . . . . . . . . . . . . . . . . . . . . n Zomar, Mauri . . . . . . . . . . . . . . . . . . . n
Yeger-McKeever, Meira Z . . . . . . . . . . n Zuckerman, Joseph D . . . . . . . . . . . . b, c – Exactech, Inc, e – Biomimetic, Smith
Yeh, Albert C . . . . . . . . . . . . . . . . . . . . n & Nephew, Progenics
Yeh, Sloane . . . . . . . . . . . . . . . . . . . . . n Zuelzer, Wilhelm A. . . . . . . . . . . . . . . n
Yen, Ruoh-Fang. . . . . . . . . . . . . . . . . . n Zuk, Patricia A. . . . . . . . . . . . . . . . . . . n
Yen, Yi-Meng . . . . . . . . . . . . . . . . . . . . a – Smith & Nephew Zurakowski, David . . . . . . . . . . . . . . . n
Yeo, C J . . . . . . . . . . . . . . . . . . . . . . . . n
Yeom, Jin-Sup . . . . . . . . . . . . . . . . . . . n
Yildiz, Muzaffer . . . . . . . . . . . . . . . . . n
Yocum, Lewis A. . . . . . . . . . . . . . . . . . a – Arthrex, Inc, DePuy, A Johnson &
Johnson Company, DJ Orthopaedics,
Genzyme, Mitek, Pfizer, Smith & Nephew,
Stryker, e – DePuy, A Johnson & Johnson
Company, Mitek
Yokouchi, Masahiro . . . . . . . . . . . . . . n
Yonekawa, Masahiro . . . . . . . . . . . . . n
Yoo, Jae Ho . . . . . . . . . . . . . . . . . . . . . n
Yoon, Kang S . . . . . . . . . . . . . . . . . . . . n
Yoon, Richard S . . . . . . . . . . . . . . . . . n
DISCLOSURE
Yoon, S. Tim . . . . . . . . . . . . . . . . . . . . a, b, e – Medtronic Sofamor Danek,

a, e – Abbott, a – Synthes, b, e – Stryker
Yoon, Su Won . . . . . . . . . . . . . . . . . . . n
Yoon, Sung-Hwan . . . . . . . . . . . . . . . n
Yoon, Taek Rim. . . . . . . . . . . . . . . . . . e – Zimmer
Yoon, Timothy . . . . . . . . . . . . . . . . . . n
Yoshida, Satoshi . . . . . . . . . . . . . . . . . n
Yoshiim, Yuchi . . . . . . . . . . . . . . . . . . n
Yoshikawa, Hideki . . . . . . . . . . . . . . . n
Yoshino, Hitohiro. . . . . . . . . . . . . . . . n
You, Seung Min. . . . . . . . . . . . . . . . . . n
Younger, Alastair S E. . . . . . . . . . . . . . a, e – Biomimetic, Zimmer, DePuy,
A Johnson & Johnson Company, a – Wyeth
Yu, Fei . . . . . . . . . . . . . . . . . . . . . . . . . n
Yuan, Brandon . . . . . . . . . . . . . . . . . . n
Yue, Wai Mun . . . . . . . . . . . . . . . . . . . n
Yuge, Itaru . . . . . . . . . . . . . . . . . . . . . . n
Zadzilka, Jayson D . . . . . . . . . . . . . . . a – Stryker Howmedica
Zaffagnini, Stefano . . . . . . . . . . . . . . . n
Zahradnik, Janet . . . . . . . . . . . . . . . . . n
Zalavras, Charalampos. . . . . . . . . . . . n
Zalzal, Paul . . . . . . . . . . . . . . . . . . . . . n
Zaman, Tariq. . . . . . . . . . . . . . . . . . . . n
Zare, Stephanie M. . . . . . . . . . . . . . . . n
Zarin, Jeffrey S. . . . . . . . . . . . . . . . . . . n
03 SYM 08:Layout 1 1/28/08 6:32 PM Page 51
◆THE LATEST INFORMATION ON TOTAL HIP

ARTHROPLASTY BEARING SURFACES:
SYMPOSIA AR HIP
PRESENTATION, ANALYSIS AND
CRITIQUE OF THE LATEST DATA
FROM AROUND THE WORLD (A)
Moderator: Daniel J. Berry, MD, Rochester, MN
This symposium will assemble national and international clinical and research experts on
hip arthroplasty bearings together to present, analyze, and critique the latest data about the
clinical performance and scientific concerns related to today’s hip bearings.
I. Metal-on-Metal Bearings
A. Synopsis of the Latest Clinical Data from Around the World on Metal-Metal
Bearings
Thomas P. Vail, MD, San Francisco, CA
B. Ions: Latest Data on Ion Levels and Their Significance After Metal-Metal THA
Steven J. MacDonald, MD, London, ON, Canada
C. ALVALS: How Frequent, How Serious?
Thomas P. Schmalzired, MD, Los Angeles, CA
D. Local Cytotoxicity: A New Cause for Concern?
Joshua J. Jacobs, MD, Chicago, IL
II. Discussion by Panel of Metal-on-Metal Bearings

Daniel J. Berry, MD, Rochester, MN
III. Ceramic-on-Ceramic Bearings

A. Synopsis of the Latest Clinical Data from Around the World on Ceramic-on-
Ceramic Bearings
James A. D’Antonio, MD, Sewickley, PA
B. Squeak in Association with Ceramic Bearings: How Frequent, What Causes It?
Peter F. Sharkey, MD, Philadelphia, PA
C. Stripe Wear, Ceramic Fractures
William L. Walter, MD, Waverton, Australia
IV. Discussion by Panel of Ceramic-on-Ceramic Bearings

V. Cross-linked Polyethylene Bearings

A. Synopsis of the Latest Clinical Data from Around the World on Cross-linked
Polyethylene Bearings
William J. Maloney, MD, Stanford, CA
B. Cross-linked Polyethylene Fractures: Frequency, Clinical Circumstances
Roy D. Crowninshield, PhD, Asheville, NC
VI. Discussion by Panel of Cross-linked Polyethylene Bearings

VII. The Next Generation of Bearing Solutions?

A. Ceramic-on-Metal
Anton Schepers, MD, Johannesburg, South America
◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
page 2. An alphabetical faculty financial disclosure list can be found starting on page 18.
51
B. New Ceramic Coatings for Metal Substrates

John P. Fisher, PhD, Leeds, United Kingdom
C. New, Improved Cross-linked Polyethylenes
John J. Callaghan, MD, Iowa City, IA
SYMPOSIA AR HIP
VIII. Panel Discussion/Audience Questions
52 ◆ The FDA has not cleared the drug and/or medical device for the use described in this presentation (i.e. the drug or medical device is being discussed for an off label use). For full information, refer to
SYNOPSIS OF THE LATEST CLINICAL DATA FROM AROUND THE

WORLD ON METAL-METAL BEARINGS
Brant Harradine, MD and Thomas Parker Vail, MD
The greatest improvements in hip arthroplasty in the past 5 ous liberation of submicron polyethylene particles as the
years center on design changes and new options for the bearing major cause of osteolysis. While metal-on-metal articula-
SYMPOSIA AR HIP
surface. The options have expanded from the single cobalt- tions pre-dated the Charnley low-friction arthroplasty, the
chrome on polyethylene to more wear resistant bearings that renewed popularity represents an effort to avoid osteolysis
include three predominant wear couples: metal on cross-linked and improve implant longevity. Most published studies to
polyethylene, metal on metal, and ceramic on ceramic. Each date yielding 5 to 10 year follow-up have not noted osteoly-
new bearing brings with it questions that clinical and laborato- sis as a cause of failure. The series published by Dorr et al
ry experience is beginning to answer. Metal on metal articula- and Lombardi et al detected no osteolysis on radiographic
tions offer the potential for wear rates up to 100 times less than exam at mid-term follow-up. Grubl et al reported proximal
conventional polyethylene, with linear penetration rates on the lesions in 1.3% of femurs and adjacent to 2.6% of the thread-
order of microns per year. The wear rates represent an order of ed cementless acetabular components at 10 years. However,
magnitude improvement over metal on polyethylene. The none of these implants required revision. Park et al. report-
lubrication regime with hard on hard metal bearings (deter- ed early osteolysis in 5.9% of hips following second genera-
mined by the lambda ratio) favors highly polished, larger diam- tion metal-on-metal hip replacement. In this series, a high
eter bearings with low clearance (on the order of 100 microns carbon content acetabular component was combined with a
diametrical clearance). The theoretical wear advantage with low carbon content (<0.07%) femoral head. Two hips
larger heads combined with the lower risk of dislocation using required revision for instability. Histological examination of
larger heads has lead to a widespread adoption of metal-metal the retrieved periprosthetic tissues from the two revised hips
bearing couples. The large clinical experience to date has shown showed perivascular infiltration of lymphocytes and
hypersensitivity as a rare clinical problem, and indicates no cor- mononuclear phagocytes in both cases. Neither particle-
relation with carcinogenesis and arthroplasty. Nevertheless laden macrophages nor polymorphonuclear cells were seen,
these issues still loom as a concern worldwide. Small case series suggesting a process other than osteolysis as we understand it
of soft tissue reactions in the presence of metal-on-metal articu- today.
lations require further investigation (Murray, et al 2007). Failed
III. REVISION RATES
implant retrievals demonstrate peri-vascular lymphocytic infil-
tration, but it is not clear that this pathologic finding is isolated Study Prosthesis Number of hips Follow-up Revisions
Park et al Ultima 169 2yrs 2-instability
to failed metal-on-metal articulations as Lombardi has noted
Saito et al Metasul 106 5yrs 1-liner dissociation
similar pathologic findings in a large series of revision cases Lombardi et al M2a 195 5yrs none
where periarticular tissues were biopsied. A causal relationship Dorr et al Metasul 96 5-11 1-loosening
between implant failure and hypersensitivity has not been 2-instability
established. While a link between metal ions produced by 1-liner dissociation
implants and carcinogenesis issue also remains unproven, it Milosev et al Sikomet 640 7yrs 6-infection
cannot be dismissed without rigorous long term study of large 23-loosening
numbers of metal on metal devices. 2-pain
3-other
Grubl et al Metasul 105 10yrs 1-infection
Synopsis of clinical performance: 1-instability
I. Clinical performance 1-HO
First-generation metal-on-metal articulations generated high 1-late GT fx
failure rates due to component loosening. This was attrib-
uted to inadequate equatorial clearance resulting in seizing IV.Reports of early failure or complications
of the couple and torque transfer to the fixation interfaces. Concerns regarding metal-on-metal bearing couples revolve
However, those implants that survived preformed well. Long- around the production of metallic wear particles and ions.
term survivorship of the McKee Farrar total hip prosthesis has Wear particles are implicated in the formation of perivascu-
been reported to be 84% at 20 years and 74% at 28 years. lar lymphocytic infiltrates seen in the periarticular tissues
Second-generation implants utilizing modern machining during implant retrieval. It has been speculated that this his-
techniques have demonstrated excellent 5 to 10 year per- tological response, consistent with a delayed-type hypersen-
formance. Lombardi et al reported a 100% survivorship at 5 sitivity reaction, may be responsible for aseptic loosening,
years. Dorr et al. reported a 98.8% survivorship at 11 years osteolysis, or unexplained groin pain. Of note is the fact that
for revision for loosening as the end point and a 96.1% sur- women seem to be more succeptible to hypersensitivity than
vivorship at 11 years for revision for any reason as the end men, if the incidence of adverse events is an accurate indica-
point. While long-term data is needed to determine if metal- tor. This tissue response has been seen uniformly in revisions
on-metal bearings will out-perform other bearing couples, performed for various modes of failure including instability
evidence to date is encouraging. and infection, thus leading to the conclusion that a direct
causal relationship between hypersensitivity and implant
II. Wear debris and osteolysis. failure has not been established. Additionally, case reports of
Periprosthetic osteolysis remains the dominant cause of THA revision surgery to address unexplained pain (thought to be
failure. The established paradigm points to macrophage caused by hypersensitivity as a diagnosis of exclusion) have
induced osteoclastic bone resorption fueled by the continu- not consistently resulted in pain relief. Concerns about the
53
long term effect of elevated serum ion levels include possible cobalt in the general population as a result of environmental
renal impairment, carcinogenesis, mutagenicity, and connec- exposure. Due to the unknown potential effects of these
tive tissue disorders. Metal-on-metal articulations are known ions, caution has been urged in using this bearing couple in
to cause up to a 7 fold increase in serum cobalt levels com- patients with renal dysfunction who might not clear the ions
pared to the general population. However, there is a wide effectively, and in women of child bearing age who might
regional variation in the baseline level of chromium and potentially expose a fetus to metal ions.
SYMPOSIA AR HIP
REFERENCES: 5. Lombardi, AV et al: Mid-Term Results of a Polyethylene-Free Metal-on-Metal

1. Grubl, A et al: Long-Term Follow-Up of Metal-on-Metal Total Hip Replacement. Articulation. The Journal of Arthroplasty Vol. 19 No. 7 Suppl. 2 2004
Journal of Orthopaedic Research 2007; 25:841–848. 6. Park, YS et al: Early osteolysis following second-generation metal-on-metal
2. Milosev, I et al: Survivorship and Retrieval Analysis of Sikomet Metal-on-Metal replacement. J Bone Joint Surg Am. 2005; 87:1515-21.
Total Hip Replacements at a Mean of Seven Years. JBJS Am 2006; 88:1173-1182. 7. P. Korovessis, G. Petsinis, M. Repanti and T. Repantis: Metallosis After
3. Dorr, LD et al: Fixation and Osteolysis with Metasul Metal-on-Metal Articulation. Contemporary Metal-on-Metal Total Hip Arthroplasty. J Bone Joint Surg Am.
The Journal of Arthroplasty Vol. 19 No. 8 December 2004 2006;88:1183-1191.
4. Saito,S et al: Midterm Results of Metasul Metal-on-Metal Total Hip Arthroplasty.

The Journal of Arthroplasty Vol. 21 No. 8 December 2006
METAL IONS: LATEST DATA ON ION LEVELS AND THEIR

SIGNIFICANCE AFTER METAL-METAL THA
Steven J. MacDonald, MD
Introduction III) Clinical Significance of Elevated Ions

All metal-on-metal total hip and resurfacing implants produce While it is universally recognized that metal-metal bearings
SYMPOSIA AR HIP
metal ions. This production is most commonly thought of as a will produce markedly elevated metal ions compared with
result of wear directly at the bearing surface, but other second- metal-polyethylene or ceramic-ceramic articulations, the clin-
ary sources have also been described (corrosion). These elevat- ical relevance of these metal ions remains unanswered. There
ed metal ions are seen in various blood samples, urine and end are however specific clinical scenarios that can be discussed;
organ tissues. There continues to remain much controversy as to
a) Renal dysfunction
the clinical significance of this ion production.
As metal ions are excreted through renal clearance, it is
important that patients receiving a metal-metal implant
I) Implant Specific Ion Levels
have adequate renal function. While there has not been an
Over the last several years there have been many articles pub-
established minimal function required for adequate metal
lished on metal ion levels in commonly used implants
ion clearance, there are case reports of dialysis dependent
around the world. There has been tremendous variability in
patients with very markedly elevated serum ions (>100X
analytical techniques, samples evaluated and reporting
normal). Obviously this bearing would not normally be
methodologies, however recently the reporting has become
indicated in this patient population, but as renal function
more standardized. This provides the opportunity to com-
can potentially decrease over time over many years, it is
pare implants with respect to measurable ion levels. The fol-
something to be cognizant of when choosing this bearing
lowing table is representative of some of the publications in
option.
the field, but is by no means exhaustive:
b) Component position
II) Important Study/Reporting Variables Gross component malposition (excessive abduction or
At present there is no universally accepted technique of meas- version) can lead to increased wear and impingement and
uring metal ions, but most authors would agree that the ICP- subsequently increased measured ion levels.
MS technique gives reproducible values and has the benefit
c) Placental barrier
of extremely low detection limits such that all samples will
A recent paper13 reviewed the transplacental transfer of
have measurable ions. A very important variable to under-
metal ions in 10 child-bearing women. The placenta did
stand is which blood sample is being analyzed. For example,
provide a modulatory effect on the rate of metal ion trans-
when analyzing cobalt levels authors have demonstrated that
fer. Compared to maternal levels, umbilical cord levels
erythrocytes will give the lowest value, whole blood an inter-
were 60% for cobalt and 29% for chromium.
mediate value and serum the highest value, all for blood
taken the same day in the same patient. Therefore when com-
paring between series it is critical to understand the method-
ology of metal ion analysis performed.
COBALT AND CHROMIUM LEVELS OF METAL-ON-METAL IMPLANTS
Implant Analytic Sample No. of Time InVivo Cobalt Levels Chromium Levels Reference
Technique Implants (yrs) (parts per billion) (parts per billion)
Metasul(i) AAS Serum 27 1 1.1 -- 1
Metasul AAS Serum 36 5 0.7 -- 2
Metasul AAS Serum 15 2 0.88 -- 3
Metasul AAS Serum 15 4.3 0.81 -- 3
Metasul AAS Serum 60 2 1.70 4.28 4
Metasul AAS Serum 42 4 1.57 2.10 9
Metasul Average 1.13 3.19
M2a(ii) ICP-MS Erythrocytes 22 2 1.10 2.50 5
M2a AAS Serum 10 6 1.55 0.84 6
M✒a Average 1.33 1.67
BHR(iii) ICP-MS Serum 16 1 2.10 7
BHR AAS Serum 111 2 4.28 5.12 4
BHR AAS Serum 16 2 1.88 3.53 8
BHR ICP-MS Whole Blood 26 4 1.20 1.10 10
BHR Average 2.37 3.25
Ultamet(iv) ICP-MS Serum 30 1 0.66 0.97 11
Durom(v) ICP-MS Serum 34 2 0.83 1.59 12
Erythrocytes 22 2 0.46 0.92
Whole blood 41 2 0.63 1.33
(AAS = Atomic Absorption Spectrophotometry, ICP-MS = Inductively Coupled Plasma

Mass Spectrometry)
55
IV) Implant Design Variability and Metal Ions Metal ion analysis provides a tool that can be used to com-
Perhaps one of the greatest values of metal ion analyses is the pare these variables as improvements and changes are made
ability it affords researchers to compare ion production to metal-metal bearings. The ongoing goal is to minimize
between implant designs. At present there are a multitude of wear (for which there is no in vivo evaluative tool) and sub-
metal-metal designs used globally with variances in: sequent metal ion production.
i) metallurgy (C content, heat treatment, fabrication)
ii) geometry (clearance, sphericity, surface finish, head size)
iii) design (monoblock, modular, modular with poly, fixa-
tion method)
SYMPOSIA AR HIP
REFERENCES 8. Back DL, Young DA, Shimmin AJ: How do serum cobalt and chromium levels
change after metal-on-metal hip resurfacing? Clin Orthop 438:177-181, 2005
1. Brodner W, Bitzan P, Meisinger V, et al: Elevated serum cobalt with metal on
metal articulating surfaces. J Bone Joint Surg 79Br:316, 1997 9. Savarino L, Greco M, Cenni E, Cavasinni L, Rotini R, Baldini N, Giunti A:
Differences in ion release after ceramic-on-ceramic and metal-on-metal total hip
2. Brodner W, Bitzan, P, Meisinger V, et al: Serum cobalt levels after metal-on-metal
replacement. Medium-term follow-up. J Bone Joint Surg 88Br:472-476, 2006
total hip arthroplasty. J Bone Joint Surg 84Am: 2168, 2003
10. Daniel, J, Ziaee H, Pradham C, Pynsent, PB, McMinn DJW: Blood and urine
3. Savarino L, Granchi D, Ciapetti G, et al: Ion release in stable hip arthroplasties
metal ion levels in young and active patients after Birmingham hip resurfacing
using metal-on-metal articulating surfaces: A comparison between short- and
arthroplasty. Four-year results of a prospective longitudinal study. J Bone Joint
medium-term results. J Biomed Mater Res 66A(3):450, 2003
Surg 89Br:169-173, 2006
4. Witzleb WC, Ziegler J, Krummenauer F, Neumeister V, Guenther KP: Exposure to
11. Depuy Internal Data
chromium, cobalt and molybdenum from metal-on-metal total hip replacement
and hip resurfacing arthroplasty. Acta Orthop 77(5):697-705, 2006 12. Vendittoli PA, Mottard S, Roy AG, Dupont C, Lavigne M: Chromium and cobalt
ion release following the Durom high carbon content, forged metal-on-metal
5. MacDonald SJ, McCalden RW, Chess DG, et al: Metal-on-metal versus polyethyl-
surface replacement of the hip. J bone Joint Surg 89Br:441-448, 2007.
ene in hip arthroplasty: A randomized clinical trial. Clin Orthop 406:282, 2003
13. Ziaee H, Daniel J, Datta AK, Blunt S, McMinn DJ. Transplacental transfer of
6. Rasquinha VJ, Ranawat CS, Weiskopf J, Rodriguez JA, Skipor AK, Jacobs JJ:
cobalt and chromium in patients with metal-on-metal hip arthroplasty: a con-
Serum metal levels and bearing surfaces in total hip arthroplasty. J Arthroplasty
trolled study. J Bone Joint Surg 80Br:301-305, 2007.
21(6 Suppl 2):47-52, 2006
7. Clarke MT, Lee PTH, Arora A, Villar RN: Levels of metal ions after small and large
diameter metal-on-metal hip arthroplasty. J Bone Joint Surg 85Br:913, 2003
METAL-METAL BEARINGS
Thomas P. Schmalzried, MD
Consistently low wear of MM bearings has been established by There is substantial patient-to-patient variability in serum ion
over 30 years of clinical experience. Not just laboratory wear levels. With a well-functioning joint, the ion levels peak at
simulations. Real experience in real patients, many under 60 around one year post-op. and then decrease slowly over time.
years of age at the time of surgery. After the run-in period, serum ion levels are not directly a func-
tion of patient activity but are a function of free-water balance.
SYMPOSIA AR HIP
Metal-metal bearings favor a larger diameter: the wear rate of a
Cup abduction angles of greater than 55 degrees have been asso-
metal-metal bearing decreases with increasing diameter and
ciated with higher ion levels. Ion levels following total knee
favors hip resurfacing. Lubrication of a metal-metal joint is a
replacement may be similar to those associated with a well-
function of sliding velocity. The larger the diameter, the higher
functioning metal-metal total hip.
the sliding velocity and the better the lubrication. Larger diam-
eters enable higher function (greater range of motion and sta- There is an increased risk of developing delayed-type hypersen-
bility), which many patients desire. sitivity (an allergic reaction) with a metal-metal bearing. Cobalt
and chromium based implants should probably not be used in
The risk of cancer associated with a metal-metal bearing is no
patients with a clear history of metal sensitivity, such as a con-
greater than that associated with a metal-polyethylene bearing.
sistent allergic reaction to jewelry. A metal-metal bearing should
Despite more than 30 years of clinical use, a health risk due to
probably not be used in patients with renal insufficiency. The
elevated cobalt and chromium ions in patients with a metal-
risks in pregnancy and to the unborn child have not been clear-
metal bearing has not been established. This needs to be com-
ly defined.
pared to the fact that the 90 day mortality following revision
total hip replacement surgery in the Medicare population is
2.6%. There is, however, limited data on patients with metal-
metal bearings for more than 20 years.
REFERENCES 4. Mahomed, N. N. et al.: Rates and outcomes of primary and revision total hip
replacement in the united states medicare population. J. Bone Joint Surg. 85-
1. Schmalzried, T.P.; Peters, P.C.; Maurer, B.T.; Bragdon, C.R., and Harris W.H.:
A:27-32, 2003.
Long duration metal-on-metal total hip replacements with low wear of the artic-
ulating surfaces. J. Arthroplasty, 11:322-331, 1996. 5. Hallab, N., Merritt, K., Jacobs, J.J: Metal sensitivity in patients with orthopaedic
implants. J. Bone Joint Surg. 83-A: 428-436, 2001.
2. Schmalzried, T.P.; Szuszczewicz, E.S.; Akizuki, K.H.; Petersen, T.D., and Amstutz,
H.C..: Factors correlating with long-term survival of McKee-Farrar total hip pros- 6. Heisel, C. et al.: The relationship between activity and ions in patients with
theses. Clin. Orthop. 329S:S48-S59, 1996. metal-on-metal bearing hip prostheses. J. Bone Joint Surg. 87-A:781-787, 2005.
3. Tharani, R. Dorey, F. J. and Schmalzried, T.P.: The risk of cancer following total 7. Luetzner, J. et al.: Serum Metal Ion Exposure after Total Knee Arthroplasty. Clin.
hip or total knee replacement. J. Bone and Joint Surg. 83-A:774-780, 2001. Orthop. 461:136-142, 2007.
57
METALLIC WEAR DEBRIS: BIOLOGICIAL RESPONSES

Joshua J. Jacobs, MD
Metal-on-metal bearing surfaces have been reintroduced to take duration of implantation.4 Acute toxicity from these elevated
advantage of the reduction in volumetric wear afforded by these levels is extraordinarily rare, however there are ongoing ques-
bearings and, it is hoped, to improve the survivorship of total tions about potential local and remote chronic toxicity in asso-
hip replacements by diminishing the long term complications ciation with chronic elevations in metal content.
of osteolysis and aseptic loosening. A critical question can be
SYMPOSIA AR HIP
One area that is of particular interest at the present time is the

posed: Will the reduction in volumetric wear be sufficient to
role that metal allergy may play in clinical performance of
achieve the desired improvement in implant survivorship?
metal-on-metal devices. Metal allergy is a phenomenon that
In vitro studies have established that the cell response to partic- has been of interest to the orthopedic community for decades.
ulate debris is a function of the size, composition and dose of The extant literature suggests that metal allergy is a real clinical
the particles. This can be considered a fundamental precept of phenomenon albeit the prevalence and clinical impact are not
cell/particle biology. Other more subtle factors that may influ- defined.5 Degradation products in the form of ionic or particu-
ence particulate biocompatibility include the aspect ratio, sur- late debris can complex with local proteins and alter their con-
face roughness of the particles, and the composition of formation so that they may not be recognized as self-proteins.
adsorbed proteins. These factors are currently incompletely This can result in an adaptive immune response. The typical
understood. In the case of metal-on-metal bearings, the volu- paradigm proposed for such an allergy is that of a delayed type
metric wear rate has been shown to be over a factor of 10 small- hypersensitivity response (Type 4) whereby the antigenic stimu-
er than that associated with metal-on-polyethylene bearings. lus interacts with antigen presenting cells and T lymphocytes to
However, the size of the particulate debris generated from elicit a cell mediated immune response. There is some evidence
metal-on-metal bearings (the majority of particles are less than that patients with metal-on-metal bearings and/or high serum
50 nanometers)1 tends to be approximately an order of magni- metal levels elicit more response to metal antigen challenge
tude smaller than that generated from metal-on-conventional measured as either patch test sensitivity or lymphocyte prolifer-
polyethylene bearings (mean particle size approximately 0.5 ation.6 Thus, while there is an idiosyncratic aspect of the aller-
micrometer or 500 nanometers).2 The net effect is that even gic response, there is also a dose response component.
though the volumetric wear rates are lower, the actual number
Recently there have been reports that there is a unique histolog-
of particles generated from metal on metal wear may exceed
ical response in patients with metal-on-metal bearings in which
that from metal-on-conventional polyethylene wear.1 Thus,
there is a prominent perivascular lymphocytic infiltration that is
one needs to understand the bioreactivity difference between
reminiscent of a delayed type hypersensitivity response. This
0.5 micrometer polyethylene particles versus 50 nanometer
response has been termed ALVAL (aseptic lymphocyte-domi-
(.050 micrometer) cobalt-alloy particles. Given the difficulty of
nated vasculitis-associated lesion) by Willert and co-authors.7
fabrication and isolation of such nanodebris, this question is
There have been other recent reports of early failure of metal on
still an active area of scientific investigation.
metal total hip replacements in patients with certain types of
Metal-on-metal bearings have experienced a tremendous resur- implant systems. These failures have been postulated to be
gence particularly with the current interest in resurfacing arthro- associated with an allergic type response based on either patch
plasty of the hip and large heads in total hip arthroplasty. The testing or the histologic changes described by Willard and col-
biological concerns with the use of metal-on-metal bearings are leagues.8-10 A separate phenomenon occurring in selected
somewhat different than with ceramic-on-ceramic or metal-on- patients with metal-on-metal bearings which generate high lev-
polyethylene given the nature and characteristic of wear and cor- els of debris due to malposition and/or impingment is that of
rosion debris that can be produced by the different articulating “metallosis”, or the intense staining of periprosthetic tissue by
surfaces. In addition to generating particulate wear debris, metallic debris, often associated with large areas of necrosis and
metal-on-metal bearings can also generate free metallic ions periarticular masses.11 These phenomena are not completely
which can subsequently interact with proteins or anions in the understood and while some metal-on-metal designs have had
local bodily fluids producing organometallic complexes or inor- suboptimal clinical results, other metal-on-metal bearing sys-
ganic metal salts or oxides. Thus, all of these degradation prod- tems have reported excellent intermediate-term results. This is a
ucts need to be considered when trying to understand the host topic that will require ongoing investigation.
response. The presence of very large numbers of nanoparticulate
Careful clinical follow-up of patients with metal-on-metal bear-
with high specific surface areas is largely responsible for the
ings is warranted. Monitoring metal ion levels in selected cases
release of metal ions into the surrounding tissues and subse-
can be useful to determine the state of the bearing.
quently into serum and urine. A number of investigators have
Furthermore, optimization of these bearing systems to further
documented order of magnitude elevations in serum and urine
diminish wear and corrosion would be highly desirable to
cobalt and chromium in patients with metal-on-metal bear-
address these reported adverse tissue reactions.
ings.3 In some studies in patients with long term metal-on-
metal bearings these elevations seem to persist throughout the
REFERENCES 2. Shanbhag, A.S., Jacobs, J.J., Glant, T.T., Gilbert, J.L., Black, J. and Galante, J.O.
1. Doorn, P.F, Campbell, P.A., Worrall, J., Benya, P.D., McKellop, H.A.: Metal wear Composition and Morphology of Wear Debris in Failed Uncemented Total Hip
particle characterization from metal on metal total hip replacements: TEM study Replacement. J. Bone Joint Surg. 76-B:60-67, 1994.
of periprosthetic tissues and isolated particles. J Biomed Mater Res 42 (1998) 3. Jacobs, J.J., Hallab, N.J., Skipor, A.K., and Urban, R.M. Metal Degradation
103-111 Products: A Cause for Concern in Metal-Metal Bearings? Clin Orthop 417:139-
147, 2003.
4. Jacobs, J.J., Skipor, A.K., Doorn, P.F., Campbell, P., Schmalzried, T.P., Black, J., 8. Korovessis P, Petsinis G, Repanti M, Repantis T. Metallosis after contemporary
and Amstutz, H.C. Cobalt and Chromium Concentrations in Patients with metal-on-metal total hip arthroplasty. Five to Nine-Year Follow-Up J Bone Joint
Metal-on-Metal Total Hip Replacements. Clin Orthop 329S:S256-S263, 1996. Surg 2006; 88A:1183-1191.
5. Hallab, N.J., Merritt, K., Jacobs, J.J. Metal Sensitivity In Patients With 9. Milosev I, Trebse R, Kovac S, Cor A, Pisot V. Survivorship and retrieval analysis of
Orthopaedic Implants. Current Concepts Review. J Bone Jt Surg 83-A:428-436, Sikomet metal-on-metal total hip replacements at a mean of seven years. J Bone
2001. Joint Surg 2006; 88A:1173-1182.
6. Hallab, N.J., Anderson, S., Caicedo, M., Skipor, A.K., Campbell, P. and Jacobs, J.J. 10. Park Y-S, Moon Y-W, Lim S-J, Yang J-M, Ahn G, Choi Y-L. Early osteolysis follow-
Immune Responses Correlate with Serum-Metal in Metal-on-Metal Hip ing second-generation metal-on-metal hip replacement. J Bone and Joint Surg;
Arthroplasty. J Arthrop 19 (Suppl 3):88-93, 2004. 87-A:1515-21, 2005.
7. Willert H-G, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, Lohmann 11. Boardman, D.R., Middleton, F.R., and Kavanagh, T.G. Case Report. A benign
SYMPOSIA AR HIP
CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip psoas mass following metal-on-metal resurfacing of the hip. J Bone and Joint
joints. A clinical and histomorphological study. J Bone Joint Surg 2005; 87- Surg; 88-B:402-404, 2006.
A:28-36.
59
ALUMINA CERAMIC-ON-ALUMINA CERAMIC BEARINGS

James A. D’Antonio, MD
The major advantages of alumina ceramic bearings include: one in six to eight thousand, and the risk of an alumina head
their extreme hardness and scratch resistance; their low coeffi- fracture is one in two to three thousand. It is known that the
cient of friction; they are very hydrophilic with improved lubri- majority of these fractures (83%) occur within the first three
cation compared to other bearing surfaces; larger diameter years following surgical implantation. In addition this bearing
femoral heads can be used; there is no potential for metal ion has a reported incidence of noise (squeaking) ranging from 1%
SYMPOSIA AR HIP
release; ceramic debris is less reactive than polyethylene and/or to 7% which in rare cases can affect the clinical result but in
metal debris; and of most importance they have superior wear most cases is insignificant or disappears over time. Retrievals as
resistance compared to all other bearing surfaces. In addition it well as simulator studies indicate that edge loading and stripe
has been demonstrated that femoral head separation in the wear are the primary etiology of squeaking and occur most
acetabulum during gait is greatest for metal-on-polyethylene often from impingement. From the surgeon’s perspective, the
bearings and least for alumina-on-alumina bearings likely relat- use of alumina ceramic bearings requires more attention to
ed to the increased wetability of the alumina ceramic bearings. detail and includes fewer intraoperative options. Greater atten-
Today’s alumina ceramics (Biolox forte) are of high quality with tion to preoperative planning and component positioning is
decreased grain size, inclusions, and grain boundaries. Current critical to maximize range of motion and minimize the risk of
alumina Biolox forte implants have far greater burst strength impingement. On the acetabular side only a zero degree liner
than pre 1995 alumina ceramics and today are mated with and on the femoral side, femoral head options of -5, 0, +5 are
implants that have excellent fixation records, high taper toler- available. In addition, if a fracture does occur, early revision is
ances, and designs that minimize the risk of ceramic impinge- advised with a complete synovectomy to remove ceramic debris.
ment. Ceramic-on-ceramic bearings have been used for over The best options following revision of a ceramic fracture are
thirty-five years and the major advantages compared to the risks ceramic-on-ceramic or ceramic-on-highly crosslinked polyethyl-
of their use have been clearly identified. In the US, a ten-year ene. Ceramic-on-ceramic can be used only with a newly
prospective randomized and controlled study has demonstrat- implanted femoral stem or with the use of ceramic revision
ed greater survivorship of the alumina–on-alumina implanted femoral heads that have been developed with an internal metal
cases (97%) compared to the control metal-on-polyethylene sleeve for use on a minimally damaged existing trunnion.
cases (91.3%). This increased survivorship for the alumina
To summarize, alumina ceramic bearings are an attractive option
ceramics includes revision for any reason as well as revision of
for the young and active high energy patient because of their
the bearing surface itself in a younger patient population.
superior wear, improved lubrication, and resultant low volume
International experiences and publications have demonstrated
of less reactive particle debris. However, careful preoperative
high survivorship and restoration of function, including some
planning, proper indications for ceramic bearings, and meticu-
reports of study patients less than 50 years of age.
lous surgical technique to avoid impingement and maximize
The major disadvantages to ceramic-on-ceramic bearings range of motion are necessary to minimize complications.
include the risk of fracture and squeaking. Currently it is esti-
mated that the risk of fracture of an alumina ceramic insert is
REFERENCES 7. Dennis DA, Komistek RD, et al: Kinematic evaluation of total hip arthroplasty
1. Clarke IC: Role of ceramic implants: design and clinical success with total hip with various bearing materials: Proceedings from Bioceramics and Alternative
prosthetic ceramic-to-ceramic bearings. CORR 282:19-30, 1992. Bearing in Total Joint Arthroplasty, 11th Biolox Symposium. Springer, 81-93,
2006.
2. Sedel L, Kerboull L, et al: Alumina-on-alumina hip replacement: results of sur-
vivorship in patients. JBJS 72(B):658-663, 1990. 8. Garino J, Rhaman M, Bal S: Reliability of modern alumina bearings in total hip
replacements. Sem Arthroplasty 17(2-4):113-118, 2006.
3. D’Antonio JA, Capello WN, et al: Alumina ceramic bearings for total hip arthro-
plasty: Five-year results of a prospective randomized study. CORR 436:164-171, 9. Walter WL, Lusty PJ, et al: Stripe wear and squeaking in ceramic total hip bear-
2005. ings. Sem Arthroplasty 17(3):190-195, 2006.
4. D’Antonio JA, Capello WN, Manley MT, et al: A titanium encased alumina 10. Yoo JJ, Kim YM, et al: Contemporary alumina-on-alumina total hip arthroplasty
ceramic bearing for total hip arthroplasty: 3-5-year results. CORR 441:151-158, performed in patients younger than forty years: a 5-year minimum follow-up
2005. study. J Biomed Mater Res B Appl Biomater 78(1):70-75, 2006.
5. Germain NA, Hatton A, et al: Comparison of the cytotoxicity of clinically rele- 11. HA YC, Koo KH, et al: Cementless alumina-on-alumina total hip arthroplasty in
vant cobalt chrome and alumina ceramic wear particles in vitro. Biomaterials patients younger than 50 years: a 5-year minimum follow-up study. J
24:469-479, 2003. Arthroplasty 22(2):184-188, 2007.
6. Hamadouche M, Boutin P, et al: Alumina-on-alumina total hip arthroplasty: a

minimum 18.5 year follow-up study. JBJS 84(A):69-77, 2002.
SQUEAK IN ASSOCIATION WITH CERAMIC BEARINGS: HOW

FREQUENT, WHAT CAUSES IT?
Peter F. Sharkey, MD
Total hip arthroplasty is arguably one of the most successful ic, the ceramic bearing had the lowest wear rates (7). This sub-
procedures in all of orthopaedics. In fact, among all surgical stantial decrease in wear is explained through the basic science
SYMPOSIA AR HIP
procedures, only coronary bypass compares in terms of effec- of lubricated bearings, or tribology. Of the three bearing sur-
tiveness and improvement in quality of life (1). However, from faces (metal, polyethylene, and ceramic), ceramic is the hardest.
the early days of Sir John Charnley to the present, one problem Increased hardness allows for a more polished surface and
has limited the otherwise universal acclaim of hip replacement thereby fewer surface irregularities.
bearing surface - wear. It is well documented that the small
In addition to being smoother, the hard surface of ceramic is
polyethylene particles generated with arthroplasty use are
more wettable. Wettability is a measure of how well the surface
responsible for osteolysis (2)(3). The consequences of osteoly-
tension of water is maintained on a material. A more wettable
sis include implant loosening, periprosthetic fracture, and pain,
surface has better fluid dynamics in a biologic (water based)
among others (3).
joint. In a fluid filled articulation, the bearings surfaces are sep-
Since the early days of total hip arthroplasty, alternatives to arated by a fluid film. With larger surface irregularities and a
polyethylene as a bearing surface have been sought. The first thinner fluid separating them, more friction occurs in the joint.
total hip using a metal on metal bearing surface was done in the Complete separation of the two bearing surfaces is called fluid
1960s, shortly after Charnley implanted the first metal head on film lubrication. In this scenario, almost no wear occurs. While
a polyethylene cup. Ceramic on ceramic as a bearing surface no current total joint surface achieves a true fluid film state, of
was first introduced in the early 1970’s in Europe by the three bearing combinations, ceramic on ceramic comes clos-
Mittelmeier. Since these pioneering implants, improvements in est. This optimal lubrication allows ceramic bearing surfaces to
manufacturing techniques and materials have lead to better achieve a very low coefficient of friction, and hence, low adhe-
long term results with all three bearing surfaces. sive wear.
Ceramic is an ideal material for low friction joint arthroplasty While the hardness of ceramic improves the lubrication and
because of its hard, smooth nature. However, as early users of smoothness of the surface, it also improves resistance to third
ceramic bearings discovered, it was very brittle and susceptible body wear. Metal on polyethylene bearings are particularly sus-
to fracture and catastrophic failure. These early failures dimin- ceptible to this type of wear. Third body particles can be any-
ished the enthusiasm for ceramic, and it was largely abandoned. thing from cement to pieces of bone to metal debris. The
Years later however, as the evidence for polyethylene particle extreme hardness of ceramic makes is very scratch resistant,
mediated osteolysis mounted, investigators began to become mostly avoiding the issue of third body wear.
enamored with ceramic again. The Mittelmeier prosthesis was
a ceramic head mated to a ceramic cup which used threads to LIMITATIONS OF CERAMIC ON CERAMIC BEARINGS
engage the acetabulum. This prosthesis suffered from critical The cost of ceramic bearings has long been a limitation to their
flaws. The first was poor design. Skirted necks and a prominent widespread use. The labor intensive and technologically com-
acetabular component rim led to impingement. It was primari- plicated process required to manufacture ceramic makes them
ly this impingement which led to chipping and ultimate failure. expensive when compared to traditional metal on polyethylene
In addition, the ceramic manufacturing method used at the bearings. However, the increased cost of newer highly cross-
time yielded a product with low density and a course linked polyethylene bearings has partially closed the price gap.
microstructure (4). Overcoming these flaws has led to a new Hip resurfacing implants, in comparison, are generally more
generation of ceramic total hip components. (FIGURE 1) expensive than ceramic on ceramic devices.
While in vitro wear of ceramic on ceramic bearings is much less
ADVANTAGES OF CERAMIC ON CERAMIC BEARINGS
than other bearing surfaces, there is evidence that in vivo oste-
There are many advantages to ceramic as a bearing surface in
olysis still may occur with ceramics. Maloney et al noted that 22
total hip arthroplasty. As mentioned, one of the primary diffi-
percent of ceramic on ceramic hips showed some evidence of
culties with polyethylene bearings is wear generated osteolysis.
osteolysis at an average of 92 months (8). In addition, tissue
Ceramic debris is comparatively more biocompatible. The par-
samples from around the prostheses have revealed ceramic par-
ticles generated with wear of ceramic bearings have a wide range
ticles with an average size of 0.71 microns, a size known to illic-
of sizes, but on the whole show less inflammatory reactivity
it some inflammatory response (9). However, the amount of
than polyethylene particles (5)(6). These ceramic wear particles
osteolysis is significantly less than that seen with polyethylene
are also in a fully oxidized state. Oxidation makes them bio-
bearing surfaces.
inert when compared to the ionic particles generated in metal
on metal articulations. Hence the increase in systemic ion lev- The catastrophic failure of previous ceramic bearings was large-
els after ceramic total hip arthroplasty are comparable to those ly a result of poor manufacturing techniques. New materials
using metal on polyethylene components, with the low levels and manufacturing methods have made catastrophic failure
resulting from the interface of the femoral head with the with modern ceramics extremely rare. Willmann reported a
femoral stem. fracture rate with modern ceramics of 0.004% (4), substantially
lower than the failure rate (due to fracture) of femoral stems,
The main advantage of using ceramic as a bearing surface in
reported to be 0.27% (10)(11).
total hip arthroplasty is improved wear characteristics. Clarke et
al, showed that of the three most common bearing surfaces, Noise associated with ceramic on ceramic bearings has been
metal on polyethylene, metal on metal, and ceramic on ceram- reported and can be very troublesome to the patient. Noise has
61
been a well known side effect of total joint arthroplasty. The early revision is imperative. Small ceramic fragments can cause
most common noise described by patients is clicking and is severe damage to the femoral trunion if not removed quickly. In
associated with all bearing surfaces. Hard on hard bearing sur- addition, diffuse ceramic debris can illicit an inflammatory
faces are more likely to cause “squeaking”. There are reports of response which can damage implant fixation. At the time of
metal on metal articulations squeaking from as early as 2005 revision, if at all possible, a new ceramic articulation should be
and the incidence has been reported at 3.9% (12). Squeaking considered to avoid third body wear from residual ceramic
after metal on metal arthroplasty appears to occur early and, debris. Regardless of the choice of new bearing surface, during
with self polishing, usually improves over time. Ceramic on revision surgery a thorough synovectomy should be performed
ceramic bearings tend not to squeak until after one year post- to optimize debris removal. If a delay in revision is encoun-
operatively. The incidence of squeaking in ceramic on ceramic tered, damage to the morse taper may require revision of the
SYMPOSIA AR HIP
bearings, has been reported to range from 1%. (13, 16, 17) femoral stem or conversion to a metal head (14). One possible
solution for a damaged trunion is a modular titanium sleeve.
The cause of squeaking in ceramic on ceramic hips remains elu-
These newly available implants make possible the continued
sive and may be multifactorial. Component position, stripe
use of a ceramic head by restoring integrity of the trunion and
wear and edge loading have all been implicated. (FIGURE 2) In
decreasing the subsequent risk of head fracture. With rapid revi-
vitro, unlubricated ceramic on ceramic articulation will squeak
sion and use of new implant augments, acceptable success rates
(personal communication from Stryker Orthopaedics). A
have been achieved after revision for this rare but devastating
study done at our own institution, Rothman Institute, in
complication (15).
Philadelphia, PA evaluated 30 ceramic on ceramic hip replace-
ments performed between 2002 and 2004 (28 patients) with Management of bearing noise is best begun during the preoper-
associated squeaking. These were then compared in a matched ative discussion and informed consent. As mentioned, the inci-
control group of patients who did not have squeaking. Review dence of squeaking with ceramic on ceramic bearings ranges
of 8 demographic factors showed no predisposing patient or from 1 to 7%. Inclusion of this possibility with the list of pos-
surgical factors associated with squeaking. Cup position, ana- sible complications can make management more acceptable to
lyzed with radiographs and CT scans, showed no difference in the patient. Some patients may not want to risk post operative
cup position between the squeakers and the control group. Of squeaking, but most understand that no hip replacement is
the 30 hips, 6 were revised to polyethylene liners. Retrieval problem free. Patients may be willing to accept this small risk
analysis showed 6/6 with edge loading of the liner, 6/6 with for the added benefits of a ceramic articulation.
stripe wear and 5/6 with impingement. Another review, at our
While definitive research remains to be done, most authors feel
institution, of 253 patients with bilateral ceramic on ceramic
that squeaking is associated with impingement and stripe wear.
total hips, exposed 5 patients with unilateral squeaking and 2
During total hip arthroplasty, a complete range of motion check
with bilateral squeaking. This data suggests that patient related
immediately after reduction can minimize the likelihood of
factors may play a role. Walter et al has suggested that a loose
impingement. In addition, the use of components with
soft tissue envelope may lead to joint subluxation and subse-
reduced neck diameters, variable offset and proportionate neck
quently more edge loading. The edge loading can then ulti-
lengths will lead to less impingent. There have been anecdotal
mately lead to squeaking (13). Their data also showed that vari-
reports of ceramic on ceramic noise managed with hyalgan
ations in version (i.e. high degrees of reto-or anteversion) of the
injections. To our knowledge, there has been no published con-
acetabular component correlated with squeaking. Patients with
clusive report showing a measurable improvement in noise with
a higher degree of anteversion were more likely to have squeak-
the use of these intra-articular injections. Most patients with
ing with hip extension. Those with retroversion were more like-
squeaking know precisely which position causes the noise. It
ly to squeak when bending over (13). These observations are
may be of benefit to develop routines and assistive devices that
consistent with the hypothesis that uncovering of the femoral
help avoid those positions. Of the patients who do develop
head, with subsequent edge loading and stripe wear, can lead to
audible squeaks, there will be some who cannot tolerate the
squeaking. To date, the definitive causes of squeaking remain
noise. In these cases it has been our experience that revision
enigmatic but appear to be multifactorial. A likely scenario
with conversion to a polyethylene liner is the most reliable
leading to squeaking begins with component impingement
method of management.
and/or edge loading. Over time, edge loading creates a wear
scar (stripe wear). An audible squeak is heard when motion of
CONCLUSION
the hip passes over the wear scar. Impingement, subluxation
Ceramic on ceramic total hip arthroplasty was introduced as a
and edge loading can occur singularly or by a combination of
bearing choice with immense promise. During the last 30 years,
high degrees of cup or stem version, low soft tissue tension
advances in manufacturing and design have made ceramic on
(with associated good range of motion) or use of components
ceramic an excellent option for young active patients requiring
with rims or collars that diminish distance to contact. (FIGURE
hip replacement. Unmatched lubrication properties and a hard,
3) It is important to recognize that even with optimal cup
smooth surface have lead to extremely low wear rates. Attention
placement, a patient with very good range of motion may
to surgical technique coupled with good patient communica-
impinge and sublux the joint. There is no evidence that squeak-
tion and education can help in avoidance and management of
ing has an adverse affect on longevity or accelerated wear, but it
possible complications. Indeed, because of low wear rates, a
can be a troublesome annoyance for patients.
ceramic on ceramic bearing may well be a life-long hip.
SURGICAL PEARLS
Fracture of modern ceramic bearings is an extremely rare com-
plication. When a fracture does occur in a ceramic bearing,
SYMPOSIA AR HIP
Figure 1 Figure 3
Figure 2
REFERENCES 10. Heck DA, Partridge CM, Reuben JD, Lanzer WL, Lewis CG, Keating EM.
1. O’Shea K, Bale E, Murray P. Cost analysis of primary total hip replacement. Ir Prosthetic component failures in hip arthroplasty surgery. J Arthroplasty, 1995;
Med J. 2002 Jun; 95(6):177-80.2. 10: 575-80.
2. Harris WH. The problem is osteolysis. Clin Orthop, 1995; 311: 46-53 11. Heisel C, Silva M, Schmalzried TP. Bearing surface options for total hip replace-
ment in young patients. J. Bone Joint Surg Am, 2003; 85: 1366-1379.
3. Schmalreid TP, Callaghan JJ. Wear in total hip and knee replacements. J Bone
Joint Surg Am 1999; 81: 115-136. 12. Back DL, Danziel R, Young D, Shimmin A. Early results of primary Birmingham
hip resurfacings: An Independent Prospective Study of the First 230 Hips. J Bone
4. Willmann G. Ceramic femoral head retrieval data. Clin Orthop, 2000; 379: 22-8. Joint Surg Br, 2005; 87-B: 324 - 329.
5. Catelas I, Petit A, Marchand RJ, Zukor DJ, Yahia LH, Huk OL. Cytotoxicity and 13. Walter WL, O’toole GC, Walter WK, Ellis A, Zicat BA. Squeaking in ceramic-on-
macrophage cytokine release induced by ceramic and polyethylene particles in ceramic hips: The importance of acetabular component orientation. J
vitro. J Bone Joint Surg 1999; 81-B: 516-521 Arthroplasty. 2007; 22(4):496-503.
6. Lerouge S, Huk O, Yahia LH, Witvoet J, Sedel L. Ceramic-ceramic and metal- 14. Goldberg JR, Gilbert JL, Jacobs J, Bauer TW, Paprosky W, Leurgans S. A multicen-
polyethylene total hip replacements: Comparison of pseudo membranes after ter retrieval study of the taper interfaces of modular hip prostheses. Clin Orthop
loosening. J Bone Joint Surg 1997; 79-B: 135-139 Relat Res, Aug 2002; (401) 149-61.
7. Clarke IC, Good V, Williams P, Schroeder D, Anissian L, Stark A, Oonishi H, 15. Allain J, Roudot-Thoraval F, Delecrin J, Anract P, Migaud H, Goutallier D.
Schuldies J, Gustafson G. Ultra-low wear rates for rigid-on-rigid bearings in total Revision Total Hip Arthroplasty Performed After Fracture of a Ceramic Femoral
hip replacements. Proc Inst Mech Eng [H], 2000; 214: 331-47. Head: A Multicenter Survivorship Study. J. Bone Joint Surg. Am., 2003; 85: 825-
8. Yoon TR, Rowe SM, Jung ST, Seon KJ, Maloney WJ. Osteolysis in association with 830.
a total hip arthroplasty with ceramic bearing surfaces. J Bone Joint Surg Am, 16. Restrepo C, Parvizi J, Purtill JJ, Sharkey PF, Hozack WJ, Rothman RH. Noisy
1998; 80: 1459-68. Ceramic Hip: Is Component Malpositioning the Problem? American Academy of
9. Willert HG, Buchhorn GH, Fyyazi A, Flury R, Windler M, Köster G, Lohmann Orthopaedic Surgeons AAOS, San Diego, California, February 14 - 18 2007.
CH. Metal-on-Metal Bearings and Hypersensitivity in Patients with Artificial Hip 17. Jarrett CA, Ranwat A, Bruzzone M, Rodriguez J, Ranawt C. The Squeaking Hip:
Joints. A Clinical and Histomorphological Study An Underreported Phenomenon of Ceramic-On-Ceramic Total Hip Arthroplasty.
J. Bone Joint Surg. Am., 2005; 87: 28-36. J Arthroplasty Vol. 22(2):302-305, 2007
63
EDGE LOADING WEAR AND FRACTURES IN CERAMIC ON CERAMIC

BEARINGS
Bill Walter, MD
Alumina ceramic-on-ceramic bearings provide an answer to the We analysed 33 retrieved bearings that had been in situ for at
osteolysis seen with traditional metal-on-polyethylene bearings. least six months. Edge loading wear was present on 12 out of
SYMPOSIA AR HIP
However sporadic reports of ceramic breakage concern some 12 bearings where the index procedure was a revision and 12
surgeons. Furthermore this new bearing has had in vivo reports out of 21 bearings where the index procedure was a primary hip
of edge loading wear which was not predicted from in vitro arthroplasty. Overall the median femoral head wear volume
studies. The investigations below shed some light onto these was 0.1 mm3 per year. Bearings with an acetabular anteversion
phenomena. of less than 15 degrees had a median femoral head wear rate of
1.2 mm3 a year, compared to 0.0mm3 from those with antev-
Breakage can occur either of the ceramic head or the ceramic
ersion of 15 degrees or more (p <0.001). Edge loading is relat-
insert due to the brittleness of the ceramic material. Ceramic
ed to abnormal loading of the bearing which is influenced by
heads placed on a used trunion are at greater risk of breakage
patient factors, surgical factors and implant design factors.
than those placed on a virgin trunion. Debris in the taper
between the ceramic and metal may lead to breakage of either a
ceramic head or insert. Fastidious surgical technique will help
to minimise the risk of ceramic breakage.
SYNOPSIS OF THE LATEST CLINICAL DATA FROM AROUND THE

WORLD ON CROSSLINKED POLYETHYLENE BEARING
William J. Maloney, MD
Highly crosslinked polyethylene was introduced into clinical head penetration was evaluated after the first year in vivo. These
practice in the United States approximately seven years ago. data were compared to a match control group. The average
SYMPOSIA AR HIP
Since that time, it has been widely adopted and is currently femoral head penetration rate in the control group was 0.14
being implanted in the majority of hip replacements that are mm/yr vs. 0.025 mm/yr in the highly crosslinked polyethylene
being done with a metal-on polyethylene bearing. group. In addition, when evaluating the difference between 28
and 32 mm heads, no difference existed in terms of study state
In general, highly crosslinked polyethylene is created by expos-
wear rates with varying head sizes in the highly crosslinked
ing the material to radiation. Radiation breaks carbon-carbon
group.
and carbon-hydrogen bonds resulting in the formation of free
radicals. Processing post radiation can then lead to cross link- 2) Comparison of the penetration rate of two polyethylene
ing between two adjacent carbon molecules resulting in the acetabular liners of different levels of cross linking: A per-
highly crosslinked material. Laboratory data has demonstrated spective randomized trial. (Triclot et al JBJS.B:2007).
that there is a relationship between radiation dose, the amount
In this study, the authors performed a randomized clinical trial
of crosslinking and wear reduction. In general, wear is reduced
comparing femoral head penetration rate of acetabular polyeth-
in a relatively linear fashion as radiation dose is increased up to
ylene inserts in patients receiving either highly crosslinked dura-
10 Mrads. After 10 Mrads, there is little further reduction in wear
sul or contemporary sulene polyethylene inserts. Using the
It’s important to note that each of the commercially available Martell system to assess penetration, the mean femoral head
highly crosslinked polyethylenes have fundamental differences penetration in the highly crosslinked group was 0.025 mm/yr
in terms of the radiation type and dose, the temperature at compared to 0.106 mm/yr in the sulene polyethylene group.
which the material is exposed to radiation, the thermal stabi-
3) Radiostereometric analysis comparison of wear of highly
lization procedure and final sterilization. As a result, each of
crosslinked polyethylene against 36 vs. 28 mm femoral
these materials has to be evaluated independently in terms of
heads. (Bragdon et al Journal of Arthroplasty 2007).
clinical behavior.
In this study, the authors used rsa to compare femoral head pen-
From the clinician’s standpoint the news as it relates to wear
etration rate of 26 vs. 36 mm femoral heads into crosslinked
reduction is good regardless of the product evaluated. There are
polyethylene. At a 3 year follow-up, there was no significant dif-
several ongoing prospective studies evaluating wear in clinical
ference in the average total femoral head penetration including
applications.
both creep and wear. In addition, after the bedding in phase, no
significant increase in the amount of femoral head penetration
Highlighted studies
occurred between years one and three.
1) Study state penetration rates of electron beam of irritated
highly crosslinked polyethylene at an average 45 month fol- Although all clinical reports to date show an improvement in
low-up. (Bragdon et al Journal of Arthroplasty October wear of highly crosslinked materials compared to polyethylene
2006). that has been gamma radiated in an inert environment or gas
plasma sterilized, follow-up is insufficient to determine whether
In this study, the author’s prospectively evaluated 53 total hip
there will be a reduction in the prevalence of osteolysis.
replacements with a minimum three year follow-up using elec-
tron beam highly crosslinked melted polyethylene. Femoral
65
CROSS-LINKED POLYETHYLENE FRACTURES:

FREQUENCY, CLINICAL CIRCUMSTANCES
Roy D. Crowninshield, PhD
I. Summary H. Thinner polyethylene that is edge loaded or impinged in

A. Many newer forms of polyethylene, particularly cross acetabular components can experience component frac-
SYMPOSIA AR HIP
linked polyethylene, have demonstrated significantly ture.

reduced wear compared to earlier materials.
II. Conclusions
B. The mechanical properties of polyethylene are sensitive
A. The use of larger femoral heads and cross-linked polyeth-
to material processing and to a material’s tendency to
ylene in well oriented acetabular components can pro-
oxidize.
vide good wear performance and can provide improved
C. Unlike some older polyethylene materials many newer
joint stability.
polyethylene materials permits the use of larger femoral
B. Poorly oriented acetabular components can result in a
heads without the generation of high polyethylene wear.
greater likelihood of component impingement and
D. Larger femoral heads have demonstrated greater
femoral head subluxation which can result in high stress
impingement free ranges of motion and may result in
development in polyethylene.
improved joint stability.
C. The selective use of larger femoral heads in situations
E. The use of larger femoral heads results in thinner poly-
that require additional joint stability may be appropriate;
ethylene components.
however, care needs to be exercised to avoid high stress
F. Acetabular component orientation, particularly more
edge loading of thin polyethylene which may result in
abducted orientations, can result in edge loading and
component fracture.
high stress development in polyethylene due to femoral
head subluxation.
G. Polyethylene component edge impingement with
femoral component necks can result high stress develop-
ment in polyethylene.
CERAMIC ON METAL BEARING SURFACES, POSSIBLE ADVANTAGES

FOR THE FUTURE
Anton Schepers, MD
I. Introduction C. Stripe wear on the ceramic head present in ceramic on

Ceramic on metal bearings in hip replacements have shown ceramic bearings, have not been observed in ceramic on
SYMPOSIA AR HIP
reduced wear in the laboratory as compared to metal on metal bearings in the laboratory.
metal bearings, and similar wear to ceramic on ceramic bear-
D. This could possibly eliminate the complications of
ings. The improvement in wear as compared to metal on
squeaking, and perhaps further decrease the risk of ceram-
metal bearings is postulated to be due to a reduction in cor-
ic head fracture.
rosive wear, and a reduction in adhesive wear due to the dif-
ferential hardness of ceramic and metal. Metal ion levels E. The reduction in corrosive wear could possibly reduce the
measured in the serum lubricant were significantly greater in metal sensitivity seen in certain patients.
metal on metal bearings, as compared to ceramic on metal
F. It is possible that the ceramic on metal bearing is less sen-
bearings.
sitive to impingement and the cup position than the
A randomised prospective single centre clinical trial is being ceramic on ceramic bearing.
carried out at the University of the Witwatersrand. The bear-
ing surfaces used are a ceramic head on cross linked polyeth- III. Head Size
ylene, a ceramic on ceramic bearing, a metal on metal bear- The current study performed used head sizes of 28mm. In
ing and a ceramic head on a metal cup. Blood metal ion lev- the laboratory the size can be increased to 36 or 40mm, with
els are measured at regular intervals. It has been found that no change in the wear properties or metal ion levels. This
the metal ion levels are not raised in ceramic on cross linked does not offer any advantage over metal on metal bearings,
polyethylene bearings, and ceramic on ceramic bearings. but as the metal cup can be thinner than the ceramic cup,
There is a significant decrease in the elevation of metal ions larger heads could be used in the ceramic on metal bearing
in the ceramic on metal bearing, as compared to the metal on than the ceramic on ceramic bearing.
metal bearing, confirming the laboratory findings.
IV. Weaknesses
II. Patient Selection The clinical trial is still incomplete, and follow up is short.
A. The ceramic on metal bearing can be considered for young Longer term follow up is necessary before firm conclusions
active male and female patients. There are possible advan- can be made. Multi centre trials using larger bearing surfaces
tages over ceramic on ceramic bearings and metal on should be performed as well.
metal bearings.
B. The metal ion levels are much lower in ceramic on metal
bearings, as compared to metal on metal bearings. This
minimised the concern of elevated metal ion levels in
child bearing women, patients with renal disease, and
patients with metal sensitivities.
67
SURFACE ENGINEERING SOLUTIONS TO REDUCE WEAR AND ION

RELEASE IN METAL ON METAL BEARINGS
John Fisher, Ian Leslie, Sophie Williams
Metal on metal bearings provide low wear, design flexibility, a The wear debris from CrN coating was similar in shape and size
large range of head sizes, a wide range of offsets and thin acetab- to the Cobalt Chrome metal debris, but was found to have
SYMPOSIA AR HIP
ular components to preserve bone. The metal on metal bearings greatly improved biocompatibility (3). For the size 28mm bear-
are not prone to the oxidative degradation found with polyeth- ings the wear rate of 1 mm3 per million cycles for metal on
ylene bearings or fracture found with ceramic components. metal bearings was reduced by 97% in the surface engineered
There remains concerns in some quarters about elevated sys- bearings after a five million cycles (2). Substantial and signifi-
temic metal ion levels and in some patients adverse immuno- cant reductions in wear were also found for the size 39 and
logical reactions to metal particles and ions have been reported 54mm CrN bearings after both 5 and 10 million cycles, in com-
in peri-prosthetic tissues. Both these concerns may be alleviated parison with the wear of the metal on metal control bearings
by developments that provide a further reduction in metal wear with larger head sizes which was less than 0.5mm3 per million.
and ion release. Surface engineering solutions are attractive as The reduction in metal ion level concentrations with surface
they have the potential to reduce surface wear, while retaining all engineered bearings after 3.6 million cycles were (for size 39
the other design and advantages of a metal on metal bearings. and 54mm respectively) 93% and 95% for cobalt and 47% and
39% for chromium. The lower reduction for chromium being
Thick (ten micrometres) AEPVD Chromium Nitride Cr N coat-
due to chromium release from the CrN wear particles.
ings were applied to size 28, 39 and 54 mm diameter metal on
metal bearing couples and the tribological performance investi- Clinical studies have indicated elevated metal on metal wear in
gated out to 10 million cycles in hip joint simulators. Cr N was steep angle cups due to head wearing on rim of cup. Laboratory
selected for long term investigation following screening of a studies have shown elevated metal on metal wear when the
range of different coatings in shorter term tests (1). Thick coat- head centre is slightly lateralised (0.4mm) with respect to cup
ings were required to accommodate initial bedding in wear and centre, (microseparation) which results in head contacting and
geometrical form changes as well as variation in form during wearing on superior rim of cup and elevated wear (4). Precise
manufacturing that can generate deviations of several microme- positioning of head centre clinically is difficult and a small off-
tres in the surface geometry. Hip simulator studies were carried set (less than 0.5mm) may well cause rim loading in many
out under standard walking conditions and the anatomical cup patients and accelerate wear in steeper cup angles. Under rim
position was 45 degrees to the loading vector for 28mm and 35 loading wear was also accelerated in CrN bearings (5). Longer
degrees to loading vector for 39 and 54mm bearings. Between 3 term studies are needed to evaluate the CrN coating durability
and 5 replicas of each bearing size wear tested and compared to under these harsh but clinically relevant conditions
metal on metal controls with the same design.
REFERENCES 3. Williams et al, Proc Instn Mech Engrs J Engineering in Medicine, 217H 155-163,
1. Fisher et al, J Mat. Sci . Mat in Med. 15 225-235 2004. 2003
2. Leslie et al, Trans ORS submitted 2008 4. Williams et al. Biomedical Materials Research 70B, 233-239, 2004.
5. Williams et al. The Journal of Arthroplasty, 19, Supplement 1, 2004, 112-117.
NEW, IMPROVED CROSS-LINKED POLYETHYLENES

John J. Callaghan, MD
In 2008, wear and fatigue damage of polyethylene is considered annealing. The hypothesis is that performing the irradiation in
the most common reason for long term failure of hip and knee three steps with annealing steps in between will improve the
replacements placed in the last two decades. Over the last 5-10 oxidative stability of the polymer when compared to the single
years, we have come to recognize that polyethylene wear can be step of irradiation and annealing. This material can potentially
reduced by radiation cross-linking. We now have 5 year data still retain residual free radicals which can oxidize.
SYMPOSIA AR HIP
including prospective randomized clinical trials to support this
Another second generation technology is the stabilization of
reduction in wear in the total hip arthroplasty construct.
free radicals through impregnation of irradiated ultra-high
As with many aspects of design, there are choices and compro- molecular weight polyethylene with alpha-tocopherol (Vitamin
mises related to cross-linked polyethylene. Irradiation not only E) which is an anti-oxidant. Alpha-tocopherol protects the
cross-links the amorphous phase of the polyethylene, but also polymer against oxidation and as melting is no longer neces-
results in residual free radicals which are now know to be the sary, the mechanical and fatigue properties are not compro-
precursors to long term oxidation. In many of the first genera- mised. Hip simulator studies have shown improved adhesive
tion highly cross-linked ultra-high molecular weight polyethyl- wear and delamination resistance as well as resistance to third
enes, to avoid long term oxidation, residual free radicals are body wear. There have been no differences in wear rates when
quenched by post-irradiation melting or annealing. Irradiation comparing 28 mm to 36 mm heads. Knee simulator studies
and melting reduces the crystallinity and the mechanical prop- and cracked propagation studies have also demonstrated excel-
erties of polyethylene (this is one reason why there has been lent resistance to wear and fatigue properties. Only one com-
some concern in using this with posterior stabilized knees). pany at the end of 2007 has a vitamin E doped product avail-
Although annealing may prevent some of the decrease in fatigue able, however, others will be on the market soon. Some com-
strength, some residual free radicals persist and have been panies are working on the use of other anti-oxidants and there
shown to produce oxidation of the polyethylene. is some interest by the one manufacturer of polyethylene resins
in the US to add vitamin E to the resin itself. Fortunately,
For this reason, second generation highly cross-linked polyeth-
although no clinical data is available, all companies involved
ylenes have and continue to be developed with the hope of
with these second generation products are formulating prospec-
maintaining fatigue strength yet preventing oxidation and still
tive randomized studies just as they did with the first generation
maintaining the markedly improved wear resistance, partially
highly cross-linked polyethylenes so that clinical information
by maintaining crystallinity. One such process of sequentially
will be available as soon as possible.
cross-linked and annealed ultra-high molecular weight polyeth-
ylene has been offered as an alternative to irradiation and
REFERENCES 3. Oral E, Wannomae KK, Hawkins N, Harris WH, Muratoglu OK. Alpha-toco-
1. Dumbleton JH, D'Antonio JA, Manley MT, Capello WN, Wang A. The basis for a pherol-doped irradiated UHMWPE for high fatigue resistance and low wear.
second-generation highly cross-linked UHMWPE. Clin Orthop Relat Res. 2006 Biomaterials. 2004 Nov;25(24):5515-22.
Dec;453:265-71.
2. Oral E, Christensen SD, Malhi AS, Wannomae KK, Muratoglu OK. Wear resistance
and mechanical properties of highly cross-linked, ultrahigh-molecular weight
polyethylene doped with vitamin E. J Arthroplasty. 2006 Jun;21(4):580-91.
69
◆HIP RESURFACING:
ART AND SCIENCE AS OF 2008
SYMPOSIA AR HIP
(AAOS/ORSII)
Organizers: Paul E. Beaulé, FRCSC, Ottawa, Canada and Patricia A. Campbell, PhD, Los Angeles, CA
Moderator: William A. Jiranek, MD, Richmond, VA
Metal on metal hip resurfacing is now being offered to patients who are relatively young
and want to maintain a high activity level. There is early clinical experience in Europe and
Australia. However, there are questions regarding who should have the operation and how
it should be performed, and there are controversies relating to the importance of femoral
head vascularity, implant design, metallurgy and cement technique. This symposium will
address these concerns with the most current clinical and basic science results as they relate
to patient selection, anatomy and vascularity of the femoral head, wear and wear products,
and surgical technique. Failure mechanisms will be examined. Bone remodeling after
resurfacing will be addressed using finite element models and measurements of remodeling
using microQ-CT and histology. Together, this symposium will provide surgeons and
researchers with an up-to-date review of the art and science of hip resurfacing.
I Introduction: Overview
William Jiranek, MD, Richmond, Virginia
II: Clinical Experience with Hip Resurfacings

Pro - Paul E. Beaulé, MD FRCSC, Ottawa, Canada
Con - Paul F. Lachiewicz, MD, Chapel Hill, NC
III. Basic and Applied Science

Anatomy and Vascularity of the Hip and Clinical Implications in Hip Resurfacings
Paul E. Beaulé, MD FRCSC, Ottawa, Canada
Biocompatibility of Metal on Metal Bearings
Joshua Jacobs, MD, Chicago, IL
Tribology and Metallurgy of Large Diameter Metal on Metal Bearings
John Medley, PhD, PEng., Waterloo, Canada
IV. Implant Retrieval Analysis of Failed Hip Resurfacings

Pat Campbell, PhD, Los Angeles, CA
V. Finite Element Predictions and Q-CT Analysis of Bone Remodeling of Hip Resurfacings
Kevin Ong, Ph.D. Philadelphia, PA
VI. Panel Discussion
HIP RESURFACING – ART AND SCIENCE AS OF 2008: OVERVIEW

William Jiranek, MD
I. History of Surface Replacement

a. Phase 1 – Hemiresurfacing (1935 – 1970)
i. Surgeons e. 8 (1.4%) dislocations
1. Wiles 1935 f. 7 (1.2%) nerve injuries
SYMPOSIA AR HIP
2. Smith-Peterson 1948 g. 1 (.2%) cup loosening
3. Charnley 1952 h. 1 (.2%) infections
4. Townley 1960 i. Reoperations 11 (1.8%)
5. Judet 1965 2. Cormet Trial (Kudrna)
6. Mueller 1967 a. N = 337 patients (68% male, 32% female),
7. Gerard 1970 started 2001
ii. Problems associated with Phase 1 b. Mean F/U 2 years
1. Articular wear c. Preop HHS 50 , Postop HHS 96
2. fixation of the cap d. Dx OA (86%), Osteonecrosis (13%), RA
3. “if the blood supply was compromised, then 1.3%
resorption and necrosis of the neck would occur” e. Complications (at 2 year F/U)
iii.Lessons learned i. 11 (3.3%) Femoral neck fractures
1. Resurface both sides of joint ii. 13 (3.9%) Femoral component loosening
2. Cement fixation of femur iii.5 (1.3%) Acetabular component loosening
3. Short metaphyseal stem benefits fixation f. Revision Rate
b. Phase 2 – Total Resurfacing with Polyethylene Bearings i. 4.7% resurfacing vs. 1.1% THR control group
(1970- 1992) iv. Results – Canada
i. Surgeons 1. Mcgill Montreal results (Antoniou)
1. Paltrinieri/ Trentani 1971 a. N= 323 ASR , min. f/u 1 year
2. Freeman 1974 b. 2.4% failure rate
3. Wagner 1974 (ceramic on metal) i. 3 (.9%) femoral neck fracture
4. Eicher / Capello 1973 ii. 4 (1.2%) infections
5. Amstutz 1975 iii.1 (.3%) avascular necrosis
6. Beuchal / Pappas 1989 v. Results – Belgium
7. McMinn 1. ANCA Medical Center, Ghent (De Smet)
ii. Problems associated with Phase 2 a. N = 2474 (1974 BHR, 500 Conserve Plus)
1. Articular wear, osteolysis b. 3.8% failure rate - .6% fracture rate
2. Femoral loosening c. 48 revisions
3. Femoral neck fracture i. Cup malposition (65%)
iii.Lessons learned ii. Femoral component malposition (19%)
1. Polyethylene not a good bearing for large head SR iii.Femoral component loosening (14%)
2. Cement fixation not good for socket iv. 29/48 had significant metallosis at revision
3. Young patient at higher risk for loosening vi. Results – UK
(THARIES) 1. Birmingham (Treacy)
c. Phase 3 – Total Resurfacing with MOM Bearings (1991 – a. N = 4000
Present) b. 9 yr. survivorship 98% in patients with
i. Surgeons osteoarthritis
1. Wagner 1991 (Metasul) i. Higher failure rates in women, previous sur-
2. McMinn 1991 (Corin) gery, pts. with ostenecrosis
3. McMinn 1996 (BHR) c. 41 revisions (1%)
4. Amstutz 1996 (Conserve Plus) i. 18 neck fractures
5. Grigoris / Roberts 1997 (Durom) ii. 5 dislocations
ii. Problems associated with Phase 3 iii.3 sciatic palsies
1. Femoral loosening vii. Results – Australia
2. Femoral neck fracture 1. Australian Registry (Shimman)
3. Acetabular cup loosening a. N = 10,000 since 1999
4. ALVAL / Pseudotumor b. 3.8 % revision rate at 5 yrs. (vs. 2.8% for THR)
iii.Results - US Reports (short followup) c. 1.9% revision rate for males <65 yrs.
1. Birmingham Safety Survey (after release 2006) i. Higher revision rates for :
Della Valle, Barrack 1. females 2x
a. N= 600 (by 89 surgeons) 2. Osteonecrosis
b. Perioperative data on 90%, 3-6 month data on 3. Inflammatory Arthritis
60% 4. DDH
c. Complications
d. 10 (1.7%) femoral neck fractures
71
II. Use of Surface Replacement around the world c. Who wouldn’t want more impact sports with equal
a. UK 7% of all hip arthroplasty results?
b. France 6%
VI. Questions for this symposium to answer
c. Germany 9%
a. Vascularity
d. Scandinavia 4%
i. are we really preserving enough?
e. Australia 7.9% in 2007
ii. Is AVN an issue in SR
(5% in 2001, 8.9% in 2006)
iii.Is neck narrowing related to vascularity?
f. Asia 3%
iv. Does the approach affect femoral head vascularity?
III. Modes of Failure of a Surface Replacement b. Wear and Tribology –
SYMPOSIA AR HIP
a. Femoral Loosening i. Metals ions – Is the clearance of all ions the same?
b. Femoral Neck Fracture ii. How important is bearing clearance?
c. Wear and Osteolysis iii.Does defomation of the acetabular component effect
d. Infection clearance?
e. Thromboembolic Disease iv. Does a larger metal head truly lead to less wear
f. What about the cup? through fluid film lubrication? What is the best met-
1. Does thinner shell improve impaction allurgy?
2. Deformation of thin shell causing loss of clearance v. What do retrievals tell us about the tribology and tis-
3. Issues of cup abduction and wear sue response to MOM SR?
c. What is the nature of bone remodeling in the femur after
IV.What are the issues?
SR
a. What have the failures taught us?
i. Is there long term positive remodeling?
i. Females 2x revision rate of males
ii. Can implantation affect bone remodeling?
ii. Smaller components do worse than larger ones
iii.Is there any evidence that SR proximal femur can tol-
iii.Thou shalt not varus
erate impact loads better than bonded THR femoral
b. Who is an acceptable candidate?
component
c. Complication Rate Different between THR and SR ?
d. What is the difference between MOM THR and MOM SR
d. Are activity restrictions different?
in the young active adult?
e. What are the groups where THR does poorly?
i. Activity level
f. Is the wear less in Surface Replacement?
ii. Bone loss proximal femur
V. How are we offering this to our patients? Are we being iii.Fixation in the femur
fair with the data? Or are we telling patients what they iv. Deformation in the thin SR acetabular comp. vs. the
want to hear? thicker THR comp.?
a. Who wouldn’t want a smaller incision with equal results? v. Durability?
b. Who wouldn’t want less bone resection with equal results?
REFERENCES 11. Beaule, P.E., Harvey, N., Zaragoza, E., Le Duff, M.J. & Dorey, F.J. 2007, "The
1. "FDA approves new hip resurfacing system", 2006, Health news (Waltham, femoral head/neck offset and hip resurfacing", The Journal of bone and joint
Mass.), vol. 12, no. 7, pp. 2. surgery.British volume, vol. 89, no. 1, pp. 9-15. .
2. Amstutz, H.C. 2006, "Hip resurfacing arthroplasty", The Journal of the American 12. Beaule, P.E., Le Duff, M., Campbell, P., Dorey, F.J., Park, S.H. & Amstutz, H.C.
Academy of Orthopaedic Surgeons, vol. 14, no. 8, pp. 452-453. 2004, "Metal-on-metal surface arthroplasty with a cemented femoral compo-
nent: a 7-10 year follow-up study", The Journal of arthroplasty, vol. 19, no. 8
3. Amstutz, H.C., Beaule, P.E., Dorey, F.J., Le Duff, M.J., Campbell, P.A. & Gruen, Suppl 3, pp. 17-22. .
T.A. 2006, "Metal-on-metal hybrid surface arthroplasty. Surgical Technique", The
Journal of bone and joint surgery.American volume, vol. 88 Suppl 1 Pt 2, pp. 13. Campbell, P., Beaule, P.E., Ebramzadeh, E., LeDuff, M., De Smet, K., Lu, Z. &
234-249. Amstutz, H.C. 2006, "The John Charnley Award: a study of implant failure in
metal-on-metal surface arthroplasties", Clinical orthopaedics and related
4. Barrett, A.R., Davies, B.L., Gomes, M.P., Harris, S.J., Henckel, J., Jakopec, M., research, vol. 453, pp. 35-46.
Rodriguez y Baena, F.M. & Cobb, J.P. 2006, "Preoperative planning and intraop-
erative guidance for accurate computer-assisted minimally invasive hip resurfac- 14. Catelas, I., Bobyn, J.D., Medley, J.B., Krygier, J.J., Zukor, D.J. & Huk, O.L. 2003,
ing surgery", Proceedings of the Institution of Mechanical Engineers.Part H, "Size, shape, and composition of wear particles from metal-metal hip simulator
Journal of engineering in medicine, vol. 220, no. 7, pp. 759-773. testing: effects of alloy and number of loading cycles", Journal of biomedical
materials research.Part A, vol. 67, no. 1, pp. 312-327.
5. Beaule, P.E. 2006, "Removal of acetabular bone in resurfacing arthroplasty of the
hip", The Journal of bone and joint surgery.British volume, vol. 88, no. 6, pp. 838. 15. Catelas, I., Medley, J.B., Campbell, P.A., Huk, O.L. & Bobyn, J.D. 2004,
"Comparison of in vitro with in vivo characteristics of wear particles from metal-
6. Beaule, P.E. & Amstutz, H.C. 2005, "Orientation of the femoral component in metal hip implants", Journal of biomedical materials research.Part B, Applied
surface arthroplasty of the hip", The Journal of bone and joint surgery.American biomaterials, vol. 70, no. 2, pp. 167-178.
volume, vol. 87, no. 5, pp. 1162.
16. Daniel, J., Pynsent, P.B. & McMinn, D.J. 2004, "Metal-on-metal resurfacing of the
7. Beaule, P.E. & Antoniades, J. 2005, "Patient selection and surgical technique for hip in patients under the age of 55 years with osteoarthritis", The Journal of
surface arthroplasty of the hip", The Orthopedic clinics of North America, vol. bone and joint surgery.British volume, vol. 86, no. 2, pp. 177-184.
36, no. 2, pp. 177-85, viii-ix.
17. Daniel, J., Pynsent, P.B. & McMinn, D.J. 2004, "Metal-on-metal versus polyethyl-
8. Beaule, P.E., Campbell, P., Lu, Z., Leunig-Ganz, K., Beck, M., Leunig, M. & Ganz, ene in hip arthroplasty: a randomized clinical trial", Clinical orthopaedics and
R. 2006, "Vascularity of the arthritic femoral head and hip resurfacing", The related research, vol. (422), no. 422, pp. 271; author reply 271-2.
Journal of bone and joint surgery.American volume, vol. 88 Suppl 4, pp. 85-96.
18. Daniel, J., Ziaee, H., Pradhan, C., Pynsent, P.B. & McMinn, D.J. 2007, "Blood and
9. Beaule, P.E., Campbell, P. & Shim, P. 2007, "Femoral head blood flow during hip urine metal ion levels in young and active patients after Birmingham hip resur-
resurfacing", Clinical orthopaedics and related research, vol. 456, pp. 148-152. facing arthroplasty: four-year results of a prospective longitudinal study", The
10. Beaule, P.E., Campbell, P.A., Hoke, R. & Dorey, F. 2006, "Notching of the femoral Journal of bone and joint surgery.British volume, vol. 89, no. 2, pp. 169-173.
neck during resurfacing arthroplasty of the hip: a vascular study", The Journal of 19. Daniel, J., Ziaee, H., Pynsent, P.B. & McMinn, D.J. 2007, "The validity of serum
bone and joint surgery.British volume, vol. 88, no. 1, pp. 35-39. levels as a surrogate measure of systemic exposure to metal ions in hip replace-
ment", The Journal of bone and joint surgery.British volume, vol. 89, no. 6, pp.
736-741.
20. Daniel, J., Ziaee, H., Salama, A., Pradhan, C. & McMinn, D.J. 2006, "The effect of 32. Muirhead-Allwood, S.K., Patel, C. & Mohandas, P. 2006, "Removal of acetabular
the diameter of metal-on-metal bearings on systemic exposure to cobalt and bone in resurfacing arthroplasty of the hip", The Journal of bone and joint sur-
chromium", The Journal of bone and joint surgery.British volume, vol. 88, no. 4, gery.British volume, vol. 88, no. 8, pp. 1117; author reply 1117.
pp. 443-448. 33. Ong, K.L., Kurtz, S.M., Manley, M.T., Rushton, N., Mohammed, N.A. & Field, R.E.
21. Itayem, R., Arndt, A., McMinn, D.J., Daniel, J. & Lundberg, A. 2007, "A five-year 2006, "Biomechanics of the Birmingham hip resurfacing arthroplasty", The
radiostereometric follow-up of the Birmingham Hip Resurfacing arthroplasty", The Journal of bone and joint surgery.British volume, vol. 88, no. 8, pp. 1110-1115.
Journal of bone and joint surgery.British volume, vol. 89, no. 9, pp. 1140-1143. 34. Rasquinha, V.J., Ranawat, C.S., Weiskopf, J., Rodriguez, J.A., Skipor, A.K. & Jacobs,
22. Itayem, R., Arndt, A., Nistor, L., McMinn, D. & Lundberg, A. 2005, "Stability of J.J. 2006, "Serum metal levels and bearing surfaces in total hip arthroplasty", The
the Birmingham hip resurfacing arthroplasty at two years. A radiostereopho- Journal of arthroplasty, vol. 21, no. 6 Suppl 2, pp. 47-52.
togrammetric analysis study", The Journal of bone and joint surgery.British vol- 35. Revell, M.P., McBryde, C.W., Bhatnagar, S., Pynsent, P.B. & Treacy, R.B. 2006,
ume, vol. 87, no. 2, pp. 158-162.
SYMPOSIA AR HIP
"Metal-on-metal hip resurfacing in osteonecrosis of the femoral head", The
23. Jacobs, J.J. & Hallab, N.J. 2006, "Loosening and osteolysis associated with metal- Journal of bone and joint surgery.American volume, vol. 88 Suppl 3, pp. 98-103.
on-metal bearings: A local effect of metal hypersensitivity?", The Journal of bone 36. Ritter, M.A., Lutgring, J.D., Berend, M.E. & Pierson, J.L., "Failure mechanisms of
and joint surgery.American volume, vol. 88, no. 6, pp. 1171-1172. total hip resurfacing: implications for the present", Clinical orthopaedics and
24. Khan, M., Takahashi, T., Kuiper, J.H., Sieniawska, C.E., Takagi, K. & Richardson, related research, vol. 453, pp. 110-114. 2006
J.B. 2006, "Current in vivo wear of metal-on-metal bearings assessed by exercise- 37. Stiehl, J.B., Jacobson, D. & Carrera, G. 2007, "Morphological analysis of the prox-
related rise in plasma cobalt level", Journal of orthopaedic research : official pub- imal femur using quantitative computed tomography", International
lication of the Orthopaedic Research Society, vol. 24, no. 11, pp. 2029-2035. orthopaedics, vol. 31, no. 3, pp. 287-292.
25. Liu, F., Jin, Z., Roberts, P. & Grigoris, P. 2006, "Importance of head diameter, 38. Treacy, R.B. 2006, "To resurface or replace the hip in the under 65-year-old: the
clearance, and cup wall thickness in elastohydrodynamic lubrication analysis of case of resurfacing", Annals of the Royal College of Surgeons of England, vol. 88,
metal-on-metal hip resurfacing prostheses", Proceedings of the Institution of no. 4, pp. 349-53; discussion 349-53.
Mechanical Engineers.Part H, Journal of engineering in medicine, vol. 220, no. 6,
pp. 695-704. 39. Vail, T.P., Mina, C.A., Yergler, J.D. & Pietrobon, R. 2006, "Metal-on-metal hip
resurfacing compares favorably with THA at 2 years followup", Clinical
26. Long, J.P. & Bartel, D.L. 2006, "Surgical variables affect the mechanics of a hip orthopaedics and related research, vol. 453, pp. 123-131.
resurfacing system", Clinical orthopaedics and related research, vol. 453, pp. 115-
122. 40. Vendittoli, P.A., Lavigne, M., Girard, J. & Roy, A.G. 2006, "A randomised study
comparing resection of acetabular bone at resurfacing and total hip replace-
27. McLardy-Smith, P., Steffen, R.T., Pandit, H., Murray, D.W. & Gill, H.S. 2006, ment", The Journal of bone and joint surgery.British volume, vol. 88, no. 8, pp.
"Metal-on-metal hip resurfacing: America, where are you?", Orthopedics, vol. 29, 997-1002.
no. 9, pp. 795-796.
41. Vendittoli, P.A., Lavigne, M. & Roy, A.G. 2006, "How do serum cobalt and
28. McMinn, D. & Daniel, J. 2006, "History and modern concepts in surface replace- chromium levels change after metal-on-metal hip resurfacing?", Clinical
ment", Proceedings of the Institution of Mechanical Engineers.Part H, Journal of orthopaedics and related research, vol. 451, pp. 292-3.
engineering in medicine, vol. 220, no. 2, pp. 239-251.
42. Wimmer, M.A., Schmid, T.M. & Jacobs, J.J. 2007, "Tribology: a portal to under-
29. McMinn, D., Treacy, R., Lin, K. & Pynsent, P. 1996, "Metal on metal surface stand joint failure?", Arthritis and Rheumatism, vol. 56, no. 11, pp. 3511-3513.
replacement of the hip. Experience of the McMinn prothesis", Clinical
orthopaedics and related research, vol. (329 Suppl), no. 329 Suppl, pp. S89-98. 43. Witzleb, W.C., Ziegler, J., Krummenauer, F., Neumeister, V. & Guenther, K.P.
2006, "Exposure to chromium, cobalt and molybdenum from metal-on-metal
30. Mont, M.A., Ragland, P.S., Etienne, G., Seyler, T.M. & Schmalzried, T.P. 2006, total hip replacement and hip resurfacing arthroplasty", Acta orthopaedica, vol.
"Hip resurfacing arthroplasty", The Journal of the American Academy of 77, no. 5, pp. 697-705.
Orthopaedic Surgeons, vol. 14, no. 8, pp. 454-463.
44. Ziaee, H., Daniel, J., Datta, A.K., Blunt, S. & McMinn, D.J. 2007, "Transplacental
31. Mont, M.A., Seyler, T.M., Marker, D.R., Marulanda, G.A. & Delanois, R.E. 2006, transfer of cobalt and chromium in patients with metal-on-metal hip arthroplas-
"Use of metal-on-metal total hip resurfacing for the treatment of osteonecrosis of ty: a controlled study", The Journal of bone and joint surgery.British volume, vol.
the femoral head", The Journal of bone and joint surgery.American volume, vol. 89, no. 3, pp. 301-305.
88 Suppl 3, pp. 90-97.
73
CLINICAL EXPERIENCE WITH HIP RESURFACING

Paul E. Beaulé MD FRCSC
In recent years, there has been a focus by industry and academia at four years19. The SARI index also proved to be relevant in
in the usage of alternative bearing surfaces for the treatment of assessing the outcome of the all cemented McMinn resurfacing
the young and active adult in order to minimize wear related implant at a mean followup of 8.7 years20. Hips which had
failures as well as the development of osteolysis1. The renewed failed or with evidence of radiographic failure on the femoral
interest in the clinically proven low wear of the metal-on-metal side had a significantly higher SARI score than the remaining
SYMPOSIA AR HIP
bearing2,3 combined with the capacity of inserting a thin wall hips, 3.9 versus 1.9.
cementless acetabular component4, has fostered the reintroduc-
Finally, one must consider the underlying diagnosis when eval-
tion of hip resurfacing. As in other forms of conservative hip
uating a patient for hip resurfacing. In cases of dysplasia, acetab-
surgery5,6,7, patient selection will help minimize complications8
ular deficiencies combined with the inability of inserting screws
and the need for early reoperation.
through the acetabular component may make initial implant
stability unpredictable. This deformity in combination with a
Activity as important determinant of Clinical Outcome
significant leg length discrepancy (<2cm) or valgus femoral
The value of a surgical intervention should assess its effect on
neck could compromise the functional results of surface arthro-
all aspects of health-related quality of life, as various aspects
plasty, and in those situations a stem type total hip replacement
of quality of life may not be affected to the same degree or
may provide a superior functional outcome21. In respect to other
even in the same manner by a particular procedure. It is also
diagnoses (osteonecrosis, inflammatory arthritis), initial analy-
well known that patients who lead an active lifestyle are at
ses have not demonstrated any particular diagnostic group at
greater risk of revision surgery9-11 either secondary to wear of
greater risk of earlier failure19 The only reservation we have is in
the bearing surface1,12 or mechanical failure of implant fixa-
patients with compromised renal function since metal ions gen-
tion10,13. However, a recent study has shown that for each sin-
erated from the metal-metal bearing are excreted through the
gle point improvement in the UCLA activity score (Table 1),
urine and the lack of clearance of these ions may lead to exces-
the SF-12 physical and mental scores would increase by 3.3
sive levels in the blood3,22. Currently, the only clear complica-
and 2.3, respectively. Thus a 3-point difference in the UCLA
tion from exposures to metal ions is a hypersensitivity reaction
activity equals a 9.9 expected difference in the SF-12 physical
known as an aseptic lymphocyte-dominated vasculitis-associat-
representing a full standard deviation improvement in the
ed lesion (ALVAL) which occurs in probably about 0.3% of
overall health related quality of life. This is especially relevant
cases23,24 and can lead to osteolytic lesions and loosening of the
since vigorous and frequent physical activity is important to
components. Finally, one should carefully counsel women of
cardiovascular health and has been shown to increase
child bearing age since metal ions are known to cross the pla-
longevity with individuals with a high activity demonstrating
cental barrier25.
a 10% increase in survivorship14. Concomitantly, Bozic and
associates15 have clearly shown that the use of hard on hard
Surgical Technique
bearings such as metal on metal is economically justifiable in
Because resurfacing has not been within the training curricu-
patients less than 60 years if revision surgery is avoided. Thus
lum of orthopaedic surgeons for the last 2 decades there will
if hip resurfacing permits a higher activity level without sig-
most likely be a learning curve in the integration of this
nificantly increasing the risk of revision surgery and if conver-
implant within clinical practice. Looking at the re introduction
sion surgery is required but comparable in its outcome to a
of unicompartmental knee arthroplasty. Lindstrand and associ-
primary total hip replacement then hip resurfacing becomes a
ates26, showed that centers of expertise were less likely to have
positive from both a quality of life standpoint as well as eco-
revisions within the first 2 years after unicompartmental knee
nomically justifiable.
arthroplasty compared to centers with less experience.
Similarly, I total of 20 cases has been cited as part of the learn-
Patient Selection and Hip Resurfacing
ing for hip resurfacing. Finally, in terms of biomechanical
Although hip resurfacing was initially plagued with high failure
reconstruction, a prospective randomized trial comparing hip
rates, the introduction of metal on metal bearings as well as
resurfacing to total hip replacement has shown the acetabular
hybrid fixation has shown excellent survivorships of 97% to
sizes to be not significantly different and that the capacity to
99% at 4-5 years followup16-19. However, it is important to criti-
achieve leg length equality and femoral offset within 4mm was
cally look at the initial published results. In all of these series
achieved a larger percentage of cases with hip resurfacing as
there was some form patient selection. For example in the
compared to THR27.
Daniel and associates18 publications only patients with
osteoarthritis with an age less than 55 with 79% of patients
CONCLUSION
being male. Treacy and associates17 stated that: “the operation
Although patients with a high activity level are likely to put their
was offered to men under the age of 65 years and women under
hip replacements at risk of earlier failure, limiting a patient’s
the age of 60 years, with normal bone stock judged by plain
activity because of fear of revision with a stem type hip replace-
radiographs and an expectation that they would return to an
ment has been shown to negatively impact the quality of life at
active lifestyle, including some sports”. However in the materi-
long term followup28. Franzen and associates28 using the
als and methods although the mean age is 52 the range is from
Nottingham Health Profile questionnaire showed that patients
17 to 76 including some patients with rheumatoid arthritis as
who had a total hip replacement for a mean time of 15 years
well as avascular necrosis. Obviously, some form of patient
faired significantly worse in comparison to age- and sex-
selection is needed but how one integrates them is where the
matched control group without arthritis in terms of perceived
Surface Arthroplasty Risk Index (SARI)8 is useful (TABLE 1). A
health, physical mobility, energy and emotional reactions. Thus
SARI score >3 represented a 4 fold increase risk in early failure
hip resurfacing arthroplasty plays a significant role in the treat-
or adverse radiological changes and with a survivorship of 89%
ment of hip arthritis by permitting a return to full activities or TABLE 1: SURFACE ARTHROPLASTY RISK INDEX
what the patient perceives as his/hers full capacities to do so, POINTS
permitting them to enjoy a better quality of life without fearing Femoral Head Cyst >1cm 2
a major hip revision. Patient Weight < 82kg 2
Previous Hip Surgery 1
UCLA Activity level >6 1
MAXIMUM SCO 6
SYMPOSIA AR HIP
REFERENCE 16. Back DL, Dalziel R, Young D, Shimmin A. Early results of primary Birmingham
Hip Resurfacings. An independent prospective study of the first 230 hips. J Bone
1. Sochart DH. Relationship of acetabular wear to osteolysis and loosening in total
Joint Surg 2005;87B(3):324-9.
hip arthroplasty. Clin Orthop Rel Res 1999;363:135-50.
17. Treacy R, Pynsent P. Birmingham Hip Resurfacing arthroplasty. A minimum fol-
2. Sieber H-P, Rieker CB, Kottig P. Analysis of 118 second-generation metal-on-
low-up of five years. J Bone Joint Surg 2005;87B(2):167-70.
metal retrieved hip implants. J Bone and Joint Surg 1999 Jan;81B(1):46-50.
18. Daniel J, Pynsent PB, McMinn DJW. Metal-on-metal resurfacing of the hip in
3. Brodner W, Bitzan P, Meisinger V, Kaider A, Gottsauner-Wolf F, Kotz R. Serum
patients under the age of 55 years with osteoarthritis. J Bone Joint Surg
Cobalt Levels after metal-on-metal total hip arthroplasty. J Bone Joint Surg
2004;86B(2):177-84.
2003;85A(11):2168-73.
19. Amstutz HC, Beaule PE, Dorey FJ, Campbell PA, Le Duff MJ, Gruen TA. Metal-
4. Beaule PE. Surface Arthroplasty of the Hip: A Review and Current Indications.
on-Metal Hybrid Surface Arthroplasty: Two to Six Year Follow-up. J Bone Joint
Semin Arthroplasty 2005;16(1):70-6.
Surg 2004;86A(1):28-39.
5. Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL. Periacetabular and
20. Beaule PE, LeDuff M, Campbell P, Dorey FJ, Park SH, Amstutz HC. Metal-on-
intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips.
metal surface arthroplasty with a cemented femoral component: a 7-10 year fol-
J Bone Joint Surg Am 1995 Jan;77(1):73-85.
low-up study. J Arthroplasty Suppl 3 2004;19(8):17-22.
6. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior
21. Silva M, Lee KH, Heisel C, dela Rosa M, Schmalzreid TP. The Biomechanical
Femoroacetabular Impingement. Part II. Midterm Results of surgical treatment.
Results of Total Hip Resurfacing Arthroplasty. J Bone Joint Surg 2004;86A(1):40-1.
Clin Orthop 2004;418:67-73.
22. Jacobs J, Skipor A, Doorn P, Campbell P, Schmalzried T, Black J, et al. Cobalt and
7. Murphy SB, Tannast M, Kim Y-J, Buly RL, Millis MB. Debridement of the adult
chromium concentrations in patients with metal on metal total hip replace-
hip for Femoroacetabular Impingement. Indications and preliminary clinical
ments. Clin Orthop Rel Res 1996;329S:S256-S263.
results. Clin Orthop 2004;429(429):178-81.
23. Willert H-G, Buchhorn GH, Fayyazi A, Flury R, Windler M, Foster G, et al. Metal-
8. Beaule PE, Dorey FJ, LeDuff MJ, Gruen T, Amstutz HC. Risk factors affecting out-
on-metal bearings and hypersensitivity in patients with artificial hip joints. A
come of metal on metal surface arthroplasty of the hip. Clin Orthop
clinical and histomorphological study. J Bone Joint Surg 2005;87Α(1):28-36.
2004;418(418):87-93.
24. Milosev I, Trebse R, Kovac S, Cor A, Pisot V. Survivorship and Retrieval Analysis
9. Chandler HP, Reineck FT, Wixson RL, McCarthy JC. Total hip replacement in
of Sikomet Metal-on-Metal Total Hip Replacements at a Mean of Seven Years.
patients younger than thirty years old. A five- year follow-up study. J Bone Joint
Surg 1981 Dec;63(9):1426-34. 3012. J Bone Joint Surg 2006;88A(6):1173-82.
10. Kilgus DJ, Dorey FJ, Finerman GA, Amstutz HC. Patient activity, sports participa- 25. Ziaee H, Daniel J, Datta AK, Blunt S, McMinn DJW. Transplacental transfer of
tion, and impact loading on the durability of cemented total hip replacements. cobalt and chromium in patients with metal-on-metal hip arthroplasty: A CON-
Clin Orthop 1991 Aug;269(269):25-31. TROLLED STUDY. J Bone Joint Surg 2007;89B(3):301-5.
11. Feller JA, Kay PR, Hodgkinson JP, Wroblewski BM. Activity and socket wear in the 26. Lindstrand A, Stenstrom A, Ryd L, Toksvig-Larsen S. The introduction period of
Charnley low-friction arthroplasty. J Arthroplasty 1994;9(4):341-5. unicompartmental knee arthroplasty is critical: a clinical, clinical multicentered,
and radiostereometric study of 251 Duracon unicompartmental knee arthroplas-
12. Schmalzried TP, Shepherd EF, McKellop HA, Jackson WO, dela Rosa M, Fa'vae F, et
ties. J Arthroplasty 2000;15(5):608-16.
al. Wear is a function of use not time. Clin Orthop Rel Res 2000;381(12):36-46.
27. Girard J, Lavigne M, Vendittoli PA, Roy A. Biomechanical reconstruction of the
13. Dubs L, Gschwend N, Munzinger U. Sports after total hip arthroplasty. Arch of
hip: A RANDOMISED STUDY COMPARING TOTAL HIP RESURFACING AND
Orthop and Trauma Surg 1983;101:161-9.
TOTAL HIP ARTHROPLASTY. J Bone Joint Surg 2006;86B(6):721-6.
14. Paffenbarger RS, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortal-
28. Franzen H, Johnsson R, Nilsson LT. Impaired quality of life 10 to 20 years after
ity, and longevity of college alumni. N Engl J Med 1986;314(10):605-13.
primary hip arthroplasty. J Arthroplasty 1997;12(1):21-4.
15. Bozic KJ, Morshed S, Silverstein MD, Rubash HE, Kahn JG. Use of cost-effective-
ness analysis to evaluate new technologies in orthopaedics. The case of alternative
bearing surfaces in total hip arthroplasty. J Bone Joint Surg 2006;88(4):706-14.
75
CLINICAL CONCERNS
Paul F. Lachiewicz, MD
Metal-Metal Total Hip Resurfacing • Resurfacing vs THA

• 3rd try ! (47-52 mm) (28 mm)
• Many different designs • Resurfacing provided less ROM than THA in extension
• Cemented femur activities
• Data “evolving” • Resurfacing had less ROM to impingement in all disloca-
SYMPOSIA AR HIP
tion activities
My concerns with modern resurfacing
• Premises for use not valid Range of Motion
• Patient selection issues Resurfacing vs. THA
• Learning curve Schmalzried et al Clin Orthop 2007
• Fractures, early failures • 50 resurfacing 44 THA
• Metal-metal articulation • 2-4 year follow-up
• No difference in postop ROM or dislocation
Premises for Resurfacing
• “High rate of failure of femoral stem” Premises for Resurfacing
False • Stress shielding with THA
No adverse events in first 20 years
Modern Uncemented Stemmed Femoral Components
Survival Yrs Prosthesis Metal-Metal Resurfacing Patient Selection
Engh 97% 12 CoCr bead Very limited number of patients for whom this procedure is
McLaughlin 94% 18 Ti plasma spray indicated
Archibeck 100% 9 Ti fiber-metal • Young, active men
Lachiewicz 100% 10 Ti fiber-metal • Osteoarthritis
Capello 99% 10 HA-coated • BMI < 35
• Leg length ≤ 1 cm short
• High horizontal fem. Offset
• Conservative – less bone removed?
— Femur – Yes In my practice
— Acetabulum – No ? • This is 6% of recent patients who have THA
• It will be difficult to develop a large surgical experience of
Acetabular Bone Removal in Resurfacing
resurfacing for proper indications
Loughead et al JBJS (B) 2006
• Larger component used in resurfacing (mean 5.4 mm) Metal-Metal Resurfacing Patient Selection Limitations
• Excess bone volume removed in resurfacing (14.9 cm3 for Eastaugh-Waring et al J Arthroplasty 2006
53 mm head) • 61 hips in patients < age 50 selected for resurfacing
• More bone removed in resurfacing! • Only 28 (46%) “suitable”
• 26 (43%) “unsuitable” femoral head
Acetabular Bone Removal in Resurfacing
• 7 (11%) “high-risk” challenge
Vendittoli et al JBJS (B) 2006
• Prospective, randomized 210 hips Metal-Metal Resurfacing Learning Curve
• Cup design Allofit® vs Duron® (165°) • Techniques for exposure, femoral prep and component
• No significant difference in acetabular size (54.9 vs 54.74 insertion more difficult than conventional THA
mm) • No “mini-incision”; OR time greater
• Notching fem neck 9% • Art of femoral cementing
More acetabular bone removed 12%
Metal-Metal Resurfacing Learning Curve
Acetabular Bone Removal in Resurfacing Mont et al JAAOS 2006
--Tradeoffs • 1st 50 hips….11 fxs, 2 other rev.
• Larger better ROM more • 2nd 50 hips… 1 fx, 1 other rev.
femoral ——> less ——> acetabular bone
Metal-Metal Resurfacing Learning Curve
head impingement removed
• If learning curve is 50-100 hips for an experienced hip sur-
• Smaller less ROM less
geon…
femoral ——> more ——> acetabular bone
• Can this procedure be “mastered” by a community
head impingement? removed
more notching? orthopaedic surgeon who performs ≤ 10 hips per year?
Early Complications — Resurfacing
Femoral neck fracture
• Hip resurfacing provides more range of motion than con-
• 1-1.9% (large series)
ventional THA
• 22% first 50 hips (Mont)
False!
• Related to: cysts, AVN, femoral reaming, cementing
Hip Resurfacing Range of Motion • Related to patient: trauma, activity
Thompson, Noble et al AAOS 2006, ORS 2007
• 3-D computer simulation
• 10 CT-reconstructed hips
Advocates have ignored the physiologic trends of the aging Are complications more with resurfacing compared to con-
femoral neck! ventional THA?
YES
Remodeling Femoral Neck
• Nerve palsy (2%)
• Men lose 18%, women 25% BMD in femoral neck from
• Clicking (23%)
age 30 to age 70
• Squeaking (4%)
• Men lose more BMD in neck than femoral shaft
Back et al JBJS (B) 2005
• Will there be more femoral neck fractures over time in
resurfaced hips? Concerns with Metal-Metal Articulation
• Blood, urine ion levels
Metal-Metal Resurfacing
SYMPOSIA AR HIP
• Lymphocytic aggregations (ALVAL)
Early Failures
• Hypersensitivity
• FDA approval BHR 5/2006
• Safety survey first 600 cases Concerns with Metal-Metal Articulation
• 89 surgeons – cadaver training, 1st 10 cases precepted Pseudotumours
• Short-term data (3-6 months) >60% • 10 cases m-m resurfacing
• Major adverse events (41) 6.8% • Onset 5-7 yrs
nerve palsy 7 • Varied presentations
dislocation 7 pain mass
• Revision (11) 1.8% path. fracture
fracture 9 late dislocation
dislocation 1 • Path: solid & cystic masses
cup loose 1 lymphocytic infiltrate
• Complications higher than expected! • Revision both components required
Della Valle et al Hip Society, September 2007 Murray et al Br. Oncol. Soc. 2007
Metal-Metal Resurfacing Metal-Metal Resurfacing
Mean 5 Year F/U Conclusions
Hing et al JBJS (B) 2007 • Used only by a limited number of experienced hip surgeons
• 230 hips • Marketing is problematic
• Survival 97.8% • Complications of resurfacing outweigh any possible advan-
• 2 revisions tages
• 8% femoral components migrated; 1 socket prob. loose;
Continue use of conventional modern uncemented THA
new neck osteolysis in 5.5%
Does this mean 14.5% impending failure?
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14. Clarke MT, Lee PT, Arora A, Villar RN. Levels of metal ions after small- and large-
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results. J Bone Joint Surg Am. 2001;83:1666–1673.
15. Daniel J, Pynsent PB, McMinn DJ. Metal-on-metal resurfacing of the hip in
5. Archibeck MJ, Surdam JW, Schultz SC Jr, Junick DW, White RE. Cementless total patients under the age of 55 years with osteoarthritis. J Bone Joint Surg Br.
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483.
16. Davies AP, Willert HG, Campbell PA. Lear month ID, Case CP. An unusual lym-
6. Back DL, Dalziel R, Young D, Shimmin A. Early results of primary Birmingham phocytic perivascular infiltration in tissues around contemporary metal-on-metal
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Joint Surg Br. 2005;87:324–329.
17. Doherty SD, Thompson MT, Usrey MM, Muirhead-Allwood S, Noble PC. Does
7. Beaulé PE, Campbell PA, Hoke R, Dorey F. Notching of the femoral neck during hip resurfacing restore normal range of motion and provide better joint motion
resurfacing arthroplasty of the hip. A vascular study. J Bone Joint Surg Br. than THR? Trans Orthop Res Soc. 2007;32:0276. Available at:
2006;88:35–39. http://www.ors.org/web/Transactions/53/0276.
8. Beaulé PE, Dorey FJ, LeDuff MJ, Gruen T, Amstutz HC. Risk factors affecting out- 18. Eastaugh-Waring SJ, Seenath S, Learmonth DS, Learmonth ID. The practical limi-
come of metal-on-metal surface arthroplasty of the hip. Clin Orthop Relat Res. tations of resurfacing hip arthroplasty. J Arthroplasty. 2006;21:18–22.
2004;418:87–93.
19. Engh CA Jr, Culpepper WJ 2nd, Engh CA. Long-term results of use of the
9. Beaulé PE, Le Duff M, Campbell P, Dorey FJ, Park SH, Amstutz HC. Metal-on- anatomic medullary locking prosthesis in total hip arthroplasty. J Bone Joint
metal surface arthroplasty with a cemented femoral component. A 7–10 year fol- Surg Am. 1997;79:177–184.
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20. Fowble VA, de la Rosa MA, Schmalzried TP. A comparison of total hip resurfacing
10. Beck TJ, Looker AC, Ruff CB, Sievanen H, Wahner HW. Structural trends in the and total hip replacement patients and outcomes. Clin Orthop Relat Res.
aging femoral neck and proximal shaft: analysis of the Third National Health 2007;465:xxx–xxx.
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SYMPOSIA AR HIP
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29. McAuley JP, Culpepper WJ, Engh CA. Total hip arthroplasty: concerns with exten- and clinical results of the Iowa hip prostheses: a study of patients less than fifty
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ANATOMY AND VASCULARITY OF THE HIP AND CLINICAL

IMPLICATIONS IN HIP RESURFACINGS
Paul E. Beaulé MD FRCSC
Although, femoral head viability may be maintained in part or Other studies have shown that the posterior approach leads to
in whole by an intraossesous blood supply, it is important to decrease in blood flow; eg Steffan et al8 showed an average drop
SYMPOSIA AR HIP
critically look at what level of evidence exists to support the role of 60%
of the extraosseous vessels as well.
These studies support the concept that a vascular process maybe
There are five consistent branches of the Medial Femoral at play after resurfacing in which the creation of extensive
Circumflex Artery osteonecrotic lesions could lead to risk of fracture and /or loss
of fixation during the reparative phase. This loss of fixation
Femoral head vascular anatomy is variable1,2:
could be followed by instability of the implant, migration and
for example, in 20 cadaveric specimens, the
eventually loosening.
MFCA originated from the profunda femoris
artery and in four, from the common
Implications for Surgical Approach in MMSA9
femoral artery.
The blood supply can be compromised by either sacrificing the
The main division of the deep branch cross- main branch of the ascending medial femoral circumflex artery
es posterior to the tendon of the obturator or damaging the retinacular vessels at the femoral head neck
externus and anterior to the tendons of the junction.
superior gemellus, obturator internus, and
Choice of surgical approach and surgical technique are there-
the inferior gemellus.
fore important.
Thus, for the majority of hips, preserving the
attachment of the obturator externus tendon during surgical ExperienceExposure Blood Supply Risk /
to Head Disadvantages
exposure and dislocation of the hip protects the ascending
Posterior Approach +++ ++ -Compromised Femoral Triangle
branch of the MCFA from rupture and/or stretching NVS structures
Lavigne et al3 showed that 80% of the femoral head Modified Lateral +++ ++ -Preserved- -Abductor Muscle
extraosseous vessel foramina were located in the anterosuperior Not well -Peroneal Nerve
documented at risk
and posterosuperior quadrants. This quite relevant to hip resur-
Troch Flip ++ +++ Preserved- -1-2% GT
facing since the femoral head neck junction is always at risk of Well documented nonunion
notching as the cylindrical reamer moves across it, as shown in -Restricted wt
our study of blood flow with simulated neck notching4 and the bearing
figure below Anterior/ Hueter + ++ Preserved Ankle Fracture
-Special Table
Does the Arthritic Process Change Femoral Head Blood Supply?
What is the role of Retinacular vessels in hips with advanced Implications for Resurfacing Failures
arthritis? Why are we not seeing a higher failure rate after hip resurfacing
The concept of predominantly Intra-osseous blood supply to with the posterior approach being widely used?
the arthritic hip was advanced by MAR Freeman in 19785, A few hypotheses can be put forward: blood flow restores itself
Whiteside demonstrated it in a canine model6. at a later point; intraosseous blood flow is present; a certain
Less is known from human studies, so we performed a series of injury threshold must be reached before osteonecrosis occurs.
intra-operative laser Doppler flowme-
try studies which confirmed the The Vascular Sparing Approach to Head
importance of the extra-osseous ves- Given the known variability in the vascular supply to the arthrit-
sels4,7. ic femoral head, it would seem prudent to preserve as much of
both the extraosseous and intraosseous sources as possible by
The decrease in blood flow after delib- using a vascular sparing approach.
erate neck notching was significant (10
of 14 hips decreased more than 50%) It may not be sufficient to choose a vascular sparing approach
as the retinacular vessels are also key and can be damaged dur-
Anterior Lateral Central ing head preparation. In order to avoid this one can:
Mean = 60% (SD 29) Mean = 48% (SD 25) • Superolateral placement of the reamers
Range = 4% - 90% Range = 0 - 88% • Hug the inferomedial neck
Median = 76% Median = 46% • Slightly oversize femoral component.
> 50% drop: 9 > 50% drop: 6
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1. Gautier E, Ganz K, Krugel N, Gill TJ, Ganz R. Anatomy of the medial circumflex ina around the femoral head and neck junction: relevance for conservative intra-
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5. Freeman MAR. Some anatomical and mechanical considerations relevant to the Vascularity of the arthritic femoral head and hip resurfacing. J Bone Joint Surg
surface replacement of the femoral head. Clin Orthop Rel Res 1978;134:19-24. 2006;88A(Suppl. 4):85-96.
6. Whiteside LA, Lange DR, Capello WN, Fraser B. The Effects of surgical procedures 10. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation
on the blood supply to the femoral head. J Bone Joint Surg 1983;65A(8):1127- of the adult hip. A new technique with full access to the femoral head and
SYMPOSIA AR HIP
33. acetabulum without the risk of avascular necrosis. J Bone Joint Surg
2001;83B(8):1119-24.
BIOCOMPATABILITY OF METAL-ON-METAL BEARINGS

Due to relatively low volumetric wear rates and the ability to use ticulate corrosion products.4 The latter are bioreactive and have
large heads, metal-on-metal bearing total hip and resurfacing been implicated in the development of periprosthetic osteoly-
arthroplasty are gaining in popularity. Despite generally favor- sis.5,6 In fact, Willert et al7 has documented that the preponder-
able short- and intermediate-term clinical results, there is con- ence of debris in the periprosthetic membranes of patients with
cern that adverse local and remote tissue responses will occur in failed metal-on-metal bearings are likely corrosion products.
SYMPOSIA AR HIP
some individuals as a consequence of the host response to the
In addition, multiple investigators have reported a distinct
metallic degradation products of these bearings.
histopathological pattern associated with failed metal on metal
It has been well documented that the serum and urine metal bearings with and without osteolysis that is suggestive of a
concentrations in patients with these implants are substantially delayed-type hypersensitivity response.8,9 Over the last two years,
higher than those seen in patients with conventional metal-on- there have been multiple published clinical reports of early fail-
polyethylene bearings and that these elevated levels may persist ures of contemporary metal on metal total hip replacements that
for the duration of the implant's lifetime.1 This is of particular have implicated metal hypersensitivity as a factor contributing to
concern in the younger and more active patient where life osteolysis and/or pain.10-12 In addition, there are also reports of
expectancy after implantation may exceed two or three decades. metallosis in association with periarticular masses.13
Even though volumetric wear rates are substantially reduced
At this time, the association of metal release from orthopedic
compared to conventional bearing couples, metal-on-metal
implants with any metabolic, bacteriologic, immunologic, or
bearings actually produce a greater number of particles since the
carcinogenic toxicity remains uncertain since cause and effect
debris generated is in the nanometer size range.2 Nanometer
have not been definitively established in patients with these
debris possesses a high specific surface area, likely accounting for
devices. Nonetheless, continued surveillance of patient popula-
relatively high rates of metal release into the surrounding tissues.
tions with metal-metal bearings is warranted to define the
Metal-on-metal bearings and metal nanodebris may also under- nature and magnitude of the risk of adverse biological respons-
go electrochemical dissolution (corrosion) leading to the forma- es, particularly those purportedly due to metal hypersensitivity.
tion of specific metal-protein complexes3 and/or cobalt-alloy par-
REFERENCES 7. Willert HG, Buchhorn GH, Gobel D, et al: Wear behavior and histopathology
1. Jacobs, J.J., Hallab, N.J., Skipor, A.K., and Urban, R.M. Metal Degradation of classic cemented metal on metal hip endoprostheses. Clin Orthop :S160-
Products: A Cause for Concern in Metal-Metal Bearings? Clin Orthop 417:139- 186, 1996
147, 2003. 8. Willert H-G, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, Lohmann
2. Doorn, P.F, Campbell, P.A., Worrall, J., Benya, P.D., McKellop, H.A.: Metal wear CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip
particle characterization from metal on metal total hip replacements: TEM study joints. A clinical and histomorphological study. J Bone Joint Surg 2005; 87-
of periprosthetic tissues and isolated particles. J Biomed Mater Res 42 (1998) A:28-36.
103-111. 9. Davies AP, Willert HG, Campbell PA, Learmouth ID, Case CP. An unusual lym-
3. Hallab,N.J., Jacobs,J.J., Skipor,A., Black,J., Mikecz,K., and Galante,J.O.: Systemic phocytic perivascular infiltration in tissues around contemporary metal-on-metal
metal-protein binding associated with total joint replacement arthroplasty. J joint replacements. J Bone Joint Surg 2005; 87-A:18-27.
Biomed Mater Res 49:353, 2000. 10. Korovessis P, Petsinis G, Repanti M, Repantis T. Metallosis after contemporary
4. Jacobs, J.J., Urban, R.M., Hallab, N.J., Skipor, A.K., M.S., Fischer, A., and Wimmer, metal-on-metal total hip arthroplasty. Five to Nine-Year Follow-Up J Bone Joint
M.A. Metal-on-Metal Bearing Surfaces. J Amer Acad Ortho Surg (In Press). Surg 2006; 88A:1183-1191.
5. Lee S-H, Brennen FR, Jacobs JJ, Urban RM, Ragasa DR, Glant TT. Human 11. Milosev I, Trebse R, Kovac S, Cor A, Pisot V. Survivorship and retrieval analysis of
Monocyte/macrophage response to cobalt-chromium corrosion products and Sikomet metal-on-metal total hip replacements at a mean of seven years. J Bone
titanium particles in patients with total joint replacements. J Orthop Res 1997; Joint Surg 2006; 88A:1173-1182.
15:40-49. 12. Park Y-S, Moon Y-W, Lim S-J, Yang J-M, Ahn G, Choi Y-L. Early osteolysis follow-
6. Jones DM, Marsh JL, Nepola JV, Jacobs JJ, Skipor AK, Urban RM, Gilbert JL, ing second-generation metal-on-metal hip replacement. J Bone and Joint Surg;
Buckwalter JA. Focal osteolysis at the junctions of a modular stainless-steel 87-A:1515-21, 2005.
femoral intramedullary nail. J Bone Joint Surg 2001; 83-A:537-48. 13. Boardman, D.R., Middleton, F.R., and Kavanagh, T.G. Case Report. A benign
psoas mass following metal-on-metal resurfacing of the hip. J Bone and Joint
Surg; 88-B:402-404, 2006.
81
IMPLANT RETRIEVAL FINDINGS OF FAILED HIP RESURFACINGS

Pat Campbell, Ph.D.
Introduction Desired Mantle (mm)

Surface arthroplasty (SA) in the past was limited by high failure DUROM 1
rates associated with polyethylene wear–induced osteolysis. C+ (US) 1
Metal-on-metal (MM) bearings for SA potentially overcome this ASR <1
limitation. This presentation will review the important retrieval C+ (Europe) 0.5
SYMPOSIA AR HIP
ReCap 0.5
findings from more than 200 MMSA cases submitted to our
CORMET 0
Implant Retrieval lab. ICON 0
BHR 0
Modes of Failure
The main modes of failure of specimens submitted to the Role of Cement in Failures
Implant Lab are: • We found variable cement mantle, penetration
• femoral neck fractures – main cause of failure, most occur • Amount & distribution are hard to control
in the first month • Cement-filled cysts contributed to large amounts
• femoral loosening – most occur after 1 year, and after a • Too little and too much can be bad - leading to loosening
period of pending failure in some designs more than others
• loose cemented cups – from the older design (cement is no
longer used for sockets) Acetabular Malposition
• loose porous coated sockets – unusual cause for failure so • Increasingly important failure mode (with important long-
far term consequences)
• acetabular malposition – steep cups are important for wear — High wear from edge loading mode (leading to atypical-
related consequences ly high ions)
• infection – similar rate as total hip replacement — Metallosis, synovitis and/ or bursa enlargement with
• unexplained pain (including metal sensitivity ) – an swelling
increasing cause for revision — Groin Pain secondary to the swelling, and/or impinge-
ment
Femoral Neck Fracture
• Main cause of short-term failure (Median 2 months) Unexplained Pain
• Fracture through weak new bone = through an area of Sometimes the cause for a patient’s pain is not obvious from
repairing surgical damage (new bone is weak and a the radiographs. Implant retrieval analysis can help determine
neck/implant lesion represents a stress riser) if the cause is largely mechanical in origin (fracture or loosen-
• Ischemic fractures are uncommon, they can take several ing ) or biological (a tissue reaction to metal wear products)
years to fail The latter can be a response to excessive wear or can be due to
— surgery induced osteonecrosis (from cutting through the an immune response (allergy)
nutrient vessels, especially with the posterior approach), Metal Sensitivity
and thermal necrosis • Appears to be a rare cause of failure, it is associated with a
Femoral Loosening history of pain, should be considered when all other causes
• 1.5 to 7 years, most 4 years for pain have been ruled out
— lack of fixation (poor quality bone, preparation, cement • Tissues contain unusual amounts of lymphocytes, plasma
technique) cells, fibrin, necrosis
— loss of fixation (instability from membranes and • Only “cured” by removing the CoCr bearings
removal of dead bone) SUMMARY & CONCLUSIONS
• Some completely dissociate when fibrous tissue replaces
bone MMSA Modes of Failure
— bone death, resorption, micromotion, membrane and • Ischemic necrosis is low
fibrosis • Metal sensitivity is rare, but is a cause for concern until a
screening test is possible
Role of Femoral Head Vascularity ? • Wear–debris induced lysis is rare, but reactivity to metal
• Histological evidence of vascular disturbance wear products causes pain
— variable extent (interfaces or throughout the head) • Neck fractures occur through damaged femoral necks
— multiple causes (thermal necrosis, monomer leakage, • Lasting fixation is achievable despite cement technique vari-
severing vessels) ation
• Short and long-term consequences ? • Injury from implantation + surgical errors in poor quality
— fracture (occur through repairing bone) bone can exceed the ability of the bone to adapt and heal,
— loosening (instability following dead bone removal) leading to failure
Implant Design Differences • Fortunately, most of them heal and adapt and survive
• Heat treatments Wear Products
• Stem proportions • Well-functioning implants – wear & ions are low
• Cementing • Poorly functioning – metallosis, high ions, joint tissues will
• US vs European Fit be affected, systemic consequences are more difficult to
We studied how these might impact failures detect
• There may be a metal dose effect locally which may or may ered to have mal-functioning implants and may, therefore
not be seen at the clinical level be at higher potential risk for long-term complications.
• Failure is Multifactorial: Success is a balance between correct
Long-Term Effects
mechanics and tolerant biology. Understanding this is the
• Difficult to document, retrieval analysis of long-term cases
key to long-term success.
is required. Patients with high ion levels should be consid-
SYMPOSIA AR HIP
FURTHER READING: 3. Morlock MM, Bishop N, Ruther W, et al. Biomechanical, morphological, and his-
1. Campbell P, Beaulé P, Ebramzadeh E, et al. A study of implant failure in metal- tological analysis of early failures in hip resurfacing arthroplasty. Proc Inst Mech
on-metal surface arthroplasties. Clin Orthop December 2006 Eng [H] 2006; 220:333-44. (This issue Is dedicated to metal-on-metal and resur-
facing)
2. Campbell P, Urban RM, Catelas I, et al . Autopsy analysis thirty years after metal-
on-metal total hip replacement. A case report. J Bone and Joint Surg 2003; 85- 4. Campbell P, Shimmin A, Walter L, Solomon M: Metal sensitivity as a cause of
A:2218-22. groin pain in hip resurfacings. J Arthroplasty, 2008 in press.
5. The December 2004 Supplement to the Journal of Arthroplasty has 22 manu-
scripts dealing with various aspects of metal-on-metal components.
83
BIOMECHANICS OF HIP RESURFACING

Kevin Ong, Ph.D.
The number of hip replacement procedures in the U.S. is expect- advised because this may mask the first signs of femoral loos-
ed to increase by four–fold by 2030. Younger patients, those ening, which are most detectable around the stem [16]. Distal
under 65 years old, are expected to account for 53% of hip fixation of the stem may also lead to overloading of the unsup-
replacements in 2030, compared to 44% in 2005. Presently, ported implant, particularly in the presence of bone loss within
national joint registry data [1, 2] indicate that the early revision the femoral head, and subsequent fatigue fracture of the stem
SYMPOSIA AR HIP
risk for hip resurfacing patients is greater than for conventional [17].
THA. The primary reasons for hip resurfacing failures at short
term are periprosthetic (neck) fracture and implant loosening Bone changes
[1, 2]. Though careful patient selection can optimize the out- DEXA studies have shown preservation of bone density around
comes with hip resurfacing [3, 4], surgical technique and the stem of the component and femoral neck [18, 19] and have
implant design are also important factors to consider. reported that hip resurfacing arthroplasty preserves bone stock
in the proximal femur. However, due to the screening effect of
Femoral Neck Fractures the metallic femoral head, these studies were unable to evaluate
The outcome of hip resurfacing is multifactorial and is influ- bone changes within the femoral head.
enced by a combination of patient, surgical, and design factors
Computational models [15, 20], as well as retrieval studies (ref),
[5]. From the surgical perspective, the learning curve for per-
have shown that bone loss from stress shielding is present with-
forming these procedures is evident [4], and the surgical tech-
in the femoral head.
niques are still being optimized [6]. Varus orientation of the
femoral component has been described as a potential factor Neck narrowing has also been reported for first generation
associated with an increased risk of femoral neck fractures [6-9]. resurfacings with stress shielding and polyethylene wear as the
Stem-shaft angle was the only factor to be independently relat- proposed causes [21]. However, in the absence of polyethylene
ed to the surface arthroplasty risk index, as described by Beaulé in newer generation metal-on-metal hip resurfacings, the etiol-
and co-workers [8]. They found that patients with adverse out- ogy is unclear and could result from a combination of stress
comes had an average implant orientation of 133 degrees com- shielding, osteonecrosis, and avascular necrosis [22]. Recent
pared to 139 degrees for the remaining patients. Varus place- clinical studies have reported neck narrowing for various
ment of more than 5 degrees has also been observed in 71% of implant designs [8, 16, 22-25], although this does not appear to
45 patients with fractured femoral necks following Birmingham have any adverse effects on short or medium term outcomes
hip resurfacing [9]. and appears to stabilize after about 3 years [22]. It has been sug-
gested that these patients may be predisposed to femoral loos-
A recent cadaveric study noted a 28% increase in fracture load
ening in the future [25].
when resurfacing femoral components were placed in 10
degrees valgus compared to natural orientation [10]. However, Implant orientation may be associated with bone remodeling
the effect of orientation on potential risk of femoral neck frac- changes around the femoral component. Previous biomechani-
tures was only applicable to specimens with normal bone den- cal studies have shown reduced loading in the proximal femur
sity but had no influence in specimens with low bone density. when the implant is placed in valgus [26-28] and have suggest-
Furthermore, excessive valgus placement of the femoral compo- ed that these conditions will minimize the risk of femoral neck
nent may also lead to notching of the neck and cause damage fractures compared to varus components [6-9]. However, the
to the blood vessels [11]. reduction in loading due to an extreme valgus implant may be
of sufficient magnitude to increase the potential for bone
Cementing resorption compared to neutral or extreme varus positioned
Previous retrieval studies have demonstrated large variability in implants [29]. Using finite element models [29], the bone
cement mantle thickness and interdigitation with cancellous resorption stimulus has been shown to extend distally and
bone [12, 13]. The proportion of retrieved femoral head sec- peripherally towards the mid-stem and femoral neck, possibly
tions filled with cement ranged from 11% to 89% [12]. The vari- associated with neck narrowing. Hence, an implantplaced in
ability in the amount and distribution of bone cement within high valgus may instead increase the risk of loosening through
the femoral heads was noted as a potential cause for implant the greater loss of bony support from stress shielding.
failure because greater amounts of cement were measured in
Furthermore, the lack of modularity in hip resurfacing poses
loosened femoral components. Of the retrieved heads exam-
some challenges in restoring the hip mechanics. Most hip resur-
ined by Morlock et al. [13], only 31% of the retrieved heads had
facing patients also have abnormal bone anatomy [30, 31],
cementing performed according to recommended techniques.
which makes it difficult to restore hip mechanics and determine
Excessive cementing has been shown to decrease bone loading appropriate implant alignment. Hip resurfacing patients tend to
in the proximal femur [14]. Furthermore, it may also promote have abnormal femoral head/neck offset [30], as well as greater
thermal necrosis [12]. valgus pre-operative neck-shaft angles and less horizontal
femoral offset than normal, contralateral hips [31].
Cementing of the stem is also controversial. Although original-
ly designed to be uncemented, stem cementing has been rec-
Cup deformation
ommended to improve initial fixation and avoid the develop-
With the objective of preserving acetabular bone stock, thinner
ment of radiolucencies around the stem [6]. However, previous
resurfacing cups are being designed [32]. Radial compressive
biomechanical studies have found that cementing the stem or
forces at the periphery of the acetabulum during press-fit
fixation of the stem can increase stress/strain shielding in the
implantation may cause the acetabular components to deform.
proximal femur [14, 15]. Cementing of the stem is also not
The deformation may be non-uniform in nature due to rim
loading by dense cortical bone along the anterior-superior and metal-on-metal bearings and result in increased wear. Of note,
Diametrical pinching deformation of up to 100 µm during

posterior-inferior margins of the acetabulum [32, 33]. cup deformation is not isolated to hip resurfacing cups [33, 34].
Cup deformation could also influence implant stability and fix-
cadaveric implantation of resurfacing cups has been reported ation, producing unfavorable conditions for osseointegration
[32], which could adversely affect the fluid film lubrication of and possibly affecting periprosthetic bone remodeling.
SYMPOSIA AR HIP
REFERENCES 18. Harty JA, Devitt B, Harty LC, et al. Dual energy X-ray absorptiometry analysis of
1. Australian Orthopaedic Association, National Joint Replacement Registry Annual peri-prosthetic stress shielding in the Birmingham resurfacing hip replacement.
Report 2007. 2007. Arch Orthop Trauma Surg 2005; 125: 693-5.
2. National Joint Registry, National Joint Registry for England and Wales: 4th 19. Kishida Y, Sugano N, Nishii T, et al. Preservation of the bone mineral density of
Annual Report. 2007. the femur after surface replacement of the hip. J Bone Joint Surg [Br] 2004; 86-B:
185-9.
3. Schmalzried TP, Silva M, de la Rosa MA, et al. Optimizing patient selection and
outcomes with total hip resurfacing. Clin Orthop Relat Res 2005; 441: 200-4. 20. Gupta S, New AM and Taylor M. Bone remodelling inside a cemented resurfaced
femoral head. Clin Biomech (Bristol, Avon) 2006; 21: 594-602.
4. Siebel T, Maubach S and Morlock MM. Lessons learned from early clinical expe-
rience and results of 300 ASR hip resurfacing implantations. Proc Inst Mech Eng 21. Berend ME and Bertrand T. Metal-metal hip resurfacing: solution to a nonexist-
[H] 2006; 220: 345-53. ent problem. Orthopedics 2007; 30: 724, 727.
5. Shimmin AJ, Bare J and Back DL. Complications associated with hip resurfacing 22. Hing CB, Young DA, Dalziel RE, et al. Narrowing of the neck in resurfacing
arthroplasty. Orthop Clin North Am 2005; 36: 187-93, ix. arthroplasty of the hip: A RADIOLOGICAL STUDY. J Bone Joint Surg Br 2007;
89-B: 1019-24.
6. Amstutz HC, Le Duff MJ, Campbell PA, et al. The effects of technique changes on
aseptic loosening of the femoral component in hip resurfacing. Results of 600 23. Beaule PE, Le Duff M, Campbell P, et al. Metal-on-metal surface arthroplasty
Conserve Plus with a 3 to 9 year follow-up. J Arthroplasty 2007; 22: 481-9. with a cemented femoral component: a 7-10 year follow-up study. J Arthroplasty
2004; 19: 17-22.
7. Amstutz HC, Beaule PE, Dorey FJ, et al. Metal-on-metal hybrid surface arthro-
plasty: two to six-year follow-up study. J Bone Joint Surg Am 2004; 86-A: 28-39. 24. Duijsens AW, Keizer S, Vliet-Vlieland T, et al. Resurfacing hip prostheses revisited:
failure analysis during a 16-year follow-up. Int Orthop 2005; 29: 224-8.
8. Beaule PE, Dorey FJ, LeDuff M, et al. Risk factors affecting outcome of metal-on-
metal surface arthroplasty of the hip. Clin Orthop Relat Res 2004; 87-93. 25. Lilikakis AK, Vowler SL and Villar RN. Hydroxyapatite-coated femoral implant in
metal-on-metal resurfacing hip arthroplasty: minimum of two years follow-up.
9. Shimmin AJ and Back D. Femoral neck fractures following Birmingham hip Orthop Clin North Am 2005; 36: 215-22, ix.
resurfacing: a national review of 50 cases. J Bone Joint Surg Br 2005; 87: 463-4.
26. Beaule PE, Lee JL, Le Duff MJ, et al. Orientation of the femoral component in
10. Anglin C, Masri BA, Tonetti J, et al. Hip Resurfacing Femoral Neck Fracture surface arthroplasty of the hip. A biomechanical and clinical analysis. J Bone
Influenced by Valgus Placement. Clin Orthop Relat Res 2007; Joint Surg Am 2004; 86-A: 2015-21.
11. Beaule PE, Campbell PA, Hoke R, et al. Notching of the femoral neck during 27. Long JP and Bartel DL. Surgical variables affect the mechanics of a hip resurfac-
resurfacing arthroplasty of the hip: a vascular study. J Bone Joint Surg Br 2006; ing system. Clin Orthop Relat Res 2006; 453: 115-22.
88: 35-9.
28. Radcliffe IA and Taylor M. Investigation into the effect of varus-valgus orientation
12. Campbell P, Beaule PE, Ebramzadeh E, et al. The John Charnley Award: a study on load transfer in the resurfaced femoral head: a multi-femur finite element
of implant failure in metal-on-metal surface arthroplasties. Clin Orthop Relat Res analysis. Clin Biomech (Bristol, Avon) 2007; 22: 780-6.
2006; 453: 35-46.
29. Ong KL, Day JS, Kurtz SM, et al. Role of surgical variations on initial bone
13. Morlock MM, Bishop N, Ruther W, et al. Biomechanical, morphological, and his- remodeling around the Birmingham resurfacing arthroplasty. In 53rd Annual
tological analysis of early failures in hip resurfacing arthroplasty. Proc Inst Mech Meeting of the Orthopaedic Research Society. 2007. San Diego, CA.
Eng [H] 2006; 220: 333-44.
30. Beaule PE, Harvey N, Zaragoza E, et al. The femoral head/neck offset and hip
14. Radcliffe IA and Taylor M. Investigation into the effect of cementing techniques resurfacing. J Bone Joint Surg Br 2007; 89: 9-15.
on load transfer in the resurfaced femoral head: a multi-femur finite element
analysis. Clin Biomech (Bristol, Avon) 2007; 22: 422-30. 31. Silva M, Lee KH, Heisel C, et al. The biomechanical results of total hip resurfac-
ing arthroplasty. J Bone Joint Surg Am 2004; 86-A: 40-6.
15. Ong KL, Kurtz SM, Manley MT, et al. Biomechanics of the Birmingham hip resur-
facing arthroplasty. J Bone Joint Surg Br 2006; 88: 1110-5. 32. Jin ZM, Meakins S, Morlock MM, et al. Deformation of press-fitted metallic
resurfacing cups. Part 1: Experimental simulation. Proc Inst Mech Eng [H] 2006;
16. De Smet KA. Belgium experience with metal-on-metal surface arthroplasty. 220: 299-309.
Orthop Clin North Am 2005; 36: 203-13, ix.
33. Squire M, Griffin WL, Mason JB, et al. Acetabular component deformation with
17. Bowman NK, Bucher TA and Bassily AA. Fracture of the stem of the femoral press-fit fixation. J Arthroplasty 2006; 21: 72-7.
component after resurfacing arthroplasty of the hip. J Bone Joint Surg Br 2006;
88: 1652-3. 34. Markel D, Day J, Siskey S, et al. Deformation of metal-backed acetabular compo-
nents and the impact of liner thickness in a cadaveric model. In 20th Annual
Symposium of the International Society for Technology in Arthroplasty. 2007.
Paris, France.
85
TECHNIQUES AND TECHNICAL TIPS IN

HIP SURGERY (J)
SYMPOSIA AR HIP
Moderator: William J. Maloney, MD, Stanford, CA

Surgical techniques have evolved dramatically over the past five years. This symposium will
provide the attendee with the most up-to-date techniques in primary and revision hip
replacement surgery.
I. Surgical Approaches in Primary Total Hip Arthroplasty

a. Mini – Anterior
Clive P. Duncan, MD, Vancouver, BC Canada
b. Mini – Anterolateral
William J. Hozack, MD, Philadelphia, PA
c. Mini- Posterior
Thomas P. Sculco, MD, New York, NY
d. Femur First – Mini – Posterior
Lawrence D. Dorr, MD, Los Angeles, CA
II. Young Adult Hip

a. Surgical Dislocation and Osteochondroplasty
Robert T. Trousdale, MD, Rochester, MN
b. Resurfacing Arthroplasty
Robert Barrack, MD, Saint Louis, MO
c. Discussion
III. Issues in Revision Surgery

a. Extensile Exposures
Clive P. Duncan, MD, Vancouver, BC, Canada
b. Removal of Well-Fixed Sockets
c. Removal of Well-Fixed Stems
d. Prostalac Technique
Arlen D. Hanssen, MD, Rochester, MN
e. Canal Preparation – Tapered Stem
Wayne G. Paprosky, MD, Winfield, IL
f. Canal Preparation – Cylindrical Stems
Robert Barrack, MD, Saint Louis, MO
g. Cementing Liners into Well-Fixed Shells
Harry Rubash, MD, Boston, MA
h. Grafting Around Well-Fixed Sockets
Harry Rubash, MD, Boston, MA
i. Socket Preparation for Revision Acetabular Replacement
Arlen Hanssen, MD, Rochester, MN
j. Use of Metal Augements for Acetabular Deficiency
k. Use of Bulk Grafts for Acetabular Deficiency
l. Discussion
THE ANTEROLATERAL APPROACH TO MISTHA

Clive P. Duncan, MD, FRCSC
This is a single incision, intermuscular approach using the • Lower end of table is split so as to create a well to accom-
anterolateral interval between gluteus medius and tensor fascia modate the operative limb.
lata, first popularized by Watson-Jones for the management of • The surgeon is positioned anterior to the hip
fractures involving the proximal femur in 1936, and since mod- • The intermuscular interval is used to expose the capsule
ified by Heinz-Roettinger in 2002 for total hip replacement. It • The capsule is retained and repaired
SYMPOSIA AR HIP
has a number of advantages when compared with other • Specialized instruments are used to avoid damage to the
approaches, particularly MIS two-incision THA in as much as: gluteus medius
• Patient in lateral position The postoperative management is similar to that used for other
• Single incision approaches, except that the ‘restrictions’ may be dropped earlier
• Lateral cutaneous nerve spared because of the fundamentally stable aspects of this surgical
• Femoral circumflex vessels avoided approach.
• Femoral canal preparation under direct vision
Peer-reviewed results of this approach have indicated its superi-
• No fluoroscopy required
ority over the mini-direct lateral (transgluteal) approach, but
• Short learning curve
not yet to the mini-posterior approach. Those results, in
• Truly an intermuscular approach
prospective randomized studies, are pending.
There are a number of important differences compared with
conventional approaches to the hip.
REFERENCES 2. Toms AD, Duncan CP: The Limited Incision Anterolateral Intermuscular
1. Duncan CP, Toms AD, Masri BA: Minimally Invasive or Limited Incision Hip Technique for Total Hip Replacement. AAOS Instructional Course Lectures Vol
Replacement: Clarification and Classification. AAOS Instructional Course 55, Chapter 22. The American Academy of Orthopaedic Surgeons, Rosemont, IL,
Lectures Vol 55, Chapter 21. The American Academy of Orthopaedic Surgeons, 2006.
Rosemont, IL, 2006.
87
DIRECT ANTERIOR APPROACH FOR THA

William J. Hozack, MD
Positioning and Draping Acetabulum Exposure

The patient is positioned in the supine position and the opera- For the acetabular preparation, additional light is helpful. This
tive leg is draped. can be achieved by use of a head mounted light or by placing a
localized light source in the wound. While the anterior retrac-
The opposite leg is supported by an additional arm board that
tor remains in place, the medial (sharp or blunt) retractor is
SYMPOSIA AR HIP
is attached to the table.

placed in the area of the transverse ligament medial and inferi-
or to the acetabulum. Incising the medial or inferior capsule
Skin Incision
will facilitate placement of this retractor. Another sharp retractor
The position of the skin incision is found by palpating the ante-
is placed inside the capsule in the area of the posterolateral
rior superior iliac spine from below. From this point, measure
acetabulum.
3 cm laterally and 3 cm distally to find the starting point and
orientate the incision along the longitudinal axis of the tensor
Reaming of the Acetabulum
fascia lata muscle.
Standard reamers can be used, but it is extremely important to
have an offset reamer handle available. The offset reamer han-
Intermuscular Portal
dle will allow you to ream in the correct orientation.
The lateral femoral circumflex nerve and its branches lie along
the surface of the sartorius muscle. As an additional step to pro-
Cup Implantation
tect the lateral femoral circumflex nerve, we recommend incis-
For cup implantation, the use of a curved cup impactor is essen-
ing the tensor fascia latae fascia sharply at its midpoint for the
tial for achieving the correct orientation of the cup.
length of the muscle and performing a strictly subfascial expo-
sure. Elevation of the medial aspect of the superficial tensor fas-
Leg Positioning and Proximal Femoral Exposure
cia lata fascia reveals a fat layer medially. This fat layer defines
Place the operated leg in hyperextension, adduction, and exter-
the Smith Peterson interval. Inserting the index finger posteri-
nally rotation. The table is broken in order to accomplish hyper-
orly at this point will allow the surgeon to reach the superior
extension. The opposite leg is abducted and placed on the arm-
aspect of the hip joint capsule. At this point, a curved retractor
board Leave the anterior retractor in place and remove all other
is placed medial to tensor fascia latae and gluteus minimus,
retractors. Grasp the lateral capsular flap with a clamp, and
near the superior hip joint capsule. Using a finger, carefully sep-
place the femoral elevator behind this flap. Another retractor
arate the remaining fibers of the sartorius and tensor fascia lata
can be placed against the greater trochanter. The supero-lateral
to fully expose the Smith Peterson interval. Place a second
capsule presents itself in the shape of a triangle between the
sharp retractor at the distal part of the incision near the greater
acetabulum and femoral neck. This flap must be carefully
trochanter. Using a wide rake or hibbs, pull the sartorius and
detached from the neck and should be removed completely. If
rectus medially. By using this instrumentation and placement
cuts are made in the posterior capsular fat pad, there is no risk
for the retractors, the lateral aspect of the hip joint is exposed
of injuring the short external rotators. Place a bone hook inside
through the direct anterior interval; the tensor fascia latae will
the femoral cavity and lift upward and laterally simultaneously
be located laterally to the exposure, and the rectus and sartorius
in order to ensure the greater trochanter is not behind the
will be located medially. This interval is truly intermuscular and
acetabulum. Place the femoral elevator dorsally to the greater
internerval; all the medial muscles are supplied by the femoral
trochanter, and be sure to push all attached muscles posteriorly.
nerve, and all the lateral muscles are supplied by the superior
Use a retractor in the calcar area placed proximally to the lesser
gluteal nerve.
trochanter to retract the medial soft tissue. Remove all remnants
of the dorsal lateral capsule at the femoral neck.
Anterior Capsulectomy
Start the capsulectomy with a cut laterally along the axis of the
Broaching of the Femoral Canal
femoral neck. Distally, be sure to remove the entire capsule, but
Always use the smallest broach available, and always use a dou-
do not cut into the lateral vastus, which will cause bleeding. Try
ble offset broach handle to broach the femoral canal. Using
to cut as far proximally as possible. This ventral capsular flap
minimal force, insert the broach handle by hand into the open
can be kept in place or completely removed. The inferior or
canal. When the broach is completely aligned with the femur,
medial retractor is then placed inside the capsule around the
impact it with the hammer. The double offset design of the
femoral neck.
broach handle eases introduction of the broach because it
reduces the need for elevating the proximal femur. The first
Double Osteotomy
broach can be used gently to further lateralize the subsequent
Typically, a double osteotomy is performed without dislocating
broaches. Trialing is done off the broach.
the hip joint. Use the saddle as a starting point for the second
osteotomy. Perform the first osteotomy 1 cm proximal to the
Implantation
first osteotomy. The order of the osteotomies can be reversed
The final femoral component should be inserted by hand into
based on surgeon preference. When removing the disk and
the space created by the broaches. Angulate a standard blunt
femoral head, be careful not to damage the surrounding mus-
impactor by 45 degrees and complete impaction of the stem.
culature on the sharp edges of the cut surfaces.
This technique will minimize the risk of medial calcar fracture.
MINI INCISION THA: ANTEROLATERAL APPROACH

William J. Hozack, MD
INDICATIONS the anterior soft tissues. The anterior and posterior borders of
Total hip arthroplasty (THA) is one of the most successful oper- the gluteus medius are then identified. The anterior third of the
ations performed in the era of modern medicine. The orthope- gluteus medius, the entire gluteus minimus, and the anterior
dic community must carefully and systematically evaluate in the half of the hip capsule are elevated as one flap. It is important
literature any changes made to a procedure with such a high to limit invasion of the vastus lateralis because this minimizes
SYMPOSIA AR HIP
success rate.Mini-incision THA requires careful patient selection bleeding, swelling, and pain. The flap is analogous to a curtain;
and education. The incidence of serious complications, such as one can elevate the soft tissue as a “curtain” to expose the
nerve injury, limb-length discrepancy, dislocation, and intraop- acetabulum and femur and then it can be repaired anatomical-
erative fracture, should not be greater than complication rates ly). This is accomplished with minimal trauma to the abductor
associated with the “traditional approaches.” The surgical tenets muscles. The capsule is incised in two locations; superiorly
of adequate exposure, minimal blood loss, and respect for the along the posterior border of the gluteus minimus tendon and
soft tissues must apply to mini-incision techniques as well. inferomedially just superior to the iliopsoas tendon. This tech-
nique of capsular incision rather than excision maximizes expo-
The surgeon must have realistic expectations regarding incision
sure while maintaining the integrity of the capsule for hip sta-
size relative to the patient’s body habitus and the surgeon’s abil-
bility, and allows the patient full, unrestricted activity immedi-
ity to attain adequate visualization for safe and proper compo-
ately after the surgery.
nent insertion. The patient must have realistic expectations of
physical change and must be counseled appropriately about the Acetabular retractors, specially designed to facilitate the mini-
risks and benefits of small incision surgery. incision approach, are placed in the following order: anterior,
superior, inferior, and posterior. A cobra retractor is used anteri-
The indications for mini-incision hip replacement are the same
orly, placed with the hip flexed to relax the anterior neurovascu-
as for traditional THA. The ideal patient will have a lower BMI
lar structures. The superior retractor is placed at the 10:00 o’clock
(<30) and relatively uncomplicated degenerative joint disease.
position (right hip) or 2:00 o’clock position (left hip). The supe-
This approach is not conducive to complicated primary THA
rior retractor has been modified for a small incision approach by
like that found with severe dysplasia or revision surgery. For
scaling down its size and adding a fiberoptic light. The initial
patients with a BMI exceeding 35, the surgical principles listed
inferior retractor is a double-angle device placed onto the ischi-
below are valid, but the incision will need to be larger. One of
um. This puts the pubofemoral ligament on stretch. This liga-
the most important contraindications is surgeon inexperience.
ment is then incised, taking care not to violate the iliopsoas ten-
The surgeon should try to gradually minimize the size of the
don. A double-footed retractor can replace the double-angle
incision using the most familiar approach. A radical change
retractor if acetabular visualization is suboptimal. The incision
from a traditional hip exposure to a minimally-invasive
can be extended distally to improve exposure. The labrum and
approach is fraught with potential complications and is a dis-
contents of the cotyloid fossa are resected. At this point, the
service to the patient.
entire periphery of the acetabulum should be visualized.
Technique Acetabular Exposure Before reaming, the surgeon should identify the anterior and
The patient is placed in the supine position, which provides sev- posterior walls and columns, medial wall, and the acetabular
eral advantages. Limb lengths are easily and accurately meas- notch. The pelvis must be level to the floor. Proper placement of
ured by simply palpating the malleoli without the use of exter- the acetabular retractors protects the skin from damage from the
nal devices. The acetabular component is positioned without reamers, regardless of incision size. Reaming should progress
concern for pelvic shift as is common with the lateral decubitus sequentially a hemisphere that is fully medialized with the infe-
position. Finally, the anatomic landmarks of the pelvis are easi- rior edge of the shell at the level of the teardrop. Do not ream
ly palpated to assist in component orientation. away walls or columns. The reamer heads may be disconnected
from the reamer shaft while in the acetabulum to facilitate
The length of the incision varies from 8 cm to 12 cm. The
extraction
length of the incision depends on surgical skill, patient weight,
local adipose thickness, muscle mass, stiffness, and anatomy.
Acetabular Bone Preparation/Prosthesis Implantation
The incision should extend from the anterior third of the tip of
The cup is generally under-reamed by 1 mm to obtain a press-
the greater trochanter to a point several centimeters distal along
fit. The component is then inserted under direct visualization.
the shaft of the femur. This incision should be centered so that
The pelvis is oriented parallel to the floor making component
it can be extended proximally for femoral exposure or distally
positioning easier. Excellent visualization of the acetabulum
for acetabular exposure.
facilitates proper cup orientation. A curved cup insertion device
The initial incision extends down to the level of the fascia. The is available for component insertion. Screws are generally not
fat is dissected from the fascia to ensure optimal visualization needed but may be used to improve initial fixation. At this point
for the fascial split. A “mobile window” is thus created that can the liner is inserted.
be shifted to maximize visualization. The length of the incision
must be sufficient to extract the femoral head. Femoral Exposure
The acetabular retractors are then removed and the limb adduct-
The most lateral aspect of the greater trochanter is then palpat-
ed and externally rotated. A double-footed retractor is placed
ed. The fascial incision should be just anterior to this landmark.
posterior to the femur. A second double-footed retractor is
The location of the split in the fascia is important to maximize
placed lateral to the femur. The retractors, if properly placed,
visualization of the acetabulum and allow for adequate expo-
will protect the soft tissues from injury during the reaming,
sure of the proximal femur . A Hibbs retractor is used to retract
broaching, and insertion process. Exposure can be improved by
89
releasing the posterior capsule from the posterior femur to rotated to facilitate repair. The gluteus maximus fascia and fas-
allow the limb greater adduction and to enhance proximal cia lata are repaired with the hip in external rotation. The skin is
femoral visualization . If the femoral exposure is still sub-opti- closed with absorbable suture and staples.
mal, the incision can be extended proximally. The entire cir-
cumference of the proximal femur must be seen to assess ver- POSTOPERATIVE REGIMEN
sion, axial stability, and rotational stability as well as to allow Patients are not required to use bracing, hip precautions, or pro-
early detection of fracture during femoral preparation and com- tected weight-bearing. Patients meeting appropriate criteria are
ponent insertion. encouraged to walk on the day of the procedure with the aid of
a physical therapist. The Foley catheter and all intravenous med-
Femoral Bone Preparation/Prosthesis Implantation ications and fluids are discontinued and the patient is encour-
SYMPOSIA AR HIP
The starter reamer is used to open the canal and the femur is aged to be out of bed as much as possible. Formal physical ther-
sequentially broached. The use of a single reamer to open the apy sessions are given twice daily. No intravenous pain medica-
canal limits potential damage to the abductors. The broach tion is used. Oral pain management consists of standardized
serves as a trial. A special head-neck insertion device is available acetaminophen, celebrex and Lyrica, with minimal need for oral
to make trial reduction easier. The hip is then tested for stabili- narcotic supplementation. The patient is discharged 2 or 3 days
ty, impingement, and limb-length, and the final component is postoperatively, depending on physical therapy goals. The
inserted. patient uses a walker on the first day postoperatively and is dis-
charged with crutches. Patients generally progress to a cane by 2
Wound Closure weeks after discharge.
The incision is closed in layers, with careful attention directed to
repair of the gluteus medius tendon . The hip can be internally
LESS INVASIVE THR: THE POSTEROLATERAL APPROACH

Thomas P. Sculco, MD
The phrase “minimally invasive surgery” when performing a hip and with adequate exposure to correctly and safely perform the
arthroplasty has always seemed like an misnomer in that hip procedure. These techniques require customized instrumenta-
replacement surgery requires considerable alteration of anato- tion to facilitate these exposures as well as significant arthro-
my regardless of the exposure or technique. The phrase has been plasty training. Hypotensive regional anesthesia reduces bleed-
captured by the media and marketing spheres and has led in ing and facilitates the procedure.
SYMPOSIA AR HIP
many instances to public misinformation and expectation. The
Less invasive total hip replacement requires proper patient selec-
term “less invasive” describes more accurately what these proce-
tion to lessen rate of complication and promote a successful
dures encompass. In many surgical disciplines these less inva-
arthroplasty. Since surgical windows are more limited to insure
sive procedures have been adopted and it was inevitable that
proper visualization patients who have Body Mass Index of less
these concepts would influence arthroplasty surgery. These
than 30 are ideal. This applies to both single and two incision
techniques now are being utilized in many different approach-
procedures although those utilizing two incision techniques
es to the hip and knee and embody less deep dissection as well
have stated body mass is not an issue in the approach.
as a more conservative skin incision. Performing hip and knee
Certainly as body weight and obesity increase more extensive
arthroplasty through less traumatic exposures is feasible but the
exposures will be necessary. Through single incision less inva-
surgeon must use good judgment and be expert in his ability to
sive procedures graduated increase in exposure may be per-
perform these arthroplasties expeditiously and without com-
formed and this is not the case with two incision approaches.
promising the quality of the arthroplasty. The surgeon interest-
As a rule less invasive surgery is not recommended in patients
ed in performing these arthroplasties through more limited
with BMI >35. Additionally patients with complex primary hip
exposures must be experienced in arthroplasty surgery.
pathology are best performed through more extensive
The concept of performing a total hip replacement utilizing a approaches. These include patients with high riding hip dislo-
smaller incision and a more limited soft tissue exposure sur- cation (Crowe 4), severe hip ankylosis with or without protru-
faced during a hip replacement about eight years ago. The pro- sion and patients with severe soft tissue scarring secondary to
cedure was being carried out through the conventional postero- extensive prior hip surgery. An additional group that may pose
lateral approach and the incision length was approximately 8-9 a problem with visualization and soft tissue retraction is the
inches in length. The PGY 4 resident assisting me at the proce- heavy, well muscled, short stature usually male patient. In these
dure queried why the incision was as long as it was and he patients, especially if the hip joint is stiff, exposure is difficult
remarked that the lower portion of the incision was not being and exposures should be extended. Patients undergoing revi-
used. Indeed this was the case and on the subsequent hip sion hip surgery also are not ideal candidates for these less inva-
arthroplasty the incision was reduced by one inch without sive approaches as failed implant removal, bone grafting and
undue struggle. This led to a progressive decrease in incision augmentation usually require additional visualization.
length and soft tissue release during hip replacement surgery.
The use of more limited exposures for total hip arthroplasty
Subsequently instrumentation has been developed to facilitate
through modified posterolateral and a two incision fluorscopi-
exposure and acetabular and femoral preparation and the
cally assisted approach have generated considerable interest. I
length of the skin incision has been reduced to 3-4 inches in
do believe the two incision technique should be reserved for
length. Proper patient selection, surgical experience and instru-
those surgeons with particular interest in the technique as
mentation and careful dissection have led to satisfactory results
reported results have been inferior with this approach and the
in over 2500 patients to date.
learning curve may be significant. Poor information released
The key surgical concept is that the result of the arthroplasty through the media has raised patient expectations and inaccu-
should not be compromised by the surgical incision and expo- rately portrayed these procedures. Additionally pressure has
sure. If during the procedure visualization is poor there is an come to bear on orthopedic surgeons to perform these proce-
increased risk of suboptimal implant positioning and intraop- dures who are less experienced in arthroplasty. More extensile
erative femoral fracture may occur. If excessive or undue tension exposures must be used whenever needed to improve the out-
is being applied to the soft tissues about the hip femoral or sci- come of the procedure. However, the advantages of these more
atic neuropraxia may occur and this complication must be limited procedures are real and include more rapid rehabilita-
avoided. When attempting to reduce the length of the surgical tion, less blood loss, better cosmesis and in our series there has
incision it is recommended that the surgeon gradually limit the not been an increase in complications or implant malposition.
incision length in increments of ½ - 1 inch until a level is
reached where hip arthroplasty progresses without difficulty
REFERENCES 2. Ogonda L, Wilson R, Archbold P, Lawlor M, Humprhreys P, O’Brien S,

1. Chimento, GF, Pavone V, Sharrock, N, Kahn, B, Cahill, J, Sculco, TP, J. Beverland, D. J Bone Joint Surg, 87, 701-10, 2005
Arthroplasty, 20:139-144, 2005 3. Sculco, TP, Jordan LC, Walter WL, Orthop. Clin North AM, 35, 137-142, 2004
4. Sculco, TP, J. Arthroplasty, 19:78-80, 2004.
91
COMBINED ANTEVERSION TECHNIQUE: FEMUR FIRST METHOD

Lawrence D. Dorr, MD
The use of cementless stems for THR introduces an important be accurately estimated. The precision estimate of the surgeon
factor besides fixation. can be as much as 12° to 16° from its true value. The stem is
between 10° to 20° anteversion only 40% of the time. 15% of
Anteversion the time it is 5° anteverted to 15° retroverted.
Anteversion of the stem is controlled by the femur bone more
SYMPOSIA AR HIP
Clearly, since femur anteversion is not repeatable, the femur

than the surgeon, whereas the surgeon hastotal control of antev-
should be prepared first so femoral anteversion can be estimat-
ersion of the cemented stem. The significance of loss of control
ed. The cup can then be anteverted the correct degrees to give a
of anteversion of the cementless stem is in its relationship to
combined anteversion of 30° to 45° (safe zone is 25° to 50°).
cup anteversion. With a cemented stem the anteversion of the
For example, if the femoral stem anteversion is 5° the cup antev-
stem is positioned at 15-20° to mate with a cup targeted to 20°
ersion should be near 30°; if stem anteversion is 25° the cup
anteversion so that the combined anteversion is 30° to 40°
anteversion should be 15°. The cup should not be targeted to a
(the recommended combined anteversion).
singular number. It is probable that dislocation has become the
With a cementless stem that will gain fixation in all types of #1 complication in total hip replacement surgery because the
bone (A,B,C) the anteversion of the stem is controlled by the stem anteversion is not repeatable. Computer navigation does
anteversion of the femur and the diaphyseal bow of the femur. provide quantitative knowledge of stem and cup anteversion.
The surgeon can visualize the anteversion of the neck of the
femur, but not the diaphyseal bow. Thus, the anteversion cannot
SURGICAL DISLOCATION AND OSTEOCHONDROPLASTY

Robert T. Trousdale, MD
I. Introduction III. Different Mechanism of Impingement as Described by

A. Most hip arthritis is secondary to mechanical abnormali- Ganz
ties ranging from instability (DDH) to impingement. A. “Cam” type
• Caused by femoral abnormalities where insufficient
Instability Normal Impingement
head-neck offsets cause damage as an increasing
SYMPOSIA AR HIP
radius is “jammed” into the acetabulum with flexion-
DDH Hip SCFE
internal rotation
Poor head-neck offset
• This leads to damage to cartilage and an outside-in
Torsional acetabular
labral avulsion
abnormalities
• Damage is typically at anterior-superior rim
Perthes
• Conditions associated with “cam” impingement:
Malunions
– SCFE
Coxa profunda
– poor head-neck offset
Etc.
– out of round femoral head
B. Concept of impingement recently popularized by the – Perthes
group from Berne and Zurich. Initially seen after poor – retroverted femoral neck (i.e. after femoral neck
positioning of acetabular fragment after acetabular reori- fracture)
entation for classic DDH. Some patients had↓hip ROM B. “Pincer” type
and pain with flexion, adduction, and internal rotation. • Caused by acetabular abnormalities which lead to
C. Implications acetabular over-coverage
• DDH leads to OA by mechanical overload (↓hip sur- • This leads to different damage than above. Labrum is
face area leads to↑contact pressures) first to fail and acetabular cartilage damage is a result
• Impingement leads to OA by damages to the acetabu- of direct impact and proceeds at a slower rate than
lar labrum and adjacent cartilage cam type.
• Conditions associated:
II. Diagnosis
– coxa profunda
A. History
– retroverted acetabulum
• Patients with impingement commonly complain of
– protrusio acetabula
activity-related groin pain
• Pain↑in positions of impingement (typically flexion, IV.Treatment
internal rotation, adduction) • In situations of endstage secondary DJD, THA is most
• Occasional mechanical symptoms will be present in reliable choice.
those with associated labral-cartilage problems • Young patients with some viable cartilage, joint salvage is
B. Diagnosis indicated.
1. Plain radiographs should include an orthograde AP • Treatments should be directed toward removing the
pelvis, AP hip, cross-table lateral pathologic elements that are creating the impingement.
2. Things to note: • Femoral abnormalities corrected by osteotomy or head-
• Version of socket neck offset by chondro-osteoplasty creating a satisfactory
• Presence of deep acetabulum had-neck offset. This can safely be done via anterior sur-
• Shape of femoral head gical dislocation. The acetabular-labral lesions can be
• “Herniation pits” at head-neck junction secondary debrided and/or repaired.
to impingement • Acetabular abnormalities should be corrected by
• Head-neck offset ratio on lateral radiograph “reverse” PAO in those with acetabular retroversion or
• Rim lesions secondary to impingement anterior acetabular debridement in those with satisfacto-
3. MRI with gadolinium - things to note: ry posterior coverage and a damaged anterior rim.
• Labral changes • Occasionally combinations of the above are indicated.
• Changes at femoral head-neck junction V. Conclusions
• Status of acetabular cartilage at site of impingement • In young patients with hip pain ± labral-rim lesions,
and opposite location (posterior-inferior acetabulum) look for structural problems ® instability (DDH) «
4. Lesions associated with impingement impingement
• Inner surface by labrum is ruptured • If viable articular cartilage remains, attempt to solve the
• Adjacent cartilage delaminated structural problem to as near normal as possible.
• Reactive bone changes on femoral neck and/or rim – DDH ® optimize hip mechanics with osteotomy
of acetabulum – Impingement ® relieve impingement by improving
structural problem that is present
93
THE YOUNG ADULT HIP: RESURFACING ARTHROPLASTY

Robert L. Barrack, MD
I. Preparation for Hip Resurfacing IV. Acetabular Preparation

A. Shortening the learning curve A. Circumferential exposure
1. Video 1. 2 Hohmans anteriorly, 1 post-inferior, 2 pin retractors
2. Scrub with experienced surgeon (posterior wall, ischium)
3. Cadaver surgery (with first assistant) 2. Excise labrum, transverse ligament
SYMPOSIA AR HIP
B. Patient selection – Avoid large patient, stiff hips, anatom- 3. Curette cotyloid notch
ic variants during learning curve B. Ream to base of notch, 1-2mm press-fit
C. Templating – Sizing, plan pin placement, note osteo- 1. Trials stands on their own
phytes – lateral view 2. Remove with moderate force
C. Remove osteophytes, no exposed metal anteriorly
II. Operative Approach – Posterior
D. Avoid vertical cup
A. Incision – Skin biased posteriorly, distally midline (avoid
gluteal sling), posterior proximally V. Femoral Preparation
B. Incise burse, identify and protect nerve early and A. Lateral pin placed relative to lesser troch
throughout case, particularly with retractor placement B. Insure circumferential clearance of neck, especially sup-
C. Release g. max tendon routinely (except mobile hips, lat, equidistant from ant and post neck
especially female) C. Vent pin in lesser troch prior to reaming
D. Separate minimus from capsule, iliac pin retractor D. Protect neck during cylindrical reaming
E. Posterior flap – Rotators, capsule, quadratus – Expose E. Lateral cartilage normally exposed after initial reaming
lesser troch, hemostatis during this stage F. Multiple cement anchor holes, curette and graft cysts,
lavage and dry thoroughly
III. Circumferential Capsulotomy
G. Avoid excessive impaction force
A. Under direct vision, under tension with electrocautery
H. Reduce under direct vision to avoid retained debris
B. Superior capsule – Hip flexed, internally rotated
I. Remove lateral guide pin
C. Inferior capsule – Hip extended, more neutral under trac-
J. Reassess hemostasis
tion
K. Close capsule and rotators
D. Expose anterior neck, remove osteophyte, size neck
REMOVING THE WELL-FIXED CEMENTLESS SOCKET

The most common indications for removal of a well fixed sock- When removing a well-fixed socket, the surgeon is often con-
et include socket malposition, polyethylene wear with or with- fronted with the problem of working around a well-fixed
out pelvic osteolysis and infection. The pre-operative planning femoral component sometimes with a non-modular head. In
processes begin with identification of the implant to be these cases, the femur must be mobilized and the extra-osseous
removed. This can often be done with radiographic review, but segment of the femoral component displaced out of the acetab-
SYMPOSIA AR HIP
sometimes requires obtaining the hospital records from the pre- ulum. Following exposure of the acetabulum, remove the
vious operation. It is helpful to distinguish between an acetabular liner. If the polyetheylene mechanism is difficult to
ongrowth surface such as a titanium plasma spray from a three- disengage, a 3.2 mm drill bit can be used to drill a hole through
dimensional ingrowth surface like titanium firbermesh or the polyethylene liner to the metal shell. If the metal shell has
cobalt chrome beads. The mechanical interlock that occurs with holes, take care not to drill through the liner into a screw or
a three-dimensional ingrowth surface makes the socket more polar hole and into the pelvis. Thread a 6.5 mm cancellous
difficult to remove and thus potentially pose a higher risk of screw into the drill hole. As it engages the metal shell, it will
iatrogenic fracture. By studying the preoperative radiographs, lever the liner out of the socket. All fixation screws should then
one can often determine where load transfer is taking place and be removed from the metal shell. Further define the implant
thus where the implant is likely to have the greatest degree of bone interface around the periphery of the socket by removing
osseointegration. remaining granuloma and capsular tissue. Use a high-speed
drill with a pencil tip burr to disrupt the implant bone interface
As part of identifying the socket preoperatively, it is also helpful
around the periphery of the socket. Using this instrument, the
to identify the locking mechanism for the polyethylene liner.
interface can be safely removed to a depth of 5 to 20 mm. The
Special tools may be available through the manufacturer to aid
high-speed drill with a pencil tip burr is less likely than an
in liner removal. Identification of the screws and more impor-
osteotome to fracture the margin of the acetabulum.
tantly the type of screw heads will ensure that the appropriate
screwdriver is available in surgery. The Explants System has revolutionized socket removal. This
system can then be used to remove an Osseo-integrated metal
A bone ingrown socket that is fixed to a thin medial wall repre-
shell with a minimum amount of bone loss. The system comes
sents a special challenge. It may be impossible to pass a space-
with thin sharp curved ostetomes in varying diameters in 2 mil-
occupying tool such as a curved osteotome between the implant
limeter increments. For each diameter, there is a short and long
and medial wall without fracturing the pelvis. In such cases, one
osteotome. Once the screws are removed, replace the acetabu-
can consider sectioning the socket and removing the socket
lar liner into the shell. Using the appropriate sized femoral
piecemeal. There are several commercially available high-speed
head begin by attaching the short osteotome that matches the
drills with metal cutting attachments that can be used to section
outside diameter of the socket to be removed. Use a mallet to
acetabular shells. Finally, at surgery, it is important to try and
engage the short osteotome disrupting the implant bone inter-
protect the posterior column and superior aspect or dome of the
face either superiorly or posteriorly where visualization is best.
acetabulum, as these structures are important for subsequent
Once the ostoeotome is fully seated, it can be rotated 360
socket fixation.
degrees disrupting the implant bone interface circumferentially.
At surgery, exposure of the entire acetabular component is Next use the long osteotome of the same diameter in a similar
important to optimize access to the implant bone interface. If fashion to complete the cup removal.
an extended trochanteric osteotomy is indicated, it may be help-
ful to perform the osteotomy prior to socket removal as it may
aid in exposure of the acetabulum. The posterolateral approach
provides the best visualization of the posterior column aiding in
bony assessment prior to implant removal.
95
REMOVING THE WELL-FIXED CEMENTLESS STEM

The most common indication for removal of an osseo-integrat- an extended trochanteric osteotomy. The osteotomy should be
ed cementless femoral component is infection. Less commonly, taken to a level just distal to the end of the porous coating. Start
well-fixed femoral components may require removal for mal- by making an episiotomy in the lateral femoral cortex along the
position (typically malrotation) and leg length inequality. line of the planned extended trochanteric osteotomy.
Again, the preoperative planning process begins with identifica- Occasionally, the episiotomy alone will allow the stem to be
SYMPOSIA AR HIP
tion of the implant to be removed. Knowing the extent and pat- extracted. If not, complete the extended trochanteric osteotomy
tern of the porous coating determines the area of the stem and use a gigli saw to disrupt the implant bone interface pos-
where bone can ongrow or ingrow. The radiographs often teromedially. Once that is done, the stem can usually be
reveal where the greatest area of bone ingrowth has occurred. removed with an extractor. If not, bone has remodelled around
Look for “spot welds” or bone densification which denotes load the non-porous stem distally. Use the pencil tip burr to remove
transfer and therefore bone ingrowth or bone ongrowth. endosteal bone just distal to the osteotomy. This will allow the
Typically, proximally coated stems tend to become fixed at the stem to be extacted.
metaphyseal-diaphyseal junction. For proximal coated stems,
In the case of a fully porous coated stem, an extended
note whether the distal stem design includes splines. Even
trochanteric osteotomy should be performed. Plan the level of
though the distal portion of a proximally coated stem is often
the osteotomy to extend distally to a point where the femoral
polished, bone can grow into the splines making it difficult to
component becomes cylindrical. Once the osteotomy has been
extract even when the osseo-inegrated region has been disrupt-
completed, use a gigli saw to disrupt the implant bone interface
ed. Similarly it is useful to note whether the distal stem design
on the un-osteomized segment proximally. Next use a metal
includes a clothespin feature. During insertion, the clothespin
cutting burr on a high-speed drill to transect the femoral com-
feature may close. It can be difficult to remove the component
ponent in the cylindrical portion of the stem. Ensure that you
if the clothespin is closed and bone remodeling has occurred
have several burrs available. The larger the diameter of the
around the distal aspect of the clothespin.
femoral component, the more metal cutting burrs required.
At surgery, it is important to mobilize the proximal femur to Once the stem has been transected, the proximal portion is
allow access to the mouth of the femur. Remove granuloma and removed. The trephine drills (DePuy, Warsaw, Indiana or
capsular tissue to expose the implant bone interface in the prox- Zimmer Warsaw Indiana) can then be used to drill over the
imal femur. Remove bone laterally into the greater trochanter to cylindrical portion of the stem. The trephines come in two
ensure as the stem is extracted the trochanter is not fractured. lengths. It is advisable to have a minimum of two for the antic-
ipated size as well as the size above and below the anticipated
For proximally coated stems, start by disrupting the implant
size.
bone interface with a pencil tipped burr on a high-speed drill.
Removing the guard on the pencil tip burr allows the burr to Fractured extensively porous coated femoral components are
extend further down the femoral canal disrupting the interface removed using a similar technique. Make an extended
in the metaphyseal region. Use of osteotomes for this task trochanteric osteotomy at or just distal to the level of the stem
increases the risk of fracture. Once the dissection has been done fracture and remove the proximal portion of the stem which
circumferentially, use a stem extractor and attempt to remove always loose. Remove the distal portion of the stem which is
the stem. If the stem cannot be extracted, the next step is to plan always ingrown using the trephines.
HIP SPACERS AND THE ANTIBIOTIC LOADED CEMENT PROSTHETIC

SPACER TECHNIQUE
Arlen D. Hanssen, MD
The Complex Infected THR reports of patients developing postoperative renal failure with
Infection is a devastating complication after total-hip arthro- an associated use of a high dose ALBC spacer, these reports are
SYMPOSIA AR HIP
plasty (THR). Treatment of these infections remains expensive, of elderly individuals and it is difficult to determine whether the
represents a difficult time course for the patient, and often renal failure was due to the ALBC or due to other perioperative
results in a suboptimal functional outcome. issues leading to this outcome. As a result, it should be remem-
bered that ALBC with aminoglycosides and/or vancomycin has
Various treatment techniques are available for more straightfor-
the potential for systemic toxicity and the use of these products
ward cases. The complex infected THR includes difficult vari-
should be with increased vigilance and prudent monitoring in
ables such as unusual or multiple organisms, bone loss, and
patients at increased risk for nephrotoxicity.
immunocompromise. These complex cases are best addressed
using a two-staged approach with high dose antibiotic-loaded Quickly while successfully eradicating infection in 96% of hips
bone cement during the interval between implant removal and with severe bone loss, and sets an appropriate soft tissue envi-
reimplantation. ronment for a relatively straightforward second stage procedure.
Although there are many reported methods of preformed or The prosthesis of antibiotic-loaded acrylic cement system
custom made antibiotic spacers, many of these spacers are suit- affords the benefits of two-stage exchange without the function-
ed for cases with minimal bone loss of the femur and acetabu- al disadvantages of an excision arthroplasty particularly when
lum. The prosthesis of antibiotic-loaded acrylic cement (antibi- the proximal femur is severely deficient. It allows flexibility for
otic loaded cement prosthetic spacer) approach is specifically the interval period and the type of fixation used, and the poten-
designed to addresses the many difficulties encountered during tial for allograft reconstruction at the final stage.
treatment of the complex hip case.
The antibiotic loaded cement prosthetic spaceR implant allows
The antibiotic loaded cement prosthetic spacer is a modular patients to have reasonable function and quality of life during
interval spacer system that allows reconstruction of even the the interim treatment for deep joint infection. Treatment of
most deficient bone stock safely and effectively using two-stage infection at the site of a hip arthroplasty with 2-stage revision
exchange arthroplasty. The interval prosthesis affords the using cementless components and an articulated spacer yields
patient pain relief and allows quicker mobilization for the recurrence rates similar to revisions where at least one of the
patient as they await reimplantation. components at the second stage is fixed with antibiotic-loaded
cement.
Use of High Dose Antibiotic Loaded Bone Cement (ALBC)
The use of an antibiotic-loaded spacer in the 2-stage treatment
It is helpful to differentiate the use of ALBC as a prophylaxis
of infected hip arthroplasties provides better infection control
method as compared with treatment of an established infec-
with good functional results and is superior to treatment in 2
tion.
stages without a spacer. Custom-made spacers had a greater
• Low dose ALBC (< or = 1 g per batch of cement) should be incidence of local complications (1 breakage, 1 dislocation, 1
used for prophylaxis sinking of the revision stem) as compared to pre-formed ones
(1 dislocation). Advantages of this technique include improved
• High-dose ALBC cement (> 1 g per batch of cement) is indi- patient function, maintenance of bone stock and soft tissue ten-
cated for treatment sion, thus simplifying reimplantation.
Use of commercially available ALBC products has been cleared The author’s recommended dose of antibiotic per 40g batch of
by the United States Food and Drug Administration only for use cement:
in the second stage of a two-stage total joint revision following
removal of the original prosthesis and elimination of active ALBC Spacers or Beads
periprosthetic infection. Commercially available ALBC products Minimum: 2g Vancomycin and 2.4 g Tobramycin or
are low dose, tobramycin or gentamicin, and are not indicated Gentamicin
nor appropriate to use for use as spacers in the presence of active Typical: 4g Vancomycin and 4.8 g Tobramycin or
infection. Rather, spacers should be fabricated to be high dose Gentamicin
ALBC products which requires hand mixing by the surgeon to
facilitate the use of high dosages and choices of multiple antibi- ALBC Prosthesis Fixation
otics. Typical: 1g Vancomycin and 1.2 g Tobramycin or
There is a significant increase in the elution of vancomycin Gentamicin
when the tobramycin dose is increased from 2.4 g to at least 3.6
g. On the basis of these results, the use of at least 3.6 g of Technical Tips
tobramycin and 1 g of vancomycin per package of bone-cement Mixing High Dose ALBC
is recommended when antibiotic-loaded cement spacers are
• Mix the polymethylmethacrylate monomer and powder
used in 2-stage exchange arthroplasty for infected THR.
together to form the liquid cement before adding the antibi-
Treatment of patients with an infected total knee arthroplasty otic powder. High volumes of antibiotic powder makes mix-
with high-dose vancomycin and gentamicin antibiotic spacers ing difficult if the powders are mixed together before intro-
seems to be clinically safe. Although there are several case ducing the liquid monomer
97
• Vancomycin powder is crystalline in nature and by leaving • The antibiotic loaded cement prosthetic spacer system is par-
the large crystals intact; the volume of antibiotic elution from ticularly helpful when a proximal femoral osteotomy has
the final composite is enhanced. One needs to remember been deemed necessary to remove the infected implant.
that when mixing vancomycin into cement being used for
prosthesis fixation that the crystals are completely pulverized • Use of the snap-fit acetabular liner is particularly helpful in
patients with proximal femoral bone loss and poor abduc-
as the crystal defects will significantly weaken the cement.
tors.
• Mixture of methylene blue dye into the cement is helpful as
the colored cement is easier to identify and remove • In patients with poor acetabular bone stock, a more aggres-
sive cement technique is recommended when using the
SYMPOSIA AR HIP
• Creating surface patterns with an increased surface area-to- snap-fit liner.

volume ratio show a significant increase in the antibiotic elu-
tion rate • At final insertion of the femoral antibiotic loaded cement
prosthetic spacer, use of additional high dose ALBC to pro-
vide fixation into and around the proximal femur is helpful
Using antibiotic loaded cement prosthetic spacer
for implant stability.
• When it is known that the spacer will be used for a given
patient, creating the spacer during setup time is helpful to
reduce overall operating room time
REFERENCES 8. Masri BA, Panagiotopoulos KP, Greidanus NV, Garbuz DS, Duncan CP.
1. Cabrita HB, Croci AT, de Camargo OP, de Lima AL. Prospective study of the Cementless two-stage exchange arthroplasty for infection after total hip arthro-
treatment of infected hip arthroplasties with or without the use of an antibiotic- plasty. J Arthroplasty. 2007 Jan;22(1):72-8.
loaded cement spacer. Clinics. 2007 Apr;62(2):99-108. 9. Patrick BN, Rivey MP, Allington DR. Acute renal failure associated with van-
2. D'Angelo F, Negri L, Zatti G, Grassi FA. Two-stage revision surgery to treat an comycin- and tobramycin-laden cement in total hip arthroplasty. Ann
infected hip implant. A comparison between a custom-made spacer and a pre- Pharmacother. 2006 Nov;40(11):2037-42.
formed one. Chir Organi Mov. 2005 Jul-Sep;90(3):271-9. 10. Pearle AD, Sculco TP. Technique for fabrication of an antibiotic-loaded cement
3. Haddad FS, Masri BA, Garbuz DS, Duncan CP. The treatment of the infected hip hemiarthroplasty (ANTILOCH) prosthesis for infected total hip arthroplasty. Am
replacement. The complex case. Clin Orthop Relat Res. 1999 Dec;(369):144-56. J Orthop. 2002 Jul;31(7):425-7.
4. Hanssen AD, Spangehl MJ. Practical applications of antibiotic-loaded bone 11. Penner MJ, Masri BA, Duncan CP. Elution characteristics of vancomycin and
cement for treatment of infected joint replacements. Clin Orthop Relat Res. 2004 tobramycin combined in acrylic bone-cement. J Arthroplasty. 1996
Oct;(427):79-85. Dec;11(8):939-44.
5. Hofmann AA, Goldberg TD, Tanner AM, Cook TM. Ten-year experience using an 12. Scharfenberger A, Clark M, Lavoie G, O'Connor G, Masson E, Beaupre LA.
articulating antibiotic cement hip spacer for the treatment of chronically infected Treatment of an infected total hip replacement with the ANTIBIOTIC LOADED
total hip. J Arthroplasty. 2005 Oct;20(7):874-9. CEMENT PROSTHETIC SPACER system. Part 2: Health-related quality of life and
function with the ANTIBIOTIC LOADED CEMENT PROSTHETIC SPACER
6. Jiranek WA, Hanssen AD, Greenwald AS. Antibiotic-loaded bone cement for implant in situ. Can J Surg. 2007 Feb;50(1):29-33.
infection prophylaxis in total joint replacement. J Bone Joint Surg Am. 2006
Nov;88(11):2487-500. 13. Springer BD, Lee GC, Osmon D, Haidukewych GJ, Hanssen AD, Jacofsky DJ.
Systemic safety of high-dose antibiotic-loaded cement spacers after resection of
7. Masri BA, Duncan CP, Beauchamp CP. Long-term elution of antibiotics from an infected total knee arthroplasty. Clin Orthop Relat Res. 2004 Oct;(427):47-51.
bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic
cement (ANTIBIOTIC LOADED CEMENT PROSTHETIC SPACER) system. J
Arthroplasty. 1998 Apr;13(3):331-8.
TREATMENT OF SEVERE ACETABULAR DEFICIENCY USING

MODULAR TRABECULAR METAL COMPONENTS AND AUGMENTS
Wayne G, Paprosky, MD, FACS
Introduction: Acetabular fixation in patients requiring revision with a tantalum augment for a Type III A or Type III B defect
total hip arthroplasty who have a non-supportive superior between January 2002 and December 2003 were followed
SYMPOSIA AR HIP
dome and proximal migration of the acetabular component annually with clinical and radiographic evaluations. As of the
(Paprosky Type III A defect) or who have a non-supportive ante- latest follow-up, one patient had died and one person was lost
rior and posterior column with proximal/medial migration of to follow-up. Twenty-four patients with an average age of 61 at
the acetabular component (Paprosky Type III B defect) cannot the time of the index surgery were evaluated at an average 1.9
be achieved reliably with the use of a hemispherical porous years post-op (range 1-3 years). 16 patients had a Type III A
coated component alone. Pelvic discontinuity is frequently acetabular defect while 8 patients had a Type III B acetabular
encountered in patients with severe acetabular bone loss. defect. Results: One acetabular component in a Type III A
Treatment of the discontinuity is dependent upon the remain- defect required revision due to aseptic loosening.
ing host bone, potential for healing of the discontinuity and Radiographically, all of the remaining components except one
potential for biologic ingrowth of acetabular components. If were stable and showed evidence of bone ingrowth. Harris hip
healing potential for the discontinuity does not exist, the dis- scores improved from an average of 34 pre-op to an average 94
continuity should be bridged and treated with distraction uti- at latest follow-up. Discussion: Acetabular revision in Type III A
lizing trabecular metal components with augments. Materials and Type III B defects utilizing tantalum acetabular components
and Methods: 26 patients who had an acetabular reconstruc- along with a tantalum augment show good results at short term
tion with the use of a tantalum acetabular component along follow-up.
99
ISSUES IN REVISION SURGERY: CANAL PREPARATION –

CYLINDRICAL STEMS
Robert L. Barrack, MD
I. Preoperative Planning 1. 7-8” straight stem – Straight reamers

A. Adequate X-rays 2. 8-10” bowed stem – Flexible reamers, trials often com-
SYMPOSIA AR HIP
1. Full extent of implant, cement, hardware bined with ETO

2. Include to isthmus and beyond 3. Press-fit - .5mm straight, 0-1mm overream for bowed
3. Lateral to evaluate bow of femur a. Use caliper on stem
B. Templating b. Insure stem is progressing
1. Engage 4-6cm of isthmus with shortest stem c. Method of extracting non-progressing stem
2. Lateral to distinguish 8” straight vs. 8” or 10” bowed B. Avoiding Fracture/Perforation
3. Straight stem rarely advisable > 8” 1. ETO when indicate, cable distal to ETO
2. Low threshold for exposing weak areas of isthmus
II. Surgical Technique
3. Low threshold for intraop X-rays
A. Obtaining Mechanical Stability
OSTEOLYSIS OF THE PELVIS: EVALUATION AND TREATMENT

Harry E. Rubash, MD
Osteolysis of the pelvis is a common and well recognized compromise placing another acetabular component. Recently, a new
plication associated with total hip arthroplasty. The diagnosis treatment strategy of retaining a well-fixed socket, exchanging
and treatment of osteolysis of the pelvis is a challenging and the liner, and grafting lesions has proven successful. Without the
controversial problem. Osteolysis of the pelvis often is asymp- removal of the acetabular shell, different techniques are needed
tomatic and does not present with symptoms until considerable to graft the osteolytic lesions. Osteolysis is a difficult problem;
SYMPOSIA AR HIP
bone loss and loosening of the acetabular socket occur. however, with radiographic surveillance to monitor patients for
Radiographs are the most common way to detect and monitor lesions, proper indications, and good surgical techniques, the
osteolysis around an implant. However, lesions viewed radi- treatment of osteolysis of the pelvis can result in a well-func-
ographically usually are underestimations of the lesions found tioning total hip arthroplasty.
intraoperatively. Moreover, some advocate computed tomogra-
phy scanning to evaluate these lesions. The indications for treat-
ment of osteolysis with cemented acetabular components are
defined more clearly than with a cementless component. If the
cemented or cementless acetabular component is loose, then
revision is necessary. However, it is less clear when to intervene
surgically with a well-fixed cup with osteolysis. Many early
reports advocated the removal of a well fixed socket during revi-
sion surgery for osteolysis and polyethylene wear. However, the
removal of a well-fixed socket has the potential for significant
damage and loss of the surrounding bone resulting in loss of
integrity of a column or pelvic discontinuity, which may com-
REFERENCES 16. Maloney WJ, Jasty M, Rosenberg A, Harris WH: Bone lysis in well-fixed cemented
1. Blaha JD:Well-fixed acetabular component retention or replacement: The whys femoral components. J Bone Joint Surg 72B:966–970, 1990.
and the wherefores. J Arthroplasty 17 (Suppl 1):157–161, 2002. 17. Maloney WJ, Paprosky W, Engh CA, Rubash H: Surgical treatment of pelvic oste-
2. Bobyn JD, Engh CA, Glassman AH: Radiography and histology of a threaded olysis. Clin Orthop 393:78–84, 2001.
acetabular implant: One case studied at two years. J Bone Joint Surg 70B:302– 18. Maloney WJ, Peters P, Engh CA, Chandler H: Severe osteolysis of the pelvis in
304, 1988. association with acetabular replacement without cement. J Bone Joint Surg
3. Burnett S, Martin EL, Paprosky WG: Surgical management of periprosthetic oste- 75A:1627–1635, 1993.
olysis after total hip arthroplasty: Classification and management of acetabular 19. Paprosky WG, Martin EL: Removal of well-fixed femoral and acetabular compo-
deficiency. Semin Arthroplasty 13:275–292, 2002. nents. Am J Orthop 31:476–478, 2002.
4. DeLee JG, Charnley J: Radiological demarcation of cemented sockets in total hip 20. Puri L, Wixson RL, Stern SH, et al: Use of helical computed tomography for the
replacement. Clin Orthop 121:20–32, 1976. assessment of acetabular osteolysis after total hip arthroplasty. J Bone Joint Surg
5. Engh CA, Griffin WL, Marx CL: Cementless acetabular components. J Bone Joint 84A:609–614, 2002.
Surg 72B:53–59, 1990. 21. Rubash HE, Sinha RK, Maloney WJ, Paprosky WG: Osteolysis: Surgical treatment.
6. Engh CA, Zettl-Schaffer KF, Kukita Y, et al: Histological and radiographic assess- Instr Course Lect 47: 321–329, 1998.
ment of well functioning porous-coated acetabular components: A human post- 22. Rubash HE, Sinha RK, Paprosky W, Engh CA, Maloney WJ: A new classification
mortem retrieval study. J Bone Joint Surg 75A: 814–824, 1993. system for the management of acetabular osteolysis after total hip arthroplasty.
7. Harris WH: Wear and periprosthetic osteolysis: The problem. Clin Orthop Instr Course Lect 48:37–42, 1999.
393:66–70, 2001. 23. Schmalzried TP, Brown IC, Amstutz HC, Engh CA, Harris WH: The role of
8. Harris WH, Schiller AL, Scholler JM, Freiberg RA, Scott R: Extensive localized acetabular component screw holes and/or screws in the development of pelvic
bone resorption in the femur following total hip replacement. J Bone Joint Surg osteolysis. Proc Inst Mech Engr 213:147–153, 1999.
58A:612–618, 1976. 24. Schmalzried TP, Fowble VA, Amstutz HC: The fate of pelvic osteolysis after reop-
9. Hozack WJ, Mesa JJ, Carey C, Rothman RH: Relationship between polyethylene eration: No recurrence with lesional treatment. Clin Orthop 350:128–137, 1998.
wear, pelvic osteolysis, and clinical symptomatology in patients with cementless 25. Schmalzried TP, Guttmann D, Grecula M, Amstutz HC: The relationship between
acetabular components: A framework for decision making. J Arthroplasty the design, position, and articular wear of acetabular components inserted with-
11:769–772, 1996. out cement and the development of pelvic osteolysis. J Bone Joint Surg 76A:677–
10. Jacobs JJ, Roebuck KA, Archibeck M, Hallab NJ, Glant TT: Osteolysis: Basic sci- 688, 1994.
ence. Clin Orthop 393:71–77, 2001. 26. Schmalzried TP, Jasty M, Harris WH: Periprosthetic bone loss in total hip arthro-
11. Jasty MJ, Floyd WE, Schiller AL, Goldring SR, Harris WH: Localized osteolysis in plasty: Polyethylene wear debris and the concept of the effective joint space. J
stable, non-septic total hip replacement. J Bone Joint Surg 68A:912–919, 1986. Bone Joint Surg 74A:849–863, 1992.
12. Kavanagh BF, Callaghan JJ, Leggon R, Heekin RD, Wold L: Pelvic osteolysis asso- 27. Sinha RK, Shanbhag AS, Maloney WJ, Hasselman CT, Rubash HE: Osteolysis:
ciated with an uncemented acetabular component in total hip arthroplasty. Cause and effect. Instr Course Lect 47:307–320, 1998.
Othopedics 19:159–163, 1996. 28. Southwell DG, Bechtold JE, Lew WD, Schmidt AH: Improving the detection of acetab-
13. Mallory TH, Lombardi Jr AV, Fada RA, et al: Noncemented acetabular compo- ular osteolysis using oblique radiographs. J Bone Joint Surg 81B: 289–295, 1999.
nent removal in the presence of osteolysis: The affirmative. Clin Orthop 29. Stulberg SD, Wixson RL, Adams AD, Hendrix RW,Bernfield JB: Monitoring pelvic
381:120–128, 2000. osteolysis following total hip replacement surgery: An algorithm for surveillance.
14. Maloney WJ: The revision acetabulum: Dealing with bone loss: Socket retention: J Bone Joint Surg 84A (Suppl):116–122, 2002.
Staying in place. Orthopedics 23:965–966, 2000. 30. Willert HG, Semlitsch M: Reactions of the articular capsule to wear products of
15. Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA: Treatment of pelvic arthificial joint prostheses. J Biomed Mater Res 11:157–164, 1977.
osteolysis associated with a stable acetabular component inserted without cement 31. Zicat B, Engh CA, Gokcen E: Patterns of osteolysis around total hip components
as part of a total hip replacement. J Bone Joint Surg 79A:1628–1634, 1997. inserted with and without cement. J Bone Joint Surg 77A:432–439, 1995.
101
SOCKET PREPARATION FOR REVISION ACETABULAR

REPLACEMENTS
Acetabular revision remains challenging due to the variable AAOS

degrees of bone deficiency and quality of remaining bone fol- Type I: Segmental Deficiencies
SYMPOSIA AR HIP
lowing implant failure or removal. The cornerstones of success- Peripheral (superior, anterior, posterior)
ful acetabular revision are accurate assessment and knowledge Central (medial)
of the patterns of bone deficiency combined with familiarity Type II: Cavitary Deficiencies
and facility of the appropriate methods of acetabular recon- Peripheral (superior, anterior, posterior)
Central (medial)
struction. The vast majority (>90-95%) of acetabular revisions
Type III: Combined Deficiencies
can be performed successfully with an uncemented hemispher- Type IV: Pelvic Discontinuity
ical implant. Type V: Arthrodesis
Indications for acetabular revision: Surgical Exposure

• aseptic loosening • Exposure of entire acetabular rim
• acetabular malposition (instability) • Origins of ischium, ilium, and pubis
• lysis (particle wear or infection) • Access to anterior/posterior columns
• miscellaneous (psoas impingement) • Rim examined for segmental loss
• Location and severity of cavitary lesions
Characteristics of acetabular bone deficiency:
• Integrity of anterior/posterior columns
• severity of bone loss
• Overall assessment to mechanically support cup and
• location of bone loss
provide host bone apposition
• quality and vascularity of remaining bone stock
Technical Tips
Goals of acetabular reconstruction:
• establish component fixation Reaming
• restore center of rotation for optimal joint mechanics and • Simple spherical reaming of remaining bone in the acetabu-
stability lum to accommodate a hemisphere cup graft is possible in
• reconstitution of bone stock 90-95% of revision situations.
• Reaming should be directed inferiorly to avoid unnecessary
Acetabular revision situations:
superior migration.
• standard hemispherical cup in normal hip position
• Some additional bone loss during reaming is required to
• high nonanatomic cup, jumbo cup
obtain good apposition.
• bone loss requiring structural support for cup
• Cup design and bone quality dictates whether reaming is
Requirements of success fixation: line to line or not.
• initial rigid mechanical fixation • Reamer sizing is limited by the AP dimension of native
• sufficient apposition of vascular host bone to ingrowth sur- socket.
face • Reverse reaming helpful in presence of poor bone quality to
• optimal ingrowth surface (2d vs 3d) avoid reamer protrusion or migration.
Potential risk factors for failure:
Cup Stability
• prior irradiation
• Cup stability may be tested by insertion of trial to assess
• pelvic discontinuity
whether the cup is stable to manual testing in the AP and
Bone Defect Classifications superior-inferior planes.
PAPROSKY • Implants with high coefficient of friction can improve ini-
Defect Migration Kohler’s Ischial Teardrop tial insertion stability
(cm) Line Lysis Lysis • Initial mechanical fixation is enhanced by multiple well-
I none intact none none fixed screws.
IIA <3 intact mild mild • The % of bone required for apposition depends on fixation
IIB <3 intact mild moderate achieved and likely success of ingrowth surface being used.
IIC <3 violated moderate moderate • Cup fixation with multiple screws rarely requires supple-
IIIA >3 intact moderate moderate
mental bone graft if >50% of host bone is apposed to the
IIIB >3 violated severe severe
cup surface.
Special Considerations
• High hip centers are reserved for situations with a deficient
inferior posterior column but adequate support is present • Restore bone stock with cancellous bone when possible
superiorly (carefully assess for impingement to avoid hip • Consider use of cups that allow ability to insert multiple
instability). screws in divergent directions to remaining bone stock
• Be careful to leave enough bone stock when performing • If necessary, ensure support of cup either graft, augments, or
jumbo cups to avoid delayed acetabular fracture. fixation flanges
SYMPOSIA AR HIP
REFERENCES 12. Jones CP, Lachiewicz PF. Factors influencing the longer-term survival of unce-
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2. Berry DJ, Lewallen DG, Hanssen AD, Cabanela ME. Pelvic discontinuity in revi- 13. Lie SA, Hallan G, Furnes O, Havelin LI, Engesaeter LB. Isolated acetabular liner
sion total hip arthroplasty. J Bone Joint Surg 1999 81-A:1692-1702 exchange compared with complete acetabular component revision in revision of
primary uncemented acetabular components: a study of 1649 revisions from the
3. Bozic KJ, Freiberg AA, Harris WH. The high hip center. Clin Orthop. 2004 Norwegian Arthroplasty Register. J Bone Joint Surg Br. 2007 89(5):591-4
(420):101-5.
14. Maloney WJ, Wadey VM. Management of acetabular bone loss. Instr Course Lect.
4. Campbell DG, Garbuz DS, Masri BA, Duncan CP. Reliability of acetabular bone 2006;55:279-85.
defect classification systems in revision total hip arthroplasty. J Arthroplasty. 2001
16(1):83-6. 15. Mitchell PA, Masri BA, Garbuz DS, et al Removal of well-fixed, cementless,
acetabular components in revision hip arthroplasty. J Bone Joint Surg Br. 2003
5. Della Valle CJ, Berger RA, Rosenberg AG, Galante JO. Cementless acetabular Sep;85(7):949-52.
reconstruction in revision total hip arthroplasty. Clin Orthop. 2004 (420):96-
100. 16. Nehme A, Lewallen DG, Hanssen AD. Modular porous metal augments for treat-
ment of severe acetabular bone loss during revision hip arthroplasty. Clin
6. D’Antonio JA, Capello WN, Borden LS, et al Classification and management of Orthop Relat Res. 2004 Dec;(429):201-8.
acetabular abnormalities in total hip arthroplasty. Clin Orthop 1989 243:126-
137 17. O'Brien DA, Rorabeck CH. Managing bone loss in revision total hip arthroplasty:
the acetabulum. Instr Course Lect. 2006;55:263-77.
7. Garcia-Cimbrelo E, Tapia M, Martin-Hervas C. Multislice computed tomography
for evaluating acetabular defects in revision THA. Clin Orthop Relat Res. 2007 18. Paprosky WG, Burnett RS. Assessment and classification of bone stock deficiency
463:138-43 in revision total hip arthroplasty. Am J Orthop. 2002 Aug;31(8):459-64.
8. Gozzard C, Blom A, Taylor A, Smith E, Learmonth I. A comparison of the relia- 19. Paprosky WG, O'Rourke M, Sporer SM. The treatment of acetabular bone defects
bility and validity of bone stock loss classification systems used for revision hip with an associated pelvic discontinuity. Clin Orthop Relat Res. 2005
surgery. J Arthroplasty. 2003 Aug;18(5):638-42. Dec;441:216-20.
9. Hadjari MH, Hollis JM, Hofmann OE, et al Initial stability of porous coated 20. Springer BD, Berry DJ, Cabanela ME, Hanssen AD, Lewallen DG. Early postoper-
acetabular implants. The effect of screw placement, screw tightness, defect type, ative transverse pelvic fracture: a new complication related to revision arthroplas-
and oversize implants. Clin Orthop 1994 307:117-123 ty with an uncemented cup. J Bone Joint Surg Am. 2005 87(12):2626-31.
10. Hansen E, Ries MD. Revision total hip arthroplasty for large medial (protrusio) 21. Weeden SH, Paprosky WG. Porous-ingrowth revision acetabular implants
defects with a rim-fit cementless acetabular component. J Arthroplasty. 2006 secured with peripheral screws. A minimum twelve-year follow-up. J Bone Joint
Jan;21(1):72-9. Surg Am. 2006 Jun;88(6):1266-71.
11. Herrera A, Martínez AA, Cuenca J, Canales V. Management of types III and IV
acetabular deficiencies with the longitudinal oblong revision cup. J Arthroplasty.
2006 Sep;21(6):857-64.
103
◆THE YOUNG PATIENT WITH HIP PAIN:

NONSURGICAL MANAGEMENT TO
SYMPOSIA AR HIP
ARTHROPLASTY: A WORLDWIDE
PERSPECTIVE (Y)
Moderator: Robert T. Trousdale, MD, Rochester, MN
This symposium will focus on treatment (nonoperative, joint salvage, and arthroplasty) of
the young patient with hip pathology.
I Who Gets Surgery and Who Doesn’t

Robert T. Trousdale, MD, Rochester, MN
II. Evaluation and Surgical Decision Making

Paul E. Beaule, MD, Ottowa, ON, Canada
III. What Causes Impingement

Michael Leunig, MD, Zurich, Switzerland
IV. Anatomy of DDH

Joel M. Matta, MD, Santa Monica, CA
V. Surgical Treatment of Impingement Scope

J.W. Thomas Byrd, MD, Nashville, TN
VI. Mini-Open
John C. Clohisy, MD, St. Louis, MO
VII. Open
Michael B. Millis, MD, Boston, MA
VIII. PAO versus Rim Trimming

Klaus Siebenrock, MD, Bern, Switzerland
IX. PAO for DDH: Technique, Results, Complications

Reinhold Ganz, MD, Zurich, Switzerland
X. Who Gets Resurfacing: Technical Tips, Results, Complications

Thomas P. Schmalzried, MD, Los Angeles, CA
XI. How I Choose my Bearing Surface for Young Active Patients

Mark Pagnano, MD, Rochester, MN
XII. Discussion
EVALUATION & SURGICAL DECISION MAKING

Paul E. Beaulé, MD
Treating the adult with hip pain is becoming more challenging arthroscopy/labral débridement maybe indicated.
because of the younger age at which patients are presenting with C) Femoroacetabular Impingement:
symptoms and the increasing number of surgical options avail- • Plain Radiography (AP & Dunn View)
able. Patients’ expectations following surgery also are a consid- • MR with Radial Reformats
eration: they now expect faster recovery times and to be able to • Cam type more common in Males
SYMPOSIA AR HIP
participate in recreational activities more quickly. — Treatment: surgical dislocation Gold Standard with
limited Anterior Hip Arthrotomy option for small
We now offer patients solutions that not only permit them to
lesions & preferable in females3
fully return to their activities but also may actually prevent or
• Pincer type more common in Females
significantly delay the onset of degenerative arthritis. However,
— Treatment can be a Peri acetabular Osteotomy or
making the correct diagnosis of the principal underlying pathol-
Acetabular Rim trimming w/labral refixation
ogy (eg, isolated labral tear, dysplasia, and impingement) can
D) Mixed Deformities:
sometimes be difficult with patients often presenting with a
• In Dysplasia, 1 in 6 will have a retroverted socket4 & >
mixed deformity of impingement and dysplasia. In addition,
50% will have an insufficient head neck offset
indications for surgical procedures such as hip arthroscopy,
Both deformities need to be addressed.
which are appealing compared to open hip surgery, are still
• In FAI, >70% of cases will have both pincer and CAM.5
being refined1. Treating advanced osteoarthritis of the hip also
Controversy exists as to the need once the CAM is treated
can be overwhelming, given the wide variety of implant designs
to treat the pincer (retroverted socket) in every case
and bearing combinations.
DECIDING ON THE OPTIMAL MANAGEMENT OF THE
EVALUATION OF THE PRE ARTHRITIC HIP PAIN: ARTHRITIC HIP
The vast majority of patients will present with an insidious In recent years, there has been a focus by industry and academia
onset of hip pain with no history of major trauma or childhood in the usage of alternative bearing surfaces for the treatment of
problems. The pain will be referred to the groin area. The phys- the young and active adult in order to minimize wear related
ical examination will reveal a relatively supple range of motion. failures as well as the development of osteolysis6. The renewed
Commonly patients will have a positive impingement sign interest in the clinically proven low wear of the metal-on-metal
indicative of labral pathology. In patients with femoroacetabu- bearing7,8 combined with the capacity of inserting a thin wall
lar impingement, internal rotation in 90 degrees of flexion will cementless acetabular component9, has fostered the reintroduc-
be less than 20 degrees. tion of hip resurfacing. As in other forms of conservative hip
surgery10,11,12, patient selection will help minimize complica-
A) Isolated Labral Tear:
tions13 and the need for early reoperation.
• Occurs in 10-15% of cases.
• Plain Radiographs (AP & Dunn View) to r/o bony dys-
morphism
• MRI w/ Gadolinium Arthrography of the hip is GOLD
STANDARD for diagnosis
• Hip Arthroscopy w/ labral débridement most appropri-
ate treatment
B) Dysplasia: -More Common in Females
• Center edge angle less than 16 degrees high risk of OA2
• Peri Acetabular Osteotomy optimal management
• In females older than 40 and mild dysplasia hip
REFERENCES 8. Brodner W, Bitzan P, Meisinger V, Kaider A, Gottsauner-Wolf F, Kotz R. Serum

Cobalt Levels after metal-on-metal total hip arthroplasty. J Bone Joint Surg.
1. Beaule PE, Clohisy JC, Schoenecker PE, Kim Y-J, Millis M, Trousdale RT. Hip
2003;85A:2168-73.
arthroscopy: an emerging gold standard. Arthroscopy 2007;23:682.
9. Beaule PE. Surface Arthroplasty of the Hip: A Review and Current Indications.
2. Murphy SB, Ganz R, Muller ME. The prognosis in untreated dysplasia of the hip.
Semin Arthroplasty 2005;16:70-76.
A study of radiographic factors that predict the outcome. J.Bone Joint Surg.
1995;77A:985-89. 10. Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL. Periacetabular and
intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips.
3. BEAULE,P.E.; ZARAGOZA,E.J.; DOREY,F.J.; and LE DUFF,M.J.: Femoroacetabular
J.Bone Joint Surg.Am. 1995;77:73-85.
Impingement of the Hip: Diagnosis, Surgical Management and Clinical Results.
68th Annual meeting of the AAOS, Scientific Exhibit: 2005.(Abstract) 11. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior
Femoroacetabular Impingement. Part II. Midterm Results of surgical treatment.
4. Li R, Ganz R. The morphology of congenital acetabular dysplasia. One in six is
Clin.Orthop. 2004;418:67-73.
retroverted. Clin.Orthop.Rel.Res. 2002;in press.
12. Murphy SB, Tannast M, Kim Y-J, Buly RL, Millis MB. Debridement of the adult
5. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of
hip for Femoroacetabular Impingement. Indications and preliminary clinical
damage to the acetabular cartilage: femoroacetabular impingement as a cause of
results. Clin.Orthop. 2004;429:178-81.
early osteoarthritis of the hip. J Bone Joint Surg. 2005;87B:1012-18.
13. Beaule PE, Dorey FJ, LeDuff MJ, Gruen T, Amstutz HC. Risk factors affecting out-
6. Sochart DH. Relationship of acetabular wear to osteolysis and loosening in total
come of metal on metal surface arthroplasty of the hip. Clin.Orthop.
hip arthroplasty. Clin.Orthop.Rel.Res. 1999;363:135-50.
2004;418:87-93.
7. Sieber H-P, Rieker CB, Kottig P. Analysis of 118 second-generation metal-on-
metal retrieved hip implants. J.Bone and Joint Surg. 1999;81B:46-50.
105
WHAT CAUSES IMPINGEMENT?

Michael Leunig, MD
The etiology of osteoarthritis of the hip has long been consid- between head and neck and produces an outside-in delamina-
ered secondary (eg, to congenital or developmental deformi- tion of the acetabulum. Pincer-type femoroacetabular impinge-
ties) or primary (presuming some underlying abnormality of ment, more prevalent in middle-aged women, is produced by a
articular cartilage). Recent information supports a hypothesis more linear impact between a local (retroversion of the acetab-
that so-called primary osteoarthritis is also secondary to subtle ulum) or general overcoverage (coxa profunda/protrusio) of the
SYMPOSIA AR HIP
developmental abnormalities and the mechanism in these cases acetabulum. The damage pattern is more restricted to the rim
is femoroacetabular impingement rather than excessive contact and the process of joint degeneration is slower. Most hips, how-
stress. The most frequent location for femoroacetabular ever, show a mixed femoroacetabular impingement pattern
impingement is the anterosuperior rim area and the most criti- with cam predominance. Supraphysiological joint loads
cal motion is internal rotation of the hip in 90° flexion. Two (hypermobility and impact) aggravate potential joint damage.
types of femoroacetabular impingement have been identified. Surgical attempts to restore normal anatomy to avoid femoroac-
Cam-type femoroacetabular impingement, more prevalent in etabular impingement should be performed in the early stage
young male patients, is caused by an offset pathomorphology before major cartilage damage is present.
TECHNICAL TIPS AND INNOVATION FOR

TOTAL KNEE ARTHROPLASTY (C)
SYMPOSIA AR KNEE
Co-moderators: William L. Healy, MD, Burlington, MA and Michael A. Kelly, MD, Hackensack, NJ
Total knee arthroplasty predictably relieves pain and improves function for patients with
painful arthritic knees. Technology and innovation have been developed to improve
surgical techniques and patient outcome. This symposium will present technical tips and
innovations for total knee arthroplasty.
I. Correcting/Balancing the Varus Knee

Richard D. Scott, MD
II. Correcting/Balancing the Valgus Knee

III. Patello-femoral Balancing

William L. Healy, MD, Burlington, MA
IV. M.I.S. – TKA in 2008

Aaron G. Rosenberg, MD, Chicago, IL
V. Computer Assisted Navigation

Douglas A. Dennis, MD, Denver, CO
Discussion
VI. Bearing Surface Selection

Michael D. Ries, MD, San Francisco, CA
VII. All Polyethylene Tibial Implants

Terence I. Gioe, MD, Apple Valley, MD
VIII. Mobile Bearing Utilization

Thomas K. Fehring, MD, Charlotte, NC
Discussion
IX. Venous Thrombo-Embolic Prophylaxis

Paul F. Lachiewicz, MD, Chapel Hill, NC
X. Peri-Operative Pain Protocol

Mark W. Pagnano, MD, Rochester, MN
XI. PMMA Spacer Design

Michael A. Kelly, MD, Hackensack, NJ
XII. Porous Metal Implants/Augments

Arlen D. Hanssen, MD, Rochester, MN
XIII. Operating Room Efficiency for TKA

Robert E. Booth, Jr., MD, Philadelphia, PA
Discussion
107
TOTAL KNEE REPLACEMENT IN SEVERE VARUS DEFORMITY

Richard D. Scott, MD
SYMPOSIA AR KNEE
SYMPOSIA AR KNEE
109
SYMPOSIA AR KNEE
SYMPOSIA AR KNEE
111
CORRECTING/BALANCING THE VALGUS KNEE

Daniel J. Berry, MD
I. Introduction: maintains lateral sided stability in flexion (if possible keep

The problems include contracted lateral soft tissue sleeve, the popliteus—a dynamic stabilizer in flexion). Use added
stretched medial soft tissue sleeve, and shortened peroneal constraint when needed, but not indiscriminately.
nerve.
SYMPOSIA AR KNEE
V. Principles of Insall’s Multiple Perforation Method:

II. General Principles of Treatment: Gradual, selective release of tight structures. Structures are
Restore correct limb alignment. Lengthen lateral soft tissue allowed to stretch by partial rather than full release of each
sleeve to equal medial soft tissue sleeve in flexion and exten- structure. Key stabilizers of knee in flexion (popliteus) is
sion. Use extra constraint if needed to provide internal splint maintained. Iterative process: gradual release achieved as
that protects ligaments. Protect the peroneal nerve. soft tissues stretch (similar to percutaneous teno-achilles
lengthening)
III. Pitfalls:
Under release of lateral side may lead to residual valgus. VI. Technique:
Over release of lateral side leads to instability and especially Tension lateral side with lamina spreads. Multiple perfora-
posterior knee dislocation in figure 4 position. Peroneal neu- tions in IT band at different levels: 15 blade. Trial—stretch
ropathy. out tissues. If still tight, gentle release of LCL with tip of
Bovie or #15 blade but don’t over do it, do it sequentially.
IV. Avoiding Pitfalls: Stretches out gradually with trial implants in place. Use cau-
Pay careful attention to optimal alignment with full length tion to avoid peroneal nerve damage. Repeat process until
standing films preop. Optimal release technique (see below) the knee is balanced. SAVE THE POPLITEUS.
REFERENCES 3. Mihalko WM; Krackow KA: Anatomic and biomechanical aspects of pie crusting
1. Clarke HD. Schwartz JB. Math KR. Scuderi GR: Anatomic risk of peroneal nerve posterolateral structures for valgus deformity correction in total knee arthroplas-
injury with the "pie crust" technique for valgus release in total knee arthroplasty. ty: a cadaveric study. J Arthroplasty 15: 347, 2000.
J Arthroplasty. 19(1):40-4, 2004 Jan. 4. Miyasaka KC, Ranawat CS, Mullaji A: 10- to 20-year follow-up of total knee
2. Insall JN, Easley ME: Surgical techniques and instrumentation in total knee arthroplasty for valgus deformities. Clin Orthop 345:29, 1997.
arthroplasty. p. 1553. In Insall JN. Scott WN, (eds): Surgery of the knee. 5. Scuderi GR, Insall JN: Fixed varus and valgus deformities. p. 111. In Lotke PS,
Churchill Livingstone, Philadelphia, 2001. (ed): Knee Arthroplasty. Raven Press Ltd., New York, 1995.
PATELLO-FEMORAL BALANCING
The goals of total knee arthroplasty include correction of defor- flexion and extension gaps and balanced medial and lateral gaps
mity, limb realignment, resurfacing of articular surfaces, and bal- in both flexion and extension. Patello-femoral instability is less
ancing of soft tissue stabilizers to produce a stable, mobile, pain- common in newer knee implant designs with right and left
free knee joint. In 2008, most knee replacement operations will femoral implants, valgus orientation of femoral trochlea groove,
SYMPOSIA AR KNEE
include patello-femoral resurfacing due to inconsistent patient deeper trochlea groove, and oval-dome patella implants.
outcomes when the patello-femoral joint is not resurfaced.
Patello-Femoral Reconstruction
Patello-femoral joint problems are the most common compli-
Patella reconstruction begins with a symmetric patellar osteoto-
cations during the first five years following total knee arthro-
my which leaves equal thickness of medial, lateral, superior, and
plasty.1 Unresurfaced patellas can be associated with anterior
inferior bony patella. Anatomic guides for the bony resection
knee pain. Specific problems associated with patello-femoral
include the quadriceps tendon insertion proximally, the “patel-
joint resurfacing include: patello-femoral maltracking and insta-
la nose” insertion of the patella ligament distally,2 and the sub-
bility, patella fracture, patella implant wear, patella implant
chondral bone of the lateral patella facet laterally. The osteoto-
loosening and dissociation, patellar osteonecrosis, patella
my should leave a bony patella between ten and fifteen mil-
clunk, and extensor mechanism disruption.
limeters thick. The goal of patella replacement is to replace
The goal of this talk is to review surgical techniques associated resected bone with prosthetic implant—some authors recom-
with achieving a balanced, stable patello-femoral reconstruction mend millimeter for millimeter replacement. Over-resection of
during a total knee arthroplasty operation. the patella to create a thin bony patella and an undersized bone-
implant composite can be associated with quadriceps discom-
Patient Factors fort and weakness. Under-resection of the patella to leave a thick
Preoperatively, surgeons should identify patients who have bony patella and an oversized bone-implant composite can be
higher than usual risk for patello-femoral complications: isolat- associated with overstuffing of the patello-femoral joint.
ed patello-femoral osteoarthritis, obesity, valgus deformity, Asymmetrical cuts of the patella can be associated with patella
patella baja, thin dysplastic osteopenic patella, prior tibial instability in the femoral trochlea and sub-optimal patient out-
osteotomy, chronic patella dislocation, and post-traumatic comes at midterm follow up.3 Medial positioning of the patella
arthritis. Surgeons can identify these patient factors with histo- implant on the bony patella with maximum coverage of the
ry, physical examination and appropriate imaging. Long stand- bony patella can improve patello-femoral balance and stability
ing x-rays including hip, knee, and ankle allow measurement of by moving the high point of the patella slightly medial. When
the mechanical axis and the tibio-femoral axis. Anteroposterior an oval shaped patella implant is used, the surgeon must ensure
weight bearing views of both knees allow determinations of the that the oval orientation is appropriate.
tibio-femoral joint line, the position of the anterior tibia tuber-
cle, and the integrity of the lateral femoral condyle. Hypoplasia Patello-Femoral Balancing
of the lateral femoral condyle associated with valgus deformity After the tibio-femoral and patello-femoral reconstruction is
and lateral displacement of the anterior tibial tubercle can pre- complete, the stability, tracking, and balance of the patello-
dispose to lateral patella subluxation. Tangential (Merchant femoral articulation are evaluated throughout a complete range
view) view of the patello-femoral joint demonstrates the posi- of motion with the “rule of no thumb” test,4 the “towel clip”
tion of the patella within the trochlear groove. This view allows test,5 and/or the “one stitch” test.6 In the “rule of no thumb”
evaluation of the bony patella and assessment of patella tilt and test, the knee is passively flexed and extended throughout a
tracking of the patella in the femoral trochlea. Lateral view of range of motion with no force applied to the extensor mecha-
the knee can demonstrate patella baja which is associated with nism. Specifically, the surgeons thumb is not used to hold the
difficult exposure of the knee. patella in the femoral trochlear groove through the range of
motion. The balance and stability of the patello-femoral joint is
Patello-Femoral Instability evaluated. The patella should not tilt or subluxate, and patello-
Patello-femoral maltracking and instability can compromise the femoral contact should be evenly distributed medially and lat-
outcome of total knee arthroplasty when it is associated with erally. In the “towel clip” test, a towel clip opposes the edges of
discomfort, fatigue, weakness, or clicking in the anterior aspect the joint capsule at the superomedial aspect of the patella. The
of the knee. Patello-femoral instability can also be a problem knee is put through a range of motion, and the balance between
when it leads to patella subluxation or dislocation of the patel- the patella and the femoral trochlear is noted. In the “one
la. Causes of patella instability following total knee arthroplas- stitch” test, one suture is used to oppose the edges of the joint
ty include: postoperative valgus alignment, valgus position of capsule at the superomedial aspect of the patella. The knee is
the femoral implant, patella alta, internal rotation of the put through a range of motion, and note is taken of the balance
femoral or tibial implants, asymmetric patella osteotomy, excess between the patella and the femoral trochlear. Some authors
thickness of the bony patella, tibio-femoral soft tissue imbal- suggest the tourniquet should be released for a true and valid
ance, tight lateral patellar retinabulum, and dehiscence of the assessment of patello-femoral tracking. We do not release the
antero-medial joint capsule repair. tourniquet to evaluate patello-femoral tracking in our practice.
The best treatment of patello-femoral instability is prevention If patella tilt or instability is detected during testing of patello-
with an anatomically and kinematically correct reconstruction of femoral tracking, the position, size, rotation, and alignment of
the knee. Prior to patella reconstruction, surgeons should the knee implants should be checked to detect technical prob-
achieve correction of deformity, resurfacing of the distal femur lems that may have occurred during the reconstruction such as:
and the proximal tibia, and tibio-femoral stability with balanced valgus positioning, medial displacement, internal rotation, or
113
oversizing of the femoral component; internal rotation of the • If the mesh expansion lateral release does not achieve patello-
tibial component; asymmetric patella osteotomy; a thin or thick femoral balance (which we have not encountered), a conven-
patella due to over- or under-resection; or lateral placement of tional lateral retinacular release from the vastus lateralis mus-
the patella implant. cle proximally to the tibial joint line distally should relieve all
laterally deforming forces. Conventional lateral release has
Major reconstructive problems such as malalignment or com-
been associated with several problems including: hemathrosis,
ponent malrotation should be corrected. If the knee reconstruc-
disruption of lateral genicular arteries, reduced viability of the
tion is satisfactory, and if a tight lateral patella retinaculum is
skin at the lateral edge of the wound, patella hypovascularity,
responsible for lateral patella instability, one of several soft tis-
osteonecrosis, patella fracture, delayed achievement of motion
SYMPOSIA AR KNEE
sue techniques can be used to balance the patello-femoral joint.

and strength milestones, tenderness over the lateral femoral
We advocate an incremental, step-by-step approach to balance
condyle, lateral skin hypoesthesia, and a lump or capsular her-
the patello-femoral joint.
niation at the site of the lateral release. Conventional lateral
• Intra-articular release of the patello-femoral ligament, which release has been associated with a significantly higher risk of
is a thickening of the synovium, can be performed. This patellar loosening and fracture.10
release does not involve the patella retinaculum. This step
During total knee arthroplasty operations, patello-femoral bal-
may balance the patello-femoral joint obviating the need for
ance and stability can be achieved using the preoperative evalu-
release of the lateral patella retinaculum.
ation and surgical techniques described. Precise surgical tech-
• A “lateral peel” of the attachment of the lateral patella reti- nique is an essential element of patello-femoral balancing.
naculum at the lateral vertical aspect of the osseous patella is
performed.7 The “lateral peel” should not create a defect in Tips For Patello-Femoral Balancing
the extensor mechanism or in the lateral retinaculum. A • Identify preoperative patient factors associated with exten-
small laterally deforming force on the patella can be relieved sor mechanism problems.
with this technique which may prevent the need to do a lat- — Tibio-Femoral Valgus
eral release. — Patello-Femoral Arthritis
— Lateral Displacement of the Anterior Tibial Tubercle
• Elevation of a lateral skin flap in the interval between the
— Patella Tilt/Subluxation
superficial fascia and the lateral knee joint capsule can reduce
— Patella Baja
laterally deforming forces on the patella, especially in
— Thin, Dysplastic, Osteopenic Patella
patients with valgus deformity and in obese patients.
— “Meltdown” Patella
Dissection of the lateral skin flap may balance the patello-
— Obesity
femoral joint without requiring release of the lateral patella
— Prior Tibial Osteotomy
retinaculum.
— Chronic Patella Dislocation
• When lateral retinacular release is required, we perform a — Post-Traumatic Arthritis
“mesh expansion lateral release”.8,9 The lateral retinaculum is • Achieve anatomic tibio-femoral alignment
meshed with multiple five to ten millimeter stab incisions. • Avoid valgus positioning, medial placement, oversizing, and
The stab incisions are confined to an area distal to the super- internal rotation of the femoral implant
olateral genicular artery and proximal to the inferolateral • Avoid internal rotation of the tibial implant
genicular artery. Specific tight bands of lateral retinaculum • Achieve a symmetric patella osteotomy
are sought and released. Meshing of the patella retinaculum • Medialize the patella implant on the bony patella
allows this tissue to expand, and the patella is allowed to • Avoid overstuffing the patello-femoral joint
assume a more medial position in the femoral trochlear • Test patello-femoral tracking
groove. The lateral retinaculum should expand sufficiently to • Balance the patello-femoral joint
allow the lateral border of the patella, which is everted nine-
ty degrees with the joint space facing medially, to be moved
to the center of the femoral trochlear when the knee is in
extension.
REFERENCES 6. Rae P, Noble J, Hodgkinson, J., Patella Resurfacing and Total Condylar Knee
1. Kelly, MA, Patello-Femoral Complications Following Total Knee Arthroplasty, Arthroplasty. Journal of Arthroplasty 1990; 5: 259-265.
Instructional Course Lecture 2001; 50:403. 7. Shaw JA. Patella Retinacular Peel: An Alternative to Retinacular Release and Total
2. Booth RE, Bowen R Nazarian DG, et al. The Patella Nose: An Anatomic Guide Knee Arthroplasty. American Journal of Orthopaedics 2003; 32:189-192.
for Patella Resurfacing. Presented at the Knee Society Combined Specialty Day 8. Healy WL, Iorio R, Warren P. Mesh Expansion Release of the Lateral Patella
Meeting 2000 Orlando, FL. Retinaculum During Total Knee Arthroplasty. Journal of Bone and Joint Surgery.
3. Pagnano M, Trouesdale RT. Asymmetric Patella Resurfacing and Total Knee 85A:10:1909-1913, October 2003
Arthroplasty. Americal Journal of Knee Surgery. 2000; 228-233. 9. Healy WL, Iorio R, Warren P. Mesh Expansion Release of the Lateral Patella
4. Scott R. Prosthetic Replacement Patello-femoral Joint. Orthopaedic Clinics in Retinaculum During Total Knee Arthroplasty: Surgical Technique. Jouranl of
North America. 1979; 10:129-137. Bone and Joint Surgery. 86A Supplement 1, Part 2: 193-200. September 2004.
5. Pagnano MW, Kelly MA. Chapter 43. The Intraoperative Assessment of Patella 10. Neding JB, Fish DO, Bereid ME, Keating EM, Faris P, Makinzak R, Ritter MA.
Tracking. Scuderi GR, Tria AJ. Surgical Techniques in Total Knee Arthroplasty, PP. Predicting Patellar Failure After Total Knee Arthroplasty. Paper #11. AAHKS
317-325, Springer 2002. Scientific Program P. 20. AAHKS Annual Meeting, Dallas, TX, Nov. 2007.
M.I.S.: TKA IN 2008

Aaron G. Rosenberg MD
MIS TKA remains in its infancy. Its benefits not yet rigorously Utilization of appropriate study design will be needed to more
proven: its complication rates not well delineated and its future thoroughly evaluate the specific advantages of these interven-
not yet secure! It is however clear that the primary purported tions. (6) Recognition of the compounding effects of patient
benefit of MIS surgery, more rapid recovery from surgery, are selection, varying peri-operative management techniques and
SYMPOSIA AR KNEE
achieved from approaching the operative experience in a man- other factors along with the use of appropriately structured
ner where all aspects of care are improved -this includes pre-op information retrieval techniques will be needed to prevent the
education and exercise, peri-operative anesthesia and analgesia, introduction of significant bias. While difficult to carry out,
and post-operative pathways protocols and management of looking at specific variables of interest with randomized,
patient expectations. Efforts in these areas can achieve as much prospective trials (as blinded as can be accomplished in this set-
or more than alterations in incision length, soft tissue dissection ting) will eventually be required to assess the actual benefits of
and modified surgical approaches. (8) these techniques.
In order to follow one of the basic tenets of the medicine, to “do The early benefits may also come at a cost. Exposure is by its
no harm”, studies by multiple investigators should be available nature limited in comparison to that obtained during standard
for practitioners to assess the potential risks and complications TKA, and may alter the ability of the surgeon to adequately pro-
which may be encountered in the new procedure. (1,2,4,5, 6, 7, tect vital structures in the standard fashion, so that extra care
9) Standard reporting methodologies of complications rates may be needed to prevent accidental incursion into these tis-
should suffice for these purposes. sues. The mobility of the wound must be utilized in conjunc-
tion with a sequential approach to bone cutting and soft tissue
Collecting and assessing general health, disease or intervention
balancing to progressively expand the operative field and so
specific outcomes measures, in cases where the effects of the
prevent excessive wound tension with risk for marginal would
intervention are large, unfortunately creates a paradoxical situa-
sloughs, more contact of the implants with the wound and
tion for data interpretation. The presence of a large standardized
therefore some increased risk of infection. The use of antibiotics
effect size (as is seen in joint replacement) creates such a loud
in the cement may be warranted. The surgeon should always be
“signal”, that the more subtle signals of interest under evalua-
aware of the potential need to make the exposure more exten-
tion can be obscured. This problem would seem to be magni-
sile-always keeping in mind that whatever benefits which may
fied by evaluation of the potentially more subtle signs of early
accrue from the MIS approach may be dramatically outweighed
recovery, as would be expected by the potential beneficial effect
by technical errors which may compromise implant function or
of MIS. Therefore, any treatment effect is not likely to be clear-
longevity. (3)
ly evaluated by the more gross measurements of health that
have been used to study arthroplasty traditionally. While the Less invasive exposures may prevent accurate assessment of
evaluation of less invasive surgical techniques should eventual- bony landmarks and the adoption of alternate methods of
ly incorporate traditional general health assessment and disease assessing jig position which are specific to the surgical technique
or intervention specific instruments, measurement of the small- employed. Less invasive jigs and cutting blocks may have more
er interval changes claimed for early recovery, require alternate tenuous fixation to the bone and therefore careful attention to
methods and time frames for data collection. The bulk of such the details of how the saw interacts with the cutting slots and
early studies confirms that minimizing soft tissue trauma is double checking the rigidity and positioning of the jigs is essen-
associated with earlier recovery, but no improvement in eventu- tial. The future of computer guided procedures and smart tools
al function. (1,2,4,5,6,7,8,9) driven by computer with advanced imaging technology will
eventually overcome these current limitations.
REFERENCES 6. King J, Stamper DL, Schaad DC, Leopold SS Minimally invasive total knee
1. Aglietti P, Baldini A, Sensi L.Quadriceps-sparing versus mini-subvastus approach arthroplasty compared with traditional total knee arthroplasty. Assessment of the
in total knee arthroplasty. : Clin Orthop Relat Res. 2006 Nov;452:106-11. learning curve and the postoperative recuperative period. : J Bone Joint Surg Am.
2007 Jul;89(7):1497-503.
2. Boerger TO, Aglietti P, Mondanelli N, Sensi L.Mini-subvastus versus medial para-
patellar approach in total knee arthroplasty. Clin Orthop Relat Res. 2005 7. Kolisek FR, Bonutti PM, Hozack WJ, Purtill J, Sharkey PF, Zelicof SB, Ragland PS,
Nov;440:82-7. Kester M, Mont MA, Rothman RH.Clinical experience using a minimally invasive
surgical approach for total knee arthroplasty: early results of a prospective ran-
3. Dalury DF, Dennis DA.Mini-incision total knee arthroplasty can increase risk of domized study compared to a standard approach. J Arthroplasty. 2007
component malalignment. Clin Orthop Relat Res. 2005 Nov;440:77-81 Jan;22(1):8-13.
4. Haas SB, Cook S, Beksac B.Minimally invasive total knee replacement through a 8. Nuelle DG, Mann K. Minimal incision protocols for anesthesia, pain manage-
mini midvastus approach: a comparative study. Clin Orthop Relat Res. 2004 ment, and physical therapy with standard incisions in hip and knee arthroplas-
Nov;(428):68-73. ties: the effect on early outcomes. J Arthroplasty. 2007 Jan;22(1):20-5.
5. Laskin RS, Beksac B, Phongjunakorn A, Pittors K, Davis J, Shim JC, Pavlov H, 9. Tashiro Y, Miura H, Matsuda S, Okazaki K, Iwamoto Y. Minimally invasive versus
Petersen M.Minimally invasive total knee replacement through a mini-midvastus standard approach in total knee arthroplasty. Clin Orthop Relat Res. 2007
incision: an outcome study. Clin Orthop Relat Res. 2004 Nov;(428):74-81. Oct;463:144-50.
115
COMPUTER ASSISTED NAVIGATION IN TKA

Douglas A. Dennis, MD
Predominant failure mechanisms of contemporary total knee 1. Multiple Options For Computer Unit
arthroplasty (TKA) include aseptic loosening, instability, prema- a) Foot Of Operating Table
ture polyethylene wear, and arthrofibrosis. Accurate component b) Opposite Side of Surgeon
positioning during TKA has been shown to reduce the incidence c) Suspended From Ceiling
SYMPOSIA AR KNEE
of each of these failure modes. Use of computer navigation sys- 2. Need a Clear Path For the Infrared Scanner
tems (CAS) has been introduced to reduce surgeon error and F. Surgical Exposure
improve long-term clinical results of TKA. Numerous prospec- 1. Standard VS. MIS
tively randomized studies have clearly demonstrated superior 2. Start with Standard Until CAS- Proficient
component position and alignment when computer navigation G. Array Placement
systems here utilized in comparison to TKA performed using 1. Inside Incision Vs. Distant From the Joint Through
standard (non-CAS) techniques. Use of CAS is also beneficial to Separate Stab Incisions
quantitate and improve precision of soft tissue and gap balancing 2. Must Be Rigid
in TKA. Additional advantages of CAS include reduced blood loss a) Consider 2-Pin Technique
and reduced intracranial and cardiopulmonary embolic loads b) Engage Endosteum of 2nd Cortex
since cannulation of the medullary canals is not required. Lastly, c) DON”T BUMP ARRAYS!!
it allows for successful completion of TKA in cases with substan- 3. Position So No Interference With Cutting Jigs
tial diaphyseal deformity or retained hardware in which use of H. Registration
traditional instrument systems would be difficult. Designs of 1. Remove Osteophytes First
computer navigation systems differ and are in various stages of 2. Include Perimeter/ High Point/ Low Point of Each
development and evolution. Strengths and weaknesses are pres- Condyle
ent in all systems which will improve in future iterations. A defi- 3. Posterior Femoral Condyles Critical
nite learning curve exists for the surgeon initially embarking on a) Component Sizing and Rotation
the use of this technology which can be lessened by attending 4. Register Tibial Periphery at Desired Resection Level
computer navigation educational courses or by viewing live sur- I. Jig Placement
gical demonstrations performed by surgeons who have extensive 1. Must Be Accurate
experience with use of computer navigation. a) Pinning May Displace Jig
b) Consider Drilling Pin Holes
I. Computer Assisted Surgery: Tips To Lessen The Learning 2. Perfect Accuracy Difficult
Curve a) Goal: Position Within 0.5°/0.5mm
A. Evolving New Technology J. Jig Options
B. Future of Joint Replacement 1. Standard Vs. Mini-Instruments
C. Not All Systems Are The Same 2. Fixed Vs. Adjustable
1. Some Just For Coronal Bone Cuts 3. Experiment With All Types
2. Others Provide Soft Tissue & Gap Balance Information 4. Surgeon Preference
D. Definite Learning Curve K. Other Advice
1. Pre-Utilization Training Imperative 1. Protect Arrays (Cover/ Remove When Not In Use)
a) Regional Courses/ Teaching Manuals 2. Take It Slow -- A Lot To Comprehend
b) Surgeon Visitations 3. Schedule Increased Time Initially
2. Must Also Educate Operating Room Personnel 4. Use Frequently ‡ Speeds the Learning Curve
E. Operating Room Set-Up
REFERENCES 4. Kalairajah Y, Cossey AJ, Verrall GM, Ludbrook G, Spriggins AJ. Are systemic
1. Bolognesi M, Hofmann A. Computer navigation versus standard instrumentation emboli reduced in computer-assisted knee surgery?: A perspective, randomized,
for TKA: a single-surgeon experience. Clin Orthop Relat Res. 2005;440:162-9. clinical trial. J Bone Joint Surg. 2006;88(2): 198-202.
2. Chauhan SK, Scott RG, Breidahl W, Beaver RJ. Computer-assisted knee arthro- 5. Luring C, Hufner T, Perlick L, Bathis H, Krettek C, Grifka J. The effectiveness of
plasty versus a conventional jig-based technique. A randomized, prospective sequential medial soft tissue release on coronal alignment in total knee arthro-
trial. J Bone Joint Surg. 2004;86(3):372-7. plasty: using a computer navigation model. J Arthroplasty. 2006;21(3):428-34.
3. Fehring TK, Mason JB, Moskal J, Pollock DC, Mann J, Williams VJ. When com- 6. Sparmann M, Wolke B, Czupalla H, Banzer D, Zink A. Positioning of total knee
puter-assisted knee replacement is the best alternative. Clin Orthop Relat Res. arthroplasty with and without navigation support. A prospective, randomized
2006;452:132-6. study. J Bone Joint Surg. 2003;85(6):830-5.
BEARING SURFACE SELECTION IN TOTAL KNEE ARTHROPLASTY

Michael D. Ries, MD
I. “Conventional” UHMWPE • Mechanical properties not reduced as much as

1. Gamma irradiation in air sterilization annealed above melt temp.
• Polymer chain scission and oxidation
III. Highly Crosslinked UHMWPE Performance
• Oxidative degradation increases over time
SYMPOSIA AR KNEE
1. Wear
• Lowers wear resistance
• Wear reduced in knee simulators
• Lowers fatigue strength
• Greater wear reduction with higher irradiation doses
• Discontinued in mid 1990’s
• Favorable clinical results in posterior cruciate retaining
2. Gamma irradiation sterilization in inert (nitrogen, argon,
(CR) TKA
vacuum) atmosphere
2. Mechanical properties
• Promotes cross linking, improves wear resistance
• Fracture of posterior stabilized (PS) post occurs in
• Free radicals may cause oxidation in vivo
conventional UHMWPE
3. Gas sterilization (EtO, gas plasma)
• Mechanical properties of highly crosslinked UHMW-
• No change in UHMWPE chemistry
PE reduced more with higher irradiation doses
• Mechanical properties maintained
• Catastrophic rim fractures of highly crosslinked
• No cross linking effects
acetabular liners (areas of unsupported UHMWPE) in
II. Highly cross linked UHMWPE Processing THA
1. Gamma or e-beam irradiated (5 to 10Mrad) and • Risk of fracture may limit use of highly crosslinked
annealed above melt temp (150 degrees C) UHMWPE particularly in PS TKA
• Wear reduced (more with higher irradiation doses)
IV. Femoral Component Counterface
• Free radicals caused by irradiation neutralized
3. Counterface materials
• Crystallinity decreased
• Cast cobalt chrome – most common counterface
• No oxidation
material in TKA
• Mechanical properties reduced (more with higher irra-
• Titanium - (no longer used) results in high rate of
diation doses)
surface roughening
2. Gamma irradiated and annealed below melt temp (130
• Alumina or zirconia ceramic – highly scratch resistant
degrees C)
surface, but risk of fracture (not FDA approved for use
• Wear reduced
in US)
• Free radicals caused by irradiation present which can
• Oxidized zirconium – zirconia metal substrate with
oxidize in vivo
ceramic surface
• Mechanical properties not reduced as much as
4. In vivo counterface roughening
annealed above melt temp
• Cobalt chrome femoral components roughen in vivo
3. Gamma irradiated, annealed below melt (130 degrees C),
• In vivo roughening can increase UHMWPE wear
and secondary process to reduce free radical concentration
• Ceramic counterface or surface hardening can
• Wear reduced
decrease abrasive wear
• Vitamin E added, sequentially annealed, or mechani-
cally deformed to reduce free radicals
REFERENCES 6. Ries, M.D., Salehi, A., Widding, K., and Hunter, G., “Polyethylene wear perform-
1. Sutula LC, Collier JP, Saum KA, Currier BH, Currier JH, Sanford WM, Mayor MB, ance of oxidized zirconium and cobalt-chromium knee components under abra-
Wooding RE, Sperling DK, Williams IR: The Otto Aufranc Award. Impact of sive conditions”, J. Bone Joint Surg., 84-A (S2), 2002, pp. 129-135.
gamma sterilization on clinical performance of polyethylene in the hip. Clin 7. Baker D, Bellare A, Pruitt L: The effects of degree of crosslinking on the fatigue
Orthop 319: 28-40, 1995. crack initiation and propagation resistance of orthopedic grade polyethylene. J
2. McKellop H, Shen FW, Lu B, Campbell P, Salovey R: Effect of sterilization Biomed Mater Res 66:146-154, 2003.
method and other modifications on the wear resistance of acetabular cups made 8. Oral E, Wannomae KK, Hawkins N, Harris WH, Muratoglu OK. Alpha-toco-
of ultra-high molecular weight polyethylene. A hip-simulator study. J Bone Joint pherol-doped irradiated UHMWPE for high fatigue resistance and low wear.
Surg 82A: 1708-1725, 2000. Biomaterials 25:5515-5522, 2004.
3. Chiu YS, Chen WM, Huang CK, Chiang CC, Chen TH. Fracture of the polyethyl- 9. Muratoglu OK, Rubash HE, Bragdon CR, Burroughs BR, Huang A, Harris WH .
ene tibial post in a NexGen posterior-stabilized knee prosthesis. J Arthroplasty Simulated Normal Gait Wear Testing of a Highly Cross-Linked Polyethylene
19:1045-1049, 2004. Tibial Insert. J Arthroplasty, 22: 435-444, 2007.
4. Levesque M, Livingston BJ, Jones WM, Spector M: Scratches on condyles in nor- 10. Wannomae KK, Bhattacharyya S, Freiberg A, Estok D, Harris WH, Muratoglu O.
mal functioning total knee arthroplasty. Trans Orthop Res Soc. 23:247, 1998. In Vivo Oxidation of Retrieved Cross-linked Ultra–High-Molecular-Weight
5. Masonis, J. L., Bourne, R.B., Ries, M.D., McCalden, R.W., Salehi, A., and Kelman, Polyethylene Acetabular Components with Residual Free Radicals. J Arthroplasty,
D.C.: Zirconia femoral head fractures: A clinical and retrieval analysis. J. 21: 1005-1011, 2006.
Arthroplasty 19: 898 - 905, 2004.
117
BACK TO THE FUTURE: THE ALL-POLY TIBIA IN PRIMARY TKA

Terence J. Gioe, MD
Introduction Are there poor results with all-poly designs?

Early designs of tibial components were almost uniformly all- Only one recent study has documented inferior results with an
polyethylene, and the total condylar designs have continued to APT design. Faris et al.11 reported a 68% survival rate at 10
show excellent clinical results at long-term followup.18, 21 years for the all-polyethylene with 73% of the failures occurring
SYMPOSIA AR KNEE
Failures of all-polyethylene tibial components in this period in association with loosening or collapse of the bone beneath
were frequently attributable to mechanical loosening of the tib- the medial tibial plateau. As reported, this design with flat-on-
ial component. Metal-backed tibial components likewise flat coronal geometry allows edge loading to occur on the
showed excellent results with the total condylar design, 18 and extreme medial/lateral edges of the tibial plateau with varus or
with time, advantages were perceived to newly modular com- valgus angulations of the femur, promoting plateau loading far
ponents that provided increased intraoperative flexibility and from the stem and increasing the stress in the polyethylene as
the ability to apply porous coating—at increased cost. Other the tibial plateau contact is decreased. In addition, the I-beam
design modifications that used metal backing did not fare so stem design and textured undersurface may not offer the same
well. Less constrained, less congruent designs to allow rotation mechanical means of fixing the device in the cement as do the
and promote “rollback” with a retained posterior cruciate liga- undercuts seen in other designs. The authors acknowledge this
ment showed higher wear and failure rates in intermediate-term design failure, and APT designs that provide better coronal con-
follow-up, and when coupled with heat-pressed, thin inserts formity (such as our studied design) theoretically should not
proved disastrous.8,19,22 suffer from this same failure mode.
As these intermediate-term results became available, other
Current studies
issues began to surface, including locking mechanism stability,
In a Level 1 RCT comparing an APT and MBT of the same design
“backside” wear, osteolysis, and prosthetic costs.
in 316 TKAs followed for a mean 115 months, there were no sig-
nificant differences in knee function (KSS, ROM, stability) or
Biomechanical issues with APT
radiographic parameters between the groups. Ten-year sur-
Most surgeons who do not use the all-polyethylene tibial com-
vivorship of the APT was 91.6% with revision for any reason and
ponent object to it on the grounds of its perceived biomechan-
100% for aseptic loosening; MBT survivorship was 88.9% with
ical inferiority or their relative comfort level with the intraoper-
revision for any reason and 94.3% for aseptic loosening (Gioe,
ative flexibility afforded by modular components. However, the
CORR 455: 212-218, 2007).
biomechanical studies done in the early 1980s that supported
the transition to metal-backed components (Walker et al. JBJS In a registry study, 443 APT TKAs (98% of which were one of
63A, 1981; Lewis et al. JBJS 64A, 1982) tested non-commercial- three designs) were followed over 14 years in a population com-
ly available components in Pedilen foam with 8mm poly exclu- posed of 78% females with a mean age of 77 years. There were
sively, and found that “the differences were not great, howev- 3 revisions (only one for aseptic loosening), with 99.4% sur-
er…the main differences were between the different design vival with revision for any reason as an endpoint (Gioe, CORR
types.” The only solid conclusion drawn from the FEA work of 464: 88-92, 2007).
the same period was that metal-backed components result in
In a second Level 1 RCT where followup is ongoing, a fixed
lower cancellous bone stresses than all-poly, which may not be
bearing APT was compared to a mobile-bearing rotating plat-
desirable. The best in vivo manner in which to examine issues
form metal-backed modular knee of the same design. 277 TKAs
of proximal tibial load distribution is unquestionably
(130 APT/147 RP) have a minimum 24 mo followup (mean 37
radiostereometric analysis (RSA). Three separate RSA studies of
mo) with no significant differences noted in KSS pain or clini-
APT versus MBT components have all shown migration effects
cal scores, ROM, or revisions (Gioe, AAOS 2007 podium pres-
to be equal or superior for the APT designs.1,2,13
entation, San Diego, CA).
Is modularity our friend? There have been a number of corroborative studies published in
What advantage does a metal-backed modular tibia offer? It recent years. Most generally have been retrospective and
allows for varying constraint options in instability issues, and chronologically biased toward the MBT that typically was
liner exchange and posterior synovectomy may be performed in implanted later during the surgeon’s experience with the same
a salvage attempt in acute infection. Modularity also may prove TKA, or used either matched-pair analysis or nonrandomized
helpful in cases of late wear, but implies that the mode of wear cohorts in comparison of various APT versus MBT designs.
failure has not involved axial malalignment necessitating com- None of these studies showed superiority of the MBT design,
plete tibial revision, and has been detected before osteolytic and the authors have universally encouraged greater use of APT
concerns or severe wear has compromised the metal backing. components.3,12,15,17,20
Two separate studies have identified the relatively limited role
for isolated polyethylene liner exchange.4,9 Micromotion Conclusion
between the tibial insert and the metal tray is now recognized as Numerous studies support the concept that a stemmed cement-
a source of wear debris, implant failure, and osteoly- ed all-polyethylene tibial design of 8 mm minimal thickness
sis.6,7,10,14,16 Finally, the metal backing reduces the thickness favoring articular congruency and available in multiple sizes
of polyethylene insert used compared with an identically sized remains practical for primary knee arthroplasty in a majority of
all-polyethylene tibial component, forcing the surgeon to patients. The MBT component offers slightly greater intraoper-
choose a compromise between additional bone resection or ative flexibility in that a “final trial” may be performed after
decreased polyethylene when preferentially selecting the metal- cementing the components in place; in the authors’ teaching
backed tibia.7 institution, this was not thought to be a limiting feature of the
APT design and late revisions for instability were rare (2 MBT ditions dictate. The appeal of liner exchange in certain limited
and 1 APT) in both designs. The metal-backed design offers situations is obvious; however, if the entire tibial component
options of stems and augments that cannot be added in the all- must be removed, the APT component can be removed more
polyethylene tibia, but such cases do not represent the majority easily and with less chance of damaging a retained femoral
of total knee arthroplasties, and were not included in our series. component. Finally, the issue of cost clearly favors the APT, and
Indeed, nothing in most current designs precludes the surgeon cost savings can be substantial over modular components.
from “switching” to a metal-backed tibia intraoperatively if con-
SYMPOSIA AR KNEE
REFERENCES 11. Faris, P. M.; Ritter, M. A.; Keating, E. M.; Meding, J. B.; and Harty, L. D.: The AGC
all-polyethylene tibial component: a ten-year clinical evaluation. J Bone Joint
1. Adalberth, G.; Nilsson, K. G.; Bystrom, S.; Kolstad, K.; and Milbrink, J.: All-poly-
Surg Am, 85-A(3): 489-93, 2003.
ethylene versus metal-backed and stemmed tibial components in cemented total
knee arthroplasty. A prospective, randomised RSA study. J Bone Joint Surg Br, 12. Najibi, S.; Iorio, R.; Surdam, J. W.; Whang, W.; Appleby, D.; and Healy, W. L.: All-
83(6): 825-31, 2001. polyethylene and metal-backed tibial components in total knee arthroplasty: a
matched pair analysis of functional outcome. J Arthroplasty, 18(7 Suppl 1): 9-15,
2. Adalberth, G.; Nilsson, K. G.; Bystrom, S.; Kolstad, K.; and Milbrink, J.: Low-con-
2003.
forming all-polyethylene tibial component not inferior to metal-backed compo-
nent in cemented total knee arthroplasty: prospective, randomized radiostereo- 13. Norgren, B.; Dalen, T.; and Nilsson, K. G.: All-poly tibial component better than
metric analysis study of the AGC total knee prosthesis. J Arthroplasty, 15(6): 783- metal-backed: a randomized RSA study. Knee, 11(3): 189-96, 2004.
92, 2000. 14. O'Rourke, M. R.; Callaghan, J. J.; Goetz, D. D.; Sullivan, P. M.; and Johnston, R.
3. Apel, D. M.; Tozzi, J. M.; and Dorr, L. D.: Clinical comparison of all-polyethylene C.: Osteolysis associated with a cemented modular posterior-cruciate-substituting
and metal-backed tibial components in total knee arthroplasty. Clin Orthop total knee design : five to eight-year follow-up. J Bone Joint Surg Am, 84-A(8):
Relat Res, (273): 243-52, 1991. 1362-71, 2002.
4. Babis, G. C.; Trousdale, R. T.; and Morrey, B. F.: The effectiveness of isolated tibial 15. Rand, J. A.: Comparison of metal-backed and all-polyethylene tibial components
insert exchange in revision total knee arthroplasty. J Bone Joint Surg Am, 84- in cruciate condylar total knee arthroplasty. J Arthroplasty, 8(3): 307-13, 1993.
A(1): 64-8, 2002. 16. Rao, A. R.; Engh, G. A.; Collier, M. B.; and Lounici, S.: Tibial interface wear in
5. Conditt, M. A.; Ismaily, S. K.; Alexander, J. W.; and Noble, P. C.: Backside wear of retrieved total knee components and correlations with modular insert motion. J
modular ultra-high molecular weight polyethylene tibial inserts. J Bone Joint Bone Joint Surg Am, 84-A(10): 1849-55, 2002.
Surg Am, 86-A(5): 1031-7, 2004. 17. Rodriguez, J. A.; Baez, N.; Rasquinha, V.; and Ranawat, C. S.: Metal-backed and
6. Conditt, M. A.; Thompson, M. T.; Usrey, M. M.; Ismaily, S. K.; and Noble, P. C.: all-polyethylene tibial components in total knee replacement. Clin Orthop Relat
Backside wear of polyethylene tibial inserts: mechanism and magnitude of mate- Res, (392): 174-83, 2001.
rial loss. J Bone Joint Surg Am, 87(2): 326-31, 2005. 18. Scuderi, G. R.; Insall, J. N.; Windsor, R. E.; and Moran, M. C.: Survivorship of
7. Edwards, S. A.; Pandit, H. G.; Ramos, J. L.; and Grover, M. L.: Analysis of polyeth- cemented knee replacements. J Bone Joint Surg Br, 71(5): 798-803, 1989.
ylene thickness of tibial components in total knee replacement. J Bone Joint Surg 19. Tsao, A.; Mintz, L.; McRae, C. R.; Stulberg, S. D.; and Wright, T.: Failure of the
Am, 84-A(3): 369-71, 2002. porous-coated anatomic prosthesis in total knee arthroplasty due to severe poly-
8. Engh, G. A.; Dwyer, K. A.; and Hanes, C. K.: Polyethylene wear of metal-backed ethylene wear. J Bone Joint Surg Am, 75(1): 19-26, 1993.
tibial components in total and unicompartmental knee prostheses. J Bone Joint 20. Udomkiat, P.; Dorr, L. D.; and Long, W.: Matched-pair analysis of all-polyethyl-
Surg Br, 74(1): 9-17, 1992. ene versus metal-backed tibial components. J Arthroplasty, 16(6): 689-96, 2001.
9. Engh, G. A.; Koralewicz, L. M.; and Pereles, T. R.: Clinical results of modular 21. Vince, K. G., and Insall, J. N.: Long-term results of cemented total knee arthro-
polyethylene insert exchange with retention of total knee arthroplasty compo- plasty. Orthop Clin North Am, 19(3): 575-80, 1988.
nents. J Bone Joint Surg Am, 82(4): 516-23, 2000.
22. Wright, T. M.; Rimnac, C. M.; Stulberg, S. D.; Mintz, L.; Tsao, A. K.; Klein, R. W.;
10. Engh, G. A.; Lounici, S.; Rao, A. R.; and Collier, M. B.: In vivo deterioration of tib- and McCrae, C.: Wear of polyethylene in total joint replacements. Observations
ial baseplate locking mechanisms in contemporary modular total knee compo- from retrieved PCA knee implants. Clin Orthop Relat Res, (276): 126-34, 1992.
nents. J Bone Joint Surg Am, 83-A(11): 1660-5, 2001.
119
MOBILE BEARINGS: DO THEY PROVIDE A BENEFIT

Thomas K. Fehring, MD
I. History of Mobile Bearings • Mobile bearings can increase the contact area from 200
• 1977 – Early adopters recognized the theoretical poten- sq mm. to 800 sq mm. with a corresponding decrease in
tial of mobile bearings concerning wear. polyethylene stress down to 5 megapascals
SYMPOSIA AR KNEE
II. Concerns of the 1980’s VIII. Molecular strain hardening of polyethylene

1. Alignment • Polyethylene exhibits molecular orientation in the princi-
2. Fixation ple direction of sliding
3. Ligamentous balancing • Polyethylene orientation leads to increased strength par-
• Wear and osteolysis were not significant clinical prob- allel to sliding and reduced strength transverse to sliding.
lems, therefore mobile bearings were not widely • In mobile bearing knees, the linear motion of the
accepted femoral component relative to the tibial bearings surface,
• Most surgeons were risk averse to using a new type of strain hardens to polyethylene.
knee that solved what they considered a non-problem • In fixed bearing knees, multi-directional motion of the
femoral component relative to the tibial surface strain
III. 1990’s Era of Knee Osteolysis Recognition
softens the polyethylene.
• Reasons for Osteolysis
1. gamma in air poly IX. Backside wear of the articulation
2. modular tibial baseplates 1. All modular fixed bearing trays are mobile bearings in
3. extension of total knee to young, active patients disguise.
2. Backside wear of a mobile bearing is also linear leading
IV. Potential Solutions for Osteolysis in Total Knees
to strengthened molecular orientation. Therefore back-
• Cross-linked polyethylene
side wear in mobile bearings may be better controlled
• Counter-surface improvement
than a fixed bearing design.
• Improved locking mechanisms
• The theoretical advantage of mobile bearings are that
• Monoblock tibias
they turn complex crossing motion seen in fixed bear-
• Mobile bearings
ing implants into linear motion at two interfaces.
V. Long-term Survivorship Data
X. Do these theoretical advantages make a difference in
• Fixed bearing
wear?
Ritter - 15 year follow-up - 98% success
• McNulty et al., ASTM, 2002 – 94% wear reduction in
• Mobile bearing
mobile bearings over fixed bearings
Buechel - 20 year follow-up - 97% success
• McEwen et al., J Biomechanics, 2005 – Four fold greater
VI. If long-term data is equivocal, why adopt mobile bear- surface wear in fixed versus mobile bearings in a high
ings as a solution for osteolysis? kinematic situation, (i.e.) a young, active patient.
• the patient cohort may have changed Æ younger cohort
XI. Should Mobile Bearings Be Adopted Based on their
currently compared to historial controls
Theoretical Advantage?
• factors affecting the durability of primary total knee pros-
1. Literature is equivocal – fixed versus mobile
theses
2. No functional superiority demonstrated
Rand, JBJS, 2003
3. Theoretical advantage of mobile bearing may not be as
94% survivorship in patients greater than 70 years old
clinically significant now that poly has been improved
83% survivorship in patients less than 55 years old
XII. Risks of Mobile Bearings
VII. Wear Reduction in Mobile Bearings
1. Spin out
• Decrease contact stress on the polyethylene by increasing
Chiavetta, Fehring et al., Orthopaedics, 2006
contact area
• 500 mobile bearing knees – no spin outs
• Mobile bearings turn complex crossing motion seen in
2. Undersurface wear
fixed bearing knees into linear motion through its ability
Brown, Fisher et al., ORS, 2005
to rotate
• fixed versus mobile simulator study – no difference
• Yield strength of polyethylene is 20 megapascals. This is
in particle size or biological activity
frequently exceeded in fixed bearing designs
VENOUS THROMBOEMBOLISM PROPHYLAXIS

Thromboembolism after TKA Jay R. Lieberman, MD

• Different “disease” than after THA Paul A. Lotke, MD
• Most thrombi occur in calf alone Javad Parvizi, MD
• Extension to proximal veins occurs infrequently Vincent Pellegrini, MD
SYMPOSIA AR KNEE
• Pulmonary embolism rare Theodore A. Stringer, MD
Paul Tornetta III, MD
Orthopaedist’s Concerns:
Prevention of: Literature Review Criteria
• Fatal PE • Center for Clinical Evidence
• Symptomatic PE Synthesis at Tufts Medical Center
• Symptomatic DVT • Prospective studies
• Knee bleeding, drainage Surgery performed since 1996
Anticoagulation Cohort study ≥ 100
• Risk of bleeding, drainage RCT ≥ 10 per treatment
• Hematomas: • Natural history (no prophylaxis)
Infection? No studies with ≥ 1000 patients
Poorer ROM? Literature Review Article Extraction
Worse outcome? • 2,713 citations MEDLINE
How important is it to prevent asymptomatic venogram or • 10 other articles from work group
Duplex scan-detected thrombi? (basis of ACCP Guidelines) • 42 articles met criteria
Pulmonary Embolism: Rare After TKA • TKA n = 11,665
• Scottish Registry THA n = 16,304
90 day fatal PE rate Results
0.15% (n = 27,000) Literature Review
• California database • Forest plots
90 day nonfatal PE rate • Intervention
0.41% (n = 222,684) • Quality, applicability
ACCP Guidelines: Prevention of DVT in THA, TKA patients • Analyses
• DVT is outcome measure (venogram or duplex scan) (pooling, REM meta-analysis, Bayesian meta-analysis)
• Limited relevance to “real world” decision-making Conclusions: Literature Review
• Emphasis on pharmacologics • PE rate ~1/300 with treatment
• Under-rate risks of bleeding and other adverse outcomes • PE death rate ~1/1700
Have the ACCP Guidelines changed the rate of PE? No difference among treatments
• No change in symptomatic or fatal PE rate over the past 10- • Bleeding death rate ~1/3000
15 years • Major bleeding more common with Systemic vs. mechani-
[Lie et al, Acta Ortho Scan 2002; Howie et al JBJS(B) 2005] cal/aspirin ~1.8% vs 0.14%
• Very wide confidence intervals
Failure of ACCP-1A Protocol for Lovenox in THA, TKA
(Burnett et al. J Arthroplasty 2007) Recommendations: Consensus Process
• 234 patients (129 THA, 105 TKA) • Assess pre-op for PE risk (III B)
• 10-day course Lovenox 30 mg BID • Assess pre-op for bleeding risk (III C)
• Major complications 9% • Consider patients with contraindications for anticoagula-
4.7% readmission tion for IVC filter (V C)
3.4% return to OR • Consider intra-op and/or immediate post-op mechanical
1.3% H.I.T. compression (III B)
• Symptomatic DVT 3.8% • Consider regional anesthesia (IV C) (in consultation with
Non-fatal PE 1.3% anesthesiologist)
• Mechanical prophylaxis post-op (IV C)
AAOS Guideline Strategy • Rapid mobilization (V C)
• Outcome: symptomatic PE • DVT/PE screening not recommended (III B)
• Interventions • Education patient on DVT/PE symptoms (V B)
aspirin, LMWH, warfarin, pentasaccharide, mechanical
• Key questions Recommendations for Medication: Literature Review -
Event rates with interventions Analysis
Adverse event rates (bleeding, death) • Standard risk PE and major bleeding
Natural history without prophylaxis aspirin
(n = 1000) LMWH
pentasaccharide
AAOS Work Group: warfarin INR ≤ 2
Norman A. Johanson, MD, Chair (III B)
121
(C dosing, timing) Limitations

• Elevated risk PE; standard risk bleeding • Large clinical heterogeneity
LMWH • No study had PE as primary outcome
pentasaccharide • Reporting of PE often vague
warfarin INR ≤ 2 • Inadequate sample sizes for estimate of event rates
(III B) • Pooled average used to estimate event rates
(C dosing, timing) • Restricted to surgery since 1996
• Standard risk PE; elevated risk bleeding
AAOS Guidelines: Conclusions
aspirin
SYMPOSIA AR KNEE
• No difference among interventions in PE, fatal PE, total

warfarin INR ≤ 2 death
none • Bleeding was very rare with aspirin and mechanical prophy-
(III C) laxis
• Elevated risk PE and bleeding • Evaluate risks of PE/bleeding pre-op
aspirin • Consider risk/benefit ratio in decision for intervention
warfarin INR ≤ 2
none
(III C)
A COMPREHENSIVE MULTI-MODAL PAIN MANAGEMENT PROGRAM

FOR TOTAL KNEE AND TOTAL HIP ARTHROPLASTY
Mark W. Pagnano, MD
I. Effective pain management V. Results are dramatic – both in primary and revision setting
SYMPOSIA AR KNEE
A. Improves patient satisfaction A. Patients have little to no pain – typical VAS Pain scores 0-
B. Decreases hospital stay 2 on day of surgery and POD 1
C. Facilitates discharge to home instead of to assisted care B. Morning of POD#1 patients are alert, oriented, happy,
typically ready to order breakfast or are reading the news-
II. Patient controlled (narcotic) anesthesia – falling from favor
paper on AM rounds
A. Represented a step in the right direction
C. Our patients who had PCA pumps for a prior surgery
B. Smoothed out some of the extreme variations in pain
and the Multi-modal Approach with Peripheral Nerve
C. Plagued though by substantial side effects
Block for a subsequent surgery clearly express a decided
D. Nausea and vomiting – unable to advance diet
preference for the multi-modal approach
E. Oversedation -- unable to participate in physical therapy
D. Catheters can be left in for 48 hours
F. Undermedication – unwilling to participate in therapy;
E. Surgeons are free to use DVT prophylaxis regimen of
lack of sleep
their choosing; no contraindication to LMWH or
G. Adynamic Ileus – NG tubes, prolonged hospital stay
Coumadin with catheter in place
H. Itching/idiosyncratic reactions to morphine/demerol/
F. Anesthesiologist can adjust the concentration of local
fentanyl
anesthetic to selectively target sensory block alone or
III. Substantial recent body of knowledge regarding periop- motor block as well – typically higher concentration and
pain management combined sensorimotor block on day of surgery and first
A. Emphasis on multi-modal and pre-emptive approach evening then taper to sensory only on POD #1 then pull
B. Stay ahead of pain and you limit total analgesia require- catheter at 36-48 hours.
ments
VI. Barriers to introduction
C. Take advantage of benefits of various medications while
A. Training anesthesia staff on technique of peripheral
staying below threshold for side effects
nerve blockade
D. Avoid the use of parenteral narcotics
1. Technique well within the grasp of most anesthesiolo-
IV. Components of Multi-modal strategy gists
A. Preoperative administration of medication 2. Added reimbursement for these blocks now provides
1. Long-acting oral narcotic (Oxycontin) an incentive for them to learn
2. Oral anti-inflammatory: typically a Cox-II (Celebrex) 3. Most effective if done in a separate block room prior
3. Begin night before or morning of surgery to surgery – this improves efficiency both for surgeon
B. Regional anesthesia and anesthesiologist
1. Peripheral nerve blocks – most selective B. Nursing resistance
a. Psoas compartment block – indwelling catheter; 1. Many are reluctant to give up PCA pump convenience
figure on left below shows distribution of psoas 2. Delivering medications on schedule more taxing
block. 3. Disbelief that THA/TKA and revisions can be done
b. Sciatic nerve block—single shot vs. indwelling; figure without requiring large doses of parenteral narcotics
on right below shows distribution of sciatic block. 4. Get your nurses through the initial phase and they’ll
c. If these peripheral nerve blocks are placed pre- be happy to deliver regular doses of Tylenol and
operatively by a different anesthesiologist than the Celebrex when they find out that majority of patients
one who does your intra-op anesthesia they can be are no longer vacillating between marked pain and
billed for separately; you now have a major incen- excessive somnolence or ongoing nausea and vomiting
tive for your anesthesia colleagues to get organized
VII. Downsides
and have blocks in place for your next case; limit
A. Initial learning curve with anesthesia can be frustrating –
turnover time; improve your productivity at same
sometimes they miss or get incomplete blocks
time you improve patient care.
B. Takes some time to do blocks – if problems encountered
2. Spinal anesthesia
can slow your day down as compared to general anesthe-
3. Epidural anesthesia
sia
C. Postoperative Analgesia
C. Sensorimotor blockade limits muscle function so weight-
1. Oxycontin 10-20 mg bid on schedule
bearing on that extremity the day of surgery or POD#1
2. Celebrex 200-400 mg qday x 3 days or Toradol 15mg
more difficult.
IV q6 hr prn 3 doses POD #1 then Celebrex
D. As experience is gained these deficiencies can be over-
3. Tylenol 1000 mg 6am; Noon; 6pm on schedule
come and ultimately the skilled anesthesiologist can
4. Oxycodone for breakthrough pain – use a pure nar-
facilitate outpatient surgery using this approach.
cotic medication like oxycodone alone (instead of
Tylenol #3 for instance) for this as it does not contain
acetaminophen and you can thus avoid overdosing
acetaminophen.
123
VIII. Major benefits

A. Clear benefits for our patients
B. Applicable to all types of major lower extremity surgery:
primary THA (MIS, mini and traditional); primary TKA
(MIS, mini, traditional) and Revision THA and TKA
SYMPOSIA AR KNEE
REFERENCES 3. Singelyn, Anesth Analg 1998 Continuous Femoral Nerve Block in TKA.
1. Scott S. Reuben,MD; Neil Roy Connelly,MD and Holly Maciolek,RN: 4. Ben-David, Anesth Analg 2003 Sciatic Nerve Block in TKA.
Postoperative Analgesia with Controlled-Release Oxycodone Anesth Analg 1999; 5. Weber, Eur J Anaesthesiol 2002 Sciatic Nerve Block in TKA.
88:1286-91
6. Stevens, Anesthesiology 2000 Psoas Compartment Blockade in THA
2. Scott S. Reuben,MD; Richard Fingeroth,MD; Robert Krushell,MD and Holly
Maciolek,RN: Evaluation of the Safety and Efficacy of the Perioperative
Administration of Rofecoxib for Total Knee Arthroplasty. J Arthroplasty 2002;
17:26-31
PMMA SPACER DESIGN

Michael A. Kelly, MD
I. Two stage reimplantation of septic TKA IV. Molded Arthrodesis Block

A. Static Cement spacers A. Evaluation from simple spacers
B. Molded Arthrodesis spacer B. Macrointerdigitation
1. Medullary Dowels C. Effective immobilization
SYMPOSIA AR KNEE
C. Mobile spacers D. Minimize bone loss and spacer migration
II. Static Cement Spacers V. Medullary Dowels
A. Assist local antibiotic treatment A. 38% In canals culture +
B. Preserve soft tissue envelope and facilitate knee exposure B. Stemmed cement implants in canal with Vancomycin
for reimplantation. and Gentamicin
Cohen et al. C. Hansen – technique with cement gun
J Arthroplasty 3:1988
VI. Mobile Spacers
Booth, Latke
A. Improved ROM following 2nd stage
Clin Orthop. 1989
B. Less overall bone loss
III. Static Cement Spacers - Complications C. Facilitate reimplantation – maintain ligament length
A. Bone injury/loss
VII. Mobile Spacers
B. Migration/Dislocation of Spacer
A. Articulating Spacers
C. Extensor Mechanism erosion
1. Molded
Calon et al.
2. Sterilized prosthesis
Clin Orthop 345:1997.
B. Prostatic
C. Cost major issue
REFERENCES 7. Hanssen AD, Spangehl MJ. Practical applications of antibiotic-loaded bone

1. Calton TF, Fehring TK, Griffin WL. Bone loss associated with the use of spacer cement for treatment of infected joint replacements. Clin Orthop Relat Res,
blocks in infected total knee arthroplasty. Clin Orthop Relat Res, (345): 148-54, (427): 79-85, 2004.
1997. 8. Hofmann AA, Goldberg T, Tanner AM, Kurtin SM. Treatment of infected total
2. Emerson RH, Jr., Muncie M, Tarbox TR, Higgins LL. Comparison of a static with a knee arthroplasty using an articulating spacer: 2- to 12-year experience. Clin
mobile spacer in total knee infection. Clin Orthop Relat Res, (404): 132-8, 2002. Orthop Relat Res, (430): 125-31, 2005.
3. Fehring TK, Odum S, Calton TF, Mason JB. Articulating versus static spacers in 9. Leone JM, Hanssen AD. Management of infection at the site of a total knee
revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop arthroplasty. J Bone Joint Surg Am, 87(10): 2335-48, 2005.
Relat Res, (380): 9-16, 2000. 10. Masri BA, Kendall RW, Duncan CP, Beauchamp CP, McGraw RW, Bora B. Two-
4. Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total stage exchange arthroplasty using a functional antibiotic-loaded spacer in the
knee replacement. Clin Orthop Relat Res, (331): 118-24, 1996. treatment of the infected knee replacement: the Vancouver experience. Semin
Arthroplasty, 5(3): 122-36, 1994.
5. Haddad FS, Masri BA, Campbell D, McGraw RW, Beauchamp CP, Duncan CP.
The PROSTALAC functional spacer in two-stage revision for infected knee. 11. Stevens CM, Tetsworth KD, Calhoun JH, Mader JT. An articulated antibiotic
spacer used for infected total knee arthroplasty: a comparative in vitro elution
6. Hanssen AD, R and JA, Osmon DR. Treatment of the infected total knee arthro- study of Simplex and Palacos bone cements. J Orthop Res, 23(1): 27-33, 2005.
plasty with insertion of another prosthesis. The effect of antibiotic-impregnated
bone cement. Clin Orthop Relat Res, (309): 44-55, 1994.
125
POROUS METALS: FIXATION AND AUGMENTATION

True biologic ingrowth of implants, as a method of long-term for use in several orthopedic applications in the knee including
durable fixation, has been a primary design goal for many TKR primary arthroplasty fixation and support for the tibial compo-
systems. Despite many reported successes, it is recognized that nent with the potential for long-term biologic fixation. Other
routine success has not been realized for all surgeons attempt- applications have included custom cases such as mega-prosthe-
SYMPOSIA AR KNEE
ing to use uncemented TKR. Successful osseointegration of ses and patella salvage.
implant surfaces has occurred with a large variety of porous
Porous metal augmentation devices have been added as new
materials such as beads, plasma spray, interlaced metal fibers,
treatment options for severe proximal tibial bone defects in revi-
and laser etched surfaces.
sion knee arthroplasty. Porous tantalum metaphyseal cones
Due to the experience of metals exhibiting surface or bulk provide mechanical support for the tibial and femoral compo-
porosity, researchers have conducted systematic research aimed nents and have the potential for long-term biologic fixation in
at clarifying the fundamental aspects of interactions between damaged metaphyseal bone. These cones facilitate restoration
porous metals and hard tissue. It has been shown that improved of the proximal tibia metaphysis in Type 2 and 3 defects aiding
fixation can be achieved by bone tissue growing into and in reconstruction of large cavitary and combined segmental
through a porous matrix of metal. Another valuable property of bone defects. These porous metal devices may eliminate or sig-
porous materials is their low elastic modulus. Implant success is nificantly reduce the need for extensive bone grafting or struc-
dependent in part on the interaction of the implant with the tural allograft in revision knee arthroplasty.
surrounding tissues. Porous structures are an advantageous
Active research in animal models has also demonstrated suc-
alternative because the elastic modulus can be adjusted to
cessful soft-tissue attachment into porous tantalum. The
match that of bone, thereby preventing bone resorption and
strength and stiffness of the tendon-implant construct reached
stress shielding.
normal levels by six to twelve weeks in one animal model. The
The pore size and porosity of these porous metals are similar to tissue attachment strength to porous tantalum was three- to six-
that of cancellous bone, meanwhile the compressive strength is fold greater than was reported in a similar study with porous
higher than that of cancellous bone. The Young's modulus is beads. The ability to directly attach soft-tissue to metal has
between that of cancellous bone and cortical bone. Current broad clinical application. The ability to achieve reattachment
designs for orthopedic implants maintain a high volumetric of soft tissues, such as tendon, directly onto a prosthetic surface
porosity (70%-80%), low modulus of elasticity (3 MPa), and would be of great benefit in case of periarticular bone loss or
high frictional characteristics, making this metal conducive to resection. These data suggest tendon healing into a prosthetic
biologic fixation. material can be successfully achieved and that many new tech-
niques of hard and soft-tissue integration with porous metals
Most of the porous metal biomaterials have been produced
will be forthcoming.
with either titanium or tantalum through a variety of different
fabrication techniques. Porous tantalum is currently available
REFERENCES 9. Levine B, Sporer S, Della Valle CJ, Jacobs JJ, Paprosky W. Porous tantalum in
1. Bobyn JD, Poggie RA, Krygier JJ, Lewallen DG, Hanssen AD et al. Clinical valida- reconstructive surgery of the knee: a review. J Knee Surg. 2007 Jul;20(3):185-94.
tion of a structural porous tantalum biomaterial for adult reconstruction. J Bone 10. Levine BR, Sporer S, Poggie RA, Della Valle CJ, Jacobs JJ. Experimental and clini-
Joint Surg Am. 2004;86-A Suppl 2:123-9. cal performance of porous tantalum in orthopedic surgery. Biomaterials. 2006
2. Bobyn JD, Stackpool GJ, Hacking SA, Tanzer M, Krygier JJ. Characteristics of 27:4671-81.
bone ingrowth and interface mechanics of a new porous tantalum biomaterial. J 11. Li JP, Li SH, Van Blitterswijk CA, de Groot K. A novel porous Ti6Al4V: characteri-
Bone Joint Surg Br. 1999 Sep;81(5):907-14. zation and cell attachment. J Biomed Mater Res A. 2005 May 1;73(2):223-33.
3. Bush JL, Wilson JB, Vail TP. Management of bone loss in revision total knee 12. Müller U, Imwinkelried T, Horst M, Sievers M, Graf-Hausner U. Do human
arthroplasty. Clin Orthop Relat Res. 2006 Nov;452:186-92. osteoblasts grow into open-porous titanium? Eur Cell Mater. 2006 Jan 19;11:8-15.
4. Cheung S, Gauthier M, Lefebvre LP, Dunbar M, Filiaggi M. Fibroblastic interac- 13. Radnay CS, Scuderi GR. Management of bone loss: augments, cones, offset
tions with high-porosity Ti-6Al-4V metal foam. J Biomed Mater Res B Appl stems. Clin Orthop Relat Res. 2006 May;446:83-92.
Biomater. 2007 82(2):440-9. 14. Reach JS Jr, Dickey ID, Zobitz ME, et al. Direct tendon attachment and healing to
5. Cohen R. A porous tantalum trabecular metal: basic science. Am J Orthop. 2002 porous tantalum: an experimental animal study. J Bone Joint Surg Am. 2007
Apr;31(4):216-7. 89(5):1000-9.
6. Fujibayashi S, Neo M, Kim HM, Kokubo T, Nakamura T. Osteoinduction of 15. Ries MD, Cabalo A, Bozic KJ, Anderson M. Porous tantalum patellar augmenta-
porous bioactive titanium metal. Biomaterials. 2004 Feb;25(3):443-50. tion: the importance of residual bone stock. Clin Orthop Relat Res. 2006
7. Hacking SA, Bobyn JD, Toh K, Tanzer M, Krygier JJ. Fibrous tissue ingrowth and Nov;452:166-70.
attachment to porous tantalum. J Biomed Mater Res. 2000 Dec 15;52(4):631-8. 16. Ryan G, Pandit A, Apatsidis DP. Fabrication methods of porous metals for use in
8. Itälä A, Heijink A, Leerapun T, Reach JS, An KN, Lewallen DG. Successful canine orthopaedic applications. Biomaterials. 2006 May;27(13):2651-70.
patellar tendon reattachment to porous tantalum.Clin Orthop Relat Res. 2007
Oct;463:202-7.
OPERATING ROOM EFFICIENCY FOR TKA

Robert E. Booth, Jr., MD
Introduction: Technique:
• Speed vs. Efficiency • “Theater” & “Performance”
• Packages & Protocols • Mental Issues
• Imposed Stresses Anticipation Male/Female Mortality
SYMPOSIA AR KNEE
• Benefits & Rewards Simplicity Checks & Balances
• Mass Customization Strategy/Tactics Customization
• Psychology of Systems • Physical Issues
3-D Capability Stereotaxis
Pieces of the Puzzle:
CAS vs. Manual Eliminating Gaps
• Pre-Admission Testing
Ambidexterity? Muscle Memory
• Pre-Surgery Conference
• Technical Issues
• SPD & Case Carts
Presentation & Attitude Responsibility
• Instrumentation
Safety Dedication
• O.R. Team
Use of Tools “Kaizen”
• Anesthesia & Induction
• Timeliness
Economics:
PRO - CON -
Volume Reimbursement
Experience Expectations
Resources Resentment
Complexity Volume Issues
Time for… Reinvestment
127
CHOICES AND COMPROMISES

FOR THE TREATMENT OF KNEE ARTHRITIS
SYMPOSIA AR KNEE
IN THE BABY BOOMER (M)

Moderator: John J. Callaghan, MD, Iowa City, IA
Due to activity and the natural progression of knee arthritis, many young active patients will
require surgery. Surgical techniques and outcomes will be outlined for this population.
I. Burden of Disease for Knee Arthritis

II. Non-Arthroplasty Considerations for Tibial-Femoral Arthritis

Annunziato Amendola, MD, Iowa City, IA
III. What Can Be Done About Patella Femoral Arthritis?

Jean-Noel Argenson, MD, Marseille, France
IV. Where Does Unicompartmental Fixation Fit?

Adolph W. Lombardi, Jr., MD, New Albany, OH
V. Total Knee Replacement Options

VI. Discussion & Questions
BURDEN OF DISEASE
Other than arthritis of the fingers, the most common joint The increasing longevity of our population will markedly
affected is the knee. Although symptomatic knee arthritis, espe- increase the prevalence of symptomatic arthritis which has def-
cially osteoarthritis, is most common in the sixth and seventh initely been shown to increase with age. The typical 50 to 60
decades of life, 5 to 10% of men and 5% of women are symp- year old patient who has a total knee replacement is not as phys-
SYMPOSIA AR KNEE
tomatic before age fifty. In addition, the increased activity of the iologically old as when joint replacements were first introduced
younger population has created more post-traumatic knee and their expectations for longevity of joint function increases
arthritis. Compared to several decades ago, patients currently with life expectancy. Although the improvement in joint
receiving total knee replacements are 20% heavier, more physi- replacement designs might be expected to improve outcomes
cally active, three times more likely to have a high school or col- and longevity, the potential offsetting changes in the population
lege education and live more than 25% longer. Twice as many needing these procedures may preclude this. In the future, accel-
people require knee replacement when compared to hip eration from the $14 billion yearly spent on knee replacements
replacement. For these reasons, more durable arthroplasty con- alone will definitely occur as the projection for the number of
structs are needed. It is clear that excessive repetitive loading of knee replacements to be performed in 2030 is 3.6 million in the
articular surfaces because of post-traumatic joint incongruity, United States alone.
instability and malalignment, demanding physical activity, obe-
sity and any joint dysplasia can lead to joint degeneration.
Newer techniques have been developed in the hope of slowing
this progression, if not eliminating it.
REFERENCES 2. Crowninshield R, et al. Changing demographics of patients with total joint

1. Buckwalter J, et al. The impact of osteoarthritis, implications for research. CORR. replacement. CORR. 443:266-272, 2006.
427S:S6-S15, 2004. 3. Kurt S, et al. Projections of primary and revision hip and knee arthroplasty in the
United States from 2005 to 2030. JBJS Am. 89-A:780-785, 2007.
129
NON-ARTHROPLASTY CONSIDERATIONS FOR

TIBIO-FEMORAL ARTHRITIS
Annunziato Amendola, MD
A. Options for treatment of tibial femoral arthritis a. Routine Series

SYMPOSIA AR KNEE
a. Optimize nonoperative management i. standing AP

i. Activity modification ii. standing tunnel
ii. Muscular rehabilitation iii. lateral
iii. Bracing iv. intra-patellar
iv. Medication b. Standing hip to ankle x-ray (target area is
v. Injections weight-bearing axis) – most important for pre-
1. steroids operative planning
2. hyaluronic acid i. Single leg standing (to see dynamic deformity)
vi. other adjuncts ii. Double leg standing *
b. considerations for non arthroplasty surgical options iii. Non weight bearing
i. alignment / realignment / joint loading pattern * preferred for preoperative planning
ii. focal articular defects
Keep in Mind:
1. arthroscopic debridement / chondroplasty
• Increasing posterior tibial slope increases tendency for anterior
2. marrow stimulation techniques
tibial translation
3. biologic articular resurfacing techniques
• Increasing posterior tibial slope worsens ACL deficit; helps PCL
4. +/- meniscal transplantation
deficit
iii. focal non biologic resurfacing
iv. diffuse multicompartmental degeneration
vi. Techniques :
1. arthroscopic debridement / chondroplasty
1. opening vs closing wedge
B. Non Arthroplasty Surgical Options 2. femoral vs tibial
a. Malalignment / Realignment 3. acute vs gradual distraction
i. Presentation b. Results ( based on literature review and references below)
1. Localized Compartment pain i. Lateral Closing Wedge HTO
a. ± deformity 1. Results deteriorate with time.
b. ± thrust a. 80% good/excellent @ 5 yrs
ii. Goals of Treatment b. 50% good/excellent @ 10 yrs
1. Pain reduction 2. Survirorship lateral closing wedge :
2. Improvement of functional stability – not passive a. Naudie et al, 1999
laxity Median time to failure 11 years
3. Reduction of thrust / instability Probability of survival 5 years 73%
4. Improve the likelihood of success post ligamen- 10 years 51%
tous/cartilage or meniscal reconstructive procedures 15 years 39%
(protect and unload ) 20 years 30%
iii. Indications and approach to realignment Age < 50 yrs and Flexion > 120 degrees
Malalignment Increased probability of survival
Malalignment 5 years 95%
+
Malalignment Malalignment +
Focal cartilage 10 years 80%
+ + Arthritis
resurfacing/ 15 years 65%
Arthritis Instability +
meniscus ii. Opening Wedge HTO for OA + varus deformity
instability
transplantation 1. Hernigou et al, JBJS 1987
iv. Contra-indications a. 10 -13 year follow-up
1. Severe degeneration of opposite tibio-femoral b. 93 patients
compartment c. Good results
2. Gross loss of motion, flexion contracture >15* i. 90% at 5 years
3. Usual medical contra-indications ii. 45% at 10 years
v. Pre-Operative Planning iii. “ .. exact post-op alignment a pre-requisite
1. Detailed history and physical exam for longest relief of symptoms ”
2. Assessment of instability iii. Is there a concern for TKJR following HTO?
3. In-office gait analysis
4. Radiographs:
TABLE 1. RESULTS OF TKA FOLLOWING HTO iv. Biologic resurfacing ( ACI ) preferred for age<25,
Koval, KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL. bipolar lesions , large lesions >2cm 2 without bone
American Academy of Orthopaedic Surgeons. 2002 Ch. 44, loss
Author YearFollow-up TKA Results v. Allograft resurfacing preferred with significant bone
(Years) (No.) loss , for failed ACI
Katz 1987 2.9 21 Results worse than primary TKA e. Rehabilitation
Staheli 1987 3.7 35 Results similar to primary TKA i. Weightbearing status
Windsor 1988 4.6 45 80% had patella baja, results 1. NWB with MS, ACI, allograft or autograft OAT
similar to revision TKA ii. CPM or ROM exercises with aany resurfacing proce-
SYMPOSIA AR KNEE
Scuderi 1989 N/A 66 89% had patella baja dure
Amendola 1989 3.1 42 Knee scores similar, but less ROM
1. additional procedures ( HTO, meniscus , etc may
in the HTO group
Jackson 1994 20 Worse results after HTO alter rehab )
compared to UKR, because of iii. functional progression
complications iv. return to activities 6-12 months following reconstruc-
Mont 1994 6.1 73 Worse knee scores in HTO group tive sx
Gill 1995 3.8 30 Better results after HTO than after
UKR
Bergenudd 1997 4-9 14 No difference in knee scores,
more complications in HTO group
Toksvig 1998 10 40 knee scores same , RSA tibial
movement same
Walther 2000 35 Worse knee scores in HTO group
Meding 2000 7.5 39 No difference in knee scores
when compared with TKA in
opposite knee
iv. Summary HTO for localized OA

1. Correction of malalignment is an essential compo-
nent in the management of the young patient with
early OA, alone or in combination with other proce-
dures.
2. The results of osteotomy are related to the accuracy of
correction, preoperative functional level, degree of E. Combined Procedures
arthrosis. a. Patient assessment
D. Biologic Resurfacing Focal Defects i. Complete evaluation preoperatively, imaging , previous
a. Indications scope/surgery information
i. Age / condition of the joint / focal vs diffuse ii. Assess the joint , alignment , stability , meniscal status
ii. Size of lesion , articular defect size, location etc, degree of arthrosis
iii.Associated pathologies : ligament stability , meniscus iii. Imaging : radiographs , MRI for preoperative plan-
status , alignment ;diffuse degeneration , inflammato- ning
ry ( ie CPPD) b. Combined Surgery ( unicompartmental disease associat-
b. Options ed with other problems)
i. Chondroplasty / debridement i. Cartilage AND Meniscus
ii. Marrow stimulation techniques ( microfracture) 1. Meniscus alone, or Simultaneous
iii. Autograft osteochondral transfer ( OAT ) ii. Cartilage AND ACL ( or other deficiency )
iv. Allograft osteochondral resurfacing 1. ACL alone, or simultaneous
v. Autologous condrocyte implantation iii. Cartilage AND Osteotomy
vi. Emerging technologies 1. Osteotomy alone, or simultaneous
c. Treatment algorithm ( see chart below ) iv. Cartilage AND Patellofemoral joint
d. Authors preference 1. Realignment alone , or simultaneous
i. Ideal candidate has stable knee, age <40, well aligned, F. Summary
meniscus intact without inflammatory or generalized a. A knee joint with balanced , flexible , strong soft tissue
disease envelope will function better than weak stiff joint
ii. Chondroplasty may be used judiciously as a primary b. A stable well aligned joint will function better than left
treatment for most lesions alone
iii. Chondroplasty or microfracture may be used in c. Cartilage restoration in the appropriate patient may be a
combination with osteotomy, realignment, ligament viable alternative to nonoperative treatment or arthro-
reconstruction, meniscal transplantation plasty.
131
REFERENCES 31. Buckwalter JA & Mankin HJ. Articular cartilage: degeneration and osteoarthritis,
1. Brown GA, Amendola A : Radiographic evaluation and preoperative planning for repair, regeneration and transplantation. Instructional Course Lectures 1998; 47:
high tibial osteotomies. In Operative Techniques in Sports Medicine W. B. 487–504
Saunders. 2000, 8: pp 2-14. 32. Jackson RW& Dieterichs C. The results of arthroscopic lavage and debridement
2. Chambat P, Selmi TAS, Dejour D, et AL : Varus tibial osteotomy. In Operative of osteoarthritic knees based on the severity of degeneration: a 4- to 6-year symp-
Techniques in Sports Medicine. W.B. Saunders. 2000. 8: pp 44-47. tomatic follow-up. Arthroscopy 2003; 19(1):13–20.
3. Coventry MB: Proximal tibial varus osteotomy for osteoarthritis of the lateral 33. Kim HKW, Moran ME & Salter RB. The potential for regeneration of articular car-
compartment of the knee. J Bone Joint Surg 1987, 69A:32-38. tilage in defects created by chondral shaving and subchondral abrasion. The
Journal of Bone and Joint Surgery 1991; 73-A:1301–1315.
4. Miniaci A, Grossmann SP, Jacob RP: Supracondylar femoral varus osteotomy in
SYMPOSIA AR KNEE
the treatment of valgus knee deformity. American J of Knee Surg. 1990. 2:65-73 34. Sterett WI, Steadman JR. Chondral resurfacing and high tibial osteotomy in the
varus knee. Am J Sports Med. 2004 Jul-Aug;32(5):1243-9. Epub 2004 May 18.
5. Puddu G, Franco V: Femoral antivalgus opening wedge osteotomy. In Operative
Techniques in Sports Med. W.B. Saunders 2000. 8: pp56-60 35. Koshino T, Murase T, Saito T. Medial opening-wedge high tibial osteotomy with
use of porous hydroxyapatite to treat medial compartment osteoarthritis of the
6. Rosenberg TD, Paulos LE, Parker RD et Al: The forty-five degree posteroanterior knee. J Bone Joint Surg Am. 2003 Jan;85-A(1):78-85.
flexion weight-bearing radiograph of the knee. J Bone Joint Surg. 1988. 70A:
1479-1483. 36. Deie M, Sumen Y, Adachi N, Nakamae A, Miyamoto A, Kanaya A, Ochi M. The
long-term results of meniscus transplantation for articular cartilage defects in the
10. Fowler, P., Tan, JL., Brown, G. Opening wedge high tibial osteotomy. How I do knee joint. Knee Surg Sports Traumatol Arthrosc. 2006 Jun 13; [Epub ahead of
it. Operative Techniques in Sports Medicine 8 (1): 2-14 : January print]
11. Amendola AS, Giffin JR, Sanders DW. Osteotomy for knee stability: The effect of 37. Jamali AA, Emmerson BC, Chung C, Convery FR, Bugbee WD. Fresh osteochon-
increasing tibial slope on anterior tibial translation. Presented at AAOSM dral allografts Clin Orthop Relat Res. 2005 Aug;(437):176-85.
Specialty Day, San Francisco, CA March, 2001.
38. Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and
12. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament future directions.Am J Sports Med. 2005 Mar;33(3):443-60.
reconstruction for varus angulated anterior cruciate ligament-deficient knees.
Am J Sports Med 28(3): 282-296, 2000. 39. Scopp JM, Mandelbaum BR. A treatment algorithm for the management of artic-
ular cartilage defects. Orthop Clin North Am. 2005 Oct;36(4):419-26.
13. Naudie D, Amendola A, Fowler P. Opening wedge high tibial osteotomy for
chronic posterior instability. AJSM,, may ,2004. 40. Steadman JR, Briggs KK, Rodrigo JJ, et al. Outcomes of microfracture for traumat-
ic chondral defects of the knee: Average 11-year follow-up. Arthroscopy
14. Dejour H, Walch G, Chambat P, et al. Active subluxation in extension: a new 2003;19:477-484.
concept of study of the ACL deficient knee. Am J Knee Surg 1:204-211, 1988.
41. Hangody L, Kish G, Karpati Z, et al. Arthroscopic autogenous osteochondral
15. Hernigou et al, Opening wedge High Tibial Osteotomy for Varus Gonarthrosis, mosaicplasty for the treatment of femoral condylar articular defects: A prelimi-
JBJS(A),1987 nary report. Knee Surg Sports Traumatol Arthrosc 1997;5:262-267.
16. Amendola A, Fowler PJ, Litchfield R, Kirkley S, Clatworthy M., Opening wedge 42. Hangody GETL, Kish G, Karpati Z. Arthroscopic autogenous osteochondral
high tibial osteotomy using a novel technique: early results and complications., J mosaicplasty: A multicentric, comparative, prospective study. Index Traumat
Knee Surg. 2004 Jul;17(3):164-9. Sport 1998;5:3-9.20. Gross AE. Fresh osteochondral allgorafts for post-traumatic
17. Markoff KL, Bargar WL, Shoemaker SC, et al. The role of joint load in knee sta- knee defects: Surgical technique. Oper Tech Orthop 1997;7:334.
bility. J Bone Joint Surg 70A: 977-982, 1988. 43. Gross AE, Aubin P, Cheah HK, et al. A fresh osteochondral allograft alternative. J
18. Hughston JC, Jacobsen KE. Chronic posterolateral rotatory instability of the Arthroplasty 2002;17(Suppl 1):50-53.
knee. J Bone Joint Surg 67A: 351-359, 1985. 44. Ghazavi MT, Pritzker KP, Davis AM, Gross AE. Fresh osteochondral allografts for
19. Coventry MB. Osteotomy of the upper portion of the tibia for degenerative post-traumatic osteochondral defects of the knee. J Bone Joint Surg Br
arthritis of the knee: a preliminary report. J Bone Joint Surg 47A: 984-990, 1965. 1997;79:1008-1013.
20. Coventry MB. Upper tibial osteotomy for osteoarthritis. J Bone Joint Surg 67A: 45. Beaver RJ, Mahomed M, Backstein D, Davis A, et al. Fresh osteochondral allo-
1136-1140, 1985. grafts for post-traumatic defects in the knee. A survivorship analysis. J Bone Joint
Surg Br 1992;74:105-110.
21. Dejour H, Neyret P, Boileau P, et al. Anterior cruciate reconstruction combined
with valgus tibial osteotomy. Clin Orthop 299:220-228, 1994. 46. Bugbee WD, Convery FR. Osteochondral allograft transplantation.Clin Sports
Med 1999;18:67-75.
22. Koval, KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL. American
Academy of Orthopaedic Surgeons. 2002 Ch. 44. 47. Garrett JC. Fresh osteochondral allografts for treatment of articular defects in
osteochondritis dissecans of the lateral femoral condyle in adults. Clin Orthop
23. A, Insall JN, Scuderi GR.Proximal Tibial Osteotomy: Subjective Outcome Study 1994;303:33-37.
Nagel JBJSA 1996
48. Minas T. Autologous chondrocyte implantation for focal chondral defects of the
24. Kalunian KC, Moreland LW, Klashman DJ et al. Visually-guided irrigation in knee. Clin Orthop 2001;391(Suppl):S349- 361.
patients with early knee osteoarthritis: a multicenter randomized, controlled
trial. Osteoarthritis and Cartilage 2000; 8(6): 412–418. 49. Micheli LJ, Browne JE, Erggelet C, et al. Autologous chondrocyte implantation of
the knee: Multicenter experience and minimum 3-year follow-up. Clin J Sport
25. Moseley JB, O’Malley K, Petersen NJ et al. A controlled trial of arthroscopic sur- Med 2001;11:223-228.
gery for osteoarthritis of the knee. The New England Journal of Medicine 2002;
347(2): 81–88. 50. Peterson L, Minas T, Brittberg M, et al. Two- to 9-year outcome after autologous
chondrocyte transplantation of the knee. Clin Orthop 2000;374:212-234
26. Hubbard MJS. Arthroscopic surgery for chondral flaps in the knee. The Journal of
Bone and Joint Surgery 1987; 69B: 794–796. 51. Gillogly SD, Voight M, Blackburn T. Treatment of articular cartilage defects of the
knee with autologous chondrocyte implantation. J Orthop Sports Phys Ther
27. Baumgaertner MR, CannonWD, Vittori JM et al. Arthroscopic debridement of the 1998;28:241-251.
arthritic knee. Clinical Orthopaedics and Related Research 1990; 253: 197–202.
52. Brittberg M, Lindahl A, Nilsson A, et al. Treatment of deep cartilage defects in the
28. Bert JM. Role of abrasion arthroplasty and debridement in the management of knee with autologous chondrocyte transplantation. N Engl J Med 1994;331:889-
osteoarthritis of the knee.Rheumatic Diseases Clinics of North America 1993; 895.
19(3): 725–739.
53. Wolf B., Amendola A., Impact of Osteoarthritis on Sports Careers. Clinics In
29. Dandy DJ. Arthroscopic debridement of the knee for osteoarthritis. The Journal Sports Medicine 24(1):187-198, January 2005.
of Bone and Joint Surgery 1991; 73B: 877–878.
54. Pagnano M., Clarke H., Jacofsky D., Amendola A., Repicci J., Surgical Treatment
30. Moseley JB, Wray NP, Kuykendall D et al. Arthroscopic treatment of osteoarthritis of the Middle-Aged Patient With Arthritic Knees. Pellegrini Jr. V. ed., Instructional
of the knee: a prospective, randomized, placebo-controlled trail: results of a pilot Course Lectures. 54:251-259, 2005.
study. The American Journal of Sports Medicine 1996; 24(1): 28–34.
WHAT CAN BE DONE FOR PATELLOFEMORAL ARTHRITIS?

Jean-Noël A. Argenson, MD and Sebastien Parratte, MD
Isolated osteoarthritis of the patellofemoral joint can be a dures should be proposed as first choice in the young popula-
source of severe anterior knee pain and may limit daily activities tion even if the effects are often limited.
such as rising from a chair or stair climbing. It can be also an
The anterior elevation of the tibial tuberosity is most of the time
important source of limitation for physical and sporting activi-
SYMPOSIA AR KNEE
averaging 15mm and the goal is to reduce cartilage load in order
ties for many young and active patients. In a patient population
to obtain pain relief. In Europe the popularity of the original
with painful knees and of forty years old or more the prevalence
Maquet procedure has diminished due to the number of post-
of isolated patellofemoral arthritis can reach 10%.1
operative complications, the absence of realignment of the
The first treatment option to consider should be conservative, extensor mechanism and the low position of the patella found
based on physiotherapy and most patients can be treated suc- in 25% of the cases at the time of revision.
cessfully by such method. Modifications of sporting activities
For the young population a medial transfer of the patella has
and the use of specific knee brace can help for reducing pain dur-
been promoted in order to avoid the disadvantages of the
ing daily or specific activities. The goal of physical therapy should
Maquet procedure while maintaining the principles of reducing
be to strengthen and stretch the structures about the knee while
the load at the site of the lateral aspect of the cartilage. This can
including water exercises. However surgical treatment may be
be combined to an anterior transfer of the tuberosity by chang-
necessary in case of persistent knee pain and several options have
ing the orientation of the cut as proposed by Fulkerson et al.13
been proposed. The non-arthroplasty options include debrid-
The best results are found in patients with arthritis limited to the
ment of the patellofemoral joint now currently performed dur-
lateral portion of the patella.
ing athroscopy procedures,2 elevation of the anterior tibial tuber-
cle originally proposed by Maquet,3 spongialization of the patel- Removal of the subchondral bone down to the cancellous bone
la or various techniques of subchondral bone removal,4 autolo- has been proposed during the mid-eigthties in order to reduce
gous chondrocyte implantation,5 or patellectomy.6 the stresses on the patellofemoral joint but progressively aban-
doned.
Total Knee Arthroplasty (TKA) can address both femorotibial
and patellofemoral osteoarthritis but this can be considered as Patellar denervation may play a role for diminishing pain when
an overly aggressive approach in case of arthritis limited to a sin- the origin is at the level of the patella.
gle compartment. This would be particularly true in a young
Autologous chondrocyte implantation may be cost-effective for
and active patient for whom the surgeon looks for the most
young patients with an apparent improvement in pain relief
bone-sparing procedure. Patellofemoral arthroplasty (PFA),
and function but the followup of these recent techniques is lim-
resurfacing both sides of the patellofemoral joint, has been pro-
ited.5
posed as an alternative to those treatments.7-12
Patellectomy has been proposed to solve the problems on the
Pre-Operative Evaluation of Patellofemoral Arthritis patellar side, but total patellectomy has significant negative con-
It is important to recognize the factors leading to patellofemoral sequences reducing the lever arm of the extensor mechanism
arthritis in the young and active population in order to choose and therefore leading to extensor weakness probably not accept-
the appropriate surgical procedure after failure of the non-opera- able nowadays in young and active patients. The best option, if
tive options. Several factors may play a significant role such as necessary for traumatic reasons, is the turn-down of a full-thick-
obesity or repetitive activity in deep knee flexion, however ness flap of quadriceps tendon sutured into the patellar tendon
trochlea dysplasia or extensor mechanism malalignment are the as described by Castaing in 1969.2
most frequent factors found for the young and active population.
A more attractive and conservative option can be the removal of
Beside the classic pain on the lateral facet of the patella found the lateral facet of the patella when the arthritis is limited to the
during physical examination the presence of patellar tilt and lateral aspect of the compartment and the clinical symptoms
instability should be explored and evaluated. The pre-operative described as lateral inpingment.
radiological analysis should include the obligatory Merchant
The plasty of the trochlea, a technically demanding procedure,
view at 30° of flexion but also lateral view of the knee for patel-
has been proposed in France by Dejour et al, in order to treat the
lar height evaluation and frontal “schuss” view for evaluation of
deficiency of the trochlea groove and improve the stability of
the femorotibial joint. The patellofemoral view at 60° of flexion
the patella.14
will evaluate the medial portion of the patellofemoral joint.
Long leg films are usefull to evaluate the mechanical axis of the
PatelloFemoral Arthroplasty
knee and search for abnormality in rotation. Whether CT-scan
The modern concept of PFA includes a metallic trochlear com-
is probably not justified for the pre-operative evaluation of
ponent articulating with a polyethylene patellar component,
femorotibial arthritis it may be particularly usefull for the eval-
and excluding isolated resurfacing of the patella or the trochlea
uation of patellar tracking and the measurement of the distance
as proposed in the early days. The first reports with intermedi-
between anterior tibial tuberosity and deepest part of trochlear
ate term follow-ups showed encouraging results but little
groove.
attempt was made to identify precise indications and character-
ize the technical aspects of the procedure leading to quick fail-
Non-Arthroplasty Procedures for Patellofemoral Arthritis
ure.
Arthroscopic procedures may include extensive debridment of
the patellofemoral joint more or less combined to lateral reti- More recent reports were able to address these issues or present
nacular release in case of evident patellar tilt and preserved longer term followup studies.15-18 In a study group of 57 knees
medial joint cartilage. These non- or minimally invasive proce- evaluated at a mean followup of 16.2 years (12 to 20 years), we
133
were not able to identify age at surgery as a detrimental factor for try to identify the etiology of the patellofemoral degeneration
survival of the procedure, with a mean age at operation of 57 and we found that this progression of osteoarthritis occured
years.17 The etiologies of osteoarthritis were divided into three mainly in the group of primary osteoarthitis of the
groups: instability with history of patellar dislocation, post-trau- patellofemoral joint with no history of patellar instability or
matic osteoarthritis primarly attributable to patellar fracture, and fracture. In this group of patients the preoperative radiographic
primary osteoarthritis of the patellofemoral joint . Fourteen knees analysis should either eliminate knees with large frontal defor-
were revised for progression of osteoarthritis in the tibiofemoral mities or indicate an associate frontal osteotomy.
compartment and converted to total knee arthroplasty. In the
The technical considerations related to PFA may include the
only available study with a comparative long term followup pub-
SYMPOSIA AR KNEE
need for lateral retinacular release or realignment of the exten-

lished by Kooijman et al,16 the authors also conclude that
sor mechanism at the time of patellofemoral arthroplasty.8,10,11
patellofemoral unicompartmental arthroplasty has a high revi-
The importance of precise alignment of the femoral component
sion rate. In the study group of 45 knees implanted with
to achieve correct patella tracking has also been noted , avoid-
patellofemoral arthroplasty and studied at an average followup of
ing flexion and internal rotation.10,12,17
15.6 years they noted seven revisions related to the arthroplasty
and twelve revisions for tibiofemoral osteoarthritis progression . In conclusion we consider that patellofemoral arthroplasty can
be a valuable option for young age patients with isolated
In these two long term studies, as well as in the recent one by
patellofemoral osteoarthritis and no important frontal
Ackroyd et al,18 progressive osteoarthritis in the unreplaced
tibiofemoral deformity. When the osteoarthritis is consecutive
tibiofemoral compartment remains the first cause of failure in
to patellofemoral instability attention should be taken to obtain
knees implanted with patellofemoral arthroplasty. Since a sig-
a correct alignment of the extensor mechanism. We believe all
nificant number of these knees will require conversion to total
the components of the PFA should be cemented and the poly-
knee arthroplasty after ten years of correct function
ethylene patellar button should be compatible with conven-
patellofemoral arthroplasty might be considered as a temporary
tional TKA designs. For patients younger than fifty we believe
procedure for young age patients. Considering this issue, the
that patellofemoral arthroplasty is not an irreversible procedure
femoral component of a patellofemoral prosthesis should then
such as patellectomy, and is more conservative than total knee
be easy to revise and the polyethylene patellar button compati-
arthroplasty which has been proposed for isolated
ble with conventional total knee arthroplasty designs.19 We did
patellofemoral arthritis.20-22
REFERENCES 12. De Cloedt P, Legaye J, Lokietek W. Femoropatellar prosthesis. A Retrospective

1. Davies AP, Vince AS, Shepstone L, Donell ST, Glasgow MM. The radiologic preva- study of 45 consecutive cases with a followup of 3-12 years. Acta Orthop Belg.
lence of patellofemoral osteoarthritis. Clin Orthop Relat Res., 2002;402:206-212. 1999;65(2):170-5.
2. Grelsamer RP, Stein DA. Patellofemoral Arthritis. Current Concepts Review. J 13. Fulkerson JP, Becker GJ, Meaney JA, Miranda M, Folcik MA. Anteromedial tibial
Bone Joint Surg Am. 2007;88:1849-1860. tubercle transfer without bone graft. Am J Sports Med. 1990;18:490-497.
3. Maquet P : Advancement of the tibial tuberosity. Clin Orthop. 1976;115:225- 14. Dejour D, Le Coultre B. Osteotomies in patello-femoral instabilities. Sports Med
230. Arthrosc. 2007;15:39-46.
4. Ficat RP, Ficat C, Gedeon P, Toussaint JB : Spongialization : A view treatment for 15. Tauro B, Ackroyd CE, Newman JH, Shah NA : The Lubinus patellofemoral arthro-
diseased patellae. Clin Orthop 144:74-83, 1979. plasty. A five to ten-year prospective study. J Bone Surg Br. 2001;83:696-701.
5. Minas T, Bryant T. The role of autologous chondrocyte implantation in the 16. Kooijman HJ, Driessen APPM, Van Horn JR : Long-term results of patellofemoral
patellofemoral joint. Clin Orthop Relat Res. 2005;436:30-39. arthroplasty. A report of 56 arthroplasties with 17 years of follow-up. J Bone
Joint Surg Br. 2003 ;85:836-840.
6. Lennox IA, Cobb AG, Knowles J, Bentley G. Knee function after patellectomy. A
12- to 48-year follow-up. J Bone Joint Surg Br. 1994 ;76 :485-487. 17. Argenson JN, Flecher X, Parratte S, Aubaniac JM. Patellofemoral arthroplasty. An
update. Clin Orthop Relat Res. 2005;440:50-63.
7. Blazina ME, Fox JM, Del Pizzo W, Bronkhim B, Ivey FM : Paellofemoral replace-
ment. Clin Orthop Relat Res. 1979;144:98-102. 18. Ackroyd CE, Newman JH, Evans R, Eldridge JD, Joslin CC. The Avon
patellofemoral arthroplasty: five-year survivorship and functional results. J Bone
8. Cartier P, Sanouiller JL, Grelsamer R : Patellofemoral arthroplasty. 2-12 year fol- Joint Surg Br. 2007 ;89 :310-315.
low-up study. J Arthroplasty 1990;5:49-54.
19. Lonner JH, Jasko JG, Booth RE. Revision of a failed patellofemoral arthroplasty
9. Argenson JN, Guillaume JM, Aubaniac JM : Is there a place for patellofemoral to a total knee arthroplasty. J Bone Joint Surg Am. 2006;88:2337-2342.
arthroplasty ? Clin Orthop Realt Res. 1995;321:162-167.
20. Laskin RS, Van Steijn M : Total knee replacement for patients with patellofemoral
10. Krajca-Radcliffe JB, Coker TP : Patellofemoral arthroplasty. A 2 to 18 year fol- arthritis. CORR 367:89-95, 1999.
lowup study. Clin Orthop Relat Res. 1996;330:143-151.
21. Parvizi J, Stuart MJ, Pagnano MW, Hanssen AD. Total knee arthroplasty in
11. Mertl P, Van FT, Bonhomme P, Vives P. Femoropatellar osteoarthritis treated by patients with isolated patellofemoral arthritis. CORR 392:147-152, 2001.
prosthesis. Retrospective study of 50 implants. Rev Chir Orthop Reparatrice
Appar Mot. 1997;83(8):712-8. 22. Mont MA, Haas S, Mullick T, Hungerford DS. Total knee arthroplasty for
patellofemoral arthritis. J bone Joint Surg Am. 2002;84:1977-1981.
WHERE DOES UNICOMPARTMENTAL ARTHROPLASTY FIT?

Adolph V. Lombardi Jr, MD, FACS and Keith R. Berend, MD
Classic Indications for UKA Average follow-up was 8 months (range: 6 weeks to 28 months).
Despite being reported more than 15 years ago, many surgeons There were 6 revision surgeries for an early survivorship of
continue to follow the standard indications outlined by Kozinn 98.1%. One knee was revised for ongoing pain, one for tibial
and Scott.1 plateau fracture, and three for tibial loosening. One knee was
SYMPOSIA AR KNEE
revised in a two-stage manner for infection. The average Knee
• Exclude patients who weigh >82 kg
Society (KS) pain score at early follow-up was 42/50, and the
• Exclude age < 60 years
overall KS score averaged 90/100. ROM averaged 118º. ROM
• Exclude patients who have more than minimal erosive
>115º was obtained in 262 knees (82%).
changes in the patellofemoral articulation
• Exclude patients with anterior knee pain, thought to be a When stratified by age younger than 50 years, there was no dif-
sign of significant patellofemoral involvement ference in early failure (Log-rank/Wilcoxon; P = ns). Higher aver-
• <15° cumulative angular deformity age KS pain scores were seen in patients older than 50 years (43
• NOT physically active or heavy labor vs. 36; P = .002). Average KS total scores were also higher in the
• ROM >90°; Flexion contracture <5° age group older than 50 years (91 vs. 84; P = .002). Age younger
• Minimal rest pain than 60 years was not predictive of early failure (Log-
• Non-inflammatory Rank/Wilcoxon; P = ns). Higher average KS pain scores were
• Intact anterior cruciate ligament (ACL) observed in the patient group over age 60 (41 vs. 43; P = .03). The
average KS total scores were not significantly different between
Applying these conservative indications, the percentage of
the groups of patients older and younger than 60 years. Weight
patients with osteoarthritic knees who may be candidates for
was not predictive of survivorship or clinical outcome when strat-
unicompartmental knee arthroplasty (UKA) has been reported
ified by weight >82 kg or weight >90 kg. When stratified by BMI,
to be between 2% and 15%.2-8
no differences in early survival or revision were observed.
Survivorship in patients with BMI >32 kg/m2, obese patients with
More Liberal Oxford Indications for UKA9-12
a BMI >35 kg/m2, and morbidly obese patients with a BMI >40
• Full thickness medial cartilage loss
kg/m2 was no different between the groups (P = ns). Clinical out-
• Anterior disease with preserved posterior bone
comes were significantly better in the <35 BMI group and the <40
• Fully correctable, full thickness lateral cartilage
BMI group.
• Intact ACL
Survivorship in knees with pre-existing radiographic signs of
Applying these more liberal indications, the percentage of
patellofemoral joint disease was not significantly different than
patients with osteoarthritic knees who may be candidates for
in knees with no preoperative patellofemoral radiographic
UKA is approximately 35%.
changes. There was a trend toward a higher average KS pain
Clinical Experience score in knees with pre-existing patellofemoral joint disease (43
In July 2004, the US FDA approved the use of a mobile-bearing vs. 41; P = .052). In knees with pre-existing patellofemoral joint
prosthesis for implantation in UKA. We investigated the early disease, the average KS total score was significantly higher than
outcomes in our practice of medial mobile-bearing UKA in in knees without patellofemoral joint arthritis on preoperative
patients who do not meet the standard inclusion criteria, specif- radiographs (91 vs. 89; P = .04). No correlation could be estab-
ically, studying the role of obesity, young age, patellofemoral lished between the presence or severity of pre-existing
arthritis, and isolated medial knee pain on the early outcomes patellofemoral joint disease and the location of preoperative
and failures of this device. pain described by the patient.
Between July 2004 and December 2006, 318 UKA were per- Isolated medial knee pain was not a significant predictor of sur-
formed in 268 patients. Among the patients were 156 (49%) vivorship or failure with the device (Log-Rank/Wilcoxon;
women, and surgery was performed on the right knee in 156 P = ns). KS pain scores in knees with isolated medial preopera-
(49%) patients. The average patient age was 61.6 years (range: tive pain was not significantly different than KS pain scores in
33-90). Patients were younger than 60 in 151 (47.5%) cases, knees with pain other than medially based pain (43 vs. 41; P =
and younger than 50 in 46 (14.5%). Average height was 1.7 m .06). KS total scores were also not significantly different between
(range: 1.42-1.85). Average weight was 92 kg (range: 51 to - groups of patients with or without isolated medial preoperative
158). In 220 knees (69%), the patient's weight was >82 kg. The knee pain (91 vs. 89; P = .16). One-way ANOVA did not reveal
average patient BMI was 32.3 kg/m2 (range: 20-58). In 83 cases a significant difference in KS clinical scores between the differ-
(26%), the patient was categorized as obese with BMI >35. ent sites of preoperative pain (P = .34; P = .46).
Patients were morbidly obese with a BMI >40 kg/m2 in 30 (9%)
of the cases. One hundred fifty (47%) UKA were performed in Anteromedial Arthritis
patients with a BMI >32 kg/m2, a category considered at risk for In patients with anteromedial disease, indicated by an intact
failure secondary to obesity. anterior cruciate ligament and functionally normal medial col-
lateral ligament with a correctable varus deformity, the results of
Patients were asked preoperatively to describe the area of their
mobile-bearing UKA have been excellent.13-18 There are certain
most severe knee pain, with those describing more than two
indications and contraindications, however, that are widely
areas categorized as global. Isolated medial pain was reported in
debated.1,18,19-23 Kozinn and Scott1 are credited with describing
211 knees (67%), anterior pain in 20 (6%), lateral pain in 9
the so-called standard indications for unicompartmental knee
(3%), posterior pain in 9 (3%) and global pain in 65 (21%).
arthroplasty. The Oxford indications do not routinely use
Pain location was not reported for four knees.
135
weight, age, activity, the presence of patellofemoral disease, or Status of the Patellofemoral Joint
the location of preoperative pain as selection criteria. Perhaps the most controversial contraindication for UKA is the
preoperative status of the patellofemoral joint. Significant involve-
Obesity and Wear Concerns ment of a second compartment, namely the patellofemoral joint,
Weight >82 kg was originally described as a contraindication to is considered a contraindication.1 Despite past consideration of
fixed-bearing UKA.1 In one series examining a resurfacing, fixed- patellofemoral joint arthritis as a contraindication, the results of
bearing type unicompartmental knee arthroplasty, BMI >32 UKA with the mobile-bearing device have been outstanding and
kg/m2 was a significant predictor of early failure.21 A recent progression of disease in the patellofemoral joint has not present-
report supported that weight or BMI is not an independent pre- ed as a clinical problem.16-18,26,27 This has not been the case with
SYMPOSIA AR KNEE
dictor of survivorship in the mid to long term.22 There is concern fixed-bearing designs. Recent reports indicate that progression of
that in the long term, increasing weight may lead to increased patellofemoral joint disease may be a significant cause of second-
wear of the bearing. Weight is not a predictor of increased wear decade failure with certain fixed-bearing designs.8,28,29 In compari-
with the Oxford fully congruent mobile bearing.24,25 son, the long-term reports of UKA with the mobile-bearing pros-
thesis do not indicate progression of patellofemoral joint arthritis
Alternatives to UKA in Young Patients as a significant failure with this device.16-18,26,27
There are few alternatives for the treatment of medial compart-
mental arthritis in young adults. High tibial osteotomy lost Recovery and Survival
favor in recent years because the long-term results have been A rapid and functional return to activities is possible after uni-
unsatisfactory.19 With traditional fixed-bearing UKA, failure in compartmental knee arthroplasty in appropriately selected
younger patients is predominantly associated with polyethylene patients.11,12 Survivorship at 7 years is 97.3% with this device.30
wear. However, good results with some fixed-bearing designs The conservative, bone preserving nature and long-term survivor-
have been obtained in younger patients.8,22 In this population, ship of the study device warrant its position at the top of the list
survivorship has been excellent, with very little wear reported of alternatives for treating medial disease in the growing middle
using the fully congruent mobile-bearing design.24,25 UKA with age population.20,22,30 In addition, by restoring the knee to the pre-
the mobile-bearing prosthesis has achieved 10-year outcomes disease state with ligamentous balance and functional kinemat-
and survivorship in patients younger than age 60 years that is ics, activity and lifestyle are considerably improved to near nor-
similar to results with older, more sedentary individuals.20 mal in many patients following this conservative procedure.31,32
REFERENCES 18. Vorlat P, Putzeys G, Cottenie D, et al. The Oxford unicompartmental knee pros-
1. Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg Am. 1989; thesis: an independent 10-year survival analysis. Knee Surg Sports Traumatol
71:145-150. Arthrosc. 2006;14:40-45.
2. Stern SH, Becker MW, Insall JN. Unicondylar knee arthroplasty: an evaluation of 19. Rees JL, Price AJ, Lynskey TG, et al. Medial unicompartmental arthroplasty after
selection criteria. Clin Orthop Relat Res. 1993;286:143-148. failed high tibial osteotomy. J Bone Joint Surg Br. 2001; 83:1034-1036.
3. Laskin RS. Unicompartmental knee replacement: some unanswered questions. 20. Price AJ, Dodd CA, Svard UG, Murray DW. Oxford medial unicompartmental
Clin Orthop Relat Res. 2001; 392:267-271. knee arthroplasty in patients younger and older than 60 years of age. J Bone Joint
Surg Br. 2005; 87:1488-1492.
4. Sculco TP. Orthopedic cross-fire: can we justify unicondylar arthroplasty as a
temporizing procedure? In opposition. J Arthroplasty. 2002; 17(suppl 4):56-58. 21. Berend KR, Lombardi AV Jr, Mallory TH, Adams JB, Groseth KL. Early failure of
minimally invasive unicompartmental knee arthroplasty is associated with obesi-
5. Naudie D, Guerin J, Parker DA, Bourne RB, Rorabeck CH. Medial unicompart- ty. Clin Orthop Relat Res. 2005; 440:60-66.
mental knee arthroplasty with the Miller-Galante prosthesis. J Bone Joint Surg
Am. 2004; 86:1931-1935. 22. Tabor OB Jr, Tabor OB, Bernard M, Wan JY. Unicompartmental knee arthroplas-
ty: long-term success in middle-age and obese patients. J Surg Orthop Adv. 2005;
6. Gesell MW, Tria AJ Jr. MIS unicondylar knee arthroplasty: surgical approach and 14:59-63.
early results. Clin Orthop Relat Res. 2004; 428:53-60.
23. Pagnano MW, Clarke HD, Jacofsky DJ, et al. Surgical treatment of the middle-
7. Ritter MA, Faris PM, Thong AE, Davis KE, Meding JB, Berend ME. Intra-operative aged patient with arthritic knees. Instr Course Lect. 2005; 54:251-259.
findings of varus osteoarthritis of the knee: an analysis of pre-operative align-
ment in potential candidates for unicompartmental arthroplasty. J Bone Joint 24. Argenson JN, O'Connor JJ. Polyethylene wear in meniscal knee replacement: a
Surg Br. 2004; 86(1):43-47. one to nine-year retrieval analysis of the oxford knee. J Bone Joint Surg Br. 1992;
74:228-232.
8. Berger RA, Meneghini RM, Sheinkop MB, et al. The progression of
patellofemoral arthrosis after medial unicompartmental replacement: results at 25. Price AJ, Short A, Kellett C, et al. Ten-year in vivo wear measurement of a fully
10-15 years. Clin Orthop Relat Res. 2004; 428:92-99. congruent mobile bearing unicompartmental knee arthroplasty. J Bone Joint
Surg Br. 2005; 87:1493-1497.
9. Goodfellow J, O'Connor J, Murray DW. The Oxford meniscal unicompartmental
knee. J Knee Surg. 2002; 15:240-246. 26. Keblish PA, Baird JL. Mobile-bearing unicompartmental knee arthroplasty: a 2-
center study with an 11-year follow-up. J Arthroplasty. 2004;19(suppl 2):87-94.
10. Murray DW, Goodfellow JW, O'Connor JJ. The Oxford medial unicompartmen-
tal arthroplasty: a ten-year survival study. J Bone Joint Surg Br. 1998; 80:983-989. 27. Rajasekhar C, Das S, Smith A. Unicompartmental knee arthroplasty: 2- 12-year
results in a community hospital. J Bone Joint Surg Br. 2004; 86:983-985.
11. Price AJ, Webb J, Topf H, et al. Rapid recovery after Oxford unicompartmental
arthroplasty through a small incision. J Arthroplasty. 2001; 16:970-976. 28. Berger RA, Della Valle CJ, Jacobs JJ, Sheinkop MB, Rosenberg AG, Galante JO.
The progression of patellofemoral arthrosis after medial unicompartmental
12. Beard DJ, Murray DW, Rees JL, Price AJ, Dodd CA. Accelerated recovery for uni- replacement: results at 10-15 years. Clin Orthop Relat Res. 2006; 452:285-286.
compartmental knee replacement---a feasibility study. Knee. 2002; 9:221-224.
29. Berger RA, Meneghini RM, Jacobs JJ Sheinkop MB, Della Valle CJ, Rosenberg AG,
13. Goodfellow J, O'Connor J. Clinical results with the Oxford knee. Clin Orthop Galante JO. Results of unicompartmental knee arthroplasty at a minimum of 10-
Relat Res. 1986; 205:21-42. years follow-up. J Bone Joint Surg Am. 2005; 87:999-1006.
14. Goodfellow J, O'Connor J. The anterior cruciate ligament in knee arthroplasty: a 30. Pandit H, Jenkins C, Barker K, Dodd CA, Murray DW. The Oxford medial uni-
risk factor with unconstrained meniscal prosthesis. Clin Orthop Relat Res. compartmental knee replacement using a minimally-invasive approach. J Bone
1992;276:245-252. Joint Surg Br. 2006; 88:54-60.
15. White S, Ludkowski PF, Goodfellow J. Anteromedial osteoarthritis of the knee. J 31. Fisher N, Agarwal M, Reuben SF, Johnson DS, Turner PG. Sporting and physical
Bone Joint Surg Br. 1991; 73:582-586. activity following Oxford medial unicompartmental knee arthroplasty. Knee.
16. Price AJ, Waite JC, Svard U. Long-term clinical results of the medial Oxford uni- 2006; 13:296-300.
compartmental knee arthroplasty. Clin Orthop Relat Res. 2005; 435:171-180. 32. Walton NP, Jahromi I, Lewis PL, Dobson PJ, Angel KR, Campbell DG. Patient-
17. Svard UC, Price AJ. Oxford medial unicompartmental knee arthroplasty. A sur- perceived outcomes and return to sport and work: TKA versus mini-incision uni-
vival analysis of an independent series. J Bone Joint Surg Br. 2001; 83:191-194. compartmental knee arthroplasty. Knee. 2006; 19:112-116.
TOTAL KNEE REPLACEMENT OPTIONS

Over the last several years, much has been learned about —6.2 year avg f/u
requirements for a durable total knee arthroplasty. Better more —No revisions
wear-resistant polyethylenes have been developed. The need for • Mont et al. J Arthroplasty, 2002
optimal capturing mechanisms for modular components has —TKA under 50
SYMPOSIA AR KNEE
been defined. Monolithic tibial components have been re-intro- —30 TKAs
duced. Mobile bearing knee replacements have been available. —7 year avg f/u
A better understanding of the ramifications of aggressive kine- —3% revised, none loosening
matics and high flexion on wear and contact stresses have been • Lonner et al. CORR, 2000
developed. Going forward, these concepts as well as the contin- —TKA under 40
ued debate of cement versus cementless fixation have an —32 TKAs
increased relevance in evaluating whether certain designs or —Min 5 year f/u
design factors will be more durable in the younger active —12.5% aseptic failure
patient. • Gioe et al. CORR, 2007
—TKA under 55
The following are the reported results of total knee replace- —1047 TKAs
ment in the younger patient population: —5.6% females revised
• Diduch et al. JBJS Am, 1997 —9.2% males revised
—Under 55 OA • Whiteside L et al. CORR, 2007
—114 TKAs —Cementless TKA under 55
—8 year avg f/u —167 TKAs
—9% tibial lucencies —Weight more than 90 kg
—Revisions: 1 wear, 3 patella, 1 instability —Min 5 year f/u
• Meding et al. CORR, 2007 —1 revised for wear
—TKA under 60 for P-F arthritis
—334 TKAs
REFERENCES 4. Meding J, et al. Total knee arthroplasty for isolated patellofemoral arthritis in
younger patients. CORR. 464:78-82, 2007.
1. Diduch D, et al. Total knee replacement in young, active patients. Long-term fol-
low-up and functional outcome. JBJS Am. 79:5-82, 1997. 5. Mont M, et al. Total knee arthroplasty in patients </= 50 years old. J Arthroplasty.
17:538-34, 2002.
2. Gioe T, et al. Knee arthroplasty in the young patient: survival in a community
registry. CORR. 2007. in press. 6. Whiteside L, et al. Young and heavy patients with a cementless TKA do as well as
older and lightweight patients. CORR. 2007. in press.
3. Lonner J, et al. Total knee arthroplasty in patients 40 years of age and younger
with osteoarthritis. CORR. 380:85-90, 2000.
137
UNICOMPARTMENTAL KNEE REPLACEMENT:

INDICATIONS AND TECHNIQUE (X)
SYMPOSIA AR KNEE
Moderator: David W. Murray, MD, Oxford, UK

Despite the resurgence of interest in unicompartmental replacement there remains great
controversy about indications and technique. These will be debated.
I. UKR as a Pre TKR

John A. Repicci, MD, Buffalo, NY
II. Fixed bearing UKR with limited indications

Alfred J. Tria, Jr., MD, Princeton, NJ
III. Fixed bearing UKR with extended indications

Gerard A. Engh, MD, Alexandria, VA
IV. Mobile Bearing UKR – A European perspective

Christopher Dodd, FRCS, Oxford, UK
V. Mobile Bearing UKR – An American perspective

Keith R. Berend, MD, Columbus, OH
VI. A discussion, question and answer session will then follow addressing
a) Indications
b) Technique
VII. Summary and conclusions
UKR: BONE SPARING TECHNIQUE

John A. Repicci, MD
SYMPOSIA AR KNEE
139
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141
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143
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145
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BONE SPARING TECHNIQUE

John A. Repicci, MD
SYMP X “The Moving Target—Elderly patients decision Avoid Supra Patellar Pouch
making regarding • The supra patellar pouch is a functioning organ which is
destroyed by patellar dislocation dramatically increasing
Arthroscopic Debridement vs. Unicompartmental
morbidity. Avoiding the supra patellar pouch reduces the
SYMPOSIA AR KNEE
Arthroplasty
morbidity to near arthroscopic proportions.
Medical compartmental OA • Avoiding patellar dislocation reduced P.T. use by 95%
• Extension Gap Disease
Technique—landmarks
Extension Gap: ACL laxity
• Femur—Extension gap Slide 39
MCL laxity
• Tibal Slide 41
Lateral tibial shift
Slide 43
• Flexion Gap: No deformity
Age of Insertion
Risk factors for progression or knee OA
• Patient choice: 58-78. patients accept “arthritic bypass”
• Ref. Wolfe F. Lane; J Rheumatol 202;30:114-120
concept as alternate to TKR
• Patients with complete loss medial joint space
8-15% will choose TKR Material Issues
Patients between 55-64 years old are twice as likely to • TKR—poly –metal 18mm
choose TKR • Unis—poly metal 10 mm or excessive bone loss
Varus is a destructive force Problems
• >2 degrees varus—3x greater risk for OA progression • Bone loss
• Poly wear and deformation
Medial tibial buttress
• Loosening
• Nature compensates for medial articulas surface loss by
increasing the width and Density of the medial tibial---but- Survival—Early Experience With Mini-invasive Technique
tress collapse is rare. • 445 patients---97% discharged from hospital in 1 day or
• Kapandji—“The overall curvatures of the lower limb reflect less
the stresses which are applied and obey the laws of Eular
Reasons for Revision
governing the behavior of columns eccentrically loaded.”
• Loosening: 30-50% (80% tibial)
• With the slow development of varus, nature compensates
• Other compartment 25%
by widening the medial tibia plateau and increasing bone
• Patella: less than 3%
density(sclerotic bone). This structure can be considered
• Other (wear , fracture design etc.)
the Medial Tibial Buttress, and is highly valuable for sup-
port of a Unicompartmental implant system. 8-Year follow Up
• 136 Patients with Mini Invasive Unicompartmental
Unis vs. TKR
Arthroplasty
• 1/3 Tibial surface support
— Non-selective survival: 91%
• Medial cortex support only
— Ahlback 2,3 96%
• Eccentrically loaded
— Ahlback 4 75%
• 10 mm Poly excessive bone loss
Note: Medial age 66, advanced disease has significantly low-
• Ligament balance: priority—not mechanical axis
ered survival rate.
Landmarks For Prosthesis Insertion
Conclusion
• Unicompartmental arthroplasty is a soft tissue balancing
• Varus is a destructive force
procedure
• Medial OA is Extension Gap Disease
• Flexion gap—no deformity, therefore, the joint line in flex-
• Patients compensate for years
ion is an absolute reference point at the posterior tibial,
• Unis are useful in restoring soft tissue balance
normal articulas surface location.
• Patients accept a low morbidity, bone sparing uni as an
• Internal landmarks—see enclosed diagrams
extension of conservative management.
Mini Invasive Technique
Technique Video
• Avoid cutting functional tissue
• Soft tissue balance
• Protect the quadriceps
147
FIXED BEARING UKA WITH LIMITED INDICATIONS

Alfred J. Tria, Jr., MD
Introduction opposite compartment or in the patellofemoral. However, if the

Unicompartmental knee arthroplasty (UKA) has become more patient describes pain in all zones of the knee, UKA is not
popular in the United States with the introduction of better appropriate. The traditional conservative measures of physical
instruments and the improved surgical approach using the min- therapy, COX 1 and COX 2 inhibitors, and external supportive
SYMPOSIA AR KNEE
imally invasive surgical (MIS) techniques. The prosthetic devices should always be considered first.
designs have been available for some twenty years and there are
The physical examination begins with the patient’s height and
many surgical reports in the literature that review the results and
weight. Either of these items alone may be misleading and the
the complications. 1,2,3,4,5,6,7,8,9 The results are improving now
body mass index is probably more helpful. The authors have
and new designs are also appearing. The replacement should be
arbitrarily chosen a cut off of 250 pounds (114 kilograms). The
part of the orthopaedist’s armamentarium for the treatment of
literature has previously indicated a limit of 200 pounds (91
arthritis of the knee; however, the indications should be limited
kilograms) with the concern of tibial component subsidence
to the ideal patient.
and/or excess polyethylene wear. The surgical technique has
been changed for these patients in an attempt to address the
History
weight increase.
The first unicondylar type devices were inserted in the early
1950’s. Duncan McKeever used a flat metallic insert that includ- UKA can be performed with a ten-degree maximum flexion
ed a keel for press fit fixation on the tibial plateau.10 MacIntosh contracture, 10 degrees of varus deformity and 15 degrees of val-
initially used an acrylic prosthesis, then, changed to titanium, gus deformity. In the ideal case, the coronal plane deformity
and, finally, changed to a vitallium tray without the keel and should correct to neutral with valgus or varus stress. This correc-
relied on the soft tissues to hold the device in place.11 Gunston tion obviates the need for any surgical ligamentous release dur-
began working with Charnley in 1966 and published the first ing the operation. The knee should have at least 110 degrees of
paper on the cemented polycentric knee in 1971.12 Marmor flexion to permit enough range of motion in the operating
inserted the first cemented unicondylar knee replacement in the room to insert the femoral component on the cut surface. The
United States using the Modular Knee design from Richards coronal plane measurements should be correlated with the
based on the concepts developed by McKeever.5 Insall and standing roentgenograms. There should be no medial or lateral
Walker published their experience with a unicondylar design thrust of the femur on the tibia through the stance phase of gait.
that resulted in 15 patellectomies in 24 replacements and they The joint lines and the patellofemoral articulation should be
concluded that the prosthetic technique was unacceptable.1 palpated to evaluate the degree of tenderness. There should be
Laskin published his data in 1978 and he reported a high inci- a clear difference in the localization of the tenderness and this
dence of subsidence of the tibial component leading to a high should correlate with the patient’s description from the history.
revision rate. 3 During the 1990’s the incidence of unicondylar All four of the major knee ligaments should be tested. It is often
replacement in the United States decreased significantly. At the said that the ACL deficient knee is a contraindication to UKA.
Mayo clinic during that decade from 1990 to 2000, 8500 total This is not true with fixed bearing designs and may only have
knee arthroplasties (TKA’s) were performed and only 3 uni- relevance in the mobile bearing prostheses.23, 24
condylar surgeries were completed.13 At the same time, the inter-
est in the European communities remained somewhat high. Imaging studies
Christiansen reported on 575 unicondylar replacements in Plain x-rays form the mainstay of the imaging studies. The
1991 with nine years of follow-up and only a 3.6% revision standing film is critical. An appropriate patellar view, such as the
rate.14 Knutson reported on 7649 replacements in 1986.15,16 Merchant x-ray, helps to show the extent of the arthritic involve-
With the Sledge knee the survival rate was 96% at six years and ment and the alignment of the patellofemoral joint. The lateral
93% with the Marmor knee. Marmor published multiple papers film is also helpful to see the patellofemoral joint and to evalu-
in the late 1980’s and reported some improvement in the ate the slope of the tibial plateau. Translocation of the tibia
results. 5, 6 Scott’s papers in the 1990’s included multiple com- beneath the femur is a relative contraindication.
plications with the Brigham Unicondylar Knee.17,18 In the mid
1990’s Repicci designed a unicondylar knee and presented an Surgical Technique
MIS approach that began to rekindle interest in the United The surgical approach can be completed with a relatively limit-
States.19 Berger published his long-term results with the Miller- ed incision according to the comfort of the surgeon. A curved
Galante Unicondylar knee in 1999 and reported 98% success at medial or lateral incision is most appropriate. Minimal medial
10 years.20 Repicci subsequently reported his own eight year fol- and lateral flaps are elevated. The arthrotomy is, then, per-
low-up data with 93% survival.21 formed on either the medial or lateral side in the line of the inci-
sion. The deep medial collateral is elevated from the tibial
Indications plateau line for visualization of the joint and not for the pur-
If the indications for UKA are limited, the results do tend to poses of release. The superficial ligament must be protected so
improve. John Insall felt that only 6 percent of patients truly sat- that excess release and overload of the lateral compartment does
isfied the indications for the procedure.22 not occur.
On the lateral side, the arthrotomy is taken down to the joint
Patient History and Physical Examination
line and the capsule
The history should be obtained with the best clarity possible
concerning the location and duration of the pain. Localized is peeled back along the tibial plateau line. If the visualization
pain on either the medial or the lateral joint line is critical. It is is not adequate, the arthrotomy incision can be extended prox-
sometimes difficult to determine the extent of symptoms in the imally for a centimeter along the medial or lateral side of the
quadriceps tendon without everting the patella. The patellar fat Once the preliminary cuts are completed, the flexion-extension
pad can also be cut back but this sometimes leads to increased gap should be tested. In the ideal case there should be 2 mm of
bleeding. laxity in full extension and at ninety degrees of flexion. It is best
not to over tighten the joint and to accept greater, rather than
UKA is a surgical procedure that depends completely upon the
less, laxity. Excess tightness can lead to early polyethylene failure
bone resections to balance the flexion and extension gaps. The
and also contributes to increase pressure on the contra lateral
order of the cuts does vary with each set of instruments and
side. If the spacing is unequal by more than 1 mm, the cuts
component designs.
should be revised to correct the imbalance.
The distal femoral cut is can be made first with an
SYMPOSIA AR KNEE
The author prefers to cement all of the components. It is best to
intramedullary reference.
cement the tibial component first and then the femoral. This
Once the distal femur is cut, the remainder of the femoral cuts permits better exposure and evacuation of cement from the pos-
can be completed with the appropriate finishing blocks. The terior aspect of the joint. Modular tibial components are easier
femoral runner should be a slight bit smaller than the original to cement because the metal tray can be inserted without the
femoral condyle surface and should be perpendicular to the tib- polyethylene and there is more space for inspection. The all
ial plateau component in full extension and in ninety degrees of polyethylene tibial insert does give more thickness of polyethyl-
flexion. The femoral component should also be centered medi- ene but it is more difficult to cement and exchange requires
al to lateral on the tibial polyethylene surface. invasion of the underlying bone.
The anatomic valgus of the distal femur is determined by the The closure of the arthrotomy is performed with non-
depth of the femoral cut. The standard amount of bone is absorbable sutures in an interrupted fashion over a single drain.
removed from the medial femoral condyle if the distal femoral The vastus closure should be anatomic without over tightening
valgus is 5 degrees or less. If the distal femoral valgus is 6 degrees or residual laxity.
or more, an additional 2 mm of bone can be resected to avoid
increase of the distal femoral valgus. If the distal femoral valgus Postoperative Management
is increased after the femoral replacement, the alignment of the The patient is encouraged to walk, full weight bearing, within
joint may be shifted into excess valgus leading to overload of the two to four hours after the surgery and flexion is instituted
lateral compartment of the knee. By avoiding this increase, the before discharge from the hospital. Most patients stay one night
resultant tibial plateau resection is decreased, conserving bone in the hospital; however, the procedure can be performed as an
on the tibial side. In most systems the total amount of femoral outpatient surgery.
resection with the deeper cut is still less than the bone removal
for a customary TKA which is 9 mm. In the valgus knee the Results
depth of the distal femoral cut should not be changed. The first 47 knees are now seven years after surgery. The average
age of the patients was 68 with the range from 42 to 93. There
The tibial cut can be made with either an extramedullary or
were two age peaks, one at 55 and one at 75 and the differences
intramedullary instrument. However, extramedullary instru-
were statistically significant between the two groups and the
mentation does favor a smaller incision. If the flexion space is
total knee population. There were 17 males and 24 females with
very small, the tibial cut should be made before the femoral cuts
45 varus knees and 2 valgus knees. There were 6 bilateral sur-
are completed to allow more room for the femoral jigs. The tib-
geries and 2 patients returned for the opposite side within the
ial cut can be angled from anterior to posterior. Most systems
first six months. There were no cases of infection, loss of
favor a 5 to 7 degree posterior slope for roll back. However, slop-
motion, DVT, pulmonary embolism, myocardial infarction or
ing this cut can also help with the flexion-extension balancing.
death. There was one case of a tibial plateau fracture that
Usually, the flexion gap is larger than the extension gap because
occurred ten days after the surgical procedure and healed with-
of a flexion contracture. As the flexion contracture increases to
out incident. One knee developed a dislocating patella 6
ten degrees, the extension gap becomes tighter. If the slope of
months after the original surgery and went on to revision TKA
the tibial cut is decreased, the cut can be made deeper anterior-
at 15 months. One patient was converted to a TKA 5 years after
ly to give greater space in extension while maintaining the same
the original operation. The Knee Society pain score improved
flexion gap. Changing the slope of the tibial plateau may affect
from 45 to 80 and the function score went from 47 to 78. These
roll back in some designs, especially if the tibial polyethylene is
results are midterm but are promising for the future.
dished. Once the tibial cut is completed, the proper size tray for
the plateau should be chosen.
Conclusions
Some techniques suggest inlaying the implant within the con- Unicondylar knee arthroplasty is now evolving into a more
fines of the cortical bone on the sclerotic subchondral base. acceptable surgical approach that can be included in the arma-
This technique is more demanding and can lead to subsidence mentarium of procedures for arthritis of the knee. The concepts
if the base is penetrated. The onlay technique is less challeng- of balancing, instruments and, overcorrecting have been
ing and rests the tray on the cortical rim. Overhang is not desir- emphasized. The UKA is not at all a TKA and should not be
able but complete coverage is important to prevent subsidence. thought of as such. Some balancing and some modifications
The tibial cut should be perpendicular to the long axis of the can be made during the surgical procedure but they are based
tibia in the coronal plane and not in any degree of varus. Some on different principles than the TKA. UKA represents a good
few degrees of valgus are tolerated but not desirable. In the alternative in the young or the elderly with unicompartmental
obese patients, the tibial plateau cut is extended more laterally disease of the knee.
(in the varus knee) and more medially (in the valgus knee) to
increase the total plateau coverage and increase the bone sup-
port for the component.
149
REFERENCES 13. Pagnano MW. “Unicompartmental Knee Arthroplasty” presented at The Tenth
1. Insall J and Walker P. Unicondylar knee replacement. Clinical Orthopaedics International Meeting of Reconstructive Surgery, Madrid, Spain, April, 2001.
1976. 120: 83-85. 14. Christensen NO Unicompartment prosthesis for gonarthrosis: Nine-year series
2. Insall J, Aglietti P. A five to seven year follow-up of unicondylar arthroplasty. JBJS of 575 knees from a Swedish hospital. Clinical Orthop 1991, 273:165 – 169.
62A: 1329-1337, 1980. 15. Knutson K, Lindstrand A, Lidgren L. Survival of knee arthroplasties a nationwide,
3. Laskin RS Unicompartment tibiofemoral resurfacing arthroplasty. JBJS 1978 multicenter investigation of 8000 cases. JBJS 1986 68B 795-803.
60A 182-185. 16. Knutson K, Lewold S, Lidgren L. Outcome of revision for failed unicompart-
4. Shurley TH, O’Donoghue DH, Smith WD, Payne RE and Grana WA. ment knee arthroplasty for arthrosis. American Academy of O S. poster exhibit.
Unicompartmental arthroplasty of the knee: A review of three-five year follow- Washington DC 1992.
SYMPOSIA AR KNEE
up. CORR 184:236-240. 17. Scott RD, Cobb AG, McQueary FG et al. Unicompartmental knee arthroplasty:
5. Marmor L: Marmor modular knee in unicompartmental disease. Minimum four- Eight to twelve year follow-up with survivorship analysis. CORR 271: 96-100,
year follow-up. JBJS 61A: 347-353, 1979. 1991.
6. Marmor L: Unicompartmental arthroplasty of the knee with a minimum of 10- 18. Scott RD. Robert Brigham unicondylar knee, surgical technique. Techn Orthop
year follow-up. CORR 228: 171- , 1988. 5:15-23, 1990.
7. Thornhill TS, Scott RD: Unicompartmental total knee arthroplasty. Orthop Clin 19. Repicci JA, Eberle RW. Minimally invasive surgical technique for unicondylar
of North America 20:245- , 1989. knee arthroplasty. Journal of the Southern Orthopaedic Association 8(1): 20-27,
1999.
8. Goodfellow JW, O’Connor BE. Clinical results of the Oxford knee. Surface
arthroplasty of the tibiofemoral joint with a miniscal bearing prosthesis. CORR 20. Berger RA, Nedeff DD, Barden RN, Sheinkop MN, Jacobs JJ, Rosenberg AG,
205: 21-48, 1986. Galante JO. Unicompartmental knee arthroplasty. CORR 367: 50- 60, 1999.
9. Palmer SH, Morrison PJM, and Ross AC. Early catastrophic Tibial Component 21. Romanowski MR and Repicci JA. Minimally invasive unicondylar arthroplasty:
wear after unicompartmental knee arthroplasty. CORR 350:143-148, 1998. Eight-year follow-up. Journal of Knee Surgery 15(1):17-22, 2002.
10. McKeever DC, Elliott RB. Tibial plateau prosthesis. CORR 18: 86-95, 1960. 22. Stern SH, Becker MW, Insall J. Unicompartmental knee arthroplasty. An evalua-
tion of selection criteria. CORR 286:143-148, 1993.
11. MacIntosh DL. The use of hemiarthroplasty prosthesis for advanced osteoarthri-
tis and rheumatoid arthritis of the knee. JBJS 40A: 1431- , 1972. 23. Goodfellow JW, Tibrewal SB, Sherman KP, O’Connor JJ. Unicompartmental
Oxford meniscal knee arthroplasty. J Arthroplasty 2:1-9, 1987.
12. Gunston FH. Polycentric knee arthroplasty. JBJS 53B: 272-277, 1971.
24. Goodfellow JW, Kershaw CJ, Benson MKD’A, O’Connor JJ. The Oxford knee for
unicompartmental osteoarthritis. JBJS 70B: 692-701, 1988.
FIXED BEARING UKA WITH EXTENDED INDICATIONS

Gerard A. Engh, MD
My Philosophy and Newman et al.6

• Often, degenerative arthritis is primarily isolated to one • Compared to TKA, benefits of UKA are:
compartment of the knee — safer procedure with reduced surgical trauma
• Occurs spontaneously in individuals in their late 50s and 60s — no blood transfusions needed
SYMPOSIA AR KNEE
• Most commonly involves both knees — reduced risk of infection
• Approximately 85% of cases involve the medial compart- — reduced risk of fat and pulmonary embolism without the
ment of the knee use of intramedullary instruments
— a secondary varus deformity develops that overloads the — shorter hospital stay (usually only one day)
medial compartment and somewhat unloads and pro- — the procedure is safely and easily performed through a muscle
tects the lateral compartment from degeneration. sparing small incision that results in less postoperative pain
— When present, damage to the cruciate ligaments is sec-
Results
ondary to
• Swedish, Australian and New Zealand National Registries
– intercondylar notch spur formation,
— provide the best source of survivorship with UKAs
– tibial subluxation,
— provide information on the revision rates for specific
– abrasion of the ACL with increasing varus deformity.
implants.
– accounts for the kissing lesion that results from
• Comparing personal experience with other implants in
impingement of the tibial spine with the lateral
both the New Zealand and Australian registries.
femoral condyle.
— 7.9% cumulative revision rate at 4 yrs for the Preservation
My Current Experience implant (Australian Nat. Registry, 2004 report)
• 47% of knee arthroplasty procedures are UKAs – is equivalent to other implants commonly used in
• More liberal indications for UKA Australian that have recorded over 100 revisions such
— I have not identified a higher failure rate in obese as the Allegretto and the Oxford 3 devices.
patients or patients with a deficient ACL if there is no – the initial revision rate was higher with the introduc-
clinical history of knee instability tion of the Preservation UKA to Australia, but is now
— Grade 3 and limited grade 4 changes in the statistically similar to other fixed and mobile bearing
patellofemoral joint have not been contraindications. unicondylar implants.
– I have found that revision for progression of arthritis — 3.4% cumulative revision rate for the Preservation UKA
in the patellofemoral joint has not been a cause of (New Zealand Nat. Registry, 2006 report)
failure except in extremely rare cases. – lower than revision rates for the Miller-Galante) and
– I have found that progression of arthritis in the lateral Oxford 3) UKAs.
compartment is rare. When it does occur, it doesn’t • Personal Experience using Extramedullay Alignment
develop until the second decade following unicondy- Technique to Implant UKAs (2001–2006)
lar arthroplasty. — 3.6% revision rate for the Preservation UKA (25/694)
– 56% required revision because of aseptic loosening
Surgical Options
(14/25).
• Include UKA, TKA or bicondylar replacement (resurfaces
- 11 of these were implanted early in my experience
the patellofemoral joint with the medial compartment)
(between 2001- 2002)
• Major advantage of options other than TKA
- The most important lesson I have learned is the
— better knee kinematics with retention of both cruciate
need to optimize the fixation interface for both the
ligaments
tibial and femoral components.
— more stable and kinematically correct knee arthroplasty
– At present, I place multiple small drill holes in all
— full knee flexion is possible
areas of dense bone prior to cementing to allow full
– with preservation of the lateral compartment, there is full
cement penetration into areas of sclerotic bone.
axial rotation and femoral roll-back on the lateral side.
I believe this will eliminate the problem with failures
• Better knee kinematics have been documented in studies
because of aseptic loosening.
utilizing video fluoroscopy by Dennis and Komistek1 and
patellar tendon angle comparisons in studies by Price et al,2 Summary
and Oxford Rig studies by Patil et al.3 The elimination of gamma irradiation-in-air sterilization has large-
• Unicondylar implants are preferred by patients over total ly eliminated problems of polyethylene wear with first generation
knee implants because of the better range of motion, pain UKAs. I anticipate that the orthopaedic community will recognize
relief, and stair climbing ability as has been documented in the kinematic benefits of UKA compared to TKA and that the num-
direct comparison studies by Cobb et al,4 Laurencin et al,5 ber of UKAs will increase, particularly for active individuals.
REFERENCES 4. Cobb AG, Kozinin SC, Scott RD. Unicondylar or total knee replacement: Patient
1. Dennis DA, Komistek RD. Kinematics of mobile bearing total knee arthroplasty. preference. J Bone Joint Surg Br. 1990;72:166.
Instr Course Lect, 2005;54:207-220. 5. Laurencin CT, Zelicof SB, Scott, RD, Ewald FC. Unicompartmental verses total
2. Price AJ, Rees JL, Beard DJ, Gill RH, Dodd CA, Murray DM. Sagittal plane kine- knee arthroplasty in the same patient. A comparative study. Clin Orthop 1991
matics of a mobile-bearing unicompartmental knee arthroplasty at 10- years: A Dec;273:151-156.
comparative in vivo fluoroscopic analysis. J Arthroplasty 2004 Aug;19(5):590-597. 6. Newman JH, Ackroyd CE, Shah NA. Unicompartmental or total knee replace-
3. Patil S, Colwell CW Jr, Ezzet KA, D’Lima DD. Can normal knee kinematics be ment? Five-year results of a prospective, randomized trial of 102 osteoarthritic
restored with unicompartmental knee replacement? J Bone Joint Surg Am. 2005 knees with unicompartmental arthritis. J Bone Joint Surg Br. 1998
Feb;87(2):332-338. Sep;80(5):862-865.
151
MOBILE BEARING UNICOMPARTMENTAL KNEE REPLACEMENT: A

EUROPEAN PERSPECTIVE
Christopher A F Dodd, FRCS
Medial unicompartmental knee replacement (UKR) has many that arthritis does not progress in the patellofemoral joint after
SYMPOSIA AR KNEE
advantages over total replacement (TKR). As all the undamaged UKR 11. There is a trend, however, for slightly lower Oxford
structures of the joint, in particular the cruciate ligaments, are scores (38 as opposed to 31) in patients who have full thickness
preserved knee function can be restored more nearly to normal. carilage loss in lateral compartment PFJ.
After UKR the range of movement is better than after TKR, the
Nor is age a contraindication. The low morbidity of UKR is a
knee feels more natural and pain relief if as good or better 1-3.
clear advantage over TKR in elderly patients. In younger sub-
In terms of morbidity, operative blood loss is less and transfu-
jects, UKR can be recommended as no more likely to fail at 10-
sion unnecessary; complications are less frequent and less seri-
15 years than TKR and with the advantage that, should failure
ous and recovery is more rapid. However, UKR has the disad-
occur, revision to TKR is simple and has good results 12,13. We
vantage that the medium and long-term revision rates are gen-
have shown that patients in their 50’s have a ten-year survival
erally higher than for TKR. UKR are therefore considered by
rate that is not significantly different from older subjects
many to be pre-knee replacements, and are only expected to last
(>90%) 13. Moderate obesity and the presence of chondrocal-
for a short period. We have attempted to minimise the failure
cinosis have both been shown to be without adverse effect on
rate of UKR to make it similar to that of TKR. The reasons for
long-term survival 14.
the failures after UKR include:
Instrumentation and surgical technique are very important in
1) The high polyethylene wear rate of thin tibial components
unicompartmental replacement, the object of which is to
subjected to incongruous loading.
restore the kinematics of the damaged compartment so that it
2) Inappropriate patient selection functions in compliance with the retained articular surfaces and
ligaments of the undamaged compartment. Using a mobile-
3) Primitive instrumentation to enable intraoperative restora-
bearing implant ensures that the prosthesis itself imposes no
tion of the retained ligaments to isometric function.
artificial constraints, but the stability of such a device depends
The Oxford UKR has spherical femoral and flat tibial compo- upon restoring ligament tension isometrically throughout the
nents. Between them lies an unconstrained mobile bearing, the range of movement. A guided power mill is used to prepare the
upper surface of which is spherically concave and the lower sur- femur by removing bone from its distal surface in 1 mm incre-
face flat, so that it is fully congruent with both metal compo- ments, gradually increasing the gap between the articular sur-
nents in all positions. The contact area is large (about 6sq. cm) faces in extension until it is the same as the gap in flexion.
and the contact pressure is therefore low. This form of articula- When the gap is filled with a bearing of the right thickness, the
tion, while imposing no constraints upon movement, dimin- ligaments are restored to their normal tension and remain so
ishes polyethylene wear to very low values. Furthermore, the throughout the range of movement. With this technique the
rate of wear is independent of bearing thickness. It is therefore incidence of bearing dislocation has been very low, and a meta-
safe to use bearings of 3.5 mm 4,5. Measurement of retrieved analysis revealed a dislocation rate of 0.4% (2 out of 551 UKR)
bearings has shown a mean linear wear rate (combining both 15.
articular surfaces) of 0.03 mm/year, and even less (0.01
The designer’s own series of primary medial unicompartmental
mm/year) if the knee had been functioning with no impinge-
replacements consisted of 144 knees (age 35 – 90), one of
ment 5.
which was lost to follow-up 6. The 10-year survival was 98%
The main indication for UKR is medial compartment (95% confidence limits (CI) 93% to 100%). The designer’s own
osteoarthritis 6. The anterior cruciate ligament should be func- results may need to be treated with caution as they are suscepti-
tionally intact 7,8. The fixed flexion deformity should be less ble to bias, however, Svard and Price 16 reported an independ-
than 15°. The varus deformity should be correctable and there ent series treated by 3 surgeons, of 420 medial UKR with none
should be full thickness cartilage in the lateral compartment lost to follow-up 17. The 15-year survival was 94% (CI 86% to
(best demonstrated by valgus stress x-rays taken with the knee in 100%). 122 of these were reviewed clinically with a follow up
20° of flexion) 9. At operation, a full thickness ulcer is often of 10 years or more and 92% had good or excellent results. In
seen in the cartilage on the medial side of the lateral femoral addition Rajasekhar, Das and Smith 18 recently reported a series
condyle caused by impingement on the tibial spine; this is not of 135 medial UKR with none lost and a 10 year survival of 94%
a contraindication. Full thickness cartilage loss in weight bear- (CI 84% to 98%), and Keys et al 19 reported a series of 40 medi-
ing areas of the lateral femoral condyle is, however, a con- al UKR with none lost and a 10 year survival of 100%. In these
traindication. Using these indications, about one in three survival studies revision for any cause was considered to be a
osteoarthritic knees needing replacement is suitable for UKR. failure. The results from both the designer’s and the independ-
ent series are therefore as good as the published results of TKR.
We have shown that many of the contraindications proposed
The 10 year clinical scores are better. The recent mid term scores
for fixed-bearing UKR are unnecessary for the mobile bearing
for TKR from the Trent Arthroplasty Group show an 80% suc-
device 6. In our practice, no knee is excluded because of fibril-
cess rate if pain is used as an outcome measure 20.
lation or erosions in the patellofemoral joint. We have found
no correlation between the state of the patellofemoral joint at By contrast a survival of only 90% at five years was reported in
operation and the clinical outcome 10 and we have not had to 1995 for the Oxford UKR in the Swedish Knee Arthroplasty
revise a knee for patellofemoral pain. Furthermore, we have Register (SKAR) 21. We were able to obtain data from Sweden
shown by radiographic comparison at an interval of ten years and found that the failure rate varied from centre to centre, from
0% to as high as 30%, and that centres implanting greater num- 23. With appropriate pain control the procedure can be done
bers had lower failure rates. The poor early results must be as a day case and patients have reported less pain during the
attributed to wrong indications and/or inappropriate surgical immediate postoperative period than they suffered preopera-
technique. The 2001 report from the SKAR 22 confirms our tively 24. A study of postoperative radiographs has shown that
observation that a surgeon needs to perform a reasonable num- the Oxford components can be implanted as precisely through
ber of Oxford UKR to be proficient. It also revealed that, in cen- the limited approach as through the previous open incision 23,
tres doing at least 2 UKR per month, the eight year survival of implying that the long-term results should be similar. We have
the Oxford UKR was 93%. The New Zealand register shows sur- reviewed our first 530 cases and at six years the survival is 98%
geons performing at least 10 Oxford UKR/per annum (1 a (CI 93% to 100%) 25. In addition the clinical results are good
SYMPOSIA AR KNEE
month) have success rates of 93% which is comparable to TKR and we attribute this to the accurate restoration of function in
rates. all the ligaments, particularly the cruciate mechanism and to the
avoidance of damage to the extensor mechanism and the supra-
In 1998 instrumentation was introduced to facilitate a mini-
patellar pouch.
mally invasive approach. The incision is from the medial pole
of the patella to the tibial tuberosity, there is minimal damage We believe that, when the indications are met, a mobile bearing
to the extensor mechanism, the patella is not dislocated and the UKR is the treatment of choice for medial osteoarthritis of the
suprapatellar synovial pouch remains intact. As a result, knee. It provides the patient with the many advantages of UKR
patients recover much more rapidly. We have found that knee over TKR without increasing the risk of failure, at least in the first
flexion, straight leg raising, and independent stair climbing are 15 years.
achieved three times faster after this procedure than after TKR
REFERENCES 13. Price AJ, Svard U, Dodd C, Goodfellow JW, O'Connor JJ, Murray DW. The
Oxford medial unicompartmental knee arthroplasty in patients under 60. .
1. Laurencin CT, Zelicof, S.B., Scott, R.D., Ewald, F.C. Unicompartmental Versus
ESSKA. London, 2000.
Total Knee Arthroplasty in the Same Patient. Clin Orthop 1991;273:151-6.
14. Woods DA, Wallace, D.A., Woods, C.G., McLardy-Smith, P., Carr, A.J., Murray,
2. Newman JH, Ackroyd, C.E., Shah, N. Unicompartmental or Total Knee
D.W., Martin, J., Gunther, T. Chondrocalcinosis and Medial Unicompartmental
Replacement? The 5 Year Results of a Prospective Randomised Trial of 102
Knee Arthroplasty. The Knee 1995;2-2:117-9.
Osteoarthritic Knees with Unicompartmental Arthritis. J Bone Joint Surg
1998;80B:862-5. 15. Price AJ, Svard U, Murray DW. Bearing dislocation in the Oxford Medial
Unicompartmental knee replacement 2000.
3. Rougraff BT, Heck, D.A., Gibson, A.E. A Comparison of Tricompartmental and
Unicompartmental Arthroplasty for the Treatment of Gonarthrosis. Clin Orthop 16. Svard UC, Price AJ. Oxford medial unicompartmental knee arthroplasty. A sur-
1991;273:157 - 64. vival analysis of an independent series. J Bone Joint Surg Br 2001;83-2:191-4.
4. Argenson J, O'Connor, J.J.,. Polyethylene Wear in Meniscal Knee Replacement. A 17. Svard U, Price AJ. The fifteen-year survival of the Oxford unicompartmental knee
One to Nine-Year Retrieval Analysis of the Oxford Knee. J Bone Joint Surg replacement. EFFORT. Rhodes, 2001.
1992;74B:228 - 32. 18. Rajasekhar C, Das S, Smith A. Unicompartmental knee arthroplasty. 2- to 12-year
5. Psychoyios V, Crawford, R., O'Connor, J., Murray, D. Wear of Congruent results in a community hospital. J Bone Joint Surg Br 2004;86-7:983-5.
Meniscal Bearings in Unicompartmental Knee Replacement. J Bone Joint Surg 19. Keyes GR, Singer R, Iverson RE, McGuire M, Yates J, Gold A, Thompson D.
1998;80B:976-82. Analysis of outpatient surgery center safety using an internet-based quality
6. Murray DW, Goodfellow, J.W., O'Connor, J.J. The Oxford Medial improvement and peer review program. Plast Reconstr Surg 2004;113-6:1760-70.
Unicompartmental Arthroplasty. J Bone Joint Surg 1998;80B:983-9. 20. Roberts VI, Esler CN, Harper WM. A 15-year follow-up study of 4606 primary
7. Goodfellow JW, O'Connor, J.J. The Anterior Cruciate Ligament in Knee total knee replacements. J Bone Joint Surg Br 2007;89-11:1452-6.
Arthroplasty. A Risk-factor with Unconstrained Meniscal Prostheses. Clin Orthop 21. Lewold S, Goodman, S., Knotson, K., Robertsson, O., Lidgren, L. Oxford
1990;276:245 - 52. Meniscal Bearing Knee versus the Marmor Knee in Unicompartmental
8. White SW, Ludkowski, P.F., Goodfellow, J.W. Anteromedial Osteoarthritis of the Arthroplasty for Arthrosis. J Arthroplasty 1995;10-6:722-31.
Knee. J Bone Joint Surg 1991;73B:582-6. 22. Robertsson O, Knutson K, Lewold S, Lidgren L. The routine of surgical manage-
9. Gibson PH, Goodfellow, J.W. Stress Radiography in Degenerative Arthritis of the ment reduces failure after unicompartmental knee arthroplasty. J Bone Joint Surg
Knee. J Bone Joint Surg 1986;68B:608-9. Br 2001;83-1:45-9.
10. Goodfellow JW, Kershaw, C.J., Benson, M.K.D., O'Connor, J.J. The Oxford Knee 23. Price AJ, Webb J, Topf H, Dodd CA, Goodfellow JW, Murray DW. Rapid recovery
for Unicompartmental Osteoarthritis. The First 103 Cases. J Bone Joint Surg after oxford unicompartmental arthroplasty through a short incision. J
1988;70B:692 - 701. Arthroplasty 2001;16-8:970-6.
11. Weale AE, Murray, D.W., Crawford, R., Bonomo, A., Howell, G., O'Connor, J., 24. Beard DJ, Murray DW, Rees JL, Price AJ, Dodd CA. Accelerated recovery for uni-
Goodfellow, J.W. Does Arthritis Progress After Oxford Medial Unicompartmental compartmental knee replacement--a feasibility study. Knee 2002;9-3:221-4.
Arthroplasty? A Clinical and Radiological Study with a Minimum 10 Year Follow- 25. Pandit H, Jenkins C, Barker K, Dodd CA, Murray DW. The Oxford medial uni-
Up. J Bone Joint Surg 1999;81B:783-9. compartmental knee replacement using a minimally-invasive approach. J Bone
12. Martin JG, Wallace, D.A., Woods, D.A., Carr, A.J., Murray, D.W. Revision of Joint Surg Br 2006;88-1:54-60.
Unicondylar Knee Replacements to Total Knee Replacement. The Knee 1995;2-
2:121-5.
153
MOBILE BEARING UKR-AN AMERICAN PERSPECTIVE

Keith R. Berend, MD and Adolph V. Lombardi, Jr. MD, FACS
Philosophy: ria do not focus on weight, or age, instead concentrating on the

Unicompartmental knee arthroplasty (UKA) or partial knee pathophysiology of Anteromedial disease.
replacement represents the ultimate minimally invasive proce-
Concern over the status of the patellofemoral joint, in an other-
dure for treating degenerative joint disease of the knee in the
SYMPOSIA AR KNEE
wise suitable candidate for UKA, is also unwarranted. It is the

appropriately indicated patient. The conservative nature of the
current authors’ opinion that the correction of varus deformity
procedure stems from the bone conservation, the preservation
with preservation of the ACL has a protective effect on the
and correction of normal ligamentous structures, and the
patellofemoral joint, even if there is significant arthritic disease
restoration of normal knee kinematics.[1] These outcomes can-
present. Despite ignoring patellofemoral disease, the long-term
not be achieved with any total knee arthroplasty (TKA).
results of Oxford UKA have not been affected by progression of
By incorporating a fully-congruent, meniscal bearing, the patellofemoral disease or anterior knee pain.[5]
Oxford UKA (Biomet, Inc., Warsaw, IN) has demonstrated some
of the lowest wear rates see with any knee implant in both Technique
retrieval studies and RSA studies.[2, 3] This wear rate averages The authors employ the surgical technique described and taught
0.02mm per year in both retrievals and RSA. Thus, wear does by the implant designers. The operative leg is placed in a spe-
not appear to be a limiting factor in the indications for or con- cialized leg-holder to suspend the limb while allowing unre-
traindications against UKA using this device. The fully congru- stricted flexion past 110 degrees. After a minimally invasive expo-
ent articulation provides a larger contact area and reduces the sure, the proximal medial tibial plateau is exposed. It is critical
contact stresses, leading to significantly decreased wear when that no medial release be performed as the procedure is designed
compared to fixed bearing, non-congruent designs.[4] to correct the knee back to it’s pre-disease state and any medial
release will result in over-correction. The proximal tibial resec-
The long-term outcomes that have been published using this
tion is performed and the explanted plateau measured for tibial
device make it one of the most successful devices available
baseplate sizing. The flexion gap is then measured (this should
today for the treatment of medial compartmental disease of the
be 4mm or more). Using an intramedullary alignment guide, the
knee and therefore make this device the logical choice for UKA.
femoral drill guide is positioned on the distal femur. Based upon
Survivorship out to 15 years and 20 years have been 95% and
pre-operative templating the correct size femoral instruments are
92% respectively in an independent series.[5]
selected. The femoral alignment guide places drill holes for the
posterior resection and for use with balancing the flexion and
Indications:
extension gaps with the use of novel spigots and reamers.
The indications for UKA have been debated widely over the past
several decades. Classical indications, when followed closely, Once the posterior resection is made the distal femur is reamed
have included only a very small percentage of degenerative with a cylindrical reamer to convert the condyle from a poly-
knees. The Kozin and Scott criteria limit the utilization of UKA centric shape to the spherical shape of the Oxford UKA implant.
to those patients older than 60, weighing less than 82kg, and The flexion and extension gaps are then balanced to within less
exclude active individuals.[6] Additionally, these classical indi- than 1mm of each other, accuracy that is not currently achiev-
cations exclude cumulative deformity of more than 15 degrees, able with TKA. This balancing is done through the use of spig-
more than minimal arthritic changes in the patellofemoral ots which allow for reaming of the distal femur. After balancing
joint, and any fixed flexion contracture of more than 5 the gaps, the final tibial preparation is done and trials inserted.
degrees.[6] With these indications, only between 2-12% of The final implant is a fully0congruent spherical device that
arthritic knees would meet the criteria for UKA.[7, 8] The so- allows for considerably more malalignment than fixed bearing
called Oxford criteria are somewhat more liberal and encom- designs. Cementing technique is critical to prevent loosening
pass an anatomic and radiographic philosophy for inclusion or and the removal of impinging osteophytes is paramount to
exclusion of patients. reduce the potential for dislocation.
The premise behind these criteria is that UKA is utilized to treat
Results
a specific disease entity: Anteromedial Osteoarthritis.
To date we have performed over 700 medial Oxford UKA. At 3
Anteromedial disease is defined as the combination of full-
years the cumulative survivorship is better than 98%. Recently,
thickness cartilage loss in the medial compartment, a correctible
we reported on 318 Medial compartmental UKA in 268 patients
intra-articular varus deformity, and preserved lateral joint space
using the aforementioned Oxford Indications.[10] 156 Patients
seen with a valgus stress-radiograph. By definition, these criteria
were female (49%) and the average age of the patients was 61.6
are only present when the ligaments are functionally intact and
years (range: 33.6-90.1; SD: 10.7). Patients were younger than
the disease is confined to the anterior 1/3rd or 2/3rd of the tib-
60 years of age in 151 UKA (47.5%) and patients were younger
ial plateau. When these criteria are present, other unnecessary
than 50 years of age in 46 UKA (14.5The average weight of the
contra-indications such as age, weight, and the status of the
patients was 92 kg (range: 51-158; SD: 18 kg). In 220 knees
patello-femoral articulation can be safely ignored without
(69%) the patient weight was greater than 82 kg. The average
affecting the outcome of Oxford UKA.
BMI of the patients was 32.3 (range: 20-58; SD: 6). 150 UKA
In the US, perhaps the 2 biggest areas of debate are obesity, and (47%) were performed in patients with a BMI greater than 32, a
the status of the patellofemoral joint. Unfortunately, in the US, category considered at risk for failure secondary to obesity.[9]
obesity has reached epidemic proportions. Combined with the Isolated medial pain was present preoperatively in 211 knees
aging of the “babyboomers”, surgeons are confronted with (67%). Anterior knee pain was described in 20 knees (6%) and
younger obese patients more and more frequently. Classical lateral pain described in 9 knees (3%). Posterior knee pain was
indications would exclude patients over 82kg. The Oxford crite- described in 9 knees (3%) and in 65 knees (21%) the pain was
described as global in nature. Follow-up averaged 8 months ing PFJ disease (p=0.052). The pre-operative site of pain was not
(range 6 weeks-28 months). There have been 6 revisions in this a significant predictor of survivorship or failure with the device
group for a early survivorship of 98.1%. One knee was revised nor did location of pain pre-operative influence post-operative
in a 2-stage fashion for infection, 1 for ongoing pain, 1 tibial knee scores.
plateau fracture, and 3 tibial loosening. The average Knee
Society (KSS) pain score at early follow-up was 42/50 and the Conclusions
overall KSS averaged 90/100. Range of motion averaged 118 Medial UKA is a conservative, truly minimally-invasive proce-
degrees. Greater than 115 degrees of motion was obtained in dure that can accurately correct malaligment, and restore an
262 knees (82%). arthritic knee to its pre-disease functional status with normal
SYMPOSIA AR KNEE
kinematics and tremendous pain relief. An anatomic basis for
When stratified by age less than 50, age less than 60, weight over
establishing the indications and contra-indications based upon
82kg, weight over 90kg, BMI greater than 32, BMI greater than
the pathgnomonic findings of Anteromedial disease appears to
35, and BMI greater than 40 there was no difference in early fail-
provide reproducible good results in up to 30-35% of arthritic
ure for any variable examined.
knees. The long-term published outcomes have been good with
Survivorship in knees with pre-existing radiographic signs of very little wear, and no failures from patellofemoral progression
patellofemoral joint disease (PFJ) was no different than in those or anterior knee pain. It is hoped that the early success in the
knees without patellofemoral disease. In fact, there was a trend United States will mirror these results. At 3 years, survivorship of
towards a higher average KSS pain score in knees with pre-exist- better than 98%, despite liberal indications, is being reported.
REFERENCES 6. Kozin JBJS-Am 1989

1. Price et al. J Arthroplasty 2004 7. Ritter et al. JBJS 2004
2. Psychoyos et al. JBJS-Br 1998 8. Laskin et al. CORR 2001
3. Price et al. JBJS-BR. 2005 9. Berend et al. CORR 2005
4. Morra JBJS-Am 2003 10. Berend et al. Orthopedics 2007
5. Price et al. CORR 2005
155
SPORTS INJURIES OF THE

SYMPOSIA FOOT/ANKLE
FOOT AND ANKLE (R)

Moderator: Brian G. Donley, MD, Cleveland, OH
This symposium focuses on foot and ankle problems in athletes for which surgical
treatment is appropriate to allow early return to play, with an emphasis on avoiding
complications.
I. Introduction
Thomas Clanton, MD, Houston, TX
II. Forefoot Injuries

Robert B. Anderson, MD, Charlotte, NC
III. Midfoot Injuries

Brian G. Donley, MD, Cleveland, OH
IV. Ankle and Hindfoot injuries

James R. Holmes, MD, Ann Arbor, MI
V. Case Presentation & Discussion/Questions
SPORTS INJURIES OF THE ANKLE

Thomas O. Clanton, MD
I. Topics posterior colliculus (anterior and posterior tibiotalar)

A. Lateral ligament injuries 3. Biomechanics
SYMPOSIA FOOT/ANKLE
B. Medial ligament injuries a) Prohibits abduction of the ankle (esp:ly tibiocal-
C. Syndesmosis injuries caneal portion) & resists external rotation in dorsi-
D. Osteochondral lesions of the talus and tibia flexion
b) Valgus tilt of talus in ankle mortise requires com-
II. Lateral ligament injuries
plete tear of both superficial and deep deltoid
A. General information and incidence
C. Mechanism of injury
1. Most common time-loss injury in sports
1. Forced abduction can cause isolated rupture of the
2. ~1 person in 10,000 per day, ~23,000 inversion ankle
deltoid, usually tibiocalcaneal band first, then deep
sprains/day in USA, ~250,000 people per year
deltoid
between ages of 15 and 50 in USA
2. Higher load to failure than any of the lateral liga-
3. Persistent symptoms in 15-20%, 4-5% with chronic
ments
instability
D. Diagnostic testing
B. Clinical presentation
1. Rule out syndesmosis injury, lateral ligament injury or
1. Acute
fracture (esp’ly Maissoneuve)
a) Variable degree of pain, swelling and ecchymosis
2. Medial pain with deltoid tenderness, feeling of giving
b) Functional weight-bearing treatment shown to be
way, valgus & pronation deformity that can be actively
as effective as immobilization
corrected with post tib muscle activation
c) Surgery for open injuries, avulsions, high level ath-
3. X-rays may show avulsion fx, otherwise use to r/o
lete with marked instability (though controversial)
other injuries
2. Acute on chronic
4. Stress x-ray shows valgus talar tilt with complete tear
a) Most common presentation of athlete with chronic
5. MRI requires careful positioning and interpretation
instability
E. Management
b) Treatment determined by severity, timing, extenuat-
1. Non-operative – effective in most acute cases with iso-
ing circumstances
lated injury to the deltoid, brace or boot or cast
3. Chronic
2. Operative – direct repair for cases of acute injury with
a) Present with instability symptoms
instability (e.g. valgus tilt or irreducible widening of
b) Rarely have pain as primary symptom
the medial clear space)
c) Must rule out other potential causes of instability
F. Chronic deltoid instability
C. Management
1. General
1. Non-operative
a) Rare in isolation
2. Operative
b) Study of 148 ankle scopes for instability found
a) Criteria: young to middle-aged patient, healthy,
40% incidence of deltoid lesions (all with lateral
instability symptoms and signs, failure of rehab,
injury as well)
positive stress fluoro or stress x-rays
c) High percentage of articular cartilage injuries in
b) Surgical technique
association with deltoid injuries (98% in one
(1) Anatomical
study)
(a) Brostrom – delayed primary repair
2. Clinical presentation
(b) Gould modification – adds tightening of
a) Medial pain and swelling
the inferior extensor retinaculum to the
b) Valgus tilt, abduction, overpronation correctable by
distal fibula
contraction of posterior tib
(c) Augmentation – Tendon graft through
3. Diagnostic studies
anatomically placed tunnels
a) Radiographs rarely show definite finding
(2) Non-anatomical
b) Stress x-ray or fluoro: valgus tilt
(a) Evans, Chrisman-Snook, Watson-Jones
c) MRI
(b) Restrict subtalar motion frequently
d) Arthroscopy – determine stability with 2 mm hook
(c) Result in late arthritis
probe and 5 mm scope
(d) Higher morbidity than Brostrom
4. Management
III. Medial ligament injuries a) Nonoperative
A. Incidence b) Operative
1. 3 of 105 cases in Brostrom’s original series of acute (1) Secondary anatomical repair (medial
sprains Brostrom) – requires adequate tissue to
2. West Point study: 4% incidence of isolated medial imbricate
sprains (2) Reconstruction of the deltoid with a tendon
B. Anatomy and biomechanics graft
1. Superficial - 3 components all originate from anterior (3) Imbrication of spring ligament
colliculus of medial malleolus (tibionavicular,
IV. Syndesmosis injury (without fibula fracture)
tibiospring, and tibiocalcaneal)
A. Introduction
2. Deep - originate from intercollicular groove and the
1. Definition
157
a) “… any loosening in the attachment of the fibula removal)

to the tibia at the inferior tibiofibular joint, and is (2) Post-op course (compliant patient)
not confined to wide separation of the bones.” (a) Splint and crutches NWB for 6-10 days
(Bonnin , Injuries to the Ankle, 1970) (b) Cast or walking boot NWB for 3-4 weeks
b) Continuum of injury from minor sprain to frank (c) Cast or boot PWB between 4 and 8 weeks
diastasis. (d) FWB in boot from 8-12 weeks
2. Incidence (e) Remove syndes screw between 8-12 weeks
SYMPOSIA FOOT/ANKLE
a) Reports vary from 1-18% of patients with ankle (i) Longer if no avulsion, heavy patient,
sprains delayed repair, deltoid required repair
b) Injury rate specifically dependent on definition of (ii) Check stability on table with C arm at
injury and method of diagnosis time of screw removal, consider endobut-
c) Calcification of syndesmosis found in 32% of ton when screw removed
Canadian professional football players (Vincelette) (f) Aircast brace for rehab
B. Anatomy and biomechanics (g) Anticipate return to sports at 5-6 months
1. Ligaments 2. Subacute injuries
a) Anterior inferior tibiofibular ligament a) No good guidelines from clinical studies
b) Posterior inferior tibiofibular ligament b) Most recommendations are anecdotal
c) Interosseous ligament c) If no arthritis, consider reconstruction
d) Interosseous membrane d) Surgical technique options
2. Movement between the tibia and fibula during gait or (1) Reconstruction with tendon graft and syndesmo-
DF/PF sis screw(or endobutton) after cleaning out scar
a) Increase in intermal distance of 1.5mm from full tissue, may require deltoid reconstruction
DF to PF (2) Creation of synostosis
b) Tibia normally rotates 5-6 degrees on the talus 3. Chronic injuries - Surgical options
c) Rotation of up to 25 degrees in horizontal plane in (1) Arthroscopic debridement
unloaded ankle (approximately half from distal (2) Reconstruction
tibiofibular joint), average of 7 degrees of internal (3) Creation of synostosis
rotation and 10 degrees of external rotation (4) Ankle arthrodesis if joint already arthritic
(Rasmussen)
V. Osteochondral lesions of the talus
d) Average of 2.4mm distal migration of fibula during
A. Etiology
stance phase of gait (Scranton)
1. Vascular - some medial lesions
3. Cutting studies - relative contribution to stability of
2. Traumatic
various ligaments (Ogilvie-Harris, 1994): AITF=35%,
a) Majority of lesions can be linked to previous trau-
IO=22%, superficial PITF=9%, deep PITF=33%
matic event
C. Mechanism of injury - most significant force is external
b) Lateral more commonly traumatic than medial
rotation, abduction mechanism requires deltoid tear or
lesions
medial malleolar fracture
3. Repetitive microtrauma
D. Diagnosis
a) Mismatch of stiffness of posteromedial talus
1. Clinical evaluation – early tenderness over syndes (not
B. Characteristics
ATFL), early swelling over syndes, squeeze test, ext rot
1. Medial talar lesions
test, Cotton test
a) Posterior
2. Radiographic evaluation – look for bony avulsion
b) Deeper
(seen in 10-50%), medial clear space widening,
2. Lateral talar lesions
decreased tibfib overlap, increased tibfib clear space
a) Anterior
3. Stress radiographs – ext rot and abduction, many false
b) Shallower
negatives
C. Berndt and Harty Classification (does not correlate with
4. Arthrography – more commonly used outside USA
arthroscopic findings)
5. Bone scan – best in chronic situation
1. Stage I Focal compression of the subchondral bone
6. Ultrasound – non-invasive, in-ofc, 67% sensitivity
(bone beneath the cartilage)
7. MRI – sensitive and specific, standard for sports med
2. Stage II: Focal compression of the subchondral bone
E. Treatment
with partial detachment of a fragment of cartilage
1. Acute injuries
3. Stage III: Focal compression of the subchondral bone
a) No diastasis – cast or walking boot if stable,?
with a fully detached fragment of cartilage, still situat-
crutches
ed in place at the site of injury
b) Diastasis
4. Stage IV: Focal compression of the subchondral bone
(1) Surgical repair –
with a fully detached fragment of cartilage, detached
(a) Anterior lateral incision, find SPN & protect,
from the site of injury and floating in the joint space
repair bony avulsions with suture anchor
D. Other classification methods
(b) If reduction difficult, confirm that debris is
1. Arthroscopic staging or grading – Chang, Ferkel,
out of tibiofibular joint, medial clear space
Applegate
reduced, no plastic deformation of fibula,&
2. CT staging – Ferkel & Sgaglione
ext rot corrected
a) May miss cartilaginous lesions or grade 1 (non-dis-
(c) Be prepared to open and fix the deltoid liga-
placed) lesions
ment if necessary
3. MRI staging – often overstates the lesion due to
(d) Support repair with syndesmosis screw or
edema
endobutton technique (no need for screw
E. Symptoms (1) Usually require arthrotomy

1. Often vague, mild and intermittent (2) Medial malleolus osteotomy for exposure
2. History of chronic post-sprain pain f) Lateral lesions
3. Stiffness, swelling, catching, clicking, locking, giving (1) Can be done arthroscopically
way 3. Drilling of intact lesions
F. Physical exam a) Provides route for vascularization
1. Pain with range of motion of the ankle especially DF b) Anterolateral easily accessible from anterolateral
SYMPOSIA FOOT/ANKLE
and inversion portal
2. Posteromedial lesions - pain with DF c) Medial lesions more challenging
3. Anterolateral lesions - pain with PF (1) Meniscal repair guide
4. Examine for coexisting joint laxity (2) Transmalleolar drilling- downfall is damage to
G. Diagnostic imaging normal tibial articular cartilage
1. X-rays (3) Transtalar drilling using guide
a) Mortise in PF for posteromedial lesions and DF for 4. Debridement and drilling or microfracture
anterolateral lesions a) For detached osteochondral lesions
b) Opposite ankle (10-25% bilateral) b) Edges debrided to healthy articular cartilage
c) Stress radiographs if laxity suspected c) Base debrided to bleeding subchondral bone
2. CT Scan d) Multiple drill or microfracture holes to stimulate
a) Best tool for assessing osseous anatomy fibrocartilage repair
b) Good for delineating size, shape, location, displace- e) 88% good and excellent results with excision,
ment of known lesions curettage, and drilling in grade III & higher lesions,
3. Bone Scan drops to 78% without drilling and to 38% with
a) Indicated when normal x-rays but persistent symp- excision alone
toms for 12 weeks 5. Cystic lesions
b) Normal scan rules out OCL a) Debride and bone graft (antegrade or retrograde)
c) If positive need MRI or CT b) Osteochondral autograft
4. MRI c) Fresh frozen allograft for large lesions
a) Used to detect early and small lesions 6. Internal fixation
b) Accurate in predicting fragment stability a) Large lesion with intact subchondral bone – size
H. Treatment suggested to be at least 7.5 mm in diameter and
1. Non-operative preferably a younger patient
a) Initial treatment recommended for all Stage I and II b) Small cancellous screws, small headless screws, or
b) 90% successful for Stage I and II bioabsorbable screws
c) 12 months of non-op management does not affect 7. Osteochondral grafts
results a) Lesions 0.5 to 3 cm_ (autograft)
d) Limit weight bearing b) Large articular cartilage lesions (allograft)
e) Immobilization c) Minimal subchondral bone loss
f) No corticosteroids d) Often requires osteotomy of malleoli
g) Meta-analysis of 14 studies (201 patients): 45% e) Graft taken from anterior talar dome or ipsilateral
success rate of nonop Rx of grade I, II, and medial femur
grade III lesions f) Use of multiple smaller grafts (mosaicplasty)
2. Operative popularized by Hangody
a) Stage I and II that failed non-op after 4 months 8. Post operative treatment
b) All stage IV a) Weight bearing as tolerated for drilling
c) Stage III b) Non-weight bearing for fixation or grafting
(1) Operative on lateral c) Early range of motion for all
(2) Initial non-operative on medial for 6 months I. Prognosis
d) Early operative treatment of athletes 1. Higher stage has worse prognosis
(1) Early rapid rehab 2. Lateral lesions have worse prognosis
(2) High grade lesions regain pre-injury level of 3. Best results with shorter delay from injury to treat-
activity ment and younger age
e) Medial lesions
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161
SPORT INJURIES OF THE FOOT AND ANKLE: THE FOREFOOT

Robert B. Anderson, MD
SESAMOID DISORDERS iii.Xray changes may follow symptoms by 6-12 months

e. Plantar prominence
I. Know your anatomy of the hallux MP joint
SYMPOSIA FOOT/ANKLE
i. Typically seen in long distance runners

a. Joint capsule
ii. Etiology
i. Thicker plantar—includes plantar plate (fibrocarti-
1. Bursitis
lage)
2. IPK
ii. Firm attachment to base of proximal phalanx, not MT
3. Both
neck
iii.Extends laterally to transverse intermetatarsal ligament III. Diagnostic evaluation
b. Collateral ligaments – medial important for “cutting” a. History
activity i. Pain localized to plantar hallux MP with weightbear-
c. Tendons – delicate balance ing
i. EHL dorsal—wide expanse ii. Sports/stair climbing worsen
ii. FHL plantar—courses between sesamoids iii.Often no precipitating event
iii.FHB tendons—medial/lateral heads b. Clinical exam
iv. Abductor hallucis—conjoined with medial head of i. Specific location of pain/tenderness
FHB 1. Plantarmedial – tibial sesamoid
v. Adductor hallucis—conjoined with lateral head of 2. Plantar – fibular sesamoid
FHB ii. Presence of swelling/warmth/erythema
d. Sesamoids iii.Joint motion/stability
i. Medial (tibial)—larger/longer, more distal greater WB 1. Restriction of motion secondary to pain or associat-
forces ed hallux rigidus
ii. Lateral (fibular)—smaller, rounder, more proximal 2. Vertical instability may follow turf toe injury
iii.Lie within conjoined tendons, connected by inters- (hyperextension)
esamoidal ligament, suspended by collateral liga- iv. Compression pain, grind
ments 1. Metatarso-sesamoid articulation
iv. Form articulating joint with MT head, separated by c. Radiographic
intersesamoidal ridge (crista) i. Standing AP/lateral foot views
v. Blood supply—medial plantar artery ii. Axial/tangential sesamoid view
vi. Ossification—9 to 11 years, often multiple areas 1. Assess for focal arthrosis
vii. Congenital partition of tibial sesamoid 10—33% 2. Plantar osteophyte/bony prominence
(10x greater than fibular), bilateral 25—85% iii.Oblique sesamoid view
viii. Function 1. Helpful for fracture of tibial sesamoid
1. Dissipate forces iv. Always place marker (B-B) on skin overlying site of
2. Elevate MT head--≠ mechanical advantage of FHB tenderness – helps to differentiate which sesamoid
3. Protect FHL, maintain its direct pull involved (or does not correlate with sesamoid loca-
tion if flexor tendon problem)
II. Etiologies
v. Fracture vs. bipartite sesamoid
a. Sesamoiditis
1. Fracture = sharp irregular borders on both sides of
i. A diagnosis or a symptom?
separation
ii. Defined as pain with negative xrays and equivocal
2. Bipartite = smooth cortical edges; relatively total
MRI
size larger than single sesamoid would be; ? bilater-
1. A diagnosis of exclusion
al presence
2. R/o bursitis, flexor tendonitis, plantarflexed 1st ray
d. MRI
iii.Often history of overuse or minor trauma
i. Excellent tool to localize pathology
b. Fracture
ii. Differentiates between bone and soft tissue abnormality
i. Acute vs. stress
iii.Assesses sesamoid viability, joint degeneration, ten-
ii. Typically tibial sesamoid
don continuity
iii.Transverse fracture line; usually mid-waist
e. Bone scan
iv. Association with MP dislocation (Jahss Type II)
i. High rate of false positives
v. Stress often in runners or aerobics (forefoot impact)
ii. 3 phase helpful
c. Degenerative
iii.Pinhole images to differentiate between sesamoids
i. Chondromalacia
1. make certain that you know which is indeed the
1. Similar to patellofemeoral
problematic one
ii. Osteophytes
f. CT
d. Osteochondrosis
i. Delineates degree of metatarso-sesamoid arthrosis
i. Unknown etiology
ii. Assesses fracture healing
1. Crush injury
2. Stress fracture IV.Nonoperative treatment
3. AVN a. RICE = rest, ice, compression, elevation
ii. Painful fragmentation/cyst formation/flattening i. Modify activity and training regiment
b. Analgesics/anti-inflammatory medication
c. Boot or cast 4. Consider transferring abductor hallucis tendon into

i. For first week in more severe injuries large defects created by excision of bipartite or frac-
ii. Toe spica extension with joint in mild plantarflexion tured sesamoids
iii.Weight-bearing as tolerated a. Dissect/release off of capsule at distal insertion
d. Taping b. Perform fasciotomy proximally to allow for
i. Provides compression and limits movement rerouting of tendon to plantar aspect.
ii. Most helpful in milder injuries 5. Consider performing concomitant bunionectomy if
SYMPOSIA FOOT/ANKLE
e. Orthoses and shoewear modifications significant hallux valgus present
i. Off-the-shelf (e.g., “Scott” turf toe plate or carbon iii.Fibular
fiber; full length or forefoot only) 1. Approach – dorsal vs. plantar? Prefer plantar!
ii. Custom-made with Morton extension to limit hallux a. Dorsal approach very difficult unless large IM
MP ROM angle with lateral subluxation of the sesamoid
1. Metatarsal pad just proximal to symptomatic complex (i.e bunion/hallux valgus) – no oppor-
sesamoid tunity to repair soft tissue defect
iii.Shoe stiffened with plate incorporated into sole of 2. Plantar
shoe a. Curvilinear incision over fibular sesamoid but
1. Maintain low heel height off of weightbearing pad of hallux MP joint
iv. Turf shoes modified by removing cleat under area of b. Identify and protect plantarlateral digital nerve
pain c. Allows for direct excision without disruption of
f. Cortisone and/or anesthetic injection abductor hallucis tendon
i. Not advised in any injury to keep athlete playing d. Allows for subsequent repair of FHB tendon
ii. May use an anesthetic injection alone for localized (lateral head)
pain in single nerve distribution, do not completely e. Closure must carefully approximate skin edges
anesthetize toe to minimize hypertrophic scar formation
iv. Postoperative
V. Operative treatment
1. “Rigid” soft dressings to maintain plantarflexion
a. Options
and either varus (tibial sesamoidectomy) or valgus
i. Sesamoidectomy
(fibular sesamoidectomy)
1. Total
2. WBTT in sandal or short walker boot for tibial
2. Partial
sesamoidectomy
ii. Bone grafting
3. NWB/heel touch for fibular sesamoidectomy
1. Stress fracture nonunions
a. Begin WBTT with sutures “in” at 10-14 days
iii.Plantar shaving
b. Suture removal at 3-4 weeks
1. For IPK
4. Removable bunion splints 2-6 weeks
2. Nearly always for tibial sesamoid
5. Gradual return to hard soled shoes
3. Resect plantar 50% leaving FHB in continuity
a. Utilize turf toe plate in athlete
iv. Soft tissue procedures
v. Results
1. Bursectomy
1. Sesamoidectomy – in general
2. Reconstruction
a. Inge and Ferguson
b. Sesamoidectomy
i. 41 feet, 25 with both sesamoids excised
i. Understand biomechanical implications (Aper et al)
ii. 42% with complete relief
1. Loss of push-off strength following sesamoidectomy
iii.82% of single sesamoid excision improved
a. Tibial = 10%
iv. 64% of those with both excised improved
b. Fibular = 16%
b. Leventen
c. Both = 30%
i. Complete satisfaction in 18/23 sesamoidec-
2. Loss may be perceived in the elite/running athlete
tomies
ii. Tibial
c. Mann et al
1. Medial/plantarmedial approach
i. 19/21 sesamoidectomies “improved”
2. Avoid plantarmedial digital nerve
ii. 50% with complete pain relief
3. Excise sesamoid from within joint or extra-articular
iii.Full ROM in 66%
a. Helpful to assess articular surfaces prior to exci-
iv. 1/13 tibial developed hallux valgus
sion
v. 1/8 fibular developed hallux varus
i. Enter the joint thru the abductor hallucis ten-
vi. 12 patients developed “weakness”
don
d. Brodsky (1991)
b. Extra-articular approach allows for repair of
i. 21/23 sesamoidectomies “satisfactory”
overlying FHB after excision
ii. 6 with persistent pain
i. Longitudinal incision and reflection of over-
e. Brodsky (1999)
lying soft tissues (subperiosteal)
i. 24 tibial/13 fibular (dorsal approach)
ii. Repair defect side-to-side with absorbable
ii. 4 tibial developed hallux valgus > 5 degrees
suture (i.e. 4-0 Vicryl)
iii.Fibular: maximum varus 3 degrees
c. Beaver blade (#69) a useful tool to circumferen-
iv. 15 excellent, 5 good
tially dissect around sesamoid
2. Fibular sesamoidectomy
d. Beware of the proximity to the FHL – must pro-
a. Mann/Coughlin (1993)
tect
i. 8% incidence of hallux varus after McBride
e. Rarely perform partial excisions due to risk of
bunionectomy
residual pain
b. Milia, et al (2002)
163
i. 12 patients followed after plantar approach 2. Proximal migration of sesamoids signifies plantar
ii. 9/12 very satisfied and 2/12 satisfied complex disruption
iii.All would do it again 3. Absolute measurements: >10.4mm from tip of tib-
iv. 11/12 returned to pre-injury activity level ial sesamoid to phalanx or >13.3mm for fibular
v. No complications (scar, neuroma, etc) sesamoid = 99.7% chance of plantar complex rup-
c. Bone grafting ture
i. Based on work of Anderson/McBryde b. Forced dorsiflexion lateral view
SYMPOSIA FOOT/ANKLE
ii. Option to sesamoidectomy in running ath- i. Patient passively hyperextends both hallux MP joints
lete – preserves push-off strength ii. Assess for distal migration of tibial sesamoid with
iii.Used for chronic stress fx nonunions of the dorsiflexion
tibial hallux sesamoid iii.May also delineate diastasis of bipartite or fractured
iv. Requirements sesamoid
1. Equal parts (mid-waist fx) c. Sesamoid views
2. Minimal diastasis (1-2 mm) i. Include axial/oblique
3. No gross motion between parts (intact ii. Assist in evaluating for diastasis or fracture
viable cartilage) d. Arthrography
v. Results i. Historical interest – displaced by MRI (or at least used
1. Anderson/McBryde with it)
a. 19/21 healed and returned to pre-injury ii. Probably is best method for identifying
level of activity presence/extent of capsular disruption
iii.Must be done early
TURF TOE INJURIES
e. MRI
I. Definition—Turf Toe i. Best defines degree of soft tissue injury, osseous and
a. Sprain of the 1st metatarsaophalangeal joint occurring in articular damage
sports and related to the shoe-surface interface ii. T2-weighted images in coronal/axial/sagittal planes
b. Most often seen in football players participating on artifi- iii.Assists in grading, identifies subtle injuries, helps for-
cial surfaces but can occur in any field sport mulate treatment plan and prognosis
iv. Obtain in all grade 2/3 injuries
II. Effect/severity
a. Loss of playing time variable and dependent upon posi- V. Nonoperative treatment – similar to sesamoid problems
tion played above
i. linemen tolerate better than runner/sprinter a. Severe injuries/bipartite diastasis = consider cast with toe
ii. mild injury often with no loss of game time spica extension holding joint in mild plantarflexion
iii.severe injuries can result in 6-8 weeks out b. Return to activity when symptoms allow
iv. career ending in chronic severe injuries a. Taping
b. Arkansas study: ankle sprains occur four times more i. Provides compression and limits movement
often but hallux MP injuries with disproportionate # of ii. Most helpful in milder injuries
missed practices and games b. Orthoses and shoewear modifications
i. Off-the-shelf (e.g., Scott turf toe plate, full length or
III. Mechanism of injury
forefoot only)
c. Primary hyperextension of hallux MP joint with attenua-
ii. Custom-made with Morton extension to limit
tion/disruption of plantar complex (usually distal to
hallux MP ROM
sesamoids)
iii.Shoe stiffened with plate incorporated into sole of
i. Usually axial load applied to heel of a foot fixed in
shoe
equines
c. Cortisone and/or anesthetic injection
ii. Similar to Lisfranc injury mechanism
i. Not advised in any injury to keep athlete playing
d. Wide spectrum of injury
ii. May use an anesthetic injection alone for localized
i. Partial tearing to frank dislocation
pain in single nerve distribution, do not complete-
ii. As plantar rupture occurs, unrestricted dorsiflexion
ly anesthetize toe/joint
may result in impaction injury of proximal phalanx
on dorsal articular surface of metatarsal head VI. Operative treatment
e. Numerous variations depending upon force of injury a. Seldom necessary unless skilled position athlete required
and position of hallux – not purely hyperextension to sprint/cut
i. Most common is valgus directed force i. Consider for:
1. Results in injury to plantar medial complex or tib- 1. large capsular avulsion with unstable joint
ial sesamoid (especially medial)
2. May result in traumatic bunion/progressive hallux 2. diastasis of bipartite sesamoid or sesamoid fracture
3. retraction of sesamoids (single or both)
IV.Radiological Evaluation
4. traumatic bunion/progressive hallux valgus
a. Routine radiographs
5. (+) vertical Lachman’s test
i. Often negative
6. loose body or chondral injury
ii. May show small avulsion fracture of plantar aspect of
ii. Technique
proximal phalanx or distal pole of sesamoid, capsular
1. Incision options
avulsions
a. Plantarmedial
iii.Assess sesamoid position
b. Medial and plantar
1. Always obtain bilateral AP standing views for com-
c. “J” – plantarmedial that extends along flexor
parison
crease at base of hallux
2. Always identify plantarmedial digital nerve and ent symptoms – stiffness/pain

protect b. Miller Clinic study (preliminary) confirms benefit in
3. In general, identify/assess of soft tissue injury and early recognition and surgical repair of complete ruptures
repair anatomically i. 19 procedures
a. Distal ruptures require primary repair of rem- ii. One failure due to progressive joint degeneration
nants from lateral to medial
HALLUX RIGIDUS IN THE ATHLETE
b. If soft tissues inadequate, use suture
SYMPOSIA FOOT/ANKLE
anchors/drill holes and nonabsorbable sutures I. Symptoms in the Athlete
to base of proximal phalanx A. Present with pain that is worse with push-off
4. If repairing medial collateral ligament/hallux MP B. Swelling, worse after activity (2-a-days)
capsule – perform adductor tenotomy (modified C. Although may have bilateral radiographic involvement,
McBride bunionectomy) almost always unilateral presentation
5. Diastasis or fracture of sesamoid requires excision D. Swelling/bony prominence may interfere with athletic
of one or both poles and repair of soft tissue defect shoewear (especially soccer, football)
a. Option for transfer of abductor hallucis tendon E. Dysthesia in dorsomedial cutaneous nerve from tight
to plantar defect shoewear impinging on bony prominence
i. serves as a new flexor F. Occasional transfer lesions from compensation or lack of
ii. plantar restraint to dorsiflexion hallux dorsiflexion (metatarsalgia)
iii.fills defect with collagen
II. Clinical grading
iii.Postoperative management
A. Can grade severity from mild to severe (or I, II, III)
1. Delicate balance between soft tissue protection and
B. Grade IV – Shurnas/Coughlin – xray djd with painful
early range of motion
motion
2. Utilize athletic trainers/physical therapists for care-
ful monitoring and hands-on passive ROM III. Treatment Considerations in the Athlete
3. General guidelines A. Need to consider
a. begin gentle passive motion under supervision i. Sporting activity and position
at 7-10 days 1. Lineman vs. running back/wide receiver
b. NWB in removable splint or boot with hallux ii. Shoewear requirement
protected for 4 weeks iii.ROM of entire foot and ankle
c. At 4 weeks increase active motion and allow B. Even more minor or early presenting cases can be prob-
ambulation in boot lematic – the athlete creates more forceful dorsiflexion
d. modified shoewear at 2 months C. Limits the function of the runner but can incapacitate
e. return to contact activity with protection from the dancer
excessive dorsiflexion at 3-4 months D. If a bad joint is provided more motion, it may hurt
f. expect 6-12 months for full recovery worse and degenerate quicker
VII. Sequelae of untreated injuries IV. Nonoperative Treatment
a. Short term A. Shoewear modifications
i. Difficulty with push-off i. Adequate size
1. Unrestrained dorsiflexion leads to secondary dam- ii. Balloon patch over bony prominences
age iii.Turf toe insert to limit dorsiflexion and impingement
a. Repetitive joint impaction and eventual hallux – this may limit performance in the elite runner
rigidus-like findings iv. Orthotic device – remember to increase shoe size to
b. Longitudinal tears or even rupture of FHL ten- accommodate
don B. Taping techniques rarely helpful
ii. Progressive hallux valgus/bunion if primarily medi- C. Steroid injections
al/plantarmedial injury i. Be selective – big game situations only?
iii.Surgical reconstruction more difficult due to retraction
V. Surgical options
of soft tissues
A. Decision making requires lengthy discussion with ath-
1. Explore/debride joint and perform cheilectomy
lete/trainer/agent
2. Advancement of soft tissues may require fas-
i. What is causing the problem?
ciotomies and fractional lengthening of
1. Bony prominence?
FHB/abductor hallucis
a. Shoewear irritation
3. Modified McBride bunionectomy for hallux valgus
2. Limited ROM?
– need to release adductor hallucis and rebalance
a. Biomechanical implications – poor push-off
joint
b. Transfer pain issues, compensatory problems
b. Long term
3. Global pain? (especially in sesamoid/metatarsal
i. Chronic pain and fixed deformity
articulation)
1. Untreated hyperextension injuries may result in
B. Cheilectomy
clawing of the hallux, IP joint contracture, and DJD
i. Patient should be counseled that underlying condi-
(cock-up deformity)
tion is degenerative joint disease and full symptom
ii. Late surgical treatment difficult
relief is not realistic
1. Consider flexor-to-extensor tendon transfer with IP
• for athlete—prolongs the athletic life of the indi-
fusion
vidual, but probably does not slow the rate of joint
VIII. Results degeneration
a. Clanton/Seifert: 20 athletes, 5 yr. F.u. = 50% with persist- • as a general rule, the dorsal ridge does not recur,
165
but progressive narrowing of the joint is expected c. Very new – will it hold up?
to occur
2ND MP JOINT PAIN (METATARSALGIA/INSTABILITY)
1. Indications:
a. Classically, lateral x-ray shows that reasonable I. Definition
space exists in the plantar _ of MTP joint a. A descriptive term rather than a diagnosis
b. No pain or crepitus with midrange motion b. Nonspecific pain in the ball of the foot
c. No sesamoid-metatarsal pain or disease c. Variety of diagnoses may contribute – can be a continu-
SYMPOSIA FOOT/ANKLE
2. Will eliminate source of painful shoe pressure um

3. “no bridges are burned” d. Rule out metatarsal trauma (stress fx), ischemic or neuro-
• salvage procedure still technically possible pathic pain, radiculopathy
a. Can remove up to 1/3 - Be Aggressive!
II. Differential Diagnosis
b. Should be able to DF to 70 degrees
a. Mechanical
i. if insufficient DF achieved after cheilectomy,
i. Lesser toe deformity (clawtoe)
then consider proximal phalangeal osteotomy
ii. MP instability
C. Phalangeal osteotomy
1. Often long distance runners
i. Principles
2. Long 2nd toe – overuse syndrome
1. Arc of motion of the hallux MP joint is translated
3. Pathophysiology = stretched or degenerative plan-
to plantar aspect of head (increase functional
tar plate
motion)
4. A continuum of isolated MP synovitis, capsulitis,
2. Creates pseudodorsiflexion – less stress on hallux
subluxation
with push-off
iii.Transfer lesion (iatrogenic)
3. Adequate plantarflexion a prerequisite
iv. Length discrepancy of metatarsals
4. Provides dorsal joint space decompression
v. Postural
(Thomas and Smith, 1999)
1. Cavus
ii. Indications
2. Plantarflexed ankle arthrodesis
1. Grade I/II/III
3. Use of heel lift
2. Adolescent hallux rigidus
b. Arthritic
3. Running athlete - ? regardless of grade
i. Degenerative
4. Most authors now recommend combining with
ii. Inflammatory
dorsal cheilectomy
c. Neurologic
iii.Technique
i. Morton’s neuroma
1. Protect FHL/EHL
1. Rarely second web space
2. Dorsal closing wedge osteotomy performed with
d. Idiopathic
microsagittal saw just distal to MP joint (avoid
i. Freiberg’s infarction
physis if adolescent) – maintain plantar cortex and
1. 2/3 metatarsal heads
“greenstick” osteotomy closure manually
2. Osteochondrosis, onset in adolescence
3. Remove 2-6 mm of dorsal cortex, with actual
3. Secondary degeneration leads to adult symptoms
amount determined by degree of joint stiffness and
ii. Fat pad atrophy
amount of plantarflexion of the hallux – goal is to
e. Neoplastic
obtain 20-30 degrees of dorsiflexion relative to 1st
i. Ganglion cyst
MT axis
ii. Rheumatoid nodule
4. Stabilize osteotomy with suture/Kwire/screw/staple
iii.PVNS/giant cell tumor of tendon sheath
– stable fixation is mandatory if combined with
cheilectomy so that early motion can be initiated, III. Evaluation
best if internal fixation a. History
i. Aggravating factors
VI. Salvage
ii. Shoewear
A. For advanced degeneration or failed
iii.Associated symptoms
cheilectomy/osteotomy
b. Examination
B. Options
i. Determine precise location of pain and tenderness
i. Arthrodesis
1. Plantar metatarsal head
1. Not in a “sprinting” athlete or dancer
a. Mechanical/overuse etiologies
2. If performed, make certain to dorsiflex (toe tip
2. Dorsal MP joint
>10mm off ground)
a. Intraarticular etiologies
ii. Resection arthroplasty
ii. Deformities – sitting and standing
1. Keller
1. Hammertoes/clawtoes
a. Only in older individual
a. Increase met head pressure by cantilever effect
2. Capsular interposition (Hamilton)
b. Assess if flexible or rigid
a. Proximal 5-10 mm of proximal phalanx resected
2. Angulatory deviation
b. Transect EHB tendon and advance dorsal cap-
a. Varus common with MP synovitis of 2nd toe
sule to plantar complex – some release FHB ten-
3. Instability
don and suture to dorsal capsule
a. Subluxation or excessive mobility in the sagittal
c. +/- temporary pin fixation
plane
3. Anchovy interposition (Coughlin)
b. Toe Lachman test
a. Conical resection on both sides of joint
c. Test should reproduce pain and be asymmetric
b. Gracilis/semitenidosis allograft
4. First ray abnormalities
a. Hallux valgus, metatarsus primus varus, and 2. Arch support

hypermobile 1st ray may increase weight bear- 3. Morton’s extension to equalize weight bearing pres-
ing pressures on lesser MT sures
b. First ray shortening after bunionectomy/fusion 4. Add “turf toe” plate or carbon fiber reinforcement
will lead to disproportionate weight distribution to limit MP joint mobility
5. Lesser ray abnormalities b. Operative
a. Prior fracture with nonunion or malunion i. Bony prominences/IPK/plantar pain
SYMPOSIA FOOT/ANKLE
b. Prior surgery with metatarsal shortening 1. Plantar condylectomy (DuVries)
iii.Plantar surface 2. Metatarsal osteotomy
1. Fat pad atrophy or migration a. Weil osteotomy
2. Intractable plantar keratoses (IPK) i. Consider double-cut or 2 saw blade tech-
a. Assess size and location nique to elevate metatarsal head
b. Types ii. Other techniques losing favor due to malu-
i. Diffuse nion/nonunion
1. Entire or multiple metatarsal heads 3. MP arthroplasty
involved a. If severe degeneration of joint or failed osteotomy
ii. Localized b. Longitudinal pin fixation; remove within 2-3
1. Discrete bony prominence/plantar condyle weeks to prevent excessive stiffness
ii. MP joint instability
IV.Diagnostic Studies
1. Stage I (synovitis only)
a. Radiographs
a. Dorsal capsulotomy
i. Standing AP view
b. Synovectomy
1. Metatarsal lengths
2. Stage II (varus/medial deviation)
2. Joint subluxation/dislocation or destruction
a. Dorsal capsulotomy
3. Prior surgery
b. Synovectomy
ii. Axial/sesamoid view
c. Tibial collateral ligament release
1. Plantar or dorsal displacement of metatarsal
d. Fibular collateral ligament reefing
head(s)
e. Flexor-to-extensor tendon transfer (optional)
2. Use marker to confirm association of lesion to
3. Stage III (varus deviation with mild hammering,
bone
dislocatable joint)
b. Bone scan
a. As in Stage III, with tendon transfer
i. Sensitive but nonspecific evaluation of inflammation
b. Add plantar condylectomy, especially if plantar
c. MRI
tenderness – adds stability/stiffness
i. Surface coil advances has improved specificity
c. Hammertoe treated with closed osteoclasis or
ii. Neuroma vs. synovitis vs. bony abnormalities
PIP arthroplasty if necessary
d. Injection
4. Stage IV (dislocation of MP joint with varus devia-
i. MP joint or web space – differentiating synovitis and
tion and hammertoe)
neuroma
a. Options
V. Treatment i. MP release + PIP arthroplasty + tendon trans-
a. Nonoperative fer
i. Cortisone injection ii. Weil osteotomy + tendon transfer and
1. Into the MP joint itself optional PIP arthroplasty
2. Must follow with taping regiment for 6 weeks – iii.MP arthroplasty and closed osteoclasis of
maintain slight plantarflexion of toe. Risk of pro- hammertoe
moting dislocation? b. Correct concomitant hallux valgus if present
ii. Toe/foot appliances c. Avoid partial proximal phalangectomy and syn-
1. Hammertoe shield/strap helpful in maintaining a dactylization
flexible hammer or clawtoe in a reduced position iii.Freiberg’s Disease (infraction)
and cushions the metatarsal head 1. Capital metatarsal osteotomy
iii.Orthoses 2. MP arthroplasty
1. Met pad
REFERENCES 5. Coughlin, M.J.: Sesamoid pain: Causes and surgical treatment. AAOS Inst.
Sesamoid Course Lec., 39:23-35, 1990.
1. Anderson, R.B.; McBryde, A.M.: Autogenous bone grafting of hallux sesamoid 6. Leventen, E.O.: Sesamoid disorders and treatment: An update. Clin. Orthop.,
nonunions. Foot Ankle International, Foot & Ankle International. 18(5):293-6, 269:236-240, 1991.
1997. 7. McBryde, A.M.; Anderson, R.B.: Sesamoid foot problems in the athlete. Clin.
2. Aper, R.L.; Saltzman, C.L.; Brown, T.D.: The effect of hallux sesamoid resection Sports Med., 7:51-60, 1988.
on the effective moment of the flexor hallucis brevis. Foot Ankle International, 8. Milia, M; Anderson, R; et al: Plantar approach for fibular sesamoidectomy.
15: 462-470, 1994. Presented at Winter AOFAS meeting, Dallas, 2002
3. Aper, R.L.; Saltzman, C.L.; Brown, T.D.: The effect of hallux sesamoid excision on Turf Toe
the flexor hallucis longus moment arm. Clin.Orthop., 325:209-17, 1996. 9. Anderson R: Turf toe injuries of the hallux metatarsophalangeal joint.
4. Brodsky, Jl: Sesamoid excision for chronic non-union. Presented at the 21st Techniques in Foot and Ankle Surgery 2: 102-111, 2002
annual meeting of the American Orthopaedic Foot and Ankle Society, Anaheim, 10. Bowers KD Jr, Martin RB: Turf-toe: A shoe-surface related football injury. Med Sci
Calif., March, 1991. Sports Exerc 8:81-83, 1976
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11. Clanton TO, Butler JE, Eggert A: Injuries to the metatarsophalangeal joints in ath- 20. Easley ME, Davis WH, Anderson RB: Intermediate to long-term follow-up of
letes. Foot Ankle 7:162-176, 1986 medial approach dorsal cheilectomy for hallux rigidus. Foot Ankle Int 1999; 20:
12. Clanton TO, Ford JJ: Turf toe injury. Clin Sports Med 13:731-741, 1994 147-152.
13. Lieber J: Turf toe: The NFL’s most pesky agony of da feet. Sports Illus 69:401-402, 21. Mann RA, Clanton, TO: Hallux rigidus: treatment by cheilectomy. J Bone Joint
1988 Surg 1988; 70-A: 400-405.
14. Mullis DL, Miller WE: A disabling sports injury of the great toe. Foot Ankle 1:22- 22. Moberg E: A simple operation for hallux rigidus. Clin Orthop 1979; (142): 55-
25, 1980 56.
SYMPOSIA FOOT/ANKLE
15. Rodeo SA, O’Brien S, Warren RF, et al: Turf-toe: An analysis of metatarsopha- 23. Thomas PJ, Smith RW: Cheilectomy with proximal phalanx osteotomy for surgi-
langeal joint sprains in professional football players. Am J Sports Med 18:280- cal treatment of hallux rigidus. Foot Ankle Int 1999; 20: 3-12.
285, 1990 24. Van Dijk CN, Veenstra KM, Nuesch BC: Arthroscopic surgery of the metatar-
16. Rodeo SA, Warren RF, O’Brien SJ, et al: Diastasis of bipartite sesamoids of the sophalangeal first joint. Arthroscopy 1998; 14: 851-855.
first metatarsophalangeal joint. Foot Ankle 14:425-434, 1993 Metatarsalgia/Instability
17. Watson T, Anderson R, Davis W: Periarticular injuries to the hallux metatar- 25. Coughlin MJ: Instability of the second metatarsophalangeal joint in athletes.
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Hallux Rigidus 26. Coughlin MJ: Subluxation and dislocation of the second metatarsophalangeal
18. Citron N, Neil M: Dorsal wedge osteotomy of the proximal phalanx for hallux joint. Orthop Clin of N America 20: 539-551, 1989
rigidus. Long term results. J Bone Joint Surg [Br] 1987; 69: 835-837. 27. Watson AD, Anderson RB, Davis WH: Metarsalgia, in (ed – Kellikian) Operative
19. Easley ME, Anderson RB: Hallux rigidus. In Adelaar R (ed): Disorders of the Treatment of the Foot and Ankle. Appleton and Lange, Stamford, 1999, pp.
Great Toe, AAOS Monograph Series, 1998. 117-126
STRESS FRACTURES OF THE FOOT & ANKLE

James R. Holmes, MD
Overview — Surgical intervention if recalcitrant

• Incidence
TARSAL NAVICULAR
SYMPOSIA FOOT/ANKLE
Pathomechanics
Overview
• Fatigue failure
Initially thought to be quite rare (0.7% - 2.4%) after first being
— Training errors
described in 1970, awareness of the injury has increased and
— Change in environment- surface, shoes, etc
may represent up to 35% of stress fractures in recent reports.
• Balance between microdamage and reparative biological
response Biomechanics
— Altered biomechanics • Navicular is compressed between talus and cuneiforms
— Altered vascularity during WB. As the talus exerts a distal force, PTT and bifur-
— Altered biological environment (nutrition, hormonal, etc) cate pull medial and lateral navicular proximally.
• Runners who are forefoot strikers, baseball and softball catch-
Classification
ers, soccer players, court sports seem particularly predisposed.
• High Risk vs. Low risk
• No particular foot type has been implicated as susceptible.
• High: Medial Malleolus, Navicular, 5th Metatarsal
Anatomy
Selected High Risk Stress fractures
• Diminished vascularity at jct of lateral 1/3 and medial 2/3
MEDIAL MALLEOLUS of bone
• Blood supply dorsal and lateral (branches of dorsalis pedis
Overview
and medial plantar artery)
Less than 10% of stress fx’s of foot and ankle. Like other
stress fractures, seen with overuse, especially court sports Evaluation
History
Biomechanics-
— Typically training errors, shoe gear changes predate insid-
Malalignment such as hindfoot varus, forefoot driven hind-
ious dull pain- often plantar ache, but typically anterior
foot varus, external tibial torsion and tibia vara, limb length
“ankle” pain
inequality, and genu varum can contribute.
Exam-
Evaluation — Tender “N” spot- dorsal medial navicular. Occasionally
• History- atraumatic onset. Overuse, often court sports. Starts swollen.
as dull ache. — Can often reproduce pain with hopping on ball of the foot
• Examination- Radiographs
— Tender medially and anteriorly (just above joint line), — Initial plain films usually WNL- beware dorsal “chip” or
mildly swollen. sclerosis
— DDx includes posterior tibial tendon pathology. — MRI is both sensitive and specific but gives less bone detail
• Radiographic Evaluation — CT most helpful in assessing propagation of fracture and
— 50% of initial plain XR normal subsequent healing
— MRI most sensitive and specific and excludes tendon/ Classification (Saxena) (by CT)
joint pathology in the DDx — Type I- break in dorsal cortex
— Type II- dorsal cortex with propagation into navicular body
Treatment
— TypeIII- propagation into another cortex (plantar or distal)
• Non-operative
— SLC or brace, initially NWB, then WBAT for 3-6 weeks Treatment
– Wean to stirrup splint at 6 weeks • Non-operative: 6 weeks non-WB cast .
– Progress from closed chain exercise to full activity as Return to full activity 5.6 months
tolerated. • Aggressive NWB associated with better
– Complete bony healing has been reported to take up results (Kahn):
to 6 months — 6 weeks NWB- 86% returned to full
– Return to ADL much sooner (6 weeks) activity
• Operative: — 2-5 weeks NWB- 69% returned to
— ORIF- perpendicular compression screws (4.0 or 4.5) full activity
and antiglide plate (depending upon fracture configura- — Activity restriction without cast- 50% returned to full
tion) activity
— Complete bony healing faster (4.2 months) – No restrictions- 29% returned to full activity
— Faster return to activity (4.6 weeks) • Operative: consider initially in type II and III fractures, elite
— Indications: failure of non-op Tx, in-season athlete, elite athletes, and failed non-op treatment and/ or recurrent
athlete stress fractures
— ORIF- -open or percutaneously,
Prevention of recurrence
– Solid or cannulated 4.0 or 4.5 mm screw in
• Proper foot gear
compression
• Address training errors
– Bone graft if sclerotic nonunion, type II and III
• Address underlying biomechanical factors
– Minimize soft tissue stripping
— Orthotics
— NWB for 6 weeks
169
— CT at 6 weeks- if healed- walking boot, bike, swim to tol- Treatment of Zone 2 and 3 fractures similar
erance • 25-50% may go on to nonunion or re-fracture
— Progress to closed chain (elliptical) at 8-10 weeks • Acute fractures are treated like Jones fracture and may treat
— If healed and pain-free, may start to jog at 10-12 weeks with non-weightbearing cast/boot for 6-8 weeks but in ath-
lete most commonly with intramedullary screw
Adjunct treatments
• Delayed union and non-union treated with intramedullary
• Pulsed low-intensity ultrasound and electrical bone stimula-
screw
tion have both been described but, at present no evidence is
SYMPOSIA FOOT/ANKLE
• Shorter median time to union (7.5 vs. 14.5 weeks and

available re: efficacy in this fracture.
sports (8vs 15 weeks) than non-op tx (Mologne)
Prevention of recurrence
Surgical Techinque
• Identify predisposing factors (shoes, environment) and
1. Bump under ipsilateral hip
modify
2. 3 cm skin incision from tuberosity proximal (extend
• Educate if training errors are responsible
distally if bone grafting- established non-union)
PROXIMAL FIFTH METATARSAL FRACTURES 3. Blunt dissection down to tuberosity
4. Careful attention to protect sural nerve branches
5. Place cannulated guide pin or drill down 5th metatarsal
shaft
6. Confirm under fluoroscopy in multiple views
7. Hold hand (pin/drill) close to foot and aim slightly dorsal
to properly place pin (“high and inside”)
8. Over-drill proximal fragment
Tuberosity Avulsion Fractures (Zone 1) 9. Tap screw hole in drill guide
• Usually extra-articular 10. Place solid partially threaded screw under fluoroscopy
• Proximal to articulation with 4th metatarsal 11. Close skin
• Mechanism is lateral band of plantar fascia
Complications
• Treatment is hard soled shoe or walking boot
• Sural nerve neuritis – careful dissection
• Usually asymptomatic at 4 weeks
• Screw fracture – usually a cannulated screw
• Radiographic union at 9 weeks
• Screw head pain – countersink screw, don’t remove screw
• Rarely intra-articular fracture with step off at cuboid
until end of athletic career
articulation will need ORIF
• Refracture of metatarsal
• Symptomatic non-union treated with excision
• Loss of reduction if screw too long and abuts distal inner
“Jones Fracture” ( Zone 2) cortex
• Fracture of metaphyseal-diaphyseal junction and intra-artic-
Post-op management
ular with 4th metatarsal
1. Splint and non-weightbearing for 1 week
• Medial comminution not uncommon
2. Wound check and place boot non-weightbearing for weeks
• Is an acute injury without prodromal symptoms
2 and 3
• Mechanism is large adduction force on planter flexed ankle
3. Remove sutures at 3 weeks and start gradual weight bearing
(misstep on lateral border of foot)
in boot for 3 weeks
Diaphyseal Stress Fractures (Zone 3) 4. At 6 weeks place in shoe with custom orthotic, no impact
• History of prodromal symptoms 5. At 8 weeks return to athletic participation, if radiographic
• Radiographic evidence of stress phenomenon of bone evidence of healing; (Healing not complete for 12 weeks
• Distal to 4th metatarsal articulation often)
• Classification 6. Wear stiff (graphite) orthotic to reduce stresses on 5th
a. acute – fracture line with sharp margins metatarsal
b. delayed union – fracture line involves both corticies, 7. Consider Electical stimulation
periosteal new bone formation, widened fracture line
and intramedullary sclerosis
c. non-union – wide fracture line, periosteal new bone for-
mation and complete obliteration of the medullary canal
at the fracture site by sclerotic bone
REFERENCES 5. Chen RC, Shia DS, Kamath GV, Thomas AB, Wright RW Troublesome Stress
Overview Fractures of the Foot and Ankle Sports Med Arthrosco Rev 2006 Dec; 14(4)
246-251
1. Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am
Acad Orthop Surg. 2000 Nov-Dec;8(6):344-53. 6. Fredericson M, Jennings F, Beaulieu C, Matheson GO. Stress fractures in athletes.
Top Magn Reson Imaging. 2006 Oct;17(5):309-25
2. Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med.
2001 Jan-Feb;29(1):100-11 7. Ciombor DM, Aaron RK. The role of electrical stimulation in bone repair. Foot
Ankle Clin. 2005 Dec;10(4):579-93,
3. Gehrmann RM, Renard RL. Current concepts review: Stress fractures of the foot.
Foot Ankle Int. 2006 Sep;27(9):750-7 Medial Malleolus
4. Kaeding CC, Yu JR, Wright R, Amendola A, Spindler KP. Management and return 8. Sherbondy PS, Sebastianelli WJ. Stress fractures of the medial malleolus and dis-
to play of stress fractures. Clin J Sport Med. 2005 Nov;15(6):442-7 tal fibula. Clin Sports Med. 2006 Jan;25(1):129-37
9. Shelbourne KD, Fisher DA, Rettig AC, McCarroll JR. Stress fractures of the medial 14. Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004
malleolus. Am J Sports Med. 1988 Jan-Feb;16(1):60-3 Mar;9(1):85-104.
10. Ariyoshi M, Nagata K, Hiraoka K, Sonoda K, Hori R, Inoue A. Stress fracture of 5th Metatarsal
the medial malleolus. Kurume Med J. 1997;44(3):233-6. 15. Rosenberg GA, Sferra JJ. Treatment strategies for acute fractures and nonunions of
Navicular the proximal fifth metatarsal. J Am Acad Orthop Surg. 2000 Sep-Oct;8(5):332-8
11. Saxena A, Fullem B. Navicular stress fractures: a prospective study on athletes. 16. Quill GE Jr. Fractures of the proximal fifth metatarsal. Orthop Clin North Am.
Foot Ankle Int. 2006 Nov;27(11):917-21. 1995 Apr;26(2):353-61
SYMPOSIA FOOT/ANKLE
12. Jones MH, Amendola AS. Navicular stress fractures. Clin Sports Med. 2006 17. Mologne TS, LundeenJM, Clapper MF et al Early screw fixation versus casting in
Jan;25(1):151-8, the treatment of acute Jones fractures Am J Sports Med2005;33:970-975
13. Burne SG, Mahoney CM, Forster BB, Koehle MS, Taunton JE, Khan KM. Tarsal
navicular stress injury: long-term outcome and clinicoradiological correlation
using both computed tomography and magnetic resonance imaging. Am J Sports
Med. 2005 Dec;33(12):1875-81.
171
◆BIOLOGIC STRATEGIES TO GROW BONE IN

DIFFICULT CLINICAL SITUATIONS
SYMPOSIA GENERAL
(AAOS/ORSI)
Moderator: Stuart B. Goodman, MD, Stanford, CA
Description: Clinicians are gaining increased access to biologic strategies to grow bone in
difficult clinical situations. These primary strategies include the use of stem cells and
osteoprogenitors, and bone morphogenetic proteins. Unfortunately, these technologies are
not formally tested initially in some of the tougher, clinically challenging situations or
during "off-label" use. The primary goals of this symposium are to educate clinicians about
the use of these technologies in tough clinical situations, highlight some of the local side
effects of these technologies, and consider strategies to avoid complications. In addition,
this symposium will identify areas that need further basic science research to facilitate the
successful use of these biologic strategies.
I. Introduction
Stuart B. Goodman, MD, Stanford, CA
II. The basics of how new bone is formed and osteoconductive agents
Steven A. Goldstein, PhD, Ann Arbor, MI
III. Growth Factor-based technologies

Scott D. Boden, MD, Atlanta, GA
IV. Cell-based technologies

George F. Muschler, MD, Cleveland, OH
V. Assessment and use of new and existing technologies for bone restoration in difficult
fractures
J. Tracy Watson, MD, St. Louis, MO
VI. Assessment and use of new and existing technologies for bone restoration is adult
reconstruction
Jay R. Lieberman, MD, Farmington, CT
VII. Assessment and use of new and existing technologies for bone restoration in spine
surgery
Harvinder S. Sandhu, MD, New York, NY
VIII. Assessment and use of new and existing technologies for bone restoration in
orthopaedic oncology
Alan W. Yasko, MD, Chicago, IL
IX. Panel Discussion, Question and Answers
BIOLOGIC STRATEGIES TO GROW BONE IN DIFFICULT

CLINICAL SITUATIONS
Stuart Goodman, MD PhD
Bone loss is a common phenomenon in cases of trauma, tumor, To understand the rational use of new technologies to enhance
SYMPOSIA GENERAL
infection and periprosthetic osteolysis. This lost bone needs to bone formation and avoid complications, we must understand
be restored for optimal function. Furthermore, enhanced meth- the basic and applied science of bone cells, matrices and growth
ods are needed to obtain spinal and joint arthrodesis, more factors. In Part 1 of this symposium, three speakers will address
expeditiously. Thus, there is a need for novel, safe and effective these points in focused lectures for the practicing orthopaedic
methods to regenerate new bone. surgeon:
Currently in the USA, approximately 800,000 surgical proce- • Basics of cells and cell-based technologies (George Muschler)
dures are performed annually in which some form of bone graft
• Basics of Bone Formation + Osteoconductive Scaffolds (Steve
is used (1). Almost half of these procedures use autograft bone,
Goldstein)
which is still the gold standard. However, autograft bone is lim-
ited in supply and the morbidity associated with harvesting of • Basics of Osteoinductive Proteins (Scott Boden)
autograft may be substantial (2-5). Bone graft substitutes and
Part 2 of this symposium will describe the assessment, use, and
extenders attempt to limit the use of autologous bone grafts,
side effects of existing and potential new technologies to
however the long-term efficacy of some of these treatments is
enhance bone formation in the following areas.
unknown.
• Difficult Fractures (Tracy Watson)
Bone formation requires 3 constituents:
• Adult Reconstruction (Jay Lieberman
• a matrix or scaffold that supports osteoprogenitor cell/bone
cell adherence and proliferation (osteoconduction) • Orthopaedic Oncology (Alan Yasko)
• growth factors that encourage osteoprogenitor cell/ bone cell • Spine (Vin Sandhu)
migration, adherence, proliferation and differentiation
Part 3 of this symposium will be comprised of an open forum
(osteoinduction)
for questions and answers by the speakers and audience
Note that an osteoinductive factor induces de novo bone for- participants.
mation in an ectopic location.
• cells (mesenchymal, osteoprogenitor or mature bone cells)
REFERENCES 4. Arrington ED, Smith WJ, Chambers HG, Bucknell AL, Davino NA.
Complications of iliac crest bone graft harvesting. Clin Orthop. 1996
1. Laurencin CT. Bone Grant Substitutes. ASTM, West Conshohocken, PA, USA,
Aug;(329):300-9.
2003.
5. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest bone
2. Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop
graft. Complications and functional assessment. Clin Orthop. 1997
Trauma. 1989;3(3):192-5.
Jun;(339):76-81.
3. Fowler BL, Dall BE, Rowe DE. Complications associated with harvesting autoge-
6. Gazdag AR, Lane JM, Glaser D, Forster RA. Alternatives to autogenous bone
nous iliac bone graft. Am J Orthop. 1995;24(12):895-903.
graft: efficacy and indications. J Am Acad Orthop Surg. 1995 Jan;3(1):1-8
173
BASICS OF BONE FORMATION AND

OSTEOCONDUCTIVE SCAFFOLDS
Steven A. Goldstein PhD
The repair or regeneration of bone follows a highly evolved adherent proteins on the surface that enables the attachment of
SYMPOSIA GENERAL
sequence of cellular activities beginning with acute hematoma cells to the surface via integrin proteins. Vascular progenitor
formation and early inflammatory response followed by granu- cells as well as osteoblasts migrate to the surface and begin the
lation tissue infiltration, recruitment, proliferation and differen- process of synthesizing and expressing tissue matrix con-
tiation of osteogenic and often chrondrogenic cells, matrix for- stituents. Osteoconductive materials do not support or encour-
mation and mineralization, and eventual remodeling. This age cartilage formation and therefore only promote direct bone
process occurs within the context of biologic and mechanical appositional formation and not endochondral bone formation.
signals. From a biologic perspective, regulation of the repair As will be noted below, some osteoconductive materials also
process is occurs through the expression of a cascade of growth enable osteoclast attachment and subsequent resorption.
factors, hormones, and cytokines that condition the wound site
and directly influence cell migration, proliferation, differentia- Chemical function
tion, and eventual matrix synthesis. The chemical properties of osteoconductive materials can be
designed to influence the migration, proliferation as well as
One of the most important components of a clinical strategy to
attachment of cells. As a result, the material could be chosen to
biologically encourage or enhance bone repair is the repair
significantly effect specific cell populations. Importantly, the
matrix. The choice of an endogenous matrix (material, archi-
chemical composition of the material can also have a substan-
tecture, mechanical and biologic properties) will depend on the
tial influence on its ability to deliver drugs, biologics or exoge-
philosophy, goals, or design principles being practiced by the
nous cells.
developer. For example, a matrix may be chosen to occupy vol-
ume, provide immediate mechanical integrity, and degrade in
Mechanical and Architectural function
time. Alternatively, the matrix may be inert, providing a perma-
Osteoconductive scaffolds can be developed to have a relatively
nent scaffold onto which living tissue form. If the matrix is
wide range of mechanical properties. The selection of these
designed to deliver cells, the properties must support the adher-
properties will have a significant influence on their clinical use.
ence, maintenance or association of the cells. The matrix might
Materials with high mechanical integrity may avoid the need for
also provide a method to deliver biomolecules that enhance
substantial fixation hardware while scaffolds with low mechani-
bone repair. The release or delivery dynamics of the matrix, its
cal properties may need to be used with more robust stabiliza-
ability to localize cells or biomolecules and its mechanical
tion systems or devices. In addition to the mechanical proper-
integrity are characteristics that can be optimized.
ties, the architecture of the scaffold will play an important role in
Although most of the literature on matrices or scaffolds focus the regeneration process. Since bone forms on the surface of
on the delivery of exogenous material to the wound site, the osteoconductive materials, their macroscopic or microscopic
matrix can also be designed to powerfully influence endoge- porosity, orientation in 3D space and surface to volume ratio will
nous factors. For example, the matrix can regulate vascular guide or direct the formation process from a special perspective.
ingrowth, provide chemotactic stimuli for endogenous cells,
modulate cell adhesion, and promote mitosis, differentiation, Resorption and Degradation
and mineralization. A large number of matrices are classified as Finally, the chemical and architectural properties of the scaffold
osteoconductive. These materials have a chemical composition, as well as the specific manufacturing process will affect the abil-
surface topology, and architecture that support the ongrowth of ity of the scaffold to be resorbed or degraded. Resorbtion is
bone. Osteoconductive materials can only support bone most often mediated by osteoclasts and is associated with mate-
ongrowth in locations where bone will normally form and have rials that have chemical properties similar to the mineral phase
access to bone progenitor cells. of bone. It is also possible that some scaffolds may be resorbed
by non-osteoclast macrophages. It is also possible to fabricate
Osteoconductive materials have become critically important
scaffolds from materials that degrade over time, most often by
elements in technologies designed to promote bone repair and
hydrolysis.
regeneration. Many examples of osteoconductive materials and
their biologic, mechanical and biophysical properties are
Examples of osteoconductive materials
described in the included reference list. The key properties of
Allografts, autografts, calcium phosphates, hydroxyapatites, cal-
osteoconductive materials and issues to consider when
cium sulfates, tri-calcium phosphate, bioglasses, specialized
evaluating a clinical technology are described below.
polymers, mineralized collagen, combinations of these materi-
als.
Biologic function
Osteocondutive materials support and promote the formation
of bone on their surface. This process involves the deposition of
REFERENCES 3. Barrere F, van Blitterswijk CA, de Groot K. Bone regeneration: molecular and cel-
1. Agrawal CM, Ray RB. Biodegradable polymeric scaffolds for musculoskeletal tis- lular interactions with calcium phosphate ceramics. International Journal of
sue engineering. J Biomed Mater Res. 2001;55:141–150. Nanomedicine. 2006;1(3):317-32.
2. Albrektsson T, Johansson C. Osteoinduction, osteoconduction and osseointegra- 4. Behravesh E, Yasko A, Engel P, Mikos AG. Synthetic biodegradable polymers for
tion. Eur Spine. 2001;J 10, S96. orthopaedic applications. Clin Orthop Relat Res. 1999;367:S118-S129.
5. Bruder SP, Fox BS. Tissue engineering of bone. Clin Orthop. 1999;367S:S68-S83. 18. Kretlow JD, Mikos AG. Review: Mineralization of synthetic polymer scaffolds for
6. Burg KJL, Porter S, Kellam JF. Biomaterial developments for bone tissue engineer- bone tissue engineering. Tissue Engineering. 2007;13(5):927-938.
ing. Biomaterials. 2000;21:2347-2359. 19. Lane JM, Bostrom, MPG: Bone Grafting and New Composite Biosynthetic Graft
7. Chapman MW, Bucholz R, Cornell C. Treatment of acute fractures with a colla- Materials. In Cannon Jr WD (ed). AAOS Instructional Course Lectures. Vol 47.
gen-calcium phosphate graft material. J Bone Joint Surg Am. 1997;79-A:495-502. Ed 57. Rosemont, IL, American Academy of Orthopaedic Surgeons Publications
525–534, 1998.
8. Cornell CN. Osteoconductive materials and their role as substitutes for autoge-
nous bone grafts. Orthop Clin North Am. 1999;30:591-598. 20. Larsson S, Bauer TW. Use of injectable calcium phosphate cement for fracture fix-
ation: a review. Clin Orthop Relat Res. 2002;395:23-32.
9. De Long WG Jr., Einhorn TA, Koval K, McKee M, Smith W, Sanders R, Watson T.
Bone grafts and bone graft substitutes in orthopaedic trauma surgery. J Bone 21. Laurencin CT, Attawia MA, Elgendy HE, Herbert KM. Tissue engineered bone-
SYMPOSIA GENERAL
Joint Surg Am. 2007 Mar;89(3):649-58. regeneration using degradable polymers: the formation of mineralized matrices.
Bone. 1996;19(1 Suppl):93S-99S.
10. del Real RP, Ooms E, Wolke JG, Vallet-Regi M, Jansen JA. In vivo bone response
to porous calcium phosphate cement. J Biomed Mater Res A. 2003;65:30-6. 22. Lee KY, Alsberg E, Mooney DJ. Degradable and injectable poly(aldehyde glu-
curonate) hydrogels for bone tissue engineering. J Biomed Mater Res.
11. El-Amin SF, Attawia M, Lu HH, et al. Integrin expression by human osteoblasts 2001;56:228-233.
cultured on degradable polymeric materials applicable for tissue engineered
bone. J Orthop Res. 2002;20:20-28. 23. Oakes DA. Lee CC. Lieberman JR. An evaluation of human demineralized bone
matrices in a rat femoral defect model. Clin Orthop Rel Res. 2003 Aug;(413):281-
12. Garcia AJ, Ducheyne P, Boettiger D. Effects of surface reaction stage on 290.
fibronectin-mediated adhesion of osteoblast-like cells to bioactive glass. J
Biomed Mater Res. 1998;40(1):48-56. 24. Peter SJ, Lu L, Kim DJ, et al. Marrow stromal osteoblast function on a
poly(propylene fumarate)/beta-tricalcium phosphate biodegradable orthopaedic
13. Guldberg RE, Duty AO. Functional Tissue Engineering. New York: Springer- composite. Biomaterials. 2000;21:1207-1213.
Verlag;2004. Chapter 12, Design Parameters for Engineering Bone Regeneration;
p.146-161. 25. Shors EC. The development of coralline porous ceramic bone graft substitutes.
In: Laurencin CT, editor. Bone graft substitutes. West Conshohocken, PA:ASTM
14. Herron S, Thordarson DB, Winet H, Luk A, Bao JY. Ingrowth of bone into International; 2003. p 271-288.
absorbable bone cement: an in vivo microscopic evaluation. Am J Orthop.
2003;32:581-584. 26. Vunjak-Novakovic G, Goldstein SA. Basic orthopaedic biomechanics and
mechano-biology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2005.
15. Holy CE, Shoichet MS, Davies JE. Engineering three-dimensional bone tissue in Chapter 8, Biomechanical Principles of Cartilage and Bone Tissue Engineering; p.
vitro using biodegradable scaffolds: investigating initial cell-seeding density and 343-407.
culture period. J Biomed Mater Res. 2000;51:376-382.
27. Yaszemski MJ, Payne RG, Hayes WC, Langer R, Mikos AG. Evolution of bone
16. Hutmacher DW. Scaffolds in tissue engineering bone and cartilage. Biomaterials. transplantation: molecular, cellular and tissue strategies to engineer human
2000;21:2529-2543. bone. Biomaterials. 1996;17:175-185.
17. Kenley RA, Yimn K, Abrams J, Ron E, Turek T, Marden LJ, Hollinger JO.
Biotechnology and bone graft substitutes. Pharm Res. 1993;10:1393-1401.
175
GROWTH FACTOR-BASED TECHNOLOGIES

Scott D. Boden, MD
1. Introduction i. Several different isoforms

a. ICBG is the “gold standard” for difficult healing situations ii. Not osteoinductive
i. Osteoconduction- scaffold iii.Helpful for diabetic wound healing
ii. Osteogenesis- live cells iv. Possibly helpful for diabetic fracture repair
SYMPOSIA GENERAL
iii.Morbidity may be up to 20% of patients v. Inhibitory for spine fusion when combined with
b. Osteoinductive bone graft alternatives are experiencing autograft or DBM
increasing popularity vi. Can inhibit BMP activity in cell cultures
i. Osteoinductive means it is capable of inducing bone vii. May require optimal concentration and pulsed
de novo in ectopic location rather than constant release
ii. Bone graft extenders or enhancers d. Prostaglandin Agonists
iii.Bone graft substitutes i. PGE2 increases bone mass administered systemically
iv. Osteopromotive category – helpful when bone is or locally
already forming, but not capable of ectopic bone for- ii. An agonist to prostaglandin receptor EP2 enhanced
mation from scratch healing of canine long bone segmental defects
c. Burden of Proof – osteoinductive proteins
3. Bone Morphogenetic Proteins
i. Ability of preclinical models to predict clinical out-
i. Timeline
comes
1. 1965 – Urist – Autoinduction principle (DBM)
1. Applicable – indication-specific for the intended
2. 1988 - Rosen, Wozney et al cloned BMP cDNAs
use
3. 2001 - rhBMP-7 (OP-1) approved for spine fusion in
2. Histological and radiographic (CT scan) success –
Australia, then Europe, later for long bone nonunions
100% success
4. 2002 - rhBMP-2/ACS (InFuse) PMA approved by FDA
3. Reproducible – demonstrate consistent efficacy in
for Interbody Spine Fusion
each preclinical models before progressing to next
5. 2003 - rhBMP-7 (OP-1) HDE approved by FDA for
order of animal eventually leading up to clinical
long bone nonunion and eventually posterolateral
evaluations
spine fusion nonunion
ii. Four levels of proof
6. 2005 - rhBMP-2 (InFuse) PMA approved by FDA for
1. Rat ectopic model to demonstrate inductivity
open tibia fractures
2. Larger animal model to demonstrate location-
7. 2007 - rhBMP-2 (InFuse) PMA approved by FDA for
specific efficacy (rabbit, canine, sheep, goat)
dental applications
3. Non-human primate to demonstrate species-
ii. Mechanism of Action
specific efficacy (prefer rhesus monkey)
1. BMPs are chemotactic for MSCs
4. Human clinical investigation
2. BMP homo/hetero dimers bind to cell surface recep-
a. Level III
tors (serine threonine kinase) resulting in phosphory-
i. Retrospective cohort studies
lation of Smad 1/5 which binds to Smad4 and
ii. Case-control studies
translocates into the nucleus where it can bind to spe-
b. Level II
cific DNA sequences in promoters of osteoblastic
i. Prospective cohort study
genes.
ii. Lesser-quality randomized study (e.g. < 80%
3. Inhibitory Smads can block this process
follow-up, blinding, improper randomization)
4. Smurf1 can result in ubiquitin-mediated proteosomal
c. Level I
degradation of Smads
i. Prospective, randomized, controlled trial with
5. Much crosstalk with other pathways that may affect
statistical significance or narrow confidence
cellular responsiveness to BMPs – poorly understood.
intervals
6. Osteoinductive BMPs can induce bone and bone mar-
2. Peptide Signaling Molecules row formation de novo in an ectopic location.
These peptide growth factors stimulate the activity of osteo- iii.Are all BMPs created equal? NO
progenitor cells and osteoblasts and may enhance osteogen- 1. Most osteogenic BMPs are BMP-2, BMP-6, BMP-9
esis. They cannot induce bone formation from undifferen- 2. Somewhat less osteogenic BMPs are BMP-4, BMP-7
tiated cells. 3. Data based on in vitro effects on pluripotent cells,
a. Fibroblast Growth Factor (FGF) immature OB, mature OB as well as in vivo ectopic
i. Expressed during fracture repair bone formation with each BMP delivered by AdV vec-
ii. FGF-2 can accelerate fracture repair in NH primates tor in thigh muscle of athymic rat
(baboons) 4. Different BMPs can have different distant organ effects
iii.Phase III clinical trials for tibial fractures underway a. rhBMP-7 has positive effects on kidney (was consid-
b. Vascular Endothelial Growth Factor (VEGF) ered as a potential treatment for acute renal failure)
i. Ability to induce angiogenesis b. rhBMP-6 has been examined for osteoporotic bone
ii. Necessary for bone healing, but not sufficient to be enhancement
osteoinductive
4. Summary of Outstanding Issues with BMPs
iii.Can enhance bone healing and can enhance
a. Are there differences between BMPs?
suboptimal doses of BMP
b. Will difficult patients (revisions, diabetes, smokers,
c. Platelet Derived Growth Factor (PDGF)
steroids) require higher doses of BMPs?
c. Are there safety issues (antibodies)? – probably not clini- f. Segmental Defect is tougher than routine fracture.
cally relevant Posterolateral spine fusion is tougher than interbody
d. Local Side Effects with rBMPs? fusion – must validate BMP dose and carrier in specific
i. Ectopic Bone (PLIF, TLIF) healing environment
ii. Seroma, Edema (ACDF, PLIF, TLIF, PLF) g. Rhesus monkey is most predictive model of clinical
iii.Transient Local Resorption (ALIF, PLIF, TLIF) near can- behavior of BMP+ carrier
cellous bone h. Less than 100% successful bone induction suggests:
iv. Can be minimized by avoiding hyperconcentration of i. Inferior BMP
BMP solution on carrier, switching carriers with ii. Inadequate dose
SYMPOSIA GENERAL
unknown release kinetics, avoiding overstuffing iii.Inadequate carrier
BMP/carrier into fixed defect/device volumes
e. Carrier plays an important role in success and dose of
BMP needed
REFERENCES 21. Louis-Ugbo, J et al. “Evidence of osteoinduction of Grafton Matrix in nonhuman

primate spine fusion model.” Spine, (29): 360-366, 2003.
1. Wozney JM et al. “Novel regulators of bone formation: Molecular clones and
activities” Science (242): 1528 – 1534, 1988 22. Kraiwattanapong C et al. “Comparison of HEALOS/Bone Marrow to INFUSE
with a collagen-ceramic sponge bulking agent as graft substitutes for lumbar
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spine fusion.” Spine, (30), In Press, 2005
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– 575, 2002 23. Walsh, WR et al. “Spinal fusion using an autologous growth factor gel and a
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381, 2000 verse fusions.” Spine. 2003 Sep 1;28(17):1968-70.
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bony sites” Orthopedics 22(7): 669 – 671, 1999 tive clinical study.” Eur Spine J. 2001 Oct;10 Suppl 2:S178-84.
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37. Magit DP et al. “Healos/recombinant human growth and differentiation factor-5
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adjunct in posterolateral lumbar spine fusion: A prospective CT-scan analysis at
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2863, 2002. fusion using osteogenic protein-1 (OP-1) versus local autograft with ceramic
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40. Shields LB et al. “Adverse effects associated with high-dose recombinant human
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177
CELL-BASED STRATEGIES AND TECHNOLOGIES

George F. Muschler, MD
I. Bone Tissue Engineering Material properties (stiffness strength, ductility)

Engineering translates fundamental knowledge in physics, Macroarchitecture – (50 to 5000 microns)
chemistry, and biology into materials, devices, systems, and (relevant to cell migration revascularization)
strategies to achieve practical benefits. Tissue engineering Pores size
SYMPOSIA GENERAL
applies this conceptual framework to advance the repair, Void volume

augmentation, replacement or regeneration of organs and Connectivity
tissues.1-3 Miroarchitecture – (< 10 micron) relevant to molecu-
lar diffusion
II. Stem Cells and Progenitors in Bone Tissue Formation, Surface Texture – relevant to attachment cell migra-
Remodeling and Health tion
A. Stem Cell Definition - A cell which is capable of “self Surface area, channeling
renewal” (i.e. dividing to provide on or more cells that Surface Chemistry – interaction with cells and bio-
have identical phenotype and biological potential to the molecules
starting cell) Implantation and Degradation Environment
B. Stem Cell Paradigm if Tissue Health and Maintenance pH
C. Stem Cell Life Cycle Osmolarity
D. Stem Cell Compartment Kinetics in Bone Tissue Solubility
E. Stem Cell and Progenitor Cell Nomenclature Delivery
Colony Forming Units (“CFU”) O2, Glucose
Cell which gives rise to a colony of progeny, in vitro Bioactive molecules
or in vivo. (e.g. CFU-GM is a cell that gives rise to Adhesion Molecules
progeny that become granulocytes and macrophages) Bioactive molecules and Growth Factors
Colony Forming Unit-Fibroblastic (“CFU-F”) C. Signaling and Inductive Environment
Cell which gives rise to a colony of progeny, in vitro Survival Factors (proapoptosis and antiapoptotis balance)
or in vivo, which exhibits a fibroblastic phenotype. Inflammatory Factors
(Friedenstein) Mitogens – increasing proliferation
Bone Marrow Stromal Cells (BMSC) Angiogenic Factors
Culture expanded cell that supports hematopoiesis Differentiation/Inductive Factors (factors that change cell
Mesenchymal Stem Cells (MSC) fate – i.e. differentiation path)
Purified, homogeneous, culture expanded cells that Homing Factors
retain the ability to differentiate into bone, cartilage, D. Mass Transport
fat, fibrous tissue (Caplan Papers and Patents) Local Vascularity
Connective Tissue Progenitors (CTP) Diffusion – oxygen, glucose, CO2, lactate, urea
The entire heterogeneous population of cells in Convection
native tissues that can proliferate to give rise to proge- E. Biophysical Environment
ny capable of differentiating into one or more con- Mechanical Environment
nective tissues (including blood, bone, cartilage, fat, Stain, Frequency, Duration, Wave form
fibrous tissue) Electro-Magnetic Environment
Connective Tissue Progenitors-Osteogenic (CTP-O) Modality, Magnitude, Frequency, Duration, Wave form
The entire heterogeneous population of cells in native Ultrasound
tissues that can proliferate to give rise to progeny
V. CTP-O Harvest and Transplantation Options
capable of differentiating into bone. (Muschler)
a. Sources
III. Cell-based Tissue Engineering Strategies for Bone Repair i. Autograft
Targeting 1. Bone – Conventional Autogenous Cancellous Bone
Transplantation (ACB)
Homing a. Value – efficacy, familiar handling properties
Biological Modification b. Disadvantage:
i. high morbidity, OR time, associated costs
IV. Cell-Level Factors Influencing Bone Tissue Formation and
ii. pain and scarring
Repair in Bone Defects
iii. non-renewable, can’t go back to same site
A. Local Cell Population
iv. variability between patients and sites
Stem Cells and Progenitor Cells (i.e. CTPs)
2. Marrow – Aspiration from Iliac Crest, vertebral
Concentration
body, other sites
Prevalence
a. Value:
Biological Potential
i. Efficacy
Non-Progenitor Cells
ii. Low morbidity, time and cost
Non-Contributing Cells - RBCs
iii. Renewable resource, can go back to same site!
Inhibitory Non-Progenitors - ?
b. Disadvantage:
Contributing Non-Progenitors - ?
i. Time (5-10 min)
B. Matrix or Scaffold Environment
Bulk Material
ii. Technique/learning/comfort curve (albeit i. Centrifuge (**See work of Connolly and Hernigou)
short) 1. Value
c. Other factors – a. Efficacy in preclinical studies and clinical
i. Negative - variability between patients cohorts
3. Fat – Currently experimental b. 3-4 fold increase in CTP-O concentration
a. Value: c. Reduced Red Cells
i. Possibly low morbidity, time 2. Disadvantage
ii. Renewable resource, can go back to same site a. Time, cost
or others! b. No nucleated cell selection (i.e. reduction in
SYMPOSIA GENERAL
iii.Higher prevalence of CTPs than BM other “competing” cells)
b. Disadvantage ii. Selective Retention (Cellect™)
i. Efficacy uncertain 1. Value
ii. Time & Cost (10-15 min harvest plus need a. Efficacy in preclinical studies and clinical
for processing) cohorts
iii.Greater bruising, scar, pain, risk than BM b. 3-18 fold increase in CTP-O concentration
harvest? (depending on matrix and marrow volume
iv. Equipment/technique/learning/comfort curve ratio)
v. Biological Potential of CTPs uncertain c. Reduced Red Cells
compared to BM-derived CTP population. d. Selection of CTPs - reducing transplantation of
c. Other factors – other non-retained “competing” cells
i. Negative - variability between patients and 2. Disadvantage
sites a. Time (5-15 min)
4. Muscle - Currently experimental b. Cost (~$30-100/cc) depending on the matrix
5. Peripheral Blood after “stem cell mobilization”- used (Still much cheaper than BMPs, however,
Currently experimental which run $200-1000/cc).
ii. Allograft iii.Future Processing Options
1. Bone – (e.g. – “Trinity ™)” 1. Magnetic Separation of Bone Marrow
a. Potential value – allograft cell signaling a. Capture Release
and allocell survival? b. Continuous Flow Systems
b. Risk – allocell survival, neoplasia, Disease
VI. Combination Options and Future Opportunities
transmission
a. Cells plus Factors?
c. Other factors – cost $$, variability between
i. Theoretical Advantages
donors
1. Preclinical studies suggest that an improved target
b. Harvest Methods
cell population can enhance the performance of
i. Open excision
BMPs
1. Bone
ii. Barriers
ii. Percutaneous harvest
1. No published clinical data!
1. Bone IC or metaphyseal cores (up to 2-3 ccs)
2. Large and complex study required to show added
2. IM reaming
value of combination over either alone.
a. Conventional collection of reamings
3. Dose and carrier not currently optimized for exoge-
b. Reaming with irrigation (e.g. RIA device™)
nous cell delivery. Which to use?
iii.Aspiration
4. Who will fund the study?
1. Bone Marrow
b. Factors mixed with alternative scaffold ?
a. Low volume aspiration - < 2ccs per needle
i. Theoretical Advantages
position
1. Use of alternative scaffolds can improve fill and
c. Biological Comparison of Sources
retention in large defects.
i. Yield
ii. Barriers
ii. Prevalence
1. Little clinical data!
iii.Biological Performance
2. Who will fund the study?
d. Intraoperative Marrow Processing Options
REFERENCES: 7. Pittenger MF et al. Multilineage potential of adult human mesenchymal stem

1. Griffith LG, Naughton GK. Tissue engineering -- current challenges and expand- cells. Science. 1999;284(5411): 143-7.
ing opportunities. Science. 2002;295: 1009-1014. 8. Friedenstein AJ, Petrakova KV, Kurolesova AI, Frolova GP. Heterotopic of bone
2. Muschler GF, Midura R: Connective Tissue Stem Cells and Progenitors in bone marrow.Analysis of precursor cells for osteogenic and hematopoietic tissues.
Grafting Applications – Practical Concepts and Guidelines. Clin Orthop Rel Res Transplantation. 1968;6(2): 230-47.
395:66-80, 2002. 9. Muschler GF, Boehm C, Easley K. Aspiration to obtain osteoblast progenitor cells
3. Muschler GF, Midura R, Nakamoto C: Practical Modeling Concepts for from human bone marrow: the influence of aspiration volume. J Bone Joint Surg
Connective Tissue Stem Cell and Progenitor Compartment Kinetics. J Am. 1997;79(11): 1699-709.
Biomedicine and Biotechnology. 3: 170-193, 2003 10. Connolly J, Guse R, Lippiello L, Dehne R. Development of an osteogenic bone-
4. Muschler GF, Nakamoto C, Griffith L: The Engineering Principles of Tissue marrow preparation. J Bone Joint Surg Am. 1989;71(5): 684-91.
Engineering. (Current Concepts) J Bone Joint Surg Am. 86-A:1541-58, 2004 11. Muschler GF, Nitto H, Boehm C, Easley K. Age- and gender-related changes in
5. Owen M, Friedenstein AJ. Stromal stem cells: marrow-derived osteogenic precur- the cellularity of human bone marrow and the prevalence of osteoblastic progen-
sors. Ciba Found Symp. 1988;136: 42-60 itors. J Orthop Res. 2001;19: 117-125.
6. Caplan AI. Mesenchymal stem cells. J Orthop Res. 1991;9(5): 641-50.
179
12. Connolly JF, Guse R, Tiedeman J, Dehne R. Autologous marrow injection as a 21. McLain RF, Fleming JE, Boehm CA, Muschler GF: Aspiration of Osteoprogenitor
substitute for operative grafting of tibial nonunions. Clin Orthop. 1991;266: Cells for Augmenting Spinal Fusion: Comparison of Progenitor Cell
259-70. Concentrations from the Vertebral Body and Iliac Crest. J Bone Joint Surg Am.
13. Connolly JF, Guse R, Tiedeman J, Dehne R. Autologous marrow injection for 87:2655-2661, 2005.
delayed unions of the tibia: a preliminary report. J Orthop Trauma. 1989;3(4): 22. Bidula J, Boehm, Powell K, Barsoum, Nakamoto C, Mascha E, Muschler GF:
276-82. Osteogenic Progenitors in Bone Marrow Aspirates from Smokers and Non-
14. Connolly JF. Injectable bone marrow preparations to stimulate osteogenic repair. Smokers. Clin Orthop Rel Res 442:252-259, 2006
Clin Orthop. 1995;313: 8-18. 23. Takigami H, Kumagai K, Latson L, Togawa D, Bauer T, Powell K, Katz E, Muschler
15. Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone mar- GF: Bone Formation following OP-1 Implantation is Improved by Addition of
Autogenous Bone Marrow Cells in a Canine Femur Defect Model. J. Orthop. Res.
SYMPOSIA GENERAL
row grafting. Clin Orthop. 2002;405: 14-23.

(In Press) Epub 2007 June 5.
16. Prockop DJ. Marrow stromal cells as stem cells for nonhematopoietic tissues.
Science. 1997;276(5309): 71-4. 24. Hernigou, Ph. Poignard, A. Beaujean, F. Rouard, H., Percutaneous autologous
bone-marrow grafting for nonunions. Influence of the number and concentra-
17. Griffith LG. Emerging design principles in biomaterials and scaffolds for tissue tion of progenitor cells. Journal of Bone & Joint Surgery - American Volume.
engineering. Ann N Y Acad Sci. 2002;961: 83-95. 87(7):1430-7, 2005 Jul.
18. Hubbell JA. Bioactive biomaterials. Curr. Opinion Biotech. 1999;10: 123-129. 25. Hernigou P. Poignard A. Manicom O. Mathieu G. Rouard H., The use of percuta-
19. Muschler GF, Nitto H, Matsukura Y, Boehm C, Easley K, Valdevit A, Kambic H, neous autologous bone marrow transplantation in nonunion and avascular
Davros W, Powell K: Spine fusion using cell matrix composites enriched in bone necrosis of bone. Journal of Bone & Joint Surgery - British Volume. 87(7):896-
marrow derived cells. Clin Orthop Rel Res 407:102-118, 2003. 902, 2005 Jul.
20. Muschler GF, Matsukura Y, Nitto H, Boehm CA, Valdevit AD, Kambic HE, Davros
WJ, Easley KA, Powell KA. Selective retention of bone marrow-derived cells to
enhance spinal fusion. Clin Orthop Related Res 2005 Mar;(432):242-251.
BIOLOGIC STRATEGIES TO GROW BONE IN DIFFICULT

CLINICAL SITUTATIONS
J. Tracy Watson, MD
ASSESSMENT AND USE OF NEW AND EXISTING local environment
SYMPOSIA GENERAL
TECHNOLOGIES FOR BONE RESTORATION IN DIFFICULT (a) May require angiography / MRI to determine
FRACTURES vascularity/viability of host defect. Most graft
There are clearly no well defined indications for use of a specif- failures are as a result of inadequate or poor
ic type of bone graft substitute or use of inductive factor when host nutrition to the local graft region as most fx
dealing with complex fractures, especially when dealing with sites and nonunions are often at the site of thick
acute bone loss in the setting of associated severe soft tissue scar and / or relative avascularity. There is no
damage. The use of all of these resources should be based on substitute for preparing the host recipient bed
contemporary fracture management principles and current appropriately by resecting the avascular tissue
levels of evidence for use of these materials and providing healthy tissue for revasculariza-
tion phenomenon and thus success of the graft.
1) Metaphyseal defects (b) Flap / soft tissue coverage…..reconstitution of
a) For most metaphyseal defects, it has been shown inflammatory phase of Fx healing (neo vascu-
experimentally that a simple cancellous void will larization)
reconstitute on its own and heal completely given a (4) Size of defects
sound biologic environment without the addition of (5) Infection status
any further grafting material. The danger here is that the (6) Mechanical stability
subchondral surface will collapse if this defect does not ii) Acute defect / delayed union / subcritical defect (with-
reconstitute fast enough to provide subchondral support out total segmental loss) With internal fixation i.e.
with the initiation of wt. bearing plate / IM nail
i) Conductive substrates (1) Graft options
(1) Ca ceramics. CaSO4 / CaPO4 (a) Composite grafts
(a) Incorporation characteristics…i.e rates of (i) DBM + Autogenous cellular concentrates, +, -
osteointegration platelet gels (as carrier)
(b) Ultimate compressive strength mPa 1. Limited success with centrifuged aspirate
(c) Delivery mechanism. Particulate vs self setting alone (Connelly, Watson)
“cements” 2. Concentration of CFU’s in conjunction
(d) Incorporation time vs bone regenerated into with carrier materials (Hernigou)
defect (Jimenez….Astrom technique)
(i) Cellular mediated vs chemical degradation of iii) Acute critical sized defect / nonunion. (segmental
materials loss <4cm)
(ii) Use of marrow concentrates to accelerate (1) Graft options
incorporation characteristics. “seeding the (a) BMP-2 implantation at time of wound closure
graft” (open tibia fx) (BESTT study results)
(e) Multiple studies with good Level I and II evi- (b) Segmental defects up to 4 cm ( Bucholz, Jones
dence support use of both sulfate and phos- et.al)
phate materials for contained metaphyseal (c) OP-1 (McKee ..Canadian open tibial shaft
defects. study)
(i) Demonstrated superiority over autogenous (d) OP-1 for nonunions ( equivalent efficacy
graft materials. between autograft and OP-1)
(2) MECHANICAL Factors. Use of conductive sub- (e) Providing scaffolding for mesenchymal cell infil-
strate materials in metaphyseal defects augmented tration. Depending on the temporal relation-
with use of locking plates for plateau, distal ship of the delivery of the inductive factor to the
femoral, and pilon fractures cell population in question, will determine the
(a) MINIMAL evidence currently available for use specific effect that each protein has on the frac-
of locking plates in these locations. ture healing cascade. It is important that these
stem cells have the appropriate conductive sur-
2) Diaphyseal fractures
face to migrate on to initiate the further produc-
a) Use of adjuvant materials in this location depends on
tion of their specific induced function.
numerous factors
(f) Providing Colony forming units (CFU’s)
i) Evaluation of fx site. Mid shaft tibia fracture is usually
(Hernigou)
a biologically “challenged” region
iv) Large segmental defects
(1) The appropriate migration of cellular components
(1) Staged reconstruction
to the site of bone graft or fracture is crucial in
(a) Antibiotic spacer / beads / rods
continuing the progression of the fracture healing
(i) Carrier for inductive materials
cascade. Consideration of delivering these cells to
(ii) Carrier for antibiotics
the region in question.
1. PMA
(2) Acute bone loss vs non-union defect
2. CaSO4
(3) Condition of soft tissues and “zone of injury”
181
(b) Development of vascularized pseudo-mem- eling and as such these defects are prone to
branes fatigue failure and stress fracture. Large segmen-
(i) Grafting directly into vascularized pseudo tal defects often require bone transport versus
membrane free tissue transfer such as vascularized iliac
(ii) Membrane directed bone regeneration crest or free fibula or combinations of both.
(2) Bone transport (b) Ultrasound directed rapid transport of over nail
(a) Segmental bone loss remains problematic and with autodistractors
usually requires massive quantities of graft (c) Augmentation of rapid regenerate with BMP’s
material, whether it be a composite graft utiliz- (3) Free tissue transfer
SYMPOSIA GENERAL
ing transplant of autogenous cellular material (a) Combination methodologies with bone trans-
in combination with a competent osteoconduc- port and inductive factor augmentation
tive substrate as well as inductive proteins are (4) Ti cage / graft / IM nail.... defect replacement
necessary to bridge large structural defects. (Lindsey)
Problems here include the lack of rapid remod-
REFERENCES 18. Hernigou P et al; Treatment of Osteonecrosis with Autologous Bone Marrow
1. Tiedeman JJ, Garvin KL, Kile TA, et al. The role of a composite, demineralized Grafting. Clin Orthopaedics and Rel Res., 405: 14 – 23, 2002
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tion grafting of resistant femoral non-unions. A preliminary report. Clin. cells from human bone marrow: the influence of aspiration volume. J Bone
Orthop., 230:257-265, 1988. Joint Surg Am 1997Nov (11):1699-1709
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genetic protein 7) in the treatment of tibial nonunions. J Bone Joint Surg Am substitute for operative grafting of tibial nonunions. Clin Orthop 1991;
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tal radial fractures. A randomized study. J Bone Joint Surg Am, 84-A(11): 2127- acute shortening and lengthening versus bone transport in the management of
37, 2003. tibial non-unions. Injury. 36(5):662-668, 2005.
11. Lobenhoffer P, Gerich T, Witte F and Tscherne H. Use of an injectable calcium 31. Matsuyama J, Ohnishi I, Kageyama T, Oshida H, Suwabe T, Nakamura K.
phosphate bone cement in the treatment of tibial plateau fractures: a prospective Osteogenesis and angiogenesis in regenerating bone during transverse distraction:
study of twenty-six cases with twenty-month mean follow-up. J Orthop Trauma, quantitative evaluation using a canine model. Clin Orthop. 433: 243-250, 2005.
16(3): 143-9, 2002. 32. Mekhail AO, Abraham E, Gruber B, Gonzalez M. Bone transport in the manage-
12. Watson JT. The Use of an Injectable Bone Graft Substitute in Tibial Metaphyseal ment of posttraumatic bone defects in the lower extremity. J Trauma. 56(2):368-
Fractures. Orthopedics 27(1): 103-105, 2004. 378, 2004.
13. Horstmann WG, Verheyen CC and Leemans R. An injectable calcium phosphate 33. Oedekoven G, Jansen D, Raschke M, Claudi BF: The monorail system--bone
cement as a bone-graft substitute in the treatment of displaced lateral tibial segment transport over unreamed interlocking nails. Chirurg. 67(11):1069-
plateau fractures. Injury, 34(2): 141-4, 2003. 1079, 1996.
14. Schildhauer TA, Bauer TW, Josten C and Muhr G. Open reduction and augmen- 34. Song HR, Kale A, Park HB, Koo KH, Chae DJ, Oh CW, Chung DW: Comparison
tation of internal fixation with an injectable skeletal cement for the treatment of of internal bone transport and vascularized fibula femoral bone defects. J
complex calcaneal fractures. J Orthop Trauma, 14(5): 309-17, 2000. Orthop Trauma. 17(3):203-211, 2003.
15. Muschler GF, Midura MJ. Connective Tissue Progenitors: Practical Concepts for 35. Watson JT. Treatment of Tibial Fractures with Bone Loss. Techniques in Orthop.
Clinical Applications. Clin Orthop 2002; 395:66-80. 11(2): 132-143, 1996.
16. Muschler, GF, Midura RJ, Nakamoto C. Practical modeling concepts for connec- 36. Watson JT, Anders, M, Moed BR: Management Strategies for Bone Loss in Tibial
tive tissue stem cell and progenitor compartment kinetics. J Biomed Biotechnol. Shaft Fractures. Clin Orthop. 315:138-152, 1995.
2003:3(2003)1-20. 37. Rozbruch RS, Weitzman AM, Watson JT, Freudigman P, et.al. Simultaneous
17. Hernigou P et al; Percutaneous Autologous Bone-Marrow Grafting for Treatment of Tibial Bone and Soft –tissue Defects with the Ilizarov Method. J
Nonunions. J. Bone and Joint Surg., 87-A No. 7 July 2005 Ortho Trauma 20(3):197-205, 2006.
38. Watson JT, Distraction Osteogenesis. Journal of AAOS Oct; 14(10) 168-74. 2006. 41. Hernigou P et al; Percutaneous Autologous Bone-Marrow Grafting for
39. Delong, W, Einhorn, T, Koval, K, Watson JT, et.al. Bone Grafts and Bone Graft Nonunions. J. Bone and Joint Surg., 87-A No. 7 July 2005
Substitutes in Orthopaedic Trauma Surgery. A critical analysis. J Bone Joint Surg 42. Hernigou P et al; Treatment of Osteonecrosis with Autologous Bone Marrow
Am. 2007 Mar;89(3):649-58. Review. Grafting. Clin Orthopaedics and Rel Res., 405: 14 – 23, 2002
40. Quigley K, Watson JT, Mudd C, Iliac Crest Aspiration and Injection in the
Treatment of Delayed and Nonunion. Paper Presentation. Abstracts of the 22nd
Annual Meeting OTA. Phoenix ,AZ. Oct 3-7, 2006.
SYMPOSIA GENERAL
183
ASSESSMENT AND USE OF NEW AND EXISTING TECHNOLOGIES

FOR BONE RESTORATION IN ADULT RECONSTRUCTION
Jay R. Lieberman, MD
I. Bone Repair osteoinductive proteins (BMP), and their

SYMPOSIA GENERAL
A. Definitions osteoconductive and osteoinductive activity is variable.

1. Osteoconductive – material acts like a scaffolding for 3. Limited biomechanical properties
new bone to form on 4. Variable biological activity
2. Osteoinductive – induces pleuripotential cells to a. Variable amounts of BMP
differentiate into bone forming cells b. Different carriers
3. Osteogenic – support the formation of bone ( i.e. 5. Pre-clinical studies
bone marrow cells) a. Different DBM preparations have different
B. Critical elements – Four key factors biological activity in various animal models
1. Osteogenic signal i) femoral defect
2. Responding cells (osteoprogenitors) ii) spinal fusion
3. Matrix – scaffold for bone repair
IV.Ceramics
4. Vascular supply
A. Properties
Note: In every bone repair situation whether it be a
1. Osteoconductive
treatment of a delayed or non-union, pseudoarthrosis of
2. Synthetic or marine coral
the spine or an osteolytic lesion, the surgeon must assess
a. Hydroxyapatite
the environment and see if these elements are present. If
b. Tricalcium phosphate
these 4 elements are not present, then the surgeon will
c. Calcium phosphate
have to supply them.
i) Norian SRS
C. Traditional approach –
ii) a-BSM
1. Autogenous bone – gold standard
3. Resorption
2. Allograft bone – osteoconductive
4. Pore interconnectivity
a. Frozen
B. Calcium Phosphate
b. Freeze-dried (cancellous chips)
1. Norian SRS
D. Recent advances - Bone Graft Extenders/Substitutes
a. Augmentation of fracture repair
1. Demineralized bone matrix
b. Hardens into dahlite
2. Bone marrow cells
c. Remodeling – requires further study
3. Platelet rich plasma
2. BSM
4. Recombinant proteins
a. Calcium orthophosphate cement
5. Ceramics
b. Poorly crystalline calcium phosphate apatite with
II. Allografts favorable absorption characteristics
A. Preparation c. Hydrated with saline – paste
1. Fresh – immunogenic d. Osteoconductive
2. Frozen – less immunogenic (osteochondral) e. Pre-clinical studies – combine with recombinant
3. Freeze-dried – decreased biomechanical properties BMP
B. Osteoconductive
V. Cell Therapies
C. Structural support
A. Bone Marrow Cells – attractive strategy, deliver
1. Distal femur and femoral head
progenitors without the morbidity
2. Strut grafts
a. Osteogenic
D. Nonstructural
b. Successfully used to treat tibial non-unions (Connolly,
1. Morcellized cancellous and cortical chips
Clin Orthop 1989)
E. Disease transmission
c. Should probably be combined with some type of
III. Demineralized Bone Matrix (DBM) matrix
A. DBM Properties d. Treatment of tibial non-unions – Hernigou et al JBJS,
1. Produced by acid extraction of bone 2005
2. Consists of noncollagenous protein, collagen and e. Selective Retention technology- concentrate the
growth factors osteoprogenitor cells to enhance bone repair
3. Osteoconductive agent B. Platelet Rich Plasma
4. Limited osteoinductive potential a. Platelets contain a number of different growth of
B. DBM prepartations different growth factors. Including (BMP, PDFG,TGF,
1. DBM prepared with different formulations and are IGF)
available as gels, pastes, putty, powders, or strips b. May enhance bone formation when used in the
a. Glycerol – Grafton correct environment
b. Hyaluronic acid – DBX c. The PRP should be combined with a matrix to
c. Calcium sulfate – Allomatrix promote osteogenic activity
d. Gelatin – Osteofil d. Delivery systems have been developed by a number of
2. The DBMs have different amounts of calcium and different companies
e. The amount of each growth factor delivered and their C. Other Growth Factors
biologic activity requires further evaluation 1. Platelet Derived Growth Factor (PDGF), Insulin
growth factor (IGF), Vascular Endothelial Growth
VI. Growth Factors
Factor (VEGF) require further study
A. Bone morphogenetic protein
a. Osteoinductive potential not defined
1. Osteoinductive (BMP-2 and BMP-7)
2. Member of TGF-B superfamily VII. Clinical Applications
3. Multiple functions A. Hip surgery
a. Cell growth 1. Revision hip surgery – morcellized cancellous grafts
SYMPOSIA GENERAL
b. Bone development and DBMs are used routinely in revision total hip
c. Bone repair arthroplasty cases
4. Stimulate differentiation of pleuripotential cells to an a. Osteolytic defects in the acetabulum (cavitary)
osteochondroblastic lineage b. The question is does this material really incorporate
5. Carriers issues (kinetics of protein delivery) with the host bone. What techniques can be used
6. Potential clinical applications to maximize incorporation?
a. Non-unions d. No large series to date looking at graft
b. Fresh fractures incorporation because it is difficult to evaluate on
c. Spine fusion plain radiographs
d. Osteonecrosis e. There is interest in using concentrated marrow cells
e. Arthroplasty (bone defects) to enhance bone repair based on success in treating
7. Present clinical use non -unions
a. Spine fusion – rhBMP-2, collagen sponge, cage 2. Osteonecrosis and Core Decompression – DBMs or
b. Recalcitrant non-union – (Humanitarian Device morcellized chips are being used to bone graft core
Exemption) – OP-1 (BMP-7) tracts
f. Carrier issues – need to optimize protein delivery a. Does this grafting make a difference?
Note: These agents are presently not approved for use i) no randomized trials comparing bone grafts
for total joint anthroplasty applications. with core decompression alone
8. Carrier b. In the future, combining core decompression with
a. Kinetics of delivery an osteoconductive or angiogenic agent may
b. Promote cell recruitment and potentiate chemotaxis improve results
c. Void space – cell migration and promote B. Total Knee Arthroplasty
angiogenesis 1. Revision Surgery
d. Biodegrade – no inflammatory response a. Treatment of contained defects in tibia or distal
e. Handling properties femur
f. Biomechanical properties i) morcellized chips more commonly used
9. Canine Arthroplasty Models to Assess Biologic Activity ii) no data on DBMs – handling characteristics are
of BMPs in Total Joint Arthroplasty (TJA) an issue
a. Coat implant with BMP-2 to enchance bone b. Non-contained defects – more controversial
ingrowth (Bragdon) i) technique advocated by Leo Whiteside to use
b. Treat acetabular defect around cup with OP-1 morcellized graft with non-contained defects
(Barrack) (Clin Orthop 357: 149,1998).
c. Use OP-1 to enhance incorporation of a strut graft
(Barrack) Note: There is interest in using cell-based therapies or
B. Fibroblast Growth Factor (FGF) recombinant BMP to treat osteolytic defects but these
1. Cell proliferation agents have not been evaluated clinically.
2. Angiogenesis
3. Clinical potential – adjunctive agent
4. Not commercially available
REFERENCES: 3. Hsu WK, Lieberman JR. The Role of Bone Graft Substitutes in Total Hip
1. Finkemeier CG. Bone-Grafting and Bone-Graft Substitutes. J Bone Joint Surg Am. Arthroplasty. In: The Adult Hip, Lippincott Williams Wilkins, Philadelphia 2007
2002 Mar;84-A(3):454-64 pp. 329-342.
2. Lieberman JR, Daiuiski A, Einhorn TA. The Role of Growth Factors in the Repair
of Bone. Biology and clinical applications. J Bone Joint Surg Am. 2002 Jun; 84-
A(6):1032-44
185
ASSESSMENT AND USE OF NEW AND EXISTING TECHNOLOGIES

FOR BONE RESTORATION IN SPINE SURGERY
Harvinder S. Sandhu, MD
1) Indications for bone restoration or creation along the ii) 1971 Urist: active agents are BMPs
SYMPOSIA GENERAL
spinal column: iii) 1986 individual BMPs are isolated

a) Deformity (ex. scoliosis) iv) 1988 rhBMP-2, 7 (OP-1) are osteoinductive
b) Trauma v) 1994 rhBMPs induce PSF in dogs, rabbits
c) Infection vi) 1995 rhBMPs induce ALIF in sheep, goats
d) Tumor vii) 1996 rhBMPs induce fusions in primates
e) Degenerative instability (ex spondylolisthesis) viii) 1997 Clinical human trials for spine fusion
f) Degenerative arthropathy (ex disc or facet pain) begin
ix) 2002 Approval of rhBMP-2, OP-1
2) Spinal Fusion
e) Efficacy of rhBMP-2 in spinal fusion applications
a) An artificial mechanical condition created to restore
i) Anterior lumbar interbody fusion with cages
integrity and function of the spinal column and/or to
(1) Pivotal study leading to FDA clearance (99%
minimize future neurologic compromise and pain
radiographic fusion)
b) A solid bone union between adjacent vertebrae, lamina,
ii) Anterior lumbar interbody fusion with allograft bone
transverse processes, facets, or spinous processes, or
dowels
combinations thereof.
(1) Excellent fusion with accelerated remodeling but
3) Mechanical and biologic advantages/disadvantages of some osteolysis
intervertebral (anterior column) vs posterior or iii) Posterior lumbar interbody fusion
posterolateral (posterior column) fusions (1) Good efficacy but ectopic bone, intense seroma
a) Intervertebral fusion formation, occasional excessive osteolysis and
i) Larger surface area of decorticated bone radiculitis
ii) Shorter distance to arthrodesis iv) Posterolateral lumbar fusion
iii) Favorable loading environment (compression vs (1) Higher fusion rate compared to iliac crest autograft
tension) but no clinical difference in outcome
iv) Greater surgical approach risks v) Anterior cervical fusion
(1) Anterior (vascular, ureteral, reproductive in males) (1) Excellent fusion rate but no better than autograft
(2) Posterior (neurologic) (2) Intense mast cell response with
b) Many biologic devices work superbly in the anterior hyperconcentration (re-intubation risk)
column but poorly along the posterior column because (3) Recent data suggest excellent fusion rate with
of the above mechanical and biologic conditions allograft
i) Be careful not to extrapolate (a) Is expensive augmentation strategy really
necessary?
4) Gold standard is autogenous bone graft (osteoinductive,
f) Efficacy of OP-1 in spinal fusion applications
osteoconductive, osteogenic)
i) Very limited data
a) More than 1 million bone graft harvests worldwide
ii) Pilot study of posterolateral fusion showing better
i) One of the most common orthopaedic operations in
clinical outcome compared to controls
the world
iii) Not certain whether mast cell response, osteolysis, or
b) More than 50% performed for spinal fusion
acute radiculitis seen with BMP-2 is also seen with
c) Failure of the gold standard
OP-1
i) Morbidity of iliac crest harvest (9%-30%) using
iv)Await pivotal study data
traditional techniques
g) BMP-2 vs OP-1
ii) Post-op pain (>30% 2 years after tricortical iliac crest
i) No direct comparison in human trials
graft for cervical fusion)
ii) Far more industry funded trials on BMP-2
iii) 5% to 40% pseudarthrosis rate
iii) Efficacy well demonstrated with BMP-2 in several
iv) Insufficient volume for deformity or revision surgery
spinal applications
5) Augmentation strategies (1) Dose related? (12 mg BMP-2 vs 3.5 mg OP-1)
a) Osteoinductive (factors) iv)Toxicity noted with BMP-2 (seroma, edema, osteolysis,
b) Osteoconductive (matrices) radiculitis)
c) Osteogenic (cells) (1) Dose related?
(2) Rothman Institute study of BMP-2 induced
6) Osteoinductive (factors)
radiculitis
a) The bone morphogenetic proteins are the only factors
(a) 23% incidence
that are known to be capable of inducing differentiation
(b) mean duration at least 13 months
of progenitor cells to the bone forming line
(c) 5 patients with persistent symptoms
b) rhBMP-2, rhBMP-7 (OP-1), GDF-5
(d) TNF inhibitors for BMP-2 induced radiculitis
c) >120,000 patients per year in US are implanted with a
BMP 7) Osteoconductive (Matrices)
d) Timeline a) Most widely used product – allograft
i) 1965 Urist: “bone formation by osteoinduction” i) More than a century of experience
ii) Historical clinical data iv)Clinical spine experience limited and poor
iii) Issues: supply, disease transmission, host reaction v) DBM-polymer composites
iv)Alternatives: ceramics, collagen, polymers (1) Inductive conductive partnership
b) Ceramics
8) Cells
i) Bioinert, bioactive, can be resorbable, low cost of
a) Stem cells
manufacture
i) Quiescent in vivo
ii) Tricalcium phosphate 10x to 20x faster resorption than
ii) Near limitless self-renewal
hydroxyapatite
iii) Produce daughter cells that can differentiate along
iii) Optimum pore size 150 to 500 um
SYMPOSIA GENERAL
one or more lineages
iv)Connectivity not efficient (except coral)
iv) Types
v) Brittle with little tensile strength
(1) Unipotent: hepatic cells
vi)Once remodeled, comparable to cancellous bone
(2) Multipotent: hematopoietic stem cells (HSC),
vii) Higher porosity is better
mesenchymal stem cells (MSC)
(1) Toth study on anterior cervical fusion in goats
(3) Totipotent: zygote, embryonic stem cells (ES)
(a) 30% porous = 0% fusion
b) Fresh bone marrow
(b) 50% porous = 67% fusion
i) Simplest form of stem cell therapy
(c) 70% porous = 83% fusion
ii) Bedside therapy, not FDA regulated
viii) Scoliosis clinical data
iii) Problem: considerable variability in cellular yield and
ix)Vitoss beta-TCP
activity
(1) Most commonly used ceramic augmentation in
iv)Problem: optimization and standardization
spinal surgery in US
v) Clinical spine data is limited
(2) clinical data and images
c) Selective retention technologies
c) Resorbable polymers
i) Problem: variability in source material
i) Poly lactides and poly glycolides
d) Future possibilities
ii) Advantages
i) Role of stem cells in disease management
(1) Strength
ii) Expansion and manipulation of cells may have a
(2) Non-brittle
significant future role in spinal fusion and, more
(3) Resorbable
importantly, in regeneration
(4) Radiolucent
iii) Disadvantages
(1) Inflammatory response
(2) Acidity may retard osteoinduction
187
MUSCULOSKELETAL ONCOLOGY APPLICATIONS

Alan W. Yasko, MD
I. Clinical Settings F. Growth Factors

A. Benign osseous tumors 1. osteoinductive
1. intralesional excision by curettage 2. bone morphogenetic proteins (BMP-2, OP-1 (BMP-7)
2. physical and chemical adjuvants to extend 3. not approved for use in oncologic applications
SYMPOSIA GENERAL
intracavitary surgical margin

IV. Clinical Applications
B. Bone sarcomas
A. Cavitary defects
1. en bloc resection
1. metaphyseal, non-load bearing defects
2. concomitant chemotherapy
2. particulate cancellous grafts and DBMs are used
3. cyclical immunosuppression
routinely
C. Soft tissue sarcomas
3. ceramics are an alternative to bone preparations
1. wide excision
4. predictable new bone formation with rapid
2. adjuvant radiation ± chemotherapy
consolidation
3. in-field radiation effects on bone
B. Segmental intercalary defects
D. Complications of oncologic treatment
1. structural large segment allografts
1. allograft fracture/nonunion
2. free fibular grafts
2. particulate bone graft resorption
3. combination of both
3. radiation-associated fractures
4. particulate bone graft ± DBM ± bone marrow at
4. bone loss with endoprosthetic loosening
junction sites
II. Osseous Defects 5. once healed – durable long term
A. Cavitary 6. nonunion is major limitation of allografts
1. majority are metaphyseal 7. constraints in size and length major limitation of
2. local environment affected by biology of tumor fibular grafts
3. surface alterations by surgical adjuvants (e.g. liquid C. Osteoarticular defects (adults)
nitrogen, phenol) 1. structural large segment frozen OA allografts (also
B. Segmental (whole or hemicortical) intercalary unicondylar)
1. majority are diaphyseal 2. preserve mobile joint
2. large segment (usually greater than 10 cm) defects 3. may be combined with prosthesis (allograft-prosthesis
3. may include one or both metaphyses or rarely the composites)
entire bone 4. particulate bone graft ± DBM ± bone marrow at
4. resection bed with variable loss of overlying soft tissues junction site
C. Osteoarticular 5. durable functional restoration
1. most common 6. fracture, nonunion, joint instability, and early
2. large resection (usually greater than 10 cm) defect degenerative arthritis
3. ligament and tendon reattachments for joint function D. Osteoarticular defects (pediatric)
4. resection bed with variable loss of overlying soft tissues 1. near maturation: frozen OA allografts (also
D. Flat Bones unicondylar) or APC same benefits, outcome, risks
1. total or subtotal resection of the pelvis or scapula and limitations as for adults
2. usually suboptimal residual bone for fixation 2. skeletally immature (wide open physes) – free fibula
3. resection bed with major loss of muscle with vascularized epiphyseal transplantation ideal for
proximal humerus (to preserve longitudinal growth)
III. Reconstruction Strategies
E. Flat bone reconstruction
A. Allografts
1. structural large segment frozen OA allografts (total or
1. Frozen large segment – intercalary, osteochondral,
subtotal)
whole bone
2. pelvis – peri-acetabular – used with total hip
2. Frozen or freeze-dried particulate – bone-void fillers
arthroplasty
B. Autografts
– ilium (hip joint-sparing) – free fibular grafts
1. free fibular grafts – most common structural
to reestablish pelvic ring continuity
2. iliac crest particulate – small osseous defects, graft for
3. scapula – total or periglenoid
host-allograft junctions
F. Radiation-associated fractures
C. Demineralized bone matrix
1. osteogenic capacity of bone compromised
1. various preparations with osteoinductive potential,
2. hostile soft tissue bed
albeit limited
3. free fibula with internal fixation
2. particulate bone graft extender
4. data on outcomes limited
3. injection material for bone cysts
G. Allograft fractures/nonunions
4. with bone graft for host-allograft junctions
1. osteogenic potential and osteoinductivity absent
D. Ceramics
2. avascular
1. osteoconductive
3. free fibular graft with internal fixation
2. cavitary defect filler
4. predictable healing
E. Bone marrow
1. autologous osteoprogenitor cells
2. with DBM or particulate allograft
V. Strategies in evolution B. vascularized allograft transplantation

A. growth factor application, especially BMPs C. bone transportation methodologies
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Bone Joint Surg Am. June 2002; 84-A(6):921-9. with a structural pelvic allograft after resection of a malignant bone tumor. J
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SYMPOSIA GENERAL
Instr Course Lect. 2005;54:505-12. 22. Mankin HJ, Hornicek FJ, Raskin KA. Infection in massive bone allografts. Clin
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junction. Clin Orthop Relat Res, (382): 87-98, 2001. adjuvant chemotherapy on osteoarticular allografts. Clin Orthop Relat Res. Apr
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graft for diapyhseal reconstruction after resection of primary extremity bone sar- with radiation therapy. J Bone Joint Surg Am. Apr 2000;82(4):544-554.
comas. Plast Reconstr Surg. Dec 2005; 116(7):1918-25. 36. Pelzer M, Larsen M, Ching YG, Ohno T, Platt JL, Friedrich PF, Bishop AT. Short-
16. Zaretski A, Amir A, Meller I, Leshem D, Kollender Y, Barnea Y, Bickels J, Shpitzer term immunosuppression and surgical neoangiogenesis with host vessels main-
T, Ad-El D, Gur E. Free fibula long bone reconstructive options. Plast Reconstr tains long-term viability of vascularized bone allografts. J Orthop Res. Mar
Surg. Jun 2004;113(7):1989-2000. 2007;25(3):370-7.
17. Mnaymneh WA, Temple HT, Malinin T. Allograft reconstruction after resection of 37. Lee FY, Storer S, Hazan EJ, Gebhardt MC, Mankin HJ. Repair of bone allograft
malignant tumors of the scapula. Clin Orthop Relat Res. Dec 2002;(405):223-9. fracture using bone morphogenetic protein-2. Clin Orthop Relat Res. Apr
18. Bell RS, Davis AM, Wunder JS, Buconjic T, McGoveran B, Gross AE. Allograft 2002;(397):119-26.
reconstruction of the acetabulum after resection of stage-IIB sarcoma. 38. Awad HA, Zhang X, Reynolds DG, Guldberg RE, O’Keefe RJ, Schwartz EM. Recent
Intermediate-term results. J Bone Joint Surg Am. Nov 1997; 79 (11):1663-74. advances in gene delivery for structural bone allografts. Tissue Eng. Aug
19. Sakuraba M, Kimata Y, Iida H, Beppu Y, Chuman H, Kawai A. Pelvic ring recon- 2007;13(8):1973-85.
struction with the double-barreled vascularized fibular free flap. Plast Reconstr 39. Ozaki T, Nakatsuka Y, Kunisada T, Kawai A, Dan’ura T, Naito N, Inoue H. High
Surg. Oct 2005;116(5):1340-5. complication rate of reconstruction using Ilizarov bone transport method in
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189
THE VALUE OF NATIONAL REGISTRIES: HAS

THE FINDINGS CHANGED PRACTICE (H)
SYMPOSIA GENERAL
Moderator: Henrik Malchau, MD, Boston, MA

National joint replacement registries now exist in many countries, including most English-
speaking countries except the United States. This symposium will present data from several
national and regional registries that has had a direct impact on joint replacement surgery.
I. The Value of National Registries

II. Outcomes of a Hip and Knee Replacement on a National Level

Gary J. Hooper, MD, Christchurch, New Zealand
III. Experience with Registries as a Feedback Mechanism to Improve Patient Care

Robert S. Namba, MD, Corona Del Mar, CA
IV. The Role of National Registries in Identifying Risk Factors for TKA Surgery -
Robert B. Bourne, MD, London, ON, Canada
V. Unicondylar or Total Knee Arthroplasty? What can Registries tell us?

Ove N. Furnes, MD, Bergen, Norway
VI. The Patella in Primary TKA: To resurface or not resurface

Otto Robertsson, MD, Reykjavik, Iceland
VII. The Impact of Fixation Type on Outcome of THR in the Young Patient
Johan N. Karrholm, MD, Molndal, Sweden
VIII. Resurfacing Hip Replacement: Early Failure and Indications

Stephen Graves, MD, Adelaide, Australia
IX. Dislocation in Hip Replacement

David G. Lewallen, MD, Rochester, MN
X. Effect of Prevention for Heterotrophic Ossification on survival of THR.

Soren Overgard, MD, Lyngby, Denmark
XI. Current status of a national US registry

David G. Lewallen, MD, Rochester, MN
XII. The International Society for Registries

Henrik Malchau, MD, Boston, MA
THE VALUE OF THE NATIONAL JOINT REPLACEMENT REGISTRY

The demand for total hip and total knee replacement continues high volume expert surgeons. They are often from institutions
to grow. From 1998 to 2004, the growth in total knee replace- which are also high volume procedures and in general probably
ments alone has gone from 266,000 per year to 478,000 per do not represent the outcomes in the general orthopaedic com-
year. For hip replacement, growth has gone from 160,000 to munity. In addition, the data from these retrospective studies
SYMPOSIA GENERAL
234,000 over the same time period. Along with the growth in are not reported in a timely fashion. They are retrospective by
numbers, there has been a slow decrease in the mean age of nature. Data collection and analysis can often take a year or
patients undergoing these procedures. It has been estimated by more. Publication process also takes more than a year.
the year 2030, there will be approximately 2 million primary
At this point in time, there is no reliable way in the United States
total knee replacements being done in the United States alone.
to provide the surgeon and patient with the timely data as it
The question then is how we track outcomes in these patients relates to outcome for specific procedures and technologies.
when there are hundreds of different implants available for use Although the Food and Drug Administration often mandates
and hundreds of thousands of patients undergoing these proce- post market surveillance with approval of new technologies, the
dures. Historically, outcomes have been tracked in one of three current methodologies are ineffective for provision of feedback
ways. The gold standard is obviously the randomized clinical to surgeons and patients. In addition, the medical device report-
trial. However, randomized clinical trials as it relates to technol- ing system for failed implants is similarly ineffective. Thus, there
ogy such as hip and knee replacement are impractical for a vari- is no effective mechanism to provide outcome data in a timely
ety of reasons. First, there are simply too many different implant manner. There is increasing awareness in both the surgeon
technologies available to perform randomized clinical trials. In patient community of the need to better evaluate treatment in a
addition, the cost of such trials would be prohibitive and to date timely fashion. Joint Registries have demonstrated the capacity
funding agencies have not been willing to fund these types of to accomplish this goal. Registries have been shown to serve as
studies. Second method for analyzing outcomes is the use of early warning system. They can influence surgeon behavior and
met analysis. However, this requires a significant number of in the long run decrease revision burden, patient morbidity, and
high level of trials and again in joint replacement those do not mortality and decrease costs of treatment.
exist and are unlikely to exist in the future. Thus, the most com-
mon way we currently track outcomes is through retrospective
studies. These studies are often done by innovators who are
191
THE RELATIONSHIP BETWEEN THE POST SURGERY OXFORD 12

QUESTIONNAIRE SCORE AND EARLY REVISION OF HIP AND KNEE
ARTHROPLASTY
A Rothwell, G Hooper, T Hobbs and C Frampton
SYMPOSIA GENERAL
Aim hips a score greater than 20 has 8 times the risk of needing a
To determine whether there is any relationship between the revision within two years compared to a person with a score
Oxford 12 Questionnaire score 6 months following primary equal or less than 20. Alternatively the ROC analysis predicted
total hip and knee arthroplasty and early revision. 73% of the revisions within two years. For knees it was demon-
strated that an Oxford score greater than 28.5 has 8 times the
Method risk of needing revision within 2 years compared to a person
The New Zealand Joint Registry (NZJR) has been in existence for with a score equal or less than 28.5. Alternatively the ROC
nine years and as part of data collection patients return the analysis predicted 73% of the revisions within 2 years.
Oxford 12 Questionnaire six months following primary hip and
By plotting the patient scores in groups of 5 against a propor-
knee arthroplasty. In this study analysis of the six month scores
tion of hips revised for that same group it demonstrated that
for 16541 primary and 12521 primary knee arthroplasties was
there was an incremental increase in the risk of revisions, par-
undertaken comparing the scores of those that had had revi-
ticularly during the first 2 years, related to the Oxford score. A
sions between six months and two years, two years and four
person with a score of greater than 40 has 24 times (hips) and
years and four years and six years against those that had not
27 times (knees) the risk of a revision compared to a person
been revised. The statistical methods used were logistic regres-
with a score between 16 and 20.
sion, receiver operating characteristic (ROC) curves and plotting
groups of scores against revisions.
Conclusion
A strong relationship between the Oxford 12 score at 6 months
Results
and revision within 2 years using 3 different methods of analy-
During the eight year period of the study 361 of the 16541 pri-
sis has been demonstrated. From the clinical practice perspec-
mary hip arthroplasties and 273 of the 12521 knee primary
tive a surgeon can gain further guidance as to which patients
arthroplasties had been revised. This was an overall revision rate
need to be more closely monitored following primary joint
of 0.63 per 100 component years for hips and 0.56 per 100 com-
arthroplasty by collecting 6 month post surgery Oxford
ponent years for knees.
questionnaire scores.
By logistic regression analysis it was shown that for every one
A further aid to clinical practice provided by the NZJR is that
unit increase in the Oxford score there was an 11% risk of revi-
each surgeon is annually provided with their personal revision
sion within the first two years, a 5% increase risk between 2 and
rate/100 component years which can be compared to the
4 years and a 3% increase between 4 and 6 years for both hips
national revision rate for self audit purposes.
and knees. (p<0.001). A ROC analysis demonstrated that for
THE KAISER PERMANENTE TOTAL JOINT REGISTRY: AN EFFECTIVE

TOOL TO IMPROVE CLINICAL CARE
Robert Namba, MD
The unique organization of healthcare in Kaiser Permanente has al findings reported by Mahomed et al who used the Medicare
SYMPOSIA GENERAL
facilitated creation, and maintenance, of a working total joint database. Since our database includes, but is not limited by
registry. The program was voluntarily created by surgeons, Medicare, enrollees of younger age band patients were investi-
enabled by the healthcare administration, and supported by gated. The burgeoning volume of total joint replacement proce-
clinical and administrative staff. Dissemination of Registry find- dures evident in our studies has helped our organization begin
ings have provided surgeons with pertinent data and feedback planning with hiring total joint surgeons, increasing operating
which influenced clinical care. The new computerized health room capacity, and improve efficiencies of scale. The increasing
record system will provide opportunity for even greater detail, volume in younger age patients requires surveillance since the
and expeditious feedback, for surgeons. new technology targeted for these patients is expensive.
Kaiser Permanente is a prepaid healthcare organization with The integration of all our system databases permits comprehen-
integration of medical services and information systems. There sive capture of data for complications, including infections of
are over 14 million individuals who receive care at Kaiser total joint procedures. Obesity, rheumatoid arthritis, and revi-
Permanente, each member having a unique patient identifica- sion procedures were found to be a significant risk factors for
tion code. Unlike many fee-for-service insurance plans, member infection. Recommendations have been made system-wide for
turnover is very low. Approximately 20% of members have increasing cefazolin doses for patients over 100 kilogram.
Medicare as their primary insurance. Tighter control of blood glucose levels in diabetics has been tar-
geted. Higher vigilance in patients with rheumatoid arthritis
Total knee and hip replacement surgery within Kaiser
and in revision procedures has been recommended. Patients
Permanente is delivered by over 300 orthopedic surgeons per-
with BMI over 35 have been referred within our organization to
forming inpatient surgical procedures at over 50 medical cen-
total joint specialists. Since volume of procedures by surgeons
ters. On an annual basis, over 14,000 primary and revision total
was not found to be a significant risk factor for joint infections,
joints are performed. The majority of total joint procedures are
many uncomplicated primary joint procedures continue to be
performed by fellowship trained adult reconstructive specialists,
performed by general orthopedic surgeons.
but general orthopedists perform many of the primary proce-
dures. Early failure of unicompartmental knee replacements was
observed concurrent with an increase in volume of this proce-
The Kaiser Permanente Total Joint Registry was created in 2001
dure with the advent new implants and refined instrumenta-
as a voluntary program by orthopedic surgeons. Paper forms
tion. We found that there was a learning curve effect with most
were developed to record preoperative, intra-operative, and fol-
failures occurring within the first 3 cases of a surgeon’s experi-
low-up data. In addition to patient demographics, a 10 point
ence. More experienced UKR surgeons had lower failure rates.
visual analog pain scale and 10 point visual analog satisfaction
Dissemination of this information led to a drop in the rate of
scale are included. Details of surgical procedures include type of
UKR procedures with referral of selected patients to high vol-
anesthesia, operative approach, surgical time, fixation of
ume surgeons. With the introduction of hip resurfacing proce-
implants, use of drains and DVT prophylaxis, as well as bar
dures, only a select few surgeons were trained, with selected
codes of the implanted devices. The data are entered with scan-
cases channeled to them, facilitating their clinical experience
ners and manual entry by dedicated Registry personnel. An inte-
and avoiding multiple surgeons going through a learning curve.
grated administrative database is utilized to cross-reference the
Registry database for completeness. Infections are validated on Similarly, early experience with minimally invasive surgery
a case-level basis in conjunction with a National Infection (MIS) with the two-incision total hip and MIS total knee
Control program. Using a newly updated system-wide electron- replacement surgery led to change in clinical practice. A higher
ic health record systems, an automated process for registry data rate of intraoperative femur fracture and revisions was observed
acquisition is being developed. with the two incision MIS THR procedure. There was also lower
clinical outcomes at early followup, even in uncomplicated
Acceptance of the importance of the Registry by our surgeons
cases. Whereas complications were not seen with MIS total knee
has been a key factor to the success of the program. Following
procedures, more pain and less satisfaction was observed in the
the recommendation by founders of the Swedish National Hip
early postoperative period. As a direct result of this study, the
Registry, we have confirmed that providing meaningful feed-
number of MIS two-incision THR and MIS total knee replace-
back is critical to the voluntary support by surgeons. Biannual
ment surgery dropped dramatically.
meetings, an interactive website, and Registry personnel, who
are available to provide customized reports and data analysis to There is an inherent delay in the availability of published clini-
interested surgeons, provide tangible rewards for their efforts. cal reports. The peer review process of publications assures the
reader of reliable, and pertinent information, but is accompa-
One of the main goals for creating the Kaiser Permanente Total
nied with a delay of one to two years. A tendency to avoid
Joint Registry was to facilitate clinical research. Since follow-up of
admission of poor results may skew publications towards favor-
the new registry is short, early studies have focused on epidemi-
able findings. Multi-center, prospective studies are difficult to
ological investigations and analysis of peri-operative complica-
perform, few in number, and take a long time to accomplish
tions. The epidemiological studies were complemented with
and publish. The availability of data within the Registry pro-
archival administrative data to show the rates of primary and
vides our surgeons with up-to-date information, which may
revision total joint replacements within our organization across
age-bands and over time spans. Our results have mirrored sever-
193
affect their clinical practice long before a procedure, or implant, which has affected clinical care within our organization. The
falls out of favor in the orthopedic community. value of the Registry is evident to the surgeons and administra-
tors and the importance of the early results has spurred devel-
The Kaiser Permanente Total Joint Registry is quite young com-
opment of multiple other registries within Kaiser Permanente.
pared to established registries such as the Swedish National Hip
The expanding utility of the electronic medical record system
Registry and the Norwegian Joint Registry. As such, long-term
will soon provide instantaneous feedback to surgeons on data
follow-up of specific implants and specific surgical techniques
within the Registry to help guide care of the patient sitting in
are not available. Analysis of epidemiologic data and early com-
front of them in their office.
plications has already provided important clinical information
SYMPOSIA GENERAL
REFERENCES 14. Mohan V, Khatod M, Paxton E, Bini S, Fithian D, Namba R, Weiner D, Kaiser
1. Barber, T., Paxton. E., Inacio, M. & Fithian, D. Limitations of hospital administra- Permanente Total Joint Registry. Failure Modalities in 601 Unicompartmental
tive databases for assessment of total hip replacement outcomes. American Knee Arthroplasties. Proceedings of the American Academy of Orthopaedic
Academy of Orthopaedic Surgeons 75th Annual Meeting; accepted for 2008; San Surgeons 74th Annual Meeting; February 14-18, 2007; San Diego, CA.
Francisco, CA. 15. Namba, Robert. Experience with Registries as a Feedback Mechanism to Improve
2. Bini S, Kathod M, Paxton E, Inacio M, Fithian D, Namba R. Does Disposition Patient Care. American Academy of Orthopaedic Surgeons 75th Annual Meeting;
Following Primary Total Joint Replacement Affect Readmission Rates? accepted for 2008 Symposium; San Francisco, CA.
Proceedings of the American Academy of Orthopaedic Surgeons 73rd Annual 16. Namba, R., Dee, D., Paxton, E., Fithian, D. Low-dose antibiotic loaded cement
Meeting; March 22-26, 2006; Chicago, IL. did not lower TKA infection rates. American Academy of Orthopaedic Surgeons
3. Bini S, Kathod M, Paxton E, Inacio M, Fithian D, Namba R. Does Disposition 75th Annual Meeting; accepted for 2008; San Francisco, CA.
Following Primary Total Joint Replacement Affect Readmission Rates? 17. Namba, R., Paxton, E., Fithian, D., Stone, M.L. Obesity and Peri-operative
Proceedings of the 70th Annual Meeting of the Western Orthopaedic Morbidity in Total Hip and Total Knee Replacement Patients. Proceedings of the
Association, 2006 October 11-15; Santa Fe, NM. American Association of Hip and Knee Surgeons 14th Annual Meeting; 2004
4. Bini S, Inacio M, Paxton E. Do Minimally Invasive (10cm Or Less) TKAs Do November 3-5; Dallas, TX.
Better Than Standard? Proceedings of the 70th Annual Meeting of the Western 18. Namba, R., Paxton, E., Fithian, D., Stone, M.L. Obesity and Perioperative
Orthopaedic Association, 2006 October 11-15; Santa Fe, NM. Morbidity in Total Hip and Total Knee Replacement Patients. Journal of
5. Bini S, Inacio M, Paxton E. Increased post-operative pain following Minimally Arthroplasty, 20(7 suppl 3): 46-50, 2005.
Invasive Total Knees. Proceedings of the American Academy of Orthopaedic 19. Namba, R., Paxton, E. Barkan, H., Dee, D., Fithian, D., Shah, S. Predictors of TKA
Surgeons 74th Annual Meeting; February 14-18, 2007; San Diego, CA. deep infections in 23,089 cases. American Academy of Orthopaedic Surgeons
6. Brox, T., Paxton, E., Low, R., Fithian, D. Are gender specific implants necessary for 75th Annual Meeting; accepted for 2008; San Francisco, CA.
TKR? American Academy of Orthopaedic Surgeons 75th Annual Meeting; accept- 20. Namba, R., Paxton, E., Bottom, P., Khatod, M., Fithian, D. Patient factors domi-
ed for 2008; San Francisco, CA. nate risk of total knee arthroplasty infections. Proceedings of the American
7. Fithian, D., Paxton, E., Namba, R., Ryan, M. The epidemiology of 17,842 Total Academy of Orthopaedic Surgeons 72nd Annual Meeting; February 23-27, 2005;
Joint Arthroplasty Procedures. Proceedings of the American Academy of Washington, D.C.
Orthopaedic Surgeons 70th Annual Meeting; February 5-9, 2003; New Orleans, 21. Namba, R., Paxton, E., Fithian, D., Stone, M.L. Obesity and Peri-operative
LA. Morbidity in Total Hip and Total Knee Replacement Patients. Proceedings of the
8. Khatod, M., Barber, T., Paxton, E., Namba, R., Fithian, D. Dislocation risk factors American Academy of Orthopaedic Surgeons 73rd Annual Meeting; March 22-
in 1970 Total hip arthroplasty patients form a community based Joint Registry. 26, 2006; Chicago, IL.
Proceedings of the American Academy of Orthopaedic Surgeons 72nd Annual 22. Namba R, Inacio M. Early and Late Manipulations Improve Flexion Following
Meeting; February 23-27, 2005; Washington, D.C. Total Knee Replacement. Proceedings of the American Association of Hip and
9. Khatod, M., Paxton, E., Namba, R., Fithian, D. A Prospective evaluation of VTE Knee Surgeons 16th Annual Meeting; 2006 November 3-5, Dallas, TX.
prophylaxis in 4109 TKA patients from a community joint registry. Proceedings 23. Namba R, Inacio M. Early and Late Manipulations Improve Flexion Following
of the American Academy of Orthopaedic Surgeons 72nd Annual Meeting; Total Knee Replacement. Journal of Arthroplasty (In Press).
February 23-27, 2005; Washington, D.C. 24. Navarro, R., Paxton, E., Bottom, P., Fithian, D. (2005). Does prior knee
10. Khatod M; Barber T, Paxton E; Namba R; Fithian D. An Analysis of the Risk of arthroscopy affect peri-operative TKA results? Proceedings of the American
Hip Dislocation with a Contemporary Total Joint Registry. Clinical Orthopedics Academy of Orthopaedic Surgeons 72nd Annual Meeting; February 23-27, 2005;
and Related Research. 447:19-23, 2006. Washington, D.C.
11. Khatod M, Bini S, Namba R, Inacio M, Paxton E, Fithian D. 17,080 Knee 25. Navarro, R., Paxton, E., Bottom, P., Fithian, D. Does prior knee arthroscopy affect
Replacements: Epidemiology, Outcomes, and Trends. Proceedings of the peri-operative TKA results? Arthroscopy Association of North America 24th
American Academy of Orthopaedic Surgeons 74th Annual Meeting; February 14- Annual Meeting; May 12-15, 2005; Vancouver, BC, Canada.
18, 2007; San Diego, CA. 26. Navarro, R., Paxton, E., Bottom, P., Fithian, D. (2005). Does prior knee
12. Khatod M, Dee D, Paxton E, Namba R, Fithian D. Clinically Relevant Outcomes arthroscopy affect peri-operative TKA results? Proceedings of the 5th Biennial
from VTE prophylaxis in 6457 primary unilateral Knee Replacements. International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports
Proceedings of the American Academy of Orthopaedic Surgeons 74th Annual Medicine Congress; April 3-7, 2005. Hollywood, FL.
Meeting; February 14-18, 2007; San Diego, CA. 27. Paxton, E., Fithian, D. Outcome Instruments for Patellofemoral Arthroplasty.
13. Mahomed, NN et al. Epidemiology of total knee replacement in the United Clinical Orthopedics and Related Research, (436): 66-70, 2005.
States Medicare population. J Bone Joint Surg , 87A(6): 1222, 2005 28. Zawadsky, M., Dee, D., Paxton, E. Lower cenentless TLA survival rate among
19,966 primary TKAs. American Academy of Orthopaedic Surgeons 75th Annual
Meeting; accepted for 2008; San Francisco, CA.
THE ROLE OF NATIONAL REGISTRIES IN IDENTIFYING RISK

FACTORS FOR TKA SURGERY
Robert B. Bourne, MD
Historically, national joint replacement registries have linked a patient acceptance of TKA, accurate predictions of future TKA
SYMPOSIA GENERAL
patient to an implant, surgeon and hospital, thereby providing need have been made. In addition, patients on the tails of the
nationwide post-market surveillance and fostering continuous TKA bell curve (ie. <55 years of age and >85 years) have demon-
quality assurance, highlighting implants and hospitals with strated the greatest growth in TKA usage. in addition, obesity has
higher than anticipated revision rates. More recently, registries been demonstrated to have a profound effect on TKA utilization
have been utilized to anticipate future need for joint replace- with patients with a body mass index > 40 revealing a stagger-
ment surgery, assess patient satisfaction, determine the minimal ing 33X increased risk for TKA surgery, as compared to normal
important clinical difference and assess risk factors for joint weight patients!
replacement surgery.
The future of national joint replacement registries is indeed
With regards total knee arthroplasty (TKA) surgery, the utiliza- bright. The potential of these registries is only beginning to be
tion of TKAs has eclipsed that of total hip replacements (THRs) tapped in improving joint replacement surgery, but also under-
in 1995 and the gap between these two types of arthroplasty has standing the effect of patient factors on the need for this type of
widened since that time. Using this data combined with popu- surgery.
lation studies, data on aging of our population and increased
195
UNICONDYLAR OR TOTAL KNEE ARTHROPLASTY? WHAT CAN

REGISTRIES TELL US?
Ove Furnes MD, PhD
There has been only one randomized trial comparing uni- due to better function, and the problem of poor mechanical
SYMPOSIA GENERAL
condylar and total knee replacement (1). The study included support of the components on a smaller surface area. The uni-
102 knees with 5 year follow up and showed better range of condylar knees were associated with a lower risk of infection
motion (ROM) and better function in unicondylar knees as compared with total knee replacement (5). The difference in
compared to total knees. The study was sufficiently powered to functional improvement and pain relieve between unicondylar
detect differences in function and pain, but rare outcomes such and total knees, were small in register studies (6). The remain-
as revision can normally not be detected in small randomized ing question will be if a small improvement in function and
trials. To have an 80 % chance of detecting as significant (at the pain is worth the double revision risk? To aid in such decisions
two sided 5 % level) a difference in survival at 10 years from 80 cost-effectiveness analyses have been performed on register data
to 90 %, 400 patients would be required. Since there is only one and we found that unicondylar knee replacement compared
randomized study no meta-analysis can be done. The main well with total knee replacements (9, 6).
alternative to evidence from randomized trials, is evidence from
Register studies have also shown that the operating volume on
large observational studies like national arthroplasty registers.
a hospital level is important, with fewer revisions in high vol-
Results from observational register-based studies may be less
ume hospitals, especially with some prostheses designs (10,5).
conclusive than those from randomized trials. However, Beson
and Hartz compared observational studies with randomized tri- In observational studies there will always be a question
als, and found little evidence for the results of well designed whether the patients and the surgical techniques are
observational studies being qualitatively different from those of comparable, and if the recording and adjustment of
randomized trials (2). For rare incidences as side-effects, confounding factors have been sufficient. There is a need for
infections, death, bleeding and revision surgery observational large well powered randomized studies, designed to answer the
studies might be the only practical alternative (3, 4). questions on whether unicondylar knees should be preferred
over total knees in selected patients groups.
Data from national arthroplasty registers show that the risk for
revision surgery was 2 times as high in unicondylar knees com-
Conclusion:
pared to total knees after ten years, in all age groups. These find-
Register studies show that the revision rate of unicondylar knees
ings are highly statistical significant and support can be found
was 2 times higher than for total knees. The functional results
from several national registers (5, 6, 7, 8). The reason for the
and satisfaction in patients operated with unicondylar knees
high revision rate in unicondylar knees was a 5 and 2 times
was marginally better than in patients with total knees and the
higher revision rate due to aseptic loosening of the femoral and
rate of revision due to infection was lower. This combined with
tibial components respectively, compared to total knees, and
lower cost and lower short-term morbidity can defend the use
also more revisions due to periprosthetic fractures were found.
of unicondylar knees in selected patients.
The explanation is probably a combination of higher activity,
REFERENCE 6. Robertsson O. The Swedish Knee Arthroplasty Register. Validity and outcome
1. Newman JH, Ackroyd CE, Shah NA. Unicompartmental or total knee replace- (PhD thesis). Lund. Sweden: Lund University 2000.
ment? Five-year results of a prospective, randomised trial of 102 osteoarthritic 7. Graves et al. Australian Orthopaedic Association National Joint Replacement
knees with unicompartmental arthritis. J Bone Joint Surg Br. 1998;80:862-5 Registry annual report 2005. www.dmac.adelaide.edu.au/aoanjrr.
2. Beson K, Hartz AJ. A comparison of observational studies and randomized, con- 8. Koskinen E, Paavolainen P, Eskelinen A, Pulkkinen P, Remes V. Unicondylar knee
trolled trials. N Engl J Med 2000;342:1878-1886 replacement for primary osteoarthritis:a prospective follow-up study of 1819
3. Hunter D. First, Gather the Data. N Engl J Med 2006;354:329-331 patients from The Finish Arthroplasty Register. Acta Orthop 2007;78:128-35
4. Lagerquist B, James SK, Stenestrand U, Lindbäck J, Nilsson T, Wallentin L, 9. Slover J, Espehaug B, Havelin LI, Engesæter LB, Furnes O, Tomek I, Tosteson A.
SCAAR Study group. Long-term outcomes with drug-eluting stents versus bare- Cost-Effectiveness of Unicompartmental and Total Knee Arthroplasty in elderly
metal stents in Sweden. N Engl J Med 2007;356:1009-19 low demand Patients. A Markov decision analysis J Bone Joint Surg Am
2006;88:2348-2355
5. Furnes O, Espehaug B, Lie SA, Vollset SE, Engesæter LB, Havelin LI. Failure mech-
anisms after unicompartmental and tricompartmental primary knee replacement 10. Robertsson O, Knutson K, Lewold S, Lidgren L. The routine of surgical manage-
with cement. J Bone Joint Surg Am 2007;89:5219-525. ment reduces failure after unicompartmental knee arthroplasty. J Bone Joint Surg
Br.2001;83:45-9.
THE PATELLA IN PRIMARY TKA: TO RESURFACE OR NOT

RESURFACE
Otto Robertsson, MD
SUMMARY For the TKA inserted 1985-1994 the revision pattern was differ-
SYMPOSIA GENERAL
The paper describes the revision pattern after TKA inserted in ent. The unresurfaced knees were most often revised for prob-
Sweden with and without use of a patellar button. lems that could be related to anterior knee pain while those
resurfaced were at higher risk of being revised for wear and loos-
ABSTRACT ening. This also reflected the type of revisions performed. In the
There is still considerable controversy regarding if the patella unresurfaced group, patellar additions were much more com-
should be routinely resurfaced or not in TKA. The main mon than patellar extractions/exchanges in the resurfaced group
argument for using a patellar button is that it reduces the risk and they occurred relatively early after the primary surgery. The
of anterior knee pain while those favoring leaving the patella resurfaced group had a higher proportion of extensive revisions
unresurfaced state the risk of complications when using a such as revision to a superstabilized implant or arthrodesis.
button.
Regarding patient satisfaction it was found overall that the pro-
This paper makes use of information in The Swedish Knee portion of satisfied patients was higher, at least during the first
Arthroplasty register, a national database that since 1975 years, if the patella had been resurfaced. Further, for a specific
prospectively has followed patients operated with knee model available with both a universal and anatomic femoral
arthroplasty. component, patients with unresurfaced patella were found to be
more often satisfied if the anatomic component had been used.
In Sweden the use of patellar button peaked in 1985 when 80%
of TKA patients had their patella resurfaced. Since then use of
CONCLUSION
button has constantly diminished so that in 2005 it was only
Anterior pain problem in TKA without patellar buttons are
used in less than 10% of cases. During 1985-1994, 14,000 TKA
typically addressed relatively early after primary surgery while
were inserted in Sweden of which a button was used in 6,000.
component failures more often occur later.
These TKA were followed for 12 to 20 years with respect to the
reason for and type of revisions. Further, information from two Patella resurfaced patients are at a higher risk of being subject to
cross-sectional mail-surveys performed in 1997 and 2003 was serious revision surgery than those unresurfaced.
used in an effort to evaluate the effect of patellar resurfacing on
Overall, patella resurfaced, patients are more likely to be satis-
patient satisfaction.
fied with their knee. However, this is dependent on the form of
the femoral component.
197
TOTAL HIP ARTHROPLASTY IN PATIENTS UP TO 50 YEARS

Johan Kärrholm, MD, PhD, and Sverrir Hilmarsson, MD
Introduction. osteoarthritis due to childhood disease (Table 1). The risk

Total hip arthroplasty in the young patient has been associated decreased with increasing age at the index operation and if both
with inferior outcome. Nonetheless survival rates of almost 70% the cup and stem had been cemented. It was also decreased in
have been reported after 30 years for cemented implants patients with inflammatory osteoarthritis. In the selected cohort
SYMPOSIA GENERAL
(Keener et al 2003). Some uncemented stems with a survival of we found similar results except from an increased risk for revision
95-98% after 15 years follow-up or more have a potential to of completely uncemented implants.
reach the same success rate, but so far seems uncemented fixa-
The risk of stem revision was increased in men and if the stem
tion on the acetabular side to be inferior to the most well doc-
had been fixed with cement. There was a decreased risk in
umented cemented designs (Havelin et al 2000, Eskelinen et al
patients with inflammatory osteoarthritis. Revision of the cup
2006, Kearns et al 2006).
was increased in patients with secondary osteoarthritis due to
childhood disease. Patients with primary osteoarthritis also
Patients and Methods.
showed a slightly increased risk when compared to all cases
Young patients are different from the older population. The dis-
with secondary osteoarthritis. Use of a cemented cup also had a
tributions of diagnoses vary, overall the bone quality may differ
negative influence.
and they are supposed to be more active. To obtain more knowl-
edge about this young population we evaluated the demo- After 14 years the overall survival for the completely cemented
graphics, choice of fixation and overall results in the young implant was 80.2% (78.7-81.7) with 143 remaining observa-
patient population recorded in the Swedish Hip Arthroplasty tions. The survival for the combined group of completely unce-
Register between 1992 and 2006. Cox regression analysis was mented fixation, hybrids and reversed hybrids after the same time
used. period was 67.4% (65.9-68.9) with 213 remaining observations.
TABLE 1.
Results.
Risk of revision (excl. infection) in patients >= 50 years.
During this period 9264 primary total hip replacements had been
operated in the age group up to 50 years. 52.1% of the implants all implants most frequent implants
had been inserted in women. Compared with a patient popula- n=9264 n=6691
Increased risk
tion older than 50 years of age all types of secondary osteoarthri-
Seq. childhood disease 1.42 1.18-1.70 1.41 1.12-1.78
tis except from failed femoral neck fracture were more common. Uncemented cup and stem - - 1.24 1.00-1.54
The relative amount of young patients in the total cohort Decreased risk
remained over the period rather constant (5.3-5.8%). Until year Cemented cup and stem 0.68 0.59-0.79 0.68 0.55-0.85
2000-2001 the relative amount of uncemented implants Increasing age per year 0.97 0.96-0.98 0,98 0.97-0.99
decreased followed by a continuous increase up to 2006. After Inflammatory OA 0.78 0.64-0.95 0.73 0.58-0.95
year 2004 the number of inserted uncemented hips surpassed the Categorical variables are related to all other categories within the grouping.
frequency of cemented hips. In total 914 revisions were per-
formed. 61 of those were due to infection. The most common Discussion.
procedure was revision of the cup or liner only (n=500) followed Young patients remain a challenge to the arthroplasty surgeon
by revision of stem and cup or liner (n=284). Isolated exchange due to a complex interaction of a number of factors, which jeop-
of the stem was performed in 106 hips. The average follow-up ardize the longevity of a THR. Increased incidence of bony anato-
time is 6.2 years (SD=4.2). Factors with influence on the revision my such as a narrow femoral canal or a dysplastic acetabulum
rate (excluding infection) were evaluated using Cox regression. In and for some diagnoses inferior bone quality place in addition to
this analysis we evaluated the influence of age, gender, diagnosis, increased demands related to patient activity require a more spe-
type of incision and fixation. In further one analysis we excluded cific selection of implant design and fixation. Finding of high
implants used with a low frequency (uncemented implants: less rates of cup and liner revision rates suggests that recently intro-
than 100, cemented implants: less than 500). I this analysis there duced new articulations with improved wear properties at least
were 6691 hips available with an average observation time of 6.1 partly could address these problems. In Sweden these types of
(4.1 years). The risk for revision of any of the components in the implants have not been used in larger numbers until recently,
total cohort was increased in cases operated because of secondary which means that follow is too short for any relevant conclusions.
REFERENCES 3. Kearns SR, Jamal B, Rorabeck CH, Bourne RB. Factors affecting survival of unce-
1. Eskelinen A, Remes V, Helenius I, Pulkkinen P, Nevalainen J, Paavolainen P. mented total hip arthroplasty in patients 50 years or younger. Clin Orthop Relat
Uncemented total hip arthroplasty for primary osteoarthritis in young patients: a Res. 2006 Dec;453:103-9.
mid-to long-term follow-up study from the Finnish Arthroplasty Register. Acta 4. Keener JD, Callaghan JJ, Goetz DD, Pederson DR, Sullivan PM, Johnston RC.
Orthop. 2006 Feb;77(1):57-70. Twenty-five-year results after Charnley total hip arthroplasty in patients less than
2. Havelin LI, Engesaeter LB, Espehaug B, Furnes O, Lie SA, Vollset SE. The fifty years old: a concise follow-up of a previous report. J Bone Joint Surg Am.
Norwegian Arthroplasty Register: 11 years and 73,000 arthroplasties. Acta Orthop 2003 Jun;85-A(6):1066-72.
Scand. 2000 Aug;71(4):337-53.
RESURFACING HIP REPLACEMENT:

EARLY FAILURE AND INDICATIONS
Stephen E. Graves, MD
The Australian National Joint Replacement Registry commenced matory arthritis all have significantly higher rates of revision
SYMPOSIA GENERAL
implementation in 1999 becoming fully national in 2002. This compared osteoarthritis. Women are revised 2.3 times more fre-
closely coincided with the introduction of resurfacing hip quently than men. The rate of revision progressively increases
replacement in this country. This presentation reports on the with age with almost 10% of patients aged over 75 undergoing
five year outcomes of almost 9,000 procedures recorded by the revision within 6 months. There is also a very strong association
Registry to the 31st December 2006. with increasing risk of revision with smaller head sizes. This is
apparent in younger and older patients as well as men and
Resurfacing hip replacement accounts for 7.9% of all primary
women. Procedures where the head size is less than 44 mm
total hips recorded by the Registry. There is a significant differ-
have an 8 times higher rate of revision than those procedures
ence in the demographic pattern of use compared to conven-
with a head size greater than 55 mm.
tional primary total hip. Resurfacing is used more frequently in
males (71.6% compared to 44.5% for conventional primary The Birmingham hip is the least revised resurfacing prosthesis.
total hip) and younger patients (mean age = 53.4 years for resur- The more recently introduced ASR and Durom prostheses have
facing and 68.1 years for primary conventional hip). twice the rate of revision of the Birmingham at two years. The
Cormet 2000 (HAP) has over three times the revision rate of the
The five year cumulative revision rate for resurfacing hip replace-
Birmingham at three years.
ment is 3.8% and this is significantly higher than for primary
conventional total hip (2.8%) (Hazard Ratio (adjusted for age
Conclusion
and sex for OA only) = 1.4, 95% CI (1.22, 1.68) p-
The five year outcome of resurfacing hip replacement is very
value<0.0001). Fracture of the neck of femur is the major reason
much dependant on patient and prosthesis selection. The best
for revision in the first five years. They account for almost half
results are achieved in men aged less than 65 years at the time
of all resurfacing revisions.
of surgery with osteoarthritis and who require a head size of 50
A number of factors are associated with an increased risk of revi- mm or more.
sion. Primary diagnoses of avascular necrosis, DDH and inflam-
199
THE MAYO CLINIC TOTAL JOINT REGISTRY AND HIP DISLOCATION

David G. Lewallen, MD
I. Introduction
A. Joint registries/databases can perform different functions depending on the level of detail of collected data.
B. National registries—to be practical—must collect only
SYMPOSIA GENERAL
high level data on huge numbers of patients.

C. Institutional registries (databases) can collect more
detailed data on a limited number of patients.
1. The value of these data is dependent on their com-
pleteness, accuracy, length of follow-up, and database
size.
2. Data completeness requires vigilant follow-up; accura-
cy requires trained staff and well defined end points.
II. Dislocation is an example of a well-defined end point— 2. Larger femoral head diameter is associated with lower
obvious to the patient and registry personnel dislocation risk. This was theoretically predicted but
III. What have we learned about dislocation using the Mayo not proven until the power of a large joint registry
Clinic Joint Registry that we would NOT have learned with detailed information on the subject could
without a registry? demonstrate a substantial difference. (N=22,174)3
A. Dislocation occurs as a function of time. The prevalence
is highest early, but first-time dislocation continues to
occur for the lifetime of the implant (N=6623)1,2
B. Dislocation is more common in specific demographic

groups.
1. Example: Females have a dislocation rate greater than
2 times males. Females have a higher early and late
dislocation rate (N=6623)1
C. Dislocation risk is dependent on surgical factors.

1. Anterolateral and transtrochanteric approaches
demonstrate lower dislocation risk than posterolateral
approaches (at least before the era of capsular repair).
(N=22,174)3
REFERENCES 2. von Knoch M, Berry DJ, Harmsen MS, Morrey BF: Late dislocation after total hip
1. Berry DJ, von Knoch M, Schleck CD, Harmsen WS: The cumulative long-term arthroplasty. J Bone Joint Surg 84A(11):1949-1953, 2002.
risk of dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg 3. Berry DJ, von Knoch M, Schleck CD, Harmsen WS: Effect of femoral head diam-
86A(1):9-14, 2004. eter and operative approach on risk of dislocation after primary total hip arthro-
plasty. J Bone Joint Surg 87A:2456-2463, 2005.
RISK OF REVISION AFTER NON-CEMENTED AND CEMENTED

PRIMARY TOTAL HIP ARTHROPLASTY (THA) FOLLOWING
POSTOPERATIVE TREATMENT WITH NSAID’S
Søren Overgaard
SYMPOSIA GENERAL
NSAID’s have been used routinely in order to prevent ectopic We used Cox`s regression analysis (Cox 1972) to estimate the
bone formation. Moreover NSAID’s are use as pain killers in the relative risk (RR) of revision and data is presented with 95%
early postoperative period. confidence interval.
Experimentally, several studies have shown that NSAID’s are
Results
capable to reduce bone repair around cementless implants
During the period, 1995-2006, 8,531 THA of 67,670 primary
resulting in impaired fixation. Clinically, none of the random-
THA had prophylatic NSAID’s. 409 (4.8%) THA which had
ized clinical trails conducted in order to study the effect of
NSAID’s to prevent ectopic were revised.
NSAID’s on ectopic bone formation, have shown increased risk
for revision. However, the studies had lack of statistical power to Overall the risk for revision was reduced for patients treated
show minor differences. with NSAID’s. Subgroup analysis showed that the reduction was
within cemented THA (0.81 (0.70-0.94)) whereas there was no
In the Danish Hip Arthroplasty Register (DHR) the use of
difference in cementless THA (1.17 (0.85-1.61)) for both any
NSAID’s in order to prevent ectopic bone formation is regis-
reason and aseptic loosening.
tered. The present analyses were performed in order to investi-
gate the effect of NSAID’s on the risk of revision following pri-
Discussion and conclusion
mary THA.
The present investigation from DHR, is a good example of a
register study which not could have been conducted in a normal
Materials and Methods
clinical study.
DHR is established January 1, 1995 and covers all clinics in
Denmark. The clinics report primary and revision cases to DHR. The results showed that NSAID’s, administered in order to pre-
The register is linked to central databases and every Danish citi- vent ectopic bone formation, did not increase the risk of revi-
zen has a unique civil register number. This offers the possibili- sion of cementless THA, and in contrast the risk of revision in
ty to calculate completeness of the register data with regard to cemented THA was reduced.
both primary and revision cases. A completeness < 90% is
unsatisfactory.
201
THE AMERICAN JOINT REPLACEMENT REGISTRY

David G. Lewallen, MD
Background Complications
The AAOS initiated American Joint Replacement Registry (AJRR) Infection – wound, urinary tract, pneumonia
is intended as a long-term data collection and follow-up project Fracture
that would gather prospective data on patients in U.S. hospitals Nerve Injury
SYMPOSIA GENERAL
with total joint replacements (TJR), beginning with arthroplas- Vascular Injury
ties of the hip and knee. Its mission is to foster a national cen- Pulmonary Embolism
ter for data collection and research on total hip and knee replace- Dislocation (Hip)
ment with far-reaching benefits to society including reduced MI
morbidity and mortality, improved patient safety, improved CHF
quality of care and medical decision-making, reduced medical Arrhythmia
spending, and advances in orthopaedic science and bioengineer- Renal Failure
ing. The goals of a national total joint replacement registry are: Death
1. Establish an infrastructure and a uniform system for tracking The collection of these data points is more complicated than
implant devices and monitoring outcomes of TJR through- Level 1 data and would require a pilot to establish the best
out the U.S.; methods for capturing valid and reliable information in a cost-
effective manner. Separate financial support via grants or an
2. Identify patients who may need follow-up evaluation there-
additional funding mechanism would then be needed to extend
by increasing patient safety;
this more detailed data collection effort to a larger sub-set of the
3. Create real-time survivorship curves in order to detect poorly U.S. registry hospitals.
performing implants;
Structure and Function
4. Establish a uniform system that can be used to define the epi-
Data collection should be web-based, to reduce barriers to par-
demiology of TJR for outcomes research to improve the qual-
ticipation that are inherent in other modalities (e.g., paper-
ity and outcomes of patient care.
based collection) and to facilitate compliance. Other advan-
tages to web-based collection is the ability to link existing data
Data
collection systems to the registry to populate common fields
The data needed to meet the first two goals of the registry is the
and reduce the time and opportunity for error in data transcrip-
most easily collected and is referred to in this project as Level 1
tion and entry.
data. The data points collected include: patient, surgeon, and
hospital identifiers, and core surgical data – date of surgery, A separate entity, a patient safety organization (PSO), would
patient diagnosis by ICD-9 code, surgical procedure by ICD-9 oversee the day-to-day operations of the registry, with input
code, laterality, and implant identification codes. These data from a steering committee. The steering committee should be
points, with the exception of laterality and implant informa- comprised of orthopaedic surgeons, patient safety representa-
tion, are already captured by CMS billing via the UB92 form. tives, and lay members.
Level 2 data, (the information that is required to meet goals 3 Individual surgeons and hospitals will be able to view their own
and 4), is similar to the data CMS is seeking to gather through data and compare themselves to the aggregate, but not to other
pay-for-performance. The four categories of Level 2 data – individual entities. Data access will be controlled by system IDs
patient factors/comorbidity, surgical procedure, post-operative and passwords. Policies for reports requested by external organ-
care, and complications – are detailed below: izations and other non-participants must be developed and
could provide a revenue stream to support the maintenance and
Patient Factors/Comorbidity expansion of the registry.
Obesity
A registry collecting only Level 1 data could be implemented
Nutritional Status
nationwide. However, the collection of Level 2, and eventually
Diabetes Mellitus
Level 3 data, will require a tiered approach. Several models for
Immunocompromised
implementation of Level 2 data collection could serve this pur-
Coronary Artery Disease
pose. A regional system could be established with large medical
H/O Thromboembolic Disease
centers beginning the data collection and providing support
Functional Status
and training to smaller institutions in the region as they are
Cognitive Status
brought in to the project. Alternatively, a state-by-state or
Surgical Procedure region-by-region approach could be taken, bringing all hospi-
Approach tals in a given state or region online at the same time. The
Cement Technique regions or states could be selected based on many criteria,
Surgical Time including infrastructure, volume of procedures in their geo-
Bone Grafts graphic location, and number of Medicare patients in the
Post-Op Care region/state.
DVT Prophylaxis
Infection Prophylaxis Funding Plan
Discharge Destination Six potential sources of funding for the registry project have
Length of Stay been identified:
1. Device surtax
2. Federal Agency funding – direct or via grants (CMS, NIH, Potential Benefits and Cost Savings
AHRQ, FDA) The benefits that could be realized in the United States as a
3. AAOS funding – for initial support of a limited pilot and result of a national joint registry can be extrapolated from those
via participation of it’s representatives in governance, over- observed with existing registries across the world, such as
sight and support Sweden and Australia. In Sweden the revision burden was
4. Private pay model (i.e. current Virginia Regisirty) reduced from 17% to 7%, the cost of total hip replacement was
5. Grants – private vs governmental reduced, patient outcomes were improved, and poorly perform-
6. “Participating” third parties, such as insurers or hospitals – ing implants were identified earlier, thus reducing their negative
either through the purchase of reports and services from the impact.
SYMPOSIA GENERAL
registry or via fees for participation in the registry.
In 2003-2004, the Australian Orthopaedic Association National
The cost of a registry project can vary widely depending on the Joint Replacement Registry reported a 0.6% decrease in knee
scope of the project. Three examples from existing registries are replacement revisions and a decrease of $8.7 million in the cost
listed here: of total knee replacement.
Registry Location Data Cost/ National/ In 2003, 33,000 total knee and 36,000 total hip revision proce-
Collected Patient Regional
dures were performed in the United States.1 The costs per pro-
Australian Australia Patient, Surgeon, $15 (US) National
Orthopaedic and Hospital Identifiers, cedure were $42,000 and $45,000, respectively. A mere 1.0%
Association procedure information, reduction in the revision rate for both these procedures would
National Joint primary v. revision, , result in a savings of $30 million in one year.
Replacement diagnosis laterality,
Registry device information Likely Next Steps
American College US Demographics – $50- National 1. Await the release of the Patient Safety Organization (PSO)
of Surgeons/ 9 variables $100 regulations by AHRQ provided for by 2005 legislation;
National Surgical profile –
2. Establish a PSO-based national registry as a separate non-
Surgical Quality 9 variables
Improvement Pre-operative data – profit foundation per regulations, as soon as they are avail-
Project 40 clinical and able;
13 laboratory variables 3. Establish financial model, (per business plan) for an inde-
Intra-operative data – pendent self funded level 1 registry and begin parallel
18 clinical and efforts to seek additional support (public and private) for
3 occurrence variables expanded data collection and analysis.
Post-operative data – 4. Launch a Level 1 registry in the original AJRR pilot sites,
20 clinical, 12 laboratory,
and expand by region once data collection is established (5
and 9 discharge variables
Cleveland Clinic US VAS $25 Regional year plan);
Foundation SF-12 5. Plan for a demonstration project (Level 2 data) for the
Comorbidities development of risk-adjusted performance measures once
Device information level 1 national registry is formed.
from billing system
Using the above information and 2003 numbers for total hip
and total knee replacement procedures in the U.S., if all
638,000 procedures were captured, the cost of the registry for
one year would range from $16 million to $63.8 million.
203
THE INTERNATIONAL SOCIETY FOR ARTHROPLASTY REGISTRIES

Henrik Malchau, MD, Ph.D.
At the February 2005 in Washington USA it was agreed to form to be established more quickly and so reduce or avoid mis-
an International Society of Arthroplasty Registers and a core takes in registry design and implementation.
group or steering committee were nominated to plan and devel-
Sharing results in an organized collaborative manner will be
op infrastructure and guidelines for the society. For further
SYMPOSIA GENERAL
supportive to all registries. It will assist in validation of find-

details please visit www.isarhome.org
ings that is both reassuring and protective of individual reg-
istries. It also increases the opportunity to undertake analysis
Mission
of more extensive data than is available to an individual reg-
The members of the International Society of Arthroplasty
istry
Registries have a shared purpose of improving outcomes for
individuals receiving joint replacement surgery worldwide. The 3. Encourage collaborative activities
focus of the society is to utilize the strength of cooperation and
This could be on multiple levels. It may consist of registries
sharing of information and further enhance the capacity of indi-
working together to achieve specific registry-defined objec-
vidual registries to meet their own aims and objectives. The soci-
tives. It may also be that enhanced contact between registries
ety is involved in the development of frameworks to encourage
encourages working together on specific projects through
collaborative activities and provides a support network for
data sharing, opportunities for personnel exchange etc.
established and developing registries.
The nature of the support, information sharing and collabora-
Aims and Objectives tion can be more precisely defined by setting specific objectives.
The purpose of any arthroplasty registry is to improve outcomes These would need to be regularly re-evaluated to ensure that the
of joint replacement surgery. Registries establish their own indi- society retains relevance in the long-term and adapts to chang-
vidual aims and objectives in order to achieve this. They are spe- ing needs of the members. This process would be added to by
cific to local circumstances and take account of the needs and the development of time specific milestones for some of the
requirements of the communities they serve and the organiza- objectives, in particular those objectives where there is a clear
tions to which they are responsible. In general they focus on task to be achieved. The use of this approach would help to
such issues as: The nature and quality of data collection; The ensure that the society is actively undertaking what members
need to determine outcomes of different prostheses and surgi- may require.
cal techniques; Targets for information dissemination;
There are many potential objectives such as: Establish conformi-
Education and audit activities.
ty of terminology; Standardization of statistical analysis; Generic
For an international society to be relevant, it must have the implant feature based analysis; Establish standard format for
shared purpose of improving outcomes of joint replacement annual reports; Develop a web based implant database. These
surgery. The aims and objectives of the society will differ from objectives are currently developed and the progress can be
the aims and objectives of individual registries, as the focus of followed on the society’s web portal.
the society should be to utilize the strength of linkage and devel-
op a framework that supports the activities of both established Membership
and developing registries. It was agreed at the Chicago meeting 2006 that a tiered
membership would be developed. A full membership would
Specific aims for the society require over 90% of procedures being recorded with data
1. Support Network collected validated. An associate membership includes those
Registries that are up and running but with a less than 90% of
One aim of the Society is to provide a support network for
validated procedures recorded nationally or is established as
established and developing registries.
Regional Registries. Affiliate Membership includes developing
This support could occur in at least two important areas. The Registries and may also include individuals that have been
first involves support for individual registries through collec- appointed by recognized professional bodies or government
tive communication with external organizations, most with the role of examining the potential for establishing a
importantly with industry and potentially with government. registry.
The second is the establishment of a forum and mechanisms Full membership: Sweden Knee, Sweden Hip, Finland, Norway,
to assist in enhancing inter-registry communication both in Australia, Denmark Hip, Denmark Knee, New Zealand.
a formal and informal manner. Although this latter aspect is
Associate Membership: Canada, Romania, England & Wales,
not critically dependant on the establishment of a society, it
Slovakia, Moldavia, Hungary, Turkey, Austria, Czech Rep., South
has the potential to be significantly assisted through this
Africa, Scottish Arthroplasty Project, Emilia-Romaga (Italy),
process.
ROLP (Lombardia,Italy), Catalunya (Spain), US Regional- and
2. Encourage cooperation and sharing of information Insurance Registers.
Sharing of information can be done in many different ways: Affiliate Membership: USA, Israel, Greece, Italy, Singapore,
it can be sharing experience or sharing results. Sharing of Germany, France, Croatia, Bulgaria, Netherlands, Lithuania,
experience is particularly important for developing registries, Portugal, Catalan Spain, Virgina Registry, Kaiser Permanente
as previously established registries would have solved many Registry
of the problems that arise when establishing a registry. Advice
and support is likely to assist new and developing registries
RECOMMENDED NATIONAL ARTHROPLASTY REGISTRY ESSENTIAL There is the potential to attempt collection of considerable
MINIMUM DATASET amounts data in this section but it is important to consider the
SECTION DATA impact on compliance and the reduced accuracy associated with
Prosthesis Details Catalogue number collecting additional data.
Lot number
Patient Details National Identity Number Steering Committee
Full name Past president professor Stephen Graves (Australia), Professor
Age Bob Bourne (Canada), Professor Leif Havelin (Norway),
Gender
Professor Peter Herberts (Sweden), Dr Gerold Labek (Austria,
SYMPOSIA GENERAL
Address
Operative Hospital Patient Identifier EFFORT), Professor Lars Lidgren (Sweden)
Surgery Details Date The steering committee reports to the general group on progress
Site/Side of developments.
Diagnosis
Primary or Revision
Hospital Details Identity Number (or name and address)
205
◆SCAPHOID FRACTURES AND NONUNIONS:

SYMPOSIA HAND/WRIST
WHAT’S HOT, WHAT’S NOT (V)

Moderator: Scott W. Wolfe, MD, New York, NY
Acute fractures of the scaphoid continue to be a frustrating source of missed diagnosis,
progression to nonunion, prolonged disability time and degenerative change in a young
and active population. Timely diagnosis and cast treatment leads to excellent healing rates,
at the expense of months of upper extremity immobilization and a persistent but low rate
of nonunion. Minimally invasive techniques have been recently demonstrated to reduce
complications and speed recovery of hand function for acute fractures and selected scaphoid
nonunions. Novel techniques of computer-assisted navigation of percutaneous scaphoid
fixation will be demonstrated to improve implant targeting and minimize the risk of
hardware complication. The panel will review and discuss a series of complications of
scaphoid fracture treatment to highlight tips and tricks.
I. Scaphoid Biology and Kinematics: Avoiding Scaphoid Nonunion

Scott W. Wolfe, MD, New York, NY
II. Indications, Tips and Tricks of Percutaneous Scaphoid Surgery

Joseph F. Slade, III, MD, New Haven, CT
III. The Role of Arthroscopy in Reduction and Treatment of Scaphoid Fractures and
Nonunions
William F. Geissler, MD, Jackson, MS
IV. Is There a Role for Computer Navigation of Scaphoid Fixation?

Scott W. Wolfe, MD, New York, NY
V. Cases, Panel Discussion, Audience Questions

Faculty Panel,
Moderator: Joseph F. Slade, III, MD, New Haven, CT
SCAPHOID BIOLOGY AND KINEMATICS:

AVOIDING SCAPHOID NONUNION
Scott W. Wolfe, MD
SYMPOSIA HAND/WRIST
I. Demographics of scaphoid fractures a. Increased disability time from work or sports 7wks(20)
a. Age 20-30, 4-1 male:female, athletic, employed(1) b. Non-union rate from casting acute fractures 4-11%(21-
b. 23-43/100,000 population(2) 23)
c. 1995: 475,000 in US alone(3) c. Residual weakness and motion loss persist(20;22)
d. 79% of carpal bone fractures(4) d. Acute percutaneous fixation union rates approach
e. 80% waist fractures, most non-displaced 100%(20;24-27)
f. 15% of suspected fractures are fractured(5) e. Immediate fixation of acute fractures is cost-
effective(28;29)
II. Scaphoid vascular supply
a. Tenuous, retrograde(6) V. Goals: scaphoid fracture management
b. 33% of scaphoids have 0-1 vascular perforators proximal a. Expeditious fracture union
to waist(7) b. Restore mobility, strength, function
c. Predictors of proximal pole ischemia c. Minimize disability, time from work
i. Size of fragment d. Cost-effective treatment paradigm
ii. Location e. Avoid disability, complexity, and costs of nonunion
iii. Energy of injury
VI. Algorithm for acute scaphoid fracture management in
d. Collapse is rare; high potential for revascularization
2008
e. Avascular necrosis is a spectrum of injury(8)
a. Stable fractures, nondisplaced
f. Vascular supply cannot be determined with radiographs
i. Tubercle: short arm cast x 6-8 wks
g. Proximal pole fractures; delayed and non-union more
ii. Distal 1/3 and waist fractures
frequent
1. Percutaneous screw fixation or ORIF
III. Kinematics and SNAC wrist a. active, young, manual worker
a. Few, if any, nonunions remain stable and painless(9;10) b. athlete, high demand occupation
b. Relentless progression to degenerative arthritis(11) c. preference for early ROM
c. Carpal collapse, “humpback” scaphoid(12;13) 2. Cast protocol (prefer 6wk LAC, 6wk SAC)(21)
d. Lunate dorsal rotation(14) a. pediatric patients(30)
e. Surgical complexity increased by need for intercalated b. geriatric
graft(15-17) c. sedentary or low-demand occupation
f. Union rates decreased, especially with avascular d. preference for non-operative treatment
necrosis(18) iii. Proximal pole fractures
1. Percutaneous or open fixation, antegrade
IV.The real cost of scaphoid treatment: rationale for acute
b. Displaced and unstable fractures: ORIF or arthroscopic
operative fixation
reduction and percutaneous fixation
“While it is probable that most navicular fractures will unite if
c. Concomitant injury (distal radius, multi-trauma,
well immobilized for a long time, it is equally probable that
perilunate): ORIF
such triumphs might be reflected in economic catastrophes
d. Sub-acute fractures (un-united, >8wk from injury): ORIF
for the young male breadwinners who are most prone to
sustain this injury.”(19) Harrison J. McLaughlin, 1969
REFERENCES 8. Desser TS, McCarthy S, Trumble T. Scaphoid fractures and Kienbock's disease of
1. Wolfe SW. Fractures of the Carpus: Scaphoid Fractures. In: Weiss AP, Berger RA, the lunate: MR imaging with histopathologic correlation. Magn Reson Imaging
editors. Hand Surgery.New York: Lippincott, Williams and Wilkins; 2004. p. 381- 1990;8(4):357-61.
408. 9. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-
2. Gutow AP. Percutaneous fixation of scaphoid fractures. J Am Acad Orthop Surg union. J Bone Joint Surg [Am] 1984;66(4):504-9.
2007 Aug;15(8):474-85. 10. Leslie IJ, Dickson RA. The fractured carpal scaphoid. Natural history and factors
3. Praemer A, Furner S, Rice DP. Health Care Utilization. Musculoskeletal influencing outcome. J Bone Joint Surg [Br] 1981;63-B(2):225-30.
Conditions in the United States.Rosemont: Amer.Acad. Ortho. Surgeons; 1999. 11. Watson H, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of
p. 112-3. degenerative arthritis. J Hand Surg 1984;9A:358-65.
4. Amadio PC, Moran SL. Fractures of the Carpal Bones. In: Green DP, Hotchkiss 12. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP3, Linscheid RL.
RN, Pederson WC, Wolfe SW, editors. Operative Hand Surgery. 4 ed. Scaphoid malunion. J Hand Surg [Am] 1989;14(4):679-87.
Philadelphia: Elsevier Churchill Livingston; 2005. p. 711-68. 13. Fisk GR. Carpal instability and the fractured scaphoid. Ann Roy Coll Surg Engl
5. Grover R. Clinical assessment of scaphoid injuries and the detection of fractures. 1970;46:63-76.
J Hand Surg [Br] 1996;21(3):341-3. 14. Smith DK, Cooney WP3, An KN, Linscheid RL, Chao EY. The effects of simulated
6. Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg unstable scaphoid fractures on carpal motion. J Hand Surg [Am] 1989;14(2 Pt
1980;5A:508-13. 1):283-91.
7. Obletz BE, Halbstein BM. Non-union of fractures of the carpal navicular. J Bone 15. Fernandez DL. Anterior bone grafting and conventional lag screw fixation to treat
Joint Surg Am 1938;20:424-8. scaphoid nonunions. J Hand Surg [Am] 1990;15(1):140-7.
207
16. Fernandez DL. A technique for anterior wedge-shaped grafts for scaphoid 23. Hambidge JE, Desai VV, Schranz PJ, Compson JP, Davis TR, Barton NJ. Acute
nonunions with carpal instability. J Hand Surg [Am] 1984;9(5):733-7. fractures of the scaphoid. Treatment by cast immobilisation with the wrist in
17. Fisk GR. Volar wedge grafting of the carpal scaphoid in non-union associated flexion or extension? [see comments]. J Bone Joint Surg Br 1999;81(1):91-2.
with dorsal instability patterns (discussion). In Proceedings of the Seventh 24. Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation. A pilot study. J
Combined meeting of the Orthopaedic Associations of the English Speaking Bone Joint Surg Br 1998;80(1):95-9.
World, Cape Town, South Africa, March 1982. J Bone Joint Surg[Br] 25. Inoue G, Shionoya K. Herbert screw fixation by limited access for acute fractures
1982;64:632-3. of the scaphoid. J Bone Joint Surg Br 1997;79(3):418-21.
18. Robbins RR, Carter PR. Iliac crest bone grafting and Herbert screw fixation of
SYMPOSIA HAND/WRIST
26. Yip HS, Wu WC, Chang RY, So TY. Percutaneous cannulated screw fixation of
nonunions of the scaphoid with avascular proximal poles. J Hand Surg acute scaphoid waist fracture. J Hand Surg [Br] 2002 Feb;27(1):42-6
1995;20A(5):818-31. 2002;27(1):42-6.
19. McLaughlin HL, Parkes JC. Fracture of the carpal navicular (scaphoid) bone: gra- 27. Slade JF, III, Geissler WB, Gutow AP, Merrell GA. Percutaneous internal fixation
dations in therapy based upon pathology. J Trauma 1969;9(4):311-9. of selected scaphoid nonunions with an arthroscopically assisted dorsal
20. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast approach. J Bone Joint Surg Am 2003;85-A Suppl 4:20-32.
immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg [Am] 28. Davis EN, Chung KC, Kotsis SV, Lau FH, Vijan S. A cost/utility analysis of open
2001;83-A(4):483-8. reduction and internal fixation versus cast immobilization for acute nondisplaced
21. Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. Comparison of short mid-waist scaphoid fractures. Plast Reconstr Surg 2006 Apr;117(4):1223-35.
and long thumb-spica casts for nondisplaced fractures of the carpal scaphoid. J 29. Arora R, Gschwentner M, Krappinger D, Lutz M, Blauth M, Gabl M. Fixation of
Bone Joint Surg 1989;71A:354-7. nondisplaced scaphoid fractures: making treatment cost effective. Prospective
22. Alho A, Kankaanpaa U. Management of fractured scaphoid bone: a prospective controlled trial. Arch Orthop Trauma Surg 2007 Jan;127(1):39-46.
study of 100 fractures. Acta Orthop Scand 1975;46:737-43. 30. Wulff RN, Schmidt TL. Carpal fractures in children. J Pediatr Orthop
1998;18(4):462-5.
INDICATIONS, TIPS AND TRICKS OF PERCUTANEOUS

SCAPHOID SURGERY
Joseph F Slade III,M.D.
SYMPOSIA HAND/WRIST
Most common reason for failed healing of scaphoid fracture
after ORIF.
• Un-Reduced Scaphoid Fracture
Principles of Scaphoid Fracture Fixation-Choice of
Implant(Rigidity ~ r4 )Wider screws are stronger
Toby 1997;Implant Placement-Screw Placement in Central
Axis-
• Clinical studies have shown higher non-union rates with
eccentrically placed screws; Adams et al. JHS 1988; Pring et
al. JHS 1987; Trumble et al. JBJS-A 1996
• Dodds- 2006- “Screw fixation of scaphoid fractures: a bio-
mechanical assessment of screw length and screw augmen-
tation”
• The closer the fracture to trailing end of the screw the
greater the compression
• Solid Fixation Requires 4 Threads Across Fracture Site
• Bindra 2004 IFSSH- Micro-CT scanner-Scaphoid Bone
Density Greatest at Scaphoid Poles
• Bone Quality-Comminution; Decrease Bone Density; Bone
Graft
ORIF of Scaphoid Fractures
• Traditional Open Repair-100 % union for acute scaphoid
fractures;Herbert & Fisher 1984; Retting 1994,
1999;Trumble 2000
• Complications of open scaphoid repair
• Why do Scaphoid fractures fail to Heal ? Filan & Herbert 1996 - 431 pts
• Stages of Fracture Healing • Hypertrophic scar 13%
• Prerequisites for Scaphoid Fracture Healing • AVN 20
• DO SCAPHOID FRACTURES FAIL TO HEAL BECAUSE OF • Carpal instability (S-L tear) 2
POOR BLOOD SUPPLY? • Donor site pain- bone graft 20
• Dawson JS. “ Scaphoid blood flow and acute fracture healing. • Infection 5
A dynamic MRI study with enhancement with gadolinium.” • Screw protrusion 14
2001- AVN vs NON-UNION no statistical relationship • RSD 4
• Carter PR, Malinin TI, Abbey PA, Sommerkamp TG-“The Dias , J. 2005- Open Repair of Scaphoid fractures vs. Plasters
scaphoid allograft: a new operation for treatment of the very Cast (n = 44) vs ORIF (n = 44) with Herbert Screw
proximal scaphoid nonunion or for the necrotic, fragmented • Surgery (10/44) complications 22%
scaphoid proximal pole”.J Hand Surg [Am]. 1989 – Surgery technically difficult - 16%
Jan;14(1):1-12.-Allograft rigidly fixed healed to distal – Wound infections 1
scaphoid – Sensitive scar 3
Forces acting at the Fractures Site are – Hypertrophic scar 4
– Sensitive scar and Hypertrophic scar 1
“Bending Forces & Translational Forces” – Causalgia 1
∑ Smith 1989 - Bending Moment • SHORT ARM CAST 22% (10/44) nonunion rate
∑ Kobayashi 1997- Axial loading Straw RG, 2002- Scaphoid nonunion: treatment with a
∑ Kaneshiro 1999- shearing pedicled vascularized bone graft based on the 1,2 intercom-
Augat P. partmental supraretinacular branch of the radial artery.
∑ Shearing motion at the fracture site delays healing in a dia- – Six/22 (27%) nonunions united
physeal fracture model. Tools: Mini-Fluroscopy guide arthroscopy; Mini-Fluroscopy-
∑ Micro-motion results in formation of fibrous tissue not frac- real time imaging during surgery; Longitudinal
ture callos Traction- Ligamentotaxis
∑ J Orthop Res. 2003 Arthroscopy; Diagnosis ligament injury & occult fractures;
Confirm Implant Placement; Confirm fracture
Kaufer H: Mechanics of the treatment of hip injuries. Clin reduction with guide-wire
Orthop. 1980 -Principles of Rigid Bone Fracture Fixation
• Strength of a fracture fragment-implant construct Advantages of Percutaneous/ Arthroscopic Scaphoid Fracture
• Determined by 5 independent variables: Bone quality, Reduction & Fixation
Fragment geometry, Fracture Reduction, Choice of Implant, • Rigid Fixation
Implant Placement • Preserve Uninjured Ligaments & Scaphoid Blood Supply
209
• Avoid Complications of Open Repair

• Early Restoration of Hand Function
Nonunion Rate of 22-50%- Scaphoid Non-Unions
Treated with ORIF & Bone Graft
• Cooney 1988- non-union- 29% Healed- loss of function
— Extension 10%/ flexion 26%; Grip loss 25%
• Barton 1997- non-union- 22% Herbert Screw &BG; 45
SYMPOSIA HAND/WRIST
%Russe Bone Graft

• Inoue 1997 - 18% proximal pole
• Shah 1998 < 5years 20% ; > 5years 50%
• Schuind 1999 - 25%
The Technique in Detail for combined scaphoid & distal
radius fx
Conclusion
Percutaneous techniques have provided a powerful tool for
limiting iatrogenic injuries and speeding healing and recovery.
Fluroscopic imaging and arthroscopy are instruments required
to achieve restoration of the injured extremity. Over the past
ten years percutaneous fixation of non-displaced scaphoid
fractures has resulted in high union rate, early return of hand
function with minimal complications. Using these same tools,
displaced scaphoid fractures and non-unions can be reduced
and rigidly fixed. Permitting rapid healing and an early return
of hand function.
REFERENCES 11. Slade JF 3rd, Grauer JN. Dorsal Percutaneous repair of scaphoid fractures with
arthroscopic guidance. Atlas of the Hand Clinics, New Techniques in Wrist
1. Barton NJ. Apparent and partial non-union of the scaphoid. Journal of Hand
Arthroscopy, ed. W. Geisler, 2001 Sep; 6 (2): 307-32
Surgery - British Volume. 1996;21(4):496-500.
12. Slade JF 3rd. Jaskwhich D. Percutaneous fixation of scaphoid fractures. Hand
2. Cosio MQ, Camp RA. Percutaneous pinning of symptomatic scaphoid
Clinics. 2001;17(4):553-74.
nonunions. J Hand Surg [Am]. 1986; 11(3): 350-5.
13. Slade JF 3rd. Gutow AP. Geissler WB. Percutaneous internal fixation of scaphoid
3. Dias JJ, Taylor M, Thompson J, Brenkel IJ, Gregg PJ. Radiographic signs of union
fractures via an arthroscopically assisted dorsal approach. Journal of Bone &
of scaphoid fractures: an analysis of inter-observer agreement and reproducibility.
Joint Surgery - American Volume. 2002;84-A Suppl 2:21-36.
J Bone Joint Surg [Br] 1988;70-B:299-301.
14. Slade JF 3rd. Geissler WB. Gutow AP. Merrell GA. Percutaneous internal fixation
4. Faran KJ, Ichioka N, Trzeciak MA, Han S, Medige J, Moy OJ. Effect of bone quali-
of selected scaphoid nonunions with an arthroscopically assisted dorsal
ty on the forces generated by compression screws. J Biomech 1999: 861-864.
approach. Journal of Bone & Joint Surgery - American Volume. 85-A Suppl 4:20-
5. Kaneshiro SA, Failla JM, Tashman S. Scaphoid fracture displacement with fore- 32, 2003.
arm rotation in a short-arm thumb spica cast. J Hand Surg [Am] 1999;24A: 984-
15. Slade, JF; Merrell, GA; Geissler, WB: Fixation of Acute and Selected Nonunion
991.
Scaphoid Fractures. In: Wrist Arthroscopy. Geissler, WB (ed). Springer-Verlag,
6. Kobayashi M. Garcia-Elias M. Nagy L. Ritt MJ. An KN. Cooney WP. Linscheid RL. New York,2005. pp (15) 112-124.
Axial loading induces rotation of the proximal carpal row bones around unique
16. Operative Techniques in Plastic and Reconstructive Surgery, Vol. 9, No. 4: pp
screw-displacement axes. Journal of Biomechanics. 1997;30(11-12):1165-7.
143-150, Nov 2003, Ed. L. Ketch page 1-18, Scaphoid Injuries, ed. J. Slade III
7. Merrell GA, Wolfe SW. Slade JF 3rd. Treatment of scaphoid nonunions: quantita-
17. Slade JF 3rd, Dodds SD:Minimally invasive management of scaphoid
tive meta-analysis of the literature. Journal of Hand Surgery - American Volume.
nonunions. Clin Orthop Relat Res. 2006 Apr;445:108-19.
2002;27(4):685-91.
18. Smith DK, Cooney WP, An KN, et al. The effects of simulated unstable scaphoid
8. Schuind F, Haentjens P, Van Innis F, Vander Maren C, Garcia-Elias M. Sennwald
fractures on carpal motion. J Hand Surg [Am] 1989;14A: 283-291.
G. Prognostic factors in the treatment of carpal scaphoid nonunions. Journal of
Hand Surgery - American Volume. 1999;24(4):761-76. 19. Toby EB, Butler TE, McCormack TJ, Jayaraman. A comparison of fication screws
for the scaphoid during application of cyclic bending loads. J Bone and Joint
9. Shah J, Jones WA. Factors Affecting the Outcome in 50 Cases of Scaphoid
Surg [Am] 1997;79-A: 1190-1197.
Nonunion Treated With Herbert Screw Fixation. J-Hand-Surg-Br. 1998;23B:680-
685. 20. Trumble TE, Gilbert M, Murray LW, Smith J, Rafijah G, McCallister WV.
Displaced scaphoid fractures treated with open reduction and internal fixation
10. Slade JF 3rd, Grauer JN, Mahoney JD. Arthroscopic reduction and percutaneous
with a cannulated screw. Journal of Bone & Joint Surgery - American Volume.
fixation of scaphoid fractures with a novel dorsal technique. Orthop Clin North
2000;82(5):633-41.
Am. 2001; 32(2): 247-61.
ARTHROSCOPIC ASSISTED REDUCTION OF ACUTE AND SELECTED

NONUNIONS OF THE SCAPHOID
William B. Geissler, MD
SYMPOSIA HAND/WRIST
SCAPHOID FRACTURES A primary guide pin is placed down the center of the barrel jig
Acute nondisplaced scaphoid fractures have traditionally been and its position is evaluated under fluoroscopy. A cannulated
managed with cast immobilization. The duration of drill tap and cortical broach are successively used and the
immobilization required to achieve union increases as the appropriate sized Herbert/Whipple screw is inserted.
fracture site moves in proximal direction. Union of optimally
managed waist fractures average 3 months while proximal-third VOLAR APPROACH:
fractures may require 4 to 6 months of casting. Closed A stab wound is made over the scaphoid tubercle just radial to
immobilization is standard for nondisplaced fractures while the FCR. A 0.045 Kirschner wire is inserted through a soft tissue
ORIF is recommended for displaced fractures. Arthroscopic protector down to the distal pole of the scaphoid. The pin should
and/or percutaneous reduction offers the patient an alternative be aimed as perpendicular to the fracture site as possible and
middle ground between these two traditional treatments. angulated approximately 45 degrees to the long axis of the
forearm. The position of the wire is evaluated under fluoroscopy.
HERBERT/WHIPPLE SCREW A cannulated headless screw is inserted after standard drilling
Whipple pioneered this approach and developed elaborate and possible tapping. The length of the screw is measured from
equipment for this procedure. Despite the instrumentation, this the scaphoid of the opposite wrist.
is a very demanding technique.
DORSAL APPROACH:
Procedure: This technique was popularized by Slade. It is an excellent
Make a 1.5 cm incision over volar tubercle of trapezium just technique and easy to do. Its advantages are easy placement of
radial to FCR. Expose the scaphotrapezial joint through a a 0.045 Kirschner guide pin under fluoroscopic control from
T-shaped incision and excise the volar tubercle of the trapezium. dorsal to volar. The key is to be down the center of the cylinder
of the scaphoid as seen under the fluoroscope as the wrist is
The wrist is then suspended for the arthroscopic portion of the
flexed and pronated. First pronate the wrist to align the proximal
procedure. The radiocarpal space is evaluated and any other
and distal poles of the scaphoid and then flex the wrist to form
associated injuries are identified and managed. The arthroscope
a cylinder. The wrist is then suspended and the reduction of the
is then placed in the radial midcarpal portal. The reduction of
fracture is arthroscopically evaluated from the midcarpal space.
the fracture is then evaluated. Wrist extension and supination
If the reduction is unsatisfactory, the guide pin is withdrawn
should reverse a mild humpback deformity. If not, insert 0.045
volarly out of the proximal pole but still remaining in the distal
Kirschner wire joysticks into the scaphoid tubercle volarly and
pole. The guide wire may be used as a joystick or additional
the proximal pole of the scaphoid dorsally and manipulate the
joysticks may be used to reduce the fracture as it is viewed
fracture. If the fracture can not be anatomically reduced by these
arthroscopically. The guide pin is then advanced dorsally once
methods, it may then be required to abandon the procedure and
anatomic reduction has been achieved. The screw is placed
expose the fracture site.
percutaneously from dorsally with the wrist hyperflexed. The
The alignment guide is inserted once anatomic reduction of the advantage of this technique is that it places the guide wire down
scaphoid is confirmed. The arthroscope is placed in the 3-4 portal the central axis of the scaphoid perpendicular to the fracture.
and a 1-2 portal is created. Identify the correct location with a Once the screw is placed, check placement of the screw
needle before incising the skin. Remember that millimeters make arthroscopically from the radiocarpal space and fracture
a difference in wrist arthroscopy between an easy procedure and compression from the midcarpal space.
a struggle. Incise the skin only and spread with a hemostat to the
joint capsule. The arthroscope is transferred to the 4-5 portal and MODIFICATION (GEISSLER)
the alignment guide is placed through the 1-2 portal. The target Occasionally it is difficult to obtain the cylinder under
hook is placed 1-2 mm from the scapholunate interosseous fluoroscopic control. In these situations, place the arthroscope
ligament along the dorsal aspect of the proximal pole. in the 4-5 portal and look across the wrist at the proximal pole
Hyperextend the thumb to facilitate exposure of the distal pole of the scaphoid. Take a 14-gauge needle and impale the proximal
of the scaphoid and swing the barrel of the alignment guide on pole of the scaphoid exactly where you want the guide wire to
the radial aspect of the scaphoid. The jig is then compressed to start in the scaphoid (1-2 mm medial to the S-L ligament, dorsal
secure the reduction. The reduction may be evaluated on proximal pole of scaphoid). Take wrist out of traction and
arthroscopically with the scope in the radial midcarpal portal and under fluoroscopic guidance advance the guide pin down the
under fluoroscopy. axis of the scaphoid with the wrist flexed.
211
ARTHROSCOPIC MANAGEMENT SCAPHOID NONUNION WITHOUT

BONE GRAFTING
Joseph F. Slade, MD and William B. Geissler, MD
SYMPOSIA HAND/WRIST
15 patients – Class II and III • Percutaneous cannula under fluoroscopic control

JBJS Supplement 85A:20-32, 2003 All patients healed – • Percutaneous cannulated putty pusher
average 3 months without grafting — Insert over guide wire
— Insert DBM into nonunion site
Arthroscopic Management Cystic Scaphoid Nonunions with
• Insert cancellous bone chips
DBM (Geissler, ASSH 2006)
• Evaluate under fluoroscopy as bone chips inserted into
• Potential for arthroscopic management if no humpback
nonunion site
deformity
• Insert screw
• Percutaneous bone grafting or injection of bone
• Arthroscopically re-evaluate joint
morphogenic protein (100 %BMP)
• Evaluate screw placement in scaphoid (radiocarpal space)
TECHNIQUE — Screw is fully inserted in scaphoid
• Place guide wire as before – dorsal approach
• Drill over guide wire – do not drill through articular surface
scaphotrapezial joint
REFERENCES 9. Slade, JF; Gutow, AP; Geissler, WB: Percutaneous internal fixation of scaphoid
1. Haddad, FS; Goddard, NJ: Acute percutaneous scaphoid fixation – a pilot study. J fractures via an arthroscopically assisted dorsal approach. J Bone Joint Surg, 84A
Bone Joint Surg. 80(B):95-99, 1998. Suppl 2:21-32, 2002.
2. Inoue, G; Shionoya, K: Herbert screw fixation by limited access for acute fractures 10. Slade, JF; Jaskwhich, D: Percutaneous fixation of scaphoid fractures. Hand Clin,
of the scaphoid. J Bone Joint Surg. 17(B):415-419, 1997. 17:553-74, 2001.
3. Kozin, SH: Internal fixation of scaphoid fractures. Hand Clin. 13:573-586, 1997. 11. Slade, JF; Mahoney, JD: Carpal fractures and dislocations – percutaneous treat-
ment of scaphoid fractures. In: Plancher, K (ed): Master Cases: Hand and Wrist
4. McCallister, WV; Knight, J; Kaliappan R; Trumble, TE: Central placement of the Surgery. New York, Thiemia Publishing, 2000 (in press).
screw in simulated fractures of the scaphoid waist: a biomechanical study. J Bone
Joint Surg, 85A:72-77, 2003. 12. Taras, JS; Sweet, S; Shum, W; Weiss, LE; Bartolozzi, A: Percutaneous and arthro-
scopic screw fixation of scaphoid fractures in the athlete. Hand Clin. 15:467-473,
5. Osterman, AL: Wrist arthroscopy. In: Green, D (ed): Operative Techniques in 1999.
Hand Surgery. Philadelphia. Churchill-Livingstone, pp 207-222, 1999.
13. Trumble, TE; Gilbert, M; Murray, LW; et al: Displaced scaphoid fractures treated
6. Osterman, AL; Mikulics, M: Scaphoid non union. Hand Clin. 4:437-455, 1988. with open reduction and internal fixation with a cannulated screw. J Bone Joint
7. Rettig, AC; Ryan, RO; Stone, JA: Epidemiology of hand injuries in sports. In: Surg, 82A:633-641, 2000.
Strickland, JW; Rettig, AC (eds): Hand Injuries in Athletes. Philadelphia. WB 14. Whipple, TL: The role of arthroscopy in the treatment of intraarticular wrist frac-
Saunders. pp 37-48, 1992. tures. Hand Clin. 11:13-18, 1995.
8. Riester, JN; Baker, BE; Mosher, JF; et al: A review of scaphoid fracture healing in 15. Wozasek, GE; Moser, KD: Percutaneous screw fixation for fractures of the
competitive athletes. Am J Sports Med. 13:159-161, 1985. scaphoid. J Bone Joint Surg, 73B:138-142, 1991.
16. Geissler, WB; Freeland, AE; Weiss, APC; Chow, JC: Techniques of wrist
arthroscopy. J Bone Joint Surg. 81:1184-1197, 1999.
COMPUTER-ASSISTED SCAPHOID FIXATION

Wolfe, S.W., Walsh, E., Richards, J., Plaskos, C., Granchi, C., Crisco, J.J.
Introduction: nearly half the time of the traditional fluoroscopic technique

Accurate percutaneous placement of a central screw in the (15.0 ± 8.2 min vs. 7.8 ± 7.0min; p = 0.17). In all but one
SYMPOSIA HAND/WRIST
scaphoid is difficult and there is little in the literature to help navigation specimen, a single K-wire attempt was necessary; in
guide the surgeon.(31-34) We hypothesize that computer- comparison, an average of 2.4 ± 1.1 attempts was needed for the
assisted navigation of volar percutaneous scaphoid screw traditional method. Global radiation exposure was significantly
placement improves precision when compared with (P= 0.02) reduced with the use of navigation (72.2 ± 7.2sec vs.
fluoroscopic-assisted methods, requiring less operative time and 258.2 ± 142.7sec). Similarly, radiation exposure during K-wire
significantly decreased radiation exposure. placement (p < 0.05) and screw placement (p< 0.001) were each
significantly reduced using the navigation method. Finally, actual
Methods: screw axis compared to the targeted ideal screw axis using the
Cadaver wrists (n=10) were randomized to computer-assisted computer navigation technique demonstrated a variance of 1.6
versus fluoroscopic-assisted volar percutaneous scaphoid screw ± 0.5 degrees.
placement. Student’s t-test and rank sums were used to
compare outcome variables: time of the overall procedure, set- Discussion/Conclusion:
up time, number of K-wire attempts and time for ideal guide Computer-assisted percutaneous scaphoid fixation (CAPS) offers
wire placement; radiation time for setup, K-wire and implant a rapid [you don’t prove this – no diff.] and highly precise
placement; precision of the actual screw axis to the planned alternative to traditional surgical methods, with a significant
target axis. reduction in radiation exposure to surgeon and patient. The
technique greatly reduces the technical complexity of rapid and
Results: precise cannulated screw placement by minimizing the number
There was no difference in the overall procedural time for of k-wire attempts and ensuring containment of the implant
scaphoid screw placement; however, the time to place the within the narrow subcortical scaphoid “safe zone.”
targeting K-wire using the computer-assisted technique was
REFERENCES 3. Levitz S, Ring D. Retrograde (volar) scaphoid screw insertion-a quantitative com-
1. Beek M, Abolmaesumi P, Luenam S, Ellis RE, Sellens RW, Pichora DR. Validation puted tomographic analysis. J Hand Surg [Am] 2005 May;30(3):543-8.
of a new surgical procedure for percutaneous scaphoid fixation using intra-oper- 4. Murase T, Moritomo H, Goto A, Sugamoto K, Yoshikawa H. Does three-dimen-
ative ultrasound. Med Image Anal 2007 Sep 14. sional computer simulation improve results of scaphoid nonunion surgery? Clin
2. Beek M, Abolmaesumi P, Luenam S, Sellens RW, Pichora DR. Ultrasound-guided Orthop Relat Res 2005 May;(434):143-50.
percutaneous scaphoid pinning: operator variability and comparison with tradi-
tional fluoroscopic procedure. Med Image Comput Comput Assist Interv Int
Conf Med Image Comput Comput Assist Interv 2006;9(Pt 2):536-43.
213
OSTEOPOROSIS AND THE MYTH OF COLLES:

SYMPOSIA HAND/WRIST
DO THEY ALL DO WELL? (W)

Moderator: Amy L. Ladd, MD, Palo Alto, CA
The common but misunderstood osteoporotic distal radius fracture deserves scrutiny and
special consideration. This symposium elucidates steps for improved recognition and
treatment.
I. Nonoperative (Conservative) Treatment: When I Use It

Terry S. Axelrod MD, Toronto, ON Canada
II. Internal Fixation: Is This the New Gold Standard

Amy L. Ladd MD, Palo Alto, CA
III. Contemporary Perspectives on The Role Of Stable Internal Fixation With

Osteoporotic Wrist Fractures
Jesse B. Jupiter MD, Weston, MA
IV. Fixation Augmentation Techniques: When And How

Antonio Moroni MD, Bologna, Italy
V. Bone Health Across the Life Span

Aenor Sawyer, MD, San Ramon, CA
VI. Discussion, Question & Answer
NONOPERATIVE (CONSERVATIVE) TREATMENT: WHEN I USE IT

Terry S. Axelrod MD MSc FRCS (C)
The myth that Sir Abraham Colles said of the fracture "they all do • With a mildly displaced fracture that can be
well" has persisted with at least some foundation. With our reasonably predicted to heal with acceptable
SYMPOSIA HAND/WRIST
expanding elderly population, many leading active lifestyles, we deformity.
have greater experience with what fractures indeed do well with • Individual with severe medical or psycho-social co-
minimal intervention. Surgical outcome may be unsatisfactory morbidities
because of the difficulty in obtaining reliable fixation in III. The patient that will rarely have conservative
mechanically weak bone. Some low demand patients may accept management as the only option:
wrist deformity, and some may also accept degrees of The higher demand, independent patient:
dysfunction. Even in the face of optimal wrist alignment--with • Living independently
or without surgery--functional return may be independent of • Higher functional demands with leisure activity, sport
alignment, or difficult to regain. The goal of this presentation is and/or employment
to discuss the degree of deformity that is acceptable in general • Severe fracture deformity, comminution,
and specific terms, and to present techniques for minimizing redisplacement
deformity with little or no surgical intervention.
With this, please remember that:
During this symposium you will be introduced to a multitude of
Conservative Management does not mean NO
options and “state of the art” techniques for the management of
MANAGEMENT!!
distal radius fractures in the presence of osteopenic bone. I urge
Many fractures can be reduced under regional block, conscious
you to maintain a reasonable perspective regarding the
sedation or haematoma block into a very reasonable alignment
framework of these discussions in that the techniques and
and this reduction may be maintained with a proper protocol of
standards apply to subsets of patients with these fractures, and
splintage, follow-up, repeat manipulation and casting.
NOT everyone with a distal radius fracture.
What constitutes an acceptable reduction and ultimate position of
As all of us, as practicing Orthopaedic surgeons know, many of
healing is often patient dependent. This applies particularly to the
these fractures occur in the very elderly, low demand individual,
elderly population with osteopenia. A recent publication by
often with impaired cognitive function. These individuals do not
Wilcke, Abbaszadegan and Adolphson confirms the relationship
require a “perfect anatomic” reduction, nor textbook anatomy
between poorer patient outcomes, as measured by DASH score
upon union. They will generally function very well, with minimal
and radiographic parameters of malunion. Radial shortening
complaints even with a mal-united fracture of the distal radius.
>/=2mm, dorsal angulation >15 degrees, and radial angulation.
These same individuals will not do well with an operation, no
matter how minimal. There is the potential of severe 1. Axelrod: Conservative Treatment
consequences to hospitalization, displacement from familiar >10 degrees were each significantly associated with a poorer
surroundings, anaesthesia, sedation and/or analgesia and the DASH score. Reduced grip strength, extension, and ulnar
techniques themselves.Thus patient selection is of paramount deviation correlated with a poorer DASH score.
importance in deciding on the role of conservative vs. surgical
Della Santa et al confirm that with time, the patient adapts to the
management. I tend to think of patients with osteopenic
deformity and the extent of the deformity no longer correlates
fractures of the distal radius in three wide categories in terms of
with the outcomes of function and pain.
decision-making.
McQueen and Beumer have found a lack of benefit to closed
1. Axelrod: Conservative Treatment reduction in the very old and frail individual. In 53 of 60 patients
I. The patient that will always have conservative with distal radius fractures treated by closed reduction, the
management: reduction was subsequently lost with no correlation between
The nursing home type patient: initial displacement, fracture classification and final radiographic
• Cognitive impairment appearance. They conclude that reduction of fractures of the
• Bedridden, poor ambulation distal radius is of minimal value in the very old and frail,
• Low functional demand dependent or demented patient.
II. The patient that may have conservative management:
Some guidelines will be provided through the presentations of
The elderly, but relatively independent patient:
the faculty in this symposium.
• Living in the community
• Independent for most of self care and household
upkeep
REFERENCES 3. Ring D, Jupiter JB. Treatment of osteoporotic distal radius fractures. Osteoporos
Int. 2005 Mar;16 Suppl 2:S80-4. Epub 2004 Dec 22.
1. Beumer A, McQueen MM Fractures of the distal radius in low-demand elderly
patients: closed reduction of no value in 53 of 60 wrists. Acta Orthop Scand. 4. Wilcke MK, Abbaszadegan H, Adolphson PY Patient-perceived Outcome after
2003 Feb;74(1):98-100. Displaced Distal Radius Fractures A Comparison between Radiological
Parameters, Objective Physical Variables, and the DASH Score. J Hand Ther. 2007
2. Della Santa D, Sennwald G [Is there still a place for conservative treatment of dis-
Oct-Dec;20(4):290-9.
tal radius fractures in the adult?] . Chir Main. 2001 Dec;20(6):426-35.
215
INTERNAL FIXATION: IS THIS THE NEW GOLD STANDARD?

Amy L. Ladd, MD
Learning Objectives — Restoration of Function:

1. Identify Major Contributions to Past and Current Trends in Address Defects of Bone
SYMPOSIA HAND/WRIST
Wrist Fracture Treatment – Cancellous

2. Identify Pros and Cons of Various Treatment Methodologies – Cortical
3. Understand Characteristics of Osteoporotic Fractures Which — Early Fixation Provides Early
Complicate Treatment Stability and Early Functional
1) Major Contributions in Understanding Wrist Fractures: Return (everybody with a plate
Description and Treatment in past 10 years)
∑ Patients Demand Early
Rehabilitation
∑ Aging Population is More Active
∑ Potentially Cost-Effective (but not borne by health carri-
ers, only to patient thus far)
CONS
• Historical ∑ The (Mis) Interpretation of Colles: “They All Do Well”
— Claude Pouteau 1783 (1), Abraham Colles 1814 (2), ∑ Better External Fixators Today
J-G-B Goyrand 1832 (3) — Agee Wrist Jack
— John Rhea Barton 1838 (4), Robert Smith 1847 (5) — Non-bridging – McQueen (34)
— Frederic Cotton 1900 (6), Ricardo Galeazzi 1934 (7) — No uniformity to suggest internal fixation is superior
∑ Modern Era: Treatment – Cochrane Database (35, 36)
— Sir John Charnley’s Closed Management book (8) — Functional Outcome Acceptable with Ex Fix (37)
— John C. Hughston 1957 (9) ∑ Complications
— Pins and Plaster (?) — Osteoporosis Confounds Treatment & Complications
— Roger Anderson (10) with Internal Fixation
— John Agee: ligamentotaxis 1993 (11) ∑ Equipment and Operative Costs borne by health carriers
∑ Modern Era: Classifications and patient
— Anatomy: Older 1965 (12),
Frykman 1967 (13), AO 1987 The Downside (Cons) of Specific Internal Fixation Systems:
(14), Mayo 1992 (15), Melone ∑ Dorsal Plating
1984 (16) — Wrist Stiffness
— Severity: Lafontaine 1989 (17) — Tendon Irritation (36)
— Mechanism: McMurtry1992 — Wound, Hardware Complications
(18), Fernandez/Jupiter 1996 ∑ Fragment Specific
(19) — Technically Demanding
— Treatment: Rikli 1996 (20), — Difficult with Osteoporosis
Medoff 1999 (21) ∑ Volar Plating
∑ Modern Era: Improved Technology in Internal Fixation — System Specific
— Low Profile Dorsal Plates – Fiddle Factor
– Forte - Carter (22), Pi Plate - Hastings/Jupiter (23) – Hardware Fixation
— Fragment Specific Approach – Medoff (20) – Self-tapping Screws
— Volar Fixed Angle Plates Understand Characteristics of Osteoporotic Fractures Which
– Tine Plates – Putnam (24) Confound Treatment
– Fixed Distal Pegs – Orbay (25) “The silent crippler. . . “
– Fixed with Variability (Everybody) Clinical Problems of Osteoporotic Wrist Fractures
∑ Modern Era: Improved Adjunctive Treatment ∑ Healing - rare
— PMMA: Charnley (26) ∑ Maintaining reduction
— Calcium Phosphate Cements & Materials - Norian ∑ Restoring function
SRS, ß-TCP, etc (27)
— Calcium Sulfate - temporary void filler (?) Typical Osteoporotic Fracture = Colles’ Fracture (2)
∑ Modern Era: Corrective Osteotomy – Fernandez (28) ∑ “True” Colles
∑ Modern Era: Treatment Outcomes — Extra-articular
— Disabilities of Arm, Shoulder, & Hand - DASH (29) — Fails in Tension (Bending)
— SF-36, SF-12 (30, 31) — Low Energy
— The Physical Activity Scale for the Elderly PASE (32) ∑ Stable if—
— Dorsal Periosteum Intact
Pros and Cons of Internal Fixation vs. More “Traditional” — Comminution minimal
Means (33) ∑ Unstable if—
PROS — Displaced Intra-articular
∑ Anatomic Reduction Roughly Parallels Restoration of — Comminution high
Function — Bone quality is low
— “Form Ever Follows Function” (Louis Henri Sullivan,
architect) Atypical Fracture
∑ High Energy
∑ Different Fracture Pattern — Osteotomy

— Shear, Shaft, Carpal Involvement – Closing vs. Opening Wedge
∑ All the Problems of Young Adult Fractures and More! – Graft vs. substitute
– Fusion
Complications
— (Wish you had never operated!)
“There is no problem so bad that cannot be made worse with
surgery” --Jack Hughston, the “father” of sports medicine Treatment Decisions
∑ Predisposing Factors ∑ Patient factors
SYMPOSIA HAND/WRIST
— Failure to Recognize ∑ Define Injury
Problem ∑ Fracture Fragments
– Reduce (adequately) ∑ Associated Injuries
– Provide stability - ∑ Assess Stability
Hardware
Conclusions: Is Internal Fixation The New Currency of
sufficient/appropriate
Treatment?
– Address fragments
∑ The Gold Standard is a Quasi-Standard
– Loss of Reduction
— historical “modified gold bullion standard” until
– Address cortical and can-
1978
cellous bone
— now gold is a commodity, not a basis of currency
∑ Problems
(fluctuates with the market)
— Malunion
∑ Internal Fixation: Enhanced Distal Radius Fracture
– Clinical complaints
— Treatment
∑ distal ulna, lack of supination
— Recognition
— Hardware problems
∑ A Methodology, not an Absolute
– Pins backing out
∑ So Don’t Throw Out the . . .
– Screws loosening
— Plaster
– Self-tapping screws
— External Fixator
— Other typical problems
— Rush Rods
– CTS, Stiffness, CRPS (RSD), Wound Healing
— History Articles & Charnley’s Book
∑ Treatment Options
— Address ulna (leveling, Sauve-Kapandji, resection)
REFERENCES 17. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures.
1. Pouteau C. Memoire, contenant quelques reflexions sur quelques fractures de l'a- Injury. 1989 Jul;20(4):208-10.
vant-bras sur les luxations incomplette du poignet sur les diastasis. In: Oeuvres 18. McMurtry R, J Jupiter: Fractures of the distal radius. In B Browner, J Jupiter, A
Posthumes de M Pouteau. Paris: Ph.-D. Pierres, 1783 Levine, P Trafton: Skeletal Trauma. Philadelphia: WB Saunders, 1993
2. Colles A. On the fracture of the carpal extremity of the radius. Edinburgh Med 19. Fernandez, Diego L, and Jesse B Jupiter: Fractures of the Distal Radius. A Practical
Surg J. 1814;10:181-6. Approach to Management. New York: Springer, 1996
3. Goyrand G: Memoire sur les fractures de l'extrémité inférieure du radius qui 20. Rikli DA, Regazzoni P.: Fractures of the distal end of the radius treated by inter-
simulent les luxations du poignet. Gaz Med 3:664-667, 1832 nal fixation and early function. A preliminary report of 20 cases. J Bone Joint
4. Barton, John Rhea: Views and treatment of an important injury of the wrist. Surg Br. 1996 Jul;78(4):588-92
Medical Examiner 1:365-368, 1838 21. Medoff RJ, Kopylov, P. Open reduction and immediate motion of intra-articular
5. Smith, Robert W: A treatise on Fractures in the Vicinity of Joints, and on Certain distal radius fractures with a fragment specific fixation system. Arch Am Acad
Forms of Accidental and Congenital Dislocations. Dublin: Hodges and Smith, Orthop Surg 2: 53-61, 1999
1847, p. 162 22. Carter PR, HA Frederick, GF Laseter: Open reduction and internal fixation of
6. Cotton, Frederic J: The Pathology of Fracture of the Lower Extremity of the unstable distal radius fractures with a low-profile plate: a multicenter study of 73
Radius. Annals of Surgery, 32:194-218, 1900 fractures. J Hand Surgery, 23A:300-307, 1998
7. Galeazzi, Ricardo: Concerning a particular syndrome of injury of the forearm 23. Ring D, Jupiter JB, Brennwald J, Buchler U, Hastings H II: Prospective multicenter
bones. Arch orthop Unfallchir, 35:557-562, 1934 (translated by D. Pevsner) trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg 22A:777-
84, 1997
8. Charnley, John: The Closed Treatment of Common Fractures. 3rd ed. Edinburgh:
Churchill Livingstone, 1950, 1961 24. Gesensway D, Putnam MD, Mente PL, Lewis JL.Design and biomechanics of a
plate for the distal radius.J Hand Surg [Am]. 1995 Nov;20(6):1021-7.
9. Hughston JC: Fracture of the distal radius shaft. Mistakes in management. J Bone
Joint Surg 1957; 39A: 249-264. 25. Orbay JL.The treatment of unstable distal radius fractures with volar fixation.
Hand Surg. 2000 Dec;5(2):103-12.
10. Grana WA, Kopta JA. The Roger Anderson device in the treatment of fractures of
the distal end of the radius.. J Bone Joint Surg Am. 1979 Dec;61(8):1234-8 26. Charnley J: The healing of human fractures in contact with self-curing acrylic
cement. Clin Orthop 1966; 47:157-63
11. Agee, John M. Distal radius fractures. Multiplanar ligamentotaxis. Hand Clin
9:577-85, 1993 27. Cassidy C, Jupiter JB, Cohen M, Delli-Santi M, Fennell C, Leinberry C, Husband
J, Ladd A, Seitz WR, Constanz B. Norian SRS cement compared with convention-
12. Older, TM, EV Stabler, WH Cassebaum: Colles' fracture: Evaluation and selection al fixation in distal radial fractures. A randomized study. J Bone Joint Surg Am.
of therapy. J Trauma 5:469-476, 1965 2003 Nov;85-A(11):2127-37.
13. Frykman, Gösta: Fracture of the distal radius including sequelaeÑshoulder-hand- 28. Fernandez DL. Radial osteotomy and Bowers arthroplasty for malunited fractures
finger syndrome, disturbance in the distal radio-ulnar joint and impairment of of the distal end of the radius.. J Bone Joint Surg Am. 1988 Dec;70(10):1538-51.
function. Acta Orthop Scand (suppl) 1-155, 1967
29. Hudak PL, PC Amadio, C Bombardier: Recent developments and future issues in
14. Fernandez, Diego L: Avant-bras segment distal. In: Classification AO des Fracture the use of health status assessment measures in clinical settings. Med Care
des Os Longs, ME Müller, ed. Berlin: Springer-Verlag,, 106-115, 1987 30:MS23-MS41, 1992
15. Missakian M, WP Cooney, PC Amadio, HL Glidewell: Open reduction and inter- 30. Ware JE Jr, CD Sherbourne: The MOS 36-item short-form health survey (SF-36).
nal fixation for distal radius fractures. J Hand Surgery 17A:745-755, 1992 I. Conceptual framework and item selection. Med Care 30:473-483, 1992
16. Melone Charles P Jr: Articular fractures of the distal radius. Orthopedic Clinics of
North America 15:217-236,1984
217
31. Ware JE Jr, M Kosinski, SD Keller: A 12 item short-form health survey, construc- 35. Handoll HH, Madhok R: Surgical interventions for treating distal radial fractures
tion of scales and preliminary tests of reliability and validity. Med Care 34::220- in adults. Cochrane Database Syst Rev. 2001;(3):CD003209.
233, 1996 36. Handoll HH, Madhok R, Howe TE.Rehabilitation for distal radial fractures in
32. Washburn RA, et al: The Physical Activity Scale for the Elderly (PASE): develop- adults. Cochrane Database Syst Rev. 2002;(2):CD003324.
ment and evaluation. J Clin Epidemiol. 1993 Feb;46(2):153-62 37. Hegeman JH, Oskam J, Vierhout PA, Ten Duis HJ. External fixation for unstable
33. Ladd AL, ed: Fractures of the Distal Radius: A Visual Approach. CD-ROM, intra-articular distal radial fractures in women older than 55 years. Acceptable
American Society for Surgery of the Hand, 2001. functional end results in the majority of the patients despite significant second-
ary displacement. Injury. 2005 Feb;36(2):339-44.
SYMPOSIA HAND/WRIST
34. McQueen MM. Redisplaced unstable fractures of the distal radius. A randomised,
prospective study of bridging versus non-bridging external fixation. J Bone Joint 38. Kambouroglou GK, TS Axelrod: Complications of the AO/ASIF titanium distal
Surg Br. 1998 Jul;80(4):665-9. radius plate system (pi plate) in internal fixation of the distal radius: a brief
report. J Hand Surgery 23:737-741, 1998
CONTEMPORARY PERSPECTIVES ON THE ROLE OF STABLE

INTERNAL FIXATION WITH OSTEOPOROTIC WRIST FRACTURES
Jesse B Jupiter, MD
SYMPOSIA HAND/WRIST
I. The Issues 1. Studies have emphasized the need for placement of
A. Aggressive push toward internal fixation although little the distal most screws or pegs just beneath the
evidence to support this subchondral bone of the articular surface to achieve
B. How to try to explain this maximum benefit of volar fixed angle plates
1. The patient—changing epidemiologic patterns C. Rationale for volar plate fixation especially for unstable
2. Greater understanding of injury patterns and anatomy Colles’ fxs
3. New anatomically shaped implants with angular 1. Ease of anatomic reduction due to volar cortex less
stable fixation comminuted than dorsal side
4. Patient rated outcomes 2. Less problems with overlying soft tissues
3. Palmar cortex stronger and flatter than dorsum
II. Patient Factors 4. Early return to hand and independent upper limb
A. According to 2000 US census pts >65 yrs = 12% function
population. This is projected to increase to almost 20% 5. Diminished need for follow-up visits and therapy
(70 million) by 2030. 6. Decreased risk of late malunion
B. Numerous studies demonstrate a trend to older 7. Potential cost savings remain to be evaluated
individuals leading healthier and more active lives.
C. 1999 US Census demonstrated 23% persons >65 yrs V. Outcome Measures
lived alone and 41% >75 yrs lived alone. A. Emphasis on patient-rated outcomes reflects a global
D. Despite living longer and healthier, the continued high shift in how operative treatments are evaluated.
prevalence of osteopenia and osteoporosis places this B. General tools have included SF-36 and DASH
segment of population at a high ris for distal radius C. The Patient Rated Wrist Evaluation (PRWE) more specific
fracture. to distal radius fractures
D. Specific to the elderly, it has become evident that:
III. Understanding the injury Age is not a good indicator or functional needs or
A. Greater research has illuminated more regarding the activity level
mechanisms of injury, structural anatomy, radiocarpal Activity level poorly reflected in many outcome tools
stability, carpal kinematics, and distal radioulnar joint E. The Physical Activity Scale for the Elderly (PASE) validated
function. for the elderly activity function and outcome and was used
B. The structural anatomy of the volar surface of the distal in a restrospective study by Jupiter et al in evaluation of
radius and the fact that even in displaced dorsal Colles’ internal fixation in elderly patients with successful return
fracture, the volar cortex is generally without comminution to function based on this quantitative scale
has stimulated many to realize volar surgery is more
predictable and with less soft tissue complications. VI. What is the evidence?
A. Existing Level 1 evidence inconclusive in randomized
IV.Angular Stable Fixation prospective studies however have not looked carefully at
A. Critical Features of angular stability in general volar locked plating.
1. stability not achieved by the creation of friction B. From studies to date:
between the plate and bone as in traditional screw Internal fixation yields radiographic results and two yr
fixation which depends upon good quality of bone. clinical results comparable with augmented external
2. stability is achieved by mechanical bridging of the fixation
bone and load-bearing occurs through the locked
screw-plate construct. VII. Complications
3. locking-head screws do not rely on the bone thread for A. Although volar locking plates may limit tendon irritation,
purchase they have not eliminated them.
4. screws that lock into the plate prevent loosening B. Irritation and rupture of the FPL, FCR, and even EPL from
within the implant prominent screw tips have been reported.
B. Biomechanical features of volar plate fixation C. Contracture from ischemia of the pronator quadratus
D. Neurologic complications
REFERENCES 6. Drobetz H et al. Volar fixed angle plating of distal radius extension fractures—a
1. Chen N, Jupiter JB. Current Concepts The Management of Distal Radius biomechanic study in a cadaveric model. J. Hand Surg 2006; 31: 615-22.
Fractures. J Bone Joint Surg. AM 2007; 89-A: 2051-62. 7. Washburn RA et al. The Physical Activity Scale of the Elderly (PASE): develop-
2. Rowe JW, Kahn RL. Successful Aging. New York: Pantheon Books, 1998. ment and evaluation. J. Clinical Epidemiol.1993; 46: 153-62.
3. Rozental T et al. Survival among elderly patients after fractures of the distal 8. Jupiter JB et al. Surgical treatment of redisplaced fractures of the distal radius in
radius. J Hand Surg 2002; 27:948-52. patients older that 60 years. J Hand Surg. 2002;27: 714-23.
4. Pechlaner S et al. Distal radius fractures and concomitant lesions. Experimental 9. Wright TW et al. Functional outcome of unstable distal radius fractures: ORIF
studies concerning the pathomechanism. Handchir Mikrochir Plast Chir 2002; with a volar fixed-angle tine plate versus external fixation. J Hand Surg 1999; 30:
34: 150-7. 289-99.
5. Orbay JL, Fernandez D. Volar fixed-angle plate fixation for unstable distal radial 10. Grindel SI et al. Biomechanical comparison of fixed-angle volar plate versus
fractures in the elderly. J Hand Surg 2004; 29:96-102. fixed-angle volar plate plus fragment fixation in a cadaveric distal radius fracture
model. J Hand Surg 2007; 32: 194-99.
219
FIXATION AUGMENTATION TECHNIQUES: WHEN AND HOW

Antonio Moroni, MD
The Problem B. PMMA

With osteoporotic wrist fractures, although the healing potential • Technically-demanding
SYMPOSIA HAND/WRIST
is normal, there is a high incidence of poor functional outcomes. • Time consuming

In these patients fracture re-displacement is quite common after • Increased cost
conservative treatment because of the inability of the fracture • Complications
ends to withstand axial compression. Similarly malunion is • Risk of inhibiting fracture healing
frequent following surgical fixation because of the inability of • Difficult removal
the implants to maintain fracture reduction over the time needed Technique # 1
for complete fracture healing. • Drill hole
• Fill with PMMA
Because of the poor bone quality in the elderly patients with wrist
• Allow to set
fractures, screw purchase is generally insufficient. It should also
• Re-drill hole
be considered that screw fixation deteriorates inevitably over
• Tap and implant screw
time. This deterioration is particularly severe in cancellous bone.
Technique #2
• Drill hole
I. What are fixation augmentation techniques
• Fill with PMMA
Fixation augmentation techniques can be defined as surgical
• Implant screw before cement sets
procedures aimed at increasing implant stability. Our
PMMA fixation effective in Colles’ fractures that re-
classification of fixation augmentation techniques include
displaced after closed reduction. (3,10)
augmentation with: polymethylmethacrylate (PMMA), bone
C. Bone grafts
grafts, bone graft substitutes, calcium phosphate cements,
Cancellous/Cortical Autografts
coatings, modified implants and other innovative concepts.
• Enhance osteogenic response
When managing fragility fractures, the diagnosis of • Generally harvested from patient’s iliac crest
osteoporosis is the first hurdle that the orthopaedic surgeon • Same biological potential as normal healthy bone
encounters. Among the several diagnostic tools available, dual • Increased morbidity
energy x-ray absorptiometry (DXA) scanners have been • Structural support to maintain fracture reduction
identified as the gold standard since 1994 by the World Health Allografts
Organization. Regrettably, when treating elderly fracture • Mechanical potential for improved fracture stability
patients, the use of DXA scanners prior to surgery is not • Used opposite to the plate for improved screw
common practice. This imposes a limitation for the purchase (15)
orthopaedic surgeon who is lacking crucial data concerning • No donor-site morbidity
patient bone quality. Knowing patient bone quality prior to • Theoretical possibility for disease transmission
surgery would be useful not only for the administration of the Prospective randomized study of 17 unstable distal
correct medical therapy, which is effective for secondary forearm fractures (2)
fracture prevention, but also for selecting the correct surgical • Cancellous allografts and external fixation
treatment, including the use of fixation augmentation • Impacted at the fracture site to fill the gap
techniques. When treating wrist fractures in patients over 65 • Results: 3 excellent; 8 good; 6 fair
years old, DXA of the contralateral wrist should be taken prior • Cancellous bone allografts is a useful adjunct to
to surgery. external fixation
• Effective and offer advantages over standard
Existent problems focus on the implant in retaining good
autografting techniques
fixation at the bone-screw interface. Currently, there are no
D. Bone-graft Substitutes CP Granules/Blocks
implants specifically designed for osteoporotic bone fixation.
• Several FDA approved products
All the available implants, including screws are designed for
• High and low crystallinity mixture of hydroxyapatite
normal healthy bone.
• Slow resorption
• Osteointegration
II. When fixation augmentation techniques should be
• Low mechanical strength
considered
• Paucity of comparative studies with autografts
• Osteoporotic bone (DXA BMD T-Score < -2.5 SD)
• No objective data showing direct comparisons
• Unstable fractures
between different products
• Fractures which re-displaced after conservative treatment
25 Unstable Distal radius fractures (8)
• Surgically treated fractures with poor screw purchase
• Dynamic external fixation augmentation with
and/or large metaphyseal defects
hydroxyapatite spacer
III. What is the role of fixation augmentation techniques? • Results: 24/25 excellent (Gartland and Werely’s
A. Advantages demerit Point)
• Structural support • Conclusions: “Hydroxyapatite was useful as a
• Improved fixation substitute for bone graft”
• Improved fracture stability 21 Distal Radius Fractures (13)
• Early recovery • External fixation and K-wires augmented with
• Reduced morbidity Coralline Hydroxyapatite
• Reduced complications
• Results 17/18 good or excellent (Gartland and • Higher than the corresponding insertion torque at
Werely’s demerit Point) each pin position in the group managed with
• Conclusions: “Coralline hydroxyapatite effective at hydroxyapatite-coated pins (p = 0.001).
maintaining articular surface reduction when • Good fixation with HA coated pins regardless of pin
combined with external fixation and K-wires” insertion torque
E. Calcium phosphate cements • Pin-track infection:
Advantages 2 patients with standard pins
SYMPOSIA HAND/WRIST
• Injectable 0 patients with HA-coated pins
• Non-exothermic • No difference in pain at pin removal
• Structural support G. Why do we need Modified Implants?
• Compressive strength higher than cancellous bone • Current implants do not perform well
• No morbidity • All available implants, including screws, designed for
• Good bone penetration normal bone
• No adverse biological effects • No implants specifically designed for fixation of
Burning Issues osteoporotic bone
• Remodelling capacity? New screw design (16,17,18)
• Resorption? • Smaller pitch
• Mechanical strength? • Greater screw thread angle
• Long-term effects? • Smaller core diameter
• Cost effective compared to the standard treatment? • Interlocking screw
• Reducing the need for external and internal fixation? • Expandable screw
• Reducing healing time? • Cannulated ported screws
Prospective Randomized Study (5) Modified Implants
• -110 patients IM implants
• -55 cast • Minimally-invasive technique: 2 cm incision over the
• -55 Norian SRS and cast for 2 weeks radial styloid
• Outcome: Function • Zero profile technology eliminating soft tissue
• -Norian SRS 82% satisfactory complications
• -Cast 56% satisfactory • Fixed angle support with locking pegs
• Radiologic Fixed angle plates
• -Norian 18% malunion • Unicortical self-drilling/tapping screws
• -Cast 42% malunion • Threaded plate holes
At 1 year more satisfactory results and lower • Plate and screws form single mechanical unit
malunion rate in Norian group. • HA-coated screws could improve results even further
Prospective randomized study of 323 distal radial H. Innovative concepts
fractures (1) Osteoinductive Molecules (19)
• Clinical differences at six and eight weeks post-op • Osteogenic protein-1 (OP-1, BMP-7)
• Norian vs. Cast or External fixation • Bone Morphogenic Protein-2 (BMP-2)
• Better function at 6-8 weeks in Norian group, no • Potential for increased local bone density
clinical differences at 1 year • Potential for accelerated fracture healing
• Loss of reduction in 37% Pharmacological Agents
• Cement in extraosseous locations in 70% • Bisphosphonates (Alendronate, Ibandronate,
• Extraosseous material disappeared in 83/112 patients Zolendronic Acid)
in 1 year • PTH
Highlights • Animal and clinical studies have shown that
• CP cement alone without additional fixation is not bisphosphonates improve early screw fixation in both
satisfactory for metaphyseal bone defects in wrist cortical and cancellous bone (5, 11, 20)
fractures Combined Strategies
F. Screw coatings • Cements loaded with osteoinductive growth factors,
• Highly crystalline CP layers cells and drugs
• Well bound to metals • Coated fracture fixation implants loaded with
• Stable in vivo osteoinductive growth factors, cells and drugs
• Optimal fixation and osteointegration ability with
Conclusions
hydroxyapatite-coated screws
• Some effective FAT are already in clinical use
• Reduced incidence of screw loosening
• Others will be available in the near future
• Reduced incidence of pin-track infection
• Tool the surgeon should not disregard when treating
Prospective randomized study (7)
osteoporotic wrist fractures
• 20 female patients with osteoporotic wrist fracture
treated with ex fixation
• Randomized to receive either standard tapered pins or
hydroxyapatite-coated tapered pins.
Mean extraction torque:
• Lower than the corresponding insertion torque at each
pin position in the group treated with standard pins
(p < 0.05)
221
REFERENCES: 10. Schmalholz A. External skeletal fixation versus cement fixation in the treatment
1. Cassidy C, Jupiter JB, Cohen M, Delli-Santi M, Fennell C, Leinberry C, Husband of redislocated Colles’ fracture. Clin Orthop Relat Res 1990; (254): 236-41.
J, Ladd A, Seitz WR, Constanz B: Norian SRS cement compared with convention- 11. Skoglund B, Holmertz J, Aspenberg P: Systemic and local ibandronate enhance
al fixation in distal radial fractures. A randomized study. J Bone Joint Surg Am screw fixation. J Orthopaedic Research 2004; 22: 1108-1113.
2003; 85-A (11): 2127-2137. 12. Stromse, K. Fracture fixation problems in osteoporosis. Injury 2004; 35 (2), 107-
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unstable distal radius fractures with cancellous allograft and external fixation. J 13. Wolf SW, Pike L, Slade JF III, Katz LD: Augmentation of distal radius fracture fixa-
Hand Surg 1999. 24 (6): 1269-78
SYMPOSIA HAND/WRIST
tion with coralline hydroxyapatite bone graft substitute. J Hand Surg Am 1999;
3. Kofoed H. Comminuted displaced Colles’fractures. Treatment with 24: 816-827.
intramedullary methylmethacrylate stabilization. Acta Orthop Scand. 1983; 54 14. Zimmerman R, Gabl M, Lutz M, Angermann P, Gschwenter M, Pechlaner S.
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146. Arch Orthop Trauma Surg 2003; 123: 22-27.
5. Miyaji T, Nakase T, Azuma Y, Shimizu N, Uchiyama Y, Yoshikawa H: Alendronate 15. Moroni A, Caja VL, Sabato C, Rollo G, Zinghi G J. Composite bone grafting and
inhibits bone resorption at the bone-screw interface. Clin Ortho Relat Res 2005; plate fixation for the treatment of nonunions of the forearm with segmental
430: 195-201. bone loss: a report of eight cases. J Orthop Trauma. 1995;9(5):419-26.
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7. Moroni A, Faldini C, Marchetti S, Manca M, Consoli V, Giannini S. Improvement Bone. Internal Fixation in Osteoporotic Bone, Thieme Med. Publ., New York,
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Surg 2001 26 (5). 923-930.
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radius with a remodellable bone cement: a prospective, randomized study using
Norian SRS. J Bone Joint Surg [Br] 2000 82 (6): 856-63.
BONE HEALTH ACROSS THE LIFE SPAN

Aenor J. Sawyer, MD
I. Background Hormonal influences

A. Osteoporosis: BMI
SYMPOSIA HAND/WRIST
Definition - “a skeletal disorder characterized by C. Chronic Illness
compromised bone strength, predisposing to an D. Medications
increased risk of fracture,”
VI. Bone Health in Childhood and Adolescence
B. An Epidemic:
A. The “window of opportunity” to prevent osteoporosis
Expected that 12 million people in US > 50yo diagnosed
B. Critical for 2 reasons
w/ OP by 2010
Development of adequate peak bone mass
C. Fragility fractures
Potential to decrease childhood fractures
> 1.5 million Americans sustain osteoporotic fractures
each year VII. Worrisome trends
Enormous impact on individual and society A. Increasing incidence of childhood fxs
B. Association of fracture with low BMD, high BMI, poor
II. Major focus on osteoporosis has been in adults
nutrition
A. Postmenopausal women
C. Bone building behaviors are worsening
Estimated 30–50% of women have a lifetime risk of
Nutritional trends
sustaining fracture related to OP
Decreasing physical activity
Women with low trauma wrist or spine fracture early in
Obesity
life may be twice as likely to have a hip fracture later in
D. Adolescent vulnerability
life
Peak height velocity vs. peak bone acquisition curves
B. Men
Behaviors
Estimated: 15–30% of men have a lifetime risk of
sustaining fragility fracture VIII. How can we optimize bone health in childhood and
Men more likely than women to die after a hip fracture. adolescence?
Much more likely to become disabled and need long- A. Nutrition – updates on calcium, vitamin D, other dietary
term medical care. influences
Men who sustain a wrist fracture have increased risk for Recommendations
hip fracture. Effectiveness
C. Pre-menopausal women B. Physical Activity – updates on exercise intervention
Low trauma wrist fractures in pre-menopausal women strategies
associated with low BMD and increased risk for
IX. Considerations in assessing bone density
subsequent fractures
A. Measurement techniques:
III. Skeletal health across the life span DXA: currently clinical gold standard in adults and
A. Bone acquisition and loss curve children
B. Key Points: B. Limitations of DXA
Childhood / Adolescence C. Concerns with DXA in children
Peak bone mass D. When to order a DXA?
Early adulthood
X. What can orthopedists do?
Midlife
A. Patients with fracture history.
Late adulthood
1. Assess underlying causes of fracture:
C. Fracture threshold is complex, (not just BMD)
a. risk factors for low bone mass
D. Fracture risk assessment tool forthcoming from WHO in
b. fall risk
next few months
c. risk for subsequent fx
IV. Peak bone mass 2. Communicate with PMD
A. Definition: maximal bone mass accrued by end of B. Patients with acute fracture
skeletal maturation (30 yr) 1. Initiate assessment – risk factor hx, imaging, labs
80-90% achieved by end of 2nd decade, but site specific 2. Appropriate interventions (non-pharma and pharma)
B. Importance of peak bone mass on adult osteoporosis and 3. Educate
fragility fractures Kreipe Model 4. Refer as indicated and communicate with PMD
Need longitudinal studies C. Optimize bone development in childhood and
adolescence
V. Determinants of bone mass
When treating pediatric patients with or without fracture
A. Non-modifiable: Heredity, ethnicity, gender, age
history:
B. Modifiable:
1. Assess fracture history and risk factors for skeletal
Nutrition: Calcium, vit D, calories, protein, other
health deficits
contributing factors
2. Educate/provide resources to parent and child on
Physical Activity
bone building behaviors
223
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225
SPINE PROBLEMS IN YOUNG ATHLETES (N)

S Y M P O S I A P E D I AT R I C S
Moderator: David L. Skaggs, MD, Los Angeles, CA

Description: The young athlete faces unique spine problems. Without knowledge of these
problems delay in diagnosis and sub-obtimal care could result.
I. History, physical, and imaging

David L. Skaggs, MD, Los Angeles, CA
II. C-spine issues

Laurel C. Blakemore, MD, Washington DC
III. Epidemiology/ high risk sports/ Return to sport after spine surgery
Daniel J. Sucato, MD, Dallas, TX
IV. Prevention, Bracing and Rehabilitation

Angela D. Smith, MD, King of Prussia, PA
V. Controversies in the treatment of Spondylolysis/Spondylolisthesis

Behrooz A. Akbarnia, MD, La Jolla, CA
VI. Question Session
VII. Case discussions with panel

John M. Flynn, MD, Philadelphia, PA
VIII. Question Session
SPINE PROBLEMS IN YOUNG ATHLETES: AAOS SYMPOSIUM

David L. Skaggs, MD
HISTORY, PHYSICAL AND IMAGING • Pain with deep palpation of midline bone vs. para-midline
soft-tissues
History:
• Stiff-legged gait of tight hamstrings
∑ Sports Related
60 second spine-neuro exam:
— Can you still participate?
— Hop on one foot at a time
— Is it activity related?
— Walk on heels
– Recent increase in training?
— Reflexes – umbilicus, patella tendon, Achilles tendon
– Does pain improve with period of rest?
— Quick ankle dorsiflexion to assess muschle tone and
– Overuse from specific activity or present with many
clonus
activities
— Sensation of L3-S1
• Red Flags
— Popliteal angle
— Night pain – that wakes you up at night?
— Bowel/bladder/ejaculation problems Imaging:
— Radiation to limbs? • X-ray first
— Progressively worse over time — Spondylolysis/listhesis - lateral often best
— Feelings of weakness or clumsiness — Endplate fx – often misread
• Psychological • MRI
— Does the parent talk more than the child? — notorious for missing spondylolysis
— Is this a way out of the sport for the child? — good for soft-tissue, tumors
— In adolescents those with psychological difficulties 60% — early stress fracture
more likely to experience low back pain • Bone Scan with SPECT
— Multiple locations of pain make chance of discovering — impending pars fractures
treatable pathology in spine less likely — may be overly sensitive for atheletes with active stress and
remodeling
Physical:
— lumbosacral transitional vertebrae – missed on
• Pain exacerbated by
radiographs, SPECT may show activity
— Trunk flexion – standard mechanical
— a great localizer
— Trunk extension – spondylolysis/listhesis
• CT
– Localized back pain most exacerbated by extension is a
— Best defines Spndylosysis
posterior element fracture until proven otherwise
— Can show healing over time
• Finger test for localization
REFERENCES 4. Quantitative Assessment with SPECT Imaging of Stress Injuries of the Pars
1. L. J. Micheli and R. Wood, Back pain in young athletes. Significant differences Interarticularis and Response to Bracing, Journal of Pediatric
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Vol. 149 No. 1, January 1995 5. Gareth T. Jones, MSc.Econ*, , Kath D. Watson, PhD*, Alan J. Silman, MD*,
2. Leonard P. Connolly, MD1, Pierre A. d’Hemecourt, MD2, Susan A. Connolly, Deborah P.M. Symmons, MD* and Gary J. Macfarlane, PhD*, Predictors of Low
MD1, Laura A. Drubach, MD1, Lyle J. Micheli, MD2 and S. Ted Treves, MD1, Back Pain in British Schoolchildren: A Population-Based Prospective Cohort
Skeletal Scintigraphy of Young Patients with Low-Back Pain and a Lumbosacral Study PEDIATRICS Vol. 111 No. 4 April 2003, pp. 822-828
Transitional Vertebra The Journal of nuclear medicine, Vol. 44 No. 6, 909-914, 6. R. S. D. Campbell, A. J. Grainger, I. G. Hide, S. Papastefanou and C. G.
2003. Greenough, Juvenile spondylolysis: a comparative analysis of CT, SPECT and
3. Sward L, Hellstrom M, Jacobsson B, Nyman R, Peterson L: Disc degeneration and MRI, Skeletal Radiology, Volume 34, Number 2 / February, 2005
associated abnormalities of the spine in elite gymnasts:Amagnetic resonance
imaging study. Spine 1991;16:437-443.
227
SPINE PROBLEMS IN YOUNG ATHLETES

PART II C-SPINE ISSUES
Laurel Blakemore, MD
I. Anatomy IV. On-Field Evaluation

Different under age 8
V. Return to play
Normal variants
VI. Prevention
II. Downs Syndrome
Return to play
III. Injury Patterns
Spearing
Stingers
EPIDEMIOLOGY/HIGH RISK SPORTS/

RETURN TO SPORT AFTER SURGERY
Daniel J. Sucato, MD MS
Epidemiology: — High risk sports
• Back Pain in Adolescent Athletes vs Adults — Acute pain onset
Adolescent Athlete Adult — Hamstring tightness
Spondylolysis 47% 5% — Long-term follow-up nonoperative treatment
Discogenic 11% 48% – 91% good or excellent outcome scores at 11 years
Muscle tendon strain 6% 27%
Spinal stenosis/osteoarthritis 0% 10% — Following surgical treatment
• Spondylolysis – Improvement in Oswestry Disability Index and short
— Incidence = 4.4-6% form 36
— Risk Factors – 51% were soccer players
– Hyperextension sports – gymnastics, tennis, football, – 82% returned to previous sport
pole vaulting, – Buck > Scott technique
• 43% divers • Spondylolisthesis
• 30% wrestlers — SRS members response
• 23% weight lifters – Decision to return to sports based on
• 17% gymnasts • Radiographic fusion mass 85-88%
• 17% rowers • Time since surgery 92-94%
– Familial – autosomal dominant vs. recessive • Patient’s age-moderate importance
• Spondylolisthesis • The intended sport
— Prevalence: Adults = 6%, Eskimos – 50% – Return to activities
— Risk Factors • Gym-6 months 35-40%, 1 year 60-65%
– Spondylolysis • Noncontact-6 months 45%, 1 year 34%
– Deep-seated L5 with large transverse processes risks • Contact-6 months 20%, 1 year 36%, advised
L4-5 spondy against-
• Lumbar Disc Degeneration/Herniation – Sports most commonly forbade
— Degeneration • Gymnastics
– 75% of elite gymnasts vs. 31% of non-athletes • Football & rugby
– Location is dependent on sport type • Wrestling
• Weight lifters-upper lumbar • Weight lifting
• Soccer players-L4-5 • Skydiving; bungee jumping
— Incidence dependent on proper training techniques • Scoliosis
– Volleyball players – good technique 21% degenerative — Return to sports following no treatment or conservative
changes vs. 62% with poor technique treatment
• Low Back Pain – Less athletic activities than controls
— Lifetime prevalence – No correlation to curve size
– Wrestlers 59% vs 31% for age-matched controls – Pain and pain function inversely correlates with sports
– Gymnasts 79% vs. 38% age-matched controls activity
– Adolescents 46% vs. 18% non-athletes — Return to sports following surgical treatment
– Gymnasts most likely to have severe pain – Less activity than controls
— Cause – Curve size inversely correlated with sports activity
– Muscle strain- 27% of adolescent athletes – The extent of fusion does not correlate with sports
– Sprain-stretch at one or more spinal ligaments activity
• Interspinous ligament most common — Survey of SRS members: When to return to athletics
– Associated with endplate changes on lateral x-rays following surgery
• Sacral Stress Fracture – Gym: 6 months (38%), 1 year (44%)
— Uncommon, but more common in females – Noncontact: 6 months (40%)
— Nearly exclusively long distance runners – Contact: 1 year (61%), 11% advised against
— Insidious onset of asymmetric low back pain – Collision: 1 year (32%), Advised against (36%),
— No history of acute injury Forbade (24%)
— “Hopping test” pain with jumping up and down in – Sports most commonly forbade:
affected leg • Football
• Gymnastics
Return to Sports: • Collision
• Spondylolysis • Trampoline
— Following nonoperative treatment — Did distal fusion affect recommendation to return to
– 87.5% at 5 months in adults sports
– 80% at 6 weeks in adolescents – Recommendations were the same if fusion was L2 to
• Worse outcome: L4
229
– If fusion to L4 or lower recommendations were — Following surgical treatment

different – 80-90% return to varsity sports
• Disc Herniation – SF-36 scores are lower before and after surgery
— Following conservative treatment compared with no scoliosis controls
– 79% returned to original sport by 5 months — Following epidural injection
– Intensity of sport did not influence decision to return – 40-50% return to sports
to sports
– Only correlation – severity of symptoms prior to
treatment
REFERENCES: 11. Torg JS. Trampoline-induced quadriplegia. Clin Sports Med 1987;6:73-85.
1. Muschik M, Hahnel H, Robinson PN, et al. Competitive sports and the progres- 12. Ikata T, Miyake R, Katoh S, et al. Pathogenesis of sports-related spondylolisthesis
sion of spondylolisthesis. J Pediatr Orthop 1996;16:p364-9. in adolescents. Radiographic and magnetic resonance imaging study. Am J Sports
2. Micheli LJ. Back injuries in gymnastics. Clin Sports Med 1985;4:p85-93. Med 1996;24:p94-8.
3. Iwamoto J, Takeda T, Wakano K. Returning athletes with severe low back pain 13. Morganti C. Recommendations for return to sports following cervical spine
and spondylolysis to original sporting activities with conservative treatment. injuries. Sports Med 2003;33:563-73.
Scand J Med Sci Sports 2004;14:346-51. 14. Micheli LJ, Wood R. Back pain in young athletes. Significant differences from
4. Miller SF, Congeni J, Swanson K. Long-term functional and anatomical follow-up adults in causes and patterns. Arch Pediatr Adolesc Med 1995;149:p15-8.
of early detected spondylolysis in young athletes. Am J Sports Med 2004;32:928- 15. Iwamoto J, Takeda T, Sato Y, et al. Short-term outcome of conservative treatment
33. in athletes with symptomatic lumbar disc herniation. Am J Phys Med Rehabil
5. Bono CM. Low-back pain in athletes. J Bone Joint Surg Am 2004;86-A:382-96. 2006;85:667-74; quiz 75-7.
6. Debnath UK, Freeman BJ, Gregory P, et al. Clinical outcome and return to sport 16. Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc
after the surgical treatment of spondylolysis in young athletes. J Bone Joint Surg degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic
Br 2003;85:244-9. Games. Br J Sports Med 2003;37:263-6.
7. d'Hemecourt PA, Zurakowski D, Kriemler S, et al. Spondylolysis: returning the 17. Wang JC, Shapiro MS, Hatch JD, et al. The outcome of lumbar discectomy in
athlete to sports participation with brace treatment. Orthopedics 2002;25:653-7. elite athletes. Spine 1999;24:570-3.
8. Rubery PT, Bradford DS. Athletic activity after spine surgery in children and ado- 18. Matsunaga S, Sakou T, Taketomi E, et al. Comparison of operative results of lum-
lescents: results of a survey. Spine 2002;27:423-7. bar disc herniation in manual laborers and athletes. Spine 1993;18:2222-6.
9. Parsch D, Gartner V, Brocai DR, et al. Sports activity of patients with idiopathic 19. Sakou T, Masuda A, Yone K, et al. Percutaneous discectomy in athletes. Spine
scoliosis at long-term follow-up. Clin J Sport Med 2002;12:95-8. 1993;18:2218-21.
10. Bennett DL, Nassar L, DeLano MC. Lumbar spine MRI in the elite-level female 20. Jackson DW, Rettig A, Wiltse LL. Epidural cortisone injections in the young ath-
gymnast with low back pain. Skeletal Radiol 2006;35:503-9. letic adult. Am J Sports Med 1980;8:239-43.
PREVENTION, BRACING AND REHABILITATION

Angela Smith, MD
I. Introduction wear brace 20-22 hrs/day, out of brace for non-

A. Causes of low back pain in adolescent athletes lumbar-extension PT
B. Bone scan findings 6. At discharge, expect:
a) Normal lumbar mobility
II. Prevention
b) Normal lower extremity flexibility
A. Never become bipedal
c) Ability to attain and maintain neutral spine position
B. Improve lumbar mobility
d) For high-level athlete should be able to do a “star”
C. Maintain flexibility of hip flexors and hamstrings
balanced position with good form, and double leg
D. Sufficient lumbopelvic stabilizer strength for the sport
lowering to an angle of 60 degrees with the exam
III. Bracing/spondylolysis healing table before the lumbar spine begins to lift off the
A. Brace types exam table
1. Anti-lordotic Boston overlap brace e) Appropriate sport-specific biomechanics
2. Lordotic brace
IV. Author’s recommendation
3. Semi-rigid corset
A. Pre-participation
4. Warm-n-form or other minimalist brace
1. Correct limited lumbar mobility
B. Overall protocols, including relative rest, PT
2. Restore normal hip flexor and hamstring flexibility; in
C. Return to sports
sports like gymnastics, need greater than normal
1. Most rapid successful return reported by Boston group
flexibility to meet the sport requirements
with anti-lordotic brace and PT; expect return to sport
3. Ensure sufficient lumbopelvic stability and good sport-
in 4-6 weeks; this is our experience as well
specific mechanics for the athlete’s sport and level
2. If no brace, most published protocols suggest 3
B. Injured
months out of sports initially, or longer if still
1. Begin isometric lumbopelvic stabilization exercises as
symptomatic
soon as able to do so without pain (usually almost
D. Healing
immediately); planks, bird dog, minimal pelvic tilt
1. To my knowledge, only published reports showing
2. Correct limited lumbar mobility; almost immediately
healing utilized bracing and decreased activity, at
can begin pelvic tilt, hip hike feeling vertebra-by-
minimum; healing can occur even athletes who are
vertebra mobilization
fully participating in their sport, with a brace
3. Stretch out lower extremity flexibility deficits
Rehabilitation
4. Out of sports until have brace; as soon as brace arrives,
2. Stretch out lower extremity flexibility deficits – those
most are already pain-free, so may gradually work into
with significant deficits should start here
sport, wearing the brace, as long as remain pain-free;
a) Iliopsoas Hamstrings Rectus femoris
wear brace 20-22 hrs/day, out of brace for non-
3. Strengthening
lumbar-extension PT
a) Begin isometric lumbopelvic stabilization exercises
5. PT complete when meet expectations shown above
as soon as able to do so without pain (usually
C. Healing
almost immediately, at first office visit); planks,
1. More likely to heal if no true cortical fracture, small
bird dog, minimal pelvic tilt
fracture gap without sclerotic bone at fracture gap,
b) Once some lumbar mobility is obtained, progress
and/or unilateral defect
to higher level abdominal and spine extensor
2. 3 months after beginning treatment (typically 2
strengthening, but always maintaining neutral or
months after get brace), repeat CT (may begin to
flexed lumbopelvic position
switch to special MRI sequences soon); if no sign of
c) Emphasize lower abdominals in this population
healing, consider adding electrical stimulation
4. Correct limited lumbar mobility
3. At 6 months, again repeat imaging; patient decision
a) Almost immediately can begin pelvic tilt
whether or not to continue treatment if not healing
b) Hip hike feeling vertebra-by-vertebra mobilization
4. My experience last 10 years, using this protocol, all
c) Cat-back
returned to sport, and to my knowledge all at same
5. Out of sports until have brace; as soon as brace arrives,
level (although I do not know if all were able to
most are already pain-free, so may gradually work into
maintain that level), at the time of discharge
sport, wearing the brace, as long as remain pain-free;
REFERENCES: 4. Treatment of symptomatic spondylolysis and spondylolisthesis with the modi-

1. Lumbar mobility and low back pain during adolescence: A longitudinal three- fied Boston Brace. Steiner ME, Micheli LJ, Spine 10:937-943, 1985
year follow-up study in athletes and controls. Kujala UM, Taimela S, Oksanen A, 5. Current evaluation and management of spondylolysis and spondylolisthesis.
Am J Sports Med 25:363-368, 1997 McTimoney CA, Micheli LJ, Curr Sports Med Rep 2:41-46, 2003
2. Union of defects in the parts interarticularis of the lumbar spine in children and 6. Young athletes with low back pain: skeletal scintigraphy of conditions other than
adolescents. The radiological outcome after conservative treatment. Fujii K, Katoh part interarticularis stress. Connolly LP, Druback LA, Connolly SA, Treves ST, Clin
S Sairyo K. JBJS Br 86:225-231, 2004 Nucl Med 29:689-93, 200
3. Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars
interarticularis. Debnath UK, Freeman BJ, Grevitt MP, Sithole J, Scammell BE,
Webb JK. Spine 32:995-1000, 2007
231
CONTROVERSIES IN THE TREATMENT OF

SPONDYLOLYSIS/SPONDYLOLISTHESIS
Behrooz A. Akbarnia, MD
Introduction with 3 month cessation and non-op treatment (brace, PT).

The etiology and symptoms of back pain is different in adoles- Those who didn't have 3 month sport cessation did worse [5].
cents than adults especially when we discuss spondylolysis and Exercises:
spondylolisthesis. Adolescent athletes with back pain have a • Lumbar extensor and abdominal muscles strengthening.
high rate of "true" posterior element pathology, especially • Lumbar spine and lower extremity range of motion.
spondylolysis, compared to adults and should be worked up Bracing indications: Acute or delayed symptomatic spondylol-
more aggressively (CT, MRI, etc) for back pain [1]. ysis or grade 1 spondylolisthesis and unilateral pars fracture.
• Retrospective review of 73 adolescent athletes treated
Athletes involved in activities associated with repetitive hyper-
between 1988-95 using Boston overlap brace. 80% did well.
extension such as gymnasts or football linemen are predisposed
Adolescents returning to “high-risk” sports were 5 times
to the development of spondylolysis. Combination of repetitive
more likely to do poorly compared to “low risk” sports.
axial loading and extreme hyperextension of the spine over-
Hamstring tightness and acute onset pain were associated
loads the posterior elements and predispose them to pars frac-
with poorer outcomes [6].
tures. Some of the patients may have concomitant spondylolis-
• Patients with spondylolysis showing greater signal intensity
thesis with spondylolytic type being the most common.
on SPECT had better outcome with bracing treatment than
Etiology and Natural history: did patients with lower intensity, indicating the benefit of
• Spondylolysis progresses more frequently during the growth early bracing [7].
period, whereas progression is rare afterward [2]. • Osseous union is greater in unilateral lesions and a high
• The growth plate—the site of least sheer resistance—likely percentage of patients are able to return to their activities
plays a role in why spondylolysis occur and progress during with nonsurgical treatment [8].
growth periods [2]. • Indication for surgery: Progression and failure of non sur-
• The pars begins to ossify at 12 to 13 weeks' gestation by gical treatment after 6 months
endochondral ossification. In the upper lumbar vertebrae, the • Pars repair
ossification center is at the end of the pedicle—so the trabec- — Non degenerative disc
ulation pattern is REGULAR at the pars. In the lower lumbar — Inactive bone scan
vertebrae, the ossification center originates in the region of — Defects < 7 mm.
the pars itself, resulting in IRREGULAR distribution of trabec- • Spinal Fusion
ulation and cortication of the pars. Accordingly, L4 and L5 — Advanced spondylolisthesis
might be embryologically predisposed to spondylolysis [3]. — Disc degeneration
• Comparison of Pelvic incidence (PI), sacral table angle Results:
(STA) and lumbar index (LI) has shown that STA in the • Of 40 young athletes, 32 completed surveys, 11 volunteered
normal population for each group varies but seems to be for follow-up CT. All had x-ray negative, scintigraphy posi-
significantly related to occurrence of spondylolysis. STA tive diagnosis of spondylolysis. Functional and radiograph-
was more highly correlated with the occurrence of spondy- ic outcome assessed 7-11 yrs later. 29/32 (91%) had good or
lolysis than PI [4]. excellent low back outcome scores.11/32 had follow-up CT:
7 had bilateral defects and did NOT heal. 3/7 progressed to
EVALUATION grade I slip. 4 had unilateral defects and ALL 4 healed. Most
Clinical: young athletes conservatively treated for early spondylolysis
• Back pain: aggravated with activities. maintain good functional outcome up to 11 years later [9].
• Stiff-legged gait: hamstring spasm and limitation of forward • Long term outcomes of Scott repair (28 pts) versus uninstru-
flexion. mented fusion in situ (28 pts) was assessed with ODI, SRS,
• Paraspinal muscle spasm and VAS and with x-ray and MRI. Repair group continued to
• Step-off at spinous processes show MRI/xray evidence of disc degeneration, loss of lumbar
• Radiculopathy of L5 nerve root mobility at that level as well as adjacent levels—Theoretical
Treatment: benefits of repair vs fusion could not be proven [10].
• Nonoperative: • No good data available of the outcome of different spinal
• Hyperextension bracing, exercises and restriction of sport activities fusion procedures in young athletes.
• Review of 57 adolescent soccer players treated with different
nonoperative modalities. 53/57 had good/excellent results
REFERENCES: 6. d'Hemecourt PA, et al.Spondylolysis: returning the athlete to sports participation

1. Micheli LJ, Wood R. Back pain in young athletes. Significant differences from with brace treatment. Orthopedics 2002;25(6):653-7.
adults in causes and patterns. Arch Pediatr Adolesc Med 1995;149(1):15-8. 7. Anderson K, et al. Quantitative assessment with SPECT imaging of stress injuries
2. Kajiura K, et al. Slippage Mechanism of Pediatric Spondylolysis: Biomechanical of the pars interarticularis and response to bracing. J Pediatr Orthop 2000; 20
Study Using Immature Calf Spines. Spine 2001;26(20):2208-12. (1): 28-33.
3. Sagi HC, et al. Histomorphic Analysis of the Development of the Pars Interarticu - 8. Sys J, et al. Nonoperative treatment of active spondylolysis in elite athletes with
laris and Its Association With Isthmic Spondylolysis. Spine 1998;23(15):1635-9. normal X-ray findings: literature review and results of conservative treatment. Eur
Spine J 2001;10(6):498-504.
4. Whitesides TE et al. Spondylolytic spondylolisthesis: a study of pelvic and lum-
bosacral parameters of possible etiologic effect in two genetically and geographi- 9. Miller SF, et al. Long-term functional and anatomical follow-up of early detected
cally distinct groups with high occurrence. Spine 2005;30(6 Suppl):S12-21. spondylolysis in young athletes. Am J Sports Med 2004;32(4):928-33.
5. El Rassi G, et al. Lumbar spondylolysis in pediatric and adolescent soccer players.
Am J Sports Med 2005;33(11):1688-93.
DEFORMITIES OF THE CHILD'S FOOT:
EVALUATION AND PRINCIPLES-BASED
MANAGEMENT (Q)
Moderator: Vincent S. Mosca, MD, Seattle, WA
The foot is not a joint. Most congential deformities of the child’s foot are comprised of two
of more deformities that are in different planes or directions from each other. Each of the
individual deformities must be identified and a plan to correct each one must be
established preoperatively. Methods for clinical and radiographic evaluation of foot
deformities will be discussed. The principles, as well as the specifics, of operative
management for many complex deformities of the child’s foot will be presented. Primary
clubfoot management will not be discussed.
I. Normal Foot / Ankle Function: Biomechanics and Quantitative Assessment

Jon R. Davids, MD, Greenville, SC
II. Assessment and Principles of Management of Deformities of the Child’s Foot

Vincent S. Mosca, MD, Seattle, WA
III. The valgus hindfoot: deformities and their management

James R. Kasser, MD, Boston, MA
Vincent S. Mosca, MD, Seattle, WA
IV. Pes cavus

James G Wright, MD, Toronto, ON, Canada
233
NORMAL FOOT / ANKLE FUNCTION: BIOMECHANICS AND

QUANTITATIVE ASSESSMENT
Jon R. Davids, MD
I. Foot / Ankle Function During Normal Gait III. Quantitative Assessment of Foot / Ankle Function:
A. Terminology to Describe Segmental Movement Kinematics
1. Inversion / Eversion (Varus / Valgus) A. Dynamic Segmental (Kinematic) Analysis
2. Adduction / Abduction 1. Currently Utilized Foot Model
3. Supination / Pronation a. Simplistic
B. Stance Phase Function b. Data Generated May be Misunderstood
1. Shock Absorption 2. Sophisticated Foot Models
a. First / Heel Rocker a. Technically Possible
b. Loading Response b. Biomechanically Correct, Clinically Irrelevant
2. Stability 3. Three Segment Foot / Ankle Model: Davis et al, Foot
a. Second / Ankle Rocker and Ankle Motion Analysis: Clinical Treatment and
b. Mid Stance Technology, 2007
3. Lever Arm a. Built Upon Inman Model
a. Third / Forefoot Rocker b. Clinical / Technical Markers
b. Terminal Stance
IV. Quantitative Assessment of Foot / Ankle Function:
C. Swing Phase Function
Pedobarography
1. Clearance
A. Foot Pressure Analysis
2. Pre-position for Heel Strike at Initial Contact
1. Overview of Pedobarography
a. Achieve First / Heel Rocker
a. Contact Area
II. Quantitative Assessment of Foot / Ankle Function: b. Peak Pressure Analysis
Radiographs c. Center of Pressure Progression
A. Static Assessment of Foot Alignment 1. Best Representation of Lever Arm Dysfunction
1. Assumption: Static Alignment Predicts Dynamic 2. Clinical Application of Pedobarography
Loading a. Challenges
B. Updated Inman Foot Model 1. Small, Deformed Feet
1. 4 Segments 2. Incomplete Contact With the Floor
a. Ankle / Hindfoot / Midfoot / Forefoot b. COPP Technique: Jameson et al J Pediatr Orthop,
2. 2 Columns In Press, 2007
a. Medial / Lateral Columns 1. Foot Length / Width Ratio
C. Assessment of Foot Segmental Alignment 2. Normal COPP + 1 Standard Deviation
1. Describe Segments 3. Displacement of COPP
a. Relative to Global Reference / Proximal Segment a. Medial = Valgus Loading
b. Bone-Bone Relation Within Segment b. Lateral = Varus Loading
2. Qualitative Most Common
V. The Future
3. Quantitative
A. Correlation
a. Angle Measurements
1. Plain Radiographics
b. Comprehensive Scheme: Davids et al J Pediatr
2. Kinematics
Orthop 25:769-776, 2005
3. Pedobarography
1. 3 Radiographic Views, 10 Measurements
2. Normal Mean Values, Standard Deviations
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6. Carson, M. C., Harrington, M. E., Thompson, N., et al.; Kinematic analysis of a 13. Gage, J. R.; The clinical use of kinetics for evaluation of pathologic gait in cere-
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235
ASSESSMENT AND MANAGEMENT PRINCIPLES FOR FOOT

DEFORMITIES IN CHILDREN
Vincent S. Mosca, MD
I. “The foot is not a joint!” III. Radiographic assessment of the foot

A. In all congenital and developmental foot deformities, A. Insist on weight-bearing or simulated weight-bearing
there are at least 2 segmental deformities in opposite radiographs!
directions from each other, “as if the foot was wrung out” B. Ankle
B. Each must be identified and managed individually, yet 1. AP, lateral, and mortis
concurrently 2. ankle joint perpendicular to tibia by age 3-4 years
C. There may also be a deformity in the ankle C. Foot
D. Cavo-varus is a combination of hindfoot varus and 1. Standing AP, lateral, and (medial) oblique
forefoot pronation a. axis of talus and 1st metatarsal on AP and lateral
E. Flatfoot is a combination of hindfoot valgus and forefoot images
supination b. medial oblique - assess calcaneo-navicular tarsal
coalition
II. Clinical assessment of the foot
2. lateral (external) oblique - assess accessory navicular
A. Hindfoot - subtalar joint complex
3. Harris/axial – calcaneal fx, talo-calcaneal tarsal
1. Position = varus
coalition
2. Motion = inversion
4. “block” AP – cavus
a. internal rotation, plantar flexion, supination of the
5. clubfoot
“acetabulum pedis”
a. maximum dorsiflexion AP and lateral
b. “down and in”
b. not necessary for diagnosis
3. Position = valgus
c. helpful to confirm deformity correction and
4. Motion = eversion
residual/recurrent deformity
a. external rotation, dorsiflexion, pronation of the
d. NO need for pelvis x-ray. DDH and clubfoot are not
“acetabulum pedis”
related.
b. “up and out”
6. congenital vertical talus
5. carefully assess subtalar motion – hypermobility at
a. maximum dorsiflexion and maximum plantar
Chopart’s joints can give the impression of talo-
flexion lateral
calcaneal motion
D. Bone scan for localization of pain
6. a medial midfoot prominence is:
E. CT in 3 planes for tarsal coalition
a. an accessory navicular if it moves with inversion
F. MRI for soft tissue mass, possible fibrous tarsal coalition
and eversion
b. the talar head of a flatfoot if it remains stationary IV.Principles of management
with inversion and eversion A. Appreciate age-related physiologic variations in the shape
B. Midfoot of the foot
1. adduction 1. flatfoot, metatarsus adductus, and curly toes are very
2. abduction common and normal anatomic shapes in babies and
C. Forefoot (in relation to the hindfoot) less common in older children and adults
1. pronation = plantar flexion of the 1st ray B. Understand the natural history of each variation and
2. supination = dorsiflexion of the 1st ray deformity
D. Ankle 1. the roughly 90% of babies with flatfeet become
1. don’t ignore this joint when assessing foot deformities approximately 25% of adults with flatfeet through
2. hindfoot valgus can be in the ankle joint, the subtalar normal growth and development
joint, or in both joints 2. at least 90-95% of the metatarsus adductus deformities
3. malleolar height seen in infants correct spontaneously
a. lateral malleolus distal to medial malleolus in C. Appreciate the effect of growth and development on the
normal ankle over the age of 4 years chosen intervention
b. lateral and medial malleoli equidistant from the 1. consider how the foot will appear and function at:
knee and the floor in a valgus ankle a. the end of the operation?
E. Evaluate the excursion of the gastrocnemius and Achilles b. the end of the year?
tendons using the Silverskiold test c. the end of childhood?
1. flex the knee d. the end of adolescence?
2. lock the subtalar joint in neutral (to slight varus) e. middle age and beyond?
3. dorsiflex the ankle and record the degree of D. Preserve joint motion by utilizing soft tissue releases and
dorsiflexion osteotomies instead of arthrodesis
4. maintain subtalar position and extend the knee; 1. the subtalar joint is the shock absorber of the foot and
record the degree of dorsiflexion the entire lower extremity
F. Skin pressure/calluses E. Correct deformities AND balance muscle forces
G. Muscle strength, sensation, vascularity 1. this may require 2 closely spaced operative procedures
in cavo-varus foot deformities
F. Establish and follow clear, evidence-based (where 2. natural history – progression, increasing rigidity
available) indications for surgery, the primary one being 3. combine deformity correction with muscle balancing
the failure of prolonged non-surgical treatment to relieve in single or 2 closely staged operations
pain and functional disability 4. correct deformities - in the following order
G. Flatfoot a. soft tissue releases
1. surgical indications: severe valgus deformity of the b. osteotomies
hindfoot with failure of prolonged conservative c. arthrodeses – rarely used in young children and
attempts to relieve the pain/callus under the talar adolescents; consider for older adolescents,
head, or pain in the sinus tarsi extremely severe and rigid deformities; avoid
2. there will be either 2 or 3 deformities in symptomatic subtalar arthrodesis for as long as possible
adolescent flatfeet 5. balance muscle forces
a. valgus deformity of the hindfoot a. right muscle to right location at right tension
b. supination deformity of the forefoot b. available muscles with adequate strength
c. contracture of the gastrocnemius or triceps surae c. appropriate phase of activity
(the main cause of pain and disability) 6. think of the future
H. Cavo-varus foot a. underlying neuromuscular abnormality persists, so
1. surgical indications: pain and excessive callus recurrence is possible
formation at base of 5th metatarsal or under 1st
metatarsal head, ankle instability with recurrent
sprains, progressive deformity
237
VALGUS FOOT
James Kasser, MD
The valgus foot is a hindfoot deformity with eversion through the subtalar joint and mechanics of the
the subtalar joint, variably referred to as pronation or flatfoot. hindfoot.
d. There is a possible role for arthrodesis or
A. The deformity is characterized by: osteotomy in some cases rather than excision
1. Lateral shift of the calcaneal tuberosity but this is limited.
2. Eversion through the subtalar joint b. Vertical talus or rigid oblique talus: The etiology of this
3. Incompetence of the pes acetabulum is generally a congenital deformity with a rigid oblique
a. with a talar head medially deviated relative to the talus. It also may be acquired in certain neuropathic
navicular which is laterally displaced conditions of cerebral palsy, arthrogryposis and spinal
b. the talar head falls medially and plantarward relative dysraphism.
to the anterior facet of the calcaneus 1. In infancy, the Dobbs method of casting followed
4. The normal tripod, important in stance, with bearing by pinning and limited release of tendons appears
weight on the calcaneal tuberosity of the 1st and 5th to have a role. Long-term follow-up will be
metatarsal is lost. Push-off over the first ray is impossible. required.
The force of the gastroc falls lateral to the ankle joint at a 2. In older patients with rigid foot deformity, surgical
mechanical disadvantage. management with reduction of the talonavicular
5. Frequently, a tight heel cord is associated with a joint and release of tight anterior tendons, peroneal
symptomatic flatfoot tendons, and to some degree, the calcaneocuboid
joint and hindfoot is required. A two-incision,
B. Symptoms
simultaneous technique appears to give the best
1. Symptoms from flatfoot or pronated foot tend to be
result. Generally, heel cord and posterior capsular
pain, limp, deformity, excessive shoe wear and fatigue.
release is needed.
Pain should be localized. Muscle testing needs to be done
2. The Semi-Rigid Valgus Deformity
both for contracture and strength. Look for tight heel
a. Skewfoot: The skewfoot is a complex deformity with
cord or weak posterior tibial.
hindfoot valgus accompanied by lateral translation of
2. Imaging: Standing AP and lateral of the foot, as well as
the navicular and medial deviation of the forefoot.
oblique x rays, is mandatory. CT scan of the hindfoot is
b. Imaging: Standing AP and lateral x ray
helpful in evaluating pathologic hindfoot conditions.
c. Treatment: Many mild cases resolve spontaneously
C. Conditions leading to valgus foot or are easily tolerated with no symptoms and
1. Rigid valgus foot deformity regular shoe wear. In the more severe, symptomatic
a. Tarsal coalition: his generally is either a talocalcaneal cases, the combination of hindfoot valgus with
or calcaneonavicular coalition presenting with painful, lateral translation of the navicular and medial
rigid foot deformity. This must be differentiated from deviation of the talar head and first metatarsal is
other causes of peroneal spastic flatfoot including documented by x ray. If symptoms persist, the
arthritis, trauma, infection. major areas of symptoms are documented and
1. Imaging: standing AP, lateral and oblique of the addressed, using a combination of first cuneiform
foot with CT scan opening osteotomy, lateral column closing
2. Treatment: osteotomy, or lateral column lengthening
a. Excision of calcaneonavicular coalition requires osteotomy, or calcaneal translational osteotomy.
definition of the extent and direction of the The technique for each of these osteotomies is
lesion. Involvement of the anterior facet of the described in another part of this lecture. Heel cord
subtalar joint should be determined. Adjacent lengthening may accompany cases of very tight
articular surfaces of the talonavicular joint and hindfoot aggravating the condition.
the calcaneocuboid joint should not be injured. 3. Flexible Valgus Deformity: The flexible valgus deformity
Soft tissue interposition with EDB or fat is used. is one in which flatfoot deformity is present but hindfoot
b. Excision of the talocalcaneal coalition is will reconstitute when non-weight-bearing and in rising
indicated in the symptomatic foot with less than up on tiptoes. The degree of deformity is documented
50% involvement of the subtalar joint and the based on Meary’s angle, calcaneal pitch and uncovering
absence of degenerative joint disease. Valgus of the talar head. It may occur in a normal child or a
deformity must be treated as well but in itself is child with connective tissue disorder such as Marfan’s
not a contra-indication to excision. In excising disease, neurofibromatosis, or Ehlers-Danlos. Pain,
talocalcaneal coalition, the neurovascular bundle fatigue and poor push-off are seen as symptoms with this
is isolated; the coalition is excised, protecting the deformity.
FHL, FDL and posterior tibial tendons. Articular a. Imaging: The severity of this deformity of this deformity
surfaces must be visualized and clear motion in is documented by standing AP and lateral x rays
the subtalar joint re-established. b. Treatment: Conservative management includes an
c. Following excision of tarsal coalitions, excessive arch support, a UCB, SMO, +/= exercise. Failure of
valgus deformity should be treated with either conservative management is an indication for further
translational or lengthening calcaneal treatment with osteotomy or reconstruction of the
osteotomies to restore the proper alignment of foot.
c. Operative Treatment: Possible treatments include technique, the tuberosity of the os calcis is shifted
calcaneal translation osteotomy, calcaneal lengthening medially to align the weight-bearing axis.
osteotomy, arthrodesis of the subtalar joint, rarely 2. Calcaneal lengthening is done through the neck of
indicated, and arthrorhesis of the subtalar joint, the calcaneus as an opening wedge osteotomy. If
likewise rarely indicated. forefoot supination is present, first ray osteotomy is
1. Calcaneal translational osteotomy – In this done and the heel cord is always lengthened.
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1. Brown RR, Rosenberg ZS, Thornhill BA. The C sign: more specific for flatfoot 81:250-254.
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17:777-780. 24. Mazzocca AD, Thomson JD, Deluca PA, et al. Comparison of the posterior
3. Cooperman DR, Janke BE, Gilmore A, et al. A three-dimensional study of calca- approach versus the dorsal approach in the treatment of congenital vertical talus.
neonavicular tarsal coalitions. J Pediatr Orthop, 2001; 21:648-651. J Pediatr Orthop, 2001; 21:212-217.
4. Emery KH, Bisset GS, 3rd, Johnson ND, et al. Tarsal coalition: a blinded compar- 25. Napiontek M. Congenital vertical talus: a retrospective and critical review of 32
ison of MRI and CT. Pediatr Radiol, 1998; 28:612-616. feet operated on by peritalar reduction. J Pediatr Orthop B, 1995; 4:179-187.
5. Gonzalez P, Kumar SJ. Calcaneonavicular coalition treated by resection and inter- 26. Matthew B. Dobbs, MD1, Derek B. Purcell, MD1, Ryan Nunley, MD1 and Jose A.
position of the extensor digitorum brevis muscle. J Bone Joint Surg Am, 1990; Morcuende, MD, PhD, Early Results of a New Method of Treatment for
72:71-77. Idiopathic Congenital Vertical Talus, The Journal of Bone and Joint Surgery
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181:1565-1572. and medial column lengthening in the treatment of severe forefoot adductus.
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16. Takakura Y, Sugimoto K, Tanaka Y, et al. Symptomatic talocalcaneal coalition. Its ening and medial cuneiform opening wedge osteotomies. J Pediatr Orthop,
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332.
239
PES CAVUS
James G. Wright, MD, MPH, FRCSC
Etiology: Multiple possible causes requiring family history, • Osteotomies

neurologic and spine examination, and MRI • Fusion
• Muscular: muscular dystrophy
Plantar Release: Older child have better formed tarsal joints

• Peripheral nerve: Charcot Marie Tooth
• Technique: percutaneous or open
• Spinal Cord: spina bifida, diastematomyelia
• Incision: medial, plantar, or lateral
• Pyramidal/Extrapyramidal: cerebral palsy, Friedrich’s ataxia
• Release: plantar fascia/short plantar muscles/capsulotomies
• Congenital: clubfoot
• Idiopathic Transfers
• Peroneus longus to brevis
Pathoetiology: Multiple competing theories – none proven
• Long extensors to head metatarsals (plus fusion IP joints)
and may vary by disease
• Transfer tibialis anterior to base first metatarsal (plus
• Weak anterior muscles/strong peroneus longus
cuneiform plantar opening osteotomy)
• Weakness of peroneus brevis/strong peroneus longus
• Transfer EHL to head first metatarsal (plus IP
• Paralysis of intrinsic muscles/strong long flexors
tenodesis/fusion)
• Weakness of triceps surae/strong long flexors
• Tibialis posterior to midfoot through interosseous
Deformity: Peroneus longus plantar flexors first ray membrane
• Planter flexion of metatarsals (first ray most plantar flexed • Antero/lateral muscles (tibialis anterior/peroneal muscles)
leading to forefoot pronation) to heel for calcaneus
• Clawing of toes: may be secondary to metatarsal plantar • Tendo-Achilles tendodesis for calcaneus
flexion or primary abnormality
Osteotomies
• Hindfoot varus: may be secondary to pronated forefoot
• First metatarsal/medial cuneiform for first ray plantar
• Calcaneus or equinus: essential to distinguish because
flexion
posterior release inappropriate in calcaneus
• Midfoot osteotomies: wedge tarsectomy, “V” osteotomy: all
Clinical Assessment broachs midfoot joints
• Clinical history: progressive/stable, family history • Calcaneal: shift/closing
• Gait
Fusion
• Upper extremity weakness/wasting
• Cuneiform – first metatarsal
• Spine: signs of spinal dysraphism
• Tarsometatarsal
• Neurologic examination
• IP toes
• Foot/ankle
• Triple
• Coleman block test: forefoot pronation causing hindfoot
varus Calcaneocavus
• Proximal slide (plus plantar release)
Diagnostic Images
• Crescentric osteotomy
• Standing AP/lateral: Meary’s angle (lateral talar-first
• Closing wedge for varus
metatarsal angle), calcaneal pitch, talar-first metatarsal on
AP Treatment: Early
• MRI • Plantar release
• Peroneus longus to brevis
Foot Static Alignment: Radiographic Analysis
• Metatarsal/cuneiform osteotomy
• Quantitative segmental analysis (Davids, et al. JPO 25:769-
• Jones transfer
776, 2005)
• 3 radiographic views Treatment: Mid
• 10 measurements • Plantar release
• 60 normal feet • Calcaneal shift/Dwyer
– Mean age 9 years • Metatarsal osteotomies
– Values
Treatment: Late
Symptoms • Midfoot, calcaneal, metatarsal osteotomies
• Metatarsalgia • Tibialis posterior tendon transfer
• Pain lateral border of foot/base of 5th metatarsal • Fusion
• Difficulty shoe wear
Conclusion
• Recurrent ankle sprains
• Cavus is a complex deformity
• Drop foot gait
• Osteotomies more reliable than soft tissue procedures
Treatment • Role of early surgery to prevent worsening uncertain
• Fit shoe to foot to relieve pressure: custom orthotics effective
before onset of hindfoot varus
• Surgery: fit foot to shoe
Operative Treatment (usually combination of procedures)
• Soft tissue release
• Tendon transfer(s)
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241
SYMPOSIA PRACTICE MANAGEMENT
CURRENT STATE OF THE FELLOWSHIP

HIRING PROCESS: IS A UNIVERSAL MATCH
NECESSARY? IS IT POSSIBLE? (F)
Moderator: Christopher D. Harner, MD, Pittsburgh, PA
This symposium is designed to present the current state of the post graduate fellowship
hiring process. It is intended to foster a strategic dialogue within the AAOS and Subspecialty
Societies to ultimately make recommendations for improvement. Specifically, discussions
will be focused on the development of new processes such as a Universal Orthopaedic
Fellowship Match Program.
I. Overview of the Current State: Why are we here?

Christopher D. Harner, MD, Pittsburgh, PA
II. Origin, History and Design of the Residency Match: Historical Perspective
G. Paul DeRosa, MD, Chapel Hill, NC
III. Hand Surgery Match: A Successful Match Process?

Peter J. Stern, MD, Cincinnati, OH
IV. Foot and Ankle: A Match Reborn?

Shepard R. Hurwitz, MD, Chapel Hill, NC
V. Gastroenterology Match: A Potential Model for Orthopaedics

Muriel Niederle, PhD, Stanford, CA
VI. The Resident Perspective

Anil Ranawat, MD, New York, NY
VII. Discussion
CURRENT STATE OF FELLOWSHIP HIRING: IS A UNIVERSAL MATCH

NECESSARY? IS IT POSSIBLE?
Christopher D. Harner, MD, G. Paul DeRosa, MD, Peter J. Stern, MD, Shepard R. Hurwitz, MD, Muriel Niederle, PhD,
Alvin E. Roth, PhD, and Anil S. Ranawat, MD
Introduction: presently not participating in a match suffer from common

Currently, approximately ninety percent of the six hundred problems of a decentralized market.
twenty graduating orthopaedic residents are planning on enter-
ing a post-graduate fellowship. Since January of 2005, two of the
largest fellowship match programs, Sports Medicine and Spine
Surgery, were dissolved by the NRMP due to the gradual decline
in participation, leaving approximately seventy percent of appli-
cants in a non-match, decentralized system. This leaves Hand
Surgery, Shoulder and Elbow and, Foot and Ankle, as the only
orthopaedic subspecialties still in a match program. To address
this critical issue, the American Orthopaedic Association (AOA)
organized a symposium at their annual meeting in 2007
focused on the “Current State of Fellowship Employment”. In
addition, the AOA embarked on a process to develop two on-
line surveys: one survey was designated for the residents of the
Resident Leadership Forum (RLF), while the second survey was
designed for the fellowship directors. These surveys were
designed by two economists, who have extensive experience in
analyzing the impact of organized matches in hiring markets.
These economists were also instrumental in data collection and
This figure shows the impact of a centralized and decentralized
analysis of both surveys. Prior to the 2007 AOA annual meeting,
process on the residents. In a centralized clearinghouse, appli-
the RLF of 2007, which is an invited group of post graduate year
cation, interview and offer times are determined by the match
(PGY) four residents, met to discuss and deliberate the current
and are centered over a few months time span. On the other
state of the fellowship hiring process. The results of both surveys
hand, in a decentralized system, the process spans well over a
and the RLF deliberations were then incorporated into the AOA
year and shifts earlier and earlier in the training of the residents.
symposium the following day.
In addition, the offering process plays out over a long time, with
This symposium will focus on the current state of fellowship different fellowship programs making offers at different times,
employment and hiring in orthopaedic surgery. We found that and with programs and applicants having to make decisions
in contrast to fellowship markets that use a match (eg with very little information about their alternatives.
Gastroenterology), the current fellowship markets for specialties
243
GASTROENTEROLOGY MATCH: A DECLINE AND REBIRTH LESSONS

FOR ORTHOPAEDICS
Muriel Niederle, Alvin E. Roth
Outline Psychology Internships in the U.S. and CA (1999)
• State of the Orthopedics Fellowship Market: Hiring practices Neuropsychology Residencies in the U.S. & CA (2001)
and problems Osteopathic Internships in the U.S. (before 1995)
• How can a Match help? Pharmacy Practice Residencies in the U.S. (1994)
• Problems of a successful (re)start of the Match, and policies Articling Positions with Law Firms in Alberta, CA(1993)
to address them (lessons from Gastroenterology - GI). Medical Residencies in CA (CaRMS) (before 1970)
• Other benefits of a Match.
The shortcomings of the current market for Orthopaedic
Stable Centralized Clearinghouses fellows
NRMP / SMS: Roth Peranson Algorithm We observe three the chief problems in decentralized markets
Medical Residencies in the U.S. (NRMP) (1952) (GI and Orthopaedics and many others)
Abdominal Transplant Surgery (2005) 1. The Market is not thick
Child & Adolescent Psychiatry (1995) • At any given point in time, only a few positions (and
Colon & Rectal Surgery (1984) residents) are available
Combined Musculoskeletal Matching Program 2. Market suffers from congestion
(CMMP) • Making offers and thinking about them takes time
• Hand Surgery (1990) 3. This makes it unsafe for programs to make offers accord-
• Foot and Ankle ing to their preferences, and for residents to accept only
Medical Specialties Matching Program (MSMP) their best possible offer.
• Cardiovascular Disease (1986)
• Gastroenterology (1986-1999; rejoined in 2006)
• Hematology (2006)
• Hematology/Oncology (2006)
• Infectious Disease (1986-1990; rejoined in 1994)
• Oncology (2006)
• Pulmonary and Critical Medicine (1986)
• Rheumatology (2005)
Minimally Invasive and Gastrointestinal Surgery (2003)
Obstetrics/Gynecology
• Reproductive Endocrinology (1991)
• Gynecologic Oncology (1993)
• Maternal-Fetal Medicine (1994)
• Female Pelvic Medicine & Reconstructive Surgery (2001)
Ophthalmic Plastic & Reconstructive Surgery (1991)
Pediatric Cardiology (1999)
Pediatric Critical Care Medicine (2000)
Pediatric Emergency Medicine (1994)
Pediatric Hematology/Oncology (2001)
Pediatric Rheumatology (2004)
Pediatric Surgery (1992)
Primary Care Sports Medicine (1994)
Radiology
• Interventional Radiology (2002)
• Neuroradiology (2001)
• Pediatric Radiology (2003)
Surgical Critical Care (2004)
Thoracic Surgery (1988)
Vascular Surgery (1988)
Postdoctoral Dental Residencies in the United States
• Oral and Maxillofacial Surgery (1985)
• General Practice Residency (1986)
• Advanced Education in General Dentistry (1986)
• Pediatric Dentistry (1989)
• Orthodontics (1996)
outcome?
Gastroenterology: Policy to protect fellows from early offers

• Gastroenterology had the same concerns, they too
remember a match falling apart in the past.
• They adopted a variant of a resolution that solves this
problem for graduate school admission
• “Students are under no obligation to respond to offers of
financial support prior to April 15; earlier deadlines for
acceptance of such offers violate the intent of this
Resolution. In those instances in which a student accepts an
offer before April 15, and subsequently desires to withdraw
that acceptance, the student may submit in writing a
resignation of the appointment at any time through April
15.
Proposed AGA resolution (Niederle, Proctor, Roth 2006)
• 2. Acceptance of Offers - Before, Through and After the
Interviews & Offers: Non-match specialties Match: Gastroenterology fellowship applicants are under no
• 90% of programs had applicants cancel interviews (on obligation to accept an offer prior to the Match.
average 4). 40% had 5+ such cancellations. Furthermore, applicants are not bound by the acceptance of
• 31% make offers before they finish interviewing (and 5% an offer prior to the Match. …
had all slots filled before their last interview). • 3. Eligibility for the Match: All applicants are eligible to
• 54% of programs give deadlines of a week, and 71% of 2 participate in the Match, whether or not they have accepted
weeks or less. an offer prior to the Match. When an applicant is pressured
• 45% are asked to speed up offers for applicants who have a by a program into accepting an offer prior to the Match, he
short term offer in hand (and 27% agreed). may accept that offer and still remain eligible to participate
• 46% take the chance of acceptance into account when in the Match. Since any agreement reached through the
making a offer. Match is binding, applicants should only submit to the
• 11% had fellows renege on their former acceptance. Match a Rank Order List of programs they definitely prefer
Resident Questionnaire to any offer accepted before the Match. Applicants who have
• 68% had a deadline of a week or less (2 had to answer on accepted an offer before the Match, and received a position
the spot on the phone, 2 had less than an hour). in the Match, must announce their resignation to the
• 52% felt they had to accept offers before finishing program that made the early offer on the same day that they
interviewing. learn the Match result. … Applicants who accepted an early
• 50% felt pressure to accept earlier offers out of concern that offer, but were not matched, must honor their original
no positions or offers would be available at the end of the agreement.
interviewing process. • Applicants who receive several early (pre-Match) offers to
• About 50% of fellows accepted the first offer they received. which they are pressed to reply before the Match, can at any
time accept the one they prefer, and should contact the
What can a Match do? programs whose offers they reject, whether they have
Three of the chief functions that are central to the discussion of accepted them beforehand, or were simply considering the
resident and fellow matches is that they help offer.
1. Create a thick market • While applicants maintain their eligibility for the Match,
• Lots of people and positions should be available to be even if they are pressured to accept offers before the match,
matched at the same time such early offers violate the intent of this resolution. When
2. Overcome congestion applicants and programs are each others’ first choice, the
• There should be enough time for all offers to be Match will automatically match them when they submit
considered those preferences on their Rank Order Lists. When all
3. Make it safe for participants in the Match to reveal their participants comply with the spirit of this resolution, all
preferences positions will be offered through the Match, or after it.
Would a Match be better if most adhered? Resolution Regarding Gastroenterology Fellowship
Programs: 64% YES Applicants, Including all Research and Clinical Fellowship
• About half of those that are against, fear that there would be Applicants and Positions
too much non-adherence. • This resolution concerns the conditions surrounding
Fellows: 80% YES gastroenterology fellowship offers to applicants, acceptance
How to restart a match? How to achieve compliance? by applicants of such offers, and participation by applicants
• Not allowing early offers, or regulating participation: Very and programs in the gastroenterology fellowship Match. The
difficult (historically hasn’t worked). general spirit of this resolution is that each applicant should
• Turn to residents to help them be safe from early offers, and have an opportunity to consider all programs before making
make it feel safe for them to wait for the match, and their a decision and be able to participate in the Match. … The
best outcome. intention of this resolution is to ensure uniformity so that
• If programs knew no fellows would be taken off the market everyone participates fairly and to establish the principle
early, they can in turn safely wait for the match. that all positions should be filled through the Match or after
How can we protect fellows from early offers, from being Match Day. It therefore seeks to create rules that give both
captured (early) by a program that isn’t their best possible programs and applicants the confidence that applicants and
245
positions will remain available to be filled through the • Should different specialties have the match in the same day?
Match and not withdrawn in advance of it. • If so, should some fellows be allowed to list more than one
• This resolution addresses the issue that some applicants may specialty (in case they have very strong, say, regional
be persuaded or coerced to make commitments prior to, or preferences, and are still somewhat undecided about their
outside of, the Match. Early offers and acceptances, and offers specialty).
outside of the Match, are violations of the rules and of this
Other Advantages of a Match
resolution and are not condoned. Any applicant may
• Reverting positions:
participate in the matching process by registering for the
— A program that tries to fill a position with a research
Match to interview and consider match-participating
fellow, and fails, can decide to convert that position into
programs; however, an applicant who accepts a position
a clinical position and try to fill it under those
prior to, or outside of, the Match must comply with the
conditions.
National Resident Matching Program/Specialty Matching
— In decentralized markets: has to be done sequentially, the
Services (NRMP/SMS) Match Participation Agreement by
match can do it at once.
either resigning the accepted position if he/she wishes to
• Interviews may be more informative:
submit a rank order list of programs or by withdrawing from
— The experience in GI is that interviews that do not
the Match prior to the rank order list certification deadline,
sometimes lead to immediate offers are more intent on
which is the first week in June. In addition, no program may
transmitting information.
withdraw a position from the Match after the quota change
deadline to offer that position outside the matching process. A simple centralized clearinghouse: deferred acceptance (has
… The spirit of this resolution is to make it unprofitable for been discovered independently in many markets)
program directors to press applicants to accept early offers, • Applicants and firms interview, and then submit rank order
and to give applicants an opportunity to consider all offers as lists of one another (applicants are substitutes)
well as to provide uniform and widely acceptable rules that • Applicant-proposing deferred acceptance (Gale-Shapley ’62):
protect both applicants and fellowship programs. — Each applicant applies to his/her highest ranked firm
• The gastroenterology match for 2007 fellows was held June 21, — Each firm rejects unacceptable applicants and “holds” its
2006, and succeeded in attracting 147 of the 151 eligible highest ranked applications (up to the number of
fellowship programs, 13 of which withdrew before the match. positions it has, and rejects the rest)…
• The final participation rate: 89% — At any stage at which an applicant has been rejected,
• 98% of the positions offered in the match were filled he/she applies to her next most preferred firm
through the match. — Each firm holds its most preferred set of applications and
• Early movers couldn’t impose a big negative externality on rejects the rest.
those who waited for the match, since pre-match exploding — The algorithm stops when no rejections are issued, and
offers would not necessarily remove candidates from the each firm is matched to the applicants it is holding.
market. This made it easier for everyone to wait for the • Theorems: The outcome is Pareto efficient and stable, there
match. does not exist a firm-applicant pair that would prefer to be
• As we speak, they get ready for the second year of using the matched to one another. And the procedure gives applicants
centralized match... straightforward (dominant strategy) incentives to state their
true preferences.
Things to consider for a Match
• When should the match occur?
REFERENCES 6. Niederle, Muriel and Alvin E. Roth, “The Gastroenterology Fellowship Market:
1. Niederle, Muriel and Alvin E. Roth, “Unraveling reduces mobility in a labor mar- Should there be a Match?,” American Economic Review, Papers and Proceedings,
ket: Gastroenterology with and without a centralized match,” Journal of Political 95,2, May, 2005, 372-375.
Economy, vol. 111, no. 6, December 2003, 1342-1352. 7. Niederle, Muriel, and Alvin E. Roth, “Re-starting the Gastroenterology Match,”
2. Niederle, Muriel and Alvin E. Roth, “Relationship Between Wages and Presence letter, American Journal of Gastroenterology, vol. 100, no. 5, May, 2005, 1202-
of a Match in Medical Fellowships,” JAMA. Journal of the American Medical 1203.
Association, vol. 290, No. 9, September 3, 2003, 1153-1154. 8. Niederle, Muriel, Deborah D. Proctor, and Alvin E. Roth, “What will be needed
3. Niederle, Muriel, “Competitive Wages in a Match with Ordered Contracts”, forth- for the new GI fellowship match to succeed?” Gastroenterology, January, 2006,
coming, American Economic Review. 130, 218-224.
4. Niederle, Muriel and Alvin E. Roth, “The Gastroenterology Fellowship Match: 9. Niederle, Muriel and Alvin E. Roth, “Market Culture: How Norms Governing
How it failed, and why it could succeed once again,” Gastroenterology, 127, 2 Exploding Offers Affect Market Performance,” working paper.
August 2004, 658-666. 10. Niederle, Muriel and Leeat Yariv: “Matching through Decentralized Markets”,
5. C. Nicholas McKinney, Muriel Niederle, and Alvin E. Roth, “The collapse of a working paper 2007.
medical labor clearinghouse (and why such failures are rare),” American
Economic Review, 95, 3, June, 2005,878-889.
RECONSTRUCTING THE FOOT & ANKLE FELLOWSHIP MATCH

Shepard R. Hurwitz, MD
The Facts 2006- New!

• 1990 the Match for F/A Fellowship Began 2002 the Match Carrots and Sticks from the AOFASThe means to an end:
Ended changing behavior of fellowship directors
Timeline Post Script- Carrots
• NRMP starts 1990 and ends with the 2002 match • AOFAS to have an oversight Committee
• Warnings were issued in 2000 and 2001 about the 75% • AOFAS grants only available to faculty and fellows who play
compliance level by the rules
• AOFAS gives free publicity for fellowship programs in
Background
compliance with NRMP/AOFAS
• The NRMP process was started in 1989 by the then
• AOFAS will facilitate candidate interviews and offer
Fellowship Directors with logistical support provided by the
incentives to potential fellowship candidates
AOFAS
• Faculty from participating/compliant fellowships get priority
• Trouble with the match soon began after 1990 with many
in presentations and participation in AOFAS events
Fellowship Directors going outside the match: ‘cheating’
• Faculty receive preference in forming courses, publications
• The AOFAS leadership tried to salvage the match- it initiated
and service over those of noncompliant fellowships
dialogue among the program directors and promoted the
fellowships in a marketing campaign Penalties!
Program Director is ineligible for
Failure
• AOFAS Research grants for 3 years
• By 1999 the number of applicants was less than the number
• Podium presentations for 2 years
of available fellowship positions
• Participation in Symposium or session moderator for 2
• Discussions about a ‘fairness policy’ started within the
years
AOFAS trying to bring fellowship directors together and fix
• Committee member for 2 years
the problem
• Board of Directors position for 2 years
Doom & Gloom • * Includes other faculty of fellowship but for 1year less
Amid much rancor, the fellowship match was disbanded by
Penalties
NRMP because less than 75% of programs adhered to the
• Program pays the AOFAS $7,500
match in prior years
• Program is ineligible to get back into NRMP for 2 years
“Always go to other people’s funerals, otherwise they won’t go • Program cannot advertise in any AOFAS sponsored
to yours” Yogi Berra, I Really Didn’t Say Everything I Said, 1998 publications
• AOFAS reports breach to NRMP
2004- AOFAS
Legal
The leadership refused to accept the demise of the match- a
• Legal opinion by outside consultant and internal counsel
Task Force was assembled and the BOD created means and
• Due diligence through NRMP
measures to re-establish the NRMP for Fellowship training
• No problem was perceived with fairness, antitrust, breach of
AOFAS Goals contract etc.
To reinstate a fellowship match process that was fair to all,
(Early) Results
viable and durable
• 2007 NRMP for Foot/Ankle Fellowships- Reinstated
BOD Approach • All 38 Fellowship Directors signed an agreement with
Top down- AOFAS involvement influencing the fellowship AOFAS to honor the rules of the NRMP
directors
Results- 2007
Putting it Back Together 2005 May, 2007
• AOFAS Survey of Fellowship Directors • 41 positions matched
• S Pinney et.al. • 19 positions unfilled
• No complaints by residents
Survey Results
• No reports of violations
• Role of AOFAS in fellowship?
19 AOFAS has a role/ 3 AOFAS has NO role Results
• Support a fair ‘match’ • 1 program withdrew from the match and did not report
20 yes/ 2 no • All applicants matched
• How to solve the problem of fellowship selection?
Post Script
13/16 suggested some form of match
So far so good.
Work 1) The issue of accreditation not resolved
The Task Force and the BOD contacted all Fellowship Directors, 2) Balancing applicant numbers and fellowship positions to
created a series of incentives for ‘fair play’ and punishments for be determined
‘cheating’ and recruited all Fellowship Directors to re-enter the
Summary
NRMP
AOFAS Leadership did not let the match die, they were pro-
active and focused on the mission of the organization:
247
“promotes quality, ethical and cost effective care through Once upon a time there was an ocean,
education, and training of orthopaedic surgeons…We also Now it’s a mountain range
provide leadership and serve as a resource for…the national Something unstoppable is set into motion,
health care community.” Nothing is different- but everything has changed
Paul Simon- “Everything has Changed” 2006
Future Directions?
A new beginning
Or…
History repeating itself?
HAND MATCH

Peter J. Stern, MD
52 = Accredited and Participate in Match Did any programs offer you a position if you promised to to
3 = Accredited but Do NOT Participate in Match rank them #1?
1 = NOT Accredited and Do NOT Participate in Match • Yes (4%) N=9
24 = States that do NOT have a Hand Fellowship Program • No (91%) N=199
• AK, AR, CO, DE, District of Columbia, GA, HI, ID, KS, LA, • Skipped or N/A (5%) N=10
ME, MI, MT, NE, NV, NH, ND, OR, SC, SD, VT, WV, WY
Did any programs tell you where they ranked you?
• Yes (15%) N=31
NRMP MATCH RESULTS STATISTICS
• No (83%) N=177
Program Enrolled Programs Positions • Skipped or N/A (2%)
Statistics Programs Filled Filled
2007 52 38 (73%) 99 (85%) Did you interview at any programs that do NOT participate
2006 63 53 (84%) 122 (91%) in the NRMP Match?
2005 55 47 (85%) 111 (91%) • Yes (25%) N=56
2004 92 43 (49%) 133 (65%) • No (75%) N=171
2003 92 55 (63%) 149 (73%)
2002 112 65 (60%) 165 (72%) Overall satisfaction with the Match?
2001 120 67 (60%) 179 (77%) • Dissatisfied 1%
• Somewhat dissatisfied 3%
Data Collecting Information • Neutral 19%
• Obtained Email addresses from the ASSH Candidate • Reasonably satisfied 28%
Members database (2001-2007) • Satisfied 49%
• Survey conducted online (SurveyMonkey.com)
• 427 = Originally Invited to Participate in Survey COMMENTS (81/232 (40%))
• 21 (5%) = Non-locatable Positive
• 406 = Total Surveyed • Many spoke highly of the Hand Match compared to other
• 232 = Total Respondents (57%) programs.
• Glad for the Match Program as it allows applicants to see
Did you participate in the Hand Fellowship Match? various programs.
• Yes (87%) N=200 • The Match works well, has integrity, and protects the
• NO (12%) N=29 applicants.
• NR (1%) N=3 • The Hand Match works well as long as everyone “plays by
Did any program offer you a position before Match day? the rules” which many believe is being done.
• Yes (11%) N=24 Negative
• NO (86%) N=183 • Not enough time especially if interviewing at multiple
• N/A (2%) locations (i.e. missing days from residency, etc).
• Skipped (3%) • Too much time between conclusion of interview and the
notification of where they matched.
NRMP Fellowship Director User Guide • The Hand Match is too late in the year.
• The Match Participation Agreement does not preclude one • Programs should tell applicants upfront if they pull out of
party from expressing a high level of interest in the other. the Match.
• Although not recommended, it is not a violation for an • Programs outside of the Match do try to influence those
applicant or a program to tell the other how one will be participating in the Match (i.e. putting pressure on them to
ranked. make a decision prior to Match results).
• Any attempt to request such information is a violation.
249
A BRIEF HISTORY OF THE NATIONAL RESIDENT MATCHING

PROGRAM (NRMP)
G. Paul DeRosa, MD
Before the NRMP 1984 First Fellowship Match – Colon and Rectal Surgery.
• Pressure from hospitals to accept early appointments 1988 ROLIC introduced – disks used for the Rank Order List
• Exploding offers (ROL) entry.
• Positions filled early through side-deals 1989 NRMP Bylaws Revision – different composition of
• Students forced to accept less desirable options Board of Directors.
• Programs did not abide by uniform appointment dates 1990 First Year of AAMC Management Services.
• Students & programs did not notify each other when offers 1992 NRMP moves from Evanston, Illinois to Washington,
were accepted D.C.
• Gridlock when students held more than one offer 1996 NRMP commissions study of matching algorithm to
be developed and conducted by Al Roth, Ph.D.
Benefits of a Match
1998 First Match conducted after the study of the matching
• Allows applicants and programs to consider all options
algorithm using the applicantproposing algorithm.
before making commitments
1999 Rank Order Lists and Match Results entered and
• Creates an impartial venue for matching programs’ and
received via the Web.
applicants’ preferences
2001 Web-based registered, ranking and results system
• Establishes a uniform date for appointments to GME
introduced for all matches.
programs
2002 Main Match run on the desktop. Specialty matches
• Optimizes student and program preferences
had been run on desktop since the mid 1980s.
NRMP CHRONOLOGY*
Technology and the Match
1940s “Gentlemen’s Agreement” to set uniform date
1952 First match run using IBM punch cards
introduced.
1970s Punch cards replaced by mainframe computer
1949 Cooperative Plan for the Appointment of Interns
1988 Rank Order List Input and Confirmation (ROLIC)
adopted at 1949 AAMC Annual Meeting. Plan to send
1999 WebROLIC
telegrams offering positions by hospitals all at the
2002 Registration, Ranking, and Results System
same time. Plan was unsuccessful.
2004 Dynamic unfilled positions list
1950 Formation of the “National Interassociation
Committee of Internships”. Purpose to develop a NRMP Fellowship Matches
matching program. • Currently administering matches for 33 subspecialties with
1951 A National Student Internship Committee urged approximately 3500 positions.
adoption of the “Boston Pool Plan”. This plan used • Entering into a matching program is a binding
card sorting equipment at MGH. commitment. Both program and applicant agree to abide by
1951 First Match Conducted (under auspices of AAMC). the results of the match and to play by the “rules!”
1951 National Internship Matching Program (NIMP)
Violations do occur and are reported.
launched. Sponsoring Organizations: AMA, AAMC,
Since 2004, 48 applicants and 8 programs have been
AHA, American Protestant Hospital Association,
investigated and found to be in violation of the Match
Catholic Hospital Association, Student Representative.
Participation Agreement.
1962 Seminal published mathematical analysis that
provided the theoretical basis and justification for the Sanctions imposed have included:
matching algorithm used by the NRMP. NRMP not • Barring applicants from accepting positions in Match
aware of this analysis until mid to late 1970s. participating programs
1966 Millis Commission Report published. • Barring applicants from future NRMP matches
1968 NIMP becomes National Internship and Resident • Labeling applicants as violators in the NRMP R-3 system
Matching Program (NIRMP). • Labeling programs as violators in the NRMP R-3 system
1971 NRMP institutes “all or none” policy which indicates
Why do matches fail?
that all an institution’s GME1 positions for graduating
• Too many positions for the number of applicants
students should be included in NIRMP (internship or
• Cheating!!!
R1 positions).
1973 Free Standing Internship disappears. NRMP requirements to participate in a match include:
1974 The Match process became fully automated using • A minimum of 75% of programs be offered in the match
electronic data processing. First Match utilizing the • A subspecialty must - a) lead to ABMS certification, b) be
services of National Matching Services. affiliated with an ACGME residency program, or c) be
1978 NIRMP becomes National Resident Matching Program ACGME accredited
(NRMP).
Methods of Cheating
1978 Council of Medical Specialties Societies (CMSS)
• Pressure from program directors to accept early
becomes NRMP sponsoring organization.
appointments
1984 Simultaneous Matching of PGY1 and PGY2 positions
• Exploding offers
successfully implemented. First attempt in 1982 not
• Positions filled early through side-deals
successful.
• Residents forced to accept less desirable options
• Programs do not abide by uniform appointment dates • Creates an impartial venue for matching programs’ and
• Residents & programs do not notify each other when offers applicants’ preferences

are accepted • Establishes a uniform date for appointments to Fellowship
• Gridlock when residents hold more than one offer programs
• Optimizes resident and program preferences
Benefits of a Fellowship Match
• Allows applicants and programs to consider all options
before making commitments
251
AAOS CURRENT STATE OF FELLOWSHIP HIRING:

RESIDENT PERSPECTIVE
Anil S. Ranawat, MD
Facts phone call)

• Approximately 620 residents graduate per year • Internal candidates , less resident mobility
• Fellowship Breakdown • Exploding and lost offers
— Shoulder/Elbow – 5% • “Holding out risk” - how many offers should one deny?
— Hand – 8%
Hypothesis
— Foot & Ankle – 2%
• To obtain meaningful data to verify our assumptions
— Sports – 35%
regarding the impact of a decentralized system on residents
— Spine – 22%
in the fellowship hiring process
— Arthroplasty – 8%
— Pediatrics – 6% Material and Methods
— Trauma – 4% • AOA/HBS administered on-line survey to 112 Residents (~
— Tumor – < 1% 161 accredited Orthopaedic programs in US)
— No Fellowship – 9% — 65 (58%) completed full survey
• 90 % enter fellowship • AOA Resident Leadership Forum (RLF) of 2007 mega issue:
• 75% in decentralized system fellowship employment / hiring process
— Survey was springboard for RLF deliberations
Applying Process
• 27 question survey: general, nonmatch process, match
• Decide on Sub-Specialty
process
• Letters & Application
• Interview Survey Results
• Offer • Fellowship Breakdown
• 2 Resident Case Scenarios: 1. Shoulder/Elbow – 6%
— Spine Applicant 2. Hand – 11%
— Sports Applicant 3. Foot & Ankle – 7%
4. Sports – 43%
Case #1: Spine Applicant
5. Spine – 9%
• Application deadlines due 6/1 (well PGY-3 year) to 8/3
6. Arthroplasty – 4%
• Applied to 14 programs, received 9 offers for interviews
7. Pediatrics – 5%
• Attended only 3 interviews (dates 7/24, 8/12 and 8/16)
8. Trauma – 4%
• All 3 programs offered a position
9. Tumor – 5%
• Was given 24-48 hours to decide for each position
10. No Fellowship – 6%
• Resident accepted position on 8/17
• > 93% enter fellowship
• Turned down a total 6 interviews
• ~ 70% in decentralized system
• “Too risky not to accept position”
• Unraveling, limited interview exposure Survey: Process now takes overΩ one year: unraveling
Case #2: Sports Applicant
• Applied to 16 programs, received 8 offers for interviews
• Attended only 2 interviews (dates 11/30, 12/8)
• First program offered position and was given 24 hours to
accept position
• Resident respond next morning and accepted but was told
“his spot was now gone”
• Went on second interview at resident’s home program
• Home program offered position
• Resident accepted position immediately on 12/8
• Turned down 6 interviews
• “Partly, I stayed at my own institution for job security”
• Exploding/lost offer, internal candidate
Resident Dilemmas
• Decentralized system: Results – Training
• “unraveling” • 29% of residents did not have enough time or exposure in
— Shifts entire process earlier in training their residency to decide which subspecialty to enter
— Lengthens entire process
• Forcing residents to determine career path with less Results – Enough Time?
exposure • 76% (91% of Sports applicants) were given inadequate time
• Adds more time and cost to residents to contemplate an offer
• Creates an environment of : • Over 36% (70% of Sports applicants) asked for more time
• Pressure to accept offers on short notices (i.e. length of a to contemplate an offer
• Over 51% felt pressure to accept an early offers out of job — “uncertainty”
security not job satisfaction — “ego and fear that both sides have and are afraid of being

• 68% of residents had to respond to an offer in under one left out”
week , with 17% under one day (2 had to answer on the • Problems with a match process:
spot on the phone and 2 had less than an hour) — “compliance and consequences for violating rules”
— “not necessary” but favor a more centralized uniform
Results – Interviews
date process
• On average, residents cancelled avg. 2.7 (range 0-8) of their
— “too many small fellowships, with no incentives to join”
interviews
• Resident felt that the ideal interview timing was Jan – March Match Comments
of their PGY-4 year • “Both applicants and fellowship programs would be better
served by reinstitution of the match.”
Results – Offers
• “Match is a must for fellowship. The only way it will work is
• 52% accepted an offer prior to finishing their interviews
if there are consequences for breaking the match.”
• Overall, 50% of residents accepted their first offer!
• “A general orthopaedic fellowship match would be great.
• While 8% of residents lost an offer (i.e. had it withdrawn or
Current system is expensive, stressful, and at times unfair.”
exploded!)
RLF Deliberations
Match vs. non-Match Residents
1) The present system does not work and is unfair
• 73% of match residents felt that that the match worked well
2) Over 90% of the RLF residents prefer a significant reform
versus only 51% of non-match residents
Half the residents prefer subspecialty based matches, while
Resident Perspective the other prefer a central clearinghouse/universal match
• 80% of residents think any-type of match would be better 3) Accountability is ideal,
than the current system, if programs adhered to it 4) The AOA should devout resources to improve the fellowship
• Only 22% of the residents felt that the current system is fair hiring process
to residents.
More Resident Comments
• 61% a universal fellowship match would be better than the
“The process this year was complete chaos! I and others
current system, of the resident involved in match this was
underwent many sleepless nights seeking a program that would
92%
not only be a great fit for our professional goals (which was
• 61% felt that the best penalty for non-compliance was being
challenge enough), but also we had to contend with the
listed on a subspecialty website.
process of wondering if opportunities which were being offered
Comments would be lost without chance of equal replacement. This
• Problems with the present process: process is badly broken and we need to fix it!”
— “back door deals”
253
◆NEW DEVICES AND TECHNIQUES:

THE NEED FOR THE EVIDENCE IS REAL (L)
Moderator: James H. Beaty, MD, Memphis, TN
Description: This symposium will address methods for evaluating the scientific basis for the
adoption of new technologies, including surgical procedures, drugs, biologics and devices,
into orthopaedic clinical practice.
I. Introduction
James H. Beaty, MD, Memphis, TN
II The AAOS And Technology Assessment

Joshua J. Jacobs, MD, Chicago, IL
III. Technology Assessment in Total Joint Arthroplasty

Kevin Bozic, MD, San Francisco, CA
IV. Technology Assessment in Spine Surgery

David Wong, MD, Denver, CO
V. Technology Assessment in Orthopaedic Traumatology

Richard F. Kyle, MD, Minneapolis, MN
VI. Discussion
TECHNOLOGY ASSESSMENT AND THE AAOS

Results from three surveys indicate that AAOS Members want the that the cost to produce Overviews on newer technologies
Academy to undertake technology assessment. The first of these is lower.
surveys, the 2010 Member Needs Assessment, was not exclusively
(3) Is flexible. This plan will be re-visited three years of
devoted to TA, but did ask about it. This survey was mailed to a
approval by the Board of Directors, at which time the Board
random sample of 3,000 active and candidate members in 2004
may decide to terminate the project, continue the program
and yielded a response rate of 21%. Members rated assessment of
as is, increase the scope of the program (by increasing the
“cutting edge” technologies as 3.8 on a 5 point scale, where 1
number of Overviews produced and/or by initiating
represented “not at all important” and 5 represented “extremely
analytical systematic reviews), or otherwise modify it (e.g.
important”.
decide to also produce brochures for patients that are based
The next survey, the AAOS Technology Assessment Survey, was on AAOS’ technology assessment activities).
distributed to between 120 and 140 attendees at the National
The Overviews produced by AAOS will be prepared using the
Orthopaedic Leadership Conference (NOLC) held May 21st and
processes of systematic reviews. This means that the Overviews
22nd, 2005, in Washington DC. Sixty-two surveys were returned
will not take the form of traditional review articles. The
(44% – 52% response rate). Respondents at the NOLC meeting
shortcomings of traditional reviews are well-known, and include
strongly supported (100% of those answering the question)
lack of transparency, lack of rigor in preparation, and the
AAOS involvement in the distribution of technology reviews or
potential for bias. Performing Technology Overviews in a
assessments in a variety of formats. Support for the role of AAOS
systematic manner addresses these shortcomings. Briefly, the
providing regular summary reviews of current evidence on
steps that the Technology Overviews will employ include asking
particular topics was strongest, followed by new/updated
specific and evidence-based questions, including and excluding
evidence guidelines, and then by in-depth HTA reports.
studies according to predefined criteria, comprehensive literature
The third AAOS TA survey, the Member Technology Assessment searches, evaluating the quality of studies (i.e., assigning a level
Survey, was also conducted in 2005, and was administered to a of evidence to each study), and abstraction and presentation of
random sample of approximately 3,000 members. A total of 518 all of the relevant data.
valid responses were received, for a response rate of 17.4%. The
The Overviews will provide a panorama of the “state of the art”,
results suggested “strong support” for TA at AAOS, with a
but will not arrive at conclusions about the effectiveness of a
majority of members indicating that they would be willing to
technology. Rather, the data will be summarized and allowed to
have their dues increased $35 to $50 per year to receive these
“speak for themselves.” Readers will be asked to draw their own
technology reports. As with the NOLC survey, the strongest
conclusions.
support by members (77%) was for “summary reviews of current
evidence.” To conduct TA at AAOS, the Technology Assessment Project Team
will be sunset and the responsibilities for oversight of the
However, exactly what the members understand the term
Technology Overviews program will fall to the Guidelines
“technology assessment” to mean is unclear, their precise reasons
Oversight Committee, renamed the Guidelines and Technology
for requesting it are unclear (e.g. Do they want documents that
Oversight Committee (GTOC), which reports to the Council on
would support reimbursement, do they want to address direct-to-
Research, Quality Assessment and Technology (CORQAT).
consumer advertising, or do they want both?), the effect of a
technology assessment program on AAOS’ relationships with Technology Overviews will be prepared and directed by
industry are uncertain (although at least some industry individual Task Groups newly assembled for each Overview by
representatives have expressed support for such a program), and the GTOC, and with close cooperation with the BOS and
there is a small risk that such an activity could engender orthopaedic specialty societies. Thus, the Task Groups for
litigation. Because of these uncertainties, the present plan is a Overviews will be assembled similar to the way in which AAOS’
“go-slow” plan. guidelines Work Groups are assembled. The GTOC will develop
criteria for selecting topics. This committee will also ensure that
The components of this plan were formulated in large part
the individual Task Groups follow a standardized protocol, help
during the deliberations of the AAOS Board of Directors during
to manage potential conflicts of interest in a fashion similar to
the Technology Assessment Workshop held in Laguna Beach, Ca
the guidelines development process, and review and approve
in April, 2007. At the conclusion of this workshop, the AAOS
draft Technology Overviews.
Board was unanimous in its support of a technology assessment
activity. Members of the Tasks Groups will play a clinical role in
developing Technology Overviews. As such, they will define and
The salient features of the present plan are that it:
develop key questions and write the Overview’s introduction
(1) Begins with development of non-evaluative Overviews (i.e., (which explains the technology’s rationale), review the literature
summaries) of literature on emerging technologies. summaries produced by staff, and review the entire draft
Preparation of these Technology Overviews poses a lower Overview.
legal risk to AAOS than would other technology assessment
Staff will be responsible for literature searching, abstracting
activities (e.g., analytical systematic reviews that
published data into evidence tables, preparing summaries of data
recommend for or against use of a given technology)
that address each key question, preparing all documentation
(2) Begins by focusing on relatively new technologies. The required of a systematic review, disseminating the final Overview,
literature base for such technologies is smaller than the and for all other administrative tasks.
literature base for developed technologies, which means
255
Staff, working in conjunction with the GTOC chair and/or his fellowship, the public and policy makers. Given the central role
designees will design a survey that asks about member that new technology plays in the practice of orthopaedic surgery,
knowledge of, and satisfaction with the Technology Overviews. the AAOS should be a resource for those seeking unbiased
Staff will be responsible for administering the survey, analyzing information on newly developed surgical procedures, drugs,
its results, and preparing a report describing those results to the biologics and orthopaedic devices.
AAOS Board of Directors.
• Impact on Unity Goal
SUMMARY — Technology Overview Task Group members will also be
• Demand for project members of specialty societies, which is similar to the way
in which AAOS clinical practice guidelines Work Groups
This plan was developed in response to member requests for an
are constructed. This arrangement is proving very successful
AAOS Technology Assessment activity.
in promoting unity. Also, the BOS will be involved, which
• Goal of project will also help promote unity.
The goal of this project is to prepare literature summaries (called • Impact on Diversity Goal
Technology Overviews) for AAOS members.
— Where appropriate and feasible, the Project Team will
• Relationship to AAOS Strategic Plan identify gender, ethnic and/or racial disparities in the
outcomes of interventions employing the technology
The AAOS seeks to be the definitive source for musculoskeletal
under review
information and education. This includes education of the
TECHNOLOGY ASSESSMENT IN TOTAL JOINT ARTHROPLASTY

Kevin Bozic, MD, MBA
I. Technology Assessment in TJA 4. However, the cost-effectiveness is sensitive to

a. Introduction variability in the costs of computer navigation
i. Total hip replacement is one of the most common and systems, the accuracy of alignment achieved with
successful orthopaedic procedures. computer navigation, and the probability of
ii. An exponential rise in the volume of TJAs in the revision total knee arthroplasty with malalignmen
coming decades is expected due to different c. Physician Involvement in the Assessment Process
reasons:growing indications for surgery paralleled with i. Managed care organizations continue to stall the
the increase prevalence of osteoarthritis, US aging implementation of new technologies, via different
population, and rapid growth of revision procedures, methods.
to name a few. ii. Physicians can play an important role in choosing the
iii.As the techniques involved with Total Joint technologies they use in their clinical practice.
Arthroplasty and other medical technologies continue iii.Some of the factors that shape physician’s attitude
to evolve, the health care spending and control will towards technology adoption are:
also be influenced. 1. Personal characteristics and advanced training of
b. Importance of Technology Assessement the surgeon
i. The Government, third-party payers, patients, and 2. Access to information about clinical value and
health care providers will seek to pay close attention to profitability of technology
changes in health care spending and allocations, 3. Close ties to medical societies and professional
particularly to technologies and medical orgnizations
advancements that will affect large segments of our iv. Physicians can also influence their organizations and
population (i.e. the elderly). institutions to adopt newly developed medical
ii. When considering technology assessments, one must technologies by raising awareness among hospital
look at the Level of Evidence and strength of administrators regarding the financial incentives that
conclusions, with particular emphasis on Level I or new technoogies would provide.
Level II studies, where safety and efficacy of new d. Future Directions
technologies are compared to standard procedures. i. It is imperative then for orthopedic surgeons
iii.Case scenario: TKA computer assisted surgery conducting TJA surgeries to continue paying attention
1. Total knee arthroplasty is one of the most clinically to health technology assessment in current and future
successful and cost-effective interventions in surgical techniques and technologies.
medicine. However, implant malalignment, ii. Orthopedic surgeons should consider economic
especially in the coronal plane, is a common cause factors, evidence based outcome and technology
of early failure following total knee arthroplasty. assessment studies, as well as traditional measures,
2. Computer-assisted surgery has been employed when considering adopting new technologies for use
during total knee arthroplasty to improve the in clinical practice.
precision of component alignment.
3. Computer-assisted surgery is potentially a cost-
effective or cost-saving addition to total knee
arthroplasty.
REFERENCES 6. Morshed, S., K. J. Bozic, et al. (2007). "Comparison of cemented and uncemented
1. Beringer, D. C., J. J. Patel, et al. (2007). "An overview of economic issues in com- fixation in total hip replacement: a meta-analysis." Acta Orthop 78(3): 315-26.
puter-assisted total joint arthroplasty." Clin Orthop Relat Res 463: 26-30. 7. Novak, E. J., M. D. Silverstein, et al. (2007). "The cost-effectiveness of computer-
2. Bozic, K. J. and D. Beringer (2007). "Economic considerations in minimally assisted navigation in total knee arthroplasty." J Bone Joint Surg Am 89(11):
invasive total joint arthroplasty." Clin Orthop Relat Res 463: 20-5. 2389-97.
3. Bozic, K. J., S. Morshed, et al. (2006). "Use of cost-effectiveness analysis to evalu- 8. Pierce, R. G., K. J. Bozic, et al. (2007). "Pay for performance in orthopaedic sur-
ate new technologies in orthopaedics. The case of alternative bearing surfaces in gery." Clin Orthop Relat Res 457: 87-95.
total hip arthroplasty." J Bone Joint Surg Am 88(4): 706-14. 9. Pierce, R. G., K. J. Bozic, et al. (2007). "Health care technology assessment: impli-
4. Bozic, K. J., R. G. Pierce, et al. (2004). "Health care technology assessment. Basic cations for modern medical practice. Part I. Understanding technology adoption
principles and clinical applications." J Bone Joint Surg Am 86-A(6): 1305-14. and analyses." Am J Orthop 36(1): 11-4.
5. Bozic, K. J., A. G. Rosenberg, et al. (2003). "Economic evaluation in 10. Pierce, R. G., K. J. Bozic, et al. (2007). "Health care technology assessment: impli-
orthopaedics." J Bone Joint Surg Am 85-A(1): 129-42. cations for modern medical practice. Part II. Decision making on technology
adoption." Am J Orthop 36(2): 71-6.
257
TECHNOLOGY ASSESSMENT IN SPINAL SURGERY

David A. Wong MD, MSc, FRCS(C)
Several entities have issued technology assessments in the area • Neither of the clinical trials reaching the predicted rate of
of spine surgery. Technology Assessments (TA) have become success used to design the clinical trials (Charite 70%
increasingly important as cost, budget constraints and the need success predicted, actual 57.1%, ProDisc 85% success
to provide stockholder returns exerts pressure on an already taxed predicted, actual 63.5%).
medical system. FDA approval of new technology no longer • Number of patients classified as a success who were still on
translates to payment authorization. narcotic pain medication
• Number of patients excluded from analysis presumably
Health Technology Assessment International (HTAi) has
secondary to missing data (Charite 25.3% fusions, 14.1%
published an excellent overview of Technology assessment and
arthroplasty, ProDisc 11% fusions, 7.5% arthroplasty).
coverage decisions ( Hutton J, Trueman P, Hensall C. Coverage
• Whether a procedure with a 57.1% (Charite) and 63.5%
with Evidence Development:An examination of conceptual and
(ProDisc) composite success rate is truly a good intervention
policy issues. Int J Technol Assess Health Care 2007; 23:425-
that positively affects “net health outcomes”.
436.). It is available free of charge on the HTAi website
(http://www.htai.org/fileadmin/HTAi_Files/HTAi_Publications/P The BCBS TEC assessments are available at;
olicy_Forum_February_2007_IJTAHC_Issues_Paper.pdf) • Artificial Verteberal Disc Replacement
http://www.bcbs.com/betterknowledge/tec/vols/20/20_01.html
Analysis of recent TA’s is instructive. The TA’s of disc arthroplasty
• Artificial Lumbar Disc Replacement
by the Blue Cross Blue Shield Technology Evaluation Center
http://www.bcbs.com/betterknowledge/tec/vols/22/artificial-
(BCBS TEC) brings up a number of issues;
lumbar-disc.html
A fundamental concern expressed in the reports was the level of
evidence available for the baseline control procedure of spinal A specialty Society Coalition also testified at a Center for
fusion. This raised an element of uncertainty in the minds of the Medicare and Medicaid Services (CMS) Medicare Coverage
reviewers for comparing the intervention (disk arthroplasty) to a Advisory Committee (MCAC) meeting on Lumbar Fusion in
valid control group. November, 2006. The Agency for Healthcare Research and
Quality (AHRQ) prepared a TA for that meeting at the request of
There was criticism of the lack of randomized controlled trials
CMS. It is available at:
for disc arthroplasty (Charite and Prodisc at the time of the 2007
BCBS evaluation and Charite only at the time of the 2006 CMS http://www.cms.hhs.gov/mcd/viewtechassess.asp?from2=viewt
and 2005 BCBS reports). Several concerns were raised about the echassess.asp&where=index&tid=41&
RCT’s.
Other AHRQ TA’s in the spinal area include;
• Non inferiority of the designs vs. superiority (Charite with a • Lumar Decompression
d=0.15 i.e. 95% confidence interval could allow a 15% http://www.cms.hhs.gov/mcd/viewtechassess.asp?where=search
worse result compared to BAK and still meet non-inferiority &tid=47
criteria. For ProDisc d=0.125 i.e. 95% confidence interval • Kyphoplasty
would allow 12.5% worse result compared to http://www.cms.hhs.gov/mcd/viewtechassess.asp?where=search
circumferential fusion. FDA requested 10% for non- &tid=25
inferiority.
TECHNOLOGY ASSESSMENT IN ORTHOPAEDIC TRAUMATOLOGY

Richard F. Kyle, MD
OVERVIEW II. ORTHOBIOLOGICS

Orthopaedic surgeons are structural engineers of the skeleton. There has been an explosion of orthobiologics in the orthopaedic
Once a bone is fractured, we as orthopaedists have one of three industry. A Medline search from 1998 to 2007 shows one RCT
ways to stabilize this bone until it heals and resumes its function for allograft versus autograft for distal radial fracture; on HA
of carrying a load and restoring mobility. We can use external cement versus autograft for metaphyseal bone voids, one RCT;
fixation - we can use plates - we can use intramedullary rods. All on casting plus or minus percutaneous bone marrow injection,
of these systems have been available for years, but recently new one RCT; on BMP2 allograft versus autograft for tibial shaft
technologies have expanded techniques and the complexity of fractures with bone defect, one RCT; on BMP2 versus no graft in
these devices. In addition, orthobiologics have started to play a open distal tibial fractures, three RCTs; on DBM putty versus iliac
prominent role in trauma care. This discussion will address crest autograft for long bone fractures, one RCT. Again, this is a
technology assessment of techniques, implants and Medline search over ten years.
orthobiologics that have recently been brought into the trauma
When one critically analyzes the literature of bone grafts and
field.
bone graft substitutes in orthopaedic trauma surgery, one finds
• Evolution of Plates that DBM has only Grade C level evidence; BMP Grade A; for
Straight plates _ pre-contoured plates _ locked plates _ new allograft alone there are no articles written; calcium phosphate
insertion techniques collograft Grade B and Grade A; HA, Grade A; bone marrow
• Evolution of Intramedullary Rods aspirate, Grade B; and PRP there are no articles written. This was
IM rods unlocked _ IM rods locked _ new insertion sites _ reviewed by DeLong, et al in JBJS in 2007. (2)
techniques
The bottom line is MIPO techniques, locking plates, and ortho-
• Evolution of Orthobiologics
biologics have been integrated into standard orthopaedic practice
Autogenous Graft _ Allograft, Calcium phosphate, Calcium
despite almost complete absence of evidence to their clinical
sulfate, Coral, BMPs, DBMs, Autogenous PPP PRP _ widely
efficacy and cost effectiveness.
used for nonunions, local defect, segmental defect, open
fractures The questions for us today are, what is the best use for new
technology and how do we evaluate it?
How do orthopaedic surgeons evaluate these new developments
and integrate them into their clinical practice? 1. Is it safe?
2. Does it work?
I. TECHNIQUES 3. Is it cost effective?
Minimally invasive percutaneous plate osteosynthesis (MIPO)
III. HOW SHOULD YOU EVALUATE NEW TECHNOLOGY?
has been introduced in the last few years. This technique was
There are four basic components.
introduced by Christian Krettek, M.D. and presented in an article
1. Understand what your results are.
in Injury in 1997. (1) There were only 14 cases presented in this
2. Compare your results to your peers.
paper and five were left with clinically significant deformities.
3. Review the literature.
The author's noted that great care must be taken to restore
4. Start slowly, stay within your capabilities, make sure it is
alignment. There have been twelve case series of distal femur
really working for you.
and proximal distal tibia fixation with MIPO, but no comparative
You must look up your own outcomes and complications and
trials.
follow your patients carefully. The old saying, good judgment
There has been an explosion of locking plates for almost every comes from experience, experience comes from bad judgment is
bone in the body including the volar distal radius, proximal definitely true.
humerus, distal humerus, distal femur, proximal tibia and distal
To track your outcomes, you can use a simple computer data base
tibia. The question is, have any of these been compared to
to record your follow up and complications. There are simple
standard techniques used before locking plates? When one
scoring systems available such as SF-12, Oxford Hip and Knee
reviews a Medline Search 1998 - 2007 on volar distal radial
scores. You must then review your results periodically. Attending
plates, there is only one randomized comparative trial (RCT); on
local and national meetings to compare your results and
proximal humerus, there are no RCTs; on distal humerus, there
experience with others is critical. You must discuss these with
are no RCTs; on proximal femur, there are no RCTs; on distal
colleagues and you can many times do this over the Internet
femur, there are no RCTs; on proximal tibia, there are no RCTs;
through the AAOS or OTA. (3) The gold standard is what is
and on distal tibia, there are no RCTs. When one evaluates the
reported in JBJS and JAAOS for your review. This is critical
literature on locking plates to the distal femur during a ten-year
information to look for when beginning to think about using
review, there are a total number of 21 articles. Thirteen of these
any new technique or device.
articles are strictly clinical; only two are comparative studies and
again there are no randomized controlled trials. The FDA has a 510 Pathway to demonstrate the device to be
substantially equivalent to a legally marketed device. Definitely
There are a number of articles that have a discernable conflict.
look for 510 approval. This does not mean that the device is
The author has developed the device in seven instances and there
better, but at least it behaves equivalently to current devices.
is commercial funding involved in six instances.
When it is stated "substantially equivalent" that means that same
intended use and same technological characteristics as the
predicate device.
259
You must also look for evidence based medicine concerning any The big question is, what do you do if the literature does not give
information on the new techniques or new devices. You may you the answer? You may rely on Agency for Health Care and
look at Medline, Knowledge Finder and the Cochrane Data Base. Quality (AHR2) under Technology Assessment. The Health
You must do a critical literature review. What does this article say? Technology Assessment's may also be of value. The Cochrane
Does this article apply to your practice? Library is also a resource for new techniques and technologies.
Most important talk to colleagues who have used these new
What does this article say? Is it a clinical study or is it a
techniques and ask the critical questions - complications,
biomechanical study? Is the effect positive or negative? What is
outcomes, cost.
the effect size, odds ratio? Is the author biased or conflicted?
What is the funding source for the study? And on closer clinical In conclusion, continually evaluate your own practice, know
review, does this article apply to your practice, like patients, and what is working and what isn't, carefully consider new products,
like surgeons? rationale and innovation features. Why is this device/technique
better than what I use now and most importantly, demand
The important factors to look at are rate of complication, re-
evidence. Consider the cost versus effectiveness.
operations, functional outcome, radiological results, and cost.
When reviewing the study, you must also look at the case control; TECHNOLOGY ADVANCES ARE OFTEN GOOD BUT WE
is it a retrospective historical review or a matched prospective SHOULD NOT LET TECHNOLOGY DRIVE SURGICAL
study? Was it randomized, treatment blinded and was there an DECISION MAKING AT THE EXPENSE OF LONG
independent outcome assessment? As noted by Sung in his ESTABLISHED AND REASONABLE INDICATIONS. (5)
presentation at the 2007 OTA Annual Meeting, statistical
difference does not always mean clinically important - an
evaluation of orthopaedic randomized trials showed that a large
percentage of randomized controlled trials, report statistically
different results that are not clinically important. (4)
REFERENCES: 3. AAOS.org and OTA.org

1. Krettek, et al. Injury (Supple 1),1997. 4. Jinsil Sung; Judith Siegel; Paul Tornetta; Mohit Bhandari
2. De Long et al, JBJS 2007; 89-A:649 5. Dr. Edward Hanley, Jr, AO Dialogue 3/06

ORTHOPAEDIC ADVOCACY: THE 2008
ELECTION, THE AAOS, AND YOU (O)
Moderator: Alan S. Hilibrand, MD, Philadelphia, PA
In 2008, Americans will elect a new government which is likely to permanently change the
practice of Medicine in America. These changes will have a major impact on how
Orthopaedic surgeons practice and how they are paid. One of the most important roles of
the AAOS is advocacy on behalf of Orthopaedic surgeons across the USA. This symposium
will provide a current update for Orthopaedic surgeons on the Academy’s advocacy agenda
regarding the platforms of the 2008 Presidential candidates and parties, and describe ways
in which Orthopaedic Surgeons have become involved in the political process, both locally
and nationally.
I. Introduction
Alan S. Hilibrand, MD, Philadelphia, PA
II Advocacy Efforts of the AAOS

David A. Halsey, MD, Springfield, VT
III Washington DC Update

David Lovett, JD, Washington, DC
IV Local Advocacy Efforts and Grassroots

John T. Gill, MD, Dallas, TX
V. Discussion by Speakers and Questions
261
ORTHOPAEDIC ADVOCACY:
THE 2008 ELECTION, THE AAOS, AND YOU (O)

Alan S. Hilibrand, MD
In 2008, Americans will elect a new government which is likely a. Repeal SGR…consider new options for appropriate
to permanently change the practice of Medicine in America. reimbursements.
These changes will have a major impact on how Orthopaedic b. Maintain SGR…but with a new system of setting
surgeons practice and how they are paid. One of the most targets.
important roles of the AAOS is advocacy on behalf of 4. If formula is based upon inflation (Medical Economic
Orthopaedic surgeons across the USA. This symposium will Index):
provide a current update for Orthopaedic surgeons on the a. Could require an additional $250 billion in Federal
Academy’s advocacy agenda regarding the platforms of the 2008 spending
Presidential candidates and parties, and describe ways in which b. estimated cost of $70 billion to Medicare
Orthopaedic Surgeons have become involved in the political beneficiaries.
process, both locally and nationally. 5. Concern in Congress …How to offset these costs?
a. Elimination of drugs from Part B spending.
I. Introduction: Alan S. Hilibrand, MD, Philadelphia, PA b. Use of health information technology.
A. Roles of the AAOS c. “Quality Reporting” (“Pay for Performance”)
1. advocacy • Advocacy Efforts: Pay for Performance = “Quality Reporting”
2. education — Where we stand on “pay for performance” (P4P).
3. research — What the future holds.
B. Communicating with AAOS Fellows — No longer just a “buzzword”…it’s a reality.
1. AAOS Now — Over 50% of commercial HMOs already use P4P
2. AAOS Headlines Now — An attempt to address two concerns – quality and costs
3. Legislative updates • Problem # 1: Quality
C. Goal of Communications — Over 50% of treatment is inappropriate (McGlynn, E.:
1. raise awareness of advocacy issues NEJM, 2003.)
2. educate fellowship regarding policy matters — The older the physician the worse the quality of care.
3. provide opportunities for AAOS fellow involvement — Cost and quality - inverse relationship.
i. education of fellowship re: advocacy issues • Problem # 2: Costs
ii. interactions with patients, friends, community — Health care costs doubled in the last 6 years (16% of the
leaders GNP)
iii. contacts with politicians and policymakers — The costs of health insurance > annual salary of
D. Goal of Symposium: Answer fundamentals for minimum wage earner.
Orthopaedic surgeons — These costs cannot be sustained.
1. what are the primary advocacy issues of the AAOS, and — Many payors have developed P4P programs, even though
why? their success in reducing costs and improving quality is
2. what are the candidates saying, and what does it mean unclear.
to us? 1) Tax Relief and Healthcare Act of 2006:Mandated CMS to
3. how have Orthopaedic surgeons made a difference in implement P4P
the process? 2) March 2007: CMS established Physician Quality Reporting
Initiative (PQRI)
II Advocacy Efforts of the AAOS: David A. Halsey, MD,
— Voluntary program: Could receive a 1.5% bonus
Springfield, VT
— Physicians collect / report their practice data in 74
A. Medicare Issues
performance measures.
• Reimbursement is based upon “Sustainable Growth
— PQRI will be the precursor to a mandatory P4P program.
Rate” formula (SGR)
— CMS will probably roll out by 2009
• SGR – Applies a target for Medicare spending growth
• “Graded” approach:
• If Medicare spending exceeds the predicted value, we
— “Pay for Reporting” treatment data
receive a negative “update.”
— Pay extra if professionally-derived, evidenced-based
• Since 2001: negative “updates” overridden by Congress
guidelines followed.
~ 1.5% “fix”
— Pay more for achievement of successful outcomes.
• 2008: Scheduled reduction to be 9.9%!
• What performance measures are related to orthopaedics?
• 2009-2012: 5% reduction each year
(10 total)
• 2012: Physicians receive 30% less (overhead will not
— Appropriate antibiotic prophylaxis
be decreasing!)
— Thromboembolism prophylaxis
Advocacy Efforts (Medicare Reimbursement):
— Osteoporosis counseling
1. Address flawed formula; secure appropriate payment
• AAOS has been instrumental in development of
for physician services
orthopaedic-related measures.
2. Formula not to be based on GDP – not reflective of
• Will continue to be involved in discussions with CMS as
medical costs
program is developed.
3. Two potential solutions being considered:
• What does the future hold?
— Quality initiative is here to stay – “you can book it!” (Bob III. The Presidential Election and the Health Care Reform
Haralson, MD) Debate

— CMS has gained our attention by attaching it to A. Doctors for Medical Liability Reform Sponsored
reimbursement. Symposium in Orlando, FL in April
— It needs to be physician driven…AAOS will stay at the B. The Importance of Access to Specialty Care
forefront. C. AAOS Activities
B. Advocacy: Medical Liability Reform
IV. Local Advocacy Efforts and Grassroots: John T. Gill, MD,
— Since 1995, nine successful votes in the U.S. House
Dallas, TX
— No bills approved by U.S. Senate.
“Give ‘em Your Two Cents Worth”: John T. Gill, MD
— Democratic-controlled Congress not likely to address
this issue. “Do you know the name of your Congressman?” More
• What are the alternatives? importantly, “Does your Congressman know your name?”
— Continue to raise the issue through the broader context
Politics is about power, money and a host of other things, but
of “healthcare reform”
mostly it is about relationships. It is true that who you know
— Consider legislation that includes options other than
is much more important than what you know. To be a
caps.
successful advocate for your cause will require developing
— May 2007: Bipartisan legislation for pilot project to create
these personal relationships. Given their skill sets, however,
health courts.
physicians should be the best advocates of all.
— Supported by health care, patient safety, and public
policy organizations. Do any of these comments sound familiar?
• “Health courts:”
“Politics is dirty. Political contributions are just bribery. I am
— Expedite medical injury claims
too busy for this. I can’t afford it. Legislators are all a bunch of
— Offer reliable justice for patients and doctors alike
crooks.”
— Improve patient safety
— Improve judicial consistency These are the typical responses one gets when you ask a
— DMLR applauds the goal, but emphasizes the urgency of physician to get involved in the legislative process. As a whole,
a solution. physicians have been slow to engage in the political process,
— “…the real issue is that patients are suffering right now yet year after year we have more at stake in the halls of
because of lawsuit abuse…we can’t afford to await the Congress than just about any other group. Failure to
results of pilot projects.” Stuart Weinstein, MD participate means only that your side of the debate is never
• Focus shifted to state level. heard. The dance goes on whether you show up or not. As you
— AAOS … grants to states at “tipping point” with regards have often heard, “If you do not have a seat at the table, you
to liability reform. are almost certainly on the menu.”
— Over the past three years – over $500,000 to different
What do you have to offer? How can you get involved? What’s
states.
in it for me? How can I get others involved? In this segment we
— Vigilance is needed – trial lawyers try to “poke holes” in
will explore those questions, and more. This is the tactical side
recent initiatives
of politics. You’ve got the message, now how do we get it
• Summary
delivered.
— AAOS Advocacy efforts = Non-partisan
— Supports Congressional Members and candidates who Like many of you, I am in a small private practice. Twenty
support our issues years ago, in 1988, I opened my orthopaedic practice without
— 2008 Election relevant. a shred of political experience or any notion I would ever get
involved to the degree I have. The first ten years, I just practiced
III. Washington DC Update: David Lovett, JD, Washington,
medicine. Much of what we will be discussing comes from
DC
personal experience over the last 10 years, as I have become
I. Major Federal Legislative Issues for 2008
what I like to term, the “Accidental Advocate.” By sharing with
A. Americans for Access to Orthopaedic Surgeons
you some experiences along the way, I hope to encourage and
(AAOS) Act
motivate many more orthopaedic surgeons to interact with
The AAOS Bill - - Comprehensive Musculoskeletal
their elected officials and “Give ‘em your two cents worth.”
Legislative Package
B. Medicare Reimbursement Apply these pearls to learn –
C. The Future of Medical Liability Reform 1) How to navigate a legislative office.
D. Extremity War Injuries and Medical Research Funding 2) Effective communication techniques.
E. Other Federal issues 3) How best to build a relationship with a legislator.
II. Linkage between Federal and State Issues 4) How to budget political contributions.
A. Scope of Practice 5) The power of coalitions.
i. Physicial Therapists (Direct Access and Physician 6) How to get your colleagues involved.
Ownership
ii. Podiatric Issues V. Discussion by Speakers and Questions
B. Other State Issues
C. AAOS Resources available to State Orthopaedic
Societies
263
THE EVOLVING ORTHOPAEDIC SURGEON-

INDUSTRY RELATIONSHIP (CC)
This symposium will explore the current environment regarding the relationship and
potential conflicts of interest between orthopaedic surgeons and industry.

“STARK” THE LAW, THE EXCEPTIONS
AND HOW TO MAKE IT WORK FOR YOUR
PRACTICE WITHOUT GOING “STARK”
RAVING MAD (T)
Michele M. Zembo, MD, New Orleans, LA
Kathleen DeBruhl, New Orleans, LA
THE STARK LAW - FEDERAL PHYSICIAN SELF-REFERRAL PROHIBITION (Social Security
Act § 1877; 42 U.S.C. § 1395nn) This Symposium is a presentation on the “Stark Law” a n
d its implications for Orthopaedic Surgeons & their practices. The basics of “Stark” will be
covered from the perspective of a healthcare attorney, the government and a compliance
officer. Recent changes to “Stark” will be outlined. Specific scenarios will be presented for
interactive discussion with the presenters and the audience that highlight aspects of “Stark”
relevant to orthopaedic surgeons
A. General Discussion
B. Stark Regulations
D. Penalties Under Stark
E. Exceptions Under Stark
F. Stark II, Phase III
G. The Federal Antikickback Statute (Social Security Act §1128B(b); 42 U.S.C. §1320a-
7b(b))
Case Studies
265
“STARK” THE LAW, THE EXCEPTIONS AND HOW TO MAKE IT WORK

FOR YOUR PRACTICE WITHOUT GOING “STARK” RAVING MAD

Michele Zembo, MD, MBA and Kathleen L. DeBruhl, Esq.
THE STARK LAW - FEDERAL PHYSICIAN SELF-REFERRAL directly or indirectly, overtly or covertly, in cash or in
PROHIBITION (Social Security Act § 1877; 42 U.S.C. § kind.
1395nn) D. Penalties Under Stark
A. General Discussion 1. Denial of payment or seeking repayment of claim paid.
1. The Federal Physician Self-Referral Statute (“Stark Law”) 2. A civil money penalty of up to $15,000 for each bill or
prohibits a physician from referring a federal program claim for a service a person knows or should know is for
patient (“Medicare, Medicaid, TRICARE”) to an entity for a service for which payment may not be made and possi-
certain “designated health services” if either the physi- ble exclusion from the Medicare program.
cian, or an immediate family member, has a “financial 3. A civil money penalty of up to $100,000 for each
relationship” with the entity. arrangement or scheme which the physician or entity
2. The Stark Law also prohibits the entity from presenting, knows or should know has a principal purpose of assur-
or causing to be prevented, a claim for payment under a ing referrals which, if directly made, would be in viola-
federal program for a designated health service if such is tion of the prohibition and possible exclusion from the
furnished pursuant to a prohibited referral. Medicare program.
B. Stark Regulations 4. Any person who is required but fails to meet any report-
1. Stark is a limited statute that imposes “strict liability” for ing requirements described above, is subject to a civil
failure to comply. money penalty of not more than $10,000 for each day
2. Stark has issued three (3) sets of regulations that provide for which reporting is required to have been made and
additional restrictions or rules that govern physician possible exclusion from the Medicare program.
financial relationships. These are referred to as “Stark I, E. Exceptions Under Stark
II, and III”. The Stark Law does permit a number of financial relation-
C. Definitions of Stark ships by DHS entities with physicians if “exceptions” are
1. The term “financial relationship” is defined in the Stark met. These “exceptions include the following
Law to include both compensation arrangements and 1. Group Practice Exception. Certain DHS services are
investment and ownership interests. allowed if provided by a Physician in a “Group Practice”
2. “Referral” means the request by a physician for the item as follows:
or service, payable under Medicare Part B, the request for a. Physician Services. An exception is provided for physi-
a consultation (including any tests or procedures ordered cian services provided (i) personally by the physician
or performed by the consulting physician or under the or under the personal supervision of another physician
supervision of the consulting physician), or the request in the same Group Practice as the referring physician;
or establishment of a plan of care by a physician which or (ii) under the supervision of another physician who
includes the provision of the designated health service. is a member of the referring physician’s Group Practice
[Note: A “consulting” physician is limited to a patholo- or is a physician in the same Group Practice.
gist, radiologist or radiation oncologist.] b. In-Office Ancillary Services. This exception allows for
3. A “referral” does not occur if the physician personally referrals for DHS within the same Group Practice. In
performs the service requested. However, a “referral” can order to qualify for the exception, the following
include services provided by physician’s employees, co- requirements must be met:
workers or independent contractors. (i) The referring physician or another physician who is
4. The term “designated health services” (“DHS”) includes a Member of the same Group Practice must per-
the following: sonally furnish the services, or, if other individuals
• Clinical laboratory services such as technicians perform the services, they must
• Physical therapy, occupational therapy, and speech- be directly supervised by the referring physician or
language pathology services a physician in the Group Practice.
• Radiology and certain other imaging services (includ- (ii) The DHS must be furnished in the “same build-
ing PET and other nuclear services) ing” in which the referring physician or his Group
• Radiation therapy services and supplies Practice has an office, “Office” includes a space
• Durable medical equipment and supplies that provides clinical services at least eight (8)
• Parenteral and enteral nutrients, equipment and supplies hours per week and physician or physicians in the
• Prosthetics, orthotics, and prosthetic devices and supplies Group Practice provide at least six (6) hours of
• Home health services and supplies clinical practice.
• Outpatient prescription drugs (iii) The services must be billed by the Group Practice
• Inpatient and outpatient hospital services of which the physician practicing or furnishing
[Note: DHS does not include ambulatory surgery centers.] the services is a Member.
5. A “compensation arrangement” means any arrangement (iv) The Group must meet the definition of the
involving any remuneration between a physician (or an “Group Practice”:
immediate family member of such physician) and an • Must be a single legal entity operating primarily
entity. as an organized medical practice.
6. The term “remuneration” includes any remuneration,
• Each physician who is a Member of the Group ties listed on a recognized foreign, national, or region-
Practice must furnish substantially the full range al exchange in which quotations are published on a

of services physician routinely provides through daily basis.
the Group, including medical care, consultation, b. Hospitals. Also exempt from the ownership prohibi-
diagnosis, or treatment, through the joint use of tion are designated health services provided by hospi-
shared office space, facilities, equipment and tals if the referring physician has an ownership inter-
personnel. est in the hospital itself (and not in a subdivision of
• Substantially all of the services of the physician the hospital) and the referring physician is authorized
members of the Group are furnished through to perform services at the hospital (i.e., on the med-
the Group, are billed under a billing number ical staff).
assigned to the Group and amounts received are c. Rural Providers. The Stark Law exempts designated
treated as receipts of the Group. health services furnished by physician-owned entities
• The overhead expenses of and the income from located in rural areas. The exception applies only if
the practice are distributed in accordance with substantially all (not less than 75%) of the designated
pre-determined methods. health services furnished by the entity are furnished to
• No physician member of the Group directly or individuals residing in the rural area.
indirectly receives compensation based on the 3. Compensation Exceptions. The Stark Law also contains
volume or value of referrals by the physician, the following exceptions applicable only to the prohibi-
with the exception of certain profits and produc- tions on compensation arrangements:
tivity bonuses. a. Rental Office Space and Equipment. The exemption
• Members of the Group personally conduct at for office space protects arrangements for the use of
least seventy-five percent (75%) of the physi- premises in which the lease is in writing, signed by all
cian-patient encounters of the Group Practice. the parties, describes the space or equipment, is for at
• The Group Practice complies with all other stan- least one year and rental payments reflect fair market
dards established by CMS. value.
Note: A physician in a Group Practice may be b. Bona Fide Employment Relationships. This exception
paid a share of the overall profits of the Group, protects arrangements between employers and physi-
or a productivity bonus based on services per- cians, or their immediate family members who have a
sonally performed or services incident to the bona fide employment relationship with the employer
personally performed services, so long as the for the provision of services if the employment is for:
share or bonus is not determined in any manner • identifiable services;
that is directly related to the volume or value of • the amount of payment is consistent with fair mar-
referrals by the physician. ket value; and
(c) Implants Furnished by an ASC. Also exempted are • is not determined in a manner that takes into
implants furnished by an ASC which has physician account (directly or indirectly) the volume or value
ownership, including, but not limited to, cochlear of any referrals by the referring physician.
implants, intraocular lenses, and other implanted c. Personal Service Arrangements. The exemption for
prosthetics, implanted prosthetic devices, and personal service arrangements protects compensation
implanted DME that meet the following conditions: arrangements between an independent physician and
• The implant is implanted by the referring physician an entity where there is a written agreement; the serv-
or a Member of the referring physician’s Group ices to be performed are described with detail; the
Practice in a Medicare-certified ASC with which the term is for at least one year; the compensation to be
referring physician has a financial relationship. paid over the term of the agreement must be set in
• The implant is implanted in the patient during a advance, not exceed fair market value and not be
surgical procedure paid by Medicare to the ASC as determined in a manner that takes into account the
an ASC procedure. volume or value of any referrals or other business gen-
• The arrangement for the furnishing of the implant erated between the parties; and the services to be per-
does not violate the Antikickback Statute. formed under the arrangement must not involve the
• All billing and claims submission for the implants counseling or promotion of a business arrangement
does not violate any federal or State law or regula- or other activity that violates any state or federal law.
tion governing billing or claims submission. d. Physician Recruitment and Retention. This exemption
• The exception does not apply to any financial rela- protects payments made by a hospital to a physician
tionship between the referring physician and any to induce the physician to relocate to the geographic
entity other than the ASC in which the implant is area served by the hospital and to become a medical
furnished to, and implanted in, the patient. staff member. In order to qualify for this exemption:
2. Ownership Exceptions. (i) the physician cannot be required to refer patients
a. Publicly Traded Securities and Mutual Funds. The to the hospital, and the amount of the payment
Stark Law includes a specific exemption for ownership cannot be determined in a manner that takes into
of publicly traded securities and mutual funds, which account, directly or indirectly, the volume or value
applies to ownership of investment securities, includ- of any referrals by the referring physician.
ing shares or bonds, debentures, notes or other debt (ii) CMS provides that a hospital can make payments
instruments, purchased on terms generally available to an existing group in order to assist the group in
to the public. The securities must be listed on the recruiting the physician as long as the remunera-
New York Stock Exchange, the American Stock tion is passed directly through to and remains
Exchange, or any regional exchange in which quota- with the recruited physician, except for actual
tions are published on a daily basis, or foreign securi- recruitment expenses.
267
(iii) In the case of an income guarantee, the costs allo- into and compliant prior to the publication date of
cated by he physician or group practice to the Stark III (September 5, 2007) need not be amended
recruited physician may not exceed the actual during the original term of the arrangement or the
additional incremental costs attributed to the current renewal term. All other indirect compensa-
recruited physician. tion arrangements must be analyzed under the “stand
(iv) The physician practice receiving the hospital pay- in the shoes” provision, and if a direct compensation
ments cannot impose additional practice restric- arrangement exists under the new rules, the arrange-
tions on a physician to practice medicine in the ment must satisfy a direct compensation arrangement
geographic area served by the hospital. exception by December 4, 2007, the effective date of
(v) As part of the exception, the recruited physician Stark III.
must relocate his/her medical practice to the geo- G. The Federal Antikickback Statute (Social Security Act
graphic area serviced by the hospital (unless a resi- §1128B(b); 42 U.S.C. §1320a-7b(b))
dent physician) (the area composed of the lowest 1. Stark and the Antikickback Statute
number of contiguous zip codes from which the a. Both Stark and the federal Antikickback Statute
hospital draws at least 75% of its inpatients) as (“AKS”) address the inherent conflict between a physi-
evidence d by the physician moving his/her med- cian’s financial interests and patient care. However,
ical practice at least 25 miles; or the physician Stark is limited to physician financial arrangements
deriving 75% of his/her revenues from profession- but the AKS can affect any person or entity that vio-
al services furnished to patients not previously lates the statute.
seen by the physician during the prior 3 years. b. While Stark is a very comprehensive statute with vol-
e. Certain Group Practice Arrangements with a Hospital. umes of detailed regulations and guidance; the AKS is
The Stark Law contains an exception for designated an intent-based criminal statute with limited regulato-
health services furnished “under arrangements” to a ry guidance. The AKS is monitored by the Office of
hospital by a Group Practice. The exception is essen- Inspector General for non-compliance, which can
tially a “grandfather” of certain relationships that result in exclusion from the Medicare program and
existed prior to December 19, 1989, and has contin- criminal and civil penalties.
ued in effect without interruption since that date. c. Stark consistently states that compliance with Stark
This exception requires that there be a written agree- does not guarantee compliance with the AKS.
ment whereby “substantially all” (at least 75%) of the 2. Prohibited Activity
designated health services furnished to patients of the The AKS provides criminal penalties for individuals and
hospital are furnished by the Group under the entities that knowingly and willfully offer, pay, solicit or
arrangement and that the compensation paid over the receive remuneration in order to induce business for
term of the agreement is consistent with fair market which payment may be made under a federal healthcare
value, is fixed in advanced, and is not determined in a program. The type of remuneration covered by the
manner that takes into account the volume or value Antikickback Statute includes, but is not limited to, kick-
of any referrals or other business generated between backs, bribes and rebates. This statute applies to any
the parties. such remuneration whether made directly or indirectly,
f. Payments for Items and Services (“Purchased overtly or covertly, in cash or in kind. Moreover, prohib-
Services”). This exception protects payments made by ited conduct includes not only remuneration intended to
a physician to an entity as compensation for items or induce referrals, but also remuneration intended to
services if the items or services are furnished at a price induce the purchasing, leasing, ordering or arranging for
that is consistent with fair market value. any good, facility, service or item paid for by a federal
Note: Physicians are prohibited from “marking up” healthcare program.
certain services to Medicare Patients. 3. Penalties
F. Stark II, Phase III a. Each offense under the Antikickback Statute is punish-
In the September 5, 2007 Federal Register, CMS published able by a fine of up to $25,000 and imprisonment for
the “Stark II, Phase III” Regulations which were effective up to five (5) years. Violators also are subject to
December 4, 2007. These regulations added additional clar- exclusion from the federal healthcare programs upon
ification and restrictions to physician recruitment, personal a determination of violation by the Secretary of the
service arrangements, and lease arrangements. The most Department of Health and Human Services
significant change is in the “stand-in-the-shoes” concept. (“DHHS”), regardless of whether a criminal convic-
1. Stark II, Phase III - Physicians Now “Stand in the Shoes” tion has been obtained.
of Their Group Practice. b. Congress amended the civil monetary provision in
a. Stark III deems a physician to have direct compensa- 1997 to allow the government to recover treble dam-
tion arrangement with a DHS entity if the only inter- ages plus $50,000 for each violation of the
vening entity between the physician and the DHS Antikickback Statute.
entity is his or her “physician organization”. 4. Statutory Exemptions
b. “Physician organization” is a new defined term, which The Office of Inspector General (“OIG”) has enacted sev-
includes the referring physician’s Professional eral exceptions for certain financial arrangements:
Corporation, physician practice, or group practice. a. discounts which are properly disclosed and reflected
That is, a physician will be deemed to “stand in the in the costs claimed or charges made by the provider;
shoes” of the physician organization with which he or b. payments by an employer to an employee for bona
she has a direct financial relationship. fide employment in the provision of covered items
c. Importantly, existing arrangements, which were struc- and services;
tured to satisfy the requirements of the indirect com- c. amounts paid by providers to a group purchasing
pensation arrangement exception and were entered organization (“GPO”) where there is a written agree-
ment between the providers and the GPO specifying 8. “Special Advisory Bulletins”. The OIG has also issued a
the fee and the GPO discloses the amount of the number of “Special Advisory Bulletins” that address a

administrative fee to providers purchasing from the host of issues such as Contractual Joint Ventures, Gifts
GPO; and Other Inducements to Beneficiaries, Practices of
d. waivers of coinsurance amounts in connection with Business Consultants, and Effect of Exclusion from
certain federally qualified healthcare centers; Participation in Federal Health Programs.
e. activities protected by the safe harbor regulations a. April 2003 - Suspicious Contractual Joint Ventures.
(described below); • In this Special Advisory Bulletin, the OIG criticized a
f. certain risk-sharing arrangements; and wide range of contractual arrangements that provid-
g. electronic prescription services. ed health care services under “contract” arrangement.
5. Safe Harbor Regulations • According to the OIG, a “joint venture” is any com-
As set forth above, one of the statutory exceptions mon enterprise with mutual economic benefit.
Congress included within the Antikickback Statute is an This type of “joint venture” does not have to be a
exception for certain payment practices that the Secretary separately organized entity.
of DHHS specifies as being “safe harbored” and, there- b. “Suspect” Joint Ventures have the following character-
fore, not subject to the Antikickback Statute. Examples istics:
of the safe harbors include: • The Owner typically seeks to expand into a health
a. Investment Interests in publicly traded companies care service that can be provided to the Owner’s
b. Small Investment Interests - the “60/40" rule existing patients.
c. Group Purchasing Organizations • The newly created business predominately or exclu-
d. Investments in Group Practices sively serves the Owner’s existing patient base (or
e. Investments in Ambulatory Surgery Centers patients under the control or influence of the
f. Leases of Equipment, Space and Personnel Owner).
g. Personal Service Arrangements • The Owner’s primary contribution to the venture is
h. Investments in Underserved Areas referrals; it makes little or no financial or other
i. Ambulatory Surgery Centers investment in the business, delegating the entire
j. Sales of Medical Practices operation to the Manager/Supplier, while retaining
k. Employment profits generated from its captive referral base.
6. Protection Under the Safe Harbors • The Manager/Supplier is a would-be competitor of
a. According to public statements made by representa- the Owner’s new line of business and would nor-
tives of the OIG and the Department of Justice, as well mally compete for the captive referrals.
as the preamble to the safe harbors, if an arrangement • The Manager/Supplier provides all or many of the
meets one of the applicable safe harbors, it is fully following key services: day-to-day management,
protected from both criminal and civil liabilities billing, equipment, personnel and related services,
under the Antikickback Statute. office space, training and health care items, sup-
b. However, failure to meet all of the requirements of a plies and services.
particular, applicable safe harbor does not make the • The practical effect of the arrangement, viewed in
conduct per se illegal. Rather, the preamble to the its entirety, is to provide the opportunity to the
final safe harbor regulations indicates that conduct Owner to bill for business provided by the
outside the current safe harbors should be judged on Manager/Supplier.
a case-by-case basis. • The parties may agree to a non-compete clause bar-
7. Special Fraud Alerts ring the Owner from providing items or services to
a. The OIG also issues “Special Fraud Alerts” as a vehicle patients coming form other than the Owner and/or
for identifying fraudulent and abusive practices within barring the Manager/Supplier from providing serv-
the healthcare industry. These Special Fraud Alerts ices in its own right to the Owner’s patients.
include: [Note: The OIG extended this analysis to joint
• Joint Venture Arrangements ventures that do not serve federal program benefici-
• Routine Waiver of Co-Payments or Deductibles aries in Advisory Opinion No. 06-01. The OIG
under Medicare Part B refused to protect a DME provider’s “contractual
• Hospital Incentives to Physicians joint venture” because it would carve out all federal
• Prescription Drug Marketing Schemes program patients. The OIG said the “carve out”
• Arrangements for the Provision of Clinical Lab was not sufficient and because the physician could
Services still prescribe the DME to a Medicare patient, this
• Home Health Fraud arrangement still violated the antikickback statute.]
• Fraud and Abuse in the Provision of Medical c. Medical Device Companies. Specifically, on October
Supplies to Nursing Facilities 6, 2006, the OIG published a response to a request
• Fraud and Abuse in Nursing Home Arrangements for guidance regarding physician investment in med-
with Hospices ical device companies. The OIG stated that the princi-
• Fraud and Abuse in the Provision of Services in ples set forth in the 1989 Special Fraud Alert on
Nursing Facilities Contractual Joint Ventures (republished on December
• Physician Liability in Certification of Medical 19, 1994) should govern a physician’s investment in
Equipment and Supplies and Home Health medical device manufacturing and distribution enti-
Services ties as well as group purchasing agents. Thus, a physi-
• Rental of Office Space in Physicians’ Offices cian such as an orthopaedist, must use the following
• Inducements to Patients principles when analyzing his or her interest opportu-
• Contractual Joint Ventures nity in a medical device company:
269
• Investors shall not be chosen because they are in a Case Study No. 2
position to make referrals. A large city hospital is suffering under the weight of its emer-
• Investors who are expected to make a large number gency room. The volume of uninsured and underinsured
of referrals shall not be offered a greater investment patients seeking medical care has tripled since the for-profit hos-
opportunity than those Investors anticipated to pital down the street sold to a company that is going to reopen
make fewer referrals. as a long-term care facility. Even worse, the physician’s on-call
• Investors shall not be encouraged to make referrals has had enough. The physicians, as a medical staff, have met
or encouraged to divest their ownership interest if with the administrator and told her they have to receive some
they fail to sustain an “acceptable level” of referrals. type of compensation for their call services. While resistant, at
• The joint venture shall not track its sources of refer- first, the Board of Trustees recognizes this problem and agrees.
rals and distribute such information to its However, the attorney who advises the Board is not a health care
investors. attorney but has a vague knowledge of Stark and the anti kick-
• The amount of Capital contributed by the Investors back laws. He things this is illegal and tells the Board not to do
shall be proportionate to the returns on invest- it.
ments in the joint venture when compared to a
Is the attorney correct? Are the physicians prohibited from receiving
typical investment in a new business enterprise.
compensation for on-call services? If not, what does it take to make it
• Investors shall not be permitted to “borrow” the
happen?
amount of the Capital Contribution from the joint
venture and pay it back through profit distribution,
Case Study No. 3
thus, eliminating even the need to contribute
Big Orthopaedic Group (“BOG”) is a professional medical cor-
Capital to the joint venture.
poration that has 20 orthopaedic surgeons who practice at three
• Investors shall not be paid extraordinary returns on
different clinical sites. Two of the clinical sites are buildings
the investment in comparison with the risk
owned by BOG. The third site is a leased suite on the third floor
involved.
in a medical office building owned by a local hospital.
Case Study No. 1
BOG wants to purchase an MRI, but has no space in the build-
There are three (3) orthopaedic practices in Rural County,
ings that it owns. The hospital has offered to lease BOG space
Mississippi. Each of the medical practices has its’ own offices,
on the first floor for its MRI. The hospital has also offered to let
staff, equipment and billing systems. One of the medical prac-
BOG use the space at a reduced rate so long as BOG purchases
tices, which consist of three orthopaedic surgeons, owns an
all of its supplies from the hospital and leases an MRI technician
MRI. The physician owners of the various medical practices
who now only works part-time for the hospital. The hospital
found themselves discussing insurance companies, at an Ole
has also offered to do the MRI billing for BOG. BOG thinks this
Miss game. The physicians described how tired they were of the
all sounds like a good deal.
managed care plans negotiating competitive rates among the
groups. The Physicians decided to combat the insurance com- What should they do?
panies and “merge” their medical practices. It also helped that
the group that owned the MRI said it would “split” the profits Case Study No. 4
with the Physicians based on their percentage of referrals. The local orthopaedic group has enjoyed the services of a
regional DME provider for years. A big national DME provider
In their second meeting, the Physicians described the perfect
moves into the area and begins to compete with the regional
merger model. They would form a new “Group” but each the
DME. The local sales rep from the regional DME approaches
practices would still keep its’ own office, employees and equip-
the practice administrator of the orthopaedic group and offers
ment. Each would keep its own billing system but start to use
to do a DME “joint venture” with the group. The sales rep states
the new “Group” tax identification number. Keeping the costs
that they won’t actually form a new company, but the DME
down on this “merger” was the utmost concern. The Physicians
provider will contract with the orthopaedic group to be its
decided to assign different insurance and managed care con-
“exclusive” provider of DME and let the orthopaedic group bill
tracts to each of their practice managers to negotiate. All of the
for the DME it purchases. Additionally, to make it easy for the
Physicians were excited about being able to “band together”.
orthopaedic group, the regional DME company will provide all
Once the “merger” was completed though, they really didn’t see
the inventory, the technician needed, all the management serv-
the need to get together too often.
ices needed, and will bill and collect for the group.
If CMS or the OIG were to review this arrangement, how would the
What should the Practice Administrator do?
Group do?
SYMPOSIA SHOULDER/ELBOW
◆TRENDS AND CONTROVERSIES
IN THE MANAGEMENT OF ELBOW TRAUMA
AND POSTRAUMATIC ELBOW
RECONSTRUCTION: FROM ARTHROSCOPY
TO ARTHROPLASTY (B)
Moderator: Bernard F. Morrey, MD, Rochester, MN
This symposium reviews emerging management concepts for elbow trauma and explores
open and arthroscopic release, interposition arthroplasty, distal humerus hemiarthroplasty,
and total elbow arthroplasty as management of posttraumatic sequela.
I. Welcome and introduction.

Bernard F. Morrey, MD, Rochester, MN
II. The posttraumatic stiff elbow:

Open contracture release
Matthew L. Ramsey MD, Philadelphia, PA
Arthroscopic contracture release
Felix H. Savoie, III MD, New Orleans, LA
III. Coronoid and radial head reconstruction in chronic posttraumatic subluxation

Graham J. W. King MD, London, ON, Canada
IV. Distal humerus nonunion

Joaquin Sanchez-Sotelo MD, Rochester, NY
V. Salvage procedures for postraumatic osteoarthritis:

Interposition arthroplasty
Theodore A. Blaine MD, Providence, RI
Distal humerus hemiarthroplasty
Jeffrey S. Hughes MD, Chatswood, Australia
Total elbow arthroplasty
Bernard F. Morrey MD, Rochester, MN
VI. Case presentations
VII. Questions, answers and discussion
271
THE POSTTRAUMATIC STIFF ELBOW:

OPEN CONTRACTURE RELEASE
Matthew L. Ramsey, MD
I. Overview a. Distention does not increaes the capsule to

a. Classification nerve distance and therefore does not protect
b. Underlying Pathology the nerves when working on the capsule.
c. Considerations of Surgical Approach b. Amount of joint distension dictated by
d. Indications underlying pathology.
e. Results i. Normal Joint 25-35 cc
f. Complications ii. Ankylosis 0-10 cc
g. Conclusions iii. Inflammatory > 40 cc
II. Classification V. Indications for Surgery
a. Extrinsic a. Open Release
i. Periarticular tissues of the elbow i. Applicable to all contractures
1. Joint capsule b. Arthroscopic Release
2. Collateral ligaments i. Evolving (Individulalized based on underlying
3. Muscles pathology and physician experience)
ii. Osteophytes/loose bodies • Very useful for less severe contractures
iii. Heterotopic Ossification • Loss of extension > Loss of flexion
b. Intrinsic • More profound contractures with loss of flexion
1. Intraarticular adhesions require more advanced skills.
2. Cartilage loss or incongruity • Need to address the posteromedial (P-MCL) anf
c. Combined posterolateral capsule.
• Posttraumatic Contracture
III. Underlying Pathology
• Most difficult contractures to manage
a. Simple Contractures
arthroscopically. Pericapsular scarring makes safe
b. Capsular contracture in isolation
separation of the capsule from the underluing
i. Anterior capsule – Limits extension
structures extremely risky. To be performed by the
ii. Posteior/P-MCL – Limits flexion
most experienced arthroscopists.
c. Complex Contractures (Commonly Posttraumatic
c. Evaluation of Articular Involvement
Condition)
i. < 50% Release via approach most comfortable with
i. Capsular contracture as above
ii. > 50% Need to address articular surface
• Must be extremely cautious about capsular scarring
• Continuum of option
to the brachialis and neurovascular structures.
— Interposition arthroplasty
• Capsular volume significantly reduced in
— Total elbow arthroplasty
posttraumatic contractures.
d. Results
ii. Articular involvement
i. Open Release
• Articular adhesions
• Lateral Approach (Motion Gains)
• Articulr deformity
Flex Ext
iii. Periarticular deformity
Husband (1990) 13° 33°
• Malunion/Nonunion
Cohen (1998) 24° 31°
• Ectopic bone
Mansat (1998) 20° 25°
• Prominent hardware
19° 30°
IV.Condiserations about Surgical Approach (Open vs. • Medial Approach (Motion Gains)
Arthroscopic) Flex Ext
a. Open Release Wada (2000) 38° 26°
i. Neurovascular Structures • Considerations
Direct visualivation routine 1. Improvements in flexion better with open
• Outside/In management of the contracture medial approach. Likely because management of
a. Structures outside of the capsule are identified and the structures limiting flexion (P-MCL) are
separated from the capsule before resection capable of being managed with a medial not
b. Arthroscopic Release lateral approach.
i. Neurovascular Structures ii. Arthroscopic Release
• Direct visualization of nerves from within the Flex Ext
joint requires dissection of nerve which is not Savoie (1993) --- 35°
routine. Andrews (1994) 11° 18°
• Safety of work within the joint is increased by Yamaguchi (2002) 15.5° 25.7°
distending the joint prior to instrumentation of 13° 26°
the elbow. This increases the bone to nerve e. Complications
distance. But: i. Open
i. Neuritis
• Ulnar • Median (Jobe)

a. Described with lateral approach • Post Interosseous (Savoie)
b. All nerve problems associated with open release • Median and Radial (Adolfsson)
resolved • Ulnar (Cassells)
c. May be the result of irritation from incresed flexion e) Conclusions
without addressing the P-MCL i. Open and arthroscopic techniques both effective in
• Median managing contractures
ii. No nerve transections reported in major series. ii. Results are comparable and may be better with open
ii. Arthroscopic release. Perceived value of less early postoperative
i. Transient Neuropathy discomfort not proven.
• Most common iii. Complications with arthroscopic release can be
• Mayo Experience (2%) devastating
ii. Transection (A Who’s Who of Competent
Arthroscopists)
REFERENCES 6. Mansat, P., and Morrey, B. F.: The column procedure: a limited lateral approach
for extrinsic contracture of the elbow. J Bone Joint Surg Am, 80(11): 1603-15,
1. Ball, C. M.; Meunier, M.; Galatz, L. M.; Calfee, R.; and Yamaguchi, K.:
1998.
Arthroscopic treatment of post-traumatic elbow contracture. J Shoulder Elbow
Surg, 11(6): 624-9, 2002. 7. Miller, C. D.; Jobe, C. M.; and Wright, M. H.: Neuroanatomy in elbow
arthroscopy. J Shoulder Elbow Surg, 4(3): 168-74, 1995.
2. Cohen, M. S., and Hastings, H., 2nd: Post-traumatic contracture of the elbow.
Operative release using a lateral collateral ligament sparing approach. J Bone 8. Savoie, F. H., 3rd; Nunley, P. D.; and Field, L. D.: Arthroscopic management of
Joint Surg Br, 80(5): 805-12, 1998. the arthritic elbow: indications, technique, and results. J Shoulder Elbow Surg,
8(3): 214-9, 1999.
3. Haapaniemi, T.; Berggren, M.; and Adolfsson, L.: Complete transection of the
median and radial nerves during arthroscopic release of post-traumatic elbow 9. Timmerman, L. A., and Andrews, J. R.: Arthroscopic treatment of posttraumatic
contracture. Arthroscopy, 15(7): 784-7, 1999. elbow pain and stiffness. Am J Sports Med, 22(2): 230-5, 1994.
4. Husband, J. B., and Hastings, H., 2nd: The lateral approach for operative release 10. Wada, T.; Ishii, S.; Usui, M.; and Miyano, S.: The medial approach for operative
of post-traumatic contracture of the elbow. J Bone Joint Surg Am, 72(9): 1353-8, release of post-traumatic contracture of the elbow. J Bone Joint Surg Br, 82(1):
1990. 68-73, 2000.
5. Jones, G. S., and Savoie, F. H., 3rd: Arthroscopic capsular release of flexion con-
tractures (arthrofibrosis) of the elbow. Arthroscopy, 9(3): 277-83, 1993.
273
POST TRAUMATIC CONTRACTURES OF THE ELBOW

Felix H. Savoie III, MD
275
277
CORONOID & RADIAL HEAD RECONSTRUCTION IN CHRONIC POST-

TRAUMATIC ELBOW SUBLUXATION
Graham J. W. King, MD, MSc, FRCSC
CORONOID RECONSTRUCTION RADIAL HEAD RECONSTRUCTION

ANATOMY: ANATOMY:
• sublime tubercle • articulates with capitellum and radial notch of ulna
• guiding ridge and opening angle • articulating dish concave in shape
• medial collateral ligament, capsular and brachialis • anterolateral one-third of articular margin devoid of
attachments cartilage
• head slightly oval in shape and offset from shaft
BIOMECHANICS:
• resisted isometric flexion generates elbow forces up to four BIOMECHANICS:
times body weight • 60% of forces pass across the radio-capitellar joint
• primary stabilizer against posterior subluxation (radial head • secondary valgus stabilizer of the elbow (MCL primary)
secondary) • secondary stabilizer against posterior subluxation (coronoid
• secondary varus stabilizer of the elbow (LCL primary) primary)
• secondary posteromedial stabilizer of the elbow (MCL • secondary stabilizer against posterolateral rotatory
primary) instability (LUCL primary)
CLASSIFICATION: CLASSIFICATION:
• Regan/Morrey: • Mason: I: undisplaced; II: displaced wedge fragments; III:
— I: chip fracture – sign of subluxation/dislocation, not comminuted
avulsion • Mason-Johnson IV: radial head fracture associated with
- II: up to 50% elbow dislocation
- III: greater than 50%
IMAGING:
• O’Driscoll:
• AP, lateral, and oblique elbow radiographs
- Tip – (posterolateral rotatory mechanism)
• bilateral PA radiographs wrists (if wrist pain or comminuted
- Subtype 1. < 2mm
RH fracture)
- Subtype 2. > 2mm
• computerized tomography mandatory for reconstruction
- usually have associated LCL tear, 50% have MCL tear,
associated dislocations common RECONSTRUCTION OF RADIAL HEAD FRACTURES:
• Anteromedial - (varus, posteromedial rotation and axial • partial defect in radial head, consider osteochondral
loading mechanism) allograft
- Subtype 1. anteromedial rim • radial head arthroplasty indicated if capitellum suitable
- Subtype 2. anteromedial rim + tip • fixed head-stem may be superior to bipolar design in setting
- Subtype 3. anteromedial rim + sublime tubercle + tip of residual elbow subluxation
- associated LCL injuries common • radiocapitellar replacement should be considered if
- secondary arthritis common if not reduced capitellum severely damaged by elbow subluxation
• Base – greater than 50% of coronoid fractured, often • concomitant collateral ligament deficiency must be
comminuted addressed with repair or reconstruction
- Subtype 1. Coronoid body and base
SALVAGE OF PERSISTENT ELBOW SUBLUXATION
- Subtype 2. transolecranon basal coronoid fractures
• interposition arthroplasty
- soft tissue injury may be less severe than in tip fractures
• total elbow arthroplasty
- associated radial head fractures common
SURGICAL APPROACH:
IMAGING:
• midline posterior elbow incision preferred in the setting of
• AP, lateral, and oblique elbow radiographs
residual elbow instability
• computerized tomography required to subclassify and for
• alternatively may employ previous lateral or medial
preop planning
incisions
RECONSTRUCTION OF CORONOID FRACTURES: • to expose radial head use muscle-tendon splitting approach
• no good solution for coronoid reconstruction through extensor digitorum comminus common extensor
• best option is reduce and fix unreduced coronoid fragment tendon
• second choice is to use native radial head if available • incise the radial collateral and annular ligaments at mid
• iliac crest grafts and ipsilateral olecranon tip grafts have been portion of the radial head, anterior to the lateral ulnar
reported collateral ligament (LUCL)
• rib chondral grafts may have a role • elevate anterior portion (RCL) if required to improve
• allograft coronoid reconstruction not predictable exposure but avoid detachment of the posterior portion
• reduce and stabilize with screws or buttress plate (LUCL)
• concomitant collateral ligament deficiency must be • coronoid may be well visualized from the lateral incision if
addressed with repair or reconstuction radial head has been or will be excised
• adjuvant external fixation prevents collapse while healing • to expose smaller fragments of coronoid use flexor-pronator
split
• for larger fragments elevate flexor carpi ulnaris and common • radial head arthroplasty in the setting of elbow
flexor origin off medial ulna and medial epicondyle leaving reconstruction generally successful
cuff for reattachment
COMPLICATIONS
POST-OPERATIVE MANAGEMENT • recurrent instability
• depends on rigidity of reconstruction and whether external • non-union or resorption of radial head or coronoid grafts
fixator employed • malunion
• planned flexion contracture may be wise in the setting of • osteoarthritis
more severe boney deficiencies • painful hardware
• stiffness (capsular or due to heterotopic ossification)
RESULTS
• implant loosening
• little information available
• results of coronoid reconstruction variable
REFERENCES 19. Karlstad R, Morrey BF, Cooney WP. Failure of fresh-frozen radial head allografts
1. Amis AA, Dowson D, Wright V. Elbow joint force predictions for some strenuous in the treatment of Essex-Lopresti injury. A report of four cases. J Bone Joint Surg
isometric actions. J Biomechanics; 13:765-775, 1980. Am. 87:1828-33, 2005.
2. Beingessner DM, Dunning CE, Beingessner CE, Johnson JA, King GJW: The effect 20. King GJ, Morrey BF, An KN: Stabilizers of the elbow. J Shoulder Elbow Surg;
of radial head fracture size on radiocapitellar joint stability. Clinical 2:165-174, 1993.
Biomechanics 18:677-681, 2003. 21. King GJW, Zarzour ZDS, Dunning CD, Patterson SD, Rath D, Johnson JA.
3. Beingessner DM, Dunning CE, Gordon KD, Johnson JA, King GJW: The effect of Metallic radial head arthroplasty improves the stability of the medial collateral
radial head excision and arthroplasty on elbow kinematics and stability. J Bone deficient elbow. Clin Orthop; 368:114-125, 1999.
and Joint Surg 86A:1730-1739, 2004. 22. King GJW – “Radial Head Fractures”. Orthopaedic Knowledge Update: Shoulder
4. Beingessner DM, Dunning CE, Gordon KD, Johnson JA, King GJW: The effect of and Elbow II. Norris TR. American Academy of Orthopaedic Surgeons, pg 343-
radial head fracture size on elbow kinematics and stability. J Orthop Res 23:210- 356, 2002.
217, 2005. 23. Knight DJ, Rymaszewski LA, Amis AA, Miller JH. Primary replacement of the
5. Beingessner D, Dunning CE, Stacpoole R, Johnson JA, King GJW. The effect of fractured radial head with a metal prosthesis. J Bone Joint Surg; 75B,572-576,
coronoid fractures on elbow kinematics and stability. Clin Biomechanics 22:183- 1993.
190, 2007. 24. Kohls-Gatzoulis J, Tsiridis E, Schizas C. Reconstruction of the coronoid process
6. Chen CY, Chao EK, Lee SS. Augmentation of elbow stability with radial head with iliac crest bone graft. J Shoulder Elbow Surg. 13:217-20, 2004.
transfer: a case report and review of the literature. Changgeng Yi Xue Za Zhi. 25. Mason ML. Some observations on fractures of the radial head with a review of
19:83-9, 1996. one hundred cases. British J Surg; 42:123-132, 1954.
7. Chung CH, Wang SJ, Chang YC, Wu SS. Reconstruction of the coronoid process 26. Mikic ZD, Vukadinovic SM. Late results in fractures of the radial head treated by
with iliac crest bone graft in complex fracture-dislocation of elbow. Arch Orthop excision. Clinical Orthopaedics; 181:220-228, 1983.
Trauma Surg. 127:33-7, 2007. 27. Moritomo H, Tada K, Yoshida T, Kawatsu N. Reconstruction of the coronoid for
8. Closkey RF, Goode JR, Kirschenbaum D, Cody RP. The role of the coronoid chronic dislocation of the elbow. Use of a graft from the olecranon in two cases.
process in elbow stability. A biomechanical analysis of axial loading. J Bone Joint J Bone Joint Surg Br. 80:490-2, 1998.
Surg; 82:1749-1753, 2000. 28. Moro JK, Werier J, MacDermid J, Patterson SD, King GJW: Outcome of Metal
9. Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the poste- Radial Head Arthroplasty in Acute Radial Head Fractures. J Bone Joint Surg;
rior interosseous nerve during posterolateral approaches to the proximal part of 83A:1201-1211, 2001.
the radius. J Bone Joint Surg; 83A:809-813, 2000. 29. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow. A definition of pri-
10. Dowdy PA, Bain GI, King GJW, Patterson SD. The midline posterior elbow inci- mary and secondary constraints. Clin Orthop; 265:187-195, 1991.
sion. An anatomical Appraisal. J Bone Joint Surg. 77B:696-699, 1995. 30. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the
11. Esser RD. Reconstruction of the coronoid process with a radial head fragment. elbow joint. Am J Sports Med; 11:315-319, 1983.
Orthopedics. 20:169-71, 1997. 31. O’Driscoll SW, Morrey BF, Korinek S, An KN. Elbow subluxation and dislocation.
12. Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJW. Comminuted A spectrum of instability. Clin Orthop; 280:186-197, 1992.
radial head fractures treated with a modular metallic radial head arthroplasty. 32. O’Driscoll SW – “Coronoid Fractures”. Orthopaedic Knowledge Update:
Study of outcomes. J Bone Joint Surg 88A:2192-2200, 2006. Shoulder and Elbow II. Norris TR. American Academy of Orthopaedic Surgeons,
13. Halls AA, Travill A. Transmission of pressures across the elbow joint. Anat pg 379-383, 2002.
Record; 150:243-247, 1964. 33. Papandrea RF, Morrey BF, O'Driscoll SW. Reconstruction for persistent instability
14. Harrington IJ, Sekyi-Out A, Barrington TW, Evans DC, Tuli V. The functional out- of the elbow after coronoid fracture-dislocation. J Shoulder Elbow Surg. 16:68-
come with metallic radial head implants in the treatment of unstable elbow frac- 77, 2007.
tures: A long-term review. J Trauma; 50:46-52, 2001. 34. Patterson SD, King GJ, Bain GI. A posterior global approach to the elbow. J Bone
15. Hotchkiss RN, Weiland AJ. Valgus stability of the elbow. J Orthop Res; 5:372- Joint Surg; 77B(SIII):316, 1995.
377, 1987. 35. Smets S, Govaers K, Jansen N, Van Riet R, Schaap M, Van Glabbeek F. The float-
16. Ikeda M, Oka Y: Function after early radial head resection for fracture. A retro- ing radial head prosthesis for comminuted radial head fractures: a multicentric
spective evaluation of 15 patients followed for 3-18 years. Acta Orthop Scand; study. ActaOrthop Belg; 66:353-358, 2001.
71:191-194, 2000. 36. Szabo RM, Hotchkiss RN, Slater RR Jr. The use of frozen-allograft radial head
17. Janssen RP, Vetger J. Resection of the radial head after Mason Type III fractures of replacement for treatment of established symptomatic proximal translation of
the elbow. J Bone Joint Surg; 80B:231-234, 1998. the radius: preliminary experience in five cases. J Hand Surg 22A:269-78, 1997.
18. Johnson GW. A follow-up of one hundred cases of fracture of the head of the 37. van Riet RP, Morrey BF, O'Driscoll SW. Use of osteochondral bone graft in coro-
radius with a review of the literature. Ulster Med Journal. 31:51-56, 1952. noid fractures. J Shoulder Elbow Surg. 14:519-23, 2005.
279
DISTAL HUMERUS NONUNION

Joaquin Sanchez-Sotelo MD PhD
1. Scope of the problem — Capsular release through nonunion site (avoid

• Reported rate 10% to 25% extensive stripping _ AVN)
• Most common risk factor _ poor initial fracture fixation — Reduction
• Other risk factors – Articular surface _ anatomic
— Extensive comminution – Supracondylar level _ may be shortened if needed
— Osteopenia • No more than 2 cm of shortening
— Severe associated soft tissue injuries • Careful restoration of varus/valgus and rotation
— Smoking • Translate articular segment anteriorly
— Steroids and other immunosuppressive medications • Excavate new olecranon fossa
• Pathology — Iliac crest bone grafting (structural, bone plates)
— Nonunion is usually located at the supracondylar level — Parallel-plating internal fixation technique
— Decreased bone stock – Medial and lateral precontoured periarticular plates
– Progressive bone reabsorption at nonunion site – Multiple long distal screws (interlocking) thru’
– Previously placed hardware (windshield-wiper plates
effect) – True compression at supracondylar level
— Associated articular stiffness • Postoperative management
– Capsular contracture — Anterior splint, full extension, elevation 1-3 days
– Articular adhesions — CPM and/or splints
– Occasionally articular malunion — Monitor for surgical cultures —> antibiotic therapy if
— Ulnar neuropathy in some patients needed
• Outcome
2. Patient evaluation and treatment options
— Helfet JBJS 2003 – all comers
• History and physical exam
– 52 patients with delayed union (13) or nonunion
— Identify and correct risk factors (i.e., smoking)
(39)
— Previous skin incisions
– Previous surgery 39/52
— Ulnar nerve location and function
– Patterns
— Symptoms or signs of infection
• Intercondylar – 13
• Imaging
• Supracondylar – 27
— Plain radiographs
• Transcondylar – 6
— CT with 3D recon, extremely useful for preoperative
• Unicondylar – 6
planning (ORIF)
– Union achieved in 51/52
• Infection work-up
– Average arc of motion 94 degrees
— CBC, sedimentation rate, CRP
– Additional surgery 30%
— Aspiration (elbow joint, nonunion site), fluoroscopy
— Ring JBJS 2003 – “unstable” nonunions
may be needed
– The hand and forelimb cannot be supported
• Treatment options
against gravity
— Bracing
– 15 patients
— Internal fixation with bone grafting
• Union in 12
— Distal humerus hemiarthroplasty
• Additional surgery in 6 of the 12 healed
— Total elbow arthroplasty
— Ring JBJS 2006 – “Osteochondral” nonunions
— Osteoarticular allograft
– Very limited experience: 3 cases
— Arthrodesis
– Union in all
— Resection arthroplasty
– Good function, no AVN
3. Internal fixation — Mayo experience Nonunions with “severe bone loss”
• Goals – 12 patients, low nonunion requiring shortening
— Achieve adequate reduction and fixation and structural graft
— Bone graft/substitutes – Union achieved in all
– Stimulate bone healing – Average ROM 22 to 113 degrees
– Reconstruct structural defects – Complications: AVN (2), deep infection (1), HO (1)
— Release the associated joint contracture
4. Elbow arthroplasty
— Protect the ulnar nerve
• Rationale, indications and contraindications
• Surgical technique
— Joint replacement well accepted for other locations
— Use previous skin incision whenever possible
(femoral neck, proximal humerus, radial head)
— Work on both sides of the triceps whenever possible,
— Good-track record of some elbow implants (i.e.,
otherwise
Coonrad-Morrey)
– Olecranon osteotomy
— Benefits
– Triceps reflection (Bryan-Morrey vs TRAP)
– Extensor mechanism left undisturbed
— Identify/protect/transpose ulnar nerve
– No postoperative protection required
— Thorough nonunion debridement
– Functional ROM predictable
– Deep cultures (three to five), pathology optional
– Avoids pain secondary to DJD, AVN, malunion
– No postoperative protection required — AAROM program

— Disadvantages • Outcome (Mayo Clinic experience)
– Need to limit the use of the upper extremity for life — 92 consecutive cases
– Risk of implant related complications — Average follow-up 6.5 yrs (range 2-20 yrs)
— Indications and contraindications — Previous surgery in 83 %
– Selective as a “salvage” procedure — At most recent F/U
– ORIF felt to be unreliable – No or mild pain 79%
– Low-demand older patient – Average ROM 22 to 135 degrees
– Absence of infection – Complications
• Surgical technique • Aseptic loosening 16 cases
— Posterior skin incision • Component fracture 5 cases
— Ulnar nerve identified/protected/transposed • Deep infection 5 cases
— Bilatero-tricipital approach • Bushing wear 1 case
— Removal of hardware and nonunited fragments, — Survivorship free of removal or revision
cultures, capsular release – 95.7 % @ 2 yrs
— Humeral and ulnar preparation and implantation – 82.1 % @ 5 yrs
– Consider medium-length stem with anterior – 65.3 % @ 10 and 15 yrs
extended flange — Risk of failure increased if
– Antibiotic-loaded cement – Age under 65 years old
– Humeral shortening if needed to achieve full – Two or more previous surgeries
extension – Previous infection
• Postoperative management
— Anterior plaster splint, full extension, elevation 1-3
days
REFEREMCES 8. McKee, M.; Jupiter, J.; Toh, C. L.; Wilson, L.; Colton, C.; and Karras, K. K.:
1. Ackerman, G., and Jupiter, J. B.: Non-union of fractures of the distal end of the Reconstruction after malunion and nonunion of intra-articular fractures of the
humerus. J Bone Joint Surg Am, 70(1): 75-83., 1988. distal humerus. Methods and results in 13 adults. J Bone Joint Surg Br, 76(4):
614-21., 1994.
2. Alonso-Llames, M.: Bilaterotricipital approach to the elbow. Its application in the
osteosynthesis of supracondylar fractures of the humerus in children. Acta 9. Morrey, B. F., and Adams, R. A.: Semiconstrained elbow replacement for distal
Orthop Scand, 43(6): 479-90., 1972. humeral nonunion. J Bone Joint Surg Br, 77(1): 67-72., 1995.
3. Cil, A.; Veillette, C.; Sanchez-Sotelo, J.; and Morrey, B. F.: Linked elbow replace- 10. O'Driscoll, S. W.; Sanchez-Sotelo, J.; and Torchia, M. E.: Management of the
ment: a salvage procedure for distal humeral nonunion. In International smashed distal humerus. Orthop Clin North Am, 33(1): 19-33, vii, 2002.
Congress on Surgery of the Shoulder (ICSS). Edited, Brazil, 2007. 11. Ring, D., and Jupiter, J. B.: Operative treatment of osteochondral nonunion of
4. Figgie, M. P.; Inglis, A. E.; Mow, C. S.; and Figgie, H. E., 3rd: Salvage of non-union the distal humerus. J Orthop Trauma, 20(1): 56-9, 2006.
of supracondylar fracture of the humerus by total elbow arthroplasty. J Bone 12. Ring, D.; Gulotta, L.; and Jupiter, J. B.: Unstable nonunions of the distal part of
Joint Surg Am, 71(7): 1058-65., 1989. the humerus. J Bone Joint Surg Am, 85-A(6): 1040-6, 2003.
5. Helfet, D. L.; Kloen, P.; Anand, N.; and Rosen, H. S.: Open reduction and inter- 13. Ring, D.; Gulotta, L.; Chin, K.; and Jupiter, J. B.: Olecranon osteotomy for expo-
nal fixation of delayed unions and nonunions of fractures of the distal part of sure of fractures and nonunions of the distal humerus. J Orthop Trauma, 18(7):
the humerus. J Bone Joint Surg Am, 85-A(1): 33-40, 2003. 446-9, 2004.
6. Jupiter, J. B., and Goodman, L. J.: The management of complex distal humerus 14. Sanchez-Sotelo J.; O’Driscoll S.W.: Internal fixation using a parallel-plate princi-
nonunion in the elderly by elbow capsulectomy, triple plating, and ulnar nerve ple-based technique for distal humerus nonunion. In International Congress on
neurolysis. J Shoulder Elbow Surg, 1(1): 37-46., 1992. Surgery of the Shoulder (ICSS). Edited, Brazil, 2007.
7. McKee, M. D.; Pugh, D. M.; Richards, R. R.; Pedersen, E.; Jones, C.; and 15. Sanchez-Sotelo, J.; Torchia, M. E.; and O'Driscoll, S. W.: Complex distal humeral
Schemitsch, E. H.: Effect of humeral condylar resection on strength and function- fractures: internal fixation with a principle-based parallel-plate technique. J Bone
al outcome after semiconstrained total elbow arthroplasty. J Bone Joint Surg Am, Joint Surg Am, 89(5): 961-9, 2007.
85-A(5): 802-7, 2003.
281
SALVAGE PROCEDURES FOR POST-TRAUMATIC ELBOW ARTHRITIS:

INTERPOSITION ARTHROPLASTY
Theodore A. Blaine, MD
Available Treatments for Elbow Arthritis Summary of Interposition Results

• Arthroscopy Cheng (fascia) 5 yr f/u 62%
• Osteophyte Excision Kita (fascia) 19 yr f/u 68%
• Ulnohumeral Arthroplasty Oyemade (fascia) 5 yr f/u 76%
• Arthrodesis Froimson (cutis) 3.5 yr f/u 100%
• Allograft Replacement
Salvage after Interposition
• Interposition Arthroplasty
• Is Interposition a successful temporizing procedure?
• Distal Humeral Hemiarthroplasty
• What are the results of late conversion to TEA
• Total Elbow Replacement
• Blaine, Adams, and Morrey, Conversion of Interposition
Interposition Arthroplasty Arthroplasty to Semi-constrained Total Elbow Arthroplasty
• First described 1806 in Elbow Arthritis JBJS 2005
• Tuberculous arthrosis — 13 patients, avg age 50 years
• Park and Moreau — 10 females, 3 males
— 11/13 fascia lata
Interposition Materials
— Avg conv time 12 yrs (5-576 mos)
• Silicone
• Metals Indications
• Tendon • Severe Pain (12/13)
• Muscle • Unstable (8/12)
• Fat • Stiff (1/12)
• Fascia
Technique
Literature – Results 1. Bryan-Morrey posterior approach
1. Kita, Acta Orth Scan, 1977 2. Ulnar nerve Trans (8/13)
• 31 pts, age 27 yrs, 19 yr f/u 3. Avg Op Time 154 min (100-295)
• Fascia Lata 4. Membrane Remnant excised
• Post Trauma 14/15 (93%) sat 5. Semi-constrained TEA
• Infxn 1/8 (12%) sat 6. Cement 13/13
2. Oyemade, Int. Surg. 1983 7. Triceps Repair
• 51 pts, age 30, min 5 yr f/u
Radiographic F/U
• 42 post-trauma, 8 infxn
• Well Fixed 12/13 (92%)
• fascia lata
• Lucent lines 1/13
• 39/51 (76%) sat results
• Bushing Wear 2/13 (15%)
3. Froimson, JBJS 1976
• Bone graft Incorp 7/8 (88%)
• 5 pts, 3.5 yr f/u
• 3 post-trauma, 1 RA,1 charcot Outcomes
• cutis w/ distractor • Avg MEPS 84 (range 65-100)
• 5/5 (100%) sat results • 3 exc, 6 good (69%), 2 fair, 2 poor
• 2/5 mild instability • Pain mild/none 11/13 (85%)
4. Cheng and Morrey, JBJS 2000 • Motion 32-130 (98 degree arc)
• 13 pts, age 33 yrs, 5 yr f/u • Stable 12/13
• fascia lata and distractor ex-fix
Complications
• 62% sat, 69% pain relief
• Heterotopic Oss 1/13
• 4/13 (31%) revised to TEA
• Triceps Weakness 3/13
• 3/13 (23%) donor site morbidity
• Revisions 2/13 (15%)
Current Technique • Instability/ Bushing wear
Achilles Allograft • Osteolysis
• Available
Conclusions
• No Donor Site Morbidity
• Interposition arthroplasty is a surgical option available in
• Inexpensive
young patients with post-traumatic osteoarthritis of the
Surgical Technique elbow.
1. Drill holes distal humerus • Satisfactory results reported in approximately 70% of
2. Achilles Graft overlayed patients in most series.
3. MCL,LCL Reconstruction • Achilles allograft interposition is the current preferred
4. Distraction interposition technique (Morrey).
5. Hinged Fixator • Ligaments (MCL and LCL) should be reconstructed and
6. Distraction applied hinged fixator applied to avoid instability.
• Total Elbow arthroplasty may be performed as a salvage • Interposition may be considered as a temporizing procedure
procedure following interposition, with results comparable in young patients, with TEA planned at a more advanced
to primary TEA. age.
REFERENCES 14. Morrey, B.F.: Distraction arthroplasty: clinical applications. Clin. Orthop. 293:
1. Blaine, TA, Adams, RA, and Morrey, BF: Conversion of Interposition Arthroplasty 46-54., 1993.
to Semi-constrained Total Elbow Arthroplasty in Elbow Arthritis, Journal of Bone 15. Morrey, B.F.; and Adams, R.A.: Semiconstrained arthroplasty for the treatment of
& Joint Surgery, 87-A (2); 286-92, Feb., 2005 rheumatoid arthritis of the elbow. J. Bone Joint Surg . 74-A(4): 479-490, 1992.
2. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow. A triceps- spar- 16. Morrey, B.A.: Post-traumatic contracture of the elbow: operative treatment,
ing approach. Clin Orthop. 1982 Jun;(166):188-92. including distraction arthroplasty. J. Bone Joint Surg. 72-A(4): 601-618, 1990.
3. Cheng, S.L.; and Morrey, B.F.: Treatment of the mobile, painful arthritic elbow 17. Oyemade, G.A.A.: Fascial arthroplasty for elbow ankylosis. Int. Surg. 68: 81-84,
by distraction interposition arthroplasty. J. Bone Joint Surg., 82-B (2):233-238, 1983.
2000. 18. Ramsey, M.L.; Adams, R.A.; and Morrey, B.F.: Instability of the elbow treated
4. Cobb, T.K.; and Morrey, B.F.: Use of distraction arthroplasty in unstable fracture with semi-constrained total elbow arthroplasty. Journ. Bone and Joint Surg. 81A:
dislocations of the elbow. Clin. Orthop. 312: 201-210, 1995. 38-47, 1999.
5. Fernandez-Palazzi F, Rodriguez J, Oliver G. Elbow interposition arthroplasty in 19. Regan, W.D.; and Reilly, C.D.: Distraction arthroplasty of the elbow. Hand
children and adolescents: long-term follow-up. Int Orthop. 2007 Feb 17 Clinics. 9(4): 719-728, 1993.
6. Froimson, A.I.; Silva, J.E.; and Richey, D.G.: Cutis arthroplasty of the elbow 20. Shahriaree, H.; Sajadi, K.; Silver, C.M.; and Sheikholeslmazadeh, S.: Excisional
joint. J. Bone Joint Surg. 58-A: 863-865, 1976. arthroplasty of the elbow. J. Bone Joint Surg. 61-A: 922-7, 1079.
7. Hausman MR, Birnbaum PS. Interposition elbow arthroplasty. Tech Hand Up 21. Schlein, A.P.: Semiconstrained total elbow arthroplasty. Clin. Orthop. 121: 222-
Extrem Surg. 2004 Sep;8(3):181-8. 229, 1976.
8. Kashiwagi D: Osteoarthritis of the elbow joint: Intraarticular changes and the 22. Schneeberger, A.G.; Adams, R.A.; and Morrey, B.F.: Semiconstrained total elbow
special operative procedure, Outerbridge-Kashiwagi Method (O-K Method), in replacement for the treatment of post-traumatic osteoarthitis. J. Bone Joint Surg.
Kashiwagi D (ed). Elbow Joint. Amsterdam, Elsevier Science Publishers, 1985. 79-A: 1211-1222, 1997.
pp. 177-188. 23. Smith, M.A.; Savidge, G.F.; and Fountain, E.J.: Interposition arthroplasty in the
9. King, G.J.W.; Adams, R.A.; and Morrey, B.F.: Total elbow arthroplasty: revision management of advanced haemophilic arthopathy of the elbow. J. Bone Joint
with use of a non-custom semiconstrained prosthesis. J. Bone Joint Surg . 79-A Surg. 65-B (4): 436-440, 1983.
(3): 394-400. 24. Tan V, Daluiski A, Capo J, Hotchkiss R. Hinged elbow external fixators: indica-
10. Kita, M.: Arthroplasty of the elbow using J-K membrane: an analysis of 31 cases. tions and uses. J Am Acad Orthop Surg. 2005 Dec;13(8):503-14.
Acta. Orthop. Scand., 48: 450-455, 1977. 25. Vancabeke M, Lamraski G, Berthe JV, Coessens BC. One-stage elbow interposi-
11. Kraay, M.J.; Figgie, M.P.; Inglis, A.E.; Wolfe, S.W.; and Ranawat, C.S.: Primary tion arthroplasty with a fasciocutaneous distally planned lateral arm flap. Acta
semiconstrained total elbow arthroplasty: survival analysis of 113 consecutive Orthop Belg. 2002 Oct;68(4):392-5.
cases. J. Bone Joint Surg. 76-B: 636-40, 1994. 26. Wright, P.E. II; and Burns, E.B.: Resection and anatomic elbow arthroplasty with
12. Ljung, P.; Jonsson, K.; Larsson, K.; and Rydholm, U.: Interposition arthroplasty and without interposition: indications and results. Amer. Acad. Orth. Surg.
of the elbow with rheumatoid arthritis. J. Shoulder Elbow Surg. 5: 81-85, 1996. Instuctional Course Lectures, 40: 57-60, 1991.
13. Modabber, M.R.; and Jupiter, J.B.: Reconstruction for post-traumatic conditions
of the elbow joint. J. Bone Joint Surg. 77-A (9): 1431-1446, 1995.
283
DISTAL HUMERAL HEMIARTHROPLASTY (DHH)

Jeff Hughes MBBS FRCS(Orth)
History PATIENT FACTORS

• DHH was first described in 1947. Few small series report on Young or Middle Aged Patient
this technique. 1. Absent trochlea – DHH
• Early series reported treatment of a variety of pathologic 2. Unreconstructable or Irretrievably failed ORIF
conditions including trauma, inflammatory arthritis and
Elderly Patient (70yrs) with unreconstructable joint surface
tumour. Prostheses included both custom-made (of various
1. Osteoporotic/Limited Rehabilitation/Bilat Supracondylar
materials) and non-anantomical humeral components from
comminution or low epicondylar fracture – TEA
total elbow systems (Capitellocondyllar, Kudo) and
2. High Demand/Active patient with single column fracture –
anatomical components(Street). The longest follow-up
DHH
reported is 20 years (Shifrin et al 1990)
3. Intact Supracondylar / Epicondyles – DHH
Morphology of the Distal Humerus — Same rehab as an Olecranon fracture/ORIF
• Street (1974) performed 100 cadaveric studies ad identified — Patient cans FWB through a frame or crutches with no
a very uniform shape, with the variation being the width of issues of poly wear
the joint — Fewer implants for peri-prosthetic problems –
• Sorbie (1985) Digitalised fine slice technique reproduced fractures/sepsis etc
the 3D shape of the distal humerus
Contraindications
Role of Distal Humeral Hemiarthroplasty • Infection/ Poor soft tissue coverage
• ORIF remains the gold standard of operative treatment. • Chronic Instability
• The role of Hemiarthroplasty is to restore the complex • Inadequate neurovascular status
articular surface of the distal humerus, when it cannot be • Insufficient bony column support
reconstructed by ORIF techniques with reasonable — Especially epicondyle condylar comminution resulting in
expectations of the surgical goals being achieved. instability
— Radial Head Resection/Coronoid insufficiency
Advantages
• Addresses the primary pathology which is in the humerus only NOTE: Articular cartilage damage of the radial head and sigmoid
fossa due to arthrofibrosis or inflammatory arthropathy
• no obligatory discarding of normal ulna and Radial head
may lead to inadequate pain relief, reduced functional
• Humeral components with anterior flange and condylar
outcomes and uncertain longevity. This represents a
fixation have demonstrated very low loosening rate, which
relative contraindication that may favour a linked TEA.
may allow more demanding use of the limb if there is no
Thus if a DHH is planned it probably should be
poly wear issues to consider
undertaken early rather than late in a failed ORIF
• Avoids use of an ulna component
• Anatomical components potentially restore the normal Surgical Technique
kinematics of the elbow • Pre-requisites for DHH
• Can be converted to TEA at a later stage providing a salvage (1) the ability reconstruct both medial and lateral columns
pathway (2) intact or repairable radial head and coronoid process,
• Delays the exposure of the patient to the potential problems with good articular surface. An eburnated subchondral
of polyethylene wear bone with a congruent articulation maybe acceptable.
(3) intact or reparable MCL and LUCL
Disadvantages
(4) Intact Extensor mechanism
• Technically demanding
• Metal on cartilage articulation Implant Considerations
• Compromises Arthrodesis/Interposition • Currently there are two prostheses with a true anatomical
Arthroplasty as treatment options articulation that can be sourced as a DHH. Neither is FDA
• Additional surgical procedures potentially increases the approved for this use at this point in time.
complications of TEA if required • Early experience has not identified a difference in patient
outcomes between either prosthesis, although there are
Indications
some practical differences.
• Trauma
— Acute Prosthesis Characteristics
— Chronic (Failed ORIF/Malunion/Non-Union/Traumatic Sorbie Questor Anatomical / Monoblock
AVN (WrightMed) Able to be converted to unconstrained TEA
• Avascular Necrosis (2o steroid) Instability issues if radial head is not preserved
• Tumours Central stem allows peri-articular plate
— Resection allows preservation of the epicondyles and No long stems
collateral ligaments No anterior Flange
Articular surface envelopes condyle
• Inflammatory Joint Disease
Latitude Anatomical / Modular
— The use in inflammatory joint disease may need to be (Tornier) Anterior Flange/Longer stem resists posterior muscle vectors
revisited. Early use of hemiarthroplasty with Rheumatoid Able to be converted to either constrained or unconstrained TEA
arthritis resulted in a stiff painful joint, however there maybe Articular surface replaces condyle rather than grabs condyle
a role in the “burnt out” inflammatory joint where the joint Fixation suture hole for MCL/LCL repair
is eburnated and the architecture relatively congruent. Potential pin dissociation if not crimped correctly
In many cases, combined ORIF techniques are used for column The olecranon osteotomy is repaired next using a tension band
fixation. Pre-contoured periarticular plates, threaded K-wires and technique or a periarticular olecranon plate. Although the plate
cerclage sutures are also utilised. Locking plates allow insertion provides the best fixation (and therefore allows more aggressive
of short, unicortical screws to permit passage of the prosthetic early mobilization) there are times when soft-tissue
stem in the humeral canal. considerations prevent its use. The osteotomy is always bone
grafted medially and laterally.
Preoperative Planning
• AP and lateral of both elbows, Fine-cut CT scan to evaluate Treatment of Non-Acute Injuries
articular comminution Hemiarthroplasty may also be used as a salvage reconstruction
• Contralateral elbow xrays permits templating of the distal for cases of, malunion, fixation failure or non-union after failed
humerus for appropriate prosthesis size, if a true AP of the open reduction internal fixation.
affected limb cannot be obtained.
• Sizing is based on the direct correlation between the AP Principles of the reconstruction are:
dimensions of the articular surface and the radii of the Restore column architecture, preserving the collateral ligaments
capitellum and trochlea. As most patients will be and recreating the rotation axis, surgical debridement is essential
osteoporotic elderly females the commonest sizing will be a and in the case of non-union, (tissue should be sent for
small. histopathology and microbiology to rule out infection). If
• Except in cases where a decision has been made to proceed supracondylar bone loss is present following debridement, a
directly to TEA, all distal humeral fractures are approached shortening osteotomy may be required along with medial and
with the goal of internal fixation. In complex cases, the lateral plate fixation. Autogenous bone graft is generally necessary
necessary instruments for internal fixation, hemiarthroplasty to promote bony union, and a source such as the iliac crest
and TEA are available in the operating room and the final should be prepped in these circumstances. The ability to achieve
decision to perform DHH is made upon surgical inspection a stable reconstruction should be carefully considered in these
of the fracture. complex cases where bony and soft tissue anatomy may have
• In many cases, combined ORIF techniques are used if column been significantly altered by prior injury and treatment. If
fixation. Pre-contoured periarticular plates, threaded K-wires concern exists about this, then a linked TEA may offer a more
and cerclage sutures are also utilised. Locking plates allow reliable reconstructive option.
insertion of short, uni-cortical screws to permit passage of the
PITFALLS AND COMPLICATIONS
prosthetic stem in the humeral canal. Leave a broach in the
canal to avoid problems with humeral stem insertion. Problem Cause Solution
Flexion Contracture Oversized spool Check Template, Trial spool
Timing: Acute fractures are associated with a small risk of Prosthetic axis distal directly on to radial head
heterotopic ossification. Timing of the procedure is not to lig axis and coronoid
necessarily crucial, as long as the procedure is undertaken in 7- Insert implant deeper
10 days after acute fracture. Joint Translocation Undertensioned Collateral Re-assess lig repair
lig repair
Patient Position: Lateral decubitus position/ tourniquet with Overtensioned Lig repair
the arm secured to a short arm support. Posterior aspect of the Rotatory Instability Malrotation of component EUA with Xray
distal humerus is parallel to the floor, with the elbow Incomplete restoration
dependent and allowing more than 110 degrees of flexion. of Column Length
Failed Repair LCL
Exposure: Chevron osteotomy of the olecranon. The humeral Block to Flexion Displaced fracture fragments Check Intra-op X-ray
insertions and origins of the MCL and LUCL must be Bone Cement extravasation Await maturation
preserved. The ulna nerve is exposed and protected. Heterotopic Ossification and resect
Radio Capitellar Spool size incorrect Revise Spool
Column reduction must be anatomic so that the insertions of mismatch PLRI See Instability
the collateral ligaments will allow proper restoration of the Olecranon Inadequate Fixation Accurate reduction
rotation axis. Free-hand cuts are generally required as bone loss Osteotomy Inadequate Biology Robust ORIF – plate
from fracture comminution complicates accurate placement of Non-union Bone graft ALL Osteotomies
Ulna Neuritis Acute Neurapraxia pre-op Neurolysis? Transposition?
the cutting jigs.
Increased Neural tension Check Depth of
The trial prosthesis of appropriate size is trialled. Accurate Ulna n instability implant insertion
placement of the prosthesis axis to match the joint axis by Ulna n transposition
Painful K-wires Unstable implant Threaded K-wires, stabilise
identifying he origin of the MCL/LCL
Non-union with tension band sutures
Strict attention should be paid to the depth of insertion and Painful Joint Overstuffed Joint Downsize Spool
rotation. Once the trial is in place, the ulna is reduced over its Arthrolysis Revise to TEA
articular surface and the joint taken through a range of motion. Sepsis/Loose Prosthesis Serology/Aspirate/Staged TEA
Difficulty reducing the ulna suggests that the flexion axis is too Non-Union Serology/ORIF+/-
distal, and the humeral cuts should be revised to prevent an (Condyle/Osteotomy) Bone Graft
overly tight reconstruction. The tracking of the anterior half of Stiff Elbow Overstuffed Joint Downsize spool
the olecranon during elbow flexion and extension can also Arthrofibrosis/HO Surgical release at 6/12
provide a sense of the correct prosthesis rotation.
Post-operative Protocol
A cement restrictor should be used to provide good Patients start passive range of motion from 20-100 degrees, using
pressurization. The ulna is reduced to the distal humeral either continuous passive motion or hourly, self-guided flexion,
prosthesis and the elbow is extended (not cycled) until the extension, pronation and supination. Nighttime extension
cement is cured. splinting is commenced early and changed at six weeks to a
padded turnbuckle in patients with a significant flexion
285
contracture. Active assisted flexibility exercises are begun at 4-6 sidered at 2-3 months. Persistent stiffness despite these efforts
weeks along with antigravity extension exercises. Active use of the can be managed with contracture release by a column approach
arm for daily functions is discouraged before 6 weeks, especially at 6-12 months postoperatively. Heterotopic ossification,
if column fixation was performed as part of the reconstruction. though not common, may occur in the setting of severe elbow
Serial radiographs are obtained to follow healing of the trauma.
olecranon osteotomy and any other internal fracture fixation.

Late complications can include the development of arthrosis of
Pending adequate healing, resistive strengthening is withheld
the sigmoid notch due to mismatch with the size or orientation
until 10-12 weeks.
of the prosthesis. If these patients have disabling mid-arc pain,
Joint stiffness may occur despite a properly performed recon- conversion to a linked TEA may be necessary. Implant loosen-
struction and early mobilization. If stiffness remains unrespon- ing, peri prosthetic fracture and late infection are also possible.
sive to static night splinting, then dynamic splinting can be con-
OUTCOMES
Author No. Implant Results
Mellen + Phalen 1947 4 Acrylic custom
Venable 1952 1 Acrylic custom Good pain relief
MacAusland 1954 4 Nylon custom
Barr + Eaton 1965 1 custom Fractured 4 years post-op
Street + Stevens 1974 10 Distal condylar resurfacing with 7 sizes 5 Post-traumatic, 3 RhA, 2 Inflammatory arthritis/Haemophilia)
(JBJS 56A 1974) Medial approach
Trauma pts:4/5 painless and functional ROM
Inflammatory pts: poor movement/Instability
Schifrin 1990 1 Custom prosthesis 20 year follow-up with sustained pain relief, ROM and well fixed prosthesis
Swoboda + Scott 1999 7 Capitellocondylar Variable results
Papandrea, Hughes, 2004 22 Sorbie Questor (Wright Med) Mult-centre report
O’Driscoll, Frankle, Multiple pathology: Acute/Chronic #, AVN,
Sorbie, Mighell
(ASES Focus 2003)
Hughes, Parsons, 2005 8 Sorbie Questor (Wright Med) Acute and Chronic Distal Humeral #
O’Brien (Tech Shoulder 4 Acute, 4 Chronic distal humeral fractures, age – 46 to 83yrs
Elbow Surg 6(2) Postop ROM: Ext –10 to –45 (avg 22o)
87-97, 2005) Flex 115 to 140 (avg 126o) Movement slightly better in acute pts.
ASES Score: Acute #: 83.5, Chronic# 76.6
Acute # pts had less pain than Chronic #, Chronic pts all had less pain
postop
Union was achieved in all column and olecranon osteotomy ORIF, no
periprostheic lucent lines
Malone, Zarkadas, 2006 29 Sorbie Questor (13) (Wright Med) 3 failed ORIF, 3 Malunions, 23 acute fractures
Jansen, Hughes (Elbow Lattitude (16) Hemiarthroplasty F/U I-88 mths - avg 24mths
Hemiarthroplasty For (Tornier) F/U I-88 mths - avg 24mths
Intra-articular Distal ASES 82/100
Humeral Fracture. SESA Satisfaction 8.1/10
Meeting, Nov2006) Acute marginally better than chronic, Union achieved in 20/20 chevron
osteotomies, column recon united in 2/35 columns healed, with one
malunion
Congruency of articulation was better in chevron ost compared to triceps on
Medial lipping of ulna in 2 pts
REFERENCES 8. Malone, A.A, Zarkadas, P.C, Jansen, S, Hughes, J.S; Elbow Hemiarthroplasty For
1. Barr, J. S., and Eaton, R. G. Elbow reconstruction with a new prosthesis to replace Intra-articular Distal Humeral Fracture. SESA Meeting, Nov2006
the distal end of the humerus:A case report. J Bone Joint Surg Am 1965;47: 9. Papanderea, R.; Hughes, J.; Sorbie, Charles; Frankle, Mark; Mighell, Mark;
1408. O'Driscoll, Shawn, Prosthetic Hemiarthroplasty of the Distal Humerus. ASES
2. Gambirasio, R.; Riand, N.; Stern, R.; and Hoffmeyer, P. Total elbow replacement Meeting Nov 2004
for complex fractures of the distal humerus. An option for the elderly patient. J 10. Parsons, Moby; O'Brien, R. Jason; Hughes, Jeffery S.; Elbow Hemiarthroplasty
Bone Joint Surg Br 2001; 83(7): 974-8. for acute and salvage reconstruction of intra-articular distal humerus fractures;
3. Gramstad, G. D.; King, G. J.; O'Driscoll, S. W.; and Yamaguchi, K. Elbow arthro- Techniques in Shoulder and Elbow Surgery 6 (2):87-97,2005
plasty using a convertible implant. Tech Hand Up Extreme Surg. 2005; 9(3): 153- 11. Shifrin, P. G., and Johnson, D. P. Elbow hemiarthroplasty with 20-year follow-up
63. study. A case report and literature review. Clin Orthop 1990; 254: 128-33.
4. Inagaki, K.; O'Driscoll, S. W.; Neale, P. G.; Uchiyama, E.; Morrey, B. F.; and An, K. 12. Street, D.M and Stevens, P.S.:A humeral replacement prosthesis for the elbow.
N. Importance of the radial head component in Sorbie unlinked total elbow Results in ten elbows. J. Bone Joint Surg. 56A:1147, 1974
arthroplasty. Clin Orthop 2002; 400: 123-31. 13. Swoboda, B., and Scott, R. D. Humeral hemiarthroplasty of the elbow joint in
5. MacAusland, W. R. Replacement of the lower end of the humerus with a prosthe- young patients with rheumatoid arthritis: a report on 7 arthroplasties. J
sis: A report of four cases. Western J. Surg. Gynec. Obstet. 1954; 62: 557. Arthroplasty 1999; 14(5): 553-9.
6. Mellen, R. H., and Phalen, G. S. Arthroplasty of the elbow by replacement of the 14. Venable, C. S. An elbow and an elbow prosthesis. Am. J. Surg. 1952; 51: 1590.
distal portion of the humerus with an acrylic prosthesis. J Bone Joint Surg Am 15. Wevers, H. W.; Siu, D. W.; Broekhoven, L. H.; and Sorbie, C. Resurfacing elbow
1947; 29: 348. prosthesis: shape and sizing of the humeral component. J Biomed Eng 1985;
7. Obremskey, W. T.; Bhandari, M.; Dirschl, D. R.; and Shemitsch, E. Internal fixa- 7(3): 241-6.
tion versus arthroplasty of comminuted fractures of the distal humerus. J Orthop
Trauma 2003; 17(6): 463-5.
TOTAL ELBOW REPLACEMENT AS A TREATMENT AND SALVAGE

FOR TRAUMATIC CONDITIONS
Bernard F. Morrey, MD
FIRST RULE: Use when nothing else will reliably work These conditions have been studied in detail:
A. Acute fracture.
CORRELARY: Don’t avoid at all costs.
Of 21 consecutive elderly patients with severe comminuted
Implications elbow fractures treated by joint replacement all are free of
• Not to be used if ORIF can be reliably performed. pain and have functioning implants (Cobb). No patient has
• Not to be used if interposition arthroplasty is a viable been revised for loosening. Complications include one
option transient ulnar neuropraxia in three cases, reflex dystrophy
But: in one and a fractured ulnar component in one. A triceps
• Do not perform these non-replacement procedures if there sparing surgical technique is used for the latter two
is little chance of success. categories and appears to hasten functional recovery. The
• This lessens predictability of a successful TEA. experience was updated in 2004 revealing maintenance of a
92% satisfactory outcome at 6.5 years (Kamineni). Others
ELBOW REPLACEMENT FOR TRAUMATIC CONDITIONS
have now replicated this experience (Table 1).
I. PRESENTATION
NOTE: Of particular importance is that Frankle has
• Acute fracture
demonstrated poorer results in TEA following failed
• Established arthritis
ORIF.
• Non-union
• Instability ACUTE FRACTURE MANAGED BY COONRAD/MORREY PROSTHETIC
• Stiffness REPLACEMENT
II. INDICATIONS Author Yr Procedure FU/Yr Satisfactory Revision
1. Acute fracture Objective/Subjective
• Ages >60 (65?); low demand Cobb 1997 21 5 87/92 5
• Fx: comminuted, osteoporotic Frankle 1999 12 2 92 --
2. Arthritis Ray 2000 7 3 100 --
Gambirasio 2001 7 3 100 --
• Age >60
Garcia 2002 16 3 94 --
• Motion – unimportant for selection; pain dictates Kamineni 2004 42 6.5 90/95 5%
treatment
• Other Options – interposition arthroplasty not a B. Traumatic arthritis.
reliable option Experience with 41 patients followed for over five years
— Instability reveals a satisfactory rate of over 90 percent. Motion is
— Deformity functional and there were no instances of mechanical
— Pain at rest (+/-) loosening in patients treated with the Mayo modified
3. Nonunion – instability Coonrad implant (Schneeberger). A fracture rate of 6% of
• Age >60 (most are) the ulnar component prompted change of ulnar implant
• No other reliable option – especially osteosynthesis surface design.
• Allograft replacements are unreliable (articulation, C. Ankylosis and stiffness.
ankylosed, arthritic) In 14 patients with fused elbows, a mean flexion arc of 78
III. SPECIFIC CONSIDERATIONS degrees was obtained. This is the most challenging
A. Hemi replacement of value if stability is possible. pathology. Patient satisfaction was 79% at 11 years (Peden).
B. Implant – In general, this should be linked. D. Distal humeral nonunion.
C. Pathology – Bone loss; instability from ligament This group of patients is extremely difficult to manage due
deficiency or soft tissue dissection to address ankylosis. to the pre-existing procedures and complications. Initial
D. Design – Three options available today. experience was with 39 consecutive procedures average age
Discovery; Latitude, Coonrad/Morrey at the time of surgery is 68 years with follow-up over 4 years.
E. Exposure - If the distal humerus is resected as in acute The overall satisfactory rate was 91 percent and motion
fracture or for treating nonunion, the triceps is left averaged from 16 to 127 degrees. Subsequently we have
attached to ulna. This technique allows immediate completed a review of 92 consecutive procedures. At 6.5
motion with low morbidity. years 85% of the patients were satisfied with the operation.
F. The ulnar nerve is always identified and usually isolated; However, 16 (17%) had a mechanical (loosening, fracture)
the radial nerve is identified and managed as appropriate. complication requiring reoperation. Survival at 2 years was
IV. RESULTS – Coonrad-Morrey 96%; at 5 years 82%, and at 10-15 years 65% (Cil).
• Experience with traumatic conditions amenable to SUMMARY
prosthetic elbow includes: • Overall, in over 101 patients with traumatic conditions
1). Traumatic arthritis; treated with TEA, the success rate at five years is
2) traumatic stiffness; approximately 90%.
3) distal humeral nonunion; NOTE: Frankle has demonstrated poorer results in TEA
4) the flail elbow; and following failed ORIF.
5) selected acute fractures.
287
CONCLUSION humeral nonunion. It is effective in the management of the stiff

It is concluded that total elbow arthroplasty is a viable salvage elbow, as well as the flail elbow joint. Soft tissue balance is
option but is the treatment of choice in selected patients with important to enhance longevity; triceps sparing approaches are
acute fracture or with residual posttraumatic arthritis, and distal preferred when possible.
REFERENCES 7. Kamineni S, Morrey BF: Distal humeral fractures treated with non custom total
elbow replacement. J Bone Joint Surg 86A(5):940-947, 2004.
1. Adolfsson L, Hammer R: Elbow hemiarthroplasty for acute reconstruction of
intraarticular distal humerus fractures: a preliminary report involving four 8. Mansat P, Morrey BF: Semiconstrained total elbow arthroplasty for ankylosed
patients. Acta Orthop 77(5):785-777, 2006. and stiff elbows. J Bone Joint Surg 82(9):1260-1268, 2000.
2. Cil A, Veillette CJH, Sanchez-Sotelo J, Morrey BF: Linked elbow replacement: A 9. Mighell MA, Dunham RC, Rommel EA, Frankle MA: Primary semi-constrained
salvage procedure for distal humeral nonunion. Submitted, J Bone Joint Surg arthroplasty for chronic fracture-dislocations of the elbow. J Bone Joint Surg
Am, 2007. 87B(2):191-195, 2005.
3. Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal 10. O’Driscoll SW, An KN, Korinek S, Morrey BF: Kinematics of semiconstrained
humeral fracture in elderly patients. J Bone Joint Surg 79A(6):826-832, 1997. total elbow arthroplasty. J Bone Joint Surg 74B:297-299, 1992.
4. Frankle M, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduc- 11. Peden JP, Morrey BF: A non-custom semiconstrained total elbow arthroplasty for
tion and internal fixation and primary total elbow arthroplasty in the treatment the treatment of the fused elbow. (Accepted for publication, JBJS Br, 2007).
of intraarticular distal humerus fractures in women older than age 65. J Orthop 12. Ramsey ML, Adams RA, Morrey BF: Instability of the elbow treated with semi-
Trauma 17(7):473-480, 2003. 2003. constrained total elbow arthroplasty. J Bone Joint Surg 81A(1):38-47, 1999.
5. Gambirasio R, Riand N, Stern R, Hoffmeyer P: Total elbow replacement for 13. Ray PS, Kakarlapudi K, Rajsekhar C, Bhamra MS: Total elbow arthroplasty as pri-
complex fractures of the distal humerus. J Bone Joint Surg 83B(7):974-978, mary treatment for distal humeral fractures in elderly patients. Injury 31(9):687-
2001. 692, November 2000.
6. Garcia JA, Mykula R, Stanley D: Complex fractures of the distal humerus in the 14. Schneeberger AG, Adams R, Morrey BF: Semiconstrained total elbow replace-
elderly. The role of total elbow replacement as primary treatment. J Bone Joint ment for the treatment of post-traumatic arthritis and dysfunction. J Bone Joint
Surg 84B(6):812-816, 2002. Surg 79A:1211-1222, 1997.
CONTROVERSIAL DECISION-MAKING IN
SHOULDER ARTHROPLASTY (S)
Moderator: William N. Levine, MD, New York, NY
This symposium will address the most controversial topics in shoulder arthroplasty
presented by national leaders who will present a balanced and unbiased approach.
I. Resurfacing versus Stemmed Implants: How to Decide and Does it Matter?

Gerald R Williams, Jr., MD, Philadelphia, PA
II. The Never Ending Debate: Total Shoulder versus Hemiarthroplasty

William N. Levine, MD, New York, NY
III. Cuff Tear Arthroplathy: How Do I Decide between Reverse and HHR?
Evan L. Flatow, MD, New York, NY
IV. Treatment for Young, High-Demand Patients: The Biggest Challenge

Ken Yamaguchi, MD, Saint Louis, MO
V. Hemiarthroplasty vs ORIF for 4-Part Proximal Humeral Fractures: My Current

Approach
Leesa M. Galatz, MD, Saint Louis, MO
289
RESURFACING VERSUS STEMMED IMPLANTS: HOW TO DECIDE

AND DOES IT MATTER?
Gerald R. Williams, Jr, MD
I. Introduction 2. Tendency to overstuff the joint

a. Premises a. Oversized head
i. It is desirable to do the most anatomic procedure b. Insufficient reaming with proud placement of
possible the implant.
ii. It is desirable to preserve as much bone and cartilage c. Pain relief slower than replacement
as possible
III. Stemmed Implants—Humeral Replacement
iii. With a diseased glenoid, total shoulder replacement is
a. Two biggest advantages
preferable to hemiarthroplasty1,3-5,8,9
i. Glenoid exposure
iv. Glenoid resurfacing is less desirable in younger
ii. Potentially easier releases—especially inferiorly and
patients
posteriorly
b. Humeral resurfacing and replacement are both indicated
b. Disadvantages
and should be individualized based on the application of
i. Need to address variable humeral anatomy
these premises
1. Neck-shaft angle
II. Humeral Resurfacing 2. Humeral head offset
a. The potential for anatomic humeral reconstruction is ii. Instrumentation of the canal—may need greater
greater with resurfacing than replacement and with exposure
partial resurfacing than with complete resurfacing, 1. Peri-prosthetic fracture
although all can be performed nonanatomically. 2. Perforation
i. Partial resurfacing can maintain the differential in iii. No bone left for arthrodesis
humeral radius between the superior-inferior arc and c. Indications
the medial-lateral arc.6 i. Deficient humeral head and metaphysis
ii. Complete resurfacing obviates the need to address ii. Diseased glenoid
humeral head and intra-medullary offset.2 1. Asymmetric reaming
b. Resurfacing preserves bone for later reconstructive 2. Biologic resurfacing
procedures 3. Prosthetic resurfacing
i. Replacement iii. Severe bone deformity and stiffness
ii. Arthrodesis d. Technique
c. Partial Humeral resurfacing i. Similar to arthroplasty in general
i. Indications ii. Must remove adequate bone to insure accurate
1. Relatively normal glenoid reaming of canal
2. Partial destruction of humeral articular surface iii. Must address humeral head offset and perhaps neck-
a. Osteochondral defect shaft angle.
b. Focal Avascular Necrosis
IV. Does all this matter?
c. Osteoarthritis—mild bone deformity
a. No studies comparing resurfacing to replacement head to
ii. Technique
head.
1. Similar to arthroplasty in general.
b. No outcome studies of partial resurfacing available.
2. Generally patients have less deformity and less
c. Only one author has compared hemi-resurfacing with
stiffness, therefore, the cases are generally easier,
resurfacing and TSR and he has found no difference.7
shorter, and easier to rehabilitate from.
d. Hemi replacement vs. TSR—controversial
d. Complete resurfacing
i. More papers support better pain relief in TSR than
i. Indications
hemi
1. Relatively normal glenoid
ii. The real issue is glenoid longevity
2. Avascular necrosis
3. Osteoarthritis—younger, more active patients
ONE MAN’S APPROACH
4. Desire to avoid the intra-medullary canal
a. Prior infection Glenoid Humeral Age Activity
Disease Deformity level
b. Malunion
Partial resurfacing - + -- ++
ii. Technique Complete resurfacing - ++ -- +
1. Similar to arthroplasty in general. Replacement +++ +++ +++ +/-
REFERENCES: 3. Cofield, R. H.; Frankle, M. A.; and Zuckerman, J. D.: Humeral head replacement
for glenohumeral arthritis. Semin Arthroplasty, 6(4): 214-21, 1995.
1. Bishop, J. Y., and Flatow, E. L.: Humeral head replacement versus total shoulder
arthroplasty: clinical outcomes--a review. J Shoulder Elbow Surg, 14(1 Suppl S): 4. Edwards, T. B.; Kadakia, N. R.; Boulahia, A.; Kempf, J. F.; Boileau, P.; Nemoz, C.;
141S-146S, 2005. and Walch, G.: A comparison of hemiarthroplasty and total shoulder arthroplas-
ty in the treatment of primary glenohumeral osteoarthritis: results of a multicen-
2. Boileau, P., and Walch, G.: The three-dimensional geometry of the proximal
ter study. J Shoulder Elbow Surg, 12(3): 207-13, 2003.
humerus. Implications for surgical technique and prosthetic design. Journal of
Bone & Joint Surgery - British Volume, 79(5): 857-65, 1997.
5. Gartsman, G. M.; Roddey, T. S.; and Hammerman, S. M.: Shoulder arthroplasty 8. Orfaly, R. M.; Rockwood, C. A., Jr.; Esenyel, C. Z.; and Wirth, M. A.: A prospective
with or without resurfacing of the glenoid in patients who have osteoarthritis. J functional outcome study of shoulder arthroplasty for osteoarthritis with an
Bone Joint Surg Am, 82(1): 26-34., 2000. intact rotator cuff. J Shoulder Elbow Surg, 12(3): 214-21, 2003.
6. Iannotti, J. P.; Gabriel, J. P.; Schneck, S. L.; Evans, B. G.; and Misra, S.: The normal 9. Sperling, J. W.; Cofield, R. H.; and Rowland, C. M.: Minimum fifteen-year follow-
glenohumeral relationships. An anatomical study of one hundred and forty up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty
shoulders. J Bone Joint Surg [Am], 74(4): 491-500, 1992. years or younger. J Shoulder Elbow Surg, 13(6): 604-13, 2004.
7. Levy, O., and Copeland, S. A.: Cementless surface replacement arthroplasty
(Copeland CSRA) for osteoarthritis of the shoulder. J Shoulder Elbow Surg,
13(3): 266-71, 2004.
291
THE NEVER-ENDING DEBATE: TOTAL SHOULDER ARTHROPLASTY

VS HEMIARTHROPLASTY
William N. Levine, MD
I. Hemiarthroplasty – Outcomes 7. Matsen [4]

A. Review of peer-reviewed literature 8. Rockwood
1. Levine [1] 9. Summary – most studies have shown clear difference
2. Rockwood/Wirth [2, 3] favoring TSA over HHR with exception of Matsen and
3. Matsen [4, 5] Rockwood
4. Summary – overall satisfactory results especially from
IV.Meta-analysis/Systematic Reviews
some centers; however, concerns about asymmetric
A. Review of peer-reviewed literature
wear brought out by Levine study.
1. Radnay et al [13]
II. Total Shoulder Arthroplasty – Outcomes 2. Bryant [12]
A. Review of peer-reviewed literature 3. Bishop [11]
1. Gartsman [6]
V. Final Thoughts – Where are We Today?
2. Pollock [7]
A. Indications for HHR
3. Edwards [8]
1. 4-part fractures
4. Cofield [9]
2. AVN
5. Summary – overall high patient satisfaction, high
3. Rheumatoid with severe medialization (no glenoid
functional return, low complication rate, excellent
bone stock)
long-term survival of implants.
4. Young Patient – concern of glenoid loosening
III. Comparison Studies – TSA vs HHR B. Indications for TSA
A. Review of peer reviewed literature 1. DJD – most patients
1. Boyd [10] 2. RA – most patients
2. Bishop [11] 3. End-stage AVN with glenoid involvement
3. Edwards [8] 4. Post-capsulorrhaphy DJD
4. Gartsman [6]
5. Sandow
6. Bryant [12]
REFERENCES 8. Edwards, T.B., et al., A comparison of hemiarthroplasty and total shoulder

1. Levine, W.N., et al., Hemiarthroplasty for glenohumeral osteoarthritis: results cor- arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a
related to degree of glenoid wear. J Shoulder Elbow Surg, 1997. 6(5): p. 449-54. multicenter study. J Shoulder Elbow Surg, 2003. 12(3): p. 207-13.
2. Wirth, M.A., et al., Treatment of glenohumeral arthritis with a hemiarthroplasty: 9. Cofield, R.H., Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint
a minimum five-year follow-up outcome study. J Bone Joint Surg Am, 2006. Surg Am, 1984. 66(6): p. 899-906.
88(5): p. 964-73. 10. Boyd, A.D., Jr., et al., Total shoulder arthroplasty versus hemiarthroplasty.
3. Wirth, M.A., et al., Treatment of glenohumeral arthritis with a hemiarthroplasty. Indications for glenoid resurfacing. J Arthroplasty, 1990. 5(4): p. 329-36.
Surgical technique. J Bone Joint Surg Am, 2007. 89 Suppl 2 Pt.1: p. 10-25. 11. Bishop, J.Y. and E.L. Flatow, Humeral head replacement versus total shoulder
4. Lynch, J.R., et al., Self-assessed outcome at two to four years after shoulder hemiarthroplasty: clinical outcomes--a review. J Shoulder Elbow Surg, 2005. 14(1
arthroplasty with concentric glenoid reaming. J Bone Joint Surg Am, 2007. 89(6): Suppl S): p. 141S-146S.
p. 1284-92. 12. Bryant, D., et al., A comparison of pain, strength, range of motion, and function-
5. Matsen, F.A., 3rd, R.T. Bicknell, and S.B. Lippitt, Shoulder arthroplasty: the socket al outcomes after hemiarthroplasty and total shoulder arthroplasty in patients
perspective. J Shoulder Elbow Surg, 2007. 16(5 Suppl): p. S241-7. with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone
Joint Surg Am, 2005. 87(9): p. 1947-56.
6. Gartsman, G.M., T.S. Roddey, and S.M. Hammerman, Shoulder arthroplasty with
or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone 13. Radnay, C.S., et al., Total shoulder replacement compared with humeral head
Joint Surg Am, 2000. 82(1): p. 26-34. replacement for the treatment of primary glenohumeral osteoarthritis: a system-
atic review. J Shoulder Elbow Surg, 2007. 16(4): p. 396-402.
7. Pollock, R.G., et al., Total shoulder replacement for the treatment of primary
glenohumeral osteoarthritis. J Shoulder Elbow Surg, 1995. 4: p. S512.
CUFF TEAR ARTHROPLATHY:

HOW DO I DECIDE BETWEEN REVERSE AND HHR?
Evan L. Flatow, MD
A. HHR for Cuff deficiency C. No upward tilt to baseplate

D. Variable angle locked screws helpful
Special issues with HHR:
E. Inferior screws less angled
1. Cuff deficient: undersize head (and RCR) vs. oversize vs.
F. 0-20° retroversion humeral component notching
“just right”
G. No humerus-glenoid contact –trim osteophytes
2. ?Role for bipolars
H. Tight articulation: no shucking
Indications: PAIN, stable acromial fulcrum I. Arm in ext/ER: Pull, components should stay together
J. Repair subscapularis; consider latyissimus transfer
Technique (Cuff Loss)
K. Large drains for 48 hrs
1. Interscalene block regional anaesthesia
• higher rate hematoma/infection than reg TSR
2. Skin incision
L. Consider abduction pillow for 3-4 weeks
3. Delto-pectoral interval
M.No hard stretches/PT
4. Preserve deltoid origin and insertion
V. Treating Complications
5. Preserve coracoid
Instability
6. Avoid axillary/musculocutaneous nerves
A. Reduce and brace
7. Cement
B. Open reduce
• osteoporotic
C. Repair subscap or pec transfer
• wide canals
D. Increase spacing
• abnormal bone
E. Constrained/high wall liner
8. "New Fulcrum"
F. Larger diameter glenosphere
• preserve coracoacromial arch (esp. CA lig)
Infection
• replace head "in situ" (new superiorly translated
A. 2-stage revision
articulation)
B. Antibiotic cement
• reconstruct anterior/posterior cuff as possible (control
C. Long-term Abs
rotation)
D. Consider resection arthroplasty
9. Omit glenoid
Hematoma
10. Rehabilitation
A. Careful with coumadinized pts
• early passive motion
B. Early wash-out
• strengthening later
C. Large drains
B. Reverse prosthesis D. Prolonged antibiotics
I. Indications Axillary nerve injury
A. Best indication: cuff loss with pseudoparalysis, painful A. Avoid overtensioning
arthritis, elderly patient —be careful straying too far! B. Exploration +/- debulk subscap
B. Contraindications: deltoid loss, infection Mechanical Failure
C. Prepare pts for loss of ER/IR A. Conversion to HHR
II. Preoperative Planning B. Repair +/- grafting
A. Radiographs C. Beware ,igrating screws
B. CT or MRI: ?glenoid bone adequate
C. Deciding between HHR and Reverse-TSR
C. Be sure deltoid works
HHR: Cuff-Deficient Arthritis
III. Approach
Age < 60
A. Deltopectoral
Active
• higher dislocation rate
Stable fulcrum
• best for revision prostheses
AFE > 90 degrees
• allows extensile releases
Use HHR which can be converted to Reverse!
B. Superior
Reverse
• excellent shot for glenoid screws
TSR: Cuff-Deficient Arthritis
• lower dislocation rate
Age > 70
• harder inferior access
Inactive
IV. Technical Pearls
Antero-superior escape
A. Preserve GT even if no cuff –helps space deltoid
Pseudoparalysis
B. Glenoid baseplate flush with inferior glenoid
Use Reverse which can be converted to HHR!
REFERENCES 3. Sirveaux F., Favard L., Oudet D, Huquet D, Walch G., Mole D. “Grammont
1. Boileau P, Watkinson D, Hatzikados A, Hovorka I: The Grammont reverse shoul- inverted total shoulder arthroplasty in the treatment og glenohumeral
der prosthesis: results in cuff tear arthritis, fracture sequelae and revision arthro- osteoarthritis with massive rupture of the cuff. Results of a multicentre study of
plasty. J Shoulder Elbow Surg 15:527-540, 2006. 80 ahoulders” J Bone J Surg, 86B:388-95, 2004.
2. Grammont P, Baulot E: Delta shoulder prosthesis for rotator cuff rupture. 4. Werner C, Steinman P, Gilbart M, Gerber C: Treatment of painful pseudoparesis
Orthopaedics 16:65-68, 1993. due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-
socket total shoulder prosthesis. J Bone J Surg, 87A:1476-1486, 2005.
293
SHOULDER ARTHROPLASY IN THE YOUNG, ATHLETIC PATIENT

Ken Yamaguchi, MD
I. General Comments: Thus, I believe it remains a very good treatment option for
Treatment of the young athletic patient with shoulder patients up to the age of 55 and perhaps even to the upper
arthritis is a very challenging problem. Concerns about 40’s in age. Total shoulder arthroplasty may be appropriate in
improving quality of life during a period when a patient is patients younger than 55 when you have significant
generally active and putting stress on the shoulder must be asymmetric wear of the glenoid and asymmetric luxation of
balanced with concerns about the future longevity of an the humeral head. Additional indications to push the age limit
implant and the implications an early failure. Because of on total shoulder include very low demand individuals.
this, the gold standard of total shoulder arthroplasty is not
IV.Hemiarthroplasty:
always the optimal choice for the athletic and high demand
Hemiarthroplasty is a reasonable option in the following
patient. This presentation will discuss some of the concerns
circumstances:
involved in making arthroplasty choices and what choices
1. Preserve glenoid cartilage.
may be available.
2. Wear glenoid but in an symmetric fashion such that there
a. Fortunately, severe arthritis in the young and high
is no asymmetric wear.
demand patient is relatively rare. When this problem
3. No significant luxation of the humeral head posterior.
does exist, however, improvement of quality of life is an
4. Under the above circumstances hemiarthroplasty can
extremely important objective. Most people would
provide for relatively good pain relief although the results
consider quality of life in the early fifties and sixties more
are not as reliable as total shoulder arthroplasty.
important than quality of life in their seventies and
5. No significant inflammatory arthritis.
eighties. For this reason, delay of appropriate treatment
to a later date is not always the best choice. V. Humeral Head Resurfacing
b. Total shoulder arthroplasty in the best of circumstances Recently humeral head resurfacing has become increasingly
appears to have longevity somewhere around twenty-five popular. Long term results are lacking. However, short term
years. experience suggests that humeral head resurfacing may have
c. Anywhere from sixty to one-hundred per cent of glenoids longevity similar to a standard hemiarthroplasty. It has the
appear radiographically loose in the immediate post- following advantages:
operative period. 1. Humeral head hemiarthroplasties tend to be more
d. Fifty-nine percent of total shoulders have radiographic anatomic in inexperienced surgeons hands as they are
evidence of loosening of the glenoid over time. based on the existing humeral head.
e. Humeral heads are relatively resistant to loosening. 2. There are less concerns regarding revision procedures as
Loosening of the humeral component is generally rare. there is better bone preservation thus there are less
f. Most of these loose glenoids do not become concerns allowing the patient to be more active.
symptomatic but are concerning regarding future 3. If a shoulder fusion is to be required in the future, the
longevity. resurfacing arthroplasty may provide better bone stock
g. Given these concerns, a decision about what to do in a for this.
young patient generally revolves around the glenoid as Disadvantages include:
this is the side that generally fails. 1. A humeral head osteotomy is not performed, thus access
h. Regarding the glenoid these are the issues: to the glenoid become much more difficult if a
1. Resurfacing with a polyethylene glenoid dooms the resurfacing procedure is done on the glenoid side.
procedure to last at best, a maximum of twenty-five 2. Preservation of the bone on the humerus, while
years which is insufficient for younger individuals. theoretically has not been proven, as revision of a
Additionally, the glenoid is presumed to fail much resurfacing may require an osteotomy and eventual lack
earlier in younger patients. of bone similar to a revision of a hemiarthroplasty.
2. Not resurfacing the glenoid can lead to either glenoid- 3. There are concerns whether or not the fixation of a
based pain, loss of function secondary to pain or humeral head hemiarthroplasty will be as good as that
rotator cuff weakness, or glenoid bone erosion from experience for that of stemmed hemiarthroplasty.
metal articulation on bone.
VI. Ream and Run Hemiarthroplasty
II. Arthroplasty Choices: The concept of ream and run hemiarthroplasty in which a
Surgical treatment choices for the young patient include: hemiarthroplasty is done after reaming the glenoid back to a
1. Total shoulder arthroplasty. concentric normal everted position has recently been
2. Conventional shoulder arthroplasty. advocated by Rick Matson. The concept here is that by
3. Resurfacing hemiarthroplasty. reaming the glenoid back to a normal version and removing
4. “Ream and run” hemiarthroplasty. any posterior wear, the hemiarthroplasty will not luxate and
5. Interpositional glenoid arthroplasty with humeral will provide point contact on the glenoid. It is hoped that
hemiarthroplasty. by distributing contact of the hemiarthroplasty over a broad
concentric surface of the glenoid that there will be less
III. Total Shoulder Arthroplasty:
medialization or bone loss over time. Early results have
Total shoulder arthroplasty is the gold standard for surgical
been presented in both JSES, as well as, JBJS and appear to
treatment of arthritis. Given more anatomic humeral head
be promising. Of concern, patients who undergo ream and
replacements and better glenoid fixation methods it is
run should be informed that the procedure remains painful
possible, although not proven, that total shoulder arthroplasty
far longer than a total shoulder arthroplasty.
may have much better longevity than previously known.
VII. Interpositional Arthroplasty 4. The best technique for glenoid implantation is the
Interpositional arthroplasty has been performed in the “parachute” technique first introduced by Michael Worth.
shoulder for a multitude of years. It has been more recently This involves placement of suture anchors around the
popularized by Burkett and Hutton in JSES, 1995. peripheral glenoid and then using these suture anchors to
Resurfacing tissues have included Achilles tendon, anterior then fixate the meniscal allograft.
capsule, miniscule allograft and more recently Xenograft
VIII. Conclusions
substitutes. Long term outcomes from these biological
Treatment options in the young patient with degenerative
resurfacings are unknown. Based on presentations, the
joint disease include:
meniscal allograft seems to have mixed results. In some
1. Total shoulder arthroplasty – usually reserved for patients
experienced surgeons hands, 70 – 80% good results have
greater than 50 – 55 but pushed for younger indications
been reported. Others have reported far less encouraging
in patients with severe asymmetric wear of the glenoid or
results.
luxation or sedentary lifestyle.
My personal observations:
2. Hemiarthroplasty – best for patients with symmetric
1. The meniscal allograft is a very good technique if given
glenoids, especially with patients with some preserved
specific indications. A 70-80% good to excellent result
cartilage.
can be anticipated if done appropriately.
3. Ream and run – maybe a promising treatment method,
2. Substantial preoperative luxation of the humeral head or
but long term results regarding medialization of the
posterior wear of the glenoid is a relative contraindication
glenoid and pain relief are required before widespread
of the meniscal allografting unless extended glenoid
use.
reaming is possible to restore normal version.
4. Interpositional arthroplasty – all patients who cannot be
3. The procedure is much more difficult that a total
treated in the above fashion. This requires a concentric,
shoulder replacement as it requires posterior glenoid
normal verted glenoid.
suture placement. Thus, the exposure of the glenoid
needs to be significantly better than usually obtained for
standard total shoulder arthroplasty. The procedure
should probably be performed only by very experienced
shoulder arthroplasty surgeons.
295
ORIF VS HEMIARTHROPLASTY FOR 4 PART PROXIMAL HUMERUS

FRACTURES
Leesa M. Galatz, MD
I. Introduction by the feeding vessels from the posterior humeral

A. Anatomy- bony and vascular circumflex artery. This fracture very amenable to
1. anterior humeral circumflex artery fixation either percutaneously or open, and should not
2. posterior humeral circumflex artery be treated with arthroplasty.
B. Classification and evaluation B. Contraindications
1. physical examination 1. poor bone quality
2. xrays 2. noncompliant or uncooperative patient
3. CT scan 3. unstable reduction
C. Factors affecting decision making 4. inadequate reduction
1. age 5. significant metaphyseal comminution
2. likelihood of AVN C. Technique
3. fracture configuration 1. equipment- flouroscope, 2.7 mm terminally threaded
4. comminution- tuberosities and proximal shaft pins, cannulated screws
5. bone quality 2. reduction maneuver
6. medical comorbidities D. Pearls
1. shaft pin angle
II. ORIF of four part fractures
2. avoid axillary nerve
A. Indications
3. wide, divergent pin placement
1. younger individuals
E. Pitfalls
2. good bone quality
1. pins in coronal plane
3. minimal comminution of individual bone fragments
2. pins too close to each other
4. valgus impacted 4 part
3. unstable reduction and fixation
5. head split in young person (relative)
B. Implant options IV.Hemiarthroplasty
1. proximal humerus locking plate- preferred A. Indications
a. superior stability a. 4 part proximal humerus fractures
b. precontoured for fit- can help reduce the fracture i. Older individuals
indirectly ii. Osteoporosis- double edge sword. Osteoporosis
2. pins and screws- applicable primarily to valgus makes ORIF more difficult, but it also makes
impacted 4 parts hemiarthroplasty more difficult. It affects
a. not stable enough for other fractures tuberosity healing and failure of tuberosity healing
b. requires comfort level with percutaneous pinning is number one cause of failed hemi for fracture!!
3. intramedullary fixation b. head split fractures
a. biomechanically advantageous in the lab but this is B. Anatomic considerations
not translated clinically a. Height
4. older implants- T plates, blade plates- largely replaced i. Too high-overtension the cuff by trying to reduce
by more modern implants the tuberosities to the shaft OR no contact between
C. Technique Pearls tuberosities and shaft.
1. Deltopectoral approach ii. Too low- humeral head inferiorly subluxes resulting
2. maintain intact soft tissue sleeve- both periosteal and in pain and poor function
rotator cuff. It is common to have some intact soft b. Version
tissue sleeve in even the most comminuted fractures. i. Too anteverted- failure of greater tuberosity with
This not only maintains viability of the fracture internal rotation
fragments, helping healing, but also helps in ii. Too retroverted- failure of lesser tuberosity with
reduction. Many fractures maintain stability after external rotation
fixation by principles of ligamentotaxis. c. Soft tissue concerns- Maintain integrity of rotator cuff
3. Plate lateral- d. Component sizing critical. A head that is too large
a. Stable reduction compromises outcome by overstretching the rotator
b. Version cuff. Too much tension on the cuff impedes tuberosity
c. Head to tuberosity height- 5-8mm healing. If the tuberosities do heal, the tension results
4. avoid joint penetration in cuff attenuation. Either way, you lose with an
5. use of intraoperative fluoroscopy highly oversized head.
recommended!!!! C. Technique
a. incision and exposure
III. Percutaneous pinning
b. gain control of tuberosities
A. Indications
c. *** fracture line usually posterior to biceps groove
1. valgus impacted 4 part fractures- This fracture has a
d. remove head, use for sizing
very low incidence of nonunion due to the intact
e. ream canal
periosteal hinge medial. Blood supply is maintained
f. trial-height, version, head size
g. ***biceps groove located more anteriorly as it courses B. Con ORIF- Proximal humerus malunions and nonunions
distally are some of the most difficult problems to solve
h. always cement surgically. In the case of a malunion or nonunion where
i. suture tuberosities the tuberosity is in a poor position that requires an
i. lesser to shaft osteotomy in order to obtain reduction, a poor result can
ii. greater to shaft be expected.
iii.greater to lesser i. Therefore, if a reasonable reduction can not be
iv. one suture around whole construct- obtained and maintained, consider arthroplasty
j. bone graft tuberosities ii. Beware, locking proximal humerus plates. AVN can
lead to proud screws. Inform patients that this is a
V. The controversy
possibility and keep close surveillance.
A. Pro ORIF- Regardless of fracture type or age, people will
C. Pro arthroplasty- Some fractures not amenable to
always do better with their own bone if an anatomic,
fixation. Fractures in older individuals with high risk of
stable reduction can be obtained and the fracture heals.
AVN or malunion better treated more definitively with
Tuberosities heal much better to the head and shaft, even
hemiarthroplasty.
in the presence of some bone loss. If an anatomic
D. Con arthroplasty- This is a very technically difficult
reduction can be achieved and the tuberosities heal in a
operation and difficulty underappreciated by many.
good position relative to the head, even if the head goes
Diffucult to get optimal results. Results depend on
on to AVN, a humeral head replacement can be
tuberosity reduction and healing. Often, the people
performed with an anticipated good result.
getting a hemi have poor healing potential. This
i. Therefore, approach each fracture with an open mind
represents a significant challenge and limitation.
and see if a reduction and fixation can be reasonably
performed. If so, ORIF…
REFERENCES 6. Jaberg H, Warner JJP, Jakob RP. Percutaneous Stablization of Unstable Fractures
of the Humerus. J. Bone Joint Surg. 1992;74-A:508-515.
1. Neer CSII. Displaced proximal humerus fractures. Part I. Classification and eval-
uation. J. Bone Joint Surg. 1970;52A:1077-1089. 7. Resch H, Povacz P, Frohlich R, Wambacher M. Percutaneous fixation of three-
and four-part fractures of the proximal humerus. Journal of Bone & Joint Surgery
2. Neer CSII. Displaced proximal humeral fractures. Treatment of three-part and
- British Volume. 1997;79:295-300.
four-part displacement. J. Bone Joint Surg. 1970;52:1090-1103.
8. Kraulis J, Hunter G. The Results of Prosthetic Replacement in Fracture-
3. Hawkins RJ. Displaced Proximal Humeral Fractures. Orthopedics. 1993;16:49-
Dislocations of the Upper End of the Humerus. Injury. 1976;8:129-31.
53.
9. Boileau P, Chuinard C, Le Huec JC, Walch G, Trojani C. Proximal humerus frac-
4. Cuomo F, Flatow EL, Maday MG, al e. Open Reduction and Internal Fixation of
ture sequelae: impact of a new radiographic classification on arthroplasty. Clin
Two- and Three-Part Displaced Surgical Neck Fractures of the Proximal Humerus.
Orthop Relat Res. 2006 Jan;442:121-30.
J. Shoulder Elbow Surg. 1992;1:287-95.
10. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Molé D. Tuberosity malposi-
5. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional
tion and migration: reasons for poor outcomes after hemiarthroplasty for dis-
Outcome after Humeral Head Replacement for Acute Three- and Four-Part
placed fractures of the proximal humerus. J Shoulder Elbow Surg. 2002 Sep-
Proximal Humeral Fractures. Journal of Shoulder and Elbow Surgery.
Oct;11(5):401-12.
1995;4:81-86.
297
FRACTURES OF THE CLAVICLE-

CONTEMPORARY CONTROVERSIES (Z)
Moderator: Jesse B. Jupiter, MD, Boston, MA
This evidence-based symposium will expand on the current controversies of when and how
to treat displaced clavicle fractures, outcomes of prospective studies, and associated
complications.
I. Functional Anatomy, Kinematics, Epidemiology of Fractures

Jeremy Hall MD, Toronto, ON Canada
II. Operative versus Non-operative Treatment of Displaced Diaphyseal Fractures

Michael D. McKee MD, Toronto, ON Canada
III. Intramedullay Fixation of Displaced Diaphyseal Fractures, Indications

Jonas Andermahr MD, Mechernich, Germany
IV. Discussion and cases
V. The Lateral Clavicle Fracture—Decision making, What is the Evidence

Michael D. McKee MD, Toronto, ON Canada
VI Complications of clavicle fractures—nonunion, malunion

Jesse B. Jupiter MD, Boston, MA
VII. Discussion and cases
THE CLAVICLE
Jeremy Hall, MD
Functional Anatomy of the Clavicle fixation of 15 patients with malunited midshaft clavicle
• The clavicle forms an anterior strut to maintain the position fractures.
of the shoulder on the thoracic cage. — Mean DASH improved 32 points
• An S-shaped bone with a cephalad to caudad bow. — 14/15 satisfied results
– McKee MD, Wild LM, Schemitsch EH. Midshaft
Biomechanics of the Clavicle
malunions of the clavicle. JBJS 85:(5)790-7.
Movement of the clavicle is the result of….
• COTS, McKee et al reported on RCT
• Acromioclavicular Joint - Planar type joint allowing
— Constant Shoulder Scores were statistically improved in
approximately 20o of rotational movement of the
the operative group at all time points measured
clavicle relative to the acromion.
(p=0.001)
• Sternoclavicular Joint - diathroidal joint allowing movement
— DASH scores were statistically improved in the operative
in the horizontal and vertical planes as well as
group at all time points measured (p=0.021)
approximately 20o of rotation of the clavicle relative
to the manubrium. Complications
Through these joints, the clavicle moves up to 60o in vertical • Non-operative group (12/48):
plane, 20o in the horizantal plan and 20o of rotation. — one patient with reflex sympathetic dystrophy
— two patients with symptomatic malunions
Epidemiology
— seven patients with non-unions
• Majority of midshaft clavicle fractures result from a
— one secondarily compound req. ORIF
fall/direct blow to the shoulder.
— one cosmetic procedure
• With longitudinal compression:
• Operative group (7/52):
— Middle third fracture
— three patients experienced local plate irritation
– Anterosuperior aspect tension site
— three late wound dehiscence/infection
– Posteroinferior aspect compression site
— one nonunion
Traditional literature
Conclusions
• “Most fractures of the clavicle have a good prognosis”
• Early operative fixation of completely displaced midshaft
• “Patients have few or no residual symptoms once the
clavicle fractures results in:
fracture has healed”
— Improved patient oriented outcome
• “Overall incidence of nonunion is less than 1%”
— Improved surgeon oriented outcome
— Neer CS. Nonunion of the clavicle. JAMA 1960;172:1006-
— Earlier return to function
11.
— _ nonunion (1/52 versus 7/48, p=0.02)
— Rowe CR. An atlas of anatomy and treatment of
– Canadian Orthopaedic Trauma Society. Nonoperative
midclavicular fractures. Clin Orthop 1968;58:29-42.
treatment compared with plate fixation of displaced
Modern literature midshaft clavicular fractures. A multicenter,
• Robinson et al reported a prospective, observational cohort randomized clinical trial. JBJS 89(1):1-10, 2007 Jan.
study of a consecutive series of 868 patients with 581
diaphyseal fractures. Displaced comminuted midshaft had a
21% nonunion rate.
— Robinson CM. Fractures of the clavicle in the adult.
Epidemiology and classification. JBJS Br. 1998;80:476-84.
• Hill et al studied 52 of 66 consecutive displaced midshaft
clavicle fractures
— 15% non-union rate
— 31% unsatisfactory with patient oriented outcome measure
— displacement >2cm associated with unsatisfactory result
– Hill E, McGuire M, Crosby L. Closed treatment of
displaced middle-third fractures of the clavicle gives
poor results. JBJS [Br] 1997;79-B:537-9.
• McKee et al reported the results of osteotomy and plate
299
WHEN AND HOW TO TREAT DISPLACED FRACTURES OF THE

CLAVICLE
Michael D. McKee, MD
When to surgically repair? unsatisfactory outcome after non-operative care of displaced

The decision to recommend operative treatment depends on a clavicle fractures6. This may be explained by significant
number of factors, especially a thorough knowledge of the residual strength deficits following the conservative
outcome following operative versus non-operative care. treatment of these fractures. Using an objective strength
testing protocol for both maximal effort and endurance
1. The incidence of nonunion following non-operative care (which had not been done previously) strength deficits
of displaced mid-shaft fractures of the clavicle ranging from 10% to 35% were found in patients a mean of
A number of recent studies of completely displaced, mid- 54 months after non-operative care of a displaced fracture of
shaft fractures of the clavicle reveal nonunion rates between the clavicular shaft16.
15% and 20%5,6. These studies were recently summarized
How to surgically repair a displaced clavicle fracture?
in a meta-analysis that found a nonunion rate of 15.1%
There is still considerable controversy regarding the ideal method
following non-operative care of these fractures7.
of clavicular fracture fixation: options include plate fixation or
2. The incidence of symptomatic clavicular malunion intramedullary fixation, and there are several types of both
following non-operative care devices designed specifically for clavicle fractures. Clinical
Malunion of the clavicle is a distinct clinical entity with experience with intramedullary devices has shown that anatomic
characteristic orthopaedic (weakness, easy fatigueability, reduction is more difficult to maintain (especially shortening and
scapular winging), neurologic (thoracic outlet syndrome) rotation), as would be expected with an “unlocked”
and cosmetic (droopy, asymmetric shoulder, difficulty with intramedullary device. Also, pin migration remains a problem.
backpacks, shoulder straps etc.) symptoms9-12. It is However, excellent clinical results have been reported in some
associated with increasing degrees of clavicular shortening. series. Plate fixation reliably restores length and rotation and has,
While radiographic malunion is always seen following in general, had more consistent results in the literature. However,
displaced clavicular shaft fractures, clinically symptomatic it requires a larger incision, more soft-tissue dissection, and the
malunion has an incidence of 15-20%. patient may experience residual soft-tissue irritation from the
plate. Randomized trials comparing the two techniques are
3. The rate of nonunion following surgical repair
required to definitively answer this question. It may be that these
There are multiple, modern studies that show plate fixation
two methods are complimentary, rather than exclusionary.
is an extremely effective technique for treatment of clavicular
shaft fractures with a low complication and nonunion
Summary
rate14,15. A meta-analysis described a nonunion rate with
The choice to proceed with operative intervention for a displaced
plate fixation of 2.2%, which represents an 86% risk
mid-shaft fracture of the clavicle will be a decision made between
reduction for nonunion compared to the same fracture
surgeon and patient. There is increasing evidence from Level 1
treated non-operatively (nonunion rate 15.1%)7.
prospective and / or randomized trials that, for carefully selected
Intramedullary fixation is another option with a high, albeit
patients, primary operative fixation of displaced clavicular
variable, success rate.
fractures results in superior outcome.
4. Strength deficits following non-operative care.
Hill et. al. were the first to use a patient-oriented outcome
measure, and found 31% of patients described
REFEREMCES 8. McKee MD, Stephen DJG, Kreder HJ, Schemitsch EH, Yoo D, Harrington J,
1. Neer, C “Fractures of the Clavicle” Fractures in Adults, Rockwood and Green Eds, “Functional outcome following clavicle fractures in polytrauma patients” J
JB Lippincott, 2nd edition ,p 707-713. Trauma, Vol.47:3, p616, 2000.
2. Crenshaw AH, “Fractures of the shoulder girdle, arm and forearm”, In 9. Basamania CJ, “Claviculoplasty” J Shoulder Elbow Surg, Vol. 8, No. 5, 1999; p
Campbell’s Operative Orthopaedics, Eighth edition, Mosby-Yearbook Inc, St. 540. (Abstracts: Seventh International Conference on Surgery of the Shoulder,
Louis, p989-995, 1992 1999).
3. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin 10. Bosch U, Skutek M, Peters G, Tscherne H, “Extension osteotomy in malunited
Orthop Rel Res. 58:29-42, 1968. clavicular fractures” J Shoulder Elbow Surg, Vol. 7, No. 4, 1998; pp 402-405.
4. Neer C Nonunion of the clavicle. JAMA 172: 1006-1001, 1960. 11. Chan KY, Jupiter JB, Leffert RD, Marti R “Clavicle malunion” J Shoulder Elbow
Surg, Vol. 8, No. 4, 1999; pp 287-290.
5. Hill JM, McGuire MH, Crosby L “Closed treatment of displaced middle-third
fractures of the clavicle gives poor results” J Bone Joint Surgery(B), 79B, No.4, 12. Kuhne JE, “Symptomatic malunions of the middle clavicle” J Shoulder Elbow
1997; pp 537-541. Surg, Vol. 8, No. 5, 1999; p 539. (Abstracts: Seventh International Conference
on Surgery of the Shoulder, 1999).
6. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the
risk of nonunion following non-operative treatment of a clavicle fracture. J Bone 13. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J Bone
Joint Surg(A) 86A:7, 1359-1365, 2004. Joint Surg, 85A:5, 790-797, 2003.
7. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of mid-shaft 14. Poigenfurts J, Rappold G, Fischer W “Plating of fresh clavicular fractures: results
clavicle fractures: Systemic review of 2144 fractures. J Orthop Trauma. Vol 19:7, of 122 operations” Injury, Vol. 23, No. 4, 1992; pp 237-241.
2005, 504-508.
15. McKee MD, Seiler JG, Jupiter JB “The application of the limited contact dynamic 18. Potter J, Schemitsch EH, Jones C, Wild LM, McKee MD. Does delay matter? The
compression plate in the upper extremity: an analysis of 114 consecutive cases” restoration of objectively measured shoulder strength and patient-oriented out-
Injury, Vol. 26, No. 10, 1995; pp 661-666. come in immediate versus delayed reconstruction of displaced mid-shaft frac-
16. McKee MD, Pedersen EM, Jones C, Stephen DJG, Kreder HJ, Scemitsch EH, Wild tures of the clavicle. Accepted for publication, J Shoulder Elbow Surg.
LM, Potter J. Deficits following non-operative treatment of displaced, mid-shaft 19. McKee MD and the Canadian Orthopaedic Trauma Society. A multi-centre ran-
clavicle fractures. J Bone Joint Surg(A), 2005. domized controlled trial of non-operative versus operative treatment of displaced
17. Andersen K, Jensen PO, Lauritzen J. The treatment of clavicular fractures: Figure clavicle shaft fractures. J Bone Joint Surg(A), 2007, No.1, 1-11.
of eight bandage versus a simple sling. Acta Orthop Scand. 1987;58:71-74.
301
IM NAILING OF THE CLAVICLE

Jonas Andermahr, MD and Axel Jubel
Introduction been developed an universally acceptable classification: Current

Fracture of the clavicle is common, and it has long been thought publications use the basic AO/ASIF or the Comprehensive
that its inherent reparative capacity will lead to rapid healing Classification of Fractures (CCF) (Fig.1)11: Type A fractures are
despite little more than symptomatic treatment. 43 Deformity has simple transverse fractures, Type B fractures are wedge fractures
been described more often as a cosmetic concern since function and Type C fractures are those in which the main fragments are
is satisfactory despite malunion.31,32 It has been suggested by separated by a zone of comminution and have no contact. This
many that primary operative intervention is meddlesome and classification turns out to be very useful for the decision of which
will result in unnecessary complications. 40,43 However, although operative procedure should be carried out (plate vs
the standard of care has long been conservative therapy, operative intramedullary nail).
management of acute clavicle fractures, particularly in
polytraumatized patients and in selected cases of young athletes, Operative Treatment
has proven to be an excellent option.3,4,19-24,42 Despite the There is a simple algorism of treatment in non-complicated
proximity of major vascular, nervous and cardiopulmonary (neurovascular complications present: operation always
structures, associated injury is uncommon.27,33,34,36 indicated!) midclavicle fractures:
Interest in clavicular nonunion is relatively new,7,9,10,15,24,28,33,34 and
Nailing
has demonstrated that displaced fractures of the middle portion
When performing closed or open reduction and internal fixation
of the clavicle can in fact be troublesome injuries in adults.5,25,30
of the clavicle, we prefer minimally-invasive intramedullary
Failure of bony union following clavicular injuries can lead to
nailing with a 2.0 to 3.5 mm Titanium nails (Prevot nail) for CCF
progressive shoulder deformity, pain, impaired function, and
type A and B fractures l, and fixation with plate and screws for
neurovascular compromise. Malunion may also contribute to
CCF type C fractures. Given the fact that intramedullary fixation
weakness, pain and neurovascular compromise.16,17 Data on
of the clavicle is technically difficult owing to the curvature, high
displaced distal clavicular fractures in adult patients have
density, and small intramedullary canal of the bone, it is
demonstrated sufficient difficulties with healing to consider
remarkable that good results with this technique have been
primary operative treatment.13,14,38,40 A recent investigation
observed.12,21,24,44-46,48 Our technique for internal intramedullary
focusing on the results of the treatment of displaced
fixation of the clavicle is as follows42: Patients are positioned on
midclavicular fractures in adult patients suggests that this subset
a radiolucent operating table in the supine position. A skin
of fractures may also be prone to nonunion and delayed union.47
incision of 1 to 2 cm is made just above the sternal end of the
clavicle. Approximately 1 cm distal to the sternoclavicular joint,
Function
a hole is drilled into the ventral cortex of the medial end of the
A review of the comparative anatomy literature reveals that the
clavicle with a 2.5-mm drill and widened using an awl. The Ti
clavicle has developed from the “Os thoracale,” a construct of the
nail, 2.0 to 3.5 mm, is fixed in a universal chuck with a T-handle.
sternum and clavicle. This “distance-maintainer” between the
With oscillating movements of the surgeon’s hand the unreamed
breastbone and scapula was first observed in fossils of the earliest
Ti nail is advanced until it reaches the fracture site. To ensure
reptiles, who lived approximately 350 million years ago (Devon).
correct placement of the nail, fluoroscopic control is used for
The abilities of the “walking fish”, of which the coelacanth is the
reduction and insertion of the nail into the lateral fragment. If
most well known, were strictly dependent on the development of
closed reduction fails, an accessory incision of 3 to 4 cm is made
abduction in the front extremities. Further evidence for the
above the fracture site to enable direct manipulation of the
phylogenetically early development of the clavicle is that it
fragments. Additional fragments are maintained in their
ossifies very early during ontogenesis. The functional
positions, maintaining soft tissue connections. The protruding
consequence is, from an evolutionary perspective, the ability to
end of the nail is cut off at the site of its insertion.
abduct and raise the arms. Conversely, in animals without the
ability to abduct the front extremities (i.e. sheep or horses), For postoperative treatment, patients are instructed to mobilize
during ontogenesis the clavicle forms and is even temporarily the affected extremity. Postoperative immobilization is not
ossified before completely disappearing by the time of birth.6 performed. Physical therapy is prescribed for patients with
multiple trauma or accessory injuries.
It is not surprising then that in cases of clavicle fractures in
humans where there is shortening of the sternum-scapula
Plating
distance, there is a subsequent limitation in shoulder abduction
and elevation. The clavicle also serves as a bony framework for Open Procedure
muscular attachments; provides protection for the underlying Our technique for internal plate fixation of the clavicle is as
neurovascular structures; transmits the forces of accessory follows1,26,41: One apply a 3.5 millimeter limited contact dynamic
muscles of respiration (e.g. the sternocleidomastoid) to the upper compression plate or the locking compression plate to the
thorax, and contributes to the aesthetics of the base of the anterior or superior aspect of the clavicle. A minimum of three
neck.29,35 screws should be placed in each major fragment. When the
fracture pattern allows, an interfragmentary screw will greatly
Classification enhance the stability of the construct. In the presence of fracture
Surgeons interested in clavicle fractures have long distinguished comminution or gaps in the cortex opposite the plate, we
midclavicular fractures from fractures of the medial or lateral recommend the addition of a small amount of autogenous iliac
end.8,18 Following descriptions by Allman2, Rowe43 and Neer37-39, crest cancellous bone graft.
the clavicle has been divided into thirds for purposes of
classification. For the most common midshaft fractures there has
Percutaneous Procedure healed properly without complications. Clavicular length

An evolution of clavicle plating is a percutaneous minimal invasive (according to the contralateral side) was re-established. At 3
approach for plating the clavicle3 and unpublished results of the months, the average Constant Score was 97±3. In conclusion
authors. For that an stable-angle small fragment LC plate through percutaneous internal fixation using the LC-plate is the logical
a 1.5cm incision over the sternoclavicular joint was applyied. In extension of new operative treatments of the clavicle since the
two cases, (B-type fractures), intramedullary fixation with TEN was successful establishment of intramedullary nailing. Indications for
initially attempted without success, and the plate was then the procedure are for displaced A and B type fractures, for which
percutaneously inserted using the same incision (intraoperative intramedullary nailing is impossible (perioperative salvage-
salvage procedure through the same approach). All fractures procedures over the same incision), and for C type fractures.3
REFERENCES 24. Jubel, A.; Andermahr, J.; Weisshaar, G.; Schiffer, G.; Prokop, A.; and Rehm, K. E.:
1. Ali Khan, M. A., and Lucas, H. K.: Plating of fractures of the middle third of the [Intramedullary nailing (ESIN) in clavicular pseudoarthroses. Results of a
clavicle. Injury, 9(4): 263-7, 1978. prospective clinical trial]. Unfallchirurg, 108(7): 544-50, 2005.
2. Allman, F. L., Jr.: Fractures and ligamentous injuries of the clavicle and its articu- 25. Jupiter, J. B. L., R.D.: Non-union of the clavicle. J Bone Joint Surg, 69A: 753-760,
lation. J Bone Joint Surg Am, 49(4): 774-84, 1967. 1987.
3. Andermahr, J.; Faymonville, C.; Rehm, K. E.; and Jubel, A.: [Percutaneous plate 26. Khan, M. A. L., H.K.: Plating of fractures of the middle third of the clavicle.
osteosynthesis for clavicular fractures: Initial description.]. Unfallchirurg, 2007, Injury, 9: 263-267, 1977.
Aug 12. 27. Kitsis, C. K.; Marino, A. J.; Krikler, S. J.; and Birch, R.: Late complications following
4. Andermahr, J.; Jubel, A.; Elsner, A.; Johann, J.; Prokop, A.; Rehm, K. E.; and clavicular fractures and their operative management. Injury, 34(1): 69-74, 2003.
Koebke, J.: Anatomy of the clavicle and the intramedullary nailing of midclavicu- 28. Koss, S. D. G., H.T.; Redler, M.R.; Whitehill, R.: Nonunion of a midshaft clavicle
lar fractures. Clin Anat, 20(1): 48-56, 2007. fracture associated with subclavian vein compression: A case report. Orthopedic
5. Andermahr, J.; Jubel, A.; Elsner, A.; Prokop, A.; Tsikaras, P.; Jupiter, J.; and Rev, 28: 431-434, 1989.
Koebke, J.: Malunion of the clavicle causes significant glenoid malposition: a 29. Ljunggren, A. E.: Clavicular function. Acta Orthop Scand, 50(3): 261-8, 1979.
quantitative anatomic investigation. Surg Radiol Anat, 28(5): 447-56, 2006. 30. Manske, D. J. S., R.M.: The operative treatment of mid-shaft clavicular non-
6. Andermahr, J.; Ring, D.; and Jupiter, J.: Fracture of the Clavicle. Edited by unions. J Bone Joint Surg, 67A: 1367-1371, 1985.
Iannotti, J., 2006. 31. Marie, P., and Sainton P.: The classic: Sur la dysostose cleido-cranienne heredi-
7. Anderson, K.: Evaluation and treatment of distal clavicle fractures. Clin Sports ataire, Rev. neurol. 6:835, 1898. On hereditary cleido-cranial dysostosis. Clin
Med, 22(2): 319-26, vii, 2003. Orthop, 58: 5-7, 1968.
8. Bechtol, C. O.: Biomechanics of the shoulder. Clin Orthop, (146): 37-41, 1980. 32. Marie, P. S., P.: The classic: On hereditary cleido-cranial dysostosis. Clin Orthop,
9. Bradbury, N.; Hutchinson, J.; Hahn, D.; and Colton, C. L.: Clavicular nonunion. 58: 5-7, 1968.
31/32 healed after plate fixation and bone grafting. Acta Orthop Scand, 67: 367- 33. McKee, M. D.; Wild, L. M.; and Schemitsch, E. H.: Midshaft malunions of the
370, 1996. clavicle. J Bone Joint Surg Am, 85-A(5): 790-7, 2003.
10. Capicotto, P. N.; Heiple, K. G.; and Wilbur, J. H.: Midshaft clavicle nonunions 34. McKee, M. D.; Wild, L. M.; and Schemitsch, E. H.: Midshaft malunions of the
treated with intramedullary Steinman pin fixation and onlay bone graft. J clavicle. Surgical technique. J Bone Joint Surg Am, 86-A Suppl 1: 37-43, 2004.
Orthop Trauma, 8(2): 88-93, 1994. 35. Moseley, H. F.: The clavicle: Its anatomy and function. Clin Orthop, 58: 17-27,
11. Classification, O. T. A. C. f. C. a.: Classification. J Orthop Trauma, 10(5-9): 1-154, 1968.
1996. 36. Mueller, M.; Burger, C.; Florczyk, A.; Striepens, N.; and Rangger, C.: Elastic stable
12. Dahners, L. E.: Opinion: antegrade clavicle nailing. J Orthop Trauma, 19(7): 501- intramedullary nailing of midclavicular fractures in adults: 32 patients followed
2, 2005. for 1-5 years. Acta Orthop, 78(3): 421-3, 2007.
13. Daskalakis, E., and Bouhoutsos, J.: Subclavian and axillary vein compression of 37. Neer, C. S.: Fracture of the distal clavicle with detachment of the coracoclavicular
musculoskeletal origin. Br J Surg, 67(8): 573-6, 1980. ligaments in adults. J Trauma, 3: 99-110, 1963.
14. Daskalakis, E. B., A.: A Subclavian and axillary vein compression of muscu- 38. Neer, C. S.: Fractures about the shoulder. pp. 707-713. Edited by Rockwood, C.
loskeletal origin. Br J Surg, 67: 573-576, 1980. A., Jr.; Green, D.P., 707-713, Philadelphia, J.B. Lippincott Co., 1984.
15. Denard, P. J.; Koval, K. J.; Cantu, R. V.; and Weinstein, J. N.: Management of mid- 39. Neer, C. S.: Fractures of the distal third of the clavicle. Clin Orthop, 58: 43-50, 1968.
shaft clavicle fractures in adults. Am J Orthop, 34(11): 527-36, 2005. 40. Neer, C. S.: Nonunion of the clavicle. JAMA, 172: 1006-1011, 1960.
16. Eskola, A. V., S.; Myllynen, P.; et al.: Outcome of clavicular fracture in 89 patients. 41. Poigenfurst, J. R., G.; Fischer, W.: Plating of fresh clavicular fractures: Results of
Arch Orthop Trauma Surg, 105: 337-338, 1986. 122 operations. Injury, 23: 237-241, 1992.
17. Eskola, A. V., S.; Myllynen, P.; et al.: Surgery for ununited clavicular fracture. Acta 42. Rehm, K. E.; Andemahr, J.; and Jubel, A.: Intramedullary Nailing of the
Orthop Scand, 57: 366-367, 1986. Midclavicular Fractures with an Elastic Titanium Nail. Eur J Trauma, 31: 409-416,
18. Heinz, W. M. M., G.W.: Mid-shaft fracture of the clavicle with grade III acromio- 2005.
clavicular separation. J Shoulder Elbow Surg, 4: 141-142, 1995. 43. Rowe, C. R.: An atlas of anatomy and treatment of midclavicular fractures. Clin
19. Jubel, A.; Andermahr, J.; Faymonville, C.; Binnebosel, M.; Prokop, A.; and Rehm, Orthop, 58: 29-42, 1968.
K. E.: [Reconstruction of shoulder-girdle symmetry after midclavicular fractures. 44. Schwarz, N., and Leixnering, M.: [Technic and results of clavicular medullary
Stable, elastic intramedullary pinning versus rucksack bandage]. Chirurg, 73(10): wiring]. Zentralbl Chir, 111(11): 640-7, 1986.
978-81, 2002.
45. Sommer, C., and Bereiter, H.: [Actual relevance of minimal invasive surgery in
20. Jubel, A.; Andermahr, J.; Prokop, A.; Isenberg, J.; and Rehm, K. E.: [Minimal inva- fracture treatment]. Ther Umsch, 62(2): 145-51, 2005.
sive biological osteosynthesis of the clavicle with a titanium nail]. Kongressbd
Dtsch Ges Chir Kongr, 119: 485-90, 2002. 46. Walz, M.; Kolbow, B.; and Auerbach, F.: [Elastic, stable intramedullary nailing in
midclavicular fractures--a change in treatment strategies?]. Unfallchirurg, 109(3):
21. Jubel, A.; Andermahr, J.; Prokop, A.; Lee, J. I.; Schiffer, G.; and Rehm, K. E.: 200-11, 2006.
[Treatment of mid-clavicular fractures in adults. Early results after rucksack band-
age or elastic stable intramedullary nailing]. Unfallchirurg, 108(9): 707-14, 2005. 47. White, R. R. A., P.S.; Kristiansen, T.: Adult clavicle fractures: Relationship between
mechanism of injury and healing. Orthop Trans, 13: 514-515, 1989.
22. Jubel, A.; Andermahr, J.; Schiffer, G.; and Rehm, K. E.: [Technique of
intramedullary osteosynthesis of the clavicle with elastic titanium nails]. 48. Wu, C. C.; Shih, C. H.; Chen, W. J.; and Tai, C. L.: Treatment of clavicular aseptic
Unfallchirurg, 105(6): 511-6, 2002. nonunion: comparison of plating and intramedullary nailing techniques. J
Trauma, 45: 512-516, 1998.
23. Jubel, A.; Andermahr, J.; Schiffer, G.; Tsironis, K.; and Rehm, K. E.: Elastic stable
intramedullary nailing of midclavicular fractures with a titanium nail. Clin
Orthop Relat Res, (408): 279-85, 2003.
303
COMPLICATIONS OF CLAVICLE FRACTURE—

NONUNION AND MALUNION
Jesse B. Jupiter, MD
I. THE PROBLEMS 1. 3.5 mm LCDC plate or similar is able to be contoured

A. Shoulder girdle dysfunction to fit altered anatomy and multidirectional
1. Scapulothoracic and glenohumeral joint dysfunction compression across bone graft
2. Ptosis of the shoulder---thoracic outlet syndrome 2. with lateral clavicle nonunion, consider the use of 2
3. Pain implants, one superior and one anterior
B. Clavicular shortening—what is the evidence? 3. the experience with alternative fixations such as
1. Nordqvist et al (1997)—85 patients intramedullary nonunions is limited in the literature
Shortening not found to be a functional problem 4. Evidence—O’Conner et al (2004) 24 pts with plate
2. Eskola et al (1986) –83 patients fixation
Shortening>12mm more symptomatic 24/25 healed
3. Hill et al (1997)—52 patients Endrizzi et al
Shortening>20mm functional problem 47 pts all healed
C. Clavicle displacement—what is the evidence? 6/47 had anterior chest numbness
1. Eskola et al – > 15mm more pain G. Postoperative management
2. Nordqvist et al –found few pts with symptomatic 1. sling for comfort for 7-10 days then allow motion
malunion 2. no overhead lifting or axial loading on arm for
minimal of 6 weeks
II. CLAVICLE NONUNION
A. Incidence—what is the evidence? IV. NONUNION WITH DEFECT OR MAJOR DEFORMITY
1. Multiple studies vary from 4% up to 15% A. The problem
2. Robinson et al--- comminuted mid-diaphyseal 1. synovial nonunion commonplace
fractures with rotated vertical segment at risk for 2. bone ends tapered and sclerotic
nonunion 3. shoulder deformity can be substantial
3. Lateral fractures—Nordqvist et al (1993) 110 pts f/u 15 B. Surgical tactics
yrs 10 fractures ununited with 8/10 asymptomatic 1. debridement of synovial membrand and bone ends
2. drill open each medullary canal
III. TREATMENT CONSIDERATIONS FOR CLAVICLE 3. realignment and length adjustment with mini-distractor
NONUNION 4. sculptured tricortical graft
A. Preoperative evaluation 5. contoured implant placed anteriorly or superiorly
1. Radiographic studies 6. with major defect consider 2 plates
AP and 45 degree angled AP 7. consider “wave” plate allows more space for bone graft
Standing chest xray to compare length to opposite C. Personal experience Leupin and Jupiter 14 pts f/u 38
clavicle months
3-D CT reconstructions 1. 13/14 healed after 1st and 14/14 after second surgery
B. Physical examination 2. length within one cm of opposite clavicle
Nearly all nonunions are painful and a helpful diagnostic 3. shoulder elevation 130 deg; int rot 65 deg; ext rot 70 deg
test is to compress the nonunion to elicit pain as some 4. 8 excellent; 4 good ; 2 satisfactory by Constant Murley
xrays are difficult to interpret
C. Operative approach V. MALUNION
1. Beach chair position with entire arm free and opposite A. indications for surgery include major shortening with
iliac crest exposed functional deficit
2. Preferred incision is horizontal following Langer’s B. Evidence—Mckee et al (2003) 15 pt
lines 1. avg time from fx to osteotomy 3 yrs
D. Expose and protect the supraclavicular nerves 2. mean shortening 2.9 cm
1. ventral rami of C3-4 3. osteotomy done through original fracture without
2. cutaneous innervation of anterior chest wall intercalary graft
3. usually 3 branches-medial, intermediate, lateral 4. f/u 20 mo 14/15 healed
4. injury can lead to a dystrophic type pain syndrome 5. DASH improved from 32-12
C. Evidence---Chan, Jupiter, Marti(1999) 4 pts
E. Technical pearl—use of a mini-distractor
1. 2-3 cm shortening
1. place on dorsal surface if plan to put plate anteriorly
2. average dorsal angulation 30-45 degrees
and anterior if plate to be superior
3. avg f/u 24 months
F. Implant preference—with reconstructive procedures
4. all united within 1 cm of opposite side
consider stronger Implant
5. full shoulder mobility
REFERENCES 3. Eskola A, Vainionpaa S, Myllynen P et al. Outcome of clavicular fracture in 89

1. Nordqvist A, Redlund-Johnell I, vonScheele A, et al. Shortening of clavicle after patients. Acta. Orthop. Scand 1986; 57: 366.
fracture. Acta Orthop Scand 1997; 68:349. 4. Robinson CM. Fractures of the clavicle in the adult. J. Bone Joint Surg.1998;
2. Nordqvist A, Petersson CJ, Redlund-Johnell I. The natural course of lateral clavi- 80B:476.
cle fracture:15 year follow-up of 110 cases. Acta Orthop Scand. 1993; 64: 87.
5. Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third 12. von Unger S, Jupiter JB. The treatment of midshaft clavicle nonunion with bone
fractures of the clavicle gives poor results. J. Bone Joint Surg Br. 1997; 79:537 defect. Techniques in Shoulder and Elbow Surgery 2007; 8; 8-12.
6. Simpson S, Jupiter J. Clavicular nonunion and malunion. Evaluation and surgi- 13. Ring D, Jupiter JB. Ununited fractures of the clavicle with bony defect: treatment
cal management. J Am Acad Orthop Surg, 1996; 4:1. . with corticocancellous interposition bone graft and plate fixation. Techniques in
7. Jupiter JB, Leffert RD. Nonunion of the clavicle. Associated complications and Hand and Upper Extremity Surgery 1999; 3:193-6.
surgical management. J. Bone Joint Surg. 1987; 69A:753-60. 14. Jupiter JB. Nonunion and malunion of the clavicle. In. Marti R ed. AO Manual of
8. Mullaji AB, Jupiter J. LCDCP fixation of the clavicle. Injury 1994:25; 41-45. Nonunions and Malunions. Dubendorf. AO Publications, 2007.
9. Leupin S, Jupiter JB. LCDCP plating with bone graft in posttraumatic nonunion 15. Mckee M, Wild L, Schemitsch E. The treatment or malunited clavicle fractures. J
in the middle third of the clavicle. Swiss Med 1998: 4; 89-94. Bone Joint Surg;2003; 85A: 790-7.
10. Ring D, Barrick W, Jupiter J. Recalcitrant nonunion. Clin. Orhop. And Rel. Res. 16. Chan KY, Jupiter JB, Leffert RD, Marti R. Clavicle malunion. J. Shoulder Elbow
1997:340: 181-9. Surg. 1999; 8: 287-90.
11. Ring D, Jupiter JB. Wave plate osteosynthesis of the upper extremity. J. 17. Boyer M, Axelrod T. The treatment of atrophic nonunions of the clavicle. J Bone
Techniques in Hand and Upper Extremity Surgery. 1997; 1: 168-74. Joint Surg.Br. 1997; 79B : 302-3.
305
◆CONTROVERSIES IN
CERVICAL DISC ARTHROPLASTY (I)
SYMPOSIA SPINE
Moderator: K. Daniel Riew, MD, St. Louis, MO

A panel of leading experts in the field will give their opinions on various clinical scenarios
to discuss indications and contraindications for cervical disc arthroplasty.
I Introduction
K. Daniel Riew, MD, St. Louis, MO
II. Should we do cervical arthroplasty for Neck Pain or headaches or trapezial pain in the
absence of radiculopathy or myelopathy?
Todd J. Albert, MD, Philadelphia, PA
Rick B. Delamarter, MD, Santa Monica, CA
John G. Heller, MD, Atlanta, GA
Thomas A. Zdeblick, MD, Madison, WI
III. A patient with a 3 level anterior cervical fusion done several years ago has adjacent level
degeneration at the next caudal level with 1-2 mm of subluxation associated with
radiculopathy. Should you do an arthroplasty or a fusion?
IV. A patient with moderate facet arthrosis and HNP has radiculopathy with no neck pain.
Is arthroplasty indicated?
V. A professional athlete (golf, baseball, hockey, football, discuss all four) has a large
central herniated disc with radiculopathy. Would you do an arthroplasty?
VI. Joint arthroplasty is indicated for older patients. Who is a better candidate for cervical
arthroplasty, a 70 year old or 18 year old with a large herniated disc?
VII. Questions and Summation
◆NOVEL TECHNOLOGY
FOR THE TREATMENT OF SPINAL
SYMPOSIA SPINE
DISORDERS AND THE EFFECT
ON ORTHOPAEDIC SURGEONS (P)
Moderator: Jeffrey C. Wang, MD, Santa Monica, CA
This symposium will detail novel spinal technologies and the issues that affect Orthopaedic
Surgeons (educational processes, ethical concerns, evaluations for specific novel devices).
I. The process of developing novel technology for the spine

David A. Wong, MD, Denver, CO
II. The appropriate process of developing new technology

Richard D. Guyer, MD. Plano, TX
III. The effect of new technology on our Orthopaedic Society

Jeffrey C. Wang, MD, Santa Monica, CA
IV. Lumbar and Cervical Disc Arthroplasty: Analysis of the Introduction, Effect on
Orthopaedic Surgeons, and Current Status
V. Posterior Motion Preservation Devices, Facet Replacement: Analysis of the

Introduction, Effect on Orthopaedic Surgeons, and Current Status
Alexander J. Ghanayem, MD, Maywood, IL
307
THE PROCESS OF DEVELOPING NOVEL TECHNOLOGY

FOR THE SPINE
David Wong, MD
Reason for explosion of technology • Sofamor Danek TSRH rod/screw system:

• Patho-anatomy • Total $3,207
• Business/Financial • 2003
SYMPOSIA SPINE
• MD Reimbursement • 51yo male, smoker, L5-S1 anterior/posterior lumbar fusion

• Critical Analysis • Sofamor Danek TSRH 3D rod/screw: $4682
• How why • RTI Precision bone dowel: $2800
• Synthes DBX bone paste: $630
Patho-Anatomy
• Sofamor Danek bone void filler: $458
Wm. Kirkaldy-Willis
• Sofamor Danek BMP (large) $4900
Managing Low Back Pain-1983
• Total: $13,470
• Three Phase Concept – “Degenerative Cascade”
• Control of Dysfunctional Spinal Unit MD Reimbursement
• Decompression CMS Expenditure Targets
• Discectomy • Sean Tunis MD
• Laminectomy • Director and Chief Clinical Officer
• Laminaplasty • 2004-2005 Review Spine Surgery Reimbursement
• CV & Ortho companies
Stabilization/Movement limiting devices
• Market cap and annual revenues (2003)
• Graf ligament devices (limits flexion)
• Comparison of
• Spacer-tensioning cord structure inserted into pedicle screws
• Manufacturing costs as % of sales
(Dynesis)
• Arthroplasty Discogenic Back Pain
• Fusion • Treatment-Evolving
• Anterior • IDET/IDETA
• Posterior • Intra Discal Electrical Thermalrhizotomy/Annuloplasty
• 360° • Concerns
• Mechanism of effect
The World-Wide Drug and Medical Device Industry
• Thermal
• Source: Orthopedic Network News & Millenium Research
• Collagen denaturation /consolidation
Group, Toronto
• Nerve rhizotomy
• Spine Procedures increase 4 fold/Spine $ increase 15-fold
• ? Long term changes
• High and Rising Healthcare Costs
• Short clinical follow up
• Annals of Internal Medicine 2005
• Bodenheimer T. 142: 4 Part Series IDET RCT’s
• Freeman B, Fraser R, Cain C, Hall D, Chapple C. A random-
Seeking an Explanation
ized, double-blind, controlled trial: intradiscal electrothermal
• Technological Innovation
therapy versus placebo for the treatment of chronic disco-
• Innovation is the Driver of Health Expenditure Growth
genic low back pain. Spine 2005 Nov 1;30(21):2369-77.
• Role of Health Providers
• Pauza K, Howell S, Dreyfuss P, Peloza J, Dawson K, Bogduk
• Provider Market Power Explains High & Rising Costs
N. A randomized, placebo-controlled trial of intradiscal
• Ratio specialist/Primary Care
electrothermal therapy for the treatment of discogenic low
• Specialists perform high cost innovative procedures
back pain. Spine J. 2004 Jan-Feb;4(1):27-35
• Can Costs be Controlled While Preserving Quality
• Technology Assessment
High and Rising Healthcare Costs • Strategies
Annals of Internal Medicine 2005 • Quality Adjusted Life Year (QALY)
Part 3: Role of Health Care Providers • Cost Effectiveness
• Provider Market Power Explains High & Rising Costs • Comparative Effectiveness
• Ratio specialist/Primary Care • Non-Inferiority
• US #MD’s & Hospital bed days < median Organization • Minimum Clinically Important Difference (MCIC)
Economic Co-op & Development • Substantial Clinical Benefit (SCB)
• Specialists perform high cost innovative procedures
Web Resources
• Control Strategies
American Academy of Orthopedic Surgeons (AAOS)
• Technol Assess-set “standards”
www.aaos.org
• Global budget/Expenditure cap
North American Spine Society (NASS)
• “Malpractice and Costs”
www.spine.org
• Note 5-9% total expenditure
Orthopedic Network News (Mendenhall)
• No suggestion Tort Reform
www.orthopedicnetworknews.com/
Instrumentation for spinal fusion Blue Cross Blue Shield Tech Assessment
• 1997 www.bcbs.com/betterknowledge/tec/tec-assessments.html
• 39yo male, smoker, L5-S1 posterior lumbar fusion
THE APPROPRIATE PROCESS OF

DEVELOPING NEW TECHNOLOGY
Rick Guyer, MD
This talk would discuss how an idea is developed, introduced,

support is garnered, how the process is financed, how studies are
SYMPOSIA SPINE
developed (IDE studies, controls, superiority or equivalence,
etc..). This would be a critical analysis of the process, how it
works, both criticisms and benefits, citing case examples of
technologies, and the ethics involved.
Idea developed
IP applied and patented
Financials
• Investors
• Venture capital
• Technology transfer
IDE studies
• Development
• Implementation
• Clinical research
• Satisfy FDA and CMS
309
THE EFFECT OF NEW TECHNOLOGY ON OUR

ORTHOPAEDIC SOCIETY
Jeffrey C. Wang, MD
Novel technology NASS

• Typically developed by industry • Industry sponsored studies
SYMPOSIA SPINE
• Goal: financial gains • Class I data

• How does this effect our orthopaedic educational process • Podium presence
• Symposia on new technology
Orthopaedic residency
• Need clinical experts
• Young orthopaedic surgeons in training
• Research de-emphasized
• Exposed to novel technology
• Industry meetings AAOS
— Free trips • Exhibitor hall – significant part of meeting
— Meet executives and sales representatives • Sometimes ignore scientific presentations
— Exposed to the business side of orthopaedic surgery • Networking rather than scientific meeting
• Options for employment other than in medical practice • Social rather than academic meeting
• Wall street funds looking for physicians
Journals
• Attractive salary combined with declining reimbursements
• “throw-away” journals
and increased liability
• industry sponsored journals
Young orthopaedic surgeons • special issues sponsored by industry
• Industry meetings • academic journals – seek industry sponsors
• Academic advancement • industry studies
• Industry grants combined with declining NIH funding • push novel technology
• Easier path to exposure
Marketing
— Industry meetings allow young surgeons podium
• direct to patients
presence
• young surgeons use to build practice
— Industry chooses faculty
• exposure for surgeons both young and old
— Industry chooses grand rounds speakers
• increased use of internet – pushing novel technology
• Industry speakers bureau
• using celebrities for industry ads
• Industry funded studies
LUMBAR AND CERVICAL DISC ARTHROPLASTY: ANALYSIS OF THE

INTRODUCTION, EFFECT ON ORTHOPAEDIC SURGEONS, AND
CURRENT STATUS
Todd J. Albert, MD
SYMPOSIA SPINE
New Technologies - Order of Introduction: Cervical Arthroplasty
1) OUS experience 1) Smoother Introduction
2) IDE a. ?Radiculopathy vs Axial LBP
3) FDA Approval b. Knowledge from lumbar Disc experience.
4) Payors (CMS, Insurers) c. Superiority claims?
2) Players:
Lumbar Arthroplasy (Charite (Link – Depuy) and ProDisc-L
a. Prestige (M-M) – Approved)
(Spine Solutions – Synthes)
b. ProDisc-C (Rec for Approval)
1) Problems of Introduction led to less success than
c. Bryan (In waiting).
anticipated – Why?
d. PCM (Cervitech) – Trial
a. 1st RCT not as strong as hoped.
e. Kineflex
b. Charite IDE poor control Group
3) Reality –
c. Low back pain /DDD less clear and/or successful surgical
a. This data set more helpful
endeavour
b. Superiority claims will help with payment.
d. CMS denied
e. No superiority Claim. Responsible Introduction Algorithim:
2) ProDisc-L 1) Appropriate Basic Testing
a. Control Group A/P fusion (easier superiority) 2) Animal Testing
b. More constrained prosthesis 3) Human Pilot Data
c. ?facet joints 4) RCT (designed to measure)
3) Other Issues with Lumbar Arthroplasty a) RTW
a. Revisability b) functional improvement
b. Materials (wear) c) ?superiority of device if possible
c. Metal on metal vs poly 5) Responsible Training Programs
d. MRI compatibility
311
POSTERIOR MOTION PRESERVATION DEVICES:

FACET REPLACEMENT
Alexander J Ghanayem, MD
I) Facet Replacement c. Facet replacement

a. History and development i. Current devices (Not FDA approved)
SYMPOSIA SPINE
b. Biomechanical considerations 1. AFRS

i. Can they limit painful motion? 2. TOPs
ii. Can they mimic some degree of physiologic motion 3. TFAS
(quantity of motion)? 4. Zyre
iii. Can they mimic motion at the right time—so called
III) Some uses and indications as listed in IDE studies and
“quality of motion”?
product literature
iv. Do they act only as a posterior column device or is
a. Lumbar stenosis
there some off-loading anteriorly at the disc or
b. Low back pain and leg pain
annulus?
c. Age 21 to 85 years
II) Current devices for “Dynamic Stabilization” d. Facet joint pain
a. Pedicle based systems—act to recreate biomechanical e. As an alternative to fusion in patients undergoing
characteristic of a deficient posterior column laminectomy for stenosis
i. Semi-rigid connector between pedicle screws f. As an reconstructive option to prevent instability in
ii. Developed as motion sparing devices but has only patients undergoing laminectomy for stenosis
received FDA approval as fusion systems g. In combination with anterior disc arthroplasty
iii. Some current devices
IV) Avenues/introduction to the spine care community
1. Graf ligament
a. Medical meetings—educational displays
2. Dynesys
b. Abstracts and invited reviews
3. FASS System
c. Presentation at meeting
4. Isobar
d. Venture capital and corporate sponsored seminars
5. Protex
e. Calls for patient enrollment on the internet
6. FlexPeek
f. Spine education websites
b. Interspinous implants—act to limit extension and
g. Government websites regarding clinical trial
unbuckle the ligamentum flavum—primarily to treat
h. Advertisement
spinal stenosis
i. Some current devices V) Current standing of Facet Joint Arthroplasty and Posterior
1. Minns Motion Preservation
2. Interspinous U a. Status of clinical trials
3. Diam b. Claims made by developers
4. Wallis c. Is this a technology looking for an indication? Why are
5. X-stop we even discussing this issue?
d. Who drives the introduction on new spine care
technology?
SYMPOSIA SPORTS/ARTHROSCOPY
DOC, WHEN CAN HE GO BACK
IN THE GAME? (E)
Moderator: Mark D. Miller, MD, Crozet, VA
Several clinical scenarios will be presented and the audience (via ARS) and panel will vote
on whether to allow the athlete to return to play.
I. Introduction
Mark D. Miller, MD, Crozet, VA
II. Shoulder Cases

Robert A. Arciero, MD, Farmington, CT
Daniel E. Cooper, MD, Dallas, TX
Darren L. Johnson, MD, Lexington, KY
III Knee Cases

IV Medical Cases
Thomas A. Best, MD, Columbus, OH
V. Upper Extremity Cases

V. Lower Extremity Cases

vi. Question and Answer Session
313
RETURN TO PLAY SYMPOSIUM:

DOC, WHEN CAN HE GO BACK IN THE GAME?
Overview to 90 degrees for 3 to 4 weeks, advancing to full range of motion

Knee Meniscal Tear Miller at 4 weeks.
Knee MCL Tear Arciero
The athlete with a grade III MCL tear generally can return to play
Knee PCL Tear Cooper
by about 5 to 6 weeks post-injury. There is wide variation in this
Knee ACL Tear Johnson
number in the literature with some reports showing return as
Concussion Best
early as 3 weeks and others reporting return closer to 10 weeks.
Shoulder AC Injury Miller
Shoulder Anterior Glenohumeral Dislocation Arciero Giannotti BF, Rudy T, Graziano J. The non-surgical management of isolated medial
Shoulder Clavicle Fracture Cooper collateral injuries of the knee. Sports Med Arthrosc. 2006;14(2):74-77.
Shoulder SLAP Tear Johnson Fetto Jf, Marshall JL. Medial collateral ligament injuries of the knee: a rationale for
Spondylolysis/Spondylolisthesis Best treatment. Clin Orthop Relat Res. 1978;132:206-218.
Jones Fracture Miller
Posterior Cruciate Ligament (PCL) Injury
Tibia Fracture Arciero
PCL injuries most commonly occur in sports as a result of a direct
Hamstring Strain Cooper
blow to a flexed knee. The diagnosis is made by the presence of
Thigh Contusion/Myositis Ossificans Johnson
a knee effusion, positive posterior drawer testing, and
Infectious Mononucleosis Best
occasionally stress radiographs and/or MRI. Treatment is based
Jersey Finger Miller
on degree of injury with grade I and II isolated PCL tears being
Scaphoid Fracture Arciero
treated conservatively with quadriceps strengthening and bracing.
Elbow Dislocation Cooper
Grade III tears, combined ligamentous injury, or Grade II tears
Thumb UCL Injury Johnson
which fail to respond to adequate conservative care often require
Hypertrophic Cardiomyopathy Best
surgical reconstruction of the ligament.
Meniscal Tear If conservative treatment is indicated, return to play is allowed
Meniscal tears can occur from either trauma or as a result of age- when the effusion resolves, quadriceps and hamstring strength
related degeneration. In the athletic population meniscal tears reach 85% of the unaffected leg, and the athlete is able to
most commonly occur due to a twisting injury on a flexed knee. perform sports-specific drills including running and cutting
Symptoms are usually readily apparent and include focal pain, without reproduction of pain or instability. Surgical
swelling, and occasionally a mechanical catch or giving way of reconstruction usually requires 6 months of post-operative
the knee. Tears are most common in the “white-white” zone and rehabilitation before return to play is allowed.
therefore have extremely limited healing potential and are best
treated with partial meniscectomy. Very peripheral tears ( in the REFERENCES
red zone) are most common with associated anterior cruciate 1. Toritsuka Y, Horibe S et al. Conservative treatment for rugby football players
ligament tear and are best repaired if surgery is performed early. with an acute isolated posterior cruciate ligament injury. Knee Surg Sports
Vertical mattress sutures remain the gold standard technique Traumatol Arthrosc. 2004;12(2):110-114.
although many all-inside devices are now available which 2. Shino K, Horitbe S, et al. Conservative treatment of isolated injuries to the
approach the success of inside-out or outside in techniques. posterior cruciate ligament in athletes. J Bone Joint Surg Br. 1995;77(6):895-900.
After partial meniscectomy, return to play is allowed when the Anterior Cruciate Ligament (ACL) Injury
athlete is pain-free, has resolved his/her effusion, and has ACL injury most often occurs in a non-contact fashion. It is often
demonstrated a return of quadriceps function. This can vary from associated with meniscal pathology as well as
person to person but typically occurs at 2 to 3 weeks after surgery. osteochondral/articular cartilage injury. While few sports may
If a meniscal repair is performed, return to sport is much longer. allow return to play for an “isolated” ACL from a hyperextension
These patients are typically at 50% weight-bearing for 6 weeks, mechanism, the majority of patients undergo ACL reconstruction
can return to straight-ahead running at 3-4 months, and return within one month of acute injury with concomitant treatment
to high impact and contact sports (including soccer) 6 months of meniscal/AC pathology.
after surgery.
Return to play criteria is often sport dependent. The athlete must
REFERENCES have no signs of an inflamed knee as well as have less than a 10%
1. DeHaven KE. Meniscus repair in the athlete. Clin Orthop Relat Res. 1985;198:31-
deficit on functional evaluation testing. The athlete must then
35. “once released” undergo sport specific training as their final re-
2. McCarty EC, Marx RG, Wickiewicz TL. Meniscal tears in the athlete. Operative
intro program. Majority of patients require a minimum of 6
and nonoperative treatment. Phys Med Rehabil Clin N Am 2000;11(4):867-880. months and often up to 12 months to complete this process.
When one measures true performance of the athlete after ACL
MCL Tear reconstruction; performance remains decreased in the “first”
Grade III MCL tears are common in collision sport from a valgus return season, with return to normal in the “second” return
load to the knee, most commonly caused by a direct hit to the season.
lateral side of the knee. The hallmarks of diagnosing this
condition include medial pain, +/- pop at time of injury, laxity on REFERENCES
valgus stress testing. Diagnosis can be confirmed by MRI which 1. Gobbi A, Francisco R. Factors affecting return to sports after anterior cruciate
is also useful to rule out other associated ligament and meniscal ligament reconstruction with patellar tendon and hamstring graft: a prospective
injury. Treatment is generally conservative with bracing from 20 clinical investigation. Knee Surg Sports Traumatol Arthrosc. 2006
Oct;14(10):1021-8.
2. Button K, van Deursen R, Price P. Measurement of functional recovery in Anterior Shoulder Dislocation
individuals with acute anterior cruciate ligament rupture. Br J Sports Med. 2005 Acute anterior shoulder dislocations are common in the athletic
Nov;39(11):866-71.
population but can prove to be challenging in terms of return to
Concussion play issues in an “in-season” athlete. Treatment can be
Concussion is a potentially serious injury for athletes. Recent conservative initially but this condition is associated with a high
statistics suggest that approximately 300 000 sports-related recurrence rate in young patients and those participating in
traumatic brain injuries occur annually in the United States. collision sports. This often necessitates the need for stabilization
Soccer, rugby, football, and ice hockey are all considered high- procedures either during the season or after the season is
risk team sports for concussion. Return to play issues is one of the complete, depending on the individual athlete and his/her
most difficult tasks for physicians caring for concussed athletes. degree of limitation. Acute bankart repair may be necessary if the
There is significant variability in the evaluation and management athlete is unable to return to his/her pre-injury level and is a
of mild traumatic brain injury (mTBI). In the past decade, a means of restoring anatomy and function with predictable
tremendous amount of sport-specific research has improved our improved outcomes.
understanding of mTBI. The advent of neuro-psychologic (NP) The need to perform an acute bankart repair is a season-ending
testing batteries designed to assess concussive injury has injury. Return to full collision sport participation is at least 6
improved the assessment of cognitive dysfunction that occurs in months after this surgery. Immobilization in a sling is used for
the absence of structural brain abnormalities. The severity of the first 5 to 6 post-operative weeks with progression of passive
injury is determined by the nature, burden, and duration of and active motion after the sling is continued. Typically external
symptoms. Athletes must be asymptomatic and have a normal rotation is limited for at least the first 8 weeks and then slowly
neurologic and cognitive evaluation prior to RTP. Several factors advance along with rotator cuff strengthening exercises.
aid in making the RTP decision, including age, the severity of
injury, and history of prior mTBIs. Given the potential REFERENCES
complications of mTBI, the RTP decision must be made using a 1. Buss, D.D., et al., Nonoperative management for in-season athletes with anterior
thoughtful, individualized process. Functional magnetic shoulder instability. Am J Sports Med, 2004. 32(6): p. 1430-3.
resonance imaging (fMRI) represents an important evolving 2. Jakobsen, B.W., et al., Primary repair versus conservative treatment of first-time
technology for the understanding of brain recovery after traumatic anterior dislocation of the shoulder: a randomized study with 10-year
concussion and may help shape return-to-play guidelines in the follow-up. Arthroscopy, 2007. 23(2): p. 118-23.
future.
Clavicle Fractures
REFERENCES Clavicle fractures are commonly caused by a direct fall on the
1. Lovell MR et al. Functional brain abnormalities are related to clinical recovery “point of the shoulder.” Traditionally these fractures have been
and time to return-to-play in athletes. Neurosurgery. 2007; 61(2):352-9. treated conservatively unless severely displaced, shortened, or
2. McCrory P et al. Summary and agreement statement of the 2nd International causing significant tenting of the skin. More recently, several
Conference on Concussion in Sport, Prague, 2004. Clin J Sport Med. 2005; 15: studies have advocated more aggressive surgical fixation of
48-55. clavicle fractures. This leads to special consideration in the
athletic population where earlier healing leads to earlier return to
Acromioclavicular Joint Injury play.
Acromioclavicular (AC) joint injuries commonly occur in
athletes as a result of a direct fall on the “point” of the shoulder. As with other fractures, return to play is typically allowed when
They present with an acute onset of pain localized to the AC joint the athlete can exhibit full pain-free range of motion and the
and often an associated deformity. Treatment is based upon the fracture is united on radiographs. There remains some debate
degree of severity of the injury which is determined by obtaining about recurrent fractures after return to play with either
x-rays to include a AP of both AC joints and an axillary view of conservative or surgical treatment.
the affected side. I: AC sprain; II: AC tear, CC intact; III: AC and
REFERENCES
CC torn, up to 100% displacement; IV: AC and CC torn, clavicle
displaced posteriorly on axillary view; V: AC and CC torn, over 1. Kaplan LD, Flanigan DC, Norwig J, Jost P, Bradley J. Prevalence and variance of
shoulder injuries in elite collegiate football players. Am J Sports Med.
100% displacement; VI: AC and CC torn, clavicle inferiorly 2005;33(8):1142-6.
displaced. Types I and II are treated conservatively, Types IV, V,
2. Bernstein J. Nonoperative treatment compared with plate fixation of displaced
and VI usually require surgical reconstruction, and type III is midshaft clavicular fractures. J Bone Joint Surg Am. 2007 Aug;89(8):1866.
controversial and depends on the degree of symptoms and
impairment. SLAP Tear
Superior labral lesions may occur in isolation from a contact
Return to play after types I and II AC separations is dependent
mechanism or be part of continuum in association with shoulder
on the amount of time to return of pain-free shoulder range of
instability lesions found in the GH joint in throwing/non-
motion. If surgical reconstruction is performed, immobilization
throwing athletes. Lesions are often fixed arthroscopically with
of the shoulder is usually necessary for the first 6 weeks with
suture anchors in isolation or in combination with other labral
gradual return of motion and strength following that. Contact
pathology in shoulder instability patients.
and collision sports are avoided until 6 months after the
procedure. Return to play is often customized to the specific athlete based on
sport specific and arm dominance. Isolated lesions in the non-
REFERENCES dominate arm of a baseball first baseman may return to play in
1. Bishop JY, Kaeding C. treatment of the acute traumatic acromioclavicular 3 to 4 months, while a complex tear with associated anterior
separation. Sports Med Arthrosc 2006;14(4):234-245. labral pathology with shoulder instability may require up to nine
2. Rockwood CA Jr and Young DC: Disorders of the acromioclavicular joint. In months in a overhead dominant athlete. Criteria to use include
Rockwood CA Jr and Matsen FA III eds.: The Shoulder, 2nd ed. Philadelphia, WB careful exam of capsular mobility compared to the non-operative
Saunders, 1998, p. 495.
shoulder with arm adducted as well as in 90° of abduction.
Strength training must include CORE as well as scapular strength
315
and kinematics. Athlete must have normal kinematics (GH- REFERENCES

Scapular) prior to return to play. 1. Porter DA, Duncan M, Meyer SJ. Fifth metatarsal Jones fracture fixation with a
4.5 mm cannulated stainless steel screw in the competitive and recreational
REFERENCES athlete: a clinical and radiographic evaluation. Am J Sports Med 2005;33(5):726-

1. Funk L, Snow M. SLAP tears of the glenoid labrum in contact athletes. Clin J 733.
Sports Med. 2007;17(1):1-4. 2. Wright RW, Fischer DA, Shively RA, Heidt RS Jr, Nuber GW. Refracture of
2. Burkhart SS, Morgan C. SLAP lesions in the overhead athlete. Orthop Clin North proximal metatarsal (Jones) fracture after intramedullary screw fixation in
Am. 2001 Jul;32(3):431-41. athletes. Am J Sports Med 2000;28(5):732-736.
Spondylolysis/Spondylolisthesis Anterior Cortical Stress fracture of the Tibia

Spine injuries are a significant concern in the athletic population. Anterior cortical stress fractures (“dreaded black line”) of the tibia
The more severe spinal injuries are fortunately less common but is really a progression of the more common stress fracture seen
also produce controversy since the literature is lacking in in runners or athletes involved in repetitive jumping sports. Once
randomized control trials (RCT’s) examining sport-related spine this fracture progresses it can be visualized on plain radiographs.
injuries. With decisions relating to return to play, most authors Conservative treatment consists of rest, pneumatic bracing, and
would agree that the participant must be symptom free, have full bone stimulation but these fractures can take 6 to 9 months to
active range of motion, and have near to full strength (Level 4 heal. Intramedullary nailing is the alternative treatment which
evidence). There are no RCT tested treatment protocols for can be done acutely or after failure of 6 months of conservative
spondylolysis, but some general principles can be applied to any treatment.
treatment plan. After 4-6 weeks of relative rest, the athlete can Return to play after this injury is extremely controversial. Even
return to sport in the brace as long as he or she has become with early intramedullary nailing, return to play should be
asymptomatic. The use of bracing in the treatment of restricted until symptoms have completely resolved and the
spondylolysis has been controversial. There are many authors fracture demonstrates bony union on x-rays.
who advocate the routine use of a rigid brace and there are
reports by others who do not routinely use a brace in the REFERENCES
management of these patients. Bony healing has been shown to 1. Baublitz, S.D. and B.S. Shaffer, Acute fracture through an intramedullary
occur with the use of either a rigid brace, a soft brace, or no brace. stabilized chronic tibial stress fracture in a basketball player: a case report and
Excellent clinical outcomes are frequently achieved in the literature review. Am J Sports Med, 2004. 32(8): p. 1968-72.
absence of bony healing and there has been no association noted 2. Boden, B.P. and D.C. Osbahr, High-risk stress fractures: evaluation and
between the stage of the fracture and clinical outcome, with the treatment. J Am Acad Orthop Surg, 2000. 8(6): p. 344-53.
exception that bilateral defects may develop an associated Hamstring Strain
spondylolisthesis with time. For those who are participating in Hamstring strains also occur commonly in athletes and the
sports where the brace would impede performance, they must severity of the injury is the primary determining factor in
be pain free with lumbar extension, stork test, and have treatment and return to play. Assuming that the distal and
improvement of hamstring flexibility before undergoing a proximal attachments are intact and the injury is in the muscle
gradual return to play (Level 4 evidence). Surgery is indicated if belly itself, treatment is conservative with rest, modalities,
patients have persistent neurological symptoms, refractory pain, restoration and strength, functional rehabilitation, and
or have progressed to a Grade III or Grade IV spondylolisthesis occasionally corticosteroid injection. Surgery is not indicated for
(>50% to 100%). Lumbar vertebral fusion for slips usually mid-substance hamstring injury.
requires 6-12 months hiatus before an athlete can compete in
non-contact sports. (Level V) Return to play considerations revolve around pain, strength,
position-specific functional capacity in sports, as well as the risk
REFERENCES of recurrent injury. Most agree that the risk of reinjury is real, and
1. D’Hemecourt PA et al. Spondylolysis: returning the athlete to sports that second time hamstring strains tend to be worse than the
participation with brace treatment. Orthopedics. 2002; 25: 653-657. initial injury. Therefore, there are recommendations regarding
2. Rubery PT, Bradford DS. Athletic activity after spine surgery in children and ongoing rehabilitation even after the athlete has returned to play.
adolescents. Spine. 2002; 27: 423-427. Corticosteroid injections have been proven to speed recovery
after focal hamstring muscle belly injuries without significantly
Jones Fracture
affecting reinjury rates. (1) There is even some evidence that these
A Jones fracture may occur as a result of trauma or stress-related
corticosteroid injections might reduce reinjury rates.
changes in the base of the fifth metatarsal. By definition, a Jones
fracture is one that occurs at the proximal REFERENCES
metaphyseal/diaphyseal junction. While these are not common 1. Levine, W. et. al. “Intramuscular Corticosteroid Injection for Hamstring Injuries:
fractures in sports, they can be problematic in this particular A Thirteen Year Experience in the National Football League” American Journal of
population with high rates of delayed or nonunion and even Sports Medicine, 2000, May-June; 28 (3): 297-300.
refracture after surgical fixation. Most authors now recommend
early surgical fixation of the fracture in the high performance Thigh Contusion/Myositis Ossificans
athlete using a large (at least 4.5mm) cannulated screw. Severe thigh contusions may result in anterior compartment
hematomas which calcify _ resulting in myositis ossificans.
When to return an athlete to sport after either conservative or Return to play “too early” while the lesion is still “hot” may be
surgical treatment of a Jones fracture has been a controversial career ending because of permanent loss of motion. Once lesion
topic. Although some reports show early return after surgical has been confirmed by exam/x-ray, return to play is only allowed
fixation (as early as 10 days), most surgeons agree that return once the lesion has become quite with respect to pain and range
should be delayed until there is radiographic evidence of healing of motion has stabilized.
which is typically not until 8 weeks after the procedure.
Prevention of permanent loss of knee flexion during the
biologically hot phase is critical to prevent lesion from ending
the season or career of the athlete. Return to play is guided by
pain, thigh circumference measurements radiographs, functional 2. Peterson JJ, Bancroft LW. Injuries of the fingers and thumb in the athlete. Clin
testing of lower extremity musculature. Return to play to early Sports Med 2006;25(3):527-542.
can be catastrophic with respect to the development of severe
Scaphoid Fracture
myositis that restricts lower extremity function and therefore Scaphoid fractures are the most common carpal bone fracture
athletes’ performance. and should be suspected any time an athlete has a fall on the
REFERENCES outstretched hand. Snuffbox tenderness is the characteristic
physical exam finding and these fractures can usually be seen on
1. Aronen JG, Garrick JG, Chronister RD, McDevitt ER. Quadriceps contusions:
clinical results of immediate immobilization in 120 degrees of knee flexion. Clin plain radiographs although repeat films should be taken in cases
J Sport Med. 2006 Sep;16(5):383-7. of continued pain a week after the injury if the original x-rays
2. Cooper DE. Severe quadriceps muscle contusions in athletes. Am J Sports Med. were negative. Conservative treatment consists of thumb spica
2004 Apr-May;32(3):820. casting for 4 to 6 weeks but complete healing of the fracture can
take 3 to 4 months. Because the vascular anatomy of this bone
Infectious Mononucleosis leads to a high rate of nonunion, early screw fixation has been
Infectious mononucleosis is an acute self-limited disorder advocated.
diagnosed by clinical and hematologic measures. Current
consensus (level of evidence 4) supports that athletes be afebrile, As noted, return to play after conservative treatment of a scaphoid
well hydrated, and asymptomatic with no palpable liver or spleen fracture may take 3 to 4 months. Earlier return, as early as 10 to
before safe return to sports participation. These conditions for 14 days, may be appropriate after screw fixation. A protective
return to play do not guarantee that the spleen has returned to splint should be worn in these cases.
normal size and compliance, or that the risk of spleen rupture REFERENCES
has returned to baseline. The rate of splenic rupture is said to be
1. Haisman, J.M., R.S. Rohde, and A.J. Weiland, Acute fractures of the scaphoid.
one in 1000, however the reported number of cases suggests that Instr Course Lect, 2007. 56: p. 69-78.
the true incidence is much lower. Most splenic ruptures occur in
2. Gutow, A.P., Percutaneous fixation of scaphoid fractures. J Am Acad Orthop
the first 3 weeks of illness, and very few occur beyond weeks 4 to Surg, 2007. 15(8): p. 474-85.
5. Physical examination is too insensitive to reliably detecting the
enlarged at-risk spleen, hence the more recent reliance on Elbow Dislocation
ultrasound to document spleen size. Limitations exist with this Elbow dislocations, while not common, occur as a result of direct
approach including that the size of a normal spleen varies greatly. trauma to the upper extremity in collision sports. Posterolateral
A confounder is that a baseline, pre-illness ultrasound is rarely dislocations occur most commonly and account for
available. Further studies are required to support the routine use approximately 80% of the cases. Treatment involves closed
of ultrasound and decisions regarding return to play. It is likely reduction with splinting at 90 degrees for 7 to 10 days if the
that a single ultrasound may not be of limited value and it is elbow is stable after reduction. Unstable reductions may require
recommended that clinical judgment should prevail. an additional period of splinting for up to three weeks.
Conservative guidelines suggest a 3-week rest after diagnosis and Concurrent injury such as radial head and neck fractures are
a 4-week graded return to full activity if there is no splenomegaly. relatively common and should be evaluated with radiographs
Others suggest that if spleen size is normal, the athlete can return both pre-reduction and post-reduction if possible.
to play in 3 to 5 weeks after onset of illness, beginning with 1
Return to play considerations for this athlete will be different
week of graded activity. A careful discussion regarding risk for
based upon the degree of instability after reduction. This
splenic rupture needs to occur with the athlete prior to return to
dislocation pattern typically involves complete disruption of the
play.
ulnar collateral ligament which may require surgical repair in the
REFERENCES case of continued instability. Bracing is usually helpful and may
1. Hosey RG et al. Ultrasound assessment of spleen size in collegiate athletes. Br J speed return to play if surgery is not immediately indicated.
Sport Med. 2006; 40: 251-254.
REFERENCES
2. Waninger KN, Harcke HT. Determination of safe return to play for athletes
recovering from infectious mononucleosis: a review of the literature. Clin J Sport 1. Rettig, A. “Traumatic Elbow Injuries in the Athlete.” Orthopaedic Clinics of
Med. 2005; 15: 410-416. North America. 2002, July; 33 (3): 509-522.
2. Plancher, K. Lucas, T. “Fracture Dislocations of the Elbow in Athletes”. Clinic in
Jersey Finger Sports Medicine 2001, January. 20 (1): 59-76.
Jersey finger involves an avulsion of the flexor digitorum
profundus tendon from its insertion at the bases of the proximal UCL of thumb Metacarpal: “Skiers or Gamekeepers Thumb”
interphalangeal (PIP) joint. This injury is so named because the Injury often seen among athletes participating in ball-handling
mechanism involves forced extension of the finger as occurs and contact sports. Acute partial tears while rare are managed
when the finger gets caught in the jersey of an opposing player. with a hand-based thumb spica splint (orthoplasty) or cast for 4
Because the tendon tends to retract, treatment involves retrieval weeks, this often allows the athlete to return to play while
and reattachment of the tendon. protected.
Because the majority of cases of jersey finger require surgical The ligament plays a significant role in the athlete’s ability to
intervention, return to play is usually limited to 3 months provide pinch grip. It is for this reason; along with the
following the surgery. The athlete may be able to return to certain unpredictability of non-operative management that anatomic
drills and conditioning prior to that time if the finger is properly repair is generally required for complete disruption of the UCL in
protected. the competitive athlete.
Once repair or reconstruction is performed, protected
REFERENCES
immobilization is mandatory for 6 weeks. Depending on the
1. Kovacic J, Bergfeld J. Return to play issues in upper extremity injuries. Clin J specific sport, protection may be required for an entire 3 months.
Sports Med. 2005;15(6):448-452.
Return to play specifics entirely depends upon the sport and the
317
requirements of the hand of that person. Orthotic modifications including the most substantial hypertrophy observed in any
can be done for a majority of athletes for early return. cardiac disease (>30 mm). It may be difficult to distinguish mild
hypertrophic cardiomyopathy from normal left ventricular
REFERENCES hypertrophy in the highly trained athlete.

1. Peterson JJ, Bancroft LW. Injuries of the fingers and thumb in the athlete. Clin
Sports Med. 2006;25(3):527-42. Despite the relatively benign course for the majority of patients
2. O'Callaghan BI. Evaluating gamekeeper's thumb injuries. Am J Sports Med.
with HCM, this disease continues to be the most common cause
1997;25(2):275. of sudden death in young individuals. Sudden death results
primarily from ventricular arrhythmias, implantable cardiac
Hypertrophic Cardiomyopathy defibrillators (ICDs) are an effective therapy to prevent sudden
Hypertrophic cardiomyopathy (HCM) is a disorder of the cardiac death in patients with HCM. The Bethesda Guidelines on sports
muscle that is revealed in many different ways. The estimated participation, now in the process of being revised, consider that
prevalence of HCM in the general population is about 1 in 500. the risk to compete athletically with an ICD is unacceptably high.
The disease has a familial transmission as an autosomal- The guidelines indicate that individuals with an ICD should not
dominant trait with variable expression, so not all people with be involved in sports more active than bowling and golf (even
the gene trait will have the disease. Molecular studies though these also have not been shown to be safe either)
demonstrate the heterogeneity of this disease, which can be regardless of the underlying structural heart disease. These
caused by mutations in the cardiac sarcomere (the beta myosin guidelines are based on expert opinions, as data on this
heavy chain, cardiac troponin T, alpha tropomyosin, and myosin- population are limited and generally speculative.
binding protein C gene). Left ventricular hypertrophy involving
the septum is the predominant type of hypertrophy. In general, REFERENCES
wall thickness greater than 13 mm is very uncommon in highly 1. Graham TP Jr., Bricker JT, James FW, Strong WB. 26th Bethesda conference:
trained athletes. Left ventricular wall thickness can vary from mild Recommendations for determining eligibility for competition in athletes with
(13 to 15 mm; normal, <12 mm) to massively increased, cardiovascular abnormalities. Task Force 1: Congenital heart disease. J Am Coll
Cardiol 1994; 24:867–873.
DECISION-MAKING AND
EFFECTIVE ARTHROSCOPIC TECHNIQUES
IN THE MANAGEMENT OF
SHOULDER INSTABILITY (G)
Moderator: Richard L. Angelo, MD, Kirkland, WA
This AANA sponsored symposium provides a comprehensive discussion of the arthroscopic
management of shoulder instability. It focuses on two critical elements necessary for
achieving optimal outcomes: pre and intra-operative decision-making keys and the details
of effective arthroscopic techniques.
I. Arthroscopic Bankart Repair for Unidirectional Anterior Instability

Richard L. Angelo, MD, Kirkland, WA
II. Arthroscopic Management of Multidirectional and Posterior Instability

Felix H. Savoie III, MD, New Orleans, LA
III. Glenohumeral Bone Defects in the Management of Shoulder Instability

Stephen S. Burkhart, MD, San Antonio, TX
IV. Special Situations

Richard K.N. Ryu, MD, Santa Barbara, CA
V. Potential Complications Related to Arthroscopic Instability Repair

Georg Lajtai, MD, Althofen, Australia
VI. Case Discussions
VII. Audience Questions
319
ARTHROSCOPIC BANKART REPAIR FOR UNIDIRECTIONAL

ANTERIOR INSTABILITY
Richard L. Angelo, MD
DECISION-MAKING FOR ARTHROSCOPIC BANKART REPAIR 5. Studies

• X-ray: AP, West Point, Stryker notch – evaluate Hill-Sachs
1. Patient Goals – How to Define Success
defect
• recurrence rate of current arthroscopic suture anchor
• ArthroCT, MRI – evaluate size of glenoid rim defect / size
techniques (AS) equivalent to open stabilization
of fracture fragment
(Marquardt Arthroscopy 2007;Carriera AJSM 2006; Kim JBJS
2004; Kim Arthroscopy 2002) 6. Dx Arthroscopy
• must individualize; ??? only eliminate recurrent • Bankart lesion; capsular margin may be difficult to
dislocation / apprehension or return to normal function identify if no labrum remaining
and quality of life • ALPSA (anterior labral periosteal sleeve avulsion)
— 67 - 100% return to full sports activities (Fabbriciani — medial "attachment" of capsulolabral tissue may be
JBJS 2004) only suggestion that ALPSA is present
— faster return of normal F/ER/IR strength with scope • glenoid rim fracture – identify and estimate size / mobility
repair (Rhee AJSM 2007) — if acute and 25% or less, repair with suture anchors
• throwing, overhead athletes/workers – better chance of (Mologne AJSM 2007; Sugaya JBJS 2006))
return to high level function with arthroscopic — chronic and 25% or more, consider ORIF
stabilization • glenoid erosion; if > 25% using "bare spot" central
— complete return to throwing in 68% (Ide AJSM 2004) reference, recommend coracoid or iliac crest bone graft
• contact/collision, heavy laboring activities - depends a Latarjet (see Burkhart lecture)
great deal on capsulolabral quality / integrity; not an • capsule; "guesstimate" capsular strain - helps determine
absolute contra-indication how much capsular
— reports mixed: No increased risk - (Carriera AJSM plication/shift indicated with anchor sutures;
2006; Mazzocca AJSM 2006; Ide AJSM 2004) ; Yes — capsular "rents" - may be present even with Bankart
increased risk - (Rhee, AJSM 2007) lesion - good success if recognized and repaired (Rhee
• biomechanics: in-vitro studies show scope repair returns JSES 2006; Mizuno JBJS 2006)
normal glenohumeral translation / rotation (Marquardt • HAGL (Humeral Avulsion of Glenohumeral Ligaments) -
AJSM 2006) AS vs OS depending on pathology extent and surgeon
experience (scope repair - Burkhart Arthroscopy 2004)
2. Surgeon Experience
• Hill-Sachs lesion – if large (>25%) or “engaging”,
• we must critically asses our own skill development and
perform OS (some loss of ER may be important aspect of
decide on our ability to address each component of the
limiting recurrence (see Burkhart lecture)
instability pathology
— may consider arthroscopic "remplissage" - Wolf
• requires study, thorough planning, rehearsal with OR
• labral tears – look for associated SLAP lesions
staff
— 27% associated SLAP lesions (Carreira AJSM 2006)
3. History • partial cuff tears; may be source of ongoing Sx and
• patient age: may be higher RR if < 20-22 yo whether open require debridement
stabilization (OS) or AS; age not an absolute contra-
TECHNIQUE: SUTURE ANCHOR ARTHROSCOPIC
indication to AS - depends on capsulolabral quality /
BANKART REPAIR
tissue elasticity
— 12.5% recurrence after scope Bankart in pts 11 - 18 yo 1. optimize visualization
(Jones JPO 2007) • mildly hypotensive anesthesia (systolic approx. 90mmhg)
• as # instability episodes goes up, recurrent rate increases • epinephrine in the irrigant (1 amp1/100,000 epi/3L)
likely due to increased capsular strain / attenuation, • fluid pump vs adequate gravity
labral tearing, glenoid erosion (Habermeyer JSES 1999) 2. positioning (must be sufficient to access all pathology)
• lateral decubitus: 5-10# distal “suspension” - excessive
4. Physical Examination (must confirm clinical impression)
traction may compromise ability to retention IGHL
• laxity: excessive anterior / inferior translation; must also
— accessory lateral traction (5-10#) – perpendicular to
determine posterior and inferior laxity
humeral shaft
• ROM: greater than normal range, esp. ER suggests
— arm @ 25o abduction, 15o flexion
significant capsular laxity
• beachchair position
• + apprehension in AB/ER
— easier to convert to open procedure
• + relocation test
— access to posterior aspect of joint much more difficult
• + sulcus sign - suggests possible MDI
• hyperelasticity tests (thumbs, elbows, patellas) – if 3. portals
“hyperelastic / pathologic collagen” - a risk factor for • Posterior (P): 1.5cm inferior, 1.0 cm medial to
increased recurrence after AS (Boileau JBJS 2006) posterolateral acromial tip - direct anteromedially
toward tip of coracoid
• Anterosuperior (AS): use spinal needle to establish path; — tie simple throw with PDS around inferior limb of
enter skin 1cm lateral and slightly anterior to anterolateral anchor suture and shuttle out through capsulolabral
acromial tip; direct cannual immediately anterior to biceps tissue, then anterior cannula
• Midanterior (MA): 1 _ cm lateral, 1 _ cm inferior to • tie sliding knot (limb which exits through tissue must be
inferolateral coracoid tip - direct cannula immediately the post limb) and back-up with 1/2 hitches; repeat steps
superior to superior subscap boarder - approach glenoid to establish anchors @ 5:00, 3:30, and 2:00 o’clock on
@ 30 - 450 angle to glenoid rim in transverse plane; 8.5 the glenoid (4 anchors may be necessary)
mm clear, threaded cannula over switching stick works • also knotless anchors available
well (verify access to anterior / inferior glenoid)
6. address secondary laxity (examine after Bankart repair)
4. glenoid preparation • posterior capsular plication if posterior translation
• debridement of articular cartilage margins (turn suction exceeds 50%
off off shaver) — using suture hook deliver "pinch-tuck" plicating suture
• liberator / elevator - essential to complete inferior (PDS): begin 15 mm from glenoid rim and grasp
capsulolabral release around to 6:30 approx. 7 mm of capsule, then exit
• medial release along glenoid neck must be adequate to — allow capsule to fold and then deliver hook tip
free/mobilize capsule (subscap muscle should be visible) beneath intact labrum to exit at the labrum / articular
• light excoriation of anterior glenoid neck with shaver / burr cartilage margin (may need to use suture anchor if
• fracture fragment: labrum deficient)
— if < 15%: repair or excise by running burr in reverse — may consider shuttling permanent suture if desired
with suction off — tie sliding knot with capsular limb as post; back up
— if 15 - 25%: repair fragment, capsule and labrum with with 1/2 hitches
encircling or penetrating suture from anchor (Porcellini • close rotator interval if inferior translation exceeds 5 - 7
AJSM 2007; Sugaya JBJB 2005) mm,
— withdraw midanterior cannula to be even with capsule
5. sufficient IGHL / labral complex retensioning
layer
• drill anchor hole 2-3mm onto articular surface @ 450 to
— load suture retriever/penetrator with a #1 PDS 1 cm
the glenoid rim
from end of suture; introduce through the midanterior
— if placed on the corner of the rim, they may cut out
cannula, pass through MGHL from outside-in and
— most failures due to recurrence of the Bankart lesion
retrieve suture end with graspers through
(Marquardt JSES 2007)
anterosuperior portal
• insert anchor, test security; avoid metal (many reliable
— load the suture / retriever with the other end of the
non-metalic anchors available)
suture and introduce through the same mid-anterior
— ? higher failure with knotless anchors (No - Thal,
cannula, direct penetrator superiorly and pass through
Arthrsocopy 2007; Yes - Cho, Arthroscopy 2007)
the SGHL from outside-in and again retrieve through
— higher failure with less than 3 or 4 anchors (Boileau
the anterosuperior portal
JSES 2006)
— tie arthroscopic knot via anterosuperior portal closing
• suture delivery: (if not using a knotless anchor); many
the SGHL to MGHL; add additional sutures as
devices available - critical to deliver suture through
necessary (usually 2 or 3)
capsule at least 1 cm inferior to exit of anchor to
— may function primarily as an “internal splint” during
adequately retention capsule superiorly
healing
— retrieve inferior limb of anchor suture out posterior
cannula 7. test repair
— use cannulated suture hook to grasp 1 cm "bite" of • “palpate” repair arthroscopically
capsule / labrum (to adequately plicate capsule), then • remove arm from traction and test ROM and stability
deliver PDS and retrieve out posterior cann.
REFERENCES 8. Habermeyer, P, Bleyze,P, Rickert, M, et.al. Evolution of Lesions of the Labrum-

1. Baker, C.L., Uribe, J.W., Whitman, C.: Arthroscopic evaluation of acute initial Ligament Complex in Post-Traumatic Anterior Shoulder Instability: A Prospective
anterior shoulder dislocations. Am J Sports Med 18:25-28, 1990. Study. Shoulder Elbow Surg 1999; 66-74
2. Boileau P, Villalba M, Hery J, et al. Risk factors for recurrence of shoulder insta- 9. Hart, WJ, Kelly, CP. Arthroscopic Observation of Capsulolabral Reduction After
bility after arthroscopic Bankart repair. J Bone Joint Surg 2006;88:1755-63 Shoulder Dislocation. J Shouler Elbow Surg: 2004; 134-137.
3. Boileau P, Bicknell R, El Fegoun A, Chuinard. Arthroscopic Bristom procedure for 10. Ide,J, Maeda, S, Tagaki, K. Arthroscopic Bankart Repair Using Suture Anchors in
anterio instability in shoulders with a stretched or deficient capsule: The "belt- Athletes. Am J Sports Med 2004;32; 1899 – 1905
and-suspenders" operative technique and preliminary results. Arthroscopy 11. Itoi, E., Lee, SB, Bergland, LJ, et.al. The Effect of A Glenoid Defect on
2007;23:593-601 Anteroinferior Stability of the Shoulder After Bankart Repair: A Cadaveric Study. I
4. Carriera D, Mazzocca A, Orynon J et al. A prospective outcome evaluation of Bone Joint Surg Am 2000; 35-46.
arthroscopic Bankart repairs: minimum 2 year follow-up. Am J Sports Med 12. Jones K, Wiesel B, Ganley T, Wells L. Functional outcomes of early arthroscopic
2006;34:771-777 Bankart repair in adolescents aged 11 - 18 years. J Pediatr Orthop 2007;27:483
5. Cho N, Lubis M, Ha J, Rhee Y. Clinical results of arthroscopic Bankart repair with 13. Kim S, Ha K, Cho, et al. Arthroscopic anterior stabilization of the shoulder: two
knot-tying and knotless suture anchors. Arthroscopy 2007;23:566-7 to six year follow-up. J Bone and Joint Surg Am 2003;85:1511-18
6. Cole, B.J., L’Insalata J., Irrgang, J., Warner, J.J.:Comparison of arthroscopic and 14. Kim, SH, Ha, KI, Kim, SH: Bankart repair in traumatic anterior shoulder instabil-
open anterior shoulder stabilization. A two to six-year follow-up study. JBJS 82- ity: Open vs Arthrosocpic technique. Arthroscopy 18:755-763. 2002.
A:1108-1114, 2001. 15. Kim, S-H, Ha, K-I, Kim, Y-M, Arthroscopic Revision Bankart Repair: A Prospective
7. Fabrinani C, Milano G, Demontis A et al. Arthroscopic versus open treatment of Outcome Study Arthroscopy 2002; 18: 469-482
Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy
20:456-462,2004.
321
16. Marquardt B, Hurschler C Schneppendahl J, et al. Quantitative assessment of 26. Robinson, CM, Kelly, M., Wakefield, AE. Redislocation of the Shoulder During
glenohumeral translation after anterior shoulder dislocation and subsequent the First Six Weeks After a Primary Anterior Dislocation: Risk Factors and Results
arthroscopic Bankart repair. Am J Sports Med 2006;34:1756-62 of Treatment J Bone and Joint Surg 2002; 84A: 1552-1559
17. Marquardt B, Witt K, Liem et al. Arthroscopic Bankart repair in traumatic anteri- 27. Rhee Y, Ha J, Park K. Xlinical outxome of anterior shoulder instability with cap-
or shoulder instability using a suture anchor technique. Arthroscopy sular midsubstance tear: A comparison of isolated midsubstance tear and mid-
2006;22:931-36 substance tear with Bankart lesion. J Shoulder Elbow Surg 2006;15:586-590
18. Marquardt B, Garmann S, Schulte T et al. Outcome after failed traumatic anterior 28. Rhee Y, Ha J, Cho N. Anterior stabilization in collision athletes: Arthroscopic ver-
shoulder instability repair with and without surgical revision. J Shoulder Elbow sus open Bankart repair. Am J Sports Med 2007;35:148
Surg 1007; epub) 29. Rhee Y, Lim C, Cho N. Muscle strength after anterior shoulder stabililzation:
19. Mazzocca, AD, Brown, FM, Carreira, DS.et.al. Arthroscopic Anterior Shouler Arthroscopic versus open Bankart repair. Am J Sports Med 1007;35:1858-1874
Stabilization of Collision and Contact Athletes Am J Sports Med ;2005: 52-60 30. Richards D, Burkhart S. Arthroscopic humeral avulsion of the glenohumeral liga-
20. Mazzocca A, Brown F Jr, Carreira D, et al. Arthroscopic anterior shoulder stabi- ments (HAGL) repair. Arthroscopy 2004;20Suppl2:134-41
lization of collision and contact athletes. Am J Sports Med 2005;33:52-60 31. Ryu, RK, Open Versus Arthroscopic Stabilization for Traumatic Anterior Shoulder
21. Mishra, DK, Fanton, GS, Two-Year Outcome of Arthroscopic Bankart Repair and Instability Sports Med Arthroc Rev 2004; 12:90-98.
Electrothermal-Assisted Capsulorrhaphy for Recurrent Traumatic Anterior 32. Ryu RK. Arthroscopic approach to traumatic anterior shoulder instability.
Shoulder Instability, Arthroscopy, 2001,17:844-849 Arthrscopy;19 Suppl 1:94-101,2003.
22. Mizuno N, Yoneda M Hayashida K, et al. Recurrent anterior dislocation caused 33. Sperber, A., Hamberg, P., Karlsson, J., et.al. Comparison of An Arthroscopic and
by a midsubstance complete capsular tear. J Bone Joint Surg Am 2005;87:2717- An Open Procedure for Posttraumatic Instability of the Shoulder: A Prospective,
23 Randomized Multicenter Study J Shoulder Elbow Surg 2001, 10, 105 – 108
23. Mohtadi, NG, Bitar, IJ, Sasyniuk, TM, et.al. Arthroscopic Versus Open Repair for 34. Stein, D.A., Jazrawi, L., Bartolozzi, A.R.: Arthroscopic stabilization of anterior
Traumatic Anterior Shoulder Instability: A Meta-analysis. Arthroscopy:2005; 652- shoulder instability: a review of the literature. Arthroscopy 18:912-924, 2002.
658
35. Sugaya, H, Moriishi, J, Kanisawa, I. Et.al., Arthroscopic Osseous Bankart Repair
24. Mologne T, Provencher M, Menzel K, et al. Arthroscopic stabilization in patients for Chronic Recurrent Traumatic Anterior Glenohumeral Instability. J Bone Joint
with an inverted pear glenoid: Results in patients with bone loss of the anterior Surg (Am) 2005; 1752-1760
glenoid. Am J Sports Med 2007;35:1276-83
36. Thal R Nofziger M Bridges, Kim J. Arthroscopic Bankart repair using Knotless or
25. Porcellini G, Paladini P, Campi F, Paganelli M. Long-term outcome of acute ver- Bioknotless suture anchors: 1 - 7 year results. Arthroscopy 2007;23:367-375
sus chronic bony Bankart lesions managed arthroscopically. Am J Sports Med
2007; epub)
ARTHROSCOPIC TREATMENT OF POSTERIOR AND

MULTIDIRECTIONAL INSTABILITY
Felix H. Savoie III, MD
323
325
327
GLENOHUMERAL BONE DEFECTS IN THE MANAGEMENT OF

SHOULDER INSTABILITY
Stephen S. Burkhart, MD
A. Considerations in the Management of Glenoid Defects • expose inferior capsule and detach 1 cm medial to
1. etiology glenoid rim
• traumatic rim fracture 4. prepare glenoid
• progressive erosion secondary to recurrent instability • lightly excoriate glenoid neck
2. assessing glenoid defect size • contour coracoid to match glenoid surface
• identify central glenoid bare spot at center of inferior • insert 3 suture anchors along bone/cartilage junction
2/3 of glenoid 5. secure graft
• introduce calibrated probe from posterior portal and • match coracoid graft to glenoid defect to make it
measure distance from posterior glenoid rim to bare "flush" with articular surface
spot • fix with 2 transglenoid screws
• with same probe, measure distance from bare spot to • if slightly "proud", burr flush with glenoid
deficient glenoid rim 6. complete repair (to make bone graft extra-articular)
• estimate % defect of anterior glenoid • repair capsule with anchor sutures
• repair subscap tendon
B. Recommendations for Glenoid Defects
Type I (0-12.5% defect) D. Considerations in the Management of Humeral Head
• Excise fragment to shell and complete suture anchor Defects
repair (avoid disruption of the capsuloperiosteal layer - 1. etiology
weakens suture purchase) • prolonged dislocation
Type II (12.5 - 25% defect) • recurrent dislocations
• If "significant" fragment, consider arthroscopic reduction, 2. assessing humeral head defect size
internal fixation (ARIF) • X-ray - Stryker notch view
— suture anchor fixation • CAT scan is most accurate (with 3-D reconstructions)
– mobilize fragment, freshen / contour surfaces 3. assessing probable functional impact
– insert anchors (3 or 4) at bone / articular cartilage • creates decreased stability arc
junction • determine "engagement" in position of AB / ER during
– encircle fragment with anchor sutures, or EUA
– drill holes through fragment from posterior or 5
E. Management of Large Hill-Sachs defects
O'clock portal, tie in mattress fashion with suture
If < 30% articular surface defect and no engagement of head
from adjacent anchor
• arthroscopic Bankart repair
— may consider cannulated screw fixation (access difficult)
If > 30% articular surface defect or engagement
• If "insignificant" fragment, excise and complete suture
• consider open stabilization (Latarjet reconstruction)
anchor repair
• +/- osteochondral graft into head defect
• If no fragment, then suture anchor repair
— deltopectoral approach, dislocate humeral head
Type III (> 25% defect) "inverted pear" configuration
— size posterior defect
• If bone fragment, consider ORIF
— create matching graft from donor humeral head
• If no fragment, consider Latarjet
— secure with countersunk / absorbable screws
C. Modified Latarjet • arthroscopic "remplissage"
1. exposure — view from anterosuperior portal
• deltopectoral approach — excoriate base of defect with burr via posterior portal
• expose coracoid — introduce double-loaded suture anchor/s into
• detach pec minor with a small fragment of bone defect
2. harvest coracoid — withdraw posterior cannula to just outside
• osteotomize coracoid just anterior to coracoclavicular capsulotendinous layer (infraspinatus)
ligaments — introduce penetrator for retrograde retrieval of
• protect musculocutaneous nerve during transfer sutures (pass all sutures first)
3. expose glenoid — tie sutures outside of capsulotendinous layer (blind);
• detach/reflect upper 1/2 of subscap fills defect with infraspinatus tendon / capsule
REFERENCES 3. Walch G, Boileau P. Latarjet-Bristow procedure for recurrent anterior instability.

Tech Shoulder Elbow Surg 2000; 1: 256-261.
1. Burkhart SS, DeBeer JF. Traumatic glenohumeral bone defects and their rela-
tionship to failure of arthroscopic Bankart repairs: significance of the inverted- 4. Churchill RS, Moskal MJ, Lippett SB, Matsen FA III. Extracapsular anatomically
pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000; contoured anterior glenoid bone grafting for complex glenohumeral instability.
16(7): 677-694. Tech Shoulder Elbow Surg 2001; 2: 210-218.
2. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for
the treatment of anterior instability of the shoulder. J Bone Joint Surg Am 1998;
80(6): 841-852.
MANAGEMENT OF THE FIRST-TIME ANTERIOR

SHOULDER DISLOCATION
Richard K.N. Ryu, MD
1. Natural History athlete

a. “Pseudo” meta-analysis of recurrence rates (ranging 17% 2. Arthroscopic: recurrence rate between 5-10%
to 90%) (current)
i. Overall mean 67% c. Prospective studies
ii. Recent data: i. Kirkley ‡ arthroscopic results superior to conservative ;
1. Hovelius 2006 (AAOS) with ave 25 year follow up; WOSI results indicate better outcome in all categories
less than 50% recurrence ‡ 115 of 227 patients with early stabilization
without recurrence over 25 years ii. Bottoni /DeBernardino‡ Prospective and randomized
2. Robinson et.al JBJS 2006 ‡ prospective cohort study with small study groups; operative far better recurrence
252 pts; 70% recurrence within 5 years; younger pts rate compared to non-operative
at greatest risk iii.Jakobsen, et.al Prospective, randomized op vs.
3. Sachs et.al JBJS 2007 ‡ for majority of patients, early stabilization ‡ 56% recurrence in non-op vs 3% in
stabilization not justified; for 12-19 year old operative repair; at 10 years ‡ 72% with surgery
subgroup/contact sport : 56% recurrence satisfactory with 74% non-op unsatisfactory
a. 50% rule iv. Larain ‡ much higher recurrence rate in non-op vs op
i. 50% of all dislocators will redislocate in rugby population
ii. Only 50% of re-dislocators will seek surgery
5. Are first-time anterior shoulder dislocations analogous to
b. Study does recognize that patient population
the torn ACL in the HIGH RISK population?
does not cover NCAA , professional athletes,
a. Both can be associated with disabling functional loss
cadets
b. Both entities can lead to further tissue damage with
c. Also recognizes that studies from military
recurrent episodes
academies “have identified a subgroup that falls
c. Quality of life indicators appear to justify stabilization in
outside of the norm”
this population
iii.Begs the issue: Identification of the “appropriate”
d. Immediate stabilization is REASONABLE intervention in
candidate for first-time stabilization
high-risk population
iv. High risk profile:
1. Contact/collision athletes 6. Special circumstance: In-Season Anterior Dislocation:
2. Adolescent population a. Options:
i. Attempt to complete season with rehab/bracing; defer
2. Pathology at initial dislocation
surgery until end of season
a. Bankart lesion most common
ii. End season and stabilize the shoulder
b. Capsular tear 10-15%
1. Buss AJSM 2004 ‡ 26 of 30 returned to play with
c. Hill-Sachs >60%
ave 10 days missed; 16 with recurrence during
d. SLAP, PRCT less often
season (1.4 episodes/athlete)
3. Progressive soft tissue injury with recurrences iii.Need to discuss all options and let patient and family
a. Habermeyer ‡ increased bone and soft tissue damage decide
correlated to number of instability episodes
7. Conclusions
b. Larain ‡ greater bone loss and ligamentous injury
a. Highly selective for consideration of early surgical
c. Urayama ‡ MR evidence of capsular elongation with
intervention
recurrences
i. High risk‡ contact athlete, adolescent, lig laxity
d. Yiannakopoulos ‡ intra-articular findings in acute vs
b. Rationale similar to ACL and recurrence:
chronic instability; associated secondary injuries greater
i. Quality of life, progressive tissue damage
in chronic vs acute
c. Requires in-depth discussion of multiple variables
4. Treatment Options: between surgeon and HIGH RISK patient regarding
a. Immobilization and rehabilitation intrinsic risk factors
i. External rotation with lower recurrence rate i. Age, activity, ligamentous laxity, bone loss, contact
ii. Itoi JBJS 2007: Level II study ‡ randomized, sports
prospective immobilization in internal vs external ii. If patient opts for stabilization after first dislocation,
rotation contact sports not a contraindication to arthroscopic (
1. Overall recurrence int rotation ‡ 42% not unanimous)
2. Overall recurrence ext rotation ‡ 26% 1. Mazzocca: 10% recurrence with “early” arthroscopic
a. < or =20 yrs ‡ int rot 68% ; ext rot 41% techniques
b. > 40 yrs ‡ int rot 17% ; ext rot 13% 2. Larain : Single digit recurrence rate in rugby players
c. Nearly 40% non-compliant with protocol 3. Boileau: contact sports not a risk factor for
b. Surgical stabilization recurrence
i. Technique 4. Cho : ( contrarian) collision recurrence 28% vs 7%
1. Open vs. arthroscopic; success rates converging; in non-contact athletes
may reflect effort to preserve external rotation in the
329
REFERENCES 15. Sachs, RA, Lin, D, Stone, M.L., et.al., Can the Need for Future Surgery for Acute
Decision-Making First-Time Anterior Dislocation Traumatic Anterior Shoulder Dislocation be Predicted? J Bone Joint Surg 89:
1665-74, 2007
1. Hovelius, L., Skoglund, U, Sandstrom, B., Prognosis of First-Time Shoulder

Dislocation in the Young. Presented at AAOS 73rd Meeting. March 22-26, 2006. 16. Jakobsen, BW, Johannsen, HV, Suder, P., et.al. Primary Repair Versus Conservative
Chicago, Illinois Treatment of First-Time Traumatic Anterior Dislocation of the Shoulder: A
Randomized Study with 10=Year Follow-up. Arthroscopy 23: 188-123, 2007
2. Ryu, RK, Open Versus Arthroscopic Stabilization for Traumatic Anterior Shoulder
Instability Sports Med Arthroc Rev 2004; 12:90-98. 17. Robinson, CM, Kelly, M., Wakefield, AE. Redislocation of the Shoulder During
the First Six Weeks After a Primary Anterior Dislocation: Risk Factors and Results
3. Ryu, R. Arthroscopic Approach to Traumatic Anterior Shoulder Instability of Treatment J Bone and Joint Surg 2002; 84A: 1552-1559
Arthroscopy, 2003 (supplement), 19: 94-101
18. Boileau, P., Villalba,M., Hery, J., et.al. Risk Factors for Recurrence of Shoulder
4. Barber, F.A., Ryu, RK., Tauro, JC., Point-Counterpoint: Should First Time Anterior Instability After Arthroscopic Bankart Repair . J Bone Joint Surg Am 2006: 88A;
Shoulder Dislocations Be Surgically Stabilized? Arthroscopy 2003, 19; 305-309 1755-1763
5. Mazzocca, AD, Brown, FM, Carreira, DS.et.al. Arthroscopic Anterior Shoulder 19. Robinson, CM, Howes,J, Murdoch, H., et.al Functional Outcome and Risk of
Stabilization of Collision and Contact Athletes Am J Sports Med ;2005: 52-60 Recurrent Instability After Primary Anterior Shoulder Dislocation in Young
6. Ide,J, Maeda, S, Tagaki, K. Arthroscopic Bankart Repair Using Suture Anchors in Patients. J Bone Joint Surg 88:2326-36, 2006
Athletes. Am J Sports Med 2004;32; 1899 – 1905 20. Owens, BD, Duffey, ML, Nelson, BJ, et.al The Incidence and Characteristics of
7. Habermeyer, P, Bleyze,P, Rickert, M, et.al. Evolution of Lesions of the Labrum- Shoulder Instability at the United States Military Academy. Am J Sports Med 35:
Ligament Complex in Post-Traumatic Anterior Shoulder Instability: A Prospective 1168-1173, 2007
Study. I Shoulder Elbow Surg 1999; 66-74. 21. Larain,MV, Montenegro, HJ, Mauas, DM, et.al, Arthroscopic Management of
8. Itoi, E., Hatakayama, Y, Kido, T., et.al., A New Method of Immobilization After Traumatic Anterior Shoulder Instability in Collision Athletes: Analysis of 204
Traumatic Anterior Dislocation of the Shoulder: A Preliminary Study. J Shoulder Cases with a 4-to9-Year Follow-up and Results With the Suture Anchor
Elbow Surg 2003; 12: 413-415 Technique Arthroscopy 22:1283-80, 2006
9. Burkhart, SS, De Beer, JF, Traumatic Glenohumeral Bone Defects and Their 22. Buss, DD, Lynch GP, Meyer CP, et.al Non-operative Management for In-Season
Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the Atheltes with Anterior Shoulder Instability. Am J Sports Med 32:1430-33, 2004
Inverted-Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion, Arthroscopy, 23. Burris,MW, Johnson, DL, Mair, SD. Management of In-Season Anterior Shoulder
2000, 16:677-694. Dislocation in the Amateur Athlete. Orthopaedics 30: 362-364, 2007
10. Pagnani,MJ, Dome, DC, Surgical Treatment of Traumatic Anterior Shoulder 24. Cho, NS, Hwang, JC, Rhee, YG. Arthroscopic Stabilization in Anterior Shoulder
Instability in American Football Players JBJS 2002, 84:711-715 Instability: Collision Athletes Versus Noncollision Athletes. Arthroscopy 22: 947-
11. Magnusson, L., Kartus, J., Ejerhed, L., et.al. Revisiting the Open Bankart 953, 2006
Experience Am J Sports Med 2002, Vol.30, 778-782 25. Itoi, E., Hatakeyama, Y., Sato, T., et.al. Immobilization in External Rotation After
12. Bottoni, CR, DeBernardino, TM, et al., A Prospective Randomized Evaluation of Shoulder Dislocation Reduces the Risk of Recurrence. J Bone Joint Surg. 89:
Arthroscopic Stabilization Versus Nonoperative Treatment of Acute, Traumatic, 2124-2131, 2007
First-Time Shoulder Dislocation. Arthroscopy (abs), 2000, 16, 432 26. Miller, BS., Sonnabend, DH., Hatrick, C., et.al., Should Acute Anterior
13. Kirkley A, Griffen S, Richards,C. et al., Prospective Randomized Clinical Trial Dislocations of the Shoulder Be Immobilized in External Rotation? A Cadaveric
Comparing the Effectiveness of Immediate Arthroscopic Stabilization Versus Study. J Shoulder Elbow Surg 13: 589-592, 2004
Immobilization and Rehabilitation in First Traumatic Anterior Dislocations of 27. Yiannakopoulos,CK, Mataragas, E., Antonogiannakis, E. A Comparison of the
the Shoulder. Arthroscopy, 1999, 15:507-514. Spectrum of Intra-articular Lesions in Acute and Chronic Anterior Shoulder
14. Baker CL Arthroscopic Evaluation of Acute Initial Shoulder Dislocations, in Instability. Arthroscopy 23: 985-990, 2007
Pritchard DJ (ed): Instr Course Lect, AAOS 1996, Vol 45,, 83-89.
POTENTIAL COMPLICATIONS IN ARTHROSCOPIC

INSTABILITY REPAIR
George Lajtai, MD
Potential Problems Portals

1. Patient selection Appropriate position of the arthroscopy portals is a prerequisite
2. Technique Specific Complications for an optimal arthroscopic visual exposure of the shoulder joint.
3. Postoperative management The position of the secondary portal depend on the primary
dorsal portal, so that malpositioning of the portals not only bears
1. Patient Selection and Examination
the risk of injuring anatomical structures because not all areas or
The success or failure of arthroscopic surgery begins with
the joint may be inspected.
this step
• Medical history For optimal insertion of the scope, first, the bony structures may
• Physical examination be marked to maintain the anatomical orientation throughout
• Radiographic examination the operation, even if the soft tissues are swollen due to water
• Examination under anaesthesia escaping from the portals.
2. Technical errors
Dorsal Portal
• Poor Patient positioning
It allows for almost complete visualization of the glenohumeral
• Poor Portals
joint. Various techniques and location for this portal have been
• Placement of Anchor
described, all referring to the posterolateral border of the
• Capsule tension inadequate
acromion as reference.
• Suture Management
• Loose knots The scope should be inserted as parallel as possible to the glenoid
to achieve optimal freedom of motion and good visual exposure.
PATIENT POSITIONING
• Anterior Portals
Lateral Decubitus Position
The patient is rested on the non-operated side and the arm of the ANTERIOR-SUPERIOR-APPROACH
treated shoulder ist brought to abduction using a special
Outside in Technique
shoulder holder.
The exact anatomical location of the anterior portal will depend
on how the portal is established. Factors such as patient
Procedure:
positioning, the degree of arm flexion and abduction, and the
1. Resting of the patient on his back using a vacuum mattress
location of the anterior portal skin incision are important in this
which must reach from the trochanter region to the superior
determination. Matthews et al.have established that no
angle of the scapula.
neurovascular structures are in jeopardy if the anterior portal is
2. Anesthesia.
lateral and superior to the coracoid process.
3. turning of the patient to the non-treated side.
4. Slight dorsal inclination of the patient. The portal is established 1-2 cm anterior to the AC joint and
5. Resting of the patient with his head at the edge of the inferior to the long head of the biceps. Specially for anterior
operating table. instability surgery the arthroscopic portal should be placed
6. Adaptation of the mattress and establishment of the parallel to the glenoid joint line and as far medial as possible.
vacuum.
ANTERIOR INFERIOR APPROACH:
7. Securing of the resting position using a safety belt.
8. Application of a silicone cushion to the knee region to Outside In Technique
protect the peroneal nerve. This portal is located just lateral to the coracoid process. It is
9. Fication of the operated arm on fingers 2-4 using a Chinese established by placing is exactly superior to the subscapularis
fingertrap with the shoulder-holding crane, traction of 3-4 tendon as far lateral as possible but never medial to the coracoid
kg applied. tip.
10. Sterile scrubbing and draping.
11. Removel of the Chinese fingertrap and installation of the Technique:
definitive arm holder. For this application we utilize a SPS system (Secure Portal System,
Storz) which allows for optimal control of direction and position
Advantages of the Lateral Decubitus Position:
of the approaches.
1. the lateral decubitus position allows for ergonomic
operating on the shoulder. 1. A 1,5 mm needle is advanced transcutaneously into the joint.
2. The assistant may be fully included in the operation. The position may be corrected several times, until it penetrates
3. Operating surgeon and assistant can be positioned around the capsule at the desired spot in the right direction.
the shoulder operated on. 2. The mandrel is removed from the needle.
4. Lowering of the patient’s head for blood pressure control is 3. A 1 mm Kirschner wire is inserted through the needle into
possible. the joint cavity.
5. Positioning of the anaesthesiologist far from the operative 4. The need list removed from the joint.
field. 5. Skin incision.
6. A dilator is advanced along the Kirschner wire into the joint
cavity.
331
7. The cannula is advanced along the dilator. compressed and sheared between drill hole an anchor eyelet,
resulting in damage caused by the sharp edges of the bone.
The SPS allows the creation of an approach to the joint simply by
dilatation of the soft tissue, without sharp-object trauma.

CAPSULE TENSION
The positioning is done under arthroscopic control, providing
Tissue failure
optimal and snug fit of the cannula, which is inserted last.
• Pouch not reduced
• Enlarged or ruptured structures of the rotator interval
Complications:
• IGHL not retensioned
Neurological structures at risk are the axillary plexus and the
• Poor quality of the capsule
musculocutaneous nerve. To avoid damage to these two nerves as
well as to the brachial plexus, the following rules should be Suture Management
followed: Clear suture management is essential for successful instability
repair. During moving the sutures be aware of unloading the
• Portals medial to the coracoid process are forbidden:
anchor. View the anchor. No movement on the anchor is allowed
• For specific indications other portals may be feasible;
during manipulating the two sutures – this sign is called the
however, such approaches should only after taking into
Triangle Sign.
consideration possible damage to the structures mentioned
above, and they should only performed by an If twists during tying occur:
arthroscopically experienced shoulder surgeon. • Don´t try to disentangle the twist from the same portal as
you created it!
Injuries to nerves that occur by creating anterior portals are
• Change the camera and the working portal
avoidable.
• Have also a clear management of the shuttle
Anchor Positioning Knot patterns
Suture anchors may be utilized for various applications in There are various knots described in the literature for
surgery, wherever soft tissure needs to be attached to bone. they arthroscopic-reconstructive surgery. Despite the variety of knot-
represent the junction between bone and suture material, serving tying techniques, the surgeon must only be familiar with two
as anchors to the suture material which is used to tie soft tissue basic knot patterns: The sliding knot and the nonsliding knot. A
to bon. Even though suture anchors may also be used for exotic common nonsliding knot is the revo knot; common sliding
applications such as bladder suspension procedures, the main knots are the Tennessee slider an the Outback knot. (see:
field of application is the upper extremity, chiefly the shoulder. www.shoulder.org)
Especially in arthroscopic surgery, suture anchors are of great
value in the reconstruction of rotator cuffs, labrum defects o for 3. Postoperative Management
tenodesis of the biceps tendon. • The aim is to avoid postoperative stiffness and save the
reconstruction!
Suture: • Passive mobilization from the first day postoperative
The original idea of the suture anchor – as may be guessed by • Abduction and elevation allowed due to 80 degree
the name – was to anchor a suture in bone. Therefore, a typical • Sling for 3 weeks
suture anchor is equipped with a suture eyelet through which a • No external rotation for 6 weeks
suture is threaded and may be used to suture soft tissue to the • Underwater therapy from the first day postoperative
bone, where the anchor is inserted. Arthroscopic reconstructions • Propriorezeptive training starting 2 days after surgery
with suture anchors and sutures require proper arthroscopic • Protected range of motion for 4-6 weeks
suturing and knotting technique. In order to die arthroscopic • Strengthening: 3-6 weeks
sliding knots, the suture should slide freely through the eyelet Sports: 3 months noncontact
without high frictions, which could damage the suture anchor 6 months contact
and prevent the snug seating of the knot. Good protection of the
suture is also oft great relevance when the anchor is inserted into
the bone because in some anchor models, the suture may be
◆CURRENT TRENDS IN SPORTS MEDICINE:
AN INTERNATIONAL PERSPECTIVE (AA)
Moderator: Pietro Tonino, MD, Maywood, IL
World-wide, we have seen an exponential growth in the number of individuals of all ages
and abilities participating in organized and recreational sports. Treatment algorithms for
injuries sustained during these activities are being constantly revised as we learn more about
sports-related injuries. We have assembled an international panel of experts who will
discuss prevention strategies and non-surgical treatment options as well as the most up-to-
date surgical techniques for these injuries.
I. How can we accelerate recovery in athletes with lower extremity tendinopathies?

Nicola Maffulli, MD, Stoke on Trent, United Kingdom
II. How will we treat articular cartilage injuries in athletes in the future?
Mitsuo Ochi, MD, Hiroshima, Japan
III. Today’s approach to lateral meniscal tears in young and mature athletes.
Rene Verdonk, MD, Ghent, Belgium
IV. How can we reduce the length of disability in athletes with muscle strains?
Jacques Menetrey, MD, Geneva, Switzerland
V. Discussion
VI. ACL reconstruction-where have we been and where are we going?

Freddie Fu, MD, Pittsburgh, PA
VII. Is computer navigation necessary for optimal surgical results in Sports

Medicine?
Philippe Colombet, MD, Merignac, France
VIII. Treatment of anterior shoulder instability injury in "contact" vs. "non

contact" athletes.
Riccardo Minola, MD, Rozzano, Italy
IX. What are the best options today for ACL injury prevention?
Moises Cohen, MD, Sao Paulo, Brazil
X. Discussion
333
HOW CAN WE ACCELERATE RECOVERY IN ATHLETES WITH LOWER

EXTREMITY TENDINOPATHIES?
Nicola Maffulli, MD
Tendinopathies account for a substantial proportion of overuse Most essentially follow the same principles. Managements that
injuries in sports, and are prevalent in the workplace. The essence have been investigated with randomised controlled trials include
of tendinopathy is a failed healing response, with haphazard nonsteroidal anti-inflammatory medication, eccentric exercise,
proliferation of tenocytes, some evidence of degeneration in glyceryl trinitrate patches, electrotherapy (microcurrent and
tendon cells and disruption of collagen fibres, and subsequent microwave), sclerosing injections, and shock wave treatment.
increase in non-collagenous matrix. Over the past few years, There are no randomized or prospective studies that compare
various new therapeutic options have been proposed for the different conservative and surgical management regimens.
management of tendinopathy. Despite the morbidity associated
Musculo-skeletal physicians attempt to give their patients the best
with tendinopathy in athletes, management is far from
available management at their disposal. Recently, the concept of
scientifically based, and many of the therapeutic options
'evidence-based medicine' has come to the forefront attempting
described and in common use lacking hard scientific
to recognise and define the best scientific observation which
background.
might influence practice. Further randomized controlled trials
Physical therapy, rest, training modification, splintage, taping, are necessary to better clarify the best therapeutic options for the
cryotherapy, electrotherapy, shock wave therapy, hyperthermia, management of tendinopathy and the best recovery for athletes
pharmaceutical agents such as non-steroidal anti-inflammatory with lower extremity tendinopathies.
drugs and various peri-tendinous injections have been proposed.
REFERENCES 3. Rompe JD, Nafe B, Furia JP, Maffulli N: Eccentric loading, shock-wave treatment,
or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a
1. Maffulli N, Wong J: Rupture of the Achilles and patellar tendons. Clin Sports
randomized controlled trial. Am J Sports Med 2007, 35(3):374-383.
Med 2003, 22(4):761-776.
4. Sayana MK, Maffulli N: Eccentric calf muscle training in non-athletic patients
2. Maffulli N, Kader D: Tendinopathy of tendo achillis. J Bone Joint Surg Br 2002,
with Achilles tendinopathy. J Sci Med Sport 2007, 10(1):52-58.
84(1):1-8.
HOW WILL WE TREAT ARTICULAR CARTILAGE INJURIES IN

ATHLETES IN THE FUTURE?
Mitsuo Ochi, MD
Recently, a regenerative medicine using a tissue-engineering Articulated Distraction Arthroplasty

technique has provided a new option on how treat articular Bone marrow stimulating procedure has been a well-accepted
cartilage injuries in athletes. In this symposium, I would like to procedure for a large osteochondral defect. However, there are
introduce our present and future approaches for cartilage defects. two potential weak points to induce hyaline cartilage.
One is compressive overload on the drilled or micro fractured
Transplantation of Tissue-engineered cartilage
area at the early stage. In order to reduce the overload, we have
Since 1996 we have been performing transplantation of tissue-
developed external fixators which allows almost full ROM with
engineered cartilage made ex vivo for the treatment of
joint distraction for clinical cases based on an animal study
osteochondral defects of the joints [Ochi, et al.(1)], [Ochi, et al.
[Kajiwara, et al.(3)]. This apparatus has been successfully used
(2)]. This signifies a concept shift from cell transplantation to
for 8 patients with a large cartilage defect [Deie, et al.(4)].
tissue transplantation made ex vivo using tissue-engineering
Another weak point is a small number of mesenchymal stem
technique.
cells obtained from drilled holes. Injection of cultured MSCs in
the joint was demonstrated to be effective for a cartilage defect of
Patients:
rats. [Nishimori, et al.(5)]. The combined approach should be a
Seventy-one knees of 68 patients (mean age: 25 y.o.) of 103
new one for a large defect in the near future.
patients who had received transplantation of tissue-engineered
cartilage for cartilage defects were followed up for at least 2 years.
Cell Delivery System for Cartilage Defects
The tissue-engineered cartilage was made by cultivating
The most optimal procedure to repair cartilage defects is just
autologous chondrocytes embedded in Atelocollagen gel for 3
injection of cytokines or growth factors and cells. Our completely
weeks before transplantation.
novel approach in the future is to use cell delivery system using
an external magnetic field. Our approach was to use autologous
Results:
bone marrow mesenchymal stem cells attached to small-sized
24 months after surgery, transplantation eliminated knee locking
magnetic beads and an external magnetic field. For successful
and reduced pain and swelling in all patients. The mean Lysholm
cartilage repair, it is simple to inject mesenchymal stem cells and
score improved significantly. Arthroscopic assessment indicated
effectively collect them to a specific area in the knee joint
that 65 knees had excellent or good outcomes.
(osteochondral defect) using an external magnet force
[Kobayashi, et al.(6)]. I would like to introduce our system for
cartilage defect in the future.
REFERENCES 4. DEIE M, OCHI M., ADACHI N, KAJIWARA R, KANAYA A: A new articulated dis-
1. OCHI M, UCHIO Y, TOBITA M, KURIWAKA M: Current concepts tissue engi- traction arthroplasty device for treatment of the osteoarthritic knee joint: a pre-
neering technique for repair of cartilage defect. Artificial Organs, 2001, 25(3), liminary report. Arthroscopy, 2007, 23(8), 833-838
172-179 5. NISHIMORI M, DEIE M, KANAYA A, EXHAM H, ADACHI N, OCHI M: Repair of
2. OCHI M, UCHIO Y, KAWASAKI K, WAKITANI S, IWASA J: Transplantation of chronic osteochondral defects in the rat: The bone marrow stimulating.
cartilage-like tissue made by tissue-engineering for the treatment of cartilage Procedure with cultured allogenic bone marrow mesenchymal stromal cells.
defects of the knee. Journal of Bone Joint Surgery [Br], 2002, 84(4), 571-578 Journal of Bone and Joint Surgery [Br], 2006, 88-B(9), 1236-1244
3. KAJIWARA R, ISHIDA O, KAWASAKI K, ADACHI N, YASUNAGA Y, OCHI M: 6. KOBAYASHI T, OCHI M, YANADA S, et al: A novel cell delivery system using
Effective repair of a fresh osteochondral defect in the rabbit knee joint by articu- magnetically labeled mesenchymal stem cells and an external magnetic device
lated joint distraction following subchondral drilling. Journal of Orthopaedic for clinical cartilage repair. Arthroscopy, in press
Research, 2005, 23, 909-915
335
TREATMENT OPTIONS FOR LATERAL MENISCAL TEARS IN YOUNG

AND MATURE ATHLETES
Rene Verdonk
Introduction • As compared to the medical menisectomy the lateral

Why focus on the lateral meniscal lesion in the young and meniscectomy will not influence dramaticly the AP laxity of
mature athlete? The lateral meniscus is an essential part in the the knee, and as such will not be as dreadful for evolvement
most mobile compartment of the knee joint. As such, the lateral into degenerative joint disease.
meniscus moves more than it’s medial counterpart, where • ACL repair reduces significantly further lateral meniscus
congenital abnormalities such as cysts or discoid abnormalities degeneration.
may be present. • A lateral meniscectomy will only be required when the
lesion is irreparable and then again will be as limited as
LATERAL MENISCAL TEARS IN A STABLE KNEE possible.
Fresh ruptures • No treatment is required when the lesion is asymptomatic.
• Obvious clinical lateral meniscal lesions do not necessitate • A lateral meniscal repair will be indicated only when the
complex imaging procedures. The clinical picture is clear lesion is symptomatic or unstable.
and will lead to an arthroscopic lateral adequate
SALVAGE PROCEDURES AFTER LATERAL MENISCECTOMY
meniscectomy. This may induce a prolonged period of
Introduction
rehabilitation.
• Correct alignment is essential when further treatment is
• Suture is indicated in peripheral vertical lesions or
required.
horizontal cleavage tears in the young athlete.
Corrective osteotomy
Chronic ruptures
• Long term follow-up indicating degenerative arthritis in the
• The clinical findings are less obvious. Imaging investigation
lateral compartment requires renewed imaging and
is required and may consist of an arthro-CT scan or an
alignment control.
arthro-MR scan being a prerequisite to induce correct
treatment. Repair of chronic tears refers to well known Meniscal transplantation
techniques of inside out and outside in repair . • In case of total lateral meniscectomy and confronted with
• Moreover, these repairs will induce good results (70% of the young and mature? athlete, sports activity limitation is a
success). Including complete and incomplete healing on valuable option.
arthro-CT scan. • When the knee is normally aligned and stabilized a lateral
• In both instances the fresh and chronic tears - white on the meniscal transplant may be a salvage solution for the
white sutures need to be avoided. affected knee joint.
• A lateral meniscal allograft, both viable or fresh frozen,
LATERAL MENISCAL TEAR IN AN UNSTABLE KNEE
suggest better long term results vs. a medial meniscal
• The natural history is well known.
transplant in a comparable situation.
• The ACL rupture will induce laxity which will induce a
lateral meniscal lesion. Conclusion
• By that time, resection will be necessitated leading to • The lateral meniscus should be respected in its physical
progressive degenerative arthritis. integrity.
• The knee should be stable and well aligned.
Diagnosis and treatment
• Lateral meniscal resection should always remain minimal.
• Trauma will induce compression and shear forces onto the
• Lateral meniscal repair should be the rule in case of a
lateral meniscus. Vertical lesions around the popliteal
rupture.
tendon and horizontal cleavage tears may be found.
• Meniscus substitutes are not currently available in case of
• In a number of cases this will lead to a meniscectomy. That
partial meniscectomy but meniscal transplants do suggest
moment will become a turning point for the affected knee.
long term survival and bear potential and valuable cartilage
protection after total lateral meniscectomy.
REFERENCES 5. Krinsky MB, Abdenour TE, Starkey C, Albo RA, Chu DA. Incidence of lateral
1. Goble EM, Verdonk R, Kohn D. Arthroscopic and open surgical techniques for meniscus injury of professional basketball players. AM. J. Sports Med. 1992, 20,
meniscus replacement – meniscal allograft transplantation and tendon autograft 17-9.
transplantation. Scand. J. Med. Sci Sports, 1999, 9, 167-76. 6. Choi NH, Victoroff BN. Anterior horn tears of the lateral meniscus in soccer
2. Bonneux I, Vandekerckhove B Arthroscopic partial lateral meniscectomy long- players. Arthroscopy. 2006, 22, 484-8.
term results in athletes. Acta Orthop Belg. 2002, 68, 356-61. 7. Ahn JH, Oh I. Arthroscopic all-inside lateral meniscus suture using posterolateral
3. Terzidis IP, Christodoulou A., Ploumis A, Givissis P, Natsis K, Koimtzis M. portal. Arthroscopy. 2006, 22, 1344-3550 e.l.
Meniscal tear characteristics in young athletes with a stable knee: arthroscopic 8. Verdonk PCM, Demurie A, Almqvist KF, Veys EM, Verbruggen G, Verdonk R.
evaluation. AM. J. Sports Med. 2006, 34, 1170-5 Transplantation of Viable Meniscal Allograft J Bone Joint Surg Am 2006, 88, 109-
4. Sekiya JK, West RV, Groff YJ, Irrgang JJ, Fu FH, Harner CD. Clinical outcomes fol- 118
lowing isolated lateral meniscal allograft transplantation. Arthroscopy. 2006, 22,
771-80
HOW CAN WE REDUCE THE LENGTH OF DISABILITY IN ATHLETES

WITH MUSCLE STRAINS?
Jacques Menetrey, MD
Muscle injuries constitute one of the most frequent sports In patients with a true muscle rupture surgical re-insertion and
lesions. Prevention of muscle strain includes proper repair should be considered, particularly with lesions in the
conditioning and warm-up, and as well good management of proximal hamstrings or distal pectoralis major. The surgical
fatigue. However, most muscle strains occur in sports management of these injuries permits a reduction in the length
competition requiring velocity and force. The objective in the and degree of functional disability.
treatment of a muscle strain is to create the best mechanical and
Numerous research studies concerning the use of growth factors
biological environment to allow rapid and complete healing
and cytokines have shown promising results in improving
and thereby prevent a re-tear. Treatment must start within
muscle healing. It has been demonstrated that IGF-1, b-FGF, and
minutes after the injury, following the algorithm known as
HGF improve muscle regeneration, while anti-TGF-b agents
PRICE (Protection, Rest, Ice, Compression, Elevation) to prevent
(decorin, gamma-interferon) as well as an anti-fibrotic agent
further damage and limit hematoma formation. Protection is a
(suramin) decrease the development of fibrosis and favor muscle
crucial step for the first two to three days (crutches, or even
healing. Finally, genetically modified stem cell-based therapy
immobilization) to prevent excessive scar formation and re-
holds great promise for the treatment of muscle strain.
rupture at the injury site. In the coming years, the use of IGF-1
injection may improve and accelerate the healing process. After Recently a new treatment approach came from basic science
this protective phase which can extend up to five days in severe research. Studies concerning hyperthermia suggest that rapid
injuries, controlled isometric, isotonic and isokinetic application of controlled heat precisely at the injured region
contractions of the injured muscle group are performed with improves and accelerates the healing process. Currently, a new
increasing intensity. At the same time one should begin general device permits the application of this modality in humans and
reconditioning of the athlete, either by activation of the upper preliminary results will be presented in the symposium.
extremity in the presence of a lesion of the lower extremity, or by
The means to reduce the length of disability in athletes with
activation of the contralateral limb. Reconditioning of the
muscle strains are the following: (1) Take them off the sports
injured muscle group is mandatory. Gentle, progressive, and
field; do not even permit them to play; (2) Apply the proper
pain-free sports-specific re-programmation is rapidly begun. The
treatment immediately and PROTECT the injured muscle; (3)
criteria for time to return to sports include: (1) Ability to stretch
Start controlled motion and general reconditioning; (4)
the injured muscle as much as the contralateral healthy muscle;
Recondition the injured muscle and rapidly begin sports-specific
(2) Pain-free use of the injured muscle in sports-specific
re-programmation; (5) Surgically re-insert and repair a muscle
movements; and (3) Comparable strength between injured and
rupture (especially hamstrings proximally); and (6) Consider the
healthy muscles. There is an obvious lack of evidence in
use of hyperthermia which appears to be a promising technique
determining these criteria and these guidelines are mostly
to reduce the length of disability.
empirical.
REFERENCES 5. Järvinen TAH, Järvinen TLN, Kääriäinen M, et al: Muscle injuries. Biology and
1. Chan YS, Li Y, Foster W, Fu FH, Huard J. : The use of suramin, an antifibrotic Treatment. Am J Sports Med 2005; 35: 745-764
agent, to improve muscle recovery after strain injury. Am J Sports Med. 6. Kojima A, Goto K, Morioka S, et al: Heat stress facilitates the regeneration of
2005;33(1):43-51 injured skeletal muscle. J Orthop Sci 2007, 74-82 22-832
2. Foster W, Li Y, Usas A, Somogyi G, Huard J.: Gamma interferon as an antifibrosis 7. Menetrey J, Kasemkijwattana C, Day CS, Bosch P, Vogt M, Fu FH, Moreland MS,
agent in skeletal muscle. J Orthop Res. 2003;21(5):798-804 Huard J.: Growth factors improve muscle healing in vivo. J Bone Joint Surg Br.
3. Fukushima K, Badlani N, Usas A, Riano F, Fu F, Huard J. The use of an antifibro- 2000;82(1):131-7.
sis agent to improve muscle recovery after laceration. Am J Sports Med. 8. Peng H, Huard J.: Muscle-derived stem cells for musculoskeletal tissue regenera-
2001;29(4):394-402 tion and repair. Transpl Immunol. 2004;12(3-4):311-9. Review.
4. Huard j, Li Y, Fu FH: Muscle injuries repair: current trends in research. J Bone
Joint Surg Am 2002; 84: 8
337
ANATOMIC DOUBLE BUNDLE RECONSTRUCTION

Freddie Fu, MD
The clinical outcome of single bundle ACL reconstruction is bundle relaxes. The AM
reasonable, but by no means perfect. A critical review of the bundle has its highest tension
literature for single bundle ACL reconstruction over the past at 45 to 60 degrees of knee
decade reveals a few simple truths: 1) Between 10-30% of flexion, while the PL bundle
patients have continued pain and instability [1], 2) no more has its highest tension at 0 to
than 60% of patients will make a “full” recovery, and 3) these 15 degrees of flexion. [7] We
patients exhibit early onset radiographic evidence of degenerative tension the AM bundle at 45
joint disease in the afflicted knee, despite single bundle ACL degrees and the PL bundle at
ligament reconstruction. [3] 0.
The anterior cruciate ligament (ACL) is composed of two d. The concept and principles of
anatomic bundles: the anteromedial (AM), and the anatomic ACL reconstruction
posterolateral (PL) bundles. [6] These anatomic bundles have should be applied to all ACL
different functional capabilities. The AM bundle mainly surgery, whether it is a primary
contributes to anterior-posterior stability, while the PL bundle (single or double bundle),
plays a more significant role in rotatory stability of the knee. revision, or augmentation,
Numerous studies have demonstrated that double bundle because anatomy is the basis
reconstruction more closely approximates “normal” knee of all orthopaedic procedures.
kinematics in comparison to single bundle reconstruction. [4,5] The decision of whether to
perform a single or double bundle ACL reconstruction should
It is important to note that double bundle reconstruction is not
be based on the size of the insertion sites, and this varies from
synonymous with anatomic reconstruction. There are multiple
patient to patient.
different techniques of double bundle reconstruction, and we
believe that anatomic double bundle reconstruction will more Anatomic double bundle ACL reconstruction is a technically
closely restore normal knee kinematics. Here are the key demanding procedure. Clinical improvements have been
principles of “anatomic double bundle ACL reconstruction.” demonstrated in recent level I and level II studies, which show
superior outcomes for double bundle reconstruction. [9, 10, 11,
a. Reproducing normal
12, 13] However, while preliminary results of double bundle
anatomy: The AM and PL
reconstruction are encouraging, further study needs to be done to
bundles are first seen during
more critically examine complications and ability to return to
fetal development, and
sport in the short term, and joint kinematics, chondrosis and
remain as two distinct
development of degenerative joint disease in the intermediate
functional bundles
and long term.
throughout life. [6]
b. Reproducing the insertion site Figure Legend
of each bundle: The insertion Figure 1: ACL is composed of two functional bundles: the AM
sites of the AM and PL bundle bundle and the PL bundle. When the knee is in flexion, the two
should be marked by a bundle cross each other, whereas they are parallel to each other
thermal device and measured in knee extension.
for the purpose of both
Figure 2: In this left knee arthroscopic view, an anteromedial
anatomic tunnel placement
portal was used to visualize the lateral wall of intercondylar
and tunnel size. It is
notch. The femoral insertion sites of the AM and PL bundles were
important to note that the
marked by thermal device. The remnant of ACL, especially its
femoral insertion sites of the
upper limit (shown by arrows), can still be seen.
AM and PL bundle are
oriented vertically with the knee in extension and become Figure 3: In this left knee arthroscopic view, the tibial insertion
horizontal in 90º of knee flexion. [6] sites of the AM and PL bundle are identified and marked by
thermal device for following anatomic tunnel placement.
c. Reproducing the tension pattern of each bundle: The AM
bundle tightens in flexion as the PL bundle becomes lax, Figure 4: A finished left knee anatomic double bundle ACL
whereas the PL bundle tightens in extension and the AM reconstruction is shown.
REFERENCES 5. Yagi M, Ryosuke K, Nagamune K, et al. Double-bundle ACL reconstruction can

1. Fithian DC, Paxton EW, Stone ML, et al. Prospective trial of a treatment algo- improve rotational stability. Clin Ortho Rel Res 2007;454:100-7.
rithm for the management of the anterior cruciate ligament-injured knee. Am J 6. Chabbra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic,
Sports Med 2005;33(3):333-4. Radiographic, Biomechanical, and Kinematic Evaluation of the Anterior Cruciate
2. Biau DJ, Tournoux C, Katsahian S, Schranz P, Nizard R. ACL reconstruction: a Ligament and Its Two Functional Bundles. J Bone Joint Surg Am 2006;88(Supp
meta-analysis of functional scores. CORR, 2007 May;458:180-7 4):2-10.
3. Yunes M, Richmond JC, Engels EA, et al. Patellar versus hamstring in anterior 7. Gabriel MT, Wong EK, Wool SL, et al. Distribution of in situ forces in the anterior
cruciate ligament reconstruction: A meta-analysis. Arthroscopy 2001;17:248-257. cruciate ligament in response to rotatory loads. J Orthop Res 2004;22(1):85-9.
4. Tashman S, Collon D, Anderson K, et al. Abnormal rotational knee motion dur- 8. Cohen SB, Fu FH. Three-portal technique for anterior cruciate ligament recon-
ing running after anterior cruciate ligament reconstruction. Am J Sports Med struction: use of a central medial portal. Arthroscopy. 2007 Mar;23(3):325.e1-5
2004;32:975-83.
9. Yasuda K, Kondo E, Ichiyama H, et al. Clinical evaluation of anatomic double- 11. Muneta T, Koga H, Mochizuki T, Ju YJ, Hara K, Nimura A, Yagishita K, Sekiya I. A
bundle anterior cruciate ligament reconstruction procedure using hamstring ten- prospective randomized study of 4-strand semitendinosus tendon anterior cruci-
don grafts: comparisons among 3 different procedures. Arthroscopy ate ligament reconstruction comparing single-bundle and double-bundle tech-
2006;22(3):240-51. niques. Arthroscopy 2007, 23(6): 618-29
10. Yagi M, Ryosuke K, Nagamune K, et al. Double-bundle ACL reconstruction can 12. Jarvela T. Double-bundle versus single-bundle anterior cruciate ligament recon-
improve rotational stability. Clin Ortho Rel Res 2007;454:100-7. struction: a prospective, randomize clinical study. KSSTA 2007; 15 (5): 500-7
13. Aglietti P, Giron F, Cuomo P, Losco M, Mondanelli N. Single- and double-inci-
sion double bundle ACL reconstruction. CORR 2007; 454: 108-13
339
IS COMPUTER NAVIGATION NECESSARY FOR OPTIMAL SURGICAL

RESULTS IN SPORTS MEDICINE
Philippe Colombet, MD
Techniques in ACL reconstruction surgery have progressively length, graft length etc). Finally, navigation provides a quality
improved and postoperative outcomes are generally good. surgical record and documentary evidence of the reconstruction
However, graft failures can occur, the commonest aetiology of for health insurance companies, patients and lawyers.
which has been shown to be surgical technique, with the leading
CAS ACL reconstruction involves two steps: a planning stage
cause being bone tunnel mal-position [Harner, et al. (1)]. In
where a virtual graft is simulated and graft behavior assessed
addition, gait analysis [Georgoulis, et al. (2)]and RSA [Tashman,
(including tunnel placement, anisometry, graft impingement etc)
et al. (3)] studies have shown that normal knee joint kinematics,
and a navigation stage where the computer assists the surgeon to
particularly rotational stability are not fully restored, and 14-30
accurately place the tunnels. The latest software versions allow
% of cases may have a residual pivot “glide” [Karlson, et al. (4),
different options to be selected, from simple laxity assessment to
Lerat, et al. (5)].
complex, multi-ligament reconstructions. Navigation is
Computer navigation is an important new tool in the surgeon’s particularly helpful for concomitant peripheral reconstructions
armoury and has already been shown to improve the precision such as MCL reconstruction or lateral extra-articular tenodesis.
of ACL reconstruction in several areas: tunnel placement The computer can model the graft to achieve an optimal
[Eichhorn (6), Schep, et al. (7)], anterior laxity control [Plaweski, isometric position and using a drill guide or drill, equipped with
et al. (8)], isometric graft placement [Lavallée, et al. (9)], a navigation array, may be used to accurately drill the bone
prediction of graft impingement [Julliard, et al. (10)]. In addition tunnels. As multi-bundle ACL reconstructions have gained in
navigated laxity examination allows objective kinematic data to popularity, so, software has been developed to help overcome
be obtained during reconstruction [Colombet, et al. (11), the technically challenging aspects: assisting anatomical
Martelli, et al. (12)] providing a powerful tool for the analysis of placement of the bundles, ensuring adequate bony bridges
different ACL reconstructions [Robinson, et al. (13)] and between them, assessing bundle anisometry and potential notch
assessment of peripheral ligamentous injuries (eg the postero- impingement of each bundle. In particular navigation allows the
lateral corner [Pearle, et al. (14)]. The ability to objectively surgeon to see what happens in the notch at full knee extension,
measure the Pivot Shift in the clinical setting and the navigated a position where we are arthroscopicaly blind.
laxity exam may provide us with a better understanding of
The computer, as it done in our offices and homes, will become an
different knee laxities. As a research tool, navigation not only
indispensable tool in the operating room. As a tool to help plan,
allows the ability to perform a navigated laxity examination
perform and assess ACL reconstruction it will become invaluable
allowing the objective assessment of the anterior drawer,
as we move towards the concept of “ a la carte” surgery, tailored to
Lachman, varus/valgus, coupled rotational laxities and Pivot Shift
redressing patients’ individual patterns of instability.
test, software enables the measurements of notch width tunnel
REFERENCES 8. PLAWESKI S, CAZAL J, ROSELL P, MERLOZ P: Anterior cruciate ligament recon-

1. HARNER CD, POEHLING GG: Double bundle or double trouble? Arthroscopy, struction using navigation: a comparative study on 60 patients. Am J Sports Med,
2004, 20(10), 1013-4. 2006, 34(4), 542-52.
2. GEORGOULIS AD, PAPADONIKOLAKIS A, PAPAGEORGIOU CD, MITSOU A, 9. LAVALLÉE S, JULLIARD R, CINQUIN P, CARPENTIER E: Anterior cruciate liga-
STERGIOU N: Three-dimensional tibiofemoral kinematics of the anterior cruci- ment reconstruction: computer assisted determination of the most isometric
ate ligament-deficient and reconstructed knee during walking. Am J Sports Med, femoral attachment point European Journal of Orthopaedic Surgery &
2003, 31(1), 75-9. Traumatology, 1994, Volume 4, (Number 2 / June), 87-92.
3. TASHMAN S, COLLON D, ANDERSON K, KOLOWICH P, ANDERST W: 10. JULLIARD R, LAVALLEE S, DESSENNE V: Computer assisted reconstruction of
Abnormal rotational knee motion during running after anterior cruciate liga- the anterior cruciate ligament. Clin Orthop Relat Res, 1998(354), 57-64.
ment reconstruction. Am J Sports Med, 2004, 32(4), 975-83. 11. COLOMBET P, ROBINSON J, CHRISTEL P, FRANCESCHI JP, DJIAN P: Using
4. KARLSON JA, STEINER ME, BROWN CH, JOHNSTON J: Anterior cruciate liga- navigation to measure rotation kinematics during ACL reconstruction. Clin
ment reconstruction using gracilis and semitendinosus tendons. Comparison of Orthop Relat Res, 2007, 454, 59-65.
through-the-condyle and over-the-top graft placements. Am J Sports Med, 1994, 12. MARTELLI S, ZAFFAGNINI S, BIGNOZZI S, BONTEMPI M, MARCACCI M:
22(5), 659-66. Validation of a new protocol for computer-assisted evaluation of kinematics of
5. LERAT JL, CHOTEL F, BESSE JL, MOYEN B, BINET G, CRAVIARI T, et al.: [The double-bundle ACL reconstruction. Clin Biomech (Bristol, Avon), 2006, 21(3),
results after 10-16 years of the treatment of chronic anterior laxity of the knee 279-87.
using reconstruction of the anterior cruciate ligament with a patellar tendon graft 13. ROBINSON J, CARRAT L, GRANCHI C, COLOMBET P: Influence of Anterior
combined with an external extra-articular reconstruction]. Rev Chir Orthop Cruciate Ligament Bundles on Knee Kinematics: Clinical Assessment Using
Reparatrice Appar Mot, 1998, 84(8), 712-27. Computer-Assisted Navigation. Am J Sports Med, 2007.
6. EICHHORN J: Three years of experience with computer navigation-assisted posi- 14. PEARLE AD, SOLOMON DJ, WANICH T, MOREAU-GAUDRY A, GRANCHI CC,
tioning of drilling tunnels in anterior cruciate ligament replacement. WICKIEWICZ TL, et al.: Reliability of navigated knee stability examination: a
Arthroscopy, 2004, 20(Supplement 1), e31-e32. cadaveric evaluation. Am J Sports Med, 2007, 35(8), 1315-20.
7. SCHEP NW, STAVENUITER MH, DIEKERHOF CH, MARTENS EP, VAN HAEFF
CM, BROEDERS IA, et al.: Intersurgeon variance in computer-assisted planning
of anterior cruciate ligament reconstruction. Arthroscopy, 2005, 21(8), 942-7.
ANTERIOR INSTABILITY IN NON-CONTACT ATHLETES
Riccardo Minola, MD
Damage evaluation: • Functional Progression: sport-specific drilling, throwing.

• Imaging: not necessary to make diagnosis of instability, but • Criteria for return to play: pain free, Full ROM, normal
may find co-existing Pathology strength
— X-Ray: sublte signs of instability: antero-inferior glenoid,
Operative management:
Hill-Sachs, Humeral Head cyst. Other signs: ACJ,
• Open or Arthro: not the key issue – damage related choice:
Impingement signs.
bone deficits; poor capsular quality
— UltraSounds: reader dependent; sensitive for cuff
• Key issue: repair injuried structures to the bone – intra-
— MRI: Soft tissue: cuff, biceps, Subscap, Labrum, CHL,
operative dynamic approach
HAGL
• Surgical Pearls that lead to excellent results:
— CT: Bony lesion evaluation; Arthrogram show High
— Identify ALL pathology (do NOT just focus on anterior
definition anatomy
pathology)
Type of sport — Mobilizing soft tissue
— Enhancing local biology to promote soft-tissue healing
Type of lesion: does the athlete can cope with damage?
— Securing ANATOMIC fixation: dynamic evaluation +
In-Season VS Off-Season: Team & Athlete’s needs tension free repair
• No or little damage – Need to go on playing – Wait and see — Respect healing period: the key of post-operative
policy: delayed damage repair rehabilitation
• Severe damage – Stop and Go opportunity – Acute damage • Current trend for arthroscopy: good for first time
repair dislocators; High demand over-head athletes (360°
approach)
Non operative management:
• Poor results: Lavage alone, Thermal Capsulorrhaphy
• Immobilization:
— Pain management Cause of Failure after surgical repair: recurrence of instability,
— ER vs IR loss of motion, neurovascular injuries, hardware
— Time of immobilization: not as critical as before complications…
• In-season Athlete • Advances in technology, understanding pathoanatomy,
— Regain muscle control educational & learning can avoid or limit failures
— Brace to limit ABD+ER
Ideal Criteria for Return to Play: little-no pain; Patient
• Strenghtening: periscapular, cuff, power movers (Pec., Del)
subjectivity, Near to normal ROM, strength; Normal
• Proprioceptive training: taping, Proprioceptive
functional ability; normal sport specific skills
Neuromuscolar Facilitation
REFERENCES 7. te Slaa RL, Brand R, Marti RK. - A prospective arthroscopic study of acute first-
1. Farber JM, Buckwalter KA - Sports-related injuries of the shoulder: instability - time anterior shoulder dislocation in the young: a five-year follow-up study. - J
Radiol Clin North Am. 2002 Mar;40(2):235-49 Shoulder Elbow Surg. 2003 Nov-Dec;12(6):529-34.
2. Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, Wakabayashi I, 8. D'Alessandro DF, Bradley JP, Fleischli JE, Connor PM. - Prospective evaluation of
Nozaka K. - Immobilization in external rotation after shoulder dislocation thermal capsulorrhaphy for shoulder instability: indications and results, two- to
reduces the risk of recurrence. A randomized controlled trial. - J Bone Joint Surg five-year follow-up. - Am J Sports Med. 2004 Jan-Feb;32(1):21-33.
Am. 2007 Oct;89(10):2124-31 9. Miniaci A, Codsi MJ. - Thermal capsulorrhaphy for the treatment of shoulder
3. Gibson K, Growse A, Korda L, Wray E, MacDermid JC. - The effectiveness of reha- instability. - Am J Sports Med. 2006 Aug;34(8):1356-63. Epub 2006 May 9.
bilitation for nonoperative management of shoulder instability: a systematic Review.
review. - J Hand Ther. 2004 Apr-Jun;17(2):229-42. Review. 10. Armstrong A, Boyer D, Ditsios K, Yamaguchi K. Arthroscopic versus open treat-
4. Reuss BL, Harding WG 3rd, Nowicki KD. - Managing anterior shoulder instabili- ment of anterior shoulder instability. Instr Course Lect. 2004;53:559-63. Review.
ty with bracing: an expanded update. - Orthopedics. 2004 Jun;27(6):614-8. 11. Tauber M, Resch H, Forstner R, Raffl M, Schauer J. - Reasons for failure after sur-
Review. gical repair of anterior shoulder instability. - J Shoulder Elbow Surg. 2004 May-
5. Handoll HH, Hanchard NC, Goodchild L, Feary J. - Conservative management Jun;13(3):279-85
following closed reduction of traumatic anterior dislocation of the shoulder. - 12. McCarty EC, Ritchie P, Gill HS, McFarland EG. - Shoulder instability: return to
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004962. Review. play. - Clin Sports Med. 2004 Jul;23(3):335-51, vii-viii. Review
6. Buss DD, Lynch GP, Meyer CP. Nonoperative management for in season athletes
with anterior shoulder instability. Am J Sports Med. 2004;32:1430-1433.
341
HOW TO TREAT ACL INJURIES IN ATHLETES WITH OPEN PHYSIS

Moises Cohen, MD, PhD
ACL injury in children and teenagers will result in: Options for ACL Treatment
• Functional instability • Non-operative treatment avoiding sports activity
• Progressive damage to the knee • Bracing until growth spurt
• Physeal sparing techniques
• Trans-Physeal techniques: Partial (Over-the-Top)
Complete (crossing both tibial
and femoral physis)
To avoid growth abnormality some authors use techniques as
physeal sparing or over-the-top. However, it is important to
not that the causes of growth abnormality in ACL
reconstruction are:
• Hardware across the physis
• Bone plugs of a patellar tendon graft across the physis
MRI of the knee in a 16 years old girl. She had torn her ACL when she was 13.
Conservative treatment was performed. Note the chondral and meniscal injury after • Large tunnels ( around 12 mm)
3 years. Basic Science provides evidence to perform Trans-Physeal
ACL reconstruction may: ACL reconstruction in open physis patients:
• Stabilize the knee • Drilling small tunnels with a small cross-sectional area do
• Prevent recurrent instability not cause growth abnormality
However, possible growth abnormality by drilling across the • Drilling central tibial tunnels to decrease cross-sectional
physis may happen area. Avoid anterior or lateral tibial tunnels,
• Filling the tunnel with a soft-tissue graft prevents bone
Clinical Assessment arrest.
• Complete Physical Examination
• Radiological study : X-Rays and MRI Our preferred technique – Complete Transphyseal Technique
• Quadruple Hamstring Auto-Graft
• Tibial Tunnel- central and around 7mm of diameter
X-Rays can exclude tibial spine fracture and observe growth plates
The central tunnel decrease cross-sectional area of the tunnel, consequently less
growth plate is destroyed.
• Femoral Tunnel- 7mm of diameter and 40 mm length
MRI helps to investigate possible meniscal and chondral injuries

Evaluation of Maturity
• Tanner Stages III and IV
• In girls, menarche occurs after the growth spurt Always assisted by fluoroscopy
• In boys, the appearance of pigmented curly hair in the
axilary and pubic regions occurs after the growth spurt It is important to:
It is a consensus that in these situations there is no problem to • Drill at low speed with a smaller diameter drill, and expand
perform an ACL reconstruction with transphyseal techniques. the tunnel manually with a dilator up to 7 mm.
How about before this time? • Clean very well the tunnel to allow total contact between
graft and tunnel
• Fill completely the tunnel with the graft, feeling the graft Personal Clinical Outcomes:
enter much tied • 26 patients: Female from 11 to 14 years old
Male from 12 to 15 years old
Fixation:
• 37 months of Average follow-up (all with closed physis)
• 2 cases fail to revision
• The remaining 24 cases had a good to excellent Lysholm
and IKDC scores
• No significant growth abnormality:
• Length discrepancies compared to contralateral limb: 16
mm (0 to 70 mm) in Scanograms
• Angular deviation compared to contralateral limb: 0.5
degree
Conclusion
TransFix (5 x 40mm) above the femoral physes Transphyseal ACL reconstruction with careful attention to the
Bioscrew(under of the growth plate) + Staple in the tibia technique may have good clinical outcomes with no growth
abnormality in immature patients with open physis.
343
HOW TO TREAT THE PATELLOFEMORAL INSTABILITY IN ATHLETES

Moises Cohen, MD, PhD
Important Issue
Anatomy
• Is the medial patellofemoral ligament a new anatomical
structure?
• Has it a function to the knee?
Instabilities : Acute and Chronic
Acute:
• Traumatic
— Instability – Repair the MPFL (Femur or patella site) — Merchant Angle
Chronic:
• Predisposal Factors
— Patella Alta
— Shallow Groove
— < 20 years old
Clinical Treatment
• Rehab Program
Musculature balance
Recurrent Dislocation (44%) — Patellar Tilt
• Surgical Treatment
• PROXIMAL = Balance soft tissue
• DISTAL = Bone procedures
Literature Review
• Kaplan: described MPFL, but with different name
• Warren and Marshall: described the ligament that stabilizes
medial patella, nominating it of medial patellar femoral
ligament
• Tomographic Parameters
• Hungerford et al: main stabilizer of the patella, mainly in
— Angle of Congruency
the first 30 ° of flexion
— PatellarTilt
• Conlan: biomechanical study, the MPFL is responsible for
— TTa – GT
53% of the resistance that prevents the patella’s lateralization
• Feller JA et al and Hernandez et al : common insertion of
VMO and MPFL, dynamic element for the function of
stabilization
• Desio: dislocation of the patella with 20º of flexion
• Sandemeier RH et al: the normal tracking of the patella was
restored after reconstruction of MPFL
• Fernandez: the reconstruction of MPFL stabilizes the patella
but does not restore the patellofemoral congruence to
normal position
— Throclear Groove Angle
Indications of MPFL reconstruction
• Secondary Lateral Instability from moderate to severe
deficiency of medial restrictors
• Failure of imbrications procedures
• Insufficient distal realignment
• Revision Cases
Relative Contraindications
• Important Lateral Facet Arthritis Surgical Technique
• TAT Excessively Lateral • Precise and Anatomical points
• Permanent Patellar Tilt • Pos-operative Protocol
• Patient with no instability symptoms Personal Clinical Outcomes of MPFL reconstruction:
Medial Patellofemoral Ligament Reconstruction • Acute Traumatic Instability – Repair the MPFL
• Radiographic Parameters 09 patients: 07 Female from 13 to 23 years old
— Caton Index 02 Male with 14 and 26 years old
32 months of Average follow-up
1 case – patella dislocation after 13 months Conclusion

• Chronic Patellofemoral Instability: • The Acute Repair and the Anatomical Reconstruction of
32 patients: 21 Female from 13 to 38 years old MPFL provides subjective and radiological improvement for
11 Male from 14 to 33 years old the athletes with patellofemoral instability.
33 months of Average follow-up (Longest 53 and Shortest • Clinical outcomes are encourageous. Long-term follow-up is
18 months) needed.
3 cases fail to revision (flexion limitation)
The remaining 29 cases had a good to excellent Kujala,
Lysholm and IKDC scores
345
PEARLS FOR COMMON

FRACTURE TREATMENT (D)
SYMPOSIA TRAUMA
Moderator: Alan L. Jones, MD, Dallas, TX

This symposium will focus on the the up to date management of ankle fractures, distal
radius fractures, hip fracture and proximal humerus fracture.
I Introduction
Alan Jones, MD, Dallas, TX
II. Ankle Fractures:

David W. Sanders, MD, London, ON Canada
III. Distal Radius Fractures

David Ring, MD, Boston, MA
IV Case Discussion
V. Hip Fractures
Thomas A. Russell, MD, Eads, TN
VI. Proximal Humerus Fractures

William R. Creevy, MD, Boston, MA
VII. Case Discussion and Question and Answer
PEARLS FOR COMMON FRACTURE TREATMENT: DISTAL RADIUS

FRACTURES
David Ring, MD PhD
1. Treat patients, not x-rays. b. Volar shearing fracture

2. Understand the risks factors for fracture instability.(1, 2) i. Beware
SYMPOSIA TRAUMA
3. Median nerve symptoms. 1. Small volar lunate facet fragment.(6)
a. Exacerbation of chronic carpal tunnel syndrome. a. Can escape plate fixation.
b. Contusion/deformity. b. Carpus dislocates with the fragment.
c. Acute carpal tunnel syndrome. 2. Dorsal cortical split(7)
4. Treatment techniques: a. Present in approximately 50% of apparent volar
a. Nonoperative treatment shearing fractures.
i. For stable fractures or patients that will accept b. Use of an undercontoured plate can lead to
malalignment. dorsal translation of fragments.
ii. Optimize hand and forearm function. 3. Central articular impaction.
iii.Avoid overtight casts. a. Can be address through the fracture.
b. Percutaneous treatment techniques c. Pearls for operative technique
i. Extra-articular and simple articular dorsally displaced i. Bone Graft
fractures. 1. Graft not usually necessary with locked plating, but
ii. Take care with radial sensory nerve. might be useful to support central articular
iii.Keep the wrist close to neutral position. impaction.
iv. Take care of pin track infections. 2. In younger patients with higher energy injuries,
c. Open reduction and internal fixation substantial bone can often be found in the soft
i. Volar vs. dorsal. tissues.(8)
ii. Combined exposure often required for very complex ii. An extended FCR exposure can facilitate reduction(9):
fractures.(3) 1. Release of the brachioradialis and dorsal
5. Articular fracture patterns. periosteum.
a. Compression articular—use 3D CT to evaluate 2. Removal of blood clot from the joint and from
i. Simple sagittal split. between the fracture fragments.
1. Be cognizant of rotational deformity of the radial iii.The dorsal cortex is too thin and fragile to use for
styloid. reduction and is often too comminuted to serve as a
ii. High coronal fracture line. reliable indicator of adequate reduction. The volar
1. Can usually be treated as extra-articular fracture. cortex, in contrast, has the strongest bone in the distal
iii.Coronal split in lunate facet—rotation of volar lunate radius, which can be used to assist and monitor
fragment. reduction.
1. The volar lunate fragment typically needs open 6. Treatment of partially healed fractures.
manipulation and internal fixation.(4, 5) a. Use of the plate as a reduction aide.
iv. Central articular impaction. b. Soft tissue/callus release using the extended FCR exposure.
REFERENCES 6. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of
1. LaFontaine M, Hardy D, Delince PH. Stability assessment of distal radius frac- the volar lunate facet fragment in fractures of the distal part of the radius. J Bone
tures. Injury 1989;20:208-210. Joint Surg Am 2004;86-A(9):1900-8.
2. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial 7. Harness N, Ring D, Jupiter JB. Volar Barton's fractures with concomitant dorsal
fractures. J Bone Joint Surg Am 2006;88(9):1944-51. fracture in older patients. J Hand Surg [Am] 2004;29(3):439-45.
3. Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation 8. Lozano-Calderon SA, Doornberg J, Ring D. Fractures of the dorsal articular mar-
of complex fractures of the distal part of the radius. J Bone Joint Surg Am gin of the distal part of the radius with dorsal radiocarpal subluxation. J Bone
2004;86-A(8):1646-52. Joint Surg Am 2006;88(7):1486-93.
4. Melone CP. Articular fractures of the distal radius. Orthop Clin N Amer 9. Orbay JL, Badia A, Indriago IR, Infante A, Khouri RK, Gonzalez E, et al. The
1984;15:217-236. extended flexor carpi radialis approach: a new perspective for the distal radius
fracture. Tech Hand Up Extrem Surg 2001;5(4):204-11.
5. Melone CP. Open treatment for displaced articular fractures of the distal radius.
Clin Orthop 1988;202:103-111.
347
ORTHOPAEDIC WAR INJURIES:

NEW DEVELOPMENTS IN TREATMENT
SYMPOSIA TRAUMA
AND RESEARCH (DD)

Moderator: Dana C. Covey, MD, San Diego, CA
Over 35,000 U.S. service members have been wounded in the ongoing wars in Iraq and
Afghanistan, approximately 70 percent of whom have musculoskeletal injuries. This
symposium will highlight the unique character of orthopaedic war wounds in the context of
frontline and forward care to U.S. and Iraqi patients, new treatment strategies that have
evolved and current and future research challenges.
I. Introduction and Scope of Problem

Dana C. Covey, MD, San Diego, CA
II. Treatment of Brachial Plexus Injuries

Alexander Y. Shin, MD, Rochester, MN
III. Regenerative and Restorative Techniques to Treat Severe Limb Trauma

Christopher Born, MD, Providence, RI
IV. Level II Care of Iraqis with Musculoskeletal War Wounds

Michael A. Thompson, MD, San Diego, CA
V. Level III Care of Iraqis with Musculoskeletal War Wounds

Mark W. Richardson, MD, San Antonio, TX
VI. Current Status of War Extremity Injury Research

Michael T. Mazurek, MD, San Diego, CA
1. Review Current Federally Funded Programs Dedicated to Extremity Trauma
Incurred In the Global War on Terrorism
2. Site Specific Projects Geared Toward Improving care to Wounded Warriors
3. Discuss the Differences Between Clinical, Bench and Translational Research and
how that has aided the care of Service Members
4. Review Advances Made thus far in the Global War on Terrorism
VII. Advances in Orthopaedic Combat Casualty Care

Martin F. Baechler, MD, Washington, DC
VIII. Questions and Answers
◆MANAGING HIP FRACTURES

IN THE OSTEOPOROTIC PATIENT:
SYMPOSIA TRAUMA
WHAT IS THE EVIDENCE? (U)
Moderator: Thomas A. Russell, MD, Eads, TN
This symposium identifies current areas of controversy and evidence to guide health care
professionals in the management of hip fractures in osteoporotic patients.
I Internal Fixation Versus Arthroplasty In Femoral Neck Fractures

Philip Kregor, MD, Nashville, TN
II. Optimal Arthroplasty

Antonio Moroni, MD, Bologna, ITALY
III. Sliding Hip Screw Versus Imhs For Intertrochanteric Fractures

Michael Baumgartner, MD, New Haven, CT
IV. Trochanteric Fractures: Where Are We Headed?

Thomas A. Russell, MD, Eads, TN
V. Bone Substitutes
Peter Giannoudis, MD, Leeds, UK
349
OPTIMAL ARTHROPLASTY: WHAT IS THE EVIDENCE?

Antonio Moroni, MD
INTRODUCTION stay, blood loss, implant longevity and quality of life were
In the US more than 250,000 femoral neck fractures occur per observed.
year, representing an annual 8.7 billion dollar cost to the health
Therefore, there does not appear to be any advantage to the use
care system. The number of hip fractures is expected to increase
of bipolar hemiarthroplasty in the management of displaced
SYMPOSIA TRAUMA
considerably to approximately 500,000 per year by 2040. Despite

femoral neck fractures in the elderly.
the increasing incidence and magnitude of the problem with
femoral neck fractures, treatment outcomes are far from being However, a recent survey of the American Association of Hip and
satisfactory and the topic remains controversial. Knee surgeons showed that the pre-injury ambulatory status and
dislocation risk were the main factors in choosing between
Approximately 50% of all hip fractures are displaced
unipolar (48%) and bipolar (52%) hemiarthroplasty. Although
intracapsular fractures. Although there is a consensus among the
the majority of the surgeons believe that bipolar is a good
surgeons on hip arthroplasty as the preferred treatment for
indication in the more active patients and unipolar is best in the
elderly patients with displaced intracapsular fractures, debate
low demand patients, there is no evidence to support this.
continues to exist regarding the best type of arthroplasty. The
options include unipolar hemiathroplasty, bipolar When comparing total hip arthroplasty to hemiarthroplasty,
hemiathroplasty and total hip arthroplasty. results from meta-analyses revealed that total hip arthroplasty is
the best operation with regards to function and long term results.
Other burning questions which need to be addressed are:
• Should the prosthesis be fixed with or without bone The outcomes for patients undergoing total hip arthroplasty for
cement? femoral neck fractures are comparable with those undergoing
• What is the optimal diameter of the prosthetic head? total hip arthroplasty for osteoarthritis.
• What type of surgical approach should be used, and finally;
If we pool the data from the existing studies (table 1) we see that
• Are there any recent developments in technology that could
compared to hemiarthroplasty, total hip arthroplasty is
be beneficial for this particular patient population?
associated with a trend for higher rate of dislocation but there is
UNIPOLAR VERSUS BIPOLAR VERSUS TOTAL HIP a lower risk of mortality, hip pain and infection. It is interesting
ARTHROPLASTY: HOW TO CHOOSE? to note that most respondents of the survey of the American
The literature is confusing as there are few randomized Association of Hip and Knee surgeons claimed that prefracture
prospective studies comparing modern devices implanted hip pain is the most important factor when choosing to perform
according to current technique. total hip arthroplasty over hemiarthroplasty. The concern over
the risk of instability led the respondents away from total hip
The reported advantages of hemiarthroplasty compared to total
arthroplasty. This concern is supported by evidence based studies
hip arthroplasty are:
indirect comparisons.
• Reduced dislocation rate
• Lower rate of deep venous thrombosis TABLE 1: REVISION AND COMPLICATIONS FROM META-ANALYSES
• Shorter operating time (INDIRECT COMPARISONS)
• Less blood loss Bhandari (2001)
• Technically less demanding procedure Point estimates
• Lower cost THA(N=105) HA(N=557)
Revision 7.5% 7.5%
Unipolar hemiarthroplasty: Mortality 10% 37%
• Pain is common with or without acetabular erosion Dislocation 7.0% 3.5%
• Outdated stem design Infection 2.0% 8.0%
• High rate of loosening DVT NR 2.5%
• Low instability rate Pain 25% 23%
• Straightforward reduction in case of dislocation Function 72% 54%
Total hip arthroplasty should be indicated in the more active
Bipolar hemiarthroplasty:
patients with a reasonable life span and in the patients with pre-
• Decreased stress on articular cartilage
existing osteoarthritis.
• Pain is still common
• Less protrusion than with unipolar hemiarthroplasty
SURGICAL APPROACH:
• Bipolar heads are a source of wear potentially leading to
The choice of the surgical approach is still controversial.
fixation failure
• Revision to total hip arthroplasty is relatively easy A potential advantage of the antero-lateral approach is:
• Instability is uncommon but after dislocation reduction • lower risk of dislocation
may be difficult
A potential advantage of the postero-lateral approach is:
Although greater range of motion and faster walking speed was • no damage to the abductor mechanism
reported with bipolar hemiarthroplasty as compared with
The relationship between the approach and the incidence of
unipolar hemiarthroplasty, in the vast majority of the papers no
dislocation could be modified by the introduction of new
differences in hip rating outcomes, postoperative pain, recovery
bearings featuring large diameter heads which significantly
of ambulatory status, activity of daily living, mortality rate,
improve joint stability and range of motion. Innovations in the
number of dislocations, post-operative complications, hospital
surgical technique may also be effective. Capsular repair should
be recommended when the postero-lateral approach is used.
Minimally invasive surgery is increasing in popularity and can Another reason to choose a large diameter head is that the elderly
be applied to any hip approach. Elderly patients with hip do not tolerate changes in their joint anatomy.
fractures are perfect candidates for this surgical concept.
The correct size of the prosthetic head is the size which replicates
However, surgeons should bear in mind that too small an
the patient’s original head. In the recent past, this was not possible
incision could affect proper prosthesis implantation.
because of technological limitation. Now, there are innovative
bearings such as metal/metal and metal/polyurethane that
FIXATION:
permits the use of a prosthetic head similar in size to the patient’s
Meta-analyses of 15 trials comparing cemented and uncemented
original head.
prostheses, suggest the superiority of cemented fixation; however,
SYMPOSIA TRAUMA
in these trials older generation implants were used so that the The use of metal-on-metal bearing with large diameters heads
uncemented components were often Moore’s prostheses, which used to be popular in the past but was abandoned because of the
are known for sub-optimal performance. The introduction of introduction of metal-polyethylene bearings. Recently it has
modern generation uncemented prostheses could lead to results been reintroduced, since metal-on-metal hip resurfacing has
at least as good, if not superior, to cemented prostheses. been further developed.
In osteoporotic bone, biological fixation, a special type of Another interesting solution which has the advantage of no
uncemented fixation consisting of implants coated with calcium elevation of metal ions in the serum is metal-polyurethane
phosphates, is particularly promising. Prospective randomized bearing (Figures 2a, 2b, 2c). In the past, prostheses have provided
studies of both hip and knee arthroplasty featuring RSA analysis poor shock absorption. Because the hip is a synovial joint, it also
showed that biological fixation performs as well as cemented has excellent tribological characteristics of low friction, high load
fixation. This is always superior to standard uncemented fixation. carrying capabilities, high shock absorption and long endurance.
A newly-developed implant consisting of a buffer made of a
Clinical studies of screws coated with hydroxyapatite used to fix
polycarbonate urethane-compliant material replacing the cartilage
wrist and hip fractures showed that biological fixation is also
in the acetabulum has the advantage of minimal reaming.
effective with porous bone. As cemented fixation needs good
Furthermore, by ensuring that microelastohydrodynamic
cancellous bone in order to achieve primary stability, porous
lubrication is maintained, friction can be nearly eliminated, thus
bone is not the ideal bone substrate for cemented prostheses.
decreasing the potential for wear. Because of the relatively large
Indeed, in the osteoporotic patient very little cancellous bone is
femoral heads sizes (44-50mm) that are able to be used with this
found in the proximal femur.
system, complications such as dislocation, subluxation, or leg
An interesting surgical concept for these patients is the surgical length discrepancy are rare. The potential benefits include
technique developed by Furlong. With this technique, the minimal bone removal, increased ROM, faster rehabilitation, and
cancellous bone of the proximal femur is not removed when overall a more anatomical reconstruction of the hip which is so
broaching the canal but is fragmented and impacted. This important for elderly hip patients with osteoporosis.
technique produces a “biological bone cement” which is useful
in providing primary stability. There is evidence that even in
elderly patients with weak bone, osteointegration will occur
postoperatively (Figures 1a and 1b).
Figure 2a
Figure 2a: Polyurethane uncemented cup. This cup mimics the
primary functions of cartilage and this cup provides a lubricated
surface which can be coupled with large diameter metal heads.
As yet, this cup is not FDA approved.
Figure 1a Figure 1b
Figures 1a and 1b: 76 yr old patient treated with uncemented

Furlong implant totally coated with hydroxyapatite. X-ray taken
3 years after surgery (Fig 1b) shows bone remodeling with bone
apposition onto the prosthesis.
HEAD DIAMETER:
In the femoral neck fracture population, a large diameter head is
a solution to increasing stability thus reducing the rate of
dislocation. This is the reason why several surgeons prefer the use
of bipolar or unipolar prostheses over total hip arthroplasty. Figure 2b Figure 2c
351
Figures 2b and 2c: 76 yr old patient with femoral neck fracture large diameter metal head and an uncemented stem coated with
treated with THR featuring a polyurethane uncemented cup, a hydroxyapatite. X-ray (Fig: 2c) was taken one year post-op.
SYMPOSIA TRAUMA
REFERENCES 13. Khana I., Smithb N., Jonesc E., Finchd D.S., Camerona R.E.: Analysis and evalua-
1. Blomfeldt R, Tornkvist H et al. A randomised controlled trial comparing bipolar tion of a biomedical polycarbonate urethane tested in an in vitro study and an
hemiarthroplasty with total hip replacement for displaced intracapsular fractures ovine arthroplasty model. Part II: in vivo investigation. Biomaterials 26 633–643,
of the femoral neck in elderly patients. J Bone Joint Surg, 89 (2): 160-165, 2007. 2005.
2. Bexwada HP, Shah A, Harding S et al. Cementless Bipolar Hemiarthroplasty for 14. Moroni A, Faldini C, Hoang-Kim A, Pegreffi F, Giannini S.: Alendronate
Displaced Femoral Neck Fractures in the Elderly. The journal of arthroplasty improves screw fixation in osteoporotic bone. J Bone Joint Surg Am. 2007
19(7) suppl 2, 73-77, 2004 Jan;89(1):96-101.
3. Singh S, Trikha SP, Edge AJ. Hydroxyapatite ceramic-coated femoral stems in 15. Moroni A, Hoang-Kim A, Lio V, Giannini S.: Current augmentation fixation tech-
young patients. J Bone Joint Surg (B); 86-B:1118-23, 2004. niques for the osteoporotic patient. Scand J Surg. 2006;95(2):103-9. Review.
4. Sherry A, Slack R, Tindall et al. Results of a hydroxyapatite-coated (Furlong) total 16. Moroni A, Faldini C, Pegreffi F, Hoang-Kim A, Giannini S.: Osteoporotic
hip replacement. J Bone Joint Surg. 87-B: 1050-4, 2005. pertrochanteric fractures can be successfully treated with external fixation. J Bone
Joint Surg Am. 2005;87 Suppl 2:42-51. Review.
5. McNally, S, Shepperd J, Mann C. The results at nine to twelve years of the use of
a hydroxyapatite-coated femoral stem. J Bone Joint Surg (B) 82-B:378-82, 2000. 17. Moroni A, Faldini C, Pegreffi F, Hoang-Kim A, Vannini F, Giannini S. Dynamic
hip screw compared with external fixation for treatment of osteoporotic
6. Keating JF, Grant A, Masson M et al. Randomized comparison of reduction and pertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg Am.
fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of dis- 2005 Apr;87(4):753-9.
placed intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am.
88: 249-260, 2006. 18. Moroni A, Faldini C, Pegreffi F, Giannini S.: HA-coated screws decrease the inci-
dence of fixation failure in osteoporotic trochanteric fractures. Clin Orthop Relat
7. Bhandari M, Morrow F, Kulkarni AV, Tornetta P 3rd. Meta analyses in Res. 2004 Aug;(425):87-92.
orthopaedic surgery. A systematic review of their methodologies. J Bone Joint
Surg Am; 83-A (1): 15-24, 2001. 19. Moroni A, Faldini C, Marchetti S, Manca M, Consoli V, Giannini S.:
Improvement of the bone-pin interface strength in osteoporotic bone with use of
8. Lu-Yao GL, Keller RB, Littenberg B et al. Outcomes after displaced fractures of the hydroxyapatite-coated tapered external-fixation pins. A prospective, randomized
femoral neck. A meta-analysis of one hundred and six published reports. J Bone clinical study of wrist fractures. J Bone Joint Surg Am. 2001 May;83-A(5):717-21.
Joint Surg Am 1994; 76 (1):15-25.
20. Overgaard S, Lind M, Glerup H, Bunger C, Soballe K: Porous-coated versus grit-
9. M. S. Gilbert and J. Capozzi. Unipolar or bipolar prosthesis for the displaced blasted surface texture of hydroxyapatite-coated implants during controlled
intracapsular hip fracture? An unanswered question. Clin orthop and relat res. micromotion: mechanical and histomorphometric results. J Arthroplasty. 1998
353, 81-85, 1998. Jun;13(4):449-58.
10. J.C. Benterud, W.L. Kok and A. Alho. Primary and secondary Haenley-hastings 21. Nivbrant B, Karrholm J, Onsten I, Carlsson A, Snorrason F.: Migration of porous
hemiarthroplasty in displaced femoral neck fractures and their sequelae. Annales press-fit cups in hip revision arthroplasty. A radiostereometric 2-year follow-up
Chirurgiae et Gynecologiae 85: 72-76, 1996 study of 60 hips. J Arthroplasty. 1996 Jun;11(4):390-6.
11. A. Seth Greenwald, and Jonathan P. Garino. Alternative Bearing Surfaces: The 22. Onsten I, Carlsson AS, Sanzen L, Besjakov J.: Migration and wear of a hydroxyap-
Good, the Bad, and the Ugly. J Bone Joint Surg Am. 83:68-72, 2001. atite-coated hip prosthesis. A controlled roentgen stereophotogrammetric study.
12. Carbone A., Howie D.W, McGee, M., Field J., Pearcy M., Smith N., and Jones E: 23. J Bone Joint Surg Br. 1996 Jan;78(1):85-91.
Aging Performance of a Compliant Layer Bearing Acetabular Prosthesis in an
Ovine Hip Arthroplasty Model. fhs Journal of Arthroplasty 21, 6, 2006.
SLIDING HIP SCREW VS. IMHS FOR INTERTROCHANTERIC

FRACTURES
Michael Baumgartner, MD
SYMPOSIA TRAUMA
353
SYMPOSIA TRAUMA
SYMPOSIA TRAUMA
355
SYMPOSIA TRAUMA
NEW TRENDS IN PERTROCHANTERIC HIP FRACTURES

Thomas A.Russell MD
Incidence: U.S.A 2006 Are We Maximizing Recovery?

• 352,000 Hip Fractures a Year • Patients Self Regulate Weight-Bearing
• Double by 2050 to 650,000 • No Increased Rate Of Implant Failure With Early Protected
• =1800 Hip Fractures Per Day Weight-Bearing.
SYMPOSIA TRAUMA
• 50% Pertrochanteric Fractures • Koval et al : Postoperative weight-bearing after a fracture of
• 50% Are Unstable the femoral neck or an intertrochanteric fracture. JBJS 80-A
1998
Hip Fractures:AAOS Website 2006
• Therefore, If Patients Can’t Walk Maybe Our Fixation Is Not
• 25% Patients Will Make A Full Recovery
As Stable As We Think?
• 40% Will Require Nursing Home Care
• 50% Will Need A Cane Or Walker What About Arthroplasty?
• 24% Of Those Over 50 Will Die Within 1 Year • Mortality Rate 76% With HA and THA
• Berend, Hanna, Smith, Mallory, Lombardi
Compression Hip Screws Sliding To Prevent Cut-Out
• Journal Southern Orthopaedic Advances, 2005
• Invented By Richards Medical Co. 1956
• Mortality Rate 36% With Dislocation Rate of 44%.
• Gold Standard Approximately 1975-200?
• Haentjens et al Acta Ortho Belg 1994
• “There Is A Season To All Things….”Ecclesiastes, Chapter 3,
• Cephalomedullary Nails: Are They Better?
V1, NIV Bible.
• Anatomy:
Single Screw Nail Devices 1980’s • Intramedullary Canal And Diaphysis Begin Distal To The
• Comparative Analysis: No Outcome Difference Between Lesser Trochanter
Nail Devices and Plate & Screw Devices • Portal Placement Precision
• How Do We Define Failure: Union or Function? • Z-Effect
• What Does Sliding Mean? • Progressive Collapse Varus And Rotation Without Distal
— Leg Length Shortening = Length of Lag Screw Sliding X Locking
Sin of Nail Angle • Lustenberger, Bekic, et al 1995
— 40 Degrees for a 130 Degree Nail Unfallchirug 98(10):514-7
— 1cm Sliding X Sin40 = .643cm Short • 12% Visible Rotation of the Head-neck Fragment In
— 15.6mm Lag Slide X .643=1cm Short Leg Length Trochanteric Fractures Fixed With a Dynamic Hip Screw
• Why Did We Accept Sliding? Avoid Distraction (N = 14/112).
— Pulling Fracture Out To Length • The Distance of Lateral Impaction Was Significantly Higher
— Implant Insertion Creates Distraction in the Group With Rotation of the Proximal Fragment
— Screw And Nail Devices Initially Distract The Fracture Compared to Patients Without Rotation (P < 0.001).
• Higher Rate of Cutting-out (P < 0.01), the Rate of Delayed
Original Hypothesis For Single Screw Devices And
Union (P < 0.01) and Rate of Varus Angulation (P < 0.01)
Pertrochanteric Fractures: Due To The Large Geometry of the
• “We Conclude That Rotational Instability of a Gliding
Trochanteric Area, Once the Fx Gap is Closed the Rotational
Implant System Is a Severe Complication in the Treatment
Stresses Will Be Neutralized>Now Shown To Be False
of Trochanteric fractures.”
Single Screw Device Failures • Cutout Failure Related To Axial Load And Rotation
• 1. Rotational Instability With CHS
How Do We Fix The Problem?
— Moroni et al JBJS 2005;87:753-759.
• Hypothesis:
— Single Screw Compression Plate
• Build Constructs With Improved Translational and
— HA Coated External Fixation Pin
Rotational Stability Of The Femoral Head Neck and Shaft
— Average Migration 4 mm Of Screw In Head In Cases
Fixation To Improve Outcomes
Which Healed
— Dynamic Hip Screw Compared with External Fixation for What To Do?
Treatment of Osteoporotic Pertrochanteric Fractures 1. Technique Issues:
— New Surgical Approach: MIS:
• Varus collapse of the fracture at six months averaged 6° ±
– Bone Conservation
8° in Group A and 2° ± 1° in Group B (p < 0.002).
– Avoid Damage To Hip Muscle/Tendon Groups
• 2. Lateral Trochanteric Wall Failures
2. Prevent Peri-implant Fractures:
• Y. Gotfried, CORR 2004, 425:82-86
— New Nail Designs
• Hypothesis: Fracture of The Lateral Wall Associated With
3. Femoral Head Fixation:
Prolonged Morbidity
— New Methods Of Fixation For Femoral Head
• Collapse Of Fracture Results In Lower Extremity Shortening
• TFN Synthes (Paoli, PA)
And Abductor Weakness
• Impaction Nail Design. Biomechanical and Clinical Results
• Periprosthetic Fractures
• InterTan (Smith Nephew, Memphis, Tennessee)
— Tip Stresses?
• MIS Nail Technique 3 Components
— Instability of Nail?
— Precision Starting Point
— Precision Nail Trajectory
357
— Portal Preservation • With Load, Wheel Spin Places Eccentric Load On

• Avoidance Of Malreduction in Subtrochanteric Femur Attachment
Fractures • Single Femoral Head Screws Inherently Unstable:They Are
• OTA Meeting Phoenix 2006 Unicortical!
• T.A.Russell, Hassan R.Mir, Jason Stoneback, Brandon • Increased Interference Fit: More Stable
Downs, Jose Cohen • Pain And Ambulatory Potential Related To Nail Stability
• Presley Trauma Center Campbell Clinic Staff And Residents
Integrated Interlocking Screws
2003-2005
• Russell, Summy, Whitten
• 102 Subtrochanteric Femur Fractures Treated With Surgeon
• ORS Chicago 2006
SYMPOSIA TRAUMA
Choice Position, Approach, Nail Types And Techniques

• InterTAN Integrated Interlocking Screws
• Chi-Square Analysis of Variables
• IMHS Vs. Intertan
• Malunion Incidence
• Cut Out Single Screw 15,233 Cycles
— TriGen MIS
• Integrated 2 Screws 100,000 Cycle No Cut Out
— 4 / 77 Cases (5%)
— Free Hand Technique Cement Augmentation of Nails and Femoral Head Fixation
— 6 /23 Cases (26%) Statistically Significant Difference
Locking Plate Designs for Proximal Femoral Fractures
p<0.01.
Conclusion
Rotational Instability With Load
• Hip Fracture Care Can Be Improved
• Single Screw Is Like Axle: Wheel Spins
• Rotational Stability Is Important In ALL HIP FRACTURES
BONE SUBSTITUTES
Peter V Giannoudis, MD
Abstract calcium phosphate have also been used to complement

Technological evolution along with the better understanding of hardware fixation. [33, 34] They improve the interface between
bone healing biology has led to the development of several bone screws and bone and have the advantage of being resorbed and
graft substitutes. Fixation in osteoporotic bone can be augmented replaced by bone. [35] These cements are used to fill voids caused
SYMPOSIA TRAUMA
by adding a bone substitute that increases resistance to by osteoporosis [36, 37] or in reconstruction of femoral head
compressive forces and hardware pullout and at the same time necrosis. [38]
facilitates the fracture healing process.
The latest advances made with regard to the application of bone
While autograft is still the gold standard of bone grafting, in the substitutes in surgical reconstruction of proximal femoral
osteoporotic environment is not considered as the ideal option fractures are presented.
due to its poor mechanical properties. An alternative is to use
allograft which has much better mechanical properties but less 1. Bone substitutes in hip fractures- In vitro studies
osteogenic potential. The struts improve local bone stock for In vitro studies concerning bone substitutes and hip fractures
screw purchase and can also be incorporated to span regions of during the last 5 years focused on the use of cement to stabilize
diaphyseal deficiency. Femoral head allograft can be cut to shape both the implant- bone interface[39-42] and the bone itself [43,
and used to support the articular surface when metaphyseal bone 44] (Tab. 1).
has been lost due to impaction.
Two different cements were examined: polymethylmethacrylate
Polymethylmethacrylate (PMMA) has been used with success in cement (PMMA)[39, 41, 43, 44] and calcium phosphate
proximal femoral fractures. Both laboratory and clinical studies degradable cement (Norian SRS). [42] Both of them exert a
have demonstrated that screws in osteoporotic bone have positive effect on the stability of the bone- implant construct in
increased resistance to pullout when PMMA is used. the different study designs. Study settings differ in terms of
fracture characteristics, implants used and also the way and the
This cement can also be used to fill bone defects, however, large
location of cement application. Only one study directly
volumes may impair fracture healing. Cements made from
compares the two substitutes showing better biomechanical
calcium phosphate and calcium sulphate have also been used to
properties for PMMA.[40] The authors also describe that SRS
complement hardware fixation. They improve the interface
during pullout test failed by shear through the cement at the
between screws and bone and have the advantage of being
periphery of the screw threads whereas PMMA failed at the
resorbed and replaced by bone. These cements are used to fill
cement- bone interface. PMMA was shown to cause an
voids caused by comminution or severe osteoporosis. The
exothermic reaction, which might be harmful for bone in vivo
indication for these techniques and the current results in the
and the authors suggested the use of reinforcement materials
literature are presented.
with less exothermic reaction.[43]
Key words:
2. Bone substitutes in hip fractures- In vivo studies
Hip fracture, fracture neck of femur, trochanteric fracture,
During the last 5 years one research group from Sweden
osteoporosis, bone (graft) substitutes, cement, PMMA, calcium
conducted almost all in- vivo studies focusing on bone
phosphate degradable cement
substitutes in hip fractures[45-48] (Tab. 2).
Introduction There were two groups in which prospective randomized trials
With the steadily increasing number of elderly patients, were carried out: a) displaced fractures of the neck of femur and
orthopaedic surgeons will have to manage more fractures with b) unstable trochanteric fractures. Calcium phosphate degradable
decreased bone stock and underlying osteoporosis especially in cement was used as bone substitute versus controls. Regarding
the proximal femoral region. [1] The operative treatment of fractures of the neck of femur, in the early phase of evaluation
proximal femoral fractures remains challenging often with (up to 6 weeks) augmentation with calcium-phosphate cement
unpredictable outcomes despite the latest developments made improved the stability the fixation [46], whereas after the later
in implant technology and design. [2, 3] evaluation (up to 24 months)[48] due to a trend towards more
reoperations in the treated group augmentation as applied was
“Cutting- out” of the fixation device through the femoral head in
not recommended anymore.
both extra- and intramedullary implants is not uncommon [4-9]
and could still occur in spite of perfect reduction and the implant Focusing on unstable fractures in the trochanteric region there
being in an optimal position. was improved stability of the fixation pronounced for varus
angulation after 6 months [47] and also there was better clinical
Augmentation of the bone stock itself or the implant-bone
outcome after 6 months[45], although 2 delayed unions (healed
interface has been suggested as a technique in order to achieve
by 9 months) and 2 cases of plate loosening occurred in the
primary anchorage stability. [10, 11] In this context, lately several
augmented group after 6 months. There were no cut- outs in
bone graft substitutes have been developed. [11-21] Fixation in
either group.
osteoporotic bone can be augmented by adding a bone substitute
that increases resistance to compressive forces and hardware The only study focusing on a different substitute was carried out
pullout. [22-27] Both laboratory and clinical studies have by Szpalski et al. [49]. Beside the improvement of the stability of
demonstrated that Polymethylmethacrylate (PMMA) increased the inserted screw by Bisphenol-A-Glycidl Dimethacrylate (bis-
resistance to pullout of screws in osteoporotic bone. [28-31] GMA) Terpolymer, according to the authors one of the
advantages compared to PMMA (which was not tested in the
This cement can also be used to fill bone defects. [32] However,
large volumes may impair fracture healing. Cements made from
359
study) would be the lower temperatures that occur while femur fractures stabilized with cannulated screws, the authors
hardening. found higher reoperation rate after 24 months[48] compared to
the controls, although the difference between the treatment
Discussion groups was not statistically significant different. There was a shift
Harrington reported the successful use of cement for the fixation in the cause for reoperation from loss of early reduction among
of screws in hip fractures [28] in the year when results of pull-out controls to reoperations due to nonunion or avascular necrosis
testing of screws inserted into cement and bone under various in the augmented group after that period.
conditions were first published. [22] In the following years,
So, augmentation with calcium-phosphate cement improved the
several studies heterogenous in design were published focusing
stability of internally fixed femoral neck fractures at least in the
SYMPOSIA TRAUMA
on the same issue. [29, 31, 33, 34, 50, 51] Nevertheless, almost all
first 6 weeks after surgery and in and trochanteric fractures in the
of them concentrated on cement as a bone substitute and
first 6 months after surgery in vivo. [46, 47]
showed positive results for the use of polymethylmethacrylate
and calcium phosphate degradable cement to stabilize implants In the first instance sufficient primary stability of the implant-
in hip fractures. [11-14, 16, 18-20, 52-59] Only one in- vivo study substitute- bone construct is a great achievement and an absolute
has been focused on bisphenol-a-glycidl dimethacrylate (bis- necessity in mechanically compromised regions like the hip. But
GMA) terpolymeras an alternative for augmentation of screw beside its mechanical properties a bone substitute should also
fixation. Although it was only a case series of 6 and there was no be osteoconductive, osteoinductive, biocompatible,
direct comparison in between the different substitutes, the bioresorbable [13] and ideally to have osteogenic potential.
authors concluded that compared to PMMA their substitute PMMA accomplishes none of the characteristics requested and
offers better clinical and also technical characteristics. [49] injectable calcium phosphate cements lack osteoinductive
qualities. New cement types are already used as carriers for
From the different studies reviewed it appears that the cement
osteoinductive growth factors like BMP- 2 [60] but have lesser
implantation location varies from study to study. Whereas in
mechanical properties.
some studies only the region around the tip of the implant is
supported by cement, in other studies also the shaft of the screw So, there is a strong need for further research into better
(or only the shaft), the posteromedial corner of the proximal alternatives for bone substitutes combining these characteristics
femur or even the region above the screw is stabilized.[41, 42, but offering the same stability like cement.
44] In this context the studies are hardly comparable and a
It is of note that no clear guidelines exist regarding the indication
statement as to which technique might be superior than the other
for the use of bone substitutes in the osteoporotic hip fracture.
and therefore favourable is not possible.
Focusing on cement, there are some issues to be aware of. For
PMMA offers a good stability for implant fixation[40, 41, 44] but instance, non- biodegradable cements like PMMA administered
problems can arise because of its high polymerisation directly at the fracture site might cause nonunion [28, 29] and
temperature[43], that might cause osteonecrosis and impair might aggravate revision surgery. [33] There are also concerns
fracture healing especially when greater amounts of PMMA are about all kinds of cements introduced around the shaft of a
inserted. Furthermore PMMA is not osteoconductive. [19] sliding screw might impair the mechanism and turn it to a rigid
fixation device.[49]
Injectable osteoconductive calcium phosphate cements harden
without producing much heat, develop compressive strength Currently, it appears that it is still more the surgeon’s personal
midway between cancellous and cortical bone [42], and are experience and preference to decide if and what kind of substitute
remodelled slowly in vivo. [19] Unfortunately, they are weak in to employ. Further studies would address all of the above issues
shear[51] and mechanical properties seem to be inferior to and concerns in the not distant future.
PMMA. [40] Regarding the augmented group in the neck of
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cement. J Bone Joint Surg Br, 1994. 76(2): p. 320-3. 45. Mattsson, P., et al., Resorbable cement for the augmentation of internally-fixed
25. Taniwaki, Y., et al., Enhancement of pedicle screw stability using calcium phos- unstable trochanteric fractures. A prospective, randomised multicentre study. J
phate cement in osteoporotic vertebrae: in vivo biomechanical study. J Orthop Bone Joint Surg Br, 2005. 87(9): p. 1203-9.
Sci, 2003. 8(3): p. 408-14. 46. Mattsson, P. and S. Larsson, Stability of internally fixed femoral neck fractures
26. Van Landuyt, P., et al., Reinforcement of osteosynthesis screws with brushite augmented with resorbable cement. A prospective randomized study using
cement. Bone, 1999. 25(2 Suppl): p. 95S-98S. radiostereometry. Scand J Surg, 2003. 92(3): p. 215-9.
27. Yazu, M., et al., Efficacy of novel-concept pedicle screw fixation augmented with 47. Mattsson, P. and S. Larsson, Unstable trochanteric fractures augmented with cal-
calcium phosphate cement in the osteoporotic spine. J Orthop Sci, 2005. 10(1): cium phosphate cement. A prospective randomized study using radiostereometry
p. 56-61. to measure fracture stability. Scand J Surg, 2004. 93(3): p. 223-8.
28. Harrington, K.D., The use of methylmethacrylate as an adjunct in the internal 48. Mattsson, P. and S. Larsson, Calcium phosphate cement for augmentation did
fixation of unstable comminuted intertrochanteric fractures in osteoporotic not improve results after internal fixation of displaced femoral neck fractures: a
patients. J Bone Joint Surg Am, 1975. 57(6): p. 744-50. randomized study of 118 patients. Acta Orthop, 2006. 77(2): p. 251-6.
29. Bartucci, E.J., et al., The effect of adjunctive methylmethacrylate on failures of fix- 49. Szpalski, M., et al., Prevention of hip lag screw cut-out by cement augmentation:
ation and function in patients with intertrochanteric fractures and osteoporosis. J description of a new technique and preliminary clinical results. J Orthop
Bone Joint Surg Am, 1985. 67(7): p. 1094-107. Trauma, 2004. 18(1): p. 34-40.
30. Chow, S.P., et al., Treatment of unstable trochanteric fractures with Dimon- 50. Elder, S., et al., Biomechanical evaluation of calcium phosphate cement-aug-
Hughston osteotomy displacement fixation and acrylic cement. Injury, 1987. mented fixation of unstable intertrochanteric fractures. J Orthop Trauma, 2000.
18(2): p. 123-7. 14(6): p. 386-93.
31. Choueka, J., et al., Cement augmentation of intertrochanteric fracture fixation: a 51. Goodman, S.B., et al., Norian SRS cement augmentation in hip fracture treat-
cadaver comparison of 2 techniques. Acta Orthop Scand, 1996. 67(2): p. 153-7. ment. Laboratory and initial clinical results. Clin Orthop Relat Res, 1998(348): p.
42-50.
32. Li, Z., et al., A biomechanical study of periacetabular defects and cement filling. J
Biomech Eng, 2007. 129(2): p. 129-36. 52. Betz, R.R., Limitations of autograft and allograft: new synthetic solutions.
Orthopedics, 2002. 25(5 Suppl): p. s561-70.
33. Stankewich, C.J., et al., Augmentation of femoral neck fracture fixation with an
injectable calcium-phosphate bone mineral cement. J Orthop Res, 1996. 14(5): 53. Hoexter, D.L., Bone regeneration graft materials. J Oral Implantol, 2002. 28(6):
p. 786-93. p. 290-4.
34. Moore, D.C., et al., Hip screw augmentation with an in situ-setting calcium 54. Parikh, S.N., Bone graft substitutes: past, present, future. J Postgrad Med, 2002.
phosphate cement: an in vitro biomechanical analysis. J Orthop Trauma, 1997. 48(2): p. 142-8.
11(8): p. 577-83. 55. Parikh, S.N., Bone graft substitutes in modern orthopedics. Orthopedics, 2002.
35. Oda, H., et al., Clinical use of a newly developed calcium phosphate cement 25(11): p. 1301-9; quiz 1310-1.
(XSB-671D). J Orthop Sci, 2006. 11(2): p. 167-74. 56. Sammarco, V.J. and L. Chang, Modern issues in bone graft substitutes and
36. Bai, B., et al., The use of an injectable, biodegradable calcium phosphate bone advances in bone tissue technology. Foot Ankle Clin, 2002. 7(1): p. 19-41.
substitute for the prophylactic augmentation of osteoporotic vertebrae and the 57. Hing, K.A., Bone repair in the twenty-first century: biology, chemistry or engi-
management of vertebral compression fractures. Spine, 1999. 24(15): p. 1521-6. neering? Philos Transact A Math Phys Eng Sci, 2004. 362(1825): p. 2821-50.
37. Ikeuchi, M., et al., Mechanical augmentation of the vertebral body by calcium 58. Oakes, B.W., Orthopaedic tissue engineering: from laboratory to the clinic. Med J
phosphate cement injection. J Orthop Sci, 2001. 6(1): p. 39-45. Aust, 2004. 180(5 Suppl): p. S35-8.
38. Rijnen, W.H., et al., Impacted bone and calcium phosphate cement for repair of 59. Moroni, A., et al., Current augmentation fixation techniques for the osteoporotic
femoral head defects: a pilot study. Clin Orthop Relat Res, 2007. 459: p. 216-21. patient. Scand J Surg, 2006. 95(2): p. 103-9.
39. Augat, P., S. Rapp, and L. Claes, A modified hip screw incorporating injected 60. Seeherman, H., R. Li, and J. Wozney, A review of preclinical program develop-
cement for the fixation of osteoporotic trochanteric fractures. J Orthop Trauma, ment for evaluating injectable carriers for osteogenic factors. J Bone Joint Surg
2002. 16(5): p. 311-6. Am, 2003. 85-A Suppl 3: p. 96-108.
40. Eriksson, F., P. Mattsson, and S. Larsson, The effect of augmentation with
resorbable or conventional bone cement on the holding strength for femoral
neck fracture devices. J Orthop Trauma, 2002. 16(5): p. 302-10.
361
TAB. 1: BONE SUBSTITUTES IN HIP FRACTURES- IN VITRO STUDIES (2002- 2007)

SYMPOSIA TRAUMA
TAB. 2: BONE SUBSTITUTES IN HIP FRACTURES- IN VIVO STUDIES (2002-2007)
SYMPOSIA TRAUMA
363
THE BUSINESS OF ORTHOPAEDIC

TRAUMA CARE (BB)
SYMPOSIA TRAUMA
Moderator: James v. Nepola, MD, Iowa City, IA

In this symposium experts will discuss the “how to” basics and nuances of a successful
practice in Orthopaedic trauma allowing ample time for audience participation.
I. Introduction
James V. Nepola MD, Iowa City, IA
II. The Practice of Orthopaedic Trauma Surgery : The State of the Art
Timothy J. Bray, MD, Reno, NV
III. Acquiring the Resources Needed to Maintain a Viable Trauma Practice

Samuel G. Agnew, MD, Florence, SC
IV. Proper Coding of Orthopaedic Trauma Procedures

Bradford Henley, MD, Seattle, WA
V. Risk Management: Managing EMTALA and Liability in Your Practice

James V. Nepola, MD, Iowa City, IA
VI. Questions and Answers
EVALUATION OF BONE AND SOFT TISSUE

LESIONS FOR THE NON TUMOR SURGEONS:
SYMPOSIA TUMOR
HOW TO STAY OUT OF TROUBLE! (K)
Moderator: Kristy L. Weber, MD, Baltimore, MD
This is planned to be a compelling symposium for non tumor surgeons. It is not a surgical
“how to” session. This is an overview of the types of lesions that might occasionally be seen
in any orthopaedic practice. It will focus on principles of the work-up and diagnosis as well
as when to biopsy or refer. It will highlight examples of mistakes made by surgeons not
familiar with these principles. The intent is to have the listener leave a safer surgeon related
to bone and soft tissue lesions.
I. How to Interpret “Good” and “Bad” Lesions on Imaging Studies

Ted W. Parsons, II, MD, Detroit, MI
II. Approach to the Destructive Bone Lesion in the Older Patient

Kristy L. Weber, MD, Baltimore, MD
III. Approach to the Destructive Bone Lesion in the Younger Patient

Denis R. Clohisy, MD, Minneapolis, MN
IV. Key Points in the Evaluation of Soft Tissue Masses

Frank J. Frassica, MD, Baltimore, MD
365
HOW TO INTERPRET “GOOD” AND “BAD” LESIONS ON IMAGING

STUDIES
Ted W. Parsons, II, MD
Practicing Orthopaedic Surgeons are periodically confronted • Matrix mineralization is a helpful diagnostic clue
with unknown lesions of bone and soft tissue. This can be an — Stippled or “arc and ring” calcifications indicate a
SYMPOSIA TUMOR
anxiety provoking experience, and typically the question chondroid tumor

paramount in the mind of the practitioner is whether the lesion — Amorphous, “cloudlike” mineralization is typical of
is malignant or benign. Recognition of imaging characteristics osteosarcoma or blastic metastases such as prostate
and anatomic details from the different imaging modalities carcinoma
generally provides a great deal of information, guides the surgeon — Fibrous dysplasia typically demonstrates a “ground-glass”
to an appropriate differential diagnosis, and helps provide appearance
appropriate care for these patients. — Bone infarcts often reveal a swirling, “smoke up the
chimney” mineralized pattern
Conventional Radiography:
Bone Scintigraphy:
• Good quality, biplanar radiographs are the gold standard for
• Bone scintigraphy is particularly useful in determining
evaluation of bone lesions. These should be obtained prior
whether a bone lesion is active or indolent. Slowly growing
to any other imaging, and provide significant information
or inactive lesions typically demonstrate minimal
about the lesion.
radiopharmaceutical uptake, whereas active bone-forming
• Lodwick Classification ( zone of transition) helps determine
lesions, both benign and malignant, typically demonstrate
lesional activity
intense radiopharmaceutical uptake.
— Type I: Geographic
• Transition from mild uptake to intense uptake is an
– IA: sclerotic margins
ominous sign
– IB: Well defined Margins
• Provides sensitive screening for metastatic disease
– IC: Poorly defined margins
— Note that renal cell, myeloma, and thyroid carcinoma
— Type II: Moth Eaten (confluence of small lytic areas in
may show little uptake…do not completely rely upon
bone)
bone scan in these cases!
— Type III: Permeative (diffuse, tend to preserve outline of
• Helpful in identification of radiographically occult lesions
the bone but show diffuse destruction)
Generally, the increasing type corresponds with an Computed Tomography:
increasing aggressiveness of the lesion. Type I lesions, Excellent at evaluation of mineral and osseous density
particularly when well marginated, tend to be more • CT is particularly useful at identification of mineral density
indolent in nature. in subtle lesions, or identification of cortical integrity
• “Mankin’s Big Four” can help identify malignant vs. benign — Differentiation of chondrogenic from osteogenic lesions
lesions based on four radiographic observations. — Visualizing faint calcifications in liposarcomas or
— Size of the lesion (big is bad, small is good) synovial sarcomas
— Cortical destruction (present or not?) • CT is helpful in evaluating axial skeletal lesions (pelvis,
— Presence or absence of margination (zone of transition). spine) where the bony anatomy is complex
— Presence or absence of a soft tissue mass. • Remains the modality of choice for pelvic/abdominal
A large lesion with all these characteristics is likely to be adenopathy
aggressive. Note that there are exceptions! Infection may have • Useful for planning/conducting biopsies of lesions or RF
aggressive features (but is ‘benign’), while some metastatic ablation
lesions may look indolent (but are malignant)! Some benign
Magnetic Resonance Imaging:
lesions (giant cell tumor, chondroblastoma) may have
MRI is a superior modality for imaging soft tissue lesions and
aggressive features!
for obtaining fine anatomic details in most lesions.
• Periosteal patterns help determine the aggressiveness of a • T1 weighted images are best for evaluation of bone marrow
lesion — Marrow replacement from tumor or infection tends to be
— Solid periosteal new bone results from slow growing at least as dark as adjacent muscle
lesions • T1 weighted images are typically only bright from the
— Lamellated (‘onion skin’) or speculated (‘sun-burst’) following:
Periosteal new bone reflects aggressive behavior — Fat, met hemoglobin, gadolinium, proteinaceous fluid,
— Codman’s Triangle reflects rapid cortical destruction and melanin, and particulate calcium
the detachment of the periosteum — Reduced venous flow, surgical packing or hemostatic
• Location of the lesion helps establish the diagnosis: agents may also be bright in the post-op MRI on T1
— Chondroblastoma and giant cell tumor typically occur in weighted images
the epiphyses or apophyses of long bones • T2 weighted images reflect free water, and clearly identify
— Osteofibrous dysplasia and adamantinoma are classically most tumors, cystic lesions, joint or synovial fluid, and
tibial lesions edema
— Nonossifying fibroma is cortically based and occurs in — Densely fibrous lesions may be low on T1 and T2 images
the metaphysis of long bones • Fluid-fluid (layering of different density material) levels are
— Simple bone cysts are centrally located, often in the common in aneurysmal bone cyst, telangiectatic
proximal humerus or femur osteosarcoma, and synovial sarcoma.
— Other lesions (simple cyst with bleed, chondroblastoma, • More sensitive than Bone Scan for mets from Ewings,
giant cell tumor,even fibrous dysplasia may reveal fluid- multiple myeloma, and lytic and mixed lytic/blastic
fluid levels). carcinoma mets
• Gadolinium T1 weighted images reveal hyperemia of tissues, • Remains fairly non-specific (some benign lesions have high
and may overcall tissue involvment by tumor. uptake as well)
— “Rim enhancement” around a lesion is common with
In summary, careful evaluation of the patient, coupled with
cystic lesions, rarely with centrally necrotic lesions
careful evaluation of imaging different modalities can generally
• Gradient Echo images may be used to confirm the presence
guide the clinician to an accurate differential diagnosis. Careful
of subtle calcification or chronic blood product (e.g.
attention to the characteristics of the imaging studies and
pigmented villonodular synovitis), due to its sensitivity to
SYMPOSIA TUMOR
comparing the appearance on plain radiography to additional
signal loss from these tissues (“bloom artifact”)
studies (BS, CT. MRI, etc.) will typically allow the surgeon to
Positron Emission Tomography (PET and PET CT): identify lesions that are worrisome and should be referred to a
Evaluation of tissue metabolism and tumor physiologic activity. tumor surgeon, compared to simple, benign lesions that may be
• Sensitive in identifying small lesions and skip lesions observed. When any reasonable question regarding the diagnosis
• Degree of uptake typically correlates with the aggressiveness exists, it is always better to consult a musculoskeletal oncologist
of the lesion rather than just press on with a biopsy!
• Helpful in identification of lesion response to chemo
therapy (pre- vs. post-chemo comparison)
REFERENCES lectures, vol. 48. Rosemont: American Academy of Orthopaedic Surgeons; 1999:
1. Parsons TW, Frink SJ, Campbell SE. Musculoskeletal neoplasia: helping the 577-86.
orthopaedic surgeon establish the diagnosis. Semin Musculoskelet Radiol 5. Frassica FJ, Weber KL. Evaluation and Staging of Benign Bone Tumors. In:
2007;11:3-15. Schwartz HS, editor. Orthopaedic Knowledge Update: Musculoskeletal Tumors 2.
2. Sanders TG, Parsons TW III. Radiographic imaging of musculoskeletal neoplasia. Rosemont: American Academy of Orthopaedic Surgeons; 2007: 75-80.
Cancer Control 2001;8:221–231. 6. Lodwick, GS, et al Determining growth rates of focal lesions of bone from radi-
3. Parsons TW, Filzen, TW. Evaluation and Staging of Musculoskeletal Neoplasia. ographs. Radiology 1980;(134): 577
Hand Clinics 2004; 20(2): 137-145 7. Madewell, JE, et al Radiologic and pathologic analysis of solitary bone lesions.
4. Ward WG. Orthopaedic oncology for the non-oncologist orthopaedist: introduc- Radiol Clin North Am 1981;(19): 585
tion and common errors to avoid. In: Zuckerman JD, editor. Instructional course
367
APPROACH TO THE DESTRUCTIVE BONE LESION IN THE

OLDER PATIENT
Kristy L. Weber, MD
Overview — Thoracic spine is the most common vertebral location

In patients over 40-45 years of age, the most common diagnosis of metastasis
SYMPOSIA TUMOR
of a destructive bone lesion is metastatic carcinoma. However, — Metastatic carcinoma to the spine spares the
other tumors (including primary malignant bone tumors) do intervertebral disc
occur in this age group. The treatment of metastatic bone disease — Lesions distal to the elbow/knee are most commonly
and primary malignant bone tumors IS VERY DIFFERENT. A from lung primary
careful, stepwise approach to this particular problem will help — Pathologic fracture is a common presentation (25%)
you do the right thing and avoid compromising the life or limb — An avulsion of the lesser trochanter implies a
of the patient. pathologic process in the femoral neck with
impending fracture
1. Clinical Evaluation – work up the patient for possible • Work-Up
metastasis and if a primary lesion is not found, then do not — Plain radiographs – image in 2 planes and image the
assume it is a metastasis on history and imaging alone. entire bone (consider referred pain)
• History – — Differential diagnosis of lytic bone lesion in patient >
— Pain that is progressive - occurs at rest and with 40 includes metastatic disease, multiple myeloma,
weightbearing lymphoma and, less likely, primary bone tumors
— Constitutional symptoms (weight loss, fatigue, loss of (chondrosarcoma, osteosarcoma, MFH), Paget’s
appetite) sarcoma, hyperparathyroidism, pelvic/sacral stress
— Personal or family history of cancer fractures.
— Check for history of symptoms related to possible — Bone scan –
primary sites (hematuria, shortness of breath, hot/cold – Detects osteoblastic activity (may be negative in
intolerance) myeloma, metastatic renal cancer)
— Primary tumors may metastasize quickly or take 10-15 – Identifies multiple lesions - common in metastatic
years (breast, renal) disease
• Physical Examination — CT scan – chest/abdomen/pelvis – to identify primary
— Occasional swelling, limp, decreased joint range of lesion
motion, neurologic deficits (10-20%) at metastatic — Staging evaluation of lytic bone lesion will identify
bone sites primary site in 85% of patients
— Check for breast/prostate/thyroid/abdominal mass — Bone marrow biopsy – when considering myeloma as
— Stool guiac a diagnosis
— Regional adenopathy — MRI scan of the primary lesion – generally not
• Laboratory Studies necessary unless defining disease in the spine
— CBC – anemia suggests myeloma — Difficult to differentiate osteoporosis from metastatic
— SPEP/UPEP – abnormal in myeloma disease with a single vertebral compression fracture –
— Thyroid function tests – may be abnormal in thyroid tumor is suggested by soft tissue mass and pedicle
cancer destruction
— Urinalysis (microscopic hematuria in renal cancer)
Biopsy/Pathology
— Basic chemistry panel – check calcium, phosphorus,
• Must perform a biopsy of a destructive bone lesion unless
alkaline phosphatase, LDH
you are certain of the diagnosis
— Specific tumor markers – PSA (prostate), CEA (colon,
• Placing an intramedullary device in 65 year old with lytic
pancreas), CA125 (ovarian)
lesion in the femur without appropriate work-up is
• Common scenarios
dangerous (could be a dedifferentiated chondrosarcoma)
— Known cancer patient with multiple bone lesions –
• For diagnosis, can perform open incisional biopsy or closed
does not necessarily require confirmatory biopsy
needle biopsy (FNA/core)
— Known cancer patient with bone pain and normal
• Special IHC stains can sometimes determine the primary
radiographs – may be symptomatic from
site of disease
chemotherapy/bisphosphonates or may require bone
— TTF1 = lung, thyroid
scan or MRI to define an early destructive lesion
— ER/PR = breast
— Patient without history of cancer with a destructive
— PSA = prostate
bone lesion – must differentiate between metastatic
disease vs. primary malignant bone tumor Physiological Disruptions in Patients with Metastatic Disease
• Calcium metabolism – hypercalcemia – present in 10-15%
Radiographic Appearance/Work-Up
of cases
• Appearance
— Common with lung, breast cancer metastasis
— Osteolytic (majority) – lung, thyroid, kidney, GI
— Does not correlate with number of bone metastasis
— Osteoblastic– prostate, bladder
— Early symptoms – polyuria/polydipsia, anorexia,
— Mixed osteolytic/osteoblastic– breast
weakness, easy fatiguability
— Most common locations include spine (40%), pelvis,
proximal long bones, ribs
— Late symptoms – irritability, depression, coma, profound — Prophylactic fixation recommended for score of 9 or
weakness, nausea/vomiting, pruritus, vision abnormalities greater (33% fracture risk)
— Treatment requires hydration and possibly IV • Spinal lesions – impending fracture/collapse
bisphosphonate therapy — Thoracic
• Hematopoiesis – 50-60% of vertebral body involved alone
— Normocytic/normochromic anemia – common with – 20-30% of vertebral body with costovertebral joint
breast, prostate, lung, thyroid cancer metastasis involvement
• Thromboembolic disease — Lumbar
— Patients with malignancy have increased thrombotic risk – 35-40% of vertebral body involved alone
— Require prophylaxis especially after lower – 25% of vertebral body with pedicle/posterior element
SYMPOSIA TUMOR
extremity/pelvic surgery involvement
• Pain control/bowel abnormalities • Other factors to consider
— Use narcotics for pain control — Scoring systems are not exact and cannot predict all
— Requires laxatives/stool softener to avoid severe human factors
constipation — Histology of primary lesion
— Expected lifespan, co-morbid conditions, and activity
BIOMECHANICS
level
Stress Riser in Bone — Base most surgical decisions on plain radiographs
• Occurs whenever there is cortical destruction — Prophylactic fixation compared to fixation of actual
• Open section defect – when the length of a longitudinal pathologic fracture
defect in a bone exceeds _ of diameter, there is a 90% – Decreased perioperative morbidity/pain
reduction in torsional strength – Shorter OR time
• 50% cortical defect (centered) = 60% bending strength – Faster recovery/shorter hospital stay
reduction – Ability to coordinate care with medical oncology
• 50% cortical defect (eccentric) = >90% bending strength
Treatment
reduction
1. Primary malignant bone tumor (ie..chondrosarcoma,
IMPENDING FRACTURES/PROPHYLACTIC FIXATION osteosarcoma, MFH) – refer to an orthopaedic oncologist
for management
Indications for fixation
2. Multiple myeloma/Lymphoma – refer to a medical
• Snell/Beals criteria
oncologist for chemotherapy – often the bone lesion will
— 2.5 cm lytic bone lesion
heal with treatment. Consider surgical treatment initially in
— 50% cortical involvement
myeloma if there is a high risk for a lower extremity fracture
— Pain persisting after radiation
3. Metastatic disease – refer to a medical and radiation
— Peritrochanteric lesion
oncologist for treatment and manage the bone lesion
• Mirels scoring system – 4 factors (up to 3 points each)
operatively or nonoperatively depending on factors
— Site – peritrochanteric>lower extremity>upper extremity
previously discussed
— Pain – activity-related>moderate>mild
4. Examples of basic treatment of metastatic disease
— Radiographic appearance –
(UE, LE, spine)
osteolytic>mixed>osteoblastic
— Size of lesion – greater than 2/3 > 1/3 to 2/3 > less than
1/3
REFERENCES 3. Roodman GD: Mechanisms of bone metastasis. N Engl J Med 2004;350:1655-

1. Rougraff BT: Evaluation of the patient with carcinoma of unknown primary ori- 1664.
gin metastatic to bone. Clin Orthop Relat Res 2003;415:S105-S109. 4. Damron TA, Morgan H, Prakash D, Grant W, Aronowitz J, Heiner J: Critical eval-
2. Weber KL, Lewis VO, Randall RL, Lee AK, Springfield D: An approach to the uation of Mirels’ rating system for impending pathologic fractures. Clin Orthop
management of the patient with metastatic bone disease. Instr Course Lect Relat Res 2003;415:S201-S207.
2004;53:663-676. 5. Ward WG, Holsenbeck BA, Dorey FJ, Spang J, Howe D: Metastatic disease of the
femur: Surgical treatment. Clin Orthop Relat Res 2003;415:S230-S244.
369
APPROACH TO THE DESTRUCTIVE BONE LESION IN THE YOUNGER

PATIENT
Denis R. Clohisy, MD
History b. Symptomatic. Observe vs treat based on symptoms.

1. Pain which is constant, occurs at night, is not related to 2. When benign, aggressive tumor suspected on x-ray.
SYMPOSIA TUMOR
activity and/or increases over time is suspicious for Common examples include aneurysmal bone cyst,
malignancy. chondroblastoma and giant cell tumor.
2. Do not be misled by parents recalling an anecdotal history a. Obtain axial imaging to assist diagnosis and surgical
of trauma. Malignancies are often “associated” (by parents) planning.
with a coincidental unrelated injury. b. Biopsy. Treat surgically if suspected diagnosis confirmed.
3. Children with a pathologic fracture through a malignant c. Biopsy. Stop if malignancy suspected or diagnosis
tumor will almost always report experiencing pain prior to uncertain.
the time of fracture. 3. When benign tumor suspected on x-ray.
4. Children with malignant bone tumors almost never exhibit a. Obtain axial imaging to assist diagnosis.
constitutional symptoms of weight loss, fever, reduced b. If benign, non aggressive tumor diagnosed on axial
appetite, … imaging.
i. Incidental finding and/or asymptomatic. No further
Principle – Many childhood bone malignancies should be
evaluation.
strongly suspected based on clinical history and symptoms
ii. Symptomatic. Observe vs treat based on symptoms.
alone.
c. If benign, aggressive tumor diagnosed or suspected based
Physical exam on axial imaging.
1. When performing a physical examination, always undress i. Biopsy. Treat surgically if suspected diagnosis
the child or at least the affected area. confirmed.
2. In patients without pathologic fracture, any positive finding ii. Biopsy. Stop if malignancy suspected or diagnosis
on physical examination (limb swelling, loss of motion, uncertain.
weakness, mass, …) should raise suspicion for malignancy.
Principle - Geographic lesions on radiographs need axial
Principle – Almost all childhood malignancies should be imaging when the diagnosis is unclear.
strongly suspected based on clinical history, symptoms and
Principle – When treating a suspected benign bone tumor,
physical findings.
confirm the diagnosis with a biopsy. Do not proceed with
Imaging surgical treatment until a benign diagnosis is confirmed.
1. Large lesion on x-ray (greater than 4 cm) are often
Permeative Lesions on Radiographs.
malignant.
1. Malignant until proven otherwise by biopsy.
2. Bone lesions with a soft tissue mass on physical exam, MRI
2. Must have axial imaging and must determine the diagnosis.
or CT scan are malignant until proven otherwise.
3. When axial imaging confirms suspicion of malignancy refer
i. MRI is best to determine presence of a soft tissue mass or
to treatment center.
fluid and to define the intramedullary extent of tumor.
ii. CT scan is best to determine cortical destruction or Principle – Refer suspected pediatric bone cancers to a
calcification. treatment center.
3. Polyostotic tumors are usually benign.
Other General Guidelines, Considerations and Reminders.
4. MRI scans can be “over read” by inexperienced radiologists.
1. Always follow symptomatic lesions treated without surgery
Principle – Lesions with a soft tissue mass should be assumed until symptoms resolve and until serial imaging
malignant until proven otherwise by biopsy. demonstrates no progression.
2. A histologic diagnosis must be established before surgically
GUIDELINES FOR EVALUATION OF RADIOLUCENT BONE
treating bone tumors in younger patients.
LESIONS IN CHILDREN
3. Pathologic fractures secondary to benign tumors should
Geographic Lesions on Radiographs heal rapidly and symptoms should resolve quickly. Beware
1. When benign, non aggressive tumor diagnosed on x-ray. when this is not the case.
Common examples include non ossifying fibroma, fibrous 4. Always establish a histologic diagnosis before treating a
cortical defect, simple bone cyst, enchondroma and pathologic fracture with surgery .
osteocartilagenous exostosis.
a. Incidental finding and/or asymptomatic. No further
evaluation.
REFERENCES: 3. Patterson FR, Basra SK: Ewing’s Sarcoma. Orthopaedic Knowledge Update,
1. Frassica FJ, Weber KL: Evaluation and Staging of Benign Bone Tumors. Musculoskeletal Tumors 2, AAOS, pp 175-184, 2007.
Orthopaedic Knowledge Update, Musculoskeletal Tumors 2, AAOS, pp 75-80, 4. Seo SW, Remotti F, Lee, FY: Chondrosarcoma of Bone. Orthopaedic Knowledge
2007. Update, Musculoskeletal Tumors 2, AAOS, pp 185-196, 2007.
2. Hornicek FJ: Osteosarcoma of Bone. Orthopaedic Knowledge Update,
Musculoskeletal Tumors 2, AAOS, pp 163-174, 2007.
KEY POINTS IN THE EVALUATION OF SOFT TISSUE MASSES

Frank J. Frassica, MD
Soft Tissue Tumors –Major Errors 2) Order the correct tests

I. Failure to diagnose a soft tissue sarcoma • First – does the patient require imaging?
• Observation of a high grade malignancy — If one can not determine what a mass is by history and
• Improper diagnosis after removing the tumor physical examination, then imaging is needed
II. Inappropriate Excision of a Soft Tissue Sarcoma – Examples where imaging is not needed
SYMPOSIA TUMOR
• Removal of a sarcoma with positive margins ∑ Dorsal wrist ganglion
• Contamination of the surrounding structures following ∑ Subcutaneous lipoma
sarcoma removal ∑ Digital mucous cyst
III. Poorly performed biopsy • Second - start with a plain radiograph - AP/LAT – coned
• Failure to obtain diagnostic tissue down
• Infection following biopsy • Third - order an MRI with/without contrast
• Wound healing problems — With contrast if you think that the mass is a fluid filled
• Major alteration of treatment after biopsy cyst
3) Decision Making
Where to we stand – are we doing well or “not so good” a. Observation
Hazards of Biopsy b. Needle or Incisional Biopsy
1982 1992 • Small, longitudinal incision for open biopsy
• Major errors in Dx 18.2% 17.8% c. Excisional Biopsy
• Non-representative 10.3% 8.4% • Must know what it is before you take it out
• Complications 17.3% 17.3% • Note:
• Altered Treatment 18.2% 19.3% — Study the MRI to seek if you can determine the
• Unnecessary Amputation 4.5% 3.0% exact nature of a mass
Mankin et al JBJS 1996 — If the surgeon does not know what he mass is, he or
Mankin et al JBJS 1982 she should not remove it without doing a biopsy
#1 error- inappropriate excisional biopsy first.
How to avoid major errors – must have a systematic Determinate Masses
approach to evaluation and decision-making • Lipomas
• Ganglions
Three simple steps;
• Heterotopic Ossification
1) Know the clues to the presentation of a soft tissue sarcoma
• Hemangiomas
2) Order the correct tests
• Diabetic Myonecrosis
3) Be able to perform the appropriate decision-making
• Pigmented Villonodular synovitis
1) Know the clues to the presentation of a soft tissue sarcoma
Indeterminate Masses
• Patients present with a mass, swelling, or fullness
• Masses one cannot identify
• 20-30% of patients have a history of trauma
— Commonly -
• Occasionally there may be systemic symptoms – fever,
Low on T1
fatigue, malaise
High on T2
Typical patient – (most common presentation)
• Indeterminate masses usually require a biopsy to
• adult, extremity mass
determine their nature
• mass – feels firm, larger than 5 cm, growing, and below
the fascia
— many variations –
– may be small and superficial
– may be small and present for several years
REFERENCES 3. Frassica, FJ, Khanna JA, McCarthy, EF: The role of MR imaging in soft tissue
1. Sim FH, Frassica FJ, Frassica DA: Soft Tissue Tumors: Evaluation, Diagnosis, and tumor evaluation: perspective of the orthopedic oncologist and musculoskeletal
Management. J OF AMER ACAD OF ORTHO SURG 2(4):202-211, July/August, pathologist. Magn Reson Imaging Clin N Am, Nov; 8 (4): 915-27, 2000
1994 4. Mankin, HJ, Lange, TA, Spanier, SS: The hazards of biopsy in patients with malig-
2. Frassica, FJ, McCarthy, EF, and Bluemke, DA: Soft-Tissue Masses: When and How nant primary bone and soft tissue tumors. J Bone Joint Surg 64A:1121-1127, 1982
to Biopsy. In Instructional Course Lectures. Ed. Charles T. Price, Am. Acad. Of 5. Mankin, HJ, Mankin, CJ, Simon, MA: The hazards of biopsy, revisited. Members
Orthopaedic Surgeons; Volume 49: 437-442, 2000 of the Musculoskeletal Tumor Society. J Bone Joint Surg 78A:656-663, 1996
371
04 PPSE 08:Layout 1 1/28/08 6:06 PM Page 372
372
AAOS COMMITTEES
SCIENTIFIC EXHIBITS duced MedWatch, a medical products reporting program, to
facilitate the disclosure of adverse events and product problems
that arise from medical device usage.
SCIENTIFIC EXHIBIT NO. SE76 SCIENTIFIC EXHIBIT NO. SE78
Musculoskeletal Tissue Safety Understanding the Web of Orthopaedic Coding and
AAOS Committee of Biological Implants Reimbursement in 2008
Michael J Joyce, MD, Cleveland, OH
AAOS Coding, Coverage and Reimbursement Committee
A Seth Greenwald, DPhil Oxon, Cleveland, OH
R Dale Blasier, MD, Little Rock, AR
Scott D Boden, MD, Atlanta, GA
Bernard Andrew Pfeifer, MD, Burlington, MA
Scott A Brubaker, BSc, Mc Lean, VA
Richard J Friedman, MD, Charleston, SC
Christine S Heim, BSc, Mentor, OH
John P Heiner, MD, Madison, WI
The Orthopaedic Surgeon has the responsibility to inform
Brian J Galinat, MD, Wilmington, DE
patients about the risks and benefits of using musculoskeletal
allograft tissue in surgical procedures. The surgeon must be The development and valuation of CPT Codes is a complex
aware of the current potential for transmitting blood borne process that affects all orthopaedic surgeons. A basic under-
diseases, e.g. hepatitis, HIV and bacterial infections, etc. The standing of this process is essential for all physicians and prac-
exhibit provides an understanding of tissue bank practices in tice managers. It allows uniform documentation of physician
donor screening, serology testing, processing, and, when appli- work which expedites physician payment. Many surgeons are
cable, secondary sterilization or terminal sterilization. The unaware of their ability to participate in and influence this
historical record of disease transmission is presented and the process. The goal of this exhibit is to provide an overview of the
outstanding safety record associated with the use of allograft birth and death of codes, valuation of codes, and a brief look at
tissue is outlined. Progressive governmental regulatory oversight, tools to properly utilize these codes. This is a formal presenta-
standards, and a national voluntary accreditation program are tion by the AAOS Committee on Coding, Coverage and
reviewed. The exhibit also demonstrates that the use of human Reimbursement. There are four concepts: 1) The Birth of a Code
allograft tissue is predicated on the gracious altruistic gift from illustrates how new codes are initiated, validated, discussed, and
the donor/donor family to the patient recipient. advanced through he CPT process. 2) The Death of a Code illus-
trates how obsolete codes are changed or deleted in order to
SCIENTIFIC EXHIBIT NO. SE77 keep the orthopaedic Code Set current and inclusive. 3) The
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AAOS COMMITTEES

Valuation of a Code describes the process for assigning fair valu-
Adverse Event Reporting an FDA Requirement: ation to new or reviewed codes in the AMA’s Relative Value
What, When, How and Who Update Committee (RUC). 4) Resources for Proper Coding and
AAOS Biomedical Engineering Committee Billing illustrates the use of references and tools which enable
John S Kirkpatrick, MD, Jacksonville, FL proper use of these codes to maximize reimbursement and
A Seth Greenwald, DPhil Oxon, Cleveland, OH compliance with rules and regulations. The work of volunteer
orthopaedic surgeons in the AMA CPT and RUC processes have
Orthopaedic surgeons may encounter device failure or compli-
been highly successful in developing new codes, eliminating
cations in the course of their practice. When such device compli-
obsolete codes, and in assigning fair relative values for reim-
cations or failures result in injury, serious illness or death they
bursement. Physician involvement is critically important to code
are required to be reported by medical facilities to the FDA and
development and valuation in this process.
manufacturers. This exhibit describes the reporting requirements
in terms of orthopaedic device failure scenarios, addresses ques- SCIENTIFIC EXHIBIT NO. SE79
tions of confidentiality, liability and education, and is timely
information for the Fellowship. The requirements of reporting Say What You Mean!
adverse events will be displayed. Case examples are presented of AAOS Evidence-Based Practice Committee and AAOS
device complications or failures and the reporting of these Guidelines Oversight Committee
adverse events is discussed Surgeons can play a valuable role in Michael J Goldberg, MD, Seattle, WA
the accurate description and formal reporting of adverse events. William Charles Watters III, MD, Houston, TX
Most orthopaedic surgeons in the course of their practice will This exhibit will educate members on the appropriate language
encounter and explant medical devices used in orthopaedic of evidence-based practice, including standardized evidence-
reconstructions which have failed. Such failures may simply based recommendation terms for use in clinical practice guide-
result from long-term in-vivo device usage, component material lines. What exactly does it mean when a clinical practice
breakdown, technique at the time of implantation or patient guideline says you should do something, or says it is an option
abuse. Changes in the Safe Medical Devices Act of 1990 to do something? What is the scientific/evidence basis that
(SMDA), a Law enacted by the Congress, requires that medical allows such statements to be made? This exhibit will also review
device user facilities inclusive of hospitals, ambulatory surgical some of the new standards in evidence-based practice language
facilities and nursing homes report such events to the FDA and and recommendation development as established by the U.S.
manufacturers. These events are inclusive of device problems Preventative Services Task Force (USPSTF).
which cause or contribute to the death, serious illness or serious
injury of a patient. The orthopaedic surgeon is involved in the
identification of these problems. In June 1993, the FDA intro-
373
SCIENTIFIC EXHIBIT NO. SE80 hospital discharges from 1993 to 2005 rose from 1,900 to
Bone Graft Substitutes: Facts, Fictions and 368,600. The CDC definition of CA-MRSA has included no
history within one year of hospitalization, nursing home admis-
Applications sion, dialysis, surgery or indwelling catheter. Community
AAOS Orthopaedic Device Forum outbreaks have been reported in sports teams, child care atten-
A Seth Greenwald, DPhil Oxon, Cleveland, OH dees, prison inmates and diverse populations. However in 2005
Scott D Boden, MD, Atlanta, GA 58% of MRSA occurred outside the hospital but with a health
Victor Goldberg, MD, Cleveland, OH care associated risk factor within the previous year. The majority
Michael J Yaszemski, MD, PhD, Rochester, MN of MRSA in 2005 was related to health care. Vancomycin
Intermediate Sensitive (VISA) and Resistant Staphylococcus
The increasing use of allograft materials in joint revision and
aureus (VRSA) loom as future problems.
tumor surgical applications has stimulated an interest in the
evolution of bone substitute technologies. Current concerns SCIENTIFIC EXHIBIT NO. SE82
regarding the transmission of blood borne disease, donor avail-
ability, processing costs and cultural or religious limitations on Developing the Clinician Scientist
the use of allograft materials are further reasons for this interest. AAOS Research Development Committee
This exhibit provides a continuous update of the emergence of Constance R Chu, MD, Pittsburgh, PA
bone graft substitutes inclusive of growth factors and biologic The Research Development Committee’s efforts in clinician-
scaffolds. Differentiating these products in terms of their ability scientist development are a direct, proactive response to the
to promote osteoconduction and osteoinduction provides for decreasing ranks of orthopaedic surgeon scientists over the past
an appreciation of their utility. Through physical description and two decades. AAOS programs focus on targeting talented
direct clinical application they are viewed as alternatives and orthopaedic surgeons in training and encouraging and facili-
supplements to allograft and autograft tissue. Their advantages tating their development as surgeon scientists include an annual
and caveats are described through clinical example and their workshop, opportunities for traveling fellowships, and one-on-
future potential as drug delivery systems discussed. This exhibit one mentorship by members of the Research Development
continues to report the rapid change in availability of these Committee. The Clinician Scientist Development Program
materials. (CSDP) has been active for the past five years. During that time,
over 50 residents have attended the annual event which covers
SCIENTIFIC EXHIBIT NO. SE81 topics such as collaborations, grants, career development, and
Orthopaedic Infection: Community-Acquired and balance of family and professional life. This has the additional
Hospital-Acquired Methicillin-Resistant advantage of placing surgeon scientists in an informal setting
with the aspiring residents to develop mentorship relationships.
Staphylococcus aureus (MRSA) The Traveling Fellowship Program (TFP) has supported/is
AAOS Patient Safety Committee supporting 12 fellows. These orthopaedic scientists have identi-
Richard Parker Evans, MD, Little Rock, AR fied mentors and laboratories that would most benefit their
Terry A Clyburn, MD, Bellaire, TX career development and than have been afforded the opportu-
Paul D Holtom, MD, Los Angeles, CA nity to visit these centers. The annual Kappa Delta orthopaedic
research awards offers $20,000 awards for excellence in
94,360 invasive MRSA infections occurred in the United States
orthopaedic research. One of the three Kappa Delta Awards is
in 2005; and resulted in 18,650 deaths. Eighty-five percent are
designated specifically for Young Investigators. The feedback
health care-associated resulting in a significant public health
from both surgeon scientists and residents has been over-
concern. Community-associated or community-aquired methi-
whelmingly positive in terms of the educational and interper-
cillin-resistant Staphylococcus aureus (CA-MRSA) has been a
sonal outcomes. Several have moved forward to collaborate on
clinically distinct disease from hospital-aquired or associated
research with their mentors. The impact of this program remains
MRSA (HA-MRSA). The epidemiology and incidence of each
difficult to quantify since many of the recipients are in the latter
MRSA is changing. Understanding differences of these two
stages of their training. The development of the participants will
strains is required to effectively prevent, treat and control this
continue to be monitored to determine the impact this program
significant public health concern. Developed in conjunction
has on formation of the next generation of surgeon scientists.
with the AAOS Patient Safety Committee this exhibit summa-
The Research Development Committee directly interfaces with
rizes recommendations about emerging trends in the presenta-
the NIH regarding funding for musculoskeletal research to
tion, identification and treatment of community-aquired
complement the efforts of Clinician Scientist Development
methicillin-resistant Staphylococcus aureus (CA-MRSA) and
Program. CSDP:
hospital-aquired MRSA (HA-MRSA). It is based on current liter-
ature and Center for Disease Control (CDC) recommendations.
CA-MRSA, first identified in 1981, contains cassette chromo-
some mec type IVa, Panton-Valentine leukocidin (PVL)
dermonecrosis virulence factor and is sensitive to most non-²-
lactam antibiotics. Infection with this organism results in spider
bites, furuncles, abscesses, bacteremia and is sometimes invasive
and lethal. HA-MRSA has been a problem in hospitalized
patients since the 1960s, is sensitive predominately to
vancomycin and is associated with greater mortality, costs and
lengths of stay. The top two procedures performed in association
with MRSA infection are incision and drainage followed by soft
tissue debridement. Excision of bone is also one of the most
common surgical procedures performed. The number of MRSA
SCIENTIFIC EXHIBIT NO. SE83 and the greater public. When possible, the WHIAB will promote
The Role of the AAOS in Technology Assessment: gender-specific research. Based off the “AAOS Now” quarterly
column of the same name, the WHIAB “Putting Sex into Your
Where Evidence Meets Clinical Practice Orthopaedic Practice” exhibit will provide important informa-
AAOS Technology Assessment Workgroup tion for your practice about issues related to sex (determined by
Kevin John Bozic, MD, MBA, San Francisco, CA our chromosomes) and gender (how we present ourselves as
James S Breivis, MD, San Francisco, CA male or female, which can be influenced by environment, fami-
Joshua J Jacobs, MD, Chicago, IL lies and peers, social institutions, etc.). Specifically, it will address
Charles Turkelson, PhD, Rosemont, IL hip fractures, a recognized public health problem in women; but
also a significant problem in men. Most research studies on
David Alan Wong, MD, MSc, Greenwood Village, CO
osteoporosis and prevention of future fractures have been
Health care expenditures in the United States continue to rise conducted on women, and what is known about managing frac-
faster than general inflation, and health care technology (HT), tures in women may not directly apply to men without modifi-
defined as any medical device, drug, or procedure, is a primary cations that consider sex differences. This exhibit with regard to
driver of costs. Orthopaedic surgeons and their patients are hip fractures: will review the literature with regard to the
confronted with an increasing number of new, costly, and following: 1.analyze the curent state of research related to gender
unproven technologies on a daily basis. Health technology morphism 2.Consider risk factor differences between men and
assessment (HTA)—a multidisciplinary evaluation of the clinical women 3.Differences in co-morbidities 4.Operative choice
and economic evidence on the intended and unintended conse- differences in treatment management 5. Role of genetics, specif-
quences of using a technology—has assumed an increasingly ically any gender dimorphism in the COL I protein 6.Consider
important role in health policy and clinical decision-making. differences in the contribution of estrogen /estrogen receptor
The process of moving from innovation to controlled HT adop- with regard to risk of hip fracture. The literature has a small
tion is complex. HTA considers evidence on safety and efficacy repository with regard to gender differences in hip fractures.
from clinical trials and economic evaluations of costs and bene- Most research to date has included women with respect to osteo-
fits to determine if a technology is worthy of widespread adop- porosis and hip fracture risk. More research is needed to deter-
tion. Patients view most HT with optimism and seek providers mine how to best care for gender when it comes to prevention
offering high-tech care. Physicians respond to this demand and of hip fracture and improving quality of life. As the public ages
to incentives for professional advancement by adopting new and lives longer, more information will be needed to determine
technologies, often without careful scrutiny of long-term social the best way to prevent hip fracture based on gender-specific
and economic consequences. Health care systems managers and needs.With functional recovery optimized and tailored to
policy-makers are left to grapple with questions of safety, effi- gender needs, the ability to participate in quality of life activities
cacy, cost, and feasibility in attempts to sustain the financial and basic activities of daily living will be optimized for
health of delivery systems. Several AAOS member needs surveys everyone!
have demonstrated a strong desire among AAOS fellows for

more objective, evidence based information regarding new and
existing technologies and procedures. The AAOS Technology
Assessment Project Team has been charged with exploring the
options for AAOS involvement in HTA. This exhibit provides
background on past, present, and future AAOS involvement in
HTA, including several examples of technology assessments
related to orthopaedic technologies. Medical innovation and
patient demand will continue to drive US health care expendi-
tures. HTA will remain an important tool for critically evaluating
HT, and physicians should be aware of and involved in health
technology assessment.
SCIENTIFIC EXHIBIT NO. SE84

Putting Sex Into Your Orthopaedic Practice
AAOS Women’s Health Issues Advisory Board
Laura M Gehrig, MD, Shreveport, LA
Mary I O’Connor, MD, Jacksonville, FL
Ann Babbitt, MD, South Portland, ME
Barbara Jean Campbell, MD, Somerset, PA
Michelle A James, MD, Sacramento, CA
Elizabeth A Ouellette, MD, North Miami Beach, FL
Susan E Stephens, MD, Gates Mills, OH
The mission of the Women’s Health Issues Advisory Board
(WHIAB) is to improve orthopaedic care of gender related
musculoskeletal disorders. Since women suffer from disease in
different ways than men, this work is critical to optimizing
patient care. The WHIAB reports to the AAOS Board of Directors
to disseminate and coordinate gender-specific research informa-
tion, medical knowledge, and communications to a variety of
audiences - the Academy, our policymakers in Washington, D.C.,
375
A D U LT R E C O N S T R U C T I O N H I P
PAPERS radiographic outcomes of THA patients who participate in high
impact sports so that surgeons can caution these patients appro-
priately.
PAPER NO. 016 PAPER NO. 017
◆High Impact Sports After THA: Is the Bearing Type Ten Years Follow-Up in Cobalt Serum Determination
an Independent Predictor of Activity Level? After Metal-on-Metal Hip Prosthesis
David R Marker, BS, Baltimore, MD Jean Yves Lazennec, MD, Paris, France
Thorsten M Seyler, MD, Winston-Salem, NC Patrick J Boyer, MD, Boston, MA
Slif D Ulrich, MD, Baltimore, MD J Poupon, MD, Paris, France
Ana L Martimbianco, PT, Marc Antoine Rousseau,
Siddharth Srivastava, BS, Baltimore, MD Phillipe Ravaud, MD, PhD,
Michael A Mont, MD, Baltimore, MD Yves Catonne, MD, Paris, France
High impact sports following total hip arthroplasty (THA) are Systemic cobalt and chromium release has been demonstrated
discouraged by orthopaedic surgeons. Recently, a survey of Hip from metal-on-metal hip prostheses. Concerns exist about this
Society members indicated that a number of sports are not release as the results of allergic or carcinogenic toxicities.
recommended because of the potential negative impact on clin- Purpose of this study was to determine prospectively the serum
ical outcome. However, perhaps due to non-scientific dissemi- cobalt concentration at long term. In addition, we investigated
nation of information via the internet, marketing, and other whether bilateral joint replacement could significantly affect the
sources, many patients have the perception that high impact serum cobalt concentration compared to unilateral replacement.
sports are allowed following THA with potentially low-wear We included in this study 73 patients who underwent a
bearings such as ceramic-on-ceramic, metal-on-highly- cemented metal-on-metal hip prosthesis using the Metasul®
crosslinked polyethylene, and metal-on-metal. Patients are not bearing surface. There were 50 unilateral and 23 bilateral hip
necessarily following surgeon recommendations. The purpose replacements. At multiple time-points until 10 years after the
of this prospective study was to assess high impact sports operation, blood samples were taken in order to dose Serum
activity after total hip arthroplasty. In addition, we wanted to cobalt concentrations collected into free-metal vacutainers.
determine which factors correlated with the participation in Serum samples were analyzed using atomic absorption spec-
high impact sports. Pre- and post-operative questionnaires were trometry. In the unilateral joint replacement group, the median
used to characterize the sports activity of 303 THA patients at a serum cobalt concentration was 23.5 mmol/l at one year after
mean of 3 years following surgery. The patients indicated the surgery, 21.7 mmol/l at five years and 26.1 at ten years.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR HIP
number of times and hours they spent each week participating Regarding the bilateral group, the median serum cobalt concen-
in high impact sports including: baseball, basketball, hockey, tration was 64.7 mmol/l at one year after surgery, 59.2 mom/l at
lacrosse, jogging, soccer, volleyball, skiing (downhill and cross- five years and 103.9 mmol/l at ten years. This study brings out
country), handball, racquetball, squash, and singles tennis. new informations about systemic cobalt release from Metasul®
Using multiple logistic regression analysis, various demo- metal-on-metal hip prosthesis at long term. Values are signifi-
graphic and clinical variables were evaluated concerning their cantly below detection limit and remain in a constant range after
potential correlation with participation in high impact exer- the ‘run-in-phase’. Bilateral replacement increase by 3 to 5-fold
cises. The variables assessed included age, gender, BMI, bearing systemic cobalt release and raises questions about elimination.
surface, pre-operative sports activity, pre-operative Harris Hip Metal ions long term effects are still undetermined.
score, and time following surgery. Overall, 90 patients (30%)
participated in one or more high impact sports for an average of PAPER NO. 018
4.3 hours per week. The most common sports were singles
tennis (n = 49), downhill-skiing (n = 33), jogging (n = 28), and
Do Metal Ion Levels in Metal on Metal THAs Change
squash (n = 23). Pre-operative participation in high-impact Over Time : Midterm Results of a Prospective RCT
sports and metal-on-metal total hip arthroplasty were the only Steven J MacDonald, MD, London, ON Canada
variables that had a statistically significant correlation with Richard W McCalden, MD, London, ON Canada
post-operative participation in high impact sports. Some of the Robert Barry Bourne, MD, London, ON Canada
reasons why many patients desire a THA are improved func- Cecil H Rorabeck, MD, London, ON Canada
tionality and return to sporting activity, which was higher than
David Gordon Chess, MD, London, ON Canada
might be expected in this prospective study (30%). The results
of this study suggest that when controlling for factors such as
Abigail E Thompson, BScN, London, ON Canada
age and BMI, metal-on-metal patients are more likely to partic- Polyethylene wear is the most significant issue following total
ipate in high impact sports. There are few studies which analyze hip arthroplasty (THA) leading to the increased use of alterna-
the effect of high impact sports on these bearings. The authors tive bearing surfaces. We performed a prospective, randomized,
recommend that while all THA patients should be cautioned blinded clinical trial comparing metal versus polyethylene
regarding high impact sports, increased precautionary advice bearing surfaces in patients receiving a THA. Forty-one patients
may be necessary for metal-on-metal patients who may have were randomized to receive a metal (23) or a polyethylene (18)
been influenced by non-scientific sources. Furthermore, there is insert with identical femoral and acetabular components. The
a need for long-term studies which evaluate the clinical and metal bearing was a 28mm low carbon on high carbon couple
(MOM). Patients were evaluated pre-operatively, at 3, 6, 12
months and annually thereafter, including evaluation of erythro- PAPER NO. 020
cyte and urine cobalt, chromium, and titanium, outcome meas- Gamma Inert Sterilization: A Solution to
ures (WOMAC, SF-12, HHS) and radiographs. No patients were
lost to follow-up (average 8.1 years, range 7.0-8.8). No differ- Polyethylene Oxidation?
ences in outcome measures or radiographic findings were Steven M Kurtz, PhD, Philadelphia, PA
found. Patients receiving metal liners had significantly (p<.001) William J Hozack, MD, Philadelphia, PA
elevated metal ion measurements. At latest follow-up, compared Javad Parvizi, MD, Philadelphia, PA
to the polyethylene control group, MOM patients erythrocyte James J Purtill, MD, Philadelphia, PA
cobalt was 13 times elevated (1.5mg/L vs 0.12mg/L). Urine Peter F Sharkey, MD, Philadelphia, PA
cobalt was 19 times elevated (7.0mg/L/day vs 0.37mg/L/day)
Daniel MacDonald, BS, Philadelphia, PA
and urine chromium was 20 times elevated (3.7mg/day vs
0.19mg/day). Additionally, the metal ion levels reached an early Matthew J Kraay, MD, Cleveland, OH
steady state level and did not decrease over time. Both cobalt and Victor Goldberg, MD, Cleveland, OH
chromium ion measurements were significantly elevated in the Clare M Rimnac, PhD, Cleveland, OH
blood and urine of the MOM patients at all time intervals. In In the 1990s, polyethylene oxidation was found to occur
42% of the MOM patients, metal ion (erythrocyte cobalt) eleva- following gamma irradiation in air. Manufacturers developed
tion was still increasing at latest follow-up, and in the overall barrier packaging to reduce oxidation. This study explores the
MOM patient cohort, metal ion levels were not decreasing over hypothesis that implants sterilized in a low oxygen environment
time. undergo similar in vivo oxidative mechanisms as implants ster-
ilized in air. Over the past seven years, our multi-institutional
PAPER NO. 019 retrieval program has traced and analyzed 264 conventional
◆Osteolysis in an Early Second Generation Metal- polyethylene hip and knee components: 123 were sterilized in
air and 141 were sterilized in a low oxygen environment. The
Metal Hip Resurfacing mean implantation time of the hips was 10.1y (Air) and 4.1y
Joseph Daniel, FRCS, Birmingham, United Kingdom (Inert). Knees were implanted on average 10.8y (Air) and 2.7y
Chandra Pradhan, FRCS, Brinmginham, United Kingdom (Inert). Oxidation index was characterized in loaded and
Hena Ziaee, BSc, Birmingham, United Kingdom unloaded regions of the inserts per ASTM F2102. Measurable
Derek James Wallace McMinn, FRCS, Birmingham, United oxidation was observed in all cohorts. The oxidation was
Kingdom regional. Surfaces with access to bodily fluids were more heavily
oxidized than protected, bearing surfaces. This variation
Second generation metal-metal bearings were introduced in
appeared to be greater in gamma-air sterilized implants. This
order to reduce the incidence of osteolysis-related failures from
study explores the significance of industry-wide changes in ster-
conventional replacements. The aim of this study is to report the
ilization practice for polyethylene. We found lower oxidation in
minimum ten year results of a first-of-a-kind bearing metal-
the gamma inert-sterilized hips and knees as compared with
metal hip resurfacing. 184 consecutive hips (160 patients) were
historical gamma-air inserts. However, we also found strong
treated with an early second-generation metal-metal hip resur-
evidence that gamma inert sterilized inserts are undergoing

facing arthroplasty. Patients were invited for a clinico-radiolog-
mechanisms of in vivo oxidation that similar to those observed
ical follow-up at the minimum ten-year period. Oxford hip
following gamma irradiation in air. Our research therefore
scores and anteroposterior and lateral radiographs were
demonstrates that gamma inert sterilization may have
obtained. Mean age at operation was 54 (range 21 to 75) years.
improved, but not completely solved, the problem of polyeth-
Sex ratio was 7f:10m. Seven patients (11 hips) died at a mean 6.9
ylene oxidation for hip and knee arthroplasty.
years after operation due to unrelated causes. Mean follow-up
was 10.46 years (range 10 to 11.1). One patient was lost to
PAPER NO. 021
follow-up. Seven patients who confirmed joint survival could
not attend the review or undergo radiographs due to logistic ◆Acoustic Analysis of Squeaking Hips
difficulties. There were 29 revisions (16%) at a mean 7.3 years, William Lindsay Walter, MD, Waverton, Australia
one for infection at 1.2 years and 28 for osteolysis or aseptic Ronald M Gillies, BS, Sydney, Australia
component loosening at 3.2 to 10.9 years. The Kaplan-Meier Shane Donohoo, Sydney, Australia
cumulative survivorship at 11 years is disappointingly low at William J Hozack, MD, Philadelphia, PA
83.3%. Furthermore there were radiological adverse features in
Amar S Ranawat, MD, New York, NY
25 of the radiographed surviving hips. Osteolysis/aseptic loos-
ening was the predominant mode of failure in this series. The Squeaking is reported in hard-on-hard hip bearings but not
magnitude of this phenomenon did not become obvious until usually in polyethylene bearings. Our hypothesis is that a failure
five years after the operation prior to which only three had failed of fluid film lubrication results in an increase in friction. In vivo
through this mechanism. Our results show that wear-induced acoustic analysis: Sound recordings were collected from 38
osteolysis occurs with metal-metal bearings too and early success patients with squeaking hips and analysed by Fourier transfor-
does not guarantee long-term survival. mation to determine the frequencies of the emitted sound. In
vitro acoustic analysis The natural frequency of hip replacement
components was determined by a simple acoustic emission
analysis and by a finite element modal analysis. In vivo acoustic
analysis: We detected fundamental frequencies between 400Hz
and 7.5 kHz. All recordings demonstrated non-linear frequency
distribution which is typical of a friction induced vibrations. In
vitro acoustic analysis: The natural frequencies of the ceramic
heads, the ceramic liners and the correctly assembled modular
ceramic/titanium acetabular components are above the audible
377
range (over 18 kHz range). The fundamental frequency of the in the cross-linking and processing treatments. As with previous
unassembled titanium shells is between 3.5 kHz and 10 kHz and new and promising UHMWPE material breakthroughs, clinical
the titanium femoral components have multiple natural frequen- retrievals provide the best comprehensive assessment of in vivo
cies between 2kHz and 18 kHz. The squeaking results from fric- performance. Fifty retrieved THA devices with highly cross-
tion induced vibrations--a special case of forced vibration--where linked UHMWPE bearings of 5 different formulations from 5
the frequency is determined by the natural frequency of the manufacturers were analyzed. Visual microscopy assessment for
component parts. We conclude that sound emissions from damage modes, FTIR analysis for oxidation, and tensile testing
squeaking hips result from resonance of one or other or both of for mechanical properties were performed. No instances of rapid
the metal parts. Furthermore, dynamic uncoupling of the ceramic abrasive/adhesive wear of bearing surfaces were documented.
insert from the titanium shell should be investigated further. Mechanical properties, although lower than for non-oxidized,
non-cross-linked UHMWPE and inversely related to cross-
PAPER NO. 022 linking radiation dose, were maintained in-vivo at as-manufac-
Catastrophic Rim Fracture of Four Highly Cross- tured levels for the remelted materials. Device failure via
cracking and/or fracture occurred under conditions of point
Linked Acetabular Liners loading and thin acetabular liner rims. In retrievals with below-
Jevan Furmanski, MS, Berkeley, CA melt annealed UHMWPE, oxidation proceeded at rates faster
Sara A Atwood, MS, Berkeley, CA than shelf-aged, gamma-air sterilized polyethylene, with associ-
B Sonny Bal, MD, Columbia, MO ated fatigue damage evident in components with impingement
Martin R Anderson, MD, Carson City, NV or dislocation. The abrasive/adhesive wear reduction predicted
Brad L Penenberg, MD, Beverly Hills, CA by in vitro testing appears to be borne out in vivo. The tradeoff
David K Halley, MD, Columbus, OH of wear resistance versus mechanical properties is important in
device design. Lower mechanical properties require attention to
A Seth Greenwald, DPhil Oxon, Cleveland, OH
stress concentrations and bearing thicknesses. Long term oxida-
Lisa Pruitt, PhD, Berkeley, CA tive stability of UHMWPE remains a key concern. Remelting of
Michael D Ries, MD, San Francisco, CA irradiated UHMWPE eliminates free radicals. Below-melt
Cross-linking of ultra-high molecular weight polyethylene annealing does not eliminate free radicals, resulting in bearings
(UHMWPE) to reduce in vivo wear of artificial joint bearings also that oxidatively degrade in vivo.
affects its strength and resistance to fracture. Four clinically failed,
fractured highly cross-linked acetabular liners of radiation dose PAPER NO. 024
50-100 kGy, each from a different manufacturer, were retrieved Mechanical Stability of Metallic Transfer on
from female patients aged 25-74 years. All patients reported
dislocation or abnormal sounds during articulation, leading to Femoral Heads Following Polyethylene Articulation
revision surgery after 0.4-5.4 years in vivo. Retrieved implants Jack E Lemons, PhD, Birmingham, AL
were analyzed with optical and scanning electron microscopy, Alan Eberhardt, PhD, Dr., Birmingham, AL
and Fourier Transform Infra-Red spectroscopy. The fractures of all Travis R McKee, MS,
components had a similar location along the rim. All four John M Cuckler, MD, Birmingham, AL
implant fractures exhibited initiation sites associated with

Donald R Peterson, PhD,
locking or stress concentrating features on the outside of the
Preston Beck, MS, Birmingham, AL
acetabular liner rim. The initiation sites have a clamshell appear-
ance, indicating that incubation of the cracks occurred prior to Metallic transfer may result from contact of femoral heads with
their propagation. The shapes of these fractures imply that the edge of metallic acetabular shell components following
femoral neck impingement may be a driving force for the failure. dislocation and from the presence of metallic debris in the artic-
No significant oxidation was observed. Fractures of conventional ulation zone. Previous retrieval studies showed increased surface
UHMWPE acetabular liners have not been considered to be a roughness and accelerated polyethylene wear following such
clinical concern despite a relatively high rate of impingement that transfers. Most of these studies were of alumina femoral heads;
is know to occur during in vivo use. Highly cross-linked- less has been reported related to heads made of cobalt
UHMWPE is more susceptible to fracture, and our findings indi- chromium (CoCr) or zirconia (ZrO2). Surface roughness was
cate that the fractures typically occur along the rim where the measured on sixteen retrieved femoral heads (6 CoCr, 10 ZrO2)
liner is relatively unsupported by the metal shell. Sharp corners that showed evidence of metallic transfer. Metallic transfer was
or large concave features in the liner rim may further increase the intentionally induced on control heads (3 CoCr and 3 ZrO2),
risk of catastrophic failure, even at low (50 kGy) doses. which were then articulated against ultra-high molecular weight
polyethylene (UHMWPE) disks for 100,000 cycles at roughly 25
PAPER NO. 023 MPa. Significant increases in average roughness and root mean
square were observed for transfer regions as compared to never
Analysis of Retrieved Cross-linked Polyethylene implanted controls. Average skewness was positive for explanted
Bearings CoCr and ZrO2 heads with transfer, indicating a landscape of
Barbara H Currier, MChE, Hanover, NH peaking asperities. Increased UHMWPE wear resulted for all
Douglas Van Citters, PhD, Hanover, NH femoral heads with metallic transfer as compared to unaltered
John H Currier, MS, Hanover, NH controls. Roughness and skewness of transfer regions following
wear testing remained two orders of magnitude higher for both
Kimberly A Lyford, BA, Hanover, NH
CoCr and ZrO2 heads with transfer, as compared to controls.
John P Collier, DE, Hanover, NH Metallic transfer was associated with increased roughness on
Michael B Mayor, MD, Hanover, NH retrieved CoCr and ZrO2 femoral heads and on heads with
Highly cross-linked UHMWPE has rapidly become the material induced metallic transfer following polyethylene articulation.
of choice for acetabular polyethylene bearings. Each manufac-
turer markets a unique formulation, with significant differences
These results suggest that metallic transfers are mechanically ated for wear by one observer blinded to all clinical results and
stable on CoCr and ZrO2 femoral heads during UHMWPE artic- polyethylene liner type, using a validated computer assisted edge
ulation and may adversely influence UHMWPE wear. detection method. At an average follow-up of 6.0 years, neither
group shows significantly higher Harris Hip, SF-12, Activity or
PAPER NO. 025 WOMAC scores at any interval. Wear analysis began on six week
Wear Rate of Highly Cross-Linked Polyethylene in and one-year interval x-rays, allowing for an assessment of the
bedding-in phenomenon during the first year. There is a statisti-
THR: A Prospective RCT at 5 Years Minimum cally significant difference in wear rates at an average follow-up
Follow-Up of 6 years, with a 2-D wear rate of 0.16±0.62 mm/yr for the
Richard W McCalden, MD, London, ON Canada conventional group and a 2-D wear rate of 0.01±0.26 mm/yr for
Steven J MacDonald, MD, London, ON Canada the crosslinked group. This represents a 93 percent reduction in
Robert Barry Bourne, MD, London, ON Canada wear rate with the crosslinked polyethylene (p=0.002). At early
follow-up, there are no clinical differences. There is a statistically
Cecil H Rorabeck, MD, London, ON Canada
significant wear reduction of 93 percent with highly crosslinked
David Gordon Chess, MD, London, ON Canada polyethylene at 6 years follow-up. Longer follow-up will be
Kory Charron, London, ON Canada needed to demonstrate the continued wear reduction afforded
This study reports on the clinical and wear performance of a by highly crosslinked polyethylene.
prospective RCT comparing highly cross-linked (XLPE) to
conventional polyethylene (PE) in total hip arthroplasty at five PAPER NO. 027
years minimum follow-up. All 100 patients received identical
hybrid total hip arthroplasties except that 50 patients received a
◆Serum Ion Level After Metal-on-Metal Total Hip
PE liner (2.5 Mrads gamma-in-nitrogen sterilization) and 50 Arthroplasty in Patients With Renal Failure
patients received a XLPE liner (10Mrads; gas-plasma steriliza- Taek Rim Yoon, MD, Jeonnam, Korea, Republic of
tion). Clinical outcomes (Harris Hip, WOMAC and SF-12) were Eun Kyoo Song, MD, Kwangju, Korea, Republic of
determined by an independent study nurse. Steady-state femoral Jong-Keun Seon, MD, Lexington, MA
head penetration rates (after bedding in; i.e. years 1 to 5) were Sang Gwon Cho, MD,
determined using a validated radiographic technique (Hip
Chang-Ich Hur, MD,
Analysis Suite 8.0.1.1) for both the entire polyethylene group
and on each patient. At average follow-up of 6.0 years (range 5.1-
Min-Sun Choi, MD,
6.8 years), there were no differences in Harris Hip, WOMAC or Young-Jin Kim, MD,
SF-12 scores. XLPE had a significantly lower (p=0.048) steady- Hyun-Jong Kim, MD,
state head penetration rate of 0.018 mm/year compared to 0.050 Young-Churl Park, MD,
mm/year for PE (approximately 64% reduction). Analysis of We retrospectively reviewed cementless total hip arthroplasties
individual patient’s head penetration rates demonstrated a with metal-on-metal bearing in 6 patients with chronic renal
similar significantly lower (p=0.029) rate with XLPE (0.004 ± failure and investigated the relations between renal failure and
0.067 mm/year) compared to PE (0.045 ± 0.083 mm/year). elevated serum cobalt and chromium levels and the adverse

Interestingly, when examined by gender, the male PE group had effects of these elevations. Serum cobalt and chromium levels
a significantly higher (p=0.007) head penetration rate (0.081 ± were measured by atomic absorption spectrophotometry at last
0.084 mm/year) than both the male and female XLPE (-0.013 ± follow-up in 6 patients with chronic renal failure and in 6
0.104, 0.011 ± 0.074 mm/year, respectively). At minimum 5 patients with normal renal function after total hip arthroplasty.
years follow-up, there was a significantly lower steady-state head Clinical evaluations were performed using Harris Hip Scores and
penetration rate with first generation XLPE compared to PE. Western Ontario and McMaster Universities Osteoarthritis Index
Long-term follow-up is required to demonstrate the clinical scores. Mean serum cobalt concentration was 10.4¼g/L in
benefit of this new material. patients with chronic renal failure and this was more than 100-
fold higher than in those with the same prosthesis type, similar
PAPER NO. 026 follow-up period, but with no known renal disease. However,
A Prospective Randomized Wear Study Comparing the mean serum chromium concentration was 5.2¼g/L and was
found to be within the normal range in all 12 study patients. At
Highly Crosslinked vs. Conventional Polyethylene four years after surgery, the overall clinical results were excellent
Michael J Anderson, MD, Milwaukee, WI in both groups and have no significant difference between both
William J Maloney MD, Stanford, CA groups. Side effects related to elevation of serum cobalt or serum
John C Clohisy, MD, Saint Louis, MO chromium concentration was not identified. The serum cobalt
Brian Joseph McGrory, MD, Portland, ME level was more higher in patients with chronic renal failure.
William B Macaulay, MD, New York, NY However, no side effect attributable to elevated levels of serum
Jimmi Mangla, MD, Chicago, IL cobalt ion was found at four years of follow-up. A longer follow-
John M Martell, MD, Chicago, IL up may be necessary.
Clinical evaluation of the wear performance of highly cross-
linked polyethylene is needed. The objective of this study is to
compare clinical and radiographic follow-up results of conven-
tional vs. highly crosslinked polyethylene. 181 candidates for
primary THA from five sites are enrolled and randomized into
one of two groups: conventional polyethylene or crosslinked
polyethylene. Patients are evaluated clinically at baseline and
post-operatively using the Harris Hip Score, SF-12 Health Survey,
UCLA Activity Score and WOMAC. Follow-up x-rays are evalu-
379
PAPER NO. 028 metals cross the placenta and elevated levels cause chromosome
changes of unknown significance underlining the need for
◆Wear and Acetabular Component Orientation in continued vigilance.
C-O-C Bearings; An Analysis of 33 Retrievals
Patrick J Lusty, MD, PAPER NO. 030
William Lindsay Walter, MD, Waverton, NSW Australia Systemic Metal Exposure in Large and Small
Michael A Tuke, Surrey, United Kingdom Diameter Metal-Metal Total Hip Replacements
Alex Watson, MD,
Hena Ziaee, BSc, Birmingham, United Kingdom
William Keith Walter, MB, Waverton, NSW Australia
Joseph Daniel, FRCS, Birmingham, United Kingdom
Bernard A Zicat, MD, Waverton, NSW Australia
Chandra Pradhan, FRCS, Brinmginham, United Kingdom
Alumina-on-alumina ceramic bearings are highly wear resistant.
Derek James Wallace McMinn, FRCS, Birmingham, United
Hip simulator studies show steady state wear of only 0.05 mm3
per million cycles. Unfortunately, retrieved specimens demon-
Kingdom
strate higher wear rates than predicted from simulator studies Large diameter metal-metal total hip replacements (MMTHRs)
and often show a visible stripe of wear. We studied 33 third offer the advantages of low wear and low dislocation risk. The
generation alumina ceramic-on-ceramic bearings retrieved from aim of this investigation is to compare metal levels in large
cementless hip arthroplasties after more than 6 months in MMTHRs with small diameter MMTHRs Whole blood concen-
service. Wear volume was measured with a Roundtest machine. trations and daily output of cobalt and chromium in 28 patients
Acetabular orientation was measured from the anteroposterior with unilateral large diameter (42 to 54mm) MMTHRs at 1-year
pelvic radiograph. The median early wear rate overall was follow-up, were compared with blood levels in patients with
0.1mm3 per year, from the heads and 0.04mm3 per year from 28mm MMTHRs at 1 to 3 years. Both bearings are made of high
the liners. We excluded hips where the components had carbon cobalt-chrome alloy, the larger bearing is as-cast and the
migrated. In this subgroup of 22 bearings, those with acetabular smaller is wrought alloy. High resolution inductively coupled
anteversion of less than 15 degrees (seven femoral heads) had a plasma mass spectrometry was used for analysis. None of the
median femoral head wear rate of 1.2 mm3 a year, compared to patients had other metal devices or compromised renal func-
0mm3 from those with anteversion of 15 degrees or more (15 tion. They had either a cemented polished tapered stainless steel
femoral heads, p <0.001). Even under edge loading, wear stem or a cementless porous ingrowth titanium alloy stem
volumes with ceramic-on-ceramic bearings are small in compar- Mean whole blood levels in the small and large diameter THRs
ison with other bearing materials. Low acetabular anteversion is are not significantly different at 1 year (cobalt, 1.7 vs 2.3 µg/l and
associated with greater wear. chromium 1.7 vs 1.4 µg/l). Daily urinary output of cobalt and
chromium in the early years in both bearings were also in the
PAPER NO. 029 same range and without a significant mean difference (cobalt
11.6µg/24hrs in large diameter and 12.3µg/24hrs in small diam-
Six-Year Prospective Study of Metal Levels in eter THRs and chromium 3.7 and 4.1µg/24hrs respectively).
Patients With a Modern Hip Resurfacing This study shows that daily output of metal ions in urine; and
Arthroplasty whole blood concentrations of cobalt and chromium are similar

in both small and large diameter bearing metal-metal total hip
Joseph Daniel, FRCS, Birmingham, United Kingdom
replacements.
Hena Ziaee, BSc, Birmingham, United Kingdom
Chandra Pradhan, FRCS, Brinmginham, United Kingdom PAPER NO. 046
Derek James Wallace McMinn, FRCS, Birmingham, United
Kingdom
◆10 Years of Experience With Metal-on-Metal
This is the first six year report of a longitudinal study of metal
Hybrid Hip Resurfacing:A Review of 1000 hips
output in urine and blood following hybrid metal-metal surface Harlan C Amstutz, MD, Los Angeles, CA
arthroplasty. Urine and whole blood specimens were collected Michel Jean Le Duff, Glendale, CA
before and periodically after hip resurfacing in 26 patients after Patricia A Campbell, PhD, Los Angeles, CA
informed consent (mean age 52.9 years, mean BMI 27.9). High- Hip resurfacing is currently the fastest growing hip procedure
Resolution Inductively-Coupled Plasma Mass Spectrometer worldwide. The present study reviewed 1000 hips in 838
analysis was used. Fourteen of the 26 were reviewed at the 6-year patients who received a hybrid metal-on-metal resurfacing at a
follow-up and had excellent hip function (mean Harris hip score single institution. The average age of the patients was 49.9 years;
89, Oxford 13). Two have had more metal work implanted 73% of the study group were male. Etiologies included: idio-
excluding them from the series. Ten others will be reviewed in pathic osteoarthritis (70%), osteonecrosis (6.5%), trauma (6%),
the next few months. Urine levels of chromium and cobalt at six developmental dysplasia (11%), childhood disorders (LCP and
years were 3.63 and 7µg/24hrs and blood levels 1.07 and SCFE - 4%), rheumatoid disease (2%) and others (0.5%). The
1.03µg/l respectively. Both urine and blood levels show a statis- hips were resurfaced irrespective of femoral defect size.
tically significant early increase reaching a peak six months to Technique changes were based on retrieval analysis and were
one year postoperatively. Later there is a steady decrease over the instituted to optimize bone preparation and initial fixation. The
following five years although the reductions are not statistically study group had a mean follow-up of 5.8 years (range: 2.0 to
significant except for blood chromium where the 4 and 6 year 11.3 years). Pre-operative UCLA pain scores improved from 3.6
levels were significantly lower than the 1-year level. The effects of to 9.6, walking from 6.4 to 9.6, function from 5.8 to 9.5, and
elevated systemic metal exposure continue to cause concern in activity from 4.7 to 7.5. SF-12 quality of life surveys improved
patients treated with metal-metal resurfacings. Our results show from 32.4 to 50.9 for the physical component and from 47.7 to
that metal release in these bearings shows a reducing trend after 53.6 for the mental component.There was no acetabular compo-
an initial peak allaying the fear that a progressive build-up of nent loosening in this series. Among the 926 hips implanted
metal occurs in the system with increasing blood levels. However with a 1mm cement mantle, 6 were converted to THR for
femoral neck fracture, 20 for femoral loosening, 2 for sepsis, 1 PAPER NO. 048
for recurrent subluxation, and 1 for a reason undisclosed by the
center where the revision was performed. Five-year survivorship
◆Early 2+ year results for Metal-on-Metal Hip
improved from 91.8% (initial 300), to 98.4% (next 300) with no Surface Replacement: A Prospective Multi-Center
failures in hips implanted since 2002. Short-term failures Study
(femoral neck fractures and early component loosening) can be Bernard N Stulberg, MD, Cleveland, OH
prevented. Complication rates were comparable to those of
Thomas P Gross, MD, Columbia, SC
conventional THR except for a lower dislocation rate of 0.9%.
Femoral component loosening was associated with inadequate
Kathy Trier, PhD,
size and quality of the fixation area. Improvements in bone Marybeth Naughton, Garnerville, NY
preparation (cleaning, drying, maximization of the bone- Significant improvements in metal-metal bearings have made
cement interface and cementing technique) significantly hybrid HSR a potential alternative for the young active patient
reduced early femoral component loosening. While good bone with end-stage hip disease. Possible advantages would include
quality yielded better results with early technique, improved greater stability, bone preservation, and decreased osteolysis.
surgical techniques have been successful in optimizing initial 1,148 metal-metal HSR procedures in 1,030 subjects were
fixation and improving short to mid-term durability. Stability is prospectively enrolled in an IDE study at 12 centers between
ensured by proper socket positioning. Longer follow-up will be 4/2001 and 5/2006. The 505 patients with minimum 2 year
essential to validate this hypothesis. follow-up are reported. 72% were males; average age 51
years;average weight 194 pounds. 89% had diagnosis of
PAPER NO. 047 OA;10% AVN. 79% of procedures were posterior approach,12%
The Biomechanical Effect of Exposed Cancellous anterior,8% lateral. Average HHS score was 50 pre-op and 97
post-op. At minimum 2 years 95% report no or only slight pain.
Bone in Hip Resurfacing Arthroplasty Complications included femoral neck fracture (2.3%), femoral
Michael Olsen, loosening (1.2%), acetabular loosening (1.0%),nerve palsy
Edward T Davis, MB,ChB, Toronto, ON Canada (.3%),dislocation (.2%), late intertrochanteric fracture (.1%),
Emil H Schemitsch, MD, Toronto, ON Canada with revisions in 3.8%. X-ray review of 281 subjects showed little
Failure to completely cover reamed cancellous bone during osteolysis. Early failure in this multi-center study was due to
impaction of the femoral component has been speculated to femoral neck fracture and early loosening. Major determinants
predispose the resurfaced femur to neck fracture. The current of success were proper patient selection and implant posi-
study examined the effect of exposed cancellous bone on the tioning. Radiographic migration was the most predictable
strength of the proximal femur in hip resurfacing arthroplasty. means of evaluating radiographic success. HSR appears to be an
Eighteen Third Generation Composite Femurs were divided into appropriate alternative for the properly selected younger and
three groups of six specimens each. The first group (Partial) was more active patient. Improved patient selection and technical
prepared with the implant placed at the native femoral head consistency will result in even higher success rates.
offset of the femur. This implant position covered reamed
cancellous bone superiorly, however it left partially exposed
PAPER NO. 049

cancellous bone elsewhere along the perimeter of the prosthesis ◆Does Metal-on-Metal Resurfacing Provide
rim. The second group (Proud) was prepared with the implant Comparable Results to Standard THA?
seated 5 mm proximal to the Partial group exposing approxi-
David R Marker, BS, Baltimore, MD
mately 5 mm of reamed cancellous bone superiorly. The third
group (Complete) was seated 5 mm distal to the Partial group
Thorsten M Seyler, MD, Winston-Salem, NC
covering all reamed cancellous bone. Implant offset for the three Mija Lee, PhD,
resurfaced groups was measured by plain digital radiographs Slif D Ulrich, MD, Baltimore, MD
and compared to that of the intact specimen. The specimens Ronald Emilio Delanois, MD, Lutherville, MD
were loaded to failure in axial compression. The implant offsets Michael Akbar, MD, Heidelberg, Germany
of the three resurfaced groups were significantly different from Michael A Mont, MD, Baltimore, MD
one another (p<0.001). The implant offset of the Partial group Recently, with the advent of improved metal-on-metal pros-
was not significantly different from that of the intact femur theses, hip resurfacing has emerged as a viable arthroplasty
(p=0.279). The Proud group (mean load-to-failure 2063 N) was option. Multiple studies have reported that greater than 90% of
significantly weaker than both the Partial (mean 2974 N, resurfacing patients have satisfactory function at short to mid-
p=0.004) and Complete groups (mean 5899 N, p=0.001) when term follow-up (2 to 7 years). While these results suggest that
tested to failure. The Partial group was also significantly weaker resurfacing may provide similar outcomes to standard total hip
than the Complete group when tested to failure (p=0.001). All arthroplasty (THA), there are few studies that have performed a
fractures were consistent within groups, initiating at the superior direct comparison. We hypothesized that, when controlling for
aspect of the neck, at the component-bone interface. This study pertinent clinical and demographic factors, resurfacing provides
provides biomechanical evidence that exposed, reamed cancel- similar results to THA. The specific questions asked were whether
lous bone significantly reduces the load-to-failure of the resur- resurfacing patients had any different clinical and radiographic
faced proximal femur. The perceived benefit of reconstructing scores, satisfaction, post-operative pain, or increased rate of revi-
the femur to its native geometry may inherently weaken the sions than standard THAs. Fifty-four hips (54 patients) that were
proximal femur if reamed cancellous bone remains exposed treated with a metal-on-metal resurfacing were matched by
following impaction of the femoral component. Failure to gender, age, body mass index, medical co-morbidities, preopera-
completely cover all reamed cancellous bone following implant tive Harris Hip score (HHS), and length of follow-up to 54 hips
impaction appears to weaken the resurfaced femur and may lead in patients who received a standard THA. In each group, there
to an increased risk of femoral neck fracture in hip resurfacing. were 36 men and 18 women who had an average age of 52 years
and an average BMI of 29. The average preoperative HHS was 52
381
points and 50 points in the resurfacing and THA groups, respec- This study could not show a significant superior functional
tively. Each group had 51 hips with osteoarthritis and 3 hips with outcome for hip resurfacing when compared with total hip
avascular necrosis. Patients were followed both clinically and replacement.
radiographically for a mean of 39 months (range, 24-60). Patient
satisfaction and pain scores were numerically evaluated at final PAPER NO. 051
follow-up. Resurfacing hips were comparable to standard THA ◆Influence of Athletic Activities on Metal-on-Metal
with no significant differences in clinical and radiographic
outcomes. At final follow-up, mean HHS scores were 90 points
Hip Resurfacing Arthroplasty Outcomes
and 91 points for the resurfacing and THA groups, respectively. David R Marker, BS, Baltimore, MD
Although not statistically significant, the resurfacing patients Thorsten M Seyler, MD, Winston-Salem, NC
reported slightly higher satisfaction (9.2 versus 8.8 points) and Slif D Ulrich, MD, Baltimore, MD
lower pain scores (1.4 versus 1.6 points). The major complication Ana L Martimbianco, PT,
rates (5.6% for resurfacing, 7.4% for THA) and re-operation rates Ronald Emilio Delanois, MD, Lutherville, MD
(3.7% for resurfacing, 3.7% for THA) were similar. The two resur- Michael A Mont, MD, Baltimore, MD
facing revisions were due to a femoral neck fracture and acetab-
Many patients who receive metal-on-metal total hip resurfacing
ular component loosening. In the THA group, the cause for
arthroplasties desire to return to active lifestyles. While there are
failure was a periprosthetic infection and an acetabular cup
a number of studies that report on sports activity following
aseptic loosening. The groups demonstrated similar radiographic
conventional THA, there are few studies that specifically report
outcomes with no progressive radiolucencies. Despite potential
on the outcomes in patients receiving resurfacing. This study
advantages for resurfacing such as conservation of femoral bone
characterized the sports activity of a prospective cohort of resur-
stock and enhanced stability, it remains controversial whether
facing patients and assessed whether there is a relationship
this treatment modality provides functionality and patient satis-
between the level of sports activity and the clinical and radi-
faction similar to that of standard THA. The results of the present
ographic outcomes. Pre- and post-operative questionnaires were
study show that the early results (2 to 5 years) for resurfacing
utilized to prospectively collect activity data (hours and types of
were excellent and comparable to those found in patients with
sports) from 205 metal-on-metal resurfacing patients who had
standard THA. Although these early results are encouraging, we
surgery at between December 6, 2000 and April 1, 2006. There
await long-term results to further evaluate the efficacy of metal-
were 154 men and 51 women who had a mean age of 55 years
on-metal total hip resurfacing.
(range, 20 to 81 years). In addition to analyzing the frequency of
PAPER NO. 050 athletic activity, we utilized an activity score, which weights the
hours of activity each week by the intensity level of the activity,
Gait Analysis Comparison of the Functional to evaluate sports participation. Pre- and post-op activity levels
Outcome of Hip Resurfacing and Total Hip were compared using a Signed Rank test. Outcome measures
Replacement collected at a mean follow-up of 3 years (range, 1 to 7 years)
included Harris Hip scores (HHS), patient satisfaction, and SF-
Andrew John Shimmin, MD, Windsor, Victoria Australia 12 scores. Linear regression analysis and Pearson¢s coefficient
Kim Bennell, PhD,
were used to assess the correlation between the number of hours

Tim Wrigley, MSc, of weekly athletic activity and these various outcome measures.
Boon Whatt Lim, BS, Overall, the weekly athletic activity of this prospective cohort of
Ben Metcalf, B,PT, patients increased by 2 hours from the year prior to surgery to
Stephen Graves, MD, Adelaide, South Austalia Australia final follow-up (p < 0.001). Similarly, the weighted activity score
There has been a recent resurgence of hip resurfacing arthro- showed significant increases (p = 0.003). The most common
plasty using metal on metal articulations. New metallurgy, sports following surgery were low impact activities such as
reproducible manufacturing and updated surgical techniques weight lifting (n = 100) and stationary biking (n = 82), but there
has lead to favorable short term results. Possible advantages of were also many patients who reported participating in high
hip resurfacing arthroplasty including restoration of normal impact sports such as jogging (n =24), singles tennis (n = 17),
biomechanics leading to improved function and gait. Evidence and basketball (n = 12). At final follow-up, the mean Harris Hip
in the literature substantiating these advantages is lacking. This score was 92.7 points, patient satisfaction was 8.7 out of 10
study’s focus was a comparative analysis of function of hip resur- points, and the SF-12 mental component score (MCS) and phys-
facing and total hip replacement. This included both a gait and ical component score (PCS) were 56 and 52 points, respectively.
a radiological biomechanical analysis. Three groups of patients There was a significant positive correlation between hours of
were included in this study.(two surgical and one control). activity and HHS, satisfaction, and PCS with respective
Group A was a cohort of 12 well functioning total hip replace- Pearson¢s coefficient values of 0.23, 0.16, and 0.18. When
ments, group B was a cohort of 14 well functioning hip resur- controlling for age, body mass index, gender, and diagnosis,
facing patients. Patients in both surgical groups had a Harris Hip hours of activity remained a predictor of HHS and satisfaction
Score of 100 and a radiologically and clinically normal contra- but was no longer significant for PCS. Hours of sports activity
lateral hip. The control group was of age matched subjects with did not show a significant correlation with the MCS in either
bilaterally asymptomatic hip joint function.Gait analysis was univariate or multivariate models. Resurfacing patients are
performed using 3D motion analysis(Vicon) at fixed(1.5m/s), returning to a more active lifestyle following surgery. It impor-
fast walking and jogging pace. Both Kinetics and kinematics of tant for surgeons to understand how this increased activity may
the hips were studied. Results of gait analysis showed essentially affect patient satisfaction and functional outcome. The results of
no difference between the two surgical groups nor between the the present study suggest that increased postoperative sports
either surgical groups and the control groups. In neither of the activity is directly correlated to increased patient satisfaction and
surgical groups could we demonstrate a difference between the HHS. However, caution is still recommended by the authors
replaced or resurfaced hips and the normal contralateral hip. against high impact sports such as soccer and basketball. The
authors will continue to follow this patient cohort to see if these (reducing micro separation of the bearing during activities).
excellent results can be maintained and not affect prosthetic Enhanced proprioception due to the retained femoral neck may
longevity. also be involved in the bias towards SRA. Further follow-up is
will determine if higher activity level is detrimental to implant
PAPER NO. 052 survivorship
◆Early Return to Function After Hip Resurfacing. Is
PAPER NO. 054
it Better Than Contemporary THA?
The Role of Surgical Approaches for Preservation of
Bernard N Stulberg, MD, Cleveland, OH
Stephanie M Fitts, PhD, Mahwah, NJ Femoral Head Blood Supply During Hip Resurfacing
Ashlea Bowen, AS, Tampa, FL Robert T Steffen, MD, MRCS, Oxford, United Kingdom
Patients often request hip resurfacing believing that it will afford Kieran S O’Rourke, MD, Dublin D4, Ireland
them an earlier return to function than conventional hip Koen Aime DeSmet, MD, Heusden, Belgium
replacement. Our hypothesis was that young patients under- Darren Fern, FRCS,
going resurfacing total hip arthroplasty (THA) with metal-on- Mark Norton, MD, Plymouth, Devon, United Kingdom
metal (MOM) bearings or contemporary THA with ceramic Peter McLardy-Smith, FRCS, Oxford, United Kingdom
bearings will have comparable return of function by 24 months. Barbara Marks, Oxford, United Kingdom
Results from 337 unilateral hip resurfacing patients enrolled in Harinderjit Singh Gill, PHD, Oxford, United Kingdom
an IDE study from a total cohort of 1148 hips were compared to
David W Murray, MD, Oxford, United Kingdom
results from 266 unilateral patients with ceramic-on-ceramic
bearings that had similar baseline characteristics and follow-up Avascular necrosis of the femoral head after resurfacing hip
patterns. For this report, extensive evaluation of prospectively replacement is an important complication which may lead to
assessed Harris Hip Scores (HHS) was performed. At the 24 fracture or failure. The surgical approach may affect the blood
month follow-up, the HHS scores were indistinguishable supply to the femoral head. We compared the changes in
between groups. At earlier time-points, however, differences were femoral head oxygenation resulting from the extended posterior
observed. At 6 weeks, the total HHS for the resurfacing group approach to those resulting from the anterolateral approach, the
was statistically worse than the total hip control group; a result trochanteric flip approach and a modified, soft tissue preserving
of the resurfacing group reporting more ‘slight pain’ than the posterior approach. We recruited 48 patients who underwent
controls. At the 6 month visit, however, the total scores were hip resurfacing arthroplasty (HRA) to measure bone oxygen
higher for the resurfacing group due to advantages in the func- levels. A calibrated gas-sensitive electrode was inserted in the
tion sub-score. The trend continued at the 12 month visit, femoral head following division of the fascia lata. Intra-opera-
however, statistical significance was not reached. All differences tive X-ray confirmed correct electrode placement. Baseline
faded by the 24 month post-surgery time-point. Resurfacing oxygen concentration levels were recorded immediately after
patients report slightly more pain at 6 weeks than the total hip electrode insertion and continuous measurements were then
patients, but exhibit better HHS largely due to better function at performed throughout surgery. All results were expressed relative
6 and 12 months post surgery. These differences disappear by to the baseline, which was considered as 100% relative oxygen

the 24-month time point when both groups report HHS in the concentration and changes during surgery through the posterior
excellent range. approach (n=10), the antero-lateral approach (n=12), the
trochanteric flip approach (n=15) and the modified posterior
PAPER NO. 053 approach (n=11) were compared. The relative oxygen concentra-
tion at the end of the procedure was significantly reduced when
◆Return to Sports After Hip Resurfacing and Total hip resurfacing was performed through the posterior approach
Hip Arthroplasty: A Randomized Clinical Trial (22%, SD 31%, p<0.005), but recovered in the anterolateral
Martin Lavigne, MD, Montreal, QC Canada (123%, SD 99%, p=0.6) and trochanteric flip group (89%, SD
Vincent Masse, MD, Montreal, QC Canada 62%, p=0.5). Sub-group analysis showed that intra-operative
Alain Roy, MD, Montreal, QC Canada oxygen concentration was significantly more consistent during
surgery through the trochanteric flip approach (p<0.02). The
Pascal-Andre Vendittoli, MD, Montreal, QC Canada
modified posterior approach was less damaging than the stan-
Return to high activity level has been proposed has an advantage dard posterior, however the final measurements were unreliable
of hip resurfacing (SRA) compared to THA. However, patient because of lesser trochanter suction. This study has demon-
selection for SRA favours higher demand individuals, thus strated that disruption of blood flow to the femoral head during
leading to a biased comparison of both techniques. Patients HRA is dependent on the surgical approach. We therefore
were randomized to THA or SRA. At minimum one year follow- believe that blood supply preserving approaches (i.e. anterolat-
up, the patients were asked about the activities they have eral, trochanteric flip or modified posterior approach) may be
resumed, the level of satisfaction regarding return to sports and associated with a lower risk of avascular necrosis and femoral
the factors limiting full return to intense activities. 80 THA and neck fracture.
85 SRA with a mean follow-up of 16 months were analyzed. The
postoperative UCLA activity score was significantly higher in the
SRA group (6.3 versus 7.1, p<0.05). 77% of the SRA patients
returned to high or moderate activity level vs 39% in the THA
group (p=0.007). In the THA group, the activity level was mostly
restricted due to concern about instability. However, some THA
patients were still able to perform high demand activities. This
study suggests that SRA allows return to higher activity level
when compared to THA. This may be due in part to the larger
diameter head of SRA which improves stability and suction-fit
383
PAPER NO. 055 were significantly higher in the SRA group. This randomized
The Biomechanical Effects of Superior Neck study shows that SRA and THA present similar functional results,
patient satisfaction and complication rates after 2-5 years of
Notching and Varus Alignment in Hip Resurfacing implantation. However distinctive relative complications
Nicolas Noiseux, MD, Iowa City, IA occured in both groups. Long term follow up is necessary to
Robert T Trousdale, MD, Rochester, MN determine the survivorship of SRA over the THA.
Fazel Khan, MD, Rochester, MN
William Long, MD, New York, NY PAPER NO. 057
Laura Hansen, BSc, ◆Metal-on-Metal Hip Resurfacing: Radiographic
Notching of the superior femoral neck and varus implant orien- Evaluation Techniques
tation have been implicated as significant causes of femoral neck William R Kennedy, MD, Sarasota, FL
fracture following surface replacement of the hip. To date, only William L Jaffe, MD, New York, NY
observational clinical series of fractured resurfacings have
Rama Ramakrishnan,
reported this association. The purpose of this study was to eval-
uate the biomechanical effects of superior neck notching and Richard Sharp, Gloucestershire, United Kingdom
varus alignment in hip resurfacing. Matched pairs of cadaveric The release of hip resurfacing devices to the US market will
proximal femora were fitted with a hip resurfacing. One spec- require a new radiographic evaluation procedure due to femoral
imen from each pair was randomly assigned to receive a 3-5 mm components either with short stems or no stems. Fourteen US
notch at the superior neck or have the implant placed in ~10 surgeons implanted 1148 metal-on-metal Hip Resurfacing
degrees of relative varus. The contralateral resurfaced femur Systems in an US-IDE clinical trial, which began in 2001. 392
served as a control, ensuring no notch or varus in the prepara- patients (441 procedures, mean age 49.5 years) were enrolled as
tion. A compressive load was applied to the femurs and peak a primary group in the multicenter, prospective study. All
load to failure and energy to failure were compared for notched patients received the same cementless Cobalt Chrome acetab-
and varus pairs. In the notched group, there was not a significant ular shell with plasma sprayed titanium and HA coating. A
difference in the load to failure (-4%) or energy to failure (-6%) cemented Cobalt Chrome femoral head was used. The radi-
between resurfaced femoral heads with a superior neck notch ographs were digitized and analyzed in terms of osteolysis,
and those without a notch. In the varus group, a significant migration and loosening of both components. Radiographs of
decrease in peak load to failure (-23%) and in energy to failure 286 procedures at a minimum two-Year follow-up (mean 2.2
(-38%) was associated with varus alignment. In a biomechanical Years) were available for review. There were 44 revisions reported
loading test, varus implant orientation significantly decreased among the 1148 Hip Resurfacing procedures performed (3.8%).
the force and energy required to produce a periprosthetic frac- There were thirteen other patients with radiographic evidence of
ture in hip resurfacing, whereas notching of the superior femoral femoral component instability beyond 2 years. Instability was
neck did not. Thus, although a notch is never recommended, it evidenced by femoral subsidence > 5mm and tilt >5 degrees. Ten
may be more tolerable than varus placement. out of twelve patients did not have clinical symptoms associated
with femoral component instability. Inconsistencies in patient
PAPER NO. 056 positioning on the radiographic table could result in apparent
rotation of femoral component in serial radiographs.
◆A Randomized Study Comparing Surface Positioning of patients in a consistent manner and identification
Replacement Arthroplasty to Total Hip Arthroplasty of repeatable landmarks on the radiographs are crucial in evalu-
Martin Lavigne, MD, Montreal, QC Canada ating component position in hip resurfacing procedures.
Pascal-Andre Vendittoli, MD, Montreal, QC Canada Computer assisted measurements are more precise than manual
Alain Roy, MD, Montreal, QC Canada methods.
Daniel Lusignan, RN, Montreal, QC Canada
PAPER NO. 058
Total hip arthroplasty (THA) is a well established and docu-
mented surgical procedure with known complication rates and ◆Range of Motion After Hip Resurfacing and THA:
expected clinical results. By preserving the hip anatomy and A Single-Blind Randomized Clinical Study
biomechanics, surface replacement arthroplasty (SRA) may offer Martin Lavigne, MD, Montreal, QC Canada
additional clinical advantages in comparison to the THA. Sophie Mottard, resident, MD, St-lambert, QC Canada
Despite the enthusiasm regarding SRA, there is no direct
Julien Girard, Lille, France
prospective comparative study with THA published in the litera-
ture. 210 hips (107 SRA and 103 THA) were randomized to Pascal-Andre Vendittoli, MD, Montreal, QC Canada
receive uncemented metal-on-metal (MOM) THA or a hybrid Restoration of normal ROM has been proposed as an advantage
MOM SRA. All surgeries were performed by three contributing of hip resurfacing (SRA) over THA and is due to the use of larger
surgeons, each using a posterior approach. Perioperative and diameter femoral heads. However, the head-neck diameter ratio,
post-operative data were prospectively collected. Minimum 2 which is an important factor governing ROM, would in theory
years follow up clinical results were analyzed. Post operative allow more ROM with THA (28mm head/14mm neck = ratio
complications included 3 isolated traumatic and 1 recurrent 2:1) versus SRA (approximate ratio 1.3-2.0:1). Patients were
dislocations in the THA group needing acetabular cup revision randomized between SRA and THA. Osseous landmarks were
and 2 SRA went to revision for late head collapse. No post-oper- identified with a marker pen. Both ASIS served as the reference
ative femoral neck fracture occurred in the SRA group. Length of line for the pelvis position. Digital photographs of hip motion
stay in hospital was significantly shorter for the SRA group (5.0 were taken and a blinded rater (with respect to the side and type
vs 6.1 days, p=0.001). Patients in both groups demonstrated a of surgery) performed range of motion testing on the operated
very high satisfaction rate and achieved similar functional scores and normal side. Pre-study validation of ROM measurement
(WOMAC and Merle d’Aubigné). Hip range of motion was also method with a software program revealed high intra and inter
similar for both groups. Heterotopic ossification rate and grades observer reliability. 60 SRA and 62 THA were evaluated at
minimum follow-up of 12 months. Preoperative ROM and weight was 188 lbs ( range 89-350 lbs) and height was 67 inches
demographic data were similar for both groups. No significant ( range 49-81 inches). There were 620 females and 561 males.
differences (p>0.05) were found in the total arc of motion Head sizes utilized were 28 mm (30%), 32 mm (26%) and 36
(SRA=204.2°, THA=196.5°), arc of rotation (SRA=47.7°, mm (44%). Surgical approaches included: 2 anterior, 107
THA=44.3°), flexion-extension arc (SRA=118.1, THA=120.1), antero-lateral, 113 posterior, 917 postero-lateral and the
abduction-adduction arc (SRA=43.1°, THA=42.9°). In theory, remaining were classified as ‘other’. At an average of 27 months
ROM should have been greater in THA. Fear of instability may follow-up (range 0-73 months) 18 hips had dislocated (1.5%).
have limited ROM recovery potential in THA. Since pre operative Dislocation rates in the series were 3.7% for the 28 mm heads
soft tissue contracture is an important factor influencing post (13 out of 358 hips), 1.2% for the 32 mm heads (4 out of 308
operative ROM, the complete capsular release performed during hips) and 0.2% for the 36 mm heads (1 out of 515 hips). The
SRA may have been an advantage of this technique. larger head sizes demonstrated increased stability with a statis-
tical trend of superior stability of the 32 compared to the 28 (p=
PAPER NO. 059 0.082) and the 36 mm head was significantly more stable
◆Prevalence of Groin Pain after Hip Resurfacing compared to the 28 mm head (p<0.0001). These results were
confirmed individually for the postero-lateral approach and
Ahmad Bin Nasser, MD, Verdun, QC Canada
pooled findings from the other surgical approaches. In this large,
Michelle Elyse O’Neill, MD, Halifax, NS Canada multicentered study, we found decreasing dislocation rates with
Paul R Kim, MD, Ottawa, ON Canada increasing femoral head sizes and 36 mm heads decreased risks
Paul E Beaule, MD, Ottawa, ON Canada of dislocation regardless of surgical approaches used.
The prevalence of groin pain/iliopsoas tendonitis following hip
resurfacing is unknown. Recent literature showed 4.3% of total PAPER NO. 226
hip replacement patients would complain of groin pain/iliop- Effect of High Energy Shock Waves on Hip Joint
soas tendonitis. This study aims to determine the prevalence of
groin pain after metal on metal hip resurfacing. A total of 106
Cartilage
hips (102 patients) post resurfacing, performed by two surgeons, Susanne Wagner, MD, Munchen, Germany
were evaluated at a mean followup of 18.8 months (range 6-60). Judith Ernst, Med Student,
The mean age was 48 years old (range 23-65), 85% were male. Markus Maier, MD,
Patients were questioned about post-operative groin pain in Peter E Mueller, PhD,
detail. Physical examination evaluated range of motion, Volkmar Jansson, PhD, Munchen, Germany
impingement sign and pain with resisted straight leg raise. Joerg Hausdorf, MD,
Radiographic assessment included head/neck offset, acetabular
Extracorporeal shock waves have been established as common
component uncoverage and implant fixation. Functional
mode of treatment for periarticular affections such as calcifying
outcome measures were assessed (WOMAC and RAND), and
tendinitis and epicondylitis humeri radialis and have also been
their correlation with groin pain was evaluated. 24% of patients
discussed as treatment modality for avascular necrosis of the
had ongoing groin pain. 12% reported taking analgesics and
femoral head. We were interested in the effect of high energy
11% reported limitation of activities due to pain. 5 patients

extracorporeal shock waves on hyaline cartilage of the femoral
received a cortisone injection with variable response. The preva-
head and examined hyaline joint cartilage for signs of degenera-
lence and severity of pain did not change over the followup
tion in an animal model. The results of our study show cartilage
period. Groin pain was significantly associated with physical
changes after high energy extracorporeal shock wave application
findings of impingement. No significant association was found
on hip joints which have never been reported before. An animal
with radiographic assessment, surgical approach or the surgeon.
model was used in which the right hip joint of 18 adult Sprague-
Patients reporting groin pain had significant lower functional
Dawleys rats was treated with 1500 extracorporeal shock waves
outcome scores as measured by WOMAC and RAND. Groin
of 0.5 mJ/mm2 in vivo. The left hip joint and two untreated
pain after hip resurfacing appears to be more common than after
animals served as control. Contact radiographs were taken
conventional hip replacement. The origin is likely multi-facto-
before and after extracorporeal shock wave application. At 1, 4
rial; surgical approach, implant positioning/design and reaction
and 10 weeks after treatment the animals were sacrificed.
to wear debris. Further research is required to determine predis-
Samples were fixed, decalcified and embedded in paraffin. 4 µm
posing factors as well as means to prevent it.
sections were stained with H&E and Safranin-O. For immuno-
PAPER NO. 060 histochemistry (IHC) a polyclonal antibody against rat tenascin-
C was used. Plain radiographs did not show changes of the hip
Large Femoral Heads Can Help Reduce Risk of joints treated with extracorporeal shock waves. Microscopically,
Dislocation in THR some of the hip joints 10 weeks after treatment did show a loss
James E Dowd, MD, Virginia Beach, VA of proteoglycan in the hyaline cartilage. IHC staining for
Kirk Kindsfater, MD, Fort Collins, CO Tenascin-C showed a difference in staining between the control
group and the group 1, 4 and 10 weeks after treatment. The
William P Barrett, MD, Renton, WA
hyaline cartilage of the control group from the untreated
Carleton Southworth, MS, Warsaw, IN animals showed only a slight staining of the surface. In cartilage
David F Dalury, MD, Baltimore, MD from treated animals there was an increased signal for tenascin-
Dislocation following THR remains a significant clinical C in the pericellular region of chondrocytes in all zones.
concern. The purpose of this retrospective, non-randomized According to our results Tenascin-C was found to be increased in
multi-centered study is to compare dislocation risk following hyaline cartilage of the femoral head 1, 4 and 10 weeks after high
THR using a single acetabular system and various femoral head energy extracorporeal shock wave treatment. Tenascin-C which
sizes. 1181 consecutive total hips were performed between July is an anti-adhesion molecule found in tissues undergoing
2000 and April 2006 by 16 surgeons. Pre-operative diagnosis remodeling has been shown to be increased in osteoarthritis. We
was OA in 87% of hips. Mean age was 62 years (range 18-91); conclude that high energy extracorporeal shock waves might
385
cause degenerative effects on joint cartilage. The application of II (25 hips) patients had no dfference in age, labral disease
high energy shock waves to treat avascular necrosis of the patterns, OA grade or presence of chondromalacia. Mean follow-
femoral head should be reconsidered. up was 2.3 years and 1.7 years, respectively (p 0.014). Severe
acetabular chondromalacia was more common in Group II
PAPER NO. 227 (p=0.036). At final follow-up the Harris Hip Score was higher in
Femoroacetabular Impingement: What is the Fate Group II (91 points) compared to Group I (85 points).
Good/excellent outcomes occurred in 74% of Group I and
of the Contralateral Hip? 92.0% of Group II hips. 21.7% of hips in Group I failed
John C Clohisy, MD, Saint Louis, MO (required surgery) and no hips in Group II failed (p=0.04).
Michael Dobson, BA, These data suggest that symptomatic hips with radiographic
Lucian Craig Warth, BS, Iowa City, IA features of cam FAI have improved clinical outcomes and lower
Steve S Liu, MD, Iowa City, IA failure rates when the structural impingement abnormality is
Karen Steger-May, MD, surgically corrected.
John J Callaghan, MD, Iowa City, IA
PAPER NO. 229
Femoroacetabular impingement (FAI) is a precursor to
osteoarthritis (OA) of the hip. To investigate the fate of impinge- Do Labral Lesions Occur without Femoro-
ment abnormalities we analyzed the contralateral hip in patients acetabular Impingement?
undergoing THA for advanced FAI. Our purpose was to deter- Christopher J Dy, BS, Miami, FL
mine the bilaterality of FAI abnormalities, and to describe the
Matthew Thompson, MS, Houston, TX
prognosis of these deformities. We reviewed 508 patients d50
Philip C Noble, PhD, Houston, TX
years of age treated with THA. Radiographic review identified 70
hips that had OA secondary to FAI (71% cam, 5% pincer, 24% Damage to the acetabular labrum is a well-recognized cause of
combined). Bilaterality was determined radiographically, and hip pain and a possible precursor to degenerative joint disease.
the fate of the contralateral hip was analyzed by determining However, the mechanism of labral pathology has not yet been
radiographic presence and progression of OA, and the need for defined. Ganz hypothesizes that labral pathology is almost
subsequent THA. 71% of the patients were male and the average exclusively a consequence of femoro-acetabular impingement
age was 43.2 years. The contralateral hip was analyzed on radi- (FAI), while McCarthy suggests that repetitive twisting motions
ographs over an average 9 year period (range, 4-30 years). 100% of the hip may lead to labral damage. The current study investi-
of the contralateral hips had radiographic features of FAI. 49 gates whether labral lesions occur in morphologically normal
(70%) of the contralateral hips demonstrated degenerative hips. Sixteen intact cadaveric hip joints (average age of donors:
disease. 14 had advanced OA at presentation, 41 had progressive 73.8±9.7 years; 9 male and 7 female) were dissected and exam-
joint space narrowing, 25 had progression of Tonnis OA grade ined for separations of the labrum from the anterior acetabular
and 26 underwent subsequent THA. Statistical analysis showed cartilage. Three-dimensional models of each hip joint were
that alpha angle, LCEA, joint space width, and head-neck ratio created from CT reconstructions. The potential for cam-type
have strong predictive value for subsequent THA (p<0.001). Age morphology of each femur was evaluated by matching a sphere
to the boundaries of the femoral head. Specimens with aspher-
had predictive value for progression in Tönnis OA grade

(p<0.05). This study demonstrates that FAI abnormalities are ical femoral heads were categorized as having cam-type
commonly bilateral and are associated with OA progression in morphology. The prevalence of labral lesions in donors with and
the majority of hips. Patients diagnosed with FAI should have without cam-type morphology were compared. Labral-chondral
both hips monitored, and joint preservation surgery or THA lesions were found in 10 of the 16 specimens (63%). Six of the
considered when appropriate. 10 specimens (60%) with labral pathology possessed cam-type
morphology, while the remaining 4 specimens were anatomi-
PAPER NO. 228 cally normal. There was not a significant difference in the prob-
ability of a labral-chondral lesion between specimens with or
Labral Disease Associated with FAI: Do we Need to without cam-type morphology. The current study shows that
Correct the Structural Deformity? labral lesions can occur in the absence of cam-type morphology
John C Clohisy, MD, Saint Louis, MO of the proximal femur. While FAI certainly has a role in the
Jeffrey Nepple, MD, Saint Louis, MO development of labral pathology, in some patients, an alterna-
Ryan Nunley, MD, Saint Louis, MO tive pathway must lead to labral damage, possibly acute or repet-
itive injury without mechanical impingement.
Lukas Zebala, MD, Saint Louis, MO
Anterior femoroacetabular impingement (FAI) is recognized as a PAPER NO. 230
cause of acetabular labral disease and articular degeneration. The
purpose of this study was to compare arthroscopic partial labral Femoro-Acetabular Impingement is Caused by
resection alone (Group I), and augmentation of this procedure Several Different Bony Abnormalities
with limited open osteochondroplasty (Group II) for the treat- Steven Schroder, Houston, TX
ment of symptomatic FAI. Prior to April 2003 ‘cam’ FAI disease Andrew R Ellis, BS, Houston, TX
was treated arthroscopically with partial labral resection and
Matthew Thompson, MS, Houston, TX
chondroplasty. Subsequently, the arthroscopic procedure was
Gregory William Stocks, MD, Houston, TX
augmented with a limited open osteochondroplasty to correct
the structural abnormality. We reviewed 221 hip arthroscopies. Philip C Noble, PhD, Houston, TX
Radiographic parameters were utilized to identify FAI abnor- Osteochondroplasty of the anterior head-neck junction is often
malities. Two consecutive patient cohorts were identified: Group performed to treat femoro-acetabular impingement (FAI) on the
I - arthroscopic treatment of labrum and articular cartilage, assumption that the underlying deformity is localized thick-
Group II ‘ hip arthroscopy augmented with osteochondroplasty ening of the anterior cortex. However, other morphologic abnor-
of the femoral head-neck junction. Group I (23 hips) and Group malities, including reduced anteversion, posterior slip, and
widening of the neck can all cause loss of joint motion. In this p=0,008), whereas in Tönnis 2 it was observed only in 14 cases
study we examine whether the impinging femur is a mixture of (58,3%; p=0,354). At this point no statistical difference was
each of these abnormalities, or whether each abnormality is a observed at the subsequent three years (p=0,273, p=0,377,
distinct entity, suggesting that individualized treatments may be p=0,334). Merle D’Aubigné and WOMAC scores improved
needed for successful outcomes. Sixty-six embalmed femora (30 significantly at the latest follow-up in groups A (91,3%, p=0,010)
male and 36 female, average 76 years old) were obtained from a and B (93,4,%, p=0,024). However in group C only 45,8% of
large osteologic database. Thirteen femora were morphologically the cases improved significantly (p=0,383). Surgical results of
normal and 53 were abnormal with the following primary FAI differ in patients with Tönnis stage 0 and 1 when compared
abnormalities: Cam-type FAI (Ganz) (n=15), Post-slip (n=22) with Tönnis 2. Thus it seems to be reasonable to recommend
and Retroverted (n=16). Computer models of each femur were symptomatic patients surgical treatment of FAI as early as it
generated by reconstruction of high-resolution CT scans of each appears.
femur. Multiple morphologic measurements were performed by
computer analysis allowing measurement of neck shape and PAPER NO. 232
dimensions. Morphologic differences between groups were Direct Anterior Femoroacetabular Osteoplasty:
analyzed using one-way ANOVA comparisons with Fisher’s post
hoc significance testing. Cam-impinging (FAI) femora differed
Technique and Results of a Less Invasive Approach
from Normals in terms of their smaller head-neck ratio and OSR Javad Parvizi, MD, Philadelphia, PA
(1.60 vs. 1.76, p=0.0056; 0.16 vs.0.20, p=0.0060), and larger Luis Pulido, MD, Philadelphia, PA
neck radius (0.32 vs. 0.29 ± 0.02; p=0.0036). The FAI femora Betty Picinic, BS,
also had reduced anteversion (7.6 vs. 13.3°; p=0.0002). Post- Seung Beom Han, MD, Bryn Mawr, PA
slip cases had less anterior head offset (OSR) than the FAI Femoroacetabular impingement (FAI) is recognized as an etio-
femora (0.13 vs. 0.16, p=0.0014), but identical head-neck ratios logical risk factor for hip arthritis. The potential for joint
(1.59 ± 0.12) and anterior neck radii. FAI femora had slightly preserving surgical techniques that may delay the progression to
larger alpha angles than the Post-slip femora (79.3 vs. 75.9°; early arthritis and retard the possibility of arthroplasty at a
p=0.1995). Compared to the Normal femora, the Post-slip cases young age is promising. This study intends to present the
had similar anteversion (p=0.852), but larger values of alpha surgical technique and early results of a less invasive technique
angle (p<0.0001), head-neck ratio (p=0.0029) and OSR performed through a modified Smith-Peterson approach
(p<0.0001). Retroverted femora had significantly higher neck- without hip dislocation, or arthroscopy. Using an institutional
shaft angles than the Normal cohort (p=0.0057). The Cam-type database, a total of 40 patients with radiographic diagnosis of
FAI femur has a distinct morphology defined by a spheroid femoroacetabular impingement that underwent direct anterior
femoral head centered on a globally thickened femoral neck femoroacetabular osteoplasty (FAO) were identified. The
with decreased anteversion. In contrast, femora with a post-slip patients in this cohort are young with a mean age of 31 years
deformity have a tapered anterior neck in addition to posterior (range 16 to 47 years). Preoperative and regular postoperative
displacement of the femoral head without reduction in antever- functional evaluation was performed on these patients.
sion. As each of these different deformities can cause femoro- Intraoperative diagnosis of labral tear and osteochondral lesions
acetabular impingement, a critical step in the treatment of FAI is

in the anterosuperior acetabulum was confirmed in all cases.
identification of the true nature of the underlying deformity The surgical approach provided adequate access to allow labral
prior to possible surgical intervention to avoid unsatisfactory repair and osteoplasty of the femoral neck and the acetabulum,
outcomes. whenever needed. The mean intraoperative time was 90 minutes
with a mean estimated blood loss of 100 ml. Intraoperative diag-
PAPER NO. 231 nosis of labral tear and osteochondral lesions in the anterosu-
MIS-Treatment of Femoroacetabular Impingement. perior acetabulum was confirmed in all cases. There were no
Result Analysis After 2,7 Years in 107 Patients intra-operative complications. All patients experienced a signifi-
cant improvement in function as measured by modified Harris
Manel Ribas Fernandez, MD, Bacelona, Spain
hip scores. Majority (80%) of the patients were satisfied with the
Oliver Marin-Pena, MD, Tres Cantos (Madrid), Spain outcome of the surgery. In addition, Health Survey SF-36
Basilio De La Torre, MD, Madrid, Spain showed most patients felt their health had improved signifi-
Bertram Regenbrecht, MD, cantly. One patient with underlying arthritis has required total
Jose M G Vilarrubias Guillamet, MD, Barcelona, Spain hip arthroplasty. This study presents the early results of a less
Klaus Wenda, MD, invasive surgical treatment for femoroacetabular impingement.
Surgical treatment of femoroacetabular impingement (FAI) is This ongoing study shows that the described technique seems to
becoming a worldwide current practice. We analyse if clinical be a viable approach for treatment of this painful condition in
and functional results are influenced by preoperative degenera- the young.
tive hip changes. 107 FAI operated hips in 105 patients with a
mean follow up of 2,7 years (range: 2 ‘ 4) were evaluated and PAPER NO. 233
divided into 3 groups according to Tönnis Scala for preoperative Acetabular Cartilage Delamination in the Hip
radiological degenerative hip stages: group A 32 patients Tönnis Lucas Anderson, PA, Salt Lake City, UT
0, group B 61 Tönnis 1 and group C 24 Tönnis 2. Impingement Julia Crim, MD,
test, Merle D’aubigné and WOMAC scores were assessed 6
Brandon Park, MS,
weeks, 3 months, 6 months and every year after operation. SPSS
10.0 software used (SPSS INC, Chicago, Ill) was used for statis-
Christopher L Peters, MD, Salt Lake City, UT
tical analysis and comparisons were performed by means of chi- Delamination of acetabular articular cartilage is a common
squared test; p<0,05 was considered to be significant. After 3 pathology diagnosed at surgery in hips with femoroacetabular
months impingement test improved significantly in 30 cases impingement (FAI). Our study analysed radiographs, MRA, and
Tönnis 0 (93,75%; p=0,012) and 58 cases Tönnis 1 (95,08%; surgical findings of patients with delamination and compared
387
them with patients without delamination in an effort to identify arthroplasty (THA) is not affected because in contrast to
predisposing factors, assess MRA diagnostic accuracy, and Sugioka`s traditional technique, the greater trochanter is not
improve diagnostic criteria. Between 2001-2006, 27/63 surgical altered.
dislocation and osteochondroplasty (SDO) were found to have
acetabular cartilage delamination. A multivariable logistic PAPER NO. 235
regression was performed to assess correlation of radiograph, Isolated Varus Hip Osteotomy in 52 Young Adults
MR and CT findings with delamination status. MRA assessments
that did not correlate with operative findings were subjected to
With Dysplastic Hips. A Mean Follow-Up 12 Years
an unblinded conspicuity assessment. Error analysis was used to PanaGiotis S Koulouvaris, MD, Athens, Greece, Greece
improve diagnostic criteria. Among patients undergoing SDO Kosmas Stafylas, MD,
the odds of having delamination was 3.7 times higher for males Theodoros Xenakis, MD, Ioannina, Greece
and 4.43 and 6.15 times higher when sagging rope sign and Great strides have been made in the field of total hip arthro-
anterior bump, radiographic indicators of femoral sided FAI, plasty, but the issue of wear and osteolysis continueto be a
were present. 16/27 delamination patients had adjacent labral problem, mostly for young adults. For this population varus
pathology while only 5 had acetabular retroversion. On rotational osteotomy still remains a viable alternative tototal hip
unblinded retrospective review of the 9 patients with delamina- arthroplasty. The purpose of this prospective study was to
tion on MRA, 3 lesions were not visible even in retrospect, while describe the indications, the technique and the functional
6 were visible on unblinded retrospective read. Male gender, outcome of an isolated varus femoral osteotomy in 52 patients
predominately femoral sided FAI, and labral pathology are char- with hip dysplasia. The study cohort consisted of 52 consecutive
acteristics associated with delamination. Delamination can be patients who,between 1990 and 2000, had been evaluated at the
observed using MRA quite adequately when characteristic find- outpatient clinic of a University tertiary care centre and had
ings noted and was most conspicuous on the sagittal fat satu- subsequently undergone varus derotational intertrochanteric
rated proton density images occurring exclusively in the osteotomy for hip dysplasia. There were 44 females and eight
anterosuperior acetabular. We believe that with continued expe- males, and the mean age was 38.12 years(29’57 years).The indi-
rience and refining of diagnostic criteria, acetabular delamina- cations for varus intertrochanteric osteotomy were superolateral
tion will be diagnosed with improved accuracy. arthritis Grade I (mild loss of the jointspace and minimum
formation of osteophytes) or grade II(small cysts in the femoral
PAPER NO. 234 head, moderate loss of thejoint space) (Tonnis classification),
◆A Modified Transtrochanteric Rotational spherical femoral head, significant coxa valga, improved radi-
ographic appearance of congruency in the new position and
Osteotomy for the Osteonecrosis of Femoral Head
aminimal abduction of 15°. The mean follow-up period was12
Taek Rim Yoon, MD, Jeonnam, Korea, Republic of years (range 5-16 years). No patient was lost to follow-up. The
Chang-Ich Hur, MD, mean time of union was 4.21 months(range 3-6 months). There
Jin-Ho Lee, MD, was no mal-unionor non-union. There was no limb shortening.
Ju-Kwon Park, MD, Two patients required total hip replacement at 8 and 9 years
after the osteotomy.Survival (failure-free) probability was 98%
Yong Jin Cho, MD,

Keun Bae Lee, Gwangju, Dong Gu Korea, Republic of at 8 years and 93% at 9 years.During the first 12 postoperative
Jae Joon Lee, MD, Gwang-ju, Korea, Republic of months 36 (67%) patients complained of fatigue limp and
minimal weakness during prolonged walking. Patients with
Myung-Sun Kim, MD, Gwangju, 8, Hak-dong, Dong-gu
dysplastic hips may have vague groin painor greater trochanteric
Korea, Republic of pain that has been treated for years as a groin or trochanteric
Kwang-Cheul Jeong, MD, Gwangju, Korea, Republic of bursitis. We believe this is the challenging point of hip
The purpose of this study was to assess the clinical and radi- osteotomy. Following a complete evaluation of the patients it is
ographic results modified transtrochanteric rotational difficult to persuade them that they need this type of recon-
osteotomy (MTRO) for the osteonecrosis of the femoral head. A structive surgery to prevent osteoarthritis.Although a pelvic
MTRO was performed in 43 hips with osteonecrosis. The mean osteotomy may be a more rational procedure for this group of
age was 34.3 years (range, 20 to 51 years). According to the clas- patients, we believe that the varus femoral osteotomy if the
sification system of the Association Research Circulation above indications are adhered remains a simple and safe proce-
Osseous, 17 hips were classified as stage 2 and 26 as stage 3. We dure with low morbidity.
performed simple MTRO in 15 cases, combination of MTRO
and simple bone grafting in 3, and combination of MTRO and PAPER NO. 236
muscle pedicle bone grafting in 25. At a mean 36.6 months after Ischial Spine into the Pelvic Cavity: A New Sign for
surgery, there was further collapse of the femoral head in 3. All
these lesions were in lateral location, and 2 of which were large Acetabular Retroversion on Plain Radiographs
lesion. One of these 3 hips was converted to THA. The overall Fabian Kalberer, MD, Zurich, Sweden
survival rate was 93 percent. Among the survived 40 cases, excel- Rafael J Sierra, MD, Rochester, MN
lent results were obtained in 26 hips, good in 11, fair in 3. Of Sanjeev Madan, Southhampton, United Kingdom
three cases with progression of necrosis 2 hips obtained fair and Dominik Christoph Meyer, MD, Zurich, Switzerland
1 hip poor. The MTRO for the osteonecrosis of the femoral head Balz Isler, MD, Wintertur, Switzerland
appears to be effective in delaying the progression of collapse of
the femoral head. Particularly, advantages of MTRO have that no
greater trochanter fixation is needed, operation time is short- Michael Leunig, MD, Zurich, Switzerland
ened, early rehabilitation is possible, and subsequent total hip Femoroacetabular impingement is now considered a pre-
arthritic hip condition. It frequently occurs in patients with
subtle anatomic abnormalities of the acetabulum, acetabular
retroversion, which is seen as the cross-over sign (COS) on stan-
dard x-rays. The objective of this study is to assess the correlation PAPER NO. 238
between the COS and an easily visible landmark which is the Rotational Acetabular Osteotomy with Resection of
ischial spine within the pelvic cavity, and to discuss its possible
implications in the diagnosis and management of patients with Acetabular Edge for Advanced Stage Osteoarthritis
acetabular disorders. The AP pelvic x-rays of 1010 patients who Kunihiko Okano, MD, Nagasaki, Japan
were seen at the authors’ institution for a painful hip over a 16 Hiroshi Enomoto, MD, Nagaski, Japan
year period were reviewed. Those x-rays that did not meet stan- Makoto Osaki, MD, PhD, Nagasaki, Japan
dardized criteria were excluded leaving 149 AP radiographs (298 Hiroyuki Shindo, MD, Saitama, Japan
hips) for analysis. The COS, indicative of acetabular retroversion,
Postoperative joint congruency was reported to be important in
was recorded for each hip. An easily visible landmark, the
predicting the results of rotational acetabular osteotomy (RAO).
prominence of the ischial spine (PRIS) into the true pelvis was
The purpose of this study was to examine the results of RAO
also recorded and measured. Interobserver and intraobserver
with resection of the lateral acetabular edge to obtain good
variability was assessed. The presence of the PRIS as diagnostic
congruency. RAO with resection of the lateral acetabular edge
of acetabular retroversion showed a sensitivity of 91% (95% CI:
was performed in 14 patients (14 hips) with a mean follow-up
0.85 to 0.95%), a specificity of 98% (95% CI: 0.94 to 1.00%), a
of 6.7 years (resection group). 54 patients (57 hips) with a mean
positive predictive value of 98% (95% CI: 0.94 to 1.00%) and a
follow-up of 9.1 years were treated by RAO only (non-resection
negative predictive value of 92% (95% CI: 0.87 to 0.96%). There
group). All patients had radiographic evidence of advanced-
was good and very good interobserver and intraobserver relia-
stage osteoarthritis. Clinical and radiological results were
bility for measurements of the COS and PRIS, respectively. The
compared between the two groups. Radiologically, this proce-
highly relevant direct correlation between the PRIS and the COS
dure produced adequate improvement regarding femoral head
demonstrates that retroversion is not only a periacetabular
coverage in both the groups. The average postoperative Merle
phenomenon, but that the affected inferior hemipelvis is retro-
d’Aubigne and Postel’s total hip joint score was better than the
torted entirely. These patients do not truly have a hypoplastic
average preoperative score only in the non-resection group (P <
posterior wall or prominence of the anterior wall, and this
0.001). In the resection group, all hips exhibited progressive
finding may influence management of acetabular disorders.
osteoarthritic change, and 10 hips were observed to have chon-
drolysis or a collapse of the transferred acetabulum at follow-up.
PAPER NO. 237
In the non-resection group, osteoarthritic stage improved in 18
Combined PAO and Proximal Femoral Osteotomy hips, was unchanged in 24 hips, and progressed in 15 hips at
for the Treatment of Severe Hip Dysplasia follow-up. Our findings show that resection of the lateral acetab-
Ryan Nunley, MD, Saint Louis, MO ular edge is not a useful procedure in addition to RAO for the
treatment of advanced coxarthrosis.
Perry L Schoenecker, MD, Saint Louis, MO
John C Clohisy, MD, Saint Louis, MO PAPER NO. 239
Severe hip dysplasia in skeletally mature patients represents a
complex pathoanatomy involving both the acetabulum and
Long-Term Results Following Bernese Periacetabular
proximal femur. The optimal method of surgical correction for Osteotomy and Predictors of Clinical Outcome

these deformities remains controversial. In this study we Travis Matheney, MD, Boston, MA
analyzed the clinical and radiographic results of combined peri- Young-Jo Kim, MD, Boston, MA
acetabular osteotomy (PAO) and proximal femoral osteotomy David Zurakowski PhD, Boston, MA
in the treatment of severe hip dysplasia. 23 hips in 22 patients Catherine Matero, BA,
were analyzed. The average patient age was 22.2 years, nine were
Michael B Millis, MD, Boston, MA
male, thirteen emale, and the clinical follow-up averaged 4.1
years. No patients were lost to follow-up. The Harris hip score The Bernese Periacetabular Osteotomy (PAO) is a procedure
was used to assess clinical results. Standard radiographic analysis commonly used for treating hip dysplasia. Our goal was to
was performed. Average Harris hip scores increased from 65.5 assess >5 year results following PAO in hips with painful
preoperatively to 91.2 at follow-up (p=0.002). 16 hips had an dysplasia to demonstrate clinical and radiographic outcome.
excellent result, 3 hips good, 3 hips fair, and 1 hip a poor result. From these results, we constructed an algorithm to predict like-
21 patients (22 hips) were satisfied with their result. lihood of hip preservation from total hip arthroplasty (THA)
Radiographic analysis demonstrated an average improvement of and improve surgical decision-making. Of 189 hips (157
28.8 degrees (p<0.0001) in the lateral center-edge angle, 35.9 patients) that underwent PAO by a single surgeon from May
degrees (p<0.0001) in the anterior center edge angle, and 19.7 1991 to September 1998, 160 (in 135 patients, 84%) were
degrees (p<0.0001) in the acetabular inclination. The hip joint located and retrospectively reviewed. Hips were evaluated using
center was translated medially an average of 7.1 mm. All the WOMAC pain subscale and radiographs taken pre- and post-
osteotomies healed. The osteoarthritis grade was unchanged in operatively and at one and greater than 5 years. Logistic regres-
20 hips and progressed one grade in 3 hips. None of the hips sion, Kaplan-Meier (K-M) survivorship, and Receiver-Operator
have required total hip arthroplasty. Major complications Characteristic (ROC) curves were constructed. 140 (87%,ave age
included on transient sciatic nerve palsy. Combined periacetab- 24.5 yrs) hips were preserved at a mean of 9 years. Their average
ular osteotomy and proximal femoral osteotomy achieves reli- WOMAC pain score of 4 out of 20 (good to excellent). 20 hips
able deformity correction and good clinical results for severe (12.5%,ave age 33.5 years) underwent THA at a mean of 6.1
dysplastic hip deformities. years after PAO. K-M survivorship from THA was 83% at 10 years
after PAO (95% CI: 79-88%). Multiple logistic regression
analyses identified 3 independent predictors of failure to THA:
(1) Age > 35;(2) pre-operative fair or poor joint congruency; and
(3) minimum joint space width <2mm. Probability of THA was
summarized as 4.7% (0 predictors), 8.0% (1 predictor), 66.9%
(2 predictors), and 99.8% (3 predictors). ROC analysis indicated
389
good to excellent diagnostic performance of these multivariate At last follow-up, the average Harris Hip Scoreincreased from
predictors in identifying failure of PAO to THA. Bernese periac- 19.3 to 69.0 in the control group versus 19.7 to 75.2 in the study
etabular osteotomy was an effective joint-preserving treatment group (P > 0.05). The average leg length discrepancy was 2.6 cm
for painful, dysplastic hips with the majority having minimal to in the control group and 1.5 cm in the study group (P < 0.05).
no pain after surgery. Age greater than 35, joint incongruity, and The patients treated with a spacer had better clinical results
<2mm remaining joint space were factors that predicted progres- (81.5% of patients with good results against 60.0% for the
sion to THA. Consideration of these predictors we hope will aid control group). The use of an antibiotic-loaded spacer in the 2-
in surgical decision-making. stage treatment of infected hip arthroplasties provides better
infection control with good functional results and is superior to
PAPER NO. 240 treatment in 2 stages without a spacer. Level of Evidence:
20-year Results of Bernese Periacetabular Therapeutic study, Level I-1.
Osteotomy (PAO) PAPER NO. 347
Simon D Steppacher, MD, Bern, Switzerland The Additional Value of Tissue Biopsy in the
Moritz Tannast, Bern, Switzerland
Diagnosis of Infected Joint Arthroplasty
Klaus Siebenrock, MD, Bern, Switzerland Geert Meermans, MD, Edegem, Belgium
Since 1984, more than 1000 Bernese periacetabular osteotomies Fares Sami Haddad, FRCS, London, United Kingdom
(PAO) have been performed for the treatment of developmental Deep wound infections cause significant number of failures in
dysplasia of the hip (DDH) in adolescents and adults at the lower extremity joint replacement. Despite prevention measures,
institution where this technique was developed. We present the the postoperative infection rate in total hip arthroplasty is 0.5-
20-year follow-up of the first 75 PAOs whose initial and 10-year 1% and is even greater in total knee arthroplasty. Successful
results had been published previously. A retrospective study of treatment of an infected joint arthroplasty depends considerably
the first 75 consecutive hips (63 patients) treated with PAO for on the correct identification of the responsible pathogen. The
DDH between April 1984 and December 1987 was performed. value of a preoperative biopsy remains controversial. The goal of
The mean age at surgery was 29.3 years (13-56) and the mean this study was to compare the results of preoperative aspiration
follow-up was 20.4 years (19-23). Demographical, clinical and and tissue biopsy. In our service, aspiration and tissue biopsy
radiological parameters were systematically acquired. A Cox with a true-cut needle are routinely undertaken in the diagnostic
regression analysis was performed to detect predictive factors for work up for a suspected periprosthetic infection. All the proce-
poor outcome and to calculate the corresponding hazard ratios. dures were performed in the operating room under strict aseptic
4 patients were lost-to-follow-up, 1 patient died unrelated to conditions and general anesthesia. The results of aspiration and
surgery. Twenty-seven hips were converted to a THA or tissue biopsy were compared to the intraoperative tissue cultures
arthrodesis which were defined as endpoints. The cumulative taken at time of revision surgery. Due to suspicion of infection
Kaplan-Meier survivorship at 20 years was 61%. Six predictive of a total joint replacement, 120 patients underwent biopsy and
factors for poor outcome were found: age over 30 years, a preop- aspiration. There were 64 patients with a total hip arthroplasty
and 54 with a total knee arthroplasty. The sensitivity was 82.7%
erative Merle d’Aubigné score less than 15, a positive preopera-

tive anterior impingement test and limp, a preoperative OA for aspiration, 79.1% for biopsy and 90.0% for the combination
grade of more than 1, and a postoperative extrusion index of of both techniques. The specificity was 100% for all methods.
more than 20%. These presented long-term results prove that a The overall accuracy of aspiration, tissue biopsy and the combi-
PAO is an effective and successful technique for the treatment of nation of both techniques were 84.2%, 80.8% and 90.1%
DDH which can preserve the natural hip substantially. Increased respectively. In 4 patients extra organisms were identified with
survivorship rates are expected for more recent series after iden- tissue biopsy. There were no false positive results in this study
tification of relative contraindications based on this analysis. and we therefore recommend performing the aspiration and
biopsy under strict aseptic conditions in an operating room. Our
PAPER NO. 346 data show that tissue biopsy alone offers no clear advantage over
joint aspiration. However, the combination of aspiration and
Prospective Study of the Treatment of Infected THR
tissue biopsy gives a marked improvement of both sensitivity
with or Without an Antibiotic-Loaded Spacer and accuracy. We recommend the use of tissue biopsy as an
Henrique Berwanger Cabrita, MD, Sao Paulo, SP Brazil adjunct to joint aspiration in the diagnosis of total joint infec-
Olavo Pires Camargo, MD, Sao Paulo, SP Brazil tion.
Ana Lucia Lima, MD,
Alberto Tesconi Croci, CEP 05015-040 Sao Paulo, Brazil PAPER NO. 348
Regardless of the worldwide acceptance of the spacer as the main No Value to Obtain Microbiological Cultures of
method of treatment of infected hip replacements,no objective Femoral Head Allografts Just Prior to Transplantation
data have been reported in the literature to prove the real bene- Corne JM van Loon, MD, Arnhem, Netherlands
fits of using a spacer in 2-stage surgeries. In a prospective
G Jerry Van Der Pol, MD,
randomized study, we treated 68 infected hip arthroplasties with
Patrick D Sturm, MD, PhD,
discharging sinuses and bone loss, comparing 30 patients
treated in 2 stages without the use of a spacer (control group) Berend Willem Schreurs, MD, Malden, Netherlands
and 38 patients treated with a vancomycin-loaded spacer(study Cees Verhagen, BSc,
group). The average follow-up was 6 years (4-10.5 years). One Femoral head allografts are often used in Orthopedics to recon-
patient died of unrelated causes 4 months after first-stagesurgery struct bone stock loss. Although the donated heads are thor-
and was excluded from the study. The 2-stage surgery without oughly microbiologically tested before release by the bone bank,
spacer controlled the infection in 66.7% of patients, and the 2- some surgeons take additional cultures in the operation room
stage surgery using the spacer controlled it in 89.1% (P < 0.05). just prior to transplantation. There is no consensus about the
need to take these intra-operative cultures. We assessed the clin- PAPER NO. 350
ical significance of implantation of positive cultured bone allo- Urinary Tract Infection and Total Joint Replacement
grafts. From 426 femoral head allografts prior to implantation
intra-operative cultures from were taken. After changing surgical PanaGiotis S Koulouvaris, MD, Athens, Greece, Greece
gloves the scrub nurse took immediately after the delivery of the David Casey, MD, Fort Wayne, IN
femoral head in the surgical field bone biopsies that were sent Peter Sculco, MS,
for cultures. All files of patients who received an allograft who Eileen Finerty, RN,
had a positive culture just before implantation were checked for Robert G Marx, MD, New York, NY
signs of infection within two years after the index surgery. Forty- Thomas P Sculco, MD, New York, NY
eight out of the 426 femoral heads (11,3%) had a positive Nigel E Sharrock, MD, New York, NY
culture. The 48 heads were implanted in 48 different patients.
:Prosthetic joint infection continues to be a challenge for
The most frequently encountered microorganisms were coagu-
OrthopaediC Surgeons. Previous research efforts have identified
lase-negative staphylococci. A deep infection occurred in 2 of the
various risk factors in an attempt to reduce the incidence of
48 patients (4,2%). However, in only one patient (2.1%) is was
infection. This case-control study was undertaken to address
likely that the same microorganism caused the contamination
1.the routine placement of urine catheters and 2.the influence of
and the subsequent infection. The infection rate in patients
treated pre - operative urine tract infection (UTI) as risk factors
receiving positive cultured allografts at implantation was not
for deep sepsis after the joint replacement. A list of all patients
higher than the overall infection rate in allograft surgery. These
undergoing total hip and knee replacements in the hospital
findings indicate that the positive cultures at implantation prob-
from January 2000 ‘ December 2004 was obtained from the
ably represent contamination and that taking the additional
hospital database. In addition, all patients who underwent a
cultures just before implantation is not useful
surgical procedure for exploration of a wound, debridement of
a wound or removal of an infected prosthesis from January 2000
PAPER NO. 349
until December 2005 were obtained. Controls were randomly
Two-Stage Hip Revision for Infection: A 10-15 year selected from a list of patients within the study population who
follow-up in 103 Patients did not develop joint infection. Controls were matched 1:1 to
Timothy Kostamo, MD, London, ON Canada cases by age (±2 years), sex, surgeon, joint (hip or knee) and year
of surgery. Results: A total of 19,735 cases after joint replacement
Gurdeep S Biring, FRCS, Vancouver, BC Canada
from 2000 to 2004 were reviewed and 58 (0.29%) wound infec-
Bassam A Masri, MD, Vancouver, BC Canada tions were registered. Data analysis showed no significant asso-
Donald S Garbuz, MD, Vancouver, AB Canada ciation between the preoperative urine infection and the wound
Clive P Duncan, MD, Vancouver, BC Canada infection (x2=2.511b; p=0.102). Also analysis showed no signif-
We report the outcomes 10-15 years after two stage revision for icant association between the postoperative urine infection and
hip infection with use of an interval antibiotic-loaded facsimile the wound infection (x2=1.881b; p=0.182). Moreover, we
of the hip to achieve high levels of periprosthetic antibiotic, compared the total rate of urine infection with the rate of wound
expedite rehabilitation of the patient, and facilitate the second infection in cases and control groups and no significant associa-

stage. Re-infection was the primary outcome measurement. tion was determined (x2=0.290b; p=0.394). We found only one
Patient reported quality of life outcomes were the second meas- patient out of 19,735 (0,005%) who developed a UTI and
ures, including the Oxford-12, SF-12, and WOMAC question- wound infection and the bacteria to be the same in both infec-
naires.Of the 103 patients, 4 were excluded because they did not tions. The data of this study demonstrate that preoperative
undergo a second stage. Of the remaining 99 patients, only 7 treated UTI poses no risk for wound infection if treated for 5-8
were lost to follow-up, although 2 of these had recurrent infec- days preoperatively and it should not be a reason to delay or
tion included in our results; a 93% follow-up rate. Forty-four postpone the surgery. In addition urinary catheterization does
were deceased with their outcome confirmed using the last not appear to pose an increased risk for wound infection.
follow-up data point and interview with family members. Seven
patients had an early re-infection which responded to repeat PAPER NO. 351
surgery with no further sequelae. They were infection free. Four Comparison of Surgical Site Infection Rate in
patients had re-infection and were characterized as treatment
failures; 2 requiring a resection arthroplasty, 1 requiring hip Primary versus Revision Hip Arthroplasty
disarticulation and 1 immuno-compromised patient living with Elizabeth Ashby, MRCS, London, United Kingdom
chronic infection.We concluded that the long term success for Malcolm J Davies, MRCS,
infection control was 89% with two stages alone and 96% APR Wilson, MRCP,
following additional surgical intervention.In addition, the Fares Sami Haddad, FRCS, London, United Kingdom
patient reported QOL outcomes revealed no difference when The aim of this study is to compare surgical site infection rate in
compared with a matched cohort of patients who had under- primary versus revision hip arthroplasty using the ASEPSIS
gone revision hip replacement for aseptic failure. Two-stage revi- scoring method. ASEPSIS is a reliable and reproducible method
sion for the management of infected hip replacement,, including of scoring wound infection and is more objective than older
the use of an interim antibiotic-loaded facsimile of the hip, methods of classifying wound infections such as CDC. The
offers a high level of success and a lasting solution with a func- wounds of 293 patients undergoing primary total hip replace-
tional outcome equal to the management of non-infected cases. ment and 53 patients undergoing revision total hip replacement
were examined between 2000 and 2006 using the ASEPSIS
wound scoring method. Wound infection rates were compared
using a chi-squared test. The overall surgical site infection rate in
primary hip arthroplasty was 1.7%. The infection rate in revision
hip arthroplasty was 7.6%. The difference is statistically signifi-
cant (p<0.05). The surgical site infection rate in revision hip
391
arthroplasty is 4 times greater than the infection rate in primary olytic volume and polyethylene wear, conflicting results have
hip arthroplasty. There are several possible reasons for a higher been reported. In the context of a single cup design, this study
infection rate in revision surgery including poorer quality of soft used computed tomography to measure the volume of periac-
tissues due to scarring, greater co-morbidity, longer length of etabular osteolysis after total hip arthroplasty and evaluated the
surgery and longer post-operative stay in hospital. Patients relationship between osteolytic lesion volume and polyethylene
should be warned of this higher risk of infection when wear. We examined 134 hips (120 patients) that had a Duraloc
consenting to surgery. 100 cup (DePuy) and a computed tomography scan that was
taken at least five years postoperatively. Computed tomography
PAPER NO. 352 scans were analyzed with a computer-aided imaging program to
◆The Use of Tranexamic Acid in Revision Total Hip measure periacetabular osteolysis volume. The volumetric lysis
rate was calculated for each hip by dividing the osteolytic
Arthroplasty volume by the time in situ. Volumetric wear was evaluated based
J Brian Gill, MD, Lubbock, TX on serial anteroposterior pelvic x-rays using Martell’s Hip
Emily C Biltoft, Lubbock, TX Analysis Suite software. At a mean follow-up of 7.5 ± 2.4 years,
Alexander Rosenstein, MD, Houston, TX periacetabular osteolysis was found in 53 of 134 hip computed
Tranexamic acid is an anti-fibrinolytic agent that inhibits fibri- tomography scans. Among the 53 hips with osteolysis, the mean
nolysis, which leads to a reduction of blood loss without concur- volume was 11.8 ± 14.7 cc (range 0.2 to 56.4 cc) and correspon-
rently increasing the risk of thromboembolic complications. ding volumetric lysis rate was 1.3 ± 1.6 cc/year (range 0.02 to 6.7
Revision total hip arthroplasty is becoming a more commonly cc/year). For all 134 total hip arthroplasties, the mean volu-
performed procedure as patients are living longer and metric wear rate was 0.09 ± 0.09 cc/yr (range -0.03 to 0.45 cc/yr).
demanding more active lifestyles. However, these procedures can Among all hips, there was a moderate correlation between the
cause a significant amount of blood loss and transfusions. The volumetric wear rate and the volumetric osteolysis rate (r=0.41,
purpose of this study is to determine the efficacy of tranexamic p<0.001). In this population, higher wear rates correlated with
acid in revision total hip arthroplasty, thereby reducing the larger osteolytic lesions. Yet because the wear rate accounted for
number of blood transfusions. A double-blinded randomized only 17% of the variance in the volumetric lysis rate, the
controlled clinical trial at a single institution was done to inves- remaining variance indicated that osteolysis is a multifactorial
tigate the use of tranexamic acid in revision hip arthroplasty. process. Contrary to studies using plain radiographs, there was
Patients who had a failed total hip prosthesis without infection no wear threshold below which osteolysis did not occur.
were enrolled in the study. The tranexamic acid or placebo was
administered during the surgery only. Data collected included PAPER NO. 354
hemoglobin and hematocrit levels for the first three postopera- Cement-Within-Cement Femoral Revision:
tive days, blood loss, allogenic blood transfusions, hospital stay, A Valuable Technique Revisited
complications, and cost of using tranexamic acid with regards to
blood transfusions. A total of 10 patients (5 tranexamic acid and James J Elting, MD, Oneonta, NY
5 placebo) were enrolled in the study. No significant difference For 30 years, respected surgeons have advocated cement-within-
was found in the hemoglobin levels and total blood loss cement femoral revision (CWC) in those cases with a stable
between the two groups. The placebo group averaged 3.6±2.19 cement-bone interface. To date 4 papers discussing 130 hips
units of allogenic blood transfusions while the tranexamic acid revised by this method have been published. We have reviewed
group averaged 0.4±0.89 units (p<0.03). No significant differ- our experience; reporting indications, technique, and results. All
ence was found in length of hospital stay between the placebo patients who had undergone CWC were identified retrospec-
and tranexamic acid groups (4.8days vs. 5.5days, p=0.52). No tively. Their clinical and xray examinations were reviewed and
complications were reported in either group. The cost of allo- updated. 35 hips in 32 patients were operated in this fashion,
genic blood transfusions was reduced by approximately $800 beginning in 1997. Average age at surgery was 72; time from
per patient (p<0.03) in the tranexamic acid group. Tranexamic primary arthroplasty was 13 years. Acetabular loosening was the
acid is effective in reducing allogenic blood transfusions in revi- major indication for hip revision, recurrent dislocation the
sion total hip arthroplasty. Blood management and anesthetic second. Average time to follow-up is 4 years; 5 patients have died
protocols should be adapted to reflect the findings of this study with hips intact. No femoral stem has been revised for any
as an alternative to minimize the use of blood transfusions. reason to date. CWC is indicated in those situations where a
stable femoral cement-bone interface exists in a hip which needs
PAPER NO. 353 cup revision. An intact mantle distal to the lesser trochanter is
prerequisite. In some cases, juxta-articular trochanteric osteolysis
The Relationship Between Acetabular Osteolytic was debrided and impacted with morselized allograft. Shaping
Lesion Volume and Polyethylene Wear in of the PMMA with a burr and the addition of a small quantity of
Cementless THA new cement to accommodate a polished taper stem is our tech-
Hiroshi Egawa, MD, Alexandria, VA nique. We agree with previous authors that CWC is a valuable
part of our hip revision armamentarium.
Sarah Beykirch, Alexandria, VA
Cara Powers, MD, Arlington, VA
Robert Hopper, PhD, Alexandria, VA
C Anderson Engh Jr, MD, Alexandria, VA
Charles A Engh Sr, MD, Alexandria, VA
Osteolysis has been attributed to polyethylene debris and higher
wear rates have been associated with an increased incidence of
osteolysis. While several recent studies have used computed
tomography to examine the correlation between acetabular oste-
PAPER NO. 355 with the linear degeneration and volumetric degeneration, the
Biomechanical Comparison of Two Implants for activity showed a correlation with the linear and volumetric
degeneration. The acetabular cartilage degenerates faster as the
Reattachment of the Osteotomized Greater patient’ activity increases, and slower with a higher HHS. When
Trochanter surgeons perform hip joint arthroplasty, it is strongly recom-
Gregg Jarit, MD, New York, NY mended that the life expectancy and the level of activity be
Fredrick J Kummer, PhD, New York, NY considered when deciding between a hemiarthroplasty or total
hip arthroplasty.
Eric Strauss, MD, New York, NY
Paul E DiCesare, MD, Sacramento, CA PAPER NO. 357
Various implants have been used for reattachment of the
osteotomized greater trochanter during total hip arthroplasty.
◆Revision of Unstable Total Hip Arthroplasty Using
The purpose of our study was to compare the relative strength an Unconstrained Tripolar Implant
and stability of two fixation methods for reattachment of the Olivier Guyen, MD, Lyon, France
osteotomized greater trochanter. This biomechanical study Vincent Pibarot, MD, Lyon Cedex 03, France
compared the fixation strength of a cable-grip system to a cable- Gualter Vaz, MD,
plate system. Eight matched pairs of human cadaveric femora Alexandre Richard, MD,
were randomly divided into two groups and trochanteric
Jacques Bejui-Hugues, MD, Lyon cedex 03, France
osteotomies were performed. The trochanters were reattached
with one of the implants, and the specimens were cyclically Reoperations to manage unstable total hip arthroplasty are
tested with simulated physiologic loading. Displacement of the reported with a high failure rate. The unconstrained tripolar
trochanter was continuously measured to 105 cycles. At the end implant (mobile polyethylene component between the pros-
of testing a single 750 N load was applied and final displace- thetic head and the outer metal shell) is a useful option in such
ment measured. Initial testing during cycling showed more cases. The purpose of this retrospective study was to assess the
stable fixation with the cable-plate implant than the cable-grip, clinical and radiologic features associated with the uncon-
but this difference was not statistically significant. Two of the strained tripolar cup. Fifty one unstable total hip arthroplasties
cable-grip constructs became grossly loose and failed during (32 females, 19 males) were revised using an unconstrained
initial cycling. However, when the 750 N load was applied, the tripolar cup at our institution between March 2000 and February
cable-plate implant had significantly less displacement of the 2005. Mean age at reoperation was 67 year old (range, 35 to 98).
greater trochanter than did the cable-grip implant. The average The outcome of the revision procedure was assessed using the
displacement was 1.56 mm for the cable-plate group and 3.89 Harris Hip Score, and complications were determined by
mm for the cable-grip group (p < 0.05). The newer, fourth gener- detailed review of the patient’s records. Anteroposterior and
ation cable-plates may provide greater fixation strength and lateral radiographs of the involved joint were reviewed to assess
stability for reattachment of the osteotomized greater trochanter. the position of the prosthesis and to look for osteolysis and signs
It is unknown whether the cable plates will decrease the inci- of loosening of the implant. Mean follow-up was 4 years (range,
dence of non-union, trochanteric migration, or persistent 2 to 6.7). At last review 4 patients had died and one was lost to

trochanteric pain that is seen in vivo. Further clinical studies are follow up. Postoperatively there was a significant improvement
needed to evaluate these implants. of the Harris Hip Score. Fifty patients (98%) had no further
episodes of dislocation. There were 3 revisions for deep infec-
PAPER NO. 356 tion, and 2 for dissociation of the bipolar component. No cup
required a revision for aseptic loosening. No radiolucent lines
Degeneration of the Acetabular Articular Cartilage around the components and no osteolysis were observed at
to Bipolar Hemiarthroplasty latest follow up. The unconstrained tripolar component is a
Kyoung Ho Moon, MD, Incheon, Korea, Republic of highly effective option to manage unstable total hip arthro-
Sang Hyoup Lee, MD, Jung-Gu, Incheon Korea, Republic of plasty. Unlike constrained devices, such components provide
Joon Soon Kang, MD, encouraging radiologic results regarding the potential for loos-
ening and osteolysis. Longer follow up is needed to confirm
Dong Joo Lee, Prof,
these results.
To examine the rate of degeneration of the acetabular cartilage
by the bipolar head according to time Among 192 patients (226 PAPER NO. 358
hip joint) who were received bipolar hemiarthroplasty from
August 1996 to August 2002, 61 patients (65 hip joint), who Femoral Fractures in Revision Hip Surgeries With
were followed up for more than 2 years and showed no signs of Impacted Bone Allograft
dislocation, infection and functional problems, were enrolled in Martin Buttaro, MD, Buenos Aires, Argentina
this study. A modified form of a computer assisted vector wear German Luis Farfalli, MD, Cordoba, Argentina
analysis program was used to measure the rate of degeneration Francisco Piccaluga, MD, Buenos Aires, Argentina
of the acetabular cartilage. The subjects were divided into two
Impacted allograft bone in hip revision arthroplasty is a biologic
groups, those whose amount of degeneration of the acetabular
reconstruction method that restores bone loss. Periprosthetic
cartilage was less than average and those whose amount of
femoral fracture is one of the most frequent complications.
degeneration was more than average. The factors that appeared
Hever, the incidence, types of fracture, time of occurrence,
to affect the level of acetabular degeneration in the two groups
predisposing factors, and whether and how complication affects
were evaluated. The average linear degenerative change in the
the reconstruction are unknown. We analyzed 285 femoral revi-
acetabular cartilage and the volumetric degenerative change was
sions performed with this technique. Fractures occurred in 64
0.23±0.107 mm/yr and 114±47.2 mm3/yr, respectively. The
patients (22.4%). Fifty-nine of these 64 incidents (92%)
result showed significant differences with activity and the HHS
occurred during surgery and five within the first postoperative
between the two groups. The HHS showed a reverse relationship
year. Of the 59 intraoperative lesions, 34 were fractures (57.6%)
393
and 25 incidental perforations (42.3%). Most fractures and inci- PAPER NO. 360
dental perforations were associated with cement removal rather Long Term Follow-up of Proximal Femoral Allograft
than the reconstructive technique. The reconstruction was
compromised in two of the 34 fractures, but the remainder for Revision Hip Arthroplasty
healed without complications. Five patients developed a diaphy- Oleg Safir, MD, Toronto, ON Canada
seal fracture within the first postoperative year, four of whom Catherine Kellett, FRCS (Tr & orth)/Dr, Edinburgh, United
had an intraoperative incidental perforation. There was an Kingdom
increased risk of fractures within the first postoperative year in Michael Flint, BHB, Toronto, ON Canada
patients who had an incidental perforation during surgery and Paul Zalzal, MD, Oakville, ON Canada
in those with severe bone defects. Despite the high rate of
Yona Kosashvili, MD, Yokneam, Israel
femoral complications associated with this reconstructive tech-
nique, most did not influence the reconstruction and only the Guy Morag, MD,
intraoperative and postoperative complete diaphyseal fractures David Backstein, MD, Toronto, ON Canada
underwent additional treatment. Allan E Gross, MD, FRCSC, Toronto, ON Canada
Revision hip arthroplasty is a well recognized and successful oper-
PAPER NO. 359 ation. Re-revision of a total hip arthroplasty is becoming more
Proximal Femoral Allograft Prosthesis Composites common and is often associated with significant femoral bone
loss. A proximal femoral allograft (PFA) is a useful approach to
in Revision Hip Arthroplasty. 11 Years Follow-Up reconstitute bone stock in the multiply revised femur with
George Babis, MD, Athens, Greece segmental bone loss of greater than 5 cm. 93 PFAs were studied in
Vasilios I Sakellariou, MD, 92 patients with a follow up of 15 years or greater. The average age
Mary I O’Connor, MD, Jacksonville, FL was 63 years (range 49-81 years). The average number of previous
Arlen D Hanssen, MD, Rochester, MN revision procedures was 2.5 (range 1 - 5). Radiographic assess-
Franklin H Sim, MD, Rochester, MN ment of the construct looking for allograft-host union, compo-
Massive bone loss from the proximal femur is a complex nent stability, trochanteric union, graft fracture and resorption was
problem, occurring in multiple-revision hip arthroplasties, and performed and survivorship of the construct was analyzed. At 17.8
malignancy. APC have been used to restore bone loss and year review 36 patients had died (34 with the original PFA in situ)
provide better function of the limb. The aim is to present long and 6 were lost to follow-up. The average length of the PFA was
term follow-up results in revision THA using APC. Between 14.7 cm (range 8 -32cm). Failures due to infection occurred in
1986 and 1999, 96 patients 32 male and 64 female (mean age 4.2%, and of these 50% were successfully revised. Aseptic loos-
59.55 years), undergone at an average 2.031 revision THA, had a ening occurred in 7.4%. Nonunion occurred in 5.3% and dislo-
revision hip arthroplasty using APC due to bone loss. 29 patients cation in 9.6%. Revision of the PFA for all reasons excluding the
had previous history of infection. At an average of 11 years and acetabulum was performed in 10.9% of cases. A successful
4 months (range, 8 to 20 years) post revision, 47 patients were construct, defined as a stable implant with no need for re-revision
alive, 21 patients had died, and 1 patient had been lost to follow- surgery at the time of latest follow-up, was seen in 83.1%.
Proximal Femoral Allograft for revision hip arthroplasty in
up. 46 patients had acute or late complications: 12 patients loos-

ening of the femoral stem, 15 hip dislocations, 10 periprosthetic femoral segmental bone loss proves to be an excellent and
fractures, 7 infections. In 14 patients re-operation was needed durable alternative at an average follow-up of 17.8 years.
while in 21 re-revision of the APC was performed. The survival
PAPER NO. 511
at 10 years was 50.06% (95% CI 44.15%-55.97%, 26 patients
remaining). There was no statistically significant difference on Total Hip Arthroplasty for Primary Osteoarthritis in
survival time when comparing the gender, age, indication for Patients Fifty-Five Years Old or More
APC (including infection), number of revisions, surgical Keijo Makela, MD, Turku, Finland
approach and APC technique. The use of screws and plates was
Antti Eskelinen, MD, PhD, Espoo, Finland
the only factor affecting the survival of APC (p<0.05). The long
term results post APC arthroplasty are encouraging. We believe P Pulkkinen MS, Helsinki, Finland
that this technique provides a viable option for treatment of the Pekka Paavolainen, MD, Kasarmikat, Finland
difficult problem of severe femoral bone loss. Ville M Remes, MD, Helsinki, Finland
We evaluated the population-based survival of total hip arthro-
plasty (THA) in patients aged 55 years and over with primary
osteoarthritis (OA), and the factors affecting survival. Between
1980 and 2004, a total of 65 673 primary THAs performed for
primary OA in patients aged 55 years or more were entered in
the Finnish Arthroplasty Register. These operations were
subjected to analysis. : In patients aged 55-64 years, cementless
THA (a straight proximally porous-coated stem combined with
a modular cementless cup) had a significantly higher overall
survival than cemented THA with revision for aseptic loosening
as the end point (p<0.001). At 15 years, survival rate of cement-
less THA was 80% (95% confidence interval, 72 to 87) and that
of cemented THA 71% (95% confidence interval, 69 to 72),
respectively. In patients aged 65-74 years, the corresponding
figures were 94% (95% confidence interval, 92 to 97) and 85%
(95% confidence interval, 84 to 85) (p<0.001). In patients aged
over 74 years, there were no significant differences between
cementless and cemented THA. Secondary to a large amount of prospective, randomized two-surgeon study of 219 consecutive
revisions due to excessive liner wear, there was not any signifi- hybrid total hip arthroplasties performed with third generation
cant difference in revision risk between cementless and cement techniques. The femoral components were polished (Ra
cemented THR concepts in any age group with revision for any 7-12) or precoated (Ra 70-90) with the same geometry.
reason as the end point. Cementless THA has a lower risk of revi- Randomization, using sealed envelopes, was performed intraop-
sion as compared to cemented THA due to aseptic loosening in eratively after femoral preparation. Survival analysis to seven
patients aged 55-74 years. Excessive polyethylene wear, however, years was performed on the entire cohort. Detailed clinical and
is a significant clinical problem with modular cementless cups radiographic evaluation was performed for 133 hips at a mean
in these older patients, too. Long-term results of highly cross- follow-up at six years (range 5 to 10 years). There was no signif-
linked polyethylene and hard-on-hard articulations are needed icant difference between the groups in the preoperative diag-
to determine, whether completely cementless THA is the most nosis, age, gender, weight, component size-offset or cement
durable solution also for older patients. grade. For the entire cohort of 219 hips, there was no significant
difference in survival (failure defined as component removal or
PAPER NO. 512 loosening) between the 106 precoated (0.96) and 113 polished
Control of Intramedullary Bleeding in Cemented (0.93) stems at seven years (p = 0.43). There were three peripros-
thetic fractures with polished components that required plating,
Primary Hip Arthroplasty and one was revised for nonunion. Overall, there were two
Geert Meermans, MD, Edegem, Belgium precoated and two polished components revised for loosening.
Dr Kristoffei Govaers, MD, Kalmthout, Belgium For the cohort followed for a minimum of five years, there was
Caroline De Jager, BSc, no significant difference between the groups in Harris hip score
Hilde Bortier, PhD, Antwerpem, Belgium and the overall clinical result. There was no significant difference
Cemented femoral stems have an excellent long-term outcome. between the groups in the presence or number of bone-cement
Modern cement techniques should be used to optimize femoral radiolucent lines. At 7 years there was no significant difference in
stem fixation. Bleeding from the bone surface during cemented survival between these two cemented femoral components with
hip arthroplasty compromises the bone-cement interface. greatly different surface finishes. In the patient population
However, no studies have examined this bleeding in vivo nor the selected for a cemented femoral component, provided that good
effect of the different cleaning methods used. In the present study cement technique is used, the surface finish of the component
we evaluated bleeding patterns and efficacy of cleaning methods may not be a crucial variable.
used in third generation cementing techniques. We prospectively
performed a medulloscopy with a 10 mm laparoscope in 200 PAPER NO. 514
primary hip arthroplasties. Intramedullary bleeding was evalu- ◆Prospective Randomised Study of Post Operative
ated after femoral canal preparation and use of the different Blood Salvage and Autologous Retransfusion in THR
cleaning methods. The femoral canal was divided into three
zones to facilitate comparison. The intramedullary bleeding was
Dan Williams, MRCS, MSc, Newport, United Kingdom
standardized on a four point scale. A non-parametric repeated Lindsay Smith, MCSP, MSc,
VG Langkamer, FRCS,

measures ANOVA was used for statistical analysis. Cotton swabs
and brushes did not reduce the intramedullary bleeding signifi- Homologous blood transfusion (HBT) following primary total
cantly after broaching of the canal. Compared to these standard hip replacement (THR) is not without risk. Postoperative blood
cleaning methods, pulsed lavage and the addition of brushing salvage (POS) with autologous blood transfusion may minimize
provided better blood removal (p<0.001). There was a trend, the necessity for HBT but the clinical, haematological and
although not statistical significant (p=0.24), towards better canal economic benefits have yet to be clearly demonstrated for
cleaning if a canal filling tampon with suction was added. Arterial primary THR. The aim of this randomized prospective study was
bleeding originating from the posterior wall of the canal was to determine if the use of POS affects postoperative haemo-
noticed in 26 cases (13 percent). These could only be controlled globin levels, haematocrit and HBT requirement. Secondary
by diathermy tools. Most standard preparation techniques are outcomes included length of stay and patient satisfaction. A cost
insufficient to prepare the femoral canal before cement insertion. analysis was conducted on the basis of the results. From previous
In case of severe intramedullary bleeding, an arterial bleeding work it was determined that 72 patients would be required in
should be ruled out and if necessary treated with the aid of each group to provide sufficient power to detect a significant
diathermy tools. We recommend pulsed lavage combined with a difference in post operative haemoglobin levels. Patients were
brush and a canal filling tampon for femoral canal preparation in randomized at the point of reduction of the primary THR to
cemented primary hip arthroplasty for optimal control of receive either two vacuum drains (82 patients) or an autologous
intramedullary bleeding. retransfusion system (76 patients). Haemoglobin and haemat-
ocrit values were not significantly different between groups but
PAPER NO. 513 significantly fewer patients with the autologous system had a
Prospective, Randomized Study of Precoated vs postoperative haemoglobin value < 9.0 gdL-1 (8% vs. 20%, p =
0.035). Significantly fewer patients with the autologous system
Polished Cemented Femoral Components at 5-10 required HBT (8% vs. 21%, p = 0.022). There was an overall cost
Years saving in this group. This study has shown that use of an autol-
Paul F Lachiewicz, MD, Chapel Hill, NC ogous retransfusion system for primary THR reduces the neces-
The optimal surface finish for cemented femoral components sity for HBT and is cost effective.
remains controversial. Some investigators have reported a high
rate of osteolysis and revision with precoated femoral compo-
nents. Our hypothesis was that there would be no difference in
the clinical results or survival of hips with precoated or polished
femoral components at minimum five years follow-up. This is a
395
PAPER NO. 515 and 2 of 19 patients at 1 year follow-up. The blood flows of both
Direct Anterior Approach for Hip Arthroplasty: An patients who had persistent symptoms over 1 year after surgery
were decreased by more than 50 % during operation. Decrease of
Unselected Single Surgeon Experience blood flow of LFCN by more than 50% seems to cause persistent
Gary Worthington Bradley, MD, Santa Barbara, CA symptoms after surgery through Smith-Petersen approach even if
Less invasive hip arthroplasty has been promoted since 2002 but direct trauma to the nerve is avoided. Excessive traction by retrac-
with few reports having follow-up data. Existing information is tors is thought to be the main cause of blood flow reduction.
often from developer-surgeons, selecting patients and investi-
gating only the immediate post-operative course. More complete PAPER NO. 517
and less biased information is needed. This series, 250 hips done Complications During Introduction and
consecutively beginning April 2003, by a single surgeon using
the direct anterior approach first described by Robert Judet, is
Dissemination of New Minimally Invasive
entirely unselected: 28% obese, 16% over 80, but 20% Charnley Approaches in THA
category A. Follow-up is at least 2 years. Standardized hip scores Richard A Berger, MD, Chicago, IL
and radiographic measurements were obtained regularly. Eight Mark A Hartzband, MD, Franklin Lakes, NJ
re-operations (3.5%) were required: 2 infections (0.8%), 5 Frank R Ebert, MD, Baltimore, MD
component failures (2%) and 2 superficial wound infections Paul J Duwelius, MD, Portland, OR
(1%). There were 3 dislocations (1.2%). Charnley Merle
Craig J Della Valle, MD, Chicago, IL
d’Aubigne, WOMAC and Harris Hip Scores improved signifi-
cantly (p=0.001 for each) and component positioning was Andrew A Freiberg, MD, Boston, MA
reproducible. Over 80% of these patients were discharged Russell Glen Cohen, MD, Tucson, AZ
directly home after an average length of stay 2.2 days. Walking Steven H Weeden, MD, Fort Worth, TX
without assistance averaged 4 weeks; return to work 6 weeks. The introduction and dissemination of new approaches in joint
Surgical time and hospital stay decreased significantly during the replacement can be initially detrimental to patient outcomes
time of study (p = 0.001 for each). Given the excellent result and can impact informed consent. We prospectively studied the
from conventional hip arthroplasty, a change in technique first four surgeons to complete 100 total hip replacements each
might, at most, slightly benefit most patients at the risk of greatly using a newly developed minimally invasive approach for which
harming a few. This report suggests that the single incision direct no formal training existed. The major complication rate (frac-
anterior approach is applicable to all THA patients, early ture, dislocation, re-operation, or revision) from these 400 cases
recovery is acceptable, and a reasonable learning curve exists; but was compared to a baseline complication rate from 400 stan-
early complications may be increased when compared to the dard total hip replacements from these four surgeons. We subse-
best experience using traditional approaches. quently compared the result from the four surgeons without
formal training to the first 400 total hip replacements from four
PAPER NO. 516 different surgeons who had formal training in this new tech-
Ischemia of the Lateral Femoral Cutaneous Nerve nique, including a cadaveric course. The surgeons without
formal training had a higher complication rate than with their
During Smith-Petersen Approach to the Hip standard approach until they each did 35 cases. During the first
Takahiko Kiyama, MD, Fukuoka, Japan 25 cases from these surgeons (100 cases), the complication rate
Masatoshi Naito, MD, Fukuoka, Japan was 8%. During the subsequent 300 cases, the complication rate
Kei Shiramizu, Fukuoka, Japan for each 100 cases was 6%, 1%, and 0%, respectively. Lastly, the
Tsuyoshi Shinoda, MD, Fukuoka, Japan four surgeons without formal training had a statically higher
Akira Maeyama, MD, Fukuoka, Japan complication rate compared the four surgeons with formal
Takeshi Teratani, MD, Fukuoka, Japan training, 3.75% versus 2.5%, respectively. When new techniques
are initiated, a higher complication rate can result and must be
Akinori Takeyama, MD, Fukuoka City, Japan
explained to patients. Formal IRB approval for new techniques is
Daisetsu Karashima, MD, Fukuoka, Japan warranted until the documented complication rate matches that
Satoshi Kamata, MD, Fukuoka, Japan of the standard procedure. Furthermore, disseminating new
Lateral femoral cutaneous nerve (LFCN) injury is a common techniques, with training and cadaveric courses, results in lower
complication in Smith-Petersen approach to the hip. This compli- complication rates and must be encouraged. However, even with
cation may be induced by neural ischemia or direct trauma during proper training, a learning curve is expected and should be
the procedure. The purpose of this study was to investigate the conveyed to patients.
relationship between the neural ischemia of LFCN and postoper-
ative sensory disturbance. Nineteen patients who underwent peri- PAPER NO. 518
acetabular osteotomy through the Smith-Petersen approach were Complications in Limited Incision Posterolateral &
investigated. To evaluate neural ischemia, we measured the blood
flow of LFCN using a laser Doppler flowmetry. The measurements Standard Posterolateral Total Hip Arthroplasty
were performed before and after osteotomy at the point of 1cm Gabriel Levi, MD, Chicago, IL
distal from the lower border of the inguinal ligament. LFCN was Wayne M Goldstein, MD, Morton Grove, IL
retracted to medial side during the procedure. There was no direct Alexander Meininger, MD, Evanston, IL
trauma to LFCN in all cases. Postoperative sensory disturbance Jill Branson, RN, Kildeer, IL
was evaluated at 2weeks, 3months, and 1 year follow-up after Bettina Ann Chow, MA, Chicago, IL
surgery. After osteotomy, the blood flow of LFCN was decreased
Christopher Simmons, BS, Willow Springs, IL
from 3.3±1.7 ml/min/100g to 2.4±1.1 when compared with that
before osteotomy (p<0.01). Postoperatively, in 14 of 19 patients Results of standard incision and ‘limited incision’ total hip
had sensory disturbance at 2 weeks, 8 of 19 patients at 3 months, arthroplasty (THA) have been described by several authors.
Complications documented in limited incision THA include
intraoperative fracture, increased operative time, increased blood PAPER NO. 520
loss, component malposition, and dislocation. The techniques
are still developing and there are no large studies that compare
◆What is the Optimal Surface Roughness of a
the complication rate in limited incision posterolateral THA to Cemented Femoral Stem?
that of standard posterolateral THA. Our retrospective review Moussa Hamadouche, MD PhD, Paris, France
examines the complications in these two surgical groups. A Francois Baque, MD, Santa Monica, CA
retrospective review of all primary THA’s (n = 1681) performed Nicolas Lefevre, MD, Paris, France
by the senior author between 2001 and 2006. A control group of Luc Kerboull, MD, Paris, France
standard posterolateral THA’s (n = 712) was compared to the
Marcel Kerboull, MD, Paris Cedex 14, France
study group of limited incision posterolateral approach THA’s (n
= 969). Statistical analyses were performed to compare the peri-
Jean-Pierre Courpied PhD, Paris, France
operative complications between the two groups. The following The purpose of this study was to evaluate the minimum 10-year
complications were examined: intra-operative fracture, post- results of cemented stems according to the surface finish of the
operative fracture, dislocation, infection, nerve injury, femoral component. A prospective randomized series included
hematoma, and heterotopic ossification. No intra-operative 284 patients (310 hips) with a mean age of 64.1 years. The
femur fractures occurred in either group. There were only 3 femoral component was highly polished (Ra = 0.04 micron) in
(0.3%) post-operative femur fractures in the limited incision 165 hips and matte in 145 (Ra = 1.7 micron). A historical series
group. No post-operative fractures were found in the control performed according to the same surgical technique using a
group. This was not statistically significant. Statistical analyses satin finish stem (Ra = 0.9 micron) included 111 patients (123
also revealed that there were no statistical differences in the rates hips) with a mean age of 60.5 years. At the minimum 10-year
of infection, hematoma, nerve injury, heterotopic ossification, follow-up, 246 patients (276 hips) were still alive and had not
and total complications. Our large study demonstrates that been revised at a mean of 12.3 years, 26 patients (26 hips) had
limited incision posterolateral approach total hip arthroplasty is been revised, 80 patients (83 hips) were deceased, and 43
not associated with an increased rate of perioperative complica- patients (48 hips) were lost to follow-up. Radiologic loosening
tions. Therefore, we feel that limited incision posterolateral of the femoral component, including revision, occurred in one,
approach is a safe and effective approach to THA. four, and 15 hips for the polished, satin, and matte groups,
respectively. The survival rate at 13 years of the femoral compo-
PAPER NO. 519 nent, using loosening as the end-point, was 97.3 ± 2.6%, 97.1 ±
2.1, and 78.9 ± 5.8 for polished, satin ,and matte stems, respec-
◆Femoral Neck Remodeling After Resurfacing tively. This study demonstrated that cemented fixation of a
Arthroplasty of the Hip femoral component was more reliable in the long-term with a
Scott T Ball, MD, San Diego, CA polished or a satin surface finish. Based upon our results and the
Thomas P Schmalzried, MD, Los Angeles, CA review of the literature, we recommend abandoning the use of
Concerns have been raised regarding remodeling, erosion and cemented stems with a surface roughness greater than 1 micron.
other bone loss in the femoral neck following resurfacing. A
PAPER NO. 521
radiographic review was undertaken in an attempt to identify

cases and to correlate radiographic results with clinical results. Variation in Postoperative Pelvic Tilt May Confound
69 consecutive hips in 57 patients with a minimum of 2 years of Accuracy of Contemporary Hip Navigation Systems
clinical and radiographic follow-up were evaluated. All radi- Sebastian Parratte, MD, Marseille, France
ographs were reviewed by a single observer who was blinded to
Krista Coleman-Wood, PhD, Rochester, MN
the clinical results at the time of the review. Acetabular and
femoral component positions were recorded as were post- Kenton R Kaufman, PhD, Rochester, MN
surgical changes identified in the femoral neck or acetabulum. Daniel J Berry, MD, Rochester, MN
No components have loosened and there have been no neck Mark W Pagnano, MD, Rochester, MN
fractures. 14 hips in 13 patients (20%) demonstrated osseous Most computer navigation systems used in total hip arthroplasty
changes in the femoral neck that became apparent at an average integrate preoperative pelvic tilt to calculate the anterior pelvic
of 15 months (range 6 to 24 months). In all cases, these were plane. However the consistency of this value after THA has never
detected on the cross-table lateral view. All 14 hips demon- been proven. We asked if substantial preoperative to postopera-
strated scalloped bone loss in the posterior neck adjacent to the tive variation in dynamic pelvic tilt could cause component
femoral component and acetabular component rim while 1 hip position errors with hip navigation. This prospective study
also demonstrated similar changes in the anterior neck. The compared pre-operative and post-operative dynamic pelvic tilt
Harris Hip Score and UCLA activity scores were actually higher after THA using modern comprehensive gait analysis. Twenty-
in patients with femoral neck remodeling (97.5 and 9.2, respec- one patients who underwent unilateral total hip arthroplasty
tively) compared to those patients without changes in the were prospectively studied. Objective measurements with a
femoral neck (93.5 and 8.4, respectively). There was no signifi- computerized video motion system were performed.
cant difference in component position or range of motion Quantitative pelvic tilt changes (anterior or posterior in the
between the two groups. Remodeling or erosions of the femoral sagittal plane) relative to a laboratory coordinate system were
neck may occur after hip resurfacing. At this time period, there is compared. While mean changes in pelvic tilt were small, a
no adverse effect on clinical outcome, and it tends to occur in substantial proportion (25 %) of patients had more than a 5
active patients. Based on the location, these erosions appear to degree difference measured between preop and postop and the
be due to neck-socket component impingement, although an variability was spread over 20 degrees. Mean pelvic change were
inflammatory component cannot be excluded. -1.5 ± 4.3 º (range -7.2 to 11 º) between pre-operative and two
months post-operative, -1 ± 5.6 º (range -12 º to 8.2 º) between
two-months and one year and -2.6 ± 6 º (range -12.8º to 7.9 º)
between pre-operative and one-year. Substantial changes in
397
pelvic tilt occurred in a quarter of the patients and those changes femoral head (61%) was the most common presenting
were spread over a range of 20 degrees. While navigation clearly pathology. There were no exclusion criteria beyond those appli-
improves the precision of component position during THA it cable to any total joint arthroplasty. The mean preoperative
remains unanswered if the accuracy of component position will Harris hip score was 41 points (range, 16 to 54 points) and
be improved because of substantial variation in pelvic tilt from mean postoperative hip score was 96 points (range, 68 to 100
preop to postop. points). No hip had a femoral or acetabular component revision
because of aseptic loosening. Two hips (0.3%) were revised for
PAPER NO. 522 infection. One acetabular component (0.2%) was revised for
Newer Technologies for Bone Repair: A Meta-Analysis recurrent dislocation. Five hips (0.8%) required circlage cabling
for an intraoperative calcar fracture and one hip (0.2%) required
Khaled J Saleh, MD, Charlottesville, VA
circlage cabling for greater trochanteric fracture. This particular
Abhijit Manaswi, MD, metaphyseal loading cementless anatomic femoral component
MaCalus Hogan, MD, Charlottesville, VA without having distal stem fixation was proved to have an
Shawn Brubaker, DO, Charlottesville, VA encouraging mechanical fixation. This finding suggests that this
Wendy Novicoff, PhD, Charlottesville, VA particular femoral component does not need a distal stem fixa-
Yusuf Khan, PhD, Charlottesville, VA tion.
Advances in the technology of substances that enhance fracture
healing and bone regeneration increase our ability to heal frac- PAPER NO. 524
tures in a more effective and expedient manner, and much Osseointegration of Acetabular Cups in Total Hip
research has been published about the different techniques, tech- Arthroplasty: The Role of Bone Marrow Stromal Cells
nologies, and their respective clinical utility. This meta-analysis
reviewed available literature to assess the evidence regarding their Sujith Konan, MRCS, London, United Kingdom
current status in bone healing and regeneration. A literature P Kalia, BSc,
review was performed to identify clinical studies on various Sam Oussedik, MRCS, London, United Kingdom
modalities on fracture/bone healing and repair. The quality of the Melanie Coathup, Middlesex, HA, United Kingdom
studies was assessed and only those articles with level I and II Matthew Dodds, New York, NY
evidence were analyzed. Diagnosis, level of evidence, modality of Fares Sami Haddad, FRCS, London, United Kingdom
treatment and treatment protocol, sample size, clinical course in Gordon W Blunn, MD, Middlesex, United Kingdom
each group from baseline, observation period, end point assess-
Despite advances in total hip arthroplasty, failure of acetabular
ment, results, complications and conclusion were noted. Each
cup remains a concern. The role of bone marrow stromal cells
treatment modality was analyzed individually. Over 1500 articles
(BMSCs) to aid osseointegration of orthopaedic implants have
met the initial criteria for inclusion in the meta-analysis. In the
been recently studied. We investigated the hypothesis that autol-
majority of articles, the primary end point was not clearly identi-
ogous BMSCs sprayed on the surface of acetabular cups would
fied, and most studies were poorly randomized, decreasing the
improve bone formation and bone implant contact. Total hip
generalizability of the findings. In addition, previous and
replacements were implanted in 11 sheep, randomly assigned to
secondary treatment was not properly discussed, the follow-up
receive either acetabular implants sprayed with autologous

period was not well defined, complications and failure of treat-
BMSCs suspended in fibrin (study group) or fibrin only (control
ment were not discussed in depth, dose-effect relationships were
group). Sheep were sacrificed after six months and the acetab-
not well-defined, and the criteria for successful result were not
ulum with the implant was retrieved and prepared for undecal-
clearly outlined. Although there is a large body of evidence on the
cified histology. Implant bone contact in both groups was
clinical benefits of different agents and modalities on bone repair
compared microscopically, by noting the presence or absence of
and healing, it still is not clear how they work or in what circum-
new bone or fibrous tissue along the implant at 35 consecutive
stances they should be used. Further prospective randomized
points (every 1000 µm). The observers undertaking the histo-
studies are needed to assess the full clinical feasibility of each
logical analysis were blinded with regard to the details of the
modality in fracture healing and repair.
study and the control group. Significantly increased bone
implant contact was noted in the BMSC treated group 30.71% ±
PAPER NO. 523
2.95 compared to the control group 5.14% ± 1.67 (p = 0.014).
Is the Femoral Stem in THA Necessary in the The mean thickness of fibrous tissue in contact with the implant
Metaphyseal Loading Femoral Component? was greater at the periphery 887.21mm ± 158.89 and the dome
Young-Hoo Kim, MD, Seoul, Korea, Republic of 902.45mm ± 80.67 of the implant in the control group
compared to the BMSC treated group (327.49mm ± 20.38 at the
Jun Shik Kim, MD, Seoul, Jongno-Gu Korea, Republic of
periphery and 739.1 mm ± 173.72 at the centre). Conversely,
Yoowang Choi, MD, direct bone contact with the implant surface was significantly
Oh-Ryong Kwon, MD, greater around the cups with BMSCs. BMSCs sprayed on surface
The rationale for the design of metaphyseal loading femoral of implants improves bone implant contact. Spraying acetabular
component is to transmit forces from hip joint to most proximal cups using BMSCs could be used in humans where acetabular
part of femur to maintain as much as possible of the stresses in bone contact is compromised such as in revision procedures.
the proximal femur after THA. The purpose of this study is to
review the results of a stem designed not to contact the femoral
cortex, thus ensuring exclusive metaphyseal loading. Six
hundred and one consecutive metaphyseal loading cementless
femoral components in 471 patients were followed up for 5 to
12 years (mean 8 years 9 months). There were 297 males (63%)
and 174 females (37%). One hundred and twenty-nine patients
underwent bilateral simultaneous THAs. Osteonecrosis of
PAPER NO. 525 The incidence of osteonecrosis in group P (33%) was signifi-
Cementless, Acetabular Fixation With and Without cantly lower than in group I (100%) and group C (83%) (p <
0.001 for both). The percent necrotic area to whole bone
Screws: Analysis of Stability and Migration marrow area on cross sections in group P (8.2 ± 5.9%) was
Richard Iorio, MD, Burlington, MA significantly lower than in group I (69.8 ± 20.8%) and group C
Brian Puskas, MD, Cambridge, MA (51.5 ± 30.7%) (p < 0.005 for both). Hepatic CYP3A activity
William L Healy, MD, Burlington, MA inversely correlated with the incidence of osteonecrosis and
John F Tilzey, MD, Beverly, MA extent of the necrotic area caused by the same dose of corticos-
Lawrence Specht, MD, Burlington, MA teroids, suggesting possible prevention of the steroid-induced
osteonecrosis by reducing steroid dose in poor corticosteroid
Purpose: Cementless, porous coated acetabular components are
metabolizers.
commonly implanted with and without screw fixation for
primary THA. The purpose of this study was to compare initial PAPER NO. 572
acetabular implant stability and later acetabular implant migra-
tion with or without screw fixation. Methods: An evaluation of Total Hip Arthroplasty in Sickle Cell Disease
775 consecutive, cementless, porous coated acetabular compo- Philippe Hernigou, PhD, Creteil France, France
nents was performed. The acetabulum was prepared with Alexandre Poignard, MD,
concentric, 1 mm underreaming. The implant was press-fit into Frederic Galacteros, MD, Creteil, France
the prepared cavity. Screw fixation was utilized in 509 cups. No We report the results of 312 primary total hip arthroplasty (THR)
screw fixation was used in 266 cups. Average follow-up in the that were performed by only one surgical team with use of a
screw fixation group was 5.8 years (range 2-10 years). Average single design of prosthesis and a standardized operation tech-
follow-up in the no screw group was 6.2 years (range 2-10 years). nique. The purpose of the present study was to evaluate the
The average age of the screw fixation patients was 67.1 years and recent results of hip arthroplasty in this pathology. From 1980 to
the average age of the no screw patients was 67.25 years. 2000, 312 THR were performed in 244 patients with sickle cell
Progressive radiolucencies, osteolysis, migration, loosening and disease (SCD). 145 were homozygous for the sickle cell gene
reoperations were analyzed. Results: No acetabular components (hemoglobin SS), 87 had hemoglobin S/hemoglobin C and 12
in the screw fixation group required revision for failure of fixa- had hemoglobin S associated with beta thalassemia. The opera-
tion, and one cup (0.3%) in the no screw group required revi- tions were performed with a posterolateral approach and both
sion for failure of fixation. Five cups (1.0%) in the screw fixation components were fixed with cement with antibiotics. The
group (3 revisions for instability and 2 infections) at an average patients had regular annual clinical and radiographic evalua-
interval of 1.5 years and 4 cups (1.5%) in the no screw group (3 tions.The average age at the time of the operation was 32 years
revisions for instability, and one infection) required reoperation (range 18 to 51 years). The average duration of follow-up for the
at an average interval of 0.75 years. There was no evidence of series until the time of death, revision of one component, or the
osteolysis or late migration in either group. Conclusion: latest clinical evaluation was 13 years (range 5 to 25 years).
Cementless, porous coated acetabular fixation with and without Medical complications were observed after 85 interventions (27
screw fixation can be utilzed for successful primary THA. %). Twelve patients had posteroperatively painful sickling crises

despite intra operation and postoperation transfusion. Minor
PAPER NO. 571 complications of transfusions were observed in 62 cases. Major
Increased Hepatic CYP3A Decreases the Risk of transfusion reactions were encountered in 9 cases despite the use
Steroid-Induced Osteonecrosis in a Rabbit Model of extended Ag-matched blood. These 9 patients developed
massive intravascular haemolysis 7 days after transfusion and
Kentarou Iwakiri, MD, Osaka, Japan
needed hospitalization in reanimation during 10 days. An acute
Toshiaki Masada, MD, chest syndrome was observed in 4 patients26 orthopedic
Yutaka Oda, MD, PhD, complications were observed : Perforation of the femur was
Yasunori Kaneshiro, MD, PhD, observed in 6 patients. Two patients had a postoperative tran-
Hiroyoshi Iwaki, MD, Osaka, Japan sient (3 months) peroneal nerve palsy with footdrop. There were
Hirotsugu Ohashi, MD, Osaka, Japan 6 early dislocations. Twelve hips had heterotopic ossification.
Kunio Takaoka, MD, Osaka, Japan Infection occurred in 10 hips (3 per cent). The average time to
Low hepatic cytochrome P4503A (CYP3A) activities might play revision for infection was 11 years (range 7 to 15 years). The
an important role for inducing osteonecrosis of the femoral organisms cultured at the time of revision for infection were
head (ONFH) by corticosteroids. However, the relationship staphylococcus aureus, acinetobacter, proteus and
between hepatic CYP3A activity and steroid-induced ONFH is pseudomonas. Twenty-one acetabular components (7 per cent)
unknown. We have examined the relationship between hepatic and 17 femoral components (5 per cent) had been revised for
CYP3A activity and the inducibility of ONFH in a rabbit model. loosening by the time of the latest follow-up (mean 13 years).
Sixty rabbits were divided into 3 groups. Hepatic CYP3A inducer Considering revisions for infections and aseptic loosenings the
(phenobarbital, group P; n=15), inhibitor (itraconazole, group probability of survival of both of the original components at 10
I; n=15) or saline (group C, n=30) was administrated for three and 15 years was 91 per cent (95 per cent confidence interval, 88
weeks before intramuscular methylprednisolone. In groups P to 94 per cent) and 86 per cent (95 per cent confidence interval,
and I, hepatic CYP3A levels were measured by midazolam clear- 82 to 90 per cent), respectively. Patients with osteonecrosis
ance before treatment (baseline) and before methylpred- related to SCD can be severely disabled by the status of their hip.
nisolone injection. All animals were sacrificed three weeks after Total hip arthroplasty remains for some of these patients the
methylprednisolone injection and both femurs were harvested only surgical option according to the status of their hip, when
and examined histologically for osteonecrosis. Midazolam clear- severe degenerative changes are present after collapse.In conclu-
ance was significantly increased and decreased, compared with sion, hip arthroplasty in SCD involves a higher complications
baseline in groups P and I respectively (p < 0.0005, p < 0.002). rate and incidence of failure with revision than arthroplasty in
399
osteonecrosis related to other conditions. However, with one for infection improved from 74% using tissue cultures to 89%
experienced surgical and medical team, the risk-to-benefit ratio using sonicate culture (p <0.05) to 96% using sonicate
appears reasonable for these patients. calorimetry (p <0.001). The calorimetric detection time was 2-12
hours. The specificity of all specimen types exceeded 95%.
PAPER NO. 573 Sonication of removed orthopedic devices significantly
Outcome of Untreated Asymptomatic Osteonecrosis improved and accelerated the diagnosis of implant infections. It
has the potential to replace the current standard approach of
of the Femoral Head collecting multiple periprosthetic tissue specimens.
Byung Woo Min, MD, Daegu, Korea, Republic of
Kwang Soon Song, MD, Taegu, Korea, Republic of PAPER NO. 575
Chul-Hyun Cho, MD, Joongu, Daegu Korea, Republic of Should Outer Surgical Gloves Be Changed Intra-
Ki-Cheol Bae, MD, Daegu, Korea, Republic of Operatively Before Prosthesis Implantation?
Kyung-Jae Lee, MD, Daegu, Korea, Republic of
Sebastian Dawson-Bowling, MD, East Sussex, United
Because there is no consensus regarding the risk of collapse of
Kingdom
the femoral head in asymptomatic avascular osteonecrosis of the
hip, we studied the risk factors for collapse. Between 1990 and James Smith, MRCS,
2000, we used magnetic resonance imaging to confirm asymp- David Butt, MRCS,
tomatic avascular osteonecrosis of the femoral head in 81 Howard Cottam, MRCS,
patients (81 hips) whose other hip had nontraumatic sympto- S Umansakar, MBBS,
matic osteonecrosis and monitored them prospectively for an Andrew Armitage, MD, East Sussex, United Kingdom
average of 8.3 years. By the latest follow-up examination, 31 hips ‘Double gloving’, common practice in arthroplasty surgery, has
(38%) were symptomatic and 26 (32%) hips had collapsed. The been shown to reduce sharp injuries, but is also widely believed
mean interval between diagnosis and collapse was 4.1 years. to decrease surgical infection. Many surgeons replace their outer
With collapse as the endpoint, the cumulative rates of survival gloves intraoperatively, but the validity of this practice has never
were 91.4% at 5 years, 76.5% at 8 years, 70% at 10 years, 53.9% been assessed. 21 consecutive knee and hip replacements were
at 13 years, and 24.2% at 16 years. There was no significant studied. The team double gloved prior to surgical site prepara-
correlation between collapse and patients’ age, sex, weight, tion. After draping, the surgeon’s outer gloves were pressed in
presumed cause of osteonecrosis, or length of follow-up period. turn onto 2 numbered blood agar plates (1 for aerobic, 1 for
Survival was significantly longer survival for hips with small anaerobic incubation) before being discarded and replaced by a
necrotic lesions (100%) or medium lesions (79%) than for large new gloves; the same undertaken by the assistant. Care was
lesions (9%) and for hips with Ohzono type A lesions (100%), taken to avoid contamination of inner gloves.The operation was
Ohzono type B (100%), or Ohzono type C1 (87%) than for hips undertaken normally. Immediately before prosthesis implanta-
with Ohzono type C2 (14%) lesions. Analysis showed that tion, outer gloves were pressed onto agars before being replaced.
extent of large lesions and location of Ohzono type C2 lesions Cement, if used, was inserted prior to changing gloves. 40 pairs
are risk factors for collapse. Asymptomatic hips without these of control gloves were obtained by normal scrubbing-up and
risk factors can be treated conservatively, with observation only. double gloving; the outer gloves being immediately pressed on
to agar without handling any object.All agar plates were imme-
PAPER NO. 574 diately transported to the microbiology department for culture
◆Sonication of Removed Orthopedic Devices and and analysis. Microbiology staff were blinded to whether agars
Calorimetry for Improved Diagnosis of Infection represented gloves changed pre-/intraoperatively, or were
controls. 168 gloves were studied, 4 pairs each from 21 patients
Michaela Maria Schneiderbauer, Basel, Switzerland undergoing joint replacement, as well as 40 control gloves. There
Andrej Trampuz, MD, was no growth from any of the control gloves. Of 42 pairs
Andreas Widmer, MD, removed after preparation, 5 (11.9%) grew organisms on culture
Beat Hintermann, MD, Liestal, Switzerland (p<0.05). 3 of these were from the assistant. From 42 gloves
Bacteria causing implant infections are growing as biofilms on removed intraoperatively, 10 (21.8%) were positive (p<0.05); 6
the surface of orthopedic devices. We hypothesize that the diag- of these were the assistant’s. Lower limb arthroplasty is widely
nosis of infection can be improved by dislodging biofilms from undertaken with excellent long term results. However, infection
implant surface using sonication, followed by culture and rate remains 0.5%-4%; any practice potentially reducing this is
calorimetry of the resulting sonicate. We prospectively included welcomed. Our data suggest that glove contamination occurs
patients >18 years old from May 2005 until April 2007 from during both draping and surgical approach. This supports
whom an orthopedic implant (joint prosthesis or internal fixa- current practice of replacing gloves pre- and intraoperatively.
tion device) was removed for any reason. The implants were
aseptically collected in a container with Ringer’s solution and PAPER NO. 576
sonicated in an ultrasound bath 5 min at 40 kHz. The resulting The Impact of Diabetes on Perioperative Patient
sonicate was (i) cultured on blood agar plates aerobically and
anaerobically and (ii) investigated for heat production from
Outcomes after THA and TKA in the United States
bacteria using an ultra-sensitive calorimeter (detection limit 0.25 Michael P Bolognesi, MD, Durham, NC
µW). Implant infection was defined by purulence surrounding Milford H Marchant, Jr MD, Chapel Hill, NC
the implant, growth in e2 specimens (synovial fluid and/or Nicholas Adam Viens, MD, Durham, NC
intraoperative tissue), acute inflammation in histopathology or Chad Cook, PT, PhD, MBA,
presence of a sinus tract. 846 implants were studied (367 joint In 2005, the prevalence of diabetes mellitus (DM) in people over
prostheses and 479 internal fixation devices), median age was 71 60 years of age reached 21% in the United States. The increasing
years, 45% were males. By above definition, 171 implants (20%) prevalence of diabetes will result in a steady increase in the
were infected and 675 (80%) were aseptic cases. The sensitivity number of diabetic patients who undergo total hip and knee
arthroplasty (THA and TKA). Diabetic patients have numerous PAPER NO. 578
disease related comorbidities. The specific aim of this study was Evaluation of the Accuracy and Utility of X-Ray
to determine if patients with DM have higher rates of perioper-
ative complications in the hospital following primary and revi- Markers in Digital Templating
sion THAs and TKAs. From 1988 to 2003, the Nationwide Christopher Bayne, Fremont, CA
Inpatient Sample (NIS) recognized 751,340 patients who under- Michael Tyler Krosin, MD, Emeryville, CA
went primary or revision THA and TKA; 64,262 (8.55%) had Thomas C Barber, MD, Oakland, CA
DM. Bivariate and multivariate analyses compared patients with With the growing use of digital x-rays, traditional radiographic
and without DM regarding common surgical and systemic templating for total hip arthroplasty is becoming more complex.
complications, mortality, and hospital course alterations. Fewer Newer computer programs combined with digital x-rays allow
diabetic patients had a routine discharge to home after surgery. for digital templating, but with digital image acquisition tech-
Diabetics had significantly higher inflation-adjusted hospital niques, image magnification is often unknown and variable.
charges for all procedures. Analyses of primary THA and TKA Our purpose in this study was to assess the potential accuracy of
demonstrated significant increases in the incidence of stroke, digital templating based on x-ray marker position, as well as the
pneumonia, urinary tract infection, ileus, and transfusion interobserver reliability of measurements using digital x-ray soft-
(p<0.001). Analyses of revision procedures also demonstrated ware. Radiographs of 106 patients who had recently undergone
similar trends toward more immediate perioperative complica- total hip arthroplasty were studied to determine the accuracy
tions in diabetic patients. Patients with DM have significantly and utility of two x-ray marker types. The markers, which are
increased risks for surgical and systemic complications during used to calibrate the templating software, were evaluated by
the index hospitalization, as well as greater likelihood of non- comparing measured to true x-ray magnification at 4 distinct
routine discharge, and higher hospital charges following total positions. The Pearson r coefficient was calculated as a correla-
hip and total knee arthroplasty procedures. The result is higher tion of measurements between investigators. We found that
cost, greater burden on the healthcare system, and greater risk to greater accuracy was obtained overall for markers placed at the
patients. level of the greater trochanter directly adjacent to the skin or
with no skin overlap than for markers placed with soft tissue or
PAPER NO. 577 bone overlap on x-ray. Flexible positioning markers provided
Obesity in Total Hip Arthroplasty: Does Size Matter? greater overall accuracy than adhesive x-ray markers. There is
J Glynne Andrew, MD, Bangor, Gwynedd, United Kingdom moderate to marked interobserver agreement based on our
Jeya Palan, MRCS, Oxford, United Kingdom Pearson r coefficient. We found that greater accuracy was
John Nolan, MD, Norwich, United Kingdom obtained overall for markers placed at the level of the greater
trochanter directly adjacent to the skin or with no skin overlap
Andrew J Hamer, MD, South Yorkshire, United Kingdom
than for markers placed with soft tissue or bone overlap on x-ray.
David W Murray, MD, Oxford, United Kingdom Flexible positioning markers provided greater overall accuracy
David J Beard, DPhil, Oxford, United Kingdom than adhesive x-ray markers. There is moderate to marked inter-
The incidence of obesity and the demand for joint replacement observer agreement based on our Pearson r coefficient.
are (independently) increasing in western populations. It is

thought that obese patients may have inferior outcome after PAPER NO. 579
total hip arthroplasty (THA). The aim of this study was to iden- Evaluate Simple Guidelines for Reducing Blood
tify if obesity has an effect on clinical outcomes following THA.
A prospective, multi-centre study on 1593 THAs was undertaken Transfusion in Total Joint Replacement Patients
with a follow up time of five years. Patients were categorised into Terry Lee Arrington, MD, Chattanooga, TN
the non-obese group with a body mass index (BMI) of < 30 Mark Freeman, MD, Chattanooga, TN
kg/m2 (mean 25.1 kg/m2) (1076 hips) and the obese group Paul M Apyan, MD, Chattanooga, TN
with a BMI e 30 kg/m2 (mean 33.2 kg/m2) (325 hips). A sub Thomas W Currey, MD, Chattanooga, TN
group analysis on patients with a BMI >40 kg/m2, termed Joseph Rudd, PhD, Chattanooga, TN
morbidly obese (mean = 44.7 kg/m2) (19 hips), was also
Research has linked allogeneic transfusions with immunosup-
performed. The Oxford Hip Score (OHS) was measured in both
pression, increased postoperative infections, and wound healing
groups pre-operatively and post-operatively with 962 THAs
problems. Transfusion rates are influenced by Hgb level, blood
available for follow-up review at five years. The primary outcome
loss, and Hgb level triggers. Studies show that outcomes of
measure was the change in OHS (‘OHS). Secondary outcome
patients with Hgb of 7 g/dl were not significantly different
measures included leg length discrepancy, dislocation, revision
compared to the traditional trigger of 10 g/dl. We collected retro-
rates, increased haemorrhage and wound infection. The mean
spective data from the records of 78 consecutive hip/knee
operating time was also recorded for each group. There was no
arthroplasty patients. Perioperative hemoglobin levels, type of
difference in ‘OHS at five years between the two groups
surgery, blood loss, units of allogeneic blood transfused, post-
(p=0.767). There were no significant differences in complica-
operative complications and missed physical therapy appoint-
tions or length of operating time between the groups. This study
ments were recorded. Simple transfusion guidelines were created
provides evidence that obese patients have as much to gain in
based on prior evidenced-based studies. We then applied our
terms of improved quality of life following THA. They should
prospective protocol to a cohort of 50 consecutive patients
not be discriminated against on the grounds of diminished clin-
undergoing total hip or knee arthroplasty. 34 patients (44%)
ical results following surgery.
received 82 units of allogeneic PRBCs in the retrospective group
compared to 8 patients (16%) receiving 15 units PRBCs in the
prospective group. The number of patients without comorbidi-
ties who were transfused was reduced from 17/53 (32%) to 4/30
(13%). Complications were present in 15% of the retrospective
group with none in the prospective group. Patients missing
401
physical therapy due to blood transfusions was reduced from and Cox regression were used to determine implant survivorship
95% (19/20) in the retrospective group to 50% (2/4) in the and hazard ratios associated with hospital and surgeon proce-
prospective group. The use of these simple transfusion guide- dure volume at 0.5, 2, 5, and 8 years. Hospitals with the highest
lines resulted in a significant reduction in the need for allogeneic THA (>100) and TKA (>200) annual volume accounted for
blood transfusions in our total hip and knee arthroplasty patient about one-third and one-quarter of primary hip and knee proce-
population. dures, respectively. One-sixth of primary THA and one-third of
primary TKA procedures were performed by surgeons with an
PAPER NO. 580 annual volume of more than 50 procedures. THA patients of the
Thrombosis Prevention in Total Hip Arthroplasty: highest volume surgeons (>50) had a higher implant survival
rate at 6 months than those of surgeons with volumes of 6-10
CECT vs LMWH and 11-25 (adjusted OR of 1.66 and 1.65, respectively). TKA
Clifford W Colwell Jr, MD, La Jolla, CA patients in lowest volume hospitals (1-25) had a higher risk of
Merrill A Ritter, MD, Indianapolis, IN revision at 5 and 8 years compared to those operated in highest
Mark I Froimson, MD, Cleveland, OH volume hospitals (>200) (adjusted OR of 1.63 and 1.57, respec-
Knute C Buehler, MD, Bend, OR tively). Our findings suggest that THA patients of low volume
Douglas E Padgett, MD, New York, NY surgeons have greater revision risk at 6 months but not at longer-
Robert T Trousdale, MD, Rochester, MN term follow-up. Also, TKA patients at low volume hospitals have
greater revision risk at 5- and 8- year follow-up.
Kenny Mai, MD, San Diego, CA
Michael A Mont, MD, Baltimore, MD PAPER NO. 582
The purpose of our prospective randomized study is to evaluate
effectiveness of a new mobile, miniature compression device ◆Reduction of Pulmonary Fat and Bone Marrow
(CECT) compared with low-molecular-weight heparin (LMWH) Embolism by Use of the Cement Canal Prosthesis in
for venous thromboembolic disease (VTED) prophylaxis after THR
THA. THA patients who consented are randomized to receive
Volkmar Jansson, PhD, Munchen, Germany
LMWH (enoxaparin 30 mg subcutaneously twice daily) or CECT
for 10 days. CECT patients begin treatment intraoperatively and
Tobias Duell, MD,
may receive 81 mg aspirin daily after surgery. LMWH patients Peter E Mueller, PhD,
receive first enoxaparin injection 12-24 hrs after surgery. After 10 Voges Ole, MD,
days, all patients undergo bilateral lower extremity duplex ultra- Thomas Grupp, MD,
sound to screen for DVT. Bleeding events and CECT compliance With respect to safety concerns, pulmonary fat- and bone-
are also documented. Clinical evaluation of DVT and PE are marrow embolism remains a significant risk in cemented total
done at 12 weeks. Two-sample t-test and chi-square test are used hip replacement (THR). Parvizi et al. reported a lethality of
for testing differences between LMWH and CECT groups. 0,16% in 14.469 cemented total hips due to pulmonary
Patients were evenly randomized to each group. Demographics embolism. Several studies have demonstrated a direct relation-
were similar between groups. Mean age was 60 years; mean BMI ship between intramedullary pressure increase and fat- and
was 28.1. CECT compliance rate was 87% over 10 days with bone-marrow intravasation and embolism. It has been shown
52.8% receiving aspirin postoperatively. Mean treatment was 9.4 that the surgical procedure including bone preparation, cement
(1-11) of 10 days for LMWH group. Distal and proximal DVT introduction and stem insertion determines the extent of the
occurred in 5% and 1.3% of CECT patients, respectively, embolism. We designed a randomized-controlled study to inves-
compared with 3% distal and 0% proximal DVT in LMWH tigate whether a reduction of intraoperative embolic events can
patients. PE occurred in 0% of CECT; 1.4% of LMWH with no be achieved by the use of a novel cemented stem system while at
fatal PE. Bleeding rate was 1.3% for CECT and 4.3% for LMWH. the same time optimizing implantation quality in terms of
At 12-week follow-up, no additional DVT or PE was found by cement penetration, stem position and reproducibility of the
clinical exam. Results demonstrate CECT to be noninferior to results. A novel hip stem system based on the secondary
enoxaparin in reducing VTED with decreased bleeding after cementing technique was developed. With this system, the stem
THA. is inserted into the femoral canal prior to the femur being
cemented.. Only after the stem is in place and its location veri-
PAPER NO. 581 fied, the cement is injected through a hole-system within the
THA and TKA Survivorship in the Medicare prosthesis. Another hole-system allows air and liquids to flow
out of the cavity. The position of the stem within the femoral
Population: Effect of Hospital and Surgeon canal is defined by a distal femoral plug and a proximal seal
Procedure Volume tightly connected to the implant. 15 patient in each group
Michael T Manley, PhD, Franklin Lakes, NJ received either a cement canal stem or a conventional stem
Kevin Ong, PhD, Philadelphia, PA which was implanted using a standard primary cementing tech-
Edmund Lau, MS, Philadelphia, PA nique. Transesophageal echocardiography (TEE) was used to
Steven M Kurtz, PhD, Philadelphia, PA record and analyze intraoperative embolic events in the right
atrium at five specific points of time. According to the literature,
Fewer complications following THA and TKA surgeries have
embolic events were graded from grade 0 (no event) to grade 3
been associated with greater hospital and surgeon procedure
(combination of snowlike echoes and emboli > 5 mm and/or
volume. It remains unclear if procedure volume is associated
macro emboli). Evaluation was performed off-line and double-
with implant survival. Our study examined the association
blinded by two independent trained investigators. A highly
between hospital and surgeon volume with THA and TKA
significant difference between the two groups was found. All 15
survivorship in the Medicare population at 6 months to 8 years.
patients (100%) of the standard cemented group experienced
1997-2004 Medicare claims data was used to identify primary
embolic events of grade 3 at least once during surgery. However,
and revision THA and TKA procedures. Kaplan-Meier method
only 3 patients (20%) of the cement canal prosthesis group
showed grade 3 events, 5 patients showed grade 2 and 7 patients PAPER NO. 584
only grade 1. A correlation between surgical procedures like Pay-for-Performance in Total Joint Replacement:
rasping of the femur and reduction of the joint and embolic
events could be confirmed. In this study, we were able to show Does it Improve Quality?
that embolic events occurring during the surgical procedure in Kevin John Bozic, MD, MBA, San Francisco, CA
cemented THR can dramatically be lowered by use of the cement Amanda Smith, Res Dir, San Francisco, CA
canal prosthesis, thus increasing patients` safety. Given the fact Hal Luft, PhD,
that due to the constructive features of the cement canal stem, David S Bradford, MD, Sausalito, CA
implant position and cement penetration are of reproducibly
Recent concerns over rising health care costs in the United States
high quality, this novel system represents a new class of stems in
and significant variations in clinical practice patterns have led
cemented THR. This study had shown the influence of the
some payers to create pay-for-performance (P4P) programs to
cementing technique of the hip stem during the implantation of
incentivize higher quality, more cost-efficient care. However, the
THR for the fat- bone-marrow embolism using transesophageal
performance measures used in many P4P programs are not
echocardiography.
evidence-based, calling into question their relevance in
improving quality and reducing costs. The purpose of this study
PAPER NO. 583
was to evaluate differences in practice patterns related to total
Can Standard Femoral Radiographs be used to hip replacement (THR) and total knee replacement (TKR) in a
Reliably Assess Osteoporosis? commercially insured population, and to determine whether
Haissam S El-Zaim, MD, Kingwood, TX adherence to payer-defined guidelines for THR and TKR are
associated with improved patient outcomes and lower overall
Philip C Noble, PhD, Houston, TX
cost of care. Administrative claims data were collected for all
Christopher C Clark, Erie, PA THR (n=7,282) and TKR (n=11,819) procedures completed
Molly M Usrey, BS, Houston, TX between January 1, 2003 and December 31, 2004 in a national
Jerry W Alexander, BS, Houston, TX commercial-payer population. Adherence to five payer-defined
Sabir Ismaily, BS, Houston, TX clinical practice guidelines was evaluated, including duration of
Michael A Conditt, PhD, Houston, TX time between initial referral and surgery, and the peri-operative
Different parameters have been proposed to assess the severity of utilization of imaging studies, injections, and physical therapy
osteoporosis of the femur using standard radiographs. In this (PT). Differences in practice patterns between geographic
study we assess the sensitivity, specificity, and accuracy of each of regions were compared using summary measures normalized
these measures compared to DEXA. Twenty-eight cadaveric for severity of illness. Correlations between adherence to payer-
femurs were obtained from female cadaveric donors ranging in defined practice guidelines and patient outcomes (complica-
age from 49 to 98 years. Standard AP and lateral radiographs tions and re-operations) and total episode of care costs (defined
were prepared of each specimen. The severity of osteoporosis as all costs (market adjusted) incurred within one year pre- and
was measured by dual energy x-ray absorptiometry (DEXA) and post-operative) were evaluated. : Adherence to payer-defined
a t-score was recorded for each femur. The degree of osteoporosis guidelines, patient outcomes, and total costs of care varied

of each femur was also predicted on the basis of (i) the thickness significantly by geographic region for both THR and TKR. Some
of the anterior cortex; (ii) the percentage of the width of the guidelines appeared too lenient (i.e. re-operation rates for TKR
diaphysis occupied by cortical bone (the Cortical Index), and within 6 months ranged from 16-20% of the target guideline of
(iii) the Dorr classification (Type A, B, C), based on the shape of 8%), while others were too stringent (i.e. post-operative PT rates
the medullary canal and the posterior cortex. This data was used for total hip replacement within 3 months ranged from 259-
to calculate the sensitivity and specificity of each radiographic 284% of the target guideline of 20%). Re-operation rates within
method. Based on DEXA values, the 28 femora ranged from 1 year varied significantly among geographic regions for both
normal (1) to osteopenic (6), osteoporotic (12), and severely THR and TKR. Adherence to payer-defined guidelines did not
osteoporotic (9). Using the 3 different parameters, the femora correlate with either patient outcomes or total episode of care
were correctly classified in 81% of cases using the Cortical Index, costs. Significant variation in practice patterns related to the peri-
70% based on the medial cortical thickness and 67% based on operative care of TKR and THR patients exists between different
the Dorr classification. The sensitivity and specificity of the three geographic regions of the U.S. Further study is necessary to
methods in detecting osteoporotic cases were: Cortical Index: define evidence-based practice guidelines, and to objectively
95%/100%; medial cortical thickness: 86%/50%; and Dorr clas- investigate the correlation between adherence to performance
sification: 81%/67%. Critical cut-off values for the Cortical Index measures, clinical outcomes, and cost of care. The results of our
were 0.44 for osteopenia/osteoporosis, and 0.33 for mild/severe study suggest that adherence to non evidenced-based, payer-
osteoporosis. Our study confirms that radiographic indices can defined practice guidelines is not associated with improved
be used to accurately classify femora according to their degree of quality or lower costs. These findings underscore the need to
osteoporosis. Of the parameters examined, the Cortical Index define evidence-based performance measures for use in P4P
provides the greatest sensitivity, specificity, and accuracy, and is programs.
readily applied to plain AP radiographs.
403
PAPER NO. 585

An Analysis of Medicare Payment Policy for Total
POSTERS
Joint Replacement
Kevin John Bozic, MD, MBA, San Francisco, CA POSTER NO. P001
Daniel J Berry, MD, Rochester, MN Extended Sliding Trochanteric Osteotomy for
Thomas P Sculco, MD, New York, NY Revision Hip Arthroplasty
Harry E Rubash, MD, Boston, MA David Backstein, MD, Toronto, ON Canada
Medicare payment policy for total joint replacement (TJR) was Gerald Lim, MD, Toronto, ON Canada
modified in 2005 to reflect differences in resource utilization Petros J Boscainos, MD, Perth Scotland, United Kingdom
between primary and revision TJR procedures. However, policy
Oleg Safir, MD, Toronto, ON Canada
makers have recently recommended using APR-DRG severity of
Allan E Gross, MD, FRCSC, Toronto, ON Canada
illness (SOI), a measure of medical co-morbidities, as the
primary predictor of resource utilization, without accounting for The purpose of the study was to compare the rate of union,
procedure characteristics, such as surgical complexity. The factors affecting the rate of union, and complications, namely
purpose of this study was to compare patient characteristics, hip dislocations, in the modified extended sliding trochanteric
procedure characteristics, and resource utilization among TJR osteotomy, as performed by the senior author, with other similar
procedures, and to identify useful predictors of resource utiliza- studies. This osteotomy differs from those previously described,
tion in TJR. Clinical, demographic, and economic data was by preserving the posterior part of the greater trochanter and its
collected from 6,483 patients who underwent primary or revi- attached external rotators, leading to a lower rate of hip disloca-
sion TJR between October, 2005 and June, 2006 at one of four tion. We reviewed the results of 48 extended sliding trochanteric
high-volume TJR centers located in four different geographic osteotomies performed between March 2000 to March 2006.
regions of the United States. Costs were normalized to one The mean age at the time of revision surgery was 69 years. The
center to account for differences in procedure costs across indications for revision surgery were aseptic loosening in 41
centers. Descriptive analyses were conducted, as well as compar- cases, infection in 3 cases, peri prosthetic femoral fracture in 3
isons by ICD-9-CM procedure code (using ANOVA and post-hoc cases, and recurrent dislocation in one case. The rate of union at
Dunnetts t-test methodology). A linear regression was a mean follow up of 28 months was 95.8%. The hip dislocation
performed to predict total standardized costs by APR-DRG rate was 4.2%. Our series of extended sliding trochanteric
severity of illness (SOI) and surgical complexity. Surgical osteotomies shows a low dislocation rate by way of preservation
complexity was defined by both patient factors (e.g., major bone of the attachment of the external rotators, and exhibits a union
loss) and procedure characteristics (e.g. primary vs. revision, type rate comparable to that of other series.
of revision). Both severity of illness and surgical complexity
influenced resource utilization associated with TJR procedures,
POSTER NO. P002
with costs increasing with higher SOI values and more complex Are Acetabular Component Alignment Guides for
surgical procedures. Controlling for SOI, surgical complexity still Total Hip Arthroplasty Reliable?
resulted in higher costs for each SOI category for both THR
Yukihide Minoda, MD, Osaka, Japan
(between 25% and 34% higher) and TKR (between 22% and
29% higher) procedures. While severity of illness was found to
Kenji Ohzono, MD, Suita, Japan
be a useful predictor of resource utilization associated with TJR Masaharu Aihara, MD, Toyonaka, Japan
procedures, our research indicates that both SOI and surgical Naoya Umeda, MD, Hyogo, Japan
complexity are important independent predictors of resource Masuhiro Tomita, MD, Osaka, Japan
utilization in TJR. Since a primary goal of Medicare payment Keiko Hayakawa, MD, Hyogo, Japan
policy is to set payment rates proportional to relative resource The acetabular component orientation of total hip arthroplasty
use, both SOI and surgical complexity should be incorporated is of critical importance to the clinical results. Thus it has been
for payment equity to ensure appropriate access to care for TJR believed that the acetabular component should be implanted in
patients. the so-called ‘safe range’, which is based on the ‘radiographic’
definition. Although navigation systems have recently been
introduced, acetabular component alignment guides are still
used in most of ordinary hospitals. However, the documenta-
tion provided by manufacturers for such guides does not
routinely indicate which definitions of acetabular component
orientation have been used. Sixteen types of alignment guide
obtained from eight manufacturers were examined to determine
the definitions (radiographic, operative, or anatomical defini-
tions) used, and their accuracy. Only one guide for inclination
and three guides for anteversion used ‘radiographic’ definition,
which definition was used for postoperative evaluation of
acetabular component orientation. In three guides, the angle
which manufacturer stated in documentation and the angle
directly measured were different. The maximum difference was
7.5 degrees. Usage of alignment guides misleads anteversion
into decrease by a mean of 5.9 degrees (maximum: 12 degrees),
and inclination into increase by a mean of 1.4 degrees
(maximum: 4 degrees) in ‘radiographic’ definition, because
most of guides did not use ‘radiographic’ definition. The current
study showed that the definitions used by acetabular alignment 12 months; and yearly postoperatively. Linear wear of the highly
guides were inconsistent, and the angle indicated by some cross-linked polyethylene wear was measured and the preva-
guides was incorrect. Such setting of alignment guides could lence of osteolysis was determined. Preoperative Harris hip
result in error in acetabular component orientation. The defini- scores (39 vs 41 points) and postoperative Harris hip scores (93
tion and accuracy should be checked prior to use of acetabular vs 94 points) were similar in both group. One hp (1%) with
alignment guides. alumina-on- alumina bearing had clicking sound. No acetabular
or femoral component had aseptic loosening in either group.
POSTER NO. P003 The mean annual wear of the highly cross-linked polyethylene
Tapered Anatomic Cementless Alumina-on- was 0.06±0.03mm. No hip in either group had acetabular or
femoral osteolysis. Contemporary anatomic tapered cementless,
Alumina-Bearing THA in Young Patient with AVN of alumina-on-alumina or alumina-on-highly cross-linked poly-
Femoral Head ethylene bearing THA had excellent clinical and radiographic
Young-Hoo Kim, MD, Seoul, Korea, Republic of outcomes with no osteolysis in our young active patients.
Sung-Hwan Yoon, MD,
Jun-Shik Kim, MD, POSTER NO. P005
We hypothesized that contemporary tapered anatomic cemen- Minimally Invasive Hip Resurfacing
telss, alumina-on-alumina bearing THA would improve the Gursharan Chana, Birmingam BI, United Kingdom
longevity of prosthesis and reduce the prevalence of osteolysis in A new surgical approach for minimally invasive hip resurfacing
young active patients with AVN of femoral Head. Furthermore, is described with early results. A posterior gluteus maximus split-
we investigated the bone quality of acetabulum and proximal ting approach is used. The incision is in line with the fibres of
femur by histological analysis. Also, we documented the preva- gluteus maximus and is placed 5 cm. distal to the tip of the
lence of clicking or squeaking sounds. Patients studied included greater trochanter. Special instruments were necessary to carry
50 with a bilateral THA and 72 with a unilateral THA (85 men out surgery - MIS targeting device for placement of centring pin,
and 37 women; 172 hips), all with Ficat and Arlet stage III or IV MIS retractor system, Chana curved acetabular reamer handle,
AVN of femoral head. The mean age of the patients was 42.9 and curved acetabular impactor. 136 operations were carried out
(24-49) years. Mean duration of follow up was 5.9 (range, 5-7) from December 2001 to February 2006Average age of the patient
years. Clinical (Harris hip score) and radiographic follow-up was was 56 years (range 30-78 years)Average body mass index was
performed at 6 weeks, 3 months, 6 months, and 1 year, and 32 (range 17.5 to 41.7)Average incision range was 7 cm. (range
yearly thereafter. Cancellous bone biopsies from actabulum and 6-10 cm.)Average blood loss was 245 ml (range 100-800 ml)All
proximal femur were examined histologically. The mean Harris these patients were sent a postal questionnaire and 115 were
hip score was 41 points preoperatively and 96 points at final returned (84.5%).The average review period was 26 months
follow-up. The prevalence of clicking sound was 1% (2 hips in 1 (range 6-56 months)The median Oxford score was 9.38% and
patient). The majority of hips with idiopathic or ethanol-associ- the mean COOP score was 29.8%. There were 2 fracture neck of
ated ON had normal or nearly normal bone in the acetabulum femurs, one at 6 weeks and the other at 4 weeks post surgery.
and the proximal part of the femur. All acetabular and femoral Both of these were revised using the same approach with

components were deemed to have bone ingrown. No acetabular modular head hip replacement system giving a success rate of
of femoral osteolysis was identified. We proved our hypothesis 97.8% in situ at 26 months (average). There were no cases of
that the tapered anatomic cementless femoral stem with infection, nerve palsy, dislocation and hypertrophic bone forma-
alumina-on-alumina bearing achieved excellent clinical and tion. Minimally invasive hip resurfacing can be done safely
radiographic results with no osteolysis. through minimally invasive approach using special instruments
and the early results are very good.
POSTER NO. P004
Comparison of Al-on-Al and Al-on-Highly X-Linked POSTER NO. P006
PE Bearing THAs in the Same Patients Under 50 ◆Revision of 65 Alumina Cups With PE Cups ( a 15
Years Years Study): Strategy for the Femoral Head?
Young-Hoo Kim, MD, Seoul, Korea, Republic of Philippe Hernigou, PhD, Creteil France, France
Yoowang Choi, MD, Georges Laval, MD,
Oh-Ryong Kwon, MD, Marc Antoine Rousseau,
Jun-Shik Kim, MD, After revision of alumina cups with a polyethylene socket
The hypothesis of the present study was that contemporary without revision of the stem, there are 3 options for the femoral
anatomic tapered cementless THA using alumina-on-alumina or head: keeping the old alumina head with risk of metallic debris
alumina-on highly cross-linked polyethylene bearing would transfer and increased surface roughness; a new alumina head
improve the clinical outcome and reduce the prevalence of oste- on the old taper (risk of fracture); or a new metal head on the
olysis in young patients. A prospective, randomized study was old taper (risk of adherence of third-body particles on metal and
performed to evaluate the outcomes in 100 patients who under- increased surface roughness). 65 patients had an alumina cup
went sequential bilateral cementless THAs performed in the retrieved (loosening, luxation, impingement, or fracture) and
same patients younger than 50 years of age. Alumina-on- changed for a polyethylene cup without revision of the stem.
alumina bearing was used in one hip, and an alumina-on-highly Three different femoral heads were used. This study evaluated
cross-linked polyethylene bearing was used in the other. Femoral polyethylene wear after a mean follow-up of 17 years (15 to 25
stem and cup were identical in both hips. There were 66 men years) . Revisions were performed between 1982 and 1990. All
and 34 women; the mean age was 45.3 (25 to 49) years. The the polyethylene cups were cemented and made by the same
mean FU was 5.6 (5-7) years. Clinical and radiographic evalua- manufacturer. The old alumina femoral head was kept in 20
tions were performed preoperatively, and at 6 weeks; 3, 6, and patients; 19 new alumina and 26 new metal heads were
implanted on the original taper. All the femoral heads were 32
405
mm and made by the same manufacturer as the manufacturer of femoral head is considered an indication for RAO, even in
the old alumina hip. The mean age at revision was 63 years (48- advanced stages. In contrast, patients with a deformed femoral
74). The cohort was reviewed more than 15 years after surgery to head and advanced osteoarthritis may experience progression to
determine wear. We measured polyethylene wear radiologically end-stage with this procedure.
by determining the migration of the centre of the femoral head
relative to the centre of the cup. By comparing the co-ordinates POSTER NO. P008
of the two centres on the initial postoperative and most recent Rotational Acetabular Osteotomy for Early Stage
radiographs, the amount and the direction of penetration of the
femoral head into the polyethylene were determined after
Osteoarthritis Secondary to Dysplasia of the Hip
correction for pelvic tilting and magnification. Although the Kunihiko Okano, MD, Nagasaki, Japan
migration of the femoral head thus determined may consist not Hiroshi Enomoto, MD, Nagaski, Japan
only of true wear, but also creep deformation of polyethylene, Makoto Osaki, MD, PhD, Nagasaki, Japan
we defined it as linear wear for the purpose of this study. These Hiroyuki Shindo, MD, Saitama, Japan
65 hips were compared for wear with 65 matched primary This study examines the results of rotational acetabular
arthroplasties (same follow-up) of the same manufacturer (35 osteotomy (RAO) procedures in patients with early-stage
alumina and 30 metal heads). For the 65 matched primary hips osteoarthritis secondary to the developmental dysplasia of the
the mean linear PE wear rate was 0.07 mm/year (range 0.05 to hip, and discusses the indications for this surgery in patients
0.09 mm/year) with the 25 alumina heads, and 0.12 mm/year with a deformed femoral head. We conducted a retrospective
(range 0.08 to 0.15 mm/year) with the 20 metal heads. For the review of the results of RAO procedures in 49 hips (48 patients;
65 hips with retrieved alumina cups, the mean linear PE wear (43 female, 5 male). All patients had radiographical evidence of
was 0.08 mm/year (range 0.06 to 0.10 mm/year) in the 19 hips early-stage osteoarthritis. The mean age was 33.0 (range, 13 to
with a new alumina head, 0.24 mm/year (range 0.17 to 0.28 54) years at surgery, and the mean duration of follow-up was
mm/year) in the 20 hips with their old alumina head and 0.25 13.2 (range, 10 to 17) years. To evaluate deformity of the femoral
mm/year (range 0.16 to 0.29 mm/year) in the 26 hips with a head, the round index of the femoral head was measured on
new metal head. After revision of an alumina cup with a PE cup preoperative radiographs. Clinical follow-up was performed
, wear was significantly (p<0.05) increased with new metal using the Merle d’Aubigné and Postel system. The mean preop-
heads (alumina third-body particles?) as compared with erative clinical score was 12.5 points; this score improved to 16.6
primary arthroplasty. Old alumina heads were not associated points at the most recent follow-up (P < 0.0001). Radiologically,
with reduced polyethylene wear as compared with metal heads this procedure produced adequate improvement in femoral
probably because the surface quality was poor (first generation head coverage. At follow-up, osteoarthritic stage was unchanged
of alumina heads, metallic debris transfer). Wear was reduced in 38 hips and had progressed in 11 hips. Two of the 11 hips with
after revision (as in primary arthroplasty) with new alumina progressed osteoarthritic stage had obvious technical failure and
heads with excellent surface quality. were excluded from subsequent comparison. The mean preop-
erative round index of the femoral head was significantly
POSTER NO. P007 different among the 38 hips that maintained their osteoarthritic
Rotational Acetabular Osteotomy for Advanced
stage versus the 9 hips that progressed (54.7% and 67.8%,

Osteoarthritis Secondary to Dysplasia of the Hip respectively; P < 0.001). Patients with a deformed femoral head
may experience progression of osteoarthritis within 10 years
Kunihiko Okano, MD, Nagasaki, Japan
after the RAO procedure even in early-stage osteoarthritis.
Hiroshi Enomoto, MD, Nagaski, Japan
Makoto Osaki, MD, PhD, Nagasaki, Japan POSTER NO. P009
Hiroyuki Shindo, MD, Saitama, Japan Radiographic Assessment of Leg Length
Satisfactory long-term results have been reported using rota-
tional acetabular osteotomy (RAO) to treat early osteoarthritis.
Discrepancy in Total Hip Arthroplasty
This study examines the results of RAO procedures and discusses Geert Meermans, MD, Edegem, Belgium
the indications for this surgery in patients with advanced Fares Sami Haddad, FRCS, London, United Kingdom
osteoarthritis secondary to developmental dysplasia of the hip. Although leg lengthening may be required to provide a stable
We performed a retrospective review of the results of RAO proce- hip joint, patient dissatisfaction with leg-length discrepancy
dures in 42 patients (44 hips). All patients had radiographic (LLD) is the most common reason for litigation after total hip
evidence of advanced-stage osteoarthritis. Forty patients were arthroplasty (THA). LLD after THA has also been associated with
women, and two were men. The mean age was 43.4 years at complications including nerve palsy, low back pain, and
surgery, and the mean duration of follow-up was 12.1 years (8 abnormal gait. It is well recognized that preoperative pelvic radi-
to 19 years). Clinical follow-up was performed using the Merle ographs are helpful in assessing LLD, but are also subject to vari-
d’Aubigné and Postel system. To evaluate deformity of the ation because of changes in the position of limbs and pelvis.
femoral head, round index of femoral head were measured. The Different methods are used to determine the LLD. The goal of
mean preoperative clinical score was 10.8 points preoperatively; this study is to compare the different methods for preoperative
this score improved to 13.5 points at the latest follow-up radiographic measurement of LLD. We evaluated LLD on 20 full
(P<0.001). Radiologically, this procedure produced adequate leg measurement films. Afterwards, LLD was measured on the
improvement regarding femoral head coverage. At follow-up, anteroposterior pelvic view of the same radiograph. The biis-
osteoarthritic stage was improved in 11 hips, unchanged in 22 chial line (BI) and interteardrop line (IT) were used as a pelvic
hips, and had progressed in 11 hips. The mean preoperative reference, and lesser trochanter (LT) and center of the femoral
round index of the femoral head was significantly different head (CH) as the femoral reference. Films with rotation or tilt of
among the 33 hips that improved or maintained their the pelvis or femur were excluded. The true leg length discrep-
osteoarthritic stage versus the 11 hips that progressed (53.7% vs ancy varied from -3.8 to 9.0 mm. The mean difference of the
63.7%, respectively; P<0.001). Osteoarthritis with a round methods varied from -0.15 mm for LT-IT (range -2.6 to +2.8
mm) to +2.26 mm for LT-BI (range -9.2 to +10.1 mm). There compared between these three groups. The average femoral neck
was a statistical significant difference (p<0.01) and a clear trend anteversion was 20.4 (range: 0 to 43) in the atrophic type, 28.6
(p=0.11) when comparing the true LLD with LT-BI and the CH- (8.5 to 40.9) in the normotrophic type, and 36.5 (20 to 51.2) in
BI respectively. No statistical difference could be found the hypertrophic type. The acetabular angle was 43.7 (36 to 51),
comparing the true LLD with the IT as a pelvic reference, regard- 43.6 (35 to 55), and 44.4 (28 to 54) in each group, respectively.
less of the femoral reference. Pelvic radiographs are still Significant differences between each group (P < 0.05) were
frequently used to estimate the preoperative LLD in hip arthro- observed only in femoral neck anteversion. Our data suggest
plasty, however, our data show that there is a difference with the that femoral neck anteversion influences osteophyte formation
true LLD. The use of the biischial line as a pelvic reference in advanced degenerative hip osteoarthritis. We suspect an
should be discouraged and the interteardrop line is a better alter- increase in anteversion of the femoral neck when total hip
native. There was no statistical difference when using either the arthroplasty is performed in patients with hypertrophic type
lesser trochanter or the center of the head as a femoral reference. osteoarthritis.
POSTER NO. P010 POSTER NO. P012

Identification and Treatment of Anaemia in Patients It is More Than Just Trochanteric Bursitis
Awaiting Hip Replacement Mohammed Atef Diab, DR, England, United Kingdom
Benedict Rogers, MBBS, Woking, United Kingdom Lateral hip pain is frequently a challenging daignostic and ther-
Chris Alcock, MD, apeutic problem with complex differential diagnosis. In the past,
the presentation of chronic lateral hip pain with tenderness over
Andy Cowie, MRCS,
the greater trochanter was attributed to trochanteric bursitis.
John Rosson, FRCS,
Recently it becomes increasingly obvious that refractory
The correction of anaemia prior to hip arthroplasty reduces trochanteric bursitis is a manifestiation of more serious under-
surgical risk, hospital stay and cost. This study considers the lying pathology rather than being a primary diagnosis of its
benefits of implementing a protocol of identifying and treating own. In this study, we reviewed orthopaedic literature, to outline
pre-operative anaemia whilst the patient is on the waiting list for the development of the new concept of lateral hip pain
surgery. From a prospective series of 322 patients undergoing syndrome and its undelying pathology. A literature search was
elective total hip arthroplasty (THA), patients identified as performed using MEDLINE; reviewed articles consisted of arti-
anaemic (Hb<12 g/dl) when initially placed upon the waiting cles in English language catalogued between 1990 and June
list were appropriately investigated and treated. Pre- and post- 2006. The pathology of refractory trochanteric bursitis and
operative haemoglobin (Hb), need for transfusion, and length abductor tendinopathy were obtained from various pertinent
of hospital stay were collated for the entire patient cohort. 8.8% texts and journal articles. Pathoanatomy of tendinous attach-
of patients were anaemic when initially placed upon the waiting ments to the greater trochanter and Radiological manifestations
list for THA and had a higher transfusion rate (23% to 3%, of the underlying pathology were explored. Different options of
p<0.05) and longer hospital stay (7.5 to 6.6 days, p<0.05). Over treatment were discussed. Different names are found in
40% of these patients responded to investigation and treatment Literature to describe the condition of refractory trochanteric

whilst on the waiting list, showing a significant improvement in bursitis and the underlying tendinopathy, the most common of
Hb level (10.1 to 12.7 g /dl) and improved transfusion rate. which are: greater trochanter pain syndrome (GTPS), lateral hip
Assessment of anaemia at the time of listing for elective surgery pain syndrome, rotator cuff tears of the hip. The emphasis in
allows the waiting list time to be utilized for investigation and literature is that the conjoint tendon pathology of both gluteus
treatment resulting in reduced overall transfusion requirements medius and minimus, as revealed by MRI scans, is probably
more frequent than heretofore commonly recognized. Many
POSTER NO. P011 operative treatments for resistant refractory trochanteric bursitis
Femoral Neck Anteversion and Osteophyte are mentioned in literature, ranging between soft tissue decom-
Formation in Patients with Osteoarthritis of the Hip pression and osteotomy of greater trochanter. In a large majority
of patients, trochanteric bursitis or distension will accompany
Ko Chiba, MD, Nagasaki, Japan
an abductor tendon tears. The frequent coexistence of
Kunihiko Okano, MD, Nagasaki, Japan trochanteric bursitis and abductor tendinopathy has led some
Hiroshi Enomoto, MD, Nagaski, Japan authors to suggest that the bursitis may in fact be a result of the
Makoto Osaki, MD, PhD, Nagasaki, Japan underlying tendinopathy. One should therefore be careful in
Hiroyuki Shindo, MD, Saitama, Japan providing an isolated diagnosis of trochanteric bursitis without
There are various types of osteoarthritis regarding osteophyte first closely inspecting the abductor tendons. The MRI appear-
formation secondary to developmental dysplasia of the hip. The ance of tendinosis and tears of the abductor tendons of the hip
purpose of this study was to investigate the relationship between is the same as in other locations and includes alterations in
femoral neck anteversion, acetabular angle, and osteophyte tendon signal and caliber.Conclusion: Tendinopathy of the
formation in patients with osteoarthritis of the hip. We studied abductor tendons of the hip is becoming increasingly recog-
104 patients (91 women, 13 men) with end-stage osteoarthritis. nized as a significant cause of GTPS/lateral hip pain. trochanteric
The mean age was 61.5 years (range: 36 to 82 years). Osteophyte bursitis rather than being the primary abnormality, is often a
formation and acetabular angle were evaluated using an antero- manifestation of the underlying abductor tendon pathology.
posterior radiograph. Femoral neck anteversion was measured The presence of refractory trochanteric bursitis should thus
using computed tomography with its definition as the angle prompt a caution evaluation of the abductor tendons. MRI
formed between the posterior bicondylar plane and femoral allows accurate detection of the tears and allows effective treat-
neck axis. On the basis of the classification of Bombelli, evalu- ment planning in such cases.
ated in terms of osteophyte formation, 52 hips were graded as
atrophic type, 24 as normotrophic type, and 28 as hypertrophic
type. Femoral neck anteversion and acetabular angle were
407

Stability of Revision Acetabular Components Using Modified Posterior Approach for Revision Total Hip
the Rim-Fit Technique Arthroplasty
Jason Edward Lang, MD, Winston-Salem, NC Samuel Sanders, MD, New York, NY
Aaron K Salyapongse, MD, Pleasanton, CA Steven Andrew Stuchin, MD, New York, NY
David Richmond Whiddon, MD, Suffolk, VA Jennifer E Millman, BA, Philadelphia, PA
Darius M Moezzi, MD, Flagstaff, AZ Polyethylene failure accounts for an increasing number of late
James V Bono, MD, Boston, MA aseptic problems in patients who undergo total hip replacement.
Eric Louis Smith, MD, Newton, MA It is often necessary to create a very generous exposure to bring
This study is designed to examine the intermediate-term stability about isolated modular polyethylene exchange while contending
of one method of dealing with large, medial cavitary acetabular with a femoral component that will be preserved. If the surgeon
deficiencies, the rim-fit technique. Use of the rim-fit technique in elects the posterior approach, exposure may require extensive
revision acetabular surgery was reviewed for 20 hips in 18 dissection and resection of stabilizing soft-tissue structures. The
patients. Defects at revision surgery included isolated medial immediate morbidity associated with in creased tissue resection
segmental and global cavitary deficiencies with largely intact is obvious. The long-term consequences, however, may include
peripheral rim. Morsellized allograft and/or autograft was placed chronic instability despite well-aligned components, which is
behind a cementless cup achieving rim purchase in all cases. The difficult to explain to a patient with a previously successful
average follow-up period was 66.3 months (5.5 years), (range 27 arthroplasty who experiences recurrent dislocation after a simple
to 112 months). Cup migration was assessed using digital radi- polyethylene exchange. Between 2003 and 2006, the senior
ography. Average vertical migration was 0.17 mm superiorly, and author performed 50 hip revision procedures employing the
average horizontal migration was 0.8 mm medially. The abduc- modified posterior oblique trochanteric osteotomy approach.
tion angle changed on average by 0.25 degrees. Rim-loading of There were 18 men and 27 women. Ages ranged from 32 to 88
the cementless acetabular prosthesis using this technique for years with an average of 60. Underlying diagnoses included
treatment of cavitary acetabular defects is associated with osteoarthritis, hip dysplasia, rheumatoid arthritis, avascular
component stability and minimal component migration at this necrosis and sepsis. Procedures included polyethylene and
follow up interval modular femoral head exchange, socket revision and femoral
head exchange, stem revision and complete revision. All well
POSTER NO. P014 fixed undamaged components were preserved. Socket revision
was performed for loosening or locking mechanism damage
Isolated Liner and Ball Exchange in Revision THR usually secondary to polyethylene failure and metal on metal
Does Not Lead to Increased Risk of Dislocation wear. Stem revision was performed for fixation failure. Post oper-
David F Dalury, MD, Baltimore, MD ative precautions against dislocation were advised for six weeks
Douglas A Dennis, MD, Denver, CO and included: use of an abduction pillow at night, directions
Mary Jo Adams, BSN, Towson, MD against hip flexion beyond 90 degrees, adduction or internal rota-
tion. No hip braces or knee orthoses were used in this series.

Several reports have documented high dislocation rates
Routine follow up radiographs were obtained in the operating
following polyethylene revision in THR. This study reviews the
room, at six weeks, six months one and two years. Clinical
outcomes of a group of patients who underwent isolated liner
CorrelationA limited clinical series has identified no problem
and ball exchanges for revision THR performed for lysis or wear
referable to this exposure. No loss of reduction or nonunion has
alone. 44 hips in 41 consecutive patients were revised for osteol-
been encountered. patients’male’female’18 (40%)‘ 27 (60%)‘
ysis or wear with the shell and stem retained. Average follow-up
45age’ 57.75’ 56.95’ 59.9right’ 18(69%)‘ 8 (21%)‘ 26 (52%)left’
was 60.2 months (range 36-95 months). 2 patients were lost to
12(50%)‘ 12 (50%)‘ 24 (48%)ebl’ 1305’ 800’ 995time’ 230.6’
follow-up. All femoral heads were size 28 or 32. An abduction
238.8’ 236liner/head’ 10’ 12’ 22 (44%)R Cup/head’ 6’ 10’ 16
brace was used when necessary, with the decision to use a post
(32%)R stem’ 1’ 1’ 2 (4%) complete R’ 5’ 5’10 (20%)
op brace based on intra-operative range of motion. 2 patient
Polyethylene liners of modular acetabular components wear
dislocated- one at 8 months post op and had two subsequent
sometimes need to be replaced, despite the metal shell being well
dislocations and was eventually revised. One patient had a
fixed. Replacing the liner is a relatively simple procedure, but very
single dislocation at one year treated with closed reduction.
little is known of the outcome of revision. We have reviewed
There were no other episodes of instability or subluxation. There
several studies that investigate polyethylene liner exchanges, most
were no other operations. There were no wound problems and
of which have been fraught with a high percentage of complica-
no symptomatic leg length discrepancies. Harris Hip scores were
tions, significantly dislocation. Most of the studies involve a
not significantly changed from pre-op scores (84-86). There
repeat of the original surgical approach to the hip, which, in our
were no other implants radiographically loose or at risk at last
opinion, may lead to soft tissue tension compromise, laxity, and
follow-up. Contrary to other reports, this group of THR patients
ultimately, dislocation.
who were revised for lysis or wear had very low complication
rates and tolerated the procedure well. If a patient demonstrates
intraoperative instability, the use of an abduction brace appears
to be helpful to ensure post op stability.
POSTER NO. P016 thigh pain (p = 0.30) or a limb-length discrepancy (p = 0.34).

Modular versus Non-Modular Porous Stems in Harris hip scores correlated strongly with patient satisfaction
after RHA. Patients with moderate/severe hip pain, limited
Revision Hip Arthroplasty: Minimum 5-Year Results walking ability and those with anxiety or depression were less
Stefan R Jibodh, MD, Allston, MA satisfied with their outcome. The presence of thigh pain or a
Jeffrey S Zarin, MD, Brookline, MA limb-length discrepancy was of less importance to patients.
Henrik Malchau, MD, Boston, MA Patients who are expected to have limited walking ability after
Shawn Anthony, BS, Boston, MA RHA (for medical or other reasons) should be counseled
Daniel M Estok II, MD, Newton, MA regarding the possibility of a less satisfactory outcome.
The purpose of this study was to compare the outcomes of a POSTER NO. P018
modular extensively porous-coated implant to those of the non-
modular extensively porous-coated implants used at our institu- Proximal Femoral Biological Reconstruction in
tion. We retrospectively studied a consecutive series of patients Patients with Non-Neoplastic Disorders
who underwent revision hip arthroplasty with the above Martin Buttaro, MD, Buenos Aires, Argentina
components at a single institution and by a single surgeon. Fernando Martin Comba, Buenos Aires, Argentina
Clinical and radiographic outcomes were recorded at a
Francisco Piccaluga, MD, Buenos Aires, Argentina
minimum of five years (range, 5.0 to 9.3 years). The final study
groups included 26 hips (26 patients) treated with a non- Complete absence of the proximal femur due to loss of bone
modular stem and 57 hips (55 patients) treated with the stock is a rising condition in patients with multiple previous
modular stem. At baseline, the groups were comparable (p > failed revision procedures. We reviewed the outcome of biolog-
0.05) in terms of age, indication for revision, number of ical reconstructive surgery with the use of a circumferential metal
previous revisions, Charnley class and femoral bone loss. At mesh, impacted bone allografts and a cemented stem in patients
follow-up, there were no significant differences between the with massive bone loss of the proximal femur due to non-
groups in terms of EQ-5D(index), Harris hip score (81 and 81, neoplastic conditions. Thirteen patients with a mean age of 67
respectively), dislocation rate (8% and 10%, respectively), or years and severe proximal femoral bone defects (average 12 cm
thigh pain (0% and 7%, respectively). There was less proximal long) were reconstructed with a circumferential metal mesh,
stem ingrowth in the non-modular group (54% versus 98%, p < impacted bone allografts and a cemented stem. The indications
0.001), particularly in zone one (23% versus 84%, p < 0.001). were septic failures in 6 patients, aseptic loosenings in 3 and
Five-year survival free from revision for aseptic femoral loos- periprosthetic fractures in 4 patients. None of the patients died
ening was 95% in the non-modular group and 100% in the or were lost to follow-up. Preoperative Merle D’Aubigne and
modular group due to early failures in the nonmodular group (p Postel score averaged 4.8 points. The mean duration of follow-
= 0.05). Five-year survival free from revision for any reason was up was 38 months (range 25 to 60 months). There was a signif-
89% and 90%, respectively (p = 0.52). The two study groups had icant improvement in the functional score (p<0.05). We
similar mid-term clinical outcomes. However, there was less observed 2 fractures of the metal mesh at 31 and 48 months in
proximal bone ingrowth and a higher rate of revision for aseptic cases reconstructed with a short stem that did not bypass the
mesh. Three patients presented one dislocation that needed

loosening in the group treated with nonmodular implants.
open reduction. Two acute deep infections were treated with
POSTER NO. P017 debridement, antibiotics and component retention. Bone biop-
sies taken under the mesh in an open reduction procedure
Determinants of Patient Satisfaction after Revision evidenced mature bone trabecullae and laminar viable bone
Hip Arthroplasty with active hematopoietic bone marrow. With revision of the
Stefan R Jibodh, MD, Allston, MA stem as the end point, the survivorship of the implant was 100%
Henrik Malchau, MD, Boston, MA at 1 and 2 years. Although the incidence of complications in this
Shawn Anthony, BS, Boston, MA patients was high, this was related to the complexity of the cases.
Despite the short-term follow-up, failures of the system were not
Daniel M Estok II, MD, Newton, MA
observed except in the 2 cases presenting technical
Studies have shown that patients are less satisfied after revision defects.Patients with complete absence of the proximal femur in
hip arthroplasty as compared to primary procedures. The whom other available reconstructive procedures cannot be indi-
purpose of this study was to identify factors that influence cated may be candidates for biological proximal femoral recon-
patient satisfaction after revision hip arthroplasty (RHA). We structions using this salvage procedure.
identified 63 patients (66 hips) who underwent RHA at our
institution and were available for follow-up at a minimum of POSTER NO. P019
five years (range 5.0 to 9.3). A telephone questionnaire was
administered by a single physician (who was not the surgeon of ◆Resurfacing Arthroplasty for Patients with
record). Patients were asked to rate their overall satisfaction with Osteonecrosis
the result of their surgery from zero (completely dissatisfied) to Bernard N Stulberg, MD, Cleveland, OH
ten (completely satisfied). The mean satisfaction score was 9.0 Stephanie M Fitts, PhD, Mahwah, NJ
(range 5.0 to 10.0) and the mean Harris hip score was 82 (range Jayson D Zadzilka, MS,
37 to 100). EQ-5D (+0.428, p < 0.001) and Harris hip scores
Kathy Trier, PhD,
(+0.522, p < 0.001) correlated with patient satisfaction.
Anxiety/depression was the only EQ-5D dimension that The suitability of third generation metal-on-metal hip resur-
predicted patient satisfaction (p = 0.03). Multivariate regression facing for patients with a primary diagnosis of osteonecrosis
identified anxiety/depression (p = 0.006), moderate/severe hip (ON) has been debated. The preservation of femoral head bone
pain (p = 0.007), and walking ability less than thirty minutes (p stock for femoral prosthesis support is essential for long term
= 0.03) as independent predictors of lower satisfaction scores. stability of the implant. We hypothesized that the Kaplan-Meier
Satisfaction was not affected by the presence of activity-limiting survival estimates for resurfacing patients with a primary diag-
409
nosis of ON would be significantly lower than the survival esti- POSTER NO. P021
mates for resurfacing patients with a primary diagnosis of Pseudo-Tumours After Hip Resurfacing
osteoarthritis (OA). One thousand one hundred and forty-eight
patients were implanted with a modern hip resurfacing system Hemant G Pandit, FRCS, Oxford, United Kingdom
as part of a US multi-center investigational device exemption Peter McLardy-Smith, FRCS, Oxford, United Kingdom
(IDE) study. Of these, 116 subjects had a preoperative diagnosis Roger Gundle, Oxford, United Kingdom
of ON. A multivariate analysis of variance was performed to Duncan Whitwell, FRCS, Bristol, United Kingdom
identify risk factors for component revision for any reason. A Sion Glyn-Jones, MA MBBS, Oxford, United Kingdom
diagnosis of other than OA was found to be one significant risk N.A. Athanasou, MRCP(Path.), Oxford, United Kingdom
factor. However, the survival estimates were not significantly Harinderjit Singh Gill, PHD, Oxford, United Kingdom
different (95.9% and 95.8% at 24 months for OA and ON Max Gibbons, FRCS,
respectively, p=0.46). Comparing the Ficat stage III and IV to the
OA population also did not show a significant difference in
implant survival (95.9% OA and 96.1% ON III/IV at 24 months, Metal-on-metal hip resurfacing arthroplasty (MOMHRA) are
p=0.57). Resurfacing arthroplasty for patients with ON appears increasingly performed due to their perceived advantages: low
to be a reasonable alternative given judgments of implant size, wear rate, low dislocation rate, and ease of revision. Over the
patient gender and size of femoral deficiency. Further character- past five years, we have encountered a few unusual complica-
ization will be needed to identify those specific patients with tions after MOMHRA We present a series of 16 cases (15
ON for whom resurfacing arthroplasty is not appropriate. For patients), who developed a mass related to their MOMHRA. All
most patients however, it appears to be a safe and reasonable patients were female without previous history of metal allergy.
option. Their mean age was 51 years (35 ‘ 73). They presented at a mean
time of 28 months (range: 6 - 66) after the index procedure.
POSTER NO. P020 Their presenting symptoms were pain (n= 12), palpable lump (n
= 3), altered neurology (n = 2) symptoms of instability (n = 2)
Finding the THA Procedure to Fit the Surgeon: and spontaneous hip dislocation (n=1). In 50% cases, inflam-
Which MIS Technique Works for All? matory markers were elevated, however WBC counts were
Jurg Aebi, MD, Montauban, France normal. Ultrasound / MRI demonstrated either a solid (n = 5) or
Marc Giraud, MD, Montauban, Cedex, France cystic mass (n = 11) arising from the hip. Histology showed
Beyond the goals of standard THA, MIS-THA includes mini- lymphocyte aggregates, polymorphs being notably absent. In 11
mization of muscular violation and early restoration of func- cases, milky, straw coloured or greenish fluid was found in the
tion. However, it is reported that some MIS procedures are not joint with evidence of bone resorption in one case. Nine hips
for all patients, physically demanding for the surgeon, and yield were revised to conventional THR with satisfactory outcome. In
complication rates greater than standard techniques. The none of the cases, were the components grossly loose. We have
purpose of this study was to compare the single surgeon results described the mass as a ‘pseudo-tumour’. Considering the
using two different MIS procedures. Between January 2004 and number of MOMHRA we implanted during this period an esti-
October 2005, 276 THA procedures were performed by the mated 1% develop pseudo-tumours during the first 5 post-oper-
senior author. From these cases, the first 100 THA procedures ative years. The presentation is varied and revision to a
performed with MIS-II as described by Berger (two-incision) conventional THR is recommended if symptoms are significant.
were compared to the first 100 THA cases using the MIS-AL Further work is needed to determine the cause, consequences
approach as described by Rottinger (modified anterolateral and long term incidence.
single-MIS). Seventy six cases were performed using standard
POSTER NO. P022
THA surgical techniques and not included for study.
Preoperatively, pain, function and BMI were similar between Performance of Highly Cross-Linked Polyethylene
groups. The average intraoperative skin-to-skin time was signifi- in THA in Patients 50 Years and Younger
cantly different (p<0.05)(MIS-II 101 minutes range 75-170, Derek S Shia, MD, Saint Louis, MO
Modified 69 minutes range 45-110). Postoperatively, in the
John C Clohisy, MD, Saint Louis, MO
majority of cases, early relief of pain, restoration of function and
elimination of limp were similar between groups. However, the Mark F Schinsky, MD, Aurora, IL
number of complications related to THA differed between John M Martell, MD, Chicago, IL
groups. There were 15 in the MIS-II group (4-lateral femoral William J Maloney MD, Stanford, CA
cutaneous nerve palsy, 4-intraoperative femoral fractures(1*), 4- Highly cross-linked polyethylene has been associated with low
early post-operative femoral fractures*, 1-trochanteric fracture, in-vitro wear properties, but it has also been shown to have
2-Brooker-IV HO*) and 6 in the MIS-AL group (1-dislocation*, decreased in-vitro ultimate yield strength. This study investigates
1-femoral perforation, 4-trochanteric fractures)(*=reoperation). the early in-vivo performance of highly cross-linked polyeth-
We have discontinued the use of the MIS-II in favor of the modi- ylene in a young, active patient population. Seventy total hip
fied anterolateral single MIS-AL approach in 98% of our primary arthroplasties in 64 patients were performed utilizing a cement-
THA cases since. This procedure is one that affords the same less titanium, acetabular component fixed with screws, a highly
early results as MIS-II, has similar complications as reported cross-linked acetabular liner and cobalt chrome femoral head.
with conventional THA, is applicable to all patients, and can Demographic and clinical data including the Harris Hip score
“fit” all surgeons. were recorded at a minimum two year follow up. The radi-
ographs were evaluated for component position, loosening, fixa-
tion, and osteolysis. Polyethylene wear measurements were
analyzed using a validated, computer-assisted, edge-detection
method. The average age at surgery was 41 years (range, 19 to
50). The average follow-up was 4.0 years (range, 2.4 to 6.5). The
average Harris hip score improved from 53 to 92 at last follow- obtained fair results for the pain and range of movement, and
up. There was no evidence of acetabular or femoral loss of fixa- good results for walking, with abandonment of forearm crutches
tion, implant subsidence, or loosening. There was no detectable in 9 out of 15 patients. The preoperative discrepancy was of 49
polyethylene wear at last follow-up. None of the patients experi- mm ± 19 (15-100) and at the last follow-up 18 mm ± 5 (0-60).
enced catastrophic failure and no patient required revision The best results were achieved in patients under 65 years old. In
surgery. This study demonstrates low polyethylene wear rates addition, the longer time between the explant and the new joint
and no catastrophic failures at early follow-up in a young, active arthroplasty implant, seems to have negatively influenced the
patient cohort. Middle to long-term follow-up is essential to results. Hip joint arthroplasty in sequelae of Girdlestone’s oper-
demonstrate the sustained durability of this highly cross-linked ation is a more complex operation and gives less satisfactory
polyethylene in a young and active patient population. results in comparison with joint arthroplasty performed for
common indications. Patients undergoing this operation should
POSTER NO. P023 be studied and assessed carefully and informed clearly of the
Modular Tantalum Augments for the higher rate of complications. The best results were achieved in
patients under 65 years old.
Reconstruction of Large Acetabular Defects
Donald S Garbuz, MD, Vancouver, AB Canada POSTER NO. P025
Alexander Walter Siegmeth, MD FRCS, Cambridge, United Why Revision Total Hip Arthroplasty Fails?
Kingdom Bryan Donald Springer, MD, Charlotte, NC
Clive P Duncan, MD, Vancouver, BC Canada Thomas L Bradbury, Jr MD, Atlanta, GA
Kim Winston, MD, FRCS, Thomas K Fehring, MD, Charlotte, NC
Sanjeev R Patil, FRCS, Vancouver, BC Canada William L Griffin, MD, Charlotte, NC
Large acetabular defects can be reconstructed with various
Susan Marie Odum, MED, Charlotte, NC
methods depending on size and location of the defect. These
John Leander Masonis, MD, Charlotte, NC
include large cementless cups with or without structural allografts,
impacting grafting, oblong cups and reconstruction cages The As the number of hip arthroplasties performed continues to
authors present a prospective series of 37 cases in which the increase, so too will the burden of revision arthroplasty. The
acetabulum was reconstructed with a trabecular metal augment purpose of this study was to examine the failure modes in revi-
combined with a trabecular metal shell. All defect were classified sion hip arthroplasty. Between 1986 and 2005, 1101 patients
according to Paprosky. Radiographic signs of osseointegration on underwent revision total hip arthroplasty. Medical records and
follow-up radiographs were classified according to Moore. Quality operative reports were retrospectively reviewed to determine
of life was measured with the SF-12, WOMAC and Oxford Hip success and failure. 97% had their original problem solved by
Score. There were 15 men and 19 women with average age of 64 revision surgery. Thirty-seven patients (3%) underwent second
years (range 37-97 years). Three patients died before completing revision for the same diagnosis as their index revision.106
the minimum 24 months follow up. Thirty-four patients were patients (10%) underwent second revision for a different diag-
followed up for an average of 34 months (24-55 months). Thirty- nosis. 143 of 1101 patients (13%) required a second revision for
a variety of reasons. The reasons for failure were aseptic loos-

two patients had successful reconstructions and two were counted
as failures and required re-revision. Of the 32 patients who did ening (58/143, 41%), instability (41/143, 29%), infection
not have failure, all had stable cups by the criteria of Moore. Thirty (14/143,10%), osteolysis/wear (15/143, 10%), peri-prosthetic
out of thirty-three patients (91%) with implants in situ at the latest fracture (5/143, 3%) and miscellaneous diagnoses (10/143,
follow-up had a high hip centre preoperatively. Three patients (9 7%). Revision total hip arthroplasty was 97% successful in
%) had a high hip center of more than 35 mm postoperatively. solving the original problem. 13% of patients required re-revi-
Quality of life data was available for all patients and showed excel- sion for multiple reasons. Instability and aseptic loosening
lent improvement of all parameters assessed. Trabecular metal however accounted for 70% of these failures. The routine use of
augments provide excellent results in the short to midterm period large heads and enhanced fixation methods may improve
but longer follow-up is needed. outcomes.

Hip Joint Arthroplasty in Sequelae of Girdlestone’s Malseating of a Titanium-Encased Ceramic Liner in
Operation: Indications and Limits a Non-Hemispherical Cup During THA
Dante Dallari, MD, Medicina, Bologna Italy Christian P Christensen, MD, Lexington, KY
Cesare Stagni, MD, Bologna, Italy Cale Jacobs, PhD, Lexington, KY
Nicola Rani, MD, Due to the potential for wear reduction and an associated
reduced incidence of osteolysis, ceramic-on-ceramic bearing
Nicolandrea Del Piccolo, MD,
couples are frequently used in total hip arthroplasty. A recent
Luca Amendola, MD,
report stated that 10% of a series of THAs performed with an
Armando Giunti, MD, Bologna, Italy acetabular implant system that features a non-hemispherical cup
The Girdlestone operation, despite causing severe limb length with a titanium-encased ceramic acetabular liner were not prop-
discrepancy and impairing walking capability, has often been erly seated. The purpose of this study was to determine if a
used to treat septic loosening of hip prostheses. Often, however similar trend was present in our patient population. We evalu-
patients may require a new joint arthroplasty operation, even ated 71 consecutive THAs with this same acetabular implant
after several years. From 1990 to 2004, we performed revision system which were performed by a single high volume joint
surgery in 15 patients that had previously undergone replacement surgeon using a standard posterior approach.
Girdlestone’s operation for septic complications of hip joint During each procedure, the stability of the ceramic liner was
arthroplasty. Mean follow up was 67 months ± 44 (19-156). We carefully assessed and tested following insertion. Mean age of
411
this sample was 50.0 ± 9.4 y, and mean BMI was 31.4 ± 9.1. On patients (20 hips) were discharged on POD1, representing 5.7%
careful radiographic examination, 6/71 (8.5%) of the titanium- of this sample. Mean age of this group was 51 years, and the
encased ceramic liners in our series were malseated. Malseating mean BMI was 28.1. All patients discharged on POD1 were
was subtle in all six cases, and was noted in only one case prior allowed immediate weight bearing as tolerated; however, were
to the dedicated radiographic review performed for this study. prescribed only home health physical therapy. As a result of pain
One patient required revision following a fall where the liner and/or functional limitations, 35% (7/19) of this select group
became dissociated from the shell and the shell loosened from required at least one additional follow-up visit that was not part
the pelvis. The remaining five patients have continued to be of the standard routine following THA. Additional visits were,
asymptomatic with Harris Hip Scores of 79.4 ± 3.7. While the on average, 14.6 weeks postoperative, and outpatient therapy
five malseated liners appear to be stable, we will continue to and/or home exercise programs targeting hip abductor strength-
routinely examine these patients for either dissociation or metal ening was prescribed. We conclude that if young, active patients
fretting secondary to micromotion of the titanium-encased liner. are not properly rehabilitated in the early postoperative period,
additional care may be required, which further advocates the
POSTER NO. P027 routine use of outpatient physical therapy for active THA
Patient- and Surgery-related Factors of Squeaking patients involved with rapid recovery protocols.
and Non-squeaking Ceramic-on-Ceramic THAs POSTER NO. P029
Cale Jacobs, PhD, Lexington, KY The Orientation of the TAL and Labrum and Its
Christian P Christensen, MD, Lexington, KY
Recent reports have identified audible squeaking in patients
Relationship to the Safe Zones in THA
following otherwise successful THA with ceramic-on-ceramic Pooler H A Archbold, MB Ba, Lisburn, United Kingdom
bearings. The purpose of this study was to discern if patient- Mike Slomczykowski, MD, Wilmington, DE
related and/or surgical factors may be involved in the develop- Kort Eckman, Pittsburgh, PA
ment of this phenomenon. We compared patient age, sex, BMI, Branislav Jaramaz, PhD, Pittsburgh, PA
diagnosis; intra-operative joint laxity and range of motion; and David Beverland, MD, Belfast, Ireland
postoperative acetabular alignment between groups of patients There is a need to develop and validate a method for establishing
with non-squeaking and squeaking ceramic hips. Five of 65 hips cup orientation that is patient specific and independent of the
(7.7%) that were implanted with an acetabular component with APP. It is our hypothesis that the transverse acetabular ligament
a titanium-encased ceramic liner developed an audible squeak at and acetabular labrum can be used to do this. This study defines
an average of 15 months after surgery. Three of the 13 hips the orientation of the plane formed by the TAL and labrum and
(23%) with AVN and 2/45 hips (4%) with OA developed a examines whether these local landmarks lie within the limits of
squeak, whereas no hips treated for other diagnoses developed a acceptance for cup positioning. 25 consecutive patients, who were
squeak. All 5 squeaking hips had the same lateralized femoral being investigated for labral tears with a MRI arthrogram of the
component, with a 127º neck angle. Patients with squeaking hip, were enrolled in this prospective study. The orientation of the
hips were significantly younger with slightly lower BMI, and had TAL-labrum plane was determined by manually selecting points
significantly increased laxity compared to the non-squeaking
on the transverse acetabular ligament and labrum. The best-fit

hips. There were no differences in alignment of the acetabular plane through these points was determined and its operative
component between the two groups. Previous studies have orientation expressed with respect to a constructed pelvic coordi-
reported that increased joint laxity results in microseparation nate system. The operative anteversion of the TAL-labrum plane
and edge loading, which then leads to the development of stripe was 23.0° +/- 7.4° (mean +/- standard deviation) (Range 5.3-
wear and the creation of ceramic wear debris consisting of larger 36.1°). The inclination was 45.6° +/- 3.2° (mean +/- standard
sized particles. We suggest that younger patients with increased deviation) (Range 38.4-50.3°). The TAL and acetabular labrum
laxity and without long standing arthritis may be at greater risk offer a possible solution to the many difficulties involved in cup
of edge loading and the creation of large-sized ceramic wear placement during total hip arhroplasty. This paper highlights the
particles, which may be involved in the development of variation in the orientation of these local acetabular landmarks
squeaking ceramic bearings. and questions the logic of a set target for cup positioning.
Patients in Rapid Recovery Protocols may Require The Fate of Zone 2 Radiolucencies of Press-Fit
Additional Postoperative Visits Porous Coated Acetabular Components
Cale Jacobs, PhD, Lexington, KY Bryan Donald Springer, MD, Charlotte, NC
Christian P Christensen, MD, Lexington, KY William L Griffin, MD, Charlotte, NC
Rapid recovery protocols following THA often involve a shorter Thomas K Fehring, MD, Charlotte, NC
hospital stay after surgery, with select patients being discharged
Juan C Suarez, MD, San Juan, Puerto Rico
on postoperative day number one (POD1). While increasing in-
patient rehabilitation has allowed patients to meet discharge
goals 2-3 days faster, active patients that are not properly reha- Press fit acetabular fixation is one of the more common
bilitated after hospital discharge may develop pain or functional methods of fixation in hip arthroplasty. The purpose of this
limitations secondary to muscular weakness or gait abnormali- study was to asses the fate of incomplete seating of the acetab-
ties. Over a 3-year period, 333 patients (375 hips) underwent ular component on long term fixation. From 1990 to 2002, 587
primary THA by a single surgeon. Discharge on POD1 was hip arthroplasties were performed using a single design acetab-
offered to patients < 65 years old with no comorbidities other ular component inserted with a press-fit technique with no addi-
than hypertension, provided they were medically stable and had tional fixation. Complete radiographic follow-up at an average
met the goals of inpatient physical therapy. During this time, 19 of 110 months (range 60 to 233), was available for 348 patients.
135 patients had incomplete seating of the acetabular compo-
nent as evident by a Zone II lucency >1mm on the initial post- neck sparing stem designs. Mechanical studies have clearly
operative radiograph. This group was compared to 213 patients shown an early advantage with the intact femoral neck. To-date
that had complete seating. There were no intraoperative frac- most if not all neck-sparing stems have been somewhat disap-
tures. No acetabular components were revised for loosening. pointed in their long-term ability to stimulate and maintain the
334 patients (96%) had evidence of complete filling of the Zone medial calcar. A new design approach was undertaken to
II lucency. No cups were radiographically loose or had progres- improve proximal load transfer and to create a bone, tissue
sion of radiolucent lines. Focal osteolysis was present in 42 sparing stem that would be simple in design, amenable to repro-
patients (22 in Zone II). Incomplete seating of the acetabular ducible technique and provide for fine tuning joint mechanics
component using the press-fit technique is a safe and effective while stimulating and maintaining compressive loads to the
method to achieve initial and long term fixation. Zone II lucen- medial calcar. Review of previous published work was evaluated
cies when present initially are not associated with an increased along with new FEA modeling and mechanical testing in
risk for failure. Vigorous attempts to completely seat the acetab- creating a new approach to neck sparing stems for primary THA.
ular component risks fracture in compromised bone. Such FEA solid models of the size 1 stem and various necks were
attempts to do so appear to be unwarranted. created in UG/Solidedge and then imported into
ANSYS/WORKBENCH as a parsolid and meshed using the free
POSTER NO. P031 mesh option, with mesh refinement in regions of estimated high
Crowe IV CDH Treated with Two-Stage Progressive stress. The loading regimes were obtained from ISO 7206-4, the
parameters will be posted. Properties for the modular neck were
Femoral Lowering Followed by THA CoCr (ISO5832-12), stem properties of wrought titanium alloy
Roberto Binazzi, MD, Milano, Italy (ASTM F136). Potting cement per ISO 7206-6. Different
William J Hozack, MD, Philadelphia, PA modular head/neck combinations were simulated. FEA
Aniello Bondi, MD, modeling determined worst-case scenario for preparation of
Aniello Manca, MD, samples for mechanical testing. Worst-case neck configuration is
Crowe IV hip dypslasia requires special techniques when THA is the 12Ú medial 27mm offset. Location for the maximum tensile
planned. Trochanteric osteotomy and femoral shortening stress is at the trunnion taper junction in the neck. Blending has
approaches have been favored by most surgeons. A two stage been added to this region to reduce the stress to this state. Stress
technique (femoral distraction first, THA second) is described as in the stem is fairly linear compared to the neck that increases in
an alternative. The first stage consists of a fascio-mio-arthrolysis a more exponential fashion. FEA modeling has demonstrated
(adductor tenotomy, gluteal fasciotomy, psoas z-lengthening, clear design factors that can have an effect on material perform-
capsulectomy, femoral head resection) and application of an ance. The end result of worst-case configuration provides a factor
External Fixator. Progressive lowering of the femoral epiphysis is of safety of 3.2 and 4.1 for the neck and stem respectively. When
undertaken until the femoral neck is at the true acetabulum. The this configuration is loaded to 3,000 N (ISO rec. max. comp.
cup is placed in the true acetabulum and a straight, cementless, load for fatigue simulators) the factor drops to 2.48 and 3.2
conical stem is implanted which allows infinite versatility with respectively. This novel approach to neck sparing stem designs
respect to anteversion.14 patients (9 females and 4 males, 1 bilat- combines the proven aspects of the old and new to create a
simple reproducible approach to THA that potential provides for

eral) were treated in this fashion. Follow-up averaged 7.1 years.
The average limb lengthening was 5.1 cm. No nerve palsies were a larger indication than hip resurfacing and a more conservative
seen. No pin site infections were seen. One dislocation occurred approach than conventional THA. To date we are optimistically
treated conservatively. Lateral grafting was required in 3 cases encouraged by this work and additional testing is underway.
(20%) . No femoral component loosening or revision happened.
Overall primary type components were utilized in all cases but POSTER NO. P033
one (93.5%). Crowe IV hip dysplasia is a complicated problem Use of Navigation Improves Precision of Cup
for THA. Placing the acetabulum in the anatomic position is an Placement in Cemented THA Done for Severe
absolute requirement, which creates significant technical issues
with respect to the femur. Femoral shortening osteotomy is the Dysplasia
current standard, but this approach is technical complicated and Koji Asaumi, MD, Okayama, Japan
requires revision type femoral components. The two stage tech- Shigeru Mitani, MD, Okayama, Japan
nique described here minimizes the technical challenges of this Hirosuke Endo, MD, Okayama, Japan
surgery, and facilitates the use of primary hip components. Kazuo Fujiwara, MD,
Toshifumi Ozaki, MD,
POSTER NO. P032
Hiroshi Egawa, MD, Alexandria, VA
◆A New Approach to Neck Sparing THA Stems Orientation of a total hip arthroplasty (THA) cup in a dysplastic
Timothy McTighe, PhD, Aurora, OH acetabulum can be imprecise due to the distortion or absence of
Allen Turnbull, common anatomical references. Computer-assisted surgical
John M Keggi, MD, Middlebury, CT navigation systems have recently been developed to improve
Louis Keppler, MD, Cleveland, OH implant placement in THA. This study evaluates cup placement
John Meredith Harrison, MD, Sydney, NSW Australia in navigated and non-navigated cemented THA procedures done
for Crowe II or III developmental dysplasia. Thirty patients who
Robert Edward Kennon, MD, Middlebury, CT
had undergone cemented THA using the CT-based Navi system
Ian G Woodgate, MD, Darlinghurst, NSW Australia (navigated group) were matched to 30 patients who had
Declan Brazil, PhD, conventional cemented THA (non-navigated group) on the
Wei Ping Wu, MD, Shanghi, China basis of gender, age and Crowe’s grade (12 grade II and 18 grade
Architectural changes occurring in the proximal femur after THA III hips). In each case, a direct lateral approach was used, a
continues to be a problem. In an attempt to reduce these boney Charnley-style trochanteric osteotomy was performed for visual-
changes some surgeon designers have advocated the concept of ization, and an acetabular bulk bone graft was placed to increase
413
cup coverage. Postoperatively, we measured the cemented cup’s discharging sinuses and bone loss, comparing30 patients treated
inclination and anteversion angles and its distance from the in 2 stages without the use of a spacer (control group) and 38
medial wall (medialization depth). Cup positioning was signif- patients treated with a vancomycin-loaded spacer(study group).
icantly more accurate and precise in the navigated group. In The average follow-up was 6 years (4-10.5 years). One patient
those hips, the mean (+/-SD) angular errors (versus the preoper- died of unrelated causes 4 months after first-stagesurgery and
ative plan) were 0.8+/-0.6 degrees for inclination and 1.4+/-1.2 was excluded from the study. The 2-stage surgery without spacer
degrees for anteversion and the mean medialization depth was controlled the infection in 66.7% ofpatients, and the 2-stage
7.7+/-0.9 mm. In the non-navigated group, the mean errors were surgery using the spacer controlled it in 89.1% (P < 0.05). At last
4.1+/-4.9 degrees for inclination and 6.5+/-4.3 degrees for antev- follow-up, the average Harris Hip Scoreincreased from 19.3 to
ersion and the mean medialization depth was 6.8+/-2.6 mm. 69.0 in the control group versus 19.7 to 75.2 in the study group
Operation times and blood losses of the two groups were not (P > 0.05). The average leg lengthdiscrepancy was 2.6 cm in the
significantly different. Use of CT-based navigation in cemented control group and 1.5 cm in the study group (P < 0.05). The
THA resulted in improved cup placement within Crowe II and patients treated with a spacer had betterclinical results (81.5% of
III dysplastic acetabula. These technologies seem particularly patients with good results against 60.0% for the control group).
helpful in complex cases like these. The use of an antibiotic-loaded spacer in the 2-stage treatment
of infected hip arthroplasties provides betterinfection control
POSTER NO. P034 with good functional results and is superior to treatment in 2
Extended Release Epidural Morphine Leads to stages without a spacer. Level of Evidence: Therapeuticstudy,
Level I-1.
Decreased Length of Stay in Total Hip Arthroplasty
Khaled J Saleh, MD, MSc, FRCSC, FACS, Charlottesville, VA POSTER NO. P036
Check C Kam, MD, Miami, FL Intermediate Outcomes in Revision Hip Arthroplasty
Abhijit Manaswi, MD,
with a Modular Design and Plasma Porous Coating
Wendy Novicoff, PhD, Charlottesville, VA
Matthew Salomone, MD, Aaron B Cullen, MD, Sacramento, CA
William Michael Mihalko, MD, PhD, Charlottesville, VA Amir A Jamali, MD, Sacramento, CA
Kenneth Illingworth, PhD, John Patrick Meehan, MD, Sacramento, CA
Marcel Durieux, MD, PhD, Paul E Di Cesare, MD, Sacramento, CA
With the recent introduction of a new generation of modular
Post-operative pain following Total Hip Arthroplasty (THA)
revision femoral stem designs in hip arthroplasty we would like
impacts negatively on patient satisfaction, rehabilitation, and
to report on the results of a consecutive series of 26 surgeries in
hospital length of stay. An injection of extended release epidural
25 patients using a design that has been available for over 20
morphine (EREM) decreases pain, narcotic consumption, and
years. The design utilizes circumferential titanium plasma spray
allows patients to transition directly to oral narcotics following
porous coating, modular proximal calcar and cylindrical diaphy-
hip surgery. We evaluated the effects of EREM on narcotic
seal components and independent metaphyseal and diaphyseal
consumption, pain scores, and length of stay in patients under-
preparation to maximize fixation options in complex revision

going THA. We retrospectively studied 111 THA patients and
cases. Twenty six revision femoral arthroplasties in twenty five
compared the effects of EREM versus IV narcotics on total
patients were performed using a modular calcar titanium porous
narcotic consumption, visual analog pain scores (VAS), and
coated revision hip system over a seven year period (1999-
length of hospital stay. Patients who received EREM experienced
2006). Four revisions involved two-stage procedures for infec-
significantly less pain in the first 24 hours following THA, and
tion and three revisions were for periprosthetic fractures (one
required almost no supplemental IV narcotics in the first 48
associated with infection). All surgeries were performed through
hours compared to the IV narcotic group. Likewise, those patients
a posterolateral approach with 12 requiring extended
who received EREM experienced a significantly shorter hospital
trochanteric osteotomies. Outcome questionnares including SF-
stay of 3.4 days versus 3.8 (p<0.01). Our data demonstrates that
36 and WOMAC were collected. All twenty six revision surgeries
extended release epidural morphine provides superior pain
were considered successful at latest follow up, with one reoper-
control and obviates the need for PCA, allowing the patient to
ation for recurrent infection. Three stems had radiographic
transition more readily to oral analgesics for patients undergoing
subsidence of 2mm, 5mm, and 6mm but these have not
THA. These patients also had a significantly decreased length of
progressed. One pedestal formation (5mm subsidence patient)
stay. The benefits of using EREM should translate into increased
and no divergent radiolucent lines have been observed. Post-
use in regular practice for eligible patients.
operative Harris Hip scores increased significantly compared to
POSTER NO. P035 pre-op (90 +/-2 vs. 51 +/-3), WOMAC scores were 21+/-5, SF-36
scores averaged 68+/-3 across the nine functional parameters.
Prospective Study of the Treatment of Infected THR Modular revision femoral stem components allow independent
With or Without an Antibiotic-Loaded Spacer preparation of proximal (metaphyseal) and distal (diaphyseal)
Henrique Berwanger Cabrita, MD, Sao Paulo, SP Brazil femoral canals. This allows for optimum fit and fill in complex,
Olavo Pires Camargo, MD, Sao Paulo, SP Brazil deficient femoral revision cases. We feel the combination of a
calcar proximal component and a distal component with
Ana Lucia Lima, MD,
circumferential plasma porous spray, cylindrical diaphyseal
Alberto Tesconi Croci, CEP 05015-040 Sao Paulo, Brazil geometry and 3 point fixation helps to maximize successful
Regardless of the worldwide acceptance of the spaceras the main implant-bone stability in challenging femoral revision cases.
method of treatment of infected hip replacements,no objective
data have been reported in the literatureto prove the real bene-
fits of using a spacer in 2-stagesurgeries. In a prospective
randomized study, we treated 68 infected hip arthroplasties with
POSTER NO. P037 can permit the diagnosis and treatment of intraarticular lesions
Femoral Component Revision with a Modular Hip in the setting of PAO. Potentially, this enables the surgeon to
treat labral/ cartilage lesions and reorient the acetabulum in one
System: One Stem for All Revisions setting with less morbidity and one recovery period.
Christopher L Peters, MD, Salt Lake City, UT
Daniel B Ryssman, MD, Rochester, MN POSTER NO. P039
Jill Erickson, PA, Salt Lake City, UT Total Hip Arthroplasty Using a Large Diameter
Proximal femoral bone deficiency in failed THA can be Metal-on-Metal Articulation: Early Clinical Results
addressed with a modular hip system, providing more options
Carmen Crofoot, MD, Farmington, ME
for proximal and distal femoral bone-loss and canal-mismatch.
This study reviews the results of a modular revision system with Jill Erickson, PA, Salt Lake City, UT
multiple distal stem options. 62 femoral revisions with a Denise Portugal, MD,
modular hip system with average follow-up of 60 months (range Edward J McPherson, MD, Los Angeles, CA
48-86) were reviewed. Pre-operative radiographs were evaluated Christopher L Peters, MD, Salt Lake City, UT
for femoral defects using the Mallory classification. 25 femoral Total hip arthroplasty (THA) with large diameter metal-on-metal
defects were classified as Type II, 36 were IIIA-IIIC. Postop radi- (LDMOM) articulations has recently increased due to the theoret-
ographs were assessed for evidence of loosening, subsidence, ical advantages of improved wear and decreased dislocation rate.
radiolucency, and non-union. Harris Hip Scores (HHS) were We evaluated the early clinical and radiographic results of a
obtained pre and post-operatively. 58/62 (94%) stems remain in contemporary LDMOM THA. Between 2001 and 2006, 494
place. 4 well-fixed femoral components were removed for infec- patients (546 hips) underwent a cementless LDMOM THA.
tion, 0 for loosening. 3/4 hips that dislocated required modular Bearing size ranged from 38-56mm. Patients were evaluated at a
exchange. Other complications included 1 hematoma and 6 mean 24 months (range 12-72 months) follow-up with Harris Hip
superficial infections that required I&D. Radiographically, there Score (HHS) and radiographic examination including loosening,
was no subsidence greater than 3mm (range 0-2.1mm) and no radiolucencies and component position. Special attention was
complete radiolucent lines. A radiolucent line of 1mm was paid to failure mechanism including infection, loosening and
present in 9 stems in one zone. Extended trochanteric osteotomy hypersensitivity. The Harris Hip Score improved from 51.7 to 91.6
(ETO) was performed in 23 revisions with no evidence of (p<0.01). Three hips (0.5%) required revision for infection, 3
nonunion. Average HHS improved from 48 to 83. At average 5- (0.5%) for aseptic loosening of the acetabular component (AC)
year follow-up, revision THA with a modular hip system is and 1 (0.18%) for acetabular fracture post fall (overall acetabular
comparable to other femoral revision components in terms of revision rate of 1.2%). Two hips (0.36%) dislocated. Six hips had
fixation and complications. Modularity maximizes implant- transient clicking and one hip had intermittent squeaking with
bone contact in cases of proximal and distal femoral canal deep flexion, all of which resolved by one year. No hips required
mismatch, providing for excellent stability, ease of stem inser- revision or treatment for hypersensitivity or unexplained pain.
tion, and use in virtually all revision cases. Other complications included one death, one CVA, 4 deep
hematomas requiring irrigation and debridement (I&D), and one
POSTER NO. P038

revision for leg length discrepancy. The early clinical results of large
Acetabular Debridement With Simultaneous diameter metal-on-metal articulation compare favorably with
traditional metal-on-polyethylene THA with overall early failure
Reorientation Through a Single Incision rate of 1.2%. The dislocation rate is significantly lower with no
Lucas Anderson, PA, Salt Lake City, UT need for activity restriction except for high impact activities. While
Carmen Crofoot, MD, Farmington, ME hypersensitivity has been reported, no patients experienced this
Christopher L Peters, MD, Salt Lake City, UT potential complication. AC failure was associated with poor bone
David Morton, PhD, quality and/or altered anatomy with poor initial fixation. Modular
Five out of fifty patients who underwent surgical dislocation and AC with screw fixation should be considered in these cases.
osteochondroplasty (SDO) for femoro-acetabular impingement
between 2002 and 2006 required redirectional periacetabular POSTER NO. P040
osteotomy (PAO) to improve coverage after acetabular resection Extracorporeal Shockwave Shows Regeneration
for cartilage defects or pre-existing dysplasia. Standard PAO Effect in Osteonecrosis of the Femoral Head
exposure does not allow complete inspection and treatment of
intraarticular pathology. Our study proposed using traction and Ching-Jen Wang, MD, Kaohsiung, Taiwan
dry arthroscopy to diagnose and treat intraarticular pathology Hsuan-Ying Huang, MD, Kaohsiung, Taiwan
while performing a PAO. A modified Smith-Peterson approach Feng-Sheng Wang, PhD,
and anterior hip arthrotomy were performed on two cadaver Yi-Chin Sun, BS,
hips with the addition of ankle traction and dry arthroscopy. Ya-Ju Yang, BS,
Acetabular cartilage lesions were created, inspected, and subse- Extracorporeal shockwave was shown effective in early
quently treated with acetabular resection and reorientation. osteonecrosis of the femoral head (ONFH). However, the effect
Osteochondroplasty was performed to increase head-neck of shockwave in ONFH is poorly understood. This study investi-
offset. Labral take down and reattachment was performed to gated the regeneration effects of shockwave in ONFH. This study
simulate treatment. PAO and reinspection with dry arthroscopy included 14 femoral heads from 14 patients undergoing total hip
were subsequently performed verifying that the procedure could surgery. The study group consisted of 7 patients with 7 hips who
be accomplished in a single stage. One patient was successively were treated with shockwave prior to surgery, whereas, the
diagnosed and treated without complications. A single period of control group consisted of 7 patients with 7 hips without
six weeks of assisted ambulation was required in contrast to two receiving shockwave. Both groups showed similar demographic
periods with staged procedures. Both cadaver and patient expe- characteristics. The investigations included histomorphological
rience indicate that the addition of traction and dry arthroscopy examination for tissue distributions, and immunohistochemical
415
analyses for angiogenesis and angiogenesis-related growth and necessary for implant survival. The current study aim was to
proliferating indicators including vWF, VEGF, CD 31, VCAM, examine the effects of exposure to elevated temperatures on bone
PCNA, TUNEL, DKK-1 and Wnt3. In histomorphological exam- cells. Osteoblast and osteoclast pre-cursor cells were exposed to
ination, the study group showed significantly more viable bone elevated temperatures, 40, 50, 60 & 70ºC for 5, 10 & 15 minutes.
and cell activities, and less necrotic bone than the control group Viability and recovery as a function of temperature and exposure
(P < 0.05). In immunohistochemical analysis, the study group time was examined. Viability of osteoblasts and osteoclasts was
demonstrated significant increases in the expressions of vWF (P < affected by a temperature and time dependent mechanism.
0.01), VEGF (P = 0.0012), CD31 (P = 0.0023), PCNA (P = 0.0011) Significant decrease in osteoblast viability was seen for all
and Wnt 3 (p = 0.008), and decreases in VCAM (P = 0.0013), elevated temperature conditions. Osteoblasts were able to recover
TUNEL (P = 0.2710), and DKK-1 (P = 0.007) than the control after 48 hours only for the exposure temperature of 40ºC.
group. The hips treated with shockwave showed significantly Although temperatures below 60ºC had little effect on osteoclast
more viable bone and less necrotic bone and increased new differentiation, they exhibited a dramatic decrease in their activity
vessel formation and cell proliferation than hips without as a result of excessive temperatures. Viability of osteoblasts and
receiving shockwave. It appears that application of extracorporeal osteoclasts is affected by mild temperature increases. The use of
shockwave results in regeneration effects in hips with ONFH. techniques to reduce bone exposure temperatures are recom-
mended, especially for hip resurfacing devices.
POSTER NO. P041
Gender Specific Total Hip Replacement Outcomes POSTER NO. P043
Analysis using Prospectively Collected Clinical Data Metal on Metal Total Hip Arthroplasty: Mid-Term
Robert Barry Bourne, MD, London, ON Canada Results
Kory Charron, London, ON Canada Hari Bezwada, MD, Philadelphia, PA
Doug Naudie, MD, London, ON Canada David George Nazarian, MD, Philadelphia, PA
Richard W McCalden, MD, London, ON Canada Robert E Booth, Jr MD, Philadelphia, PA
Steven J MacDonald, MD, London, ON Canada Polyethylene wear and subsequent osteolysis have been substan-
Cecil H Rorabeck, MD, London, ON Canada tial problems affecting the longevity of total hip arthroplasty.
Gender specific total hip replacement (THR) design has been a The purpose of this study is to evaluate the mid-term results of a
recently debated topic, with implant manufacturers currently metal on metal articulation in cementless total hip arthroplasty.
launching gender designs. The purpose of this study was to inves- A consecutive series of one-hundred-eleven metal on metal
tigate the survivorship and clinical outcomes of a large primary cementless total hip arthroplasties with a 28 mm diameter head
THR cohort, specifically assessing any differences between gender were implanted in 89 patients. Fourteen were performed for
groups. A consecutive cohort of 3461 patients, having undergone osteonecrosis, the remaining 75 for osteoarthritis. Twenty-two
4114 primary THRs (1924-female, 1537-male) with a minimum patients underwent bilateral arthroplasties. The mean age was 52
of 2 years follow-up (mean 11.33±6.54, min 2, max 27.4) were (35-62) years. Clinical data was recorded using the Harris hip
evaluated. Pre-operative, latest, and change in clinical outcome scoring system. Radiographs were evaluated for component
position, osseous integration, stress shielding, subsidence, loos-
scores (HHS, SF12, WOMAC) were compared using the students

t-test. Kaplan Meier Analysis was performed to determine the ening, and osteolysis. Follow-up averaged 6.5 (6-7) years. Mean
survivorship. Males had significantly higher raw scores preopera- Harris hip scores improved from 53 to 97. Radiographic evalua-
tively and postoperatively. Significance in the change of clinical tion revealed a mean cup inclination angle of 420, no radiolu-
outcome scores was only found in the WOMAC pain score in cencies, no cup or stem migration (subsidence), and evidence of
favor of the female cohort (39.42 vs. 36.13, p=0.011). Although osseous integration in all implants. There was no quantifiable
no significance was found, females demonstrated greater wear and no osteolysis on serial radiographs. Complications
improvement than males, in HSS Pain, SF-12 Mental, WOMAC included one superficial wound infection. There were no dislo-
Function and Total. Kaplan Meier analysis revealed a cumulative cations and no revisions required. The mid-term results of a
survivorship at 10 years and 15 years of 0.903±0.010 and metal on metal articulation in cementless total hip arthroplasty
0.785±0.018 for females and 0.893±0.011 and 0.734±0.023 for are encouraging. Clearly, longer term results are required to
males respectively. Cumulative revision rates were 8.3% for determine if this will ultimately be the bearing of choice in the
females and 9.3% for males. In this cohort of patients under- younger, high demand patient.
going THRs, females demonstrated greater implant survivorship
and little statistical difference in change in clinical outcome
POSTER NO. P044
scores that were actually in favor of the female cohort. This leads ◆Hip Resurfacing By Anterior Approach.
one to question the need for a gender designed THR system. A Prospective Review of the First 100 Patients
POSTER NO. P042 Philippe Piriou, MD, Garches, France
Thierry Judet, MD, Garches, France
Osteoblast & Osteoclast Reactions to Mild Heat In our institution (Garches, France) we are doing all or primaries
Shock total hip reconstruction by the anterior approach using a trac-
Harinderjit Singh Gill, PHD, Oxford, United Kingdom tion table. We started resurfacing of the hip by this approach in
Afsaneh Sabokbar, Oxford, United Kingdom 2002. We are presenting the results and the technique of the first
Guillaume Mabilleau, PhD, Oxford, United Kingdom 100 cases. This review is prospective and continuous. All patients
Resurfacing arthroplasty of the hip is being used increasingly as were clinically reviewed and all had pelvic front standing X-Rays,
an alternative to total hip replacement, especially for young active at revision. Postel Merle d’Aubigné (PMA) scale was used for
patients. Most systems used a cemented femoral component, evaluating clinical result. Median follow-up 2002 is three years
with the potential for thermal injury of bone cells and possible and maximal follow-up is six years. All patients had a score over
necrosis; for resurfacing viable bone in the head and the neck is 17 in PMA, at maximum follow-up. We report only one femoral
neck fracture, at early post op because of a intra-operative tech- index (BMI) and height. Consistency of % error measurements
nical mistake. Positioning of the implants was correct mean time on consecutive post-operative x-rays was also evaluated. The
for surgery was 100 minutes. Intra-operative blood loss was infe- mean % error of the marker in the 211 x-ray films was 1.27% (SD
rior at 500 cc. Hip resurfacing is bone preserving on the femoral = 3.3). No relationship was demonstrated between % error and
side. For us using an anterior approach is logical because sparing BMI or height, using a Pearson correlation and scatter plots. No
muscles and soft tissues during surgery. And last of all the ante- significant differences were found between % error measure-
rior approach preserve the posterior blood supply of the femoral ments in consecutive films on the same patient. The % error
head without any trochanteric flip. Results are out standing and measured on subsequent post-op films also did not correlate
make us following this experience. with BMI (n=52). In this study, the cylindrical marker was, on
average, within 1.27% (98.73% average accuracy) of the true
POSTER NO. P045 magnification. This finding supports the use of a cylindrical radi-
Ceramic-on-Ceramic Bearing Surfaces in Total Hip ologic marker as a reliable instrument to assess x-ray magnifica-
tion. The absence of correlation between % error and BMI was
Arthroplasty: Safe for the Younger Patient? an unexpected finding and may be due to marker placement.
Ross K Leighton, MD, Halifax, NS Canada
Abdullah Al-Turki, MD, Halifax, NS Canada POSTER NO. P047
Michael McCaffrey, MD, Windsor, ON Canada Serious Symptomatic Thromboembolic Events in
Kelly Trask, Reseach, Halifax, NS Canada 500 Consecutive Elective Total Hip Replacement
Gwendolyn Dobbin, Halifax, NS Canada
The ideal bearing surface for total hip arthroplasty is still an area
Patients
of debate. Increasing numbers of total hip replacements are being Camilla Ryge, MD, Virum, Denmark
done in the younger patient population. Ceramic-on-ceramic Michael Rud Lassen, MD, Horsholm, Denmark
bearings have gained popularity due to their low wear rate; Stig Sonne-Holm, MD, Charlottenlund, Denmark
however, ceramic fractures with subsequent catastrophic failures Soren Solgaard, MD, Horsholm, Denmark
have been reported. This study reports on early results of ceramic- Thromboembolic complications in major orthopaedic surgery
on-ceramic total hip replacements. This is a study analyzing are most often described from register data in a retrospective way
prospectively collected data for 75 ceramic-on-ceramic total hip or the data come from large international multicentre studies
replacements with minimum follow up of 24 months. Average sponsored by the pharmaceutical industry. The results from
age at time of surgery was 47 years. This study focused on the these studies are often very different from the pattern of compli-
complications of this ceramic population. Complications cations that the general orthopaedic surgeon experience in the
included: one posterior dislocation, two intra-operative calcar daily clinic where unselected patients are operated. The purpose
fractures that needed wiring, one intra-operative fracture of the of this study was to describe the number and time of onset of
acetabular liner, two cases of impingement (one which resulted serious symptomatic thromboembolic complications (TE) in an
in a revision), and one periprosthetic fracture. The two patients unselected population of total hip replacement (THR) patients
that required further surgery were the periprosthetic fracture after within the first 90 postoperative days. Five hundred (430

a fall and one for component impingement. No revisions were primary THR and 70 revision THR) consecutive patients under-
performed for loosening or catastrophic failures. No wear, loos- going THR in Denmark from January 2004 until May 2005.
ening, or osteolysis was seen on radiographs. The SF-12, Patients were followed for 90 days postoperatively. The patients
WOMAC, and Harris Hip scores were not significantly different were interviewed the day before surgery,on the 5th postoperative
from other reported hip series. Ceramic-on-ceramic bearing day and 90 days postoperatively. Events were symptomatic acute
surfaces in total hip arthroplasty are a safe option with outcome myocardial infarction (AMI), pulmonary embolism (PE), deep
equivalent to standard THR in the short term. Ceramic hips may vein thrombosis (DVT), transitory cerebral ischemia(TCI)/
provide a more durable prosthesis, especially in young and active stroke, retinal vein thrombosis (RVT). The validity of the events
patients. Intra-operative technical guidelines that may enhance was checked in accordance with international criteria. 498
the quality of the results will be presented and fully disclosed. patients had 90 days follow-up. 24 patients (4.8%) experienced
at least one serious TE complication during the first 90 days after
POSTER NO. P046 the operation. Two (0.4%) patients died in relation to the oper-
Accuracy of a Cylindrical Radiographic Marker in ation. Five patients (1.0%) had PE. One patient (0.2%) had
Assessing Magnification on Total Hip Radiographs AMI, 10 (2.0%) had DVT, two (0.4%) had RVT and four (0.8%)
had TCI. Two patients experienced two events ‘ one had AMI and
Kevin Krasinski, MD, Durham, NC later on a TCI, another had PE and TCI on the same day. Nine
David Richmond Whiddon, MD, Suffolk, VA patients (38%) had their first event during the first five postop-
James V Bono, MD, Boston, MA erative days ‘ 15 patients (62%) had their first event after the 5th
This study evaluated the accuracy of a 100mm cylindrical radi- postoperative day. In the observation period 5 patients (1%)
ographic marker in assessing the true magnification of post- experienced bleeding complications. this study shows that total
operative total hip anteroposterior x-rays. Secondarily, the hip replacement still results in serious thromboembolic compli-
influence of body habitus on the measured error rates was exam- cations in an unselected population in spite of a wide use of
ined. 211 consecutive post-operative AP hip radiographs of modern anaesthesia, thrombophrophylaxis and early mobilisa-
primary THAs were examined retrospectively on a digital PACS tion. Improved post-discharge care should be developed to
system. On each film, the hemispherical acetabular implant and reduce the risk of serious thromboembolism. The majority of
cylindrical marker were measured. The implant measurement serious thromboembolic events occurring after discharge
was then compared to the actual size of the implanted compo- warrant further research in screening patients at risk before the
nent, to obtain the true magnification. This magnification was operation to prevent post discharge complications.
applied to the marker measurement and a % error calculated.
The % error was then correlated with the patient’s body mass
417
POSTER NO. P048 template-implant variance) was more common in the varus
Acetabular Center Axis: A Novel Alternative to stems, but does not predict early failure or problems with this
implant design. The study suggests there is no effect of varus
Anterior Pelvic Plane in Navigated Hip Arthroplasty femoral alignment for this tapered-cementless stem.
Sam Hakki, MD, Saint Petersburg, FL
J Daniel Oliveira, MD, POSTER NO. P050
Luis Dordelly, MS, The Inaccuracy of Anterior Pelvic Plane Acquisition
There is significant variation in registering anterior pelvic plane in Computer-Assisted Total Hip Arthroplasty
(APP) among experienced navigated hip surgeons reflecting
Sebastian Parratte, MD, Marseille, France
negatively on the accuracy of determining inclination and antev-
ersion. Whether it is variations in pelvic anatomy or improper Pascal Kilian, PhD, La Tronche, France
positioning, this inaccuracy highlights the need for alternative Vanessa Pauly, MSc,
methods of registration of which the acetabular center axis (ACA) Jean-Noel A Argenson, MD, Marseille, France
is proposed. CT scan compared accuracy of ACA and APP in The goal of this study was to evaluate in vivo and in vitro the
determining acetabular and cup anteversion and inclination. The accuracy of the anterior pelvic plane acquisition, considered as
APP and ACA were defined and registered in 20 navigated total the reference for computer-assisted total hip arthroplasty (THA).
hip arthroplasty (THA) patients. Postoperative CT scan measure- Cup placement was performed using an imageless computer-
ments of acetabular and cup inclination and version angles were assisted system in thirty patients during THA. Post-operatively
independently observed and compared with ACA and APP regis- the position of the cup was evaluated on computed tomography
tration data using t-student test analysis. Mean acetabular using a validated tridimensional software. The differences
(anatomical) version of 19.1(S.D. ±5.8), ACA version of between the perioperative and postoperative angles for abduc-
22.0(S.D.±8.2) and cup version(CT-scan) of 22.15(S.D.±8.7) tion and anteversion were compared using a two-group pair test.
showed no statistical difference denoting extremely accurate ACA On two cadavers four clinicians performed ten times the anterior
software in detecting acetabular anatomy(p=0.96) and cup orien- pelvic plane acquisition using three methods: percutaneously,
tation(p=0.96) . The mean of APP version is 17.45(S.D.±4.7) with ultrasound and by direct bony acquisition defined as the
compared to 22.15 true cup version, had no statistical difference reference. The mean error for each anterior pelvic plane acquisi-
(p=0.11).Similarly, mean acetabular inclination of tion method was compared using a univariate variance model
47.9(S.D.±7.2), final cup inclination of 42.3 (S.D.±3.7), and ACA for repeated measurements. In vivo, the mean difference
inclination of 40.3(S.D.±6.9) had no difference(p=0.27). Mean between the perioperative and postoperative abduction angles
APP inclination of 40.8.2(S.D.±4.6) was not different either. Both was 4º and not statistically significant. For anteversion, the
methods are within safety zone of Lewinnek with ACA registra- difference was 4º and not significant in patients with BMI < 27.
tion being more accurate than APP though was not statistically The difference was 11º and significant in patients with BMI >27
different. (p=0.76) Inaccessibility of ASIS, variability of pelvic (p<0.001). In vitro, the mean errors for abduction and antever-
anatomy and change of its position during APP registration leads sion were respectively 3.8 º and 19.2 º for cutaneous acquisi-
to cup orientation inaccuracies . ACA software relies on readily tion, and 2.8º and 6.2º for ultrasound acquisition. The errors
palpable acetabulum irrespective of pelvic position giving this were significantly higher with the percutaneous method (p<
system an extra accuracy in navigated THA. 0.001). According to our results, the accuracy of the standard
percutaneous acquisition method of the anterior pelvic plane in
POSTER NO. P049 computer-assisted THA is limited. The ultrasound acquisition
Clinical and Radiographic Outcomes of a Tapered method may represent a reliable alternative.
Cementless Stem Implanted in Varus POSTER NO. P051
Thomas L Bernasek, MD, Temple Terrace, FL Acetabular Remodeling Following Total Hip
Eric K Jepson, DO, Colorado Springs, CO
George John Haidukewych, MD, Temple Terrace, FL
Arthroplasty with Trabecular Metal
Varus cemented femurs in THR can yield poor results, but little Jean-Noel A Argenson, MD, Marseille, France
data exists for cementless femurs. We evaluated the radiographic Jean-Charles Grillo, MD,
and clinical outcomes of tapered-cementless femurs implanted Xavier Flecher, MD, Marseille Cedex 09, France
in varus. 150 THR’s (average 34months follow-up) were evalu- Sebastian Parratte, MD, Marseille, France
ated. Radiographic assessment for instability, loosening, subsi- Julien Bouvenot, MD,
dence and alignment was performed. Varus stems (> three The purpose of this study was to evaluate the bone mineral
degrees) and neutral stems were compared. Postoperative x-rays density (BMD) using dual-energy x-ray absorptiometry (DEXA)
were calibrated and digitally re-templated to determine disparity around cementless trabecular metal (TM) acetabular compo-
between the implanted prosthesis and templated sizes. Harris nents compared to Titanium (Ti) cups. The study included 83
Hip Scores (HHS), pain and complications were assessed. hips divided in two groups implanted with a TM or Ti cup The
27(18%) stems had over three degrees varus. Re-templating groups were comparable for age repartition, BMI , indication,
suggested varus stems were undersized by an average of 1.26 surgical technique and postoperative protocol.. The radiographic
sizes (SD 0.65). Neither group revealed bone-prosthetic tip and the DEXA evaluation was realized in the three acaetabular
stress reaction. The two groups showed no significant difference zones according to DeLee and Charnley at one week, 3 months
in HHS (Varus-93.0, neutral-92.7 p=0.88), radiographic loos- and 24 months after surgery. The average postoperative Harris
ening (0%), subsidence (none >2mm) or revisions (0%). Thigh hip score was comparable in the two groups (81 and 86 points).
pain incidence was 2.45%, however none were from the varus No significative difference was found between the two groups
group. Varus placement of cementless-tapered femoral compo- regarding implant positioning. Radio-gaps of non contact areas
nents did not affect the clinical or radiographic outcome in early were seen in 14% of group TM and 5% of group Ti, all filled at
follow-up. Undersizing of the femoral prosthesis (as defined by one year . No revision for cup loosening occured in both groups.
The BMD was significantly higher in TM group compared to Ti in this study ranged from 90mm to 110mm in all cases. The
group in zone 1 (1.323 ± 0.327 g/cm2 versus 1.110 ± 0.242 average follow-up period was 38 months (24-79 months). The
g/cm2 ) and zone 2 (1.160 ± 0.263 g/cm2 versus 1.049 ± 0.261 average age of patients at the time of surgery was 50.9 years (33-
g/cm2 ). Despite a higher number of immediate postoperative 64 years). The Harris hip score was used for clinical evaluation.
gaps in the TM group the ability of the bone to fill-in the gaps was The femoral offset of the hip and valgus angle of the femoral
greater with the trabecular metal cementless acetabular compo- component were measured on the AP radiograph. The average
nent. The bone remodeling evaluation showed less decrease in Harris hip score was 52.0 preoperatively and 93.9 postopera-
periacetabular BMD with trabecualr metal allowing a better load tively. In 7 hips, intraoperative femoral fissure fracture occurred.
transfer in the central part of the ilium. In one hip, aseptic loosening had occurred 14 months after
surgery and required revision surgery. No patients had’ signifi-
POSTER NO. P052 cant thigh pain. The average femoral offset was 35.8 mm preop-
◆Combination of Transtrochanteric Rotational eratively and 40.9 mm postoperatively. The average valgus angle
of the femoral component was 4.1°. There was a significantly
Osteotomy and Muscle Pedicle Bone Graft in negative correlation between postoperative femoral offset and
Osteonecrosis valgus angle (r=-0.59, p<0.0001). Short stem seems to have two
Taek Rim Yoon, MD, Jeonnam, Korea, Republic of major advantages in the absence of significant thigh pain and
Eun Kyoo Song, MD, Kwangju, Korea, Republic of the ease of revision THA but it is necessary to pay attention to
Jong-Keun Seon, MD, Lexington, MA the intraoperative fissure fracture and the stem position during
implantation.
Sang Jin Park, MD, Hwasun-gun, Jeonnam Korea, Republic
of POSTER NO. P054
Seong-Beom Cho, MD, Gwanju, Korea, Republic of
Mixing and Matching Total Hip Arthroplasty
Chang-Ich Hur, MD,
Jae Yoon Chung, MD, Gwangju, Korea, Republic of Components
Eun-Sun Moon, MD, Kwangju-City, Korea, Republic of Jeya Palan, MRCS, Oxford, United Kingdom
Sung Taek Jung, MD, Gwangju, Korea, Republic of J Glynne Andrew, MD, Bangor, Gwynedd, United Kingdom
The aim of this study was to evaluate the results of a combina- Peter H Gibson, FRCS, Woodend, Aberdeen, United
tion surgery of a transtrochanteric rotational osteotomy (TRO) Kingdom
and a muscle pedicle bone graft (MPBG) for the treatment of John Nolan, MD, Norwich, United Kingdom
osteonecrosis of the femoral head The combination surgery was Kenneth Tuson, FRCS, Kent, United Kingdom
performed in 60 hips (57 patients). The mean age of the patients Andrew J Hamer, MD, South Yorkshire, United Kingdom
was 33 years (range, 19-50). The mean follow-up duration was Michael Fordyce, FRCS, Tunbridge Well, United Kingdom
2.6 years (range, 2-3.6). Seven hips were classified as Ficat stage David W Murray, MD, Oxford, United Kingdom
2, 39 as stage 3, and 14 as stage 4 There was an overall 90% radi-
David J Beard, DPhil, Oxford, United Kingdom
ographic success rate. The average HHS was 90.8 points among
There has been controversy about the practice of “mixing and

the surviving 56 hips at the final follow-up. Excellent results
were obtained in 32 hips(57%), good in 14(25%), fair in matching” femoral and acetabular implants from different
8(14%) and poor in 2(4%). A comparison of the preoperative manufacturers in total hip arthroplasty (THA). We studied the
radiographs with that of the final follow-up showed that the clinical outcomes at five years, of 1404 patients who underwent
collapse was effectively arrested in all hips in stage 2, 35(89%) primary THAs, with a cemented polished femoral stem but with
out of 39 hips in stage 3, and 12(85%) out of 14 hips in stage 4. seven different acetabular components from different manufac-
Four hips(6%) failed and two of them were converted to a total turers. This was a prospective non-randomised multi-centre
hip arthroplasty A combination of TRO and MPBG was quite study. Oxford Hip Scores (OHS) were measured pre-operatively
satisfactory even in advanced cases. Although this technique is and post-operatively up to five years. The clinical benefit of
difficult to perform, it is recommended particularly for young surgery, as determined by the change in OHS (\OHS) was used
patients with stage 2 and 3, and some selective patients with as the primary outcome measure. Secondary outcome measures
stage 4 disease included dislocation and revision rates, operating time and
length of hospital stay. When the change in OHS (\OHS) was
POSTER NO. P053 assessed, there were initial significant differences at up to two
years follow up (p = 0.021) between the various acetabular cups.
Total Hip Arthroplasty using Short Stem By three and five years, these differences were no longer signifi-
Satoshi Kamada, MD, Fukuoka, Japan cant (p = 0.253, p = 0.898 respectively). There were significant
Masatoshi Naito, MD, Fukuoka, Japan differences in dislocation rates (p = 0.049) but not revision rates
Kei Shiramizu, Fukuoka, Japan (p = 0.3). There was a significant difference (p < 0.001) in mean
Hiroshi Shitama, MD, Fukuoka, Japan operating time with a maximum difference of 42.3 minutes.
Tsuyoshi Shinoda, MD, Fukuoka, Japan This study provides clinical evidence that “mixing and
Akira Maeyama, MD, Fukuoka, Japan matching” appears to be generally safe, although there remains
a concern that there is a higher dislocation rate associated with
Takahiko Kiyama, MD, Fukuoka, Japan
some acetabular components. Further work is needed to
Takeshi Teratani, MD, Fukuoka, Japan examine if this practice remains well tolerated in the longer
Akinori Takeyama, MD, Fukuoka City, Japan term.
The purpose of this study was to report the clinical and radio-
logical results of total hip arthroplasty (THA) using the short-
stem in patients with secondary osteoarthritis of the hip due to
acetabular dysplasia. A total of 107 cementless THA using short
stems were investigated in this study. The length of the stem used
419
POSTER NO. P055 of the cups in the controlgroup were within the target zone,
Acetabular Reinforcement Ring in Primary Total Hip 23/25 of thecups in the study group were placed in this
zone.(p=0.003). Imageless navigation increases accuracy in cup
Arthroplasty: A Minimum 10-Year Follow-Up positioning in minimal-invasive surgery in lateral position
Moritz Tannast, Bern, Switzerland
Hassan Sadri, MD, Riaz, Switzerland POSTER NO. P057
Gregoire Pfander, MD, Surgical Techniques for Standardized Curved
Klaus Siebenrock, MD, Bern, Switzerland Periacetaular Osteotomy
Peter Koch, Bern, Switzerland Yoon Taek Kim, MD, Irumagun, Saitama, Japan
Hiroshi Fujita, MD, Columbus, OH Hiromi Oda, Saitama, Japan
Peter Ballmer, MD, Thun, Switzerland We have performed more than 500 rotational acetabular
Reinhold Ganz, MD, Zurich, Switzerland osteotomies (RAO) in patients with subluxated osteoarthritis of
We report the results of a titanium acetabular reinforcement ring the hip secondary to acetabular dysplasia over the last 30 years.
with a hook (ARRH) in primary THA. The favorable results of this In recent years, we have selected from RAO, varus osteotomy,
device in arthroplasty for developmental dysplasia and difficult valgus osteotomy, and Chiari osteotomy, depending on the type
revisions motivated its use in primary THA. With this implant of osteoarthritis, with the aim of preserving the joint as much as
only minimal acetabular reaming is necessary, anatomic posi- possible. Since April 2005, we have also carried out curved peri-
tioning is achieved by placing the hook around the teardrop and acetabular osteotomy(CPO), mainly on the hips of patients with
a homogenous base for cementing the polyethylene cup is initial stage osteoarthritis. Between April 2005 and March 2007,
provided. Between April 1987 and December 1991, 241 THA we performed CPO on 31 hips in 31 patients and evaluated the
with insertion of an ARRH were performed in 178 consecutive status radiologically before and after the operation.
patients (mean age 58 years, 30 to 84 years) with a secondary Improvement was seen in the CE angle, the acetabular head
osteoarthrosis in 41 % of the cases. 33 patients (39 hips) had died index, the head height index, and the acetabular roof obliquity
and 17 cases had been lost to follow-up. The median follow-up after the operation, but not in the head lateralization index. As
was 122 months with a minimum of ten years. Eight hips had compared to the results after RAO, patients undergoing CPO
been revised, leaving 177 hips in 120 living patients without revi- had smaller incisions in the anterior approach( approximately
sion. Six cups were revised because of aseptic loosening. Two hips 10 cm), shorter operation times, more relief from pain postop-
were revised for sepsis. For aseptic loosening, the 10-year eratively, and earlier recovery of muscle strength because the
survivorship was 0.97 (95% CI 0.94 to 0.99). Analysis of radi- gluteal muscles were not detached. Additionally, CPO also has
ographs implied loosening in 7 other cups without clinical symp- several other advantages: it permits an accurate osteotomy cut, it
toms. The results of primary THA using an ARRH parallel the can be used to treat severe acetabular dysplasia, and it provides
excellent results of these implants often observed in difficult for easily medialization of the femoral head. We have attempted
primary and revision arthroplasty at a minimum of ten years and to standardize and conduct CPO accurately, and have found that
are comparable with cementless implants. Medial migration uniform osteotomy cuts can be made using the same curved
occurring with loosening of the acetabular component seems to osteotome as that used in RAO. CPO is a simplified procedure
be prevented with this implant. Radiographic loosening signs can with good clinical and radiological results.
exist without clinical symptoms.
POSTER NO. P058
POSTER NO. P056
Pelvic Extension After THR Places Patients at
Computer-Assisted Navigation Increases Accuracy Increased Risk of Anterior Dislocation
in Minimal-Invasive THR Matthew Thompson, MS, Houston, TX
Ernst Sendtner, MD, Bad Abbach, Germany Akin Cil, MD, Roxbury, MA
Joachim Grifka, MD, Pentling, Germany Philip C Noble, PhD, Houston, TX
Tobias Renkawitz, MD, Studies have shown that patients exhibit substantial variations in
Thomas Kalteis, MD, Bad Abbach, Germany pelvic orientation in the supine, standing and sitting positions.
The aim of the study was to evaluate accuracy of image-less This variation may influence implant alignment and stability
computer-assisted navigation in minimal-invasive THR with after THR. In this study, we examine the influence of functional
patients in lateral decubitus position In this prospective and pelvic position on the risk of impingement during everyday
randomised clinical study,acetabular cups were implanted free- activities performed after THR. 3D computer models of the hip
hand (control groupn=25) or with computer assistance using an joint after THR were prepared from CT reconstructions and CAD
image-freenavigation system (study group n=25). Total hip models of the implanted components (head diameter: 28mm;
replacement was performed with patients in lateral decubitus cup orientation: 45° abduction, 20° anteversion). Each model
position using a minimal-invasive anterior approach. The cup was placed in 4 postures simulating the typical variations in
positionwas measured postoperatively on pelvic CT using pelvic tilt seen in sitting and standing. These were: 45deg exten-
image-processing software. An average operative inclination of sion (sitting),: -2deg extension (standing or supine) (I); 42deg,
41.2° (range: 32°’58°; SD±9.0°) and anaverage operative antev- 5deg (II); 20deg, -10deg (III), and 20deg, 0deg (IV). The ROM of
ersion of 23.0° (range: -5° to 47°; SD±15.0°)were found in the the hip was measured for each model posture during 9 common
control group, and an average inclinationof 44.0° (range: activities causing instability. All values of ROM were compared
39°’49°; SD±2.8°) and an average anteversionof 14.4° (range: against minimum values for ROM reported in previous studies.
8°’23°; SD±4.6°) in the computer-assisted study group. The In all groups, pelvic extension increased hip ROM in activities
deviations from the desiredcup position (target zone: 45±5° performed in sitting. However, hip flexion during standing
inclination,15±5° anteversion)were significantlylower in the (group III), led to premature impingement in 66% of the simu-
computer-assisted study group(p<0.001 each). While only 10/25 lations performed, with an average loss of 8.8 degrees of motion.
The greatest effects of pelvic tilt were seen when the hip was malities of bony anatomy which all contribute to reduced
placed in extension. Between the 4 groups, external rotation at motion. Computer models of 71 femora (28 normal and 43
impingement varied by 20.7 degrees during pivoting and 16.3 cam-impinging) were prepared from CT scans. The 43
degrees during rolling over in bed. The best combination of impinging cases had the distinctive appearance of an extended
anterior and posterior stability was provided by Groups I and IV. head-neck junction previously reported by Ganz and coworkers.
Pelvic extension protects the hip against posterior dislocation in Morphologic parameters describing the dimensions of the head,
the sitting position. However, pelvic extension in the standing neck, and medullary canal were calculated for each specimen.
and supine positions increases the risk of posterior impinge- The anteversion angle, alpha angle of Notzli, beta angle of
ment and anterior dislocation. Optimal pelvic posture is at least Beaulé, and normalized anterior heads offset were also calcu-
20 degrees of extension in sitting and neutral pelvic tilt when lated. Average dimensions were compared between the normal
standing or supine. and impinging femora. Compared to the normal controls, the
impinging femora had wider necks (AP: 15.2 vs 13.3 mm,
POSTER NO. P059 p<0.0001), larger heads (diameter: 48.3mm vs 46.0mm,
Outcomes of Obese and Non-Obese Patients p=0.032) and decreased head/neck ratios (1.60 vs 1.74,
p=0.0002). However, there was no difference in neck/shaft angle
Undergoing Revision Total Hip Arthroplasty (125.7° vs 126.5°, p=0.582) or anteversion angle (8.70 vs
Anne Lubbeke-Wolff, MD, MS, Onex/Geneva, Switzerland 8.44°, p=0.866). As expected, the impinging FAI femurs demon-
Carl Moons, PhD, strated increased alpha angles (74.2° vs 49.0°, p<0.0001), and
Guido Garavaglia, MD, increased beta angles (51.8° vs 45.7°, p=0.048). Most signifi-
Pierre J Hoffmeyer, MD, Geneve 4, Switzerland cantly, 53% of impinging femora also had a significant posterior
The objective of our study was to evaluate the effect of obesity on slip (>2mm), compared to only 14% of normal controls.
the incidence of complications (superficial and deep infection, Average head displacements for the two groups were: FAI:
dislocation, and re-revision), functional outcome, residual pain 1.93mm vs Normals: 0.78mm (p<0.0001). The impinging
and patient satisfaction after revision total hip arthroplasty femur differs from normal in terms of its AP neck width and
(THA). We conducted a hospital-based prospective cohort study head /neck ratio, in addition to changes at the head/neck junc-
including 204 consecutive patients, who underwent a first revi- tion and in the sphericity of the head itself. Moreover, the pres-
sion THA between 1996 and 2006. We used incidence rates, rate ence of posterior displacement of the femoral head on the neck
ratios and adjusted hazard ratios to compare the incidence of should also be appreciated when assessing treatment options.
complications in obese and non-obese patients and in four BMI Surgical treatment limited to localized re-contouring of the
categories (<25, 25-30, 30-35, >35). Functional outcome and head-neck profile may fail to address significant components of
pain were measured five years postoperatively using the Harris the underlying abnormality.
Hip Score. The adjusted hazard ratio for infection (obese versus
non-obese) was 4.1 (95% CI 1.1; 15.0). The adjusted hazard POSTER NO. P061
ratio for dislocation (obese versus non-obese) was 3.5 (95% CI Can the Hemoglobin A1C Test Predict the Risk of
1.3; 9.3). The incidence rate for at least one complication Complications in Patients Undergoing THA or TKA?

increased with rising BMI (1.8, 3.4, 10.3 and 17.9 cases/100
Yossef C Blum, MD, Bronx, NY
person-years). The difference was small between normal and
overweight patients (adjusted HR 1.5, 95% CI 0.5; 4.7), became Jason L Chertoff, MD, Bronx, NY
significantly greater with BMI 30-35 (adjusted HR 4.5, 95% CI Katherine Freeman, PhD,
1.4; 14.0), and was most evident with BMI >35 (adjusted HR Neil Cobelli, MD, Scarsdale, NY
10.9, 95% CI 2.9; 41.1). Eighty patients had a 5-year follow-up There has been no established method to stratify diabetic
visit. Obese patients had moderately lower functional results patients undergoing total joint arthroplasty according to the risk
and higher levels of residual pain, but patient satisfaction was of postoperative complications. Hemoglobin A1C (HgA1C)
almost similar. Revision THA is technically challenging in obese levels have been well established to correlate with risk of diabetic
patients, probably partly related to surgical exposure. We found complications. This study evaluates the utility of the HgA1C test
an increased risk of complications, notably infection and dislo- in predicting postoperative complications in patients under-
cation, in these patients. going total hip (THA) or total knee arthroplasty (TKA). A retro-
spective chart review was performed, searching for patients who
POSTER NO. P060 underwent THA or TKA by our senior author (NJC) between
The Bony Abnormality of the Impinging Femur January 2000 and February 2007. 119 patients with HgA1C
values measured between one year prior to surgery and 120 days
Extends Beyond the Head-Neck Junction subsequent to surgery were identified. Any perioperative or post-
Steven Schroder, Houston, TX operative complications (within three months) were noted. A
Andrew R Ellis, BS, Houston, TX multivariate analysis assessed for associations between HgA1C
Matthew Thompson, MS, Houston, TX level and surgical-site complications, medical complications,
Molly M Usrey, BS, Houston, TX length of stay, and place of discharge. There was a direct associa-
Gregory William Stocks, MD, Houston, TX tion between HgA1C levels and overall surgical-site complica-
Philip C Noble, PhD, Houston, TX tions (p=0.0023), wound complications (0.0020), and overall
complications (0.0244). While there were not enough surgical-
Femoro-acetabular impingement (FAI) is a common source of
site infections to demonstrate a statistically significant associa-
impaired motion of the hip, often attributed to the presence of
tion, three of four infections occurred in patients with HgA1C
an aspherical femoral head. However, other types of femoral
levels at or above 7.5. There was no association between HgA1C
deformity, including posterior slip, retroversion, and neck
and medical complications, length of stay, or place of discharge.
enlargement, can also limit hip motion. This study was
HgA1C levels can help predict the risk of wound complications
performed to establish whether the cam-impinging femur has a
and overall complications after THA or TKA. Additional cases of
single deformity of the head/neck junction or multiple abnor-
421
surgical-site infection would be needed to potentially demon- retrospectively reviewed 103 consecutive frozen section biopsies
strate a statistically significant association with HgA1C. We were (56 knee arthroplasties and 47 hip arthroplasties) that were
unable to prove an association with medical complications, utilized as a diagnostic tool in cases where there was clinical
length of stay, or place of discharge. suspicion of infection at the time of surgery. Tissue samples were
taken from a minimum of four different sites. Definitive patho-
POSTER NO. P062 histological results were defined as multiple high-power field
Fatigue Behavior and Static Properties of Second- counts of five or more polymorphonuclear leukocytes (PMNs)
or any field with ten or more PMNs. Intra-operative cultures
Generation UHMWPE were also taken in every case. The presence of an organism was
Sara A Atwood, MS, Berkeley, CA considered a positive culture result. The tissue samples and intra-
Jevan Furmanski, MS, Berkeley, CA operative cultures were compared for each infection case and
Mike Hoang, BS, Berkeley, CA differences in positive and negative diagnoses were noted.
Michael D Ries, MD, San Francisco, CA Results were stratified by whether the patient was started on an
Lisa Pruitt, PhD, Berkeley, CA antibiotic series prior to surgical exploration, and a Chi Square
Second-generation treatments for cross-linked UHMWPE have analysis was used to compare the antibiotic and non-antibiotic
been developed to preserve some of the mechanical properties groups. Overall, there were 31 positive culture results that also
of conventional material while improving its wear resistance. had a positive frozen section. The diagnostic tests were also in
This study elucidates the effect of current treatments on static agreement for 33 negative results. There were 6 cases where the
and fatigue properties. Nine distinct formulations of UHMWPE culture was positive but the frozen section was negative and 33
were tested, including two conventional controls. The treatments cases where a negative culture occurred when there was a posi-
involve gamma irradiation in one or multiple sequential doses tive frozen section. In grouping patients on or off antibiotics,
(from 0 to 10 Mrad) with subsequent thermal treatments above there were a statistically higher proportion of antibiotic patients
or below the melting temperature (130 and 147oC). All were (53 versus 20%) that had negative results for both tests (p =
either ram extruded (RE) GUR 1050 or compression molded 0.001) and a lower percentage (8 versus 43%) that had positive
(CM) GUR 1020. Fatigue crack propagation experiments and results for both tests (p < 0.001). While antibiotic patients were
tensile tests were conducted. The crystallinity and oxidation were more likely to have one or both tests negative, the proportion of
assessed and the microstructures were qualitatively evaluated. patients showing split results (positive for one test but negative
The materials with the static and fatigue properties most similar for the other) was not statistically significant (p > 0.05). Cases
to conventional UHMWPE are (CM 1020, 5 Mrad, 147oC), as for which there are positive frozen sections with a corresponding
well as (CM 1020, 9 Mrad single and sequential, 130oC). The positive histological diagnosis should be considered as true posi-
fatigue performance of these three materials was statistically tive indicators of infection. However, the results of this study
indistinguishable. The material that is (RE 1050, 10 Mrad, suggest that all negative results should be approached with
147oC) demonstrates the substantially worst fatigue perform- caution, especially in patients who are on antibiotics. For these
ance and tensile properties. This work shows that a material with patients, there is a high likelihood that frozen sections and/or
a total cross-linking dose of 9 Mrad subjected to below-melt cultures will have false negative results. Problems are encoun-
tered when there are positive cultures, but there is no evidence
annealing preserves the crack propagation resistance, crys-

tallinity, and tensile properties of conventional UHMWPE better of pathohistological diagnosis of infection. This certainly could
than materials treated with 7.5, 9, or 10 Mrad which are subse- be a tissue or histological sampling error, but also might be a
quently remelted. However, thermal treatments can also affect contaminant or other false positive of the culture. In addition,
oxidation resistance which was not evaluated. Also, a dose of 10 we found a number of cases where there were actual infections
Mrad appears to decrease the fatigue and tensile properties on histology where there was no positive culture. This is
substantially more in RE 1050 than in CM 1020. certainly troublesome as there can be a group of patients that
have false negatives for both culture and histology but are truly
POSTER NO. P063 infected. In conclusion, this study suggests that improved tools
may be necessary to diagnose periprosthetic infections.
Accuracy of Cultures and Tissue Sampling in
Diagnosing Periprosthetic Infections? POSTER NO. P064
Michael A Mont, MD, Baltimore, MD Thirty Years’ Followup of Intertrochanteric Valgus
Slif D Ulrich, MD, Baltimore, MD Osteotomy for the End-stage Arthritic Hip
Ronald Emilio Delanois, MD, Lutherville, MD Kenji Kawate, MD, Kashihara, Nara, Japan
David R Marker, BS, Baltimore, MD Ikuo Kawahara, MD,
Michael Akbar, MD, Heidelberg, Germany Hiroyuki Kataoka, MD,
Thorsten M Seyler, MD, Winston-Salem, NC Katsuya Tamai, MD,
Recent improvements in infection prophylaxis have reduced the Tomoyuki Ueha, MD,
incidence of periprosthetic infections to 1% or lower.
Hiroshi Yajima, MD, Nara, Japan
Nevertheless, septic complications remain challenging, and
accurate diagnostic methodologies are crucial. Patients who are Seiichi Ono, MD, Nagano Pref, Japan
started on antibiotics prior to surgery may be more difficult to Yasuhito Tanaka, MD, Kashihara, Nara, Japan
diagnosis. Many studies use intra-operative cultures as a defini- Yoshinori Takakura, MD, Kashihara, Nara, Japan
tive test, but other studies suggest that permanent histological This study reviewed the long-term results of intertrochanteric
diagnosis is preferred. The purpose of this study was to correlate valgus femoral osteotomy for arthritic hips to clarify the influ-
the various sensitivities and specificities of these different tests encing factors. Seventy-four patients (88 hips) were followed-up
for diagnosing infections in total hip and total knee arthroplasty for an average of thirty-six years (range, 27 to 45 years). Average
patients, and to assess their efficacy in individuals who were age at operation was forty (range, 13 to 69). The patients were
already receiving prophylactic therapy at the time of surgery. We divided into two groups (good and poor) based on the latest
radiographs. The center-edge angle, sharp angle and acetabular tomatic patients to undergo to surgical treatment as soon as
head index were measured from AP radiographs taken immedi- possible and discuss with the patients that unpredictable results
ately postoperative, and the two groups statistically compared. could occur in Tönnis 2 cases.
The Japanese Orthopaedic Association Hip Score (100 points)
was used to clinically evaluate patients, and to divide into two POSTER NO. P066
groups (high and low). Fifty-one hips had THA at an average of Association between Procedure Duration and THA
twenty-two years (range, 3 to 38 years) after operation and the
thirty year survival rate was 40%. Center-edge angle and acetab-
and TKA Survivorship in the U.S. Medicare Population
ular head index showed significant differences between the good Steven M Kurtz, PhD, Philadelphia, PA
and poor groups with the acetabular coverage of good patients Edmund Lau, MS, Philadelphia, PA
being better than that of poor. Radiographic measurements did Michael T Manley, PhD, Franklin Lakes, NJ
not influence the scores. The mean preoperative score was sixty Kevin Ong, PhD, Philadelphia, PA
(range, 37 to 87 points) and the mean latest score was fifty-seven Duration of THA and TKA procedures has been previously iden-
(range, 27 to 99 points). The mean score of patients with unilat- tified as a significant risk factor for complications. Our study
eral involvement was higher than that of patients whose examined the association between procedure duration with
contralateral hips were involved. The acetabular coverage influ- primary THA and TKA survivorship at 8 years in the Medicare
enced the radiological results. The number of hips involved population. 1997-2004 Medicare claims data was used to iden-
influenced the clinical results. The survival rate and the average tify primary and revision THA and TKA procedures. Anesthesia
duration from osteotomy to THA encouraged us to continue time from each claim was used as a proxy for procedure dura-
performing valgus femoral osteotomies. tion. Kaplan-Meier method and Cox regression were used to
determine 8-year implant survivorship and hazard ratios associ-
POSTER NO. P065 ated with anesthesia duration. Median anesthesia duration for
Mini-Anterior Approach in Femoroacetabular primary THA and TKA decreased by about 20 and 30 minutes,
Impingement: Short-Term Results in 107 respectively, between 1997 and 2004. The median anesthesia
duration also decreased with increasing hospital and surgeon
Consecutive Cases procedure volume. Longer anesthesia duration was associated
Manel Ribas Fernandez, MD, Bacelona, Spain with males and younger patients. THA and TKA procedures
Oliver Marin-Pena, MD, Tres Cantos (Madrid), Spain lasting more than 240 minutes were significantly associated with
Bertram Regenbrecht, MD, higher revision rates compared to 120-150 minutes. TKA proce-
Basilio De La Torre, MD, Madrid, Spain dures shorter than 120 minutes and between 150-180 minutes
Klaus Wenda, MD, also had significantly higher revision rates compared to those
lasting 120-150 minutes. Procedure duration has decreased
Alfonso Valles, MD, Madrid, Spain
substantially over the 8-year period. The increase revision risk
Jose M G Vilarrubias Guillamet, MD, Barcelona, Spain
associated with shorter TKA procedures could have substantial
Paul E Beaule, MD, Ottawa, ON Canada impact on patient outcomes and associated resource utilization.
Surgical treatment of femoroacetabular impingement (F.A.I,) is

Similarly, increased wound exposure and stasis from longer THA
actually a common procedure with good short term results. Safe and TKA procedures may increase the risk of infection and
hip dislocation and arthroscopic approaches has been propose. venous thromboembolism, possibly leading to revisions. Longer
The aim of this study is to analyse clinical and functional results procedure times could reflect surgical complexity, inexperience,
of F.A.I patients after surgical treatment by means Mini-anterior or less than optimal standardization programs.
approach. A prospective study of 107 consecutive hips in 105
patients was performed. Mean follow was 2,7 years (2-4) . Cases POSTER NO. P067
were divided into three groups according to preoperative Tönnis
classification: group A: Tönnis 0 (32 patients), group B: Tönnis
◆Safety and Efficacy of an Oral Thrombin Inhibitor
1( 61 patients) and group C : Tönnis 2 (24 patients). for Preventing Major VTE Following THA and TKA
Impingement test, Merle-D’Aubigné-Postel (MDA) and Richard J Friedman, MD, Charleston, SC
WOMAC scores were assessed at 6 weeks, 3 months, 6 months Major venous thromboembolism (VTE), the composite of prox-
and every year after surgical procedure. Statistical analysis was imal deep venous thrombosis, fatal and nonfatal pulmonary
performed by SPSS 10.0 software (SPSS INC, Chicago, Ill) . Chi- embolism, is a significant complication following total hip
squared and non-parametric tests were used. p<0,05 was consid- (THA) and knee (TKA) arthroplasty. The purpose of this study
ered to be significant. Impingement test was negative in 73,8 % was to compare an oral direct thrombin inhibitor, dabigatran
of the cases after 6 weeks, 82,2 % at 3 months ,93,5% at 6 etexilate, to enoxaparin in preventing major VTE following THA
months and 97,2 % at one year. Merle D’Aubigné score and TKA. A meta-analysis of 3 phase III studies in the dabigatran
improved from 12,7 preoperative to 17,56 at latest follow up. VTE prevention program with over 8,000 patients was
Alpha angle improve from 72,78º to 32,09. We associated performed. Each of the double blind randomized studies
impingement test, MDA and WOMAC scores and the global compared 220 mg and 150 mg of dabigatran once daily
results were registered as excellent, good, fair and bad. In Tönnis following a half-dose on the day of surgery to enoxaparin, which
0/1 group, 92,2% were good or excellent , but in Tönnis 2 group, was given 40 mg sc once daily in the two European studies, and
only 53,3% were excellent or good. This difference was found to 30 mg sc twice daily in the North American study. Treatment
be statistically significant (p < 0,05). The results of minimal inva- duration was 6-15 days after TKA and 28-35 days post THA.
sive treatment of femoroacetabular impingement are statically Definitive diagnostic testing was required for all suspected symp-
different in patients with Tönnis 0/1 compared to those with tomatic VTE events. Bilateral venography was performed at the
Tönnis 2. Thus, it seems to be reasonable to recommend symp- end of the treatment period. Major VTE occurred in 3.3% of the
enoxaparin group (69 of 2096) versus 3.0% (62 of 2033) of the
dabigatran etexilate 220 mg group and 3.8% (78 of 2071) of the
423
150 mg group. Major bleeding events were infrequent, and POSTER NO. P069
comparable in all treatment groups: enoxaparin 1.4% (39 of The Impact of Type I and Type II Diabetes on
2716), dabigatran 220 mg 1.4% (38 of 2682), and dabigatran
150 mg 1.1% (29 of 2737). Dabigatran etexilate, a once daily Perioperative Outcomes after THA and TKA in the
oral direct thrombin inhibitor, was safe and efficacious when U.S.
compared to enoxaparin in the prevention of major venous Michael P Bolognesi, MD, Durham, NC
thromboembolism after THA and TKA. Nicholas Adam Viens, MD, Durham, NC
POSTER NO. P068 Milford H Marchant, Jr MD, Chapel Hill, NC
Chad Cook, PT,
Validation of Surgical Apgar Score in Total Joint Thomas Parker Vail, MD, San Francisco, CA
Arthroplasty As the prevalence of diabetes mellitus (DM) in people over 60
Thomas H Wuerz, MD, Cambridge, MA years of age is expected to increase, the number of diabetic
Henrik Malchau, MD, Boston, MA patients who undergo total hip and knee arthroplasty (THA and
Harry E Rubash, MD, Boston, MA TKA) should increase concordantly. In general, patients with
James H Herndon, MD, Boston, MA DM have significantly increased risk for adverse events following
David Kent, MD, MS, arthroplasty. The goal of this study was to determine whether the
type of DM affected the incidence of perioperative complica-
Atul Gawande, MD, MPH,
tions in the hospital after joint replacement. From 1988 to 2003,
Adverse events are a major focus of media attention and legal the Nationwide Inpatient Sample (NIS) recognized 65,769
conflict. Efforts in quality improvement and patient safety can patients who had DM and underwent joint replacement surgery.
be supported by predictive assessment of patient status. Surgical Bivariate and multivariate analyses compared patients with Type
teams lack a reliable, easy-to-use measure of patient condition I (n=8,728) and Type II (n=57,041) DM regarding common
following surgery. A 10-point Surgical Apgar Score was recently surgical and systemic complications, mortality, and hospital
developed and validated in general and vascular surgery to rate course alterations. Type I DM patients routinely had an
patients’ surgical outcomes. The score provides an instant predic- increased length of stay and increased inflation-adjusted cost
tion of major complications and death. It can be applied to after surgery (p<0.001). Type I patients also had significant
screening of high risk patients, triage and evaluation of safety increases in the incidence of myocardial infarction, pneumonia,
interventions. No similar score has been developed in total joint urinary tract infection, post-operative hemorrhage, wound infec-
arthroplasty (TJA). We validate the performance of the score in tion, and death (p<0.02). Type I and Type II DM represent very
TJA. Cohort study including patients (N=3371) undergoing different disease patterns. Type I DM generally has an earlier
primary and revision total hip and knee arthroplasty at the onset, and patients are absolutely dependent on insulin for treat-
Massachusetts General Hospital (MGH). Data on comorbidities, ment. When compared to Type II patients, Type I diabetics have
and intraoperative performance parameters (blood loss, lowest significantly increased risks for surgical and systemic complica-
heart rate, and lowest blood pressure) are collected. Patients are tions during the index hospitalization, higher mortality,
stratified to their Surgical Apgar Score based on their perform- increased length of stay, and higher hospital charges following
ance parameters. The primary endpoints are major complica- arthroplasty. The result is higher cost, greater burden on the
tions and death during hospitalization. Performance healthcare system, and greater risk to patients with Type I
characteristics will be evaluated including discrimination (C- disease.
statistic). The a priori criteria for adequate discrimination are
defined as C-statistic significantly better than 0.5. The Surgical POSTER NO. P070
Apgar Score is strongly predictive of major postoperative compli-
cations. Compared with average-scoring patients (Surgical Apgar Postoperative Acetabular Retroversion Causes
Scores 7-8), pooled/adjusted odds ratios for major postoperative Posterior Osteoarthritis of the Hip
complications are 0.58 (95%CI 0.44-0.78) for those Scoring 9- Takahiko Kiyama, MD, Fukuoka, Japan
10; 1.54 (1.22-1.95) for Scores 5-6; and 3.32 (2.22-4.98) for Masatoshi Naito, MD, Fukuoka, Japan
Scores 0-4 (all significant with p<0.001). The score achieves Kei Shiramizu, Fukuoka, Japan
good discrimination with c-statistics of 0.73 for major compli-
Tsuyoshi Shinoda, MD, Fukuoka, Japan
cations and 0.81 for deaths. The Surgical Apgar Score provides an
immediate, objective, and reliable rating of patient outcome Akira Maeyama, MD, Fukuoka, Japan
after total joint arthroplasty, based on routinely available data. Akinori Takeyama, MD, Fukuoka City, Japan
The score can detect patients at elevated risk for major compli- Takeshi Teratani, MD, Fukuoka, Japan
cations after surgery. It could serve as a powerful tool for Daisetsu Karashima, MD, Fukuoka, Japan
improving clinical audit and for evaluating surgical safety inter- Satoshi Kamada, MD, Fukuoka, Japan
ventions. This study serves as a foundation for the development Recognition of acetabular retroversion is important when
of a more comprehensive score specific for TJA. performing periacetabular osteotomy, because retroversion can
cause femoroacetabular impingement or posterior wall defi-
ciency. The purpose of this study was to assess whether the differ-
ence of acetabular version influenced the clinical and
radiographic results after periacetabular osteotomy. We retro-
spectively reviewed 33 hips in 30 patients (mean age: 39 years),
who had undergone periacetabular osteotomy for the treatment
of acetabular dysplasia and acetabular retroversion, at a
minimum 2-year follow-up. All hips were evaluated clinically
according to the Harris hip score. Radiographic evaluations of
acetabular retroversion and posterior wall deficiency were based
on the cross-over sign and posterior wall sign, respectively. POSTER NO. P072
Preoperatively, positive posterior wall sign was recognized in all
hips. Postoperatively, twelve hips (36%) had an anteverted and
◆Femoral Osteotomy for Patients With
remaining 21 hips (64%) had a retroverted acetabulum. The Osteonecrosis of the Femoral Head Compared With
posterior wall sign disappeared in hips with anteverted acetab- Natural History
ulum, but remained in 21 hips with retroverted acetabulum Yoshitada Harada, MD, Yachiyo-city, Japan
postoperatively. Among these 21 hips with retroverted acetab-
Shinji Yamamoto, MD, Chiba City, Japan
ulum, osteoarthritis of the posterior part of the hip developed
postoperatively in 5 hips (24%). However, this finding was not
Takayuki Nakajima, MD, Chiba City, Japan
detected in hips with anteverted acetabulum postoperatively. Junichi Nakamura, MD, Chiba, Japan
The average Harris hip score at the latest follow-up was higher (p Takeshi Miyasaka, MD, Chiba, Japan
= 0.051) in the hips with anteverted acetabulum than in those Chikashi Shirai, Md, Chiba City, Japan
with retroverted acetabulum. When performing corrective Shunji Kishida, MD, Sakura City, Japan
osteotomy for a dysplastic hip with acetabular retroversion, it is Osteonecrosis of the femoral head (ONFH) is unclear in its
important to correct the retroversion to prevent osteoarthritis of pathogenesis and has still difficulties for treatment with
the posterior part of the hip due to posterior wall deficiency. preserving of the femoral head. Majority of the patients with
ONFH are young and active, therefore treatment by total hip
POSTER NO. P071 arthroplasty (THA) is also concerning. We performed
Primary Cementless total hip Arthroplasty for Bony trochanteric osteotomy for selected patients and evaluated clin-
Ankylosis in Patients with Ankylosing Spondylitis ical outcomes of surgical procedures. From 1985 to 2004, two
types of trochanteric osteotomies were performed in 91 hips of
Krishna Kiran Eachempati, MS, Hyderabad, India 78 patients. Varus osteotomy in 25 hips of 21 patients (6 males
Rajesh Malhotra, MS, New Delhi, India / 15 females) and rotational osteotomy in 66 hips of 57 patients
Aman Dua, MS, Ludhiana, India (42 males / 15 females) were followed more than three years
Surya Bhan, MD, FRCS, New Delhi, India (average 117 months). As the end point was THA, survival rates
The occurrence of bony ankylosis in ankylosing spondylitis (AS) of osteotomy were compared with patients without surgery
is not precisely known. Bony ankylosis, especially in stiff spine (natural history group). Clinical evaluation was performed with
may present several exclusive challenges in its management. The the Harris hip score (HHS). HHS before surgery was 60.2+13.5
current study is an endeavor to evaluate the clinical and the radi- points and HHS at final follow up was 82.1+18.1 points in varus
ological results of cementless THA in patients with bony anky- osteotomy and HHS at pre-operation was 61.7+9.5 points and
losis of hip due to ankylosing spondylitis. We retrospectively HHS at final was 76.4+20.3 points in rotational osteotomy. The
reviewed 54 patients (92 hips) who underwent cementless total survival rate at five-year was 89% in natural history, 96% in varus
hip arthroplasty for bony ankylosis in ankylosing spondylitis osteotomy and 74% in rotational osteotomy. The survival rate at
between September 1988 and 2002. Clinical assessment was ten-year was 73% in natural history, 89% in varus osteotomy
done at follow-up, which envisages assessment of the pain, func- and 69% in rotational osteotomy. Clinical evaluation of
trochanteric osteotomy for patients with ONFH was still contro-

tion, deformities and range of motion using the Harris Hip
Score. Radiographic analysis was done. Kaplan- Meier survivor- versial. These surgeries could not change the natural history
ship analysis was done at 5 and 8.5 years using the revision for therefore indication of osteotomy should be discreet.
the removal of femoral component, acetabular component or
both due to any cause as the end point The mean age of the POSTER NO. P073
patients was 25.5 years. The mean duration of follow up was 8.5 Continuous Monitoring of Surgical Performance: An
years. The average preoperative Harris Hip Score of 49.5 Application to Total Hip Replacement
improved to 82.6 post operatively. Post operatively 10 hips had
mild to moderate pain. Anterior dislocation occurred in four David Jean Biau, MD, Paris, France
hips (4.3 %) and sciatic nerve palsy in one hip. Heterotopic ossi- Olivier Plotkine, MD,
fication was seen in 12 patients, reankylosis rate was 0%. Alexandre Milet, MD,
Thirteen arthroplasties were revised due to aseptic loosening. Raphael Porcher, PhD,
Kaplan-Meier survivorship analysis with revision as end point Philippe Anract, MD, Paris, France
revealed 98.8% survival at 5 years and 85.8% survival at 8.5 Quality control procedures have shown to be effective in
years follow up Cementless THA in osseous ankylosis in anky- increasing performance in the industrial context and have
losing spondylitis is a worthwhile surgical intervention in bony recently appeared in medicine. We have implemented a contin-
ankylosis. Newfound mobility, maneuverability and improved uous monitoring process to control the performance of implan-
ability to sit comfortably were the outcomes, which alleviated tation of hip replacement in the department. Since November
the patients’ daunted morale. However, the technically 2006, all primary total hip replacements implanted in the
demanding nature of the procedure should not be underesti- department are evaluated by an independent reviewer. Technical
mated (femoral and acetabular fracture or perforation, nerve and
vascular injuries, peroperative revision of the implants, postop-
erative dislocation or revision for any reason), stem (stem angle,
cement grading, leg length) and cup (cup abduction, cup
version, cement grading or impaction) factors are assessed and
entered in a database. Monitoring is performed with the
CUSUM test and Pareto charts and regular meetings notify
surgeons of the performance reached and the fields were
improvement is necessary. 53 total hip replacements have been
monitored so far. The median age of the patients is 64 years, the
425
main diagnosis is primary osteoarthritis (58%), and the median POSTER NO. P075
weight and height are respectively 167 cm and 70 kg.Technical
factors objectives were met at all times. However, the perform-
◆Should Monobloc Cemented Stems
ance required for the stem and cup implantation have not been Systematically Be Revised During Acetabular
met yet. 14 stems (26%) and 16 cups (30%) were not implanted Revision?
correctly. Poor cementing of the stem (23%), of the cup (17%) Moussa Hamadouche, MD PhD, Paris, France
and abduction of the cup (15%) were the most common errors.
Guillaume Grosjean, MD, Paris, France
Improvement over time is however observed. Many factors are
known to influence the survival of total hip replacements.
Marie Moindreau, BS,
Continuous monitoring of these factors allows surgeons to Nicolas Hunuo, BS,
improve performance, decrease postoperative complication rates Jean-Pierre Courpied PhD, Paris, France
due to technical errors and, in the long-term, possibly improve The main reason for failure of Charnley-type total hip arthro-
the survival of the implant. plasty is socket loosening related to polyethylene wear. In these
situations, it is unclear whether the stem can be retained. A
POSTER NO. P074 prospective series included 23 patients with a mean age of 66.1
Outcomes of Periacetabular Osteotomy in Patients years, and an average time to revision of 14.8 years. The reasons
for revision included socket loosening (15), sepsis without loos-
40 years or Older ening (1), and loosening of both components (6). All
Scott B Rosenfeld, MD, Houston, TX monobloc stems were made of 316L stainless steel with a 22.2
Ganesh V Kamath, MD, Saint Louis, MO mm femoral head. The surface roughness of the heads was eval-
Catherine Matero, BA, uated using a contact-type profilometer (Talysurf 50, Taylor
Travis Matheney, MD, Boston, MA Hobson, UK) along 8 mm lines with 0.25 micron cut-off wave-
Young-Jo Kim, MD, Boston, MA length. The mean Ra and Rt values on the pole of the femoral
heads were 0.029 ± 0.022 and 0.876 ± 1.135 microns, respec-
Perry L Schoenecker, MD, Saint Louis, MO
tively. The mean Ra and Rt values on the scratched areas were
John C Clohisy, MD, Saint Louis, MO 0.050 ± 0.049 and 1.540 ± 1.142 microns, respectively. Using a
Michael B Millis, MD, Boston, MA 0.05 and 0.5 micron threshold for Ra and Rt values, respectively,
Periacetabular osteotomy(PAO) is an effective joint preserving only 12 heads had normal pole roughness, whereas only 5
intervention for symptomatic congruous acetabular dysplasia. heads had minor scratches. There was no significant correlation
There are few reports of outcomes in older populations. We eval- between time in situ and roughness modifications. This study
uated outcomes of PAO in patients older than 40 years. 32 hips indicated surface damage largely beyond the current standards
in 27 patients with DDH met inclusion criteria of age 40 or to the femoral head of monobloc stems concerning the pole in
greater at surgery and minimum 2 year follow up. Mean age was 48% and scratched area in 78% of a consecutive series of revised
44 years (range 40 - 51). Mean follow up was 5 years (range 2 - implants. Based upon these data, we recommend revision of
10). Anterior center-edge angle (ACE), lateral center-edge angle monobloc stems during revision procedures independent of the
(LCE), and Tonnis grade were measured on pre-operative and reason for revision.
latest post-operative radiographs. Clinical evaluation was either

WOMAC or HHS. 30/32 hips (94%) were preserved at an POSTER NO. P076
average of 5 years after surgery. Two hips (6%) required THR (4 Failure Analysis of Aseptic Multiply Revised Total
and 10 years). 27/30 (90%) preserved hips had excellent or good
final WOMAC or HHS grade. 3/30 (10%) preserved hips had Hip Arthroplasties
poor WOMAC or HHS grade but were improved from pre-op Vivek Mohan, MD, Newport Beach, CA
score. Mean improvement in WOMAC pain score was 8 (p<0.01) Maria Carolina Secorun Inacio, MS, Irvine, CA
and in HHS was 23 (p<0.01). Mean LCE and ACE pre-opera- Robert S Namba, MD, Corona Del Mar, CA
tively was 5 and 7; post-operatively was 32 and 30. There was no Jessica Ziegler, MS, RD, San Diego, CA
difference in pre or post-operative LCE or ACE between
Donald C Fithian, MD, El Cajon, CA
preserved hips and failures. Mean pre-operative Tonnis grade for
preserved hips was 1 and for failures was 2. One patient had
Liz Paxton, MA, San Diego, CA
sciatic nerve palsy and nonunion and was lost to follow-up at 6 The purpose of this study was to elucidate the survivorship and
months. One patient had nonunion that was revised success- natural history of multiply revised THAs A total of 1560 aseptic
fully. 27 of 32 (84%) painful dysplastic hips in patients over 40 revision THAs were identified in a community-based TJR
were preserved with good to excellent clinical outcome at mean registry. At 4 yrs, 86.9% [N=1356] survived. Aspetic re-revisions
5 years after PAO. Pre-op degree of dysplasia was not a predictor occurred in 176 arthroplasties, representing 11.3%. A slight
of outcome. There was a trend toward worse pre-operative female predominance (55%) was seen. The difference in revi-
Tonnis grade in hips that failed. Age greater than 40 did not sion rates for primary THAs (1.7%) and revision procedures
preclude successful outcome for PAO. (13.1%) was statistically significant. At 4 yr f/u, the survival rate
of primary arthroplasties was 97% versus 51% for revisions The
failure rate of subsequent revision procedures increased dramat-
ically. Twenty-two arthroplasties (12.5%) failed the re-revision
and underwent a 3rd revision within 4 years of the index surgery.
Of these, 4 (18.2%) required a 4th revision and 25% [N=1]
required a 5th intervention. Third, 4th, 5th and 6th revisions
accounted for 28 [13.7%] of the 204 re-revisions registered. The
etiology responsible for revision vs re-revision differed.
Instability accounted for 38.7% of first revisions and represented
67.6% of the re-revision failures, an increase of 175%. The use
of constrained inserts was associated with a statistically signifi- theses (44 unstable and 63 matched stable prostheses, 19 of
cant higher revision rate. Aseptic loosening as the reason for these 63 had repeated X-rays before and after insertion) b) 24
surgery remained relatively constant at 30.9% for the first and healthy subjects who underwent supine and weight-bearing
26.1% for the re-revision operation. For the multiply revised profile X-rays of the pelvis. Forty-two percent of the subjects in
total hip arthroplasty, failure rates doubled from the second weight-bearing had an orientation of the APP different of more
(12.5%) to the fifth (25%) revision. When treating the unstable than 5 degrees from vertical plane, and 10 percent were divergent
THA, clear delineation and definitive correction of the primary of more than 10 degrees. The orientation of the APP was signif-
etiology of instability is recommended. Caution is advised with icantly modified between lying and weight-bearing (mean 1.2
constrained insert use. degrees supine to -2.3 degrees upright, 12/19 had a variation of
more than 7 degrees). THA insertion did not significantly
POSTER NO. P077 modify the APP orientation. Considering the APP is vertical in
◆Rate and Risk Factors of Prosthetic Impingement standing position may produce a range of error of 10 degrees in
orientating the cup (half of the anatomical anteversion). The
After THA: Observation of 413 Cups Retrievals APP orientation is modified by standing or supine position, that
Julien Girard, Lille, France is not included by imageless computer assistance. This study
Emmanuel Marchetti, MD, suggests the APP is not adequate to guide the cup insertion by
Philippe Laffargue, MD, Lille, France means of imageless computer assistance.
Yannick Pinoit, MD, Lille, France
Donatien Bocquet, MD, POSTER NO. P079
Henri Migaud, MD, Lille Cedex, France Is Highly Cross-Linked Polyethylene Superior to
The prosthetic impingement occurs if the range of motion of the Standard Polyethylene? a Double Blind RCT
hip exceeds implant mobility or in case of component malori- Sion Glyn-Jones, MA MBBS, Oxford, United Kingdom
entation. This study was designed to assess the frequency and Richie H S Gill, MD, Oxford, United Kingdom
the risk factors of this phenomenon. The frequency and the
Peter McLardy-Smith, FRCS, Oxford, United Kingdom
severity of the impingement were calculated from a continuous
series of 413 cups retrievals. The risk factors were analyzed for David W Murray, MD, Oxford, United Kingdom
298 retrievals that had complete clinical charts. Among the 413 No long-term clinical evidence exists to support the widespread
cups explants, the frequency of impingement was 51.3 percent use of modern varieties of Highly Cross-Linked Polyethylene
(it was severe in 12 percent, the notching exceeding 3 millime- (HXLPE). The creep and wear behavior of HXLPE and standard
tres). The impingement was the reason for removal in only 1.7 polyethylene liners (UHMWPE) were examined in a prospective
percent, meaning that it was mainly unexpected (98.3 percent). double blind RCT, using RSA. A significant problem with the in
The impingement was more frequent when revisions were vivo evaluation of polyethylene wear is determining when creep-
performed because of instability (80 percent; odd-ratio 4.2 (1.1- dominated penetration slows and when wear-dominated pene-
16.2)), and when the sum of hip motion exceeded 200 degrees tration begins. The point at which this transition occurs is
(sum of motion in the 6 degrees of freedom of the hip). The important to establish as wear can only be accurately deter-

other risk factors were: use of heads with skirts, liner with an mined once creep dominance has reduced significantly. It is
elevated rim, and head-neck ratio below 2. This study underlines therefore recommended that the in vivo penetration of polyeth-
the impingement is common when assessing cup retrievals (over ylene is measured for at least three years to accurately determine
50 percent). One should be aware of impingement when the rate of wear. A prospective double blind randomised control
performing hip replacement in patients having a high range of trial was conducted using Radiostereometric analysis (RSA). 54
motion. This situation may require prostheses with a high head- subjects were randomised to receive hip replacements with
neck ratio, as well as use of computer-assisted surgery. One either UHMWPE liners or HXLPE liners. All subjects received a
should avoid liners with elevated rim as well as heads with skirts cemented CPT stem and uncemented Trilogy acetabular compo-
to prevent dislocation, particularly when other risk factors are nent (Zimmer, Warsaw, IN, USA). The 3D penetration of the
detected. head into the socket was determined up to two years. At three
years the total penetration was 0.35mm (SD 0.14mm) for the
POSTER NO. P078 HXLPE group and 0.45mm (SD 0.19mm) for the UHMWPE
group (p<0.01). There was no difference in the amount of creep
Accuracy of the Anterior Pelvic Plane to Guide Cup (HXLPE 0.26mm SD 0.17mm, UHMWPE 0.27 mm SD 0.2mm,
Insertion By Using Imageless Computer Assistance p=0.83). Ninety percent of the creep occurred within the first six
Henri Migaud, MD, Lille Cedex, France months and virtually all within the first year. There was a signif-
Yannick Pinoit, MD, Lille, France icant difference in the wear rate from one year onwards (HXLPE
Julien Girard, Lille, France 0.03 mm/yr SD 0.06 mm/yr, UHMWPE 0.07 mm/yr SD 0.05
Olivier May, MD, mm/yr, p<0.05). Creep and wear were in significantly (p=0.01)
different directions; creep was proximal whereas wear was
Marc Soenen, MD,
proximo-medial. The penetration in the first year is creep-domi-
Philippe Laffargue, MD, Lille, France nated, from one year onwards the majority of penetration is due
The anterior pelvic plane (APP) is commonly used as a reference to wear. HXLPE has a 60% lower wear rate than UHMWPE, so it
to guide cup orientation by means of imageless computer assis- will probably perform better in the long-term. However, the
tance. This plan is mostly considered as vertical in weight performance of HXLPE is significantly worse than predicted by
bearing but there is no data that strongly confirm this hypoth- simulator studies.
esis as well as the influence of operative position, or prosthetic
insertion. The orientation of the APP was measured with regards
to the vertical plane on weight-bearing profile X-rays of the
pelvis in 131 subjects including: a) 107 patients with hip pros-
427
POSTER NO. P080 kinematic study of the hip. Nine operators each performed 18
Hip Resurfacing Has Superior Sustained Functional navigation-guided implantations. Compared to the navigation-
assisted surgery, the classical orientation gave a mean antever-
Outcomes When Compared to Total Hip sion error of only 1 degree but 5 degrees for abduction.
Arthroplasty However, 16 percent of the errors exceeded 10 degrees in antev-
Fares Sami Haddad, FRCS, London, United Kingdom ersion and 11 percent of the errors exceeded 15 degrees in abduc-
Jenni Bull, BSC, London, United Kingdom tion (mainly in the mobile configuration). Using classical
orientation, the errors consisted in excessive anteversion and
Existing outcome measures are not discriminating enough to
insufficient abduction. The classical cup orientation cannot be
highlight the potential benefits of Hip Resurfacing (HR) over
applied to all hips without impingement. In vitro, this new CAS
Total Hip arthroplasty (THA). We have performed a pilot study,
based on kinematics, guides the surgeon to reduce the risk of
using an outcome measure we designed to specifically challenge
impingement and instability.
high level function of the hip. We studied a matched cohort of
40 HR and 40 THA patients with a minimum follow-up of 2 POSTER NO. P082
years. We compared the two groups using high level functional
outcome measures for the hip, and tested pre-operatively and at Component Malposition in Patients With Very High
six weeks post ‘ op, 6 months, 1 and 2 years. The measures Metal Levels Following Hip Resurfacing
included un-supported single leg stance for one minute, un- Alister Hart, FRCS, London, United Kingdom
supported step-ups onto a 40cm block, un-supported lateral John Adam, BSC,
step-ups onto a 40cm block and a hop test in metres. These chal-
John Skinner, FRCS, London, United Kingdom
lenge balance, co-ordination, speed and directional change in
the affected hip. These were objectively measured by an inde- Sarah Muirhead-Allwood FRCS, London, United Kingdom
pendent observer. Subjects also subjectively rated these tasks for Metal-on-metal (MOM) hip resurfacing results in blood levels of
pain and difficulty There was no statistical significance in preop- approximately 5 parts per billion (ppb) for Cobalt plus
erative scores. The THA group at six weeks had an average hop Chromium combined. Some patients have metal blood levels
test length of 0.03m compared to 0.32m in the HR group, a greater than 50 ppb, and are mathematically termed ‘outliers’.
lateral step-up score of 2.5, compared to 0.7 in the HR group The prevalence and cause of these outliers is unknown. 100
(score is out of 3, with 0 being the highest score) and averaged MOM patients had whole blood Cobalt and Chromium meas-
3 step-ups in 15 seconds compared to 7 in 15 seconds compared ured by ICP Mass Spectrometry. Four patients were high metal
to the HR group.The significant differences between the groups ion outliers. We randomised 12 patients to form a control group
were maintained at 2 years Although THA with modern bearing for comparison. We measured: 1) clinical variables (BMI, IPAQ
surfaces is successful in young patients, with benefits of physical activity score, SF-36 and Harris hip scores (HHS)); 2)
decreased wear rates, this study suggests a return to a higher level concentrations of cobalt and chromium with ICP MS in joint
of function after Hip Resurfacing, which is maintained at two aspirates, whole blood and urine); 3) Component position with
years post-op. CT scanning; 4) Glomerular filtration rate using radio-isotope
clearance. The clinical variables were not significantly different
POSTER NO. P081 between the outlier and control groups. Concentrations of
cobalt plus chromium were: A) in whole blood, 61.7 ppb and 5
◆Same Orientation of the Prosthetic Cup for All ppb in outliers and controls respectively; and B) in urine were
Patients? Experimental Study With Navigation 35.6 ng/mmol creatinine in the outliers. Whole blood levels
Philippe Laffargue, MD, Lille, France were proportional to that found in the urine. Outliers normal
David Jones, MD, glomerular filtration rates. However, there was a significant
Bruno Chaminade, Toulouse, France difference in acetabular cup inclination of 56° in the outliers
versus 42° in the controls (p=0.004). 4% of patients with metal
Jacques Tabutin, MD, Lille, France
on metal hip resurfacing have blood levels of metal that are 10
Antoine Combes, MD, fold greater than the mean. These patients appear to be high
Emmanuel Marchetti, MD, generators of metal ions with high urinary excretion of the
Yannick Pinoit, MD, Lille, France metal. Increased inclination of the acetabular cup may be the
Henri Migaud, MD, Lille Cedex, France cause of high blood cobalt and chromium levels.
Jean L Puget, MD, Toulouse Cedex 9, Cerex 9 France
The same cup orientation is classically applied to hip replace- POSTER NO. P083
ments (45 degrees abduction, 20 degrees anteversion). We Is it Getting Safer to Have a Total Hip Arthroplasty?
hypothesize that this orientation must be adapted to the the Medicare Patient Safety Monitoring System
patient’s hip mobility and tested it by means of an experimental
study comparing the classical orientation and the orientation James I Huddleston, III MD, Stanford, CA
obtained with computer-assisted surgery. The experimental William J Maloney MD, Stanford, CA
model included a hemipelvis equipped with a femur which James H Herndon, MD, Boston, MA
mobility was controlled for three configurations: stiff (ampli- Yun Wang, PhD,
tudes restricted below 10 degrees except 60 degrees of flexion), Nancy Verzier, MSN, RN,
average (amplitudes restricted below 30 degrees except 80 David Hunt, MD,
degrees of flexion), mobile (amplitudes restricted below 50 Increasing public awareness of medical errors and the need to
degrees except 130 degrees of flexion). The hemipelvis and the control health care costs has led to a renewed interest in
cup holder were equipped with an electromagnetic system to improving patient safety and quality of care. We aimed to deter-
measure cup orientation. The navigation system (equipping mine if the rate of adverse events (AEs) after THA diminished
hemipelvis, femur, and cup holder) guided the cup orientation over time. Data was abstracted from a randomly-selected subset
by detecting the positions at risk for impingement through a of 91,668 Medicare inpatients. AEs in 1014 THA patients from
2002-2004 were documented. Claims data were used to deter- POSTER NO. P085
mine 30-day post-procedure rates of readmission, hip disloca- Third Generation Alumina-on-Alumina Ceramic
tion, symptomatic venous thromboembolic disease, and
mortality. 7.6% of patients experienced an AE while hospital- Bearings in Hip Arthroplasty - Minimum 5 Year
ized. Increased age (p<0.01), CHF (OR=1.8, 95% CI 1.2-2.8, Follow-up
p=0.008), and COPD (OR=1.7, 95% CI 1.23-2.39, p=0.002) William Lindsay Walter, MD, Waverton, NSW Australia
were associated with an increased risk of experiencing an AE. The Patrick J Lusty, MD,
30-day post-procedure rate of readmission for all causes was
Chen chin Tai, MD, Hertfordshire, United Kingdom
7.2%. Experiencing an AE while hospitalized increased the
length of stay (p<0.001) but not the risk of readmission. Rate of Robert P Sewhoy, MD,
hip dislocation 30-days post-procedure was 1.5%. Rate of symp- William Keith Walter, MB, Waverton, NSW Australia
tomatic venous thromboembolic disease 30-days post-proce- Bernard A Zicat, MD, Waverton, NSW Australia
dure was 0.6%. The 30-day post-procedure mortality rate was Wear debris has been implicated in the pathogenesis of osteol-
1.0%. Experiencing any AE was associated with an increased risk ysis. Alumina-on-alumina ceramic bearings have a low wear rate
of 30-day post-procedure mortality (OR= 4.22, 95% CI 1.4-13.1, which may reduce the incidence of osteolysis. The purpose of
p=0.01). The rate of AEs by year was 12.0%, 8.6%, and 5.6%. We this study was to determine the rates of wear and osteolysis asso-
found an incremental yearly improvement in the rates of AEs ciated with modern cementless alumina-on-alumina hip arthro-
from 2002-2004. AEs were associated with a longer hospital stay plasty at five years. We analyzed a series of 301 third generation
and an increased risk of mortality, but not with an increased risk alumina-on-alumina cementless primary total hip replacements
of readmission. Risk factors for the development of AEs included in 283 patients. The average age of the patients at the time of
increasing age, CHF and COPD. arthroplasty was 58 years. Two hundred and twenty two arthro-
plasties were in patients less than 65 years old. All procedures
POSTER NO. P084 were performed using the same surgical technique and the same
◆Pain Following Hip Resurfacing: Is the Angle of implant at a single center. At a minimum of five years follow up,
ten patients had died and 22 patients were lost. We assessed
Acetabular Cup Inclination to Blame? patients clinically and radiographically, and all retrievals were
Simon Jameson, Newcastle, United Kingdom analyzed for wear. At latest follow up, the mean Harris Hip Score
Antoni Nargol, FRCS, Stockton on Tees, United Kingdom was 95 points. All surviving implants were judged to be radi-
Recent reports suggest an open cup angle in hip resurfacing is ographically bone ingrown. There were nine revisions. Four
associated with high metal ion levels. An acceptable angle for stems were revised following periprosthetic fracture, and one
hip replacement is 45 degrees +/- 5 degrees. We sought to deter- stem was revised for aseptic loosening at two months. One stem
mine the effect of acetabular cup inclination angle on pain and was revised to facilitate a femoral shortening osteotomy. Two
patient satisfaction following hip resurfacing. 145 consecutive cups were revised because of psoas tendonitis, and one arthro-
hips in 123 patients were resurfaced. Acetabular cup inclination plasty was revised because of impingement and osteolysis.
angle was measured on post-operative radiographs. Cups were Survival of both components with revision for aseptic loosening
grouped into those of 50 degrees and above (A) and those below or osteolysis as the endpoint was 99% at seven years. Retrieved

(B). The presence of pain was documented as part of Harris Hip femoral heads showed an early median wear rate of 0.2 mm3 a
Scores. In group A there were 78 patients (average age 54.4, year. Cementless primary total hip arthroplasty using third
follow-up 16.8 months). In group B there were 67 patients generation alumina-on-alumina bearings showed minimal wear
(average age 57.5, follow-up 15.2 months). In group B there and osteolysis at five years minimum follow up.
were significantly more pain free patients (85%) compared with
group A (71%, p=0.026), and significantly more highly satisfied POSTER NO. P086
patients (91%) compared with group B (73%, p=0.003). Is the Blood Supply to the Femoral Head At Risk
Significantly more women reported pain in group A compared
with group B (p=0.013). There was no significant difference in
Following Resurfacing Arthroplasty?
the number of males reporting pain in the 2 groups (p=0.209). Christopher J Dy, BS, Miami, FL
An excessively open acetabular cup is associated with persisting Philip C Noble, PhD, Houston, TX
pain and lower levels of satisfaction after hip resurfacing in Matthew Thompson, MS, Houston, TX
women. This correlates with data associating high serum metal Molly M Usrey, BS, Houston, TX
ion levels and excessively open cups. The significance of this Christopher Clark, BS,
pain is unknown, but may represent an early response to high The majority of the blood supply to the femoral head arrives via
metal ion wear. We suggest an upper limit of 50 degrees of cup nutrient foramina at the head-neck junction. This raises
inclination. concerns that hip resurfacing may lead to vascular injury,
contributing to osteonecrosis and femoral neck fracture. The
current study was performed to test the hypothesis that reaming
could result in ablation of a substantial proportion of the
foramina supplying the femoral head. Twelve cadaveric femora
were harvested and 3D computer models of each specimen were
reconstructed from CT scans. The vascular foramina of the
head/neck junction were identified, as previously described
(Lavigne), and their 3D location and distribution were registered
using a clockface system. Virtual reaming of the reconstructed
femora was performed following 3D templating of standard
resurfacing components. The foramina at risk for damage were
then analyzed. An average of 26.4±8.2 vascular foramina was
429
identified per specimen. Almost half (41.8%) were located in the been described, soft tissue trauma is considered to be an impor-
anterosuperior quadrant (12:00-3:00) of the femoral head/neck tant factor. The surgical exposure for surface replacement arthro-
junction. Placement of the optimal resurfacing component was plasty (SRA) is more extensive compared to conventional THR
associated with an antero-lateral shift of the head center of which may increase the risk of developing HO. However, patient
2.86±1.34mm (range: 0.58-5.11mm). The corresponding loss of selection bias for SRA may confound the results. As part of a
vascular foramina averaged 28% (p=0.03) with a loss of up to randomized clinical trial, we collected data on the incidence and
34.6% and 33.1% from the anterosuperior and posterosuperior severity of HO in a cohort of patients who have undergone
quadrants, respectively. The distribution of vascular foramina at either SRA (107 hips) or conventional THR (103 hips).
the head/neck junction was consistent with previous findings, as Radiographs were analysed by two independent reviewers at a
the majority was found near the retinacular vessels, a main minimum follow-up of one year. The incidence of HO was
vascular supply to the femoral head. In this model of resur- 43.7% in the SRA group, compared to 30.9% in the conven-
facing, the percentage of vascular foramina vulnerable to tional THR group (p=0.057). SRA group had a significantly
damage varied graetly between femora, particularly in the supe- higher rate of severe grades (Brooker 3 and 4) of HO than the
rior quadrants. These findings suggest that in some resurfacing conventional THR group (12.6% versus 2.1%, respectively;
patients, reaming of the femoral head may substantially p=0.02). Grade 4 was observed (4.9%) exclusively in the SRA
compromise vascular supply via the retinacular vessels. group. SRA group with HO grades between 0 - 2 had a mean
WOMAC and Merle DAubigné scores of 7.7 and 17.3 respec-
POSTER NO. P087 tively, while those with HO grades between 3 and 4 had scores
Limitations of Hospital Administrative Databases of 18.6 (p=0.013) and 15.3 (p=0.01) respectively. The results of
our study suggest that SRA is an independent risk factor for
for Assessment of Total Hip Replacement Outcomes development of higher grades of HO compared to conventional
Thomas C Barber, MD, Oakland, CA THR. Surgeons offering SRA must be aware of this risk and use
Liz Paxton, MA, San Diego, CA meticulous surgical technique. Routine prophylaxis against HO
Maria Carolina Secorun Inacio, MS, Irvine, CA should also be considered.
ICD-9 discharge codes from hospital administrative databases POSTER NO. P089
provide a convenient method for assessing Total Joint replace- Uncemented Titanium-Coated Monobloc Acetabular
ment complications. In the absence of more detailed informa- Component:Analysis at minimum 15 years Follow-up
tion, a growing number of studies have used administrative
Thilo John, MD, Berlin, Germany
databases such as the Medicare database to draw conclusions
about outcomes following joint replacement in the United Christoph Heyde, MD, Berlin, Germany
States. The purpose of this study was to evaluate the accuracy of Markus Reinke, MD,
hospital ICD-9 codes for identification of post-operative Surgical Yohan Robinson, MD, Berlin, Germany
Site Infection (SSI) following Total Hip Replacement (THR). The Andrea Biechteler, MD,
sample included all THR performed in a large California HMO Michael A Mont, MD, Baltimore, MD
population between 01/01/2004 and 03/31/2006. Post-opera- Ronald Emilio Delanois, MD, Lutherville, MD
tive infections were identified with ICD-9 discharge diagnostic Slif D Ulrich, MD, Baltimore, MD
codes for the period up to 1 year postoperatively. For compar-
Monobloc components have been used on the acetabular site
ison, specially-trained infection control practitioners (ICPs)
with reports of low wear rates. Detractors from this type of pros-
reviewed all inpatient and outpatient records up to 1 year post
thetic approach claim that the lack of modularity is a disadvan-
THR, using CDC SSI guidelines to validate infections. 8224
tage for revision situations. The present study describes the
THRs were performed during the study period. ICPs identified
long-term results (15 years follow-up) of an uncemented tita-
78 THR infections (0.9%). Using ICD-9 codes, we identified 71
nium-coated monobloc acetabular component. A Total of 1876
THR infections. Compared to the chart audit by trained staff, the
cups were placed in 1584 consecutive patients who had a
ICD-9 methodology yielded 27 false positives, 44 true positives
primary total hip replacement with the monobloc acetabular
and 34 false negatives for a sensitivity of 56% and positive
component. This component has a hemispherical cup manufac-
predictive value of 62%. Although hospital administrative data-
tured from ultra high molecular weight polyethylene, with a
bases provide potential electronic screening algorithms for iden-
pure titanium powder-coated surface. The femoral component
tification of post-operative infections, ICD-9 codes alone are
was either an uncemented or cemented stem with either a 28 or
insufficient for identification of THR post-operative infections.
32 mm diameter head. All heads were ceramic or stainless steel.
Infections must be validated using CDC guidelines for more
Patients were evaluated by clinical examination (Harris-Hip-
accurate evaluation of complications following THR.
Scores), satisfaction indices (WOMAC and NHS), and radi-
ographically. We performed a survival analysis with
POSTER NO. P088
establishment of curves at 5, 10 and 15 years. In addition, the
◆The Incidence of Heterotopic Ossification authors carried out a literature search to compare outcome to
Following Surface Replacement Arthroplasty other acetabular components. The cumulative survival rate of
Martin Lavigne, MD, Montreal, QC Canada the cup was 98.2 percent at 5 years, 97.5 percent at 10 years and
96.9 percent at 15 years. Reasons for re-operation were aseptic
Reddi Buddu, MD,
loosening of the cup or stem (n=34, 1.5%) and infection (n=8,
Muthu Ganapathi, MD, Cardiff, United Kingdom 0.4%). One patient was revised for dislocation/malposition and
Pascal-Andre Vendittoli, MD, Montreal, QC Canada one for a periprosthetic fracture. At final follow-up, 90 percent of
Alain Roy, MD, Montreal, QC Canada the patients had good and excellent Harris Hip Scores. Sixty
The reported incidence of heterotopic ossification (HO) percent of the patients had a WOMAC score lower than 30
following conventional total hip arthroplasty (THR) ranges points. There were excellent radiographic results with no
from 15% to 90%. While various patient related risk factors have progressive radiolucencies in any of the cups that had not been
revised. The results of this study compared favorably with other a 10-m walkway with two force platforms recording at 120Hz.
acetabular components that were in our literature analytic Kinematics parameters were collected at 60 Hz using VICON
review. The low failure rate for loosening of this component cameras. Both kinematics and kinetics were calculated and
demonstrates that these implants have excellent ingrowth and analyzed and the results were compared between groups with a
fixation potential. This monobloc cup has been shown to func- one-way ANOVA. The statistical significance was set at p<0.05.
tion well at 15 years post-implantation. The one piece design THA-STD showed a larger energy absorption (-0.24±0.01J/kg) by
may allow for thicker plastic to distribute load-bearing forces the hip flexors (H2 Sagittal) compared to controls (-
more equally. The excellent long-term results for the use of this 0.12±0.06J/kg), THA-LDH (-0.17±0.07J/kg) and SRA (-
monobloc cup may outweigh any of its perceived disadvantages. 0.09±0.08J/kg) subjects. All patients had significantly lower
mechanical energy generation (H3 Frontal) by the abductor
POSTER NO. P090 muscles than control subjects. Despite a poor energy generation
Perioperative Testing for Sepsis in Revision Total by the hip abductors in the frontal plane, the SRA and the THA-
LDH groups return to a normal gait pattern in the sagital plane
Hip Arthroplasty while the THA-STD demonstrates a larger H2 Sagittal phase.
Craig J Della Valle, MD, Chicago, IL These results suggest a better gait pattern recovery with SRA and
Mark F Schinsky, MD, Aurora, IL THA-LDH than with THA-STD.
Scott M Sporer, MD, Wheaton, IL
Aaron Glen Rosenberg, MD, Chicago, IL POSTER NO. P092
Richard A Berger, MD, Chicago, IL Third Generation Cementless Acetabular
Wayne Gregory Paprosky, MD, Winfield, IL Components: Results at a Minimum of 10 years
While multiple tests exist to try and determine if a total hip Pedro Pablo Amenabar, MD, Santiago, Chile
arthroplasty (THA) is infected, few studies have applied a consis-
Craig J Della Valle, MD, Chicago, IL
tent algorithm to determine the utility of the various tests avail-
Bryan Royce, BA,
able. The purpose of this study was to evaluate the utility of
commonly available tests for determining periprosthetic infec- Laura R Quigley, MS,RN, Chicago, IL
tions in patients undergoing revision THA. Two hundred thirty Richard A Berger, MD, Chicago, IL
five consecutive THAs were evaluated by one of two experienced Joshua J Jacobs, MD, Chicago, IL
surgeons for the presence of infection and underwent reopera- Aaron Glen Rosenberg, MD, Chicago, IL
tion. All patients were evaluated for the presence of infection Jorge O Galante, MD, Clinton, WI
using a consistent algorithm. Receiver-operating-characteristic Previous studies have demonstrated excellent survivorship for
(ROC) curve analysis was used to determine the optimal cut- cementless acetabular fixation in primary total hip arthroplasty
point values for the white blood cell (WBC) count and percent (THA). However, the implants studied are largely no longer in
polymorphonuclear (PMN) cells of aspirated hip synovial fluid. use. The aim of this study is to report the clinical and radi-
Sensitivity, specificity, negative predictive value (NPV), positive ographic results at minimum of 10 years with the use of a third
predictive value (PPV), and accuracy were determined. Thirty generation cementless acetabular component that is in wide-

one cases were excluded leaving 204 THAs with data for evalua- spread use today. One hundred seventy six consecutive patients
tion. Fifty-five cases were judged to be infected. ROC curve (193 hips) underwent THA using a modular hemispheric, tita-
analysis illustrated an optimal cut-point for synovial fluid WBC nium-alloy acetabular shell with a titanium fiber-mesh ingrowth
count to be >4,200 WBC/mL and a differential with >80% surface and a smooth inner surface finish and a secure locking
PMNs. However, when combined with an elevated ESR and CRP, mechanism. At a minimum of ten years, 38 patients had died
the optimal cut-point for synovial fluid cell count was >3,000 (41 hips) and 6 patients (6 hips) were lost to follow-up. The
WBC/mL, which yielded the highest combined sensitivity, speci- remaining 132 patients (146 hips) were evaluated clinically
ficity, PPV, NPV, and accuracy of the tests studied. A synovial using the Harris Hip Score and examined radiographically for
fluid cell count of >3,000 WBC/ml is the most useful periopera- loosening and osteolysis. Polyethylene wear was calculated using
tive testing modality for determining the presence of peripros- the Hip Analysis Suite program. At a mean of 134 months
thetic sepsis when combined with elevated preoperative ESR and (range, 120 to 158 months) the mean Harris Hip Score
CRP in patients undergoing revision THA. improved from 47 to 89 points (range, 51 to 100; p < 0.01).
There were five revisions of the acetabular component (2.6%); 3
POSTER NO. P091 for recurrent instability and 2 for infection. One cup was classi-
◆Gait Analysis in Three Types of Hip Replacement fied as possibly loose and periacetabular osteolysis was identi-
Martin Lavigne, MD, Montreal, QC Canada fied around 10 components (7%). The average linear wear rate
Pascal-Andre Vendittoli, MD, Montreal, QC Canada was 0.11 mm/year (range, 0.012 to 0.39). Third generation tita-
nium fiber-mesh cementless acetabular components show excel-
Julie Nantel, MSc,
lent clinical results and a high rate of osseointegration at 10-13
Francois Prince, PhD, years post-operatively.
Total hip arthroplasty (THA) restores range of motion and
improves functional capacities. However, a weakness of the
abductor muscles has often been reported in locomotor analyses
within 12 months after surgery. These impairments might be
reduced with large diameter femoral head hip arthroplasty. The
aim of this study is to compare gait pattern in patients with stan-
dard THA (THA-STD), large diameter head THA (THA-LDH)
and surface replacement arthroplasty (SRA). Six months post-
surgery, 8 control subjects and three groups of 8 unilateral
patients (THA-STD, THA-LDH and SRA) were asked to walk on
431
POSTER NO. P093 results of a periacetabular osteotomy for the treatment of these
Socket Medialization Decreases the Risk of deformities. We retrospectively evaluated 16 hips in 15 patients
who underwent a periacetabular osteotomy for the treatment of
Squeaking in Ceramic on Ceramic Total Hip these deformities. Residual deformities of the hip were graded
Arthroplasty using the Stulberg classification system. Harris hip score was
John M Martell, MD, Chicago, IL used to evaluate the clinical results. Standard radiographical
Jimmi Mangla, MD, Chicago, IL analysis was performed. The average age of patients at surgery
was 35.8 years (range, 20 to 54 years), and the average follow-up
Ormonde M Mahoney, MD, Athens, GA
was 6.9 years (range, 4 to 10 years). There were 3 class II hips, 10
Javad Parvizi, MD, Philadelphia, PA class III hips, and 3 class IV hips preoperatively. The average
Richard H Rothman, MD, Philadelphia, PA Harris hip score significantly improved from the preoperative
Audible squeaking is reported in 0.5% to 7% of patients with value of 69.3 points to 91.0 points postoperatively. The average
ceramic on ceramic total hip arthroplasty. The etiology of this lateral center edge angle improved significantly from -0.9°
phenomenon has not been identified. We analyzed the impact preoperatively to 30.1°postoperatively. The other radiographical
that anatomy and biomechanics of the prosthetic reconstruction evaluations, including acetabular head index and acetabular
may have on squeaking. Squeaking was detected in 30 out of roof obliquity, also showed significant improvements postoper-
1056 hips (2.7%). Sixty normal and 15 squeaking hips having atively. None of our patients had additional surgical procedures
pre and post-operative radiographs suitable for analysis were or a major complication. Periacetabular osteotomy, as a treat-
selected from this population. Biomechanical analysis of post- ment for patients with Perthes-like deformities, produced good
operative radiographs was performed using custom software mid-term clinical and radiographical results.
which provided lever arm ratios, joint contact stresses, the posi-
tion of the prosthetic head center with respect to the tear-drop, POSTER NO. P095
and the diameter of the normal femoral head. The pre-operative Where is the Optimal Splitting Location of the Gluteus
radiographs were calibrated based on the known diameter of the
normal femoral head, allowing the pre-operative position of the Medius in Direct Lateral Approach to the Hip?
abnormal head center with respect to the teardrop to be deter- Tsuyoshi Shinoda, MD, Fukuoka, Japan
mined. Binary logistic regression was performed using Masatoshi Naito, MD, Fukuoka, Japan
squeaking as the outcome variable with the pre ‘ post head posi- Hiroshi Shitama, MD, Fukuoka, Japan
tion as the predictive factor. Medialization of the femoral head Takahiko Kiyama, MD, Fukuoka, Japan
compared to the pre-operative position was the most significant Akira Maeyama, MD, Fukuoka, Japan
predictive factor for preventing squeaking in ceramic on ceramic
Takeshi Teratani, MD, Fukuoka, Japan
total hip arthroplasty (p=0.01). The logistic regression model
was significant (p<0.0001 G=17.551), with coefficients of Akinori Takeyama, MD, Fukuoka City, Japan
0.9813, -0.3380*pre-post head position. This model was 67% Hirotaka Karashima, MD,
sensitive, 91% specific and 82% accurate in predicting squeaking Satoshi Kamada, MD, Fukuoka, Japan
(area under ROC curve = 0.81). The odds ratio of 0.71 for pre- There are some modifications of the splitting locaion of the
post head position (mm), indicates that every 10mm of femoral gluteus medius tendon in direct lateral approach to the hip.
head medialization reduces the probability of audible squeaking However, the optimal splitting location of the gluteus medius
by 56%. Lowering the prosthetic lever arm ratio by medializing tendon remains unknown.The purpose of this study was to
the femoral head center, decreases the likelihood of squeaking. investigate the optimal splitting location of the gluteus medius
We propose that increased joint forces contribute to squeaking tendon in direct lateral approach. Eleven embalmed cadavers
in ceramic hip arthroplasty. This complication can be mini- (22 hips) were utilized for this study. After removal of the
mized by medializing the acetabulum and optimizing the gluteus maximus and the tensor fascia femoris, the gluteus
biomechanics of reconstruction. medius was cut off from the iliac crest, and the gluteus medius
tendon was carefully cut off from the insertion of the greater
POSTER NO. P094 trochanter. After the tendon was divided from anterior to poste-
Periacetabular Osteotomy for the Treatment of rior into five equal parts (A, B, C, D, and E portion), the thick-
ness of the tendon at the five portions was measured by a digital
Perthes-Like Deformities of the Hip caliper. The averaged thickness of the tendon was 4.66(mm) at
Tsuyoshi Shinoda, MD, Fukuoka, Japan the portion A, 5.97(mm) at the portion B, 8.21(mm) at the
Masatoshi Naito, MD, Fukuoka, Japan portion C, 9.41(mm) at the portion D, and 9.54(mm) at the
Kei Shiramizu, Fukuoka, Japan portion E. The thickness of the tendon increased gradually from
Takahiko Kiyama, MD, Fukuoka, Japan anterior to posterior portion in the all specimens. If the splitting
Akira Maeyama, MD, Fukuoka, Japan location is more anterior, suturing failure of the tendon may
Takeshi Teratani, MD, Fukuoka, Japan occur because the anterior portion of the tendon is thinner. Our
new findings suggested that the optimal splitting location of the
Akinori Takeyama, MD, Fukuoka City, Japan
tendon might be more posterior in direct lateral approach.
Hirotaka Karashima, MD,
Satoshi Kamada, MD, Fukuoka, Japan
Perthes-Like deformities following the treatment for develop-
mental dysplasia of the hip (DDH) or after Legg-Calvé-Perthes
disease are the shortening of the femoral neck, the relative over-
growth of the greater trochanter, the flattened femoral head, and
secondary acetabular dysplasia. The optimal method of surgical
reconstruction for these deformities remains controversial. The
purpose of this study was to evaluate clinical and radiographical
POSTER NO. P096 controls and the selection, timing and mode of delivery of
Limitation of Hip Rotation in Flexion is Not a antibiotics in the changing environment of emerging resistance
of infectious agents. Maintain positive pressure in the conven-
Specific Indicator of the Underlying Bony Deformity tional operating room greater than 15 operating room volumes
Steven Schroder, Houston, TX exchanges per hour. Consider performing joint replacement in
Lindsay P Stephenson, BS, ultra clean air. Provide personnel with efficacious hand anti-
Matthew Thompson, MS, Houston, TX sepsis and skin care. Monitor and maintain normal glycemia
Molly M Usrey, BS, Houston, TX and normothermia (above 36 degrees). Perform proper skin
Philip C Noble, PhD, Houston, TX preparation using appropriate antiseptic and incise drape appli-
cation. Use the appropriate antimicrobial and dosing. Give the
Cam-type femoral acetabular impingement (FAI) is often diag-
initial dose within one hour preceding incision. Repeat the dose
nosed with a simple internal rotation maneuver performed with
during surgery as needed to maintain blood levels. Stop prophy-
the hip in 90 degrees of flexion. However, other femoral abnor-
lactic antimicrobials within 24 hours even with catheters or
malities such as reduced anteversion, coxa vara or coxa valga,
drains still in place. Vancomycin should be used to treat known
and increased acetabular depth also lead to impingement during
infections, not for routine prophylaxis. Minimize operative time,
internal rotation. In this study, we examine the reliabilty of this
maintain hemostasis, gentle handling of tissue, eradicate dead
diagnostic maneuver by analyzing the effect of components of
space, remove dead tissue and foreign bodies, close over drain
proximal femoral morphology on the internal rotation of the
when indicated. Post operative surveillance for infection.
hip to impingement. Computer models of 15 hip joints were
Standardizing each of these techniques into practice will
reconstructed from CT scans. Morphologic parameters,
decrease the approximately 500,000 Surgical Site Infections that
including neck shaft angle, alpha angle, anterior neck offset,
occur annually.
offset ratio, anteversion, head size, and acetabular index
(depth/width) were measured by computer analysis. Each hip POSTER NO. P098
reconstruction was positioned in 90° of flexion and internally
rotated till impingement (IR90). Multiple and stepwise regres- The Effect of Zoledronic Acid (ZOL) on Implant
sions were performed to isolate the contribution of each compo- Migration in THA: An Independent, Controlled Trial
nent of femoral morphology in limiting internal rotation. Gerald Friedl, MD, Graz, Austria
Femoro-acetabular impingement occurred with an average of Roman Radl, MD, Graz, Austria
15.7 degrees of internal rotation (range: 1-45°). Univariate
Christoph Stihsen, MD, Graz, Austria
correlations revealed a modest relationship between IR90 and
posterior slip of the femoral head (r=0.50, p=0.055), but not Peter Rehak, PhD, Graz, Austria
alpha angle (r=-0.418, p=0.123). 30% of femora of cam- Reinhard Windhager, MD, Graz, Austria
impinging morphology allowed internal rotation in excess of 20 Aseptic failure of fixation in total hip arthroplasty (THA) is
degrees prior to impingement. Step-wise regression showed that known to be linked to early implant migration. In the present
the only significant factors correlated with IR90 were (in order of study we aimed to improve the early implant fixation by a single
importance): posterior slip (25.3%), femoral anteversion application of ZOL in patients with osteonecrosis of the femoral

(21.6%), and acetabular depth (normalized for diameter; head, which previously was shown to be associated with higher
16.2%). These three variables explained 63.1% of the variation stem migration and implant failure rate. Forty-nine patients
in internal rotation. Neither the alpha angle nor the head/neck (mean age 61.0 ± 12.8) were randomly assigned to receive either
ratio increased the predictive power of the model. The internal i.v. ZOL 4 mg (n=25) or saline solution (CTR, n=24) following
rotation test at 90 degrees of flexion detects premature impinge- THA. A total of 576 standardized radiographs were analyzed by
ment due to posterior slips, reduced anteversion and increased the EBRA-Digital method at 0, 7, 26 weeks, and annually after
acetabular coverage of the femoral head. Its ability to detect surgery. Additionally, the Harris Hip Score (HHS, 0 - 100) was
patients with a cam-impinging deformity of the anterior head- assessed during the median follow-up period of 2.8 years. In
neck junction is limited by the compounding effects of these CTR, we found a median subsidence of 1.1 mm (range 0.3 to
other common components of femoral morphology. 2.3) and 1.3 mm (range 0.3 to 2.9) at 2 and 3 years, respectively,
Radiographic or CT analyses of acetabular depth, anteversion, and a migration of 0.8 mm (range 0.1 to 2.4) in ZOL (NS).
offset ratio, and alpha angle are essential to confirm the source EBRA-Cup analysis revealed an increasingly transverse and
of impaired femoral rotation in flexion. vertical implant migration (i.e., medialization and cranialization
of 0.6 mm each at 2 years) in CTR, while no cup-migration was
POSTER NO. P097 detected in patients treated with ZOL (0.1 and 0.05 mm, respec-
The Infected Orthopedic Surgery: Current Concepts tively). This was accompanied by significantly higher HHS in
ZOL compared with CTR. Our findings show that a single i.v.
in Infection Prevention and Treatment treatment regime of ZOL 4 mg is sufficient to increase early
Richard Parker Evans, MD, Little Rock, AR implant fixation, which might improve the long-term durability
Terry A Clyburn, MD, Bellaire, TX of THA.
This exhibit presents emerging trends in the prevention, treat-
ment and monitoring of musculoskeletal surgical site infection.
It was developed in conjunction with the AAOS Patient Safety
Committee and summarizes evidence based on the current liter-
ature and the recommendations of the Center for Disease
Control (CDC) with regard to the prevention of surgical infec-
tions and is information). This information is conceptually
organized from the outside-in as it relates to operating room
environment, personnel and patient preparation and wound
management. Emphasis is placed on the proper environmental
433
POSTER NO. P099 average body mass index (BMI) was 22.1 kg/m2 in the DAA
Increased Risk of Inferior outcomes after group and 22.6 kg/m2 in the MPA group. The primary diagnosis
was secondary osteoarthritis due to hip dysplasia or congenital
Intraoperative Femoral Fracture in Total Hip dislocation of the hip in 80% of the DAA group and 82% of the
Arthroplasty MPA group. There were no significant differences in age at oper-
Theis Muncholm Thillemann, MD, Hojbjerg, Denmark ation, gender, BMI, diagnosis and implant between the two
Alma Becic Pedersen, MD, Risskov, Denmark groups. We evaluated operative invasion, implant alignment,
operative accuracy and functional recovery. The average of opera-
S Paaske Johnsen, MD, Aarhus, Denmark
tion times were 91 minutes in the DAA group and 80 minutes in
Kjeld Soballe, MD, Aarhus, Denmark MPA group. The average intraoperative blood loss in the DAA
Intraoperative femoral fracture is a well known complication to group was 517 milliliters and 414 milliliters in the MPA
primary total hip arthroplasty (THA). Experimental canine group.Ninety-five acetabular implants of the DAA group and
studies have suggested that intraoperative fractures may affect eighty-five acetabular implants in the MPA group had been
the implant survival. However, there is limited detailed data on implanted within the safe zone of Lewinnek. Patients in the DAA
the implant survival after intraoperative femoral fractures in group were able to walk over 200 meters with the use of a single
primary THA surgery. We used data from the Danish Hip cane by 9.4 days, could stand more than 5 seconds on the single
Arthroplasty Registry, a population based clinical database, to operated limb by 13.5 days, showed a negative Tredelenburg’s
identify patients treated with a primary THA due to primary sign by 13.9 days postoperatively, had positive Tredelenburg’s
osteoarthritis in Denmark between 1995 and 2005 (n=39478). sign at 3 weeks postoperatively by 29 %, got 50-m walking time
Data was linked to two national Danish databases to conduct of 52.2 seconds at 3 weeks after operation, and were able to walk
time dependent survival analysis. Implant survival and relative without walking aids at 3 weeks postoperatively by 34 %. Patients
risk estimates were calculated for patients treated conservatively in the MPA group were able to walk over 200 meters with the use
and patients treated with osteosynthesis after sustaining intra- of a single cane by 13.1 days, could stand more than 5 seconds
operative femoral fractures during THA surgery. Furthermore we on the operated limb by 19.9 days, showed a negative
asses the relative risk for reoperations and readmission to an Tredelenburg’s sign by 18.6 days postoperatively, had positive
orthopaedic department in a 3 months postoperative period. Tredelenburg’s sign at 3 weeks postoperatively by 45 %, got 50-m
282 Patients were treated conservatively due to intraoperative walking time of 72 seconds at 3 weeks after operation and were
femoral fracture and 237 patients were treated with osteosyn- able to walk without walking aids at 3 weeks after operation by
thesis. The Kaplan-Meier survival plots revealed a significant 18 %. The DAA group had significantly faster functional recovery
inferior THA survival after osteosynthesis of intraoperative than the MPA group, such as time up to standing by single oper-
femoral fractures. In the 0-6 months postoperative period the ated limb of over 5 seconds, required time up to recognition of
adjusted relative risk (RR) for revision was 1.5 (95% CI: 1.1-1.7) negative Trendelenburg’s sign, presence of Trendelenburg’s sign
for patients treated conservatively. In the same period the at 3 weeks postoperatively, walking velocity and use of a walking
adjusted RR for revision was 5.7 (3.3-10.0) for patients treated aid at 3 weeks after operation. The results of this prospective
with osteosynthesis. In the period 6 months to 11 years postop- comparative study suggest more rapid functional recover after
erative we did not find any significant differences in the RR for MIS-THA via a DAA when compared to a MPA.
revision among the groups. Intraoperative fractures increase the

relative risk for revision the first 6 postoperative months. POSTER NO. P101
Therefore, patients should be informed about the risk for revi-
sion when sustaining an intraoperative femoral fracture. Further,
Analysis of Retrieved Acetabular Liners for
some measures should be taken after surgery in order to prevent Impingement Damage and Embedded Third Body
revision during the first 6 postoperative months. Debris
POSTER NO. P100
Hannah Lundberg, PhD,
A Prospective Comparative Study of the Direct Steve S Liu, MD, Iowa City, IA
Anterior with Mini-Posterior Approach in MIS-THA Douglas R Pedersen, PhD, Iowa City, IA
Katsuya Nakata, MD, Toyonaka, Japan Michael R O’Rourke, MD, Glenview, IL
Masataka Nishikawa, MD, Toyonaka, Osaka, Japan Devon D Goetz, MD, West Des Moines, IA
Koji Yamamoto, MD, Osaka, Japan David Vittetoe, MD, Des Moines, IA
Shigeaki Hirota, MD, Toyonaka, Osaka, Japan John C Clohisy, MD, Saint Louis, MO
Hideki Yoshikawa, MD, Thomas D Brown, PH D, Iowa City, IA
The optimum surgical approach to minimally invasive total hip The purpose of this study was to determine the relationship
arthroplasty (MIS-THA) is controversial. Fifty patients admitted between the presence of impingement damage and embedded
for THA were enrolled in this prospective comparative study to debris in retrieved acetabular liners at the time of revision total
clarify an optimum approach for rapid functional recovery in hip arthroplasty. 157 components were retrieved at revision total
MIS-THA. The purpose of this study is to compare the short-term hip arthroplasty. The average time in situ was 118 months (range
clinical and radiographic outcome of THA performed by mini- 0 to 344 months). Reasons for revision included aseptic loos-
posterior approach (MPA) with results using a direct anterior ening, wear, septic loosening, and dislocation. The acetabular
approach (DAA). Medical records of a consecutive series of 25 liners were evaluated for impingement damage based on a scale
patients who underwent MIS-THA via DAA between January and grading impingement damage according to the depth of
May in 2007 were prospectively compared with records of a damage. Additional component factors such as head size, skirted
consecutive series of 25 patients who underwent MIS-THA via femoral heads, fixation type, and cup position were evaluated for
MPA for the same period. The average age at operation was 63.5 their influence on both impingement damage and embedded
years in the DAA group and 67.6 years in the MPA group. The debris. 107/153 (70%) of acetabular liners had evidence of
impingement damage. 58/153 (38%) had embedded debris. POSTER NO. P103
Liners with impingement damage were significantly more likely Young Adults with Hip Disorders have Disease-
to have embedded debris (p=0.005). There was also a significant
increasing trend for cups with higher grades of impingement specific Alterations in Step Activity
damage being more likely to have embedded debris (p < John C Clohisy, MD, Saint Louis, MO
0.0001). The presence of a femoral head skirt, femoral head size, Devyani Hunt, MD,
and cup position were not associated with the presence of Sarah Hinkle, MPH,
embedded debris or with impingement damage. Cemented cups Perry L Schoenecker, MD, Saint Louis, MO
were significantly more likely to have embedded debris Heidi Prather, DO, Saint Louis, MO
(p=0.007). Acetabular liners retrieved at the time of revision
Improved understanding of hip disease in young adult patients
total hip arthroplasty are significantly more likely to have
has resulted in refined surgical treatment options. Clinical
embedded third body debris if they have evidence of impinge-
results need to be evaluated with sensitive outcome tools. The
ment damage on the acetabular rim. Liners with higher grades of
purpose of this study was to evaluate step activity variations in
impingement are also more likely to have embedded debris than
young patients with distinct hip disorders. 76 patients (45
those with lower grades of impingement. These findings have
female, 31 male) with an average age of 34 years (range, 15-50)
potential implications in terms of the use of alternative bearing
were studied. The StepWatchTM Activity Monitor (SAM) was
surfaces as well as a possible etiology in the explanation of wear
utilized to monitor 7 day activity patterns. This device is effective
outliers (through impingement and embedded third body
for measuring step activity, intensity and patterns of
particulate debris ingressing into the bearing surface).
activity/inactivity. SAM data was analyzed for 5 patient groups,
POSTER NO. P102 all undergoing surgery for symptomatic hip disease. These
included: controls (15 patients), isolated labral tear (LT) (12),
◆Extremely Short Stems Work Well in Cementless pre-arthritic DDH (DDH) (5), pre-arthritic impingement (IM)
THA for Osteoarthritis due to Congenital Hip (22), and endstage degeneration (OA) (22). Daily step counts
Dysplasia were: controls-5,330, LT-5,304, DDH-4,171, IM-4,327 and OA-
2,961. Daily step counts were lower for the OA group compared
Takashi Sakai, MD, Osaka, Japan to all other groups (p<0.0001). Mean time spent at high activity
Nobuhiko Sugano, MD, Suita, Japan varied between groups: control-1.3%, LT-1.7%, DDH-1.1%, IM-
Takashi Nishii, MD, Osaka, Japan 1.6% and OA-0.7%. C, LT and IM groups spent the most time at
Takehito Hananouchi, MD, Suita, Japan high activity levels (p<.05). Mean time spent at low activity was
Masaki Takao, MD, Osaka, Japan larger for the OA group compared to the C, and LT patients
Seung-Bak Lee, MD, Toyonaka, Japan (P<0.05). Inactivity time was greater for OA compared to C and
Kenji Ohzono, MD, Suita, Japan LT groups (p<0.04). IM group also had longer inactivity times
Hideki Yoshikawa, MD, compared to controls (P=0.048). SAM data indicates that OA
patients have the most profound reduction in activity, and
Short stems are unlikely to acquire bone-implant stability due to
patients with early hip disease commonly maintain near-normal
small contact surface area onto bone or varus malpositioning.

activity levels.
However, the influence of the stem length on the implant
longevity has not been well documented. In order to clarify POSTER NO. P104
whether the stem length influenced on clinical and radiographic
results, we compared different two types of cementless anatom- FDG-PET Imaging in the Differentiation of Infected
ical custom-designed femoral components which were fabri- From Non-Infected Painful Hip Prosthesis
cated of titanium alloy based on 3-D CT data, 120-130 mm-long Timothy Chryssikos, BA, Philadelphia, PA
stems (group A) and 100 mm-long stems (group B). Both Elie S Ghanem, MD, Philadelphia, PA
groups consisted of 100 hips with congenital hip dysplasia and
Javad Parvizi, MD, Philadelphia, PA
mean follow-up period was 9 years (range: 7-11 years). Both
groups had modular neck and head system with 28 mm
Andrew Newberg, MD,
alumina ceramic head. There were no significant differences in Harry Zhuang, MD, Philadelphia, PA
preoperative characters, including age, height (152cm vs Abass Alavi, MD, Philadelphia, PA
153cm), weight (54.8kg vs 53.4kg), Harris Hip Score (HHS), The accurate differentiation of aseptic loosening from peripros-
cortical index, or Crowe classification (type I/II/III: 48/41/11 thetic infection in the painful hip prosthesis is a major clinical
hips vs 46/36/18 hips). Postoperatively, although there were no challenge. FDG-PET imaging has shown great promise in various
differences in the latest HHS or proximal canal fill (anteroposte- clinical settings for detection of infection. This prospective study
rior: 92% vs 93% and lateral: 87% vs 92%), there were signifi- was designed to determine the efficacy of FDG-PET imaging in
cant differences in the number of the patients with thigh pain (7 the assessment of patients with painful hip prosthesis. One
hips vs 0 hips;p=0.007), bone ingrown fixation (88 hips vs 100 hundred and thirteen patients with 127 painful hip prostheses
hips;p=0.0003), intraoperative complications (7 hips vs 0 hips; were evaluated by FDG-PET. Approximately 60 minutes after the
p=0.007), and loosening (4 hips vs 0 hips;p<0.05). intravenous administration of FDG images of the lower extrem-
Unexpectedly, Group B components provided better results than ities were acquired using a dedicated PET machine. FDG-PET
Group A components. Extremely short anatomical femoral images were interpreted by experienced nuclear medicine physi-
components provided the feasibility of stem insertion, reduced cians. Images were considered positive for infection if PET
the intraoperative complications including varus malposi- demonstrated increased FDG activity at the bone-prosthesis
tioning, and influenced on the implant longevity. interface of the femoral component of the prosthesis. Surgical
findings, histopathology, and clinical follow-up served as the
gold standard. FDG-PET was positive for infection in 35 hips
and negative in 92 hips. Among 35 positive PET studies, 28 were
435
proven to be infected by surgical and histopathology findings as bases of the authors’ 2 institutions were used to identify all
well as follow up tests. In 92 hip prostheses with negative FDG- periprosthetic femur fractures occurring within 90 days of THA
PET findings, 87 were proven to be aseptic. The sensitivity, speci- with an uncemented proximally coated femoral component
ficity, positive and negative predictive values for FDG-PET were between 1987 and 2007. During the study period, 3346 such
0.85 (28/33), 0.93 (87/94), 0.80 (28/35), and 0.95 (87/92), stems of multiple designs were implanted at the 2 institutions.
respectively. The overall accuracy of FDG-PET in this clinical 41 hips had an acute periprosthetic femur fracture within 90
setting was 90.5% (115/127). The results demonstrate that FDG- days of the index arthroplasty. 28 of these consisted of a
PET is a highly accurate diagnostic test for differentiating displaced, unstable fracture around the proximal implant,
infected from non-infected painful hip prosthesis. Therefore, involving the femoral neck and the lesser trochanter [Vancouver
FDG-PET imaging is considered the study of choice in the eval- A(L)]. Detailed analysis of patients with this fracture pattern was
uation of patients with suspected hip prosthesis infection. performed. There were 17 females, 11 males; age 25-84 (mean
65); BMI 21-39 (mean 31). Approach was posterior in 13, ante-
POSTER NO. P105 rior in 9, transtrochanteric in 1, and was considered minimally
In-Cement Technique in Selected Aseptic Revision invasive in 5. Time from operation until fracture: 4 to 88 days
(mean 27). Mechanism of injury: 8 had no defined trauma, 10
Hip Arthroplasty Patients fell, 5 tripped or stumbled, 2 twisted, and 3 were standing. At
Lucas E Marcos, MD, Cordoba, Argentina fracture 19 patients were still using arm support to ambulate.
Martin Buttaro, MD, Buenos Aires, Argentina Fracture treatment consisted of revision THA in 24, ORIF
Fernando Martin Comba, Buenos Aires, Argentina without revision in 3, and nonoperative treatment in 1.
Francisco Piccaluga, MD, Buenos Aires, Argentina Prevalence of this fracture pattern increased in a statistically
The in-cement technique for revision hip arthroplasty involves significant manner (p<0.05) during the last 3 years of the study:
retaining the original cement-bone interface. This has been 21 of the 28 fractures occurred since 2004. This early acute post-
proven to be a biomechanically stronger method than rece- operative fracture pattern is occurring with increased prevalence
menting after complete removal of the original cement mantle. in association with contemporary North American THA practice
We reviewed a series of consecutive patients who underwent (smaller incisions, accelerated rehabilitation protocols, greater
aseptic revision hip arthroplasty using the in-cement technique. utilization of uncemented proximally porous coated stems).
Between 1999 and 2006, 37 aseptic revision hip surgeries (35 Surgeons aware of the risk of this complication may take meas-
patients) were performed using this method. There were 30 ures to reduce its occurrence.
women and 5 men with an average age of 68 years (range: 29 to
93). Indications for the in-cement technique were aseptic femurs POSTER NO. P107
presenting an intact cement mantle. The reasons for revision ◆Metal-on-Metal Hip Resurfacing in Patients With
were femoral stem fracture, cup failure, acetabular protrusion a High BMI
after hemi-arthroplasty and recurrent dislocation. Exclusion
criteria were patients with septic failures or damage to the
Harlan C Amstutz, MD, Los Angeles, CA
cement-bone interface. At a mean follow up of 46 months Michel Jean Le Duff, Glendale, CA
Frederick Dorey, PhD, Los Angeles, CA
(range: 24 to 144), none of the patients required a new femoral

revision surgery. The average post-operative Merle D´Aubigné In this study, we assessed the influence of BMI on the survival of
score was 5.7 points for pain, 5.5 for mobility and 5.4 for gait Conserve® Plus metal-on-metal hybrid hip resurfacing by
(p< 0.05). There was no evidence of radiological stem failure comparing the clinical results of patients with a BMI of 30 or
and no femoral component is considered to be at risk for loos- more with those of patients with a BMI less than 30. We identi-
ening. In this series of patients, the in-cement technique fied all patients with at least 2 years of follow-up and a BMI of
provided consistent, high functional outcomes without reopera- 30 or more (study group - 125 patients, 144 hips) or a BMI less
tions. This valid and effective alternative should be considered in than 30 (control group - 531 patients, 626 hips). Average weight
selected aseptic cases presenting a stable cement-bone interface. was 104.6 kg with a BMI of 33.4. in the study group and 78.3 kg
This technique was useful in many situations including with a BMI of 25.4 in the control group. There was no significant
enhancing exposure when performing an acetabular revision difference post-operatively between the groups in pain, walking,
and revision of a stable nonmodular stem to improve offset and and mental component of the SF-12. However, UCLA function
stability. and activity scores were lower for the study group (9.1 vs. 9.6,
p=0.001; and 7.1 vs. 7.6, p=0.002, respectively). The control
POSTER NO. P106 group had a significantly higher postoperative physical compo-
Early Femur Fracture after THA: Increased nent of the SF-12 (51.4 vs. 49.3, p=0.01) and post-operative
Harris hip score (93.8 vs. 90.6, p=0.0003). The five-year survivor-
Prevalence Associated with Modern N. American ship was 98.6% for the study group and 93.6% for the control
Practice group (p=0.0401). The risk of revision decreased two-fold as
Michael J Taunton, MD, Rochester, MN BMI increased 5 points(p=0.013). There were no acetabular
Daniel J Berry, MD, Rochester, MN loosening in either group. There were no revisions for any
Lawrence D Dorr, MD, Inglewood, CA reason and no radiolucencies observed in a subset of patients
with a BMI of 35 or more (n=27). Metal-on-metal resurfacing
William T Long, MD, Inglewood, CA
arthroplasty of the hip is performing well in patients with high
Manish Dastane, MD, Inglewood, CA BMI even though the function scores are lower compared to
Early acute displaced periprosthetic femur fracture after primary patients with a BMI less than 30. The protective effect of high
total hip arthroplasty (THA) has been uncommon. The authors BMI on survivorship results may be explained by a reduced
identified a specific fracture pattern occurring with increased activity level and greater component size in this patient popula-
frequency after THA with contemporary implants, operative tion. Surgical technique considerations only should dictate the
techniques and rehabilitation protocols. The computerized data- upper limit of acceptable BMI.
POSTER NO. P109 anteverted more than it looks. There is significant individual
variation of pelvic tilt. This imageless navigation system
◆Effect of Bearing Diameter and Radial Clearance corrected cup anteversion for pelvic tilt. Correction for pelvic tilt
on Wear of Ceramic-on-Metal Total Hip for each patient optimizes the cup position for that patient.
Replacements Computer navigation permits the cup to be positioned by a
Hani Haider, PhD, Omaha, NE scientific quantitative method rather than judgment alone.
Joel N Weisenburger, MSc, POSTER NO. ORS 1
Malcolm G Naylor, PhD,
David W Schroeder, BSc, Bone Remodeling Characteristics of a Short-
Kevin L Garvin, MD, Omaha, NE Stemmed Total Hip Replacement
Ceramic-on-metal Total Hip Replacements (THR) combine hard Hsiang-Ho Chen, PhD, Taipei, Taiwan
ceramic heads with tough metallic shells. This combination may Bernard F. Morrey, MD, Rochester, MN
reduce the potential for ceramic fracture and metal-ion release, Kai-Nan An, PhD, Rochester, MN
and lower adhesive-wear from articulation of identical materials. Zong-Ping Luo, PhD, Temple Terrace, FL
The differential hardness of ceramic-on-metal may show Bone remodeling of a metaphyseal fixed femoral stem, Mayo
different sensitivity to the radial clearance between head and Conservative Hip, was characterized by the dual-energy X-ray
liner. This study investigates the wear rates of two sizes of absorptiometry and a mathematical remodeling model.
ceramic-on-metal THRs, with two radial clearances. Six 28mm Twenty-nine patients undergoing the total hip replacement were
and six 36mm THRs comprising alumina femoral-heads and included with the mean age of 50.8 years and the mean follow-
CoCr acetabulum shells were tested on a hip simulator up of 5.7 years. The bone mineral density of the periprosthetic
according to ISO-14242-1 at 1Hz for 5 million walking cycles femur and contralateral femur was evaluated in the anterior-
(Mc). Three from each group had a higher-clearance of posterior plane. The mathematical model was based on the
81.7±3.7µm and three a lower-clearance of 29.5±4.3µm. During assumption that the bone is a biological optimized material
the first 1Mc, all CoCr liners lost weight, as run-in wear. None which tends to maximize its resistance with minimum of struc-
exceeded 1.31mm3¬ even after 5Mc. All the 36mm liners tural consumption. As anticipated, bony structure underwent
showed immeasurable wear overall, averaging a weight-gain of significant remodeling after the short-stemmed femoral arthro-
<0.007±0.006mm3/Mc. The 28mm higher-clearance liners plasty with resorption proximally and ingrowth distally/later-
showed break-away wear; they quickly lost (0.723mm3, ally. The von Mises stress distribution indicated the stress more
0.769mm3, 1.03mm3) sometime during the test, then stabi- concentrated around distal lateral canal and medial cortex and
lized into a negligible wear rate. The 28mm low-clearance liners was in a good agreement with the bone density distribution.
showed near zero wear except for one with break-away wear of The overall resorption, however, was considerably less than that
1.23mm3. All alumina femoral heads gained weight by 5Mc, that in the traditional long-stemmed prosthesis. Theoretical
and showed grey stripes. Our results confirmed extremely low prediction suggested that the remodeling was largely regulated
wear for ceramic-on-metal THR. Low-clearance and large-diam- by the mechanical loading distribution pattern determined by
eter likely increased the contact area and lubricant-film thickness

implant design.
resulting in lower wear. Increased clearance resulted in earlier
breakaway wear in the smaller size, which is worthy of note. The
weight gain of femoral-heads was likely due to material transfer
from the CoCr acetabular-liners.
POSTER NO. P110

Correcting Pelvic Tilt in Total Hip Arthroplasty by
Using Imageless Navigation System
Lawrence D Dorr, MD, Inglewood, CA
Jinjun Zhu, MD, Inglewood, CA
Zhinian Wan, MD, Inglewood, CA
Tilt of the pelvis during THA can change the anteversion of the
cup as much as 10°. The purpose of this study was imageless
navigation could identify and compensate for pelvic tilt. 436
patients (477 hips) who underwent primary THA with imageless
navigation system had pelvic tilt measured and the cup position
adjusted for this tilt. Hips were divided into five groups
according to anterior-posterior (AP) pelvic tilt: posterior tilt >5°
(Group A), posterior tilt 1-5° (Group B), Zero pelvic AP tilt
(Group C), anterior tilt 1-5° (Group D) and anterior tilt >5°
(Group E). Cup positions were validated from CT scans in 130
hips. AP tilt varied from 25° posterior to 20° anterior. 127 hips
(26.6%) had posterior tilt greater than 5° (10.1 ± 3.9); 70 hips
(14.7%) had pelvic anterior tilt greater than 5° (8.6 ± 2.6). The
greater the AP tilt, the more the computer compensated antever-
sion (Group A: 7.8 ± 3.1; Group B: 2.3 ± 1.1; Group C: 0.03 ±
0.4; Group D: -2.3 ± 1.1; Group E: -6.3 ± 1.7). Posterior tilt corre-
lates to higher BMI (> 27), so that in heavier patients the cup is
437
SCIENTIFIC EXHIBITS ters were defined by the group as adequate for obtaining
comprehensive information regarding hip structure. These
consensus definitions will be presented in detail. The radi-
ographic techniques for an anteroposterior pelvis, cross-table
SCIENTIFIC EXHIBIT NO. SE01 lateral and false profile views were defined. Eight radiographic
Thin Acetabular Shells Increase the Disassociation features were identified and described. These included: acetab-
Risk of Ceramic Liners ular depth, acetabular inclination, acetabular version, femoral
head position relative to the acetabulum, head sphericity, head-
Jonathan F.I. Greenwald, MA, Cleveland, OH
neck junction offset, joint congruency, and degree of
Mircea Rosca, BSME, Cleveland, OH osteoarthritic change. Each radiographic feature was defined and
Paul D Postak, BSc, Cleveland, OH tested. Intra and interobserver reliability studies demonstrated
A Seth Greenwald, DPhil Oxon, Cleveland, OH the measures of acetabular inclination, femoral head center
The procedural standard for the fixation of metallic acetabular position and femoral head sphericity to be the most reliable
liners is under-reaming and impaction. Recently, concerns have radiographic parameters examined. This systematic approach,
arisen regarding achieving and maintaining secure ceramic liners including definitions of radiographic technique and interpreta-
when thin shells are deformed during normal insertion. Failure tion of radiographic views, provides a common framework that
to achieve adequate ceramic taper locking has been associated will assist surgeons in diagnosing and classifying structural hip
with clinical disassembly and liner fracture. This study evaluated disorders.
the influence of shell deformation on the locking mechanism
integrity of contemporary modular acetabular designs SCIENTIFIC EXHIBIT NO. SE03
employing ceramic liners. Direct in-vivo measurements of Treatment of Early-Stage Osteonecrosis of the
acetabular shell deformations were confirmed. Clinical meas-
urements were correlated in an in-vitro under-reamed pelvic
Femoral Head
analog. Respective ceramic liners were inserted per individual- David R Marker, BS, Baltimore, MD
ized surgical procedure and the locking mechanism integrity Thorsten M Seyler, MD, Winston-Salem, NC
established utilizing ASTM F1820. This test determined the Ronald Emilio Delanois, MD, Lutherville, MD
push-out/axial disassembly force for each deformed shell (n=3). Slif D Ulrich, MD, Baltimore, MD
Comparison was made to analogous non-deformed ceramic Srivastava Siddharth, BS, Baltimore, MD
liner/shell constructs (n=3). Failure analysis was also performed Michael A Mont, MD, Baltimore, MD
to reveal interface taper damage. Shell deformation caused by
Avascular necrosis of the femoral head is a devastating disease.
interference impaction contributed to a decrease in the locking
When left untreated, patients will often go on to femoral head
mechanism retention strength in all designs studied, as well as,
collapse and the need for a total hip arthroplasty. A certain
increased asymmetric contact damage. Retention strength varied
percentage of these patients are diagnosed in the pre-collapse
with shell design most noticeably with shell thickness. This
state and are amenable to joint preserving procedures. The use
study suggests that all modular acetabular components are not
of core decompression and nonvascularized bone grafting is
alike and that care should be taken when employing thin
typically recommended for patients with early small and

metallic shells in association with a ceramic liner. Further, clin-
medium-sized lesions. The reported efficacy of these procedures
ical considerations suggest that pelvic under-reaming where thin
has been inconsistent with many studies demonstrating success
shells are employed may be contributory to early damage of
rates of 60 to 80% at short- and mid-term follow-up. More
these modular components.
recently, there has been a lot of interest to modify surgical tech-
SCIENTIFIC EXHIBIT NO. SE02 niques and enhance these procedures with the use of various
growth and differentiation factors. In order to assess whether the
A Systematic Approach to Radiographic Evaluation efficacy of core decompression and nonvascularized bone
of the Young Hip grafting has improved during the last decade, we compared
John Carlisle, MD, Webster Groves, MO recently reported radiographic and clinical success rates to
John C Clohisy, MD, Saint Louis, MO results published prior to 1997. In addition, we report the
outcomes of a cohort of avascular necrosis patients at our insti-
Paul E Beaule, MD, Ottawa, ON, Canada
tution who were treated with a nonvascularized bone grafting or
Robert T Trousdale, MD, Rochester, MN a multiple small diameter core decompression technique. We
Perry L Schoenecker, MD, Saint Louis, MO conducted a systematic review utilizing the Medline and Embase
Young-Jo Kim, MD, Boston, MA bibliographic databases using core decompression, bone
Michael B Millis, MD, Boston, MA grafting, osteonecrosis and avascular necrosis as keywords. The
Evaluation and surgical treatment of the painful young adult hip identified reports were then stratified by publication date and
are evolving rapidly. Most hip disorders in the young adult are grouped as published between the years 1997 to 2007, and
mechanically-based and associated with developmental published prior to 1997. If reported, the etiologies and the strat-
dysplasia of the hip (DDH) and/or femoroacetabular impinge- ification of preoperative Ficat stage were included in our
ment (FAI). Nevertheless, the necessary radiographic parameters analysis. The majority of patients being Ficat stage I and II and
to allow accurate diagnosis, disease classification, and quantifi- corticosteroids and alcohol being the most frequently reported
cation of anatomic abnormalities are not widely known. The diagnosis. From our institution, we identified 52 patients (79
purpose of this report is to present a consensus regarding the hips) who had a core decompression utilizing a multiple small
recommended radiographic techniques and image interpreta- diameter (3mm) technique at mean follow-up of 65 months. At
tion in the young adult hip patient. A group of 6 experienced hip the same time, we performed 47 nonvascularized bone grafting
surgeons convened to develop a practical, standardized procedures in 41 patients who had Ficat and Arlet stage II and III
approach to the radiographic diagnosis of structural hip disor- avascular necrosis of the femoral head. The outcome parameters
ders. Three radiographic views and eight radiographic parame- collected for each patient at our institution and from the reports
in literature were the number and percentage of patients who as the end-point was 99.1% at 5 years, 99.0% at 10 years, and
required additional surgeries, were clinical failures, or had radi- 98.6% at 15 years. The Mallory-Head Porous femoral compo-
ographic progression of the disease. Using core decompression, nent continues to demonstrate excellent long-term survival with
there were 2221 hips treated after 1997 and 1168 prior to 1997. an extremely low rate of failure or aseptic loosening. The tita-
The proportion of patients surviving without additional surgery nium substrate, porous plasma spray coating, and tapered
increased from 59% (range: 29 to 97%) in the earlier studies to design are the likely reasons for this design’s continued success.
65% (range: 18 to 90%) in the more recent reports (p = 0.009).
Although the respective clinical and radiographic successes in SCIENTIFIC EXHIBIT NO. SE05
the pre-1997 compared to post-1997 reports increased from Tribological Effects of Cup Deflection on Metal-on-
58% (range: 28 to 94%) to 59% (range: 29 to 86%) and 55%
(range: 0 to 87%) to 58% (range: 22 to 90%), neither of these
Metal Bearings With Various Clearances
increases was significant. The results of our cohort of patients Amir Kamali, Leeds, United Kingdom
were similar to other reports in the last decade with 66% not Hussain Azad, PhD, Leamington Spa, United Kingdom
requiring additional surgery, 62% defined as clinical successes Daniel Jasper Timothy, MEng, Leamington Spa, UK
(Harris Hip scores greater than 80 points), and 65% not Chenxi Li, PhD, Leamington Spa, United Kingdom
showing radiographic progression in Ficat stage. Analyzing the Derek James Wallace McMinn, FRCS, Birmingham, UK
literature for nonvascularized bone grafting, there we significant Youseffi Mansour, PhD, Leamington Spa, United Kingdom
fewer numbers of studies published (n=26). Success rates varied
Tim Band, MBA, Leamington Spa, United Kingdom
between 55 to 73% at short-term to mid-term follow-up.
Comparing our own experience of 47 procedures, there were 15
Roger Ashton, BEng, Leamington Spa, United Kingdom
clinical failures (32% clinical failure rate) with a mean time to Press-fitting the cup into the acetabulum generates non-uniform
femoral head collapse of 13 months (range: 2-34 months). compressive stresses on the cup and consequently causes non-
Multiple logistic regression analysis revealed that SLE and lesion uniform cup deformation. This in turn may result in equatorial
size were independent predictors of failure, p=0.015 and contact, high frictional torque and femoral head seizure. The
p=0.019 respectively. The results of the literature meta-analysis aim of this study was to investigate the deflection caused by cup
suggests that core decompression and nonvascularized bone implantation and its effect upon the tribological performance of
grafting techniques better avert the need for additional surgeries the bearings. A series of measurements on cups were carried out
in patients who have avascular necrosis of the hip. It is not clear intraoperatively. Six different MoM bearings with various clear-
whether recent advances and the addition of bone growth ances ranging from 80-300µm were friction tested in vitro using
factors provide better clinical scores or radiographic outcomes, serum, serum with hyaluronic acid, blood and clotted blood as
particularly considering the inconsistency in the measures used lubricants. These components were then deflected in the flexion
to stage success. The mid-term follow-up of the multiple small extension direction by 25-35µm before repeating the friction
diameter core decompression and nonvascularized bone test. The intraoperative study showed that cups can experience
grafting patients at our institution was longer than most studies, up to 100µm of deflection when implanted into the acetab-
and with a success rate similar to or higher than other reports, ulum. Studies were also carried out in vitro to further under-
these techniques remains the authors’ preferred modality in stand the effects of various interference press-fits on cup

deferring more radical treatment options such as total joint deflection. Friction testing in blood and clotted blood as lubri-
arthroplasty in this difficult to treat patient population. cants showed significant increase in friction with low clearance
bearings. Repeating the tests after cup deflection, further
SCIENTIFIC EXHIBIT NO. SE04 increased the friction factors in low clearance bearings. Increased
friction, results in increased frictional torque at the implant bone
Survivorship Analysis of 2000 Consecutive Tapered interface which could in turn cause cup loosening and increased
Titanium Porous Plasma Sprayed Femoral wear. This study also showed that bearings with larger clearances
Components can accommodate for the amount of distortion the cups experi-
ence during implantation. At smaller clearance values, a small
Thomas H Mallory, MD, New Albany, OH
amount of deflection can significantly increase the friction factor
Keith R Berend, MD, New Albany, OH
which may adversely affect the tribological performance of MoM
Adolph V Lombardi, Jr, MD, New Albany, OH bearings.
Joanne B Adams, New Albany, OH
Between August 1984 and June 2001, 2000 tapered titanium SCIENTIFIC EXHIBIT NO. SE06
femoral implants of a single design were inserted at one center. Gamma Inert Sterilization: A Solution to
The primary femoral component design has remained relatively
unchanged since its first implantation with circumferential prox- Polyethylene Oxidation?
imal porous coating added in 1986 and an offset option in Steven M Kurtz, PhD, Philadelphia, PA
1999. A retrospective review of all total hip arthroplasty (THA) William J Hozack, MD, Philadelphia, PA
procedures done at our institution identified 2000 consecutive Javad Parvizi, MD, Philadelphia, PA
THA in which the Mallory-Head Porous (Biomet, Inc., Warsaw, James J Purtill, MD, Philadelphia, PA
IN) component was used. Routine follow-up included annual Peter F Sharkey, MD, Philadelphia, PA
examinations and radiographs, and an attempt was made to
Daniel MacDonald, BS, Philadelphia, PA
contact all missing patients by phone or letter. Follow-up aver-
aged 6 years. To date there have been 37 femoral revisions for an
Matthew J Kraay, MD, Cleveland, OH
implant survival of 98.2%. Using the Kaplan-Meier method, Victor Goldberg, MD, Cleveland, OH
cumulative survival with any stem revision as the end point was Clare M Rimnac, PhDCleveland, OH
98.2% at 5 years, 98.1% at 10 years, and 96.2% at 15 years. In the 1990s, polyethylene oxidation was found to occur
Using aseptic loosening as the endpoint, stem survival was following gamma irradiation in air. Manufacturers developed
99.1%. Kaplan-Meier cumulative survival with aseptic loosening barrier packaging to reduce oxidation. This study explores the
439
hypothesis that implants sterilized in a low oxygen environment SCIENTIFIC EXHIBIT NO. SE08
undergo similar in vivo oxidative mechanisms as implants ster- Improved Acetabular Screw Fixation With
ilized in air. Over the past seven years, our multi-institutional
retrieval program has traced and analyzed 264 conventional Injectable Self-Curing Calcium Sulfate
polyethylene hip and knee components: 123 were sterilized in Wayne M Goldstein, MD, Morton Grove, IL
air and 141 were sterilized in a low oxygen environment. The Mark H Gonzalez, MD, Chicago, IL
mean implantation time of the hips was 10.1y (Air) and 4.1y Alexander C Gordon, MD, Highland Park, IL
(Inert). Knees were implanted on average 10.8y (Air) and 2.7y Farid Amirouche, MD, Chicago, IL
(Inert). Oxidation index was characterized in loaded and
Enhanced stability of acetabular shells is desirable in patients
unloaded regions of the inserts per ASTM F2102. Measurable
with poor bone stock in primary and revision total hip arthro-
oxidation was observed in all cohorts. The oxidation was
plasty (THA). Postoperatively, these acetabular components may
regional. Surfaces with access to bodily fluids were more heavily
rotate vertically as multiple screws allow angular motion.
oxidized than protected, bearing surfaces. This variation
Surgical grade calcium sulfate, MIIG TM115, can be injected as a
appeared to be greater in gamma-air sterilized implants. This
bone graft substitute. It solidifies with strength close to cancel-
study explores the significance of industry-wide changes in ster-
lous bone, remodeling into bone in three months. In five hip
ilization practice for polyethylene. We found lower oxidation in
revisions with poor press fit, we injected MIIG TM 115 into screw
the gamma inert-sterilized hips and knees as compared with
holes prior to screw insertion to increase the surface area around
historical gamma-air inserts. However, we also found strong
the screw to resist micromotion and enhance fixation. This
evidence that gamma inert sterilized inserts are undergoing
construct was biomechanically tested in an in vitro model.
mechanisms of in vivo oxidation that similar to those observed
Porous foam blocks were used to simulate the acetabulum in
following gamma irradiation in air. Our research therefore
four setups. Testing involved reaming 1mm larger and then
demonstrates that gamma inert sterilization may have
inserting a 60mm shell. We drilled and inserted two 20mm
improved, but not completely solved, the problem of polyeth-
superior screws. In two cups we injected MIIG TM 115 into the
ylene oxidation for hip and knee arthroplasty.
screw holes prior to screw insertion. We allowed 15 minutes for
MIIG TM 115 to set. Twelve sensors around the cup and rim
measured vertical and horizontal micromotion. Off-center cyclic
Bone Mineral Density of the Proximal Femur loading of the cup opposite the screw holes was done through a
Recovers After Metal-on-Metal Hip Resurfacing range of 50N to 300N. In Vitro-The cup with screws alone
Antonio Moroni, MD, Bologna, Italy moved grossly at 50N on the first cycle. The screws and MIIG TM
115 resisted motion and allowed horizontal and vertical micro-
Cesare Faldini, MD, Bologna, Italy
motion of 0.15 and 1.27 micrometers at 50N 0.76 and 7.3
Matteo Cadossi, MD, Bologna, Italy micrometers at 400N and 2.28 and 10.25 micrometers at 800N.
Matteo Romagnoli, MD, Bologna, Italy In Vivo-All five post op patients at two years were stable. Clinical
Federico Tesei, MD, Bologna, Italy evaluation and laboratory testing indicated enhanced stability
Amy Hoang-Kim, Bsch, Bologna, Italy when utilizing calcium sulfate in screw holes for adjunctive fixa-
E Chiarello, Bologna, Italy tion. This method will biologically enhance fixation in primary
Sandro Giannini, MD, Bologna, Italy and revision THA with poor press fit or bone stock.
Loss of periprosthetic femoral bone following standard total hip
replacement may lead to thigh pain, implant loosening, SCIENTIFIC EXHIBIT NO. SE09
periprosthetic fractures and a difficult revision. As metal-on- Cementation of a Polyethylene Liner Into a Metal
metal hip resurfacing (MOM-HR) may load the bone more Acetabular Shell
physiologically, we measured proximal femur BMD in 21
Thurston Drake, BA, Salt Lake City, UT
patients, mean age 48 (25-73), treated by Birmingham Hip
Resurfacing. DXA analysis of the treated hip was performed in Edward J Prince, MD, Saint George, UT
the 7 Gruen zones preoperatively, and at 3, 9 and 24 months Kenneth John Hunt, MD, Salt Lake City, UT
postoperatively. In Gruen zone 1 mean BMD decreased during Aaron Adam Hofmann, MD, Salt Lake City, UT
the first 3 months to 93.3% (p=0.001) and increased to 94.7% During revision hip arthroplasty, many surgeons choose to
at 9 months (p=0.001) and 96.8% at 24 months (p=0.009). In cement a new liner into a well-fixed acetabular shell. The goals
Gruen zone 7 the mean BMD decreased during the first 3 of this study were to evaluate the strength of cemented liners
months to 95.6% (p=0.005) and increased to 98.7% at 9 compared to standard locked liners, and to evaluate our liner
months (p<0.05) and 102.1% at 24 months (p=0.05). At 24 preparation technique. Polyethylene liners were inserted into
months a correlation was found between valgus positioning of acetabular shells using the standard locking mechanism (n = 10)
the femoral component and increased BMD of the femoral neck or were cemented in place with Palacos Bone Cement (n = 20)
(p=0.005). MOM-HR loads the proximal femur more physio- or Simplex P Bone Cement (n = 20); prior to insertion, ten liners
logically, as shown by a progressive increase of BMD at 9 and 24 in each cemented group were roughened with an oscillating saw.
months. A correlation between valgus positioning of the femoral Constructs were loaded to failure in either torsion or lever-out
component and increased BMD was found. This suggests that testing. On lever-out testing, there were no significant differences
valgus implantion of the femoral component is useful in between mean failure loads of cemented and locked liners or
reducing the risk of femoral neck fractures. between roughened and smooth liners. All roughened cemented
liners withstood lever-out testing until the liner itself deformed
(i.e., without failure at the cement-liner interface), while 40
percent of unroughened cemented liners failed at the cement-
liner interface On torsion testing, roughened liners withstood
higher loads than smooth liners and significantly higher loads
than locked liners. Simplex-cemented roughened liners with-
stood higher lever-out and torsional loads than Palacos- tration; -Retrieval specimen findings (cement measurements and
cemented roughened liners. The differences were significant in the histology of the cement interface) from over 50 cases,
lever-out testing. In both tests, Palacos cement performed favor- including components designed to have a cement mantle and
ably compared to locked liners. Cementation of a polyethylene those with a tighter, line-to-line fit; -Results from a study in
liner into a pre-existing metal shell is safe, strong, and a good which forty-five osteoarthritic femoral heads retrieved at the
alternative to shell replacement. Roughening the liner is a simple time of total hip replacement which received hip resurfacing
technique that strengthens the poly-cement interface. components by an experienced surgeon per manufacturer
recommendations. This information will be provided in panels
SCIENTIFIC EXHIBIT NO. SE10 and on a PowerPoint presentation format. The exhibit will show
Metal Ion Measurement as a Diagnostic Tool to that component design strongly influences the amount of
cement fixation and that both insufficient cement, and excessive
Identify Problems With Metal-on-Metal Hip cement are associated with femoral loosening. The histological
Resurfacing analyses show that there is a real possibility for cement thermal
Koen Aime De Smet, MD, Heusden, Belgium necrosis and interfacial membranes leading to loosening but
R de Haan, Helgelo, Netherlands that healing does occur, and membranes are not inevitable.
Harinderjit Singh Gill, PHD, Oxford, United Kingdom Surgeons who are offering hip resurfacing in the treatment of
arthritis need to understand this and choose their cement
Edward Ebramzadeh, PhD, Los Angeles, CA
philosophy knowing that excessive or insufficient penetration
Patricia A Campbell, PhD, Los Angeles, CA can lead to early failure.
While the limitations of radiographs to detect wear in metal-on-
metal implants are well known, using ion measurements to SCIENTIFIC EXHIBIT NO. SE12
monitor wear is not generally advocated. Well-functioning
implants produce low ion levels, and there is probably little
Reducing the Wear and Ion Levels of Metal-on-
need to monitor such cases routinely. There is evidence that Metal Hip Replacements
malpositioned or poorly functioning implants produce much Sophie Williams, PhD, Surrey, United Kingdom
higher levels of ions. The clinical experience in this large volume Eileen Ingham, PhD, Leeds, United Kingdom
resurfacing center was reviewed to determine if ion measure- Jin Zhongmin, PhD, Leeds, United Kingdom
ment was justified. More than 300 patients have provided blood
Issac Graham, PhD, Leeds, United Kingdom
samples which were tested by AAS for cobalt and chromium
John Fisher, PhD, Leeds, United Kingdom
levels in the serum. Initially, ions were taken in cases with radi-
ographic findings of component malposition, but later, samples Metal-on-metal (MOM) hip replacements have been used
were taken more routinely as part of the annual clinical assess- increasingly in more active patients, but concerns remain about
ment. The optimum intervals for follow-up assessment were the long-term effects of metal ion release. Our recent work has
reviewed based on the study of 3300 radiographs from over indicated that a significant wear mechanism is corrosion. Two
2000 patients up to 9 years postoperatively. There were 47 revi- distinctive approaches to reduce corrosive wear have been inves-
sions predominantly in female patients with component malpo- tigated: (1) ceramic-on-metal (COM) THRs and (2) application

sition. In some of the longer-term failures, there was severe of a surface engineered coating (CrN). A series of studies have
metallosis, neck narrowing, and/or osteolysis, indicating how examined potential wear and ion release reduction using these
joint problems can progress when revision is delayed. A strong bearings. Hip simulator studies have been carried out under
correlation was found between the ion levels in the synovial standard and edge loading conditions to examine the wear of
fluid and the serum. From these radiographic, retrieval and ion ceramic (head) on metal (liner) bearings and MOM bearings
level studies in large groups of well-functioning and malposi- modified with a thick (more than 10microns) CrN surface engi-
tioned metal-on-metal hip resurfacings, we found that diag- neered coating. The levels of cobalt and chromium ions were
nostic and treatment decisions were greatly assisted by ion measured, wear particles characterised and the biological activity
measurements. In combination with radiographs, routine ion of particles assessed. The total overall mean wear rate of the
measurements are a useful diagnostic tool in the effective moni- MOM THR was significantly higher in comparison to the COM,
toring and management of patients with hip resurfacings. ion levels measured for MOM serum lubricant were greater than
COM. CrN surface engineered coatings reduced wear and ion
SCIENTIFIC EXHIBIT NO. SE11 release of MOM THRs by more than 10-fold. Both COM and
CrN have reduced wear, ion and particle release of MOM THRs
◆Femoral Head Cement Penetration After Hip significantly. This is due to reduced corrosive wear compared to
Resurfacing: An in Vitro and Retrieval Analysis MOM bearings. This testing has provided valuable evidence
Paul E Beaule, MD, Ottawa, ON, Canada prior to clinical trials; COM THRs are now in clinical trial and a
Patricia A Campbell, PhD, Los Angeles, CA trend of reduced ion levels compared to patients with MOM
Wadih Matar, MD, Ottawa, ON, Canada THRs has been observed.
Philippe Poitras, BASc, Ottawa, ON, Canada
Hip resurfacing components almost exclusively use cement fixa-
tion for the femoral component but the optimal technique is a
matter of controversy. Retrieval analyses of failed metal on metal
hip resurfacings have shown variability in cement penetration
and mantle thickness. Although there are multiple factors which
can influence cement penetration, the role of femoral compo-
nent design is still unclear. This exhibit will review the issue of
cement fixation in hip resurfacing using the following perspec-
tives: -Literature review of experimental models of cement pene-
441
SCIENTIFIC EXHIBIT NO. SE13 year. The standardised mortality ratio of cancer deaths was thus
Squeaking Hips not calculated. The results of this study are comparable to other
follow-up studies on mortality following total hip replacement.
William Lindsay Walter, MD, Waverton, NSW, Australia This indicates that increased activity following hip resurfacing
Ronald M Gillies, BS, Sydney, NSW, Australia may help the patients maintain better fitness.
Shane Donohoo, Sydney, NSW, Australia
Steven M Kurtz, PhD, Philadelphia, PA SCIENTIFIC EXHIBIT NO. SE15
Amar S Ranawat, MD, New York, NY Total Hip Arthroplasty in the Superobese Patient,
William J Hozack, MD, Philadelphia, PA BMI > 50
Michael A Tuke, Surrey, United Kingdom
Robert W Tuttle, MD, St Paul, MN
Tim S Waters, MD, Stanmore, United Kingdom
Hari Bezwada, MD, Philadelphia, PA
Squeaking is a rare complication of hard-on-hard hip bearings.
David George Nazarian, MD, Philadelphia, PA
The purpose of this study is to contribute to the understanding
of the mechanism(s) underlying squeaking. We analyzed 12 Jess H Lonner, MD, Philadelphia, PA
alumina ceramic-on-ceramic bearings from squeaking hips Robert E Booth, Jr, MD, Philadelphia, PA
collected at revision surgery. Sound recordings were collected Total hip arthroplasty in obese patients remains a challenge to
from 38 patients with squeaking hips and analysed by Fourier most surgeons. Surgical complication rates as well as periopera-
transformation. The natural frequency of hip replacement tive morbidity are higher than total hip arthroplasty in the
components was determined by a simple acoustic emission nonobese. The purpose of this paper is to review our experience
analysis and by a finite element modal analysis. All 12 retrieved with total hip arthroplasty in superobese patients (BMI>50).
bearings showed evidence of edge loading wear and the median From 1998-2005, 75 patients underwent 101 hip arthroplasties.
femoral head wear volume were 2.9mm3 per year which is Twenty-six patients underwent simultaneous bilateral total hip
nearly 30 times the wear from silent ceramic head retrievals. arthroplasties and 49 patients underwent unilateral hip arthro-
Squeaking hip recordings showed fundamental frequencies plasties. They were compared with similar group of nonobese
between 400Hz and 7.5 kHz. All recordings demonstrated non- patients who underwent hip arthroplasties during the same time
linear frequency distribution which is typical of friction induced period. All patients received combined regional and general
vibrations. The natural frequencies of the ceramic components anesthesia. Mean follow-up was 3.4 years (2-7). Harris hip
are above the audible range (over 18 kHz range). The funda- scores improved by 40 points in the superobese (preop 51 to 91
mental frequency of the unassembled titanium shells is between postop) and by 43 points in the nonobese (preop 50 to 93
3.5 kHz and 10 kHz and the titanium femoral components have postop). There was a greater incidence of complications in the
multiple natural frequencies between 2kHz and 18 kHz. Edge superobese group, namely superficial wound problems and
loading wear was the common factor in all squeaking retrievals deep vein thrombosis. There was one peri-prosthetic femoral
and this may prove to be a critical mechanism. The squeaking fracture associated with late loosening and there was one recur-
results from friction induced vibrations - a special case of forced rent dislocater in the superobese group. One patient had acetab-
vibration - where the frequency is determined by the natural ular osteolysis in the nonobese group that required bone
frequency of the component parts. The results of this study grafting and head/liner exchange. Although total hip arthro-
suggest that squeaking is a complex phenomenon that may be plasty may be safely performed in the superobese, it may be
influenced by resonance of the metal parts. complicated by infection, loosening, and instability.

Cancer Incidence and Mortality Following Metal- Enhanced Cross-Linked Polyethylene Modular
on-Metal Hip Resurfacing Acetabular Designs: Performance Characteristics
Aulakh Tajeshwar Singh, MBBS, Oswestry, United Kingdom Mircea Rosca, BSME, Cleveland, OH
Patil Siddeshwar, MBBS, Oswestry, United Kingdom Paul D Postak, BSc, Cleveland, OH
Eric Vinton Robinson, BS, Oswestry, United Kingdom A Seth Greenwald, DPhil Oxon, Cleveland, OH
James Richardson, MD, Oswestry, United Kingdom Modular acetabular designs enjoy widespread use in THA proce-
Metal on metal arthroplasty has been shown to give good func- dures. Their mechanical performance has continually increased
tional results but the effects on mortality and cancer are yet to be through improved locking mechanism assemblies. Recently, a
ascertained. We present the mortality analysis and cause of death number of enhanced cross-linked polymers (5-10Mrads) have
in 3947 patients followed over a nine year period We compared emerged whose commonly heralded benefit is a reduction in
the mortality figures of 3947 patients who had hip resurfacing polyethylene wear. These processes, however, change the chem-
arthroplasty with the national mortality figures of the UK. The ical structure of the polymer affecting both static mechanical and
cause of death was determined by telephone call to the next of fatigue properties, including a decrease in the resistance to crack
kin and from the national death register. The standardised propagation. This study evaluated the influence of enhanced
mortality ratio of hip resurfacing patients compared to national cross-linked polyethylenes on locking mechanism integrity of
figures was 0.524(99 percent C.I. 0.39 to 0.69).The number of contemporary modular acetabular designs which also employ
observed deaths were 86 as compared to the expected deaths conventional polyethylene liners. Locking mechanism integrity
number 164. Out of the total 86 deaths over a nine year period, was established for both the conventional and enhanced cross-
32 deaths were due to cancer, 22 due to cardiovascular causes, 7 linked polymers through push-out/axial disassembly (n=3) for
due to respiratory conditions and 12 due to other causes such as four contemporary acetabular shell designs utilizing ASTM
suicide, accident, old age. In the cancer group 6 patients died of F1820. Comparative analyses between cup designs and liner
lung cancer and 7 died of blood cell neoplasms.The cause of materials were completed. For both liner materials, static locking
death for 13 patients was not available as the deaths were recent mechanism strength was similar for each of the designs studied,
and the information is transferred to the national registry at mid satisfying the null hypothesis (p>0.05). The push-out/axial
disassembly strength measured for the enhanced cross-linked exhibited initiation sites associated with locking or stress
polyethylene acetabular liners in this study indicate that short- concentrating features on the acetabular liner rim. The initiation
term disassociation of these components is no more likely than sites have a clamshell appearance, indicating that incubation of
that for the conventional polyethylene liners of each design. The the cracks occurred prior to their propagation. The shapes of
predominant failure mechanisms of modular acetabular cups these fractures imply that femoral neck impingement may be a
are fatigue related, and further studies of mid- to long-term clin- driving force for the failure. No significant oxidation was
ical performance, need to be established. observed. FEA predicts severe stresses during service near locking
features. Fractures of conventional UHMWPE acetabular liners
SCIENTIFIC EXHIBIT NO. SE17 have not been considered to be a clinical concern. Highly cross-
Metal-on-Metal Total Hip Arthroplasty: Mid-Term linked-UHMWPE is more susceptible to fracture, and our find-
ings indicate that the fractures typically occur along the rim
Results where the liner is relatively unsupported by the metal shell.
Hari Bezwada, MD, Philadelphia, PA Sharp or large concave features in the liner rim further increase
David George Nazarian, MD, Philadelphia, PA the risk of catastrophic failure. Lessons learned from ceramic
Robert E Booth, Jr, MD, Philadelphia, PA acetabular components are illustrative, including the severity of
Polyethylene wear and subsequent osteolysis have been substan- rim impingement failures and the widespread elimination of
tial problems affecting the longevity of total hip arthroplasty. stress concentrating features and unsupported liner rims.
The purpose of this study is to evaluate the mid-term results of a
metal on metal articulation in cementless total hip arthroplasty. SCIENTIFIC EXHIBIT NO. SE19
A consecutive series of one-hundred-eleven metal on metal ◆Imageless Navigation System for Total Hip
cementless total hip arthroplasties with a 28mm diameter head
Arthroplasty Based on Joint Kinematics
were implanted in 89 patients. Fourteen were performed for
osteonecrosis, the remaining 75 for osteoarthritis. Twenty-two Yannick Pinoit, MD, Lille, France
patients underwent bilateral arthroplasties. The mean age was 52 Philippe Laffargue, MD, Lille, France
(35-62) years. Clinical data was recorded using the Harris hip Jean L Puget, MD, Toulouse, France
scoring system. Radiographs were evaluated for component Henri Migaud, MD, Lille, France
position, osseous integration, stress shielding, subsidence, loos- Jacques Tabutin, MD, Lille, France
ening, and osteolysis. Follow-up averaged 6.5 (6-7) years. Mean Most navigation systems for computer-assisted total hip arthro-
Harris hip scores improved from 53 to 97. Radiographic evalua- plasty (THA) require prior computed tomography (CT), precise
tion revealed a mean cup inclination angle of 420, no radiolu- but requires a long planning time, or use a reference to the
cencies, no cup or stem migration (subsidence), and evidence of Lewinnek plane, but less precise. All these systems don’t integrate
osseous integration in all implants. There was no quantifiable the pelvis’s dynamic position. To remedy these problems, we
wear and no osteolysis on serial radiographs. Complications developed a computer-assisted navigation system based on a
included one superficial wound infection. There were no dislo- kinematic approach. The principle is to orient the cup in relation
cations and no revisions required. The mid-term results of a to the range of motion of the hip. Two optoelectronic sensors are
metal on metal articulation in cementless total hip arthroplasty

fixed percutaneously by two threated pins (iliac creast and distal
are encouraging. Clearly, longer term results are required to femur). Acetabulum is prepared with spherical reamers and then
determine if this will ultimately be the bearing of choice in the femur with increasing broaches. The last broach is equipped with
younger, high demand patient a large head of the size of the acetabulum. The hip is mobilized
the to maximal amplitudes and in combined movement
SCIENTIFIC EXHIBIT NO. SE18 (internal flexion-adduction-rotation and external extension-rota-
Fracture of Highly Cross-Linked UHMWPE tion) which are recorded and reconstitued by the optoelectronic
Acetabular Liners system to determine the maximal range of motion cone. The trial
cup is oriented so that the range of motion cone of the prosthesis
Jevan Furmanski, MS, Berkeley, CA
include completely the maximal range of motion of the hip. The
Sara A Atwood, MS, Berkeley, CA final cup is impacted in this ideal position. During all the proce-
B Sonny Bal, MD, Columbia, MO dure, the surgeon is informed of the limb length and the lateral-
Martin R Anderson, MD, Carson City, NV ization in relation to the size of the stem (femur neck length,
Brad L Penenberg, MD, Beverly Hills, CA prosthetic neck-shaft angle). All these parameters are recorded.
David K Halley, MD, Columbus, OH This system allows to choose the cup orientation in relation to
A Seth Greenwald, DPhil Oxon, Cleveland, OH stem position and cone of mobility to avoid impingement and
Lisa Pruitt, PhD, Berkeley, CA instability. It gives also stem position, length, lateralization.
Michael D Ries, MDSan Francisco, CA
Cross-linking of UHMWPE to reduce in vivo wear of artificial
joint bearings also reduces its strength and resistance to fracture. Percutaneously Assisted Total Hip Arthroplasty
This exhibit investigates clinical and potential fracture of cross- (PATH): A New Less Invasive Technique
linked acetabular components. Four clinically failed, fractured Brad L Penenberg, MD, Beverly Hills, CA
highly cross-linked acetabular liners of radiation dose 50-100 William Seth Bolling, MD, Los Angeles, CA
kGy, each from a different manufacturer, were retrieved from
We have developed and evaluated a new posterior approach for
female patients aged 25-74 years after 0.4-5.4 years in vivo.
less invasive total hip arthroplasty. Tendon attachments are
Retrieved implants were analyzed with optical and scanning
preserved, while maintaining excellent visualization and access.
electron microscopy, and Fourier Transform Infra-Red spec-
This exhibit will describe and demonstrate the technique and
troscopy. FEA of relevant scenarios was conducted. The fractures
provide clinical results. The first 250 patients were retrospectively
all had similar locations along the rim. All implant fractures
reviewed with a minimum 2 year follow-up. The new technique
443
requires release of only piriformis or conjoined tendon. area in 10 hips. Femoral head chondromalacia, grade 2 or 3, was
Specially designed retractors, cup holder/alignment guide, and present in 5 hips. Anterior labral degeneration was present in all
reamer driver are used. Acetabular reaming and impaction are hips. Ligamentum teres pathology was noted in 3 hips. At last
carried out through a distally placed 1cm portal. Acetabular follow-up, one patient has required conversion to THA, and one
reamers are powered by the very low profile 8mm drive shaft to other patient had progressive arthritic changes on Xray. In the
preserve visualization and control. Careful, selective reaming in primary cam impingement group, normal offset was restored on
any direction is then accomplished by steering the femur. Mean one-year follow-up Xrays. We feel combined arthroscopic/open
incision length was 8.3cm. Harris Hip scores improved from approaches optimises the assessment and treatment of pre-
48.9 preoperatively to 95.5 postoperatively. Component posi- arthritic or early arthritic hip disease due to both DDH and FAI.
tioning was within recommended parameters in 96% of Arthroscopy also allows for the avoidance of routine major
patients. There were no dislocations, nerve injuries, or wound arthrotomy and complete release of the rectus femoris. Most
problems. Hospital stay averaged three days. This new less inva- importantly, arthroscopy was useful in avoiding potentially
sive tissue preserving PATH technique has shown no increased unsuccessful open surgery in 13% of patients who were other-
risk of component malposition, dislocation, or other adverse wise PAO candidates in this series.
effects compared to traditional THA techniques. In addition, this
technique provides better results compared to reported MIS THA SCIENTIFIC EXHIBIT NO. SE22
results. Overall our clinical and radiographic results are compa- Clicking and Squeaking: in Vivo Sound and
rable to those reported for traditional results. We believe this
technique will ultimately show improved outcomes compared
Separation Correlation of Different Bearing Surfaces
to traditional techniques. In addition, we feel this technique has Diana A Glaser, MS, Knoxville, TN
a shorter learning curve than previously described techniques for Harold E Cates, Jr, MD, Knoxville, TN
less invasive THA. Richard D Komistek, PhD, Knoxville, TN
Mohamed Mahfouz, PhD, Knoxville, TN
SCIENTIFIC EXHIBIT NO. SE21 Douglas A Dennis, MD, Denver, CO
Adjunctive Hip Arthroscopy in the Treatment of The study objective was to correlate 3D hip kinematics and
Impingement and Acetabular Dysplasia subsequent audible effects using a sensor device for subjects
having a THA under in vivo conditions. Twenty subjects with a
Michael P Muldoon, MD, San Diego, CA
metal-on-metal, metal-on-polyethylene, ceramic-on-ceramic,
Richard F Santore, MD, San Diego, CA
ceramic-on-polyethylene or metal-on-metal polyethylene-sand-
Maximillian Lincoln, MD, San Diego, CA wich THA were analyzed under in vivo, weight-bearing condi-
The indications for hip arthroscopy in the treatment of develop- tions using video fluoroscopy and sound measurement while
mental dysplasia of the hip (DDH) and femoral acetabular performing gait on a treadmill. The senor detects frequencies
impingement (FAI) are evolving. We report here our case series that are propagated through the hip interaction. A data acquisi-
of 46 patients (52 hips) undergoing hip arthroscopy alone, or in tion system was used to amplify the signal and filter out noise
combination with open procedures, in the treatment of FAI and generated by undesired frequencies. The signal was converted to
DDH. Patients with symptomatic DDH and mechanical symp-
sound and then correlated with the fluoroscopic images that

toms/findings were recommended for PAO with adjunctive hip were converted to three-dimensions using a model-fitting soft-
arthroscopy. An abductor, tensor and rectus femoris (direct ware package. Subjects with metal-on-polyethylene and ceramic-
tendon) muscle-sparing approach was used in all cases. Open on-polyethylene THA experienced femoral head sliding
arthrotomy was not performed unless ostectomy of the femoral (separation) within the acetabular component. A clicking sound
neck was indicated for concomitant FAI. Additionally, patients was detected when the femoral head impacted the polyethylene
with borderline Tönnis I/II radiographs were assessed by arthro- liner. Ceramic-on-ceramic THA subjects experienced a squeaking
scope to determine suitability for PAO. Patients with sympto- sound that varied in magnitude, while subjects having a metal-
matic cam-type FAI underwent hip arthroscopy to address on-metal THA exhibited a sound similar to a rusty door hinge.
central compartment pathology. A limited anterior approach This study correlated three-dimensional THA kinematic data
(Heutter) was then used to perform femoral neck osteoplasty in with sound under in vivo conditions. Variable audible signals
these patients. We employed a specialized fluoroscopic view were detected for the different bearing surfaces, leading to the
(illustrated here) to compare pre- and post-ostectomy impinge- assumption that the type of material could affect the attenuation
ment. In the DDH group, 31 patients (34 hips) underwent hip of frequencies. Also, implant design and the pattern of sliding of
arthroscopy before planned PAO. Six hips were Tönnis II, and 13 the femoral head within the acetabular cup could lead to
Tönnis I. Chondromalacia of the anterior acetabulum was frequency and sound variations. Sound and frequency identifi-
present in all but 2 hips (94%),and labral pathology in 29/34 cation under in vivo conditions for THA generates new possibil-
(85%). Nine patients (28%) demonstrated ligamentum teres ities for better understanding of wear and failure modes in THA.
lesions, while unstable chondral defects were seen in 8 (24%).
Of significance, four patients (4/34) in this series had articular
damage severe enough to warrant cancellation of PAO. At
present two (2/4) of these patients have subsequently under-
gone hip replacement. In the FAI group, 15 patients (18 hips)
underwent combined arthroscopy and femoral neck ostectomy.
Eleven patients were felt to have primary cam-FAI while one had
secondary impingement due to AVN. One patient had LCPD
and two had previous intertrochanteric osteotomy. One patient
had developmental coxa vara and FAI. Arthroscopic examina-
tion revealed acetabular chondral delamination in 15/17 hips
(88%). Grade 4 acetabular changes were present in at least one
SCIENTIFIC EXHIBIT NO. SE23 acetabular components. The range of malpositioning included
Novel Implant Design With Covalently-Linked excessive abduction, extreme anteversion, retroversion, and
neutral cup position. The cemented liners were downsized by 2-
Antibiotics Inhibits Periprosthetic Infection 4mm to provide an acceptable cement mantle and were posi-
Valentin Antoci, Jr, MD, Philadelphia, PA tioned more appropriately in terms of both abduction angle and
Christopher S Adams, PhD, Philadelphia, PA anteversion. Mean follow-up was 4 years (3-5). Liners were reori-
Theresa Freeman, PhD, Philadelphia, PA ented for the following reasons 7 excessive abduction, 8 extreme
Helen M Davidson, BS, Philadelphia, PA anteversion, 10 neutral and retroversion, and 5 combined inap-
Constantinos Ketonis, BSN, Philadelphia, PA propriate version and abduction. One liner loosened at 18
months and required cup revision. The other 29 functioned well
Irving M Shapiro, PhD, Philadelphia, PA
with no dislocations. Radiographic analysis demonstrated no
Noreen J Hickok, Philadelphia, PA loosening in 29 cups at a mean of 4 years (3-5). Eccentrically
Javad Parvizi, MD, Philadelphia, PA cemented liners into well fixed, malpositioned acetabular
Periprosthetic infection (PPI) is a devastating complication of components in a reasonable option that has promising short-
joint arthroplasty. To address PPI, we have developed a novel term results.
implant surface tethered with covalently-linked antibiotics. Such
surface (1) prevents bacterial colonization, (2) remains effective
after serum coverage or chronic repeat bacterial challenges, (3)
inhibits PPI in animal models, (4) and allows bone cell prolif-
eration, maturation. Ti rods were passivated, silanized, and
derivatized with vancomycin. Surface was challenged with both
S. aureus and S. epidermidis; colonization and biofilm forma-
tion were evaluated by fluorescent and crystal violet staining,
bacterial counts, and SEM. Antibiotic modified rods were
implanted in S. aureus contaminated rat femora, and evaluated
for PPI by clinical and gross observation, radiography, microCT,
and microbiology. Osteoblasts and chondrocytes were seeded
on implants and evaluated for proliferation, differentiation, and
maturation by biochemical and biomolecular methods.
Vancomycin-modified implants inhibited bacterial colonization
and biofilm formation, even after serum coverage or chronic
repeat challenges, with significant differences (p<0.05)
compared to control Ti. The surface remained active for more
than 1 year in physiological medium. Furthermore, such
implants also inhibited development of PPI in animal models,
whereas femurs with control surfaces showed periosteal reac-

tion, infectious cysts, cortex penetration, and severe bone loss.
Finally, antibiotic surface allowed osteoblast and chondrocytes
proliferation and maturation, when compared to clinical
controls. Osteoblast successfully mineralized on the surface, and
chondrocytes produced abundant proteoglycan. Antibiotic
modified implants show vast superiority to current titanium
materials, inhibiting or even preventing the ravages of peripros-
thetic infection. The antibiotic may survive for the life of the
implant, providing a permanent antibacterial surface. Therefore,
this novel implant design may provide the necessary insight into
a new generation of bioactive smart implants with active biolog-
ical function.

The Results of Cemented Liners Into Well-Fixed, but
Malpositioned Cementless Acetabular Components
Robert E Booth, Jr, MD, Philadelphia, PA
The removal of well-fixed cementless acetabular components
can be challenging and may lead to tremendous bone loss. The
options for a well-fixed, malpositioned cup include cup revision,
face-changing liners, or eccentrically cementing a liner in a more
appropriate position. This study reviews our experience with a
technique of eccentrically cemented acetabular liners in well-
fixed, malpositioned cementless acetabular components. From
2002 to 2004, 30 patients underwent acetabular revisions with
eccentrically cemented liners into well-fixed, malpositioned
445
A D U LT R E C O N S T R U C T I O N K N E E
PAPERS study was to determine if this complication rate decreased with
increasing experience. A retrospective review was performed on
the first 507 medial unicompartmental arthroplasties performed
between 2001 and 2004 by 4 surgeons at our institution using
PAPER NO. 061 the same implant design. Of these 507 patients, 445 patients
The Value of Preoperative Templating for Primary have known clinical outcome at 2 years. Of these 445 patients,
Total Knee Arthroplasty 26/445 (5.8%) knees were revised, and 36/445 (8%) of knees
required a non-revision reoperation. The overall rate of having at
Daniel Del Gaizo, MD, Durham, NC
least one reoperation in this group of patients was 56/445
Paul F Lachiewicz, MD, Chapel Hill, NC (12.6%). We then divided all of these patients into subgroups to
Elizabeth S Soileau, RN, Chapel Hill, NC determine if the revision rate decreased as the institutional and
Preoperative templating for primary total knee arthroplasty is surgeon experience increased. In considering only revisions and
not widely used. Several authors have reported poor accuracy in reoperations performed within the first 2 years post-op, the first
predicting component size and significant inter and intra 253 patients had a revision rate of 9/235 (3.8%) and a reopera-
observer variation. A new protocol for preoperative templating tion rate of 16/235 (6.8%), and the second 254 patients had a
has been designed. We hypothesize that this protocol can both revision rate of 8/210 (3.8%) and a reoperation rate of 14/210
accurately predict the sizes of the components and assist in (6.7%). With several different methods of analyzing this data,
obtaining optimal coronal alignment. 200 primary total knee we could not identify any significant decrease in either the rate
arthroplasties (153 patients) were preoperatively templated by a of revision or the rate of reoperation as either institutional or
single surgeon. Lateral radiographs were templated for compo- individual surgeon experience increased. The overall rate of revi-
nent size. Standing hip-knee-ankle radiographs were templated sion (5.8%) and reoperation (8%) has remained consistent with
to determine the distal femoral resection angle and the amount our previous report. We expected to find as other authors have
of proximal tibial resection required to restore neutral mechan- reported that as our experience increased and we learned the
ical alignment. A blinded investigator measured the six week intricacies of this procedure and implant our complication rate
postoperative radiographs for the tibiofemoral angle and the would decrease. However, with the numbers available, we were
coronal alignment of the femoral and tibial components. A unable to show any statistically significant improvement in these
second blinded investigator reviewed the operative reports to rates. While we remain advocates of UKA, we explain this
confirm the component sizes implanted and the templated complication rate to our patients to aid in the surgical decision
distal femoral valgus resection angle. Preoperative templating making process.
predicted the exact size of the components used in 165(82.5%)
femoral and 159(79.5%) tibial components, with 194(97%) PAPER NO. 063
PAPERS, POSTERS & SCIENTIFIC EXHIBITS AR KNEE
femoral and 185(92.5%) tibial components templated to A Prospective, Randomized Study Comparing
within one size used. Postoperative tibiofemoral coronal align-
ment was within ±3° of the goal alignment in 191 (95.5%) Extensor Mechanism Management Exposures for
knees. Postoperative femoral and tibial component coronal MiTKA
alignment was within ±3° of the goal coronal alignment in 190 David F Dalury, MD, Baltimore, MD
(95%) and 199 (99.5%) knees respectively. The accuracy of Brian D Mulliken, MD, Towson, MD
templating the exact component size in this study is greater than
previously reported. Accurate preoperative templating of
component size provides an intraoperative check to inappro- Mary Jo Adams, BSN, Towson, MD
priate sizing, facilitates the timely and appropriate flow of instru- Proponents of MIS TKR claim that patellar eversion and
ments intraoperatively, and ensures the availability of any non complete anterior tibial translation of during total knee replace-
stocked components. Proper coronal alignment in total knee ment have a deleterious outcome on patient rehabilitation. Forty
arthroplasty is an important factor in long term implant survival. bilateral TKA patients were randomized to either patellar ever-
With preoperative femoral and tibial resection templating there sion and anterior tibial translation or patellar subluxation and
were fewer alignment ‘outliers’ in this study than other reports no anterior subluxation surgical exposure techniques on oppo-
using conventional instrumentation alone and a comparable site knee. Patients and therapists were blinded to approach.
prevalence of ‘outliers’ to those reported with computer naviga- Clinical outcomes including range of motion (ROM),
tion. dynamometer quadriceps strength testing, and patient prefer-
ence for pain, motion and strength were collected preoperatively
PAPER NO. 062 and postoperatively at 6 and 12 weeks There were no preopera-
tive differences in patient demographics, ROM, or quadriceps
Learning Curve with Minimally Invasive strength. At 6 weeks, the average ROM for both groups was 102
Unicompartmental Arthroplasty deg. The average quadriceps strength for the eversion group was
William G Hamilton, MD, Alexandria, VA 19.6 lbs and 21lbs for the subluxation group (p=. 50). At 6
C Anderson Engh Jr, MD, Alexandria, VA weeks, 37% patients felt the everted side was less painful
Debbie Ameen, MD, Alexandria, VA compared to 44% for the subluxed side. 48% of patients
Gerard Anderson Engh, MD, Alexandria, VA preferred the everted side for motion compared to 33% for the
subluxed side. 41% of everted patients felt the everted side was
We have previously reported the early rate of revision and reop-
stronger compared to 21% preferring the subluxed side. At 12
erations using the same component design with minimally
weeks, there were no significant differences between groups in
unicompartmental arthroplasty (MIUKA). The purpose of this
preference, function or strength. We could identify no differ- (p<0.021) than patients with equally sized implants (25.3% vs.
ences between patellar eversion and anterior tibial translation 13.2%). Despite having MUA’s, this group also had lower ROM
and patellar subluxation and no tibial translation at either 6 or (p<0.011) than those with equally sized implants after one year.
12 weeks. When compared to patella subluxation, patella ever- Of note, average preoperative ROM for the three implant groups
sion and anterior tibial translation during total knee replace- was similar, and no significant difference was found before one
ment appears to have no adverse affect on ROM or quadriceps year. We have demonstrated that a larger femoral component
strength or patient preference. than tibial component can affect long term ROM after TKA, and
may necessitate MUA. We postulate that this may be related to
PAPER NO. 064 greater soft tissue tension about the femoral component. This
Comparison of Lateral and Medial Parapatellar finding suggests that surgeons should more carefully consider
using femoral components that are larger than the tibial compo-
Approach in Severe Valgus Deformity of the Knee nent for a given implant system.
Nattapol Tammachote, MD, Bangkok, Prayathai Thailand
James P McAuley, MD, London, ON Canada PAPER NO. 066
Cecil H Rorabeck, MD, London, ON Canada Femoral Component Overhang Does Not Predict
Robert Barry Bourne, MD, London, ON Canada Post-TKA Pain or Range of Motion
Severe valgus knees are realized as difficult problems. The aim
Ormonde M Mahoney, MD, Athens, GA
was to determine the intermediate term outcome of lateral para-
patellar arthrotomy compared to medial arthrotomy. Using our Tracy Kinsey, RN, Athens, GA
database 36 total knee arthroplasties performed through lateral In total knee arthroplasty (TKA), much recent attention is
parapatellar arthrotomy during 1988 and 2001 were identified. directed to femoral component (FC) fit quality, with little
All knees had minimum 15 ° valgus deformity (anatomical axis) substantive data available. FC fit was measured intra-operatively
with the average of 19 °. There were five male and 30 female. during 436 consecutive TKAs (259 in females, and 177 in males)
The average age was 68 years. Mean follow up was 7 years. This utilizing the same device implanted by flexion-extension axis
group was compared to 36 patients with medial parapatellar localization technique. Overhang of metal beyond the bone cut
arthrotomy operated in the same period. The patients’ charts edge was measured in mm after permanent fixation and
and three-foot standing x-rays were reviewed. The outcomes recorded in 10 zones. Multivariate linear and logistic regression
were compared using t-test and survivorships were analyzed by models were constructed to identify factors predictive of over-
Kaplan-Meier technique. Preoperatively the two groups were not hanging fit, and of postoperative flexion and pain. Malfit was
different in valgus deformity, age, gender and Knee Society modeled four ways: the maximum mm overhang in any single
scores. Postoperatively, the lateral arthrotomy group had clinical zone; the sum mm over all zones; the number of zones with
and functional scores as 90 and 52, respectively. The average overhang >2mm; and mm specific to lateral zone 2. Pain was
clinical component and the functional part of the Knee Society modeled discretely (absent, mild, or moderate and greater).
score were not different from those of the control group Overhang > 2mm occurred most frequently in lateral zones 2
(p>0.05). There were two wound problems and two medial and 3, in 32% and 25% of males, and 57% and 48% of females,

femoral condyle fractures in this group. For the medial arthro- respectively. Female gender, shorter height, and larger FC size
tomy group, 33% had lateral retinacular released. Using Kaplan were highly predictive of increased overhang in all multivariate
Meier survival method, there was no different survival between models. Pre-operative flexion and BMI were significant predic-
the two groups (p=0.07). The outcome of lateral approach was tors of flexion at 1 year post-op, but FC fit was non-significant in
not different from medial approach. The medial condyle frac- all models for prediction of flexion or pain at 2 months or 1 year
ture and wound infection should be concerned. Randomized post-op. While FC overhang may have clinical consequences for
control trial may be helpful to further address this problem. some individuals, it was not a significant population level
predictor of pain or motion in the context of the high overall
PAPER NO. 065 prevalence of FC malfit.
Early Effect of Differing Femoral and Tibial Implant PAPER NO. 067
Size on ROM Following Total Knee Arthroplasty Does Femoral Component Overhang and
Geoffrey H Westrich, MD, New York, NY
Undersizing affect Postoperative TKA Pain?
Christopher E Urband, BS,
Thomas P Sculco, MD, New York, NY Wayne M Goldstein, MD, Morton Grove, IL
Alexander C Gordon, MD, Highland Park, IL
Many factors contribute to the range of motion (ROM) and need
for manipulation under anesthesia (MUA) following total knee Jill Branson, RN, Kildeer, IL
arthroplasty (TKA). Some such factors include preoperative Christopher Simmons, BS, Willow Springs, IL
ROM and previous surgery or trauma. The aim of this study was Kimberly A Berland, CST, Warrenville, IL
to evaluate the affect of relative component size of the femur and There has been an introduction in the market of a total knee
the tibia on postoperative ROM and MUA. We prospectively design for women. The medial/lateral dimensions are to prevent
collected ROM (preoperative and postoperative) and relative overhang and the thickness and angle of the trochlea. This study
component size in 401 primary TKA procedures (299 subjects). examines whether overhang of the implant in a female will have
Groups were created as determined by the relationship between clinical significance. Eight measurements taken for sizes 3 and 4
femoral and tibial implant sizes (femoral component larger PFC Sigma femurs were compared to the same bone cut sites on
than tibial, equal sized components, femoral component 49 size 3 (standard) and 46 size 4(large) female femurs. These
smaller than tibial). ROM and incidence of MUA were then were: height of lateral trochlea across proximal and distal ante-
compared between these groups using chi-square or Fisher’s rior chamfers, across lugs, distal and posterior chamfers, and
exact tests. Patients with femoral components larger than tibial medial and lateral posterior condylar heights. We calculated the
components had significantly higher incidence of MUA difference between actual implant size and bone width to assess:
447
exposed bone (negative number), perfect fit (0) and overhang months. Inclusion criteria: clinically infected TKA, known
(positive numbers) of the femoral component at each site. All preoperative infecting organism, no recent antibiotic therapy.
femurs were cruciate-retaining, cemented PFC Sigma (DePuy ESR and CRP were performed preoperatively. Re-aspiration of
Warsaw Indiana). Using our prospective outcome database, we the infected TKA was performed following anesthesia induction.
measured knee society scores and specifically extracted pain and IV antibiotic prophylaxis was then administered. The tourniquet
range of motion. We found overhang in the size 3 and 4 femurs was inflated following prep and draping. Intraoperative culture
at the trochlea and the anterior chamfer medial/lateral dimen- swabs and tissue were obtained at arthrotomy. The timing of
sion. There was more overhang by an average of 2-3mm when events was recorded. Pre/ post antibiotic culture data were
the knee required a size 4 femur. The average pain score, range analyzed to determine the effect of IV preoperative prophylactic
of motion and knee society score for those with and without antibiotics on cultures obtained intra-operatively. Infections
overhang were identical. The medial/lateral overhang that is were acute postoperative (2), chronic (14), and acute hematoge-
sometimes needed to match the anterior/posterior dimensions nous (2). TKA infection in females(14) outnumbered males (4).
of a femur for ligament balance and sizing had no affect on clin- Mean time from end of antibiotic infusion to tourniquet infla-
ical outcomes. tion was 14 min; to arthrotomy culture was 26 min. Preoperative
mean ESR was 79, CRP 98. The synovial fluid analysis revealed
PAPER NO. 068 a mean nucleated cell count of 40,000/mm3 with 92%
The “Femoral Peel”: Old / New Friend in Revision neutrophils. In all 18 knees the organism(s) cultured at arthro-
tomy were the same as preoperatively. In 17 knees the organism
TKR cultured was sensitive to the preoperative prophylactic antibi-
Carlos J Lavernia, MD, Miami, FL otics given; one patient grew Candida albicans. Infecting organ-
Artit Laoruengthana, MD, isms included: s. aureus-oxacillin sensitive(5), streptococcus(2),
David Gallego, MD, MRSA(3), coagulase negative staphylococcus(3), pseudomonas
Mark Rossi, PhD, Miami, FL (2), Candida(1), mixed > 2 organisms(2) The routine adminis-
Juan Salvador Contereas, MD, tration of prophylactic pre-operative IV antibiotics should not
The femoral peel to expose a difficult knee was first described by adversely affect the result of intra-operatively obtained cultures
Windsor and Insall in the mid 1980’s. No series of patients have in revision TKA surgery for infection. Preoperative antibiotics
been reported with this technique. Our Objective is to report our should not be withheld prior to surgery on an infected TKA.
experience with a modified version of the peel technique. A
PAPER NO. 070
complete soft-tissue subperiosteal peel of the femur and tibia,
including the detachment of the origin of the medial and lateral Multimodal Pain Management & Arthrofibrosis in
collateral ligaments was done in all cases. Twenty seven cases Primary TKR
were followed for a mean period of 25 months (SD+/-9).
Carlos J Lavernia, MD, Miami, FL
Perioperative data was abstracted from medical records, and
Pain management in arthroplasty has undergone significant
patient oriented outcomes were assessed, including SF-36,
changes in the last 3 years. Multimodal pain management in
WOMAC and QWB. The mean age of the cohort was 65 years,
total knee arthroplasty has been shown to significantly reduce

66% were females. The mean hospital length of stay was 7 days
opiate requirement after primary TKR. Our objective is to assess
(SD+/-4). Range of motion at time of discharge was 51 degrees
the effect of a multimodal pain management protocol on
(SD+/-32) increasing to 97 degrees (SD+/-18) at time of last
arthrofibrosis. A cohort of 1136 primary total knee arthroplasties
follow-up. There were significant improvements in WOMAC
was followed prospectively as part of an implant registry. Patient
Scores (p<.001) and HSS Knee Scores (p<.001) at last follow-up.
oriented outcomes were collected before and after surgery. 358
Four patients were re-operated due to painful replacements; two
consecutive patients received multimodal pain management
were infected. There were two cases of DVT. Neither neurovas-
including preemptive analgesia and intraoperative local injec-
cular damage nor dislocations were reported. This modified
tions and 778 patients had conventional pain management.
surgical approach, which results in a complete soft-tissue
Manipulation under anesthesia was performed on all patients
degloving of the distal femur and proximal tibia, allowed an
bending less than 85 at week 6 in both groups. Statistical
excellent exposure in all cases, standard complication rates were
analysis included Chi-Square and regression analysis. A p<0.05
observed and the soft tissue dissection brought about no
was considered significant. The average age was 68 years ± 0.3
increase in the complication rate in these difficult cases.
SE, 72.5% were females and 90% had osteoarthritis as primary
PAPER NO. 069 diagnosis. In the multimodal pain management group 7
patients were manipulated vs. 39 patients in the other group
Effect of Prophylactic Pre-Operative Antibiotic on (2% vs. 5%; p=0.01). The incidence in the number of manipu-
Intraoperative Cultures in Infected TKA lations was significantly associated with this new pain protocol
Ajay Aggarwal, MD, Columbia, MO in a regression model (p=0.36). There were no complications
Robert L Barrack, MD, Saint Louis, MO related to the new pain management protocol. Pain response
has been postulated to contribute to the development of
arthrofibrosis after primary TKR. A balanced program of multi-
Robert Stephen Burnett, MD FRCSC, Victoria, BC Canada modal analgesia significantly reduces the incidence of arthrofi-
Javad Parvizi, MD, Philadelphia, PA brosis after primary total knee arthroplasty. In this cohort of
Peter F Sharkey, MD, Philadelphia, PA patients pain was probably an important etiologic factor in the
Elie S Ghanem, MD, Philadelphia, PA development of arthrofibrosis.
A prospective study was undertaken to determine whether
prophylactic pre-operative IV antibiotics would affect the results
of cultures obtained intra-operatively. 18 TKAs with a known
infecting organism were enrolled at one institution over 24
PAPER NO. 071 significant PF dysfunction, while 276 knees (86%) and 128
Music Reduces Perceived Pain after TKA: A Blinded, knees (40%) showed significant ant. knee pain and PF dysfunc-
tion preoperatively.Postoperative anterior knee pain and PF
Prospective, Randomized, Placebo Controlled Trial function showed no correlation with the depth, size and loca-
Xavier C Simcock, BS, tion of patellar cartilage lesion (p>0.05). The presence of grade
Richard S Yoon, BS, 4 chondral lesion did not show significant effect on postopera-
Jeffrey A Geller, MD, New York, NY tive pain and function (p=0.076, 0.945). Preoperative PF pain
Peter Chalmers, BS, and dysfunction showed significant effect on postoperative PF
Howard A Kiernan Jr, MD, New York, NY dysfunction(p=0.004 and <0.001, respectively). All of 10 knees
with significant PF pain and dysfunction postop. had significant
William B Macaulay, MD, New York, NY
PF pain and dysfunction preop. With nonselective unresurfacing
Patients undergoing total knee arthroplasty (TKA) often experi- of the patella in current HF TKAs, postop. PF pain and dysfunc-
ence significant pain during the perioperative period. Using a tion were rare.The preop PF pain and function are the important
standardized intra-operative anaesthetic protocol and postoper- parameters to determine whether to resurface the patella in
ative pain management protocol, consented patients were selective resurfacing in primary HF TKA, not the Grade 4 chon-
randomized into either: 1) the interventional Music group dral lesion of the patella.
(noise-reduction headphones, patient choice/classical music) or
the control, Non-Music group (noise-reduction headphones PAPER NO. 073
only). Pain scores, aided by the Wong-Baker and Verbal
Descriptor scales, were assessed via the Visual Analog Scale (VAS)
Is there a role for Aspirin in Venous
at baseline and postoperatively at 3, 6, and 24 hours. A paired Thromboembolism Prophylaxis Following Total
Student’s t-test was utilized to determine statistical significance, Knee Replacement?
which was set at a p < 0.05. Thirty subjects were enrolled. At
Kevin John Bozic, MD, MBA, San Francisco, CA
baseline, there were no statistical differences in mean pain
between the study (2.25 ± 2.99) and the control (3.34 ± 2.67) Andrew Auerbach, MD, MPH,
groups (p = 0.17). Mean pain scores reported the Music group Judy Maselli, BA,
to have significantly less pain at 3 hours (1.39 ± 1.27 vs. 3.87 ± Thomas Parker Vail, MD, San Francisco, CA
3.44, p = 0.01), 6 hours (3.05 ± 2.50 vs. 5.26 ± 3.04, p < 0.05), American College of Chest Physicians (ACCP) guidelines for
and at 24 hours (1.93 ± 1.14 vs. 4.03 ± 2.89, p=0.02). venous thrombo-embolism prophylaxis (VTEP) following total
Intraoperative music provides an inexpensive, non-invasive knee replacement (TKR) favor LMWH, pentasaccharides
method of lowering perceived postoperative pain for patients (Fondaparinux), and warfarin over aspirin. However, recent data
undergoing a TKA. The results of this study offer a glimpse into suggest that ACCP recommended therapies may increase
how an alternative therapy or non-pharmacologic method can bleeding complications following TKR. To determine the risks
reduce postoperative pain. A larger-scale, higher powered trial and benefits of various VTEP strategies, we compared rates of
may demonstrate how music could favourably affect secondary DVT, PE, surgical site bleeding, and mortality in a large national
outcomes such as patient satisfaction, range of motion, and population of patients who received aspirin, warfarin, LMWH,

length of stay. or Fondaparinux for VTEP following TKR. We analyzed admin-
istrative data from over 93,840 patients who underwent TKR at
PAPER NO. 072 one of more than 300 hospitals between October, 2003 and
Important Parameters for Decision Making in September, 2005. Three separate treatment groups were identi-
fied based on the type of chemoprophylaxis used for VTEP.
Selective Resurfacing of the Patella in High-Flex TKA Group 1 included 4,719 patients treated with aspirin, Group 2
Chul Won Ha, MD, Seoul, Korea, Republic of included 51,923 patients treated with adjusted dose warfarin,
Byoung-ki Cho, MD, KangNaGu, irWonDong 50, Seoul and Group 3 included 37,198 patients treated with LMWH or
Korea, Republic of Fondaparinux. We then used multivariable models adjusting for
Kyung Su Lim, MD, Seoul, Korea, Republic of patient comorbidities, hospital and physician characteristics to
Kyung-Joong Kang, MD, Kang NamGu, Ir Won Dong 50 compare outcomes in patients receiving aspirin to those
Korea, Republic of receiving warfarin or LMWH/Fondaparinux for VTEP following
TKR. Patients in the aspirin VTEP group were younger and had
Grade 4 chondral lesion of patella has been considered the crit-
fewer co-morbidities than those receiving ACCP-recommended
ical factor to resurface the patella in selective resurfacing.
therapy. After adjustment, patients in the aspirin group had a
However, there has been few clinical study to support that. This
lower risk of surgical site bleeding (OR=0.61, 95%CI=0.42,
study is to identify the important parameters for decision
0.89), a lower rate of any DVT/PE (OR= 0.65, 95%CI=0.53,
making in selective resurfacing of patella in High-flex(HF) TKA.
0.80), and a lower rate of proximal DVT/PE (OR= 0.56,
We retrospectively analyzed 321 consecutive TKAs with nonse-
95%CI=0.44, 0.71) than patients who received warfarin or
lective unresurfacing of the patella. All cases were performed by
LMWH/Fondaparinux. There were no differences in rates of re-
the senior author and were followed up for 2 years. The depth,
operation for surgical site bleeding or mortality among the treat-
size and location of patellar cartilage lesions were assessed and
ment groups. These data suggest that aspirin may be a safe and
recorded prospectively. Anterior knee pain was assessed by the
effective alternative to ACCP recommended agents for VTE
questionnaires of five grades. PF function was assessed by the
prophylaxis in carefully selected TKR patients. Further study is
questionnaires on squatting, cross-leg sitting, standing from
necessary to define the patient, hospital, and procedural charac-
floor & chair and climbing up & down stairs with 5 grades in
teristics that define this patient group and the care pathways our
each function. We investigated the important parameters that
data represent.
led to poor postop. PF function or significant postop. ant. knee
pain by correlation analysis. Among the 321 knees, 3 knees(1%)
had significant postop. ant. knee pain and 7 knees(2%) showed
449
PAPER NO. 074 venous stasis, chronic warfarin use or bilateral procedures),
included warfarin instead of aspirin and no routine Duplex
◆Rivaroxaban—an Oral, Direct Factor Xa Inhibitor— scans. Prior to discharge, routine Duplex scans performed 2-9
for Thromboprophylaxis after TKA: RECORD 3 days post-op on Low Risk patients were positive for distal DVT
Michael Rud Lassen, MD, Horsholm, Denmark in 2 (0.6%) and proximal DVT in 4 (1.3%) of knees. In addition,
Alexander G Turpie, MD, Hamilton, ON Canada 2 symptomatic DVTs (0.6%) developed at 44 and 51 days post-
Nadia Rosencher, MD, op, after Duplex scans had initially revealed negative findings
Walter Ageno, MD, prior to discharge. At 90-day follow-up, a total of 2 Low Risk
TKAs (0.6%) and 3 High Risk TKAs (2.7%) had been readmitted
Jay R Lieberman, MD, Farmington, CT
for DVT or related complications. At 90-day follow-up, overall
Tiemo-Joerg Bandel, MD, mortality was 0.6% (2/329) with both patients in the High Risk
Frank Misselwitz, MD, group and both were cardiac related deaths. There were no
Lars Carl Borris, MD, Arhus C, Denmark deaths in the Low Risk protocol group. A multimodal approach
RECORD 3 was a phase III study evaluating the oral, direct Factor to DVT prophylaxis using aspirin as the primary mode of
Xa inhibitor rivaroxaban for thromboprophylaxis in patients chemoprophylaxis is successful in preventing DVT related
undergoing total knee arthroplasty (TKA). In this double-blind morbidity and mortality in Low Risk TKA patients. There were
study, 2531 patients were randomized to receive once-daily, oral no DVT related deaths and no deaths in general at 90 days
rivaroxaban 10 mg or subcutaneous enoxaparin 40 mg. follow-up coupled with a low rate of readmission for throm-
Enoxaparin was started before surgery, and rivaroxaban 6-8 hours boembolic events and no readmissions or reoperations from
after surgery; both were continued for 10-14 days. The primary bleeding in this group.
efficacy outcome comprised DVT diagnosed by mandatory bilat-
eral venography + symptomatic VTE + all-cause mortality. The PAPER NO. 091
secondary efficacy outcomes included major VTE (proximal DVT Effect of Increased Surgical Volume on Total Knee
+ PE + VTE-related death). The primary safety outcome was major
bleeding. 1220 patients received rivaroxaban and 1239 received Arthroplasty Complications
enoxaparin. The primary efficacy outcome occurred in 9.6% William C Schroer, MD, Saint Louis, MO
(79/824 patients) receiving rivaroxaban and 18.9% (166/878 George Calvert, MD, Bridgeton, MO
patients) receiving enoxaparin (RRR 49%; p<0.001). Major VTE Paul Diesfeld, PA-C, Saint Louis, MO
occurred in 1.0% and 2.6%, respectively (RRR 62%; p=0.01); no Angela LeMarr, RN, Saint Louis, MO
deaths or PEs occurred in the rivaroxaban group, compared with Mary E Reedy, RN, Saint Louis, MO
two and four in the enoxaparin group, respectively, during the
The relationship between surgical volume and patient outcomes
treatment period. Proximal DVT occurred in 1.1% (9/824) of
has been evaluated utilizing large databases comparing
patients receiving rivaroxaban, compared with 2.3% (20/878)
numerous surgeons and hospitals based on relative surgical
receiving enoxaparin. Symptomatic VTE occurred in 1.0%
volume. In contrast, this study determined the affect of increased
(8/824) and 2.7% (24/878) of patients, respectively. Major
surgical volume on the incidence of knee complications within
bleeding occurred in 0.6% and 0.5% of the rivaroxaban and

a single surgeon’s primary TKA practice. Data was collected
enoxaparin groups, respectively; and any bleeding in 4.9% and
prospectively on 600 primary TKA performed by a single
4.8%. Rivaroxaban was significantly more effective than enoxa-
surgeon. Surgical volume was determined per six month inter-
parin for the prevention of VTE after TKA, with similar safety.
vals. Major complications were defined as any knee complica-
Large-scale, phase III studies are currently investigating rivarox-
tion requiring reoperation. Minor complications were wound
aban for extended use after orthopaedic surgery and other long-
concerns that required increased surveillance or oral antibiotics.
term indications for anticoagulation.
Multivariate stepwise regression analysis determined variables
that were statistically independent. Adjusted odds ratio and
PAPER NO. 075
corresponding 95% confidence intervals (CI) determined factors
Low Morbidity Low Cost DVT Prophylaxis in Low affecting complication rates. Twelve (2.0%) major reoperations
Risk Patients Undergoing TKA occurred: six requiring revision surgery, three each for infection
Lucian Craig Warth, BS, Iowa City, IA (0.5%) and isolated tibial loosening (0.5%). Forty (6.7%)
minor knee complications occurred; mean follow-up 36 months
(24-55). Surgical volume increased from 57 to 150 procedures
Jamal Hoballah, MD, per six months through the course of this study. Increased
Steve S Liu, MD, Iowa City, IA surgical volume was associated with lower rates of both major
Chris Wells, BS, and minor complications, adjusted odds ratio 0.62 (CI: 0.40,
Optimal DVT prophylaxis following TKA is controversial. This 0.96) and 0.56 (CI: 0.43, 0.73) respectively. All complications
study addresses the question: ‘What is the efficacy of a DVT and were significantly decreased when the surgeon was performing
PE prophylaxis protocol following total knee replacement in 112 ± 44 TKA compared with 85 ± 49 TKA per six month
which Low Risk patients had only aspirin and mechanical interval. Overall reoperation rate (2.0%), infection rate (0.5%),
devices for prophylaxis, unless a pre-discharge Doppler study and early implant loosening (0.5%) were similar to published
was positive for DVT?’ 427 consecutive primary TKAs were large TKA series. Major and minor complication rates decreased
performed on 329 patients. Based on pre-op assessment, significantly as surgical volume increased. For each additional 50
patients were assigned to one of two post-op prophylactic proto- procedures performed within a 6-month interval, major compli-
cols (High v. Low Risk). DVT prophylaxis for Low Risk patients cations were reduced by 38% (p=0.03) and minor complica-
(73.1%) consisted of early ambulation (post-op day one), Teds tions were reduced by 44% (p<0.0001). This prospective study
and foot pumps, aspirin (325mg po bid), and routine pre- demonstrated that an increase in a surgeon’s primary TKA
discharge bilateral Duplex studies. DVT prophylaxis for high risk surgical volume significantly decreased the incidence of both
patients (26.0%), (including patients with history of DVT, major and minor knee complications.
PAPER NO. 092 and 64% showed some burnishing. Compared across capture
HXLPE Generated Less, Smaller and Rounder mechanisms, inserts with a posterior bevel and small anterior
locking tabs showed a significant decrease in burnishing
Particles Than Conventional PE - in Vivo - compared to all the other designs (p=0.0038). Pitting, however
Kentarou Iwakiri, MD, Osaka, Japan was not significantly affected by capture mechanism (p>0.05).
Yukihide Minoda, MD, Osaka, Japan No correlations between patient height, weight or in situ time
Akio Kobayashi, MD, Osaka, Japan and any of the wear patterns were observed (p>0.05). Compared
Hiroyoshi Iwaki, MD, Osaka, Japan with older designs studied previously, newer generation designs
Fumiaki Inori, MD, Osaka, Japan showed a slight reduction in pitting (86% vs. 90%) and moder-
ately decreased burnishing (64% vs. 77%). Capture mechanisms
Hirotsugu Ohashi, MD, Osaka, Japan
incorporating smaller anterior locking tabs instead of an addi-
Ryo Sugama, MD, Osaka, Japan tional anterior bevel significantly reduced burnishing, likely by
Yoshinori Kadoya, MD, Sakai, Japan reducing the clearance required by larger anterior locking
Kunio Takaoka, MD, Osaka, Japan features. Our results indicate that while newer designs of
Recently, highly cross-linked polyethylene (HXLPE) has been modular tibial components have slightly reduced the severity of
highlighted in THAs, which is thought to reduce wear. HXLPE damage, backside wear remains an issue in TKA.
has been proved to reduce wear in hip simulator study and
widely used as materials for THAs. However, the benefit of using PAPER NO. 094
HXLPE in TKAs is controversial. In the present study, we Diagnostic Challenges of Periprosthetic Infection:
extracted polyethylene particles from joint fluid of the well-func-
tioning TKA patients and analyzed them with comparing
What Role Do Simple Serological Tests Play?
conventional polyethylene particles. The well-functioning TKAs Mathew Austin, MD,
(Nexgen CR, Zimmer) with four HXLPE and three conventional Elie S Ghanem, MD, Philadelphia, PA
PE were analyzed 1 year after TKA. All patients were men, with a James J Purtill, MD, Philadelphia, PA
mean age of 63.8 and 59.0 at the time of TKA, respectively. We Adam Lindsay, MD,
aspirated joint fluid in the operation room with the informed Javad Parvizi, MD, Philadelphia, PA
consent and isolated polyethylene particles using a tissue diges- The differential diagnosis of pain after total knee arthroplasty
tion and image analysis developed by Cambell modified by us. (TKA) should always include periprosthetic infection (PPI). The
The average number of particles was 8.9x104 in HXLPE group current diagnostic tools vary in sensitivity, specificity, and predic-
and 1.5x106 in control group (particles/ml). Equivalent circle tive value. Currently there is no test with an absolute accuracy to
diameter (ECD) was 0.64 ± 0.14µm and 1.23 ± 0.35µm (mean aid the diagnosis of PPI. Furthermore, cost effectiveness of inves-
± S.D.) and roundness was 1.11 ± 0.10 and 1.96 ± 0.28, respec- tigations has become an important issue in recent years as
tively. The characterization of HXLPE showed less, smaller and increased expenses can place an unnecessary heavy burden on
rounder than conventional PE. This is the first report for the the medical system. We retrospectively evaluated 296 patients
particle analysis of HXLPE in well-functioning TKA. Compared who underwent revision TKA at our institution during 2000-

HXLPE with conventional PE particles isolated from well-func- 2005 and had preoperative erythrocyte sedimentation rate (ESR)
tioning TKA in the same design, HXLPE generated less, a little and C-reactive protein (CRP) performed. The criteria used for
smaller, and much rounder particles than conventional PE. diagnosing infection were a positive intraoperative culture on
solid media, presence of an abscess or sinus tract that commu-
PAPER NO. 093
nicates with the joint, positive preoperative aspiration culture,
Have We Solved the Problem of Backside Wear in and/or elevated fluid cell count and neutrophil differential of
TKA? the aspirated fluid. Noninfected patients with confounding
Mufaddal M Gomberawalla, BBA, Houston, TX factors that can elevate ESR and CRP including collagen vascular
disease, inflammatory arthropathy, malignancy, and urinary
Michael A Conditt, PhD, Houston, TX
tract infection were excluded. The sensitivity, specificity, and
Kenneth B Mathis, MD, Houston, TX predictive values of ESR and CRP were determined.
Philip C Noble, PhD, Houston, TX Combinations were performed in parallel that necessitate both
In the first generations of modular tibial components, backside tests to be negative to rule out infection. The cost of each sero-
wear made a significant contribution to the particle burden logical test was compared to that of other commonly used
released within the joint. This led to changes in design and mate- screening modalities. 116 patients (39%) were classified as
rials to reduce micromotion and particle generation. In this infected and 180 patients (61%) were considered non-infected.
retrieval study, we evaluate the efficacy of newer generations of The mean ESR and CRP of the infected patients were 85mm/hr
knee implants in eliminating backside wear as a significant issue and 110 mg/L respectively. The mean ESR and CRP of the non-
in TKR. One hundred and fifty-one polyethylene tibial inserts of infected patients were 22mm/hr and 7mg/L, respectively. The
5 modern designs were examined: Duracon (n=29), Scorpio sensitivity, specificity, positive predictive value, and negative
(n=14), NexGen (n=81), PFC (n=19), and the NK-II (n=8). All predictive value for the ESR were: 91%, 72%, 68%, and 93%.
components were retrieved at revision TKR after implantation The sensitivity, specificity, positive predictive value, and negative
times ranging from 6 to 80 months. Pitting and burnishing were predictive value for the CRP were: 94%, 74%, 70%, and 95%.
graded on each insert. Designs were also stratified by capture The sensitivity and negative predictive value for the combined
mechanism into groups composed of: 1) large anterior and studies were 96% and 95% respectively. However, five infected
posterior bevels; 2) posterior bevels with and an anterior locking patients (4%) had a normal ESR and CRP. Infection was
clip and a single tray recess for the tibial insert; 3) same as in #2 suspected in all five patients, and an organism was cultured on
with separate medial and lateral tray recesses; and 4) posterior solid media in 4 of the 5 cases. ESR and CRP were the least costly
bevels with 3 small anterior locking tabs (no anterior bevels). of all the preoperative tests including radionuclide imaging and
Across all implants designs, 86% showed some degree of pitting, joint fluid analysis. ESR and CRP are important preoperative
451
tests in diagnosis of PPI and their ability to clench the diagnosis intravenous administration of FDG, PET images of both knees
in majority of cases should not be underestimated. When were acquired and interpreted by experienced nuclear medicine
combined these simple serological tests have improved sensi- physicians. PET images demonstrating increased FDG activity at
tivity and negative predictive value to rule out infection. the bone-prosthesis interface were considered infected. Final
diagnosis was made on the basis of surgical findings,
PAPER NO. 095 histopathology, and clinical follow-up. FDG-PET correctly diag-
The Changing Organism Profile in Periprosthetic nosed 19 of the 22 infected cases for a calculated sensitivity of
86.4% (19/22). FDG-PET correctly predicted the absence of
Infection infection in 38 of 46 aseptic knee prostheses for a calculated
Javad Parvizi, MD, Philadelphia, PA specificity of 82.6% (38/46). The negative and positive predic-
Elie S Ghanem, MD, Philadelphia, PA tive values for FDG-PET imaging in this setting were 92.7%
Jill Steinbrecher, BS, (38/41) and 70.4% (19/27), respectively. The overall accuracy of
Noreen J Hickok, Philadelphia, PA FDG-PET imaging was 83.8% (57/68). FDG-PET was indetermi-
Robert L Barrack, MD, Saint Louis, MO nate in three cases which were not included in this analysis.
Periprosthetic infection (PPI) continues to compromise the These results demonstrate that FDG-PET is a useful diagnostic
outcome of otherwise successful joint replacement. Current tool for the evaluation of possible infection associated with knee
strategy for treatment of this dreadful problem is based on arthroplasty. Considering the large number of subjects who
antibiotic sensitivity of the infecting organism. The objective of undergo total knee arthroplasty and the sizable fraction who
this study was to evaluate the profile of organisms that have develop complications following surgery, the impact of FDG-
caused PPI over the last few years. All 351 patients with PPI who PET imaging could be substantial. Examination of a larger
received surgical treatment at our institution during 1999 to number of patients with painful knee prostheses will further
2005 were included. The surgical treatment involved irrigation clarify the merit of this powerful technique in this clinical
and debridement in 97 cases (28%), one-stage exchange arthro- setting.
plasty in 31 cases (9%) and two-stage exchange arthroplasty in
PAPER NO. 097
217 cases (62%). The remaining 5 cases (1%) included patients
who underwent revision arthroplasty for mechanical reasons Patient and Surgical Factors Associated with
but had multiple positive intraoperative cultures that necessi- Infection After Total Knee Arthroplasty
tated antibiotic treatment. Patients were included only once in
William P Barrett, MD, Renton, WA
the analysis unless an organism was grown during a second revi-
Devon D Goetz, MD, West Des Moines, IA
sion procedure that was different from the one cultured during
the initial surgery. The burden of PPI at our institution has Clifford K Boese, MD, Council Bluffs, IA
increased over the last few years. Gram positive cocci cause 92% Michael L Swank, MD, Cincinnati, OH
of PPI, while the incidence of infection with gram negative J Bohannon Mason, MD, Charlotte, NC
organisms (8%) was relatively low. A steady increase in the inci- Joe Nelson Jarrett Jr, MD, Myrtle Beach, SC
dence of infections caused by methicillin resistant staphylo- Jeffrey A Murphy, MS, Warsaw, IN
coccus was noted with the incidence increasing from 13% in The purpose of this study was to investigate factors associated
1999 to over twice that at 30% in 2005. Our data indicates that with infection following total knee arthroplasty. A series of 5846
a change in the profile of infecting organisms resulting in PPI prostheses were implanted in 4632 patients (2939 females and
has occurred over the last few years, at least at our institution. 1693 males) between 1989 and 2006 at seven centers. The
The increase in the number of infections caused by methicillin average age of the patients at the time of surgery was 67.8 years
resistant organisms could potentially compromise the success of (range 28’100 years) and 95.6% had a diagnosis of
current treatment for this problem. Although liberal use of osteoarthritis. Average follow-up was 2.2 years (range 3 months
antibiotic is likely to be the major reason, future studies are to 15 years). Cox proportional hazards survivorship analysis was
needed to assess the reason behind the worrisome rise in the used to identify which of the following factors were significantly
incidence of methicillin resistant periprosthetic infections. associated with post-operative infection: gender, center, diag-
nosis, age at surgery, body mass index (BMI), skin to skin surgery
PAPER NO. 096 time, and a gender by BMI interaction term. Backward elimina-
Evaluation of FDG-PET Imaging for Differentiating tion model reduction was utilized with a 1% p-value cut-off.
Septic From Aseptic Painful Knee Prosthesis There were 42 (0.7%) infections. The reduced Cox model indi-
cated 2 significant variables: gender and BMI. Males were 4.6
Javad Parvizi, MD, Philadelphia, PA times as likely as females to experience infection. For each 1-unit
Timothy Chryssikos, BA, Philadelphia, PA increase in BMI (kilograms/meters2), infection hazard increased
Harry Zhuang, MD, Philadelphia, PA by 8%. The literature is replete with references of higher infec-
Andrew Newberg, MD, tion rates among obese patients. Namba found a significantly
Abass Alavi, MD, Philadelphia, PA higher infection (p = 0.01) rate among patients with BMI > 35
Elie S Ghanem, MD, Philadelphia, PA (1.1% infected) compared to BMI < 35 (0.3% infected). Using
The accurate diagnosis of infection in the painful knee prosthesis the same 35 BMI cut-off, our study reports similar results: BMI >
poses a significant challenge to the clinician and imaging 35 (1.1% infected), BMI < 35 (0.6% infected), p = 0.04.
specialist alike. In recent years, FDG-PET imaging has shown However, the current study had triple the sample size. Gender
great promise in the evaluation of occult infection at various and BMI are important factors associated with infection
anatomic sites. The purpose of this investigation was to deter- following total knee arthroplasty.
mine the accuracy of FDG-PET imaging in diagnosing peripros-
thetic infection associated with total knee arthroplasty. Sixty
eight painful knee prostheses were referred for further evaluation
with FDG-PET imaging. Approximately 60 minutes after the
PAPER NO. 098 operations for: 3 - wound complications, 1 - manipulation, 2 -

Periprosthetic Infection: Does Irrigation and revision for aseptic loosening, 2 - definitive treatment with resec-
tion arthroplasty, 2 - above the knee amputation. Recurrent infec-
Debridement Work? tion occurred in 5 patients (26%) at a mean of 1.1 years.
Elie S Ghanem, MD, Philadelphia, PA According to Kaplan Meier analysis, 5-year implant survival is
Mark Seeley, BS, 82.5% (SD 9.25%). Three controls required manipulation
Joshi Ashish, MD, MPH, (16%), but none developed infection or required revision (mean
Fereidoon M Jaberi, MD, Philadelphia, PA follow-up 8.3 years). Previously infected knees were 4.1 times
Matthew Austin, MD, Philadelphia, PA more likely to require additional procedures than knees with no
previous infection (p=0.02, Cox proportional hazard regression).
James J Purtill, MD, Philadelphia, PA
Despite the use of antibiotic cement, and, in some, two-stage
Javad Parvizi, MD, Philadelphia, PA arthroplasty, there are high rates of recurrent infection (26%) and
Irrigation and debridement of an infected total joint arthroplasty re-operation (53%) in this patient population.
with retention of mechanically stable components is often
performed for acute cases of periprosthetic infection (PPI). PAPER NO. 100
However, the success of such a procedure to fully eradicate infec-
tion remains unknown. The objective of this study was to eluci-
Total Knee Arthroplasty Dislocation: Incidence,
date the efficacy of debridement in both infected THA and TKA Etiology, and Management
and attempt to identify risk factors responsible for failure. During Benoit P Lebel, MD, Rochester, MN
the years 2000-2005, 54 TKA and 54 THA underwent irrigation David G Lewallen, MD, Rochester, MN
and debridement for PPI. All patients were followed up prospec- Dislocation following total knee arthroplasty (TKA) is an
tively for at least two years. Detailed data including demographics, unusual but dramatic post-operative complication. Previously
comorbidities, surgical history, and medication intake was reports involve only a few isolated cases. This study retrospec-
collected. Intraoperative data, organism profile, and complica- tively analyzed the incidence, associated factors and treatment of
tions were also documented. Failure was defined as patient dislocation following TKA. All cases of TKA dislocation since
requiring reoperation for control of infection. Of the 108 patients, 1970, when the first TKA was done at our institution, were iden-
25% required repeat irrigation and debridement for postoperative tified from our institutional total joint registry. The medical
drainage, hematoma formation, or systemic symptoms. Two stage history and X-ray were reviewed on all cases with this diagnosis.
resection arthroplasty was inevitably performed in 54 patients The 58 cases identified were reviewed with particular attention to
(50%) of the entire cohort. The failure rates of THA (61%) and associated factors that might contribute to this problem. The
TKA (52%) individually were similar (p=0.33). Statistical analysis overall incidence of TKA dislocation was 1.87 per 1.000 arthro-
revealed that an elevated ASA which is an indicator of the general plasties, with a rate of 0.93 and 6.61 for primary and revision TKA
health of the patient was as significant predictor of failure respectively. The dislocations occurred at the mean of 29.5
(p=0.04). Steroid use was significantly more prevalent in patients months (range 0 to 193). Original prosthesis designs used were
who failed irrigaiton and debridement (p=0.03). Although the posterior-stabilized (53%), cruciate retaining (31%) and rotating

concept of conservative management of PPI with debridement hinge (16%). Dislocation was associated with a history of liga-
and retention of components is an attractive alternative to resec- ment laxity in 45.6% of patients, extensor mechanism deficiency
tion arthroplasty, we have found that 50% of patients undergoing in 35.5% and TKA infection in 25.9%. The mean follow-up post
this procedure will inevitably require two-stage arthroplasty, and dislocation was 4.8 years (range 0.1 to 20.1). Non operative treat-
an additionl 6% will require multiple additional debridements to ment was used for 29 knees and resulted in 25 knees experi-
control infection. Therefore, because of the high failure of this encing further symptomatic instability. The remaining knees were
strategy I&D should be reserved for a select group of patients. treated by surgery. Of those treated by revision TKA (N=27) only
3 complained of symptomatic instability (P<0.001). TKA dislo-
PAPER NO. 099 cation is a major complication. Conservative treatment is ineffec-
Primary Total Knee Arthroplasty following Infected tive. Revision TKA reliably yields a stable knee in 89% of cases so
Tibial Plateau Fracture treated. These results emphasize the importance of proper
surgical technique, careful soft tissue balancing, and adequate
Annalise N Larson, MD, Rochester, MN
constraint in the prevention and treatment of this problem.
Joseph Ralph Cass, MD, Rochester, MN
Total knee arthroplasty performed following tibial plateau frac- PAPER NO. 101
ture has a known high rate of complications. This is the first
report addressing the outcomes of total knee arthroplasty (TKA)
Prevalence of Fat Embolism After TKA Performed
performed after infected tibial plateau fracture. Between 1971 and With or Without Computer Assisted Navigation
2005, 19 primary TKAs were performed following infected tibial Young-Hoo Kim, MD, Seoul, Korea, Republic of
plateau fractures. Patients were matched for age, gender, and Jun Shik Kim, MD, Seoul, Jongno-Gu Korea, Republic of
arthroplasty date to 19 controls s/p TKA for tibial plateau fracture Ki-Sook Hong, MD,
with no previous history of infection. Clinical outcomes and Youn-Jin Kim, MD,
Knee Society (KS) scores were assessed retrospectively. Fifteen
Jong-Hak Kim, MD,
patients had operative treatment of the fracture; four, nonopera-
tive. All had deep infection. Time from fracture to arthroplasty We determined whether TKA performed with or without
was a mean of 6.5 years. Mean age at arthroplasty was 49.2 years. computer-assisted navigation without breaching femoral canal
Five patients had a two-stage arthroplasty. Eleven received antibi- resulted in a different prevalence of fat and/or bone marrow cell
otic-impregnated cement with the arthroplasty. Mean clinical embolization. We enrolled 160 patients (210 knees) undergoing
follow-up was 5.8 years. Following surgery, KS scores significantly TKA performed with navigation and 160 patients (210 knees)
improved from 44.8 to 61.1 for pain (p=0.0012) and from 38.8 undergoing TKA performed without navigation. One hundred
to 63.5 for function (<0.0001). Ten patients (53%) required re- and sixty patients had bilateral simultaneous TKA at the same
453
surgical setting. Arterial and right atrial blood samples were procedures to revisions of TKA performed following a standard
obtained before insertion of a femoral alignment rod or cutting surgical approach. A consecutive series of revision TKA
the distal femur (baseline); at 1, 3, 5 and 10 mintutes after inser- performed at three centers by five surgeons over a three year time
tion of an alignment rod or cutting the distal femur and before period was reviewed. Revisions performed for infection and re-
insertion of a tibial component broach (baseline) and at 1, 3, 5, revisions were excluded. Review of clinical and radiographic
and 10 minutes after insertion of tibial component broach; and data determined incision type, gender, age, time to revision, and
at 24 and 48 knees after the operation. We determined the pres- primary diagnosis at time of revision. 237 first time revisions
ence of fat (oil red O fat stain) and bone marrow cell (Wright- were performed of which 44 (18.4%) had been MIS TKA and
Giemsa stain). The prevalence of fat embolization was 44% 193 (81.8%) had been standard TKA. Patients with MIS were
(159 of 360 knees) in the TKA group managed with navigation younger (62.1 years vs. 66.2 years, p=.02). There was a trend
and 45% (163 of 360 knees) in the TKA group without naviga- towards a higher percentage of females in the MIS group (75%
tion (P=0.2674). The presence of bone marrow cell emboliza- vs. 63%) although this difference was not significant (p=0.12).
tion was 10% (36 of 360 knees) in the TKA group performed Most striking was the difference in time to revision which was
with navigation and 11% (41 of 360 knees) in the TKA group significantly shorter for the MIS group (14.8 months vs 80
performed without navigation (P=0.259). The prevalence of fat months, p<.001). The MIS group was much more likely to fail at
and/or bone marrow cell embolization was not significantly <12 months (37% vs. 5%, p<.001) and at <24 months (81% vs.
different between the patients who underwent TKA performed 22%, p<.001). MIS TKA accounted for a substantial percentage
with or without navigation. of revision TKA in recent years at these centers. The high preva-
lence of MIS failures occurring within 24 months is disturbing
PAPER NO. 102 and warrants further investigation.
Improved Results of Manipulation After TKR With
PAPER NO. 104
Intra-Articular Steroid Injection
Lower Cementless Total Knee Arthroplasty (TKA)
Amar S Ranawat, MD, New York, NY
Vineet Sharma, MD, Flushing, NY Survival Rate Among 19,966 Primary TKA’s
Chitranjan S Ranawat, MD, New York, NY Mark W Zawadsky, MD, San Francisco, CA
Joanne Weiskopf, PA, New York, NY Debra O Dee, El Cajon, CA
Stiffness after TKR requiring a manipulation has an incidence of Jason Daniel Provus, MD, San Francisco, CA
1.7 to 11 %. The purpose of this study was to report the inci- Liz Paxton, MA, San Diego, CA
dence of stiffness with 2 different pain management protocols Robert S Namba, MD, Corona Del Mar, CA
and with various implant designs. Also we report the results of Donald C Fithian, MD, El Cajon, CA
manipulation with or without an intra-articular steroid injection Cementless total knee arthroplasty has shown mixed results in
A total of 286 TKR’s done between January, 2002 and December, the literature with several studies demonstrating an increased
2003 formed the 1st group of patients. No intra-articular injec- revision rate for cementless fixation, while others have shown
tion was given at the time of TKR for pain control and all equivalent results. Cementless implants routinely have higher
patients received PCA. The 2nd group consisted of 292 TKR’s costs. This study compared the survival rates of cementless and
done between January, 2004 and March, 2006. These patients cemented total knee arthroplasty after 5 years of data collection
had a peri-articular steroid injection at surgery. No patient in a large community based total joint registry. A prospective
received PCA for pain control. All manipulations in the 2nd study using a total joint registry of 19,966 primary total knee
group received a repeat steroid injection at the time of manipu- arthroplasties was conducted to assess survival rates of both
lation. The incidence of stiffness requiring manipulation in cemented and cementless TKA’s (17,934 and 2,032 respectively).
knees without and with the steroid injection was 2.44 and Chi-square and Mann Whitney tests were used to compare
2.05% respectively (p= 0.3). Initial ROM post-manipulation was patient demographics. TKA survival was assessed using Kaplan
similar in both groups. Final ROM was significantly greater in Meier survival curves with the endpoint of revision. Multiple
patients with a steroid injection. The difference was due to the variables were examined including implant type. The Registry
fact that patients who had an injection lost very little motion has standing IRB approval. Analysis showed that cementless fixa-
from the value achieved at the time of manipulation. We tion was used at a higher rate in patients under age 55 (13% vs.
conclude that injection of a peri-articular cocktail did not signif- 8%) (p<0.001) and in male patients (44% vs. 35%) (p<0.001).
icantly impact the overall incidence of manipulation. The injec- Overall, cementless TKA had a lower cumulative survival rate
tion at the time of manipulation, however, helped patients than cemented TKA (95% vs. 99%) (p=0.001). With age stratifi-
maintain the ROM achieved at the time of manipulation. cation and controlling for gender, lower survival rates for
cementless TKA were identified in patients under age 55 (90%
PAPER NO. 103 vs. 94%) (p=0.028), patients under age 55 with osteoarthritis
Minimal Incision Surgery as a Risk Factor for Early (87% vs. 93%) (p=0.011), female patients (97% vs. 98%)
Failure of Total Knee Arthroplasty (p=0.047), and females with osteoarthritis (96% vs. 98%)
(p=0.025). Analysis of our total joint registry data shows that the
Robert L Barrack, MD, Saint Louis, MO use of cementless TKA has a statistically lower early survival rate
C Lowry Barnes, MD, Little Rock, AR at 5 years when compared to cemented fixation.
Derek W Miller, DO, Joplin, MO
Robert Stephen Burnett, MD FRCSC, Victoria, BC Canada
William J Maloney MD, Stanford, CA
A study was undertaken to determine the current prevalence of
revisions of total knee arthroplasty (TKA) following minimal
incision surgery (MIS) and to compare revisions of MIS TKA

Survivorship of UKA Revisions in a Community Three-Dimensional Bone Creation and
Joint Registry Landmarking Using Two Still X-Rays
Thomas E Dudley, MD, Alexandria, MN Mohamed Mahfouz, PhD, Knoxville, TN
Terence J Gioe, MD, Apple Valley, MN Abdel Fatah Emam, BSc, Knoxville, TN
Penny Sinner, MPH, Hatem E Dakhakhn, MS,
Susan Clay Mehle, BS, Saint Paul, MN Ramon Tadross, MS,
Kathleen Killeen, OT, Saint Paul, MN Richard D Komistek, PhD, Knoxville, TN
When unicompartmental knee arthroplasties (UKA) fail, revi- The objective of this study was to accurately re-create three-
sion to total knee arthroplasty is generally recommended. dimensional bone models from two still two-dimensional x-rays
Perceptions of the difficulty and outcome of UKA revision and define pertinent landmarks and axes throughout the lower
(UKAR) vary. The purpose of this study was to analyze the extremity. Initially, a statistical atlas was created for the femoral
survival of UKAR compared to total knee arthroplasty revision and tibial bones. A calibration target was attached to the
(TKAR) in a community total joint registry. We hypothesized subject’s femur and tibia for the algorithm to capture the camera
that UKAR would have better survival, a lower infection rate, and properties. Two still x-rays are then taken (any two planes) of the
lower costs than TKAR. 180 knee arthroplasty revisions (68 subject and scanned into the system. Using the statistical bone
UKAR/112 TKAR), defined as a minimum of tibial or femoral atlas, average shape of the bone and various modes of variation
component revision, were identified from a community joint are captured by principle component analysis (PCA). The opti-
registry population of 7587 knee implants performed between mization steps allow the reconstruction algorithm to find the
1991 and 2005. Variables analyzed for this population included change shape parameters and orientation of the bone in order to
indication for revision, components used, and implant/hospital reconstruct the bone with high accuracy. Pertinent landmarks
costs. Univariate analyses were done using Pearson’s chi-square are located by the algorithm and rigidly defined on each bone
for categorical variables and Student’s t-test for continuous vari- which in turn is used by the automated analysis to accurately
ables. Cumulative revision rates were calculated using the reconstruct the posterior-condylar line, trans-epicondylar axis,
Kaplan-Meier method and the log-rank test was used to compare mechanical axis, varus/valgus alignment and cutting planes. An
different groups. 5.9 % (4/68) of the UKAR were revised for a error analysis was conducted using fresh cadavers. These
second time and 6.3% (7/112) of the TKAR were re-revised. cadavers were CT scanned to recover the ground-truth three-
TKAR was predictably more complex and resulted in greater dimensional bone models. These were then compared to the
bone loss than UKAR. 39% (44/112) of TKAR surgeries required model generated from the process described above. Matching
more than one femoral or tibial metal augment compared to 0% the CT scanned bones with the bones recovered using our
of the UKAR patients (p < .001). Similarly, 39% (44/112) of the system revealed an accuracy of 98%. This is the first system
TKAR surgeries had two stemmed components placed compared developed which accurately recovers three-dimensional bones
to 1% (1/68) of the UKAR surgeries (p <.001). The mean liner and associated, pertinent landmarks for live subjects using two
thickness for the tibial insert was also significantly greater for the still x-ray images and can be used with high accuracy during clin-

TKAR group (15.5mm, range 8-30mm) than for the UKAR ical visits and surgery.
group (12.8mm, range 8-25mm) (p<.001). 57% (39/68) of
UKA revisions required no form of augmentation and were PAPER NO. 197
revised as a ‘primary’ TKA. UKAR did not demonstrate a lower Functional Flexion Axis of the Knee as a
infection rate, though there were significantly more TKARs
performed for the indication of infection (13% vs. 2%, p <.001),
Registration Tool for Femoral Component
There were significantly more TKAR than UKAR patients (42% Placement in TKA
vs. 12%, p < .001) with an implant cost e $5200 and more TKAR William Michael Mihalko, MD, PhD, Charlottesville, VA
patients (48% vs. 25%, p= .002) with hospital costs e $33,000. Matthew J Phillips, MD, Buffalo, NY
There was no significant difference in survival between the two David A McQueen, MD, Wichita, KS
groups. The UKAR group had a CRR of 9.7% (95% CI = 0.3% -
Joel M Bach, PhD, Aurora, CO
19.1%) and the TKAR group had a CRR of 26.9% (95% CI =
5.9% - 47.9%). Although UKAR has demonstrably lower cost
Michael M Nogler, MD, Oberperfuss, Austria
and less bone loss than TKAR, we were unable to demonstrate Kenneth A Krackow, MD, Buffalo, NY
either improved survival or a lower infection rate for UKAR vs. The epicondylar axis (EA) and the AP axis have now been
TKAR. Possible reasons for the similar survival curves include a utilized for over 15 years as a major landmark for femoral
lower activity profile for the TKAR patients, or for revision component rotation during total knee arthroplasty. The EA
patients in general, or the loss of complex re-revisions however can be difficult to assess at times given the amount of
performed outside the registry capture. soft tissue overlying the bony landmarks or exposure limitation
with newer MIS techniques. Both of these landmarks can be
utilized with CAS techniques but are reliant upon surgeon input
and therefore may have decreased reliability. 35 cadaveric speci-
mens were utilized for this study. Femoral and tibial trackers
(Stryker Navigation, Kalamazoo, MI) were placed in a percuta-
neous fashion. A medial parapatellar approach was made to
each knee and the standard registration process performed. The
intact knee was flexed and extended and the functional flexion
axis (FFA) calculated. The protocol involved measuring the knee
kinematics with a 111N traction force applied to the lower
extremity by one of six surgeons using a calibrated scale. Each
455
cadaver underwent a CT scan with fiducial markers and the PAPER NO. 199
epicondylar axis digitized and used as the ground truth for
comparison of the navigation techniques. The CT documented
◆In Vivo Knee Forces During Recreational
axis along with the EA and AP axis were compared using the Activities After Total Knee Arthroplasty
calculated functional axis of the knee as measured using naviga- Clifford W Colwell Jr, MD, La Jolla, CA
tion techniques. The robustness of the FFA (0.89+2.42 degrees) Darryl D D’Lima, MD, La Jolla, CA
was not different when compared to the CT scan registered Shantanu Patil, MS, La Jolla, CA
epicondylar axis (0+1.68 degrees). The surgeon recorded AP Nick Steklov, BS, La Jolla, CA
(1.96+3.97 degrees) and epicondylar axis (1.12+3.42 degrees)
Peter C Chen, PhD, La Jolla, CA
were not significantly different but were when compared to the
Total knee arthroplasty (TKA) provides pain-free function for
FFA (p<0.05). The FFA for these varus cadaveric knees was found
patients with end-stage arthritis. However, return to recreational
to represent a more precise registration algorithm than the
and athletic activities is often restricted based on the potential
epicondylar or AP axis. More investigations must be performed
for long-term wear and damage to the prosthetic components.
to make sure this representation holds true for higher deformity
Advice regarding safe and unsafe activities is typically based on
cases as well as for valgus deformed knees but may serve as a
the individual surgeon’s subjective bias. We measured knee
promising new technique for surgeons to utilize with a higher
forces in vivo to develop a more scientific rationale for advice on
level of accuracy.
post-TKA activities Four patients underwent TKA with tibial
PAPER NO. 198 trays that were instrumented to measure tibial forces. Tibial
forces were measured at 1-year postoperatively for the following
Lower Extremity Alignment Following TKR with activities: treadmill walking, biking, jogging, golf swing, and
Intramedullary Instrumentation: A Prospective tennis. Walking on level ground generated mean peak force of
Analysis 2.6±0.4 xBW (times body weight), while treadmill walking
generated significantly lower forces 2.05±0.3 xBW. Biking at
Carl T Talmo, MD, Waltham, MA several intensities within patient tolerance and pedaling rates of
Jason Edward Lang, MD, Winston-Salem, NC up to 90 rpm generated mean peak forces 1.3±0.7 xBW. Jogging
David Richmond Whiddon, MD, Suffolk, VA generated mean peak forces of 4.3±0.8 xBW. Golf swing gener-
James V Bono, MD, Boston, MA ated mean peak forces of 4.5±0.6 xBW on the forward knee (left
Alignment after total knee replacement is a significant factor in knee in right-handed golfers) and 3.2±0.4 xBW in the opposite
patient satisfaction and the long-term survival of implants. The knee. Playing tennis produced mean peak forces of 3.8±0.3,
best operative technique for achieving appropriate postoperative 3.6±0.3, and 3.1±.4 xBW while serving, forehand stroke, and
alignment remains controversial with proponents of backhand stroke, respectively. Treadmill walking and biking
extramedullary, intramedullary and computer-assisted tech- appeared to be the safest activities especially for long-duration
niques. 192 consecutive patients undergoing total knee replace- exercise. Surprisingly the golf swing also generated high forces in
ment using the same technique were prospectively evaluated the forward knee. As expected, tennis, and jogging generated
with preoperative and postoperative (6 week) full-length radi- high forces. Modification of these activities such as altering the
ographs of their lower-extremities. All patients underwent serve technique and treadmill jogging may reduce knee forces.
cemented total knee replacement with current-generation pros-
thesis, using intramedullary instrumentation on both the PAPER NO. 200
femoral and tibial sides. Femoral resection was attempted at 5 Are High Flexion Activities After High-Flex Total
degrees of valgus and tibial resection in 0 degrees varus/valgus as
given by the intramedullary cutting jigs. No accessory alignment
Knee Replacement Safe?
devices were utilized. Digital full-length radiographs were Seung Baik Kang, MD, Seoul, Dongjakgu Korea, Republic of
analyzed using PACS software. Femoral and tibial component Kang S Yoon, MD, Seoul, Korea, Republic of
alignment was measured in the coronal and sagittal planes, Hyuk Soo Han, MD, Seoul, Seoul Korea, Republic of
along with overall coronal alignment from the hip to the ankle. To acquire high flexion has been a current topic in TKA.
The average postoperative tibio-femoral angle was 3.56 degrees However, there is concern about the trade-off between high
(std dev 2.97). The average tibial component alignment was flexion and safety. The purpose of this study was to determine
90.00 degrees (std dev 1.52), and 99% were within 3 degrees the factors contributing to the high rate of aseptic loosening in
varus/valgus of a neutral mechanical alignment with only 2 femoral components of LPS-flex TKAs that we experienced.
(1%) outliers (greater than 3 degrees varus or valgus). Femoral From March 2003 to September 2004, 72 consecutive TKA were
component alignment averaged 4.21 degrees of valgus (std dev. performed in 47 osteoarthritic patients by a single surgeon. The
2.32). Intramedullary instrumentation resulted in excellent high-flex design fixed total knee prostheses (NexGen LPS-Flex)
postoperative tibial component and lower extremity alignment. were used in all knees. The weight-bearing high flexion activities
These results question the need for a computerized technique. A such as squatting were permitted as tolerable. We retrospectively
5-degree distal femoral cut resulted in a slight underestimation analyzed the clinical and radiological outcome of this case series.
of the postoperative tibio-femoral angle. Further follow-up is At a mean of 32 months (range, 30 to 48 months), 27 (38%)
required to correlate these results with long-term function and cases had shown the radiological findings of aseptic loosening
outcome. around the femoral components and fifteen (21%) cases have
been revised for the progression of component loosening and
pain. Postoperatively, the average maximal flexion was 136º in
the loosening group, which was higher than 125º in the no-
loosening group (P=0.022). The percentage of patients who
could squat, kneel or sit cross-legged postoperatively was greater
in the loosening group (85% versus 44%) (P=0.001). The
femoral component demonstrated movement into flexion, from
a mean of 4° to a mean of 7° (³ angle) in the loosening group tion of the implanted components. Patients were each asked to
and not in the no-loosening group. The high-flex implant perform a deep-knee-bend to maximum flexion, while under
allowed for greater range of motion and high-flexion activities, fluoroscopic surveillance. Using an accurate model-fitting
and however, showed high rate of early femoral component analysis, in-vivo data was recovered in three-dimensions and
loosening, which was associated with weight-bearing high- analyzed to determine patient’s axial rotation patterns, specifi-
flexion activities. cally the magnitude and pattern of rotation. Seven different
mobile bearing TKA groups were analyzed and compared to
PAPER NO. 201 both fixed bearing TKA and the normal knee. Three significant
Does Greater Knee Flexion Increase Patient findings were recovered from the data: (1) On average, the
mobile bearing TKA groups experienced minimal axial rotation
Function and Satisfaction After TKA? of the femoral component relative to the tibial component
Brandon N Devers, BA, Houston, TX (Range = -1.1º to 6.3º), significantly less than the normal knee
Michael A Conditt, PhD, Houston, TX averaging 27.7º (p<0.001); (2) a high incidence of subjects
Matthew David Driscoll, BBA, having a mobile bearing TKA experienced an opposite axial rota-
John Rankin, BS, tion pattern compared to the normal knee (Range = 10 to 75%);
Brian S Parsley, MD, Houston, TX and (3) the mobile bearing insert often rotates less than 2.0º
Philip C Noble, PhD, Houston, TX with respect to the tibial component and, at times rotates in the
wrong direction. Although, conceptually it would appear that a
In recent years there has been increasing interest in maximizing
mobile bearing TKA would offer the patient a greater advantage
range of motion in patients following TKA. The purpose of this
to achieve a more normal axial rotation pattern, under in-vivo
study was to determine whether patient satisfaction and func-
conditions these seven TKA types did not afford statistically
tion is affected by the range-of-motion of the knee following
greater amounts of axial rotation when compared to a fixed
TKA, and, if so, whether a minimum threshold is present for
bearing TKA (p>0.05).
satisfactory function from the patient’s perspective. At a
minimum of 1 year after primary TKA, 122 patients (M=29, PAPER NO. 203
F=93, average age 69yrs), were enrolled in the study with IRB
approval. All procedures were performed by the same surgeon The Mechanical Axis May be the Wrong Target in
using prostheses of a standard design (not high-flexion). Each Computer-Assisted TKA
patient completed a self-administered, validated Knee Function Mark W Pagnano, MD, Rochester, MN
Questionnaire consisting of 55 scaled multiple choice questions
Robert T Trousdale, MD, Rochester, MN
examining each patient’s participation in a broad range of activ-
Daniel J Berry, MD, Rochester, MN
ities involving the knee, their level of satisfaction, their func-
tional limitations, and the extent to which TKA had fulfilled Sebastian Parratte, MD, Marseille, France
their expectations. Patients’ post-operative degree of knee flexion A fundamental premise of computer-assisted TKA is that
was measured and recorded (average degree of flexion 120Ú, correcting the mechanical axis will promote implant durability.
range 85Ú to 143Ú). Patients were then grouped into one of Only one publication has correlated postoperative limb align-

three groups: low flexion (d110Ú; n=21), mid flexion (111Ú to ment assessed on full-length x-rays with survivorship and those
130Ú; n=81), or high flexion (>130Ú; n=20). There was no authors used a knee implant substantially different from
correlation between maximum knee flexion and the Knee modern designs. With substantial resources being devoted to
Society Score. Greatest satisfaction rates were observed in computer-assisted TKA we decided to review, in a large group
patients with flexion >130Ú. However, the overall correlation with full-length radiographs, the fundamental premise that
between knee flexion and satisfaction was not statistically signif- correction of the mechanical axis predicts long-term durability
icant (high flexion: 93% satisfied, mid: 73%, low: 74%; p=0.24). of modern TKA. Between 1984 and 1991 one surgeon
Increased knee flexion was positively associated with meeting performed 399 primary cemented TKA where standardized pre
patient expectations (high: 94%, mid: 68%, low: 50%; p=0.02), and post-operative full-length radiographs were done. Age was
elimination of functional limitations (high: 93%, mid: 50%, 69.6 ±8.5 years and BMI 29±4 Kg/m². Failure was defined as
low: 52%; p=0.008), and restoration of a knee that ‘felt normal’ aseptic loosening, implant revision or substantial wear. A multi-
(high: 87%, mid: 70%, low: 43%; p=0.01). While the degree of variate model evaluated survivorship, mechanical alignment
post-operative knee flexion did not affect the overall level of and associated factors. Postoperative alignment was 180 +/- 3 in
patient satisfaction, it did influence fulfilment of patients’ expec- 293 knees. In 106 knees postoperative alignment deviated more
tations, their functional ability, and their perception of their than 3 degrees from the mechanical axis (outliers). At 14 years
knee. This suggests that increased knee flexion, particularly to +/- 4.7 years, survival to revision, aseptic loosening, or substan-
>130Ú may lead to improved outcomes after TKA. tial wear was 84.6% for the group within 180 +/- 3 degrees. At
the same interval the survival for the 106 outliers was 87%. We
PAPER NO. 202 were surprised by the finding that outliers had somewhat better
14-year survival. While computer navigation improves the preci-
In Vivo Assessment of Axial Rotation in Mobile
sion of TKA this study suggests that we may be aiming at the
Bearing TKA wrong target. This work challenges advocates of navigation to
Ray C Wasielewski, MD, New Albany, OH truly define the appropriate target for limb alignment that maxi-
Richard D Komistek, PhD, Knoxville, TN mizes both patient function and implant durability in various
Mohamed Mahfouz, PhD, Knoxville, TN patient groups.
Sumesh M Zingde, BS, Knoxville, TN
Over the past 12 years, over 2500 knees have been analyzed in
our laboratory using fluoroscopy. The objective of this study was
to analyze previously collected data for mobile bearing TKA to
assess possible advantages for patients with respect to axial rota-
457
PAPER NO. 204 outcomes of two unselected groups of 81 consecutive knees that
Three-Dimensional Analysis of CT-based each underwent primary TKA using either a CAS navigation tech-
nique or a MIS technique. In the CAS group there were 33
Navigation System for Total Knee Arthroplasty women (52 knees) and 22 men (29 knees) with a mean age of
Shuichi Matsuda, MD, Fukuoka, Japan 64 years (39-100) and a mean preoperative deviation of the
Hideki Mizuuchi, MD, Fukuoka, Japan mechanical axis of 1.1° valgus (15° varus to 20° valgus). In the
Hiromasa Miura, MD, Fukuoka, Japan MIS group, there were 37 women (53 knees) and 18 men (28
Ken Okazaki, MD, Fukuoka, Japan knees) with a mean age of 71 years (47-88) and a preoperative
Yukihide Iwamoto, MD, Fukuoka, Japan deviation of 1.7° valgus (9° varus to 14° valgus). Comparisons
were made for operative times, length of hospitalization, Knee
A new three-dimensional analysis system with postoperative CT
Society scores, complications associated with the surgical tech-
data was developed to evaluate accuracy of implantation of CT-
niques, patient satisfaction, and radiographic alignment. The
based navigation system. Fifty-three primary TKAs in 47 patients
mean length of hospitalization was 3.4 days (2-8) for the CAS
were included in this study. All procedure was performed with
group and 3.3 days (2-7) for MIS group, p=0.634, which
CT-based navigation system (Vector Vision Knee 1.6, Brain Lab,
includes extended care, also note that the MIS group of patients
Germany). Postoperative CT was performed in the same manner
were older (7 years). The mean duration of the operation was
as the preoperative CT. The hip joint, the ankle joint and the
121 minutes (60-202) for the CAS and 58 minutes (37-134) for
implants in knee joint were extracted with adequate thresholds.
the MIS group (p<0.001). The Knee Society pain and functional
Outer shape of the extracted images was coordinated by a house-
scores for the CAS group improved from a mean of 39 and 46 to
written software, and then loaded on a CAD software (CATIA Ver
91 and 92, respectively (p<0.001). Similarly, the Knee Society
5.12, Dassault Systemes, France). From these images, we
pain and functional scores for the MIS group improved from 31
analyzed the postoperative alignment of the femoral and the
and 34 to 93 and 91, respectively (p<0.001). A comparison
tibial component. The mean coronal femoral angle was 89.0 ±
between both groups showed no significant difference in Knee
1.4 (85.5-92.8) degrees, and the coronal tibial component was
Society pain and functional scores at final follow-up, p=0.527
89.2 ± 1.0 (87.4-91.6) degrees. Hip-Knee-Ankle angle was 178.2
and p=0.539 respectively. Postoperative analysis of alignment
± 1.5 (173.9-181.8) degrees with 3D evaluation and 178.5 ± 1.8
showed no difference between both groups in the coronal plane
(173.5-181.2) degrees with 2D evaluation. The mean difference
(femoral flexion, p=0.08; tibial angle, p=0.680) but superior
between two methods was 0.3 ± 1.8 (-2.7-3.4) degrees. External
results for the CAS group in the sagittal plane (femoral flexion,
rotational alignment of the femoral component relative to the
p=0.044; tibial angle, p<0.001). Assessment of motion at final
surgical epicondylar axis was -0.5 ± 1.7 (-3.2-3.4) degrees. 34
follow-up yielded better postoperative range of motion in the
knees (91.9%) were obtained within 3 degrees from 0 degrees.
CAS group (117° versus 114°, p<0.03). There were significantly
The results of this study demonstrated that computed tomog-
more complications (p=0.012) in the CAS group compared to
raphy-based navigation system provided almost satisfied
the MIS group, including tracker site fracture, tracker site infec-
component alignment. This study also showed discrepancy
tions, manipulations under anaesthesia, and bleeding possibly
between 2D and 3D evaluation was up to 3.4 degrees. These
from vessel injuries caused by tracker insertion. CAS and MIS
results suggest that 3D analysis is necessary to evaluate accuracy
TKA are both emerging technologies that have distinct strengths

of navigation system.
and weaknesses. In a community hospital setting, we found that
additional operating time is needed when using a navigation
PAPER NO. 205
system which adds to the existing cost of purchasing and main-
Navigation-assisted TKA versus Minimally Invasive taining a navigation system. In addition, the authors found a
TKA: Benefits and Drawbacks significant higher incidence of complications in the CAS group
Peter M Bonutti, MD, Effingham, IL which may outweigh its radiographic benefits (MIS group
demonstrated less accurate implant position in sagital plane in
component alignment). Further work is needed to refine this
David R Marker, BS, Baltimore, MD technology or its application.
Lindsay Rudert, BS,
Daniel A Dethmers, MD, Effingham, IL PAPER NO. 206
Slif D Ulrich, MD, Baltimore, MD Comparative Study of Stability after TKA Between
Michael A Mont, MD, Baltimore, MD
Navigation and Conventional Techniques
A number of investigators have demonstrated that total knee
arthroplasties (TKAs) implanted with computer-assisted naviga- Jong-Keun Seon, MD, Lexington, MA
tion surgery (CAS) lead to a more accurate component align- Eun Kyoo Song, MD, Kwangju, Korea, Republic of
ment than those implanted conventionally. In contrast, TKAs Sang Jin Park, MD, Hwasun-gun, Jeonnam Korea, Republic
implanted with minimally invasive surgery (MIS) TKA have of
been associated with rapid recovery, improved postoperative Seong-Beom Cho, MD, Gwanju, Korea, Republic of
muscle strength, and reduced length of hospital stay, but some- Sang Gwon Cho, MD,
times less accuracy in component alignment secondary to the Taek Rim Yoon, MD, Jeonnam, Korea, Republic of
limited exposure at implantation. Thus, there are numerous
Keun Bae Lee, Gwangju, Dong Gu Korea, Republic of
concerns with both CAS and MIS, including training of
personnel, extra time requirements, learning curve, knee align-
Young-Jin Kim, MD,
ment, extra costs, and ability to demonstrate improvements in Recently, computer assisted navigation systems have been devel-
clinical outcomes. The purpose of the present study was to oped to help surgeons improve TKA alignment accuracy, and
compare the short-term results in regard to functional outcome these systems have been demonstrated to reduce some align-
and component alignment between CAS TKA and MIS TKA in a ment errors. However, despite improved alignment accuracies,
community hospital. We evaluated the clinical and radiographic soft tissue balancing remains a challenge. To the best of our
knowledge, no reports are available on knee stability after TKA
performing using a navigation system.Therefore, we performed PAPER NO. 208

this study to evaluate the stability and the short-term clinical Comparison of Minimally Invasive Unicondylar Knee
results of navigation-assisted total knee arthroplasties (NA-
TKAs) and to compare these with those of conventionally Arthroplasty with or without a Navigation System
performed TKAs with a gap technique (CON-TKAs). Forty-two Eun Kyoo Song, MD, Kwangju, Korea, Republic of
NA-TKA knees (the NA group) and 44 CON-TKA knees (the Jong-Keun Seon, MD, Lexington, MA
CON group) both with a minimum 1-year follow-up were Sang Jin Park, MD, Hwasun-gun, Jeonnam Korea, Republic of
included in this study. We evaluate and compared the stabilities Seong-Beom Cho, MD, Gwanju, Korea, Republic of
of mediolateral laxity in extension and anteroposterior laxity in Sang Gwon Cho, MD,
90 degrees of flexion using stress radiographs on both groups.
Taek Rim Yoon, MD, Jeonnam, Korea, Republic of
Clinical results were also compared between two groups using a
modified HSS (excluding laxity and ROM), and ROM measure- Dam-Sum Lee, MD,
ment were taken at final follow-up before stress radiographs in Sung Taek Jung, MD, Gwangju, Korea, Republic of
order to exclude bias. Mean medial laxities were 3.5° in the NA In total knee arthroplasty, navigation systems that help achieve
group and 4.0° in the CON group, and mean lateral and antero- accurate alignment of the lower limbs have been applied widely,
posterior laxities were 4.4° and 4.2°, 7.1mm and 7.0 mm, and these techniques are currently being used in minimally inva-
respectively. These results showed no significant differences sive unicondylar knee arthroplasty (MIS UKA) with good align-
between the two groups. In addition, no significant differences ment results. To the best of our knowledge, there are no studies
were found between the two groups in modified HSS scores or showing whether or not MIS UKA using a navigation system has
ROMs. We concluded that there is no significant difference a significant influence on the clinical results. This prospective
between navigation-based and conventional techniques in terms study investigated the hypothesis that minimally invasive
of TKA stability and short-term clinical results. unicompartmental knee arthroplasty using navigation system
(NA-MIS UKA) will produce better short-term clinical results
PAPER NO. 207 than MIS UKA without navigation system. After a minimum
Does Extensive Experience With Computer-Assisted two-year follow-up, the short-term functional results included
the ranges of motion, Hospital for Special Surgery (HSS) scores,
Navigated TKA Improve the Component Position? and WOMAC scores and the alignment accuracy of the compo-
Young-Hoo Kim, MD, Seoul, Korea, Republic of nents of 31 NA-MIS UKAs (NA-MIS group) compared with those
Jun Shik Kim, MD, Seoul, Jongno-Gu Korea, Republic of of 33 MIS UKAs without a navigation system (MIS group). The
Yoowang Choi, MD, surgery time was also recorded and compared. The HSS and
Oh-Ryong Kwon, MD, WOMAC scores showed significant improvement at the final
We hypothesized that extensive experience with nacigated TKAs follow-up in both groups, showing no significant inter-group
improved the limb and implant alingment and reduce the preva- difference(p=.096). The ranges of motion also showed signifi-
lence of outliers in conventional TKAs. Also, we asked whether cant improvements in both groups, but there was no significant
clinical and radiographic results in conventional TKAs were difference between two groups (p=.687). However, the surgery

affected by the extensive experience with navigated TKAs. One time was longer in MIS group than in NA-MIS group. NA-MIS
hundred and sixty patients (320 knees) were included in the UKA produces significant improvement in the desired mechan-
study: 60 patients had bilateral conventioanl TKAs; 50 patients ical axis with prosthetic alignment outliers compared with that
had bilateral navigated TKAs; and 50 patients had bilateral without the navigation system. NA-MIS UKAs produce no signif-
conventional TKAs. Radiological and CT imaging was carried out icant differences in any of the functional parameters compared
to determine the alingment of the components. The mean with that without the navigation system after 2 year follow-up
follow-up was 3.4 years (range, 3 to 4 years). The pre-or postop-
PAPER NO. 209
erative knee scores were not significantly different in 3 groups of
patients (P>0.05, respectively). The radiographic results and the Prospective Randomized Study of Fat Emboli in
number of outliers for all radiological parameters were not TKA: CAS vs Standard Technique
significanty different in 3 groups of patients (P>0.05). The oper- Mary I O’Connor, MD, Jacksonville, FL
ating time was significantly longer in the navigated group
Mark Preston Brodersen, MD, Jacksonville, FL
(P<0.001). However, the operating time was not significantly
different between the two groups of patients who had conven- Neil Feinglass, MD,
tional TKAs (P=0.321 and 0.720, respectively). We found that Bruce Leone, MD, Durham, NC
extensive experience with navigated TKAs did not improve the Barbara E Murray, BA,
limb and implant alingment and did not reduce the prevalence Julia Crook, PhD,
of outliers in conventional TKAs. Clinical and radiographic To compare the extent of transesophageal echocardiogram
results in conventional TKAs were not affected by the extensive (TEE)-detected fat emboli in patients undergoing TKA who had
experience with navigated TKAs and they were similar in all 3 been randomly assigned to either standard surgical instrumen-
groups of patients tation or computer assisted navigation (CAS). Forty-six 46
patients undergoing TKA were studied with TEE: 24 randomly
assigned to standard surgical instrumentation and 22 to CAS.
Anesthetic protocols were nearly identical for all patients.
Videotaping of the TEE was performed for 5 minutes upon
tourniquet deflation. An emboli score was created based on the
amount, duration and size of the emboli by two blinded evalu-
ators. No significant differences existed between the two study
groups with the exception of the CAS patients having higher co-
morbidities. Mean tourniquet time differed by 17.8 minutes
459
with patients randomized to standard technique having shorter ACL deficiency. Although goals of surgery are to correct
times (p<0.001). Overall emboli scores did not differ signifi- malalignment, decrease knee joint load, relieve symptoms of
cantly between the two groups (p=0.19). The scores ranged instability and enable continued participation in sports, few
between 4.6 and 7.6 (CAS) and 4.6 and 7.9 (standard tech- prospective studies evaluating these outcomes exist. The purpose
nique). Emboli subscores describing the amount, duration and of this study was to evaluate the 2-year changes in these
size of emboli were not significantly different between random- outcomes. Thirty patients with varus alignment, medial
ization groups. However, ratings in the CAS group were slightly compartment knee OA and ACL deficiency have undergone
lower for all three subscores with greater scores representing medial opening wedge HTO and hamstring tendon ACL recon-
more and/or larger emboli. This study showed no significant struction during a single operation. Full-length, standing AP
difference in fat emboli amount, duration and size during the radiographs (mechanical axis angle), dynamic knee joint loads
five minutes following tourniquet deflation as evaluated by TEE. (the peak external adduction moment about the knee during
Ratings of each of these categories were, however, slightly lower self-paced walking) and the Knee Injury and Osteoarthritis
in patients undergoing TKA with CAS. Outcome Scale (KOOS) were completed before and a minimum
of 24 months after surgery. Based on the 14 patients currently at
PAPER NO. 210 24.9 ± 1.67 months postop (12 males; age = 38.5 ± 7.5 yrs.; BMI
Total Knee Replacement After Medial Opening = 29.5 ± 5.6, median Kellgren and Lawrence grade = 2), mechan-
ical axis angle decreased significantly (p<0.005) from -6.7 ±
Wedge Osteotomy 3.64° to 0.61±1.64°. Despite a small (0.06 ± 0.10m/s), but
Doug Naudie, MD, London, ON Canada significant (p<0.05), increase in self-paced walking speed after
Sani Erak, mbbs fracs, Greenmount, Wa Australia surgery, the peak knee adduction moment decreased signifi-
Steven J MacDonald, MD, London, ON Canada cantly (p <0.001) from 2.96 ± 0.61 %BW*ht to 1.58 ± 0.48
Richard W McCalden, MD, London, ON Canada %BW*ht [mean decrease = 1.38 %BW*ht (95% CI: 0.87 -
Robert Barry Bourne, MD, London, ON Canada 1.89)]. Each domain of the KOOS also improved significantly
Tony Cervinka, MD, London, ON Canada (p<0.05), with the mean sports and recreation domain
increasing (p=0.001) from 26.92 ± 24.29 to 66.54 ± 28.09
Cecil H Rorabeck, MD, London, ON Canada
[mean increase = 39.62 (95% CI: 20.09 - 51.14)]. Data from 30
Medial opening wedge osteotomy is a popular treatment option patients will be available at time of presentation. Two-year
for medial compartment osteoarthritis of the knee. One of the outcomes after simultaneous medial opening wedge HTO and
proposed advantages of this procedure is easier conversion to a ACL reconstruction suggest this treatment results in substantial
total knee replacement (TKR), however, there is little literature to improvements in alignment, knee joint load and self-reported
support this notion. The purpose of this study was to review our functioning during sport.
experience with the technical issues involved in converting 36
medial opening wege osteotomies to TKRs, and to report our PAPER NO. 287
early clinical results. Operative notes were reviewed in 36 cases of
conversion of an opening wedge osteotomy to a TKR for the tech- Accuracy of High Tibial Osteotomy (HTO):
nical issues involved. Preoperative Xrays were examined in this Comparison Between Open- and Closed-Wedge
group. A subgroup of 26 patients had more than 2 year followup Technique

available. This group was compared to an age and sex matched
Stefan Hankemeier, Dr med, Hannover, Germany
control group of TKRs performed without an osteotomy. Knee
Society Score and WOMAC scores were collected for these Johannes Zeichen, Hannover, Germany
groups, and radiological review undertaken. The conversion to a Michael Jagodzinski, MD, Hannover, Denmark
TKR was relatively straightforward. Tibial stems tended to be used Rupert Meller, MD, Hannover, Denmark
earlier in this series if hardware was being removed. There was no Christiane Meyer, MD, Hannover, Denmark
difference in preoperative Knee Society or WOMAC scores Anne Lubowicki, MD, Hannover, Denmark
between the study and control groups. In the study group there Christian Krettek, MD, Hannover, Germany
was a lower function score for the Knee Society score, and a lower Clinical results after HTO depend on the accuracy of the correc-
pain score on the WOMAC score, compared to the control group. tion of the mechanical axis. How exact is the postoperatively
Poor results in the study group were associated with worker achieved correction in comparison to the preoperative plan-
compensation cases and prior chronic pain patients. We ning? Does the accuracy of open-wedge HTO differ from closed-
conclude that conversion of a medial opening wedge osteotomy wedge technique? In a prospective study, 61 patients with
to a TKR is a relatively straightforward technical procedure. The medial gonarthritis were either treated by closed-wedge HTO
clinical results may be inferior to that of the control group, (n=26, between 2001-2003), or by open-wedge HTO (n=35,
although results were biased by a small group of chronic pain 2004-2005) fixed with angle-stable implants (Tomofix,
and workers compensation cases. Synthes). Preoperative planning and postoperative analysis was
performed with a special planning software (MediCAD, Hectec)
PAPER NO. 286 on long leg standing radiographs. The influence of the operative
Simultaneous Medial Opening Wedge HTO and ACL- technique, aetiology (31 primary vs. 30 posttraumatic
R: 2 year Alignment, Knee Joint Load and Function gonarthritis), age (48±12 years), number of previous surgeries
(1.8±1.2) and amount of correction (9.9±4.2°) on the accuracy
Crystal Kean, MSc, London, ON Canada
of the correction was analysed. The overall postoperative
Trevor B Birmingham, PhD, London, ON Canada mechanical axis differed form preoperative planning by
Ian Jones, MBBA, London, ON Canada 2.1±1.7°. The accuracy in the open-wedge group (1.7±1.4°) was
Robert Giffin, MD, London, ON Canada significantly higher than in the closed wedge group (2.6±1.8°;
Simultaneous high tibial osteotomy (HTO) and ACL recon- p=0.038). Patient age, number of previous surgeries and amount
struction has been proposed as a treatment for patients with of correction did not have a significant influence, whereas
combined medial compartment knee osteoarthritis (OA) and
corrections of primary osteoarthritis were significantly more were recorded before and after surgery. Radiographic measure-
accurate compared to operations of posttraumatic osteoarthritis ments were performed to determine the alignment of compo-
(p=0.020). Conversion to knee arthroplasty was necessary nents and were grouped into: a reference group (within 2.5
51±13months after closed-wedge HTO in 12%, and in 3% after degrees of neutral component position), and two groups on
open-wedge HTO. Due to these results, the authors recommend either side of this reference group. These groups were then
open wedge technique of HTO in combination with angle stable compared for changes in the Oxford Knee Score (‘OKS) and
implants. Future studies will have to investigate, if the accuracy radiolucency at five years. 90% of the femoral components were
can be improved with intraoperative use of navigation modules. positioned between 10 degrees varus and valgus. However, there
was no significant difference in ‘OKS (p=0.550) or radiolucency
PAPER NO. 288 (p=0.921) between the groups. All tibial components were posi-
UKA versus HTO. Clinical Results at Short Term tioned between 5 degrees varus and valgus and there was no
significant difference in ‘OKS (p=0.568) or radiolucency
Follow-Up (p=0.911) amongst the groups. The posterior tilt of the tibial
Federico Dettoni, MD, Torino, TO Italy implant was between 5 degrees superiorly to 5 degrees inferiorly
Gianni L Maistrelli, MD, Toronto, ON Canada in 90% of cases. Again, no difference was demonstrated in ‘OKS
Prof Paolo Rossi, Turin, Italy (p=0.20) or radiolucency (p=0.911) between the groups.
Filippo Castoldi, MD, Torino, Italy Femoral malalignment of up to 10 degrees is compatible with
Dragan Stojimirovic, MD, good clinical and radiological outcomes. For tibial components,
Roberto Rossi, MD, Turin, Italy 5 degrees of varus, valgus, superior or inferior tilt is acceptable.
We conclude that the Oxford UKA is tolerant to component
The aim of this prospective study was to compare clinical and
malalignment within the ranges above.
functional results of 56 consecutive Unicompartmental Knee
Arthroplasties (UKA) and 54 Opening Wedge High Tibial PAPER NO. 290
Osteotomies (HTO). The study was carried out in cooperation
between the University of Toronto (Canada) and the University Is Lateral Unicompartmental Knee Arthroplasty as
of Torino (Italy) In all cases, the diagnosis was primary medial Reliable as Medial UKA ?
unicompartmental knee arthritis. Accuris (Smith&Nephew) pros- Jean-Noel A Argenson, MD, Marseille, France
thesis was implanted in 56 (28 M, 28 F) patients, and Puddu
Antoine Bertani, MD,
plate (Arthrex) in 54 (29 M, 25 F) patients. The mean age was 55
Xavier Flecher, MD, Marseille Cedex 09, France
years for the HTO and 65 years for the UKA. All patients were
evaluated preoperatively and at 6 months, 1, 2 and 3 years, using Sebastian Parratte, MD, Marseille, France
the Knee Society Score (KSS) and the WOMAC Osteoarthritis Jean-Manuel Aubaniac, MD, Marseille, France
Index. Student t test was performed (using the SPSS 13.0 soft- Limited long term follow-up data are available for unicompart-
ware) The average follow-up time was 4 years for HTO and 3 mental knee arthroplasty (UKA) performed for lateral
years for UKA. The KSS Knee Score and Function Score improved femorotibial osteoarthritis. The aim of this study was to report
from 38 and 55 to 76 and 91 for the HTO group, and from 43 the average 10 yearfollow-up of a consecutive series of lateral

and 50 to 93 and 84 for the UKA group. The WOMAC Score were UKA performed in the same institution. Between 1984 and
48 (HTO) and 45 (UKA) preoperatively, 15 (HTO) and 14 (UKA) 2004, 33 lateral UKA were performed and followed in the insti-
at last evaluation. The mean postoperative rehabilitation time tution while 703 medial UKA were performed during the same
was 7.2 and 4.3 weeks for HTO and UKA, respectively. Both treat- period. All patients were evaluated pre and post-operatively
ments showed good results at 2-4 years follow-up. However using the Knee Society Score. The radiological indication was
differences were not significative, the rehabilitation time was based on full loss of cartilage limited to the lateral femorotibial
shorter in UKA group, and UKA showed slightly better Knee compartment evaluated on stress X-rays and full weight bearing
Score, while HTO showed a better Function Score. views of the limbs evaluating the mechanical axis. All compo-
nents were cemented. The average follow-up was 10.8 years
PAPER NO. 289 (range, 4 to 20 years). All patients had marked preoperative pain
Unicompartmental Knee Arthroplasty: Effect of preoperatively and the average preoperative mechanical axis
(hip ‘ knee ‘ankle) was 6° of valgus. The average Knee Society
Component Alignment on Clinical & Radiological Score improved from 55 to 95 and from 58 to 92 for function.
Outcomes The average posterative mechanical axis was 2° of valgus. Four
A Gulati, MS, DNB, Oxford, United Kingdom knees were revised, one for tibial migration and three for
R Chau, MRCS, progression of osteoarthritis. Implant survival at 20 years was
80% (0.62 ‘ 0.99). Lateral UKA represents in our experience 5%
Hemant G Pandit, FRCS, Oxford, United Kingdom
of all UKA implantations. However the long term results of
D Simpson, MD, Oswestry, Shropshire, United Kingdom lateral UKA presented in this study compares at least equally
David J Beard, DPhil, Oxford, United Kingdom with those reported for medial UKA.
Christopher A F Dodd, FRCS, Oxford, United Kingdom
Harinderjit Singh Gill, PHD, Oxford, United Kingdom
The commonest malalignment following Unicompartmental
Knee Arthroplasty (UKA) is varus or valgus position of the
femoral or tibial components, or variations in the tibial slope.
This study aims to assess the influence of component alignment
on the long term clinical and radiological outcomes following
surgery. Patients (n=157) who received the Oxford UKA using a
minimally invasive approach were studied. Oxford Knee Scores
461
PAPER NO. 291 ROM, stride length, stance time, or VAS scores between the mid-
Unicompartmental Knee Arthroplasty for vastus MIS and the standard technique. Within three months
from TKR, there appears to be no short term benefit between the
Spontaneous Osteonecrosis: A Multicentric Study mid-vastus MIS compared to the reduced-length standard tech-
Sebastian Parratte, MD, Marseille, France nique for TKR regarding speed of recovery.
Alexander P Sah, MD, Chicago, IL
Jean-Manuel Aubaniac, MD, Marseille, France PAPER NO. 293
Jean-Noel A Argenson, MD, Marseille, France ◆Fixed vs. Mobile High Flex Total Knee
Richard D Scott, MD, Boston, MA Replacement: A Prospective, Randomized, Single-
The reported clinical and radiological outcomes after modern Blind Study
unicompartmental knee arthroplasty (UKA) specifically for
spontaneous osteonecrosis of the knee are limited. We hypothe- Scott T Ball, MD, San Diego, CA
sized that unicondylar replacement for the treatment of primary Ormonde M Mahoney, MD, Athens, GA
avascular necrosis can be as reliable and durable as it is for Thomas P Schmalzried, MD, Los Angeles, CA
osteoarthritis. We retrospectively reviewed 40 cemented UKAs Yong In, MD,
implanted for spontaneous osteonecrosis of the knee in two High flex knee designs and mobile bearings continue to be of
institutions by two experienced surgeons between 1989 and great interest in knee replacement. We compared outcomes in
2004. Twenty-six patients were women and 14 men, with a patients treated with a mobile bearing versus a fixed bearing
mean patient age of 67 years (range, 45 to 84) and mean body TKA which was designed for increased flexion. Under the
mass index of 27.4 Kg/m2 (range, 18 to 44). Clinical and radio- auspices of an FDA IDE randomized, single-blind clinical trial,
logical evaluations were performed by an independent observer with 2 surgeons at different institutions, 93 knees in 67 patients
in each center according to the same protocol at a minimum were evaluated at a minimum of 2 years. Forty-two knees had
follow-up of 3 years (mean 8 years; range, 3-17.5 years). The received a fixed bearing (FB), posterior-stabilized TKA and 51
mean Knee Society Knee score improved from 60 preoperatively knees had received the rotating platform (RP) version of the
to 95 post-operatively. The mean Knee Society Function score same knee. All components were fixed with cement and all
improved from 50 preoperatively to 89 post-operatively. patellae were resurfaced. There were no significant differences in
Restoration of an appropriate lower-limb mechanical axis was pre-op demographics of the patients. At 2 years, there were no
achieved for 36 knees (90%). Two knees were revised for aseptic significant differences in Knee Society (KS) clinical scores and
loosening. The Kaplan-Meier survivorship was 95 % at 12 years. SF-12 scores. KS functional scores were higher in the RP group
Spontaneous osteonecrosis of the knee can be a challenging (92.2) than the FB group (85.7) (p=0.07). This was due to
problem to treat. In this setting, UKA can provide reliable and significantly higher scores in the stair climbing sub-category of
durable outcomes at midterm followup which are comparable the KS functional scores of patients treated with RP knees
to those performed for osteoarthritis. (p=0.02). Post-op range of motion between the groups was
similar (FB knees, 1-125º; RP knees 1-126º). There was no
PAPER NO. 292 difference in complication rates. There were no bearing disloca-
MIS versus Standard TKR: A Prospective tions or subluxations. The RP version was found to be at least
as efficacious as the FB version with no differences in KS clinical
Randomized Blinded Study Comparing scores, SF-12 scores and range of motion. KS functional scores
Postoperative Strength were higher due to significantly improved stair climbing ability
Charles Toulson, MD, Mckinney, TX in patients treated with the RP design.
Bryan J Nestor, MD, New York, NY
Stephen Lyman, PhD, New York, NY PAPER NO. 294
Sherry I Backus, PT, New York, NY Little Differences in Outcomes Between Genders
Howard Hilstrom, PhD, Using a Contemporary Total Knee System
A prospective, randomized, double-blinded study has been David F Dalury, MD, Baltimore, MD
done for patients undergoing bilateral TKR (total knee replace- Mary Jo Adams, BSN, Towson, MD
ment) comparing a minimally invasive surgery (MIS) mid-
A great deal of interest has recently been focused on gender
vastus technique to a reduced length standard approach for MIS.
specific knees. The purpose of this study is to review a large series
We hypothesize that there is no difference between the mid-
of patients utilizing a modern unisex total knee system too see if
vastus MIS method and the reduced length standard quad split-
we could identify any differences in outcomes between the sexes.
ting MIS technique as they pertain to recovery of strength or
Between 6/96 and 12/97 1970 Sigma knees were implanted in
greater reduction in postoperative pain Fifteen patients under-
1512 patients in 8 centers. There were 920 female and 592 male
going single stage bilateral TKR were randomized to undergo a
patients. Average age of the group was 69.7 years (range 31-93.)
mid-vastus MIS in one knee and a standard quad-splitting
Pre-operative diagnosis was OA in 96.1%. There were no statis-
approach in the other knee. The patients and investigators
tical differences between the 2 groups in regards to age or diag-
remain blinded because the skin incisions are the same length.
nosis. 1316 knees had minimum 5-year follow-up and overall
The primary outcome measurement is post-operative strength as
compliance was 85.1%. There were minimal differences in
determined by Biodex isokenetic and isometric peak torque
outcomes between the male and female patients. Overall KSS
testing. Secondary outcome measures include range of motion
improvements were higher for the male patients (p=0.01)
(ROM), Visual Analog Scale (VAS) pain scores, stride length, and
however, differences in function scores, pain scores, and flexion
stance time during gait analysis of each knee. Outcomes were
(degrees) were not statistically significant between the 2 groups.
assessed at 1, 2, and 3 days, 3 weeks, 6 weeks, and 3 months
Male patients had a higher incidence of osteolysis (3.4% versus
postoperatively. With a study enrollment of fifteen patients,
1.0%) and this was statistically significant (p <0.01). There were
there was no significant difference in post-operative strength,
no significant differences in 10-year survivorship estimates: male
97.8% and female 96.9% (log rank p-value = 0.96). We could a significant improvement in the ROM, knee and function scores
identify little differences between genders in this large series from pre to post op in both groups. There was no significant
using a modern unisex total knee system. difference in the net improvement (post-pre) for flexion, knee
scores and function scores between the groups. The ability to
PAPER NO. 295 consistently achieve higher degrees of knee flexion is increasing
The Affect of Gender on Prospectively Collected with conventional non high flex knee designs. Patients achieving
high flexion in this study did not experience higher satisfaction
Clinical Outcome in Total Knee Replacements or function of their TKA when compared to those patients with
Steven J MacDonald, MD, London, ON Canada average flexion. While higher flexion is thought to provide better
Kory Charron, London, ON Canada function, this study indicates that other factors need to be
Doug Naudie, MD, London, ON Canada considered.
Richard W McCalden, MD, London, ON Canada
Robert Barry Bourne, MD, London, ON Canada PAPER NO. 297
Cecil H Rorabeck, MD, London, ON Canada Knee Society Functional Scores More Related to
Gender specific total knee replacement design has been a Function of Non-Operative Limb
recently debated topic. The purpose of this study was to investi- Cale Jacobs, PhD, Lexington, KY
gate the survivorship and clinical outcomes of a large primary
Christian P Christensen, MD, Lexington, KY
total knee arthroplasty cohort, specifically assessing any differ-
Joint-specific outcome scores have been widely used to docu-
ences between gender groups. A consecutive cohort of 3730
ment functional ability prior to and following arthroplasty
patients, having undergone 5139 primary total knee replace-
procedures. Many scoring systems, such as the Knee Society
ments (3026-female, 2113-male) with a minimum of 2 years
Functional Score (KFS), require patients to self-report their
follow-up were evaluated. All surgeries were performed at the
ability to navigate stairs and rise from a seated position. The
same institution by one of four surgeons. Pre-operative scores,
purpose of this study was to determine if objective force data
latest scores, and change in clinical outcome scores (KSCRS,
from instrumented functional tests were related to the KFS. Prior
SF12, WOMAC) were compared and tested for significance using
to undergoing either TKA or UKA, 40 patients performed sit-to-
the students t-test. While men had higher raw scores preopera-
stand (STS) and step-up-and-over (SUO) tests on a dual force
tively, women demonstrated statistically greater improvement
platform, with force data being collected on each limb individ-
(p<0.05) in all WOMAC domains including pain (29.72 vs.
ually. During the STS, we recorded the force generated by each
27.49), joint stiffness (26.69 vs. 24.12), function (27.04 vs.
limb during lift-up. During the SUO, we recorded the lift-up
23.04) and total scores (28.21 vs. 25.13) There were no gender
force as well as the impact force when returning to the platform.
differences in improvements of SF12 scores. Men demonstrated
In addition, patients answered questions necessary to calculate
statistically greater improvement (p<0.05) than women in Knee
the KFS. Spearman’s correlation coefficients were used to deter-
Society function (22.05 vs. 18.55) and total scores (70.16 vs.
mine the relationship between force data collected during
65.53), but not the Knee Society knee score. Cumulative revision
instrumented functional tests and the KFS and each of its
rates were 10.6% for males and 8.3% for females. In this cohort

subcomponents. Lift-up force of the non-operative limb during
of patients undergoing total knee replacements, women demon-
the SUO test was significantly related to the KFS score (rho=0.50,
strated greater implant survivorship, statistically greater
p=0.008), and there were no significant correlations between
improvement in WOMAC scores and less improvement in KSCR
force data of the operative limb and the KFS. Lift-up force during
scores, leading one to question the hypothesis of an inferior clin-
the bipedal STS was significantly related to the KFS (rho=0.47,
ical outcome in total knee arthroplasty that is gender based.
p=0.013); however, patients placed 7.1% more body weight on
PAPER NO. 296 the non-operative limb during this test. In order to accurately
determine functional ability of the surgical limb prior to and
Higher Knee Flexion Following TKA Does Not Result potentially following arthroplasty, more objective functional
in Improved Function or Satisfaction measures need to be used.
Brian S Parsley, MD, Houston, TX
Roberto Bertolusso, MS, Houston, TX PAPER NO. 298
Patients desire for higher degrees of flexion following TKA The Outcome of Primary PS TKA After a Previous
continues to increase. This study compares the functional Patellectomy
outcomes of patients who achieved >= 120 degrees of flexion Nattapol Tammachote, MD, Bangkok, Prayathai Thailand
and those with < 120 degrees of flexion utilizing a conventional
Robert Barry Bourne, MD, London, ON Canada
TKA design. : 320 patients since January 1996 underwent
Steven J MacDonald, MD, London, ON Canada
primary TKA by the same surgeon (ave. age 65.6, range 32-89,
62% female, 38% males) with a standard knee design (not high Richard W McCalden, MD, London, ON Canada
flex) and were enrolled in this study with IRB approval. All Doug Naudie, MD, London, ON Canada
patients were selected if they consistently achieved >= 120 Cecil H Rorabeck, MD, London, ON Canada
degrees (184 knees) or < 120 degrees (136 knees) throughout In patients with patellectomy previous studies have shown
the post operative period. Only patients who had isolated knee contradictory results. There interpretation is limited by small
arthritis and no other joint procedures performed were number of patients, included primary and revision implants or
included. Any patients who underwent additional surgery on the involved a heterogeneous group of different constraint implants.
operative knee were also eliminated. Prospective collection of We performed retrospective match controlled analysis of a poste-
ROM, knee and function scores was performed. There was no rior stabilized primary total knee arthroplasty in 42 patients who
difference in gender, age or BMI between the two groups. The had previous patellectomy. There were 19 male and 23 female
high flexion group had a higher knee function score pre-op (51.5 patients. The average age was 59 years. These patients had
vs. 44.2, p<0.01) and post-op (75.9 vs. 67.0. p<0.01). There was average three surgeries before total knee replacement. The
463
average follow-up was 5.3 years. The control group was matched PAPER NO. 300
by age, sex, prosthesis type and surgeon. We used the student-t Total Knee Arthroplasty in the Superobese Patient,
test to compare the outcome and Kaplan Meier technique to
compare survivorship with the end point of revision. BMI > 50
Preoperatively, the patellectomy and control were not different Hari Bezwada, MD, Philadelphia, PA
in term of Knee Society clinical and functional scores or range of Jess H Lonner, MD, Philadelphia, PA
motion. In patellectomy group the postoperative clinical and David George Nazarian, MD, Philadelphia, PA
functional score were equal to 70 and 58 respectively. The Robert E Booth, Jr MD, Philadelphia, PA
average clinical component of knee society score in the patellec-
Total knee arthroplasty in obese patients remains a challenge to
tomy group was significantly lower compare to control (p<0.05)
most surgeons. Surgical complication rates as well as periopera-
however the functional part of the knee society score wasn’t
tive morbidity are higher than total knee arthroplasty in the
(p>0.05). The patellectomy group also had less extension
nonobese. The purpose of this paper is to review our experience
(higher extension lag) (p<0.05). In the patellectomy group the
with total knee arthroplasty in superobese patients (BMI>50).
survivorship free of any revision at ten years was 76 % which was
From 1998-2005, 84 patients underwent 148 knee arthroplas-
significantly worse compared to control (p=0.02). In patellec-
ties. Sixty-four patients underwent simultaneous bilateral total
tomy group patients significantly improved but not as much as
knee arthroplasties and 20 patients underwent unilateral knee
control especially the function of extensor mechanism. The
arthroplasties. They were compared with similar group of
patellectomy group also has higher revision rate compared to
nonobese patients who underwent knee arthroplasties during
control.
the same time period. All patients received combined regional
and general anesthesia. Mean follow-up was 3.8 years (2-7).
PAPER NO. 299
Knee society scores improved by 36 points in the superobese
The Affect of BMI on Total Knee Replacement (pre-op 47 to 83 post-op) and by 45 points in the nonobese
Outcomes (pre-op 47 to 93 post-op) (p<.05). There was a greater incidence
Steven J MacDonald, MD, London, ON Canada of complications in the superobese group, namely superficial
wound infections and deep vein thrombosis. There was late
Kory Charron, London, ON Canada
loosening in three tibial components and instability in two
Doug Naudie, MD, London, ON Canada patients that required revision in the superobese group. No
Richard W McCalden, MD, London, ON Canada reoperations in the nonobese group. Although total knee arthro-
Robert Barry Bourne, MD, London, ON Canada plasty may be safely performed in the superobese, it may be
Cecil H Rorabeck, MD, London, ON Canada complicated by infection, loosening, instability, and lower knee
The growing trend of morbidly obese (BMI 40+) patients scores.
requiring a total joint replacement is becoming major concern
in total knee Arthroplasty (TKA). The purpose of this study was PAPER NO. 436
to investigate the effects that BMI may have on implant longevity Population-Based Survival and Cost-Effectiveness
and clinical patient outcome using historical patient data. A
consecutive cohort of 3083 TKAs in 2048 patients since 1995

of Unicondylar and Total Knee Arthroplasty
(minimum 2 years follow-up) were evaluated. Pre-operative Antti Eskelinen, MD, PhD, Espoo, Finland
scores, latest scores, and change in clinical outcome scores Esa Koskinen, MD,
(KSCRS, SF12, WOMAC) were analyzed using ANOVA and Pekka Paavolainen, MD, Kasarmikat, Finland
Kaplan-Meier (K-M) survivorship was determined. K-M cumula- P Pulkkinen MS, Helsinki, Finland
tive survival at 10 years by BMI group was 0.951±0.033 for Ville M Remes, MD, Helsinki, Finland
Normal and Underweight (<25, n=277), 0.944±0.024 for Purposes of this population-based study were to compare
Overweight (25-29.9, n=915), 0.882±0.032 for Obese (30-39.9, survival of unicondylar knee arthroplasty (UKA) with that of
n=1460) and 0.843±0.076 for Morbidly Obese (40+, n=352). total knee arthroplasty (TKA) and survival of the three most
Cumulative revision rates were 1.8% for Normal and commonly used unicondylar knee implants with total knee
Underweight, 1.9% for Overweight, 2.9% for Obese and 2.8% implants from the same manufacturer, and to conduct a cost-
for Morbidly Obese. All pre-operative clinical scores were signif- benefit analysis comparing UKA with TKA in patients with
icantly different between the Morbidly Obese and all other BMI primary osteoarthritis (OA). 1886 primary UKAs and 48 607
groups (p<0.05), with the non-morbidly obese having higher primary TKAs performed for primary OA and entered in the
scores in all cases. Significant difference was found in the change Finnish Arthroplasty Register between 1980 and 2003 inclusive
in WOMAC domain scores and the KSCRS knee score (p<0.05) were subjected to analysis. UKAs had a 60% (95% CI 54 ‘ 66)
between the morbidly obese group and all other BMI groups, and TKAs an 80% (95% CI 79 ‘ 81) survival rate at 15 years with
with the morbidly obese having the greatest improvement in all any revision taken as the end point. Overall survival of UKAs was
domains. The morbidly obese patient cohort (BMI>40) under- significantly worse than that of TKAs (p<0.001). All three UKA
going TKA demonstrated the most significant improvement in designs had significantly poorer overall survival than the corre-
clinical outcome scores; however they also had the lowest cumu- sponding TKA designs. In the theoretical cost-benefit analysis,
lative 10 year survivorship. This risk/benefit information is the cost saved by lower implant prices and shorter hospital stay
important in pre-operative discussions with this challenging, of UKA as compared to TKA did not cover the costs of the extra
and increasingly prevalent, patient population. revisions. At a nation-wide level, UKA had a significantly poorer
long-term survival than TKA. What is more, UKA did not have
even a theoretical cost benefit over TKA in our study. Based on
these results, we can not recommend wide-spread use of UKA in
treatment of unicompartmental OA of the knee.
PAPER NO. 437 year radiographs. 6 knees were revised (all related to wear and
15 Year Outcome of 4665 Primary Knee osteolysis). Average Knee Society clinical scores only deterori-
ated from 92 points to 89 points between 10 and 15 years. This
Arthroplasties: Results from a U.K. Joint Register cemented modular CR TKA performed well at 15 years with only
Colin Esler, MD, FRCS, Leicester, United Kingdom 6% of knees requiring revision. All revisions occurred after 10
Veronica Roberts, MRCS, years and were related to wear and osteolysis. 2/3 of the revisions
William Harper, MD, Leicester, United Kingdom could be salvaged without tibial component revision in this
This audit aims to assess the 15 year results of total knee arthro- closely followed series. Hopefully these results can be improved
plasty performed in a generalist setting in the U.K. 4665 primary with better wear-resistant designs and better quality polyeth-
knee arthroplasties were registered prospectively on a U.K. regi- ylene. Especially into the second decade, patients with modular
ional joint register in 1990 to 1992. The surgery was performed by tibial tray TKA constructs should be closely followed to optimize
77 surgeons in 21 hospitals on 4311 patients. The data was vali- their utility allowing less costly and less complex revisions in
dated by a peripatetic clerk. 32 different brands prostheses were cases with polyethylene wear.
implanted. The mean age at primary surgery was 70.1 yrs. 80% of
the knees were replaced for osteoarthritis. 64% of the patients
PAPER NO. 439
were female. The surviving patients were traced using the National Prospective Comparative Study of ROM in Cruciate
Strategic Tracing Service and the surviving patients were sent a self Retaining TKA - High-Flexion vs Standard Design
administered, joint specific, outcome questionnaire. 2456 of the
Jong-Keun Seon, MD, Lexington, MA
4311 (57%) patients had died at the time of review.447 could not
be traced. Responses were obtained from 912 patients. The 3 Eun Kyoo Song, MD, Kwangju, Korea, Republic of
month mortality rate was 0.4% and 1.9% at 1 year.The infection Taek Rim Yoon, MD, Jeonnam, Korea, Republic of
rate was 1.78%. Overall survivorship at 15 yrs was 91.1%. Implant Sang Jin Park, MD, Hwasun-gun, Jeonnam Korea, Republic of
survival was independent of whether the arthritis was inflamma- Young-Jin Kim, MD,
tory or whether cement was used for fixation. 15 year survival was Jae Joon Lee, MD, Gwang-ju, Korea, Republic of
87% for males, 93% for females, and 86% for patients who had Myung-Sun Kim, MD, Gwangju, 8, Hak-dong, Dong-gu
their surgery aged 55 years or less. Female patients tended to be Korea, Republic of
more satisfied with their surgery. Omnifit (97%) and IB II High-flexion, posterior cruciate ligament stabilized (PS) total
(96%)performed best and Kinematic worst (88%). The results of knee prostheses enables increased high flexion of the knee by
total knee arthroplasty in a generalist setting in the U.K. restoring posterior femoral translation. Recently in the cruciate
performed 15 years ago are satisfactory. The results from this study retaining (CR) prosthesis, high-flexion knee (CR-Flex) was
allow us to provide better informed consent to patients under- designed to allow a greater and safer flexion after TKA. The aim
going primary knee arthroplasty surgery. Total knee implants have of this prospective randomized study was to evaluate ROM in
evolved in the last 15 years and few of these implants are still avail- patient who had TKA with high-flexion fixed-bearing CR
able, but it would be difficult to improve on a 97% 15 yr survival, (Nexgen CR-Flex) knees and to compare them to those of
though kinematics of current arthroplasties may be superior.

patients who had TKA with standard fixed-bearing CR knees
(Nexgen CR). Fifty TKAs with high-flexion knees and 50 TKAs
PAPER NO. 438
with standard knees with a minimum 2-year follow-up included
Is the Potential Utility of Modular Tibial TKA in this study. The ROM (weight bearing and non-weight bearing),
Components Realized? a Minimum 15 Year number of knees that allowed comfortable kneeling, and cross-
legged sitting were evaluated. Functional outcomes of the two
Follow-Up groups were assessed with the Hospital for Special Surgery (HSS)
Andrew S Malin, MD, Iowa City, IA scores. At the final follow-up, the average non-weight ROM of the
John J Callaghan, MD, Iowa City, IA high-flexion knees was 133.3° and that of standard group was
Kevin John Bozic, MD, MBA, San Francisco, CA 131.4°, showing no statistical significance. Moreover, in the
Steve S Liu, MD, Iowa City, IA weight-bearing ROM, there was no significant difference between
Devon D Goetz, MD, West Des Moines, IA two groups (124.7° in high-flexion and 123.7° in standard
Nicholas Sullivan, BS, knees). In the number of knees allowing kneeling and cross-
Scott S Kelley, MD, Durham, NC legged sitting, there were no significant inter-group differences.
Average HSS knee scores were 94.4 in high flexion group and
Few reports are available at minimum 15 year follow-up of
92.4 in standard group (p>.05). In conclusion, in the cruciate
cemented modular cruciate retaining TKA, especially where all
retaining TKA, high-flexion design prosthesis had any advantages
polyethylene patella components were utilized. This paper
over standard design prosthesis concerning range of motion in
addresses the questions ‘What is the durability of cemented
non-weight or weight bearing conditions. Moreover, there were
modular cruciate retaining TKA with all polyethylene patella
no significant differences between high-flexion and standard CR
components at 15 years?’ and ‘Did modular tibial trays demon-
knees in the other functional result
strate their utility in terms of the potential for less costly and less
complex revisions?’ 101 Press Fit Condylar TKA’s were PAPER NO. 440
performed consecutively over a 27 month interval and followed
prospectively for a minimum of 15 years. The average age at UNI or TKR. The 15-year Results of a Randomized
surgery was 72 years. Clinical Knee Society scores, need for revi- Controlled Trial (RCT)
sion, radiographic evidence of loosening, and osteolysis were Ravikumar Pydisetty, FRCS, Liverpool, United Kingdom
recorded. All patients were recalled at 5 year intervals. At John Newman, FRCS, Bristol, United Kingdom
minimum 15 year follow-up, 34 patients with 45 knees were
There has been a recent major increase in the use of unicompart-
living and 40 patients with 54 knees were deceased (one patient
mental knee replacement (UKR) but some still feel that total
[2 knees] was lost to follow-up). 81% of living patients had 15
knee replacement (TKR) is a more enduring procedure. Between
465
1989 and 1992 a randomized controlled trail (RCT) was under- PAPER NO. 442
taken in which 102 cases suitable for UKR were allocated to Revision Rate of Oxford Unicompartmental Knee
receive either St Georg Sled UKR or a Kinematic Modular TKR.
The groups were well matched with a predominance of females, Arthroplasty at 6 Years
a mean age of 69 years and preoperative Bristol Knee Scores Sanjeev Agarwal, FRCS, Leeds, United Kingdom
(BKS) of 54.7 and 57.2 in the UKR & TKR group. At 5 years the Steven Godsiff, Norwich, United Kingdom
UKRs were better in terms of rehabilitation, range of movement, The oxford medial unicompartmental knee replacement is a well
and overall excellence. We now present the 15-year outcome established procedure for the treatment of medial compartment
using the BKS and radiographs 43 cases have died with their osteoarthritis. Various studies have reported an excellent survival
knees known to be intact. Of the remaining 59 patients 7 knees of the prosthesis. We report our results with this procedure. A
have been revised, 3 UKRs and four TKRs. The reason for revision retrospective study was undertaken to identify patients with
was loosening in the TKR group, progression of arthritis in the Oxford unicompartmental knee replacements from 1999 to
UKR group. There were no impending failures identified in the 2003. A total of 72 patients were found and 14 had bilateral
radiographsAt 15 years the UKR group had a median BKS of 92 procedure, making a total of 86 implants. The average time since
compared with 87.5 in the TKR group. Pain relief was good for surgery was 6 years. All patients had medial compartment arthritis
most of the patients in both groups but the number of knees able and were suitable for the procedure. The average age at the time of
to flex e 120 was significantly higher in the UKR group The better surgery was 65 years. 46 were right side and 40 left sided. There
early results with UKR are maintained at 15 years with no greater were 31 males and 41 females. At an average of six years, 9
failure rate. The median BKS scores of the UKR group was 91.1 at implants had been revised. Six were revised for medial side pain
five years and 92 at 15 years suggesting little functional deterio- and three for progressive arthritis on the lateral compartment.
ration in either the prosthesis or remainder of the joint. These One patient with medial pain grew coagulase negative staphylo-
results would seem to justify the increased use of UKR. coccus on secondary subculture and remained free of infection
following the single stage revision. Three had a loose tibial
PAPER NO. 441 component and two patients were noted to have anterior
RCT of a Porous Metal Tibial Monoblock TKA impingement of the mobile polyethylene. All had an improve-
Component using RSA: 2 Year Results ment in knee score following revision. In our centre, the Oxford
medial unicompartmental knee replacement has shown a higher
Michael Dunbar, MD, PhD, Halifax, NS Canada revision rate than expected from the results reported in literature.
David Wilson, BEng, We feel that the technique is demanding and surgeons should be
Allan Hennigar, Halifax, NS Canada aware of their own results and closely follow up their patients.
John David Amirault, MD, Halifax, NS Canada
Gerald Peter Reardon, MD, Halifax, NS Canada PAPER NO. 443
Michael Gross, MD, Halifax, NS Canada Predicting Patellar Failure After Total Knee
Porous metal technology may have significant impacts on Replacement
implant fixation and long-term survival due to their high co-effi-
John B Meding, MD, Mooresville, IN

cient of friction and similarity to trabecular bone in morphology
and mechanical behavior. While promising, the in vivo mechan- Merrill A Ritter, MD, Indianapolis, IN
ical behavior and micromotion at the interface has not previ- Michael E Berend, MD, Mooresville, IN
ously been reported on. We report on the 2-year results of an E Michael Keating, MD, Mooresville, IN
RCT using radiosterometric analysis (RSA) to asses a porous Philip M Faris, MD, Mooresville, IN
metal(PM) monoblock tibial component. Patients undergoing Robert A Malizak, MD,
TKA were randomized to receive a either the PM (n=34) or the Mark Fish, DO, Clive, IA
cemented tibial component (n=33). A standardized surgical Patella failure remains the most common aseptic complication
protocol was used for intra and post-operative factors. RSA following primary TKR. The purpose of this study was to identify
exams were obtained postoperatively within 4 days of surgery the pre-operative or intra-operative factors which may be associ-
and at 6, 12 and 24 months. One patient was excluded due to ated with patellar component failure. From a computerized study
an intraoperative complication, and four others were lost to base of 10,884 TKR implanted between January 1983 and
follow-up due to poor bead visibility or morbidity. Standard December 2003, 8,530 TKR were performed in 5,640 patients
subjective outcome measures were applied. There were no revi- using the same PCL-retaining TKR, including the same cemented
sions in either group. The PM group exhibited two distinct all-PE patellar component. Pre-operative variables studied
migration patterns. One group stabilized immediately with included gender, age at operation, BMI, ROM, Knee Society
similar migration to the cemented cases (0.38 vs. 0.46 p=0.4). A scores, alignment, and diagnosis. Intra-operative variables
subset of 6 PM cases demonstrated significantly higher initial studied included patellar thickness, tibial and femoral compo-
migration (mean=2.01mm, p<0.01) but appeared stable at 2 nent size, femoral component rotation, lateral release, and
years. In addition, 3 of the 6 high migration cases manifested patellar position. Patellar failure was defined as loosening,
independent bead subsidence. This was determined to be due to patellar fracture, or patellar revision. All infections were excluded.
PM plate deformation. Two cemented cases were considered at Statistical analysis using Kaplan-Meier and Cox Regression was
risk for early failure due to aseptic loosening because of RSA used to determine risk between the variable studied and patellar
migration pattern. There were no differences between groups in failure. TKRs with a lateral release and patients with a BMI >
the subjective health outcome measures. A subset of PM compo- 30kg/m2 were at the greatest risk of patellar loosening and frac-
nents demonstrated high early migration followed by stabiliza- ture (p<0.05). Male gender, varus alignment, and a larger patellar
tion. It appears that some of these PM components deformed component size also predicted a higher risk of patellar fracture
under load, most often in the posteromedial corner, perhaps as (p<0.05). Whereas, medial patellar component position, tibial
a result of malalignment or ligament imbalance. The implica- PE thickness >12mm, pre-operative valgus alignment >10
tions of this finding are yet to be determined. degrees, and ROM >100 degrees were predictive of patellar loos-
ening (p<0.05). An awareness of these objective factors which revisions and 1.99 for re-revision procedures. The rate of revision
predict patellar failure after TKR may help determine the relative for primary arthroplasties [1.3%] versus that for aseptic revisions
indications for TKR and may also influence surgical technique. [8.7%] was statistically significant (p<0.001) and represented a
6.7 times higher revision risk. With subsequent revisions, failures
PAPER NO. 444 occurred at a rate of 9.4%The incidence of revision diagnoses
Two Stage Revision TKR for Infection. Mid to Long remained constant with the revision and re-revision procedure.
The most common failure modalities were aseptic loosening and
Term Results instability. The average time to failure for the 64 re-revision artho-
Mirco Pietri, MD, Firenze, FI Italy plasties was 391 days. Subsequent failures resulted in 3rd and 4th
Robert Barry Bourne, MD, London, ON Canada revisions performed at 246 and 155 days, respectively. A statistical
Cecil H Rorabeck, MD, London, ON Canada significance was seen in survival time for primary [3.94 yrs]
Steven J MacDonald, MD, London, ON Canada versus revision [3.6 yrs] procedures (p<0.001). For the multiply
Richard W McCalden, MD, London, ON Canada revised total knee arthroplasty, with subsequent procedures the
Silvia Lucarini, MD, Florence, Italy onset of failure occurred more rapidly. Caution is advised to
clearly delineate and aggressively treat the etiology at time of first
Short-term cure rates of two stage revision for infection after TKR
revision to diminish the need for further interventions.
are approximately 90%. Little is known about the long-term rein-
fection-free survival or the mechanical durability of the reim- PAPER NO. 446
planted prostheses. The purpose of the study is to evaluate the
mid to long term results of this technique with regards to persist- Why Do Revision Total Knee Arthroplasties Fail?
ence of infection, clinical and radiographic results. The hypothesis Juan C Suarez, MD, San Juan, Puerto Rico
is that the success rate of the technique is maintained through William L Griffin, MD, Charlotte, NC
long term follow-up, with a low rate of recurrent infection and Susan Marie Odum, MED, Charlotte, NC
mechanical implant failure. From January 1990 to august 2002, Bryan Donald Springer, MD, Charlotte, NC
121 two stage revision TKR for infection were performed at Our
The demand for revision knee arthroplasty is expected to double
Institution with mean follow-up of 9,8 years (5 to 17,5). The clin-
by the year 2015. There is limited information available on the
ical results were evaluated with SF12, WOMAC, and KSCRS
outcomes of revision knee arthroplasty to help surgeons prepare
performed preoperatively and postoperatively at 5 and 10 years. A
for this increased burden. The purpose of this study was to analyze
radiographic analysis was performed using x-rays of the last avail-
the mechanisms of failure of revision knee arthroplasty and to
able follow-up. The WOMAC and KSCRS significantly improved
identify risk factors associated with failure. We retrospectively
at the 5 years follow-up decreasing slightly at 10 years. The SF12
reviewed first time revision knee arthroplasties performed at our
postoperative variation was not significant. The radiographic
institution between 1986 and 2005. There were six hundred and
results showed loosening of the tibial or femoral components on
forty-four index revision arthroplasties. Patient demographics,
17% and 12% of patients respectively. There were 24 reoperations
index revision diagnosis, and surgical variables were analyzed to
(22% of patients), 10 of which (9% of patients) for persistent
identify risk factors associated with failure. Sixty-eight (12.0%)
infection. Other five patients (4% of total) were under chronic

index revisions failed, requiring a second revision at an average
antibiotic suppression for persistent infection. The cumulative
time to failure of 40.1 months. Forty-one (60%) underwent re-revi-
survival at 10 years with operation for any reason as an endpoint
sion for a diagnosis different than their index revision. Re-revision
was 75%. We are encouraged by the 10 years cumulative survival
failure modes included: infection (46%), aseptic loosening (19%),
in these difficult cases. Particularly, infection wasn’t eradicated in
instability (13%), extensor mechanism (9%), and wear/lysis (4%).
13% of patients. The long term clinical and radiographic results
Only 4.3% (6/129) of the patients revised for aseptic loosening
are satisfactory. The study supports the sustained use of this tech-
required re-revision (failure rate of 1.1% per year). Twenty-one
nique for infected total knee arthroplasties.
percent of the patients revised for infection required re-revision
(failure rate of 4.1% per year). Younger patients and polyethylene
PAPER NO. 445
exchange procedures rather than full component revisions were
Failure Analysis of Aseptic Multiply Revised Total more likely to fail. Mechanisms of failure for revision TKAs are
Knee Arthroplasties different than for primary total knees. Revisions for infection are
Vivek Mohan, MD, Newport Beach, CA four times more likely to fail than revisions for aseptic loosening.
The survivorship for the entire cohort, with revision for any reason
Maria Carolina Secorun Inacio, MS, Irvine, CA
as an end point, was 82% at twelve years.
Robert S Namba, MD, Corona Del Mar, CA
Jessica Ziegler, MS, RD, San Diego, CA PAPER NO. 447
Donald C Fithian, MD, El Cajon, CA High and Low Molecular Weight Hyaluranon
Liz Paxton, MA, San Diego, CA
The purpose of this study was to elucidate the survivorship and
Injections in the Knee Produce Similar Outcomes
natural history of multiply revised TKAs. A total of 1317 revision Timothy S O’Brien, MD, Colorado Springs, CO
TKAs were identified in a community-based TJR registry. Terri Busey, BA, Colorado Springs, CO
Excluding those for infections, 1050 arthoplasties were analyzed Megan L Caraway, BS,
at 4 yr f/u, of which 91.3% [N=959] survived. Re-revisions for David Weinstein, MD, Colorado Springs, CO
aseptic etiologies occurred in 64 (6.1%) arthroplasties. Septic William J Ciccone, II MD, Colorado Springs, CO
etiologies accounted for 2.6% [N=27]. Six of the aseptic re-revi- John S Xenos, MD, Colorado Springs, CO
sions required a third revision procedures and one (N=1)
John J Elias, PhD, Colorado Springs, CO
required a fourth revision. Third and 4th revisions accounted for
Intra-articular injection of hyaluronan (HA) is a popular nonop-
9.9% [N=7] of the re-revisions registered.The ratio of infections
erative treatment option for osteoarthritis of the knee. Both
versus aseptic failures increased from 1.3 for primaries to 2.3 for
native low molecular weight HA and cross linked high molec-
467
ular weight HA are commonly used for injections. The current PAPER NO. 449 - WITHDRAWN
study compares outcomes following a series of intra-articular
injections between a high molecular weight HA and a low
molecular weight HA. Subjects received three injections of either
a high molecular weight (Synvisc) or low molecular weight PAPER NO. 450
(Hyalgan) HA preparation. Subjective assessments of pain, func- Porous Tantalum Cones for Large Tibial Defects in
tion and symptoms were recorded using the WOMAC and
KOOS scoring systems prior to treatment at 3 and 12 months Revision TKA: Minimum 2 Year Follow-up
following initiation of treatment. Outcome data was collected at William Long, MD, New York, NY
all time points for 89 knees that received no additional treat- Giles R Scuderi, MD, New York, NY
ments, 47 of which were treated with Synvisc. Kellgren-Lawrence Significant proximal tibial bone loss is a challenging reconstruc-
radiographic scores were also recorded for the medial and lateral tive problem in revision TKA. Uncemented porous tantalum
compartments of the tibiofemoral joint. Scores at 3 and 12 tibial cones are designed to act as modular substitutes for allo-
months were compared between the two treatment groups using graft bone in cases with significant proximal tibial bone loss. A
an analysis of covariance, with the pre-treatment score treated as single surgeon performed a consecutive series of thirteen cases of
the covariate. Scores were compared between the three time revision TKA with bone loss classified as T2 or greater (AORI clas-
points using a repeated measures ANOVA, with a Student- sification) requiring porous tantalum tibial cone augmentation.
Neuman-Keuls post-hoc test. The statistical significance of corre- These were reviewed at a minimum two years following implan-
lations between improvement in an outcome score and initial tation. Twelve patients had thirteen procedures (one staged bilat-
radiographic score was also calculated. No statistically signifi- eral) requiring the use of porous tantalum tibial cones for 2 T2B,
cant differences in pain, symptoms or function were identified 4 T3A, and 7 T3B tibial bone defects following 10 cases of aseptic
between the two treatment groups, at either 3 or 12 months. For loosening and 3 cases of staged re-implantation for infection. In
both treatment groups combined, measurements of pain, func- all cases tibial cones were used to establish a stable base for prox-
tion, and symptoms improved significantly at 3 and 12 months. imal tibial reconstruction upon which a stemmed tibial and
Correlations between improvement in pain and function and constrained condylar knee system was used. There were two case
initial joint space were also statistically significant. The results of recurrent sepsis requiring removal of a well-fixed cone. At an
indicate that three injection regimens of Synvisc and Hyalgan are average 32 months (24-36) no patients were lost to follow-up. In
equally effective for treatment of knee osteoarthritis. The benefi- the remaining eleven cases the reconstructions were functioning
cial effects of HA injections typically last for at least one year. well with no re-operations. Radiographic imaging showed re-
establishment of the joint line, neutral mechanical axis, and signs
PAPER NO. 448 of stable fixation of the cones. There were no cases of radi-
ographic or clinical loosening at the most recent follow-up. Short
Surface Temperature Variation After Total Knee
term results with the use of porous tantalum cones for tibial bone
Arthroplasty loss in revision TKA show promising results and no new compli-
Sridhar Rachala, MD, Cheektowaga, NY cations. Longer-term follow-up will be important in determining
Kenneth A Krackow, MD, Buffalo, NY the durability of these new reconstuctive tools.
Leslie Manohar, MD, Buffalo, NY
Mary T Bayers-Thering, MS, Buffalo, NY
Vasu Chirumamilla, MD,
Knee surface warmth is a common clinical observation after
Total Knee Arthroplasty (TKA) and could be of concern to the
patient as well as the treating surgeon who may consider this as
a sign of infection. The question also exists as to whether the
temperature elevation present in an infected TKA is significantly
higher than that seen in a normal post-operative course. The
purpose of this study is to quantitatively evaluate the knee
surface temperature variations in relation to TKA and infection.
253 consecutive patients presenting for a routine office visit
prior to or after a primary TKA were included in the study. A
non-invasive infrared thermometer was utilized to measure the
surface temperature on the anterior surface of both knees. Body
temperature, room temperature, range of motion, Knee Society
Score, and pain level were also recorded. The surface tempera-
ture of arthritic and non-pathological knees did not differ statis-
tically (P=0.12). When compared to a non-pathological knee,
the largest rise in the surface temperature of operated knee
occurred at 6 week visit (Mean, 6.05°F; 95% CI, 5.20°-6.90°F).
A statistically significant rise in temperature was also noted at 12
weeks (Mean, 4.35°F; 95% CI, 3.37°-5.34°F) and 6 months
post-operatively (Mean, 3.39°F; 95% CI, 2.29°-4.50°F), but not
at 1 year. To date, we have had 2 patients with documented knee
infections. The knee surface temperature rises after a total knee
arthroplasty and may stay elevated up to a year. This warmth,
when present alone, is usually not indicative of infection.
POSTERS the surgeon’s ability to duplicate a consistent femoral cement

mantle seen with a standard exposure. Cement debris is also
more common.
Trochlear Dysplasia - An Under Recognised Cause Wear of Polyethylene is Less in Lateral Than in
of Patellofemoral Arthritis (PFOA) Medial Unicompartmental Tibial Components
Jonathan DJ Eldridge, MD, Bristol, United Kingdom Philippe Hernigou, PhD, Creteil France, France
John Newman, FRCS, Bristol, United Kingdom Gerard Deschamps, MD, Dracy Le Fort, France
Mike Hendrix, MD, Bristol, United Kingdom This study evaluated the creep and true wear in 55 medial and in
Mahesh Kulkarni, FRCS, 35 lateral fixed bearing unicompartmental implants that had a
Trochlear dysplasia (TD) is generally considered uncommon flat articular surface at the time of implantation. All the polyeth-
and to present purely as persistent patella dislocation. ylene components had the same design, the same sterilization,
Information was extracted from that prospectively recorded on and were retrieved from 11 to 244 months after their implanta-
the Knee Replacement Database. Since 1989 627 isolated patello tion. The postoperative deformity had been measured on
femoral replacements (PFRs) have been performed. Before 2003 weight-bearing radiographs of the whole limb (hip-knee-ankle
none of the 333 cases were recognised as being associated with angle). The retrieved implants were placed in a coordinate meas-
TD though 227 were recorded as having lateral facet arthritis and uring machine.Using this system, a three dimensional scaled
48 previous dislocations or subluxations. Once the condition image was used to calculate the total penetration of the femoral
was recognised 42 of the next 139 cases were noted at surgery to implant in relation with true wear and creep. To separate plastic
have TD, which had been the precursor of the painful deformation from true wear, the volume of true wear was calcu-
arthritis.87 such patients received a questionnaire about their lated by wheighing the tibial components and comparing the
initial symptoms. 60% had suffered adolescent anterior knee results with non implanted components . Difference between
pain. Lack of trust, stair problems, giving way and catching were the penetration determined by the coordinate machine and
also common symptoms which proved to be very varied. Only penetration determined by wheighing was considered to be in
66% had ever suffered a dislocation, their troubles had started at relation with creep. Total linear penetration rates ranged from
age 12 years, as opposed to age 24 for those with pain and insta- 0.2 to 2.6 mm/year (mean 0.19 mm/year) and was significantly
bility symptoms but no dislocation.A careful retrospective less in lateral (mean 0.14 mm/year) than in medial implants
review of 40 PFR cases under the age of 55 showed evidence of (mean 0.25 mm/year). Linear penetration rates in relation with
TD in over 50%, based on operative findings, a crossing sign on wear ranged from 0.1 to 1.4 mm/year (mean 0.13 mm/year),
the true lateral radiograph and a sulcus angle of >145o. TD is and penetration in relation with creep ranged from 0.1 to 1.9
poorly recognised and can present in a variety of ways. The mm/year (mean 0.12 mm/year). The linear penetration of the
condition is a frequent cause of PFOA and often results in femoral condyle in relation with true wear was negatively corre-
complete loss of cartilage in the lateral patello femoral joint lated with length implantation in both medial and lateral

before the age of 50; severe pain and disability can follow. implants. The linear penetration in relation with creep was
higher in the first two years after the implantation versus the
POSTER NO. P112 subsequent years in both medial and lateral implants. Using
Does MIS Technique Compromise Cement Mantle multiple linear regression analyses to remove the confounding
effects of age, weight, gender and thickness of the implant, we
Quality at the time of TKR? found that an increase of the postoperative deformity was in
Frank R DiMaio, MD, Mineola, NY relation (p = 0.03) with an increase of creep and an increase of
Yong Kwon, MD, Stony Brook, NY true wear for medial implants. But an increase of the postopera-
Christopher M Breen, RPA-C, East Norwich, NY tive deformity was not in relation (p = 0.34) with an increase of
John Asheld, BS, creep or an increase of true wear for lateral implants. The post-
The pupose of this study is to determine whether or not the less operative deformity has a high influence on the penetration rate
invasive midvastus exposure during MIS TKR compromises of the femoral condyle in the polyethylene of medial unicom-
cement mantle grade when compared to a standard parapatella partmental fixed bearing tibial implants. This phenomenon was
arthrotomy and standard TKR 50 consecutive cemented MIS not observed for the lateral fixed bearing implants and wear was
TKR’s(MIS) were clinically and radiographically evaluated and significantly ( p= 0.01) less in lateral than in medial implants.
compared to a cohort of 50 consecutive cemented standard This phenomenon (important for the surgical technique and the
TKR’s(STD), which were completed prior to the advent of MIS choice of implant designs) may be in relation with different
technique within the lead surgeon’s practice. Patients were eval- kinematics in the two compartments .
uated pre and postoperatively via KSCRS. Analog radiographs
from the first and last postoperative visits were independently POSTER NO. P114
analyzed. Cement mantle grades were determined by Ewald’s Assessment of Outcome in Patients Undergoing the
criteria. Lucent lines, cement voids and cement debris were Avon Patellofemoral Knee Replacement
recorded for each group. Similar clinical KSCRS are reported for
both the MIS and STD groups at 2 years. Radiographic analysis Anthony F McGrath, MRCS, Aberdeen, United Kingdom
revealed compromised femoral component cement mantle W M Ledingham, FRCS, Banchory, United Kingdom
grades in the MIS group. A statistically significant number of Kapil Kumar, FRCS MCh, Scotland, United Kingdom
anterior femoral cement voids(zone 1) were recorded in the MIS Patellofemoral replacement surgery has been characterised by
group. Peri-patella and tibial cement debris in the MIS group implants dogged by poor durability. Improvements made with
was also more common The midvastus approach compromises the Avon knee has made selective resurfacing of the
patellofemoral joint far more viable than before and a real alter-
469
native to total knee replacement surgery. We reviewed 44 Avon POSTER NO. P116
patellofemoral arthroplasties performed between 2002 and Incidence of Stem Pain With Long Slotted and
2005 in 40 patients ranging from age 53 to 81 years. In addition
we compared outcome in patients with(17) and without(23) Flutted Stems in Cementless Revision TKA
comorbidities. Radiographic and arthroscopic evaluation was William Michael Mihalko, MD, PhD, Charlottesville, VA
performed pre-operatively to exclude patients with tibio-femoral Leo A Whiteside, MD, Saint Louis, MO
disease. Follow up ranged from 2 to 5 years, (mean 36 months). The number of primary TKA cases performed per year continues
Oxford Knee Scores, Bartlett Patellofemoral Scores and SF-36 to increase along with a greater number of revision cases. The
questionnaire were conducted pre and post operatively, at 3 revision TKA often requires a long tibial or femoral component
months and then 12 monthly intervals in addition to radi- stem for added support. Long stems in cemented revision TKA
ographic evaluation. No patient was lost to follow up. 4 devel- have been reported to have both a significant incidence of
oped tibio-femoral disease but none required revision surgery. femoral and tibial pain but no report of cementless revision
Early complications included 3 superficial wound infections and stem pain has been published. 119 patients were retrospectively
1 DVT. Overall there was significant improvement made reviewed who had undergone femoral and tibial revision with a
following surgery but also significant differences in outcome cementless component and a long fluted and slotted stem.
between these 2 groups. In those without comorbidities Oxford During their follow-up each was asked if they had pain in their
Knee Scores improved from 19(pre-op) to 38(post-op) as thigh or leg and if so to rate the severity. Radiographs were also
compared to 17 to 31 in those with co-morbidity.Bartlett scores reviewed and the amount of closure of the slot in the stem
improved from 9 to 24 in the healthy group and from 7 to 17 in recorded for analysis. 100 patients who underwent cementless
the co-morbidity group. SF-36 scores demonstrated improved primary TKA were retrospectively reviewed as a control group
pre-operative ‘starting’ points and greater benefit seen in those and asked the same questions concerning pain. Our data indi-
without co-morbidity. We conclude that the Avon knee is a valu- cates a 15.9 percent incidence of tibial stem pain (19/119) that
able surgical option in a motivated patient with isolated could not be attributed to stem size, patient age or radiographic
patellofemoral disease but that consideration must be made of convergence of the stem slot. These patients have rated pain
co-morbidities. from mild to severe (8 mild, 10 moderate, 1 severe) and reported
that it interferes with daily activities. Only 6/100 primary
POSTER NO. P115 cementless patients reported similarly located pain of mild
Tourniquet on with Deep Knee Flexion & Lateral nature. Tibial stem pain after revision TKA utilizing cemented
Tibial Release Facilitates Exposure in MIS TKA tibial base plates and cemented long stems has been reported.
No report has been published concerning tibial stem pain after
Aree Tanavalee, MD, Bangkok, Thailand cementless revision. Our data show that this may be a problem
Naraphong Hangasaphuk, MD, Pathumwan, Bangkok, in cementless revision cases when a tibial long stem is used but
Thailand found no incidence of thigh pain related to the presence of a
Srihatach Ngarmukos, MD, Stanford, CA long stem in the femur.
Recently, variations of surgical approach for MIS TKA have been
proposed. In general, if the visualization with the MIS approach POSTER NO. P117
or patellar subluxation are too limited, extension of the surgical Is Functional Improvement After TKA Related to
incision is recommended. However, no literature has studied the
effect of the knee position when turning on the tourniquet or
Increased Sports Activity in Osteoarthritis Patients?
the effect of the provisional lateral proximal tibia soft tissue Michael A Mont, MD, Baltimore, MD
release on patellar subluxation and visualization in the surgical Thorsten M Seyler, MD, Winston-Salem, NC
field. A consecutive series of 40 patients (40 knees) scheduled Frank R Kolisek, MD, Indianapolis, IN
for MIS TKA using a limited medial parapatellar arthrotomy Slif D Ulrich, MD, Baltimore, MD
incision (2 cm above the quadriceps tendon insertion) were Peter M Bonutti, MD, Effingham, IL
prospectively studied. The distance of patellar subluxation from David R Marker, BS, Baltimore, MD
the Whiteside’s line at 50-deg knee flexion was measured for
Osteoarthritis is a debilitating disease which ultimately leads to
every knee under 4 consecutive conditions; a) the tourniquet on
a loss of functionality and an inability to participate in athletic
with knee in full extension, b) no tourniquet pressure applied,
activity. Total knee arthroplasty is typically recommended in
c) the tourniquet on with knee in deep flexion and d) the tourni-
advanced cases of this disease. Improved prosthetic designs and
quet on with knee in deep flexion together with a provisional
surgical techniques have allowed surgeons to not only treat the
lateral proximal tibial release about 1 cm from the tibial joint
pain associated with osteoarthritis but also to restore functional
line towards the mid lateral tibial plateau. The average distance
capabilities. Ideally, this return of function leads to higher
of patellar subluxation with condition a) was 10 mm.
activity levels following surgery and an overall healthier lifestyle.
Conditions b) and c) provided 14.5 and 14.8 mm subluxated
The purpose of the present study was to analyze whether the
distance with statistical difference from condition a). However;
increase in physical activity of patients following surgery is asso-
there was no difference between condition b) and c) in terms of
ciated with their level of functional improvement. Additionally,
subluxation distance. Condition d) had an average 22-mm
we determined whether patients continue to participate in
subluxated distance and it was significantly different from
similar types of sports activity. An activity questionnaire was
condition a), b) and c). According to the distance of patellar
utilized to collect information from 212 consecutive patients
subluxation with 4 different conditions measured in the same
regarding the hours and types of sports activity they participated
knee, we found that turning on the tourniquet with knee in deep
in during the year prior to their receiving a total knee arthro-
flexion and performing a provisional lateral proximal tibial
plasty. The patients were given the questionnaire regarding their
release facilitated more exposure. This technique can reduce an
sports activity at a mean follow-up of 5 years following surgery.
unnecessary extension of the surgical incision in MIS TKA.
Additionally, the functional capabilities of all patients were
determined prior to surgery and at final follow-up using the
Knee Society objective rating system. The correlation between Spectroscopy. The most significant finding was that Zr / XLPE
pre- and post-op Knee Society function scores and the weekly was unmeasurable wear. Thus the present results can be consid-
increase in hours of athletic activity following surgery was deter- ered extremely encouraging for the use of advanced zirconia
mined based on the Pearson Product Moment Correlation. A materials in TKR and also may prove excellent for active patients
multivariate linear regression analysis was used to assess any who may otherwise risk high wear rates over many years of use.
differences in the correlation due to gender and other demo-
graphic parameters. A similar analysis was conducted to deter- POSTER NO. P119
mine if there was any correlation between the improvement in Does Higher Patient Activity Account for UKA
function scores and any change in mean activity score The mean
Knee Society functional score improved from 45 points preop-
Failures? a Note for High-Performance TKA Designs
eratively to 94 points postoperatively. Patients also reported an Mir H Ali, MD, Rochester, MN
increase of 1.8 hours of athletic activity and 3.2 points in the Diane Lynn Dahm, MD, Rochester, MN
mean activity score following surgery. Overall, the amount of Mark W Pagnano, MD, Rochester, MN
improvement in Knee Society function score was shown to Unicompartmental knee arthroplasty (UKA) has some recog-
predict both the increase in hours of weekly athletic activity nized advantages over TKA including better ROM, in-vivo knee
following surgery (r = 0.28) and the increase in weighted activity kinematics, and patient-rated function but at the price of a
score (r = 0.32). The multivariate linear regression analysis higher revision rate. Recent work has correlated postoperative
revealed that improvement in Knee Society function scores activity with the risk for failure. We sought to quantify activity
remained significant when controlling for age, gender, follow- after UKA compared to TKA to determine if greater activity might
up, and comorbidities Many knee osteoarthritis patients desire account for some of the difference in revision rates. We hypoth-
to participate in sports activity with a return to full function and esized that compared to TKA: 1) UKA patients would routinely
elimination of pain. The results of this study suggest increased engage in more demanding activities; 2) UKA patients would
range of motion and improved functional capabilities are corre- more often participate in sports deemed not recommended; and
lated with higher levels of activity following total knee arthro- 3) UKA patients would attain a higher level of function. 203
plasty. Activity levels are positively correlated to improved patients with a UKA done between 2000 and 2005 were
outcomes and further study will be needed to assess longer-term surveyed at 2 years minimum. Knee Society, UCLA activity,
effects of these activity levels on the durability of these pros- Tegner, patient-rated activity scores and participation in 40
theses. different athletic activities were documented. 1) UKA patients
engaged in more demanding activities than TKA patients (UCLA
POSTER NO. P118 score 7.8 versus 6.1; p <0.05); 2) UKA patients more often partic-
Improved Wear ZrO2/7-Mrad UHMWPE Knee Joint ipated in high impact sports not recommended by the Knee
and Phase Analysis by Confocal Raman Society (31% versus 16%; p<0.05); and 3) UKA patients
achieved higher levels of function (Knee Function score 79.2 vs.
Spectroscopy 71; p<0.05) Part of the difference in UKA and TKA revision rates
Riichiro Tsukamoto, MD, Loma Linda, CA is likely attributable to substantially greater activity after UKA.

Hiromu Shoji, MD, Riverside, CA While interest exists to develop TKA designs that more closely
Kazuo Hirakawa, MD, Kamakura, Japan mimic UKA function surgeons should be aware that an unin-
Prof Kengo Yamamoto, Tokyo, Japan tended consequence may be greater patient activity resulting in
higher revision rates.
Giuseppe Pezzotti, PhD, Loma Linda, CA
Mikiko Tsukamoto, MD, POSTER NO. P120
Ian C Clarke PhD, Loma Linda, CA
Ryoko Mine, Med Student,
A New Tibial Landmark in TKR
Shin Sasaki, MD, David F Dalury, MD, Baltimore, MD
Zirconia (y-TZP) was introduced as high-strength and high
Mary Jo Adams, BSN, Towson, MD
toughness ceramic as an alternative to alumina ceramic. Since It is well established that rotation of components is an impor-
the introduction of zirconia in 1985, the clinical outcomes and tant predictor of long-term success of TKRs. This paper describes
successes for hip joint have been controversial. ZrO2 and CoCr a reproducible landmark on the proximal tibia, visible through
femoral condyles were compared in the Bisurface knee configu- even the smallest incisions for correct tibial preparation. 50
ration (Japan Medical Materials Inc, Japan). The tibial inserts consecutive osteoarthritic knees were the study group. The
(XLPE) were gamma-irradiation sterilization to 3.5-Mrad and 7- average pre-operative standing X-ray alignment of the knees was
Mrad. Knee simulation was conducted on a 6 station simulator. 3 degrees of varus (range 15 degrees valgus to 14 degrees of
Lubricant was serums (20mg/ml protein) with additive EDTA. varus). After a standard tibial exposure, a line was drawn on the
Serum was changed every 0.5 Mc until 5 Mc durations and then surface of the tibia along the length of the sulcus of the medial
every 1 Mc until 10 Mc duration and wear trends assessed by and lateral tibial spines towards the anterior knee and a perpen-
linear regression techniques. Microscopic characterization was dicular to this was drawn on the anterior portion of the tibia.
carried out on the polyethylene tibial inserts using confocal When the above-described line was drawn, in all cases the line
Raman microprobe spectroscopy (irradiation with a blue laser ended up within 1 to 3 mms to the medial border of the exposed
with wavelength 488 nm) after 10 Mc durations. The wear tibial tubercle. Post op standing radiographs revealed that when
showed uniform linear trending for the control implants (CoCr the tibia was cut perpendicular to the drawn line (or parallel to
/ UHMWPE) averaging 4.5 mm3/Mc. The Zr / XLPE 7-Mrad the line on the tibial surface) the tibia had been placed between
combination also showed that wear was unmeasurably small. 0 and 3 degrees relative to the mechanical axis in 46/50 knees.
Raman spectroscopy studies confirmed that no transformation In 2 knees the tibial spines couldn’t be accurately identified and
or structural modification of the zirconia surface occurred. This in 2 other cases this line would have malrotated the tibia. In no
is also the first study of zirconia knees/XLPE by Raman knee was there more than 1-3 mm of medio-lateral opening
when measured in slight flexion. The tendency in medial
471
approaches to the knee is to internally rotate the tibial cutting groups had improvement in KSS after 1 year follow-up as
jig. If posterior slope is added to an internally rotated tibial cut compared to the pre-operative values, not significantly different
the result will be postero-lateral instability. This paper demon- than each other (MB: mean 88, FB: mean 86). Knee flexion at 3
strates a new landmark for tibial orientation, which is reliable in months and 1 year were better for mobile (105 degrees, 114
a wide variety of knees. As smaller incisions become more degrees) versus fixed bearing (95 degrees, 101 degrees). The
popular in TKR surgery, this easily visible landmark can help simulator data demonstrated less wear and post damage with
align the tibial cut in most knees and avoid postero-lateral insta- MB components. Revision TKA can be complex, but patients still
bility expect pain relief and restoration of function comparable to
primary surgery. As many active patients are undergoing TKA,
POSTER NO. P121 one would expect that some of these patients will require revi-
A New Algorithm for Identifying the Joint Line in sions. As our results demonstrate, mobile bearing revision
surgery has the potential for increased durability and function as
Knee Arthroplasty using Inter-Epicondylar Distance compared to fixed bearing implants.
Trichy Srinivasarangan Rajagopal, Dr., London, United
Kingdom POSTER NO. P123
Dinesh K Nathwani, MD, Middlesex, United Kingdom Preoperative Pain Location has a Poor Correlation
Restoration of the position of the prosthetic joint line to the with Intraoperative Findings in TKA patients
same level as the natural joint line, is a challenging problem in
primary and revision knee arthroplasty and there is no reliable David F Dalury, MD, Baltimore, MD
method for achieving this objective. We hypothesise that there is Ricardo Gonzales, MD, Hopkinton, NH
a constant ratio between the inter-epicondylar distance and the Susan Marie Odum, MED, Charlotte, NC
distance from the inter-epicondylar line to the joint line, and Mary Jo Adams, BSN, Towson, MD
this could be used to estimate the position of the joint line. We Some surgeons utilize the location of a patient’s knee pain to
analysed one hundred Computerised Tomography (CT) scans of help decide whether to offer a patient with end-stage Xray find-
the knee to study this relationship. The inter-epicondylar ings, a unicompartmental knee or total knee replacement. Only
distance and the perpendicular distance from this inter- modest associations have been found between radiographic
epicondylar line to the joint line was measured using both the disease, gross and arthroscopic findings and pain severity expe-
clinical and surgical epicondylar axes for each knee as described rienced by patients with knee osteoarthritis (OA). The purpose
in previous literature. The results showed that using the clinical of this study is to systematically examine these relationships
epicondylar axis the inter-epicondylar distance was 3 times the among patients undergoing total knee arthroplasty (TKA).
perpendicular distance from the inter-epicondylar line to the Information was collected preoperatively from seventy-two
joint line (the median and mean ratio 3.0, Standard Deviation consecutive patients (100 knees) undergoing primary TKA for
±0.21). Using the surgical epicondylar axis the ratio was 3.3 (the knee OA. Patients with ipsilateral hip or spine symptoms were
median and mean ratio 3.3, SD ±0.25). We conclude that the excluded. Pain severity, stiffness, and function were assessed by
position of the joint line from the inter-epicondylar line is one- the Western Ontario MacMaster (WOMAC) questionnaire.
third of the inter-epicondylar distance which is a valuable guide Patient reported pain was recorded on a standardized drawing of
especially when there is significant bone loss at the tibio-femoral the knee. Radiographs were reviewed and assigned an overall
articulation. This distance is easily calculated when using Kellgren-Lawrence grade (K/L) and joint-space narrowing grade
Computer Navigation for the surgery in both the primary and (JSN) for each compartment. At the time of surgery, the severi-
revision setting and the modern software programmes for ties of cartilage defects were graded. Severe medial compartment
Computer Assisted TKR should be modified accordingly. disease (JSN 3 ‘ 4) was present in 86 knees, and varus deformity
was present in 78 knees. Spearman Rank correlation coefficients
POSTER NO. P122 were significantly small as follows: inferomedial pain and
Mobile Bearing Revision Total Knee Arthroplasty: medial compartment JSN on weightbearing AP radiograph
(0.17; p=0.04); inferomedial pain and medial tibial cartilage
Rationale and Early Clinical Results
degeneration (0.15; p=0.07) or medial femoral cartilage degen-
Alexander C Gordon, MD, Highland Park, IL eration (0.17; p=0.04). The strongest association found was a
Wayne M Goldstein, MD, Morton Grove, IL medium correlation between WOMAC total stiffness scores and
Jill Branson, RN, Kildeer, IL superolateral pain (0.38; p=0.001). Despite a preponderance of
Christopher Simmons, BS, Willow Springs, IL medial compartment disease, the correlation between medial
Kimberly A Berland, CST, Warrenville, IL JSN, gross medial cartilage degeneration and medial knee pain
The rates of revision total knee arthroplasty are expected to was weak. When systematically studied, the pain experienced by
increase, as more TKAs are implanted in younger patients. This patients with knee OA is variable. This may be an important
problem will require durable revision systems that provide the consideration when evaluating surgical treatment options,
function patients expect. We present the rationale for, and our particularly the decision whether to recommend a Uni or a TKR
early experience with, mobile bearing (MB) revision knees. Fixed in isolated unicompartmental disease.
and mobile bearing constrained (TC3) revision knee compo-
nents were tested in a knee simulator under normal gait condi- POSTER NO. P124
tions. Gravimetric wear and surface damage was analyzed. 71 A Use of an Oxidized Zirconium Cemented Femoral
knee revisions implanted between 8/2004 and 12/2006 with the Component in Primary TKR: A 6 Year F.U.
DePuy MBT revision system were compared to 55 fixed bearing
Richard Sheldon Laskin, MD, New York, NY
(FB) revision knees implanted between 1999 and 2004 for early
complications, range of motion, KOOS and Knee Society scores. This study reports the 6 year follow up of the use of a cemented
Early re-operation rates between designs were similar, 5 percent ceramic surfaced oxidized Zr femoral component for 100 patients
FB and 4 percent MB, with one dislocation in each group. Both under the age of 65 that were undoing a tricompartmental total
knee replacement. Patients were evaluated clinically and radi- obtained balanced extension/flexion gaps technique to
ographically at 1,3,5 and 6 years after surgery. The Knee Society anatomic landmarks. If anatomic landmarks are used for
rating system for clinical and radiographic findings was used. As femoral component rotation with a conventional or CAS tech-
randomsly selected subset underwent an MRI to evaluate the nique, this may result in an asymmetric trapezoidal flexion gap.
implant cement interface. In pre clinical biomechanical testing Rotation of the femoral component as determined using CAS
there was a decrease in both adhesive and abrasive wear as with balanced extension and flexion gaps may result in better
compared to Cobalt-Chrome alloy when the materials were artic- biomechanics throughout the arc of motion.
ulated against UHMWPE. In patients in whom long term
longevity of the arthroplasty was required, this combination of POSTER NO. P126
oxidized zirconium and polyethylene was therefore felt to be ◆Gait Patterns in Patients Following Total and
potentially advantageous. The mean Knee Society score at 6 years
after surgery was 93. The mean Knee Society Function Score was
Unicompartmental Knee Replacement Surgery
72. The mean Knee Society pain score was 46.5. There were no Julian Feller, MD, Melbourne, VIC Australia
cases of recurrent synovitis in the series. Two patients had a radi- Jodie A McClelland, BA,
olucency under the posterior lateral femoral condyle < 1mm I Kate Webster, PhD, Bundoora, VIC Australia
thickness which was non progressive. Other than for this there Three dimensional gait analysis has identified abnormal loading
were no femoral radiolucencies. In a subset of the patients, MRI patterns across the knee which could be expected to adversely
evaluation of the interface between the implant and the femoral affect the prosthetic components in terms of loosening and
cement revealed a bland interface with no evidence of loosening wear. It has been suggested that the preservation of the anterior
or inflammation. There were not cases of femoral component cruciate ligament (ACL) in UKR may result in a different, and
loosening. One patient developed a secondary infection to his potentially more normal biomechanical outcome than after
knee from a dental abscess. The implant was removed as part of TKR. The aim of this study was therefore to compare the biome-
a two stage exchange 3 ½ years after surgery. The femoral compo- chanics of UKR and TKR patients during gait. Eleven TKR (8
nent was noted to have no scratches. No demonstrable abrasive male, 3 female) and 8 UKR (5 male, 3 female) patients with a
wear could be found on the tibial component. There were no good or excellent outcome on the Knee Society Score twelve
adverse effects attributable to the use of the oxidized ceramic months following surgery were included in the study. Sagittal
surfaced component. There was no evidence of loosening nor peak angles, sagittal and coronal peak moments, and vertical
osteolysis at the implant cement interface. ground reaction force for the operated knee were obtained using
a three dimensional motion analysis system and force plate.
POSTER NO. P125 Subjects completed 10 walks of 10 metres at a comfortable
Computer Assisted Evaluation of Anatomic speed. There were no differences between the UKR and TKR
Landmarks for Femoral Component Rotation in TKA patient groups for each of the variables. Additionally, all patients
displayed a biphasic external flexion-extension moment pattern
Mark Clatworthy, MD, Auckland, New Zealand about the knee during stance. UKR patients walked with similar
David Carl Pollock, MD, Lewisville, NC biomechanics to patients with TKR. This challenges the notion

Douglas A Dennis, MD, Denver, CO that preservation of the ACL, as in UKR, allows restoration of
The method for determining femoral rotation in TKA is contro- more normal biomechanics during walking than TKR, in which
versial. Two methods are typically employed. Rotation of the the ACL is excised. The results also show that TKR patients walk
femoral component is determined by using anatomic land- with biomechanics that exceed previous expectations. The deci-
marks or a soft tissue balancing technique. Two hundred sion to use a UKR should be based on criteria other than the
patients underwent a TKA by two CAS experienced surgeons biomechanical outcome.
utilizing the DePuy Ci navigation system. This system employs a
ligament balancing technique whereby femoral rotation is deter- POSTER NO. P127
mined by cutting the femur parallel to the tibial cut with the liga- Survivorship of the Cementless LCS Rotating
ments balanced. Standard anatomic landmarks; epicondylar
axis, Whitesides line and the posterior condylar axis are also
Platform Knee Arthroplasties Over a 15-Year Period
collected as references. The techniques were compared. The Apostolos Simeon Chatzisymeon, MD, San Antonio, TX
epicondylar axis was a mean of 0.5º externally rotated Dimitris Kaltsas, MD, Chigwell, Essex, United Kingdom
compared with Ci technique (Range 11º internal rotation - 12º Adnan Majid, MBBS,
external rotation). Using this technique the flexion gap would be Clington Fernando, MBBS,
balanced +/- 3º 47% of the time.There was no significant corre- Introduction: Rotating platform knee replacements were
lation between epicondylar axis and Ci techniquer = -0.09 designed and implanted to minimize the wear and loosening
p=0.38.The posterior condylar axis was a mean of 0.5º inter- problems seen with fixed bearing implant designs. Methods: We
nally rotated compared with Ci technique (range 10º internal report the clinical results of 164 cementless Low Contact Stress
rotation - 11º external rotation). Using this technique the flexion Rotating Platform Knee Replacement (LCS De Puy) with a
gap would be balanced +/- 3º 55% of the time.There was no maximum follow-up of 15 years. The mean age was 69 years
significant correlation between posterior condylar axis and Ci (range 52-81years). Revision for any reason was considered as a
technique r=-0.01 p=0.96. Whitesides line was a mean of 2.8º failure. The principle indication for surgery was osteoarthritis
externally rotated compared with Ci technique (range 11º (96%). Results: Radiographic evaluation at a maximum 15-year
internal rotation - 12º external rotation). Using this technique follow-up showed stable fixation of all components, but in 7
the flexion gap would be balanced +/- 3º 33% of the time. There knees (4.26%) significant osteolysis had occurred. Four knees
was no significant correlation between Whitesides line and Ci had osteolysis beneath a loose tibial component after 10.2 years
technique, r=-0.17 p=0.08.There was a mean variation of 5.7º from the index surgery and revised to a cemented long-stem
between these bony landmarks for each patient There was tibial component. Three knees were treated with bearing
significant variation in femoral rotation when comparing a CAS exchange and with bone graft in the tibial lytic region at an
473
average 11.4 years from the index surgery. No cementless POSTER NO. P129
rotating-bearing patella loosened, dissociated, or fractured but Total Knee Arthroplasty for Hemophilic Arthropathy:
one cementless rotating-bearing patella (0.60 %) required revi-
sion due to polyethylene wear 10.6 years after the initial proce- 21-year Experience in Taiwan
dure. They were three revisions (1.8%) for infection. Chien-chung Chiang, MD, Taipei City, Taiwan
Conclusion: The survivorship of the cementless knee replace- Wei-Hsin Lin, MD,
ments using rotating platform with end points of revision for Ming-Hsiao Hu, MD, Taipei, Taiwan
any mechanical reason (but infection) was 96.34% at 15 Karl Wu, MD, Taipei, Taiwan
years.The long term results of the cementless LCS mobile- Rong-Sen Yang, MD, Taipei, Taiwan
bearing prostheses are excellent and very similar to the best
Po Quang Chen, MD, PhD, Taipei, Taiwan
results of fixed bearing total knee replacement in terms of loos-
ening, wear, and osteolysis. This is due to the large tibial-femoral Chen-Kun Liaw, MD, Taipei Hsien, Taiwan
contact areas of the mobile bearing knee prostheses that reduce We retrospectively evaluated 26 patients with hemophilia after
polyethylene wear. However, complications due to an increased TKA in the past 21 years to investigate the surgical outcomes and
incidence of osteolysis after 10 years follow-up are also reported. possbile complications. 35 TKA in 26 patients with hemophilic
arthropathy were done between November 1985 and July 2006.
POSTER NO. P128 There are 25 males and 1 female. 23 patients were diagnosed of
hemophilia A and 3 were diagnosed of hemophilia B. All were
Mid-term Results of a New Rotating Hinge Total was performed by a single surgeon. The mean age at index oper-
Knee Arthroplasty ation was 34.2 years (23.4~47 years) and the mean follow-up
Christoph Muller, MD, Leipzig, Germany period was 79.9 months (12~258 months). No inhibitor of
Christian Melzer, MD, Bad Duben, Germany coagulation factor or HIV infection was detected in our popula-
Erhan Basad, MD, Giessen, Germany tion. The average preoperative range of motion was 63.2 degrees
The use of unconstrained TKA in the severely deformed knee is (15~78.2 degrees) with flexion contracture 15 degrees, whereas
limited. The aim of this study was to evaluate the clinical the average postoperative range of motion was 79.8 degrees
outcome of a rotating hinge prosthesis in unstable knees with (5.5~ 85.3 degrees) with flexion contracture 5.5 degrees.
advanced varus or valgus deformity. In this retrospective study, we Improvement of range of flexion was 7.1 degrees (p=0.18);
reviewed a consecutive series of 88 patients listed for primary improvemet of range of extension was 9.5 degrees (p=0.01).
TKA using a cemented, stemmed, semi-constrained rotating Average increase of range of motion was 16.6 degrees (p=0.02).
hinge prosthesis. Of these, 61 patients were available for follow- Pain score was 7 preoperatively and 48 postoperatively; func-
up, 12 had died, 7 were lost to follow up, 8 underwent revision tional score was 42 preoperatively and 77 postoperatively
(4 septic loosening, 1 aseptic loosening, 3 periprosthetic frac- (p<0.05). 3 patients received manipulations due to inadequate
ture). IRB approval was obtained for the study. Mean follow-up range of motion. 3 infection episodes (MSSA, MSSE,
time was 77.4 months (range: 48.9-99.2 months), age at opera- pseudomonas) were treated with debridement and 1 among
tion 66.5±7.5 years, duration of operation 94.5 min. The KSS was them was revised after removal of prosthesis. Another 1 patient
recorded prior to surgery and at follow-up. Clinical and radi- received revision TKA due to loosening of femoral component.
ographic results were evaluated using the Knee Society rating The other 1 patient received revision TKA with thicker insert due
system. Perioperative complications were documented. to subluxation of the prosthesis. Though improvement in range
Cumulative survival probability was 90.0% with explantation for of flexion is not significant in hemophilic arthropathy of knee
any reason as the end-point. The mean preoperative knee score after TKA, the result showed significant increase in total range of
and function score was 23.7 and 45.6 and improved at follow-up motion after operation, especially in improvement of flexion
to 90.8 and 61.8 respectively. ROM increased from 96.3 preoper- contracture. It also showed great pain relief and significant func-
atively to 111.5 at follow-up. Of 59 patients with varus / valgus tional gain. Under the circumstance of acceptable infection rate
deformity 55 patients demonstrated straight leg alignment. and complication, TKA is an effective method to achieve pain
Patient satisfaction was good: 93.4% of the patients were very or relief and gain better quality of life in patients with hemophilic
mostly satisfied. Radiographic evaluation did show solid fixation arthropathy of knee.
of the femoral (93.4%) and tibial (96.7%) component. Bone loss
POSTER NO. P130
occurred under the tibial tray (18%). Migration of the femoral
stem with loosening was seen in 2 patients. Radiolucent lines The Cost Effectiveness of Computer Assisted
without clinical evidence of loosening appeared in 22.2% Navigation in Total Knee Arthroplasty
(femur) and 26.2% (tibia). Perioperative complications included Erik J Novak, MD,PhD, San Francisco, CA
one femoral fracture, one deep infection, two patients with
Marc D Silverstein, MD, Houston, TX
delayed wound healing, one peripheral nerve palsy. This study
demonstrates excellent mid-term outcome for a rotating hinge Kevin John Bozic, MD, MBA, San Francisco, CA
TKA. Its use would appear beneficial for patients with severe Total knee arthroplasty (TKA) is one of the most clinically
deformity in osteoarthritis of the knee. successful and cost-effective interventions in medicine. However,
implant malalignment, especially in the coronal plane, is a
common and preventable cause of early failure following TKA.
Computer assisted surgery (CAS) has been employed in TKA to
improve the precision of component alignment. The purpose of
this study was to evaluate the cost-effectiveness of CAS to deter-
mine whether the improved alignment achieved with computer
navigation provides a sufficient decrease in failure rates and revi-
sions to justify the added cost. A decision analysis model was
used to estimate the cost-effectiveness of CAS in TKA. Model
inputs including costs, effectiveness, and clinical outcome prob- POSTER NO. P132
abilities were obtained from a review of the literature. Sensitivity 18 Years Experience with Isolated Patellofemoral
analyses were performed to evaluate the impact of component
alignment precision using computer-assisted and mechanical Arthroplasty
alignment guides, TKA failure rates secondary to malalignment, Christopher Ackroyd, FRCS, Bristol, United Kingdom
and costs of CAS systems on the cost-effectiveness of computer Jonathan DJ Eldridge, MD, Bristol, United Kingdom
navigation in TKA. CAS is both more effective and more expen- John Newman, FRCS, Bristol, United Kingdom
sive than mechanical alignment systems. Given an additional The Bristol Knee Group has prospectively followed the results of
cost of $1500 per surgery, a 14% improvement in coronal align- over 560 isolated patellofemoral arthroplasties. Initial experi-
ment precision (within 3° of neutral mechanical axis), and a 11- ence with the Lubinus prosthesis was disappointing. The main
fold increase in revision rates at 15 years with coronal causes of failure were mal-tracking and instability leading to
malalignment, the incremental cost of using CAS is $45,554 per excessive polythene button wear and disease progression in the
quality-adjusted life year gained. Cost-savings is achieved if the tibio femoral joint. This experience resulted in the design of a
added cost of CAS is $629 or less per surgery. Variability in new prosthesis to correct tracking and improve the wear charac-
published clinical outcomes, however, introduces uncertainty in teristics. We now report the results of over 484 cases of this
determining the cost-effectiveness. CAS is potentially a cost-effec- arthroplasty with a maximum follow-up of 11 years.
tive or cost-saving addition to TKA. However, the cost-effective- Survivorship for revision at 5 years is 96% and the functional
ness is sensitive to variability in the costs of computer navigation outcome is over 80% satisfactory. Symptomatic progression of
systems, the accuracy of alignment achieved with computer navi- the arthritic disease in the medial or lateral tibio femoral
gation, and the probability of revision TKA with malalignment. compartments has occurred in 8% of cases causing recurrent
joint pain. There have been few cases of tracking problems (3%).
POSTER NO. P131 Several cases have required realignment with the Elmslie or
Autologous Interleukin-1 Receptor Antagonist for Insall procedures. Radiographic follow-up has shown a higher
the Treatment of Symptomatic Knee Osteoarthritis rate of disease progression emphasising the importance of
careful assessment of patients prior to operation.We have inves-
Gie Kiem Auw Yang, MD, Utrecht, Netherlands
tigated 12 cases of persistent unexplained pain which suggests 3
Natasja Raijmakers, MSc, possible causes which will be discussed. Six cases have been
Ewout Van Arkel, MD, successfully treated by revision of the femoral component. The
Paul Rijk, MD, PhD, Avon prosthesis is giving promising results with few problems.
W Jaap Willems, MD, PhD, Bergen, Netherlands Minor misplacement of the femoral component can lead to reti-
Jacco Zijl, MD, nacular impingement causing persistent pain. Attention to detail
W.JA. Dhert, PhD, Utrecht, Netherlands in the performance of the operation will prevent these problems.
Daniel B F Saris, MD, Ph D, Utrecht, Netherlands Disease progression remains a risk in any compartmental arthro-
Incubation of blood with CrSO4-coated glass beads stimulates plasty and strict preoperative criteria are essential.

synthesis of anti-inflammatory cytokines, such as Interleukin-1
POSTER NO. P133
receptor antagonist (IL-1ra), IL-4, IL-10, and IL-13. As
Interleukin-1² (IL-1²) is thought to play a key-role in ◆Mobile Bearing Improves Patellar Tracking and
osteoarthritis (OA) development, this treatment (Orthokin) PF Contact Force in Total Knee Arthroplasty
might be a viable approach to alter the course of OA through
Tokifumi Majima, MD, PhD, Sapporo, Japan
modulation of the joint homeostasis by blocking the IL-1
receptor. An IRB-approved prospective, double blind, placebo
Naohiro Sawaguchi, MD,
controlled RCT was conducted. 167 patients (54 ± 10 years old) Masahiro Inoue, MD, Hyogo, Japan
with symptomatic knee OA were treated by intra-articular injec- Takuya Watanabe, MD, PhD,
tions with either Orthokin or physiological saline (placebo). The Takayuki Ishigaki, MD,
WOMAC, VAS for pain, KOOS and KSCRS were administrated Osamu Nishiike, MD,
pre-treatment, and at 3, 6, 9 and 12 months post-treatment. The Akio Minami, MD, Sapporo, Japan
primary efficacy objective consisted of 30% superiority on the Controversies exist in clinical study concerning the effect of
WOMAC. Improvements on the WOMAC were comparable for rotating platform on patellar tracking. The aim of this in vivo
Orthokin and placebo treatment (16.8% vs. 16.5% respectively). study was to compare patellar tracking and patello-femoral
Orthokin did result in significantly more improvement on the contact force in mobile bearing and fixed platform intra-opera-
KOOS symptomatology (P = 0.002) and KOOS sport (P = tively in the same knee. Fifty knees of posterior stabilized total
0.042) parameters. In addition, for most other outcome param- knee prostheses (P.F.C. Sigma RP-F, DePuy, USA) were evaluated
eters, Orthokin consistently resulted in higher scores as using a CT-guided navigation system (Vector Vision, Brain LAB,
compared to placebo (n.s.). The statistically significant improve- Germany). Surgery was performed by single surgeon using
ments on symptomatology and sport parameters together with subvastus approach. No patients received lateral retinacular
the superiority of IL1-ra on most other parameters indicate a release. The intraoperative comparison was performed with the
beneficial biological effect of Orthokin on symptomatic knee mobile and fixed platform trial components into place in the
OA and, therefore, seem to support further investigations into same patient. The force exerted on the patellar component was
the possible chondroprotective effect of Orthokin. However, the measured directly using ultra thin (100um) force transducer.
primary efficacy objective was not met and, therefore, the clin- Medial shift and lateral tilt of patella were significantly smaller
ical benefit of Orthokin when administered in trial conditions in mobile knee. Maximum contact force was significantly
seems limited. smaller in mobile knee (58.6+/-9.0N) than fixed knee (113.3+/-
23N). PF contact force increased during knee flexion in all knees.
In the present in-vivo study showed that rotating platform
475
improved patellar tracking and patello-femoral contact force. Statistical analysis at 95% confidence level was conducted in
The self-aligning feature of a rotating platform knee would order to determine which variables are different for a subject,
decrease the prevalence of tilt and medial shift of patella. having a TKA, who experienced greater weight-bearing flexion.
Strength of the present study is that the measurements were Both the lateral and the medial condylar contact positions for
performed in the same knee. Furthermore, the surgery was subjects in Group 2 were significantly more posterior (p<0.05)
performed using CT based navigation, which can make surgery than the subjects in Group 1 at 0°, 30°, 60°, 90° and maximum
accurately. The measurement of kinematics under anesthesia is flexion. Interestingly, although the contact positions were statis-
one of the limitations of this study. tically different, the amount of posterior femoral rollback was
not different between these groups from full extension to 90°
POSTER NO. P134 flexion (p>0.05). However, this trend changed when assessing
Computer-Assisted Analysis of the Effect of overall motion form full extension to maximum knee flexion as
subjects in Group 2 achieved statistically greater posterior
Ligamentous Injuries on the Axial Rotation of the femoral rollback of both condyles (P<0.05). The overall amount
Knee of axial rotation and the incidence of lift off for the two groups
Philippe Massin, MD, Angers Cedex, France were statistically similar. Since subjects in Group 2 achieved
Gregory Biette, MD, Paris, France greater weight-bearing flexion, it could be expected that these
Pascal Kilian, PhD, La Tronche, France subjects would experience greater posterior femoral rollback at
maximum flexion. However, it is interesting that these subjects
The effect of severe sprains on the axial rotation of the knee was
achieved statistically more posterior contact positions of both
studied using a dedicated navigation system. An infrared camera
condyles at each increment of knee flexion. It was also inter-
array tracked 3 beacons fixed to the femur and the tibia. A
esting that axial rotation did not play a role in the subjects in
working model of the cadaver’s knee was obtained by means of
Group 2 achieving greater weight-bearing knee flexion.
the bone morphing technique. The computer displayed the
most distal point of each condyle relative to its tibial glenoid. POSTER NO. P136
Thus the axis joining the lateral and medial femoro-tibial
contact points was shown in real time. The instantaneous center Comparison of Patellofemoral Mechanics for High
of rotation was the intersection between 2 axes at 1° intervals of Flexion TKA and Normal Subjects
flexion. In a wider range of flexion, the centre of rotation was Adrija Sharma, Knoxville, TN
calculated as the barycentre of the instantaneous centres of rota-
Filip Leszko, MSc, Knoxville, TN
tion. Eight embalmed cadaver knees were tested. Sequential liga-
Richard D Komistek, PhD, Knoxville, TN
mentous sections were done. After section of the anterior
cruciate ligament (ACL), the femoro-tibial contact points Harold E Cates Jr, MD, Knoxville, TN
between -5 and +5° migrated posteriorly. After section of the Giles R Scuderi, MD, New York, NY
posterior cruciate ligament (PCL), the medial condyle roll The purpose of this study was to analyze patellofemoral kine-
forward started earlier (at about 40° versus 80° in the intact matics in high flexion TKAs and determine if the patellofemoral
knee).After section of the popliteus, the lateral condyle roll back joint is subject to detrimental forces in high flexion ranges.
started later (at about 110° instead of 60° in the intact knee)The Twenty TKA (10 PCR, 10 PS) and seven normal patients
section of the medial collateral ligament (MCL) annealed the performing deep knee bend were analyzed. The in vivo
axial rotation. The ACL controls the end of rotation. The PCL femorotibial and patellofemoral kinematics were determined
stabilizes the medial condyle in mid flexion. The popliteus is a using previously reported methods based on fluoroscopy. The
starter of the lateral condyle roll back. The MCL appears as the kinematical data were entered into a 3D inverse dynamics math-
pivot of the axial rotation. ematical model to determine the in vivo contact forces at the
knee. During the early phase of flexion the average
POSTER NO. P135 patellofemoral contact point in the normal knee was 10mm
Kinematic Difference between Subjects Having Low inferior to the TKA knees. Patellotibial tilt measurements
showed that at deeper flexion there was a significant difference
and High Flexion for the Same Flexion Angles between TKA and the normal knees. The in vivo patellofemoral
Adrija Sharma, Knoxville, TN forces increased monotonically with increase in knee flexion
Douglas A Dennis, MD, Denver, CO and average values at maximum flexion were 2.83BW, 2.77BW
Richard D Komistek, PhD, Knoxville, TN and 2.73BW for the PS TKA, PCR TKA and the normal knees,
Mohamed Mahfouz, PhD, Knoxville, TN respectively. Multivariate correlation analysis revealed that the
Matthew Anderle, BS, patellofemoral force was highly correlated to the knee contact
force (both the medial and the lateral side), the quadriceps force
Chris D Little, BS,
and the patellar ligament force. The patellofemoral force also
In vivo fluoroscopic studies have determined that the kinematic had very strong correlation with the patellar tilt angle. Even
patterns for TKA are often quite variable, but an in-depth though the measurements revealed differences between TKA and
analysis of this variability has not yet been quantified. Therefore, normal patellofemoral kinematics, the maximum contact forces
the objective of this study was to compare the in vivo kinematics were not significantly different. These results may suggest that
for subjects having a TKA who were not able to achieve high the mechanical performance of the TKA patellofemoral joint is
flexion versus those subjects who routinely experience greater not fraught with detrimental kinetic conditions.
weight-bearing flexion to determine which variables are statisti-
cally different between these two groups. Two hundred subjects
having a TKA were evaluated using fluoroscopy during a deep
knee bend to determine their in vivo kinematics. Eighty-two of
these subjects experienced 95° or less of weight-bearing flexion
(Group 1), while 118 subjects achieved 110° or more (Group 2).
POSTER NO. P137 re-infection, 2 for (MCL) instability, and 2 for aseptic loosening.
Development of a Clinically Relevant Lubricant for The latest mean knee society score was 135, ROM 110 degrees
and progressive radiolucent lines in only 2 patients. Kaplan-
In-Vitro Wear Testing of Total Knee Replacements Meier survivorship analysis revealed a probability of survival free
Jan Mels B Brandt, London, ON Canada of revision for aseptic loosening of 98% at 12 years. The use of a
Kory Charron, London, ON Canada hybrid cement technique in revision knee arthroplasty can
Lin Zhao, PhD, provide good mid to long-term results. Radiographic analysis
John B Medley, PhD, Waterloo, ON Canada has shown continued satisfactory appearances regardless of
Steven J MacDonald, MD, London, ON Canada constraint, stem size and augments. Our reported survivorship
of a hybrid fixation technique for revision knee arthroplasty is
comparable to reported long-term survivorship for cemented
Richard W McCalden, MD, London, ON Canada stems in revision knee arthroplasty.
There is no universal consensus on the protein sub-constituents,
serum osmolality, addition of hyaluronate (HA) and microbial POSTER NO. P139
growth inhibitors for lubricants used in knee implant wear
testing. The present study obtained clinical data on synovial
Comparison of BMD Around the Knee Between
fluid (SF) composition, compared it with current lubricants and Trabecular Metal and Cemented Tibial Component
proposed a more clinically relevant lubricant. SF was drawn Yukihide Minoda, MD, Osaka, Japan
from 20 patients and the protein sub-constituents and osmo- Akio Kobayashi, MD, Osaka, Japan
lality were determined. Knee simulator (AMTI) wear tests for 13 Hiroyoshi Iwaki, MD, Osaka, Japan
million cycles were conducted on gas-plasma sterilized polyeth- Mitsuhiko Ikebuchi, MD, Abeno-ku Osaka, Japan
ylene inserts (AMK, DePuy) with 3 calf sera of different protein
Fumiaki Inori, MD, Osaka, Japan
sub-constituents: alpha (ACS), newborn (NCS) and bovine
(BCS). The effect of osmolality and hyaluronic acid (HA) on Yoichi Ohta, MD, Osaka, Japan
wear was assessed. Electrophoresis, protein degradation, micro- Yoshinori Kadoya, MD, Sakai, Japan
bial contamination and protein shear were determined. The Hirotsugu Ohashi, MD, Osaka, Japan
protein sub-constituent concentrations for NCS and BCS were Kunio Takaoka, MD, Osaka, Japan
largely different from SF; ACS was closest to SF. The wear rate was Trabecular metal (Zimmer, Warsaw, IN) is a new material that
different between all three calf sera (p<0.05). Increased protein recently has been introduced for total knee arthroplasty. Its
degradation caused higher wear (p<0.05). Increased albumin- porosity, low modulus of elasticity, and high frictional charac-
alpha-1 globulin concentration reduced the wear rate (p<0.05). teristics was expected to have feasible effect on host bone quality.
Diluting ACS with distilled water resulted in non-clinical osmo- However, the effect of trabecular metal tibial component on the
lality levels and increased the wear (p<0.05). ACS diluted with bone mineral density (BMD) was not reported. The purpose of
buffered-saline and HA increased the wear rate (p<0.05). Using this study was to compare the BMD between trabecular metal
antibiotics over sodium azide eradicated microbial contamina- and cemented tibial component. 31 knees receiving trabecular

tion and reduced the wear rate (p<0.05). The wear rate increased metal tibial component and 33 knees receiving cemented tibial
with increased protein shear (p<0.05). The most clinically rele- component had dual energy x-ray absorptiometry (DEXA) scans
vant lubricant was ACS diluted with buffered-saline + HA + at preoperatively and 3 weeks, 3, 6, 12, 18, 24 months post-oper-
antibiotics to closely mimic the in-vivo boundary lubrication atively, to assess peri-prosthetic BMD. Average follow up period
conditions. Similarities in surface pitting and roughness was 1.8 (1.5 - 2 ) years. Preoperative BMD in femoral neck, wrist,
between simulator tested and retrieved femoral components lumbar spine and knee between two groups were not significant.
were found. In both groups, BMD in tibia decrease postoperatively. However,
postoperative decrease of BMD in lateral aspect of tibia was
POSTER NO. P138 significantly less in trabecular metal component than cemented
Mid to Long-term Results of Hybrid Cement tibial component (p=0.0007). This is the first report on BMD
after total knee arthroplasty using trabecular metal tibial compo-
Fixation in Revision Total Knee Arthroplasty nent. DEXA study revealed that trabecular metal tibial compo-
Gavin Wood, MD, Chorley, United Kingdom nent showed a favorable effect on BMD of proximal part of the
Doug Naudie, MD, London, ON Canada tibia after total knee arthroplsaty.
Richard W McCalden, MD, London, ON Canada POSTER NO. P140
The use of stems in revision knee arthroplasty is universally Conventional Vs. Computer Assisted Technique: A
accepted. The ideal method of stem fixation remains controver- Prospective Alignment Study of 1000 TKRs
sial with advantages and disadvantages to both cemented and
press-fit designs. Several studies suggest that cemented revision Christian Luring, MD,
knee stems may provide better long-term survival. The purpose Lars Perlick, MD, Bad Abbach, Germany
of this study was to report our mid to long-term experience with Joachim Grifka, MD, Pentling, Germany
hybrid cement fixation in revision total knee arthroplasty. Holger Bathis, MD, Cologne, Germany
Patients who underwent revision total knee arthroplasty using a Markus Tingart, MD, Regensburg, Germany
hybrid cement technique with a titanium fluted revision knee Restoration of the mechanical leg axis and component posi-
implant were identified. 127 patients (135 knees) with a mean tioning are crucial factors affecting long term results in total knee
age at surgery of 71 years were reviewed. Mean follow-up was arthroplasty (TKA). Recently, computer-assisted surgery became
5years (range, 2 to 12). Patients were followed with the Knee popular in TKA and first results are promising. The aim of this
Society score and radiographic assessment. Of the 135 knees, 36 prospective study was to analyse the accuracy of computer-
died and 2 were lost to follow-up. Six knees were revised; 2 for assisted surgery on a high number of unselected patients oper-
477
ated on by different surgeons In a prospective study, 1000 POSTER NO. P142

patients were operated on either using a CT-free navigation
system or the conventional jig-based technique. Operations were
◆Accuracy of Navigated Minimally- Invasive
performed by 18 different surgeons. Leg alignment and compo- Unicompartmental Knee Arthroplasty
nent orientation was determined on postoperative long-leg Peter Muller, PhD, München, Germany
coronal and lateral x-rays. The mechanical leg axis was signifi- Jean-Yves Jenny, MD, Illkirch Graffenstaden, France
cantly better in the computer-assisted group (95%, within ± 3° Reinhard Weyer, MD,
varus / valgus) compared to the conventional group (74%, Patrick Weber, MD,
within ± 3° varus / valgus) (p<0.001). The coronal alignment of
John Michael, MD,
the femoral and tibial component as well as the sagittal align-
ment of the femoral component was more accurate in the
Eugene Ciobanu, MD,
computer-assisted group. On average, the operating time was Thomas Bacher, MD,
increased by 8min in the computer-assisted group. No signifi- Wolfram Neumann, MD, Magdeburg, Germany
cant differences were seen between senior surgeons and younger Volkmar Jansson, PhD, Munchen, Germany
ones regarding postoperative leg alignment and operating time. The minimally invasive approach to implant unicompartmental
Computer-assisted TKA leads to a more accurate restoration of knee prostheses leads to a significant shorter rehabilitation time
leg alignment and component orientation compared to the and better functional results (Oxford knee prosthesis, HSS- score
conventional jig-based technique in clinical routine. The addi- after 1 year, standard open: 78 points, minimally- invasive: 92
tional time needed in the computer-assisted group seems to be points). In both groups there are a lot of suboptimal implant posi-
reasonable. Potential benefits in long-term outcome and functions that could lead to early failure. A unicompartmental navi-
tional improvement require further investigation. gated prosthesis was designed to have a better implant positioning
without loosing the advantages of a minimally-invasive approach.
POSTER NO. P141 This multi-centre trial shows the results of the first 65 implanta-
Midterm Follow-up Comparison of a Metal Backed tions. They are compared to the results of 87 minimally invasive
implanted Oxford prostheses. In 4 centres the newly designed cine-
and All Polyethylene Tibia w Identical Topography matic navigated unicompartmental knee prosthesis was implanted
David F Dalury, MD, Baltimore, MD in 65 patients (f: m = 42:23 average age: 65 [48-84]) with medial
Donald L Pomeroy, MD, Louisville, KY gonarthrosis. The orientation of the tibial and femoral implants
Ricardo Gonzales, MD, Hopkinton, NH were assessed on a lateral and a.p. view and compared with the
Thomas A Gruen, MS, Wesley Chapel, FL results from the Oxford prosthesis. 98% of the femoral implants
Jeffrey A Murphy, MS, Warsaw, IN were within a +/- 10° varus- valgus range, compared to 93% in the
Mary Jo Adams, BSN, Towson, MD minimally- invasive Oxford group. On the lateral view 75% of the
implants were within a range from 5 to 15° flexion. In the Oxford
Janene A Empson, RN, ONC, Louisville, KY
group 49% were in a 5° flexion- 5° extension range. 98% of the
The purpose of this study is to compare the mid-term clinical
tibial implants were <10° varus and <5° Valgus, in the Oxford
and radiographic results of a metal backed modular tibial
group 99% were in this range. The tibial slope was in 94% in a
component (MB) with an all-polyethylene tibial component
range between 82 and 92° (optimal value: 87°), in the Oxford
(AP) with identical surface geometries and from the same
group, 90% were in a range between +7° and ‘5°. Minimally- inva-
implant system (P.F.C.Ò SigmaÔ). This was done in a retrospec-
sive navigated unicompartmental knee arthroplasty leads in a high
tively matched, paired subset of patients with an independent
percentage to an exact positioning of the implants, compared to a
reviewer of radiographs. We compared a group of 74 elderly
non- navigated implantation. The flexion- extension positioning of
patients (88 knees) treated with an AP to a matched cohort
the femoral implant was a bit worse, but due to some new devel-
based on age, gender, and bilateral surgery treated with a MB.
opments the latest implantations were accurate. In all centres we
Average age was 73.6 (range 63 to 86 years) and follow-up aver-
see a learning curve in the navigated technique, the latest implan-
aged 7.5 years (range 7 to 9) with a compliance of 84%. Knees
tations being very exact. The navigated technique permits an excel-
were evaluated for radiolucency, osteolysis, complications,
lent positioning of the implants and preserves the advantages of a
survivorship, and knee society scores (KSS). We found no statis-
minimally invasive approach with rapid good functional results.
tical difference in terms of KSS with the exception of KSS func-
Long-term results need to follow.
tion score, which showed significant improvement for the AP
(25.2 points) compared to the MB (4.3 points). Independent X- POSTER NO. P143
ray review showed lower incidences of osteolysis (0% versus
5.71%) and radiolucencies (2.78% versus 8.57%) in the AP Clinical application of Electromagnetic navigation
compared to the MB. Survivorship was 100% in the AP and in TKR
95.5% in the MB (p=0.07) at 8 years. At mid-term follow-up, the Eun Kyoo Song, MD, Kwangju, Korea, Republic of
AP group was comparable or superior to a MB matched cohort Sang Jin Park, MD, Hwasun-gun, Jeonnam Korea, Republic of
of patients. This, plus the added benefit of cost savings (approx-
Jong-Keun Seon, MD, Lexington, MA
imately $2000), makes it an attractive option for elderly
patients.
Seong-Beom Cho, MD, Gwanju, Korea, Republic of
Sang Gwon Cho, MD,
Il-Gyu Gong, MD,
Computer based navigation system improved the accuracy of
limb and component alignment and decreased the incidence of
outliers. The majority of previous studies were based on the
infrared navigation system. We evaluate the availability and accu-
racy of the electromagnectic(EM) navigation system in total knee
arthroplasty From July 2006 to January 2007, 40 patients (50
TKAs) with osteoarthritis were participated in this study. POSTER NO. P145
AxiEM(Medtronics) was used and Nexgen CR(26 cases), and Over-Utilization of MRI in the Osteoarthritis Patient
Nexgen CR flex(24 cases) were used. We analyzed the failure
mode of navigation (7 cases), operation time and radiologic Wayne M Goldstein, MD, Morton Grove, IL
results (limb and component alignment) Total registration time Alexander C Gordon, MD, Highland Park, IL
was 4 minutes 45 seconds in average (Range : 3 minutes 45 Jill Branson, RN, Kildeer, IL
seconds ~ 6 minutes 55 seconds). Failures in clinical applications Christopher Simmons, BS, Willow Springs, IL
resulted from non-recognition of EM tracker or paddle by Kimberly A Berland, CST, Warrenville, IL
metallic interference in 4 cases and from informational changes Daniel S Willsey, MS, PA-C, Chicago, IL
during surgery by fixation loss or loosening of the tracker in 3 Amanda L Andrews, PA-C, Des Plaines, IL
cases. Radiologically, the mechanical axis changed from -
Medical imaging now consumes 10% to 15% of Medicare
11.2±7.21 (Range : -25.8~3.1) to 1.0±1.25(Range : -2.1~4.0) and
payments to physicians, compared with less than 5% only a
1 case of outlier occurred (valgus 4°). Component alignment is
decade ago. Imaging costs are expected to keep growing at an
measured as followed: 89.3±1.6° of Theta angle, 89.9±1.5° of
annual rate of 20% or higher, now outpacing the cost of
Beta angle, 1.8±2.5° of Gamma angle, 86.1±2.9 of Delta angle°.
prescription drugs. Over-utilization of MRI contributes to cost,
There were no complications related to the EM navigation The
especially in a radiographically proven osteoarthritic knee. A
EM navigation system helped to achieve accurate alignment of
random sample of 50 patients with primary total knee arthro-
component and lower leg axis without any complications. It had
plasty for osteoarthritis were reviewed to see if within the last
several advantages such as relatively less invasiveness in fitting
two years they had an MRI of their knee. Data was obtained by
small instruments, not disturbing operation field, no interrupted
chart review and phone call to verify that the patient had MRI
line of sight, portable use, and applicability to any implant.
prior to seeing the senior author for total knee arthroplasty. The
However, metallic interference may be still problematic.
senior author routinely obtains routine knee radiographs
including weight-bearing views. These patients had TKA due to
POSTER NO. P144
evidence of bone on bone articulation in any or all of the three
Variability of Digitizing the Epicondylar Axis Using compartments. 32 of 50 patients had MRI done prior to consul-
CT Scan Based Imaging tation, which was ordered by their primary care or orthopaedic
William Michael Mihalko, MD, PhD, Charlottesville, VA physician. More than half did not have radiographs prior to
being seen. There is no or minimal benefit to MRI in patients
Matthew J Phillips, MD, Buffalo, NY
with osteoarthritis of the knee. The patient is often referred by
Elmar Rakebrand, MD, Primary Care with the finding of ‘torn meniscus’ and many
Stefan Kilma, MD, patients expect arthroscopy and seem upset that the orthopedic
Thomas Stock, MD, surgeon does not use the MRIs. The average reimbursement by
Kenneth A Krackow, MD, Buffalo, NY Medicare for MRI of the knee is $582.27. Commercial insurance
The epicondylar axis has served as a popular anatomical land- can be significantly higher. Possibly due to lack of muscu-
mark for femoral component rotation during total knee arthro- loskeletal education, MRI is ordered instead of x-rays. This study

plasty. Its accuracy may be limited due to the recognition of the suggests the need for strict guidelines or credentialing of those
true bony landmarks by the surgeon during the procedure from who order musculoskeletal MRIs.
overlying soft tissue and available access during MIS surgery. Even
with newer computer navigation techniques the technology relies POSTER NO. P146
upon the accuracy of registration during the process to properly ◆In Vivo Analysis of Knee Kinematics for Subjects
align the component during surgery. To determine the variability
of measuring the epicondylar axis 35 CT scans from whole body
Implanted With Various High Flexion TKA Designs
cadaveric specimens were utilized among 5 different surgeons. Sumesh M Zingde, BS, Knoxville, TN
The average CT determined EA was considered the ground truth Douglas A Dennis, MD, Denver, CO
for these specimens and used for comparison to the registered Giles R Scuderi, MD, New York, NY
points utilizing a three dimensional CT viewing system. The vari- Jean-Noel A Argenson, MD, Marseille, France
ability of the digitized points were then recorded for both the Richard D Komistek, PhD, Knoxville, TN
medial and lateral epicondyle according to differences in an The objective was to determine in vivo kinematics and
anatomic grid about each epicondyle in an anterior, posterior, maximum weight-bearing flexion for subjects implanted with
proximal or distal location to the average digitized epicondylar various high flexion TKA designs. In vivo knee kinematics were
point. The lateral epicondyle was the most variable with a spread assessed for 97 subjects implanted by six surgeons with four
of over 8 degrees in rotational alignment (-4.8 to 3.6 degrees and different high flexion TKA designs. All subjects performed a
a standard deviation overall of 1.7 degrees). For both the medial maximum weight-bearing deep knee bend maneuver under
and lateral epicondyle the variation in the proximal distal loca- fluoroscopic surveillance. Twenty subjects were implanted with
tion resulted in the widest range of digitized locations (up to an LPS High Flex Mobile Bearing (MB) PS TKA (Surgeon #1)
9.9mm variation). The AP variation was less than the proximal while 19 subjects received an LPS High Flex Fixed Bearing (FB)
distal variation but still significant with more variability for the PS TKA (Surgeon #2). Twenty subjects were implanted by
medial epicondyle (up to 6.1mm) than the lateral (up to Surgeon #3, 12 subjects by Surgeon #4, and 16 subjects by
3.8mm). Even though the EA has been documented as an appro- Surgeon #5 and all received a PFC Sigma RP-F PS MB TKA. Ten
priate landmark for femoral component rotation the results of subjects received a Scorpio SuperFlex FB TKA (Surgeon #6). All
this study have shown there still remains the opportunity for 97 TKAs were judged clinically successful (HSS scores > 90). The
significant variation in its registration during navigated total knee average weight-bearing flexion was 125.4º, 116.3º, 124.8º,
arthroplasty. If significant inter observer variations exist using CT 102º, 103.2º, and 95.1º for TKA subjects in surgeon groups 1-6
registration then certainly this is magnified when direct digitiza- respectively. Posterior femoral rollback was greater in the groups
tion with overlying soft tissue exists in the operating room. with greatest postoperative flexion. Multiple TKA designs
479
provided high weight-bearing knee flexion although it was rior slope of proximal tibia after open wedge HTO. Preoperative
design specific. Flexion magnitudes in study groups 1 and 3 and postoperative full weight bearing teleoroentgenogram and
represent the highest mean weight-bearing flexion magnitudes the posterior slope of the proximal tibia in lateral radiograph
(125º) observed in over 40 individual TKA studies (> 1000 TKA) were evaluated. The amount of anterior opening wedge was
performed in our research laboratory. The fact that one TKA about 67% of posterior opening wedge when posterior slope
design exhibited both high and lower levels of flexion indicates was maintained in every cases. Mechanical axis was corrected
factors other than implant design (surgical technique, patient adequately to valgus 2.69°(range 0.5-4.99) in average. Posterior
factors, etc) play important roles in determination of maximum slope was maintained almost the same as preoperative angle
flexion following TKA. (from 7.9 to 8.4°). Use of navigation for open wedge high tibial
osteotomy provide reliable and safe frontal plane correction.
POSTER NO. P147 The normal tibial posterior slope can be maintained if anterior
Variation in the Rotational Reference Axes of the opening height is around 67 % of the posterior opening height.
Distal Femur in the Non-Arthritic Population POSTER NO. P149
Trichy Srinivasarangan Rajagopal, Dr., London, United Gender Differences in Anterior Condylar Anatomy:
Kingdom
Dinesh K Nathwani, MD, Middlesex, United Kingdom
Reality or Ruse?
The design features of the most commonly used conventional Thomas K Fehring, MD, Charlotte, NC
jig-based total knee replacement instrumentation assume a Josh Hughes, BS,
constant relationship of 3 degree external rotation between the Susan Marie Odum, MED, Charlotte, NC
posterior condylar axis and the epicondylar axis and many use Bryan Donald Springer, MD, Charlotte, NC
the posterior condylar axis as the rotational reference point. The Claims that gender differences in anterior condylar anatomy are
aim of this study was to analyse the variation in these axes in dramatic, has led to implants for women with thinner anterior
subjects who did not have pre-existing arthritis in the knee using condyles. This study sought to determine if gender differences in
CT scans. One hundred CT scans of the knee were assessed. The anterior condylar anatomy exist. 212 randomly selected MRI’s
reference axes were constructed and the condylar twist angle, the were evaluated (112 male, 100 female). The anterior condyle was
posterior condylar angle and the angles made by the clinical and defined as bone anterior to the patellofemoral sulcus, 10 mm.
surgical epicondylar axis and the line perpendicular to the above the joint line. The height of the medial and lateral ante-
Whiteside’s line were measured. The mean posterior condylar rior condyles was measured. Medial and lateral dimension
angle was 2.27 ± 1.55 degrees (Range -1.3 to 5.6) and the mean between the epicondyles at this level was also measured. The
condylar twist angle was 6.0 ± 1.71 degrees (Range 2.1 to 10.5). ratio between these two was calculated. Anterior condylar height
In relation to the Whiteside’s line, the clinical epicondylar axis was highly variable regardless of gender. Similar bell-shaped
was internally rotated by 0.85 degrees and the surgical curves for each gender were seen. The average medial condyle
epicondylar axis was externally rotated by 2.88 degrees. The height for males was 5.7 mm (SD=2.4) compared to 4.6
posterior condylar axis and the transepicondylar axes were more (SD=2.6) for females (p=0.001). The average lateral condyle
consistent and reliable than the Whiteside’s line. Between the height for males was 7.3 mm (SD=3.0) compared to 6.8
two epicondylar axes, the clinical epicondylar axis is more reli- (SD=3.1) for females (p=0.16). The average medial-lateral
able and reproducible. While the mean values were comparable dimension between epicondyles for males was 86.6 mm
to that of the arthritic population, there was a wide variation in (SD=4.9) compared to 76.6 (SD=6.5) for females (p<0.0001).
the range of values. This variation should be taken into account The average medial condyle ratio for males was 0.07 mm
during pre-operative planning of primary and revision knee (SD=0.03) compared to 0.06 (SD=0.03) for females (p=0.13).
arthroplasty if outcomes are to be improved and patellofemoral The average lateral condyle ratio for males was 0.08 mm
complications avoided. (SD=0.03) compared to 0.09 (SD=0.04) for females (p=0.50).
We conclude that anterior condylar anatomy is highly variable
POSTER NO. P148 regardless of gender. Differences in gender with regard to ante-
◆Navigation Assisted Open Wedge HTO - How to rior condylar anatomy are small and probably clinically insignif-
icant. Implants and/or surgical techniques should take into
Prevent Unintended Increase of Posterior Slope account the variability of anterior condylar anatomy and try to
Sang Jin Park, MD, Hwasun-gun, Jeonnam Korea, Republic of reproduce such anatomy regardless of gender.
Eun Kyoo Song, MD, Kwangju, Korea, Republic of
Jong-Keun Seon, MD, Lexington, MA POSTER NO. P150
Seong-Beom Cho, MD, Gwanju, Korea, Republic of Early Failure in Unicondylar Arthroplasty - Are We
Sang Gwon Cho, MD, Doing Enough to Do Them Well?
Jin-Ho Lee, MD,
Thomas K Fehring, MD, Charlotte, NC
Open wedge high tibial osteotomy (HTO) with navigation
provides accurate axial alignment correction in frontal plane. But
it can cause unintentional increase of the proximal tibial slope. John Leander Masonis, MD, Charlotte, NC
This study is to figure out how to prevent it during navigation Bryan Donald Springer, MD, Charlotte, NC
assisted open wedge HTO. 40 open wedge HTO using Aescula Unicondylar arthroplasty has reemerged as an option for isolated
open wedge plate (B. Braun Aesculap, Korea) was performed compartment knee arthritis. Coincident with this we have noted
using the Orthopilot navigation system (HTO version 1.3, B. an increase in the need for early revision of this construct in our
Braun Aesculap, Tuttligen, German). Preop 3D CT were recon- revision practice. This study sought to determine if the need for
structed from the patient of medial unicompartmental OA with unicondylar revision has increased over time and what factors
varus deformity. And virtual open wedge HTO were simulated may have led to early failure. Revision total knee arthroplasty
and calculate the amount of opening wedge to maintain poste- between 1990 and 1999 (Period 1) were compared to revisions
performed between 2000 and 2007 (Period 2). The prevalence of the average gravimetric wear rates of the inlays made from
unicondylar revision, time to failure and reasons for failure were crosslinked polythelene were 0.63 (0.47 - 0.79) mg/year for
calculated. Between 1990 and 1999, 323 revision total knees inlay A vs. an average wear rate of 1.95 (1.45 - 2.45) mg/year for
were performed, 6 of which were uni-revisions (1.9%). These had inlay B [p < 0.05] and the average volumetric wear rate was 0.67
been in place an average of 112.7 months, (range 13 months-248 (0.50 - 0.85) mm³/year for inlay A vs. 2.07 (1.55 - 2.62)
months). Between 2000 and 2007, 421 revision total knees were mm³/year for inlay B [p < 0.05]. Crosslinked polyethylenes are
performed, 32 of which were uni-revisions (7.6%). These had suitable for total knee prostheses. Simulator testing showed
been in place an average of only 38 months (range 8.3-159 overall reduced wear rates compared to conventional UHMWPE
months). The dominant reasons for failure in Period 1 included and fatigue symptoms were not observed, so that a monitored
poly wear and loosening. Reasons for failure in Period 2 were clinical investigation can be recommended. Gravimetric and
variable but included a number of technical errors. Early failure volumetric wear rates vary depending on the manufacturing
of unicondylar arthroplasty appears to be on the rise. process. Crosslinked polyethylenes manufactured by annealing
Acknowledging that these patients came from an unknown pool seem to produce still lower wear rates than those manufactured
or ‘N’, we are concerned that market pressure may have led to by remelting, at least when used in total knee prostheses.
inappropriate patient selection and that surgical inexperience
with this procedure may have led to the technical problems POSTER NO. P152
noted in Period 2. Patients should be apprised of the possibility Mid-Term Outcomes of Oxidized Zirconium Femoral
of early revision with this procedure.
Components for Total Knee Athroplasty
POSTER NO. P151 John Leander Masonis, MD, Charlotte, NC
Crosslinked Polyethylene - An Adequate Material Marshall Kuremsky, MD, Charlotte, NC
for Total Knee Prostheses?
Bryan Donald Springer, MD, Charlotte, NC
Sandra M Hauptmann, MD, Munich, Germany
Evaluate the midterm clinical and radiographic outcomes of the
Norbert Harrasser, MD, initial 50 consecutive total knee arthroplasties performed with
H R Durr, MD, Munich, Germany an oxidized zirconium femoral component in patients less than
Patrick Weber, MD, 60 years of age. A consecutive series of the first 50 cemented
Wolfgang Plitz, MD, Munchen, Germany TKAs (47 patients) at a single institution using an oxidized zirco-
Volkmar Jansson, PhD, Munchen, Germany nium femoral component were evaluated at a minimum of five
Aseptic loosening is one of the main reasons for revision of total years. Knee Society Scores and radiographic review for osteolysis,
joint replacements. A chronic inflammatory adverse reaction to radiolucencies, and component migration were performed. Of
wear particles in the surrounding tissues can lead to osteoclast the 47 patients, 5 knees were revised, 2 patients were deceased
activation, so that articulating surfaces with low wear rates and a and 13 patients (12 knees) were lost to follow up. 31 of 50 knees
minimum amount of particles are required.Compared with were available for review. The mean age was 51.4. There were 17
conventional ultra high molecular weight polyethylene males and 33 females. Mean follow up was 72 mos (range 60-

(UHMWPE) crosslinked polyethylene (XPE) shows a signifi- 79 mos). 33 of 50 were cruciate retaining, 3 were posterior
cantly reduced wear rate in a hip simulator. The crosslinking substituting and 17 were dished. The average poly thickness was
process reduces the mechanical properties of UHMWPE, partic- 10mm. 5 patients underwent revision surgery (3 infections, 1
ularly its fatigue strength. This is achieved by gamma or elec- allergy, 1 loosening). The median KSS score was 89. The average
tronic radiation, followed by heat treatment either above the extension was 0.3 and average flexion was 114. Radiographic
melting point (remelting) or below (annealing). UHMWPE review revealed one non-progressive tibial radiolucency. There
fatigue occurs more frequently in the knee joint than in the hip were no femoral radiolucencies or osteolysis. Oxidized zirco-
joint due to its changing tribocontact areas combined with high nium femoral components in cemented TKA demonstrate
weight bearing. This is why crosslinked polyethylene is still acceptable outcomes in this young population at midterm
controversially discussed for use in total knee prostheses, while follow up. There was a higher than expected rate of late infection
related studies have not yet been conducted.Question: Is (7.8%). There were no negative findings attributable to the
crosslinked polyethylene proven appropriate for the use in total unique femoral material. Longer follow up is needed to deter-
knee prostheses in simulator testing? Does the manufacturing mine if the improved simulator wear characteristics of oxidized
process affect the wear properties? In a knee joint simulator* 3 zirconium will lead to a longer in-vivo performance.
inlays made from type A crosslinked polyethylene (manufac-
turing process: annealing below the melting point), 3 inlays POSTER NO. P153
made from type B crosslinked polyethylene (manufacturing Aspiration as an Aid to the Diagnosis of Prosthetic
process: remelting above the melting point) and 3 inlays made Knee Instability
from type C (conventional UHMWPE) were tested according to
the ISO standard. For 5 million cycles in a fixed bearing knee the
Thomas K Fehring, MD, Charlotte, NC
gravimetric (mg/year) and the volumetric (mm³/year) wear rates Gregory Ernest Raab, MD, Knoxville, TN
were measured and the wear mechanism was analyzed by means Susan Marie Odum, MED, Charlotte, NC
of a scanning electron microscope.* Stallforth-Ungethuem knee J Bohannon Mason, MD, Charlotte, NC
joint simulator All inlays showed signs of abrasion, scratching William L Griffin, MD, Charlotte, NC
and wear polishing, but no traces of pitting, delamination or Knee instability is a common cause of prosthetic knee failure.
other fatigue reactions. Both types of crosslinked polyethylene With gross instability the diagnosis is seldom in doubt.
produced significantly (p<0,05) lower wear rates than the However, in cases of subtle instability the diagnosis can be
conventional UHMWPE. The average gravimetric wear rate of elusive. This study sought to determine if synovial fluid analysis
inlay C was 13.08 (11.02 - 15.14) mg/year, the average volu- can be a useful diagnostic tool in making the diagnosis of pros-
metric wear rate was 13.98(11.78 - 16.19) mm³/year. Whereas thetic knee instability. Between 1987 and 2006, 133 knees were
481
revised for instability at a single institution. Aspirations were POSTER NO. P155
performed in those patients who had elevated serology and in Two- to 6-year Results of Fulkerson Osteotomy:
those in whom the diagnosis of instability was in doubt. Those
patients with gross instability and normal serology were not Retrospective Evaluation
aspirated. The unstable group of patients was compared to 120 William H Ulmer, Jr, DO, York, PA
patients in whom aspirations were performed for other diag- Lorenzo Silvestri, MD, Middletown, RI
nosis, excluding infection. The average red blood cell count for Sara E Pearson, PhD, Richmond, VA
the group of patients with instability was 79,365, range 300- William R Beach, MD, Richmond, VA
960,000. The median red blood cell count was 9,175 (IQR
Tibial tubercle anteromedialization (Fulkerson osteotomy) can
37,750-2338). In those patients with other diagnoses, the
help decrease pain and improve function in patients with
average red blood cell count in the synovial fluid was 56,292,
chronic patellofemoral (PF) malalignment. The purpose of this
range 30-207,900. The median red blood cell count was 5450,
study was to evaluate the long term results of Fulkerson
IQR 22,875-2272 (p =.64). Our study confirms that unstable
osteotomy. Sixty-two patients who underwent Fulkerson
total knees have preoperative bloody effusions. This is thought
osteotomy from January 1997 to December 2002 were identi-
to be related to microtrauma of the synovial lining due to a
fied; 42 were lost to follow-up, 3 declined, and 8 missed their
specific instability pattern. The prognostic significance of this
study appointments and chose not to reschedule. The remaining
finding however must be questioned as patients with other diag-
9 patients returned for follow-up at a mean 48.0±14.1 months
noses have similar numbers of red blood cells in synovial aspi-
(range, 27.9-69.8). Follow-up included physical exam, objective
rates. Physical exam remains central to the diagnosis of
testing, x-rays and subjective assessment. Tegner, Lysholm, Visual
prosthetic knee instability.
Analog Score (VAS) and IKDC scores were calculated. Mean age
was 41.1±6.6 years (range, 34.8-54.0). All were female. Seven
POSTER NO. P154
(78%) were white and 2 (22%) were African-American. Three
How Retrieval Analysis Provides Insight Into the had surgery on both knees for a total of 12 knees. The contralat-
Development of the 30-Year Knee eral knee was normal in 2 (17%), nearly normal in 6 (50%) and
John P Collier, DE, Hanover, NH abnormal in 4 (33%). Two knees (17%) suffered contact
injuries. All patients would opt to have surgery again.Mean
Michael B Mayor, MD, Hanover, NH
Lysholm score was 61.7±17.3 (range, 32-91). Lysholm grades
Kimberly A Lyford, BA, Hanover, NH were good in 1 knee (8%), fair in 4 (33%) and poor in 7 (58%).
Mariah K Hughlock, BS, Hanover, NH None was rated as excellent. Mean Tegner score was 2.3±1.2
Barbara H Currier, MChE, Hanover, NH (range, 0-4). Mean VAS was 14.0±17.6 (range, 1-61). Eleven
Douglas Van Citters, PhD, Hanover, NH knees (92%) had a B rating on IKDC evaluation and 1 (8%) had
Orthopedic researchers and companies are striving to develop a C rating. This patient had a 23° passive flexion deficit and a
longer-performing knee replacements. Damage and wear of 35° active flexion deficit relative to the contralateral side as well
polyethylene bearings installed in the 1990’s has led to the as frequent pain, swelling, locking and giving way. Only 2 other
development of hard coatings, new geometries and highly cross- knees had flexion deficits (5° each in active and passive flexion).
linked polyethylene. The evaluation of retrieved components Overall results were poor; only 1 patient had good, pain-free
suggests that a different and less expensive set of improvements function at an average of 4 years postoperative. This could be
is more likely to lead to a longer lasting knee replacement. Two due to advanced PF pathology. Younger patients with less
hundred retrieved knee inserts from 9 manufacturers were eval- chronic PF arthrosis might yield better results. Fulkerson
uated for clinical wear. Visual microscopy assessment for osteotomy can also be useful for correcting malalignment prior
damage modes, FTIR analysis for oxidation, and tensile testing to future total knee replacement.
for mechanical properties (when possible) were performed.
Cracking and delamination were present in 66% of all retrievals, POSTER NO. P156
(but 90% of those with oxidation above 1.5). Wear of articular Safety of Intra-articular Cortisone During
surfaces that do not show fatigue damage secondary to oxida-
tion remained low in both fixed and mobile bearings. Backside-
Preoperative TKR Time Period
wear of components articulating against polished CoCr surfaces David F Dalury, MD, Baltimore, MD
was very low (less than 0.02mm/yr) while fixed bearings mated Mary Jo Adams, BSN, Towson, MD
to rough titanium surfaces wore at a mean rate of (0.05 mm/yr). Intra-articular cortisone is an accepted modality for treating
This study confirmed that articular fatigue damage and oxida- arthritis of the knee. Frequently, it can become more important
tion are directly related. Eliminating oxidation by non-gamma in managing knee pain as a patient’s knee fails. Questions arise
sterilization after cross-linking and remelting is likely to reduce about the safety of using cortisone in the pre-op time period
the fatigue failure of knee bearings to a very low level. Mating the prior to TKR. In particular, were any wound healing problems
polyethylene, whether fixed or mobile, to polished trays should identified and were any post operative knee infections seen in a
reduce the overall wear rates (articular and backside combined) group who had an injection within a one month time frame of
to less than 0.02 mm/yr. Careful design and materials selection their TKR? We reviewed 50 consecutive patients from our data-
should permit the service life of total knees to be raised by a base who had received an intra-articular cortisone injection
factor of three with current technology. within 4-6 weeks (range 19 days to 42 days) of having their knee
replacement. This represented a subset of 1301 TKR’s done
during this time period. Average age of the group was 69 (range
54 to 88). Pre-operative diagnosis was osteoarthritis in all
patients. Using the ASA classification, 37 patients were ASA 2, 13
patients were ASA 3. Four patients were non-insulin diabetics
but no patients were considered immunocompromised. At three
months f/u there were no instances of infections, wound healing
problems, or drainage issues in this patient group. One patient, component. Between February 2002 and March 2005, 151
a 73 yr old non-insulin dependant male, developed a tooth patients (186 knees) received a medial UKA with an all-polyeth-
abscess 4 months postop and eventually seeded his TKR ylene tibial component design. All patients met the criteria for
requiring revision. Other than a single patient, (1 of 4 of the selection for a UKA defined by Deshmukh and Scott. This cohort
entire 1301 group who became infected) who developed what consisted of 79 men and 72 women. Patient’s mean age at the
appeared to be a metastatic infection from a tooth abscess, we time of surgery was 72 years (range, 45 to 90 years) and their
could identify no adverse effect of having had an intra-articular mean body mass index was 29 (range, 19 to 44). They were
cortisone injection in the weeks prior to knee replacement followed for a mean of 34 months (range, 24 to 54 months).
surgery. In a non-immunocompromised patient, it appears that The underlying diagnosis was osteoarthritis in 177 knees (95%)
cortisone injections can be safely used up to one month prior to and osteonecrosis in 9 knees (5%). All patients were evaluated
surgery. utilizing the Knee Society objective and functional scoring
system. Radiographic evaluation assessed progressive radiolu-
POSTER NO. P157 cencies. In addition, an analysis of various clinical and demo-
Clinical Value of Regular Passive ROM Exercise by graphic factors was performed to determine if there were any
independent predictors of failure. The mean preoperative Knee
Physical Therapist After TKA Society pain and functional scores were 55 points (range, 31-77
Tae Kyun Kim, MD, Seongnam-si, Gyeonggi-do Korea, points) and 49 points (range, 35-60 points). Postoperatively,
Republic of both the Knee Society pain and functional scores improved
Kwan Kyu Park, MD, significantly to a mean of 92 points (range, 45-100 points) and
Su Won Yoon, MD, Seongnam-Si, Gyeonggi-do Korea, 89 points (range, 10-100 points), respectively (p <0.001). The
Republic of overall implant survivorship with revision surgery as the primary
Chong Bum Chang, MD, Seongnamsi, Gyunggido Korea, endpoint was 93%, with 13 knees (8 men and 5 women) being
revised to a TKA. Eight (62%) of the revisions were in obese
Republic of
patients (BMI > 30). The specific reasons for revision surgery
Jae Ho Yoo, MD, Seoul, Seoul Korea, Republic of were aseptic loosening of the tibial component in 5 knees,
Byung June Chung, MD, progressive patellofemoral disease and pain in 4 knees, and
Sae Kwang Kwon, MD, subsidence of the tibial component in 4 knees. In addition to
Sang Cheol Seong, MD, Seoul, Korea, Republic of these revisions, radiographic analysis revealed 8 knees with tibial
Regular passive ROM exercise (pROME) by a physical therapist radiolucencies. Three of these knees are pending revision for
is frequently incorporated in the rehabilitation protocols after progressive radiolucencies. Using multiple regression analysis,
total knee arthroplasty (TKA). In this randomized, controlled various parameters including age, gender, and BMI were shown
trial, we asked whether incorporation of pROME to the postop- to not be predictive of success or failure of this UKA design. We
erative rehabilitation protocols would bring better clinical believe that the high failure rate of this design is multifold.
outcomes after TKA. Fifty consecutive patients who underwent Cement fixation to an all polyethylene tibial component may be
bilateral TKAs staged 2 weeks apart received pROME for one inferior to fixation to a metal-backed component. Also, a tibial

knee and did not for the other knee. Comparisons between the keel with only a single point of fixation may not be adequate for
knees with pROME and the knees without pROME were made fixation and this implant showed a high incidence of radiolu-
for pain level (7D and 14D), patients preference (before cencies and tibial loosening. Finally, resurfacing the femur with
discharge, 6M), maximum flexion (7D, 14D, 3M, 6M) and extramedullary alignment instruments may not allow repro-
American Knee Society and WOMAC scores (6M). No signifi- ducible femoral component position in UKA and may cause an
cant differences were found in maximum flexion, pain level, alteration in the joint line. This may increase the load across the
patients preference, AKS scores and WOMAC scores. This study medial compartment leading to late onset tibial loosening, stress
demonstrates that incorporation of pROME would not bring fracture, or implant subsidence. The results of this study may
clinical benefits to patients after TKA. lead to further refinements in the indications, design, and tech-
nique for UKA to more optimally enhance outcomes.
POSTER NO. P158
Evaluation of an All-Polyethylene Tibial Component POSTER NO. P159
Design in UKA Risk Factors for Reinfection of the Infected Total
Peter M Bonutti, MD, Effingham, IL Knee Arthroplasty After a 2-Stage Reimplantation
David R Marker, BS, Baltimore, MD Bryce T Wolf, BA, Brookline, MA
Slif D Ulrich, MD, Baltimore, MD Scott David Martin, MD, Boston, MA
Margot McMahon, RN, Effingham, IL William Michael Reichmann, MA, Boston, MA
Lindsay Rudert, BS, Lewis L Shi, MD, Boston, MA
Thorsten M Seyler, MD, Winston-Salem, NC Thomas S Thornhill, MD, Boston, MA
Michael A Mont, MD, Baltimore, MD Reinfection after a two-stage reimplantation for an infected total
Over the last three decades there has been controversy about the knee arthroplasty (TKA) is a rare but devastating challenge to the
effectiveness and the indications for unicompartmental knee orthopedic surgeon. The risk factors for an infected primary TKA
arthroplasties (UKA). Despite discouraging initial results, recent are well-established, although those for reinfection are largely
studies have demonstrated that with refined surgical techniques unknown. The purpose of this case-control study was to evaluate
and modern prosthetic designs with metal-backed tibial trays, the risk factors for reinfection after a two-stage reimplantation in
the short and mid-term survivorship rates are comparable to 19 patients. The risk factor analysis used a case-control design.
standard total knee arthroplasties (TKA). The purpose of the Cases included 19 subjects with reinfection after a two-stage
present study was to analyze the clinical and radiographic reimplantation for an infected TKA identified from administra-
outcomes of a UKA design with an all- polyethylene tibial tive data between 1976 and 1996. Controls included 57 patients
483
who had a successful two-stage reimplantation for an infected conforming articulation between femoral and tibial compo-
TKA between 1971 and 1995. Predictors of reinfection were nents that may result in less polyethylene wear. The purpose of
identified by multivariate logistic regression analysis. The multi- the present study was to compare the outcomes of contempo-
variate logistic regression identified body mass >= 30 (OR=8.19, rary PS and CR total knee designs. A consecutive series of 109
p=.006) and infection within the first six months of the primary patients who received a unilateral knee arthroplasty were
TKA (OR=4.24, p=.026) as significantly associated with a higher randomized to either PS or CR total knee designs. The series was
risk of becoming reinfected. A history of an infection at a remote performed by a two surgeons using a standard medial parap-
site (OR=3.03, p=.081) and peripheral vascular disease atellar approach for both the PS and CR cases. Overall, the mean
(OR=2.78, p=.135) had associations with reinfection that were age was 65 years (range, 40 to 81 years), and the mean body
substantial but not statistically significant. Age, gender, primary mass index was 32 (range, 23 to 47) which was similar in both
diagnosis, serum WBC, ESR, type of bacteria, use of allograft, groups. Preoperative diagnoses included osteoarthritis in 106
number of total procedures, and the use of skin grafts or delayed knees and avascular necrosis in 3 knees. All patients were evalu-
skin closure were not associated with reinfection. This case- ated using the Knee Society Score (KSS), Functional Score (FS),
control study showed that obesity and early infection increases range of motion, and radiographic analysis. Survival analysis
the risk of reinfection after a two-stage reimplantation. Infection was conducted with clinical failures (KSS of less than 70 points
at a remote site and peripheral vascular disease also appear to be at final follow-up) and revision surgeries used as end points. At
risk factors but must be confirmed in larger studies. 6 year mean follow-up, the mean KSS improved from 38 points
(range, 0 to 83 points) to 89 points (range, 34 to100 points) for
POSTER NO. P160 the PS and from 45 points (range, 20 to70 points) to 91 points
TKR in Severe Valgus Knees - Results with the (range, 39 to100 points) for the CR. The FS showed similar
improvements for both groups. The range of motion in the PS
Lateral Condylar Osteotomy group improved from 95 degrees to 119 degrees and in the CR
Michel Bercovy, MD, Paris, France group from 99 degrees to 122 degrees at final follow-up.
TKA with more than 10° fixed valgus deformity is a difficult Radiographic analysis revealed 2% radiolucencies in the PS and
challenge which may necessitate an extensive lateral release and 5% in the CR knees with none of these being complete or
consequently a constrained TKR. The lateral condylar osteotomy progressive. Survival was similar for the two groups with 2 revi-
(LCO) avoids this drawback and allows the use of less sions and 5 clinical failures in the CR cases and 2 revisions and
constrained TKR. 17 knees with osteoarthritis were replaced in 5 clinical failures in the PS patients. Based on these results, there
15 patients with a mobile bearing low constrained arthro- were no notable differences in the outcome measures between
plasty.The preoperative fixed valgus angle was 13° +/- 4° ( 10° - the PS and CR groups. The excellent improvement with both
21°). As a symmetric ligament balance could not be obtained designs did not conclusively demonstrate the superiority of one
neither in flexion , nor in extension, an osteotomy of the lateral knee design over the other, suggesting that the choice of implant
condyle was performed following the tibial superior and should be based on surgeon preference. The investigators await
femoral distal cuts. The flexion and extension gaps were equal- longer-term data to see if these excellent results can be main-
ized by tightening the lateral structures and the osteotomy was tained for both groups.
then fixed with 2 screws. The final mechanical axis was 1.5° +/-
3° valgus . The mediolateral stability was less than 3°. The range POSTER NO. P162
of flexion was 124° +/- 7°. The knee score 96/100 and the func- Five Year Outcome of a Cemented One-piece Porous
tion score 91/100. There was no clinical significant difference
between the LCO group and the group with the normal proce- Tantalum Tibial Component in Total Knee
dure which preoperative valgus angle was inferior to 10° . The Replacement
LCO is an easy and safe procedure for severe fixed valgus knee. Thomas Joseph O’Keefe, MD, Ann Arbor, MI
It allows the use of low constrained TKR and avoids extensive Suzanne Winter, BS, Ypsilanti, MI
lateral ligament releases. It achieves the same mechanical align-
Douglas D Robertson, MD, Pittsburgh, PA
ment and ligament balance as the normal procedure even for
David G Lewallen, MD, Rochester, MN
low constrained TKR’s which require a perfect ligament balance
Robert A Poggie, PhD, Allendale, NJ
POSTER NO. P161 This study describes the five-year clinical and radiographic
outcomes of a cemented, monoblock porous tantalum-polyeth-
A Prospective Randomized Study of Posterior-
ylene, posteriorly stabilized tibial component. A single surgeon
Stabilized vs. Posterior Cruciate performed 137 consecutive TKAs on 101 patients from April
Ligament-Retaining TKA 2001 to June 2002, using the Implex CKS knee system with a
Frank R Kolisek, MD, Indianapolis, IN monoblock porous tantalum tibial component. All tibial
components were implanted with a cemented horizontal surface
and press-fit pegs. All patients were contacted on the 5-year
Nennette Jessup, Indianapolis, IN anniversary of their operation for clinical evaluation and radi-
David R Marker, BS, Baltimore, MD ographic assessment. An independent radiologist evaluated
Thorsten M Seyler, MD, Winston-Salem, NC digital radiographs. No patients were lost to follow-up; however,
C Lowry Barnes, MD, Little Rock, AR 30 patients were unable to return for the 5-year examination (11
Various studies have reported conflicting outcomes for both deceased, 17 ill or out of the area, 1 revision for arthrofibrosis
posterior-stabilized (PS) and posterior cruciate ligament- and 1 revision for late infection 3 years post-op). Ninety-one
retaining (CR) total knee designs. The potential advantages of knees in 71 patients were available for examination at a mean
CR knee designs include preservation of normal knee kine- follow-up of 5.2 years (minimum 5 years). Knee Society scores
matics, increased range of motion, and protection of the bone- averaged 87.7(SD 20.7). The mean post-op range of motion was
cement interface from sheer stresses. Advantages associated with 120 degrees (range; 55 to 138). There were no knee revisions for
the use of a PS system include increased knee stability and a component loosening or mechanical failure, no impending revi-
sions and no radiographic evidence of component loosening or incidence and risk factors of DVT and PE in TKA patients with
osteolysis. There were no radiolucent lines greater than 1 mm in aspirin and mechanical prophylaxis. [Methods] Preoperative
depth in more than 50% of any radiographic zone. No compo- and 10-day postoperative ascending venographies were
nent migration or bone density change occurred. Survivorship performed prospectively in 500 primary TKA patients. In all
free of revision for tibial component loosening was 100% at 5 patients, use of the foot pump and elastic stocking was started
years. Total knee arthroplasty using a cemented monoblock immediately after surgery, followed by initiation of 162mg/day
porous tantalum tibial component is clinically reliable and radi- aspirin dosage two days postoperatively. Multivariate analysis
ographically stable at minimum 5-year follow-up. identified risk factors including age, BMI, ROM, lab data, tourni-
quet time, and preoperative venogram findings. [Results] The
POSTER NO. P163 incidence of DVT in the 500 patients was 34%, which was lower
Limb Lengthening is a Common Consequence of than the incidence in patients without any prophylaxis. All the
DVT was observed in the distal veins (tibial and peroneal veins)
Total Knee Arthroplasty and no DVT occurred in the proximal veins (femoral and iliac
Jason Edward Lang, MD, Winston-Salem, NC veins). There was no fatal PE, nor PE with severe symptoms.
Jess H Lonner, MD, Philadelphia, PA There were no complications induced by aspirin, including
Stephen B Murphy, MD, Boston, MA brain, abdominal, spinal and joint hemorrhage. Among the risk
David Richmond Whiddon, MD, Suffolk, VA factors, limitation of preoperative ROM, preoperative venogram
Aaron K Salyapongse, MD, Pleasanton, CA findings, age, and BMI statistically correlated with the occurrence
Eric Louis Smith, MD, Newton, MA of DVT. [Conclusions] Aspirin and mechanical prophylaxis is
thought to be safe and sufficient to prevent proximal DVT and
James V Bono, MD, Boston, MA
PE in most TKA patients, except some cases with very high risk
Richard D Scott, MD, Boston, MA of coagulation tendency.
Little is known about how limb length is effected by total knee
arthroplasty. Changes in the limb length may result from inser- POSTER NO. P165
tion of the prosthetic components, which restores the lost carti-
lage space, as well as from correction of sagittal and coronal
Are Routine Intraoperative AFB and Fungal Cultures
deformities and ligament releases on the concavity of the defor- Necessary?
mity. The purpose of this study is to investigate the limb length Veronica Marie Rita Wadey, MD, Toronto, ON Canada
changes that occur following total knee arthroplasty. Pre- and James I Huddleston, III MD, Stanford, CA
post-operative full length standing radiographs, with a radi- Stuart Barry Goodman, MD, Stanford, CA
ographic marker, were obtained in ninety-seven patients who
David J Schurman, MD, Palo Alto, CA
underwent unilateral total knee arthroplasty. Digital radiog-
William J Maloney MD, Stanford, CA
raphy software was used to measure the limb length, mechanical
and anatomic axes. Average preoperative coronal alignment was While it is recommended to obtain at least 5 intraoperative spec-
2.89 degrees of mechanical varus (average for varus knees = 8.67 imens for aerobic and anaerobic culture to diagnose a deep
periprosthetic infection, the role of routine acid-fast bacilli

degrees; average for valgus knees 9.42 degrees). Postoperative
limb alignment averaged 0.96 degrees of mechanical varus (AFB) and fungal cultures in this setting remains unclear. The
(average for varus knees = 2.09 degrees varus; average for valgus purpose of this study was to develop a protocol for collecting
knees = 1.45 degrees valgus). Eighty-one of 97 operative limbs intraoperative AFB and fungal cultures during orthopaedic
were longer post-operatively (83.5%). Ninety-four percent of procedures. 446 AFB cultures and 486 fungal cultures were
valgus cases were longer; 80% of varus cases were longer. The processed over a 2-year period from both total hip and knee
overall average limb length increase was 6.3mm (std. dev. = replacements as well as other orthopaedic procedures. The
6.7mm, range 10.8mm shortening, to 23.9mm lengthening). number of positive cultures was determined. A protocol specific
The average increase in limb length was 5.17mm in patients to handling these specimens, in conjunction with cost analysis,
with a preoperative varus deformity; it was 8.83mm in those was developed. 0/446 (0%) AFB cultures and 3/486 (0.6%)
with a preoperative valgus deformity (p=0.02). Limb length typi- fungal cultures were positive for Fusarium (significant), Candida
cally increases following total knee arthroplasty. Correction of albicans in broth only (significance unknown) and Candida
preoperative valgus deformity leads to a larger increase in limb parapsilosis (1 colony only, significance unknown). If only one
length than preoperative varus deformity. Patients should be of 5 intraoperative samples was tested for AFB and fungus, the
advised preoperatively about the likelihood of limb lengthening lab would save 6.9 hours and $518.00 per culture. This translates
as a consequence of total knee arthroplasty. to a cost savings of $965,552 per year at our academic medical
center. Samples were saved for processing additional AFB and
POSTER NO. P164 fungal cultures, if clinically indicated, at a later date. The infre-
quency of positive AFB and fungal cultures in this study suggest
Aspirin and Mechanical Prophylaxis Was Effective that it may not be necessary to routinely test intraoperative spec-
to Prevent Proximal DVT and PE in TKA patients imens for AFB and fungus. We recommend obtaining AFB and
Koh Shimizu, MD, Chiba, Japan fungal cultures only in cases where a high index of clinical suspi-
Sara Shimizu, MD, Chiba, Japan cion is present. Implementation of this protocol has the poten-
Junichi Iwasaki, MD, Ichihara City, Chiba, Japan tial to lead to significant cost reduction and resource savings.
Masahiro Yamagata, MD, Ichihara city, Chiba, Japan
Warfarin and LMWH has been recommended to prevent DVT in
TKA ‘patients because of its great anticoagulation effect,
although such anticoagulants may increase hemorrhage and
infection. Contrarily, aspirin is thought to be safer, although the
sole usage is not recommended. [Purpose] To determine the
485
POSTER NO. P166 the thrombophilic state in the post surgery epidural analgesia
Tibial Tubercle Osteotomy for Exposure During group. The group with epidural anaesthesia evidenced a longer
INR time, inferior values in the formation of thrombin-
Revision and Complex Primary Total Knee antithrombin (T-AT) complexes (indirect markers of the state of
Arthroplasty activation of coagulation) and a lesser production of D-Dimer
Hari Parvataneni, MD, Miami, FL than intravenous and intradural anaesthesia, reflecting a lesser
Dennis W Burke, MD, Boston, MA degree of hyper coagulation. Epidural anaesthesia reduces the
normal hyper coagulation state that follows total hip and knee
We report on the technique as well as clinical and radiographic
arthroplasty and should be recommended as the elective form of
results of tibial tubercle osteotomy (TTO) for gaining wide expo-
anaesthesia for these surgical procedures.
sure for select cases of complex primary and revision total knee
arthroplasty. Over a 13-year period, 79 TTOs were performed in POSTER NO. P168
73 patients by a single surgeon at a single institution. All proce-
dures were performed using a standardized technique with Mini-Subvastus Versus Mini-Midvastus Approach
meticulous technique during osteotomy and repair (using in Minimally Invasive Total Knee Arthroplasty
wires). A minimum 2-year clinical and radiographic review was Mumenori Matsueda, MD, Niigata City, Japan
performed. Sixty TTOs were performed during revision surgery Osamu Tanifuji, MD,
(including 9 for removal of infected components and 8 for reim-
We compared short-term functional results of the mini-
plantation). The remaining 19 TTOs were performed during
subvastus approach with the mini-midvastus approach for mini-
complex primary surgery. The mean age at the time of surgery
mally invasive total knee arthroplasty. We compared 18 TKAs
was 62.2 years. Mean follow-up was 5.5 (range 2.1-12.9) years.In
done through the mini-subvastus approach (Sub group) with 25
all cases, the TTO allowed excellent visualization of and access to
TKAs done through the mini-midvastus approach (Mid group).
the entire knee. There were no wound complications and no
We studied operation time, blood loss, and first active straight-
reoperations related to the TTO. There was no symptomatic
leg raise days. We measured the range of motion, power of knee
hardware and no wires were removed. Mean final flexion
extension and a visual analog scale at preoperative day, 1-week
achieved was 110 degrees.Mean time to radiographic union was
and 3-week postoperatively. We assessed recovery rate (postop-
15.5 weeks. There were 10 cases of non-union including 9 with
erative/ preoperative × 100 %) of ROM and the power of knee
some proximal migration of the tubercle. None of these cases
extension. The mean operation time and the mean blood loss
required re-operation and the mean extensor lag was 15 (range
did not have differences in the two groups. Active straight-leg
5-30) degrees in this group. In select cases of total knee arthro-
raise achieved postoperative 1 day in both groups. VAS were
plasty with very limited exposure and motion, tibial tubercle
lower in the Sub group than in Mid group at 1-week (Sub: 2.4;
osteotomy offers excellent wide exposure and favorable clinical
Mid: 3.8) but similar at 3-week (Sub: 2.2; Mid: 2.4) postopera-
and radiographic outcomes.
tively. Sub group had better recovery rate of ROM at 1-week
POSTER NO. P167 (Sub: 100 %; Mid: 93.8 %) but at 3-week recovery rate of ROM
were similar in both groups (Sub: 109 %; Mid: 109.8 %). Sub
Comparison of Pro Coagulative Markers in Total
group had better recovery rate of the power of knee extension at

Knee and Hip Replacement 1-week (Sub: 100 %; Mid: 84.6 %) and at 3-week (Sub: 123 %;
Ignacio Garutti-Martinez, MD, Madrid, Spain Mid: 107.6 %). The mini-subvastus approach gained more rapid
Manuel Villanueva, MD, Madrid, Spain functional recovery and had better pain scores than the mini-
midvastus approach. But ROM were similar in the two groups at
Antonio Rios, MD, El Ejido, Almeria, Spain
3-week postoperatively.
Francisco Chana Rodriguez, MD, Madrid, Spain
Elena De la Fuente, MD, POSTER NO. P169
Berenice Gutierrez, MD, Agrressive Early Debridement can be successful for
Cristina Pascual, MD,
Ana Rodriguez-Huerta, MD,
the Infected TKA
Surgery is related to a thrombogenic state in the post surgery Fares Sami Haddad, FRCS, London, United Kingdom
period, that even physiologic, can predispose to thrombogenic Up to 2% of the knee arthroplasties are still complicated by
complications. We performed a controlled and prospective clin- infection. This leads to dissatisfied patients with poor function,
ical trial to analyse the influence of different anaesthesia and and has far-reaching social and economic consequences. The
analgesia techniques on biological pro coagulative markers challenge in these cases is the eradication of infection, the
during the post surgery period following total hip or knee restoration of full function and the prevention of recurrence. We
arthroplasty. 51 patients were randomized into three groups: report the outcome of prosthesis sparing early aggressive
intradural-intravenous, intradural-epidural, general-intravenous debridement in the acutely infected knee arthroplasty. We
anaesthesia. Samples were taken at four different times: pre-op, studied 29 consecutive referred with acutely infected knee
at the end of surgery, 16 h and 36 hours post surgery. arthroplasties (18 primaries, 11 revisions) which occurred
Demographic and surgical parameters were homogeneous. within 6 weeks of the index operation or of haematogenous
There were neither thrombogenic complications nor differences spread. Microbiology confirmed bacterial colonization in all
in blood loss, transfusions, platelets or red cells accounts cases with 20 early post-operative infections and 9 cases of acute
between groups. Post op pain scales showed no differences haematogenous spread. All the patients underwent aggressive
between intravenous and epidural anaesthesias. We found statis- open debridement, a thorough synovectomy and a change of
tically significant differences between the three groups in the insert. Systemic antibiotics were continued until inflammatory
parameters of fragment 1 and 2 of prothrombin (F1-F2) and markers and the plasma albumin concentration returned to
partial time activate thromboplastin (APTT) (hyper coagulation within normal limits. Three patients required multiple
markers), in the 36h post surgery sample, with an attenuation of washouts. 8 patients needed a two stage revision. 21 patients had
a return to their previous functional level without removal of the one year post-procedure. Resource use and costs were estimated
implants and with no radiographic evidence of prosthetic based on hospital records, Medicare data and expert opinion.
failure. At a minimum 2 years follow-up after the cessation of During the acute hospitalization, 97% of MRS patients were
treatment we had a 72% infection control rate. The outcome was ambulatory compared to 8.8% of AKA patients. Hospital costs
significantly better in patients treated in the first 72 hours after for MRS patients were $29,478 compared to $16,751 for AKA
presentation. The evidence suggests that there is a role for early patients, despite a longer average hospital stay among AKA
aggressive open debridement in acute knee infections with a patients (11.3 vs. 7.8 days, p<0.01). Considering hospitalization
good chance of prosthesis salvage. We believe that this is only alone, the cost was $14,300 per additional walking patient. At 90
appropriate in selective cases where infection occurs within the days postoperatively, 80.0% of MRS vs. an estimated 14.5% of
first 4-6 weeks after the onset of acute post-operative or acute AKA patients were ambulatory. Accounting for costs accrued
haematogenous infection, and in the absence of any prosthetic through the first 90 days ($31,587 for MRS patients vs. $25,707
loosening.. An aggressive and complete debridement must be for AKA patients), the cost per additional walking patient was
performed and systemic antibiotic administration is imperative reduced to $5,881. At one year, the cost per additional walking
for success. patient was $1,543. Findings suggest that MRS is cost-effective
compared to AKA.
POSTER NO. P170
Functional Spacers have Medium Term Advantages POSTER NO. P172
for the Infected TKA Are Gender-Specific Implants Necessary for Total
Fares Sami Haddad, FRCS, London, United Kingdom Knee Replacement?
Up to 2% of the knee arthroplasties performed are still compli- William Timothy Brox, MD, Fresno, CA
cated by infection. This leads to dissatisfied patients with poor Liz Paxton, MA, San Diego, CA
function, and has far-reaching social and economic conse- Richard Low, San Diego, CA
quences. The challenge in these cases is the eradication of infec- Donald C Fithian, MD, El Cajon, CA
tion, the restoration of full function and the prevention of The rationale for gender-specific TKA implants is based on
recurrence. Two stage exchange remains the gold standard and is anatomical differences and an assumption that TKA outcomes
used in over 70% of our patients. We have undertaken a prospec- differ by gender. Although anatomical differences are well estab-
tive randomised study of static and mobile spacers in the lished, there is less information on gender variation in TKA
management of the infected TKA. 52 consecutive patients were outcomes. To evaluate gender specific outcomes following
enrolled into a prospectve study of static versus a mobile intra- primary TKA with standard TKA implants. 20,718 primary TKAs
operatively made antibiotic loaded functional spacer. The were identified using a community-based total joint registry
second stage procedure was undertaken after a mean of 9 weeks from April 2001 through March 2006. Demographics, diag-
(4-21 weeks). All the patients were followed up for a minimum noses, surgical technique and outcomes were evaluated to deter-
of 2 years. THere was no difference in success in eradicating mine if there were differences by gender. The sample consisted
infection with one failure in each group. In the functional spacer of 13,250 females and 7,468 males. Mean age at the time of

group, the second stage procedure and length of hospital stay surgery was similar for males and females (68.01 years vs. 68.08
were shorter. THis group also had a greater final range of motion years, p=0.911). Males had a lower mean BMI (30.76 vs. 32.07,
and fewer extensor lags. Patellar tracking remains the greatest p<0.001), a higher rate of diabetes (16.1% vs. 13.8%, p=0.001),
problem in both groups There are significant advantages to the a lower rate of Rheumatoid Arthritis (1.1% vs. 2.6%, p<0.001)
use of functiona intra-operatively designed antibiotic loaded and a higher rate of post-Traumatic Arthritis (2.0% vs. 1.0%,
spacers and there is no deletrious effect on the eradication of p<0.001) than females. At 4 weeks to 8 months post-op and at
infection. Our technique which does not involved expensive >9 months post-op, males had a lower change in pain than
equipment leads to improved outcomes females (4.3691 vs. 4.5449, p=0.004; 5.0464 vs. 5.4124,
p<0.001). Changes in flexion did not differ by gender (p>.05).
POSTER NO. P171 Changes in extension from pre-op indicated males had a higher
A Cost-effectiveness Comparison of Tumor change than females at >9months post-op (3.0156 vs. 2.8470,
Prosthesis and Above Knee Amputation p=0.023). Implant survival rates were similar between genders at
2 years post-op. Women had higher mean BMI, more inflam-
Molly D Black, MD, Wichita, KS
matory disease, and slightly better pain scores. Despite these
Teresa L Jones, MPH, Wichita, KS differences, outcomes in ROM, pain, and revision were similar.
David A McQueen, MD, Wichita, KS The results of this study do not substantiate the need for gender
Jordana K Schmier, MA, Alexandria, VA specific implant designs.
Eric Rugo, Mahwah, NJ
The Modular Replacement System (MRS, Stryker) tumor pros- POSTER NO. P173
thesis can be an attractive alternative to above knee amputation The Effect of ACL Insuffiency on the Wear of
(AKA) for older arthroplasty and trauma patients with signifi-
cant bone and soft tissue loss around the knee. We hypothesized
Articular Cartilage of Medial Tibial Plateau
that MRS is a cost-effective option, despite its higher initial cost. Chul Won Ha, MD, Seoul, Korea, Republic of
We identified 35 MRS and 35 matched AKA patients from a Byoung-ki Cho, MD,
hospital database. The cost-effectiveness analysis used hospital Kyung Su Lim, MD, Seoul, Korea, Republic of
costs and walking ability (walking e 10 feet with or without assis- Kyung-Joong Kang, MD, Kang NamGu, Ir Won Dong 50
tive device). Cost-effectiveness of MRS compared to AKA was Korea, Republic of
defined as difference in cost divided by difference in outcome Anterior cruciate ligament(ACL) insufficiency alters kinematics
(percent of ambulatory patients). Analyses considered three of the knee and the wear pattern at the tibiofemoral interface.
time periods: acute hospitalization, 90 days post-procedure, and Biomechanical studies suggested that the ACL deficient knees
487
had a different contact pattern on medial tibial plateau. POSTER NO. P175
However, there are few clinicopathological studies supporting
the altered kinematics. This study is to demonstrate the distribu-
◆Tibial Fixation Without Screws in Cementless
tion of wear on medial tibial plateau in osteoarthritic knees and Knee Arthroplasty (Average 8 years Follow-up)
to correlate this with the status of the ACL. Three hundred tibial William Lindsay Walter, MD, Waverton, NSW Australia
plateaux resected during total knee arthroplasties (TKA) for Ian Paul Holloway, London, United Kingdom
osteoarthritis were obtained and photographed. The status of Patrick J Lusty, MD,
ACL was recorded introperatively as intact, partial insufficieny William Keith Walter, MB, Waverton, NSW Australia
and complete insuffiency. The extent of wear were evaluated by
Bernard A Zicat, MD, Waverton, NSW Australia
reviewing the photography. The medial tibial plateau was
Osteolysis has been reported in association with screw holes in
divided into anterior, posterior zone in the anteroposterior
cementless tibial trays. We examined a series of cementless total
direction and medial, lateral in the mediolateral direction. The
knee arthroplasties using a tibial tray without screw holes and
ACL status and the wear extent were analysed statistically by
with a fixed polyethylene bearing. We hypothesize that stable
Crosstabulation method. In the anteroposterior direction, the
fixation of the tibia can be obtained without screws. All patients
proportion of posterior wear were 19% at the ACL intact group,
who underwent primary total knee arthroplasty from November
25% at the ACL partial insuffiency group and 65% at the ACL
1995 through December 1997 had the same implant regardless
complete insufficieny group. The wear extent expanded more
of age or bone quality. 216 knees were implanted in 191 patients.
posteriorly with worsening ACL status (p=0.01). In the medio-
The components used were the cementless Anatomic Modular
lateral direction, the proportion of lateral wear were 22% at the
Knee femoral component with the Duofix tibial tray (both
ACL intact group, 32% at the ACL partial insufficiency group
Depuy, Warsaw, Indiana, USA). All radiographic and clinical
and 60% at the ACL complete insuffiency group. The wear extent
scores were performed prospectively and recorded on a rela-
expanded more laterally with worsening ACL status (p=0.016).
tional database. The tibial tray was manufactured from a tita-
In the presence of ACL insufficiency, the wear extented more
nium alloy (TiVaAl) and had a porous surface that was
posteriorly and laterally on the medial tibial plateau, which
undercoated with 50 microns of hydroxyapatite. Patients have
reflects the altered kinematics in the ACL deficient knees. This
been followed up for an average 7.6 years (range 5 to 10 years).
study will help the decision making when considering
Hospital for Special Surgery knee scores improved from an
Unicompartmental Arthroplasty of the knee.
average of 54/100 to 84/100 post-operatively. Two tibial base-
POSTER NO. P174 plates were revised for catastrophic polyethylene failure. Four
percent of tibiae had incomplete nonprogressive radiolucent
Rotational Alignments of Femoral Components in lines involving one or two of ten defined zones. Two percent of
Total Knee Arthroplasty -Navigation Vs. tibiae had minor osteolysis related to the edge of the tray. All
Conventional tibial components were bone ingrown by radiographic criteria.
We conclude that the tibial tray provides adequate primary
Hyuk Soo Han, MD, Seoul, Seoul Korea, Republic of stability, and good medium term outcome
Myung Chul Lee, MD, Seoul, Korea, Republic of
Sahnghoon Lee, MD, Seoul, Korea, Republic of POSTER NO. P176

Sang Cheol Seong, MD, Seoul, Korea, Republic of Incidence and Etiology of Patellar Clunk Syndrome
This study was undertaken to compare the accuracy of the rota-
tional alignments of the femoral components in total knee
in Modern Mobile Bearing Posterior Stabilized TKAs
arthroplasty using a navigation system and two conventional Akio Kobayashi, MD, Osaka, Japan
techniques. From July 2005, 92 patients who underwent total Kenji Fukunaga, MD,
knee arthroplasty by a single surgeon were prospectively Ryo Sugama, MD, Osaka, Japan
randomized into three groups (group N, a non-image-based Yukihide Minoda, MD, Osaka, Japan
navigation, 31 cases; group M, a modified gap technique, 30 Kentarou Iwakiri, MD, Osaka, Japan
cases; group C, a classic 3° external rotation method, 31 cases). Yoshio Tokuhara, MD,
We measured the posterior condylar angles (PCA, the angles
Yoshinori Kadoya, MD, Sakai, Japan
between posterior condylar lines and transepicondylar axes) on
CT images before and after surgery. There were no significant
Hiroyoshi Iwaki, MD, Osaka, Japan
differences between the two techniques in terms of mean errors Hirotsugu Ohashi, MD, Osaka, Japan
(group N, 1.37°±1.53; group M, 1.17°±2.08; group C, Patellar clunk syndrome (PCS) was one of the major patello-
1.91°±2.36) (p>0.05). However, the percentage of postoperative femoral complications in the first generation posterior stabilized
PCA outliers (more than 3 degrees) was 12.9% in group N, (PS) total knee arthroplasties (TKA), and has been reduced after
16.7% in group M, and 38.7% in group C. The navigation improvement of the femoral component design. There is,
system showed no superiority of the accuracy to the modified however, some reports recently about PCS in modern PS TKA
gap technique but higher accuracy than the 3° external rotation with or without patella resurfacing. In this study, we evaluated
method by reducing outliers. the incidence of PCS in a single type of mobile PS TKA, and radi-
ographically analyzed the risk factors for PCS. 95 TKAs (PFC RP,
Depuy) in 77 patients were consecutively performed. All of the
patellae were resurfaced. PCS was defined as knees with any
anterior knee sound in the active motion from 90 degree flexion
to extension regardless of pain. All of the knees were radi-
ographically analyzed for patella tilting angle, Insall-Salvati ratio
and patella height (the distance from the joint line to the supe-
rior margin of the patella component). 13 knees (13.7%) had
PCS, and 6 of them had pain. Onset of all of the13 cases were
within 12 months. Five of the 6 painful cases underwent arthro- dardized uptake value (SUV), and differences in maximum SUV
scopic resection of the fibrous tissue around the patella. In radi- (SUVmax) among each stage (according to the Koshinos classi-
ographic examination, the tilting angle was significantly higher fication), and correlative relation between SUVmax and size of
in PCS positive cases (5.86 ± 0.95 degree, Mean ± SE) than that ON lesion in radiographs respectively. PET image showed that
in PCS negative knees (3.99 ± 0.32, p=0.048). There were no accumulation of 18NaF increased in medial condyle in all knees
statistical differences in Insall-Salvati ratio and patella height and in tibial plateau in 3 knees. The average SUVmax of the
between both groups (Logistic regression analysis). The inci- medial condyle was 15.5±3.9 that was the highest value
dence of PCS in a modern mobile PS TKA was substantial, and compared with medial tibial plateau and lateral compartment of
tilting angle related to the onset of PCS. the knee. The SUVmax was 12.4±3.3 in stage 2, 16.4±1.4 in stage
3, and 17.5±4.2 in stage 4. Although SUVmax have no signifi-
POSTER NO. P177 cant differences among each stage, there were significant corre-
Increasing Age Predicts More Improvement in Knee lation between SUV and size of the lesion measured in
radiographs. 18NaF-PET was useful for clinical application to
Scores in Primary Cemented Total Knee diagnose ON and to evaluate the size of the lesion that is
Arthroplasty suggested to be the indicator of prognosis of ON developing to
Samuel Secord Wellman, MD, Brookline, MA the osteoarthritis. These images might indicate that ON is not
Nicholas Adam Viens, MD, Durham, NC attributed to ischemic disorder but might be the consequence of
Chad Cook, PT, fracture that causes high metabolic bone activity.
Michael P Bolognesi, MD, Durham, NC POSTER NO. P179
Thomas Parker Vail, MD, San Francisco, CA
Cemented primary total knee arthroplasty (TKA) provides
Does Eversion of the Patella Cause Patella Baja?
predictable and durable pain relief and function in elderly and Amar S Ranawat, MD, New York, NY
lower-demand patients. This success has led to the use of TKA in Vineet Sharma, MD, Flushing, NY
younger, more active patients. Given the different expectations Chitranjan S Ranawat, MD, New York, NY
of these patient groups, it is not clear that outcomes will be the Trevor W Koob, New York, NY
same. The specific aim of this study was to isolate age at surgery There have been claims by some surgeons that eversion of
as a singular continuous variable, using clinical and radiographic patella leads to patella baja. Studies have shown that decease in
parameters as dependant variables. 100 knees in 80 patients patellar tendon length measured by Insall-Salvati ratio (ISR)
were reviewed. Minimum clinical and radiographic follow-up occurs in 50% of cases and patella baja (defined as ISR < 0.8) in
was two years. Clinical outcomes were measured using the Knee 9.7% cases. The purpose of the present study was to establish if
Society scoring system, and radiographs were analyzed using the patellar eversion during TKR leads to patella baja. A total of 58
modified Knee Society criteria. Pre-operative scores were consecutive total knee replacements (TKR) were reviewed retro-
compared with the scores recorded at most recent follow-up. spectively. All knees were operated with a midline incision (10-
Age was analyzed as a continuous variable against outcomes 20 cm) and with eversion of patella. Lateral radiographs (in

measures. Increasing age was strongly predictive of greater 30-35 degrees flexion) before surgery and at 6 weeks and 1 year
improvement in the Knee Society knee score (p=0.013). There were evaluated for ISR. Two surgeons evaluated the radiographs
was no threshold age at which this correlation diminished. independently. For this study, a change in ISR by 0.10 ratio units
There was no correlation between age and radiographic meas- compared to pre-operative ratio was considered significant. No
ures. Younger patients may not improve as much as older patient had pre-operative patella baja. Fifty out of 58 knees had
patients when age is considered as a continuous variable. the ISR ratio within 0.10 of the pre-operative value. In 6 knees,
Radiographic outcomes do not stratify by age at surgery. This the ratio increased and in 2 knees it decreased from the pre-oper-
finding might be dismissed as being attributable to shortcom- ative value. No patient had post-operative patella baja. There was
ings of the Knee Society clinical scoring system. Nevertheless, no difference in KSS for pain and function between patients with
this finding is contrary to the expectations of younger patients decrease in ISR and the rest of the group. We conclude that
and must be considered when counseling this group of arthro- everting the patella at surgery does not increase the risk of patella
plasty candidates. baja. The reported cases in the literature are probably due to
either pre-existing patella baja or surgical errors like elevating the
POSTER NO. P178 joint line
18NaF-Positorn Emission Tomography for
Osteonecrosis of the knee for diagnosis POSTER NO. P180
Masato Aratake, MD, Yokohama, Japan Five Types of Inflammatory Arthritis Following Total
Takahashi Akira, MD, Knee Arthroplasty
Ryohei Takeuchi, Yokohama city, Japan Yasuo Niki, Tokyo, Japan
Izumi Saito, MD, PhD, Hideo Matsumoto, MD, Tokyo, Japan
Haruhiko Bito, MD, Hiroyuki Enomoto, MD, PhD, Tokyo, Japan
Tomoyuki Saito, MD, Yokohama, Japan Koichiro Komiya, MD, Nakagawa-ku, Japan
Spontaneous osteonecrosis of the knee (ON) is a rare disease. Atsushi Funayama, MD, Tokyo, Japan
The purpose of this study was to evaluate 18-Sodium-Fluoride Shinichi Maeno, MD, Tokyo, Japan
(18NaF) positron emission tomography (PET), which is a new Toshiro Otani, MD, Tokyo, Japan
imaging modality to evaluate bone activity. After intravenous Yasunori Suda, MD, Tokyo, Japan
injection of 18NaF, fifteen knees with spontaneous
Joint effusion found more than a year after total knee arthro-
osteonecrosis (ON) were imaged using PET scanner. After PET
plasty (TKA) is considered as a manifestation of certain inflam-
acquisition, we analyzed that; the distribution of 18NaF, stan-
matory reactions within prosthetic joints. This study investigated
489
the causes of joint effusion following TKA and analyzed pheno- POSTER NO. P182
typic characteristics of joint fluid leukocytes for each cause. Comparative Analysis of Knee Society Knee and
Forty-six TKAs in 42 patients with rheumatoid arthritis (RA) and
49 TKAs in 46 patients with osteoarthritis (OA) displaying joint Function Scales
effusion were investigated. Causes of joint effusion were clini- Carlos J Lavernia, MD, Miami, FL
cally identified and frequencies of each cause were compared Michele R Dapuzzo, MD, Hialeah, FL
between RA and OA. Joint fluid cell phenotypes were analyzed David Lee, PhD, Miami, FL
using a flow cytometry. Clinical diagnoses for joint effusion were The Knee Society Clinical Rating System (KSCRS) consists of two
classified into 5 different groups: deep infection; increased scales, the knee score (KS) which consists of pain assessments
activity of RA; particle-induced synovitis; metal sensitivity; and and clinical assessment of knee stability, alignment, and range of
non-specific synovitis. The most frequent cause of post-TKA effu- motion, with the second focusing on patient walking and stair
sion was increased disease activity in RA, and non-specific climbing ability (KS-function). In the present analysis we
synovitis in OA. Interestingly, biomaterial-related arthritis such compare the strength of correlations between these measures
as particle-induced synovitis and metal sensitivity were more and the WOMAC, an accepted measure of functional impair-
frequent with OA than with RA. Analysis of synovial fluid cell ment due arthritis, and two broader measures of quality of life,
phenotypes revealed that the characteristic cells for each diag- the Quality of Well Being Scale (QWB) and the SF-36. A total of
nosis were CD16+CD14- neutrophils in increased activity of RA 363 patients undergoing total joint replacement surgery of the
and deep infection, CD14+ macrophages in particle-induced knee were preoperatively administered the KSCRS, WOMAC,
synovitis, and CD3+CD45RO+ T cells in metal sensitivity. This QWB and the SF-36. Spearman rank order correlations were
indicates that the leukocyte types recruited from peripheral used to assess associations among the measures. Correlation
blood differ with the cause of arthritis. Post-TKA joint effusion is between the KS and KS-function scale was 0.35. The KS-function
clinically caused by 5 different types of arthritis. Phenotypic score was slightly more correlated with the WOMAC than was
characteristics of joint fluid leukocytes reflect joint pathology, the KS (r= -0.55 versus r=-0.43). However, KS-function was more
and analysis of leukocyte phenotypes using flow cytometry highly correlated with the QWB than was the KS (r= 0.50 versus
contributes to diagnosis and exclusion of biomaterial-related r= 0.29). As expected, KS-function was more highly correlated
arthritis. with the SF-36 physical functioning score than was the KS (r=
0.56 versus r=0.29). However, the KS-function was consistently
POSTER NO. P181 more highly correlated with other SF-36 subscales than was the
Assessment of Leg Length Change Due to Total KS (eg., social functioning r= 0.45 versus r=0.18). The KS-func-
Knee Arthroplasty tion score is more highly correlated with general quality of life
measures among patients presenting for knee replacement
Stephen B Murphy, MD, Boston, MA
surgery relative to the KS score. Improvement in KS-function
Mark Nadzadi, MS, scores may therefore be a broader indicator of surgical success
Jonathan Nielsen, MS, than the KS scores in terms of overall patient quality of life.
Timo M Ecker, MD, Boston, MA
Jason Edward Lang, MD, Winston-Salem, NC POSTER NO. P183

Leg length change during TKA has not been effectively studied Preoperative Hyperglycemia is a Risk Factor for
yet. We investigated change in limb length resulting from total
knee arthroplasty using a novel surgical navigation system. Seven
Pulmonary Embolism Independent of Diabetes
knees (7 patients) underwent computer-assisted TKA (Achieve Mellitus
CAS, Smith-Nephew, Memphis, TN). A second navigation system Javad Parvizi, MD, Philadelphia, PA
was used simultaneously for continuous recording of kinematic Luis Pulido, MD, Philadelphia, PA
data. After initial kinematic assessment, the distance between the Joshi Ashish, MD, MPH,
hip center and ankle center was calculated for preoperative leg Jeffrey I Joseph, MD,
length measurement, by holding the limb in a fully extended
Boris Mraovic, MD,
position. Subsequently, the procedure was performed as usual
and after completion, the length measurement was repeated. Zvi Grunwald, MD,
Change in overall limb length was then calculated. Overall limb Incidence of pulmonary embolism (PE) after major orthopedic
length increased an average of 5.68mm (range 2.83-9.19) as a procedures still remains between 0.6-4 %. Hyperglycemia is
result of surgery. Limb length change due to correction of coronal believed to result in hypercoagulable state. It is not, however,
malalignment, averaged 1.55mm (range 0.27-5.48). The preop- known if high blood glucose (BG) is an independent risk factor
erative coronal malalignment ranged from 4.83 degrees of varus for PE. This study investigates if preoperative BG e200 mg/dl is
to 9.38 degrees of valgus, and the postoperative coronal align- an independent risk factor for PE. The medical records of 7,226
ment averaged 0.29 degrees of varus (range 2.20 degrees varus to patients undergoing TJA between 2001 to 2006 at our institution
1.27degrees valgus). The limb length change due to the supe- were included in this study. The diagnosis of PE was based on a
rior/inferior changes in the joint lines averaged 4.14mm (range positive finding with a chest CT or a lung scan. Numerous vari-
2.47-6.32). While deliberate change in limb length is not typi- ables including demographics, ASA status, duration of surgery,
cally possible during primary total knee arthroplasty, posterior type of surgery, comorbidities, perioperative anticoagulation,
cruciate preserving total knee arthroplasty increased limb length and preadmission BG were evaluated. The data were analyzed
by an average of 5.68mm with 4.14mm attributable to increase using logistic regression, with odds ratios and 95% CIs. The inci-
in distance between the femur and tibia and the remainder due dence of PE was 1.49 % (108 patients). Multivariate analysis
to correction of sagittal plane malalignment. showed that preoperative BG e200 mg/ml increased risk of PE by
2.7 (CI 1.1 - 6.8, P=0.035) when compared to patients with BG
d110 mg/dl, older age increased risk by 2.0 (CI 1.02 ‘ 3.9,
P=0.022), BMI of 30 to 40 kg/m2 by 1.8 (CI 1.2 ‘ 2.9) and BMI
> 40 kg/m2 by 2.2 (1.1 ‘ 4.5, P=0.016). Among the medical Direct Compression Molded (DCM) 1900H (n=2), Gamma Air
conditions congestive cardiac failure increased the risk of PE by Ram Extruded GUR 415 (n=16), Gamma-N2 DCM 1900H
2.5 (1.1 ‘ 5.6, P=0.028). DM was not found to be a risk factor. (n=12), Gamma-N2 Bulk Compression Molded GUR 1050
TKA carried 2.4 (1.5 - 3.9, P<0.001) times more risk than THA. (n=29). Both condyles were scored for the presence and extent
Bilateral procedure increased the risk by 1.8 (0.995 - 3.17, of pitting and delamination using the Hood technique. 200
P=0.052). Our data suggests that preoperative hyperglycemia is micron sections were microtomed from the medial condyle and
an independent risk factor for developing PE after major ortho- unloaded central spine and scanned through the thickness using
pedic surgery, but DM is not. It appears that preoperative BG is Fourier transform infrared spectroscopy. The maximum oxida-
as important as other major risk factors for PE, and it should be tion index was calculated in accordance with ASTM F2102-01.
well controlled (<200 mg/dl) before major surgical procedures. Delamination was significantly more prevalent and extensive
A prospective, randomized, controlled trial would determine if among the air sterilized inserts than among the inert sterilized
control of preoperative glucose leads to a decrease incidence of inserts. Pitting appeared to be equally prevalent and extensive
PE in this clinical setting. among all implant groups. Oxidation in gamma air sterilized
inserts was significantly higher than in Gamma-N2 sterilized
POSTER NO. P184 inserts. Gamma air sterilized inserts had the longest implanta-
Clostridium Difficile Infection Following Total Joint tion times and were associated with the highest oxidation near
the bearing surface, and also displayed more prevalent and
Arthroplasty: Who is at Risk? extensive delamination. Due to their relatively short shelf lives
Luis Pulido, MD, Philadelphia, PA and the significant regional variations between the surface and
Mark F Kurd, MD, Philadelphia, PA backsides, oxidation was inferred to have taken place in vivo,
Joshi Ashish, MD, MPH, supporting our hypothesis that in vivo oxidation is a
James J Purtill, MD, Philadelphia, PA contributing factor to delamination in TKA. We found no
Javad Parvizi, MD, Philadelphia, PA evidence to suggest that in vivo oxidation is related to pitting.
Clostridium Difficile-associated diarrhea (CDAD) is an unde-
POSTER NO. P186
sired complication after total joint arthroplasty (TJA). While
some risk factors such as old age, administration of antibiotics, In Vivo Oxidation Rate of Gamma-Sterilized
and increased length of hospital stay have been proposed, the UHMWPE - Assessing the Risk for Bearing Failure
predisposing factors for this condition following TJA remain
Barbara H Currier, MChE, Hanover, NH
unknown and were the objective of this study. We were able to
John H Currier, MS, Hanover, NH
identify 16 cases of confirmed Clostridium difficile infection
following 9,880 total joint arthroplasty (0.16% incidence) Kimberly A Lyford, BA, Hanover, NH
between 2,001 and May 2,006 at our institution. The cases were Michael B Mayor, MD, Hanover, NH
matched with 32 control patients for month/year of surgery and Douglas Van Citters, PhD, Hanover, NH
surgeon. Detailed data was extracted to evaluate potential John P Collier, DE, Hanover, NH
predisposing factors using univariate analysis. Significant predis- Oxidation of polyethylene bearings following gamma-steriliza-

posing factors for Clostridium difficile infection following TJA tion seriously degrades mechanical properties. Although
was longer hospital stay, higher ASA score, and the number of orthopaedic implant manufacturers changed sterilization
antibiotics administered. None of the other factors examined methods from gamma-air to gamma-barrier sterilization, the
were found to be significant. The majority of the patients recov- installed base of 3 million gamma-sterilized bearings has the
ered without adverse consequences, except for two patients who potential to oxidize in service. Previously published oxidation
developed toxic megacolon that necessitated colectomy. This rate equations are compared with retrieval outcomes to predict
study suggest that patients following total joint arthroplasty with long-term performance of gamma-sterilized polyethylene bear-
longer hospital stays, underlying medical conditions or who ings. Ninety-five retrieved UHMWPE gamma-air bearings (73
receive greater than one antibiotic are at a higher risk for devel- with shelf life 0 to 18 months, in vivo time 3 to 16 years; 22 with
oping Clostridium difficile infection after TJA. shelf life >18 months, in vivo time 0.1 to 13 years) were evalu-
ated for oxidation by FTIR spectroscopy. Retrievals were rated for
POSTER NO. P185 clinical damage. Retrieved bearings had location-dependent
In Vivo Oxidation is the Primary Contributor to oxidation profiles with lowest oxidation on metal-backed
surfaces and highest oxidation on more exposed surfaces.
Delamination in TKA
Fatigue damage (cracking, delamination, bearing fracture) was
Steven M Kurtz, PhD, Philadelphia, PA identified in 58% of retrievals. Fatigue damage in retrieved bear-
Javad Parvizi, MD, Philadelphia, PA ings with minimal pre-implant shelf time resulted from in vivo
James J Purtill, MD, Philadelphia, PA oxidation combined with cyclic stress in vivo. The in vivo oxida-
Peter F Sharkey, MD, Philadelphia, PA tion rate equation for GUR415/412 predicts oxidation >1.5
Daniel MacDonald, BS, Philadelphia, PA (sufficient to allow fatigue damage) after 12 years in vivo. This
Eric Brenner, BS, study found 100% of gamma-air retrievals with in vivo time >12
Matthew J Kraay, MD, Cleveland, OH years had fatigue damage. These findings suggest that implanted
polyethylene bearings that have been gamma-sterilized will
Victor Goldberg, MD, Cleveland, OH
become increasingly at risk for fatigue damage secondary to
Clare M Rimnac, PhD, Cleveland, OH oxidation over time in vivo. Knowing in vivo oxidation rates and
It remains unclear to what extent in vivo oxidation contributes patient activity alerts surgeons to identify patients most at risk
to fatigue wear in TKA. We studied the oxidation profiles in 59 for bearing failure.
consecutively traced TKA inserts from one manufacturer. The
implants were grouped according to sterilization method,
conversion method and UHMWPE resin type: Gamma Air
491
POSTER NO. P187 eratively, and this is maintained postoperatively. Patients with
Mid-Term Clinical Results of Medial Pivot Total obesity should be counseled as to realistic expectation regarding
ROM following TKA.
Knee Arthroplasty
Robert H Schmidt, MD, Ft. Worth, TX POSTER NO. P189
C Lowry Barnes, MD, Little Rock, AR Three Myths of Knee Design Challenged By Clinical
The Medial Pivot total knee arthroplasty features an asymmetric Retrievals
tibial articulating surface. The component has a congruent “ball
and socket” design medially and a less conforming articular Michael B Mayor, MD, Hanover, NH
surface laterally. The congruency of the medial surface permits a John P Collier, DE, Hanover, NH
posterior cruciate sacrificing surgical technique without the use Nicola M Mootoo, AB, Hanover, NH
of a central post. This study evaluates mid-term clinical results of Kimberly A Lyford, BA, Hanover, NH
this tibial insert. From July 1997 to January 2006, 405 Medial John H Currier, MS, Hanover, NH
Pivot total knee arthroplasties were performed by the senior Barbara H Currier, MChE, Hanover, NH
author using a cruciate sacrificing technique. All patients were There are several points of conventional wisdom regarding unce-
retrospectively reviewed clinically and radiographically at six mented knee replacements: tibial components did not biologi-
weeks, three months, and annually. Knee Society rating forms cally stabilize, metal backed patellae all failed, and thin
and Short Form 36 scores were recorded. The KS system using polyethylene was the cause of bearing failure in many designs.
zonal analysis was used to categorize radiolucencies. 374 knees 850 uncemented tibial knee components of 19 designs, 420
were available for followup. 16 patients were deceased and 15 uncemented metal backed patellae of 13 designs, and 23 ETO
patients were lost to followup. Mean followup was 5.4 years. The sterilized tibial components of 6 designs (including 13 Unis)
mean Knee Society rating score at last followup measured 90.4 were evaluated for bone ingrowth, wear, oxidation, polyethylene
clinical and 74 functional. One component was revised for late thickness and failure mechanism. Many designs of tibial compo-
infection and one component was revised following a traumatic nents showed little evidence of ingrowth; those that demon-
injury. There were no reported instances of knee dislocation. strated successful ingrowth had either a large, porous coated
Radiographic analysis revealed no progressive lucencies or central peg or were fixed with multiple screws. However, screw
component migration. This is the first series to report mid-term holes often showed migration of debris and osteolysis was a
results using the Medial Pivot implant design. Concerns frequent reason for retrieval. Tibial trays which were polished
regarding accelerated polyethylene wear due to the congruency cobalt alloy with mobile bearings were very effective in achieving
of the medial joint compartment, or instability due to the ingrowth. Metal backed patellae were a frequent source of failure
absence of a central post, do not appear to be warranted. The by disassociation or wear-through of the polyethylene.
possible long-term benefits of an asymmetric articulating surface Successful designs were highly congruent or used techniques to
requires further study. firmly bond the polyethylene to the metal backing and were
non-modular. The most frequent contributor to tibial fatigue
POSTER NO. P188 failure was oxidation secondary to gamma radiation steriliza-
Effect of BMI on Range of Motion and Manipulation tion. Many thin bearings sterilized with EtO survived more than
Following Total Knee Arthroplasty 20 years in designs similar to those which failed early due to
oxidation. Younger, more active patients may challenge cement
Geoffrey H Westrich, MD, New York, NY
fixation. Development of uncemented, high performance
Christopher E Urband, BS, designs for this group should include careful tibial fixation
Thomas P Sculco, MD, New York, NY design without screws, patellae with congruent, non-modular
Many factors contribute to the range of motion (ROM) and need bearings and polyethylene inserts which contain no free radicals
for manipulation under anesthesia (MUA) following total knee to eliminate oxidation as a source of fatigue failure. Mobile
arthroplasty (TKA). Some such factors include preoperative bearing designs should be an option to minimize the stresses at
ROM, previous surgery or trauma, and body mass index (BMI). the bone-implant interface.
The aim of this study was to evaluate the affect of BMI on post-
operative ROM and MUA. We prospectively collected ROM POSTER NO. P190
(preoperative and postoperative), BMI, and incidence of MUA Anatomic Variation in Anteroposterior and
data in 399 TKA procedures (309 patients). Groups were created
as determined by BMI (<25.0, 25.0-29.9, >29.9). ROM and inci- Mediolateral Size Distribution of Primary TKA
dence of MUA were then compared between these groups using Implants
chi-square or Fisher’s exact tests. BMI affected postoperative Adolph V Lombardi Jr, MD, New Albany, OH
ROM. The smallest group had significantly greater ROM than Keith R Berend, MD, New Albany, OH
the largest group preoperatively (p<0.000), and postoperatively
Jeffrey W Salin, DO, Overland Park, KS
at discharge (p<0.008), 6 weeks (p<0.011), 1 year (p<0.000),
and 2 years (p<0.027). Moreover, the smallest group had Joanne B Adams, New Albany, OH
improved ROM over the middle group immediately after Long clinical history and outstanding success are established
surgery, but this was not maintained at 6 weeks or beyond. No with total knee arthroplasty (TKA) using standard implant sizes
difference in ROM was noted after 2 years. Furthermore, inci- ranging from 55 to 80mm in 5mm proportionate increments in
dence in manipulation was not significantly different between the mediolateral dimension. It became evident that smaller
the three BMI groups. We have demonstrated that BMI plays a increments in sizing may be needed for different size femurs and
role in both pre- and postoperative ROM. Those patients with to address specific size differences between genders. The purpose
the highest BMI values have significantly decreased ROM preop- of this study is to examine the utilization of intermediate size
TKA femoral components in primary TKA, specifically
addressing gender differences. We reviewed 1322 consecutive,
primary, cruciate-retaining TKA performed with a single implant tries but variable distal configurations consisting of 4 groups:
design in 1065 patients between February 2003 and October Group 1: non-modular, Group 2: modular blasted tray with
2005. Of these patients, 694 (65%) were women. In March 2004 standard micromotion, Group 3: modular polished tray with
intermediate size components became available for implanta- standard micromotion and Group 4: modular blasted tray with
tion. There were 389 TKA prior to intermediate size availability. reduced micromotion. Displacement sensors were positioned in
During that time, 50% of female TKA were size 65mm. After knee simulator wear stations to record micromotion. For
intermediate sizing, 34% were 62.5mm, 19% were 65mm and moderate gait kinematics, the wear rates of modular group 3
9% were 67.5mm. In men, the most common sizing was 70mm (polished- standard micromotion) and 4 (blasted-reduced
representing 47% of pre-intermediate sizes. Following interme- micromotion) were statistically similar to the non-modular
diate sizing 40% of male femurs remained 70mm. The use of the Group 1. However, Group 2 (blasted-standard micromotion)
65mm femur in the male patient dropped from 28% before wear rates were significantly greater than the non-modular
intermediate sizing to 13% after, and 23% of male femurs were group (p=0.03). For aggressive conditions, micromotion of all
67.5mm. In conclusion, the addition of intermediate size modular trays increased at least 2 fold and wear rates increased
femoral components has served to more effectively address vari- 2.5 to 4 fold. Wear rates for non-modular Group 1 and modular
ations in the anterior-posterior to medial-lateral dimensions of Group 3 (polished-standard micromotion) remained similar
the femur. This is particularly true of the female femur where and trended lower than blasted modular groups 2 and 3. The
better fit and size ratio is accomplished with the majority of wear rate of Group 4 (blasted- reduced micromotion)
femoral components now in the intermediate sizes. approached the wear rate of Modular Group 2 (blasted- stan-
dard micromotion). The study suggests that TKA with polished
POSTER NO. P191 modular interfaces afford wear rates comparable to non-
Radiographic Evaluation of the Locking Mechanism modular components. The results for blasted tray conditions
were dependent on the kinematics. Under moderate kinematic
After Total Knee Replacement conditions, reduced micromotion -blasted designs performed
Matthew Hepinstall, MD, New York, NY comparable to non-modular components but under aggressive
Jose A Rodriguez, MD, New York, NY conditions behavior was most similar to blasted designs with
Anterior subluxation of the polyethylene insert relative to the standard micromotion.
tibial baseplate can occasionally be identified on the lateral radi-
ograph after total knee arthroplasty. This finding is anecdotally POSTER NO. P193
associated with failure of the locking mechanism at revision Manufacturing Technique Affects Backside Wear of
surgery. Failure of the locking mechanism can cause backside
polyethylene wear and consequently periarticular osteolysis, so a
Total Knee Arthroplasty Modular Tibial Inserts
radiographic clue to this mode of failure could be clinically Brad Ellison, MD, Columbus, OH
useful. We retrospectively identified 10 Press Fit Condylar total Keith R Berend, MD, New Albany, OH
knee replacements that were found to have failure of the locking Adolph V Lombardi Jr, MD, New Albany, OH
mechanism at the time of revision surgery for synovitis and oste- Wear of the polyethylene insert backside surface has been impli-

olysis. Operative reports were reviewed for status of the locking cated in osteolysis and failure of total knee arthroplasty (TKA).
mechanism and presence of backside wear. Preoperative lateral Manufacturing and sterilization methods reduce the rate of artic-
radiographs were inspected for polyethylene subluxation. The ular sided wear. The aim of the current study was to determine
operative report noted failure of the locking mechanism in 10 the impact of polyethylene manufacturing technique on the
knees, and all 10 had significant backside wear. Nine of these 10 severity of backside wear. Thirty-nine explanted tibial bearings
knees had anterior polyethylene subluxation evident on a preop- were examined in a blinded fashion using visual, stereomicro-
erative radiograph, whereas the anterior margin of the polyeth- scopic, and scanning electron microscopic techniques. Twenty-
ylene could not be readily identified on the preoperative six direct compression molded (DCM) components and 13
radiograph of the remaining patient. Fatigue failure of the ante- non-DCM components were examined. A backside wear severity
rior locking tab was found in 4 of these cases. Anterior polyeth- score was determined (0: no wear to 27: severe). Time in vivo,
ylene subluxation on the lateral radiograph is a subtle sign of tibial baseplate material and manufacturing technique were
failure of the locking mechanism in Press Fit Condylar total knee used as variables for statistical comparison. Backside wear was
arthroplasty. It may be associated with fatigue fracture of the significantly related to polyethylene manufacturing process with
anterior locking tab, although this is not necessary for failure. direct compression molded (DCM) implants having a wear
Backside wear is evident whenever failure of the locking mecha- score of 2.3 and non-DCM a score of 5.7 (p=0.03). Multiple
nism is present. linear regression demonstrated DCM and time in vivo to be
significant (p=0.003). Grouped linear regression analysis
POSTER NO. P192 demonstrates DCM to be a predictor of significantly decreased
The Influence of Tibial Tray Modularity, Surface backside wear independent of time in vivo (p=0.05).
Manufacturing technique involving DCM is an independent and
Finish and Micromotion on TKA Wear
significant predictor of reduced backside wear in TKA polyeth-
Donald McNulty, MS, PE, Warsaw, IN ylene inserts.
Steve Swope, MD,
Wear debris generated from modular tibial interfaces has been
implicated in osteolysis. The objective of this study was to assess
the wear contribution of surface finish and interface micromo-
tion in modular tibial components relative to non-modular
components for moderate and aggressive kinematics in a knee
simulator. Wear testing was conducted using cruciate retaining
TKA components with identical tibio-femoral articular geome-
493
POSTER NO. P194 (p=0.83). The use of commercially available ABLC did not
Predictors of Total Knee Arthroplasty Deep reduce primary TKA infection rates. This included high risk
diabetic patients, and other high risk patients for whom
Infections in 23,089 Cases surgeons in this cohort selected use of ABLC. With concerns of
Robert S Namba, MD, Corona Del Mar, CA allergic reactions, toxicity, antimicrobial resistance, mechanical
Liz Paxton, MA, San Diego, CA failures and cost, the routine use of antibiotic-laden cement does
Howard Barkan, PhD, not seem warranted.
Debra O Dee, El Cajon, CA
POSTER NO. P196
Swapnil B Shah, MD, San Francisco, CA ◆Navigated Freehand Bone Cutting for TKR
The reported incidence of infections in total knee arthroplasty Surgery: Experiments With Seven Independent
(TKA) varies widely. Various prophylactic measures, and risk Surgeons
factors, have been implicated but unproven. A prospective study
O Andres Barrera, MS, Omaha, NE
using a TKA registry of community based hospitals was
performed utilizing a comprehensive infection surveillance Hani Haider, PhD, Omaha, NE
program with strict adherence to CDC guidelines. Multivariate Kevin L Garvin, MD, Omaha, NE
logistic regression analysis was utilized to determine the effects Craig Robert Mahoney, MD, West Des Moines, IA
of prophylactic measures, operative time, procedure (primary vs. Amar S Ranawat, MD, New York, NY
revision), and use of drains. Patient factors evaluated included Chitranjan S Ranawat, MD, New York, NY
age, gender, ASA scores, diagnosis, and co-morbidities. 21,759 A previously introduced navigated-freehand bone cutting tech-
primary and 1,330 revision TKAs were performed in 50 hospi- nique for TKR has been tested only by our surgeons. This study
tals (2001-2006). The deep infection rate was .7% for primary reports on evaluation in the hands of external surgeons with
and 1.7% for revision cases (p<.001). Prophylactic antibiotics widely-varying TKR expertise. Seven orthopaedic surgeons
were utilized in all procedures. Laminar flow was utilized in prepared a synthetic distal femur. The Nebraska Orthopaedics
8,529 (37%) cases, body exhaust suits in 16,223 (70%), clean air Minimally Invasive Surgery System (NoMiss) was used to navi-
in 5,193 (37%), antibiotics in cement in 1820 (8%). 21% of the gate the bone-specimen and a saw to osteotomize the femur.
patients were diabetic. Primary diagnosis was osteoarthritis Each surgeon performed five timed experiments and each exper-
(OA) in 86% and rheumatoid arthritis in 2%. Male gender iment required the completion of all five cuts of one bone-spec-
(p=.01), ASA >2 (p=.0004), diagnosis other than OA (p=.004), imen. Implant “fit” and “alignment” were physically measured
and higher operative time (p=.04) were associated with higher with a navigated implant trial and produced numeric fit and
risk of deep infection when statistically controlling for other alignment indices. All cut-bones were also digitized to compute
factors. Laminar flow, body suits, antibiotics in cement, use of smoothness and alignment indices representing how rotated
drains had no effect above prophylactic IV antibiotics. A low rate and offset the implant was relative to ideal. The average cutting-
of primary TKA infection with prophylactic antibiotics was time was 10.2±4.3min. The average-roughness Ra was 0.19mm,
observed, but efficacy of other measures was not proven. Of
and the difference between the highest-50-peaks and lowest-50-

factors that are under the surgeon’s control, only operative time valleys was <1.2mm. Twenty-one out of 35 bones were tight on
had a significant influence. the implant-trial without cementation. The worst looseness was
in flexion and extension with average range <1.6°, and <1mm in
POSTER NO. P195 translation. Average implant alignment error was 1.2°. Linear-
Low-Dose Antibiotic Loaded Cement Did Not Lower translation errors averaged 1.4mm. Analysis of all cut-surfaces
Primary TKA Infection Rates showed the chamfers as the extreme-outliers. This study showed
high reproducibility of cuts and a narrow envelope of alignment
Robert S Namba, MD, Corona Del Mar, CA error. Alignment with NoMiss in previous studies was superior
Debra O Dee, El Cajon, CA and the cutting was faster compared to using conventional TKR
Liz Paxton, MA, San Diego, CA cutting-blocks, and this was echoed here. Feedback from the
Donald C Fithian, MD, El Cajon, CA surgeons surpassed our expectations. We anticipate significant
Antibiotic-loaded Cement usage for infection prophylaxis in further improvements with the inclusion of novel smart soft-
primary TKA is controversial. Previous studies have demon- ware/hardware techniques.
strated reduction in infection rates, especially in high risk
patients with diabetes mellitus. A community based total joint POSTER NO. P197
registry, an integrated administrative database, and a compre- ◆Tibiofemoral Contact Mechanics with a Non-
hensive infection surveillance program were used to evaluate
deep infection in 15,859 primary TKAs from May 2003 (start
functional Meniscus and Femoral Resurfacing
date of available commercially prepared ABLC in the U.S.) to Prosthesis
April 2006. Deep infection rates were compared between ABLC Christoph Becher, MD, Marburg, Germany
TKAs and non-ABLC TKAs. Center for Disease control defini- Roland Huber, GE,
tions were used to define and validate (by infection control prac- Hajo Thermann, MD, Heidelberg, Germany
titioners) deep infection occurrence. Patients with diabetes
Carsten Oliver Tibesku, MD, Marburg, Germany
mellitus were also compared ABLC was used in1240 patients
(7.8%). Among 3,339 (21.1%) diabetic patients, ABLC was used
Prof Susanne Fuchs, MD, Marburg, Germany
in 301 (9.0%) patients. The overall rate of deep infection was Hans H Paessler, MD, Heidelberg, Germany
1.1% (n=14) for TKA with ABLC and 0.7% (n=102) without Gobert Skrbensky, MD,
ABLC (p=0.09). Among diabetics, the deep infection rate was This in vitro study aims to determine the peak contact pressure
1.3% (n=4) with ABLC and 1.2% (n=36) without ABLC in the tibiofemoral joint with a contoured articular partial
femoral resurfacing device (HemiCAP®) and a complete radial
tear of the medial meniscus. Increased contact stress with a non- POSTER NO. P199
functional meniscus is of concern for potential deleterious Cemented or Uncemented Fixation of Miller-Galante
effects on tibiofemoral contact mechanics. Peak contact pres-
sures were determined in seven fresh frozen cadaveric specimens II TKA Randomized Study With 10-Year Follow-Up
using a Tekscan sensor placed in the medial compartment above Kjell G Nilsson, MD, Umea, Sweden
the menisci. A knee simulator was used to test each knee in static Tore Dalen, MD, Adelaide, SA Australia
stance positions (5°/15°/30°/45°) with body weight ground It is still unclear whether cemented or uncemented fixation is the
reaction force (GRF). The ground reaction force was adjusted to best in TKA. The aim of this randomized study was to analyze
the living body weight of the cadaver donor. All specimens were the quality of fixation of the Miller-Galante II (MG II) TKA in 3
tested in three different conditions: (1) untreated; (2) flush different modes of fixation: a) cemented (C), b) porous coated
device implantation (medial femoral condyle); (3) complete (PC), and c) hydroxy-apatite coated (HA) for a follow-up of 10
radial tear at the posterior horn of the medial meniscus. A paired years. 68 knees (mean age 72, range 51-86) were operated with
sampled t-test to compare means (significance, P<0.05) was MG II TKA. Randomization was done intraoperatively by
used for statistical analysis. On average, no statistically signifi- opening of a sealed envelope after tibia was cut: 24 knees had
cant differences were found in any testing condition comparing precoated implant fixed with Palacos cement (C), 22 knees had
the normal knee with flush device implantation as well as at 5° titanium fiber mesh implant (PC), and 22 knees had HA-coated
stance position after creating the meniscus tear. The meniscus implant (HA). The PC and HA groups had 4 additional screws.
tear resulted in a significant increase of mean peak contact pres- Follow-up was with radiostereometry (RSA) and Knee Society
sures by 63%, 57%, and 57% (all P<0.05) at 15°, 30° and 45° Score at 3, 12, 24, 60, and 120 months. There were no losses to
stance position. Resurfacing with the prosthetic device appears follow-up and no revisions. At 10 years twenty patients had died
not to increase peak contact pressures. However, the data (7 C, 7 PC, 6 HA). The C group displayed initially low migration
suggests that a non-functional meniscus appears to be biome- which continuously increased. The PC group showed larger
chanically disadvantageous in an in-vitro application. Possible initial migration with no stabilization over time. The HA group
effects of reduced meniscal tissue and biomechanical integrity of showed intermediate initial migration, but thereafter stabiliza-
the meniscus must be considered in an in-vivo application. tion up to 10 years. After the initial 3 months the HA coated
implants stabilized and were stable up to 10 years, whereas the
POSTER NO. P198 Cemented and Porous coated groups displayed continuously
Revision of Total Knees Replacements for Allergies increasing migration over this period. HA-coating improves
Against One or More Components uncemented implant fixation by inducing early stabilization.
Juan J Rodrigo, MD, Spartanburg, SC POSTER NO. P200
Jennifer Henderson, BS, Spartanburg, SC
Risk to the Popliteal Artery with Changes in Knee
Tonya Stott, OT, Spartanburg, SC
Evidence has accumulated that immune responses can occur Flexion and Subluxation
against ions from metals, metal alloys, polyethylene, or methyl- Marc Wilson Hungerford, MD, Baltimore, MD

methacrylate (1-12.) We hypothesized that removing the mate- Carmen P Pichard, MD, Baltimore, MD
rials responsible for the allergic reaction and revising with Harpal Singh Khanuja, MD, Baltimore, MD
different materials would improve the status of the failed total Lynne C Jones, PhD, Baltimore, MD
knee. Eleven knee revisions in eight patients were done for Popliteal artery injury during TKA is a rare but devastating
failure of anti-inflammatory medications in the treatment of complication. Traditional TKA techniques advocate cutting the
known strong allergies to specific materials. Four patients are tibia in deep flexion to allow the popliteal artery to move away
continuing non-operative treatment. A lymphocyte proliferation from the posterior capsule. With minimally invasive techniques,
assay was used to measure immune reactions to cobalt-chrome, the surgical field is reduced, and the surgeon must work with less
titanium, polyethylene, and methacrylate in these patients (13). visualization. This study characterized the risk to the popliteal
Pain at rest was the principle functional parameter followed, artery during tibial resection in various degrees of flexion and
although knee society scores and overall functional ratings were subluxation. Radiocontrast dye was injected into the popliteal
collected. Improvement of pain at rest in the immediate post- artery of 6 cadaveric specimens. Using a jig, the knee was held in
operative period occurred in seven of eight knees, and pain specific flexion angles in the upright position. TKA exposure was
improvement persisted in eiht of eleven. One of the two failures performed. A small peg was placed in the tibia just lateral to the
had an initial strong allergy to cobalt-chrome, became strongly PCL insertion. Direct lateral radiographs were obtained at 90o
allergic to polyethylene and methacrylate after changing his and 115o of flexion at neutral, 50% and 100% subluxation.
cobalt-chrome to ion bombarded titanium. Two other failures Radiographs were analyzed using Endomap templating soft-
were judged to have inadequate removal of her cement, which ware. The distance from the peg to the popliteal artery was meas-
they were strongly allergic to. After removing the patellar cement ured 7mm distal to the joint line for each degree of flexion and
and converting to a tantalum backed patella, their pain and subluxation. Risk of artery laceration was categorized as low
function improved. Improvement of functional outcome from a (>40mm), medium (20-40 mm), or high (< 20mm).
poor status was seen in eight of eleven, but was fair in two of the Interobserver correlation of measurements was good. Average
eight. Three of eleven did not improve. Preliminary evidence distance from the tibial peg to the popliteal artery at 7mm below
suggests that knee revisions for allergies will improve pain at rest, the joint line was 28.1 +/- 9.3 mm at 90o flexion and 33.1 +/-
but only occasionally gives good functional outcomes. 5.4 mm at 115o flexion. With increased subluxation, the
distance increased. At maximal subluxation, the distance meas-
ured 34.9 +/- 8.5 mm at 90o and 40.0 +/- 2.8 mm at 115o
flexion. In several specimens at 115o, a line perpendicular to the
axis of the tibia 7mm below the joint line failed to intersect the
popliteal artery. The flexion/subluxation combination with the
495
highest risk was 90o flexion/no subluxation. The flexion/sublux- study reflects the risk of joint replacement infection with psori-
ation combination with the lowest risk was 115o flexion/100% asis in a community based practice in a large number of patients.
subluxation. To minimize the risk of popliteal artery laceration No increased risk of infection with psoriasis was identified.
during tibial resection in TKR, the surgeon should cut the tibia
in as much flexion and tibial subluxation as possible. POSTER NO. P203
◆Optimization of Polymethylmethacrylate (Pmma)
POSTER NO. P201
Formulations for Local Delievery of Antibiotics
Reduction of Articular Rotational Constraint in
Richard Parker Evans, MD, Little Rock, AR
Prosthetic Design Improves in Vivo Knee Mark S Smeltzer, PhD, Little Rock, AR
Kinematics Brian Weiss, BA,
Ormonde M Mahoney, MD, Athens, GA Warren Haggard, MD, Memphis, TN
Tracy Kinsey, RN, Athens, GA Objective was to define a formulation that required a minimum
Kathy J Simpson, PhD, Athens, GA amount of daptomycin that did not alter the structural integrity
Tetsu Watanabe, MD, Suita-city, Japan of PMMA beads which yielded an elution profile of at least 100X
Takaharu Yamazaki, PhD, the minimum inhibitory concentration (MIC) and a sustained
Published results of in vivo fluoroscopic analyses of numerous concentration at least 5X the MIC defined for a daptomycin-
posterior stabilized total knee arthroplasty (TKA) designs have sensitive strain of Staphylococcus aureus. Assays of different
demonstrated the occurrence of physiologic internal tibial rota- bead formulations at 24 hr intervals over the course of 10 days
tion during closed chain knee flexion activities in 76% of using bioassays for antibacterial activity, and HPLC analysis to
subjects (Dennis, et al., CORR, 2004). The net rotational deflec- determine absolute levels were employed. 2 gm daptomycin and
tions averaged less than five degrees; much less than normal 22 gm xylitol per 40 gm package of PMMA (Palacos) resulted in
knees (16.5 degrees). This study was undertaken to asses the a peak concentration on day 1 of 640 ug/ml and a sustained
capacity of selected implant design characteristics to more concentration on day 10 of 5 ug/ml as determined by bioassay.
consistently and more nearly reproduce normal knee rotational As determined in concomitant control assays using freshly-
kinematics. The TKA implant we studied featured a design that prepared daptomycin these values correspond to over 1000X
was modified by moving the post cam mechanism posteriorly, and 8X the MIC of the test strain respectively. HPLC analysis
centering it under the femoral center of rotation. The tibial yielded comparable values of 640.2 ug/ml on day 1 and 9.56
inserts were machined along a rotational arc to allow 25 degrees ug/ml on day 10. These results confirm bioassay data and indi-
of unrestricted internal and external rotation. Seventeen knees cate that daptomycin eluted from xylitol/PMMA after 10 days of
were examined radiographically utilizing three dimensional incubation at 37OC. This same formulation was effective for the
shape matching technology to delineate prosthetic orientation. delivery of vancomycin or gentamicin. As in the case of dapto-
The subjects were studied performing a closed chain knee mycin, the gentamicin elution objectives could be achieved with
flexion maneuver (stand to squat). Patterns of tibial internal considerably less antibiotic when combined with xylitol
compared to PMMA beads without xylitol. Results demonstrate
rotation demonstrated approximately linear progression

through the squat maneuver. Two patients demonstrated slight that xylitol can be an inexpensive filler to enhance the elution
paradoxical rotations (1.5 degrees external). Total internal tibial profile of daptomycin, gentamicin and vancomycin from PMMA
rotation averaged 9.1 degrees. This study suggests that by modi- beads. Transient high antibiotic levels that significantly exceed
fying the implant articular surfaces and post-cam positions we the minimum inhibitory concentration for a sustained period
can improve post TKA kinematics. were obtained. This approach could be used to enhance local
antibiotic therapy augmentation with drugs that exhibit both
POSTER NO. P202 concentration and time-dependent bacterial killing. Xylitol can
be used to increase the optimal elution of daptomycin and other
Impact of Psoriasis on Deep Infection Following antibiotics from polymethylmethacrylate (PMMA). These
Primary Knee and Hip Arthroplasty formulations can be used as local antibiotic therapy augmenta-
D Ron Anderson, MD, Rancho Palos Verdes, CA tion and can provide bactericidal levels of chemotherapy.
Debra O Dee, El Cajon, CA
POSTER NO. P204
Psoriasis is a common skin condition afflicting 2-3% of adults.
Although patients with psoriasis are known to harbor bacteria in Extensor Mechanism Impingement of Five Different
their skin, previous studies of psoriasis on infection during joint PS Type TKA Designs During High-Flexion
replacement surgery have yielded contradictory results. In this Takashi Azuma, MD, Nara Pref, Japan
study, the impact of psoriasis on infection following primary
Makoto Kondo, MD, Nara, Japan
TKA and THA was examined. 9130 unilateral TKA and 4555
THA surgeries performed between 2003 and 2006 were identi-
Tadashi Fujii, MD, Rochester, MN
fied using a total joint registry. Administrative databases were Hiroshi Kitagawa, PhD, MD,
utilized, identifying 217 (2.4%) of patients undergoing primary Yoshinori Kadoya, MD, Sakai, Japan
TKA and 79 (1.8%) THA carried the diagnosis of psoriasis. 3/217 Anterior knee pain due to extensor mechanism impingement of
(1.4%) of the TKA patients with psoriasis developed infection polyethylene (PE) inserts has been reported in posterior-stabi-
during the year following the surgery compared to 77/8913 lized (PS) TKA patients.This study investigated radiographically
(0.8%) of the patients without psoriasis (p=0.27). 1/79 (1.3%) the incidence of extensor mechanism impingement during high
of the THAs with psoriasis became infected compared to flexion in five different PS TKA designs. One hundred and six
28/4376 (0.6%) THAs without psoriasis (p=0.41). Among TKAs, TKAs (OA 68 knees, RA 38 knees, average age 70.9 years) with
the difference in infection rate was 0.5% with a 95% confidence greater than 125 degrees of flexion were investigated. The pros-
interval of ±1.6%. For THAs, the difference was 0.64±2.5%. This theses used were 11 IB-II, 8 Nex-Gen PS, 42 LPS, 17 LPS-Flex
(Zimmer) and 28 Vanguard PS (Biomet). Impingement was
evaluated in lateral radiographs obtained in maximum flexion at POSTER NO. ORS 2

1 year postoperatively. It was regarded as positive when the The Patellar Tendon After ACL Reconstruction with
minimum distance between the extensor mechanism and the PE
insert was less than 1 mm. Impingement was positive in 63.6% a Bone-Patellar Tendon-Bone Autograft
of IB-II, 75% of Nex-Gen PS, 73.8% of LPS and none of LPS-Flex Samuel K. Van de Velde, MD, Boston, MA
or Vanguard PS. The prevalence of anterior knee pain was 57.1% Thomas J. Gill, Boston, MA
with IB-II, 16.7% with Nex-Gen PS, 9.7% with LPS and absent Louis E. DeFrate, ScD, Boston, MA
in LPS-Flex and Vanguard PS. The results of the current study Ramprasad Papannagari, MS, Boston, MA
show that during high flexion, the extensor mechanism Guoan Li, PhD, Boston, MA
frequently impinges on the PE in old PS TKA designs. The
Introduction: Anterior knee pain has been reported in patients
impingement rate was related directly to the prevalence of ante-
with anterior cruciate ligament (ACL) reconstruction with a
rior knee pain, indicating that the design modification of the
bone-patellar tendon-bone (BPTB) graft. The change in the
anterior part of the PE insert which is incorporated into contem-
biomechanics of the patellar tendon after removal of its
porary PS TKA designs is effective. A mobile bearing mechanism
middle third has been assumed responsible for the postopera-
was not essential to eliminate impingement and the consequent
tive complication. We investigated the effects of ACL recon-
anterior knee pain.
struction on the elongation of the patellar tendon. Methods:
POSTER NO. P205 Eight patients with an acute ACL injury in one knee and the
contralateral side intact were included. Magnetic resonance
10-Year Follow-Up of Lateral Unicompartmental and dual-orthogonal fluoroscopic imaging techniques were
Knee Arthroplasty with the Allegretto Prosthesis used to compare the elongation of the patellar tendon between
Prof Sergio Romagnoli, MD, the intact, ACL-injured, and ACL-reconstructed knees.
Francesco Verde, MD, Pietra Ligure SV, Italy Reconstruction was performed in a standard fashion using a
10-mm BPTB autograft. Data was collected pre-operatively, and
Robert W Eberle, Apex, NC
at six months following ACL reconstruction. Results: ACL defi-
Unicompartmental knee arthroplasty was developed as an alter- ciency significantly increased the elongation of the patellar
native to the finality of tricompartmental, TKA, and in the tendon. ACL reconstruction with a BPTB graft reduced the
medial compartment has shown excellent intermediate results. elongation of the patellar tendon to levels not significantly
Lateral UKA is not as common and there are few reported different from those of the intact knee. Conclusions: Our find-
results. The purpose of this study was to report the intermediate- ings suggest that there might be an improvement in antero-
term, single surgeon use of the Allegretto unicondylar knee pros- posterior tibiofemoral stability following reconstruction.
thesis for the lateral knee compartment. We evaluated 63 lateral When the tibial tubercle moves more posteriorly relative to the
unicompartmental knee arthroplasties in 59 patients that were patellar apex, the abnormal elongation of the patellar tendon
implanted by a single surgeon using the Allegretto prosthesis. may potentially be decreased, thus improving the extensor
The average age of the patients at the time of surgery was 69 mechanism function.
years. No patients were lost to follow-up. Eight patients (eight

knees, 13%) died from unrelated causes. None of the patients
that died underwent revision of the index UKA component. The
average time to follow-up for those patients available prospec-
tively was 10.3 years (KS Survival 94.4 ±4.0). Clinical evaluations
revealed an average pre-operative HSS score of 56 points which
improved at the most recent post-operative follow-up to an
average of 92 points. At the most recent average time to follow-
up, the post-operative range of motion was assessed at an
average of 0.2 degrees of extension through 125.8 degrees of
flexion. Radiographically, no component showed evidence of
loosening as defined as change in position of the components
on serial radiographs. There were the cases in which the UKA
prosthesis required revision. Provided correct patient selection
and technical expertise, the Allegretto UKA system allows for the
expected relief of pain, restoration of function and component
survival in those patients with lateral compartmental knee
arthrosis through 10-years.
497
SCIENTIFIC EXHIBITS management of severe femoral bone loss in 37 patients, and

performed between 1998 and 2005. Average patient age was 76
years (SD: 9.6 yrs). Indications for hinged prosthetic distal
femoral replacement included: 13 periprosthetic fractures, 11
SCIENTIFIC EXHIBIT NO. SE25 infected TKA, 7 loose complex revision TKA, 4 instability
An Efficient Operative Technique for Total Femur following revision TKA, 2 complex primary TKA with massive
Replacement in Failed Hip/Knee Arthroplasty bone loss, 1 distal femoral nonunion, and 1 acute distal femur
fracture. Follow-up averaged 45 months. Eight patients died
Michael MacGregor, PA-C, Philadelphia, PA
during follow-up. There were 5 reoperations: 2 cases of recurrent
David George Nazarian, MD, Philadelphia, PA infection following 2-stage treatment; one requiring repeat 2-
Robert W Tuttle, MD, St Paul, MN stage, and one requiring amputation. One periprosthetic fracture
Hari Bezwada, MD, Philadelphia, PA occurred. One late hematogenous infection was treated with
The increasing rates of revision hip and knee arthroplasty and successful irrigation and drainage. One patient underwent
periprosthetic femoral fractures require revision surgeons to deal bearing exchange to treat hyperextension. No failures from
with progressively impoverished bone quality. In situation where aseptic loosening were seen. Knee Society scores improved from
femoral hip or knee implant fixation is severely compromised, 39 preoperatively to 87 at most recent follow-up. Pain scores
then a total femur replacement may be the only reconstructive improved from 18 preoperatively to 43. Distal femoral pros-
option Eight (8) patients underwent a total femur replacement thetic replacement with a tumor-type implant in severe cases
from 2003 to 2005 at one institution. Patients were treated for provides excellent pain relief and function with a low rate of
either an inter-prosthetic fracture, failure of periprosthetic frac- reoperation and an implant survivorship of 89.8%.
ture fixation, or failure of a distal femoral replacement. All
patients were placed in the supine position with simultaneous SCIENTIFIC EXHIBIT NO. SE27
sterile preparation of both their hip and knee. The procedure was Balancing the Flexion Gap: The Relationship
initiated with excision of the distal femur through an extended
anterior approach to the knee. A long-stemmed, 7cm. cemented
Between Tibial Slope and PCL Release With ROM
hinged tibial component was implanted and connected to distal Jorge Aziz, MD, New Albany, OH
femoral replacement prosthesis along with an intercalary Adolph V Lombardi, Jr, MD, New Albany, OH
segment between 10 to 15cm. in length. Closure of the knee was Keith R Berend, MD, New Albany, OH
completed and a provisional dressing applied. The operative Mark Davis, DO, Wesley Chapel, FL
table was raised to shoulder height and an extended lateral Successful total knee arthroplasty (TKA) depends on ligament
approach to the proximal femur and hip was conducted. Excision balancing throughout the range of motion (ROM). A tight
of the proximal femur and acetabular reconstruction was flexion gap can be corrected in cruciate-retaining total knee
performed with a constrained liner. A proximal head and body arthroplasties (CR-TKA) by partial posterior cruciate ligament
with the appropriate length trial intercalary segment was selected (PCL) release, whether by femoral recession or tibial V-osteotomy
in order to restore proper leg lengths. A novel intervening connec- or increasing posterior tibial slope. The purpose of this study is to
tion segment was used to mate the proximal trial intercalary identify the relationship between posterior tibial slope and the
segment to the distal actual intercalary segment which was previ- requirement for PCL release and correlate this with postoperative
ously implanted at the knee. Assembly of the multiple intercalary ROM and the need for manipulation. Hypothesis one: if poste-
segments is achieved with a Morse taper connection. Circlage rior tibial slope is increased then the need for PCL release would
claw fixation of a trochanteric osteotomy is performed when be lower. Hypothesis two: if both increased tibial slope and PCL
possible. All patients improved significantly regarding their Knee release are performed, the ROM would be higher and the need
Society scores from 47 preoperatively to 83 postoperatively and for manipulation lower. We retrospectively reviewed 416 CR-TKA
Harris Hip Scores from 54 preoperatively to 85 postoperatively. (Vanguard, Biomet Inc, Warsaw, IN) done in 339 patients by two
Three (3) patients used a cane and five (5) patients required no surgeons. Need and type of PCL release, 6-week and most recent
walking aid. There were no infections, dislocations, or loosening. ROM, and need for manipulation were noted. Posterior tibial
One (1) patient had patellar subluxation with average follow-up slope was measured in a blinded fashion using a calibrated PACS
of 3.2 years. Total femur replacement for extreme failure of fixa- system. Follow-up averaged 15.3 months. The median postoper-
tion in hip or knee arthroplasty is a viable procedure for marked ative tibial slope was 3.0°, with 208 knees having less than 3.0°
reduction of pain and improved function in this challenging and 208 having greater than 3.0°. Partial release of a tight PCL
group of patients. This technique allows a significantly complex was required in 136 TKA (32.7%). Tibial slope was higher in
dual procedure to be performed more efficiently and with fewer knees without PCL release (3.3 versus 3.0; p<0.05). The need to
complications through two separate incisions. perform a PCL release was greater in knees with less than 3° tibial
slope (37.5%) compared with knees having more than 3° tibial
SCIENTIFIC EXHIBIT NO. SE26 slope (27.9%; p=0.0365). The need to perform a manipulation
Distal Femoral Replacement in Management of was no different in knees with less (5.3%) or greater (7.7%) than
Severe Femoral Bone Loss in Non-Oncologic Cases 3° tibial slope (p=NS), or whether or not a PCL released was
performed (5.0% with release vs. 9.6% without release; p=NS).
Keith R Berend, MD, New Albany, OH
ROM at 6 weeks was not related to need or type of PCL release or
Adolph V Lombardi, Jr, MD, New Albany, OH posterior slope, nor was ROM improved when both tibial slope
Severe distal femoral bone loss and instability in revision total exceeded 3° and release was performed. ROM at most recent
knee arthroplasty (TKA) is a challenging clinical scenario. evaluation was higher in knees which required release and had
Surgical options include allograft composite reconstruction and less than 3° tibial slope (p<0.05). By balancing the flexion gap
distal femoral replacement. We reviewed the indications and either through increased slope or PCL release or a combination
outcomes of 38 consecutive rotating-hinged distal femoral when necessary, satisfactory ROM is achieved and the need for
replacement devices (OSS, Biomet, Warsaw, IN) used in the manipulation is low.
SCIENTIFIC EXHIBIT NO. SE28 component rotation was aligned with the AP and epicondylar
Comparison of Highly Cross-Linked Polyethylene axis of the femur using a posterior referencing guide of three
degrees relative to the posterior condylar axis that was not stati-
With Standard Polyethylene in Total Knee cally applied to the femur. Twenty-seven of the identified 86
Arthroplasty (31%) knees had 6 degrees or less of valgus (Group1) preopera-
Jeffrey Thomas Hodrick, MD, Park City, UT tively and 59 had valgus alignment greater than 7 degrees
Aaron Adam Hofmann, MD, Salt Lake City, UT (Group 2). Group 1 knees average 6.3mm of lateral tibial
subluxation; Group 2 averaged 4.5mm. Postoperative alignment
Erik P Severson, MD, Salt Lake City, UT
averaged 5 degrees in Group 1 and 4 degrees in Group 2. A
Deborah M McAlister, MD, Norman, OK cadaveric model of the effect of varying degrees of femoral
Brian Dahl, BS, Salt Lake City, UT component external rotation on the size of the medial and
Introduction: The purpose of this study is to compare the radi- lateral flexion space was created and correlated with release of
ographic and clinical outcomes of patients receiving a total knee the PT complex. Release of a tight PT complex may be required
arthroplasty using a highly cross-linked or standard polyeth- in both the valgus and varus primary TKA. Intrinsic contracture
ylene liner with a minimum follow-up of five years Materials of the PT may explain the need for release in the valgus knee. In
and Methods: Highly cross-linked polyethylene became avail- the varus or valgus knee, increased femoral component external
able for use in February of 2001 and was used consecutively at rotation relative to the AP or epicondylar axis leading to relative
our institution since that date. We retrospectively reviewed the overstuffing of the lateral flexion gap may necessitate PT release.
first 100 patients receiving this implant and compared them to Posterior referencing of worn or denuded medial posterior
100 patients immediately proceeding this date, who received a femoral condyle may be a more precise etiology in the varus
standard polyethylene insert sterilized with gamma radiation in knee and over-estimation of lateral femoral condyle hypoplasia
an oxygenless environment. All patients underwent routine may contribute in the valgus knee. Surgeons who perform
physical exams and radiographs from which a knee score was primary TKA should be aware of these varibles affecting soft
calculated. Findings: Of the 200 patients, 12 had died and 20 tissue balancing of the flexion space in primary TKA.
were lost to follow-up, leaving 82 patients in the standard group
and 88 patients in the highly cross-linked group with a SCIENTIFIC EXHIBIT NO. SE30
minimum follow-up of 66 months and 60 months respectively. Survivorship of a Modular Titanium Baseplate
Five patients in the standard group were reoperated: two for
infection, two for instability, and one for patellar subluxation. In Inserted With a Surface Cementing Technique
the cross-linked grouped, three were reoperated, one for insta- Christopher L Peters, MD, Salt Lake City, UT
bility, one for infection, and one for a loose body. Knee scores Jill Erickson, PA, Salt Lake City, UT
for each group were the same at 197. Fifteen patients in the stan- Bryce Allen, MD, Salt Lake City, UT
dard group had radiographs with grade I osteolytic lesions. No Although total knee arthroplasty (TKA) is widely successful,
osteolysis or wear was seen in the highly cross-linked polyeth- there exists a paucity of data regarding outcomes of current
ylene group. Conclusion: In this study, highly cross-linked poly- generation modular TKA designs, particularly those utilizing

ethylene showed similar clinical findings to standard surface cementation of a modular baseplate with cementless
polyethylene, however, there were fewer revisions and no oste- technique for a cruciate primary-stem. The clinical and radi-
olytic lesions seen on radiographs. Highly cross-linked polyeth- ographic outcomes of 1000 consecutive primary total knee
ylene showed good durability at this intermediate interval and arthroplasties placed with cemented tibial components were
should continue to perform well long-term. reviewed at average 50 months follow-up (range: 24-144). The
tibial component was a modular titanium baseplate and cruciate
SCIENTIFIC EXHIBIT NO. SE29 stem with a grit-blasted surface. Sixty-four percent were female,
Popliteus Tendon Release in the Varus or Neutral 36% were male. Average age was 63 (range: 28-87), average
Knee: Incidence and Potential Etiology height was 66 inches (50-79) and average weight was 207
pounds (range: 109-400). The diagnosis was osteoarthritis in
Carmen Crofoot, MD, Farmington, ME
91%, Rheumatoid arthritis in 4%, posttraumatic arthritis in 4%,
Erik P Severson, MD, Salt Lake City, UT and AVN in 0.6% of primary TKA. Ninety-six percent were
Rhett Hallows, MD, Salt Lake City, UT surface cemented tibial components and 4% were fully
Jill Erickson, PA, Salt Lake City, UT cemented tibial components. Fifty-five percent of femurs were
Christopher L Peters, MD, Salt Lake City, UT cementless, 45% were cemented. The bearing surface was
Release of the popliteus tendon (PT) to obtain a balanced cruciate-retaining in 84% of the knees, anterior-stabilized in 7%,
flexion gap during a total knee arthroplasy (TKA) in the valgus posterior-stabilized in 8%, and more constrained in 1%.
knee has been well reported in the literature. In contrast, PT Complications included 7 deep infections (0.77%) in 6 patients
release in the varus or neutral knee has not been well described. treated with 2-stage revision. One tibial component was
The aim of this study is to describe the anatomy of the PT removed to place a hinge for an MCL-reconstruction failure.
complex as it relates to TKA and report the incidence of PT There have been 18 other revisions of the femur, patella or poly,
release in a large group of primary TKA’s. The incidence and but 892/900 tibial components have been retained with 99.1%
proposed etiology for PT release in the varus or neutral knee is survival. There have been no aseptic loosenings of the tibial
emphasized. A computerized database of 723 primary knees was component in 1000 primary TKAs by one surgeon, 96% of
reviewed for the incidence of PT release. Eighty-six (12%) knees which were surface-cemented. The results support the use of a
were identified. The preoperative and postoperative radiographs more limited cement technique with a modular grit-blasted tita-
were reviewed. The tibiofemoral angles and degree of lateral nium tibial component with a cruciate stem.
tibial subluxation were measured. Lateral tightness of the flexion
gap while distracting the femur from the tibia determined need
for PT release regardless of preoperative alignment. Femoral
499
SCIENTIFIC EXHIBIT NO. SE31 be that other techniques using fluoroscopy or ultrasound may
Computer-Assisted Surgery in Total Joint become available to effectuate similar information as computer-
assisted surgery. Trackers will be developed that are noninvasive
Arthoplasty: Complications, Pitfallls and Solutions utilizing techniques that map landmarks through the skin (ultra-
Slif D Ulrich, MD, Baltimore, MD sound or through small incision). The techniques have initially
Peter M Bonutti, MD, Effingham, IL higher complications rates, which appear to be part of the
David R Marker, BS, Baltimore, MD learning curve Computer assisted surgery appears promising and
Daniel A Dethmers, MD, Effingham, IL the authors believe it will be the standard technique in the future.
Johansson Henning Reinhold, BS, Baltimore, MD The authors believe that the provided algorithm will help over-
come various complications and pitfalls.
Yohan Robinson, MD, Berlin, Germany
Lynne C Jones, PhD, Baltimore, MD SCIENTIFIC EXHIBIT NO. SE32
◆The Influence of Contemporary Knee Design
Computer assisted surgery has generated significant interest and Geometry on High Flexion Motion: A Kinematic
controversy in the orthopaedic community. The technology has Comparison
been developed to try to improve the alignment of total joint Edward Morra, MSME, Cleveland, OH
replacements and make the procedure easier to perform and A Seth Greenwald, DPhil Oxon, Cleveland, OH
hopefully lead to better short and long-term outcomes. The
Although Total Knee Arthroplasty (TKA) achieves surgical
purpose of this exhibit is to identify the main pitfalls and compli-
outcomes classified as good to excellent in 90% of cases, many
cations associated with computer-assisted surgical techniques
patients report difficulty adjusting their gait to accommodate the
and define a set of techniques and tips for avoiding or compen-
articulating geometries of contemporary knee implant designs.
sating for difficulties. Specifically, we will be examining the
Paradoxical motion and patellar clunk are descriptive of aberrant
complete literature for scientific evidence supporting the use of
kinematics following TKA. This study compares the motions of
these new technologies. Another purpose of this study will be to
four contemporary TKA designs with an un-operated normal
assess how scientific evidence supports or refutes specific
knee during high flexion activities. A three-dimensional compu-
commonly asked questions concerning computer-assisted
tational model of the femoral, tibial and patellar components of
surgery. In addition, we will address a cost analysis of computer
each knee design were developed from physical measurements of
assisted surgery in a community hospital setting. A prospective
the articular surfaces of sterile, implantable quality production
detailed assessment of complications associated with computer
parts. The components were virtually implanted in a
assisted surgery was made from December 2004 to April 2007.
LifeMOD/KneeSIM computational model of a cadaveric leg
One hundred and eighty-six cases were analyzed and the possible
mounted in an Oxford style knee rig following the published
reasons for related complications were stratified into various cate-
surgical procedure for each knee design. Once implanted, active
gories; (a) fractures; (b) hematomas; (c) infection (d) muscle
muscle forces and soft tissue constraints drove the high flexion
trauma (e), pain (f), and (g) postoperative bleeding from tracker
activity. The resulting translational and rotational displacements
sites. Further assessments included treatment time and device

of the femoral component relative to the tibial component were
and software-related problems. A detailed cost analysis in a
calculated and visualized as dynamic animations, charts, and
community hospital was performed including cost for surgical
graphs. When compared to the un-operated normal knee, all four
time and instrumentation. The authors carried out a literature
TKA designs fell short of restoring normal knee kinematics and
search to compare the outcome of other computer assisted
produced a wide variety of results between designs. This study
surgery studies. An algorithm and solutions were developed to
definitively illustrates that optimizations in surgical technique,
overcome the complications and pitfalls. Thirteen documented
inclusive of soft tissue releases, may enable a specific design to
cases of severe complications at the tracker sites in 186
achieve a closer approximation of normal knee kinematics.
orthopaedic procedures were found (incidence of 7%). The
complications included 4 infections, 3 hematomas, one acute SCIENTIFIC EXHIBIT NO. SE33
case of bleeding, and three fractures at the tracker sides. In addi-
tion, 23 patients reported pain from the tracker side and 2 Survivorship of a TKA System With Optimized
patients neuropathies. The mean surgical time was 101 minutes Congruent Contact and Femoral/Tibial
(range: 47 to 199 minutes). At a community hospital, our study Interchangeability
evaluated the surgical cost for navigation using hospital charges
of $40 per additional minute of operating time. This led to an
Adolph V Lombardi, Jr, MD, New Albany, OH
average of $800 increased cost per surgical procedure. Navigation Joanne B Adams, New Albany, OH
also required additional anesthesia units and disposable naviga- Keith R Berend, MD, New Albany, OH
tion pins. Therefore, each surgery led to additional costs of The Maxim Complete Knee System (Biomet, Warsaw, IN) incor-
$1,141 per procedure. Finally, there is the initial cost of the navi- porates a condylar radius design that is congruent in the coronal
gation system greater than $200,000. The results of this study plane for contact stress reduction while providing interchange-
compared favorably with higher complication rate, increased ability between all primary femoral and tibial component sizes.
surgical time and postoperative outcome. The algorithm provides To determine the impact of these features on survivorship, we
clues and tips to reduce complications to allow for more optimal retrospectively reviewed a consecutive series of 921 patients under-
placement, positioning of the tracker pins, and correct set up of going 1291 primary cemented TKA performed by a single surgeon
the system to save operating time. These findings suggest that from 1994 to 1996 using the Maxim system. Age averaged 67
computer-assisted navigation, especially when trackers require years and 62% of patients were women. Underlying diagnosis was
additional pin fixation and location, may increase the risk of osteoarthritis in 1101 knees (4 patellectomized), 104 posttrau-
complications. Computer-assisted surgery is more expensive and matic (3 patellectomized), 72 rheumatoid, 9 osteonecrosis, 3
remains to be seen whether this is worthwhile. In addition, it may psoriatic and 2 acute fracture. Based on a previously published
algorithm for determining PCL retention or sacrifice by disease SCIENTIFIC EXHIBIT NO. SE35
severity, cruciate-retaining designs were used in 504 knees, poste- The Impact of Constraint on Wear of the Articular
rior-stabilized in 776, and constrained in 11. To date, reoperation
for any reason has been required in 75 TKA (5.8%). Of these, 19 and Backside Surface in Primary Modular TKA
had arthrotomy only without component extraction, 10 required Brad Ellison, MD, Columbus, OH
radical debridement for 2-stage treatment of sepsis, 8 involved Jenifer K Hickman, CNP, New Albany, OH
polyethylene insert exchange only, 17 included patella revision or Keith R Berend, MD, New Albany, OH
removal, 2 were full revisions for periprosthetic fracture, and 19 Adolph V Lombardi, Jr, MD, New Albany, OH
involved revision of the femoral and/or tibial components for Thomas H Mallory, MD, New Albany, OH
instability (9), arthrofibrosis (3) and aseptic loosening (7). Mid-
Articular and backside wear of the modular tibial insert in primary
to long-term results using the current knee system demonstrate
total knee arthroplasty (TKA) can result in failure. We hypothe-
outstanding survivorship with a very low 5.8% rate of reoperation
sized that higher constraint in TKA results in increased wear of the
for any reason. Considering revision of the femoral and/or tibial
articular and backside surfaces. We assessed polyethylene wear at
components as an end-point, the Maxim Complete Knee System
the articular and backside surfaces of 21 retrieved bearings
achieved 98.5% survival at up to 13 years follow-up.
including cruciate retaining (CR; n = 9) and posterior stabilized
SCIENTIFIC EXHIBIT NO. SE34 (PS; n = 12) designs. All utilized a single tibial locking mechanism
(Biomet Inc., Warsaw, IN; Maxim and Vanguard). Tibial inserts
Factors Affecting Loading in TKA: What is Causing were assessed in a blinded fashion using direct visualization and
Implant Failure and Loosening? stereomicroscopy. A wear severity score from 0 (no wear) to 27
Michael E Berend, MD, Mooresville, IN (severe, more than 50% area, greater than 1mm deep) was given
Scott R Small, MS, Mooresville, IN to the articular and backside surfaces. Mean implant duration was
4.3 years for CR (range: 15 days to 13.4 years) and 4.4 years for PS
Robert Michael Meneghini, MD, Indianapolis, IN
(range: 5.5 months to 11 years; p=NS). Direct visualization artic-
Merrill A Ritter, MD, Indianapolis, IN ular wear scores for CR and PS were 5.5 and 8.1, respectively.
Christine A Buckley, PhD, Chicago, IL Stereomicroscopy articular wear scores for CR and PS were 6.7 and
Kurt Dierking, MS, Mooresville, IN 8.6. Direct visualization wear severity scores of the backside for CR
James C Merk, MS, Mooresville, IN and PS were 2.6 and 4.4. Stereomicroscopy backside wear scores
Failure in TKR has been attributed to abnormal loading condi- for CR and PS were 3.2 and 4.6. A direct relationship was observed
tions. TKR loading is dependent on alignment, ligament between increasing constraint and articular wear and backside
balance, and implant design; however, the respective contribu- surface wear of retrieved bearings from primary TKA.
tion of each factor to failure is not known. This study quantified Identification of polyethylene wear patterns provides valuable
the effect of metal backing, component size mismatch, depth of information needed to improve the performance and longevity of
tibial resection, ligament imbalance, and coronal plane geom- modular total knee arthroplasty.
etry on loading. Composite tibiae were coated with photoelastic
material allowing full field dynamic strain quantification under SCIENTIFIC EXHIBIT NO. SE36

3X BW throughout the loading cycle when viewed through a Patellar Fracture in TKR
polariscope. Changes in strain were quantified in 24 proximal Jose A Rodriguez, MD, New York, NY
tibial regions. The data represent percent change in surface strain
Norberto Baez, MD, Sabana Grande, PR
(all-polyethylene vs metal backing) circumferentially at depths
of 0-10mm, 10-20mm, and 20-30mm, respectively; Vijay J Rasquinha, MD, Brooklyn, NY
Anteromedial Peripheral: +211, +46, +21; Anteromedial Central: Chitranjan S Ranawat, MD, New York, NY
+636, +457, +101; Anterolateral Central: -30, -44, +30; Patellar fracture following TKR has been noted in 3 - 5% of
Anterolateral Peripheral: +109, +146, +129; Posteromedial patients. The mechanical integrity of the patellar bone can be
Peripheral: +75, +49, +51; Posteromedial Central: +192, +41, weakened by the technique of removing the articulating surface.
+46; Posterolateral Central: +484, +70, +71; and Posterolateral We present the results of a patellar resection technique that
Peripheral: +41, +54, +25. All changes above +101 were statisti- preserves the subchondral bone of the lateral facet 393 TKR were
cally significant (p<.05). The largest percent change in strain was performed between 1989 and 1994. Forty-five patients with 48
observed with all-poly vs. metal backed components (636 knees died, and 37 patients with 41 knees were lost to follow-up.
percent). Anterior strains increased more than posterior. Distal Three hundred four knees were followed for an average 10 years
resection levels and resulting smaller tibial component sizes and (range: 5 -16 yrs). In all patients the patellar surface was resected
relative posterior and peripheral component position signifi- with an oscillating saw without the use of a cutting guide. The
cantly increases posterolateral, peripheral strains (583 percent). medial facet, and most of the articular cartilage of the lateral facet
Larger femoral components exhibited increased peripheral was resected, while preserving the lateral half of the subchondral
strains (113 percent). Peripheral strains decreased with increased bone of the lateral facet. The patella was resurfaced with a dome-
coronal plane dishing compared to flat on flat designs (9-27 shaped all-polyethylene implant with a single central fixation
percent). (Dramatic video loop images captured throughout the peg, (PFC PS). There have been 2 fractures in the cohort, for a
loading cycle will be displayed in the exhibit on video moni- prevalence of 0.66%. Eight TKRs in this series were revised for
tors.) Edge loading and failure in TKA are multifactorial synovitis, and osteolysis, and patellar ostelysis was found in 4 of
processes. This is the first study to quantify the influence of these cases, with loosening of 3 of these patellas, and 1 patellar
femoral component size, depth of resection, imbalanced fracture. Two patellar implants had global radiolucencies and
loading, metal backing, and coronal plane dishing on tibial were considered loose. The average knee score in unrevised knees
strain distribution. Better understanding of in vitro loading improved from 48.6 to 92.2 at recent follow-up, while the func-
patterns will help prevent failure in the future. tional score improved from 50 to 81.1. Preservation of the
subchondral bone of the lateral facet of the patella may help
protect against patellar fracture, even in cases of osteolysis
501

The Ilio-Tibial Band as Autograft for Patellar Tendon
Ruptures Following Total Knee Arthroplasty
Jess H Lonner, MD, Philadelphia, PA
Extensor mechanism disruption following total knee arthro-
plasty can be devastating. Patellar tendon ruptures and repairs
following total knee arthroplasty may have compromised results
due to the previous dissection, scarring, and altered blood
supply. This study reviews our experience with patellar tendon
repairs with ilio-tibial band augmentation following total knee
arthroplasty. From 1998 to 2005, 38 patellar tendon repairs were
performed with ilio-tibial band augmentation at our institution.
The patellar tendon rupture occurred at a mean of 7 months (2-
18) following the index knee arthroplasty. The patellar tendon
was repaired using a standard technique with a Krackow stitch in
the tendon and through drill holes in the patella. The ilio-tibial
band was then dissected and with the use of a tendon stripper a
portion sized 1.5cm in width and 18 to 20cm in length was
harvested. The insertion was left intact and the tendon was
weaved over the patella and stapled to the medial tibial meta-
physis. At a mean follow-up of 4 years (2-7), 36 of 38 repairs
were functioning well. Two patients suffered re-ruptures and
required a revision with an extensor allograft. Twelve patients
had a 5-10 degree extensor lag and three patients had a 20 degree
extensor lag. The other 21 patients had full range of motion and
no functional compromise. Patellar tendon repairs following
total knee arthroplasty can be reliably augmented with ilio-tibial
band autograft and may lead to improved results.

Total Knee Arthroplasty in the Superobese Patient,
BMI > 50
Jess H Lonner, MD, Philadelphia, PA
Total knee arthroplasty in obese patients remains a challenge to
most surgeons. Surgical complication rates as well as periopera-
tive morbidity are higher than total knee arthroplasty in the
nonobese. The purpose of this paper is to review our experience
with total knee arthroplasty in superobese patients (BMI>50).
From 1998-2005, 84 patients underwent 148 knee arthroplas-
ties. Sixty-four patients underwent simultaneous bilateral total
knee arthroplasties and 20 patients underwent unilateral knee
arthroplasties. They were compared with similar group of
nonobese patients who underwent knee arthroplasties during
the same time period. All patients received combined regional
and general anesthesia. Mean follow-up was 3.8 years (2-7).
Knee society scores improved by 36 points in the superobese
(preop 47 to 83 postop) and by 45 points in the nonobese
(preop 47 to 93 postop) (p<.05). There was a greater incidence
of complications in the superobese group, namely superficial
wound infections and deep vein thrombosis. There was late
loosening in three tibial components and instability in two
patients that required revision in the superobese group. No
reoperations were performed in the nonobese group. Although
total knee arthroplasty may be safely performed in the super-
obese, it may be complicated by infection, loosening, instability,
and lower knee scores.
BASIC RESEARCH
SCIENTIFIC EXHIBITS SCIENTIFIC EXHIBIT NO. SE40
◆Highly Porous Reticulated Titanium Foam for
Orthopedic Implant Applications
SCIENTIFIC EXHIBIT NO. SE39 Dirk Scholvin, MS, Arlington, TN
◆Animal Modeling of Interventions to Promote Richard Obert, MS, Arlington, TN
Fracture Healing in the Face of Adverse Jon Moseley, PhD, Arlington, TN
Comorbidities Michael E Carroll, Arlington, TN
William D Lew, MS, Minneapolis, MN Robert M Urban, Chicago, IL
Joan E Bechtold, PhD, Minneapolis, MN Thomas M Turner, DVM, Chicago, IL
Dean T Tsukayama, Minneapolis, MN Deborah J Hall, BS, Chicago, IL
Andrew H Schmidt, MD, Plymouth, MN David D Waddell, MD, Shreveport, LA
David W Polly, Jr, MD, Minneapolis, MN G Lynn Rasmussen, MDSalt Lake City, UT
A novel 60-70 percent reticulated porous titanium material was
Robert S Gilley, DVM, Minneapolis, MN
developed to serve as a scaffold for bone ingrowth in load-
Richard F Kyle, MD, Minneapolis, MN
bearing orthopedic applications. In order to evaluate this mate-
Xinqian Chen, MD, Minneapolis, MN rial, tests were conducted to determine the mechanical
Fracture healing is impaired when associated with infection, properties, chemical composition, adherence to titanium alloy
diabetes, smoking, and glucocorticoid use. Interventions that substrates and in vivo performance in metaphyseal and transcor-
stimulate bone formation in these instances are needed. Bone tical canine models. Ultimate compressive and flexural strength
morphogenetic proteins (BMPs) promote osteogenesis in bone was shown to dependend on porosity, with compressive
fracture or defect models in healthy animals. The goal of this strengths of 79-93 MPa at 70 percent and 141 MPa at 64 percent
work was to use animal modeling to determine BMP efficacy porosity. The compressive modulus ranged from 2.5 GPa to 3.8
when comorbidities associated with impaired fracture healing GPa. Flexural strength of samples near 70 percent porosity was
are present. A stabilized femoral segmental defect rat model was in excess of 100 MPa. Abrasion resistance of the porous titanium
used to determine whether BMP could overcome inhibition of coating per FDA guidance was found to be equivalent to that of
bone formation due to acute or chronic infection with porous bead coatings while exceeding the abrasion resistance of
Staphylococcus aureus. A closed femoral fracture rat model with titanium plasma spray coatings. The coefficient of friction of the
streptozotocin-induced diabetes was used to assess the ability of titanium foam was higher than that of porous bead coatings and
PAPERS, POSTERS & SCIENTIFIC EXHIBITS BASIC RESEARCH

BMP to overcome inhibition of fracture healing from diabetes. equivalent to that of plasma spray coatings. Lap-shear and
Similarly, the closed fracture model with subcutaneous implan- tensile pull-off tests of coated Ti6Al4V substrates resulted in
tation of time-release prednisolone pellets was used to deter- strengths greater than 40 MPa, exceeding minimum require-
mine whether BMP could counteract delayed healing from ments of 20 MPa set by the FDA. Elemental composition of the
glucocorticoids. Finally, this model was used to assess whether porous titanium was shown to be equivalent to that of porous
nicotine, tobacco extract, or both was responsible for delayed titanium bead coatings. The canine studies showed rapid bone
fracture healing. In all cases, bone formation was assessed using ingrowth and integration of the porous titanium specimens in
imaging, torsional failure testing and histology. BMP stimulated both trabecular and cortical bone. The extensive testing
bone formation after surgical debridement of the rat femoral performed on this new porous titanium implant material has
defect with a chronic infection, despite implant retention. BMP shown that it is an excellent choice for both orthopedic implant
improved callus formation in the diabetic and glucocorticoid- coatings and stand-alone implants.
treated animals. Nicotine alone did not impair fracture healing,
but tobacco extract with or without nicotine did. BMP may stim- SCIENTIFIC EXHIBIT NO. SE41
ulate fracture healing in patients with device-related infection,
Evolving Implant Retrieval Program: What’s New?
diabetes or glucocorticoid therapy. Nicotine patches in smokers
may satisfy their addiction while not delaying fracture healing. Jack E Lemons, PhD, Birmingham, AL
Confirmatory clinical studies are needed. Preston Beck, MS, Birmingham, AL
Patricia Lott, MS, Birmingham, AL
John M Cuckler, MD, Birmingham, AL
Donald W Petersen, Arlington, TN
K David Moore, MD, Birmingham, AL
Alan Eberhardt, PhD, Dr., Birmingham, AL
A retrieval and analysis program has collected explanted compo-
nents over four decades which includes more than 6000. A new
NIH NIBIB-BRP is now providing in situ cadaveric specimens
with grant emphasis on: (1) new systems, (2) articulation, (3)
bone integration, and (4) interactions with debris.
Collaborations for specimens include University Hospitals and
the Department of Pathology under approved IRB and HIPPA
guidelines and most (>85%) implants demonstrate anticipated
bulk and surface conditions. Minor and unanticipated alter-
503
ations were less than 15% of the total received full analysis capa-
bilities are necessary for unanticipated implant studies.
Unanticipated alterations (<5%) have included: secondary
metallics on articulating surfaces and abrasive wear; property
and topography changes for ceramic femoral heads; disassembly
of ceramic-ceramic and fretting-corrosion of some metallic
modular connections; surgical instrumentation based changes;
features on oxidized zirconium; and in vivo transfers of small
size debris products. Wear and fatigue of biomaterials has
demonstrated product specific alterations with time and func-
tion. Unanticipated alterations initiated extensive studies to
determine cause-effect relationships, and a multidisciplinary
team of biological and physical scientists have contributed.
Studies of explanted systems have provided data on minimal,
slight and major alterations of surfaces and tissue interfaces
occurring prior to revision. Some alterations have been associ-
ated with clinical outcomes and the program on cadaveric spec-
imens is evolving. Cadaveric specimens will provide new
opportunities for studying in situ and in-function conditions
with a focus on success.Support of NIBIB-BRP grant 1 RO1
EB001715-01A2 is acknowledged.

Surgical Navigation Systems: Evaluating
Electromagnetic Versus Optical Technology in the OR
Brandon Cole Merkl, BSc, Knoxville, TN
Michael J Kuhn, BSc, Knoxville, TN
Mohamed Mahfouz, PhD, Knoxville, TN
David Kent DeBoer, MD, Nashville, TN
The clinical outcome of total knee arthroplasty (TKA) is mainly
determined by the accuracy of the surgical procedure itself. The
incorporation of surgical navigation systems into the surgical
procedure is aimed at increasing this accuracy. Also, during
PAPERS, POSTERS & SCIENTIFIC EXHIBITS BASIC RESEARCH
surgery, a navigation system can guide the surgeon in

completing the planned strategy. The method is based on meas-
uring the differences in positions between optical and electro-
magnetic (EM) trackers through a range of motion of expected
kinematics during a flexion-extension motion. Quantitatively,
the optical system achieved higher overall accuracy with errors
in the range of 0.1mm, while the EM system was found to have
higher errors of 1.0mm. Qualitatively, each system was found to
have drawbacks. The EM system had a small measurement
volume and was affected by metal objects near the device. The
optical system had the requirement that line-of-sight had to be
preserved between the probe and the sensors. While both
systems have individual drawbacks, both systems suffer from
the proximity of occluding objects near the probes. It was found
that the optical systems offer advantages over EM systems in
both accuracy and ease of use, when used in a range of motion
procedure.
B OS (BOARD OF ORTHOPAEDIC SPECIALTIES)

In Vivo Mechanics of the Normal Knee, ACL Current Hot Topics in Orthopaedic Research
Deficient Knee and Implanted Knee Orthopaedic Research Society - BOS Society
Knee Society - BOS Society Anthony M DiGioia III, MD, Pittsburgh, PA
Richard D Komistek, PhD, Knoxville, TN Thomas D Brown, PH D, Iowa City, IA
Mohamed Mahfouz, PhD, Knoxville, TN Christopher H Evans, PhD, Boston, MA
Douglas A Dennis, MD, Denver, CO Johnny Huard, PhD, Pittsburgh, PA
Jean-Noel A Argenson, MD, Marseille, France Tony Keaveny, PhD, Berkeley, CA
Ray C Wasielewski, MD, New Albany, OH Jay R Lieberman, MD, Farmington, CT
Robert E Booth, Jr, MD, Philadelphia, PA Maurizio Pacifici, PhD, Philadelphia, PA
Chitranjan S Ranawat, MD, New York, NY Scott Alan Rodeo, MD, New York, NY
The objective of this study was to determine the in vivo Timothy M Wright, PhDNew York, NY
mechanics of the human knee through various stages of surgical Orthopaedic research continues to progress rapidly as new
intervention beginning with the normal condition to a total methodology becomes available. Members of the Orthopaedic
knee arthroplasty (TKA). Twenty normal knees, five ACL defi- Research Society conduct investigations on a wide range of
cient (ACLD) knees, 95 unicondylar knee arthroplasty (UKA) topics relevant to improving our knowledge of the etiology, diag-
and over 2500 total knee arthroplasty were analyzed using fluo- nosis, and treatment of musculoskeletal disease. Many different
roscopy. Initially subjects were analyzed to determine their in areas of expertise contribute to current orthopaedic research,
vivo kinematics. Then a subset from each knee type was including biochemistry, molecular biology, biomaterials, biome-
analyzed to determine their in vivo kinetics. Subjects having a chanics, and advanced imaging. Some of the current exciting
normal knee exhibited similar kinematic patterns where the areas of investigation include tissue engineering using stem cells,
lateral condyle exhibited greater posterior motion then the adipose-derived cells, and muscle cells; studies examining the
medial condyle. The ACLD subjects experienced more variable effects of mechanical forces (stress and strain) on cells and
kinematic patterns and did not achieve normal tibial rotation. tissues; newly-identified mediators of bone resorption (osteo-
The UKA subjects achieved more normal-like kinematic patterns protegerin) and bone formation (PTH) that may play important
if the ACL functioned properly and the TKA subjects exhibited roles in osteolysis and osteoporosis; gene expression in healing
the greatest amount of variability. Subjects having a normal knee bone, ligament, and tendon; novel imaging techniques such as
demonstrated the least amount of peak force and the greatest Fourier-transform infrared (FTIR) and double-quantum-filtered
similarity of the kinetic patterns. The results from this study NMR; new biomaterials that may be used for implants and
suggest that the ACL plays a significant role in kinematic and tissue regeneration, and gene therapy methods to induce expres-
PAPERS, POSTERS & SCIENTIFIC EXHIBITS BOS

kinetic patterns of the knee and to date arthroplasty (UKA and sion of key molecules in healing bone, cartilage, ligament,
TKA), albeit successful, does not adequately restore complete tendon, meniscus, nerve, and muscle.
function of the knee lost when the ACL becomes dysfunctional
or is sacrificed. SCIENTIFIC EXHIBIT NO. SE88
Women in Orthopaedics: Focus on Mentoring and
Career Development
Biopsy Principles in Musculoskeletal Oncology Ruth Jackson Orthopaedic Society - BOS Society
Musculoskeletal Tumor Society - BOS Society Lisa K Cannada, MD, Dallas, TX
Carol D Morris, MD, New York, NY Toni M McLaurin, MD, New York, NY
Cynthia M Kelly, MD, Golden, CO Women make up over 50% of medical school classes, yet repre-
Edward A Athanasian, MD, New York, NY sent only 3% of board certified orthopaedic surgeons and <10%
Ginger E Holt, MD, Nashville, TN of orthopaedic residents. The pupose of this exhibit is to educate
Scott D Weiner, MD, Akron, OH viewers about the role of the Ruth Jackson Orthopaedic
Albert J Aboulafia, MD, Baltimore, MD Society(RJOS) in addressing this disparity and to provide exam-
The biopsy of a musculoskeletal neoplasm is the first step of a ples of the resources available for women interested in a career
successful limb salvage procedure. It has been well established in orthopaedics. The RJOS is an AAOS Specialty Society founded
that biopsies performed by surgeons unfamiliar with proper in 1983 in honor of Ruth Jackson, MD; the first board certified
biopsy techniques are associated with more adverse outcomes orthopaedic surgeon. It was created to provide support and
including unnecessary amputation. While it is advantageous to networking opportunities for female orthopaedic surgeons and
refer biopsies to orthopaedic oncologic specialists, such referral those women interested in orthopaedic surgery, and has grown
are not often possible due to geographic or insurance from a membership of 42 to more than 450. As more women
constraints. This exhibit will review the principles and tech- enter orthopaedic residencies and begin to make career choices,
niques of needle biopsies and open biopsies for bone and soft RJOS wants to provide them with resources and mentoring to
tissue tumors. N/A. Examples of common pitfalls will be illus- increase the chances of these women having successful careers in
trated with instruction on avoiding such complications. The orthopaedic surgery. There are a multitude of choices one must
surgical approaches used in limb sparing surgery will be empha- make when choosing a career focus and job. In addition, strate-
sized. In addition, participants will have an opportunity to prac- gies for dealing with issues unique to women need to be
tice needle biopsy techniques with the commonly used devices. addressed. Numerous resources are available to help women in
505
orthopaedics. In addition to mentoring programs offered

through the AAOS, J. Robert Gladden Society and RJOS, addi-
tional guidance is available. This exhibit highlights opportuni-
ties available for women in orthopaedics and introduces the
“RJOS Guide for Women in Orthopaedic Surgery”, written for
our target audience of women interested in orthopaedics in all
stages of their training.
PAPERS, POSTERS & SCIENTIFIC EXHIBITS BOS
FOOT AND ANKLE

PAPERS quet, intraoperative bloodless field and ease of removal was
scored on a scale of 1-10. Patients were followed up at 2 weeks.
30 patients were randomised into group one with pneumatic
tourniquet (average age 63.7) and 30 patients in group two with
PAPER NO. 256 S-MARTTM tourniquet (average age 61.8). The average tourni-
Do Preoperative Footbaths Reduce Bacterial quet placement time in-group one was 147.66 seconds as
Colonisation of the Foot Before and After Surgery? compared to 11.3 seconds in-group two (p value < 0.001 using
unequal variance t-test). The mean ease of application scores was
Aaron Ng, MD, Salford, United Kingdom
4.30 in-group one as compared to 1.56 in-group two. Total
Foley Adeyemo, FRCS, Oldham, United Kingdom tourniquet time was more in-group one. Intraoperative
R Samarji, MD, Salford, United Kingdom haemostasis was rated higher in-group two. SMARTTM tourni-
Previous studies have demonstrated higher infection rates quet provides a good intraoperative haemostasis and is easy to
following elective procedures on the foot and ankle as compared apply. The limitation is it cannot be reinflated and cannot be
with procedures involving other area of the body. Previous used in patients with fractures.S-MART tourniquet is a good for
studies also have documented the difficulty of eliminating foot surgery, provides a good operative field, is easy to apply and
bacteria from the forefoot prior to surgery. The purpose of the saves precious theatre-time and resources.
present study was to ascertain that preoperative chlorhexidine
bathing provide significant local flora reduction in elective foot PAPER NO. 258
and ankle surgery. From October 2005 to October 2006, a Different Composition of Clinical Iliac Crest and
prospective study was undertaken to evaluate 50 consecutive
patients undergoing planned, elective surgery of the foot and Tibial Bone Grafts
ankle. 50 patients were prospectively enrolled and randomly Christopher P Chiodo, MD, Boston, MA
assigned to have preoperative footbath with Chlorhexidine Jochen Hahne, MD,
Gluconate (Hibitane) (Group 1) or ‘no footbath’ (Group 2). Michael G Wilson, MD, Boston, MA
Culture swabs were taken from all web spaces, before the preop- Julianne Glowacki, PhD, Boston, MA
erative antiseptics bath, during the procedures and immediately Cancellous bone grafts are frequently used for orthopedic proce-
completion of surgery. 50 patients were enrolled (mean age: dures, such as non-unions, fracture repair, and arthrodeses. The
42.6 years; range: 19 ‘85; F: M = 29:21). 25 patients are assigned iliac crest is the most common donor site, but the tibia has
to each groups. 100% bacterial isolation preoperatively in both become an option, especially in foot/ankle procedures. This
groups prior to antiseptics bathing. In group1, bacteria grew on
PAPERS, POSTERS & SCIENTIFIC EXHIBITS FOOT/ANKLE

study tests the null hypothesis that there is similar tissue compo-
intraoperative culture in 60% cases and 0% in immediate post- sition of iliac and tibial bone grafts. Tibial bone pieces were
operative culture. In group 2, 96% in intraoperative swab culture harvested from the region of Gerdy¢s tubercle. Iliac bone pieces
and 16% in postoperative swab culture. The intraoperative swab were taken from the anterior superior iliac spine. Specimens
culture bacterial count is statistically significant (p= 0.002). The from the tibia (n= 10) and the iliac crest (n= 10) that were in
postoperative swab culture bacterial count is marginally signifi- excess of that needed for patients (22- 73 years) undergoing a
cant (p=0.055) when comparing 2 groups. No complications foot/ankle procedure were examined histologically. Specimens
were recorded in both groups. These data indicate that chlorhex- were fixed in 2% paraformaldehyde (pH 7.4), decalcified, and
idine provides better reduction in skin flora. In addition, the embedded in glycol methacrylate. Sections were stained with
study also demonstrates less bacterial recolonization at the end Toluidine blue and graded on the basis of % of bone surfaces
of surgery comparing 2 groups (0% vs. 16%). Based of these opposing active hematopoietic marrow, with Grade I at 0%,
data, we recommend the use of chlorhexidine footbath as well through Grade VI at 81-100%. Difference in numbers of grafts
as the surgical preparatory agent for the foot and ankle surgery. ranked as Grade V or VI was evaluated with Fisher¢s Exact Test.
Both iliac crest and tibial bone grafts showed trabecular frag-
PAPER NO. 257
ments with abundant osteocytes. All iliac grafts included stroma
S-MART and Pneumatic Tourniquet in Foot Surgery and hematopoietic marrow. In surprising contrast, medullary
-A Randomised Controlled Study space of tibial grafts contained fat and little hematopoiesis. Nine
Arvind Mohan, MBBS, Epsom, Surrye, United Kingdom of the 10 iliac bone grafts were graded V or VI; all 10 tibial bone
grafts were graded I or II. This difference was statistically signifi-
Palanisamy Ramesh, FRCS Orth, Kingston Upon Thames,
cant (p = 0.0001). Iliac grafts contained active hematopoietic
United Kingdom marrow, but quiescent fat predominated in tibial grafts. These
M J Curtis, FRCS, Kingston, United Kingdom striking histological differences in graft composition raise ques-
We undertook a prospective randomised study to assess the effi- tions about cellular contributions to bone healing.
cacy of the S-MART tourniquet in foot surgery as compared to
the pneumatic tourniquet. A literature review confirms this is the
first randomised controlled study objectively measuring the
outcomes of this tourniquet system. We included 60 consecutive
patients who had foot surgery from May 2006 to November
2006. Informed consent with local medical ethical approval was
obtained. We excluded patients with history of diabetes mellitus,
deep vein thrombosis, fractures, limb circumference more than
40 centimetres and smokers. The ease of application of tourni-
507
PAPER NO. 259 union (96% union rate), at a mean time = 11W (CT); AJ = 10W;
A Human Feasibility Trial Evaluating rhPDGF vs. STJ =12W; TNJ = 12.7W; CCJ= 11W. Overall, [All Fusion Sites] vs.
[Historical control non-high risk patients 12-14W]: two-tailed
Autologous Bone Graft during Foot and Ankle Fusion P<0.0001 (Mann-Whitney Test), statistically
Christopher W DiGiovanni, MD, Providence, RI significant.Difference time union between [Ankle/STJ/TNJ/CCJ]:
Judith F Baumhauer, MD, Rochester, NY P=0.2571 (Kruskal-Wallis Test Nonparametric ANOVA) not
Sheldon S Lin, MD, Newark, NJ statistically significant. All sites: [No graft] vs. [Autograft] vs.
Wayne Sarkis Berberian, MD, Newark, NJ [Allograft]: P=0.2421 (Kruskal-Wallis Test Nonparametric
Adolph Samuel Flemister Jr, MD, Rochester, NY ANOVA), not statistically significant.Complications: NU: 5 of
112 joints (4% NU rate) (3 patients): STJ, n=2; TNJ, n=1; CCJ,
Matthew Joseph Enna, MD, Santa Monica, CA
n=1. Two wound complications, 1 deep infection: successfully
Peter Evangelista, MD, treated with local wound care or VAC dressings/systemic antibi-
June Newman, MSN, RNP, otics. Conclusion: rhBMP-2 is an effective adjunct for bone
The purpose of this prospective, controlled, randomized, multi- healing in high-risk foot & ankle surgery, statistically improving
center feasibility clinical trial was to compare the safety and effi- time to healing, with low complications.
cacy of Recombinant Platelet-Derived Growth Factor
(rhPDGF-BB) in conjunction with a tricalcium phosphate carrier PAPER NO. 261
(²-TCP) to Autogenous Bone Graft (ABG) during ankle and Total Joint Reconstruction of the Arthritic Ankle
hindfoot fusion. 20 adult subjects from three U.S. centers were
enrolled. Randomization was 2:1 and post-operative follow-up Joint Using Bipolar Shell Osteochondral Allograft
was nine months. The primary endpoint was radiographic Sandro Giannini, MD, Bologna, Italy
union based on x-ray and CT evaluation. Secondary endpoints Roberto Buda, Bologna, Italy
included clinical union, time to full weight-bearing, AOFAS Francesca Vannini, MD, Bologna, Italy
Ankle-Hindfoot Scale, Foot Function Index, SF-12, and visual Roberto Bevoni, MD, Faenza, Ravenna Italy
analog pain scale (VAS). Interim 12 week results indicated that Brunella Grigolo, MD, Bologna, Italy
four of thirteen (30.8%) rhPDGF-BB versus one of six (16.7%)
Fresh bipolar shell osteochondral allografts provides viable carti-
ABG patients demonstrated x-ray union. Seven of eleven
lage that can survive transplantation and have been proposed as
(63.6%) rhPDGF-BB versus three of six (50%) ABG subjects had
a treatment in post-traumatic arthritis of the ankle (PTAA). Aim
greater than 50% osseous bridging on CT evaluation. Six of nine
of this study is to review the results of a series of patients treated.
(66.7%) rhPDGF-BB versus three of four (75.0%) ABG patients
25 patients, mean age 32±11 years affected by PTAA grade III
had achieved full weight bearing. The interim mean VAS and
received ankle allograft. A specifically designed instrumentation
AOFAS scores for the rhPDGF-BB and ABG subjects were 16.4
was used enabling modular cuts during allograft transplanta-
versus 21.6 and 60.8 versus 53.3, respectively. Adverse events
tion. Patients evaluation included clinical AOFAS score, X-Rays,
were reported in nine of sixteen (64.3%) rhPDGF-BB and in five
CT scans, MRI preoperatively and at different established follow-
of six (83.3%) ABG patients, with no serious adverse events.

up. Before surgery the mean AOFAS score was 24±11, while it
Average procedure times were 117.6 versus 143.7 minutes,
was 86±10 at 30 months follow-up (range 24-42) (p<0.005). A
respectively. Early union rates for rhPDGF-BB subjects appear to
medial malleolar fracture and a graft malpositioning occurred as
be at least equivalent to patients undergoing ABG, and
intraoperative complications. All the patients demonstrated
outcomes measures trended favorably for the former.
good consolidation rates of the allograft at X-Rays, CT scan and
Preliminary data suggest that rhPDGF-BB may have utility as a
MRI controls. Normal ROM of the ankle and regular gait with
viable bone graft substitute during foot and ankle fusion.
no pain was resumed in 22 patients. Post-operative complica-
PAPER NO. 260 tions included fracture of the fibula and damage of the malpo-
sitioned graft requiring revision. The technique presented allows
◆rhBMP-2 in High-Risk Ankle & Hindfoot Fusions: a precise and reproducible. Although preliminary results are
Results of a Prospective, Intention to Treat Study encouraging, longer follow-up is required in order to confirm
Christopher Bibbo, MD, Marshfield, WI longer term cartilage viability and the validity of the technique
Sheldon S Lin, MD, Newark, NJ PAPER NO. 262
Introduction: The use of rhBMP-2 in foot & ankle surgery has
not been clinically evaluated. The purpose of this study was to Fixator Assisted Nailing for Revision of Failed Ankle
evaluate rhBMP-2 as an adjuvant for bone healing in high-risk Fusion With Bone Loss and Deformity
ankle & hindfoot fusion surgery. IRB approval was obtained. Minoo Keki Patel, MD, Malvern East, VIC Australia
High-risk elective ankle & hindfoot fusions were prospectively Alan Macleod, MD, Salford, United Kingdom
enrolled bone healing augmentation with rhBMP-2. Patients
Mahmoud Mahran, MD,
with PVD, infection, unavailable for CT, were excluded from
analysis. Internal and/or external fixation utilized; bone graft
Gregory Zeiders, DO, Oklahoma City, OK
used only for defects/malalignment. Postoperatively, patients Failed ankle fusions with bone loss and deformity are a recon-
were NWB & followed every 2-4 weeks: X-rays (3 views/site); at struction challenge. We present a new technique of revision
X-ray union, confirmatory CT obtained; if union not CT fusion using an Ilizarov or Taylor Spatial Frame for deformity
confirmed, repeat CT performed upon further X-ray progression. correction and fixator assisted retrograde nailing (FAN) for revi-
Results: 112 fusion sites (69 patients) for analysis. Mean age = 52 sion ankle fusion. Between 2001 and 2007, 12 cases of failed
(R=21-84); 37M (53%), 32F (47%); Smokers, n = 44 (64%); ankle fusion with bone loss and deformity were treated using
Diabetes, n = 13 (19%); History of high-energy trauma, n = 47 the FAN technique. All had bone loss and or deformity. 4 were
(68%); AVN = 22 (32%); Patients with multiple risk-factors, n = Charcot joints, 3 with diabetes and one with severe sero-negative
45 (78%). Bone Healing: Overall, 108 fusion sites went on to arthropathy. 5 cases had primary osteoarthritis, 2 had secondary
post-traumatic arthritis and one had rheumatoid
arthropathy.The joint surfaces were revised from a lateral PAPER NO. 264
approach described by Paley and Herzenberg. The fibula and Tibiotalocalcaneal and Tibiocalcaneal Arthrodeses :
medial malleolus were osteotomised. The fibula was reamed
with an acetabular reamer for local bone graft.If the deformity A Prospective Outcomes Study
was correctable acutely a retrograde nail was inserted primarily. David William Wang, MD, Durham, NC
The Biomet revision ankle fusion nail was ideal for this applica- Steven Douglas Sides, MD, Greeley, CO
tion with its adjustable locking jig. The frame was used for John S Reach, MD, New Haven, CT
stability and compression. The nail was initially locked distally Mark E Easley, MD, Durham, NC
only. Once union was achieved the nail was locked proximally
Tibiotalocalcaneal (TTC) and tibiocalcaneal (TC) hindfoot
and frame removed.If the deformity was not amenable to acute
fusion are useful methods for limb salvage in patients with
correction, the fixator was used to obtain gradual correction and
painful deformity despite optimized conservative management.
compression. Once union was achieved a locked retrograde nail
This study prospectively examined hindfoot arthrodeses using a
was used to augment the stability of fusion. 11/12 cases achieved
straightforward talus-based treatment algorithm. 36 arthrodeses
union. One Charcot joint with persistent non-union and foot
were performed in 35 patients according to a standardized treat-
infection opted for a below-knee amputation. Three cases
ment algorithm: utilization of a retrograde IM compression nail
required secondary anterior bone grafting. Two required the
if the talus was felt to be adequate (TTC arthrodesis), or utiliza-
insertion of an implantable bone stimulator. Even though there
tion of a cannulated blade plate with crossed lag screws when the
were instances of minor pin site infection there was no primary
talus was inadequate (TC arthrodesis). The patients were assessed
de novo infection. There was reactivation of osteomyelitis in one
preoperatively and at follow-up by an independent observer. The
cases, resulting in loosening of the nail and non-union. Union
talus was preserved in 24 feet, and a retrograde IM nail TTC
was finally obtained with re-application of frame,
arthrodesis was performed. The talus was not preserved in 12 feet,
intramedullary reaming and insertion of antibiotic cement rod.
and a lateral blade plate was utilized for TC arthrodesis. Leg
All patients had a plantigrade foot. The average time in frame
length discrepancy averaged 1.45 cm in the TTC arthrodesis
was 11 weeks. Fixator assisted retrograde nailing (FAN) is a reli-
group and 2.32 cm in the TC group. Radiographic union rate was
able technique for revision ankle fusions with bone loss and
83.3% (30/36). Postoperative AOFAS Hindfoot score for the TTC
deformity.
group was 71.9; for the TC group, 64.7. Complications included
3 symptomatic nonunions, 3 deep infections, and 2 fractures
PAPER NO. 263
above the fusion. 11 patients (30.6%) required at least one addi-
Pantalar Arthrodesis. Salvage Procedure or Surgical tional operation. This paper presents a straightforward treatment
Option? algorithm to guide surgical management of end-stage arthrosis of
Stefanos Provelengios, MD, PhD, Palaio Faliro, Greece the ankle and hindfoot. All patients improved from their preop-
erative levels and would recommend the procedure to others
John Margaritis Kirkos, MD, Thessaloniki, Greece
with similar deformity. Prior investigations also show a high
Kyriakos Athanasios Papavasiliou, Dr, Thessaloniki, Greece complication rate in treating complex hindfoot pathology.

Margaritis J Kyrkos, MD, Thessaloniki, Greece Tibiotalocalcaneal and tibiocalcaneal arthrodeses remain salvage
George A Kapetanos, MD, Thessaloniki, Greece procedures for patients with severe hindfoot pain and deformity
John Haritidis, MD, Kilkis, Greece who wish to avoid amputation.
Pantalar Arthrodesis (PA), a relatively difficult and quite chal-
lenging operative procedure, is considered by many as a final PAPER NO. 265
step prior to amputation. Its basic indications are severe pain, Comparison of Reoperation Rates Following Ankle
deformity and instability of the foot. Aim of this retrospective
case-control study was the evaluation of the long-term results of
Arthrodesis and Total Ankle Arthroplasty
PA, as far as its impact on adjacent joints and walking ability are Nelson Fong SooHoo, MD, Los Angeles, CA
concerned. Between 1953 and 1973, thirty-two male and 34 David Zingmond, MD, Los Angeles, CA
female patients underwent one-stage PA (Steindler procedure). Clifford Ko, MD, Los Angeles, CA
Unfortunately, we managed to locate and re-evaluate only 26 The purpose of this study is to compare the reoperation rates of
(19 men, 7 women) of them. All patients underwent physical ankle arthrodesis and ankle replacement using observational,
examination, answered a questionnaire concerning daily activi- population-based data from all inpatient admissions in California
ties and underwent radiographic examination of the fused foot over a ten-year period. Our hypothesis was that patients under-
and adjacent joints. Patients’ age upon operation ranged from going ankle replacement would have a lower risk of subtalar
14-28 years (mean: 20.2); upon their last evaluation from 45-74 fusion but a higher overall risk of major revision surgery. We iden-
years (mean: 56.9). The majority of the patients (24/26) under- tified patients undergoing ankle replacement and ankle
went PA due to poliomyelitis sequels. One patient had been arthrodesis in the years 1995-2004 as inpatients using California’s
suffering from osteomyelitis and one from congenital talipes discharge database. Short-term outcomes were examined
equinovarus. The average follow-up period was 37.3 years including rates of reoperation for a major revision procedure,
(range: 27-51 years). The long-term results were graded (Hunt pulmonary embolism, amputation and infection. Long-term
and Thompson classification scheme) as excellent in 7 outcomes analyzed included rates of major revision surgery and
cases/patients, very good in 10, good in 8 and poor in 1. PA is a subtalar joint fusion. Logistic and proportional hazard regression
demanding procedure that served well a useful purpose for models were used to estimate the impact of the choice of ankle
stabilizing the ankle, rear-foot and mid-foot. Living in the era of replacement or ankle fusion in predicting the rates of adverse
arthroplasty, its indications are extremely limited. Nevertheless, outcomes, accounting for patient factors including age and
if successfully performed in carefully selected patients, it offers a Charlson comorbidity. A total of 4,705 ankle fusions and 480
strong and stable foot that will function adequately well for the ankle replacements were performed during the ten-year study
rest of the patient’s life. period. Patients undergoing ankle replacement had an increased
risk of device-related infection and major revision procedures. The
509
rates of major revision surgery for ankle replacement patients were percent). 27 percent of the cohort had a preoperative varus or
9% at 1-year and 23% at 5-years post-operatively compared to 5% valgus deformity of more than 10 degrees. 11 component revi-
and 11% following ankle arthrodesis. Ankle arthrodesis patients sions were performed (2 for stiffness, 2 medial malleolar fractures,
had a higher rate of subtalar fusion at five-years post-operatively 2 liner fracture/dislocation, 4 instability and 1 component malpo-
than ankle replacement patients (2.8% and 0.7%, respectively). sition) and 3 ankles fused (deep infection, varus instability, ante-
Regression analysis confirmed a statistically significant increase in rior tibial collapse), giving a cumulative survivorship of 90 percent
the risk for ankle replacement patients of major revision surgery at 5 years. There were no other cases of deep infection and no revi-
(hazard ratio 1.93, p<0.001) but a decreased risk of subtalar sions for aseptic loosening. 7 asymptomatic ankles had none-
fusion (hazard ratio 0.28, p=0.03) compared to ankle fusion progressive lucent lines behind the tibial component. Correction
patients. This study demonstrates a higher risk of reoperation for of preoperative hindfoot deformity to within 5 degrees was
major revision surgery and infection following ankle replacement. achieved in 84 percent of cases. The mean postoperative American
However, ankle replacement patients are less likely to require Orthopaedic Foot and Ankle Society Score was 80. Total ankle
fusion of the adjacent subtalar joint on long-term follow-up. This arthroplasty is a reliable procedure for ankle arthrosis at interme-
study confirms a higher risk of complications following ankle diate term follow up. It provides good functional results and
replacement but also its potential advantages in avoiding subtalar symptomatic benefit, with a low complication and revision rate.
joint pathology when compared to ankle fusion.
PAPER NO. 268
PAPER NO. 266 Mid- to long-term Survivorship of HINTEGRA total
Take Down of Painful Ankle Fusion and Conversion Ankle
into Total Ankle Arthroplasty Beat Hintermann, MD, Liestal, Switzerland
Alexej Barg, MD, Basel, Switzerland Alexej Barg, MD, Basel, Switzerland
Beat Hintermann, MD, Liestal, Switzerland Markus Knupp, MD, Liestal, Switzerland
A painful ankle arthrodesis may progress into a pantalar fusion While encouraging short- to mod-term results of total ankle
with its increased limitations and morbidity. An alternative treat- arthroplasty (TAA) with current three-component designs have
ment could be the takedown of the ankle arthrodesis and the been reported, little is known about the survivorship at mid-term
conversion to a total ankle arthroplasty (TAA). The aim of this to long-term. The aim of this study was to determine the survivor-
prospective study was to report on a consecutive series of 30 cases ship of TAA with the use of the HINTEGRA ankle in a consecutive
in which an ankle arthrodesis was taken down and converted to a series of 340 primary TAA. Between 05/2000 and 12/2006, 340
TAA by using a current three-component ankle prosthesis. TAA primary TAA were performed in 322 patients (females, 165;
was done in 29 patients (12 females [13 ankles]; 17 males [17 males, 157, age 57.3 ± 13.4 years). Underlying diagnosis was post-
ankles]; mean age 58.3 ± 14.9 years [ 30.9 - 83.7] years) after ankle traumatic osteoarthritis in 272 ankles, primary osteoarthritis in 26
arthrodesis (27 ankles; 12.7 ± 11.9 [0.4 - 57.0 ] years after fusion) ankles and inflammatory arthritis in 42 ankles. All patients were
or attempted fusion (2 ankles with non-union after 1.5 [1.4 - 1.5] clinically and radiologically assessed after 6.2 (1.1 - 7.5) years, and
years). Early complications included a fracture of the malleoli in 3 survivorship analysis was calculated. Revision of a metallic
ankles, but all surgeries were successful, and no further revision implant or conversion into ankle arthrodesis was taken as the
was needed in any case until the latest follow-up at a mean of 5.5 endpoint. Four ankles were revised to TAA (component loos-
± 1.4 (2.3 - 7.7) years. The AOFAS- hindfoot score increased from ening, 3; pain, 1), and 2 ankles (component loosening and recur-
preoperatively 34 ± 15 points to 66 ± 19 points. The average clin- rent misalignment, 1; pain, 1) were revised to ankle arthrodesis.
ically measured ROM of 24.1 ± 10.1° (8 - 40°) amounted to 56.4 Overall survivorship at 6 years was 98.2%, being 97.9% for the
± 28.8% (11.1 - 121.4%) of the range of the not affected contralat- talar component and 98.8% for the tibial component. Obviously,
eral ankle. Our results were promising and showed high patient TAA using a current anatomic design of 3-component prosthesis
satisfaction regarding pain relief and regained function. As far as it (HINTEGRA) have evolved to a safe procedure with reliable
is possible to compare these patients with those who underwent results at mid- to long-term. These encouraging results support
primary TAA, obtained results were slightly inferior. The reported our belief that TAA has become a viable alternative to ankle
technique represents a valuable alternative to current treatment arthrodesis even for younger patients and more difficult condi-
options of painful sequels of longstanding ankle arthrodesis. tions, as often the case in posttraumatic osteoarthritis.

The STAR Total Ankle Replacement: Prospective, Impact of Talar Component Rotation on Contact
Medium Term Results of 165 Cases Pressure after Total Ankle Arthroplasty
Sunil Dhar, FRCS, Derby Road, Nottingham, United Tomiko Fukuda, MD, Houston, TX
Kingdom Yupeng Ren, MS,
Sally Hobson, MD, Nottingham, United Kingdom Li-Qun Zhang, PhD, Chicago, IL
Few intermediate term studies of total ankle replacement have Contact pressure is an important consideration when looking at
presented data on a large cohort. This independent, prospective the long-term viability of total ankle arthroplasties. Due to the
study provides functional and survivorship data on 165 STAR high loads that the ankle is known to experience, increasing peak
total ankle replacements. 165 consecutive STAR total ankle pressures can exceed the limitations of the ultra high molecular
replacements were performed in 148 patients, aged 32 to 81 weight polyethylene. The impact of talar component rotation on
(mean 65 years) between March 1999 and January 2006 by a ankle contact pressure has not previously been described. We
single surgeon. These were prospectively followed for a mean of hypothesized that with talar component mal-rotation the peak
3.2 years (1-8 years). 50 cases have at least 5 years of follow up. pressures would increase and the overall contact area would
160 ankle replacements were available for follow up (5 deaths). decrease. Six left male cadaveric below knee specimens were used
The predominant indication for surgery was osteoarthritis (82 for this study. Appropriately sized Agility total ankles were placed
in each of the specimens. The sequence of talar rotation for each be a promising option for a patient with a failed total ankle. More
specimen was randomized between three positions: Neutral, experience is needed, however, to better define the possibilities
7.5º Internal Rotation and 7.5º External Rotation. Contact pres- and limitations of revision arthroplasty.
sure in the tibiotalar articulation was measured using ankle
specific Tekscan sensors during: static sequential loading to 740 PAPER NO. 361
newtons [N] in a neutral plantigrade position, 10 simulated Implementation of the Ottawa Ankle Rules to
dynamic strides at 650 N load. A JR3 6-Axis sensor was used to
account for coupled forces about the ankle throughout testing.
Exclude Fractures of the Ankle and Midfoot
During both sequential static and dynamic gait simulation under Leonid Arieh Kandel, MD, Jerusalem, Israel
650N load, we found increased peak pressures (PP) with both Keren Romas, MD,
7.5º internal rotation (mean static PP650N=7.0 ± 0.27MPa Yoav Mattan, MD, Jerusalem, Israel
(p=0.000); mean dynamic PP= 7.8 ± 0.22 MPa (p=0.001)) and Mayer Brezis, MD,
7.5º external rotation (mean static PP650N =6.2 ± 0.22 MPa; Ruth Stalnikowicz, MD,
mean dynamic PP= 7.6 ± 0.29 MPa (p=0.004)) as compared to Ankle and midfoot injuries are one of the most common
neutral alignment rotation (mean static PP650N =5.5 ± 0.13 orthopaedic complaints, both in the general medicine and the
MPa; mean dynamic PP= 6.3 ± 0.11 MPa) during sequential orthopedic practice. The percentage of fractures among these is
loading condition and dynamic gait simulation at 650 N. Under small, however many of them will undergo an xray. Ottawa
static conditions, the peak pressures at 7.5º internal rotation were ankle rules are clinical guidelines developed for the use of radi-
also statistically greater than 7.5º external rotation (p=0.028), ography in these cases. This aim of this prospective study was to
but under dynamic gait simulation the difference was not signif- examine these rules’ implementation in the Israeli emergency
icant (p=0.436). During static loading, the contact areas [CA] medicine department and our ability both to predict a fracture
were reduced for both 7.5º internal rotation (Mean CA650N = and to reduce the amount of unnecessary xrays. 92 consecutive
97.38 ± 17.71 mm2 (p=0.001)) and 7.5º external rotation (Mean patients with ankle injuries attending our emergency medicine
CA650N = 152.66 ± 16.81 mm2 (p=0.022)) as compared to department were divided in two groups. Study group included
neutral rotation (Mean CA650N = 190.02 ± 13.79 mm2); there 32 patients who arrived during the morning shift and were
was a trend, but no significant difference when comparing the examined by an internal medicine specialist according to the
mal-rotated positions to each other (p=0.059). We detected a Ottawa ankle rules. Patients discharged without an xray were
statistically significant rotation torque for the mal-rotated posi- followed in the clinic or by telephone communication. Control
tion as compared to the neutral alignment that increased with group included 60 patients who were examined during the
loading in our specimens (p=0.044). At the extremes of talar mal- evening and night shifts by orthopedic residents unaware of the
rotation, we found a consistent pattern of two-point loading; the study. 9 patients (30%) in the study group underwent an xray as
axis of which opposed the direction of mal-rotation. Internal opposed to 55 patients (92%) in the control group (p<0.001).
talar rotation was least tolerated due to significant increases in There was one fracture diagnosed in each group. In the study
peak pressures and decreases in contact area. In addition, there is group, no fractures were found later in patients discharged

a rotatory torque that opposes the direction of component rota- without an xray. The mean time spent in the emergency depart-
tion that increases with loading. Talar malrotation can lead to ment was 58 minutes in the study group and 98 minutes in the
premature polyethylene wear as well as potential talar loosening control group (p<0.002). The Ottawa ankle rules were devel-
secondary to the rotational torque generated as the geometry of oped as a simple ‘yes/no’ decision tool as to whether to xray the
the prosthesis attempts to seek congruency. ankle. In our emergency department, these rules were proved
both accurate and safe. They can be effectively used by profes-
PAPER NO. 270
sionals not trained in trauma. It can save radiation and patient
Revision Arthroplasty for Failed Total Ankles waiting time without jeopardizing the treatment.
Beat Hintermann, MD, Liestal, Switzerland
Alexej Barg, MD, Basel, Switzerland PAPER NO. 362
Once a total ankle replacement fails, arthrodesis has been advo- Randomised Controlled Trials of Immediate Weight-
cated as the treatment of choice. With the availability of a wide Bearing Mobilisation for Achilles Tendon Ruptures
spectrum of implants, however, re-arthroplasty may become a
Matthew L Costa, FRCS, Coventry, United Kingdom
viable alternative. The main question is, however, to which extent
an ankle where bone loss to the tibia or the talus has occurred may
K MacMillan, MCSP,
be able to be revised by a new prosthesis. This prospective study D Halliday, MCSP,
includes a consecutive series of 37 cases (37 patients; females, 19; Rachel Chester, MSc,
males, 18; mean age, 59.6 ± 11.2 years) in which a failed ankle was Lee Shepstone, PhD,
revised by using a current three-component ankle prosthesis after Andrew H Robinson, MD,
2.4 ± 1.3 (0.4 ‘ 5.4) years. The reason for failure was loosening of Simon Thomas Donell, MD, Norwich, United Kingdom
one component (29 ankles), and of both components (7 ankles), Chetan S Modi, MRCS,
granuloma formation (1 case), and pain (9 ankles). For revision, Rehabilitation after Achilles tendon rupture is delayed due to
normal components were used for talus (20) and tibia (19); slow healing of the tendon and muscle atrophy associated with
whereas, revision or custom made components were used for immobilisation.Experimental models have suggested that early
talus (8) and tibia (2). Early complications included a fracture of loading of the ruptured Achilles tendon prevents detrimental
the malleoli in 2 ankles and a dislocation of the polyethylene alterations in muscle characteristics and favours healing.We
insert in 1 case, but all surgeries were successful, and no further performed two randomised controlled trials to assess the poten-
revision was needed in any case until the latest follow-up at a tial benefits of immediate weight-bearing mobilisation for
mean of 3.6 ± 1.6 years (range, 1.2 to 6.4 years). The AOFAS-hind- Achilles tendon ruptures. Ninety-six patients who had acutely
foot score increased from preoperatively 39 ± 15 to 72 ± 14 points ruptured their Achilles tendons were recruited from three
at follow-up. This series has proven that revision arthroplasty may
511
orthopaedic centres, of which half entered trial 1 (operative) and PAPER NO. 364
the other half entered trial 2 (non-operative). Patients were Minimally Invasive Method of Harvesting the Flexor
randomised to either immediate mobilisation (orthosis) or
traditional plaster cast immobilisation. Return to normal Digitorum Longus Tendon: A Cadaver Study
activity, as reported by the patient, the EuroQol health status Vinod Kumar Panchbhavi, MD, Galveston, TX
question

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Celebrate with your Academy:

Learn, interact and enjoy the 75th Anniversary projects!

75th Annual Meeting Proceedings

Take in a three-dimensional art exhibit - this stunning,

Travel the Digital Timeline - this must-see Digital

Enjoy the eMotion Pictures art show - admire the

Flip through a commemorative coffee table book -

2008 San Francisco, CA

“Get it Straight” with a historical reference book -

Visit the Celebratory Web site - everything the 75th

75th Annual Meeting Proceedings

Take in a three-dimensional art exhibit - this stunning,

Travel the Digital Timeline - this must-see Digital

Enjoy the eMotion Pictures art show - admire the

Flip through a commemorative coffee table book -

2008 San Francisco, CA

“Get it Straight” with a historical reference book -

Visit the Celebratory Web site - everything the 75th

6300 North River Road

We have also included:

Daniel J. Berry, MD Lynn A. Crosby, MD Gene R. Barrett, MD

DISCLAIMER FDA STATEMENT

a. Research or institutional support has been received;

b. Miscellaneous non-income support (e.g. equipment or

d. Stock or stock options; or

n. Disclosed nothing of value received

The Academy does not view the existence of these disclosed

The alphabetical disclosure list begins on page 18.

Subspecialty Guide to the Annual Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Abstracts of Podium Presentations, Poster Presentations, and Scientific Exhibits . . . . . . . . 373

Abstracts of Multimedia Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776

Key Word Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809

Abstracts of Podium Presentations, Poster Presentations, and Scientific Exhibits

Abstracts of Multimedia Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769

Author Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 776

Key Word Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809

Room 3014 West operative Management, Room 3002 West

Symposia and Critique of the Latest Data Gateway Ballroom

Instructional Courses 125

Instructional Course 104 181 144 164

Scientific Exhibits 7:00 AM-6:00 PM SE43-SE47

Scientific Posters 7:00 AM-6:00 PM P206-P225

Instructional Courses 1SK, 107 127 147 167, 169

Scientific Exhibits 7:00 AM-6:00 PM SE52-SE53

Scientific Posters 7:00 AM-6:00 PM P241-P260

Current State of Fellowship Employment:

Scientific Exhibits 7:00 AM-6:00 PM SE55-SE57

Trends and Controversies in the Management

Scientific Posters 7:00 AM-6:00 PM P346-P405

Scientific Posters 7:00 AM-6:00 PM P521-P545

Scientific Posters 7:00 AM-6:00 PM Hip P001-P110 Knee P111-P205

Techniques and Technical Tips in Choices and Compromises for

the Treatment of Knee Arthritis in

Instructional Courses 205 225

Scientific Exhibits 7:00 AM-6:00 PM SE43-SE47

HAND AND WRIST

Scientific Posters 7:00 AM-6:00 PM P261-P285

Scientific Exhibits 7:00 AM-6:00 PM SE55-SE57