Annual Meeting Proceedings - American Academy of Orthopaedic ...

AAOS 2011 

A N N U A L M E E T I N G 

E D U C A T I O N • C M E • N E T W O R K I N G 

P R O C E E D I N G S 

S A N DIEGO, C A LIFORNIA 

M EETING DAT ES: FEBRUARY 15 –19 

E XHIBIT DAT ES: FEBRUARY 16 –18 

• TEC HN ICAL EXHIBITS • WHAT ’S NEW

Dear Colleagues: 

Welcome to the AAOS 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 CD-ROM is divided into sections which include symposia handouts, podium and poster abstracts, 

scientific exhibit abstracts, and multimedia education. Each section is classified by subspecialty. 

We also have included: 

• 

• 

• 

the subspecialty guide to the Annual Meeting (which separates presentations by subspecialty) 

an author index 

a key word index 

The Proceedings material is also available in a Smartphone version and as a pdf on the AAOS website. As a 

green initiative, the book is no longer printed. 

These compiled materials comprise some of the most exciting topics presented at the 2011 Annual Meeting. 

We hope that you find this resource useful now and in the future. 

Sincerely, 

Annunziato Amendola, MD 

Chair, Program Committee 

William H. Seitz, Jr., MD 

Chair, Exhibits Committee 

6300 North River Road 

Rosemont, Illinois 60018 

P. 847.823.7186 

F. 847.823.8125 

www.aaos.org 

Kevin D. Plancher, MD 

Chair, Multimedia Education Center 

Subcommittee

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

Committee Listing . . . . . . . . . . . . . . . . . . . . . . . . . .16 

Disclosures ..................................19 

Symposia Handouts 

3 

Adult Reconstruction Hip ...................68 

Adult Reconstruction Knee .................119 

Foot and Ankle ...........................164 

General .................................178 

Hand and Wrist ..........................233 

Pediatrics. ...............................253 

Practice Management ......................280 

Shoulder and Elbow. ......................346 

Spine ...................................374 

Sports Medicine and Arthroscopy ............402 

Trauma .................................428 

Tumor/Metabolic Disease ..................438 

TABLE OF CONTENTS 

Abstracts of Podium Presentations, Poster 

Presentations, and Scientific Exhibits 

Adult Reconstruction Hip ..................445 

Adult Reconstruction Knee .................518 

Basic Research ............................579 

Foot and Ankle ...........................581 

General .................................602 

Hand and Wrist ..........................603 

Pediatrics. ...............................622 

Practice Management/Non-clinical. ..........648 

Rehabilitation ............................664 

Shoulder and Elbow. ......................672 

Spine ...................................717 

Sports Medicine and Arthroscopy ............763 

Trauma .................................810 

Tumor ..................................861 

Abstracts of Multimedia Education. ............882 

Author Index. ...............................894 

Key Word Index .............................935

4 

SuBSpECiALTy guidE TO ANNuAL MEETiNg 

Tuesday, February 15 

1:00-6:00 PM 1:30-3:30 PM 1:30-5:30 PM 1:30-6:00 PM 4:00-6:00 PM 

Adult ReconstRuction Hip And Knee 

Instructional Courses 102 

Scientific Exhibits 

1:00 PM-6:00 PM 

Scientific Papers 

Scientific Posters 

1:00 PM-6:00 PM 

Symposia 

BAsic ReseARcH 


1:00 PM-6:00 PM 

Symposia 

Foot And AnKle 


1:00 PM-6:00 PM 


SE01-SE16 - Hip 

SE17-SE29 - Knee 

P001-P207 

SE30-SE33 

SE34-SE35 

Adult Knee I: Outcomes of 

Total Knee Replacement 

(001-015) Room 5 

New Frontiers in Cartilage 

Imaging of the Hip (ORSI) 

Room 6B 

Can Platelet-Rich Plasma Really 

Improve Connective Tissue 

Healing? Making Sense of it All 

(C - 1:30-2:30 PM) Room 8 


1:00 PM-6:00 PM 

GeneRAl 

P208-P228 


Symposia 

HAnd And WRist 


1:00 PM-6:00 PM 

Symposia 


1:00 PM-6:00 PM 

pediAtRics 


1:00 PM-6:00 PM 

SE36-SE38 

P229-P244 

SE39-SE40 


1:00 PM-6:00 PM 

P245-P264 

pRActice MAnAGeMent / non-clinicAl 

Instructional Courses 181 182- NO CME CREDIT 


1:00 PM-6:00 PM 


1:00 PM-6:00 PM 

sHouldeR And elBoW 

SE41-SE48 

P265-P289 

Adult Hip I: Hip Surfacing/ 

Osteotomy (031- 045) 

Room 5 

Debates on Contemporary 

Issues in Total Knee 

Replacement (B) Ballroom 20 

Foot and Ankle I: Trauma 

and Arthroplasty 

(046-060) 

Room 7 

Research for Immediate 

Translation to Orthopaedic 

Practice (ORSII) Room 6B 

Operative Fixation of 

Pediatric Hand and Upper 

Extremity Fractures: Case 

Based Symposium 

(D - 4:00-5:00pm) Room 8 



1:00 PM-6:00 PM 


1:00 PM-6:00 PM 

spine 


1:00 PM-6:00 PM 


SE49-SE55 

P290-P350 

SE56-SE59 

Spine I: Cervical Spine 

(016-030) 

Room 7 


1:00 PM-6:00 PM 

P351-P411 

spoRts Medicine And ARtHRoscopy 


1:00 PM-6:00 PM 

SE60-SE73 


1:00 PM-6:00 PM 

P412-P461 

Symposia 

Complex Shoulder Pathology 

in the Young Athlete: A

5 


1:00 PM-6:00 PM 

Tuesday, February 15 


1:00 PM-6:00 PM 

P290-P350 

1:00-6:00 PM 1:30-3:30 PM 1:30-5:30 PM 1:30-6:00 PM 4:00-6:00 PM 

Adult spine ReconstRuction Hip And Knee 

Instructional Scientific Exhibits Courses 

1:00 PM-6:00 PM 


1:00 PM-6:00 PM 



SE56-SE59 



102 


Adult Knee (016-030) I: Outcomes of 

Total Knee Room Replacement 7 

(001-015) Room 5 

Adult Hip I: Hip Surfacing/ 

Osteotomy (031- 045) 

Room 5 


1:00 PM-6:00 PM 

P351-P411 P001-P207 

spoRts Medicine And ARtHRoscopy New Frontiers in Cartilage 

Symposia 


Imaging of the Hip (ORSI) 

1:00 PM-6:00 PM 

SE60-SE73 

Room 6B 

BAsic Scientific Posters ReseARcH 

Scientific 1:00 PM-6:00 Exhibits PM 

P412-P461 

1:00 PM-6:00 PM 

SE30-SE33 


Debates on Contemporary 

Issues in Total Knee 

Replacement (B) Ballroom 20 

Symposia 

Symposia 

Can in Platelet-Rich the Young Plasma Athlete: Really A 

Case-Based Improve Connective Symposium Tissue (A) 

Healing? Ballroom Making Sense 20 of it All 

tRAuMA 


(C - 1:30-2:30 PM) Room 8 

Instructional Courses 


1:00 PM-6:00 PM 

SE34-SE35 

111 


1:00 PM-6:00 PM 

SE74-SE80 

Foot and Ankle I: Trauma 

Scientific Posters Papers 

1:00 PM-6:00 PM 

P462-P526 

and Arthroplasty 

(046-060) 

Room 7 

tuMoR Scientific Posters / MetABolic 

1:00 PM-6:00 PM 

P208-P228 

diseAse 

GeneRAl 


Instructional 1:00 PM-6:00 Courses PM 

SE81-SE85 

101 

Research for Immediate 

Symposia 

Translation to Orthopaedic 

Practice (ORSII) Room 6B 

HAnd Scientific Posters And WRist 

1:00 PM-6:00 PM 


1:00 PM-6:00 PM 

P527-P553 

SE36-SE38 

Operative Fixation of 

Pediatric Hand and Upper 

Symposia 

Extremity Fractures: Case 

Based Symposium 

(D - 4:00-5:00pm) Room 8 


1:00 PM-6:00 PM 

pediAtRics 

P229-P244 


1:00 PM-6:00 PM 

SE39-SE40 


1:00 PM-6:00 PM 

P245-P264 


Instructional Courses 181 182- NO CME CREDIT 


1:00 PM-6:00 PM 


1:00 PM-6:00 PM 


SE41-SE48 

P265-P289 



1:00 PM-6:00 PM 


1:00 PM-6:00 PM 

spine 


1:00 PM-6:00 PM 


P265-P289 





1:00 PM-6:00 PM 

SE49-SE55 

SE49-SE55 

P290-P350 

SE56-SE59 


(016-030) 

Room 7 


1:00 PM-6:00 PM 

P351-P411 



1:00 PM-6:00 PM 

SE60-SE73 


1:00 PM-6:00 PM 

P412-P461 


in the Young Athlete: A

6 

wednesday, February 16 

7:00-10:00 AM 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 201, 202 221, 222 241, 242 261, 262, 263 


7:00 AM-6:00 PM 



7:00 AM-6:00 PM 

Symposia 




P001-P207 

Adult Hip II: Metal on Metal Bearing 

Surfaces (061-075) Room 6B 

Current Controversies in TJA (E) 

Ballroom 20 

Adult Knee II: Infection and Other 

Complications (121-135) Room 6B 

Joint Preservation Hip Surgery: How 

To Avoid And Treat Complications and 

Failures (J) Room 6A 



7:00 AM-6:00 PM 

SE30-SE33 

Adult Hip III: Revision Hip 

Arthroplasty (181-195) Room 6B 

Adult Knee III: Revision Total Knee 

Replacement (241-255) Room 6D 


Instructional Courses 203 223 243 264 


7:00 AM-6:00 PM 

SE34-SE35 


Foot and Ankle II: Ankle and 

Hindfoot (091-105) Room 5 


7:00 AM-6:00 PM 

P208-228 

The Land of Ligaments: Navigating 

Symposia 

GeneRAl 

Sprains, Strains and Ruptures About 

the Foot and Ankle (K) Room 6C 

Instructional Courses 204 281 268 

Symposia 




7:00 AM-6:00 PM 

SE36-SE38 

Hand and Wrist I: Outcomes: 


Hand (271-285) 

Room 7 


7:00 AM-6:00 PM 

pediAtRics 

P229-P244 

Instructional Courses 206 226 247, 253 3SK 266 


7:00 AM-6:00 PM 



SE39-SE40 

Pediatrics I: Trauma (166-180) 

Room 7 


7:00 AM-6:00 PM 

P245-P264 


Instructional Courses 207 227, 234 244, 254 


7:00 AM-6:00 PM 

SE41-SE48 


Practice Management I: Health Care 

Economics (106-120) Room 7 


7:00 AM-6:00 PM 

P265-P289 

Symposia 


AAOS Quality Initiatives, Health care 

Reform and You (F) Room 6C 

Hospital-Based Employment of 

Orthopaedic Surgeons: Passing Trend 

or New Paradigm? (L) Room 6A 

Instructional Courses 1SK 208, 209 228, 229 248 287, 2SK 269, 270 


7:00 AM-6:00 PM 

SE49-SE55 


Shoulder and Elbow I: Shoulder 

Arthroplasty (076-090) Room 6D 

Shoulder and Elbow II: Rotator 

Cuff (151-165) Room 5 


7:00 AM-6:00 PM 

P290-P350 

Symposia 

spine 

Lessons Learned: How to Minimize 

Complications in Common and Complex 

Shoulder Surgery - A Case-based 

Symposium (H) Ballroom 20 

Instructional Courses 210 284 231 252 274 


7:00 AM-6:00 PM 

SE56-SE59 

Scientific Papers Spine II: Lumbar Spine (256-270) Room 5 


7:00 AM-6:00 PM 

P351-P411 

Symposia 

Cervical Spine Trauma: Current 

Concepts (G) Room 6A 


Instructional Courses 211 283 230 250, 251 267, 271 


7:00 AM-6:00 PM 

SE60-SE73 

Sports Medicine/Arthroscopy I: 


Articular Cartilage Clinical and 

Research (196-210) Room 6D

7 

Symposia 


7:00 AM-6:00 PM 


SE39-SE40 



Pediatrics I: Trauma (166-180) 

Room 7 






7:00 AM-6:00 PM 

1SK 208, 209 228, 229 248 287, 2SK 

SE49-SE55 SuBSpECiALTy guidE TO ANNuAL MEETiNg 

269, 270 





Cuff (151-165) Room 5 


7:00 AM-6:00 PM 

P290-P350 

Symposia 

7:00-10:00 AM 8:00-10:00 AM 


wednesday, February Complications in Common and Complex 16 


8:00-11:00 AM 10:30 Symposium AM-12:30 (H) Ballroom 20 PM 1:30-3:30 PM 1:30-4:30 PM 4:00-6:00 PM 




Scientific 7:00 AM-6:00 Exhibits PM 

7:00 

Scientific 

AM-6:00 

Papers 

PM 

SE01-SE16 SE56-SE59 - Hip 


201, 210 202 284 221, 231 222 241, 252 242 261, 262, 274 263 

Spine II: Lumbar Spine (256-270) Room 5 


Scientific 

7:00 AM-6:00 

Papers 

PM 

P351-P411 

Adult Hip II: Metal on Metal Bearing 

Surfaces (061-075) Room 6B 

Adult Knee II: Infection and Other 

Complications (121-135) Room 6B 

Adult Hip III: Revision Hip 

Arthroplasty (181-195) Room 6B 

Adult Knee III: Revision Total Knee 

Replacement (241-255) Room 6D 

Scientific SymposiaPosters 

7:00 AM-6:00 PM 

P001-P207 




Symposia 

Current Controversies in TJA (E) 


Ballroom 

211 

20 


BAsic 7:00 AM-6:00 ReseARcH PM 

SE60-SE73 

283 

Joint Preservation Hip Surgery: How 

To Avoid And Treat 230 Complications and 

Failures (J) Room 6A 

250, 251 267, 271 

Instructional Scientific Papers Courses 224 



Research (196-210) Room 6D 

Scientific Exhibits Posters 

7:00 AM-6:00 PM 

tRAuMA 

P412-P461 SE30-SE33 

Foot Instructional And Courses AnKle 

212, 213 282 232, 233 245, 249 286 272, 273 


Scientific 

7:00 AM-6:00 

Exhibits 

PM 

7:00 Scientific AM-6:00 Papers PM 



Scientific 

7:00 AM-6:00 

Posters 

PM 

7:00 AM-6:00 PM 

SE74-SE80 

SE34-SE35 

P462-P526 

P208-228 

203 

Foot and Ankle II: Ankle and 

Hindfoot (091-105) Room 5 

223 

Trauma I: Basic Science (136- 

150) Room 6D 

243 

Trauma II: Pelvis Acetabulum Hip 

(211-225) Room 5 

264 

tuMoR Symposia / MetABolic diseAse 


The Land of Ligaments: Navigating 

Sprains, Strains and Ruptures About 

the Foot and Ankle (K) Room 6C 

285 

Scientific GeneRAl Exhibits 

7:00 Instructional AM-6:00 Courses PM 


Symposia 


7:00 AM-6:00 PM 


Symposia Instructional Courses 


7:00 AM-6:00 PM 

SE81-SE85 

P527-553 

SE36-SE38 

204 

205 

281 

Imaging Interpretation of Oncologic 

Musculoskeletal Conditions: 225 Understand 

What You See! (I) Room 6C 

Tumor/Metabolic Disease I: Diagnosis and 

Prognostic Facotrs (226-240) Room 7AB 

246 

268 

265 

Hand and Wrist I: Outcomes: 


Hand (271-285) 

Room 7 


7:00 AM-6:00 PM 

pediAtRics 

P229-P244 

Instructional Courses 206 226 247, 253 3SK 266 


7:00 AM-6:00 PM 

P245-P264 


Instructional Courses 207 227, 234 244, 254 


7:00 AM-6:00 PM 

SE41-SE48 


Practice Management I: Health Care 

Economics (106-120) Room 7 


7:00 AM-6:00 PM 

P265-P289 

Symposia 




Hospital-Based Employment of 



Instructional Courses 1SK 208, 209 228, 229 248 287, 2SK 269, 270 


7:00 AM-6:00 PM 

SE49-SE55 





Cuff (151-165) Room 5 


7:00 AM-6:00 PM 

P290-P350 

Symposia 

spine 


Complications in Common and Complex 


Symposium (H) Ballroom 20 



7:00 AM-6:00 PM 

SE56-SE59 

Scientific Papers Spine II: Lumbar Spine (256-270) Room 5 


7:00 AM-6:00 PM 

P351-P411 

Symposia 




Instructional Courses 211 283 230 250, 251 267, 271 


7:00 AM-6:00 PM 

SE60-SE73 




Research (196-210) Room 6D

8 

Thursday, February 17 



Instructional Courses 301, 302 321, 322, 323 341, 342 386 361, 362, 365 


7:00 AM-6:00 PM 



7:00 AM-6:00 PM 

Symposia 




P001-P207 

Adult Knee IV: Basic Science 

(286-300) Room 6B 



7:00 AM-6:00 PM 

SE30-SE33 

Adult Hip IV: Hip Arthroplasty: 

(346-360) Room 6B 

Adult Knee V: Outcomes of Total Knee 

Replacement II (406-420) Room 6B 

Adult Hip V: Complications and 

Infections (466-480) Room 6B 

Current Controversies in 

Partial Knee Arthroplasty (P) 

Ballroom 20 


Instructional Courses 303 324 343 7SK 364 


7:00 AM-6:00 PM 

SE34-SE35 



Foot and Ankle III: Research and 

Forefoot (496-510) 

Room 5 


7:00 AM-6:00 PM 

GeneRAl 

P208-P228 

Instructional Courses 305 381 327 344, 353 363 

Disaster-Relief Orthopaedics: 

Symposia 


What You Need to Know Before 

You Go (N) Room 6C 



7:00 AM-6:00 PM 

SE36-SE38 


Hand and Wrist II: Outcomes: 

Wrist (331-345) Room 7 


7:00 AM-6:00 PM 

P229-P244 

Symposia 

pediAtRics 

Distal Radius Fractures: Current Concepts 

and Evolving Technologies (O) Room 6A 



7:00 AM-6:00 PM 

SE39-SE40 


Pediatrics II: Spine (391-405) 

Room 7 

Pediatrics III: Foot, Lower Extremity 

and General (421-435) Room 6D 


7:00 AM-6:00 PM 

P245-P264 

Symposia 


Adult Consequences of 

Pediatric Orthopaedic 

Conditions (R) Room 6A 



7:00 AM-6:00 PM 

SE41-SE48 


Practice Management II: Conflict 

of Interest, Education and 

Practice Environment 

(451-465) Room 7 


7:00 AM-6:00 PM 

P265-P289 


Instructional Courses 4SK 309, 310 384 328, 329 347, 348 6SK 367, 368, 373 


7:00 AM-6:00 PM 

SE49-SE55 

Shoulder and Elbow III: Revision 


Shoulder Arthroplasty and 

Miscellaneous (361-375) Room 6D 


7:00 AM-6:00 PM 

P290-P350 

Symposia 

spine 

Hot Topics and Controversies in Primary 

Shoulder Arthroplasty (M) Ballroom 20 

Instructional Courses 5SK 308 333 350 371 


7:00 AM-6:00 PM 

SE56-SE59 


Spine III: Spinal Deformity 

(436-450) Room 5 


7:00 AM-6:00 PM 

P351-P411 


Instructional Courses 311 331 349, 352 387 


7:00 AM-6:00 PM 

SE60-SE73 


Sports Medicine/Arthroscopy II: 

ACL Reconstruction Adult 

(316-330) Room 5 

Sports Medicine/Arthroscopy III: ACL 

Reconstruction Pediatric, Revision, PCL 

and Meniscus (481-495) Room 6D 


P412-461

9 


7:00 AM-6:00 PM 

P265-P289 




7:00 AM-6:00 PM 

4SK 309, 310 384 328, 329 347, 348 6SK 

SuBSpECiALTy SE49-SE55 

guidE TO ANNuAL MEETiNg 

367, 368, 373 






7:00 AM-6:00 PM 

Symposia 

P290-P350 

7:00-10:00 AM 8:00-10:00 AM 

Thursday, February 17 

8:00-11:00 AM 10:30 AM-12:30 PM 


Shoulder 1:30-3:30 Arthroplasty (M) PM Ballroom 20 1:30-4:30 PM 4:00-6:00 PM 


Instructional Courses 5SK 301, 308 302 321, 322, 333 323 341, 350 342 386 361, 362, 371 365 

Scientific 

Scientific 

Exhibits 

Exhibits 

7:00 

7:00 

AM-6:00 

AM-6:00 

PM 

PM 





Adult Knee IV: Basic Science 

(286-300) Room 6B 

Adult Hip IV: Hip Arthroplasty: 

(346-360) Room 6B 


Adult Knee (436-450) V: Outcomes Room of Total 5 Knee 

Replacement II (406-420) Room 6B 

Adult Hip V: Complications and 

Infections (466-480) Room 6B 


7:00 AM-6:00 PM 

P001-P207 P351-P411 


Instructional 

Symposia 

Courses 


BAsic 7:00 AM-6:00 ReseARcH PM 

SE60-SE73 

311 331 349, 352 387 

Current Controversies in 

Partial Knee Arthroplasty (P) 

Ballroom 20 

Instructional Scientific Papers Courses 


ACL Reconstruction 304 Adult 

(316-330) Room 5 



and Meniscus (481-495) Room 6D 

Scientific Exhibits Posters 

7:00 AM-6:00 PM 

tRAuMA 

SE30-SE33 P412-461 

Foot Instructional And Courses AnKle 

313 383 332, 334 351 369, 370 


7:00 

Scientific 

AM-6:00 

Exhibits 

PM 

Scientific 7:00 AM-6:00 Papers PM 

SE74-SE80 

SE34-SE35 

303 

Trauma III: Femur (301-315) Room 6D 

324 

Trauma IV: Lower Extremity and 

Bone Grafting (376-390) Room 5 

343 7SK 364 


7:00 Scientific AM-6:00 Papers PM 

P462-P526 

Foot and Ankle III: Research and 

Forefoot (496-510) 

Symposia 

Advances and Challenges Room in 5the 

Management 

of Extremity Blast Injuries (Q) Room 6C 

tuMoR Scientific Posters / MetABolic diseAse 

Instructional 7:00 AM-6:00 Courses PM 

P208-P228 

314 

GeneRAl 




Symposia 

SE81-SE85 

305 381 327 344, 353 

Disaster-Relief Orthopaedics: 

What You Need to Know Before 

You Go (N) Room 6C 

363 

Tumor/Metabolic Disease II: 

Treatment, Surgical Techniques and 

Outcomes (511-525) Room 7 

HAnd Scientific Posters And WRist 


P527-P553 

306 382 325 345 374 


7:00 AM-6:00 PM 

SE36-SE38 


Hand and Wrist II: Outcomes: 

Wrist (331-345) Room 7 


7:00 AM-6:00 PM 

P229-P244 

Symposia 

pediAtRics 

Distal Radius Fractures: Current Concepts 

and Evolving Technologies (O) Room 6A 



7:00 AM-6:00 PM 

SE39-SE40 


Pediatrics II: Spine (391-405) 

Room 7 

Pediatrics III: Foot, Lower Extremity 

and General (421-435) Room 6D 


7:00 AM-6:00 PM 

P245-P264 

Symposia 


Adult Consequences of 

Pediatric Orthopaedic 

Conditions (R) Room 6A 



7:00 AM-6:00 PM 

SE41-SE48 


Practice Management II: Conflict 

of Interest, Education and 

Practice Environment 

(451-465) Room 7 


7:00 AM-6:00 PM 

P265-P289 


Instructional Courses 4SK 309, 310 384 328, 329 347, 348 6SK 367, 368, 373 


7:00 AM-6:00 PM 

SE49-SE55 






7:00 AM-6:00 PM 

P290-P350 

Symposia 

spine 


Shoulder Arthroplasty (M) Ballroom 20 

Instructional Courses 5SK 308 333 350 371 


7:00 AM-6:00 PM 

SE56-SE59 



(436-450) Room 5 


7:00 AM-6:00 PM 

P351-P411 


Instructional Courses 311 331 349, 352 387 


7:00 AM-6:00 PM 

SE60-SE73 




ACL Reconstruction Adult 

(316-330) Room 5 



and Meniscus (481-495) Room 6D

Friday, February 18 



Instructional Courses 401, 402, 403 421, 422 441 484 461, 462, 463 


7:00 AM-6:00 PM 




Adult Hip VI: Highly Cross-Linked Polyethylene and 

Thromboembolic Prophylaxis (526-540) Room 6B 

Adult Knee VI: Complications of Knee Arthroplasty 

(586-600) Room 6B 

Adult Hip VII: Biomechanics and Practice Issues 

(706-720) Room 6B 


7:00 AM-6:00 PM 

P001-P207 

Symposia 


Managing Complications after Primary Total Hip 

Arthroplasty in Your Practice (V) Ballroom 20 



7:00 AM-6:00 PM 


SE30-SE33 



7:00 AM-6:00 PM 

SE34-SE35 


7:00 AM-6:00 PM 

GeneRAl 

P208-P228 

Instructional Courses 445 469 

Symposia 


Bone Defects: When Are Orthobiologics Indicated? 

(W) Room 6C 



7:00 AM-6:00 PM 

SE36-SE38 


Hand and Wrist III: Basic Science and Complications 

(556-570) Room 5 


7:00 AM-6:00 PM 

pediAtRics 

P229-P244 

Instructional Courses 8SK 406 426, 427 446 466 


7:00 AM-6:00 PM 

SE39-SE40 


Pediatrics IV: Hip/Neuromuscular/General (541-555) 

Room 6D 


7:00 AM-6:00 PM 

P245-P264 

Pediatric Sports Medicine: 

Symposia 

A Case-Based Update (Z) 

Room 6A 


Instructional Courses 408, 413 424, 428, 430, 434 442, 447, 448 468, 474 


7:00 AM-6:00 PM 

SE41-SE48 


7:00 AM-6:00 PM 

P265-P289 

Symposia 

Healthcare Reform Bill: Past, Present and Future (S) 

Ballroom 20 

EMR: Mandatory Components and Efficient Use for the 

Practicing Orthopaedic Surgeon (X) 

Room 6A 

Measuring Value in Orthopaedics: 

What a Clinician Needs to 

Know (Y) 

Room 6C 

The Elephant in the Living Room: Impact of Emotional 

Health on Functional Outcomes (AA) 

Room 6C 

ReHABilitAtion 



Rehabilitation Medicine I (616-630) 

Room 5 

Instructional Courses 409, 410 433 452 472, 473 


7:00 AM-6:00 PM 

SE49-SE55 


Shoulder and Elbow IV: Shoulder Trauma and 

Instability (601-615) 

Room 6D 

Shoulder and Elbow V: 

Elbow and Acromioclavicular Joint 

(676-690) 

Room 5 


7:00 AM-6:00 PM 

spine 

P290-P350 

Instructional Courses 407, 412 429 450 


7:00 AM-6:00 PM 

SE56-SE59 



7:00 AM-6:00 PM 

P351-P411 

Spine IV: Bone Graft Substitutes, 

Fracture and Infection (661-675) 

Room 6D 

Spine V: General Topics (736-750) 

Room 5 

Spinal Deformity: What Every Orthopaedic Surgeon 

Symposia 

Needs to Know (T) 

Room 6C 


Instructional Courses 411 482 449 485 465, 467, 470 


7:00 AM-6:00 PM 

SE60-SE73 



Sports Medicine/Arthroscopy IV: Shoulder Cuff and 


Room 7 

Sports Medicine/Arthroscopy V:Hip Impingement, 

Arthroscopy and Hamstring (631-645) 

Room 7 

Sports Medicine/Arthroscopy 

VI: Leg, Ankle and Arthroscopy 

(646-660) 

Room 6B 


7:00 AM-6:00 10 PM 

P412-P461 

Multiple Ligament Injured Knees: Cases and 

Symposia 

tRAuMA 

Controversies (BB) 

Room 6A 

Instructional Courses 9SK 414 431, 432 451, 453 486 471 


SE74-SE80






Room 5 

SuBSpECiALTy 409, 410 guidE TO 433ANNuAL MEETiNg 

452 472, 473 


7:00 AM-6:00 PM 

SE49-SE55 



7:00 AM-6:00 PM 7:00-10:00 P290-P350AM 

8:00-10:00 AM 



Room 6D 

Friday, February 18 

8:00-11:00 AM 10:30 AM-12:30 PM 



(676-690) 

Room 5 

1:30-3:30 PM 1:30-4:30 PM 4:00-6:00 PM 

spine Adult ReconstRuction Hip And Knee 

Instructional Courses 401, 407, 402, 412403 421, 429422 450 441 484 461, 462, 463 

Scientific 

Scientific 

Exhibits 

Exhibits 

7:00 

7:00 

AM-6:00 

AM-6:00 

PM 

PM 



Scientific 

Scientific 

Papers 

Papers 


Scientific 7:00 AM-6:00 Posters PM 

7:00 AM-6:00 PM 

Symposia 

Symposia BAsic ReseARcH 

P001-P207 

P351-P411 

Adult Hip VI: Highly Cross-Linked Polyethylene and 

Thromboembolic Prophylaxis (526-540) Room 6B 



Adult Knee VI: Complications of Knee Arthroplasty 

(586-600) Room 6B 

Managing Complications after Primary Total Hip 

Arthroplasty in Your Practice (V) Ballroom 20 



Room 6D 

Adult Hip 

Spine 

VII: 

V: 

Biomechanics 

General Topics 

and 

(736-750) 

Practice Issues 

(706-720) 

Room 

Room 

5 

6B 

Instructional Courses Room 4056C 


7:00 spoRts AM-6:00 Medicine PM And SE30-SE33 ARtHRoscopy 

Instructional 

Foot And 

Courses 

AnKle 


7:00 

Instructional 

AM-6:00 

Courses 

PM 

SE60-SE73 

411 

404 

482 

483 423 

449 

443 

485 465, 467, 470 

464 


7:00 AM-6:00 PM 



7:00 AM-6:00 PM 

SE34-SE35 

P208-P228 



Room 7 



Room 7 



(646-660) 

Room 6B 

Scientific GeneRAl Posters 

7:00 

Instructional 

AM-6:00 

Courses 

PM 

P412-P461 

445 469 

Symposia 


Bone Defects: When Are Orthobiologics Indicated? 

(W) Room 6C 



Room 6A 

tRAuMA 




7:00 

Scientific 

AM-6:00 

Papers 

PM 


Scientific 

7:00 AM-6:00 

Papers 

PM 

pediAtRics 

Instructional Scientific Posters Courses 

7:00 AM-6:00 PM 


7:00 AM-6:00 PM 

Symposia 


SE36-SE38 

9SK 

SE74-SE80 

P229-P244 

P462-P526 8SK 

SE39-SE40 

414 

Hand and Wrist III: Basic Science and Complications 

(556-570) Room 5 

406 

Pediatrics 

Orthopaedic 

IV: Hip/Neuromuscular/General 

Trauma Mythbusters II 

(541-555) 

(U) 

Room 

Room 

6D 

6A 

431, 432 

426, 427 

451, 453 

Trauma V: Upper Extremity, 

Amputations and Biomechanics 

(691-705) 

Room 7 

446 

486 471 

Trauma VI: Multi-trauma, Wound Care and Infections 

(721-735) 

Room 6D 

466 


tuMoR 7:00 AM-6:00 / PM MetABolic P245-P264 diseAse 


Scientific SymposiaExhibits 

7:00 AM-6:00 PM 

SE81-SE85 

Pediatric 444, Sports 454 Medicine: 

A Case-Based Update (Z) 

Room 6A 

Scientific pRActice PostersMAnAGeMent 

/ non-clinicAl 

7:00 AM-6:00 PM 

P527-P553 

Instructional Courses 408, 413 424, 428, 430, 434 442, 447, 448 468, 474 


7:00 AM-6:00 PM 

SE41-SE48 


7:00 AM-6:00 PM 

P265-P289 

Symposia 


Healthcare Reform Bill: Past, Present and Future (S) 

Ballroom 20 

EMR: Mandatory Components and Efficient Use for the 

Practicing Orthopaedic Surgeon (X) 

Room 6A 

Measuring Value in Orthopaedics: 

What a Clinician Needs to 

Know (Y) 

Room 6C 

The Elephant in the Living Room: Impact of Emotional 

Health on Functional Outcomes (AA) 

Room 6C 




Room 5 

Instructional Courses 409, 410 433 452 472, 473 


7:00 AM-6:00 PM 

SE49-SE55 




Room 6D 



(676-690) 

Room 5 


7:00 AM-6:00 PM 

spine 

P290-P350 

Instructional Courses 407, 412 429 450 


7:00 AM-6:00 PM 

SE56-SE59 



7:00 AM-6:00 PM 

P351-P411 



Room 6D 

Spine V: General Topics (736-750) 

Room 5 


Symposia 


Room 6C 


Instructional Courses 411 482 449 485 465, 467, 470 


7:00 AM-6:00 PM 

SE60-SE73 




Room 7 



Room 7 



(646-660) 

Room 6B 


7:00 AM-6:00 11 PM 

P412-P461 


Symposia 

tRAuMA 


Room 6A 



9SK 414 431, 432 451, 453 486 471

12 


saTurday, February 19 

7:00 AM-5:30 PM Specialty Day – Times Vary and Subject to Change (See Below) 


Hip Society/AAHKS 8:00 AM – 5:00 PM 

Marriott Hotel & Marina, Marriott Hall, Salon1 

Specialty Day 

Knee Society/AAHKS 8:00 AM – 5:00 PM 

Marriott Hotel & Marina, Marriott Hall, Salon 4 

LLRS 7:40 AM – 5:00 PM 

SDCC, Room 4 


7:00 AM-5:30 PM 


7:00 AM-5:30 PM 



7:00 AM-5:30 PM 


Specialty Day 


7:00 AM-5:30 PM 


7:00 AM-5:30 PM 


Specialty Day 


7:00 AM-5:30 PM 


7:00 AM-5:30 PM 

pediAtRics 

Specialty Day 


7:00 AM-5:30 PM 


7:00 AM-5:30 PM 



P001-P207 

SE30-SE33 

SE34-SE35 

P208-P228 

SE36-SE38 

P229-P244 

SE39-SE40 

P245-P264 



7:00 AM-5:30 PM 


7:00 AM-5:30 PM 


Specialty Day 


Specialty Day 


7:00 AM-5:30 PM 


7:00 AM-5:30 PM 

spine 

Specialty Day 


7:00 AM-5:30 PM 


7:00 AM-5:30 PM 


Specialty Day 


7:00 AM-5:30 PM 


SE41-SE48 

P265-P289 

SE49-SE55 

P290-P350 

SE56-SE59 

P351-P411 

SE60-SE73 

AOFAS 7:00 AM – 5:00 PM 

SDCC, Room 6C 

ASSH/AAHS 7:30 AM – 6:00 PM 

Marriott Hotel & Marina, Marina Ballroom E 

POSNA 8:00 AM – 5:00 PM 

SDCC, Room 5 

ORA 7:30 AM – 3:30 PM 

SDCC, Room 1B 

ASES 7:25 AM – 5:00 PM 

SDCC, Room 6A 

FOSA 7:55 AM – 5:10 PM 

SDCC, Room 6D 

AANA 7:50 AM – 5:00 PM 

SDCC, Ballroom 20C 

AOSSM 7:30 AM – 5:00 PM 

SDCC, Ballroom 20A

13 


Specialty Day 


SuBSpECiALTy guidE TO ANNuAL ASES 7:25 AM MEETiNg 

– 5:00 PM 

Specialty Day 


7:00 AM-5:30 PM 

saTurday, February 19 


7:00 AM-5:30 PM 

P290-P350 

7:00 AM-5:30 PM Specialty Day – Times Vary and Subject to Change (See Below) 


Specialty Day 

Specialty Day 

Hip Society/AAHKS 8:00 AM – 5:00 PM 

Marriott Hotel FOSA & 7:55 Marina, AM – Marriott 5:10 PM Hall, Salon1 

Knee Society/AAHKS SDCC, Room 8:00 6D AM – 5:00 PM 

Marriott Hotel & Marina, Marriott Hall, Salon 4 

LLRS 7:40 AM – 5:00 PM 


7:00 Scientific AM-5:30 Exhibits PM 

7:00 AM-5:30 PM 



SDCC, Room 4 


7:00 AM-5:30 PM 


7:00 BAsic AM-5:30 ReseARcH PM 

P001-P207 

P351-P411 


7:00 AM-5:30 PM 

SE30-SE33 



AANA 7:50 AM – 5:00 PM 

Specialty 

Specialty 

Day 

Day 


AOFAS 7:00 AM – 5:00 PM 

AOSSM SDCC, 7:30 Room AM – 6C 5:00 PM 

SDCC, Ballroom 20A 



7:00 AM-5:30 PM 


Scientific 7:00 AM-5:30 Posters PM 

7:00 AM-5:30 PM 


tRAuMA 

Specialty Day 

Specialty Day 


7:00 AM-5:30 PM 


7:00 Scientific AM-5:30 Exhibits PM 

7:00 AM-5:30 PM 

pediAtRics 

SE34-SE35 

SE60-SE73 

P208-P228 

P412-P461 

SE36-SE38 

P229-P244 

SE74-SE80 

Specialty 


Day 

7:00 AM-5:30 PM 

P462-P526 


7:00 tuMoR AM-5:30 / PM MetABolic diseAse 

SE39-SE40 

Specialty Day 



P245-P264 

7:00 AM-5:30 PM 

SE81-SE85 

Scientific pRActice PostersMAnAGeMent 

/ non-clinicAl 

7:00 AM-5:30 PM 

P527-P553 


7:00 AM-5:30 PM 

SE41-SE48 


7:00 AM-5:30 PM 


Specialty Day 


Specialty Day 


7:00 AM-5:30 PM 


7:00 AM-5:30 PM 

spine 

Specialty Day 


7:00 AM-5:30 PM 


7:00 AM-5:30 PM 


Specialty Day 


7:00 AM-5:30 PM 


SE49-SE55 

P265-P289 

SE49-SE55 

P290-P350 

SE56-SE59 

P351-P411 

SE60-SE73 

ORA 7:30 AM – 3:30 PM 

SDCC, Room 1B 

SDCC, Room 6A 

ASSH/AAHS 7:30 AM – 6:00 PM 

Marriott Hotel & Marina, Marina Ballroom E 

OTA 7:30 AM – 5:30 PM 

SDCC, Room 6B 

POSNA 8:00 AM – 5:00 PM 

SDCC, Room 5 

MSTS 7:00 AM – 4:00 PM 

SDCC, Room 2 

ORA 7:30 AM – 3:30 PM 

SDCC, Room 1B 

ASES 7:25 AM – 5:00 PM 

SDCC, Room 6A 

FOSA 7:55 AM – 5:10 PM 

SDCC, Room 6D 

AANA 7:50 AM – 5:00 PM 


AOSSM 7:30 AM – 5:00 PM 

SDCC, Ballroom 20A

DISCLAIMER 

The material presented at the Annual Meeting has been made 

available by the American Academy of Orthopaedic Surgeons for 

educational purposes only. This material is not intended to represent 

the only, nor necessarily best, method or procedure appropriate for 

the medical situations discussed, but rather is intended to present an 

approach, view, statement or opinion of the faculty which may be 

helpful to others who face similar situations. 

The AAOS disclaims any and all liability for injury or other damages 

resulting to any individuals attending a session for all claims, which 

may arise out of the use of the techniques demonstrated therein 

by such individuals, whether these claims shall be asserted by a 

physician or any other person. 

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 specifically prohibited. 

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, which relates directly or indirectly to the subject of their 

presentation. The Academy has identified the options to disclose as 

follows: 

1 – Royalties 

2 – Speakers Bureau/paid presentations 

3a. – Employee 

3b. – Paid consultant 

3c. – Unpaid consultant 

4 – Stock or stock options; or 

5 – Research or institutional support as a principal investigator has 

been received; 

6 – Other financial or material support; 

7 – Royalties, financial or material support from publishers; 

n – No conflicts to disclose 

These codes reflect the numbers used in a series of questions 

answered by all persons participating in the Academy’s overall 

online Disclosure Program, which is available at . 

www.aaos.org/disclosure. 

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; however, these data 

are offered to the audience as additional information that may be 

helpful in evaluating the educational presentations. 

The alphabetical disclosure list begins on page 19. 

14 

FDA STATEMENT 

Some drugs or medical devices demonstrated at the Annual Meeting 

have not been cleared by the FDA or have been cleared by the FDA for 

specific purposes only. The FDA has stated that it is the responsibility 

of the physician to determine the FDA clearance status of each drug 

or medical devices he or she wishes to use in clinical practice. 

Academy policy provides that “off label” uses of a drug or medical 

device may be described in the Academy’s CME activities so long as 

the “off label” use of the drug or medical device is also specifically 

disclosed (i.e. it must be disclosed that the FDA has not cleared 

the drug or device for the described purpose). Any drug or medical 

device is being used “off label” if the described use is not set forth on 

the products approval label. 

Product Code #05236

15 

Start here 

to begin your participation in the 

2012 Annual Meeting 

San Francisco, California 

February 7 – 11 

Call for Abstracts 

Share your research with orthopaedic surgeons from around the world at the 2012 Annual 

Meeting. Nowhere else will your discoveries reach such a wide-ranging orthopaedic audience. 

NEW Abstract Submission Website 

Submit full-page abstracts, attach images, and more! 

Present your research to its best advantage on our new user-friendly website. 

Submissions open Spring 2011. Watch for announcements! 

ATTENTION PRESENTERS: 

DISCLOSURE RULES 

KNOW Your Co-Authors. Be sure to obtain up-to-date contact information for your co-authors. 

All co-authors must disclose financial relationships in the AAOS Disclosure Database prior to abstract submission. 

Abstracts will not be graded without this information.

16 

2011 ANNuAL MEETiNg COMMiTTEES 

The following AAOS Committees are responsible for the scientific program, the scientific exhibits and the multimedia education program. 

They grade abstracts and applications, suggest moderators, identify hot topics and evaluate sessions all in an effort to bring you an exciting and 

innovative program. 

EXHiBiTS COMMiTTEE 

William H . Seitz, Jr ., MD, Cleveland, OH, 

Chair 

George W. Balfour, MD, Van Nuys, CA 

J. David Blaha, MD, Ann Arbor, MI 

Dennis B. Brooks, MD, Pepper Pike, OH 

A. Seth Greenwald, D. Phil (Oxon), 

Cleveland, OH 

Steven M. Kurtz, PhD, Philadelphia, PA 

Pekka A. Mooar, MD, Philadelphia, PA 

Joseph T. Moskal, MD, Roanoke, VA 

David L. Nelson, MD, Greenbrae, CA 

John R. Tenny, MD, Dallas, TX 

ADULT RECONSTRUCTION HIP 

Adolph V Lombardi Jr, MD, New Albany, OH, 

Chair, 

David Christopher Ayers, MD, Worcester, MA 

Thomas J Blumenfeld, MD, Sacramento, CA 

Mathias P G Bostrom, MD, New York, NY 

Paul E DiCesare, MD, Sacramento, CA 

Brian A Klatt, MD, Pittsburgh, PA 

James Charles Kudrna, MD, Glenview, IL 

Glenn C Landon, MD, Houston, TX 

Gwo-Chin Lee, MD, Philadelphia, PA 

Scott E Marwin, MD, Westbury, NY 

Bassam A Masri, MD, Vancouver, BC 

John B Meding, MD, Mooresville, IN 

J Wesley Mesko, MD, Lansing, MI 

Douglas E Padgett, MD, New York, NY 

Wayne Gregory Paprosky, MD, Winfield, IL 

Jeffrey M Passick, MD, Chappaqua, NY 

Christopher L Peters, MD, Salt Lake City, UT 

Juan J Rodrigo, MD, Spartanburg, SC 

Edwin P Su, MD, New York, NY 

Dean C Sukin, MD, Billings, MT 

Marc Evan Umlas, MD, Miami Beach, FL 

Michael B Vessely, MD, Lake Oswego, OR 

Richard E White, Jr MD, Albuquerque, NM 

ADULT RECONSTRUCTION KNEE 

Giles R Scuderi, MD, New York, NY, Chair 

James B Benjamin, MD, Tucson, AZ 

Keith R Berend, MD, New Albany, OH 

Hari Bezwada, MD, Philadelphia, PA 

Gary W. Bradley, MD, Santa Barbara, CA 

Fred D Cushner, MD, New York, NY 

David F Dalury, MD, Baltimore, MD 

Kevin L Garvin, MD, Omaha, NE 

Jeffrey A Geller, MD, New York, NY 

Terence J Gioe, MD, Apple Valley, MN 

Atul B Joshi, MD, Lubbock, TX 

E Michael Keating, MD, Mooresville, IN 

MuLTiMEdiA EduCATiON 

CENTEr SuBCOMMiTTEE 

Kevin D . Plancher, MD, New York, NY, Chair 

Joseph A. Abboud, MD, Philadelphia, PA 

James M. Bennett, MD, Missouri City, TX 

William B. Geissler, MD, Jackson, MS 

Michael L. Granberry, MD, Mobile, AL 

Tally E. Lassiter, Jr, MD, Durham, NC 

Peter Maurus, MD, Coralville, IA 

Russell D. Meldrum, MD, Indianapolis, IN 

Ronald A. Navarro, MD, Rolling Hills, CA 

Mark W. Zawadsky, MD, Washington, DC 

Robert H. Quinn, MD, Consultant, 

Albuquerque, NM 

Mark T. Scarborough, MD, Consultant, 

Gainesville, FL 

prOgrAM SuBCOMMiTTEE MEMBErS 

Michael A Kelly, MD, Hackensack, NJ 

Matthew J Kraay, MD, Cleveland, OH 

Ormonde M Mahoney, MD, Athens, GA 

Arthur L Malkani, MD, Louisville, KY 

Thomas A Malvitz, MD, Grand Rapids, MI 

William Michael Mihalko, MD, PhD, Memphis, TN 

David J Olysav, MD, Springfield, IL 

Jeffery L Pierson, MD, Carmel, IN 

James A Shaw, MD, Cabin John, MD 

FOOT AND ANKLE 

Steven L Haddad, MD, Glenview, IL, Chair 

Donald R Bohay, MD, Grand Rapids, MI 

Daniel C Farber, MD, Baltimore, MD 

Justin K Greisberg, MD, New York, NY 

Stuart D Miller, MD, Baltimore, MD 

HAND AND WRIST 

Thomas E Trumble, MD, Seattle, WA, Chair 

George Walter Balfour, MD, Van Nuys, CA 

Gordon A Brody, MD, Palo Alto, CA 

Richard T Herrick, MD, Pinellas Park, FL 

Joseph E Imbriglia, MD, Wexford, PA 

PEDIATRICS 

Martin Joseph Herman, MD, Philadelphia, PA, 

Chair 

Kerwyn Jones, MD, Akron, OH 

Donna M Pacicca, MD, Kansas City, MO 

Peter D Pizzutillo, MD, Philadelphia, PA 

Jeffrey R Sawyer, MD, Germantown, TN 

PRACTICE MANAgEMENT 

John DiPaola, MD, Tualatin, OR 

Ty Henry Goletz, MD, San Antonio, TX 

Patrick J Horan, MD, Tampa, FL 

Bertrand Paul Kaper, MD, Prescott, AZ 

Thomas A Malvitz, MD, Grand Rapids, MI 

prOgrAM COMMiTTEE 

Annunziato Amendola, MD, Iowa City, IA, 

Chair 

Scott D. Boden, MD, Atlanta, GA 

Joseph A. Bosco, III, MD, New York, NY 

Steven L. Frick, MD, Charlotte, NC 

Michael J. Stuart, MD, Rochester, MN 

SHOULDER AND ELbOW 

John William Sperling, MD, Rochester, MN, Chair 

Theodore A Blaine, MD, Providence, RI 

Raymond M Carroll, MD, Cary, NC 

Lynn A Crosby, MD, Augusta, GA 

Mark A Frankle, MD, Temple Terrace, FL 

David L Glaser, MD, Philadelphia, PA 

G Russell Huffman, MD, Philadelphia, PA 

Spero G Karas, MD, Atlanta, GA 

Keith Kenter, MD, Cincinnati, OH 

Michael J Pagnani, MD, Nashville, TN 

Steve A Petersen, MD, Lutherville, MD 

Stephen C Weber, MD, Sacramento, CA 

Riley Joseph Williams, MD, New York, NY 

SPINE 

Michael Vives, MD, Newark, NJ, Chair 

Charles J Banta II, MD, Dallas, TX 

Norman Barrington Chutkan, MD, Augusta, GA 

John G Finkenberg, MD, San Diego, CA 

Walter J Finnegan, MD, Allentown, PA 

Christian Ivan Fras, MD, Haverford, PA 

Christopher George Furey, MD, Cleveland, OH 

Hubert Lee Gooch, Jr MD, Asheville, NC 

Steven M Mardjetko, MD, Morton Grove, IL 

Thomas A McNally, MD, Bartlett, IL 

James W Ogilvie, MD, Brighton, UT 

Jory Richman, MD, Pittsburgh, PA 

Paul Saiz, MD, Las Cruces, NM 

Eeric Truumees, MD, Royal Oak, MI 

SPORTS MEDICINE/ARTHROSCOPy 

Diane Lynn Dahm, MD, Rochester, MN, Chair 

James C Dreese, MD, Monkton, MD 

Michael S George, MD, Houston, TX 

Darren L Johnson, MD, Lexington, KY 

Morgan H Jones, MD, Cleveland Heights, OH 

Robert F LaPrade, MD, PHD,Vail, CO 

Keith W Lawhorn, MD, Fairfax, VA 

Dean K Matsuda, MD, Los Angeles, CA

SPORTS MEDICINE/ARTHROSCOPy (Cont.) 

K Kip Owen, MD, Mc Allen, TX 

Kevin D Plancher, MD, New York, NY 

Jeffrey M Schwartz, MD, New York, NY 

Daniel Jordan Solomon, MD, Novato, CA 

Patrick St Pierre, MD, Rancho Mirage, CA 

Robin Vereeke West, MD, Presto, PA 

Ronald W B Wyatt, MD, Walnut Creek, CA 

TRAUMA 

Bruce Ziran, MD, Decatur, GA, Chair 

Animesh Agarwal, MD, San Antonio, TX 

Peter L Althausen, MD, Reno, NV 

Craig Scott Bartlett, MD, South Burlington, VT 

David F Beigler, MD, Glenview, IL 

Jose A Bossolo, MD, Brownsville, TX 

Cory Alan Collinge, MD, Fort Worth, TX 

Gregory John Della Rocca, MD, Columbia, MO 

Thomas J Ellis, MD, Columbus, OH 

Paul Levin, MD, Bronx, NY 

Robert M Orfaly, MD, Portland, OR 

Henry Claude Sagi, MD, Tampa, FL 

Philip R Wolinsky, MD, Sacramento, CA 

TUMOR AND METAbOLIC DISEASE 

R Lor Randall, MD, Salt Lake City, UT, Chair 

Joel Mayerson, MD, Columbus, OH 

Bryan Scott Moon, MD, Houston, TX 

Shervin V Oskouei, MD, Atlanta, GA 

Jason Scott Weisstein, MD, Boca Raton, FL 

17 

prOgrAM SuBCOMMiTTEE MEMBErS 

(continued) 

This Proceedings Book is divided into four sections, Symposia 

handouts and then Podium Presentations, Poster Presentations, 

and Scientific Exhibits by classification and finally Multimedia 

Education. 

PODIUM PRESENTATIONS 

The Scientific Program features 750 podium presentations. All 

podium presentations are six minutes in groups of three followed by 

an open floor discussion moderated by chosen Academy members. 

The Scientific Program takes place at the San Diego Convention 

Center at various times and locations please see the final program 

for the schedule. 

POSTER PRESENTATIONS 

Five hundred and seventy eight Poster Presentations will be exhibited 

during the Annual Meeting. All Poster Presentations will be displayed 

the entire five days of the meeting. Included in these are Board of 

Specialty Societies (BOS) posters. The BOS posters will be indicated 

by their Society’s name or the name of their presentation. The Program 

also features selected posters from the Orthopaedic Research Society. 

We hope that you spend time visiting the poster presentations and 

discussing the information with the presenters who will be at their 

display from 11:30 AM until 12:30 PM Wednesday through Friday in 

Academy Hall, Sails Pavilion. 

The Scientific Program Committee is very appreciative of the effort 

extended by all the presenters and congratulates them on the high 

quality of the abstracts that were submitted for evaluation. 

Poster awards will be presented to the highest rated poster in each 

of the 11 classifications and from them one overall winner will be 

chosen. 

Adult Hip. ............................... P001 – P110, ORS1 

Adult Knee. .............................. P111 – P205, ORS2 

Foot and Ankle . ..........................P206 – P225, ORS3 

Hand and Wrist. ..........................P226 – P240, ORS4 

Pediatrics ......................................P241 – P260 

Practice Management/Rehabilitation ...............P261 – P285 

Shoulder and Elbow .......................P286 – P345, ORS5 

Spine ...................................P346 – P405, ORS6 

Sports Medicine and Arthroscopy ..................P406 – P455 

Trauma. .................................P456 – P520, BOS2 

Tumor ............................P521 – P545, ORS7, BOS1 

Best of ORS ....................................P546 – P555 

Allied Health ...................................P556 – P559 

Guest Nation – Turkey ...........................P560 – P569 

SCIENTIFIC EXHIbITS 

San Diego Convention Center, Academy Hall, Sails Pavilion 

The Scientific Exhibit format is used to graphically illustrate a study or 

a complex procedure. It differentiates itself from a poster presentation 

in the amount of material that is presented and uses audiovisual, 

interactive demonstration, or some other type of enhancement in 

its presentation. The Scientific Exhibits are located in Academy Hall, 

Sails Pavilion and open at 1:00 PM on Tuesday, March 9, and at 7:00 

AM, Wednesday through Saturday, to allow you to view the exhibits 

before the scientific program sessions. The authors of the exhibits are 

requested to be present Wednesday through Friday between 11:30 

AM and 12:30 PM to discuss their ideas and presentation.

Scientific Exhibits have been grouped in the following categories: 

Adult Reconstruction Hip. .........................SE01 - SE16 

Adult Reconstruction Knee. ....................... SE17 - SE29 

Basic Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SE30 - SE33 

Foot/Ankle .................................... SE34 - SE35 

Hand/Wrist .................................... SE36 - SE38 

Pediatrics ...................................... SE39 - SE40 

Practice Management .............................SE41 - SE48 

Shoulder/Elbow ................................ SE49 - SE55 

Spine ......................................... SE56 - SE59 

Sports Medicine/Arthroscopy. ..................... SE60 - SE73 

Trauma. ....................................... SE74 - SE80 

Tumor .........................................SE81 - SE85 

AAOS Committees Scientific Exhibits: 

Biological Implants Committee. ..................SE60 

Committee on Professionalism ...................SE46 

Evidence-Based Practice Committee ...............SE43 

Extremity War Injuries & 

Disaster Preparedness Project ....................SE74 

Medical Liability Committee .....................SE47 

Orthopaedic Device Forum ......................SE84 

Patient Safety Committee. .......................SE45 

Women’s Health Issues Advisory Board ............SE32 

BOS Scientific Exhibits: 

American Association for Hand Surgery ............SE37 

Limb Lengthening and Reconstruction Society ......SE39 

Musculoskeletal Tumor Society ...................SE81 

Orthopaedic Research Society ....................SE33 

18 

POSTERS, SCIENTIFIC EXHIbITS, AND 

THE MULTIMEDIA EDUCATION CENTER 

ARE LOCATED IN THE SAN DIEgO 

CONVENTION CENTER, ACADEMy HALL 

IN THE SAILS PAVILION 

POSTER EXHIbIT, SCIENTIFIC EXHIbIT AND MULTIMEDIA 

EDUCATION CENTER HOURS: 

Tuesday, February 15 ....................1:00 PM – 6:00 PM 

Wednesday- Friday, February 16-18. ........7:00 AM – 6:00 PM 

Saturday, February 19 ....................7:00 AM – 5:30 PM 

MULTIMEDIA EDUCATION CENTER 

Orthopaedic education benefits greatly from visual examples. This is 

the place to learn by example and to prepare for your future. Select 

from dozens of surgical technique videos and multimedia programs 

and enjoy them at your convenience. Learn more about leading 

edge technologies and techniques in minimally invasive surgery. 

Strengthen your knowledge of surgical anatomy, exposures, and 

more. 

We are deeply indebted to our program authors. Without their 

voluntary contributions of know-how, time, and talent, the 

Multimedia Education Center would not be possible. 

Video and multimedia programs are grouped by area of anatomy: 

Award Programs . ........................... MEC01 - MEC04 

Adult Reconstruction Hip: Primary ............. MEC05 - MEC07 

Adult Reconstruction Hip: Revision ............MEC08 - MEC12 

Adult Reconstruction Knee ...................MEC13 - MEC17 

A dult Reconstruction Knee: Unicompartmental. ..MEC18 - MEC19 

Foot and Ankle .............................MEC20 - MEC22 

Hand and Wrist. ....................................MEC23 

Pediatrics Sports: ACL. .......................MEC24 - MEC25 

Pediatrics: Hip. .............................MEC26 - MEC27 

Elbow. ....................................MEC28 - MEC37 

Shoulder: Reverse Total Shoulder .............. MEC29 - MEC31 

Shoulder ..................................MEC32 - MEC37 

Spine .............................................MEC38 

S ports Medicine/Arthroscopy: Upper Extremity. ..MEC39 - MEC40 

Sports Medicine/Arthroscopy: Knee ............ MEC41 - MEC43 

Trauma. ...................................MEC44 - MEC45 

Tumors & Metabolic Disease . . . . . . . . . . . . . . . . . . MEC46 - MEC53

NAME DISCLOSURE NAME DISCLOSURE 


19 

Why disclosure? 

As an accredited provider of continuing medical education 

(CME) the Academy is required by the Accreditation Council for 

Continuing Medical Education (ACCME) to obtain and share with 

participants of any AAOS CME activity any potential conflicts of 

interest by faculty, program developers, and CME planners. 

The ACCME Standards of Commercial Support, Standard 2 states 

the requirements: 

2.1 The provider must be able to show that everyone who is in 

a position to control the content of an education activity has 

disclosed all relevant financial relationships with any commercial 

interest to the provider. 

2.2 An individual who refuses to disclose relevant financial 

relationships will be disqualified from being a planning committee 

member, a teacher, or an author of CME, and cannot have 

control of, or responsibility for, the development, management, 

presentation or evaluation of the CME activity. 

The AAOS disclosure policy requires that faculty submit all 

financial relationships with industry occurring within the past 12 

months. 

Each participant in the Annual Meeting has been asked to disclose 

if he or she has received something of value from a commercial 

company, which relates directly or indirectly to the subject of their 

presentation. The Academy has identified the options to disclose 

as follows: 

disclosure 

Board of Directors 

John J. Callaghan, MD President: 1 – DePuy, A Johnson & Johnson Company; 

7 – Wolters Kluwer Health - Lippincott, Williams & Wilkins 

Daniel J. Berry, MD 1st Vice President: 1, 5 – DePuy, A Johnson & Johnson Company 

John R. Tongue, MD 2nd Vice President: ........................................n 

Frederick M. Azar, MD Treasurer: 4 – Pfizer; 7 – Saunders/Mosby-Elsevier 

Joseph D. Zuckerman, MD Past President: 1 – Exactech, Inc.; 4 – Neostem; 7 – SLACK 

Incorporated, Thieme, Wolters Kluwer Health – Lippincott, Williams & Wilkins 

Richard J. Barry, MD Chair Board of Councilors: 2 – Zimmer 

David Teuscher, MD Chair-Elect Board of Councilors: .............................n 

Fred C. Redfern, MD Secretary Board of Councilors: ...............................n 

M. Bradford Henley, MD, MBA, FACS Chair BOS: 1 – Zimmer; 2 – Stryker, Zimmer; 

3B – Gerson Lehrman Group, Guidepoint Global, MedACorp, Medical Resource 

Network, Milliman Care Guidelines, Premera Blue Cross, Providence Health & Services, 

Stryker, United Health Care, Zimmer; 3C – DeRoyal, Karen Zupko and Assts., Smith & 

Nephew, Synergy Surgical Technologies, Zimmer; 4 – Synergy Surgical Technologies; 

7 – Wolters Kluwer Health – Lippincott, Williams & Wilkins 

Jeffrey Anglen, MD Chair-Elect BOS: ...........................................n 

Gregory A. Mencio, MD Secretary BOS: 6 – 3M, Covidien/Kendall, Ethicon Medical 

Mission Assistance Program, Schmidt Trust, Stewart Trust, Surgical Resource 

George Zachary Wilhoit, MS, MBA Lay Member: 4 – Amgen Co., Pfizer 

Kevin P. Black, MD Member at Large: ..........................................n 

Michael Lloyd Parks, MD Member at Large: 3B, 5 – Zimmer; 4 – Johnson & Johnson, 

Merck, Pfizer, Procter & Gamble, Zimmer 

Paul Tornetta III, MD Member at Large: 1, 3B – Smith & Nephew; 


Daniel W. White, MD Member at Large: ........................................n 

Karen L. Hackett, FACHE, CAE Ex-Officio: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Council on Education 

Edward Akelman, MD Chair: 1 – Integra; 2, 5 – Auxillium Pharmaceuticals; 

3B – Biomimetic Therapeutics; 4 – Biomimetic Therapeutics, Osteospring Medical; 


Charles N. Cornell, MD Member: 1 – Exactech, Inc.; 7 – Clinical Orthopaedics and 

Related Research 

Daryll C. Dykes, MD Member: 2 – Stryker; 3B – Stryker, Zimmer 

Stuart James Fischer, MD Member: 7 – Jones and Bartlett 

1 – Royalties 

2 – Speakers Bureau/paid presentations 

3a. – Employee 

3b. – Paid consultant 

3c. – Unpaid consultant 

4 – Stock or stock options; or 

5 – Research or institutional support as a principal investigator 

has been received; 

6 – Other financial or material support; 

7 - Royalties, financial or material support from publishers; 

n – No conflicts to disclose 

These codes reflect the numbers used in a series of questions 

answered by all persons participating in the Academy’s overall 

online Disclosure Program, which is available at www.aaos.org/ 

disclosure. 

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; however, these 

data are offered to the audience as additional information that 

may be helpful in evaluating the educational presentations. 

Jeffrey S. Fischgrund, MD Member: 1 – DePuy, A Johnson & Johnson Company; 

3B – Apatech, DePuy, A Johnson & Johnson Company, Relieveant, Smith & Nephew, 

Stryker; 5 – Apatech, Axial Biotech, Smith & Nephew, Stryker; 7 – JAAOS 

Evan L. Flatow, MD Member: 1, 2, 3c – Zimmer; 5 – Wyeth; 7 – Wolters Kluwer Health - 

Lippincott, Williams & Wilkins 

Mark C. Gebhardt, MD Member at Large: 7 – Clinical Orthopaedics and Related Research 

William A. Grana, MD, MPH Member: .........................................n 

Thomas J. Grogan, MD Member: 4 – Excelerate, Pfizer, Zimmer 

Jesse B. Jupiter, MD Member: 3B – OHK; 3C – Eisomed, Synthes; 4 – OHK; 5 – AO 

Foundation; 7 – Elsevier Thieme 

Kenneth J. Koval, MD Member at Large: 1 – Biomet; 2 – Biomet, Sanofi-Aventis, Stryker; 

3B, 5 – Biomet, Stryker; 7 – Wolters Kluwer Health – Lippincott, Williams & Wilkins 

William J. Maloney MD Member at Large: 1 – Wright Medical Technology, Inc., Zimmer; 

3C – ISTO Technologies, Moximed; 4 – Abbott, Gillead, ISTO Technologies, Johnson & 

Johnson, Merck, Moximed, Pfizer; 5 – AO, Biomet, DePuy Spine, DePuy, A Johnson & 

Johnson Company, Nuvasive, Smith & Nephew, Stryker, Zimmer 

Norman Y. Otsuka, MD Member: .............................................n 

Chad T. Price, MD Member: 1, 2, 3B – Biomet; 5 – Wright Medical Technology, Inc. 

Craig S. Roberts, MD Member: 5 – Synthes; 7 – Skeletal Trauma 

Vincent James Sammarco, MD Member: n 

Matthew S. Shapiro, MD Member: 1 – Hely-Weber Company 

David Teuscher, MD Member: ................................................n 

John R. Tongue, MD Member: ................................................n 

Gerald R. Williams, Jr., MD Member: 1 – DePuy, A Johnson & Johnson Company; 

2 – DePuy, A Johnson & Johnson Company, Mitek; 3B, 5 – Tornier; 4 – In 

Vivo Therapeutics; 7 – Journal of Shoulder and Elbow Surgery, Wolters Kluwer 

Health – Lippincott, Williams & Wilkins 

Mark Wieting, MA Staff Liaison: 4 – Abbott, GE Healthcare, Pfizer 

Annual Meeting Committee 

Charles T. Price, MD Chair: 1, 2, 3B – Biomet; 5 – Wright Medical Technology, Inc. 

Annunziato Amendola, MD 2010 Program Committee Chair: 1 – Arthrex, Inc., 

Arthrosurface; 3B – Arthrex, Inc.; 4 – Arthrosurface 

Edward D. Arrington, MD BOC Representative: 6 – Geneva Foundation, Henry M. 

Jackson Foundation for the Advancement of Military Medicine 

The codes after the name are identified as 1 – Royalties; 2 – Speakers Bureau/paid presentations, 3a. – Employee, 3b. – Paid consultant, 3c. – Unpaid consultant, 4 – Stock or stock options; 5 – Research or institutional 

support as a principal investigator has been received; 6 – Other financial or material support;7 - Royalties, financial or material support from publishers; n – No conflicts to disclose. For full information refer to page 19.


Oheneba Boachie-Adjei, MD International Committee Representative and 

BOS Member: 1 – DePuy, A Johnson & Johnson Company, K2 Medical, Inc.; 

2, 3B, 5 – DePuy, A Johnson & Johnson Company, K2 Medical, Inc., Osteotech, Trans1; 

4 – K2 Medical, Inc.; 6 – DePuy, A Johnson & Johnson Company, K2 Medical, Inc., 

Osteotech 

George J. Haidukewych, MD Member at Large: 1 – DePuy, A Johnson & Johnson 

Company; 4 – Orthopediatrics, Surmodics 

Timothy J. Hunt, MD Allied Health Representative: ................................n 

Theodore Miclau, MD ORS Representative: 3B – Amgen Co.; 4 – Johnson & Johnson, 

Merck, Pfizer; 5 – Stryker, Synthes, Zimmer 

Mark W. Pagnano, MD 2012 Instructional Course Committee Chair: 1 – DePuy, A Johnson 

& Johnson Company, MAKO; 5 – Zimmer; 7 – Clinical Orthopaedics and Related 

Research 

William H. Seitz Jr., MD Exhibits Committee Chair: 2 – Stryker, Tornier; 3B – Kapp 

Surgical, SBI, Stryker, Tornier 

Michael J. Stuart, MD 2012 Program Committee Chair: 3B – Arthrex, Inc., Fios; 

5 – Stryker 

Paul Tornetta III, MD 2011 Instructional Course Committee Chair: 1, 3B – Smith & 

Nephew; 7 – Wolters Kluwer Health – Lippincott, Williams & Wilkins 

Adolph J. Yates Jr., MD Member at Large: 3A – GlaxoSmithKline 

James C. Krieg, MD LFP Member: 1 – CMF, SAM Medical, Synthes; 3B – Synthes 

Aaron Omotola, MD Resident at Large: .........................................n 

Susan A. McSorley Staff Liaison: ..............................................n 

Exhibits Committee 

William H. Seitz Jr., MD Chair: 2 – Stryker, Tornier; 3B – Kapp Surgical, SBI, Stryker, 

Tornier 

George Walter Balfour, MD Member: 3B – Upex 

J. David Blaha, MD Member: 1, 3B – Wright Medical Technology, Inc. 

Dennis B. Brooks, MD Member: ..............................................n 

A. Seth Greenwald, DPhil Oxon Member: 3B – DePuy, A Johnson & Johnson Company; 

5 – Acumed, LLC, Amedica, ConforMIS, Encore Medical, Japan Medical Materials, 

Maxx Health, Nuvasive, Ranier, SBI, Synvasive, TJO, Wright Medical Technology, Inc.; 

7 – Seminars in Arthroplasty 

Steven M. Kurtz, PhD Member: 5 – Active Implants, Biomet, Invibio, Medtronic, 

Stelkast, Stryker, Synthes, Ticona, Zimmer 

Pekka A. Mooar, MD Member: 3B – Baxter 

Joseph T. Moskal, MD Member: 1 – DePuy, A Johnson & Johnson Company; 2, 3B, 

3C – DePuy, A Johnson & Johnson Company, Zimmer 

David L. Nelson, MD Member: 1, 3B, 4, 6 – Orthofix, Inc.; 2 – Orthofix, Inc., Synthes 

John R. Tenny, MD Member: .................................................n 

Pat Whitaker Staff Liaison: ...................................................n 

Instructional Course Committee 

Paul Tornetta III, MD 2011 Chair: 1, 3B – Smith & Nephew; 7 – Wolters Kluwer 


Kenneth A. Egol, MD Member: 3C – Exactech, Inc.; 4 – Johnson & Johnson, Surgix 

Inc.; 5 – Biomet, Stryker, Synthes; 7 – SLACK Incorporated, Wolters Kluwer Health - 

Lippincott, Williams & Wilkins 

Robert A. Hart, MD Member: 1 – SeaSpine; 2 – DePuy, A Johnson & Johnson Company, 

Synthes; 3B – DePuy, A Johnson & Johnson Company; 4 – SpineConnect; 5 – DePuy, A 

Johnson & Johnson Company, Medtronic, OREF, Synthes 

Mary I. O’Connor, MD Member: 3B – Zimmer; 3C, 4 – Accelalox, Inc. 

Mark W. Pagnano, MD Member: 1 – DePuy, A Johnson & Johnson Company, MAKO; 

5 – Zimmer; 7 – Clinical Orthopaedics and Related Research 

Dempsey S. Springfield, MD Ex-Officio: 4 – Johnson & Johnson, Merck 

Kathie Niesen Staff Liaison: ..................................................n 

Program Committee 

Annunziato Amendola, MD Chair: 1 – Arthrex, Inc., Arthrosurface; 3B – Arthrex, Inc.; 

4 – Arthrosurface 

Scott D. Boden, MD Member: 1 – Osteotech; 7 – Saunders/Mosby-Elsevier 

Joseph A. Bosco, III MD Member: .............................................n 

Steven L. Frick, MD Member: 5 – Biomet 

Michael J. Stuart, MD Member: 3B – Arthrex, Inc., Fios; 5 – Stryker 

20 

disclosure 

Kathie Niesen Staff Liaison: ..................................................n 

Subcommittees 

Adult Reconstruction Hip Instructional Course Subcommittee 

Jay R. Lieberman, MD Chair: 3B – DePuy, A Johnson & Johnson Company; 5 – Amgen 

Co., Arthrex, Inc. 

Edward M. Adler, MD Member: 3B – Stryker; 4 – Abbott, Procter & Gamble 

Gary Ferguson, MD Member: 1 – DJ Orthopaedics, Encore Medical, 2, 3B, 3 C – Encore 

Medical 

Frank A. B. Gottschalk, MD Member: ..........................................n 

John F. Tilzey, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

William G. Ward, MD Member: 3B – Smith & Nephew, Wright Medical Technology, Inc.; 

5 – Musculoskeletal Transplant Foundation, Wright Medical Technology, Inc. 

Adult Reconstruction Knee Instructional Course Subcommittee 

Brett R. Levine, MD Chair: 2 – Angiotech, Ethicon; 3B – Zimmer; 5 – Biomet, Zimmer 

Douglas A. Dennis, MD Member: 1 – DePuy, A Johnson & Johnson Company, 

Innomed; 2, 3B – DePuy, A Johnson & Johnson Company; 5 – DePuy, A Johnson & 

Johnson Company, Porter Adventist Hospital 

Timothy S. Kavanaugh, MD Member: 4 - Zimmer 

Jay D. Mabrey, MD Member: 1, 2, 3B – Exactech, Inc. 

Amar S. Ranawat, MD Member: 1, 2, 5, 6 – DePuy, A Johnson & Johnson Company, 

Stryker; 3B – DePuy, A Johnson & Johnson Company, MAKO; 3C, 4 – ConforMIS, 

Stryker 

Bryan Donald Springer, MD Member: 2 – DePuy, A Johnson & Johnson Company; 

3B – Stryker Convatec Surgical 

Foot and Ankle Instructional Course Subcommittee 

Mark P. Slovenkai, MD Chair: 2 – Tornier 

Richard J. De Asla, MD Member: 4 – Pfizer 

John E. Femino, MD Member: ................................................n 

Thomas Gregory Harris, MD Member: 1 – Arthrex, Inc.; 2, 3B – Arthrex, Inc., Integra 

Lifescience 

Garnett Andrew Murphy, MD Member: 3C – Wright Medical Technology, Inc.; 

5 – Biomimetic; 7 – Saunders/Mosby-Elsevier 

Gene W. Shaffer, MD Member: ................................................n 

Hand and Wrist Instructional Course Subcommittee 

Marco Rizzo, MD Chair: 3C – Synthes; 5 – Ascension, SBI 

Michael S. Bednar, MD Member: 2 – DePuy, A Johnson & Johnson Company 

Nicholas Benjamin Bruggeman, MD Member: n 

Lewis B. Lane, MD Member: ..................................................n 

Matthew J. Meunier, MD Member: ............................................n 

Steven S. Shin, MD Member: 2 – MicroAire Corporation 

Pediatric Instructional Course Subcommittee 

Anthony A. Stans, MD Chair: ................................................n 

Richard E. Bowen, MD Member: ..............................................n 

Timothy Desmond Brown, MD Member: .......................................n 

J. Eric Gordon, MD Member: 1, 3B – Orthopediatrics 

Daniel J. Hedequist, MD Member: 3B – Medtronic Sofamor Danek 

Kelly L. Vanderhave, MD Member: ............................................n 

Practice Management Instructional Course Subcommittee 

A. Herbert Alexander, MD Chair: .............................................n 

Robert H. Blotter, MD Member: 4 – Alpha Med-Surge, Inc., Pioneer Surgical 

Thomas R. Burgdorff, MD Member: ...........................................n 

Stanley H. Dysart, MD Member: 2 – Ferring Pharmaceuticals, Accelero, 3B – Ferring 

Pharmaceuticals 

Ira H. Kirschenbaum, MD Member: 1 – Innomed; 2, 3B, 4, 5 – Stryker 

Shoulder and Elbow Instructional Course Subcommittee 

William N. Levine, MD Chair: ................................................n 

Carl J. Basamania, MD Member: 1 – DePuy, A Johnson & Johnson Company; 2, 

3B – DePuy, A Johnson & Johnson Company, Sonoma Orthopaedic Products, Inc. 

Edward V. Craig, MD Member: 1, 2, 3B – Biomet; 7 – Wolters Kluwer 


Larry D. Field, MD Member: 3B – Smith & Nephew; 5 – Arthrex, Inc., Mitek, Smith & 

Nephew 




Gordon I. Groh, MD Member: 1 – Encore Medical; 2 – Arthrocare, DePuy, A Johnson & 

Johnson Company, DJ Orthopaedics; 3B – Ascension Orthopaedics, DePuy, A Johnson 

& Johnson Company, DJ Orthopaedics, Upex; 4 – Upex; 5 – Ascension, DePuy, A 

Johnson & Johnson Company; 7 – DJ Orthopaedics 

Wesley M. Nottage, MD Member: 6 – Arthrex, Inc., Conmed Linvatec, Smith and 

Nephew 

Spine Instructional Course Subcommittee 

Robert V. Dawe, MD Chair: 3B – Medtronic; 4 – Spinewave 

Edward Ratcliffe Anderson, III, MD Member: ...................................n 

Jacob M. Buchowski, MD Member: 2, 3B – Stryker 

Joseph H. Perra, MD Member: 1, 2, 3B, 4 – Medtronic; 5 – DePuy, A Johnson & Johnson 

Company 

Paul D. Sponseller, MD Member: 1 – DePuy, A Johnson & Johnson Company, Globus 

Medical; 3B, 5 – DePuy, A Johnson & Johnson Company; 7 – Oakstone Medical 

Mark Weidenbaum, MD Member: 2 – Shona Ika 

Sports Medicine/Arthroscopy Instructional Course Subcommittee 

Samuel D. Young III, MD Chair: ..............................................n 

Jeffrey S. Abrams, MD Member: 1 – Arthrocare, ConMed Linvatec; 2 – Mitek; 

3B – Arthrocare, ConMed Linvatec, Wright Medical Technology, Inc.; 4 – Arthrocare, 

Cayenne Medical, Ingen Medical, KFx Medical; 7 – Springer 

Peter E. Rork, MD Member: ..................................................n 

Richard K. N. Ryu, MD Member: 2 – Mitek; 3B – MedBridge 

Marc Safran, MD Member: 1 – Stryker; 3B – Arthrocare, Cool Systems, Inc.; 

3C – Biomimedica, Cool Systems, Inc., Cradle Medical, Inc., Ferring Pharmaceuticals; 

4 – Biomimedica, Cool Systems, Inc., Cradle Medical, Inc.; 5 – Ferring Pharmaceuticals; 

7 – Saunders/Mosby-Elsevier, Wolters Kluwer Health – Lippincott, Williams & Wilkins 

Felix H. Savoie, III, MD Member: 3B, 5 – Mitek, Smith & Nephew; 

3C, 4 – Cayenne Medical 

Trauma Instructional Course Subcommittee 

Paul J. Dougherty, MD Chair: ................................................n 

Cory Alan Collinge, MD Member: 1 – Advanced Orthopedic Systems, Biomet, Smith & 

Nephew; 3B – Biomet 

Kevin Joseph Pugh, MD Member: 2 – Medtronic, Smith & Nephew, Synthes; 3B, 

5 – Medtronic, Smith & Nephew; 3C – Synthes 

David C. Templeman, MD Member: 1 – Zimmer; 2, 3B – Stryker; 3C – Asut 

Tumor/Metabolic Disease Instructional Course Subcommittee 

Valerae O. Lewis, MD Chair: 5 – Stryker 

Joseph Benevenia, MD Member: 2 – Musculoskeletal Transplant Foundation; 

5 – Biomet, Musculoskeletal Transplant Foundation 

B. Hudson Berrey, MD, FACS Member: .........................................n 

Timothy Rapp, MD Member: 5 – Department of Orthopaedic Surgery Hospital for Joint 

Diseases at NYU Langone Medical Center: AO Spine, Arthrex, Arthritis Foundation–NY 

Chapter, Arthritis National Research Foundation, Asterland, Biomet, DePuy, DJO, 

Encore, Exactech, Ferring Pharmaceuticals, Geisinger, Integra, Johnson & Johnson, KCI, 

Medtronic, NIH, OMEGA, OREF, Orthopaedic Trauma Association, Osteosynthesis and 

Trauma Care Foundation, Paradigm Spine, Progenics, SBI, Smith and Nephew, Stryker, 

Surgix, Synthes 

Adult Reconstruction Hip Program Subcommittee 

Adolph V. Lombardi, Jr., MD Chair: 1 – Biomet, Innomed; 2, 3B, 5 – Biomet 

David Christopher Ayers, MD Member: 5 – Zimmer 

Thomas J. Blumenfeld, MD Member: 1, 2, 3B – DePuy, A Johnson & Johnson Company 

Mathias P. G. Bostrom, MD Member: 3B – Smith & Nephew; 5 – Bone Support, Smith 

& Nephew 

Paul E. DiCesare, MD Member: 3B – Stryker; 5 – GlaxoSmithKline, Stryker 

Brian A. Klatt, MD Member: 7 – SLACK Incorporated 

James Charles Kudrna, MD Member: 1 – DePuy, A Johnson & Johnson Company, 

Innomed; 2 – Convatec, DePuy, A Johnson & Johnson Company; 3B, 4 – DePuy, A 

Johnson & Johnson Company 

Glenn C. Landon, MD Member: 3B – CareFusion, Wright Medical Technology, Inc. 

Gwo-Chin Lee, MD Member: .................................................n 

Scott E. Marwin, MD Member: 1, 2, 3B – Smith & Nephew 

Bassam A. Masri, MD Member: 2 – DePuy, A Johnson & Johnson Company, Zimmer; 

3B – Zimmer 

John B. Meding, MD Member: 1 – Biomet 

J. Wesley Mesko, MD Member: 3B – Stryker; 6 – Biomet 

21 

disclosure 

Douglas E. Padgett, MD Member: 3B, 4 – MAKO 

Wayne G. Paprosky, MD Member: 1 – Wright Medical Technology, Inc., Zimmer; 

2 – Zimmer; 3B – Biomet, Zimmer; 7 – Journal of Arthroplasty 

Jeffrey M. Passick, MD Member: ..............................................n 

Christopher L. Peters, MD Member: 1, 3B, 5, 6 – Biomet 

Juan J. Rodrigo, MD Member: 5 – Arthrocare, Breg, DJ Orthopaedics, Greenville 

Hospital Systems University Medical Center, Medequip, Inc., Ossur, Smith & Nephew 

Edwin P. Su, MD Member: 3B – Smith & Nephew; 5 – Cool Systems, Inc., Smith & 

Nephew 

Dean C. Sukin, MD Member: 2 – Biomet, 4 – Johnson & Johnson 

Marc Evan Umlas, MD Member: ..............................................n 

Michael B. Vessely, MD Member: 4 – Forest Laboratories, Protein Design Laboratories 

Richard E. White, Jr. MD Member: 1 – Zimmer; 3B – Ardent Health Services Lovelace 

Medical Center 

Adult Reconstruction Knee Program Subcommittee 

Giles R. Scuderi, MD Chair: 1, 2, 3B – Salient Surgical, Zimmer; 7 – Springer Elsevier 

Thieme, World Scientific 

James B. Benjamin, MD Member: 2, 3B – DePuy, A Johnson & Johnson Company 

Keith R. Berend, MD Member: 1 – Biomet; 3B – Biomet, Salient Surgical, Synvasive; 

4 – Angiotech; 

5 – Biomet, Salient Surgical 

Hari Bezwada, MD Member: 2 – Genzyme; 3B – Biomet, Zimmer 

Gary Worthington Bradley, MD Member: 1 – Innomed; 3B – Medacta, Wright Medical 

Technology, Inc. 

Fred D. Cushner, MD Member: 1 – Smith & Nephew; 2 – Sanofi-Aventis; 3B, 

4 – Angiotech; 7 – Thieme 

David F. Dalury, MD Member: 1, 2, 3B, 5 – DePuy, A Johnson & Johnson Company 

Kevin L. Garvin, MD Member: 1, 3A – Biomet; 2 – ConvaTec; 7 – Wolters Kluwer 


Jeffrey A. Geller, MD Member: ................................................n 

Terence J. Gioe, MD Member: 4 – Eli Lilly, Johnson & Johnson; 5 – DePuy, A Johnson & 

Johnson Company 

Atul B. Joshi, MD Member: 2 - Genzyme 

E. Michael Keating, MD Member: 1, 5 – Biomet; 2, 3B – Biomet, Johnson & Johnson; 

4 – Johnson & Johnson 

Michael A. Kelly, MD Member: 1 – Zimmer; 3B – Johnson & Johnson, Zimmer; 

4 – Pfizer 

Matthew J. Kraay, MD Member: 5 – National Institutes of Health NIAMS & NICHD, 

Zimmer 

Ormonde M. Mahoney, MD Member: 1, 2, 3B, 5 – Stryker 

Arthur L. Malkani, MD Member: 1, 3B – Stryker; 5 – Synthes, Stryker 

Thomas A. Malvitz, MD Member: 6 – DePuy, A Johnson & Johnson Company 

William M. Mihalko, MD, PhD Member: 1, 2, 3B, 6 – Aesculap/B.Braun; 5 – Aesculap/B. 

Braun, Corin U.S.A., Smith & Nephew, Stryker; 7 – Elsevier Inc. 

David J. Olysav, MD Member: 3C – Zimmer; 4 – Eli Lilly, Zimmer; 5 – Cubist 

Jeffery L. Pierson, MD Member: 3B – Zimmer 

James A. Shaw, MD Member: .................................................n 

Foot and Ankle Program Subcommittee 

Steven L. Haddad, MD Chair: 2 – Stryker; 3B – Wright Medical Technology, Inc.; 3C, 

4 – OrthoHelix Surgical Designs; 5 – Biomimetic 

Donald R. Bohay, MD Member: 1, 5 – MMI; 2, 3B – BESPA; 4 – Biomemetic, Osteotech 

Daniel C. Farber, MD Member: 4 – JMEA, Inc. 

Justin K. Greisberg, MD Member: 7 – Saunders/Mosby-Elsevier 

Stuart D. Miller, MD Member: 1 – Biomet; 2 – IntegraLifesciences; 3B – Biomet, 

IntegraLifesciences; 4 – Arthrocare, IntegraLifesciences, Orthovita, Osiris 

Hand and Wrist Program Subcommittee 

Thomas E. Trumble, MD Chair: 3B – Biomet, MicroAire Surgical Instruments LLC 

George W. Balfour, MD Member: 3B – Upex 

Gordon A. Brody, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Richard T. Herrick, MD Member: ..............................................n 

Joseph E. Imbriglia, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 




Pediatric Program Subcommittee 

Martin Joseph Herman, MD Chair: ...........................................n 

Kerwyn Jones, MD Member: 3C – Orthopediatrics; 7 – Cambridge Publishing 

Donna M. Pacicca, MD Member: ..............................................n 

Peter D. Pizzutillo, MD Member: .............................................n 

Jeffrey R. Sawyer, MD Member: 3B – Synthes; 3C – Medtronic 

Practice Management Program Subcommittee 

John DiPaola, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Ty Henry Goletz, MD Member: ...............................................n 

Patrick J. Horan, MD Member: ................................................n 

Bertrand Paul Kaper, MD Member: 3B – Smith & Nephew 

Thomas A. Malvitz, MD Member: 6 – DePuy, A Johnson & Johnson Company 

Shoulder and Elbow Program Subcommittee 

John William Sperling, MD, MBA Chair: 1 – Biomet, DJ Orthopaedics; 3B – Tornier; 

4 – Emerge Surgical, Tornier 

Theodore A. Blaine, MD Member: 2, 3B – Zimmer 

Raymond M. Carroll, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Lynn A. Crosby, MD Member: 1, 2, 3B, 5 – Exactech, Inc. 

Mark A. Frankle, MD Member: 1, 2, 3B – DJ Orthopaedics; 3C – DePuy, A Johnson & 

Johnson Company; 5, 6 – DJ Orthopaedics, EBI, Eli Lilly, Encore Medical; 7 – SLACK 

Incorporated 

David L. Glaser, MD Member: 4 – GlaxoSmithKline, 5 - Mitek 

G. Russell Huffman, MD Member: ............................................n 

Spero G. Karas, MD Member: 1, 2 3B – DJ Orthopaedics; 5 – Synthes; 6 – Arthrex, Inc., 

ConMed Linvatec, Mitek 

Keith Kenter, MD Member: ...................................................n 

Michael J. Pagnani, MD Member: 4 – Baxter, Norvartis; 6 – STAR Physical Therapy 

Steve A. Petersen, MD Member: 5 – DJ Orthopaedics 

Stephen C. Weber, MD Member: 3C – DePuy, A Johnson & Johnson Company 

Riley Joseph Williams, MD Member: 1 – Arthrex, Inc.; 5 – Smith & Nephew; 

7 – Springer 

Spine Program Subcommittee 

Michael Vives, MD Chair: 2 – Biomet, Musculoskeletal Transplant Foundation; 

3B – Zimmer; 4 – Accelalox 

Charles J. Banta, II, MD Member: 1, 3B - Biomet 

Norman Barrington Chutkan, MD Member: 1, 3C – Globus Medical 

John G. Finkenberg, MD Member: 1, 6 – Biomet; 2, 3, 4 – EBI 

Walter J. Finnegan, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Christian Ivan Fras, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Christopher George Furey, MD Member: .......................................n 

Hubert Lee Gooch, Jr., MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Steven M. Mardjetko, MD Member: 3C – DePuy, A Johnson & Johnson Company, K2M 

Corporation, Medtronic Sofamor Danek; 4 – Axial Biotech, Spinecraft Corporation; 

5 – K2M Corporation 

Thomas A. McNally, MD Member: 2, 3B – DePuy, A Johnson & Johnson Company 

James W. Ogilvie, MD Member: 1 – Medtronic; 2 – DePuy, A Johnson & Johnson 

Company; 4 –Axial Biotech, Nuvasive; 7 – Wolters Kluwer Health – Lippincott, Williams 

& Wilkins; 

Jory Richman, MD Member: ..................................................n 

Paul Saiz, MD Member: 2, 3B, 5 - Zimmer 

Eeric Truumees, MD Member: 1 – Stryker; 4 – Doctor’s Research Group; 7 – North 

American Spine Society 

Sports Medicine/Arthroscopy Program Subcommittee 

Diane Lynn Dahm, MD Chair: ...............................................n 

James C. Dreese, MD Member:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Michael S. George, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Darren L. Johnson, MD Member: 3B – Smith & Nephew; 5 – DJ Orthopaedics 

Morgan H. Jones, MD Member: 5 - Arthrosurface 

22 

disclosure 

Robert F. LaPrade, MD, PhD Member: 1, 3B – Arthrex, Inc.; 5 – Arthrex, Inc., Ossur, 

Smith & Nephew; 7 – Thieme 

Keith W. Lawhorn, MD Member: 1, 3B – Biomet 

Dean K. Matsuda, MD Member: 1 – Arthrocare, Smith & Nephew 

K. Kip Owen, MD Member: ..................................................n 

Kevin D. Plancher, MD Member: ..............................................n 

Jeffrey M. Schwartz, MD Member: 4 – Eli Lilly, Johnson & Johnson, Merck, Procter & 

Gamble 

Daniel Jordan Solomon, MD Member: 2 – Arthrex, Inc., Pacific Medical 

Patrick St Pierre, MD Member: 1 – DJ Orthopaedics; 2, 3B – DJ Orthopaedics, Mitek 

Robin Vereeke West, MD Member: ............................................n 

Ronald W. B. Wyatt, MD Member: .............................................n 

Trauma Program Subcommittee 

Bruce Ziran, MD Chair: 2 – Stryker, Synthes; 3B – Mondeal/Forcetec, Stryker, Synthes, 

Tekartis; 4 – Osteotech, Stryker 

Animesh Agarwal, MD Member: 3B – Acrymed, Medtronic, Smith & Nephew, Synthes 

Peter L. Althausen, MD Member: ..............................................n 

Craig Scott Bartlett, MD Member: 4 – Merck 

David F. Beigler, MD Member: ................................................n 

Jose A. Bossolo, MD Member: ................................................n 

Cory Alan Collinge, MD Member: 1 – Advanced Orthopedic Systems, Biomet, Smith & 

Nephew; 3B – Biomet 

Gregory John Della Rocca, MD Member: 4 – Amedica; 5 – Smith & Nephew, Stryker, 

Synthes, Wound Care Technologies 

Thomas J. Ellis, MD Member: 1 – Acute Innovations; 3B, 5 – Stryker 

Paul Levin, MD Member: ....................................................n 

Robert M. Orfaly, MD Member: 1, 3B – Acumed, LLC; 2 – DePuy, A Johnson & Johnson 

Company, MicroAire Surgical Instruments LLC 

Henry Claude Sagi, MD Member: 2, 3B, 5 – Smith & Nephew, Stryker, Synthes 

Philip R. Wolinsky, MD Member: 3B – Biomet, Zimmer; 5 – Synthes 

Tumor/Metabolic Disease Subcommittee 

R. Lor Randall, MD Chair: ...................................................n 

Joel Mayerson, MD Member: .................................................n 

Bryan Scott Moon, MD Member: ..............................................n 

Shervin V. Oskouei, MD Member: 2 – Wright Medical Technology, Inc., Orthofix, Inc., 

3B – Wright Medical Technology, Inc. 

Jason Scott Weisstein, MD Member: ...........................................n 

Multimedia Education Center Subcommittee Disclosures 

Kevin D. Plancher, MD Chair: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Joseph A. Abboud, MD Member: 2 – DePuy, A Johnson & Johnson Company; 

3B – Ascension Orthopaedics; 7 – Wolters Kluwer Health – Lippincott, Williams & 

Wilkins 

James Michael Bennett, MD Member: 2, 3C – Ascension Orthopaedics 

William Bennett Geissler, MD Member: 1 – Acumed, LLC, Arthrex, Inc.; 2 – Acumed, 

LLC, Arthrex, Inc., Ascension Orthopaedics, Medartis, 3B – Acumed, LLC, Ascension 

Orthopaedics; 4 – Tornier; 7 – Springer 

Michael Lee Granberry, MD Member: 5 – DePuy, A Johnson & Johnson Company 

Tally E. Lassiter Jr, MD Member: ..............................................n 

Peter B. Maurus, MD Member: 2, 3B – Wright Medical Technology, Inc. 

Russell D. Meldrum, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Ronald Anthony Navarro, MD Member: ........................................n 

Robert H. Quinn, MD Consultant 5–OREF, Smith & Nephew, Stryker, Synthes 

Mark T. Scarborough, MD 

Consultant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Mark W. Zawadsky, MD Member: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n 

Reid L. Stanton Staff Liaison: 4 – Abbott, Bristol-Myers Squibb, Eli Lilly, Exact Sciences, 

Hologic, Pfizer, Reservelogix 




23 

disclosure 

FACULTY 

Shahram Aarabi, MD, MPH .................................................n 

Eline Aas, PhD ............................................................n 

Aziz Abbaspour, PhD .......................................................n 

Emam Abdel Fatah .........................................................n 

Ahmed Mohammed Abdel-aal, MD ...........................................n 

Matthew P Abdel, MD ......................................................n 

William A Abdu, MD .......................................................n 

Jesse Abeler, ATC, OTC ......................................................n 

Linda Abella, ONC .........................................................n 

Nicholas S Aberle, II MD ....................................................n 

Nicholas A Abidi, MD 1 – Acumed, LLC, Arthrex, Inc.; 2, 3B – Acumed, LLC, Arthrex, 

Inc., Biomet; 4 – Global Orthopaedic Solutions, LLC 

Celeste Abjornson, PhD ....................................................n 

Albert J Aboulafia, MD 7 – AAOS 

Simon Abram, BA ..........................................................n 

Jeffrey S Abrams, MD 1 – ConMed Linvatec, Arthrocare; 2 – Mitek; 3B – ConMed 

Linvatec, Arthrocare, Wright Medical Technology, Inc.; 4 – Arthrocare, Cayenne Medical, 

KFx Medical, Ingen Medical; 7 – Springer 

Joshua Matthew Abzug, MD .................................................n 

Francesco Acri, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Silvano Adami, MD 2 – GlaxoSmith Kline, Merck, Amgen Co., Eli Lilly; 3B – Amgen 

Co., GlaxoSmithKline; 5 – Merck 

Annette L Adams, PhD ......................................................n 

Brian D Adams, MD 5 – Tornier 

Joanne B Adams, BFA, CMI ..................................................n 

Julie E Adams, MD 3B – Arthrex, Inc., DePuy, A Johnson & Johnson Company, Wright 

Medical Technology, Inc. 

Mary Jo Adams, BSN .......................................................n 

Samuel Bruce Adams, Jr MD .................................................n 

Gregory J Adamson, MD ....................................................n 

Samer Adeeb, PhD .........................................................n 

Anthony Adili, MD .........................................................n 

Bahar Adeli, BA ............................................................n 

Ronald S Adler, MD, PhD 3B – Philips Medical 

Per Y Adolphson, MD 4 – AstraZeneca 

Sean Adwar, BA ............................................................n 

Richard Afable, MD ........................................................n 

Steven Agabegi, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Gabriel Agar, MD 3C – Procon; 4 – APOS Medical & Sports Technologies Ltd. 

Animesh Agarwal, MD 3B – Medtronic, Smith & Nephew, Synthes, Acrymed 

Ajay Aggarwal, MD .........................................................n 

Purnima Aggarwal, MD .....................................................n 

Mehran Aghazadeh, MD ....................................................n 

Gary Aghazarian, BS .......................................................n 

Ismail Agir, MD ............................................................n 

Samuel G Agnew, MD 3B – Zimmer Delphi HealthCare Partners; 3C – Accelero Health 

Care Partners, Select International; 7 – eMedicine 

Uzondu Francis Agochukwu, MD ............................................n 

Meenakshi Agrawal, MD ....................................................n 

Marc A Agulnick, MD 2 – Stryker 

Haluk Agus, MD, Prof ......................................................n 

Torbjorn E Ahl ............................................................n 

Elke R Ahlmann, MD .......................................................n 

Christopher S Ahmad, MD 3B – Acumed, LLC, Arthrex, Inc.; 5 – Stryker; 6 – Zimmer 

Tashfeen Ahmad, MD ......................................................n 

Kasra Ahmadinia, MD ......................................................n 

Issaq Ahmed, MRCS ........................................................n 

Christine Ahn, BA ..........................................................n 

Michael Craig Ain, MD 1 – LANX; 2, 3B, 6 – Stryker 

Yukio Akasaki, MD, PhD ....................................................n 

Michael Akbar, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Behrooz A Akbarnia, MD 1 – DePuy Spine; 2 – Nuvasive, K2M; 3B – Nuvasive, K2M, 

Ellipse, K Spine, DePuy, A Johnson & Johnson Company; 4 – Nuvasive, Ellipse, K Spine, 

Nocimed; 5 – K2M, DePuy Spine, Nuvasive, Ellipse 

Christopher F Ake, PhD .....................................................n 

Koji Akeda, MD, PhD ......................................................n 

Yelena Akelina .............................................................n 

Edward Akelman, MD 1 – Integra; 2, 5 – Auxillium Pharmaceuticals; 3B – BioMimetic 

Therapeutics; 4 – BioMimetic Therapeutics, Osteospring Medical; 7 – Wolters Kluwer 

Health - Lippincott Williams & Wilkins 

Mariam Al-Hamad, BS ......................................................n 

Ghassan Alami, MD ........................................................n 

Marco Alberghini, MD ......................................................n 

Christoph Emanuel Albers, MD ..............................................n 

Todd J Albert, MD 1, 3B – DePuy, A Johnson & Johnson Company; 4 – Bioassets, 

Biomerix, Breakaway Imaging, Crosstree, Gentis, International Orthopaedic Alliance, 

Invuity, Paradigm Spine, PIONEER, Reville Consortium; Vertech; 6 – United Healthcare; 

7 – Saunders/Mosby-Elsevier, Thieme 

Francis G Alberta, MD 2, 3B – Arthrex, Inc. 

Jose Carlos Alcerro, MD ....................................................n 

Kris J Alden, MD ...........................................................n 

Thomas J Aleto, MD ........................................................n 

Peter G Alexander, PhD .....................................................n 

Michael M Alexiades, MD 3B – Biomet 

Daniel Alfonso, MD ........................................................n 

Sheila Marie Algan, MD .....................................................n 

Omid Alizadehkhaiyat, MD .................................................n 

D Gordon Allan, MD 5 – DePuy, A Johnson & Johnson Company, Corin U.S.A. 

Allison Allgier, OTR/L ......................................................n 

Daniel C Allison, MD ......................................................n 

Valeria Allizond ...........................................................n 

Luiz Henrique Almeida, MD .................................................n 

Fredrik Almqvist, MD 3B – Tigenix 

Julian Alonso, MS ..........................................................n 

Hasson Alosh, MD .........................................................n 

Mhd Alsawaf, MD ..........................................................n 

Sattar Alshryda, MD ........................................................n 

Helen Alsop, BSc(Hons) MSCP, SRP ..........................................n 

David W Altchek, MD ......................................................n 

Peter L Althausen, MD ......................................................n 

Carlos M Alvarado, MD .....................................................n 

Abdullatif Alzolibani, MD ...................................................n 

Derek Amanatullah, MD 4 – Stryker, Merck; 5 – Stryker 

Kanzo Amano, MD .........................................................n 

Eyal Amar, MD ............................................................n 

Marcus Vinicius Galvao Amaral, MD ..........................................n 

Terry David Amaral, MD ....................................................n 

Divya Ambati, A ...........................................................n 

Annunziato Amendola, MD 1 – Arthrex, Inc., Arthrosurface; 3B – Arthrex, Inc.; 

4 – Arthrosurface 

Luca Amendola, MD .......................................................n 

Richard Amendola, Post Grad 1 – Arthrex, Inc., Arthrosurface, Inc.; 3B – Arthrex, Inc.; 

4 – Arthrosurface Inc.; 7 – Journal of the American Academy of Orthopaedic Surgeons 

Christopher Ames, MD 1 – Aesculap/B.Braun Lanx; 2, 5 – Medtronic, DePuy, Stryker; 

3B – Medtronic; 4 – Trans1 

S Elizabeth Ames, MD 5 – Stryker 

Osama Ahmed Amin, MD ...................................................n 

Farid Amirouche, MD ......................................................n 

Harlan C Amstutz, MD 1, 5 – Wright Medical Technology, Inc. 

Angel An, MS ..............................................................n 

Ana Garcia De Frutos, MD ..................................................n 

Raymond E Anakwe, MRCS Ed ...............................................n 

Okechukwu A Anakwenze, MD ..............................................n 

Ashish Anand, MD .........................................................n 

Rajan Anand, MBBS ........................................................n 

Aditya Ancha, BA ..........................................................n 

Matthew Anderle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Romney C Andersen, MD ...................................................n 

Allen F Anderson, MD 3B – Orthopediatrics; 7 – American Journal of Sports Medicine 

Andrew E Anderson, PhD ...................................................n 




D Greg Anderson, MD 1, 2 – Medtronic, DePuy, A Johnson & Johnson Company; 

3B – DePuy, A Johnson & Johnson Company, Medtronic, Synthes, Sea spine; 5 – DePuy, 

A Johnson & Johnson Company; 7 – Thieme 

David T Anderson, MD .....................................................n 

Donald D Anderson, PhD ...................................................n 

Edward Ratcliffe Anderson, III MD ...........................................n 

John Anthony Anderson, MD ................................................n 

John G Anderson, MD 4 – Pfizer 

Kyle Anderson, MD 1, 2, 3B – Arthrex, Inc.; 3A – Mitek 

Lucas Anderson, MD .......................................................n 

Mark W Anderson, MD 4 – Pfizer; 7 – Elsevier 

Megan E Anderson, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Paul A Anderson, MD 1 – Pioneer, Stryker; 3B – Aesculap/B.Braun, Expanding 

Orthopedics, Medtronic Sofamor Danek, Spartec, Titan Surgical; 4 – Pioneer Surgical, SI 

Bone, Spartec, Titan, Titan Surgical 

Robert B Anderson, MD 1 – Arthrex, Inc., DJ Orthopaedics, Wright Medical 

Technology, Inc.; 3B, 5 – Wright Medical Technology, Inc.; 7 – Wolters Kluwer Health - 

Lippincott Williams & Wilkins 

Sarah Anderson, MD .......................................................n 

Christopher Andrecovich, BS ................................................n 

Brett M Andres, MD ........................................................n 

J Glynne Andrew, MD ......................................................n 

Christopher Mark Andrews, Mr 2, 3 – JRI Ltd. 

James R Andrews, MD 1 – Biomet Sports Medicine, Biomet; 3A – Biomet Sports 

Medicine, Bauerfiend, Theralase, Mimed, Physiotherapy Associates; 3B – Biomet 

Sports Medicine, Bauerfiend, Theralase, Mimed; 4 – Patient Connection, Connective 

Orthopaedics 

Jack T Andrish, MD ........................................................n 

David Angelillo, MD .......................................................n 

Andrea Angelini, MD .......................................................n 

Richard L Angelo, MD 2, 3B – DePuy, A Johnson & Johnson Company 

Aslam Anis, PhD ...........................................................n 

Aneel Ansari, MBBS ........................................................n 

Dr Pierluigi Antinolfi 2 – Sanofi-Aventis; 6 – Smith & Nephew 

Anne Antonellis, BA ........................................................n 

John Antoniou, MD 2 – DePuy, A Johnson & Johnson Company, Bayer; 3B, 5 – DePuy, 

A Johnson & Johnson Company 

Chie Aoki, MD ............................................................n 

Stephen K Aoki, MD 5 – Biomet 

Tomoki Aoyama, MD, PhD ..................................................n 

Alexios Apazidis, MD .......................................................n 

Luis Alberto Aponte-Tinao, MD ..............................................n 

Paul Appleton, MD 2 – Acumed, LLC 

Sebastian Apprich, MD .....................................................n 

Alessandro Aprato, MD .....................................................n 

Michael T Archdeacon, MD 2 – Smith & Nephew, Stryker, AO North America; 

3B – Stryker, CardioMEMS; 6 – Stryker; 7 – SLACK Incorporated 

Kristin Archer, PhD ........................................................n 

Douglas Archibald, PhD(c) .................................................n 

Jason Archibald, MD .......................................................n 

Robert A Arciero, MD 2, 5 – Arthrex, Inc. 

Nigel Arden, MD ...........................................................n 

Sergio Arellano, MS ........................................................n 

Elizabeth A Arendt, MD 3B – Tornier 

Jean-Noel A Argenson, MD 1, 3B – Zimmer; 5 – Johnson & Johnson, Stryker, Zimmer, 

Adler-Ortho, Symbios, Angiotech, Bayer 

Giuseppe Argento, MD .....................................................n 

Takashi Ariizumi, MD ......................................................n 

Jun Arimizu ...............................................................n 

Ronald Arky, MD ..........................................................n 

Bryan M Armitage, MD .....................................................n 

April D Armstrong, MD .....................................................n 

Douglas G Armstrong, MD ..................................................n 

Sally Arno, MSc ............................................................n 

24 

disclosure 

Steven P Arnoczky, DVM 2 – Musculoskeletal Transplant Foundation, Wright 

Medical Technology, Inc.; 3B – Musculoskeletal Transplant Foundation, Regeneration 

Technologies, Inc., Wright Medical Technology, Inc., Smith & Nephew, Novalign, Active 

Implants, Rotation Medical 

Edward D Arrington, MD 6 – Geneva Foundation, Henry M. Jackson Foundation for 

the Advancement of Military Medicine 

Buchi R B Arumilli, MRCS ..................................................n 

Tsuyoshi Asano, MD .......................................................n 

Yumiko Asanuma, MD, PhD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Rudolf Ascherl, MD ........................................................n 

Murat Asci, MD ............................................................n 

Adedayo O Ashana, BA .....................................................n 

Elizabeth Ashby, MRCS .....................................................n 

Nomaan Ashraf, MD .......................................................n 

Fiona Ashton, MB ChB 3A – Johnson & Johnson 

Mehmet Asik, MD ..........................................................n 

Michael Askew 5 – Medtronic, Stryker, IC Med Tech 

Vipin Asopa, MRCS ........................................................n 

Dimitrios Aspros, MRCS ....................................................n 

Mathieu Assal, MD .........................................................n 

William Aston, FRCS .......................................................n 

Ata Can Atalar, MD .........................................................n 

Alfred Atanda, MD .........................................................n 

Ozgur Ahmet Atay, MD, Prof ................................................n 

Tolga Atay, Asst Prof, MD ...................................................n 

Kivanc Israel Atesok, MD ...................................................n 

NA Athanasou 3B – Smith & Nephew 

George S. Athwal, MD 2 – ConMed Linvatec; 5 – Wright Medical Technologies, 

Arthrosurface, ConMed Linvatec, Tornier, Arthrex 

Farhaan Atlaf, MRCS .......................................................n 

David E Attarian, MD 7 – DataTrace 

Jereme B Atupan, MD ......................................................n 

Joerg Atzwanger, MD .......................................................n 

Keegan Peter Au, MD .......................................................n 

Jean-Manuel Aubaniac, MD .................................................n 

Michelle Aubin, MD ........................................................n 

Joshua D Auerbach, MD 3B – Paradigm Spine, Synthes Spine, Musculoskeletal Clinical 

Regulatory Advisors (MCRA); 5 – Paradigm Spine, Centinel Spine 

Peter Augat, PhD 3B – Amgen Co., Stryker, Eli Lilly; 3C – Arthrex, Inc., Smith & 

Nephew; 5 – Aesculap/B.Braun, Stryker, Servier, Eli Lilly 

Salvador Augustin, MD .....................................................n 

Luke Austin, MD ...........................................................n 

Matthew Austin, MD 3B – Zimmer; 5 – DePuy, A Johnson & Johnson Company 

Thomas W Axelrad, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

David Christopher Ayers, MD 5 – Zimmer 

Miguel Angel Ayerza, MD ...................................................n 

Michael C Aynardi, MD .....................................................n 

Frederick M Azar, MD 4 – Pfizer; 7 – Saunders/Mosby-Elsevier 

Abdul Aziz, BSc ............................................................n 

Bieta Azmoudeh, BS ........................................................n 

Takashi Azuma, MD ........................................................n 

Prof Muharrem Babacan ....................................................n 

George Babis, MD 2 – Bayer; 5 – Bayer, Amgen Co. 

Geneva Baca ..............................................................n 

Bernard R Bach Jr, MD 7 – SLACK Incorporated 

Katrien Backers, PhD .......................................................n 

David Backstein, MD 2, 3B – Stryker, Zimmer 

Sherry I Backus, PT .........................................................n 

Marie Badalamente, PhD 1 – Biospecifics Technologies Corp.; 3B, 5 – Auxilium 

Pharmaceuticals 

Sameer Badarudeen, MD ....................................................n 

Dae Kyung Bae, MD ........................................................n 

Donald S Bae, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Hyun W Bae, MD 1 – Biomet, Stryker, Zimmer, Nuvasive; 2 – Medtronic, Synthes; 

3B – Medtronic, Zimmer, Synthes; 4 – Medtronic, Stryker, Orthovita, Spinal Restoration, 

Difusion; 5 – Stryker, LDR, Johnson & Johnson, Orthovita, Medtronic 




Ki-Cheor Bae, MD ..........................................................n 

Won Bae ..................................................................n 

David G Baer, PhD .........................................................n 

Ramin Bagheri, MD 1 – Nuvasive, Lanx; 2, 3B, 5 – Nuvasive; 4 – Phygen, Embassy 

Spine 

Armita Bahrami, MD .......................................................n 

James R Bailey, MD ........................................................n 

Gregory I Bain, MD 2 – SBI, Zimmer; 3B – AO Foundation 

Glen Olsen Baird, MD ......................................................n 

Sarvottam Bajaj, BE ........................................................n 

Alex Baker, FRCS ...........................................................n 

Mr Charlie Baker 3A, 4 – Smith & Nephew 

Christine P Baker, PT, EdD ..................................................n 

Dale Baker ................................................................n 

Erin Ann Baker, MS ........................................................n 

Joseph Baker, MD ..........................................................n 

Kevin Baker, MS ...........................................................n 

Hatem MA Bakr, MD .......................................................n 

B Sonny Bal, MD 1, 3B – Zimmer; 4 – Amedica 

Eric Balaguer, MD ..........................................................n 

Halil I Balci, MD ...........................................................n 

Todd H Baldini 6 – Synthes, Stryker 

Christine Baldus, MD ......................................................n 

Keith D Baldwin, MD 4 – Pfizer 

George Walter Balfour, MD 3B – Upex 

Chris Balinger, MD 4 – Pfizer 

Scott T Ball, MD 3C – DePuy, A Johnson & Johnson Company 

Jorge Ballester .............................................................n 

H Brent Bamberger, DO 1, 4 – Upex 

Giuliana Banche ...........................................................n 

Lorenzo Banci, MD 5 – Johnson & Johnson Medical Ltd. 

Philip Band, PhD 2 – Smith & Nephew; 3B – Smith & Nephew Baxter Healthcare 

Becton Dickinson; 3C – Avanca Medical Devices 

Stefano Bandiera, MD ......................................................n 

Shunichi Bandoh, PhD .....................................................n 

Rahul Banerjee, MD, FACS 5 – Synthes, Smith & Nephew, Medtronic, Stryker; 

7 – Elsevier 

Yannic Bangert, MD ........................................................n 

Trevor Banka, MD .........................................................n 

Charles J Banta II, MD 1, 3B – Biomet 

Yaron Bar Ziv, MD .........................................................n 

Mark E Baratz, MD 1, 2, 5 – Integra Life Sciences; 3B – Elizur; 4 – Upex; 7 – SLACK 

Incorporated 

Michael Baratz, MD ........................................................n 

David Barei, MD, FRCS(C) 2, 5 – Zimmer, Synthes; 3B – Synthes 

William R Barfield, PhD ....................................................n 

Alexej Barg, MD ...........................................................n 

Brian Barlow, MD ..........................................................n 

Ian W Barlow, FRCS ........................................................n 

Jonathan D Barlow, MD ....................................................n 

C Lowry Barnes, MD 1, 3C – Wright Medical Technology, Inc.; 5 – Johnson & Johnson, 

Stryker, Wright Medical Technology, Inc., ConforMIS 

Clint D Barnett, MD ........................................................n 

Steven L Barnett, MD 2, 3B – DePuy, A Johnson & Johnson Company; 5 – DePuy, A 

Johnson & Johnson Company, Stryker 

Jonathan C Barnwell, MD ...................................................n 

Joseph S Barr Jr, MD .......................................................n 

Robert L Barrack, MD 1 – Smith & Nephew; 5 – Biomet, Biospace Med, Medical 

Compression Systems, National Institutes of Health (NIAMS & NICHD), Smith & 

Nephew, Wright Medical Technology, Inc.; 7 – Wolters Kluwer Health - Lippincott 

Williams & Wilkins 

William P Barrett, MD 1, 2, 3B, 5 – DePuy, A Johnson & Johnson Company 

John W Barrington, MD 3B, 5 – Biomet 

Thomas Barrington, DDS ...................................................n 

25 

disclosure 

Wael K Barsoum, MD 1 – Exactech, Inc., Wright Medical Technology, Inc., Shukla 

Medical; 2 – Stryker; 3B – Stryker, Wright Medical Technology, Inc., Shukla Medical; 

4 – Otismed; 5 – Stryker, Zimmer, TissueLink, Orthovita, Cool Systems, Brand X 

Robert Boyd Bartelt, MD ....................................................n 

Craig Scott Bartlett, MD 4 – Merck 

Gavin Bartlett, MBBS .......................................................n 

Carrie Bartley, MA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Stephen Bartol, MD 3C – Musculoskeletal Transplant Foundation, Innovative Surgical 

Solutions, LLC; 4 – Innovative Surgical Solutions, LLC 

Yair Barzilay, MD 3C – MAZOR Surgical Technologies 

Carl J Basamania, MD 1 – DePuy, A Johnson & Johnson Company; 2, 3B – DePuy, A 

Johnson & Johnson Company, Sonoma Orthopedic Products, Inc. 

Luca Basiglini, MD .........................................................n 

Aroon Baskaradas, MRCS ...................................................n 

Harpreet Singh Basran, MD .................................................n 

Johannes Dominik Bastian, MD .............................................n 

Tracey Bastrom, MA ........................................................n 

Vineet Batta, MD ..........................................................n 

Milva Battaglia, MD ........................................................n 

Nicholas Battaglia, BS ......................................................n 

Andrea S Bauer, MD ........................................................n 

Jennifer M Bauer ...........................................................n 

Thomas W Bauer, MD, PhD 3B – Alphatec Spine, Biomet, Osteotech, Smith & Nephew, 

Stryker; 4 – Alphatec Spine; 5 – DePuy, A Johnson & Johnson Company 

Sebastian F Baumbach, MD .................................................n 

Judith F Baumhauer, MD, MPH 3B – DJ Orthopaedics, Carticept, Extremity Medical; 

3C – BioMimetic; 5 – DJO 

Eric D Bava, MD ...........................................................n 

Metin Lutfi Baydar, MD .....................................................n 

Barbaros Yakup Baykal, MD, Assoc Prof .......................................n 

Keith E Baynes, MD ........................................................n 

Alp Bayramoglu, MD, Assoc Prof .............................................n 

William R Beach, MD 5 – Arthrex, Inc., Smith & Nephew, Bon Secours Health Systems, 

Synthes 

Doug Beall, MD 2 3B, 4, 5 – Lilly, Amendia, Medtronic 

Timothy C Beals, MD .......................................................n 

Brandon S Beamer, MD 3A – Medtronic Sofamor Danek 

Thomas F Bear, MD 5 – Zimmer, Astro Met, IC-MedTech 

David J Beard, DPhil 3B – Biomet, Stryker; 5 – Wright Medical Technology, Inc., 

Stryker, Genzyme, Biomet 

Dorcas Beaton, OT .........................................................n 

Cammie Beattie, PT ........................................................n 

James H Beaty, MD 6 – Orthopaediatrics; 7 – Wolters Kluwer Health - Lippincott 

Williams & Wilkins, Saunders/Mosby-Elsevier 

Christopher Paul Beauchamp, MD 3B – DePuy, A Johnson & Johnson Company; 

7 – Saunders/Mosby-Elsevier 

Paul E Beaule, MD 1, 4 – Wright Medical Technology, Inc.; 2 – Wright Medical 

Technology, Inc., Smith-Nephew; 3B – Corin U.S.A., Smith & Nephew, Wright Medical 

Technology, Inc.; 5 – Corin U.S.A.; 7 – Journal of Bone and Joint Surgery - American 

Eric Beaumont, PhD .......................................................n 

Pierre H Beaumont, MD ....................................................n 

Lauren Beaupre, PhD .......................................................n 

Edward H Becker, III MD ...................................................n 

Jeremy Beckworth, MD .....................................................n 

Hany Bedair, MD ..........................................................n 

Asheesh Bedi, MD 2 – Mitek, Smith & Nephew; 3B – Smith & Nephew 

Michael J Beebe, MD .......................................................n 

Farhana Begum, BscEng ....................................................n 

Steve Brian Behrens, MD ....................................................n 

Bob Beitcher ..............................................................n 

Jacques Bejui-Hugues, MD 1, 6 – Amplitude 

Jeff Belkora ...............................................................n 

John-Erik Bell, MD .........................................................n 

Kimberly Bell, BA ..........................................................n 

Rebecca Bell, BS ...........................................................n 

Simon Bell, MD 3C – Mathys Ltd. 




Carlo Bellabarba, MD 2 – Synthes; 5 – Stryker, Synthes 

Enrico Bellato, MD .........................................................n 

Johan Bellemans, MD 1 – Smith & Nephew; 2, 3B – Smith & Nephew Mobilife 

Boehringer Ingelheim; 4 – Pfizer, Tigenix, Praxim, Stryker; 5 – Zimmer, Sanofi, 

Aventis, Biomet, DePuy Johnson and Johnson, Regentis, Synthes, Smith and Nephew, 

Boehringer Ingelheim, Heraeus, TOB, Orteq, Serica; 6 – Praxim Brainlab; 7 – Acco 

Springer Verlag 

Philip J Belmont, Jr MD ....................................................n 

Mohan Belthur, MD ........................................................n 

Michael John Beltran, MD ..................................................n 

Etienne Belzile, MD 2 – Bayer Inc., DePuy, A Johnson & Johnson Company; 

5 – Arthrex, Inc., Bristol-Myers Squibb, Canadian Institutes of Health Research (CIHR), 

Medtronic Sofamor Danek, Stryker 

Oren Ben Lulu, MD ........................................................n 

Peleg Ben-Galim 5 – Medtronic, DePuy, Smith & Nephew, Persys Medical 

Edward T Bender, PhD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

John A Bendo, MD .........................................................n 

Shaike Benedict, MD .......................................................n 

Joseph Benevenia, MD 2 – Musculoskeletal Transplant Foundation; 5 – Biomet, 

Musculoskeletal Transplant Foundation 

Stephen K Benirschke, MD 3C – Synthes, Zimmer 

James B Benjamin, MD 2, 3B – DePuy, A Johnson & Johnson Company 

Michael T Benke, MD .......................................................n 

Rodney W Benner, MD .....................................................n 

Phillip W Bennion, MD .....................................................n 

George Bentley, CHM FRCS 7 – Journal of Arthroplasty 

Max Robert Berdichevsky, MD ...............................................n 

Pedro K Beredjiklian, MD 4 – Tornier 

Keith R Berend, MD 1 – Biomet; 3B – Biomet, Salient Surgical, Synvasive; 

4 – Angiotech; 5 – Biomet; Salient 

Michael E Berend, MD 1, 2 – Biomet; 3B – Angiotech; 5 – Biomet; ERMI 

Richard A Berger, MD 1 – Zimmer; 3B – Salient Surgical, Smith & Nephew 

Patrick F Bergin, MD .......................................................n 

Neil R Bergman, MD 3B – Stryker 

Alexandros Beris, MD ......................................................n 

Eric N Berkowitz, PhD ......................................................n 

Mark J Berkowitz, MD ......................................................n 

Scott D Berkowitz, MD 3A – Bayer HealthCare Pharmaceuticals 

Gregory Charles Berlet, MD 1 – Bledsoe Brace, Wright Medical Technology, Inc.; 

2, 3B – Wright Medical Technology, Inc.; 4 – Bledsoe Technologies, Wright Medical 

Technology, Inc.; 5 – DJ Orthopaedics; 7 – Foot and Ankle Specialist (SAGE) 

Orjan K Berlin, MD ........................................................n 

Matthew S Bernard, MD ....................................................n 

Thomas L Bernasek, MD 1, 3B – DePuy, A Johnson & Johnson Company 

Nicholas Bernat, BA ........................................................n 

Andrew S Bernhardson, MD .................................................n 

Joseph Bernstein, MD 7 – Clinical Orthopaedics and Related Research 

Nicholas Bernthal, MD .....................................................n 

Daniel J Berry, MD 1, 5 – DePuy, A Johnson & Johnson Company 

John C Berschback, MD ....................................................n 

Jack M Bert, MD 2 – Genzyme, Regen Biologics; 3B – Genzyme; 5 – Exactech, Inc., 

Genzyme, Wright Medical Technology, Inc. 

Alexander Bertelsen, PA .....................................................n 

Nicky Bertollo, PhD ........................................................n 

J Bertumen, BS ............................................................n 

Sigurd H Berven, MD 2, 3B – Medtronic Sofamor Danek, Alphatec Spine, Biomet, 

DePuy, A Johnson & Johnson Company; 4 – Baxano, Simpirica, Providence Medical, 

Axis, AccuLif; 5 – OREF, AO Foundation, Medtronic Sofamor Danek 

James L Beskin, MD ........................................................n 

Javier Besomi, MD .........................................................n 

Thomas M Best, MD, PhD, FACSM ...........................................n 

Alex Betech, MD ...........................................................n 

Graziano Bettelli, MD ......................................................n 

Brad W Betz, MD 3C – GE Healthcare 

26 

disclosure 

Randal R Betz, MD 1 – DePuy, A Johnson & Johnson Company, Medtronic, Osteotech, 

Synthes; 2 – DePuy, A Johnson & Johnson Company, Osteotech; 3B – DePuy, A 

Johnson & Johnson Company, Medtronic, Osteotech, Synthes, Orthocon, SpineGuard, 

Orthovita, SpineMedica; 3C – Orthobond; 4 – SpineGuard, SpineMedica, Orthocon; 

5 – DePuy, A Johnson & Johnson Company, Synthes; 7 Thieme 

Catherine Bevan, MD .......................................................n 

Michael Bey, PhD 5 – DJ Orthopaedics 

Sarah Beykirch ............................................................n 

Shaul Beyth, MD ...........................................................n 

Hari Bezwada, MD 2 – Genzyme; 3B – Biomet, Zimmer 

Arup K Bhadra, MD ........................................................n 

Mohit Bhandari, MD 3B – Amgen Co., Eli Lilly, Pfizer, Stryker, Smith & Nephew 

Tarun Bhargava, MD .......................................................n 

Suneel B Bhat, MPhil .......................................................n 

Nitin N Bhatia, MD 1, 5 – Alphatec Spine, Sea spine; 2, 3B – Biomet, Alphatec Spine, 

Sea spine; 4 – DiFusion 

Sanjeev Bhatia, MD ........................................................n 

Timothy Bhattacharyya, MD 3B – Best Doctors, AllMed 

Leela C Biant, FRSCEd 5 – JRI (Joint Replacement Instrumentation) 

Orhan Bican, MD ..........................................................n 

Ali Bicimoglu, MD .........................................................n 

Jacob Bickels, MD 3B – Synthes 

Alison M Biercevicz, BS 6 – RIH Orthopaedic Foundation, Inc. 

Louis U Bigliani, MD 1 – Zimmer 

Simone Bignozzi 3A, 6 – I + S.r.l. 

Fikri Erkal Bilen, MD .......................................................n 

Fabrizio Billi, PhD 3B – Biomet; 5 – Biomet, DePuy, A Johnson & Johnson Company, 

Medtronic Sofamor Danek, National Institutes of Health (NIAMS & NICHD), Stryker, 

Wright Medical Technology, Inc. 

Victor Joseph Bilotta, MD 3A – Aesculap/B.Braun 

Randipsingh R Bindra, MD 1 – Tornier; 2 – AM Surgical, Integra NeuroSciences; 

3B – Acumed, LLC, Anspach, Integra LifeSciences, Tornier 

Francois Binette, Dr 3A – Medtronic; 4 – Medtronic, Johnson & Johnson 

Stefano Alec Bini, MD ......................................................n 

Odion Binitie, MD .........................................................n 

Cynthia A Bir ..............................................................n 

Ann Birch, MD ............................................................n 

John G Birch, MD 1 – Orthofix, Inc.; 7 – Mosby-Elsevier 

Sherri B Birchansky, MD ....................................................n 

Ali Birjandinejad, Prof 5 – Synthes 

Patrick Birmingham, MD ...................................................n 

Allen T Bishop, MD ........................................................n 

Michael J Bishop 4 – Eli Lilly, GlaxoSmithKline, Pfizer, Merck 

Pepijn Bisseling, MD .......................................................n 

Alessandro Bistolfi .........................................................n 

Rudi Bitsch, MD 2 – DePuy, A Johnson & Johnson Company; 5 – Biomet, DePuy, A 

Johnson & Johnson Company, Smith & Nephew, Wright Medical Technology, Inc., 

Zimmer 

Dennis Black 2 – Amgen Co.; 5 – Novartis, Roche, Merck 

James Clinton Black, MD ...................................................n 

Kevin P Black, MD .........................................................n 

Lorne H Blackbourne, MD ..................................................n 

J David Blaha, MD 1, 3B – Wright Medical Technology, Inc. 

Theodore A Blaine, MD 2, 3B – Zimmer 

James Alan Blair, MD .......................................................n 

Jamie L Blair, BS ...........................................................n 

Kim Blake, CTC ............................................................n 

Laurel C Blakemore, MD 2, 3B, 5 – K2M 

Ryan Blalock, BS ...........................................................n 

Char Blanchard ............................................................n 

Agustin Blanco Pozo, MD ...................................................n 

John S Blanco, MD .........................................................n 

Donna G Blankenbaker, MD ................................................n 

Theodore Blatt, MD ........................................................n 

John J Block, MD ..........................................................n 

Davide Blonna, MD ........................................................n 




Robert H Blotter, MD 4 – Pioneer Surgical, Alpha Med-Surge, Inc. 

Yossef C Blum, MD ........................................................n 

Eric Michael Bluman, MD 3B – Arthrex, Inc., DePuy, A Johnson & Johnson Company, 

Joint Restoration Foundation; 6 – EMS/Swiss Dolorclast 

Todd Blumberg, BS ........................................................n 

Thomas J Blumenfeld, MD 1, 2, 3B – DePuy, A Johnson & Johnson Company 

Oheneba Boachie-Adjei, MD 1 – DePuy, A Johnson & Johnson Company, K2 Medical, 

Inc.; 2, 3B, 5 – k2 Medical, Inc., DePuy, A Johnson & Johnson Company, Osteotech, 

Trans1; 4 – K2 Medical, Inc.; 6 – k2 Medical, Inc., DePuy, A Johnson & Johnson 

Company, Osteotech 

David Laurence Boardman, MD ..............................................n 

J Dennis Bobyn, PhD .......................................................n 

Chandra Sekhar Bodanki, MS ...............................................n 

Henrik Boden, MD, PhD ....................................................n 

Scott D Boden, MD 1 – Osteotech; 7 – Saunders/Mosby-Elsevier 

Teresa Bodette, BA .........................................................n 

Nathan Daniel Bodin, MD 3A, 4 – AstraZeneca Pharmaceuticals, LLP 

R Paul Boesch, MD .........................................................n 

Christoph Boese, MD .......................................................n 

Friedrich Boettner, MD 3C, 5 – Smith & Nephew; 4 – Smith & Nephew, Zimmer, 


Michele Boffano ...........................................................n 

Ghassan Boghosian, DO ....................................................n 

Donald R Bohay, MD 1 – MMI; 2, 3B – Stryker, MMI, Osteotech; 4 – Osteotech, 

BioMimetic; 5 – MMI 

Henry H Bohlman, MD .....................................................n 

Eric R Bohm, MD 2 – DePuy, A Johnson & Johnson Company; 3B – Smith & Nephew 

Walther Hartmuth Bohne, MD ...............................................n 

Pascal Boileau, MD 1 – Tornier; 3B – Smith & Nephew 

Alicja Bojan, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

William Seth Bolling, MD ...................................................n 

Michael P Bolognesi, MD 2 – Zimmer; 3B – Zimmer, Biomet, Total Joint Orthopedic; 

3C – Amedica; 4 – Amedica, Total Joint Orthopedic; 5 – DePuy, A Johnson & Johnson 

Company, Zimmer, Wright Medical Technology, Inc. 

Tommaso Bonanzinga, MD .................................................n 

Fiona Bonar, MBBS ........................................................n 

Davide E Bonasia, MD ......................................................n 

Jeffrey R Bond, MD ........................................................n 

Jennifer Bondy, BSc ........................................................n 

Daniel Lluch Bonete, MD ...................................................n 

Nicolas Bonnevialle, MD ....................................................n 

Michel Bonnin, MD 1 – Tornier, Zimmer; 7 – Springer 

Christopher M Bono, MD 6 – Barricaid; 7 – Informa, Wolters Kluwer Health - 


James V Bono, MD 3B – Stryker; 7 – Springer 

Peter M Bonutti, MD 1 – Arthrocare, Stryker, Synthes, Biomet, Joint Active Systems, Inc.; 

2, 3B – Stryker; 4 – Joint Active Systems, Inc. 

Hikel Alfred Boohaker ......................................................n 

David Warner Boone, MD 4 – Pfizer 

Harm-Willem Boons, MD ...................................................n 

Robert E Booth, Jr MD 2, 3A – Zimmer 

Barbara Bordini, MD .......................................................n 

Olivier Borens, MD ........................................................n 

Luca Boriani, MD ..........................................................n 

Stefano Boriani, MD .......................................................n 

Lindsey Bornstein ..........................................................n 

Joseph Borrelli, Jr MD 3B – Wright Medical Technology, Inc. 

Michael J Borroff 3A – DePuy, A Johnson & Johnson Company; 4 – Johnson & Johnson 

Mrs Ellis Bos ..............................................................n 

Joseph A Bosco, III MD .....................................................n 

Santiago Bosio, MD ........................................................n 

Frederiek Bosscher, MD .....................................................n 

Michael J Bosse, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Bora Bostan, MD ..........................................................n 

Mathias P G Bostrom, MD 3B – Smith & Nephew; 5 – Smith & Nephew, Bone Support 

Sergiu O Botolin, MD ......................................................n 

27 

disclosure 

Itamar Botser ..............................................................n 

Michael J Botte, MD ........................................................n 

Michael Bottlang, PhD 1, 2 – Synthes; Zimmer 

Nicholas J Bottomley, MRCS .................................................n 

Martin Boublik, MD 4 – Arthrocare, Cayenne Medical 

Martin Bouliane 6 – Synthes 

Christina B Boulton, MD 6 – Synthes Resident Program 

Gerard Martin Bourke, FRACS 1 – Arthrex, Inc.; 5 – Endotech 

Robert Barry Bourne, MD 1 – Genesis II/Legion TKRs R3 Acetabular Cup, Smith & 

Nephew; 3B – Genesis II/Legion TKRs R3 Acetabular Socket; 5 – Stryker, DePuy 

Thomas R Bowen, MD ......................................................n 

Lyndsay N Bowers, BS, MS ..................................................n 

Russell Bowman, MSc 6 – Stryker 

Robert Bowser, PhD 3B, 4 – Cytonics Corporation 

John Bowsher, PhD ........................................................n 

Barbara D Boyan, PhD 2 – TitanSpine, Inc.; 3B – Exactech, Inc., Musculoskeletal 

Transplant Foundation, National Institutes of Health (NIAMS & NICHD); 3C – Institut 

Straumann AG; 4 – MedShape Solutions, Arthrocare, Carticept Medical, Inc.; 

5 – Musculoskeletal Transplant Foundation 

Louise Reid Boyce Nichols, MD ..............................................n 

Martin I Boyer, MD 1 – OrthoHelix; 4 – Mimed, OrthoHelix; 7 – American Society for 

Surgery of the Hand 

David Boyle, MS 5 – Pfizer, Genentech 

David J Bozentka, MD 2 – Medartis 

Kevin John Bozic, MD, MBA .................................................n 

Laura Bozzuto, AB .........................................................n 

Pierangiola Bracco .........................................................n 

Elena Brach Del Prever, Prof .................................................n 

Gary Worthington Bradley, MD 1 – Innomed; 3B – Wright Medical Technology, Inc., 

Medacta 

James P Bradley, MD 1, 5 – Arthrex, Inc. 

Neil Bradley, FRCS .........................................................n 

Charles R Bragdon, PhD 1 – Zimmer 

Michael E Brage, MD .......................................................n 

Brett Braly, MD ............................................................n 

Jefferson C Brand Jr, MD ....................................................n 

Richard A Brand, MD 7 – Association of Bone and Joint Surgeons (Owners of Clinical 

Orthopaedics and Related Research) 

Bruno Lobo Brandao, MD ..................................................n 

Rickard Branemark 3A, 4 – Integrum 

Richard Jackson Bransford, MD 2, 5 – Synthes 

Nicholas Brassart ..........................................................n 

Adam Brekke ..............................................................n 

Ivan Brenkel, FRCS 2 – Bayer; 4 – Bayer, GlaxoSmithKline 

Kindyle L Brennan, PhD ....................................................n 

Michael L Brennan, MD ....................................................n 

Mark Brezinski, MD, PhD ...................................................n 

Hans-Peter Brickwede, MD ..................................................n 

Keith H Bridwell, MD 3B – DePuy, A Johnson & Johnson Company, Medtronic, Stryker; 

7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Karen K Briggs, MPH 5 – Ossur, Smith & Nephew, Arthrex, Inc., Siemens 

Lisa Briggs, Sonographer ....................................................n 

Tim Briggs, FRCS 5 – Biomet 

Ole Brink, MD, PhD, MPA ..................................................n 

Martin Brix, CM ...........................................................n 

Darrel S Brodke, MD 1 – DePuy, Amedica; 3B – Medtronic, DePuy; 4 – Amedica, 

Pioneer, Vertiflex 

James White Brodsky, MD 5 – Synthes, Small Bone Innovations 

Gordon A Brody, MD .......................................................n 

Henry M. Broekhuyse, MD 5–Stryker, Synthes 

Amanda E Brooks, PhD .....................................................n 

Peter J Brooks, MD 3B – Stryker, Smith & Nephew 

Robert H Brophy, MD 3B – DePuy, A Johnson & Johnson Company 

Justin Brothers, MD ........................................................n 

Kim M Brouwer, MSC ......................................................n 

Haydee C. Brown, MD ......................................................n 




Kate Brown ...............................................................n 

Kate V Brown, BM BCh .....................................................n 

Matthew L Brown ..........................................................n 

Nicholas M Brown, BS ......................................................n 

Richard A Brown, MD 2 – Auxilium; 4 – Merck, Pfizer 

Thomas D Brown, PH D 3B – Smith & Nephew; 7 – Journal of Bone and Joint 

Surgery - American 

James Andrew Browne, MD .................................................n 

Martin Browne, PhD 3A, 3B – Finsbury Development 

Richard H Browne, PhD ....................................................n 

Bruce D Browner, MD ......................................................n 

William Timothy Brox, MD .................................................n 

Thomas Bruckner, Dipl.Math. ...............................................n 

Robert J Brumback, MD 3B – Biomet, Zimmer 

Danilo Bruni, MD .........................................................n 

Samuel Brunner, MD .......................................................n 

Lance Michael Brunton, MD .................................................n 

Matteo Bruzzone, MD ......................................................n 

Deniz Bucak, BS ...........................................................n 

Christina Bucci-Rechtweg, MD 3A, 4 – Novartis 

Barbara Buch, MD .........................................................n 

Jacob M Buchowski, MD 2, 3B – Stryker 

Jenni M Buckley, PhD 5 – Acumed, LLC, Arthrex, Inc., Biomet, Brainlab, DePuy, A 

Johnson & Johnson Company, MAZOR Surgical Technologies, Medtronic, Nuvasive, 

OREF, Philips, Sawbones/Pacific Research Laboratories, SBI, Smith & Nephew, Stryker, 

Synthes, Ulrich Medical 

Richard E Buckley, MD .....................................................n 

Joseph A Buckwalter, MD 3B – ISTO and Carbylan Bioscience; 7 – Journal of 

Orthopaedic Research 

Roberto Buda .............................................................n 

Rogerio Serpone Bueno, MD ................................................n 

William Bugbee, MD 1 – DePuy, A Johnson & Johnson Company, Zimmer, Smith & 

Nephew; 3B – DePuy, A Johnson & Johnson Company, Smith & Nephew, Zimmer, Joint 

Restoration Foundation, Moximed, Advanced BioHealing; 4 – Moximed, OrthAlign; 

5 – NIH, Joint Restoration Foundation, OrthAlign, Alter-G 

Susan V Bukata, MD 2 – Amgen Co., Eli Lilly, Novartis; 3B – Amgen Co., Eli Lilly 

Peter G Bullough, MD ......................................................n 

Robert L Buly, MD 4 – Pivot Medical 

Janice Y Bunn, PhD ........................................................n 

Shane Burch, MD 2, 3B – Medtronic; 3C – Eli Lilly; 5 – Eli Lilly, Nuvasive 

Christoph Burger, MD ......................................................n 

Evalina L Burger, MD 2 – Stryker 

Travis Burgers, PhD ........................................................n 

Mary F Burke, MPH ........................................................n 

Stephen S Burkhart, MD 1, 3B, 5 – Arthrex, Inc.; 7 – Wolters Kluwer Health - Lippincott 


Wayne Z Burkhead Jr, MD 1, 2, 4 – Tornier; 3B – Tornier, Wright Medical Technology, 

Inc.; 5 – Wright Medical Technology, Inc. 

Colin Burnell, MD 2 – DePuy, A Johnson & Johnson Company; 3B – DePuy, A Johnson 

& Johnson Company, Smith & Nephew; 5 – DePuy, A Johnson & Johnson Company, 

Smith & Nephew, Stryker, Zimmer 

Travis C Burns, MD ........................................................n 

Brandon Burris, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Douglas C Burton, MD 3A – Pfizer; 3B, 5 – DePuy, A Johnson & Johnson Company 

Lucas J Burton, MD ........................................................n 

Matthew L Busam, MD .....................................................n 

Michael T Busch, MD .......................................................n 

Tiziana Buscio, MD ........................................................n 

Daniel D Buss, MD 3B – Wright Medical Technology, Inc.; 4 – Disc Dynamics; 

6 – Minnesota Twins 

Dale R Butler, MD 4 – Stryker 

Ian R Byram, MD 3A, 4 – Eli Lilly 

J W Thomas Byrd, MD 3B – Smith & Nephew, A2 Surgical; 4 – A2 Surgical; 5 – Smith 

& Nephew 

Daniel Byrne, PhD .........................................................n 

Young Soo Byun, MD .......................................................n 

28 

disclosure 

David N Caborn, MD 1 – Arthrex, Inc.; 2 – Genzyme, Zimmer, Joint Restoration 

Foundation; 3B – ConMed Linvatec, Zimmer, Smith & Nephew, Regen, Joint Restoration 

Foundation; 4 – IBalance Medical, Zimmer; 6 – Smith & Nephew 

Enrique Caceres, Prof 1 – Surgival; 2 – Medtronic; 3B – DePuy, A Johnson & Johnson 

Company 

Patrick John Cahill, MD 3B – DePuy, A Johnson & Johnson Company, Osteotech, 

Synthes; 5 – DePuy, A Johnson & Johnson Company 

Michelle S Caird, MD .......................................................n 

Gokhan Cakmak, Asst. Prof. .................................................n 

Teresa Calabro, MD ........................................................n 

Lucia Calbucci, MD ........................................................n 

James Calder, MD 2, 3B – Smith & Nephew; 5 – DePuy, A Johnson & Johnson 

Company, DJ Orthopaedics 

Joseph M Caldwell, II MD ...................................................n 

Ryan Patrick Calfee, MD 5 – Medartis 

Jason H Calhoun, MD 5 – Biocomposites 

John Callaci, PhD ..........................................................n 

John J Callaghan, MD 1 – DePuy, A Johnson & Johnson Company; 7 – Wolters Kluwer 


Barbara Callewaert .........................................................n 

Briana Calore, MD .........................................................n 

Javier Camacho-Galindo, MD ................................................n 

Frank P Cammisa Jr, MD 1 – Nuvasive, HydroCision, K2M, Orthovita; 3B – Centinel 

Spine, Disc Motion Technologies, HydroCision, K2M, Orthovita, Paradigm Spine, 

Vertebral Technologies; 4 – Alphatec Spine, Disc Motion Technologies, Healthpoint 

Capital, HydroCision, K2M, Major, Nuvasive, Paradigm Spine, Orthovita, Royer, Scent’s 

USA, Spinal Kinetics, Vertebral Technologies 

John Camp, MD 3C – Sonosite, Inc. 

Antonio Campacci .........................................................n 

Elizabeth Campagnna, MS ..................................................n 

Jane Campbell .............................................................n 

Joel Campbell, BA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Patricia A Campbell, PhD 2 – Biomet; 5 – DePuy, A Johnson & Johnson Company, 

Wright Medical Technology, Inc., Zimmer, Smith & Nephew Inc., Corin/Stryker Inc. 

Fabrizio Campi, MD .......................................................n 

Jonathon Campion, FRCS ...................................................n 

S Terry Canale, MD 7 – Campbells Operative 

Lautaro Candioti, MD ......................................................n 

Eugenio Canesin Dal Molin, MD .............................................n 

Arturo C Canete, MD .......................................................n 

Philippa Cann, PhD ........................................................n 

Lisa K Cannada, MD 5 – Zimmer, Synthes 

William N Capello, MD 1, 3B, 4 – Stryker 

Ludovico Caperna, MD .....................................................n 

Jason Capo, MD ...........................................................n 

John T Capo, MD 1 – Wright Medical Technology, Inc.; 3B – Synthes, Wright Medical 

Technology, Inc.; 7 – Informa Healthcare 

James D Capozzi, MD 1 – BodyworksMD; 4 – Pfizer 

Auro Caraffa, MD ..........................................................n 

Mario J Cardoso, MD .......................................................n 

James L Carey, MD .........................................................n 

Jason P Carey, PhD .........................................................n 

Yannick Carillon, MD ......................................................n 

Graeme S Carlile, MBChB, MRCS ............................................n 

John Carlisle, MD ..........................................................n 

Fernando Carlos, MSc 2, 3B – Roche; 6 – Eli Lilly, Roche, Johnson & Johnson, Sanofi- 

Aventis 

Fulvio Carluzzo, MD .......................................................n 

Kelly D Carmichael, MD ....................................................n 

Kimberly Carney Young, MD ................................................n 

Cyrus Theodore Caroom, MD ...............................................n 

James E Carpenter, MD 4 – Stryker, Pfizer 

Andrew J Carr 6 – Smith & Nephew; 7 – Oxford University Press 

Christopher Carr ..........................................................n 

Diana Deane Carr, MD .....................................................n 

John Austin Carr, MS .......................................................n 




Eugene Carragee, MD 3B – Synthes, Medtronic, Dept. of Justice, Dept. of Defense, 

Ascension Health; 3C – BioAssets, Intrinsic, Cytonics, Simpirica; 4 – BioAssets, Cytonics, 

Simpirica; 5 – AOSpine, DePuy, OREF 

Joaquin Carrasco, PhD .....................................................n 

Guillermo Carrera, MD .....................................................n 

Jean-Paul Carret, MD 1 – Amplitude 

Richard Carrington, MD 2 – Smith & Nephew 

John Anthony Carrino, MD 3C – GE Healthcare, Carestream Health, Siemens Medical 

Systems; 5 – Siemens Medical Systems, Carestream Health, Toshiba Medical 

Charles Carroll IV, MD .....................................................n 

Colin Carroll, BS ..........................................................n 

Kaitlin M Carroll, BS .......................................................n 

Michael E Carroll 3A, 4 – Wright Medical Technology, Inc. 

Jeffrey L Carson, MD .......................................................n 

William Carson, PhD 1, 4 – Isola Implants Inc. 

Aaron Carter ..............................................................n 

Thomas R Carter, MD 1 – Arthrex, Inc.; 2 – Arthrex, Inc., Musculoskeletal Transplant 

Foundation, Regeneration Technologies, Inc.; 3B – Arthrex, Inc., Regeneration 

Technologies, Inc.; 5 – Regeneration Technologies, Inc. 

Philippe Edmond Cartier, MD 1, 2, 3B – Smith & Nephew 

Jacob Cartner 3A – Smith & Nephew 

Christian Carulli, MD ......................................................n 

Salvatore Caruso, MD ......................................................n 

Danielle Casagrande, MD ...................................................n 

William J Casey, MD .......................................................n 

Kara Cashman, BSc (HONS) ................................................n 

Paul M Caskey, MD ........................................................n 

Garrick Wayne Cason, MD ..................................................n 

David Casper, MD .........................................................n 

Kyle Cassas, MD ...........................................................n 

Ezequiel H Cassinelli, MD 3B – Globus Medical, Synthes, Stryker 

Nelson Cassis, MD .........................................................n 

Renan C Castillo, MD ......................................................n 

Tiffany Castillo ............................................................n 

Filippo Castoldi, MD .......................................................n 

Roberto Castracini, MD .....................................................n 

Louis W Catalano III, MD ...................................................n 

Yves Catonne, MD .........................................................n 

Charles Catton 2 – Abbott 

Rafael Cavalcanti, BS .......................................................n 

Marco Cavallo, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Peter Cavanagh, PhD 4 – Zin Medical DIApedia 

Ivana Cechova, MD ........................................................n 

Giuliano Cerulli, MD .......................................................n 

Eugenio Cesari, MD ........................................................n 

Gokben Nesrin Cetin, Asst Prof, MD .........................................n 

Luca Cevolani, MD .........................................................n 

Aron Chacko ..............................................................n 

Harbinder S Chadha, MD 2, 3B – Wright Medical Technology, Inc. 

Dara Chafik, MD ..........................................................n 

Nadeen Chahine, PhD 6 – Medtronic, Spinal Associates 

Aaron Mark Chamberlain, MD ...............................................n 

Hank G Chambers, MD 3B – Allergan Corporation 

Lauchlan Chambers, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Bill Champion ............................................................n 

Gilbert Chan, MD ..........................................................n 

Ka Yan Chan ..............................................................n 

Keith Chan, MD ...........................................................n 

Rajesh Chandra, MS ........................................................n 

Bong-Soon Chang, MD 2, 3C, 4, 5 – Bioalpha 

Chong Bum Chang, MD 2 – Pfizer, DePuy, A Johnson & Johnson Company, 

GlaxoSmithKline; 3B – GlaxoSmithKline; 5 – Smith & Nephew 

Edward Chang, MD ........................................................n 

Ki Young Chang, MD .......................................................n 

Cholawish Chanlalit, MD ...................................................n 

29 

disclosure 

Jens R Chapman, MD 2 – Synthes; 5 – Medtronic, Stryker 

Christopher D Chaput, MD 2 – Globus Medical; 3B – DePuy, A Johnson & Johnson 

Company; 3C – Link Orthopaedics; 5 – DePuy, A Johnson & Johnson Company, Stryker, 

Nuvasive, Spine Guard 

Susan Charkin, MPH .......................................................n 

Susan Charman, BSc .......................................................n 

John Charopoulos, MD .....................................................n 

Kory Charron .............................................................n 

Dr Moahmmadreza Chehrassan .............................................n 

Albert C Chen, PhD ........................................................n 

Antonia Chen, MD 3A – Novartis 

Chun-Ho Chen, MD ........................................................n 

Dan Chen, MS .............................................................n 

Justin Chen, BS ............................................................n 

Lan Chen, MD .............................................................n 

Minsi Chen, PhD ..........................................................n 

Pei-yu Chen, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Po Quang Chen, MD, PhD 2 – Honorarium from university-based conference in China 

Yuexin Chen, BS ...........................................................n 

Edward Y Cheng, MD 1 – Innomed; 4 – Fulfillium, Inc., Sensurtec, Inc.; 5 – Aastrom 

Biosciences; 6 – Musculoskeletal Transplant Foundation 

Ivan Cheng, MD 1 – Nuvasive; 3A – Synthes; 3B – Stryker Medtronic; 4 – Orthovita; 

5 – Stryker 

Joseph S Cheng, MD, MS 2 – Synthes; 5 – Medtronic Sofamor Danek 

Robert Cheng, MS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

David Cheong, MD ........................................................n 

John Cherf, MD, MPH, MBA 1 – Innomed; 2, 3 – Breg; 4 – DePuy, A Johnson & 


Sunny Cheung, MD ........................................................n 

Christophe J Chevillotte, MD ................................................n 

Abhinav Bobby Chhabra, MD 7 – Saunders/Mosby-Elsevier 

Shi-lu Chia, MBBS 5 – DePuy, A Johnson & Johnson Company; 6 – DePuy, A Johnson 

& Johnson Company, Zimmer 

Eugenio Chiarello, MD .....................................................n 

Catharina Chiari, MD ......................................................n 

Rosetta M Chiavacci, BSN ...................................................n 

Samir Chihab, MD .........................................................n 

Zachary Allen Child, MD ....................................................n 

Dylan Childs, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Matthew S Chin, MD .......................................................n 

Pak Lin Chin, FRCSEd 3C – Zimmer; Stryker 

Vernon Chinchilli, PhD 3B – Bristol-Myers Squibb, Centocor 

Christopher P Chiodo, MD 1 – Aircast (DJ), Arthrex, Inc.; 3B – MMI; 4 – Johnson & 

Johnson, Merck, Zimmer; 5 – DJ Orthopaedics, EBI 

Vanessa Chiu, MPH ........................................................n 

Byung Ki Cho, MD .........................................................n 

Chul-Hyun Cho, MD, PhD ..................................................n 

Hyung Joon Cho, MD ......................................................n 

Kye-Youl Cho, MD .........................................................n 

Robert Hyun Cho, MD ......................................................n 

Samuel Kang-Wook Cho, MD ................................................n 

Woojin Cho, MD ..........................................................n 

Hyonmin Choe, MD ........................................................n 

Daniel Choi, MS ...........................................................n 

Dr Duck-Hyun Choi ........................................................n 

Euisung Choi, MD .........................................................n 

Horim Choi, MD ..........................................................n 

In Ho Choi, MD ...........................................................n 

Ja-Young Choi .............................................................n 

Leera Choi, BA ............................................................n 

Young-Seok Choi, PhD .....................................................n 

Theodore J Choma, MD 2, 3B – Stryker; 4 – Gentis, Inc.; 5 – DePuy, A Johnson & 

Johnson Company, Stryker 

Hwei Chi Chong ...........................................................n 

Loretta Chou, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Jack Choueka, MD .........................................................n 




James Chow, MD 2, 5 – Wright Medical Technology, Inc.; 3B – Wright Medical 

Technology, Inc., Smith & Nephew 

Roxanne Chow, MD ........................................................n 

Kevin P Christensen, MD ...................................................n 

Thomas Christensen, MD ...................................................n 

Michael J Christie, MD 1 – DePuy, A Johnson & Johnson Company, Zimmer; 

4 – Exactech, Inc. 

Laurent-Panayiotis Christofilopoulos 3C – Medacta Switzerland 

Constance R Chu, MD ......................................................n 

Susanna G Chubinskaya, PhD 5 – Zimmer, Joint Restoration Foundation, Regentis, 

LLC 

Yong-Min Chun, MD .......................................................n 

Byung June Chung, MD .....................................................n 

Chin Youb Chung, MD, PhD ................................................n 

Christine Chung, MD ......................................................n 

Dae-Huk Chung, MD .......................................................n 

Jae Yoon Chung, MD .......................................................n 

Kyung-Chil Chung, MD .....................................................n 

Seok Won Chung, MD ......................................................n 

Chris Church, PT ..........................................................n 

Norman Barrington Chutkan, MD 1, 3C – Globus Medical 

Michael G Ciccotti, MD .....................................................n 

Alec Cikes, MD ............................................................n 

Alessandro Ciompi, MD ....................................................n 

Cara A Cipriano, MD .......................................................n 

Musa Citak, MD ...........................................................n 

Alfred Cividino, MD 2 – Abbott, Roche, GlaxoSmithKline; 3B – Abbott, Roche; 

5 – Abbott, Bristol-Myers Squibb, Canadian Institutes of Health Research (CIHR), 

Merck, Pfizer, Roche, Wyeth; 6 – Abbott 

Roberto Civinini, MD ......................................................n 

Steven AJ Claes, MD ........................................................n 

Thomas O Clanton, MD 2 – Arthrex, Inc., Small Bone Innovations; 3B – Arthrex, Inc.; 

3C – Wright Medical Technology, Inc. 

Charles Richard Clark, MD 1, 2 – DePuy, A Johnson & Johnson Company; 3B, 

5 – DePuy, A Johnson & Johnson Company, Smith & Nephew; 6 – Zimmer; 7 – Journal 

of Bone and Joint Surgery - American 

H Jolene Clark .............................................................n 

Jason C Clark, MD .........................................................n 

Henry D Clarke, MD 5 – Stryker 

Theodore J Clarke, MD .....................................................n 

Martin Clauss, MD .........................................................n 

Philippe Clavert, MD, PhD 3B – Tornier, Mitek 

Catharine Clay ............................................................n 

Jean-Luc Clement, MD 1, 3B, 3C – Medicrea International 

Nicholas D Clement, MRCS Ed ..............................................n 

Jill Clemente, MS ..........................................................n 

John C Clohisy, MD 2, 3B – Biomet; 5 – Wright Medical Technology, Inc., Zimmer, Inc. 

Myles Clough, MD 3C, 4 – Orthopaedic Web Links (OWL) 

Frederic C Cloutier, MD ....................................................n 

Terry A Clyburn, MD 1, 7 – Nimbic Systems; 2, 3B – ConforMIS; 4 – Nimbic, 

ConforMIS 

Andrew Cobb, MD 5, 6 – DePuy, A Johnson & Johnson Company 

Justin Peter Cobb, MD 2 – Biomet; 3B – Aesculap/B.Braun, DePuy, A Johnson & 

Johnson Company; 3C – JRI, Ceramtec; 4 – Stanmore Implants Worldwide; 5 – DePuy, 

A Johnson & Johnson Company, Ceramtec 

Elizabeth Cody, BS .........................................................n 

Stephanie Cody, BS ........................................................n 

Marcus P Coe, MD .........................................................n 

J Chris Coetzee, MD 1 – Arthrex, Inc., DePuy, A Johnson & Johnson Company; 2, 

3B – Arthrex, Inc.; DePuy, A Johnson & Johnson Company, Tornier; 3C, 4 – KMI; 

5 – DePuy, A Johnson & Johnson Company 

Robert H Cofield, MD 1 – DJ Orthopaedics, Smith & Nephew; 7 – Wolters Kluwer 


Benjamin Cohen, MD ......................................................n 

Bruce E Cohen, MD 1 – Arthrex, Inc., DJ Orthopaedics, Wright Medical Technology, 

Inc.; 3B, 5 – Wright Medical Technology, Inc.; 7 – Wolters Kluwer Health - Lippincott 


30 

disclosure 

Marcio Theo Cohen, MD ....................................................n 

Mark S Cohen, MD 1, 5 – Integra; 2, 3B – Mylad 

Steven Brad Cohen, MD 2 – Smith & Nephew; 3B – Smith & Nephew, Knee Creations, 

Inc.; 4 – Knee Creations, Inc. 

Henry B Colaco, MRCS .....................................................n 

Marco Colangeli, MD .......................................................n 

Fabio Colantonio, MD ......................................................n 

Ashley Cole, MPH ..........................................................n 

Brian J Cole, MD 1 – Arthrex, Inc., DJ Orthopaedics, Lippincott, Elsevier; 2 – Genzyme; 

3B – Zimmer, Arthrex, Inc., Carticept, BioMimetic, Allosource, DePuy; 5 – Regentis, 

Arthrex, Smith and Nephew, DJ Ortho; 7 – Lippincott, Elsevier, WB Saunders 

Peter A Cole, MD 3B – Synthes 

Jill Coleman, RN 3A, 4 – Sanofi-Aventis 

Struan H Coleman, MD 3B – Stryker 

John P Collier, DE 3B, 5 – DePuy, A Johnson & Johnson Company; 4 – Stryker 

Cory Alan Collinge, MD 1 – Biomet, Smith & Nephew, Advanced Orthopedic Systems; 

3B – Biomet 

Gianluca Collo, MD ........................................................n 

Matthew Colman, MD ......................................................n 

Clifford W Colwell Jr, MD 5 – Stryker, Medical Compression Systems 

Thomas Krebs Comfort, MD 5 – Stryker 

Michael A Conditt, PhD 3A, 4 – MAKO Surgical Corp. 

Sean B Conkle, OTC ........................................................n 

Chad Stephen Conner, MD ..................................................n 

Patrick J Connolly, MD 3B, 7 – K2M; 5 – ApaTech 

Patrick Michael Connor, MD 1 – Biomet; 3B – Zimmer 

Fabio Conteduca, MD ......................................................n 

Jacopo Conteduca, MD .....................................................n 

Juan S Contreras ...........................................................n 

Richard Contreras, MS ......................................................n 

Janet Donohue Conway, MD 1 – University of Florida; 3B – Orthofix, Inc.; 

5 – Medtronic, Synthes 

Chad Cook, PT ............................................................n 

James L Cook, DVM, PhD 1 – Arthrex, Inc.; 2 – Arthrex, Inc., Pfizer; 3B – Arthrex, Inc., 

Pfizer, Zimmer, Stryker; 5 – Arthrex, Inc., Musculoskeletal Transplant Foundation, Pfizer, 

Zimmer 

Jon R COOK, PT ...........................................................n 

Stephen D Cook, PhD 2 – Biomet; 5 – Medtronic Sofamor Danek; 6 – DePuy, A 

Johnson & Johnson Company, Zimmer, Smith & Nephew, Stryker 

Todd Cook, MD ...........................................................n 

Nicholas Cooke, FRCS ......................................................n 

Richard RH Coombs, DM ...................................................n 

William P Cooney, III MD 1 – Small Bone Innovations, OREF; 2, 3B, 4, 6 – Small Bone 

Innovations; 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Ross Cooper, MA ..........................................................n 

Charlotte Coopmans, MSc ..................................................n 

Julie Coplan, DScPT ........................................................n 

Lawson A B Copley, MD ....................................................n 

Steven Copp, MD 2 – Stryker; 4 – Nuvasive 

Ian Corcoran-Schwartz .....................................................n 

Ronda Cordill, RN, CIC, MPH ...............................................n 

Bryan Cornwall, PhD 3A, 4 – Nuvasive 

Adrian J Correa, MD, MBA ..................................................n 

Eva Correa ................................................................n 

Rickson Guedes De Moraes Correia, MD ......................................n 

Kristoff Corten, MD ........................................................n 

Doug Cortez, BS ...........................................................n 

Andrew J Cosgarea, MD 7 – Elsevier 

Anthony Costa, MD ........................................................n 

Christopher R Costa, MD ...................................................n 

Luigi Costa, Prof ...........................................................n 

John George Costouros, MD ................................................n 

Ralph Richard Coughlin, MD ................................................n 

Marlon Osman Coulibaly, MD ...............................................n 

Charles M Court-Brown, MD 7 – Wolters Kluwer Health - Lippincott Williams & 

Wilkins 




Etevaldo Coutinho, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Ian Cowgill, MS ...........................................................n 

Christopher Cox, MD ......................................................n 

Catelyn Coyle, BS ..........................................................n 

Ellen Coyne, MS ...........................................................n 

Edward V Craig, MD 1, 2, 3B – Biomet; 7 – Wolters Kluwer Health - Lippincott 


Matthew Craig, MD ........................................................n 

Mattia Cravino, MD ........................................................n 

Alvin Howell Crawford, MD 1, 2, 3B, 5 – DePuy, A Johnson & Johnson Company 

Charles H Crawford, III MD 2, 6 – Medtronic 

Haemish Alexander Crawford, Mb.chB 6 – Synthes 

Kelli Crawford, PA-C .......................................................n 

Lindsay Michele Crawford, MD ..............................................n 

Scott Nicholas Crawford, MD ................................................n 

Aaron Creek. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

William R Creevy, MD, MBA .................................................n 

Robert Alexander Creighton, MD 2 – Mitek 

Renn J Crichlow, MD 2, 3C – Stryker; Synthes 

Brett D Crist, MD 4 – Amedica Corporation; 5 – KCI, Medtronic, Novalign, Smith & 

Nephew, Stryker, Synthes, Wound Care Technologies 

Lynn A Crosby, MD 1, 2, 3B, 5 – Exactech, Inc. 

Jessica Dale Cross, MD .....................................................n 

Michael B Cross, MD .......................................................n 

William Wood Cross, MD ...................................................n 

Lawrence S Crossett, MD 1, 2, 3B – DePuy, A Johnson & Johnson Company 

Aristides I Cruz, Jr MD ......................................................n 

Rick P Csintalan, MD .......................................................n 

Anna Maria Cuffini .........................................................n 

William Cumberland, MD ..................................................n 

Don R Cummings, CP LP ...................................................n 

Nancy Madsen Cummings, MD 4 – Cardiosolutions 

Stephen H Cummings, MD ..................................................n 

Steven Cummings, MD 3C – Amgen Co., Eli Lilly 

Frances Cuomo, MD .......................................................n 

Thomas W Currey, MD .....................................................n 

Barbara H Currier, MChE 2, 3B, 3C – DePuy, A Johnson & Johnson Company; 


John H Currier, MS 2, 3B, 3C – DePuy, A Johnson & Johnson Company; 4 – Johnson 

& Johnson 

Jessica I Curry, MS .........................................................n 

Patrick Curry ..............................................................n 

Brian M Curtin, MD ........................................................n 

Shane Curtiss .............................................................n 

Fred D Cushner, MD 1 – Smith & Nephew; 2 – Sanofi-Aventis; 3B, 4 – Angiotech; 

7 – Thieme 

Daniel J Cuttica, DO .......................................................n 

Jean-Claude D’Alleyrand, MD ................................................n 

Jean D’Angelo, BA 7 – National Board of Medical Examiners, American Board of 

Orthopaedic Surgery 

James A D’Antonio, MD 1, 2, 3B, 5 – Stryker 

Michele R D’Apuzzo, MD ...................................................n 

THERESA D’ERRICO 3A, 4 – Stryker 

Darryl D D’Lima, MD 3B – National Institutes of Health (NIAMS & NICHD), MAKO 

Surgical; 3C – Stryker, Zimmer, Orthocyte; 5 – Stryker, Zimmer, Smith & Nephew 

Luca D’Orazio, Med Student ................................................n 

Hossam Dabis, MB ChB FCRS ...............................................n 

Shlomo Dadia, MD ........................................................n 

Kwon Dae Gyu, MD ........................................................n 

Nirvikar Dahiya, MD .......................................................n 

Annette W Dahl, PHD ......................................................n 

Diane Lynn Dahm, MD .....................................................n 

Joseph Michael Dai III, MD .................................................n 

Monica Daigl Cattaneo, MS .................................................n 

George Daikos, MD 2, 3B – Novartis; 5 – Pfizer 

31 

disclosure 

Michael T Daines, MD ......................................................n 

Danilo Canesin Dal Molin, MD ..............................................n 

Eden Dal Molin, MD .......................................................n 

Paul A Dale, MD ...........................................................n 

Erika L Daley, BS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Jacqueline A Daley, MLT 2 – 3M; 4 – Pfizer, GE Healthcare, 3M 

Aaron Daluiski, MD 3B – Wright Medical Technology, Inc. 

David F Dalury, MD 1, 2, 3B, 5 – DePuy, A Johnson & Johnson Company 

Timothy A Damron, MD 5 – Wright Medical Technology, Inc., Genentech, Inc., 

Orthovita, Inc.; 7 – Lippincott, Williams, and Wilkins, Wolters Kluwer Health 

Lindsay Dancy, BS .........................................................n 

Daniel Choi, BA ...........................................................n 

Stephen Daniels, DO .......................................................n 

Timothy Rudolf Daniels, MD 2 – BioMimetic, Wright Medical Technology, Inc., 

Carticept, Hintegra (New Deal); 3B – Carticept, BioMimetic, Wright Medical; 

5 – BioMimetic, Arthrex, Inc., Carticept, New Deal (Hintegra) 

Beate Danielson, PhD ......................................................n 

Samira Daou, Med Student ..................................................n 

Aditi Das, MBBS ...........................................................n 

Anat Daskal, MSc ..........................................................n 

Michael David Daubs, MD 3B – Synthes; 5 – Stryker 

Margot C Daugherty, MSN, MEd, RN, EMT-P ...................................n 

J Rod Davey, MD 1 – Biomet; 2, 3B – Stryker, Exactech, Inc., Biomet; 6 – Smith & 

Nephew 

Dr Bertrand David 5 – Osteotech 

Tal S David, MD 2 – Arthrex, Inc., Cayenne Medical, Inc.; 3C, 4 – Cayenne Medical, 

Inc.; 7 – SLACK Incorporated 

Nadav Davidovic, MD ......................................................n 

Roy Davidovitch, MD 3C, 4 – Surgix Ltd. 

Jon R Davids, MD ..........................................................n 

David Davidson, MD .......................................................n 

Philip A Davidson, MD 2 – Arthrosurface, Kensey Nash; 3B – Arthrosurface, Kensey 

Nash, Core Essence; 4 – Arthrosurface, Core Essence; 5 – Kensey Nash 

Adrian Thomas Davis, MD 5 – Synthes, Zimmer 

Brent R Davis, MD .........................................................n 

Brian Davis, PhD ..........................................................n 

Charles M Davis III, MD ....................................................n 

Chris Davis, BS 6 – Kensey-Nash 

Dr Jason J Davis ...........................................................n 

Kenneth Davis, MS 4 – Merck, Lilly, Giliad, Pfizer 

Rebecca Davis, MS .........................................................n 

William Hodges Davis, MD 1 – Arthrex, Inc., DJ Orthopaedics, Wright Medical 

Technology, Inc.; 2 – DJ Orthopaedics, Smith & Nephew, Wright Medical Technology, 

Inc.; 3B – Smith & Nephew, Wright Medical Technology, Inc.; 4 – Wright Medical 

Technology, Inc.; 5, 6 – DJ Orthopaedics, Wright Medical Technology, Inc.; 7 – Wolters 

Kluwer Health - Lippincott Williams & Wilkins 

Ross Dawkins, MD .........................................................n 

Charles S Day, MD, MBA 5 – Boston Scientific, Small Bone Innovations 

Judd Day, PhD 3A – Exponent, Inc.; 6 – Stryker; Zimmer 

Michael S Day, MPhil .......................................................n 

Nicky Day ................................................................n 

Justin Dazley, MD ..........................................................n 

Massimo De Benedetto, MD .................................................n 

Joost De Bruijn, PhD 3A, 4 – Progentix Orthobiology BV 

Angelo De Carli, MD .......................................................n 

Marcello De Fine, MD ......................................................n 

Anthony De Giacomo, MD ..................................................n 

Juan Carlos De La Fuente, MD ...............................................n 

Adriana De La Rocha .......................................................n 

Francis De Neve, Med Student ...............................................n 

Nicholas De Roeck, FRCS ...................................................n 

Richard De Steiger, MD 3B – Zimmer; 5 – Brainlab 

Henrica CW De Vet, Prof, PhD ...............................................n 

Lieven De Wilde ...........................................................n 

Allison De Young ..........................................................n 

Daniel Brian Dean, MD .....................................................n 




Laura E Dean ..............................................................n 

Rebecca Dean, MA .........................................................n 

John T Dearborn, MD 1 – Zimmer 

Thomas M DeBerardino, MD 2, 5 – Arthrex, Inc., Genzyme, Musculoskeletal Transplant 

Foundation; 3B – Arthrex, Inc.; 3C, 4 – Advanced Biomedical Technologies, Inc. 

Ronen Debi, MD ...........................................................n 

David Kent DeBoer, MD 1 – DePuy, A Johnson & Johnson Company, Wright Medical 

Technology, Inc.; 3B – Wright Medical Technology, Inc. 

Michael Decker ............................................................n 

Michael DeFranco, MD .....................................................n 

Florence Degroot, PhD .....................................................n 

Henry DeGroot, MD 4 – Abbott, Merck, Pfizer, GlaxoSmithKline 

Emile Dehoux, PhD 3C – Zimmer 

Angelo Del Buono, MD .....................................................n 

Rainero Del Din, MD .......................................................n 

Daniel J Del Gaizo, MD .....................................................n 

Mylene A Dela Rosa ........................................................n 

Katrina Dela Torre, MS .....................................................n 

Michael Delacruz, MD ......................................................n 

Rick B Delamarter, MD 1 – Stryker, Synthes, Zimmer; 3B – Synthes; 6 – Synthes 

Jonathan T Deland, MD 3B – Arthrex, Inc., Tornier, Zimmer 

Kevin Delaney, MD .........................................................n 

Ronald Emilio Delanois, MD 2, 3B – Stryker; 5 – Wright Medical Technology, Inc. 

Regidor B Deleon III, MD 3A – ADJ’s Trading 

Richard M Dell, MD ........................................................n 

Gregory John Della Rocca, MD 4 – Amedica; 5 – Synthes, Smith & Nephew, Stryker, 

Wound Care Technologies 

Craig J Della Valle, MD B – Angiotech, Biomet, Kinamed, Smith & Nephew; 5 – Pacira, 

Zimmer 

Demetris Delos, MD .......................................................n 

Peter A De Luca, MD .......................................................n 

Peter F DeLuca, MD ........................................................n 

Kevin Deluzio, MSC 3B – Nuvasive; 5 – DePuy, A Johnson & Johnson Company 

Marlene DeMaio, MD ......................................................n 

Nicolas Demaurex, MD, PhD ................................................n 

Constantine Demetracopoulos, MD ..........................................n 

Deniz Demiryurek, MD, Assoc Prof ..........................................n 

Satoru Demura, MD ........................................................n 

Vincenzo Denaro, MD ......................................................n 

Xiang-Hua Deng, MD ......................................................n 

Douglas A Dennis, MD 1 – DePuy, A Johnson & Johnson Company, Innomed; 2, 

3B – DePuy, A Johnson & Johnson Company; 5 – DePuy, A Johnson & Johnson 

Company, Porter Adventist Hospital 

James E Dennis, PhD 4, 5 – Cell Targeting, Inc.; 6 – Zimmer 

David G Dennison, MD 5 – DePuy, A Johnson & Johnson Company 

Ricardo E Dent, MD 3A, 4 – Amgen Co. 

James Keith DeOrio, MD 1 – Merete; 2 – Acumed, LLC, Wright Medical Technology, 

Inc., SBI, Tornier, Integra, Datatrace Publishing; 3B – SBI, Exactech, Inc., Wright Medical 

Technology, Inc., Acumed, LLC, Integra, Arthrex; 3C – BioPro; 4 – Wright Medical 

Technology, Inc.; 5 – Synthes, Arthrex, Inc. 

Peter Derman, BS ..........................................................n 

G Paul De Rosa, MD .......................................................n 

Sergulen Dervisoglu, Prof ...................................................n 

Rasesh R Desai, MD ........................................................n 

Kaat Desloovere, PhD ......................................................n 

Arthur A DeSmet, MD ......................................................n 

Koen Aime DeSmet, MD 1 – Wright Medical Technology, Inc.; 2, 3B – Finsbury, Wright 

Medical Technology, Inc.; 3C – Ceramtec; 5 – Biomet, Smith & Nephew 

Federico Dettoni, MD ......................................................n 

PJ Devereaux, MD, MSc .....................................................n 

Clinton J Devin, MD 5 – DePuy, A Johnson & Johnson Company 

Vedat Deviren, MD 1 – Nuvasive; 3B – Nuvasive, Stryker, Guidepoint Global; 

5 – Nuvasive, Stryker 

Christopher J DeWald, MD 4 – Medtronic, Phygen 

Ashvin Kumar Dewan, MD ..................................................n 

Christopher B Dewing, MD .................................................n 

32 

disclosure 

Francesco Di Caprio, MD ...................................................n 

Alberto Di Martino, MD ....................................................n 

Alessandro Di Martino, MD .................................................n 

Berardo Di Matteo, Med Student .............................................n 

Christian Di Paola, MD 2 – Medtronic; 3B – DePuy, A Johnson & Johnson Company, 

Allem Medical Systems 

Vincenzo Di Sanzo, MD ....................................................n 

Priscilla Di Sette, MD .......................................................n 

Mohammed Atef Diab, MD ..................................................n 

Beverly E Diamond, DSW ...................................................n 

Veronica A Diaz, MD .......................................................n 

Francesco DiCaprio ........................................................n 

Paul E DiCesare, MD 3B – Stryker; 5 – GlaxoSmithKline; Stryker 

Daniel Dichter, BA .........................................................n 

Kyle F Dickson, MD 3C – Trauma Research Corporation, DJ Orthopaedics, Stryker 

Paul Didomenico, MD ......................................................n 

Glenn Diekmann, MD ......................................................n 

Paul Diesfeld, PA-C ........................................................n 

Jason P Dieterle, DO .......................................................n 

Rachel L DiFazio, MS, RN, cPNP .............................................n 

Anthony M DiGioia III, MD 4 – Blue Belt Technologies, Inc. 

Benedict F DiGiovanni, MD .................................................n 

Christopher W DiGiovanni, MD 1 – Extremity Medical, Inc.; 2, 3B, 4 – BioMimetic 

Extremity Medical, Inc.; 5 – BioMimetic; 6 – Curamedix, Inc., Performance Orthotics, 

Inc.; 7 – Saunders Elsevier 

Goksel Dikmen, MD .......................................................n 

Erica Dillon, BS ...........................................................n 

David M Dines, MD 1 – Biomet, Tornier; 3B, 6 – BioMimetic, Biomet, Tornier; 

7 – Journal of Shoulder and Elbow Surgery 

Joshua Dines, MD 1 – Biomet; 2 – Arthrex, Inc.; 3B – Arthrex, Inc., Tornier; 

5 – BioMimetic; 7 – Elsevier 

Anthony Ding, MD .........................................................n 

John DiPaola, MD .........................................................n 

Douglas R. Dirschl, MD 1–Biomet 

Jessice M Dirusso, SPT ......................................................n 

Mauricio Disilvo, MD, FACS .................................................n 

Jeffrey S. Dlott, MD ........................................................n 

Anton E Dmitriev ..........................................................n 

Huong Do, MS ............................................................n 

Nam Hoon Do, MD ........................................................n 

Josh Doan, MS ............................................................n 

Matthew Barrett Dobbs, MD 1, 3B – D-Bar Enterprises; 7 – Clinical Orthopaedics and 

Related Research 

Christopher A F Dodd, FRCS 1, 2, 3B – Biomet; 5 – Stryker; 7 – Oxford University Press 

Christopher Dodson, MD ...................................................n 

Michael Doerner, BA .......................................................n 

Stephan Domayer ..........................................................n 

Benjamin Domb, MD 3B, 5 – Arthrex, Inc. 

Henry J Donahue, PhD .....................................................n 

William F Donaldson III, MD 5 – Stryker 

Derek J Donegan, MD ......................................................n 

Ryan P Donegan, MD ......................................................n 

Brian Gerard Donley, MD 1 – Extremity Medical; 2 – Tornier, Extremity Medical; 

3B – Medtronic, Tornier, Extremity Medical, Tensegrity; 4 – Extremity Medical, Infoslate; 

7 – Belvoir Publications 

Onorfio Donzelli, MD ......................................................n 

Josef Doornink, MS ........................................................n 

Ryan M Dopirak, MD .......................................................n 

Mahmut Nedim Doral, MD .................................................n 

John P Dormans, MD 5 – Synthes, Medtronic; 7 – Brooke’s Publishing, Elsevier, Mosby 

Ronald Dorotka, MD .......................................................n 

Lawrence D Dorr, MD 1 – Zimmer; 3C – MAKO Surgical Corp.; 4 – MAKO Surgical 

Corp., Total Joint Orthopedics 

Ian G Dorward, MD ........................................................n 

Sonia Dosanjh, MSW .......................................................n 

Keith C Douglas, MD .......................................................n 




Sepehr Doustdar, MD ......................................................n 

Thomas Charles Dowd, MD .................................................n 

Katheryne Downes, MPH ...................................................n 

Brian Downie, PA ..........................................................n 

Mike S Doyle ..............................................................n 

Shevaun Mackie Doyle, MD .................................................n 

Gabriele Drago, MD ........................................................n 

Jason L Dragoo, MD 3B – Genzyme, Ossur; 5 – Linvatec, Ossur 

James C Dreese, MD ........................................................n 

Niv Dreiangel, MD .........................................................n 

Brian Drew, MD ...........................................................n 

Jacob M Drew, MD .........................................................n 

Michael Drexler, MD .......................................................n 

David M Dromsky, MD .....................................................n 

Darren Sean Drosdowech, MD, FRCSC ...6 – DePuy, A Johnson & Johnson Company 

Marcel Dudda, MD .........................................................n 

Thomas Edward Dudley, MD ................................................n 

Rosanna Duester, PA-C .....................................................n 

Jeffrey R Dugas, MD 1 – Biomet 

Jules Arthur Dumais, MD ...................................................n 

Michael Dunbar, MD, PhD 3B, 5 – Stryker 

Robert Paul Dunbar, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Clive P Duncan, MD 2 – Zimmer; 3B – Smith & Nephew, Zimmer; 5 – DePuy, A 


Douglas D Duncan, MD 5 – Biomet 

Daniel V Dungca, MD ......................................................n 

Godfredo V Dungca III, MD 2, 3C – Merck Sharpe & Dohme, Philippines Speakers’ 

Bureau 

Warren Dunn, MD, MPH 6 – Arthrex, Inc. 

Page Dunning .............................................................n 

Thomas Duquin, MD .......................................................n 

Xavier A Duralde, MD ......................................................n 

Craig Dushey, MD 4 – Sanofi-Aventis 

Anil K Dutta, MD 1 – Ortho Helix; 2 – Tornier, Synthes; 3B – Tornier 

Arup Dutta, FRCS ..........................................................n 

Jason R Dutton, DO ........................................................n 

Marcel F Dvorak, MD 1, 3B – Medtronic Sofamor Danek; 2 – Medtronic Sofamor 

Danek, Synthes; 5 – Medtronic Sofamor Danek, DePuy, A Johnson & Johnson 

Company, Synthes, Arcus; 6 – DePuy, A Johnson & Johnson Company, Medtronic 

Sofamor Danek, Synthes; 7 – Thieme 

Christopher John Dy, MD ...................................................n 

George S Dyer, MD .........................................................n 

Michael Eagan, MD ........................................................n 

Emily Earl-Royal, BA 3A – Allergan, Inc.; 4 – GlaxoSmithKline, Allergan, Inc. 

Mark E Easley, MD 2 – Small Bone Innovations; 7 – Saunders/Mosby-Elsevier 

Patrick Brian Ebeling, MD ..................................................n 

Prouskeh Ebrahimpour, MD ................................................n 

Edward Ebramzadeh, PhD 5 – Zimmer 

Jason C Eck, DO 2 – Medtronic, Stryker; 7 – Saunders/Mosby-Elsevier, Thieme 

Eckart Mayr, MD 2, 3B, 5 – Stryker 

Tobin Eckel, MD ...........................................................n 

Timo M Ecker, MD .........................................................n 

Kostas Economopoulos, MD ................................................n 

Avram A Edidin, PhD 3A, 4 – Medtronic 

Eric Edmonds, MD 5 – Synthes 

Christopher Edwards, BA ...................................................n 

Paul K Edwards, MD .......................................................n 

Thomas Bradley Edwards, MD 1 – Tornier, Orthohelix; 2, 5, 6 – Tornier; 3B – Kinamed, 

Tornier; 3C – Gulf Coast Surgical Services; 7 – Journal of Shoulder and Elbow Surgery, 

Saunders/Mosby-Elsevier 

Turgay Efe, MD ............................................................n 

Takeshi Egi, MD 5 – Astellas Pharma Inc. 

W Andrew Eglseder, MD 2, 3B – Mylad Orthopedic Solutions LLC 

Kenneth A Egol, MD 3C – Exactech, Inc.; 4 – Johnson & Johnson, Surgix Inc.; 

5 – Biomet, Stryker, Synthes; 7 – SLACK Incorporated, Wolters Kluwer Health - 


33 

disclosure 

Natalia Egorova, PhD, MPH .................................................n 

Michael G Ehrlich, MD 3B, 4 – BioMimetic, Carbylan 

John R Ehteshami, MD .....................................................n 

Markus Eichler, MD ........................................................n 

Thomas A Einhorn, MD 1 – Osteotech; 2 – Smith & Nephew; 3B – Smith & Nephew, 

Lilly, Novartis, Anika, Kuros; 4 – Osteogenix, Biomineral Holdings, HealthpointCapital, 

NeoStem, Implant Protection; 7 – Journal of Bone and Joint Surgery - American, 

Lippincott Williams and Wilkins, Elsevier 

Eric Eisemon, MD ..........................................................n 

Gerald Eisenberg, MD 5 – Abbott, Genzyme, Roche 

Eric A Eisner, MD ..........................................................n 

Leandro Ejnisman, Md .....................................................n 

Anders L Ekelund, MD 1, 2, 3C – DePuy, A Johnson & Johnson Company 

Carl Ekholm, MD ..........................................................n 

Axel Ekkernkamp, MD 2 – DePuy, A Johnson & Johnson Company, Johnson & 

Johnson Medical; 5 – Biomet, DePuy, A Johnson & Johnson Company, Pfizer, Bayer- 

Schering 

Antoun El Chemaly, PhD ...................................................n 

Yasser H El Miligui, MD, FRCS ...............................................n 

Sherif El Shafie, MB BCh ....................................................n 

Saadiq F El-Amin, III MD ...................................................n 

Hebah El-Gendi, MS .......................................................n 

Bassel El-Osta, MB BCh .....................................................n 

Mohammad Mostafa El-Sharkawi, 

MD ......................................................................n 

Neal S ElAttrache, MD 1, 2, 3A, 3B, 4, 5, 6 – Arthrex, Inc. 

Salah Elfatori, MD .........................................................n 

Bassem T Elhassan, MD .....................................................n 

John J Elias, PHD 6 – Arthrex, Inc. 

Ilia Elkinson, MD ..........................................................n 

Erik Brian Eller, MD ........................................................n 

Dawn M Elliott, PhD .......................................................n 

Winston Elliott ............................................................n 

Andrew R Ellis .............................................................n 

David J Ellis, FRCS .........................................................n 

Scott Ellis, MD ............................................................n 

Thomas J Ellis, MD 1 – Acute Innovations; 3B, 5 – Stryker 

Brad Ellison, MD ..........................................................n 

Karim Ahmed Elsharkawy, MD ..............................................n 

Barbara Elspas, MPH .......................................................n 

John B Emans, MD 1, 5 – Synthes; 3B, 3C – Medtronic Sofamor Danek, Synthes 

Gwendolyn Beth Emerson, MD ..............................................n 

Roger H Emerson, Jr MD 1, 2, 5 Biomet; 3B – Biomet Salient Surgical Technologies 

Sanford E Emery, MD, MBA 6 – Medtronic 

MAKOto Emori, MD .......................................................n 

Ivan Encalada, MD .........................................................n 

Naoto Endo, MD ..........................................................n 

Terrence J Endres, MD ......................................................n 

C Anderson Engh Jr, MD 1, 2, 3B – DePuy, A Johnson & Johnson Company; 4 – DePuy, 

A Johnson & Johnson Company, Stryker; 5 – DePuy, A Johnson & Johnson Company, 

Smith & Nephew, Inova Health Care Services 

Charles A Engh, Sr MD 1, 5 – DePuy, A Johnson & Johnson Company; 4 – Johnson & 

Johnson, Stryker, Alexandria Research Technology 

Gerard Anderson Engh, MD 1 – DePuy, A Johnson & Johnson Company, Innomed; 

2 – Smith & Nephew; 3B – DePuy, A Johnson & Johnson Company, Smith & 

Nephew; 3C, 4 – Alexandria Research Technologies; 5 – DePuy, A Johnson & Johnson 

Company, Smith & Nephew, U.S. Army Medical Research & Materiel Command & 

the Telemedicine & Advanced Technology Research Center, Medtronic, Inova Health 

Systems 

Vahid Entezari, MD ........................................................n 

Geoffrey Epie, MBBS .......................................................n 

David M Epstein, MD .......................................................n 

Noah Epstein, MD .........................................................n 

Levent Eralp ...............................................................n 

Erik M Erbe, PhD 3A, 4 – Nuvasive 

Burcu Ercakmak, MD .......................................................n 

Mehmet Erdem, MD ........................................................n 




Meghan A Erdman, MS .....................................................n 

Rifat Erginer, MD ..........................................................n 

Jill Erickson, PA ...........................................................n 

Mark A Erickson, MD 2 – Biomet 

Unal Erkorkmaz, PhD ......................................................n 

Gurkan Erkula, MD ........................................................n 

Thomas J Errico, MD 1 – K2M, Fastenetix; 3B – Stryker; 3C – Orthocon; 4 – K2M, 

Stryker; 5 – Paradigm Spine; 7 –Elsevier 

James C Esch, MD 1 – Breg; 2, 3B – Smith & Nephew Endoscopy; 4 – KFx Medical 

Mark Eskander, MD ........................................................n 

Birgitte Espehaug, PhD .....................................................n 

Christina Ilona Esposito ....................................................n 

Amanda Esquivel, PhD .....................................................n 

Aaron Essner, MS 2, 3A, 6 – Stryker; 4 – Stryker, Pfizer 

Daniel M Estok II, MD ......................................................n 

Arthur Ethington, PA-C .....................................................n 

Susan L Ettner, PhD ........................................................n 

Selena Eunice, MSPH .......................................................n 

Nick Eustace, FRCA ........................................................n 

Gregory Thomas Evangelista, MD ............................................n 

Bruce G Evans, MD .........................................................n 

Christopher H Evans, PhD 3B – TissueGene Inc.; 4 – Orthogen AG 

Heather N Evans, BA .......................................................n 

Korboi N Evans, MD .......................................................n 

Richard Parker Evans, MD 2 – Cubist; 3B – DePuy, A Johnson & Johnson Company, 

Smith & Nephew 

David C Evans, GED ........................................................n 

Jesse L Even, MD ...........................................................n 

Jesse Exaltacion, MD .......................................................n 

Kace A Ezzet, MD 3B – Smith & Nephew; 5 – Smith & Nephew, Wright Medical 


Nicola Fabbri, MD .........................................................n 

Ken Faber, MD 1 – Tenet Medical; 4 – Zimmer 

David W Fabi, MD .........................................................n 

Meredith Fabing, DO .......................................................n 

Peter David Fabricant, MD ..................................................n 

Paul Fadale, MD ...........................................................n 

Bryan C Fagan, MD 3B – Smith & Nephew 

Juan-Carlos Falcon, MD, MSc ................................................n 

Richard Falcone Jr, MD, MPH ................................................n 

Cesare Faldini, MD .........................................................n 

Yuri Falkinstein, MD .......................................................n 

Gregory Carl Fanelli, MD 7 – Sports Medicine and Arthroscopy Review, Wolters Kluwer 


Chien-Feng Fang, MD ......................................................n 

Bobbi A Farber, MD ........................................................n 

Daniel C Farber, MD 4 – JMEA, Inc. 

Mariana Custodio Farcetta, PhD .............................................n 

Jean-Pierre C Farcy, MD 3B – Stryker; 5 – DePuy, A Johnson & Johnson Company 

German Luis Farfalli, MD ...................................................n 

Yasser Farid, MD, PhD ......................................................n 

Philip M Faris, MD 1, 5 – Biomet; 3B – Zimmer 

Payam Farjoodi, MD .......................................................n 

Frances A Farley, MD 4 – Medtronic; 5 – Medtronic, DJ Orthopaedics, Johnson & 

Johnson, Genzyme, Pfizer, Stryker, Wright Medical Technology, Inc., Zimmer, Synthes 

Eugene Farng, MD 3A, 4 – IVAX Corporation 

Courtney Fahnhorst, BA ....................................................n 

Christine L Farnsworth, MS .................................................n 

Frances Faro, MD ..........................................................n 

Francine Farouz, PhD ......................................................n 

Jack Farr II, MD 1 – Stryker, DePuy, Johnson & Johnson Companies; 2 – Genzyme, 

DePuy, Johnson & Johnson Companies, Zimmer; 3B – Genzyme, Arthrex, Inc., DePuy, 

A Johnson & Johnson Company, Mitek, Regeneration Technologies, Inc., Zimmer, 

Stryker, ABS, VOT; 4 – ABS, VOT; 5 – Genzyme, Mitek, Stryker, Biomet, Regeneration 

Technologies, Inc., ABS, Zimmer, Advanced Bio Surfaces, DePuy/ATRM, Osiris 

Therapeutics, Eli Lilly, Biomet 

34 

disclosure 

Mazda Farshad, MD ........................................................n 

Luc Favard, MD 1, 3C – Tornier 

Tony Elias Fayad, MD MRCS .................................................n 

Umberto Giuseppe Fazzi, FRCS ..............................................n 

Alexander N Fedenko, MD ..................................................n 

Catherine Julia Fedorka, MD ................................................n 

Brian Feeley, MD ...........................................................n 

Keith Fehring, MD 1, 2, 3B, 5, 6 – DePuy, A Johnson & Johnson Company 

Thomas K Fehring, MD 1, 2, 3B, 5 – DePuy, A Johnson & Johnson Company 

Edward V Fehringer, MD 1, 2, 4, 5 – Tornier; 7 – Elsevier 

John E Femino, MD ........................................................n 

Duncan Ferguson, MD .....................................................n 

James Ferguson, MRCS .....................................................n 

Peter Ferguson, MD ........................................................n 

Richard D Ferkel, MD 1, 3B – Smith & Nephew; 7 – Wolters Kluwer Health - Lippincott 


Edwin Darren Fern, MBChB .................................................n 

Mariano Fernandez-Fairen, MD ..............................................n 

Joel Ferreira, MD ..........................................................n 

Louis Ferreira, MSc .........................................................n 

Andrea Ferretti ............................................................n 

Matteo Ferretti, MD ........................................................n 

Andrea Ferro, MD ..........................................................n 

Alberto Ferruzzi, MD .......................................................n 

Jonas Meling Fevang, MD ...................................................n 

James R Ficke, MD .........................................................n 

Larry D Field, MD 3B – Smith & Nephew; 5 – Arthrex, Inc., Mitek, Smith & Nephew 

Giuseppe Filardo, MD ......................................................n 

Anthony Fine, BS ..........................................................n 

Kenneth M Fine, MD 2 – Sanofi-Aventis 

Henry A Finn, MD 1, 2, 3B – Biomet 

Marta Fiocco, PhD .........................................................n 

Gary S Firestein, MD .......................................................n 

Charla R Fischer, MD .......................................................n 

Jeffrey S Fischgrund, MD 1 – DePuy, A Johnson & Johnson Company; 3B – Apatech, 

DePuy, A Johnson & Johnson Company, Relieveant, Smith & Nephew, Stryker; 

5 – Apatech, Axial Biotech, Smith & Nephew, Stryker; 7 – JAAOS 

Anthony Colin Fisher, PhD 7 – Elsevier 

Charles G Fisher, MD 1 – Medtronic Sofamor Danek, Nuvasive; 2 – Medtronic Sofamor 

Danek, Synthes, DePuy, A Johnson & Johnson Company, Nuvasive; 3B – Nuvasive, 

Medtronic Sofamor Danek 

David A Fisher, MD 1, 2, 3B – DePuy, A Johnson & Johnson Company; 

3C – Orthopediatrics; 4 – Eli Lilly, Pfizer, Tornier, Incisive Surgical, Visible Assets; 

5 – DePuy, A Johnson & Johnson Company, Incisive Surgical 

Steven Fisher, MBA .........................................................n 

Erica Fisk, MD .............................................................n 

Robert D Fitch, MD ........................................................n 

Wolfgang Fitz, MD 1, 3B, 4 – ConforMIS Inc.; 5 – Oped Inc., IGB.com 

John D Fitzgerald, MD, PhD, MPH ...........................................n 

Daniel C Fitzpatrick, MD 1 – Synthes, CMF, Zimmer; 2, 3B – Synthes, CMF 

Evan L Flatow, MD 1, 2, 3C – Zimmer; 5 – Wyeth; 7 – Wolters Kluwer Health - 


Erin E Fleck, MD ...........................................................n 

Cassie M Fleckenstein ......................................................n 

Thomas B Fleeter, MD ......................................................n 

Nicholas D Fletcher, MD ....................................................n 

Kathy J. Flint, RN ..........................................................n 

Charles Henri Flouzat-Lachaniette, 

MD ......................................................................n 

Evelyn Flynn, MA ..........................................................n 

Dr Jeffrey Flynn ............................................................n 

Jack M Flynn, MD 1 – Biomet; 7 – Wolters Kluwer Health - Lippincott Williams & 

Wilkins 

Patrick Flynn, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Susan Foad, MS ............................................................n 

Kathryn Fong, BS ..........................................................n 




Li Foong Foo, MD 3B – Histogenics Inc. 

Jared R H Foran, MD .......................................................n 

Kevin Ray Ford, MS ........................................................n 

Andrew Forester, FRCS .....................................................n 

Stefan Fornalski, MD .......................................................n 

Eric D Fornari, MD .........................................................n 

Douglas S Fornfeist, MD ....................................................n 

Maryam Forootan, BS ......................................................n 

Jonathan Agner Forsberg, MD ...............................................n 

Rosemarie Forstner, MD ....................................................n 

Antonio Maria Foruria de Diego, MD, PhD ....................................n 

John R Fowler, MD .........................................................n 

Alice JS Fox, MSc ...........................................................n 

Joshua C Fox, MD ..........................................................n 

Marilyn L Fox, PhD ........................................................n 

Austin Thomas Fragomen, MD 1 – Small Bone Innovations; 2, 5 – Biomet, Smith & 

Nephew, Small Bone Innovations 

Christian R Fraitzl, MD .....................................................n 

Caroline Frampton, BS .....................................................n 

John C France, MD 6 – Medtronic Sofamor Danek 

Francesco Franceschi, MD ...................................................n 

Dunia Francesconi, MD .....................................................n 

Elizabeth Frank, MS ........................................................n 

Dr Jeremy S Frank .........................................................n 

Rachel Frank ..............................................................n 

Mark A Frankle, MD 1, 2, 3B – DJ Orthopaedics; 3C – DePuy, A Johnson & Johnson 

Company; 5, 6 – DJ Orthopaedics, EBI, Eli Lilly, Encore Medical; 7 – SLACK 

Incorporated 

Patricia Franklin, MD 5 – Zimmer 

Frank J Frassica, MD .......................................................n 

Robert W Frederick, MD 1 – Arthrotex/Biomed, Arthrex, Inc. 

Brett Freedman, MD 5 – Medtronic 

Ilan S Freedman, MD .......................................................n 

Michael Q Freehill, MD .....................................................n 

Michael T Freehill, MD .....................................................n 

Carl R Freeman, MD 1 – Innomed 

Heather Freeman, PT .......................................................n 

Robert Freeman, MBBS .....................................................n 

Theresa Freeman, PhD 5 – Cerapedics 

Andrew A Freiberg, MD 1, 3B – Biomet; Zimmer; 4 – ArthroSurface 

Per Freitag, MD 2 – Alphatec Spine 

Bruce Green French, MD 3B – Biomet 

Steven L Frick, MD 5 – Biomet 

Kevin B Fricka, MD 5 – Zimmer, INOVA Health Care Services 

Jan Friden, MD, PhD .......................................................n 

Laura Frieboes, PhD ........................................................n 

Gary E Friedlaender, MD 3B – BioMimetic Therapeutics, Inc.; 4 – BioMimetic 

Therapeutics, Medtronic, Pfizer, Stryker, CrossCart; 6 – BioMimetic 

Daniel Friedman, BSc ......................................................n 

Richard J Friedman, MD 1 – DJ Orthopaedics; 3B – Boehringer Ingelheim, DJO 

Surgical; 5 – Astellas US; 7 – CRC Press 

Nicole A Friel, MD .........................................................n 

Jennifer K Friend, AS .......................................................n 

Darin M Friess, MD 3B – Acumed, LLC 

Helga Fritsch, MD 3B – Stryker 

Germaine R Fritz, DO ......................................................n 

John Marshal Froelich, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Simon Frostick, MD 1 – Biomet; 2 – Biomet, Boehringer Ingelheim, Bristol-Myers 

Squibb, Pfizer; 3B – Biomet, Boehringer-Ingelheim; 3C – DePuy, A Johnson & Johnson 

Company; 5 – DePuy, A Johnson & Johnson Company, Johnson & Johnson 

Freddie H Fu, MD 1 – Arthrocare; 3A – Stryker; 3C, 5 – Smith & Nephew 

Professor Susanne Fuchs-Winkelmann ........................................n 

Carl Hans Fuersenberg, MD .................................................n 

Duretti Fufa, MD ..........................................................n 

Takeshi Fuji, MD ...........................................................n 

35 

disclosure 

Hiroshi Fujimaki, MD ......................................................n 

Jun Fujimori, MD ..........................................................n 

Satoru Fujita, MD ..........................................................n 

Hiroyoshi Fujiwara, MD ....................................................n 

Shingo Fukagawa, MD ......................................................n 

John P Fulkerson, MD 1 – Arthrex, Inc., DJ Orthopaedics; 3C – DJ Orthopaedics; 

4 – Merck; 6 – Kinamed, Smith & Nephew; 7 – Wolters Kluwer Health - Lippincott 


T Ted Funahashi, MD .......................................................n 

Philipp Theodor Funovics, MD ..............................................n 

Christopher George Furey, MD ..............................................n 

Bridgette D Furman, PhD ...................................................n 

Ove Nord Furnes, MD 2 – OrtoMedic, Norway; 5 – Smith & Nephew, OrtoMedic, 

Norway 

Moritoshi Furu, MD, PhD ...................................................n 

Kazuma Futai, MD .........................................................n 

Joanne Daggy, PhD ........................................................n 

Keith Robert Gabriel, MD ...................................................n 

Bishoy V Gad, MD 4 – Advanced Cell Technology Inc. (ACTC) 

Naomi Gadinsky, Research Coor.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Varun Kashyap Gajendran, MD ..............................................n 

Jorge O Galante, MD 3B – Biomet; 4 – Johnson & Johnson, Zimmer 

Leesa M Galatz, MD 3C – Tornier 

Kieran R Gallagher, MRCS ..................................................n 

Jiri Gallo, MD 6 – Aesculap/B.Braun, Zimmer, Bayer 

Marc T Galloway, MD 6 – Arthrex, Inc., DJ Orthopaedics, DePuy, A Johnson & Johnson 

Company 

Karina Galoian, PhD .......................................................n 

Armen Galoyan, MD, PhD ..................................................n 

James G Gamble, MD, PhD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Rajiv Gandhi, MD ...................................................5 – Pfizer 

Theodore J Ganley, MD 3B – OrthoPediatrics Corp. 

George D Gantsoudes, MD ..................................................n 

Reinhold Ganz, MD 3C, 4 – Pivot 

Tigran Garabekyan, MD ....................................................n 

Nickolas G Garbis, MD .....................................................n 

Donald S Garbuz, MD 3B – Zimmer; 5 – DePuy, A Johnson & Johnson Company, 

Zimmer 

Grant Garcia ..............................................................n 

Ryan Garcia, MD ...........................................................n 

Michael J Gardner, MD 3B – Synthes, DGI Med, Amgen Co.; 5 – Synthes, Amgen Co.; 


Thomas R Gardner, MCE ....................................................n 

Bhavuk Garg, MS Ortho ....................................................n 

Rishi Garg, MD ............................................................n 

Rohit Garg, MBBS ..........................................................n 

Sudhir Garg, MD ..........................................................n 

Sumeet Garg, MD ..........................................................n 

Jonathan P Garino, MD 1 – DePuy, A Johnson & Johnson Company, Smith & Nephew; 

2 – Smith & Nephew; 3B – Ceramtec 

Matthew Robert Garner, MD .................................................n 

David N Garras, MD ........................................................n 

William E Garrett, Jr MD 2 – Arthrex, Inc., DJ Orthopaedics; 3B – Omeros; 5 – DJ 

Orthopaedics, Omeros 

Kevin L Garvin, MD 1, 3A – Biomet; 2 – ConvaTec; 7 – Wolters Kluwer Health - 


Alessandro Gasbarrini, MD .................................................n 

Selom Gasinu .............................................................n 

Olivier Gastaud, MD .......................................................n 

Charles J Gatt, Jr MD 2 – Musculoskeletal Transplant Foundation, Smith & Nephew; 

5 – Musculoskeletal Transplant Foundation 

Rachel E Gaume, BS ........................................................n 

Elizabeth Gausden, BS ......................................................n 

Deepa Gavini, MS ..........................................................n 

Andre Nicolas Gay, MD .....................................................n 

David Gay, MD 4 – Pfizer 




Zulma Gazit, PhD ..........................................................n 

Dongxia Ge, MD, MS .......................................................n 

Mark C Gebhardt, MD 7 – Clinical Orthopaedics and Related Research 

Albert Ooguen Gee, MD ....................................................n 

William H Geerts, MD 2, 3B, 3C, 6 – Pfizer, Sanofi-Aventis 

Rudolph Gerbrand Geesink, MD,PhD 2, 3B – Stryker; 7 – Springer 

Thorsten Gehrke, MD ......................................................n 

Robin Michael Gehrmann, MD ..............................................n 

William Bennett Geissler, MD 1 – Acumed, LLC, Arthrex, Inc.; 2 – Acumed, LLC, 

Arthrex, Inc., Medartis; 3B – Acumed, LLC, Ascension; 4 – Tornier; 7 – Springer 

James Genuario, MD .......................................................n 

Michael S George, MD ......................................................n 

Christian Gerber, MD 1 – Zimmer; 3B – Storz; 5 – Medacta 

Tad L Gerlinger, MD ........................................................n 

Margherita Germano, MD ...................................................n 

Charles L Getz, MD 2 – Mitek; 5 – Zimmer 

Ghislain Geurts, MD .......................................................n 

Alexander J Ghanayem, MD .................................................n 

Raju S Ghate, MD 3B – Zimmer 

Ebrahim Ghayem Hassankhani ..............................................n 

Riccardo Ghermandi, MD ...................................................n 

Gary Ghiselli, MD 1 – Zimmer; 4 – Rhygen Difusion Technologies 

Neil S Ghodadra, MD ......................................................n 

Hassan Ghomrawi, PhD ....................................................n 

Ali Ghoz, MB BCH MRCS MRCS 

(Ed) ......................................................................n 

Giannis Giakas, MD ........................................................n 

Silvio Giannetti, MD .......................................................n 

Sandro Giannini, MD ......................................................n 

Peter Giannoudis, MD 2 – DePuy, A Johnson & Johnson Company, Stryker, Synthes, Eli 

Lilly; 3B, 5 – DePuy, A Johnson & Johnson Company, Stryker, Synthes; 3C – Pfizer 

Christopher T Gibbons, FRCS ...............................................n 

Max Gibbons, FRCS 3B, 3C – Biomet 

Johnny M Gibbs, MD .......................................................n 

Anthony Gibson 6 – Nuvasive 

Graham Allan Gie, MD 1, 3B, 5 – Stryker 

Corey A Gilbert, MD .......................................................n 

Josh W Giles, BESc .........................................................n 

Harinderjit Singh Gill, PHD 2, 3B – Wright Medical Technology, Inc.; 5 – Wright 

Medical Technology, Inc., DePuy, A Johnson & Johnson Company, Stryker 

Richie H S Gill, MD 2, 3B – Wright Medical Technology, Inc.; 5 – DePuy, A Johnson & 

Johnson Company, Stryker, Wright Medical Technology, Inc., Zimmer 

Thomas James Gill, MD 3B – ConMed Linvatec 

David L Gilliam, MD .......................................................n 

Scott D Gillogly, MD 3B – Genzyme, Exactech, Inc., Carticept; 4 – Pfizer; 5 – Smith & 

Nephew, Genzyme, Arthrex, Inc. 

Allison Gilmore, MD .......................................................n 

Louis A Gilula, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Terence J Gioe, MD 4 – Eli Lilly, Johnson & Johnson; 5 – DePuy, A Johnson & Johnson 

Company 

Giovanni Giordano, MD ....................................................n 

Nicholas John Giori, MD ...................................................n 

Federico Pablo Girardi, MD 1 – DePuy, A Johnson & Johnson Company, Nuvasive, 

LifeSpine, OrthoDevelopment; 3B – Centinel Spine, DePuy, A Johnson & Johnson 

Company, LifeSpine, OrthoDevelopment, Osteotech, Orthogem, Orthovita; 

4 – Nuvasive 

Ida Leah Gitajn, MD ........................................................n 

Jennifer L Giuffre, MD ......................................................n 

Jeffrey R Giuliani, MD ......................................................n 

M. Russell Giveans, PhD ....................................................n 

Jan-Erik Gjertsen, MD, PhD .................................................n 

David L Glaser, MD 3A, 4 – GlaxoSmithKline; 5 – Mitek 

Diana A Glaser, PhD 5 – Alphatec Spine 

John A Glaser, MD 4 – Mekanika 

Andrew H Glassman, MD 1 – Innomed, Zimmer; 3B – Exactech, Inc.; 4 – Stryker 

David Michael Glassman, MD ...............................................n 

36 

disclosure 

Steven D Glassman, MD 1, 3B – Medtronic Sofamor Danek 

Mark Glazebrook, MD 2 – BioMimetic, Wright Medical Technology, Inc.; 

3B – BioMimetic, BioSet, ConMed Linvatec, Wright Medical Technology, Inc.; 4 – Smith 

& Nephew, Stryker, Wright Medical Technology, Inc.; 5 – Boise, DePuy, A Johnson & 


Nicholas Glembotski, BS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Steven Z Glickel, MD 4 – Abbott, Zimmer, Pfizer, Johnson & Johnson 

David Glos ................................................................n 

Michael P Glotzbecker, MD .................................................n 

Sion Glyn-Jones, MA MBBS 2 – Zimmer, Stryker, Wright Medical Technology, Inc.; 

3B – Zimmer, Stryker; 3C – Corin U.S.A.; 5 – Zimmer 

Alberto Gobbi, MD ........................................................n 

Reuben Gobezie, MD 3B – Arthrex, Inc.; 5 – Arthrex, Inc., Tornier, Neurowave 

Can Gocuk, MD ...........................................................n 

Maria S Goddard, MD ......................................................n 

Jonathan Godin, BA ........................................................n 

Tom Goehre, MD ..........................................................n 

Anshul Goel, MBBS ........................................................n 

Danny Goel, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Devon D Goetz, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Tom Goetz, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Frank Gohlke, MD 3C – Tornier; 7 – Journal of Shoulder and Elbow Surgery 

Ziya L Gokaslan 4 – Spinal Kinetics and U.S. Spine; 5 – Integra, AO North America; 

6 – DePuy, A Johnson & Johnson Company, Medtronic 

Stuart M Gold, MD 2, 3B – Smith & Nephew; Stryker; 5 – Stryker 

Michael J Goldberg, MD ....................................................n 

Charles A Goldfarb, MD ....................................................n 

Ariel Goldman, MD 2 – Osteotech; 5 – Stryker 

Steven R Goldring, MD 2 – Fidia Framiceuticals, NicOx, Inc.; 3B – Biomet, Novartis, 

Roche, Pfizer, Merck Serono, Abbott; 5 – Merck Serono, Boehringer Ingelheim, Abbott 

Jeffrey Andrew Goldstein, MD 2 – Synthes; 3B – Medtronic Sofamor Danek, Nuvasive, 

Synthes, K2M; 4 – K2M 

Wayne M Goldstein, MD 1 – Smith & Nephew, Innomed; 2, 3B, 6 – DePuy, A Johnson 

& Johnson Company, Osteotech, Smith & Nephew; 4 – Doctors Research Group; 


Elan Michael Goldwyn, MD .................................................n 

Ty Henry Goletz, MD .......................................................n 

Michael Golf, DPM .........................................................n 

S Raymond Golish, MD, PHD 3B, 4 – Cytonics, Inc. 

Francisco Gomar, MD ......................................................n 

Bruna Gomes, BS ..........................................................n 

Joao Ellera Gomes, MD .....................................................n 

Dominic T Gomez-Leonardelli, MD ..........................................n 

Andreas H Gomoll, MD 2 – Arthrex, Inc., Genzyme; 3B – Genzyme; 5 – Genzyme, 

ConforMIS; 7 – SLACK Incorporated 

Alejandro M Gonzalez Della Valle, MD 3B – Stryker 

Bernal Gonzalez, MD .......................................................n 

Humberto Gonzalez Ugalde, MD ............................................n 

Guillem Gonzalez-Lomas, MD ...............................................n 

Miguel Gonzalez-Thompson, MD ............................................n 

Ruben Gonzalez, MD .......................................................n 

Hubert Lee Gooch, Jr MD 4 – Johnson & Johnson, Medtronic Sofamor Danek, Procter 

& Gamble, Pioneer Surgical 

Gens Pierce Goodman, DO .................................................n 

Mark A Goodman, MD .....................................................n 

Murray J Goodman, MD 4 – Genzyme, Johnson & Johnson, Merck, Pfizer, Stryker, 

Zimmer 

Stuart Barry Goodman, MD 3B – BioMimetic, Synthes; 4 – Accelalox, StemCor, Tibion; 

5 – Amgen Co., Musculoskeletal Transplant Foundation, National Institutes of Health 

(NIAMS & NICHD); 7 – Clinical Orthopaedics and Related Research 

Andrew D Goodwillie, MD ..................................................n 

Robert S Gorab, MD 1 – Stryker, DePuy, A Johnson & Johnson Company; 3B, 


John T Gorczyca, MD 3B – Zimmer 

J Eric Gordon, MD 1, 3B – Orthopediatrics 

Wade T Gordon, MD .......................................................n 

Simon Gortz, MD 6 – Joint Restoration Foundation 




Richard A Gosselin, MD ....................................................n 

Tarun Goswami, DSc .......................................................n 

Akira Goto, MD, PhD ......................................................n 

Hideyuki Goto, MD ........................................................n 

Christian Gotze, MD .......................................................n 

Yannick Goubau, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Krista Goulding, MD .......................................................n 

Monique C Gourdine-Shaw, DPM ............................................n 

Amrit Goyal, MD ..........................................................n 

Nitin Goyal, MD ...........................................................n 

Robin Nestor Goytia, MD ...................................................n 

Vadim Goz, BA ............................................................n 

Gregory Grabowski, MD ....................................................n 

Ivan A Gradisar Jr, MD 3B, 4 – Exactech, Inc. 

Ronald D Graff, PhD .......................................................n 

David Grainger, PhD 3C – Accelr8 Technologies, Inc.; 4 – Accelr8 Technologies, Inc., 

CellSeed, Ltd.; 6 – Accelr8 Technologies, Inc. 

George A Grammatopoulos, MRCS ...........................................n 

William A Grana, MD, MPH .................................................n 

Daniel A Grande, PhD 3B – Tigenix; 4 – Cartilix, Tigenix; 5 – BioMimetic 

Gian Luca Grandi, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Struan F Grant, PhD 1 – COLIA1, Sequenom 

Guido Grappiolo, MD 1 – Zimmer; 2, 3B – Biomet; Zimmer; 3C – Lima, Finceramica; 

5 – Sanofi-Aventis 

Carly Gratopp .............................................................n 

Mathew Graves, MD ........................................................n 

Stephen Graves, MD ........................................................n 

Sascha Gravius, MD ........................................................n 

Robert R Gray, MD .........................................................n 

Tinker Gray, MA, ELS .......................................................n 

Frank E Greaves, OPA-C, OTC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Andrew Green, MD 1 – Tornier; 2 – DJ Orthopaedics; 3B – IlluminOss, Tornier; 

4 – IlluminOss Medical, Pfizer; 5 – Arthrex, Inc., Smith & Nephew, Wyeth; 7 – Elsevier 

Daniel William Green, MD 1 – Pega Medical; 3B – DePuy, A Johnson & Johnson 

Company; 7 – Current Opinion in Pediatrics 

Steven Marshall Green, MD 4 – GlaxoSmithKline, Pfizer, Stryker, Auxilium 

Stuart A Green, MD 1 – Smith & Nephew ;3B, 4 – Ellipse Technologies 

Jordan N Greenbaum, MD, MBA .............................................n 

Jeffrey A Greenberg, MD 3B – Stryker; 5 – Acumed, LLC 

Richard A. Greendyk, BS ....................................................n 

Denise Greene, RNP ........................................................n 

Joseph Greene, MD ........................................................n 

Meridith Greene 6 – Biomet, Zimmer 

A Seth Greenwald, DPhil Oxon 3B – DePuy, A Johnson & Johnson Company; 

5 – Amedica, SBI, Wright Medical Technology, Inc., Maxx Health, ConforMIS, Encore 

Medical, Nuvasive, Synvasive, TJO, Acumed, LLC, Ranier, Japan Medical Materials; 

7 – Seminars in Arthroplasty 

Prof Paul J Gregg ..........................................................n 

Nelson Victor Greidanus, MD 5 – Zimmer 

Thomas H Greidanus, MD ..................................................n 

Justin K Greisberg, MD 7 – Saunders/Mosby-Elsevier 

Mike Greiwe, MD ..........................................................n 

Ruby Grewal, MD ..........................................................n 

Michael Griesser, MD .......................................................n 

Anthony M Griffin, MSC ....................................................n 

Harry Grigg, BSc ...........................................................n 

Nathan L Grimm, MD ......................................................n 

Charles Simpson Grimshaw, MD .............................................n 

Tahnee Groat, MPH ........................................................n 

Alan J Grodzinsky, PhD .....................................................n 

Thomas J Grogan, MD 4 – Pfizer, Excelerate, Zimmer 

Gordon I Groh, MD 1 – Encore Medical; 2 – Arthrocare, DePuy, A Johnson & Johnson 

Company, DJ Orthopaedics; 3B – DePuy, A Johnson & Johnson Company; DJ 

Orthopaedics; Ascension Orthopaedics, Upex; 4 – Upex; 5 – Ascension, DePuy; 7 - DJ 

Orthopaedics 

Allan E Gross, MD, FRCSC 1, 2, 3B – Zimmer 

37 

disclosure 

Jonathan Michael Gross, MD ................................................n 

Thomas Gross, MD, PhD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Joshua D Grossman, BA ....................................................n 

Alexander Gruebl, MD 2 – DePuy, A Johnson & Johnson Company 

Gary S Gruen, MD 3B – Smith & Nephew 

Robert C Grumet, MD ......................................................n 

Thomas Grupp, MD 3A – Aesculap/B.Braun 

Konrad Gruson, MD 4 – Amgen Co., Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, 

Johnson & Johnson, Medtronic, Merck, Pfizer, Procter & Gamble, Stryker, Zimmer 

Stephen Gryzlo, MD ........................................................n 

Yang Gu, BS ...............................................................n 

Carlos Guanche, MD 2 – Tornier, Smith & Nephew; 3B – Tornier; 6 – Allen Medical; 


Teja Guda, PhD ............................................................n 

Suribabu Gudipati, MBBS, MRCS ............................................n 

Scott Guelcher, PhD 3B, 5, 6 – Osteotech 

Enrico Guerra, MD .........................................................n 

Giovanni Guerra, MD ......................................................n 

Marcos Guerrero, MD ......................................................n 

Joseph Guettler, MD 4 – Johnson & Johnson, Genzyme, Stryker; 5 – Omeros 

Benjamin G Guevara, MD ...................................................n 

Farshid Guilak, PhD 3B, 4, 6 – Cytex Therapeutics; 5 – Osteotech; 7 – Osteoarthritis 

and Cartilage Journal of Biomechanics 

Oscar Guillamondegui, MD, MPH ...........................................n 

Farid Guirguis, MD ........................................................n 

Thierry Guitton, MSc .......................................................n 

Ashish Gulati, MS, DNB ....................................................n 

Bethany C Gulick, RT .......................................................n 

Lawrence Gulotta, MD 3C – Collplant, Inc. 

Mahir Gulsen, Prof.Dr. .....................................................n 

Kenneth Robert Gundle, MD ................................................n 

Roger Gundle 2 – Biomet 

Adem Gundogan, MD ......................................................n 

Taner Gunes, MD ..........................................................n 

Akash Gupta, BA ...........................................................n 

Ranjan Gupta, MD 5 – Arthrex, Inc., Smith & Nephew, Synthes; 7 – McGraw 

Rishi R Gupta, MD .........................................................n 

Tushar Gupta, MBBS .......................................................n 

Vikas Gupta, MS ...........................................................n 

Sabahat Gurdezi, BPharm, MBBS, FRCS .......................................n 

Jennifer Gurske de Perio, MD ................................................n 

Kenneth A Gustke, MD 2, 4, 5 – Zimmer; 3B – Zimmer, MAKO 

Sergio Gutierrez, PHD ......................................................n 

Gordon Guyatt, MD ........................................................n 

Olivier Guyen, MD 1, 6 – Amplitude Company 

Charles H Guymon, MA ....................................................n 

Gregory P Guyton, MD .....................................................n 

David E Gwinn, MD ........................................................n 

Chul Won Ha, MD 5 – Medipost 

Eun-Young Ha, MD ........................................................n 

Yong-chan Ha, Prof ........................................................n 

Janet Haas, MD ............................................................n 

Joerg Haasters, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Rohan Ashok Habbu, MS, MBBS .............................................n 

Prof Dr Peter Habermeyer ...................................................n 

Sadia Habib, MSc ..........................................................n 

Donald A Hackbarth Jr, MD 6 – Musculoskeletal Transplant Foundation 

Thomas R Hackett, MD 2 – Arthrex, Inc., Sonoma Orthopaedics; 3B – Regeneration 

Technologies, Inc., Arthrex, Inc., Sonoma Orthopaedics; 4 – Sonoma Orthopaedics; 

5 – Arthrex, Inc, 

Fares Sami Haddad, FRCS 1, 5 – Smith & Nephew; 2 – Pfizer; 3B – DePuy, A Johnson 

& Johnson Company, Smith & Nephew, Stryker 

Steven L Haddad, MD 2 – Stryker; 3B – Wright Medical Technology, Inc.; 3C, 

4 – OrthoHelix Surgical Designs; 5 – BioMimetic 

Scott R Hadley, MD ........................................................n 




Moustafa Ismail Hafez, PhD .................................................n 

Tomonobu Hagio, MD .....................................................n 

Michael P Hahn, MD .......................................................n 

Theodore J Hahn, MD ......................................................n 

George John Haidukewych, MD 1 – DePuy, A Johnson & Johnson Company; 

4 – Surmodics, Orthopediatrics 

David J Hak, MD 2 – Medtronic; 3B – Medtronic, Amgen; 4 – Emerge; 5 – Synthes, 

Stryker 

Arnavaz Hakimiyan, BS .....................................................n 

Sam Hakki, MD 2, 3C – Aesculap/B.Braun; 5 – Aesculap/B.Braun, Pfizer 

Sema Hakki, DT ...........................................................n 

Hakon Hakonarson, MD, PhD ...............................................n 

Matthew Halanski, MD 3C – Orthopaediatrics; 5 – Biomet and Stryker 

Abdul Ahad Haleem, MD ...................................................n 

Jeremy Hall, MD, FRCS (ORTHO), MEd 5, 6 – Pfizer, Zimmer, Synthes, Stryker, Smith 

& Nephew, Amgen Co. 

Carolina Halliburton .......................................................n 

Benjamin Warren Halligan, MD ..............................................n 

Mark Halstead, MD ........................................................n 

Moussa Hamadouche, MD PhD 3B, 5 – Osteotech 

Dustin Hambright, BA ......................................................n 

Nady Hamid, MD ..........................................................n 

Christopher Lawrence Hamill, MD ...........................................n 

William G Hamilton, MD 2 – DePuy, A Johnson & Johnson Company, Salient Surgical; 

3B – DePuy, A Johnson & Johnson Company; 5 – DePuy, A Johnson & Johnson 

Company, Inova Health Care Services 

Kyle E Hammond, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Sommer Hammoud, MD ....................................................n 

Chang-Dong Han, MD .....................................................n 

Seung Beom Han, MD ......................................................n 

Nicholas J Hancock, FRCS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Douglas P Hanel, MD 3B – Aptis Medical LLC 

Lewis Hanna, PhD 3A – Cytonics Corporation; 4 – Bristol-Myers Squibb, Johnson & 

Johnson, Cytonics Corporation 

Sammy A Hanna, MRCS ....................................................n 

Benjamin Hansen, MD 3A – Forest Pharmaceuticals, Myriad Genetics 

Patricia L Hansen, BS .......................................................n 

Sigvard T Hansen Jr, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins, 

Thieme Medical Publishers 

Sarah Hanslow, MD ........................................................n 

Beate Hanson, MD .........................................................n 

Jean Hanson, RN, PhD .....................................................n 

Arlen D Hanssen, MD 1 – Stryker, Ortho Development Corp.; 5 – Biomet, A Johnson & 

Johnson Company, Stryker, Zimmer 

Josa Hanzlik, MS ..........................................................n 

Toshiaki Hara, PhD ........................................................n 

Yoshitada Harada, MD 2 – Biomet, Sanofi-Aventis, Wright Medical Technology, Inc.; 

3B – Stryker, Wright Medical Technology, Inc.; 3C – Stryker, Smith & Nephew; 5 – Smith 

& Nephew 

Ziad Harb, MRCS ..........................................................n 

John McCall Hardcastle, V MD ...............................................n 

L Alberto Harfush-Nasser, MD ...............................................n 

Kengo Harigane, MD .......................................................n 

Sanaz Hariri, MD ..........................................................n 

Alain Harisboure, MD 2, 3B – Aesculap/B.Braun 

Jaap Harlaar, PhD 5 – Prosensa; 6 – OIM, Netherlands 

William Harmsen, MS ......................................................n 

Christopher D Harner, MD 5 – DePuy, A Johnson & Johnson Company 

Paul Richard Harnett, MB, ChB ..............................................n 

Alex HS Harris, PhD, MS ....................................................n 

Joshua Harris, MD .........................................................n 

Michael D Harris, BS .......................................................n 

Mitchel B Harris, MD .......................................................n 

Steven M Harris, JD ........................................................n 

Alicia Karin Harrison, MD ..................................................n 

Jim Harrison, MBBS ........................................................n 

38 

disclosure 

James Harrop, MD 2 – DePuy, A Johnson & Johnson Company, Stryker, Neurostem; 

3B – DePuy, A Johnson & Johnson Company; 3C – Geron, AScubio; 4 – Axiomed 

Alister Hart, FRCS 3A, 4 – Corin; 5 – Biomet, Corin U.S.A., DePuy, A Johnson & 

Johnson Company, Finsbury, Mathys Ltd., Smith & Nephew, Zimmer 

Deborah Hart, MD .........................................................n 

Nathan Hart, MD ..........................................................n 

Robert A Hart, MD 1 – SeaSpine; 2 – DePuy, Synthes; 3B – DePuy; 4 – SpineConnect; 

5 – DePuy, Medtronic, OREF, Synthes 

Gary Dean Harter, MD 2 – DJ Orthopaedics, Genzyme; 3B, 5 – DJ Orthopaedics 

Robert Hartman, MS .......................................................n 

Zane Hartsell 3A, 4 – Smith & Nephew; 4 – Smith & Nephew 

Langdon A Hartsock, MD 5 – Synthes 

Mark A Hartzband, MD 1, 2, 3B, 5 – Zimmer 

Satonaka Haruhiko, MD, PhD ...............................................n 

Katherine F Harvey-Kelly, MB BSc ............................................n 

Edward J Harvey, MD 3C – MedTexel; 5 – Synthes, Stryker, Smith & Nephew, Zimmer 

Samer S Hasan, MD, PhD 3B – DJ Orthopaedics; 5 – DJ Orthopaedics, Arthrex, Inc. 

Saqib Hasan, BS ...........................................................n 

Zabeolla Hasanzadeh, MD ..................................................n 

Thomas Hash, MD .........................................................n 

Amir Hasharoni, MD .......................................................n 

Zaid Hashim, MBBS ........................................................n 

Hideo Hashimoto, MD .....................................................n 

Tomoyuki Hashimoto, MD ..................................................n 

Yusuke Hashimoto, MD ....................................................n 

Andrew Haskell, MD .......................................................n 

Joachim Hassenpflug, MD ..................................................n 

Hiroshi Hatano ............................................................n 

Kazuhika Hatayama, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

H Paul Hatten Jr, MD 3B – BoneSupport, AB, DFine, Inc. 

Steven J Hattrup, MD 3B – Zimmer 

Michael Hausman, MD 1 – Smith & Nephew; 3B – Checkpoint Surgical; 

4 – Checkpoint Surgical, NDI Medical 

Leif Ivar Havelin, MD .......................................................n 

Ammar Hawasli, MD, PhD ..................................................n 

David Hawkes, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Richard J Hawkins, MD 1 – DePuy, A Johnson & Johnson Company, Ossur; 

5 – Arthrocare, DJ Orthopaedics, Breg, Smith & Nephew, Medica, OrthoRehab; 


Nicola Hawkinson, MA, RNFA, NP 3B – DePuy, A Johnson & Johnson Company 

Mary Hawn, MD, FACS .....................................................n 

Hiroyuki Hayashi, MD ......................................................n 

Katsuhiro Hayashi, MD .....................................................n 

Kenji Hayashida, MD 3B – Zimmer 

Roman A Hayda, MD 2 – AONA; 3C – BioIntraface 

Brett Hayden, BA ..........................................................n 

Rex Haydon, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Solomon Hayon, BS 3A – Biogen, Idec 

Peyton Hays, MD ..........................................................n 

Sprague Hazard, MD .......................................................n 

Alexandra Hazlerigg, MBBS, MRCS ...........................................n 

Tong-Chuan He, MD, PhD ..................................................n 

John H Healey, MD, FACS 7 – Clinical Orthopaedics and Related Research 

William L Healy, MD 1 – DePuy, A Johnson & Johnson Company 

Wendell M Rogan Heard, MD 6 – Stryker, Extremity Medical 

Andrew C Hecht, MD 2, 3B – Stryker 

James D Heckman, MD 7 – Journal of Bone and Joint Surgery - American, Wolters 


Kimberly Heckman, RN .....................................................n 

David Hedden, MD 3B – Smith & Nephew; 5 – Zimmer; 6 – DePuy, A Johnson & 

Johnson Company, Pfizer, Smith & Nephew 

Daniel J Hedequist, MD 3B – Medtronic Sofamor Danek 

Eric Hegedus, DPT, MSC 7 – Prentice-Hall 

Jo Ellen Hegmann .........................................................n 

Christine S Heim ..........................................................n 

John P Heiner, MD .........................................................n 




David Leonard Helfet, MD 3C – Synthes, OHK Medical Devices, FxDevices 

John G Heller, MD 1, 2, 4 – Medtronic; 3B – Medtronic, Zimmer 

Yonah Heller, BS ...........................................................n 

Edward J Hellman, MD .............................2, 3B – Stryker, NovoNordisk 

Michael Hellman, MD ......................................................n 

Hany F Helmy, MD 5 – Corin U.S.A. 

Xavier Hemery, MD ........................................................n 

Stefan Hemmer, MD .......................................................n 

Cynthia Henderson, OTC, CO 2 – Bledsoe Brace; 3A, 3B, 4 – Viscent Orthopedic 

Solutions; 3C – Bledsoe Brace, BSN Healthcare; 6 – Viscent Orthopedic Solutions, BSN 

Healthcare 

Drew Henderson, MSIV .....................................................n 

Eric Henderson, MD 3A – Medtronic Sofamor Danek 

William G Henderson, PhD .................................................n 

John D Henley, PhD 1 – Motion Analysis 

M Bradford Henley, MD, MBA, FACS 1 – Zimmer; 2 – Stryker, Zimmer; 3B – Gerson 

Lehrman Group, Guidepoint Global, MedACorp., Medical Resource Network, Milliman 

Care Guidelines, Premera Blue Cross, Providence Health & Services, Stryker, United 

Health Care, Zimmer; 3C – DeRoyal, Karen Zupko and Assts., Smith & Nephew, Synergy 

Surgical Technologies, Zimmer; 4 – Synergy Surgical Technologies; 7 – Wolters Kluwer 


R Frank Henn, III MD ......................................................n 

William L Hennrikus Jr, MD .................................................n 

Robert Mikael Henshaw, MD 5 – Amgen Co. 

Matthew Hepinstall, MD ....................................................n 

Jonah Hebert-Davies, MD ...................................................n 

Harry N Herkowitz, MD 1 – Medtronic; 4 – Globus Medical; 7 – Saunders/Mosby- 

Elsevier 

Martin Joseph Herman, MD .................................................n 

Alexia Hernandez-Soria, MD ................................................n 

James H Herndon, MD 7 – Journal of Bone and Joint Surgery - American 

Philippe Hernigou, PhD ....................................................n 

Richard T Herrick, MD .....................................................n 

Wolfgang Herzberg ........................................................n 

John E Herzenberg, MD 4 – Voyant 

Mary A Herzog, MD ........................................................n 

Susanne Hess, MD 3A – Bayer Schering Pharma 

Sydney Hester, MD .........................................................n 

Iftach Hetsroni, MD ........................................................n 

Carolyn Hettrich, MD, MPH .................................................n 

Hinrich JD Heuer, MS ......................................................n 

Peter Heumann, MD .......................................................n 

Timothy E Hewett, PhD .....................................................n 

Nurettin Heybeli, MD, MSc ..................................................n 

Alma Heyl, CCRC ..........................................................n 

Thomas Jan Heyse, MD 3B – Smith & Nephew 

Benton E Heyworth, MD ....................................................n 

Noguchi Hideo, MD ........................................................n 

Laurence D Higgins, MD 1 – Zimmer; 2, 3B – Johnson & Johnson 

Thomas F Higgins, MD 2 – AONA, Smith & Nephew 

Hiroshi Higuchi, MD .......................................................n 

Carlos A Higuera, MD ......................................................n 

Kevin A Hildebrand, MD ....................................................n 

Alan S Hilibrand, MD 1 – Aesculap/B.Braun, Alphatec Spine, Amedica, Biomet, Stryker, 

Zimmer; 4 – Amedica, Benvenue Medical, Life Spine, Nexgen, Paradigm Spine, Pioneer 

Surgical, PSD, Syndicom, Vertiflex 

Joshua Hillman, MS ........................................................n 

Howard Hillstrom, PhD 5 – Ossur 

Ryan Himes ...............................................................n 

Cynthia K Hinds ...........................................................n 

Beat Hintermann, MD 1, 3B, 5 – Integra 

Anthony Christopher Hinz, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

John Hipp, PhD 3A, 4 – Medical Metrics, Inc. 

Cori Hirai, BS .............................................................n 

Kazuo Hirakawa, MD 2 – Zimmer, Biomet, Sanofi-Aventis; 3B, 5 – Zimmer 

Jayme Hiratzka, MD ........................................................n 

39 

disclosure 

Ryo Hirosima, MD .........................................................n 

Philip Hirst, MD 3B – DePuy, A Johnson & Johnson Company; 4 – Advanced Medical 

Solutions 

Kristin Hitchcock ..........................................................n 

Kirby Hitt, MD 1, 3B, 5, 6 – Stryker; 2 – Stryker Convatec 

Murat Hiz, MD ............................................................n 

Karen Hjerstedt, RN ........................................................n 

Christine Ann Ho, MD .....................................................n 

Duarte Y Ho, BS ...........................................................n 

Henry Ho, MSC 4 – Pfizer 

Jessica Mayan Ho, MD ......................................................n 

Pei-Ran Ho, MD 3A, 4 – Amgen Co. 

Bang H Hoang, MD ........................................................n 

H J Hoekstra, MD 5 – Biomet 

Heinz R Hoenecke Jr, MD 1 – Tornier, Arthrex, Inc.; 2, 3B, 5 – Tornier 

Thomas Hoffelner, MD .....................................................n 

Martin Hoffman, MD .......................................................n 

Robert M Hoffman, PhD ....................................................n 

Pierre J Hoffmeyer, MD 5 – DePuy, A Johnson & Johnson Company, Zimmer, Synthes, 

Medacta 

Aaron Adam Hofmann, MD 3B – Zimmer 

Jochen G Hofstaetter, MD ...................................................n 

Paul C Hogrebe, BS ........................................................n 

Justin Hohl, MD ...........................................................n 

Tatsuya Hojo ..............................................................n 

Jorge Hokama, MD ........................................................n 

Annemiek Hol, MsC ........................................................n 

David W Holdsworth .......................................................n 

Danny C Holland, DO ......................................................n 

James Holland, MD 2 – Finsbury; Zimmer; 5 – Smith & Nephew 

Julianne Holloway, BS ......................................................n 

April Holmes ..............................................................n 

Laurens Holmes, PhD, DrPH ................................................n 

Ginger E Holt, MD .........................................................n 

Kathleen Holtzman, BA, BS .................................................n 

Nicolas Holzer, MD, PhD ...................................................n 

Martin Homering, PhD 3A, 4 – Bayer Schering Pharma 

Gabriel James Hommel, MD ................................................n 

Sittisak Honsawek, MD, PhD ................................................n 

Gary John Hooper, MD .....................................................n 

M Hoover, SPT ............................................................n 

Stephen A Hoover, Jr MD 1 – Innomed 

William John Hopkinson, MD 4 – DePuy, A Johnson & Johnson Company, Zimmer, 

Pfizer 

Robert Hopper, PhD 5 – DePuy, A Johnson & Johnson Company 

Martha Hoque, PhD ........................................................n 

Ryan David Horazdovsky, MD ...............................................n 

Kazuichiro Hori, MD .......................................................n 

Shuji Horibe, MD ..........................................................n 

Yutaka Horinouchi, MD ....................................................n 

Walter Horne, DVM 3B – Athersys, Inc. 

John G Horneff, MD .......................................................n 

Francis J Hornicek, MD 3B, 5 – Stryker 

MaryBeth Horodyski, EdD, ATC, 

LAT ......................................................................n 

Daniel Scott Horwitz, MD 1 – DePuy, A Johnson & Johnson Company; 2, 3B – DePuy, 

A Johnson & Johnson Company, Stryker 

Harish Sadanand Hosalkar, MD 2, 3B – Synthes; 4 – GlaxoSmithKline, Johnson & 

Johnson, Pfizer; 5 – Zimmer; 7 – Journal of Bone and Joint Surgery - American, Turner 

White 

Christopher Max Hoshino, MD ..............................................n 

Yuichi Hoshino, MD .......................................................n 

Munier Hossain, FRCS, MSc .................................................n 

Richard Hotchkiss, MD .....................................................n 

Robert N Hotchkiss, MD 7 – Saunders/Mosby-Elsevier 




Tetsuo Hotta, MD ..........................................................n 

Justin Houman, BS .........................................................n 

Thomas Houston, MD ......................................................n 

Lennart Hovelius, MD ......................................................n 

Caitlin Howard, AB ........................................................n 

Jonathan Richard Howell, MD 1, 3B, 5 – Stryker; 

Stephen M Howell, MD 1 – Biomet; 2, 3B – Biomet, Stryker; 7 – Saunders/Mosby- 

Elsevier 

William J Hozack, MD 1, 3B, 5 – Stryker 

Michael Timothy Hresko, MD 3B – Abbott; 4 – Johnson and Johnson; 6 – Biogen Idec 

Adam H Hsieh, PhD 5 – Synthes 

Jui-Yang Hsieh, MD ........................................................n 

Jason Hsu, MD ............................................................n 

Joseph R Hsu, MD 5 – The Geneva Foundation 

Patricia A Hsu, MD .........................................................n 

Wellington Hsu, MD 2 – Stryker; 5 – Baxter, Medtronic Sofamor Danek, Pioneer 

Surgical 

Serena S Hu, MD 3B – Medtronic Sofamor Danek; 5 – DePuy, A Johnson & Johnson 

Company 

Yue-Yung Hu, MD ..........................................................n 

Hsiang-Yao Huang, MD .....................................................n 

Ronald Huang .............................................................n 

Russel C Huang, MD .......................................................n 

Johnny Huard, PhD 3B – Cook Myosite 

James I Huddleston, III MD 2, 5 – Biomet; 3B – Biomet, Smith & Nephew, Zimmer, 

Porosteon 

Paul M Huddleston, MD 3B – Synthes; 4 – Johnson & Johnson, Medtronic Sofamor 

Danek, Novartis, Amgen Co.; 5 – Regeneration Technologies, Inc. 

Axel Hueber, MD ..........................................................n 

Janet L Huebner 4 – Johnson & Johnson, Pfizer 

Carmen Huemmer, MD .....................................................n 

G Russell Huffman, MD ....................................................n 

Alexander P Hughes, MD 3B – BOSS Medical / Bovie; 5 – Nuvasive 

Jeannie Huh, MD ..........................................................n 

Catherine Hui, MD .........................................................n 

Emily Hui .................................................................n 

Olga Huk, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Jason Ray Hull, MD ........................................................n 

Maury L Hull, PhD 6 – Stryker 

Heidi Hullinger, MD .......................................................n 

Kristina G Hulten, PhD .....................................................n 

Matthew Thomas Hummel, MD ..............................................n 

Catherine A Humphrey, MD 3B – Synthes 

Clark T Hung, PhD .........................................................n 

Marc Wilson Hungerford, MD 3B – Zimmer 

Devyani Hunt, MD .........................................................n 

Kenneth Hunt, MD 2 – Smith & Nephew 

Kim Hunter, FRCA .........................................................n 

Robert E Hunter, MD 3B – Breg, Smith & Nephew; 5 – Breg, Biomet, Smith & Nephew 

Tomy S Huon, BS ..........................................................n 

Jennifer Caitlin Huot 6 – DePuy, A Johnson & Johnson Company 

Patrick E Hurley, DO .......................................................n 

Jason Michael Hurst, MD ...................................................n 

Lawrence C Hurst, MD 1 – Biospecifics Technologies Corp.; 3B, 5 – Auxilium 

Pharmaceuticals, Inc. 

Simon A Hurst, MBBS BSc ..................................................n 

James A Hurt, III MD .......................................................n 

Shepard R Hurwitz, MD 7 – Saunders/Mosby-Elsevier 

Sohail Husain, MD .........................................................n 

Nasir Hussain .............................................................n 

Mark R Hutchinson, MD ....................................................n 

Jonathan R Hutt, MBBS, MRCS ..............................................n 

Lorraine Hutzler, BA .......................................................n 

Bo-Hyun Hwang, MD ......................................................n 

Byoung-Yoon Hwang, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

40 

disclosure 

Steven W Hwang, MD 5 – DePuy, A Johnson & Johnson Company 

Robert Hymes, MD 2 – Smith & Nephew; 3B – Smith & Nephew LifeNet Health; 

5 – Southeastern Fracture Consortium 

Joseph P Iannotti, MD, PhD 1 – DePuy, A Johnson & Johnson Company; 3B – DePuy, 

A Johnson & Johnson Company, Tornier, Wyeth; 7 – Wolters Kluwer Health - Lippincott 


Dr Tsuyoshi Ichinose .......................................................n 

Takahiro Ida, MD ..........................................................n 

Osaretin B Idusuyi, MD .....................................................n 

Toru Iga, MD ..............................................................n 

Hirotaka Iguchi, MD 2, 3C – DJ Orthopaedics 

Takahiro Iida, MD .........................................................n 

Katsunori Ikari, MD 2 – Abbott, Eisai, Mitsubishi-Tanabe 

Tessyu Ikawa, MD ..........................................................n 

Hiroyuki Ike, MD ..........................................................n 

Mitsuhiko Ikebuchi, MD ....................................................n 

Ryosuke Ikeguchi, MD ......................................................n 

Roberto Ikemoto, MD ......................................................n 

Victor Manuel Ilizaliturri Sanchez, Jr MD 1, 5 – Smith & Nephew; 2, 3B – Biomet 

Smith & Nephew 

Kevin Ilo. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Asif Ilyas, MD 2 – Medartis; 3B – Integra, Wright Medical Technology, Inc.; 5 – Medartis, 


Kan Imai, MD .............................................................n 

Carl W Imhauser, PhD ......................................................n 

Igor Immerman, MD .......................................................n 

Meghan N Imrie, MD .......................................................n 

Yutaka Inaba, MD 2 – GlaxoSmithKline, Stryker, Sanofi-Aventis, Smith & Nephew; 

5 – Stryker, Smith & Nephew 

Maria Carolina Secorun Inacio, MS ...........................................n 

Stephen J Incavo, MD 1, 2 – Wright Medical Technology, Inc., Stryker; 3B – Wright 

Medical Technology, Inc.; 4 – Wright Medical Technology, Inc., Stryker, Nimbic Systems; 

5 – Stryker, Surgical Monitoring Associates, Inc., Surgical Synergies, Synthes 

Zach Ingwer, BS ...........................................................n 

Alan Innes, MD ............................................................n 

Bernardo Innocenti, PhD 3A – Smith & Nephew 

Massimo Innocenti, MD ....................................................n 

Hirokazu Inoue, MD .......................................................n 

Masayuki Inoue, MD .......................................................n 

Shinichi Inoue, MD ........................................................n 

Taucha Inrig, RN ...........................................................n 

Carrie Inwards, MD ........................................................n 

Christopher August Iobst, MD 2 – Smith & Nephew 

Carlo Iorio, MD ...........................................................n 

Raffaele Iorio, MD .........................................................n 

Richard Iorio, MD .........................................................n 

Michael Iosifidis, MD .......................................................n 

Lisa Ipp, MD ..............................................................n 

James J Irrgang, PhD .......................................................n 

Takashi Ishida, MD ........................................................n 

Katsushi Ishii, MD .........................................................n 

Yoshinori Ishii, MD ........................................................n 

Craig L Israelite, MD 3B – Zimmer 

Nomura Issei, MD .........................................................n 

Eiji Itoi, MD 1 – Alcare; 2 – Eli Lilly, Sanofi-Aventis; 5 – Smith & Nephew 

Shintaro Iwai, MD .........................................................n 

Hiroyoshi Iwaki, MD .......................................................n 

Naoyuki Iwamoto, MD .....................................................n 

Takuji Iwamoto, MD 2 Abbott, Mitsubishi Tanabe Pharma 

Yukihide Iwamoto, MD .....................................................n 

Michael Iwanik, PhD .......................................................n 

Junichi Iwasaki, MD ........................................................n 

Henry J Iwinski, MD .......................................................n 

Teruaki Izaki, MD ..........................................................n 

Byron H Izuka, MD ........................................................n 

Atiba Jackson, MD .........................................................n 




Mark P Jackson, FRCS MBBS ................................................n 

Nancy M Jackson ..........................................................n 

William Jackson, FRCS 2 – Biomet; 4 – Smith & Nephew 

Craig Jacobs, DC ...........................................................n 

Joshua J Jacobs, MD 3B – Medtronic Sofamor Danek, Zimmer; 3C, 4 – Implant 

Protection; 5 – Medtronic Sofamor Danek, Spinal Motion, Zimmer 

Michael A Jacobs, MD 1, 2 – Smith & Nephew, Biomet; 3B – Biomet, Corin U.S.A.; 

6 – Brainlab 

Justin Jacobson, MD .......................................................n 

David Joseph Jacofsky, MD 1 – Stryker, Smith-Nephew; 3B – Stryker; 4 – Bacterin; 

5 – Biomet, Stryker, Smith-Nephew, Arthrex; 7 – SLACK Incorporated 

Marc C Jacofsky, PhD 1 – Stryker; Smith & Nephew; 3B – Stryker, Bacterin; 4 – Bacterin; 

5 – Stryker; 6 – Arthrex, Inc., Corin U.S.A., Mitek, Stryker, Smith & Nephew, Wyeth, KCI, 

Exactech, Inc., Biomet, VQ Orthocare 

Christina L. Jacovides ......................................................n 

Robin Jacquet .............................................................n 

George N Jada .............................................................n 

Sebastian Jaeger, MSc .......................................................n 

S. Mehdi Jafari, MD ........................................................n 

Fredrick Francis Jaffe, MD 2, 3B – Stryker 

William L Jaffe, MD 3B, 5 – Stryker 

Amit Jain, BS ..............................................................n 

Viral Jain, MD .............................................................n 

Parag Kumar Jaiswal, MRCS .................................................n 

Amir A Jamali, MD 3B – Biomet 

Omar Jameel, MD ..........................................................n 

Philip James, PhD 6 – management consultant for a medical data company 

James S Jelinek, MD ........................................................n 

Stephen E James, FRCS .....................................................n 

Simon Jameson ............................................................n 

Miranda Jamieson 3A – MAKO Surgical Corp. 

James M Jamison, PhD 3C, 5 – IC MedTech 

Jim Janey, DC .............................................................n 

Jak Jang, MD ..............................................................n 

Sung-Won Jang, MD ........................................................n 

Yoon Jong Jang, MD ........................................................n 

Jai Jani, MD ...............................................................n 

Abigail Trinidad Jao, BS, MEM-BME 3A – Orthopaedic International, Inc. 

Bryan T Jarrett .............................................................n 

Claudius Jarrett, MD .......................................................n 

Pooya Javidan, MD .........................................................n 

Andrew Jawa, MD ..........................................................n 

Muhammad Umar Jawad, MD ...............................................n 

Subramanyan Jayasankar, MD ................................................ 

Arvind Jayaswal, MS ........................................................n 

Reza Jazayeri, MD ..........................................................n 

Laith M Jazrawi, MD 2 – Smith and Nephew; 3B – Ferring Pharmaceuticals, Core 

Essence 

Kelly Jeans, MSc ...........................................................n 

Mehrad M Jaberi ...........................................................n 

Louis George Jenis, MD 3B – Stryker; 5 – OREF 

Cathy Jenkins, MA .........................................................n 

Cathy Jenkins, MSc .........................................................n 

Matthew V Jenkins, MD .....................................................n 

Paul John Jenkins, MRCSEd .................................................n 

Cyrus D. Jensen, MB BS, MRCS ..............................................n 

Kelly Jensen, DO ...........................................................n 

Eun Kee Jeong, PhD ........................................................n 

Jae-heon Jeong, MD ........................................................n 

Mun Su Jeong, MD .........................................................n 

Kyle James Jeray, MD 2 – AONA; 3B – Zimmer; 5 – Synthes, Zimmer 

Hyung-min Ji, MD .........................................................n 

Xiaofeng Jia, MD, PhD .....................................................n 

Ching Chuan Jiang, MD ....................................................n 

Chunyan Jiang, MD ........................................................n 

41 

disclosure 

Ramon L Jimenez, MD 3B – Zimmer 

Rohit Jindal, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Riyaz H Jinnah, MD 1 – Wright Medical Technology, Inc.; 2, 3B – Wright Medical 

Technology, Inc., MAKO Surgical; 5 – Smith & Nephew, Wright Medical, MAKO Surgical 

William A Jiranek, MD 1, 3B – DePuy, A Johnson & Johnson Company; 5 – Stryker 

Sungkweon Jo, MD ........................................................n 

Frank W Jobe, MD .........................................................n 

Charles M Jobin, MD .......................................................n 

Anders Joensson, MD, PhD .................................................n 

Siddharth B Joglekar, MD ...................................................n 

Norman A Johanson, MD 1 – Exactech, Inc. 

Aaron J Johnson, MD .......................................................n 

Anthony E Johnson, MD 4 – Pfizer 

Darren L Johnson, MD 3B – Smith & Nephew; 5 – DJ Orthopaedics 

Derek R Johnson, MD ......................................................n 

Donald Hugh Johnson, MD 3C – Arthrex, Inc.; 5 – Biosyntech 

Geoffrey V Johnson, FRCS 2 – JRI 

James A Johnson, PhD ......................................................n 

Jared Johnson, MD .........................................................n 

Jeffrey Einer Johnson, MD 1 – OrthoHelix Surgical Designs, Inc.; 3B – OrthoHelix 

Surgical Designs, Inc., Midwest Stone Institute; 4 – OrthoHelix Surgical Designs, Inc., 

Midwest Therapy, LLC; 5 – Midwest Stone Institute, Inc. 

Marie-Clare Johnson, GDP, MMACP ..........................................n 

Mia Johnson, MPH .........................................................n 

Michael Johnson, MD ......................................................n 

Timothy Shane Johnson, MD ................................................n 

Casey D Johnston, MD .....................................................n 

Charles Eugene Johnston II, MD 1, 2, 3C, 5 – Medtronic Sofamor Danek; 


Donald William Cooper Johnston, 

MD ......................................................................n 

Richard C Johnston, MD ....................................................n 

Katherine Johnston, SPT ....................................................n 

Carroll Payne Jones, MD 1 – Arthrex, Inc., Wright Medical Technology, Inc.; 

2, 3B – Wright Medical Technology, Inc., Smith & Nephew; 4 – Wright Medical 

Technology, Inc., RTIX; 5 – Orthofix, Inc.; 7 – Wolters Kluwer Health - Lippincott 


Clifford B Jones, MD 2 – AONA 

Deryk G Jones, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Grant L Jones, MD 3C – Arthrotek; 5 – Biomet, Genzyme 

Kay S Jones, RN ............................................................n 

Kerwyn Jones, MD 3C – Orthopediatrics;7 – Cambridge Publishing 

Kevin Jones, MD ...........................................................n 

Kristofer Jones, MD ........................................................n 

Lynne C Jones, PhD ........................................................n 

Jong-Hwan Joo, MD ........................................................n 

Yonsik Yoo ................................................................n 

Charles J Jordan, MD .......................................................n 

Martin I Jordanov, MD ......................................................n 

Anton Yang Jorgensen, MD ..................................................n 

Rohan Joshi, BA ...........................................................n 

Bernhard Jost, MD 3B, 5 – Zimmer 

Patrick Jost, MD ...........................................................n 

Thomas Joyce, PhD ........................................................n 

Kevin L Ju, MD ............................................................n 

Kethy Jules-Elysee, MD .....................................................n 

Ho Joong Jung ............................................................n 

Kwang Am Jung, MD .......................................................n 

Martin Jung, MD ...........................................................n 

Michael Jung, PhD .........................................................n 

Mr Woo Bin Jung ..........................................................n 

Woon-hwa Jung, MD .......................................................n 

Young-Bok Jung, MD .......................................................n 

Donald Jungkind, MD 6 – Pfizer 

Jesse B Jupiter, MD 3B, 4 – OHK; 3C – Synthes, Eisomed; 5 – AO Foundation; 

7 – Elsevier Thieme 




Tamon Kabata, MD ........................................................n 

Korush Kabir, MD .........................................................n 

Ron Kaczmarek, MD .......................................................n 

Anish Raj Kadakia, MD .....................................................n 

Yoshinori Kadoya, MD 1, 2 – Biomet 

Warren R Kadrmas, MD 3C, 4 – Pivot Medical 

Christopher C Kaeding, MD 3B – Biomet; 5 – Omeros Company 

David M Kaehr, MD ........................................................n 

Dinesh Kafle, MD ..........................................................n 

Yoan Kagoma, BS ..........................................................n 

Alexandra Kaider, MSc ......................................................n 

David N Kaimrajh 5 – Novalign, FxDevices, Alphatec, Nutek, Mediscope 

Yoshitomo Kajino, MD .....................................................n 

Sanjeev Kakar, MD .........................................................n 

Masataka Kakihana, MD ....................................................n 

Ryosuke Kakinoki, MD .....................................................n 

David Mark Kalainov, MD 2 – UPEX 

Michael Kalisvaart, MD .....................................................n 

Niraj Kalore, MD ..........................................................n 

Check C Kam, MD .........................................................n 

Satoshi Kamada, MD .......................................................n 

Atul F Kamath, MD 7 – Elsevier, Vindico 

Koya Kamikawa, MD .......................................................n 

Srinath Kamineni, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Christine Kaminski, BA .....................................................n 

Nikolaos K Kanakaris, MD 3B – Stryker; 5 – DePuy, A Johnson & Johnson Company, 

AMGEN, KUROS, Synthes 

Masahiro Kanayama, MD 2 – DePuy, A Johnson & Johnson Company, Stryker; 

3B – Robert-Reid Inc. 

Kazuki Kanazawa, MD ......................................................n 

Vamsi Kancherla, MD ......................................................n 

Utku Kandemir, MD 5 – Biomet, Stryker, Synthes 

Patrick Kane, MD ..........................................................n 

Takeshi Kaneko, MD, MS ...................................................n 

Tetsuya Kaneko, MD .......................................................n 

Tomonori Kaneko, MD .....................................................n 

Bun-Jung Kang, MD ........................................................n 

Daniel Kang, MD ..........................................................n 

Hyun-Guy Kang, MD .......................................................n 

James Kang, MD 5 – Johnson & Johnson, Stryker 

Jung Ho Kang, MD .........................................................n 

Kyung-Do Kang, MD .......................................................n 

Matthew M Kang, MD ......................................................n 

Richard W Kang, MD .......................................................n 

Yeon Gwi Kang, MD ........................................................n 

Linda E A Kanim, MA 4 – Medtronic 

Mr Wajdi Kanj .............................................................n 

Masanobu Kano, MD .......................................................n 

Stephen R Kantor, MD 3C – DePuy, A Johnson & Johnson Company; 4, 5 – DePuy, 

A Johnson & Johnson Company, Stryker, Zimmer 

Bertrand Paul Kaper, MD 3B – Smith & Nephew 

Leon Kaplan, MD 3C – Medtronic Sofamor Danek, MAZOR Surgical Technologies 

Lige Kaplan, MD ...........................................................n 

Sheldon L Kaplan, MD 5 – Cubist; 7 – Elsevier 

Thomas Kappe, MD ........................................................n 

Ashley L Kapron, BS ........................................................n 

Bart L Kaptein, PhD ........................................................n 

Mustafa Karahan, MD ......................................................n 

Georgios I Karaliotas, MD, MSc ..............................................n 

Spero G Karas, MD 1, 2, 3B – DJ Orthopaedics; 5 – Synthes; 6 – Mitek, ConMed 

Linvatec, Arthrex, Inc. 

Hirotaka Karashima, MD ...................................................n 

Lauren E Karbach, MS ......................................................n 

Rami Kardosh, MD .........................................................n 

Judson W Karlen, MD ......................................................n 

42 

disclosure 

Jon Karlsson, MD ..........................................................n 

Lori A Karol, MD 7 – Journal of the American Academy of Orthopaedic Surgeons, 


Johan Nils Karrholm, MD 2 – Stryker, Link Orthopaedics; 4 – RSA Biomedical, Umeå, 

Sweden; 5 – Zimmer, Biomet, DePuy, A Johnson & Johnson Company 

Yuichi Kasai, MD 1 – KiSCO Co. Ltd. 

Nobuhiro Kashima, MD ....................................................n 

Monika Kasinova, SPT ......................................................n 

Sina Kasraeian, MD 4 – Stryker, Smith & Nephew 

James R Kasser, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Satoshi Kato, MD ..........................................................n 

Yuki Kato, MD .............................................................n 

Pavlos Katonis, MD ........................................................n 

Gregory Katz ..............................................................n 

Jeffrey N Katz, MD .........................................................n 

Annette Kaufman, PhD, MPH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Akira Kawabata, MD .......................................................n 

Norio Kawahara, MD .......................................................n 

Kosei Kawakami, MD .......................................................n 

Keiichi Kawanabe 1 – Nakashima Medical (Japan); 2 – Japan Medical Materials 

Osamu Kawano, MD .......................................................n 

Hiroyuki Kawashima, MD ...................................................n 

David B Kay, MD 3C, 4 – OrthoHelix Surgical Designs 

Mitsunori Kaya, MD ........................................................n 

Kathryn E Kean, BA ........................................................n 

Thomas J Kean, PhD 3B, 3C – Cell Targeting LLC; 4 – Aastrom Bioscience, GE 

Healthcare 

Stephen Kearing, MS .......................................................n 

Sean Patrick Kearney, MD ...................................................n 

Kenneth Kearns, MD .......................................................n 

E Michael Keating, MD 1, 5 – Biomet; 2, 3B – Biomet, Johnson & Johnson; 4 – Johnson 

& Johnson 

Gail Sue Keating, OPA 1, 6 – Biomet; 2 – Johnson & Johnson; 3B – Biomet, Johnson & 

Johnson; 5 – Baxter 

Khaled M- Kebaish, MD 2 – DePuy, A Johnson & Johnson Company, Stryker; 3B, 

5 – DePuy, A Johnson & Johnson Company; 4 – K2M 

Johannes Keck .............................................................n 

Eric Keefer, MD ............................................................n 

Marius Keel, MD ...........................................................n 

John Joseph Keeling, MD ...................................................n 

Mary Ann E Keenan, MD ....................................................n 

James S Keene, MD .........................................................n 

Jay D Keener, MD ..........................................................n 

James A Keeney, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Rose Kelem, RN ...........................................................n 

Mehmet Halidun Kelestemur, Assc Prof .......................................n 

James F Kellam, MD ........................................................n 

Andres Keller, MD .........................................................n 

Julie M Keller, MD .........................................................n 

Catherine Kellett, FRCS .....................................................n 

Todd Kelley, MD ...........................................................n 

Paula Kelly-Pettersson, RN ..................................................n 

Anne Mary Kelly, MD .......................................................n 

Bryan T Kelly, MD 3C, 4 – Pivot Medical, A-2 Surgical; 5 – Pivot Medical 

Derek Michael Kelly, MD ....................................................n 

James D Kelly, II MD 2, 3B, 4, 5 – Tornier 

John D Kelly IV, MD 7 – SLACK Incorporated 

Matthew J Kelly, MD 6 – Arthrocare 

Michael Kelly, PA-C 4 – OMNI Life Science Osseon 

Michael A Kelly, MD 1 – Zimmer; 3B – Johnson & Johnson, Zimmer; 4 – Pfizer 

Natalie Kelly ..............................................................n 

Sean Kelly ................................................................n 

Graham Kemp, DM ........................................................n 

Dan Kemper, MD ..........................................................n 

Laurence Kempton, MD ....................................................n 




Daniel Kendoff, MD ........................................................n 

Benjamin JL Kendrick, MRCS ................................................n 

Oguro Kenji, MD ..........................................................n 

John G Kennedy, MD .......................................................n 

William R Kennedy, MD 5, 6 – Corin U.S.A. 

Julia A Kenniston, MD ......................................................n 

Keith Kenter, MD ..........................................................n 

Iwasaki Kenyu, MD ........................................................n 

Gun Keorochana, MD ......................................................n 

Curtis J Kephart, MD .......................................................n 

Christopher Kepler, MD ....................................................n 

James Kercher, MD .........................................................n 

Brian Scott Kern, MD .......................................................n 

Michael Kertzner ...........................................................n 

David Keyes, MD ..........................................................n 

Mahmoud Michael Khair, MD ...............................................n 

Saurabh Khakharia, MD ....................................................n 

Yaser Emam Khalifa ........................................................n 

Jad Khalil, MD 6 – GE Healthcare 

Bushra Khan, RN ..........................................................n 

Shah Alam Khan, MD ......................................................n 

A Jay Khanna, MD 3B – Orthofix, Inc.; 4 – New Era Orthopaedics, LLC; 6 – Siemens, 

Inc.; 7 – Thieme Medical Publishers 

Monica Khanna, MD .......................................................n 

Harpal Singh Khanuja, MD .................................................n 

Monti Khatod, MD .........................................................n 

Dharmesh Khatri, MS ......................................................n 

Dr Michael S Khazzam .....................................................n 

Ahmed Khefacha. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Akbar Khodadadi, MD ......................................................n 

Amal Khoury, MD ..........................................................n 

Anthony Khoury, BS ........................................................n 

W Benjamin Kibler, MD 3C, 4 – Alignmed 

Leonard K Kibuule, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Karl-Philipp Kienle .........................................................n 

Theresa Kijek, BS ..........................................................n 

Ayhan Kilic, MD ...........................................................n 

Kathleen Killeen, OT .......................................................n 

Cecilia E Kim, BA 3B, 4, 5 – ELAN 

Choll Kim, MD 1 – Hydrocision; 2, 3B – Globus Medical, Synthes, Spine view; 

4 – Globus Medical 

David Kim, MD ............................................................n 

Dong-Soo Kim, MD ........................................................n 

Dongwook Kim, MD .......................................................n 

Hee Joong Kim, MD 1 – Corentec, Zimmer; 3B – Bayer; 4 – Corentec 

Hubert T Kim, MD .........................................................n 

Hye Ran Kim, PA ...........................................................n 

Hyeon Joo Kim, PhD .......................................................n 

Hyun Min Kim, MD ........................................................n 

Hyunchul Kim, MS .........................................................n 

Jae Kwang Kim, MD ........................................................n 

Jaehon M Kim, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Jeffrey D Kim, BS ..........................................................n 

Jeong Suh Kim, MD ........................................................n 

Joon Yub Kim, MD .........................................................n 

Joon-Hyung Kim, BS .......................................................n 

Jun Shik Kim, MD .........................................................n 

Jung Man Kim, MD ........................................................n 

Kang-Il Kim, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Ki-Choul Kim, MD .........................................................n 

Paul D Kim, MD ...........................................................n 

Paul R Kim, MD 3B – Stryker, Wright Medical Technology, Inc.; 5 – Wright Medical 


Raymond H Kim, MD 2, 5 – DePuy, A Johnson & Johnson Company 

Sae Hoon Kim, MD ........................................................n 

43 

disclosure 

Seong Eun Kim, PhD .......................................................n 

Seung-Ho Kim, MD 3B – Arthrex, Inc.; 5 – Arthrex, Inc., Tornier, Neurowave 

Dr Stephen Kim ...........................................................n 

Sung-Hwan Kim, MD .......................................................n 

Sung-Jae Kim, MD .........................................................n 

Sun-Mi Kim, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Sunny H Kim, PhD 3B – Heraeus Medical GmbH 

Tae Kyun Kim, MD 2, 3B, 5 – Smith & Nephew; Aesculap/B.Braun 

Tae-young Kim, Prof .......................................................n 

Woo Kim, PhD ............................................................n 

Yang-Soo Kim, MD .........................................................n 

Yong Sik Kim, MD .........................................................n 

Yong-Min Kim, MD ........................................................n 

Yong H Kim, MD 3B – Biomet 

Yongjung J Kim, MD 5 – DePuy, A Johnson & Johnson Company 

Young-Hoo Kim, MD 1 – DePuy, A Johnson & Johnson Company 

Young Jo Kim, MD 3C, 6 – Siemens Heath Care; 4 – Johnson & Johnson, Procter & 

Gamble; 5 – Bayer Health Care, Siemens Health Care 

Atsushi Kimura, MD .......................................................n 

Hiroaki Kimura, MD .......................................................n 

Kirk Kindsfater, MD 2, 3B, 5 – DePuy, A Johnson & Johnson Company 

Akilah B King, BA ..........................................................n 

David M King, MD .........................................................n 

Graham J W King, MD 1 – Wright Medical Technology, Inc., Tornier, Tenet Medical; 

3B – Wright Medical Technology, Inc., Tornier 

Joseph John King, III MD ...................................................n 

Tammy King ..............................................................n 

Kouichi Kinoshita, MD .....................................................n 

Stuart D Kinsella, BA .......................................................n 

Tracy Kinsey, RN 5 – Stryker 

Amit Kiran, MA ............................................................n 

Kiran Singisetti, MRCS .....................................................n 

Jess McKarns Kirby, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Joern Kircher, MD 2 – Bayer Healthcare; 3B – Lima SPO SPA 

Andrew Kirkpatrick, BS .....................................................n 

Kevin L Kirk, DO ..........................................................n 

Kelley Kirkpatrick, BS ......................................................n 

Marcus Kirkpatrick, MD ....................................................n 

John M Kirkwood, MD .....................................................n 

Faraj Kirmanj, MD .........................................................n 

Shunji Kishida, MD 5 – Wright Medical Technology, Inc.; 6 – Stryker 

John D Kisiday, PhD .......................................................n 

Michael John Kissenberth, MD ..............................................n 

Alison Kitay, MD ...........................................................n 

Diana L Kivirahk ..........................................................n 

Takahiko Kiyama, MD ......................................................n 

Brian A Klatt, MD 7 – SLACK Incorporated 

Joshua Klatt, MD ..........................................................n 

Wolfgang Klauser, MD 1, 3B, 5 – Zimmer; 2 – Link Orthopaedics, Zimmer 

Brian D Kleiber, MD .......................................................n 

Gregg R Klein, MD 2 – Zimmer; 3B – Biomet, Zimmer 

Sandra E Klein, MD ........................................................n 

Conor P Kleweno, MD ......................................................n 

Alison K Klika, MS .........................................................n 

Matthew L Klima, DO ......................................................n 

Erica Knavel, BS ...........................................................n 

Jeffrey B Knox, MD .........................................................n 

Markus Knupp, MD ........................................................n 

Jih-Yang Ko, MD ...........................................................n 

Hiroaki Kobashi ...........................................................n 

Masaaki Kobayashi .........................................................n 

Naomi Kobayashi, MD .....................................................n 

Tsutomu Kobayashi, MD ....................................................n 

Nursen Koc, PhD ..........................................................n 




Tugrul Kocak, MD .........................................................n 

Baris Kocaoglu, MD ........................................................n 

Prof Mehmet Kocaoglu .....................................................n 

Mininder S Kocher, MD, MPH 1 – Biomet; 3B – Biomet, OrthoPediatrics, PediPed, 

Smith & Nephew; 4 – Fixes 4 Kids, Pivot Medical; 7 – WB Saunders 

Gautam Kodikal, MD .......................................................n 

Elizabeth A Koehler, MS ....................................................n 

Steven Koehler ............................................................n 

Werner Koehnlein, MD .....................................................n 

Linda A Koester ............................................................n 

John Koethe, ND. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Atsushi Koguchi, PT ........................................................n 

In Jun Koh, MD ...........................................................n 

Jason L Koh, MD 3B – Aesculap/B.Braun, Arthrex, Inc.; 3C – Aperion 

Kyoung-Hwan Koh, MD ....................................................n 

Young Do Koh, MD, PhD ...................................................n 

Joachim Kohn PhD 1 – TyRx Pharma, Inc., Reva Medical, Inc.; 3B, 4, 5 – Reva Medical, 

Inc., Trident Biomedical, Inc., Lux Biosciences, Inc. 

Tatsuya Koike 2, 5 – Abbott, Bristol-Myers Squibb, Takeda, Eisai, Mitsubishi Tanabe, 

Chugai, Ono, Teijin; 3C – Bristol-Myers Squibb; 6 – Kyusai 

Hayato Koishi .............................................................n 

Kota Koizumi, MD .........................................................n 

Alison Kok ................................................................n 

Alexander Kolb, MD ........................................................n 

David J Kolessar, MD 2 – Ferring Pharmaceuticals; 4 – Zimmer 

Patricia A Kolowich, MD ....................................................n 

David E Komatsu, PhD 4 – Amgen Co., Medtronic 

Richard D Komistek, PhD 3B – DePuy, A Johnson & Johnson Company; 5 – DePuy, 

A Johnson & Johnson Company, Medtronic, National Institutes of Health (NIAMS & 

NICHD), Tornier, Wright Medical Technology, Inc. 

Elizaveta Kon, MD .........................................................n 

Sujith Konan, MRCS .......................................................n 

Geoffrey Konopka, MPH ....................................................n 

Kyung-Hoi Koo, MD .......................................................n 

Kyung Hoe Koo, MD .......................................................n 

Dr Deborah Kopansky-Giles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Wael MT Koptan, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Yael Korin, PhD ...........................................................n 

Feza Korkusuz, MD ........................................................n 

Petek Korkusuz, MD, PhD ..................................................n 

Martin B Kornblum, MD 3B, 4 – Nuvasive 

Tatiana Korotkova .........................................................n 

Yona Kosashvili, MD .......................................................n 

Nusret Kose, MD ...........................................................n 

Resit Dogan Koseoglu, MD ..................................................n 

Paul K Kosmatka, MD ......................................................n 

Dhanasekaran Kotilingam, MD ..............................................n 

Stephen Kottmeier, MD .....................................................n 

Prakash Kotwal, MS ........................................................n 

Suhel Kotwal, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Dimitrios Kotzamelos, MD ..................................................n 

Denise Koueiter ...........................................................n 

Stelios A Koutsoumbelis, MD ................................................n 

Rudy Kovachevich, MD .....................................................n 

Mark W Kovacik 4 – Cardinal Health; 5 – Zimmer, Astro Met, IC-MedTech 

Kenneth J Koval, MD 1 – Biomet; 2 – Biomet, Sanofi-Aventis, Stryker; 3B, 5 – Biomet, 

Stryker; 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Jens Kowal, PhD 3B – Surgical Planning Associates 

Marc S Kowalsky, MD ......................................................n 

Loukas Koyonos, MD .......................................................n 

Milan Kolar, MD, PhD 2 – Pfizer, Merck, Abbott 

Jeanine Kozich, MD ........................................................n 

Scott H Kozin, MD .........................................................n 

Matthew J Kraay, MD 5 – Zimmer, National Institutes of Health (NIAMS & NICHD) 

Kenneth A Krackow, MD1, 3B, 5 – Stryker 

44 

disclosure 

Paul Kraemer, MD 2 – Stryker; 3A – Exactech, Inc. 

Martin Hans Krag, MD 1 – DePuy, A Johnson & Johnson Company; 3B, 5 – Spineology 

John F Kragh Jr, MD 3C – Tiger Tourniquet, LLC, Tactical Medical Solutions, LLC, 

Combat Medical Solutions, Inc., Composite Resources Inc., Delfi Medical Innovations, 

Inc., North American Rescue Products LLC, H & H Associates, Inc., Creative & Effective 

Technologies, Inc., TEMS Solutions, LLC, Blackhawk Products Group, Hemaclear 

Patricia Kramer, PhD .......................................................n 

Nadine Kraska, MD ........................................................n 

Svetlana Krasnokutsky, MD .................................................n 

Andrew Kraszewski, MS .....................................................n 

Virginia Byers Kraus, PhD 3B – GlaxoSmithKline, Regeneron, TransPharma 

James A Krcik, MD .........................................................n 

Viktor Erik Krebs, MD 1 – Shukla Medical (Extract-All); 2 – Shukla Medical (Extract- 

All), Stryker, Salient Surgical; 3B – Stryker, Shukla Medical (Extract-All) 

Hans J Kreder, MD 5 – Synthes, Biomet, Zimmer 

Philip James Kregor, MD 3C – Synthes, AO Technical Commission 

Cole Robert Kreofsky, BS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Jennifer Kreshak, MD ......................................................n 

James C Krieg, MD 1 – SAM Medical, Synthes, CMF; 3B – Synthes 

Sumant G Krishnan, MD 1 – Tornier, TAG Medical, Ossur; 2 – Tornier; 3B – Tornier, 

TAG Medical; 6 – Deputy, Mitek, Tornier; 7 – Wolters Kluwer 

Ajit A Krishnaney, MD ......................................................n 

Martin Krismer, MD 5 – Stryker; 6 – Link Orthopaedics 

Chad A Krueger, MD .......................................................n 

Lisa M Kruse, MD 3A, 4 – Medtronic 

Aaron J Krych, MD .........................................................n 

William J Krywicki, MD 4 – Johnson & Johnson 

Erik Kubiak, MD 3B – DJ Orthopaedics, Orthopaedic Development Co. (ODC), 

Tornier, Zimmer; 6 – Biomet, Synthes 

Tadahiko Kubo, MD, PhD ...................................................n 

Toshikazu Kubo, MD .......................................................n 

Mitchell D Kuhl, DO .......................................................n 

John E Kuhn, MD 1 – Pfizer; 5 – Arthrex, Inc. 

Matt Kuklis, MS 4 – Pfizer, Procter & Gamble 

Abhaya V Kulkarni, MD .....................................................n 

Sachin Kulkarni, MD .......................................................n 

Ashok Kumar, MS Orth .....................................................n 

Vijay Kumar, MD ..........................................................n 

Kensuke Kume, ME ........................................................n 

Sanford S Kunkel, MD ......................................................n 

Tsutomu Kurata, PT ........................................................n 

Mark F Kurd, MD ..........................................................n 

Michael Kurdziel, BS .......................................................n 

Daisuke Kuroda, MD .......................................................n 

Anton Kurtz, MD ..........................................................n 

Steven M Kurtz, PhD 5 – Stryker, Zimmer, Biomet, Medtronic, Synthes, Invibio, 

Stelkast, Ticona, Active Implants 

William B Kurtz, MD 3C – Wright Medical Technology, Inc. 

John Kurylo, MD ..........................................................n 

Peter R Kurzweil, MD 2 – Covidien; 3C – Pierce Surgical Corporation; 4 – Orteq 

Harvey Kushner, PhD 3A, 4 – Auxilium 

Ifedayo Kuye ..............................................................n 

Paul Robert Kuzyk, MD, FRCSC, MSc 5 – Stryker 

Steve Kwak, MD ...........................................................n 

Seok-hyun Kweon, Prof .....................................................n 

John Y Kwon, MD 7 – Journal of Bone and Joint Surgery - American 

Michael Soon Kwon, MD ...................................................n 

Sae Kwang Kwon, MD ......................................................n 

Soon Yong Kwon, MD ......................................................n 

Young-Min Kwon, MD, PhD .................................................n 

Young W Kwon, MD, PhD 3B – Exactech, Inc., Smith & Nephew 

Richard F Kyle, MD 1, 3B – Smith & Nephew, Zimmer 

Lee Kyoung Min, MD .......................................................n 

Gonzalo Labarca, MS .......................................................n 

Luca Labianca, MD .........................................................n 




Sameh A Labib, MD 2 – Arthrex, Inc.; 4 – ConforMIS Inc., Zimmer 

Paul F Lachiewicz, MD 1 – Innomed; 3B – GlaxoSmithKline; 5 – Zimmer 

Debra Lackie, BSN .........................................................n 

Richard D Lackman, MD 3B, 5 – Stryker 

Amy L Ladd, MD 1 – Orthohelix; 3B – Acumed, LLC; 4 – Articulinx LLC, Extremity 

Medical LLC, Illuminoss, OsteoSpring Medical, Inc.; 5 – OREF 

Rani Lador, MD ............................................................n 

Virginia Lafage 4 – Nemaris LLC 

George Yves Laflamme, MD 3B – Stryker; 5 – Smith & Nephew, Synthes, DePuy, A 


Laurent Lafosse, MD 1, 2, 3B, 3C, 5 – TAG 

Daniel Lage, BA ............................................................n 

Catherine N Laible, MD .....................................................n 

Dror Lakstein, MD .........................................................n 

Ferdinand Lali, PhD ........................................................n 

Patrick H Lam .............................................................n 

Lauren Elizabeth Lamont, MD ...............................................n 

Mario Lamontagne .........................................................n 

Gerard F Lancaster, MD .....................................................n 

Sarah L Lancianese, PhD 3A, 4 – Wright Medical Technology, Inc. 

Stefan Landgraeber, MD 3B – Wright Medical Technology, Inc. 

William J Landis ...........................................................n 

Glenn C Landon, MD 3B – Wright Medical Technology, Inc., CareFusion 

Joseph M Lane, MD 2 – Eli Lilly, Harvest Technologies, Inc., Novartis, Weber Chilcott; 

3B – Amgen Co., BioMimetic, Zimmer, DFine, Inc., Graftys SA, Eli Lilly, Bone 

Therapeutics, Inc., Innovative Clinical Solutions, Zelos, Inc., Kuros, Inc. 

Jeffrey K Lange, MD ........................................................n 

Maxwell K Langfitt, MD .....................................................n 

David Langton 2 – Wright Medical Technology, Inc., DePuy, A Johnson & Johnson 

Company; 3B – Wright Medical Technology, Inc. 

Todd Joseph Lansford, MD ..................................................n 

David Lansky, PhD .........................................................n 

Jacob Lantry, MD ..........................................................n 

Joseph T Lanzi, Jr MD ......................................................n 

William Lanzinger, MD .....................................................n 

Anthony S Lapinsky, MD 3B – Pioneer 

Peter Lapner, MD ..........................................................n 

Dawn LaPorte, MD 4 – Auxilium 

Robert F LaPrade, MD, PHD 1, 3B – Arthrex, Inc.; 5 – Arthrex, Inc., Smith & Nephew, 

Ossur; 7 – Thieme 

Joaquin Lara, MD 3B - Stryker 

Justin M LaReau, MD 2, 6 – Arthrex, Inc. 

Robert Kamiel Lark, MD ....................................................n 

Connor Raymond LaRose, MD ...............................................n 

Annalise Noelle Larson, MD .................................................n 

Christopher Larson, MD 2, 5 – Smith & Nephew; 3B – Smith & Nephew, A2 Surgical; 

4 – A2 Surgical 

Tally E Lassiter Jr, MD ......................................................n 

Carmen Latona, MD ........................................................n 

Loren L Latta, PhD 3B – Biedermann Motech, GmbH; 3C – FxDevices, NuTek 

Orthopaedics; 5 – Alphatec Spine, DePuy, A Johnson & Johnson Company, Lippincott, 

National Institutes of Health (NIAMS & NICHD), Synthes, DOD; 7 – Springer, 


Michael J Latteier, MD ......................................................n 

Edmund Lau, MS 3B – Stryker, Kyphon Inc., Amgen Co., Alcon Corp. 

Kristen Lauing, BS .........................................................n 

Cato T Laurencin, MD, PhD 2 – Zimmer, Smith and Nephew; 3B – Soft Tissue 

Regeneration; 4 – Osteotech, Bristol-Myers Squibb 

Carlos J Lavernia, MD 1, 3B, 5 – MAKO Surgical Corp.; 4 – Johnson & Johnson, 

Zimmer 

Keith W Lawhorn, MD 1, 3B – Biomet 

J. Todd R. Lawrence, MD 4 – Practice Medical Instruments, LLC 

Bryan K Lawson, MSc .......................................................n 

Michel Jean Le Duff ........................................................n 

Jason T Le, BS .............................................................n 

Ryan W Leaver, DPT ........................................................n 

45 

disclosure 

Darren R Lebl, MD .........................................................n 

Christopher T LeBrun, MD ..................................................n 

Lance E LeClere, MD .......................................................n 

Stephane Leduc, MD 2, 3B – Stryker; 5 – Amgen Co., DePuy, A Johnson & Johnson 

Company, Synthes, Stryker, Smith & Nephew 

Arthur T Lee, MD ..........................................................n 

Choon-Ki Lee .............................................................n 

Choong-Hee Lee, MD .......................................................n 

Chung-Chien Lee, MD ......................................................n 

Donald H Lee, MD 1, 2, 3B, 5, 6 – Biomet; 7 – Elsevier 

Dong-Ho Lee, MD .........................................................n 

Elaine Lee 3A – Johnson & Johnson, Medtronic, Medtronic Sofamor Danek; 

4 – Johnson & Johnson, Medtronic 

Eric K Lee, MD ............................................................n 

Gwo-Chin Lee, MD .........................................................n 

Gye Wang Lee, MD .........................................................n 

Ho Hyung Lee, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Hyun-Il Lee, MD ...........................................................n 

Hyun-Joo Lee, MD .........................................................n 

Hyung-joon Lee, MD .......................................................n 

Jae Young Lee, MD .........................................................n 

Joe Lee, MD ...............................................................n 

Jonathan H Lee, MD ........................................................n 

Joon Kyu Lee, MD ..........................................................n 

Joon Yung Lee, MD .........................................................n 

Kenny Won Jae Lee, MD ....................................................n 

Keun Bae Lee ..............................................................n 

Ki Seok Lee, Prof ...........................................................n 

Kil Jae Lee, MD ............................................................n 

Kwang-Bok Lee, MD ........................................................n 

Kyung-Hag Lee, MD ........................................................n 

Kyung-Jae Lee, MD .........................................................n 

Lorrin SK Lee, MD .........................................................n 

Mark A Lee, MD 2 – Synthes, Zimmer; 3B – Synthes, Zimmer, Biomet; 5 – Synthes, 

Zimmer, Smith & Nephew; 6 – Synthes 

Myung Chul Lee, MD .......................................................n 

Paul T H Lee, MD ..........................................................n 

Sahnghoon Lee, MD ........................................................n 

Sang Hak Lee, MD .........................................................n 

Sang-Min Lee, MD .........................................................n 

Seung Yup Lee, MD ........................................................n 

Simon Lee, MD ............................................................n 

Stella Lee, BA ..............................................................n 

Steve K Lee, MD 3C – Arthrex, Inc., Synthes; 5 – Arthrex, Inc., Stryker, Mitek 

Su-Chan Lee, MD ..........................................................n 

Sung-Yoon Lee, MD ........................................................n 

Thay Q Lee, PhD 5 – Arthrex, Inc., Smith & Nephew, Synthes; 7 – McGraw 

Tong Joo Lee, MD, PhD .....................................................n 

Woo Suk Lee, MD ..........................................................n 

Young-Kyun Lee, MD .......................................................n 

Yun-Kyoung Lee ...........................................................n 

Mark C Leeson, MD, FACS ..................................................n 

Arabella I Leet, MD ........................................................n 

Sean Lefloch, BS 3B – Synthes 

Ronald Arthur Lehman, MD .................................................n 

Ross K Leighton, MD 1 – Zimmer; 2 – Biometric, DePuy, A Johnson & Johnson 

Company, Etex, Smith & Nephew, Stryker, Synthes; 3B – Etex, Smith & Nephew; 

5 – DePuy, A Johnson & Johnson Company, Smith & Nephew, Synthes; 6 – Etex, Smith 

& Nephew 

Charles F Leinberry, MD 1, 7 – Core Essence; 2 – Auxilium, Core Essence; 3B – Core 

Essence, Auxilium, Xylos, Knee Creations, Core Essence; 4 – Knee Creations; 5 – Xylos 

Jeff Leiter, MSc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Andreas Leithner, MD ......................................................n 

Elliott H Leitman, MD ......................................................n 

Angela LeMarr, RN .........................................................n 




Tom E Lemaster, MSN, MEd, RN, EMT-P ......................................n 

Mesfin A Lemma, MD 2, 3B – Orthofix, Inc. 

Jack E Lemons, PhD 2, 3B – Biomet, Smith and Nephew; 6 – Biomet, Smith and 

Nephew, Stryker, Zimmer 

Stephen E Lemos, MD, PhD .................................................n 

Christopher J Lenarz, MD ...................................................n 

Martha K Lenhart, MD ......................................................n 

Mark Lenhoff 4 – Pfizer 

Lawrence G Lenke, MD 1, 3C – Medtronic; 5 – DePuy, A Johnson & Johnson Company, 

Medtronic, Axial Biotech; 7 – Quality Medical Publishing 

Roorda Leo, MD, PhD 5 – Pfizer, Servier 

James Patrick Leonard, MD .................................................n 

James Leonards ............................................................n 

Danilo Leonetti, MD .......................................................n 

Seth S Leopold, MD ........................................................n 

Daniel M Lerman, MD ......................................................n 

Benjamin A. Lerner, AB .....................................................n 

Pisit Lertwanich, MD .......................................................n 

James Lesko, PhD 3B – DePuy, A Johnson & Johnson Company 

Bryson Lesniak, MD ........................................................n 

G Douglas Letson, MD 2, 3B – Stryker 

Michael Leunig, MD 3B – Smith & Nephew; 3C, 4 – Pivot Medical 

Brian Levack ..............................................................n 

Fraser J Leversedge, MD 1, 3B, 4, 5 – Orthohelix Surgical Designs; 7 – Wolters Kluwer 


Gabriel Levi, MD ..........................................................n 

Paul Levin, MD ............................................................n 

Brett Russell Levine, MD 2 – Angiotech, Ethicon; 3B – Zimmer; 5 – Zimmer, Biomet 

David S Levine, MD ........................................................n 

Harlan B Levine, MD 2 – Zimmer; 3B – Biomet 

William N Levine, MD ......................................................n 

Timothy J Levison, MS ......................................................n 

Seth Levitz, MD ............................................................n 

Bruce A Levy, MD 1 – VOT Solutions; 3B – Arthrex, Inc. 

David Levy, MD 1 – Trainer’s Choice Sports Medicine Products 

Jonathan Chad Levy, MD 2 – Arthrex, Inc.; 3B, 5 – DJ Orthopaedics; 4 – MAKO Surgical 

David G Lewallen, MD 1 – Orthosonics, Osteotech, Zimmer 

Nicholas Lewing, BS ........................................................n 

Courtland G Lewis, MD 5 – Biomet 

Gregory S Lewis, PhD ......................................................n 

John Strudwick Lewis, Jr MD ................................................n 

Paul B Lewis, MD 3A – Baxter 

Valerae O Lewis, MD 5 – Stryker 

Dan Lewitus, MS ...........................................................n 

Bing Li, PhD ..............................................................n 

Guoan Li, PhD ............................................................n 

Rachel W Li, MD, PhD ......................................................n 

Robert Li, BS ..............................................................n 

Ru Li, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Xin Li, MD ................................................................n 

Yi-Chen Li, MD ............................................................n 

Zhongyu John Li, MD 5 – Wright Medical Technology, Inc. 

Sherry Liang, BS ...........................................................n 

Jen-Chung Liao, MD .......................................................n 

Cesar Libanati, MD 3A, 4 – Amgen Co. 

Sven Lichtenberg, MD 1, 2, 3B – Arthrex, Inc. 

Richard L Lieber, PhD 2, 3C – Mainstay Medical; 3B, 5, 6 – Allergan, Inc.; 7 – Wolters 


Meir Liebergall, MD ........................................................n 

Isador H Lieberman, MD, MBA, FRCSC 1 – AxioMed, MAZOR Surgical Technologies, 

Stryker, Merlot Orthopaedix; 2 – Trans1 Inc.; 3B, 6 – AxioMed, MAZOR Surgical 

Technologies, Merlot Orthopaedix; 4 – AxioMed, MAZOR Surgical Technologies, Merlot 

Orthopaedix, CrossTrees; 7 – Quality Medical Publishers 

Jay R Lieberman, MD 3B – DePuy, A Johnson & Johnson Company; 5 – Amgen Co., 

Arthrex, Inc. 

Jeremy A Lieberman, MD 3B – Medtronic 

46 

disclosure 

Thoralf R Liebs 5 – DePuy, A Johnson & Johnson Company 

John Lien, MD .............................................................n 

Terry R Light, MD ..........................................................n 

Steven A Lillmars, DO ......................................................n 

Byung-Ho Lim, MD ........................................................n 

Kerry Lim, MBBCh .........................................................n 

Letitia Lim, MD ............................................................n 

Moojoon Lim, MD .........................................................n 

Seung-Jae Lim, MD .........................................................n 

Tae Kang Lim, MD .........................................................n 

Young Wook Lim, MD ......................................................n 

Edward Lin, MD ...........................................................n 

Hui-Wen Lin, PhD .........................................................n 

Michael Y Lin, MD .........................................................n 

Patrick P Lin, MD 5 – Pfizer 

Daniel Lindbom, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Derek P Lindsey, MS .......................................................n 

Breton G Line, BS ..........................................................n 

Elizabeth Anne Lingard, MD 6 – DePuy, A Johnson & Johnson Company, Smith & 

Nephew, Stryker 

Moi-Lin Lingg, MBBS .......................................................n 

Thomas Link 3B – GE Healthcare, Merck 

James Linklater, MD ........................................................n 

Raymond J Linovitz, MD 1 – Orthofix, Inc.; 2 – Orthovita; 3B – Orthofix, Inc., Zimmer, 

Spinal Kinetics, BioTissue; 4 – Axiomed, Spinal Kinetics, Core Technologies 

David M Lintner, MD 2, 3B – Mitek; 6 – Breg 

Frank A Liporace, MD 2, 3B – DePuy, A Johnson & Johnson Company, Osteotech, 

Synthes, Smith & Nephew; 3C – AO; 5 – Synthes, Smith & Nephew 

William Lippert, MPH ......................................................n 

Andrzej Lisowski, MD ......................................................n 

Mr Lukas Lisowski .........................................................n 

Robert B Litchfield, MD 2 – Ferring Pharmaceuticals, Smith & Nephew, Linvatec, Mitek; 

3B – Wright Medical Technology, Inc., BioMimetic, Smith & Nephew; 4 – Smith & 

Nephew, Johnson & Johnson; 5 – Wright Medical Technology, Inc., Smith & Nephew 

Chris Little ................................................................n 

Kevin James Little, MD .....................................................n 

Bin Liu, MD ...............................................................n 

Chuan-ju Liu, PhD .........................................................n 

Fang Liu, MD, PhD .........................................................n 

Raymond Liu, MD .........................................................n 

Sen Liu, MD ...............................................................n 

Shing-Hwa Liu, PhD .......................................................n 

Steve S Liu, MD ............................................................n 

Wanjun Liu, MD ...........................................................n 

Xuhui Liu, MD ............................................................n 

Victoria Liublinska, PhD ....................................................n 

Roald Jon Llado, MD .......................................................n 

Joan C Lo, MD 5 – Johnson & Johnson, GlaxoSmithKline 

Ngai-Nung Lo, MD 1, 3B – Zimmer; 5 – Eli Lilly, Zimmer 

Terrence R Lock, MD .......................................................n 

Randy W Loftus, MD .......................................................n 

Rajani Logishetty, FRCS .....................................................n 

Stefan Lohmander, PhD ....................................................n 

Christine Loiseau, BS .......................................................n 

Adolph V Lombardi Jr, MD 1 – Biomet, Innomed; 2, 3B, 5 – Biomet 

Umile Guiseppe Longo, MD .................................................n 

Baron Lonner, MD 2 – DePuy, A Johnson & Johnson Company, Spine Wave; 3B, 

5 – DePuy, A Johnson & Johnson Company; 4 – K2M, Axial Biotech, Paradigm 

Jess H Lonner, MD 1 – Zimmer; 2, 3B – Zimmer, MAKO Surgical; 4 – MAKO Surgical; 

7 – Wolters Kluwer Health - Lippincott Williams & Wilkins, Saunders/Mosby-Elsevier 

Nicola Lopomo, MSc, PhD ..................................................n 

James Lord, MSc ...........................................................n 

Dean G Lorich, MD ........................................................n 

Elena Losina, MD ..........................................................n 

Paul A Lotke, MD 1 – DePuy, A Johnson & Johnson Company, Innomed; 2 – DePuy, A 

Johnson & Johnson Company; 3B, 6 – Stryker; 7 – Springer 




Scott Traver Lovald, PhD, MBA ...............................................n 

Elizabeth Lowder ..........................................................n 

Anthony Lowman, PhD 1, 5 – Synthes 

Santiago A. Lozano Calderon, MD ...........................................n 

Zhen Lu ..................................................................n 

Anne Lubbeke-Wolff, MD, DSc ..............................................n 

Brennen L Lucas, MD .......................................................n 

Justin Lucas, BS ............................................................n 

Deianira Luciani, MD ......................................................n 

Scott J Luhmann, MD 1 – Globus Medical; 2 – Medtronic Sofamor Danek, Stryker; 

3B – Globus Medical, Medtronic Sofamor Danek, Stryker; 5 – Stryker 

Trevor Lujan, PhD .........................................................n 

Daniel Pizarro Luna, MSc, MD ...............................................n 

Jeffrey TP. Luna, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Douglas W Lundy, MD 2 – AO, Synthes; 3C – Synthes; 4 – Livengood Engineering 

Jon D Lurie, MD 3B – Sanofi-Aventis 

Gaurav Aman Luther, BA ....................................................n 

Kevin Feldman Lutsky, MD ..................................................n 

Hue H Luu, MD ...........................................................n 

Kyle Lybrand, BS ...........................................................n 

Stephen Lyman, PhD .......................................................n 

Scott A Lynch, MD .........................................................n 

Russ Lyon, MD 3B – Medtronic 

Steven Thomas Lyons, MD 1 – Zimmer; 3B – Zimmer, Total Joint Orthopaedics; 

4 – Zimmer, Stryker, Amedica, Total Joint Orthopaedics 

ChunBong Benjamin Ma, MD 5 – Wyeth, Histogenics 

Yan Ma, PhD ..............................................................n 

Travis G Maak, MD .........................................................n 

William B Macaulay, MD 3B – United HealthCare, Goldman Sachs; 6 – Pfizer, Wright 


Elena Maccagnan, MD ......................................................n 

Joy C MacDermid, PhD .....................................................n 

Daniel MacDonald .........................................................n 

David Macdonald, FRCS ....................................................n 

Peter Benjamin MacDonald, MD 3C – ConMed Linvatec 

Steven J MacDonald, MD 1 3B – DePuy, A Johnson & Johnson Company; 5 – DePuy, A 

Johnson & Johnson Company, Smith & Nephew, Stryker 

John Dougald MacGillivray, MD 2, 3B, 5, 6 – Stryker 

Michael Shaun Machen, MD .................................................n 

Nicola Mackay, BMSc .......................................................n 

John D MacKenzie, MD .....................................................n 

William G Mackenzie, MD ..................................................n 

Grady Maddox, MD ........................................................n 

Steven Michael Madey, MD 1, 3C – Zimmer, Synthes 

Uma Maduekwe, MD .......................................................n 

Takashi Maeda 2 – DePuy, A Johnson & Johnson Company 

Toru Maeda, MD ...........................................................n 

Ruben Maenza, MD ........................................................n 

Tristan Maerz, BS ..........................................................n 

Akira Maeyama, MD ........................................................n 

Professor Nicola Maffulli ...................................................n 

Rajesh Magattil, MRCS ......................................................n 

Jay Magaziner, MD 3B – Amgen Co., Eli Lilly, Sanofi-Aventis; 5 – Merck, Eli Lilly, 

Novartis 

Petra Magosch, MD ........................................................n 

Kathleen Maguire, BA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Clara Magyar, PhD .........................................................n 

John Mahajan, BS ..........................................................n 

Shahab Mahboubian, DO ...................................................n 

Suzanne A Maher, PhD 3B – Kensey Nash Corporation; 5 – Stryker, Kensey Nash 

Corporation, Orteq Ltd. 

Rohit Maheshwari, FRCS ....................................................n 

Mohamed Mahfouz, PhD 1 – Zimmer; 3B, 5 – Biomet; Zimmer 

Mostafa Mahmoud, MD ....................................................n 

Nizar Mahomed, MD 5 – Bayer 

47 

disclosure 

Ormonde M Mahoney, MD 1, 2, 3B, 5 – Stryker 

Kenny Mai, MD ............................................................n 

Martin Majewski, MD ......................................................n 

Anna Lena MAKOwski, MS ..................................................n 

Martin M Malawer, MD .....................................................n 

Henrik Malchau, MD 1 – Smith & Nephew; 3B – Biomet, Smith & Nephew; 4, 6 – RSA 

Biomedical Inc.; 5 – Biomet, Smith & Nephew, Zimmer 

Matthew M Malerich, MD ...................................................n 

Gregory B Maletis, MD .....................................................n 

Margaret M Maley, BSN, MS 3B – Wright Medical Technology, Inc., CareFusion 

Rajesh Malhotra, MS .......................................................n 

Robert Andrew Malinzak, MD 2, 3B – Biomet; 5 – Biomet, Zimmer, DePuy 

Arthur L Malkani, MD 1, 3B – Stryker; 5 – Synthes, Stryker 

William J Maloney MD 1 – Wright Medical Technology, Inc., Zimmer; 3C – ISTO 

Technologies, Moximed; 4 – Abbott, Gillead, ISTO Technologies, Johnson & Johnson, 

Merck, Moximed, Pfizer; 5 – AO, Biomet, DePuy Spine, DePuy, A Johnson & Johnson 

Company, Nuvasive, Smith & Nephew, Stryker, Zimmer 

Thomas A Malvitz, MD 6 – DePuy, A Johnson & Johnson Company 

Ajay Malviya, MD ..........................................................n 

Tallal C Mamisch, MD 3B – Siemens Healthcare AG, EMD Serono; 4 – Roche Siemens; 

6 – Merck Serono SA 

Peter J Mandell, MD ........................................................n 

Marco Manfrini, MD .......................................................n 

Devin R Mangold, BS .......................................................n 

Henry J Mankin, MD .......................................................n 

Gideon Mann, MD .........................................................n 

Jeffrey Adam Mann, MD 2 – Sanofi-Aventis, Small Bone Innovations; 3B – Small Bone 

Innovations 

Roger A Mann, MD 2, 3B – SBI; 7 – Elsevier 

Sandeep Mannava ..........................................................n 

David W Manning, MD 2, 3B – Biomet; Smith & Nephew 

Andrei Manolescu, MD .....................................................n 

Theodore T Manson, MD ...................................................n 

Jacob B Manuel, MD .......................................................n 

Givenchy Manzano, BS .....................................................n 

Dayle L Maples, MD 4 – Stryker 

Nidu Maran ...............................................................n 

Robert Marburger, RN ......................................................n 

Maurilio Marcacci, MD 1, 5– Finceramica S.p.A. 

Andrew J Marcantonio, DO .................................................n 

David Marcantonio, MD ....................................................n 

Gerard March, MD .........................................................n 

Giulio Marcheggiani Muccioli, MD 6 – Regen Biologics 

Luis Marchi, MS ...........................................................n 

Randall Evan Marcus, MD 4 – Stryker, Medtronic, Steris 

Rodrigo M Mardones, MD 1 – Bios Chile; 2 – Boehringer; 3B – Smith & Nephew 

Geoffrey Marecek, MD ......................................................n 

David Stephen Margolis, MD ................................................n 

Danica Marinac-Dabic, MD, PhD ............................................n 

Alessandro Marinelli, MD ...................................................n 

Eleonora Marini, MD .......................................................n 

Chad Marion, MD .........................................................n 

Michael W Mariscalco, MD ..................................................n 

David C Markel, MD 2, 3B, 5 – Stryker; 4 – Novi Bone and Joint Center, Pfizer, Stryker, 

Biogen 

David R Marker ............................................................n 

Andrew David Markiewitz, MD 7 – CRC Press 

Barbara Marks .............................................................n 

Michelle Marks, NMD ......................................................n 

Timothy Marks, BS .........................................................n 

Victoriano Marlet ..........................................................n 

Meir Tibi Marmor, MD .....................................................n 

Antongiulio Marmotti, MD ..................................................n 

Guido Marra, MD 3B – Zimmer 

Tricia Marriott, PA-C .......................................................n 




John Lawrence Marsh, MD 1 – Biomet; 7 – Oxford Press 

John M Martell, MD 3B – Biomet, Smith & Nephew, Stryker, Zimmer, Harris 

Foundation 

Ashley J Martin 6 – DePuy, A Johnson & Johnson Company 

James A Martin, PhD .......................................................n 

Sadie Martin, MD ..........................................................n 

Scott David Martin, MD ....................................................n 

Tamara Lynn Martin, MD ...................................................n 

William Martin III, MD .....................................................n 

Sara Martinez-Martos .......................................................n 

Rodrigo Klafke Martini, MD .................................................n 

Jeffrey Dean Martins .......................................................n 

Keishi Maruo, MD .........................................................n 

Julianne Marvin, MD .......................................................n 

Simran Marwah, MBBS .....................................................n 

Robert G Marx, MD ........................................................n 

Michelle Mary .............................................................n 

Kazuhiro Masada, MD ......................................................n 

AS M Mashfiqul, FRCS ......................................................n 

Brendan David Masini, MD .................................................n 

Edward O Mason, PhD .....................................................n 

James Mason ..............................................................n 

James Mason, PhD .........................................................n 

Bassam A Masri, MD 2 – Zimmer, DePuy, A Johnson & Johnson Company; 

3B – Zimmer 

Alessandro Masse, MD ......................................................n 

Robyn Masseth, OTC .......................................................n 

Patrick Allen Massey, MD ...................................................n 

Michael Massini, MD 1 – DePuy, A Johnson & Johnson Company, Stryker; 2, 3B, 

5 – Stryker; 4 – Procter & Gamble, Annika Therapeutics, Angiotech Products 

Koichi Masuda, MD 3A – Nuvasive; 5 – Johnson & Johnson, Medtronic, Zimmer, 

Nuvasive, Nippon Zoki, Halozyme 

Antonia Matamalas, MD ....................................................n 

Fabrizio Matassi, MD .......................................................n 

Doug Matey, DO ...........................................................n 

Gulraj Matharu, BSc ........................................................n 

Travis H Matheney, MD .....................................................n 

Richard C Mather, III MD 5 – Forest Pharmaceuticals 

Vasilios Mathews, MD 3B, 6 – Wright Medical Technology, Inc., Biomet; 5 – Biomet 

Kenneth B Mathis, MD 1 – Smith & Nephew, Zimmer; 2, 3B – Smith & Nephew 

Sameer Mathur, MD ........................................................n 

Amir Matityahu, MD 1 – Synthes; 2 – Synthes, DePuy, A Johnson & Johnson Company; 

3B – DePuy, A Johnson & Johnson Company; 4 – Anthem Orthopaedics, LLC; 

5 – Stryker 

Kjell Matre, MD 2 – Stryker; 5 – Smith & Nephew 

Frederick A Matsen III, MD 1 – Kinamed 

Hidenori Matsubara, MD ...................................................n 

Dean K Matsuda, MD 1 – Arthrocare, Smith & Nephew 

Shuichi Matsuda, MD ......................................................n 

Ko Matsudaira, MD, PhD ...................................................n 

Toshihiro Matsuo, MD, PhD ................................................n 

Masatake Matsuoka, MD ....................................................n 

Takashi Matsushita, MD 2 – Smith & Nephew, Sanofi-Aventis, Stryker; 3B – Stryker; 

5 – Teijin Pharma Limited 

Ashley Matthies, BSc .......................................................n 

Kristofer S Matullo, MD 2 – Synthes 

Elizabeth G Matzkin, MD ...................................................n 

Raphael Mauprivez, MD ....................................................n 

Craig S Mauro, MD ........................................................n 

Konstantinos Mavridis, BSc .................................................n 

Andreas Mavrogenis, MD ...................................................n 

Megan May, MD ...........................................................n 

Mark Mayer, MD ...........................................................n 

Michael Mayer, MD ........................................................n 

Joel Mayerson, MD .........................................................n 

48 

disclosure 

Robert E Mayle, MD ........................................................n 

David Jacob Mayman, MD 2, 3B – Smith & Nephew; 4 – OrthAlign 

Michael B Mayor, MD 1, 3C – DePuy, A Johnson & Johnson Company 

Jason S Mazza, OPA-C ......................................................n 

Timothy R McAdams, MD ...................................................n 

Steven McAnany, MD .......................................................n 

Mark Philip McAndrew, MD .................................................n 

Craig Joseph McAsey, MD ...................................................n 

Richard W McCalden, MD 2, 3B – Smith & Nephew; 5 – Smith & Nephew, J&J, DePuy, 

Stryker 

Richard Evan McCall, MD 3C – Medtronic 

Peter D McCann, MD 7 – American Journal of Orthopedics 

Edward F McCarthy Jr, MD ..................................................n 

James J McCarthy, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Joseph C McCarthy, MD 1, 6 – Arthrex, Inc., Innomed, Stryker; 3B – Stryker 

Moira Margaret McCarthy, MD ...............................................n 

Richard E McCarthy, MD 3C – Medtronic Sofamor Danek 

Leroy Pearce McCarty, III MD 2 – Genzyme Corporation for Carticel; 3B – Wright 


Michael McCaslin, CPA 4 – Pfizer 

Robert Trigg McClellan, MD 3C, 5 – Skeletal Kinetics, LLC; 4 – Biomineral Holdings, 

LLC 

Anna McClung, RN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Scott McCLURE, bs .........................................................n 

Vance McCollom, MD ......................................................n 

Jody McCollum, MPAS ......................................................n 

Richard A McCormack, MD .................................................n 

Frank McCormick, MD .....................................................n 

Jeremy J McCormick, MD 2 – Smith & Nephew; 6 – Midwest Stone Institute, Wright 


Christopher McCrum, BS ...................................................n 

Kirk A McCullough, MD ....................................................n 

Heather McDonald-Blumer, MD 2 – Amgen Co., Bristol-Myers Squibb, Eli Lilly, Merck, 

Novartis, Procter & Gamble, Sanofi-Aventis 

Erik McDonald 3A, 4 – Boston Scientific 

Lucas McDonald, MD ......................................................n 

E Barry McDonough, MD 2 – Ferring Pharmaceuticals 

Edward G McFarland, MD 3B – Stryker DePuy-Mitke, DePuy, A Johnson & Johnson 

Company, Stryker; 5, 6 – DJ Orthopaedics 

Eric D McFeely, BA .........................................................n 

Michelle H McGarry, MD 3A, 4 – Alphatec Spine 

Kevin C McGill, MPH .......................................................n 

Mark McGinnis, MD ........................................................n 

Tim James McGlaston, BS 4 – Merck 

Richard Louis McGough, MD ................................................n 

Linda McGrail, RN .........................................................n 

Ciara Megan McGuire, MD ..................................................n 

Kathleen A McHale, MD ....................................................n 

Terence McIff, PhD .........................................................n 

Jody McIlroy, PhD .........................................................n 

Professor Iain B McInnes ...................................................n 

Neil McInnis ..............................................................n 

Louis F McIntyre, MD 3B, 4 – Tornier 

Michael D McKee, MD 1 – Stryker; 2, 3B – Synthes; Zimmer; 5 – Wright Medical 

Technology, Inc., Zimmer; 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Kathleen E McKeon, MD ....................................................n 

Peter McLardy-Smith, FRCS 1 – Biomet; 2 – Zimmer, Wright Medical Technology, Inc.; 

3B – Wright Medical Technology, Inc.; 3C – Zimmer 

Alexander C McLaren, MD 5 – OREF Herb Loius Fund, AO North America, SWOTA 

(South West Orthopaedic Trauma Assoc.), Banner Health, Arizona Biomedical Research 

Commission; 6 – Synthes, Hanger Prosthetics and Orthotics, Artificial Limb Specialists, 

Stryker, Banner Health 

Toni M McLaurin, MD ......................................................n 

Alexander Stewart McLawhorn, MD, MBA .....................................n 

Ryan McLemore, PhD ......................................................n 

James F McMillan, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 




Thomas A McNally, MD 2, 3B – DePuy, A Johnson & Johnson Company 

Gary L McPhail, MD ........................................................n 

Edward J McPherson, MD 1, 2, 3B – Biomet 

Laura McPherson, BA 1, 2, 3B – Biomet 

Margaret M McQueen, MD 5 – Acumed, LLC 

Sheila McRae, MSc .........................................................n 

James D McDermott, BA ....................................................n 

Sean McSweeney, MD ......................................................n 

James R McWilliam, MD ....................................................n 

Nelson Mead, BS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Simon Mears, MD 4 – MAKO 

John Medige, PhD .........................................................n 

John B Meding, MD 1 – Biomet 

Robert J Medoff, MD 3A, 4 – Trimed 

Michael Medvecky, MD 2 – Smith & Nephew; 5 – Wyeth 

John Patrick Meehan, MD 2 – DePuy, A Johnson & Johnson Company; 5 – DePuy, A 

Johnson & Johnson Company, DJ Orthopaedics, EBI, Eli Lilly 

Dominic Meek, MD FRCS 3C – DePuy, A Johnson & Johnson Company; 6 – Hereaus 

Patrick A Meere, MD .......................................................n 

Geert Meermans, MD 6 – Johnson & Johnson, Smith & Nephew 

Morteza Meftah, MD .......................................................n 

Amir A Mehbod, MD 1, 3B – Stryker; 4 – Medtronic, Stryker, Nuvasive 

Susan Clay Mehle ..........................................................n 

Charles T Mehlman, DO, MPH 3C – Stryker; 7 – Oakstone Medical Publishing 

Shahid Mehmood, MRCS ...................................................n 

David R Mehr, MD .........................................................n 

Samir Mehta, MD 2 – Zimmer, Smith & Nephew, AO North America; 3B – Smith & 

Nephew; 5 – Amgen Co., Medtronic, Smith & Nephew; 7 – Wolters Kluwer Health - 


Eric G Meinberg, MD 2 – Synthes 

Robert J Meislin, MD 3B – Mitek, Musculoskeletal Transplant Foundation 

J Mark Melhorn, MD 2, 5 – Auxilium; 4 – Abbott, Bristol-Myers Squibb, Eli Lilly, 

Johnson & Johnson, Merck, Pfizer; 7 – American Medical Association Publications 

Barbara Melis, MD .........................................................n 

Vicente Meliton, MS ........................................................n 

Isaac Meller, MD ...........................................................n 

Stephen J Mellon, PhD .....................................................n 

Stavros G Memtsoudis, MD, PhD ............................................n 

Katrin Mende, PhD .........................................................n 

Robert Michael Meneghini, MD 3B, 5, 6 – Stryker 

Lawrence R Menendez, MD 3B – Stryker 

Brandon Mennaer, BS ......................................................n 

Frank D Mentch, MS .......................................................n 

Deana Mercer, MD .........................................................n 

Michael Mercincavage, BS, MAd, CPHQ .......................................n 

Mario Mercuri, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Praveen Mereddy, MRCS ....................................................n 

Antonio Merono, MD ......................................................n 

Addisu Mesfin, MD .........................................................n 

Thomas Meskey, BS ........................................................n 

J Wesley Mesko, MD 3B – Stryker; 6 – Biomet 

Adam Messina, BS 3A, 4, 6 – Smith & Nephew 

Umesh Metkar, MD ........................................................n 

Paul D Metzger, MD ........................................................n 

Matthew J Meunier, MD .....................................................n 

Dominik Christoph Meyer, MD 3B, 7 – Woodwelding Ltd,, Schlieren Switzerland; 

3C – Synthes; 4 – Mestex AG, Zürich 

Robert Scott Meyer, MD 4 – Bristol-Myers Squibb, Pfizer, Procter & Gamble 

Susan Meyer, MD ..........................................................n 

Kathleen Meyers, MS .......................................................n 

Mark S Myerson, MD 1 – Biomet, DePuy, A Johnson & Johnson Company; 2 – Biomet, 

DePuy, A Johnson & Johnson Company, Orthohelix; 3B – Biomet, DePuy, A Johnson 

& Johnson Company, Medtronic, Stryker, Tornier, Orthohelix, Extremity Medical; 

3C – Medtronic; 4 – Orthohelix; 5 – Biomet, OREF, Allosource; 7 – Elsevier 

Giovanni Micera, MD .......................................................n 

Andrew W Michael, MD ....................................................n 

49 

disclosure 

Jefferey E Michaelson, MD 2, 3B – Biomet; 4 – Parcus Medical 

Karl Michaelsson, MD, PhD .................................................n 

Linda J Michaud, MD .......................................................n 

Lyle J Micheli, MD 3C – Carticel; 5 – Genzyme 

Elisabeth Michels 4 – Procter & Gamble 

Ryan F Michels ............................................................n 

Theodore Miclau, MD 3B – Amgen Co.; 4 – Johnson & Johnson, Merck, Pfizer; 

5 – Stryker, Synthes, Zimmer 

Saskia Middeldorp, MD, PhD ...............................................n 

Fiona Middleton, MRCS ....................................................n 

Scott Middleton, Mb, ChB ...................................................n 

William D Middleton, MD 7 – Saunders/Mosby-Elsevier 

Megan Mignemi, MD .......................................................n 

William Michael Mihalko, MD, PhD 1, 2, 3B, 6 – Aesculap/B.Braun; 5 – Aesculap/B. 

Braun, Smith & Nephew, Stryker, Corin U.S.A.; 7 – Elsevier Inc. 

Hidenobu Miki, MD ........................................................n 

Joseph C Milbrandt, PhD 5 – Corin U.S.A. 

Todd A Milbrandt, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Andrew Hill Milby, MD .....................................................n 

Neal L Millar, MD ..........................................................n 

Bjarne Moller-Madsen, MD, MSCI ............................................n 

Bruce S Miller, MD .........................................................n 

Daniel James Miller, BS .....................................................n 

Freeman Miller, MD 7 – Springer 

Geraldine Miller, MD 3B – Pfizer 

Lisa Miller, BSc ............................................................n 

Mark C Miller, PHD 5 – Zimmer; 6 – Integra Life Sciences 

Mark D Miller, MD 6 – Miller Orthopaedic Research & Education (MORE); 

7 – Saunders/Mosby-Elsevier, Wolters Kluwer Health - Lippincott Williams & Wilkins 

Matthew D Miller, MD ......................................................n 

Micah Miller, BS ...........................................................n 

Robert Andrew Miller, BS ...................................................n 

Stuart D Miller, MD 1 – Biomet; 2 – IntegraLifesciences; 3B – Biomet; 

IntegraLifesciences; 4 – Arthrocare, IntegraLifesciences, Osiris, Orthovita 

Peter J Millett, MD, MSc 1 – Arthrex, Inc.; 3B – Arthrex, Inc., Arthrocare; 4 – Game 

Ready, VuMedi; 5 – Arthrex, Inc., Arthrocare, OrthoRehab, Ossur Americas, Siemens 

Medical Solutions USA, Smith & Nephew 

Michael B Millis, MD .......................................................n 

Edward L Milne 6 – Alphatec Spine, Embrace Medical, FxDevices LLC 

Byung Woo Min, MD .......................................................n 

Kyong Su Min, MD .........................................................n 

Tom Minas, MD 1, 4 – ConforMIS; 2, 3B – Genzyme, ConforMIS 

Yukihide Minoda, MD 5 – Biomet, Wright Medical Technology, Inc., DePuy, A Johnson 

& Johnson Company 

Joan Miquel ...............................................................n 

Amer J Mirza, MD 3C – Seattle Information Systems 

Faisal Mirza, MD, FRCSC 2, 3B – Acumed, LLC; 4 – Tensegrity Technologies 

Maria Teresa Miscione, MD ..................................................n 

Adam Mitchell, MD ........................................................n 

Joseph W Mitchell .........................................................n 

Naoto Mitsugi, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Hiroto Mitsui, MD .........................................................n 

Kim Mitsunari, MD ........................................................n 

Hiroaki Mitsuyasu, MD .....................................................n 

Shinji Miwa, MD ...........................................................n 

Masunao Miyao, MD .......................................................n 

Hideki Mizuuchi, MD ......................................................n 

Yuichi Mochida, MD .......................................................n 

Pablo Mococain, MD .......................................................n 

Berton R Moed, MD 1 – DePuy, A Johnson & Johnson Company; 5 – Stryker; 

7 – Clinical Orthopaedics and Related Research 

Ahmed Salem Mohamed, MD ...............................................n 

Saqr Mohamed, MD ........................................................n 

Vivek Mohan, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Karen J Mohr, PT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Gregory Moineau, MD ......................................................n 




Daniel Mole, MD 1 – Tornier 

Massimo Molinari, MD .....................................................n 

Ryan Molli, DO ............................................................n 

Anne Molloy, RN ..........................................................n 

Robert M Molloy, MD 5 – Stryker 

Shigeki Momohara 2 – Abbott, Pfizer, Wyeth, Astellas Pharma, Chugai, Eisai, Kaken 

Pharmaceutical, Mitsubishi Tanabe, Santen, Bristol-Myers Squibb; 3B – Zimmer, Bristol- 

Myers Squibb 

Keith Oster Monchik, MD 3B – Depuy Mitek, Symmetry Medical, Smith & Nephew; 

5 – Stryker 

James T Monica, MD .......................................................n 

Andrew P Monk, MRCS .....................................................n 

Michael A Mont, MD 1 – Stryker; 3B – Stryker, Wright Medical Technology, Inc.; 

5 – National Institutes of Health (NIAMS & NICHD), Stryker, Tissue Gene, Wright 


Antonello Montanaro, MD ..................................................n 

Aldo Campusano Montaño .................................................n 

Martim Teixiera Monteiro, MD ...............................................n 

Pasquale X Montesano, MD 1 – Scient’x, Spinal USA; 4 – Cytonics 

Park Moon Seok, MD .......................................................n 

Bryan Scott Moon, MD .....................................................n 

Kyoung Ho Moon, MD 2 – DePuy, A Johnson & Johnson Company, Korea Bone Bank; 

3C, 4, 5 – Korea Bone Bank 

Young-Wan Moon, MD .....................................................n 

James F Mooney III, MD 3B – Synthes Spine 

Molly Moor ...............................................................n 

Andrew M Moore, MD ......................................................n 

Drew Douglas Moore, MD ..................................................n 

Claude T Moorman III, MD 2 – Nutramax Corp.; 3B – Smith & Nephew; 

4 – Healthsport; 5 – Stryker, Histogenics, Breg, Mitek, DJ Orthopaedics, Arthrex 

Claudio Moraga, MD .......................................................n 

Luis Moraleda, MD .........................................................n 

Raymond Moran, FRCS .....................................................n 

Steven L Moran, MD 1, 2 – Ascension 

Lawrence G Morawa, MD 1, 3B – Stryker 

Dan Morell, MBBS, BS ......................................................n 

Vincent Michael Moretti, MD ................................................n 

Dr Joseph A Morgan .......................................................n 

Eiji Mori, MD .............................................................n 

Mario Moric, MS ...........................................................n 

Ryo Morimoto, MD ........................................................n 

Tetsuro Morita, MD ........................................................n 

Deml Moritz, MD ..........................................................n 

Tokuhide Moriyama, MD ...................................................n 

Antonio Moroni, MD 2, 3B, 4 – Active Implants; 7 – Orthofix 

Edward Morra, MSME ......................................................n 

Bernard F Morrey, MD 1 – SBI, Don Joy; 3B – Zimmer; 7 – Wolters Kluwer Health - 

Lippincott Williams & Wilkins, Elsevier 

Brent J Morris, MD .........................................................n 

Carol D Morris, MD ........................................................n 

Michael James Morris, MD 5 – Biomet 

Carol Morrison, PhD .......................................................n 

William B Morrison, MD 1, 3C – Apriomed, Inc.; 2 , 3B – General Electric Medical 

Systems; 7 – Elsevier, Amirsys 

Melanie Morscher ..........................................................n 

Saam Morshed, MD 5 – Stryker, Synthes 

S M Javad Mortazavi, MD ...................................................n 

Anne Morton, PhD .........................................................n 

Vincent Stephen Mosca, MD .................................................n 

Colin F Moseley, MD 3C – Orthopaediatrics 

Rami Mosheiff, MD ........................................................n 

Timothy J Mosher MD 3B – Kensey Nash Corporation; 4 – Johnson & Johnson 

Mathew Most, MD 5 – DePuy, A Johnson & Johnson Company 

Richard A Mostardi, PhD 5 – Zimmer, Astro Met 

John Motley, PT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Michael P Mott, MD 4 – Johnson & Johnson; 5 – GE Healthcare 

50 

disclosure 

Geraldo Motta, MD ........................................................n 

Calin Stefan Moucha, MD ...................................................n 

Loran Mounir-Soliman, MD .................................................n 

Waleed Fouad Mourad, MD .................................................n 

Alexandre Mouttet, MD .....................................................n 

Vasilios Moutzouros, MD ...................................................n 

Petter Mowinckel, PhD .....................................................n 

Luis Emilio Moya , MD .....................................................n 

Kyle C Moylan, MD ........................................................n 

Thomas Edward Mroz, MD 2 – Stryker; 4 – PearlDiver, Inc. 

Scott J Mubarak, MD 4, 6 – Rhino Pediatric Orthopedic Designs, Inc. 

Chaitanya S Mudgal, MD ...................................................n 

John P Mueller, PhD 6 – Medtronic, DePuy, A Johnson & Johnson Company, Wright 


Sarah Muirhead-Allwood FRCS 1, 3B – DePuy, A Johnson & Johnson Company, 

Zimmer, Corin U.S.A.; 5 – Zimmer 

Debi P Mukherjee, Sc.D .....................................................n 

Kevin James Mulhall, MD ...................................................n 

Scott Muller, MBBS MD, FRCS ...............................................n 

Brian Mullis, MD 5 – Amgen Co., Synthes 

Kishore Mulpuri, MD .......................................................n 

Gregory M Mundis, MD 2 – Nuvasive, K2M; 3B – K2M, Nuvasive; 5 – Nuvasive, DePuy, 

A Johnson & Johnson Company, OREF 

Joel Murachovsky, MD ......................................................n 

Akira Murakami, MD .......................................................n 

Hideki Murakami, MD .....................................................n 

Orhun K Muratoglu, PhD 1 – Biomet, Zimmer, Corin U.S.A.; 2, 3C – Biomet; 

5 – Biomet, Zimmer, MAKO, DePuy 

Christopher D Murawski ....................................................n 

Professor Antonio Murcia Asensio ...........................................n 

Antonio Murcia-Mazon, MD .................................................n 

Garnett Andrew Murphy, MD 3C – Wright Medical Technology, Inc.; 5 – BioMimetic; 


James Murphy, MD .........................................................n 

Stephen B Murphy, MD 1 – Wright Medical Technology, Inc.; 3B – Wright Medical 

Technology, Inc., Ceramtec, AG; 4 – Surgical Planning Associates, Inc. 

Clint Murray, MD ..........................................................n 

David W Murray, MD 1 – Biomet, Wright Medical Technology, Inc.; 5 – Biomet, DePuy, 

A Johnson & Johnson Company, Stryker, Zimmer, Wright Medical Technology, Inc. 

Douglas H Murray, MD 3C – Exactech, Inc. 

Martha M Murray, MD 3B, 4 – Connective Orthopaedics 

Michael R Murray, MD ......................................................n 

Paraic A Murray, MD .......................................................n 

Trevor G Murray, MD .......................................................n 

Prof George A C Murrell, MD 5 – Arthrocare 

Yvonne M Murtha, MD .....................................................n 

Anand M Murthi, MD 3B – Zimmer, Ascension 

A N Murty, MBcHB, FRCS ...................................................n 

Volker Musahl, MD ........................................................n 

Dana Lynn Musapatika, MS .................................................n 

George F Muschler, MD 4 – Cleveland Biolabs; 5 – Synthes, Procter & Gamble 

Domingo Luis Muscolo, MD ................................................n 

Mrinal Musib, PhD .........................................................n 

Gregory Donald Myer, PhD .................................................n 

Andy Myerson, PA-C 4 – Wright Medical Technology, Inc.; 6 – Ocean Surgical Inc. 

Mark S Myerson, MD 1 – Biomet, DePuy, A Johnson & Johnson Company; 2 – Biomet, 

DePuy, A Johnson & Johnson Company, Orthohelix; 3B – Biomet, DePuy, A Johnson 

& Johnson Company, Medtronic, Stryker, Tornier, Orthohelix, Extremity Medical; 

3C – Medtronic; 4 – Orthohelix; 5 – Biomet, OREF, Allosource; 7 – Elsevier 

Valentin Myrtille, MS .......................................................n 

Karen Myung, MD .........................................................n 

Colin Nabb, BS ............................................................n 

Matthew C Nadaud, MD ....................................................n 

Dr Mohammad Nasir Naderi ................................................n 

Yuko Nagaya, MD ..........................................................n 

Daniel J Nagle, MD ........................................................n 




Satoshi Nagoya, MD ........................................................n 

Lakshmi Sreedharan Nair, PhD 3C, 4 – Soft Tissue Regeneration 

Masatoshi Naito, MD .......................................................n 

Ichiro Nakahara ...........................................................n 

Hiroaki Nakamura, MD .....................................................n 

Junichi Nakamura, MD .....................................................n 

Nobuo Nakamura, MD .....................................................n 

Takashi Nakamura, MD .....................................................n 

Takuya Nakamura, MD 2 – Zimmer, Lima; 3B – Zimmer; 5 – JMM 

Yoshinari Nakamura, MD ...................................................n 

Yuko Nakashima, MD ......................................................n 

Katsuya Nakata, MD 5 – Corin; 6 – Corin Japan 

Amgad Ihab Nakhla, MSc, FRCS .............................................n 

Ufuk Nalbantoglu, MD .....................................................n 

Denis Nam, MD ...........................................................n 

Kwang Woo Nam, MD ......................................................n 

Robert S Namba, MD 1 – Innomed; 7 – Mc Graw Hill 

Surena Namdari, MD, MSc ..................................................n 

Chaitanya Nandipati, BS ....................................................n 

Matteo Nanni, MD .........................................................n 

Robert J. Napleton, JD ......................................................n 

Antoni Nargol, FRCS .......................................................n 

Jason Warren Nascone, MD 3B – Synthes 

Adam Nasreddine, BS ......................................................n 

Rima Nasser, MD ..........................................................n 

Ahmad Nassr, MD .........................................................n 

Sonali Natu, MD ...........................................................n 

Doug Naudie, MD 1 – Smith & Nephew; 2, 3B – Smith & Nephew, Stryker; 5 – Smith & 

Nephew, DePuy, A Johnson & Johnson Company, Stryker 

Aaron Nauth, MD ..........................................................n 

Ronald Anthony Navarro, MD ...............................................n 

Syed Nawaz, MRCS .........................................................n 

Tariq Ali Nayfeh, MD 3B – Smith & Nephew 

Samir Nayyar, MD .........................................................n 

Ara Nazarian ..............................................................n 

Qais Naziri, MD ...........................................................n 

Deborah R Neal, BS ........................................................n 

Stefan Nehrer, MD 5 – Arthro Kinetics, Chroma Pharma 

Michael John Neil, MD 2, 5 – DePuy, A Johnson & Johnson Company; 3B – Global 

Orthopaedic Technology 

Geraldine Neiss, PhD .......................................................n 

Rob G H H Nelissen, MD 3C – Biomet, Synthes, Stryker, BroadVector, Implantcast; 

5 – Stryker, Biomet, Synthes, Implantcast 

Kate W Nellans, MD ........................................................n 

Andrea Nelson, ATC, OTC ...................................................n 

Charles L Nelson, MD 3B – Zimmer 

Christopher D Nelson, DO ..................................................n 

David L Nelson, MD 1, 3B, 4, 6 – Orthofix, Inc.; 2 – Orthofix, Inc., Synthes 

Eric W Nelson, MD .........................................................n 

Fred R T Nelson, MD 7 – Elsevier 

Sandra Bliss Nelson, MD 4 – Abbott, Johnson & Johnson, Hospira, Biogen 

Scott C Nelson, MD ........................................................n 

Scott Nemec, DO ..........................................................n 

Jeffrey Nepple, MD .........................................................n 

Bryan J Nestor, MD .........................................................n 

Philip R Neubauer, MD 3A, 4 – Celgene 

Brian J Neuman, MD .......................................................n 

Adam Z Neustein, BS .......................................................n 

Enrico Neven, MD .........................................................n 

Claire Newell, BSc .........................................................n 

Drew K Newhoff, BA 4 – Stryker 

Ms Lori Newman ..........................................................n 

Peter O Newton, MD 1, 2, 3B – DePuy, A Johnson & Johnson Company; 3C – Stryker; 

4 – Nuvasive; 5 – DePuy, A Johnson & Johnson Company, Axial Biotech, Biospace Med; 

7 – Thieme Publishing 

51 

disclosure 

Lionel Neyton, MD 3B – Tornier, Mitek 

Aaron Ng, MD .............................................................n 

Cho Ng, MBBS ............................................................n 

Vincent Ng, MD ...........................................................n 

Mthunzi Ngcelwane, MD ....................................................n 

Trung Ngo, DC ............................................................n 

Dat Nguyen, PharmD 3A, 3B, 4 – Auxilium Pharmaceuticals 

Ngoc Quyen Nguyen, MD ...................................................n 

Sang-Eun Nha, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Shane Nho, MD 5 – Arthrex, Inc., Linvatec, Smith & Nephew, DJ Orthopaedics, 

Miomed, Athletico 

Yoon-Mi Nho ..............................................................n 

Christophe Nich, MD 5 – Osteotech 

Alexander S Nicholls .......................................................n 

David P Nicholls, PhD ......................................................n 

Gregory P Nicholson, MD 1 – Innomed, Zimmer; 3B, 4 – Zimmer; 5 – EBI, Tornier, 

Zimmer; 7 – SLACK Incorporated 

Florian Nickisch, MD 2, 3B – Smith & Nephew 

Kathie Niesen .............................................................n 

Marc J Nieuwenhuijse, MD ..................................................n 

Marco Nigrisoli, MD .......................................................n 

Vassilios Nikolaou, MD .....................................................n 

James T Ninomiya, MD .....................................................n 

Lana Nirenstein, MSII ......................................................n 

Hideji Nishida, MD ........................................................n 

Takashi Nishii, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Carl Wilson Nissen, MD 2 – Genzyme 

Lorenzo Nistri, MD ........................................................n 

Marco Nitri, MD ...........................................................n 

Philip C Noble, PhD 1 – Zimmer, Stryker, Smith & Nephew; 2 – Smith & Nephew; 

3B – Smith & Nephew, Zimmer; 5 – Synthes, Zimmer; 6 – Musculoskeletal Transplant 

Foundation, Zimmer, Plus Orthopedics 

Ulrich Noeth ..............................................................n 

Michael M Nogler, MD 2, 3B – Stryker; 5 – Stryker, Heraeus; 7 – Springer 

Monica Paschoal Nogueira, MD ..............................................n 

Won Noh, MD .............................................................n 

Rahime Nohutcu, DT .......................................................n 

Dr Elizabeth M Nolan ......................................................n 

Lutz P Nolte, PhD ..........................................................n 

Tomohiro Nomura, MD ....................................................n 

Ken J Noonan, MD 1, 3B, 5 – Biomet 

Vanessa Noonan, PhD ......................................................n 

Robert L Nora, JD ..........................................................n 

Sean E Nork, MD 2 – Synthes, AONA; 3B – Synthes, AONA, Amgen; 5 – Synthes, 

AONA, OTA 

Masoud Norouzi ...........................................................n 

Casey Northam, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Mark Norton, MD 3C – Corin UK 

Tom F Novacheck, MD ......................................................n 

Eduardo Nilo Novais, MD ...................................................n 

Jenna B Noveau, BS ........................................................n 

Wendy Novicoff, PhD 3B – Exactech, Inc., Smith & Nephew 

Robert J Nowinski, DO 2 – Tornier; 3B – Tornier, Renovis; 5 – Tornier, Lifecell 

Frank R Noyes, MD 1 – Smith & Nephew; 2 – Genzyme; 6 – Arthrex, Inc., DePuy- 

Mitek, Regeneration Technologies, Inc., AlloSource; 7 – Saunders/Mosby-Elsevier 

Masahiro Nozaki, MD ......................................................n 

Akosua A Nti, BA ..........................................................n 

Gordon W Nuber, MD 4 – Johnson & Johnson, Stryker; 5 – Sage Pharmaceuticals 

Syam Prasad Nukavarapu, PhD ..............................................n 

James Albert Nunley II, MD 1 – Wright Medical Technology, Inc.; 3B – SBI, Smith & 

Nephew, Stryker, Wright Medical Technology, Inc., Integra Lifesciences; 4 – Bristol-Myers 

Squibb, Merck, Johnson & Johnson; 5 – Biomet, EBI, OREF, Pfizer, Synthes, DePuy, A 

Johnson & Johnson Company, Arthrex, Inc.; 7 – Springer, Datatrace 

Ryan Nunley, MD 3B – Smith & Nephew, Wright Medical Technology, Inc., Salient 

Surgical; 5 – Biomet, Wright Medical Technology, Inc., Stryker, Smith & Nephew, 

Biospace, Mobile Compression Systems 




Thomas Nunn, BS .........................................................n 

Katja MR Nuss, DVM .......................................................n 

Eric Nussbaum, ATC ........................................................n 

Benedict U Nwachukwu ....................................................n 

Jason Nydick, DO ..........................................................n 

Joseph R O’Brien, MD 3B – DePuy, A Johnson & Johnson Company, Stryker, Smith & 

Nephew; 4 – Doctors Research Group; 5 – BioSET, Nuvasive 

Daniel P O’Connor, PhD 3C – Nimbic Systems, Inc.; 7 – SLACK Incorporated 

Mary I O’Connor, MD 3B – Zimmer; 3C, 4 – Accelalox, Inc. 

Thomas FX O’Donnell, BS ..................................................n 

Turlough O’Donnell, MD ...................................................n 

Shawn W O’Driscoll, MD 1 – Acumed, LLC, Tornier, Aircast (DJ); 2 – Acumed, LLC 

Regis J O’Keefe, MD 4 – LaGET 

Martin J O’Malley, MD ......................................................n 

Kieran O’Shea, MD .........................................................n 

Brian O’Sullivan, MD .......................................................n 

Patrick O’Toole, MD ........................................................n 

Robert V O’Toole, MD 3B – Synthes; 5 – Synthes, Stryker, OREF 

Hannah CL Oag, MD .......................................................n 

Carol A Oatis, PT, PhD 7 – LWW 

Isi Obadan, MD ...........................................................n 

Shuji Obata, MD ...........................................................n 

Barbara Obermayer-Pietsch, MD .............................................n 

Beate Obermeyer, BSc ......................................................n 

Thomas S Obermeyer, Jr MD ................................................n 

Richard Obert, MS 3A, 4 – Wright Medical Technology, Inc. 

William Obremskey, MD 3B – Medtronic 

Mitsuo Ochi, MD, PhD .....................................................n 

Masafumi Oda, PhD .......................................................n 

Ryo Oda, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Saurabh Odak, MBBS, MRCS ................................................n 

Susan Marie Odum ........................................................n 

Sarah Offley, MD 5 – Endopharmaceuticals 

Kyo-Ichi Ogawa, MD .......................................................n 

Masato Ogawa, MD ........................................................n 

Akira Ogose, MD ..........................................................n 

Chang-Wug Oh, MD 2, 5 – Synthes; 3C – Zimmer 

Chung Hee Oh, MD ........................................................n 

Irvin Oh, MD ..............................................................n 

Joo Han Oh, MD 3B – ConMed Linvatec 

Kwang Jun Oh, MD ........................................................n 

Fumihiro Oha, MD ........................................................n 

Xavier Ohl, MD ............................................................n 

Yasuo Ohori, MD, PhD .....................................................n 

Hiroyuki Ohta, PhD ........................................................n 

Seiji Ohtori ...............................................................n 

Ji-Hoon Ok, MD ...........................................................n 

Hiroyuki Oka, MD .........................................................n 

Fumiaki Okada, MD .......................................................n 

Tadashi Okano, MD ........................................................n 

Hiroshi Okazaki, MD ......................................................n 

Ken Okazaki, MD ..........................................................n 

Hisashi Okumura, MD .....................................................n 

Tsaiwei Olee, PhD .........................................................n 

Daniel Oliveira, MD ........................................................n 

Leonardo Oliveira, MD .....................................................n 

Anders Olofsson, MD ......................................................n 

Michael Olsen .............................................................n 

Steven A Olson, MD 6 – Synthes 

Dana Olszewski, MD .......................................................n 

David J Olysav, MD 3C – Zimmer; 4 – Eli Lilly, Zimmer; 5 – Cubist 

Hakan Omeroglu, MD, Prof .................................................n 

Ted M Omilanowski, PA-C ..................................................n 

Yasushi Omori, MD ........................................................n 

52 

disclosure 

Dan Omoto, MD ..........................................................n 

Ercument Onder, DT .......................................................n 

Erol Onel, MD 3A – Pacira 

Alvin C Ong, MD 2 – Pfizer; 3B – Stryker, Smith & Nephew; 5 – AK Pharma, KCI, 

Zimmer 

Crispin C Ong, MD ........................................................n 

Kevin Ong, PhD 5 – Stryker, Medtronic 

Takashi Ono, MD ..........................................................n 

Shin Onodera, MD .........................................................n 

Ikechukwu Onyedika, MD ..................................................n 

Yasuo Oohori, MD .........................................................n 

Ebru Oral, MD 1 – Zimmer 

Joseph R Orchowski, MD ...................................................n 

Debbie Ordes .............................................................n 

Robert M Orfaly, MD 1 , 3B – Acumed, LLC; 2 – DePuy, A Johnson & Johnson 

Company, MicroAire Surgical Instruments LLC 

Lori A. Orlando, MD .......................................................n 

Fabio Orozco, MD 3B – Stryker; 5 – Pfizer, AKA Pharma; 6 – Pfizer 

Justin D Orr, MD ..........................................................n 

Cristian Ortiz, MD .........................................................n 

Uche Osadebe .............................................................n 

Toshihisa Osawa, MD ......................................................n 

Daryl C Osbahr, MD .......................................................n 

Daniel Osei, MD ...........................................................n 

Vladimir Osipov, MD .......................................................n 

A Lee Osterman, MD 2 – Auxilium, Medartis; 3B – Auxilium; 7 – Elsevier 

Robert F Ostrum, MD 5 – AONA, Synthes 

Daniel Osuch, MD .........................................................n 

Masafumi Otani, MD .......................................................n 

Norman Yoshinobu Otsuka, MD .............................................n 

Takanobu Otsuka, MD .....................................................n 

Karim Oudina, MS .........................................................n 

Elizabeth A Ouellette, MD 3B – Stryker 

Sylvia Ounpuu, MS ........................................................n 

John R Owen, PE ..........................................................n 

Brett D Owens, MD ........................................................n 

Christopher J Owens, MD ...................................................n 

Lesa Owens, NP ...........................................................n 

Michael C Owens ..........................................................n 

H. Mustafa Ozdemir, MD, Assoc Prof .........................................n 

Handan Ozdemir, Assoc Prof ................................................n 

Satoru Ozeki, MD ..........................................................n 

Mehmet Hakan Ozsoy, MD, 

Assoc Prof ................................................................n 

Abdullah Ozturk, PhD ......................................................n 

Adnan Ozturk, DT .........................................................n 

Fatih Ozyer, MD ...........................................................n 

Cleber A Jansen Paccola ....................................................n 

Lorenzo Pacelli, MD 1, 2, 3B – Ascension Orthopadic 

Wilfredo B Pacheco, MD 3A, 4 – Warner Chilcott; 3C – Surgical Implant Generation 

Network (SIGN) 

Donna M Pacicca, MD ......................................................n 

Douglas E Padgett, MD 3B – MAKO, Stryker; 4 – MAKO 

Michelle A. Padley .........................................................n 

Stavroula Pagkrati, MD .....................................................n 

Michael J Pagnani, MD 4 – Novartis, Baxter; 6 – STAR Physical Therapy 

Mark W Pagnano, MD 1 – DePuy, A Johnson & Johnson Company, MAKO; 

5 – Zimmer; 7 – Clinical Orthopaedics and Related Research 

Michael R Pagnotto, MD ....................................................n 

Jenny R Pahys, MPH ........................................................n 

Joshua Pahys, MD ..........................................................n 

Haines Paik, MD ...........................................................n 

Satya Pakianathan, MD, PhD ................................................n 

Nader Paksima, DO 2, 3B, 5 – Stryker; 4 – SBI 

Elisa Pala, MD .............................................................n 




Paolo Paladini, MD ........................................................n 

Lisa Palermo, PhD 3B – Nycomed 

George A Paletta Jr, MD 2 – Genzyme 

Dror Paley, MD 1 – Smith & Nephew; 7 – Springer 

Winnie Palispis, BS ........................................................n 

David Paller, MS ...........................................................n 

Cameron Palmer, MD ......................................................n 

William Palmer, MD 3B – Johnson & Johnson 

Giuseppe Palmese, PhD ....................................................n 

Alessio Palumbo, MD ......................................................n 

Brian Palumbo, MD ........................................................n 

Georgia Panagopoulos, PhD ................................................n 

Joaquin C Pandanan, MD ...................................................n 

Rajeev Pandarinath, MD 4 – Procter & Gamble, AstraZeneca 

Hemant G Pandit, FRCS ....................................................n 

Nirav Kiritkumar Pandya, MD ...............................................n 

Nicola Panfoli, MD ........................................................n 

Hee-Nee Pang, MBBS, MRCS ................................................n 

David Panicek, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Arsen M Pankovich, MD 7 – McGraw-Hill Publishers 

Pavlos Panteliadis, MD .....................................................n 

Jwo-Luen Pao, MD .........................................................n 

Rocco Papalia, MD .........................................................n 

Rick F Papandrea, MD 2, 3B – Acumed, LLC, Exactech, Inc. 

Periklis Papapetropoulos, MD ...............................................n 

Guido Pape, MD ...........................................................n 

Hans-Christoph Pape, MD 2 – Synthes; 3B – Stryker; 3C – Canadian Orthopedic 

Foundation; 7 – Journal of Orthopaedic Research, Wolters Kluwer Health - Lippincott 


Nick D Pappas, III MD ......................................................n 

Wayne Gregory Paprosky, MD 1 – Wright Medical Technology, Inc., Zimmer; 

2 – Zimmer; 3B – Biomet, Zimmer; 7 – Journal of Arthroplasty 

Daniele Paravani, MD ......................................................n 

Ted William Parcel, DO .....................................................n 

Farhad Parhami, PhD ......................................................n 

Shital Parikh, MD ..........................................................n 

Byung Chul Park, MD ......................................................n 

Daniel K Park, MD .........................................................n 

Don Young Park, MD .......................................................n 

Gi Heon Park, MD .........................................................n 

Hoon Park, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Jae-Hyun Park, MD .........................................................n 

Jangwon Park, MD .........................................................n 

Jeong Min Park, MD ........................................................n 

Ju-Kwon Park, MD .........................................................n 

Justin J Park, MD ..........................................................n 

Kun-woo Park, MD .........................................................n 

Kwan Kyu Park, MD ........................................................n 

Kyoung Jin Park, MD .......................................................n 

Kyung Soon Park, MD ......................................................n 

Min Jung Park, MD, MSc ....................................................n 

Sang Eun Park, MD, MBA, PHD ..............................................n 

Yong-Bum Park, MD .......................................................n 

Youn Soo Park, MD ........................................................n 

Brent G Parks, MSC 1 – Arthrex, Inc., DJ Orthopaedics; 3B – Zimmer; 6 – Arthrex, Inc., 

DePuy, A Johnson & Johnson Company, Synthes, Integra Life Sciences 

Michael Lloyd Parks, MD 3B – Zimmer; 4 – Johnson & Johnson, Merck, Pfizer, Procter 

& Gamble, Zimmer; 5 – Zimmer 

Nancy L Parks .............................................................n 

Raviinder Parmar, MD 4 – Stryker 

Nata Parnes, MD ...........................................................n 

Dante Parodi, MD .........................................................n 

Sebastian Parratte, MD .....................................................n 

Billy Keith Parsley, MD .....................................................n 

Brian S Parsley, MD 2, 5 – ConforMIS; 6 – DePuy, A Johnson & Johnson Company 

53 

disclosure 

Bradford Parsons, MD 2, 3B – Zimmer; 5 – Wyeth 

Theodore W Parsons, MD, FACS 5 – GE Healthcare 

Paul Francis Partington, MD 2 – Heraeus 

Javad Parvizi, MD 3B – Stryker; 5 – 3M, Musculoskeletal Transplant Foundation, 

Stryker; 7 – Saunders/Mosby-Elsevier, SLACK Incorporated, Wolters Kluwer Health - 


Ebrahim Paryavi, MD .......................................................n 

Dritan Pasku ..............................................................n 

Gilles Pasquier, MD 3C – Symbios SA 

Alpesh Ashwin Patel, MD 1, 3B – Amedica; 2 – Biomet, Medtronic Sofamor Danek, 

Stryker, Amedica 

Amar Patel, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Amar Arun Patel, BS ........................................................n 

Patel’Anay Rajendra, MD ....................................................n 

Ashish Patel, MD ..........................................................n 

Chetan K Patel, MD 1 – Globus Medical; 2 – Medtronic; Stryker; 3A, 4 – Medtronic; 

3B – Globus Medical, Medtronic, Osteotech, Stryker 

Jay J Patel, MD .............................................................n 

Neeraj Patel, MBBS .........................................................n 

Priyesh Patel, MD ..........................................................n 

Satyam Rajnikant Patel, MD .................................................n 

Shelain Patel, MRCS ........................................................n 

Vikas Vanarsi Patel, MD 1 – Aesculap/B.Braun, Biomet; 2 – Synthes, Lanx, Baxter, 

Stryker; 3B – Cerapedics, Baxter, Trans-1, Aesculap/B.Braun; 4 – Medtronic Sofamor 

Danek, Stryker, Zimmer, Cerapedics; Snowasis; 5 – Synthes, Show-Ika, Aesculap, 

Orthofix, CrossTrees Medical, Cerapedics, Pioneer; 7 – Springer 

Silvio Patella, MD ..........................................................n 

Shantanu Patil, MD ........................................................n 

Gary Patou, MD 3A, 3B, 6 – Pacira Pharmaceuticals, Cerimon Pharmaceuticals, Peplin 

Ltd.; 4 – GlaxoSmithKline 

Laura P Patron, MS 4 – Amgen Co.; 5 – Medtronic Sofamor Danek, Osteogenix, 

Ascension Orthopedics, Joe & Dorothy Dorsett Brown Foundation 

Joshua C Patt, MD .........................................................n 

Darren Patten .............................................................n 

Thilo Patzer, MD ...........................................................n 

Sophia Paul, BA ...........................................................n 

George Pavlou, Bsc, MRCS ..................................................n 

Jeff Pawelek ...............................................................n 

Liz Paxton, MA ............................................................n 

Terrance D Peabody, MD ....................................................n 

William Joseph Peace, MD ..................................................n 

Michael L Pearl, MD ........................................................n 

Andrew D Pearle, MD ......................................................n 

Carola Pechey .............................................................n 

Robert A Pedowitz, MD 7 – Springer, Wolters Kluwer Health - Lippincott Williams & 

Wilkins 

Walter J Pedowitz, MD ......................................................n 

Angela D Pedroza, MPH ....................................................n 

Sebastian Charles Peers, MD ................................................n 

Murat Pekmezci, MD .......................................................n 

Dr Syephane Pelet 5 – Arthrex, Inc. 

Vincent D Pellegrini Jr, MD 1 – DePuy, A Johnson & Johnson Company; 3B – Covidien 

Ortho McNeil Pharmaceuticals; 7 – Journal of Bone and Joint Surgery - American 

Brad L Penenberg, MD 1, 2, 3B, 5 – Wright Medical Technology, Inc.; 4 – Radlink Corp. 

Lauren Peng, MD ..........................................................n 

Jowan G Penn-Barwell, MB ChB .............................................n 

Scott Pennington, MD ......................................................n 

W Wesley Pennington, MS 5 – Smith & Nephew, Arthrex, Inc., Ossur Americas, Siemens 

Medical Solutions USA, Saucony, OrthoRehab, Alignmed LLC, Opedix 

Andrew T Pennock, MD .....................................................n 

Tom Penoyer, MD ..........................................................n 

Raymond A Pensy, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Michael Peppers, PharmD ...................................................n 

Marco Antonio Percope-Andrade, MD 2 – Stryker, Sanofi-Aventis 

Paul William Perdue, Jr MD .................................................n 

Regina Pereira, MD, PhD ...................................................n 




Renata Pereira, PhD ........................................................n 

Tatiana Soares Pereira, PT ...................................................n 

Daniel Pereles, MD 4 – Merck, Zimmer 

Tony Pericle ...............................................................n 

Georgio Perino ............................................................n 

Joseph H Perra, MD 1, 2, 3B, 4 – Medtronic; 5 – DePuy, A Johnson & Johnson 

Company 

Aimee Perreira, MD ........................................................n 

Daniel Perrien, PhD ........................................................n 

Kevin I Perry, MD ..........................................................n 

Wilfred Peter, PT ...........................................................n 

Christopher L Peters, MD 1, 3B, 5, 6 – Biomet 

Steve A Petersen, MD 5 – DJ Orthopaedics 

William J Petersilge, MD ....................................................n 

Alain Petit, PhD ...........................................................n 

Herve Petite, PhD 5 – Osteotech; 6 – Biocoral 

Agnica Petkovic, MD .......................................................n 

Anthony Petrella, PhD ......................................................n 

Dr Massimo Petrera ........................................................n 

Frank Petrigliano, MD ......................................................n 

Brad Petrisor, MD 2, 3B – Stryker; 5 – Stryker, Synthes; 6 – Synthes 

David Petron, MD .........................................................n 

Damon H Petty, MD 3B – Breg, Stryker, I-Flow 

Emily Petty, MMS, PAC .....................................................n 

Ferris Pfeiffer, PhD .........................................................n 

Christian Pfirrmann, MD ...................................................n 

Robert Pflugmacher, MD ....................................................n 

Terrence Philbin, DO 1 – Orthohelix, Biomet; 2 – Arthrocare, DJ Orthopaedics, 

Pfizer, Biomet, Footmax, Orthohelix; 3B – Biomet, Orthohelix; Pfizer; 4 – Orthohelix; 

5 – Biomet, DJ Orthopaedics, Pfizer, BioMimetic 

Marc J Philippon, MD 1 – Smith & Nephew, Bledsoe, Donjoy, Arthrosurface; 2, 3B, 

6 – Smith & Nephew; 4 – Smith & Nephew, Arthrosurface, Hipco, MIS; 5 – Ossur, 

Arthrex, Savcony, OrthoRehab, Opedix, Siemens, Steadman Philippon Research 

Institute; 7 – SLACK Incorporated 

Frank M Phillips, MD 1 – Nuvasive, DePuy, A Johnson & Johnson Company; 

3B – DePuy, A Johnson & Johnson Company, Kyphon Inc., Stryker, K2M; 4 – Nuvasive, 

Baxano, Spinal Kinetics, Spinal Motion, Axiomed, Flexuspine, CrossTrees, PearlDiver, 

BioAssets 

Jonathan H Phillips, MD 1, 2, 5 – Biomet; 3B – Synthes, Biomet 

Lee Garrit Phillips, MD .....................................................n 

Michael Phillips, MD .......................................................n 

William A Phillips, MD 4 – Orthologic 

Phinit Phisitkul, MD .......................................................n 

Vincent Pibarot, MD 1 – Amplitude 

Brad Matthew Picha, MD 5 – Synthes 

Raymond O Pierce Jr, MD ...................................................n 

Jeffery L Pierson, MD 3B – Zimmer 

Matthew Alan Pifer, MD ....................................................n 

Bart G Pijls, MD ...........................................................n 

Jeffrey Pike, MD ...........................................................n 

Luiz Pimenta, MD 2, 3C, 5 – Nuvasive 

Mahesh Pimple, FRCS ......................................................n 

Leo A Pinczewski, FRACS 1, 3B – Smith & Nephew; 4 – Australian Biotechnology, 

Orthopaedic Group Ltd. NSW; 5 – Smith & Nephew, Surgical Synergies 

Stephen J Pinney, MD 3B – United Health Care 

Alfonso E Pino, MD ........................................................n 

Ellie Pinsker ..............................................................n 

Jonathan Pinsky, MD .......................................................n 

Vivek Pinto 3A, 4 – Sanofi-Aventis AstraZeneca; 6 – Accutrol Inc. 

Michael S Pinzur, MD 2 – Small Bone Innovations, Smith & Nephew, Tornier; 3B – SBI; 

5 – BioMimetic 

Piergiorgio Pirani, MD .....................................................n 

Shafique P Pirani, MD ......................................................n 

Ulrike M Pirker-Fruhauf, MS ................................................n 

J David Pitcher, Jr MD ......................................................n 

Peter D Pizzutillo, MD ......................................................n 

54 

disclosure 

Kevin D Plancher, MD ......................................................n 

Christopher Plaskos, PhD 3A – Praxim 

Avraam L Ploumis, MD, PHD ................................................n 

David A Podeszwa, MD .....................................................n 

Alexandre Poignard, MD ....................................................n 

Mahesh Polavarapu ........................................................n 

Daniil Polishchuk, MD .....................................................n 

Dijana Poljak .............................................................n 

Andrew N Pollak, MD 1 – Extraortho; 2 – KCI; 3B – Smith & Nephew; 5 – Smith & 

Nephew, Stryker; 7 – AAOS 

David W Polly Jr, MD 2, 3B – Former Medtronic Spine and Medtronic Navigation 

Brent A Ponce, MD 2 – Arthrex, Inc., Tornier 

Ravi Kumar Ponnappan, MD 3B – DePuy, A Johnson & Johnson Company; 

3C – Biomet 

Robin Poole 1 – IBEX Pharmaceuticals; 3B, 6 – DePuy, A Johnson & Johnson Company, 

Merck, Serono, IBEX Pharmaceuticals; 4 – Merck, Johnson & Johnson, Roche 

Rudolf W Poolman, MD,PhD 3B – Amgen Co., Link Orthopaedics; 3C – Biomet, 

Zimmer; 5 – Amgen Co., AstraTech, Zimmer, Link Orthopaedics 

Peter Poon, MD 5 – Lima New Zealand 

Manny D Porat, MD ........................................................n 

Giuseppe Porcellini, MD ....................................................n 

Daniel Porter, MD 7 – Elsevier Publishing House 

Martyn Porter, MD 1 – DePuy, A Johnson & Johnson Company; 2 – Boehringer 

Ingelheim 

Martin A Posner, MD .......................................................n 

Sivaiah Potla, MD ..........................................................n 

Benjamin Potter, MD .......................................................n 

Hollis Potter, MD 3B – Histogenics Corporation, Kensey Nash Corporation, 

BioMimetic, Smith & Nephew, DePuy; 5 – General Electric Healthcare 

Lazaros A Poultsides, MD ...................................................n 

James N Powell, MD 3B – Smith & Nephew 

David Powles, MD, FRCS ...................................................n 

Alexis Pozen ..............................................................n 

Anupam Pradhan, MD ......................................................n 

Luis Gustavo Prata Nascimento, MD ..........................................n 

Heidi Prather, DO .........................................................n 

Daniel Pratt, PhD ..........................................................n 

Michael J Prayson, MD 2 – Smith & Nephew, AO faculty; 3B – Smith & Nephew; 

5 – Smith & Nephew, Synthes 

Paul Prefontaine, PT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Nikolaos Prevezas, MD .....................................................n 

Erin M Prewitt, MD ........................................................n 

Andrew J Price, FRCS 2, 3 – Biomet; 5 – Biomet, Genzyme, Smith & Nephew, Zimmer 

Dritan Prifti, ECFMG .......................................................n 

David McKeon Prior, MD ...................................................n 

Tamir Pritsch, MD .........................................................n 

Robert A Probe, MD 2 – Stryker, Synthes; 3B – Stryker 

Laura J Prokuski, MD .......................................................n 

Matthew T Provencher, MD ..................................................n 

Kevin Joseph Pugh, MD 2 – Smith & Nephew, Synthes, Medtronic; 3B, 5 – Medtronic, 

Smith & Nephew; 3C – Synthes 

Miguel Puigdevall, MD .....................................................n 

Nicholas Pulos, BA .........................................................n 

Marc Puls, PhD ............................................................n 

Stephanie Pun, MD ........................................................n 

Derek Pupello 3B – DJ Orthopaedics 

Ed Purdue, PhD ...........................................................n 

Lalit Puri, MD 1 – Stryker; 3B – Stryker, Salient Surgical; 5 – OREF 

Rajeev D Puri, MD .........................................................n 

James J Purtill, MD .........................................................n 

Amit B Putti, MBBS ........................................................n 

Christian Puttlitz, PhD 3B – Medtronic Sofamor Danek; 5 – BioMimetic, Cerapedics, 

DePuy, A Johnson & Johnson Company, Medtronic Sofamor Danek, National Institutes 

of Health (NIAMS & NICHD), Synthes 

Cornelia Putz, MD .........................................................n 

Tamara Pylawka, MD .......................................................n 




Paul Pynsent, PhD 5 – Smith & Nephew 

Erion Qamirani, MD .......................................................n 

Erion Qanirani, MD, PhD ...................................................n 

Robin M Queen, PhD ......................................................n 

Xing Qiu, PhD ............................................................n 

Ryan Quigley, BS 4 – Amgen Co.; 5 – Medtronic Sofamor Danek, Osteogenix, 


Robert H Quinn, MD 5 – OREF, Smith & Nephew, Stryker, Synthes 

Sheeraz Qureshi, MD 2 – Medtronic, Stryker 

Michael Rabago, PA 2 – Regeneration Technologies, Inc. 

Brien Rabenhorst, MD ......................................................n 

Deepthi Rachala, MS .......................................................n 

James Nick Rachel, MD .....................................................n 

Adam Wesley Racusin, MD ..................................................n 

Kristen E Radcliff, MD ......................................................n 

Christof Radler, MD 2, 3B – Smith & Nephew 

Vincenza Ragone, MD ......................................................n 

Ole Rahbek, MD ...........................................................n 

Mohammad Rahimi ........................................................n 

Luthfur Rahman, MRCS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Hans Rahme, MD ..........................................................n 

Steven M Raikin, MD 3B – DePuy, A Johnson & Johnson Company; 5 – BioMimetic 

Sam Rajaratnam, MD .......................................................n 

Eduardo Rajdl, MD ........................................................n 

PPJ Raju, FRCR ............................................................n 

Kawan Rakhra, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Raghu Raman, MRCS 2 – Genzyme, JRI 

Arun J Ramappa, MD .......................................................n 

Jayasree Ramaskandhan, MSc 5 – Smith & Nephew 

Rohit Rambani, MS(ortho) ..................................................n 

Palanisamy Ramesh, FRCS Orth .............................................n 

Claudia Ramirez, BS .......................................................n 

Jose G Ramon, MD 4 – Pfizer 

Nicholas Ramos, BA ........................................................n 

Matthew Lee Ramsey, MD 2 – Zimmer, Mitek; 3B – Zimmer, Ascension; 4 – Johnson & 

Johnson, Novartis, Teva; 5 – Biomet 

Rex D Ramsier, PhD ........................................................n 

Sumit Hamendra Rana, MD .................................................n 

Amar S Ranawat, MD 1, 2, 5, 6 – DePuy, A Johnson & Johnson Company, Stryker; 

3B – DePuy, A Johnson & Johnson Company, MAKO; 3C, 4 – ConforMIS 

Anil Ranawat, MD 1, 6, 7 – DePuy, A Johnson & Johnson Company, Stryker; 2 – MAKO, 

ConforMIS, Nova, DePuy, A Johnson & Johnson Company, Stryker; 3B – MAKO, DePuy, 

Stryker; 3C – ConforMIS; 4 – ConforMIS, NOVA Surgical; 5 – MAKO, DePuy, Stryker 

Chitranjan S Ranawat, MD 1, 2 – DePuy, A Johnson & Johnson Company, Stryker; 

3B – MAKO; 3C – DePuy, A Johnson & Johnson Company, Stryker, Amedica; 4, 


R Lor Randall, MD .........................................................n 

Filippo Randelli, MD 1 – Sanofi-Aventis, Link Orthopaedics; 2 – Sanofi-Aventis, Bayer; 

3B – Johnson & Johnson; 3C – Smith & Nephew; 5 – Sanofi-Aventis 

Joseph C Randolph, MD 5 – Cool Systems, Inc. 

Scottie Rangel .............................................................n 

Nalini Rao, MD ............................................................n 

Bradley Raphael, MD .......................................................n 

Michael Raschke, MD .......................................................n 

Christopher H Rashidifard, BA ...............................................n 

Kevin A Raskin, MD 3C – KCI 

Dima Raskolnikov, BS ......................................................n 

Vijay J Rasquinha, MD ......................................................n 

Farbod Rastegar, BS ........................................................n 

Shishir Rastogi, MD ........................................................n 

Stephen J Raterman, MD 3B – Smith & Nephew 

Christopher Rathbone, PhD .................................................n 

Karl E Rathjen, MD 3C – Orthopaediatrics; 7 – Saunders/Mosby-Elsevier 

Dr Giovanni Ravazzolo .....................................................n 

Raymond B Raven III, MD 1, 2, 3B – Osteomed; 3C – Auxillium 

Krishna Ravi Cidambi, MD ..................................................n 

55 

disclosure 

Adala Raviraj, MD ..........................................................n 

Faizal Rayan, MBBS,MRCS, 

DORTHO .................................................................n 

Guy Raz, MD ..............................................................n 

Yadollah Razaei, MD .......................................................n 

Ali Razif, MD ..............................................................n 

Pasquale Razzano, MS ......................................................n 

Jeffrey Maurice Reagan, MD .................................................n 

John Realyvasquez .........................................................n 

Juan A Realyvasquez, MD ...................................................n 

Glenn R Rechtine, II MD 5 – Endo Pharmaceuticals 

Robert N Reddix, Jr MD 2 – Orthofix, Inc., Smith & Nephew, Integra Life Sciences; 

3B – Smith & Nephew; 5 – Orthofix, Inc. 

Sudheer C Reddy, MD ......................................................n 

Andrea Redler, MD .........................................................n 

Elaine Reed, PhD ..........................................................n 

Mike R Reed, MBBS MD 2 – Biomet, Heraeus Medical, Care fusion, Ethicon; 

5 – Augustine, Biomed, Ethicon, Heraeus Medical 

Mary E Reedy, RN ..........................................................n 

Harold Wharton Rees, MD ..................................................n 

Ricky Regalbuto, BS ........................................................n 

Rasham Rehman, MSc ......................................................n 

Heiko Reichel, MD .........................................................n 

J Spence Reid, MD 2 – Smith & Nephew; 3B – Smith & Nephew, Synthes 

Terry-Elinor R Reid .........................................................n 

Chris Reilly, MD 6 – DePuy, A Johnson & Johnson Company 

James H Reilly, PhD ........................................................n 

Mark C Reilly, MD 2 – Synthes, Smith & Nephew, Stryker 

Felipe Reinares, MD ........................................................n 

Adriana Reinersman ........................................................n 

Keith R Reinhardt, MD .....................................................n 

Donnie M Reinhart, DO 4 – Medtronic Sofamor Danek 

Michael M Reinold, PT 3B – Genzyme 

Abilio Antunes Reis, MD 4 – Bristol-Myers Squibb 

Aldo Riesgo, BS ............................................................n 

William Reisman, MD ......................................................n 

Charles A Reitman, MD .....................................................n 

Weiping Ren, MD ..........................................................n 

Norma Rendon ............................................................n 

John A Repicci, MD 1, 3C – Biomet 

Herbert Resch, MD .........................................................n 

Camilo Restrepo, MD ......................................................n 

Arthur C Rettig, MD 5 – Biomet, Biologics Inc. 

Gregory T Reveal, MD ......................................................n 

Mr Matthew Revell 5 – Smith & Nephew 

Mauricio Reyes, PhD .......................................................n 

Sarah Reynolds, PT .........................................................n 

Shaun Reynolds, MD .......................................................n 

John JM Rhee, MD 1 – Biomet; 2 – Biomet, DePuy; 3B – Biomet, Synthes; 4 – Phygen; 

5 – DePuy, A Johnson & Johnson Company, Kineflex, Medtronic 

Peter C Rhee, MD ..........................................................n 

Monica Rho, MD ..........................................................n 

Anthony S Rhorer, MD 2, 3B – Medtronic Sofamor Danek, Smith & Nephew; 5 – Smith 

& Nephew; 6 – Synthes 

Kee Hyung Rhyu, MD 3B – The Korean Human Tissue Bank 

Pedro Ricart Hoffiz, MD ....................................................n 

William M Ricci, MD 1, 2, 3B, 3C – Smith & Nephew, Wright Medical Technology, Inc.; 

5 – Smith & Nephew, Wright Medical Technology, Inc., Synthes, AONA; 7 – Wolters 


Marc Joseph Richard, MD 5 – Zimmer 

B Stephens Richards III, MD 2 – Medtronic; 4 – Pfizer; 7 – Wolters Kluwer Health - 


Justin E Richards, MD ......................................................n 

Meagan Richardson-Frazzitta, BS ............................................n 

David R Richardson, MD ...................................................n 

Joshua Richman ...........................................................n 




Johannes S Rieger, MSc .....................................................n 

Michael D Ries, MD 1, 3B – Smith & Nephew 

K Daniel Riew, MD 1 – Biomet, Medtronic Sofamor Danek, Osprey; 4 – Benvenue, 

Expanding Orthopedics, Nexgen, Osprey, Paradigm Spine, PSD, Spinal Kinetics, 

Spineology, Vertiflex 

Wynne M Rigal, MD ........................................................n 

Jeffrey Rihn, MD 5 – Medtronic Sofamor Danek 

W J Rijnberg, MD ..........................................................n 

Clayton H Riley, MD .......................................................n 

Michelle Riley, PA ..........................................................n 

David C Ring, MD 1 – Wright Medical Technology, Inc.; 2 – Acumed, LLC; 

3B – Acumed, LLC, Biomet, Wright Medical Technology, Inc.; 4 – Illuminos, Mimedex; 

5 – Biomet, Stryker 

James R Ringler, MD .......................................................n 

Lawrence A Rinsky, MD .....................................................n 

Gilberto Rios, MD .........................................................n 

Pascal Rippstein, MD 1, 2, 3B – DePuy, A Johnson & Johnson Company 

Lucas Eduardo Ritacco, MD .................................................n 

Amber E Ritenour, MD .....................................................n 

Merrill A Ritter, MD ........................................................n 

Todd F Ritzman, MD .......................................................n 

Dennis Rivenburgh, PA-C 2 – 3M 

Terry E Rives, PhD .........................................................n 

Randy Rizek, MD ..........................................................n 

Claire E Robbins, PT, DPT, MS, GCS ..........................................n 

David Roberge, MD, FRCSC 5 – Merck 

Craig S Roberts, MD 5 – Synthes; 7 – Skeletal Trauma 

David Roberts, MD .........................................................n 

Matthew Roberts, MD ......................................................n 

Timothy Roberts ...........................................................n 

Otto Robertsson, MD, PhD 3C – Biomet; 4 – Astra Zeneca 

James Robinson, PhD 2, 5 – Genentech 

Michael Robinson, FRCS ....................................................n 

Michael Aaron Robinson, MD ...............................................n 

Paul S Robinson ...........................................................n 

Yohan Robinson, MD 6 – DePuy, A Johnson & Johnson Company, Synthes 

Sheri Rocha, BS ............................................................n 

Martin William Roche, MD 1, 4 – MAKO Surgical; 3B, 5 – DePuy MAKO Surgical 

Scott Alan Rodeo, MD 2 – Musculoskeletal Transplant Foundation; 3B – Novartis; 

4 – Cayenne; 5 – Wyeth 

Robert Rodine, BSc, DC .....................................................n 

Carlos M Rodriguez ........................................................n 

Edward Rodriguez, MD 1, 3B – Extra-Ortho; 4 – MXO Orthopedics; 5 – Synthes 

Laryssa Korduba-Rodriguez 3A, 4 – Stryker 

Sergio Rodriguez, MD ......................................................n 

Justin Phillip Roe, MD 3B, 5 – Stryker 

Margaret M Roebuck, PhD 1 – Biomet; 2 – Biomet, Boehringer Ingelheim, Bristol- 

Myers Squibb, Pfizer; 3B – Biomet, Boehringer-Ingelheim; 3C – DePuy, A Johnson & 

Johnson Company; 5 – DePuy, A Johnson & Johnson Company, Johnson & Johnson 

Michael J Rogal, MD 4 – Pfizer, Merck, Eli Lilly 

Ann Rogers, MD ...........................................................n 

Benedict Rogers, MBBS 3B – Bayer 

John Sargent Rogerson, MD .................................................n 

Thana Rojpornpradit, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Andrew S Rokito, MD 3B – Core Essence Orthopaedics 

Carlo Romano, MD ........................................................n 

J R Romanowski, MD .......................................................n 

Matteo Romantini, MD .....................................................n 

Anthony A Romeo, MD 1, 3B – Arthrex, Inc.; 2 – Arthrex, Inc., DJ Orthopaedics; 

5 – Arthrex, Inc., Ossur, Smith & Nephew; 6 – Arthrex, Inc., DJ Orthopaedics; 


Alex Romero, MD 5 – Arthrex, Inc. 

Joanna Helena Roocroft, MA ................................................n 

Anne Roques, PhD 3A – Finsbury Orthopaedics Ltd. 

Cecil H Rorabeck, MD 1, 2, 3, 4 – Smith & Nephew; 7 – JBJS (Journal of Bone & Joint 

Surgery (Am)) 

56 

disclosure 

David Rose ................................................................n 

Peter S Rose, MD ..........................................................n 

Jeffrey E Rosen, MD 2, 3B – Ferring Pharmaceuticals; 5 – Ferring Pharmaceuticals, 

Darco, DePuy, A Johnson & Johnson Company 

Aaron Glen Rosenberg, FACS, MD 1, 2, 3B, 4 – Zimmer; 7 – Wolters Kluwer Health - 

Lippincott 

Melvin Paul Rosenwasser, MD 3B – Biomet, Stryker 

Tarek Roshdy, MD .........................................................n 

Michael Rosner, MD 2 – Medtronic; 5 – US Congressional Grant 

F Patrick Ross, PhD 4 – Amgen Co.; 5 – Medtronic Sofamor Danek, Osteogenix, 


Mark Rossi, PhD ...........................................................n 

Roberto Rossi, MD .........................................................n 

Alan Roth, PhD ............................................................n 

David E Rothem, MD .......................................................n 

Richard H Rothman, MD 1, 3B – Stryker; 7 – Journal of Arthroplasty 

Roberto Rotini, MD ........................................................n 

Dominique Rouleau, MD 5 – DePuy, A Johnson & Johnson Company, KCI, Smith & 

Nephew, Stryker, Synthes 

Tracy Rounds ..............................................................n 

Yannick Roussanne, MD ....................................................n 

Constantinos Roussos, MD ..................................................n 

Rajesh Rout, MD ...........................................................n 

Milton L Routt Jr, MD ......................................................n 

Louis Roy, MD .............................................................n 

Marcel Roy, PhD 3C – Signal Medical Corp. 

David Price Roye Jr, MD 2 – DePuy, Biomet, Medtronic; 5 – Biomet 

S Robert Rozbruch, MD 1, 3B – Small Bone Innovations; 2, 5 – Smith & Nephew; 

4 – Intramed 

Adam Rozumalski, MS ......................................................n 

Harry E Rubash, MD 1 – Zimmer; 5 – Biomet, Zimmer 

Paul T Rubery Jr, MD 4 – Johnson & Johnson, LAGeT LLC, Axial Biotech; 5 – Axial 

Biotech 

David A Rubin, MD 4 – Amgen Co.; 5 – Medtronic Sofamor Danek, Osteogenix, 


Todd A Rubin, BS ..........................................................n 

David Simms Ruch, MD ....................................................n 

John F Rudan, MD 2, 3B, 5 – DePuy, A Johnson & Johnson Company 

Guy J Alexander Rudin, MD 4 – Zimmer, Pfizer 

John-Paul H Rue, MD ......................................................n 

Alberto Ruffilli, MD ........................................................n 

Prof Pietro Ruggieri ........................................................n 

Erin Ruh, MS ..............................................................n 

Michell Ruiz Suarez, MD, MS 3B – ConMed Linvatec 

Jeremy K Rush, MD ........................................................n 

George V Russell Jr, MD 2 – AONA; 4 – Zimmer; 5 – Synthes 

Kelvin J Russell, MD ........................................................n 

Thomas A (Toney) Russell, MD 1, 2, 3B – Smith & Nephew; 3C – Etex; 4 – Etex, Smith 

& Nephew, Stryker, Pfizer, Medtronic; 7 – Wolters Kluwer Health - Lippincott Williams 

& Wilkins 

Martin Russlies, MD ........................................................n 

Wolfgang Ruther, MD 1, 3B – Zimmer; 2 – Bayer; 5 – Link Orthopaedics; 7 – Elsevier 

Laura Ruzzini, MD .........................................................n 

Paul M Ryan, MD ..........................................................n 

Philip Ryan, FAFPHM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Leon Rybak, MD ...........................................................n 

Jessica Ryu, BA ............................................................n 

Richard K N Ryu, MD 2 – Mitek; 3B – MedBridge 

Ehsan Saadat, BS ..........................................................n 

Coleen S Sabatini, MD .....................................................n 

Hamid Sabet 3A, 6 – DePuy, A Johnson & Johnson Company, Johnson & Johnson; 


Sanjeev Sabharwal, MD 5 – Smith & Nephew 

Janice T Sacks .............................................................n 

Stanley E Sacks, MA ........................................................n 

Dr Rachid Saddiki .........................................................n 




Kazuhiko Saeki, MD .......................................................n 

Oleg Safir, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Marc Safran, MD 1 – Stryker; 3B – Cool Systems, Inc., Arthrocare; 3C – Cool Systems, 

Inc., Cradle Medical, Inc., Ferring Pharmaceuticals, Biomimedica; 4 – Cool Systems, 

Inc., Cradle Medical, Inc., Biomimedica; 5 – Ferring Pharmaceuticals; 7 – Wolters 

Kluwer Health - Lippincott Williams & Wilkins, Saunders/Mosby-Elsevier 

Henry Claude Sagi, MD 2, 3B, 5 – Stryker, Synthes, Smith & Nephew 

Alexander P Sah, MD .......................................................n 

Robert Sah, MD, ScD 3B – Alphatec Spine; 4 – GlaxoSmithKline, Johnson & Johnson, 

Medtronic 

Subrata Saha, PhD 5 – Stryker 

Hacer Sahin, Phd ..........................................................n 

Comron Saifi, BS ..........................................................n 

Jason C Saillant, MD .......................................................n 

Susumu Saito, MD .........................................................n 

Tomoyuki Saito, MD .......................................................n 

Paul Saiz, MD 2, 3B, 5 – Zimmer 

Hiroaki Sakai, MD .........................................................n 

Takashi Sakai, MD .........................................................n 

Toshihiko Sakakibara, MD ..................................................n 

Manoon Sakdinakiattikoon .................................................n 

Jeremy Saklatvala, MD ......................................................n 

Yu Sakuma, MD 2 – Mitsubishi Tanabe Pharma 

Nima Salari, MD ...........................................................n 

Pooria Salari, MD ..........................................................n 

Michael Salata, MD ........................................................n 

Khaled J Saleh, MD, MSc, FRCSC, FACS 1 – Smith & Nephew; 3B – Aesculap/ B. Braun, 

Osteotech, Blue Cross, Blue Shield, Kimberly Clark; 5 – Aesculap/B. Braun, Stryker, 

Smith & Nephew; 7 – Elsevier 

Jacobo Saleme, MD ........................................................n 

Mats Salemyr, MD 4 – AstraZeneca 

Samantha L Salkeld, MSE 2 – Biomet; 5 – Medtronic Sofamor Danek 

Dr Lucy J Salmon ..........................................................n 

Guillem Salo, MD ..........................................................n 

David Salonen, MD 2 – Pfizer, Merck; 3B – Abbott, Johnson & Johnson, Merck, Pfizer 

Charles L Saltzman, MD 1, 4 – Tornier; 3B – Zimmer, Tornier; 7 – Saunders/Mosby- 

Elsevier 

Matthew Saltzman, MD 2 – CareFusion 

Eduardo Agustin Salvati, MD ................................................n 

Davide Salvo, MD ..........................................................n 

Andrew A Sama, MD 1 – DePuy, A Johnson & Johnson Company, Osteotech, 

Orthodevelopment Corporation; 2 – DePuy, A Johnson & Johnson Company, Bacterin 

Harvest; 3B – DePuy, A Johnson & Johnson Company, Osteotech, Life Spine, Spineview, 

Orthodevelopment Corporation; 4 – Small Bone Innovations, Paradigm Spine; 

5 – Mesoblast 

Amer Samdani, MD 2, 3B – DePuy, A Johnson & Johnson Company, Synthes, 

SpineGuard 

Yashuito Samejima, MD ....................................................n 

Syed Sami, MD ............................................................n 

Vincent James Sammarco, MD ...............................................n 

Barry Sampson, MD 3B – DePuy, A Johnson & Johnson Company, Implantcast 

Thomas G Sampson, MD 2 – Smith & Nephew, ConMed Linvatec 

Jonathan Samuels, MD .....................................................n 

Thomas P San Giovanni, MD 1 – Arthrosurface; 2 – Arthrex, Inc., Arthrosurface; 

3B – Arthrex, Inc.; 4 – Cytonics 

Joaquin Sanchez-Sotelo, MD 1 – Stryker; 5 – Stryker, DePuy, Zimmer 

Bengt Sanden, MBBS 5 – DePuy, A Johnson & Johnson Company, Kyphon Inc. 

David Sanders, MD 3B – Smith & Nephew; 5 – Smith & Nephew, Synthes 

James O Sanders, MD 3C – Orthopediatrics; 4 – Abbott, Hospira; 5 – Medtronic 

Sofamor Danek 

Roy W Sanders, MD 1 – ConMed Linvatec, DePuy, A Johnson & Johnson Company, 

Smith & Nephew, Stryker; 2, 3B – Smith & Nephew, Medtronic; 5 – Health and Human 

Services, National Institutes of Health (NIAMS & NICHD), Medtronic, Smith & 

Nephew, Stryker, METRC (DOD); 7 – Journal of Orthopaedic Trauma 

Timothy G Sanders, MD 7 – Elsevier 

57 

disclosure 

Harvinder S Sandhu, MD 1 – Osteotech, Spinewave; 3B – Aesculap/B. Braun, 

Spinewave, Osteotech, Amedica, Simpirica; 4 – Amgen, Pfizer, Sanofi-Aventis, 

Spinewave, Amedica, Simpirica, Paradigm Spine, Providence Medical, Soalni Healthcare, 

K2M 

Bjorn Sandstrom, MD ......................................................n 

Jose A Sanhudo, MD .......................................................n 

Edward Rainier G Santos, MD 5 – Medtronic; 6 – Synthes 

Elhadi Sariali, MD .........................................................n 

Vishal Sarwahi, MD 2 – Medtronic, DePuy, A Johnson & Johnson Company; 

5 – DePuy, A Johnson & Johnson Company, Stryker, K2M 

Takeshi Sasagawa, MD ......................................................n 

Jun Sasahara, MD ..........................................................n 

Mikito Sasaki, MD .........................................................n 

Rick C Sasso, MD 1 – Medtronic; 4 – Biomet; 5 – Cerapedics, Medtronic, Smith & 

Nephew, Stryker; 7 – Saunders/Mosby-Elsevier 

Adam Sassoon, MD ........................................................n 

Robert L Satcher Jr, MD .....................................................n 

Keshthra Satchithananda, FRCR .............................................n 

Yukata Sato, MD ...........................................................n 

Haruhiko Satonaka, MD, PhD ...............................................n 

Jibanananda Satpathy, MD ..................................................n 

James Matthew Saucedo, MD ................................................n 

Katherine R Saul, PhD 3A, 6 – Wyeth, Pfizer; 4 – Pfizer 

Stuart M Saunders, MD .....................................................n 

Jason Wayne Savage, MD ....................................................n 

Edgar Savidge, PT, DPT, OCS ................................................n 

Felix H Savoie, III MD 3B, 5 – Mitek, Smith & Nephew; 3C, 4 – Cayenne Medical 

Feray Savrun, Prof .........................................................n 

Prasad J Sawardeker, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Amy Sawhill, BA ...........................................................n 

Jeffrey R Sawyer, MD 3B – Synthes; 3C – Medtronic 

Siraj A Sayeed, MD .........................................................n 

Michele Scelsi, MD .........................................................n 

Jonathan L Schaffer, MD 1 – Zin Medical, Inc.; 3B – Zin Medical, Inc., Biorita, Inc., 

AcelRx Pharmaceuticals, Inc.; 4 – iBalance Medical, Inc., Biorita, Inc.; 7 – Taylor and 

Francis, Elsevier 

Lawrence A Schaper, MD 4 – Johnson & Johnson 

Daniel Scharfstein, ScD 3B – Johnson & Johnson, MELA Sciences, Otsuka; 4 – Abbott, 

Merck, Johnson & Johnson, Pfizer 

Thomas J Scharschmidt, MD ................................................n 

Michael Schaufele, MD 3B – Medtronic, Smith & Nephew 

Justin Scheer ..............................................................n 

Emil H Schemitsch, MD 1 – Stryker; 3B – Amgen Co., Pfizer, Stryker, Synthes, Smith & 

Nephew, Baxter, Wright Medical Technology, Inc.; 5 – Smith & Nephew; 6 – Canadian 

Institutes of Health Research (CIHR), Brainlab, OMEGA; 7 – Saunders/Mosby-Elsevier 

David M Scher, MD ........................................................n 

Susan A Scherl, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Jonathan R Schiller, MD ....................................................n 

Cathy D Schleck ...........................................................n 

Theodore F Schlegel, MD 1 – DJ Orthopaedics; 3B – DJ Orthopaedics Rotation 

Medical; 4 – Cayenne Medical 

Thomas P Schmalzried, MD 1, 4 – DePuy, A Johnson & Johnson Company, Stryker; 2, 

3B, 5 – Stryker 

Christopher C Schmidt, MD .................................................n 

Jan O Schmitt, MD .........................................................n 

Christian Schmitz, MD .....................................................n 

Charlotte-Dorothe Schneckener, CM .........................................n 

Robert Schneider, MD 3B – DePuy, A Johnson & Johnson Company 

Andrew Schoenfeld, MD ....................................................n 

Markus Schofer, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Vanessa A Scholtes, PhD ....................................................n 




Lew C Schon, MD 1 – Aircast(DJ)-DJ Orthopaedics, Arthrex, Inc., Darco, Nexa 

Orthopaedics, Tornier, Zimmer; 2 – Nexa Orthopaedics, Tornier, Biomet, Zimmer, 

Arthrex, Inc.; 3B – Arthrex Inc., BioSET Inc., Zimmer, Nexa Orthopaedics-Tornier, 

Biomet, MiMedx, Inc., Mylad, Zimmer, Guidepoint Global, Gerson Lehrman 

Group; 3C – Royer Biomedical, Inc., Carestream Health, The Snyder Center of Pain 

Pharmacology; 4 – Nexa Orthopaedics-Tornier, Royer Biomedical, Inc., Bioactive 

Surgical Technologies, Inc., Healthpoint Capital; 5 – DePuy, A Johnson & Johnson 

Company, Synthes, Zimmer, Aircast(DJ Orthopedics), Stryker, Nexa Orthopaedics- 

Tornier, Arthrex, Inc., BioMimetic, Biomet, Royer Biomedical, Inc., Integra Life Sciences, 

Omega, Osteotech, Trimed; 6 – Bioactive Surgical Inc., Concepts in Medicine LLC; 

7 – Elsevier 

Jan W Schoones, MSc .......................................................n 

Verena M Schreiber, MD ....................................................n 

Steven Schroder, MD .......................................................n 

Joshua Schroeder, MD ......................................................n 

William C Schroer, MD 5 – Biomet, Pfizer 

Samuel Ray Schroerlucke, MD ...............................................n 

Mark Schrumpf, MD .......................................................n 

Reinhard Schuh, MD .......................................................n 

Caitlin Schulte, BA .........................................................n 

Ben Schulz, MD ...........................................................n 

John R Schurman II, MD 2, 3B – Stryker 

Frank J Schwab, MD 3B, 5 – Medtronic Sofamor Danek, DePuy, A Johnson & Johnson 

Company; 4 – Nemaris 

Joseph Hasbrouck Schwab, MD 6 – Globus Medical 

Bernd Schwantes, MD ......................................................n 

Daniel M Schwartz, PhD 4 – Gentis 

Jeffrey M Schwartz, MD 4 – Eli Lilly, Johnson & Johnson, Merck, Procter & Gamble 

Michael H Schwartz, PhD ...................................................n 

Dana M Schwarz, RN .......................................................n 

Ran Schwarzkopf, MD ......................................................n 

James Douglas Schwender, MD 1, 2, 3B – Medtronic Sofamor Danek 

Jens Schwiesau 3A – Aesculap/B. Braun 

Marcus F Sciadini, MD 2 – Stryker, Smith & Nephew; 3B, 4 – Stryker 

John Alan Scolaro, MD .....................................................n 

Joanna Scoon, BA ..........................................................n 

Andreas Scorilas, Prof ......................................................n 

David Forrest Scott, MD 2 3B – Stryker, OMNI life science; 4 – OMNI life science, 

Amedica; 5 – Stryker, OMNI life science, Novartis, Proctor & Gamble 

Kelly Scott, BA 1 – Zimmer; 7 – Saunders/Mosby-Elsevier 

W Norman Scott, MD 1 – Zimmer 

Gaetano J Scuderi, MD 4 – Cytonics, K2, Atlas Spine; 6 – Cytonics 

Giles R Scuderi, MD 1, 2, 3B – Zimmer, Salient Surgical; 7 – Springer, Elsevier, Thieme, 

World Scientific 

Thomas P Sculco, MD ......................................................n 

Sean P Scully, MD, PhD .....................................................n 

Renyi Benjamin Seah, MBBS ................................................n 

Art Sedrakyan, PhD ........................................................n 

Ludwig Seebauer, MD 1, 3B – DePuy, A Johnson & Johnson Company 

Joern Bengt Seeger .........................................................n 

Ego Seeman, Prof 2 – Amgen Co., Eli Lilly, Medtronic Sofamor Danek, Novartis, Procter 

& Gamble, Servier 

Julieanne P Sees, DO .......................................................n 

Lee S Segal, MD ...........................................................n 

Neil Segal, MD ............................................................n 

Keith A Segalman, MD ......................................................n 

Jennifer Sehn, BS ..........................................................n 

Atsushi Seichi, MD .........................................................n 

Christof Seiler, PhD ........................................................n 

William H Seitz Jr, MD 2 – Stryker, Tornier; 3B – SBI, Stryker, Tornier, Kapp Surgical 

Jon K Sekiya, MD 1 – Arthrex, Inc., OrthoDynamix, LLC; 3B – Arthrex, Inc.; 3C, 

4 – OrthoDynamix, LLC; 7 – Elsevier 

David Seligson, MD 3B – Stryker 

Gillian Soles, MD ..........................................................n 

Jonathan N Sembrano, MD 5 – Nuvasive 

Stephen A Sems, MD 1, 3B – DePuy, A Johnson & Johnson Company 

Cengiz Sen ................................................................n 

58 

disclosure 

Chusheng Seng, MBBS, MRCS ...............................................n 

Dilip K Sengupta, MD 1, 2, 3C, 4, 5 – Globus Medical 

Eun Seok Seo, MD .........................................................n 

Hee Soo Seo, MD ..........................................................n 

Hyoung Yeon Seo, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Young-Jin Seo, Prof ........................................................n 

Chang-Woo Seok, MD ......................................................n 

Jong-Keun Seon, MD .......................................................n 

Sang Cheol Seong, MD .....................................................n 

Fernando Serna, MD .......................................................n 

Anthony K Sestokas, MD ....................................................n 

Anil Sethi, MD ............................................................n 

Erik P Severson, MD .......................................................n 

Mathew Sewell ............................................................n 

Shaun Alan Sexton, FRCS ...................................................n 

Thorsten M Seyler, MD 3C – Heraeus Medical 

James J Sferra, MD 1 – Orthohelix; 2 – Acumed, LLC, Orthohelix, Arthrex 

Nicholas A Sgaglione, MD 1 – Biomet; 3B – ConMed Linvatec, Smith & Nephew 

Benjamin S Shaffer, MD 4 – Stryker 

Christopher I Shaffrey, MD 1 – Medtronic; 2 – Biomet, DePuy, A Johnson & Johnson 

Company; 3B – Medtronic, Biomet, DePuy, A Johnson & Johnson Company; 5 – DePuy, 

A Johnson & Johnson Company 

Kushal Shah, BS ...........................................................n 

Nirav Shah, MD ...........................................................n 

Ritesh Shah, MD ...........................................................n 

Suken A Shah, MD 1, 5 – Arthrex, Inc., DePuy Spine, A Johnson & Johnson Company; 

2, 3B – DePuy Spine, A Johnson & Johnson Company; 3C – K Spine, Inc.; 4 – Globus 

Medical 

Suraj Shah, BSc ............................................................n 

Swapnil B Shah, MD .......................................................n 

Ab-Rahman Shaifuzain, MBBS ...............................................n 

Jonathan Sham, MD ........................................................n 

K Samer F Shamieh, MD ....................................................n 

Raj Harry Shani, MD .......................................................n 

Frederic Shapiro, MD 3A – Millennium Pharmaceuticals; 7 – Saunders/Mosby-Elsevier 

Alok D Sharan, MD 3B – Paradigm Spine 

Peter F Sharkey, MD 1, 4 – Physician Recommended Nutriceuticals, Inc.; 2, 3B – Stryker, 

Stelkast, Inc.; 7 – Journal of Arthroplasty, American Journal of Orthopaedics, Clinical 

Orthopaedics & Related Research. American Journal of Orthopaedics 

Adrija Sharma .............................................................n 

Amit Sharma, MD ..........................................................n 

Hemant Sharma, MRCS, MS .................................................n 

Vinod Kumar Sharma, MS ..................................................n 

Nigel E Sharrock, MD 4 – OR Comfort 

Christopher Shaw, FRCS ....................................................n 

Scott Shawen, MD 3C – Wright Medical Technology, Inc. 

Barbara Shay, PhD 5 – DePuy, A Johnson & Johnson Company 

Kevin G Shea, MD .........................................................n 

Natalie Shearwood-Porter, Meng .............................................n 

Mr Eoin C Sheehan ........................................................n 

Shahin Sheibani-Rad, MD ...................................................n 

Ali Sheikhzadeh, MD 3A, 4 – Roche 

K Donald Shelbourne, MD 1 – DJ Orthopaedics; 3C – Kneebourne Therapeutics, Inc.; 

4 – Abbott, Pfizer 

John Shelton, BS ...........................................................n 

Walter R Shelton, MD 2, 3C – Smith & Nephew, Zimmer 

Francis H Shen, MD 1 – Globus Medical; 2, 3B, 6 – DePuy, A Johnson & Johnson 

Company, Synthes; 5 – Musculoskeletal Transplant Foundation, Medtronic; 


James Shen, MD ...........................................................n 

Jianhua Shen 3A, 4 – Stryker 

Bryan Shepherd, PhD ......................................................n 

Zachary R Sheppard, BS ....................................................n 

Seth Sherman, MD .........................................................n 

Dhiren S Sheth, MD ........................................................n 

Neil P Sheth, MD ..........................................................n 




Anil Shetty, PhD ...........................................................n 

Kenrin Shi, MD ............................................................n 

Shao-Min Shi, MD .........................................................n 

Derek S Shia, MD 3A – Smith & Nephew 

Keiichiro Shiba, MD .......................................................n 

Kazuyuki Shibusawa, MD ...................................................n 

Tomonori Shigemura, MD ..................................................n 

Keiichi Shigenobu, MD .....................................................n 

Juan Manuel Shiguetomi-Medina ............................................n 

Matthew Charles Shillito, MD ...............................................n 

Sang Ho Shim, MD ........................................................n 

Shang Mi Shim, MD ........................................................n 

Norimichi Shimamoto, MD .................................................n 

Adam L. Shimer, MD .......................................................n 

Koh Shimizu, MD ..........................................................n 

Masaki Shimizu, MD .......................................................n 

Sara Shimizu, MD .........................................................n 

Tohru Shimizu, MD ........................................................n 

Shoji Shimose, MD, PhD ...................................................n 

Alexander Yong Shik Shin, MD 5 – Musculoskeletal Transplant Foundation, Integra 

Life Sciences 

Jin Hyup Shin, MD .........................................................n 

Sang-Jin Shin, MD .........................................................n 

Sangmin Ryan Shin, MD ....................................................n 

Andrew A Shinar, MD 1 – Smith & Nephew; 3B – Smith & Nephew, Zimmer 

Takata Shinjiro, PhD .......................................................n 

Rikuo Shinomiya, MD ......................................................n 

Tetsuya Shinozaki ..........................................................n 

Toshiharu Shirai, MD ......................................................n 

Yousef Shishani, MD .......................................................n 

Hitoshi Shitara, MD ........................................................n 

Hyun-Chul Shon, MD ......................................................n 

Ben Shore, MD ............................................................n 

Jennifer Shores, RN ........................................................n 

Michael Shorofsky, BS ......................................................n 

Michael D. Shortt, FRCS ....................................................n 

Rania Ayman Shourbaji .....................................................n 

Michael Wade Shrader, MD 5 – Biomet, Stryker; Smith & Nephew 

Harry L Shufflebarger, MD 1 – DePuy Spine, A Johnson & Johnson Company; 2, 

5 – DePuy Spine, Axial Biotech; 3B – DePuy Spine 

David R Shukla, MB, B Ch 6 – Acumed, LLC, Tornier 

Michael S Shuler, MD 1, 6 – Somanetics, Inc.; 3B – SBI 

Paul Shupe, MD ...........................................................n 

Mashfiqul Arafin Siddiqui, MBBS, MRCS ......................................n 

Brenda Sides, MA ..........................................................n 

Feroze Sidhwa, BA .........................................................n 

Klaus Siebenrock, MD ......................................................n 

Judith Siegel, MD 3B – Smith & Nephew; 7 – Wolters Kluwer Health - Lippincott 


Rafael Jose Sierra, MD 3B – Biomet; 5 – DePuy, A Johnson & Johnson Company, 

Zimmer, Stryker 

Debra Sietsema, PhD 2, 3B – Eli Lilly 

Cecilia Signorelli, MS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Thea Sijbesma, MD 5 – Biomet 

Mauricio Silva, MD 2 – Baxter Corporation, Bayer Healthcare; 3B – Baxter Corporation 

Vincent J Silvaggio, MD 1, 3B – Globus Medical; 4 – Amgen Co., Globus Medical, 

Johnson & Johnson, Pfizer 

Andrew M Silverman, BS ....................................................n 

Matthew Silvis, MD ........................................................n 

Franklin H Sim, MD 7 – Saunders/Mosby-Elsevier 

James S Fitzsimmons, BSc 6 – Acumed, LLC 

Ana Christina Simoes-Silva, MD, PhD ........................................n 

David R Simpson, PhD 3B – Biomet 

Stephen H Sims, MD .......................................................n 

Nicole Simunovic ..........................................................n 

59 

disclosure 

Fabrizio Sinapi, MD ........................................................n 

Marc F Sinclair, MD 3B – Semeda 

Anshuman Singh, MD ......................................................n 

Jagwant Singh, MRCS ......................................................n 

Jasvinder Singh, MD 3B – Savient, URL Pharma, EuroRSG, Novartis; 5 – Takeda, 

Savient 

Ernest L Sink, MD 3B – Biomet 

Ethel Siris, MD 2 – Amgen Co., Eli Lilly; 3B – Amgen Co., Eli Lilly, Merck, Novartis, 

Sanofi-Aventis, Pfizer, Wyeth 

Fabio Sirugo, MD ..........................................................n 

Francois Sirveaux, PhD 1 – Tornier; 2 – DePuy, A Johnson & Johnson Company, 

Sanofi-Aventis 

Peter Siska, MD ............................................................n 

David Lee Skaggs, MD 2, 3B – Medtronic, Stryker; 7 – Wolters Kluwer Health - 


Kira F Skaggs 2, 3A, 3B, 6 – Stryker, Medtronic; 5 – Axial Biotech; 7 – Lippincott 

Michael D Skeels, DO ......................................................n 

Faith Skeete ...............................................................n 

Jack Gerard Skendzel, MD ..................................................n 

John Skinner, FRCS ........................................................n 

Richard L Skolasky, Jr Prof 5 – DePuy Spine 

Olof Skoldenberg, MD .....................................................n 

Nebojsa V Skrepnik, MD 2, 3B – Auxilium; 5 – Biomet, DePuy, A Johnson & Johnson 

Company, Ferring Pharmaceuticals, BioMimetic, Pfizer, Smith & Nephew, Zimmer, 

Wyeth 

Mark A Slabaugh, MD ......................................................n 

Nicholas R Slenker, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

William Slikker, III MD .....................................................n 

Gerard Slobogean, MD, MPH ................................................n 

Jennifer Slough, BS ........................................................n 

James D Slover, MD 5 – Biomet 

David Joseph Slutsky, MD 4 – South Bay Hand Surgery, LLC; 7 – Saunders/Mosby- 

Elsevier 

Milton J Smit, MD .........................................................n 

E O’Brian Smith, PhD ......................................................n 

Frank C Smith, FRCSC, CHB, MB ............................................n 

Harvey Smith, MD .........................................................n 

Holly Smith, BSc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Julie Macaulay Smith, MBChB ...............................................n 

Karen Smith, CRA ..........................................................n 

Lucas Smith, BS ...........................................................n 

Michael D Smith, MD 1, 3B – Biomet 

Paul N Smith, MD 4 – Joint Research Pty. Ltd.; 5 – Stryker, Smith & Nephew, Synthes 

R Lane Smith, PhD 3B – Histogenics; 5 – Zimmer 

R M Smith, MD ............................................................n 

Thomas L Smith, PhD 5 – Zimmer, Wright Medical Technology, Inc., Medtronic, KCI, 

DePuy, A Johnson & Johnson Company 

Thomas Waddell Smith 6 – Arthrex, Inc. 

Wade Russell Smith, MD 2, 5 – Synthes ; 3B – Osteotech, Synthes; 7 – McGraw-Hill 

Jose MH Smolders, MD .....................................................n 

Patrick J Smolinski .........................................................n 

Joseph Douglas Smucker, MD 5 – Medtronic Sofamor Danek, Biomet, Pioneer 

Surgical, Baxter, SpineGuard, Orthocon 

Christine Snearly, MS .......................................................n 

Michael A Sneller, BS .......................................................n 

Benjamin Matthew Snyder, MD ..............................................n 

Brian Snyder, MD, PhD .....................................................n 

Guilherme Soares, MD .....................................................n 

Kjeld Soballe, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Jeffrey F Sodl, MD .........................................................n 

Elizabeth S Soileau, RN .....................................................n 

Shima Sokol, MD 6 – Medartis 

Gbolabo Olabiyi Sokunbi, MD ..............................................n 

Matthew C Solan, FRCS 2, 3B – DePuy, A Johnson & Johnson Company; 5 – Cartiva; 

6 – DePuy, A Johnson & Johnson Company, Smith & Nephew 

Mark Solarz, BS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 




Gandhi Nathan Solayar, MD .................................................n 

Daniel Jordan Solomon, MD 2 – Arthrex, Inc.; Pacific Medical 

Ian Solsky, BS 3A, 4 – Roche; 

Tomotsu Soma, MD ........................................................n 

Eun Kyoo Song, MD ........................................................n 

Frederick Suh Song, MD ....................................................n 

Hae Ryong Song, MD .......................................................n 

Ji-Hoon Song, MD .........................................................n 

Kyung Jin Song, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Sang Jun Song .............................................................n 

Yanna Song, PhD ..........................................................n 

Nelson Fong SooHoo, MD ..................................................n 

Elliott Sorene, FRCS ........................................................n 

Alexandra Soroceanu, MD ..................................................n 

Louis J Soslowsky, PhD 7 – Journal of Shoulder and Elbow Surgery 

Christopher D Souder, MD ..................................................n 

Bruno Goncalves Schroder Souza, MD 6 – Smith & Nephew 

Demetrios Spandidos, MD ..................................................n 

Jeffrey T Spang, MD 3C – Mitek 

Mark J Spangehl, MD 5 – Stryker 

Lawrence Specht, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Stacy C Specht, MPA ........................................................n 

Tim D Spector, MD 2 – Novartis, Pfizer; 3B – Ono, Expanscience; 5 – Pfizer 

Leann Speering ............................................................n 

John William Sperling, MD, MBA 1 – Biomet, DJ Orthopaedics; 3B – Tornier; 

4 – Tornier, Emerge Surgical 

David Andrew Spiegel, MD ..................................................n 

Robert Jay Spinner, MD 3B – Mayo Medical Ventures 

Andrew I Spitzer, MD 1, 5 – DePuy, A Johnson & Johnson Company; 2 – Genzyme, 

DePuy, A Johnson & Johnson Company, Sanofi-Aventis; 3B – Genzyme, DePuy, A 


Jeffrey M Spivak, MD 1, 6 – Titan Spine; 3B – Synthes, Titan Spine; 4 – Etex, Titan 

Spine, Paradigm Spine; 5 – Synthes 

Paul D Sponseller, MD 1 – Globus Medical, DePuy, A Johnson & Johnson Company; 

3B, 5 – DePuy, A Johnson & Johnson Company; 7 – Oakstone Medical 

Scott M Sporer, MD 3B – Smith & Nephew, Zimmer; 5 – Cool systems; 7 – SLACK 

Incorporated 

Sheila Sprague 3B – Amgen 

Bryan Donald Springer, MD . . 2 – DePuy, A Johnson & Johnson Company; 3B – Stryker, 

Convatec Surgical 

Andy Sprowson, MD .......................................................n 

Giannis Spyropoulos, MSc ..................................................n 

Michael S Sridhar, MD ......................................................n 

Umasuthan Srikumaran, MD 2 – Novartis; 3A – Abbott 

Arjun Srinath, MD .........................................................n 

Supatra Sritulanondha .....................................................n 

Lauren St John ............................................................n 

Patrick St Pierre, MD 1 – DJ Orthopaedics; 2, 3B – Mitek, DJ Orthopaedics 

Cara Marie Stabile, BS ......................................................n 

Arthur P Staddon, MD ......................................................n 

Giles Hugo Stafford, FRCS ..................................................n 

Philip Frank Stahel, MD 2 – Synthes, Stryker, NovoNordisk 

Kimberly Stakleff, PhD .....................................................n 

Alec C Stall, MD ...........................................................n 

Nathan Stall, BSc ..........................................................n 

Richard Stange ............................................................n 

James P Stannard, MD 2 – KCI, Medtronic Sofamor Danek; 3B – KCI, Medtronic 

Sofamor Danek, Novalign; 5 – Synthes; 7 – Theime 

Anthony A Stans, MD .......................................................n 

James Starman, MD 3A – Smith & Nephew 

Adam Jennings Starr, MD 1 – Starrframe, LLC; 2 – Smith & Nephew 

Roland Starr, MS ...........................................................n 

Mark Stasiak ..............................................................n 

Garen Steele, MD ..........................................................n 

Matthew Steensma, MD .....................................................n 

Karen Steger-May, MD 7 – Pfizer, Lilly 

60 

disclosure 

Benjamin Eric Stein, MD ....................................................n 

Lynne S Steinbach, MD 3B – Pfizer; 7 – Saunders/Mosby-Elsevier, Wolters Kluwer 


Scott P Steinmann, MD 1 – DePuy, A Johnson & Johnson Company; 3B – Arthrex, Inc., 

DePuy, A Johnson & Johnson Company, Wright Medical Technology, Inc.; 5 – Wright 

Medical Technology, Inc.; 7 – Journal of Hand Surgery - American, Journal of Shoulder 

and Elbow Surgery, Yearbook of Hand Surgery 

Michael P Steinmetz, MD 2, 3C – Biomet 

Julia Steinrucken, MD ......................................................n 

David Stelzeneder, MD .....................................................n 

Paul M Stemniski, MS 3A, 4 – Wright Medical Technology, Inc. 

Dirk Stengel 2 – Biomet, DePuy, A Johnson & Johnson Company; 5 – Biomet, DePuy, A 

Johnson & Johnson Company, GlaxoSmithKline, Stryker, Aesculap/B.Braun 

David J Stephen, MD 6 – Synthes 

Simon D Steppacher, MD ...................................................n 

Hal Sternberg, PhD 3A, 4 – BioTime Inc. 

Andrew Steval .............................................................n 

Vladan Stevanovic, MD .....................................................n 

Peter M Stevens, MD 1, 2, 3B – Orthofix, Inc. 

Melissa Stewart, BS .........................................................n 

Rena Stewart, MD 5 – KCI, Pfizer, Synthes 

Jeffrey Stimac, MD .........................................................n 

Daniel J Stinner, MD 5 – Smith & Nephew, EZ Care 

Joel Stitzel, PhD 4 – Merck 

Gregory William Stocks, MD 3C, 4 – Nimbic Systems, Inc. 

Hans Stodkilde-Jorgenson, MD, 

DMSci ....................................................................n 

Holbrook Stoecklein, BS ....................................................n 

Geoffrey Stoker, BS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

David W Stoller, MD .......................................................n 

Austin V Stone, MD ........................................................n 

James W Stone, MD 4 – Amgen Co., Johnson & Johnson, Procter & Gamble, Pfizer 

Jason W Stoneback, MD 5 – Synthes 

Matthew Stonestreet, MD ...................................................n 

Michael David Stover, MD 5 – Synthes 

Richard E Strain Jr, MD 2, 3B – Easi, Ethicon; 5 – Pfizer, Takeda, Bristol-Myers, Meda, 

Sanofi-Aventis, Astellas 

Eric J. Strauss, MD .........................................................n 

Philipp Nicolas Streubel, MD ................................................n 

Keith Stringer, MD .........................................................n 

Roger D. Strode, JD ........................................................n 

Gregory Strohmeyer, MD ...................................................n 

Eric Strose, MD ............................................................n 

Peter Strzepa, MSME 3A – Fellowship of Orthopaedic Researchers, Inc. 

Michael J Stuart, MD 3B – Arthrex, Inc., Fios; 5 – Stryker 

Allston J Stubbs, IV MD 3B – Smith & Nephew, Johnson & Johnson; 4 – Johnson & 

Johnson 

Steven Andrew Stuchin, MD 3B – Osteotech 

Charlton Stucken, MD ......................................................n 

Diane Studzinski ..........................................................n 

Bernard N Stulberg, MD 1 – Exactech, Inc.; 2 – Sanofi-Aventis; 3B – Exactech, Inc., 

Stryker; 5 – Corin U.S.A. 

S David Stulberg, MD 1 – Aesculap/B.Braun, Biomet, Innomed, Omniscience; 

2 – Genzyme, Stryker, Aesculap/B.Braun; 3B – Aesculap/B.Braun, Stryker, OmniScience; 

3C – Blue Belt Technologies; 4 – Johnson & Johnson, Stryker; 7 – Peachtree Publishers 

Douglass E Stull, MD .......................................................n 

Paul Sturch, MBBS .........................................................n 

Jose A Stuyck ..............................................................n 

Brian W Su, MD 3B – Gentis 

Edwin P Su, MD 3B – Smith & Nephew; 5 – Smith & Nephew, Cool Systems, Inc. 

Hsiu Su, MD ..............................................................n 

Sri Subanesh, MBBS ........................................................n 

Daniel J Sucato, MD 2 – Medtronic; 7 – Saunders/Mosby-Elsevier 

Akihiro Sudo, Prof. ........................................................n 

Eduardo M Suero, MD ......................................................n 

Kazuomi Sugamoto, MD ....................................................n 




Nobuhiko Sugano, MD 3B – Stryker 

Etan Sugarman, MS ........................................................n 

Michelle T Sugi ............................................................n 

Yuko Sugioka, MD .........................................................n 

Takashi Sugita, MD, PhD ...................................................n 

Michael Suk, MD 6 – Synthes 

Mohamed Sukeik, MD ......................................................n 

Atul Sukthankar, MD .......................................................n 

Takanobu Sumino, MD .....................................................n 

Doo Hoon Sun, MD ........................................................n 

Jui-Sheng Sun, MD .........................................................n 

Toru Sunagawa ............................................................n 

Martin Sunberg, MD, PhD 2 – Biomet; 3C – Asept Medical; 5 – Stryker 

Grant Sutter, MS ...........................................................n 

Piriya Sutthirunjwong, MD ..................................................n 

Kou Suzuki, MD ...........................................................n 

Osami Suzuki, MD .........................................................n 

Olle Svensson, MD .........................................................n 

Chad Swaims, PAC .........................................................n 

Krishna Swamy, MBBS, FRCS ................................................n 

Russell P Swann, MD .......................................................n 

Christopher E Swanson, MD ................................................n 

David Swanson, PhD .......................................................n 

Eric F Swart, MD ...........................................................n 

Kyle Sweeney, BS ..........................................................n 

Fred A Sweet, MD ..........................................................n 

Marc F Swiontkowski, MD 3B – Baxter Healthcare, Eli Lilly, Kuros, Zimmer; 

7 – Saunders/Mosby-Elsevier, Wolters Kluwer Health - Lippincott Williams & Wilkins 

Julie A Switzer, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Ishaq Syed, MD ............................................................n 

Khalid Syed, MD ...........................................................n 

Joshua Bengtson Sykes, MD .................................................n 

Robert Morris Szabo, MD, MPH 5 – Medartis 

Edward Szuszczewicz, MD 2, 3B – Omni Life Sciences; 4 – Omni Life Sciences, Osseon 

Alex Taborek, BS 4 – Merck, Nuvasive 

Toshiya Tachibana, MD .....................................................n 

Masahiro Tada, MD ........................................................n 

Cyrus Emil Taghavi, MD ....................................................n 

Amir David Tahernia, MD 1 – Sea spine, Globus Medical; 2 – Orthovita; 

3B – Orthovita, Spinal Solutions; 5 – Facet Solutions 

Siti Tahir. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Jenni Tahmassebi, MSc .....................................................n 

Tsuyoshi Tajika, MD ........................................................n 

Kenji Takagishi, Prof .......................................................n 

Mark Takahashi, MD .......................................................n 

Kazuhisa Takahashi, MD ....................................................n 

Yoshihiro Takamori ........................................................n 

Karren M Takamura, BA .....................................................n 

Masaki Takao, MD .........................................................n 

Tsuneaki Takao, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Kunio Takaoka, MD ........................................................n 

Munetomo Takata, MD .....................................................n 

Kei Takato, MD ............................................................n 

MAKOto Takazawa, MD .....................................................n 

Hideaki Takeda ............................................................n 

Mitsuhiro Takeda, MD ......................................................n 

Takashi Takemae, MD ......................................................n 

Richelle C Takemoto, MD ...................................................n 

Steven Takemoto, PhD .....................................................n 

Munenori Takeshita, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Akihiko Takeuchi, MD ......................................................n 

Eiji Takeuchi, MD ..........................................................n 

Naoya Taki, MD ...........................................................n 

James B Talmage, MD 7 – American Medical Association Publications, Reed Group, Ltd. 

61 

disclosure 

Carl T Talmo, MD 3A – Astra-Zeneca 

Vishwas R Talwalkar, MD ...................................................n 

Thomas Tampere, BSc ......................................................n 

Eric Tan, MD ..............................................................n 

Seang Beng Tan, MD .......................................................n 

Tim Tan, BS ...............................................................n 

Virak Tan, MD 1, 3B, 4 – Wright Medical Technology, Inc. 

Kazunori Tanaka, MD ......................................................n 

MAKOto Tanaka, MD .......................................................n 

Miho Jean Tanaka, MD .....................................................n 

Sakae Tanaka, MD, PhD ....................................................n 

Yoshinari Tanaka, MD ......................................................n 

Yoshitsugu Tanaka, MD .....................................................n 

Aree Tanavalee, MD ........................................................n 

Dan Tancredi, PhD 6 – UC Davis 

Jessica Anne Tang, BS .......................................................n 

Peter Tang, MD ............................................................n 

Wan Tang, PhD ............................................................n 

Jason C Tank, MD ..........................................................n 

Moritz Tannast ............................................................n 

Yoshikazu Tanzawa, MD ....................................................n 

Michael Tanzer, MD 1, 3B – Zimmer; 2 – Johnson & Johnson, Zimmer; 4 – Novartis; 5, 


John S Taras, MD 4 – Union Surgical, LLC 

Ivan Seth Tarkin, MD 2, 5 – Synthes 

Yasutaka Tashiro, MD, PhD .................................................n 

Enrico Tassinari, MD .......................................................n 

Penny Tatman, MPH .......................................................n 

Michael J Taunton, MD .....................................................n 

Kaneaki Tawada, MD .......................................................n 

Bobby Tay, MD 2 – Biomet; 3C – Laurimed 

Keng Jin Darren Tay, FRCS ..................................................n 

Adrian Taylor, MD 2 – Biomet 

Dean C Taylor, COL, MD 5 – Histogenics 

Emma Taylor, MD ..........................................................n 

Erica Taylor, MD ...........................................................n 

Samuel Arthur Taylor, MD ..................................................n 

Sharlene A Teefey, MD 4 – Envisioneering 

Shawn Tejiram, bsC ........................................................n 

Nirmal C Tejwani, MD 1 – Biomet; 2, 3B – Zimmer, Stryker 

Alessandra Tellini, MD .....................................................n 

H Thomas Temple, MD 3B – Stryker 

David C Templeman, MD 1 – Zimmer; 2, 3B – Stryker; 3C – Asut 

Yuksel Tenekecioglu, MD ...................................................n 

Gregory S Tennant, DO 3A – GlaxoSmithKline, Steifel Company 

Richard M Terek, MD 4 – Novartis, Pfizer; 7 – Lippincott 

Michael L Terrin, MD, MPH .................................................n 

Michael A Terry, MD 1, 6 – Smith & Nephew; 2 – Victory Pharmacy, Magellan; 

3B – DePuy, A Johnson & Johnson Company, Smith & Nephew, Linvatec; 7 – Saunders/ 

Mosby-Elsevier 

Caroline Terwee, PhD ......................................................n 

Sotirios Tetradis, PhD, DDS .................................................n 

Matthew Tetreault, BA ......................................................n 

David Teuscher, MD ........................................................n 

Ahmed Mohamed Thabet, MD ...............................................n 

Nikhil Anand Thakur, MD 4 – Nephros, Advanced Cell Technologies; 5 – DePuy, A 


Seng Choe Tham, MBBS, MMed, FRCR ........................................n 

Christine K Thang, BS ......................................................n 

John Theodoropoulos, MD 2, 5 – Smith & Nephew 

Benoit Theriault, MD .......................................................n 

Emmanuel Thienpont, MD 2 – Biomet, Zimmer; 4 – Tigenix, Boston Scientific 

Scott Thies, PhD 3A, 4 – Fate Therapeutics, Inc. 

Darryl Thomas, MD 2, 3B – Arthrocare, Genzyme 

Dimitri M Thomas, MD .....................................................n 




Geraint Emyr Rhys Thomas, MA, MBBS, MRCS .................................n 

Thad Thomas, BSE .........................................................n 

Steve Thomopoulos, PhD ...................................................n 

Darby Thompson, MS ......................................................n 

George H Thompson, MD 3C – OrthoPediatrics, SpineForm; 7 – Journal of Pediatric 

Orthopedics 

Matthew Thompson, MS 1 – Zimmer; 3B – MAKO Surgical Corp. 

Matthew T Thompson ......................................................n 

Norfleet Buckner Thompson, MD ............................................n 

Sean Thompson, MD .......................................................n 

Beverly Thornhill, MD ......................................................n 

Thomas S Thornhill, MD 1, 3B – DePuy, A Johnson & Johnson Company; 3C, 

4 – ConforMIS 

Troy Thorum, RN ..........................................................n 

Thomas Throckmorton, MD 2, 5 – Biomet 

John Vincent Tiberi, MD ....................................................n 

James E Tibone, MD 1 – Arthrex, Inc. 

Lisa Tibor, MD ............................................................n 

John F Tilzey, MD ..........................................................n 

Nina Timmesfeld, PhD .....................................................n 

John Timperley 1 – Stryker 

Muharrem Timucin, PhD ...................................................n 

Nicholas Ting, MD .........................................................n 

Scott M Tintle, MD .........................................................n 

John E Tis, MD ............................................................n 

Fotios Paul Tjoumakaris, MD ................................................n 

Allison Tobola, MD ........................................................n 

Yuki Tochigi, MD, PhD .....................................................n 

Dane Todd, BS ............................................................n 

Michael S Todd, DO ........................................................n 

Daisuke Togawa, MD 2, 3B – Medtronic Sofamor Danek, Robert Reed Inc. 

Emre Togrul, MD ..........................................................n 

Junya Toguchida, MD, PhD .................................................n 

Fumiaki Tokimura, MD .....................................................n 

John Michael Tokish, MD 2 – Arthrex, Inc. 

Asami Tokita, MD 2 – Mitsubishi Tanabe Pharma 

Yoshio Tokuhara, MD ......................................................n 

Daisaku Tokunaga, MD .....................................................n 

Stephen R Tolhurst, MD ....................................................n 

Eric Thorpe Tolo, MD ......................................................n 

Vernon T Tolo, MD 7 – Journal of Bone and Joint Surgery - American, Wolters Kluwer 


Yasunori Tome, MD ........................................................n 

Ivan M Tomek, MD 5 – Stryker, Zimmer, DePuy, A Johnson & Johnson Company 

Katsuro Tomita, MD ........................................................n 

Lauren Tomlinson, BA ......................................................n 

Bryan J Tompkins, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Mayu Toner, BS ............................................................n 

John R Tongue, MD ........................................................n 

Aldo Toni, MD 2 – Zimmer, Ceramtec, Adler Ortho; 3B – Zimmer, Ceramtec, Adler 

Ortho 

Brian Christopher Toolan, MD 4 – Pfizer 

Jesse T Torbert, MD ........................................................n 

Paul Tornetta III, MD 1, 3B – Smith & Nephew; 7 – Wolters Kluwer Health - Lippincott 


Ian P Torode, MD 1, 3C – Medtronic Sofamor Danek; 7 – Hodder-Arnold 

David Torrance, DC ........................................................n 

Carlos Torrens, MD 2, 3B – DePuy, A Johnson & Johnson Company 

Armando Torres-Gomez, MD ................................................n 

Ana Isabel Perez Torres, MD .................................................n 

Michael Torry, PHD 1, 4 – Alignmed, LLC, Exploramed-Moximed, LLC; 3B – Alignmed, 

LLC; 3C – Ossur 

Laura Lowe Tosi, MD 3B – Amgen Co., KCI, Medtronic 

Anna Tosteson, ScD 3B – Eli Lilly, Amgen Co. 

Tor Tosteson, ScD ..........................................................n 

62 

disclosure 

Alison P Toth, MD 2 – Genzyme, Tornier; 5 – Tornier 

John Toth, DO ............................................................n 

Mr Robert Toth ............................................................n 

Martin Totsch, MD .........................................................n 

Benjamin Phak Boon Tow, MD ..............................................n 

Shogo Toyama .............................................................n 

Peter G Trafton, MD 4 – Johnson & Johnson; 7 – Saunders/Mosby-Elsevier 

Ian A Trail, MD 1, 3B – Integra Life Sciences; 5 – Tennis Elbow Study 

Francesco Traina, MD ......................................................n 

Terry Ralph Trammell, MD 3B – Biomet, Medtronic Sofamor Danek, K2M; 

5 – Nuvasive, Medtronic Sofamor Danek, K2M 

Andrej Trampuz, MD 2 – Novartis; 5 – Mathys Ltd., Pfizer, Novartis 

Ensor E Transfeldt, MD 1, 2, 3B – Medtronic 

George Joseph Trappey, IV MD ..............................................n 

Andrew Travlos, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Marc A Tressler, DO ........................................................n 

Michael E Trice, MD ........................................................n 

Anjan Trikha, MD ..........................................................n 

Hans Joerg Trnka, MD 1 – OFA Rathgeber; 2 – Johnson & Johnson, Wright Medical 

Technology, Inc., Arthrex, Inc.; 3C – Wright Medical Technology, Inc. 

Christophe Trojani, MD ....................................................n 

Alessia Tron, MD ..........................................................n 

Robert T Trousdale, MD 1 – DePuy, A Johnson & Johnson Company, Wright Medical 

Technology, Inc., Ortho Development; 3B – DePuy, A Johnson & Johnson Company, 


Lisa Marie Truchan, MD ....................................................n 

Walter Huu Truong, MD ....................................................n 

Eeric Truumees, MD 1 – Stryker; 4 – Doctor’s Research Group; 7 – North American 

Spine Society 

Alexandros Tsarouhas, MD ..................................................n 

Samuel Tseng .............................................................n 

Elefterios Tsiridis, FRCS ....................................................n 

Hideki Tsuboi, MD .........................................................n 

Toshikazu Tsuboi, MD ......................................................n 

Hiroyuki Tsuchiya, MD .....................................................n 

Koji Tsuji, MD .............................................................n 

Matthew Tsuji, MD .........................................................n 

Masaya Tsujii, MD, PhD ....................................................n 

Rocky S Tuan, PhD 7 – Wiley - Birth Defects Research Part C: Embryo Today, 

BioMedCentral - Stem Cell Research and Therapy 

Eray Tuccar, MD, Prof ......................................................n 

John Keith Tucker, FRCS ....................................................n 

Kimberly K Tucker, MD .....................................................n 

Mike Tuke 3A, 3B – DePuy, A Johnson & Johnson Company, Finsbury; 4 – Newco 

Kirsten Tulchin, MS ........................................................n 

Chris Tulloch, FRCS ........................................................n 

Yucel Tumer, MD ..........................................................n 

Ismail Cengiz Tuncay, MD ..................................................n 

Christopher Tuohy, MD 2 – Synthes 

Luigino Turchetto ..........................................................n 

Robert Emile Turcotte, MD FRCSC 4 – Novartis; 6 – Stryker 

Alexis Turgeon, MD, MNSc, FRCPC ...........................................n 

Thomas Robert Turgeon, MD 5 – Smith & Nephew 

Metin Turkmen, Prof .......................................................n 

A Simon Turner, DVM ......................................................n 

Alexander W Turner, PhD 3A, 4 – Nuvasive 

Joseph Turner, MS 3A, 4 – Medtronic, Wright Medical Technology, Inc. 

Francesco Turturro, MD ....................................................n 

Stacy L Twigg, PA-C ........................................................n 

Roy Twyman ..............................................................n 

Wakenda Tyler, MD ........................................................n 

Shiau-Tzu Tzeng, MD .......................................................n 

Maite Ubierna .............................................................n 

Atsumasa Uchida, MD ......................................................n 

Kazushi Uemura, MD ......................................................n 




Takeshi Uemura, MD .......................................................n 

Takayoshi Ueta ............................................................n 

Ali Engin Ulusal, MD .......................................................n 

Masood Umer, MD .........................................................n 

Marc Evan Umlas, MD ......................................................n 

Richard Underwood, PhD 6 – Biomet, DePuy, A Johnson & Johnson Company, Corin 

U.S.A., Finsbury, Smith & Nephew, Zimmer, Mathys Ltd. 

Mehmet Can Unlu, MD .....................................................n 

Aasis Unnanuntana, MD ....................................................n 

Kenneth P Unruh, MD ......................................................n 

Vidyadhar V Upasani, MD ..................................................n 

BN V Upendra, MS .........................................................n 

Carlos Uquillas, MD .......................................................n 

Michael Urban, MD ........................................................n 

Scott E Urch, MD ..........................................................n 

Molly M Usrey .............................................................n 

Sinan Ustundag, MD .......................................................n 

Sofia Uzunishvili, MD ......................................................n 

Alexander Vaccaro, MD, PhD 1 – Aesculap/B.Braun, DePuy, A Johnson & Johnson 

Company, Globus Medical, Medtronic Sofamor Danek, K2M, Stout Medical, Progressive 

Spinal Technology, Applied Spinal Intellectual Properties; 3B – K2M; 4 – Globus 

Medical, Disk Motion Technology, Progressive Spinal Technologies, Advanced Spinal 

Intellectual Properties, Computational Biodynamics, Stout Medical, Paradigm Spine, 

K2M, Replication Medica, Spinology, Spine Medica, Orthovita, Vertiflex, Small Bone 

Technologies, NeuCore, Crosscurrent, Syndicom, In Vivo, Flagship Surgical, Pearl Driver, 

Location Based intelligence, Gamma Spine ;5 – AO North America, DePuy, A Johnson & 

Johnson Company, Medtronic Sofamor Danek, Stryker; 7 – Elsevier, Thieme 

Antonio Vadala, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Rahul Vaidya, MD 2, 5, 6 – Synthes; 3C – Stryker 

Thomas Parker Vail, MD 1, 3B – DePuy, A Johnson & Johnson Company; 4 – Pivot 

Medical 

Suketu B Vaishnav, MD .....................................................n 

Antonis Vakis, MD .........................................................n 

Juanjose Valderrama, MD ...................................................n 

Antonio D C Valdevit 3B – Stryker; 5 – Stryker, Medtronic Sofamor Danek 

Luigi Valeo, MD ...........................................................n 

Fernando Valero Gonzalez, MD ..............................................n 

Edward R Valstar 5 – Biomet, Stryker 

Douglas Van Citters, PhD 2, 3B, 5 – DePuy, A Johnson & Johnson Company; 

3A – Synthes 

Dr Michel Van den Bekerom .................................................n 

Hans Van der Bracht, MD ...................................................n 

Just Van Der Linden, MD ...................................................n 

Jaap Van Der Maas, MD .....................................................n 

Jan Van Der Meulen, MBBS ..................................................n 

Walter A P C van der Weegen, MD 5 – Biomet 

C Niek Van Dijk, MD 3C – Boehringer Ingelheim; 5 – GlaxoSmithKline, Stryker, Biomet 

Carola F Van Eck, MD ......................................................n 

Marnix Van Holsbeeck, MD 4 – GE Healthcare, Bristol-Myers Squibb, Johnson & 

Johnson, Novartis; 5 – GE Healthcare; 7 – Saunders/Mosby-Elsevier 

Hans Peter W Van Jonbergen, MD 5 – Smith & Nephew 

Albert van Kampen, MD ....................................................n 

Maarten Van Orsouw, MD ...................................................n 

Roger P van Riet, MD 2 – Smith & Nephew, Stryker; 6 – Zimmer, B&Co. 

Job L C Van Susante, MD, PHD 2, 3B – Wright Medical Technology, Inc.; 5 – Zimmer, 


Geoffrey Van Thiel, MD .....................................................n 

Michael Vance, MD .........................................................n 

Kelly L Vanderhave, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Daniel Vanel, MD ..........................................................n 

Francesca Vannini, MD .....................................................n 

Kartik Varadarajan, MS 4 – Merck, MAKO Surgical Corp. 

Thomas F Varecka, MD 2 – Stryker, Synthes; 3C – Stryker 

Daniel Varin, B.Sc. .........................................................n 

Eric S. Varley, DO ..........................................................n 

Roberto Varsalona, MD .....................................................n 

Dimitrios N. Varvarousis, MD ...............................................n 

63 

disclosure 

Tanawat Vaseenon .........................................................n 

Luis Vasquez, MS ..........................................................n 

Sebastiano Vasta, MS .......................................................n 

Jeffrey M Vaughn, DO ......................................................n 

Carlos Vaz, phD ...........................................................n 

David Vecchione, MD ......................................................n 

Ryan Vellinga, BS ..........................................................n 

Ricardo Velutini, MD .......................................................n 

John H Velyvis, MD 3B – Zimmer, Stryker, MAKO Surgical; 4 – MAKO Surgical; 

5 – Baxter, MAKO Surgical, Zimmer, Wright, Stryker 

Pascal-Andre Vendittoli, MD 2 – Stryker; 3B – Wright Medical Technology, Inc., Stryker, 

Zimmer; 5 – Zimmer, Wright Medical Technology, Inc., Stryker, Biomet; 6 – Biomet, 

OMEGA, Zimmer, Wright Medical Technology, Inc., Stryker 

Peter Verdonk, MD, Phd 2, 3B, 5 – Orteq Sports Medicine 

Rene Verdonk, MD, PhD 1 – DePuy, A Johnson & Johnson Company; 2, 3B, 4 – Orteq; 

7 – Springer 

Alejandro Verdugo, MD .....................................................n 

Luk Verhelst, MD ..........................................................n 

Christopher Verioti, DO ....................................................n 

Kushagra Verma, MD .......................................................n 

Nikhil N Verma, MD 1, 3B – Smith & Nephew; 2 – Arthrosurface; 4 – Omeros; 

5 – Arthrex, Inc., Smith & Nephew, Ossur, DJ Orthopaedics; 7 – Vindico Medical- 

Orthopedics Hyperguide 

James John Verner, MD .....................................................n 

Frederik Verstreken, MD ....................................................n 

Judith Anne Vessey, PhD 4 – Johnson & Johnson, Pfizer, Wyeth 

Alexander Michael Vezeridis, BA .............................................n 

Peter S Vezeridis, MD .......................................................n 

Nicholas Adam Viens, MD ..................................................n 

Volker Vieth, MD ..........................................................n 

Srinivasan Vijayakumar, MD ................................................n 

Sridhar Vijayan, BSC, MBBS .................................................n 

Ola Vikerfors, MD .........................................................n 

Camilo E Villalobos, MD ...................................................n 

Marco Villano, MD .........................................................n 

Robert Javier Villarreal, MD .................................................n 

Pablo Villavicencio, MD ....................................................n 

Diego Villegas, MD ........................................................n 

Kelly Vince, MD 1, 2, 3B – Zimmer 

Tarjei Vinje, MD ...........................................................n 

Nazeem Virani, MD ........................................................n 

Walter W Virkus, MD 2, 3B – Smith & Nephew, Stryker; 3A – Novartis; 4 – Stryker, 

Johnson & Johnson 

Carl Virtanen ..............................................................n 

Michael G Vitale, MD 1 – Biomet; 3B – Biomet, Stryker; 5 – Synthes 

Michael Vives, MD 2 – Biomet, Musculoskeletal Transplant Foundation; 3B – Zimmer; 

4 – Accelalox 

Frank Vizesi, PhD 3A, 4 – Nuvasive 

Jacob Vogelstein, PhD 1–Genzyme, Biomed Valley Discoveries 

Pramod Babu Voleti, MD ...................................................n 

David A Volgas, MD 5 – Pfizer, Synthes 

Gian Paolo Volpato, MD ....................................................n 

Arvind Gabriel Von Keudell, MD .............................................n 

Brigitte von Rechenberg, MD 5 – National Institutes of Health (NIAMS & NICHD), 

Swiss National Science Foundation, Plus Orthopedics, Smith & Nephew, Synthes 

Anand Mahesh Vora, MD 2 – Arthrex, Inc., Smith & Nephew; 3B, 5 – Arthrex, Inc. 

James Turner Vosseller, MD .................................................n 

Mark S Vrahas, MD 4 – Pioneer Medical; 5 – Synthes, Zimmer, DePuy, A Johnson & 


Ana-Maria Vranceanu, PhD ..................................................n 

Gudrun Waaler, MSc .......................................................n 

Takuro Wada, MD,PhD .....................................................n 

James P Waddell, MD 1, 3B – Smith & Nephew; 6 – Smith & Nephew, Stryker; 


Charles Wade, PhD ........................................................n 

Veronica Marie Rita Wadey, MD ..............................................n 




Joe Wagener, MD ..........................................................n 

Emilio Wagner, MD 6 – Helico 

Eric R Wagner, BS ..........................................................n 

Reese Wain, MD ...........................................................n 

Walid Waked, MD ..........................................................n 

Christopher Wakeling, MBChB, 

MRCS ....................................................................n 

Shigeyuki Wakitani 2 – Chugai Pharmaceutical Company; 3B – Sunstar; 5 – Olympus 

Seikagaku Corporation 

Gilles Walch, MD 1 – Tornier 

Janet Walker, MD ..........................................................n 

John J. Walker, PAC, DSc ....................................................n 

Matthew H Walker, MD .....................................................n 

Peter S Walker, PhD 1 – Stryker, Zimmer; 3B, 3C, 5 – Zimmer, MAKO 

Eric Wall, MD 1 – SpineForm, LLC; 3B – OrthoPediatrics; 3C – Stryker Trauma 

Lindley B Wall, MD ........................................................n 

Peter David Henry Wall, MBChB, MRCS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Charles Douglas Wallace, MD ...............................................n 

Philip Waller, MD 5 – Abbott, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, 

Johnson & Johnson, Merck, Procter & Gamble, Roche, Sanofi-Aventis, Wyeth 

Anders Walloe, MD ........................................................n 

Phil Walmsley, FRCS 5 – DePuy, A Johnson & Johnson Company 

Michael Walsh, PhD ........................................................n 

Pauline Walsh, BSc, PhD ....................................................n 

William R Walsh, PhD 2 – Surgical Synergies; 3B, 5 – Exactech, Inc., IsoTis 

Orthobiologics, Nuvasive, Surgical Synergies 

Stephen Walter, PhD .......................................................n 

William K Walter, MBBS, FRACS 1 – Stryker; 3B – Stryker, DePuy, A Johnson & Johnson 

Company; 5 – Stryker, DePuy, A Johnson & Johnson Company, Ceramtec 

William Lindsay Walter, MD, PhD 1 – Stryker, DePuy, A Johnson & Johnson Company; 

3B – DePuy; 5 – Stryker, Ceramtec, Depuy 

Thomas J Walters, PhD .....................................................n 

Andrea Wang 3A, 4 – Amgen Co., Pfizer 

Chen-Chie Wang, MD ......................................................n 

Ching-Jen Wang, MD 3B – Sanuwave; 4 – Tissue Regeneration Technology 

Chung-Li Wang, MD .......................................................n 

Cunlin Wang ..............................................................n 

Feng-Sheng Wang, PhD .....................................................n 

Jaw-Lin Wang, PhD ........................................................n 

Jeffrey C Wang, MD 1 – Aesculap/B.Braun, Biomet, Medtronic Sofamor Danek, 

Stryker, Zimmer, Osprey, Alphatech, Sea spine, Amedica; 4 – Fziomed, Promethean 

Spine, Paradigm Spine, Benevenue, NexGen, K2 Medical, Pioneer, Amedica, Vertiflex, 

Electrocore, Surgitech, Invuity, Axiomed, Bone Biologics, VG Innovations, Corespine, 

Expanding Orthopaedics, Syndicom, Curative Biosciences, Facet Solutions, Pearl diver 

Joon Ho Wang, MD ........................................................n 

Lingjun Wang, MA, PA-C ....................................................n 

Lushun Wang, MBBS, MRCS(Edin) ...........................................n 

Ting-Ming Wang, MD .......................................................n 

Vincent Wang .............................................................n 

Xiaomei Wang, PhD ........................................................n 

Yun Wang, PhD ............................................................n 

Zhenhai Wang, MD ........................................................n 

Zhong Wang, PhD .........................................................n 

Zhuo Wang, MD ...........................................................n 

John Paul Wanner, BS ......................................................n 

Keith K Wannomae ........................................................n 

Keith L Wapner, MD 2 – Small Bone Innovations, Wright Medical Technology, Inc.; 

3B – Small Bone Innovations, Wright Medical Technology, Inc., MemoMetal Inc.; 

4 – MemoMetal Inc.; 5 – Small Bone Innovations 

Peter Ward, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Russell A Ward, MD ........................................................n 

Samuel R Ward, PhD 3C – Allergan 

Shan G Ward, PhD 3C – Naviscan, Salient 

Winston J Warme, MD 2 – Arthrex, Inc., DJ Orthopaedics; 3B – DJ Orthopaedics; 

5 – Pacific Medical; 6 – Arthrex, Inc., DJ Orthopaedics, Pacific Medical 

Kelly Warmington .........................................................n 

Cory Warner, MPT .........................................................n 

64 

disclosure 

Jon J P Warner, MD 1 – Zimmer; 6 – Arthrocare, DJ Orthopaedics, Arthrex, Inc., Mitek, 

Breg, Smith & Nephew 

William C Warner Jr, MD 3C – Medtronic Sofamor Danek; 7 – Saunders/Mosby- 

Elsevier 

Adam Warren, MD .........................................................n 

Russell F Warren, MD 1 – Biomet, Smith & Nephew, ConMed; 4 – Cayenne 

Scott M Wasserman, MD 3A, 4 – Amgen, Inc. 

Kenichi Watanabe, MD 3A – Japan Medical Materials Corporation 

Koji Watanabe .............................................................n 

Nobuyuki Watanabe, MD ...................................................n 

Brian Waterman, MD .......................................................n 

Peter M Waters, MD 4 – Sangamo, Celgene 

J Tracy Watson, MD 1 – DePuy, A Johnson & Johnson Company, Smith & Nephew; 

3B – Digimed; 3C – Accelalox 

Jeffrey Dean Watson, MD ...................................................n 

Jeffry T Watson, MD ........................................................n 

Tyler Steven Watters, MD 3B – Bristol-Myers Squibb 

Jennifer S Wayne, PhD 5 – Ascension Orthopaedics; 6 – Trimed 

Justin M Weatherall, MD 4 – GE Healthcare 

Paul E. Weathington, JD ....................................................n 

DeWayne Lynn Weaver, MD .................................................n 

Michael J Weaver, MD ......................................................n 

Lawrence Xavier Webb, MD 2 – Musculoskeletal Transplant Foundation; 3B – Zimmer; 

6 – Synthes, Smith & Nephew, Stryker, Kinetic Concepts, Inc. 

Nicholas Paul Webber, MD ..................................................n 

Alexander Weber, MD ......................................................n 

Donald Weber, MD ........................................................n 

Kristy L Weber, MD ........................................................n 

Marc-Andre Weber, MD 5 – Bayer Vital AG, Bracco 

Robert Weber, MD .........................................................n 

Stephen C Weber, MD 3C – DePuy, A Johnson & Johnson Company 

John H Wedge, MD 4 – Procter & Gamble, Johnson & Johnson 

James Wee, MBBS, MRCS (Edin) .............................................n 

Marshall Weesner, MS ......................................................n 

Brian Wegman, MD ........................................................n 

Alexander Wegner, BS ......................................................n 

Derek Weichel, MD ........................................................n 

Dennis P Weigel, MD .......................................................n 

Yoram A Weil ..............................................................n 

Andrew J Weiland, MD 1 – Wright Medical Technology, Inc.; 3B – Acumed, LLC, 

Medartis 

Jacob Weinberg, MD .......................................................n 

Bradley K Weiner, MD ......................................................n 

Dennis S Weiner, MD .......................................................n 

Paul Weinhold, PhD .......................................................n 

James N Weinstein, DO, MS .................................................n 

Stuart L Weinstein, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

David M Weir, BS ..........................................................n 

Robert Weir, MD ...........................................................n 

Jennifer M Weiss, MD ......................................................n 

Michael Weiss, MD .........................................................n 

Jason Scott Weisstein, MD ..................................................n 

Jeffrey A Welge, PhD .......................................................n 

Amanda Lindsley Weller, MD ................................................n 

Christopher W Wells, BA ....................................................n 

Jessica Wells. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Lawrence Wells, MD ........................................................n 

Haoling H Weng, MD ......................................................n 

Dennis R Wenger, MD 3C – Orthopediatrics, Inc.; 4 – Rhino Pediatric Orthopedic 

Designs; 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Doris Wenger, MD .........................................................n 

Joseph C Wenke, PhD 6 – Smith & Nephew 

Glenn Wera, MD ...........................................................n 

Judi Werkema, RN .........................................................n 

Jason Werle, MD ...........................................................n 




Stefan Werlen, MD .........................................................n 

Brian C Werner, MD ........................................................n 

Jean Wessel, PhD ..........................................................n 

Daniel Wessell, MD, PhD ...................................................n 

Michael West, PhD 3A – BioTime, Inc., OrthoCyte Corporation; 4 – BioTime, Inc.; 

7 – Academic Press Elsevier 

Geoffrey H Westrich, MD 1 – Exactech, Inc.; 3B – DJ Orthopaedics, Exactech, Inc., 

Stryker; 5 – DJ Orthopaedics, Exactech, Inc., Stryker 

Peter G Whang, MD 2 – Baxter; 3B – Stryker, Smith & Nephew, Cerapedics, Paradigm 

Spine; 4 – DiFusion; 5 – Vertiflex 

Gregory R White, MD 2 – Stryker 

Neil White, MD, FRCSC .....................................................n 

Richard E White, Jr MD 1 - Zimmer, 3B - Ardent Health Services Lovelace Medical 

Center 

Richard H White, MD 3B – Sanofi-Aventis, Boehringer Ingelheim; 5 – Johnson & 

Johnson 

Tom White, BSc, MBBS, MRCS ...............................................n 

Leo A Whiteside, MD 1 – Smith & Nephew, Stryker; 2, 3C – Smith & Nephew; 3A, 

4 – Signal Medical Corp.; 3B – Signal Medical Corp., Smith & Nephew 

Thomas E Whitesides Jr, MD 7 – Saunders/Mosby-Elsevier 

Patrick W Whitlock, MD 6 – Brainlab 

Duncan Whitwell, FRCS 2 – Zimmer, Biomet; 3B – Finsbury 

Dr Cari Whyne 3B – Relievant; 5 – Baylis Medical 

J Michael Wiater, MD 2 – Zimmer; 3B – Synthes, Zimmer 

Michael Wich, MD 1 – DePuy, A Johnson & Johnson Company; 2 – Stryker, DePuy, 

A Johnson & Johnson Company, Synthes; 3B – Biomet, DePuy, A Johnson & Johnson 

Company, Stryker 

Thomas L Wickiewicz, MD 1 – MAKO Surgical; 7 – Wolters Kluwer Health - Lippincott 


James C Widmaier Jr, MD 2 – Synthes 

Roger F Widmann, MD .....................................................n 

John Wiebelhaus, BS .......................................................n 

Bernd Wiedenhoefer, MD 3C – Ulrich Medical; 5 – Aesculap/B.Braun, DePuy, A 


Thomas A Wiedrich, MD 2 – Auxillium; 3B – Apex; 4 – MiMedx 

Carl Wierks, MD ...........................................................n 

Britta Wieskoetter, MD .....................................................n 

Lindsay Wiesner, BS ........................................................n 

Coen A Wijdicks, MSc ......................................................n 

John H Wilckens, MD 7 – Wolters Kluwer Health - Lippincott Williams & Wilkins 

Dana Wild, PT, PhD ........................................................n 

SE Wilfred, BA .............................................................n 

W Jaap Willems, MD, PhD 3B, 5 – Tornier 

Ariel Williams, MD .........................................................n 

Bart Williams, PhD ........................................................n 

Benjamin R Williams .......................................................n 

Dan Williams, MRCS, MSc ..................................................n 

Daniel K Williams, MD .....................................................n 

Frank Williams ............................................................n 

Gerald R Williams Jr, MD 1 – DePuy, A Johnson & Johnson Company; 2 – DePuy, 

A Johnson & Johnson Company, Mitek; 3B – Tornier; 4 – In Vivo Therapeutics; 

5 – Tornier; 7 – Journal of Shoulder and Elbow Surgery, Wolters Kluwer Health - 


John Barton Williams, BA 4 – Merck 

John Leicester Williams, PhD 5 – Corin Ltd.; 6 – LifeModeler Inc. 

Johnathan Williams, BS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Kelly M Williams, PA-C .....................................................n 

Nicole T Williams, OTC 3B – 3M Healthcare 

Riley Joseph Williams, MD 1 – Arthrex, Inc.; 5 – Smith & Nephew; 7 – Springer 

Sean Wilkinson, BA ........................................................n 

Chris Williamson, MD ......................................................n 

Matthew Parker Willis, MD 2, 5 – DJ Orthopaedics 

APR Wilson, MRCP 2 – Ethicon 

Philip L Wilson, MD .......................................................n 

Vasthi Wilson, MD .........................................................n 

Robert Lane Wimberly, MD .................................................n 

Matthias Dominik Wimmer, MD 4 – GE Healthcare, Linde AG 

65 

disclosure 

Tyler Conway Wind, MD ....................................................n 

Reinhard Windhager, MD 2 – Johnson & Johnson, Boehringer Ingelheim; 5 – Johnson 

& Johnson 

Robert Winn ..............................................................n 

Robert A Winquist, MD 1, 3C – Zimmer 

Robert B Winter, MD 1 – EBI 

Brian Winters, MD .........................................................n 

Michael A Wirth, MD 1 – DePuy, A Johnson & Johnson Company; 2, 3B – DePuy, A 

Johnson & Johnson Company, Tornier; 4 – Tornier; 7 – Saunders/Mosby-Elsevier 

Dieter Wirtz, MD ..........................................................n 

Lauren Wisk ..............................................................n 

Donald A Wiss, MD ........................................................n 

Johan Witt, MD ............................................................n 

James C Wittig, MD ........................................................n 

Antonia Woehnl, MD .......................................................n 

Brian R Wolf, MD ..........................................................n 

Fredric M Wolf, PhD 7 – Sage Publications 

Jennifer Moriatis Wolf, MD 7 – SLACK Incorporated, Elsevier 

Carmen Wolfe, BA .........................................................n 

Scott W Wolfe, MD 2 – Trimed, SBI; 3B – Extremity Medical; 7 – Elsevier, Inc. 

Aviva Wolff, CHT, OTR/L ....................................................n 

Philip R Wolinsky, MD 3B – Biomet, Zimmer; 5 – Synthes 

Adam Laurance Wollowick, MD 2 – DePuy, A Johnson & Johnson Company; 

5 – Stryker, DePuy, A Johnson & Johnson Company, K2M 

Jennifer Woltz .............................................................n 

Man Hee Won, MD .........................................................n 

Melissa Wong .............................................................n 

Robert E. Wood, MD 3C – Olympus Corporation 

Jessica Woodcock, MD ......................................................n 

Barrett Ivory Woods, MD ....................................................n 

Chase Woodward, BS .......................................................n 

Spencer Woolwine, CS ......................................................n 

Alicia Worden, MD .........................................................n 

Adam Wright, MD .........................................................n 

Dennis Wright, MD, FACS ...................................................n 

Elizabeth A. Wright, PhD 4 – Johnson & Johnson, Pfizer 

James G Wright, MD 7 – Journal of Bone and Joint Surgery - American, Saunders/ 


John Wright, MD 3B – DePuy, A Johnson & Johnson Company 

Judy L Wright, MD .........................................................n 

Patty Wright, MD ..........................................................n 

Rick W Wright, MD 5 – Smith & Nephew; 7 – Wolters Kluwer Health - Lippincott 


Russel C Wright, BS ........................................................n 

Timothy M Wright, PhD 1 – Mathys Ltd.; 4 – Exactech, Inc.; 5 – Synthes, Stryker, Smith 

& Nephew; 7 – Journal of Orthopaedic Research, Wolters Kluwer Health - Lippincott 

Williams & Wilkins; 

Chung-Ding Wu, MD .......................................................n 

Eileen Wan-Ying Wu, MD ...................................................n 

Karl Wu, MD ..............................................................n 

Tuoh Wu, MD .............................................................n 

Dane K Wukich, MD 1 – Arthrex 

Jay Wunder, MD ...........................................................n 

Rosanna Lisa Wustrack, MD .................................................n 

Ronald W B Wyatt, MD .....................................................n 

Christopher D Wybo, MS 3A – Innovative Surgical Solutions, LLC; 4 – Innovative 

Surgical Solutions, LLC, Nuvasive 

Jack W Wylie, MD ..........................................................n 

John W Xerogeanes, MD 1, 3B – Linvatec 

Dr Yang Xia ...............................................................n 

Yinghua Xu, MBBS .........................................................n 

Fragiskos Xypnitos, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Alem Yacob, MD ...........................................................n 

Shahan V Yacoubian, MD 1 – AOS; 2 – DJ Orthopaedics; 3B – AOS, Wright Medical 

Technology, Inc.; 5 – AOS 

Stephan Vahe Yacoubian, MD 1, 5 – AOS 




Jacques YaDeau, MD 4 – Johnson & Johnson, Pfizer 

Mitsuru Yagi, MD, PhD .....................................................n 

Burak Yalcin ..............................................................n 

Josh Yamada, MD 2 – Integra Life Sciences Institute for Continuing Medical Education 

Katsuhisa Yamada, MD .....................................................n 

Koji Yamada, MD ..........................................................n 

Susumu Yamada, MD .......................................................n 

Masatsugu Yamagata, MD ...................................................n 

Ken Yamaguchi, MD ........................................................n 

Tamonori Yamaguchi, BS ...................................................n 

Go Yamako, PHD 3A – Mizuho Ikakogyo 

Atsushi Yamamoto, MD, PhD ................................................n 

Nobuyuki Yamamoto, MD ..................................................n 

Norio Yamamoto, MD ......................................................n 

Takuaki Yamamoto, MD ....................................................n 

Mitsuyoshi Yamamura, MD .................................................n 

Takayuki Yamashita ........................................................n 

Toshihiko Yamashita, MD ...................................................n 

Kensuke Yamauchi .........................................................n 

Alan Yong Yan, MD ........................................................n 

Ick-Hwan Yang, MD ........................................................n 

Kuender D Yang, MD .......................................................n 

Quinton Yang .............................................................n 

Rong-Sen Yang, MD ........................................................n 

Syngil Steven Yang, MD 3A – Pfizer; 3B – Integra Lifesciences Corporation; 4 – Pfizer 

Adam Blair Yanke, MD ......................................................n 

Koichiro Yano, MD 2 – Mitsubishi Tanabe Pharma 

Matthew G. Yantis, MD .....................................................n 

Jeffrey Yao, MD 1 – Arthrex, Inc.; 3B – Smith & Nephew, Arthrex, Inc.; 7 – Saunders/ 


Jeffrey Jon-Michael Yaste, MD ................................................n 

Kazunori Yasuda, MD ......................................................n 

Natsuo Yasui ..............................................................n 

Yuji Yasunaga, MD .........................................................n 

Burt Yaszay, MD 1 – Orthopediatrics; 2, 5 – DePuy, A Johnson & Johnson Company, 

KCI; 3B – KCI, Synthes, K2M, Ellipse; 6 – DePuy, A Johnson & Johnson Company 

Michael J Yaszemski, MD, PhD 4 – BonWrx 

Adolph J Yates Jr, MD 3A – GlaxoSmithKline 

Albert C Yeh ...............................................................n 

Tedd Yemm, PT ............................................................n 

Seng-Jin Yeo, FRCS 2, 3C – DePuy, A Johnson & Johnson Company 

Jin-Sup Yeom, MD, PhD 2 – Medtronic Sofamor Danek, DePuy, A Johnson & Johnson 

Company 

Harris S Yett, MD ..........................................................n 

Anthony T Yeung, MD 1 – Richard Wolf Surgical Instrument Co.; 2 – Richard Wolf 

Surgical Instrument Company, Elliquence Radiofrequency, Surgimax, Disc FX System; 

4 – Bonovo, Surgitech, Ouroborous, Paradigm Spine, Replication Medical, Small Bones 

Innovation, Pioneer Surgical 

Dr Eric Yeung .............................................................n 

Andy Yew, PhD ............................................................n 

Edward Yian, MD ..........................................................n 

Gokce Yildirim, MSc .......................................................n 

David A Yngve, MD ........................................................n 

Lewis A Yocum, MD 3B – Mitek 

Yasukazu Yonetani, MD .....................................................n 

David Yonick, MD 4 – Baxter 

Jae Ho Yoo, MD ...........................................................n 

Jae-Chul Yoo, MD ..........................................................n 

Jaedoo Yoo, Prof 3B, 4 – Korean Bone Bank 

Dr Je Hyun Yoo ............................................................n 

Jeong-hyun Yoo, MD, PhD ..................................................n 

Jeong Joon Yoo, MD ........................................................n 

Ju Hyung Yoo, MD .........................................................n 

Jung U Yoo, MD ...........................................................n 

Jangwhon Yoon, PhD, PT ...................................................n 

66 

disclosure 

S Tim Yoon, MD, PhD 3B – Medtronic, Meditech; 4 – Phygen; 5 – Biomet 

Taek Rim Yoon, MD, PhD ...................................................n 

Petya Yorgova, MS ..........................................................n 

Sally York, RN .............................................................n 

Hironori Yoshida, MD ......................................................n 

Taku Yoshida, MD .........................................................n 

Hideki Yoshikawa, MD .....................................................n 

Ichiro Yoshimura, MD ......................................................n 

Katsuhito Yoshioka, MD ....................................................n 

Shinichi Yoshiya, MD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .n 

Zongbing You, MD .........................................................n 

Allan Young, PhD 6 – Tornier 

Brett H Young, MD .........................................................n 

Simon Young, MD .........................................................n 

Alastair S E Younger, MD 3B – ConMed Linvatec, Small Bone Innovations, BioMimetic; 

5 – BioMimetic; ConMed Linvatec, Wright Medical Technology, Inc., Synthes, Integra 

Foundation Carticept 

Jim A Youssef, MD 1 – DePuy, A Johnson & Johnson Company, Nuvasive, Osprey, 

SeaSpine, Aesculap/B.Braun, Amedica; 3B – DePuy, A Johnson & Johnson Company, 

Nuvasive, Aesculap/B.Braun, SeaSpine, Vertiflex Spine; 4 – Amedica; 5 – DePuy, 

A Johnson & Johnson Company, Nuvasive, Stryker, Stryker Biotech, BioSurface 

Engineering Technologies, Facet Solutions, Advanced Technologies & Regenerative 

Medicine, Axial Biotech, Vertiflex Spine 

Warren D Yu, MD 1 – Sea spine Inc.; 2 – Stryker, Kyphon Inc.; 3B – Sea spine Inc., 

SpineFrontier Inc.; 3C – Zimmer; 4 – SpineFrontier Inc., Doctors Research Group 

Yangyang Yu, BA ...........................................................n 

Brandon J Yuan, MD .......................................................n 

Xunhua Yuan, PHD ........................................................n 

Bing Yue ..................................................................n 

Eric J Yue, MD .............................................................n 

Wai Mun Yue, MD 2, 3B – DePuy, A Johnson & Johnson Company, Medtronic Sofamor 

Danek; 5 – Medtronic Sofamor Danek 

Itaru Yugue, MD ...........................................................n 

Youhei Yukizawa, MD ......................................................n 

Yeo-Hon Yun, MD .........................................................n 

Nicole Yurgin, PhD 3A – Amgen Co. 

James E Zachazewski, PT 4 – Abbott, Bristol-Myers Squibb, Genzyme, Medtronic, 

Merck, Pfizer, Procter & Gamble, Zimmer; 7 – Saunders/Mosby-Elsevier 

Mary Zadnik Newell, OTR ...................................................n 

Jayson D Zadzilka, MS ......................................................n 

Antonia Zaferiou, BE .......................................................n 

Stefano Zaffagnini, MD 6 – I + s.r.l.; 7 – Springer 

Michael P Zafuta, MD ......................................................n 

Ira Zaltz, MD 5 – DePuy, A Johnson & Johnson Company 

Marco Zanetti, MD .........................................................n 

Jana Zapletalova, PhD ......................................................n 

Peter Constantine Zarkadas, MD .............................................n 

Mohammad Zarrabian, MD .................................................n 

Michael Zatushevsky, MD 4, 6 – Nuvasive 

John Alexander Zavala, MD .................................................n 

Rad Zdero, PhD 6 – Stryker 

Lukas P. Zebala, MD ........................................................n 

Harald Zehetgruber, MD ....................................................n 

Seth Zeidman, MD 4 – Amedica, Globus 

Evan Zeitler, BA ............................................................n 

Jason Zell, DO. MPH .......................................................n 

Reinhard Zeller, MD, DSc, FRCSC 1 – Spinevision; 3C – Paradigm Spine 

Kristine Zellers Fortuna, MD ................................................n 

Yo Zen, MD ...............................................................n 

Amer Zeni, MD ............................................................n 

Haitao Zhang, PhD ........................................................n 

Hongbin Zhang, PhD ......................................................n 

Kai Zhang ................................................................n 

Yang Zhang, MS ...........................................................n 

Zhen Zhang, MS ...........................................................n 

Caixia Zhao, MD ...........................................................n 




Li Zhao, PhD ..............................................................n 

Qianqian Zhao, MS ........................................................n 

Wen Zhao, MD ............................................................n 

Wenyan Zhao, PhD ........................................................n 

Gehua Zhen, MD ..........................................................n 

Kathy Zheng, MPH .........................................................n 

Jinjun Zhu, MD, PhD .......................................................n 

Bernard A Zicat, MD 1 – DePuy, A Johnson & Johnson Company, Zimmer; 3B – Smith 

& Nephew 

Kai Ziebarth ...............................................................n 

Daniel Ziegler, MD 5 – Eli Lilly 

Yoram Zilberman, PhD .....................................................n 

Sumesh M Zingde ..........................................................n 

Patrick Oliver Zingg, MD ...................................................n 

David Zingmond, MD ......................................................n 

Raul Zini, MD .............................................................n 

Argyrios Ziogas, PhD .......................................................n 

Lewis Evan Zionts, MD 4 – Abbott, Amgen Co., Bristol-Myers Squibb, Johnson & 

Johnson, Merck, Pfizer, Sanofi-Aventis 

Bruce Ziran, MD 2 – Stryker, Synthes; 3B – Stryker, Synthes, Mondeal/Forcetec, Tekartis; 

4 Osteotech, Stryker 

Michael Pawel Zlowodzki, MD ...............................................n 

Benjamin Zmitzkowski, MD .................................................n 

Angelos Zografos, MEng ....................................................n 

Alan Zonno, MD 5 – Arthrex, Inc. 

Ioannis Zouzias, MD .......................................................n 

Joseph D Zuckerman, MD 1 – Exactech, Inc.; 4 – Neostem; 7 – SLACK Incorporated, 

Thieme, Wolters Kluwer Health - Lippincott Williams & Wilkins 

David Zukor, MD 2 – DePuy, A Johnson & Johnson Company; 6 – DePuy, A Johnson & 

Johnson Company, Synthes 

Mark Zunkiewicz, MD 3B – Smith & Nephew; 4 – Pfizer, Johnson & Johnson, 

GlaxoSmithKline, Merck, Roche, Bristol-Myers Squibb, Zimmer, Siemens; 6 – Arthrex, 

Inc., Mitek, Smith & Nephew 

Karen Zupko 3B – Understand.com, Zimmer 

David Zurakowski PhD .....................................................n 

Lukas Zwicky, MSc .........................................................n 

Michael G Zywiel, MD ......................................................n 

67 

disclosure 



68 

u New FroNtierS iN Cartilage 

imagiNg oF the hip (aaoS/orS i) 

u 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 14. An alphabetical faculty financial disclosure list can be found starting on page 19. 

SympoSia AR Hip 

Moderator: Paul E. Beaulé MD FRCSC 

High resolution MRI for cartilage mappling is a rapidly evolving field in our understanding of osteoarthritis. Basic science and 

clinical applications for the hip will be discussed. 

Objectives: 

• Clinical applications of cartilage imaging in regards to patient selection and prognosis for joint preserving surgery of the 

hip i.e. osteotomy, arthrosccopy. 

• Understand how early diagnosis of cartilage degeneration i.e. loss of proteoglycan concentration and collagen integrity 

can be investigated using high resolution MRI with cartilage mapping in the knee and how this maybe applied to the hip. 

• Understand the application and challenges of different cartilage imaging modalities: T2, T1Rho, dGemric. 

• Review of current clinical results of cartilage mapping in dysplasia and femoroacetabular impingement. 

OUTLINE: 

I. Current Status of Cause and Prevention of Hip Osteoarthritis as Well as Socioeconomic Burden. 

Paul E. Beaulé, MD, Ottawa, ON, Canada 

II. Relationships Between Imaging Signal Abnormalities and Biomechanical/Compositional Abnormalities in the Knee. 

Thomas D. Brown, PhD, Iowa City, IA 

III. Overview of Techniques of Cartilage Imaging in the Hip and its Challenges. 

Tallal C. Mamisch, MD, Bern, Switzerland 

IV: Current Data and Evidence in Treatment of Hip Dysplasia. 

Young Jo Kim, MD, Boston, MA 

V. Current Data and Challenges in Femoroacetabular Impingement 

Kawan Rakhra, MD, Ottawa, ON, Canada 

VI. Discussion and Case Illustrations

69 

New FroNtierS iN Cartilage imagiNg oF the hip 

Paul E. Beaulé MD FRCSC 

OBJECTIVES: 

• Define current burden of disease of hip arthritis 

• Define current bony abnormalities associated with hip arthritis 

and current methods of clinical assessment. 

• Clinical applications of cartilage imaging in regards to patient 

selection and prognosis for joint preserving surgery of the hip 

i.e. osteotomy & arthroscopy. 

Current status of Cause and prevention of Hip Osteoarthritis as 

well as socioeconomic burden 

Osteoarthritis (OA) of the hip is a debilitating and painful condition 

affecting a significant proportion of the population. It is the main 

reason for total hip arthroplasty, of which there were over 33,000 

cases in Canada in 2008-09 and over 300 000 cases in the US 

alone. In addition, the proportion of patients requiring a total hip 

arthroplasty in the 45-64 age group has gone from 26% to 36% in 

the last decade. 1 This volume of cases will cost the Canadian and 

US healthcare system up to $2.4 billion and 8.5 billion, respectively 

over the next five years. More importantly, with patients younger 

and more active, avoiding or even delaying the need for a total hip 

replacement is critical goals in maintaining their quality of life over 

their life. 

Consequently, the development of an effective screening program 

for hip deformities thought to lead degenerative hip arthritis as well 

as answering the basic question that as treating physicians we are 

asked by our patients: “Will surgical correction of my hip deformity 

provide me with better function as well as delay and/or prevent the onset of 

degenerative changes?” is critical. 

To answer this question we must better understand what clinical 

factors such as patient age, gender, severity of deformity are 

predictive of this with the overall health of the articular cartilage 

crucial in that regards. This symposium will focus primarily on the 

assessment of the structural integrity of hyaline cartilage as this is 

the basic foundation for a well functioning joint. 

Current etiology of Hip Osteoarthritis 

Murray2 and Stulberg et al3 both identified that childhood or young 

adult hip conditions were associated with the development of hip 

arthritis and identified the following: dysplasia; Legg-Calve Perthes; 

slipped capital femoral epiphysis. In addition, they coined the terms 

tilt and pistol grip deformity to denote minor abnormalities (i.e. not 

noticed during childhood) putting patient at risk of developing hip 

arthritis. In regards to the pathomechanism leading to degenerative 

changes with dysplasia4,5 insufficient coverage of the femoral head 

by the acetabulum leads to an intra-articular instability secondary 

to failure of the labral-chondral junction due to edge loading as 

well as pure static overloading the articular cartilage. Whereas for 

the tilt or pistol grip deformity, it is not until the description of 

femoroacetabular impingement (FAI) by Ganz6 that the dynamic 

nature of this degenerative process was fully understood as well as 

defining treatment methods. FAI can be sub grouped into Pincer 

(acetabular retroversion/coxa profunda) and CAM (insufficient 

femoral head/neck offset-lack of anterior neck concavity). 

Clinical Evaluation 

The history and physical examination of pre arthritic hip pain are 

fairly constant where patients have a history of chronic groin pain 

which may have been miss-diagnosed as a hip flexor injury. The 

length of hip symptoms can vary from several years to a few months. 

However, there is no real good evidence correlating length of hip 




symptoms and degree of osteoarthritis. 

RADIOGRAPHIC EVALUATION 

Plain Radiographs 

The hip joint anatomy needs to be assessed with a well-centered AP 

radiograph as well as a specialized lateral radiograph such as the 

Dunn view. 

For Dysplasia: 

• Tonnis angle > 10¼ on AP 

• Center edge (VCE) angle of Wiberg < 20¼ 

• Anterior center angle of Lesquesne and deSeze 7 on false-profile 

of 50¼; lack of concavity at anterior 

neck. 

• Grading of Osteoarthritis: The AP pelvis will also provide 

an assessment of the condition of the articular cartilage by 

measuring of the width of the joint space. There is currently no 

consensus as to having weight-bearing or supine radiographs 

to measure the joint space. Most commonly, the Tonnis 

Classification of Hip Osteoarthritis 9 is used (Figure 1). 

Figure 1: Tonnis Classification 9 

In regards to joint preserving surgery for dysplasia and survivorship 

of the hip joint, Trousdale et al 10 clearly demonstrated that the 

degree of joint space narrowing preoperatively dictates the longevity 

of hip joint after osteotomy (Figure 2).

However, it is unclear if these findings necessarily apply to FAI where 

there is little data on joint survivorship post surgical correction 

based on preoperative joint space width. 11 If anything, the amount of 

narrowing that can be acceptable maybe less than with dysplasia. In 

addition, because of the limitations of the 2D view provided by plain 

radiographs unless there is evidence of significant arthritis: narrowing 

>2mm; subchondral sclerosis; osteophytes and cysts, it becomes 

difficult for the physician to counsel the patient on the overall 

longevity of their native hip joint with at best recommendations 

such as: “you have 70-80% chance of a good to excellent result” or that 

“if you do not do anything your hip joint won’t get better”. 

MAGNETIC RESONANCE IMAGING 

For both conditions of dysplasia femoroacetabular, magnetic 

resonance imaging with gadolinium arthrography (MRA) has 

proved effective in the visualization of labral tears 12 , paralabral cyst 

formations 13 , and cartilage delamination 14 . Coronal, para-axial and 

para-sagittal sections are obtained in the plane of the femoral neck. 

REFERENCES 

1. Kim S. Changes in Surgical Loads and Economic Burden of Hip and Knee 

Replacements in the US: 1997-2004. Arthritis Rheum. 2008;59:481-88. 

2. Murray RO. The aetiology of primary osteoarthritis of the hip. Br.J.Radiol 

1965;38:810-824. 

3. Stulberg,SD; Cordell,LD; Harris,WH; Ramsey,PL; and MacEwen,GD. 

Unrecognized childhood hip disease: a major cause of idiopathic 

osteoarthritis of the hip. In The Hip, Proceedings of the Third Open 

Scientific Meeting of the Hip Society., p 212-228. Edited by H. C. Amstutz. St. 

Louis, C.V. Mosby, 1975. 

4. Murphy SB, Ganz R, Muller ME. The prognosis in untreated dysplasia of the 

hip. A study of radiographic factors that predict the outcome. J.Bone Joint 

Surg. 1995;77A:985-89. 

5. Cooperman DR, Wallensten R, Stulberg D. Acetabular Dysplasia in the adult. 

Clin.Orthop.Rel.Res. 1980;175:79-85. 

6. Ganz R., Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis 

of the hip : an integrated mechanical concept. Clin.Orthop.Rel.Res. 

2008;466:264-72. 

7. Lequesne M, de Seze S. Le faux profil du bassin. Nouvelle incidence 

radiolographique pour l’etude de la hanche. Son utilite dans les dysplasies et 

les differentes coxapathies. Rev.Rhum. 1961;28:643-52. 

8. Beaule PE, Allen DJ, Clohisy JC, Schoenecker PE, Leunig M. The young adult 

with hip impingement: deciding on the optimal intervention. J Bone Joint 

Surg 2009;91:210-221. 

70 




In addition for FAI, quantitative assessment of cam impingement 

contour abnormality is done with the alpha angle15 . Although this 

imaging provides useful information in regards to macroscopic 

identification of cartilage defects as well as better characterization 

of labral changes (hypertrophy w/ dysplasia) which may provide 

some guidance in regards to the surgical reconstruction that might 

be needed at the time of surgery, it does not provide prognostic 

information on longevity of the hip joint. Consequently, early 

diagnosis of cartilage degeneration would require the ability to 

noninvasively detect changes in PG concentration and collagen 

integrity before gross morphologic changes occur. 

Having said that, high resolution MR imaging techniques can permit 

the quantification and characterization of the cartilage extracellular 

matrix i.e. proteoglycan content as well as orientation of the type II 

collagen fibers. The PG with the attached glycosaminoglcans interact 

with the ground substance composed of the collagen fibres (mainly 

type II) which are oriented parallel to the articular surface in the 

superficial zone, perpendicular in the radial zone, and arcade-like 

in the transitional zone. Early events during cartilage breakdown 

include the loss of PGs, changes in water content, and molecularlevel 

changes in collagen. These changes can quantified using high 

resolution MR imaging with several techniques being currently used: 

dGEMRIC, T2, T1Rho in the hip as well as in the knee16 . 

CONCLUSION: 

Clearly there is a relationship between severity of deformity and 

risk of disease progression for hip osteoarthritis. Plain radiographs 

provide important information in defining the bony abnormality as 

well as determining the classic signs of arthritis, however because of 

its 2-dimensional nature, complete assessment of the health of the 

articular cartilage is limited both from a 3-dimensional nature but as 

well as from a structural standpoint. 

9. Tonnis D, Heinecke A. Acetabular and femoral anteversion:relationship with 

osteoarthritis of the hip. J Bone Joint Surg. 1999;81A:1747-70. 

10. Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL. Periacetabular and 

intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic 

hips. J.Bone Joint Surg.Am. 1995;77:73-85. 

11. Ribas M, Ledesma R, Cardenas C, Marin-Pe–a O, Toro J, Caceres E. Clinical 

results after anterior mini-open approach for femoroacetabular impingement 

in early degenerative stage. Hip Int. 2010;20(Suppl 7)(S7):36-42. 

12. Leunig M, Werlen S, Ungersbock A, Ito K, Ganz R. Evaluation of the 

acetabular labrum by MR Arthrography. J Bone Joint Surg. 1997;79B:230- 

234. 

13. Magee T, Hinson G. Association of paralabral cysts with acetabular disorders. 

AJR Am.J.Roentgenol. 2000;174:1381-84. 

14. Beaule PE, Zaragoza EJ, Copelan N. Magnetic Resonance Imaging with 

Gadolinium Arthrography to Assess Acetabular Cartilage Delamination. A 

Report of Four Cases. J Bone Joint Surg. 2004;86A:2294-98. 

15. Notzli HP, Wyss TF, Stoecklin CH, Schmid MR, Treiber K, Hodler J. The 

contour fo the femoral head-neck junction as a predictor for the risk of 

anterior impingement. J Bone Joint Surg. 2002;84B:556-60. 

16. Li X, Pai A, Blumenkrantz G, Carballido-Gamio J, Link T, Ma B, Ries 

M, Majumdar S. Spatial distribution and relationship of T1rho and T2 

relaxation times in knee cartilage with osteoarthritis. Magn Reson Med. 

2009;61(6):1310-18.

71 

relatioNShipS betweeN imagiNg SigNal abNormalitieS aNd 

biomeChaNiCal/CompoSitioNal abNormalitieS iN the kNee 

Thomas D. Brown, PhD 

1. Introduction 

2. Structural assessments 

A. Manual segmentation [12] 

B. Semi-automated segmentation [6] 

C. Automated segmentation [13] 

3. Compositional assessments 

A. T2 [5,8] 

B. T1-rho [7,8,10] 

REFERENCES 

1. Deng X, Farley M, Nieminen MT, Gray M, Burstein D: Diffusion tensor 

imaging of native and degenerated human articular cartilage. Magnetic 

Resonance Imaging 25: 168-171, 2007. 

2. Filidoro L, Dietrich O, Weber J, Rauch E, Oerther T, Wick M: High-resolution 

diffusion tensor imaging of human patellar cartilage: feasibility and 

preliminary findings. Magnetic Resonance Imaging 53: 993-998, 2005. 

3. Goetz HW, Trattnig S, Scheffler KS, Szomonanyi P, Quirbach S, Marlovits S, 

Domayer S, Bieri O, Mamisch TC. Magnerization Transfer Contrast and T2 

Mapping in the Evaluation of Cartilage Repair Tissue with 3T MRI. Journal of 

Magnetic Resonance Imaging 28: 979-986, 2008. 

4. Gray ML. Toward Imaging Biomarkers for Glycosaminoglycans. Journal of 

Bone and Joint Surgery 91-A Suppl.1: 44-49, 2009. 

5. Gray ML, Burstein D, Kin Y-J, Maroudas A. Magnetic Resonance Imaging 

of Cartilage Glycosaminoglycan: Basic Principles, Imaging Technique, and 

Clinical Applications. Journal of Orthopaedic Research 26: 281-291, 2008. 

6. Koo S, Giori NJ, Gold GE, Dyrby CO, Andriacchi TP. Accuracy of 3D 

Cartilage Models Generated from MR Images Is Dependent on Cartilage 

Thickness: Laser Scanner Based Validation of In Vivo Cartilage. Journal of 

Biomechanical Engineering 131: 121004-1 -121004-5, 2009. 

7. Krause FG, Klammer G, Benneker LM, Werlen S, Mamisch TC, Weber M. 

Biochemical T2* MR Quantification of Ankle Arthrosis in Pes Cavovarus. 

Journal of Orthopaedic Research 28: 1562-1568, 2010. 




C. dGEMRIC [4,5,9] 

D. Lesser-used modalities 

1. Sodium [11] 

2. T2* [7] 

3. Diffusion tensor imaging [1,2] 

4. Magnetization transfer [3] 

4. Conclusions and path forward 

8. Li X, Pai A, Blumankrantz G, Carballido-Gamio J, Link T, Ma B, Ries M, 

Majumdar S: Spatial Distribution and Relationship of T1-rho and T2 

Relaxation Times in Knee Cartilage with Osteoarthritis. Magnetic Resonance 

in Medicine 61:1310-1318, 2009. 

9. Pollard TCB, McNally EG, Wilson DC, Wilson DR, Madler B, Watson M, 

Gill HS, Carr AJ. Localized Cartilage Assessment with Three-Dimensional 

dGEMRIC in Asymptomatic Hips with Normal Morphology and Cam 

Deformity. Journal of Bone and Joint Surgery 92: 2557-2569, 2010 

10. Regatte RR, Akella SVS, Lonner JH, Kneeland JB, Reddy R. T1-rho Relaxation 

Mapping in Human Osteoarthritis Cartilage: Comparison of T1-rho with T2. 

Journal of Magnetic Resonance Imagine 21: 547-553, 2006. 

11. Staroswiecki E, Bangerter NK, Gurney PT, Grafendorfer T, Gold GE, 

Hargreaves BA: In Vivo Sodium Imaging of Human Patellar Cartilage with a 

3D Cones Sequence at 3 T and 7 T. Journal of Magnetic Resonance Imaging 

32: 446-451, 2010. 

12. Wirth W, Larroque S, Davies RY, Nevitt M, Gimona A, Baribaud F, Lee JH, 

Benichou O, Wyman BT, Hudelmaier M, Maschek S, Eckstein F. Comparison 

of One-Year versus Two-Year Change in Regional Cartilage Thickness 

in Osteoarthritis Results from 346 Participants from the Osteoarthritis 

Initiative. Osteoarthritis and Cartilage (2010). EPub ahead of print, PMID 

21044690. 

13. Yin Y, Zhang X, Williams R, Wu X, Anderson DD, Sonka M. LOGISMOS 

– Layered Optimal Graph Image Segmentation of Multiple Objects and 

Surfaces: Cartilage Segmentation in the Knee Joint. IEEE Transactions on 

Medical Imaging (2010), EPub ahead of print, PMID 20643602.

72 

overview oF teChNiqueS oF Cartilage imagiNg iN the hip aNd 

itS ChalleNgeS. mri FiNdiNgS iN the Normal / abNormal hip 

Tallal Charles Mamisch, MD 

Introduction 

For imaging of intra-articular hip pathology magnetic resonance 

imaging (MRI) represents the best technique due to its ability to 

directly visualize cartilage, superior soft tissue contrast, and the 

prospect of multi-dimensional imaging. However, opinions differ 

on the diagnostic efficacy of MRI and on the question of which MRI 

technique is most appropriate. 

At present, magnetic resonance (MR) arthrography using intraarticular 

contrast material has been established as the standard 

method for imaging of labral lesions. However, the diagnostic 

reliability of cartilage lesion remains moderate. Furthermore, the 

diagnostic reliability of acetabular cartilage delamination by MRI is 

still challenging. 

To detect the early degenerative pathology of the hip in correlation 

to the morphology changes it is becoming recognized that standard 

coronal, axial and sagittal MRI planes are less reliable than radially 

reconstructed planes perpendicular to the acetabular opening 

around the femoral neck. For the assessment of the femoral headneck 

morphology (alpha-angle and head-neck offset) as well as 

the depth and coverage of the acetabulum (acetabular depth), 

radial reconstructions along the femoral neck axis improve the 

understanding This imaging technique is increasingly recognized 

as an important tool for morphologic assessment of FAI as well as 

improved technique to detect early labral and chondral damage in 

the hip. 

The aim of this overview is to discuss the current use of MRI in 

Cartilage imaging in the hip. 

Normal findings 

Normal MRI findings in asymptomatic volunteer: Right side: PD TSE 

none fat sat with triangular and normal intense acetabular labrum 

(white arroe) 3T imaging with separation of acetabular and femoral 

cartilage Left Side: PD TSE fat sat sequence with normal cartilage 

status anterior and posterior. Separation of acetabular and femoral 

cartilage (white arrow) using 3T imaging 

Abnormal findings 

1. Cam Impingement: 

Cartilage diagnosis: None arthrography and arthrography 

techniques are described for the detection of cartilage lesions, 

where MR arthrography showed improved classification but the 

accuracy is reported still moderate (sensitivity of 47%). Overall 

the cartilage diagnosis in the hip is limited so far and no reliable 

staging and grading system has been established. The use of 




new pulse sequences and 3.0 T imaging in combination with 

MR arthrography can overcome these limitations and improve 

cartilage diagnosis in the hip significantly. 

Cam type impingement with cartilage delamination on a sagittal 

PD TSE sequence using MR arthrography. 

2. Pincer type FAI: 

Acetabular Labrum: The labrum is often hypertrophic and torn in 

the anterior superior portion. 

Cartilage: Degeneration with thinning up to complete loss of the 

cartilage posterior. This can be seen in straight sagittal PD TSE 

images 

3. Mixed type FAI: 

In mixed type FAI, which is often, combination of cam-type and 

pincer-type findings for the acetabular labrum and cartilage can 

be seen. 

In cases of retroversion with cam type deformity of the head-

73 

neck offset a acetabular rim fracture can be seen in MRI with 

degeneration of the cartilage anterior-superior. 

REFERENCES 

1. Locher S, Werlen S, Leunig M, et al. [MR-Arthrography with radial sequences 

for visualization of early hip pathology not visible on plain radiographs]. Z 

Orthop Ihre Grenzgeb 2002;140(1): 52-7. 

2. Schmid MR, Notzli HP, Zanetti M, et al. Cartilage lesions in the hip: 

diagnostic effectiveness of MR arthrography. Radiology 2003;226(2): 382-6. 

3. Pfirrmann CW, Mengiardi B, Dora C, et al. Cam and pincer femoroacetabular 

impingement: characteristic MR arthrographic findings in 50 patients. 

Radiology 2006;240(3): 778-85. 




4. Kassarjian A, Yoon LS, Belzile E, et al. Triad of MR arthrographic findings 

in patients with cam-type femoroacetabular impingement. Radiology 

2005;236(2): 588-92. 

5. Mamisch TC, Zilkens C, Siebenrock KA, Bittersohl B, Kim YJ, Werlen S MRI 

of Hip Osteoarthritis and Implications for Surgery Radiol Clin N Am , 2009. 

6. Mamisch TC, Bittersohl B, Hughes T, Kim YJ, Welsch GH, Dudda M, 

Siebenrock KA, Werlen S, Trattnig S. Magnetic resonance imaging of the hip 

at 3 Tesla: clinical value in femoroacetabular i mpingement of the hip and 

current concepts. Semin Musculoskelet Radiol. 2008 Sep;12(3):212-22.

74 

CurreNt data aNd evideNCe iN treatmeNt oF hip dySplaSia 

Young-Jo Kim, MD, PhD 

MRI technologies with the ability to directly visualize the molecular 

ultra-structure of cartilage have promising potential for orthopaedic 

clinical research. Several clinical studies have been performed 

recently which demonstrate that delayed Gadolinium enhanced 

MRI of cartilage (dGEMRIC) and T2 mapping can provide useful 

additional data in the clinical setting. 

Briefly, dGEMRIC is based on the fact that the fixed charge density of 

articular cartilage is directly linked to its glycosaminoglycan (GAG) 

content, which is lost in early OA. Negatively charged contrast agent 

(GdDTPA 2- 

), which alters T1 relaxation time, will accumulate in an 

inversely proportional manner to cartilage GAG concentration after 

an intravenous injection and time delay for contrast equilibration in 

the tissue. A post-contrast T1 map can be obtained which provides 

quantitative information regarding the charge density of cartilage 

from which the amount of cartilage damage can be inferred. 

Aberrant hip anatomy as found in developmental dysplasia (DDH) 

or femoroacetabular impingement (FAI) is known to increase the 

risk of early OA. Surgical treatment aims to correct these anatomic 

deformities prior to onset of significant OA, since outcome depends 

on the extent of cartilage damage at the time of surgery. Conventional 

radiographs can assess bony deformities, but will only demonstrate 

late stage OA. Advanced MRI has become the favored diagnostic tool 

in the pre-op assessment of the hip to not only better define the 

abnormal bony anatomy but also to document the damaged soft 

tissue structures such as articular cartilage and labrum. In particular 

loss of GAG is considered to be an early event in the development of 

OA; therefore, its direct visualization by dGEMRIC has the potential 

ability to demonstrate the effect of joint-preserving hip surgery on 

OA progression. 

DDH 

In dysplasia, the shallow acetabulum leads to a reduced loadtransferring 

area which leads to increased mechanical stress on the 

cartilage. Pre-operative assessment of hips with acetabular dysplasia 

using dGEMRIC scans demonstrated that symptoms, assessed with 

the WOMAC score, correlated with the dGEMRIC index but not 

with joint space width measured in radiographs. Additionally, the 

dGEMRIC index correlated with the lateral center edge angle (LCE) 

demonstrating that even in young patients early articular cartilage 

changes could be seen in severely dysplastic hips. In a categorical 

comparison of the degree of dysplasia (mild, LCE > 15°, moderate, 

LCE between 6° and 15°, severe, LCE < 5°), the dGEMRIC indices 

differed significantly between all categories, while joint space width 

did not (1). 

Using a cohort of 52 hips, Cunningham, et al. (2) evaluated the 

predictive value of the dGEMRIC index after Bernese periacetabular 

osteotomy. Pre-operative demographic and radiographic variable 

including dGEMRIC index were compared to the early clinical and 

radiographic outcomes. When clinical and radiographic failure 

groups were compared to satisfactory groups, predictors that were 

identified: radiographic joint subluxation, Tšnnis Grade, joint space 

width, and the dGEMRIC Index (498 ± 105 ms (satisfactory) versus 

370 ± 88 ms (failed), P< 0.01). A multiple logistic regression model 

that included joint space width, joint subluxation, Tšnnis grade, and 

dGEMRIC index as independent variables showed the preoperative 

dGEMRIC value and joint subluxation prior to the surgery to 

be significant predictors of early postoperative failure of the 

periacetabular osteotomy. The probability of total hip arthroplasty 

increased dramatically when the dGEMRIC index was below 390 ms. 




The dGEMRIC index in morphologically normal hips averaged 570 ± 

90 ms; dGEMRIC index of 390 ms, which is two standard deviations 

below normal was thus defined as the threshold for osteoarthritis. 

These prior studies appear to demonstrate the validity of dGEMRIC 

as a metric of OA in dysplastic hips. Traditional studies on OA 

mainly utilized plain radiographic features of OA. In attempt 

to better understand the anatomic and demographic factors that 

may predispose a hip to early OA, a study involving 96 hips with 

acetabular dysplasia was performed to look at risk factors of early 

OA as defined using dGEMRIC (3). Using hips with dGEMRIC index 

below 390 ms as the definition of hips with early OA, cases below 

390 ms were significantly older, had significantly smaller lateral 

and anterior center-edge angles and joint space width, and had a 

significantly increased incidence of radiographic joint subluxation 

and labral tears. Using this data, the probability of significant OA 

(T1

In summary, joint preserving hip surgery for DDH already benefits 

from the use of the dGEMRIC in the clinical setting. dGEMRIC 

is helpful in identifying hips that are poor candidates for surgery, 

hence, leading to overall better surgical outcomes. In FAI, promising 

results have been reported, however the possible predictive value for 

the outcome after surgery, as found in DDH, remains to be evaluated. 

REFERENCES 

1. Kim YJ, Jaramillo D, Millis MB, Gray ML, Burstein D. Assessment of early 

osteoarthritis in hip dysplasia with delayed gadolinium-enhanced magnetic 

resonance imaging of cartilage. J Bone Joint Surg Am. 2003;85-A(10):1987- 

1992. 

2. Cunningham T, Jessel R, Zurakowski D, Millis MB, Kim YJ. Delayed 

gadolinium-enhanced magnetic resonance imaging of cartilage to predict 

early failure of Bernese periacetabular osteotomy for hip dysplasia. J Bone 

Joint Surg Am. 2006;88(7):1540-1548. 

3. Jessel RH, Zurakowski D, Zilkens C, Burstein D, Gray ML, Kim YJ. 

Radiographic and patient factors associated with pre-radiographic 

osteoarthritis in hip dysplasia. J Bone Joint Surg Am. 2009;91(5):1120-1129. 

75 




MRI at 3T has the potential to yield higher resolution images that 

may allow for the separate assessment of the acetabular and femoral 

cartilages. The presence of delamination is particularly difficult to 

detect. 3D dGEMRIC at 3T may aid in improving the sensitivity and 

specificity of detection of cartilage delamination. 

4. Jessel RH ZC, Tiderius C, Dudda M, Mamisch TC ,Kim YJ, . Assessment 

of Osteoarthritis in Hips with Femoroacetabular Impingement using 

Delayed Gadolinium Enhanced MRI of Cartilage. J Magn Reson Imaging. 

2009;30(5):1110-1115. 

5. Mamisch TC, Dudda M, Hughes T, Burstein D, Kim YJ. Comparison of 

delayed gadolinium enhanced MRI of cartilage (dGEMRIC) using inversion 

recovery and fast T1 mapping sequences. Magn Reson Med. 2008;60(4):768- 

773. 

6. Bittersohl B, Steppacher S, Haamberg T, Kim YJ, Werlen S, Beck M, 

Siebenrock KA, Mamisch TC. Cartilage damage in femoroacetabular 

impingement (FAI): preliminary results on comparison of standard 

diagnostic vs delayed gadolinium-enhanced magnetic resonance imaging of 

cartilage (dGEMRIC). Osteoarthritis Cartilage. 2009;17(10):1297-1306.

76 

CurreNt data aNd ChalleNgeS iN FemoroaCetabular 

impiNgemeNt 

Kawan Rakhra, MD 

Femoroacetabular impingement(FAI) has become a well-recognized 

pathogenic factor in the evolution of hip osteoarthritis(OA). The 

impingement is secondary to anatomic abnormalities of the femoral 

head-neck junction(cam type) and/or the acetabulum(pincer type). 

With hip motion, there is pathologic contact between the two 

surfaces of the joint resulting in altered biomechanics, premature 

degeneration and damage to hyaline and fibrocartilage, resulting in 

a predisposition to OA. 

The presence of predisposing anatomic deformities alone may 

not reliably predict or diagnose clinically significant FAI. The 

orthopaedic diagnosis and management of FAI often requires 

adjuvant radiologic evidence of a primary dysmorphism, and more 

importantly, of secondary joint damage such as to hyaline cartilage, 

prior to intervening with surgical procedures. 

Magnetic resonance imaging(MRI) is a powerful, non-invasive 

tool for evaluating hip joint hyaline cartilage. Traditional MRI and 

magnetic resonance arthrography(MRA) techniques have been 

effective in identifying macroscopic changes to cartilage. Specifically 

related to FAI, these MRI sequences can detect chondral injury such 

as focal or global, partial or full thickness defects, or delaminations. 

However, these gross structural alterations often manifest later in 

the OA pathway, at a point where treatment options may be limited 

to invasive, surgical procedures. Consequently, advanced MRI 

techniques are being explored in hope of detecting biochemical 

changes in the macromolecular matrix, which can alter the 

biomechanical properties of cartilage, before gross, morphologic 

cartilage damage occurs. These techniques may have both diagnostic 

and prognostic value. The early detection of hip hyaline cartilage 

biochemical damage may be used to confirm clinically suspected FAI 

before the irreversible, chondral insults evolve. 

Several different biochemical imaging protocols including 

delayed gadolinium enhanced magnetic resonance imaging of 

cartilage(dGEMRIC), T1ρ, and T2/T2* cartilage mapping have been 

conducted, to varying degrees in the normal and symptomatic 

hip. Although found to be technically feasible, and able to detect 

differences in cartilage profiles between asymptomatic and FAI/OA 

hips, there is limited information in the literature on the prognostic 

value and impact on clinical outcomes that these methods may have 

in the context of FAI. 

dGEMRIC is a technique which indirectly measures proteoglycan 

content within hyaline cartilage. It requires the intravenous injection 

of gadolinium contrast, followed by a variable delay and/or exercise 

regime. The gadolinium accumulates within the hyaline cartilage, 

inversely proportional to the concentration of proteoglycan. In the 

FAI hip dGEMRIC has been shown to correlate with pain, and size of 

the cam deformity and demonstrate abnormal cartilage profiles even 

in asymptomatic subjects with FAI predisposing joint morphology. 

T1-Rho(T1ρ) is another technique providing information on 

proteoglycan content of hyaline cartilage. However, it does not 

require the administration of intravenous gadolinium contrast. T1ρ 

has been performed in the normal asymptomatic hip, in the OA 

hip, and recently in the FAI hip. The technique has been able to 

detect differences in the cartilage profiles of normal and diseased 

hips, although the number of published studies to date is small and 

further validation is required. 




T2 cartilage mapping is a non-contrast based technique sensitive 

to changes in collagen content and architecture as well as cartilage 

hydration but has not been performed in the FAI hip to date. T2* 

mapping may proved similar information as T2 with regards to 

collagen status, although is sensitive to other compositional changes 

such as calcification in cartilage. T2* has been carried out in single 

study in FAI patients showing significant correlation with dGEMRIC. 

There are inherent challenges to biochemical imaging of hip cartilage 

compared to other joints such as the knee, upon which much of 

the initial research on cartilage mapping was based. Hip hyaline 

cartilage is much thinner, especially in the periphery of the joint 

where the earliest chondral damage is known to occur in FAI. As 

well, the hip joint is grossly spherical with resultant curvature of the 

joint space and articular surfaces, such that planar acquisition slices 

can be susceptible to volume averaging artifacts. 

The articular surfaces of the acetabulum and femoral head are very 

closely opposed to one another, making spatial separation of the 

two surfaces challenging. For this reason several previous studies on 

cartilage mapping in the hip performed the analysis on a combined 

bilayer, including both the acetabular and femoral surfaces together. 

However, in the context of FAI, evaluating a cartilage bilayer is not 

optimal since it assumes that directly opposed areas of cartilage 

are impinging and being affected equally. This assumption should 

not be made as different pathomechanisms of chondral injury can 

preferentially affect different sides and regions of the joint, and to 

varying degrees. Distinguishing between both articular cartilage 

surfaces will allow for non-opposing surfaces of the acetabulum and 

femoral head to be individually analyzed and compared. Static, two 

dimensional images cannot capture the spatially separate impinging 

articular surface zones with the hip in neutral flexion and rotation. 

Given this, future cartilage mapping investigations in FAI should 

consider analyzing each cartilage surface individually while targeting 

the known zones of impingement and high risk sites for early 

cartilage damage. 

For these reasons, cartilage imaging in the hip requires thin slice 

imaging, with high in-plane spatial resolution to allow for detailed of 

assessment of the hyaline cartilage. The advent of high field scanners 

(3.0 T and higher), 3D volume acquisitions, and continual advances 

in scanner hardware and surface coil technology will facilitate this 

with higher signal to noise ratios and shorter scan times. Further 

studies of cartilage mapping in the FAI hip are required with larger 

sample sizes, and further correlation with clinical joint function and 

post-surgical outcomes are required, similar to what has been done 

for hip dysplasia. 

MRI cartilage mapping may be able to fulfill the rapidly growing 

medical demand for a reliable, objective, non-invasive and 

quantitative investigation of cartilage status. At present, most 

medical and surgical therapies for OA are only palliative, and 

concentrate on the treatment of symptoms. However advanced 

biochemical imaging techniques will detect changes much earlier, 

possibly before any symptoms or significant joint damage occurs. 

This may lead to a shift in the management of OA, from palliative, to 

more preventative and disease modifying. Furthermore, these novel 

protocols may serve as a future tool in monitoring the progression 

of cartilage changes and the responses to therapy, in both the clinical 

and research environments.

SELECTED READINGS: 

1. Blumenkrantz, G. and S. Majumdar, Quantitative magnetic resonance 

imaging of articular cartilage in osteoarthritis. Eur Cell Mater, 2007. 13: p. 

76-86. 

2. Mamisch, T.C., et al., Magnetic resonance imaging of the hip at 3 Tesla: 

clinical value in femoroacetabular impingement of the hip and current 

concepts. Semin Musculoskelet Radiol, 2008. 12(3): p. 212-22. 

3. Pollard, T.C., et al., Localized cartilage assessment with three-dimensional 

dGEMRIC in asymptomatic hips with normal morphology and cam 

deformity. J Bone Joint Surg Am., 2010. 92(15): p. 2557-69. 

4. Bittersohl, B., et al., Cartilage damage in femoroacetabular impingement 

(FAI): preliminary results on comparison of standard diagnostic vs delayed 

gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC). 

Osteoarthritis Cartilage, 2009. 17(10): p. 1297-306. 

77 




5. Bittersohl, B., et al., Feasibility of T2* mapping for the evaluation of hip 

joint cartilage at 1.5T using a three-dimensional (3D), gradient-echo (GRE) 

sequence: a prospective study. Magn Reson Med, 2009. 62(4): p. 896-901. 

6. Watanabe, A., et al., T2 mapping of hip articular cartilage in healthy 

volunteers at 3T: a study of topographic variation. J Magn Reson Imaging, 

2007. 26(1): p. 165-71. 

7. Carballido-Gamio, J., et al., Feasibility and reproducibility of relaxometry, 

morphometric, and geometrical measurements of the hip joint with 

magnetic resonance imaging at 3T. J Magn Reson Imaging, 2008. 28(1): p. 

227-35.

78 

CurreNt CoNtroverSieS iN tJa (e) 




Moderator: Thomas P. Vail, MD, San Francisco, CA 

This symposium will review current controversies in primary and total hip arthroplasty in debate format and with case based 

panel discussions. 

I. THA Bearing Surface Options – Interpreting The Latest Data 

a. Highly Cross-linked Polyethylene - a stellar early track record. What does the future hold? 

Jay R. Lieberman MD, Farmington, CT 

b. Ceramic on Ceramic - newer and tougher materials. Can the problem with noise be understood and managed? 

William J. Hozack MD, Philadelphia, PA 

c. Metal on Metal: Low wear and stable, will metal ion issues derail this technology? 

Keith Berend, MD, New Albany, OH 

II. Does Hip Resurfacing Have a Role For The Young Active Patient? 

a. Affirmative: 

Thomas P. Vail, MD, San Francisco, CA 

b. Negative: 

Paul F. Lachiewicz MD, Chapel Hill, NC 

III. Displaced Femoral Neck Fractures: THA for All 

a. Affirmation: 

Carlos J. Lavernia, MD, Coral Gables, FL 

b. Negative: 

Javad Parvizi, MD, Philadelphia, PA 

Case discussions and questions 

IV. High Flexion TKA - Is it Technology Over Reason? 


Daniel J. Berry, MD, Rochester, MN 

b. Negative: 

Craig J. Della Valle, MD, Chicago, IL 

V. Highly X-Linked Polyethylene is Optimal for TKA 


Terence J. Gioe, MD, Apple Valley, MN 

b. Negative: 

David G. Lewallen, MD, Rochester, MN 

VI. Patella Resurfacing Is Not Necessary 


Robert L. Barrack, MD, Saint Louis, MO 

b. Negative: 

Thomas K. Fehring MD, Charlotte, NC 

Case discussions and questions.

79 

highly CroSSliNked polyethyleNe: 

a SaFe ChoiCe but iS there trouble loomiNg? 

Jay R. Lieberman, MD 

I. Highly Cross Linked Polyethylene (XLP) 

A. Properties 

1. Reduce particle load by reducing wear volume which 

will lead to a decrease in the incidence of osteolysis and 

aseptic loosening 

2. XLP is manufactured by irradiating UHMWPE with 

gamma irradiation or electron beam irradiation and 

the free radicals that are created are removed by a heat 

treatment or an annealing phase 

3. Cross linking enhances the wear resistance of UHMWPE 

but also decreases its mechanical properties (i.e. fatigue 

crack propagation resistance) 

B. Advantages of XLP 

1. The development of XLP is not a radical departure from 

prior polyethylene. The irradiation has been increased to 

improve the wear resistance 

2. Flexibility 

a. Multiple liner options-elevated rim, lateralized liners, 

protrusio 

b. Multiple head sizes available with numerous head/ 

neck options 

c. Impingement – probably increases wear but in 

general is fairly well tolerated 

3. Low cost 

4. Not a hard on hard bearing 

a. No fractures of head or liner (i.e. ceramic on ceramic) 

b. No generation of metal ions or induction of 

hypersensitivity reactions (i.e. metal on metal) 

c. Probably tolerates malposition better than hard on 

hard bearings 

C. Disadvantages of XLP 

1. Reduced mechanical properties 

2. Increased wear compared with hard on hard bearings 

II. Laboratory Data 

A. XLP liners have been tested extensively in hip simulators 

B. Components manufactured with either gamma irradiation 

or electron beam irradiation demonstrated minimal wear 

even out to 12 million cycles. 

REFERENCES 

1. Digas G, Karrholm J, Thanner J, et al. Highly cross-linked polyethylene in 

total hip arthroplasty. Clin Orthop. 429: 6-16. 2004 

2. Dorr LD, Wan Z, Shahrdar C, Sirianni L, et al. Clinical Performance of a 

Durasul highly cross-linked polyethylene acetabular liner for total hip 

arthroplasty at five years. J Bone Joint Surg Am. 87: 1816-21. 2005 

3. Engh CA Jr., Stepniewski AS, Ginn SD, et al. A randomized prospective 

evaluation of outcomes after total hip arthroplasty using cross-linked 

Marathon and non-cross linked Enduron polyethylene liners. J Arthroplasty. 

21 (Suppl 2):17-21. 2006 

4. Heisel C, Mauricio S, dela Rosa MA, Schmalzried TP. Short-term in vivo wear 

of crosslinked polyethylene. J Bone Joint Surg Am. 86: 748-751. 2004 

5. Martell J, Verner J, Incavo S. Clinical performance of a highly cross-linked 

polyethylene at two years in total hip arthroplasty: a randomized prospective 

trial. J Arthroplasty. 18: 55-59. 2003 




III. Clinical Data 

A. Data from multiple centers in both randomized trials and 

matched pair analyses demonstrate significant reductions in 

wear when comparing short-term performance (short and 

medium term follow-up) of cross-linked polyethylene versus 

conventional polyethylene. Some of the studies that will be 

reviewed are listed below. 

Martell et al, J Arthroplasty, 2003 

Digas et al, CORR, 2004 

Heisel et al, JBJS, 2005 

Dorr et al, JBJS, 2005 

Rohrl et al, J Arthroplasty, 2005 

Engh et al, J Arthroplasty , 2006 

Digas et al, Acta Orthop, 2007 

Bitsch et al, JBJS, 2008 

Engh et al, Hip Society, 2010 

Malchau et al, Hip Society 2010 

B. Femoral head size and wear of X linked polyethylene 

1. Lachiewicz et al (Clin Orthop; 2009)- The authors noted 

greater volumetric wear in patients with X linked liners 

with 36 and 40mm heads than with the small heads at a 

mean follow-up of 5-7 years. 

IV. Second Generation Cross-linked Polyethylenes 

A. Goal: Wear reduction with improved mechanical properties 

1. Use irradiation to cross-link the PE and an annealing 

phase below the melt temperature to maintain 

mechanical properties 

2. Need to eliminate free radicals 

3. Methods to eliminate free radicals 

a. Pharmacologic additives (i.e. vitamin E doping) 

b. Sequential low-dose irradiation and annealing 

c. Mechanical deformation 

4. These 2nd generation XLPE liners are now available 

Summary: Short term data demonstrates promising results 

will XLPE liners. Longer studies assessing the effect of thinner 

polyethylene ( ie larger head size) on wear rates are necessary. 

6. Oral E, Christensen SD, Malhi AS, Wannomae KK, Muratoglu OK. Wear 

resistance and mechanical properties of highly cross-linked, ultrahighmolecular 

weight polyethylene doped with vitamin E. J Arthroplasty. 21:580- 

91, 2006 

7. Digas G, Karrholm J, Thanner J, Herberts P. 5-year experience of highly crosslinked 

polyethylene in cemented and Uncemented sockets: two randomized 

studies using radiostereometric analysis. Acta Orthop. 78:746-54, 2007. 

8. Bitsch RG, Loidolt T, Heisel C, Ball S, Schmalzried TP. Reduction of osteolysis 

with use of Marathon cross-linked polyethylene. A concise follow-up, at a 

minimum of five year, of a previous report. J Bone Joint Surg Am. 90:1487- 

91, 2008. 

9. Lachiewicz PF, Heckman DS, Soileau ES, Mangla J, Martell JM. Femoral head 

size and wear of highly cross-linked polyethylene at 5 to 8 years. Clin Orthop 

Relat Res. 2009;467(12):3290-6. 

10. Malchau H. et al. Seven to Eleven Year Follow-Up of Highly Cross-linked 

Polyethylene Liners in Total Hip Arthroplasty. Hip Society, 2010. 

11. Engh C. et al. A prospective Randomized Study of Crosslinked and Noncrosslinked 

Polyethylene for THA at 10-year Follow-up. Hip Society 2010.

80 

CeramiC oN CeramiC - iNterpretiNg the lateSt data 

William Hozack, MD 

Squeaking - do we understand and can we manage this problem? 

Clinical performance - what are the results? 

New ceramic bearings - are we getting what we want? 

COC squeaking is a phenomenon that tends to develop at about 

one year after surgery and can be persistent and bothersome for 

the patient. There seems to be a wide variation in the incidence 

of squeaking. Some (D’Antonio, Murphy) report an incidence less 

than 1%, while others identify a very high incidence (Ranawat 

11%, Keurentjes 21%). At this time, there is no direct evidence that 

squeaking adversely affects longevity although squeaking is related 

to a higher rate of wear (Walter, JOA 2010) and there is a report of 

osteolysis in a squeaking ceramic hip with neck to rim impingement 

(Murali, JOA 2008). Restrepo (CORR, 2010) evaluated the natural 

history of squeaking - of 95 patients who developed a squeak, the 

intensity and frequency of squeaking did not change in most over 

time once it started. In 30% the squeaking noises diminished with 

time, but in none did it ever disappear entirely. 9 patients underwent 

revision surgery to eliminate the squeaking phenomenon. Revision 

for squeaking does not appear to compromise the result (Matar, JOA 

2010). The central cause of COC squeak is felt to be edge loading of 

the ceramic head on the ceramic liner. The primary source of this 

edge loading is likely to be impingement –either prosthetic neck 

to rim impingement or bone and soft tissue impingement. This 

leads to separation of the femoral head from the liner leading to 

edge loading. Edge loading leads to localized fluid-film break down 

creating a localized area of increased wear of the ceramic head (a 

wear scar or stripe), and increased friction. This results in increased 

frictional energy which is released through implant vibration - 

squeaking with a variety of activities. A recent study Chevillotte 

(CORR 2010) suggests that squeaking may result from titanium 

deposition within the bearing surface, which may develop if edge 

loading and impingement occurs. Component position is a key factor 

in edge loading and impingement. Walters (JBJS 2008) found that 

“squeakers” were more likely to have acetabular components placed 

outside the acceptable range of anteversion and abduction. This 

was confirmed by a recent analysis (Fraser, AAHKS, 2010) in which 

increased cup abduction or anteversion increased the incidence of 

squeaking. Component selection is also a factor in the incidence of 




squeaking. Our data found that squeaking was significantly higher 

with a TMZF femoral component with a V-40 neck diameter (8.6%) 

versus a TAV femoral component with a C-taper neck diameter 

(0.7%) (Restrepo, JBJS 2010). Other published data reflect this as 

well (Ranawat, Keurentjes). Acetabular component design also may 

play a role. The highest incidence of squeaking has occurred with 

acetabular components containing a ceramic insert with an elevated 

rim (Swanson, JOA 2010). It is my opinion that squeaking can be 

minimized, if not eliminated. Component position should be 

optimized to minimize impingement. This involves paying close 

attention to cup abduction and anteversion, as well as combined 

anteversion. Impingement should also be minimized by restoring 

hip offset and by eliminating any potential sources of impingement. 

Larger femoral heads may play a role as well. Proper seating of the 

liner inside the cup also must be ensured at the time of surgery. 

Some patients may not be well suited for a COC bearing - specifically 

small, flexible (usually female) patients - who force the surgeon to 

use smaller components with smaller femoral heads and who have 

tremendous ROM setting up a high potential for impingement and 

squeaking. 

Clinical performance of THA with COC bearings at longer 

followups is encouraging. A minimum 10 year study (Lee, JBJS 2010) 

demonstrated a 99% survivorship, but had 2% head fractures, no 

liner fractures, 1% squeaking, and fretting of the femoral neck in 

7%. A minimum 20 year study (Petsatodis, JBJS 2010) demonstrated 

a 85% survivorship, with no fractures of the ceramic bearing or head. 

Importantly, osteolysis is almost eliminated with the use of COC 

bearings. 

Newer COC bearings offer the potential of improved longevity with 

fewer complications related to squeaking (more resistant to stripe 

wear) and fracture (tougher) - one such material is an alumina 

composite with nano-sized zirconia particles. The other advantage 

related to the toughness of the new bearing is that it is possible to 

reduce the bearing thickness, thereby allowing the surgeon to use 

a larger diameter femoral head with smaller cup sizes, in theory 

reducing the risk of impingement, stripe wear, and instability. The 

published studies are short-term, so provide little information 

regarding the longevity issue. The two published studies (Hamilton 

CORR 2010, Lombardi CORR 2010) demonstrated persistent issues 

related to ceramic fractures.

81 

metal oN metal: low wear aNd Stable - 

will metal ioN iSSueS derail thiS teChNology? 

Conventional polyethylene was plagued by wear induced osteolysis, 

and both early and late dislocation. These two factors have been 

the driving force in the search for an optimal bearing. Metal-onmetal 

(MoM) articulations have a long record of use and offer low 

wear, larger head size, and increased stability. However, there are 

increasing reports and growing concerns surrounding the issues 

of implant design related failures, failure of ingrowth, metallosis, 

pseudotumors, hypersensitivity and unexplained pain occurring in 

patients with MoM THA. 

We examined experience with 3 different MoM THA designs to 

examine survivorship at minimum 2-year follow-up and extrapolate 

the failure modes with differences in implant design. A retrospective 

review of all primary THA performed at our institution from 1996 

to 2006 identified 1590 THA in 1365 patients done utilizing 3 

different metal-on-metal implant designs. Design 1 represents 

a titanium (Ti) shell with Porous Plasma Sprayed (PPS) coating 

mated with a chromium cobalt (CoCr) tapered insert of 28- or 32 

mm inner diameter. Design 2 is a CoCr monoblock shell with Ti- 

PPS surface coating, a standard head diameter of 38mm, and wall 

thickness increasing with outer diameter. Design 3 is a resurfacing 

style monoblock cup of CoCr with Ti-PPS surface coating, a constant 

wall thickness of 3mm for an effective outer diameter 6mm larger 

than the femoral head, with head sizes available from 40- to 60mm. 

Minimum 2year follow-up was available for 1211 THA (76%) in the 

overall series. Of the 1211 THA with minimum 2-year follow-up, 583 

were in female patients and 628 were in males. 

Overall, our experience with MoM articulations has yielded a 94.9% 

survivorship at an average of 60 months. Follow-up was longest for 

Design 1, followed by Design 2 then Design 3. Design 2 demonstrated 

significantly higher early mechanical failure including failure of 

bony ingrowth or subsidence (3.5%, defined as aseptic loosening), 

than the titanium shell (Design 1: 1.7%; p

8. Griffin WL, Nanson CJ, Springer BD, Davies MA, Fehring TK.Reduced 

articular surface of one-piece cups: a cause of runaway wear and early failure. 

Clin Orthop Relat Res. 2010 Sep;468(9):2328-32. 

9. Jacobs JJ, Urban RM, Hallab NJ, Skipor AK, Fischer A, Wimmer MA. Metalon-metal 

bearing surfaces. J Am Acad Orthop Surg. 2009 Feb;17(2):69-76. 

10. Jeffers JR, Roques A, Taylor A, Tuke MA. The problem with large diameter 

metal-on-metal acetabular cup inclination. Bull NYU Hosp Jt Dis. 

2009;67(2):189-92. 

11. Latteier MJ, Berend KR, Lombardi AV Jr, Ajluni AF, Seng BE, Adams JB. 

Gender is a significant factor for failure of metal-on-metal total hip 

arthroplasty. J Arthroplasty. (In submission). 

12. Lombardi AV Jr, Mallory TH, Cuckler JM, Williams J, Berend KR, Smith 

TM. Mid-term results of a polyethylene-free metal-on-metal articulation. J 

Arthroplasty. 2004 Oct;19(7 Suppl 2):42-7. 

13. Lombardi AV Jr, Skeels MD, Berend KR, Adams JB, Franchi OJ. Do large 

heads enhance stability and restore native anatomy in primary total hip 

arthroplasty? Clin Orthop Relat Res. 2010 Oct 16. [Epub ahead of print] 

14. Molli RG, Lombardi AV Jr, Berend KR, Adams JB, Sneller MA. Metal-on-metal 

versus metal-on-improved polyethylene bearings in total hip arthroplasty. J 

Arthroplasty. (In submission). 

82 




15. Ng VY, Lombardi AV Jr, Berend KR, Skeels MD, Adams JB. Perivascular 

lymphocytic infiltration is not limited to metal-on-metal bearings. Clin 

Orthop Relat Res. 2010 Sep 28. [Epub ahead of print] 

16. Ollivere B, Darrah C, Barker T, Nolan J, Porteous MJ. Early clinical failure of 

the Birmingham metal-on-metal hip resurfacing is associated with metallosis 

and soft-tissue necrosis. J Bone Joint Surg Br. 2009 Aug;91(8):1025-30. 

17. Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons 

CL, Ostlere S, Athanasou N, Gill HS, Murray DW. Pseudotumours 

associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008 

Jul;90(7):847-51. 

18. Park YS, Moon YW, Lim SJ, Yang JM, Ahn G, Choi YL. Early osteolysis 

following second-generation metal-on-metal hip replacement. J Bone Joint 

Surg Am. 2005 Jul;87(7):1515-21. 

19. Vendittoli PA, Roy A, Mottard S, Girard J, Lusignan D, Lavigne M. Metal ion 

release from bearing wear and corrosion with 28 mm and large-diameter 

metal-on-metal bearing articulations: a follow-up study. J Bone Joint Surg Br. 

2010 Jan;92(1):12-9. 

20. Williams S, Leslie I, Isaac G, Jin Z, Ingham E, Fisher J. Tribology and wear of 

metal-onmetal hip prostheses: influence of cup angle and head position. J 

Bone Joint Surg Am. 2008 Aug;90 Suppl 3:111-7

83 

doeS hip reSurFaCiNg have a role For the youNg aNd 

aCtive patieNt? – aFFirmative 

Thomas Parker Vail, MD 

I. Introduction. 

A. Hip resurfacing is the only available hip arthroplasty option 

that allows femoral bone conservation. 

B. The ideal candidate has been refined and narrowed 

through analysis of clinical outcomes reports in case series, 

international joint registries, and retrieval studies. iii 

II. Indications 

A. Based upon the reported experience, the optimal patient for 

resurfacing has excellent femoral neck bone quality, is under 

55 years of age, has minimal biomechanical alteration due 

to bone loss or remodeling, and has a larger than average 

femoral head size. iii,iv,v 

B. a patient who benefits from a metal bearing is one who is at 

risk for wear of a polyethylene bearing due to young age or 

high use 

C. Both the diagnosis of developmental dysplasia and 

osteonecrosis have been reported to have increased rates of 

early failure than osteoarthritis patient cohorts 

III. Contraindications 

A. Surface replacement is contraindicated in patients with 

inadequate femoral head, neck or acetabular bone. 

1. The definition of inadequate bone may include 

osteoporosis of the femoral neck, large cysts of the 

femoral head or neck (especially cysts >10-12 mm or 

cysts located at the osteo-articular junction where stress 

transfer is high after resurfacing) 

2. primary or metastatic neoplasms, active infection, posttraumatic 

arthrosis with extensive femoral neck bone loss 

3. large segments of osteonecrosis of the femoral head with 

collapse of the head into the neck, or proximal femoral 

deficiencies. 

B. Another important contraindication to resurfacing is a 

situation where the patient may be at risk for an adverse 

reaction to the metal substrate of the implant. 

1. These cases are uncommon (the exact incidence is not 

clearly defined, and varies geographically) but difficult or 

impossible to predict. 

2. Exposure to high levels of metal ions has been associated 

with aggressive, non-cancerous soft tissue reactionsvi and 

hypersensitivity reactions in a small number of patients. vii 

a) The majority of the cases reported in the largest series 

are female 

b) no other significant demographic or biologic 

similarities among these patients have been 

consistently identified to date. viii 

C. Another category of patients who assume additional risk 

with hip resurfacing is the group of women who might 

become pregnant after hip resurfacing. 

1. Detrimental effects of metal ions on a fetus have not 

been demonstrated and the exact risk is not known 

2. it is known that metal ions will cross the placenta. 

D. Patients with known sensitivity to metal, renal insufficiency 

(which interferes with elimination of metal ions), or women 

of child bearing age may not be ideal candidates for hip 

resurfacing 

IV. Life expectancy 




A. The average age of a hip resurfacing patient is 47 years.ix 

1. Using the National Vital Statistics Reports, a patient at 40 

years of age has approximately an additional 40-year life 

expectancy. 

2. For a 55 year old patient, the life expectancy is 26.6 years. x 

V. Bone conservation. 

A. A hip resurfacing obviously saves bone on the femoral side 

because of the conservative initial cuts. 

B. An additional consideration is that bone loss due to stress 

shielding is minimized in hip resurfacing compared to total 

hip replacement. 

1. This phenomenon is demonstrated in in vivo models 

using photoelastic coatings or finite element modeling,xi 

and from bone density analysis of patients with hip 

resurfacing devices implanted. 

VI. Biomechanical restoration. 

A. Hip resurfacing can correct some common biomechanical 

and functional problems. xii 

B. According to some reports, a surgeon is more likely to 

lengthen a leg with a total hip and more likely to shorten 

with a hip resurfacing. xiii,xiv 

C. There are many cases where hip resurfacing is not 

appropriate or not the best implant choice due to 

biomechanical considerations. These situations include: 

1. when the femoral neck is shortened or mal-oriented a 

total hip is a better option. 

2. a long neck, high offset, and a metaphyseal diaphyseal 

mismatch, 

3. retained internal fixation hardware where the hip 

resurfacing does a better job of restoring the mechanics 

or avoiding hardware that could complicate standard 

implant insertion. 

4. In cases where the biomechanics are abnormal on the 

acetabular side, a hip resurfacing allows the surgeon to 

bring the hip center down and medially towards the 

anatomic hip center, thereby restoring leg length and 

joint mechanics. 

5. cases of high dislocation such as Crowe III and IV 

developmental dysplasia cases associated with segmental 

bone loss that could compromise the fixation of a 

monoblock acetabular component are not ideal for hip 

resurfacing 

6. inadequate acetabular bone available to securely 

and solidly implant a monoblock resurfacing cup 

in developmental dysplasia, and large area of head 

involvement or collapse in osteonecrosis should 

disqualify patients from consideration for hip 

resurfacing. 

VII. Functional outcome. 

A. a large femoral head is more resistant to dislocation, 

and perhaps has a better range of movement than hip 

resurfacing. 

B. some data suggesting that the gait mechanics, abductor 

moment and ground reaction force may be improved 

with hip resurfacing compared to large head total hip 

replacement. xv

VIII. Complications 

A. the procedure is technically demanding, as is reflected by the 

complications reported in the initial clinical experience in 

the United States. xvi,xvii 

B. the success of hip resurfacing is very dependent upon 

technical details. xviii,xix,xx 

C. Hip resurfacing has some unique complications associated 

with the procedure 

1. femoral neck fracture. xxi,xxii,xxiii,xxiv 

D. some hip resurfacing failures may be within the power of the 

surgeon to control. xxv 

E. Retrieval analysis shows that failures are related to damage 

to the femoral neck during surgery (notching and fracture), 

poor cement technique (failure to achieve cementbone 

integration, or excessive cement penetration), and 

incomplete component seating. xxvi 

1. Higher wear rates noted in retrieval analysis correlate 

with more vertical and anteverted socket position. 

Nevertheless, anteversion and inclination together 

explain only 30% of the variation in wear rate. 

2. This finding strongly implies that other factors such 

as subluxation due to impingement, or rim loaded 

situations causing secondary implant edge damage and 

corrosion might play a role in ion release. 

3. When the resurfacing bearing functions as intended, the 

wear rates are very low. 

4. Elevation in metal ion levels may serve as a marker for 

bearing malfunction or implant loosening xxvii 

5. Lymphocytic infiltrates have been found in high-wearing 

retrievals. Longer exposure to high metal levels or delayed 

type hypersensitivity in a subset of susceptible patients 

could lead to a higher incidence of adverse soft tissue 

reaction over time. 

6. Recent data indicates that the majority of tissue reactions 

are associated with high metal ion levels. 

IX. Revision. 

A. The complexity of the revision is dictated by the reason for 

revision, with poorer outcomes in cases associated with 

damage to soft tissues. 

B. Most revisions of hip resurfacing components are related to 

femoral neck fracture or acetabular loosening. 

REFERENCES 

i. Amstutz HC, Le Duff MJ, Campbell PA, Dorey FJ. The effects of technique 

changes on aseptic loosening of the femoral component in hip resurfacing. 

Results of 600 Conserve Plus with a 3 to 9 year follow-up. J Arthroplasty. 

2007;22:481-489. 

ii. Pollard TC, Baker RP, Eastaugh-Waring SJ, Bannister GC. Treatment of the 

young active patient with osteoarthritis of the hip. A five- to seven-year 

comparison of hybrid total hip arthroplasty and metal-on-metal resurfacing. 

J Bone Joint Surg Br. 2006;88:592-600. 

iii. Beaule PE, Dorey FJ, LeDuff M, et al: Risk factors affecting outcome of metalonmetal 

surface arthroplasty of the hip. Clin Orthop 2004:87-93, 2004 

iv. Sibanda N, Copley LP, Lewsey JD, et al: on behalf of the Steering Committee 

of the National Joint Registry (NJR) for England and Wales: Revision Rates 

after Primary Hip and Knee Replacement in England between 2003 and 

2006. PLoS Med. Sep 2;5(9):e179, 2008 

v. Australian Orthopaedic Association National Joint Replacement Registry. 

Annual Report 2008. Adelaide: AOA: 2008. Available at www.aoa.org.au 

vi. Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons 

CL, Ostlere S, Athanasou N, Gill HS, Murray DW. Pseudotumours associated 

with metal-onmetal hip resurfacings. J Bone Joint Surg Br. 2008;90:847-851. 

vii. Campbell P, Shimmin A, Walter L, Solomon M. Metal sensitivity as a cause of 

groin pain in metal-on-metal hip resurfacing. J Arthroplasty. 2008;23:1080- 

1085. 

84 




C. When the revision necessitated due to the more rare cases 

of soft tissue damage due to metal ion toxicity,xxviii the 

results could be quite different for either a total hip or a hip 

resurfacing conversion. xxix,xxx 

D. With regard to retention of the acetabular component, when 

a new femoral head is combined with an existing socket, 

wear simulator analysis shows that there is a secondary runin 

phase with the bearing that is about 80% of the initial 

run-in phase. 

X. Literature and registry data. 

A. The metal-on-metal hip resurfacing devices in common use 

today were introduced into clinical practice within the last 

decade. 

B. Published literature includes investigator and designing 

surgeon reports, non-designer case series, registry data, and 

limited prospective and randomized studies . xxxi,xxxii,xxxiii.xxxiv 

C. The synopsis of world experience indicates that patient 

selection, surgeon experience, and surgical technique are 

extremely important variables impacting the outcome. xxxv 

D. Registry data supports the concept that operations performed 

on younger patients, with larger size implants, and perhaps 

male gender by more experienced surgeons are associated 

with a lower risk of early failure. 

1. Newer registry data show overall failure rates that are not 

as good as the best published series 

a) In the U.K total joint registry, the revision rate for hip 

resurfacing is 2.6 overall at 3 years, but for males, the 

three-year revision rate for resurfacing is less than 

cementless total hip. 6 

b) Australian registry data from 2008, while the overall 

revision rate for resurfacing is high, in the males 

under 55 years of age out to seven years after surgery, 

the revision rate for resurfacing is lower than for total 

hip replacement. 7 

c) The advantage for hip resurfacing in both the 

Australian registry and the UK registry has not held up 

in the 2010 publications 

E. There is variability in results depending upon the device, the 

surgeon, and the location of surgery 

viii.Mabilleau G, Kwon YM, Pandit H, Murray DW, Sabokbar A. Metal-on-metal 

hip resurfacing arthroplasty: a review of periprosthetic biological reactions. 

Acta Orthop. 2008;79:734-74 

ix. Vail TP. Mina CA. Yergler JD. Pietrobon R. Metal-on-metal hip resurfacing 

compares favorably with THA at 2 years followup. Clin Orthop. 453:123-31, 

2006 

x. National Center for Health Statistics, Health, United States 2008. Available 

at www.cdc.gov/nchs/data 

xi. Vail TP, Glisson RR, Dominguez DE, et al: Position of hip resurfacing 

component affects strain and resistance to fracture in the femoral neck. J 

Bone Joint Surg Am 90:1951-1960, 2008 xii Loughead JM, Chesney D, 

Holland JP, McCaskie AW: Comparison of offset in Birmingham hip 

resurfacing and hybrid total hip arthroplasty. J Bone Joint Surg Br. 87:163- 

166, 2005 

xiii. Girard J, Lavigne M, Vendittoli PA, et al: Biomechanical reconstruction of 

the hip: a randomised study comparing total hip resurfacing and total hip 

arthroplasty. J Bone Joint Surg Br. 88:721-726, 2006 

xiv. Pollard TC, Baker RP, Eastaugh-Waring SJ, et al: Treatment of the young active 

patient with osteoarthritis of the hip. A five- to seven-year comparison of 

hybrid total hip arthroplasty and metal-on-metal resurfacing. J Bone Joint 

Surg Br. 88:592-600, 2006 

xv. Queen RM, Abbey AN, Sabesan V, et al. Gait symmetry: hip resurfacing 

versus total hip arthroplasty (unpublished data).

xvi. Della Valle CF, Nunley RM, Raterman SJ, Barrack RL. Initial american 

experience with hip resurfacing following FDA approval. Clin Orthop Relat 

Res (2009) 467:72-78. 

xvii.Stulberg BN, Trier KK, Naughton M, Zadzilka JD. Results and lessons learned 

from a United States hip resurfacing investigational device exemption trial. J 

Bone Joint Surg Am 2008;90:21-26. 

xviii. 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 Conserve Plus with a 3 to 9 year follow-up. J Arthroplasty 

22:481-489, 2007 

xix. Mont MA, Seyler TM, Ulrich SD, et al. Effect of changing indications and 

techniques on total hip resurfacing. Clin Orthop 465;63-70, 2007 

xx. Stulberg BN, Trier KK, Naughton M, et al: Results and lessons learned from a 

United States hip resurfacing investigational device exemption trial. J Bone 

Joint Surg Am 90:21-26, 2008 

xxi. Morlock MM, Bishop N, Zustin J, et al: Modes of implant failure after hip 

resurfacing: morphological and wear analysis of 267 retrieval specimens. J 

Bone Joint Surg Am 90 Suppl 3:89-95, 2008 

xxii.Shimmin AJ, Back D: Femoral neck fractures following Birmingham hip 

resurfacing: a national review of 50 cases. J Bone Joint Surg Br. 87:463-464, 

2008 

xxiii. Shimmin AJ, Bare J, Back DL: Complications associated with hip resurfacing 

arthroplasty. Orthop Clin North Am. 36:187-193, 2005 

xxiv. Marker DR, Seyler TM, Jinnah RH, et al: Femoral neck fractures after metalon-metal 

total hip resurfacing: a prospective cohort study. J Arthroplasty. 

22:66-71, 2007 xxv De Haan R, Campbell PA, Su EP, et al : Revision of metalon-metal 

resurfacing arthroplasty of the hip: the influence of malpositioning 

of the components. J Bone Joint Surg Br. 90:1158-1163, 2008 

85 




xxvi. Morlock MM, Bishop N, Zustin J, Hahn M, Ruther W, Amling M. Modes of 

implant failure after hip resurfacing: morphological and wear analysis of 267 

retrieval specimens. J Bone Joint Surg Am. 2008;90 Suppl 3:89-95. 

xxvii. DeSmet K, DeHaan R, Calistri A, et al. Metal ion measurement as a 

diagnostic tool to identify problems with metal-on-metal hip resurfacing. J 

Bone Joint Surg Am 2008;90:202-208. 

xxviii. Zustin J, Amling M, Krause M, et al: Intraosseous lymphocytic infiltrates 

after hip resurfacing arthroplasty : a histopathological study on 181 retrieved 

femoral remnants. Virchows Arch. 454:581-588, 2009 

xxix. Campbell P, Shimmin A, Walter L, Solomon M. Metal sensitivity as a cause 

of groin pain in metal-on-metal hip resurfacing. J Arthroplasty 23:1080- 

1085, 2008 

xxx.Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, et al: Pseudotumours 

associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 

90:847-851, 2008 

xxxi. Vail TP, Mont MA, McGrath MS, et al: Hip resurfacing: patient and treatment 

options. J Bone Joint Surg Am. 91 Suppl 5:2-4, 2009 

xxxii. Siebel T, Maubach S, Morlock MM. Lessons learned from early clinical 

experience and results of 300 ASR hip resurfacing implantations. Proc Inst 

Mech Eng H. 220:345353, 2006 

xxxiii. Della Valle CF, Nunley RM, Raterman J, et al: Initial american experience 

with hip resurfacing following FDA approval. Clin Orthop 467:72-78, 2009 

xxxiv. Shimmin A, Beaule PE, Campbell P. Metal-on-metal hip resurfacing 

arthroplasty. J Bone Joint Surg Am. 2008;90:637-654. 

xxxv. Vail TP, Glisson RR, Dominguez DE, Kitaoka K, Ottaviano D. Position of 

hip resurfacing component affects strain and resistance to fracture in the 

femoral neck. J Bone Joint Surg Am 2008;90:1951-1960

86 

hip reSurFaCiNg iS the beSt For the youNg aCtive patieNt: 

Negative 

Paul F. Lachiewicz, MD 

The first decade of experience of modern metal-metal hip resurfacing 

(HR) has disclosed numerous problems and concerns that have not 

been a problem with conventional total hip arthroplasty (THA) 

using highly cross-linked polyethylene in young active patients. 

This presentation will focus on 5 particular problems: 

• Outcomes of HR compared to THA 

• Groin pain 

• Surgical learning curve 

• Rates of revision 

• Pseudotumour and other adverse complications 

Patient Outcomes Prospective Randomized Trials 

• No difference in hip scores, quality of life (Garbuz et al) 

• No difference in hip scores or most gait analysis parameters 

(Lavigne et al) 

Patient Outcomes Matched Pairs Studies 

Fowble et al 50 HR 50 THA 

• No difference in ROM or rate of dislocation 

• HR had higher function-activity level, but higher incidence of 

slight or mild pain 

Hall et al 33 HR 99 THA 

• No significant benefit for one group over the other 

Mont et al 54 HR 54 THA 

• No difference in pain, outcomes, complications, revision rates 

at 2-5 years 

• HR patients had higher postop weighed activity scores than THA 

(but higher preop scores) and some gait parameters 

Range of Motion and Impingement after HR and THA 

(Incavo et al J Arthroplasty 2010 epub) 

• Combined CT and cadaver simulation study ¥ HR had worse 

range of motion, higher rate of impingement, and greater risk of 

dislocation than conventional total hip! 

Groin Pain: An emerging serious problem after HR! 

Causes: Iliopsoas tendinitis 

Neck impingement 

Acetabular loosening 

Frequency: Nasser et al 18% (21 of 116 patients) 

10% limited ADL 

10% required pain medication 

Bartelt et al after conventional THA 7% 

Metal-metal THA 15% 

Hip resurfacing 18% (p=0.032) 

Patients with HR were more likely to have moderate or severe pain! 

SURGICAL LEARNING CURVE 

Non-experienced Surgeons 

1. North American safety study (Della Valle et al) 

• 537 BHR cases; 1 year data reported 449 HR 

• 40 adverse events (including 9 nerve palsies and 8 

dislocations) 

• Revision rate 3.1% (1st year) 

2. Multi-center Canadian Study (Kim et al) 

• 200 patients 

• 7% revision @ mean 19.5 months 

• 10/14 failures due to acetabular loosening 

3. Multicenter IDE Trial (Stulberg et al) 




• 337 Cormet¨ HRs 

• 24 revisions 7% 

Experienced Hip Surgeons (Nunley et al) 

• 650 HRs 5 surgeons 

• Complication rate only 2% 

• Learning curve for achieving desired component position: 

75-100 cases (or more)! 

Hip Resurfacing Revision Rates Registry Data 

Registry Revision rate 

Australian 3.7% 5yrs 

Swedish 3.4% 

England + Wales 1.8% 3yrs 

“Best available data” Revision rates after HR are 1.4 to 3.6 times 

higher than THA! McGrory et al AAOS Technology Overview 

JAAOS 2010 

Revisions of failed HR Same as primary THA? 

• Re-revision of revised failed HR 11% at 5 years! 

• Compared to 2.7% revision of primary THA @ 5yrs and 

8.2% re-revision THA @ 3yrs 

• Australian registry data (Corten + MacDonald) 

Adverse Reactions to Metal-Metal Articulation 

• Elevated metal ion levels 

• Hypersensitivity reactions 

• Pseudotumours 

• ALVAL type reactions 

Literature Search HR 2008-June 2010 

• 133 papers 32 papers (24.8%) related to adverse reactions 

14 Pseudotumour 

11 High metal levels 

7 Other adverse reactions 

Pseudotumours after Metal-metal HR (Glyn-Jones et al) 

• 1419 HR (1224 patients) 

• 1.8 % revision overall 

• At 8 years: 4% overall (95% CI: 2.2-5.8%) 

Men: 0.5% 

Women >40: 6% 

Women

3. Surgical learning curve remains formidable. 

4. Adverse tissue reactions and pseudotumours on the rise? 

5. Risks of metal-metal HR: revision rate and complications 

outweigh any possible benefit. 

6. Continue conventional THA in all patients. 

REFERENCES 

1. Bartelt RB, Yuan BJ, Trousdale RT, Sierra RJ.The prevalence of groin pain after 

metal-on-metal total hip arthroplasty and total hip resurfacing. Clin Orthop 

Relat Res 2010; 468: 2346-2356. 

2. Corten K, MacDonald SJ. Hip resurfacing data from national joint registries: 

what do they tell us? What do they not tell us? Clin Orthop Relat Res 2010; 

468:351-357. 

3. Della Valle CJ, Nunley RM, Raterman SJ, Barrack RL. Initial American 

experience with hip resurfacing following FDA approval. Clin Orthop Relat 

Res 2009; 467:72-78. 

4. Fowble VA, dela Rosa MA, Mylene A, Schmalzried TP. A comparison of total 

hip resurfacing and total hip arthroplasty-patients and outcomes. Bull Hosp 

Joint Dis 2009; 67: 108-112. 

5. Garbuz DS, Tanzer M, Greidanus NV, Masri BA, Duncan CP. Metal-onmetal 

hip resurfacing versus large-diameter head metal-on-metal total hip 

arthroplasty A randomized clinical trial. Clin Orthop Relat Res 2010; 468: 

318-323. 

6. Glyn-Jones S, Pandit H, Kwon Y-M,Doll H, Gill HS, Murray DW. Risk factors 

for inflammatory pseudotumour formation following hip resurfacing. J Bone 

Joint Surg 2009; 91-B: 1566-1574. 

7. Grammatopolous G, Pandit H, Kwon Y-M, Gundle R, McLardy-Smith P, 

Beard DJ, Murray DW, Gill HS. Hip resurfacings revised for inflammatory 

pseudotumour have a poor outcome. J Bone Joint Surg 2009: 91-B: 1019- 

1024. 

8. Hall DP, Srikantharajah D, Anakwe RE, Gaston P, Howie CR. Patient-reported 

outcome following metal-on-metal resurfacing of the hip and total hip 

replacement. Hip International 2009; 19: 245-250. 

87 




9. Incavo SJ, Thompson MT, Gold JE, Patel RV, Icenogle KD, Noble PC. Which 

procedure better restores intact hip range of motion: total hip arthroplasty 

or resurfacing? A combined cadaveric and computer simulation study. J 

Arthroplasty 2010; in press, epub. 

10. Kim PR, Beaule PE, Laflamme GY, Dunbar M. Causes of early failure in a 

multicenter clinical trial of hip resurfacing. J Arthroplasty 2008; 23(Suppl 1): 

44-49. 

11. Lavigne M, Therrien M, Nantel J, Roy A, Prince F, Vendittoli PA. the 

functional outcome of hip resurfacing and large-head THA is the same A 

randomized clinical trial. Clin Orthop Relat Res 2010; 468: 326-336 

12. McGrory B, Barrack R, Lachiewicz PF, Schmalzried TP, Yates AJ, Watters WC, 

Turkelson CM, Wies JL, St. Andre J. AAOS technology overview Modern 

metal-onmetal hip resurfacing. J Am Acad Orthop Surg 2010; 18: 306-314. 

13. Mont MA, Marker DR, Smith JM, Ulrich SD, McGrath MS. Resurfacing is 

comparable to total hip arthroplasty at short-term follow-up. Clin Orthop 

Relat Res 2009; 467: 66-71. 

14. Nasser AB, Beaule PE, O’Neill ME, Kim PR, Fazekas A. Incidence of groin 

pain after metal on metal hip resurfacing. Clin Orthop Relat Res 2010; 468: 

392-399. 

15. Nunley RM, Zhu J, Brooks PJ, Engh Jr, CA, Raterman SJ, Rogerson JS, Barrack 

RL. The learning curve for adopting hip resurfacing among hip specialists. 

Clin Orthop Relat Res 2010; 468: 382-391. 

16. Stulberg BN, Trier KK, Naughton M, Zadzilka JD. Results and lessons learned 

from a United States hip resurfacing investigational device exemption trial. J 

Bone Joint Surg 2008; 90-A (Suppl 3): 21-26.

Issues 

• Resolution of pain 

• Restoration of function 

88 

diSplaCed Femoral NeCk FraCtureS: tha For all 

(aFFirmative) 

Carlos J. Lavernia, MD 

Operative Procedure 

Complexity, Host, and Surgeon Experience 

• Internal Fixation: Less Blood Loss and Operative Time 

— Complications 

— Reoperations 

Internal Fixation THA 

42% 4% 

Internal Fixation THA 

47% 4% 

Perioperative Complications: OR time, Blood Loss 

Perioperartive complications THR 

• Loss of fixation components 

• Nerve Damage 

• Dislocation 

• Loosening with time 

Perioperative complications ORIF 

• Loss of Fixation 

Post Operative Function 

• THR 

— Young --- Restrictions impact loading 

— Old ----Faster return to preactivity level 

• ORIF 

— Young --- Longer period NWB and with restrictions 

Back to all activities -- longer timeframe 

— Old ---Harder to be NWB 

Back to all activities –Longer time Frame 

Two Years ---THR vs ORIF 

• Pain and Function 

Worldwide National Registries 

THA use for femoral neck fractures (2005) 

• Sweden 8.6% 

• Norway 8.2% 

• Canada 4% 

• Australia 2.7% 

• England 1.2% 

In the United States (1997-2001): hemi vs. ORIF vs. THA 

Treatment for femoral neck fractures 




American Association of Hip and Knee Surgeons 

Treatment of Displaced Femoral Neck Fracture (2004) 

Long Term Results 

• Implant Survival 

• Pain 86% No Pain – Mild Pain 

• Complications 

— 17% Operative Complications 

— 10% Dislocations 

THA Versus Hemiarthroplasty: at 13 Years: 

• Revision Rate 

• Dislocations 

• Pain 

• Harris Hip Score 

Hemiarthroplasty THA 

24% 6.8% 


13% 20% 


45% 6% 


55% 80% 

Costs : Iorio et al. (2001): Costs 2 Years Postoperatively 

internal Fixation $24,606 

Unipolar Hemiarthroplasty $21,597 

Bipolar Hemiarthroplasty $22,043 

Hybrid THA $21,066 

Cemented THA $20,670 

Slover et al. (2009): Decision Model 

Average Cost Average QALY ICER* 

Hemiarthroplasty $38,100 4.44 

THA $41,100 5.97 $1,960 

ICER: Incremental Cost-Effectiveness Ratio. ($50,000 threshold to 

determine a cost-effective intervention)

Rogmark et al. (2003): Costs 2 Years Postoperatively 

89 

Internal Fixation $21,000 

THA $15,000 

Cognitively Impaired 

• High risk of dislocation in THA (32%) 

• Lower pain??? 

• Costs 

REFERENCES 

1. Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J. Comparison 

of internal fixation with total hip replacement for displaced femoral neck 

fractures. Randomized, controlled trial performed at four years. J Bone Joint 

Surg Am 2005;87-8:1680-8. 

2. Heetveld MJ, Rogmark C, Frihagen F, Keating J. Internal fixation versus 

arthroplasty for displaced femoral neck fractures: what is the evidence? J 

Orthop Trauma 2009;23-6:395-402. 

3. Hopley C, Stengel D, Ekkernkamp A, Wich M. Primary total hip arthroplasty 

versus hemiarthroplasty for displaced intracapsular hip fractures in older 

patients: systematic review. Bmj;340:c2332. 

4. Iorio R, Healy WL, Lemos DW, Appleby D, Lucchesi CA, Saleh KJ. Displaced 

femoral neck fractures in the elderly: outcomes and cost effectiveness. Clin 

Orthop Relat Res 2001-383:229-42. 

5. Iorio R, Schwartz B, Macaulay W, Teeney SM, Healy WL, York S. Surgical 

treatment of displaced femoral neck fractures in the elderly: a survey of the 

American Association of Hip and Knee Surgeons. J Arthroplasty 2006;21- 

8:1124-33. 

6. Jain NB, Losina E, Ward DM, Harris MB, Katz JN. Trends in surgical 

management of femoral neck fractures in the United States. Clin Orthop 

Relat Res 2008;466-12:3116-22. 

7. Johansson T, Bachrach-Lindstrom M, Aspenberg P, Jonsson D, Wahlstrom O. 

The total costs of a displaced femoral neck fracture: comparison of internal 

fixation and total hip replacement. A randomised study of 146 hips. Int 

Orthop 2006;30-1:1-6. 

8. Johansson T, Jacobsson SA, Ivarsson I, Knutsson A, Wahlstrom O. Internal 

fixation versus total hip arthroplasty in the treatment of displaced femoral 

neck fractures: a prospective randomized study of 100 hips. Acta Orthop 

Scand 2000;71-6:597-602. 

9. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison 

of reduction and fixation, bipolar hemiarthroplasty, and total hip 

arthroplasty. Treatment of displaced intracapsular hip fractures in healthy 

older patients. J Bone Joint Surg Am 2006;88-2:249-60. 

10. Lee BP, Berry DJ, Harmsen WS, Sim FH. Total hip arthroplasty for the 

treatment of an acute fracture of the femoral neck: long-term results. J Bone 

Joint Surg Am 1998;80-1:70-5. 




Johansson et al. (2006) 

Accumulated average cost within 2 years of the fracture 

Total Costs 

Lucid Cognitive Impaired* 

Internal Fixation EURO 14,000 EURO 11,000 

THA EURO 11,900 EURO 13,900 

* 29% Dislocation Rate 

11. Leonardsson O, Sernbo I, Carlsson A, Akesson K, Rogmark C. Long-term 

follow-up of replacement compared with internal fixation for displaced 

femoral neck fractures: results at ten years in a randomised study of 450 

patients. J Bone Joint Surg Br;92-3:406-12. 

12. Macaulay W, Pagnotto MR, Iorio R, Mont MA, Saleh KJ. Displaced femoral 

neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty. J 

Am Acad Orthop Surg 2006;14-5:287-93. 

13. Miyamoto RG, Kaplan KM, Levine BR, Egol KA, Zuckerman JD. Surgical 

management of hip fractures: an evidence-based review of the literature. I: 

femoral neck fractures. J Am Acad Orthop Surg 2008;16-10:596-607. 

14. Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus total 

hip arthroplasty for displaced subcapital fractures of femur-13 year results of 

a prospective randomised study. Injury 2000;31-10:793-7. 

15. Rogmark C, Carlsson A, Johnell O, Sembo I. Costs of internal fixation and 

arthroplasty for displaced femoral neck fractures: a randomized study of 68 

patients. Acta Orthop Scand 2003;74-3:293-8. 

16. Rogmark C, Spetz CL, Garellick G. More intramedullary nails 

and arthroplasties for treatment of hip fractures in Sweden. Acta 

Orthop;815:588-92. 

17. Sayana MK, Lakshmanan P, Peehal JP, Wynn-Jones C, Maffulli N. Total hip 

replacement for acute femoral neck fracture: a survey of National Joint 

Registries. Acta Orthop Belg 2008;74-1:54-8. 

18. Slover J, Hoffman MV, Malchau H, Tosteson AN, Koval KJ. A costeffectiveness 

analysis of the arthroplasty options for displaced femoral neck 

fractures in the active, healthy, elderly population. J Arthroplasty 2009;24- 

6:854-60. 

19. van den Bekerom MP, Hilverdink EF, Sierevelt IN, Reuling EM, Schnater 

JM, Bonke H, Goslings JC, van Dijk CN, Raaymakers EL. A comparison of 

hemiarthroplasty with total hip replacement for displaced intracapsular 

fracture of the femoral neck: a randomised controlled multicentre trial in 

patients aged 70 years and over. J Bone Joint Surg Br;92-10:1422-8.

90 

diSplaCed Femoral NeCk FraCture: tha For all 

Javad Parvizi MD, FRCS 

Introduction: 

The North American population is ageing. Projections show that 

by 2020, 16.3 percent of the U.S. population, and approximately 25 

percent of the Canadian population will be age 65 or over compared 

with fewer than 13 percent in this age group currently. According to 

statistics from World Health Organization, there has been a steady 

rise in life expectancy over the last decade. Currently life expectancy 

in North America is 75.9 years for men and 81 years for women. 

People are living nearly twice as long today than they lived in year 

1900 when life expectancy was 47.3 years. The most profound trend 

has been the disproportionate rise in the number of elderly patients. 

For example, the number of octogenarians rose 274% between 1960 

to 1994 with 3 million (1%) of the population in 1994 being 80 

years of age or older. This trend will continue. It is expected that by 

year 2050, 19 million (5%) of the population will be octogenarians 

or older. In fact people 85 and over are the most rapidly growing 

elderly age group in the population. 

Life expectancy is germane to joint replacement surgery as the 

prevalence of osteoarthritis of the hip and knee as well as hip fracture 

is related to ageing. That is, the older a population, the greater the 

prevalence of osteoarthritis and hip fractures. Each year more than 

five million people in the world sustain a hip fracture. 

Arthroplasty for Hip Fracture 

Joint arthroplasty continues to confer immense benefits to patients 

with hip fracture. In recent years evidence has emerged that total joint 

arthoplasty is the better option for patients with hip fracture leading 

to a decline in the use of hemiarthoplasty in these patients. I accept 

that THA compared to hemiarthoplasty offers better functional 

outcome and is associated with lower reoperation rate. I personally 

perform THA in most patients with displaced THA. However the 

following facts need to be born in mind when deciding which of 

these options to offer to our patients with displaced femoral neck 

fracture: 

1) Sudden Death: Previous studies have shown that patients with hip 

fracture are at risk of sudden death during or after hip arthroplasty. 

Extensive research has been performed in this field hat implicates 

fat and marrow embolization as the mitigating. Patients with hip 

fracture because of their underlying ospetopenia or osteoporosis 

have a wide and capacious venous canal that allows easier entry 

of fat and marrow emboli predisposing these patients to death. 

In one study, patients with hip fracture undergoing cemented 

hip arthroplasty were 200 times more likely to die than elective 

patients undergoing THA for osteoarthritis. Because of the rare, 

yet real, potential for mortality in hip fracture patients, there 

has been a trend toward the use of uncemented hip arthroplasty 

in this patient population. Interestingly the risk of mortality 

in patients with hip fracture, in one study was found to be 

significantly higher when the fracture is was intertrochanteric 

in nature and the patient was receiving total hip arthroplasty vs 

hemiarthroplasty. 

2) Instability: One of the major problems associated with THA in 

fracture patients is the increased incidence of instability. In fact 

the fear of instability averts many surgeons from performing total 

hip arrthroplasty in this patient population. Although lower, 

instability can still occur following hemiarthoplasty also. Registry 

data and multiple studies have shown the incidence of instability 

to be higher in patients undergoing hemiarthroplasty compared 




to THA. In particular patients in the following category may be at 

increased risk: 

a. History of neuromuscular disorder: As mentioned above, 

one of the major problems associated with THA for patients 

with hip fracture is instability. Patients with Alzheimer’s, 

Parkinson’s disease, previous cerebrovascular accidents that 

has resulted in global muscle weakness, and those with 

hyperlaxity syndromes are particularly at risk of dislocation 

after THA. 

b. History of alcoholism: The incidence of alcoholism is believed 

to be much higher among elderly that previously assumed. 

Thus patients with ongoing alcoholism may not be ideal 

candidates for THA. 

3) Expense: The number of patients with hip fracture is on the 

rise and this will place an immense burden on society. With the 

limited resources available, we may need to be cost-conscious 

in selecting the type of surgical procedures. There is no doubt 

that THA is more costly compared to hemiarthoplasty. The 

differential in cost is assumed to be between $500-1400 when 

an acetabular component is used. The latter is widely variable 

as some studies only consider the cost of acetabular component 

and not the added operative time and possibly higher incidence 

of reoperation asscociated with dislocation. In addition the type 

of bearing surface used in the acetabulum influences the cost. 

4) Expected Outcome: It is a well known fact that up to 25% of 

patients with femoral neck fraccture may die within one year 

of their fracture. Although the exact reason for higher mortality 

following hip fracture is not known, it is believed that the 

following patients are at risk of early death following femoral 

neck fracture. Hemiarthoplasty in this group of patients may be 

preferable to THA. 

a. Minimal ambulators- patients who are minimal (house) 

ambulators place minimal demand on their prosthesis and it 

is unlikely that the wear of acetabular cartilage would occur 

in these patients necessitating conversion to THA. In addition 

these patients may experience a rapid deterioration in their 

ambulation status following hip fracture which may lead to 

higher mortality. 

b. Patients with poor family support: In some studies this 

factor has been most strongly associated with early mortality 

following femoral neck fracture. 

c. History of cancer: Studies have shown that previous history of 

cancer is also strongly associated with mortality either during 

arthroplasty or within one year of hip fracture. Although 

some patients with previous cancer may be assumed to be 

“cured” of their disease, history of cancer should be a strong 

dissuading factor from placing an acetabular component in 

these patients 

d. Severe medical comorbidity: Elderly patients with extensive 

medical comrbidity are particularly at risk of mortality 

following hip fracture. Both based on reduced life expectancy 

in these patients and also the fact that expeditious surgery 

is likely to minimize the incidence of intraoperative and 

postoperative complications, one may choose to perform 

hemiarthoplasty compared to THA in this group of patients.

REFERENCES: 

1. U.S. Census Bureau. U.S. Interim Projections by Age, Sex, Race, and Hispanic 

Origin. Edited, 2004. 

2. Loh S, George MV. Projected Population Sizeand Age Structure for Canada 

and Provinces: With and Without International Migration. Canadian Studies 

in Population. 2007:34(2):103-27. 

3. World Population Prospects: The 2002 Revision. Edited, United Nations 

Population Division, 2002. 

4. Van den Bekerom MPJ, Hilverdink EF, Sierevelt IN, Reuling EMBP, Schnater 

JM, Bonle H, Goslings JC, van Dijk CN, Raaymakers ELFB. A comparison 

of hemiarthoplasty with total hip replacement for displaced intracapsular 

fracture of femoral neck. J Bone Joint Surg 92-B:1422-8, 2010 

91 




5. Bhandari M, Deveraux PJ, Tornetta P 3rd. Operative management of 

displaced femoral neck fracture in elderly patients: an international survey J 

Bone Joint Surg 87: 2122-30, 2005 

6. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized 

comparison of reduction and fixation, bipolar hemiarthoplasty, and total 

hip arthroplasty:treatment of displaced intracapsular hip fractures in healthy 

older patients. J Bone Joint Surg 88:249-60, 2006 

7. Blomfeldt R, Tornkvist H, Eriksson K. A andomized controlled trial 

comparing bipolar hemiarthoplasty with total hip replacement for displaced 

intracapsular fracture fractures of the femoral neck in elderly patients. J Bone 

Joint Surg 89-B: 16-5, 2007 

8. Parker MJ, Gurusamy K. Arthroplasties (with and without bone cement) for 

proximal fractures of adults. In: Cochrane Library 2006. Issue 3 CD001706, 

Chichester: John Wiley and Son 2008

92 

high FleXioN kNee: iS it teChNology over reaSoN? 

Daniel J. Berry, MD 

I. INTRODUCTION: 

A. Obtaining satisfactory motion to carry out activities of daily 

living is an important goal of TKA. For most activities of 

daily living in Western societies 105 to 110¡ of knee flexion 

allows satisfactory function. However, it is important to 

recognize that greater range of motion may be appreciated 

by many.2 For patients in some societies, and in selected 

patients in Western societies, obtaining considerably greater 

flexion is essential to their daily goals. So-called high flexion 

implants were designed to facilitate or enable flexion beyond 

120¡ (in most cases). The main design features to achieve 

this include modification of the posterior condyles of the 

femoral component, relief of anterior tibial polyethylene, 

and in some cases trochlear and/or cam-post modifications. 

II. PERFORMANCE OF HIGH FLEXION DESIGNS 

A. Range of Motion 

1. A number of early studies suggested that “high flexion” 

designs could provide better range of motion than 

conventional TKA. However, most studies were selected 

series of patients.8 

2. In the past several years a number of high quality Level 

I randomized clinical trials have evaluated the ROM 

performance of “high flexion” TKA versus conventional 

TKA. The results are listed below in Table I. In aggregate 

these studies suggest that “high flexion” TKA designs do 

not provide better ROM than conventional TKA. 

REFERENCES 

1. Cho SD, Youm YS, Park KB. Three to six year follow-up results after highflexion 

ktax: Can we allow passive deep knee bending. Knee Surg Sports 

Traumatol Arthroscopy 1-5, 2010. 

2. Devers BN, Conditt MA, Jamieson ML, Driscoll MD, Noble PC, Parsley BS. 

Does greater knee flexion increase patient function and satisfaction after total 

knee arthroplasty? J Arthroplaasty (in press). 

3. Hamilton WG, Engh Jr CA, Sritulanondha S. Prospective randomized 

comparison of high flex and standard rotating platform TKA. AAHKS 

Clinical Award Paper, AAHKS 20th Annual Meeting, Dallas, TX, November 

5-7, 2010. 

4. Kim YH, Choi Y, Kim JS. Comparison of a standard and a gender-specific 

posterior cruciate-substituting high-flexion knee prothesis: a prospective, 

randomized, short-term outcome study. J Bone Joint Surg 92A:19111920, 

2010. 




Table I. 

Author Year Study Type Results 

Hamilton et al 3 2010 RCT 

Kim et al 4 2010 RCT 

Kim et al 5 2010 RCT 

McCalden et al 6 2009 RCT 

Nutton et al 9 2008 RCT 

Mehin 7 2010 

Metaanalysis 

No difference in ROM 

Conventional vs High Flexion 









No ROM difference 


B. Implant Fixation 

1. Recently concerns have been raised that at least some 

“high flexion” designs may be associated with higher 

implant loosening rates.1 Some “high flexion” designs 

require extra posterior condylar resection and it is 

possible that in deep flexion the vector of force pushing 

the femoral component distally is greater than for 

conventional designs. 

C. Polyethylene Wear 

1. Studies to date are too short term to evaluate whether 

“high flexion” designs provide improved PE wear 

compared to conventional TKA. “High flexion” implants 

are designed to provide better PE congruity in deep 

flexion and this could improve PE wear in patients who 

achieve very high flexion. 

2. Whether many patients spend sufficient time in deep 

flexion for this design feature to prove to be a major 

advantage remains to be seen but could be one advantage 

of these implants. 

D. Other Issues 

1. Many “high flexion” designs require extra bone resection 

from the posterior femur. This is a drawback if revision is 

required. 

2. Many “high flexion” designs cost considerably more than 

their counterparts. 

5. Kim YH, Choi Y, Kim JS. Comparison of standard and gender-specific 

posterior cruciate retaining high-flexion total knee replacements: a 

prospective, randomized study. J Bone Joint Surg 92B:639-645, 2010. 

6. McCalden RW, MacDonald SJ, Bourne RB, Marr JT. A randomized controlled 

trial comparing “high flex” vs “standard” posterior cruciate substituting 

polyethylene tibial inserts in total knee arthroplasty. J Arthroplasty 24:33-38, 

2009. 

7. Mehin R, Burnett RS, Brasher PMA. Does the new generation of high-flex 

knee prostheses improve the postoperative range of movement? A metaanalysis. 

J Bone Joint Surg 92B:1429-1434, 2010. 

8. Murphy M, Journeaux S, Russell T. High-flexion total knee arthroplasty: a 

systematic review. International Orthop 33:887-893, 2009. 

9. Nutton RW, van der Linden ML, Rowe PJ, Gaston P, Wade FA. A prospective 

randomized double-blind study of functional outcome and range of flexion 

following total knee replacement with the NexGen standard and high flexion 

components. J Bone Joint Surg 90B:37-42, 2008.

93 

high FleXioN iN tka : teChNology over reaSoN—Negative 

Craig J. Della Valle, MD 

Introduction 

Total knee arthroplasty (TKA) remains the gold standard for treating 

end-stage arthritis of the knee that has been recalcitrant to nonoperative 

treatment. Although many outcome measures attest to the 

successfulness of the procedure, a substantial number of patients 

remain dissatisfied with the procedure despite objective findings that 

we interpret as success. Among the potential causes of dissatisfaction 

is limited range of motion. There is thus appeal in the idea of a 

specific device or version of a device that offers the hope of “high 

flexion”. However, concerns exist including: 

• Good quality trials that prove such claims of better range of 

motion 

• Increased cost of a high flexion design 

• Potential negative effects of a high flexion design 

High Flexion: Is it Necessary? 

The first question that needs to be answered is “Is it desirable to have 

higher flexion post TKA?”. The long and short of it is YES!!!! Stiffness 

is among the most common complaints following TKA and one of 

the outcomes that we as surgeons and our patients use to measure 

the success of the TKA that we have performed. 

• Improvement in range of motion (ROM) is a common desire 

for patients 

• ROM is among the main focuses of post-operative physical 

therapy. 

• Critical portion of our assessment (Knee Society Score). 

• Facilitates the resumption of many recreational activities that 

patient’s value. 

• High flexion may be critically important in certain cultures/ 

religions 

Although many of us believe that flexion of >110 degrees is a 

successful result, one study of more than 5,000 TKA by Ritter et. Al 

showed that patients with > 128 degrees of flexion had 

• Highest scores for pain, walking and function and the Highest 

overall KSS 

• Outcomes were compromised when ROM was < 118 degrees 

High Flexion: Making it Happen 

There seem to be several variables that effect range of motion 

including: 

• Patient related factors (specifically, pre-operative ROM seems 

critical). 

• Surgical technique and Post-Operative management 

• Prosthetic design? (By far, the most controversial). 

There are several aspects of the surgical technique that seem 

important: 

• Optimizing all aspects of your TKA!!! 

— Appropriate component size, rotation and slope 

SELECTED REFERENCES 

1. Ritter MA, Lutgring JD, Davis KE, Berend ME. The effect of postoperative 

range of motion on functional activities after posterior cruciate-retaining 

total knee arthroplasty. J Bone Joint Surg Am. 2008;90:777-784. 

2. Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. The role of pain and 

function in determining patient satisfaction after total knee replacement. 

Data from the National Joint Registry for England and Wales. J Bone Joint 

Surg Br. 2007;89:893-900. 




— Optimized ligamentous balancing 

— Recreation of appropriate patellofemoral kinematics 

— Removal of osteophytes and redundant capsule posteriorly 

• PS vs. CR does not seem to matter 

• Similarly RP does not seem to increase flexion (some studies 

suggest worse ROM) 

Post-operative protocols that optimize pain control also seem to 

result (at least in the short term) in better range of motion. 

• CPM and variants do not seem to results in long-term 

improvements in ROM. 

• Interestingly, most studies show that similarly physiotherapy 

does not have much of a beneficial effect. 

So what about “High Flexion” prosthetic designs? Do they make a 

difference? Most companies now either offer a “high flex” version or 

consider their designs as “high flexion”. Modifications to the femoral 

component including changes to the posterior condylar geometry, 

the sagittal geometry, femoral trochlea and/or the polyethylene 

are amongst the design features that either “allow” or “facilitate” 

flexion. 

What does the data show? Unfortunatley it is mixed… 

Author, Year Study Design Prosthesis Conclusion 

Choi, 2010 RCT, 170 TKA pS, Rp No difference 

Crow, 2010 Retrospective, 164 TKA CR High flex better 

Huang, 2005 Retrospective, 50 TKA pS High flex better 

Kim, 2005 100 TKA, bilateral study pS No difference 

Kim, 2009 108 TKA, bilateral study CR No difference 

Lee, 2010 Retrospective, 80 TKA (all 

< 100 degrees flexion 

preop) 

pS High flex better 

McCalden, 2009 RCT, 100 TKA pS No difference 

McCalden, 2010 Retrospective, 1534 TKA CR, pS High flex better 

Seon, 2009 RCT, 100 TKA CR No difference 

Weeden, 2007 RCT, 50 TKA pS High flex better 

Are there any concerns with a high flex design? 

• Increased cost? A real concern that may be dependent on pricing 

at your hospital. 

• Increased bony resection in some designs (is that really 

clinically relevant?) 

• Increased stresses on the poly/implant interfaces (more data is 

needed at longer fu) 

Conclusions: 

At this point, it is unclear if a high flexion design allows or actually 

can improve ROM. Further high quality studies will be required to 

answer this question and longer-term follow-up will be required 

to ensure that there are no detrimental effects of modifying the 

prosthetic design in the hopes of improving ROM. 

3. Bengs BC, Scott RD. The effect of patellar thickness on intraoperative knee 

flexion and patellar tracking in total knee arthroplasty. J Arthroplasty. 2006 

Aug;21(5):650-5. 

4. Ritter MA, Harty LD, Davis KE, Meding JB, Berend ME. Predicting range of 

motion after total knee arthroplasty. Clustering, log-linear regression, and 

regression tree analysis. J Bone Joint Surg Am. 2003 Jul;85-A(7):1278-85.

highly X-liNked poly iS the optimal beariNg SurFaCe For tka: 

aFFirmative 

Terence J. Gioe, MD 

1. Wear in TKA is multifactorial 

A. Patient factors (BMI, activity level) 

B. Surgeon factors (alignment, ligament balance) 

C. Component factors 

1. Poly thickness 

2. Sterilization method 

3. Locking mechanism 

4. Manufacturing technique 

5. Shelf life 

6. Component geometry/surfaces 

2. TKA Wear Mechanisms 

A. Wear mechanisms in TKA differ from THA because of the 

bearing surface and because of the combination of rolling, 

sliding, and rotational motions. Less contact area increases 

the contact stress which leads to delamination, pitting, and 

fatigue fractures 

3. UHMWPE is a semi-crystalline polymer with crystalline and 

amorphous phases: 

A. Crystalline phase results in: 

ductility 

elastic modulus 

contact stresses 

wear 

mechanical properties (strength, toughness) 

B. Amorphous phase results in: 

ductility 

elastic modulus 

contact stresses 

wear 

mechanical properties 

4. How is highly-crosslinked poly (HXLPE) manufactured? 

A. HXLPE = UHMWPE with covalent bonds (“cross-links”) 

between polymer chains in the amorphous phase (Ries & 

Pruitt, CORR 2005) 

B. Irradiating UHMWPE creates cross-links 

1. Cross-Linking induced ~25kGy (2.5Mrad) 

2. Irradiation dosing for purposes of sterilization ~25- 

40kGy (2.5-4Mrad) 

3. Irradiation dosing for purposes of cross-linking ~90- 

100kGy (9-10Mrad) 

4. HXLPE reduces wear in vitro as shown in multiple 

simulator studies 

6. There is a delicate balance between wear resistance and 

toughness 

A. Cross-linking improves wear resistance, but results in less 

ductility, and less resistance to crack propagation 

B. Radiation-induced HXLPE contains free radicals that increase 

oxidative degradation 

C. Free radicals can be eliminated by post-processing remelting 

or annealing 

D. Remelting results in decreased mechanical properties while 

annealing leaves residual free radicals 

E. 2nd generation HXLPE uses sequential annealing cycles or 

Vitamin E doping to reduce free radicals while preserving 

better mechanical properties 

7. What’s available for HXLPE inserts? 

94 




A. Durasul (Zimmer Natural Knee, 2001): 95 kGy 

B. E1 (Biomet Vanguard, 2008): 100 kGy, Vit E doped, 

annealed 

C. XLPE ( S & N): 75 kGy, remelted 

D. XLK (Depuy): 50 kGy, remelted 

E. Prolong (Zimmer): 65 kGy, remelted 

F. X3 (Stryker): 90 kGy sequentially annealed 

8. Can we make XHLPE strong enough? There have been 

numerous reports of tibial post fractures with UHMWPE 

inserts, so concern exists regarding crack propagation with 

HXLPE 

A. Oral et al (JOA, 2008) compared unaged and aged 

UHMWPE and Vit E-doped HXLPE in a tibial post model 

and found comparable bending resistance in the unaged 

samples and substantially improved bending resistance for 

the HXLPE in aged samples 

B. Stoller et al (JOA 2010) compared UHMWPE and HXLPE PS 

inserts (Prolong, Zimmer, Inc.) all aged, in knee simulator 

to 5m cycles 

1. Novel anterior/posterior testing of tibial post (unaged) 

2. Wear volume reduced 67-75% for HXLPE 

3. Superior post durability for HXLPE (longer fatigue life, p 

= .007 and 1/15 vs. 5/15 post fractures 

9. How about delamination concerns? 

A. Wannomae et al (JOA, 2010) compared unaged and 

aged UHMWPE and Vit-E doped HXLPE samples for 

delamination/pitting and found improved wear resistance 

and no delamination in the HXLPE samples, both aged/ 

unaged, compared to the UHMWPE 

10. Can we simulate wear better as we test poly in vitro? 

A. Muratoglu et al (JOA, 2007) simulated gait wear testing (7m 

cycles) of UHMWPE and HXLPE (Prolong, Zimmer, Inc.) 

CR inserts 

1. All components new; within 5 days 

2. Gravimetrically, combined articular and backside wear 

roughly 5X higher for UHMWPE 

3. Articular surface wear rates roughly 3X higher for 

UHMWPE 

11. There is relatively little information available from retrieval 

studies 

A. Willie et al ( J Biomedical Mater Res Part B, 2008) compared 

5 new HXLPE inserts (Durasul) and 5 new UHMWPE 

(Sulene, Zimmer) inserts to: 

1. 13 Durasul inserts implanted for 4-27 mos and ex vivo 

for 0-38 mos 

2. 18 Sulene inserts implanted for 4-158 mos and ex vivo 

3-40 mos 

B. “Oxidation index” measured at 1.5mm subsurface depth 

C. The OI was NOT significantly different for new and 

explanted Durasul inserts--shelf age, in vivo and ex vivo 

duration were not significant predictors 

D. The OI was significantly different for new and explanted 

Sulene inserts, and in vivo and ex vivo duration were 

predictors 

12. Clinical studies, in this time frame, are also limited 

A. Hodrick et al (CORR 466, 2008) performed a retrospective

95 

review of 100 cases with Durasul inserts with 100 

immediately preceding Sulene inserts, all in Natural 

Knees (Zimmer) 

B. Mix of CR and PS knees, cemented and uncemented 

C. Min/mean followup: 69/75 mos and 82/91 mos 

D. Standard group: 20 TKAs with radiolucencies, 4 loose tibial 

components, 3 revised 

E. HXLPE group: 2 TKAs with radiolucencies, 0 loose, 0 revised 

SELECTED REFERENCES: 

1. Hodrick et al.: Highly crosslinked polyethylene is safe for use in total knee 

arthroplasty. CORR 466: 2806-2812, 2008. 

2. Muratoglu et al.: Simulated normal gait wear testing of a highly crosslinked 

polyethylene tibial insert. JOA 22(3): 435-444, 2007. 

3. Oral et al.: Highly crosslinked ultrahigh molecular weight polyethylene with 

improved fatigue resistance for total joint arthroplasty. JOA 23(7): 1037- 

1044, 2008. 

4. Stoller et al.: Highly crosslinked polyethylene in posterior-stabilized total 

knee arthroplasty. JOA, 2010 epub ahead of print. 




13. Conclusions 

A. HXLPE appears to have wear advantages and seems “strong 

enough” for PS posts in this time frame 

B. Second generation HXLPE MAY strike a better balance 

between wear and strength 

C. Not all HXLPE inserts are the same 

D. Improvement in sterilization methods, knowledge of shelf 

life oxidation issues, locking mechanisms, etc., has also 

resulted in better UHMWPE inserts 

5. Gencur et al.: Fatigue crack propagation resistance of virgin and highly 

crosslinked, thermally treated ultra-high molecular weight polyethylene. 

Biomaterials 27: 1550-1557, 2006. 

6. Willie et al.: Examining the influence of short-term implantation on 

oxidative degradation in retrieved highly crosslinked polyethylene tibial 

components. J Biomed Mater Res Part B 85B: 385-397, 2008. 

7. Wannomae et al.: Delamination and adhesive wear behavior of α-tocopherolstabilized 

irradiated ultrahigh-molecular-weight polyethylene. JOA 25: 635- 

643, 2010.

patella reSurFaCiNg iS Not NeCeSSary - aFFirmative (debate) 

Robert L. Barrack, MD 

I. Introduction: History Notes: 

A. Patella resurfacing not original part of TKA. 

B. 1970’s – 1980’s – Patellar resurfacing incorporated into TKA 

(Scuderi, et al., J AAOS 199427). 

C. 1980’s – Patellar resurfacing emerges as major complication 

of TKA. 

1. Accounts for 50% of revision procedures (Dennis, AJKS 

19929). 

2. Most common FDA Medical Device Report (MDR) 

relating to TKA (Castro, et al., J Arth 19978) was failure 

of patellar components. 

II. Disadvantages of patellar resurfacing: 

A. Overresection - fracture. 

B. Underesection – Decreased ROM, anterior knee pain. 

C. Oblique resection – Pain, reoperation (Pagnano, Trousdale 

AJKS 200024). 

D. Late, potentially devastating complications (Kavolus, et al., J 

Arth 2008)17. 

1. Fracture – 5.9% 

2. Loosening – 1% 

3. AVN – 8.9% 

4. AKP 

III. Advantages of not resurfacing patella: 

A. Avoid major complications. 

B. Maintains normal bone, best results if revision necessary. 

C. Operative time, cost (Barrack, et al., JBJS Am 19972). 

D. Ability of native patella to remodel. 

IV. Limited indications for resurfacing: 

A. Inflammatory arthritis. 

B. Deformed, maltracking patella. 

C. Primary patellofemoral arthritis. 

V. Available evidence pertinent to patellar resurfacing: 

A. Laboratory studies. 

1. Contact area, stress. 

a. Forces across Patellofemoral joint, 8X body weight 

with deep knee bend (Benjamin, et al., Orthop Trans 

19983). 

b. TKA decreases Patellofemoral contact area, increases 

contact stress (Matsuda, et al., J Arth 199721). 

c. Patellar resurfacing leads to much higher stresses 

and lower contact areas compared to not resurfacing 

(Singerman, et al., J Arth 199930; McLean, et al., 

Orthop Trans 199423). 

d. These stresses exceed the yield point of polyethylene 

(Matsuda, et al., J Arth 199721). 

2. Kinematics: 

a. TKA alters kinematics to some degree. 

b. More normal kinematics with non-resurfaced 

compared to resurfaced patella (Singerman, et al., J 

Arth 199930). 

3. Anatomic studies – significant variability, in anatomy of 

distal femur, trochlear groove (Feinstein, et al., CORR 

199613; Eckhoff, et al., CORR 199610). 

a. Patellar groove perpendicular to transepicondylar axis, 

BUT 16¡ range. 

b. Sulcus 2.4mm lateral to midpoint, BUT 10.8mm 

range. 

c. TKA therefore significantly reorients Patellofemoral 

96 




anatomy, stresses in substantial percentage of cases. 

d. Unresurfaced patella has the ability to remodel (Shih, 

et al., JBJS Am 200428; Gerber, Maenza. Orthopade 

199815). 

B. Component design: “patella friendly” features 

1. Deeper patellar groove (Adriacchi, et al., J Arth 19971). 

2. Distal extent of trochlear groove (Matsuda, et al., 

Orthopedics 200022). 

3. Smoother transition to intercondylar notch (Larson, et 

al., J Arth 199919). 

4. Increased congruency (Petersilge, et al., CORR 199426). 

C. Clinical studies: 

1. The Dilemma: Disparate results continue, even with same 

Notes: component, same journal. 

Patellar resurfacing vs. nonresurfacing 

in TKA 

Garneti, et al. J Knee Surg 2008 14 . 

142 Knees 239 Knees 

Component: Scorpio 

F/U Nonresurfaced 33 months 

Resurfaced 18 months 

AKp 25% Nonresurfaced 

7% Resurfaced 

Equivalent: KSS, Euroqol score, every 

functional parameter 

Outcome of patellar resurfacing vs. 

nonresurfacing in TKA 

Epinette, et al. J Knee Surg 2008 12 . 

Component: Scorpio 

F/U 9 years 

No difference in any parameter. 

“Some designs patellar friendly.” 

“Given the significant cost of patella 

resurfacing and the resulting well-known 

complication, we continue to avoid 

systematic resurfacing of the patella 

during Scorpio TKA.” 

2. Bilat TKA, one resurfaced, one not. Results either 

equivalent or favored nonresurfaced. 

Series of bilateral TKA (one side resurfaced) either equivalent or favored 

non-resurfaced 

Author Ref # Knees 

Levitsky 20 CORR 1993 13 

Enis 11 CORR 1990 25 

Shoji 29 JBJS 1989 34 

Keblish 18 JBJS 1994 30 

Barrack 2 JBJS 1997 32 

Burnett 4 CORR 2007 32 

3. Prospective randomized, recent: 

a. Smith, et al., Australia, JBJS Br 200831: 159 Profix 

TKRs at 3.7 years blinded study. “No benefit was 

shown of TKR with patellar resurfacing over that 

without resurfacing with respect to any of the 

measured outcomes.” 

b. Campbell, et al., Australia, JBJS Br 20067: “We are 

unable to recommend routine patellar resurfacing in 

OA patients 

c. undergoing TKA based on our findings.” Peng, et 

al., Singapore Med J 200325: “The functional and 

symptomatic outcome of TKR with or without patellar 

resurfacing is the same in the local population” 

d. “Patella resurfacing vs. nonresurfacing in TKA:

REFERENCES: 

97 

Results of a randomized controlled clinical trial at 

a minimum of 10 years’ follow-up”(Burnett, et al., 

CORR 2004 5 ). 

1) 100 AMK TKA 

2) Minimum 10 year follow-up 

3) No patient lost to F/U 

4) Intraoperative cartilage quality was not a predictor 

of outcome 

“The results showed no significant difference between 

the groups for all outcome measures at a minimum of 10 

years of follow-up.” 

e. Burnett, et al., JBJS Am In Press 6 . Minimum 10 yr 

follow-up of randomized blinded trial resurfaced 

patients lost more points on knee score over time 

than unresurfaced. 

f. Decision Tree Analysis 

1) “To Resurface or not to Resurface the Patella in 

TKA” (Helmy, et al., CORR 2008 16 ). 

Model predicts patellar resurfacing is best path unless AKP 

after nonresurfacing falls below 12%. 

2) “Recent tool in clinical decision making: 

Computer-assisted decision analysis in 

orthopaedics” (Zangger, et al., J Arth 200032) 

a. Methodology: 

1. Andriacchi TP, Yoder D, Conley A, Rosenberg A, Sum J, Galante JO. 

Patellofemoral design influences function following total knee arthroplasty. J 

Arthroplasty 1997;12(3):243-9. 

2. Barrack RL, Wolfe MW, Waldman DA, Milicic M, Bertot AJ, Myers L. 

Resurfacing of the patella in total knee arthroplasty. A prospective, 

randomized, double-blind study. The J Bone Joint Surg Am 1997;79(8):1121- 

31. 

3. Benjamin J, Szivek, JA, Hammond, AS, et al. Contact areas and pressure 

between native patellae and prosthetic femoral components. Orthop Trans 

1998;22:18. 

4. Burnett RS, Boone JL, McCarthy KP, Rosenzweig S, Barrack RL. A prospective 

randomized clinical trial of patellar resurfacing and nonresurfacing in 

bilateral TKA. Clin Orthop Relat Res 2007;464:65-72. 

5. Burnett RS, Haydon CM, Rorabeck CH, Bourne RB. Patella resurfacing versus 

nonresurfacing in total knee arthroplasty: results of a randomized controlled 

clinical trial at a minimum of 10 years’ followup. Clin Orthop Relat Res 

2004(428):12-25. 

6. Burnett RSJ, Boone JL, Rosenzweig S, Barrack RL. A Prospective Randomized 

Clinical Trial of Patellar Resurfacing / Nonresurfacing in Total Knee 

Arthroplasty: A concise Follow-up at a Minimum 10-years of a Previous 

Report. J Bone Joint Surg Am 2008:In Press. 

7. Campbell DG, Duncan WW, Ashworth M, Mintz A, Stirling J, Wakefield 

L, Stevenson TM. Patellar resurfacing in total knee replacement: a ten-year 

randomised prospective trial. J Bone Joint Surg Br 2006;88(6):734-9. 

8. Castro FP, Jr., Chimento G, Munn BG, Levy RS, Timon S, Barrack RL. An 

analysis of Food and Drug Administration medical device reports relating to 

total joint components. J Arthroplasty 1997;12(7):765-71. 

9. Dennis D. Patellofemoral complications in total knee arthroplasty: A 

literature review. Am J Knee Surg 1992;5:156-66. 

10. Eckhoff DG, Burke BJ, Dwyer TF, Pring ME, Spitzer VM, VanGerwen DP. The 

Ranawat Award. Sulcus morphology of the distal femur. Clin Orthop Relat 

Res 1996(331):23-8. 

11. Enis JE, Gardner R, Robledo MA, Latta L, Smith R. Comparison of patellar 

resurfacing versus nonresurfacing in bilateral total knee arthroplasty. Clin 

Orthop Relat Res 1990(260):38-42. 

12. Epinette JA, Manley MT. Outcomes of patellar resurfacing versus 

nonresurfacing in total knee arthroplasty: a 9-year experience based on a case 

series of scorpio PS knees. J Knee Surg 2008;21(4):293-8. 

13. Feinstein WK, Noble PC, Kamaric E, Tullos HS. Anatomic alignment of the 

patellar groove. Clin Orthop Relat Res 1996(331):64-73. 

14. Garneti N, Mahadeva D, Khalil A, McLaren CA. Patellar resurfacing versus 

no resurfacing in Scorpio total knee arthroplasty. J Knee Surg 2008;21(2):97- 

100. 




i. Build decision tree. 

ii. Meta-analysis of probabilities 

iii. Estimation of probabilities. 

iv. Computer calculation of preferable option. 

b. Probability theory and Bayesian logic applied 

to patellar resurfacing TKA. 

c. Not Resurfacing Favored IF: 

i. Probability of AKP non-resurfaced 

30. Singerman R, Gabriel SM, Maheshwer CB, Kennedy JW. Patellar contact 

forces with and without patellar resurfacing in total knee arthroplasty. J 

Arthroplasty 1999;14(5):603-9. 

31. Smith AJ, Wood DJ, Li MG. Total knee replacement with and without patellar 

resurfacing: a prospective, randomised trial using the profix total knee 

system. J Bone Joint Surg Br 2008;90(1):43-9. 

98 




32. Zangger P, Detsky A. Computer-assisted decision analysis in orthopedics: 

resurfacing the patella in total knee arthroplasty as an example. J 

Arthroplasty 2000;15(3):283-8.

99 

why i reSurFaCe all patellae iN total kNee replaCemeNt 

Thomas K. Fehring, MD 

I. Historical Evolution 

• Early total knees had no anterior flange. Therefore there was 

a high prevalence of anterior knee pain 

• In the early ‘70’s an anterior flange was added to address 

anterior knee pain. However, there was no improvement in 

anterior knee pain with this design modification. 

• In 1974, the first patella resurfacing was performed in the IB 

Total Condylar knee replacement to address knee pain. 

• A gradual refinement of early design errors and improved 

surgical technique have led to the policy of patella 

resurfacing by most arthroplasty surgeons. 

II. Design Evolution 

Historical Implants Current Implants 

Shallow trochlear groove 

with with sharp box 

edge leading to clunk 

Uniform femoral 

component with straight 

trochlear groove groove 

deeper, more anatomic 

groove distal extension to 

prevent clunk 

side specific angled 

trochlear groove 

Metal backing all poly designs 

(exception LCS) 

III. Surgical Technique Evolution 

patella fracture 

Problem Solution 

avascular necrosis 

maltracking 

maintaining adequate 

patellar thickness 

preserving lateral 

geniculate artery during 

lateral release 

recognition of the 

importance of femoral 

and tibial rotation 

IV. Biomechanics of the Patellofemoral Joint 

• Patella is the largest sesamoid bone in the body 

• Acts as a dynamic fulcrum for the extensor mechanism 

• Patella provides 50% increase in knee extension strength vs. 

a patellectomy 

V. Relative Indications for Patella Resurfacing and 

Nonresurfacing in Total Knee Arthroplasty – Insall & Scott, 

Surgery of the Knee 

Resurfacing Indications Nonresurfacing Indications 

older age younger age 

anterior knee pain noninflammatory arthritis 

inflammatory arthropathy thin patients 

obesity thin/hypoplastic patella 

female intraoperative preserved patellar 

cartilage 

history of patellar subluxation and maltracking intraoperative congruent patellar 

tracking 

intraoperative patellofemoral wear anatomic trochlea groove on 

femoral implant 

Nonanatomic trochlea groove on femoral implant 




VI. Controversy exists whether or not to resurface the patella. 

There are four resources to make that determination. 

1. Prospective randomized studies with greater than 100 

patients 

2. Registry data 

3. Meta-analysis 

4. Results of revision of unresurfaced patella 

VII. Prospective randomized studies in with >100 patients 

• Wood et al. – JBJS, 2002 

— 198 patients MG II 

— no difference in Knee Society scores, range of motion or 

complications 

— anterior knee pain 

31% non-resurfaced 

16% resurfaced 

• Waters and Bentley – JBJS, 2003 

— 474 patients PFC 

— anterior knee pain 

25% non-resufaced 

5% resurfaced 

— in bilateral case where only one side resurfaced stat. sig. 

preference for resurfacing ( p

100 

resurfacing really matter? Pain and function in 972 patients 

after primary total knee arthroplasty.” 

— no difference in pain and function 

— no power numbers given - ? Type 2 error 

— ? selection bias – all revised patients were excluded 

IX. Meta-analysis 

• He et al., Knee, May ’10 – 3034 patients -16 RCT’s 

Reoperation for PF problems more common in nonresurfaced 

(p=0.03) 

• Nizard, CORR 432, Mar 2005 -__ patients – 12 RCT’s 

risk for reoperation, anterior knee pain, and pain with 

stair climbing in non-resurfaced 

• Parvizi et al., CORR 438, Sept., 2005 - __ pts., 14 RCT’s 

No difference in complications 

incidence of anterior knee pain and need for revision 

in unresurfaced 




• Pakos et al., JBJS, July 2005 – 1223 pt., 10 RCT’s 

14% in anterior knee pain if resurfaced 

X. Results of isolated, unresurfaced patellar revision 

• Garcia et al., J Arthroplasty, August 2010 

— 17 patients 

— 47% (7/17) dissatisfied with continued anterior knee 

pain 

• Khatod, J Knee Surg, July 2004 


— 48% dissatisfied 

• Mvoneke et al., JBJS-Br., July, 2003 


— 55% not improved or worse

101 

JoiNt preServatioN hip Surgery: 

how to avoid aNd treat CompliCatioNS 

aNd FailureS (J) 




Moderator: John C. Clohisy, MD, Saint Louis, MO 

Joint preservation of the hip has become more commonplace. Multiple procedures have demonstrated pain relief, and 

improved function. Nevertheless, there is limited literature regarding the characteristics and management of complications 

and treatment failures. This symposium will explore the etiologies and treatment methods for complications and clinical 

failures. 

I. Making the Right Diagnosis 

Bryan T. Kelly, MD, New York, NY 

II. Pitfalls/Limitations of Imaging 

Young-Jo Kim, MD, Boston, MA 

III. Periacetabular Osteotomy: Avoiding and Treating Complications/Failures 

John C. Clohisy, MD, Saint Louis, MO 

IV. Surgical Dislocation of the Hip: Avoiding and Treating Complications/Failures 

Michael Leunig, MD, Zurich, Switzerland 

V. Hip Arthroscopy: Avoiding and Treating Complications/Failures 

Christopher Larson, MD, Edina, MN 

VI. Joint Preservation Technique to Optimize Future Hip Surgery 

Paul E. Beaule, MD, Ottawa, Canada 

VII. Discussion, Questions and Answers 

All Faculty

Purpose 

• To summarize the current comprehension of clinical assessment 

of the young adult and adolescent with non-arthritic hip pain. 

Introduction 

• Concept of Hip Preservation: 

— Early hip disease is not a disease per se but rather a 

pathomechanical process by which the human hip can fail. 

— There is an identifiable mechanical source of hip pathology. 

— Preservation of the joint spaced and cartilage surfaces. 

— The hip at risk… 

Historical background 

• Algorithmic Approach to Evaluation of the Non-Arthritic Hip: 

Why we need a team… 

— History 

— Clinical Exam 

— Radiographic / Mechanical Diagnosis 

— Intra-articular Damage Pattern 

— MRI / Arthrogram 

— Intra-operative findings 

Layered Approach 

• Layer 1: Osteochondral Layer 

— Structures: Femur, Pelvis, Acetabulum 

— Purpose: Joint congruence and normal osteo / arthro 

kinematics 

• Layer 2: Inert Layer 

— Structures: Labrum, joint capsule, ligamentous complex, 

ligamentum teres 

— Purpose: Static stability of the joint 

• Layer 3: Contractile Layer 

— Structures: All musculature including lumbosacral 

musculature 

— Purpose: Dynamic stability 

• Layer 4: Neuromechanical Layer 

— Structures: TLS Plexus, Lumbopelvic structures, LE structures 

— Purpose: Neuromuscular linking and functional control of 

the entire segment as it functions within its environment 

• History 

• Physical Exam – Focused 

• ROM: 

• IR @ 90 degrees flexion 

— Flexion 

— External Rotation 

— Extension 

— Abduction in supine position 

— Craig’s Test 

• Provocative Pain 

— Impingement (FADIR) 

— Sub-Spine Impingement Sign 

— Superolateral impingement 

— Trochanteric Pain Sign 

— Lateral Rim Impingement 

— Instability 

— Posterior Impingement 

— Ischio-Femoral Impingement Sign 

• Normal Passive Hip ROM 

— Adduction 30˚ 

— Abduction 45˚ 

— Flexion 110˚ 

— Extension 0˚ 

102 

makiNg the right diagNoSiS 

Bryan T. Kelly, MD 




— IR 30˚ 

— ER 50˚ 

• IR Block Test 

— How do you assess ROM? 

• Strength 

— Hip Flexion 

— Adduction 

— Abduction 

• Palpation Pain 

— Central Pubic 

— Resisted Sit-Up 

— ASIS 

— Hip Flexors 

— Abductors 

— Adductors 

— Proximal Hamstrings 

— Ischium 

• Peritrochanteric Space Exam 

— Pain over trochanter 

— Anterior 

— Lateral 

— Posterior 

— Weakness in Abduction 

— Knee Extended 

— Knee Flexed 

— Snapping 

• COMPREHENSIVE EXAMINATION OF THE ADULT HIP 

— Five points for five body positions 

STANDING; SITTING; SUPINE; LATERAL; PRONE 

— ADDITIONAL TESTS AS NEEDED 

• STANDING EXAMINATION 

— General 

— Gait 

— Spine 

— Pelvis 

— Trendelenburg Test 

• SEATED EXAMINATION 

— Neurologic 

— Circulation 

— Skin 

— Lymphatic 

— IR/ER 

• SUPINE EXAMINATION 

— Passive ROM 

— Flexion, Abduction, Adduction, IR, ER 

— Impingement (FADIR) 

— Thomas Test 

— Patrick / Faber’s 

— Instability Test (extension / ER) 

• LATERAL EXAMINATION 

— Palpation GT, ABDUCTORS, SI, ISCHIAL BURSAE 

— Obers Test FLEXION, EXTENSION 

— Passive / Active ROM MEDIUS / MAX 

— FADDIR IMPINGEMENT 

— Lateral Rim Impingement 

– Lateral Hip Anatomy 

– 4 facets, 3 have distinct insertions 

• PRONE EXAMINATION 

— Craig’s Test (Femoral anteversion) 

— Ely’s (Rectus Femoris Contracture)

103 

— Hyperextension 

— Lumbar Spine 

— Palpation (Paravertebral muscles, spinous process) 

Arthritis 

• How much arthritis is too much? 

Treatment Plan 

• The location and quality of the pain should correspond to the 

mechanical diagnosis and secondary injury patterns. 

• If they do, then correcting the mechanical problems and 

secondary injuries should lead to a good outcome…. 

Summary 

• Algorithmic Approach to Evaluation of the Non-Arthritic Hip 

— History 

— Clinical Exam 

— Mechanical Diagnosis 

— Intra-articular Damage Pattern 

— Intra-operative findings 

• Dynamic Impingement 

— Cam Impingement 

— Rim Impingement 

REFERENCES 

1. Dwek J. Pfirrmann C. Stanley A. Pathria M. Chung CB. MR imaging of the 

hip abductors: normal anatomy and commonly encountered pathology 

at the greater trochanter. Magnetic Resonance Imaging Clinics of North 

America. 13(4):691-704, vii, 2005 Nov 




— Global overcoverage 

— Focal overcoverage 

— Femoral Retroversion 

— Femoral Varus 

• Static Overload 

— Acetabular Dysplasia 

— Anterior undercoverage 

— Lateral undercoverage 

— Femoral Anteversion 

— Femoral Valgus 

• Hip Instability 

— Traumatic labral detachment 

— Loose bodies 

— ? “Capsular Laxity” 

• Psoas Impingement 

— Internal Snapping Hip 

— Anterior labral pathology 

• Peritrochanteric Space Pathology 

— Combine these forces with dynamic or static overload to the 

joint…

Radiographic and advanced imaging is critical in characterizing the 

femoral and acetabular deformities that lead to hip instability or 

impingement. Additionally, radiographic and MRI assessment of 

pre-existing osteoarthritis can predict surgical outcome and should 

be an important variable in patient selection for joint preserving 

surgery. 

The main radiographic view utilized for assessing acetabular coverage 

and orientation is the anteroposterior pelvic view. The view most 

commonly utilized is taken in the supine position, which is the same 

view that would be obtained intra-op to assess deformity correction. 

A standing AP pelvic view is useful in cases of hip instability due to 

the fact that a standing view will accentuate the instability and the 

anti-lordotic position of the pelvis in the standing position will often 

bring out the anterior undercoverage that is often more severe in mild 

acetabular dysplasia. Quantitative measures such as the center-edge 

angle of Wiberg, acetabular slope of Tšnnis, impingement angle, and 

joint space width are frequently utilized and are often more reliable 

than qualitative assessment of hip deformity. Qualitative measures 

of acetabular orientation and coverage are often used; however, 

these measures are sensitive to rotation and tilt of the pelvis on the 

radiograph; hence should be interpreted with caution. Commonly 

used radiographic signs are relative position of the femoral head with 

respect to the ilioishcial line to look for protrusio. Medial position of 

the tear drop relative to the ilioischial line is a sign of coxa profunda. 

The presence of a cross over sign and posterior wall sign can suggest 

acetabular retroversion. Isolated cross over sign can suggest isolated 

anterior overcoverage. 

A lateral view of the acetabulum, which is the false profile view of 

Lequesne, is a sensitive view for detecting mild acetabular dysplasia 

and should be taken when hip instability condition is suspected. 

An abduction, internal rotation view is often taken in acetabular 

104 




imagiNg pitFallS 

Young-Jo Kim, MD, PhD 

dysplasia to assess the congruency of the joint after acetabular 

orientation. A joint with poor congruency and joint space narrowing 

in the abduction/internal rotation view is a poor candidate for joint 

preservation. 

When hip impingement is suspected, a lateral view of the proximal 

femur is usually necessary to detect the cam lesion. Multiple views 

such as frog lateral, Dunn lateral, and true lateral views have been 

utilized. A combination of an AP pelvic xray and a 45 degree Dunn 

lateral view appears to provide the highest sensitivity for detecting 

an impingement deformity. 

Advanced imaging such as MRI is not only useful in detecting the 

intra-articular damage such as labral and chondral tears, but is also 

useful in detecting the subtle deformity. Radially projected cuts 

around the femoral neck axis will demonstrate the cam deformity 

that can be missed on radiographs. Thin cuts through the acetabular 

roof, femoral neck, and distal femur will allow you to quantify 

the rotational profile of the acetabulum and the proximal femur. 

High resolution MRI will allow you to characterize the shape of 

the acetabular labrum and damage. Acetabular shape is enlarged in 

cases of hip instability, while, ossification of the labrum may suggest 

a more pincer type mechanical abnormality. Finally, acetabular 

cartilage can be detected on an MRI much earlier than on plain 

radiographs, especially, when biochemical imaging such as delayed 

Gadolinium Enhanced MRI of Cartilage is utilized. 

A combination of clinical symptoms that is consistent with the 

radiographically characterized deformity is necessary before joint 

preserving surgery is contemplated. Advanced imaging may be 

necessary to fully characterize the deformity and to stage the preexisting 

cartilage damage prior to surgery. Careful patient selection 

should lead to improved patient outcome.

105 

periaCetabular oSteotomy: avoidiNg aNd treatiNg 

CompliCatioNS/FailureS 

John C. Clohisy, MD 

Objectives: 

1) Review the potential complications and treatment failures of the 

PAO 

2) Present the indications, patient selection criteria and the 

surgical technique of the PAO with emphasis on avoiding 

complications/failures 

3) Discuss perioperative care strategies to avoid complications 

4) Present case examples of secondary surgery to treat 


Introduction: 

The Bernese periacetabular osteotomy (PAO) is an effective 

surgical technique for acetabular reorientation in the treatment 

of symptomatic acetabular dysplasia. Multiple surgeons/centers 

wordwide have reported favorable results in most patients. 

Nevertheless, all clinical series have reported complications and 

treatment failures. The procedure is associated with a significant 

learning curve. This presentation will review the most common 

complications and treatment failures and will present strategies to 

minimize suboptimal clinical results. 

1) Review the potential complications and treatment failures of 

the PAO 

• patient selection/surgical indication mistakes 

• major nerve/vascular injury/palsy 

• acetabular fracture 

• malreduction, loss of fixation 

• nonunions 

• osteonecrosis 

• infection, DVT, heterotopic bone, wound problems, blood 

loss 

• LFCN, symptomatic hardware 

2) Present the indications, patient selection criteria and the 

surgical technique of the PAO with emphasis on avoiding 


Indications/patient selection 

• Majority of patients < 40 years, healthy 

• Symptomatic structural instability (acetabular dysplasia) 

• Well-preserved hip motion (unless combined FAI) 

• Well-preserved joint space (Tonnis 0 or I preferred) 

• Adequate patient compliance 

• Adequately conditioned, BMI < 30 

Surgical Technique of the PAO 

• Learning Curve issues 

REFERENCES: 

1. Clohisy JC, Schutz AL, St. John LC, Schoenecker PL, Wright RW. 

Periacetabular Osteotomy: A Systematic Literature Review. Clin Orthop Relat 

Res 467(8):2041-2052, 2009. PMCID: PMC2706361 

2. Clohisy JC, Beaule PE, O’Malley A, Safran MR, Schoenecker P. AOA 

Symposium. Hip Disease in the Young Adult: Current Concepts of Etiology 

and Surgical Treatment. J Bone Joint Surg 90(10):2267 - 2281, 2008. 

3. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical 

dislocation of the adult hip a technique with full access to the femoral head 

and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 

2001;83(8):1119-24. 

4. Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the 

treatment of hip dysplasias. Technique and preliminary results. Clin Orthop 

Relat Res 1988(232):26-36. 




— Consider fluoroscopy, peripheral nerve monitoring, blood 

reinfusion 

• Exposure- LFCN, Neurovascular structures, 

• Periacetabular osteotomies 

— Ischium 

— Superior pubic ramus 

— Iliac 

— Posterior column 

— Mobilization of the acetabular fragment 

• Acetabular reduction and fixation 

— Lateral coverage, anterior coverage, sourcil inclination, 

horizontal position of hip center, acetabular version, 

secondary FAI, screw position (intraoperative radiographic 

assessment), range of motion check 

• Associated femoral procedures 

— Check for secondary FAI- head-neck osteochondroplasty 

— Proximal femoral osteotomy- residual instability (coxa valga, 

varus producing PFO) or poor mechanics/congruency/ 

residual FAI (coxa vara, valgus producing PFO) 

3) Discuss perioperative care strategies to avoid complications 

• Patient selection 

• Preoperative planning 

• Surgical technique- final checks in OR 

• Infection prophylaxis 

• DVT prophylaxis 

• H.O. prophylaxis 

• Pain management 

• Rehabilitation (weight bearing, ROM, strengthening, return to 

activity/sport) 

4) Case examples of secondary surgery to treat complications/ 

failures 

Key Points: 

1) With sound patient selection and surgical technique the PAO 

is an effective, safe surgical intervention. 

2) The learning curve is substantial and there is significant 

potential for complications and early failures. 

3) Patient selection for surgery and preoperative planning are 

extremely important. 

4) Precise surgical technique, knowledge of complications and 

awareness of potential failure mechanisms are important in 

optimizing clinical results and survivorship of the natural hip 

joint. 

5. Clohisy JC, Keeney JA and Schoenecker PL: Preliminary Assessment and 

Treatment Guidelines for Hip Disorders in Young Adults. Clin Orthop Rel 

Res 441: 168-179, 2005. 

6. Clohisy JC, Barrett SE, Gordon JE, Delgado ED and Schoenecker PL: Surgical 

Technique of the Periacetabular Osteotomy in the Treatment of Severe 

Acetabular Dysplasia. J Bone and Joint Surg 88 (Supp 1, Part 1) 65-83, 2006. 

7. Clohisy JC, Nunley R, Curry MC, Schoenecker PL: Periacetabular Osteotomy 

for the Treatment of Acetabular Dysplasia Associated with Major Aspherical 

Head Deformities. J Bone Joint Surg AM 89 (7): 1417-1423, 2007. 

8. Clohisy JC, Carlisle JC, Beaule PE, Kim YJ, Trousdale RT, Leunig M, 

Schoenecker PL, Millis MB. A Systematic Approach to the Radiographic 

Evaluation of the Young Adult Hip. J Bone Joint Surg Am Suppl 4 90:47-66, 

2008. PMCID: PMC2682767

9. Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year 

followup of Bernese periacetabular osteotomy. Clin Orthop Relat Res 

2008;466(7):1633-44. 

10. Siebenrock KA, Leunig M, Ganz R. Periacetabular Osteotomy: The Bernese 

Experience. J Bone Joint Surg Am 2001;83-A:449-55. 

106 




11. Leunig M, Siebenrock KA, Ganz R. Rationale of periacetabular osteotomy 

and background work. J Bone Joint Surg Am 2001;83:438-48.

107 

SurgiCal diSloCatioN oF the hip: avoidiNg aNd treatiNg 

CompliCatioNS/FailureS 

Michael Leunig, PD, MD 

Purpose 

• To describe the technique of surgical hip dislocation detailing 

how to avoid or treat complications 

Treatment timing/options 

• Identifying the appropriate timing for surgical intervention 

in treating hip disease secondary to FAI is still evolving and 

although physiotherapy and/or antiinflammatory therapy 

remain the first line of treatment of musculoskeletal injuries, its 

benefits in FAI are questionable 

• Delay in the surgical correction of symptomatic patients with 

these bony abnormalities may lead to disease progression to the 

point where joint preservation is no longer indicated 

• Radiographically diagnosed symptomatic FAI requires correction 

of the underlying bony abnormality and that is possible by 

surgery only 

Treatment goals 

• To safely and exactly correct morphological abnormalities, to 

alleviate symptoms, and to slow or stop the progression to early 

osteoarthritis regardless of the surgical technique. 

Treatment target 

• FAI-causing bony morphologies need to be addressed surgically. 

Open hip dislocation has been the first technique to treat FAI, 

with good to excellent short-to mid-term results around 70% 

to 80%. With an improved appreciation of hip pathology, less 

invasive approaches such as hip arthroscopy with/without mini 

open procedures have emerged. 

• Recent studies clearly demonstrated that simply resecting the 

labrum while neglecting the underlying bony pathology (FAI) 

is a major cause of treatment failures. This is due to the fact that 

most, if not all, labral abnormalities occur in the presence of 

structural deformities. 

• Indications for labral refixation are still evolving but it currently 

appears that resecting the labrum from its bony attachment is 

to be avoided whenever possible. Considering its physiological 

role, the reattachment of the intact portion of the labrum 

appears logical since an absent labrum might, similar to 

meniscectomy of the knee, lead to OA. 

• Indications for cartilage repair (microfracture, AMIC, mosaic 

plasty, etc.) of the femoral head and/acetabulum are evolving 

Choice on technique 

• Hip disorders should be characterized by the anatomic location 

of the disease, the presence or the absence of structural osseous 

abnormality, and the degree of joint degeneration. 

• Even today, complex bony abnormalities including 

REFERENCES: 

1. Ganz R, Huff TW, Leunig M. Extended retinacular soft-tissue flap for 

intra-articular hip surgery: surgical technique, indications, and results of 

application. Instr Course Lect 2009;58:241-55. 

2. Leunig M, Beaule PE, Ganz R. The concept of femoroacetabular 

impingement: current status and future perspectives. Clin Orthop Relat Res 

2009;467(3):616-22. 

3. Leunig M, Huff TW, Ganz R. Femoroacetabular impingement: treatment of 

the acetabular side. Instr Course Lect 2009;58:223-9. 




extraarticular impingement, major deformities, and global 

pincer FAI still seem to be more precisely treated by open hip 

dislocation or periacetabular osteotomy. 

• Hip arthroscopy ± mini open techniques are a valid treatment 

option for intraarticular disorders without substantial 

structural abnormality (labral and chondral lesions, loose 

bodies, synovitis) and for mild structural abnormality with 

intraarticular deformity (cam FAI, focal pincer FAI, cam 

impingement secondary to mild SCFE) in the absence of 

advanced joint deterioration. 

• Most importantly, the present pathomorphology, rather than 

the technical preference of the surgeon should govern the choice 

on technique. 

Surgical hip dislocation 

• Using the technique of the extended retinacular flap, the 

technique of surgical hip dislocation additionally allows 

femoral osteotomies at the level of the head/neck, base of the 

neck, or intertrochanteric region when these seem appropriate. 

• The extended retinacular soft-tissue flap is designed for active 

and visual protection of the femoral head blood supply 

during execution of the intra-articular osteotomy. Subcapital 

osteotomies in SCFE but also closing-wedge osteotomies of 

the femoral neck and rotational osteotomies can be performed 

similar to the subcapital osteotomy. 

• Even a lateral segment of the head (intracapital osteotomy) can 

be mobilized as a free fragment, pedicled on the retinaculum, 

while the medial segment remains perfused, similar to a Pipkin 

II fragment by the posteromedial branch of the MCFA. 

• To improve of muscular biomechanics and resolve extraarticular 

and intra-articular impingement relative lengthening of 

the femoral neck is possible by this approach. 

Avoiding surgical complications 

• Over-/underresection: Careful preoperative planning 

-Trochanteric failure: Step cut osteotomy of the greater 

trochanter -Ectopic ossifications: Perform sufficient soft tissue 

release before dislocation -AVN: Understanding of vascular 

anatomy of proximal femur -Adhesions: Perform early passive 

motion to the hip -Persisitng pain: Don’t miss concomitant 

pathologies -Etc. 

Treating complications 

• Over-/underresection: Overresection – osteotomy (PAO), 

underresection - reresection -Trochanteric pain: Hardware 

removal -Adhesions: Physical therapy or surgical release of 

adhesions -Etc. 

4. Leunig M, Nho SJ, Turchetto L, Ganz R. Protrusio acetabuli: new insights and 

experience with joint preservation. Clin Orthop Relat Res 2009;467(9):2241- 

50. 

5. Parvizi J, Leunig M, Ganz R. Femoroacetabular impingement. J Am Acad 

Orthop Surg 2007;15(9):561-70. 

6. Philippon MJ, Stubbs AJ, Schenker ML, Maxwell RB, Ganz R, Leunig M. 

Arthroscopic management of femoroacetabular impingement: osteoplasty 

technique and literature review. Am J Sports Med 2007;35(9):1571-80. 

7. Sierra RJ, Trousdale RT, Ganz R, Leunig M. Hip disease in the young, active 

patient: evaluation and nonarthroplasty surgical options. J Am Acad Orthop 

Surg 2008;16(12):689-703.

108 

arthroSCopiC hip JoiNt preServatioN: 

avoidiNg aNd treatiNg CompliCatioNS 

Christopher M. Larson MD 

#1 = Verify Hip Joint Proper is the Source of Pain 

• Physical examination consistent 

• Relief with intra-articular anesthetic injection 

— Followed by Physical Examination / Exercise Challenge 

AVOIDING COMPLICATIONS: 

• Iatrogenic labral injury 

— Anterolateral portal made blindly using fluoroscopy • Place 

spinal needle and release neg pressure 

— Remove needle and replace under labrum 

— If difficult visualization or mobility think labral penetration 

• Remainder of portals made under direct visualization 

— Iatrogenic articular cartilage injury 

— Obtain adequate distraction (at least 10mm) 

— Angle cannulas / instruments towards the acetabulum 

– Both entering and exiting the central compartment 

– Avoid femoral head chondral injury 

• In FAI cases limited working space despite adequate distraction 

— Prominent anterior acetabulum / Os Acetabuli = difficulty 

placing anterior portal 

– Perform capsulotomy early and work outside the central 

compartment 

– Alternatively access through the peripheral compartment 

first with hip flexion 

• Neuropraxias 

— Traction / pressure 

• Pudendal, sciatic, femoral, peroneal, dorsum of the foot / 

great toe 

• Limit traction time to < 2 hours 

• I limit to < 1 hour 

• Alternate between central and peripheral compartment 

• Well padded peroneal post 

• Larger / more padding if longer traction times 

• Smaller posts if shorter traction time 

o Allows better dynamic assessment 

• Pad the dorsum of foot and medial aspect of the great toe 

— Portal related (anterior / mid-anterior) 

• Lateral femoral cutaneous 

• Avoid deep portal incision 

• Under and Over-resection 

— Appropriate preoperative diagnosis based on imaging studies 

— Structural impingement vs Structural instability 

– Structural instability cannot be corrected arthroscopically 

> Dysplasia with retroversion 

¬ Resection of the anterior rim creates global 

instability 

¬ Reports of iatrogenic dislocation 

¬ CE angles < 20, lateralization, break Shentons line 

† Corrective osteotomy 

– Not all structural impingement can be predictably 

managed arthroscopically 

> Posterior based cam lesions 

> Protrusio difficult to dynamically assess 

> Avoid resection > 30% width of the femoral neck 

> Lateral position 

¬ Tendency to under-resect antero-inf cam extension 

> Supine position 

¬ Tendency to under-resect superior cam extension 




– Intra-operative assessment of resections • Recreate preop 

AP image with intra-op fluoro 

> Posterolateral portal for global rim resections 

> Hip flexion for anterior and inferior cam extension 

> Hip extension / IR for supero-posterior cam extension 

> Dynamic assessment (FADDIR, Butterfly, ext / IR) 

— Extra-articular impingement is difficult to define and 

should be addressed with an open surgical procedure when 

suspected 

– Trochanteric impingement against the pelvis / AIIS 

(Perthes) 

• Post-operative adhesions 

— Encourage early ROM (POD # 0 or 1) CPM or well leg cycle 

• Heterotopic ossification 

— After bony resections / Typically form at the capsulotomy 

— Meticulous removal of bony debris from muscle deep to 

capsule 

— NSAIDS for 3 weeks post-operatively 

• Failures with preoperative OA 

— > 50% narrowing (100% failure 3 yrs), any narrowing 

decreased outcome 

— Bipolar grade 3-4, chondral delamination > 2cm, medial 

head wear 

– Minimize the procedure if encounter the above findings 

— OA treated with Hip arthroplasty not arthroscopy 

TREATING COMPLICATIONS: 

• Over-resection 

— Avoid this!! 

— Limited arthroscopic options 

— Acute iatrogenic dislocation \ 

– Reduction and Capsular repair 

— Chronic Instability 

– Corrective Pelvic Osteotomy / THA 

— Femoral Neck Fracture 

– Cannulated Screw fixation +- Bone grafting 

• Under-resection 

— 3D CT to verify residual impingement 

— Anesthetic injection to verify joint as source of pain! 

— Appropriate arthroscopic indications as noted previously 

— Use the above mentioned techniques to verify appropriate 

resection 

• Adhesions 

— Recreate capsulolabral recess 

— Take down adhesions from capsule to femoral neck 

— Early post-op ROM (well leg cycle / CPM) 

• Symptomatic Heterotopic Ossification (H.O.) 

— Arthroscopic resection is feasible (often at level of 

capsulotomy) 

— Post-op Irradiation / NSAIDS 

• Psoas Impingement 

— Bruising at 3 (R hip) or 9 o clock (L hip) position 

— Preoperative bursal injection = relief of pain 

— Psoas tenotomy (central compartment / fractional 

lengthening) 

• Labral Deficiency 

— Most revisions able to preserve labrum 

— If previously excised ?? Reconstruction

109 

– • ITB / Gracilis / Ligamentum / Reflected head rectus 

— No convincing data to support if treating other pathology 

– Residual impingement / persistent labral tear / adhesions 

REFERENCES: 

1. Mardones RM, Gonzalez C, Chen Q, et al. Surgical treatment of 

femoroacetabular impingement:evaluation of the effect of the size of the 

resection. surgical technique. J Bone Joint Surg Am. 2006;88 suppl 1:84-91 

2. Larson CM, Wulf CA. Intraoperative fluoroscopy for evaluation of 

bony resection during arthroscopic management of femoroacetabular 

impingement in the supine position. Arthroscopy 2009; 25:1183-1192 

3. Matsuda D. Acute iatrogenic dislocation following hip impingement 

arthroscopic surgery. Arthroscopy 2009;25:400-404 




4. Ranawat A, McClincy M, Sekiya J. Anterior dislocation of the hip after 

arthroscopy in a patient with capsular laxity of the hip. J Bone Joint Surg Am 

2009;91:192-197. 

5. Benali Y, Katthagen BD. Hip subluxation as a complication of arthoscopic 

debridement. Arthroscopy 2009;25:405-407 

6. Larson CM, Taylor M, Giveans MR. Does arthroscopic FAI correction improve 

function with radiographic arthritis? Clin Orthop Rel Res (Accepted 2010) 

7. Heyworth, Shindle, Voos, Rudzki, Kelly. Radiologic and intraoperative 

findings in revision hip arthroscopy. Arthroscopy. 2007. Dec 23(12):1295- 

302

JoiNt preServatioN teChNique to optimize Future hip Surgery 

Paul E. Beaulé, MD and Joshua K.L. Lee FRCS 

Beyond these classic osteotomies of perciacetabular osteotomy 

(PAO) and proximal femoral osteotomy (PFO), there also has 

been in the last ten years the emergence of impingement surgery as 

well as hip arthroscopy. Although successful operations there will 

be a proportion of patients who ultimately develop symptomatic 

arthritis requiring total hip arthroplasty (THA). There have been 

varying reports of higher complication rates and less than optimal 

outcomes of THA after previous surgical interventions around the 

hip. In this presentation we will review how these joint preserving 

procedures can impact the performance of a total hip arthroplasty 

and to minimize their clinical impact. 

PELVIC OSTEOTOMY: PAO & OTHERS 

Pelvic osteotomy for the treatment dysplasia is a well established 

with the Bernese PAO becoming the gold standard in recent years. 

Having said, patients needing a total hip will still present after other 

types of pelvic osteotomies such as Chiari, triple innmominate and 

Salter. Although the latter two have provided good results for the 

treatment of dysplasia they do present technical challenges that need 

to be considered. The Chiari osteotomy is less commonly utilised 

than in the past, but the results of conversion to THA may allow one 

to judge the outcomes with more modern pelvic osteotomies such 

as the PAO’s. Hashemi-Nejad et al5 reported on 28 failed hips after 

Chiari osteotomy with a mean interval from osteotomy to THA of 17 

years, compared to 50 primary THA’s for sequelae of developmental 

dysplasia who had not undergone Chiari osteotomy. They reported 

that the previous osteotomy facilitated acetabular reconstruction for 

THA with a significant number not needing structural bone grafting 

(7% vs 28%), decreased operative time as well blood loss. In addition, 

they noted improved host bone coverage with the hip centre of 

rotation being more anatomical as deepening and medialization 

was less likely to be necessary. The complication rate, functional and 

radiographic outcomes and revision rate at five years was similar to 

the control DDH group. And they concluded that previous Chiari 

osteotomy does not compromise intermediate term outcomes of 

THA. Conversely Minoda et al8 found in a shorter term study that 

comparing previous Chiari osteotomy compared to THA for DDH 

with not previous history of surgery, had a significant increase in 

operative time and blood loss with no observed difference in need 

for bone graft, functional and radiological outcomes. 

There has been one report on THA after triple innominate osteotomy 

(TIO)11. Patients with failed TIO were compared with those who had 

primary or secondary osteoarthritis. Though there was no difference 

in radiological outcomes, there was a significant difference in 

functional outcomes. There was a significant difference between the 

post-operative Harris Hip Scores (HHS), 76 in the TIO group and 88 

in the control with the main difference being accounted for by the 

pain component with scores of 32 compared to 40, the functional 

scores were similar. From a technical standpoint, they authors noted 

greater difficulty in the conversion cases with a significant greater 

blood loss as well as greater use of the S-ROM modular stem: 61% vs 

15%. The authors concluded that though TIO facilitates future THA, 

especially acetabular coverage, with radiographical outcomes similar 

to primary THA, clinical results did not reflect this. 

To date there have been two reports on the conversion of the Bernese 

osteotomy to THA. Parvizi et al10 reported on 45 hips in 41 patients 

who required THA after progression to symptomatic arthritis with a 

mean follow-up of 6.9 years: 2 revisions for aseptic loosening, one 

dislocation, one case of HO. BaquŽ et al1 had a smaller study group 

110 




of 8 hips and a mean follow-up of 2.3 years. Both reports showed 

good clinical outcomes with improvements in Merle d’AubignŽ 

scores from 11.2 to 17.110 and 13.7 to 171. The majority of patients 

rated the outcome to be excellent to good. One key difference 

between the two series, is the use of the direct anterior approach 

for the conversion surgery by BaquŽ et al which further minimizes 

the overall impact of the PAO as the standard approach for this 

osteotomy is also anterior (Smith-Petersen). 

Key Technical Points: 

• Acetabular Retroversion: 

— Salter >>> PAO 

— Requires resection of anterior overhang & direction of 

reaming into posterior column. 

— Consider use of modular stem such as S-ROM 

• Hip Center of Rotation/Press-Fit: 

— Chiari>>>PAO 

— Morsellized bone grafting 

— PAO: acetabulum more dishaped w/ fossa & incisura being 

more posterior and medial. BaquŽ et al used unaltered 

ilioischial line as a surrogate for the medial wall and 

the superior aspect of the obturator foramen for the 

radiographic teardrop 

• Routine removal of internal fixation not necessary. 

PROXIMAL FEMORAL OSTEOTOMY (PFO) 

There have been conflicting reports of results of THA post PFO, 

many earlier articles show poor results, but more recently the reports 

have been more encouraging. Most publications are regarding THA 

post-intertrochanteric osteotomy (ITO)2-4,6,7,9,12. Failure rates 

as high as 18.12 and 20.6%4 at 10 years have been reported for 

cemented THA’s, equally Iwase et al7 found 22.5% failure rate of 

uncemented stems at 4 years, but 100% survival of cemented stems. 

It has been felt that the initial poor results with cemented stems was 

due to first generation cementing techniques and there has been a 

marked improvement of results with second generation cementing 

techniques with no stems revised at 16 years12. 

More recent reports have shown good survivorship of both 

cemented6 and uncemented3,9 components. Haverkamp et al6 

found 10 year survivorship of cemented THA of 90% compared to 

92% for a control group of primary THA’s in patients with primary 

or secondary osteoarthritis with no prior hip surgery. At 15 years 

the rates were similar at 83% and 81% respectively. Parsch et al9 

showed stem survival in uncemented THA of 91% at 15 and 20 years. 

Interestingly both groups used standard non-custom, non-modular 

implants. 

Though there may be contradictory results regarding implant 

survival, reports have shown that the clinical outcome is similar to 

control groups. Boos et al2 showed no differences in the HHS and 

improvement in HHS in patients with a prior ITO compared to a 

group of diagnosis matched patients. Comparing prior ITO against 

THA for primary and secondary osteoarthritis with no previous hip 

surgery, Haverkamp et al found no differences in the average HHS6. 

Key Technical Points: 

• Routine Removal Internal Fixation: 

— Though several authors have cautioned that empty screw 

holes may affect effective cement pressurisation and 

interdigitation2,4, as well as possible fracture with them 

acting as stress risers2, they have not shown worse outcomes

with concomitant removal of hardware2,4,12. Haverkamp et 

al felt that removal of hardware at the time of THA increased 

the risks of intraoperative complications, though at their 

institution they routinely removed hardware one to two 

years after the osteotomy6. 

— Required almost all the time. 

— Plan for greater blood loss. 

• Femoral Canal Deformity: 

— Trochanteric Osteotomy maybe required especially post 

varus osteotomy. 

— Rotational Alignment can be difficult as well as component 

sizing for offset restoration. Consider modular implant 

— Sclerosis of the subtrochanteric region may require smaller 

canal finder or intra-operative imaging in order to avoid 

perforation of femoral canal. 

NEWER TECHNIQUES: SURGICAL DISLOCATION & HIP 

ARTHROSCOPY 

There are no reports in the literature analyzing the outcome of 

total hip replacement after failed hip arthroscopy and/or surgical 

dislocation. For the former, one would assume that the surgery 

would be no different than a regular primary total hip replacement. 

Having said, with surgeons performing labral refixation techniques 

more commonly with or without acetabular rim trimming, the 

REFERENCES: 

1. Baque, F.; Brown, A.; and Matta, J.: Total hip arthroplasty after periacetabular 

osteotomy. Orthopedics, 32(6): 399, 2009. 

2. Boos, N.; Krushell, R.; Ganz, R.; and Muller, M. E.: Total hip arthroplasty after 

previous proximal femoral osteotomy. J Bone Joint Surg Br, 79(2): 247-53, 

1997. 

3. Breusch, S. J.; Lukoschek, M.; Thomsen, M.; Mau, H.; Ewerbeck, V.; 

and Aldinger, P. R.: Ten-year results of uncemented hip stems for failed 

intertrochanteric osteotomy. Arch Orthop Trauma Surg, 125(5): 304-9, 2005. 

4. Ferguson, G. M.; Cabanela, M. E.; and Ilstrup, D. M.: Total hip arthroplasty 

after failed intertrochanteric osteotomy. J Bone Joint Surg Br, 76(2): 252-7, 

1994. 

5. Hashemi-Nejad, A.; Haddad, F. S.; Tong, K. M.; Muirhead-Allwood, S. K.; 

and Catterall, A.: Does Chiari osteotomy compromise subsequent total hip 

arthroplasty? J Arthroplasty, 17(6): 731-9, 2002. 

6. Haverkamp, D.; de Jong, P. T.; and Marti, R. K.: Intertrochanteric osteotomies 

do not impair long-term outcome of subsequent cemented total hip 

arthroplasties. Clin Orthop Relat Res, 444: 154-60, 2006. 

111 




impact of these procedures are unknown in regards to the acetabular 

component preparation and fixation. Finally, in regards to total hip 

after surgical dislocation, often there will retained internal fixation 

in the greater trochanter which will require removal and this maybe 

difficult since often there is bony overgrowth and if 3.5mm screws 

were used than the screw heads might easily break off so having 

the broken removal screw set available is important. Using 4.5mm 

screws initially might facilitate this. 

CONCLUSION: 

Subsequent THA does not appear to the compromised by previous 

PAO, though caution needs to be taken when judging the placement 

of the acetabular component in relation to distorted anatomical 

landmarks. It is unclear if the same clinical outcome after conversion 

of pelvic osteotomies can be applied to other pelvic osteotomies 

(Chiari, TIO) or PFO. More specifically because the Chiari and Salter 

osteotomies do not leave the posterior column intact this can have 

significant implications in regards to acetabular component fixation 

as well as placement. Whereas with a previous PFO (inter trochanteric 

osteotomy) the total is technically more demanding and care needs 

to be taken when preparing the femur and selection of implants 

with specially consideration given to modular implants such as the 

S-ROM. Finally, there is little to no data on the outcome of total hip 

replacement after hip arthroscopy and/or surgical dislocation. 

7. Iwase, T.; Hasegawa, Y.; Iwasada, S.; Kitamura, S.; and Iwata, H.: Total hip 

arthroplasty after failed intertrochanteric valgus osteotomy for advanced 

osteoarthrosis. Clin Orthop Relat Res, (364): 175-81, 1999. 

8. Minoda, Y.; Kadowaki, T.; and Kim, M.: Total hip arthroplasty of dysplastic 

hip after previous Chiari pelvic osteotomy. Arch Orthop Trauma Surg, 

126(6): 394-400, 2006. 

9. Parsch, D.; Jung, A. W.; Thomsen, M.; Ewerbeck, V.; and Aldinger, P. R.: Good 

survival of uncemented tapered stems for failed intertrochanteric osteotomy: 

a mean 16 year follow-up study in 45 patients. Arch Orthop Trauma Surg, 

128(10): 1081-5, 2008. 

10. Parvizi, J.; Burmeister, H.; and Ganz, R.: Previous Bernese periacetabular 

osteotomy does not compromise the results of total hip arthroplasty. Clin 

Orthop Relat Res, (423): 118-22, 2004. 

11. Peters, C. L.; Beck, M.; and Dunn, H. K.: Total hip arthroplasty in young 

adults after failed triple innominate osteotomy. J Arthroplasty, 16(2): 188- 

95, 2001. 

12. Shinar, A. A., and Harris, W. H.: Cemented total hip arthroplasty following 

previous femoral osteotomy: an average 16-year follow-up study. J 

Arthroplasty, 13(3): 243-53, 1998.

112 

maNagiNg CompliCatioNS aFter 

primary total hip arthroplaSty 

iN your praCtiCe (v) 




Moderator: Paul F. Lachiewicz, MD, Chapel Hill, NC 

This symposium will assist the practicing surgeon in the management of common complications after primary total hip 

arthroplasty. 

I. Intraoperative Fracture of the Femur and Acetabulum 

Will address risk factors, prevention, treatment (wire, cable; adjustment PT). 

David G. Lewallen, MD, Rochester MN 

II. Dislocation 

Will address risk factors, use of large heads, prophylactic bracing role; treatment of first, second events; when, what type of 

revision for recurrence. 

Douglas E. Padgett, MD, New York, NY 

III. Iliopsoas and Abductor Tendon Problems After Hip Arthroplasty 

Will address iliopsoas tendinitis- evaluation and treatment; abduction tendon avulsion - evaluation and treatment; treatment of 

abductor tear at time of initial THA. 

Paul F. Lachiewicz, MD, Chapel Hill, NC 

IV. Sciatic nerve injury 

Will address techniques to prevent nerve injury and prognostic factors for recovery. 

Chitranjan S. Ranawat, MD, New York, NY 

V. Recognizing and Treating Problems After MoM and CoC Hip Arthroplasties 

Will address unexplained pain after metal/metal, pseudotumor evaluation and treatment; evaluation and treatment of ceramic/ 

ceramic squeaking and fracture. 

Robert L. Barrack, MD, Saint Louis, MO 

VI. Management of the Draining Hip Incision and Diagnosis/Treatment of Early and Late Hip Infections 

Will address evaluation and treatment of early draining incision, early documented infection and late infection, with new data 

about cell counts, new modalities and changing microbiology. 


VII. Questions and Answers 

Faculty

113 

diSloCatioN aFter total hip arthroplaSty 

Douglas E. Padgett, MD 

1. What to do with the patient who dislocates after THR? 

a. Who did the surgery ? 

i. You: what happened at primary procedure ? 

ii. Elsewhere: try to find out what happened at procedure ? 

b. Timing of Instability: 

i. Early (first 6-8 weeks) 

ii. Later 

iii. First timer vs multiple dislocator 

c. Direction of instability: 

i. This is important and relative to approach. 

1. i.e.-early dislocator who subluxes anteriorly done via 

a posterior approach has a different natural history 

than a posterior dislocator 

d. Mechanism: 

i. What were the circumstances? 

1. Don’t accept the “spontaneous dislocation”: I was just 

sitting there and my hip popped out ! 

2. Adherence to precautions ? 

3. Does the patient understand them ? 

e. Radiographic evaluation: 

i. Minimal data set: 

1. Centered AP pelvis, true lateral of the femur 

a. Socket: abduction angle, version angle on true 

lateral 

b. Femur: length, offset 

c. Combined offset: look at opposite hip 

d. If this is the acute dislocation: must determine 

the direction of dislocation because it will affect 

reduction techniques 

f. Reduction of the dislocated hip: 

i. Knowledge of direction of instability to guide reduction 

maneuver 

1. Sedation 

2. Strength not as important as appropriate leverage: 

a. Think martial arts 

3. Post-reduction: check ROM for stability 

g. Bracing: 

i. Controversial 

ii. Data not compelling: 

iii. Type of brace: 

1. Hip abduction brace 

a. Posterior dislocation: 

i. Motion limits: 

• Hip flexion stop at 70 degrees 

• Abduction fixed at 25-30 degrees 

BIBLIOGRAPHY: 

1. Padgett DE and Warashina: The Unstable Total Hip Replacement. Clin 

Orthop Rel Res. 420:72-79, 2004. 

2. Berry DJ, von KnochM, Schleck CD, Harmsen WS.: The cumulative long term 

risk of dislocation after primary Charnley THR. JBJS, 86A:9-14, 2004. 




b. Anterior dislocation: 

i. Need to control rotation and restrict extension 

• Hip flexion arc 20 degrees to 70 degrees 

• Long leg extension to limit external rotation 

iv. Duration of bracing: 

1. Data not clear 

2. Most recommend 6 week course of bracing BUT 

reenforcement of hip precautions 

h. Prognosis 

i. Patient Factors: 

1. Sex, diagnosis, cognition 

ii. Implant Factors: 

1. Head size, cup size, head-neck ratio, offset (femoral, 

acetabular) 

iii. Surgeon Factors: 

1. Soft tissue tension (leg length/ offset) 

2. Offset affect upon impingement: 

a. Socket offset 

b. Femoral offset 

c. Combined 

3. Version: stem / cup and combined ! 

iv. The Natural History of the THR: 

1. Cumulative Dislocation Rate 

2. Distribution of when dislocation occurs 

3. What happens to the : 

a. Early dislocator 

b. Late dislocator 

2. The Recurrent Dislocator: 

a. Role of conservative treatment: 

i. Limited ! 

ii. Perhaps in the cognitively impaired, noncompliant 

patient 

b. Surgical management of the recurrent dislocator: 

i. Tailor to etiology (if known!) 

ii. Options: 

1. Change version (stem/cup) 

2. Change head size/liner 

3. Trochanteric advancement: 

a. An older but effective treatment 

4. Constrained liners: 

a. Short term success outstanding BUT: 

b. Same criteria for acceptable cup position in the 

primary THR 

c. Poorly placed cup is NOT salvaged by simply 

placing in a constrained liner. 

3. Shapiro GS, Weiland DE, Markel DC, Padgett DE, Sculco TP, and Pellicci PM: 

The Use of a constrained acetabular component for Recurrent dislocation. J 

Arthroplasty 18(3):250-258, 2003.

114 

iliopSoaS teNdiNitiS aNd abduCtor teNdoN problemS aFter 

total hip arthroplaSty 

Paul F. Lachiewicz MD 

Iliopsoas tendinitis after THA 

• An UNDERαRECOGNIZED cause of groin pain and disability 

after THA! 

Frequency of Groin Pain after THA 

Nasser 18% after resurfacing 

AlaEddine 4.3% after THA 

Bartlelt 18% after resurfacing 

15% after metalαmetal THA 

7% after conventional THA 

Iliopsoas Tendinitis after THA related to: 

• Prominent, malpositioned acetabular component 

• Acetabular cage or ring 

• Retained cement; long screws 

• Excessive offset or leg length discrepancy (?) 

Iliopsoas tendinitis ? increased frequency with: 

• Metal –metal hip resurfacing 

• Very large head metal-metal THA 

Iliopsoas Anatomy 

• Confluence of 2 muscles that insert into anteromedial lesser 

trochanter 

• Bursa separates tendon from hip capsule 

• Tendon is extra-articular, but may become intra-articular if 

anterior capsule divided/resected during THA 

History + Physical Findings 

• Persistent groin pain, exacerbated by stair-climbing, arising from 

chair/bed, or entering/exiting auto 

• Onset from 1 to 96 months after THA 

• Slight limp; groin tenderness, mass, snap 

• Pain reproduced with resisted seated hip flexion, leg raise, active 

external rotation 

Initial Evaluation 

• ESR, CRP ------ hip aspiration if elevated 

• Radiographs, including shoot through lateral 

• Technetium bone scan, to detect occult fracture, loosening 

Diagnostic Tests 

• Plain radiographs 

• CT scan; ? MRI 

• Ultrasonography 

• Diagnostic injection 

Lateral radiograph—look for prominent anterior edge(uncovered) 

acetabular component 

CT scan—can measure version and detect tendon/bursa 

hypertrophy 

Mean prominence 5.8 mm (range 2-10) in one study; 

> 12 mm in 8 cases in another study 

Ultrasonography—tendon displaced anteriorly + medially; largest 

REFERENCES 

1. Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis after 

total hip arthroplasty. J Am Acad Orthop Surg 2009; 17: 337-344 




series 39 patients (11 THA) May be technique and experience 

dependent 

Diagnostic Injection—guided by fluro, CT, or ultrasound 

Radiologist injects tendon sheath with local anesthetic +/- steroid 

Temporary relief of pain confirms diagnosis 

Non-operative Treatment 

• Rest, medication, physical therapy stretches 

• Steroid injection ? repeat once if effective 

• Botox injection ? one case report 

Operative Treatment 

• Iliopsoas tendon release/ resection 

• Removal of prominent metal, cement, or screws 

• Acetabular component revision +/- tendon release or resection 

Iliopsoas tendon release/ resection 

• Anterior or posterior approach 

• Only if acetabular component not malpositioned 

Acetabular Component Revision 

• Indicated when Xray or CT scan shows that the anterior edge of 

component protrudes in front of anterior bony rim 

• Medialize and antevert new acetabular component (below 

anterior rim) 

• Release or resect iliopsoas tendon/ bursa 

Pooled Analysis of Treatment in Literature 

• 112 hips, female 66% Mean patient age 57 years 

• Mean duration of symptoms 24 months 

• 84% of hips had an uncemented acetabular component 

Pooled Analysis of Non-Operative Treatment 

• Successful in only 49% of THAs (28/57) 

• Single largest series 19 hips (Nunley etal) 

29 month f/u telephone questionnaire 

— Injection helped 13 patients (68%) however, 9 had a 2nd 

injection 

— Surgery performed 6 patients 

Pooled Analysis of Operative Treatment 

• Tenotomy 39; Revision +/- tenotomy 40 

• Successful 93% Mean follow-up only 17 months 

• No study compared tenotomy/ resection with acetabular 

component revision 

Conclusions 

• Consider diagnosis in patients with groin pain and disability 

after THA, especially resurfacing 

• Evaluate with shoot-through lateral radiograph, CT scan (?MRI), 

or ultrasound 

• Diagnostic/ therapeutic injection recommended 

• Operative treatment—tendon release/ resection or acetabular 

revision highly successful 

2. Bartelt RB, Yuan BJ, Trousdale RT, Sierra RJ.The prevalence of groin pain after 

metal-on-metal total hip arthroplasty and total hip resurfacing. Clin Orthop 

Relat Res 2010; 468: 2346-2356.

115 

abduCtor teNdoN problemS aFter primary 

total hip arthroplaSty 

Paul F. Lachiewicz, MD 

Lateral Hip Pain 

Greater Trochanter Pain Syndrome 

• Called greater trochanteric bursitis 

• More prominent in women, peak onset 4thα6th decade 

• Tenderness, limp, weakness 

• Usual treatment: NSAIDs, physical therapy, steroid injection 

Refractory Lateral Hip Pain + weakness Chronic tear of abductor 

tendon (“rotator cuff tear of hip”) 

Imaging 

• Plain radiographs 

— Usually normal 

— May see sclerosis, osteophytes, or cyst in greater trochanter 

• MRI 

— Partial tear increased signal T2 

— Full tear discontinuity of tendon 

— Fatty atrophy of gluteus medius poor prognosis 

Clinical Scenarios 

1. Chronic tear, no hip arthritis classic “rotator cuff tear of hip” 

2. Coincident finding at time of elective THA for arthritis or at 

athroplasty for femoral neck fx 

3. Abductor tendon avulsion after THA through anterolateral 

(Hardinge) approach 

SCENARIO 2 Abductor tendon tear found at time of primary 

THA 

• Found in 22% patients with femoral neck fracture 

• Found in 22% women, 15% men at time of elective THA for 

arthritis 

• Fluid, chronic inflammation in bursa; check integrity of anterior 

gluteus medius tendon 

Treatment 

• Proceed with routine arthroplasty (consider large head) 

• Excise trochanteric osteophytes, sclerotic bone 




• Repair tendon with 2-3 non-absorbable sutures through 

transosseous tunnels 

• Protect with 2 supports/ walker for 6 weeks 

SCENARIO 3 Abductor Tendon Avulsion after Primary THA 

through anterolateral approach 

Frequency: 4.9% lateral pain (Iorio) 

27/97 hips had > 2 cm separation of tendon (metal 

marker study) 

• 2.5 cm correlated with limp 

Treatment observation, support; surgical intervention for mod/ 

severe pain and limp 

Results of Repair of Abductor tendon Avulsion after THA 

Weber etal 5/9 limp improved; pain not reliably improved 

Miozzari etal 9/12 pain improved; persistent limp in 4 

patients 

Fatty atrophy of gluteus medius on MRI 

associated with limp, weakness 

Late reconstruction (repair not feasible) 

• Transfer gluteus maximus flap (Whitesides etal) 

• Achilles tendon allograft (Fehm etal) 

Summary Abductor Tendon Tears after THA 

• Consider in patients with lateral hip pain, weakness, limprefractory 

to nonop treatment 

• MRI scan sensitive + specific 

• Relatively common finding at time of THA or arthroplasty for 

femoral neck fracture 

• Avulsion after THA—uncommon cause of postop pain, limp, 

need for supports 

• Repair or reconstruction helpful in 3/4s of patients

116 

SCiatiC Nerve palSy iN primary total hip arthroplaSty 

Chitranjan S. Ranawat, MD 

Abstract: 

The etiology of sciatic nerve palsy after total hip arthroplasty is 

multifactorial, in more than half of all cases, the mechanism of 

injury remains unknown [1-5]. Several authors have suggested that 

intra-operative compression and or traction from an unrecognized 

source may play a role in these unexplained cases [1,2,6], but the 

specific source of injury has not been clearly defined. 

The reported incidence of nerve palsy after primary total hip 

arthroplasty varies between 0.09% and 3.7% [6,7,8]. Combining 

data from multiple studies, Schmalzried et al [9] determined that 

the incidence of nerve injury after primary total hip arthroplasty is 

0.9% and that the sciatic nerve is involved in 79% of all cases of 

postoperative nerve palsy. Female patients are at nearly twice the 

risk of sciatic nerve palsy as men [3,4,9], and the incidence of nerve 

palsy in patients with DDH (5.2%) is also greater [9]. The known 

causes of postoperative sciatic nerve palsy have been described to 

REFERENCES 

1. Navarro RA, Schmalzried TP, Amstutz HC, et al. Surgical approach and nerve 

palsy in total hip arthroplasty. J Arthroplasty 1995;10:1. 

2. Schmalzried TP, Amstutz HC, Dorey FJ. Nerve palsy associated with total hip 

replacement. Risk factors and prognosis. J Bone Joint Surg 1991;73A:1074. 

3. Johanson NA, Pellicci PM, Tsairis P, et al. Nerve injury in total hip 

arthroplasty. Clin Orthop 1983; 179:214. 

4. Edwards BN, Tullos HS, Noble PC. Contributory factors and etiology of 

sciatic nerve palsy in total hip arthroplasty. Clin Orthop 1987;218:136. 

5. Simon JP, Van Delm I, Fabry G. Sciatic nerve palsy following hip surgery. Acta 

Orthop Belg 1993; 59:156. 




be direct operative trauma, constriction with suture, wire or cable, 

heat from polymerizing cement, excessive leg lengthening, vascular 

compromise, compression from retractor placement or subgluteal 

hematoma formation, and underlying spinal stenosis aggravating a 

more distal insult (double crush syndrome) [2-4,7-9]. In more than 

50% of cases of sciatic nerve palsy, the cause is unknown [1-5]. 

Magnetic resonance imaging (MRI) findings in recent years (10), has 

localized the site of compression for the so-called “cases of unknown 

etiology”, the location of the compressive lesion is under the gluteus 

maximus tendon which becomes taut in flexion, adduction and 

internal rotation of the hip, creating a compressive neuropathy 

of the sciatic nerve at the level between the ischial tuberosity and 

gluteus maximus insertion. 

Release of the gluteus maximus tendon insertion from the femoral 

attachment has been shown to almost eliminate the sciatic nerve 

palsy after THR. 

6. Nercessian OA, Macaulay W, Stinchfield FE. Peripheral neuropathies 

following total hip arthroplasty. Clin Orthop 1994;6:645. 

7. Weber ER, Daube JR, Coventry MB. Peripheral neuropathies associated with 

total hip arthroplasty. J Bone Joint Surg 1976;58A:66. 

8. Wilson JN, Scales JT. The Stanmore metal on metal total hip prosthesis using 

a three pin type cup. A follow-up of 100 arthroplasties over nine years. Clin 

Orthop 1973;95:239. 

9. Schmalzried TP, Noordin S, Amstutz HC. Update on nerve palsy associated 

with total hip replacement. Clin Orthop 1997;344:188. 

10. Hurd JL, Potter HG, Dua V. Ranawat CS, Sciatic nerve palsy after primary 

total hip arthroplasty: a new perspective, J Arthroplasty 2006; 21:796.

117 

reCogNiziNg aNd treatiNg problemS aFter mom aNd CoC hip 

arthroplaStieS 

Robert L. Barrack, MD 

I. Common features of hard-on-hard bearings 

A. Positives: 

1.Increased utilization after 2000. 

2. Potential for low wear rate. 

a. Clear advantage over standard metal/PE. 

b. Much less clear advantage over metal/cross-linked PE 

3. Ability to use larger heads. 

a. Substantial market trend in recent years. 

b. May increase stability, improve ROM, decrease 

dislocations (major complication following THA). 

B. Negatives: 

1. Increased cost. 

2. Increased noise production. 

a. May be benign. 

b. May be harbinger of impending failure. 

3. Less margin for error in component placement. 

4. Fewer component options. 

a. Ceramics. 

b. Monoblock metal-metal. 

II. Evaluation of painful hard-on-hard bearings. 

A. Rule out infections – “Advanced” bearing THA get infected 

too. 

1. May be less common due to young, healthy profile of 

many cohorts. 

2. May delay diagnosis. 

3. Reports of increased infection rate for metal-metal1 

probably spurious, 2˚ to inaccuracy of coding of infection 

in administrative data bases.2 

B. Rule out aseptic loosening (especially monoblock acetabular 

components). 

1. Classic clinical signs. 

2. Tc99 scan helpful. 

C. Psoas impingement, groin pain may be more common with 

large heads, hip resurfacing. 

D. Carefully assess component position, potential for 

impingement. 

1. Shoot-through lateral 

2. CT scan. 

III. Complications unique to alternative bearings. 

A. Hip resurfacing. 

1. Femoral neck fracture. 

a. Occurs 1st 6-12 months. 

b. More common with notching, elderly, female, may be 

trauma related. 

c. Conversion to THA can give similar results to 

primary THA (if cup well aligned, well-fixed, and not 

damaged). 

2. Groin pain – reportedly more common. 

a. Assess component position. 

b. Assess anterior femoral neck and anterior acetabular. 

c. Treatment options. 

1) Conservative – P.T., nsaids, injection. 

2) Surgical – arthroscopic or open FAI procedure; 

rarely complete revision. 




B. Metal-metal hip arthroplasty. 

1. Malposition, impingement leading to metallosis. 

a. Assess radiographically. 

b. Metal ions often elevated. 

c. Complete revision with synovectomy, debridement 

often necessary. 

d. Results vary with degree of tissue damage. 

2. More subtle malposition leading to edge loading. 

a. High percentage of primary THA outside of “safe 

zone”.3 

b. Suboptimal inclination, cup version, OR combined 

version can lead to edge loading, increased metal 

debris. 

1) Wide spectrum of “adverse reaction to metal 

debris”. 

2) Degree of surgery and expected outcome also 

widely variable depending on degree of tissue 

destruction. 

3) Early recognition, treatment desirable, necessary – 

clinical + radiographic surveillance. 

4) Incidence highly dependent on component 

position, fixation, AND product type. 

c. Debris generation, corrosion from non-bearing 

surfaces (e.g., taper junctions). 

1) Highly design specific. 

2) Can lead to aggressive tissue response. 

3) May require complete revision. 

d. Metal hypersensitivity. 

1) Probably least common. 

2) Female preponderance? 

3) Single high LTT level most supportive of this 

diagnosis. 

4) Revise to different bearing. 

C. Ceramic-ceramic THA. 

1. Component fracture – liner or head. 

a. Less common with modern components diagnosis 

may be delayed – beware of any change in function, 

symptoms. 

b. Early intervention desirable. 

1) Complete synovectomy. 

2) Inspect taper, may require stem revision. 

3) Taper sleeve, new ceramic head may be an option. 

4) Results variable. 

i. Increased 2˚ revision rate – Allain et al4, 105 

cases. 

ii. High success rate – Sharma et al5, 8 cases. 

2. Squeaking. 

a. Variable incidence, 1-7%, design dependent. 

b. Numerous etiologies – impingement, microseparation 

stripe wear, edge loading, inadequate lubrication, 

component malseating. 

c. Assess for impingement – early revision to minimize 

tissue damage. 

d. Revision for squeaking alone – conversion to standard 

metal-poly reported good results.6

REFERENCES: 

1. Bozic KJ, Ong K, Lau E, et al. Risk of complication and revision total hip 

arthroplasty among Medicare patients with different bearing surfaces. Clin 

Orthop Relat Res. 2010;468:2357-62. 

2. Froimson MI. Paper No. 232: Administrative Data is a Poor Surrogate for 

Clinical Outcomes. In: American Academy of Orthopaedic Surgeons Annual 

Meeting. New Orleans, LA, March, 2010. 

3. Callanan MC, Jarrett B, Bragdon CR, et al. The John Charnley Award: Risk 

Factors for Cup Malpositioning: Quality Improvement Through a Joint 

Registry at a Tertiary Hospital. Clin Orthop Relat Res. 2010. 

118 




4. Allain J, Roudot-Thoraval F, Delecrin J, Anract P, Migaud H, Goutallier D. 

Revision total hip arthroplasty performed after fracture of a ceramic femoral 

head. A multicenter survivorship study. J Bone Joint Surg Am. 2003;85- 

A:825-30. 

5. Sharma V, Ranawat AS, Rasquinha VJ, Weiskopf J, Howard H, Ranawat CS. 

Revision total hip arthroplasty for ceramic head fracture: a long-term followup. 

J Arthroplasty. 2010;25:342-7. 

6. Matar WY, Restrepo C, Parvizi J, Kurtz SM, Hozack WJ. Revision hip 

arthroplasty for ceramic-on-ceramic squeaking hips does not compromise 

the results. J Arthroplasty. 2010;25:81-6.

119 

debateS oN CoNtemporary iSSueS iN 

total kNee replaCemeNt (b) 



SympoSia AR KNEE 

Moderator: Arlen D. Hanssen, MD, Rochester, MN 

Ten mini-debates on patient-specific instruments, femoral component design, new bearing surfaces, perioperative pain 

management, drain use, stem fixation, patellar bone loss, and infected knee replacement. 

I. Introduction of Symposium and 

Moderator 1st Session 

Arlen D. Hanssen, MD, Rochester, MN 

II. Patient-Specific Instruments Primary TKA: For 

Adolph V. Lombardi, MD, New Albany, OH 

III. Patient-Specific Instruments Primary TKA: Against 

Thomas P. Vail, San Francisco, CA 

IV. Multi-Radius Femoral Geometry 

Aaron G. Rosenberg, MD, Chicago, IL 

V. Single Radius Femoral Geometry 

Ormonde M. Mahoney, MD, Athens, GA 

VI. High Flexion Design Improves Motion 

Michael A. Kelly, MD, Hackensack, NJ 

VII. High Flexion Design Does Not Improve Motion 

William L. Healy, MD, Burlington, MA 

VIII. Cross-linked Polys Should Be Used In TKR: For 

Aaron A. Hofmann, MD, Holladay, UT 

IX. Cross-linked Polys Should Be Used In TKR: Against 

Kevin L. Garvin, MD, Omaha, NE 

X. Multi-modal Regional Block Protocols 

Mark W. Pagnano, MD, Rochester, MN 

XI. Peri-articular Injections For Optimal Pain Control 

Chitranjan S. Ranawat, MD, New York, NY 

XII. Audience Questions and Answers 


XIII. Moderator 2nd Session 

Robert B. Bourne, MD, London, ON, Canada 

XIV. CPM Machines Are Beneficial Following TKR 

Robert G. Booth, Jr., MD, Philadelphia, PH 

XV. CPM Machines Are Not Beneficial Following TKR 

Steven J. MacDonald, MD, London, ON, Canada 

XVI. Drains Should Be Used After TKR 

Gerard A. Engh, MD, Alexandria, VA 

XVII. Drains Do Not Need To Be Used After TKR 

Michael E. Berend, MD, Mooresville, IN 

XVIII. Revision Stems Should Be Cemented 

Robert T. Trousdale, MD, Rochester, MN 

XIX. Revision Stems Should Be Press-Fit And Uncemented 

Christopher L. Peters, MD, Salt Lake City, UT 

XX. Biconvex Patella For The Thin Revision Patella 

Robert B. Bourne, MD, London, Canada 

XXI. Bone Grafting For The Thin Revision Patella 


XXII. Static Spacers for Infected TKR 

Giles R. Scuderi, MD, New York, NY 

XXIII. Mobile Spacers for Infected TKR 

Thomas K. Fehring, MD, Charlotte, NC 

XXIV. Audience and Faculty Questions 

Robert B. Bourne, MD, London, ON, Canada 

XXV. Adjourn

120 

patieNt SpeCiFiC iNStrumeNtS For primary tkr: For 

Adolph V. Lombardi, Jr., MD, FACS 

Patient specific positioning guides for total knee arthroplasty (TKA) 

have been introduced with several significant goals. This technology 

facilitates preoperative planning by providing the surgeon with a 

three dimensional (3-D) anatomical reconstruction of the knee, 

thereby improving the surgeon’s understanding of the preoperative 

pathology. Intramedullary canal penetration of the femur and tibia 

is unnecessary, and consequently, any potential for fat emboli is 

eliminated. Component position and alignment are improved 

with decreased outliers. Surgical time is reduced due to intense 

preoperative planning and a decreased number of surgical steps. 

Operating room efficiency is improved in both set up time and 

turn over time. This instrument decrease has the potential to reduce 

operating room field contamination. A further benefit of decreased 

instrumentation is a decreased burden for cleaning and sterilizing of 

instruments. 

It is in response to the conundrum of limited accuracy of intramedullary 

and extramedullary alignment guides and chaos caused 

by computer assisted orthopaedic surgery that patient specific 

instruments were developed. Patient specific instruments utilize 

detailed magnetic residence imaging (MRI) or computed tomography 

(CT) scans of the patient’s knee with additional images from the 

hip and ankle for determination of critical landmarks. From these 

studies a 3-D model of the patient’s knee is created and with the 

integration of rapid prototyping technology, guides are created to 

apply to the patient’s native anatomy to direct the placement of the 

cutting jigs and ultimately the placement of the components. 

Technique of Patient Specific Instrumentation 

The steps in considering utilization of patient specific instruments 

are as follows: 1) the surgeon determines that the patient is a 

candidate for TKA, 2) an MRI or CT scan is obtained at an approved 

facility in accordance with a specific protocol, 3) the MRI or CT 

is forwarded to the manufacturer, 4) the manufacturer creates the 

3-D reconstructions, anatomical landmarks are identified, implant 

size is determined, and ultimately femoral and tibial component 

implant placement determined via an algorithm, 4) the surgical plan 

is executed, 5) the physician reviews and modifies or approves the 

plan, 6) the jigs are then produced via rapid prototyping technology 

and delivered to the hospital for the surgical procedure. 

Guides generated from MRIs are designed to uniquely register on 

cartilage surface whereas guides produced from CT scans must 

register on bony anatomy. There are currently two types of guides 

produced: those which register on the femur and tibia and allow for 

the placement of pins to accommodate the standard resection blocks; 

and those produced by some manufacturers which accommodate 

the saw blade and therefore are a combination of resection and pin 

guides. Performance of the TKA procedure is facilitated by the patient 

specific instruments as the surgeon, manufacturer’s representative 

and surgical team aware of sizing required for the patient. Most 

manufacturers have streamlined the surgical instruments based on 

this preoperative knowledge; therefore, reduced OR set up time. 

Surgical approach is based on surgeon preference. Once the distal 

femur and proximal tibial are exposed the femoral guide is registered 

on the femur. The surgeon can choose to have the model of the 

patient’s femur and tibia on the field in order to visualize registration 

of the guide on the model and then determine if the guide registers 

in a similar fashion on the patient. Once the guide is registered, it 

is then pinned in place if being used as a resection guide or the drill 

holes are placed for the distal femoral cutting block and for the 4-in- 




1 cutting block. The guide is then removed and the distal femoral 

resection and the AP and chamfer resections are performed. The 

tibia is then exposed and the tibia guide is registered. The drill pins 

are then placed for the tibial resection guide. Some manufacturers 

offer assistance in sizing the tibia and rotation of the tibia. The tibial 

resection guide is then placed and tibial resection is performed. 

These patient specific guides assist the surgeon in performing 

appropriate bone resections. However, they do not substitute for 

the other requirements of TKA, namely attention to the soft tissues. 

Only after the bony resections are performed should any peripheral 

osteophytes be removed since these actually secure the registration 

of the guides and are integral to the accurate placement of the guides. 

These patient specific guides should be thought of as adjunctive 

instrumentation to assist in proper positioning of femoral and tibial 

components. 

Validation 

Two surgeons performed bilateral TKA on nine cadavers, using 

standard instrumentation on one side and custom guides 

contralaterally. TKA were evaluated postoperatively with CT for 

accuracy of femoral and tibial resection and femoral rotation. 

Outliers were defined as >3˚ from goal. Accuracy for standard versus 

custom-guided cadaveric TKA femoral alignment averaged 2.1°±1.8˚ 

versus 1.5°±1.4°, for rotation averaged 1.6°±1.1˚ versus 1.0°±0.6°, 

and for tibial alignment averaged 1.3°±0.8˚ versus 1.5°±0.7°, which 

are not significantly different with numbers available. There were 

four outliers overall in the standard group versus one using customguides 

(NS). 

Using patient-specific guides we have performed primary TKR in 

405 patients (469 knees). There have been no adverse events related 

to the use of the guides. 91 custom-guided TKA were matched 

retrospectively to 91 randomly selected TKA performed with manual 

instrumentation during the same time period. Postoperative 

standard AP standing radiographs were evaluated via a calibrated 

picture archiving and communication system by an independent 

observer for femorotibial, femoral component, and tibial component 

alignment. Outliers were defined as >3˚ from goal. In the standard 

film radiographic study, femorotibial, femoral component, and 

tibial component alignment were all significantly more accurate 

using custom guides. Furthermore, there were more outliers in the 

standard group (6.6%; 18/273) than the custom-guided group 

(1.5%; 4/273; p=0.002). 

In a separate radiographic review, long-leg standing alignment 

radiographs were obtained postoperatively for 93 TKA, including 59 

performed with custom guides and 34 with manual instrumentation. 

Restoration of the mechanical axis was measured by an independent 

observer. The mechanical axis was restored within the central third 

of the tibia in 90% of custom-guided TKA versus 85% of TKA 

performed with manual instrumentation. 

In a study to determine the radiographic accuracy of an MRI-based 

custom guides and compare it to traditional manual instrumentation, 

the mechanical axis and component alignment were measured on 

postoperative long-leg standing radiographs by two independent 

observers in a case-control series of 464 consecutive TKA (364 customguided, 

100 manual instrumenta-tion) performed by a single surgeon 

In all cases involving manual instrumentation, extramedullary tibial 

and intramedullary femoral jigs were used. The mechanical axis of 

the extremity passed through the central third of the tibia more often

with custom guides (87.9%) compared to manual instrumentation 

(77%) (p

122 

patieNt SpeCiFiC iNStrumeNtS For primary tkr: For 

Thomas Parker Vail, MD 

Introduction. 

Patient specific instruments have been developed as an alternative to 

standard instrumentation for total knee replacement. The concept 

is that customized cutting blocks can be created using preoperative 

imaging. The cutting blocks would be fabricated to fit the distal femur 

and proximal tibia and direct a saw cut in the predetermined direction. 

Imaging prior to surgery is used to determine the appropriate size, 

cutting axis in the sagittal, coronal, and axial planes, and depth of 

bone resection. This concept has conceptual appeal, but multiple 

serious pragmatic and philosophical shortcomings at this time. 

Patient perspective. 

The most appealing argument for this concept is based upon the 

flawed concept that this technology creates a patient specific total 

knee implant. One can conjure a “personalized medicine” story to 

go along with the fabrication of a cutting system that is based upon 

the patients’ own anatomy. The reality is that the implants are not 

different than implants used with standard cutting systems. The 

other reality is that true “customization” in knee surgery is achieved 

with intraoperative decision-making, not assumptions based upon 

static imaging done in the radiology suite. 

Surgeon perspective. 

For a surgeon looking for a way to sell his/her practice, the concept 

of marketing a total joint program around a “customized” approach 

has appeal. However, one can argue that such an approach would 

be disingenuous as it relates to this particular technology given the 

points previously stated about the reality of what is actually being 

delivered to the patient. The surgeon must add to his/her volume 

of work required to perform a total knee replacement when this 

technology is employed. There is a significant but undefined cost 

associated with the (unreimbursed) time associated with measuring, 

templating and estimating sizes, cuts, cartilage thickness, etc. 

The accuracy and efficiency of the technology is not proven in the 

published literature. One preliminary report describes 21 cases, two 

of which had tibial resections outside of the desired window of 

accuracy.(1) The difference in tourniquet time between the standard 

technique and the custom blocks was only 13 minutes in that series. 

Anecdotally, surgeons have reported that the femoral blocks seem to 

fit the distal femur reasonably well, but the tibial blocks are not as 

stable or accurate. The presence of a flexion contracture, soft tissue 

contracture, or unanticipated abnormality in the bone anatomy has 

the potential to render a custom cutting block unstable, or at worst, 

inaccurate in guiding either the direction or depth of resection. 

Even when employing a custom block, patterns of instability or 

contracture still require intra-operative decision-making, with 

confirmation of overall alignment, balanced gaps, and proper patella 

tracking. The custom block system is not robust when it comes to 

changing alignment, recutting, the bone surfaces, or dealing with 

any unanticipated challenges related to balancing and sizing. 

REFERENCES. 

1. Spencer BA, Mont MA, McGrath MS, Boyd B, Mitrick MF. Initial experience 

with custom-fit total knee replacement: intra-operative events and long-leg 

coronal alignment. Int Orthop (2009) 33:1571-1575. 




Hospital perspective. 

If one can assume that the administration of the hospital relies upon 

the surgeon to make the call regarding the quality of the surgery and 

the product that is delivered to the patient, then the surgeon might 

be able to interest the hospital in this technology if data on quality 

were available. The lack of clinical data on this technique means 

that neither the surgeon nor the vendor can make a valid claim in 

support of this new product to a hospital technology assessment 

committee. 

If the quality is demonstrated, the next question that a hospital 

administrator will ask before supporting a new product or system 

centers on the “value” of the product. For example, a technology 

assessment committee might ask “is this method advantageous 

because it provides superior quality, better value, or a unique 

clinical niche?” The answer is no, unless the hospital sees value in 

embarking upon a marketing campaign unsupported by facts. At 

this point, the only win is for the vendor who would potentially 

gain the opportunity to sell to the hospital both the implant and 

the instruments (custom blocks). This situation could represent a 

major cost shift to the hospital, since the vendor was previously 

taking responsibility for providing the instruments and only selling 

the implant to the hospital. Other scenarios that could ultimately be 

important include the cost associated with wasting blocks that do 

not work as intended, 

Payer perspective. 

The payer perspective will be similar to the hospital perspective, with 

the additional caveat that the payer is now being asked to cover the 

costs associated with the advanced imaging required to fabricate 

the custom cutting blocks, in addition to the cost of the blocks 

themselves, the implants, the surgery, the surgeon, etc. Unless the 

custom cutting block system has a positive impact on the patient 

experience or significantly impacts the overall paradigm of care in 

total knee replacement, it is logical to assume that this approach will 

be met with skepticism. 

The “value proposition.” 

At present, the technology provides no value proposition for the 

patient, the surgeon, or the hospital. Because the fabrication of the 

cutting blocks and the imaging represents an additional charge for 

each case, the incremental cost to the system may be more than the 

cost of a computer navigation system or a robotic system that can 

be amortized over the time of use or anticipated volume of cases 

to which the technology is applied. The technology increases the 

volume of images done simply for the sake of creating the cutting 

blocks, these are not images that would otherwise be obtained. 

While musculoskeletal healthcare has benefited immeasurably from 

the development of new technology, the health system in the United 

States is also desperately in need of systems that increase quality for 

lesser cost. If the custom cutting block system can somehow change 

the paradigm of total knee replacement through value to the patient 

or the system, then it will be welcomed by all.

123 

multi-radiuS Femoral kNee geometry 

Aaron G Rosenberg MD, FACS 

During flexion the surfaces of the femur and tibia interact in a 

complex pattern with the contact points of the femur and tibia 

moving relative to one another. 2, 4, 9, 10, 11, 12, 13, 14 Some of the motion 

occurs through rolling while some is sliding. Pure rolling involves 

rotation about a contact point between a sphere or cylinder and 

a flat surface (in knees this would be represented by the tibiofemoral 

contact point-though this is not purely a flat surface). As 

rolling occurs it is accompanied by translation of one body relative 

to the other (rollback). In this situation as the opposing surfaces 

contact each other they translate relative to one another so that their 

contact areas are constantly changing. Pure sliding occurs when one 

surface contact region translates relative to a stationary area on the 

opposing contact surface. This motion can be measured about the 

center of a sphere or cylinder but results in no relative translation 

(no rollback). 

Normal knee motion is a complex combination of rolling and 

sliding with rolling pre-dominating in extension and early flexion 

(the stance phase of gait). The natural anatomy of the condyles is 

asymmetric. The distal aspect of the lateral condyle clearly has a 

larger radius and is flatter than the distal medial condyle. 1, 7, and 8 The 

medial condyle is more prone to sliding and is the basis of a term 

such as “medial pivot.” As flexion progresses rolling is more dramatic 

on the lateral condyle and is accompanied by posterior translation 

of the femur relative to the tibia. 

A single radius femur that only slides—that is to say it simply rotates 

about a single axis of flexion is an over-simplification of normal 

knee motion. Not to say that it can’t be forced upon the knee by 

design of the implant. A classic example is the “hinged” knee of 

several decades ago as a pure hinge is a true single radius design. 

The argument for a single radius design is that there is a single axis 

of flexion approximated by the TEA. This is an over-simplification of 

actual knee motion simply rotating about this axis that could only 

be true if knee motion was pure rolling. Motion at the femoro-tibial 

articulation is a combination of rolling and sliding with no single 

axis of flexion. The center of rotation varies instantaneously between 

REFERENCES: 

1. Pinskerova, V. et al. “The shapes and relative movements of the femur and 

tibia in the unloaded cadaveric knee: A study using MRI as an anatomic 

tool.” Chapter 10. In Surgery of the Knee, J.N. Insall & W. N. Scott (Eds.), 3rd 

Edition, pp. 255-282. 

2. Pinskerova, V. et al. “Does the femur roll-back with flexion?”, JBJS-Br, 86- 

B(6), 925-931, 2004. 

3. Li, G. et al. “Three-dimensional tibiofemoral articular contact kinematics of a 

cruciate-retaining total knee arthroplasty”, JBJS-Am, 88-A(2): 395-402, 2006. 

4. Komistek, R.D. et al. “In vivo determination of total knee arthroplasty 

kinematics”, J. Arthroplasty, 23(1): 41-50, 2008. 

5. Banks, S.A. and W.A. Hodge. “Design and activity dependence of kinematics 

in fixed and mobile-bearing knee arthroplasties”, J. Arthroplasty, 19(7): 809- 

816, 2004. 

6. Nuno, N. and A.M. Ahmed. “Three-dimensional morphometry of the 

femoral condyles”, Clinical Biomechanics, 18: 924-932, 2003. 

7. Siu, D. et al. “Femoral articular shape and geometry: A Three-dimensional 

computerized analysis of the knee”, J. Arthroplasty, 11(2): 166-173, 1996. 




the arc center of the femoral sagittal radius and the tibio-femoral 

contact point depending on the amount of rolling or sliding at any 

degree of flexion. 

When considering maintenance of the normal ligamentous 

structures of the knee (such as the PCL alone or both the ACL and 

PCL) the kinematic interaction of the femur and tibia should model 

that of the normal articular surfaces such that ligament tension is 

appropriate through out the range of motion. The single radius 

design eliminates this possibility and replaces it with motions that 

are designed to approximate an average center of rotation. This is 

more effective when the knee is going to roll only and not slide. 

While multiple knee designs with PCL retention have been shown 

to have “paradoxical” anterior motion occurring during flexion, 

similar analysis of patients operated on by different surgeons using a 

femoral implant designed with asymmetrical condylar radii were the 

only CR knees found to demonstrate normal differential posterior 

motion of the condyle on the lateral tibia. The more normal knee 

kinematics were attributed to the differential radius of curvature of 

the medial and lateral condyles. 15 

In a study of single radius, multi-radius, asymmetric, and symmetric 

condyle knees kinematics the asymmetric design was the only one 

demonstrating a slightly medial center of axial rotation during the 

stance phase of gait (as seen in normal knee function) while the 

single radius design had a slightly lateral center. 6 

Even when considering the posterior stabilizing knee designs, no 

femoral component are truly single radius. Portions of the surface 

arcs are single radius, but most are very similar in this regard, even 

though they are “described by their manufacture as something 

different for marketing purposes. For example one PS “multi-radius” 

knee design has a constant radius over an arc of 114˚ (from 17˚- 

131˚) and a smaller radius for increased flexion beyond 131˚ while 

a knee marketed as “single radius” has a true single radius over an 

arc of 100˚ (10˚-110˚). The more the designer wants to accommodate 

normal motion and normal ligament tension when ligaments are 

retained, the more a single radius will not do what’s needed. 

8. Scarvell JM, et. al. Comparison of kinematic analysis by mapping 

tibiofemoral contact with movement of the femoral condylar centres in 

healthy and anterior cruciate ligament injured knees. J Orthop Res. 2004 

Sep;22(5):955-62. 

9. Iwaki H, et. al. Tibiofemoral movement 1: the shapes and relative 

movements of the femur and tibia in the unloaded cadaver knee. J Bone 

Joint Surg Br. 2000 Nov;82(8):1189-95. 

10. Hill PF, et. al. Tibio-Femoral movement 2: the loaded and unloaded living 

knee studied by MRI. J Bone Joint Surg Br. 2000 Nov;82(8):1196-8. 

11. Nakagawa S, et.al. Tibiofemoral movement 3: full flexion in the living knee 

studied by MRI. J Bone Joint Surg Br. 2000 Nov;82(8):1199-200. 

12. Freeman MA, Pinskerova V. The movement of the normal tibio-femoral joint. 

J Biomech. 2005 Feb;38(2):197-208. 

13. Johal P, et.al. Tibio-femoral movement in the living knee. A study of weight 

bearing and non-weight bearing knee kinematics using ‘interventional’ MRI. 

J Biomech. 2005 Feb;38(2):269-76. 

14. Komistek R, et. al. In vivo determination of total knee arthroplasty 

kinematics: a multicenter analysis of an asymmetrical posterior cruciate 

retaining total knee arthroplasty. J Arthroplasty. 2008 Jan;23(1):41-50.

124 

SiNgle radiuS Femoral geometry 

Ormonde Mahoney, MD 

The single flexion / extension axis of the distal femur was first 

identified between 1982 and 1986 by then doctoral student, 

Mark Kester. He utilized a devise called an axis finder, which was 

being used by Paul Brand to localized the centers of rotation of 

the phalanges. Kester was searching for the isometric position for 

attachment of soft tissue for extra-articular tenodesis procedures for 

anterior cruciate instability. Kester realized that the femoral condyles 

appeared spherical when viewed along the axis. 1 

The realization that the majority of the weight bearing articular surface 

of the distal femur could be described as a sphere has subsequently 

been confirmed by a number of independent investigators. 2-7 This 

anatomic characteristic has several implications for total knee 

design. 

First, since the surface is spherical there is only one rotational axis in 

the distal femur and it lies posterior to the axis incorporated in most 

classic total knee designs. Utilizing a single more posterior flexion 

axis results in a longer extensor moment arm and the potential for 

improved quad function. This has been shown in bench testing as 

well as in the clinical setting. 8-10 

REFERENCES 

1. Kester M. Biomechanical implications of transverse centers of rotations of 

normal and pathologic knees [Dissertation]. Tulane University Graduate 

School, 1985. 

2. Hollister AM, Jatana S, Singh AK, Sullivan WW, Lupichuk AG. The 

axes of rotation of the knee. Clinical Orthopaedics & Related Research 

1993(290):259-68. 

3. Churchill DL, Incavo SJ, Johnson CC, Beynnon BD. The transepicondylar 

axis approximates the optimal flexion axis of the knee. Clinical Orthopaedics 

& Related Research 1998(356):111-8. 

4. Eckhoff DG, Bach JM, Spitzer VM, Reinig KD, Bagur MM, Baldini TH, 

Flannery NM. Three-dimensional mechanics, kinematics, and morphology 

of the knee viewed in virtual reality. The Journal Of Bone And Joint Surgery. 

American Volume 2005;87 Suppl 2:71-80. 

5. Freeman MAR, Pinskerova V. The movement of the knee studied by magnetic 

resonance imaging. Clinical Orthopaedics & Related Research 2003(410):35- 

43. 

6. Freeman MAR, Pinskerova V. The movement of the normal tibio-femoral 

joint. Journal of Biomechanics 2005;38(2):197-208. 

7. Pinskerova V, Iwaki H, Freeman MA. The shapes and relative movements of 

the femur and tibia at the knee. Orthopade 2000;29 Suppl 1:S3-5. 

8. Mahoney OM, McClung CD, dela Rosa MA, Schmalzried TP. The effect of 

total knee arthroplasty design on extensor mechanism function. The Journal 

Of Arthroplasty 2002;17(4):416-421. 




Second, by maintaining a single flexion axis throughout the majority 

of the weight bearing arc, there is not radius change which could result 

in a symptomatic instability in mid-flexion where the change occurs 

in many femoral component designs. In one gait lab study patients 

with multi radius knees demonstrated out of plane antagonistic 

muscle co-contractions as they crossed the zone of radius change. 

This antagonistic muscle activity was not seen in a second group of 

patients treated with a single axis knee. 11 

Third, since the normal condyles are spherical, it is intuitive that 

restoring normal geometry during arthroplasty may be more likely 

to result in more normal post-arthroplasty knee kinematics. Several 

radiographic studies have demonstrated just that. 12,13 In fact, Tamaka 

has demonstrated nearly normal rotational kinematic deflections in 

a posterior stabilized single radius total knee design. 13 

In summary, single radius knees have been shown to offer improved 

potential for approaching more normal knee kinematics when 

studied through multiple modalities and by multiple authors than 

some multi-radius knee designs, with out sacrificing durability. 14,15 

9. D’Lima DD, Poole C, Chadha H, Hermida JC, Mahar A, Colwell CW, Jr. 

Quadriceps moment arm and quadriceps forces after total knee arthroplasty. 

Clinical Orthopaedics And Related Research 2001(392):213-220. 

10. Hall J, Copp SN, Adelson WS, D’Lima DD, Colwell CW, Jr. Extensor 

mechanism function in single-radius vs multiradius femoral components for 

total knee arthroplasty. The Journal Of Arthroplasty 2008;23(2):216-219. 

11. Wang H, Simpson KJ, Chamnongkich S, Kinsey T, Mahoney OM. A 

biomechanical comparison between the single-axis and multi-axis total knee 

arthroplasty systems for the stand-to-sit movement. Clinical Biomechanics 

(Bristol, Avon) 2005;20(4):428-433. 

12. Mahoney OM, Kinsey TL, Banks AZ, Banks SA. Rotational kinematics of 

a modern fixed-bearing posterior stabilized total knee arthroplasty. The 

Journal Of Arthroplasty 2009;24(4):641-645. 

13. Tamaki M, Tomita T, Yamazaki T, Hozack WJ, Yoshikawa H, Sugamoto K. In 

vivo kinematic analysis of a high-flexion posterior stabilized fixed-bearing 

knee prosthesis in deep knee-bending motion. The Journal Of Arthroplasty 

2008;23(6):879-885. 

14. Mahoney OM, Kinsey TL. 5-to 9-year survivorship of single-radius, posteriorstabilized 

TKA. Clinical Orthopaedics and Related Research 2008;466:436- 

442. 

15. Kolisek FR, Barnes CL. Scorpio posterior-stabilized knee system: 5-year 

clinical and functional results. Journal of Arthroplasty 2006;21(8):1187-92.

125 

high FleXioN deSigN improveS motioN 

Michael A. Kelly, MD 

I. High Flexion after total knee replacement – increasingly 

important. 

A. Younger, more active patients. 

B. Better pre-op flexion. 

C. Asian lifestyles 

D. Middle Eastern – Religious demand. 

E. Patient expectations. 

II. Range of Motion following TKA is multifactorial. 

A. Patient 

1. pre-op range of motion. 

2. motivation 

B. Surgical techniques 

C. Implant design 

III. Regular TKA designs –concerns with high flexion. 

A. Posterior tibial polyethylene contact stresses/edge loading 

>130˚ flexion. 

B. Flexion instability 

C. Patellofemoral stresses 

IV. High Flexion Designs introduced into TKA. 

A. Posterior Cruciate substituting TKA 

B. PCL Retaining TKA 

C. Fixed and Mobile Bearings 

V. Design features in High Flexion TKA – 

A. Increased conformity with improved tibio-femoral contact 

stresses at high flexion. 

B. TKA designs to safely achieve 150-155˚ flexion. 

C. Fixed and Mobile-Rotating Platform designs. 

D. Improved tibial spine-femoral cam mechanics in PCL 

substituting designs. 

E. Increased Patellar tendon excursion with anterior tibial 

recess. 

VI. High Flexion TKA literature. 

VII. Morra et al. 

A. Six contemporary HF TKA designs (three cam-post; 3 no 

cam-post) 

REFERENCES 

1. Argenson, JN; Scuderi GR, Komistek RD, Scott WN, Kelly MA and Aubanrac 

JM: In vivo kinematic evaluation and design considerations related to high 

flexion in total knee arthroplasty. J. Biomech 38 (2):277-284, 2005. 

2. Barink, M, DeWahl Malefijt M, Celeda P, Vena P, VanKampen A and 

Verdonschot N. A mechanical comparison of high-flexion and conventional 

total knee arthroplasty. Proc I Mech E, Part H. Journal of Engineering on 

Medicine 2008 Vol 222 #3 p297-307. 

3. Bellemans J, Banks S, Victor J, Vandenneucker H, Moemans A. Fluoroscopic 

analysis of the kinematics of deep flexion in total knee arthroplasty. 

Influence of posterior condylar offset. J. Bone Joint Surg Br. 2002;84:50-3. 

4. Gupta SK, Ranawat AS, Shah V, Zikria BA, Zikria JF and Ranawat CS. The PFC 

Sigma RP-F TKA designed for improved performance: a matched-part study. 

Orth. 2006:29 (9 suppl): 49-52. 

5. Kim YH, Choi Y, Kim JS. Range of motion of standard and high-flexion 

posterior cruciate-retaining total knee prostheses a prospective randomized 

study. J Bone Joint Surg Am. 2009;91:1874-81. 




B. Complications Kinematics 

C. Cam-Post Designs 

1) more high flexion 

2) less osseus impingement 

VIII. Most E, CORR 2006 

A. Conventional tibiofemoral contact poly posterior edge 15- 

30˚ before high flexion design. 

B. HF-TKA contact areas similar to conventional. 

C. Improved tibiofemoral contact biomechanics with highflex 

CR TKA with flexion 150°. 

IX. Liet al. JBJS A 2004. 

A. 13 cadaveric knees with high flexion PS TKA design – robotic 

testing system. 

B. Femoral component geometry with high flexion design and 

increased posterior conformity up to 150˚ flexion improved 

tibiofemoral contact mechanics. 

X. McCalden RW et al. 

A. Evaluated conventional CR/PS and High flex PS designs 

B. Patients with high flexion pre-op were more likely to gain 

flexion with HF-PS design. (HF 32%; PS 15%; CR 4.5%) 

XI. Clinical studies 

A. No difference conventional CR or PS and High flex design. 

B. No difference HF CR vs. PS. 

C. Ranawat -Improved flexion with rotating platform HF design 

vs conventional. 

D. Most studies performed in Asian population with high preop 

flexion. 

XII. Summary 

A. High flexion after TKA multifactorial ie. patient surgical 

technique and implant design. 

B. High flexion designs have improved high flexion contact, 

reduced polyethylene stresses. 

C. These designs allow a more optimal environment for high 

flexion after TKA. 

D. Clinical significance of these designs in short term follow-up 

still to be determined. 

6. McCalden RW, MacDonald SJ, Charron KDJ, Bourne RB and Naudie DD. 

The role of polyethylene design on post operative TKA flexion: an analysis of 

1534cases. Corr 2009 Vol 468 Issue 1 

7. Morra EA, Rosca M, Greenwald JFI and Greenwald AS. The influence of 

contemporary knee design on high flexion. A kinematic comparison with the 

normal knee. JBJS 2008;90A:195-201. 

8. Most E. Tibio-femoral contact behavior is improved on high-flexion cruciate 

retaining TKA. Corr 2006-Vol 452, Pg. 59-64. 

9. Nutton RW, Vanderlinden ML, Gaston P and Wade FA. A perspective 

randomized double-blind study of functional outcome and range of flexion 

following total knee replacement with the NexGen standard and high flexion 

components. JBJS 2008;90-B Issue 1 37-42. 

10. Sultan PG, Most E. Schule S. Li G, Rubash HE. Optimizing flexion after total 

knee arthroplasty: advances in prosthetic design. Clin Orthop Related Res. 

2003; 416 -167-73.

126 

high FleXioN deSigN doeS Not improve kNee motioN 

William L. Healy, MD 

Range of motion following total knee arthroplasty is associated 

with: pre-operative range of motion, surgical technique, the TKA 

implant, and patient compliance with physical therapy. 1 Excellent 

range of motion for TKA has been defined as 120-125˚ flexion to 

full extension (0˚). Satisfactory range of motion has been defined 

as 105˚-110˚ flexion to 0-5˚ short of full extension, and this range of 

motion is compatible with walking, kneeling, using an eighteen inch 

high toilet, and climbing nine to twelve inch high stairs. 2 

High flexion TKA designs have been developed to increase the 

flexion arc of reconstructed knees and increase functional range of 

motion. Specific design features used in high flexion TKA designs 

to allow additional femoral roll back, enhanced posterior femoral 

translation, and a 155˚ flexion arc include: 3,4 

• Decreasing sagittal radii of curvature on the posterior femoral 

condyle. 

• Increased posterior femoral condylar offset. 

• Thicker posterior femoral condyle. 

• Increased posterior femoral condyle conformity. 

• Thicker posterior femoral condyle. 

• Improved condylar contact in flexion. 

• Longer patello-femoral trochlear groove on the femoral implant. 

• Anterior recess for the patella tendon on the tibial implant. 

For posterior stabilized knees, high flexion TKA design changes also 

include: 

• Moving the tibial intercondylar post posteriorly. 

• Increasing the height of the tibial intercondylar post to increase 

the jump distance. 

• Increasing the depth of the intercondylar box on the femoral 

implant. 

Some high flexion TKA designs incorporate mobile bearings on the 

tibial implant. In order to answer the question of whether high flex 

knee designs increase range of motion, we must consider the three 

variables associated with range of motion. 

Pre-operative Range of Motion: 

The potential benefit of increasing range of motion with a high flex 

knee design is not likely unless the pre-operative range of motion is 

greater than 125˚. This is not common in western cultures. In Asian, 

REFERENCES 

1. Ranawat CS, Design May Be Counterproductive for Optimizing Flexion After 

TKA. Clinical Orthopaedics. 416:174-176, November 2003. 

2. Rowe PJ, Myles CM, Walker C, Nutton R. Knee Joint Kinematics in Gait and 

Other Functional Activities Measured Using Flexible Electrogoniometry: How 

Much Knee Motion is Sufficient for Normal Daily Life? Gait Posture. 12:143- 

155, 2000. 

3. Long WJ, Scuderi GR. High Flexion Knee Arthroplasty. Journal of 

Arthroplasty 23:7. Supp.1, 6-10. October 2008. 

4. Kelly MA. High-Flexion Knees: More Hype Than Hope? In Opposiion. 

Journal of Arthroplasty 21:4, Supp 1, 42-43. 2006. 

5. Kim YH, Choi Y, Kim J-S. Range of Motion of Standard and High 

Flexion Posterior Cruciate Retaining Total Knee Prosthesis: A Prospective 

Randomized Study. Journal of Bone & Joint Surgery. 91A, No. 8, August 

2009. 

6. Seon JK, Park SJ, Lee KB, Yoon TR, Kozanek M, Soong EK. Range of Motion 

in Total Knee Arthroplasty: A Prospective Comparison of High Flexion and 

Standard Cruciate Retaining Designs. Journal of Bone & Joint Surgery, 91A, 

No. 3, March 2009. 




Indian and Muslim cultures, where pre-operative range of motion 

in arthritic knees may be 120-140˚, the high flex TKA implants may 

offer a functional benefit. 

Surgical Technique: 

The technique of implanting a high flex TKA implant is not 

substantially different from implanting a standard TKA implant. 

There are small differences in preparation of the distal femoral bone, 

but this is guided by instruments. When using hi-flex implants, 

surgeons must avoid matching high flex TKA implants with standard 

TKA implants. 

TKA IMPLANTS: 

Posterior Cruciate Retaining: 

Two investigators evaluated the impact of high flex TKA implants with 

posterior cruciate retaining designs using a prospective randomized 

clinical trial. High flex PCR designs did not increase range of motion 

compared with standard TKA implants. 5,6 

Posterior Stabilized: 

Two investigators evaluated the impact of high flex TKA implants 

with posterior stabilized designs using a prospective randomized 

clinical trial. High flex PS designs did not increase range of motion 

compared with standard TKA implants. 7,8 

Current data suggest that high flexion TKA implants do not improve 

range of motion. 9 Furthermore, recent data suggest that in the event 

high flexion TKA implants do improve range of motion, they are not 

associated with improved patient satisfaction or increased patient 

function. 10-11 

High flexion TKA 

May offer Asian, Indian, and Muslim patients who maintain 

high knee range of motion (130-150˚) with an arthritic knee the 

opportunity to regain painless high range of motion following TKA. 

Western patients who routinely participate in high flexion activities 

may also benefit from high flexion TKA implants. 

No. High flexion TKA designs do not improve range of motion 

following TKA. If pre-operative range of motion is greater than 125- 

130˚, high flexion TKA implants may have some benefit. 

7. McCalden RW, McDonald SJ, Bourne RB, Marr JT. A Randomized Control 

Trial Comparing “High Flex” vs. “Standard” Posterior Cruciate Substituting 

Polyethylene Tibial Inserts in Total Knee Arthroplasty. Journal of 

Arthroplasty. Vol. 24, No.6. Supplement 1. September 2009. 

8. Nutton RW, van der Linden ML, Rowe PJ, Gaston P, Wade FA. A Prospective 

Randomised Double Blind Study of Functional Outcome and Range of 

Flexion Following Total Knee Replacement With the NexGen Standard and 

High Flexion Components. Journal of Bone & Joint Surgery. 90B, No. 1, 

January 2008. 

9. Ghandi R, Tso P, Davey JR, Mahomed NN. High Flexion Implants in Primary 

Total Knee Arthroplasty: A Metanalysis. The Knee. 16:14-17. 2009. 

10. Devers BN, Conditt MA, Jamieson ML, Driscoll MD, Noble PC, Parsley BS. 

Does Greater Knee Flexion Increase Patient Function and Satisfaction After 

Total Knee Arthroplasty? J. Arthroplasty. (In Press 2010.) 

11. Meneghini RM, Pierson JL, Bagsay D, Ziemba-Dalis M, Berend ME, Ritter 

MA. Is There A Functional Benefit to Obtaining High Flexion After Total 

Knee Arthroplasty? Journal of Arthoplasty. 22:6. Supp. 2, 43-46. September 

2007.

127 

CroSS-liNked polyethyleNe Should be uSed iN tkr 

Aaron A. Hofmann, MD 

Total knee arthroplasty failure mechanisms consist primarily of wear 

related issues. Irradiation induced crosslinks in the polyethylene 

significantly reduce wear. Material properties may suffer in wear 

simulator assessment of cross linked polyethylene. However, except 

for some early notable exceptions, clinical failures to date have not 

supported this in vivo. Polyethylene retrievals have demonstrated 

significant reduction in global wear due to crosslinks compared to 

REFERENCES 

1. Sharkey et al. Install Award paper. Why are total knee arthroplasties failing 

today? Clinical Orthopaedics & Related Research (2002) (404) PP. 7-13. 

2. Asano et al. Dose effects of cross-linking polyethylene for total knee 

arthroplasty on wear performance and mechanical properties. J Biomedical 

Material Research (2007) vol. 83 (2) pp. 615-22. 




conventional polyethylene which will reduce the long-term revision 

rate for wear. Highly crosslinked polyethylene shows similar clinical 

findings to standard polyethylene. In our experience, there were 

fewer revisions and fewer osteolytic lesions seen on radiographs. 

Highly crosslinked polyethylene showed good durability at this 

intermediate interval and should continue to perform well longterm. 

3. Muratoglu, Rubash, Burroughs, Harris et al : Simulated normal gait wear 

testing of a highly crossed-linked polyethylene tibial insert. J Arthroplasty 

(2007) vol. 22 (3) pp. 435- 

4. Hodrick, Hofmann et al. Highly crosslinked polyethylene is safe for use in 

total knee arthroplasty. Clinical Orthopaedics & Related Research. (2008) 

vol. 466 (11) pp. 2806-12.

128 

CroSS-liNked polyethyleNe Should Not be uSed iN tkr 

Kevin L. Garvin, MD 

The long-term success of total knee arthroplasty requires a wellfunctioning 

and durable-bearing surface. Ultra High Molecular 

Weight Polyethylene (UHMWPE) has been the primary choice for 

the bearing surface of a total knee replacement. It has performed 

remarkably well and has made severe wear due to delamination an 

infrequent problem. This otherwise unaltered UHMWPE has been 

challenged because of alternative treatments with higher crosslinking 

to reduce further wear. 

Before we can endorse highly cross-linked polyethylene (HXLPE) 

for total knee arthroplasty we must first ask how it is defined. Is it 

extra radiated with electron beams or gamma rays and with what 

radiation dosage would it be considered highly cross-linked? Is 

it remelted or annealed to below melting point? If it is annealed, 

is it sequentially annealed and with how much radiation at each 

step? Further, does this include those polyethylene bearings that are 

also impregnated with antioxidants such as Vitamin E to remove or 

stabilize the residual free radicals induced during radiation crosslinking 

theoretically, without the resultant loss of crystallinity? What 

about those in which the Vitamin E is blended at the powdered stage? 

Are they the same? And lastly, what of Cold Irradiated Mechanically 

Annealed (CIMA) UHMWPE? 

We must also ask which patients are candidates for this new 

technology. Should we be concerned about this material? We must 

remember that the benefits of highly cross-linking have come 

with known risks of reduced crystallinity up to nearly half, if melttreated 

during or after radiation. Any free radicals that remain with 

annealing can still cause oxidation in the medium to long term 

and would compromise the UHMWPE polymer chains. While not 

necessarily directly affecting wear, decreased crystallinity and/or 

reduced oxidation resistance can cause reduced strength (modulus), 

increased creep, reduced strain to fracture (toughness), and decreased 

crack propagation resistance. 

REFERENCES: 

1. Berry DJ, Bozic KJ. Current practice patterns in primary hip and knee 

arthroplasty among members of the American Association of Hip and Knee 

Surgeons. J Arthroplasty. 2010;25:2-4. 

2. Currier BH, Currier JH, Mayor MB, Lyford KA, Van Citters DW, Collier JP. 

In vivo oxidation of gamma-barrier-sterilized ultra-high-molecular-weight 

polyethylene bearings. J Arthroplasty. 2007;22:721-731. 

3. Furmanski J, Goldberg VM. Commentary on an article by B.H. Currier, 

MChE, et al.: “In vivo oxidation in remelted highly cross-linked retrievals”. J 

Bone Joint Surg Am. 2010;92:e23. 

4. Hodrick JT, Severson EP, McAlister DS, Dahl B, Hofmann AA. Highly 

crosslinked polyethylene is safe for use in total knee arthroplasty. Clin 


5. Illgen RL, Forsythe TM, Pike JW, Laurent MP, Blanchard CR. Highly 

crosslinked vs conventional polyethylene particles--an in vitro comparison of 

biologic activities. J Arthroplasty. 2008;23:721-731. 




The compromised properties may be exploited because of the 

stresses and conformity of total knee arthroplasty. The motions 

required in the knee dictate relatively nonconforming articular 

surfaces and thus higher stresses than in the hip. Any compromised 

mechanical properties can be much more punishing in knee 

replacement. Decreased fracture toughness results in risk of fracture 

of components, especially at the interlocking sites of polyethylene 

to the base plate. Patellar pegs which are also small and under shear 

stress have been noted to fracture in biomechanical studies as well. 

Are there any clinical studies supporting its use? Hodrick et al have 

published their results documenting the safety of the material with 

no catastrophic failures at the medium-term (69-82 months) followup. 

Finally, if we cannot document clinical improvement, we can 

document increased cost for the material. While our hospitals do 

have discounts for implants the cost for HXLPE is still significantly 

greater than that for standard UHMWPE. 

The particle size of the debris generated has been another argument 

against highly cross-linked UHMWPE. Even with lower overall 

volumetric or gravimetric wear, very small particles have been 

seen and however little overall wear there might be, there would 

be billions of these particles generated. Small particles are more 

biologically active than their large predecessors and their relative 

long-term influence is yet to be fully determined. 

More research is being carried out today on the many new emerging 

technologies described. It is my conclusion that we must first have a 

clearer and simplified understanding of how we define highly crosslinked 

UHMWPE so that we can accurately compare the results. 

Second, we must more fully evaluate the current and additional basic 

science studies used to corroborate this information with special 

emphasis on more stringent laboratory tests. We have seen previous 

failures with carbon fiber reinforcement, heat-pressed polyethylene, 

and Hylamer. We must not risk repeating the past. 

6. Jacofsky DJ. Highly cross-linked polyethylene in total knee arthroplasty: In 

the affirmative. J Arthroplasty. 2008;23:28-30. 

7. Oral E, Malhi AS, Wannomae KK, Muratoglu OK. Highly cross-linked 

ultrahigh molecular weight polyethylene with improved fatigue resistance 

for total joint arthroplasty: Recipient of the 2006 Hap Paul Award. J 

Arthroplasty. 2008;23:1037-1044. 

8. Ries MD. Highly cross-linked polyethylene: The debate is over--in 

opposition. J Arthroplasty. 2005;20:59-62. 

9. Rimnac C, Pruitt L, Implant Wear Symposium 2007 Engineering Work 

Group. How do material properties influence wear and fracture mechanisms? 

J Am Acad Orthop Surg. 2008;16 Suppl 1:S94-100. 

10. Rodriguez JA. Cross-linked polyethylene in total knee arthroplasty: In 

opposition. J Arthroplasty. 2008;23:31-34. 

11. Wright TM. Polyethylene in knee arthroplasty: What is the future? Clin 

Orthop Relat Res. 2005;440:141-148.

129 

CompreheNSive multi-modal paiN maNagemeNt program 

Mark W. Pagnano, MD 

I. Effective pain management 

A. Improves patient satisfaction 

B. Decreases hospital stay 

C. Facilitates discharge to home instead of to assisted care 

II. Substantial recent knowledge regarding periop-pain 

management 

A. Emphasis on multi-modal and pre-emptive approach 

B. Stay ahead of pain and you limit total analgesia 

requirements 

C. Take advantage of benefits of various medications while 

staying below threshold for side effects 

D. Avoid the use of parenteral narcotics 

III. Components of Multi-modal strategy 

A. Preoperative administration of medication 

1. Long-acting oral narcotic (sustained release oxycodone) 

2. Oral anti-inflammatory: typically a Cox-II (celecoxib) 

3. Begin night before or morning of surgery 

REFERENCES 

1. Pagnano MW, Hebl J, Horlocker T: Assuring a painless THA: a multimodal 

approach emphasizing peripheral nerve blocks. J Arthroplasty 2006; 21(sup) 

80-84 




B. Regional anesthesia 

1. Peripheral nerve blocks – most selective 

a. Psoas compartment block – indwelling catheter 

b. Sciatic nerve block – single shot vs. indwelling 

2. Spinal anesthesia 

3. Epidural anesthesia 

C. Postoperative Analgesia 

1. Sustained release oxycodone 10-20 mg bid on schedule 

2. Celecoxib 200-400 mg qday x 3 days or Ketorolac 

tromethaine 15mg IV q6 hr prn 3 doses POD #1 then 

celecoxib 

3. Acetaminophen 1000 mg 6am; Noon; 6pm on schedule 

4. Oxycodone for breakthrough pain – use a pure narcotic 

medication like oxycodone alone for this as it does 

not contain acetaminophen and you can thus avoid 

overdosing acetaminophen. 

2. Horlocker T, Kopp S, Pagnano MW, Hebl J: Analgesia for THA and TKA: a 

multimodal approach. J Am Acad Orthop Surg 2006 14:126-135. 

3. Hebl JR, Kopp SL, Ali M et al: A comprehensive anesthesia protocol that 

emphasizes peripheral nerve blockade. JBJS-Am 2005 87-S2:63-70.

peri-artiCular iNJeCtioNS For optimal paiN CoNtrol aFter tkr 

Chitranjan Ranawat, MD 

INTRODUCTION: 

Uncontrolled pain after total knee replacement has a deleterious 

effect on recovery of function, including decreased range of motion 

(ROM), higher complication rates, and poorer overall outcomes. 

MATERIALS AND METHODS: 

From October 1, 2003 through June 30, 2004, 36 patients (52 knees) 

underwent total knee replacement at our institution with an advanced 

postoperative pain management protocol. Preoperatively, all patients 

received refecoxib, 50 mg; oxycodone, 20 mg; and warfarin, 5 mg. All 

patients were given spinal anesthesia. Intraoperatively, a local mixture 

of bupivicaine. 80 mg; methylprednisolone, 40 mg; morphine, 4 

mg; , epinephrine, 300 mcg; cefuroxime 750 mg; and clonidine, 100 

mcg, was injected into the periarticular ligamentous attachments, 

posterior capsule, and quadriceps tendon arthrotomy site. Patients 

were followed with postoperative pain scales, patient assessment 

questionnaires, and monitored for narcotic requirements. 

REFERENCE 

1. Ranawat CS and Ranawat AS: The effect of modifying the acute postoperative 

pain response after TKR on recovery of function. Presented at the Knee 

Society Interim Meeting, September 2004. 

130 




RESULTS: 

During the study period, narcotic pain requirements, manipulation 

rates, and the need for prolonged physical therapy were significantly 

reduced compared to historical controls. Recovery of function and 

ROM were achieved at an earlier period. 

DISCUSSION: 

A relationship appears to exist between acute postoperative pain and 

the development of arthrofibrosis. By controlling acute pain in the 

critical early postoperative period following TKR (three days), the 

presented pain management protocol allowed for improved recovery 

of knee ROM and function with lower rates for manipulation and 

prolonged rehabilitation.

I. Origins and initial premise 

Bleeding/Edema/Fibrosis/Stiffness 

131 

Cpm maChiNeS are helpFul aFter tkr 

Robert E. Booth, Jr., MD 

II. Premise – to accelerate recovery and to increase flexion 

III. Realities 

• NSD @ 4-6 weeks and beyond 

• But: increased early motion 

Some decreased length of stay 

Some decreased pain and narcotic use 

IV. Benefits (Theoretical) 

• Decreased swelling and stiffness 

• Decreased venous stasis and DVT 

• Increased patient focus 

REFERENCES 

1. Alkire MR, Swank ML: “Use of inpatient continuous passive motion versus 

no CPM in computer-assisted total knee arthroplasty.” Orthop Nurs. 2010 

Jan-Feb;29(1):36-40. 

2. Lenssen TA, van Steyn MJ, Crijns YH, WaltjŽ EM, Roox GM, Geesink RJ, van 

den Brandt PA, De Bie RA: “Effectiveness of prolonged use of continuous 

passive motion (CPM), as an adjunct to physiotherapy, after total knee 

arthroplasty.” BMC Musculoskelet Disord. 2008 Apr 29;9:60. 

3. Denis M, Moffet H, Caron F, Ouellet D, Paquet J, Nolet L.: “Effectiveness of 

continuous passive motion and conventional physical therapy after total 

knee arthroplasty: a randomized trial.” Phys Ther. 2006 Feb;86(2):174-85. 

4. Bennett LA, Brearley SC, Hart JA, Bailey MJ.: “A comparison of 2 continuous 

passive motion protocols after total knee arthroplasty: a controlled and 

randomized study.” J Arthroplasty. 2005 Feb;20(2):225-33. 

5. Brosseau L, Milne S, Wells G, Tugwell P, Robinson V, Casimiro L, Pelland 

L, Noel MJ, Davis J, Drouin H.: “Efficacy of continuous passive motion 

following total knee arthroplasty: a metaanalysis. J Rheumatol. 2004 

Nov;31(11):2251-64. 




V. Weaknesses 

• Prioritizes flexion over extension 

• Decreased patient access and mobilization 

• Increased nursing demands 

• What to do with bilaterals? 

VII. Sociology 

• Patient demand 

• Prior surgical experience 

• Substitute for therapists 

• Home use 

VIII. So why….? 

• Why MIS? 

• Whence “evidence based medicine” 

6. Milne S, Brosseau L, Robinson V, Noel MJ, Davis J, Drouin H, Wells G, 

Tugwell P: “Continuous passive motion following total knee arthroplasty.” 

Cochrane Database Syst Rev. 2003;(2)CD004260. 

7. Davies DM, Johnston DW, Beaupre LA, Lier DA: “Effect of adjunctive rangeof-motion 

therapy after primary total knee arthroplasty on the use of health 

services after hospital discharge.” Can J Surg. 2003 Feb;46(1):30-6. 

8. Hewitt B, Shakespeare D.: “Flexion vs. Extension: a comparison of postoperative 

total knee arthroplasty mobilsation regimes.” Knee. 2001 

Dec;8(4):305-9. 

9. Lau SK, Chiu KY: “Use of continuous passive motion after total knee 

arthroplasty.” J Arthroplasty. 2001 Apr;16(3):336-9. 

10. Chen B, Zimmerman JR, Soulen L, DeLisa JA: “Continuous passive motion 

after total knee arthroplasty: a prospective study. Am J Phys Med Rehabil. 

2000 Sep-Oct;79(5):421-6. 

11. O’Driscoll SW, Giori NJ:“Continuous passive motion (CPM): theory 

and principles of clinical application.” J Rehabil Res Dev. 2000 Mar- 

Apr;37(2):179-88. 

12. Worland RL, Arredondo J, Angles F, Lopez-Jimenez F, Jessup DE: “Home 

continuous passive motion machine versus professional physical therapy 

following total knee replacement”. J Arthroplasty. 1998 Oct;13(7):784-7.

I. Introduction 

• Continuous passive motion (CPM) has been a proposed 

adjunct to the postoperative care of the total knee 

arthroplasty (TKA) patient 

• CPM could theoretically: 

a) increase final postoperative range of motion 

b) increase the speed with which postoperative range of 

motion is attained 

c) reduce lengths of hospital stay 

d) reduce manipulation rates 

• there have been many well designed randomized clinical 

trials (RCT’s) studying CPM following TKA 

II. Proposed Advantages of CPM 

I) Range of Motion 

— while it is an attractive premise that patients receiving 

CPM following TKA will achieve both quicker and greater 

ultimate knee range of motion, this simply has not been 

borne out in multiple clinical trials. If there is a difference 

found, it is normally of very modest measure and of 

questionable clinical relevance. In a Cochrane database 

systematic review of 20 RCT’s, CPM increased passive and 

active motion by only 2-3 degrees at most. 

II) Lengths of Stay 

— again this has been a proposed advantage of CPM, but 

multiple RCT’s have failed to demonstrate a reduction in 

hospital lengths of stay 

REFERENCES 

1. Denis M, Moffet H, Caron F, Ouellet D, Paquet J, Nolet L.: Effectiveness of 

continuous passive motion and conventional physical therapy after total 

knee arthroplasty: a randomized clinical trial. Phys. Ther., 86(2):174-185, 

2006. 

2. Harvey LA, Brosseau L, Herbert RD.: Continuous passive motion following 

total knee arthroplasty in people with arthritis. Cochrane Database Syst 

Review, 17(3), 2010. 

132 

Cpm iS Not beNeFiCial iN tka 

Steve J. MacDonald, MD 




III) Manipulation rates 

— the need for manipulation is a relatively rare occurrence 

following TKA. To date, there is no evidence that the 

routine use of CPM reduces manipulation rates 

III. Disadvantages of CPM 

I) Machine costs 

II) Indirect costs 

— the machine has to be set up at the bedside, has to be 

adjusted at times and patients monitored. These time 

commitments are not cost neutral 

III)Postoperative pain 

— several studies have demonstrated that patients have 

increased pain while receiving CPM treatments and have 

increased analgesic requirements 

IV)Postoperative bleeding 

— at least one RCT has demonstrated increased blood loss 

in the patient cohort receiving CPM treatments 

IV. Conclusion 

I) The routine use of CPM following TKA is not supported by 

evidence based literature review 

II) There are costs, and potential clinical disadvantages, to the 

routine use of CPM 

III) For the most part, patients tolerate and seem to be 

inherently attracted to the use of CPM following TKA, 

making it difficult to not employ it if other arthroplasty 

surgeons in your institution are indeed using it. 

3. Leach W, Reid J, Murphy F.: Continuous passive motion following total knee 

replacement: a prospective randomized trial with follow-up to 1 year. Knee 

Surg Sports Traumatol Arthrosc., 14(10):922-926, 2006. 

4. MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW, Kramer J, Vaz M.: 

Prospective randomized clinical trial of continuous passive motion after total 

knee arthroplasty. Clin Orthop., 380:30-35, 2000. 

5. Pope RO, Corcoran S, McCaul K, Howie DW.: Continuous passive motion 

after total knee arthroplasty. Does it offer any benefits? J Bone Joint Surg., 

79(6):914-917, 1997.

133 

draiNS Should be uSed aFter tka 

Gerard A. Engh, MD 

The use of a drain following routine primary total knee arthroplasty 

has been challenged on the grounds that a wound drain might – 1) 

increase bleeding by eliminating the tamponade effect of a closed 

and undrained wound, and 2) increase the risk of infection by 

providing a portal of entry for bacteria. 

In response to premise number 1, studies evaluating blood loss 

following total knee arthroplasty have not found a statistically 

significant difference in drained versus undrained knees. In a 

prospective randomized study of 136 consecutive primary total knee 

arthroplasties, Holt1 reported no difference in decrease in hemoglobin 

or transfusion requirements between drained and undrained knees. 

Sundaram2 measured a comparable drop in hemoglobin of 3.26g/ 

dl versus a drop of 3.33 g/dl in a retrospective review of 100 drained 

versus 100 undrainded primary total knee arthroplasties. Adalberth3 found no difference in drop in either hemoglobin or hematocrit in 

a prospective randomized study comparing 3 groups: those with no 

drain, those with an auto transfusion drain, and those with closed 

suction drains. In a retrospective study of 44 knee replacements with 

drains and 48 without drains, Kumar4 reported an average fall in 

the hemoglobin level of 2.6g% in the drained group compared to 

2.8g% in the undrained group and no difference between the blood 

transfusion units. 

If we can agree that post operative blood loss is not altered with the 

use of a drain as documented in many studies such as these, then we 

must consider the consequences of not evacuating the blood from 

the tissues surrounding the knee. When drains are used the average 

blood collected in the drain is an average of nearly 500 mL. 1 In 

REFERENCES 

1. Holt BT, Parks NL, Engh GA, Lawrence JM. Comparison of closed-suction 

drainage and no drainage after primary total knee arthroplasty. Orthopaedics 

1997; 20(12): 1121-1125. 

2. Sundaram RO and Parkinson RW. Closed suction drains do not increase the 

blood transfusion rates in patients undergoing total knee arthroplasty. Intl 

Orthopaedics (SICOT) 2007; 31: 613-616. 




Holt’s study, the recorded number of dressing reinforcements with 

two to three ABD pads in 40% of the undrained group compared 

to 0% in the drained group. Sixty-nine percent of the undrained 

knees developed ecchymosis compared to 39% of the drained knees. 

The area of ecchymosis measured 92 cm2 in the undrained knees 

compared to 28cm2 in the drained knees. If we take all of these 

carefully measured and statistically significant perimeters, we can 

only conclude that when no drain is used, the blood either escapes 

through the wound creating an unsightly dressing or dissects into 

the surrounding soft tissues. The blood often moves by gravity to 

the proximal thigh or to the ankle creating a cellulitic response that 

is undesirable and may contribute to the postoperative fever often 

found in patients after total knee arthroplasty. 

Premise number 2—that the use of a drain provides a portal of 

entry for bacteria is purely hypothetical. No study in the literature 

has demonstrated a difference. Advocates of drains would argue 

equally strongly that the accumulation of blood within a wound is 

an opportune environment for infection. Unfortunately, no study 

in the literature has enough statistical power to address this issue of 

infection given a reported 0.5% occurrence for this complication. 5 

The real question that needs to be asked is not whether drains are 

required with total knee arthroplasty but are drains beneficial to total 

knee arthroplasty. Preventing and evacuating a wound hematoma is 

a basic standard of care that is upheld by the practicing orthopaedic 

community by the routine use of a drain following total knee 

arthroplasty. 

3. Adalberth G, Bystrom S, Kolstad K, et al. Postoperative drainage of knee 

arthroplasty is not necessary. Acta Orthop Scand 1998; 69(5): 475-478. 

4. Kumar S, Penematsa S, Parekh S. Are drains required following a routine 

primary total joint arthroplasty? Intl Orthopaedics (SICOT) 2007; 31: 593- 

596. 

5. Insall JN, ed. In: Surgery of the Knee. Total Joint Replacement. New York, NY: 

Churchill Livingston; 1984.

Introduction 

“To drain or not to drain”, that is the question… 

134 

draiNS do Not Need to be uSed aFter tkr 

Michael E. Berend, MD 

The decision to use a drain following TKA is steeped in dogma. “I use 

drains or I don’t use drains” are comments often bantered about by 

knee surgeons during discussion of this topic. In theory drains provide 

the opportunity to remove intra-articular blood and fluids from the 

knee joint. Advocates hypothesize that drains possibly decrease the 

risk of postoperative hematoma formation, infection, and stiffness. 

The evidence from randomized studies and large meta-analyses do 

not support the use of drains in TKA. One limitation in the literature 

surrounding drain use is that many studies on the subject have been 

underpowered to make conclusions regarding infection rates which 

have been reported to be lower but underpowered to reach statistical 

significance. 

Ritter, et al in a series of 415 joint replacements found “no statistical 

difference in: 

(1) the number of patients who had excessive postoperative 

drainage from a drained or non-drained wound 

(2) amount of transfused blood 

(3) the preoperative and postoperative hemoglobin levels 

between drained and non-drained knees. 

Furthermore, they found no statistical differences between drained 

and non-drained wounds with respect to the daily knee range of 

motion during the first seven days post-op from a TKA. 

REFERENCES 

1. Ritter MA, Keating EM, Faris PM. Closed wound drainage in total hip or total 

knee replacement. A prospective, randomized study. J Bone Joint Surg Am. 

1994 Jan;76(1):35-8. 




Parker, et al performed a meta-analysis on 36 studies examining 5464 

patients. Using the Cochrane Database they found no statistically 

significant difference in the incidence of wound infection, hematoma, 

dehiscence or re-operations between those allocated to drains and 

the un-drained wounds. Blood transfusion was required more 

frequently in those who received drains. The need for reinforcement 

of wound dressings and the occurrence of bruising were more 

common in the group without drains. They concluded that there is 

insufficient evidence from randomized trials to support the routine 

use of closed suction drainage in Orthopaedic surgery. 

The same authors performed another meta-analysis on 3495 patients 

and found the pooled results indicated that there was no significant 

difference between the wounds treated with a drain and those 

treated without a drain with respect to the occurrence of wound 

infection (relative risk, 0.73; 95% confidence interval, 0.47 to 1.14), 

wound hematoma (relative risk, 1.73; 95% confidence interval, 0.74 

to 4.07), or reoperations for wound complications (relative risk, 

0.52; 95% confidence interval, 0.13 to 1.99). A drained wound was 

associated with a significantly greater need for transfusion (relative 

risk, 1.43; 95% confidence interval, 1.19 to 1.72). Reinforcement 

of wound dressings was required more frequently in the group 

managed without drains. They also found no difference between the 

groups was seen with respect to limb-swelling, venous thrombosis, 

or hospital stay. 

In conclusion, the evidence does not support the use of drains in 

TKA. 

2. Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound 

drainage after orthopaedic surgery. Cochrane Database Syst Rev. 2007 Jul 

18;(3):CD001825. 

3. Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and 

knee arthroplasty. A meta-analysis. J Bone Joint Surg Am. 2004 

Jun;86-A(6):1146-52.

Value of Stems in TKA Revision: 

• Stems off load stress to diaphysis thereby protecting 

metaphyseal interface areas from failure 

Cemented Vs Uncemented 

• So, should stems be cemented or uncemented? 

Conclusions: 

• No single answer for all patients 

• Advantages and disadvantages of both 

• Use both methods of fixation in specific circumstances 

Uncemented Stems 

Advantages: 

• Expeditious 

• Compatible with IM based instrumentation 

• Easy to remove if necessary 

• Fill diaphysis, help guarantee limb alignment 

Disadvantages: 

• Offload stress but provide little true long term fixation 

• ? potential for end of stem pain (analogous to THA) 

• Don’t fit all canal deformities 

• Under some circumstances can force implants into 

malalignment 

Unknowns: 

• Optimal length 

• Optimal surface finish 

• Optimal preparation technique 

135 

reviSioN StemS Should be CemeNted 

Robert T. Trousdale, MD 

Cemented Stems 

Advantages: 

• Provide initial and long term fixation in fresh metaphyseal and 

diaphyseal bone 

• Allow more latitude in adjusting for canal geometry 

abnormalities 


• More difficult to remove 

• Don’t fill canal, therefore don’t guarantee alignment under most 

circumstances 

Results 

Cemented Stems: 

• Favorable results at 10 years 

• Whaley, Trousdale, Rand, Hanssen: 

REFERENCES 

1. Shannon BD, Klassen JF, Rand JA, Berry DJ, Trousdale RT: Revision 

Total Knee Arthroplasty with Cemented Components and Uncemented 

Intramedullary Stems. J Arthroplasty, in press, J Arthroplasty. 2003 Oct;18(7 

Suppl 1):27-32. 




— 38 revision consecutive kinematic stabilizer prosthesis 

performed 1981-1989 

— 10 year component survival free of revision/aseptic 

loosening -94% 

Uncemented Stems: 

• Multiple series with favorable results at ~5 years 

• Shannon, Klassen, Berry, Trousdale: 

— 63 consecutive TKAs with cemented component fixation and 

uncemented stems 

— 10% revised for aseptic loosening at mean F/U of 5.75 years 

— Majority have radiodense lines about uncemented stem 

• Good diaphyseal bone 

• Canal geometry allows pressfit 

• Limited metaphyseal bone loss or metaphyseal loss that can be 

reconstructed to allow a good cement interface 

• Good for periprosthetic fx, APC, ? reimplant for infection 

Indications 

Cemented: 

• Very poor diaphyseal bone, huge canal diameter 

• Canal geometry unfavorable for uncemented 

• Such sclerotic/damaged metaphyseal bone that even after 

reconstruction interface fixation would be inadequate unless 

cementation is extending into canal 

Technique Issues 

Uncemented Stems: 

• Take advantage of offset stems (femur), or offset trays (tibial) 

• Don’t let the stem force you to put implant in suboptimal 

position 

• Use longer stems to engage the diaphysis 

• Avoid the short uncemented stem that doesn’t really engage 

diaphysis 

• Uncover cancellous bone in metaphysis 

• Restore cancellous bone structure to metaphysis 

• Push cement into metaphyseal bone 

Cemented Stems: 

• Use cement restrictors and cement gun 

• Use antibiotic in cement 

Conclusions 

Cemented and uncemented stems both work well in proper 

circumstances 

2. Whaley AL, Trousdale RT, Rand JA, Hanssen AD: Cemented Long-Stem 

Revision Total Knee Arthroplasty. J Arthroplasty, 18:592, 2003.

136 

reviSioN StemS Should be preSS-Fit aNd uNCemeNted 

Christopher L. Peters, MD 


The burden of revision total knee replacement has risen steadily 

over the past two decades and is estimated to double by 2015. 

Recent data supports the concept that sepsis is the most common 

cause of revision TKA and the most common failure mechanism 

of revision TKA. Implant fixation strategies must therefore 

consider reliability of fixation as well as ease of revision and 

preservation of femoral and tibial bone. 

II. Technique of “Hybrid” fixation (metaphyseal cement and 

press-fit cementless stems for Revision TKA.) 

A. General Concepts 

1. Stems determine implant alignment via engagement into 

diaphysis of femur/tibia. 

2. Metaphyseal floating stems provide insufficient fixation 

3. Cement fixation into preserved metaphyseal bone 

predominate fixation mode, stems further offload 

interface stresses. 

B. Technique is simple/teachable and applicable for most 

revision cases. 

C. Offset stems help fine tune implant placement, providing 

near 360 degree adjustability of condylar portion of the 

implant relative to diaphyseal engaged stem. 

III. Uncemented stem advantages 

A. Reproducible Fixation 

0% aseptic loosening in recent report of 184 revision TKA 

B. Reproducible Alignment – due to diaphysis of femur/tibia 

guiding implant position. 

REFERENCES 

1. Peters, C.L., Erickson, J.A., Gililland, J.M. Clinical and Radiographic Results 

of 184 Consecutive Revision Total Knee Arthroplasties Placed with Modular 

Cementless Stems. Journal of Arthroplasty Vol. 24 No. 6 Suppl 1 2009. 

2. Kurtz S, et al. Projections of primary and revision hip and knee arthroplasty 

in the United States from 2005 to 2030. J. Bone Joint Surg Am 2007;89:780. 

3. Bottner F., et al. Hybrid component fixation in revision total knee 

arthroplasty. Clin Orthop Relat Res 2006;446:127. 

4. Haas SB, et al. Revision total knee arthroplasty with use of modular 

components with stems inserted without cement. J Bone Joint Surg Am 

1995;77:1700. 

5. Peters CL, et al. Revision total knee arthroplasty with modular components 

inserted with metaphyseal cement and stems without cement. J Arthroplasty 

2005;20:302. 




C. Revise-ability – obviates need to remove cement from 

diaphysis which can be difficult. 

D. Simple operative technique. 

IV. Uncemented Stem Disadvantages 

A. Large metaphyseal/diaphyseal alignment mismatch (due to 

bowing or angulation) may require smaller cemented stem 

placed eccentric in canal). 

B. Reduced volume of antibiotic impregnated cement 

1. Speculative importance 

C. End of stem pain 

1. Variable in nature 

2. Estimates 2-30% 

V. Literature Review Summary 

A. Lack of direct comparison of cemented vs uncemented stem 

fixation 

B. Clinical series in general show favorable (> 85% 

survivorship) with either technique at short to mid-term 

follow-up. 

C. Biomechanical studies favor cemented stems 

VI. New Technology 

A. Increased availability of highly porous metal cones/ 

augments may improve metaphyseal fixation and allow for 

stem fixation. 

B. Increased offset/rotational adjustment of modular stem 

designs facilitates optimum condylar implant position with 

diaphyseal stem fixation. 

6. Peters CL, et al. Revision total knee arthroplasty with a cemented posteriorstabilized 

or constrained condylar prosthesis: a minimum 3-year and average 

5-year follow-up study. J Arthropalsty 1997;12:896. 

7. Shannon BD, et al. Revision total knee arthroplasty with cemented 

components and uncemented intramedullary stems. J Arthroplasty 

2003;18(7 Suppl 1): 27. 

8. Fehring TK, et al. Stem fixation in revision total knee arthroplasty: a 

comparative analysis. Clin Orthop 2003;416: 217. 

9. Fehring TK, et al. Revision Total Knee Arthroplasty: Planning, Management, 

and Controversies. AAOS ICL, Vol 57, 2008. 

10. Bozic KJ, et al. The Epidemiology of Revision Total Knee Arthoplasty in the 

United States. Clin Orthop Relat Res (2010) 468:45-51.

137 

biCoNveX patella For the thiN reviSioN patella 

Introduction 

At the time of revision total knee replacement, reimplantation of a 

patellar implant can be difficult in the face of lost patellar bone stock 

(1). Some authors have advocated caution in using an onlay patellar 

component when there is less than ten millimeters of remaining 

patellar bone thickness (2). Leaving the patella unresurfaced due 

to poor bone stock at the time of total knee replacement revision 

has been associated with inferior clinical outcomes (3). Recently, 

three options have been advocated for revising the patella with poor 

remaining bone, namely the use of a biconvex patellar prosthesis 

(4, 5, 6), the use of a porous tantalum implant (7) and the use of 

bone grafting (8). The purpose of this paper is to present our five 

to fourteen year (mean 8.3 year) clinical outcomes of 89 cemented 

biconvex inset patellar components used in revision total knee 

replacement (9). 

Methods 

Between 1990 and 2001, 89 knees in 85 patients underwent revision 

knee arthroplasty which included revision of an existing patellar 

component using a cemented biconvex patellar component. At the 

revision procedure, 6 knees required a tibial tubercle osteotomy, 8 

a quadriceps turndown and 17 a quadriceps snip for exposure. A 

standard 13mm thick, biconvex, cemented patellar component was 

used in 65 knees and a 17mm biconvex patellar component revision 

component in 24 knees. 

Results 

Mean patient age at the time of the revision knee arthroplasty was 

72 (48-88) years. There were 37 females and 48 males. The mean 

body mass index was 31 (17-44).The reasons for revision were wear, 

osteolysis or aseptic loosening in 57, infection in 25, isolated patellar 

revision in 5 and unexplained pain in 2 patients. 

At latest follow-up (mean 8.3, range 5-14 years) 30 patients (31 

knees) had died with their patellar component still in place, 2 

patellar components had been revised for aseptic loosening, 2 were 

removed for recurrent infection and 3 patients (3 knees) were lost to 

follow-up. For the two revised patellar components, one loosened at 

6 months following a transverse fracture of a patella with only 3 mm 

of residual bone and the second loosened at 13 years in association 

with avascular necrosis of the patella. 

References 

1) Berry DJ, Rand JA. Isolated patellar component revision of total knee 

arthroplasty. Clin Orthop Rel Res. 1993. 286:110-115 

2) Garcia RM, Kraay MJ, Conroy-Smith PA, Goldberg VM. Management of the 

deficient patella in revision total knee arthroplasty. Clin Orthop Rel Res. 

2008. 466:2790-2797 

3) Barrack RL, Matzkin E, Ingrham R, Engh GA, Rorabeck CH. Revision knee 

arthroplasty with patellar replacement versus bony shell. Clin Orthop Rel 

Res. 1998. 356:139-143 

4) Garcia RM, Kraay MJ, Conroy-Smith PA, Goldberg VM. Management of the 

deficient patella in revision total knee arthroplasty. Clin Orthop Rel Res. 

2008. 466:2790-2797 




Robert B. Bourne, MD 

The Kaplan-Meier survivorship using revision of the patellar 

component for aseptic revision as the endpoint was 99% at 10 

years. If aseptic loosening or possible radiographic loosening were 

combined, the Kaplan-Meier survivorship was 92% at 10 years. 

All patients demonstrated improved Knee Society pain and function 

scores at follow-up. The mean Knee Society score improved from 

40 (2-94) preoperatively to 89 (52-100) postoperatively. The mean 

preoperative function score was 44 (-10 to 90) and improved to 54 

(-10 to 100). Only 2 patients demonstrated a mild (5 mm. 

There were 11 fractures noted, two transverse and nine peripheral 

with five being associated with avascular necrosis of the patella. Both 

the transverse fractures required re-operation. Residual patellar bone 

thickness less than 6 mm was associated with a greater fracture risk 

(p=0.045). 

Conclusions 

The cemented biconvex patellar component has proven to be a useful 

implant when performing a revision of a failed patellar component, 

particularly when there was less than 10 mm of remaining patellar 

bone stock. The best outcomes were achieved with a vascular patella 

which was six or more millimeters thick. Having the option to use a 

thicker revision biconvex patellar button to restore patellar thickness 

and extensor mechanism biomechanics has been found to be an 

effective strategy. 

5) Rorabeck CH, Mehin R, Barrack RL. Patellar options in revision total knee 

arthroplasty. Clin Orthop Rel Res. 2003. 416:84-92 

6) Maheshwer CB, Mitchell E, Kraay MJ, Goldberg VM. Revision of the patella 

with deficient bone using a biconvex component. Clin Orthop Rel Res. 2005. 

440:126-130 

7) Nasser S, Poggie RA, Revision and salvage patellar arthroplasty using a porous 

tantalum implant. J Arthroplasty. 2004. 19(5):562-572 

8) Hanssen AD. Bone-grafting for severe patellar bone loss during revision knee 

arthroplasty. J Bone Joint Surg. 2001. 83A:171-176 

9) Erak S, Bourne RB, MacDonald SJ, McCalden RW, Rorabeck CH. The cemented 

inset biconvex patella in revision knee arthroplasty. The Knee. 2009. 16:211- 

215

138 

patellar boNe graFtiNg For Severe patellar boNe loSS 

Arlen D. Hanssen, MD 

Severe patellar loss, requiring alternative treatment options during 

revision TKR, occurs in about 10-15% of cases. Typically, bone loss 

can be categorized as mild, moderate or severe and is most often 

calculated by thickness measurements of remaining patellar bone 

stock. One of the primary problems when comparing treatment 

alternatives is the location of bone loss and where patellar thickness 

is actually measured as there may be variable amounts of central bone 

with segmental rim deficiencies or complete loss of all cancellous 

bone with an intact peripheral rim of patellar bone. 

In general, when considering measurement of remaining central 

cancellous bone, 10-15mm is considered to be mild; 6-10 mm 

is moderate; and

139 

StatiC CemeNt SpaCerS For iNFeCted tkr 

Giles R. Scuderi, MD 

Infection is a devastating complication following total knee 

arthroplasty. The treatment for late chronic infection is a two-stage 

procedure with removal of the implant, insertion of a antibioticimpregnated 

cement spacer, IV antibiotics and then re-implantation. 

Insall first described this course of treatment in 1983 and because 

of success rates > 90% this has become the standard of care in the 

United States. 

The addition of static antibiotic-impregnated cement spacers has 

demonstrated better clinical success over two-stage procedures 

without the insertion of spacers. PMMA serves as a delivery vehicle for 

local antibiotics. Antibiotics are eluted from the surface and pores of 

cement, as well as from the micro-cracks within it. The elution of the 

antibiotic from the cement spacer is dependent upon the antibiotic 

dose, the combination of antibiotics used and the type of cement. 

The clinical efficacy of antibiotic-impregnated cement spacers relies 

on: the elution characteristics of the selected antibiotics, the strength 

and fatigue life of the polymethylmethacrylate cement and the 

mixing technique. The antibiotic used must be thermostable during 

the exothermic reaction; have the ability to diffuse in water; it should 

also be broad spectrum and bactericidal at low concentrations and 

carry a low risk of allergy or delayed hypersensitivity. Finally the 

antibiotic must be available in powder form. 

The benefits of static cement spacers include: distraction and 

preservation of the joint space for subsequent re-implantation; 

stabilization of the limb until re-implantation; and the use of 

large doses of antibiotics within the cement. The introduction of 

intramedullary femoral and tibial antibiotic-impregnated cement 

REFERENCES 

1. Cui Q, Mihalko W, Shields J, et.al: Antibiotic – impregnated cement spacers 

for the treatment of infection associated with total hip or knee arthroplasty. 

JBJS 89A: 871-882, 2007 

2. Jacobs C, Christensen CP, Berend ME: Static and mobile antibiotic 

impregnated cement spacers for the management of prosthetic joint 

infection. J AAOS 17(6): 356-368, 2009 




rods also permits elution of the antibiotics within the medullary 

canals. Complications of static spacers include bone loss, dislocation, 

continued pain, decreased mobility and occasionally fracture. 

However, most of these reported complications are the result of 

improper preparation of the static antibiotic-impregnated cement 

spacers. 

The preferred technique for static antibiotic-impregnated cement 

spacers is to place the doughy cement between the femur and tibia 

with distraction of the joint in such a manner as to avoid invagination 

of the cement into the cancellous bone. Cement dowels can be 

fabricated and inserted into the femoral and tibial canals. The solid 

stable construct should extend to the cortical margins of the femur 

and tibia and an anterior flange should be included between the 

femur and patella. The “hockey puck” or “hamburger” spacers 

Symposium B: Scuderi-Static Cement Spacers 

should be avoided since they are unstable, can easily displace and 

result in excess bone loss. At the conclusion of the procedure, the 

knee is immobilized in either a cast or long leg brace. The advantage 

of immobilization beyond stabilization is that it allows the inflamed 

soft tissues to heal. 

While the re-infection rates and clinical results with static spacers 

are comparable to those of mobile spacers, there is a marginal 

advantage to post-op range of motion with mobile spacers. Potential 

disadvantages of mobile spacers include problems with tibio-femoral 

instability, patella instability, wound healing, and increased risk of 

cement fracture. 

3. Jaeblon T: Polymethylmethacrylate properties and contemporary uses in 

orthopaedics. J AAOS 18(5): 297 – 305, 2010 

4. Joseph TN, Chen AL, DiCesare PE: Use of antibiotic-impregnated cement in 

total joint arthroplasty. J AAOS 11(1) 38 – 47, 2003 

5. Insall JN, Thompson FM, Brause BD: Two stage re-implantation for the 

salvage of infected total knee arthroplasty. JBJS 65A: 1087-1098, 1983


• Periprosthetic infection is a devastating complication for 

patient and surgeon alike. 

• Twostage reimplantation is the Gold standard for the 

management of the infected total knee 

• Twostage protocol 

— Removal of infected arthroplasty and all cement 

— Staged placement of an antibiotic impregnated spacer 

with high dose antibiotics 

— Six weeks IV antibiotics followed by a drug holiday, 

reaspiration, implant if ESR and CRP trending down and 

aspirate negative 

• Management between stages is controversial 

II. Spacer block technique for infected total knee – Booth/Lotke 

CORR 1989 

• Local antibiotic delivery system 

• Improved soft tissue healing 

• Prevention of soft tissue contracture 

• Improved patient comfort between stages 

III. Bone loss associated with the use of static spacers in infected 

total knee arthroplasty – Calton/Fehring et al., CORR, 1997 

• Significant bone loss noted in 15 of 25 patients 

• Solution – Articulating spacer block 

1. Temporary molded antibiotic loaded PMMA implant 

2. Allows range of motion between stages 

3. A custom mold is used 

4. Patient should be nonweightbearing 

5. Motion is held until wound healing is assured 

REFERENCES 

1. Booth RE, Lotke PA: The results of spacer block technique in revision of 

infected TKA. Clin Orthop 248; 5760, 1989. 

2. Calton TF, Fehring TK, Griffin WL: Bone loss associated with the use of spacer 

blocks in infected total knee arthroplasty. Clin Orthop 345; 148154, 1997. 

3. Fehring TK, Odum S, Calton TF, Mason JB: Articulating versus static spacers 

in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin 

Orthop 380; 916, 2000. 

140 

the CaSe For mobile SpaCerS 

Thomas K. Fehring, MD 




6. Then motion is allowed 3 times a day, no formal physical 

therapy 

IV. Results 

• Articulating versus static spacers in revision total knee 

arthroplasty for sepsis – Fehring et al., CORR 380, 2000 

— Bone loss in static group. 15 out of 25 had tibial femoral 

bone loss averaging 612 mm. 

— No measurable bone loss noted in the articulating spacer 

group 

— Reinfection rate 

Mobile – 7% 

Static – 12% 

V. Static vs. mobile spacers 

• Reinfection rate similar 

• Bone loss decreased in articulating spacer 

• Exposure is facilitated in articulating spacer 

VI. Functional advantage of articulating vs. static spacers in twostage 

revision for total knee arthroplasty infection – Freeman/ 

Fehring et al.,J Arthroplasty 22,2007 

• 28 static spacers vs. 48 articulating spacers 

— similar eradication rates 

— significantly improved functional result of articulating 

spacers over static spacers – p=.05 

VII. Added advantage of mobile spacers 

1. Patient convenience between stages 

2. Ease of exposure at the time of reimplantation 

4. Emerson RH Jr, Muncie M, Tarbox TR, Higgins LL: Comparison of a static 

with a mobile spacer in total knee infection. Clin Orthop 404; 132138, 2002. 

5. Freeman MG, Fehring TK, Odum SM, Fehring K, Griffin WL, Mason JB: 

Functional advantage of articulating versus static spacers in 2stage revision 

for total knee arthroplasty infection. J Arthroplasty Vol 22 (8); 11161121, 

2007.

141 

CurreNt CoNtroverSieS iN partial 

kNee arthroplaSty (p) 

Moderator: Adolph V. Lombardi, MD, New Albany, OH 

Partial knee arthroplasty has enjoyed a renewed interest in the last decade. Isolated medial, lateral and patellofemoral 

arthroplasty are all becoming the norm for the treatment of monocompartmental disease. 

I. The Patellofemoral Compartment 

a. Patellofemoral Arthroplasty: Custom Inlay Technique Offers a Patient Specific Approach 

Adolph V. Lombardi, Jr., MD, New Albany, OH 

b. Patellofemoral Arthroplasty: Onlay Techniques Are More Effective in Treating Complex Patellofemoral Arthrosis 

Jess H. Lonner, MD, Philadelphia, PA 

II. The Lateral Compartment 

a. Lateral UKA Is Better than the Medial UKA 

William B. Macaulay, MD, New York, NY 

b. Tricks of the Trade to Improve Results of Lateral UKA 

Keith R. Berend, MD, New Albany, OH 

c. Why Bother with a Partial Knee Arthroplasty When a Total Works Much Better? 

Giles R. Scuderi, MD, New York, NY 

III. The Medial Compartment 

a. Fixed Bearing Inlay Medial UKA Represents the Most Conservative Approach 

John A. Repicci MD, Buffalo, NY 

b. Fixed Bearing Onlay Is Tried and True 

Craig J. Della Valle, MD, Chicago, IL 

c. Don’t Worry about Wear with a Mobile Bearing Medial UKA 

Michael E. Berend, MD, Mooresville, IN 

d. No One Can Do a Better Medial UKA than a Robot 

Riyaz H. Jinnah MD, Winston-Salem, NC 

e. Custom Medial UKA Optimizes the Result for Each Patient 

Wolfgang Fitz, MD, Chestnut Hill, MA 

f. The Perfectly Balanced UKA Can Only Be Accomplished with Soft Tissue Guided Surgery 

Gerard A. Engh, MD, Alexandria, VA 

g. The ACL Deficient Knee Can Be Approached with a Combination ACL Reconstruction and Medial UKA 

Jason M. Hurst, MD, New Albany, OH 

IV. Case Based Discussion 



SympoSia AR KNEE

142 

patelloFemoral arthroplaSty: CuStom iNlay teChNique 

oFFerS a patieNt SpeCiFiC approaCh 

Adolph V. Lombardi, Jr., MD, FACS 

It has been reported that the incidence of isolated patellofemoral 

arthroplasty in patients older than 55 years presenting with 

symptomatic osteoarthritis of the knee is 11% in males and 24% in 

females. 1 A review of the literature on patellofemoral arthroplasty 

revealsthatapproximately75% ofthepatientsarefemale. 2 This overall 

higher incidence in females is related to patellofemoral malalignment 

and dysplasia which are more common in females than males. The 

important contributing factors to future patellofemoral arthrosis are 

history of adolescent anterior knee pain, trochlear dysplasia, patella 

alta or history of recurrent patellofemoral instability. 

The clinical presentation of patellofemoral arthritis is anterior 

knee pain exacerbated by activities such as ascending/descending 

stairs, squatting, sitting with the knee flexed, rising from a seated 

position and ambulating on uneven terrain. Patients may also 

complain of grinding and cracking localized to the patellofemoral 

articulation with range of motion. On physical examination 

crepitation with range of motion or effusion can be noted. There is 

generally peripatellar facet tenderness and pain with patellofemoral 

compression. A positive apprehension sign maybe noted. There may 

also be considerable quadriceps atrophy. Symptoms are generally 

reproducible with provocative maneuvers such as squatting, stair 

stepping or rising from a chair. Patellar tracking should be evaluated 

from 90˚ of flexion to extension. Malalignment or muscle imbalance 

can be detected by the “J” sign, which is visible lateral subluxation of 

the patella as the knee proceeds from flexion into the terminal 20˚ of 

extension. Furthermore, the quadriceps angle should be measured. 

A high “Q” angle >20˚ in females and >15˚ in males may require 

treatment with an anterior medialization tibial tubercle osteotomy, 

known as a Fulkerson osteotomy. With respect to imaging studies, 

standing AP and PA flexed views should be evaluated to determine 

the degree of degenerative disease involving the tibial femoral 

articulation. Varus and valgus stress views may also be helpful to 

determine if there any tibial femoral arthrosis. Lateral radiographs 

are useful for identifying patella alta or patella baja and occasionally 

patellofemoral osteophytes and joint space narrowing are noted. 

Actual radiographs reveal trochlear dysplasia, patellar tilt or 

subluxation and the extent of patellofemoral arthrosis. Axial CT may 

have a role in accessing patellofemoral tracking. MRI evaluation can 

further assess the status of the cartilage of the entire knee. 

The initial treatment should focus on non-operative measures such 

as weight loss, physiotherapy focused on quadriceps strengthening, 

non-steroidal anti-inflammatory medications and injection therapy 

of both corticosteroids and viscosupplementation. Included in 

the operative armamentarium for patellofemoral arthrosis is 

arthroscopic debridement, microfracture articulation restoration, 

lateral retinacular release, soft tissue re-alignment of the extensor 

mechanism, anterior medialization tibial tubercle osteotomy, 

mosaicplasty/autologous chondrocyte implantation, lateral patella 

partial facetectomy, patellectomy, patellofemoral arthroplasty and 

ultimately total knee arthroplasty. 

There is a limited role for the non-arthroplasty options involving 

arthroscopy, lateral retinacular release and facetectomy. Biological 

articular restoration in patellofemoral arthroplasty has had very 

compromised results secondary to the inherent hostile force load 

environment, distortions of joint congruency and limitations of 

healing in an avascular tissue. Patellectomy represents a last resort 




option in the elderly. It certainly has its limitations in the active 

patient population. Anterior medialization tibial tubercle osteotomy 

is the most popular osteotomy. It is best for the younger patient with 

lateral arthrosis and concomitant instability. 

The indications therefore, for patellofemoral arthroplasty are 

advanced patellofemoral osteoarthritis, post-traumatic arthritis, 

advanced chondromalacia of the patellar or trochlear or both, tibial 

femoral Ahlbäck scores ≤1 and severe symptoms affecting daily 

activity referable to patellofemoral joint degeneration unresponsive 

to non-operative treatments. The contraindications to patellofemoral 

arthroplasty are any evidence of tibial femoral arthritis, advanced 

chondromalacia or chondrocalcinosis. Systemic inflammatory 

arthritis, “Q” angle >20˚ in females and >15˚ in males should be 

corrected with anterior medialization tibial tubercle osteotomy prior 

to performance of patellofemoral arthroplasty, complex regional 

pain syndrome and finally infection. 

When considering patellofemoral arthroplasty the surgeon has 

a choice between custom or patient specific designs vs off shelf 

designs. Within the off shelf designs there are essentially two types; 

inlay trochlear design and onlay trochlear designs. While having 

the advantage of being bone conservative, inlay trochlear designs 

were plagued by difficulty to match the variability in trochlear 

morphology. Components of onlay trochlear designs note the 

ability to perform an anterior resection coincident with the anterior 

femoral cortex. The preparation of the trochlea is perpendicular to 

the AP axis or Whiteside’s line and parallel to the transepicondylar 

axis. These designs extend proximally and generally are wider than 

inlay designs. 

The significant disadvantages of both the inlay and onlay designs 

are their inability to be customized to match the patient, and, 

specifically with the onlay designs, more aggressive bone resection. 

The advantages of custom patellofemoral arthroplasty are that 

they do not require femoral bone resection. Rapid prototyping 

technology based on computer tomography modeling is used 

to achieve a custom fit to the patient’s femoral anatomy. Normal 

kinematics are achieved by re-establishing the alignment and depth 

of the trochlear groove. The overall thickness of the patellofemoral 

arthroplasty implant along with the patella component was designed 

to re-establish normal anatomy. The distal margin of the implant 

rests 3-5mm from the apex of the femoral intercondylar notch. The 

implant has a thickened lateral border to compensate for the usual 

lateral bony deficiency of the trochlear groove. 

The major disadvantage of custom patellofemoral arthroplasty is 

the associated cost including preoperative computer tomography 

scan, the implant cost, and the time required for manufacturing of 

the implant. Critics of custom patellofemoral arthroplasty also note 

the difficulty of orienting the component parallel with the AP axis 

and perpendicular to the transepicondylar axis. However, these can 

be addressed at the time of preoperative planning. The surgeon is 

involved with the preoperative plan and reviews the 3D modeling 

generated from the CT scan. At that time, adjustments can be made 

to correctly position the component. 

The surgical technique for custom patellofemoral arthroplasty 

involves the procurement of a computer tomography scan in 

accordance with the requirements of the manufacturer of the 

implant. Therefore, the facility must be pre-certified by the implant

manufacturer. With the utilization of rapid prototyping technology a 

3D model of the distal femur is created for the surgeon to review. It is 

at this time that the surgeon can make modifications to the implant 

specifically addressing orientation and component placement. The 

model is returned to the manufacturer for definitive component 

creation. The overall manufacturing time from when the CT scan is 

delivered to the manufacturer is approximately four weeks. 

An incision is made over the medial third of the patella, generally 

commencing two finger-breadths proximal to the patella, transversing 

patella and extending one finger-breadth 

below the distal pole of the patella. A standard medial parapatellar 

arthrotomy is performing taking care to avoid injury to the medial 

meniscus. The patella is displaced laterally. The tibial-femoral 

articulation is evaluated to determine if acceptable to proceed with 

patellofemoral versus total knee arthroplasty. Proper fit of the custom 

drill guide is achieved by removing articular cartilage. The custom 

drill guide is utilized to assess the fit of the implant onto the trochlear 

groove. The position is then outlined with methylene blue and a 

scalpel is used to dissect through then remove the cartilage. Curettes 

are helpful to remove the articular cartilage within the outlined area 

and expose the subchondral bone. The custom drill guide is now 

placed on the exposed bone and appropriate position is achieved. 

With the drill guide correctly positionedthree holes are drilled 

through the guide with an 8mm stop drill. Small drill holes can be 

placed in the subchondral bone of the trochlear groove to enhance 

cement indigitation. The patella is now prepared in a standard 

fashion. The thickness of the patella is noted pre-resection and 

recreated with the patellar implant. The custom implant and patella 

components are now cemented in place and the cement allowed to 

cure. The tourniquet is now released, hemostasis is accomplished and 

patellofemoral tracking is assessed using the no thumbs technique. If 

there is any suggestion of less than satisfactory tracking of the patella 

SUGGESTED READING: 

1. Ackroyd CE, Newman JH, Evans R, Eldridge JD, Joslin CC: The Avon 

patellofemoral arthroplasty: Five-year survivorship and functional results. J 

Bone Joint Surg Br 2007;89:310-315. 

2. Arciero RA, Toomey HE. Patellofemoral arthroplasty: A three- to nine-year 

follow-up study. Clin Orthop Relat Res 1988;236:60-71. 

3. Argenson JN, Guillaume JM, Aubaniac JM: Is there a place for patellofemoral 

arthroplasty? Clin Orthop Relat Res 1995;321:162-167. 

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An update. Clin Orthop Relat Res 2005;440:50-53. 

5. Becher C, Renke A, Heyse TJ, Schofer M, Tibesku CO, Fuchs-Winkelmann S. 

[Patellofemoral arthroplasty--results of a nation-wide survey in Germany and 

review of the literature]. Z Orthop Unfall. 2008 Nov-Dec;146(6):773-81 

6. Blazina ME, Fox JM, Del Pizzo W, Broukhim B, Ivey FM. Patellofemoral 

replacement. Clin Orthop Relat Res 1979;144:98-102. 

7. Butler JE, Shannon R. Patellofemoral arthroplasty with a custom-fit femoral 

prosthesis. Orthopedics. 2009 Feb;32(2):81. 

8. Cartier P, Sanouiller JL, Grelsamer R. Patellofemoral arthroplasty. J 

Arthroplasty 1990;5:49-55. 

9. Cartier P, Sanouiller JL, Khefacha A: Long-term results with the first 

patellofemoral prosthesis. Clin Orthop Relat Res 2005;436:47-54. 

10. Davies AP, Vince AS, Shepstone L, Donell ST, Glasgow MM. The radiologic 

prevalence of patellofemoral osteoarthritis. Clin Orthop Relat Res. 2002 

Sep;402:206-12. 

11. deWinter WE, Feith R, van Loon CJ. The Richards type II patellofemoral 

arthroplasty: 26 cases followed for 1-20 years. ActaOrthop Scand 

2001;72:487-490. 

12. Donell ST, Glasgow MM. Isolated patellofemoral osteoarthritis. Knee. 2007 

Jun;14(3):169-76. 

13. Gupta RR, Zywiel MG, Leadbetter WB, Bonutti P, Mont MA. Scientific 

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143 




a lateral retinacular release is performed. Postoperatively patients are 

allowed full weight bearing and physiotherapy commences within 

hours of the surgical procedure to enhance range of motion. 

The major pitfalls to be avoided are lack of adherence to the 

preoperative computer tomography scanning protocol of the 

manufacturer, lack of communication with the manufacturer 

regarding any planned osteophyte removal, surgery for inappropriate 

indications, aggressive removal of femoral trochlear cartilage with a 

burr causing unintentional removal of the subchondral bone under 

the custom patellofemoral implant, under-resection of the patella 

leading to overstuffing of the patellofemoral articulation, and finally, 

failure to correct patellar alignment and tracking intraoperatively. 

Sisto and Sarin have reported the longest follow-up on custom 

patellofemoral arthroplasty of the knee. They reported on 22 patients 

with 25 knees with a mean duration of 11.3 years of follow-up (range 

7.8-14.9 years). All 25 patellofemoral arthroplasties were in place 

and all patients reported satisfaction with the arthroplasty. There 

were no reports of weakness, instability or additional surgery. All 

22 patients noted that they would undergo custom patellofemoral 

arthroplasty again. 

In conclusion custom patellofemoral arthroplasty offers a 

personalized approach to a very difficult clinical situation. It is 

well documented that there are a small number of patients who 

would benefit from patellofemoral arthroplasty. By utilizing the 

customized technique the surgeon can more appropriately plan 

for the procedure preoperatively. This patient specific design and 

manufacturing technique ensures accurate and precise anatomic 

fit while simultaneously providing proper patellofemoral 

alignment and medial lateral constraint. The keys to success of any 

patellofemoral arthroplasty custom or off shelf are proper selection 

of patients and meticulous attention to detail, especially with respect 

to patellofemoral tracking. 

14. Hendrix MR, Ackroyd CE, Lonner JH: Revision patellofemoral arthroplasty: 

Three- to seven-year follow-up. J Arthroplasty 2008;23:977-983. 

15. Kooijman HJ, Driessen AP, van Horn JR: Long-term results of patellofemoral 

arthroplasty: A report of 56 arthroplasties with 17 years of followup. J Bone 

Joint Surg Br 2003;85:836-840. 

16. Krajca-Radcliffe JB, Coker TP: Patellofemoral arthroplasty: A 2- to 18-year 

follow up study. Clin Orthop Relat Res 1996;330:143-151. 

17. Lonner JH: Patellofemoral arthroplasty. Pros, cons, and design 

considerations. Clin Orthop Relat Res 2004; 428:158-165. 

18. Lonner JH, Jasko JG, Booth RE Jr: Revision of the failed patellofemoral 

arthroplasty to total knee arthroplasty. J Bone Joint Surg Am 2006;88:2337- 

2342. 

19. Lonner JH: Patellofemoral arthroplasty. J Am Acad Orthop Surg 2007;15:495- 

506. 

20. Lonner JH, Mehta S, Booth RE Jr: Ipsilateral patellofemoral arthroplasty and 

autogenous osteochondral femoral condylar transplantation. J Arthroplasty 

2007;22:1130-1136. 

21. Lonner JH: Patellofemoral arthroplasty: The impact of design on outcomes. 

Orthop Clin North Am 2008;39:347-354. 

22. Lonner JH. Patellofemoral arthroplasty. Instr Course Lect 2010; 59:67-72. 

23. McAlindon TE, Snow S, Cooper C, Dieppe PA. Radiographic patterns of 

osteoarthritis of the knee joint in the community: The importance of the 

patellofemoral joint. Ann Rheum Dis 1992;51:844-849. 

24. Merchant AC: Early results with a total patellofemoral joint replacement 

arthroplasty prosthesis. J Arthroplasty 2004;19:829-836. 

25. Minkowitz RB, Bosco JA 3rd. Patellofemoral arthritis. Bull NYU Hosp Jt Dis. 

2009;67(1):30-8. Review. 

26. Odumenya M, Costa ML, Parsons N, Achten J, Dhillon M, Krikler SJ. 

The Avon patellofemoral joint replacement: Five-year results from an 

independent centre. J Bone Joint Surg Br. 2010 Jan;92(1):56-60

27. Saleh KJ, Arendt EA, Eldridge J, Fulkerson JP, Minas T, Mulhall KJ. 

Symposium. Operative treatment of patellofemoral arthritis. J Bone Joint 

Surg Am. 2005 Mar;87(3):659-671. 

28. Sisto DJ, Sarin VK. Custom patellofemoral arthroplasty of the knee. J Bone 

Joint Surg Am 2006;88:1475-1480. 

29. Sisto DJ, Sarin VK. Custom patellofemoral arthroplasty of the knee. Surgical 

technique. J Bone Joint Surg Am. 2007 Sep;89 Suppl 2 Pt.2:214-25. 

30. Sisto DJ, Sarin VK. Patellofemoral arthroplasty with a customized trochlear 

prosthesis. Orthop Clin North Am. 2008 Jul;39(3):355-62, vi-vii. 

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31. Tauro B, Ackroyd CE, Newman JH, Shah NA: The Lubinus patellofemoral 

arthroplasty: A five- to ten-year prospective study. J Bone Joint Surg Br 

2001;83:696-701. 

32. van Jonbergen HP, Poolman RW, van Kampen A. Isolated patellofemoral 

osteoarthritis. Acta Orthop. 2010 Apr;81(2):199-205. 

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Oct;25(7):1066-71

145 

oNlay troChlear CompoNeNt deSigNS iN patelloFemoral 

arthroplaSty are moSt eFFeCtive 

Jess H. Lonner, MD 

I. Indications for PF Arthroplasty 

a. Isolated PF OA or posttraumatic PF arthritis 

b. Trochlear/patellar dysplasia 

c. Failed PT and nonoperative interventions 

d. Anterior knee pain (retro- and peri-patellar) with stair 

descent, sitting 

e. No medial or lateral joint line pain, tenderness or wear 

f. No age restrictions 

II. Contraindications 

a. Inflammatory arthritis or chondrocalcinosis 

b. Gr. III-IV tibiofemoral chondromalacia 

c. Uncorrected patellar maltracking or malalignment (Q angle) 

i. Slight tilt, mild subluxation acceptable (if corrected) 

ii. Correct high Q angle 

d. Significant coronal plane deformities 

e. Flexion contracture 

f. Limited ROM 

III. Clinical results of PFA 

a. Dependent on: 

i. implant design 

1. cemented better than cementless 

2. onlay trochlear component better than inlay for 

patellar tracking 

ii. patient selection 

1. PF alignment 

2. TF alignment (coronal plane) 

3. chondromalacia on WB condyles 

4. underlying diagnosis (Dysplasia vs. Primary OA vs. PTA) 

iii. surgical indications 

iv. technical proficiency 

v. component alignment 

vi. duration of follow-up (tibiofemoral arthritis may develop 

in approximately 20% at 15 yrs) 

b. Major source of failures: 

i. Patellar instability 

1. component malposition 

2. extensor mechanism malalignment 

3. impact of trochlear component geometry 

a. more common with inlay style trochlear components 

ii. TF degeneration 

1. will be primary failure mode with onlay designs 

2. more common in primary OA cases 

3. less common in PF dysplasia and PTA 

4. “bridging” procedure 

iii. Loosening rare 

1. Combined series > 600 cases 

a. Less than 1.5% trochlear loosening (beware of 

cementless implants) 

b. Less than 0.5% patellar loosening or wear 

IV. Key Terminology 

a. Inlay trochlear design 

i. Trochlear component inset flush with surrounding 

trochlear/condylar cartilage 

ii. Rotational alignment parallels trochlear inclination 

iii. Highly conservative method of trochlear bone preparation 

iv. Component typically shorter (ends at proximal cartilage 

edge) and narrower than onlay designs 




v. Poor fit due to variability in trochlear morphology 

(unless “customized”) 

b. Onlay trochlear design 

i. Trochlear preparation perpendicular to Whiteside 

(anteroposterior) axis (parallel to TEA) 

ii. Anterior resection flush with anterior femoral cortex 

iii. Component typically extends more proximal than native 

trochlear edge and wider than inlay designs 

V. Variation in Trochlear Morphology 

a. Lonner, Jasko, Thomas (2008) 

i. 100 female and 100 male surgical specimens 

ii. Mean lateral trochlear height: 

1. Female: 10.47 mm (range: 2.0-19.0 mm) 

2. Male: 11.95 mm (range, 6.5-20.5 mm) 

iii. Mean medial trochlear height: 

1. Female: 6.95 mm (range, 2.0-18.0 mm) 

2. Male: 7.71 mm (range, 1.0-18.0 mm) 

b. Biedert et al (2010) 

i. In a non-dysplastic trochlea the most anterior aspect of 

the lateral trochlear condyle is higher than the anterior 

aspect of the medial trochlear condyle 

c. Kamath, Lonner et al (2010) 

i. Trochlear prominence angle (angle from lateral to medial 

peaks of trochlear articular cartilage relative to AP axis of 

femur) is typically internally rotated (except in cases of 

severe trochlear dysplasia). 

d. Shih et al (2004) 

i. Anterior condylar angle: 2.7 +/- 6.2˚ (range, -11˚ to 10˚) 

VI. Implication of Trochlear Morphology on Trochlear 

Component Alignment 

a. Prominent lateral trochlear flange relative to medial 

trochlear flange 

i. leads to internal rotation of trochlear component with 

inlay style trochlear designs 

ii. predisposes to patellar maltracking and instability with 

inlay style designs 

VII. Internal Rotation of Femoral Component in Knee 

Arthroplasty 

a. Berger et al (1998) 

i. Femoral component internal rotation relative to the 

transepicondylar axis predisposes to patellar instability in 

TKA 

1. Medializes trochlea 

2. Increases the Q-angle 

3. Puts tension on lateral retinaculum 

b. Lonner (2008, 2010) 

i. PFA trochlear component internal rotation predisposes to 

patellar maltracking/subluxation 

1. Can be resolved with revision to onlay style 

component rotated perpendicular to AP axis of femur 

VIII. Clinical Results Inlay vs. Onlay Trochlear Designs 

a. Onlay designs have substantially improved patellar tracking 

and reduced the patellar instability common with inlay 

designs 

b. Inlay Designs 

i. Blazina et al (1979) 

1. Implant: Richards Types I and II (n=85)

146 

2. 81% G-E results (f/u 8-42 mos) 

3. High need for subsequent surgeries (n=37) to realign 

components or soft tissues and improve patellar 

tracking 

ii. DeWinter et al (2001) 

1. Implant: Richards Type II (n=26) 

2. 27% required secondary surgery for PF problems 

iii. Tauro (2001) 

1. 7.5 yr f/u 

2. Implant: Lubinus 

3. 32% patellar maltracking (related to design) 

iv. Board (2004) 

1. 19 mo f/u (range, 2 – 56 mos) 

2. Implant: Lubinus 

3. 36% patellar cicking/subluxation/locking 

v. Lonner (2004) 

1. Implant: Lubinus: n=30 

2. Patellar maltracking: 17% 

vi. Sisto (2006) 

1. Custom inlay trochlear component 

2. Implant: Kinematch 

3. Technique: 

a. Trochlear cartilage removed 

b. Subchondral bone preserved 

4. Implant design 

a. Trochlear component anteriorized to enhance 

quad function/mechanical advantage 

b. Lateral “build-up” 

5. 73 mo f/u (range, 32-119 mos) 

6. 72% excellent; 28% good 

7. Potential problems: 

a. Internally rotated 

b. Anteriorized 

c. Overstuffed 

d. No other series have corroborated these results 

c. Onlay Designs 

i. Lonner (2004) 

1. Implant: Avon: n=25 

2. 96% G-E results 

REFERENCES 

1. Blazina ME, Fox JM, Del Pizzo W, Broukhim B, Ivey FM. Patellofemoral 

replacement. Clin Orthop. 144:98-102, 1979 

2. de Winter WE, Feith R, van Loon CJ. The Richards type II patellofemoral 

arthroplasty: 26 cases followed for 1-20 years. Acta Orthop Scand. 72:487- 

490, 2001 

3. Tauro B, Ackroyd CE, Newman JH, Shah NA. The Lubinus patellofemoral 

arthroplasty. A five- to ten-year prospective study. J Bone Joint Surg. 83B:696- 

701, 2001 

4. Board TN, Mahmood A, Ryan WG, Banks AJ. The Lubinus patellofemoral 

arthroplasty: A series of 17 cases. Arch Orthop Trauma Surg. 124:285-287, 

2004 

5. Lonner JH: Patellofemoral arthroplasty. In Lotke PA, Lonner JH (eds.). 

Master Techniques In Orthopaedic Surgery: Knee Arthroplasty. 3rd Edition. 

Philadelphia. Lippincott Williams and Wilkins. 2009 

6. Lonner JH. Patellofemoral Arthroplasty. Pros, Cons, and Design 

Considerations. Clin Orthop 428:158-165, 2004 

7. Ackroyd CE. Development and early results of a new patellofemoral 

arthroplasty. Clin Orthop. 436:7-13, 2005 

8. Sisto DJ. Sarin VK. Custom patellofemoral arthroplasty of the knee. J Bone 

Joint Surg. 88A:1475-1480, 2006 

9. Lonner JH, Mehta S, Booth RE. Ipsilateral patellofemoral arthroplasty and 

autogenous osteochondral femoral condylar transplantation. J Arthrop. 

22:1130-1136, 2007 

10. Lonner JH, Jasko JG, Booth RE. Revision of a failed patellofemoral 

arthroplasty to a total knee arthroplasty. J Bone Joint Surg. 88A:2337-2342, 

2006 




3. Patellar maltracking: 1%; PF crepitus: 4% 

ii. Ackroyd (2007) 

1. Implant: Avon (n=109) 

2. 5.2 yr f/u (range, 5-8 yrs) 

3. 95.8% survival rate (revision as endpoint) 

4. 80% success 

5. Primary failure mode: TF arthritis (28%) 

6. Patellar maltracking: 1% 

iii. Leadbetter et al (2008) 

1. Implant: Avon (n=79) 

2. F/U 3 yrs (range, 2-5.5 yrs) 

3. Patellar maltracking 1.2 % 

iv. Lonner (unpublished) 

1. Implant: Gender Solutions PFJ (n=116) 

2. F/U 3 mos - 3 yrs 

3. Patellar instability:

oth are great, but lateral uka iS better thaN the medial uka! 

William Macaulay, MD 

The Benefits of UKA 

• Reduced Invasiveness and Morbidity 

• Preservation of Bone Stock 

• Preservation of Cruciates and Proprioception 

• Less Blood Loss and Lower Risk for Infection 

• Faster Post-Operative Rehabilitation 

• More Cost Effective than TKA 

Early Studies of UKA (when surgical technique and implant 

design were inferior) 

• Lateral UKA had Better Outcomes than Medial UKA 

• Insall et al. (1976): 5 Lateral UKA Patients had HSS Knee Scores 

increase from 49 pre-operatively to 86 post-operatively; 19 

Medial UKA Patients had Scores increase from 49 to 64. 

• Laskin (1978): Average Follow-up Rating of 3 Lateral UKA 

Patients Greater than that for 34 Medial UKA Patients. 

• Insall et al. (1980): At 5-7 years follow-up, “The lateral 

replacements [5] did much better than the medial replacements 

[17].” 

• Scott et al. (1981): 2/12 Lateral UKA Patients required Revision 

in setting of Pre-Operative Valgus Deformities of 30˚ and 15˚. 

Medial UKA versus Lateral UKA Today 

• Unicompartmental Femorotibial OA affects Medial 

Compartment More than Lateral. 

• Ratio of Medial to Lateral UKA is approximately 10:1. 

• Lateral UKAs make up Less than 1% of Knee Arthroplasty 

Procedures. 

• Although Lateral UKA can be Highly Successful Procedure, it is 

Rarely Performed. 

Outcomes of Lateral UKA and Medial UKA 

Lateral UKA Series 

147 

Authors Number 

of UKAs 

Type of Implant Mean Followup 

(years) 

Survivorship 

(Number of 

Revisions) 

Marmor (1983) 14 Cemented, all poly 

tibia 

7.4 (2.5-9.83) NA (2) 

Gunther et al. (1996) 53 Cemented, metal- 5 (2.5-9.83) 82% at 5 years 

backed,mobilebearing (11) 

Ohdera et al. (2001) 18 Four different 

designs 

8.25 (5-15.75) NA (2) 

Ashraf et al. (2002) 83 Cemented all poly 9 (2-21) 74% at 15 

tibia 

years (15) 

O’ Rourke et al. (2005) 14 Cemented all poly 24 (17-28) 72% at 25 

tibia 

years (2) 

pennington et al. 29 Cemented, metal- 12.4 100% at 12.4 

(2006) 

backed (75%); all 

poly tibia (25%) 

(3.1-15.6) years (0) 

Sah et al. (2007) 49 Three different 5.2 (2-14) 100% at 5.4 

designs 

years (0) 

Argenson et al. (2008) 38 Four different 12.6 (3-23) 84% at 16 

designs 

years (5) 

REFERENCES 

1. Argenson JN, et al. Modern unicompartmental knee arthroplasty with 

cement: a three to ten-year follow-up study. J Bone Joint Surg Am. 2002 

Dec;84-A(12):2235-9. 

2. Argenson JN, et al. Long-term results with a lateral unicondylar replacement. 

Clin Orthop Relat Res. 2008 Nov;466(11):2686-93. 




Medial UKA Series 

Authors Number 

of UKAs 

Type of Implant Mean 

Follow-up 

(years) 

Marmor (1986) 53 Cemented, all poly 

tibia 

Squire et al. (1999) 48 Cemented, all poly 

tibia 

Argenson et al. (2002) 145 Cemented, metalbackedfixedbearing 

perkins and Gunckle 40 Cemented, metal- 

(2002) 

backed (60%); all 

poly (40%) 

Gioe et al. (2003) 474 Nine different 

designs 

Naudie et al. (2004) 113 Cemented, metalbacked,fixedbearing 

Berger et al. (2005) 62 Cemented, metalbacked,fixedbearing 

O’Rourke et al. (2005) 122 Cemented all poly 

tibia 

Eickmann et al. (2006) 411 Twelve different 

designs 

Survivorship 

(Number of 

Revisions) 

11 (10-13) 70% at 10 

years (20) 

18 84% at 22 

(15.8-21.8) years (5) 

5.5 (3-9.33) 94% at 10 

years (5) 

6 (3-10) 74% at 10 

years (6) 

NA 88.6% at 10 

yrs (36) 

10 (2-14) 86% at 10 

years (11) 

12 (10-13) 95.7% at 13 

years (2) 

24 (17-28) 72% at 25 

years (17) 

9 (0.1-19.3) 80% at 9 

years (96) 

Conclusions 

• Revision Rates for Lateral UKA have Markedly Decreased in 

Recent Series. 

• Lateral UKA has Comparable Outcomes to Medial UKA. 

• Outcomes will Continue to Improve with Innovations in 

Implant Design, Surgical Technique, Computer/Robotic 

Assistance and Refinement of Patient Selection Criteria 

3. Ashraf T, et al. Lateral unicompartmental knee replacement survivorship and 

clinical experience over 21 years. J Bone Joint Surg Br. 2002 Nov;84(8):1126- 

30. 

4. Berger RA, et al. Results of unicompartmental knee arthroplasty at 

a minimum of ten years of follow-up. J Bone Joint Surg Am. 2005 

May;87(5):999-1006.

5. Eickmann TH, et al. Survival of medial unicondylar arthroplasties placed by 

one surgeon 1984-1998. Clin Orthop Relat Res. 2006 Nov;452:143-9. 

6. Gioe TJ, et al. Analysis of unicompartmental knee arthroplasty in 

a community-based implant registry. Clin Orthop Relat Res. 2003 

Nov;(416):111-9. 

7. Gunther T, et al. Lateral unicompartmental knee arthroplasty with Oxford 

meniscal knee. The Knee. 1996; 3: 33-39. 

8. Heyse TJ, et al. Lateral unicompartmental knee arthroplasty: a review. Arch 

Orthop Trauma Surg. 2010 Jun 18. 

9. Insall J, et al. Unicondylar knee replacement. Clin Orthop Relat Res. 1976 

Oct;(120):83-5. 

10. Insall J, et al. A five to seven-year follow-up of unicondylar arthroplasty. J 

Bone Joint Surg Am. 1980 Dec;62(8):1329-37. 

11. Laskin RS. Unicompartmental tibiofemoral resurfacing arthroplasty. J Bone 

Joint Surg Am. 1978 Mar;60(2):182-5. 

12. Marmor L. Lateral compartment arthroplasty of the knee. Clin Orthop Relat 

Res. 1984 Jun;(186):115-21. 

13. Marmor L. Unicompartmental arthroplasty of the knee with a minimum tenyear 

follow-up period. Clin Orthop Relat Res. 1988 Mar;(228):171-7. 

148 




14. Naudie D, et al. Medial unicompartmental knee arthroplasty with the Miller- 

Galante prosthesis. J Bone Joint Surg Am. 2004 Sep;86-A(9):1931-5. 

15. O’Rourke MR, et al. The John Insall Award: unicompartmental knee 

replacement: a minimum twenty-one-year follow-up, end-result study. Clin 

Orthop Relat Res. 2005 Nov;440:27-37. 

16. Ohdera T, et al. Unicompartmental knee arthroplasty for lateral gonarthrosis: 

midterm results. J Arthroplasty. 2001 Feb;16(2):196-200. 

17. Pennington DW, et al. Unicompartmental knee arthroplasty in patients sixty 

years of age or younger. J Bone Joint Surg Am. 2003 Oct;85-A(10):1968-73. 

18. Perkins TR, et al. Unicompartmental knee arthroplasty: 3- to 10-year results 

in a community hospital setting. J Arthroplasty. 2002 Apr;17(3):293-7. 

19. Sah AP, et al. Lateral unicompartmental knee arthroplasty through a medial 

approach with an average five-year follow-up. J Bone Joint Surg Am. 2007 

Sep;89(9):1948-54. 

20. Scott RD, et al. Unicondylar unicompartmental replacement for 

osteoarthritis of the knee. J Bone Joint Surg Am. 1981 Apr;63(4):536-44. 

21. Squire MW, et al. Unicompartmental knee replacement. A minimum 15 year 

follow-up study. Clin Orthop Relat Res. 1999 Oct;(367):61-72.

149 

triCkS oF the trade to improve reSultS oF lateral uka 

Keith R. Berend, MD 

Introduction 

Isolated unicompartmental arthritis occurs less frequently 

than tricompartmental arthritis. In isolated disease, the medial 

compartment is affected more commonly than the lateral 

compartment. 7 Isolated lateral compartment disease occurs at a 

rate of 5% to 10%. 11, 12 Medial UKA is performed 10 times more 

commonly than lateral, with LUKA representing approximately 

1% of all arthroplasty procedures. 12 LUKA is also considered more 

technically demanding than medial UKA or TKA due to the more 

complex kinematic profile laterally. 3,4,11,12 

Operative Technique 

An abbreviated mid-line incision is created from 2cm proximal to the 

superior pole of the patella, extending to the proximal, lateral aspect 

of the tibial tubercle. Via this skin incision, a lateral parapatellar 

approach is performed with careful dissection of the superficial 

fascia and preservation of the infrapatellar fat pad. Extra-medullary 

tibial and femoral alignment guides are used. Instrumentation and 

implant technique proceeds according to the implant manufacture’s 

technique guides. 

A trans-patellar tendon vertical resection of the tibia is used to allow 

appropriate internal rotation of the tibial baseplate and ensure that 

the femur articulates with the tibial polyethylene even through 

the screw-home mechanism. Balancing the lateral compartment is 

different than medial UKA or TKA. Laterally, in the ligamentously 

intact knee, the flexion gap is lax in comparison to the extension 

gap. This normal disparity in flexion and extension gap balance is 

recreated to avoid overcorrection. The surgeon should be familiar 

with a lateral approach for TKA in case intra-operative conversion 

is needed. 

Lateral UKA is a true resurfacing procedure in which the joint line 

should be reconstructed to anatomic. This requires resection of the 

tibial plateau to the level at which the tibial trial can be inserted 

in extension, prior to making any bony resections of the distal 

femur. This is far different that mobile bearing medial UKA. It is 

recommended, currently, that a fixed bearing device be used for 

lateral UKA due to the high range of motion, femoral posterior 

subluxation, screwhome mechanism, and significant laxity of the 

lateral compartment in flexion. 

REFERENCES 

1. Argenson JN, Komistek RD, Aubaniac JM, Dennis DA, Northcut EJ, Anderson 

DT, Agostini S. In vivo determination of knee kinematics for subjects 

implanted with a unicompartmental arthroplasty. J Arthroplasty. 2002; 17: 

1049-1054. 

2. Argenson JA, Parratte S, Bertani A, Flecher X, Aubaniac J. Long-term results 

with a lateral unicondylar replacement. Clin Orthop Relat Res. 2008; 466; 

2686-2693. 

3. Ashraf T, Newman JH, Evans RL, Ackroyd CE. Lateral unicompartmental knee 

replacement survivorship and clinical experience over 21 years. J Bone Joint 

Surg Br. 2002; 84: 1126-1130. 

4. Fitz W. Unicompartmental knee arthroplasty with use of novel patientspecific 

resurfacing implants and personalized jigs. J Bone Joint Surg Am. 

2009; 91: 69-76. 

5. Gunther T, Murray D, Miller R. Lateral unicompartmental knee arthroplasty 

with Oxford meniscal knee. The Knee. 1996; 3: 33-39. 

6. Kendrick BJ, Longino D, Pandit H, Svard U, Gill HS, Dodd CA, Murray DW, 

Price AJ. Polyethylene wear in Oxford unicompartmental knee replacement: a 

retrieval study of 47 bearings. J Bone Joint Surg Br. 2010 Mar; 92(3): 367-373. 




Clinical Results and Outcomes 

Wereportedon109knees(102patients)withminimum1-yearfollowup 

(average follow-up 30 months +/- 16.5 months). Post-operatively, 

the average KSS improved significantly (p

150 

why bother with a partial kNee arthroplaSty wheN a total 

workS muCh better? 

Giles R. Scuderi, MD 

Degenerative arthritis and post-traumatic arthritis in a young active 

patient is a therapeutic dilemma. Non-operative management, such as 

non-steroidal medication, physiotherapy, and activity modification, 

should be exhausted before surgery is contemplated. Surgical 

options, as mentioned above, include arthroscopic debridement, 

femoral or tibial osteotomy, unicondylar replacement and total knee 

replacement (TKR). Few patients are willing to accept the functional 

limitations of an arthrodesis. Arthroscopic debridement has had 

limited success and is not a predictable procedure, especially when 

there is limb malalignment or chondrocalcinosis. 10 Proximal tibial 

or distal femoral osteotomy may be indicated for the young patient 

with limb malaligment and unicompartmental disease, and who 

wish to continue in heavy labor or sports. While the early results 

are good, the long term results deteriorate with time. 3,14,17,19 Previous 

osteotomy may not compromise the outcome of a subsequent total 

knee replacement, but it does make the conversion to a total knee 

replacement technically more demanding. Unicondylar replacement 

offers an alternative, as a bone sparing procedure, but often16,24 degenerative arthritis is not limited to one compartment of the knee. 

As the indications for total knee replacement expand, the decision 

to proceed with this procedure in a young active patient needs to 

individualized and consider alternatives as noted above. Total 

knee replacement has been shown to be a durable and predictable 

procedure in elderly patients, providing relief of pain, improving 

function and correcting deformity. 2,9,13,15,23Potentiallooseningandthe need for multiple revisions had initially discouraged the widespread 

use of total knee replacement in young patients with degenerative 

arthritis. This concern arose from the poor results in young patients 

undergoing total hip replacement. 6,12,20 However, early results with 

total knee replacement were encouraging and did not reflect the 

experience with total hip replacement. Many of the initial studies had 

a large proportion of patients with rheumatoid arthritis or juvenile 

rheumatoid arthritis, since there were no other options available for 

these patients. Based on the initial success, the indications were then 

expanded to young patients with osteoarthritis. 

Stuart and Rand reviewed 44 cemented TKR in patients with 

rheumatoid arthritis less than 40 years old. 22 At an average follow-up 

of 5 years, 86% had an excellent or good result. Dalury et al. reported 

on 103 TKR in patients young than 45 years old. 4 The majority of 

patients (87%) had a diagnosis of rheumatoid arthritis. The average 

follow-up was 7 years. While there were 2 patellar fractures and 

one infection, there were no revisions for component loosening. 

Boublik et al. reviewed 22 cementless TKR in young patients with 

juvenile rheumatoid arthritis.1 At an average follow-up of 3.9 years, 

the average HSS knee score was 92. Ranawat et al. reported on 90 

TKR in patients less than 55 years old with rheumatoid arthritis and 

osteoarthritis. 18 At an average follow-up of 6 years, the average HSS 

score was 87. In a study that reviewed only osteoarthritic knees, Stern 

et al. had 55 excellent and 13 good results in patients 55 years old or 

younger, at an average follow-up of 6 years. 21 

These short-term and mid-term results have withstood the test 

of time, even in more active patients with degenerative or posttraumatic 

arthritis. Duffy et al. reported on 74 consecutive TKR in 

54 patients who were 55 years old or younger (average age 43 years) 

at the time of the index procedure. 7 All patients had a minimum 

follow-up of 10 years with an average of 13 years (range 10 – 17 




years). The preoperative diagnosis was rheumatoid arthritis in 47, 

osteoarthritis in 12, post-traumatic arthritis in 6, osteonecrosis 

in 3, hemophilia in 2 and one each with pigmented villonodular 

synovitis, tuberculosis, SLE, and achondroplasia. All knees had a 

cemented condylar prosthesis. The final functional score was 60 

(0–100) at latest follow-up. Two knees were revised: one at 3 years 

because of ligamentous laxity; and one at 13 years because of aseptic 

loosening of the tibial component. At last follow-up, there were no 

loose components. These investigators concluded that cemented 

TKR in the young patient is a reliable procedure and has excellent 

results at thirteen year follow-up and an estimated survivorship of 

99% at 10 years. 

Since most long term studies include a larger percentage of older 

patients with a variety of diagnoses, including rheumatoid patients 

and those with multiple joint involvement, it is important not to 

overly interpretate these results and extrapolate them to the younger 

active patients with osteoarthritis. This subgroup of patients tends to 

be more active and possibly even gainfully employed as a physical 

laborer. Their activity requirements are greater and may put higher 

demands on the prosthetic surface and fixation. Therefore, it is 

necessary to look at a study that specifically evaluates this subset. 

Such a study was undertaken by Diduch and co-workers. These 

investigators reviewed 108 knees in 84 patients with a diagnosis of 

either osteoarthritis or post-traumatic arthritis, with 58% having 

prior knee surgery, and all but one patient had a cemented posterior 

stabilized prosthesis. The one remaining patient had a total condylar 

prosthesis. One hundred and three unrevised knees were available 

for clinical evaluation with an average followup of 8 years (range 

3–18 years). Thirty six knees were followed for more than 10 years. 

The average post-operative HSS knee score was 92, the average Knee 

Society knee score was 94 and the functional score was 89. All knees 

were rated as either good or excellent. The average Tegner activity 

score improved from an average of 1.3 pre-operatively to 3.5 postoperatively 

(range 1–6). All but two patients improved their level 

of activity, while 24% had an activity level greater than 5 points, 

indicating regular participation in activities such as tennis, skiing, 

cycling or strenuous farm or construction work. There were two 

revisions for late infection, one for polyethylene wear and one 

for flexion instability. In all these cases, the femoral and tibial 

components were well fixed. Considering failure as revision of either 

the femoral or tibial component, the cumulative survivorship was 

94% at 18 years. There were an additional three cases which required 

revision of loose patellar components. These durable results support 

treatment of the osteoarthritic knee in a young active patient with a 

cemented posterior stabilized prosthesis when less invasive measures 

have failed. 

Despite the good results experienced by several skilled surgeons and 

supported by the clinical reports, common sense suggests that total 

knee replacement should continue to be considered with caution for 

some young patients. Deferment of the definitive surgical procedure 

may be the best option until the symptoms warrant total knee 

replacement. If total knee replacement is performed, these young 

patients need to realize that activities that involve high impact loads, 

such as running and jumping, should be avoided. Finally, while some 

studies have reported good results as long as eighteen years, these are 

incidental cases, with specific implant designs, and should not be

construed as a guaranteed norm with all implants in all cases. While 

there does not appear to be any evidence of catastrophic component 

loosening or failure, further long term information needs to be 

REFERENCES 

1. Boublik M; Tsahakis PJ; Scott RD: Cementless total knee arthroplasty in 

juvenile onset rheumatoid arthritis. Clin Orthop 286: 88 – 93, 1993 

2. Colizza WA; Insall JN; Scuderi GR: The posterior stabilized total knee 

prosthesis. Assessment of polyethylene damage and osteolysis after a ten year 

minimum follow-up. J Bone Joint Surgery 77A: 1713 – 1720, 1995 

3. Coventry MB: Upper tibial osteotomy for gonarthrosis. The evolution of the 

operation in the last 18 years and long term results. Orthop Clin NA 10: 191 

– 210, 1979 

4. Dalury DF; Ewald FC; Christie MJ; Scott RD: Total knee arthroplasty in a 

group of patients less than 45 years of age. J Arthroplasty 10: 598 – 602, 

1995 

5. Diduch DR; Insall JN; Scott WN; Scuderi GR; Font-Rodriguez D: Total Knee 

Replacement in young Active Patients. J Bone Joint Surgery 79A: 575 – 582, 

1997 

6. Dorr LD; Kane TJ; Conaty JP: Long-term results of cemented total hip 

arthroplasty in patients 45 years old or younger: A 16 year follow-up study. J 

Arthroplasty 9: 453 – 456, 1994 

7. Duffy GP; Trousdale RT; Stuart MJ: Total Knee Arthroplasty in Patients 55 

years Old or Younger. 10 to 17 year results. Clin Orthop 356: 22 – 27, 1998 

8. Ewald F, Christie MJ: Results of cemented total knee replacements in young 

patients. Orthop Trans 11: 442, 1987 

9. Ewald FC; Jacobs MA; Miegel RE; et al.: Kinematic total knee replacement. J 

Bone Joint Surgery 66A: 1032 – 1040, 1984 

10. Harwin S.: Arthroscopic debridement for osteoarthritis of the Knee: 

Predictors of patient satisfaction. Arthroscopy 15: 142 – 146, 1999 

11. Hungerford DS; Krackow KA; Kenna RV: Cementless total knee replacement 

in patients 50 years old and under. Orthop Clinics NA 20: 131-145, 1989 

12. Joshi AB; Porter ML; Trial IA; et al.: Long term results of Charnley low friction 

arthroplasty in young patients. J Bone Joint Surgery 75B: 616 – 623, 1993 

151 




gathered before universal acceptance of total knee replacement in the 

treatment of osteoarthritis in the young active patient is obtained. 

13. Insall JN, Kelly MA: The total condylar prosthesis. Clin Orthop 205: 43 – 48, 

1986 

14. Insall JN; Joseph DM; Msika C: High tibial osteotomy for varus gonarthrosis. 

A long term follow-up study. J Bone Joint Surgery 66A: 1040 – 1048, 1984 

15. Insall JN; Lachiewicz PF; Burstein AH: The posterior stabilized condylar 

prosthesis. A modification of the total condylar design. Two to four year 

clinical experience. J Bone Joint Surgery 64A: 1317 – 1323, 1982 

16. Katz MM; Hungerford DS; Krackow KA; Lennox DW: Results of total knee 

arthroplasty after failed proximal tibial osteotomy for osteoarthritis. J Bone 

Joint Surgery 69A: 225 – 233, 1987 

17. McDermott ACG; Finkelstein JA; Farine I.; et al.: Distal femoral varus 

osteotomy for valgus deformity of the knee. J Bone Joint Surgery 70A: 110 – 

116, 1988 

18. Ranawat CS; Padgett DE; Ohashi Y: Total knee arthroplasty for patients 

younger than 55 years. Clin Orthop 248: 27 – 33, 1989 

19. Ritter MA; Fechtman RA: Proximal tibial osteotomy. A survivorship analysis. J 

Arthroplasty 3: 309 – 311, 1988 

20. Solomon MI; Dall DM; Learmonth ID, Davenport, JM: Survivorship of 

cemented total hip arthroplasty in patients 50 years of age or younger. J 

Arthroplasty 7: 347 – 352, 1992. 

21. Stern SH; Bowen MK; Insall JN; Scuderi GR: Cemented total knee 

arthroplasty for gonarthrosis in patients 55 years old or younger. Clin 

Orthop. 260: 124 – 129, 1990 

22. Stuart MJ; Rand JA: Total knee arthroplasty in the young adult. Ortho Trans 

11: 441 – 442, 1987 

23. Vince KG; Insall JN; Kelly MA: The total condylar prosthesis 10- to 12- year 

results of a cemented knee prosthesis. J Bone Joint Surgery 71B: 793 – 797, 

1989 

24. Windsor RE; Insall JN; Vince KG: Technical considerations of total knee 

arthroplasty after proximal tibial osteotomy. J Bone Joint Surgery 70A: 547 – 

555, 1988

152 

FiXed beariNg iNlay medial uka repreSeNtS the moSt 

CoNServative approaCh 

John A. Repicci, DDS, MD 

Knee Osteoarthritis: 

The relationship between pain, disability and disease severity is 

complex and not closely related to radiographic findings. Wolfe 

and Lane1 found that only 8-15% of patients with knee pain and 

radiographs revealing complete loss of knee joint space will, on initial 

exam, accept a total knee replacement (TKR). Medial osteoarthritis is 

an extension gap disease. 

Varus Malalignment: 

Varus is a destructive force. Greater than 2˚ of varus provides threefold 

greater risk for osteoarthritis progression in the knee. 

Accommodation: 

Kneeosteoarthritisisahighlysegementalprocessthatispredominately 

medial. Patients often accommodate for a decade or more. 

REFERENCES 

1. Wolfe F, Lane NE. The longterm outcome of osteoarthritis: rates and 

predictors of joint space narrowing in symptomatic patients with knee 

osteoarthritis. J Rheumatol. 2002 Jan;29(1):139-46 




Survival of UKA – Norwegian Registry Data, Cemented UKA by 

Age at Surgery2: 

• Age ≥70 years: 87% 10-year survival 

• Age 60-69 years: 85% 10-year survival 

• Age ≤ 60 years: 55% 10-year survival 

— Highly related to age and activity level. 

Minimally Invasive, Bone Conserving: 

• Adding bone-sparing, surface enhancement to an out-patient 

arthroscopic knee surgical procedure utilizing a minimally 

invasive surgical approach through a 3-inch incision is an 

appealing concept to many elderly patients.3 

• Use of a bone-sparing technique allows a wider range of surgical 

indications and is of significant interest to the elderly patient in 

order to relieve pain and prevent or delay the need for TKR. 

2. Furnes O, Espehaug B, Lie SA, Vollset SE, Engesaeter LB, Havelin LI. Failure 

mechanisms after unicompartmental and tricompartmental primary knee 

replacement with cement. J Bone Joint Surg Am. 2007 Mar;89(3):519-25 

3. Repicci JA, Hartman JF. Minimally invasive unicondylar knee arthroplasty 

for the treatment of unicompartmental osteoarthritis: an outpatient arthritic 

bypass procedure. Orthop Clin North Am. 2004 Apr;35(2):201-16. Review.

153 

FiXed beariNg oNlay iS tried aNd true 

Craig J. Della Valle, MD 

Introduction 

Among the many controversies with unicompartmental knee 

arthroplasty (UKA) include which design concepts that provide the 

simplest, most reproducible surgical techniques combined with 

optimal long term results. Specific controversies include: 

• Fixed bearing vs. mobile bearing designs 

• Onlay vs. inlay designs 

• The use of a metal backed vs. an all polyethylene tibial 

component. 

It is my belief that a fixed bearing onlay design with a metal backed 

tibial component provides the orthopaedic surgeon with a simple, 

reproducible operation with published results that show a low rate 

of failure. 

The Surgical Technique is Straight-forward and familiar 

Among the many lessons we have learned as adult reconstructive 

surgeons is that for an operation to be successful, surgeons must be 

able to perform it easily and reproducibly. 

• The surgical technique is familiar to adult reconstructive 

surgeons; similar to a TKA 

• Intramedullary alignment can be utilized for the distal femoral 

cut (like a TKA). 

• Extra-medullary alignment for the tibial cut (like a TKA). 

• Posterior referencing for femoral sizing and preparation (similar 

to some TKA). 

While the technique is similar to a TKA, there are several important 

differences and tips to optimize outcomes. 

• The tibial cut must be conservative (typically removing 2-3mm 

of bone) 

— Deeper cuts (10mm) advocated in the past have lead to 

problems if a revision was required and promulgated the 

idea that conversion from a UKA to a TKA is difficult. 

— Deeper cuts also lead to placement of the tibial component 

in weaker bone with a higher risk of failure. 

— Polyethylene wear has NOT been a major source of failure 

and a thin polyethylene is compatible with excellent long 

term survivorship (more on this later). 

• The femur must track centrally on the tibia to prevent edge 

loading of the polyethylene (or you will have problems with 

wear). 

• The knee should have 2-3mm of laxity in both full extension 

and 90 degrees of flexion. If you make the knee too tight, it will 

push it into valgus and you will get lateral compartment degeneration 

and worse results! 

The Use of a Modular Metal Backed Tibial Component is an 

Advantage 

While the use of an all polyethylene tibial component has some 

theoretical advantages including decreased cost and the ability to use 

a thicker polyethylene for the bearing surface: 

REFERENCES 

1. Clark M, Campbell DG , Kiss G , et Al. Reintervention after mobile-bearing 

Oxford unicompartmental knee arthroplasty. Clin Orthop Relat Res. 

2010;468:576-80. 

2. Song MH , Kim BH , Ahn SJ , et Al. Early complications after minimally 

invasive mobile-bearing medial unicompartmental knee arthroplasty. J 

Arthroplasty. 2009;24:1281-4. 

3. Bonutti PM , Dethmers DA . Contemporary unicompartmental knee 

arthroplasty: fixed vs mobile bearing. J Arthroplasty. 2008;23:24-7. 




• Clinical results with an all polyethylene tibial component in 

general show a higher rate of tibial component loosening. 

• The use of an all polyethylene tibial component predisposes to 

leaving retained cement which is a real cause of persistent pain 

and the need for re-operation. With a modular component, 

retained cement is far easier for the surgeon to visualize and 

remove. 

• Polyethylene wear has not been a major cause of failure with 

most successful fixed bearing designs. 

There is No Risk of Bearing Dislocation 

Although mobile bearing designs are associated with excellent 

results, a small proportion of knees (particularly early in the socalled 

“learning curve”) are associated with failure secondary to 

bearing dislocation. This also precludes the use of a mobile bearing 

design with currently available components in the USA. 

• Clark et al., CORR 2010; (4) Re-opeations related to mobile 

bearing of 398 (1%) 

• Song et al., J Arthroplasty 2009 (4) bearing dislocations in first 

100 cases (4%) 

• Whitaker et al., CORR 2010; (1) bearing dislocation of 79 

mobile UKA (1.3%) 

• Gleeson et al., Knee 2004 (3) Bearing dislocations out of 47 

knees (6.4%) 

• FDA trial 2 bearing dislocations of 125 knees (1.6%) 

The Long Term Results Are Excellent and Wear is Rarely the 

Cause of Failure 

Although one early design was associated with a high failure rate 

secondary to wear (the polyethylene was gamma irradiated in air 

with a prolonged shelf life), most studies do not show wear to be 

a major cause of failure. Lower wear is proposed as a theoretical 

advantage of a mobile bearing design. 

Author, Year Patients, FU Survivorship Wear Related 

Failures 

Foran, 2011 

(presented AAOS) 

62 UKA at min 15 yrs 93% at 15 yrs 0% 

Naudie, 2004 113 UKA at mean 

10 yrs 

90% at 10-14 years 2.7% 

pennington, 2003 46 UKA (65 yo at time 

of surgery 

Reported) 

Fixed bearing onlay UKA offers the surgeons a simple and familiar 

surgical technique with a low rate of failure in multiple series 

published from multiple centers at intermediate term follow-up. 

4. Gleeson RE , Evans R , Ackroyd CE , Webb J , Newman JH . Fixed or mobile 

bearing unicompartmental knee replacement? A comparative cohort study. 

Knee. 2004;11:379-84. 

5. Berger RA, Meneghini RM, Jacobs JJ et. Al.: Results of unicompartmental knee 

arthroplasty at a minimum of ten years of follow-up. J Bone Joint Surg Am, 

87(5): 999-1006, 2005. 

6. O’Rourke MR, Gardner JJ, Callaghan JJ, et Al. The John Insall Award: 

unicompartmental knee replacement: a minimum twenty-one-year followup, 

end-result study. Clin Orthop Relat Res, 440: 27-37, 2005.

7. Argenson JN, Chevrol-Benkeddache Y, Aubaniac JM. Modern 

unicompartmental knee arthroplasty with cement: a three to ten-year followup 

study. J Bone Joint Surg Am, 84-A(12): 2235-9, 2002. 

8. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN. Unicompartmental 

knee arthroplasty in patients sixty years of age or younger. J Bone Joint Surg 

Am, 85-A(10): 1968-73, 2003. 

154 




9. Naudie D, Guerin J, Parker DA, Bourne RB, Rorabeck CH. Medial 

unicompartmental knee arthroplasty with the Miller-Galante prosthesis. J 

Bone Joint Surg Am, 86-A(9):1931-5, 2004.

155 

doN’t worry about wear with mobile beariNg partial kNee 

arthroplaSty 

Michael E. Berend, MD 

Introduction 

Mobile bearing UKA has been approved 

in the US for the past six years with an 

educational training requirement from 

the FDA. The hope of restoration of knee 

kinematics, decreasing polymer wear 

through increased implant conformity, 

and lower polyethylene stresses are 

appealing with a mobile bearing device 

and may improve long-term implant 

performance. 

Importantly however, mobile bearing 

UKA does not improve our indications 

and patient selection, nor surgeon performance that are critical 

elements of UKA clinical success and survivorship. This section of 

the Symposium will discuss indications, outcomes, technical factors, 

and laboratory correlations with mobile bearing UKA. 

Clinical Results and Survivorship 

Excellent results with 98% survival at 6 years are seen with liberal 

indications using this mobile bearing partial knee replacement 

have been reported by Berend, et al. Longer-term results have been 

reported by Price and Svard to be 91% at 16-years and no additional 

failures at 20-years (91%). Importantly there have been no reported 

revisions due to polyethylene wear in these long term cohorts. 

Furthermore, registry data demonstrate that polymer wear with a 

mobile bearing UKA is quite rare. The high success and low incidence 

of perioperative complications make this an ideally suited operation 

with nearly no contraindications in patients with anteromedial OA 

of the knee. 

Polyethylene Wear 

Poly wear has been a concern in fixed 

bearing metal backed implants. Much of 

this limitation however has been better 

understood as we have understood the 

adverse effects of poly oxidation through 

increased shelf life and sterilization 

methods in the presence of oxygen. Poly 

wear has been an infrequent indication 

for revision of mobile bearing implants. 

Wear rates on retrieved mobile bearings 

has been reported to be 0.03 mm/yr on 

penetration testing. Bearing impingment has been shown to increase 

poly wear in mobile bearing devices and highlights the importance of 

surgical technique in order to ensure an impingement free kinematic 

environment. 

Indications 

The indications for UKA 

have changed significantly 

over the last decade in 

our practice and may be 

changing in the US for 

mobile bearing metal 

backed implants based 

on emerging data. It is 




interesting to note that the classic “Kozinn and Scott” criteria have no 

adverse data on ignoring the assumed contraindications to support 

their recommendations. We have retrospectively applied the Kozinn 

and Scott criteria to our TKA database and found between 4-6% of 

varus knees would becandidates for UKA. Since that time we have 

utilized more physiologic criteria including confirming anteromedial 

osteoarthritis of the knee with an intact ACL. Our prevalence 

of UKA has gone from 4-6% in 2004 to 37% in 2010. What has 

changed? I believe a better understanding of the pathophysiology 

of “anteromedial OA” that was described by White and Goodfellow 

many years ago for medial compartment OA. Berend, KR, et al 

presented a summary of the indications at the AAOS, OLC, Knee 

Course in 2010 entitled, “Indications for Unicompartmental Knee 

Arthroplasty: Is there any science?” It is summarized below and 

brings an abundance of data to the table in this ongoing debate. 

Unicompartmental knee arthroplasty (UKA) has seen increasing 

interest due to better implant design, minimally invasive techniques, 

and improved outcomes. Survivorship with revision of any kind of 

Mobile Bearing UKA appears to rival that of total knee arthroplasty, 

despite more liberal indications than those traditionally used. It is 

these expanded indications for UKA that continue to be debated. 

Traditional or “Classical” indications preclude the use of UKA in 

patients younger than 60, heavier than 82kg (or BMI greater than 

32), patients with radiographic patellofemoral disease, and patients 

with pain that is not isolated to the medial side of the knee. Although 

absolutely no data exists to corroborate these contraindications, 

surgeons frequently cite Kozin and Scott (JBJS-Am 1989) when 

deciding whom to offer UKA. 

The purpose of the report by Berend, et al was to examine various 

so-called “classical” inclusion and exclusion criteria and determine 

how these impact the outcomes and revisions in a consecutive series 

of UKA implanted for anteromedial osteoarthritis. The study groups 

for this report are taken from a consecutive series of 1,500 medial, 

mobile-bearing UKA performed between July 2004 and January 

2010, by 2 surgeons. 

Indications: The indication for medial UKA is anteromedial 

osteoarthritis (AMOA), a clinical condition originally described by 

White et al. (JBJS-Br 1991). AMOA is a distinct disease that in and of 

itself defines the indications for medial UKA. This disease involves 

complete bone-on-bone arthrosis medially on a weight bearing 

radiograph, functionally intact ACL and MCL, and a correctible 

varus deformity. Correctability of deformity is examined using a 

valgus-stress radiograph in each UKA candidate. Using these criteria, 

the indications for UKA can be as high as 35-40% of osteoarthritic 

knees which has paralleled our practices adoption in New Albany 

and Mooresville. 

Weight and Age: At up to 72 months follow-up, 31 of 1,500 knees 

have been revised for a survivorship of 97.9%. No difference in 

survivorship was noted in patients heavier than 82 kg, heavier 

than BMI 32, or younger than 60 years of age (p>0.05). We did 

note a higher Knee Society score in older, lighter patients (90 vs 

88; P=0.001), however the scores averaged good/excellent in both 

groups that fell within and outside the classical criteria. 

BMI: Further investigation of BMI and its effect on survival was 

performed looking at our series, and that of the Oxford group.

Together, we evaluated 2586 consecutive UKA. Life-tables were 

constructed to evaluate the effect of BMI on survival. Survival in 764 

UKA with BMI 30-35 was 94%, in 310 UKA with BMI 36-40 survival 

was 95%, and in 209 knees with BMI >40 survival was 98%. No 

statistical difference was seen between any BMI group (P>0.05). 

Patellofemoral disease: Standardized radiographs from 626 Knees in 

which a mobile bearing medial UKA was implanted were reviewed 

by an evaluator blinded to patient outcome or revision status. The 

evaluator recorded the pre-operative state of the patellofemoral joint 

using 

the Altman Classification. The Altman classification grades the 

patellofemoral joint medially and laterally for sclerosis, osteophytes, 

and joint space narrowing with a score of 0-4, with 4 representing 

severe, erosive bone-on-bone disease. Log-rank and Kaplan-Meier 

analysis were used to evaluate survivorship between knees with 

significant pre-operative patellofemoral disease and those without. 

Within this subset of 626 knees, there were 17 revisions at up to 

6 years (97.2% survival). In only 384 knees (61.3%) was the 

patellofemoral joint normal or Altman 0-1. Survival in this normal 

PFJ cohort was 93.8%. In 242 knees, or 37.8% of cases, with preoperative 

PFJ disease (Altman 2-4) the predicted survival was 97.9%. 

Of these, 92 knees (15%) had significant disease (Altman 3 or 

greater) and the survival was 97.0%. 

Morbidity and Mortality: With 35-40% of varus osteoarthritic knees 

meeting these expanded inclusion criteria and pathological diagnosis 

of AMOA, it is amazing that surgeons still do not utilize UKA in their 

practices, or use it sparingly. In the current series, better than 98% 

survival at 6 years using AMOA as the indication for UKA is seen. 

Perhaps most convincing, however, is the stark difference in 

morbidity and mortality associated with UKA when compared to 

TKA. We evaluated 1,000 consecutive UKA for 90 day perioperative 

morbidity and mortality. There were no deaths (0.0%), one DVT 

(0.1%), and one deep infection (0.1%). Five patients required 

a transfusion (0.5%) and 7 patients had a cardiac complication 

including CHF, arrhythmia, or myocardial infarction (0.7%). Thus 

the early morbidity associated with mobile bearing UKA warrants 

that this procedure be defined as truly minimally invasive, in 

contradistinction from TKA. With such a low rate of perioperative 

complications, surgeons may be over-treating patients with TKA in 

knees with anteromedial OA who meet the expanded indications 

for UKA, putting them at undue risk. These liberal indications for 

UKA, based on the patho-anatomic condition of anteromedial 

osetoarthritis, appear to be a safe and accurate measure of candidacy 

for UKA. 

Tibial Implant Design 

It appears metal backed implants may be more resistant to implant 

loosening most notably in obese patients as Berend, et al reported 

that all poly implants had higher failure rates in patients with a 

higher BMI. Higher strains in the tibial bone were observed in our 

laboratory with 

all poly tibial 

c o m p o n e n t s. 

We also found 

that excessive 

implant slope 

in both the 

anterior and 

p o s t e r i o r 

direction may 

p r e d i s p o s e 

to implant 

s u b s i d e n c e 

156 




with all poly designs. (Aleto) The effects of the development of MIS 

techniques during this study period are as of yet unknown. 

Tibial Loading under Mobile Bearing UKA 

Observing early (< 1 yr) tibial subsidence in series of all poly 

implants (Aleto) led us to investigate the influence of metal backing 

on tibial loading throughout knee motion. With in vitro photoelastic 

strain quantification methods we directly compared all poly tibial 

implants to metal backed tibial 

implants. We found higher overall 

strains and more localized strain 

concentration in the posterior 

medial tibia with all poly implants 

compared to metal implant designs 

(Small) as shown on the lower 

image on the right. We hypothesize 

that our in vitro observation may at 

least partly explain the biomechanics behind tibial subsidence in 

high BMI patients with all poly implants. 

Bearing Mobility and Tibial Loading 

We have also studied the effects of bearing mobility (simulating 

flexion and extension of the knee) in mobile bearing UKA on 

proximal tibial loading. The figure below shows the comparison 

between mid flexion on the left and full extension on the right. The 

increased intensity and localization in the photoelastic color pattern 

with the bearing in the anterior aspect of the tibial tray (which 

simulates knee extension) shows increased loading in the anterior 

medial aspect of the tibia. This correlates with an area often noted 

to have early pain in the medial tibial metaphysis. I have heard this 

comment from many UKA surgeons around the country with various 

implant designs. Many believe this to be soft tissue inflammatory 

pain about the pes tendons and bursa. 

We hypothesize that tibial overload and 

remodeling may at least in part be part of 

the pain and remodeling in this area in 

response to changes in tibial strains over 6-12 

months may correlate with pain resolution. 

Supplemental observations of increased activity 

on postoperative bone scan evaluations may 

support this hypothesis.

Risks 

Risks unique to mobile bearing UKA 

include the adverse risks of bearing 

impingement and poly wear, bearing 

dislocation, interpretation of postoperative 

tibial radiolucencies, and reported 

increased revision rates in registry data. 

In order for a medial mobile bearing to 

dislocate both medial joint distraction 

and bearing spinning must occur 

simultaneously. Anatomic bearings have 

been designed to prevent 90o of bearing rotation on the tibial 

tray. The anterior portion of the bearing has a 5 mm lip while the 

posterior aspect has a 3 mm lip. Bearing dislocation occurs when 

REFERENCES 

1. Berend KR, Lombardi AV Jr, Adams JB.: Obesity, young age, patellofemoral 

disease, and anterior knee pain: identifying the unicondylar arthroplasty 

patient in the United States. Orthopedics. 2007 May;30(5 Suppl): 19-23. 

2. Berend KR, Lombardi AV Jr, Mallory TH, Adams JB, Groseth KL.: Early failure 

of minimally invasive unicompartmental knee arthroplasty is associated with 

obesity. Clin Orthop Relat Res. 2005 Nov; 440: 60-6. 

3. Price AJ, Waite JC, Svard U.: Long-term clinical results of the medial 

Oxford unicompartmental knee arthroplasty. Clin Orthop Relat Res. 2005 

Jun;(435):171-80. 

4. Price AJ, Svard U. A second decade lifetable survival analysis of the Oxford 

unicompartmental knee arthroplasty. Clin Orthop Relat Res 2010 Aug 13 

(epub ahead of print). 

5. White S, Ludkowski PF, Goodfellow J. Anteromedial O\osteoarthritis of the 

knee. JBJS 1991, 73Br; 582-586. 

6. Kozinn SC, Scott R. Unicondylar Knee Arthroplsty. JBJS 1989, 71Am; 145- 

150. 

7. Berend KR, Lombardi, Jr. AV, Hurst JM, Morris M, Indications for UKA, Is 

there any science, AAOS OLC presentation, Oct 2010. 

8. McGovern TF, Ammeen DJ, Collier JP, Currier BH, Engh GA, JBJS-A, 2002 

9. Collier MB, Engh CA Jr, Engh GA., JBJS-A, 2004. 

10. Small SR, Berend ME, Ritter MA, Buckley CA, Rogge RD. Metal backing 

significantly decreases tibial strains in a medial unicompartmental knee 

arthroplasty model. J Arthroplasty. 2010 Sep 24. 

11. Small SR, Berend ME, Ritter MA, Buckley CA. Bearing mobility affects tibial 

strain in mobile-bearing unicompartmental knee arthroplasty. Surg Technol 

Int. 2010;19:185-90. 

12. Psychoyios V, Crawford RW, O’Connor JJ, Murray DW. Wear of congruent 

meniscal bearings in unicompartmental knee arthroplasty: a retrieval study 

of 16 specimens. J Bone Joint Surg Br. 1998 Nov;80(6):976-82. 

13. Collier MB, Engh CA Jr, Engh GA. Shelf age of the polyethylene tibial 

component and outcome of unicondylar knee arthroplasty. J Bone Joint Surg 

Am. 2004 Apr;86-A(4):763-9. 

14. Hamilton WG, Collier MB, Tarabee E, McAuley JP, Engh CA Jr, Engh 

GA. Incidence and reasons for reoperation after minimally invasive 

unicompartmental knee arthroplasty. J Arthroplasty. 2006 Sep;21(6 Suppl 

2):98-107. 

157 




the bearing impinges on bone, cement, and retained osteophytes. 

Surgical technique is important to prevent bearing dislocation. 

Radiolucencies (RLL) have been reported under cemented metal 

backed mobile bearing UKA’s. The clinical significance of these 

RLL has been investigated and found to not correlate with pain 

or poor postoperative outcomes. The importance of radiographic 

interpretation of RLL cannot be overemphasized. In the absence 

of implant migration a cautious approach to revision should be 

employed. 

Registry data suggest higher revision rates for UKA than TKA. This 

is a complex subject and one must remember that the threshold to 

revise a dissatisfactory UKA is much lower than revision a painful 

TKA. 

15. McGovern TF, Ammeen DJ, Collier JP, Currier BH, Engh GA. Rapid 

polyethylene failure of unicondylar tibial components sterilized with gamma 

irradiation in air and implanted after a long shelf life. J Bone Joint Surg Am. 

2002 Jun;84-A(6):901-6. 

16. Kendrick BJ, Longino D, Pandit H, Svard U, Gill HS, Dodd CA, Murray DW, 

Price AJ. Polyethylene wear in Oxford unicompartmental knee replacement: 

a retrieval study of 47 bearings. J Bone Joint Surg Br. 2010 Mar;92(3):367-73. 

17. Price AJ, Svard U. A second decade lifetable survival analysis of the oxford 

unicompartmental knee arthroplasty. Clin Orthop Relat Res. 2010 Aug 13. 

18. Price AJ, Waite JC, Svard U. Long-term clinical results of the medial 

Oxford unicompartmental knee arthroplasty. Clin Orthop Relat Res. 2005 

Jun;(435):171-80. 

19. Svärd UC, Price AJ. Oxford medial unicompartmental knee arthroplasty. 

A survival analysis of an independent series. J Bone Joint Surg Br. 2001 

Mar;83(2):191-4. 

20. Ritter MA, Faris PM, Thong AE, Davis KE, Meding JB, Berend ME. Intraoperative 

findings in varus osteoarthritis of the knee. An analysis of 

pre-operative alignment in potential candidates for unicompartmental 

arthroplasty. J Bone Joint Surg Br. 2004 Jan;86(1):43-7. 

21. White SH, Ludkowski PF, Goodfellow JW. Anteromedial osteoarthritis of the 

knee. J Bone Joint Surg Br. 1991 Jul;73(4):582-6. 

22. Gulati A, Chau R, Pandit HG, Gray H, Price AJ, Dodd CA, Murray DW. The 

incidence of physiological radiolucency following Oxford unicompartmental 

knee replacement and its relationship to outcome. J Bone Joint Surg Br. 2009 

Jul;91(7):896-902. 

23. Aleto TJ, Berend ME, Ritter MA, Faris PM, Meneghini RM. Early failure of 

unicompartmental knee arthroplasty leading to revision. J Arthroplasty. 2008 

Feb;23(2):159-63. 

24. Clarius M, Hauck C, Seeger JB, James A, Murray DW, Aldinger PR. Pulsed 

lavage reduces the incidence of radiolucent lines under the tibial tray of 

Oxford unicompartmental knee arthroplasty: pulsed lavage versus syringe 

lavage. Int Orthop. 2009 Dec;33(6):1585-90. Epub 2009 Feb 14. 

25. Pandit H, Jenkins C, Beard DJ, Gallagher J, Price AJ, Dodd CA, Goodfellow 

JW, Murray DW. Cementless Oxford unicompartmental knee replacement 

shows reduced radiolucency at one year. J Bone Joint Surg Br. 2009 

Feb;91(2):185-9.

158 

No oNe CaN do a better medial uka thaN a robot 

Riyaz H Jinnah MD, FRCS and Ryan Bunch, DO 

Robotically assisted unicompartmental knee arthroplasty. 

Total Knee Arthroplasty 

• an effective treatment for end stage arthritis 

• alleviating pain and restoring function 

Unicompartmental Knee Replacement -early problems 

• Techniques 

• Implants 

• Materials 

Medial-Lateral Malalignment: Axial Malalignment: 

Failure at 4 years 

Component to component alignment is critical 




Component-Component Malalignment Results in: 

• Edge loading 

• High contact stresses 

• Accelerated polyethylene wear 

• Implant loosening 

Why Robotics? 

• to avoid imbalance and malalignment 

Unicompartmental Knee Arthroplasty [UKA] 

• renewed interest 

• relatively less morbid procedure 

• leading to a shorter hospital stay & 

• faster rehabilitation 

The latest UKA system – a step further 

• Robotically assisted 

• software accurately plan implant size 

• optimize position and orientation 

• based on preoperative CT scan 

• Precise – enhanced longevity 

• Minimally invasive – reduced morbidity 

Intra-Operative Planning: Trace Points 

• At captured poses, the tibial articular surface centroid is mapped 

• Tibia ROM is shown as a series of dots 

• Based on plan, graphs show femoral - tibia (tight) or gaps 

(loose) 

• Adjust femoral or tibia plan to achieve the desired balance 

Modern UKA Systems 

• Oxford [Biomet] 

• Triathlon , Eius [Stryker], 

• Preservation [ Depuy] 

• Hiflex Uni [Zimmer] 

Improvement in: 

• Surgical instrumentation 

• Implant designs 

• Material properties [Poly] 

• Refinement in patient selection 

Technique – Implant Planning: 

Technique: Bone Preparation:

Technique Bone Preparation and Cementing the Prosthesis 

Clinical Outcomes: 

Roche et al (2008) - 43 Robotically guided UKA patients 

• improved every measured clinical outcome at 3 months 

followup (p

160 

CuStom medial uka optimizeS the reSult For eaCh patieNt 

Wolfgang Fitz, MD 

Indication – based on clinical exam: 

• ROM >90° 

• Correctable deformity

Anatomic Challenges: 

161 

Figure 7: Medial condyle is curved 

and longer than lateral 

Figure 8: Off-the-shelf J-curve 

compared to individual medial 

J-curves 

Figure 9: Individual J-curves in combination with engineered 

coronal curvature provide contact area similar compared to off-theshelf 

implants 

Figure 10: Onlay-UKA increase risk of PF impingement compared 

to tapered designs 

BIBLIOGRAPHY 

1. Steklov N et al., Unicompartmental knee resurfacing: enlarged tibiofemoral 

contact area and reduced contact stress using novel patient-derived 

geometries. Open Biomed Eng J, 2010. 4: p. 85-92. 




Figure 11: Off-the-shelf UKA cannot cover more than 75% of 

cortical bone 

Surgical Technique - Review surgical plan: 

Figure 11: Orange marked osteophytes have to be removed 

• Remove all cartilage off the femur (inferior of sulcus terminalis) 

and off the tibia 

• Balance knee in 10¡ to 30¡ (balancing chip) 

• Attach tibial cutting block 

• Place femoral cutting jig, drill pegs and cut posterior condyle 

removing planned amount of bone 

• For bicompartmetnal make additional anterior cut 

• Prepare anterior trench and smooth transition to posterior cut 

using a 5mm high-speed burr 

• Place trial implants and verify component placement and 

balancing 

• Prepare femur and tibia for cementing 

Results: 

Isolated medial TF OA Medial TF and PF OA 

Radiographic examples from personal experience 

Koeck et al [2]: 

• 32 individual UKA 

• correction from 7¡ varus to 1¡ 

• preservation of pre-op tibial slope 

All images reproduced courtesy of Wolfgang Fitz, MD. 

2. Koeck FX et al., Evaluation of implant position and knee alignment after 

patient-specific unicompartmental knee arthroplasty. Knee, 2010 Aug 3. 

[Epub ahead of print].

162 

the perFeCtly balaNCed uka CaN oNly be aCCompliShed with 

SoFt tiSSue guided Surgery 

Gerard A. Engh, MD 

Condylar total knee implants have provided excellent pain relief 

but limited knee function for over 30 years. Outcome studies1 

document lower patient satisfaction and limited activities following 

knee arthroplasty when compared to age-matched, non-arthroplasty 

individuals. The altered kinematics is documented in gait and video 

fluoroscopy studies.2 

A conventional knee replacement alters the intimate relationship 

between the patient’s hard tissue anatomy and the soft tissue 

envelope. Anatomy unique to each patient is modified when we 

reconstruct knees with bone cuts performed independent of the 

patient’s capsular and ligamentous structures. Implant’s and implant 

position alter the patient’s unique hard tissue anatomy with a 

traditional knee arthroplasty which alters the soft tissue tension that 

REFERENCES 

1. Noble PC, Gordon MJ, Weiss JM, Reddix RN, Conditt MA, Mathis KB. 

Does total knee replacement restore normal knee function? Clin Orthop 

2005;431:157-165. 




guides motion and provides stability, proprioception, and strength 

to the knee. 

Tissue guided surgery enlists the patients capsular and ligamentous 

structures to guide bone preparation.3 Instrumentation for bone 

milling is placed within the joint cavity on the resected tibial surface 

and the knee articulated under a distraction load that tensions the 

soft tissues. Tension in the capsular and cruciate ligaments dictates 

the precise amount of bone and cartilage that is removed. The 

unique kinematic relationship between bone and soft tissues is 

thereby restored through a full arc of motion. The final implants are 

resurfacing and replace only the thin layer of bone and cartilage that 

was removed under the guidance of the soft tissue structures. 

2. Dennis DA, Komistek RD, Mahfouz MR. In vivo fluoroscopic analysis of 

fixed-bearing total knee replacements. Clin Orthop 2003;410:114-130. 

3. Engh GA. Tissue guided surgery in unicompartmental knee arthroplasty 

TGS¨. Orthopreneur 2010 Jan/Feb:28-31.

163 

the aCl deFiCieNt kNee CaN be approaChed with a 

CombiNatioN aCl reCoNStruCtioN aNd medial uka 

Jason M. Hurst, MD 

Introduction 

Deficiency of the anterior cruciate ligament (ACL) is a common 

finding in end-stage osteoarthritis (OA). Varus osteoarthritis in 

ACL-competent knees demonstrates the classic anteromedial 

osteoarthritic pattern that has been shown to be successfully treated 

with unicompartmental arthroplasty. However, ACL deficient knees 

have a unique pattern of OA with a more posteromedial location.1 

Traditional indications for unicompartmental knee arthroplasty 

(UKA) have restricted the procedure to ligamentously normal knees 

with bone-on-bone medial compartmental arthrosis.2 Previous 

studies have demonstrated that UKA in knees without an intact 

anterior cruciate ligament (ACL) have decreased survivorship.3-5 

As interest in UKA has increased and significant advantages have 

been reported, such as speed of recovery and ultimate function, 

younger more active patients are presenting with end-stage 

arthritis and concomitant ACL insufficiency.6-8 In these patients 

with degenerative arthrosis and concomitant instability, cartilage 

restoration options are limited and total knee arthroplasty is not ideal 

considering the patients young age and usually high activity level. 

Therefore, less invasive arthroplasty options have been considered 

despite the relative contraindication of ACL deficiency. We studied 

the indications and surgical technique for arthroscopically assisted 

simultaneous UKA-ACL (Berend, Cannone, Hurst, Lombardi), 

noting the early outcomes of the procedure. 

Materials & Methods 

Between June 2007 and August 2010 arthroscopically assisted 

simultaneous UKA-ACL has been indicated and performed in 17 

cases at our institution, representing 1.6% of medial UKA during the 

study period. Indications for the procedure include ACL-deficiency 

and medial joint arthrosis with a correctible deformity on valgus 

stress radiograph. Arthroscopic evaluation and confirmation of 

unicompartmental disease is performed, following by arthroscopic 

establishment of the femoral and tibial tunnels using the socalled 

“all inside technique”. The UKA is then performed via a 

limited arthrotomy, trial components placed, and the graft passed, 

tensioned, and fixated. Final cementation of UKA components is 

then performed. The post-operative rehabilitation was similar to the 

typical UKA rehabilitation with additional focus on proprioception, 

balanced hamstring/quadriceps strength, and graft protection 

until nine months post-operatively. High impact activities were 

REFERENCES 

1. Ritter MA, Faris PM, Thong AE, Davis KE, Meding JB, Berend ME. Intraoperative 

findings in varus osteoarthritis of the knee. An analysis of 

pre-operative alignment in potential candidates for unicompartmental 

arthroplasty. J Bone Joint Surg Br. 2004 Jan;86(1):43-7. 

2. Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg Am. 

1989 Jan;71(1):145-50. 

3. Deschamps G, Lapeyre B. [Rupture of the anterior cruciate ligament: 

a frequently unrecognized cause of failure of unicompartmental knee 

prostheses. Apropos of a series of 79 Lotus prostheses with a follow-up of 

more than 5 years] Rev Chir Orthop Reparatrice Appar Mot. 1987;73(7):544- 

51. 

4. Goodfellow JW, Kershaw CJ, Benson MK, O’Connor JJ. The Oxford Knee for 

unicompartmental osteoarthritis. The first 103 cases. J Bone Joint Surg Br. 

1988 Nov;70(5):692-701. 




discouraged and ACL-dependent sport was limited until 9 months 

from surgery. 

Results 

There have been 2 reoperations in 17 cases: one graft fixation failure 

requiring revision ACL and one manipulation. The average age 

was 50 years (range: 38-63). In patients with 1-year follow-up the 

range of motion and Knee Society pain scores averaged 113 and 40 

respectively. We found a high success rate in terms of pain and range 

of motion in this young group of patients. 

Discussion 

Younger patients with significant medial arthrosis and concomitant 

ACL deficiency present a difficult clinical dilemma – total knee 

arthroplasty is not ideal in this young and active group, and cartilage 

restoration is typically contraindicated. Even though ACL-deficiency 

has been considered a contra-indication to unicompartmental 

arthroplasty, a less-invasive arthroplasty option still remains 

attractive in this population because of the young age at which these 

patients present with severe medial disease. The ACL/UKA procedure 

may provide implant longevity considering the increase rate of 

implant failure in UKA performed with concomitant ACL deficiency. 

ACL/UKA provides more normal kinematics and it is a less invasive 

arthroplasty option in comparison to TKA. In addition, ACL/UKA in 

younger patients may delay arthritic progression. 

When considering a ACL/UKA, it is important to consider the 

etiology of the ACL deficiency. There are two main types of ACL 

deficiency. The first is the traumatic ACL deficiency in which medial 

OA is secondary to ACL deficiency. In this type, there is a classic 

isolated posteromedial pattern and limited contracture of the medial 

collateral ligament. The ACL/UKA combined procedure is a viable 

treatment option in these cases of traumatic ACL deficiency because 

the varus deformity still remains correctable. On the contrary, the 

second type is attrition ACL deficiency in which the ACL ruptures 

secondary to the degenerative process. In this type, the arthritic 

pattern starts anteromedially and progresses posteriorly as the ACL 

fails secondary to the degenerative process. There is often significant 

contracture of the medial collateral ligament with attrition ACLdeficiency, 

and when the varus deformity is uncorrectable, total knee 

arthroplasty is warranted. 

5. Swank M, Stulberg SD, Jiganti J, Machairas S. The natural history of 

unicompartmental arthroplasty. An eight-year follow-up study with 

survivorship analysis. Clin Orthop Relat Res. 1993 Jan;(286):130-42. 

6. Lee GC, Cushner FD, Vigoritta V, Scuderi GR, Insall JN, Scott WN. Evaluation 

of the anterior cruciate ligament integrity and degenerative arthritic 

patterns in patients undergoing total knee arthroplasty. J Arthroplasty. 2005 

Jan;20(1):59-65. 

7. Pandit H, Van Duren BH, Gallagher JA, Beard DJ, Dodd CA, Gill HS, 

Murray DW. Combined anterior cruciate reconstruction and Oxford 

unicompartmental knee arthroplasty: in vivo kinematics. Knee. 2008 

Mar;15(2):101-6. 

8. Pandit H, Beard DJ, Jenkins C, Kimstra Y, Thomas NP, Dodd CA, Murray DW. 

Combined anterior cruciate reconstruction and Oxford unicompartmental 

knee arthroplasty. J Bone Joint Surg Br. 2006 Jul;88(7):887-92.

164 

the laNd oF ligameNtS: 

NavigatiNg SpraiNS, StraiNS, aNd 

ruptureS about the Foot aNd aNkle (k) 

Steven L. Haddad, MD, Moderator 

I. Introduction: Ligaments From Birth to Death: Anatomy and Pathophysiology in Health and Injury 

Mark Glazebrook, MD, Halifax, NS, Canada 

II. The Syndesmosis: Binding the Tibia and Fibula 

Robert B. Anderson, MD, Charlotte, NC 

III. The Deltoid and Spring Ligaments: Supporting the Medial Column 

Steven L. Haddad, MD, Glenview, IL 

IV. Back to Basics: The Lateral Collateral Ligaments of the Ankle 

Thomas O. Clanton, MD, Vail, CO 

V. Lisfranc’s Ligament: Preventing Midfoot Collapse 

J. Chris Coetzee, MD, Eagan, MN 

VI. Case Presentations and Discussion 

Steven L. Haddad, MD, Glenview, IL 



SympoSia FOOT & ANKLE

165 

iNtroduCtioN: ligameNtS From birth to death: aNatomy aNd 

pathophySiology iN health aNd iNJury 

Mark Glazebrook, MSc, PhD, FRCS(C) MD 

Ligament Structure 

Gross Anatomy – Ligaments of the ankle 

• Dense bands of Connective Tissue that connect bones 

— Band or Cable-like structures 

— Blend with surrounding connective tissues 

— Sometimes indistinguishable 

Microscopically: 

• Similar to tendons 

• Row of fibroblast 

• “Crimped” Parallel bundles of predominately collagen matrix 

• Also less predominante: 

— Uniform vascularity providing nutrition fibroblasts 

— Variety of pain fiber (nocioception and proprioception) 

Biochemistry[1]: 

70% Water 

20% Collagen Type I 

3-5% Other Collagens 

1-2% Elastin 

1-2% Fibronectin & Other Glycoproteins 

1% Proteoglycans 

Bone Attachment: Indirect vs. Direct 

• Indirect (most common) 

— Superficial layer contiguous with periosteum 

— Deep layer anchors to bone via Sharpys fibers 

• Direct 

— 4 Morphologically distinct zones: 

Ligament 

Fibrocartilage 

Mineralized fibrocartilage 

Bone 

Biomechanics 

• Tensile Properties are expressed in terms of: 

— Structural properties (Bone Lig Bone complex) 

— Mechanical properties (Ligament Alone) 

• Load Elongation Curve (Stress Strain) describes ligament 

behavior to uniaxial force: 

— Toe region-Initial Low stiffness region (low Slope) 

— Linear region – Higher stiffness region (higher slope) 

— Faliure (with continuity) – individual fiber failure 

(decreasing slope) 

— Ultimate Load Failure point – rupture (reverse slope) 

• Non linear strain stiffening structural response via 

— Loss of Crimp – straightening of the undulation Collagen 

Fibrils 

— Non Uniform recruitment of collagen fibrils 

• Time and History Dependant Behavior 

— Creep – Time dependant elongation with constant Load 

— Stress relation – Time dependant decrease in load with 

constant elongation 

— Hysteresis – With increasing numbers of cycles the stress 

strain curve changes 

• Factors influencing the properties of Ligaments 

— Skeletal Maturation 

— Biochemistry 

— Immobilization 

— Age 

• Skeletal maturity[2] results in increased: 



SympoSia FOOT & ANKLE 

— Stiffness ~2x 

— Ultimate Load ~3x 

— Energy absorbed at failure ~4x 

— Modulus increase (~10%) 

• Aging in humans[3] results in decreases in : 

— Stiffness 

— Ultimate load 

• Immobilization [4] results in dramatic decreases in: 

— Ultimate Load 

— Energy absorbed at failure 

Injury to Ligaments 

• Clinical Classification: 

Grade 1 Mild – No change in length 

No laxity on exam but tender 

Mild signal changes on MRI no structural changes 

Grade 2 Moderate – Change in length 

Laxity on exam and tender 

Signal and structural changes on MRI with 

Grade 3 Severe – Complete disruption 

Obvious Laxity on exam and paradoxically less tender 

Signal and structural changes on MRI with torn ends visible 

and fluid filled gap 

Ligament healing 

The repair process occurs as a continuum but 3 overlapping phases 

occur: 

• Phase I – Inflammation (~72 hrs) 

— Disruption of blood vessels: 

– Hematoma with fibrin clot 

– Potent vasodilators increase existing capillary 

permeability 

Histamine 

Serotonin 

Bradykinins 

Prostaglandins 

— Transudation of fluid and inflammatory cells including 

Monocytes and Macrophages that clear necrotic tissue and 

stimulate angiogenisis 

— Fibroblast proliferation begins and rudimentary scar with 

quick synthesis of Collagen type III predominating. 

• Phase II – Matrix and Cellular proliferation (~6 weeks) 

— Fibroblasts, macrophages and mast cells predominate over 

other inflammatory cells 

— Increasing organization of the fibrin clot 

— Gap filled with granulation tissue 

— Vascular endothelial buds communicate 

— Active collagen synthesis (collagen type III replaced by 

stronger collagen type I) 

— Increases in Glycosaminoglycans 

• Phase III – Remodelling and Maturation (up to 12 months) 

— Transition from proliferation to remodeling 

— Decreased cellularity and vascularity 

— Increase density and organization of collagen network 

Innovations of ligament Healing 

• Future research into the biology of ligament healing will 

be designed to help stimulate biologic factors and promote 

healing.

• A recent review paper [5] focuses on Platelet-rich plasma (PRP) 

as an example of a biological stimulant that has been used 

clinicallyin humans for its healing properties by increasing 

concentrations of growth factors and secretory proteins that 

will affect healing. 

• PRP can potentially enhance healing by the delivery of various 

growth factors and cytokines from the granules contained in 

platelets including: 

— transforming growth factor¥(TGF) 

— platelet-derived growth factor (PDGF) 

— insulin-like growth factor (IGF-I, IGF-II) 

— vascular endothelial growth factor (VEGF) 

— endothelial cell growth factor. These cytokines play 

important 

— epidermal growth factor 

— fibroblast growth factor (FGF) 

• These growth factors and Cytokines play roles in cell 

proliferation, chemotaxis, cell differentiation, and angiogenesis 

that will ultimately affected the healing process. 

• PRP is made from anticoagulated whole blood that is 

centrifuged to isolate a plasma with concentrated platelets and 

no RBCs or WBCs. 

• PRP is then delivered to desired site by clotting or by 

combination carrier systems such as a fibrin matrix. 

• Current research on the benefits of PRP includes: 

— Basic Science Studies 

— Animal studies 

— Case reports 

— Rare case controlled studies 

REFERENCES 

1. Frank, C.B., Ligament injuries: Pathophsiology and Healing, in Athletic 

Injuries and Rehabilitation, Z. JE, M. DJ, and Q. WS, Editors. 1996, Saunders: 

Philadelphia PA. p. 15. 

2. Woo, S.L., E. Young, and K. MK, Fundamental Studies in Knee ligament 

mechanics, in Knee Ligaments: Structure, function, injury and repair, A. D 

and O’Conner, Editors. 1990, Raven Press: New York. p. 115-134. 

3. Woo, S.L., et al., Tensile properties of the human femur-anterior cruciate 

ligament-tibia complex. The effects of specimen age and orientation. Am J 

Sports Med, 1991. 19(3): p. 217-25. 

166 




• Conservative treatment using plasma rich in growth factors 

(PRGF) for injury to the ligamentous complex of the ankle[6] 

Retrospective Review (Level IV): 

• 11 patients with acute injury to the lateral ligamentous complex 

of the ankle were treated by plasma rich in growth factors 

(PRGF) infiltration. 

• Autologous PRGF activated with calcium chloride was used to 

infiltrate the injured tissues followed by immobilization of the 

joint and its subsequent rehabilitation. 

Results: 

• The average time of healing was 5.18 weeks. 

• 4 no signs of instability at 4 weeks after therapy and could 

return to their previous sports activities. 

• One patient had lateral ankle instability at 5 weeks and 

therefore the therapy continued with prolonged immobilization 

and then rehabilitation at a slower pace. 

• The average lateral opening of the tibiotalar intra-articular space 

at 4 or 6 follow-up weeks was 4.73 degrees from pre-op 17.45 

degrees 

• At 6 weeks after therapy, 90.9% of the patients resumed their 

full sports activities. 

CONCLUSIONS: 

• PRP is one of the options for treating injuries to the Ankle 

ligaments 

• Accelerating and improving the healing of traumatic lesions and 

postoperative conditions. 

4. Woo, S.L., et al., Mechanical properties of tendons and ligaments. II. 

The relationships of immobilization and exercise on tissue remodeling. 

Biorheology, 1982. 19(3): p. 397-408. 

5. Foster, T.E., et al., Platelet-rich plasma: from basic science to clinical 

applications. Am J Sports Med, 2009. 37(11): p. 2259-72. 

6. Frei, R., et al., [Conservative treatment using plasma rich in growth factors 

(PRGF) for injury to the ligamentous complex of the ankle]. Acta Chir 

Orthop Traumatol Cech, 2008. 75(1): p. 28-33.

167 

the SyNdeSmoSiS: biNdiNg the tibia aNd Fibula 

I. Anatomy 

a. Syndesmosis = fibrous articulation in which opposing 

surfaces are united by ligaments 

b. Anterior tibiofibular ligament 

i. Anterior lateral malleolus to anterolateral tubercle of the 

distal tibia 

ii. Anterior inferior tibiofibular ligament is inferior portion 

that can be visualized arthroscopically as it covers the 

anterolateral corner of the ankle and anterolateral dome 

of the talus 

c. Posterior tibiofibular ligament 

i. Superficial portion = obliquely from lateral malleolus to 

tibia; runs “upward” 

ii. Deep portion = more transverse; very strong; acts as 

labrum to posterior talus; aka transverse tibiofibular 

ligament 

iii. Now accepted that posterior-inferior ligament is most 

important restraint to the syndesmotic joint 

d. Tibiofibular interosseous membrane/ligament 

i. Membrane spans most of the length of the tib-fib 

ii. Ligament is thickening of the membrane that lies just 

superior to the ATF/PTF ligaments 

iii. Acts as a mild restraint to external rotation (compared to 

ATF) 

II. Incidence of syndesmotic injuries 

a. Relatively uncommon; 1% of ankle sprains reported but 

likely much higher in recent years 

i. “Low” high ankle sprain 

b. Boytim (1991): professional football team with 18 in 6 years 

c. Hopkinson (1990): 15/3.5 years in West Point cadets 

d. NFL Data Base – increasing incidence on certain surfaces? 

i. Presented at 2009 AAOS: 30% increased rate of 

“eversion” ankle injuries in NFL players on Field Turf 

III. Mechanism of injury 

a. Mechanism variable and poorly recalled by athlete; different 

than classic inversion ankle sprain 

b. Generally thought to be external rotation forces 

c. Can also occur with dorsiflexion and inversion 

d. Occurs more commonly with a fracture 

i. Weber C 

ii. Lauge-Hansen pronation-external rotation 

iii. Lauge-Hansen supination-external rotation 

IV. Clinical evaluation 

a. Tenderness over the syndesmosis 

b. Always assess for deltoid tenderness 

c. Proximal fibular tenderness – r/o Maisonneuve fracture 

d. Swelling and ecchymosis may be minimal or late in 

appearance 

e. Calf rise – inability to perform suggestive of more severe 

injury 

f. “Squeeze test” 

i. midcalf compression (in absence of fracture) produces 

pain in the syndesmosis 

ii. Hopkinson – highly reliable; 9/10 patients with positive 

test later developed interosseous calcification 

g. External rotation stress test 

i. Sitting: pain reproduced in syndesmosis with foot and 

ankle externally rotated while the knee is held flexed at 

90 degrees 

Robert B. Anderson, MD 




ii. Standing: single limb stance on affected side and then 

rotate body externally - pain reproduced in syndesmosis 

V. Radiographic evaluation 

a. Plain radiographs (including proximal leg) assessed for bony 

injury or gross syndesmotic disruption 

i. Frank diastasis without fracture or applied stress is rare 

ii. Avulsion fracture at posterior tibial tubercle can 

occasionally be seen on lateral view (Boytim) 

iii. Mortise and AP views assessed for increased medial clear 

space (> 6 mm) 

iv. Interosseous calcification often visible after 6 weeks 

b. Stress views 

i. Traditional = external rotation and lateral displacement 

applied 

1. Compare to contralateral uninjured ankle 

2. Assess mortise/AP views for increased medial 

clear space and lateral view for posterior fibular 

displacement 

ii. Single limb standing AP may accentuate diastasis (pain 

permitting) 

iii. Flouroscopic assisted (in office or training room) 

c. MRI 

i. Very sensitive for syndesmotic injuries but not predictive 

for instability = static test 

ii. Hemorrhage/edema with interosseous space – variable 

and not prognostic 

iii. Anecdotally it seems that posterior t-f lig involvement 

correlates with more severe injury and perhaps longer 

RTP 

1. Edema in FHL muscle 

d. Bone scan 

i. Found to be sensitive for syndesmotic injury but can not 

determine extent/degree like MRI 

e. CT 

i. Axial cuts important 

ii. Comparing bilateral ankles may elicit subtle subluxation 

of syndesmosis 

iii. More useful in chronic situation and when assessing for 

associated bony injury/healing or arthritis (Harper, 2001) 

VI. Treatment, in general 

a. Syndesmotic injury without fracture (or Maisonneuve 

fracture) 

i. Clinical signs of syndesmotic injury without radiographic 

findings or stress instability should be treated 

nonoperatively 

1. WBAT 

2. Ankle devices to limit external rotation 

3. 15-step single limb hop test to determine when to 

return to athletics 

a. In general, require about twice the recovery of a 

classic grade 3 lateral ankle sprain 

ii. Those with instability on stress testing but no diastasis 

can be managed with NWB cast for 4 weeks then SLWC 

for 2-4 weeks with serial radiographs 

1. I prefer fixation in elite athlete – improved rehab and 

quicker recovery (specifics below) 

2. Arthroscopy very helpful in identifying subtle cases 

iii. Gross diastasis requires reduction and fixation 

iv. Beware of plastic deformation of the fibula that may

168 

necessitate fibular osteotomy (rare) 

v. Percutaneous vs. open reduction of the syndesmosis 

1. Open if anatomic reduction not obvious 

a. Beware of displaced/shortened Maisonneuve 

fracture 

b. Malrotation more common that previously 

thought (HSS paper ’06) 

2. May require medial incision and decompression/ 

repair of deltoid ligament if syndesmotic reduction 

not possible 

3. Arthroscopic assisted? 

With fracture Without fracture 

VII. Controversies of screw fixation 

a. Number of screws 

i. 1 or 2 

ii. With or without plate 

b. Number of cortices of fixation 

i. 3 or 4 

c. Size of screw 

i. 3.5, 4.0, or 4.5 

ii. One study showed no biomechanical advantage to larger 

screw (Thompson, FAI, 2000) 

d. Type of screw 

i. Cortical vs. cancellous 

ii. Cannulated vs. solid? 

iii. Absorbable 

1. No difference in results with 4.5mm PLA vs. stainless 

steel screw; with fibular fx and plate fixation 

(Thordarson et al, FAI, 2001) 

e. Location of screw 

i. 2.0 cm above ankle joint ideal? (McBryde et al, FAI, 

1997) 

ii. Syndesmosis is a joint – stay out of it! 

f. Position of ankle during screw insertion 

i. Push towards compression with ankle in plantarflexion 

(Toretta, JBJS 2001); can not overtighten 

g. Screw removal 

i. Necessity 

1. Needleman/Steihl – rec. due to loss of external 

rotation 

ii. Timing 

1. 8, 10, 12 weeks? 

2. Best to go longer if purely ligamentous injury 

h. Option to screw fixation 

i. Suture button 

1. Can place one or two; can use thru plate hole 

2. No long term studies – conflicting reports 

a. Adequate for early rehab? 

b. Will it stretch out? 

c. Adequate control of external rotation forces? 




VIII. Author’s preferred approach 

a. Most importantly, have a low threshold for syndesmotic 

fixation 

b. Syndesmotic injury without associated distal fibular fracture 

i. Nonathlete 

1. Two solid 4.5 mm cortical screws or suture button 

2. 4 cortices of fixation 

3. Percutaneous, cannulated if anatomic reduction of 

syndesmosis assured 

4. Distal screw or button approximately 2.0-2.5 cm 

above joint, aim 20-30 degrees anterior to hit tibia 

5. NWB x 8 weeks, then WB in boot 

6. Screw removal left to discretion of patient 

a. Remove in office (if feasible) after 12 weeks 

ii. Athlete (accelerated return to play) 

1. Open reduction of syndesmosis 

2. 4-hole one-third tubular plate; central two 

holes filled with a 4.5 mm cortical screw (4 

cortices) and a suture button 

a. Proximal and distal fibular holes filled 

with 3.5 mm cortical screws with 2 

cortices of fixation 

3. NWB x 4-6 weeks, then boot 

4. Begin pool rehab when wound sealed – 2 

weeks 

5. RTP when symptoms/function allow, based 

on 15 hop test etc 

6. Remove 4.5 mm screws after 12 weeks (or 

after season), leaving plate to minimize 

stress risers 

a. Advantage of suture button – no 

removal or evidence of failure 

b. Can fill screw hole with a suture button 

device 

IX. Prognosis – acute injuries 

a. Reports are sketchy and none are prospective – most authors 

state good results with or without surgery (at least short 

term) 

i. Fritschy: 1/10 World Cup skiers had residual pain; all 

returned to full athletic activity 

b. Anatomic reduction necessary/better? – no studies available 

c. High incidence of heterotopic ossification but has no 

correlation to late symptoms 

X. Late symptoms/chronic injuries 

a. Recurrent/persistent widening 

i. Syndesmotic debridement with joint reduction 

1. Screw fixation 

a. controversy – is grafting and fusing joint better 

than debridement/reduction alone 

i. Harper: delayed reduction and screw 

stabilization successful in 5/6 

2. Hansen textbook (2000): technique of using extensor

169 

tendons to reconstruct 

a. No results available 

b. Painful syndesmosis 

i. Consider true syndesmotic arthritis vs interosseous 

membrane calcification 

1. in general, a complete synostosis does not hurt 

ii. Attempt injection of syndesmosis 

1. Fluoroscopic guidance; arthrogram confirmation 

a. therapeutic 

b. diagnostic 

BIBLIOGRAPHY 

1. Amendola A: Controversies in diagnosis and management of syndesmotic 

injuries of the ankle. Foot Ankle 1992; 13: 44-50. 

2. Boden SD et al: Mechanical considerations for the syndesmotic screw: a 

cadaver study. J Bone Joint Surg Am 1990; 71: 1548-1555. 

3. Boytim MJ, Fischer DA, Neumann L: Syndesmotic ankle sprains. Am J Sports 

Med 1991; 19: 294-298. 

4. Gardner MJ et al: Malrotation of the tibiofibular syndesmosis in ankle 

fractures. FAI 2006; 27: 788-792. 




iii. Debridement vs. fusion 

1. If debridement without calcification, consider 

arthroscopic method (Tasto) from the ankle joint 

a. For Bassett type lesions (lower syndesmotic joint) 

2. Open treatment for excision of incomplete synostosis 

3. Fuse if significant degeneration/incongruity of 

syndesmosis or failed prior reconstruction 

5. Harper MC: Delayed reduction and stabilization of the tibiofibular 

syndesmosis. Foot Ankle Intl 2001; 22: 15-18. 

6. Hopkinson WJ et al: Syndesmotic sprains of the ankle. Foot Ankle 1990; 10: 

325-330. 

7. Needleman RL, Skrade DA, Stiehl JB: Effect of the syndesmotic screw on 

ankle motion. Foot Ankle 1989; 10: 17-24. 

8. Toretta P et al: Overtightening of the ankle syndesmosis: is it really possible?: 

J Bone Joint Surg Am, 2001; 83: 489-492. 

9. Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad 

Orthop Surg 1997; 5: 172-181.

THE DELTOID 

170 

the deltoid ligameNt: iS it reCoNStruCtable? 

Steven L. Haddad, MD 

Introduction 

• Deltoid ligament insufficiency has been shown to decrease 

tibiotalar contact area and increase peak pressures within the 

lateral ankle mortise 

— Sectioning of the deltoid ligament has been shown to 

decrease tibiotalar contact area by 43%. 

— This detrimental effect may create an arthritic ankle joint if 

left unresolved. 

— Reconstructive efforts thus far have been less than 

satisfactory 

• Pankovich and Shivaram described the deltoid ligament as 

having superficial and deep components based on insertion 

sites 

— The superficial layer originates from the anterior colliculus of 

the medial malleolus and inserts on the navicular, calcaneus 

and talus 

— The deep layer originates from the intercollicular groove and 

posterior colliculus and inserts on the talus 

— Boss and Hintermann noted that the most consistent and 

strongest bands of the deltoid were the tibiocalcaneal and 

posterior deep tibiotalar ligaments 

• Chronic deltoid ligament insufficiency may be seen in several 

disorders including 

— trauma and sports injuries 

— posterior tibial tendon disorders 

— prior triple arthrodesis with valgus malunion 

— total ankle arthroplasty with improper component 

positioning or pre-existing ligament laxity 

– The reconstruction of the deltoid ligament in these 

settings may be critical to the prevention of tibiotalar 

arthrosis or failure of ankle prostheses from edge loading 

and polyethylene wear 

Techniques 

• Deland (JBJS 2004) 

— Non-anatomic repair by weaving peroneus longus through 

talus from lateral-to-medial, then through medial malleolus 

into anterior distal tibia 

— At best, reconstructs only one limb of the ligament 

– 5 patients had average correction to 3.6 degrees 

• Myerson 

— Allograft technique using interference screw fixation 

– Graft is split into two limbs at the tip of the medial 

malleolus 

– Relies on distal tensioning of graft into talus and 

calcaneus after securing proximally 

~ Concerns about graft shearing, pull out, and creep 

• Haddad (FAI, 2010) 

— Reconstructed both limbs of the deltoid (deep and 

superficial) via a whole (non-split) semitendinosis tendon 

graft 

– Strength of repair through endo-button/biceps button 

securing graft distally through lateral cortical stability and 

without shearing graft 

– Tensioned proximally through drill hole in medial 

malleolus, anchored with screw and post 

~ Results 

¤ under low torque, was able to restore eversion and 

external rotation stability to the talus, which was 




statistically similar to the native deltoid ligament 

¤ though maximally tension this graft to give the 

most secure repair possible, no increased stiffness 

in the ankle joint noted 

¤ Eversion testing 

¤ External Rotation Testing 

• Haddad (FAI, 2010): Technique 

— Measure diameter of semitendinosis graft 

– Generally 4 to 5mm 

— Drill 6mm to 7mmm hole from tip of medial malleolus 

directed anteriorly 

– Exits at medial anterior cortex 

– Measure length of tunnel 

— Drill 4mm to 5mm hole from medial talus at deep deltoid 

footprint (deep to posterior tibial tendon) 

– Exits anterior to fibula 


— Drill 4mm to 5mm hole from sustentaculum tali at 

superficial deltoid footprint 

– Directed inferior and distal (to avoid sinus tarsi) exiting 

at lateral wall calcaneus 


— Measure distance between origin and exit points of 

superficial and deep deltoid ligament drill holes 

— Sum all measurements 

– Add 4 to 5 cm to this sum to account for tendon exiting 

tibial tunnel anteriorly 

¤ Allows for screw and post fixation 

— Prepare tendon graft at appropriate measured length

References: 

1. Garrick JG: The frequency of injury mechanism of injury and epidemiology 

of ankle sprains. Am J Sports Med 5: 241-242, 1977 

2. Baumhauer JF, Alosa DM, Renstroem PA: A prospective study of ankle injury 

risk factors. Am J Sports Med 23: 557-564, 1995 

3. Barbari SG, Brevig K, Egge T. Reconstruction of the lateral ligamentous 

structures of the ankle with a modified Watson-Jones procedure. Foot Ankle. 

1987;7:362-368. 

4. Hoy GA, Henderson IJ. Results of Watson-Jones ankle reconstruction 

for instability. The influence of articular damage. J Bone Joint Surg Br. 

1994;76:610-613. 

5. Krips R, Brandsson S, Swensson C, et al. Anatomical reconstruction 

and Evans tenodesis of the lateral ligaments of the ankle. Clinical and 

radiological findings after follow-up for 15 to 30 years. J Bone Joint Surg Br. 

2002;84:232-236. 

6. Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of 

the ankle. Foot Ankle. 1980;1:84-89. 

7. Karlsson J, Bergsten T, Lansinger O, et al. Reconstruction of the lateral 

ligaments of the ankle for chronic lateral instability. J Bone Joint Surg Am. 

1988;70:581-588. 

8. Karlsson J, Eriksson BI, Bergsten T, et al. Comparison of two anatomic 

reconstructions for chronic lateral instability of the ankle joint. Am J Sports 

Med. 1997;25:48-53. 

9. Sugimoto K, Takakura Y, Kumai T, et al. Reconstruction of the lateral ankle 

ligaments with bone-patellar tendon graft in patients with chronic ankle 

instability: a preliminary report. Am J Sports Med. 2002;30:340-346. 

171 




– Tubularize tendon graft, pre-tension to 20lbs for at least 

15 minutes 

– Endobutton sutured at each end via Krakow method (#2 

Fiberwire) with at least 1cm suture length at each and to 

allow passage 

— Pass tendon through talus and calcaneal tunnels, flip 

endobuttons 

– May require small lateral incisions to insure button 

opposes lateral cortices 

— Pass looped graft through tibial tunnel 

— Place 4.5mm drill hole at apex of loop 

– Generally advance graft at least 5mm to 1cm to increase 

tension 

— Secure graft proximally with 6.5mm cancellous screw and 

large spiked ligament washer 

— Graft secure 

– May over-sew residual deltoid tissue 

Modified Radiographs Property of Steven L. Haddad, MD (personal file) 

10. Paterson R, Cohen B, Taylor D, et al. Reconstruction of the lateral ligaments 

of the ankle using semi-tendinosis graft. Foot Ankle Int. 2000;21:413-419. 

11. Pankovich AM, Shivaram MS. Anatomical basis of variability in injuries of 

the medial malleolus and deltoid ligament. Acta Orthop. Scand., 50:217- 

223, 1979 

12. Boss PA, Hintermann B. Anatomical study of the medial ankle ligament 

complex. Foot Ankle Int. 2002: 23: 547-553. 

13. Earll M, Wayne J, Brodrick C, et al. Contribution of the deltoid ligament 

to the ankle joint contact characteristics: a cadaver study. Foot Ankle Int. 

17:317-324, 1996 

14. Close JR: Some applications of the functional anatomy of the ankle joint. J 

Bone Joint Surg., 38A:761-781, 1956 

15. Harper MC: Deltoid ligament: an anatomical evaluation of the function. 

Foot Ankle, 8:19-22, 1987 

16. Rasmussen, O.: Stability of the ankle joint. Analysis of the function and 

traumatology of the ankle ligaments. Acta Orthop. Scand.,Suppl. 211, 1985 

17. Rasmussen, O., Kromann-Andersen, C., Boe, S.: Deltoid ligament. Function 

of the medial collateral ligamentous apparatus of the ankle joint. Acta 

Orthop. Scand., 54:36-44, 1983. 

18. Greisberg J., Hansen ST,: Ankle replacement: management of associated 

deformities. Foot Ankle Clin N Am 2002; 7:721-736. 

19. Wood PLR, Deakin S,.: Total ankle replacement: The results in 200 ankles. J 

Bone Joint Surg 85B:334-341, 2003 

20. Deland JT, de Asla, RJ, Segal A.: Reconstruction of the chronically failed 

deltoid ligament: a new technique. Foot Ankle Int., 25: 795-799, 2004 

21. Haddad SL, et.al: : Deltoid Ligament Reconstruction: A Novel Technique with 

Biomechanical Analysis . Foot Ankle Int., 31(7): 639-651, 2010.

172 

baCk to baSiCS: 

the lateral Collateral ligameNtS oF the aNkle 

Thomas O. Clanton, MD 

I. Epidemiology 

A. General 

1. Most common time-loss injury in sports 

2. 1 per 10,000 person-days 

3. 2 million/yr in USA 

4. Persistent symptoms n 15-20% 

B. Risk factors 

1. Age – peak incidence at ages 10-19 

2. Sex – males age 15-24, females age 30-99 

3. Athletic involvement – accounts for 45-50% (esply 

volleyball, basketball, football, soccer, and cheerleading) 

4. Race – higher in blacks and whites than Hispanic 

C. Contributing factors 

1. Obesity – “greater mass moment of inertia acting about 

the ankle” 

2. Skeletal foot morphology – e.g. heel varus, increased foot 

width, increased eversion movement, posterior fibular 

position 

3. Exposure to high risk activities, e.g. sports, military 

activity 

4. Connective tissue properties, e.g. Achilles contracture 

II. Clinical presentation 

A. Acute vs. chronic lateral ankle sprain 

B. Acute sprain with a history of chronic lateral instability 

C. Chronic lateral ankle instability 

D. Associated lateral ankle pain or other pain 

III. Treatment based on presentation 

A. Acute lateral ankle sprain – mild to moderate 

1. Non-operative treatment with RICE and 

a) Supervised early exercise 

b) Anti-inflammatory medication or patches 

c) Functional treatment with early weight bearing 

(1)Lace-up brace 

(2)Semi-rigid stirrup brace (most data to support) 

(3)Walking boot 

(4)Crutches used only as needed for pain control 

B. Acute lateral ankle sprain – severe 

1. Treatment issues 

a) Cost – higher with surgery 

b) Complications – rare but more with surgery 

c) Reinjuries – more with functional treatment 

d) Late arthritis – controversial, ? more with surgery 

e) Return to pre-injury status – similar 

f) Functional outcome – slightly better with surgery 

2. Who would be considered for surgery? 

a) Open injury 

b) Other clear pathology 

(1) Dislocating peroneal tendon(s) 

(2)Osteochondral fracture/loose body 

(3) Bimalleolar fracture variant 

c) Large avulsion fracture or with >2mm displacement 

d) High level athlete 

C. Acute on chronic lateral ankle sprain 

1. Is the ankle mechanically unstable? 

2. Has the patient previously sprained the ankle badly? 

3. Has the patient previously rehabilitated the ankle 

properly? 




4. Are there signs of secondary problems? 

a) Peroneal tendon pathology 

b) Osteochondral lesion and/or loose body 

c) Marginal osteophytes/early arthritis 

5. Is this a good time to fix the instability? 

D. Chronic lateral ankle instability 

1. Confirm mechanical instability – history, physical exam, 

imaging 

a) Definition - “… laxity of a joint due to structural 

damage to ligamentous tissues which support the 

joint.” 

b) i.e., a mechanical problem requiring a mechanical 

solution! 

2. Rule out other causes of instability symptoms 

a) Chronic laxity/hyperflexibility 

b) Tarsal coalition 

c) Neuromuscular disease 

d) Peroneal tendon pathology 

e) Neurological disorders 

f) Functional instability 

(1)Definition - “… the occurrence of recurrent joint 

instability and the sensation of joint instability 

due to the contributions of any neuromuscular 

deficits.” 

(2)Primarily related to injury to the joint 

mechanoreceptors and afferent nerves 

(a) Impaired balance 

(b)Reduced joint position sense 

(c) Slower firing of peroneal muscles in response 

to inversion stress 

(d)Slowed nerve conduction velocity 

(e) Impaired cutaneous sensation 

(f) Strength deficits 

(g) Decreased ankle dorsiflexion 

IV. Diagnostic studies 

A. Routine x-rays 

1. The Ottawa Ankle Rules 

a) X-ray for any pain in the malleolar zone and any one 

of the following: 

b) Bone tenderness along the distal 6 cm of the posterior 

edge of the tibia or tip of the medial malleolus, OR 

c) Bone tenderness along the distal 6 cm of the posterior 

edge of the fibula or tip of the lateral malleolus, OR 

d) An inability to bear weight both immediately and in 

the emergency department for four steps. 

B. Stress x-rays 

1. Controversial 

a) Variability in normal 

b) Anesthesia or not 

c) Manual or instrumented 

d) Side-to-side comparison or just affected side 

2. No clear need acutely 

3. Chronic instability usefulness 

a) Value in documenting what the patient feels 

b) Value in before & after images 

C. MRI 

1. Controversial

173 

a) Expensive 

b) Doesn’t correlate with instability 

2. No clear need acutely 

3. Chronic instability 

a) Value in documenting what the patient feels 

b) Value in before & after images 

c) Identifies cartilage, tendon, loose bodies, bone bruise 

– useful when patient has pain + instability 

V. Surgical techniques for chronic lateral ankle instability 

A. Options for surgical treatment 

1. Anatomical 

a) Brostrom type or Brostrom + Gould 

b) Tendon graft with anatomically placed attachments 

2. Non-anatomical/tenodesis 

a) Watson-Jones 

b) Evans 

c) Chrisman-Snook 

B. Surgical technique 

1. Brostrom + Gould modification video 

2. Anatomically placed tendon graft video 

C. Best patients for tendon graft reconstruction 

1. Failed prior reconstruction 

2. Inadequate tissue for Brostrom 

3. Quality of secondary reconstruction judged to be 

inadequate 

4. Other potential uses: 

a) Large athlete 

b) Hypermobility 

D. Principles of Ligament Reconstruction 

1. Basics 

a) Graft selection 

(1)Graft and graft fixation should be stronger than 

the ligament being reconstructed 

(a) ATFL – 138.9 ± 23.5 N 

(b)CFL – 345.7 ± 55.2 N 

(2)Tissue Graft Source 

(a) Peroneus brevis - ~800 N (1/2PB=400) 

(b)Peroneus longus - 1342 ± 135 N 

(c) Semitendinosis – 1216 ± 50 N 

(d)Gracilis – 838 ± 30 N 

(e) Allograft 

(i) Ant tib – 1706 N 

(ii)Post tib – 1695 N 

b) Positioning - anatomical 

(1)Key to successful long-term outcome 

(2)Avoids 

(a) Capturing joint and thereby restricting subtalar 

and tibiotalar motion 

(b)Stretching out reconstruction over time 

c) Fixation – must be strong enough 

d) Tensioning – must be tight enough 

e) Avoidance of stress risers – eliminate bone spurs, 

varus, and protect adequately 

f) Intensive rehabilitation program - regain strength, 

ROM, proprioception, endurance, and functional 

ability 

2. Incorporation of a biologic graft 

a) Ligamentization of a biologic graft 

(1)All intra-articular segments of tendon undergo 

similar process 

(2)Initial phase of acellular and avascular necrosis 

(~2wks) 

(3)Collagen scaffold remains intact and unaffected 

(~1mo) 




(4)Cellular repopulation by the host synovial cells 

(~3mos) 

(5)Revascularization (~3 - 6mos) 

(6)Ligament maturation (~6 - 9mos) 

3. Fixation Issues in Ligament Reconstruction 

a) Bone tunnel, trough, cortical onlay 

b) Tendon length necessary 

c) Fixation strength 

d) Time efficiency 

e) Hardware issues 

f) Removal? 

g) Imaging distortion? 

h) Cost? 

4. Methods of Fixation 

a) Suture of tendon to itself after passing through drill 

tunnel 

b) Cortical onlay with suture anchors or staples 

c) Endobutton 

d) Interference fit screw in bone tunnel 

5. Strength of Fixation Devices 

a) Retrobutton – 927.6 N 

b) Bio-Tenodesis Screw – 227.35 N 

c) Achilles SutureBridge – 434 N 

d) Mini Bio-Suture Tak – 75 N 

e) V-Tak – 35.6 N 

f) Bioabsorbable Trim-It Screw – 590 ± 297 N 

g) MiniLoc – 32.7 N 

h) MicroFix Quickanchor – 37.5 N 

i) Endobutton CL Ultra for ACL – 1482.9 N 

j) Endobutton CL for ACL – 1350 N 

k) EZLOC for ACL – 1427 N 

l) ToggleLoc for ACL – 1406.8 N 

6. Fixation research with tendon grafts 

a) Interference fit screw vs metal suture anchor 

(1)60 porcine models 

(2)Young cadaver tendons harvested along with talus 

and fibula bones 

(3)Digital flexor 

(4) Tibialis anterior 

(5) Tibialis posterior 

(6)Result – “clear advantage to use of an interference 

screw related to both load to failure with single 

pull and cyclical loading” 

b) Tendon-Tunnel Healing 

(1)4 wks postop before tendon-tunnel interface 

provides most of fixation strength & off-loads 

the mechanical strength provided by the fixation 

device 

c) Tendon-Tunnel Healing 

(1)20 dogs underwent transplant of digital extensor 

tendon sacrificed at 2, 4, 8 and 12 weeks to have 

biomechanics evaluated 

(a) At 2 weeks, maximum strength = ~100 N 

(b)At 4 weeks, maximum strength = ~280 N 

(c) At 8 weeks, maximum strength = ~ 300 N 

(d)At 12 weeks, maximum strength = ~360 N 

(e) Serial histology – progressive re-establishment 

of collagen-fiber continuity between the bone 

and the tendon 

(f) Failure mode = pull-out of tendon from tunnel 

in all cases up to 8 wks 

d) Recommend protection of healing ligament up to 8 

wks (for the knee) 

7. Advantages of interference fit screw fixation

174 

a) Bone tunnel can be shorter 

b) Less tendon length necessary 

c) Aperture fixation 

d) Fixation strength more than adequate 

e) Time efficiency 

f) Hardware issues 

(1) Removal unnecessary 

(2) No imaging distortion 

8. Necessary Instruments and Equipment 

a) Mini C-arm 

b) Long Keith needles 

c) Beath pin (pin with hole to pass suture through bone 

d) Various size drill bits or cannulated reamers (4.5- 

6mm) 

e) Suture passer 

9. Principles of Interference Screw Fixation 

a) Screw composition – all materials can work, avoid 

metal just in case there is a need for later MRI 

BIBLIOGRAPHY 

1. Ahovuo J et al. Diagnostic value of stress radiography in lesions of the lateral 

ligaments of the ankle. Acta Radiol 29:711, 1988 

2. Attarian DE et al. Biomechanical characteristics of human ankle ligaments. 

Foot Ankle Int 6:54, 1985 

3. Aydogan U et al. Extensor retinaculum augmentation reinforces anterior 

talofibular ligament repair. CORR 442:210, 2006. 

4. Bauer JS et al. Magnetic resonance imaging of the ankle at 3.0 Tesla and 1.5 

Tesla in human cadaver specimens with artificially created lesions of cartilage 

and ligaments. Investigative Radiol 42:604, 2008 

5. Becker HP et al. Stress diagnostics of the sprained ankle: evaluation of the 

anterior drawer test with and without anesthesia. Foot Ankle 14:459, 1993 

6. Bridgman SA et al. Population based epidemiology of ankle sprains attending 

accident and emergency units in the West Midlands of England, and a survey 

of UK practice for severe ankle sprains. Emerg Med J 20:508, 2003 

7. Clanton TO, McGarvey WC. Athletic Injuries to the Soft Tissues of the Foot 

and Ankle. In Surgery of the Foot and Ankle, edited by Coughlin, Mann, & 

Saltzman. 8th edition. Elsevier, Philadelphia, 2010 (online), pp 1425-1564 

8. Cox JS, Hewes TF. “Normal” talar tilt angle. CORR 140:37, 1979 

9. Coughlin MJ et al. Comprehensive reconstruction of the lateral ankle for 

chronic instability using a free gracilis graft. Foot Ankle Int 25:231, 2004. 

10. Dowling S et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the 

ankle and midfoot in children: a meta-analysis. Acad Emerg Med 16:277, 

2009 

11. Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ligament 

complex. Foot Ankle Clin 11:659, 2006 

12. Frey C et al. A comparison of MRI and clinical examination of acute lateral 

ankle sprains. Foot Ankle Int 17:533, 1996 

13. Frost SC, Amendola A. Is stress radiography necessary in the diagnosis of 

acute or chronic ankle instability? Clin J Sport Med 9:40, 1999 

14. Gerber JP et al. Persistent disability associated with ankle sprains: a 

prospective examination of an athletic population. Foot Ankle Int 19:653, 

1998. 

15. Gulotta LV, Rodeo SA. Biology of autograft and allograft healing in anterior 

cruciate ligament reconstruction. Clin Sports Med 26:509, 2007 

16. Hertel J. Functional instability following lateral ankle sprain. Sports Med 

29:361-371, May 2000 

17. Hintermann B et al. Arthroscopic findings in patients with chronic ankle 

instability. Am J Sports Med 30:402, 2002. 

18. Jeys L et al. Bone anchors or interference screws? A biomechanical evaluation 

for autograft ankle stabilization. Am J Sports Med, 32: 1651, 2004 




b) Screw shape – should have rounded threads 

c) Diameter of tissue graft – measure, usually a 

semitendinosis or gracilis are 5-6mm in diameter 

d) Diameter of bone tunnel – must be size of tendon 

graft or half millimeter larger, graft should pass easily 

e) Diameter of implant – within O.5mm of tunnel size 

f) Length of implant – as long as possible and should 

get cortico-cancellous bone purchase 

10. Postoperative Management 

a) 1 week non weight bearing splint 

b) 3-5 weeks protected weight bearing 

c) Brace / protection for sport activity 6 months 

d) Physical therapy with avoidance of inversion & forced 

plantar flexion 

e) Rarely “too tight” with anatomic repair 

19. Kannus P, Renstrom P. Treatment for acute tears of the lateral ligaments of 

the ankle. Operation, cast, or early controlled mobilization. Current Concept 

Review. JBJS 73A:305, 1991 

20. Kerfhoffs GM et al. Surgical versus conservative treatment for acute injuries of 

the lateral ligament complex of the ankle in adults. Cochrane Database Syst 

Rev 2:CD000380, 2007 

21. Korkala O et al. A prospective study of the treatment of severe tears of the 

lateral ligament of the ankle. Int Orthop 11:13, 1987 

22. Oae K et al. Evaluation of anterior talofibular ligament injury with stress 

radiography, ultrasonography and MR imaging. Skeletal Radiol 39:41, 2010 

23. Perrich KD et al. Ankle ligaments on MRI: appearance of normal and injured 

ligaments. Am J Roentgenol 193:687, 2009 

24. PihlajamŠki H et al. Surgical versus functional treatment for acute ruptures 

of the lateral ligament complex of the ankle in young men. A randomized 

controlled trial. JBJS 92A:2367, Oct 2010 

25. Pijnenburg AC et al. Operative and functional treatment of rupture of the 

lateral ligament of the ankle. A randomized, prospective trial. JBJS 85B:525, 

2003 

26. Prisk VR et al. Lateral ligament repair and reconstruction restore neither 

contact mechanics of the ankle joint nor motion patterns of the hindfoot. 

JBJS 92A:2375, Oct 2010 

27. Rodeo SA et al. Tendon-healing in a bone tunnel. A biomechanical and 

histological study in the dog. JBJS 75A:1795, 1993 

28. Rubin G, Witten M. The talar-tilt angle and the fibular collateral ligaments: a 

method for the determination of talar tilt. JBJS 42A:311, 1960 

29. Soboroff SH et al. Benefits, risks, and costs of alternative approaches to the 

evaluation and treatment of severe ankle sprain. CORR 183:160, 1984 

30. Stiell IG et al. A study to develop clinical decision rules for the use of 

radiography in acute ankle injuries. Ann Emerg Med. 21:384, 1992 

31. Stiell IG et al. Implementation of the Ottawa ankle rules. JAMA. 271:827, 

1994 

32. Stiell IG et al. Multicentre trial to introduce the Ottawa ankle rules for use 

of radiography in acute ankle injuries. Multicentre Ankle Rule Study Group. 

BMJ. 311:594, 1995 

33. Taga I et al. Articular cartilage lesions in ankles with lateral ligament injury. 

An arthroscopic study. Am J Sports Med 21:120, 1993. 

34. Waterman BR et al. Epidemiology of ankle sprain at the United States 

Military Academy. Am J Sports Med 38:797, Apr 2010. 

35. Waterman BR et al. The epidemiology of ankle sprains in the United States. 

JBJS 92A:2279, Oct 2010 

36. Zacharias I et al. In vivo calibration of a femoral fixation device transducer 

for measuring anterior cruciate ligament graft tension: a study in an ovine 

model. J Biomech Eng, 123:355, 2001

TMT joints Anatomy 

• very stable 

— Roman arch 

— little motion 

• injury by high energy forces 

— MVA, industrial, sports 

Lisfranc / TMT articulation 

• 2nd base held by tough ligament 

— sectioning studies - cut all but LF 

ligament 

• can rotate foot around intact LF ligament 

175 

liSFraNC (tarSometatarSal) iNJurieS 

J. Chris Coetzee, MD 

Etiology 

1) Direct Force 

— Force centers on dorsum of 

foot 

— Leads to tensile stress on 

plantar side 

— Intensity and angle of force 

determine ligament and/or 

fracture 

2) Indirect Force 

— more common 

— Bending or twisting force 

on foot 

Radiographic assessment 

• AP view 

— Medial border of the 

2nd MT base and medial 

border of the middle 

Cuneiform form a straight 

unbroken line. 

— Disruption of this line 

indicative of injury. 

— Always compare with normal side in subtle injuries. 

• Lateral 

— MT never more dorsal than its respective cuneiform. 




• Oblique 

— Medial border of 4th MT base 

and medial border of cuboid 

form a straight unbroken line. 

Broad classification 

1) Low energy injuries (Nunley and Vertullo) 

— Stage 1: less than 2 mm diastases. No arch collapse 

— Stage 2: >2-5 mm diastases. No arch collapse 

— Stage 3: >2-5 mm diastases. Medial longitudinal arch 

collapse 

2) High energy injuries 

— Without significant intra-articular fractures 

— With significant intra-articular comminution 

A) Low Energy injuries 

• Stage 1 

— can WB, but not return to previous activity 

— point tender over TMTJ 

— WB x-rays show < 2 mm diastases between 1st and 2nd rays 

— no collapse of the medial arch. 

• Stage 2 

— similar findings, but… 

– there is >2-5mm diastases 

– still no arch collapse on lateral view. 

• Stage 3 

— >2-5 mm diastases 

— longitudinal arch collapse. 

How do you determine the stage? 

• History 

— What type of sport? Mechanism of injury? Did someone see 

it? Could you walk? How much pain? 

• Physical Examination 

— Swelling 

— Pain, tenderness along TMT joint 

— Pain with passive abduction and pronation 

— Plantar Medial Ecchymosis 

• Imaging studies 

— Radiographs 

– Gap between base of 1 and 2 MTs 

— Stress Radiographs 

Painful; should be done under block/sedation 

— CT scan and/or MRI helpful to further define injury in 3D 

Management 

• Stage 1 

— Plantar ligaments intact 

— Partial Lisfranc ligament injury 

— Lisfranc complex is “stable” 

• Return to play (RTP)

— Orthotics – medial arch support is very helpful 

— Tape – an alternative or addition to taping 

— RTP as tolerated 

— Usually anywhere from 1-4 weeks 

• Stage 2 

— Take a very close look 

— Best to do an EAU 

— Stable – treat like a stage 1 injury 

— Unstable - ORIF 

• Return to play 

— Stage 2 (stable) 

— Orthotics 

— Tape 

— RTP might be delayed due to pain with push-off. Can be 2-6 

weeks 

• Stage 3 

— 5 mm widening 

— Medial arch collapse 

Post Operative Care 

— After 3 months, use cushioned shoe / molded insert 

— Begin PT - Gait training; ROM/BAPS; PREs/strengthening/LE 

rehab 

• Return to play 

— These are severe injuries and it takes a long time to return to 

sports 

— TTWB for 6 weeks – Short leg cast or Boot 

— Progress to FWB in boot for 4-6 weeks 

— Start rehab after 9-12 weeks 

— Don’t remove screws earlier than 16 weeks if at all 

Complications 

• Early 

— Missed diagnosis 

• Late 

— Minimal cartilage damage: 80% will have a good/excellent 

result 

— Obvious cartilage damage:< 25% good results 

B) High Energy injuries 

Classification 

• Hardcastle 

LITERATURE 

1) Gaines RJ, Wright G, Stewart J. Injury to the tarsometatarsal joint complex 

during fixation of Lisfranc fracture dislocations: an anatomic study. J Trauma. 

Apr 2009;66(4):1125-8 

2) Cook KD, Jeffries LC, O’Connor JP, Svach D. Determining the strongest 

orientation for “Lisfranc’s screw” in transverse plane tarsometatarsal injuries: 

a cadaveric study. J Foot Ankle Surg. Jul-Aug 2009;48(4):427-31. 

3) Kaar S, Femino J, Morag Y. Lisfranc joint displacement following sequential 

ligament sectioning. J Bone Joint Surg Am. Oct 2007;89(10):2225-32. 

176 




I prefer a broad “classification” 

1) Dislocation but also significant intra-articular fractures 

2) Dislocation Without significant intra-articular fractures 

• Both groups could create controversy 

Why? 

• Conventional wisdom states that “all do well with an ORIF” 

• But – the reality is that there is a fair percentage that develop 

chronic disability and osteoarthrosis despite: 

— Accurate diagnosis 

— Early treatment 

— Anatomic reduction 

Outcome 

• These patients often need a conversion to an arthrodesis of the 

tarsometatarsal joints. Most older literature felt an Arthrodesis 

was an salvage procedure for: 

— Failed open reduction and internal fixation 

— Delayed or misdiagnosis 

— Severely comminuted intra-articular fracture 

Diagnosis 

• The same Imaging studies are used, and the diagnosis is usually 

much easier due to the severe fracture dislocation 

• CT scan 

— very helpful to determine the extent of intra-articular 

comminution 

— Severe intra-articular fractures should be an indication for 

early fusion 

Treatment 

• Be objective in decision making. 

— Severe instability might not do well with conventional ORIF 

— Significant articular cartilage loss will not do well with an 

ORIF 

• Method of Fixation is somewhat personal preference, but also 

determined by injury pattern 

— Comminuted fractures are better fixed with plates and screws 

— Staples are somewhat easier for lateral TMT joints than 

screws 

Summary 

• ORIF is still standard of care for most low energy Lisfranc 

injuries, but… 

— Despite anatomic reduction there could be 

– Persistent pain 

– Development of post-traumatic degenerative 

• There are Subsets of Lisfranc injuries that are better treated with 

primary arthrodesis 

— High Energy Ligamentous Lisfranc injuries 

— comminuted intra-articular fracture 

— Complex fracture/dislocations 

4) Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the 

tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint 

Surg Br. 1982;64(3):349-56. 

5) Lattermann C, Goldstein JL, Wukich DK, et al. Practical management of 

Lisfranc injuries in athletes. Clin J Sport Med. Jul 2007;17(4):311-5. 

6) Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete. 

Am J Sports Med. Jul-Aug 1993;21(4):497-502. 

7) Kadel N, Boenisch M, Teitz C, et al. Stability of Lisfranc joints in ballet pointe 

position. Foot Ankle Int. May 2005;26(5):394-400.

8) Sherief TI, Mucci B, Greiss M. Lisfranc injury: how frequently does it get 

missed? And how can we improve?. Injury. Jul 2007;38(7):856-60. 

9) Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction 

of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic 

resonance imaging with intraoperative findings. J Bone Joint Surg Am. Apr 

2009;91(4):892-9. 

10) Nunley JA, Vertullo CJ. Classification, investigation, and management of 

midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. Nov-Dec 

2002;30(6):871-8. 

11) Philbin T, Rosenberg G, Sferra JJ. Complications of missed or untreated 

Lisfranc injuries. Foot Ankle Clin. Mar 2003;8(1):61-71. 

12) Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: 

primary arthrodesis compared with open reduction and internal fixation. A 

prospective, randomized study. J Bone Joint Surg Am. Mar 2006;88(3):514- 

20. (Level 1) 

13) Alberta FG, Aronow MS, Barrero M, et al. Ligamentous Lisfranc joint injuries: 

a biomechanical comparison of dorsal plate and transarticular screw fixation. 

Foot Ankle Int. Jun 2005;26(6):462-73. 

14) Coss HS, Manos RE, Buoncristiani A. Abduction stress and AP weightbearing 

radiography of purely ligamentous injury in the tarsometatarsal joint. Foot 

Ankle Int. Aug 1998;19(8):537-41. 

177 




15) Kuo RS, Tejwani NC, Digiovanni CW. Outcome after open reduction and 

internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. Nov 

2000;82-A(11):1609-18. [Medline] . Subgroup (purely ligamentous Lisfranc 

injury) that may be better treated with primary fusion. (level 3) 

16) Myerson MS, Fisher RT, Burgess AR. Fracture dislocations of the 

tarsometatarsal joints: end results correlated with pathology and treatment. 

Foot Ankle. Apr 1986;6(5):225-42. [Medline] . 

17) Mulier et al (Foot and Ankle International 2002) Compared primary 

arthrodesis vs. ORIF for severe Lisfranc injuries. Retrospective, surgeon 

randomized study advocating ORIF or partial arthrodesis for severe Lisfranc 

injuries. Primary complete arthrodesis (all 5 MT) should be reserved as a 

salvage procedure 

18) Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open 

reduction internal fixation versus primary arthrodesis for lisfranc injuries: a 

prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22. 

19) Rammelt S, Schneiders W, Schikore H, Holch M, Heineck J, Zwipp H. 

Primary open reduction and fixation compared with delayed corrective 

arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture 

dislocation. J Bone Joint Surg Br. 2008 Nov;90(11):1499-506. 

20) Teng AL, Pinzur MS, Lomasney L, Mahoney L, Havey R. Functional outcome 

following anatomic restoration of tarsal-metatarsal fracture dislocation. Foot 

Ankle Int. 2002 Oct;23(10):922-6.

178 

CaN platelet-riCh plaSma really 

improve CoNNeCtive tiSSue healiNg? 

makiNg SeNSe oF it all (C) 

Moderator: Steven P. Arnoczky, DVM, East Lansing, MI 

A review of the basic science behind platelet-rich plasma including how variations in preparation techniques can affect the 

final product and what impact this may have on clinical outcomes. 


Steven P. Arnoczky, DVM, East Lansing, MI 

II. The ABC’s of PRP: What are You Putting into Your Patients and What is it Supposed to do? 

Steven P. Arnoczky, DVM, East Lansing, MI 

III. Clinical Outcomes Using PRP: Does the Hype Match Reality? 

Scott A. Rodeo, MD, New York, NY 

VI. Questions 

Steven P Arnoczky, DVM, East Lansing, MI and 

Scott A. Rodeo, MD, New York, NY 



SympoSia GENERAL

179 

the abC’S oF platelet-riCh plaSma (prp): what are you 

puttiNg iNto your patieNtS aNd what iS it SuppoSed to do? 

Steven P Arnoczky, DVM 

Platelet-rich plasma (PRP) has been advocated as a way to introduce 

increased concentrations of growth factors and other bioactive 

molecules to injured tissues in an attempt to optimize the local 

healing environment. PRP has been used extensively in dental and 

cosmetic surgery for almost 30 years and its safety and efficacy in 

these areas is well-established. Recently, PRP has been increasing 

utilized in a variety orthopaedic applications in the hopes that the 

increased levels of autologous bioactive proteins provided by the 

concentrated platelets could enhance tissue repair and regeneration. 

However, all PRP preparations are not the same. Variations in the 

volume of whole blood used, platelet recovery efficacy, the final 

volume of plasma in which the platelets are suspended, as well as 

the presence or absence of red and/or white blood cells, and the 

addition of thrombin or calcium chloride to induce fibrin formation, 

can all affect the character and potential efficacy of the final PRP 

product. This lecture will review the basic principles involved in 

creating PRP and examine the potential basic science significance of 

the individual blood components contained in the various forms of 

PRP currently used in orthopaedics. 

I. Platelet-rich Plasma: What’s in a name? 

• Platelet-rich plasma (PRP) has been classially described as 

‘a volume of plasma that has a platelet count above baseline 

[of whole blood]’. ( Marx 2001) 

• However, cuurent PRP products can vary markedly in: 

— the amount of blood used and the efficacy of platelet 

recovery 

— the presence or absence of white and/or red blood cells 

— +/- activation of platelets with thrombin 

— level of fibrin production 

• To more precisely delineate these various products based on 

their leukocyte and fibrin content the following categoris 

have been proposed. (Dohan Ehrenfest 2009) 

— pure platelet-rich plasma (P-PRP) 

— platelet-leukocyte-rich plasma (P-LRP) 

— pure platelet-rich fibrin (P-PRF) 

— leulocyte and platelet rich fibrin (L-PRF) 

II. Creating Platelet-rich Plasma: The basics 

• Fundamentally based on the selective separation of liquid 

and solid components of anticoagulated whole blood 

(plasmapheresis) via centrifugation. 

• Initial ‘soft spin’ (lower g-force) to separate plasma and 

platelets from red and white cells followed by a ‘hard spin’ 

(higher g-force) of the plasma-platelet supernatant to further 

concentrate the platelets into platelet-rich plasma (PRP) and 

platelet-poor plasma (PPP) components. 

• However, even when specific PRP protocols are used, the 

platelet concentration of the final PRP can not only vary 

greatly between techniques but also within a given technique 

(Castillo 2010; Leitner 2006; Mazzucco 2009; Weibrich 

2005). Therefore, unlike United State Pharmacopeia (USP) 

regulated pharmaceuticals in which the precise contents, 

concentrations and potency are clearly known, PRP 

preparations have no such guarantee. 

III. Platelets: Are more really better? 

• Platelets are anucleate cells that serve in a variety of critical 

functions including hemostasis, inflammation, angiogenesis, 



SympoSia GENERAL 

and wound healing. They harbor over 1100 proteins 

including growth factors and othr bioactive molecules 

involved in tissue repair. 

• The final platelet concentration of any PRP product is 

dependent upon: 

— the initial volumne of whole blood taken -the platelet 

recovery efficiency of the technique used -the final 

volume of plasma utilized to suspend the concentrated 

platelets 

• While numerous in vitro studies have demonstrated a 

dose-response relationship between the chemotactic, 

mitogenic, and synthetic stimuli this response is not linear. 

Once cell surface receptors for a specific growth factor 

are occupied additional concentrations of growth factors 

provide no additional effect. Some growth factors can exert 

an inhibitory effect once a high enough concentration is 

reached. (Alberts 1994). 

IV. White blood cells: To include or not include 

• WBC’s are known to play a key role in the initial phases of 

inflammation. 

• WBC’s increase muscle damage. (Tidball 2005) 

• WBC’s increase potential for localized pain (Mei-Dan 2010) 

• WBC concentration correlates with increase in expression of 

catabolic genes. (McCarrel 2009) 

• Role of specific WBC (i.e. monocytes vs PMNs) in PRP 

preparations still unclear and a positive or negative effect 

includingWBC’s in PRP preparations cannot be generalized 

to all tissues and all clinical conditions. 

• Inclusion of WBC’s in PRP preparations may not have any 

scientific rationale but rather reflect an inability of the 

preparation technique to completely eliminate this cellular 

component. (Dohan Ehrenfest 2009; Mei-Dan 2010) 

V. Exogenous Thrombin: Is activation necessary? 

• Circulating platelets have a half-life of 7 days and their 

cytokine contents remain within their granules until some 

event triggers platelet activation and secretion of these 

factors. (Blair 2009) 

• Platelet activation can be initiated by a number of methods 

such as shear forces caused by fluid flow, contact with a 

variety of materials inlcuding fibrillar collagen and the 

basement membranes of cells, and thrombin. (Blair 2009) 

• Besides catalyzing the conversion of fibrinogen to fibrin, 

thrombin also activates platelets causing them to secrete 

their contents of growth factors. 

• Because growth factors have a very short half-life (minutes 

to hours) thrombin activation could actually decrese the 

availability of growth factors when compard to collagen 

activation of platelets (Harrison 2010). 

• A recent study has demonstratd that exogenous thrombin 

activation of a PRP product actually diminished the efficacy 

o fthi mproductnto indice boine formation whne ocmparesd 

to non- thromin activated PRP (Han 2009). 

VI. Fibrin Precipitation: Is there an advantage? 

• Fibrin is nature’s provisional scaffold and its formation 

following tossue injury and hemorrhage is a critical initial 

step in the wound healing process.

180 

• Fibrin also binds growth factors and allows for their gradual 

release ove rtime (Visser 2010) 

• Some PRP preparations add calcium chloride and/ or 

thrombin to precipitate fibrin and create PRP constructs that 

range from a gel-like substance to a robust fibrin membrane 

(Visser 2010) 

• The creation of a platelet-rich fibrin construct may allow 

for the prolonged availability of increased levels of growth 

factors at the injury site. (Visser 2010; O’Conner 2009) 

VII. Summary 

It is important to realize that all PRP and PRP-related products are 

not the same and variations in content between products, as well as 

the potential for variations in consistency within a given product, 

REFERENCES: 

1. Foster TE et al. (2009) Am J Sports Med 37:2259-2272. 

2. Alberts B et al. (1994) Molecular Biology of the Cell. 

3. Arnoczky SP, Caballero O (2010) J Am Acad Ortho Surg 18:444-445. 

4. Blair P, Flaumenhaft R (2009) Blood Reviews 23:177-189. 

5. Castillo TN et al. Am J Sports Med (in press) 

6. Dohan Ehrenfest DM, et al. (2009) Trends in Biotechnology 27:158-167. 

7. Han B et al. (2009) J Bone and Jt Surg Am 91:1459-1770 

8. Leitner GC et al. (2006) Vox Sanguinis 91:135-139. 




make global conclusions on the efficacy of PRP in augmenting 

connective tissue repair extremely difficult. It is also critical to 

understand how (or if) the variations in current commercial PRP 

preparation techniques affect the clinical outcomes in specific 

indications. It is possible that one PRP product may not be useful 

in all applications. The true answer will only come from welldesigned, 

prospective, randomized, blinded (Level 1) clinical 

studies which carefully and comprehensively investigate the 

role of the various PRP preparations in connective tissue repair. 

Once we understand the precise mechanism(s) by which PRP 

may enhance tissue healing in various applications, and most 

importantly, are able to assure the contents and potency of the 

final product, platelet-rich plasma could be a useful tool in the 

armamentarium of the orthopaedic surgeon. 

9. Marx RE (2001) Implant Den 10:225-228. 

10. Mazzucco L et al. (2009) Vox Sanguinis 97;110-118. 

11. McCarrel T, Fortier L (2009) J Orthop Res 27:1033-1042 

12. Mei-Dan O et al. (2010) Br J Sports Med 44:618-619. 

13. O’Connor SM et al. (2008) Wound Rep Reg 16:749-756. 

14. Tidball JG (2005) Am J Physiol Regul Integr Comp Physiol 288:R345-353. 

15. Visser LC et al. Vet Surg 39;811-817, 2010. 

16. Weibrich G et al. (2005) In J Oral Maxillofac Implants 20:118-123.

181 

CliNiCal outComeS uSiNg prp: doeS the hype matCh reality? 

Scott A. Rodeo, MD 

What is the Rationale for using PRP? 

• Cytokines are known to have important and fundamental roles 

in connective tissue biology. 

• Cytokines affect cell proliferation, matrix synthesis, 

angiogenesis, chemotaxis in cells derived from ligament, 

tendon, bone, cartilage, meniscus, and muscle. 

• Connective tissue healing requires a complex timing and 

sequence of cytokine expression → thus, single factor therapy 

has distinct limitations 

• The rationale and attraction of PRP is the ability to deliver 

numerous cytokines in physiologically-relevant proportions 

• Will review basic science and clinical data for bone, tendon, 

cartilage, ligament, meniscus, and muscle, focusing on clinical 

studies with higher levels of evidence 

PRP IN TENDON REPAIR 

Basic Science 

• Basic laboratory studies demonstrate positive effect of PRP on 

matrix protein gene expression and protein synthesis in tendon 

(Mc Carrel et al, 2009) 

• Positive effects shown using PRP to treat intrinsic degenerative 

tendon lesion (Bosch et al, 2010) 

Clinical Studies 

• Variable results reported 

• De Vos et al, J. American Medical Association, 2010 

— Double-blind, placebo-controlled trial Chronic Achilles 

tendinopathy N=27 each group 

— Eccentric exercise + PRP injection or saline injection 

— Mean VISA score improved significantly in both groups at 24 

weeks 

— No difference between groups 

• Peerboms et al, Amer.J. Sports Medicine 2010 

— Randomized controlled trial PRP (N=51) vs steroid injection 

(N=49) Level of evidence 1 

— Successful score on VAS: 

– 24 of the 49 patients (49%) in the corticosteroid group 

– 37 of the 51 patients (73%) in the PRP group 

— Significantly different (p

182 

muscle strains” 

— 18 pro athletes treated with autologous conditioned serum, 

compared to 11 historical controls 

— Injections given 2 d. after diagnosis and repeated every 2nd 

day for a mean total of 5.4 injections 

— Average time to recovery: 22.3 days (control) versus 16.6 in 

ACS group 

— MRI at 2 weeks demonstrated superior healing (less edema, 

greater resorption) in ACS than control 

PRP IN MENISCUS HEALING 

Basic Science 

• Ishida et al, Tissue Engineering 2007 

— Meniscal cells cultured with PRP: 

– Increased DNA and ECM synthesis in (p

183 

reSearCh For immediate traNSlatioN 

to orthopaediC praCtiCe (aaoS/orS ii) 

Moderators: Philip C. Noble, PhD, Houston, TX and William J. Maloney, MD, Redwood City, CA 

Participants will learn about the latest advances from orthopedic research that every surgeon can use, in both Biology and 

Biomaterials. 


Philip C. Noble, PhD, Houston, TX 

II. Stem Cells in Orthopaedic Surgery 

Thomas A. Einhorn, MD, Boston, MA 

III. Mechanism of Cartilage Degeneration / Strategies for OA Prevention 

Joseph A. Buckwalter, MD, Iowa City, IA 

IV. Chondroprotective Agents: Fact and Fiction 

Constance R. Chu, MD, Pittsburgh, PA 

V. Discussion 

VI. PRP and Cell-Based Therapies for Cartilage Repair 

Scott Rodeo, MD, New York, NY 

VII. Emerging Technologies in Cartilage Regeneration 

William J. Maloney, MD, Redwood City, CA 

VIII. Discussion 

IX. Smart Implants for Prevention of Deep Infection 


X. New Options in Polymers and Ceramics for Joint Replacement 

Philip C. Noble, PhD, Houston, TX 

XI. Metal-on-Metal Bearings and Biocompatibility 

Joshua J. Jacobs, MD, Chicago, IL 

XII. Discussion 



SympoSia GENERAL

184 

Stem CellS iN orthopaediC Surgery 

Thomas A. Einhorn, MD 

I. Definitions 

A. Stem Cells – Undifferentiated, unspecified cells that 

can renew themselves and also give rise to one or more 

specialized cells with specific functions in the body. 

B. Cellular Potency 

1. Totipotent – able to generate all of the cell fates of an 

animal. 

2. Pluripotent – able to generate several of the cell fates 

of an animal. (embryonic stem cells are pluripotent 

– they give rise to most but not all tissues during fetal 

development and can regenerate tissue after birth and in 

adult life). 

3. Multipotent – able to generate a limited number of cell 

fates of an animal in closely related family of cells (adult 

stem cells are multipotent). 

II. Stem Cells vs. Progenitor Cells 

Stem Cell Progenitor Cell 

Self-renewing Non-self renewing 

Long-lived Short-lived 

Low proliferative capacity High proliferative capacity 

Perhaps the best example of stem cell renewal is the hematopoietic 

system. Because circulating blood cells survive for only a few days 

or months, hematopoietic stem cells in the bone marrow must 

provide a continuous source of progenitors for red cells, platelets, 

monocytes, granulocytes, and lymphocytes. Adult muscle cells can 

rebuild a muscle and they do so when needed. Progenitor cells are 

further along the path of cellular differentiation. They are in the 

“center” between stem cells and fully differentiated cells. 

III. Sources of Stem Cells 

A. Embryo 

B. Umbilical cord 

C. Placenta 

D. Adult bone marrow 

E. Blood 

F. Fat 

G. Synovial fluid 

IV. Culture Expanded Stem Cells vs. the Hematopoietic Niche 

Some technologies use allogeneic mesenschymal stem cells that 

have been cultured expanded. These cells have already undergone 

commitment to a mesenschymal lineage and are expected to 

differentiate along a chondro or osteoprogenitor pathway. They must 

function outside of their normal hematopoietic niche. Although 

some surgeons have reported favorable anecdotal results with these 

cells, recent evidence suggests that hematopoietic stem cells can 

differentiate to osteoblasts through a mesenschymal intermediate. 

This plasticity has been demonstrated in response to inflammation 

and tissue injury and provides a basis for the concept that stem cells 

therapies could include hematopoietic as well as mesenchymal stem 

cells as they function in a more physiological manner when provided 

in an environment that is similar to their physiological norm. 

V. Applications of Stem Cells in Orthopaedic Conditions 

A. Nonunions 

1. Hernigou et al. studied 60 patients with non-infected 

nonunions who underwent bone marrow aspiration 

from both iliac crests. Samples were concentrated on cell 

separators and injected. Union was obtained in 53 out of 




60 patients. Positive correlations were observed between 

the volume of mineralized callus at four months and 

the number and concentration of colony forming units 

in culture. The seven patients who did not unite had 

significantly lower numbers of colony forming units. 

B. Avascular Necrosis of the Femoral Head 

1. Gangji et al. studied 13 patients with ARCO Stage 1 

or 2 avascular necrosis and randomized them to core 

decompression (control) or core decompression plus 

antologous bone marrow mononuclear cell grafting. 

Results showed that after 24 months there was a 

significant reduction in pain (p = 0.021) and symptoms 

(p = 0.001) by Lequesne and WOMAC respectively in the 

bone marrow versus core decompression group. Five 

out of eight controls and one out of eight bone marrow 

injected patients progressed to Stage 3 (p = 0.016). 

Implantation of marrow stem cells was associated with 

only minor adverse events. At two years after treatment, 

several of the bone marrow stem cell injected femoral 

heads showed resolution of the avascular necrosis. 

2. Treatment of avascular necrosis of the medial femoral 

chondyle of the knee with bone marrow stem cells. 

VI. Future Clinical Applications 

A. Autologus bone marrow-derived mesenchymal stem cells vs. 

autolgous chondrocyte implantation 

1. Nejadnik et al. conducted an observational cohort 

study in which 72 lesions in age-matched patients 

underwent cartilage repair using chondrocytes (n=36) 

or bone marrow stem cells (n=36). Clinical outcomes 

were measured before operation and at three, six, nine, 

twelve, eighteen and twenty-four months after operation 

using the International Cartilage Repair Society Cartilage 

Injury Evaluation Package which included questions 

from the Short Form Health Survey, International Knee 

Documentation Committee, Lysholm Knee Scale, and 

Tegner Activity Level Scale. Results showed there was 

significant improvement in patients’ quality of life and 

cartilage repair in both groups. There was no difference 

between the bone marrow stem cells and the autologous 

chondrocyte implantation groups in terms of clinical 

outcomes with the exception of the Physical Role 

Functioning outcome that showed a greater improvement 

over time in the bone marrow stem cell group. The 

authors concluded that the use of bone marrow stem 

cells in cartilage repair is as effective as the use of 

chondrocytes and required less knee surgery, reduced 

costs, and minimized donor site morbidity. 

2. Fortier et al. compared the outcomes of treatment 

of bone marrow stem cells with the outcomes of 

microfracture in the repair of full thickness cartilage 

defects in horses. Fifteen millimeter diameter full 

thickness defects were created in the lateral trochlear 

ridge of the femur in 12 horses. Bone marrow was 

aspirated from the sternum and centrifuged to generate 

the bone marrow concentrate which included stem cells. 

The defects were treated with bone marrow concentrate 

and microfracture or with microfracture alone. All 

scoring systems and magnetic resonance imaging data 

indicated that delivery of the bone marrow stem cells

REFERENCES 

185 

resulted in increased fill of the defects and improved 

integration of repair tissue into surrounding normal 

cartilage. In addition, there was greater Type 2 collagen 

content and improved orientation of the collagen, as 

well as significantly more glycosaminoglycan in the bone 

1. Hernigou P, Daltro G, Filippini P, Mukasa MM, Manicom. Percutaneous 

implantation of autologous bone marrow osteoprogentiro cells as treatment 

of bone avascular necrosis related to sickle cell disease. Open Orthop J. 2008 

Apr 25;2:62-5. 

2. Hernigou P, Poignard A, Manicom O, Mathieu G, Rouard H. The use of 

percutaneous autolgoous bone marrow transpaltation in nonunion and 

avascular necrosis of bone. J Bone Joint Surg Br. 2005 Jul;87(7):896-902. 

3. Beaujean F, Hernigou P. Treatment of osteonecrosis with autolgous bone 

marrow grafting. Clin Orthop Relat Res. 2002 Dec;(405):14-23. 

4. Gangji V, Hauzeur JP, Matos C, De Maertelaer V, Toungouz M, Lambermont 

M. Treratment of osteonecrosis of the femoral head with implantation of 

autolgoous bone-marrow cells. A pilot study. J Bone Joint Surg Am. 2004 

Jun;86-A(6):1153-60. 

5. Gangji V, Hauzeur JP. Treating osteonecrosis with autolgoous bone marrow 

cells. Skeletal Radiol. 2010 Mar;39(3):209-11. 

6. Gangji V, Hauzeur JP. Treatment of osteonecrosis of the femoral head with 

implantation of autologous bone-marrow cells. Surgical technique. J Bone 

Joint Surg Am. 2005 Mar;87 Suppl 1(Pt !):106-12. 




marrow stem cell treated defects than in the microfracture 

treated defects. The authors concluded that delivery of 

bone marrow stem cells can result in healing of acute 

full-thickness cartilage defects that are superior to that 

after microfracture alone in this equine model. 

7. Nejadnik H, Hui JH, Feng Choong EP, Tai BC, Lee EH. Autologous bone 

marrow-dervied mesenschymal stem cells versus autologous chondrocyte 

implantation: an observational cohort study. Am J Sports Med. 2010 

Jun;38(6):1110-6. Epub 2010 Apr 14. 

8. Fortier LA, Potter HG, Rickey EJ, Schnabel LV, Foo LF, Chong LR, Stokol T, 

Cheetham J, Nixon AJ. Concentrated bone marrow aspirate improves fullthickness 

cartilage repair compared with microfracture in the equine model. 

J Bone Joint Surg Am. 2010 Aug 18;92(10):1927-37. 

9. Mendez-Ferrer s, Michurina TV, Ferraro F, Mazioom AR, Macarthur BD, Lira 

SA, Scadden DT, Ma’ayan A, Enikolopov GN, Frenette PS. Mesenchymal and 

haematopoietic stem cells form a unique bone marrow niche. Nature. 2010 

Aug 12;466(7308):829-34. 

10. Wu JY, Scadden DT, Kronenberg HM. Role of the osteoblast lineage in the 

bone marrow hematopoietic niches. J Bone Miner Res. 2009 May;24(5)759- 

64. 

11. Sacchetti B, Funari A, Michienzi S, DeCesare S, Piersanti S, Saggio I, 

Tagliafico E, Ferrari S, Robey PG, Riminucci M, Bianco P. Self-renewing 

osteoprogenitors in bone marrow sinusoids can organize a hematopoietic 

microenvironment. Cell. 2007 Oct 19;131(2):324-36.

186 

preveNtiNg oSteoarthritiS FollowiNg JoiNt iNJurieS 

Joseph A Buckwalter, MD 

Excessive mechanical loadings, single or repetitive, cause progressive 

degeneration of an articular surface and subsequent development 

of the clinical syndrome of post-traumatic osteoarthritis (PTOA). 

Joint injuries are common and often affect young adults: each year 

one in 12 people between the ages of 18-44 seeks medical attention 

for treatment of joint injury, and more than 12% of all lower limb 

osteoarthritis is caused by joint trauma. The onset of PTOA may occur 

as soon as three months after a severe injury, or decades after much 

less severe injuries, or after injuries that leave the joint with residual 

instability or incongruity. Despite advances in surgical treatment and 

rehabilitation of injured joints, the risk of PTOA following ligament 

tears and intra-articular fractures has not decreased in the last 50 

years. Advances in understanding of the risk factors and putative 

thresholds for mechanical damage to articular cartilage, and of the 

biologic mediators that cause progressive loss of articular cartilage 

after injury, will lead to better treatments of joint injuries and 

improved strategies for restoring damaged joint surfaces. 

I. Incidence and Impact of PTOA 

a. Results of current joint injury treatments – 20% to > 70% 

risk of PTOA 

b. Impairment due to PTOA equal to end-stage kidney disease 

and heart failure 

c. PTOA prevalence > 12% of all lower extremity osteoarthritis 

II. Mechanical Injury – Risk Factors & Thresholds (What is 

excessive mechanical loading?) 

a. Acute mechanical damage to cells and matrix 

i. Cell death 

ii. Rupture of matrix macromolecular framework 

REFERENCES 

1. Anderson DD, Mosqueda T, Thomas T, Hermanson EL, Brown TD, Marsh JL: 

Quantifying tibial plafond fracture severity: absorbed energy and fragment 

displacement agree with clinical rank ordering. J Orthop Res 26:1046-1052, 

2008. 

2. Beecher BR, Martin JA, Pedersen DR, Heiner AD, Buckwalter JA: Antioxidants 

block cyclic loading induced chondrocyte death. Iowa Orthop J 27:1-8, 

2007. 

3. Buckwalter JA: Osteoarthritis and articular cartilage use, disuse and abuse: 

experimental studies. J Rheumatol (suppl 43) 22:13-15, 1995. 

4. Buckwalter JA, Lane NE: Aging, sports and osteoarthritis. Sports Med Arth Rev 

4:276-287, 1996. 

5. Buckwalter JA, Lane NE, Gordon SL: Exercise as a Cause of Osteoarthritis. in 

Kuettner KE, Goldberg VM, Editors: Osteoarthritic Disorders, pp. 405-417. 

Rosemont IL: American Academy of Orthopaedic Surgeons, 1995. 

6. Buckwalter JA, Mankin HJ: Articular cartilage I. Tissue design and 

chondrocyte-matrix interactions. J Bone Joint Surg 79A(4):600-611, 1997. 

7. Buckwalter JA, Martin JA, Mankin HJ: Synovial Joint Degeneration and the 

Syndrome of Osteoarthritis. Instructional Course Lectures 49:481-489, 2000. 

8. Buckwalter JA, Martin JA, Olmstead M, Athanasiou KA, Rosenwasser MP, 

Mow VC: Osteochondral repair of primate knee femoral and patellar 

articular surfaces – Implications for preventing post-traumatic osteoarthritis. 

Iowa Ortho J 23:66-74, 2003. 

9. Buckwalter JA, Brown TD: Joint injury, repair and remodeling: Roles in posttraumatic 

osteoarthritis. Clin Ortho Rel Res 423:7-16, 2004. 

10. Ding L, McCabe DJ, Stround NJ, Buckwalter JA, Martin JA: A single blunt 

impact stimulated activation of mitogen activated protein kinases in bovine 

chondrocytes. Osteoarthritis Cartilage 16: suppl 4:S83, 2008. 

11. Goreham-Voss CM, McKinley TO, Brown TD: A finite element exploration 

of contact stress near an articular incongruity during unstable motion. J 

Biomech 40:3438-3447, 2007. 




b. Acute mechanical stress & osteoarthritis 

i. CT measures of the energy of an acute articular surface 

injury & risk of osteoarthritis – threshold effect 

ii. MRI measures of articular surface damage & risk of 

osteoarthritis 

c. Cumulative mechanical stress & osteoarthritis – risk factors 

i. Incongruity 

ii. Instability 

iii. Incongruity & Instability 

III. The Role of Age in Post-Traumatic Osteoarthritis 

a. Increased risk of PTOA with increasing age – studies of intraarticular 

fractures and meniscal injuries 

b. Decreased chondrogenic capacity of chondrocytes and 

mesenchymal stem cells 

IV. Biologic Mediators of Progressive Cartilage Loss After 

Mechanical Injury 

a. Reactive oxygen species & matrix fragments 

i. Stimulation of progressive loss of cells 

ii. Progressive degradation of matrix & loss of mechanical 

properties 

b. Inhibition of Mediators – prevent progression of tissue 

damage 

V. Prevention of PTOA? Better treatments of joint injuries 

and improved strategies for repairing or restoring articular 

surfaces 

a. Biological 

b. Mechanical 

12. Li W, Anderson DD, Goldsworth JK, Marsh JL, Brown TD: Patient-specific 

finite element analysis of chronic contact stress exposure after intraarticular 

fracture of the tibial plafond. J Ortho Res 26:1039-1045, 2008. 

13. McCabe DJ, Stround NJ, Ramaskrishnan PS, Buckwalter JA, Pedrsen 

DR, Martin JA: Intracellular oxidant production by chondrocytes in 

osteochondral explants following blunt impact injury. Osteoarthritis 

Cartilage 16: suppl 4:S91, 2008. 

14. McKinley TO, Rudert MJ, Koos DC, Brown TD: Incongruity versus instability 

in the etiology of posttraumatic arthritis. Clin Ortho Rel Res 423:44-51, 

2004. 

15. McKinley TO, Rudert J, Tochigi Y, Pedersen DR, Koos DC, Baer TE, Brown TD: 

Incongruity-dependent changes of contact stress rates in human cadeveric 

ankles. J Ortho Trauma 20:732-738, 2006 

16. McKinley TO, Tochigi Y, Rudert MJ, Brown TD: Instability-associated changes 

in contact stress and contact stress rates near a step-off incongruity. J Bone 

Joint Surg 90:375-383, 2008. 

17. Marsh JL, Buckwalter J, Gelberman R, Dirschl, D, Olson S, Brown, TD, Llinias 

A: AOA Symposium-Articular Fractures: Does an anatomic reduction really 

change the result? J Bone Joint Surg 84A:1259-1271, 2002. 

18. Martin JA, Buckwalter JA: The role of chondrocyte-matrix interactions in 

maintaining and repairing articular cartilage. Biorheology 37:129-140, 

2000. 

19. Martin JA, Buckwalter JA: The Role of Chondrocyte Senescence in the 

Pathogenesis of Osteoarthritis and in Limiting Cartilage Repair. J Bone Joint 

Surg 85A-Supplement 2:106-110, 2003. 

20. Martin JA, Klingelhutz AJ, Moussavi-Harmi F, Buckwalter JA: Effects of 

oxidative damage and telmomerase activity on human articular cartilage 

chondrocyte senscence. J Gerontology: Biol Sciences 59:B324-36, 2004. 

21. Martin JA, Brown T, Heiner A, Buckwalter JA: Post-traumatic Osteoarthritis: 

The Role of Accelerated Chondrocyte Senescence. Biorheology 41:479-491, 

2004. 

22. Martin JA, Brown TD, Heiner AD, Buckwalter JA: Chondrocyte senescence, 

joint loading and osteoarthritis. Clin Orthop Rel Res 427S: S96-S103, 2004.

23. Martin JA, Buckwalter JA: Post-traumatic osteoarthritis: The role of stress 

induced chondrocyte damage. Bioreheology 43:517-521, 2006. 

24. Moussavi-Harami F, Duwayri Y, Martin JA, Moussavi-Harami F, Buckwalter 

JA: Oxygen effects on senescence in chondrocytes and mesenchymal stem 

cells: consequences for tissue engineering. Iowa Orthop J 24:15-20, 2004. 

187 




25. Tochigi Y, McCabe DJ, Martin JA, Rudert J, Buckwalter JA, Brown TD: Acute 

chondrocyte damage in human ankle intraarticular fracture. Osteoarthritis 

Cartilage 16: suppl 4:S99, 2008.

188 

ChoNdroproteCtive ageNtS: FaCt aNd FiCtioN 

Constance R. Chu, MD 

I. Chondroprotective Agent: A substance that protects cartilage 

by acting against agents that would damage or destroy 

cartilage. 

II. Working definition: Substances that: 

1) stimulate chondrocyte synthesis of matrix components 

(collagen and proteoglycans) 

2) inhibit cartilage matrix degradation; and 

3) stabilize the synovium. 

III. Standard Anti-inflammatory Agents 

a. Corticosteroids 

b. NSAID 

Frisbie DD, Kawcak CE , Trotter GW , Powers BE , Walton RM , McIlwraith 

CW. Department of Clinical Sciences, College of Veterinary Medicine and 

Biomedical Sciences, Colorado State University, Fort Collins 80523, USA. 

Effects of triamcinolone acetonide on an in vivo equine osteochondral 

fragment exercise model. Equine Vet J. 1997 Sep; 29(5):349-59. 

Garvican ER, Vaughan-Thomas A, Redmond C, Gabriel N, Clegg PD.,MMPmediated 

collagen breakdown induced by activated protein C in equine 

cartilage is reduced by corticosteroids. J Orthop Res. 2010 Mar; 28(3):370-8. 

O’Connor JP, Lysz T. Celecoxib, NSAIDs and the skeleton.UMDNJ-New Jersey 

Medical School, Newark, New Jersey 07103, USA. oconnojp@umdnj.edu 

Drugs Today (Barc). 2008 Sep; 44(9):693-709. 

Seshadri V, Coyle CH, Chu CR. Lidocaine potentiates the chondrotoxicity of 

methylprednisolone. Arthroscopy. 2009 Apr;25(4):337-47. Epub 2009 Feb 

13. 

Alternative treatments for your arthritis pain. Tai chi, fish oil, and capsaicin gel 

might be effective, drug-free alternatives to NSAIDs. [No authors listed] Duke 

Med Health News. 2009 Sep;15(9):4-5. 

IV. Hyaluronic Acid 

a. Viscosupplementation is regulated as a device 

b. One injection vs. multiple injections 

c. Effect of molecular weight 

d. Mechanisms of action? 

e. Clinical Results 

Ghosh P, Guidolin D., Potential mechanism of action of intra-articular 

hyaluronan therapy in osteoarthritis: are the effects molecular weight 

dependent? Semin Arthritis Rheum. 2002 Aug; 32(1):10-37. 

Takahashi K, Hashimoto S, Kubo T, Hirasawa Y, Lotz M, Amiel D.,Effect of 

hyaluronan on chondrocyte apoptosis and nitric oxide production in 

experimentally induced osteoarthritis. Department of Orthopaedics, 

University of California San Diego, 92093-0630, USA. J Rheumatol. 2000 

Jul; 27(7):1713-20. 

V. Glucosamine 

a. Glucosamine sulfate vs Glucosamine HCl 

b. Bioavailability within Joints 

c. Mechanisms of action? 

d. Clinical Results 

Laverty S, Sandy JD, Celeste C, Vachon P, Marier JF, Plaas AH. Synovial fluid levels 

and serum pharmacokinetics in a large animal model following treatment 

with oral glucosamine at clinically relevant doses.FacultŽ de MŽdicine 

VŽtŽrinaire, UniversitŽ de MontrŽal, Montreal, Quebec, Canada. Arthritis 

Rheum. 2005 Jan; 52(1):181-91. 




Persiani S, Rotini R, Trisolino G, Rovati LC, Locatelli M, Paganini D, Antonioli D, 

Roda A.,Synovial and plasma glucosamine concentrations in osteoarthritic 

patients following oral crystalline glucosamine sulphate at therapeutic dose. 

Rotta Research Laboratorium/Rottapharm, Monza, Italy. stefano.persiani@ 

rottapharm.com. Osteoarthritis Cartilage. 2007 Jul; 15(7):764-72. Epub 

2007 Mar 13. 

VI. Chondroitin Sulfate 

a. Bioavailability within Joints 

b. Mechanisms of action? 

c. Clinical Results 

Monfort J, Martel-Pelletier J, Pelletier JP. Chondroitin sulphate for symptomatic 

osteoarthritis: critical appraisal of meta-analyses.Unitat de Recerca en 

Fisiopatologia Ossia i Articular, Institut Municipal d’Investigaci— M dica 

(IMIM), Hospital del Mar, Universitat Aut˜noma de Barcelona, Parc de 

Recerca Biom dica de Barcelona, Spain. Curr Med Res Opin. 2008 May; 

24(5):1303-8. Epub 2008 Apr 15. 

Uebelhart D. Clinical review of chondroitin sulfate in osteoarthritis. Department 

of Rheumatology and Institute of Physical Medicine, University Hospital 

Zurich, Switzerland. daniel.uebelhart@usz.ch Osteoarthritis Cartilage. 2008; 

16 Suppl 3:S19-21. Epub 2008 Jul 31. 

VII. Emerging Therapies 

a. Growth Factors 

b. Anti-oxidants 

c. Cytokine inhibition 

d. Matrix Protection 

i. Collagen – “anti” matrix metalloproteinases 

ii. Proteoglycan – “anti” aggrecanase 

e. Gene Therapy 

Brandt KD, Mazzuca SA, Katz BP, Lane KA, Buckwalter KA, Yocum DE, Wolfe 

F, Schnitzer TJ, Moreland LW, Manzi S, Bradley JD, Sharma L, Oddis 

CV, Hugenberg ST, Heck LW. Effects of doxycycline on progression of 

osteoarthritis: results of a randomized, placebo-controlled, double-blind 

trial. Arthritis Rheum. 2005 Jul; 52(7):2015-25. 

Evans CH, Robbins PD, Ghivizzani SC, Wasko MC, Tomaino MM, Kang R, 

Muzzonigro TA, Vogt M, Elder EM, Whiteside TL, Watkins SC, Herndon JH. 

Gene transfer to human joints: progress toward a gene therapy of arthritis. 

Department of Orthopaedic Surgery, University of Pittsburgh School of 

Medicine, Pittsburgh, PA 15261, USA.cevans@rics.bwh.harvard.edu Proc 

Natl Acad Sci U S A. 2005 Jun 14;102(24):8698-703. Epub 2005 Jun 6. 

Malemud CJ. Anticytokine therapy for osteoarthritis: evidence to date. 

Department of Medicine, Division of Rheumatic Diseases, Department of 

Anatomy, Case Western Reserve University, School of Medicine & University 

Hospitals Case Medical Center, Cleveland, Ohio 44106-5076, USA. cjm4@ 

cwru.edu Drugs Aging. 2010 Feb 1; 27(2):95-115. 

VIII. Diet, Exercise, Weight Management 

Roos EM and Dahlberg L. Positive effects of moderate exercise on 

glycosaminoglycan content in knee cartilage: a four-month, randomized, 

controlled trial in patients at risk of osteoarthritis. Arthritis Rheum. 2005 

Nov; 52(11):3507-14. (Exercise/Chondroprotection)

189 

traNSlatioNal reSearCh you CaN uSe: 

Cell-baSed approaCheS For Cartilage repair 

Scott A. Rodeo, MD 

General Points: 

• Cell-based approaches hold great promise but there are still 

limitations to overcome 

• Implanted cells need appropriate signals to drive differentiation 

• The inflammatory signals in the post-operative joint likely have 

negative effect on biology of implanted cells. 

• Cells need to do more than just matrix protein gene 

expression—also need appropriate post-translational protein 

modification, assembly into matrix ultrastructure, etc. 

• The composition (specific matrix proteins) are often made by 

the cells but the structure of hyaline cartilage is not completely 

reformed 

• We can learn lessons from fetal development—ideal goal would 

be to recapitulate the events that occur during embryogenesis. 

Fetal wounds heal without scar formation (“scarless healing”)due 

to absence of inflammatory response. Could we ultimately 

reproduce a similar environment in cartilage repair?? 

Current and Future Cell-Based Approaches for Cartilage Repair 

Autologous chondrocyte implantation (ACI) 

• Limitations of first generation ACI: 

— Requires 2 operations 

— Technically demanding to suture periosteum to cartilage 

— Cells can de-differentiate in culture 

— Graft hypertrophy following implantation 

— Incomplete incorporation of newly-formed tissue with 

adjacent host cartilage 

• Newer generation ACI (2nd and 3rd generation): 

— Cells suspended and cultured in matrix (hyaluronic acid or 

collagen scaffold) 

— Technically simpler- material can be applied with fibrin glue 

rather than suturing to periosteum 

— The matrix material acts as a scaffold to support neo-cartilage 

formation 

— “Characterized chondrocytes” (Chondroselect)- - this 

technique selects a subset of cells that express chondrocyte 

phenotype in culture. 

— These techniques are currently used in Europe but are not yet 

FDA approved in the U.S. 

• Juvenile chondrocytes (Zimmer De Novo) 

Amer. J. Sports Medicine 2010) 

(Adkisson et al, 




— There is a dramatic age-related decline in human 

chondrocyte chondrogenic potential 

— Juvenile tissue has much proliferative capacity 

— Minced cartilage derived from juvenile human donors 

(allograft) 

— The material is suspended in fibrin glue and attached to 

lesion site using fibrin glue 

Stem Cells 

• Tremendous potential for cartilage tissue regeneration 

• Further information needed to identify best way to control 

differentiation of these cells 

• Cells can be from various sources: 

— Derived from adult tissue (muscle, fat, bone marrow) 

— Embryonic stem cells 

— Induced pluripotent cells (IPS) have interesting potential 

– IPS are formed by re-programming differentiated adult 

fibroblasts to express “pluripotency genes” by infection 

with transcription factors OCT 3/4, SOX2, KLF4, and 

c-MYC (Takahashi and Yamanaka, 2006) 

Cytokines 

• Cytokines have tremendous potential to affect basic cell biology 

• Limitations of single factor therapy provides compelling 

rationale for use of platelet-rich plasma 

• FGF-18 is being evaluated as potential cytokine to enhance 

cartilage healing 

• An important challenge is cytokine delivery to the desired site 

Platelet-Rich Plasma 

• PRP has potential to affect cartilage biology 

• PRP been shown to increase DNA content, as well as 

proteogylcan and collagen synthesis in chondrocytes 

• Numerous important limitations at this time due to variability 

between various commercial PRP systems 

• Variability in: 

— Platelet recovery 

— Growth factor content per platelet 

— Inclusion/exclusion of WBCs 

— Fibrin content 

— Timing of platelet activation 

— Kinetics of cytokine release from the PRP

190 

SelF-proteCtive Smart orthopediC implaNtS 

We are entering an exciting era in orthopedic surgery. Biological 

modifications of conventional devices to counteract the current 

implant associated problems are underway. Self-protective ‘smart’ 

implants are examples of such accomplishments. The modification 

of the implant surface with a permanent covalent bond and tethering 

of antibiotics or other biofactors, if proven to be effective, is likely 

to transform the practice of orthopedic surgery and other medical 

specialties. The current strong interest in translational products has 

brought experts from both the basic sciences and clinical practice to 

exploit the advances in biotechnology in hope of further improving 

the practice of medicine. 

SELF-PROTECTIVE SMART IMPLANTS 

Current advances in biomaterials and biotechnology have introduced 

a new notion of implants with ‘smart’ surfaces. These implants are 

usually designed to take advantage of molecular knowledge and 

target specific cellular responses at the cell and molecular level. 

Surface coatings and direct surface modifications allow interactions 

with cellular membranes and integrins to modulate cell survival, 

proliferation, differentiation, and signaling. However, production of 

such surfaces and their introduction into mainstream medicine has 

been hampered by the complexity of such projects. Advanced surface 

modifications involve nanoscale chemistry and biomaterial design. 

The synthesis of such materials is difficult to control and practically 

impossible to reproduce with uniform consistency. To overcome 

such problems, innovative synthesis methods were developed that 

rely on self-organization and assembly. Such systems are similar to 

organizations found in biology as pertinent to quaternary structures 

in proteins and self-assembled membranes. Furthermore, due to 

the possibly reversible interactions that take place, such complexes 

can be further modified to respond to external cues, thus actively 

interacting with the immediate environment and being “smart”. 

Smart implant technology is superior to surface coatings by 

providing a permanent surface integral to the implant. Using such 

designs allows for a self protective surface capable of detecting and 

responding to infecting organisms, possibly over the life of the 

implant. By applying the direct knowledge of peri-prosthetic infection 

and the current available treatment strategies, we have developed 

an innovative approach that can address some of the problems 

associated with the use of implants such as periprosthetic infection. 

In contrast to surface coatings that are susceptible to degradation in 

the host environment, a smart implant surface is permanent through 

the application of nanotechnology and has bactericidal effects, 

without modification or loss of the antibiotic. Such an implant is 

not yet available in clinical practice. In order to make this review 

timely and complete, we further describe some of our published and 

unpublished current work on developing the ideal self-protective 

implant To create such bactericidal surfaces, we have utilized 

organosilane covalent bonds to tether antibiotics and other biofactors 

to the surface of the implant The silane chemistry used during this 

process is well characterized for various materials. We have further 

modified the chemistry to suit pure titanium and currently applying 

SELECTED REFERENCES 

1. Parvizi J, Wickstrom E, Zeiger AR, Adams CS, Shapiro IM, Purtill JJ, Sharkey 

PF, Hozack WJ, Rothman RH, Hickok NJ: Titanium surface with biologic 

activity against infection. Clinical Orthopaedics & Related Research. 

(429):33-38, 2004. 




Javad Parvizi MD, FRCS 

similar methods to Ti6Al4V alloys used in orthopaedics. Using this 

scheme, a nanoscale antibiotic surface is being engineered, and the 

covalent linkage should render the antibiotic stable on the surface, 

being able to prevent bacterial colonization without exhaustion, 

possibly throughout the life of the implant. In addition, the absence 

of antibiotic elution prevents distant host tissue toxicity or antibiotic 

gradients that could lead to resistance. Furthermore, by adapting 

the chemistry, specific antibiotics could be tailored to the infectious 

organisms or the individual patient to improve treatment times. Such 

technology is easy to apply clinically by avoiding additional surgical 

steps or techniques during implant placement with no distinction in 

approach when compared to currently available implants. 

Various other smart implants are currently being considered across 

medicine. Biodegradable thermoplastic elastomers designed to adapt 

and change shape, wireless sensor-equipped implants for feedback 

and monitoring, electroactive polymers capable of stimulating 

cardiac muscle, bioresponsive materials with selective release of 

molecules when signaled by other molecules are some examples of 

such smart implants currently under research. Several attempts at 

producing self-protective surfaces have also been considered however 

both the surface or the antimicrobial agents used are not suitable 

for orthopaedics. Several of those products have been elaborated 

primarily for vascular and other surgical applications. Furthermore, 

use of innovative antimicrobial agents suits industrial purposes 

while being problematic in medicine due to required FDA approval 

and acceptance. Still, a cross-disciplinary approach to smart selfprotective 

implants has the potential to introduce truly remarkable 

innovations in medical devices. 

KEY ISSUES 

• Implant use is rapidly increasing, resulting in escalating 

expenditure. Biotechnological innovations are required to 

prevent complications of implant use and reduce costs. 

• Despite aseptic loosening currently being one of the most 

common complications of arthroplasty, recent research suggests 

that periprosthetic infection is on the rise and will soon be 

the most prevalent complication. Periprosthetic infection is a 

challenging problem with high morbidity. 

• Understanding the mechanism of periprosthetic infection is 

critical for the design of successful preventive and therapeutic 

strategies. 

• It is known that the implant surface provides an ideal 

environment for bacterial colonization that manages to escape 

systemic immune surveillance. Bacterial attachment is the 

critical step in formation of biofilm. Eradication of organisms 

organized into biofilm by antibiotics is practically impossible 

and requires surgical resection of the implant. 

• No ideal local antibiotic delivery system exists. Antibiotic 

impregnated cement and surface coatings, though useful, have 

numerous shortcomings. 

• Advances in the field of nanotechnology have allowed the 

design of self-protective, stable, and effective implant surfaces. 

2. Jose B, Antoci VJr, Zeiger AR, Wickstrom E, Hickok NJ: Vancomycin 

covalently bonded to titanium beads kills Staphylococcus aureus. Chemistry 

and Biology 12(9):1041-1048. 2005 

3. Bauer T, Parvizi J, Kobayashi N, Krebs V. Diagnosis of periprosthetic 

infection. Journal of Bone and Joint Surgery American 88[4], 869-882. 2006. 

4. Costerton JW, Stewart PS, Greenberg EP: Bacterial biofilms: a common cause 

of persistent infections. Science 284(5418):1318-22, 1999

191 

New optioNS iN polymerS aNd CeramiCS For 

JoiNt replaCemeNt 

Philip C Noble, MD 

The Clinical Problem 

Conventional Polyethylene(UHMWPE) / Metal joints exhibit 

problems related to bearing failure, notably 

1. Osteolysis secondary to biologically active particulate debris 

2. Wearing out of the UHMWPE bearing surface through 

accelerated wear (typically due to 3rd body particles) 

3. Mechanical failure of the UHMWPE component (early: 

inadequate mechanical properties; late: embrittlement from 

oxidation). 

Solutions 

1. Improved Polymers: 

a. Cross-linked UHMWPE 

Rationale: Cross-linking of polymer chains increases 

mechanical properties and wear resistance. Most common 

method is to use radiation (5-10MRads). However, radiation 

also generates free radicals which can react with dissolved 

oxygen and polymer chains causing degradation and 

embrittlement. 

To avoid embrittlement, cross-linking has been achieved 

using the following strategies: 

(i) Irradiate without oxygen; store without oxygen until use. 

• Benefit: mechanical properties preserved. 

• Drawback: Free radicals still present to react with chains 

and oxygen dissolved from body fluids in vivo. 

• Reality: Wear resistance significantly improved; oxidation 

and embrittlement slow in vivo and limited to peripheral 

and backside surfaces. 

(ii)Eliminate free radicals. This can be achieved using the 

following methods: 

• Heating above melting point: 

Imparts wear and oxidation resistance but degrades 

strength and fatigue resistance. Increased incidence of 

mechanical failure. 

• Annealing below melting point: 

Wear and fracture resistance retained; oxidation resistance 

variable,, depending on process. 

• Addition of chemical compounds (eg. Vitamin E) to 

scavenge free radicals 

• Has potential to provide wear resistance without loss of 

initial properties 

b. Alternative Polymers 

i. Polyurethanes 

ii. PEEK 

2. Ceramic bearing surfaces 

Rationale: In most cases of catastrophic wear after THA, and in many 

failures of TKA, third body particles damage the bearing surface of 

the metal component. This causes the wear rate to increase by 2-8 

REFERENCES 

Polymers in THA/TKA 

1. Birman MV, Noble PC, Conditt MA, Li S, Mathis KB. Cracking and 

impingement in ultra-high-molecular-weight polyethylene acetabular liners. 

J Arthroplasty. 2005; 20(7 Suppl 3): 87-92. 

2. Carbone A, Howie DW, McGee M, Field J, Pearcy M, Smith N, Jones E. Aging 

performance of a compliant layer bearing acetabular prosthesis in an ovine 

hip arthroplasty model. J Arthroplasty. 2006; 21: 899–906. 




times, depending on the severity of the damage and the loading 

conditions. 

A strategy to increase the wear resistance of the joint is to prevent 

or minimize the susceptibility of the metal bearing surface to third 

body abrasion, either through the use of a metallic oxide composite 

(e.g. Oxinium) or a ceramic ball (Alumina or Zirconia-reinforced 

alumina). 

Outcome: Mixed results. In some series run-away wear was greatly 

reduced compared to CoCr. In other series- no difference. Mid to 

long-term clinical series are awaited on Oxinium in THR. Extensive 

damage after dislocation and reduction has been demonstrated. 

3. Ceramic on Ceramic Articulations 

Rationale: The weak link in the UHMWPE-ceramic couple is the 

polymer. However, osteolysis rarely occurs below a threshold burden 

of wear debris. Therefore, eliminate UHMWPE from the articulation 

to avoid excessive wear and osteolysis. 

Materials available: Alumina-alumina (ALX-ALX) has a 40-year 

history in THA demonstrating extremely low wear rates and the least 

biological reactivity of any bearing material. Zirconia-reinforced 

alumina (ZRA) is 60% stronger than alumina. Currently, only ZRA 

balls are FDA approved, though outside the USA, ZRA balls are 

approved for implantation with ALX and ZRA liners. 

Outcome: 

• The wear performance of COC bearings in vivo has been 

generally good, but this bearing is very sensitive to cup 

orientation and rim impingement. Micro-separation 

(subluxation of 1-3mm) of the joint is relatively common 

leading to localized areas of “stripe wear” and a 10-fold increase 

in wear rate. Reports of osteolysis are rare. 

• Catastrophic failure of COC hips is rare, with a prevalence of 

2-8 per 10,000 cases. Intraoperative rim fractures have been 

more common, with documented accounts in up to 3% of 

cases. 

• Squeaking has been reported as a relatively common 

complication of some metal backed ceramic cup inserts, with 

rates of 7-21% with some designs. Whereas squeaking joints 

are rare with flush-mounted cups (approx 0.6%), in cups with 

an elevated metal rim is 5 times higher, and twice as common 

again (7%) when the cup is coupled with one particular stem 

design. Thus it appears that most cases of squeaking can be 

prevented through careful implant selection. 

4. Alternative materials 

a. Silicon Nitride 

b. Diamond compacts and coatings 

3. Currier BH, Currier JH, Collier JP, Mayor MB, Scott RD. Shelf life and in vivo 

duration. Clin Orthop.1997; 342:111–122. 

4. D’Antonio JA, Manley MT, Capello WN, et al. Five-year experience with 

Crossfire highly cross-linked polyethylene. Clin Orthop Relat Res. 2005; 441: 

143-50. 

5. Dorr LD, Wan Z, Shardrar C, Sirianni L, Boutary M, Yun A. Clinical 

Performance of a Durasul Highly Cross-Linked Polyethylene Acetabular Liner 

for Total Hip Arthroplasty at Five Years. J Bone Joint Surg AM. 2005; 87: 

1816-1821.

6. Furmanski J, Anderson M, Bal S, Greenwald AS, David Halley D, Penenberg 

B, Ries M, Pruitt L. Clinical fracture of cross-linked UHMWPE acetabular 

liners. Biomaterials. 2009; 30, 5572–5582. 

7. Geerdink CH, Grimm B, Vencken W, Heyligers IC, Tonino AJ. Cross-linked 

compared with historical polyethylene in THA: An 8- year clinical study. Clin 

Orthop Relat Res. 2009; 467(4): 979-84. 

8. Leung SB, Egawa H, Stepniewski A, Beykirch S, Engh CA, Engh CA. Incidence 

and Volume of Pelvic Osteolysis at Early Follow-up with Highly Cross-linked 

and Noncross-linked Polyethylene. J Arthroplasty. 2007; 22: 134-140. 

9. Masonis JL, Bourne RB, Ries MD, McCalden RW, Salehi A, Kelman 

DC. Zirconia femoral head fractures: A clinical and retrieval analysis. J 

Arthroplasty. 2004; 19: 898–905. 

10. McKellop H, Shen FW, Lu B, Campbell P, Salovey R. Effect of Sterilization 

Method and Other Modifications on the Wear Resistance of Acetabular Cups 

Made of Ultra-High Molecular Weight Polyethylene: A Hip-Simulator Study. 

J Bone Joint Surg. 2000; 82:1708-1725. 

11. Oonishi H, Ishimaru H, Kato A. Effect of Cross-linkage by Gamma 

Irradiation in Heavy Doses to Low Wear Polyethylene in Total Hip 

Prostheses. J. Mater. Sci. Mater. Medicine. 1996; 7, 753-763. 

12. Orala E, Rowella SL, Muratoglua OK. The effect of a-tocopherol on the 

oxidation and free radical decay in irradiated UHMWPE. Biomaterials. 2006; 

27:5580–5587. 

13. Spector BM, Ries MD, Bourne RB, Sauer WS, Long M, Hunter G. Wear 

performance of ultra-high molecular weight polyethylene on oxidized 

zirconium total knee femoral components. J Bone Joint Surg Am. 2001; 83- 

A( Suppl 2): 80–86. 

14. Sutula LC, Collier JP, Saum KA, et al. Impact of sterilization on clinical 

performance of polyethylene in the hip. Clin Orthop. 1995; 319:28–40. 

Ceramic Bearings in THA/TKA 

1. Bal BS, Khandkar A, Lakshminarayanan R, Clarke IC, Hoffman AA, Rahaman 

MN. Testing of silicon nitride ceramic bearings for total hip arthroplasty. J 

Biomed Mat Res. 2008; 87B: 447–454. 

192 




2. Capello W, D’Antonio J, Feinberg J R, Manley M, Naughton M. Ceramic-on- 

Ceramic Total Hip Arthroplasty: Update. J Arthroplasty. 2008; 23(7): 39-43. 

3. D’Antonio JA, Sutton K. Ceramic Materials as Bearing Surfaces for Total Hip 

Arthroplasty. J. Am. Acad. Orthop Surg. 2009; 17(2): 63-68. 

4. Ecker T M, Robbins C, van Flandern G, Patch D, Steppacher SD, Bierbaum 

B, and Murphy SB. Squeaking in Total Hip Replacement: No Cause for 

Concern. ORTHOPEDICS. 2008; 31(9): 875-877. 

5. Eickmann T, Manaka M, Clarke I, Gustafson A. Squeaking and neck-socket 

impingement in a ceramic total hip arthroplasty. Bioceramics. 2003; 15, 

240(2): 849–852. 

6. Ha YC, Kim SY, Kim HJ, Yoo JJ, Koo KH. Ceramic liner fracture after 

cementless alumina-on-alumina total hip arthroplasty. Clin Orthop Relat 

Res. 2007; 458: 106-10. 

7. Ha Y, Koo H, Jeong S, Joon Y, Kim Y, Joong K. Ten-year survivorship of 

cemented ceramic-ceramic total hip prosthesis. J Bone Joint Surg Am.2006; 

88: 780–787. 

8. Hamadouche M, Boutin P, Daussange J, Bolander ME, Sedel L. Alumina-onalumina 

total hip arthroplasty: a minimum 18.5-year follow-up study. J Bone 

Joint Surg Am. 2002; 84-A(1): 69-77. 

9. Hernigou P, Mathieu G, Poignard A, Manicom O, Filippini P, Demoura 

A. Oxinium, a new alternative femoral bearing surface option for hip 

replacement. Eur J Orthop Surg Traumatol. 2007; 17:243–246. 

10. Heros RJ, Willmann G. Ceramic in total hip arthroplasty: history, mechanical 

properties, clinical results, and current manufacturing state of the art. 

Seminars in Arthroplasty. 1998; pp. 114-122. Edited, 114-122. 

11. Murali R, Bonar SF, Kirsh G, Walter WK, Walter WL. Osteolysis in Third- 

Generation Alumina Ceramic-on-Ceramic Hip Bearings With Severe 

Impingement and Titanium Metallosis. J Arthroplasty. 2008. 

12. Murphy SB, Ecker TM, Timo M, Tannast M. Two to 9 Year Clinical results of 

Alumina Ceramic-on-Ceramic THA. Clin Orthop Relat Res. 2006; 453: 97- 

102.

193 

metal oN metal beariNgS aNd bioCompatibility 

Joshua J. Jacobs, MD 

Histological examination of the tissues surrounding secondgeneration 

metal-on-metal hip replacement prostheses generally 

confirms the primary rational for the reintroduction of these bearings. 

The number of particle-laden histiocytes is greatly diminished 

relative to conventional metal-on-polyethylene articulations due to 

lower wear rates and the lesser volume of wear particles generated 

when metal-on-metal bearings function as intended. 1-3 However, as 

continuing experience with these devices is gained, unanticipated 

local tissue responses in some patients, including immunological/ 

necrotic reactions, 4-6 and novel degradation products such as 

chromium phosphate7,8 have come to light. 

It is now recognized that unusual lymphocytic aggregates occur in 

the periprosthetic tissues of some patients with second-generation 

CoCr metal-on-metal hip replacements that are not generally found 

in tissues surrounding other articulations. 4,5 These findings have 

been in association with pain, joint effusion, aseptic loosening and 

osteolysis. 4,5,9 The histological and immunohistochemical appearance 

of the tissues is dominated by peri-vascular and diffuse infiltrates of 

T and B-lymphocytes, including secondary lymphoid follicles that 

are morphologically suggestive of a hypersensitivity reaction. These 

findings of primarily lymphocytic inflammation are in contrast to 

tissues surrounding metal-on-polyethylene bearings where a very 

large number of particle-laden macrophages may be seen, and where 

suchlymphocyticaggregatesarerareinpatientswithoutinflammatory 

arthritis. While this phenomenon was first observed in the European 

patient population where metal-on-metal bearings have had a more 

extensive history, 4,5 it has now being reported in patients who have 

received contemporary metal-on-metal bearings in North America8 and Asia. 9 The prevalence of metal hypersensitivity reactions in the 

periprosthetic tissues of metal-on-metal bearings is unknown; 4,5 and 

a causal relationship between metal hypersensitivity and osteolysis 

has been suggested but remains to be established. 10 Released soluble 

metal can activate the immune system by forming complexes with 

native proteins and are considered to be candidate antigens (or 

allergens). Polymeric wear debris (not easily chemically degraded 

in vivo) has not been implicated as a major source of allergic-type 

immune responses. 11-14 

Metal hypersensitivity is a well-established phenomenon, where 

dermal hypersensitivity to metal affects about 10-15% of the 

population. 11 Implant hypersensitivity responses are generally 

classified as Type IV Delayed Type Hypersensitivity (DTH). Metalantigen 

sensitized T-DTH lymphocytes release various cytokines 

that result in the accumulation and activation of macrophages. The 

majority of DTH participating cells are macrophages, and only 5% 

of cells present are lymphocytes. There is crossover between the 

cytokine cascades involved in a DTH reaction and in inflammatory 

bone loss (osteolysis). 15 This may explain the clinical observations of 

a DTH-like histological response in association with osteolysis in a 

subgroup of patients who have undergone revision of a symptomatic 

metal-on-metal bearing hip reconstruction. 4,9,16,17 

The incidence of metal sensitivity as determined by patch testing 

among patients with both well and poorly functioning implants is 

roughly twice as high as that of the general population, approximately 

25%. The average incidence of metal sensitivity among patients with 

a “failed” implant (in need of revision surgery) is approximately 50- 

60%. 11 This increased prevalence of metal sensitivity among patients 

with a failed implant has prompted the speculation that immunologic 

reactivity may contribute to implant loosening. However, there is a 

lack of a clear connection between incidence of metal sensitivity 




and implant residence time, infection, reason for removal, or pain. 

At this time, however, it is unclear whether metal sensitivity causes 

implant loosening or whether implant loosening results in the 

development of metal sensitivity. Specific types of implants with 

greater propensity to release metal in vivo may be more prone to 

induce metal sensitivity, e.g. metal-on-metal bearing surfaces. 18 

While general patch testing protocols and commercial kits do exist 

for a variety of commonly antigenic substances, 19 there is mounting 

concern about the applicability of dermal testing to the study of 

immune responses to orthopedic implants; in particular, there 

is a lack of knowledge about appropriate antigen presenting cells 

and metal challenge agents. 12 In vitro lymphocyte transformation 

tests (LTT) testing involves measuring the proliferative response of 

lymphocytes (obtained from peripheral blood) following exposure 

with antigen. The use of LTT testing has been established as a 

method for testing sensitivity in a variety of clinical settings. The use 

of LTT testing for correlating implant performance with related metal 

reactivity has been limited. 20-22 However, the few investigations that 

have been conducted indicate that metal sensitivity may be more 

readily detected by LTT than by dermal patch testing. 20,21,23 If true, 

such reports seem to indicate LTT testing may be equally or better 

suited for the testing of implant related sensitivity than dermal patch 

testing. 

In addition to the nanometer-size wear particles known to be 

generated by metal-on-metal bearings, 24 particles of chromium 

phosphate corrosion products have been reported in the periprosthetic 

tissues of failed metal-on-metal arthroplasties of several different 

designs. 7,8 Chromium phosphate has been previously identified as 

a product of accelerated corrosion of chromium-containing alloys, 

notably cobalt-chromium and stainless steel25 and while reported in 

association with corroded stainless steel plate and screw junctions 

and adjacent to spinal instrumentation, 25 it has been studied most 

extensively in connection with corrosion of femoral component head 

and neck modular junctions. 53 Chromium phosphate particles have 

been associated with femoral diaphyseal osteolysis around corroded 

modular stainless steel intramedullary nails27 as well as cementless 

hip stems. 28 Chromium phosphate particles are capable of inducing 

the release of proinflammatory cytokines from macrophages in 

cell culture and bone resorption in organ culture. 29 Huber and 

co-workers, 7 also using histological and electron microscopic 

identification methods, observed particles of chromium phosphate 

corrosion product in the periprosthetic tissues of patients with a 

CoCrMo-alloy metal-on-metal bearing. In a previous study from 

our laboratory, particles of chromium phosphate were identified in 

the joint pseudocapsules of 4 of 5 metal-on-metal hip replacements 

revised for pain or aseptic loosening.8,30 

In summary, although the volume of wear particles generated 

appears quite low in patients with metal-on-metal bearings 

unusual local tissue responses, including perivascular lymphocyte 

aggregations suggestive of a hypersensitivity reaction, can develop 

in some patients.4-6 These inflammatory responses occur not only 

in the joint pseudocapsule, but also at the bone-implant interfaces4 

and have implications for maintaining implant fixation, although a 

causal relationship with loosening has not yet been established.10 In 

addition, deposits of chromium phosphate corrosion products have 

been identified in the periprosthetic tissues of patients with secondgeneration 

metal-on-metal bearings.7,8 However, the toxicological 

significance of these findings is as yet unknown.

Acknowledgements: Funding for the research described in this review 

was provided by NIH/NIAMS, Zimmer, Inc, Wright Medical, Inc., the 

REFERENCES 

1. Campbell P, Shen F-W, McKellop H. Biologic and tribologic considerations 

of alternate bearing surfaces. Clin Orthop 2004; 418:98-111. 

2. Clarke IC, Donaldson T, Bowsher JG, Nasser S, Takahashi T. Current concepts 

of metal-on-metal hip resurfacing. Orthop Clin N Am 2005; 36:143-62. 

3. Dumbleton JH, Manely MT. Metal-on-metal total hip replacement. What 

does the literature say? J Arthroplasty 2005; 20(2):174-88. 

4. Willert H-G, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, 

Lohmann CH. Metal-on-metal bearings and hypersensitivity in patients with 

artificial hip joints. A clinical and histomorphological study. J Bone Joint 

Surg 2005; 87-A:28-36. 

5. Davies AP, Willert HG, Campbell PA, Learmouth ID, Case CP. An unusual 

lymphocytic perivascular infiltration in tissues around contemporary metalon-metal 

joint replacements. J Bone Joint Surg 2005; 87-A:18-27. 

6. Pandit HP, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons 

CL, Ostlere S, Athanasou NA, Gill HS, Murray DW: Pseudotumors associated 

with metal-on-metal hip resurfacings. J Bone Joint Surg 2008;90B:847-851. 

7. Huber M, Reinisch G, Linter F, Zweymuller K. Histological and electron 

microscopic identification and analysis of corrosion products in 

periprosthetic tissue after total hip replacement. In: Zippel H and Dietrich M, 

editors. Bioceramics in joint arthroplasty. 8th BIOLOX Symposium, Berlin, 

March 28-29, 2003 Proceedings. Darmstadt: Steinkopff Verlag; 2003. p 73-8. 

8. Urban RM, Jacobs JJ. Allergic and systemic effects of particles. In: Zippel 

H and Dietrich M, editors. Bioceramics in joint arthroplasty. 8th BIOLOX 

Symposium, Berlin, March 28-29, 2003 Proceedings. Darmstadt: Steinkopff 

Verlag; 2003. p 97-102. 

9. Park Y-S, Moon Y-W, Lim S-J, Yang J-M, Ahn G, Choi Y-L. Early osteolysis 

following second-generation metal-on-metal hip replacement. J Bone and 

Joint Surg; 87-A:1515-21, 2005. 

10. Jacobs, J.J. and Hallab, N.J. Editorial. Loosening and Osteolysis Associated 

with Metal-on-Metal Bearings: A Local Effect of Metal Hypersensitivity? J 

Bone Jt Surg 88A:1171-1172, 2006. 

11. Hallab, N., Merritt, K., and Jacobs, J.J.: Metal sensitivity in patients with 

orthopaedic implants. J Bone Joint Surg Am 83-A:428, 2001. 

12. Hallab, N.J., Jacobs, J.J., Skipor, A., Black, J., Mikecz, K., and Galante, J.O.: 

Systemic metal-protein binding associated with total joint replacement 

arthroplasty. J Biomed Mater Res 49:353, 2000. 

13. Hallab, N.J., Mikecz, K., and Jacobs, J.J.: A triple assay technique for the 

evaluation of metal-induced, delayed-type hypersensitivity responses in 

patients with or receiving total joint arthroplasty. J Biomed Mater Res 

53:480, 2000. 

14. Hallab, N.J., Mikecz, K., Vermes, C., Skipor,A., and Jacobs,J.J.: Differential 

lymphocyte reactivity to serum-derived metal-protein complexes produced 

from cobalt-based and titanium-based implant alloy degradation. J.Biomed. 

Mater.Res 56:427, 2001. 

15. Hallab N.J., Anderson S, Stafford T, Glant T, Jacobs J.J., Hypersensitivity 

responses in patients with total hip arthroplasty , Journal of Orthopaedic 

Research, 23 (2):384-391, 2005). 

16. Korovessis P, Petsinis G, Repanti M, Repantis T. Metallosis after contemporary 

metal-on-metal total hip arthroplasty. Five to Nine-Year Follow-Up J Bone 

Joint Surg 2006; 88A:1183-1191. 

194 




Crown Family Chair of Orthopaedic Surgery and the Rush Arthritis 

and Orthopaedics Institute. 

17. Milosev I, Trebse R, Kovac S, Cor A, Pisot V. Survivorship and retrieval 

analysis of Sikomet metal-on-metal total hip replacements at a mean of 

seven years. J Bone Joint Surg 2006; 88A:1173-1182. 

18. Hallab, N.J., Anderson, S., Caicedo, M., Skipor, A.K., Campbell, P. and Jacobs, 

J.J. Immune Responses Correlate with Serum-Metal in Metal-on-Metal Hip 

Arthroplasty. J Arthrop 19 (Suppl 3):88-93, 2004. 

19. Rooker, G.D. and Wilkinson, J.D.: Metal sensitivity in patients undergoing 

hip replacement. A prospective study. The Journal of Bone and Joint Surgery 

62-B:502, 1980. 

20. Carando, S., Cannas,M., Rossi,P., and Portigliatti-Barbos,M.: The lymphocytic 

transformation test (L.T.T.) in the evaluation of intolerance in prosthetic 

implants. Ital.J Orthop Traumatol. 11:475, 1985. 

21. Granchi, D., Ciapetti,G., Stea,S., Cavedagna,D., Bettini,N., Bianco,T., 

Fontanesi,G., and Pizzoferrato,A.: Evaluation of several immunological 

parameters in patients with aseptic loosening of hip arthroplasty. Chir 

Organi Mov 80:399, 1995. 

22. Pizzoferrato,A., Ciapetti,G., Stea,S., Cenni,E., Arciola,C.R., Granchi,D., and 

Savarino,L.: Cell culture methods for testing biocompatibility. Clin Mater 

15:173, 1994. 

23. Donati, M.E., Savarino,L., Granchi,D., Ciapetti,G., Cervellati,M., Rotini,R., 

and Pizzoferrato,A.: The effects of metal corrosion debris on immune system 

cells. Chir Organi Mov 83:387, 1998. 

24. Doorn, P.F, Campbell, P.A., Worrall, J., Benya, P.D., McKellop, H.A.: Metal 

wear particle characterization from metal on metal total hip replacements: 

TEM study of periprosthetic tissues and isolated particles. J Biomed Mater 

Res 42 (1998) 103-111 

25. Urban RM, Jacobs JJ, Gilbert JL, Skipor AK, Hallab NJ, Mikecz K, Glant TT, 

Marsh JL, Galante JO. Corrosion products generated from mechanically 

assisted crevice corrosion of stainless steel orthopaedic implants. In Stainless 

steels for medical and surgical applications, STP 1348, pp 262-72, edited 

by GL Winters and MJ Nutt, ASTM International, West Conshohocken, PA, 

2003. 

26. Urban RM, Jacobs JJ, Gilbert JL and Galante JO. Migration of corrosion 

products from modular hip prostheses. Particle microanalysis and 

histopathological findings. J Bone Joint Surg 1994; 76-A:1345-59. 

27. Jones DM, Marsh JL, Nepola JV, Jacobs JJ, Skipor AK, Urban RM, Gilbert JL, 

Buckwalter JA. Focal osteolysis at the junctions of a modular stainless-steel 

femoral intramedullary nail. J Bone Joint Surg 2001; 83-A:537-48. 

28. Urban RM, Jacobs JJ, Sumner DR, Peters CL, Voss FR, Galante JO. The boneimplant 

interface in femoral stems with non-circumferential porous coating: 

A study of specimens retrieved at autopsy. J Bone and Joint Surg 1996; 78- 

A:1068-81. 

29. Lee S-H, Brennen FR, Jacobs JJ, Urban RM, Ragasa DR, Glant TT. Human 

Monocyte/macrophage response to cobalt-chromium corrosion products 

and titanium particles in patients with total joint replacements. J Orthop Res 

1997; 15:40-49. 

30. Hodge WA, Harman MK, Banks SA, Jacobs JJ, Urban RM, Skipor AK, 

Campbell P, Amstutz HC: Early clinical experience with contemporary metalon-metal 

total hip arthroplasty: A multicenter collaboration. 68th Annual 

Meeting of the American Academy of Orthopaedic Surgeons, San Francisco, 

CA, 2001.

195 

aaoS quality iNitiativeS, 

health Care reForm aNd you (F) 




Moderator: Kristy L. Weber, MD, Baltimore, MD 

This symposia will outline how AAOS will help lead the movement toward Quality in US Health Care and how this will affect 

you as an orthopaedic surgeon. 

I. What the AAOS Quality Initiative Means to You 

Kristy L. Weber, MD, Baltimore, MD 

II. How the American Joint Replacement Registry Will Affect Your Practice and Reimbursement 

William J. Maloney, MD, Redwood City, CA 

III. Current AAOS Quality Initiatives and Introduction of Appropriate Use Criteria 

Kristy L. Weber, MD, Baltimore, MD 

IV. How to Integrate AAOS Practice Guidelines into Your Workflow for Improved Patient Care 

Michael J. Goldberg, MD, Seattle, WA 

V. Aligning Our Efforts with Employers and Payors to Improve Patient Care 

M. Bradford Henley, MD, Seattle, WA 

VI. What is on the Horizon – A Purchaser’s Perspective 

David Lansky, PhD, San Francisco, CA

196 

what the aaoS quality iNitiative meaNS to you 

1. How the AAOS Quality efforts align with current US health care 

reforms 

Examples 

2.. How this Affects the Individual Orthopaedic Surgeon 

Reimbursement 

Legal implications 

Maintenance of certification 




Kristy Weber, MD

197 

how the ameriCaN JoiNt replaCemeNt regiStry will aFFeCt 

your praCtiCe aNd reimburSemeNt 

William J. Maloney, MD 

National joint replacement registries have been established in several 

countries throughout the world including almost every English 

speaking country except the United States. When developed, operated 

and reported by orthopaedic surgeons, the data from national joint 

replacement registries has been used to improve outcome, identify 

poorly performing technology and generate research questions. In 

the United States, hip and knee replacement represent the single 

biggest expense for CMS. Failure is costly. Between 1997 and 2003, 

revision surgery accounted for approximately 19% of Medicare 

hip replacement expenditures and 8.2% of knee replacement 

expenditures. The ability of a national joint replacement registry 

to reduce the revision burden is well documented in the Sweden. 

Through the process of continuous feedback to hospital centers and 

operating surgeons, the revision burden in Sweden has declined over 

the past two decades. In 1990, the revision burden for hips in Sweden 

was approximately 10% compared to 18% in the United States. 

Today, the revision burden for hips in Sweden is 8%. In the United 

States, it remains at approximately 18%. Similarly, the cumulative 

frequency of hip revision in Sweden has steadily declined from 10% 

at 11 years for cases done in 1979 to 4% at 11 years for cases done 

1989. They attribute this in large part to the Swedish Hip Registry. 

The need for a national joint replacement effort in the United States 

is obvious and is the impetus for this RFA. There are more than one 

million hip and knee replacements performed in the United States 

each year, an order of magnitude greater than any other country in 

world. Demand has increased steadily from 1990 to the present. The 

number of knee replacements alone is projected to grow by 673% to 

3.48 million by the year 2030. Most new hip and knee replacement 

systems are introduced to the market via the 510k process. Little if any 

effective post-market surveillance occurs. Despite the fact that new 

hip and knee systems are designed, manufactured and implanted 

with the expectation that they are at least equivalent to existing 

products, problems can and do occur. Currently, there is no effective 

mechanism to identify poorly performing implant technologies or 

techniques. As a result, nationally we are performing a large clinical 

trial but neglecting to track outcomes. The outcome is that inferior 

technologies and techniques continue to be utilized longer than 

necessary and patients suffer. 

There is a growing body of evidence to suggest that implant registries 

that generate real time survivorship curves can serve as a clinical 

trip wire for inferior technology. When sufficiently large numbers 

of procedures are tracked, patient and surgeon factors that impact 

outcome tend to evenly distributed across various implant designs. 

Implant technology then tends to dominate overall survivorship. 

Figure one is a socket survivorship data from a single institution 

for patients undergoing primary total hip replacement. Statistical 

analysis identifies outliers. Investigation of inferior performance 

and notification to key stakeholders can lead to correctional activity 

minimizing patient exposure enhancing patient safety and reducing 

overall costs. 




Figure 1: Survival Free of Cup Revision for Primary Hips 

The Australian Hip and Knee Registry is a relatively recent joint 

replacement registry that documents the impact collection of the 

minimum data set can have on informed decision making. Metal 

on metal hip resurfacing was introduced in Australia in 1999. 

Analysis of the level one data demonstrated that at four years there 

was a significant increased risk of revision surgery for hip resurfacing 

compared to conventional total hip replacement. Further analysis 

demonstrated subgroups (elderly and women) that were at very high 

risk of failure. This information had an immediate impact on patient 

selection. Metal on metal hip resurfacing was introduced in the 

United States in 2006 through a controversial FDA approval. With 

approval came the requirement of post-market surveillance. These 

studies may be ongoing, but to my knowledge the information is 

not being presented to surgeons and patients. Within the past year, 

metal-metal hip replacements have been withdrawn from the US 

market based in part on data from international registries. 

There are many documented examples where national joint 

registries have identified poorly performing technology. In Norway, 

they have identified inferior results as early as three years following 

market introduction. Several uncemented implant designs and two 

bone cements have been withdrawn from the market as a result. 

The Australian Joint Replacement Registry demonstrated inferior 

performance of a uni-compartmental knee spacer leading to market 

withdrawal. Interesting, that same implant is still sold in the United 

States. 

Using level one data (minimum data set), implant registries can 

also distinguish between poorly performing technologies and 

technologies that are technically difficult to perform. The Swedish 

Knee Registry provides an excellent example. In this registry, the 

eight year survivorship of the Oxford UKR in the hands of high 

volume surgeons exceeded 92% compared to less than 82% with low 

volume surgeons. In contrast, the Endo Link UKR likely represented 

a technically more straight forward procedure. Overall survivorship 

was good and surgical volume has little impact on outcome. Finally, 

the PCA UKR during the time period reported documented inferior 

technology. This implant had poor survivorship regardless of surgical

experience. This data can also be utilized to examine the learning 

curve associated with introduction of new technology. 

To analyze outcomes in more depth, additional data elements are 

required. Level one data is the minimum data set and provides the 

data elements necessary for a functional registry with the capacity 

to perform the types of analysis outlined above. To be successful on 

a national level, level one data collection has to be an institutional 

responsibility and thus have a low burden. Level two data represent 

additional elements concerning the patient (eg: co-morbidities), 

198 




the procedure (eg: surgical approach), and the peri-operative care 

(eg:DVT Prophylaxis). Level three data are outcome measures that 

include patient reported data. Examples would include the WOMAC, 

Harris Hip Score and the SF-36. The ability to collect level two and 

three data provides a platform for prospective studies and permits a 

more detailed analysis for comparative effectiveness studies. Finally 

level four data are radiographic images. Collection of this data 

would allow more detailed analysis of implant failures.

199 

CurreNt aaoS quality iNitiativeS aNd iNtroduCtioN oF 

appropriate uSe Criteria 

Kristy Weber, MD 

A) Brief overview of Current AAOS Quality Efforts 

Evidence-based Clinical Practice Guidelines 

Technology Overviews 

Performance Measures (via PCPI) 

American Joint Replacement Registry 

B) Appropriate Use Criteria: Filling in the Guidelines Evidence 

Gap 

• Rationale 

— Orthopedics is in the spotlight for high volume/high cost 

procedures 

— High level evidence or sufficiently detailed data often not 

available 

— Examples of value-based insurance delivery 

— Large variations in care/escalation of numbers of specific 

procedures (Dartmouth) 

– ?Appropriate vs inappropriate use 

– Disparities in care 

— Model on American College of Cardiology AUC/”Culture 

of Quality” 

• Definition 

— AUC specify when it is appropriate to perform a 

procedure/service Physicians must decide when to use/ 

not use a procedure despite lack of evidence Largely 

guideline-based along with clinical scenarios Evaluate 

relative risks/benefits of a procedure/service for a specific 

indication “Reasonable to do” 

• Methods 

— RAND/UCLA Method with modified Delphi process 




– Combines best evidence with collective judgment of 

experts to develop a statement re/appropriateness of 

performing a procedure based on patient sx, medical 

history, test results 

— 3 panels 

– Writing Group – develops vignettes/scenarios (need 

volunteers) 

– Review Group 

– Technical Rating Panel (minimize bias) 

— Ranking of Indications 

– 7-9: Appropriate procedure for specific indication 

– 4-6: Uncertain/unclear if appropriate for specific 

indication 

– 1-3: Inappropriate test for specific indication 

• Benefits 

— Provide clear and public demonstration of how ortho 

community works for pts 

— Give AAOS a stronger voice with payers and healthcare 

purchasers 

— May result in guaranteed reimbursement and reduced 

paperwork for those who practice in accordance with 

these criteria 

C) What can you do? 

• Participate in the development of Guidelines 

• Participate in AAOS registries 

• Participate in the development of AUC (multiple opportunities) 

• Develop ‘best practices’ in your group/hospital

200 

how to iNtegrate aaoS praCtiCe guideliNeS iNto your 

workFlow For improved patieNt Care 

Michael Goldberg, MD 

Answer to the question: “How to integrate AAOS practice guidelines 

into your workflow for improved patient care” is: “I don’t know!” 

However, finding solutions to the following questions will give us 

some answers: 

1. Is there evidence that integrating practice guidelines into your 

workflow will improve patient care? 

2. What’s in it for you? 

a. Getting paid 

b. Becoming credentialed and/or certified 




3. How to change office and hospital culture? 

4. How not to slow the flow? 

a. Data collection burden 

b. Easy to use tools 

5. How to distinguish information from data? 

6. How will integrating guidelines into your practice answer the 

questions: “Are we helping? How do we know? And who else 

should know?”

201 

aligNiNg our eFFortS with employerS aNd payorS to 

improve patieNt Care 

Brad Henley, MD, MBA 

Quality 

• Purchasor/patient interests align 

• Little data available 

• International data suggests high variability 

• US practice driven by technology, marketing, reimbursement vs 

outcomes/continuous feedback 

• Example: 2008 vs 2010 reimbursement of fixation for intertoch/ 

subtroch fx fixation 

— Geographic variation 

— CPT codes 

PQRI Measures Applicable to Orthopedics 

Clinical and Administrative measures 

Orthopaedic Quality Institute 

• Rationale – AAOS is behind in quality arena, lack of true 

partnership with govt/payors/etc 

• American College of Cardiology (ACC) initiative started in 2002 

• Goal: Identify opportunities/barriers to improving quality care 

• Format: Brief presentations, panel discussions, roundtables, 

case studies, collaboration 

• Benefits of OQI 

— CERT Arthroplasty Clawbacks 




— CERT Audits – 2009 

— Interqual Procedures Criteria 

• Summary of ACC Medical Directors Institute 

• Potential topics for Orthopaedic Quality Institute 

— Current AAOS Quality efforts 

— Relationship between quality and cost effectiveness 

— Physician profiling/tiering 

— Reimbursement for Quality 

— Public/private reporting of Quality 

— Topics for orthopaedic guidelines/AUC 

— Comparative Effectiveness Research in Orthopedics 

• Attendees: 

— Medical/administrative leaders from national health plans 

— Representatives from nation’s largest employers 

— Non-profit groups that represent large employers 

— Government agencies (CMS, AHRQ, etc.) 

— AAOS Presidential line, Council Chairs, Key leaders in 

Quality movement, Liaisons to national Quality committees 

(NQF, PCPI, AQA, etc.) 

• Occurs in Washington DC each Fall –focused meeting 

• Build the bench of liaisons to National Quality organizations 

from orthopaedics

202 

diSaSter-relieF orthopaediCS: 

what you Need to kNow beFore you go (N) 

Moderator: Matthew T. Provencher, MD, San Diego, CA 

Current world conditions have led to an increasing demand for Orthopaedic care in austere environments as a result of 

natural disaster and war. This symposium will instruct surgeons on understanding, preparing for, and successfully providing 

care in these challenging conditions. 

Faculty: Roman A. Hayda, MD, Providence, RI James R. Ficke, MD, San Antonio, TX Warren R. Kadrmas, MD, Lackland, TX 


II. Preparation and Planning 

III. Treatment Challenges 

IV. Care and Transport 

V. Discussion, Questions and Answers 



SympoSia GENERAL

203 

evaluatioN oF hoSt NatioN CapabilitieS 

LCOL Benjamin Kam, MD, MC, USAF 

During conflict or disaster response, careful assessment must be 

accomplished as the medical response is initiated. Often this 

assessment is performed simultaneously with deployment of medical 

assets, because the situation is often dynamic, and constant strategic 

re-assessment must be performed. Host Nation capabilities at each 

level, or echelon of care, vary greatly and may vary with geography 

within the country itself. The International Red Cross handbook on 

War Surgery is helpful in this regard. Four examples of scenarios are 

given that can be generalized to most combat/disaster areas: 

1. Safe urban setting 

• Urban, developed environment 

• Single, isolated event 

• Casualty numbers relatively small compared to population 

of city 

• Infrastructure intact: roads, emergency vehicles 

• Health infrastructure intact, sophisticated hospitals 

• Short evacuation time: route is secure 

• Good communications 

• Personnel: adequate number and quality of trained health staff 

• Materials adequate 

• Environment good: weather, daytime 

• Final destination of the wounded is known 

2. Unsafe urban setting 

• Low-income country: under-developed or destroyed urban 

setting 

• Continuing danger: street fighting and bombardment in city 

• Continuing and unpredictable casualty flow including 

massive influx of wounded 

• Poor infrastructure: potholed roads, debris in streets 

• Disrupted health infrastructure: hospitals damaged or looted 

• Availability and length of evacuation uncertain or unknown 

• No or poor communications 

• Minimum health personnel available 

• Material re-supply uncertain, irregular, or non-existent 

• Environment poor: cold, wet, dark 

• Final destination of the wounded not always obvious 

3. Unsafe rural setting 

• Low-income country: under-developed rural area neglected 

in peacetime 

• Constant danger: ongoing combat, landmines 

• Continuing and unpredictable casualty flow 

• Poor infrastructure: badly maintained or no roads 

• Poor health infrastructure: few health posts, even fewer 

district hospitals 

• Availability and length of evacuation uncertain, long and 

arduous 

• No or poor communications 

• Minimum health personnel available 

• Material re-supply uncertain, irregular, or non-existent 

• Environment poor: extreme cold or heat, rainy season and 

dry season 

• Final destination of the wounded not always obvious 

4. Safe but austere setting 

• Low-income country 

REFERENCE 

1. Giannou, C., War Surgery volume 1, International Committee of the Red 

Cross, ICRC May 2010, Annex 6a., pp. 146-150. 




• Continuing danger: ongoing low-intensity warfare 

• Discontinuous casualty flow; includes irregular mass 

evacuations 

• Poor infrastructure: few good roads and few vehicles 

• Minimum of health infrastructure: some rural clinics or 

health centres, fewer district hospitals 

• Evacuation predictable but long and arduous 

• Poor to moderate communications 

• Minimum to moderate number of health personnel 

available 

• Minimum material re-supply 

• Environment harsh 

• Final destination of the wounded: distant, but known 

Key questions for each topic: 

1. Geography/logistics: 

• Where is the fighting taking place/where is the disaster zone? 

• What demarcates safe areas from dangerous areas? 

• Military activity, natural disaster or major accident? (Is 

health infrastructureintact?) 

• Urban or rural setting? 

• Industrially-developed or low-income country: recources 

available? 

• How are the wounded transported from point of wounding 

to hospital? 

— private means 

— public transportation 

— ambulance service 

— military services: air, land, etc. 

• Assessment of efficiency of evacuation system 

• Which hospitals receive the wounded? 

2. Echelon 1 first aid/buddy care 

a. Trained paramedics? 

b. Combat medics? 

c. Civilian first-responders? 

3. Echelon 2 forward medical assets 

a. Local medical assets? 

i. Capability assessment? 

ii. Resupply assessment? 

b. Mobile medical/surgical teams? 

i. Insertion capability? 

ii. Evacuation capability? 

4. Echelon 3 hospitals in country 

a. Capability assessment 

b. Damage assessment 

c. Remaining trained staffing 

d. Logistics resupply 

e. Water and power 

5. Echelon 4 hospitals in country or supporting nations 

a. Evacuation capability 

b. Diplomatic visa 

c. Repatriation 

6. Echelon 5 hospitals in country or other fully industrialized nation 

a. Evacuation capability 

b. Diplomatic visa 

c. Repatriation

204 

eXtremity Care logiStiCal NeedS 

LCOL Benjamin Kam, MD, MC, USAF 

Logistical needs for extremity care run the gamut from surgical 

supplies for extremity trauma, to inpatient musculoskeletal nursing 

and therapy, to outpatient clinic supplies and durable medical 

equipment (DME), to prostheses. Depending on the situation, level 

of host-nation/local healthcare available, and transport, the logistical 

needs may be minimal (local modern healthcare available), to total 

(no local care and full spectrum logistical support needed). These 

needs are dynamic, as the balance between supply and demand 

changes based on casualty volume and time course from the disaster 

or initial event. 

Surgical needs 

• Adequate anesthesia services 

• Adequate sterilization system 

• Adequate nursing and surgical technician support 

• Supplies for common musculoskeletal operations 

— Irrigation and debridement/fasciotomy/escharotomy/ 

amputation 

– Sterile irrigation fluids 

– Low pressure irrigation tubing 

– Basic orthopaedic instruments set 

– Gigli saw 

– Tourniquet 

– Assortment of surgical drains 

– Sterile dressings 

– Braided and monofilament sutures 

— External fixation of long bone fractures 

– External fixation instrumentation 

– Hand or power drill with Jacobs chuck 

– Radiographic imaging 

— Percutaneous or internal fixation of small bone fractures 

– Basic orthopaedic instruments set 

– Small fragment set 

– K-wire set 

– Power drill with chucks/wire drivers 

– 20 ga wire 

– Radiographic imaging 

— Shunting of concomitant vascular injury 

– Basic surgical instruments set 

– Atraumatic vascular clamps 

– Vascular loops 

– Fogarty catheters 

– Shunts of various sizes 

– Vessel Doppler 

Inpatient needs 

• Skilled nursing staff 

• Skilled physical therapy staff 

• Radiologic services 

• Laboratory services 

• Oxygen delivery 

• Sterile supplies 

• Walker/crutches/bedside commode 

• IV medications to include narcotics and antibiotics 

• Overhead trapeze, traction assembly 

• Negative pressure dressing therapy 

Outpatient needs 

• Radiographic services 

• Laboratory services 

• Orthotic/bracing services 




• DME products (wheelchair/walker/crutches/cane) 

• Casting/splinting capability 

— Plaster rolls and splints 

— Fiberglass rolls 

— Cotton/synthetic webril padding and stockinette 

— Ace/elastic bandages 

— Cast saw 

— Cast spreader 

— Tape (various) 

• Injectable supplies 

— Syringes/needles/alcohol prep/gauze/bandaids 

— Local anesthetic (1% lidocaine) 

— Corticosteroids 

• Prosthetic services 

The International Red Cross textbook on War Surgery provides an 

excellent guide to assessment of local facilities. This should be done 

first, in order appropriately plan for what care can be provided at any 

given facility and will be needed for sustainment: 

General 

Name of the hospital: 

Assessment done by: Date: 

Country: Town: 

Key questions: 

1. Type (MoPH, private, military, missionary, NGO, others): 

2. Catchment population: 

3. Assistance from others than the authority in charge: 

4. Level of reference (rural, district, regional): 

5. If rural or district hospital, number of primary facilities served 

(first-aid dispensaries, health centers): 

6. Possibilities for further referral: 

7. Transport system for patients (in and out): 

8. Reputation of the hospital (indicate source of information): 

9. Bed capacity, effective number of beds (breakdown by 

department): 

10. Present bed occupancy: 

11. Activities including specialities (surgery, medicine, paediatric, 

obstetric, specialized services, etc.): 

12.Security (Is the area safe? Is the hospital secured? i.e. clearly 

marked, fenced, watchmen present, absence of arms inside the 

hospital compound?): 

13.Endemic diseases and epidemic risk in the region: 

MANAGEMENT & ADMINISTRATION 

I. General management 

1. Set-up (management team/board): 

2. How are decisions taken and implemented? 

II. Human resources management 

1. Who is in charge? 

2. Does the staff receive salary/incentives? 

3. Total number of personnel/breakdown by function (MD, 

medical assistants, nurses, students, etc.): 

4. Is there a roster system in place in the hospital? 

III. Financial management 

1. Management of finance (Is there a budget? How is the 

hospital financed?): 

2. Is there any cost participation, “cost-recovery system”? Do 

the destitute have access to care?

IV. Statistics 

1. Management of statistics and reporting: 

2. Are statistics available? 

3. Is there an annual report? 

4. Are there people specifically in charge of collecting data? 

V. Infrastructure & utilities (general condition of ): 

1. Wall and roof: 

2. Water (running water, wells, safety of water supply, etc.): 

3. Sanitation (type of toilets, etc.): 

4. Electricity and/or generator (number of hours per day, fuel 

supply, etc.): 

5. Heating/fans/air-conditioning: 

6. Maintenance team (number, composition, etc.). Is there a 

maintenance schedule? 

7. Is there a functioning workshop? 

VI. Waste disposal 

1. Waste management systems (including toxics such as X-ray 

developer/fixator, etc.): 

2. Incinerator (type, condition, etc.): 

VII. Non-medical support services 

1. Kitchen (staff, nutritionist, origin of food, number of meals 

served per day, special diets, etc.): 

2. Laundry (staff, washing by hand, machine, supplies, etc.): 

3. Tailor (staff, supplies, etc.): 4. Cleaning and hygiene 

(system, staff, supplies, etc.): 5. Morgue (infrastructure, 

management, etc.): 

MEDICAL SUPPORT SERVICES 

I. Pharmacy 

1. Pharmacy staff and management: 

2. Is there a standard list of medicines? 

3. Are stock cards used? 

4. Where do the drugs and medical equipment come from 

(regular supplier, local market, donations, etc.)? 

5. Is there a reliable system of communication between the 

pharmacy and the wards (request forms, delivery forms, 

etc.)? 

6. Did the pharmacy run out of basic drugs last month 

(penicillin, antimalaria, paracetamol, ORS)? 

7. What are the storage conditions (air-conditioning, 

refrigerator, etc.)? 

8. Is medical equipment regularly maintained and serviced? 

II. Laboratory 

1. Laboratory staff and management: 

2. Tests available (hematology, chemistry, parasitology, 

bacteriology, serology, etc.): 

3. Source of supplies: 

4. Is there a reliable system of communication between the 

laboratory and the wards (request and results forms)? 

5. Quality of working relationship between clinical and 

laboratory staff: 

III. Blood transfusion 

1. Staff and management: 

2. Policy of blood sampling and transfusion: HIV/AIDS policy? 

3. Indications for blood transfusion/average number of 

requests: 

4. How are the blood units kept? Is there a functioning 

refrigerator to store the blood? 

5. Testing process and quality control: 

IV. Imaging (X-ray & ultrasound) 

1. Staff and management: 

2. Average number of X-rays per day: 

205 




3. Type and quality of machine: 

4. Are there guidelines for the prescription of X-rays? 

5. Is more sophisticated imaging equipment available? 

V. Other diagnostic services 

1. ECG, EEG, etc.: 

CLINICAL SERVICES 

I. Outpatient department (OPD) 

II. Admission/emergency department 

1. Number of beds: 

2. Is there a team on duty 24 hours a day; composition of the 

team? 

3. Is there an on-call system in place? 

4. Is there an admission book or regular procedure for 

admitting and registering patients? 

5. Is there a regular procedure to send patients to the 

appropriate wards or to the OT? 

6. Number and type of emergencies per day: 

7. Are basic supplies and equipment available? 

III. Operating theatre (OT) 

1. Staff and roster: 

2. Hygiene of the OT: 

3. Is there an accurate operation book? If yes, number of 

surgical operations in the last month: 

4. What kind of surgery is performed? 

5. What kind of instruments and sets are available (laparotomy, 

caesarean section, debridement, skeletal traction sets, etc.)? 

6. Number of operating rooms, tables: 

7. Surgical linen (availability and source of provision): 

8. Functioning surgical equipment (lamps, suction, diathermy, 

oxygen, etc.): 

9. Source of materials and consumables: 

IV. Sterilization 

1. Staff and roster: 

2. Equipment (autoclaves, dry ovens): 

3. Protocols in place? 

V. Anesthesia 

1. Staff and roster (MD and/or anesthetist nurses): 

2. Is a laparotomy performed safely with full muscle relaxation 

(including endotracheal intubation) by a trained anesthetist? 

Role of the OPD (consultation, follow-up of patients, 

admission, emergency): Are there specialized OPDs? Are 

there criteria to admit the patient to the OPD? Is there a 

register with data about all patients seen every day? Average 

number of cases seen every day (medicine, paediatric, 

surgery, obstetric, etc.): Personnel in charge (MD, medical 

assistants, nurses): Is there a clear roster? Opening days and 

hours: Main pathologies: 

3. Common anesthesia (gas, ketamine, spinal, local): 

4. Type of anesthesia machines: 

5. Availability of other equipment (pulse oximeters, oxygen 

supply, etc.): 

VI. Nursing care 

1. Is there 24-hour nursing supervision in the wards? 

2. Are the patient records complete? 

3. Is the nursing handover book used properly? 

4. Are drugs administered on time? 

5. Is a laparotomy performed safely with the patient supervised 

(vital signs) for 24 hours post-operatively in a room with 

light, and where he or she receives intravenous fluids and 

antibiotics? 

6. What do dressings look like (clean, smelly, etc.)?

206 

7. Are bedsores a problem? 

8. Are relatives involved in patient care? 

VII. Frequently asked questions 

1. Availability of mosquito nets for all beds: 

2. Is there an admission book or regular procedure for 

admitting and registering patients in the ward? If yes, 

number of admissions to the ward in the last month? 

3. Is there a person in the admissions/ER and wards who 

controls a system whereby the patients are assessed and then 

go to the OT or receive treatment? 

4. Are new admissions systematically seen by a senior surgeon/ 

MD and within what timeframe? 

5. Are there regular rounds in the wards and/or regular 

meetings to discuss the cases? 

6. Are the diagnosis and treatment clearly formulated in the 

patients’ files and the treatment copied onto the patientsα 

charts? 

VIII. Surgical care 

1. Main pathologies present in the wards (fractures, burns, 

chest, abdomen, etc.): 

2. Management of the ward/hygiene: 

3. Human resources (number, composition, roster): 

REFERENCE 

1. Giannou, C., War Surgery volume 1, International Committee of the May 

2010, Annex 6a., pp. 140-α145. Red Cross, ICRC 




4. Infrastructure and beds: 

5. Is a laparotomy performed safely – patients seen a few days 

after operation with healing wound and eating normally? 

6. Can five or more laparotomies be performed in 24 hours 

under good conditions including anesthesia? If not, why? 

7. What type of orthopaedic treatment is present in the surgical 

wards (POP, skeletal traction, external or internal fixation)? 

8. What do wounds present in ward look like (clean, dirty, 

smelly, pus)? 

IX. Physiotherapy unit 

1. Are patients walking on crutches in the wards? If not, why? 

2. Management of physiotherapy department: 

3. Human resources: 

Conclusion 

1. First general impression (cleanliness/hygiene, staff, presence 

of patients): 

2. Main positive findings: 

3. Main negative findings: 

4. Capacity to cope with mass influx of wounded: 

5. Emergency/contingency plan: 

6. Proposals: 

7. Next step:

207 

eXtremity vaSCular iNJurieS iN aN auStere eNviroNmeNt: 

what you Need to kNow aNd briNg 

Major Joanna Branstetter, MD 

Define the initial evaluation and demonstrate appropriate evaluation 

techniques of a patient with an extremity vascular injury 

• Initial evaluation should always follow ATLS protocol 

• Application of a tourniquet above the level of injury is 

appropriate in patients with active hemorrhage who fail to 

respond to direct compression at the wound. 

• Once the patient is stabilized, evaluation of limb perfusion 

should be performed 

• Palpate all accessible peripheral pulses 

— In the upper limb: Brachial, Radial and Ulnar artery 

— In the lower limb: Femoral, Popliteal, Dorsalis Pedis and 

Posterior Tibial artery 

• If deficits in pulses, exam should progress proximally to identify 

site of vascular injury 

• Identify “Hard” or “Soft” Signs of vascular injury 

— “Hard” Signs of vascular injury 

– Active pulsatile hemorrhage 

– Pulsatile or expanding hematoma 

– Palpable/audible bruit 

– Signs of limb ischemia 

– Diminished or absent pulses 

— “Soft” Signs of vascular injury 

– Hypotension or shock 

– Developing neurologic deficits 

– Stable non-pulsatile hematoma 

– Proximity of wound to major vascular structures 

• Presence of peripheral pulses does not rule out vascular injury. 

[Rose] 

• Proceed with arterial pressure index if presence of “Soft” signs of 

vascular injury 

• Arterial pressure index is used to compare arterial pressure in an 

injured compared to noninjured limb 

• Can be an Ankle:Brachial index (ABI) for lower extremity 

trauma or Arm:Arm index (AAI) for upper extremity trauma 

• To obtain an arterial pressure index, a blood pressure cuff is 

placed about the ankle or arm of the injured extremity. The cuff 

is inflated and then slowly deflated, and the Doppler probe is 

used to determine the systolic pressure in the extremity. The 

probe may be placed over the posterior tibial artery or dorsalis 

pedis in the lower extremity or the Radial or Ulnar artery in the 

upper extremity. The systolic pressure in the injured extremity 

is then compared to the systolic pressure of an uninjured limb 

(arterial pressure index=Doppler systolic arterial pressure in 

injured limb/Doppler systolic arterial pressure in uninjured 

limb) 

• Normal arterial pressure index is >0.9 

• In penetrating trauma, arterial pressure index have a reported 

sensitivity and specificity of 95% and 97% for significant 

vascular injury. [Johansen] 

• In knee dislocations, arterial pressure index have a reported 

sensitivity and specificity of 100% and 100% for significant 

vascular injury. [Mills] 

Understand the indication for vascular stents/shunts/bypass graft and 

demonstrate appropriate surgical techniques 




Patient Preperation 

• Always prep to allow access for proximal vascular control 

— Upper extremity: Subclavian Artery 

— Lower extremity: Common Femoral Artery 

• Preparation should include access to uninvolved limb in case 

vein graft is needed to be harvested 

• Systemic heparinization (50-75 units/kg IV) should be initiated 

in stable patients with a vascular injury 

Exposures 

• Longitudinal incisions over named vascular structures allow for 

widest exposure 

• Curvilinear type incisions made across joints 

• In contaminated wounds, adequate debridement is essential 

• If ligation of a major artery is required, distal embolectomy 

should be performed followed by administration of heparin to 

preserve collateral circulation [Gorman] 

Stents 

• Currently there is limited role for endovascular procedures in 

penetrating extremity trauma 

• Endovascular stents may be utilized for blunt trauma or 

proximal arterial injury where open surgical exposure is difficult 

i.e. Iliac artery 

Shunts 

• Temporary revascularization can be performed with 

intraluminal shunts 

• After placement, patency should be confirmed with 

intraoperative continuous wave Doppler 

• Shunts may remain patent for 24 hours without systemic 

heparinization [Dawson] 

• Shunts have been reported to maintain limb perfusion up to 48 

hours during military operations [Brounts] 

Bypass Graft 

• Greater Saphenous vein is a common conduit utilized for lower 

extremity trauma 

• Veins should be harvested from the uninvolved limb and be 

reversed to allow directional flow 

• Bypass grafting should usually be performed at a Combat 

Support Hospital level 

• Grafting or repair in a grossly contaminated wound should be 

delayed[Fox] 

• Prophylactic fasciotomy should be considered after any 

revascularization procedure 

Describe techniques for performing extremity arteriography in an 

austere environment 

• Equipment needed: 18 to 20-G butterfly needle, a three-way 

stopcock, two 20- to 30-mL syringes, and intravenous contrast. 

• One syringe is used for aspiration and flushing with heparinized 

saline solution and the second is used to inject full strength 

contrast 

• Artery is clamped proximal to the injection site 

• Injection of 15 to 20 mL of contrast into the artery proximal to 

the suspected injury. 

• Fluoroscopy during the injection, if available, or X-ray at the 

completion of the injection

REFERENCES 

1. Rose SC, Moore EE. Trauma angiography: the use of clinical findings to 

improve patient selection and case preparation. J Trauma. 1988; 28(2):240- 

245 

2. Johansen K, Lynch K, Paun M, Copass M. Non-invasive vascular tests 

reliably exclude occult arterial trauma in injured extremities. J Trauma. 1991; 

1(4):515-519 

3. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for 

diagnosing arterial injury after knee dislocation: a prospective study. J 

Trauma 2004; 56(6):1261-5 

4. Gorman JF. Combat arterial trauma. Analysis of 106 limb-threatening 

injuries. Arch Surg 1969;123:534-579 

208 




5. Blounts lR, Wickel D, Arrington ED, Place RJ, Rush RM. The Use of a 

Temporary Intraluminal Shunt to Restore Lower Limb Perfusion Over a 

4,000 Mile Air Evacuation in a Special Operations Military Setting: A Case 

Report. Clin Med Trauma 2008; 1: 5-9 

6. Dawson D, Putnam T, Light J. Temporary arterial shunts to maintain limb 

perfusion after arterial injury: an animal study. J Trauma 1999; 47: 64-71 

7. Fox CJ, Gillespie DL, O’Donnell SD, et al. Contemporary management of 

wartime vascular trauma. J Vasc Surg. 2005;41:638–644. 

8. Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM Jr. Extremity 

vascular injuries on the battlefield: tips for surgeons deploying to war. J 

Trauma. 2006 Feb; 60(2):432-42.

209 

eXtremity FraCtureS iN aN auStere eNviroNmeNt: 

what you Need to kNow aNd briNg with you 

CPT Jessica D Cross and CPT Daniel R Possley 

A majority of the wounds sustained by soldiers serving in the 

combat zone are to the extremities, largely due to the effectiveness 

of modern body armor. Similarly, high energy extremity injuries are 

seen during natural disasters. For example, 85% of injuries sustained 

by survivors of the recent earthquake in Haiti were orthopaedic in 

nature including fractures and amputations. The surgeon caring 

for victims of war and disaster must be aware of the management 

challenges of extremity fractures in the austere environment. 

Extremity fracture care in the austere environment follows many 

of the principles used in treating these injuries at any US civilian 

trauma center. Appropriate wound management followed by fracture 

stabilization are the mainstays of treatment. 

INITIAL ASSESSMENT 

• Primary and secondary surveys must come first. 

• Extremity Injury First Step: control hemorrhage if bleeding and 

restore perfusion if vascularity is disrupted. 

• Extremity Injury Exam: 

— In an alert patient, perform an exam to assess the injured 

compartments, check pulses, and asses the neurological 

status. 

— In an obtunded patient, examine and palpate the 

compartments and check the pulses. 

WOUND MANAGEMENT 

Basics of wound management are essential. 

• Early and thorough wound debridement. 

— Far forward injury care many not have the capacity to 

administer surgical debridement, but early irrigation with 

removal of gross contamination is likely possible at any level 

of care. 

— Thorough surgical debridement and irrigation should be 

performed as soon as possible. (LINK TO SOFT TISSUE 

MODULE: DEBRIDEMENT) 

– Debris and devitalized tissue should be removed. 

– Bone fragments with any soft tissue attachment should 

be maintained. Bone fragments that are devitalized 

should be debrided with the exception of large articular 

fragments. 

– Preserve viable tissue in order to permit the receiving 

surgeons the greatest number of definitive care options. 

• Administer antibiotics as soon as possible, primarily a broad 

spectrum cephalosporin. 

• Fracture instability can compromise tenuous soft tissue viability; 

therefore, fracture stabilization is part of the soft tissue wound 

management. 

• Fracture stabilization will help protect open wounds from 

further soft tissue damage and is crucial in the setting of a 

vascular repair. 

NON SURGICAL FRACTURE MANAGEMENT 

ADVANTAGES 

• Splints may be the only far forward option for fracture 

stabilization. 

• Splints afford the receiving surgeons the greatest number of 

surgical options. 

• Splinting may be the most appropriate option for low energy 

and closed fractures such as wrist, hand, ankle, and foot 

fractures. 




PRINCIPLES 

• Address open wounds first. Document the status of open 

wounds that will be covered by splints for continuity of care. 

Status of underlying wounds may be written directly on the 

splint. 

• If the patient is to be transported, splints must be suitable for 

the mode of transportation and acceptable within the limits of 

the passenger space. 

• Caution should be utilized so that splints are not constrictive or 

predispose to compartment syndromes, especially prior to long 

evacuations. 

• Temporary splints are intended to limit further injury and not 

meant to be definitive treatment. Definitive reduction may not 

be possible or necessary. 

• In general, splints should immobilize the joint above and below 

the injury. 

UPPER EXTREMITY SPLINTS and CASTS 

• Finger and hand injuries may be immobilized with standard 

splinting methods. 

• Forearm and elbow injuries may best be splinted with a long 

arm posterior splint, double sugar tong splint or bivalved long 

arm cast. 

• Humerus and shoulder fractures are best immobilized using a 

Velpeau cast, padding the arm against the chest. 

— Velpeau casts require casting material to be wrapped around 

the trunk and may not be appropriate for casualties with 

chest injuries. 

— Always bivalve Velpeau casts which will allow for cast 

removal if the wounded develops respiratory compromise. 

LOWER EXTREMITY SPLINTS and CASTS 

• Tibia and ankle fractures may be splinted. Slab splinting, 

however, may not provide adequate stability for transport or 

surgical delay if the fracture is highly unstable or the fracture is 

surrounded by a tenuous soft tissue envelope. 

— Long leg casts provide the most stable immobilization. 

— Cast with the knee flexed 20 degrees and place a 

supracondylar mold. 

— Bivalve the cast. 

• Hip and femur fractures can be immobilized with a hip spica 

cast. 

— Bony prominences must be well padded including the 

sacrum and anterior superior iliac spines. 

— Spica casts require the abdomen be wrapped in the cast, and 

therefore may not be suitable for polytrauma patients with 

abdominal trauma. 

— Adequate space must be left about the perineum for hygiene. 

— Bivalve the cast. 

SURGICAL FRACTURE MANAGEMENT 

Open fractures should receive a thorough surgical debridement as 

soon as possible to decrease the incidence of infection. Surgical 

management of fractures may include internal and external fixation. 

Internal fixation, due to logistical constraints and concern for 

contamination, is not ideal in the austere environment. Therefore, 

the surgeon should be well versed on external fixator placement 

about the humerus, forearm, femur and tibia. 

ADVANTAGES of EXTERNAL FIXATION 

• External fixation affords adequate fracture stabilization to

minimize additional soft tissue trauma. 

• External fixators allow access to the soft tissue for wound care 

and frequent assessments. 

• External fixation may be rapidly applied in the setting of 

polytrauma and mass casualties. This is also of physiological 

benefit, as early fracture stabilization is recommended to 

blunt inflammatory mediators associated with fractures in 

polytrauma. 

• The stability afforded by external fixation is also beneficial for 

pain control and ease of transport, avoiding the remanipulation 

of splints or casts during transport and at each higher echelon of 

care. 

PRINCIPLES 

• External fixation in the austere environment is performed 

within the restrictions of equipment and fluoroscopy 

availability. 

• Specific portable external fixation kits, designed for military use, 

include the Hoffman II Sterile Field Kit (Stryker Howmedica 

Osteonics, Rutherford, NJ). This kit contains carbon fiber rods, 

clamps, and self drilling and self tapping pins that may be 

inserted without the need for electrical power drilling. 

• Frame stability may be increased by optimizing reduction, 

minimizing the bone to bar distance, maximizing space 

between pins, and adding additional pins. 

• Using the minimum number of pins possible to maintain 

fracture stabilization will allow the receiving surgeons the most 

options. Consider future internal fixation plans when choosing 

pin placement. 

• External fixation has been shown to be safe in the austere 

environment with no major complications (defined as 

neurovascular injury, mechanical failure, septic joint, and pin 

tract osteomyelitis) identified in a recent review of 55 tibial 

external fixators. 

CRITICAL SKILLS of EXTERNAL FIXATION 

External fixation may be performed in the austere environment 

without the use of fluoroscopy. Pin placement is described below. 

Ideally, pins should be placed to minimize the impact on future 

internal fixation. 

Pin placement should be performed as follows: 

• Make a small vertical incision at the site of the pin placement. 

• Spread down to the bone bluntly. 

• Load the pin in the drill or manual driver and place the pin into 

the incision until the pin meets bone. 

• Use the pin tip to feel either side of the bone. For example, 

lateral pin placement in the femur should be performed though 

the mid portion of the shaft. “Walk” the pin anteriorly and 

posteriorly to feel the edges of bone so that the mid portion 

may be identified. 

• Advance the pin through the near cortex. Stop at the purchase of 

the far cortex without over penetrating. 

• Subsequent pin placement on the same bone should be 

performed in parallel to allow the pin to bar clamps to engage 

both pin elements without difficulty. The clamp may be used as 

a guide for placement. 

• Avoid pin positioning too close to the fracture site. Pins within 

the fracture itself will decrease the external fixator’s ability to 

maintain stability of the fracture. 

• External fixators may be placed to span joints if fractures extend 

into the articular surface. 

FEMUR 

• Half pins may be inserted at any point along the lateral aspect 

of the femur with a low risk to neurovascular structures. Over 

penetrating the medial cortex may put the profudus femoris 

210 




artery at risk. 

• Anterior half pins may be used in the midshaft; however the 

posterior cortex must not be violated so not to injure the sciatic 

nerve. 

• Transfixation pins may be placed distally, however assure 

adequate proximal distance from knee joint capsule. Pins 

should be placed medially to laterally. 

KNEE 

• Lateral pins in the distal femur and anteromedial pins in the 

proximal tibia may be bridged with additional bar to bar 

clamps. 

TIBIA 

• Half pins should be placed on the anteromedial surface of the 

bone. This is easily palpable as it is subcutaneous the entire 

length of the bone. 

ANKLE 

• The ankle may be incorporated into lower extremity external 

fixators by a delta shaped construct or a unilateral construct. 

• Transfixation pins may be inserted into the calcaneus from the 

medial to lateral position. Ensure the pin start point is posterior 

and distal to the medial and lateral planter nerves. 

• The proximal shaft of the first metatarsal may accept pins 

perpendicular to the long axis of the metatarsal. Do not enter 

the base of the metatarsal as this may tether the tibialis anterior 

tendon. 

HUMERUS 

• Lateral half pins are used. Do not over penetrate the medial 

cortex proximally so not to damage the neurovascular bundle. 

• Anterior half pins may also be used. Proximally, avoid the 

palpable deltoid tendon. At mid shaft, do not over penetrate the 

posterior cortex so not to damage the radial nerve. 

ELBOW 

• Half pins or transfixation pins may be placed laterally to 

medially. Avoid the anterior neurovascular structures and the 

ulnar nerve in the groove posterior and medial to the medial 

epicondyle by placing the pins in plane with the epicondyles, 

palpable on each side of the elbow. 

FOREARM 

• The ulna is easily palpable and pins may generally be placed 

along any border. Typically, lateral entry pins are used, keeping 

in mind the ulnar nerve proximally. 

• Closed pin placement in the proximal portion of the radius is 

not recommended because of risk to the posterior interosseous 

nerve. Radial pins may be placed about the distal portion. 

CONSIDERATIONS FOR FRACTURES TREATED IN 

HOST NATION CASUALTIES 

One particular challenge for those administering medical care in the 

host nation environment is the high likelihood of treating a host 

nation individual to whom unknown follow up care is available. 

• While internal fixation is generally not recommended in the 

austere environment, certain low energy fractures may warrant 

open reductions and internal fixations or closed reductions and 

percutaneous pinning for host nation casualties. 

• External fixation is also on option if transfer to a higher level 

of host nation care is possible, or the tempo of casualties 

and individual treatment facility allow for delayed internal 

stabilization. 

• Low energy, closed fractures may also be definitely treated with 

a splint or cast. 

• In the setting of a high energy wound with extensive soft 

tissue loss, an amputation that may be definitely closed in a

211 

short period of time must be considered. The unavailability 

of prolonged and advanced surgical care makes difficult limb 

salvages challenging. 

REFERENCES 

1. Emergency War Surgery, 3rd Edition. Borden Institute, Walter Reed Medical 

Center, Washington, DC. 2004. 

2. Camuso MR. Far-forward fracture stabilization: external fixation versus 

splinting. J Am Acad Orthop Surg 2006; 14: S118-S123. 

3. Hoppenfeld S. “Approaches for External Fixation” in Surgical Exposures in 

Orthopaedics, 4th Edition. Lippincott Williams and Wilkins. Philadelphia. 

2009. 




ACKNOWLEDGEMENTS 

The authors acknowledge LTC Joseph Hsu, MD and MAJ Glenn 

Kerr, MD for the clinical photographs, video, and many of the 

radiographs. The authors acknowledge COL Damian Rispoli for the 

diagrams. 

4. Possley DR, Burns TC, Stinner DJ, Murray CK, Wenke JC, Hsu JR, and Skeletal 

Trauma Research Consortium. Temporary external fixation is safe in a 

combat environment. J Trauma 2010; 69: S135-S139. 

5. Handicap International. “Preliminary findings about persons with injuries – 

Haiti Earthquake 12 January 2010.” Published January 29, 2010. http://www. 

handicap-international.us/in-the-world/states-of-intervention/programs/ 

haiti/haiti-earthquake-documents. Accessed April 2010.

212 

eXtremity SoFt tiSSue Care aNd amputatioNS iN aN auStere 

eNviroNmeNt 

MAJ Travis Burns, MD 

Understand the factors that affect the care options for different 

patient groups (Locals, detainees, foreigners/Soldiers and those 

with evacuation options) 

In the austere setting of conflict and disaster, medical professionals 

may treat patients from several different categories to include: hostnation 

locals, foreigners, detainees, and military personnel. Initially, 

providers may encounter injured personnel from all groups, and as 

the situation matures, casualty care may become organized by injury 

type, as well as by nationality or personnel category. Medical rules of 

engagement may be established to create guidelines for patient care 

within personnel categories. Priority of care for all patients must be 

according to medical urgency. 1 

Determining a treatment plan for a patient must take into 

consideration follow-on care after initial treatment. The availability 

of evacuation, wound care, specialized surgical care, rehabilitation, 

medical supplies, and prosthetics influence treatment decisions and 

are likely to differ by patient category. Definitive care of host-nation 

casualties may be limited by the rules of evacuation and availability 

of specialized care. These limitations may need to be considered 

when formulating the treatment plan. 

U.S. personnel, and those from other supporting nations, will 

likely have access to rapid evacuation and state of the art care and 

rehabilitation. These patients must be stable for transport and the 

immediate surgical care should focus on providing definitive care 

surgeons with the most reconstructive options. The orthopedic 

surgical care is focused on debridement of devitalized soft tissues 

and contamination, while retaining viable soft tissue and bone for 

future reconstruction. 

Casualties that must remain in country for medical treatment and 

definitive care and rehabilitation, may require treatment plans that 

are tailored to available in-country resources. These patients may need 

to be initially stabilized before transfer to local facilities for followon 

care. Many of these patients may not have access to complex 

surgical reconstructions, wound care, rehabilitation, or prosthetics. 

Assessment of future treatment capabilities will guide treatment 

decisions and may influence decisions for limb salvage. For example, 

in non-salvageable lower extremity injuries in this group, attempts 

should be made to maintain as much limb length as possible. A 

transtibial amputation may be more functional for patients with 

access to prosthetics; however, a Syme or Chopart amputation is 

likely to be more functional for a patient without access to prosthetic 

fitting and devices. See figures 3-5. One consideration to maintain 

soft tissue length in an open amputation requiring transport may 

be skin traction. Stockinette wrap proximal to the open wound can 

be used to anchor 6 to 8 lbs of skin traction to prevent soft tissue 

retraction. The International Committee of the Red Cross (ICRC) 

has described healing by delayed primary closure with this method 

in a refugee population. 

DEFINE AND DEMONSTRATE DEBRIDEMENT 

Introduction 

The term debridement is derived from the French verb “débrider” 

and was initially used to denote the action of “cutting certain parts 

which-like a bridle-constrict or strangulate the organs which they 

2, 3 cover.” 

The goal of surgical debridement is to save lives, preserve function, 




and to remove contaminants and nonviable tissue to reduce risk 

of infection and associated complications. The large zone of injury 

associated with high energy wounds is likely to evolve over time and 

will likely require serial surgical procedures.4 Viable tissue should be 

retained for reconstructive efforts at higher levels of care. 

Indications 

The indications for operative management of a wound sustained 

in an austere environment include: associated fracture, wound 

size greater than 2cm, fascial defects, and penetration of pleura, 

peritoneum, vascular structures, and joint capsule. 

Wound evaluation and skin incision 

Wound debridement necessitates extension of the wound edges, 

exploration and inspection of the tissues within the zone of injury, 

and removal of contamination and nonviable tissue. The devitalized 

skin edges should be sharply excised. Skin is remarkably resilient and 

excision of large areas should be avoided except for grossly damaged 

or shredded skin. For traumatic skin flaps if the base to length ratio 

exceeds more than 1:2 it should be sharply excised. Extension of 

the traumatic wound is usually made in the long axis of the limb. 

Extensions across flexor creases should be done obliquely to prevent 

contractures. 

Muscle and subcutaneous tissue evaluation 

Damaged subcutaneous tissue and fascia are sharply excised. 

Complete fasciotomies should be performed for compartments with 

elevated intracompartmental pressure. 

Color, consistency, contractility, and capacity to bleed are classic 

indicators to determine muscle viability but may be unreliable during 

initial evaluation.5 Color is the least reliable sign for muscle viability 

as surface tissue may be discolored due to contusion, blood under 

the myomesium, or local vasoconstriction. Contraction is assessed 

by observing retraction with the pinch of a forceps or stimulus with 

the electrocautery device. Consistency of muscle and the ability to 

rebound to its initial shape after grasping with a forceps may be 

the most reliable early sign. Capacity to bleed may be difficult to 

detect early due to vasospasm. Further objective assessment of tissue 

viability or adequacy of debridement is not currently available. 

Sharp dissection is utilized to incrementally remove devitalized 

tissue from a wound. Neurovascular structures in continuity are left 

intact unless a revascularization procedure is necessary for an arterial 

injury. Neurovascular structures should be covered with muscle, 

fat, or skin if possible. Tendons should be preserved and covered 

with local tissue. Vacuum assisted devices should not be used near 

exposed arteries, nerves, or veins. Repeat assessment with serial 

surgical debridements is likely to be beneficial in complex wounds. 

See figures 1-2. 

Appropriately balancing wound debridement to minimize infectious 

complications with preservation of soft tissue for reconstruction is 

a challenge. A more aggressive debridement is likely warranted if 

wound evaluation will not be possible for greater than 24 hours. 6 

Osseous evaluation 

It is necessary to deliver the bone ends in open fractures for adequate 

debridement of fracture edges and the intramedullary canal. Open 

wounds that penetrate the joint capsule require an arthrotomy and

irrigation of the intraarticular space. The joint capsule should be 

reapproximated if tissue is available for closure. Bone fragments 

lacking periosteum or soft tissue attachments are debrided. Major 

articular fragments should be retained regardless of soft tissue 

attachments if the joint is to be salvaged. 

Irrigation 

After completion of the debridement, wounds are irrigated with 

warm, low-pressure pulse irrigation or simple low pressure flow 

through sterile tubing. The volume and type of irrigation has not 

been defined by scientific studies, and the volume largely depends 

on wound size and contamination. Current recommendations are 

for 3L of irrigation for grade 1 fractures, 6L for grade II fractures, 

and 9L for grade 3 fractures. 7 Antiseptics and antibiotics are not 

recommended additives to irrigation solution due to toxicity to host 

cells and lack of proven benefit. Potable water can be utilized in 

austere environments if sterile solutions are unavailable. 

Postoperative care 

Traumatic open wounds in an austere environment should not 

be closed primarily in order to minimize the risk of infectious 

complications. Sterile dressings or negative pressure wound therapy 

devices should be used between procedures and during medical 

evacuation. A splint should be applied to all severe extremity soft 

tissue wounds for patient comfort and soft tissue rest, and should 

immobilize the joint above and below the zone of injury. Open 

wounds are reevaluated every 24 to 48 hours or after transfer 

to the next level of care. Determination of need for a repeat 

surgical debridement is largely subjective but important patient 

considerations are evidence of persistent contamination, devitalized 

tissue, high energy mechanism, and local or systemic signs of 

infection. Management issues to consider include the time until 

evacuation, length of evacuation, and the volume of other operative 

cases. 

Debridement Surgical Steps 

• Administer appropriate IV antibiotics and tetanus prophylaxis 

for all penetrating wounds as early as possible 

— Cefazolin 1g q8hrs for gram-positive coverage 

— Gentamicin 5mg/kg/24hrs for gram-negative coverage 

— Penicillin 2,000,000u IV q4hrs for anaerobic/clostridia 

coverage 

• Sterile preparation of the entire limb including prehospital 

applied tourniquet as the extent of the zone of injury is not 

always evident 

• Once the surgical team is prepared, and anesthesia has proper 

vascular access, the field tourniquet is released 

• Control active hemorrhage 

• Longitudinal extension of traumatic wound if necessary to 

evaluate soft tissue 

• Excise nonviable tissue 

— Necrotic skin and subcutaneous tissue 

— Muscle that is friable, noncontractile, ischemic, severely 

damaged, or grossly contaminated 

— Bone that is grossly contaminated or devoid of soft tissue 

• Identify major arterial injuries and determine limb viability and 

need for revascularization procedure 

• Identify major nerves and leave in continuity 

— Primary repair of transected nerves is not performed in 

austere environments if definitive care resources are available 

to the patient. 

• Deliver bone ends on open fractures out of traumatic wound 

and clean the contents of the medullary canal 

• Irrigate with low pressure pulsatile lavage or simple flow 

through cystoscopy tubing 

213 




• Flaps should not be fashioned for closure 

• Leave wound open and apply sterile dressing 

• Splint for soft tissue rest and comfort during transport 

Describe the indications for and demonstrate the ability to 

perform battlefield/austere environment amputations 

Amputations performed in an austere environment are performed 

in two distinct patient groups. The first is the early amputation 

performed for a nonviable limb or a severely injured patient that is 

physiologically unable to tolerate limb salvage. The second group 

includes the definitive amputation performed on local nationals and 

other patients without access to higher levels of care. 

The goals for initial care of the severely injured patient is to preserve 

life, prepare the patient for evacuation if available, and leave the 

maximum number of definitive treatment options. 8 

Specific guidelines for indicating an extremity for amputation based 

on injury characteristics or physiologic parameters are unavailable. 

Extremity injury characteristics that may indicate an early amputation 

include: a nonviable limb after debridement of devitalized tissue, 

an ischemic limb with greater than 6 hours of warm ischemia, and 

irreparable vascular injury or failed repair with an ischemic limb. 

Systemic characteristics that may indicate an early amputation 

is a severely injured extremity and rising serum lactate levels. If a 

patient has a viable limb and evacuation is available, amputation 

indications are more appropriately based on physiologic status than 

on predicted ultimate limb functionality. 

Austere environment amputations should be performed at the most 

distal level possible to retain options for future reconstructive efforts 

and to minimize soft tissue retraction. All viable skin, soft tissue, and 

osseous length should be preserved during the initial debridement. 

Viable soft tissue (muscle and skin) distal to the bone loss may be 

used as a rotational flap and may enable the patient to maintain a 

more distal level amputation. This is especially important for short 

tibial segments where distal soft tissue may be rotated to preserve knee 

function. Fractures proximal to the level of a planned amputation 

need not decide the amputation level and may be initially treated 

with external fixation or splint application. The definitive treatment 

plan and level of amputation may be established after considering 

viable bone and soft tissue, availability of evacuation and expected 

prosthetic availability for the patient. The most commonly utilized 

levels of amputation are illustrated in figures 3-5. 

Description of the surgical technique for each available amputation 

level is beyond the scope of this section. Refer to the links below 

for video content and descriptions of surgical techniques for various 

upper and lower extremity levels. Skin traction is unnecessary in 

amputations that will be reevaluated within 24 to 48 hours. However, 

longer delays prior to repeat evaluation may warrant skin traction. 

Amputations should not be closed initially. A sterile dressing or 

negative pressure dressing should be applied with a splint for soft 

tissue rest during transport. 

Amputation Surgical Technique 

• Administer appropriate IV antibiotics and tetanus prophylaxis 

as early as possible 

— Cefazolin 1g q8hrs for gram-positive coverage 

— Gentamicin 5mg/kg/24hrs for gram-negative coverage 

— Penicillin 2,000,000u IV q4hrs for anaerobic/clostridia 

coverage 

• Sterile preparation of the entire limb including prehospital 

applied tourniquet 

• Once the surgical team is prepared and anesthesia has proper 

vascular access, the field tourniquet is released 

• Control active hemorrhage

• Excise nonviable tissue 

— Necrotic skin and subcutaneous tissue 

— Muscle that is friable, noncontractile, ischemic, severely 

damaged, or grossly contaminated 

— Bone that is grossly contaminated or devoid of soft tissue 

• Bone cuts for a definitive amputation should not be a priority. 

If the limb is nonviable a bone cut should be made as distal as 

possible while removing the necrotic tissue. 

• Identify and ligate major arteries and veins to prevent bleeding 

during transport 

• Identify and tag the major nerves and evaluate for bleeding 

• Irrigate with low pressure pulsatile lavage or low pressure flow 

through cystoscopy tubing 

USEFUL LINKS: 

1. Emergency War Surgery (EWS) handbook: http://www.bordeninstitute.army. 

mil/other_pub/ews.html 

2. Definitive Amputation Surgical Techniques for Transfemoral, Knee 

Disarticulation, Transtibial, Transmetatarsal, and Partial Calcanectomy levels: 

http://www.ampsurg.org/html/amplevels.html# 

www.ampsurg.org 

REFERENCES: 

1. Szul A, Davis L, eds. Chapter 34: Care of Enemy Prisoners of War/Internees. 

Washington, DC: Department of the Army; 2004. 

2. Bowyer G. Debridement of extremity war wounds. J Am Acad Orthop Surg 

2006;14:S52-6. 

214 




• Flaps should not be fashioned for closure and sutures should 

not be used to maintain muscle flap position 

• Leave wound open and apply sterile dressing 

• A splint should be applied for soft tissue rest, patient comfort, 

contracture prevention, and to minimize soft tissue retraction. 

Generally the splint should immobilize a joint above and below 

the zone of injury. 

• Skin tissue traction may be placed for any patient that will 

require more than 2 to 3 days before evaluation at a higher level 

of care or for further surgical treatment 

3. Rechert F. The historical development of the procedure termed debridement. 

Bull Johns Hopkins Hosp 1928;42:93-104. 

4. Ficke JR, Pollak AN. Extremity War Injuries: Development of Clinical 

Treatment Principles. The Journal of the American Academy of Orthopaedic 

Surgeons 2007;15:590-5. 

5. Scully R, Artz C, Sako Y. An evaluation of the surgeon’s criteria for determing 

the viability of muscle during debridment. Arch Surg 1956;73:1031-5. 

6. Szul A, Davis L, eds. Chapter 22: Soft Tissue Injury. Washington, DC: 

Department of the Army; 2004. 

7. Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop 

Surg 2001;9:219-26. 

8. Szul A, Davis L, eds. Chapter 25: Amputations. Washington, DC: Department 

of the Army; 2004.

215 

u boNe deFeCtS: wheN are 

orthobiologiCS iNdiCated? (w) 

Moderators: Stuart B. Goodman, MD, Redwood City, CA and 

A. Seth Greenwald, DPhil Oxon, Cleveland Heights, OH 

This symposium reviews the available “Tool Box” of bone graft materials and other technologies for repair of bone defects in 

three common difficult clinical settings. 

I. Today’s Biologic Tool Box 

a. Autograft Bone 

Thomas A. Einhorn, MD, Boston, MA 

b. Osteoconductive Scaffolds 

Michael J. Yaszemski, MD, Rochester, MN 

c. Osteoinductive/Osteopromotive Growth Factors 

Scott D. Boden, MD, Atlanta, GA 

d. Osteogenic Cells 

George F. Muschler, Cleveland, OH 

II. Decisions 

a. Fractures – Any Stage from Acute Fractures or Non-Unions 

Theodore Miclau, MD, San Francisco, CA 

J. Tracy Watson, MD, Saint Louis, MO 

b. Lumbar Spinal Fusion – ALIF/PLIF or PLF – Single or Multilevel 

Isador H. Lieberman, MD, Plano, TX 

Harvinder S. Sandu, MD, New York, NY 

c. Periprosthetic Defects and Metaphyseal Bone Loss 

Allan E. Gross, MD, Toronto, Canada 

Wayne Paprosky, MD, Winfield, IL 

III. Discussion – Panel with Audience Questions 

a. Matching Graft to Biological Need 

b. Addressing Differences of Opinion 

c. Balancing Goals? 

i. Rapid Return of Function 

ii. Avoiding Complications (Infection, Neurovascular Compromise, Hematoma/Seroma, Reoperation) 

iii. Limiting Cost? 

d. Any Absolute Rules? 

i. Never? 

ii. Always? 

e. Take Home Messages All Speakers 

f. Stump the Professors 



SympoSia GENERAL

I. Traditional Autogenous Bone Grafting 

It is estimated that more than 2.2-million bone grafts are performed 

worldwide each year with 450,000 being performed in the United 

States. In addition to the treatment of orthopaedic injuries and 

conditions, a significant number of grafts are used in the repair and 

reconstruction of craniofacial bones. The so-called gold standard 

for bone grafting remains autogenous bone graft, as it provides the 

basic components required to stimulate skeletal repair including 

osteoinductive factors, an osteoconductive extracellular matrix, 

and osteogenic stem cells present in bone marrow elements. 

Osteoinduction refers to the process by which pluripotent 

mesenchymal stem cells are recruited from the surrounding host 

tissues and differentiate into bone forming osteoprogenitor cells. 

This is mediated by graft-derived growth factors such as bone 

morphogenetic proteins (BMPs)and other peptide signaling 

molecules. Osteoconduction is a process in which the macroscopic 

and microscopic architecture of the bone, as well as its chemisty 

and charge, combine to provide a scaffold to support the ingrowth 

of blood vessels and the attachment of osteoprogenitor cells. This 

occurs in an ordered sequence determined by the three dimensional 

structure of the graft, the local blood supply and biomechanical 

factors exerted on the graft and surrounding tissues. Osteogenesis 

refers to the process of bone formation and is conducted by fully 

mature osteoblasts. With regard to bone grafting, an osteogenic 

material is one that contains live donor osteoblasts capable of 

producing bone, or osteoprogenitor cells that have the ability to 

differentiate into osteoblasts in the host. 

Autogenous bone grafting provides consistent results with regard 

to healing and integration, however, the morbidities associated 

with grafting such as donor site, pain, nerve or arterial injury, and 

infection are reported with rates of between 8 and 10%. 

A. Sources of Autogenous Bone 

The most common and best described sources of autogenous 

bone include the pelvis, distal radius, fibula, proximal tibia, 

and ribs. In addition, local bone reamings obtained during 

intramedullary nailing, local bone obtained from spinous 

processes during spinal fusion, and femoral heads obtained 

during total hip arthroplasty are also commonly used. Through 

the harvesting of the patient’s own bone, the potential for 

graft versus host reaction is eliminated as is the risk of disease 

transmission. Based on the type of graft needed, either 

cancellous or cortical bone can be harvested. 

B. Incorporation of Autogenous Bone 

The sequence of events that occur following bone grafting 

are similar to those involved in the normal bone repair 

process. These include hematoma formation and recruitment 

of circulating progenitor cells in response to the release of 

proinflammatory and proangiogenic factors. The recruited cells 

then begin the process of graft incorporation and osteoclasts 

begin resorption of necrotic graft material. Pluripotential 

mesenchymal cells respond to local factors and differentiate 

into osteoblasts and produce osteoid. While osteoblasts and 

endosteal lining cells on the surface of the graft may survive the 

transplantation and contribute to the healing, it is likely that the 

main contribution of the graft is to act as an osteoconductive 

substrate. These properties provide the necessary physical and 

chemical requirements to support the attachment, spreading, 

division and differentiation of cells that form bone. The final 

stages in the process involve mineralization of the osteoid and 

216 




autogeNouS boNe 

Thomas A. Einhorn, MD 

remodeling of the callus. The process of remodeling of the 

callus (composed of woven bone) involves the coordinated 

activities of osteoblastic bone formation and osteoclastic bone 

resportion, with woven bone ultimately being replaced by 

lamellar bone. 

C. Use of Autogenous Cancellous Bone Graft 

Cancellous bone is an effective graft material for specific clinical 

settings, particularly those that do not require immediate 

structural support from the graft. Its main function is to act as 

a scaffold for the attachment of host cells and to provide the 

osteoconductive and osteoinductive functions required for the 

laying down of new bone. Since this type of graft is rapidly 

incorporated, the remolding process known as “creeping 

substitution” is usually completed at one year, by which time 

the graft will have been replaced by new bone. While cancellous 

bone graft does not provide structural support by itself, it can 

be impacted into skeletal sites and in conjunction with internal 

fixation devices, support an area of bone loss. 

D. Use of Autologous Cortical Bone Graft 

Cortical bone can provide structural support as well as 

osteoconductive and osteoinductive properties. Cortical bone 

grafts are usually harvested from the ribs, fibula, or crest of 

the ilium and can be transplanted with or without a vascular 

pedicle. Non-vascularized grafts are mostly osteoconductive and 

possibly provide some osteoinductive properties but possess 

little or no osteogenic properties as they contain very few 

osteoblasts or osteoprogenitor cells. The diffusion of nutrients 

is limited by the thickness of the cortical matrix and, as such, 

the survival of transplanted osteocytes is limited. The density of 

the graft also plays a role in the incorporation and remodeling 

process. Revascularization of the graft is slow as there is 

extensive bone substrate for osteoclastic bone resportion. 

Remodeling then proceeds as it does for cancellous bone but 

can require up to two years for completion. 

II. Minimally Invasive Methods 

Several minimally invasive methods of harvesting autogenous bone 

graft have been developed and include core biopsy, suction trap 

method and RIA (Reamer Irrigator Aspirator). Studies have been 

done to determine the biological potential of reaming aspirate. In 

one investigation, iliac crest bone reaming debris and irrigation 

samples were harvested during intramedullary nailing procedures. 

Platelet-rich plasma (PRP) was prepared from blood. The growth 

factors in the bony materials (iliac crest or reaming debris) and the 

liquid materials [platelet-poor plasma (PPP), platelet-rich plasma, 

or reaming irrigation] were compared. Elevated levels of fibroblast 

growth factor α, platelet derived growth factor, insulin-like growth 

factor-1, transforming growth factor-α1 and BMP-2 were measured 

in the reaming debris as compared to the iliac crest curettings. VEGF 

and FGF-α were significantly lower in the reaming debris than from 

iliac crest samples. In comparing PRP and PPP, all detectable growth 

factors, except IGF-1, were enhanced. In the reaming irrigation, FGF-α 

and FGF-α were higher but VEGF, PDGF, IGF-1, and TGF-α1 and BMP- 

2 were lower compared to PRP. BMP-4 was not measurable in any 

sample. These data show that bone reaming debris is a rich source 

of growth factors with a content comparable to that from iliac crest. 

The irrigation fluid from the reaming also contains growth factors. In 

a more recent study, investigators implanted human bone reamings 

using RIA, irrigation fluid (usually discarded as waste), tricalcium 

phosphate, and tricalcium phosphate mixed with waste irrigation into

muscle pouches of athymic nude mice. Histological analysis showed 

that the implants of RIA reamings or waste irrigation (with or without 

tricalcium phosphate) led to the formation of bone. The investigators 

suggested that the RIA system may allow for the collection of large 

volumes of autogenous osteoinductive graft material. 

Systemic Effects of Bone Graft Harvest 

Although autogenous bone, allogeneic bone and bone graft 

substitutes are generally evaluated as independent materials, it is 

worth considering systemic factors associated with the harvesting of 

autogenous bone. Several studies have shown that intramedullary 

reaming produces a systemic anabolic skeletal response. In addition, 

bleeding is associated with a central stimulation of bone marrow 

that could also upregulate skeletal metabolism. The act of harvesting 

autogenous bone may itself produce a host response that could 

enhance healing. 

III. Questions and Answers: 

A. Is autogenous bone truly osteoinductive? 

Autogenous bone contains the full complement of bone matrix 

proteins including those present in the transforming growth 

factor beta superfamily and the BMP subfamily. As such, it is 

reasonable to assume that some quantities and concentrations 

of osteoinductive factors exist in autogenous bone. However, 

the contribution that those factors make to healing and 

regeneration when autogenous bone is used clinically has never 

been clearly defined. If one defines osteoinduction as the ability 

REFERENCES 

1. Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site 

morbidity. A statistical evaluation. Spine 1995 May 1;20(9):1055-60. 

2. Bolander ME. Regulation of fracture repair by growth factors. Proc Soc Exp 

Biol Med 1992 June;200(2):165-70. 

3. Fowler BL, Dall BE, Rowe DE. Complications associated with harvesting 

autogenous iliac bone graft. Am J Orthop 1995 December;24(12):895-903. 

4. Goulet JA, Senunas LE, DeSilva GL, Greenfield ML. Autogenous iliac crest 

bone graft. Complications and functional assessment. Clin Orthop Relat Res 

1997 June;(339):76-81. 

5. Lewandrowski KU, Gresser JD, Wise DL, Trantol DJ. Bioresorbable bone 

graft substitutes of different osteoconductivities: a histologic evaluation of 

osteointegration of poly(propylene glycol-co-fumaric acid)-based cement 

implants in rats. Biomaterials 2000 April;21(8):757-64. 

6. Stevenson S. Biology of bone grafts. Orthop Clin North Am 1999 

October;30(4):543-52. 

7. Tessier P, Kawamoto H, Matthews D et al. Autogenous bone grafts and 

bone substitutes--tools and techniques: I. A 20,000-case experience 

in maxillofacial and craniofacial surgery. Plast Reconstr Surg 2005 

October;116(5 Suppl):6S-24S. 

8. Tessier P, Kawamoto H, Posnick J, Raulo Y, Tulasne JF, Wolfe SA. 

Complications of harvesting autogenous bone grafts: a group experience of 

20,000 cases. Plast Reconstr Surg 2005 October;116(5 Suppl):72S-3S. 

9. Springfield DS. Massive autogenous bone grafts. Orthop Clin North Am 

1987 April;18(2):249-56. 

10. Urist MR. Osteoinduction in undemineralized bone implants modified by 

chemical inhibitors of endogenous matrix enzymes. A preliminary report. 

Clin Orthop Relat Res 1972 September;87:132-7. 

11. Finkemeier CG. Current Concepts Review: Bone-Grafting and Bone-Graft 

Substitutes. J Bone Joint Surg 2002 March(84A):454-464. 

12. Gray JC, Elves MW. Early osteogenesis in compact bone isografts: a 

quantitative study of contributions of the different graft cells. Calcif Tissue 

Int. 1979;29:225-37. 

13. Heslop BF, Zeiss IM, Nisbert NW. Studies on the transference of bone. I. A 

comparison of autologous and homologous bone implants with refence 

to osteocyte survival, osteogenesis and host reaction. BR J Exp Pathol. 

1960;41:269-87. 

14. Burwell RG. Studies in the transplantation of bone. BII. The fresh composite 

homograft autograft of cancellous bone. An analysis of factors leading to 

osteogenesis in marrow transplants and in marrow-containing bone grafts. J 

Bone Joint Surg Br. 1964;46:110-40. 

217 




to form bone when an osteoinductive material is implanted 

in a non-skeletal site (for example, a muscle pouch), then in 

order for autogenous bone to be considered osteoinductive, 

it would have to form bone in this manner. To this speaker’s 

knowledge, such an observation has never been clearly made. 

It is more likely that autogenous bone provides a low level of 

osteoinduction which is insufficient to regenerate bone by itself, 

but which functions synergistically with the osteogenic and 

osteoconductive properties of the grafts. 

B. What percentage of cells remain viable when autologous bone is 

transplanted from one skeletal site to another? 

Various reports have suggested that between 3% and 30% 

of osteocytes and osteoblasts in autogenous bone survive 

autogenous transplantation. This speaker has not been able to 

locate the evidence to support these claims. At this time, the 

viability of cells transplanted, and the percentage of cells that 

survive the transplant are not clearly known. 

C. Is autogenous bone truly the “gold standard”? 

Determination of a reference material is not made by scientific 

development but rather by investigator or user choice. 

Therefore, if orthopaedic surgeons wish to consider autogenous 

bone the “gold standard” against which other graft materials 

are compared, then all they need do is agree to do that. At this 

time, most clinicians, as well as federal regulatory agencies 

accept autogenous bone as the comparator for other materials 

developed as bone graft substitutes. 

15. Dell PC, Burchardt H, Glowczewskie FP Jr. A roentgenographic, 

biomechanical, and histological evaluation of vascularized and nonvascularized 

segmental fibular canine autografts. J Bone Joint Surg Am. 

1985;67-105-12. 

16. Doi K, Tominaga S. Sjobata T. Bone grafts with microvascular anastomosis 

of vascular pedicles: an experimental study in dogs. J Bone Joint Surg Am. 

1977;59:806-15. 

17. Enneking Wf, Burchardt H, Puhl JJ, Piotrowski G. Physical and biological 

aspects of repair in dog cortical-bone transplants. J Bone Joint Surg Am. 

1975;57:237-52. 

18. Ray RD. Vascularization of bone grafts and implants. Clin Orthop. 

19723;87:43-8. 

19. Enneking WF, Mindell ER. Observations on massive retrived human 

allografts. J Bone Joint Surg Am. 1992;73:1123-42. 

20. Stevenson S. Ehnacement of fracture healing with autogenous and allogeneic 

bone grafts. Clin Orthop. 1998;344 Suppl:S239-46. 

21. Schmidmaier G, Herrmann S, Green J, Weber T, Scharfenberger A, Haas NP, 

Wildemann B. Quantitative assessment of growth factors in reaming aspirate, 

iliac crest, and platelet preparation. Bone 2006;39:1156-1163. 

22. Stewart RL, Stannard JP, Volgas DA, Chaudry IH, Duke JN, Alonso JE. Bone 

graft and waste irrigation obtained using the Reamer-Irrigator_Aspirator 

(RIA) induce bone growth in the rat muscle pouch. Trans. Orthop. Trauma 

Assn. 24:121, 2008 

23. Bab I, Gazit D, Muhlrad A, Shteyer A: Regenerating bone marrow produces 

a potent growth-factor activity to osteogenic cells. Endocrinology 123:345- 

352, 1988. 

24. Einhorn TA, Simon G, Devlin VJ, et al: The osteogenic response to distant 

skeletal injury. J Bone Joint Surg 72A:1374-1378-, 1990. 

25. Gazit D, Karmish M, Holzman L, Bab I:Regenerating marrow induces 

systemic increase in osteo-and chondrogenesis. Endocrinology 126:2607- 

2613, 1990. 

26. Ilizarov GA, Chepelenko TA, Izotova SP, Kechetkov YuS: Effect of acute blood 

loss on stromal regulation of hemopoietic stem cells and reparative bone 

regeneration. Patol Fiziol Eksp Ter 5:54-58, 1986. 

27. Lucas TS, Bab IA, Lian JB, Stein GS, Jazrawi L, Majeska RJ, Attar-Namdar 

M, Einhorn TA:Stimulation of systemic bone formation induced by 

experimental blood loss. Clin Orthop., 340:267-275, 1997.

The material presented at this course has been made available by the AAOS for 

educational purposes only. The AAOS disclaims any and all liability for injury, 

loss or other damages resulting to any individual attending the course and for all 

claims which may arise from the use of techniques and strategies demonstrated 

therein. The material is not intended to represent the only methods, procedures 

or strategies for the situations discussed. Rather, the course is intended to present 

an array of approaches, views, statements, and opinions which the faculty 

believe will be helpful to course participants. Some drugs or medical devices 

demonstrated in Academy educational programs or materials have not been 

cleared by the FDA or have been cleared by the FDA for specific uses only. The 

FDA has stated that it is the responsibility of the physician to determine the FDA 

clearance status of each drug or device he or she wishes to use in clinical practice. 

Introduction 

1. Bone Defect Classification 

2. Definitions: Scaffold, Osteoconductive, Osteoinductive, 

Osteogenic 

3. Natural Scaffolds: Autograft Bone, Allograft Bone, Collagen 

4. Synthetic Scaffolds: Polymers, Metals, Ceramics 

Bone Defect Classification 

1. Contained 

2. Non-Contained 

3. Segmental 

Definitions 

1. Scaffold 

a. Maintains space 

b. Porosity 

c. Interconnectivity 

2. Osteoconductive 

a. Cells attach, migrate, grow, divide 

3. Osteoinductive 

218 

oSteoCoNduCtive SCaFFoldS 

Michael J Yaszemski MD PhD 




a. Growth factors 

b. Demineralized bone matrix 

c. Autogenous bone marrow: Cells and growth factors 

4. Osteogenic 

a. Cells capable of synthesizing osteoid 

Natural Scaffolds 

1. Autograft Bone 

2. Allograft Bone 

3. Collagen 

Synthetic Scaffolds 

1. Polymers 

a. Polyesters (e.g. PLGA, PLLA) 

b. Polycarbonates 

c. Polyanhydrides 

d. Injectable, Moldable, Preformed 

e. Shape specific 

2. Metals 

a. Porous Tantalum 

b. Porous Titanium 

3. Ceramics 

a. Hydroxyapatite 

b. Tricalcium phosphate 

c. Calcium sulfate 

Clinical Applications 

1. Spine 

2. Tumor 

3. Trauma 

4. Adult and Pediatric Reconstruction

219 

oSteoiNduCtive/oSteopromotive growth FaCtorS 

Scott D. Boden, MD 

1) Introduction 

a) ICBG is the “gold standard” for difficult healing situations 

i) Osteoconduction- scaffold 

ii) Osteogenesis- live cells 

iii) Morbidity may be up to 20% of patients 

b) Osteoinductive bone graft alternatives are experiencing 

increasing popularity 

i) Osteoinductive means it is capable of inducing bone de 

novo in ectopic location 

ii) Bone graft extenders or enhancers 

iii) Bone graft substitutes 

iv) Osteopromotive category – helpful when bone is already 

forming, but not capable of ectopic bone formation from 

scratch 

2) Peptide Signaling Molecules 

These peptide growth factors stimulate the activity of 

osteoprogenitor cells and osteoblasts and may enhance 

osteogenesis. They cannot induce bone formation from 

undifferentiated cells. 

a) Fibroblast Growth Factor (FGF) 

i) Expressed during fracture repair 

ii) FGF-2 can accelerate fracture repair in NH primates 

(baboons) 

iii) Phase III clinical trials for tibial fractures underway 

b) Vascular Endothelial Growth Factor (VEGF) 

i) Ability to induce angiogenesis 

ii) Necessary for bone healing, but not sufficient to be 

osteoinductive 

iii) Can enhance bone healing and can enhance suboptimal 

doses of BMP 

c) Platelet Derived Growth Factor (PDGF) 

i) Several different isoforms 

ii) Not osteoinductive 

iii) Helpful for diabetic wound healing 

iv) Possibly helpful for diabetic fracture repair 

v) Inhibitory for spine fusion when combined with 

autograft or DBM 

vi) Can inhibit BMP activity in cell cultures 

vii) May require optimal concentration and pulsed rather 

than constant release 

d) Prostaglandin Agonists 

i) PGE2 increases bone mass administered systemically or 

locally 

ii) An agonist to prostaglandin receptor EP2 enhanced 

healing of canine long bone segmental defects 

3) Bone Morphogenetic Proteins 

i) Timeline 

(1)1965 – Urist – Autoinduction principle (DBM) 

(2)1988 -Rosen, Wozney et al cloned BMP cDNAs 

(3)2001 - rhBMP-7 (OP-1) approved for spine fusion in 

Australia, then Europe, later for long bone nonunions 

(4)2002 - rhBMP-2/ACS (InFuse) PMA approved by FDA 

for Interbody Spine Fusion 

(5)2003 -rhBMP-7 (OP-1) HDE approved by FDA for long 

bone nonunion and eventually posterolateral spine 

fusion nonunion 

(6)2005 -rhBMP-2 (InFuse) PMA approved by FDA for open 

tibia fractures 




(7)2007 -rhBMP-2 (InFuse) PMA approved by FDA for 

dental applications 

ii) Mechanism of Action 

(1)BMPs are chemotactic for MSCs 

(2)BMP homo/hetero dimers bind to cell surface receptors 

(serine threonine kinase) resulting in phosphorylation 

of Smad 1/5 which binds to Smad4 and translocates into 

the nucleus where it can bind to specific DNA sequences 

in promoters of osteoblastic genes. 

(3)Inhibitory Smads can block this process 

(4)Smurf1 can result in ubiquitin-mediated proteosomal 

degradation of Smads 

(5) Much crosstalk with other pathways that may affect 

cellular responsiveness to BMPs – poorly understood. 

(6)Osteoinductive BMPs can induce bone and bone marrow 

formation de novo in an ectopic location. 

iii) Are all BMPs created equal? NO 

(1)Most osteogenic BMPs are BMP-2, BMP-6, BMP-9 

(2)Somewhat less osteogenic BMPs are BMP-4, BMP-7 

(3) Data based on in vitro effects on pluripotent cells, 

immature OB, mature OB as well as in vivo ectopic bone 

formation with each BMP delivered by AdV vector in 

thigh muscle of athymic rat 

(4)Different BMPs can have different distant organ effects 

(a) rhBMP-7 has positive effects on kidney (was 

considered as a potential treatment for acute renal 

failure) 

(b)rhBMP-6 has been examined for osteoporotic bone 

enhancement 

4) Summary of Outstanding Issues with BMPs 

a) Are there differences between BMPs? 

b) Will difficult patients (revisions, diabetes, smokers, steroids) 

require higher doses of BMPs? 

c) Are there safety issues (antibodies)? – probably not clinically 

relevant 

d) Beware of Off-Label (Physician-Directed) use – increased 

possibility of local side effects 

e) Local Side Effects with rBMPs? 

i) Ectopic Bone (PLIF, TLIF) 

ii) Seroma, Edema (ACDF, PLIF, TLIF, PLF) 

iii) Transient Local Resorption (ALIF, PLIF, TLIF) near 

cancellous bone 

iv) Transient Radiculopathy (TLIF, ? PLIF) 

v) Can be minimized by avoiding hyperconcentration of 

BMP solution on carrier, switching carriers with unknown 

release kinetics, avoiding overstuffing BMP/carrier into 

fixed defect/device volumes 

f) Carrier plays an important role in success and dose of BMP 

needed 

g) Segmental Defect is tougher than routine fracture. 

Posterolateral spine fusion is tougher than interbody fusion 

– must validate BMP dose and carrier in specific healing 

environment 

h) Rhesus monkey is most predictive pre-clinical model of 

clinical behavior of BMP+ carrier 

i) Less than 100% successful bone induction suggests: 

i) Inferior BMP 

ii) Inadequate dose 

iii) Inadequate carrier

REFERENCES: 

1. Wozney JM et al. “Novel regulators of bone formation: Molecular clones and 

activities” Science (242): 1528 – 1534, 1988 

2. Sandhu HS et al. “Histological evaluation of the efficacy of rhBMP-2 

compared with autograft bone in sheep spinal anterior interbody fusion” 

Spine, 27 (6): 567 – 575, 2002 

3. Boden SD et al. “Laparoscopic anterior spinal arthrodesis with rhBMP-2 in a 

titanium interbody threaded cage” J Spinal Disorders, 11 (2): 95 – 101, 1998 

4. Boden SD et al. “The use of rhBMP-2 in interbody fusion cages. Definitive 

evidence of osteoinduction in humans: A preliminary report” Spine, 25 (3): 

376 – 381, 2000 

5. Burkus JK et al. “Anterior interbody fusion using rhBMP-2 with tapered 

interbody cages” J Spinal Disorders, 15 (5): 337 – 349, 2002 

6. Cunningham BW et al. “Interbody spinal arthrodesis using a mineralized 

collagen matrix and threaded fusion cage. A non-human primate study” 46th 

Annual Meeting of ORS, pp357, 2000 

7. Welch WC et al. “A prospective randomized study of interbody fusion: Bone 

substitute or autograft” http://www.orquest.com/pdfs/welch.pdf, 2002 

8. Akamaru T et al. “Simple carrier matrix modifications can enhance delivery 

of recombinant human bone morphogenetic protein-2 for posterolateral 

spine fusion” Spine 28(5):429-434, 2003 

9. Cool SD “Preclinical and clinical evaluation of osteogenic protein-1 (BMP-7) 

in bony sites” Orthopedics 22(7): 669 – 671, 1999 

10. Cunningham BW et al. “Posterolateral spinal arthrodesis using osteogenic 

protein-1: An in vivo time-course study using a canine model” 15th Annual 

Meeting NASS, p139 – 140, 2000. 

11. Cheung KMC et al. “Augmentation of intertransverse spinal fusion in 

promates using OP-1” ISSLS Annual Meeting, Paper 7, 1999 

12. Hilibrand AS et al. “One year follow-up on patients in a pilot safety and 

efficacy study of OP-1 (rhBMP-7) in posterolateral lumbar fusion as a 

replacement for iliac crest autograft” 70th Annual Meeting AAOS, Paper 161, 

2003 

13. Grosse A et al. “Mineralized collagen as a replacement for autogenous bone 

in posterolateral lumbar spinal fusion” Eur Spine J , 8 (Suppl 1): S27 – S28, 

1999 

14. Urist MR et al. “The bone induction principle” Clin Orthop (53): 243 – 283 

(1967) 

15. Sassard WR et al. “Augmenting local bone with Grafton Demineralized 

bone matrix for poaterolateral lumbar spine fusion: avoiding second site 

autologous bone harvest” Orthopedics, 23(10): 1059 – 1064, 2000 

16. Suh, D.Y. et al. “Delivery of recombinant human bone morphogenetic 

protein-2 (rhBMP-2) using a compression resistant matrix in posterolateral 

spine fusion in the rabbit and non-human primate” Spine, (27): 353-360, 

2002. 

17. Boden, S.D. et al. “Posterolateral lumbar transverse process spine arthrodesis 

with recombinant human bone morphogenetic protein-2/hydroxyapatitetricalcium 

phosphate after laminectomy in the nonhuman primate” Spine, 

(24): 1179-1185, 1999. 

18. Boden, SD et al. “Use of recombinant human bone morphogenetic protein-2 

to achieve posterolateral lumbar spine fusion in humans: A prospective, 

randomized, clinical pilot trial. 2002 Volvo Award in Clinical Studies.” Spine, 

(27) 2862-2863, 2002. 

19. Tay, BK et al. “Use of a collagen hydroxyapatite matrix in spinal fusion. A 

rabbit model. Spine, (23): 2276-2281, 1998. 

20. Martin, GM et al. “New formulations of demineralized bone matrix as a 

more effective graft alternative in experimental posterolateral lumbar spine 

arthrodesis”, Spine, (24): 637-645, 1999. 

220 




21. Louis-Ugbo, J et al. “Evidence of osteoinduction of Grafton Matrix in 

nonhuman primate spine fusion model.” Spine, (29): 360-366, 2003. 

22. Kraiwattanapong C et al. “Comparison of HEALOS/Bone Marrow to INFUSE 

with a collagen-ceramic sponge bulking agent as graft substitutes for lumbar 

spine fusion.” Spine, (30), In Press, 2005 

23. Walsh, WR et al. “Spinal fusion using an autologous growth factor gel and a 

porous resorbable ceramic.” Eur Spine J. 2004 Jul;13(4):359-66. 

24. Hartman, EH et al. ”Ectopic bone formation in rats: the importance of the 

carrier.” Biomaterials. 2005 May;26(14):1829-35. 

25. Weiner and Walker. “Efficacy of autologous growth factors in lumbar 

intertransverse fusions.” Spine. 2003 Sep 1;28(17):1968-70. 

26. Carreon, LY et al. “Platelet gel (AGF) fails to increase fusion rates in 

instrumented posterolateral fusions.” Spine. 2005 May 1;30(9):E243-6. 

27. Haid, RW Jr et al. ” Posterior lumbar interbody fusion using recombinant 

human bone morphogenetic protein type 2 with cylindrical interbody 

cages.” Spine J. 2004 Sep-Oct;4(5):527-38 

28. Baramki, HG. “The efficacy of interconnected porous hydroxyapatite 

in achieving posterolateral lumbar fusion in sheep. “Spine. 2000 May 

1;25(9):1053-60. 

29. Meadows GR et al. “Adjunctive use of ultraporous beta-tricalcium phosphate 

bone void filler in spinal arthrodesis.” Orthopedics. 2002 May;25(5 

Suppl):s579-84. 

30. Muschik, M et al. “Beta-tricalcium phosphate as a bone substitute for dorsal 

spinal fusion in adolescent idiopathic scoliosis: preliminary results of a 

prospective clinical study.” Eur Spine J. 2001 Oct;10 Suppl 2:S178-84. 

31. Villavicencio AT, et al. “Safety of transforaminal lumbar interbody fusion 

and intervertebral recombinant human bone morphogenetic protein-2.” J 

Neurosurg Spine. 2005 Dec;3(6):436-43. 

32. Lanman TH, et al. “Lumbar interbody fusion after treatment with 

recombinant human bone morphogenetic protein-2 added to poly(Llactide-co-D,L-lactide) 

bioresorbable implants.” Neurosurg Focus. 2004 Mar 

15;16(3):E9. 

33. Burkus JK, et al. “Use of rhBMP-2 in combination with structural cortical 

allografts: clinical and radiographic outcomes in anterior lumbar spinal 

surgery.” J Bone Joint Surg Am. 2005 Jun;87(6):1205-12. 

34. Smucker JD et al. “Increased swelling complications associated with off-label 

usage of rhBMP-2 in the anterior cervical spine.” Spine 2006: 31:2813-2819. 

35. Dimar JR et al. “Clinical outcomes and fusion success at 2 years of singlelevel 

instrumented posterolateral fusions with recombinant human bone 

morphogenetic protein-2/compression resistant matrix versus iliac crest bone 

graft. Spine 2006: 31:2534-2539. 

36. McClellan JW et al. “Vertebral bone resorption after transforaminal lumbar 

interbody fusion with bone morphogenetic protein (rhBMP-2)”. J Spinal 

Disord Tech 2006: 19:483-486. 

37. Magit DP et al. “Healos/recombinant human growth and differentiation 

factor-5 induces posterolateral lumbar fusion in a New Zealand white 

rabbite model. Spine 2006 31:2180-2188. 

38. Singh K et al. “Use of recombinant human bone morphogenetic protein-2 

as an adjunct in posterolateral lumbar spine fusion: A prospective CT-scan 

analysis at one and two years”. J Spinal Disord Tech 2006: 19:416-423. 

39. Kanayama M et al. “A prospective randomized study of posterolateral 

lumbar fusion using osteogenic protein-1 (OP-1) versus local autograft with 

ceramic bone substitute: Emphasis of surgical exploration and histologic 

assessment.” Spine 2006: 31:1067-1074. 

40. Shields LB et al. “Adverse effects associated with high-dose recombinant 

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Spine 2006: 31:542-547.

221 

traNSplaNtatioN oF autogeNouS oSteogeNiC CellS 

George F. Muschler, MD, Tonya Caralla, Tom Patterson, PhD 

1) Only osteogenic connective tissue progenitors and stem cells 

make bone (i.e. osteogenic CTPs aka, CTP-Os) [1] 

2) CTP-Os cells can be found in the following locations 

a. Bone Marrow, periosteum, endosteum, perivascular marrow 

i. The concentration is low, but adequate for healing in 

most injury settings. 

ii. Heterogeneous mixture of committed and inducible 

osteogenic cells, mixed with other non-osteogenic CTPs 

b. Fat, Muscle, Synovium 

i. Concentration is higher 

ii. Prevalence of osteogenic differentiation is lower 

3) In some settings the available progenitor population is 

deficient 

a. Local disease 

b. Prior infection and scarring 

c. Prior radiation 

d. Avascular or hypovascular tissue 

e. Surgical debridement 

f. Segmental defects 

4) Local CTP-O deficiency may be a limiting factor in the 

performance of all sites and all current graft materials 

a. Osteoconductive Materials 

b. Osteoinductive materials (e.g. BMP-2, OP-1 (aka BMP-7) 

5) Some current graft materials are not biologically suitable as a 

cell delivery vehicle[2, 3] 

a. Hyperosmolar materials – glycerol, CaSO4 

b. Acidic materials – CaSO4 

c. Hyperthermic materials – setting cements 

6) Bone Marrow Aspiration (BMA) has been the preferred 

method for minimally invasive harvest of osteogenic cells. 

a. Pros 

i. Minimal morbidity (local bruising in 0.002%) 

ii. Less time consuming than autograft harvest (5-10 min vs 

30min) 

iii. Less costly than autograft (OR time, complications, 

length of stay) 

iv. Clots by itself 

v. Autogenous Marrow used fresh or with minimal 

manipulation is regulated as an autogenous tissue. 

vi. RBCs from contaminating peripheral blood bring 

with them hemoglobin which may serve as an oxygen 

reserve or oxygen tension buffer early in wound repair, 

particularly after exposure to room air. 

vii. Much more available for rapid intraoperative processing 

than fat or muscle sources 

1. no enzymatic digestion required 

b. Cons 

i. Not all surgeons are comfortable with aspiration 

ii. Osteogenic CTPs are diluted by about 4-fold from native 

concentration by peripheral blood 

iii. Overall yield of CTPs may still be suboptimal (2000 CTP- 

Os/cc in avg. healthy adult) 

iv. Contains materials that may inhibit bone formation or 

compete with CTP-Os 

1. RBCs 

a. Degrade to create debris in the wound site that 

needs to be removed by macrophages, which 

i. delays bone formation and remodeling 




ii. results in inflammation and increased local 

metabolic demand contributing to local hypoxia 

2. WBCs 

a. Respiration of vast numbers of transplanted non- 

CTPs adds to local hypoxia. 

b. Contain cells likely to be inhibitory as well as cells 

likely to be stimulatory for bone repair 

3. Platelets and platelet degranulation products 

a. May enhance bone repair or may enhance scar 

formation, depending on the setting. 

4. Serum Proteins and cytokines – from marrow or 

released following aspiration 

a. May be stimulatory or inhibitory 

7) Marrow processing can be used to increase [CTP-O] back to 

native tissue levels and to remove unwanted cells 

a. Centrifuge 

i. Pros 

1. Increases CTP-O concentration by 2-4 fold 

(intrinsically limited by physical ability to separate 

buffy coat from RBC mass without a larger density 

gradient) 

2. Removes bulk of RBCs 

3. Devices regulated as 510K under “minimal 

manipulation” guidelines. 

ii. Cons 

1. Time consuming (~5-15 staff opening and set up time 

and 10-30 min intra-operative processing time) 

2. Expensive – $400-800 above cost of graft matrix 

3. Requires a minimum of 40ccs to 120ccs of marrow 

4. Cells leave the sterile field and sometimes the OR 

increasing chances for contamination. 

5. No large case series and no prospective randomized 

studies. 

b. Selective retention 

i. Pros 

1. Increased CTP-O concentration by 2-20 fold 

(depending on ratio of marrow to matrix volume and 

surface area used) 

2. Increases prevalence of CTP-Os (1.5 – 3 fold using 

current materials – porous allograft or CaPO4 

ceramics) 

a. Removes RBCs AND 60-90% of competing non- 

CTPs (WBCs that do not attach) 

i. Reduces local metabolic demand which should 

increase CTP-O survival 

3. Cells are processed in the OR on the sterile field, 

reducing risk of contamination. 

4. Attached cells are less likely to become dislodged 

from the scaffold after transplantation than 

centrifuged marrow secondarily added to a scaffold 

5. Devices regulated as 510K under “minimal 

manipulation” guidelines. 

6. 20,000+ cases performed in US 

ii. Con 

1. Time consuming (~5-10 min opening and set up time 

and 10 min intra-operative processing time) 

2. Expensive - $400-800 above cost of graft matrix (need 

to confirm) 

3. No large case series and no prospective randomized 

studies.

222 

4. Case reports contain mixture of SR with other methods 

5. Muschler experience (72 non-unions with 6 

reoperations >90% success) not publishable due to 

COI limitations. 

c. Magnetic Separation 

i. Pros 

1. May increase concentration by 2- 200 fold 

2. May increase CTP-O prevalence by 2-200 fold 

a. Further reducing local competition and metabolic 

demand for oxygen and other substrates. 

3. Clinical magnetic separation technologies are well 

established in hematology setting. 

ii. Cons 

1. Time consuming (30 – 240 min of intra-operative 

processing time) 

2. Expensive – $800+ above cost of graft matrix 

(projected) 

3. Minimum number of ccs uncertain, since no clinical 

products yet 

4. Cells leave the sterile field and sometimes the OR 

increasing chances for contamination. 

5. No large or small animal series to date 

6. No clinical experience 

7. Devices regulatory status uncertain 

8) Conclusion 

a. Justification for clinical use of bone marrow or marrow 

processing 

REFERENCES: 

1. Muschler, G.F., R.J. Midura, and C. Nakamoto, Practical Modeling Concepts 

for Connective Tissue Stem Cell and Progenitor Compartment Kinetics. J 

Biomed Biotechnol, 2003. 2003(3): p. 170-193. 

2. Muschler, G.F. and J.M. Lane, Spine fusion: principles of bone fusion., in The 

Spine, H.N. Herkowitz, et al., Editors. 1999, WB Saunders: Philadelphia. p. 

15731589. 

3. Muschler, G.F., C. Nakamoto, and L.G. Griffith, Engineering Principles of 

Clinical Cell-Based Tissue Engineering. J Bone Joint Surg Am, 2004. 86-A(7): 

p. 1541-58. 

4. Ma, H.L., T.H. Chen, and S.C. Hung, Development of a new method in 

promoting fracture healing: multiple cryopreserved bone marrow injections 

using a rabbit model. Arch Orthop Trauma Surg, 2004. 124(7): p. 448-54. 

5. Djapic, T., et al., Compressed homologous cancellous bone and bone 

morphogenetic protein (BMP)-7 or bone marrow accelerate healing of longbone 

critical defects. Int Orthop, 2003. 27(6): p. 326-30. 

6. Muschler, G.F., et al., Spine Fusion Using Cell Matrix Composites Enriched in 

Bone Marrow-Derived Cells. Clin Orthop Rel Res, 2003. 407: p. 102-118. 

7. Cui, Q., et al., Comparison of lumbar spine fusion using mixed and cloned 

marrow cells. Spine, 2001. 26(21): p. 2305-10. 

8. Curylo, L.J., et al., Augmentation of spinal arthrodesis with autologous bone 

marrow in a rabbit posterolateral spine fusion model. Spine, 1999. 24(5): p. 

434-8; discussion 438-9. 

9. Muschler, G.F., et al., Selective Retention of Bone Marrow-Derived Cells to 

Enhance Spinal Fusion. Clin Orthop, 2005(432): p. 242-251. 

10. Brodke, D., et al., Bone grafts prepared with selective cell retention 

technology heal canine segmental defects as effectively as autograft. J Orthop 

Res, 2006. 24(5): p. 857-66. 

11. Klimczak, A., et al., Donor-origin cell engraftment after intraosseous or 

intravenous bone marrow transplantation in a rat model. Bone Marrow 

Transplant, 2007. 40(4): p. 373-80. 

12. Hernigou, P. and F. Beaujean, Treatment of osteonecrosis with autologous 

bone marrow grafting. Clin Orthop, 2002. 405: p. 14-23. 

13. Hernigou, P., et al., Percutaneous autologous bone-marrow grafting for 

nonunions. Surgical technique. J Bone Joint Surg Am, 2006. 88 Suppl 1 Pt 2: 

p. 322-7. 

14. Hernigou, P., et al., Percutaneous autologous bone-marrow grafting for 

nonunions. Influence of the number and concentration of progenitor cells. J 

Bone Joint Surg Am, 2005. 87(7): p. 1430-7. 




i. Biological rationale clear, particularly in graft site or 

setting in which local CTP-O deficiency is likely. 

1. Innumerable preclinical animal studies showing 

that addition of marrow-derived cells improves graft 

performance, even in the absence of local tissue 

disease or suspected deficiency[4-11]. 

2. Several preclinical studies showing that bone marrow 

processing (centrifuge or selective retention) adds 

significantly to the rate and extent of bone repair in 

bone spine fusion and bone defect settings[6, 9, 12-17]. 

ii. Low risk 

iii. Low burden 

iv. High potential impact for selected patients with 

challenging clinical settings. 

v. Far less cost than use of alternative adjuvant to implanted 

scaffold (e.g. BMPs) (10 fold lower cost per cc of graft) 

vi. Clinical Findings 

1. No randomized trials 

2. Several non-randomized reports suggesting clinical 

efficacy[12, 14, 15, 18-28] 

3. No evidence that BM-derived cells every compromise 

bone repair (as reported for platelet gels in some 

settings) 

b. Justification for not using marrow or marrow processing 

i. Adds cost 

ii. No prospective clinical trials to demonstrate clinical 

efficacy or cost effectiveness over scaffold alone. 

15. Hernigou, P., et al., The use of percutaneous autologous bone marrow 

transplantation in nonunion and avascular necrosis of bone. J Bone Joint 

Surg Br, 2005. 87(7): p. 896-902. 

16. Muschler, G.F. Clinical Experience with Intra-operative Stem Cell 

Concentration and Selection. in Emerging Technologies Sumposium. 2002. 

Washington, DC. 

17. Takigami, H., et al., Bone formation following OP-1 implantation is 

improved by addition of autogenous bone marrow cells in a canine femur 

defect model. J Orthop Res, 2007. 25(10): p. 1333-42. 

18. Ateschrang, A., et al., Fibula and tibia fusion with cancellous allograft 

vitalised with autologous bone marrow: first results for infected tibial nonunion. 

Arch Orthop Trauma Surg, 2009. 129(1): p. 97-104. 

19. Lindsey, R.W., et al., Grafting long bone fractures with demineralized bone 

matrix putty enriched with bone marrow: pilot findings. Orthopedics, 2006. 

29(10): p. 939-41. 

20. Tetreault, P. and H.A. Ouellette, Healing of a clavicle fracture nonunion with 

bone marrow injection. J Shoulder Elbow Surg, 2007. 16(1): p. e23-4. 

21. Faundez, A.A., S. Taylor, and A.J. Kaelin, Instrumented fusion of 

thoracolumbar fracture with type I mineralized collagen matrix combined 

with autogenous bone marrow as a bone graft substitute: a four-case report. 

Eur Spine J, 2006. 15 Suppl 5: p. 630-5. 

22. Goel, A., et al., Percutaneous bone marrow grafting for the treatment of tibial 

nonunion. Injury, 2005. 36(1): p. 203-6. 

23. Wilkins, R.M., B.T. Chimenti, and R.M. Rifkin, Percutaneous treatment of 

long bone nonunions: the use of autologous bone marrow and allograft 

bone matrix. Orthopedics, 2003. 26(5 Suppl): p. s549-54. 

24. Connolly, J.F., et al., Autologous marrow injection as a substitute for 

operative grafting of tibial nonunions. Clin Orthop, 1991. 266: p. 259-70. 

25. Garg, N.K., S. Gaur, and S. Sharma, Percutaneous autogenous bone marrow 

grafting in 20 cases of ununited fracture. Acta Orthop Scand, 1993. 64(6): p. 

671-2. 

26. Healey, J.H., et al., Percutaneous bone marrow grafting of delayed union and 

nonunion in cancer patients. Clin Orthop, 1990. 256: p. 280-5. 

27. Lindholm, T.S. and M.R. Urist, A quantitative analysis of new bone 

formation by induction in compositive grafts of bone marrow and bone 

matrix. Clin Orthop, 1980(150): p. 288-300. 

28. Salama, R. and S.L. Weissman, The clinical use of combined xenografts of 

bone and autologous red marrow. A preliminary report. J Bone Joint Surg Br, 

1978. 60(1): p. 111-5.

223 

FraCtureS – aNy Stage From aCute FraCtureS to NoN-uNioNS 

(CaSe preSeNtatioNS) 

Theodore Miclau, MD and J. Tracy Watson, MD 

There are clearly no well defined indications for use of a specific type 

of bone graft substitute or use of inductive factor when dealing with 

complex fractures or nonunions. This is especially true when treating 

acute bone loss in the setting of associated severe soft tissue damage 

or infected nonuions. The use of all of these new resources should 

be based on contemporary fracture or nonunion management 

principles and guided by current levels of evidence for use of these 

materials. 

1) Common biological requirements for bone regeneration 

a) Cells: Adult progenitor cells from the marrow, periosteum, 

and other sources 

b) Blood supply: For the delivery of nutrients, oxygen, and 

systemic factors required for cell survival 

c) Molecules and their receptors: Provides for the induction 

of cells to proliferate and differentiate into osseous tissue 

(osteoinduction) 

d) Extracellular matrix: To provide a scaffold for cells 

(osteoconduction), and storage site for growth factors 

2) Extracellular matrix: 

a) Properties for function 

i) Space filler (biocompatibility) 

ii) Structural properties (mechanical) 

iii) Microstructural (biological for cell surface adhesion/ 

healing) 

b) ECM scaffolding characteristics 

i) Substrates for bone replacement 

ii) Resorption over time 

iii) Requires cells for cytokines or potency 

iv) Dependent upon defect types or loads 

v) Clinical studies frequently compare efficacy of 

osteobiologics to cancellous autograft as gold standard 

3) Consideration for specific anatomic locations: Metaphyseal 

defects 

a) For most metaphyseal defects, it has been shown 

experimentally that a simple cancellous void will 

reconstitute on its own and heal completely given a sound 

biologic environment without the addition of any further 

grafting material. The danger here is that the subchondral 

surface will collapse if this defect does not reconstitute fast 

enough to provide subchondral support with the initiation 

of weight bearing. 

i) Conductive substrates: Issues 

(1)Ca ceramics. CaSO4 / CaPO4 

(a) Incorporation characteristics, specifically rates of 

osteointegration 

(b)Ultimate compressive strength (mPa) 

(c) Delivery mechanism. Particulate vs. self-setting 

“cements” 

(d) Incorporation time vs. bone regenerated into 

defect 

(i) Cellular mediated vs. chemical degradation of 

materials 

(ii)Use of marrow concentrates to accelerate 

incorporation characteristics. “seeding the 

graft” 

(e) Multiple studies with good Level I and II evidence 




support use of both sulfate and phosphate 

materials for contained metaphysical defects. 

(i) Demonstrated superiority over autogeous graft 

materials. 

(2)Mechanical Factors Use of conductive substrate 

materials in metaphyseal defects augmented with 

use of locking plates for plateau, distal femoral, and 

pilon fractures. One should be aware of the relative 

compressive strengths of these materials. The strength 

should match that of native cancellous bone. Also, 

one should be aware of the rate of degradation. This is 

important when considering timing of weight bearing 

When the material begins to osteo- integrate, the 

compressive strength will also begin to decrease. Thus 

weight bearing at this time can result in late articular 

collapse. 

(a) Minimal evidence currently available for use of 

locking plates in these locations. 

(b)No evidence currently available for use of these Ca 

ceramics for the solitary treatment of diaphyseal 

defects, either for acute bone loss or in nonunion 

situations. 

4) Consideration for specific anatomic locations: Diaphyseal 

fractures and nonunions 

a) Use of adjuvant materials in this location depends on 

numerous factors 

i) Evaluation: Fracture site (the mid-shaft tibia fracture is 

usually a biologically “challenged” region) 

(1) The appropriate migration of cellular components 

to the site of bone graft or fracture is crucial in 

continuing the progression of the fracture healing 

cascade. Possible delivery of these cells to the region 

in question may be necessary. 

(2)Acute bone loss vs. non-union defect 

(3)Condition of soft tissues and “zone of injury” local 

environment 

(a) May require angiography / MRI to determine 

vascularity/viability of host defect. Most graft 

failures are as a result of inadequate or poor 

host nutrition to the local graft region as most 

fracture sites and nonunions are often at the site 

of thick scar and/or relative avascularity. There is 

no substitute for preparing the host recipient bed 

appropriately by resecting the avascular tissue 

and providing healthy tissue for revascularization 

phenomenon and thus success of the graft. 

(b) Flap/soft tissue coverage, including timing (i.e. 

reconstitution of inflammatory phase of fracture 

healing-neovascularization) 

(4)Size of defect 

(a) Minor defect (.< 1 cm bone loss/nonunion gap) 

(b)Critical size defects (circumferential bone loss / 

nonunion gap >1cm to 4 cm) 

(c) Massive defects (> 6 cm). 

(5) Infection status 

(6)Mechanical stability 

ii) Treatment: Acute defect/delayed union/subcritical defect

REFERENCES 

224 

(without total segmental loss) with internal fixation (i.e. 

plate/IM nail) 

(1)Graft options 

(a) Composite grafts 

(i) DBM + Autogenous cellular concentrates, +, - 

platelet gels (as carrier) 

1. Limited success with centrifuged aspirate 

alone (Connelly, Watson) 

2. Concentration of CFU’s in conjunction 

with carrier materials (Hernigou) (Jimenez, 

Astrom technique) 

iii) Treatment: Acute critical sized defect/nonunion 

(segmental loss

16. Muschler GF, Midura MJ. Connective Tissue Progenitors: Practical Concepts 

for Clinical Applications. Clin Orthop 2002; 395:66-80. 

17. Muschler, GF, Midura RJ, Nakamoto C. Practical modeling concepts for 

connective tissue stem cell and progenitor compartment kinetics. J Biomed 

Biotechnol. 2003:3(2003)1-20. 

18. Hernigou P et al; Percutaneous Autologous Bone-Marrow Grafting for 

Nonunions. J. Bone and Joint Surg., 87-A No. 7 July 2005 

19. Hernigou P et al; Treatment of Osteonecrosis with Autologous Bone Marrow 

Grafting. Clin Orthopaedics and Rel Res., 405: 14 – 23, 2002 

20. Muschler GF, Nakamoto C, Griffith LG. Engineering principles of clinical 

cell-based tissue engineering. J Bone Joint Surg Am. 2004 Jul; 86-A (7):1541- 

1558. 

21. Muschler, GF, Boehm, C, Easley K. Aspiration to obtain osteoblast progenitor 

cells from human bone marrow: the influence of aspiration volume. J Bone 

Joint Surg Am 1997Nov (11):1699-1709 

22. Connolly JF, Guse R, Tiedeman J, Dehne R. Autologous marrow injection as 

a substitute for operative grafting of tibial nonunions. Clin Orthop 1991; 

266:259-269. 

23. Connolly J, Guse R, Lippiello L, Dehne R. Development of an osteogenic 

bone-marrow preparation. J. Bone and Joint Surg. 1998; 5:684-690. 

24. Tiedeman JJ, Connolly JF, Strates BS, Lippiello L. Treatment of nonunion by 

percutaneous injection of bone marrow and demineralized bone matrix. An 

experimental study in dogs. Clin Orthop.1991 Jul ;( 268):294-302. 

25. Brude Slater M, et al. Involvement of Platelets in Stimulating Osteogenic 

Activity J Ortho Research 13:655-663, 1995. 

26. Marx RE, Carlson ER, Eichstaaedt RM, et. al, Platelet Rich Plasma; Growth 

Factor Enhancement for Bone Grafts. June 1998, J Ortho Research 85(6) 

13:655663, 1995. 

27. Cierny G, Zorn KL. Segmental tibial defects, comparing conventional and 

Ilizarov methodologies. Clin. Orthop. 301: 118-133, 1994. 

28. Green SA, Jackson JM, Wall DM, Marinow H, Ishkanian J. Management of 

segmental defects by the Ilizarov intercalary bone transport method. Clin 

Orthop: 280:136-142, 1992. 

29. Gold SM, Wasserman R. Preliminary results of tibial bone transports with 

pulsed low intensity ultrasound (Exogen). J Orthop Trauma. 19(1):10-6, 

2005. 

30. Lowenberg DW, Feibel RJ, Louie KW, Eshima I. Combined muscle flap and 

Ilizarov reconstruction for bone and soft tissue defects. Clin Orthop. 332:37- 

51, 1996. 

31. Mahaluxmivala J, Nadarajah R, Allen PW, Hill RA.: Ilizarov external fixator: 

acute shortening and lengthening versus bone transport in the management 

of tibial non-unions. Injury. 36(5):662-668, 2005. 

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32. Matsuyama J, Ohnishi I, Kageyama T, Oshida H, Suwabe T, Nakamura K. 

Osteogenesis and angiogenesis in regenerating bone during transverse 

distraction: quantitative evaluation using a canine model. Clin Orthop. 433: 

243-250, 2005. 

33. Mekhail AO, Abraham E, Gruber B, Gonzalez M. Bone transport in the 

management of posttraumatic bone defects in the lower extremity. J Trauma. 

56(2):368-378, 2004. 

34. Oedekoven G, Jansen D, Raschke M, Claudi BF: The monorail system--bone 

segment transport over unreamed interlocking nails. Chirurg. 67(11):1069- 

1079, 1996. 

35. Song HR, Kale A, Park HB, Koo KH, Chae DJ, Oh CW, Chung DW: 

Comparison of internal bone transport and vascularized fibula femoral bone 

defects. J Orthop Trauma. 17(3):203-211, 2003. 

36. Watson JT. Treatment of Tibial Fractures with Bone Loss. Techniques in 

Orthop. 11(2): 132-143, 1996. 

37. Watson JT, Anders, M, Moed BR: Management Strategies for Bone Loss in 

Tibial Shaft Fractures. Clin Orthop. 315:138-152, 1995. 

38. Rozbruch RS, Weitzman AM, Watson JT, Freudigman P, et.al. Simultaneous 

Treatment of Tibial Bone and Soft –tissue Defects with the Ilizarov Method. J 

Ortho Trauma 20(3):197-205, 2006. 

39. Watson JT, Distraction Osteogenesis. Journal of AAOS Oct; 14(10) 168-74. 

2006. 

40. Delong, W, Einhorn, T, Koval, K, Watson JT, et.al. Bone Grafts and Bone Graft 

Substitutes in Orthopaedic Trauma Surgery. A critical analysis. J Bone Joint 

Surg Am. 2007 Mar;89(3):649-58. Review. 

41. 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. 

42. Hernigou P et al; Percutaneous Autologous Bone-Marrow Grafting for 

Nonunions. J. Bone and Joint Surg., 87-A No. 7 July 2005 

43. Hernigou P et al; Treatment of Osteonecrosis with Autologous Bone Marrow 

Grafting. Clin Orthopaedics and Rel Res., 405: 14 – 23, 2002 

44. Ristiniemi J, Lakovaara M. etal. Staged Method Using Antibiotic Beads and 

Subsequent Autografting for Large Traumatic Tibial Bone Loss. Acta Ortho 

2007;78(4): 520-527. 

45. Viateau V, Guillemin G, et. al. Induction of a Barrier Membrane to Facilitate 

reconstruction of Massive Segmental Diaphyseal bone defects: An Ovine 

Model. Veterinary Surgery 35: 445-451. 2006. 

46. Viateau V, Guillemin G, et. al. Long –Bone Critical –Size Defects Treated 

with Tissue-Engineered Grafts: A Study on Sheep. Journal of Orthopaedic 

Research, June : 2007, 741-749. 

47. Patterson TE, Kumgai K, et al. Cellular Strategies for Enhancement of Fracture 

Repair. J Bone Joint Surg Am 90 (Suppl. 1): 111-9, 2008.

226 

biologiC SolutioNS poSterolateral (plF) aNd poSterior 

lumbar iNtervertebral FuSioN (pliF) 

Harvinder S. Sandhu, MD 

Biologic challenges, PLIF vs PLF 

1. Advantages of intervertebral vs posterolateral 

a. Broader decorticated fusion bed for PLIF 

b. Shorter gap to heal for PLIF 

c. Wolff’s law: compression for PLIF vs tension for PLF 

d. Better vascular environment for PLIF 

2. Disadvantages of PLIF 

a. Technically more challenging 

b. Neurologic risk 

Biologic challenges related to pseudarthrosis / revision surgery 

1. Posterolateral fusion 

a. Compromised fusion bed 

i. Vascular 

ii. Muscular (osteoprogenitor cells) 

iii. Skeletal (bony bed) 

b. Shortage of autograft 

i. Local products of decompression 

ii. Previously harvested iliac crest 

c. Mis-identified pseudarthrosis 

2. Intervertebral fusion 

a. Implant revision technically challenging 

i. Posterior perineural scar 

ii. Often requires anterior corpectomy / vertebrectomy 

iii. Sagittal correction 

b. Associated with failed posterior fixation 

Biologic strategies in general 

1. Osteoinductive 

a. factors 

2. Osteoconductive 

a. matrices 

3. Osteogenic 

a. Cells 

Biologic strategies in specific 

1. Intervertebral 

a. Better biologic and mechanical environment allows more 

options 

b. Role of load sharing osteoconductive scaffoldings 




i. Structural allografts + inductive factors 

ii. Structural cages + inductive factors 

iii. Resorbable composites + inductive factors 

c. Role of local bone graft 

d. Role of iliac crest graft and novel harvesting techniques 

e. Clinical data with commonly used solutions 

i. Calcium phosphate ceramics 

ii. 

iii. Demineralized bone matrices 

iv. BMPs 

1. Efficicacy in clinical trials 

2. Anecdotal experience and clinical examples 

3. Risks 

a. Seroma formation 

b. Osteolysis 

c. Radiculitis 

d. Exuberant bone formation 

2. Posterolateral 

a. Poorer biologic and mechanical environment, fewer options 

i. Most challenging spinal fusion 

b. Gold standard remains iliac crest harvested autograft 

i. Associated morbidity and failure rate 

c. Popularity of local bone graft 

i. Products of decompression 

ii. Failure as an isolated solution 

iii. Local bone enhancement with osteoinductive factors 

d. Role of DBMs 

i. Limited clinical data, variability in inductivity 

e. Role of BMPs 

i. Most common use of BMP-2 in humans in “off-label” 

application 

ii. Anecdotal experience, clinical data strong 

1. Examples of clinical outcome 

iii. Risks of supraphysiologic doses of BMP-2 

1. Host response, mast cell response 

2. Radiculitis 

3. Exuberant bone formation 

4. Fetal antibody issue 

iv. BMP-2 vs BMP-7 (OP-1)

orthobiologiCS oF aNterior lumbar iNterbody FuSioN; 

optioNS, role oF dbmS & bmpS, algotithm For deCiSioN makiNg 

Isador Lieberman MD MBA FRCSC 

A Simple “Bone Setters” Fusion Philosophy 

• What are we doing? Fusion 

• What do we need? Osteoinduction 

Osteoconduction 

OsteoGenesis 

Vascularized bed & 

Mechanical stability 

• What do we want to avoid? Pseudoarthrosis 

Bone Graft site morbidity 

A Simple “Bone Setters” Reconstruction Philosophy 

• What are we doing? Filling gaps 

• What do we want? Axial support & stability 

• What do we need? Biological pillars 

• What do we want to avoid? Pseudoarthrosis 

Bone Graft site morbidity 

Obscured radiographs 

Resorption/Subsidence 

Grafting Options & Summary of Clinical Results 

• Autograft 

• Allograft 

• Femoral Rings 

• Cancellous Chips 

• Demineralized Bone Matrix 

• Bone Morphogenetic Proteins 

• Bone Graft Substitutes 

• Platelet derived growth factors 

• Bone Marrow Aspirate 

• Other cages & spacers α(PEEK, Titanium, etc) 

Biological Bone Formation “Requirements” 

• Osteoconduction (MATRIX) a scaffold to support bone growth 

• Osteoinduction (PROTEINS) recruitment and differentiation of 

osteoprogenitor cells to local environment to form bone 

• Osteogenesis (CELLS) formation of bone by osteoblasts or 

osteoblast precursors 

Decision Making 

Guidelines for the performance of fusion procedures; interbody 

techniques. Resnick et al, J Neurosurg: Spine 2:692-699 

• Insufficient evidence to recommend a treatment standard, most 

evidence is poor quality and retrospective 

• No class I or II evidence in support of ALIF with a better clinical 

outcome 

• For a single level ALIF addition of PLF not recommended 

• Improvement in fusion rates is associated with increased risk 

Lumbar fusion versus nonsurgical treatment for chronic low back 

pain: a multicenter randomized controlled trial from the Swedish 

Lumbar Spine Study Group. 

Fritzell P, Hagg O, et al. Spine 2001; 26: 2521-2532. 

• 294 patients with CLBP with disease at L4-5, L5-S1or both 

• randomized into 4 groups 

• surgery (N=222) and non-surgery (n=72) 

• Non inst PLF, PLF with ped screws, ALIF with ped screws 

• 98% follow-up @ 2 years 

• statistically significant improvement favoring surgery: (VAS, 

Oswestry, Depression) 

• Class I, 63% successful clinical outcome with surgery 

227 




• Class III, ped screw and ALIF group had better fusion rate and 

higher complication rate 

Role of BMPs & DBMs 

• What works? 

• What does not work? 

• Importance of carriers 

DBM’s (Demineralized Bone Matrix) 

BMP’s (Bone Morphogenic Protein) 

• Osteoinductive/Osteogenic soluble, low molecular-weight 

noncollagenous glycoproteins that belong to an expanding TGFsuper 

family of growth and differentiation factors 

• Unlike DBM, pure BMP’s are nonimmunogenic and nonspecies 

ß specific 

Decision Making 

Guidelines for the performance of fusion procedures; bone graft 

extenders and substitutes. Resnick et al, J Neurosurg: Spine 2:733- 

736 

• 6 papers with class III or better evidence 

• Insufficient evidence to recommend a treatment standard, most 

evidence is poor quality and retrospective 

• rhBMP-2 is recommended in conjunction with a threaded 

titanium cage when performing an ALIF 

• Several forms of bone graft extenders are recommended when 

used in combination with autologous bone 

• rhBMP-2 may be used with bone graft extenders as a substitute 

for autograft 

Anterior lumbar interbody fusion using rhBMP-2 with tapered 

interbody cages. Burkus JK, et al. J Spinal Disorder 2002; 15: 337-349 

• 279 patients well matched patients with CLBP 

• randomized into 2 groups, rhBMP-2 vs Autograft 

• 90% follow-up @ 2 years 

• Clinical improvement equivalent in both groups 

• Higher fusion rate in the rhBMP-2 group (95% vs 89%) 

• Class I, supporting use of rhBMP-2 vs autograft in a cage 

Use of rhBMP-2 in ALIF Burkus JK, et al. JBJS 2005 Jun;87(6):1205- 

1212 Burkus JK, et al. Spine 2006 Apr, 1;31(7):775-781 

• 131 patients well matched patients with CLBP 

• Multicenter randomized into 2 groups, rhBMP-2 (n=79) vs 

Autograft (n=52) in threaded cortical dowel 

• 12 - 24 month follow-up 

• Statistically better fusion rate & clinical outcome in rhBMP-2 

group 

• Class I, supporting use of rhBMP-2 vs autograft in a threaded 

dowel 

Accelerating lumbar fusions using rhBMP-2, Slosar PJ, et al. Spine J, 

2007; May-Jun;7(3):301-307 

• Prospective cohort ALIF with rhBMP-2 (n=45) vs ALIF alone 

(n=30) 

• Minimum follow-up = 2 years 

• Fusion rate; rhBMP-2 = 100% vs ALIF alone = 89% (statistically 

higher) 

• Revision rate; rhBMP-2 = 0% vs ALIF alone = 13% 

• Class III, rhBMP-2 enhances fusion in ALIF with FRA 

Graft resorption with the use of BMP: lessons from ALIF with FRA 

Pradhan BB, et al. Spine 2006; 1:31(10):E277-284

• Prospective cohort ALIF with rhBMP-2 compared to historical 

• Historical control - 27 patients with stand alone FRA 

• Study group – 9 patients FRA with rhBMP-2 

• Minimum follow-up = 2 years 

• Pseudoarthrosis in historical control = 36%, 

228 




• Pseudarthrosis in study group = 56% 

• Statistical significance not established because of early study 

termination 

• Class III, rhBMP-2 does not enhance fusion in ALIF with FRA

229 

boNe deFeCtS: wheN are orthobiologiCS iNdiCated? 

Allan E. Gross and Wayne Paprosky 

Introduction 

The goals of revision arthroplasty of the hip are to restore the 

anatomy and achieve stable fixation for new acetabular and femoral 

components. It is now widely recognized that for the best results, the 

articulating hip centre should be established at the correct anatomic 

level. Remaining bone stock is the single most important parameter 

in determining whether or not that can be achieved. It is important 

to restore bone stock thereby creating an environment for stable 

fixation for the new components. 

The bone defects encountered in revision arthroplasty of the hip 

can be classified either as contained (cavitary) or uncontained 

(segmental). Contained defects on both the acetabular and femoral 

sides can be addressed by morsellized bone graft that is compacted 

and impacted so that stable fixation can be achieved for new 

components. Uncontained defects are more of a problem particularly 

on the acetabular side where bypass fixation such as distal fixation 

on the femoral side is not really an alternative. Most authors agree 

that the use of morsellized allograft bone for contained defects is 

the treatment of choice as long as stable fixation of the acetabular 

component can be achieved and there is a reasonable amount 

of contact with bleeding host bone for eventual ingrowth and 

stabilization of the cup. On the femoral side, contained defects can 

be addressed with impaction grafting, more popular in the United 

Kingdom and Europe, or bypass fixation in the diaphysis of the 

femur using more extensively coated femoral components which is 

more popular in North America. 

Segmental defects on the acetabular side have been addressed with 

structural allografts for the past 15 to 20 years with some problems 

when the graft supports over 50% of the new acetabular component. 

This symposium will address when and where structural allografts 

are still indicated, with acceptable 10 year results, and when and 

where alternatives to the structural allografts are now being utilized 

with shorter but encouraging results. One of these new porous metals 

is trabecular metal (tantalum) which has a high porosity similar to 

trabecular bone. It also has a high co-efficient friction which provides 

excellent initial stability. The porosity provides a very favourable 

environment for bone ingrowth and bone graft remodeling. Porous 

metal acetabular components are now more commonly used when 

there is limited contact with bleeding host bone and porous metal 

augments of all sizes are being used instead of structural allografts 

in some situations. 

On the femoral side metaphyseal bone loss whether contained or 

uncontained is most often addressed by diaphyseal fixation with 

long porous coated implants, modular if necessary. Distal fixation 

requires at least 4 to 6 cms or healthy diaphyseal bone and there 

are situations where this is very difficult to achieve. In that situation 

a choice must be made between a mega prosthesis or a proximal 

femoral allograft. The proximal femoral allograft can restore 

bone stock for future surgery. The mega prosthesis which is more 

appropriate in the tumour population, may require total femoral 

replacement if there is not enough diaphyseal bone for distal 

fixation either by a porous coat or cement. These mega prostheses 

are therefore more appropriate in the tumour population than in the 

revision population. 

Another biologic that has gained universal acceptance is the cortical 

strut allograft which has many indications in revision arthroplasty 

of the hip. They can be used for non-circumferential diaphyseal 

bone defects to stabilize proximal femoral allografts, to bypass stress 




risers and to serve as a biological plate for stabilizing periprosthetic 

fractures. 

This symposium will address the present status of bone grafts and 

porous metals in revision arthroplasty of the hip in an attempt to 

establish the indications and principles for each. 

ACETABULAR REVISION 

Contained Defects: 

Most acetabular revisions can be managed by conventional cementless 

cups as long as contact can be made with enough bleeding host 

bone to provide cup stability and ingrowth and eventual biologic 

fixation. The amount of host bone necessary depends of course on 

its location. For example, bleeding host bone in the dome or in the 

posterior aspect of the acetabulum would probably require less than 

50% host bone contact but by and large up until now, the 50% rule 

has been applied. 1 In these situations morsellized allograft bone has 

been used for cavitary defects. The use of trabecular metal cups has 

challenged the 50% rule and our early results would indicate that 

once again depending on the location of the bleeding host bone, 

that far less than 50% is necessary for eventual fixation of the cup. 

Once again even with trabecular metal cups, the cavitary defects are 

addressed with morsellized host bone. The trabecular metal appears 

to provide an excellent environment for graft remodeling. When 

however there is a massive contained defect, where contact with any 

bleeding host bone is impossible, then morsellized allograft bone 

protected by a cage into which a polyethylene cup is cemented is 

the time proven option.(Fig. 1) Mid and long term results have been 

published on the use of the antiprotrusio cage, with an acceptable 

success rate but still a failure rate that ranges from 10 to 25% at 5 

years. 2 The main cause of failure was that conventional cages did 

not provide a surface to which bone graft could adhere to after 

remodeling took place. This led to late loosening and even flange 

breakage of the cages. 2 This led to the concept of the cup cage3 which 

is a combination of trabecular metal and a cage. The trabecular metal 

cup is inserted onto a bed of morsellized allograft bone fixed by 2 

or 3 screws, and then protected by a cage while remodeling of the 

allograft bone takes place and eventual biological fixation of the 

cup. The cage therefore protects the trabecular metal cup while this 

bone graft remodeling takes place, and then the stress is taken off 

the cage and onto the trabecular metal cup. The theory is that the 

cage therefore won’t loosen or break at 5 to 10 years. The preliminary 

results of this concept have so far been very encouraging. (Fig. 2) 

Uncontained Defects: 

Uncontained defects (segmental) on the acetabular side can be 

addressed by structural graft or porous metal augments. When the 

defect involves less than 50% of the acetabulum, the prognosis for 

structural grafts is in fact quite good with long term survival rates 

of 80%. 4 These grafts have also been shown to restore bone stock 

for future revision surgery.(Fig. 3) Another option is the trabecular 

metal augment which helps to stabilize the cup in the correct 

anatomic position, and provides a surface to which host bone can 

ingrow. 5 (Fig. 4) These augments probably do not restore bone stock 

for future revision surgery, and for that reason the structural graft 

that supports less than 50% of the cup would be the best option for 

the younger higher demand patient that is likely to require another 

revision during their lifetime. The results of the trabecular metal 

augments that support less than 50% of the cup thus far have been 

very good although early. 5

Uncontained (segmental) defects that involve greater than 50% of 

the acetabulum can be addressed by structural grafts or porous metal 

column augments. The structural allograft that replaces greater than 

50% of the acetabulum has a much more guarded prognosis and 

has to be protected by a cage. 6 (Fig. 5) The major column augments 

thus far have provided encouraging results but once again these are 

very early.(Fig. 6) At the present time in the younger high demand 

patient likely to require another revision during their lifetime, a 

major structural allograft protected by a cage should be considered, 

whereas in the lower demand patient the major column porous 

metal augment might be the best option. 

REVISION OF THE FEMUR 

Contained Defects: 

Contained defects of the metaphyseal region of the femur can be 

addressed by impaction grafting, more popular in the United 

Kingdom and Europe7 , or distal fixation by using long porous coated 

or corrundumized titanium implants. 8 Modular femoral implants 

have made this option even more attractive. Distal fixation of course 

requires 4 to 6 cms of diaphyseal bone in order to achieve this. The 

results however have been uniformly good. 8 When impaction grafting 

is performed, morsellized allograft bone usually deep frozen with the 

morsels being less than 5mm in diameter is the biological material 

of choice. The implant is then cemented onto the reconstituted 

femoral tube and the long term results have been excellent. This is a 

technique dependent procedure and also utilizes a large amount of 

allograft bone. It is best reserved for centres that use this technique 

for a significant number of femoral revisions. 7 With the occasional 

revision surgeon distal fixation is the safer option. 

Uncontained (Segmental) Defects: 

Uncontained (segmental) defects of less than 5cm in length can 

be easily addressed with traditional implant systems which offer 

calcar buildup. Uncontained (segmental) defects that extend into 

the diaphysis precluding the use of distal fixation implants have to 

be addressed with proximal femoral allografts or tumour implants 

which involve replacement of the entire femur and knee. Tumour 

implants (mega prostheses) have a higher dislocation rate and do not 

provide effective reattachment of bone and muscles particularly the 

abductors. Tumour prostheses are more appropriate for the tumour 

population while the proximal femoral allograft is more appropriate 

for the revision population. 9 The long term results of proximal 

femoral allografts have been excellent, but once again this is very 

technique specific and should be performed only in centres where a 

significant number of revisions are being carried out. 10 (Fig. 7) 

Cortical Strut Allografts: 

Cortical strut allografts can be deep frozen or freeze dried and 

have multiple indications in the revision population. 11 Their use is 

universally accepted with excellent results. Cortical strut allografts 

should be kept as part of an inventory in the freezer in any hospital 

that does a significant number of revision arthroplasties. They are 

particularly effective for non-circumferential segmental defects, for 

bypassing stress risers such as in impaction grafting, to stabilize 

proximal femoral allografts, and for periprosthetic fractures where 

they serve as a biological plate. They are technically easy to use and 

do in fact restore bone stock for future revision surgery. Cortical 

strut allografts can be hemi-cylinders of humerus or tibia, or whole 

segments of fibula. They are effective in a freeze-dried form which can 

be stored on the shelf, or as deep frozen plus or minus irradiation. 

(Fig. 8) 

REFERENCES: 

1. Garcia-Cimbrelo E: Porous coated cementless acetabular cups in revision 

surgery. J Arthroplasty 14(4):397-406, 1999. 

230 




2. Goodman S, Saastamoinen H, Shasha N, et al: Complications of ilioischial 

reconstruction rings in revision total hip arthroplasty. J Arthroplasty 19:436- 

446, 2004. 

3. Hanssen AD, Lewallen DG: Modular acetabular augments: composite void 

fillers. Orthopedics 28:971-972, 2005. 

4. Woodgate IG, Saleh KJ, Jaroszynski G, et al: Minor column structural 

acetabular allografts in revision hip arthroplasty. Clin Orthop Relat Res 

371:75-85, 2000. 

5. Paprosky WG, Perona PG, Lawrence JM: Acetabular defect classification 

and surgical reconstruction in revision arthroplasty: A 6-year follow-up 

evaluation. J Arthroplasty 9:33-44, 1994. 

6. Nehme A, Lewallen DG, Hanssen AD: Modular porous metal augments for 

treatment of severe acetabular bone loss during revision hip arthroplasty. 

Clin Orthop Relat Res 429:201-208, 2004. 

7. Gross AE, Goodman S: The role of cages and rings: when all else fails. 

Orthopedics 27:969-970, 2004. 

8. Halliday BR, English HW, Timperley AJ, Gie GA, Ling RS. Femoral impaction 

grafting with cement in revision total hip replacement: evolution of the 

technique and results. J Bone Joint Surg Br. 2003;85:809-817. 

9. Paprosky WG, Aribindi R. Hip replacement: treatment of femoral bone loss 

using distal bypass fixation. Instr Course Lect. 2000;49:119-130. 

10. Parvizi J, Sim FH. Proximal femoral replacements with megaprostheses. Clin 


11. Blackley HR, Davis AM, Hutchison CR, Gross AE. Proximal femoral allografts 

for reconstruction of bone stock in revision arthroplasty of the hip: a nine to 

fifteen-year follow-up. J Bone Joint Surg Am. 2001;83:346-354. 

12. Gross AE, Blackley H, Wong P, Saleh K, Woodgate I. The role of allografts in 

revision arthroplasty of the hip. Instr Course Lect. 2002;51:103-113. 

Figure 1A: Pre-op Figure 1B: Post-op 10 Years 

Massive contained defect Revision with morsellized 

allograft bone protected by a cage 

Figure 2A: Cup Cage Construct Trabecular metal cup protected by a cage 

into which poly cup is cemented

Figure 2B: Pre-op Massive contained defect due to osteolysis 

Figure 2C: Post-op Reconstruction with morsellized allograft bone and 

cup cage 

Figure 3: Structural allograft supporting less than 50% of cup 

Figure 4A: Trabecular metal cup and trabecular metal augment 

231 




Figure 4B: Uncemented cup with osteolysis supero lateral to cup 

Figure 4C: Post-op reconstruction right hip with trabecular metal cup and 

augment 

Figure 5A: Uncontained defect with pelvic discontinuity 

Figure 5B: Reconstruction with structural allograft protected by a cage

Figure 6A: Large figure of trabecular metal augment 

Figure 6B: Large uncontained defect and pelvic discontinuity 

Figure 6C: Reconstruction with large trabecular metal augment and 

trabecular metal cup 

232 




Figure 7: Proximal femoral allograft 

Figure 8: Cortical strut allograft

233 

operative FiXatioN oF pediatriC 

haNd aNd upper eXtremity FraCtureS: 

CaSe baSed (d) 

Moderator: Scott H. Kozin, MD, Philadelphia, PA 

The goal of this symposium is to provide current practice recommendations for fixation of pediatric upper extremity fractures 

and to offer technical pearls to maximize success. Case presentations will be used to highlight many of the salient points and 

to encourage audience participation 

Scott H. Kozin, MD, Philadelphia, PA 

Donald S. Bae, MD, Boston, MA 

Peter Waters, MD, Boston, MA 

I. List pediatric upper extremity fractures that require fixation 

II. Recognize fracture patterns of the pediatric upper extremity 

III. Apply principles of fracture fixation to the pediatric upper extremity 

IV. Assess fracture reduction via clinical and radiologic criteria 

V. Analyze expected outcomes following pediatric upper extremity fractures 



SympoSia HANd & WRiST

234 

operative FiXatioN oF pediatriC haNd aNd upper eXtremity 

FraCtureS: CaSe baSed SympoSium 

HAND FRACTURES 

Epidemiology 

• Hand fractures common in children and adolescents (Chung, 

Feehan) 

— Incidence of phalangeal fractures in children 0-4 years of age 

is 207.2 per 100,000 

— Incidence of phalangeal and metacarpal fractures in children 

5-14 years of age 100 and 185 per 100,000, respectively 

— Highest rate of multiple hand fractures in patients 0-4 years 

of age (29.8%) 

— Peak incidence of hand fractures in 10-14 year age group 

— Proximal phalanx of border digits (index and small) most 

common 

• Bimodal distribution (Bhende, Vadivelu) 

— Fingertip injuries, crushing mechanisms, in infants and 

toddlers 

— Metacarpal and phalangeal fractures, sports-related, in 

adolescents 

• One third of hand fractures are physeal (Hastings, Rajesh, 

Worlock) 

— Salter-Harris II most common 

— Post-traumatic physeal arrest uncommon 

• Hastings and Simmons, 1984 

— Retrospective analysis of 354 pediatric hand fractures 

— Majority treated successfully with non-surgical care 

— Small percentage of fractures ➞ large percentage of 

complications 

— High risk fractures 

– Displaced articular fractures 

– Physeal fractures of the distal phalanx 

– Phalangeal neck fractures 

– Open fracture 

— Risk factors associated with fracture malunion, poor results 

– Failure to obtain adequate injury radiographs 

– False assumptions regarding remodeling potential 

– Failure to evaluate clinical deformity 

Specific injuries: Hand 

• Seymour’s fracture (Al-Qattan, Seymour) 

— Displaced physeal fracture of distal phalanx with nailbed 

laceration 

— “Open fracture,” commonly with interposed soft tissue 

— Failure of recognition ➞ infection, physeal arrest, nail plate 

deformity 

— Surgical treatment 

– nail plate removal 

– irrigation and debridement 

– open reduction and stabilization of physeal fracture 

– nailbed repair 

• Phalangeal neck fractures (Al-Qattan, Hastings) 

— Characteristic “door jamb” injuries of childhood 

— True lateral radiograph is critical for diagnosis 

— Poor remodeling potential 

— Non-displaced fractures ➞ cast immobilization, serial 

radiographs 

— Displaced fractures ➞ closed reduction and pinning 

– Reduction maneuver: traction, correction of rotation, 

flexion 

– Cross pin, entering collateral recess and engaging 



SympoSia HANd & WRiST 

opposite cortex 

– Use size- and age-appropriate smooth pins (0.035”) 

– Avoid crossing pins at fracture site 

– Avoid lateral bands to minimize adhesions, stiffness 

– Cast x 3-4 weeks 

— Consider osteoclasis in late-presenting cases (Waters) 

– Appropriate candidates: fracture line radiographically 

visible and tenderness at fracture site 

– Percutaneous smooth pin osteoclasis performed radial 

and ulnar to extensor mechanism 

– If needed, use pin to lever fracture fragment 

– Cross pin as above 

— Established malunions ➞ subcondylar fossa reconstruction 

(Simmons) 

– Volar approach to phalangeal neck and IP joint 

– Use small rongeurs or burr to perform ostectomy 

– Avoid excessive resection to minimize risk of iatrogenic 

fracture 

– Goal: >90 degrees IP flexion 

– Avoid corrective osteotomy due to risk of ostenecrosis 

• Phalangeal shaft fractures 

— Check for malrotation 

— Closed reduction recommended for malrotation or 

angulation >10 degrees 

— Closed reduction, percutaneous pinning for unstable or 

malaligned fractures 

– Pinning techniques similar to adult fractures 

– Use small, size-appropriate smooth pins 

• Phalangeal physeal fractures 

— “Extra octave fracture” 

— Closed reduction for malrotation or angulation >10 degrees 

— Pin fixation for unstable injuries (rare) 

– Size-appropriate smooth pins 

– “physeal friendly” fixation 

• Unicondylar fractures (Bergeron, Weiss) 

— Varying clinical presentations 

— Treatment based upon articular congruity and angular/ 

rotational deformity 

— Nondisplaced fractures ➞ cast immobilization, serial 

radiographs 

— Displaced fractures ➞ closed vs. open reduction and 

stabilization with 2 points of fixation 

– Curvilinear dorsal incision 

– Incise between extensor and lateral band 

– Open reduction under direct visualization 

– Preserve collateral ligament and soft-tissue attachments 

to fracture fragment 

– Smooth pins vs. screws 

– Cast x 3-4 weeks vs. early motion 

• Metacarpal head fractures (Prosser, McElfresh) 

— Unusual injuries 

— ORIF recommended for displaced fractures with articular 

incongruity 

– Fixation with screws, pins, suture 

– Preserve soft-tissue attachments to avoid osteonecrosis 

• Metacarpal neck fractures 

— Large amount of deformity (apex dorsal angulation) can be 

accepted in ring and small fingers due to compensatory MCP 

and CMC motion

— In general, 10-30 degrees of angulation greater than the 

corresponding range of CMC motion well tolerated 

— Remodeling potential 

— Non-displaced fractures ➞ cast immobilization 

— Unacceptable alignment ➞ closed reduction, cast 

immobilization vs. pin fixation 

– Brief immobilization with MCP extended efficacious and 

safe (Hofmeister, Tavassoli) 

– Pin fixation with smooth pins entering collateral recesses 

• Metacarpal shaft fractures 

— Isolated diaphyseal fractures of central rays inherently stable 

— Fractures of border rays, multiple metacarpals more unstable 

— Surgical indications: open fractures, multiple fractures, 

unstable fractures with unacceptable alignment 

— Treatment options: percutaneous pinning, transmetacarpal 

pinning, screw fixation, plate fixation, IM fixation, external 

fixation 

• Salter-Harris III fractures of the thumb proximal phalanx 

— Pediatric “gamekeeper’s thumb” 

— ORIF for displaced fractures 

– Dorsoulnar curvilinear incision 

– Identify and protect radial sensory nerve branches 

– Incise adductor aponeurosis 

– Incise capsule at fracture site, preserving soft-tissue 

attachments to displaced fracture fragment 

– Fracture reduction under direct visualization 

– Fix with parallel smooth pins 

~ Pin with fracture reduced 

~ Place pins through fracture site first, then retrograde 

into reduced fracture fragment 

– Sutures to augment fixation 

– Cast x 4 weeks 

SPECIFIC INJURIES: WRIST 

• Scaphoid fractures 

— Most commonly fractured carpal bone 

— Radiographic evaluation 

— Distal pole fractures most common? (Vahvanen) 

– Excellent healing potential 

– Treatment: cast immobilization x 4-6 weeks 

— Waist fractures 

– Nondisplaced fractures 

~ Long vs. short arm spica cast immobilization (Fabre, 

Gellman) 

~ Role of percutaneous screw fixation? (Adolfsson, 

Bond, Dias, McQueen) 

– Displaced fractures 

• ORIF 

– Non-unions (Chloros, Henderson) 

~ ORIF with structural or vascularized bone graft 

~ Role of percutaneous screw fixation? (Jeon) 

• Triquetrum fractures 

— Dorsal avulsion fractures common ➞ cast or splint 

immobilization x 4 weeks 

— Displaced body fractures ➞ ORIF 

• Hamate fractures 

— Hook of hamate fractures most common 

– CT scans helpful in diagnosis 

– Acute treatment: cast immobilization x 4-6 weeks 

– Excision vs. ORIF for established symptomatic nonunion 

WRIST/FOREARM FRACTURES 

I. Wrist fractures 

a. Distal radius 

i. Common fracture pattern 

235 




ii. Signs and symptoms 

1. Point tenderness 

2. Ecchymosis 

3. MUST examine nerve and tendons 

iii. Classification 

1. Physeal 

2. Greenstick (incomplete) 

3. Torus (compression) 

4. Complete 

iv. Physeal 

1. Usually Salter Harris I or II 

2. Dorsal displacement 

3. Closed reduction 

4. X-ray once a week for three week to check for 

displacement 

5. ORIF if irreducible, usually periosteal flap interposed 

v. Greenstick 

1. Incomplete fracture 

2. Treatment depends upon displacement and 

angulation 

3. Repeat displacement common 

4. Completion of fracture?? 

vi. Torus 

1. Compression fracture 2-3 cm proximal to physis 

2. MUST have pain-free rotation of forearm 

a. Pain free α isolated radius fracture 

b. Painful α Galeazzi variant 

vii.Complete 

1. Higher energy fractures 

2. Can involve distal radius and ulna 

3. Treatment depends upon reducibility of fracture 

b. Complications 

i. Malunion 

ii. Growth arrest 

1. Avoid forceful and repeat manipulations 

2. Follow-up x-rays after initial treatment 

3. Treatment 

a. Resection of bar 

b. Delayed lengthening 

PEDIATRIC ELBOW FRACTURE/ DISLOCATIONS 

I. Pediatric elbow 

a. Incidence 

i. Peak incidence between 5 and 10 years of age 

ii. More common boys 

iii. Seasonal in summer 

b. Anatomy 

i. Ossification process 

1. Girls earlier than boys 

2. Timing of appearance 

3. Medial epicondyle last to fuse to the metaphysis 

ii. Growth plate 

1. Classification of physeal injuries 

a. Salter-Harris I- complete separation 

b. Salter-Harris II 

i. Metaphyseal fragment 

ii. Thurston Holland sign 

iii. Most common pattern 

c. Salter-Harris III- through epiphysis 

d. Salter-Harris IV 

i. Vertical split 

ii. Growth arrest more common 

e. Salter-Harris V- crush injury 

2. Status of soft tissues also important 

iii. Lateral condyle and growth plate

1. Only nonarticular and extracapsular along a small 

portion posterior 

2. Tenuous blood supply 

3. Lateral ossification center extends into lateral portion 

of trochlea! 

iv. X-ray examination 

1. Lateral x-ray 

a. Anterior humeral line (middle capitellum) 

b. Teardrop fossa 

c. Fat pads 

2. Anteroposterior x-ray 

a. Baumann’s angle- physis of lateral epicondyle and 

long axis of humerus 

b. Comparison views useful 

II. Distal humerus fractures 

a. Supracondylar (peak age 5 to 8 years) 

i. Extension types (98%) 

ii. Types 

1. I-nondisplaced (periosteum intact) 

2. II- hinged 

3. III- completely displaced (most common 

posteromedial) 

4. IV- unstable anterior and posterior 

iii. Treatment 

1. Careful assessment 

2. Neurovascular status 

a. Radial most common 

b. Median nerve (AIN)- often posterolateral 

displacement 

c. Ulnar nerve 

3. No treatment type I 

4. Type II closed reduction- must assess rotation 

5. Type II CRIF or ORIF if irreducible 

a. Must correct sagittal, coronal, and rotational 

deformity 

b. Traction and medial-lateral correction 

c. Elbow flexion for sagittal alignment 

d. Rotation difficult to judge, forearm pronation 

helpful for posteromedial displacement 

e. Pin fixation- size, order, technique 

iv. Complications 

1. Vascular 

a. Most serious complication 

b. Must assess vascular status before and after 

reduction 

c. Partial or complete ischemia can be present 

d. Algorithm for treatment remains controversial 

e. Ischemia requires reconstruction 

2. Malunion- most common cubitus varus 

a. Evaluation 

b. Treatment 

c. Technique 

3. Nerve injury- usually resolve spontaneously 

v. Flexion types (2%) 

1. Less common 

2. Ulnar nerve in jeopardy 

3. Similar classification 

4. Closed reduction more difficult in type III fractures, 

often ORIF required 

b. Physeal 

i. Lateral condylar physis 

1. Can be difficult to diagnose and evaluate 

displacement 

2. Usually Salter Harris II fractures that pass into 

236 




trochlea and associated with overt elbow instability 

(Milch II) 

3. Less commonly Salter Harris fractures IV that traverse 

epiphysis (Milch I) 

4. X-ray can be confusing 

a. Metaphyseal flake is a sign of displacement 

b. May require advanced imaging studies 

5. Treatment 

a. Nondiplaced immobilization 

b. Displaced ORIF- MUST avoid posterior dissection 

ii. Medial condylar physis 

1. Much less common 

2. Fracture line can traverse through the trochlea 

notch (more common, Salter Harris II, Milch I) or 

capitotrochlear groove (less common, Salter Harris IV, 

Milch II) 

3. Similar to lateral physeal injuries, diagnosis can be 

difficult 

c. Apophyseal Injuries 

i. Medial epicondylar apophysis 

1. Later peak age (11 to 12 years of age) 

2. Multiple mechanisms of injury 

a. Direct blow 

b. Avulsion (throwing, arm wrestling) 

c. Elbow dislocation, can be incarcerated in the joint 

3. Classification 

a. Undisplaced or minimally displaced (can be 

difficult to diagnose) 

b. Significantly displaced 

4. Treatment 

a. Non-operative treatment preferred 

b. Surgery 

i. Widely displaced 

ii. Incarcerated in joint 

iii. Ulnar nerve symptoms 

ii. Lateral epicondylar apophysis 

1. Rare entity 

2. Non-operative treatment preferred 

III. Dislocations of the Joint of the Elbow 

a. Elbow dislocation 

i. Later peak incidence than supracondylar fractures (13-14 

years of age) 

ii. Limited numbers and series 

iii. Posterior elbow dislocations 

1. Most common direction 

2. Must assess neurovascular status prior to reduction 

3. Closed reduction usually successful 

4. Sedation or general anesthesia preferred 

5. Multiple reduction techniques 

a. Be aware of medial epicondyle!! 

b. Be aware of associated fractures 

c. Be aware potential nerve entrapment (median 

nerve most common) 

6. Complications 

a. Insufficient reduction 

b. Recurrent instability (rare)- posterolateral more 

recognized over time, associated with lateral 

ligament pathology 

c. Osteochondral fractures 

d. Synostosis 

7. Heterotopic ossification 

iv. Anterior and divergent dislocations 

a. Rare 

b. Limited experience

237 

b. Dislocation of the radial head 

i. Pathology 

1. Often Monteggia variant, average age 7 years 

2. Ulnar bow sign (subtle bow of ulna toward with 

convexity toward radial head) 

3. Differential diagnosis- radial head dislocation 

a. Trauma 

b. Pain 

c. Bilateral 

d. Configuration of head and capitellum 

e. Ulnar variance 

4. Treatment 

a. Acute- closed reduction with elbow flexed to 120¡ 

REFERENCES 

Hand References 

1. Adolfsson L, Lindau T, Arner M. Acutrak screw fixation versus cast 

immobilization for undisplaced scaphoid waist fractures. J Hand Surg Br 

2001; 26: 192-195. 

2. Al-Qattan MM. Extra-articular transverse fratures of the base of the distal 

phalanx (Seymour’s fracture) in children and adults. J Hand Surg Br 2001; 

26: 201-206. 

3. Al-Qattan MM. Phalangeal neck fractures in children: classification and 

outcome in 66 cases. J Hand Surg Br 2001;26: 112-121. 

4. Bergeron L, Gagnon I, l’Ecuyer C, Caouette-Laberge L. Treatment outcomes 

of unstable proximal phalangeal head fractures of the finger in children. Ann 

Plast Surg 2005; 54: 28-32. 

5. Bhende MS, Dandrea LA, Davis HW. Hand injuries in children presenting to 

a pediatric emergency department. Ann Emerg Med 1993; 22: 1519-1523. 

6. Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast 

immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg 2001; 

83: 483-488. 

7. Chloros GD, Themistocleous GS, Wiesler ER, Benetos IS, Efstathopoulos DG, 

Soucacos PN. Pediatric scaphoid nonunion. J Hand Surg 2007; 32: 172-176. 

8. Chung KC, Spilson SV. The frequency and epidemiology of hand and 

forearm fractures in the United States. J Hand Surg 2001; 26: 908-915. 

9. Dias JJ, Wildin CJ, Bhowal B, Thompson JR. Should acute scaphoid fractures 

be fixed? A randomized controlled trial. J Bone Joint Surg Am 2005; 87: 

2160-2168. 

10. Fabre O, De Boeck H, Haentjens P. Fractures and nonunions of the carpal 

scaphoid in children. Acta Orthop Belg 2001; 67: 121-125. 

11. Feehan LM, Sheps SB. Incidence and demographics of hand fractures in 

British Columbia, Canada: a population-based study. J Hand Surg 2006; 31: 

1068-1074. 

12. Gellman H, Caputo RJ, Carter V, Aboulafia A, McKay M. Comparison of 

short and long thumb-spica casts for non-displaced fractures of the carpal 

scaphoid. J Bone Joint Surg 1989; 71: 354-357. 

13. Hastings H, Simmons BP. Hand fractures in children. A statistical analysis. 

Clin Orthop Relat Res 1984; 188: 120-130. 

14. Henderson B, Letts M. Operative management of pediatric scaphoid fracture 

nonunion. J Pediatr Orthop 2003; 23: 402-406. 

15. Hofmeister EP, Kim J, Shin AY. Comparison of 2 methods of immobilization 

of fifth metacarpal neck fractures: a prospective randomized study. J Hand 

Surg 2008; 33: 1362-1368. 

16. Jeon IH, Kochhar H, Micic ID, Oh SH, Kim SY, Kim PT. Clinical result of 

operative treatment for scaphoid non-union in the skeletally immature: 

percutaneous versus open procedure. Hand Surg 2008; 13: 11-16. 

17. McElfresh EC, Dobyns JH. Intra-articular metacarpal head fractures. J Hand 

Surg 1983; 8: 383-393. 




b. Delayed (> 3 weeks)- open reduction 

c. Subluxation of the radial head 

i. Pulled elbow syndrome (a.k.a. nursemaid’s elbow, 

supermarket elbow, temper tantrum elbow) 

ii. Average age 2 to 3 years 

iii. Pathology- partial tear orbicular ligament, subluxates into 

radiocapitellar joint 

iv. X-rays usually normal 

v. Treatment 

1. Supination then flexion 

2. Limited to no immobilization 

vi. Recurrences 5 to 39% 

18. McQueen MM, Gelbke MK, Wakefield A, Will EM, Gaebler C. Percutaneous 

screw fixation versus conservative treatment for fractures of the waist of the 

scaphoid: a prospective randomized study. J Bone Joint Surg Br 2008; 90: 

66-71. 

19. Prosser AJ, Irvine GB. Epiphyseal fracture of the metacarpal head . Injury 

1988; 19: 34-35. 

20. Seymour N. Juxta-epiphyseal fracture of the terminal phalanx of the finger. J 

Bone Joint Surg Br 1966; 48: 347-349. 

21. Simmons BP, Peters TT. Subcondylar fossa reconstruction for malunion of 

fractures of the proximal phalanx in children. J Hand Surg 1987; 12: 1079- 

1082. 

22. Tavassoli J, Ruland RT, Hogan CJ, Cannon DL. Three cast techniques for the 

treatment of extra-articular metacarpal fractures. Comparison of short-term 

outcomes and final fracture alignments. J Bone Joint Surg 2005; 87: 2196- 

2201. 

23 Vahvanen V, Westerlund M. Fracture off the carpal scaphoid in children. A 

clinical and roentgenological study of 108 cases. Acta Orthop Scand 1980; 

51: 909-913. 

24. Valdivelu R, Dias JJ, Burke FD, Stanton J. Hand injuries in children: a 

prospective study. J Pediatr Orthop 2006; 26: 29-35. 

25. Weiss AP, Hastings H. Distal unicondlar fractures of the proximal phalanx. J 

Hand Surg 1993; 18: 594-599. 

26. Waters PM, Stewart SL. Surgical treatment of nonunion and avascular 

necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint 

Surg 2002; 84: 915-920. 

27. Waters PM, Taylor BA, Kuo AY. Percutaneous reduction of incipient 

malunion of phalangeal neck fractures in children. J Hand Surg 2004; 29: 

707-711. 

28. Worlock PH, Stower MJ. The incidence and pattern of hand fracturs in 

children. J Hand Surg 1986; 11: 198-200. 

Elbow References 

1. Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH. The effect of 

surgical timing on the perioperative complications of supracondylar fractures 

in children. J Bone Joint Surg 2001;83A:323-327. 

2. Mazda K, Boggione C, Fitoussi F, Pennecot GF. Systematic Pinning of 

Displaced Extension-type Supracondylar Fractures of the Humerus in 

Children. A Prospective Study of 116 Consecutive Patients. J Bone Joint Surg 

2001;83-B:888-893. 

3. Parikh S N, Wall E J, Foad S, Wiersema B, Nolte B. Displaced Type II 

Extension Supracondylar Humerus Fractures Do They All Need Pinning? J 

Pediatr Orthop 2004;24:380-384 

4. Pirone AM, Graham HK, Krajbich JI. Management of displaced extensiontype 

supracondylar fractures of the humerus in children.

238 

diStal radiuS FraCtureS: 

CurreNt CoNCeptS aNd evolviNg 

teChNologieS (o) 

Moderator: John S. Taras, MD, Philadelphia, PA 

A comprehensive review of distal radius topics including the recently released AAOS clinical guidelines, current and evolving 

internal fixation options, the role of external fixation options, complex fracture management, and distal radius malunion 

considerations. 

I. Introduction/Summary of Clinical Guidelines/Fixation Options 

John S. Taras, MD, Philadelphia, PA 

II. Distal Radius Bone Graft Substitutes/Treatment of Fragility Fractures 

Amy L. Ladd, MD, Palo Alto, CA 

III. Current Applications for External Fixation 

David J. Slutsky, MD, Torrance CA 

IV. Complex Fracture Management 

Douglas P. Hanel, MD, Seattle, WA 

V. Distal Radius Malunion 

David C. Ring, MD, Boston, MA 



SympoSia HANd & WRiST

239 

iNtroduCtioN, Summary oF CliNiCal guideliNeS & 

FiXatioN optioNS 

John S. Taras, MD 

Course Summary 

Fracture of the distal radius is the type of fracture most commonly 

seen in emergency departments. The understanding of the nonsurgical 

and surgical care of distal radius fractures is evolving with recently 

developed methods of fixation. It is worthwhile to review some 

new methods of treatment, the role of bone grafting and synthetic 

substitutes, and the treatment of common complications of distal 

radius fractures. (AAOS Instr Course Lect 2010;Volume 59, 313-316) 

Most important factors determining recovery of function: 

• Fracture alignment 

• Patient’s age 

Malalignment and poor outcome are most highly correlated 

with: 

• Intraarticular incongruity exceeding 2 mm 

• Dorsal angulation of more than 20° is associated with loss of 

wrist flexion and function 

• Radial shortening of more than 4 mm is associated with loss of 

forearm rotation 

• Radial shortening of more than 5 mm is associated with ulnar 

wrist pain 

Relative risk of poor outcome 50% for patients: 

• Younger than 65 years who had fracture healing with dorsal 

angulation of more than 10° 

• Radial inclination of less than 15°, or 

• Radial shortening of more than 3 mm 

Reasonable treatment goals for an active person include: 

• Sustained reduction with less than 1 to 2 mm of articular 

displacement 

• 10° of dorsal angulation 

• 2 to 3 mm of radial shortening 

The optimal evidence-based treatment of distal radius fractures 

has not yet been clearly defined. Methods and techniques 

available for maintaining fracture alignment include: 

• Cast or splint immobilization 

• Percutaneous pinning with casting 

• Bridging or nonbridging external fixation 

• Internal fixation 

Evolution of procedures to treat extraarticular distal radius 

fractures has looked at factors including: 

• Bone quality 

• Patient’s ability to tolerate the procedure 

• Fracture type 

Treatment modalities have evolved from the immobilization as 

originally described by Colles to: 

• Percutaneous pinning 

• Pins and plaster 

• External fixation 

• Internal fixation 

Fractures treated in plaster have a tendency to redisplace with 

time. 

• Mackenney, McQueen, and Elton 

— 60% of initially displaced fractures redisplaced to a position 

of malunion when treated in a cast. 

• LaFontaine and colleagues identified risk factors associated with 




redisplacement of distal radius fractures after initial satisfactory 

reduction; these factors include: 

— Dorsal angulation of more than 20 degrees 

— Comminution 

— Intraarticular involvement 

— Associated fracture of the distal ulna 

— Age greater than 60 years 

— When 3 or more risk factors were present the likelihood of 

fracture collapse was high. 

• Dias, Wray, and Jones noted that osteoporosis was a factor 

leading to a greater progression of deformity after cast 

treatment. 

Percutaneous pinning of the reduced fracture 

• Good-to-excellent results reported 

• Smooth straight wires most common 

• Threaded wires occasionally used 

• Most techniques complement pinning with cast immobilization 

for 4-6 weeks 

• Pinning techniques have included: 

— 2 pins placed through the radial styloid 

— 2 crossed pins 

— 3 to 4 intrafocal pins within the fracture site 

— Transulnar oblique pinning with a threaded wire, 

— 1 radial styloid pin and a second across the distal radioulnar 

joint 

— Multiple trans-ulnar to radius pins, including the distal 

radioulnar joint 

Limitations of standard pinning techniques include: 

• Redisplacement rates of 25-33% despite pinning and casting 

• Infection when pins are left long outside the skin 

• Irritation and skin breakdown when cut beneath the skin 

• Tendon rupture when placed in close proximity to extensor 

tendons 

• Requirement of a procedure to remove pins cut beneath the skin 

Purpose-designed, cannulated, threaded pin 

• Unstable, extra-articular, dorsally displaced distal radius fracture 

• Holds fracture fragments securely 

• Technique similar to common pinning techniques 

• Break-off driver section allows placement entirely within the 

distal radius eliminating tendon or skin irritation 

• Placed over a guide wire utilizing a small incision to expose the 

insertion site 

• More secure purchase of the fracture fragments compared to 

smooth wires 

• Allows for early wrist range of motion, facilitating recovery of 

function 

External Fixation 

• Bridges the fracture by distal fixation in the metacarpals 

indirectly reducing the fracture through ligamentotaxis, or 

• Placing distal fixation directly in the distal fracture fragment 

• Bridging external fixation remains a useful fixation option for: 

— Initial management of open fractures with soft tissue loss 

— Temporizing measure in patients with polytrauma 

— Distal shear fractures where internal fixation of the distal 

fragment cannot be achieved. 

• Nonbridging external fixation has been used successfully to treat

unstable extra-articular fractures. This technique requires at least 

1 cm of intact volar cortex for pin purchase. 

• McQueen compared bridging and nonbridging external fixation 

and found radiological and functional indices better at both 

early and late healing phases in the nonbridging group. 

Common complications/limitations of external fixation 

• Injury to the superficial radial nerve 

• Pin tract infections. 

• Excessive distraction through bridging external fixation causes 

stiffness and median nerve dysfunction 

• One limitation of bridging external fixation relates to the 

viscoelastic behavior of ligaments. There is a gradual loss of 

the initial distraction force applied through stress relaxation 

resulting in some loss of initial fracture reduction during the 

healing phase. 

• pattern: 2 purpose-designed pins inserted from the radial styloid 

BIBLIOGRAPHY 

1. Abramo A, Kopylov P, Tagil M: Evaluation of a treatment protocol in distal 

radius fractures: A prospective study in 581 patients using DASH as outcome. 

Acta Orthop 2008;79:376-385. 

2. Altissimi M, Antenucci R, Fiacca C, Mancini GB: Long-term results of 

conservative treatment of fractures of the distal radius. Clin Orthop Relat Res 

1986;206:202-210. 

3. Benoit LA, Freeland AE. Buttress pinning in the unstable distal radius 

fracture. A modification of Kapandji technique. J Hand Surg 1995;20B:82-96 

4. Catalano LW III, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J 

Jr: Displaced intra-articular fractures of the distal aspect of the radius: Longterm 

results in young adults after open reduction and internal fixation. J 

Bone Joint Surg 1997;79A:1290-1302. 

5. Chia B, Catalano LW 3rd, Glickel SZ, Barron OA, Meier K. Percutaneous 

pinning of distal radius fractures: an anatomic study demonstrating the 

proximity of K-wires to structures at risk. J Hand Surg 2009:34A(6):1014- 

1020. 

6. Clancey G. Percutaneous Kirschner-Wire fixation of Colles fractures. J Bone 

Joint Surg 1984:66A:1008-1014. 

7. DePalma A. Comminuted fractures of the distal end of the radius treated by 

ulnar pinning. J Bone Joint Surg. 34A:651-662. 

8. Dias JJ, Wray CC, Jones JM: Osteoporosis and Colles’ fractures in the elderly. 

J Hand Surg 1987;12B(1):57-59. 

9. Epinette JA, Lehut JM, Cavenaile M, et al: Pouteau-Colles fracture: 

double-closed ‘basket-like’ pinning according to Kapandji: apropos of a 

homogeneous series of 70 cases. Ann Chir Main 1982;1:71-83. 

10. Fernandez DL and Palmer AK. Fractures of the distal radius. In:Green D, 

Hotchkiss R, Pederson, W, eds. Green’s Operative Hand Surgery (ed4) . New 

York, NY: Churchill Livingstone; 1999: 929-985. 

11. Fernandez DL and Wolfe SW: Distal radius fractures. In: Green’s Operative 

Hand Surgery (ed5). Green DP, Hotchkiss RN, Pederson WC and Wolfe SW 

(eds). Pp 645-710. 

12. Fernandez DL, Geissler WB: Treatment of displaced articular fractures of the 

radius. J Hand Surg 1991A;16:375-384. 

13. Fernandez DL: Should anatomic reduction be pursued in distal radial 

fractures? J Hand Surg 2000;25B:523-527. 

14. Forward DP, Davis TR, Sithole JS: Do young patients with malunited 

fractures of the distal radius inevitably develop symptomatic post-traumatic 

osteoarthritis? J Bone Joint Surg 2008;90B:629-637. 

15. Greating MD, Bishop AT: Intrafocal (Kapandji) pinning of unstable fractures 

of the distal radius. Orthop Clin North Am. 1993;24:301-307. 

16. Grewal R, MacDermid JC: The risk of adverse outcomes in extra-articular 

distal radius fractures is increased with malalignment in patients of all ages 

but mitigated in older patients. J Hand Surg 2007;32A:962-970. 

17. Grewal R, Perey B, Wilmik M, et al: A randomized prospective study on 

the treatment of intraarticular distal radius fractures: open reduction 

and internal fixation with dorsal plating versus mini open reduction, 

percutaneous fixation and external fixation. J Hand Surg 2005;30A:764-772. 

18. Handoll HH, Madhok R: Surgical interventions for treating distal radius 

fractures in adults. Cochrane Database Syst Rev 2003;3:CD003209. 

240 




Open reduction and internal fixation 

• Koval noted a recent trend away from percutaneous and external 

fixation towards internal fixation. 

• Most useful application for fixation of displaced intra-articular 

fractures but also commonly used for unstable extra-articular 

fractures 

• Plates can be applied on the volar, dorsal, or radial cortices of 

the radius to maintain fracture reduction. 

• Particularly useful for fractures with metaphyseal comminution 

are implants that incorporate screws that lock into the plate 

thereby enhancing fracture stability. 

Limitations of internal fixation with plates include 

• Tendon rupture from chronic irritation over the plate or screws, 

although newer low profile plate designs have lessened this risk. 

• Care must be taken when applying distal radius plates to ensure 

that the screws do not penetrate past the far cortex due to the 

risk of tendon rupture. 

19. Jakob M, Rikli DA, Regazzoni P: Fractures of the distal radius treated by 

internal fixation and early function. J Bone Joint Surg 82B:340-344, 2000. 

20. Kapandji A: Intra-focal pinning of fractures of the distal end of the radius 10 

years later. Ann Chir Main 1987;6;57-63. 

21. Kapandji A: L’osteosynthese par double enbrochage intrafocal: traitement 

fonctionnel des fractures nonarticulaires de l’extrémitié inferieure du radius. 

Ann Chir Main. 1976;30;903-908. 

22. Kapandji, A. Treatment of non-articular distal radius fractures by intrafocal 

pinning with arum pins. In: Saffer P, Cooney WP, eds. Fractures of the Distal 

Radius. Philadelphia: Lippincott Williams & Wilkins; 1995: pp 71-83. 

23. Knirk JL, Jupiter JB: Intra-articular fractures of the distal end of the radius in 

young adults. J Bone Joint Surg 1986;68A:647-659. 

24. Koval KJ, Harrast JJ, Anglen JO and Weinstein JN. Fractures of the distal part 

of the radius: The evolution of practice over time. Where’s the evidence?. J 

Bone Joint Surg 2008;90A:18551861. 

25. Kreder HJ, Hanel DP, Agel J, et al: Indirect reduction and percutaneous 

fixation versus open reduction and internal fixation for displaced intraarticular 

fractures of the distal radius: A randomized, controlled trial. J Bone 

Joint Surg 2005;87B:829-836. 

26. Lafontaine MJ, Delince P, Hardy D, et al: Instability of fractures of the 

lower end of the radius: apropos of a series of 167 cases. Acta Orthop Belg 

1989;55:203-216. 

27. Lenoble E, Dumontier C, Goutallier D, et al. Fracture of the distal radius: A 

prospective comparison between trans-styloid and Kapandji fixations. J Bone 

Joint Surg 1995;77A:562-567. 

28. Mackenney PJ, McQueen MM, Elton R: Prediction of instability in distal 

radius fractures. J Bone Joint Surg 2006;88A(9):1944-1951. 

29. McQueen MM: Non-spanning external fixation of the distal radius. Hand 

Clin 2005;21;375-380. 

30. Mortier JP, Kuhlmann JN, Richet C, Baux S. Horizontal cubito-radial pinning 

in fractures of the distal radius including a postero-internal fragment. Rev 

Chir Orthop Reparatrice Appar Mot. 1986; 72:567-572. 

31. Porter M, Stockley I: Fractures of the distal radius: Intermediate and 

end results in relation to radiologic parameter. Clin Orthop Relat Res 

1987;220:241-252. 

32 Rayhack JM, Langworthy JN, Belsole RJ: Transulnar percutaneous pinning 

of displaced distal radial fractures: A preliminary report. J Orthop Trauma 

1989; 3:107-114. 

33. Rikli DA, Regazzoni P: Fractures of the distal end of the radius treated by 

internal fixation and early function: A preliminary report of 20 cases. J Bone 

Joint Surg 1996;78B:588-592. 

34. Ring D, Jupiter JB, Brennwald J, et al: Prospective multicenter trial of a plate 

for dorsal fixation of distal radius fractures. J Hand Surg 1997;22A:777-784. 

35. Rozental TD, Beredjiklian PK, Bozentka DJ: Functional outcome and 

complications following two types of dorsal plating for unstable fractures of 

the distal part of the radius. J Bone Joint Surg 2003;85A:1956-1960. 

36. Stein H, Katz S. Stabilization of comminuted fractures of the distal inch of 

the radius: percutaneous pinning. Clin Orthop Rel Research 1975; 108:174- 

181.

37. Sun JS, Chang CH, Wu CC, et al: Extra-articular deformity in distal radial 

fractures treated by external fixation. Can J Surg 2001;44;289-294. 

38. Taras JS, Ladd AL, Kalainov DM, Ruch DS, Ring DC. New concepts in the 

treatment of distal radius fratures. AAOS Instructional Course Lectures 2010; 

59;313-332. 

241 




39. Taras JS, Zambito KL, Abzug JM: T-Pin for distal radius fracture. Tech Hand 

Up Extrem Surg 2006;10:2-7. 

40. Winemaker MJ, Chinchalkar S, Richards RS, et al: Load relaxation and forces 

with activity in Hoffman external fixators: a clinical study in patients with 

Colles’ fractures. J Hand Surg 1998;23A:926-932.

242 

diStal radiuS boNe graFt SubStituteS 

Amy L. Ladd MD 

Key Points - Learning Objectives 

Why use them? 

• Describe the potential advantages and disadvantagesof using 

graft and graft substitutes for distal radius fractures 

Which can I use? 

• Identify the major categories of grafting alternatives available, 

and their potential utility 

When to use them? 

• Identify patient factors and fracture patterns which are 

potentially amenable to adjunctive grafting 

What’s on the horizon? 

• Identify future directions for graft alternatives 

INTRODUCTION 

• Popular Mechanics meets Better Homes & Gardens 

• Organic Carpentry 

• The Business of Bone is Big! 

Why? –History & Review 

• Quest for graft replacement (Table 1) 

— Morbidity 

— Availability 

— (Expense) 

TABLE 1 Advantages & disadvantages of autologous bone graft 

Advantages of autograft Disadvantages of autograft 

Osteoinductive and osteoconductive 

Osteogenic 

Available in cortical and cancellous 

forms 

provides structural support 

Biocompatable 

incorporates into host site 

Remodels to become normal bone 

problems associated with harvest: 

increased operative time, 

hospital stay, cost 

increased blood loss, post- 

operative pain, risk of infection, 

risk of fracture 

Avascular bone: potential nidus 

for infection 

Limited supply 

Variable quality 

Science and Stoichiometry 

• Osteoconduction: scaffolding for new bone 

• Osteoinduction; stimulation of new bone 

• Osteogenesis: cells as engine for new bone formation 

Which can I use? --Types of Graft 

Autograft 

• Cortical (conductive) 

• Cancellous (inductive) 

• Cortico-cancellous (conductive/inductive) 

• Bone Marrow Aspirate (inductive/genic?) 

Allograft 

• Composite 

REFERENCES 

1. 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 conventional fixation in distal radial fractures. A randomized study. J 

Bone Joint Surg Am. 2003;85-A(11):2127-2137. 

2. 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. A critical analysis. J Bone Joint Surg Am. 2007;89(3):649-658. 




• Demineralized Bone Matrix (DBM) 

— Carrier the money and the controversy 

Mineral Composites (Allograft, Xenograft, Synthetics) 

Xenograft: Collagen 

• Minerals (Conductive): Porosity and Resorption are Key 

Features 

— Solid Blocks, granules, pellets, etc—void filler 

– Coralline and bovine hydroxyapatite (HA) 

– Calcium sulfate in many formulations 

~ Soluble, non-physiologic salt 

– Calcium phosphates 

~ Beta tricalcium phosphate (§-TCP) 

— Injectable Cements—potential weight-bearing 

– Calcium sulfate 

– Calcium phosphate 

• Bioglasses and Polymers (Conductive) 

— Silicates 

— Biologic bonding 

• Factors and Proteins 

— Bone Marrow Aspirate 

— Plasma Rich Proteins (PRPs) 

– “buffy coat” 

— Peptides 

– inflammation precursors 

— Cytokines 

– Transforming Growth Factors (TGF-§) 

~ Bone Morphogenic Proteins (BMPs) 

~ Vascular, Fibrous, Platelet Factors 

When to use them? – Indications 

• Specific need (potentially) dictates substitute 

— Void 

— Structure 

— Healing 

— Fixation 

• Marketing and Availability dictate use today 

— Absence of clinical comparative studies in similar injuries 

What’s on the Horizon? Future 

• Viral Probes 

— Influence cellular (inflammatory) response 

• Composite Osteogenic Substances 

— Carrier (conductive/inductive, inert) + cells 

CONCLUSION 

Graft substitutes provide many options 

• Beware of false claims (caveat emptor!) 

Market-driven growth industry 

• More than ever, understand principles of bone 

— Bone composition 

— Bone healing 

• The surgeon’s toolbox now needs a gardening 

3. Kelly CM, Wilkins RM, Gitelis S, Hartjen C, Watson JT, Kim PT. The use 

of a surgical grade calcium sulfate as a bone graft substitute: results of a 

multicenter trial. Clin Orthop Relat Res. 2001(382):42-50. 

4. Ladd AL, Pliam NB. Use of bone-graft substitutes in distal radius fractures. 

J Am Acad Orthop Surg. 1999;7(5):279-290. 

5. McCalden RW, McGeough JA, Court-Brown CM. Age-related changes in the 

compressive strength of cancellous bone. The relative importance of changes 

in density and trabecular architecture. J Bone Joint Surg Am. 1997;79(3):421- 

427.

6. Peltier LF, Bickel EY, Lillo R, Thein MS. The use of plaster of paris to fill 

defects in bone. Ann Surg. 1957;146(1):61-69. 

7. Tsiridis E, Bhalla A, Ali Z, Gurav N, Heliotis M, Deb S, DiSilvio L. Enhancing 

the osteoinductive properties of hydroxyapatite by the addition of human 

mesenchymal stem cells, and recombinant human osteogenic protein-1 

(BMP-7) in vitro. Injury. 2006;37 Suppl 3:S25-32. 

243 




8. Wolff J: The Law of Bone Transformation, 1892. Translated by P Maquet, 

New York: Springer-Verlag, 1986 

9. Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop 

Trauma. 1989;3(3):192-195.

244 

CurreNt appliCatioNS For eXterNal FiXatioN 

David J. Slutsky, MD, FRCS(C) 

Bridging external fixation of distal radius fractures typically relies 

on ligamentotaxis to both obtain and maintain a reduction of the 

fracture fragments. As longitudinal traction is applied to the carpus, 

the tension is transmitted mostly through the radioscaphocapitate 

and long radiolunate ligaments to restore the radial length. In 

a similar vein, pronation of the carpus can indirectly correct the 

supination deformity of the distal fragment. 

Ligamentotaxis has a number of short comings when applied 

to the treatment of displaced intra-articular fractures of the distal 

radius. Firstly, since ligaments exhibit viscoelastic behavior, there is 

a gradual loss of the initial distraction force applied to the fracture 

site through stress relaxation. The immediate improvement in radial 

height, inclination and volar tilt are significantly decreased by the 

time of fixator removal. Traction does not correct the dorsal tilt of the 

distal fracture fragment. This is because the stout volar radiocarpal 

ligaments are shorter and they pull out to length before the thinner 

dorsal radiocarpal ligaments exert any traction. Excessive traction 

may actually increase the dorsal tilt. 

When there is a sagittal split of the medial fragment, traction causes 

the volar medial fragment to rotate which often necessitates an open 

reduction. External fixation cannot control radial translation and 

cannot therefore be used with an unstable distal radioulnar joint. 

Bridging External Fixation: Indications 

1. Unstable Extra-articular distal radius fractures. 

2. Two-part and selected 3-part intra-articular fractures without 

displacement. 

3. Combined internal and external fixation. 

Contraindications 

1. Ulnar translocation due to an unstable distal radioulnar joint. 

2. Intra-articular volar shear fractures (Bartons, reverse Bartons). 

3. Disrupted volar carpal ligaments / radiocarpal dislocations. 

4. Marked metaphyseal comminution. 

Complications 

Pin site complications include infection, loosening and interference 

with extensor tendon gliding. The risk of injury to branches of 

the superficial radial nerve mandate open pin site insertion. Bad 

outcomes associated with external fixation are often related to over 

distraction. More than 5 mm of wrist distraction increases the load 

required for the FDS to generate MCP joint flexion for the middle, 

ring, and small fingers. For the index finger, however, as much as 

2 mm of wrist distraction significantly increases the load required 

for flexion at the MCP joint. Many cases of intrinsic tightness and 

finger stiffness that are attributed to reflex sympathetic dystrophy 

are a consequence of prolonged and excessive traction which can 

be prevented by limiting the duration and amount of traction and 

instituting early dynamic MP flexion splinting even while in the 

fixator. 

The degree and duration of distraction correlates with the amount 

of subsequent wrist stiffness. Distraction, flexion and locked ulnar 

deviation of the external fixator encourage pronation contractures. 

Distraction also increases the carpal canal pressure which may 

predispose to acute carpal tunnel syndrome. Metaphyseal defects 

BIBLIOGRAPHY / REFERENCES 

1. Agee JM. Distal radius fractures. Multiplanar ligamentotaxis. Hand Clin 

1993: 9: 577-85. 




should be grafted to diminish bending loads and to allow fixator 

removal after 6-7 weeks which minimizes the fixator related 

complications. 

Nonbridging External fixation: Indications 

Nonbridging external fixation is indicated in any extra-articular 

fracture where there is a high risk of late collapse or if there is 

redisplacement of the fracture following an acceptable closed 

reduction. It is ideally suited for the treatment of 2- and 3-part intraarticular 

fractures of the distal radius provided there is good bone 

density and a stable DRUJ. It’s use following an arthroscopic-aided 

reduction and k-wire fixation of an intra-articular fracture permits 

early protected wrist motion although bridging fixation is warxranted 

in the presence of marked articular comminution. 


Nonbridging external fixation is contraindicated when the distal 

fragment is too small for pin placement. At least 1 cm of intact volar 

cortex is required for pin purchase. This technique is not applicable 

to volar displaced or volar shear fractures and in children with open 

epiphyses. 

Complications 

Pin pullout due to fracture of the distal fragment can occur if the 

distal fragment is too small or osteopenic, or if the reduction is too 

vigorous. If this occurs the fixator can be converted to a bridging 

construct. An incomplete reduction is also possible, especially with 

nascent malunions. Over-reduction of the fracture can also occur, 

especially when there is volar comminution. 

AAOS Guidelines pertaining to External Fixation 

RECOMMENDATION 5. Is external fixation superior to casting: 

Inconclusive. We are unable to recommend for or against operative 

treatment for patients over age 55 with distal radius fractures. There 

were three trials that met the inclusion criteria that compared ex 

fix to casting and K-wires to casting in age >55 yrs. There were no 

significant differences in pain, function, complications or SF-36 at 

any time point. 

RECOMMENDATION 25. Does the duration of distraction affect 

the outcomes: Inconclusive. Two level II studies met the inclusion 

criteria. No statistically significant association of distraction and 

non-validated patient outcome score. Downgraded to “inconclusive” 

on basis that: The important adverse effect of finger stiffness was not 

evaluated and that it was unethical to conduct a prospective study to 

examine the effect of over-distraction. 

RECOMMENDATION 28. Does fixing ulnar styloid fractures affect 

the outcome:Inconclusive. We are unable to recommend for or 

against fixation of ulnar styloid fractures associated with distal 

radius fractures. There were two studies that met the inclusion 

criteria. One study found no difference between treatment 

(fixation) and no treatment. The other study identified ulna styloid 

fractures after treatment was completed therefore no ulnar styloid 

fractures were treated at the time of surgery. Although the patients 

with ulnar styloid fractures had poorer outcomes, the study did 

not address the question of whether early operative intervention is 

indicated. 

2. Wolfe SW, Swigart CR, Grauer J, Slade JF, 3rd, Panjabi MM. Augmented 

external fixation of distal radius fractures: a biomechanical analysis. J Hand 

Surg [Am] 1998: 23: 127-34.

3. McQueen MM. Redisplaced unstable fractures of the distal radius. A 

randomised, prospective study of bridging versus non-bridging external 

fixation. J Bone Joint Surg Br 1998: 80: 665-9. 

4. Gradl G, Jupiter JB, Gierer P, Mittlmeier T. Fractures of the distal radius 

treated with a nonbridging external fixation technique using multiplanar 

k-wires. J Hand Surg [Am] 2005: 30: 960-8. 

245 




5. Slutsky DJ. Nonbridging External Fixation of Intra-articular Distal Radius 

Fractures. Hand Clinics: Distal Radius Fractures. Vol 21, No. 3 August 2005, 

pp 381-394. 

6. AAOS Treatment of Distal Radius Fracture Guidelines 2010. http://www.aaos. 

org/research/guidelines/DRFguideline.asp

1. BACKGROUND Questions 

A. Is there any fracture too difficult to manage with plate 

fixation 

B. Does every fracture deserve skeletal reconstruction 

2. The Premise(s) of this lecture 

Premise # 1 A Fracture Is A Soft Tissue Injury That Involves 

Bone 

Premise # 2 The Status of the Soft Tissues Dictate Fx 

Management 

Premise # 3 The Surgeon Not the Implant Is the Operation 

3. Classification 

A. Open Injuries Gustillo-Anderson 

Type I (Puncture Wounds) and Type II (Tidy Lacerations) 

Relatively Low Energy 

Minimal Soft Tissue Coverage or Contamination Issues. 

Results Same as: Closed Fractures 

Type III 

High Energy “Combined Complex” 

A “Soft Tissue Injury That Involves Bone” 

Urgency of Rx Dictated by Viability and Contamination 

Results Reflect Debridement then 

Vascular> Nerve> Tendon> Coverage> Bone3,24 

Type IIIA 

After Debridement And Skeletal Stabilization 

Soft Tissues Close Primarily Or By Delayed Without The 

Need For Grafts Or Flaps 

Type IIIB and IIIC 

Grossly Contaminated 

Soft Tissue Stripped from Bone 

Torn Muscle Bellies 

Avulsed Abraded Tendon 

Crushed /Avulsed / Transected Nerves 

IIIC – Vascular Compromise 3,18 

B. Concept of Combined Complex Injuries Buchler-Hastings 

Injuries Are Not Simply Additive 

They Impact Geometrically8 

End Results Reflect 24,28 

> Soft Tissue Debridement And Coverage 

>Return of Neuro Function 

>Critical Joint Function 

Elbow > PIP joints 

> Shoulder 

> Wrist 

C. Wrist Fracture Classification 

(Open Fx’s are difficult enough keep it simple) – 

H.Kleinert, GD Lister 

Fernandez/Jupiter15 

Bending 

Shearing 

Radiocarpal Dislocation 

Compression 

All of Which Can Be Combined-Complex 

D. A Working “High Energy” Wrist Fracture Classification 

a. Not Open but Should Be! 

Impending or evolving Compartment Syndrome 

Progressive Neuro Defecit 

b. Not So Bad If It Weren’t for Everything Else 

The poly traumatized patient 

c. Open Injuries as defined above 

246 

CompleX FraCture maNagemeNt 

Doug Hanel MD 




4. Initial Soft Tissue Management 

A. Closed 

Neuro: Acute Crush Vs Evolving Compression 

(compartment syndrome) 

B. Open 

— Debridement – “The Ability to Keep Contaminated 

Tissue from Becoming Septic”—Büchler 

— Removal of Doubtfully Viable Tissue (Tumor Like 

Resection) 17 

— Vessels and Nerves are Never Doubtfully Viable 

— Dead and Dieing Muscle and Skin 

˜ 

Petri Dish 

— Wound Cultures & Gram Stains 

— An Unnecessary and Costly Procedure 

— Antibiotics 

— Type I & II – Your Favorite 

– Staph /Strep Coverage 

– Cephalosporins (12-24 hours) 

— Type III –As Above + Aminoglycosides (for 24 hours after 

closure)11-14 

5. Skeletal Stabilization 

A. Isolated Extremity Injury 

Open vs Closed …. No Difference 

B. Associated with other Injuries 

Will the U.E. be weight bearing? 

C. Treatment Goals 

Preservation of Hand Function >> Restoration of Wrist 

Motion 10,29 

D. Closed / Isolated Injury 

I. Reduction per Agee 1 

Longitudinal Txn 

Palmar Translation of Carpus Relative to Forearm 

Slight Pronation of Hand Relative to Forearm 

Slight Ulnar Deviation 

II. Treat According To Reduction 

Restore Length 

Stabilize Volar Ulnar Corner Radius 

Restore Palmar Tilt (correct dye punch) 

Stabilize Radial Styloid 

Address DRUJ after Above 

III. Fixation 

Pins, Plates, Screws, Wire-forms for Articular Segment 

Combined with 

Meta -Diaphyseal Plates 3.5mm DC or LCDC Plates 

Periarticular Plates Other Plates May Not Be Long 

Enough 

External Fixators 20 

Internal Fixators 4,9 

E. Open and Multiple Extremity (Especially Pelvis) Injuries 

I. Routine Stabilization Is NOT Stable Enough Force 

Transmission of Weight Bearing Through Wrist is Greater 

Than Any Study Construct (> 40 N) 

II. Augmented fixation Small Plates at 60 Offset Angles + 

External Fixation 22,25 Articular Reconstruction + Spanning 

Plates 9,21,26 

III. Ex Fx and Perc K-wire Fixation >>> Stability than K-wires 

Alone 30 

IV. Ex Fx strength proportional to pin spread and distance 

from Bone Strongest “Ex Fx “is a plate sitting on a bone 5,6 

F. Technique of Spanning Plates

REFERENCES 

247 

I. Open Technique 

Dorsal Exposure 

EPL Mobilized 

Elevation of Dorsal Compartments 

Intraarticular Reconstruction 

Wires, Bone Graft, Small Plates and Screws 

Capsule closure 

Spanning Plate 

Third Metacarpal to Radius (3.5 LCDC or DC Plate) 

II. Limited Open Technique 

Reduction Maneuver per Agee 

Percutaneous Manipulation 

Limited Open Bone Graft 

Plate Fixation 

2.4 mm AO Mandibular Reconstruction Plate 

2.4mm Non Locking -Screw, 

2.4mm Locking Screws or 

3.2mm Locking Screws 

2.7 mm AO Wrist Spanning Plate(SD242.003) 

(Stainless Steel) 

“Combination Holes” 

2.4mm Non Locking (Wrist) 

2.7mm Locking (Wrist) 

2.7mm Locking (Distal Humerus 

Application: 

Incisions (3 cm long) 

Proximal to the Outcroppers ECRL/ECRB Interval 

Distal From Second Metacarpal Base 

Tendon Passer and Wire loop (20 gauge) Passed Beneath 

Outcroppers In Line With and Between ECRL ECRB 

Plate Pulled From Distal to Proximal 

Proximal Most and Distal Most Screws Secured 

With Non Locking screws 

Followed by Locking Screws 

Augment Fixation With percutaneous Pins 

Through The Plate 

III. Periarticular Plate Fixation 

Works Well With Combined 

Articular, Metaphyseal, Diaphyseal Fxs 

Covers Distal 2/3’s of Forearm 

IV. Address DRUJ VERY important but covered elsewhere 

V. Post Op 

Splint in Supination if DRUJ has been reconstructed ? 

Convert to neutral at 2-3 weeks 

Work on Digit ROM, Forearm ROM (esp Supination) 

Wrist ROM will follow with time 

Allow Weight Bearing Through Elbows 

Remove Spanning Plates (in OR) in 12-30+ Weeks) 

Expect Full ROM pro/sup, 50-60/50-60 Wrist Ext/Flx 

1. Agee, J. M.: External fixation. Technical advances based upon multiplanar 

ligamentotaxis. Orthop Clin North Am, 24(2): 265-74, 1993. 

2. Arnez, Z. M., and Hanel, D. P.: Free tissue transfer for reconstruction of 

traumatic limb injuries in children. Microsurgery, 12(3): 207-15, 1991. 

3. Axelrod, T. S., and Buchler, U.: Severe complex injuries to the upper 

extremity: revascularization and replantation. J Hand Surg Am, 16(4): 574- 

84, 1991. 

4. Becton, J. L.; Colborn, G. L.; and Goodrich, J. A.: Use of an internal fixator 

device to treat comminuted fractures of the distal radius: report of a 

technique. Am J Orthop, 27(9): 619-23., 1998. 

5. Behrens, F.: A primer of fixator devices and configurations. Clin Orthop, 

(241): 5-14., 1989. 

6. Behrens, F.; Johnson, W. D.; Koch, T. W.; and Kovacevic, N.: Bending stiffness 

of unilateral and bilateral fixator frames. Clin Orthop, (178): 103-10., 1983. 




7. Soft Tissue Reconstruction 

I. Immediate Tendon Reconstruction 

II. Immediate Nerve repair 

III. Immediate Vascular Repair 

IV. Soft Coverage 

Arguments (Settings) For Immediate Closure 

a. Wound Adequately Debrided Minimal Skin Loss 

b. Wound Adequately Debrided Minimal Surgeon Fatigue 

Then Complete Closure With 

Skin Grafts 

> Local Flaps 

> Distant Flaps 2,7,16,17,19,23,27 

Arguments (Settings) For Delayed Closure 31 

a. Wound Viability / Debridement ??? 

b. Wound Adequately Debrided But Surgeon Fatigued 

c. Wound Adequately Debrided But Surgeon doesn’t Know 

How to Do Coverage 

V. Post Op 

Digit ROM, Forearm ROM Dictated by Tendon Repairs 

Mobilization is Dictated Soft Tissue Coverage 

Allow Weight Bearing Through Elbows 

When Soft Tissues Allow 5 . 

5. Summary 

Open Fracture: High Energy Soft Tissue Injuries Associated With 

Broken Bones 

Reconstruction is Approached as a Unit 

Highest Priority Is Debridement & Compartmental Syndromes 

> Progressive Nerve Injuries 

> Skeletal Injury 

Skeletal Stabilization 

Designed to Promote General Rehabilitation of the 

Multiplied Injured Patient 

Soft Tissue Reconstruction 

Create an environment conducive to healing 

Approach open fractures like Dean Smith Coached Basketball 

Play hard 

(There are short cuts, you may look like your winning in the 

first half but you won’t in the second half) 

Play together 

(Address all the problems or get it to some one who can) 

Play smart 

(Use what you know…learn from past mistakes…and avoid 

being a one trick pony) 

7. Buchler, U., and Frey, H. P.: Retrograde posterior interosseous flap. J Hand 

Surg [Am], 16(2): 283-92, 1991. 

8. Buchler, U., and Hastings, H. n.: Combined Injuries. In Operative Hand 

Surgery, pp. 1563-1585. Edited by Green, D. P., 1563-1585, New York, 

Edinburgh, London, Melbourne, Tokyo, Churchill Livingstone, 1993. 

9. Burke, E. F., and Singer, R. M.: Treatment of comminuted distal radius 

with the use of an internal distraction plate. Techniques in Hand & Upper 

Extremity Surgery, 2(4): 248252, 1998. 

10. Burkhalter, W. E.; Butler, B.; Metz, W.; and Omer, G.: Experiences with 

delayed primary closure of war wounds of the hand in Viet Nam. J Bone 

Joint Surg Am, 50(5): 945-54, 1968. 

11. Dellinger, E. P.: Antibiotic prophylaxis in trauma: penetrating abdominal 

injuries and open fractures. Rev Infect Dis, 10: S847-57, 1991. 

12. Dellinger, E. P. et al.: Duration of preventive antibiotic administration for 

open extremity fractures. Arch Surg, 123(3): 333-9, 1988.

13. Dellinger, E. P.; Miller, S. D.; Wertz, M. J.; Grypma, M.; Droppert, B.; and 

Anderson, P. A.: Risk of infection after open fracture of the arm or leg. Arch 

Surg, 123(11): 1320-7, 1988. 

14. Dellinger, E. P.; Wertz, M. J.; Lennard, E. S.; and Oreskovich, M. R.: Efficacy 

of short-course antibiotic prophylaxis after penetrating intestinal injury. A 

prospective randomized trial. Arch Surg, 121(1): 23-30, 1986. 

15. Fernandez, D., and Jupiter, J.: Fractures of the Distal Radius. A Practical 

Approach to Management. Edited, 345, New York, Springer, 1996. 

16. Gilbert, A., and Teot, L.: The free scapular flap. Plast Reconstr Surg, 69(4): 

601-4, 1982. 

17. Godina, M.: Early microsurgical reconstruction of complex trauma of the 

extremities. Plast Reconstr Surg, 78(3): 285-92, 1986. 

18. Gustilo, R. B., and Anderson, J. T.: Prevention of infection in the treatment 

of one thousand and twenty-five open fractures of long bones: retrospective 

and prospective analyses. J Bone Joint Surg Am, 58(4): 453-8, 1976. 

19. Hanel, D. P.: Open Wrist Fractures. Problems in Plastic and Reconstructive 

Surgery, 2(2): 281-299, 1992. 

20. Hanel, D. P.; Jones, M. D.; and Trumble, T. E.: Wrist fractures. Orthop Clin 

North Am, 33(1): 35-57, vii., 2002. 

21. Hanel, D. P.; Ruhlman, S. D.; Katolik, L. I.; and Allan, C. H.: Complications 

associated with distraction plate fixation of wrist fractures. Hand Clin, 26(2): 

237-43, 2010. 

22. Jakob, M.; Rikli, D. A.; and Regazzoni, P.: Fractures of the distal radius treated 

by internal fixation and early function. A prospective study of 73 consecutive 

patients. J Bone Joint Surg Br, 82(3): 340-4, 2000. 

248 




23. Lister, G., and Scheker, L.: Emergency free flaps to the upper extremity. J 

Hand Surg Am, 13(1): 22-8, 1988. 

24. Nyquist, S. R., and Stern, P. J.: Open radiocarpal fracture-dislocations. J Hand 

Surg Am, 9(5): 707-10, 1984. 

25. Rikli, D. A., and Regazzoni, P.: Fractures of the distal end of the radius treated 

by internal fixation and early function. A preliminary report of 20 cases. J 

Bone Joint Surg Br, 78(4): 588-92, 1996. 

26. Ruch, D. S.; Ginn, T. A.; Yang, C. C.; Smith, B. P.; Rushing, J.; and Hanel, D. 

P.: Use of a distraction plate for distal radial fractures with metaphyseal and 

diaphyseal comminution. J Bone Joint Surg Am, 87(5): 945-54, 2005. 

27. Scheker, L. R.; Kleinert, H. E.; and Hanel, D. P.: Lateral arm composite tissue 

transfer to ipsilateral hand defects. J Hand Surg Am, 12(5 Pt 1): 665-72, 

1987. 

28. Scheker, L. R.; Langley, S. J.; Martin, D. L.; and Julliard, K. N.: Primary 

extensor tendon reconstruction in dorsal hand defects requiring free flaps. J 

Hand Surg Br, 18(5): 568-75, 1993. 

29. Tamai, S.: Twenty years’ experience of limb replantation--review of 293 upper 

extremity replants. J Hand Surg Am, 7(6): 549-56, 1982. 

30. Wolfe, S. W.; Swigart, C. R.; Grauer, J.; Slade, J. F., 3rd; and Panjabi, M. 

M.:Augmented external fixation of distal radius fractures: a biomechanical 

analysis. J Hand Surg [Am], 23(1): 127-34, 1998. 

31. Yaremchuk, M. J.: Acute management of severe soft-tissue damage 

accompanying open fractures of the lower extremity. Clin Plast Surg, 13(4): 

621-32, 1986.

249 

CompliCatioNS oF diStal radiuS FraCture repair: 

maluNioN aNd NoNuNioN 

David Ring MD PhD 

NONUNION 

Pathophysiology – Definition: Very unstable fracture after 

allowing mobilization. 

Pathophysiology – Incidence: Very uncommon: less than 1% of 

all fractures 

Pathophysiology – Mechanism 

1. Inadequate immobilization 

2. Distraction with external fixation 

3. Inadequate internal fixation 

Pathophysiology – Classification 

1. Extra-articular 

a. 5 millimeters or fewer of subchondral bone under the lunate 

facet (ulnar side of the radius) 

b. Greater than 5 millimeters of bone under the lunate facet 

2. Articular 

Diagnosis 

1. Clinical 

a. Pain and sense of weakness 

b. Unstable wrist 

2. Radiographs 

a. Persistent fracture line 

b. Often scalloping/bone loss of the distal (metaphyseal) 

fragment 

c. Loosening or breakage of internal fixation 

Management – Treatment Options 

1. ORIF and autogenous bone grafting +/- Darrach 

2. Wrist arthrodesis 

Management - Considerations 

1. Articular nonunion 

2. Degree of malalignment 

3. Infirmity and activity level 

MALUNION 

Pathophysiology - Definition 

1. Distal radius malunion is best defined as malalignment 

associated with dysfunction. 

2. Malalignment does not always result in dysfunction. In 

particular, the vast majority of older, low demand patients 

function very well with deformity (38). 

3. Dysfunction can be loss of motion, loss of strength, or pain (4, 

5, 12) 

4. Pain can be the most difficult to associate with deformity. 

Osteotomy for pain—as with any surgery for pain—isrelatively 

unpredictable and should be undertaken with caution. Articular 

malalignment, arthrosis, carpalmalalignment, and distal 

radioulnar joint malalignment are all potentially painful and 

can be variably addressed. 

5. The relationship between distal radius malunion and carpal 

tunnel syndrome is disputed. Some surgeons claim adirect 

causal relationship as well as the ability to improve carpal 

tunnel syndrome with osteotomy alone. 

Pathophysiology - Incidence 

1. Defining the incidence of malunion is complex: 

a. Radiographic vs. symptomatic 




b. Radiographic cutoff for malunion? 

2. MacKenney, McQueen, and Elton(19) 

a. Radiographic definition of both displacement and 

malunion: Dorsal tilt > 10 degrees; Shortening by ulnar 

variance > 3 millimeters. 

b. According to this definition 744 of 1296 displaced fractures 

(60%) went on to malunion. 

i. It goes without saying that most of these radiographic 

malunions are acceptable to patients. 

ii. Only a small percentage of patients with radiographic 

malunion are considered for osteotomy. 

Pathophysiology – Mechanism 

1. Risk factors for fracture instability/loss of reduction/malunion. 

a. LaFontaine and colleagues.(17) 

i. Age over 60 years 

ii. Greater than 20 degrees of dorsal angulation 

iii. Dorsal metaphyseal comminution 

iv. Comminution extending to the volar metaphyseal cortex 

v. Associated fracture of the ulna 

vi. Displaced articular fracture 

b. MacKenney, McQueen and Elton (19) 

i. Predictors of loss of alignment of initially displaced 

fractures. 

1. Age 

2. Metaphyseal comminution 

3. Dorsal tilt (late instability only) 

4. Ulnar variance 

5. Lack of functional independence 

2. Remanipulation of reduced fractures that redisplace in a cast or 

splint is not worthwhile (17, 23) 

3. Limitations of various treatment techniques 

a. Percutaneous pins alone may not be sufficient to maintain 

alignment when there is substantial metaphyseal 

comminution (35). 

b. External fixation alone—without ancillary percutaneous pin 

fixation of the fracture—may not be sufficientto maintain 

reduction(1, 22, 32). 

c. Non-locked plates may loosen in the osteopenic 

metaphyseal bone.(8, 9) 

4. Early removal of pins or external fixator: Settling of the fracture 

can be observed after implant removal greater thansix weeks 

after injury, particularly when there is substantial metaphyseal 

comminution(15). 

5. Complacence. Many older patients desire optimal wrist 

alignment and function and treatment decisions should notbe 

made on chronological age alone(13). 

Pathophysiology – Classification 

1. Extra-articular elements of deformity—either isolated or 

combined. 

a. Dorsal 

b. Volar (33) 

c. Radial/ulnar (7) 

d. Rotational (28) 

2. Articular (21, 30, 34) 

a. Subluxation 

b. Step

Diagnosis - Overview 

1. Loss of alignment can be measured on radiographs. 

a. Palmar tilt. 

i. The term can be confusing because in malunion this 

often becomes dorsal tilt. 

ii. Perhaps better generalized to angulation of the articular 

surface on the lateral view. 

iii. Definition: the angle between a line connecting the 

dorsal and palmar lips of the distal radius articular 

surface on the lateral view and a line perpendicular to the 

radial shaft. 

b. Ulnar inclination. 

i. Often called radial inclination, but this is a misnomer 

since the articular surface tilts towards the ulnar. Perhaps 

best called ulnarward inclination for clarification. 

ii. Definition: the angle between a line connecting the 

ulnar limit and the radial limit of the distal radius 

articular surface on the posteroanterior view and a line 

perpendicular to the radial shaft. 

c. Measures of shortening 

i. Radial length 

1. Definition: the distance between two lines 

perpendicular to the radial shaft, one at the corner 

of the lunate facet the other at the tip of the radial 

styloid. 

2. Drawbacks: reflects loss of ulnarward inclination as 

well as axial shortening. 

ii. Ulnar variance 

1. Definition: the distance between two lines 

drawn perpendicular to the radial shaft on the 

posteroanterior view, one at the level of the most 

ulnar corner of the lunate facet and the other at the 

distal limit of the ulnar head. 

2. Positive ulnar variance means that the ulna is longer 

than the radius. Negative means the ulna is shorter. 

d. Sources of variability in radiographic measurements 

i. Variability in the radiographs 

ii. Imprecision in the measurement techniques 

iii. Selection of the points of reference 

1. Both a dorsal and a volar limit of the ulnarmost part 

of the lunate facet are visible onmost posteroanterior 

radiographs. There is no standard way to deal with 

this, but weusually select a point midway between the 

two. 

2. Similarly the choice of dorsal and volar lips of the 

articular surface on the lateral viewmay be different 

for the lunate and scaphoid facets. 

2. Correlation of radiographs with complaints. 

a. Ulnar sided wrist pain can improve for a year or more after 

fracture of the distal radius and patience is warranted. 

b. Lack of forearm rotation may be related to capsular 

contracture or bony malalignment. 

c. Pain can be multifactorial and difficult to relate directly to 

malalignment. 

Diagnosis – Patient History 

1. Need to focus the complaints into a goal and determine if that 

goal can be achieved. 

2. For instance, better flexion or better supination. 

3. Pain relief is an achievable goal only when consistent with an 

objective, correctable anatomical deformity. 

Diagnosis – Physical Examination 

1. Motion 

a. Wrist flexion and extension, ulnar and radial deviation 

250 




b. Forearm rotation—supination and pronation. 

2. Ulnocarpal compression 

3. Stability 

a. DRUJ instability 

b. Scaphoid shift test 

c. Midcarpal shuck test 

4. Grip strength. Compare to opposite side 

Diagnosis - Imaging 

1. Standard radiographs: Posteroanterior and lateral views of the 

wrist. 

2. Specific radiographs for joint surface. (2, 16) 

a. Lateral radiograph with forearm tilted 20 degrees towards 

the collector provides tangential view of articular surface. 

b. Posteroanterior view with forearm tilted 10 degrees towards 

the collector provides tangential view of the articular surface. 

3. Computed tomography 

4. Three-dimensional computed tomography—particularly useful 

for articular malunion 

Diagnosis – Other Tests 

1. Neurophysiological testing (nerve conduction velocity and 

electromyography) for any symptoms or signs of carpaltunnel 

syndrome that may need to be addressed. 

Diagnosis – Differential Diagnosis 

1. Stiffness--Capsular stiffness/ tendon adhesions 

2. Numbness--Idiopathic carpal tunnel syndrome 

3. Pain--Another discrete source of pain or even idiopathic pain 

Management – Treatment Options 

1. Exercises. 

a. Active assisted exercises to improve motion 

b. Static or dynamic splinting for wrist flexion-extension or 

forearm rotation 

c. Strengthening 

2. Capsular release/implant removal 

a. Distal radioulnar joint capsular release for loss of 

supination( 14) 

b. Dorsal or arthroscopic capsular release 

c. Implant removal and tenolysis/capsulolysis 

3. Distal radius osteotomy: correction of radial alignment. 

4. Ulnar osteotomy: improvement of wrist alignment by 

shortening the uninjured bone.(27, 36) 

5. Darrach or Sauve-Kapandji: Salvage for distal radioulnar joint 

arthritis or instability. (3, 6) 

6. Partial or total wrist arthrodesis for arthrosis/articular injury.(6) 

Management - Considerations 

1. Enthusiasm for distal radius osteotomy is increased by: 

a. Confidence that osteotomy will achieve the patient’s goals 

b. Good patient understanding and compliance 

c. A balance of the risks and benefits of intervention in favor of 

the potential benefits 

Management – Indications for Surgical Repair 

1. Symptomatic ulnocarpal impaction syndrome 

2. Dysfunction of the distal radioulnar joint (limited forearm 

motion, instability, arthrosis) 

3. Weak grip or dysfunction from extra-articular deformity 

4. Articular incongruity 

Management – Contraindications for Surgical Repair 

1. Infirm patient 

2. Unrealistic expectations/poor understanding/unclear 

indications. This is an elective surgery. When in doubt, it 

isalways better to do nothing. 

3. Infection

4. Very poor hand function (e.g. chronic regional pain syndrome, 

Volkman’s) 

Management - Complications 

1. Nonunion 

2. Loss of alignment 

3. Loss of fixation 

4. Infection 

5. Wound problems 

6. Nerve injury 

Surgeries 

1. Radius osteotomy 

a. Dorsal osteotomy (4, 5, 12, 31) 

b. Volar osteotomy (11, 20, 29, 33) 

c. Radial osteotomy (7) 

d. Intra-articular osetotomy (21, 30, 34) 

e. Bone graft options: 

i. Corticocancellous (31) 

ii. Cancellous (31) 

iii. Bone graft substitutes (18, 37) 

2. Resection of the distal ulna 

a. Darrach 

b. Bower’s/hemiresection 

3. Arthrodesis of the distal radioulnar joint: Sauve-Kapandji 

4. Partial wrist arthrodesis 

5. Total wrist arthrodesis 

PREFERRED TECHNIQUE: Volar Extra-Articular Distal Radius 

Osteotomy for a Dorsally Angulated MalunionInstrumentation/ 

Setup 

1. Tourniquet 

2. Image intensifier 

3. Kirschner wires 

4. Plates and screws 

Indications 

1. Dorsally displaced, extra-articular fracture 

2. Functional deficit clearly related to deformity 

3. or, deformity likely to lead to function deficit 


1. Medical risks 

2. Unrealistic expectations/poor understanding/unclear 

indications—elective surgery, always better to do nothing 

3. Infection 

4. Very poor hand. (e.g. s/p RSD or Volkman’s) 

Principles 

1. Plan the procedure on radiographs. 

2. Execute a dorsal exposure that will minimize the potential for 

tendon irritation. 

3. Create the osteotomy at the original fracture site when possible. 

4. Use cancellous bone graft and angular stable (locked plates). 

5. Encourage active functional use and exercises immediately after 

the surgery. 

Pearls 

1. Making a detailed pre-operative plan will improve the efficiency 

and efficacy of the procedure. 

2. Using an extended FCR exposure(24-26) (which takes you 

dorsal through a volar exposure) allows release of thedorsal 

periosteum and z-lengthening of the brachioradialis, both of 

which facilitate realignment of the radius. 

3. The use of locked plates and cancellous (non-structural) bone 

graft allows the use of nonstructural graft. 

Pitfalls 

1. The reduction can be difficult—even impossible—without the 

251 




releases provided by the extended FCR exposure. 

2. Manipulation of the distal fragment can be much more difficult 

with poor-quality bone. The use of one or two distractors in 

addition to a lamina spreader are useful for decreasing the 

overall force needed 

and distributing that force to avoid additional injury to the 

bone and loss of provisional fixation or alignment. 

3. Flexor pollicis longus irritation or rupture. Flexor digitorum 

profundus and be irritated with a prominent plate or screw on 

the lunate side. 

4. Extensor tendon irritation or rupture from an excessively long 

screw. 

Rehabilitation 

1. Active and active-assisted exercise of the fingers and forearm is 

encouraged immediately. 

2. Finger exercises to reduce swelling and active functional use of 

the limb for light tasks are also encouragedimmediately. 

3. The initial plaster splint is exchanged for a plastic removable 

splint two weeks after the surgery. 

4. The patient gradually weans out of the splint between 4 and 6 

weeks after surgery and initiates active and active assisted wrist 

exercises. 

5. Strengthening and forceful use of the arm are restricted until 

early radiographic union is apparent. 

6. Unrestricted use of the limb is allowed when solid union is 

present. 

Outcome 

1. Several small papers have established the safety and efficacy of 

volar osteotomy for a dorsally displaced fracture.(11, 20, 29, 33) 

Surgical Procedure 

1. Plan the desired angular, rotational, and length corrections 

based upon pre-operative radiological studies, includingan x-ray 

of the opposite wrist if uninjured. 

2. Exanguinate arm and elevate tourniquet. 

3. A volar-radial, flexor carpal radialis (FCR), Henry exposure (10) 

is best for extra-articular volar osteotomies. 

4. A Longitudinal incision is made over the FCR tendon. The 

incision should cross the wrist flexion creases obliquelyif it 

crosses them. 

5. It is safest to use the FCR tendon sheath to access the deepest 

structures, leaving the radial artery undissectedand protected in 

the radial soft-tissues. 

6. Once the floor of the FCR tendon sheath is incised, the fat 

overlying the pronator quadratus can be sweptulnarward with a 

blunt elevator. 

7. The most distal aspect of the origin of the flexor pollicis longus 

is elevated (taking care to cauterize a consistent artery in this 

region) and the FPL is swept ulnarward and retracted with a 

small Hohman retractor placed around theulnar border of the 

radius. 

8. The radial border of the radius is exposed using a blunt elevator 

and Hohman retractors. 

9. The prontator quadratus is incised on its most radial and distal 

limits (L-shaped incision) and elevatedsubperiosteally. Leaving 

the periosteum with the muscle can facilitate later repair. 

10. If the fracture is not yet completely healed (the so-called nascent 

malunion—usually within 4 months of injury), theoriginal 

fracture line can be recreated by carefully removing fracture 

callus and recreating the fracture site. This calluscan be saved 

and used as bone graft. 

11. If the fracture is solidly healed an attempt can be made to 

identify the prior fracture site. If this is uncertain, thesurgeon 

can choose a site that creates a big enough distal fragment to

facilitate manipulation and internal fixationwhile trying to 

stay distal enough to take advantage of the healing capacity of 

metaphyseal bone. 

12.An extended FCR exposure is useful for the majority of dorsal 

malunions treated through a volar approach. Thebrachioradialis 

is z-lengthened. The periosteum is elevated from the radial shaft 

proximally. After osteotomy theproximal shaft is pronated out 

of the wound providing access to the dorsal periosteum, which 

can be isolated anddivided. The soft tissue releases facilitate 

fracture realignment. 

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252 




13.A fixed angle volar implant is applied. Provisional Kirschner 

wires are applied either through or adjacent to theplate. 

14. After final plate fixation and removal of provisional fixation, 

cancellous graft is applied to the osteotomy site. 

15.The tourniquet is deflated and hemostasis ensured. 

16.The pronator quadratus is repaired if possible. It can be sutured 

to the brachioradialis tendon. 

17. The skin is closed. 

18.A bulky dressing incorporating a volar plaster wrist splint is 

applied. 

21. Marx RG, Axelrod TS. Intraarticular osteotomy of distal radial malunions. 

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22. McQueen MM. Redisplaced unstable fractures of the distal radius: a 

randomized, prospective study of bridgingversus non-bridging external 

fixation. J Bone Joint Surg 1998;80B:665-669. 

23. McQueen MM, MacLaren A, Chalmers J. The value of remanipulating Colles’ 

fractures. J Bone Joint Surg1986;68B:2332-233. 

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extended flexor carpi radialisapproach: a new perspective for the distal radius 

fracture. Tech Hand Up Extrem Surg 2001;5(4):204-11. 

25. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the 

distal radius: a preliminary report. J Hand Surg 2002;27:205-215. 

26. Orbay JL, Indriago I, Badia A, Khouri RK, Gonzalez E, Fernandez DL. 

Corrective osteotomy of dorsally maiunited fractures of the distal radius via 

the extended FCR approach. J Hand Surg [Am] 2003;28A(Suppl 1):2. 

27. Oskam J, Kingma J, Klasen HJ. Ulnar-shortening osteotomy after fracture of 

the distal radius. Arch Orthop Trauma Surg 1993;112(4):198-200. 

28. Prommersberger KJ, Froehner SC, Schmitt RR, Lanz UB. Rotational deformity 

in malunited fractures of the distalradius. J Hand Surg [Am] 2004;29(1):110- 

5. 

29. Prommersberger KJ, Ring D, Del Pino JG, Capomassi M, Slullitel M, Jupiter 

JB. Corrective osteotomy for intra-articular malunion of the distal part of the 

radius. Surgical technique. J Bone Joint Surg Am 2006;88 Suppl 1Pt 2:202-11. 

30. Ring D, Prommersberger KJ, Gonzalez del Pino J, Capomassi M, Slullitel M, 

Jupiter JB. Corrective osteotomy for intra-articular malunion of the distal 

part of the radius. J Bone Joint Surg Am 2005;87(7):1503-9. 

31. Ring D, Roberge C, Morgan T, Jupiter JB. Comparison of structural and nonstructural 

bone graft for correctiveosteotomy of distal radius malunion. J 

Hand Surg 2002;27A:216-222. 

32. Seitz WH, Froimson AI, Leb R, Shapiro JD. Augmented external fixation of 

unstable distal radius fractures. J Hand Surg 1991;16A:1010-1016. 

33. Shea K, DL DLF, Jupiter JB, Martin C. Corrective osteotomy for malunited, 

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Am 1997;79A:1816-26. 

34. Thivaios GC, McKee MD. Sliding osteotomy for deformity correction 

following malunion of volarly displaced distalradial fractures. J Orthop 

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(Kapandji) pinning of distal radius fractureswith and without external 

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36. Wada T, Isogai S, Kanaya K, Tsukahara T, Yamashita T. Simultaneous radial 

closing wedge and ulnar shorteningosteotomies for distal radius malunion. J 

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37. Yasuda M, Masada K, Iwakiri K, Takeuchi E. Early corrective osteotomy for a 

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cement: a case report. J Hand Surg [Am] 2004;29(6):1139-42. 

38. Young BT, Rayan GM. Outcome following nonoperative treatment of 

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J Hand Surg 2000;25A:19-28.

253 

u adult CoNSequeNCeS oF pediatriC 

orthopediC CoNditioNS (r) 

Moderator: Martin J. Herman, MD, Philadelphia, PA 

This symposium provides management strategies for the adult consequences of pediatric orthopedic conditions. DDH, SCFE, 

scoliosis, spondylolisthesis and extremity trauma and deformity will be included. 


Martin J. Herman, MD, Philadelphia, PA 

A. Course Format 

1. Literature-derived information 

2. Expert opinion 

3. Q and A (20 minutes total) 

B. Primary Objectives 

1. Learn modern pediatric orthopedic care of common 

disorders and the expected outcomes of treatment. 

2. Understand best methods of patient evaluation for common 

adult consequences of these disorders. 

C. Lecture format overview 

1. Review of pediatric treatment for specified condition 

2. Adult consequences of the condition(s) 

3. Patient evaluation and treatment 

a. Literature-based 

b. Expert opinion 

II. Hip Disorders 

James J. McCarthy, MD, Cincinatti, OH 

A. FAI/SCFE/LCPD 

1. Consequences 

a. Labral injury, premature cartilage wear 

b. DJD 

2. Treatment 

a. Arthroscopy vs Surgical hip dislocation 

b. THA 

B. DDH 


a. Subluxation (pre-DJD) 

b. DJD-THA 

2. Treatment 

a. PAO and other osteotomies 

b. THA 

III. Spine Disorders 

Todd J. Albert, MD, Philadelphia, PA 

A. Idiopathic Scoliosis 


a. Progressive deformity 

b. Complications after fusion 

2. Surgical indications and options 

B. Isthmic Spondylolisthesis 


a. Progressive slippage/pain in untreated cases 

b. Pain in treated cases 

2. Surgical indications and options 

IV. Knee disorders 

Mininder S. Kocher, MD, Boston, MA 

A. Mensical pathology including prior menisectomy, discoid 

meniscus 


a. Pain, repeat tear 

b. DJD 



SympoSia pEdiATRiCS 

2. Treatment 

a. Arthroscopic techniques including meniscal 

reconstruction 

b. Arthroplasty options 

B. ACL injuries 


a. Instability 

b. DJD 

2. Treatment 

a. Non-surgical 

b. Surgical indications and options 

C. OCD lesions 


a. Pain, loss of ROM 

b. DJD 

2. Treatment options 

a. Arthroscopic treatments 

b. TKA 

V. Lower extremity deformity 

Martin J. Herman, MD, Philadelphia, PA 

A. Blount disease/genu varum 


a. Knee instability/pain 

b. Knee DJD 

2. Treatment 

a. Non-surgical 

b. Osteotomies 

c. TKA 

B. Leg-length discrepancy 


a. Gait disturbance 

b. Pain spine/hip/knee 

2. Treatment 

a. Shoe lift 

b. Limb lengthening/shortening surgery 

VI. Upper extremity deformity/trauma 

Scott H. Kozin, MD, Philadelphia, PA 

A. Cubitus varus from supracondylar fracture 


a. Cosmetic deformity 

b. Elbow instability 

2. Treatment 

a. Patient evaluation/indications for treatment 


B. Nonunion lateral condyle fracture 


a. Cubitus valgus/instability 

b. Tardy ulnar nerve palsy 

2. Treatment 

a. Nonunion repair 

b. Osteotomies/nerve transposition 

C. Outcomes of congenital anomalies

A. Impingement 

Abnormal anatomy can result in altered biomechanics, 

subsequent hip pain and potentially osteoarthrosis of the hip. 

It has been well established that inadequate bony constraint will 

lead to increased stress about the hip, premature hip pain and 

arthrosis. It is now becoming recognized that too much coverage 

or abnormally directed coverage, as well as inadequate femoral 

offset, can lead to hip disorders, and potentially osteoarthrosis, 

as well. There are numerous pediatric etiologies for femoral 

acetabular impingement syndromes (FAI) about the hip, or this 

can be idiopathic. 

1. Review of Pediatric Treatment for Impingement 

a. Etiology 

i. FAI-Idiopathic 

Can occur as femoral (Cam - type), acetabular 

(Pincer-type) or a combination of both. 

ii. Slipped capital femoral epiphysis (SCFE) 

Primarily femoral, but differs from idiopathic FAI 

in that the head is reoriented, and therefore the 

normal articular cartilage is redirected posteriorly. 

iii. Legg-Calve-Perthes 

Variable in location and structure, is considered 

to be primarily femoral but may have acetabular 

changes secondary to remodeling or surgical 

intervention. Cartilage changes always occur but 

may go unrecognized. 

b. Treatment (Childhood) 

i. FAI 

The indications for treatment are evolving, but 

symptomatic idiopathic FAI in adolescents is 

becoming more commonly diagnosed and 

treated. 

ii. SCFE 

Treatment algorithms are changing, in an 

effort to decrease the complications. Capsular 

decompression and open treatments are being 

explored in an effort to decrease AVN. Open 

reductions (with an open surgical dislocation 

technique) are being performed in an effort to 

redirect the proximal femur early, before secondary 

degenerative changes occur. 

iii. Legg-Calve-Perthes (LCP) 

Decades of clinical research had not codified the 

pediatric treatment of LCP disease. Classically 

surgery is reserved for more involved children with 

a bone age of over 6 years. The procedure of choice 

varies by surgeon and institution. 

2. Adult Consequences 

The final common pathway for all of these conditions 

is hip osteoarthritis (OA). There are differences in how 

these disorders manifest which influences treatment and 

outcomes. 

a. FAI 

May lead to OA, but the impingement itself can cause 

pain, functional limitations and disability. 

b. SCFE 

A combination of mechanical issues, including 

reorientation of the thickest, weight bearing articular 

cartilage, impingement of the metaphyseal portion of 

254 

hip diSorderS 

James McCarthy, MD 




the proximal femur and complications of treatment 

or the disease, especially avascular necrosis (AVN), 

will all play a role in the final clinical outcome. 

c. Legg-Calve-Perthes (LCP) 

Significant variations in the disease process and 

treatment will result in a large diversity of outcomes, 

but in general appear to be related to the size and 

shape of the femoral head and how well it conforms 

to the acetabulum (congruency). The effects on the 

articular cartilage may be from abnormal wear or as a 

direct consequence of the disease process. 

3. Patient Evaluation and Treatment 

a. Treatment: literature-based 

Treatment options vary and should be based on 

careful anatomic and clinical evaluation. Additional 

imaging can be helpful, including MR arthrograms 

and 3 dimensional CT reconstructions. 

i. Arthroscopy 

Well-suited for smaller, femoral based idiopathic FAI. 

ii. Mini-open 

iii. (Open) Surgical hip dislocation 

Larger case with more involved rehabilitation 

and the need for a trochanteric osteotomy. The 

incidence of AVN appears to be low and the 

technique allows for all aspects of FAI to be 

addressed and can be combined with other 

interventions. 

iv. Realignment 

May be considered for SCFE or LCP. Some cases of 

significant acetabular retroversion are treated with 

a Periacetabular Osteotomy (PAO) 

iii. THA 

A final common pathway is end stage OA best 

treated with arthroplasty. Previous surgery may 

make this more difficult. 

b. Expert-opinion 

B. Developmental Dysplasia of the Hip (DDH) 

It has long been recognized that insufficient acetabular coverage 

will lead to osteoarthrosis (OA). It appears that measurements 

of subluxation are the most predictive of poor long term 

outcome. Other factures may play a role and FAI and hip 

dysplasia can co- exist. Femoral anteversion does not appear 

to be associated with OA. Treatment as a child may complicate 

future interventions, or, on rare occasion, supplement bone 

stock. 

1. Review of Pediatric Treatment for DDH 

DDH is a spectrum of disorders that varies from mild 

dysplasia to complete dislocation. Treatment depends 

on the age of diagnosis, degree of subluxation and 

bony deformity. The ultimate goal is to have a perfectly 

congruent (concentric) hip. 

a. Indicators of long -term outcome 

Measurements of hip subluxation and treatment 

-induced complications (AVN) appear to be the best 

predictors of long- term outcomes. A completely 

dislocated hip cannot develop OA but often results in 

pain. 

b. Consequences of treatment 

AVN, infection, and failed reduction may all lead to a

255 

poor long- term outcome. Acetabular remodeling can 

be variable and long- term follow- up is needed. 

2. Adult Consequences of the Condition 

a. Subluxation (pre-OA) 

Hip pain can occur in the absence of OA. This may 

be the result of instability, labral pathology, capsular 

stress or inflammatory changes. 

b. Osteoarthritis 

3. Patient Evaluation and Treatment 

a. Treatment: literature-based 

REFERENCES 

1. Abraham E, Gonzalez MH, Pratap S, Amirouche F, Atluri P, Simon P. 

Clinical implications of anatomical wear characteristics in slipped capital 

femoral epiphysis and primary osteoarthritis. J Pediatr Orthop. 2007 Oct- 

Nov;27(7):788-95. 

2. Boero S, Brunenghi GM, Carbone M, Stella G, Calevo MG. Pinning in 

slipped capital femoral epiphysis: long-term follow-up study. J Pediatr 

Orthop B. 2003 Nov;12(6):372-9. 

3. Carney BT, Weinstein SL, Noble J. Long-term follow-up of slipped capital 

femoral epiphysis. J Bone Joint Surg Am. 1991 Jun;73(5):667-74. 

4. Casaletto JA, Perry DC, Foster A, Bass A, Bruce CE. The height-to-width 

index for the assessment of femoral head deformity following osteonecrosis 

in the treatment of developmental dysplasia. J Bone Joint Surg Am. 2009 

Dec;91(12):2915-21. 

5. Chen RC, Schoenecker PL, Dobbs MB, Luhmann SJ, Szymanski DA, Gordon 

JE. Urgent reduction, fixation, and arthrotomy for unstable slipped capital 

femoral epiphysis. J Pediatr Orthop. 2009 Oct-Nov;29(7):687-94. 

6. Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. 

Periacetabular osteotomy for the treatment of severe acetabular dysplasia. J 

Bone Joint Surg Am. 2005 Feb;87(2):254-9. 

7. Fraitzl CR, Käfer W, Nelitz M, Reichel H. Radiological evidence of 

femoroacetabular impingement in mild slipped capital femoral epiphysis: 

a mean follow-up of 14.4 years after pinning in situ. J Bone Joint Surg Br. 

2007 Dec;89(12):1592-6. 

8. Ganz R, Parvizi J, Beck M, Leunig M, Nštzli H, Siebenrock KA 

Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin 

Orthop Relat Res. 2003 Dec;(417):112-20. 

9. Gent E, Clarke NM. Joint replacement for sequelae of childhood hip 

disorders. J Pediatr Orthop. 2004 Mar-Apr;24(2):235-40. 

10. Hägglund G, Hannson LI, Sandstršm S. Slipped capital femoral epiphysis in 

southern Sweden. Long-term results after nailing/pinning. Clin Orthop Relat 

Res. 1987 Apr;(217):190-200. 

11. Hasegawa Y, Iwata H. Natural history of unreduced congenital dislocation of 

the hip in adults. Arch Orthop Trauma Surg. 2000;120(1-2):17-22. 

12. Herman MJ, Dormans JP, Davidson RS, Drummond DS, Gregg JR. Screw 

fixation of Grade III slipped capital femoral epiphysis. Clin Orthop Relat 

Res. 1996 Jan;(322):77-85. 

13. Kartenbender K, Cordier W, Katthagen BD. Long-term follow-up study after 

corrective ImhŠuser osteotomy for severe slipped capital femoral epiphysis. J 

Pediatr Orthop. 2000 Nov-Dec;20(6):749-56. 




i. PAO and other osteotomies 

Pelvic osteotomies can reorient the acetabulum 

and provide reasonable short- to medium 

-term results. Potentially, there may be benefit 

in providing greater bone stock for total hip 

arthroplasty (THA) if this procedure fails. 

ii. THA 

Surgery can be complicated and typically results 

are worse in this active patient population. 

b. Expert-opinion 

14. Kim HW, Morcuende JA, Dolan LA, Weinstein SL. Acetabular development 

in developmental dysplasia of the hip complicated by lateral growth 

disturbance of the capital femoral epiphysis. J Bone Joint Surg Am. 2000 

Dec;82-A(12):1692-700. 

15. Krych AJ, Howard JL, Trousdale RT, Cabanela ME, Berry DJ. Total hip 

arthroplasty with shortening subtrochanteric osteotomy in Crowe type-IV 

developmental dysplasia: surgical technique. J Bone Joint Surg Am. 2010 

Sep;92 Suppl 1 Pt 2:176-87. 

16. Leunig M, Horowitz K, Manner H, Ganz R. In situ pinning with arthroscopic 

osteoplasty for mild SCFE: a preliminary technical report. Clin Orthop Relat 

Res. 2010 Jun 8. [Epub ahead of print]. 

17. Leunig M, BeaulŽ PE, Ganz R. The concept of femoroacetabular 

impingement: current status and future perspectives. Clin Orthop Relat Res. 

2009 Mar;467(3):616-22. Epub 2008 Dec 10. Review. 

18. Matheney T, Kim YJ, Zurakowski D, Matero C, Millis M. Intermediate to 

long-term results following the bernese periacetabular osteotomy and 

predictors of clinical outcome: surgical technique. J Bone Joint Surg 2009 

91A:2113-23. 

19. Mladenov K, Dora C, Wicart P, Seringe R. Natural history of hips with 

borderline acetabular index and acetabular dysplasia in infants. J Pediatr 

Orthop. 2002 Sep-Oct;22(5):607-12. 

20. Ohmori T, Endo H, Mitani S, Minagawa H, Tetsunaga T, Ozaki T. 

Radiographic prediction of the results of long-term treatment with the Pavlik 

harness for developmental dislocation of the hip. Acta Med Okayama. 2009 

Jun;63(3):123-8. 

21. Schultz WR, Weinstein JN, Weinstein SL, Smith BG. Prophylactic pinning 

of the contralateral hip in slipped capital femoral epiphysis : evaluation of 

long-term outcome for the contralateral hip with use of ecision analysis. J 

Bone Joint Surg Am. 2002 Aug;84-A(8):1305-14. 

22. Sink EL, Zaltz I, Heare T, Dayton M. Acetabular cartilage and labral damage 

observed during surgical hip dislocation for stable slipped capital femoral 

epiphysis. J Pediatr Orthop. 2010 Jan-Feb;30(1):26-30. 

Spence G, Hocking R, Wedge JH, Roposch A. Effect of innominate and femoral 

varus derotation osteotomy on acetabular development in developmental 

dysplasia of the hip. J Bone Joint Surg Am. 2009 Nov; 91(11):2622-36. 

Weinstein SL. Natural history and treatment outcomes of childhood hip 

disorders. Clin Orthop Relat Res. 1997 Nov;(344):227-42. Review. 

Weinstein SL. Natural history of congenital hip dislocation (CDH) and hip 

dysplasia. Clin Orthop Relat Res. 1987 Dec;(225):62-76. Review.

256 

adult CoNSequeNCeS oF SColioSiS aNd SpoNdyloliStheSiS 

Todd J. Albert, MD 

I. “I had scoliosis as a kid, and now I’m an adult and I’m 

having problems” 

A. Presenting Symptoms 

a. Pulmonary Function Deterioration 

i. Generally occurs with larger thoracic curves (>80 

degrees) 1 

ii. Thoracic curves reaching 50 – 80 degrees at skeletal 

maturity tend to progress at a rate of about 1 degree/ 

year 2 

iii. Also occurs with lumbar deformity leading to 

decompensations that causes abdominal contents 

to impinge on lungs thus leading to pulmonary 

dysfunction. 

b. Back Pain 

i. Most common symptom at long-term follow-up 

• Present in 40% of patients with AIS at age 401 

• Incidence does not correlate with magnitude, 

• More common in thoracolumbar curves (52%) 1 

ii. Most frequently from curve collapse, disk 

degeneration, facet degeneration, and/or sagittal 

imbalance. 

iii. Lumbar curves reaching 30 degrees at skeletal 

maturity tend to progress at 0.4 degrees/year2 

iv. Most common indication for surgical intervention 

(83%) 3 

c. Radiculopathy 

Rotatory subluxation, segmental collapse, and/or lateral 

listhesis in the lumbar spine often lead to exiting nerve 

impingement. 

B. Approach to Management 

a. Conservative Treatment Options 

i. Bracing, extensor/core strengthening (lumbar, 

thoracic), injections (epidurals, selective nerve root 

blocks). 

ii. Patients often have co-existent spinal stenosis and/or 

instability 

b. Surgical Indications 

i. Deformity progression, debilitating pain following 

nonoperative treatment, stenosis requiring 

decompression (which will then necessitate a fusion). 

ii. Patients are often elderly with multiple comorbid 

conditions. Thus, surgical risks may be significant and 

must be discussed. 

c. Surgical Options: A/P vs. Posterior-Only Fusion 

i. Posterior-only surgery is often successful in achieving 

global alignment correction. 

ii. Combined Anterior/Posterior surgery often required 

in the following situations: 

thoracic curves > 70 degrees, 

lumbar curves > 60 degrees, 

lumbar kyphosis > 30 degrees 

significant osteoporosis 

extension to the sacrum is anticipated 

iii. Side-bending radiographs are often helpful in 

determining segmental mobility. 

d. Principles of Deformity Correction 

i. Restoration of global coronal and sagittal balance 

must always take priority over “fixing” the curve. 

ii. A “corrected” curve with plumb line 10 cm anterior to 

the lumbosacral disc will do poorly5 




iii. Caudal vertebra of the fusion construct must be 

flexible enough to be brought into neutral alignment 

and should not be in a kyphotic segment. 

C. Outcomes 

a. Ali et al., Spine 20035: 28 patients with AIS treated 

surgically as adults 

• 71% A/P, 29% posterior 

• Major preop and postop curve: 65 • 24 degrees 

• Relief of symptoms in 74% 

• 87% satisfied with results of surgery 

II. “I had an isthmic spondylolysis as a kid, and now I’m adult 

and my back hurts” 

A. Presenting Symptoms 

BACK PAIN 

i. It is often assumed that in adults presenting with 

spondylolysis and/or spondylolisthesis and back pain, 

the pain must be from the defect or the slip. This is 

likely not the case, since we know that the clinical 

course of children with such abnormalities follows 

that of the general population 6 

ii. Beutler et al., Spine 2003 6 : prospectively followed 30 

children with spondylolysis and spondylolisthesis for 

45 years 

• Patients with a bilateral L5 defect followed a 

clinical course similar to the general population 

• No correlation between slip progression and 

functional scores 

iii. Risk factors associated with the development of 

back pain include slippage > 25%, a low lumbar 

index, L4 spondylolysis, and early radiographic disc 

degeneration 7 

B. Approach to Management 

a. Conservative Treatment Options 

i. The majority of adult patients with spondylolysis 

and/or spondylolisthesis are asymptomatic. 

ii. Should symptoms develop, these patients should 

be treated similar to any other patient presenting 

with low back pain. This generally included physical 

therapy, anti-inflammatories, and reassurance. 

iii. MRI is warranted after 4-6 of nonoperative treatment 

in order to identify neural compression, the 

status of the intervertebral discs, to rule out more 

ominous diagnoses. Discography may be helpful 

in determining and/or confirming the responsible 

segment(s) in suspected discogenic back pain. 

b. Surgical Indications 

i. Surgery is generally recommended only after at least 

6 weeks of nonoperative treatment modalities in 

patients that continue to have intolerable back pain 

and/or leg pain. 

ii. If surgery is to be considered for axial low back 

pain, it is imperative that patients understand that 

the reported outcomes of fusion vs. nonoperative 

treatment are mediocre at-best. 

iii. Of the 3 published randomized studies comparing 

fusion and nonoperative treatment8-10, the only 

study that has claimed superiority of surgery reported 

that only 63% of patients reported an improvement 

in back pain. 8

References 

257 

c. Surgical Options 

i. Direct pars repair is a popular treatment option for 

children, but is not indicated in adults. 

ii. Surgical options in the adult include 

• Posterolateral fusion (PLF) 

• Interbody fusion via ALIF, TLIF, or PLIF 

• Combined interbody and posterolateral fusion 

iii. PLF is technically easier than concomitant interbody 

fusion, but radiographic and clinical success rates 

associated with interbody techniques are higher11-16 

1. Weinstein SL, Zavala DC, Ponseti IV. Idiopathic scoliosis: long-term followup 

and prognosis in untreated patients. JBJS Am 1981 63(5):702-12. 

2. Weinstein S, Ponseti I: Curve progression in idiopathic scoliosis: Long-term 

follow-up. J Bone Joint Surg Am 1983;65(4):447-55. 

3. Ali RM, Boachie-Adjei O, Rawlins BA. Functional and radiographic outcomes 

after surgery for adult scoliosis using third-generation instrumentation 

techniques. Spine 2003;28:1169-70. 

4. Glassman SD, Bridwell K, Dimar JR et al. The impact of positive sagittal 

balance in adult spinal deformity. Spine 2005;30:2024-9. 

5. Ali RM, Boachie-Adjei O, Rawlins BA. Functional and radiographic outcomes 

after surgery for adult scoliosis using third-generation instrumentation 

techniques. Spine 2003;28:1169-70. 

6. Beutler WJ, Fredrickson BE, Murtland A, et al. The natural history of 

spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine 

2003 28(10):1027-35. 

7. Saraste H. Long-term clinical and radiological follow-up of spondylolysis 

and spondylolisthesis. J Pediatr Orthop 1987;7(6):631-8. 

8. Fritzell P, MD, Hagg O, MD, Wessberg P, et al. 2001 Volvo Award winner 

in clinical studies: lumbar fusion versus nonsurgical treatment for chronic 

low back pain. A multicenter randomized controlled trial from the Swedish 

Lumbar Spine Study Group. Spine 2001;26:2521-34. 

9. Brox JI, S¿rensen R, Friis A, et al. Randomized clinical trial of lumbar 

instrumented fusion and cognitive intervention and exercises in patients 

with chronic low back pain and disc degeneration. Spine 2003;28:1913-21. 




iv. Patients also requiring decompression tend to have 

inferior outcomes with PLF (vs. patients not requiring 

decompression), likely related to increased dynamic 

instability 17-18 

v. There are risks and benefits to every approach, and 

the specific procedure of choice should take into 

account the surgeon’s experience, thje availability and 

skill of an access surgeon (if an anterior approach is 

considered), as well as the patient’s own preferences. 

10. Fairbank J, Frost H, Wilson-MacDonald J, et al. Randomised controlled 

trial to compare surgical stabilisation of the lumbar spine with an intensive 

rehabilitation programme for patients with chronic low back pain: the MRC 

spine stabilisation trial. BMJ 2005;330:1233. 

11. Barrick WT, Schofferman JA, Reynolds JB, et al. Anterior lumbar fusion 

improves discogenic pain at levels of prior posterolateral fusion. Spine 

2000;25:853–7. 

12. L’Heureux EA Jr, Perra JH, Pinto MR, et al. Functional outcome analysis 

including preoperative and postoperative SF-36 for surgically treated adult 

isthmic spondylolisthesis. Spine 2003;28:1269–74. 

13. La Rosa G, Conti A, Cacciola F, et al. Pedicle screw fixation for isthmic 

spondylolisthesis: does posterior lumbar interbody fusion improve outcome 

over posterolateral fusion? J Neurosurg 2003;99:143–50. 

14. Johnsson R, Stromqvist B, Axelsson P, et al. Influence of spinal 

immobilization on consolidation of posterolateral lumbosacral fusion: 

a roentgen stereophotogrammetric and radiographic analysis. Spine 

1992;17:16–21. 

15. Lenke LG, Bridwell KH, Bullis D, et al. Results of in situ fusion for isthmic 

spondylolisthesis. J Spinal Disord 1992;5:433–42. 

16. Vaccaro AR, Ring D, Scuderi G, et al. Predictors of outcome in patients with 

chronic back pain and low-grade spondylolisthesis. Spine 1997;22:2030–4. 

17. Carragee EJ. Single-level posterolateral arthrodesis, with or without posterior 

decompression, for the treatment of isthmic spondylolisthesis in adults: a 

prospective, randomized study. J Bone Joint Surg Am 1997;79:1175–80. 

18. de Loubresse CG, Bon T, Deburge A, et al. Posterolateral fusion for radicular 

pain in isthmic spondylolisthesis. Clin Orthop 1996;323:194–201.

258 

oCd, meNiSCal iNJury aNd aCl tear oF the kNee 

I. Osteochondritis Dissecans (OCD) 

a. Introduction 

i. Acquired, potentially reversible idiopathic lesion 

of subchondral bone resulting in delamination 

and sequestration with or without article cartilage 

involvement and instability 

ii. Etiology remains controversial 

1. Inflammation 

2. Repetitive trauma 

3. Ischemia 

iii. Classification 

1. Anatomic location 

2. Scintigraphic findings 

3. Surgical appearance 

4. Chronological age 

5. Juvenile vs. Adult depending on physeal maturity 

iv. Prevalence 

1. 15-30 per 100,000 individuals 

2. Male to female ration 2-3:1 

3. Bilateral involvement 15-33% 

v. Location 

1. Posterolateral aspect of the medial femoral condyle – 

70% 

2. Other locations – 30% 

a. Lateral condyle 

b. Trochlea 

c. Patella 

b. Presentation 

i. Generalized knee pain 

ii. Stiffness 

iii. Catching 

iv. Intermittent swelling 

c. Treatment 

i. Early, stable lesions 

1. Activity restriction - minimum 3 months 

2. Protected weight bearing 

3. Bracing 

4. Physical therapy 

5. Anti-inflammatories 

ii. Unstable lesions 

1. Arthroscopy – drilling and/or fixation 

d. Evidence 

i. No randomized, controlled trials – surgery vs. nonsurgical 

interventions 

ii. European, multicenter review 

1. Predictors of healing 

a. Open physes 

b. Younger age 

c. Smaller sized lesions 

d. Optimal lesion location – MFC>PF>LFC 

e. Acute lesion 

iii. Cahill 

1. 50% juvenile lesions heal with non-operative 

intervention within 10-18 months if physis open and 

patient is compliant 

iv. Kocher 

1. Excellent functional and radiographic outcomes with 

drilling stable juvenile lesions with intact articular 

surface 

2. High healing rates and good outcomes with internal 

Mininder S. Kocher, MD, MPH 




fixation of unstable lesions 

e. Adult sequelae 

i. Presentation 

1. Swelling 

2. Stiffness 

3. Mechanical symptoms 

4. Antalgic gait 

5. Joint line/ condylar tenderness 

6. Wilson’s sign – pain with internal rotation of the tibia 

between 90 and 30 degrees 

7. Effusion 

8. Crepitus with range of motion 

9. Quadriceps atrophy 

ii. Imaging 

1. Plain radiographs – characterize and localize the 

lesion 

2. Bone scan – assess blood flow and osteoblast activity 

3. MRI – Identify extent of bony edema, estimate lesion 

size, evaluate status of cartilage and underlying bone, 

identify high signal beneath fragment, identify loose 

bodies 

iii. Interventions 

1. Non-operative management rarely successful 

2. Early operative management is needed to maintain 

articular congruency and integrity of the joint 

a. Indications 

i. Detached or unstable lesions 

ii. Failure of non-operative management 

iii. “Open” lesion – dissection of synovial fluid into the 

lesion 

b. Goals 

i. Promote healing of the underlying subchondral bony 

sequestrum 

ii. Maintenance of joint congruity 

iii. Rigid fixation of unstable fragments 

iv. Repair of osteochondral defects 

c. Treatment options 

i. Arthroscopic drilling – less success in the adult 

population compared to juveniles 

ii. Autogenous bone grafting and fixation of bony defects 

iii. Abrasionplasty 

iv. Microfracture 

v. Autologous chondrocyte implantation 

vi. Osteochondral auto- or allografts 

f. Author’s Preferred Management 

i. Skeletally immature patients 

1. Stable lesions 

a. 3 phase non-operative protocol 

i. 4-6 weeks knee immobilization with partial weight 

bearing 

ii. 4-6 weeks weight bearing as tolerated without knee 

immobilization 

iii. 4-6 weeks rehabilitation emphasizing range of motion 

and low impact quadriceps and hamstring strengthening 

2. Unstable lesions and stable lesions that failed nonoperative 

management 

a. Arthroscopic drilling and fixation when indicated 

II. Anterior Cruciate Ligament (ACL) Injury 

a. Introduction

i. Intrasubstance ACL injuries in children and adolescents 

are being diagnosed with increased frequency 

ii. ACL deficient knees predispose the patient to meniscal 

and chondral injuries and early degenerative arthritis 

iii. ACL injury reported in 10-65% of pediatric knees with 

acute traumatic hemarthroses 

iv. No definitive evidence that ACL reconstruction forestalls 

the progression of OA after initial injury 

v. Conventional surgical reconstruction risks potential 

iatrogenic growth disturbance due to physeal violation 

1. Fixation hardware across physis 

2. Bone plugs across physis 

3. Large (12 mm) tunnels 

4. Suturing near the tibial tubercle apophysis 

vi. Surgical options for skeletally immature patients 

1. Primary repair – poor results 

2. Extra-articular tenodesis – poor results 

3. Transphyseal reconstruction – good to excellent short 

term outcomes 

4. Partial transphyseal reconstruction 

5. Physeal sparing reconstruction 

b. Adult sequelae 


1. Instability / “giving way” 

2. Difficulty weight bearing 

3. Quad avoidance gait 

ii. Imaging 

1. Plain radiographs – rule out other abnormalities 

a. Segond fracture 

2. MRI – evaluate other internal derangements i.e. 

meniscal injuries, chondral defects 


1. Non-operative management 

a. Elderly, sedentary individuals willing to avoid high risk 

activities 

b. Pre-existing advanced knee arthritis or joint sepsis 

c. Conservative therapy 

i. Bracing 

ii. Rehabilitation – quadriceps and hamstring strengthening 

and neuromuscular and proprioceptive training 

iii. Activity modification 

2. Surgical management 

a. Goal – restore the functional stability of the knee 

c. Expert Opinion 

i. Skeletally immature - determine bone age with hand/ 

wrist radiographs 

ii. Avoid acute reconstructions during the first 3 weeks after 

injury to minimize risk of arthrofibrosis 

iii. Prescribe pre-operative rehabilitation to regain ROM, 

minimize swelling, and maximize strength 

iv. Reconstruction technique is based on physiologic and 

skeletal age 

1. Prepubescent skeletally immature patient – physeal 

sparing combined intra/extra-articular reconstruction 

with iliotibial band 

2. Adolescent with growth remaining (open physes) 

– transphyseal reconstruction with hamstring and 

metaphyseal fixation 

3. Older adolescents with closed physes – adult ACL 

reconstruction with interference screw fixation of 

either bone patellar tendon bone or hamstrings 

III. Meniscal Injury 

a. Introduction 

i. Reported incidence in skeletally immature patients 

259 




increasing 

ii. Traumatic meniscal injuries in children under age 10 

typically occur in the setting of discoid menisci 

iii. Non-discoid meniscal injuries occur due to twisting 

injuries in older children and adolescents 

iv. 50% of meniscal tears in adolescents involve the 

periphery and therefore are more amenable to repair 

1. Repair favored over menisectomy to prevent any 

progression towards the onset of early arthritis 

b. Presentation 

i. Stanitski et al. – 47% of preadolescents (age 7-12) and 

45% of adolescents (age 13-18) with acute traumatic 

hemarthrosis have meniscal tears 

1. Medial meniscus more likely in both groups – 70% 

and 88% respectively 

2. Concurrent ACL tear in 36% of adolescent group 

ii. Snapping 

iii. Inability to fully extend the knee 

iv. Lateral knee pain 

c. Treatment options 

i. Resection 

ii. Repair 

iii. Allograft transplantation 

iv. Saucerization of discoid menisci 

d. Adult sequelae 


1. Pain 

2. Stiffness 

3. Locking 

4. Swelling 

5. Joint line tenderness 

a. Best clinical sign of a meniscal tear (Weinstabl et 

al) 

6. Positive McMurray, Steinman, or Apley Compression 

tests 

ii. Imaging 

1. Plain radiographs – need notch views to rule out 

other bony pathologies such as OCD and early 

degenerative changes as the source of knee pain 

2. MRI – 80-90% accuracy in detection of meniscal tears 

(Muellner et al) 

a. Child’s posterior horn of the medial meniscus has 

increased vascularity which can be misinterpreted 

as a tear 


1. Non-operative 

a. Reserved for asymptomatic lesions with minimal 

effect on activities of daily living 

2. Surgical intervention 

a. Indications 

i. Mechanical symptoms 

ii. Persistent pain or effusion 

b. Options 

i. Partial menisectomy-general guidelines for 

arthroscopic resection (Metcalf et al) 

ii. Meniscal repair 

1. Utilized for any peripheral tear in the redred 

zone or amenable tears in the red-white 

zone 

2. Technique options 

a. Inside out – vertical mattress are the 

gold standard repair 

b. Outside in 

c. All inside – bioabsorable screws, darts,

260 

arrows, anchors 

iii. Meniscal allograft 

1. “Ideal” indications 

a. Near total or total menisectomy and 

joint line pain 

b. Early chondral changes 

c. Normal anatomic alignment 

d. Ligamentously stable knee 

2. Paucity of long term data 

e. Expert Opinion 

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Osteochondritis Dissecans 

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dissecans of the knee: current concepts review. Am J Sports Med. 2006 

Jul;34(7):1181-91. 

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multicenter study of the European Pediatric Orthopedic Society. J Pediatr 

Orthop B. 1999 Oct;8(4):231-45. 

3. Cahill BR. Osteochondritis Dissecans of the Knee: Treatment of Juvenile and 

Adult Forms. J Am Acad Orthop Surg. 1995 Jul;3(4):237-47. 

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ACL Injury 

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children and adolescents. J Pediatr Orthop. 1993 Jul-Aug;13(4):506-10. 

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2000 Mar-Apr;28(2):168-75. 




i. Skeletally immature 

1. Provide every effort for meniscal repair prior to partial 

menisectomy 

2. Treat posterior horn tears with inside out repair 

3. Treat anterior horn lesions with either open or with 

outside in technique 

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a near complete menisectomy with early degenerative 

changes and normal alignment and ligamentous 

stability 

13. Guzzanti V, Falciglia F, Stanitski CL. Preoperative evaluation and anterior 

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in skeletally immature patients. A preliminary report. J Bone Joint Surg Am. 

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Meniscal Injury 

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261 

leg-leNgth diSCrepaNCy aNd blouNt’S diSeaSe 

Martin J. Herman, MD 

LEG-LENGTH DISCREPANCY (LLD) 

Significant LLD considered greater than 2 cm 

• More than half of population believed to have some inequality 

but only approximately 1/1000 in general population with LLD 

> 2 cm 

Treatment for children 

• < 2 cm requires no treatment 

• 2-6 cm treated with contralateral epiphyseodesis or shortening 

• > 6 cm treated with lengthening 

Ultimate goal of any treatment is limb equalization within 1 cm 

at skeletal maturity with the least surgery and complications 

• Gait deviations cause inefficient energy expenditure 

• The patient’s diagnosis and associated conditions may alter 

treatment algorithm; for example, a child with hemiplegia may 

benefit from a shorter weak leg 

Adult consequences of significant LLD 

Controversial, limited good data to judge long-term effects 

• Back Pain 

— Back pain is multifactorial and very common. 

— Studies exist to support or refute the notion that a significant 

LLD causes back pain. 

• Scoliosis 

— Patients with scoliosis secondary to a significant LLD 

typically develop scoliosis with pelvic obliquity and a 

lumbar curve with an apex toward the short-leg side. 

Standing x-rays with a lift determine curve flexibility. 

— Not all patients with LLD have this pattern, suggesting that 

some have idiopathic scoliosis and LLD. 

• Premature Osteoarthritis of the Hip 

— Premature OA of the lumbar spine, hip, and knee have been 

associated with significant LLD. 

— Biomechanical analysis shows increased forces across the 

hip of the long leg. Studies confirm that arthrosis of the hip 

occurs more commonly in the long leg’s hip compared to 

the short leg’s hip. 

• Assessment of adult with LLD 

— Determine chief complaint and the severity of pain or 

disability. 

— Perform complete clinical exam of spine and joints of lower 

limb. 

— Use blocks placed under short limb to determine LLD 

clinically by leveling pelvis. 

— Obtain radiographs of joints, scanogram of LEs. 

• Treatment options 

— Trial of shoe lift to determine if limb equalization improves 

symptoms. 

— Trail of medical options for OA. 

— Surgery is offered for pain, disability from gait deviation 

– Limb equalization with shortening or lengthening is 

associated with relatively high morbidity and increased 

length of recovery. 

— THA with shortening or lengthening is useful for 

equalization for patients with both OA and significant LLD. 

— Thorough discussion of risks, benefits, and expectations is 

mandatory. 

BLOUNT’S DISEASE 

Proximal medial tibial growth disturbance resulting in varus 




deformity of the lower limb. 

• Internal tibial torsion, posteromedial sloping of tibial plateau, 

varus angulation of the distal femur, LLD and lateral knee 

ligament laxity are other associated findings. 

Classification based on age of onset 

• Infantile (early-onset) forms are diagnosed after age 2 years 

when the disease can be easily distinguished from physiologic 

bowing. 

• Adolescent Blount’s (late-onset disease) presents in older 

child or young teen and is commonly seen in association with 

childhood obesity. 

Treatment for children and adolescents 

• Bracing 

— Infantile forms can be managed with long-leg bracing; there 

is no role for bracing in late-onset forms. 

• Guided-growth techniques 

— Infantile and mild adolescent forms may be managed 

by hemiepiphyseodesis of the lateral proximal tibia with 

removeable staples or plates for younger patients or 

percutaneous ablation for older children. 

• Osteotomy 

— Proximal tibia/fibula osteotomy and correction is used for 

severe deformities of all ages. 

— Acute correction with internal fixation or external fixation 

and gradual correction with external fixation are all viable 

options. 

Ultimate goals of treatment include restoration of a normal 

mechanical axis of the limb, equalize limb lengths, restore 

ligament balance about the knee and level the knee joint 

(plateau) relative to the floor. 

Adult consequences of Blount’s disease 

• Several studies of adults treated for Blount’s disease as children 

show some increase in knee arthrosis and medial meniscus 

pathology. 

• The association of subclinical (untreated) Blount’ s disease 

with premature knee OA that necessitates osteotomy or TKA is 

unclear. 

— Varus malalignment is a known factor in the development 

of premature OA. However, not all patients with knee varus 

develop knee OA (Framingham study). 

— Tibial fracture malunion and undiagnosed Blount’s disease 

are potential causes of varus. 

— The multifactorial nature of OA makes it impossible 

to implicate Blount’s disease, a relatively uncommon 

condition, as a major cause of knee OA. 

Assessment of adult with tibial varus or previous diagnosis of 

Blount’s disease 

• Observe gait for rotational alignment and lateral knee thrust. 

• Assess ROM of hip, knee, ankle on affected side. Check knee 

ligament stability. 

• Scanogram of the LEs and standing radiographs of both 

limbs from hip to ankle permit limb alignment assessment. 

Radiographs of femur amd tibia allow assessment of 

morphology. 

• Knee arthrography is useful to assess joint congruity and 

stability. 

• MRI permits through analysis of quality of articular cartilage.

Treatment options 

• Knee bracing that unloads medial knee joint or orthotics with 

lateral posting may provide some relief for knee pain 

• Tibial osteotomy is best for younger adult with mild knee 

arthrosis 

— Acute correction and internal fixation is best for < 20 degrees 

of deformity. 

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262 




— Gradual correction with external fixation is best for greater 

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263 

upper eXtremity FraCtureS aNd CoNgeNital diagNoSeS 

Scott H. Kozin, MD 

Upper Extremity Deformity/Trauma 

A. Cubitus Varus from Supracondylar Fracture 


a. Cosmetic deformity only? 

b. Secondary fracture 

b. Elbow instability- posterolateral 

c. Snapping triceps 

d. Lack of motion- sagittal alignment 

2. Treatment 

a. Patient evaluation/indications for treatment 


i. Configurations 

ii. Techniques 

c. Results 

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B. Nonunion Lateral Condyle Fracture 

1. Initial treatment 

a. Fixation 

b. Duration 


a. Cubitus valgus/instability 

b. Tardy ulnar nerve palsy 

c. Fishtail 

3. Treatment 

a. Cubitus valgus 

b. Nonunion repair 

c. Osteotomies/nerve transposition 

d. Fishtail sequelae 

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Surg. 1955;43:88-94.

264 

pediatriC SportS mediCiNe: 

a CaSe-baSed update (z) 

Moderator: Mininder S. Kocher, MD, Boston, MA 

This symposium discusses the pediatric athlete and provides a case-based update on the management of controversial injuries 

in pediatric sports medicine including juvenile OCD of the knee, ACL injuries, and elbow injuries in throwers. 


Moderator: Mininder S. Kocher, MD, Boston, MA 

II. Youth Sports: Dramatic Changes, Increased Injuries 

Lyle J. Micheli, MD, Boston, MA 

III. Lecture: Juvenile OCD of the Knee 

Theodore J. Ganley, MD, Philadelphia, PA 

IV. Cases: Juvenile OCD of the Knee 



Allen F. Anderson, MD, Nashville, TN 

Michael T. Busch, Atlanta, GA 

George A. Paletta, Jr., MD, Chesterfield, MO 

V. Lecture: Elbow throwing injuries in the Pediatric Athlete 


VI. Cases: Elbow Injuries 



James R. Andrews, MD, Birmingham, AL 



VII. Lecture: ACL Injuries in the Skeletally Immature Athlete 


VIII. Cases: ACL Injuries 






IX. Conclusions: STOP: A Paradigm for the Prevention of Youth Sports Injuries and How You Can Get Involved 

James R. Andrews, MD, Birmingham, AL 



SympoSia pEdiATRiCS

265 

SympoSium z: aCl reCoNStruCtioN iN the Skeletally 

immature patieNt 

Mininder S. Kocher, MD, MPH 

• Hot Area 

– Pediatric Orthopaedics 

• POSNA 

– Sports Medicine 

• AOSSM 

– General Orthopaedics 

• AAOS 

– Pediatrics 

• AAP 

– Medicine 

• ACSM 

– Athletic Training 

• NATA 

Controversy: Pediatric ACL Injuries 

• Initial Management 

– Nonoperative vs Operative 

• Operative Management 

– Technique 

• Nontransphyseal 

• Partial Transphyseal 

• Transphyseal 

– Graft Choice / Fixation 

– Age / Skeletal Maturity 

• Complications 

– Growth Disturbance 

• Nonoperative Rx (complete tears): 

– Angel & Hall (Arthroscopy 1989) 

» 5/7 failure (ACL reconstruction) 

– Graf et al (Arthroscopy 1992) 

» 7/8 failure (ACL reconstruction, meniscal tears) 

– Janarv et al (J Pediatr Orthop 1996) 

» 16/23 failure (ACL reconstruction) 

– Mizuta et al (JBJS-B 1985) 

» 1/18 return to preinjury sport level, 6/18 meniscal tears 

– McCarroll et al (AJSM 1988) 

» 3/16 return to preinjury sport, 4/16 meniscal tears 

– Millett et al (Arthroscopy 2002) 

» medial meniscus tears with delay in treatment 

– Moksnes H et al (KSSTA 2008) 

» 20 children, 50% copers, 10% meniscal tear 

• Kocher et al (Am J Sports Med 2002) 

– Patients 

• Skeletally Immature 

• Arthroscopically Documented Partial Tear 

– 45 pts, 13.9 yrs old, 6.1 yr F/U 

• Exclusion Criteria 

– Initial ACL Reconstruction 

» Repairable Meniscal Tear 

» Grade C or D Lachman Exam 

» Grade C or D Pivot-Shift Exam 

– Treatment 

– Outcome 

– 31% (14/45) Subsequent Reconstruction 

• Extra-Articular Reconstruction 


• 10 pts (skel immature); IT band tenodesis; 26 mo F/U: 




10/10 laxity, 5/10 instability 

• Repair 

– Engebretsen et al (Acta Orthop Scand 1988) 

• 8 pts (skeletally immature); repair to femur; 3-8 yrs F/U: 

8/8 laxity, 5/8 instability 

• Physeal-Sparing ACLr 

– Brief (Arthroscopy 1991) 

• 6 pts (skeletally immature); hamstrings; 3-6yr F/U: 6/6 

laxity, 1/6 instability 

– Guzzanti et al (AJSM 2003) 

• 8 pts (prepubescent); hamstrings, tibial tunnel; 2-7yr F/U: 

1.8mm laxity, 0/8 instability 

– Anderson et al (JBJS 2003) 

• 12 pts (skeletally immature); hamstrings & tunnels; 2-8yr 

F/U: 1.5 laxity, 0/12 instability 

– Kocher et al (JBJS 2005) 

• 44 pts (prepubescent); ITB extra & intra-articular; 2-15 yr 

F/U: 4.5% revision, 96 & 97 

• Partial Transphyseal ACLr 

– Andrews et al (AJSM 1994) 

» 8 pts (open physes); soft tissue allografts; tibial physis- 

>over the top 

» 58 month F/U: 3/8 >3mm laxity, 1/8 poor result, no LLD 

– Lo et al (Arthroscopy 1997) 

» 5 pts (wide open physes); soft tissue autografts; tibial 

physis->over the top 

» 7.4 yr F/U: 0/5 >3mm laxity, 1/5 poor result, no LLD 

• Transphyseal ACLr 

– Lipscomb & Anderson (JBJS-A 1986) 

• 24 pts (12-15 yrs old, 11 wide open physes); hamstrings 

autografts 

• 35 month F/U: 15/24 return to sport, 1.6 mm laxity, 1.3 

cm LLD, 2.0 cm LLD 

– Matava & Siegel (Am J Knee Surg 1997) 

• 8 pts (skel immature, 14.9 yrs old); hamstrings autografts 

• 32 month F/U: 8/8 return to sport, 3/8 >3mm laxity, no 

LLD 


• 47 pts (skeletally immature: 20 initial, 20/27 non-op); 

B-PT-B autografts 

• 4.2 yr F/U: 90% return to sport, no LLD 

– Aronwitz et al (AJSM 2000) 

• 19 pts (skeletally immature >14 bone age, Achilles allo 

• 2.1 yr F/U; 84% RTS; 97 Lysholm; 1.7mm KT1000 

• Problems 

– Small Series 

– Retrospective 

– Growth Remaining 

• Chronological Age 

– Not Skeletal Age 

– Not Physiological Age 

• Tanner 4 

• Age 

– Chronological Age 

– Skeletal Age

266 

• Greulich & Pyle 

– Hand & Wrist 

• Pyle & Hoerr 

– Knee 

– Physiological Age 

• Tanner & Whitehouse 

– Stage 1: Prepubertal 

– Stage 2: Prepubertal 

– Stage 3: Pubertal: Young Adolescent 

– Stage 4: Pubertal: Older Adolescent 

– Stage 5: Skeletally Mature 

• Growth Disturbance 

– Animal Models 

• Guzzanti (JBJS 1994) 

– Rabbit, 2mm tunnels, 3/21 Disturbance 

• Stadelmeier (AJSM 1995) 

– Canine, 5/32” tunnels, No Disturbance 

• Edwards (JBJS 2001) 

– Canine, 80N, Femoral Valgus 

– Clinical Series 

• 2 Cases 

– Lipscomb (JBJS 1986) 

– Koman (JBJS 1999) 

Management and Complications of Anterior Cruciate Ligament 

Injuries in Skeletally Immature Patients: A survey of The 

Herodicus Society and The ACL Study Group Kocher et al 

(Journal of Pediatric Orthopaedics, 2002) 

– 8 Cases: Distal Femoral Valgus with Bony Bar 

• 3: Implants (Interference Screws) across Physis 

• 3: Patellar Tendon graft bone block across Physis 

• 1: Large (12 mm) Tunnel with Patellar Tendon graft 

• 1: Over-the-Top Graft Placement 

– 2 Cases: Genu Valgum without Bony Bar 

• Lateral Extra-Articular Tenodesis 

– 2 Cases: Leg-Length Discrepancy 

• 2.5cm shortening (PT bone block across physis) 

• 3.0cm overgrowth (6mm hamstrings graft) 

– 3 Cases: Recurvatum with Apophyseal Bar 

• Hardware across Tibial Tubercle Apophysis 

• Recommendations 

– Avoid Hardware across Lateral Distal Femoral Physis 

– Avoid Hardware across Tibial Tubercle Apophysis 

– Avoid Bone Plugs across Physes 

• Hamstrings Graft 

– Avoid Large Tunnels 

– Avoid Extra-Articular Tenodesis 

– Minimal Over-the-Top Dissection & Notchplasty 

– Consider Physeal Sparing Reconstruction in Prepubescent 

Patients 

• Prepubescents 

• Options 

– Nonoperative Treatment 

– Transphyseal (Paletta) 




– Epiphyseal (Anderson) 

– IT B Physeal Sparing 

• Technique 

– MacIntosh 2 variation 

– Extra/Intra-Articular 

• Over-the-Top 

• Over-the Front 

– Trade-Off 

• Nonanatomic vs Physeal-Sparing 

• Physeal-Sparing Combined Intra/ Extra- Articular ACLr with IT 

Band 

• Kocher et al (J Bone Joint Surg, 2005) 

– 44 pts (10.3 yrs old (3.6-14.0)) 

– 5.3 yr follow-up (2.0-15.1) 

– 4.5% revision rate (4.7 & 8.3 yrs) 

– IKDC: 96.7 + 6.0 

– Lysholm: 95.7 + 6.7 

– 21.5 cm growth (9.5 – 118.0) 

– No growth disturbance 

– Video Journal of Orthopaedics (3/06) 

• Conclusions 

• Pediatric Athlete 

– “Child is not a little adult.” 

– “Child athlete is not a little adult athlete.” 

• Recommendations 

– Know Patient’s Growth Remaining 

– Shared Decision Making 

• Risks: Nonoperative Treatment 

– Meniscal/ Chondral Injury 

• Risks: Operative Treatment 


– Understand Pediatric Knee Anatomy 

• Distal Femoral Physis & Over-Top 

• Proximal Tibial Apophysis 

• Avoid Hardware/ Bone across Physis 

– Technique 

• Adolescents: Transphyseal Hamstrings 

• Prepubescents: Physeal-Sparing 

• Prospective Cohort Study 

• Multicenter 

• Arms 

– Nonoperative Treatment 

– Transphyseal Reconstruction 

– Physeal-Sparing Reconstruction 

• Assessment 

– Growth Remaining 

– Failure Rate 


– Functional Outcome 

• Pedi-IKDC 

– Modify IKDC for Children & Adolescents 

– Validate Pedi-IKDC

267 

youth SportS: dramatiC ChaNgeS, iNCreaSed iNJurieS 

Lyle J. Micheli, MD 

ORGANIZED SPORTS FOR CHILDREN: WORLDWIDE 

1. IOC 

2. FIFA 

3. ACSM 

4. AOSSM 

ORGANIZED SPORTS CHILDREN: BENEFITS 

1. Enjoyment 

2. Intro Skills 

3. Fitness 

4. Psych / Social 

ORGANIZED SPORTS FOR CHILDREN: CONCERNS 

1. Thermal Stress 

2. Psych Stress 

3. Injury 

SPORTS INJURY: CHILDREN 

1. Acute Trauma 

2. Overuse / Overtraining 

3. Combination 

CHILDRENS SPORTS INJURIES: FOCUS 

1. OCD 

2. ACL 

3. Throwing Injuries 

4. Concussion 

EPIDEMIOLOGY 

The study of the nature, cause, control and determinants of 

the frequency and distribution of disease, injury or death in 

populations. 

PURPOSES OF EPIDEMIOLOGY: SPORTS INJURY 

1. Etiology 

2. Control Methods: Game vs Practice, etc. 

3. Risk: Age, Gender, Position, etc. 

4. Prevention 

INJURY SURVEILLANCE SYSTEMS 

1. Incidence of injury / season / population 

2. Relative Risk per Exposure 

a. Ideal = Injury Risk / 1000 hr. 

3. Temporal Trends 

4. EFFECTS OF SAFETY INTERVENTIONS 



SympoSia pEdiATRiCS

268 



SympoSia pEdiATRiCS

269 



SympoSia pEdiATRiCS

270 

maNagiNg oSteoChoNdritiS diSSeCaNS oF the kNee 

Theodore J. Ganley, MD 

OVERVIEW OF GOALS/OBJECTIVES 

Understand: 

• The Clinical Presentation 

• The Decision Making Algorithm 

• Surgical Options 

Background/Key facts 

• Idiopathic etiology 

• Disorder of the subchondral bone 

— Secondarily affects overlying articular cartilage 

— Can lead to cartilage separation and fragmentation 

• Repetitive microtrauma can contribute to focal ischemia and 

alteration of growth 

• Location: 

— Lateral aspect of the MFC most common site, up to 75% 

— Inferior-central lateral 15-20% / Patellar 5-10% / Trochlea 

(Donaldson 2008) 

— 20 OCD lesions in 12 skeletally immature patients 

— Mean age 12 years, mean follow up 2.7 years 

— Lysholm score improved from 72.3 to 95.8 

— 19 lesions healed @ 4.4 months on X-ray and 7.6 months 

on MRI (Adachi 2009) 

• Drilling from the intercondylar bare area 

— 16 Knee lesions in 12 patients, failed non-op tx, then 

drilling, mean f/u - 16 months 

— All lesions healed after drilling / Lysholm score improved 

from 70.4 to 97.8 

— Average time of healing 4 months by X-ray and 7 months on 

MRI (Kawasaki 2003) 

• Arthroscopic Fixation 

— 12 knees w/ stable lesions, 14.8 years, 32.4 months follow up 

— Arthroscopic fixation of the fragments using polylactide 

bioabsorbable pins 

— All returned to sport 

Treatment of Massive / Atypical potentially Unstable lesions 

• Epiphyseal Drilling with supplemental grafting 

— With or without the use of intraoperative 3D CT scanning 

(Ganley 2010) 

Treatment of unstable lesions – partially detached 

• Fixation +/- graft 

— Metal implant (pin or screw) 

— Bio-absorbables 

– Pla bioabsorbable pins 20 (Din 2006) 

11 patients/Ages 12-16/ 32 mo fu 

Union noted on all MRIs 

1 case of early synovitis 

– Pga bioabsorbable pins 21,22 (Weiler 1996) 

40% degrade w/in 6 mos 

Sheep model 

Foreign tissue reaction/lytic lesions 

– Bone Sticks 23 (Navarro 2002) 

11 patients/ Ages 11-20/ 48 mo mean fu 

90.9% Satisfactory, 1 Houghston poor 

Synovitis/effusions – arthroscopy 

— Lesion integration 

— Return to competitive sports 

• Bioabsorbable Implants for Unstable Lesions 

— 24 patients, mean age 14.4 years , mean follow up 39.6 

months 

— At 19.2 months, plain films, 

– Complete healing in 13 pts/interval healing in 9 pts, no 

change in 1 pt 

– Loose bodies with no interval healing in 1 patient 

— Interval healing was present in 16/17 MRIs 

— All 24 patients had good-to-excellent outcomes (Tabaddor 

2010) 

— Cancellous screws (Herbert) 24 (Makino 2005) 

– 14 patients/ Ages 12-35/ 50 mo mean fu / MFC/LFC 

– 2nd Look Arthroscopy / MRI/ IKDC 

– 14-15 Stable fragment 

— Various methods 25 (Kocher 2007) 

– 24 patients/ Ages 11-16/ 51 mo mean fu 

– 9 fissured, 11 partially attached, 6 detached 

– Screws – cancellous and pitch/ absorbable tacks and pins 

– 22 of 26 healed, (6 of 6 detached) 

– No differences in location, fixation or lesion grade in 

healing 

• Osteochondral autograft 26-29 

— Techniques 

271 




– 4.5 mm diameter plug at center of lesion / Additional 

plugs around periphery Graft harvest from femoral 

trochlea Stay perpendicular / Check depth / Minimize 

impaction on cartilage 

— IKDC Scores27-29 

– Preop-5 nearly normal / 10 abnormal / 7 severely 

abnormal Postop - 6 mo. 17 normal, 2 nearly normal, 

1 abnormal, 0 severely abnormal 18 mo. - 18 normal, 2 

nearly normal, 0 abnormal, 0 severely abnormal 

— Advantages 

– Creates vascular access channel Biologic bridge between 

cartilage and bone Secures the lesion 

• Autogenous Osteochondral Plugs 

— 12 patients, mean age 16.0 years, follow-up at 4.5 years 

— Hughston Rating Scale -8 excellent, 3 good, and 1 fair 

— No complications arising from the donor site area 

— T2-MRI – Cancellous bone - Signal change of donor site 

-high to homogeneous by 1 yr post op (Miura 2007) 

• Large osteochondral fragment with a thin wafer of bone 

— All Arthroscopic Suture Bridge 

— Parachute fixation for Large Femoral Osteo-Chondral 

fragments (Trivedi, Lawrence, Ganley 2011) 

• Loose body/fragment removal 

(creates full thickness lesion—see below) 

Treatment of unstable lesions – detached 

• Fixation +/- graft 

• Recruitment - Messenchymal Cell Stimulation (Not 

microfracture) 

— Principally type I collagen with components of type II, VI, 

and IX (hyaline types) 

– Technically simple / Single stage / Arthroscopic / Low 

morbidity / Cost effective 

– Repair defects primarily with fibrocartilage – 

unpredictable durability 

— Indications Grade IV possibly grade III lesions / Intact 

“shoulders” / Perimeter contained 

• Autologous Transplantation vs. Microfracture in Adolescent 

patients 

— 47 patients, mean age of 14.3 years, mean follow-up of 4.2 

years 

– Randomized to either the OATS (25 patients) or MF 

(22 patients) 

– Grade 3 or 4 MFC Lesions 

— At 1 year - Good to Excellent - OATS 92% vs MF 86% 

— At 4.2 years - Good to Excellent – OATS vs. MF 63% 

(Gaudas 2009)

• Osteochondral Allografts in Adults 

— 64 patients – 65 knees, age 28.6 yrs (mean), Follow up 7.7 

yrs (mean) 41 MFC lesions, 25 LFC lesions, All type 3 or 4 

72% were rated good/excellent, 11% were rated fair, 2% was 

rated poor. 15% underwent reoperation (Emmerson 2007) 

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272 




• Autologous Chondrocyte Implantation 

— 37 patients , 14 w/ OCD lesions, age 16 (mean) , 4.3 year 

follow-up (mean) 23 had a prior cartilage repair procedure 

35 patients had single defects 1 patient had an implantation 

that failed 32 patients had significant clinical improvements 

(Micheli JPO 2006) 

Current and Future Directions: 

AAOS Guideline on the Diagnosis and Treatment of 

Osteochondritis Dissecans 

• Clinical Practice Guidelines Committee of the American 

Academy of Orthopaedic Surgeons 

• AAOS Guidelines available at www.aaos.org/guidelines 

Research for Osteochondritis Dissecans of the Knee 

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• The Clinical Presentation 

• Decision Making Algorithm 

• Surgical Option 

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274 

elbow iNJury iN the youNg throwiNg athlete 

George A. Paletta, Jr., MD 

Incidence of Injuries 

• Professional Baseball 

— 28% of injuries involve SHOULDER 

— 22% of injuries involve ELBOW 

— Injury rate increasing 

• Youth Baseball 

— 50% of 9-14 yr olds complain of shoulder or elbow pain 

— Number of severe injuries (ligament tears) is increasing 

Comparison of Youth and Professional Pitchers 

• Kinematics — patterns of motion 

— no differences except elbow flexion angle increases with age 

• Kinetics — forces of motion 

— significant differences at all levels 

— elbow and shoulder torques and forces increase with age and 

skill 

Forces at the Elbow 

• Tension/distraction 

— MCL 

— Medial epicondyle 

• Compression 

– Radius/capitellum 

Common Injury Patterns 

• Elbow 

— Medial Tension 

– “Little Leaguer Elbow” 

– Apophyseal Injury 

– Tendonitis 

– Ligament Injury 

— Lateral Compression 

– Osteochondritis dissecans 

— Posterior Valgus/Extension 

– Olecranon 

Skeletal Immaturity 

• Skeletally Immature 

— Open Physes, Unfused Apophyses 

– Biomechanically vulnerable 

– “Weak Link” 

“Little Leaguers Elbow” 

• Wastebasket Term 

• Encompasses Multiple Conditions 

— Medial epicondylar apophysitis/avulsion fractures 

— Ulnar collateral ligament sprain 

— Osteochondritis of the capitellum 

— Osteochondrosis of the radial head 

— Olecranon apophysitis 

Medial Apophysitis 

• Clinical History 

— Common age 10-13 

— Gradual onset medial elbow pain 

— Pain with activity 

— Inability to throw at full speed 

— Inability to fully straighten the elbow 

• Physical Exam 

— Tenderness at medial epicondyle 

— +/- mild flexion contracture 

— +/- pain on resisted wrist flexion 

— +/- pain, NO LAXITY on valgus 




Radiographs 

• Normal? 

• Widening 

• Fragmentation 

• Comparison views!! 

— Critical 

Additional Imaging 

• MRI 

— Rarely required 

— Used to rule out other pathology 

– UCL tear 

– Flexor-Pronator tear 

• Ultrasonography 

— Harada et al, AJR 2006 

— Survey study 

— 153 Little Leaguers 

— Ages 9-12 

— Successful detection of medial epicondylar fragmentation in 

33 

— All confirmed by x-ray 

Treatment 

• Active Rest 

— Pinch Hit/DH 

• Ice 

• NSAIDs 

• Physical Therapy? 

— Core 

— Shoulder 

— Address Deficits 

• Gradual return to activity when symptom free and exam WNL 

• Typical return 6-12 weeks 

• Modification of throwing to minimize recurrence risk. 

Medial Apophyseal Avulsion 

• Clinical History 

— Acute event 

• Single pitch or throw 

— Sudden “pop” 

— Pain medial elbow 

— Acute inability to throw — +/- ulnar nerve symptoms 

• Physical Exam 

— Swelling, ecchymosis 

— Epicondylar tenderness 

— Limited ROM 

— Pain with wrist flexion 

— Pain with valgus stress 

— ? Valgus Instability 

— ? Ulnar Nerve Sxs 

Radiographs 

• Usually Diagnostic 

• Apophyseal Widening 

• Fragmentation 

• Displacement 

— Inferior/Distal 

— Rotational!! 

• Stress Views 

— Motion at apophysis 

• Woods & Tullos Classification 

— AJSM 5, 1977

275 

— Type 1 

– Younger athlete 

– Large, displaced fx 

— Type 2 

– Adolescents 

– Small fragment 

Treatment 

• Guidelines 

— Degree of Displacement 

— Bennett & Tullos 

– 3-8 mm displaced 

— Ireland & Andrews 

– Clin Sports Med 1988 

– Accept NO displacement 

• Treatment 

— Non-displaced 

– Short term immob 

– Early ROM 

— Displaced (> 2 mm) 

– Surgical treatment 

– Percutaneous screw fixation 

– ORIF 

Treatment Outcomes 

• Osbahr et al, J Shoulder Elbow Surg, 2010 

— Level IV, Case Series of 8 pts. 

— Non-op if 5mm displacement 

— All healed, all returned to play 

— Ave time to return = 7.6 mos (4-10) 

— Risk Factor = non-compliance with USA Baseball Pitching 

Recommendations 

Late Sequelae 

• Malunion 

• Medial Epicondylar Prominence 

• Persistent Pain 

Late Sequelae 

• Painful Non-Union 

• Ulnar Nerve Sxs 

Treatment of Late Sequelae 

• Gilchrist and McKee, JSES 2002 

• Fragment Excision and UCL Repair 

— 5 cases of non-union 

— Average 10.1 yrs after fracture 

— Initial treatment non-op in ALL 

— Mayo Elbow Performance Score 

• 66 pre-op vs. 91 post-op (p

Takahara et al, JBJS 1998 

Natural History 

• UNPREDICTABLE !! 

— no good criteria to predict healing 

— IF healing usually by physeal closure 

— late sequelae 

– loose bodies 

– residual capitellar deformity 

– degenerative changes 

– Radial head enlargement 

Treatment Principles 

Guided by lesion classification! 

Lesion Classification 

• Baumgarten et al, AJSM 1998 

• Petrie & Bradley, in DeLee/Drez 2003 

Non-Surgical Treatment 

• Indications 

— Intact, stable lesion 

— Lesions without collapse 

— No mechanical symptoms 

Non-Surgical Treatment 

• STOP THROWING 

• NSAIDs 

• early splinting for acute symptoms 

• maintain range of motion 

• periodic radiographic follow-up 

• gradual return to activity when asymptomatic 

• ? radiographically healed ? 

Results of Non-Op Rx 

Takahara et al, AJSM 1999 

• 24 patients, ages 11-16 (ave 13.3 yrs) 

• Rx = activity modification 6 months 

• F/up = 5.2 yrs ave 

Surgical Indications 

• Indications 

— Type I Lesions which fail conservative Rx 

— UNSTABLE LESIONS = Type II, III, IV 

Surgical Technique 

• Intact Articular Cartilage 

— arthroscopic drilling +/- pinning 

— “outside in” technique 

— fluoroscopic guidance 

— arthroscopic visualization 

– do not violate articular cartilage 

Surgical Options 

• Unstable Articular Cart 

— In-situ fixation 

— must consider how much subchondral bone backing on 

lesional tissue 

— “How much is enough” -UNKNOWN 

— In situ fixation technically demanding 


• Unsalvageable Loose Fragment 

— Reattachment ONLY if acutely detached, ideal match 

— Debridement alone 

— Debridement + Microfracture 

— Mosaicplasty 

– Osteochondral autograft 

– Synthetic plugs 

Bipolar Lesions 

276 




• Limited Options 

— Radial head microfracture 

— Radial head resection/replacement 

Classification, Treatment, and Outcome of OCD of the Humeral 

Capitellum Takahara et al, JBJS 89-A, 2007 

• Review of 106 cases 

• Mean age 15.3 years 

• 36 non-op Rx 

• 70 operative Rx 

— 55 fragment removal 

— 12 fragment fixation 

— 3 mosaicplasty 

• 7.2 years mean f/up 

• Prognostic Factors 

— Non-op Group 

– Open capitellar physis 

– Good elbow ROM 

– Localized subchondral bone flattening 

— Operative Group 

– Closed capitellar physis 

– Flex contracture > 20o 

– Fragmentation on xray 

Results of Lesion Debridement 

Bauer et al, CORR 1992 


• 23 years ave. f/up 

• All Rx’d with fragment removal, debridement 

• 50%residual symptoms 

— pain, loss of extension 

• 61% with radiographic degenerative changes 

• 58% radial head enlargement 


Ruch et al (Arthroscopy 1998) 

• 12 adolescents 

• Debridement alone 

• 3.2 yrs follow-up 

• 92% satisfied 

• 100% capitellar remodeling by x-ray 

• 42% radial head enlargement 

• 42% lateral capsular avulsion fragment 

— Poor prognostic sign 

— Recently reiterated by Kocher et al 


Takahara et al (CORR 1999) 


— 14 non-surgical 

— 39 surgical 

• Ave. 12.6 yrs f/up 

• Lesion Factors 

— Chronicity 

— Size 

— Degenerative changes 

• Poor Outcome Predictors 

— Lesion size 

• > 70% capitellum 

— Presence of DJD on X-ray 

• No Outcome Effect 

– Lesion chronicity 

Results of Lesion Drilling 

• Jackson et al, Arthroscopy 1989 

— review of 9 cases in female gymnasts 

— arthroscopy, curettage, drilling, removal of loose bodies

277 

— average follow-up = 2.9 yrs. 

— all noted improvement in symptoms 

— 1/9 returned to gymnastics (with pain) 

Results of Marrow Stimulation Technique 

Baumgarten et al (AJSM 1998) 

— review of 17 elbows 

— debridement + abrasion chondroplasty 

— Min. follow-up = 24 mos. 

— Ave. follow-up = 48 mos. 

— 7/9 returned to throwing 

— 4/5 returned to gymnastics 

— 3/3 returned to presurgery activities 

— 8/17 capitellar flattening on x-ray 

— 2/17 required reoperation 

Mosaicplasty Outcomes 

• Yamamoto et al 

— AJSM 34, 2006 

— 18 baseball players 




— Mean age 13.6 years 

— 9 Unstable In Situ 

– All subjectively improved 

– No objective improvement 

– 6/9 returned to baseball 

— 9 Displaced Lesions 

– All improved subjectively and objectively 

– 8/9 returned to baseball 

• Iwasaki et al 

— AJSM 34, 2006 

— 8 baseball pitchers 

— Mean f/up = 24 months 

— 7/8 pain free 

— All grafts incorporated by x-ray and MRI 

— 6/8 returned to pitching 

Closing Wedge Valgus Humeral Osteotomy 

Kiyoshige Y. et al; AJSM 28, 2000 

Thank You

278 

Stop (SportS trauma aNd overuSe preveNtioN): 

a paradigm For the preveNtioN oF youth SportS iNJurieS 

aNd how you CaN get iNvolved 

James R. Andrews, MD 

The Problem 

1. 30 million children participate in organized sports. (Source: 

Safe Kids USA) 

2. Participation in high school athletics is increasing, with more 

than 7.3 million high school students participating annually. 

(Source: National Federation of State High School Associations) 

3. High school athletics account for more than 2 million injuries 

annually, including: 

a. 500,000 doctor visits 

b. 30,000 hospitalizations 

(Source: Centers for Disease Control and Prevention) 

4. Young athletes are specializing in sports (and positions) at an 

earlier age, with more than 3.5 million children under age 14 

treated annually for sports injuries. (Source: Safe Kids USA) 

5. Immature bones, insufficient rest after injury, and poor training 

and conditioning contribute to overuse injuries. 

6. Overuse injuries account for half of all sports injuries in middle 

school and high school. (Source: Safe Kids USA) 

The Lasting Problem: A child’s history of injury is….. 

1. A risk factor for future injury during both their youth and 

adulthood. 

2. A contributor to longαterm degenerative diseases, such as 

osteoarthritis. 

3. 70% of kids participating in sports drop out by the age of 13 

because of 

a. Adults 

b. Coaches 

c. Parents 

These children lose the benefits of exercise, teamwork and 

healthy competition! 

What is Overuse? 

Overuse is considered excessive and repeated use that results in 

injury to the bones, muscles or tendons involved in the action. 

Why are Injuries on the Rise? 

1. Immature bones 

2. Insufficient rest after an injury 

3. Poor training or conditioning 

4. Specialization in just one sport 

5. Year-round participation 

What Can We Do to Prevent Overuse and Trauma Injuries? 

1. Promote injury prevention on multiple levels, including: 

a. Learning about the STOP Sports Injuries campaign and 

visiting www.STOPSportsInjuries.org for resources 

b. Holding ongoing discussions with athletes about the 

importance of rest 

c. Mandating preαseason physicals 

d. Requiring warmαup and coolαdown routines 

e. Encouraging proper strength training routines 

f. Be sure kids drink enough water based on activity and 

temperature levels. 

g. Educate athletes on proper nutrition for performance. 

h. Supervise equipment maintenance. 

i. Encourage kids to speak with an athletic trainer, coach or 

physician if they are having any pain. 




j. Work with local athletic governing bodies to mandate pitch 

counts and limit the number of matches or tournaments 

played. 

k. Encourage participation for fun and limit emphasis on 

winning. 

l. Discourage early specialization. 

m. Treat symptoms of problems/injury EARLY. 

Proper Technique is Key 

1. Provide proper instruction on throwing mechanics. 

a. Discourage the teaching of curve balls until high school 

(after puberty). 

b. Ban the radar gun in youth sports. 

c. Mandate a threeαmonth “rest period” each year for throwing 

athletes. 

Organizational Partners for STOP Sports Injuries Campaign 

1. Sports Medicine Organizations 

a. American Orthopaedic Society for Sports Medicine 

b. National Athletic Trainers’ Association 

c. American Medical Society for Sports Medicine 

d. American Academy of Orthopaedic Surgeons 

e. American Academy of Pediatrics – Sports Section 

f. National Strength and Conditioning Association 

2. Related Organizations 

a. Youth Sports Leagues (Little League) 

b. Professional Leagues 

c. Medical Institutions (Cleveland Clinic) 

d. Safe Kids USA 

Campaign Focuses on 12 Sports 

1. Baseball 

2. Swimming 

3. Football 

4. Basketball 

5. Cheerleading 

6. Tennis 

7. Dancing 

8. Gymnastics 

9. Soccer 

10. Running 

11. Volleyball 

12.Softball 

Educational Content 

1. Sports tips (Sportαspecific information) 

2. Video Podcasts 

3. Specific educational tool kits focused on various audiences 

a. Parents 

b. Athletes 

c. Coaches 

d. Healthcare providers 

Web Site resources 

1. Educational resources 

2. Media center 

3. Downloadable applications 

4. Online survey 

5. Quizzes

6. Blogging 

7. RSS feeds 

8. Social media interaction through Facebook and Twitter 

What Does the Future Hold? 

1. Better prevention of injury 

2. Evaluation of new, less invasive surgical techniques to treat 

injuries 

3. Ongoing research to understand the injury risk and how to 

prevent it 

4. Continued rise in injury rates unless education is increased 

279 




Other Resources 

www.STOPSportsInjuries.org 

www.orthoinfo.org 

www.nata.org 

www.sportsmed.org 

www.SAFEKids.org 

Let’s Work Together to STOP Sports Injuries And Keep Kids in 

the Game for Life!

280 

hoSpital-baSed employmeNt oF 

orthopaediC SurgeoNS: paSSiNg treNd 

or New paradigm? (l) 

Moderator: Kevin J. Bozic, MD, San Francisco, CA 

We will evaluate the factors that favor provider alignment and the pros/cons of hospital-based employment from the 

physician, hospital, payer, patient, and healthcare system perspectives. 

I. Overview 

Kevin J. Bozic, MD, San Francisco, CA 

II. Current Trends in Hospital Employment of Specialists 

John Cherf, MD, Chicago, IL 

III. A View from the Trenches: Pros and Cons Hospital-Based Employment 

Martin W. Roche, MD, Ft. Lauderdale, FL 

IV. Am I Ready to be an Employee? 

Samuel G. Agnew, MD, Florence, SC 

V. The Hospital’s Perspective on Specialist Employment and Alignment 

Richard Afable, MD, Newport Beach, CA 

VI. Discussions, Questions & Answers 

All Faculty 



SympoSia pRACTiCE

281 

hoSpital-baSed employmeNt oF orthopaediC SurgeoNS: 

paSSiNg treNd or New paradigm? 

Kevin J. Bozic, MD, MBA 

1. Overview: Current Trends in Hospital Employment of 

Specialists 

a. Early 1990’s hospitals acquire primary care physician 

practices 

i. Increasing market share by controlling referrals of 

patients enrolled in managed care plans and increasing 

negotiating leverage with managed care organizations. 

ii. Employment relationships hastily developed, with very 

little foresight and planning regarding the goals and 

responsibilities of each party. 

iii. Importance of physician leadership, accountability, and 

cultural differences between hospitals and physician 

practices were grossly underestimated. 

iv. Most of these relationships resulted in financial losses 

and were divested by the end of the decade (Reese SM 

2010) (Berenson, Ginsburg et al. 2007) (Casalino and 

Robinson 2003). 

b. Since the mid-late 2000’s, there has been an increasing trend 

towards hospital acquisition and employment of specialist 

physicians. 

i. Physician recruiting agencies note that hospitals 

are among their fastest growing clients, and now 

compromise the largest percentage of their physician 

recruiting activity. 

ii. Specialist physicians, including orthopaedic surgeons, 

are among the most common hospital-based physician 

recruitments (Merritt Hawkins & Associates (MHA) 

2009). 

2. Overview: Factors Driving Trends in Hospital Employment of 

Specialists 

a. Factors Driving Trends: Hospital Perspective 

i. Gain/preserve market share 

ii. Eliminate competition 

iii. Stabilize medical staff (clinical needs, E.R. call, indigent 

care) 

iv. ‘Control’ physicians 

v. ‘Enterprise development’ (halo effect0 

vi. Reduce operating costs through alignment (supply chain) 

vii.Rationalize large capital investments (e.g., EHR) 

viii. Help implementing Quality Initiatives 

ix. Health Reform (ACO’s, bundled payments) 

b. Factors driving Trends: Physician perspective 

i. Declining professional reimbursement 

ii. Rising overhead 

iii. Increasing regulation (e.g., Stark, anti kick-back) 

iv. Uncertainty about the future 

v. Off-load financial, regulatory risk 

vi. Desire to reduce administrative burden, focus on clinical 

care (HR, Payroll, Capital Budgeting, etc) 

vii.Lack of formal business training 

REFERENCES 

1. Agnew SA, Henley MB, Nepola J and Bray T (2008). The Business of 

Orthopaedic Trauma: cause and effect of failure. OTA-AAOS Branded 

Symposium, AAOS Annual Meeting. San Francisco, CA. Developing a 

Hospital-Physician Alignment Strategy: Employment Is Not the Only Answer. 

Great Boards; 2008. 



SympoSia pRACTiCE 

viii. Generational, lifestyle factors 

c. Other factors driving trend towards hospital employment of 

orthopaedic surgeons 

i. Health care policy and reimbursement trends 

ii. Vertically integrated delivery networks (Intermountain 

Health Care, Geisinger Health System, and the Mayo 

Clinic) 

3. Potential Benefits of Employment Model 

a. Improved quality and efficiency of care 

b. Vertically integrated, coordinated care 

c. Seamless transitions between inpatient, outpatient care 

d. Shared EHR 

e. Alignment of incentives => improved financial performance 

f. Increased access to quality improving, cost-saving 

technologies (e.g, EHR, inventory management) 

g. Contracting leverage 

h. Supply chain 

i. Payers (bundled payments, ACO’s) 

j. Ability to treat patients regardless of payer mix 

k. Shared accountability, responsibility, and rewards 

l. Increase patient satisfaction 

4. Potential Risks of Employment Model 

a. Decreased productivity 

b. Less efficient site of service (increased cost) for certain 

services (e.g., imaging, ASC v. HOPS, etc.) 

c. Decreased competition 

d. Fewer checks and balances 

e. Decreased choice for patients 

f. Legal exposure to anti kick-back statutes 

g. Loss of professional autonomy 

h. Fragmentation of the profession 

i. Impact on professional society involvement 

5. Keys to Successful Partnership 

a. Clear understanding of roles, responsibilities 

b. Well-defined goals, performance metrics 

c. Sustainable, patient-centric value creation 

d. Quality, efficiency 

e. Legal considerations (commitment of resources, dispute 

resolution, exit strategy, indemnification) 

f. Strong physician leadership (problem solvers) 

g. Visionary hospital administrators 

h. Integration of cultures 

i. Mutual trust, respect 

6. Questions still remain 

a. Sustainability 

b. Impact of health reform 

c. Challenges/Opportunities 

d. Important for our leadership, membership to understand 

implications, factors necessary for success 

2. Berenson, R. A., P. B. Ginsburg and J. H. May (2007). “Hospital-physicians 

relations: cooperation, competition, or separation?” Health Aff (Millwood) 

26(1): w31-43. Buschmann JR and Bozic KJ (2009). “Hospital-physician 

alignment: Passing trend or a new paradigm?” AAOS Now 3:10. 

3. Casalino, L. and J. C. Robinson (2003). “Alternative models of hospitalphysician 

affiliation as the United States moves away from tight managed 

care.” Milbank Q 81(2): 331-51, 173-4.

4. Casalino, L. P., E. A. November, R. A. Berenson and H. H. Pham (2008). 

“Hospitalphysician relations: two tracks and the decline of the voluntary 

medical staff model.” 

Health Aff (Millwood) 27(5): 1305-14. 

5. Eisenberg SA. http://www.physiciansnews.com/2009/02/04/the-boomerangeffecthospital-employment-of-physicians-coming-back-around. 

Warminster, 

PA. Accessed February 14 2009. 

6. Health Leaders Magazine. http://www.healthleadersmedia.com/content/ 

HOM203629/Ties-That-Bind-Developing-HospitalPhysician-Alignment. 

html##. Accessed July 2010. 

282 




7. Medical Group Management Association (MGMA). http://www.mgma.com/ 

press/default.aspx?id=34032. Accessed July 2010. 

8. Medical Group Management Association (MGMA). http://www.mgma.com/ 

WorkArea/DownloadAsset.aspx?id=33964. Accessed July 2010. 

9. 2009 Review of Physician and CRNA Recruiting Incentives. 2009. 

10. Episode-Based Payments: Charting a Course for Health Care Payment 

Reform. National Institute for Health Care Reform Policy Analysis; 2010. 

11. Physician-Hospital Employment: Gaining Ground, but What’s Beyond the 

Bend? Medscape Business of Medicine; 2010.

283 

hoSpital-baSed employmeNt oF orthopaediC SurgeoNS: 

paSSiNg treNd or New paradigm? 

John Cherf MD, MPH, MBA 

I. Orthopaedics has traditionally been a lucrative specialty and 

a key source or revenue for healthcare providers 

• Demand forecasting for orthopedic services over the next 

ten years suggests moderate inpatient growth and strong 

outpatient growth 

• There will also be a significant physician shortage that may 

double during the next ten years. The demand for orthopedic 

surgeons will continue to outpace the supply 

II. Centers of Medicare and Medicaid Services (CMS) covers 

more insured lives than any other payer and is expected to 

grow in the future 

• In order to help control healthcare costs, CMS is moving 

toward value-based purchasing. This is transforming CMS 

from a passive payer to an active purchaser of high-quality, 

efficient care 

III. New payment pilots and programs are clearly defined in the 

Patient Protection and Affordable Care Act 

• A continuum of payment models is emerging 

• New payment models are a deviation from fee-for-service 

and traditional capitation 

IV. Commercial and private payers are also taking a role in 

shaping programs for their patients in order to reduce costs 

and improve quality 

• Gatekeeper models 

— Achieve cost savings by creating barriers to surgical 

consults 

— Require authorization and precertification 

— Reduce surgery and imaging utilization 

REFERENCES 

1. Orthopaedic Practice and Medical Income in the US 2008. AAOS 

Department of Research and Scientific Affairs. June2009. 

2. Centers for Medicare&Mediciad Servces. 2007. 

3. The Health Care Acquisition Report, Fifteenth Edition. Irving Levln 

Associates Inc. 2009. 

4. Merritt Hawkins & Associates. 2008. 

5. Orthoindex Analysis. 2009. 




• Value Designations 

— Uniformly elevate the level and quality of care 

— Achieve cost savings by steering patients to high-quality, 

low-cost providers 

• Patients may be incentivized to use “high-quality” providers 

V. Tighter Hospital-physician alignment improves performance 

and value 

VI. Macroeconomic trends suggest that physicians have 

experienced larger decreases in payment than other 

healthcare stakeholders 

• The SGR has dramatically impacted physician payment 

• Orthopedic surgeons remain a highly compensated provider 

and a significant source of revenue for hospitals 

• A physician cost/benefit analysis suggests that hospital 

employment of orthopedic surgeons is a reasonable 

investment of capital 

VII. Hospital-physician integration is reemerging 

• The dynamics of orthopedic surgeons practices are changing 

• Provider collaboration can be achieved through a spectrum 

of options 

• More orthopedic surgeons engaging in formal hospital 

relationships 

• What is the up side and what are the risks? 

VIII. There is no “one size fits all” 

• Opportunity and Alternatives 

• Compensation and Governance 

• Regulatory considerations and legal exposure 

6. Page L. Physician Shortages impede hospitals’ service linedevelopment. 

http://www.beckershospitalreview.com/news-analysis/physician-shortagesimpedehospitals-service-line-development.html. 

Accessed May 2010. 

7. Medicare Hospital ValueBased Purchasing Plan. Senate Finance Committee 

Rountable March 62008Sg2 analysis. 2009. 

8. Sg2 Analysis. 2009. 

9. The Henry J Kaiser Family Foundation. Health Reform Implementation 

Timeline. Accessed September 2010.

284 

aN employed phySiCiaN’S perSpeCtive 

Martin Roche, MD 

Why it Started: 

• 1996 significant penetration of HMO’s 

• MD : Loss of “Practice Value “ to sell 

• Practice Expenses increasing 

• Debt and start up costs for New Surgeons 

• Managing an office and support staff more difficult 

• Reimbursements Declined 

• Dealing with government regulations were becoming more 

onerous and complicated 

• Referral Patterns Changed 

— physicians affiliated with integrated networks ( panels ) in 

order to receive new business and referrals 

Top 10 Issues for Doctors in 2010-11-10 

Dealing with rising operating costs (that are rising more rapidly than 

revenues, 2008, 2009) Managing finances with the uncertainty of 

Medicare reimbursement rates Selecting and implementing a new 

electronic health record system Maintaining physician compensation 

levels (in an environment of declining reimbursement, 2008, 2009) 

Recruiting physicians Collecting from self-pay, high-deductible health 

plan and/or Health Savings Account patients Negotiating contracts 

with payers Managing teamwork and group dynamics among 

physicians Modifying your physician compensation methodology 

Participating in the Medicare Physician Quality Reporting Initiative 

Model of Multispeciality Hospital Based Group 

Initial Orthopedic Group of 10 Surgeons 1996 

4 Joint Surgeons / 2 Foot and ankle / 3 sports / 1 general 

Hired 4 out of training (podiatrist, 2 Physiatrists, 1 joint) 

2 independent surgeons joined 2007 

5 man local group joined 2008 

Benefits: 

• Early Risk Reduction 

1.) Guaranteed Salary – No start up costs (401K, Medical, 

Disability, Life, Malpractice) 

2.) Leveraged Insurance Negotiations 

3.) Hospital Facility / Technical Fee (Office visit, x-ray, 

procedures) 

4.) Ortho Director and Management 

Billing / Collections / Coding 

5.) No “buy in “ to “Partner” 

6.) Your Employees are Hospital Employees (HR, salary, etc..) 

7.) One Hospital based practice – improved efficiencies with 

less FTE’s 

8.) In- House Legal team for medical defense, define emerging 

legal relationships for Hospital – Surgeon 

9.) Hospital In house recruitment team 

10.) Improved Communication (Team approach with staff and 

Hospital) 

Group Multispeciality Benefits: 

• Multispecialty Referral Base 

• Inter- group referral (subspecialists) 

• Leverage with numbers in negotiations 

• Equal Shared Ancillaries / Individual Overhead 

• Paid ER call, call 1/10 weeks 

• Experienced First Call PA/ nurses 

• Efficient OR staff, 2 rooms for >6 cases/ Day 

• Fully dedicated Orthopaedic Floor 

Individual Surgeon Contracted with Hospital Employment 




Models 

• Salary 

• RVU (relative value units) 

• Fee for Service 

• Concierge / Out of Network 

Ancillaries 

• Joint – Venture ASC 

• Physical Therapy (Designated Health Care Service) 

• MRI 

• DME 

• Stark Law Prevail 

Purchasing 

• Office Equipment (hospital chain discounts ) 

• DME/ Digital X-ray/ EMR 

• Hospital Builds out New Facilities with low rent (FMV) 

• Implant Negotiations 

— Open access – no technology limitations 

— Work collectively to support hospital 

— No gain sharing to date 

Research: 

• In house research capabilities 

• Full time research position 

• IRB 

• Institute Designation allows patient gifts, donations that are 

designated for Orthopaedic research 

• Improved data collection with hospital- office -PT 

Marketing: 

• Fully Budgeted Marketing Team 

• Website Development 

• Educational Seminars 

• Close News contacts 

Disclosures 

• Physician Industrial Relationships 

• Any entity that does business with the Hospital 

• Surgeon retains all his/ her IP 

Potential Negatives of an Employment Contract: 

• Long term contract with 1 year release 

• You have a “boss” 

• Heavy Medicare oversight – corporate compliance – coding- etc.. 

• Local Non-Compete in Contract 

• Cannot prevent a “ hire” MD/ Adm etc… 

• No Practice to “sell” – Develop Hospital Name vs Individual? 

• Non- for –Profit status adds regulations (FMV etc..) 

• Relationship with CEO can change 

• Your importance is based on volume and present profitability 

for the hospital “Service Line” 

• Minimal pre-tax deductions vs solo (PA) 

• No Equity in Individual Practice 

• Slow integration of EMR – Software systems for whole medical 

grp and hospital 

OUTLINE FOR SUCCESS REQUIRES 

• Trust and openness from beginning with Administration (Chief 

/ Board / Meetings) 

• Work as a team regarding strategy to providing superior patient 

care “Integrated Care Pathways” 

• Educate surgeons on Hospital decisions and constraints while 

maintaining personnel autonomy regarding patient care

• Aligned Mission and Philosophy with a Growth Plan 

• Develop a multispecialty Orthopedic group - allows expertise, 

inter referrals, minimizes competition, hiring decisions 

• Joint surgeons need to develop a strong relationship with 

hospital to navigate future reimbursement strategies and 

technology advancements 

REFERENCES 

1.) Hospital-physician alignment: Passing trend or a new paradigm? By Jacque 

Roche Buschmann and Kevin J. Bozic, MD, MBA 

2.) http://www.aaos.org/news/aaosnow/oct09/reimbursement3.asp 

3.) http://www.hospitalimpact.org/index.php/leadership/2006/10/11/physician_ 

employme nt_the_other_capital_e 

4.) http://www.mgma.com/press/default.aspx?id=34032 

5.) http://www.mgma.com/WorkArea/mgma_downloadasset.aspx?id=33964 

285 




Build the foundation to respond to a dynamic healthcare 

delivery system 

• Bundled Payment to hospital – MD 

ACO’s (Accountable Care Organizations) 

• Define Clinical Pathways / PQRI / EMR 

• Comparative Effectiveness 

• Outcome Registries / Pay for Performance 

• Profit Sharing / Stark / Implant Decisions 

• Income Options as Reimbursement Decreases 

6.) http://www.mgma.com/stark/ 

7.) http://physicianlaw.foxrothschild.com/2009/08/articles/fraud-andabuse/ 

hospitalphysician-employment-compensation-may-run-afoul-of-stark/ 

8.) http://www.greatboards.org/newsletter/reprints/GB-2008-Winter-Hospital- 

Physician-Alignment-Strategy-reprint.pdf 

9.) http://www.healthleadersmedia.com/content/HOM-203629/Ties-That-Bind- 

Developing-HospitalPhysician-Alignment.html##

Seek outside help to achieve your intended goal: 

Resources: 

AAOS Practice Management: 

http://www3.aaos.org/member/prac_manag/prac_manage.cfm 

http://www3.aaos.org/member/prac_manag/company/ 

res_intro.cfm 

Legal: Fox Rothschild LLP: http://www.foxrothschild.com/ 

Background: 

• How did you arrive at the decision to be an Employed Surgeon; 

< 25% of all Orthopaedic Surgeons are full time employees of a 

facility or Health System? 

— Recruiter Techniques/Tactics 

— Right Location 

— Right Compensation 

• What problem or strategic plan did employing a surgeon fix or 

compliment? 

— Market acquisition or niche program development? 

— Call Panel support? 

— Ancillary Revenue Maintenance? 

• What strategic component of your career plan did being 

employed by your Institution accomplish? 

— Are these compatible plans/goals? 

• What pro forma was produced to justify said position? 

— What methodologies for growth in your sector are budgeted 

for? 

• What contract review process was undertaken? 

— Contract attorney? 

— Mentor, Fellowship director, Co-worker? 

• SWOT Analysis? 

• Operational Issues: The Successful Surgeon 

• The Contract (PSA) is the tool for ultimate success, in its generic 

(template) form it is nothing more than a compensation 

formula with a 90, 120, or 180 day out. 

Operational Issues: The Successful Surgeon 

• Defined Expectations and Deliverables and the accordant 

timeline. 

• Institutional and Individual performance guarantees 

• Operational Authority 

• Process improvement authority 

• Service Line re-investment formulae 

Aligned Interests: 

• Sustainable performance-based model capable of yearly 

improvements in both surgeon lifestyle and Institution 

Contribution Margin 

• Growth Objectives 

— Anatomic 

— Geographic markets 

Metrics: Transparent and reportable 

• New Physician acquisitions 

• Cost Containment 

• Enterprise Effects 

• Satisfaction surveys 

BIBLIOGRAPHY 

Database Queries: 

1. U.S Department of Health and Human Services: Agency for Healthcare 

Research and Quality: H-CUP.net http://hcupnet.ahrq.gov/. Accessed 

September 1, 2010 

286 

the eFFeCtive employed SurgeoN 

Samuel G. Agnew MD FACS 




The Generational changes that have occurred through evolutional 

developments in the personalities of our colleagues is real, and has 

been a factor driving the Employment sector as Millennials seek 

change from the norm as an over-arching belief/quest, combined 

with having work restricted training. 

Decision-bias: The perception that only 2 options (private or 

employed) exist there is a natural shift to the new alternative. 

Hospitals and Health Systems by and large do not want to 

employ legions of physicians; however it has become a bona fide 

strategy and the only new Orthopaedic strategy. 

• Reluctant employer who seeks above all else compliance and 

consistency. 

Consequences noted from the employed sector: 

1. Loss of Autonomy 

2. Compliance supersedes creativity and ingenuity 

3. Service Line development supersedes Career Development 

4. Medical Staff societal impacts 

The unique culture that is Orthopaedic Surgery has not universally 

been developed in the employed sector, service lines consisting of 

combined lines: Orthopaedics, General Surgery, and Neurosurgery 

are oftentimes too disparate culturally given temporal, technological, 

and clinical diversities to be universally managed even with Physicianled, 

Professionally managed ethos. 

Effective Employed Surgeons: 

I. Design processes that generate mutual Value. 

II. Create standardized protocols and pathways that reduce waste 

or loss, and streamline processes. 

III. Produce annual growth-anatomic and geographic. 

IV. Improve performance of individual and institution on a regular 

(and reportable) basis. 

V. Place Institution over Individual needs 

VI. Physicians become strategic partner & core customer 

VII. Operate under a Performance-based model. 

VIII. Undergo some form of Best-fit analysis pre-induction. 

Alternatives do exist that deliver personal freedom returns, autonomy, 

and mutual success, and value: however require a unique personal 

skill set on behalf of the practitioner that must be either identified or 

developed. Being an MD does not = Strong Leadership by decree. 

I. Hospital-Within-a-Hospital model 

a. Dedicated service executive required 

b. Executive Management committee 

II. Management Service Organization: MSO 

a. Physician management and Leadership opportunity 

III. 3rd Party Management: 

a. Generally reserved for a comprehensive fracture or Trauma 

specific service 

Value, Performance and Leadership are the pillars of a successful 

Hospital-Physician Alliance on any level in any model. 

2. American College of Emergency Physicians Survey: www.acep.org/WorkArea/ 

downloadasset.aspx?id=8974. Accessed September 1, 2010 

3. Institute of Medicine Report: http://www.iom.edu/CMS/3809/16107/35007. 

aspx. Accessed September 1, 2010

4. American Academy of Orthopaedic Surgeons. Hospital Employment of 

Orthopaedic Surgeons. A Primer for Orthopaedic Surgeons. March 2010 

http://www3.aaos.org/member/prac_manag/prac_manage_cfm 

5. American Hospital Association Rapid Response Survey, Telling the Hospital 

Story Survey March 2010 http://www.aha.org/aha/research-and-trends/ 

health-and-hospital-trends/2010.html Accessed September 2, 2010 

6. American Academy of Orthopaedic Surgeons 2008 Member Census 

http://www3.aaos.org/research/opus/2008CensusMembers.cfm Accessed 

September 1, 2010. 

7. United States Department of Labor Bureau of Labor Statistics, http://www. 

bls.gov/oco/ocos074.htm Accessed September 3, 2010 Merritt Hawkins: 2010 

Inpatient/Outpatient Revenue Survey. Accessed September 2, 2010 

8. http://www.merritthawkins.com/pdf/2010revenuesurvey.pdf 

9. Institute of Medicine of the National Academies, Committee on the Future 

of Emergency Care in the United States Health System: Hospital-Based 

Emergency Care At The Breaking Point. The National Academies Press, 

Washington D.C. www.nap.edu http://www.nap.edu/openbook.php?record_ 

id=11621&page=R1 Accessed September 1, 2011 

General References: 

10. Covey S: 7 Habits of Highly Effective People New York: Simon and Schuster, 

1994 (ISBN -684-80203-Nordt JC III: The coming manpower shortage 

in Medicine. AAOS Now.February 2009 Issue http://www.aaos.org/news/ 

aaosnow/feb09/youraaos8.asp Accessed September 1, 2010. 

11. Borges NJ, Manuel S, Elam CL, Jones BJ: Comparing Mellenial and 

Generation X Medical Students at One Medical School. Academic Medicine, 

Vol.81, No. 6, 571-576. 2006 

12. Agnew SA, Vallier H: Career and Practice Management Issues in Orthopaedic 

Trauma, Orthopaedic Knowledge Update 4, Koval K, section editor, AAOS 

publication, September 2010 

13. Berenson RA, Ginsburg PB, May JH: Hospital-Physicians Relations: 

Cooperation, Competition, or Separation? Health Affairs, 26, no. 1 (2007): 

w31-w43 (Published online 5 December 2006) Retrieved January 12, 2007 

www.healthaffairs.org http://content.healthaffairs.org/cgi/content/full/26/1/ 

w31 doi: 10.1377/hlthaff.26.1.w31. Accessed September 1, 2010 

14. Budetti, PR., Shortell, SM., Waters, TM., Alexander, JA., Burns, LR., Gillies, 

RR., et al.: Physician and health system integration, Health Affairs, Vol. 21, 

No.1, 2002, pp. 203–210. 

287 




15. Casalino LP, November EA, Berenson RA, Pham HH Hospital-Physician 

Relations: Two Tracks and The Decline Of The Voluntary Medical Staff 

Model, Health Affairs, 27, no. 5 (2008): 1305-1314. www.healthaffairs. 

org http://content.healthaffairs.org/cgi/content/abstract/27/5/1305 doi: 

10.1377/hlthaff.27.5.1305 Accessed January 12, 2010 

16. Cortese, D, Smoldt R: Taking Steps Toward Integration 

Health Affairs, 26, no. 1 (2007): w68-w71 (Published online 5 December 

2006) www.healthaffairs.org 

http://content.healthaffairs.org/cgi/content/full/26/1 doi: 10.1377/ 

hlthaff.26.1.w68 Accessed September 1, 2010 

17. Eisenberg SA: The Boomerang Effect: Hospital Employment of Physicians 

Coming Back Around. , www.physiciansnews.com 

http://www.physiciansnews.com/2009/02/04/the-boomerang-effect-hospitalemployment-of-physicians-coming-back-around 

Accessed September 1, 2010 

18. Fabrizio NA, Bohlmann RC: Integrated Delivery Systems: Ensuring Successful 

Physician-Hospital Partnerships. Medical Group Management Association 

Publication pp. 57-87, 2010. 

19. Gillies RR, Zuckerman HS, Burns LR, Shortell SM, Alexander JA, Budetti PP, 

Waters TM.: Physician-system relationships: stumbling blocks and promising 

practices. Med Care. 2001 Jul;39 (7 Suppl 1):I92-106. 

20. Hauser M: “The ups and downs of managing employed physicians - Medical 

Management: A Profession in Transition”. Physician 

Executive. FindArticles.com. Retrieved 25 Jan, 2010. http://findarticles.com/p/ 

articles/mi_m0843/is_n5_v21/ai_16881953/ 

21. Warren, BJ: Employed Specialists: Is It The Right Service Line Strategy? 

Accelero Health Partners White Paper, November 2009, 

Retrieved February2010 www.accelerohealth.com/assets/file/Employed_ 

Specialists11_09(1).pdf 

22. White J: Putting a dollar figure on a Doctors worth to a Hospital. Retrieved 

Wall Street Journal On-Line April 2010. www.wsj.com http://blogs.wsj.com/ 

health/2010/03/17/putting-a dollar-figure-on-a-doctors-worth-to-a-hospital/ 

Accessed September 2, 2010 

23. Ziran BR, Barrette-Grischow MK, Marucci K: Economic Value of Orthopaedic 

Trauma: The (Second to) Bottom Line J. Orthop 

Trauma Vol 22, No 4, 227-233. 2008

288 

employed orthopediSt: the Strategy oF laSt reSort 

Richard Afable, MD, MPH 

1. Challenges for Hospitals and Physicians 

• Health Care Reform 

• Changing Consumer Expectations 

• Demographic Shifts Among Doctors 

2. “Know Your Circumstances” 

• Critical Elements of Personal and Organizational Strategy 




3. Aligned Incentives (or Not) 

• Medical Staff 

• Employment 

• Other Options: Joint Venture, Co-Managment, Shared 

Savings, ACO 

4. Hoag Orthopedic Institute: Case Study 

5. Conclusion and Recommendations

289 

healthCare reForm bill: 

paSt, preSeNt aNd Future (S) 




Moderator: John J. Callaghan, MD, Iowa City, IA 

The health care reform act (The Patient Protection and Affordable Care Act of 2010) is now law. The purpose of this symposia 

is to outline the events leading up to the enactment of the law as well as to outline the aspects of the health care reform bill 

that we believe will affect our AAOS members. Present strategies will be outlined. A perspective concerning the possible 

future and implementation of the health care reform bill will be addressed. A panel discussion including the leadership of 

the AAOS will then ensue. 

Participants: John J. Callaghan, MD, Iowa City, IA, Peter J. Mandell, MD, Burlingame, CA, and Stuart L. Weinstein, MD, Iowa City, IA 

Panel: Daniel J. Berry, MD, Rochester, MN, William Martin, III MD, Washington, DC, and John R. Tongue, MD, Tualatin, OR 


John J. Callaghan, MD, Iowa City, IA 

II. Health Care Reform: Promise and Reality 

Stuart L. Weinstein, MD, Iowa City, IA 

III. Health Reform Bill: The AAOS Perspective 

Peter J. Mandell, MD, Burlingame, CA 

IV. Future Strategy of the AAOS for Implementation of Health Care Reform 

John J. Callaghan, MD, Iowa City, IA 

V. Discussion, Questions and Answers 

All Faculty

This presentation will include information on the following aspects 

of Healthcare Reform: 

1. Why was healthcare reform a high priority for the Obama 

administration 

a. Escalating costs of healthcare 

b. Issues related to Quality 

c. Issues related to Access and Coverage 

2. History of Healthcare reform attempts in US 

a. Employer based healthcare system 

b. Attempts at reform from Teddy Roosevelt to Obama 

290 

healthCare reForm SympoSium 

Stuart L. Weinstein, MD 




3. Process of passage of PPACA 

a. Obama election, November 2008, to Passage of Healthcare 

reform (PPACA) legislation 2010 

b. The Process: Congressional choices and compromises 

leading to PPACA passage 

4. PPACA 

a. Outline of bill 2010 to 2018 

i. What it did 

ii. What it didn’t do 

b. Implementation phase

291 

the aaoS perSpeCtive oN the ppaCa 

Peter J Mandell, MD 

• AAOS anticipated the health care reform debate and prepared 

for it with 3 position statements: 

— Existing Government Programs—Medicaid and SCHIP 

Reform (3/08) 

— Principles of Medicare Reform (3/08) 

— Principles of Health Care Reform (2/09) 

• How closely does the PPACA align with AAOS principles on: 

— A permanent fix for the Medicare Physician Fee Schedule 

Sustainable Growth Rate (SGR) adjustment? 

— Meaningful medical liability reform? 

— Leveling the antitrust playing field? 

— Employee Retirement Income Security Act of 1974 (ERISA) 

reform? 

• How closely does the PPACA align with our patients’ goals to: 

— Choose their own orthopaedic surgeon? 

— Access high quality and value orthopaedic care? 

— Have affordable and portable health insurance? 

— End health insurance rescissions? 

— Eliminate preexisting condition denials? 

— Access physician owned, responsibly run facilities for their 

orthopaedic care? 




• Does the PPACA single out specialists for particular attention 

with: 

— The Independent Payment Advisory Board? 

— Restricting physician owned hospitals? 

— Not providing meaningful Medical Liability Reform? 

• How are Orthopaedic patients and their doctors affected by 

the phased rollout of the PPACA’s provisions? 

— Immediate reforms 

– High risk pools 

– 80-85% insurance medical loss ratio 

– Children’s’ coverage to age 26 

– End to lifetime limits on coverage 

– Elimination of insurance rescissions 

— Later reforms 

– No preexisting condition exclusions 

– State run insurance exchanges 

• The Republican alternative: 

— High risk pools for preexisting conditions 

— Ending junk lawsuits and reducing defensive medicine 

— Encouraging insurance purchasing pools for small business 

— Allowing purchase of insurance across state lines 

— Not mandating insurance coverage

292 

Future Strategy oF the aaoS For implemeNtatioN oF 

health Care reForm 

John J. Callaghan, MD 

The Patient Protection and Affordable Care Act and the Health Care 

and Education Reconciliation Act were signed into law March 2010. 

As implementation continues, the AAOS will address both legislative 

and regulatory issues which affect our patients and the profession. 

We will continue to advocate for our patients to receive the best 

quality of care for their musculoskeletal problems. 

Legislative Issues 

1) Sustainable Growth Rate (SGR) 

• The AAOS has and will continue our work with Members 

of Congress to permanently repeal and replace the SGR 

to ensure our patients maintain access to high quality 

orthopaedic care. This will continue to be our top priority. 

2) Independent Payment Advisory Board (IPAB) 

• IPAB is an independent appointed body tasked with 

reducing the growing costs of the Medicare program. 

As currently constructed, the Board does not have full 

authority over all aspects of the health care system, but 

rather is required to selectively exempt certain providers, 

such as hospitals, from its purview. This system incentivizes 

the Independent Payment Advisory Board to further cut 

Medicare reimbursements in areas under its jurisdiction. 

• In addition, the process and structure is fraught with 

potential unintended consequences – including preventing 

practicing physicians from serving on the Board and 

restricting access to important specialty care interventions 

and services for Medicare patients. 

• The AAOS will continue to strongly oppose the delegation of 

Congressional authority of the Medicare system to the IPAB 




or any other entity and will work with our Congressional 

champions to repeal this Board. 

3) Physician Owned Hospitals 

• The new health care reform law significantly restricts 

physician owned hospitals. The AAOS believes that 

physician owned hospitals are an important component 

of our health care delivery system. Physician owners have 

greater control over the facility and the quality and efficiency 

of care which can lead to higher quality patient care. 

• The AAOS will continue to work with our allies to repeal the 

restrictions on physician owned hospitals. 

Regulatory Issues 

Much of implementation of the new health care reform law will 

happen through the regulatory process. Some issues to watch for 

include: 

• New payment models including Accountable Care 

Organizations 

• Quality and Comparative Effectiveness 

• Utilization of Physical Therapy and Imaging 

• Patient Safety 

Your Academy will work through the newly established AAOS 

Institute of Quality to develop clinical guidelines, provide new 

technology assessments, and construct appropriate use criteria and 

performance measurements which will better define the “value” of 

interventions for our patients. The AAOS will continue to promote 

the American Joint Registry which is founded along with our 

Specialty Society partners.

293 

emr: maNdatory CompoNeNtS aNd 

eFFiCieNt uSe For the praCtiCiNg 

orthopaediC SurgeoN (X) 




Moderator: Jack M. Bert, MD, St. Paul, MN 

Participants will learn how to incorporate/maximize the efficiency of their current EMR and its components (templates, 

scanners and voice recognition) and understand basic E&M coding. 

I. Introduction: The problem with EMR; Are there any simple solutions? 

Jack M. Bert, MD, St. Paul, MN 

II. Determining Appropriate Components and Functions of an EMR: Is Meaningful Use Worth Obtaining? 

Louis F. McIntyre, MD, White Plains, NY 

III. Implications of Coding and EMR:Can We Make It Work Effectively? 

William R. Beach, MD, Richmond, VA 

IV. The process of EMR Implentation into Private Practice; How It Really Works 

Tony Pericle, Glen Allen, VA 

V. Discussion, Questions & Answers 

All Faculty

294 

emr: maNdatory CompoNeNtS aNd eFFiCieNt uSe For the 

EM R: Mandatory 

EM R: Mandatory 

praCtiCiNg orthopaediC SurgeoN 

Components and Efficient Use 

for the EM Practicing R: Mandatory 

Orthopedic 

Components Surgeon 

and Efficient Use 


Orthopedic 


and Faculty 

Efficient Use 

Jack M. Bert, MD 

for the Practicing Bil Beach, MD 

Orthopedic 

Louis McIntyre, MD 

Surgeon 

Faculty 

Jack M. Bert, MD, William R. Beach, MD, Louis F. McIntyre, MD, Tony Pericle 

Tony Pericle 

Jack M. Bert, MD 

Bil Beach, MD 

Louis Faculty 

McIntyre, MD 

Jack Tony M. Pericle 

Bert, MD 

Bil Beach, MD 

Louis McIntyre, MD 

Tony Pericle 

The problem s with current EM R 

system s 


system s 

•They They are cumbersome. 

•Drop The Drop The dow problem n boxes require s with significant current manual labor 

EM R 

•3 3 to 4 minutes/patient to enter data means 1.5 to 2 

hours of data entry for system a 30 patient s 

clinic!!! 

•They •Hire Hire They scribes are cumbersome. 

or med tech to do the work? 

•Drop •Have Have Drop dow patient n boxes enter require a l history significant data excluding manual labor 

HPI, 

Meds, •3 Meds, 3 to 4 pertinent minutes/patient surgical to hx. hxenter 

enter . which data must means be 

1.5 to 2 

individualized/patient? 

hours 

•They 


hours of data entry for a 30 patient clinic!!! 

They are cumbersome. 

•Hire Hire scribes or med tech to do the work? 

•Drop Drop dow n boxes require significant manual labor 

•Have Have patient enter a l history data excluding HPI, 

Meds, 

•3 

Meds, 

3 to 4 pertinent minutes/patient surgical to hx. hx 

enter . which data must means be 

1.5 to 2 


hours 


hours of data entry for a 30 patient clinic!!! 

•Hire Hire scribes or med tech to do the work? 

•Have Have patient enter a l history data excluding HPI, 

Meds, pertinent surgical hx. hx. 

which must be 


Requirements of Efficient EM R’s R 

Requirements of Efficient EM R’s R 

•Must Must use tem plates 

•Must Must use patients to enter data 

•Must Must have easy data entry 

•Must use optical scanning technology 

•Must Must use tem plates 

•Must Must have 

plates 

have macros for pre-populated pre populated material 

•Must Must use patients to enter data 

•Must Must have 

data 

have complete surgeon compliance 

•Must Must have easy data entry 

•Must Must use use tem optical tem optical plates 

scanning technology 

•Must Must use have use have patients macros to for enter pre-populated pre populated data 

material 

•Must Must have have easy complete easy complete data surgeon entry 

compliance 

•Must Must use optical scanning technology 

•Must Must have macros for pre-populated pre populated material 

•Must Must have complete surgeon compliance 

Requirements Must use optical scanning of technology Efficient EM R’s R 




Components and Efficient Use 


Orthopedic 




Orthopedic 



efficient” system 

for the Practicing workflow Practicing requirements”? Orthopedic 

Surgeon 

•W What hat are the necessary components? 

•How How to satisfy government requirements 

•How How to choose an “efficient 

•W What hat are the “workflow requirements 

•W What hat are the necessary components? 

•How How to 

components? 

to make the tem plates work for you 

•How How to satisfy government requirements 

•How How to 

requirements 

to reduce physician “work work time” time 

•How How to choose an “efficient efficient” system 

•W What hat are are the the 

necessary “workflow necessary workflow components? 

requirements”? 

requirements 

•How How to to satisfy make satisfy make the government tem plates requirements 

work for you 

•How How to to reduce choose reduce choose physician an “efficient efficient” “work work system 

time” time 

•W What hat are the “workflow workflow requirements”? 

requirements 

•How How to make the tem plates work for you 

•How How to reduce physician “work work time” time 


system s 


system s 

•Can Can these problem s be solved to result in an 

efficient, The problem simple to use s system with that current requires ; 

EM R 

PW PW T (patient work system time) 

s 

•Can decreased Can decreased these problem TET (team s be encounter solved to time) result time) result in an 

efficient, simple to use system that requires ; 

decreased decreased PET (physician encounter time 

PW PW T (patient work time) 

•Can Can these problem s be solved to result in an 

efficient, decreased decreased simple TET to (team use encounter system that time) 

requires ; 

 


 

PW PW T (patient work time) 

decreased decreased TET (team encounter time) 


 

 

 

 

Elem ents of a functional, 

efficient EM R & Meaningful Use 

Elem Louis ents McIntyre, of a functional, 

MD 

efficient EM R & Meaningful Use 

Elem Chair Louis of ents of ents AANA’s AANA McIntyre, of Health a Health a functional, 

Policy 

MD 

efficient Committee 

EM R & Meaningful Use 

Member of AAOS Coding Committee 

Chair Louis of AANA’s AANA McIntyre, Health Policy 

MD 

Consultant Committee Consultant Committee to RUC 

Member Chair Member of AANA’s AANA of AAOS Health Coding Policy 

Committee 

Consultant Committee 

Consultant to RUC 

Member of AAOS Coding Committee 

Consultant to RUC

295 

ARRA 

“Stimulus Stimulus Bil” Bil 

Signed into law 2009 

1.1 Bilion for implem entation of 

EM R/HER “HITECH HITECH Act” Act 

Final rules MANDATE EM R use by 

2015 or face decrease in Medicare 

reimbursement 

Prom ote 

Utilization 

Minimize 

Workflow 

Disruption 

Maximize 

Physician 

Productivity 

Surgeon Issues 

Unprepared 

No Templates 

Planned for use of “Cruise Cruise Pads” Pads for 

data entry 

No Vendor Support 

No Clue! 

Took 18 months to implem ent! 




EM R Efficient Use 

Surgeon User Issues 

Old Chart Issues 

Support Issues 

Hardw are Issues 

Prom ote Utilization 

PREPARATIO N 

Templates/D ata 

Entry 

Exposure to the 

System 

Support from 

Vendor 

Carrots & Sticks 

Preparation:Tem Preparation: Tem plates 

Make sure your vendor has a library 

of orthopedic problem tem plates 

They need to satisfy the three 

components of a good record: 

Clearly and accurately reflect encounter 

Legal document 

Satisfy documentation for E and M 

coding rules

296 

Templates 

Vendor library should be easily edited 

for surgeon preference/experience 

Can use voice recognition etc also 

The The easier easier the the data data entry entry , , the the 

be be ter ter th th e e surgeon surgeon utilization utilization of of 

the the EM EM R! R! 

Outline Headings 

Subjective Complaints 

Objective Findings 

Diagnostic Tests 

Assessm ent 

Plan of Treatment 

Structure 

Legal Attributes 

Contain a l pertinent 

positive and negative 

findings 

Document informed 

consent and patient 

education 

Store a l interaction; 

hospital, office, telephone 

ca ls, e-mails e mails 

Templates 

Need to keep them am ount of “clicks” to a 

minimum to speed data entry 

Should have “auto-negative”button to 

strike a l entries since most historical and 

physical findings are such 

Pu l-dow n lists with modifiers increased 

accuracy and completeness 

Free-text boxes can a low for 

individualization of any entry 




Attributes of the Medical Record 

Structure 

Must be clear and concise 

Form at should be 

recognizable and 

resemble current paper 

methods 

W e l organized and easy 

to read 

Should be comprehensive 

and include a l data 

Secure 

Function 

1. Stores information used 

to coordinate patient care 

2. Provides legal 

documentation of care 

3. Used by Medicare and 

third party payers to 

determine level of 

reimbursement 

Templates 

Should have separate screens for 

HPI, PM H, ROS, Physical Exam , 

Im aging, diagnosis and treatment 

Should be able to toggle through the 

screens instantaneously 

Each screen should fit inside the 

monitor so the data points are always 

in the same place. Quickens data 

entry by “m otor memory” 

Templates 

Pre-populated tem plates (i.e. right 

ankle sprain) are very efficient 

Can be selected and modified quickly 

to enhance workflow 

Especia ly effective with post-op 

visits, injections, telephone ca ls and 

common conditions like epicondylitis, 

etc.

297 


How How data is entered also matters 

Work stations 

Tablets 

Voice Recognition 

Have discussions prior to 

implem entation and be flexible 

afterward to change. Be wiling to 

experiment! 

Workflow Disruption 

EM R wil change the way you practice 

FO FO R R THE THE BETTER BETTER 

Need to Accommodate for the EM R 

learning curve 

Miler et al found doctors worked longer 

hours for an average of 4 months post 

implem entation of EM R 

“Cham Cham pions” pions worked even more 

After 26 months of use 11/14 groups were 

“tightly tightly integrated” integrated with the EM R 


Remember, it’s it s not 

just the docs who 

are getting used to 

the system ! 

Staff needs time to 

assimilate skil with 

the EM R also! 





Be wiling to invest time in choosing, 

developing and m odifying 

tem plates to make data entry EASY 

Maximize adoption of the EM R and 

physician productivity 


We went from double-booking double booking (8 

patients/hour) to single booking (4 

patients/hour) for one month post 

implem entation 

Maximize EM R Functionality 

Physician “Cham Cham pions” pions of EM R must 

be able to communicate the 

functionality and applications of the 

EM R to co leagues less versed in 

computer technology 

Push EM R e-mail, e mail, in-patient in patient 

management tools, home and road 

utilization

298 

A l paper 

correspondences 

must be scanned 

into the EM R 

Easy to do with 

NEW charts, but 

what of the old 

files? 

Chart Issues 

Scanning Old Charts 

Make sure the old records are 

scanned into recognizable folders for 

MRI, PT, Op Reports etc for easy 

retrieval 

The office note should come up right 

in the EM R notes 

Vendor Support 

Critical for success 

Onsite technical personnel for both 

docs and and staff for software 

Onsite technical personnel for 

hardware support also 

Stay onsite for three weeks with 

option of coming back 




Scanning Old Charts 

Can take considerable am ount of time 

and manpow er 

The more active charts, the more 

aggressive the scanning routine 

Scan in two week blocks of schedule 

11,200 charts in six months without 

hiring additional em ployees 

Getting Rid of Paper Charts 

Turned Chart 

Room into Exam 

Room 

Eliminate 1 FTE 

File Clerk 

IT Support 

New need for ongoing tech support 

Larger groups wil want to have their 

ow n in-house in house IT department 

Sm a ler groups can hire support 

We hired 24-7 24 7 support for 

$1600/month and kept that for 10 

months

299 

Hardware Issues 

Hardware glitches are inevitable 

Most revolve around the destination 

of prescriptions to printers 

Need to have hardware tech support 

there for three weeks post 

implem entation 

HITECH 

Meaningful Use Criteria for EM R 

Stage 1 2011 2011 

2011 Capture PHI in coded 

(structured) format 

Track clinical conditions 

Coordinate care 

Report clinical quality measures and 

public health information 

Meaningful Use Funds 

The Carrot 

2011 2012 2013 2014 2015 2016 

2011 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000 

2012 $18,000 $12,000 $8,000 $4,000 $2,000 $44,000 

2013 $15,000 $12,000 $8,000 $4,000 $39,000 

2014 $12,000 $8,000 $4,000 $24,000 

2015 0!!! 




Summary 

Preparation is the key to successful 

transition to EM R 

A low for workflow adju stment 

during the transition period 

Ensure adequate software and 

hardware support for three weeks 

post implem entation 

Meaningful Use Stages 

2011 2012 2013 2014 2015 

2011 Stage I Stage I Stage II Stage II Stage III 

2012 Stage I Stage I Stage II Stage III 

2013 Stage I Stage II Stage III 

2014 Stage I Stage III 

2015 Stage III 

Meaningful Use Funds 

The Stick 

2015 1% 

2016 2% 

2017 3%

300 

Meaningful Use Criteria 

Record Demographics 50% 

Record Vital Signs 50% ** 

Maintain Active Dx List 80% 

Medication List 80% 

Provide Clinical Summaries 

50% 

Maintain Active A lergy 80% 

Sm oking Status >13 50% ** 

Provide EHI on demand 50% 

who request 

E-prescription 

prescription 40% 

Core Set 

Use Physician computerized 

order entry (CPO E) 30% 

Drug-Drug/D Drug Drug/D rug AAllergy lergy 

checks Enable Function 

Electronic clinical information 

exchange 1 Test 

Clinical decision rule support 1 

Protect data privacy Test as 

per Final Rule 7/2010 

Report quality measures to 

CM S as per Final Rule 

7/2010 

Meaningful Use: 

How to get there 

Vendor Certification and support are 

KEY to eligibility for Stimulus Funds 

Also need to have Secure Secure Patient Patient 

Portal Portal Function Function to communicate 

electronica ly with patients 



Office National 

Coordination- 

Coordination 

Authorized Testing 

and Certification 

Bodies (O NC-ATB) NC ATB) 

1. Certification 

Commission for 

Health 

Information 

Technology 

(CCHIT) 

2. Drummond Group 

3. InfoGuard Labs 




Meaningful Use Criteria 

Drug Drug Form Form ulary ulary Checks Checks 

Enable Enable Function Function 

Generate Generate patient patient lists lists by by 

condition condition 1 1 list list 

Identify Identify patient--specific 

patient specific 

education education resources resources 10% 10% 

Send Send care care reminders reminders to to 

patients patients 20% 20% > > 65 65 or or

301 

 



Key is vendor 

support 

Vendors have been 

listed as 

“Approved Approved” by 

CCHIT 

List available 

at:http://www.cchit 

at: http://www.cchit 

.org/products/onc- 

atcb 

ONC-ATB ONC ATB 

Certification is first 

step in m eeting 

Stage I Criteria for 

meaningful use 

Meaningful Use 

If you’re you re getting an EM R just to get 

the Stimulus $$$, Don’t Don t do it! 

Get an EM R if it makes business 

sense for your practice 

Stil great uncertainty regarding a l 

the new regulations and mandates 

and the requirements, incentives and 

penalties may change 

CPT 

ICD 

E&M 

RUC 

CM S 

ASC 

IPPS/O PPS 

EO B 

TERMINOLO GY 

NCCI and GSD 

CERT – * 

RAC – * 

ZPIC – * 




Meaningful Use 

Have to document 90 days or MU 

starting in 2011. 

Can apply for Stimulus Funds 

($18,000 per doc) as of May, 2011. 

Wil be difficult to do and require 

dedication of physician/staff 

resources to become compliant 

EM R & Coding 

Bil Beach, MD 

Chair AAOS Health Policy Committee 

Member of AAOS coding committee 

Chair AOSSM health policy committee 

Consultant to RUC 

AAOS Health System s Committee 

TERMINOLO GY 

CPT – Common Procedural Terminology 

ICD – International Classification of Disease 

E&M – Evaluation and Management 

RUC – Relative Value Update Committee 

CM S – Center for Medicare and Medicaid 

Services 

ASC – Am bulatory Surgery Center 

IPPS/O PPS – Inpatient/O utpatient Perspective 

Paym ent System 

EO B – Explanation of Benefits 

NCCI– NCCI National Correct Coding Initiative 

GSD – Global Services Data Book

302 

 

 

CPT 

Common Procedural Term inology – 

CPT 

Owned by the AM A 

The major source of revenue for the 

AM A ($300 milion/year?) 

Maintained by the AM A Editorial Panel 

Five –digit digit num erical (alpha-numeric) 

(alpha numeric) 

system 

Represents a l physician services 

ACL reconstruction – 29888 

Level 3 new patient office visit – 99201 

E&M 

Evaluation and Management 

Office, hospital, ER and consultation services 

5 levels of service for outpatient/ER services 

3 levels for inpatient services 

Consultation services codes have been 

eliminated for CM S only and paid on new and 

established basis 

New patients (99201-05) 

(99201 05) 

Established patients– patients patient was seen by your 

group in the past 3 years (99211-99215) 

(99211 99215) 

RUC 

RUC – Relative Value Update 

Committee 

Made up of representatives of a l the major 

medical/surgical societies, CM S, insurers 

and associated professionals 

Anyone can apply for a CPT code 

The AM A Editorial Panel confirm s a new 

code 

The RUC determines the value of the 

procedure based on physician work/time, 

intensity, post-op post op care and malpractice risk 

 




 

ICD 

International Classification of 

Diseases (ICD) 

ICD 9 (current for the US) and 10 

(m ost other countries) 

Description of diseases 

Insurers require appropriate ICD 

codes to accompany CPT codes 

(diagnoses must correspond to 

surgical procedures) 

CM S/Med 

Pac/ASC/IPPS/O PPS 

CM S = Center for Medicare and Medicaid Services 

(M edicare), the world’s world s largest payorfor payor for medical 

services 

MedPac - Advisory Committee for CM S 

Non-elected Non elected and limited physician 

representation 

ASC = Am bulatory Surgical Center 

IPPS = Inpatient Prospective Paym ent System 

OPPS = Outpatient Prospective 

Paym ent System 

90 Global/EOB 

90 day global – reimbursement for a surgical 

procedure includes a l the office visits for 90 

days (except shoulder manipulation). This 

does not include casting, radiologic services 

or physical therapy. 

EO B – Explanation of Benefits. The insurer 

provides the beneficiary and the physician 

with an accounting of charges and paym ents. 

It is mandatory that physicians and/or their 

staff review these frequently to insure proper 

reimbursement.

303 

 

NCCI/G SC/COPN 

NCCI – National Correct Coding 

Initiative 

CM S’s S s bundling package 

Published quarterly 

GSD – Global Services Data Book 

AAOS bundling package 

Published/edited yearly 

COPN – Certificate of Public Need 

Stark Laws – perm its self referrals on 

a limited basis (safe harbors) 

Legislation Creating “The The Police” Police 

Im proper Payments Act of 2002 

Medicare Modernization Act 

Tax Relief and Healthcare Act of 

2006 

20 years – no worries until now!!! 

Trust me – you should be too!!! 

 




Medicare and Payment Reform 

The Social Security Act of 1965 created 

Medicare 

2008 Data 

44 milion Medicare beneficiaries 

Expenditures = $428 bilion = 15% federal 

budget 

Reducing Medicare waste and detecting 

fraud and abuse is one of the Sec. of 

Health and Human Services highest 

priorities 

 

Programs 

CERT – Comprehensive Error Rate 

Testing 

RAC – Recovery Audit Contractors 

ZPIC – Zone Program Integrity 

Contractors 

 

Payment Error Rate CERT, RAC and ZPIC 

CERT 

CM S random audit of 120,000 bilings 

Recovery Audit Contractors (RAC) 

CM S 

Congressiona ly mandated 

Zone Program Integrity Contractors 

(ZPIC) 

Department of Justice (D OJ) 

Medicare Administrative Contractors

304 

FO CUS of CERT/RAC/ZPIC 

Review of Medicare bilings 

 

DME and hospital 

Physicians E&M 

Focused Focused vs. random review with 

extrapolation 

Penalties/fines Penalties/fines with interest 

ZPIC ZPIC – contracts, etc. 

Exam ple – RAC Review 

Four RAC companies and sub- 

contractors – divided the country into 

four districts 

 

 

RAC vs. ZPIC 

RAC’s RAC – wel defined processes and 

requirements, limitations on the 

number of charts, etc. 

ZPIC’s ZPIC – no such restrictions 

Identify errors 

Select charts of specific errors 

Extrapolate errors based on the know n 

errors, not random ized 

Long and difficult appeal process 




Program Purview 

A l CM S for fee-for fee for-service service programs, 

The expansion schedule can be 

view ed at: w ww.cm s.hhs.gov/rac 

RACs wil not be able to review claims 

paid prior to October 1, 2007 

RACs wil be able to look back three 

years from the date the claim was paid 

ZPIC – no know n limits -DOJ DOJ 

 

Extrapolation – Sm a l“Selected l Selected” 

Samples Applied to Large Volum es 

of W ork (10/1000) 

 

MY/O UR GOAL 

Be “compliant compliant” 

Don’t Dont 

wait for RAC’s RAC to complete 

the hospital/D ME audits 

Start today! 

Start Yesterday

305 

Know if You are Subm itting Claims 

for Im proper Paym ents 

Carefu ly conduct an internal 

assessment to identify if you are in 

compliance with Medicare rules 

Identify corrective actions to prom ote 

compliance 

Appeal when necessary 

Learn from past experiences -websites websites 

 

David Glaser – HC attorney 

in MN 

E&M are auditable 

Significant risks exist for every facet of the 

review process -potentia potentia ly ilegible 

signatures, the internal review process or 

untimely signatures. 

Consider law yer/client privilege for the review 

May stil be lega ly discoverable 

Discuss indem nification clause in your new or 

existing contract/employee agreem ent 

Beware of bil subm ission prior to 

signature!! 

 

Coding – Painful but Im portant! 

Medicare Fraud – intentional or 

unintentional, doesn’t doesn t matter 

Based on what you should know , not what 

you may know (= at least, what I know ) 

5 years in prison 

$10,000 fine 

For every occurrence 

Plus interest 

Disqualified from participation in Medicare 

You cannot abdicate this responsibility 




Review s not audits 

Internal Review 

Required annua ly by HIPPA (since 2006) 

The review results should be shared with the 

physicians/providers involved 

Documentation of provider education required 

Are errors: 

Under documentation – correct with 

addendum s 

Over biling 

Refund? 

Laws exist that mandate repaym ent (felony 

offense) 

Seek legal advice 

 

Review Information 

Physician “must must” prepare for future 

CERT/RAC/ZPIC 

E&M coding and compliance are mandatory 

for every physician 

Fo low a l possible Medicare coding rules 

Remember– Remember it is NOT what you know but 

what you should know 

You must know at least what I know ! 

Sign every document 

Prescription, Order, Note and Test 

LEARN E&M CODING!! 

E&M Coding – New Approach 

DO NOT UNDER-ESTIMATE UNDER ESTIMATE YOUR RISK 

The most common and significant loss 

of practice revenue is office patient visit 

“down down-coding coding” (60% of incom e is E&M) 

Down-coding Down coding is technica ly as 

“fraudulent fraudulent” as up-coding up coding 

Avoid RAC/ZPIC RAC/ ZPIC’s 

Exam ple – 30 patients per week coded 

as E3 instead of E4 = $25 = $750/wk X 

48 wks/year = $22,500, $22,500, 10 man man group group 

= $225,000/year

306 

Classification of E/M Services 

Office and other outpatient 

New patient (99201-99205) 

(99201 99205) 

Established patient (99211-99215) 

(99211 99215) 

Office consultation (99241-99245) 

(99241 99245) 

Gone for CM S (only?) 

Em ergency department (99281-85) 

(99281 85) 

Hospital Inpatient Services 

Initial hospital care (99221-99223) 

(99221 99223) 

Subsequent care (99231-99233) 

(99231 99233) 

Hospital discharge services (99338-99339) 

(99338 99339) 

 

The Key Components/PEARLS 

Chief Complaint and History 

Physical Exam 

Medical Decision Making 

Every medical record must have each of these 

documented or referenced for audit purposes 

Reimbursement is based on the Low Lowest est 

Level Level of service for these required key 

components* (3/3 for New Pt, 2/3 for 

Established Pt) 

 

Keeping it Simple – Bu lets and Buckets 

Bu lets = identified (docum ented) data points 

Data points = information (positive Lachman’s Lachman test 

= 1 bu let) 

1997 E&M Guidelines describes the num ber of 

documented bu lets required to m eet each level of 

service – defines a level of reimbursement 

Divide E&M Coding into two “buckets buckets” because 

the rules are slightly different (but logical) 

New patients 

 

Established patients 




Four Functions of the Medical Record 

Convey medical information for medical 

care providers 

Medico-legal Medico legal record 

Documentation of the level of service 

(E&M) (Important for potential audits) 

Data co lection/Pay for 

Performance/Meaningful User 

 

My Approach to E&M Coding 

Develop/acquire a l the necessary paper 

tools to facilitate data co lection and 

documentation 

Define the expected/anticipated level of 

service (N 3 and E3 or E4) 

Understand the variations of the 

expected level of service 

Document the E&M service 

Code the service 

Develop – Define – Document (D ³) ) & 

KEEP IT SIMPLE 

 

 

1997 E&M Guidelines – Outlines 

the Required Number of Bu lets 

Confusion = the subsection 

requirements are given names 

instead of num eric bu let mandates 

Exam ple – in the physical exam 

section there are 4 descriptors for 5 

levels of service 

Focused = 1 bu let 

Expanded = 6 bu lets 

Detailed = 12 bu lets 

Comprehensive = 30 bu lets

307 

 

 

NEW PATIENT 

VISIT 

Patient Form s 

Can be used as the official medical 

record if: 

The form is signed and dated by the 

patient 

The form is signed and dated by the 

physician 

Signing the document implies that you 

have review ed the information with the 

patient and this is the intent of CM S 

You CANNOT pre-sign pre sign the form or stam p 

the form with your signature 




 

KEY COMPONENT 

HISTORY 

Always Level 5 

New Patient History 

99201 99202 99203 99204 99205

308 

Im portant! portant 

The patient provides you with a 

level 5 history, every visit. You 

provide the form(s) form(s ) at registration 

or via the web. New patient or 

fo low -up up visit visit form. form. 

We have just completed one-third one third 

of the E/M coding for every office 

visit. 

Bubble scan technology 

 

 

Physical Exam 

Six body parts by CM S convention 

Tw Tw o arms 

Tw Tw o legs 

Neck Neck 

Back/Spine Back/Spine 




Past Medical, Family and Social 

History 

 

 

KEY COMPONENT 

NEW PATIENT 

PHYSICAL EXAM 

Level 3 

PHYSICAL EXAM 

Constitutional evaluation 

Vital Vital signs signs (3 of of 7) 7) 

W Wel el developed, wel nourished 

Musculoskeletal 

Gait Gait and station

309 

Orthopedic Exam = TRIM 

T – Tenderness 

R – Range of Motion 

I– Instability/Stability 

M – Muscle Strength 

 

Physical Exam Bu lets (N 3 = 12) 

Development/nutritional status (W DW N) = 1 

Gait and station (nl ( nlgait gait & wbl) wbl) 

= 1 

Involved and contra-lateral contra lateral comparison 

Tenderness to palpation = 2 

Range of motion = 2 

Stability or instability = 2 

Muscle strength = 2 

Sensation = 2 

Pulses = 2 

Skin = 2 TOTAL =16 

 

New Patient Physical Exam 

99201 99202 99203 99204 99205 

1 

body 

part 

1 

body 

part 

2 

body 

parts 

4 

body 

parts 

4 

body 

parts 




 

Physical Exam 

Neurological/Psychological 

Coordination testing 

Deep tendon reflexes 

Sensation 

Mental status 

Oriented Oriented to time, place and 

person 

M M ood and affect 

Physical Exam Bu lets -TRIM TRIM 

KEY COMPONENT 

NEW PATIENT 

MEDICAL DECISION MAKING 

 

Level 3

310 

Medical Decision Making 

Components 

Data and X-ray X ray 

Diagnosis and Im pression 

Plan and Risk – low risk = ankle 

sprain, sprain, moderate moderate risk risk = injection injection 

2 of 3 sections required – for audit 

purposes only 

 

Level of Service 

New Patient – 3 of 3 key components 

and and the the low low est est level level of a l 3 determines 

determines 

the code 

 

99201 99202 99203 99204 99205 

CC/Hx PF EPF DETAIL COMP COMP 

PE PF EPF DETAIL COMP COMP 

MDM STRFRW D Low LO W MOD HIGH 

Key to Increase Revenue 

(N 3) can/should equal an established 

level 4 (E4) visit 

Tw o additional requirements 

Data – interpret/read rad. report 

Tw o problem s – to satisfy the 

diagnosis and impression component 

Any prescription medication, injection 

or surgery 

 




MDM New Patient 

9920 

1 

99202 99203 99204 99205 

ESTABLISHED PATIENTS 

 

 

Hx, Hx, 

PE and MDM Audit Strategy 

New patient – a l three key 

components 

Established patient – 2 of 3/2 of 3 

rule 

“Pass Pass-on on” the physical exam – we 

need only 2 of the 3 key 

components (from an audit 

standpoint!) 

“Pass Pass-on on” the data or the diagnosis 

portion of the MDM

311 

 

Established EstablishedPatientHistory 

PatientHistory 

Bu lets 

(Copy and Paste) 

Orthopods – Be Complete 

Problem list – multiple medical 

problem s 

Rheumatoid/Lupus/Psoriasis 

DM, Asthm a, HTN, Heart disease 

Any diagnosis which impacts 

orthopedic care should be included 

in the the MDM MDM diagnosis diagnosis section!!! section!!! 

If there are two diagnoses or more 

– document! 


Established Established Pt Pt – 2 of of 3 key key components 

components 

and and the the low low est est level level of of the the 2 

determines the code 

 

99211 99212 99213 99214 99215 

CC/Hx N/A PF EPF DETAILED COMP 

PE N/A PF EPF DETAILED COMP 

MDM N/A STRFRW D LO W MOD HIGH 




Physical Exam – PASS ON THE 

AUDIT 

99211 9921 

2 

99213 99214 99215 

Established Established Patient Patient MDM MDM 

99212 99213 99214 99215 


New Patient – 3 of 3 key components 

and and the the low low est est level level of a l 3 determines 

determines 

the code 

 

99201 99202 99203 99204 99205 

CC/Hx PF EPF DETAIL COMP COMP 

PE PF EPF DETAIL COMP COMP 

MDM STRFRW D Low LO W MOD HIGH

312 

Summary 

Level 3 New patient visit 

History = 5, PE* PE (2 body parts) = 3, MDM 

= 3 

Level 4 Established patient requires: 

Level 4 or higher historyPass history Pass on the PE 

Level 4 MDM *Rate limiting key component 

 

* 

Data = 3 points OR 2 Diagnoses 

Level 4 Plan/Risk = 

Prescription 

Injection 

Surgery 

Constructing the ideal EM R: 

An inside look!! 

Tony Pericle 

Software Engineer 

EM R designer 

Discussion and 

Questions 




 

KEYS to Success and Safety 

Be an educated coder (just like 

you are an educated physician 

and surgeon) 

Work backwards – if you you wrote wrote a 

prescription/inject/schedule 

surgery document the remainder 

of the requirements and charge 

an E4. 

Constructing the ideal EM R: 

An inside look!! 

Tony Pericle 

Management 

Data Integrity 

Outcomes Data Co lection 

A CASE STUDY: Issues with 

implem entation into a 10 man group.

A. The Legal Environment 

1. Recovery Audit Contractors (RAC’s) 

2. Zone Program Integrity Contractors (ZPIC’s) 

3. Comprehensive Error Rate Testing (CERT’s) 

B. HIPAA – compliance requirement 

C. Use/Meaningful Use of EMR Does Not Abdicate the Provider 

from Correct Coding Responsibility 

D. The Ten Most Important Facts a Physician Must Know About 

Coding/EMR 

1. Penalties for incorrect coding are based on “what you should 

know, not what you know.” Medicare fraud is punishable – 

5 years in jail and a $10,000 per occurrence 

2. Evaluation and Management (E&M) coding is based on: 

a. 1995 E&M Guidelines 

b. 1997 E&M Guidelines 

c. Most EMR’s use the 1997 Guidelines because 97’ uses a 

bullet based system that is easily counted/score 

3. Templates (paper or electronic) are imperative to accurate/ 

correct coding 

4. Every documented patient encounter must contain or refer 

to “3 Key Components” 

a. Chief Complaint and History 

b. Physical Exam 

c. Medical Decision Making 

5. Reimbursement is based on the lowest level of service for the 

“3 Key Components” 

6. The vast majority of orthopedic new patient visits should be 

level 3 (99203) and limited by the physical exam 

313 




emr aNd CodiNg 

William R. Beach, MD 

a. Level 5 history 

b. Level 3 physical exam 

c. Level 3 medical decision making 

d. Level 3 physical exam requires evaluation of 2 body areas 

and 12 bullets 

7. Established patient visits are routinely either 99213 or 

99214. The medical decision making is the determining 

factor 

a. Level 5 history 

b. Physical exam (because of the 2/3 rule) –audit pass 

c. Normally level 3 (99213) but if the plan is for any of the 

following the level of risk equates to a level 4 (99214) if 

the data or diagnosis requirements are met: 

1. Prescription 

2. Aspiration/injection 

3. Surgery 

8. Consultation codes have been eliminated by The Center for 

Medicare and Medicaid Services (CMS) but are still being 

used by many private insurers 

9. Carefully review your EMR coder function and determine 

if the coding metrics are correct. Create several coding 

scenarios and determine your confidence level of the internal 

coding resource. 

10. Continue to be a compliant, educated coder. Using 

templates for completeness and appropriate tools (voice 

recognition software, bubble scans, etc.) to maximize your 

efficiency and accuracy.

314 

CmS FiNal rule meaNiNgFul uSe 

Stage 1 aCtioN plaNNiNg doCumeNt 

CORE SET – Eligible Professionals (EP) required to complete all 15 core set of objectives 

MENU SET – Eligible Professionals (EP) required to complete 5 objectives out of 10 

Objective Core/Menu Measure Reporting Requirements Exclusions Action (What needs to be done) 

Use CpOE for 

medication orders 

directly entered 

by any licensed 

healthcare 

professional who 

can enter orders into 

the medical record 

per state, local 

and professional 

guidelines 

implement drug-drug 

and drug-allergy 

interaction checks 

Generate and 

transmit permissible 

prescriptions 

electronically (eRx) 

Record demographics 

including; preferred 

language, gender, 

race, ethnicity, dOB 

Core More than 30% 

of unique patients 

with at least one 

medication have at 

least one medication 

order entered using 

CpOE. 

Core The Ep has enabled 

this functionality 

for the entire EHR 

reporting period 

Core More than 40% 

of all permissible 

prescriptions 

written by the Ep 

are transmitted 

electronically 

using certified EHR 

technology. 

Core More than 50% of 

all unique patients 

seen by the Ep 

have demographics 

recorded as 

structured data 

Numerator: The number of 

patients in the denominator that 

have at least one medication order 

entered using CpOE. 

Denominator: Number of 

unique patients with at least one 

medication in their medication 

list seen by the Ep during the EHR 





Any Ep who 

writes fewer 

than 100 

prescriptions 

during the EHR 

reporting period. 

1. determine if the exclusion applies. 

2. Research more applicable state, and local laws regarding 

CpOE. 

3. Test functionality of CpOE feature on your EMR system. 

4. Create and implement policies, procedures and protocols 

to enable orders to be entered via CpOE. 

5. Train all physicians in the practice to use this EMR system 

feature. 

6. Take steps to ensure that more than 30% of unique 

patients seen by each Ep have at least one medication 

order entered via CpOE during the reporting period. 

7. On an ongoing basis, conduct an audit to be certain 

medication orders are being entered according to the 

protocols. 

8. Contract with a pharmacy electronic system, if necessary. 

Yes/No Attestation None 1. Test the functionality of your EMR system’s drug-drug and 

drug-allergy interaction features. 

2. implement policies, procedures to enable these checks 

are performed for every patient seen during the reporting 

period. 

3. Train all physicians in the practice to use this program 

feature. 

4. Take steps to ensure that teach Ep performs these checks. 

5. An escalation procedure is required if an Ep chooses to 

override interaction notice. 

6. On a regular basis, conduct an audit to ensure checks are 

being performed for all patients. 


prescriptions in the denominator 

generated and transmitted 

electronically. 

Denominator: The number of 

prescriptions written for drugs 

requiring a prescription in order to 

be dispensed other than controlled 

substances during the EHR 


Numerator: The number of unique 

patients in the denominator 

who have all the elements of 

demographics (or a specific 

exclusion if the patient declined to 

provide one or more elements or if 

recording an element is contrary to 

state law) recorded as structured 

data. 


unique patients seen by the Ep 

during the EHR reporting period. 

Any Ep who 

writes fewer 

than 100 

prescriptions 




2. Test functionality of EMR system’s eRx feature. 

3. Establish connections with pharmacy systems. 

4. Review HipAA and HiTECH policies related to transmittal 

of pHi. 

5. Consult GetRxConnected (www.getrxconnected.com) 

6. implement policies, procedures and protocols to enable 

transmission of permissible prescriptions electronically. 

7. Train all physicians in the practice to use this program 

feature. 

8. Take steps to ensure that each Ep transmits more than 

40% of permissible prescriptions electronically. 

9. On a regular basis, conduct an audit to ensure lower 

threshold will be reached by the end of the reporting 

period. 

None 1. Test the functionality of your EMR system to record 

demographics as structured data. 

2. implement policies, procedures and protocols to enable the 

recording of demographics in the EMR. 

3. Train all physicians and staff to use this feature. 

4. Take steps to ensure each Ep records demographics as 

structured data for at least 50% of their patients. 

5. On a regular basis, conduct an audit to ensure 

demographics are recorded for at least 50% of unique 

patients seen during the reporting period.

315 




Maintain up-to-date 

problem list of current 

and active diagnoses 

Maintain an active 

medication list 

Maintain an active 

medication allergy list 

Record and chart vital 

signs: height, weight, 

blood pressure, 

calculate and display 

BMi, plot and display 

growth charts for 

children 2‐20 years, 

including BMi 

Record smoking 

status for patients 13 

years old or older 



seen by the Ep have 

at least one entry 

or an indication 

that no problems 

are known for the 

patient recorded as 

structured data. 



seen by the Ep have 


(or indication that 

the patient is not 

currently prescribed 

any medication) 

recorded as 


Core More than 80% of all 

unique patients seen 

by the Ep who have 


(or an indication that 

the patient has know 

known medication 

allergies) recorded 

as structured data 

in their medication 

allergy list. 



age 2 and over 

seen by the Ep 

have height, weight 

and blood pressure 

are recorded as 


during the HER 




13 years old or 

older seen by the 

Ep have smoking 

status recorded as 



patients in the denominator who 

have at least one entry or an 

indication that no problems are 

known for the patient recorded as 

structured data in the problem list. 






have a medication( or an indication 

that the patient is not currently 

prescribed any medication) 

recorded as structured data. 




Numerator: The number of unique 


have at least one entry (or an 

indication that the patient has 

no known medication allergies) 

recorded as structured data in their 

medication allergy list. 






have at least one entry of their 

height, weight and blood pressure 



unique patients age 2 and over 

seen by the Ep during the EHR 



patients in the denominator with 

smoking status recorded as 








None 1. Test the functionality of the EMR system to maintain an up 

to date diagnosis list as structured data. 

2. Ensure the system can document if there are no known 

problems. 

3. Train all physicians and staff in the practice to use this 

feature at every outpatient appointment documentation. 

4. Take steps to ensure that each Ep records diagnoses as 

structured data for more than 80% of unique patients. 

5. On a regular basis, conduct an audit to ensure diagnosis 

information is recorded for at least 80% of unique patients. 

None 1. Ensure your EMR system has the capability to record 

medications for patients. System must also have the 

capability to document if no medications have been 

prescribed. 


active medications to be entered as structured data. 

3. Tran all physicians and staff in the practice to use this 

feature at every outpatient visit document review. 

4. Take steps to ensure that each Ep records the information 

for more than 80% of all unique patients. 

5. On regular basis during the reporting period, conduct an 

audit to ensure this information is recorded for at least 

80% of unique patients. 

None 1. Ensure the practice’s EMR system has the capability to 

record medication allergies for patients and to keep the 

list up‐to‐date. Ensure the system also can document if no 

medication allergies have been identified. 


medication allergies to be entered and stored. 


feature at every outpatient visit documentation. 

4. Take steps to ensure that Ep records the information for 

more than 80% of all unique patients. 

5. On a regular basis during the reporting period, conduct 

an audit to ensure this information is recorded for at least 

80% of unique patients. 

Any Ep who 

sees only 

patients 2 years 

or younger. Any 

Ep who believes 

that all three 

vital signs of 

height, weight 

and blood 

pressure have 

no relevance to 

their scope of 

practice may 

attest to be 

excluded. 

Any Ep who 

sees no patients 

13 years or 

older 



the recording of height, weight and blood pressure as 



feature at every outpatient appointment document review. 

4. Take steps to ensure each Ep records the information for at 

least 50% of patients seen during the EHR reporting period 

who are age 2 and over. 

5. On a regular basis during the reporting period, conduct an 

audit tonsure this information is in fact recorded for at least 

50% of unique patients who are age 2 and over. 

1. determine if the exception applies: physician sees no 

patients 13 years and older. 

2. if an exception does not apply, implement policies, 

procedures and protocols to enable smoking status to be 


3. Take steps to ensure the information is recorded for at 

least 50% of patients 13 years and older seen during the 



audit to ensure this information is in fact recorded for at 

least 50% of unique patients 13 years and older.

316 




implement one clinical 

decision support rule 

relevant to specialty 

or high clinical priority 

along with the ability 

to track compliance to 

that rule 

Report ambulatory 

clinical quality 

measures to CMS or 

the states 

provide patients with 

an electronic copy of 

their health information 

(including diagnostic 

test results, problem 

list, medication lists, 

medication allergies), 

upon request 

provide clinical 

summaries for 

patients for each 

office visit 

Core implement one 

clinical decision 

support rule 

Core For 2011 provide 

aggregate 

numerator, 

denominator 

and exclusions 

through attestation 

as discussed in 

section ii(A)(3) of 

the final rule. For 

2012 electronically 

submit the clinical 

quality measures as 

discussed in section 

ii(A)(3) of the final 

rule 


all patients of the 

Ep who request 

an electronic copy 

of their health 

information are 

provided it within 3 

business days 

Core Clinical summaries 

provided to patients 

for more than 50% of 

all office visits within 

3 business days 




Yes/No Attestation None 1. identify Orthopaedic related clinical decision support 

rules for both hospital and office —e.g. Failed Total Joint 

Replacement or periprosthetic infection. 

2. Take action to treat patient. 

3. Audit activities. 

4. Follow up with patient and document actions taken as 

necessary 

An Ep would provide the aggregate 

numerator and denominator 

through attestation 



receive a copy of their health 

information within 3 business days. 


unique patients seen by an Ep 

for an office visit during the EHR 




are provided a clinical summary of 

their visit within 3 business days. 



for an office visit during the EHR 


None; Ep can 

report “0” 

(zero) in the 

denominator 

Any Ep that has 

no requests 

from patients 

or their agents 

for an electronic 

copy of 

patient health 

information 



Any EpS who 

have no office 

visits during the 

EHR reporting 

period. 

1. develop reporting programto CMS or your state. 

2. Note core measures and potential Orthopaedic measures. 

3. Audit activities. 

4. Follow up with patient and document actions taken as 

necessary. For 2012-1. Submit report electronically as 

required. 

1. determine if the exception applies 2. Test functionality of 

practice’s EHR system to ensure that it can generate an 

electronic copy of patients’ electronic health records. 

3. document request and provision of data and information to 

the patient during the EHR reporting period. 


patients to receive records within 3 business days. 

5. Take steps to ensure that requests received from patients 

and agents are always processed within 3 business days. 


audit to ensure that at least 50% of patients requesting 

copies of their electronic information receive the data 

within three business days. 

1. determine if the exception applies. Tip: develop and 

implement an action plan for this measure in case office 

visits start occurring toward the end of the period. 

2. Test functionality of practice’s EHR system to ensure that 

it can generate clinical summaries of patients’ electronic 

health records. 

3. determine how many patients have visited the practice 

during the reporting period; multiply by 50%. 


patients to receive clinical summaries within 3 business 

days. Specifically, determine how information will be 

delivered to ensure data security. 

5. Take steps to ensure that clinical summaries are provided 

for at least 50% of all patients’ office visits within three 

business days. 


an audit to ensure that clinical summaries are provided to 

more than 50% of patients within three days of their visit.

317 




Capability to 

exchange key clinical 

information (for 

example, problem 

list, medication 


allergies, diagnostic 

test results), among 

providers of care and 

patient authorized 

entities electronically 

protect electronic 

health information 

created or maintained 

by the certified EHR 

technology through 

the implementation of 

appropriate technical 

capabilities 

implement 

drug‐formulary checks 

incorporate lab test 

results as structured 

data 

Generate lists of 

patients by specific 

conditions to use for 

quality improvement, 

reduction of 

disparities, research 

or outreach 

Core performed at least 

one test of certified 

EHR technology’s 

capacity to 

electronically 

exchange key clinical 

information 

Core Conduct or review 

a security risk 

analysis per 45 CFR 

164.308 (a)(1) in the 

July 13, 2010 Final 

Rule and implement 

security updates 

as necessary and 

correct identified 

security deficiencies 

as part of its risk 

management 

process 

Menu The Ep has enabled 

drug‐formulary 

functionality and 

has access to at 

least one internal or 

external formulary 

for the entire EHR 


Menu More than 40% of 

all clinical lab tests 

results ordered 

by the Ep during 

the EHR reporting 

period whose 

results are either in 

a positive/negative 

or numerical format 

are incorporated 

in certified EHR 

technology as 


Menu Generate at least 

one report listing 

patients of the Ep 

with a specific 

condition 




Yes/No Attestation None 1. Test the practice’s EHR system’s capability to send key 

clinical information to other providers of healthcare and 

receive information from those providers. 

2. Verify that the transmission of information complies with 

HipAA and other federal and state regulations. 

3. Research the status of the state’s Health information 

Exchange program (see http://www.hhs.gov/recovery/ 

programs/hitech /factsheet.html). 

Yes/No Attestation None 1. develop policies, procedures and protocols to ensure data 

security that are consistent with HipAA and HiTECH. See 

AAOS Now, November, 2010 issue for a list of policies and 

more information on data security requirements. 

2. Conduct file audits regularly to determine who is 

accessing secure patient files. The Act requires that ten 

patient files be reviewed annually. 

Yes/No Attestation Any Ep who 

writes fewer than 

100 prescriptions 



Numerator: The number of label 

test results whose results are 

expressed in a positive or negative 

affirmation or as a number and are 

incorporated as structured data. 


label tests ordered during the EHR 

reporting period by the Ep whose 

results are expressed in a positive 

or negative affirmation or as a 

number 

Any Ep who 

orders no lab 

tests whose 

results are either 

in a positive/ 

negative or 

numeric format 



1. Cross check prescribe ddrug with any formulary. 

pharmacy may provide information necessary to 

document the information. 

2. Consider developing online links to all insurance company 

formularies, if available, to expedite cross check. 

1. determine if an exception applies. Tip: develop and 

implement an action plan for this measure in case lab tests 

start to be ordered toward the end of the period. 

2. Test functionality of practice’s EHR system to incorporate 

clinical lab tests as structured data. 

3. implement, policies, procedures and protocols for 

downloading information (including information received 

from third parties) into the practice’s EMR system. perform 

any needed special programming. 

4. Verify that sample data is entered accurately into a sample 

record. 

5. Take steps to cause lab information ordered by the Ep to be 

downloaded into the practice’s EMR system. 


an audit to ensure that at least 40% of applicable lab test 

results are entered into the EHR as structured data. 

7. Train all physicians and staff to use this feature . Evaluate 

and put into place systems. 

Yes/No Attestation None 1. Ensure the practice’s EHR system has the capability to 

generate lists of patients seen who have presented with a 

specific condition. 

2. Generate at least one list during the reporting period. 

3. Use the list in connection to improve quality of care, to 

reduce disparities in care provision or in connection with 

outreach activities (such as osteoporosis screening).

318 




Send reminders to 

patients per patient 

preference for 

preventive/follow‐up 

care 

provide patients with 

timely electronic 

access to their health 

information (including 

lab results, problem 


allergies) within four 

business days of the 

information being 

available to the Ep 

Use certified EHR 

technology to identify 

patient-specific 

education resources 

and provide those 

resources to the 

patient if appropriate 

The Ep who receives 

a patient from 

another setting of 

care or provider of 

care or believes 

an encounter is 

relevant should 

perform medication 

reconciliation 

The Ep who 

transitions their 

patient to another 

setting of care or 

provider of care or 

refers their patient to 

another provider of 

care should provide 

summary of care 

record for each 

transition of care or 

referral 



65 years or older 

or 5 years old or 

younger were sent 

an appropriate 

reminder during the 

EHR reporting period 


al unique patients 

seen by the Ep are 

provided timely 

(available to the 

patient within four 

business days of 

being updated 

in the certified 

EHR technology) 

electronic access 

to their health 

information subject 

to the Ep’s discretion 

to withhold certain 

information 

Menu More than 10% of all 

unique patients seen 

by the Ep or admitted 

are provided 

patient‐specific 

education resources 

Menu The Ep performs 

medication 

reconciliation for 

more than 50% of 

transitions of care in 

which the patient is 

transitioned into the 

care of the Ep 

Menu The Ep who 

transitions or refers 

their patient to 

another setting of 

care or provider 

of care provides a 

summary of care 

record for more than 

50% of transitions of 

care and referrals 


patients in the denominator 

who were sent the appropriate 

reminders. 


unique patients 65 years old or 

older or 5 years old or younger. 



have timely (available to the 

patient within 4 business days of 

being updated in the certified EHR 

system ) electronically access to 

their health information online. 






are provided patient education 

specific resources. 




Numerator: The number 

of transitions of care in the 

denominator where medication 

reconciliation was performed. 


transition of care during the HER 

reporting period for which the 

Ep was the receiving party of the 

transition. 


transitions of care and referrals in 

the denominator where a summary 

of care record was provided. 


transition of care and referrals 

during the HER reporting period for 

which the Ep was the transferring 

or referring party of the transition. 




Any Ep who 

has no patients 

65 years old or 

older or 5 years 

old or younger 

Any Ep that 

neither orders 

nor creates 

any of the 

information 

listed at 45 CFR 

170.304 (g) in 

the July 13, 2010 

Final Rule during 

the EHR reporting 

period. 

1. determine if an exception applies. 

2. Test the functionality of the practice’s EMR system to 

send reminders to patients, according to their preferred 

methodology. Alternatives include phone, email and U.S. 

mail. practice must comply with security guidelines set 

forth by HipAA and HiTECH. 

3. determine how many patients within the age ranges will 

be seen during the reporting period. Calculate 20% of this 

number. 

4. determine patient preferences for reminders. 

5. implement policies, procedures protocols for sending 

reminders to patients in these age ranges according to the 

expressed preferences. 

6. Take steps to ensure that reminders are sent to more than 

20% of these patients. 


audit to ensure that reminders are sent out to at least 20% 

of patients in the stipulated age groups. 

1. develop and implement a patient portal that complies with 

HipAA and HiTECH data security requirements. 

2. Sign up patients to use the portal. 

None 1. provide patient education to patients, e.g. patient 

instructions noting internet resources (e.g. Your 

Orthopaedic Connection from AAOS). 

2. document action taken in patient record. 

Any Ep who 

was not the 

recipient of any 

transitions of 

care during the 

EHR reporting 

period. 

Any Ep who 

neither transfers 

a patient to 

another setting 

nor transfers 

a patient to 

another provider 



1. develop an dimplement procedures to verify accuracy of 

medication list. 


feature. 

3. Evaluate and put into place systems. 

1. Follow The Joint Commission SBAR (Situation, Background, 

Assessement, Recommendation) requirements for patient 

transfer. (see AAOS practice Management Center for 

information on SBAR). 

2. develop policies and procedures.

319 




Capability to submit 

electronic data 

to immunization 

registries or 

immunization 

information 

Systems and actual 

submission in 

accordance with 

applicable law and 

practice 

Capability to submit 

electronic syndromic 

surveillance data 

to public health 

agencies and 

actual submission 

in accordance with 

applicable law and 

practice 

Menu performed at least 



capacity to submit 

electronic data 

to immunization 

registries and followup 

submission if the 

test is successful 

(unless none of 

the immunization 

registries to which 

the Ep submits such 

information have the 

capacity to receive 

the information 

electronically) 

Menu performed at least 



capacity to provide 

electronic syndromic 

surveillance data 

to public health 

agencies and followup 

submission if the 

test is successful 

(unless none of 

the public health 

agencies to which an 

Ep, eligible hospital 

or CAH submits such 

information have the 

capacity to receive 

the information 

electronically) 

Important note 1: 

One of the final two publicαhealth related initiatives are required in 

the “menu.” 

Important note 2: 

For the Medicaid incentive, CMS has granted states the ability to 

require up to four menu criteria as “core.” EPs should check with 

their state to 

*** Required “clinical quality” core measures: 

1. Hypertension: Blood Pressure Management 

2. Tobacco Use Assessment and Cessation Intervention 

3. Adult Weight Screening and Follow-up 




Yes/No Attestation Any Ep that has 

not given any 

immunizations 

during the HER 


Yes/No Attestation Any Ep that 

does not collect 

any reportable 

syndromic 

information on 

their patients 



1. Test system to document immunization procedures, e.g. 

tetanus for patients with lacerations. 

2. Review your state’s laws related to immunization 

registeries. 

3. identify location of state registry, if exists. 4. document 

test date. 

1. Test system to document capability. 

2. document test date. 

Alternative core measures: 

1. Influenza Immunization for Patients ≥ 50 years old 

2. Weight Assessment and Counseling for Children and 

Adolescents 

3. Childhood Immunization Status

320 

meaSuriNg value iN orthopaediCS: 

what a CliNiCiaN NeedS to kNow (y) 




Moderator: Todd J. Albert, MD, Philadelphia, PA 

This symposium will introduce the concept of value-driven orthopaedic care, define the components of the value equation, 

and review the concept of comparative effectiveness research. 

I. Introduction: Value Based Health Care 

Todd J. Albert, MD, Philadelphia, PA 

II. Value-based Orthopaedic Care: Is This Where We Are Heading and How Do We Get There? 

Kevin Bozic, MD, San Francisco, CA 

III. The Value Equation: The Use of Ulility Measures in Determining Value (SF6D, EQ5D, HUI) 

Sigurd H. Berven, MD, San Francisco, CA 

IV. Discussion, Questions and Answers 

All Faculty 

V. Cost Effectiveness Analysis in Orthopaedic Surgery 

Jeffrey Rihn, MD, Philadelphia, PA 

VI. When the Rubber Meets the Road –Operationalizing Outcomes Collection and Its Utilization. 

Steven D. Glassman, MD, Louisville, KY 

VII. Discussion, Questions and Answers 

All Faculty

321 

meaSuriNg value iN orthopaediCS – iNtroduCtioN 

Todd J Albert, MD 

Value Definition Cost / Quality 

Cost: Direct /Indirect – Time consuming/difficult Quality – to create 

appropriate measures need Health Utility Score. At present work is 

done to convert our common measures to Utility scores (ie Oswestry 

Disability Index (ODI), Neck Disability Index (NDI). SF-36 and 

EQ -5D can be converted. This exercise is crirical to perform cost 

effectiveness research and measure one intervention against another. 

The concept of disease specific measures versus generic health 

outcome measures is critical. Disease specific measures more likely 

to be sensitive to smaller changes but not generalizable. Generic 

measure allow comparisons across diseases but may be incencitive 

to the nuances of certain specific disease states. 

Why do this? Who cares? 

The government, large employers, other payors, patients. 

Evolving Methodology 

1) Othopaedists used to measure healing rate, xrays, range of 

motion etc. 




2) Now we measure those plus patients’ perception of health and 

well-being (SF-36, EQ 5-D) 

3) Because of difficulty in measuring all aspects of well-being, 

hospitals, insurers, and governing bodies have chosen that 

which they can measure – process measures – Hospital aquired 

infections, length of stay, DVT rate, compliance with giving 

properative antibiotics. 

How do we get there 

1) Walk before running 

2) Begin collecting 

3) Keep it simple 

4) Registries 

5) Diagnosis Specific /Generic 

6) Significant resources are needed (human and capital) to insure 

data capture and follow-up. Systems are being created which 

may simplify to an extent the process, but a paradigm shift and 

committment are necessary to insure success.

322 

value baSed health Care: iS thiS where we are headiNg aNd 

how do we get there? 

Kevin J. Bozic, MD, MBA 

1) US Health Care System 

a) Concerns regarding U.S. Healthcare System 

i) U.S. ranks highest in total health expenditure per capita 

but among the lowest in public satisfaction with our 

healthcare system. (Institute of Health Economics 2007) 

ii) The “Quality Chasm” is growing: 45% of patients do not 

receive care in accordance with best practices. (Institute 

of Medicine Committee on Health Care in America 2001) 

(Institute of Medicine Committee on Health Care in 

America 2000) (McGlynn, Asch et al. 2003) 

iii) Rising costs, variable quality have resulted in increasing 

scrutiny of providers (Millenson 2000) (Abelson 2008) 

iv) National Standards to rank physicians, checklist 

2) U.S. Health Care Crisis Multifactorial 

a) Inefficient operations 

b) Medical error/medicolegal system 

c) Moral Hazard 

d) Unnecessary care 

e) Technology 

3) U.S Health Care Policy Strategies 

a) Controlling costs by controlling utilization and limiting 

access to health care services 

b) Imposing reimbursement controls that force high-end 

providers to become more efficient 

c) Using government money to subsidize the high costs of 

health care for targeted segments of the population 

4) Defining value in health care and defining measuring 

a) Value = Quality/Cost 

i) Value in any field must be defined around the customer 

(e.g. patient) 

b) Value Based Competition 

c) Moral Hazard 

5) Value Based Purchasing 

a) Describes efforts by health care purchasers to use their 

purchasing clout to require more transparency and better 

value – based on some quality measures of quality and costfor 

the money they spend on health care 

6) Prerequisites for Value Based Health Care (Shaller, Sofaer et 

al. 2003) 

a) Consumers convinced quality and efficiency problems are 

real and consequential and can be improved 

b) Develop risk adjusted measures of quality, efficiency 

i) Information on quality and efficiency must be relevant to 

consumers, to easy to understand and use 

c) Purchasers and policymakers ensure that quality and 

efficiency reporting is standardized and universal 

d) Improved dissemination of information 

e) Payors reward improvements in quality and efficiency 

f) Providers create information and organizational 

infrastructure to improve quality and efficiency 

7) Defining measuring and reporting value in health care 

a) Increasing demand for measuring, reporting quality, cost 

i) Questions remain: 

(1) Relevance, accuracy, reliability, and actionability of 

quality information 




(2)Process, efficiency, patient satisfaction, outcome 

(3)Who’s perspective 

8) End Users of Quality/Efficiency Measures 

a) Providers: (hospitals, physicians, others): Benchmarking, 

quality improvement 

b) Patients: Comparison Shopping 

c) Payers, Purchasers: Payment incentives (e.g. P4P), benefit 

design 

9) Do Patients want Quality Info? 

10) Accessibility of Quality Info? 

11) Benefits of Quality Measurement/Reporting 

a) Potential to improve quality, efficiency 

i) Benchmarking 

ii) Hawthorne Effect 

iii) Low quality providers exit the market (Swedish Registry) 

b) Promote value-based competition 

i) Help patients, purchasers make informed decisions 

c) Encourage payers, purchasers to reward quality/efficiency 

d) Increase public trust 

i) Increase accountability 

12) Arguments against quality measurement/reporting 

a) Logistics, expense of data collection 

b) Misuse of invalid or inaccurate information 

i) Insufficient risk adjustment, sample size 

ii) Time lag 

iii) Difficult for consumers to understand, use 

iv) Medico-legal considerations 

c) Problems with attribution (MA PCI study) 

d) Potential for risk-avoidance, deselection of vulnerable, risky 

patients (NY/PA CABG experience) 

e) Top performers can’t treat everyone 

13) “Risk Avoidance Creep” (Resnic and Welt 2009) 

14) Public (vs. Private) Reporting Adds Value (Hibbard, Stockard 

et al. 2005) (Barr, Giannotti et al. 2006) 

15) Who will define “quality” in healthcare 

16) Comparison Shopping based on cost (Detroit Free Press, 

March 11, 2009) 

17) Opportunity: Quality and Efficiency Measurement and 

Reporting 

a) Participate in multi-stakeholder development of quality/ 

efficiency measures, appropriate use criteria, risk adjustment 

tools 

b) Encourage increased transparency of cost, quality 

information 

c) Embrace competition based on value 

18) Comparative Effectiveness 

a) “As applied in the health care sector, an analysis of 

comparative effectiveness is simply a rigorous evaluation of 

the impact of different options that are available for treating 

a given medical condition for a particular set of patients.” 

(Congressional Budget Office 2007) 

b) Disruptive Innovation (Christensen 1997) 

c) “Cheaper, simpler, more convenient products or services that

323 

start by meeting the needs of less-demanding customers” 

d) Inferior functionality when compared with existing 

technologies 

e) Over time, functionality improves, begin to meet the needs 

of mainstream consumers 

f) Improves the “value equation” by lower cost, improving 

quality 

g) Sustaining Innovation (Christensen 1997) 

h) The functionality of sustaining innovation nearly always 

exceeds what consumers can utilize or are willing to pay for 

19) Sustaining Innovations in Health Care 

a) Advanced Imaging, computer-assisted surgical navigation 

tools, pacemakers, MERCI Clot Retriever 

20) Disruptive Innovations in Health Care 

a) Physicians assistants, nurse practitioners, shared decision 

making tools, clinical care pathways, crew resource 

management, patient focused care initiatives 

21) Comparative Effectiveness: Opportunities 

a) Define ‘comparative effectiveness’ in your field 

i) Identify low value technologies/procedures 

b) Funding opportunities for clinical, translational health 

services research 

c) Shape policy decisions around CER: 

i) Coverage decisions 

REFERENCES 

1. Abelson, R. (2008). National Standards to Rank Physicians Planned. New 

York Times. 

2. Barr, J. K., T. E. Giannotti, S. Sofaer, C. E. Duquette, W. J. Waters and M. K. 

Petrillo (2006). “Using public reports of patient satisfaction for hospital 

quality improvement.” Health Serv Res 41(3 Pt 1): 663-82. 

3. Christensen, C. The Innovator’s Dilemma: When New Technologies Cause 

Great Firms to Fail. Boston, MA. Harvard Business School Press; 1997. 

4. Congressional Budget Office. Research on the Comparative Effectiveness 

of Medical Treatments. http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18- 

ComparativeEffectiveness.pdf. Accessed October 29 2010. 

5. Hibbard, J. H., J. Stockard and M. Tusler (2005). “Hospital performance 

reports: impact on quality, market share, and reputation.” Health Aff 

(Millwood) 24(4): 1150-60. 

6. Institute of Health Economics. World in Your Pocket: A Handbook of 

International Health Economic Statistics. Accessed November 7 2008. 




ii) Financial incentives for incorporating CER into practice 

iii) Patient education, shared decision making 

d) Allow disruptive innovations to emerge 

22) Leadership opportunities 

23) Future of Health Care in the U.S. 

a) Incentive Alignment: physicians, hospitals, health plans, 

patients 

i) Bundled payments 

ii) Gainsharing between physicians and hospitals 

iii) Accountable care organizations 

iv) Conflict of interest disclosure and resolution 

b) Patient engagement 

i) Cost sharing and value-based benefit design 

ii) Shared decision making and appropriateness of care 

c) Improved quality of evidence 

i) Randomized control trials 

ii) Registries 

iii) Incentives for reporting outcomes 

iv) Patient reported outcomes 

v) Data aggregation 

d) Transparency/Accountability 

i) Public reporting of costs, quality 

ii) Payment tied to outcomes 

iii) Value-based competition 

e) Positive sum competition 

7. Institute of Medicine Committee on Health Care in America (2000). To 

Err Is Human: Building a Safer Health System Washington, D.C., National 

Academy Press. 

8. Institute of Medicine Committee on Health Care in America. Crossing the 

quality chasm: a new health system for the 21st Century. 

http://books.nap.edu/openbook.php?isbn=0309072808. Accessed November 

3, 2008 

9. McGlynn, E. A., S. M. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro 

and E. A. Kerr (2003). “The quality of health care delivered to adults in the 

United States.” N Engl J Med 348(26): 2635-45. 

10. Millenson, M. Demanding Medical Excellence: Doctors and Accountability 

in the Information Age University Of Chicago Press; 1 edition (February 15, 

2000) 2000; 

11. Resnic, F. S. and F. G. Welt (2009). “The public health hazards of risk 

avoidance associated with public reporting of risk-adjusted outcomes in 

coronary intervention.” J Am Coll Cardiol 53(10): 825-30. 

12. Shaller, D., S. Sofaer, S. D. Findlay, J. H. Hibbard, D. Lansky and S. Delbanco 

(2003). “Consumers and quality-driven health care: a call to action.” Health 

Aff (Millwood) 22(2): 95-101.

324 

the value equatioN: uSe oF utility meaSureS 

iN determiNiNg value 

Sigurd Berven, MD 

1) Definition of Value 

a. In a healthcare economy with limited resources, providers 

and consumers of healthcare services need to be accountable 

for the end result of care, and the cost of care. The value 

proposition in healthcare is an analysis of the benefits of 

care relative to the direct cost and risk of providing the 

care. Measurement of benefits and costs is challenging, 

and a consensus on the measures that encompass the 

relevant components of the value equation has not been 

reached. Traditional outcome measures in orthopaedics 

including survival, radiographic outcomes, and diseasespecific 

outcome tools do not adequately reflect the patient’s 

healthcare experience, or the impact of an intervention on 

health-related quality of life. Similarly, measuring cost of 

care is complex, and may encompass both direct costs of 

treatment and alternative treatments, and indirect costs 

including time from work or family role, loss of productivity, 

and cost of caretakers. 

b. The right goal for healthcare delivery is superior patient 

value. i Patient value is measured at the level of specific 

medical conditions. Measurement of outcomes of care needs 

to reflect the patient’s long-term healthcare experience, and 

the impact of one intervention compared with alternatives 

on the patients self-assessment of health-related quality of 

life. 

c. The Value Equation 

The value equation in healthcare is an analysis of the 

benefits of care relative to the direct cost and risk of 

providing the care 

Value= Fxn(Benefit/Cost) 

The value equation may vary depending on the perspective 

of the stakeholder in the healthcare economy. Hospitals 

and facilities providing care may measure outcome and 

costs by factors that affect their short-term, single admission 

interaction, including length of stay, implant utilization, 

and complications. Third party payors for healthcare may 

focus on a timeframe that is longer that a single admission, 

and may include factors in the value equation such as 

readmission within 90 days, or cost of outpatient care. 

Patients, physicians, and society consider value over 

a lifetime. The cost of a single episode of care will be 

significantly discounted by the duration of the benefit. 

Patient preference for different health states over time offer 

the most useful measure of value of healthcare interventions. 

2) Measurements of Quality and Value 

a. Hospitals and payors for healthcare have established 

measures of quality that may be misinterpreted as measures 

of outcome or value. Length of stay, surgical times, 

compliance with antibiotic or thromboembolic prophylaxis, 

and perioperative complications are process measures 

that may be useful to compare hospital and provider 

performance when appropriately matched and stratified. 

However, none of these process measures are useful in 

measuring the patient’s healthcare experience, or the impact 

of an orthopaedic intervention on long-term health-related 

quality of life. In fact, a focus on quality and process 




measures alone may be misleading in the pursuit of value in 

healthcare, and may provide incentive for counterproductive 

care strategies that serve the measurement system rather than 

the patient. 

b. The priority of the patient’s self assessment of the impact 

of healthcare on their long-term health status requires 

emphasis, and efforts to substitute process measures for 

health status measures need to be avoided in the pursuit of a 

value-based healthcare system. ii 

3) Disease-specific measures of Outcome 

a. In orthopaedic surgery, patient self-assessment of health 

status and quality of life may include disease-specific 

measures, and general health status measures. 

i. Disease-specific measures are useful to optimize 

responsiveness to change, and psychometric properties. 

ii. General health status outcome tools are useful in 

providing a measure of outcome that may be translatable 

across a spectrum of medical and surgical conditions. 

b. An important limitation of many outcome measurement 

tools is that the measures are unitless, and changes in health 

status to not have a clear threshold for clinical significance, 

or value based on tangable measures 

i. Defining Minimal Clinically Important Difference 

1. MCID is the minimal threshold of change that 

patients recognize as an improvement or decrement 

in health statusiii,iv ii. Substantial Clinically Important Difference 

1. SCID describes the amount of change that a patient 

recognizes as a major improvementv 

4) An introduction to Utility scores 

a. Health status preference 

i. Health-related quality of life may be measured and 

ranked by a community preference, or societal preference, 

for various health state. Generic indices to reflect 

preference-based health-related quality of life include: 

1. EuroQol –Dimension (EQ-5D) 

a. Developed using time trade off 

2. Short Form 6-D 

a. Developed using standard gamble 

3. Health Utilities Index 

a. Developed using standard gamble 

4. Quality of Well-being Scale-Self-Administered Form 

(QWB-SA) 

a. Developed using VAS valuation 

b. Preference scoring algorithms were developed using 

econometric modelling including time trade-off, visual 

analogue score valuation and standard gamble.vi The result 

is a health status preference or utility score that has units of 

quality-adjusted life years, or an equivalence to the amount 

of time in perfect health that a change in health status is 

worth. 

c. Quality-Adjusted Life Year: 

The area under the time utility curve represents the value of an 

intervention in units of Quality-adjusted life years (QALYs)

325 

Baseline 3 mos 6mos 1yr 2yrs 

5) Crosslinking Disease-specific measures and Utility Scores 

a. Disease-specific measures in orthopaedic surgery have the 

advantage of increased responsiveness to change and better 

psychometrics, including floor and ceiling effects, than 

general health status measures. Therefore, validated diseasespecific 

measures have utility in outcome analysis. 

b. A valid translation or cross-linking of disease-specific 

measures and utility scores may be useful in applying 

disease-specific measures. 

c. ODI to SF-6D crosslinking: vii 

d. NDI to SF-6D crosslinking: 

6) Threshold for cost effectiveness in medical and surgical care 

a. Measure of $/QALY permit a comparison of the costeffectiveness 

of healthcare alternatives that may be useful in 

public policy decision-making regarding allocation of care 

b. Establishing a threshold for cost-effectiveness of medical and 

surgical interventions requires a consideration of a society’s 

willingness to pay for healthcare interventions. 

c. Thresholds may differ based upon age considerations of the 

population under care, and upon patient preferences for care. 

d. Common Orthopaedic conditions have an impact on health 

status that is comparable with other common medical 

conditions. 

REFERENCES 

i. Porter ME, Teisberg EO: Redefining Health Care. Creating Value-based 

competition on results. Harvard Business School Press, 2006. 

ii. Berven S, Smith A, Bozic K, Bradford DS: Pay-for-performance: 

considerations in application to the management of spinal disorders. Spine 

(Phila Pa 1976). 2007 May 15;32(11 Suppl):S33-8. 




7) Threshold for cost effectiveness in new technologies 

a. Consideration of incremental cost-effectiveness has utility 

in assessing the value of new technologies. A comparison 

of the cost and benefit of a new technology compared 

with an existing technology may define the value of a 

new technology and an appropriate price point for new 

technologies. viii 

b. A new technology that is less expensive and offers more 

benefit presents a clear cost advantage. A new technology 

that is more expensive and offers less benefit is a clear 

disadvantage. 

c. The slope of the cost-benefit curve, or the line of costeffective 

equipose, is determined by societies willingness to 

pay for new technologies 

iii. Spratt KF: Patient-level minimal clinically important difference based on 

clinical judgment and minimally detectable measurement difference: a 

rationale for the SF-36 physical function scale in the SPORT intervertebral 

disc herniation cohort. Spine (Phila Pa 1976). 2009 Jul 15;34(16):1722-31. 

iv. Hägg O, Fritzell P, Nordwall A; Swedish Lumbar Spine Study Group: The 

clinical importance of changes in outcome scores after treatment for chronic 

low back pain. Eur Spine J. 2003 Feb;12(1):12-20.

v. Glassman SD, Copay AG, Berven SH, Polly DW, Subach BR, Carreon LY: 

Defining substantial clinical benefit following lumbar spine arthrodesis. J 

Bone Joint Surg Am. 2008 Sep;90(9):1839-47. 

vi. Cherepanov D, Palta M, Fryback DG: Underlying dimensions of the 

five health-related quality-of-life measures used in utility assessment: 

evidence from the National Health Measurement Study. Med Care. 2010 

Aug;48(8):718-25. 

326 




vii. Carreon LY, Glassman SD, McDonough CM, Rampersaud R, Berven S, 

Shainline M: Predicting SF-6D utility scores from the Oswestry disability 

index and numeric rating scales for back and leg pain. Spine (Phila Pa 1976). 

2009 Sep 1;34(19):2085-9. 

viii.Bozic KJ, Pierce RG, Herndon JH: Health care technology assessment. 

Basic principles and clinical applications. J Bone Joint Surg Am. 2004 

Jun;86-A(6):1305-14.

327 

CoSt-eFFeCtiveNeSS aNalySiS iN orthopaediC Surgery 

Jeffrey A. Rihn, MD 

The concept of value-based health care takes into consideration both 

the quality and cost of care measured over time. There are three main 

components of the value equation: (1) the quality of care must be 

measured using some type of health outcome measure, (2) the cost 

of care must be measured, and (3) these measurements must be 

made over an appropriate time period to capture future events that 

will affect the overall value of an intervention. 

Cost-effectiveness analysis (CEA) is a specific type of economic 

analysis that estimates the value of an intervention. The purpose of 

this analysis is to calculate the ratio between the cost of a specific 

healthcare intervention (numerator) and the benefit provided by 

that intervention as determined by a health outcomes measure 

(denominator). A Cost-utility analysis is a specific type of costeffectiveness 

analysis in which the benefit is expressed as a utility 

measure, i.e. a preference based measure of health-related quality 

scored as a number ranging from 0 (death) to 1(perfect health). 

The utility measure can be used to calculate quality adjusted life 

years (QALYs). From the policy makers’ and payers’ perspective, the 

value of specific types of orthopaedic interventions should not only 

compared to each other within the field of spinal care, but should also 

be compared to the value of interventions for other disease states, for 

example the treatment of diabetes or coronary artery disease. 

A cost-utility analysis, based on a preference-based utility measure, 

provides data that allows for this comparison across various 

disciplines of medicine. It is this type of economic analysis that will 

be used to guide payers and policy makers when making coverage 

decisions. In 1996 the United States Panel on Cost-Effectiveness in 

Health and Medicine published consensus-based recommendations 

for performing a cost-effectiveness analysis. 15 According to these 

recommendations, the four key components of a cost-effectiveness 

analysis are the following: (1) the use of the societal perspective, 

(2) appropriate incremental comparisons between treatments, (3) 

appropriate discounting of both the cost and health effect of the 

treatment, and (4) the use of a community preference-based utility 

measure 15 2 . Additionally, the panel recommended the use of 

sensitivity analysis to address uncertainties within the study and 

recommended that studies have an appropriate time horizon or 

period of follow-up, as not to miss incidents that may affect the cost 

and/or outcome of a particular intervention. 15 

Despite the importance of the information provided by cost-utility 

analyses, there has been a relative paucity of these types of studies 

performed in the area of spinal care. A systematic review of costutility 

analysis in orthopaedic surgery published in 2007 reviewed 

all relevant studies published between 1976 and 2003. 1 The 

comprehensive review identified 62 articles total, 52 of which were 

cost-utility analyses with results reported in units of cost/QALY. The 

other 10 articles were reported in units of cost/life year. The number 

of cost-utility analysis was reported to increase significantly in the 

last decade, with 73% of the studies having been published after 

1998. 1 Only 21% of these articles used the societal perspective in the 

analysis, i.e. included indirect costs in the analysis. 1 

The basics to performing a cost-utility analysis include measuring 

outcomes and measuring costs. Although this seems straight forward, 

in real clinical practice it is quite the opposite. Measuring outcomes 

alone can be difficult logistically and conceptually. Measuring costs 

is even more challenging, with wide variations in methodology in 

existing studies. There is no true standardized method of accurately 

determining direct and indirect costs and many of the published 




methods depend largely on estimates and assumptions. Outcome 

Measurement in Orthopaedic Surgery 

Various disease specific and general health measures are currently 

used as health related quality of life measures in orthopaedic 

patients. Process measures are also used by some to characterize the 

care that is delivered to patients. It is important to select appropriate 

outcome measure(s) when determining quality. The ideal quality 

measure should be patient centered, reliable, valid, responsive, 

simple to collect and score, comparable across various disease states, 

and applicable to cost-effectiveness calculations (e.g. able to be used 

to calculate quality adjusted life years). Unfortunately, this ideal 

measure does not exist. 

It is important to understand what outcome measures to currently 

exist and which ones are preferable when determining the value of 

spinal care. 

Process-Based Measures 

Process-based measures assess various aspects of the care delivered 

to the patients before, during and after a treatment or intervention. 

Examples o f such measures include length of hospital stay, length 

of surgery, estimated blood loss, administration of antibiotics, 

use of DVT prophylaxis, and readmission rates. Process measures 

are relatively easy to collect and store in electronic databases and 

are free from many of the biases that complicate the collection of 

patient-reported health related outcomes. Although these measures 

characterize various aspects of a patient’s care, they are not “patientcentered” 

and may not be reflective of the quality of care. A patientcentered 

outcome measure is one which measures those things that 

are most important to the patient, including level of pain, function, 

return to work, and return to sporting activity. Patients care more 

about these outcomes than process measures such as estimated 

blood loss during surgery and length of hospital stay. This is not 

to say that process measures are not useful, they just may not be 

the best outcome measures to use in the value equation. Process 

measures are, however, readily available to policy makers and payers. 

For this reason, if policy makers and payers are not provided with 

other patient-centered outcome measures for orthopaedic patients, 

they may use process measures to grade performance and potentially 

make payment and coverage decisions. It is therefore important for 

orthopaedic providers to make efforts to monitor patient outcomes 

using patient-centered measures than can then be communicated to 

the various stakeholders in health care delivery. 

Disease Specific Measures 

Disease-specific measures are those health related quality of life 

measures that are intended to measure outcomes in patients who 

are being treatment for a specific disease or who have a problem 

in a specific anatomical region. For example, in spinal care, the 

Oswetry Disability Index (ODI) is a disease-specific measure 

intended to measure how a disorder of the lumbar spine affects the 

function of the patient. Disease-specific measures are, in general, 

more responsive than measures of general health (e.g. SF-36) when 

it comes to detecting differences in the level of patient disability 

following treatment of a specific disorder. They ask questions that 

are tailored to a specific condition, as compared to general health 

measures, which ask general questions about a patients overall 

health and function. Disease specific measures cannot be used to 

make comparisons to other disease states and have not typically been 

able to be used in the value equation because they cannot be used

directly to calculate QALYs. Numerous disease-specific measures 

have, however, recently been successfully converted into a utility 

measure that can be used to calculate QALYs. For example, Carreon 

et al 7 recently described models for converting the ODI to the SF-6D, 

which is a preference-based utility measure that was derived from 

the SF-36 and that can be compared to other disease states and can 

be used to calculate QALYs. Disease specific measures in other areas 

of orthopaedic surgery have also been converted to utility measures 

for the purpose of performing cost-effectiveness research. 

General Health Measures 

General patient-reported health related outcome measures are not 

specific to a certain disease process or area of the body but rather 

measure the overall health of the patient. These measures are 

advantageous in that they are comparable across various disease 

states and, for the most part, can be used to calculate QALYs and 

assess cost effectiveness. They may not, however, be as responsive 

as disease-specific measures to changes in patient health status that 

occur following a specific intervention. 

The most commonly used general health measure is the SF-36, 

which was developed from the Medical Outcomes Study and has 

undergone extensive analysis and validation. 3,6 The original version 

of the SF-36 was revised in 1996 to its current version, version 2 (i.e. 

SF-36v2). This 36-item questionnaire is a comprehensive measure 

of physical and mental health. It addresses 8 health domains (i.e. 

physical functioning, role-physical, bodily pain, general health, 

vitality, social functioning, role-emotional, and mental health) and 

provides both physical component summary (PCS) and mental 

component summary (MCS) scores. The SF-36 does not, however, 

provide a single, overall summary score. The domains of physical 

pain and bodily function have been used as primary outcome 

measures in several studies of spinal conditions. The SF-36 has 

been validated for use in the general population as well as in 

patients undergoing surgical and non-surgical treatment for various 

orthopaedic conditions. 

Due to concerns of test-taker burden (i.e. time and number of 

questions) when filling out forms, a shorter version of the SF-36, the 

SF-12, was developed which contains a subset of 12 questions from 

the SF-36 form. 14 Like the SF-36, there are two version of the SF- 

12. Version 2 (i.e. SF-12v2) is currently used, which reliably allows 

for calculation of the 8 domain scores as well as the PCS and MCS 

scores. With the first version of the SF-12, separate domain scores 

could not be reliably reported and therefore the results of the SF- 

12v1 were reported as the PCS and MCS scores. 14 The SF-8 is an 

even shorter version of the SF-36, which asks a single question for 

each of the eight health domains. It is intended to be used in studies 

involving groups with large sample sizes and/or large population 

surveys. It is advantageous in that is it very simple to complete and 

provides scores than can be directly compared to scores from either 

of the other two SF surveys (i.e. SF-36 and SF-12). The SF forms 

are available in standard four-week and acute one-week versions. 

These differ only in the recall period that is requested of the patient 

when filling out the questionnaire. The more recent, acute one-week 

version is intended to be used in settings that require weekly or biweekly 

collection of outcomes data. 

The main downside to these forms is that they are proprietary and 

therefore those who wish to administer and score the forms must 

pay licensing fees. These forms are not simple to score and require a 

complex algorithm. 

Utility Measures 

Utility measures are preference-based measures of general health 

that are derived from economic and decision theory. Using these 

328 




methods, utility weights are assigned to numerous health states, 

providing a range of utility scores that range from 0, which is 

equivalent to death, to 1, which is equivalent to perfect health. Utility 

measures are advantageous in that they can be compared across 

different disease states and can be used in cost-effectiveness research 

through the calculation of QALYs. Several utility measurement tools 

exist, including the Euroquol-5D (EQ-5D), the Health Utility Index, 

and the SF-6D. The EQ-5D is a brief, preference-based measure 

of general health that was developed by a group of European 

researchers in the 1980’s. 10 It includes 5 domains of health, including 

mobility, self-care, daily activities, pain and discomfort, and anxiety 

or depression. For each domain there are three possible responses, 

ranging from 1 to 3, with 1 representing no problems, 2 representing 

some problems, and 3 representing extreme problems. From 

this questionnaire, there are a total of 243 possible health states. 

Although the questionnaire is very simple to complete, scoring of the 

EQ-5D requires a complicated algorithm. The EQ-5D is proprietary 

and users must pay for licensing in order to administer and score 

the form. Although the EQ-5D was developed in Europe, United 

States population-based preference weights for the EQ-5D have been 

developed 10. The simplicity and general nature of the EQ5D raises 

concerns regarding the responsiveness of such a measure to various 

interventions for orthopaedic disorders. There is literature, however, 

that reports acceptable validity, reliability, and responsiveness of the 

EQ-5D when used to measure outcomes in orthopaedic patients 

treated for a specific problem. 8,11 

The SF-6D is a utility measure that was derived from the SF-36. 3,4,5 

This utility measure addresses six dimensions of health assessed, 

include physical functioning, role limitations, social functioning, 

pain, mental health and vitality. 5 This measure provides 18,000 

possible health states. The utility score generated from this measure 

is used in cost-effectiveness analyses. Although the SF-6D and EQ- 

5D are both utility measures, differences between the two measures 

preclude their interchangeable use and direct comparison. 9,13 

Utility measures, the QALY, and cost-effectiveness 

The benefit of the utility measure is that it can be used to calculate 

QALYs. The QALY is a measurement that incorporates both the 

quality of health as well and the length of time (expressed in years) 

over which the quality of health exists. The QALY is currently the 

standard measure used in cost-effectiveness research in several 

countries, including the United States and Great Britain, where the 

cost-effectiveness of a particular intervention is expressed as cost/ 

QALY gained. In the United States there is no standard willingness 

to pay threshold, although values of $50,000/QALY gained and 

$100,000/QALY gained have been promoted as thresholds, above 

which an intervention is not considered cost-effective. In Great 

Britain, the National Institute for Health and Clinical Excellence 

(NICE) has a willingness to pay threshold that ranges between 

£20,000 and £30,000/QALY gained. This threshold is used to make 

coverage decisions, i.e. those interventions that have a reported cost/ 

QALY ratio that is greater than this threshold are not paid for by the 

insurer. 

The QALY is calculated as the area under the curve when the utility 

measure (x axis) is plotted against time (y axis). For example, if a 

patient who undergoes a lumbar decompression and fusion for 

degenerative spondylolisthesis and stenosis has a .6 increase in the 

EQ-5D over the baseline value for a 2year period of follow-up. The 

QALYs gained are equal to .6 (the utility value for the health state) 

x 2 (number of years in that health state), or 1.2 (which equals the 

time the patient spent in perfect health measured in years). This is 

assuming that the .6 point improvement in EQ-5D over baseline is the 

same over the 2-year follow-up time period. If there is considerable

variation in the ED-5D at each follow-up time period, calculating the 

area under the curve is more complicated. 

Cost estimation 

Cost represents one half of the value equation. Unfortunately, the 

measurement of cost is just as complicated, if not more complicated 

than the measurement of quality and there is not a standard 

methodology for estimating costs. 

Direct Costs 

Direct costs refer to those costs that are directly attributed to patient 

care. These include the cost of outpatient visits, medications, hospital 

admissions, diagnostic testing, surgical and anesthesia fees, resource 

items (e.g. implant costs, blood products, biologics), and physical 

therapy. Although it seems straight forward, the calculation of direct 

costs is complex. The variation and lack of transparency in pricing 

and the difficulty in accurate recording of delivery of these services 

(e.g. number of injections, physical therapy visits, and imaging study 

each patient receives) contributes to this complexity. Costs for all of 

the above mentioned services vary widely depending on geography 

and insurance and medical device company contracts. For this reason, 

the calculation of direct costs typically involves cost estimates and 

often depends on patient recall of utilization of services. Tosteson 

et al 12 published a cost-effectiveness analysis of the treatment of 

stenosis and degenerative spondylolisthesis from the Spine Patient 

Outcomes Research Trial (SPORT) database. This study depended, 

in part, on patient-reported utilization of services, meaning that the 

patient filled out a form and reported how many outpatient visits, 

injections, radiographs, MRIs, and physical therapy visits he/she 

had during the study. Unit costs based on the 2004 Medicare rates 

were assigned to each type of service, and the direct cost of these 

services was calculated by adding up all of these unit costs for each 

patient. The other component of direct costs in this study was the 

surgical cost, which included the hospital charges, as well as the 

surgeon and anesthesia fees. The hospital charges were determined 

using the diagnosis-related group payment (i.e. 2004 Medicare rates) 

for the given procedure and associated complications, if any. The 

surgeon fees were based off of 2004 Medicare reimbursement rates, 

and the anesthesia costs were based on operative time. Although this 

method of calculation likely provides a reasonable estimate of the 

direct costs, there are some limitations. It depends largely on patient 

recall regarding the services utilizes and estimates charges based on 

Medicare payments, which is not applicable in many situations. 

Furthermore, these methods of calculation are not standard amongst 

cost-effectiveness studies, thus making meaningful comparisons 

difficult. 

Indirect costs 

Indirect costs are all of those costs that are not attributed to direct 

patient care. This largely refers to those costs attributable to loss 

REFERENCES 

1. Brauer CA, Neumann PJ, Rosen AB. Trends in cost effectiveness analyses in 

orthopaedic surgery. Clin Orthop Relat Res 2007;457:42-8. 

2. Brauer CA, Rosen AB, Olchanski NV, et al. Cost-utility analyses in 

orthopaedic surgery. J Bone Joint Surg Am 2005;87:1253-9. 

3. Brazier J, Roberts J, Deverill M. The estimation of a preference-based measure 

of health from the SF-36. J Health Econ 2002;21:271-92. 

4. Brazier J, Roberts J, Tsuchiya A, et al. A comparison of the EQ-5D and SF-6D 

across seven patient groups. Health Econ 2004;13:873-84. 

5. Brazier J, Usherwood T, Harper R, et al. Deriving a preference-based single 

index from the UK SF-36 Health Survey. J Clin Epidemiol 1998;51:1115-28. 

6. Brazier JE, Harper R, Jones NM, et al. Validating the SF-36 health survey 

questionnaire: new outcome measure for primary care. BMJ 1992;305:160-4. 

329 




of productivity that result from a particular health condition. This 

includes not only the time off of work for the patient, but also time 

that the patient requires an unpaid caregiver. Furthermore, patients 

who continue to work despite a certain level of disability have 

decreased productivity that is very difficult to estimate in a reliable, 

reproducible fashion. Indirect costs should not be eliminated from 

the value equation, in fact, they can make up a significant proportion 

of the total cost of care. 

The most common method of indirect cost estimation is the 

human capital approach. This approach assumes that the value of 

a person’s productivity is equivalent to his/her wages and benefits. 

In this approach, therefore, the calculation of indirect costs due to 

the loss of productivity is determined by multiplying the time off 

of work by the sum of the wages and benefits. The time component 

of this estimation can be many years for those patients who are 

permanently disabled. If a patient never returns to work, a “friction 

period” exists, which is defined as the time that it takes an employer 

to replace the patient who has gone out on permanent disability. 

The “friction period” varies considerably depending on the type 

of job and training required. The friction cost approach to indirect 

cost measurement may be more accurate than the human capital 

approach when studying patient populations who are out of work 

for extended periods of time. 

The cost-effectiveness study on stenosis and degenerative 

spondylolisthesis by Tosteson et al12 includes an estimation of indirect 

costs using the human capital approach. The authors depended 

on patient-reported loss of productivity, i.e. lost day from work 

or homemaking as well as duration of care required by an unpaid 

caregiver. This was assesses at each patient follow-up appointment. 

The authors estimated indirect costs by multiplying time lost from 

work by the patient’s individual wage rate, as reported by the patient 

at the time of study enrollment. The costs of missed time from 

homemaking and/or attributed to unpaid care giving were based on 

the average wage rate and non-health benefits of those greater than 

35 years-old. This represents an example of indirect cost estimation. 

It is important to realize, however, that no standardized method has 

been universally adopted for use in cost-utility analyses. 

Conclusions 

In the age of value-based health care, the importance of costeffectiveness 

analysis in orthopaedic surgery is becoming more 

apparent. This review has provided a brief overview of the components 

of a cost-effectiveness analysis. It is important to measure outcomes, 

preferably using a measure that is or can be converted to a utility 

score, and therefore be used to calculate QALYs. It is also important 

to measure cost, however, this can be complicated and is typically an 

estimation of cost rather than a true calculation of cost. 

7. Carreon LY, Glassman SD, McDonough CM, et al. Predicting SF-6D utility 

scores from the Oswestry disability index and numeric rating scales for back 

and leg pain. Spine (Phila Pa 1976) 2009;34:2085-9. 

8. Garratt AM, Klaber Moffett J, Farrin AJ. Responsiveness of generic and 

specific measures of health outcome in low back pain. Spine 2001;26:71-7; 

discussion 7. 

9. Petrou S, Hockley C. An investigation into the empirical validity of the EQ- 

5D and SF-6D based on hypothetical preferences in a general population. 

Health Econ 2005;14:1169-89. 

10. Shaw JW, Johnson JA, Coons SJ. US valuation of the EQ-5D health states: 

development and testing of the D1 valuation model. Med Care 2005;43:203- 

20. 

11. Solberg TK, Olsen JA, Ingebrigtsen T, et al. Health-related quality of life 

assessment by the EuroQol-5D can provide cost-utility data in the field of 

low-back surgery. Eur Spine J 2005;14:1000-7.

12. Tosteson AN, Lurie JD, Tosteson TD, et al. Surgical treatment of spinal 

stenosis with and without degenerative spondylolisthesis: cost-effectiveness 

after 2 years. Ann Intern Med 2008;149:845-53. 

13. Walters SJ, Brazier JE. Comparison of the minimally important difference 

for two health state utility measures: EQ-5D and SF-6D. Qual Life Res 

2005;14:1523-32. 

330 




14. Ware J, Jr., Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: 

construction of scales and preliminary tests of reliability and validity. Med 

Care 1996;34:220-33. 

15. Weinstein MC, Siegel JE, Gold MR, et al. Recommendations of the Panel on 

Cost-effectiveness in Health and Medicine. JAMA 1996;276:1253-8.

331 

meaSuriNg value iN orthopaediCS: operatioNaliziNg 

outComeS ColleCtioN aNd itS utilizatioN 

Steven D. Glassman, MD 

I. Comparative Effectiveness Research 

Institute of Medicine (IOM) definition: CER is the generation 

and synthesis of evidence that compares the benefits and 

harms of alternative methods to prevent, diagnose, treat and 

monitor a clinical condition, or to improve the delivery of 

care. The purpose of CER is to assist consumers, clinicians, 

purchasers, and policy makers to make informed decisions that 

will improve health care at both the individual and population 

levels. 

II. Background 

1. IOM: The Learning Healthcare System 2007 

2. 2008 Presidential Campaign – Pay for what works. 

3. American Recovery and Reinvestment Act of 2009 (ARRA) – 

enacted 2/17/09 

• $700 million to Agency for Healthcare Research and 

Quality (AHRQ) 

• IOM to determine research priorities 

• Top Quartile: Registry of treatment of low back pain. 

• Second Quartile: Treatment strategies for neck pain 

Exercise and medical treatment for osteoporotic hip and 

vertebral fractures 

III. Conference on Comparative Effectiveness of Treatments for 

the Lumbar Spine 

1. Professional Society Coalition Lumbar Fusion Task Force 

(AAOS/NASS/AANS/CNS/SRS) 

• AHRQ Grant 

• July 1113, 2010 Madison, WI – Multistakeholder 

conference 

2. Participants 

• Surgical Societies – Task Force parent societies, SAS, CSS 

• Nonsurgical Societies – AAFP, AAPM, AAPMR, ACP, APS, 

APTA, ASA 

• Government Representatives – AHRQ, U.S. Dept. 

Veteran’s Affairs, NIH 

• Payers – CMS, BC/BS, Noridian, Trek 

• Epidemiologists/Data Experts SPORT 

• Information Technology Experts Exponent 

• Quality Advocates – NCQA, NQF, Value Council 

3. Agenda 

• Five panels examining critical elements for registry 

development 

• Two panels on specific registry content 

• Three panels on rationale and implementation 

IV. Conference Panel Highlights 

1. Panel #1: Why is this worthwhile? 

• Keynote: Jean Slutsky, PA, MSPH, Director, Center for 

Outcomes & Evidence Agency for Healthcare Research & 

Quality (AHRQ) 

— Review of AHRQ mandate for evidence development 

• Evidence Gaps – Jyme Schafer, MD, Medical Officer, 

Coverage and Analysis Centers for Medicare and 

Medicaid Services (CMS) 

— MedCAC experience 

• Administrative Data – Carole Flamm, Executive Medical 

Director Blue Cross and Blue Shield Association 

— Existing administrative data: a mile wide and an inch 




deep 

2. Panel #2: Who are we treating? 

• Simplicity v. Accuracy 

• Defining the key data points: 

a. Demographics – tie to secondary databases? 

b. Comorbidities – are existing indices to complex 

(CCMI) 

c. Diagnosis greatest deficiency in existing data 

collection systems 

• Diagnostic Coding System development efforts 

Invited Guest Lecture: Hip Registry Experience 

Daniel J. Berry, MD, 

President, AAOS Chair, Department of 

Orthopaedic Surgery, Mayo Clinic 

— Need for simplicity and high participation levels 

3. Panel #3: How are we keeping track? 

• Keynote: Stephen L. Ondra, MD, Senior Policy Advisor 

for Health Affairs, Office of the Secretary, Department of 

Veterans Affairs VA experience with EMR development 

and translation into value 

— Incorporation of outcomes collection in EMR Need 

for decision making prior to EMR system adoption 

• Guideline Development Kristy Weber MD, Chair, 

Council on Research, AAOS 

• Recognition Programs – Elizabeth Kraft, NCQA 

• Complicating Issues 

— Data security 

— Privacy 

4. Panel #4: What are we measuring? 

• Selecting appropriate outcome measures 

a. ODI/SF36 – Are both generic and disease specific 

measures needed 

b. Health utilities – EQ5D vs. SF6D 

c. Medicare specific measures 

d. Psychometric measures 

• Study Design – Limitations of RCT design 

• Spine Specific Dataset – Michael Rapp, MD, Director, 

Quality Measures Group 

Centers for Medicare and Medicaid Services (CMS) 

5. Panel #5: How do we make this work? 

• Initiatives for participation 

a. Charles Branch, MD (ABNS) – tie to professional 

certification 

b. Leanne Larson (Outcomes Sciences) – hospital driven 

process 

c. Richard Rosenquist, MD (ASA) – patient based 

initiatives 

d. Ajay Wasan, MD (AAPM) – industry sponsorship/ 

funding 

• Quality measures 

— PQRI 

— Links to payment 

V. Conference Conclusions 

1. Time sensitive need for evidence development 

2. Registry data likely to play an important role in clinical 

guidelines

332 

3. Need for simplicity in registry development 

4. Balance between “mile wide inch deep” and “inch wide – 

mile deep” approaches 

REFERENCES 

1. Drummond M. Introducing economic and quality of life measurements 

into clinical studies. Ann Med. 2001 Jul;33(5):3449. Review. PubMed PMID: 

11491193. 

2. Drummond M, Brixner D, Gold M, Kind P, McGuire A, Nord E; Consensus 

Development Group. Toward a consensus on the QALY. Value Health. 2009 

Mar;12 Suppl 1:S315. PubMed PMID: 19250129. 

3. Johannesson M, Jšnsson B, Karlsson G. Outcome measurement in economic 

evaluation. Health Econ. 1996 JulAug;5(4):27996. Review. PubMed PMID: 

8880165. 

4. Hansson T, Hansson E, Malchau H. Utility of spine surgery: a comparison of 

common elective orthopaedic surgical procedures. Spine (Phila Pa 1976). 

2008 Dec 1;33(25):281930. PubMed PMID: 19050588. 

5. Siegel JE, Torrance GW, Russell LB, Luce BR, Weinstein MC, Gold MR. 

Guidelines for pharmacoeconomic studies. Recommendations from 

the panel on cost effectiveness in health and medicine. Panel on cost 

Effectiveness in Health and Medicine. Pharmacoeconomics. 1997 

Feb;11(2):15968. Review. PubMed PMID:10172935. 




5. In the absence of data, decision will still be made. 

6. Siegel JE, Weinstein MC, Russell LB, Gold MR. Recommendations for 

reporting costeffectiveness analyses. Panel on CostEffectiveness in Health 

and Medicine. JAMA. 1996 Oct 2330;276(16):133941. Review. PubMed 

PMID: 8861994. 

7. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations 

of the Panel on Costeffectiveness in Health and Medicine. JAMA. 1996 Oct 

16;276(15):12538. Review. PubMed PMID: 8849754. 

8. Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MC. The role of costeffectiveness 

analysis in health and medicine. Panel on CostEffectiveness in 

Health and Medicine. JAMA. 1996 Oct 9;276(14):11727. Review. PubMed 

PMID:8827972. 

9. Glassman SD, Carreon LY, Djurasovic M, Dimar JR. Johnson JR, Campbell 

MJ, Puno RM. Lumbar Fusion Outcomes Stratified By Specific Diagnostic 

Indication. Spine J. 2009 JanFeb;9(1):1321. Epub 2008 Sep 19. 

10. Glassman SD, Copay A, Berven S, Polly DW, Subach BS, Carreon LY. 

Defining substantial clinical benefit following lumbar spine arthrodesis 

(Defining Substantial Clinical Benefit in Lumbar Spine Fusion). J Bone Joint 

Surg Am. 2008 Sep;90(9):183947

333 

the elephaNt iN the liviNg room: 

impaCt oF emotioNal health 

oN FuNCtioNal outComeS aFter 

orthopediC Surgery (aa) 




Moderator: David C. Ayers, MD, Worcester, MA 

This symposia will review the role of emotional health in functional recovery following orthopaedic surgery of the lower 

extremity and upper extremity and include total joint replacement, upper extremity trauma, and rotator cuff repair. The 

clinical management challenges will be discussed with emphasis on potential strategies to identify high risk patients preoperatively 

and improve functional outcomes in these challenging patients. Attendees will learn about current intervention 

research to assure more uniform functional gain after surgery in the high risk population. Attendees will also learn that 

surgeons may not need to improve the patient’s emmotional health but provide a separate post-op pathway to improve 

functional outcomes after orthopedic surgery. 

I. Outcome Measurement Tools; Indentifying High Risk Patients 

David C. Ayers, MD, Worcester, MA 

II. Psychosocial Aspect of Disabling Musculoskeletal Pain of the Upper Extremity 

David C. Ring, MD, PhD, Boston, MA 

III. Improving Post-Op Patient Function in High Risk Patients 

Patricia Franklin, MD, MPH, Worcester, MA 

IV. Maximizing Functional Improvement in the High Risk Population After TKR 

David C. Ayers MD, Worcester, MA

•outstanding pain relief 

the Impact elephaNt of Em otional Health iN on the liviNg room: impaCt oF emotioNal in Orthopedic Practice health 

Functional Outcomes 

•Successful Surgical TKR 

oN FuNCtioNal Procedure 

nt of choice outComeS 

334 

David C. Ring MD, PhD 

Pat Franklin MD, MPH, MBA 

The Elephant in the Room : 

The Elephant in the Room : 

Impact of Em otional Health on 


David C. Ayers y MD 


Low Em Pat otional Franklin Health MD, MPH, Patients MBA At Risk 

For Less Functional Improvem ent 

Low Em otional Health Patients At Risk 


•Upper Extremity Surgery 

•Lower Extremity Surgery 

• Si Spine Surgery S 

•Elective Surgery 

•Trauma and Fracture Surgery 

• MCS: Mental Composite Score 

Functional Summary Outcom of Emotional es Vary Function with 

Em otional Health 

SF 36 SUMMARY SCORES 

• Trauma/ Fracture Repair 

• PCS: Physical Composite Score 

• Rotator Cuff Repair 

Summary of Physical Function 

• Sports: ACL Reconstruction 

• Total Hip Replacement 


• Total Knee Replacement 

• Hand Summary and Upper of Extremity Emotional Function 

•Successful Surgical 

Procedure 

•Sustained Pain Relief 

•Improved Physical 

Function 

SF-36 




ood/excellent 

•Improved Physical ollow-up •precise surgical technique 

Function 

•a smooth peri-operative course w/o 

complication 

ORTHOPEDIC OUTCOME STUDIES SHOW : 

Im portance Of Em otional Health 

•Growing number of publications document 

that ortho pts with poor emotional health 

tating 

before surgery are at risk for sub-optimal 

David C. Ayers y MD 


functional improvement after surgery 

David C. Ayers, MD, David C. Ring, MD, PhD, Patricia Franklin, MD, Despite: MPH 

ood/excellent 


•Improved Physical ollow-up 

•precise surgical technique 

Pat Franklin MD, MPH, MBA 

Function 


complication 

ORTHOPEDIC OUTCOME STUDIES SHOW : 

•outstanding Im portance pain Of relief Em otional Health 

in Orthopedic Practice 






Low Em otional Health Patients At Risk 











Summary of Emotional Function 




Has been reported in: 

• Spine Surgery 

•General Health Survey 

SF-36 


nt of choice 

tating 

ood/excellent 

ollow-up 

TKR 

•Extensive Use All Types Surgical 

Interventions 

•8 Domains 

•Summary Scores 


Interventions 

•8 Domains 

SF-36 



Interventions 

•8 Domains 

•Summary Scores 

Disease •Summary Specific Scores Outcome Measures 

•WOMAC 

• DASH 

•OSWESTRY 

•NECK DISABILITY INDEX 

Disease Specific Outcome Measures 

•WOMAC 

• DASH 

•OSWESTRY 


Spine Surgery 

“Do Patient Expectations of Spinal Surgery 

Disease Relate to Specific Functional Outcome?” Outcome Measures 

• Pt’s with low pre-op MCS more likely to be 

dissatisfied after spine surgery 

Yee et al. CORR 2008 May: 466(5) 1154 

“Depression •WOMAC Is Associated with Poorer 

Ot Outcomes ofLumbar fL b SpinalStenosis 

S i lSt i 

• 

Surgery” 

DASH 

••OSWESTRY Practices should include routine assessment of 

depression before spinal stenosis surgery 


Sinikallio et al.Eur Spine J 2007 Jul: 16(7) 905 

•Growing number of publications document 

that ortho pts with poor emotional health 

before surgery are at risk for sub-optimal 

functional improvement after surgery 

Despite: 

•precise surgical technique 


complication SF-36: 8 Domains 

•outstanding •Physical pain relief functioning 

•Role- physical 

•Bodily pain 

•General health 

•Vitality 

•Role-emotional 

•Mental health 

SF-36: •Social 8 functioning Domains 

•Physical functioning 




•Vitality 



•Social functioning 

SF-36: 8 Domains 

•Physical functioning 




•Vitality 



•Social functioning 

Functional Outcome After Ortho Surgery 

Varies With Patient Attributes 

PHYSICAL 

HEALTH 

•Medical Co-morbidities 

•BMI 

•Age 

Functional •Gender Outcome After •Poor Ortho Social Support Surgery 


PHYSICAL 

HEALTH 

•Medical Co-morbidities 

•BMI 

EMOTIONAL 

HEALTH 

•Anxiety 

•Depression 

•Poor Coping Skills 

EMOTIONAL 

HEALTH 

•Anxiety 

•Depression 

•Age 


Spine Surgery 

•Gender 

•Poor Social Support 

Functional Outcome After Ortho Surgery 


“Pre-Surgical Biopsychosocial Factors Predict 

Multidimensional Patient Outcome of Interbody 

Cage Lumbar Fusion” 

PHYSICAL 

EMOTIONAL 

• Pre-surgical HEALTHbiopsychosocial 

variables HEALTH predicted 

patient outcomes; and provide possible targeted 

interventions 

•Medical Co-morbidities •Anxiety 

•BMI 

LaCaille et al. Spine •Depression 

J 2005, Jan: 5 (1) 71 

•Age 


•Gender 

•Poor Social Support

335 

psychological distress, and return to work 

correlated with patient satisfaction 

O’Toole et al . JBJS(A) 2008 Jun; 90 (6): 1206 

Trauma/ Fracture Care 

“Determinants of Patient Satisfaction 

After Severe Lower-Extremity Injuries” 

•No pt demographic, treatment, or injury 

characteristics correlated with pt 

satisfaction 

•Only measures of physical function, 

psychological distress, and return to work 

correlated with patient satisfaction 

O’Toole et al . JBJS(A) 2008 Jun; 90 (6): 1206 

Sports / ACL 

“Psychological Impact of Returning to Sport 

Following ACL Reconstruction Surgery” 

Webster et al. Phy Ther Sport 2008 Feb; 9(6): 9 

“Health Related QOL in Patients with ACL 

Insufficiency Undergoing Arthroscopic 

Reconstruction” 

Calvisi et al. J Orthop Trauma 2008 Dec; 9(11) 

Sports / ACL 

“Psychological Impact of Returning to Sport 

Following ACL Reconstruction Surgery” 

•Can improve Webster et patient al. Phy Ther functional 

Sport 2008 Feb; 9(6): 9 

outcome after surgery in low MCS 

pts without treating/curing the 

“Health Related QOL in Patients with ACL 

Insufficiency depression/anxiety Undergoing Arthroscopic underlying the 

Reconstruction” 

low MCS 

Calvisi et al. J Orthop Trauma 2008 Dec; 9(11) 

•Perhaps, by identifying the high risk 

patient pre-operatively and placing 

them in a different post-op pathway 




pain relief and patient satisfaction. Appropriate 

assessment of emotional health may enable a 

modification in the way these pts are managed 

Rolfson et al. JBJS(B) 2009 Feb; 91 (2): 157 

Total Hip Replacem ent 

“Predicting Dissatisfaction After THA; a Study of 

850 patients” 

• Depression, MCS and symptomatic OA of another 

joint predicted dissatisfaction after 1 year 

Anakwe et al. J Arthroplasty 2010 May 10; S1532 

“Variables Determining g Outcome in THR 

Surgery” 

• Depression/Anxiety scores are strong predictors of 

pain relief and patient satisfaction. Appropriate 

assessment of emotional health may enable a 

modification in the way these pts are managed 

Rolfson et al. JBJS(B) 2009 Feb; 91 (2): 157 

Em otional Health Influences Patient 


• Hand and Upper Extremity Surgery 

David Ring MD 

• TtlK TotalKnee RReplacementSurgery l tS 

David Ayers MD 

• NIH RO1 to Improve Function in 

High Risk TKR Group 

Pat Franklin MD, MPH 

Em otional Health Influences Patient 


• Hand and Upper Extremity Surgery 

David Ring MD 

• TtlK TotalKnee RReplacementSurgery l tS 

David Ayers MD 

• NIH RO1 to Improve Function in 

High Risk TKR Group 

Pat Franklin MD, MPH 

Tashjian et al. 

J Shoulder Elbow 2007 Nov; 18(6) 

Rotator Cuff Repair 

• Patient’s Pre-operative Expectations Predict 

The Outcome of Rotator Cuff Repair 

Henn et al. 

JBJS (A) 2007 Sept; 89(9); 1913 

• Factors Influencing Patient Satisfaction 

After Rotator Cuff Repair 

Tashjian et al. 

J Shoulder Elbow 2007 Nov; 18(6) 

Unifying Concepts: 

•Patients at risk for less functional 

improvement following surgery can 

be identified pre-operatively 

•Risk factors include emotional and 

physical patient attributes 

•Functional improvement often 

related to patient satisfaction 

Unifying Concepts: 

•Patients at risk for less functional 

improvement following surgery can 

be identified 

David 

pre-operatively 

C. Ayers, M.D. 

The Arthur Pappas Professor & Chair 

•Risk Department factors of include Orthopedics emotional & Rehabilitation and 

Director, Musculoskeletal Center of Exce lence 

physical patient attributes 

University of Massachusetts Medical School 

•Functional Orthopaedist-in-Chief 

improvement often 

related UMass to patient Memorial satisfaction 

Healthcare System

336 

pSyChoSoCial aSpeCtS oF muSCuloSkeletal illNeSS 

David Ring, MD PhD 

Psychology: 

The scientific study of mental processes and behavior. A highly 

functioning human mind is prone to errors. Magicians fool us 

through our strengths, not our weaknesses. 

Science: 

systematic knowledge of the physical or material world gained 

through observation and experimentation. 

• Science is what humans invented to keep from fooling 

themselves or being fooled by others. 

Stigma: 

A mark of disgrace or infamy Psychology is stigmatized as being 

about what is wrong with the mind. There is shame associated 

with psychology and psychological illness. In social science, Ervin 

Goffman: “the situation of the individual who is disqualified from 

full social acceptance”. (1) 

• Poor coping skills 

• Depression 

• Anxiety 

• Pain catastrophizing 

These are seen as offensive and degrading. 

Mind vs. Body: 

The strict separation between mental and physical illness in modern 

culture is Descartes’ fault. It is a consequence of how the mind 

functions, reinforced by the stigma associated with the psychological, 

behavioral, and sociological aspects of illness. 

• All illness is both mental and physical and any attempt to separate 

them will be fruitless and counterproductive. 

Illness vs. Disease: 

• Disease: A harmful deviation from the normal structure or 

function of an organism. 

• Illness: The state of being unwell. 

• Surgeons and their patients instinctually act as if illness is always 

due entirely to disease. Find and address the disease and the 

illness will resolve. “Find it and fix it”. This is representative 

of the traditional biomedical model of illness. However, the 

degree of illness does not correlate directly with the disease/ 

pathophysiology. (2, 3) Illness is a biopsychosocial behavioral 

phenomenon. 

Impairment vs. Disability: 

• Impairment: Objective pathophysiology. 

• Disability: The biopsychosocial behavioral condition of not 

being capable of a specific activity. 

• The degree of disability does not correlate directly with 

impairment. (4) 

Pain vs. Nociception: 

• Nociception: the neural processes of encoding and processing 

noxious stimuli. 

• Pain: the psychological response to nociception. 

Eye-openers: 

1. Patients in the Netherlands take almost no narcotics after ORIF 

ankle fracture and have higher satisfaction with pain-relief than 

patients in the United States. (5) 

2. Disability correlates more with pain and psychosocial factors 




than objective impairment for many conditions. (2, 3) 

3. Depression produces the greatest decrement in health among 

chronic diseases in the world and it exacerbates decreased 

health from other medical conditions. (6) 

4. Misinterpretation or overinterpretation of nociception (called 

pain catastrophizing by psychologists) strongly correlates with 

disability related to ongoing pain in most anatomical areas. (3) 

5. Believing that one is receiving effective treatment is often as 

good as actually receiving treatment, but only in the treatment 

of pain, nausea, depression and other psychosocial behavioral 

aspects of illness. (6, 7, 8) In other words, we have the capacity 

within ourselves to create health and wellness. 

Coping strategy: a behavioral tool that may be used by individuals 

to offset or overcome adversity, disadvantage, or disability without 

correcting or eliminating the underlying condition. 

Ineffective coping strategies (3): 

• Drugs 

• Violence 

• Fear-Avoidance 

• Cognitive Errors 

— Catastrophizing: “It will only get worse” 

— Emotional reasoning: “This is taking too long” 

— Should: “I should not feel pain” 

— Control fallacies: “If I find the right doctor, they will take my 

pain away” 

— Overgeneralization: “I hurt myself using that tool. I will 

always hurt myself using that tool” 

— Black and white thinking: “My life was perfect before. Now 

it’s horrible” 

Cognitive Behavioral Therapy: 

• Distinguish between thoughts and reality 

• Increase awareness of negative automatic thoughts 

• Cognitive restructuring: Learn how to change automatic 

thoughts and behaviors 

Cognitive Behavioral Therapy is something that all health care 

providers can incorporate into their care, but it requires very 

good communication skills. 

Post-traumatic Stress Disorder: 

A severe anxiety disorder after a highly stressful event 

Chronic Regional Pain Syndrome: 

An illness construct for disproportionate pain. Psychologists 

understand it as extremely ineffective coping strategies. Specifically, 

strong misinterpretation or overinterpretation of nociception (pain 

catastrophizing). 

Somatoform Disorder: 

• Hypochondriasis: Preoccupation with the fear or belief that one 

has a serious, undiagnosed disease based on a misinterpretation 

of benign physical sensations and persisting despite appropriate 

reassurance to the contrary 

• Somatoform Pain Disorder: Pain disorder associated with 

psychological factors and with or without a general medical 

condition: Both the psychological factors and the general 

medical condition have important roles in the onset, severity, 

exacerbation, or maintenance of the pain.

REFERENCES 

1. Goffman E. Stigma: Notes on the management of spoiled identity. New York, 

NY: Simon and Schuster Inc; 1963. 

2. Ring D, Kadzielski J, Fabian L, Zurakowski D, Malhotra LR, Jupiter JB. Selfreported 

upper extremity health status correlates with depression. J Bone 

Joint Surg Am. 2006 Sep;88(9):1983-8. 

3. Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling 

musculoskeletal pain. J Bone Joint Surg Am. 2009 Aug;91(8):2014-8. Review. 

4. Doornberg JN, Ring D, Fabian LM, Malhotra L, Zurakowski D, Jupiter JB. 

Pain dominates measurements of elbow function and health status. J Bone 

Joint Surg Am. 2005 Aug;87(8):1725-31. 

5. Lindenhovious AL, Helmerhorts GT, Schnellen AC, Vrahas M, Ring D, 

Kloen P. Differences in prescription of narcotic pain medication after 

operative treatment of hip and ankle fractures in the United States and The 

Netherlands. J Trauma. 2009 Jul;67(1):160-4. 

337 




6. Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, 

chronic diseases, and decrements in health: results from the World Health 

Surveys. Lancet. 2007 Sep 8;370(9590):851-8. 

7. Hr—bjartsson A, G¿tzsche PC. Is the placebo powerless? An analysis of 

clinical trials comparing placebo with no treatment. N Engl J Med. 2001 May 

24;344(21):1594-602. 

8. Hr—bjartsson A, G¿tzsche PC. Placebo interventions for all clinical 

conditions. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD003974. 

9. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton 

RC, Fawcett J. Antidepressant drug effects and depression severity: a patientlevel 

meta-analysis. JAMA. 2010 Jan 6;303(1):47-53. Review.

338 

patieNt Support to optimize FuNCtioN aFter total kNee 

replaCemeNt 

Patient support to optimize 

function after Total Knee 

Patient Replacem support to ent 

optimize 

function after Total Knee 

Patient Replacem support to ent 

optimize 

Patricia D. Franklin MD MPH 

function AAOS after 2011 Total Knee 

patricia.franklin@ atricia.franklin@ um assm ed.edu 

Replacem ent 


AAOS 2011 



AAOS 2011 


Total knee replacem ent 


• Technica ly successful procedure to 

relieve pain in advanced knee OA 


•NIH NIH Consensus Statem ent, 2003 


• Functional Technica Functional ly gain successful varies widely procedure after 

to 

relieve TKR, relieve TKR, important pain in advanced to patient knee health. OA 


• Technica ly successful procedure to 

• Functional gain varies widely after 


TKR, important to patient health. 


• Functional gain varies widely after 

TKR, important to patient health. 

Costs to working adults with OA 


• Working Working-aged aged adults increasingly choose 

TKR; Current = 40% of total 

• Working aged adults with OA 

• Working Working-aged • Limited aged activities adults 23% increasingly of the time ( (vs vs choose 9%) 

TKR; • Lose Current 8 more = annual 40% workdays of total 

• Working • Adjusted aged for age, adults gender, with job OA OAcharacteristics, 

• Working Working-aged co-morbidities, aged adults total per- increasingly OA employee choose cost: 

• Limited activities 23% of the time ( (vs vs 9%) 

• TKR; Current $1800 in benefits 

• Lose 8 more = annual 40% workdays of total 

• $7454 in lost productivity 

• Working • Adjusted • Total= aged over for age, $9000/person/year. adults gender, with job OA OAcharacteristics, 

(Muchmore, 2003) 

• Limited co-morbidities, activities total 23% per- of the OA time employee ( (vs vs 9%) cost: 

• • Lose $1800 8 more in benefits annual workdays 

• $7454 in lost productivity 

• Adjusted for age, gender, job characteristics, 

• Total= over $9000/person/year. (Muchmore, 2003) 

co-morbidities, total per- OA employee cost: 

5 

–Recommended Recommended to treat OA 

–Supports Supports post-TKR post TKR recovery 

Physical Exercise/physical – Benefitsovera Benefitsovera activity lhealthand lhealthand activity 

benefits wel-being wel 

welbeing health being 

–Recommended Recommended to treat OA 

50% –Supports Supports of TKR post-TKR post patients TKR recovery 

have joint pain in 

Exercise/physical lum Exercise/physical – Benefitsovera Benefitsovera bar spine, one lhealthand lhealthand activity 

or both wel-being wel 

welbeing hips, being contra- 

lateral –Recommended Recommended knee. to treat Ayers, OA 

Franklin Franklin 2010 

–Supports Supports post-TKR post TKR recovery 

50% of TKR patients have joint pain in 

lum – Benefitsovera Benefitsovera bar spine, one lhealthand lhealthand or both wel-being wel 

welbeing hips, being contra- 

lateral knee. Ayers, Franklin 2010 

50% of TKR patients have joint pain in 

lum bar spine, one or both hips, contra- 

u The FDA • $1800 has not in cleared benefits the drug and/or medical device for the use 5 described in this presentation (i.e. lateral the drug knee. or medical device is Ayers, being Franklin discussed 2010 

for an off label use). 

For full information • $7454 in lost refer productivity to page 14. An alphabetical faculty financial disclosure list can be found starting on page 19. 

• Total= over $9000/person/year. (Muchmore, 2003) 


5 


Patricia Franklin, MD, MPH 

3 

3 

3 

Today’s session 

Today’s session 

1. Rationale for patient support to optimize 

function after TKR 

-Role of Self-efficacy 

Today’s 1. Rationale session for patient support to optimize 


2. Overview of RCT of ongoing support 

-Role of Self-efficacy 

1. Rationale 

intervention 

for 

for 

patient 

TKR patients 

support to optimize 



3. Im -Role plications of Self-efficacy for orthopedic practice 

intervention for TKR patients 


3. Im 

intervention 

plications 

for 

for 

TKR 

orthopedic 

patients 

practice 

3. Im plications for orthopedic practice 

Osteoarthritis-related disability: 

a public health priority 

Osteoarthritis-related OA affects 50% of all adults > disability: 

65 years 

>21 million US adults; more women than men. 

a public health priority 

Osteoarthritis-related OA disability: 

OA OA 

affects 

is is #1 #1 cause cause cause 

50% 

of of 

of 

disability/limited disability/limited 

all adults > 65 years 

mobility 

mobility 

1/3 of all US adults report disability due to OA 

a public >21 million health US adults; priority 

more women than men. 

 

OA OA 

OA 

affects is 

patients 

is #1 #1 cause cause 

who 

50% of of 

choose 

of disability/limited disability/limited 

TKR have 

all adults > 65 years mobility 

mobility 

significant functional limitation 

>21 1/3 of million all US US adults adults; report more disability women due than to men. 

OA 

Mean pre pre-TKR TKR SF/PCS= 28 

> 2 standard deviations below the mean for healthy 

adults 

1/3 77% of unable all functional US to adults walk report >5 limitation 

blocks disability due to OA 



adults 

functional limitation 

77% unable to walk >5 blocks 



adults 

77% unable to walk >5 blocks 

OA OA is patients is #1 #1 cause cause who of ofchoose disability/limited disability/limited TKR have mobility 

mobility 


OA patients who choose TKR have 


Physical activity benefits health 

Exercise/physical activity 

Physical activity benefits health 

12/2/201 

12/2/201

339 

Obese patients inactive after TKR 

Franklin, Ayers et al, Subm itted for publication 

Exercise and physical activity in the post post- 

TKR rehabilitation improve global 

function and benefit OA in other joints j 

and global health. 

How optimize functional gain after TKR? 

Self-efficacy 

Self-efficacy is a person’s belief in his or her 

ability to succeed in a particular situation. 

(Bandara, 1995) 

Develop self-efficacy 

1. Mastery experiences- performing a task 

successfully 

2. Social modeling- seeing similar person succeed 

at a task. 

3. Social persuasion- receive positive 

encouragement to achieve a goal. 




Wide variation in functional gain after TKR 

Percennt 

15 

10 

5 

0 

Distribution of Functional Improvement 

(12 Month Post Total Knee Replacement Surgery) 

QuickTime and a 

decompressor 

are needed to see this picture. 

-20 0 20 40 

SF36 PCS Change 

Source: Zimmer TKR Registry 

Can a l patients further improve functional gain? 

Knee OA self-care improves function 

Lorig- arthritis self-care programs 

(1993, 1999, 2001, 2003) 

– Target self-efficacy 

– 20% reduction in joint pain pain, improved function 

– No significant deterioration between 1-2 year follow-up 

– Minority of patients use programs 

van den Akker-Scheek, 2007 

– Self-efficacy at 6 weeks after TKR/THR correlated with 

long term physical function. 

Keefe, 2002 

– Multiple-component support programs reduce pain and 

disability in rheumatoid and OA. 

Self-efficacy (2) 

4. Psychological Responses 

Moods, emotional states, physical reactions, 

and stress levels can all impact how a 

person feels about their abilities (selfefficacy) 

in a particular situation. 

--Role of self-efficacy and emotional health in 

post-TKR rehabilitation and functional gain?

340 

Exercise self-efficacy and MCS 

TKR patients: poorer em otional health (low MCS) associated 

w ith poorer self-efficacy (p< 0.009). 

Self-efficacy and Depression 

TKR patients: greater depression (higher score) associated 

w ith poorer self-efficacy. (p< 0.000) 

Predictors of poor post-TKR function 

Target Population 

1. Older age (5 year increase) 

2. Extreme obesity y( (BMI>40) ) 

3. Lower pre-TKR PCS (physical function) 

4. Lower pre-TKR MCS (emotional health) 

5. Fair/poor quadriceps strength 

Latent class mixture models, multivariate regression,12 month PCS 

2008 Knee Society Ranaw at Aw ard Franklin, Li, Ayers 




Exercise self-efficacy and Anxiety 

TKR patients: greater anxiety (higher score) associated w ith 

poorer self-efficacy. (p< 0.003) 

Joint Joint Action:Optimizing Action: Optimizing patient 


NIAM S R01 AR 054479-01; 2008-2011 

Franklin, Ayers, Rosal, Li, O atis 

Study Model: Patient Role in TKR Functional Outcome 

Patient following TKR 

Patient Modifiers 

Age, Gender, BMI 

Physical health 

Emotional health 

Self-care Support 

Behavioral Skills 

Attitudes, Knowledge 

Slf Self-efficacy ffi 

Home Exercise 

Physical Activity 

Physical Therapy 

Exercise Skills 

Knowledge 

Self 

Care 

Patient Outcome 

Physical Function 

Knee Function

341 

Telephone support for TKR: 

Joint Joint Action Action RCT 

• Goal: Goal: 180 UMM HC patients 

• 156 enro led to date 

77 intervention; 79 usual care 

• Stratified M CS, BM I, gender 

• Primary outcomes at 6 and 12 months 

•Self Self-report report function (SF/PCS; W OM AC) 

•Objective Objective Activity (accelerom eter) 

•Clinical Clinical function (stair climb; 5 min walk) 

Peri-TKR Self-care Program 

• 12 sessions to support self self-efficacy; efficacy; 

optimize daily exercise and activity. 

• Timing: 4 pre-op and 8 post-TKR sessions 

• Patient Patient-centered: centered: tailored self self-care care goals based 

on patient motivations and needs 

• Format: telephone individual counseling plus one 

in hospital visit 

• Interventionist: health educator; English- 

Spanish language 

• 100% patient retention to date. 

 

 

 

Exercises that you do on your own mak e a difference in your knee recovery. 

The exer cises in the UMa ss Total Knee Book will help you begin to restore 

mo vement and strength to you r knee. 

These exer cises can be performe d twice a day or as man y times as you and 

your surgeon and therapist decide. 

Try these exercises at home before surgery so you are familiar w ith them. Try 

to do them everyd ay at the hosp ita l, th e reha bilitat ion cent er, and home. 

Breathe norma lly when doing these exercises. Do not ho ld your bre ath 

during an exercise becaus e that can raise your blood pressu re. 

As you imp rov eyou r ph ysical therap ist ma y progress th ese exe rcises or teach 

you new on es. 

 

After exer cising, you r knee ma y hu rt mo re. Rest and use ice on you r knee 

after exer cise to help the increased soreness go away in 30-60 minut es. 

If th e soreness continues you may hav e done too much or performed an 

exercise incorrectly. 

Discuss an y difficulties with your physical therapist or surgeon. 

As you imp rove, your th erap ist may give y ou new exer cises. Be su re to 

discuss with your therap ist how to add or su btract exercises from you r da ily 

routine. 

6/8/2010 




MD #1 

TKR Surgery scheduled 

Random assignment 

Condition 1 Condition 2 

Control Telephone Support 

Pre-admit Session 

TKR Surgery 

Pre-TKR Telephone 

SSessions i 

MD #2, MD #3 

Same process 

PT /Exercise Log PT /Exercise Log 

PLUS Telephone Sessions 

6 and 12 month Functional Status 

** 85% of eligible patients agreed to participate 

Computer-assisted sessions 

1. Computer structures each call (mean= 18 minutes) 

• Assess progress 

• Advise adherence to exercise/activity 

• Assist in weekly goal setting and problem solving 

• A Arrange next t call ll 

2. Educator training 

• Motivational interviewing 

• Self Self-efficacy efficacy 

• Knowledge 

• Skills 

• Goal Goal-setting setting 

• Self Self-monitoring monitoring 

3. Patient between sessions: exercise/activity logs 

Next steps 

Complete data collection: Spring 2011 

Data Analysis goal: 

• Do patients with telephone support have 

greater and more uniform functional gain 

at 6 months? 

• If so, identify patient sub-groups with 

greatest effect. 

• If so, do benefits persist at 12 months?

342 

Translation to orthopedic practice 

1. Trained health educators 

Role of Self-efficacy; Patient-self-monitoring 

2. Standardize intervention software 

3. Orthopedic office ability to identify patients 

who may benefit (e.g., low MCS) 

Future: Tailored TKR rehabilitation? 

To patient condition 

– Emotional health, BMI, gender 

To patient expectations and goals 

–Working adults; Recreational activity 

Facilitated through enhanced selfefficacy 

for daily exercise and activity 



SympoSia pRACTiCE

ood/excellent 

•Improved Physical ollow-up 10.4 Delta PCS 

Department of Orthopaedics and Rehabilitation 

Function 

University of Massachusetts Medical School 

(p 30 points. 

• 98% report pain relief following TKR 

Summary 

• Wide variation exists in the degree of individual 

• Pre-TKR 

functional 

PCS 

improvement 

is normally distributed 

at 12 months 

and 

after 

demonstrates primary TKR, poor despite function uniform among pain patients reliefchoosing 

TKR Post (mean TKR = Improvement 

27) 

• The mean PCS improvement is 10.5 points; 

• The 12 month post-TKR PCS distribution is bimodal. 

comparable to the PORT study. 

Summary • The change in pre-to- 12 month post PCS ranges 

from neg/0 to >30 points. 

• PPost-TKRfunction t TKRf ti suggests t two t patient ti t groups 

• 98% report pain relief following TKR 

Group 1: significant gain in PCS 

Mean gain =21 (SD=7) 

Summary 

Group 2: limited gain in PCS 

• Wide variation exists in the degree of individual 

functional Mean improvement gain =4.1 (SD=7) at 12 months after 

primary TKR, despite uniform pain relief 

•Successful Surgical 

Procedure 





Percent 

Percent 

Percent 

nt of choice 

tating 

ood/excellent 

ollow-up 

TKR 

•Improved Physical 

Function 


Franklin PD, Li W, Ayers DC 

2008 Knee Society Ranawat Award 

CORR, Nov 2008, p 2597-2604 

Functional Outcome After TKR 

Functional • 31 states and 224 Outcome hospitals After TKR 

• 31 states and 224 hospitals 

Functional • 41% of hospitals Outcome reported < 50 TKR After cases/yearTKR 




CORR, Nov 2008, p 2597-2604 

• 8300 Pi Primary TKR 

• > 200 surgeons submitted cases 

• 30% percent submitted > 20 cases/year 

• 78% of Distribution all cases were of treated Functional by these Improvement surgeons 

(12 Month Post Total Knee Replacement Surgery) 

• 31 states and 224 hospitals 

15 

• 41% of hospitals reported < 50 TKR cases/year 

10 

10 

0 

-20 0 20 40 


Source: Zimmer Distribution TKR Registry of Functional Improvement 

•Do patients (12 Month with Post Total small Knee Replacement post-TKR Surgery) 

15 

10 




CORR, Nov 2008, p 2597-2604 

5 

5 

•Is there variation in functional 

0 




• 78% of all cases were treated by these surgeons 

0 

-20 0 20 40 

Distribution of SF36 Functional PCS ChangeImprovement 

Source: Zimmer (12 TKR Month Registry Post Total Knee Replacement Surgery) 

15 

5 




• 78% of all cases were treated by these surgeons 

• 41% of hospitals reported < 50 TKR cases/year 

Question? 

functional improvement start with 

higher PCS and have less room to 

improve? 

Or 

improvement across pre-TKR PCS? 

-20 0 20 40 


Source: Zimmer TKR Registry 

SFF12 

PCS Change 

AYERS, DC et al: 

J. of Arthroplasty 2001 

250 Consecutive Primary TKR 

30.8 Mean Preop PCS 

41 41.22 Mean Postop PCS 

10.4 Primary TKR Delta patients PCS N>8300 

(p 70% Caucasian (353 African American; 271 

Hispanic) 

95% diagnosis g knee osteoarthritis 

• Pain: (KSS); pre-TKR = 37; post= 80. 

• Function: 

54% moderate or severe pain at rest 

Primary 92% moderate/severe TKR patients pain when N>8300 walking 

Zimmer 

 

NexGen 

77% walk 

implants 

70% Caucasian (353 African American; 271 

Hispanic) 



• Function: 


92% moderate/severe pain when walking 

Primary TKR patients N>8300 

77% walk 70% Caucasian (353 African American; 271 

Hispanic) 



• Function: 

Distribution of SF36 PCS Score 


.06 

Pre-operative 

92% moderate/severe pain when walking 

12 month post-operative 

77% walk

Change in Knee K Soc. Pain Score 

CHANGE in these patients ranges from negative/0 to 

plus 30 points 

• Higher pre-TKR PCS is associated with smaller 

change in PCS at 12 months. 

AND 

• Patients with poorest function (PCS=20) have wide 

variation in functional improvement (0-35 points) 

Summary 

•Patients with poor emotional health (MCS=50 have clear 

improvement (right shift) of distribution. 

Summary 

•Patients with poor emotional health are less 

likely to have functional improvement at 12 

months. 

100 

12 Month Postoperative Changes in 

SF12 PCS and Knee Society Pain Score 

75 

•Patients 50 with poor emotional health (MCS=50 have clear 

-25 

improvement (right shift) of distribution. 

Change in Knee K Soc. Pain Score 

-50 

100 

75 

-30 -20 -10 0 10 

Change in SF12 PCS 

20 30 40 

Source: Zimmer TKR Registry 2000-2005; N=3,118 

Summary 

•Patients with poor emotional health are less 

likely to have functional improvement at 12 

months. 

12 Month Postoperative Changes in 

SF12 PCS and Knee Society Pain Score 

•Patients 50 with poor emotional health (MCS=50 have clear 

-25 

“TKR improvement Patients (right With shift) LOW of Pre-op distribution. Em otional 

-50 

Health -30 (MCS -20 -10 =22 1.164 0.561 0.066 2.263 0.038 

Baseline Change PCS in physical -0.745 function 0.040 -0.823 (PCS) -0.666 0.000 

Osteoarthritis 2.461 0.771 0.949 3.973 0.001 

Knee Society Pain Score -0.017 0.010 -0.037 0.003 0.095 

• Poor 10.1 or fair quadriceps Times More Likely If Also Have 

One or More Medical Co-morbidities 

strength -0.938 0.459 -1.838 -0.039 0.041 

Ayers et al 

J Arthroplasty 2003 

LOW PREOP MCS PATIENTS 

•3 Times More Likely to Have Less 

Change in physical function (PCS) 

• 10.1 Times More Likely If Also Have 

One or More Medical Co-morbidities 

METHODS: 

•3 Times More Likely to Have Less 

• 100 non-consecutive TKR patients 

Change in physical function (PCS) 

•• SF-36, 10.1 Times WOMAC More surveys Likely If completed: Also Have 

One 2 or Weeks More Preop Medical Co-morbidities 

6Months Postop 

•PCS and MCS calculated 

Ayers et al 


LOW PREOP MCS PATIENTS 

Ayers et al 


•Telephone psychological assessment 

preop 

Pain relief, 

PCS improved 

2,685 85.9 100.00 

Total 3,118 100.00 

Frequency Percent Cumulative 

No pain relief, 

no PCS 

improvement 

34 1.1 1.1 

Pain relieved, 

no PCS 

368 12.0 13.1 

improvement 

Higher No pain relief, odds of less 31 functional 1.0 gain associated 14.1 

PCS improved 

with: 

Pain relief, 2,685 85.9 

Lower pre-op MCS 

PCS improved 

Total Greater 3,118 BMI 100.00 

100.00 

Each 5 year increase in age 


more .1 than 2:1 odds of poorer functional gain after TKR 

MCS=50, 12 month post-operative 

Higher odds of less functional gain associated 

Dennsity 

12 Month Change in PCS and KSS Pain Score 

.05 

.025 

0 

Non-OA Non OA diagnosis 

Poor/fair quadriceps strength 

Patients with BMI >40 and poor quadriceps strength had 

.05 

MCS=50, Pre-operative 

20 30 40 50 60 

SF36 PCS 


more .1 than 2:1 odds of poorer functional gain after TKR 

MCS=50, 12 month post-operative 

Higher odds of less functional gain associated 

Dennsity 

with: 

.025 

0 


Greater BMI 





HYPOTHESIS: 

Peri-op intervention targeting 

low MCS patients might improve 

post-op physical outcome 

Ayers, Franklin et al 


Peri-op intervention RESULTS: targeting 

low MCS MCS Distribution patients might 100 Patients improve 

MCS 50 

Ayers, Franklin et al 

68% 


PURPOSE: 

METHODS: 

RESULTS: 

•Standard Psych Components 

• 100 non-consecutive TKR patients 

MCS Distribution 100 Patients 


344 associated with low MCS TKR 

• SF-36, WOMAC surveys completed: 

patients 

For 

are 

full 

unknown 

information refer to page 14. An alphabetical faculty financial 2 Weeks disclosure Preop list can be found starting on page 19. 

MCS 50 

68% 

the First step in development of a 

•PCS and MCS calculated 

Pre-Surgical Intervention SympoSia pRACTiCE 

•Telephone psychological assessment 

with: 


Greater BMI 





more than 2:1 odds of poorer functional gain after TKR 

HYPOTHESIS: 

post-op physical outcome

• MCS50 

– BDI= 6.4 

345 

0 

=50 

BECK DEPRESSION INVENTORY 

• Higher Scores - More 

Depression 

12 

SPIELBERGER TRAIT ANXIETY 

• 10-18 -Minimal Depression 

Sub-clinical, No need to treat 8 

•Significantly higher anxiety score in 

6 

patients with MCS

346 

leSSoNS learNed: how to miNimize 

CompliCatioNS iN CommoN aNd 

CompleX Shoulder Surgery - 

a CaSe-baSed SympoSium (h) 

Moderator: William N. Levine, MD, New York, NY 

The goals of this symposium are to present common and complex shoulder cases that all registrants manage highlighting the 

lessons learned from experts to minimize complications. 

I. AC Joint Injuries 

Christopher S. Ahmad, MD, New York, NY 

a. When should we really operate? 

b. Anatomic reconstruction – lessons I’ve learned to avoid complications 

c. My current rationale for treatment 

II. Rotator Cuff Repair in 2011 – Does any of this stuff really matter if they are all going to fail anyway? 

Ken Yamaguchi, MD, Saint Louis, MO 

a. Is it the number of rows or the number of sutures that really matters? 

b. Lessons I’ver learned to avoid complications 

c. What do I do for the 50 y.o patient with a massive tear? 

d. My current rationale for treatment 

III. Choices for Instability Surgery 

Evan L. Flatow, MD, New York, NY 

a. Paradigm shift – soft tissue vs bone, not “open vs scope” 

b. Lessons I’ve learned to avoid complications 


IV. Clavicle fractures – Do I really have to fix them all? 

Michael D. McKee, MD, Toronto, Canada 

a. Where there’s a will there’s a prospective randomized study to answer the question! 

b. Plates, nails, and screws – I’ve seen them all fail – lessons learned to avoid complications 


V. Case Discussions, Questions, Interactive Session 



SympoSia SHOULdER & ELBOW

347 

aC JoiNt iNJurieS: wheN Should we operate aNd 

whiCh proCedure Should i do? 

Christopher S. Ahmad, MD 

History 

• 1940 - Murray transfixed the AC joint with k-wires 

• 1941- Bosworth inserted coracoclavicular (CC) screw 

• Other fixation methods – Hook plate, ex-fix 

• Muscle transfers 

• Ligament transfers 

• Ligament reconstructions 

• > 60 surgical procedures described to treat AC separations 

• No gold standard treatment 

Weaver-Dunn 

• Weaver JK, Dunn HK. JBJS 1972 

• Weinstein et al, AJSM 1995 

• Loss of Reduction – 24% 

• Reasons 

— CA lig strength only 20% of CC ligaments 

— Attachment vector of transferred ligaments different than 

native CC ligaments 

Ligamentous Anatomy and Biomechanics 

• CC ligaments provide vertical stability 

— Conoid is primary restraint to anterior and superior load 

— Trapezoid is primary restraint to posterior load 

• AC capsule provides horizontal stability 

Mechanism of Injury 

Direct trauma 

• Fall or blow with arm adducted 


Type 1 

• AC capsule stretched or partially torn 

• Most common 

Type 2 

• Mild displacement 

• AC capsule torn 

• CC ligaments intact 

Type 3 

• Complete tear of AC and CC ligaments 

• Visible deformity 

• CC interspace 25-100% > than unaffected side 

Type 4 

• Type III with dist clavicle displaced posteriorly through the 

trapezius 

• Must have axillary view! 

Type 5 

• Type III with dist clavicle severely displacement superiorly 

• Skin tenting 

• CC interspace 100-300% > than unaffected side 

Type 6 

• AC dislocation with clavicle displaced inferiorly 

• CC interspace compared to unaffected side 

Clinical Findings 

• Deformity apparent 

• Posterior displacement with adduction 

• AC joint tenderness 

• Disruption of the deltotrapezial fascia 

• Pain with cross-body adduction 

• Active compression test 



SympoSia SHOULdER & ELBOW 

• Reducibility - stabilizing the clavicle with one hand and placing 

an upward force under the ipsilateral elbow with the other 

Type III vs IV or V 

• based on whether the AC joint dislocation can be reduced 

Imaging 

• Axillary x-ray to check for posterior displacement 

Treatment 

• Type I and II - Non-op 

• Type III - Controversial 

• Type IV, V, VI - Surgical 

Surgical Treatment 

CC Ligament Reconstruction 

• First reported case - Jones, Lemos Schepsis, AJSM 2001 

• Mazzocca et al, Op Tech Sp Med 2004 – introduces 2 bundle 

reconstruction with screw fixation 

Biomechanics of CC Ligament Reconstruction 

Mazzocca AJSM 2006 

• 42 cadavers 

• CC ligament recon vs Mod Weaver-Dunn 

• Cyclic loading in ant, post, and sup, directions 

• CC ligament recon superior to Weaver Dunn 

Rational for CC ligament Reconstruction 

• Better reproduction of anatomy 

• Better biomechanics 

• Better clinical results 


Approach 

• Beach chair position 

• Incision 3-4 cm medial to AC joint 

• Divide deltotrapezial fascia 

• Elevate from clavicle 

• Distal clavicle excision for chronic case 

• Clavicle reduced with superior force on humerus 

• CC Ligament Reconstruction 

Tunnel Creation 

• Conoid tunnel 

— 45 mm from distal clavicle 

— Posterior 1/2 

— 6 mm reamer 

• Trapezoid tunnel 

— 30 mm from distal clavicle 

— Center 

— 6 mm reamer 

Graft Harvest 

• Ipsilateral semitendinosus autograft vs allograft 

• Tendon stripper 

• Native ligament controlled with Fiber-Wire suture 

Graft Passing 

• Curved clamp around coracoid 

• Pass graft and # 5 braided non-aborbable suture 

Graft Fixation 

• Conoid fixed first 

• 5.5mm IF screw 

• Augmentation suture and native graft suture through 

cannulation of screw

• Trapezoid fixed with clavicle reduced - Humerus up, clavicle 

down 

• Augmentation and native ligament sutures tied 

• Remaining graft passed across AC joint 

• Fixed in acromion with suture anchors or bone tunnels 

Deltotrapezial fascia repaired 

Post-Op Radiographs 

Rehabilitation 

• First 6-8 wks – supportive brace 

• Brace removed to groom and supine ROM 

• 8 wks - begin upright active ROM 

• 12 wks – begin strengthening 

— Emphasize scapular stabilizers 

• 3-5 mos – aggressive strengthening 

• 6 mos – contact sports 

Clinical Results 

Nicholas et al, AJSM 2007 

• Case series; Level of evidence, 4. 

• 9 pts CC lig recon with cadaver semi-T 

• Grade V acromioclavicular separation 

• ASES scores 96 ± 5 

• Penn Shoulder Scale 97 ± 3 

• SST scores 11.6 ± 0 out of 12 

• Postop radiographs - no loss of reduction 

Tauber et al AJSM 2009 

• Cohort study; Level of evidence, 2. 

• 24 pts (mean age, 42 years) 

• III - V AC separation 

• 12 - Modified Weaver-Dunn 

• 12 - CC lig recon 

• Follow-up 37 months 

• ASES and Constant Score sig better in CC recon 

• CC distance with stress 

• 14.9 ± 6 mm in the Weaver-Dunn group 

• 11.8 ± 3 mm in the CC recon 

Carofino, Mazzocca, JSES 2010 

• 16 pts, 2 lost to follow up 

• Ave follow-up 21 months (range, 6-61) 

• DCE peformed 2 patients 

• ASES improved 52 to 92 

• SST improved 7.1to 11.8 

• X-ray side to side CC difference - 0.96 mm. 

• 3 failures 

• 1 persistent pain localized to the AC joint 

• 1 chronic infection - requiring removal of the allograft anda 

lattissimus flap for soft tissue coverage 

• 1 loss of reduction. 

Revision surgery with CC ligament recon 

Tauber et al JSES 2007 

• Mod Weaever Dunn revised with CC ligament recon 

• Autogenous semi-T 

• Augmented with cerclage or Bosworth screw 

• Ave f/u 50 months 

• Constant score improved 61.3 to 76.4 

348 




LaPrade and Hilger, Arthroscopy 2005 

• Mod Weaever Dunn revised with CC ligament recon 


• Neither patient had any residual limitations at 37 nor 27- 

• months follow-up 

Complications 

• Loss of reduction 

• Clavicle fracture 

• Coracoid base fracture 

• Osteolysis 

• Infection 

• Stiffness 

Turman, Miller Miller, JBJS 2010 

• 7 cases CC Lig recon 

• 3 complications 

• 2 clavicle fx’s 

• 1 post wall blowout 

Pearls and pitfalls 

Maintain reduction 

• Deltoid and trapezius repair 

• Augment fixation, suture and screw 

• Retain distal clavicle 

• Postop protection 

Avoid fracture 

• Adequate spacing of bone tunnels 20-25 mm 

• Diameter no greater than 6mm 

• Avoid wall blowout 

• Avoid lateral tunnel closer than 10-15 mm 

Distal Clavicle Excision 

• Controversial 

• ? Improved biomechanics with clavicle retention 

• Retention not a clinical problem 

— Murray G, Can Med Assoc J 1940 

— Bosworth BM, Ann Surg 1948 

— Bosworth BM, N Engl J Med, 1949 

— Carofino and Mozzocca, JSES 2010 

• Retention is a clinical problem 

— Park et al, AJSM 1980 

— Weinstein et al AJSM 1995 

Future Directions 

Debardino et al, JSES 2010 

• Arthroscopic CC Recon 

• Subacromial arthroscopic approach 

• Subcoracoid button, clavicle washer, central graft 

• 10 cases ACJ separation 

• All f/u > 6 months 

• All return pre-injury act 

• No complications 

Summary 

• Most ACJ injuries non-op 

• Evolution to anatomic repair 

• Weaver-Dunn of historic interest only?

349 

rotator CuFF repair iN 2011 – doeS aNy oF thiS StuFF really 

matter iF they are all goiNg to Fail aNyway? 

Ken Yamaguchi, MD 

COMPLICATIONS 

I. General Comments 

Shoulder pain is one of the leading sources of musculoskeletal 

disability in the United States. Surgical treatment of rotator cuff 

disease is among the most common orthopedic procedures 

performed. Fortunately, the outcome from surgery is generally 

very reliable and complication rates small. 

II. Most common pitfalls 

a. Surgical indications 

b. Failure to address biceps pathology 

c. Overly aggressive decompression / acj resection 

d. Overly aggressive deltoid retraction / inadequate repair 

e. Fluid management 

III. Most common complications 

a. Persistent pain 

b. Loss of function 

c. Deltoid injury 

d. Failure to heal 

e. Infection 

f. Implant failure 

IV. Preoperative Pitfalls 

1. Improper diagnosis 

i. Cervical myeloradiculopathy 

ii. ACJ, biceps, labrum, arthritis 

iii. Local neuropathies 

2. Weak surgical indications – this may be one of the most 

important variables to achieving good outcome. 

i. Pt age 

ii. General health 

iii. Stage of disease – chronic tear, retraction, atrophy, size of 

defect, etc. 

3. Surgical Indications – given all of the above considerations 

surgical indications can be organized for three groups of 

people based mostly on the above considerations and the 

risks of non-operative treatment: 

A. Group 1 – These are patients who are not at risk of 

obtaining irreversible changes if they are treated nonoperatively. 

In other words, non-operative treatment of 

any significant period will not result in an irreversible 

risk. These patients do not have a risk of acquiring the 

chronic changes spoken of above. 

1. Patients who have an intact rotator cuff 

2. Patients with very small partial thickness tears 

B. Group 2 – These are patients who have a significant risk 

of acquiring chronic or irreversible changes with a delay 

in surgery. These are patients for whom a “bridge can be 

burned” if there is a surgical delay. They include: 

1. Patients with small or medium sized tears 

2. Acute tears of any size 

a. these usually are tears that follow a distinct 

significant injury and are within a three month 

period. 

3. Very large painful degenerative partial tears 

4. Tears of any size where the MRI or imaging study 

show that good tendon and muscle quality still exists. 

5. Tears in younger patients (less than 60 years old) 




C. Group 3 – These are patients who have already realized 

chronic irreversible changes. These are patients for whom 

“the bridge has already been burned.” They include: 

1. Tears in elderly patients greater than age 70 

2. Patients with large or massive rotator cuff tears with 

chronic changes 

4. Timing of Surgery – Discussed bellow with reference to 

healing 

III. Operative Pitfalls/Complications 

1. Patient setup –patient set-up is one of the most important 

factors which can lead to consistent, good results. Poor 

set-up conversely leads to inconsistent and more difficult 

surgery. It can not be emphasized enough. 

i. Consistent positioning 

ii. Precise Portal placement 

iii. Careful draping and prep 

2. Intra operative considerations 

i. First do no harm 

1. protect deltoid 

2. protect arch 

ii. Arthroscopy time/visualization limits 

iii. Careful anchor implantation – test strength of fixation by 

pulling on sutures 

iv. Fluid control – use minimum pressure to achieve 

visualization. Balance with hypotensive blood pressure 

control 

v. Retractor control – be aware of prolonged and significant 

retraction on the deltoid. This is mostly a problem with 

miniopen procedures with self-retainers. Sometimes a 

full open is less morbid to deltoid. 

vi. Careful bicep observation – look at the lateral bicep to 

insure structural integrity 

vii.Surgical repair strategy 

1. Approach – arthroscopic, mini open, or open. Do 

what you do best, but complication rates decrease 

with arthroscopic procedures. 

2. repair construct – controversial, no advantage 

conclusively demonstrated with double row 

viii. Use of pain pumps – Currently not warranted. Limited 

benefit demonstrated and serious complications 

potential 

3. Acromioplasty 

i. Inadequate? – at this time, there is no good evidence that 

removal of normal bone is necessary. Aggressive bone 

resection is not warranted. Removal of spurs is generally 

preferred. 

ii. Too aggressive – remember that the acromion is the 

deltoid origin. Compromise of this bone can have 

significant consequences to deltoid function and head 

containment. 

IV. Post-operative Pitfalls/Complications 

1. Activity restrictions – No active motion should be allowed 

for 6 weeks and generally return to normal takes a minimum 

6 mo. 

2. Rehab protocols – Early vs. Delayed motion is controversial. 

There appears to be a trend towards more conservative rehab. 

In any case, resistive exercises should be avoided before 3 mo

post op 

3. Infection – rare but can be devastating to surgical construct. 

Usually requires take down of repair and debridement / 

removal of implants. Interestingly, good results can often be 

obtained despite loss of the surgical repair. 

4. Severe Pain 

5. NSAIDs? 

6. Repair Healing – The best information is that rotator 

cuff healing is far less predictable and occurs and that 

failure rates occur at a much higher level than previously 

considered. previously considered. 

ROTATOR CUFF HEALING 

I. General Comments 

Reported healing after rotator cuff repair has been variable with 

rates as low as 6% and high as 100%. A general consensus is 

that healing rates are lower than previously considered and 

there remains multiple opportunities for improvement. 

In general, improvements in healing of rotator cuff repairs may 

occur in the following areas: 

1) Surgical indications 

2) Surgical technique 

3) Rehab protocol 

4) Miscellaneous perioperative factors ( smoking, NSAIDs) 

5) Biologics 

II. Surgical Indications 

Patient selection probably has the most influence regarding 

prognosis for healing after rotator cuff repair. This mostly 

based on the fact that biology is more a limiting factor than 

mechanical issues. Thus in a biologically poor patient such as 

a 80yo patient with a chronic tear, the chances of obtaining 

healing will be poor regardless of the surgical technique 

employed. However, in a patient with good biologic potential, 

the surgical technique may become the limiting factor – it 

becomes more important to have a better construct. 

1) Factors which predict good potential for healing 

a) Patient age ( less than 60-65 ) 

b) Small size of tear 

c) Absence of muscle atrophy or fatty infiltration 

d) Acute tears ( less than 3 mo ) 

e) No hx of smoking? 

2) Factors which predict poor potential for healing 

a) Older age 

b) Large, chronic tear with muscle changes 

c) Co-morbidities (smoking, diabetes, inflammatory 

arthropathy, etc)? 

3) Surgical Indications – given all of the above considerations 

surgical indications can be organized for three groups of 

people based mostly on the above considerations and the 

risks of non-operative treatment: 

A. Group 1 – These are patients who are not at risk of 

obtaining irreversible changes if they are treated nonoperatively. 

In other words, non-operative treatment of 

any significant period will not result in an irreversible 

risk. These patients do not have a risk of acquiring the 

chronic changes spoken of above. 

1. Patients who have an intact rotator cuff 

2. Patients with very small partial thickness tears 

B. Group 2 – These are patients who have a significant risk 

of acquiring chronic or irreversible changes with a delay 

in surgery. These are patients for whom a “bridge can be 

burned” if there is a surgical delay. They include: 

1. Patients with small or medium sized tears 

350 




2. Acute tears of any size 

a. these usually are tears that follow a distinct 

significant injury and are within a three month 

period. 

3. Very large painful degenerative partial tears 

4. Tears of any size where the MRI or imaging study 

show that good tendon and muscle quality still exists. 

5. Tears in younger patients (less than 60 years old) 

C. Group 3 – These are patients who have already realized 

chronic irreversible changes. These are patients for whom 

“the bridge has already been burned.” They include: 

1. Tears in elderly patients greater than age 70 

2. Patients with large or massive rotator cuff tears with 

chronic changes 

4. Timing of Surgery – Given the organization of non-operative 

risks given above, the timing of surgery can be dictated by 

the risk for acquiring irreversible changes. Thus: 

A. Group 1 – Patients for whom non-operative treatment 

can be maximized. You should error towards nonoperative 

treatment in these patients. A high success rate 

with non-operative treatment should be expected. 

B. Group 2 – Patients for whom early surgical treatment is 

probably warranted. Non-operative treatment in these 

patients may expose them to significant risks. 

C. Group 3 – Patients for whom non-operative treatment 

should again be maximized. There are no significant 

problems with prolonged nonoperative treatment. 

5. Surgical Strategy Based on Patient Profiles 

A. Group 2 – These are patients for whom biology is best 

suited to obtain healing after rotator cuff repair. In 

this case, it makes sense to provide the best operative 

construct possible: 

1. Full release of contractures 

2. Strong mechanical construct such as Mason-Allen 

sutures or mattress sutures. 

3. Double row fixation 

B. Group 3 – These are patients for whom biology is 

probably the limiting factor regardless of surgical 

technique. In this group, the goal may be more modest. 

Instead of trying to obtain a healed cuff, the goal may 

be more reasonable to change a symptomatic to an 

asymptomatic cuff tear. In this group of patients, from a 

surgical standpoint: 

1. A double row fixation may not be possible and 

probably will not change the chances of healing. 

2. A conservative approach to surgery should be 

considered including: 

a. no decompression 

b. no detachment of the deltoid 

6. Summary - From a treatment rationale standpoint, Group 1 

patients have a small risk with conservative treatment and 

a good chance for success with non-operative methods. If 

surgery is performed, a rotator cuff repair is generally not 

required. Group 2 – these are patients with a significant 

risk by conservative treatment. The patient should generally 

proceed towards early surgery and surgical and rehabilitation 

methods should be aimed at maximizing the probability 

of healing of the rotator cuff. This includes conservative 

rehab and secure broad-based fixation of the cuff. Group 

3 – these are patients that have a small risk with conservative 

treatment and thus, non-operative measures should be 

maximized. If an operative treatment is required, then the 

risk of the procedure should be kept small. A decompression 

should not be performed and the deltoid should not be

harmed. Prolonged cases, trying to obtain extra fixation of 

the cuff is probably not warranted, and probably does not 

help ultimate healing. 

III. Surgical Technique 

As noted above, surgical technique can be modified based on 

biologic potential to heal. Patients with good potential to heal 

may benefit from more elaborate surgical constructs such a 

double row repair – although at this time the evidence is not 

there. Patients with poor ability to heal may not benefit from 

double row – this may explain inconsistencies in the literature. 

351 

Repair constructs can be divided up into three broad catagories: 

a) Single-row repair 

b) Single-row but double-row equivalent repair 

c) Double-row repair 

All of the repairs should have the following characteristics 

a) Tension-free repair through proper releases 

b) Good suture purchase through reasonable tissue 

c) Good recognition of tear pattern to provide for anatomic 

repair 

d) Debridement of bone to bleeding base 

1) Single-row repair 

a) Generally the most simple constructs 

b) Best achieved with multiple sutures to achieve “seal” 

of the joint at anatomic neck 

2) Double-row repair 

a) Provides larger footprint 

b) Trans osseous equivalent (suture bridge) perhaps 

easiest and most effective construct. 

c) Supportive evidence controversial 

3) Double-row equivalent 

a) Tension band repair 

b) Trans osseous repair 

REFERENCES 

1. Morse K, Davis AD, Afra R, Kaye EK, Schepsis A, Voloshin I: Arthroscopic 

versus mini-open rotator cuff repair: a comprehensive review and metaanalysis. 

Am J Sports Med. 36(9):1824-8.2008. 

2. Szabo I, Boileau P, Walch G: The proximal biceps as a pain generator and 

results of tenotomy. Sports Med. Arthrosc. 16(3) 180-6: 2008. 

3. Krishnan SG, Harkins DC, Schiffern SC, Pennington SD, Burkhead WZ: 

Arthroscopic repair of full-thickness tears of the rotator cuff in patients 

younger than 40 years. Arthroscopy. 24(3):324-8.2008. 

4. Kircher J, Martinek V, Mittelmeier W: Heterotopic ossification after minimally 

invasive rotator cuff repair. Arthroscopy. 23(12): 1359.el-3.2007. 

5. Struzik S, Glinkowski W, Gorecki A: Shoulder arthroscopy complications. 

Orthop Traumatol Rehabil. 5(4):489-94.2003. 

6. Chin PY, Sperling JW, Cofield RH, Stuart MJ, Crownhart BS: Complications 

of shoulder arthroscopy. J of Shoulder Elbow Surg. 16(6):697-700. 2007. 




IV. Rehab Protocol 

Use of conservative rehab protocols have become more popular 

as concerns for healing have increased. Many surgeons have 

decreased the rate of mobilization until healing has had a 

chance to take hold. Typical conservative protocols include: 

1) No motion for 6 wks 

2) Passive for additional 6 wks 

3) Active at 12 wks 

4) Resistive exercises only after full ROM achieved 

At this time there is no evidence in humans that conservative 

protocols lead to better healing. Small animal research is 

somewhat suggestive. 

V. Perioperative Factors 

Recent evidence suggests that smoking is a risk factor for 

development of rotator cuff tears. It is not known whether 

smoking affects healing; however, it seems prudent to advise 

against smoking. Additionally, the use of NSAIDs in the 

immediate post operative period may be detrimental. 

VI. Biologics 

Recently the use of commercially available grafts has been 

investigated for possible augmentation of surgical healing. 

Generally, the use of these grafts requires open surgery although 

very experienced surgeons can do it arthroscopically. A clinical 

benefit to the construct has not been demonstrated with at least 

one xenograft product. 

Use of growth factors to enhance bone-tendon healing is a 

potentially important strategy which at this time is not available 

for general use. 

7. Cole BJ, McCarty LP 3rd, Kang RW, Alford W, Lewis PB, Hayden JK: 

Arthroscopic rotator cuff repair: prospective functional outcome and repair 

integrity at minimum 2-year follow-up. J of Shoulder Elbow Surg. 16(5):579- 

85.2007. 

8. Hsu SL, Ko JY, Chen SH, Wu RW, Clou WY, Wang CJ: Surgical results in 

rotator cuff tears with shoulder stiffness. J Formos Med Assoc. 106(6):452- 

61.2007. 

9. Brislin KJ, Field LD, Savoie FH 3rd: Complications after rotator cuff repair. 

Arthroscopy. 23(2):124-8.2007. 

10. Gumina S, DiGiorgio G, Bertino A, Della Rocca C, Sardella B, Postacchini 

F: Recurrent infection of the rotator cuff after open repair: case report. J 

Shoulder Elbow Surg. 15(1):122-3.2006. 

11. Hata Y, Saitoh S, Murakami N, Kobayashi H, Takaoka K: Atrophy of the 

deltoid muscle following rotator cuff surgery. J Bone Joint Surg Am.86-A 

(7):1414-9.2004. 

12. Magee T, Shapiro M, Hewell G, Williams D: Complications of rotator cuff 

surgery in which bioabsorbable anchors are used. AJR Am Roentgenol. 

181(5):1227-31.2003.

• Treatment of instability has progressed from non-anatomic 

reconstruction procedures complicated by stiffness to more 

anatomic reconstructions complicated by recurrence 

• Recurrence Can be from: 

Wrong diagnosis 

Wrong surgery 

Technical failure 

Post-operative rehab failure 

New trauma 

A. Establishing Diagnosis: 

— Not simply direction of instability or whether its MDI, 

— Aimed is to identify all contributing pathology i.e. labrum, 

bone, capsule 

— This will aid in choice of treatment 

1. History 

a. Focus on initial event 

b. Patients correct 95% regarding direction1 

c. Type of instability: subluxation vs. dislocation 

d. Need for assisted reduction 

e. What has been the progression How it happened, how 

often, what has been done? 

f. Progressively less traumatic dislocations can indicate 

bone loss 

g. Family history of laxity 

h. Know activities of patient (thrower, football lineman etc.) 

i. In revision cases, review all op reports, especially EUA 

and number of anchors used, when and how redislocation 

happened 

2. Exam 

a. Hyperlaxity 

1. MCP extension >90 

2. Elbow hyperextension 

3. Knee hyperextension 

4. Thumb to wrist 

5. External rotation >85degrees 

b. Rotator Interval 

1. Sulcus Sign, does it decreased in external rotation? 

c. Laxity in IGHL 

1. Gagey Sign 

d. Apprehension 

1. In low range may indicate bone loss 

2. Jerk test 

e. Rotator cuff exam 

1. Particularly if older than 40 yrs and 1st dislocation 

2. Subscap failure may be cause for recurrence after open 

repair 

f. Nerve function 

g. Don’t forget scapula kinematics 

3. Imaging: 

a. X-Ray 

1. Indicates but can’t quantify bone loss well 

2. Loss of sclerotic glenoid margin= sig loss 

b. MRI/MRA 

1. See soft tissue lesions and bone 

2. Sagittal cuts to evaluate glenoid 

3. ALPSA, HAGL 

4. Patulous capsule 

c. CT 

1. with 3D recon 

352 

ChoiCeS iN iNStability Surgery 





2. Best demonstrates bone loss on glenoid and head 

3. Gerber and Nyffeler method to quantify glenoid bone 

defect 2 

Gerber et al CORR 2002 

If x>r, resistance to dislocation only 70% of uninjured joint 

B. Management: 

1. Choosing surgery: Consider all contributing pathology 

a. Open Bankart repair remains the gold standard 

Rowe et al 3.5% recurrence rate treating “all comers” 

65% had greater than 25% bone loss on glenoid 

77% had Hill Sachs lesions 3 

Loss of motion is minimal and rarely symptomatic 

b. Arthroscopic methods improving (4-18% recurrence) 

c. Patients expect/request arthroscopic 

d. Risk factors for failure of arthroscopic soft tissue 

stabilizations 4-6 

Age20% loss 

but little data to define exact percentage 9 

1. Itoi et al 21% 10 

e. Crest Graft, coracoid transfer, allograft for glenoid 

f. Humeral loss rarely needs to be address 

g. Critical amount of humeral loss not defined and likely 

depends upon associated glenoid loss 

h. When necessary, options include grafting, remplissage, 

resurfacing in older patients 

3. Technical Pearls 

A. EUA prior to every case to confirm diagnosis, complete 

diagnostic scope to r/o associated pathology 

B. Arthroscopic Stabilization 

1. Take the time to adequately mobilize labral/ALPSA 

2. A minimum of 3 anchors (maybe 4) required from 

3:00–5:30 

3. Capsular stretch is always part of the pathology 

4. Plication should be uniformly incorporated into 

Bankart repair, bring inferior to superior 

5. Establish a bleeding bed on glenoid face to improve 

healing 

C. Latarjet 

1. Increased popularity with better recognition of bony 

lesions and reported results (1.2% recurrence)11 

2. Triple blocking theory

3. Can be done arthroscopically by a few (less invasive?) 

4. Transfer must be placed anterior AND inferior 

REFERENCES AND SUGGESTED READINGS 

1. Mair SD, Hawkins RJ: Open shoulder instability surgery. complications. Clin 

Sports Med 1999;18:719-736. 

2. Gerber C, Nyffeler RW: Classification of glenohumeral joint instability. Clin 

Orthop Relat Res 2002;(400):65-76. 

3. Rowe CR, Patel D, Southmayd WW: The bankart procedure: A long-term endresult 

study. J Bone Joint Surg Am 1978;60:1-16. 

4. Porcellini G, Campi F, Pegreffi F, Castagna A, Paladini P: Predisposing factors 

for recurrent shoulder dislocation after arthroscopic treatment. J Bone Joint 

Surg Am 2009;91:2537-2542. 

5. Voos JE, Livermore RW, Feeley BT, et al: Prospective evaluation of 

arthroscopic bankart repairs for anterior instability. Am J Sports Med 

2010;38:302-307. 

6. Boileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L: Risk factors for 

recurrence of shoulder instability after arthroscopic bankart repair. J Bone 

Joint Surg Am 2006;88:1755-1763. 

353 




5. No lateral overhang is acceptable 

6. Medial placement of 1-2mm is well tolerated 

7. Balg F, Boileau P: The instability severity index score. A simple pre-operative 

score to select patients for arthroscopic or open shoulder stabilisation. J 

Bone Joint Surg Br 2007;89:1470-1477. 

8. Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach BR,Jr, Provencher MT: 

Glenoid bone deficiency in recurrent anterior shoulder instability: Diagnosis 

and management. J Am Acad Orthop Surg 2009;17:482-493. 

9. Beran MC, Donaldson CT, Bishop JY: Treatment of chronic glenoid defects in 

the setting of recurrent anterior shoulder instability: A systematic review. J 

Shoulder Elbow Surg 2010;19:769-780. 

10. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN: The effect of a glenoid defect on 

anteroinferior stability of the shoulder after bankart repair: A cadaveric study. 

J Bone Joint Surg Am 2000;82:35-46. 

11. 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;80:841-852.

354 

ClaviCle FraCtureS: do i really have to FiX them all? 

Michael D. McKee 

1. Introduction: Clavicle fractures are common injuries 

accounting for 2.6% of all fractures1 and occur most commonly 

in young active individuals2. Middle third (or mid-shaft) 

fractures account for approximately 80% of all clavicle 

fractures1,2, and have traditionally been treated non-operatively, 

even when significantly displaced. However, more recent studies 

have shown non-union rates of up to 21% in displaced midshaft 

clavicle fractures and unsatisfactory patient oriented outcomes 

in up to 31%.In addition, clavicular malunion has recently 

been described by multiple authors as a distinct clinical entity 

with characteristic clinical and radiographic features. Possible 

explanations for the increased residual disability seen following 

the non-operative care of these fractures may be changing 

injury patterns, increased patient expectations, more complete 

follow-up (including patient-oriented outcome measures) and 

eliminating children (with their inherently good prognosis 

and remodeling potential) from the data analysis. It is clear 

that there is a role in selected individuals for primary operative 

fixation of displaced fractures of the shaft of the clavicle. 

2. Operative indications for displaced fractures of the clavicle. 

In general patients selected for primary operative fixation 

should be young (age 16 to 60 years), healthy and active. Select 

indications include: 

Fracture-specific 

1. Displacement or shortening > 2 centimeters 

2. Increasing comminution (> 3 fragments) or segmental 

fractures 

3. Open or Impending open fractures with soft-tissue 

compromise 

4. Scapular malposition and winging on initial examination 

Associated Injuries 

1. Vascular injury requiring repair 

2. Progressive neurologic deficit 

3. Ipsilateral upper extremity injuries / fractures 

4. Multiple ipsilateral upper rib fractures 

5. “Floating shoulder” 

Patient Factors 

1. Polytrauma with requirement for early upper extremity 

weight -bearing / arm use 

2. Patient motivation for rapid return of function (elite sports, 

self-employed professional, etc.) 

3. Surgical Approaches / Fixation 

a) Antero-superior plating 

Antero-superior plating is the most popular of operative 

fixation methods for fixation of the clavicle. Its advantages 

include a familiarity with this approach, the ability to extend 

it simply to both the medial and lateral ends of the clavicle 

and the benefit of clear radio-graphic views of the clavicle 

post-operatively. Disadvantages include the trajectory of 

screw placement (from superior to inferior) that can be 

difficult, and inadvertent “plunging” with the drill can 

place the underlying lung and neurovascular structures at 

risk. Also, the clavicle is fairly narrow in it’s superoinferior 

References 

1. Neer, C “Fractures of the Clavicle” Fractures in Adults, Rockwood and Green 

Eds, JB Lippincott, 2nd edition ,p 707-713. 




dimension, and typically the length of screws inserted range 

from 14-16 mm (female) to 16-18 mm (male). In thin 

individuals, hardware prominence can be problematic, and 

may lead to hardware removal. 

b) Antero-inferior plating 

Several groups have published large series on the advantages 

of anteroinferior plating of acute clavicle fractures. Advantages 

of this technique include an easier screw trajectory with less 

likelihood of serious injury with inadvertent over-penetration 

of the drill (although the incidence of iatrogenic nerve 

injury is very low), and the ability to insert longer screws in 

the wider antero-posterior dimension of the clavicle, and 

decreased hardware prominence. It is also technically easier 

to contour a small-fragment compression plate along the 

anterior border as opposed to the superior surface: however, 

the advent of pre-contoured plates has largely negated 

this particular advantage. Potential disadvantages of this 

technique include the lack of general familiarity with the 

approach, and obscuring the fracture site radiographically. 

Biomechanical studies have in general shown that the most 

advantageous position for plate placement is the superior 

surface. Since the contouring of the plate is performed in the 

long axis of the plate, it is much simpler to contour a straight 

compression plate to the anterior, as opposed to the superior 

surface. Additionally, it is usually possible to place screws that 

are 2-4 millimeters longer in the antero-posterior dimension 

of the clavicle. 

4. Outcomes 

A number of recent studies of completely displaced, mid-shaft 

fractures of the clavicle reveal nonunion rates between 15% 

and 20% 5,6 . These studies were recently summarized in a metaanalysis 

that found a nonunion rate of 15.1% following nonoperative 

care of these fractures7 . 

Malunion of the clavicle is a distinct clinical entity with 

characteristic orthopaedic (weakness, easy fatigueability, 

scapular winging), neurologic (thoracic outlet syndrome) 

and cosmetic (droopy, asymmetric shoulder, difficulty with 

backpacks, shoulder straps etc.) symptoms 9-12 . It is associated 

with increasing degrees of clavicular shortening. While 

radiographic malunion is always seen following displaced 

clavicular shaft fractures, clinically symptomatic malunion has 

an incidence of 15-20%. There are multiple, modern studies 

that show plate fixation is an extremely effective technique for 

treatment of clavicular shaft fractures with a low complication 

and nonunion rate 14,15 . A meta-analysis described a nonunion 

rate with plate fixation of 2.2%, which represents an 86% risk 

reduction for nonunion compared to the same fracture treated 

non-operatively (nonunion rate 15.1%) 7 . Hill et. al. were the 

first to use a patient-oriented outcome measure, and found 31% 

of patients described unsatisfactory outcome after non-operative 

care of displaced clavicle fractures 6 . This may be explained by 

significant residual strength deficits following the conservative 

treatment of these fractures (strength deficits ranging from 10% 

to 35% were found in patients a mean of 54 months after nonoperative 

care of a displaced fracture of the clavicular shaft) 16 . 

2. Rowe CR. An atlas of anatomy and treatment of midclavicular fractures. Clin 

Orthop Rel Res. 58:29-42, 1968.

3. 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, 1997; pp 537-541. 

4. Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating 

the risk of nonunion following non-operative treatment of a clavicle fracture. 

J Bone Joint Surg(A) 86A:7, 1359-1365, 2004. 

5. Zlowodzki M, Zelle BA, Cole PA, Jeray K, McKee MD. Treatment of mid-shaft 

clavicle fractures: Systemic review of 2144 fractures. J Orthop Trauma. Vol 

19:7, 2005, 504-508. 

6. Basamania CJ, “Claviculoplasty” J Shoulder Elbow Surg, Vol. 8, No. 5, 

1999; p 540. (Abstracts: Seventh International Conference on Surgery of the 

Shoulder, 1999). 

7. Chan KY, Jupiter JB, Leffert RD, Marti R “Clavicle malunion” J Shoulder 

Elbow Surg, Vol. 8, No. 4, 1999; pp 287-290. 

8. Kuhne JE, “Symptomatic malunions of the middle clavicle” J Shoulder 

Elbow Surg, Vol. 8, No. 5, 1999; p 539. (Abstracts: Seventh International 

Conference on Surgery of the Shoulder, 1999). 

355 




9. McKee MD, Wild LM, Schemitsch EH. Midshaft malunions of the clavicle. J 

Bone Joint Surg, 85A:5, 790-797, 2003. 

10. McKee MD, Pedersen EM, Jones C, Stephen DJG, Kreder HJ, Scemitsch EH, 

Wild LM, Potter J. Deficits following non-operative treatment of displaced, 

mid-shaft clavicle fractures. J Bone Joint Surg(A), 2005. 

11. Andersen K, Jensen PO, Lauritzen J. The treatment of clavicular fractures: 

Figure of eight bandage versus a simple sling. Acta Orthop Scand. 

1987;58:71-74. 

12. Potter J, Schemitsch EH, Jones C, Wild LM, McKee MD. Does delay matter? 

The restoration of objectively measured shoulder strength and patientoriented 

outcome in immediate versus delayed reconstruction of displaced 

mid-shaft fractures of the clavicle. Accepted for publication, J Shoulder 

Elbow Surg. 

13. McKee MD and the Canadian Orthopaedic Trauma Society. A multi-centre 

randomized controlled trial of non-operative versus operative treatment of 

displaced clavicle shaft fractures. J Bone Joint Surg(A), 2007, No.1, 1-11.

356 

u hot topiCS aNd CoNtroverSieS iN 

primary Shoulder arthroplaSty (m) 

Moderator: John W. Sperling, MD, Rochester, MN 

In this symposium, faculty members will debate controversies associated with shoulder arthroplasty including navigation, 

minimally invasive approaches, reverse arthroplasty, resurfacing, and biologic interposition. 

I. The Gold Standard-All Polyethylene Glenoid Component 

Edward V. Craig, MD, New York, NY 

II. Biologic Replacement-Role of Fascial Interposition 

Wayne Z. Burkhead, Jr., MD, Dallas, TX 

III. Ream and Run? - Glenoidplasty 

Frederick A. Matsen, III, MD, Seattle, WA 

IV. Faculty Debate 

V. The Gold Standard-Stemmed Humeral Components 

Michael A. Wirth, MD, San Antonio, TX 

VI. Evolving Technology-Surface Replacement 

Gerald R. Williams, Jr., MD, Philadelphia, PA 

VII. Faculty Debate 

VIII. The Gold Standard-Hemiarthroplasty 

David M. Dines, MD, Great Neck, NY 

IX. Who Needs to Worry about Tuberosity Healing? – Reverse 

Francois Sirveaux, PhD, France 

X. Faculty Debate 

XI. The Gold Standard-Radiographic and Intra-operative Evaluation 

Edward V. Fehringer, MD, Omaha, NE 

XII. Emerging Technology-Computer-Assisted 

T. Bradley Edwards, MD, Houston, TX 

XIII. Faculty Debate 

XIV. The Gold Standard-Deltopectoral Approach 


XV. New Technique: Mini-incision TSA 

Laurent Lafosse, MD, France 

XVI. Faculty Debate 



SympoSia SHOULdER & ELBOW

357 

the gold StaNdard—all polyethyleNe CompoNeNt 

Edward V. Craig MD, MPH 

I. Little Argument—Hemiarthroplasty (no glenoid component) 

• Glenoid” Too Good”—many fractures, early osteonecrosis, 

tumor surgery 

• Glenoid “Too bad”—non reconstructable bone loss 

• Rotator Cuff Insufficiency 

-----both for some fractures and cuff insufficiency, Reverse Shoulder 

Prosthesis appears to be a viable alternative to a hemiarthroplasty 

II. The Evidence Based Approach— 

In December of 2009, the AAOS approved its Clinical Practice 

Guidelines for the treatment of glenohumeral osteoarthritis, based 

upon a systematic review of published studies on the treatment 

of osteoarthritis in adults.(5) As with other CPG, it showed where 

good evidence exists, where evidence is lacking, and identified 

topics for future research. In this study 16 recommendations were 

addressed, both surgical and non surgical, relating to GH arthritis 

treatment in the shoulder. Of these 16 recommendations, 9 

were inconclusive and 2 were reached by consensus. Among the 

highlights of this publication were: 

Despite an exhaustive review of the literature,there was 

insufficient evidence to conclude either in favor of or against 

efficacy of open debridement and non prosthetic and/or 

interposition arthroplasty, including osteoarticular allograft, 

interpositional soft tissue allograft, and autograft 

TSR and hemiarthroplasty are options providing improvement 

in pain, global health assessment, function, and quality of 

life scores. Most studies supported use of hemiarthroplasty 

when performed in naturally concentric glenoids or one 

reamed to concentricity. TSR was then compared directly with 

hemiarthroplasty 

Recommendation is for TSR over hemiarthroplasty, based on 

2 level-II studies 

a) global health assessment scores and pain relief were 

statistically significantly better after TSR 

b) 14% of patients treated with hemiarthroplasty required 

revision to TSR because of progressive glenoid arthrosis 

and pain, while no TSRs require such 

c) function and quality of life outcome measures showed 

no statistically significant difference between groups 

III. Argument Against a Glenoid 

• avoid glenoid component problems 

In evaluating survival and complication rates in TSR, the 

glenoid has generally been felt to be the most vulnerable 

of the components. Published series have shown a 

highly variable incidence of radiolucent lines (6-100%, 

progressive 0-30%). Despite a measurable incidence 

of lucent lines, incidence of revision surgery for clinical 

loosening has generally been felt to be low 

A number of studies have suggested a lower incidence of 

radiolucent lines using pegged rather than keeled glenoid 

components, and all- poly components have been felt to 

have lower incidence of lucent lines than metal backed 

components. 

• easier to do 

• faster to do TSR 35 minutes longer (4) 

• less blood loss 150 cc more blood loss (4) 

• • cheaper to do 




Cost of the glenoid component in any system adds 

expense.,TSR added $1177 more expense. (4) 

• easier to revise hemi 

In the absence of a glenoid component, the glenoid bone 

has been undisturbed, and if necessary, a glenoid can be 

added if continued pain makes it necessary 

• soft tissue interposition, hemiarthropasty after contouring 

the glenoid for concentricity do about as well as TSR 

Both “ream and run” and interposition arthroplasty with 

allograft, meniscus, and other soft tissue have shown 

encouraging results, including a long term study with 

allograft.(2,3,6,7,11) 

IV. Argument for a Glenoid 

• issue is exposure: can be taught 

Insertion of the glenoid component is the most 

technically difficult part of the TSR. However, with 

increasing access to education regarding surgical 

technique, the ability to expose the glenoid is being 

taught to an increasing number of surgeons 

• does not add much time 

The addition of a glenoid component, particularly 

with current reproducible instrumentation, adds 

approximately 20-30 minutes to the operation (4) 

• hemiarthroplasty results fall off over time 

A survivorship study from Mayo Clinic, showed for 

hemiarthroplasty 92% at 5 yrs, 83% at 10 yrs, and 73% 

at 15 years; while for TSR, survivorship analysis showed 

97% at 5 yrs, 97% at 10 yrs, and 84% at 15 years (14) 

A group of hemiarthroplasties with concentric glenoids 

were followed for 7-9 yrs ((Bauer et al, AAOS, 2002) At 

the 2-4 year point, 86% were satisfactory. (8) At the 79 

year point, this same group had satisfactory results fall off 

to 67% of group 

• significant expense to revise Hemi 

In Gartsman study, revision of Hemi to TSR averaged 

$16,000, while cost of each TSR about $1000 more than 

hemi (4) 

• results: better pain relief and function with TSR 

In 2005, Bryant published a meta-analysis 

of 4 randomized controlled trials comparing 

hemiarthroplasty and TSR. Compared with 

hemiarthroplasty, TSR showed superiority in both pain 

relief and functional outcomes (1) 

As noted above in AAOS clinical guidelines, The Lo 

study showed that global health assessment scores and 

pain relief were significantly better after TSR. (9) This 

echoed the Gartsman which also showed a statistically 

significantly greater degree of pain relief following TSR 

(4) 

• Sleep better at night 

Some patients in the follow up period after both TSR 

and hemiarthroplasty will continue to complain of pain. 

It is often difficult to elucidate the reasons, which may 

include infection, stiffness, incomplete rehabilitation, 

rotator cuff tearing, neurogenic pain, etc. It may be 

disturbing to the operating surgeon who has left a clearly 

diseased glenoid unresurfaced when attempting to define 

whether post op pain is do to residual glenoid fossa 

arthrosis

358 

• revision of hemi vs TSR 9:1 A recent review of relative 

frequency of revision of hemiarthroplasty vs Total Shoulder 

at Mayo Clinic has revealed that for every revision of a 

painful TSR there are 9 revisions of hemiarthroplasty to TSR 

• TSR more Cost Effective 

In a recently published study Mather et al looked at 

the cost effectiveness of TSR vs. hemiarthroplasty. (10) 

Using as outcome measures average incremental costs, 

incremental effectiveness, incremental QALYs, and 

net health benefit, hemiarthroplasty showed $1194/ 

QALY, while that for TSR was $957/QALY. There was 

a greater utility for both patient and lower cost for 

payer for TSR and thus TSR was the preferred treatment 

for osteoarthritis for both patient and payer In fact, 

REFERENCES 

1. Bryant,D., Litchfield,R, Sandow, M., et al. A comparison of pain, strength, 

range of motion, and functional outcomes after hemiarthroplasty and total 

shoulder arthroplasty in patients with osteoarthritis of the shoulder. A 

Systematic review and meta-analysis. J Bone Joint Surg Am. 2005; 87; 1947- 

56 

2. Clinton,J., Franta, A.K., Lenters,T.R., et.al. Nonprosthetic glenoid arthroplasty 

with humeral hemiarthroplasty and total shoulder arthroplasty yield similar 

self-assessed outcomes in the management of comparable patients with 

glenohumeral arthritis. J Shoulder Elbow Surg. 2007 Sept-Oct; 16(5)534-8 

3. Elhassan, B., Ozbaydar, M., Diller, D, et.al. Soft tissue resurfacing of the 

glenoid in the treatment of glenohumeral arthritis in active patients less than 

fifty years old. J Bone Joint Surg Am. 2009 Feb; 91 (2): 419-24 

4. Gartsman, G.M.,Roddey T.S., and Hammerman, S.M. Shoulder Arthroplasty 

with or without resurfacing of the glenoid in patients who have 

osteoarthritis. J Bone Joint Surg Am 2000;82(1): 26-34 

5. Izquierdo, R., Voloshin, I., Edwards, S., et.al. Treatment of glenohumeral 

osteoarthritis. J.Am Acad Orthop Surg, 18 (6) June 2010, 375-83 

6. Krishnan,S.G., Reineck, J.R., Nowinski, R.J. Humeral hemiarthroplasty with 

biologic resurfacing of the glenoid for gllenohumeral arthritis. Surgical 

technique. J Bone Joint Surg Am. 2008 Mar; 90 Suppl 2 Pt 1: 9-19 

7. Krishnan, S.G., Nowinski, R.J., Harrison, D, et al. Humeral hemiarthroplasty 

with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to 

fifteen year outcomes. J Bone Joint Surg Am. 2007 Apr; 89(4): 727-34 




authors reported that for every 1000 hemiarthroplasties 

performed, there would have been a savings of 

$1,970,000 and 770 QALY had a TSR been performed 

instead. 

• Newer Designs May Positively 

Impact on glenoid longevity While there are not as yet 

studies documenting dimininution of lucent lines, longer 

survivorship, or diminished revision rates with newer 

designs of glenoid implant, these newer designs have 

included implants which have porous metal backing, 

permitting bone ingrowth, or hybrid designs which 

combine immediate fixation of bone cement with porous 

metal, permitting bone ingrowth over time. It remains to 

be seen whether these newer designs will offer advantages 

in clinical effectiveness and implant survival. 

8. Levine, W, Djurasovic,M., Glasson,J. et al Hemiarthroplasty for glenohumeral 

arthritis: results correlated to degree of glenoid wear. J Shoulder Elbow Surg 

1997, Vol 6(5) A-1 

9. Lo,I.K., Litchfield R.B., Griffin, S et al. Quality of life outcome following 

hemiarthroplasty or total shoulder arthroplasty in patients with 

osteoarthritis: A prospective randomized trial. J Bone Joint Surg Am 2005; 

87(10)2178-85 

10. Mather,R.C.III, Watters,T.S., Orlando, L.A. et al. Cost –effectiveness analysis 

of hemiarthroplasty and total shoulder arthroplasty. J Should Elbow Surg, 

2010 April;19(3):325-34 

11. Matsen, F.A. III, Bicknell, R.T., Lippitt, S.B. Shoulder arthroplasty: the socket 

perspective J Shoulder Elbow Surg. 2007, Sept-Oct;16(5 Suppl) S241-7 

12. Pfahler, M., Jena, F., Neyton, L, et al. Hemiarthroplasty versus total shoulder 

prosthesis: results of cemented glenoid components. J Shoulder Elbow Surg: 

2006 Mar-Apr;15(2):154-63 

13. Radnay, C.S., Setter, K.J., Chambers L., Total Shoulder Replacement compared 

with humeral head replacement for the treatment of primary glenohumeral 

osteoarthritis: A systematic review. J Shoulder Elbow Surg 2007; 16 (4): 396- 

402 

14. Sperling J, Cofield, R, Rowland, . Minimum fifteen year followup of Neer 

hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg. 

2004 13(6), 604

I. Disclosures 

359 

biologiC replaCemeNt – role oF FaSCial iNterpoSitioN 

Wayne Z. Burkhead, Jr., MD, William Paterson MD, Sumant G. Krishnan MD 

II. History of Arthroplasty 

III. Shoulder Arthroplasty Options 

a. Hemiarthroplasty as an isolated procedure not a good choice 

when compared to TSA 

b. Total shoulder arthroplasty Pegged vs Keel How to decide 

c. Reverse total shoulder arthroplasty? Walch B2 glenoid 

IV. Factors in Decision Making 

a. Patient age, etiology, bony defects, soft tissue contracture 

V. Complications in Total Shoulder Arthroplasty 

a. Glenoid loosening can account for 32% of complications 

VI. Interpositional Arthroplasty of the Shoulder 

a. Current techniques and applications Represents 5% of our 

arthroplasty practice 

VII. Principles of Biologic Resurfacing 

a. Create a smooth wettable low coefficient of friction bearing 

surface to articulate with a Stemmed Humeral Arthroplasty 

in patients 

VIII. Technique of Interposition for Osteoarthritis 

a. Deltopectoral approach 

b. Management of subscap contracture 

c. Anatomic humeral hemiarthroplasty 

d. Glenoid reaming to subchondral bone only correct version 

e. Deep drill holes into scapular body surface 

f. Suture of soft tissue bearing surface to labrum prp cover the 

entire glenoid surface 




IX. Hemiarthroplasty with Biologic Resurfacing: 5-13 Year 

Outcomes 

a. Study patient factors and diagnoses 

b. Methods 

i. Multiple resurfacing materials: anterior capsule, 

autogenous fascia lata, allograft Achilles, human acellular 

dermal allograft 

c. Results 

i. Good pain relief 

ii. Increase in ROM 

iii. Radiographic evaluation 

1. No humeral sided complications 

2. Glenoid wear stabilizes at 5 years postop 


1. Subscap deficiency associated with anterior capsule 

resurfacing 

2. Three revisions to TSA 

X. Conclusions 

a. Total Shoulder Arthroplasty remains the Gold Standard for 

the treatment of Osteoarthritis 

b. In a select group of individuals Biologic resurfacing can 

provide pain relief similar to TSA without the risk of poly 

wear particle induced osteolysis has in our opinion a definite 

role in the treatment of glenohumeral arthritis in the young 

patient. Newer graft materials and Biologic enhancements 

are encouraging. 

c. Informed consent will allow the patient to choose the 

best option. If TSA is performed in a young person I prefer 

keeled component so that defect has higher chance of being 

contained at time of revision.

360 

hemiarthroplaSty with NoN-proSthetiC gleNoid 

arthroplaSty- the ream aNd ruN 

If the “Gold Standard” is the cemented polyethylene component, 

why bother with anything else? Maybe all that glitters is not gold: 

(1)Concern about glenoid component failure is rising: 

(2)Glenoid component failure is commonest reason for revision of 

TSA 

(3) Revision of failed glenoid component difficult because of bone 

loss 

(4)Polyethylene not perfect for the shoulder: every retrieval study 

shows wear/cold flow. 

(5)Reluctance to allow full activity after TSA because of concern for 

the glenoid. 

The ream and run: a technically difficult and imperfect 

alternative—not for every surgeon/not for every patient. 

• Patient selection is key 

— Non-smoker 

— Not on major narcotics or steroids 

— No socio/economic/legal complexities 

— No inflammatory arthritis 

— Ready to accept longer period of more challenging rehab 

— Ready to accept risk of need for revision to total shoulder 

— Dedicated to success of the surgery 

• Surgeon selection is key 

— Technically excellent/experienced at shoulder arthroplasty 

— Dedicated to success of each patient, ready for frequent 

contact 

REFERENCES 

1. Mercer, D. M., B. B. Gilmer, et al. “A quantitative method for determining 

medial migration of the humeral head after shoulder arthroplasty: 

Preliminary results in assessing glenoid wear at a minimum of two years after 

hemiarthroplasty with concentric glenoid reaming.” J Shoulder Elbow Surg. 

2010 

2. Saltzman, D. M, A. M. Chamberlain, D. M. Mercer, W. J. Warme, A. L. 

Bertelsen, F A. Matsen III. “Shoulder hemiarthroplasty with concentric 

glenoid reaming in patients 55 years old or less” J Shoulder Elbow Surg. 2010 

Frederick Matsen, MD 




• Details 

— Concentric reaming – diameter 2 mm greater than head 

— Perfect register 

— 150 degrees of flexion before discharge and ever after 

— No strengthening until range comfortable 

The recovery of function after ream and run (all data from all 

unrevised) 

Revisions of our 276 cases to date 

Revision for subscapularis failure 5 

Manipulations for stiffness 3 

Surgical release for stiffness 7 

Converstion to total shoulder 7 

Patients can achieve very high levels of function. 

3. Saltzman, M. D., D. M. Mercer, et al. “Comparison of patients undergoing 

primary shoulder arthroplasty before and after the age of fifty.” J Bone Joint 

Surg Am 92(1): 42-7, 2010 

4. Clinton, J., W. J. Warme, J. R. Lynch, S. B. Lippitt, F. A. Matsen. “Shoulder 

Hemiarthroplasty with Nonprosthetic Glenoid Arthroplasty. The Ream and 

Run.” Techniques in Shoulder & Elbow Surgery 10(1): 43-52, 2009

361 

the gold StaNdard – Stemmed humeral CompoNeNtS 

Michael A. Wirth, MD 


1) Overall prevalence of humeral component loosening is 1% 

2) Nearly 7% of 414 complications identified from MEDLINE 

and OVID databases 1 

II. Literature Review 

1) Sperling et al 2 reported incomplete radiolucent lines 

adjacent to eleven (18%) of 62 humeral implants (six were 

judged to be “ at risk”). One required revision (Follow-up 

average of 4.6 years). 

2) Matsen et al 3 found radiolucent lines in 77 (61%) of 127 

shoulders (majority occurred at stem tip) 

REFERENCES 

1) Kamal I. Bohsali, Michael A. Wirth and Charles A. Rockwood, Jr.. 

Complications of Total Shoulder Arthroplasty. JBJS Am 2006;88:2279-2292 

2) Sperling JW, Cofield RH, O’Driscoll SW, Torchia ME, Rowland CM. 

Radiographic assessment of ingrowth total shoulder arthroplasty. J Shoulder 

Elbow Surg. 2002;9:507-13. 




3) None demonstrated subsidence or shift in position (Followup 

average of 3 years). 

4) Sanchez–Sotelo et al 4 reported radiolucent lines in 16 of 

43 cemented implants. In contrast to report of Matsen , 

prevalence, extent, and thickness of radiolucent lines were 

higher in association with TSA. (Follow-up average of 6.6 

years) 

III. Conclusion 

1) Loosening of humeral stemmed components has an overall 

prevalence of 1% 

2) Complete radiolucent lines about humeral components are 

rare 

3) Survival may be affected by type of implants, mode of 

fixation, and biologic response to wear particles 

3) Matsen FA 3rd, Iannotti JP, Rockwood CA Jr. Humeral fixation by press-fitting 

of a tapered metaphyseal stem: a prospective radiographic study. J Bone Joint 

Surg. Am. 2003;85:304-8. 

4) Sanchez-Sotelo J, O’Driscoll SW, Torchia ME, Cofield RH, Rowland CM. 

Radiographic assessment of cemented humeral components in shoulder 

arthroplasty. J Shoulder Elbow Surg. 2001;10:526-31

362 

reSurFaCiNg implaNtS iNdiCatioNS, reSultS, aNd 

CompliCatioNS 

Gerald R. Williams, Jr, MD 


a. Premises 

i. It is desirable to do the most anatomic procedure 

possible 

ii. It is desirable to preserve as much bone and cartilage as 

possible 

iii. With a diseased glenoid, total shoulder replacement is 

preferable to hemiarthroplasty 3,5-7,11,13 

iv. Glenoid resurfacing is less desirable in younger patients 

b. Humeral resurfacing and replacement are both indicated and 

should be individualized based on the application of these 

premises 

II. Humeral Resurfacing 

a. The potential for anatomic humeral reconstruction is 

greater with resurfacing than replacement and with partial 

resurfacing than with complete resurfacing, although all can 

be performed nonanatomically. 14 

i. Partial resurfacing can maintain the differential in 

humeral radius between the superior-inferior arc and the 

medial-lateral arc. 8 

ii. Complete resurfacing obviates the need to address 

humeral head and intra-medullary offset. 4 

b. Resurfacing preserves bone for later reconstructive 

procedures 

i. Replacement 

ii. Arthrodesis 

c. Partial Humeral resurfacing 

i. Indications 

1. Relatively normal glenoid 

2. Partial destruction of humeral articular surface 

a. Osteochondral defect 

b. Focal Avascular Necrosis 

c. Osteoarthritis—mild bone deformity 

ii. Contraindications (relative) 

1. Complete involvement of the humeral head 

2. Severe stiffness 

3. Glenoid deformity/involvement 

iii. Technique 

1. Similar to arthroplasty in general. 

2. Generally patients have less deformity and less 

stiffness, therefore, the cases are generally easier, 

shorter, and easier to rehabilitate from. 

iv. Results 

1. Sparse. No level one or two evidence 

2. Case series in Avascular necrosis shows good results 

early, no complications. 15 

REFERENCES 

1. Alund, M.; Hoe-Hansen, C.; Tillander, B.; Heden, B. A.; and Norlin, R.: 

Outcome after cup hemiarthroplasty in the rheumatoid shoulder: a 

retrospective evaluation of 39 patients followed for 2-6 years. Acta Orthop 

Scand, 71(2): 180-4, 2000. 

2. Bailie, D. S.; Llinas, P. J.; and Ellenbecker, T. S.: Cementless humeral 

resurfacing arthroplasty in active patients less than fifty-five years of age. J 


3. 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): 141S-146S, 2005. 




d. Complete resurfacing 

i. Indications 

1. Relatively normal glenoid—although it is possible 

to access glenoid with resurfacing, it is more difficult 

than when the head has been removed. 

2. Avascular necrosis 

3. Osteoarthritis—younger, more active patients 

4. Desire to avoid the intra-medullary canal 

a. Prior infection 

b. Malunion 

ii. Contraindications 

1. Absent humeral head 

a. Complete—fracture sequelae 

b. Partial (AVN)--? 75% of reamed surface required 

2. Poor bone quality (RA, some CTA) 

iii. Technique 

1. Similar to arthroplasty in general. 

2. Tendency to overstuff the joint 

a. Oversized head 

b. Insufficient reaming with proud placement of the 

implant. 

c. Pain relief slower than replacement 


1. Glenoid erosion 9,16 

2. Joint overstuffing 

a. Stiffness 2 

b. Subscapularis rupture 2 

3. Intra-operative fracture 12 

4. Loosening (especially rheumatoids with poor bone) 1 

III. Does all this matter? 

a. No studies comparing resurfacing to replacement head to 

head. 

b. Outcome studies of partial resurfacing sparse. 15 

c. Comparison of resurfacing with resurfacing with glenoid 

component is sparse and currently shows no difference. 10 

d. Preservation of bone may be a theoretical argument 

e. Resurfacing may not be an easier option 

One Man’s Approach 

Glenoid 

Disease 

Humeral 

Deformity 

Age Activity level 

partial resurfacing - + -- ++ 

Complete resurfacing - ++ -- + 

Replacement +++ +++ +++ +/- 

4. Boileau, P., and Walch, G.: The three-dimensional geometry of the proximal 

humerus. Implications for surgical technique and prosthetic design. Journal 

of Bone & Joint Surgery -British Volume, 79(5): 857-65, 1997. 

5. Cofield, R. H.; Frankle, M. A.; and Zuckerman, J. D.: Humeral head 

replacement for glenohumeral arthritis. Semin Arthroplasty, 6(4): 214-21, 

1995. 

6. Edwards, T. B.; Kadakia, N. R.; Boulahia, A.; Kempf, J. F.; Boileau, P.; Nemoz, 

C.; and Walch, G.: A comparison of hemiarthroplasty and total shoulder 

arthroplasty in the treatment of primary glenohumeral osteoarthritis: results 

of a multicenter study. J Shoulder Elbow Surg, 12(3): 207-13, 2003.

7. Gartsman, G. M.; Roddey, T. S.; and Hammerman, S. M.: Shoulder 

arthroplasty with or without resurfacing of the glenoid in patients who have 

osteoarthritis. J Bone Joint Surg Am, 82(1): 26-34., 2000. 

8. Iannotti, J. P.; Gabriel, J. P.; Schneck, S. L.; Evans, B. G.; and Misra, S.: The 

normal glenohumeral relationships. An anatomical study of one hundred 

and forty shoulders. J Bone Joint Surg [Am], 74(4): 491-500, 1992. 

9. Lee, K. T.; Bell, S.; and Salmon, J.: Cementless surface replacement 

arthroplasty of the shoulder with biologic resurfacing of the glenoid. J 

Shoulder Elbow Surg, 18(6): 915-9, 2009. 

10. 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. 

11. Orfaly, R. M.; Rockwood, C. A., Jr.; Esenyel, C. Z.; and Wirth, M. A.: 

A prospective functional outcome study of shoulder arthroplasty for 

osteoarthritis with an intact rotator cuff. J Shoulder Elbow Surg, 12(3): 

21421, 2003. 

363 




12. Peidro, L.; Plaza, R.; and Sastre, S.: Perioperative fracture-dislocation of the 

humeral head during a resurfacing hemiarthroplasty. Int J Shoulder Surg, 

2(2): 41-2, 2008. 

13. Sperling, J. W.; Cofield, R. H.; and Rowland, C. M.: Minimum fifteen-year 

follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in 

patients aged fifty years or younger. J Shoulder Elbow Surg, 13(6): 604-13, 

2004. 

14. Thomas, S. R.; Sforza, G.; Levy, O.; and Copeland, S. A.: Geometrical analysis 

of Copeland surface replacement shoulder arthroplasty in relation to normal 

anatomy. J Shoulder Elbow Surg, 14(2): 186-92, 2005. 

15. Uribe, J. W., and Botto-van Bemden, A.: Partial humeral head resurfacing for 

osteonecrosis. J Shoulder Elbow Surg, 18(5): 711-6, 2009. 

16. Werner, B. S., and Gohlke, F.: [Cementless humeral head replacement for 

dislocation arthropathy of the shoulder joint.]. Orthopade, 39(11): 1036- 

1043, 2010.

364 

hemiarthroplaSty For CompleX FraCture+/- diSloCatioN oF 

proXimal humeruS-the gold StaNdard 

David Dines MD 

Complex Proximal Humeral Fractures 

Treatment Algorithms Evolving; 

• ORIF – more even in older patients 

• HA 

• Reverse TSA 

Tuberosity Healing Critical for either form of Arthroplasty 

“Rule of 50%” Boileau 

• 50% get better 

• Tuberosity fail in 50% 

• Successful Tuberosity reconstruction key to result 

Indications for Arthroplasty; 

• Severely comminuted displaced fractures+/- dislocation 

• Osteoporotic bone 

• Vascular compromise- intraosseous arcuate artery 

• Inability to restore and maintain anatomy (ORIF) 

• Motivated patient (medical and rehab) 

• Pathologic Indications 

— 4 part fx/dislocations 

— 3 part Fx/dislocations (lesser tuberosity) 

— Impression fractures >50% >6 month 

To be successful this is what matters most; 

• Proper patient indication 

• Dedicated Fracture Prosthesis 

• Proper Component Positioning and Fixation 

• Successful Tuberosity reconstruction 

Reported results; 

Krishnan et al JSES 2005 

• 32 patients (24F 10M 2 died) 

• 72 yo (43-93) 

• ASES 52 AAE 117 degrees; pain 2.7(10); satisfaction 7.2 (10) 

• 81% tuberosity healed 

• 14 < 120 degrees older and tuberosity fail 

• 18 > 120 degrees younger all tuberosities healed 

Kontakis etal, JBJS Br 2008 

• Meta-analysis 16 studies/810 HA for Fx 

• Ave age 67.7 (22-91) 

• 3.7 yr F/U 

• Results; 

— Constant score 56.6 

— FE 106 degrees, ABD 92.4 degrees, 

— Cxs 

– Tuberosity failure 86/771 (11.15%) 

– Infection 0.64% 

– Superior migration 6.8% 

HA v Reverse TSA 

In either procedure tuberosity healing is critical 




• HA with healed tuberosity reconstruction ◊best results 

• HA with failed tuberosity reconstruction ◊worst results 

• Revision of Failed HA for Fracture most difficult cohort group 

Dines, J, 

Dines, D, Fealy, S et al JBJS 2007 

• HA v Reverse- Sirveaux 2008 

— Results in both groups related to tuberosity healing 

Healed Constant AAE AER 

HA 59 116’ 14’ 

Reverse 

Non-united 

59 107’ 11’ 

HA 41.9 75’ 25’ 

Reverse 55 116’ 13 

• Sirveaux Tech Sh Elb Surg 2008, JSES 2009 

— Reverse is an alternative to HA in select elderly patients 

— HA and Reverse for Fx both demanding procedures which 

depend upon greater tuberosity healing for best result 

(ER)- reverse more forgiving in elevation –more high risk 

complications 

Results depend upon; 

• Age 

— Less than 70 better than over 70 

• Timing of surgery 

— Acute (

365 

reverSe Shoulder arthroplaSty For aCute FraCture : who 

NeedS to worry about tuberoSity healiNg ? 

Francois Sirveaux, PhD, D Block, F Wein, D Molé 

Introduction 

The current indications for primary hemiarthroplasty include a 

displaced four-part fracture with or without humeral head dislocation 

and head splitting or impaction fracture with involvement of 

more than 40% of the articular surface1. The incidence of these 

fractures increased dramatically since 1970, especially in women. 

Considering the natural increase in the size of elderly population, 

one can estimated that the number of proximal humeral fracture in 

elderly may triple by the year 2030. This means that the potential 

indication for shoulder replacement for fracture in elderly may 

increase in the future. However, several studies have clearly shown 

age to be a negative factor in the results of hemiarthroplasty for 

fracture. Tuberosities migration remains the main cause of failure of 

hemiarthroplasty for fracture in elderly despite recent development 

in shoulder prosthesis design for fracture. The failure of tuberosity 

healing leads to a complete and irreversible loss of active elevation. 

Influence of cuff status in RSA for CTA 

It’s now accepted that the reverse shoulder prosthesis allows restoring 

active anterior elevation in pseudoparalytic shoulder whatever the 

status of the cuff. But, as reported previously, the recovery in active 

external rotation is influenced by the status of the infraspinatus and 

teres minor. Preoperative atrophy or fatty infiltration of these muscles 

causes a loss of external rotation. In a multicentric series2, the average 

active external rotation, elbow to the side, was of 4° when the minor 

teres was atrophied or absent, against 15° in average when it was 

present or hypertrophic. In abduction position, the active external 

rotation was of respectively 34° and 52° in average. Moreover, the 

status of the subscapularis influence the recovery in internal rotation. 

In the study of Wall and al3, patients with repair of the subscapularis 

knew greater improvement in the amount of internal rotation (from 

L5 to L4) than did those without repair (from the sacrum to L5). 

Preoperative fatty infiltration of the subscapularis muscle on the CT- 

Scan had been identified as risk factor for postop instability. 

RSA for acute fracture 

Modern reverse design has been introduce by Grammont in 90’s. 

Grammont himself used this prosthesis for acute fractures and 

fracture sequelae early in his experience (22 cases between 1989 and 

1993) but the results were not published. 

Our preliminary results of a prospective study showed that the 

patients treated with a reverse prosthesis in the case of acute fracture 

achieved an average of 113° in active elevation compared with 88° 

with hemiarthroplasty 4. The overall results were not as good as in 

patients treated with a reverse prosthesis for cuff tear arthropathy. 

In 2006, Cazeneuve and Cristofari 5 reported their experience of 

23 cases of reverse prosthesis for acute fracture. 16 cases had been 

reviewed at an average follow-up of 86 months. The mean age of 

the patients was 75 years (58-90). The mean Constant score was 

60 points and active anterior elevation was over 120 degrees in all 

the cases except for the two cases requiring revision. Bufquin et al 

6reported the largest series of reverse prostheses for fracture (43 

cases - 40 included with a mean age of 78 years). At a mean followup 

of 22 months (6 to 58), the average active anterior elevation was 

97 degrees. We reviewed a small series of 15 cases and compared 

with a series of elderly patients treated with hemiarthroplasty 7. 

The mean results in active anterior elevation were not significantly 

different between the two groups but the distribution of the results 




was different. In the reverse group, only one patient had less than 90 

degrees of active anterior elevation but the active anterior elevation 

never exceeded 150 degrees; whereas in the hemiarthroplasty group, 

11 percent had more than 150 degrees but 50 percent only achieved 

90 degrees or less. Regarding these series, RSA for fracture gives good 

and reproducible results in active anterior elevation and functional 

improvement compared to hemiarthroplasty in elderly. Tuberosity 

fixation around the RSA seemed not affect the recovery in elevation. 

Effect of tuberosity fixation 

At the beginning of their experience, many surgeons considered 

the RSA for fracture as a salvage procedure and the fixation of the 

tuberosities was not recommended. But as in CTA, the recovery in 

active external rotation cannot be achieved if the infraspinatus and 

teres minor are not functional8. That leads to a hornblower sign 

and this impairment crucially affected daily life as supported the 

study of Gallinet et al9. Cazeneuve et al5 noticed that the recovery 

of active external rotation was better in cases where the tuberosities 

had been fixed. Klein el al is the only one reporting recovery in 

external rotation while they had removed the tuberosities during the 

procedure, but they don’t differentiated active from passive rotation 

in the article10. In the series of Bufquin et al6, radiographically the 

tuberosities were displaced in 53% of the cases (13.8% malunion and 

38.8% non-union). They reported better recovery in active external 

rotation when the greater tuberosity had healed. The principle of 

tuberosities fixation around the reverse prosthesis is similar to the 

technique previously described by Boileau11 for hemiarthroplasty. 

After reduction, the greater tuberosity is mobilized and temporarily 

reduced around the shaft. The remaining sutures are led around the 

lesser tuberosity and tightened on the lateral side. This provides a 

horizontal assembly, holding the tuberosities around the implant. 

The fixation is completed using the sutures threaded through the 

shaft and led in a figure-of-8 through the tendon/bone junction to 

ensure vertical stability. The medialization of the proximal humerus 

and the resection of the supraspinatus reduce rotator cuff tension. 

New reverse designed stem has been developed to improve the 

healing the tuberosities12. 

We reviewed our series of 63 cases operated since 2001(mean age 79 

years, from 69 to 87). The tuberosities were fixed with this technique 

in all the cases. All of them were immobilized in a sling for few 

days and started early rehabilitation. Four were lost and 11 died. 47 

were reviewed with more than 6 months FU in order to evaluate the 

healing of the tuberosities and the early clinical results. We noticed 3 

complications: one acromiale fracture, one traumatic humeral shaft 

fracture and one late infection. We did not have any case of instability 

contrary to series without fixation of the tuberosities. Fixation of the 

tuberosities may restore anterior and posterior reins to limit the risk 

of postoperative dislocation. At a mean follow up of 30 months, the 

constant score averaged 55 points, and the average active anterior 

elevation was 130 degrees. The greater tuberosity healed in 86 p.cent 

of the cases, and 98% for the lesser tuberosity. The Constant score 

was influenced significantly by the healing of the greater tuberosity 

: 57 points versus 45 points (p=0.01). The mean active external 

rotation was 12.7 degrees when the greater tuberosity healed versus 

4 degrees when they were migrated or resorbed. Surprisingly, we 

noticed that the recovery in active anterior elevation was improved 

as well by healing of the tuberosty (124 degrees versus 97 degrees).

In this series, 15 fracture reverse designed prostheses has been used. 

In this group the healing of the tuberosities was obtained in all the 

cases. The mean active anterior elevation ranged 130 degrees and the 

mean active external rotation was 20 degrees. 

Conclusion 

Our experience and the literature confirmed that the reverse 

shoulder arthroplasty allows recovery in active elevation whatever 

the status of the cuff and tuberosities. Indeed, a reversed prosthesis 

may be indicated for fracture in case of factors of poor prognosis 

for tuberosity consolidation with hemiarthroplasty, especially in the 

REFERENCES 

1. Palvanen, M.; Kannus, P.; Niemi, S. et al.: Update in the epidemiology of 

proximal humeral fractures. Clin Orthop Relat Res, 442: 87-92, 2006. 

2. Baulot, E.; Valenti, P.; Garaud, P. et al.: Résultats des proth ses inversées. Rev 

Chir Orthop, 93(6 (suppl I)): 63-92, 2007. 

3. Wall, B.; Nove-Josserand, L.; O’Connor D, P. et al.: Reverse total shoulder 

arthroplasty: a review of results according to etiology. J Bone Joint Surg Am, 

89(7): 1476-85, 2007. 

4. Sirveaux, F.; Navez, G.; Favard, L. et al.: Reverse prosthesis for acute proximal 

humerus fracture, the multicentric study. In Reverse Shoulder Arthroplasty, 

clinical results -complications -revision. Edited by Walch, G.; Boileau, P.; and 

Mole, D., Montpellier, Sauramps Medical, 2006. 

5. Cazeneuve, J. F., and Cristofari, D. J.: Arthroplastie inversée de Grammont 

pour fracture récente de l’humérus proximal chez la personne âgée avec un 

recul de 5 ˆ 12 ans. Rev Chir Orthop 92(6): 543-8, 2006. 

6. Bufquin, T.; Hersan, A.; Hubert, L. et al.: Reverse shoulder arthroplasty for 

the treatment of three-and four-part fractures of the proximal humerus in the 

elderly: a prospective review of 43 cases with a short-term follow-up. J Bone 

Joint Surg Br, 89(4): 516-20, 2007. 

7. Sirveaux, F.; Navez, G.; Roche, O. et al.: Reverse prosthesis for proximal 

humerus fracture, technique and results. Techniques Shoulder Elbow Surg, 

9(1): 15-22, 2008. 

366 




elderly. Nevertheless, healing of the greater tuberosity is mandatory 

to recover the active external rotation and that influences the 

functional results. Moreover, it may decrease the risk of instability. The 

tuberosity fixation does not compromise early active mobilization. 

A meticulous technique of fixation and a dedicated fracture designed 

stem can improve the rate of tuberosity healing and the overall 

clinical results. The reverse prosthesis is a constrained prosthesis 

and the current literature raises concerns regarding the durability 

of the fixation of the prosthesis in the long term13. That’s why the 

indication for a reverse prosthesis must balance the advantages and 

the risks of either reverse or hemiarthroplasty. 

8. Sirveaux, F.; Mole, D.; and Boileau, P.: The reversed prosthesis. In Complex 

and revision problems in shoulder surgery, pp. 497-511. Edited by Warner, J. 

J.; Iannotti, J. P.; and Flatow, E., 497511, Philadelphia, Lippincott Williams & 

Wilkins, 2006. 

9. Gallinet, D.; Clappaz, P.; Garbuio, P. et al.: Fractures complexes trois 

ou quatre fragments de l’humérus proximal: hémiararthroplastie ou 

arthroplastie inversée? Etude comparative ˆ propos de 40 cas. Rev Chir 

Orthop, 95(1): 49-56, 2009. 

10. Klein, M.; Juschka, M.; Hinkenjann, B. et al.: Treatment of comminuted 

fractures of the proximal humerus in elderly patients with the delta III 

reverse shoulder prosthesis. J Orthop Trauma, 22(10): 698-704, 2008. 

11. Boileau, P.; Krishnan, S. G.; Tinsi, L. et al.: Tuberosity malposition and 

migration: reasons for poor outcomes after hemiarthroplasty for displaced 

fractures of the proximal humerus. J Shoulder Elbow Surg, 11(5): 401-12, 

2002. 

12. Sirveaux, F.; Roche, O.; and Mole, D.: Shoulder arthroplasty for acute 

proximal humerus fracture. Orthop Traumatol Surg Res, 96: 683-694, 2010. 

13 Guery, J.; Favard, L.; Sirveaux, F. et al.: Reverse total shoulder arthroplasty. 

Survivorship analysis of eighty replacements followed for five to ten years. 

J Bone Joint Surg Am, 88(8): 1742-7, 2006.

367 

the gold StaNdard radiographiC aNd 

iNtra- operative evaluatioN 

Edward V. Fehringer, MD 

I. Assumptions 

a. TSA 

b. All surgeons/prostheses striving for anatomic humeral 


c. Many surgeons/prostheses to achieve humeral goals 

d. Humerus reconstruction not the f 

e. Biconcavities- must be addressedocus 

f. All polyethylene glenoids 

g. Shoulder navigation, not hip/knee 

II. Focus- Glenoid reconstruction 

a. Stability 

b. ROM 

c. Loosening 

d. Wear 

e. Anatomic? 

III. A Balance 

a. “Correcting” Version 

i. Neutralizing 

ii. “Face-planing” or accepting < neutral 

iii. Bone graft 

iv. How much“medialization” is too much? 

1. Affects overall soft tissue balance/offset 

2. Affects quality of bone onto which one is placing 

glenoid 

b. Soft tissue balancing 

i. Posterior subluxation & laxity 

ii. Anterior releases 

iii. Tension changes w/ reaming, incl. eccentric 

iv. Rotator interval &/or posterior capsulorraphy 

c. Simplicity/Practicality/Reproducibility 

i. Efficacy (works in hands of select individuals in a 

specificsetting) vs.effectiveness (efficacious procedure 

works in hands of general medical community). 

ii. Less steps/correction=less chance for errors. 

d. Cost 

i. O.R. time 

ii. Prostheses 

iii. Outcome improvements w/ increased investment? 

iv. Payer amount is only going to decrease 

e. Component support 

i. Any face cement? 

ii. Keel vs. pegged. 

iii. How much % bone support is necessary? 

f. “Genetic and biomechanical determinants of glenoid 

version…” Landau JP, Hoenecke HR. JSES 2009. 

IV. Radiographic Evaluation 

a. Plain x-rays 

i. If adequate True AP and axillaryÎmay be enough on most 

ii. Inexpensive 

b. CT 

i. Cost- is it justified w/ improved outcomes? 

ii. Is it required for every reconstruction? 

iii. If CT: 

1. Recognitionof axial cuts plane 




2. Should be 3D- better appreciation of deficiencies. 

3. Better able to plan for bone grafting 

c. MRI- Is it necessary for majority of shoulder arthritis cases 

if no previous surgery & if head reasonably centered on 

glenoid? 

V. Intra-operative evaluati 

a. Gold standard on 

b. Recognizing that….many variables affect glenoid access & 

reconstruction: 

i. scapular position 

ii. variable glenoid versions 

iii. bed 

iv. patient size 

v. retractors 

vi. reamert 

vii.stiffnessype/size 

viii. pathology 

ix. deltoid size 

x. glenoid morphology 

xi. component placement sup-inf & ant-post 

xii. patulous posterior capsule 

xiii. inability to ascertain how much has been reamed and 

where 

c. Can choose to try to get to “neutral version”….is this 

realistic? 

d. Vs. evaluation & creation of concavity to support component 

e. Can assess & adjust reaming 

VI. Navigation 

a. Most useful if utilizes pre-op CT data 

b. Need real time feedback 

c. Possible improved component placement 

d. Cost 

i. O.R. time 

ii. Instrumentation 

iii. Is it justified by improved outcomes? 

e. KeyOverall component position is the only variable 

addressed w/navigation. 

VII. Conclusions 

a. For economical & effective glenohumeral reconstructions: 

i. Adequate pre-op true AP & axillary 

ii. CT- w/ 2-& 3-D recons w/ recognition ofaxial cut 

orientationfor those w/ significant bone deficiency….or if 

unsure 

iii. MRI- previous cuff repair &/or elevated head position 

iv. Consistentpositioning & technique 

v. Creating concavity for as much glenoid bone support as 

poss. 

vi. Accepting

368 

emergiNg teChNology: Computer aSSiSted tSa 

T. Bradley Edwards, MD 

Introduction 

Computer-aided navigation techniques have been developed to 

improve implant alignment in knee and hip arthroplasty and early 

reports have demonstrated their effectiveness.1,2 Like knee and hip 

arthroplasty, successful shoulder arthroplasty depends primarily on 

technique with incorrect component alignment leading to instability, 

loosening, and suboptimal function. During unconstrained shoulder 

arthroplasty, a severe biconcave glenoid deformity, for example, can 

present significant intraoperative difficulties, even for experienced 

shoulder arthroplasty surgeons. Additionally, increasing clinical 

experience with the reverse prosthesis emphasizes the importance 

of glenoid prosthetic positioning in avoiding glenoid complications. 

Finally, in fracture cases normally reliable landmarks are often 

displaced. The risk of placing the humeral stem at the incorrect 

height or version is increased because of this lack of recognizable 

landmarks. Therefore, we believe that computer guided navigation 

can play an important role in both unconstrained and reverse 

shoulder arthroplasty. Since 2005 we have been using an image free 

computer navigation system to assist with shoulder arthroplasty in 

many of our patients. 

Computer Guidance in Correction of Glenoid Deformity in 

Primary Unconstrained Total Shoulder Arthroplasty 

For the glenoid component, computer assisted navigation allows 

precise correction of pathological glenoid version and inclination 

caused by osseous glenoid wear. Without computer assisted 

navigation, correction of pathological glenoid version and inclination 

through reaming is largely dependent on surgeon experience. 

Unfortunately, most surgeons performing shoulder arthroplasty 

do less than ten cases per year. Of cases of primary osteoarthritis, 

only 25 to 35% have posterior glenoid wear with biconcave glenoid 

morphology. If the average surgeon only performed replacements 

for primary osteoarthritis (which is of course untrue), then he or 

she would encounter less than three of these cases per year making 

it extremely difficult to gain experience in treating this difficult 

situation. The use of computer assisted navigation for correction of 

these glenoid deformities eliminates a large portion of the learning 

curve. 

Computer Guidance in Correction of Glenoid Deformity in 

Primary Reverse Shoulder Arthroplasty 

Our early experience suggests that the reverse prosthesis is a 

compelling application for computer guided shoulder navigation 

technology particularly during glenoid reaming. Chronic superior 

migration of the humeral head may result in superior erosion of 

the glenoid that should be corrected at the time of reverse shoulder 

arthroplasty. Additionally, many surgeons regularly implanting the 

reverse prosthesis recommend placing the glenoid component with 

slight inferior tilt.3,4 This inferior tilt serves three purposes: first, it 

increases stability of the prosthesis by maximizing deltoid tension 

by distalizing the humerus; second, it acts to reduce the incidence of 

scapular notching; and third, it helps avoid inadvertently placing the 

glenoid component in a superiorly oriented position which can lead 

to early glenoid failure. Computer guidance during glenoid reaming 

provides an accurate and reproducible method for correction of 

superior glenoid wear and for establishing appropriate inferior 

glenoid tilt in reverse shoulder arthroplasty. This may improve 

survivorship by minimizing shear forces across the bone-implant 

interface and potentially reducing the incidence of scapular notching. 

In our hands, reaming of the glenoid surface at a specific amount 




of negative inclination is readily accomplished with computer 

guidance. 

Computer Guidance in Humeral Stem Placement During 

Hemiarthroplasty for Fracture 

The lack of normal anatomical landmarks in fracture cases confounds 

proper placement of the humeral stem. Placing the humeral stem in 

incorrect height and/or version risks tuberosity complications such 

as malunion, nonunion, and migration. Using the contralateral 

uninjured humerus as a template, computer navigation can be 

utilized to place the humeral component in the correct height and 

version. Although our experience with this technique is in its infancy, 

early results have been promising. 

Computer Guided Correction of Glenoid Deformity in Total 

Shoulder Arthroplasty – Surgical Technique 

As per our standard protocol for shoulder arthroplasty, native 

glenoid morphology is evaluated using preoperative computed 

tomography.5 Based on the native version angle of each glenoid, 

we determine how much correction is needed during intraoperative 

glenoid preparation (Figure 1). 

Each patient is operated on in the modified beach chair position. A 

standard deltopectoral approach is used to expose the shoulder joint. 

Following humeral preparation, a tracking device is attached to the 

coracoid process to allow for glenoid navigation. A navigated glenoid 

referencing device is used to capture the version and inclination of 

the native glenoid surface. A navigation tracker is attached to the 

glenoid reamer. The glenoid is reamed while the navigation system 

provides real-time feedback on the change in version and inclination 

relative to the native glenoid. Following completion of glenoid 

reaming, the scapular tracking device is removed and the glenoid 

component is implanted using standard techniques. 

Figure 1. The preoperative glenoid version is determined using preoperative computed 

tomography. in this case the native glenoid version measures 30 degrees of retroversion. 

We would plan a correction of 25 degrees resulting a more nearly normal glenoid 

retroversion of 5 degrees.

Figure 2. Typical navigational computer screen observed during real time correction of 

glenoid deformity. 

Computer Guidance in Humeral Stem 

Placement During Hemiarthroplasty for 

Fracture – Surgical Technique 

The contralateral humeral length from 

the top of the humeral head to the 

transepicondylar axis is measured from a 

magnification controlled anterior posterior 

radiograph. This length is entered into the 

navigational computer. The epicondyles and 

the intramedullary axis of the humerus are 

referenced and entered into the navigational 

computer during surgery. This data is used to 

control placement of the height and version 

of the humeral stem in real time during 

implantation (Figure 3). 

Figure 3. Humeral tracker attached to a humeral fracture 

stem. 

REFERENCES 

1. Digioia AM 3rd, Jaramaz B, Plakseychuk AY, et al. Comparison of a 

mechanical acetabular alignment guide with computer placement of the 

socket. J Arthroplasty 2002;17:359-364. 

2. Haaker RG, Stockheim M, Kamp M, et al. Computer-assisted navigation 

increases precision of component placement in total knee arthroplasty. Clin 

Orthop 2005;433:152. 

369 




Computer Guided Shoulder Arthroplasty – Clinical Results 

From August 2005 through September 2006, twenty-seven shoulder 

arthroplasties were performed on twenty-seven patients by us 

using the navigation system. Twenty-four patients had primary 

osteoarthritis, instability arthropathy, or osteonecrosis and were 

treated with an unconstrained total shoulder arthroplasty. Three 

patients had rotator cuff tear arthropathy and were treated with a 

reverse prosthesis. The patients ranged in age from 39 to 85 years at 

the time of surgery. Body mass index ranged from 18 to 64. 

There were no intraoperative or postoperative complications that 

could be attributed to use of the navigation system. The tracking 

devices were safely and securely attached to the proximal humerus 

and coracoid process without damage to bony or neurovascular 

structures. The tracking devices held secure during each procedure 

and did not impede surgical performance or access to the operative 

site. The navigation system reported glenoid reaming orientation 

relative to the native glenoid (+3.0¼ ± 6.3¼ of version; -6.7¼ ± 

4.4¼ of inclination). 

Our experience thus far with computer guided shoulder arthroplasty 

demonstrates that the technology is safe and can provide valuable 

intraoperative measurements. When the magnitude of deformity 

is measured on preoperative computed tomographic images, the 

navigation system provides real-time feedback for glenoid reamer 

angles as they relate to the deformed native glenoid. Additionally, 

early results using computer navigation to assist in humeral stem 

positioning during fracture cases show promise. 

3. Frankle M, Siegal S, Pupello D, et al. The Reverse Shoulder Prosthesis for 

glenohumeral arthritis associated with severe rotator cuff deficiency. A 

minimum two-year follow-up study of sixty patients. J Bone Joint Surg 

2005;87-A:1697-1705. 

4. Wall B, Williams MD, Walch G, et al. Scapular notching in reverse shoulder 

arthroplasty. Presented at the 20th Congress of the European Society for 

Surgery of the Shoulder and the Elbow, 2006, Athens, Greece. 

5. Friedman RJ, Hawthorne KB, Genez BM. The use of computerized 

tomography in the measurement of glenoid version. J Bone Joint Surg 1992; 

74-A:1032-1037.

370 

the deltopeCtoral approaCh For total Shoulder 

arthroplaSty 

Evan L. Flatow, MD 

Optimally Invasive Surgery 

• More than 30 years of experience with arthroplasty through this 

approach 

• Extensile, allows easy identification of axillary nerve (and 

brachial plexus if necessary) 

• Greater than 90% good to excellent results long term 

• Complications: Glenoid loosening, infection, instability 1 

• Subscapularis insufficiency: now well recognized with multiple 

solutions 2-4 

A. Lesser tuberosity Osteotomy 

1. Qureshi et al 25/30 patients had no difficulty with 

terminal IR 5 

2. Gerber et al 89% of 57 shoulders had negative belly 

press 4 

Figure from Miller at al JSES 2003 

B. Tendon to tendon repair with protected rehab 

1. 45/45 patients with neg belly press post-op 6 

C. Comparisons 

1. Scalise et al found only 1/15 and 0/20 patients who 

underwent tenotomy or LT osteotomy respectively had 

full thickness subscap tears on ultrasound after 1 year 7 

• With a lesser tuberosity osteotomy, the deltopectoral approach 

is completely muscle and tendon sparing approach. 

Mini-Incision Technique Creating New Problems 

• Humeral sided problems are rare with traditional TSA8 

• 6/17 patients in original description of technique had a 

humeral cut to high or low9 

• Humeral trialing is limited by space, cannot trial stem and head 

together 

REFERENCES 

1. Chin PY, Sperling JW, Cofield RH, Schleck C: Complications of total shoulder 

arthroplasty: Are they fewer or different? J Shoulder Elbow Surg 2006;15:19- 

22. 

2. Edwards TB, Boulahia A, Kempf JF, Boileau P, Nemoz C, Walch G: The 

influence of rotator cuff disease on the results of shoulder arthroplasty for 

primary osteoarthritis: Results of a multicenter study. J Bone Joint Surg Am 

2002;84-A:2240-2248. 

3. Miller SL, Hazrati Y, Klepps S, Chiang A, Flatow EL: Loss of subscapularis 

function after total shoulder replacement: A seldom recognized problem. J 

Shoulder Elbow Surg 2003;12:29-34. 

4. Gerber C, Yian EH, Pfirrmann CA, Zumstein MA, Werner CM: Subscapularis 

muscle function and structure after total shoulder replacement with lesser 

tuberosity osteotomy and repair. J Bone Joint Surg Am 2005;87:1739-1745. 

5. Qureshi S, Hsiao A, Klug RA, Lee E, Braman J, Flatow EL: Subscapularis 

function after total shoulder replacement: Results with lesser tuberosity 

osteotomy. J Shoulder Elbow Surg 2008;17:68-72. 




• Humeral “wrenching” necessary to establish version. Implant is 

placed in anteversion and wrenched posteriorly as it is inserted 

to avoid contact with the acromion. 

Humeral Exposure with Miniincision 

From: primary total shoulder 

arthroplasty performed entirely 

through the rotator interval: 

Technique and minimum twoyear 

outcomes Lafosse et al 

JSES 2009 

• The consequences of the wrenching technique humeral fixation 

are unknown? Is wrench fit the same as press fit? 

• Most common reason for failure of TSA is glenoid loosening 10 

• Life of the glenoid dependent upon proper alignment of BOTH 

components 

• Can proper version of humeral component be consistently 

established with a wrench but not trial? 

• Nerve Injury

371 

leSS iNvaSive Shoulder arthroplaSty 

Laurent Lafosse, MD 

Topic: The “Triple S TSA” 

SubScapularis Sparing Total Shoulder Arthroplasty 

When performed correctly, primary total shoulder arthroplasty 

(TSA) provides excellent pain relief and predictable outcomes in the 

majority of patients. Although complications after subscapularis 

tenotomy and takedown in open anterior surgical approaches to the 

glenohumeral joint have been well documented, increasing attention 

has been recently given to subscapularis dysfunction and failure 

postoperatively. With this in mind, the “Triple S,” or SubScapularis 

Sparing approach for TSA was developed to minimize the potential 

for poor clinical outcomes due to soft-tissue and subscapularis 

tendon related complications. 

I. TSA works… but how can we improve patient outcomes? 

1. Minimize Subscapularis Related Dysfunction: 

In 2003, Miller et al. showed subscapularis dysfunction in 

67% by lift-off test & in 66% with the belly press test after 

subscapularis tenotomy. Others have shown less severe, but 

significant dysfunction, after lesser tuberosity osteotomy. 

i. Minimize Subscapularis Tendon Failure: 

1. Rates as high as 4-14% documented. 

2. How many failures go unrecognized? 

• High index of suspicion is required. 

ii. Minimize Subscapularis Fatty Infiltration (FI): 

In 2002, Edwards et al. found postoperative FI negatively 

influenced clinical outcomes in a large cohort of TSAs for 

primary OA. 

1. Picard et al. found a 50% loss of internal rotation 

strength and stage II-IV FI in 41% after inverted-L 

tenotomy for open stabilization surgery. 

2. In 2005, Gerber et al. showed with lesser tuberosity 

osteotomy, FI advanced postoperatively by at least 1 

stage in 40% and 2 stages in 15% of patients. 

• Etiology of FI not fully understood. 

2. ELIMINATE the need for postoperative immobilization: 

i. No restrictions on active internal rotation or passive 

external rotation. 

ii. Questions to be answered: 

1. Does this improve patient outcome parameters? 

a. Less Subscapularis FI, etc. 

2. Does this improve patient satisfaction? 

• Initial results are encouraging! 

II. Evolution of a Concept: 

1. Knowledge of the rotator interval and experience with the 

superior approach for reverse TSA led to the consideration of 

this approach for conventional TSA. 

Through experience… 

i. Developed better anatomic understanding of the rotator 

interval and its dimensions. 

ii. Developed better exposure of the humerus and glenoid 

from superior portal. 

iii. Concerns and problems encountered: 

1. Acromioplasty required. 

2. Issues with deltoid insufficiency and diminished 

function after takedown. 

3. Difficult access and removal of inferior humeral 

osteophytes. 

Thus evolved the current technique for “Triple S TSA.” 




III. The “Triple S TSA”: A Two Window Technique 

Table 1: Summary of Steps involved with “Triple S TSA” 

Step 1 Anesthesia and patient positioning. 

Step 2 Skin incision and initial approach. 

Step 3 Creation of “inferior window” and inferior osteophyte resection. 

Step 4 Opening of rotator interval “superior window” & biceps tenodesis. 

Step 5 Humeral shaft preparation, head resection, & osteophyte removal. 

Step 6 Glenoid preparation, trialing and resurfacing. 

Step 7 Final humeral preparation, trialing and insertion. 

Step 8 Wound closure. 

1. Anesthesia and Patient Positioning: 

i. General Anesthetic + Interscalene block/catheter 

ii. Standard beach chair position 

1. Back support elevated to ~45 degrees. 

2. Side rest on operative side removed. 

• Facilitates humeral adduction for later humeral 

head and canal preparation. 

3. Arm draped free (no articulated device). 

2. Skin Incision and Initial Approach: 

i. Deltopectoral approach 

1. Incision ~10cm in length 

2. Lateralized 2-3cm from the coracoid. 

• Facilitates later glenoid visualization. 

3. Interval and cephalic v. are exposed. 

4. Deltoid and cephalic vein are retracted laterally. 

5. The fascia at the lateral conjoint tendon is divided 

exposing the underlying subscapularis tendon. 

6. The superior and inferior subscapularis borders are 

clearly identified. 

3. Creation “Inferior Window” & osteophyte resection: 

i. The arm is flexed to ~60deg with ~20 ER to improve 

inferior exposure. 

ii. The anterior humeral circumflex vessels may be ligated at 

the inferior subscapularis border. 

iii. The inferior subscapularis is bluntly dissected and 

mobilized superiorly to expose the inferior capsule. 

iv. A Hohmann retractor is placed inferiorly beneath the 

capsule retracting the axillary nerve inferiorly and 

medially. 

v. Inferior capsulotomy and complete inferior capsular 

release are performed on the humeral and glenoid sides. 

vi. The Hohmann retractor is then repositioned into the 

glenohumeral joint, exposing the inferior osteophytes. 

vii. A curved osteotome and rongeurs are used to fully resect 

the inferior humeral osteophytes. 

• Visualization is improved by humeral flexion & 

varying degrees of internal/external rotation. 

viii. After completion, the distal retractors are removed 

and the arm is repositioned in adduction and neutral 

rotation. 

4. The “Superior Window” and Biceps Tenodesis: 

i. The long head biceps tendon is palpated and exposed 

in the groove. The bicipital groove is opened and traced 

proximally to the rotator interval (RI). 

ii. The biceps is tenodesed in the groove using nonabsorbable 

suture and the proximal stump is resected.

372 

iii. The RI is further exposed and the SGHL and CHL are 

identified and resected. 

iv. Two small, modified Hohmann retractors are placed in 

the interval allowing humeral head exposure superiorly. 

1. The first is placed posteriorly and retracts the 

supraspinatus tendon. 

2. The second is placed anteriorly retracting the 

susubscapularis tendon. 

• Adequate humeral head exposure should be possible 

without excessive traction on either tendon. It is 

sometimes necessary to check retractor placement and 

reposition them for optimal exposure. 

5. Humeral Shaft Preparation, Humeral Head Osteotomy, and 

Osteophyte Removal: 

i. A sharp awl is used to sound the humeral canal at the 

appropriate location with the arm fully adducted. 

ii. The humeral shaft is prepared with successive reamers 

until cortical friction is encountered. 

iii. The appropriate sized reamer is left in place and the 

humeral cutting guide is attached to facilitate the correct 

inclination and version for the humeral head cut. 

• Cut height is determined from the superior articular 

margin. 

• Version is based on native humeral anatomy, the 

bicipital groove, and forearm position. 

iv. The guide is secured in place with two smooth pins. 

v. The head is resected using the combination of an endcutting 

saw and osteotomes. 

• The cuts are completed with an osteotome to 

prevent inadvertent damage to deep structures and 

surrounding tendons. 

vi. After head resection, remaining osteophytes are palpated 

and removed. 

• Do not hesitate to return to the inferior window if 

needed for osteophyte removal. 

6. Glenoid Preparation, Trialing and Resurfacing: 

i. The glenoid is exposed using a combination of modified, 

small Hohmann retractors anteriorly and posteriorly, and 

a standard inferior glenoid retractor. 

• The humeral head in translated inferiorly without the 

need for dislocation, excessive humeral rotation, and/ 

or tension on the cuff. 

ii. After adequate exposure and capsular release, the guide 

pin is placed and central glenoid pilot hole is drilled. 

iii. The glenoid is reamed in standard fashion depending on 

the anatomy encountered. 

iv. The guide for the pegged glenoid is then inserted and 

drilled with a dedicated drill bit. 

• Note: The posterior inferior peg is often the most 

difficult to prepare because of soft tissue tension. 

v. The glenoid trial is placed and glenoid osteophytes are 

removed. 

vi. The definitive glenoid implant is then inserted, and the 

inferior glenoid retractor is removed. 

7. Final Humeral Preparation, Trialing and Insertion: 

i. The humeral head is translated superiorly for final 

preparation and prosthesis insertion. 

ii. The anterior and posterior Hohmann retractors are 

repositioned for humeral exposure as needed. 

iii. Broach preparation of the proximal humerus is carried 

out, and this is facilitated by specific straight handled 

broaches. 




iv. Prosthetic humeral head height is determined from the 

resected humeral head. 

v. Prosthetic humeral head diameter is determined from 

either direct measurement of the resected head or the 

humeral head footprint remaining. 

vi. The humeral head trial selected can then be placed on a 

stemless metaphyseal trial component and inserted for 

ROM and stability assessment. 

vii.Once the correct size is confirmed, the final prosthesis is 

assembled and inserted. 

viii. The humeral component must initially be inserted in 

anteversion due to soft tissue constraints. The humeral 

head is then rotated into correct version under the 

supraspinatus tendon. 

• Humeral component rotation is achieved with the use 

of a customized spanner attached at the prosthetic 

head/stem junction. 

ix. After appropriate version is obtained definitive humeral 

impaction is carried out and final ROM and stability are 

assessed. 

x. The humeral component is then palpated and observed 

through the “inferior window” for confirmation of 

appropriate height and placement. 

xi. Final observation is performed ensuring no soft tissue 

entrapment at the prosthesis/bone interface has occurred. 

8. Drain Placement and Wound Closure: 

i. The wound is irrigated and a drain is placed in standard 

fashion. 

ii. The wound is closed in layers with a running, 

subcuticular closure of the superficial layer. 

• The RI is not closed. 

IV. Perceived Benefits of the “Triple S TSA” Approach 

1. Subscapularis sparing: 

i. Theoretically minimizes the risk of postoperative tendon 

failure, fatty infiltration, and instability. 

ii. Allows immediate, unrestricted, active participation in 

physical therapy. 

iii. Early outcomes show comparable component 

positioning to traditional techniques, excellent patient 

satisfaction, and impressive early return of motion. 

2. The technique does not require prolonged extremes of 

rotation or dislocation of the shoulder joint. 

i. Minimizes traction injury to the rotator cuff musculature 

and surrounding neurovascular structures. 

3. Intact rotator cuff tendon footprints circumferentially 

facilitates anatomic version of the prosthesis. 

4. Novel technique through the deltopectoral interval allows 

for the removal of inferior osteophytes and preserves deltoid 

muscle attachment and function. 

5. This approach can be converted to a traditional method of 

subscapularis tenotomy or lesser tuberosity osteotomy at any 

time during the procedure. 

V. Pitfalls of the SubScapularis Sparing Approach: 

1. The procedure is more difficult in the setting of severe 

glenohumeral stiffness and in young, muscular, male 

patients. 

i. Again, it can be converted to a conventional approach 

when needed. 

2. The exposure is often more difficult and timely than 

traditional techniques utilizing subscapularis detachment. 

3. Risk for inadequate resection of periarticular osteophytes.

373 

i. The long-term clinical significance is unknown, although 

early results have shown no significant difference in 

outcome. 

4. Potential need for specific modified retractors and 

instrumentation to perform the approach. 

BIBLIOGRAPHY 

1. Gerber C, Pennington S, Yian EH, Pfirrmann CAW, Werner CML, Zumstein 

MA. Lesser Tuberosity Osteotomy for Total Shoulder Arthroplasty - Surgical 

Technique. J Bone Joint Surg Am. 2006 88-A Sup 1 Pt 2: 170 - 177. 

2. Miller, SL, Y Hazrati, S Klepps, A Chiang, and EL. Flatow. “Loss of 

subscapularis function after total shoulder replacement: A seldom recognized 

problem.” J Shoulder Elbow Surg 1, no. 1 (January / February 2003): 29 - 34. 

3. Gerber C, Yian EH, Pfirrmann CAW, Zumstein MA, Werner CML. 

Subscapularis muscle function and structure after total shoulder replacement 

with lesser tuberosity osteotomy and repair. J Bone Joinmt Surg Am. 

2005;87:1739-1745. 

4. Bohsali KI, Wirth MA, Rockwood CA. Complications of Total Shoulder 

Arthroplasty. J Bone Joint Surg Am. 2006;88:2279-2292. 

5. Goutallier D, van Driessche S, Le Mou‘l, Puzzo P, Zilber S. 

Transsupraspinatus arthrotomy through an enlarged transacromial approach 

for total shoulder replacement. Orthopaedics & Traumatology: Surgery & 

Research. 2009;95:145-150. 




5. The axillary nerve is at risk inferiorly if care is not taken 

during inferior capsulotomy and capsular release. 

6. Inability to use the exposure with resurfacing procedures 

where external rotation is limited by the intact subscapularis 

tendon. 

6. Qureshi S, Hsiao A, Klug RA, Lee E, Braman J, Flatow EL. Subscapularis 

function after total shoulder replacement: Results with lesser tuberosity 

osteotomy. J Shoulder Elbow Surg. 2008;17: 68-72. 

7. Edwards TB, Boulahia A, Kempf JF, Boileau P, Nemoz C, Walsh G. The 

influence of rotator cuff disease on the results of shoulder arthroplasty for 

primary osteoarthritis: results of a multicentre study. J Bone Joint Surg Am. 

2002;84:2240-2248. 

8. Lafosse L, Schnaser E, Haag M, Gobezie R. Primary total shoulder 

arthroplasty performed entirely thru the rotator interval: Technique and 

minimum two-year outcomes. J Shoulder Elbow Surg. 2009;18:864-873. 

9. Picard F, Saragaglia D, Montbarbon E, Tourne Y, Thony F, Charbel A. 

Anatomo-clinical effect of subscapular muscle vertical section in Latarjet 

procedure. Revue de chirurgie orthopedique 1998;84:217-23. 

10. Scheibel M, Habermeyer P. Subscapularis dysfunction following anterior 

surgical approaches to the shoulder. J Shoulder Elbow Surg 2008;17:671-683

374 

u CerviCal SpiNe trauma: 

CurreNt CoNCeptS (g) 



SympoSia SpiNE 

Moderator: Rick C. Sasso, MD, Indianapolis, IN 

Learn the initial assessment, imaging, and clearing of cervical trauma; closed reduction techniques and OC trauma including 

odontoid and Hangman fractures, subaxial injuries including UID, BID, and burst: and finally difficulty with CervicoThoracic 

trauma. 


Rick C. Sasso, MD, Indianapolis, IN 

II. Assessment and clearing of the cervical spine 

Mitchel B. Harris, MD, Boston, MA 

III. Occipitocervical injuries including Odontoid fractures 

Rick C. Sasso, MD, Indianapolis, IN 

IV. Subaxial unjuries including timing of closed reduction 

Alexander Vaccaro, MD, Philadelphia, PA 

V. CervicoThoracic injuries 

Jens R. Chapman, MD, Seattle, WA 

VI. Case presentations / discussions and debate with audience participation 

All Faculty

375 

oCCipitoCerviCal iNJurieS iNCludiNg odoNtoid FraCtureS 

Rick C. Sasso, MD 

Trauma occurring at the OC junction is more frequent due to 

successful in-field resuscitation and transport; potentially devastating 

due to the high rate of missing these injuries during the initial 

evaluation because of imaging difficulties and causing additional 

damage to the brainstem and upper spinal cord; and complex to 

stabilize due to the unique anatomy of the occiput and atlantoaxial 

vertebrae. 

Anatomy 

The intricate interconnecting array of anterior ligaments requires 

the occipitocervical junction (occiput, C1, and C2) to be regarded 

as a unit. The strong paired alar ligaments attach the tip of the 

odontoid to the occipital condyles, while the tectorial membrane (a 

continuation of the posterior longitudinal ligament) connects the 

odontoid to the foramen magnum. The transverse atlantal ligament 

is a posterior odontoid sling attaching to the lateral masses of the 

atlas, preventing anterior dislocation of C1 on C2. 

The C1-C2 articulation is a very unique, flat joint that allows great 

rotation. An average range of motion of 47° is present to each side. 

This represents approximately 50% of the axial rotation of the entire 

cervical spine. The internal anatomy of the axis is important to the 

understanding of fracture and internal fixation mechanics. Very 

dense, thick trabecular bone is present in the center of the tip of 

the dens, and cortical bone at the anterior base of the body of C2 

(where the anterior longitudinal ligament attaches) is uniformly 

thick. High-density trabecular bone is also present in the lateral 

masses beneath the superior facets. Hypodense bone, however, is 

consistently present beneath the odontoid at the upper portion of 

the body of C2. Anterior odontoid screws obtain strong fixation at 

their entrance site (the anterior-inferior aspect of the C2 body) and 

exit site (the tip of the dens); however the screws traverse very weak 

hypodense bone in the body of C2. 

The quantitative aspects of the axis have also been well described. 

The most variable dimension is dens angle in the sagittal plane, 

which ranges from -2° (leaning slightly anterior) to 42° (leaning 

posterior). This may make the assessment of fracture reduction 

very challenging. There is also considerable variability in all dens 

dimensions, which have a poor predictive value for body size in 

estimating the size of the odontoid. The diameter of the odontoid 

process in a significant percentage of people is less than 6mm, which 

is not sufficient to accommodate the passage of two 3.5mm screws. 

Another structure of the axis with significant variability is the 

vertebral artery groove. This is in the anterior, inferior surface of the 

C2 pars interarticularis. Because the C2 body is relatively narrow, the 

vertebral artery is more medial than in the subaxial spine. The artery 

travels in an almost transverse direction into the transverse foramen 

of the atlas, crossing immediately in front of the C2-C3 facet joint. 

Anomalous position of the vertebral artery is found on at least one 

side in 20% of patients. A high riding transverse foramen is of great 

concern if transarticular C1-C2 screw fixation is considered. Before 

this technique of atlantoaxial fixation is performed, spiral computed 

tomography (CT) scanning with sagittal reconstructions is useful to 

look for this vascular anomaly. More recently, safer techniques have 

been developed with the advent of universal polyaxial-screw/rod 

instrumentation which allows segmental fixation into the occiput 

(with occipital screws and now possibly occipital condyle screws), 

C1 (with lateral mass screws), and C2 (with pedicle and laminar 

screws) which significantly decrease risk to the vertebral artery. 




Instrumentation 

Instrumentation of junctional injuries of the cervical spine has 

been limited historically by failure to achieve rigid internal fixation 

in multiple planes. The evolution of these techniques has required 

increased insight into the morphology and unique biomechanics of 

the occipitocervical junction. Systems initially based on onlay bone 

graft combined with wiring techniques have evolved to include 

systems incorporating rigid, longitudinal rods that accommodate 

multiplanar screws placed in the lateral masses, pedicles, transarticular 

regions, and occipital bone. 

Managing traumatic injuries at the OC junction is burdened by the 

fact that these are usually very unstable fractures in a region where 

an extremely mobile cervical spine transitions into a very rigid 

occiput. Because of this instability, these junctional injuries have 

a high incidence of significant and devastating spinal cord injury. 

The occipitocervical junction is a challenge to approach from the 

front and due to unique anatomy, is difficult to stabilize with 

standard anterior instrumentation. The “workhorse” approach for 

stabilization of these junctional injuries is thus via a posterior route. 

Providing a means for stabilizing junctional regions with posterior 

instrumentation has traditionally been extremely challenging 

because of the very unique and diverse anatomy available for 

instrumentation at the occipitocervical junction. Advancements in 

the technology of posterior constructs have provided for an increase 

in stability and allowed for surgical treatment of more complex 

craniocervical pathology. Such techniques have the added benefit of 

less cumbersome postoperative immobilization. Initial onlay fusion 

and simple wire techniques required periods of traction and longterm 

bed rest followed by a halo. Rod and wire constructs were more 

stable but continued to have difficulty controlling axial loads due 

to the rods pistoning through the sublaminar wires. Hook and rod 

constructs were fraught with complications of the sublaminar hook 

within the cervical spinal canal. Plate and screw constructs were the 

first truly stable types of fixation but depended on fixed hole-hole 

distances in the plate, which made proper insertion of the screws 

difficult. These devices also failed to have a rigid connection of the 

screw to the plate. Modern screw-rod devices allow independent 

insertion of the screw anchors as well as stable connection to the 

longitudinal rod. 

Occipitocervical Fusion 

The occipitocervical junction represents a complex interaction 

between the cranium and the upper cervical spine. A significant 

amount of motion in the sagittal and axial planes occurs in this 

region. Instrumentation constructs must resist such forces as well as 

the lever arm that is created by the angle of the suboccipital bone and 

the cervical spine. These systems must also accommodate adjustments 

that allow a surgeon to achieve an appropriate occipitocervical 

neutral position. Therefore, a system must be flexible with regard 

to application, but rigid once it is applied. For the reasons detailed 

above, occipitocervical instability secondary to trauma presented a 

major challenge to surgeons in the early half of the 20th century. 

Foerster described one of the first techniques of occipitocervical 

fusion in 1927. Since that time, techniques have included onlay 

bone graft with halo immobilization, wire fixation, pin fixation, 

hook constructs, metallic loops, rectangles fixed to bone with wires 

and screws, and plate/rod constructs with screws. Many of the most 

recent techniques borrow heavily from initial experiences with rod 

and plating systems combined with screws. The ultimate goal of all 

of these systems is to achieve fusion; however, the techniques were

modified to provide ease of application and internal rigidity during 

the time that fusion is occurring. Onlay bone graft may be performed 

with or without wiring. This technique has the advantage of being 

simple and relying on minimal use of internal instrumentation. 

High fusion rates have been reported; however, immediate stability 

is not the hallmark of these techniques. Patients require some form 

of external immobilization by means of tongs, Minerva jacket, or 

halo orthosis until a solid fusion is achieved. This may take 12 weeks. 

Many bone graft sources have been used, including fibula, tibia, and 

iliac crest. In a series of nine patients, Hamblen described occiput to 

cervical fusion with varying caudal fusion levels and several different 

types of autograft sources. Wire fixation was used in these techniques 

and patients were fitted in Minerva plaster jackets after surgery for 4 

to 6 weeks. Following removal of the plaster jacket, patients wore a 

rigid cervical collar for and additional 3 to 6 months. 

Jain et al described a technique in which occipitoaxis posterior wiring 

was used for patients with atlantoaxial dislocation. The technique 

was based on a “bone bridge” along the posterior margin of the 

foramen magnum which created an “artificial atlas.” Conventional 

fusion with wiring was performed between the artificial atlas and 

the C2 lamina using an interposed bone strut graft. The Locksley 

technique combined wire-bone and wire-plate constructs to achieve 

a stable three-point internal fixation. This technique uses bilateral 

rib autograft struts attached to twisted wires in the suboccipital 

bone, which have passed through drill holes adjacent to a keyhole 

craniectomy. Ribs are secured by sublaminar wires and supplemental 

internal fixation is achieved with a T-plate. 

An inverted hook technique as described by Faure et al involves the 

insertion of inverted hooks through a burr hole in the occipital bone 

attached to hooks placed in caudal laminae. The laminar hooks 

create a “clamp” construct that is attached by contoured rods to the 

occipital construct. A similar technique was described by Paquis et 

al in which occipital and interlaminar claws are used. Prebent rods 

are secured to the spine with hooks that are then tightened and 

positioned to create claw constructs. 

Sonntag and Dickman have described a rod-wire technique for 

occipitocervical fusion in which a contoured 5/32-inch threaded 

Steinmann pin is used in a U shape such that the closed end of the 

U rests against the suboccipital bone. Wires interact with the threads 

on the rod to provide some resistance to migration of the construct. 

Wires are passed below the laminae bilaterally over all segments. 

Wires secure the cranium to the U-shaped rod via burr holes. A high 

rate of fusion with postoperative halo immobilization has been 

reported with this technique. 

Other rod-wire techniques include the Ohio Medical Instruments 

loop with lateral mass linkages, the Hartshill-Ransford loop, customformed 

Luque rods, and other combinations. 

Pin and wire fixation has been described as a successful method 

of internal fixation in patients with upper cervical spine instability 

secondary to cancer metastasis. This method relies on a pin that 

is passed through the external occipital protuberance, the ends of 

which are used as points of fixation for the attachment of rods or 

wires that secure the cervical spine to the occiput. 

Screw-plate techniques have been well described in the literature and 

have many supporting proponents and systems. Such techniques 

include the use of AO plates and inverted Y-shaped plates secured to 

C1–C2 with transarticular screws and to the suboccipital bone with 

paramedian screws. The suboccipital bone has varying thickness, 

and screw selection in this region is important to the technique to 

avoid injury to cerebellar structures. Modification of this technique 

may include use of lateral mass screws below C1–C2 to include 

additional caudal levels in the construct. The “inside-outside” 

376 




technique of Pait et al combines lateral mass plating with a bolt 

construct in the occiput oriented from the epidural space outward; 

this technique does not rely on posterior elements for fixation. Vale 

et al have also described a device consisting of a plate secured to the 

C1–C2 junction with transarticular screws and to the occiput with 

bone screws. High rates of fusion with long-term excellent functional 

results have been reported with many of these techniques. 

The screw-plate constructs were the first rigid forms of occipitocervical 

fixation that did not require postoperative halo immobilization. 

The fundamental problems of posterior cervical plates are: 

1. Fixed hole-hole distance with difficulty placing anchors (screws) 

along the length of the plate when it spans multiple segments; 

2. Limited ability to direct screws divergent from the screw holes 

especially when screws are placed into different structures (lateral 

mass, pedicle, occiput) along the same plate; 

3. Nonrigid connections between the screws and longitudinal 

member (plate); 

4. Lack of adequate space for bone graft over the facet joints after 

the plate is screwed down onto the dorsal surface of the lateral 

mass; 

5. Inability to capture an anchor that is medial or lateral to the 

longitudinal member (the screw has to go through the plate 

hole); 

6. Requirement of removing and replacing the screw if a plate 

change occurs; 

7. Inability to compress or distract the screws relative to each other 

once they have been placed. 

The ideal posterior screw-based stabilization device allows the screw 

to be driven into the perfect position at the proper trajectory and 

then not removed as the longitudinal member is attached. To date, 

this can only be accomplished with a rod-based system. 

Many screw-rod systems are available for occipitocervical spine 

fixation. In general, these systems are used for their flexibility with 

regard to correcting/accommodating deformity, their ability to 

achieve immediate rigid internal fixation, and their high rates of 

fusion. Rods may be contoured to the multiple points of cervical 

fixation, including lateral mass screws, screws inserted via the Magerl 

transarticular C1–C2 technique, screws inserted into the C2 pedicle, 

pars, or laminae, and screws inserted into the lateral masses of C1. 

The multiplicity of techniques for instrumentation of C2 result from 

the risks associated with transarticular screw placement. Specifically, 

C2 laminar screws have been suggested as a safe and effective way 

to instrument this segment with little risk to neurologic or vascular 

elements. 

Systems generally vary with regard to their method of fixation to the 

occiput. A modified rod that attaches to the cranium via a plate, or 

a custom plate attached to the occiput which connects to a rod, are 

options. The strength of the occipital fixation can be compromised 

as plates constrain the ability to place occipital screws along the 

midline, which has been shown to be the thickest and strongest 

part of the occiput. Also, hole spacing often makes placement of 

cervical screws difficult. Plates designed for midline occipital screw 

placement only allow for fixation in one plane with only two or three 

screws. These plates are potentially weak in torsion since the points 

of fixation are parallel to the axis of rotation. Many occipital fixation 

systems have limitations with regard to prominence in the midline 

of the occiput, which may contribute to wound healing problems. 

New independent occipital plate designs have addressed these issues 

by allowing for both midline and lateral screw placement while

maintaining a low profile. 

The most versatile method of occipital screw fixation uses bilateral 

contoured rods with medial offset connectors that allow placement 

of six occipital screws in the thickest and strongest bone along the 

midline, while easily connecting to screws in the cervical spine. 

Bilateral rods with medial offset connectors allow parasagittal 

placement of six bicortical screws in the thickest and strongest bone 

along the occipital midline. (Figures a, b, c, d, e, f) 

The use of six occipital screws has been shown to be biomechanically 

advantageous. The paramedian orientation may help resist torsion 

as all of the screws are not parallel to the torsional axis of rotation. 

Optimal screw placement in the cervical spine is promoted as the 

rod contouring accommodates connection to the cervical screws. 

Figure a 

Figure b 

In addition to the many techniques described herein, a C1–occipital 

condyle screw technique exists as described by Gonzalez et al. This 

technique relies on fluoroscopically guided placement of a guidewire 

across the O–C1 joint with subsequent placement of a screw across 

the joint. Correct placement of this screw assumes proper entry 

377 




point at the midpoint of the posterior aspect of the lateral mass 

of C1 and appropriate direction of the guide wire and subsequent 

screw approximately 10¡ to 20¡ medial and toward the middle aspect 

of the occipital condyle from the entry point. 

Dvorak et al recently described a case report of anterior screw 

fixation of the axis to the occiput. This technically demanding 

technique is suggested as an alternative to posterior techniques 

when such techniques are not technically feasible or have already 

failed. A biomechanical study of this technique was also undertaken 

to evaluate the stability of this technique in comparison to the more 

traditional posterior techniques. They concluded that the anterior 

screw fixation technique was as effective as a posterior plate with 

transarticular screws in stabilizing between the occiput and C2 in 

axial rotation and lateral bending. In extension and flexion, the 

anterior screw technique was not as effective as a posterior plate with 

transarticular screws in providing stability. 

Several biomechanical studies have contributed to the understanding 

and evolution of fusion techniques in the occipitocervical region of 

the spine. While all techniques have the possibility of mechanical 

failure in the face of pseudarthrosis, most techniques provide timedependent 

stability in many planes of movement. Methods noted 

to be most stable are those that involve screw fixation in shorter 

segments. This has been verified in studies in which lateral mass 

screws were compared with sublaminar fixation techniques in 

patients with rheumatoid arthritis. Another study concluded that 

occipitocervical stabilization with C1–C2 transarticular screws or C2 

pedicle screws was biomechanically advantageous to stabilization 

that is dependent on hook or wire constructs. 

As internal fixation techniques have evolved, so too have the 

options for bone grafting and fusion techniques. The traditional 

corticocancellous onlay graft or rib autograft techniques that were 

used with early wire constructs are slowly being replaced with 

modified central cancellous autograft techniques combined with 

facet grafting in a well-prepared graft bed. Such techniques have 

not been thoroughly investigated, likely secondary to the rapid 

expansion of instrumentation techniques in the recent past. 

The rapid evolution of instrumentation technologies combined 

with advances in imaging techniques have created an environment 

in which surgeons have a variety of tools to apply to pathology in 

the cervical spine. Whatever the chosen technique of fusion for 

treatment of this pathology in junctional regions, the primary goals 

are similar: achievement of stable internal fixation, accommodation 

of appropriate graft material, restoration of acceptable anatomic 

position, and decompression of neural elements. Many of the 

recent technologies in posterior cervical spinal systems allow for 

low profile, rigid instrumentation of complex disease processes. 

Such techniques and their modifications require appropriate 

training before implementation as they also have the potential for 

significant morbidity. Despite a rapid evolution of techniques and 

instrumentation technologies, it remains incumbent on the physician 

to provide the patient with a surgical procedure that balances the 

likelihood of a favorable outcome with the risk inherent in the 

implementation of the procedure. 

ODONTOID FRACTURE 

Epidemiology 

Odontoid fractures are a relatively common upper cervical spine 

injury, comprising nearly 60% of all fractures of the axis, and 10- 

18% of all cervical spine fractures. In the upper cervical spine 

there is a proportionally greater space available for the cord than 

in the lower cervical spine. Therefore, the incidence of neurologic 

involvement is relatively low (18-26%). Furthermore, if significant

cord damage occurs, patients are frequently dead on arrival due to 

respiratory arrest. 

Although odontoid fractures occur in all age groups, the mean age is 

approximately 47 years with a bimodal distribution. In the younger 

patients, these fractures are usually secondary to high energy trauma; 

motor vehicle accidents (MVA) are responsible for the majority of 

the injuries. Concomitant spinal injuries are present in up to 34%, 

of which 85% occur in the cervical spine with the atlas being most 

common. 

The second peak in the incidence of odontoid fractures is in the 

elderly. In fact, they are the most common cervical spine fracture 

in patients older than 70 years. These fractures, unlike those in the 

younger patients, tend to be the result of low energy injuries such 

as falls from a standing height. The mechanism of injury is often 

hyperextension resulting in posterior displacement of the odontoid. 

Associated spinal trauma is much less common. 


The classification system of Anderson and D’Alonzo has withstood 

the test of time because it is anatomically simple, reliably predictive 

of outcome, and able to direct treatment. 

Described in 1974, they divided fractures into three types based upon 

the anatomic location. Type I is an oblique avulsion fracture from 

the tip of the odontoid above the transverse ligament, attached to the 

alar ligament. This fracture is clinically rare accounting for 1% to 5% 

of odontoid fractures and may be associated with occipitoatlantal 

dislocation. Type II fractures occur through the neck of the odontoid. 

They are the most common type of odontoid fracture (38-80%). Type 

III fractures extend into the body of C2. They comprise 15% to 40% 

of all odontoid fractures. Hadley et al. proposed an additional type 

IIA subtype, defined as a type II fracture with marked comminution 

at the base. For this subtype, they recommended early operative 

management, due to inherent instability and failure of external 

immobilization to maintain alignment. 

Treatment 

Definitive treatment of odontoid fractures is determined by multiple 

factors, including fracture type, presence of associated injuries, 

patient age, and patient co-morbidities. Type I injuries, which have 

an intact TAL attached to the remaining odontoid process, are stable. 

These may be managed with simple cervical collar immobilization 

until comfort and stability are documented. Although this has been 

described as a stable odontoid fracture, this avulsion fracture can 

be seen in association with occipitoatlantal dislocation and these 

patients must be carefully evaluated for this injury. 

Type III injuries are generally regarded to heal uneventfully with 

nonoperative management due to the large cancellous fracture 

surface. If closed reduction can be achieved, immobilization in a 

halo vest for 12 weeks is highly successful with a 96% chance of 

union. However, if the fracture is closer to the neck of the odontoid 

(high and shallow based), the fracture may act like a type II fracture 

with an increased incidence of nonunion. 

The proper management of type II fractures remains highly 

controversial. These fractures have a poor prognosis treated 

nonoperatively with a nonunion rate of 35% to 85%. Some studies 

suggest this high rate of nonunion is secondary to the disruption 

of the odontoid process vascular supply. Other investigators have 

demonstrated adequate blood flow from both above and below the 

odontoid process base, leading them to conclude that inadequate 

immobilization is the primary cause of this problem. Proposed 

predictors of type II nonunion include the following: initial 

displacement greater than 6 mm (with several studies finding it 

378 




to be the most important single factor in determining the success 

of nonsurgical management), posterior displacement, age over 40 

years, delay in diagnosis greater than three weeks, and angulation 

greater than 10 degrees. This poor healing rate--even with halo vest 

immobilization--has led to significant controversy over treatment 

methods. 

Because of this high nonunion rate, some investigators have 

recommended primary internal fixation for selected type II and 

shallow type III odontoid fractures (primarily those with significant 

initial displacement), and most subtype IIAs. Improved fracture 

healing rates with early surgical management in specific patients could 

theoretically decrease the uncommon but very real complication of 

late-onset progressive myelopathy secondary to odontoid nonunion. 

This can also help avoid significant halo related complications such 

as pin site infections, pulmonary compromise, brain abscesses, skin 

breakdown, facet joint stiffness, and loss of alignment. Additionally, 

others have advocated primary surgical treatment over halo 

immobilization as a means to significantly decrease in-hospital 

mortality and avoid potential adverse affects in elderly patients with 

type II fractures. Surgical indications include initial displacement of 

greater than 6 mm, neurologic deficit, patients with polytrauma or 

on a ventilator, failure after three months in a halo or the inability to 

tolerate a halo. Present surgical options include posterior atlantoaxial 

arthrodesis and direct anterior odontoid internal fixation. 

Traditional forms of atlantoaxial arthrodesis include Gallie 

(sublaminar C1 wire and intra-spinous C2) and Brooks (additional 

sublaminar wiring of C2) type wirings using autogenous iliac 

bone graft. Reported fusion rates have been as high as 95%, but 

most authors describe the use of supplementary postoperative 

halo immobilization. The advantage of the Brooks technique is 

increased rotational stability, but with increased neurologic risk. 

Flexible cables have increased the ease of sublaminar wire passage 

and thus may decrease the rate of iatrogenic neurologic deficit from 

wire passage, which has been reported as 5%. Wiring techniques rely 

upon the integrity of the posterior arch of the atlas and intraoperative 

reduction is sometimes lost during the healing period. Especially 

prone to failure are posterior displaced odontoid fractures treated 

with a Gallie type technique. 

Posterior C1-C2 transarticular screw fixation has been recommended 

due to biomechanical advantages over posterior wirings, avoidance 

of fusion extension to the occiput in the relatively common event of 

concomitant C1 posterior arch insufficiency/fracture, and the ability 

to avoid postoperative halo immobilization. In 1987, Magerl and 

Seemann described a technique of atlantoaxial screw fixation that 

involves the placement of bilateral transarticular screws through a 

posterior approach. Transarticular screws allow stable fixation of 

C1 and C2 in the reduced position even in cases of absence of the 

posterior arch of the atlas. Minimal postoperative immobilization is 

required even in the presence of gross instability. Grob et al. compared 

the Gallie, Brooks, Magerl, and Halifax systems in reestablishing 

stability to the C1-C2 segment. Although all procedures decreased 

motion in the segment, the Gallie technique was least effective in 

limiting motion of the C1-C2 articulation and allowed significantly 

more rotation than the other fixation techniques. The Magerl 

transarticular screw technique was most effective in limiting motion. 

In other studies, the Magerl technique was more stable in rotation, 

shear, and translation. 

The increased stability of the transarticular C1-C2 screw fixation 

demonstrated in biomechanical studies is attributed to the twoscrew 

fixation construct, which prevents rotational, lateral, and 

sagittal movements of C1 on C2. The transarticular screws are 10 

fold stiffer in rotation than is C1-C2 conventional wiring. In a series

of 161 patients undergoing transarticular screw fixation, no instances 

of vertebral artery or spinal cord injury occurred, and only 6% of 

the patients had complications from the screws. The pseudarthrosis 

rate was less than 1%. This technique requires detailed knowledge of 

the surgical anatomy and is technically demanding. With a superior 

biomechanical profile, there is an inherent risk of neurovascular 

injury. Due to vertebral artery anomalies, this technique may not be 

possible in up to 20% of attempts. In one recent survey, the risk of 

vertebral artery injury with this method was 4%, although the risk of 

subsequent neurologic deficit after vascular injury was only 0.2%. 

Although the success rate of posterior C1-C2 fusion is very high, 

this “success” results in significant loss of axial rotation (50%). 

Especially in a young person, this may be quite debilitating. The 

loss of neck motion, as a result of these surgical procedures, led to 

the development of direct methods of internal fixation for odontoid 

fractures. The rationale for direct anterior fixation is the preservation 

of C1-C2 rotation while providing rigid internal fixation and 

avoiding restrictive bracing and the complications associated with 

bone grafting techniques. 

Direct anterior osteosynthesis of the odontoid fracture with 

anterior odontoid screw fixation is an alternative to atlantoaxial 

arthrodesis for management of odontoid fractures that are at risk 

for nonunion which avoids halo immobilization. This technique 

has been demonstrated to achieve a high fusion rate similar to 

posterior atlantoaxial arthrodesis (92-100%), with a similarly low 

complication rate. This high fusion rate has not been found to be 

dependent upon the number of screws used. A theoretical advantage 

of this technique over posterior methods is the preservation of 

atlantoaxial motion. Anterior screw stabilization of the odontoid 

allows preservation of axial rotation. 

Anatomic reduction of the odontoid fracture is imperative before 

attempting this technique and inability to achieve reduction is an 

absolute contraindication. Relative contraindications to anterior screw 

fixation include transverse atlantal ligament disruption, nonunion, 

and an oblique fracture in an anteroinferior to posterosuperior 

plane which could cause the odontoid fragment to shear anteriorly 

at the fracture site during lag compression. This shearing could cause 

iatrogenic translation of C1 anterior on C2. 

Odontoid screw fixation provides a reasonable approach to odontoid 

fractures with a concomitant C1 Jefferson burst fracture and especially 

in multiple trauma patients, in whom immediate mobilization has 

proven beneficial. It can also be used in patients who refuse halo 

treatment and in whom fracture reduction can be obtained but not 

maintained. Caution should be used in osteopenic patients. 

Odontoid screw fixation is a technically demanding procedure that 

requires thorough preoperative planning and adequate surgical 

training. The entry point is critical at the anterior margin of the 

inferior endplate. If started more cephalad, the angle of inclination 

for fracture fixation cannot be achieved and anterior gapping of the 

fracture is a common result. Also, poor proximal fragment purchase 

with subsequent screw cut-out may occur as previously discussed. It 

is important to engage the far cortex of the odontoid tip to ensure 

adequate purchase and it is mandatory to lag the fracture fragments 

either through screw design or by creating a gliding hole through the 

body fragment. AP and lateral fluoroscopy is essential for constant 

monitoring during all stages of this procedure. 

Overall, the literature has established this technique as an efficacious 

treatment of odontoid fractures. Complications and their incidence 

reported in clinical series as a result of direct anterior odontoid 

screw fixation include the following: screw malposition, 2%; screw 

breakout, 1.5%; neurologic or vascular injury, 0%. The series has 

an aggregate fusion rate of 94.5%. Controversy, however, does exist 

379 




regarding selection of patients, whether or not to use the technique 

in nonunions, and whether one or two screws should be applied. 

The placement of two screws is technically more difficult, often not 

anatomically possible, and offers no biomechanical advantage, as 

compared to one-screw fixation. Sasso et al. compared the use of 

one or two screws for stabilization of the odontoid. Mechanically 

produced type II odontoid fractures were stabilized with either 

one or two 3.5 mm screws. After internal fixation, the stability was 

restored to one half that of the unfractured odontoid. The use of 

two screws did not significantly enhance the stability in testing to 

re-failure. Graziano et al. also found no difference between one and 

two screws in bending and torsional stiffness of the instrumented 

odontoid. 

Traditionally, the first-line treatment of type II odontoid fractures 

after prompt closed reduction has been halo-vest immobilization 

for 3 months with the knowledge that a significant percentage will 

require subsequent surgery for established nonunion. Since the 

results of delayed posterior C1-C2 fusion is as good as primary 

atlantoaxial arthrodesis, this initial non-operative plan has been 

reasonable. With increased clinical and basic science literature on 

anterior odontoid screw fixation, its role in our traditional treatment 

plan is uncertain because it is not a reliable procedure in the setting 

of a nonunion. Thus, if initial non-operative treatment is chosen and 

it fails, then C1-C2 arthrodesis is the only viable surgical option with 

concomitant decreased range of motion. 

HANGMAN’S FRACTURE 

Epidemiology 

The eponym “hangman’s fracture” was coined by Schneider in 

1965, describing traumatic axis injuries which bore a radiographic 

resemblance to those produced by judicial hanging. Despite 

this similarity, their mechanism of injury is different. Traumatic 

spondylolisthesis is the second most common fracture of the axis, 

representing approximately 25% of C2 injuries. Because the bilateral 

C2 pars interarticularis fractures of this injury (the anatomically 

“true” C2 pedicle lies more anteriorly) tend to produce an acute 

decompression of the neural canal, neurologic involvement is seen 

in only 6-10% of surviving patients. 

As with odontoid fractures, associated spinal injuries are seen 

in up to 31% of hangman’s fractures, of which 94% occur in the 

upper three cervical vertebrae. The mean patient age with this 

injury is approximately 38 years, and the most common cause is 

motor vehicle accidents. The majority of these injuries are due to 

hyperextension-axial compression forces, such as when the face 

impacts upon the windshield in an MVA. These biomechanical forces 

produce the characteristic fracture patterns due to the fact that the 

pars interarticularis is the thinnest portion of the axis ring, as well as 

the unique transitional anatomy of the axis, bridging the upper and 

lower cervical spine. 


Several classification schemes of traumatic spondylolisthesis of the 

axis have been proposed. Currently, the most widely used system in 

the literature is that of Levine and Edwards, a modified version of 

Effendi’s initial classification method. This system is based upon the 

amount of translation and angulation of C2 on C3, as demonstrated 

on lateral radiographs. Type I injuries, comprising approximately 

70% of all traumatic spondylolisthesis of the axis, are those with 

bilateral fractures through the base of the pars interarticularis, but 

without angulation and less than 3 mm displacement. The injury 

force is not sufficient to damage the C2-C3 intervertebral disc or 

longitudinal ligaments, thus retaining translational and angulatory 

stability.

Type II injuries (27% of total) are those in which there is greater 

than 3 mm displacement of C2 on C3 and are thought to occur 

when the usual hyperextension-axial compression is followed by 

a rebound flexion force, as seen in deceleration/acceleration forces 

in MVAs. This produces disruption of the C2-C3 disk and partial 

tearing of the posterior longitudinal ligament. Type IIA injuries (5% 

of total) have minimal translational displacement, but significant 

angulation of the C2 body. This particular injury pattern is thought 

to involve a unique flexion-distraction mechanism of injury. This is 

of importance, as the application of traction in this injury subset can 

result in an increased deformity and distraction when an attempt is 

made to reduce the fracture. 

The rare type III injury represents a unilateral or bilateral facet 

dislocation at C2-C3 in addition to the bilateral pars fractures. These 

have been demonstrated to result from a flexion force that creates 

the facet injury and a hyperextension force that produces the typical 

neural arch fracture. This pattern is associated with a substantially 

higher mortality rate and incidence of neurologic injury. 

Starr and Eismont have described an atypical hangman’s fracture that 

extends into the C2 vertebral body so that a portion of the body is 

attached to the pedicle and posterior elements. The spinal canal may 

be compromised and the incidence of spinal cord injury is higher. 

Treatment 

As noted previously, these fractures have a significant rate of 

associated cervical spinal injuries, which impacts management 

decisions. Careful initial evaluation is required to make appropriate 

treatment recommendations. 

Type I, nondisplaced, hangman’s fractures are stable. Simple cervical 

collar immobilization for 8 to 12 weeks is recommended. 

Type II injuries have traditionally been treated with traction 

reduction, followed by halo vest immobilization for 10-12 weeks. 

Excellent outcomes and fusion rates up to 95% have been reported. 

The exception to this treatment approach is the type IIA injury, 

where initial traction is to be avoided, as discussed previously. In 

these instances, some have advocated a controlled reduction under 

fluoroscopy to determine the best position to maintain alignment, 

followed by halo vest application. 

More recently, several reviews have reported the successful treatment 

of type I and II injuries with cervical collar immobilization for 

8-12 weeks. In one study, type II injuries with greater than 6 mm 

of displacement were treated in halo vests, while those with less 

displacement were placed in cervical collar immobilization. All 

patients ultimately went on to bony union. Although the majority 

of displaced fractures healed with some residual malalignment, 

this did not affect functional outcomes. Rare treatment failures 

attributed to nonunion or painful posttraumatic facet arthropathy 

can be managed with an instrumented anterior C2-C3 arthrodesis or 

posterior cervical fusion. 

The treatment of Type III injuries is controversial. Closed reduction 

attempts of the unilateral or bilateral facet dislocation are unlikely to 

be successful and posterior open reduction is usually required. After 

reduction is obtained, stability may be maintained with a halo vest, or 

a multilevel C1-C3 posterior fusion. To avoid adding the atlantoaxial 

joint to the fusion, direct pars repair with lag screws to stabilize the 

reduced pars interarticularis fractures can be accomplished with the 

screws passing across the pars interarticularis into the C2 pedicles. 

These are then connected to C3 lateral mass screws via plates or 

rods. This is an elegant but technically demanding technique that 

should only be performed by fellowship trained spine surgeons with 

extensive experience in complex craniocervical instrumentation. 

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C1 and C2 Instrumentation 

Historically, fixation into C1 has been limited by the inability 

to attach a stable, longitudinal construct to the adjacent motion 

segments. Over the past several years, the introduction of universal 

polyaxial screw/rod instrumentation for the posterior cervical spine 

has enabled the surgeon to individually anchor into C1 and C2; 

providing stability comparable to transarticular screws; versatility 

of incorporating the occiput and the subaxial cervical spine easily 

into the construct; with safer and less difficult screw insertion. There 

has been considerable confusion in the literature regarding screws 

placed into the C2 vertebra from a posterior approach, with the 

distinction between C2 pedicle screws and C2 pars interarticularis 

screws hinging on the anatomic definitions of the true pedicle 

and pars interarticularis. Additionally, the recent advent of the C2 

intralaminar screw has been introduced as a safe, alternative option 

for purchase into the C2 vertebra. A detailed discussed of the current 

trends in posterior atlantoaxial fixation follows. 

There are many fractures and traumatic cervical injuries that 

require posterior C1-C2 fixation. Subluxation of the atlantoaxial 

joint including: transverse atlantal ligament rupture, fixed and 

unstable rotatory subluxation of C1-C2, unstable C1 Jefferson 

burst fracture, unstable odontoid fractures, and occipitocervical 

dislocations are some of the more common injuries requiring C1-C2 

instrumentation. Historically, fixation into C1 has been limited by 

the inability to attach a stable, longitudinal construct to the adjacent 

motion segments. Gallie introduced a posterior wiring technique 

that was supported by a structural bone graft. Since then, numerous 

techniques have been developed including double-looped wiring 

and Halifax clamps. These constructs were fraught with failures, 

with nonunion rates approaching 15% secondary to the failure 

of the posterior, structural bone graft. Then, Magerl designed the 

transarticular screw to be placed from the C2 pars interarticularis 

into the lateral mass of C1. He coupled that with posterior wiring 

between the spinous processes to provide three-point fixation of the 

atlantoaxial joint. 

Transarticular screw fixation provided a major advantage over 

the traditional wire/cable techniques as they are more stable 

biomechanically under both shear and rotational forces. 

Additionally, postoperative halo immobilization is not required, 

and provides extremely high fusion rates without the morbidity of 

halos. Magerl screws, however, do have several disadvantages and 

carry the distinction of being the most dangerous screw that a spine 

surgeon implants. They require surgical acumen and are technically 

demanding. The C1-C2 articulation must be perfectly reduced prior 

to attempting transarticular screw insertion, and it is impossible 

to obtain the steep cranial trajectory in many settings of a fixed 

cervicothoracic kyphosis. The use of biplane fluoroscopy is required 

intraoperatively and preoperative parasagittal CT reconstructions are 

mandatory to assess for a high-riding vertebral artery groove in C2 

which precludes transarticular screw implantation up to 20% of the 

time. 

Over the past several years, the introduction of universal polyaxial 

screw/rod instrumentation for the posterior cervical spine has enabled 

the surgeon to individually anchor into C1 and C2; providing stability 

comparable to transarticular screws; versatility of incorporating the 

occiput and the subaxial cervical spine easily into the construct; with 

safer and less difficult screw insertion. Recently, Melcher et al found 

that screw-rod systems were equivalent to transarticular screw-wiring 

constructs in reducing relative atlantoaxial motion. 

The lateral mass of C1 is a very strong and safe anchor point for 

a screw and may be used to provide additional fixation points in 

occipitocervical constructs, thus increasing resistance to construct

failure in the cervical spine without increasing the number of cervical 

levels fused. 

There has been considerable confusion in the literature regarding 

screws placed into the C2 vertebra from a posterior approach, with 

the distinction between C2 pedicle screws and C2 pars interarticularis 

screws hinging on the anatomic definitions of the true pedicle 

and pars interarticularis. Additionally, the recent advent of the C2 

intralaminar screw has been introduced as a safe, alternative option 

for purchase into the C2 vertebra. 

C1 lateral mass screws 

The atlantoaxial joint is challenging to stabilize because of the unique 

characteristics of the C1 and C2 vertebrae. The anatomical differences 

between C1 and C2 require special strategies as insertion of fixation 

points into these vertebrae are different from the remainder of the 

subaxial cervical spine. The lateral mass of C1 is not analogous to the 

lateral mass of the subaxial vertebrae. The most challenging aspect of 

implanting C1 lateral mass screws is the exposure of the C1 lateral 

mass and C1-C2 joint from a cranial to caudal direction as well as 

mobilization of the C2 nerve root. Proper exposure of the C1 lateral 

mass proceeds in a rostral to caudal direction, opposite from the 

direction most spine surgeons are comfortable proceeding as during 

insertion of transarticular C1-C2 screws. 

Dissection of the posterior arch of C1 lateral to 1.5 cm from the 

midline is performed with caution because the vertebral artery 

runs in a groove on the superior surface of the posterior arch. It is 

typically protected by a thin rim of bone along the superior border 

of this posterior arch. Dissection of the posterior arch is performed 

subperiosteally. The venous plexus surrounding the C2 nerve root 

is cauterized with a bipolar and mobilized caudally. Subperiosteal 

dissection is performed from the inferior aspect of the posterior 

arch of C1, anteriorly down to the lateral mass of C1. The medial 

wall of the lateral mass is identified using a forward angle curette 

to identify the medial aspect of the mass for screw placement. The 

medial aspect of the transverse foramen is identified as the lateral 

limit for screw placement. The entry point for screw placement is 

3-5 mm lateral to the medial wall of the lateral mass, at the junction 

of the lateral mass and inferior aspect of the C1 arch. A high speed 

drill with a 3 mm round burr is used to remove a small portion of 

the inferior aspect of the posterior C1 arch overlying the entry point. 

This “groove” is made to create a recess for the screw head. Removing 

this lip from the inferior aspect of the C1 posterior arch also assists 

in accessing the vertical wall which leads to the lateral mass. Failure 

to create a groove in the posterior arch makes it extremely difficult to 

subperiosteally dissect the venous plexus surrounding the C2 nerve 

from a cephalad to caudal direction. An assistant retracts the C2 

nerve inferiorly and protects it during drilling and screw placement. 

The use of a hemostatic agent such as FloSeal is used in conjunction 

with a thrombin soaked paddie to aid in safely retracting the nerve 

root and to control bleeding. A cervical probe with a diameter equal 

to the inner diameter of the polyaxial screw is used to forage a path 

into the cancellous bone of the C1 lateral mass with 10-15 degrees 

of medial angulation and 10-20 degrees of cephalad angulation. 

It is imperative to maintain a medial trajectory as to avoid the 

vertebral artery that lies lateral; whereas the cephalic tilt is used to 

avoid the C1-2 articulation as well it is important to avoid C2 nerve 

root impingement. Another option for establishing the screw path 

is to use a power drill or hand held drill. The spinal canal is not 

at risk because the starting point for this screw on the lateral mass 

is near the anterior aspect of the canal. Removing the lip of bone 

from the inferior aspect of the posterior arch assists in allowing a 

more horizontal trajectory. If this lip remains, it forces a steeper path 

through the lateral mass. 

381 




The screw head should sit on the inferior aspect of the posterior arch 

of C1 in the trough created with the burr. On lateral fluoroscopic 

imaging the probe is aimed toward the anterior tubercle of C1 

midway between the superior and inferior facets of C1. Secondary 

to the strong screw purchase in the lateral mass, we do not routinely 

obtain bicortical purchase through the anterior cortex of C1. If there 

is concern about the sturdiness of the screw, then a 2.5mm drill can 

perforate the anterior cortex. Care must be taken to avoid the internal 

carotid artery as it lies just lateral to the exit point of this screw. 

C2 Fixation Methods 

As previously discussed, fixation into the C2 vertebrae has undergone 

a significant evolution over the past several years. Secondary to the 

aberrant course of the vertebral artery, nearly 23% of all patients are 

not deemed suitable for transarticular fixation across the C1-2 joint. 

If the vertebral artery is injured, there have been reports of secondary 

medullar infarction, cerebellar infarction and death with aberrant 

placement of screws. 

C2 Pars Interarticularis Screw 

The anatomic description for pars and pedicle screws is often 

inconsistently described. The pars interarticularis, by definition, is the 

portion of the C2 vertebra between the superior and inferior articular 

surfaces. A screw placed in this portion of C2 has often been called a 

pedicle screw, but is more appropriately termed a “pars” screw as it is 

placed in a trajectory similar to that of the C1-C2 transarticular screw. 

The starting point for the C2 pars screw is 3 - 4 mm cephalad and 3 - 4 

mm lateral to the inferomedial aspect of the inferior articular surface 

of C2. The screw follows a steep trajectory, similar to a transarticular 

screw trajectory, however the pars screw does not violated the C1-2 

facet. An appropriately steep trajectory (40 degrees or more) is 

achieved by aligning the shaft of the drill or screwdriver with the tip 

of the T1 spinous process. This trajectory may be achieved by using 

percutaneous stab incisions about 2 cm lateral to the T1 spinous 

process. The screw trajectory is approximately 10 degrees of medial 

angulation. Screw length is typically 16 mm, which will stop short 

of the C1-C2 facet joint. This can be confirmed with sounding the 

screw tract or with lateral fluoroscopic evaluation intraoperatively. 

This short screw also usually stops short of the transverse foramen, 

avoiding injury to the vertebral artery. When possible, a larger (4.0 

mm) diameter screw is used to achieve increased pullout resistance 

since the screw is unicortical. 

C2 Pedicle Screws 

The C2 pedicle is defined as that portion of the C2 vertebra 

connecting the dorsal elements with the vertebral body. This area is 

very narrow, essentially a window, between the vertebral body and 

the pars interarticularis. The trajectory for the C2 pedicle screw is 

quite different from that of the C2 pars screw, with 30 degrees of 

cephalic angulation and 30 degrees of medial angulation. The entry 

point for C2 pedicle screw fixation is in the pars interarticularis, 

lateral to the superior margin of the C2 lamina. This will be about 

3 mm superior and 3 mm lateral to the entry point for the C2 pars 

screw. One can remove a small amount of ligamentum flavum and 

palpate the medial aspect of the pars. The thick medial wall of the 

C2 pars will help redirect the screw if necessary and prevent medial 

wall breakout. The entry point can be adjusted based on palpation of 

the pars as well as the lateral fluoroscopic view if the probe does not 

easily advance. C2 pedicle screws are generally angled with a caudalto-rostral 

inclination, so that the tip is aimed towards the ventral 

C2 body just below the base of the dens. This trajectory (30 degrees 

up angle) allows safe purchase through the pedicle into the C2 

body providing greater resistance to screw pullout. Additionally, the 

trajectory of the C2 pedicle screw will be medial to the C2 transverse 

foramen, therefore allowing for a safety factor during insertion.

C2 Intralaminar Screws 

Because C2 fixation remains technically difficult, recently the C2 

intralaminar technique has been described. The C2 pedicle screw 

placement remains tenuous as cadaveric studies have demonstrated 

an unacceptably high rate of violation of the foramen transversarium. 

For insertion of intralaminar screws into C2, the high-speed burr 

is used to open a small cortical window at the spinous process/ 

lamina junction. The right sided burr hole is for placement of the 

left intralaminar screw. Care must be taken to start the right screw 

on the rostral aspect of the lamina and caudal on the left lamina 

for placement of the right laminar screw. This will ensure adequate 

cancellous space so the screw will not encroach on one another. Then 

with the use of a pedicle probe the contralateral lamina is foraged to 

a depth of 25-30mm. The trajectory is parallel to the dorsal aspect 

of the lamina with a slight dorsal angulation to ensure that any 

variation in the anterior-posterior direction occurs dorsally to avoid 

spinal canal violation. Next, a small ball-tipped probe is used to 

“sound” the screw path to ensure no violations have occurred and to 

verify the length of the screw. Finally, a 4.0mm screw is then placed 

into the screw path, being careful not to fully seat the head onto 

the lamina to allow for proper function of the multiaxial nature of 

the screw. The contralateral screw can then be placed, followed by 

decortication of the lamina on both sides. Rods are then cut to fit and 

inserted between C1 and C2, and posterior structural autograft and 

cables are used as desired. The rods thus connect the C1 lateral mass 

to the ipsilateral C2 screw head (i.e. the contralateral intralaminar 

screw). 

After choosing the preferred method for the C1-2 fixation, the 

arthrodesis can be performed with either sublaminar cable and 

structural grafting or interspinous autograft if the laminae of C1 

and C2 are preserved. Otherwise, lateral arthrodesis is performed by 

carefully decorticating the exposed surfaces of the C1-C2 joints with 

a high-speed drill, and then packing cancellous iliac crest autograft 

into these joints. The rod is then positioned and fixed to the C1 and 

C2 implants. 

Comparison of C2 Pars, Pedicle and Intralaminar Screws 

The fundamental problems with the C2 pars screw is that it is a very 

short screw (14-18 mm) compared to the C2 pedicle screw (30-40 

mm), but is fraught with all the potential complications of vertebral 

artery injury as the C1-C2 transarticular screw. The C2 pedicle screw, 

by definition is positioned into the C2 vertebral body and thus is 

much longer and biomechanically stronger than the pars screw. 

Also, since it angles medially much more than the pars screw, it is 

less likely to damage the vertebral artery. The pedicle screw also starts 

more cephalad than the pars screw and most times this entry point is 

above the vertebral artery as it courses from medial to lateral under 

the inferior articular process of C2. The ability to begin the screw 

more cephalad is an advantage because the higher the screw starts, 

the more likely the vertebral artery has already passed underneath 

the starting point. 

Since the C2 lamina is the largest in the upper cervical spine, the 

use of crossing intralaminar screws may provide for safer fixation 

at this level without concern for the course of the vertebral artery 

which may be aberrant in up to 23% of patients. Additionally, the 

space available for the cord (SAC) is largest at the C2 level, allowing 

for an additional safety factor in case a ventral laminar violation 

occurs. Because the insertion of the intralaminar screws is based 

on visual and tactile feedback, there is no need for intraoperative 

fluoroscopy or image guidance. Several concerns for the intralaminar 

technique include the potential for C2-3 facet violation if too long 

a screw is used as well as potential difficulty in identifying ventral 

canal violation by screw threads via intraoperative or postoperative 

382 




imaging modalities. A recent study compared the biomechanical 

characteristics of C2 intralaminar and pedicle screws in a destabilized, 

odontoidectomy model. They found similar reduction in range of 

motion (ROM) between bilateral C2 pedicle screws, a C2 pedicle 

and a C2 intralaminar screw and bilateral C2 intralaminar screws. 

Complications of Occipito-Cervical Fixation 

Complications during stabilization of the craniovertebral junction 

(CVJ) include those related to: fixation/pseudarthrosis, neurologic 

injuries, craniocervical alignment, screw placement and vascular 

injuries. Occipitocervical fixation (OCF) is indicated for OC 

instability, or atlantoaxial instability where the patient is not a 

candidate for atlantoaxial arthrodesis (AAA) or has failed prior C1- 

C2 fusion attempt. Though technically demanding, OCF can be 

performed safely with an understanding of anatomy, biomechanics 

and potential complications. Familiarity with different techniques 

and implants allow surgeons to adapt to patho-anatomic variability 

while giving the patient the best chance to heal. 

One potential pitfall of OCF is inadequate fixation, potentially 

leading to progressive instability, pseudarthrosis and fixation failure. 

Originally, OCF was attempted with on-lay grafting, often with 

simple wire techniques through the facets, spinous processes, and/or 

sublaminar spaces. These non-rigid constructs maintained a large bed 

for fusion, but added little rotational, lateral bending and axial load 

stability, and required traction and/or post-operative immobilization 

with a Minerva cast or halo. Additionally, addressing more complex 

instabilities was difficult and relatively high failure rates of surgical 

stabilization were seen, as well as significant complications such as 

further cranial settling. Atlantoaxial arthrodesis (AAA) with Gallie, 

Brooks-Jenkins, or interspinous wiring resulted in 3-80% failure 

rates and relatively high pseudarthrosis rates (up to 30% or more). 

Wire passage can be difficult, and has been reported to result in 

iatrogenic neurologic deficits in 5-7%.Flexible cables may decrease 

this rate. Rod and wire constructs improved fixation, but inability 

to stabilize axial loads due to pistoning through sublaminar wires 

led to failure rates up to 30% and to a biomechanical assessment as 

the least stable OCF devices. In contrast, C1-2 transarticular screw 

fixation: markedly increases stability (especially rotational) over 

wiring constructs (up to 10-fold stiffer), eliminates the need for halo 

use postoperatively, and has reported fusion rates of up to 100% for 

bilateral screws and 95% for unilateral transarticular screws. 

Use of contemporary modular systems simplify OCF, minimize 

fixation failure risk by allowing polyaxial screw placement in optimal 

locations, and maintain the ability to easily attach rods with minimal 

contouring. Subsequently, the chance of obtaining rigid fixation and 

using no post-operative halo is significantly enhanced, and these 

constructs are strong, decreasing fixation-related morbidities. Plate 

and screw fixation is similarly biomechanically strong, providing 

90% of the stabilizing effect of an intact OC junction. However, 

optimal plate contour can be difficult and screws must be placed 

through predetermined holes—both disadvantages can increase 

fixation-related complications, especially in cases of bony destruction 

or anatomic variability. Additionally, screws are not locked to the 

plates, so fixation is dynamic (semi-rigid) and potentially less stable 

than newer rigid screw-rod systems. 

Complications from screw placement often relate to injury to deeper 

structures (dura, neurological, vascular). Patient anatomy or choice of 

implant can limit the ability to drill, tap or place screws in optimally 

safe locations, increasing the risk of screw placement complications. 

Examples include some contoured plates, a hyperkyphotic (or 

obese) upper thoracic spine, or bony destruction of the occipital 

plate. The confluence (“torcula”) of the inner table large venous 

sinuses lies behind the EOP, while the transverse venous sinuses are

on the inner skull behind the superior nuchal line. Occipital bone 

may be insufficiently thin for fixation, due to local pathology, or 

if occipital cortex has been taken down for prior attempted fusion 

or decompression. Pre-op CT correlation with external occipital 

anatomy should yield safe fixation points and augmentation with 

wire/cable fixation may be necessary. Low placement of occipital 

screws, as may occur if too close to the foramen magnum, can 

be difficult due to a steep drill angle, or in patients with kyphotic 

thoracic spines (or obesity, short necks). Positioning closer to the 

superior nuchal line may help, particularly in cases of significant 

occiput resection/destruction or a hyperkyphotic thoracic spine. If 

required, screws can be placed above the superior nuchal line with 

care to avoid the torcula or the transverse venous sinuses. If they are 

encountered, bone wax or an absorbable hemostat can be placed, 

followed by screw placement. Do not attempt repair, which can be 

fraught with complications. If CSF is encountered during drilling, 

tapping or screw placement, bone wax can be placed followed 

expediently by a screw. 

Occipital screw purchase is critical to construct stability. During 

placement, the far cortex must be drilled and tapped through the 

entire cortex. If not, blunt screw ends and tight thread design can 

result in thread/bone stripping in the hard inner cortex, leading to 

palpably poor purchase. High speed drilling should occur in 2 mm 

incremental increases to ascertain screw length, followed by tapping 

at or just slightly longer than that length. Additionally, occipital 

screws should be placed last, since their location will dictated by the 

spinal implant being used, availability of occipital bone, and location 

of screws placed more caudally. Place the C2 (or transarticular) screw 

first, followed by lateral mass C1 screws. Contour the rod (or plate) 

early, critically evaluating craniocervical angle and close proximity 

of caudal screw heads. Incomplete C1-2 reduction increases risk 

of fixation loss and VA injury for C1-2 transarticular screws, but 

staying as dorsal and medial within the C2 isthmus optimizes the 

potential for C1-2 joint purchase and minimizes VA injury risk. 

Slight medialization of C2 pars screws and appropriate ~30-35 

degree medial angulation of C2 pedicle screws, will minimize VA 

risk as well. 

Rigid fixation has resulted in lower rates of complications related to 

inadequate fixation, including halo/cast-associated problems, further 

cranial settling/instability, and fixation failure often associated with 

pseudarthrosis. Newer fixation techniques can minimize prior risks 

of nonrigid wire/rod systems, and focus the fusion/construct only 

to unstable segments. Choice of fixation/implant is paramount 

and must be based on the patients’ anatomy, pathology and bone 

quality. Occipital screws are the strongest form of fixation, with six 

having the highest stiffness in cadaveric studies. Similar fixation is 

seen with plate/C1-2 transarticular screw constructs and both can 

prevent further cranial settling due to better resistance to axial loads. 

Bicortical screws have increased pullout strength and are preferred, 

but unicortical screws at the dense external occipital protuberance 

(EOP) have similar pullout strengths to that of bicortical screws in 

other locations. Unicortical fixation is thus strong in the midline at 

the EOP and at the medial nuchal line descending below the EOP, 

and limits the possibility of dural or venous sinus penetration during 

drilling, tapping or screw placement. Lateral bicortical fixation adds 

significant torsional strength. Graft type is important and iliac crest 

autograft remains the gold standard. Structural rib autograft also can 

be used to minimize pseudarthrosis rates, and should be anchored 

to the construct with cranial and/or other wiring techniques, or even 

an occipital screw through the graft. Alternatively, Apfelbaum et al. 

have found fusion rates comparable to autograft using structural 

bicortical iliac crest allograft well-seated between C1 and C2 when 

using C1 lateral mass/C2 pedicle screws or TAS. Despite our best 

383 




attempts, pseudarthrosis rates remain substantially higher in those 

over 75 years of age. However, in this patient population, it is possible 

a stable pseudarthrosis may obviate the need for further surgery and 

protect their neurological status. 

Neurologic Complications 

Neurologic complications include injury to the spinal cord, 

hypoglossal nerve, or C1 and C2 nerve roots and positioningrelated 

deficits. Pre-operative positioning in reverse trendelenburg 

can decrease venous engorgement and may aid in control of 

bleeding. Attention to pre- and post-positioning neurophysiologic 

monitoring is essential and signal loss/decreases mandate(s) rapid 

correction of positioning. The incidence of spinal cord injury 

during OCF is extremely low, but can occur during standard upper 

cervical decompression or via excessive medialization of C2 pedicle 

screws with an inappropriate starting point. The hypoglossal nerve 

innervates the tongue and sits anterior to the C1 cortical ring. C1 

lateral mass (or C1-2 transarticular) screws too long can injury the 

hypoglossal nerve in this location. C1 or C2 nerve root injury can 

occur during exposure of optimal screw starting points or during 

drilling, tapping or screw placement. To minimize C2 root injury 

during lateral mass screw placement, C2 root mobilization is best 

achieved with subperiosteal dissection along the posterior inferior 

C1 arch/lateral mass. Gentle caudal retraction of the C2 root with 

its venous leash can expose the C1 lateral mass screw entry point, 

at the base of the C1 posterior arch and cephalad C1 lateral mass. 

If bleeding occurs it is often dark and can be profuse, but is best 

controlled by packing it locally and proceeding with dissection 

on the contralateral side. Use of partially threaded C1 lateral mass 

screws may limit C2 root irritations by screw threads. 

Craniocervical Alignment Complications 

Sagittal (or coronal) malalignment of the OCJ during fusion can lead 

to significant complications. Head position should be as close to 

neutral as possible. Longer OC constructs placed in extension can be 

disabling (for safe ambulation, ADLs). If error occurs it should tend 

towards slight occipitocervical flexion without kyphosis, the latter 

of which can lead to a higher incidence of post-operative dysphagia 

and dyspnea and decreased oropharynx volumes. Pre-operative 

and intra-operative comparison of Phillips’ angle and use of Halo, 

Gardner-Wells tongs or a Mayfield can assist in optimizing neutral 

positioning, maintaining reduction, and minimize associated 


Vascular Complications 

Injury to the vertebral artery (VA) or internal carotid artery (ICA) 

can occur during OCF. Reported rates of VA injury during posterior 

cervicalspinesurgeriesvarydependingoninstrumentationtechnique, 

but range from no injury to 4.1% to 8.2% for C1-C2 transarticular 

screws. A 161 patient study of transarticular screw placement noted 

no VA or spinal cord injuries and 6% screw-related complications. 

At a mean of 6.5 years this same population demonstrated an 11% 

late complication rate requiring revision surgery. One study suggests 

risk of VA injury is ~2% per transarticular screw, but subsequent 

neurologic deficit after VA injury has been reported at 0.2%. 

VA injury predominantly occurs during drilling, tapping, or screw 

placement, or during dissection. Since pathology commonly alters 

local anatomy, safe access to the craniovertebral junction begins 

with meticulous dissection of safe screw entry points. Dissection 

on the C1 posterior ring should not deviate more than 12 mm 

lateral from the midline and when cephalad on C1 should stay 

within 8mm of midline. Decompressive C1 laminectomy should 

respect these boundaries. Bony and VA variations, seen in 18-23% of 

patients, also increase risk of VA injury during OCF. Normally, the VA

enters the foramen transversarium (FT) at C6 in ~90% of patients, 

ascending cephalad to reach the more medial C2 FT and coursing 

laterally through the C1 FT. During ascent, it crosses anterior to 

the C2 pars and C2-C3 joint. In patients with a high-riding VA and 

corresponding FT, the C2 pars become significantly narrowed and 

limits safe transarticular (or pars) screw placement. In this case, C1 

lateral mass screws with C2 pedicle screws may be necessary, but ~9% 

of patients have anatomy that precludes C2 pedicle screw placement. 

Adding to VA injury risk, other anatomic variants around C1-2 

include a posterior ponticulus, other VA anomalies, and a bifid C-1 

arch. Analysis of over 1000 patients using 3-D CT angiography, Hong 

et al. found that the prevalence of a C1 posterior ponticulus was 

15.6%, and the incidences of a persistent first intersegmental artery 

(PFIA) and fenestrated VA (fVA) were 4.7% and 0.6%, respectively— 

combining for a rate of 20.9%. A posterior ponticulus may be 

mistaken for a broad C1 lamina but if present, placing the screw 

too superiorly might cause VA injury. A PFIA courses abnormally 

below the C1 arch potentially making C1 lateral mass screws quite 

dangerous and a transarticular C1-2 screw preferred. A high index 

of suspicion for anomalous VA should be raised in patients with an 

atretic (or atrophic) FT and/or deep groove on the inner aspect of 

the C1 posterior ring. Pre-operative CT angiography can be critical to 

surgical planning and complication prevention. However, as recently 

demonstrated by Yeom et al., even in normal VA/bony anatomy, 

undetected VA injury can occur, particularly at the medial part of the 

VA groove just lateral to the C2 pedicle. 

As for the ICA, it courses just anterior to the C1lateral mass before 

entering the skull base. Currier et al. demonstrated that the ICA passes 

only 2-4 mm from the center of the C1 lateral mass anterior cortex 

anterior in neutral neck rotation. Transarticular C1-2 or C1lateral 

mass screws that reach (or go beyond) the anterior cortex of the C1 

anterior tubercle risk injury to the ICA, but medial screw angulation 

appears to decrease this risk. 

If injury to the VA has occurred, bright red (possibly pulsatile) 

bleeding occurs. Immediate control of bleeding can usually be 

obtained by placing the screw. However, a critical caveat is preoperative 

assessment of which VA is dominant, either via vascular 

caliber, flow or both. Usually, the left VA is dominant and larger if 

asymmetry is present. The posterior inferior cerebellar artery (PICA) 

branches from the VA to provide hindbrain blood flow. When 

complete occlusion of the dominant VA occurs with inadequate 

compensation via the contra-lateral VA, ischemia can lead to a lateral 

medullary infarction and Wallenberg’s syndrome. Thus, if intraoperative 

injury to the dominant VA occurs, every attempt should be 

made to safely control bleeding and repair the injury. Post-operative 

CT (or MR) angiography is warranted, as is close neurologic 

monitoring for stroke and sequelae of Wallenberg’s syndrome. In 

patients with co-dominant VA’s, unilateral VA injury is usually well 

tolerated. As bilateral VA injuries can be fatal, do not attempt screw 

placement on the opposite side if VA injury has already occurred. 

Technically, less steep upward (or shallow) angulation can injure 

384 




even a normally placed VA, often early during drilling through C2. 

When C1 is not anatomically reduced and is anterior to C2, entry into 

the C1 lateral mass often requires a shallow trajectory, again placing 

the VA at risk. When transarticular screw placement is lateral, the 

VA is at risk at well, primarily around C1. Slight medial angulation 

(2-10 ¼) and steep cephalad angulation may prevent this and safe, 

bony purchase is optimized in the most dorsal and medial portion 

of the C2 isthmus. 

The consequences of VA injury can manifest days to even years 

later. Post-operative manifestations usually indicate complete 

vessel occlusion. Later occurring events include thrombotic-related 

complications leading to embolic events from a partially occluded VA. 

This may relate to a variety of sequelae, including pseudoaneurysm, 

arteriovenous fistulae, late-onset hemorrhage or thrombosis with 

embolic incidents leading to cerebral ischemia, stroke, and even 

death. 

VA injury management should accomplish three goals, as nicely 

reviewed by Peng et al.: 1) control local hemorrhage, 2) prevent 

immediate vertebrobasilar ischemia, and 3) avoid cerebral embolic 

complications. Anesthesia must maintain perfusion pressure and 

fluid status. Gaining local control of bleeding may initially require 

absorbable hemostats and/or bone wax. Because risk of delayed 

hemorrhage or fistula formation is too high using packing alone, it 

should not be the primary method of hemorrhage control. A critical 

branch-point exists next, as to whether the injured VA is dominant 

or not. When in question, intra-operative angiography should 

be considered. The intra-operative assistance of an endovascular 

specialist can help tremendously in surgical decision making for 

repair versus ligation or occlusion, as well as in helping to delineate 

VA dominance and remnant collateral posterior circulation. As 

pointed out by Peng et al. and others, normal VA angiography 

after injury or even following direct repair does not preclude later 

pseudoaneurysm formation, even out to several years following 

surgery. If not the dominant VA, most agree that screw placement 

(e.g. C1-2 transarticular screw) is usually sufficient to control 

bleeding. One can also consider embolization or proximal and 

distal VA ligation, but ligation-associated morbidities such as 

cerebellar infarct, cranial nerve palsies, hemiplegia and even a 

mortality rate of 12% have been reported. In dominant VA injury, 

direct repair should be considered despite the technical demands 

of exposure/microvascular repair. Repair can minimize immediate 

and delayed risks of injury and ischemia and may profoundly affect 

patient outcome. Post-operatively, controversy exists as to whether 

or not angiography is required. Similar to that proposed by Peng et 

al., we suggest immediate post-operative angiography be performed 

if declines in the patient’s clinical condition occur or if packing, 

bone wax or direct repair of the VA injury was performed. Following 

cerebral flow assessments, endovascular techniques may assist 

in further medical management either via embolization, fistula 

occlusion, or stenting.

385 

CerviCal SpiNe trauma: SubaXial SpiNe 

Alexander R. Vaccaro, MD, PhD 

Cervical Dislocations 

There are two primary controversial questions. The first is—should 

a MRI be obtained prior to performing a closed reduction. And the 

second, is it safe to performed a closed reduction in an incomplete 

injury. 

The use of MRI in cervical dislocation is not, in itself, controversial. 

It is the timing of the MRI that is controversial and has been debated 

for many years in many different forums. 

The decision to perform a closed reduction has been a question 

of risk versus benefit. In the intact patient, there is nothing to gain 

and everything to lose by doing a closed reduction. There is very 

high risk and very little benefit. In this situation, many recommend 

obtaining an MRI before closed reduction and certainly before open 

reduction. 

In the patient with a complete spinal cord injury, there is much to 

gain and little to lose by attempting an immediate closed reduction, 

and most recommend, for this reason, immediate closed reduction 

prior to MRI. 

In patients with a radicular deficit, it is similar to the intact 

situation, with little to gain and much to lose, and this is somewhat 

controversial. But the most controversial of the situations in a patient 

with an incomplete spinal cord injury. There is moderate risk and 

benefit, and this situation has been extensively debated. 

Case example. A 34 year old female involved in an MVA. The patient 

presented within 2 hours of the accident with complaints of neck 

pain. She was awake and alert, had no drugs or alcohol on board, 

and physical exam revealed that she had an incomplete spinal cord 

injury. The steroid protocol was initiated. Imaging revealed bilateral 

jumped facets at C6-7. The sagittal CT scan confirms the bilateral 

jumped facets. 

The question is, what is the next step in management? Do you get 

a MRI to look for the presence of a herniated disk, do you do an 

immediate closed reduction using gardner-wells tongs, or do you 

take the patient to the OR, administer general anesthesia, and do an 

open reduction. 

In 1982, Allen and Ferguson looked at 165 cases of lower cervical spine 

injuries and described a classification system of numerous patterns 

of injury based on the mechanism of injury, including compressive 

flexion, vertical compression, distractive flexion, compressive 

extension, distractive extension, and lateral flexion. They described 

four types of flexion distraction injuries: Type I is a strain of the 

facet capsules. Type II is a unilateral facet dislocation, which is often 

associated with approximately 25% of anterior subluxation, Type 

III is a bilateral facet dislocation, with greater than 50% vertebral 

subluxation. And Type IV is a bilateral facet dislocation with 100% 

subluxation or spondyloptosis. 

The spine trauma study group published a subaxial cervical spine 

injury classification system and severity scale that parallels the 

thoracolumbar classification system. It is based on the morphology 

of the injury, the status of the discoligamentous complex and the 

neurological status of the patient. Facet dislocation is of the distraction 

morphology. In such an injury, the discoligamentous complex is 

disrupted, with propagation of the ligamentous disruption through 

the facet joints posterior and disc space anteriorly. 

Why do these injuries get so much attention? They are associated 

with a relatively high rate of neurological compromise. Unilateral 




fact dislocation is associated with neurological deficit 92% of the 

time, with 24% having spinal cord injury. Bilateral facet dislocation 

has a higher rate of neurological injury, with 50 to 84% having a 

spinal cord injury. 

The argument for obtaining a MRI prior to attempts at reduction 

in cases of cervical dislocation has been popularized by Frank 

Eismont and is based on a case series that Eismont published in 

the journal of bone and joint surgery in 1991. The argument is that 

cervical dislocation can be associated with disc herniation that, upon 

reduction, is pushed into the spinal canal, thus potentially causing 

neurological injury. 

Eismont’s case series involved 68 patients that were treated surgically 

for cervical facet subluxation or dislocation. 6 of these 68 patients 

were identified as having a herniated disc at the level of injury. There 

were two cases of post reduction neurological worsening. Neither of 

these patients had preoperative MRIs. One patient worsened after 

open posterior reduction and fusion. The other patient worsened 

after an ACDF. This patient was a complete injury upon presentation, 

with postoperative ascension of the neurological deficit and eventual 

death. The disk in this case was identified by intraoperative ultrasound 

following reduction of the facets. 

The case on which the entire argument of Eismont is based is this 

one. A 33 year old with C6-7 bilateral facet dislocations who had 4/5 

triceps strength, but otherwise was intact. There was a failed attempt 

at closed traction reduction with up to 50 pounds of weight applied. 

The patient then underwent posterior reduction and fusion using 

sublaminar wires without obtaining any imaging prior to surgery. 

The patient woke up a quadriplegic. 

A post operative CT myelogram showed what the authors said was 

complete block at the C6 level with anterior compression of the spinal 

cord. Although this is the image shown in their paper demonstrating 

this spinal cord compression. There is question as to whether the 

disk or the sublaminar wire actually caused the compression of the 

cord. The patient was taken back for an ACDF, and the authors noted 

the presence of a herniated disc at the level of injury. From this case 

series, level IV evidence, Eismont concluded that any patient with 

cervical dislocation should have and MRI before reduction. Every 

disc herniation would then be detected, minimizing the risk of 

neurological deterioration at the time of reduction. 

It is important to understand some of the basic science of acute 

spinal cord injury. It is not only the initial mechanical trauma that 

causes injury to the cord, but is also the pathophysiological processes 

that ensue in the time period following the initial insult. A lot of 

research has been directed towards stopping, slowing, or reversing 

this second hit to the spinal cord. One of the questions is whether 

early removal the mechanical compression affects this process and 

improves neurological outcome. 

In the early 1950’s, Tarlov did a series of studies to develop a canine 

model for spinal cord injury through gradual and acute compression 

using a balloon. In 1954, he published a study that evaluated the 

effect of acute spinal cord compression and the effect of the timing 

of decompression. He found that smaller balloons and earlier 

decompression led to greater neurological recovery. 

Dimar and others developed a rat model for spinal cord injury. 

These authors placed spacers in the rat spinal canal taking up either 

20%, 35%, or 50% of the canal both in rats with normal spinal cords 

and inured spinal cords. These authors found that the prognosis for

neurological recovery is adversely affected by both a higher percentage 

of canal narrowing and a longer duration of canal narrowing after a 

spinal cord injury. The tolerance for spinal canal narrowing with a 

contused cord appears diminished, indicating that an injured spinal 

cord may benefit from early decompression. The longer the spinal 

cord compression exists after an incomplete spinal cord injury, the 

worse the prognosis for neurological recovery. 

In a histological analysis of the rats spinal cords, these authors found 

that increased time to decompression lead to increased necrosis and 

cavitation of the spinal cord, again supporting early decompression 

in spinal cord injury. 

In 1999, Fehlings and Tator did a systematic review of the literature, 

and concluded that there is significant biological evidence from 

animal studies that shows that early decompression improves 

neurological outcome following spinal cord injury 

Fehlings and Perrin performed two more recent systematic reviews of 

the literature looking at clinical studies. Both of these studies showed 

that there have been several prospective clinical studies that suggest 

that early decompression is safe and may improved neurological 

outcome. A meta analysis by La Rosa concluded that early 

decompression within 24 hr from injury resulted in better outcomes 

than delayed decompression or conservative management. Based 

on their systematic reviews of the clinical literature, these authors 

recommended urgent decompression of bilateral facet dislocation 

in patients with incomplete injuries or patients with neurological 

deterioration. 

The benefits of immediate traction reduction are that it is relatively 

fast, and can be performed within 2 hr, and it can in the majority of 

cases provide adequate decompression of the spinal canal. 

The question is whether or not immediate traction reduction is 

safe. In 1993, Cotler reported on 24 awake patients with cervical 

facet dislocation who underwent closed reduction with gardner 

wells tongs. Patient’s neurological status was closely monitored. All 

patients had successful reduction with weight ranging from 10 o 140 

pounds. No patients had any neurological worsening during or after 

reduction. 

Additional studies by Star, Rizzolo, and Aebi demonstrated the 

safety of awake closed reduction of facet dislocation with the 

potential for neuralgic improvement following reduction. In 1999, 

Vaccaro published a prospective study that looked at MRI pre and 

post reduction of cervical facet dislocation. 11 patients underwent 

awake, closed reduction 9 of whom had successful reduction. Of 

these nine patients, 2 patients had mri evidence of disc herniation 

prereduction, and 5 had disk herniation postreduction. No patients 

had neurological worsening. The authors concluded that although 

closed reduction may increase disk herniation, it has no negative 

effect on neurological status. There are risks associated with 

delaying closed reduction and getting a MRI first. First, there is a 

delay in reduction and decompression that otherwise could lead 

to neurological improvement. Also, there is risk of neurological 

worsening associated with transport of the patient with an unstable 

cervical injury. There is also a risk of leaving a potentially unstable 

patient in the MRI suite, with risk of hypotension and hypoxia, 

which can have negative effects on the injured cord. 

Marshall performed a prospective analysis of 283 spinal cord 

injury patients. These authors found that 5.4% of the patients who 

were transported for imaging or change of beds had neurological 

deterioration. 

Numerous studies have documented the negative effects of 

hypotension on the injured spinal cord. Harrop showed that 

386 




sustained hypotension was in part responsible for neurological 

deterioration of 12 of 186 patients with complete injury. Vale showed 

that maintaining the mean arterial pressure above 85 mmHg lead to 

improved neurological recovery in spinal cord injury patients. 

The prerequisites for safely performing a closed awake reduction 

include an awake, cooperative patient, and experienced physician, 

a dedicated radiology technician, a complete cervical spine series to 

rule out additional injuries, and the absence of a skull fracture that 

could be worsening with significant traction through gardner wells 

tongs. 

It is important to realize that graphite tongs with titanium pins are 

not as strong as the steel tongs and pins, which can hold up to 225 

pounds of traction. In a cadaveric study, the titanium pins failed at 

only 75 pounds and failed from bending of the pins. The steel pins 

did not fail until 225 pounds, and failed from fracture of the skull. 

Pin sites should be prepped with betadine solution and numbed 

with lidocaine. The pins should be place about 1cm above the 

pinnae in line with the external auditory meatus, below the equator 

of the skull. The pins should be tightened simultaneously until the 

button on the one pin pops out about 1mm 

You should start with 10lbs of traction, serial exams should be 

performed during the reduction. Serial radiographs are obtained 

at each interval of increased weight. A period of about 10 minutes 

should pass before increasing the weight, which should be increased 

in 5-10 pound increments. Counter traction can be used and may be 

necessary, especially as the weight increases. The necessary weight 

varies, in Cotlers series it varied between 10 and 140 pounds, the 

majority requiring more than 50lbs. 

To help unlock the facet dislocation, slight flexion can be helpful 

during the initial reduction, followed by extension to hold the 

reduction. Traction should be stopped if there is any worsening in 

the neurological status of the patient, if there is not progress towards 

reduction despite increase in weight. And if excessive distraction of 

the spinal elements is noted on the x-ray. 

Although the timing of MRI remains a controversial topic, a MRI 

should certainly be obtained in cases of failed closed reduction, 

patients who cannot be examined during reduction due to the 

presence of mind altering substances or just an inability to 

cooperate, and an MRI should be obtained prior to surgery to 

guide operative planning. In regards to surgical treatment, Joon 

Lee recently performed a survey study involving 10 cases of cervical 

facet dislocation distributed to 25 members of the spine trauma 

study group. The goal of the survey was to evaluate the surgeon’s 

preference in surgical approach for a variety of injury patterns with 

and without neurological compromise. This study found relatively 

poor agreement among the surgeons, with a kappa value of

Cervicothoracic Trauma 

Objectives: 

1. Evaluation; Diagnosis-radiographic protocol 

2. Anatomy; Posterior fixation options 

3. Treatment; 

a) Stable v unstable 

b) Anterior v posterior v combined – ant. Approach options 

c) Instrumentation 

i. Anterior - supine v lateral 

ii. Posterior – cervicothoracic options 

OUTLINE: 

I. Diagnosis 

• Plain lateral x-ray may insufficiently visualize C6-T2 

• Missed and delayed diagnosis often due to inadequate x-rays 

of the lower cervical spine 

• Need visualization of the upper endplate of T1 and the C7- 

T1 facet joint. 

• Shoulder “pull-down” views or “swimmer’s” view may 

increase visibility of this area. 

• If inadequate, CT (helical with sagittal and coronal 

reformation) is required. 

• If spinal cord injury, need MRI. 

II. Treatment 

• Standard resuscitation-if SCI consider steroids per NASCIS 

protocol 

• Assess stability from physical exam, x-rays, CT, MRI 

• Goals of treatment 

1. Reduce dislocation and realign spine 

2. Protect spinal cord from further damage-stabilize spine 

• Closed reduction of subluxations and dislocations at the 

cervicothoracic junction usually require higher weights and 

are less successful than closed reduction technique of the 

subaxial cervical spine 

• Nonoperative treatment of unstable fractures 

1. Recumbent traction –complications of bed rest are many 

including PE, skin problems, and pulmonary difficulty 

especially in patients with spinal cord injury 

2. Halo vest –stability of the cervicothoracic junction is 

poor. Due to the biomechanical disadvantage of the halo 

vest in this region of the spine, nonoperative treatment 

is recommended only for stable fractures in patients 

without neurologic deficits. 

III. Surgical Options 

• Posterior –biomechanical challenge of connecting the highly 

mobile cervical spine to the anatomically different thoracic 

vertebrae. 

1. Hook and rod constructs are designed for the 

thoracolumbar spine, but hooks and sublaminar wires 

carry a significant risk of neurologic injury in the cervical 

canal. 

2. Standard fixation to the cervical spine is the lateral mass, 

but this is not an option in the thoracic spine. 

a) Magerl v Roy-Camille technique 

b) Bicortical v unicortical fixation 

3. Screw fixation in the thoracic spine is through the 

pedicles or transverse processes. 

a) Screws placed lateral to the pedicle usually engage the 

base of the rib and are quite strong. 

387 




CerviCothoraCiC iNJurieS 

Jens R. Chapman, MD 

4. The anatomy of C7 is different because it is a transitional 

vertebra. Important anatomical issues: 

a) The lateral mass is smaller than the rest of the 

subaxial cervical spine, thus lateral mass screws will 

be shorter and biomechanically weaker 

b) The pedicle is larger than the rest of the subaxial 

cervical spine and closer to the size of upper thoracic 

pedicles 

c) The foramen transversarium does not usually contain 

the vertebral artery, thus pedicle screw placement is 

safer. (Beware-5% will harbor the VA) 

• Posterolateral 

1. Transpedicular 

Advantages: 

— simple technique 

— Less soft tissue and bony dissection than other 

Posterlat. approaches 


— limited ventral exposure 

— Not appropriate for multilevel pathology 

2. Costotransversectomy 

Technique: 

— rib of interest identified, isolated, divided at its angle, 

and disarticulated 

— Intercostal neurovascular bundle isolated and 

followed to the foramen and thecal sac 

— 1 or 2 ribs removed for adequate exposure 

— plane developed between the endothoracic fascia and 

the parietal pleura 

— plane carried lateral to the vertebral body, and the 

parietal pleura is retracted ventrally 


— wound related complications 

— Neurovascular bundle sacrifice 

— Potential pneumothorax and CSF leak 

— Ventral exposure limited to the lateral 2/3 of the 

vertebral body 

— Difficult exposure for multilevel decompressions 

3. Lateral Extracavitary 

Technique: 

— midline hockey-stick incision 

— Myocutaneous flap developed superficial to erector 

spinae group 

— Lateral to medial elevation of erector spinae, 

beginning at its lateral margin 

— Rib resection and lateral thecal sac exposure 

— Vertebral body resection 

— Anterior reconstruction 

— Posterior instrumentation and fusion 

Advantages: 

— simultaneous ventral and dorsal exposure 

— Best access to ventral pathology of the posterolateral 

procedures 

— Disadvantages: extensive soft tissue exposure 

— Visualization and decompression of canal less 

optimal than formal anterior thoracotomy 

— Technically demanding 

— Neurovascular bundle sacrifice 

— Blood loss may be considerable after epidural 

decompression

— Less ability to directly distract the anterior column 

and adaquately seat the anterior construct as well as 

difficulty placing anterior instrumentation 

• Anterior –standard approach to the cervical spine usually allows 

exposure of T2, but placement of instrumentation may be 

difficult because of the clavicle or sternum. Possible injury to 

the recurrent laryngeal nerve, thoracic duct, and great vessels. 

Lung apex may be problematic. 

1. Extensile options include osteotomy of the clavicle or 

median sternotomy. Allows access as low as T4. 

2. Standard lateral thoracotomy with mobilization of the 

scapulae allows exposure of T2, but the vertebral bodies are 

388 




too small for application of non-custom anterior thoracic 

instrumentation. 

a) Transaxillary approach: variant of transthoracic approach 

Advantages: 

— Axillary incision avoids muscle division 

— Intrathoracic extrapleural approach via the third rib 

bed 

— Access to T1-T4 


— Deep, very limited exposure

389 

u SpiNal deFormity: 

what every orthopaediC 

SurgeoN NeedS to kNow (t) 


Joseph Perra, MD, Minneapolis, MN 

II. Assessing Patients with Spinal Deformity 

Adam Wollowick, MD, New York, NY 

III. Early Onset Scoliosis 

Behrooz Akbarnia, MD, La Jolla, CA 

IV. Adolescent Idiopathic Scoliosis 

Lawrence Lenke, MD, Saint Louis, MO 

V. Pediatric Spondylolisthesis 

Paul Sponseller, MD, Baltimore, MD 

VI. Discussion, Q&A 

All faculty 

VII. Adult Scoliosis 

Frank Schwab, MD, New York, NY 

VIII. Sagittal Plane Deformity 

Steve Glassman, MD, Louisville, KY 

IX. Adult Spondylolisthesis 

Joseph Perra, MD, Minneapolis, MN 

X. Discussion 

All faculty 




Moderator: Joseph Perra, MD, Minneapolis, MN

390 

aSSeSSiNg patieNtS with SpiNal deFormity 

Adam L. Wollowick, MD 

1. Basic Principles 

a. What is Spinal Deformity? 

i. Definitions: Scoliosis, Kyphosis, Lordosis, 

Spondylolisthesis 

b. Comprehensive History: 

i. Symptoms, deformity onset, constitutional symptoms, 

treatment history, bowel/bladder issues, overall function 

ii. Medical History 

iii. Family History: spinal deformity, syndromes, familial 

disorders 

c. Physical Examination: 

i. Inspection: Gait, skin, spinal movement, shoulder 

asymmetry, pelvic obliquity 

1. Heel/Toe Walking, Static and Dynamic Romberg 

ii. Motor 

iii. Sensory 

iv. Reflexes: DTR’s, Babinski, Clonus, Abdominal 

v. Special Tests: Adam’s Forward bend, Angle of Trunk 

Rotation, C7 plumb line 

d. Imaging Studies: 

i. X-rays 

1. Full-length standing radiographs (C/T/L/S Spines + 

Pelvis/Hips) 

a. Knees straight: assess sagittal balance 

b. Coned-down views of selected regions 

2. Cobb Angle calculation 

a. Main Thoracic, Proximal Thoracic, 

Thoracolumbar/Lumbar 

b. Thoracic Kyphosis, Lumbar Lordosis 

3. Supine Left and Right Bending radiographs 

4. Push-Prone radiograph, Supine AP radiograph, 

Traction radiograph 

5. Fulcrum Bending 

ii. CT: risk of radiation exposure 

1. Congenital bony anomalies 

2. Pedicle Assessment: ??? Value 

3. Myelography: may be more helpful than MRI with 

severe deformity 

iii. MRI 

1. Assessment of patients with radiculopathy, 

myelopathy, claudication 

2. High grade spondy, spondy with radiculopathy 

3. Early onset, juvenile, selected AIS 

iv. Nuclear 

2. Pediatrics 

a. History: Symptoms/pain, onset of menses, family history 

of deformity, activity restrictions, development milestones, 

intrauterine course, ? rapid progression 

i. Age Determination: Chronologic vs. Metabolic 

1. Tanner Stages: ? physician comfort (young girls): ask 

about early breast development and rapid foot growth 

2. Risser: convenient, but approach with skepticism 

a. Often appears after peak height velocity 

3. Tri-radiate cartilage: closure signals end of peak 

growth spurt 

ii. Growth History: 

1. Peak Height Velocity: occurs 6-12 months prior to 

onset of menses (F) or appearance of axillary/facial 

hair (M) 




a. Normal Girls: 10 – 14 years; Normal Boys: 12 – 16 

years 

2. Onset of menses: after PHV and does not correlate w/ 

Risser sign 

b. Physical Examination: 

i. Inspection: Scapulae, rib/paraspinal prominence, 

shoulder, pelvis/waistline 

1. Anterior: Breast asymmetry may be first sign of 

deformity 

2. Posterior Skin Changes: CafŽ au lait spots, sinuses, 

hairy patches, palpable defects, step-off, dimpling 

3. Spondylolisthesis: hyperlordosis, step-off, heartshaped 

buttocks 

ii. Forward Bend Test: Scoliometer: 70 better than 50. More 

sensitive and specific: If > 70, need x-rays and/or referral 

to spine specialist 

iii. Leg length discrepancy, hip pathology, ligamentous laxity 

1. Hamstring tightness in setting of spondy 

iv. Neurologic Exam 

1. Complete neurologic assessment 

2. Assess for radiculopathy in spondy 

a. High-grade spondy: rectal exam 

c. Imaging Studies: 

i. MRI: 

1. Any neurologic abnormality on history or physical 

exam (NF) 

2. All congenital and Infantile/Juvenile Scoliosis > 200: 

(Occiput – Sacrum) 

a. Controversial 

b. Relationship to physical exam and progression 

3. Boys, left thoracic curves ???? 

d. Special Considerations in Congenital Scoliosis 

i. Cardiac Abnormalities (10 – 37%): Echo 

ii. Urologic Abnormalities (21 – 34%): Renal Ultrasound 

iii. Neural Axis Abnormalities: (20 – 40%): Syrinx, Tethered 

Cord, Chiari 

iv. Thoracic Insufficiency: ??? Pulmonary Function Tests 

v. Syndromes (38 – 55%): VATER, VACTERL, Goldenhar’s 

vi. Associated Orthopaedic conditions: DDH, C1-C2 

instability, Klippel Feil 

3. Adults 

a. History: Axial pain, radicular pain, claudication 

i. Assess for cancer, infection, trauma as cause of deformity 

ii. More likely to present with pain and/or progressive trunk 

imbalance 

1. Change in height or posture, waistline, fit of clothing: 

? progression 

2. Most adults with spondylolisthesis are asymptomatic, 

but may present with back or leg pain or both 

iii. Prior surgical history: pseudoarthrosis, flatback, adjacent 

segment, post-laminectomy syndrome 

iv. Previous treatments 

v. Quality of life assessment/ Cosmesis 

vi. Comprehensive medical history 

1. Shortness of breath/respiratory issues 

2. Cardiac history 

b. Physical Examination: 

i. Don’t forget the Hips !

391 

1. Asssessment of hip/knee contractures and leg length 

discrepancy 

ii. Thorough neurologic assessment for radiculopathy/ 

myelopathy 

1. Patients usually have normal neurologic exams 

iii. Rib-Ilium contact: pain, GI issues 

c. Imaging Studies: 

i. MRI: Assess for stenosis &/or disc degeneration 

REFERENCES: 

1. Akbarnia BA. Management themes in early onset scoliosis. J Bone Joint Surg 

Am. 2007 Feb;89 Suppl 1:42-54. 

2. Ferguson RL. Medical and congenital comorbidities associated with spinal 

deformities in the immature spine. J Bone Joint Surg Am. 2007 Feb;89 Suppl 

1:34-41. 

3. Hu SS, Tribus CB, Diab M, Ghanayem AJ. Spondylolisthesis and 

spondylolysis. J Bone Joint Surg Am. 2008 Mar;90(3):656-71 

4. Lenke LG, Dobbs MB. Management of juvenile idiopathic scoliosis. J Bone 

Joint Surg Am. 2007 Feb;89 Suppl 1:55-63 




ii. Spondylolisthesis: Must visualize the pelvis on x-rays: 

Pelvic Incidence, Pelvic Tilt, Sacral Slope 

1. Upright AP/ Lateral x-rays 

2. Flexion/Extension Views 

d. Special Considerations: 

i. Cardiac Evaluation 

ii. Nutritional Assessment 

iii. Bone Density: osteopenia, osteoporosis 

5. Lonner, BS. Spinal Deformity in the Clinical Settting. In T.J. Errico, B.S. 

Lonner, A. Moulton, Surgical Management of Spinal Deformities, pp. 61-70, 

Saunders, 2008. 

6. O’Brien, MF and Shufflebarger, H. Evaluation of the Patient with Scoliosis. 

In P.O. Newton, Adolescent Idiopathic Scoliosis, pp. 11-21, AAOS, 2004. 

7. O’Brien, MF, Kuklo, TR, et al, editors. Spine Deformity Study Group 

Radiographic Measurement Manual. Medtronic Sofamor Danek USA, Inc. 

2005. 

8. Sanders JO. Maturity indicators in spinal deformity. J Bone Joint Surg Am. 

2007 Feb;89 Suppl 1:14-20.

a) Introduction: 

i) Onset of scoliosis of all etiologies presenting in the first five 

years of life 

ii) Severe cardiopulmonary problems can occur in pts with 

untreated progressive curves 

iii) Radiographic criteria may assist in some cases of IIS to 

distinguish between the curves that will progress and those 

that will spontaneously resolve. 1 

b) Normal spinal and lung growth: 

i) Spinal growth is greatest in the first five years of life being 

approximately 2 cm per year reducing to about 1 cm from 5 

to 10 years 

ii) Two thirds of sitting height is achieved by the age of 5.2 

iii) Normal development and increase in number and volume 

of respiratory units occurs in the first 8 year of life. 

c) Etiology: 

i) Idiopathic, congenital, syndromic and neuromuscular. 

ii) Natural history and the outcome of treatment are different 

among these groups 3 

iii) Curves with major thoracic deformity before 5 yrs are most 

likely to be associated with major pulmonary complications 

in addition to their growth abnormalities. 

d) Clinical evaluation: 

i) Birth history (Breech presentation, prematurity) and 

developmental milestones 

ii) Physical examination: cutaneous marks, plagiocephaly, chest 

wall deformity, shoulder and pelvic imbalance and lower 

limb discrepancy. 

iii) DDH, inguinal hernia and congenital heart disease are also 

quite common. 

iv) Neuro exam: gait, muscle tone, reflexes including superficial 

abdominal reflexes 

e) Radiographic assessment: 

i) PA and Lateral standing scoliosis radiographs including the 

pelvis. 

(1) Reviewed for congenital vertebral and rib anomalies, 

curve pattern, rib vertebral angle difference (RVAD), 

coronal balance, T1 tilt and linear base line measurements 

of T1-T12 and T1-S1 distance for future assessment of 

growth and space available for lungs (SAL). 4 

(2)Assessment of thoracic kyphosis and sagittal balance 

ii) Bending /traction films 

iii) 3-D CT scan or dynamic MRI of the lungs is a substitute for 

PFT’s in this group 

iv) MRI may also be needed to detect any intraspinal 

pathologies. 1 

f) Management: 

i) Goals: stop curve progression, improve pulmonary function 

and correct the deformity while allowing the growth of the 

spine and chest to continue. 

(1) Recognition of importance of thoracic volume has shifted 

focus of treatment to maintenance of growth of thorax 

and preservation of pulmonary function. 

ii) If the curves are non-progressive, observation may be all that 

is needed. 

iii) Casting still plays a role 

iv) Posterior spinal fusion results in a short trunk, 

disproportionate body height, possible crankshaft deformity 

392 




early oNSet SColioSiS 

Behrooz A. Akbarnia, MD 

and adversely affects lung development in young children. 1 

g) Operative treatment: 

i) Failure of the non operative treatment (e.g. non compliance, 

skin problem or progressive nature of the deformity) 

and deterioration of pulmonary function are the main 

indications for surgical intervention. 

(1)The Cobb angle alone is not an indication 

(2)Cobb angle > 35˚ in IIS and > 45˚ in JIS, RVAD >20˚ and 

phase II rib-vertebral relationship in idiopathic cases are 

strong indicators of curve progression 

(3)Growth compatible implants: Distraction based 

including VEPTR and Growing Rods (GR), Guided 

growth such as Luque-Trolley and Shilla, and Tension 

based including staples and tethers. 5 

h) Results of Growing Rods Surgery: 

i) Klemme et al. 8 reported the outcome of Minnesota 

experience of single-rod distraction based correction of 

scoliosis in 67 children over the course of 20 years. 

(1)They had a 30 % (67˚ to 47˚) curve correction at final 

follow up with the average growth of 1 cm/year 

ii) Akbarnia et al. in 2005 first reported the clinical outcomes 

following dual growing rod surgery. An average of 6.6 

lengthenings per patient at an interval of 7.4 months 

achieved with 2 years of follow up. Mean curve improved 

from 82˚ to 38˚ after initial surgery and 36˚ at last followup 

or post final fusion. T1-S1 increased by 1.21 cm/year. 

Children with more frequent lengthenings (≤6 months), 

have generally better growth rate and Cobb correction 

iii) The results of a recent comparison of dual vs. single rod 

constructs by Thompson et al. quite convincingly favor the 

dual growing rod technique. 

i) VEPTR: (Vertical Expandable Prosthetic Titanium Rib) 

i) Progressive deformity in a child with thoracic insufficiency 

syndrome EOS with RVAD >20° in phase II in whom the 

deformity has progressed despite casting or bracing or in 

whom casting or bracing is not practical because of medical 

co morbidities 

ii) All etiologies of progressive EOS in which the surgeon 

wishes to avoid or minimize direct exposure of the spine. 10 

j) GR vs. VEPTR: 

i) The best candidate for GR procedure is a normally 

segmented deformity such as infantile idiopathic scoliosis 

not controlled by bracing or casting 

ii) Most ideal case for VEPTR is a thoracogenic scoliosis with 

multiple fused ribs in association of congenital spinal 

deformity and TIS 

iii) Choice of growing rods vs. VEPTR should be based on 

the origin of the deformity, preference and experience of 

the surgeon, and associated problems such as soft tissue 

coverage, previous infection and upper thoracic kyphosis 

iv) Contraindications to VEPTR include the absence of adequate 

ribs to support distraction, inadequate soft-tissue coverage, 

and an easier or better way to accomplish the control of 

EOS. 

v) Excessive upper thoracic kyphosis is a relatively 

contraindication to VEPTR and is better handled with GR. 

vi) GR may be continued into the uppermost thoracic or 

lower cervical spine for control of upper thoracic kyphotic

393 

deformity. vii)EOS managed with VEPTR may have some 

advantage over that managed with GR at the end of 

treatment at the time of definitive fusion. 9,10,12 

k) Complications: 

i) Complications are common in the treatment of EOS by 

growth-sparing techniques. 

ii) Rrod breakage, loss of anchor points, infection, need for 

revision or exchange, premature cessation of treatment 

REFERENCES: 

1. Gillingham BL, Fan RA, Akbarnia BA. Early Onset Idiopathic Scoliosis. J Am 

Acad Orthop Surg 2006;14:10-112 

2. Dimeglio A: Growth of the spine before age 5 years. J Pediatr Orthop B 

1993;1:102-107 

3. Akbarnia BA, Salari P, Thompson GH et al. Outcomes of Growing Rod 

Techniques in Early Onset Scoliosis: Does the Etiology Matter? Presented 

at the 45th annual meeting of Scoliosis Research Society, September 21-24, 

2010 Kyoto, Japan. 

4. Campbell RM, Smith MD, Mayes TC, et al. The characteristics of thoracic 

insufficiency 

syndrome associated with fused ribs and congenital scoliosis. J Bone Joint 

Surg Am 2003;85:399–408. 

5. Skaggs DL. Classification of treatment of early onset scoliosis. Presented at 

2nd international congress on early onset scoliosis & growing spine (ICEOS). 

November 7-8, 2008. Montreal, Quebec. 

6. Betz RR, Kim J, D’Andrea LP et al. An innovative technique of vertebral body 

stapling for the treatment of patients with adolescent idiopathic scoliosis: a 

feasibility, safety, and utility study. Spine 2003, 28:S255–S265 




(1)Early aggressive treatment of implant-related infection 

can often allow retention of the implants and subsequent 

continued lengthening. 

iii) Surgeon must perform lengthenings in a timely basis, but an 

excessive number of lengthening procedures may lead to an 

increased number of complications 

iv) Future research is needed to determine optimal interval for 

construct lengthening. 12,13 

7. McCarthy RE. Chapter 48, Growth guided instrumentation: Shilla Procedure 

in Akbarnia BA, Thompson GH, and Yazici M. The Growing Spine. 2010, 

Berlin-Heidelberg: Springer-Verlag. 

8. Akbarnia BA, Thompson GH, and Yazici M. Editors, The Growing Spine: 

Management of Spinal Disorders. Springer-Verlag Berlin Heidelberg 2011 

9. Akbarnia BA, Breakwell LM, Marks DS et al. Dual growing rod technique 

followed three to eleven years until final fusion: The effect of frequency of 

lengthening. Spine 2008;33(9):984-990. 

10. Campbell RM. Chapter 37, VEPTR Expansion Thoracoplasty in Akbarnia BA, 

Thompson GH, and Yazici M. The Growing Spine. 2010, Berlin-Heidelberg: 

Springer-Verlag. 

11. Sankar WN, Skaggs DL, Yazici, M et al. Lengthening of dual growing rods: Is 

there a law of diminishing returns? Presented at the 44th annual meeting of 

Scoliosis Research Society, September 23-26, 2009 San Antonio, USA. 

12. Akbarnia BA, Emans JB. Complications of Growth-Sparing surgery in Early- 

Onset Scoliosis. Spine, November 2010. 

13. Bess S, Akbarnia BA, Thompson GH and et al.: Complications of Growing- 

Rod Treatment for Early-Onset Scoliosis: Analysis of One Hundred and Forty 

Patients. J. Bone Joint Surg Am 2010 92(15): 2533-43

I. Diagnosis & “Facts” 

a. Common spinal deformities 

i. Scoliosis “Diagnosis of Exclusion” 

ii. Congenital 

iii. Neuromuscular 

iv. Syndrome associated 

b. Idiopathic scoliosis 

i. Categories – Chronology 

1. Infantile (0-3 years of age) 

2. Juvenile (3-10 years of age) 

3. Adolescent (10-18 years of age) 

4. Adult (>18 years of age) 

c. Prevalence 

i. 2-3% (10-18 years) 

ii. 3.6:1 female:male ratio 

iii. 1:1 female:male (10˚ curves) 

iv. 9:1 female:male (>50˚ curves) 

d. Natural History 

i. Younger age + Risser sign + Larger Cobb angle + Genetics 

= risk of progression! 

II. Evaluation 

a. Radiographic 

i. “Typical curve patterns” 

1. Rt. thoracic/double thoracic/double major – Rt. 

thoracic/Lt. lumbar; Lt. TL/L 

ii. Atypical x-ray features – non-idiopathic 

1. Lt. thoracic curve – incidence (10-40%) of spinal 

canal abnormalities (e.g., syrinx) 

2. Sharply angulated curves (e.g., neurofibromatosis) 

3. Very large curves (>100˚) (e.g., Marfan syndrome) 

4. Congenital bony abnormalities (e.g., unilateral bar, 

hemivertebra) 

iii. MRI needed??? 

b. Clinical 

i. H&P 

1. Shoulder height 

2. Trunk shift 

3. Waistline asymmetry 

4. Thoracic (rib)/lumbar prominence 

5. Breast asymmetry 

III. Classification = Curve type + coronal lumbar modifier + 

sagittal thoracic modifier 

394 

a. Curve types 

b. Coronal lumbar modifier = A, B, C 

adoleSCeNt idiopathiC SColioSiS 

Lawrence G. Lenke, MD 




c. Sagittal thoracic modifier = -, N, + 

IV. Treatment 

a. Non-conventional/orthopaedic 

b. Observation 

i. Most common Tx! 

ii. Mild deformity Boys 

ii. Spinal fusion

BIBLIOGRAPHY 

395 

1. PSF w/instrumentation – trend 

2. ASF w/instrumentation – trend 

3. ASF/PSF w/instrumentation – trend 

1. Weinstein SL, Dolan LA, Cheng JC, et al. Adolescent idiopathic scoliosis. 

Lancet 2008;371:1527-37 

2. O’Brien MF, Lenke LG, Bridwell KH, et al. Preoperative spinal canal 

investigation in adolescent idiopathic scoliosis curves ≥70˚. Spine 

1994;19:1606-10 

3. Lenke LG, Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new 

classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 

2001;83:1169-81 

4. Vedantam R, Lenke LG, Bridwell KH, et al. A prospective evaluation of 

pulmonary function in patients with adolescent idiopathic scoliosis relative 

to the surgical approach used for spinal arthrodesis. Spine 2000;25:82-90 




4. Endoscopic techniques rare 

5. Non-fusion techniques rare 

5. Luhmann SJ, Lenke LG, Kim YJ, et al. Thoracic adolescent idiopathic scoliosis 

curves between 70 degrees and 100 degrees: is anterior release necessary? 

Spine 2005;30:2061-7 

6. Cheh G, Lenke LG, Lehman Jr. RA, et al. The reliability of preoperative 

supine radiographs to predict the amount of curve flexibility in adolescent 

idiopathic scoliosis. Spine 2007;32:2668-72 

7. Lehman Jr. RA, Lenke LG, Keeler KA, et al. Operative treatment of adolescent 

idiopathic scoliosis with posterior pedicle screw-only constructs: Minimum 

three-year follow-up of one hundred fourteen cases. Spine 2008;33:1598- 

604 

8. Sangole AP, Aubin CE, Labelle H, et al. Three-dimensional classification of 

thoracic scoliotic curves. Spine 2009;34:91-9

I. Natural History & Basic Principles 

A. Spondylolysis: Frederickson JBJS 1984 (Guthrie Clinic) 

• X-Ray 500 newborns 

• No -lysis 

• 500 children at 6,10,15,18+ years 

• Prevalence of lysis ~4.4% at 5 yrs, 6% at adulthood 

Listhesis in 2/3; max 30% 

• + family history in 35-50 % 

• Spina bifida occulta in >70% 

• Symptoms rare, mild 

45 year follow-up: Mean slip 18%; maximum 39%; SF-36 scores 

= general No back disability, No neuro deficits. One patient 

underwent fusion 

B. Natural History of Grade III/IV spondylolisthesis 

• 20 year follow up of 11 pts; Harris & Weinstein 1987 

• 36% asymptomatic; 55% mild symptoms;11% severe 

symptoms 

• 45% had neurologic findings. “All led active lives” 

C. Risk Factors for isthmic spondylolysis 

• Abnormal pars; + family History; Spina bifida occulta 

L5 

• Excessive Stress (may cause fx or symptoms) 

• Scheuermann; gymnastics; football lineman; athetosis 

D. Risk Factors for progressive slip: 

• Preadolescent; female; dysplastic; high grade; high slip 

angle; conn. tissue disorder 

E. Symptoms: 

• Most commonly develop in adolescence 

Activity-related back pain,worse with extension 

• ± Pain in buttocks/proximal thighs 

F. Signs 

• ± Stiff-legged gait or pelvic waddle 

• Limited forward flexion 

• Prominent ilia 

• ± palpable step-off of spinous processes 

G. Additional studies 

• Bone scan + SPECT (acute vs. chronic) 

• CT (my study of choice) 

• MRI does not reliably show pars defect 

II. Treatment-Spondylolysis 

A. Brace/cast 

• Used for healing or symptom relief 

• 2 months typical duration 

• Pantaloon brace most effective; least practical 

• Radiographic Healing ~ 5%! (McClellan SRS 2009) 

B. Surgical repair of pars defect 

• Indications: persistent symptoms; Age < 25;Slip < 5 mm 

• Technique of Pars Repair 

• Intra-osseous screw 

• Wires from T.P. to S.P. 

• Pedicle screw-hook construct 

• Results of Repair 

REFERENCES 

1. Debnath UK: Clinical Outcome after surgical treatment of spondylolysis in 

young athletes. JBJS 2003; 85B: 244-9 

2. Fredrickson BE, Baker D, McHolick WJ, Yuan HA, Lubicky JP. The natural 

history of spondylolysis and spondylolisthesis.J Bone Joint Surg Am. 1984 

Jun;66(5):699-707. 

396 

pediatriC SpoNdyloliStheSiS 

Paul D. Sponseller MD 




19/22 professional athletes returned to sport 

(Debnath UK, 2003) 

C. Treatment – Spondylolisthesis 

Conservative: The mainstay for grade 0-2 slip 

• Activity restriction as needed 

No restriction mandatory for asymptomatic grade I-II 

• Abdominal & extensor strengthening, hamstring 

stretching 

• Brace/cast for acute/persistent sx 

• Continue periodic follow-up during growth ~every 1-2 

yrs 

D. Surgical Fusion 

• Indication: Slip > 50%, or persistent symptoms with any 

defect 

• In Situ Fusion 

• Still a valid option 

• Circumferential fusion slightly better at long term f/u for 

severe slips 

• Surgical Fusion: Technique 

— One-level posterior if < 50%; 2-level if >50% 

— In situ is gold standard 

— Results proportional to T.P. size 

— Instrumentation not mandatory 

— Role of cast, instrumentation is controversial 

E. Reduction of slip 

• Risk: L5 nerve palsy 

• Benefits: 

— Deformity improvement 

— May decrease one fusion level 

F. Surgical Tips 

• Expose to transverse processes of L5 

• Expose ala of sacrum 

• Avoid midline exposure through bifid levels (be aware of 

laminar integrity) 

• Beware small L5 transverse processes 

G. Fibular bone graft Anterior or posterior Spondylectomy and 

reduction 

III. Pitfalls & Controversies 

A. Neurologic deficit: 

• if detected, obtain CT for graft & screw malposition. 

• If none detected, surgeon may elect to decrease the 

amount of reduction. 

B. Adding-on/ junctional kyphotic deformity may develop at 

L4-5 more likely if L4 was temporarily instrumented 

C. Interbody fusion is controversial. It is more beneficial in 

older patients, those with foraminal narrowing and those 

with small transverse processes. 

D. Other Points 

• Appearance improves even after in-situ fusion 

— Only 2/17 w. severe slip aware of cosmetic difference 

• Cauda equina syndrome may occur even after in-situ 

fusion (Schoenecker) 

• Pseudarthrosis: salvage with ant+post fusion 

3. Harris IE Weinstein SL: Long-term follow up of severe spondlylolisthesis. J 

Bone Joint Surg 1987: 69:960-9. 

4. Johnson JR, Kirwan EO. Long-term Results of in-situ fusion for severe 

spondylolisthesis. J Bone Jt Surg 1983: 65: 43-6 

5. McTimoney C, Micheli LJ: Current Management of Spondylolysis. Cur Sport 

Med Rep 2003 2:

6. Nozawa S Wire repair of spondylolysis. Am J Sports Med 2003. 31: 359-64. 

7. Beutler WJ: Natural History of Spondylolysis and Spondylolisthesis: 45Year 

Follow-up. Spine 2003. 15;28(10):1027-35. 

8. D’Hemecourt PA: Returning the Athlete to Sports participation with brace. 

Orthopedics 2001;25:653-7 

397 




9. Lamberg T, Remes V, Helenius I, Schlenzka D, Seitsalo S, Poussa M: 

Uninstrumented in situ fusion for high-grade childhood and adolescent 

isthmic spondylolisthesis: long-term outcome. J Bone Joint Surg Am. 2007 

89:512-8.

398 

adult SColioSiS aNd aSSoCiated SpiNal deFormitieS 

Frank Schwab, MD 

I. Etiology, Prevalence and Natural History 

1. Denovo Degenerative Scoliosis: DDS probably most 

common 

2. Idiopathic in the Adult: AISA Common 

3. Iatrogenic: increasingly common, most complex 

4. Overall Prevalence depends upon population studied 

a. reportedly range from 6% to over 50% (older adults) 

b. for AISA 68% of the curves progressed after skeletal 

maturity. 

5. AISA 

a. curves

3. Health and function of patients with untreated idiopathic scoliosis ; 

Weinstein SL, Spratt KF et al. JAMA 289(5) 2003 

4. Weinstein SL and Ponseti IV. Curve progression in idiopathic scoliosis. J 

Bone Joint Surg 65-A(4):447-455, 1983. 

399 




5. Bridwell KH, Glassman S, Horton W, Shaffrey C, Schwab F, Zebala LP, 

Lenke LG, Hilton JF, Shainline M, Baldus C, Wootten D.: Does treatment 

(nonoperative and operative) improve the two-year quality of life in patients 

with adult symptomatic lumbar scoliosis: a prospective multicenter evidencebased 

medicine study. Spine (Phila Pa 1976). 2009 Sep 15;34(20):2171-8.


1. Historically deformity assessment focused primarily on 

coronal plane parameters 

a. Curve magnitude. 

b. Coronal balance 

2. Sagittal plane deformity (Kyphosis) was considered 

separately 

a. Scheurmann’s Kyphosis 

b. Post-traumatic Kyphosis 

c. Post-scoliosis Fusion Flatback 

II. Correlation between sagittal alignment and symptoms 

1. Analysis of Spine Deformity Study Group Database 

a. 298 patients with adult spinal deformity 

b. Radiographic parameters vs. HRQOL measures 

2. Moderate Contribution of Coronal Imbalance 

3. Dominant Impact of Sagittal Imbalance 

4. Subsequent Studies on Sagittal Balance 

REFERENCES: 

1. Lowe TG, Line BG: Evidence Based Medicine: Analysis of Scheurmann’s 

Kyphosis. Spine. 2007 Sep 1;32(19 Suppl):S115-9. 

2. Coe JD, Smith JS, Berven S, Arlet V, Donaldson W, Hanson D, Mudiyam R, 

Perra J, Owen J, Marks MC, Shaffrey CL: Complications of Spinal Fusion for 

Scheurmann’s Kyphosis: A report of the Scoliosis Research Society Morbidity 

and Mortality Committee. Spine. 2010 Jan 1;35(1):99-103. 

3. Vaccaro AR, Silber JS: Post-traumatic Spinal Deformity. Spine. 2001 Dec 

15;26(24 Suppl):S111-8. 

4. Buchowski JM, Kuhns CA, Bridwell KH, Lenke LG: Surgical Management of 

Posttraumatic Thoracolumbar Kyphosis. Spine J. 2008 Jul-Aug;8(4):666-77. 

5. Potter BK, Lenke LG, Kuklo TR: Prevention and Management of Iatrogenic 

Flatback Deformity. J Bone Joint Surg Am. 2004 Aug:86-A(8):1793-808. 

400 

Sagittal plaNe deFormity 

Steven D. Glassman, MD 




a. Pelvic Parameters 

b. Cervical Alignment 

III. Clinical Applications 

1. Lumbar Spine Pathology 

a. Attention to Sagittal Balance in treatment of Standard 

Lumbar Degenerative Disease 

b. Lordosis as a predictor of Adjacent Level Disease 

c. Management of Spondylolisthesis 

2. Thoracolumbar Fracture 

a. Restore Sagital Plane 

b. Internal Bracing 

c. Pros/Cons of Early Treatment 

3. Degenerative Deformity 

a. Lumbar Kyphosis and Stenosis 

4. Adult Scoliosis 

a. Role of Osteotomies 

b. Fusion to Pelvis 

6. Glassman SD, Berven S, Bridwell K, Horton W, Dimar JR: Correlation of 

Radiographic Parameters and Clinical Symptoms in Adult Scoliosis. Spine. 

2005 Mar 15;30(6):682-8. 

7. Glassman S, Bridwell K, Berven S, Horton W, Schwab F: The Impact of 

Positive Sagittal Balance in Adult Spinal Deformity. Spine. 2005 Sep 

15;30(18):2024-2029. 

8. Schwab F, Lafage V, Patel A, Farcy JP: Sagittal Plane Considerations and the 

Pelvis in the Adult Patient. Spine. 2009 34(17):1828-1833. 

9. Roussouly P, Nnadi C: Sagittal Plane Deformity: An Overview of 

Interpretation and Management. Eur Spine J. 2010 Jun 22. [Epub ahead of 

print]. 

10. Bridwell KH: Causes of Sagittal Spinal Imbalance and Assessment of the 

Extent of Needed Correction. Instr Course Lect. 2006;55-567-75. 

11. Gill JB, Levin A, Burd T, Longley M: Corrective Osteotomies in Spine Surgery. 

J Bone Joint Surg Am. 2008 Nov; 90(11):2509-20.

1. Overview 

a. Classification 

b. Presentation(s) 

c. Treatments 

2. Classification/Grading 

a. Grading 

i. Meyerding 

ii. Newman 

b. Wiltse 

i. dysplastic, 

ii. isthmic, 

iii. degenerative, 

iv. traumatic 

v. pathologic 

c. Marchetti – Bartolozzi 

i. Developmental 

1. High Dysplasitc 

2. Low Dysplastic 

ii. Accquired 

1. traumatic, 

2. post-surgery, 

3. pathologic, 

4. degenerative 

d. Future ? (Labelle) 

i. Sagital Profile and pelvic parameters 

3. Presentation(s) 

a. Assymptomatic 

b. Back Pain 

i. Mechanical 

ii. Referred 

iii. Stenotic 

c. Leg Pain 

REFERENCES: 

1. Boachie-Adjei, O., T. Do, and B.A. Rawlins, Partial lumbosacral kyphosis 

reduction, decompression, and posterior lumbosacral transfixation in highgrade 

isthmic spondylolisthesis: clinical and radiographic results in six 

patients. Spine, 2002. 27: p. 161-168. 

2. Bradford, D., Controversies: instrumented reduction of spondylolisthesis 

(con). Spine, 1994. 14: p. 1536-1537 

3. Fabris, D.A., S. Constantini, and U. Nena, Surgical treatment of severe L5-S1 

spondylolisthesis in children and adolescents. Spine, 1996. 21: p. 728-733. 

4. Frennered, A.K., B.I. Danielson, and A.L. Nachemson, Natural history 

of symptomatic isthmic low-grade spondylolisthesis in children and 

adolescents: a seven-year follow-up study. J Pediatr Orthop, 1991. 11: p. 209- 

213. 

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46-54, 2005. 

7. Ishikawa, S., S.J. Kumar, and B.C. Torres, Surgical treatment of dysplastic 

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9. Marchetti and Bartolozzi chapter in Bridwell textbook of spine 2nd edition 

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approaches. Spine, 1999. 24(16): p. 1701-1711. 

401 




adult SpoNdyloliStheSiS 

Joseph Perra, MD 

i. Radicular 

ii. Stenotic 

d. Deformity 

i. Listhetic 

ii. Scoliotic 

4. Treatments 

a. Do Nothing (educate) 

b. Symptomatic 

i. Exercise 

ii. Therapy 

iii. Medication 

1. Oral 

2. Injection(s) 

iv. Surgery 

1. Decompression 

2. Stabilization 

a. Fusion 

i. Instrumentation 

ii. Posterior, anterior, both 

3. Reduction 

5. Outcomes 

a. SPORT 

b. Historical literature 

6. Complications 

a. Perioperative 

i. Neurologic deficit (new) 

ii. Implant related 

iii. Infection 

iv. durotomy 

b. Late 

i. Adjacent degeneration 

ii. Pseudoarthrosis 

11. Poussa, M., et al., Surgical treatment of severe isthmic spondylolisthesis in 

adolescents. Reduction or fusion in situ. Spine, 1993. 18: p. 894-901. 

12. Roca, J., et al., One-stage decompression and posterolateral and interbody 

fusion for severe spondylolisthesis. An analysis of 14 patients. Spine, 1999. 

24: p. 709-714. 

13. Saraste, H., Long-term clinical and radiological follow-up of spondylolysis 

and spondylolisthesis. J Pediatr Orthop, 1987. 7: p. 631-638. 

14. Scaglietti, O., G. Frontino, and Bartolozzi, Technique of anatomical 

reduction of lumbar spondylolisthesis and its surgical stabilization. Clin 

Orthop, 1976. 117: p. 165-175. 

15. Seitsalo, S., et al., Severe spondylolisthesis in children and adolescents: longterm 

review of fusion in situ. J Bone Joint Surg [Br], 1990. 72: p. 259-265. 

16. Seitsalo, S.O. and H. Hyvarinen, Progression of spondylolisthesis in children 

and adolescents: a long-term follow-up of 272 patients. Spine, 1991. 16: p. 

417-421. 

17. Smith, M.D. and H.H. Bohlman, Spondylolisthesis treated by a single stage 

operation combining decompression with in situ posterolateral and anterior 

fusion: an analysis of eleven patients who had long-term follow-up. J Bone 

Joint Surg [Am], 1990. 72: p. 415-421. 

18. Weinstein,J.N., Lurie, J.D., Tosteson, T.D., Blood,E.A., Birkmeyer, N., 

Herkowitz,H., 

19. Longley,H.M., Lenke, L., Emery,S., Hu,S.S., Surgical Compared with 

Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis. 

Four-Year Results in the Spine Patient Outcomes Research Trial (SPORT) 

Randomized and Observational Cohorts. J Bone Joint Surg Am. 

2009;91:1295-1304. 

20. Wiltse, L.L., P.H. Newman, and I. Macnab, Classification of spondylolysis 

and spondylolisthesis. Clin Orthop Relat Res, 1976(117): p. 23-9.

402 

CompleX Shoulder pathology 

iN the youNg athlete: 

a CaSe-baSed SympoSium (a) 

Moderator: Matthew T. Provencher, MD, San Diego, CA 

Utilizing a case-based presentation format and interactive audience discussions, multiple shoulder cases will be presented 

in order to determine optimal workup, treatment, with an extensive discussion of potential pearls and pitfalls to avoid 

postoperative complications. 

I. Introduction and warm-up case 

Matthew T. Provencher, MD, San Diego, CA 

a. goals of the symposium 

b. interactive audience participation, live microphones entire course 

c. PANEL discussion throughout the course 

d. Introduce ARS – when utilized for treatment options and clinical decision making 

Brief outline of shoulder topics to be presented: 

• Instability o Anterior with bone loss case 

— Posterior instability, missed diagnosis case 

— Soft tissue issues, MDI 

— Combined bone loss case, failed instability 

— Rotator interval treatment with above cases 

• Rotator Cuff o Partial thickness cuff tear (PASTA and PAINT lesions) 

— Cuff augmentation (patches – dermal, allograft, etc) indications? 

— Failed tear in young patient – rehab considerations 

• Biceps and SLAP o Biceps pulley case – diagnosis and management 

— Failed SLAP repair case 

— Internal impingement in thrower – optimal rehab; operative? 

— Snapping scapula case – nonoperative vs operative care 

• Acromioclavicular Joint o Type 3 separation – acute management 

— Type 5 separation – acute management – options? 

— Failed AC separation case – wrap up 

• Miscellaneous o Postarthroscopic chondrolysis management/prevention 

— Os acromiale – diagnosis and management 

• Warm up cases: Instability 

— Anterior with bone loss case - ARS 

— Posterior instability, missed diagnosis case 

— Soft tissue issues, MDI 

— Combined bone loss case, failed instability - ARS 

— Rotator interval treatment with above cases - ARS 

II. Rotator Cuff – Case Presentations 

Richard K. N. Ryu, MD, Santa Barbara, CA 

a. Partial thickness cuff tear (PASTA and PAINT lesions) - ARS 

b. Cuff augmentation (patches – dermal, allograft, etc) indications? 

c. Failed tear in young patient – rehab considerations – ARS 

III. Biceps and SLAP 

Jeffrey S. Abrams, MD, Princeton, NJ 

a. Biceps pulley case – diagnosis and management -ARS 

b. Failed SLAP repair case 

c. Internal impingement in thrower – optimal rehab; operative? - ARS 

d. Snapping scapula case – nonoperative vs operative care 



SympoSia SpORTS MEd/ARTHRO

403 

IV. Acromioclavicular Joint 

John M. Tokish, MD, Peoria, AZ 

• Type 3 separation – acute management - ARS 

• Type 5 separation – acute management – options? 

• Failed AC separation case – wrap up – ARS 

• Miscellaneous 

— Postarthroscopic chondrolysis management/prevention - ARS 

— Os acromiale – diagnosis and management 

V. Wrap-up, Final Questions and Answers 





404 

CompleX Shoulder pathology iN the youNg athlete: 

gleNoid boNe loSS 

Matthew T. Provencher, MD CDR MC USN, Rachel Frank, BS 

1. Potential Pitfalls in Any Shoulder Instability Repair 

• Glenoid bone loss – Lots of attention in recent literature 

• Significant Hill-Sachs lesion – combined with Glenoid bone 

loss may be more important than previously realized 

• Revision situation – post thermal cases 

• Revision situation with prior capsular insufficiency 

• Prior anchor placement 

• Error in diagnosis 

• Rehabilitation issues and compliance 

• Technical errors 

— Correct anchor placement 

— Proper capsular mobilization (HAGL) 

— RI Closure? 

— Prior thermal cases? 

— Adequate capsular tensioning – 1cm? 

— HAGL injuries 

• Associated injuries 

— SLAP, HAGL, bony deficiencies 

— Neurologic injury (winging!) 

• Boileau (JBJS 2006) 4 – “Risk factors for recurrence of 

shoulder instability after arthroscopic Bankart repair” 

— 91 patients followed prospectively 

— 15.3% recurrence (36 months f/u), at 17 months postsurgery 

— Recurrence higher in hyperlaxity, bone loss, and number 

of anchors (4 or more was good prognostic sign) 

• Tauber 32 – “Reasons for failure after surgical repair of 

anterior shoulder instability” 

— 41 patients followed 49 months 

— At revision surgery – 56% with persistent bony defect, 

patulous capsule 22%, laterally torn capsule 5% 2 . 

Glenoid Bone Loss – Prevalence, Etiology, Classification, 

and History 

• Burkhart and DeBeer Arthroscopy 2000 5 

— 21 of 194 patients with “significant” glenoid bone loss 

— Defined “Inverted Pear” glenoid 

— 61% failure in patients with inverted pear glenoid treated 

arthroscopically 

• 100 CT scans of shoulder instability patients (Sugaya JBJS 

2003) 28 

— 50% osseous Bankart lesion (1 large – 27%, 27 med – 

11%, 22 small – 3%) 

• Location of glenoid defect – mean at 4:17 o’clock (anteroinferior). 

(Saito AJSM 2005) 27 

— Parallel to long axis of glenoid 

— At higher % defects, the line of bone loss changes 

somewhat to slightly more oblique 

• Griffith – AJR 2008 9 

— More bone loss in recurrent instability 

— 145 patients with CT scan – 

– 0-10% bone loss – 51% 

– 10-20% bone loss – 37% 

– 20-25% bone loss – 6% 

– >25% bone loss – 6% 

• Glenoid bone loss higher rate of failure after stabilization 

procedures (Bigliani AJSM 1998) 2 

— Amount and type of bone loss quantified and classified 

into 3 types 



SympoSia SpORTS MEd/ARTHRO 

— 25 patients with glenoid rim lesions were classified 

— 22 / 24 shoulder with good stability at 30 months (88%) 

— Type I (16 pts); Type II (5 pts); Type IIIA (3 pts); Type 

IIIB (1 pt) 

Recommendations from their clinical experience: 

Type I Avulsion fracture Bone/capsule repair 

Type II Medial fragment Capsular Repair 

Type IIIA 25% bone loss Coracoid transfer 

• Burkhart and DeBeer, Arthroscopy 2000 5 

— 194 athletes (101 rugby players) with arthroscopic 

Bankart Repair 

— 3 metallic suture anchors on average 

— 173 without bony defects 4% recurrence 

— 10.8% recurrence rate (21 total; 14 redislocations, 7 

subluxations) 

— 21 with bony defects 67% recurrence 

– Contact athletes with bone defect 89% recurrence 

— Significant bone defect = “Inverted pear glenoid” 

(not precisely measured, but as viewed from the 

anterosuperior portal the inferior diameter of the glenoid 

was smaller than the superior diameter”) 17 

CONCLUSION: Patients with significant bone defects, especially 

contact athletes are not candidates for arthroscopic repair 

— Approximately 11% had significant glenoid bone defects 

• Patient History – low threshold for glenoid bone loss 

suspicion especially if (Piasecki, Provencher, Romeo et al; 

JAAOS 2009): 

— Long-term history of recurrent shoulder instability 

— Multiple dislocations 

— Mechanical clunk 

— Multiple reductions/Emergency Room reductions 

— Progressive ease of dislocation and also reduction 

— History of self reduction (Not MDI) 

— Instability symptoms in mid-ranges of motion 

— Examination with instability in mid-ranges of motion; or 

palpable clunk 

• Consider this Overall approach to a patient with recurrent 

instability: When approaching a patient with recurrent 

shoulder instability think about “How much bone loss do 

they have” in order not to miss it. 

— Bone loss is likely the #1 cause of failed arthroscopic 

instability repair 

3. Glenoid Bone Loss - Biomechanics 

— Biomechanics: Itoi (JBJS 2000)15 

— glenoid defects anteroinferiorly of >21% (mean 6.8 mm) 

causes persistent instability and limit ER after Bankart 

repair. 

— However, he demonstrated stability in ABER position due 

to competent capsular constraints. ABD&IR allowed to 

subluxate. 

CONCLUSION: Glenoid Defects >21% (approx 6.8 

mm) may cause continued instability and limit ER after 

Bankart Repair (especially with capsular repair) Clinical

405 

Applicability: What is also inferred from Itoi’s work is that 

in up to a 21% bone defect, the capsular restraints will 

potentially be enough for stability when adequately repaired 

4. Glenoid Bone Loss – Treatment Algorithm 

*** Clinical suspicion remains paramount! **** 

• Low threshold to obtain advanced imaging to assess for 

glenoid bone loss with the following (not all inclusive): 

— Prior failed instability procedure 

— Multiple prior instability events, multiple subluxations or 

dislocations 

— Long history, chronic instability (> 6 months?) 

— Trivial trauma for first instability event (glenoid 

hypoplasia) 

— Bilateral history of shoulder instability 

— Plain film suggestion of bony glenoid deficiency 

• Best to know ahead of time your operative plan, as surgical 

technique is based upon the amount of glenoid bone loss 

6. Glenoid Bone Loss – Treatment Options 

• Based upon preoperative or intraoperative determination of 

bone loss 

• Key: How to obtain a successful stabilization procedure with 

minimal losses of motion 

• Nonoperative 

— Smaller fragments 

— Lower demand individuals 

— Maquieira (JBJS-Br 2007) found no redislocations 

in 14 patients with >5 mm bone fracture treated 

nonoperatively 

Arthroscopic Repair 

• Glenoid bone loss less than 20 to maybe 25% 

• Can be successful 

• Provencher et al (2007)19– results better with incorporation 

of bony fragment; 3 types of fragments seen in study: 

— Attritional loss – no bone fragment 

— Attritional loss with some bone fragment 

— Bony fragment present that represents the true amount of 

bone loss (no attritional losses) 

• Sugaya et al (2006)29, 30 – bony lesion, if repaired with 

arthroscopic techniques can heal to more normal/near 

anatomic position 

— Reconstitutes the bone loss of glenoid 

— Better if more acute injury 

— Less predictable if attritional/erosion loss 

Open Repair without Bony Augmentation 

• Described for open capsulolabral repair to address bone loss 

— Probably similar to arthroscopic repairs, potentially 




higher success? 

— 0/14 recurrences in open repair procedure20 

• Open repairs – screw fixation of acute fractures31 

Bone Augmentation Procedures 

• Glenoid bone loss of potentially any amount 

• Especially in loss >20-25% 

• Variety of options and techniques 

• Arthroscopic bone grafts 

— Arthroscopic coracoid transfer 

• Open bone grafts 

— Coracoid transfer 

– Bristow – “tip” of coracoid 

– Latarjet – larger piece of coracoid 

– Management of the “Latarjet” – can be confusing 

– Many “ways” to do a Latarjet 

– Subscapularis tendon management 

~ Split longitudinal 

~ Complete take-down 

– Conjoint tendon management 

~ Leave on as a “sling” 

~ Reattach to remnant coracoid 

– Orientation of the coracoid 

~ Lateral edge (traditional) or inferior edge 

(Burkhart) as the glenoid face 

~ With INFerior edge as glenoid face: 

- More bone to work with – up to 14mm 

- Better congruity of the glenoid and humerus 

(Ghodadra, Romeo, Provencher et al 2009 JBJS 

in print) 

- “Fits better” 

• Iliac crest bone graft 

— Large inner table shelf 

— Haaker10 (Mil Medicine); Warner33 

— Can be utilized for very large defects 

• Allograft 

— Concerns of noncontained graft incorporation in the past 

— Femoral head allografts have been shown to heal (1996 

data)12 

— May be option in future? Have to demonstrate efficacy, 

healing, and capsular management 

New advancement – Allograft Option Recently Described: 

• Fresh osteochondral distal tibia allograft as an alternative to 

fresh glenoid 

• Prior difficulty obtaining fresh glenoid allograft (contamination 

and harvest issues) - Investigated novel application of distal 

tibia to the glenoid (REF) 

— Exceptional fit and near perfect radius of curvature to the 

humeral head and glenoid (REF) 

— Figure: 

— Fresh – weight bearing bone; excellent corticocancellous 

fixation 

— As of Sept 2009, have performed 7 cases, most over 10 

months out, all with documented healing on CT scan (axial 

images) and full return to military duties 

— Still “investigational” as prior allograft concerns are evident, 

however, this represents new fresh allograft technique to the 

glenoid. 

• No prior graft processing (radiation, sterilization) 

• Excellent weight-αbearing dense tibia bone 

• Basic science and clinical evidence that the bone “fits” well 

7. Glenoid Bone Loss – Selected Results 

• Previously discussed Burkhart and De Beer (Arthroscopy 2000) 

— Very high recurrence (67%) with “inverted pear glenoid”

• Sugaya et al. (JBJS 2005)29 – “Arthroscopic osseous Bankart 

repair for chronic recurrent traumatic anterior glenohumeral 

instability” 

— 42 patients followed 34 months with mean loss of 24.8% 

anterior glenoid. 

– All had osseous fragment that was incorporated into the 

Bankart Repair (anchors) 

– 39/42 G/E result at final f/u – 2 with reinjury 

• Provencher, Mologne et al AJSM 200719 

— 23 patients (mean age 25 years, San Diego military 

population) 

— 93% follow-up at mean of 37 months 

— Mean of 25% anterior glenoid bone loss 

— All treated with arthroscopic repair (3 to 4 bioabsorbable 

anchors) 

— 11 patients had “Attritional loss” (no bony Bankart); 10 

patients had Bony Bankart 

— 3 Failures all in the “attritional” group (2 sublux, 1 

dislocated) 

– Mean loss ABER = 8 degrees 

• Porcellini et al AJSM 200722 

— 215 arthroscopic repairs over 6 years 

— 31.5% had bony Bankart; operated on early versus late 

— Review of results showed chronic (61 Rowe score) had less 

favorable outcomes than acute (92 Rowe score) 

• Rhee et al Int Orthop 200725 

— Open Bankart repair those with glenoid bone loss (20 pts) 

and those without (20 pts) 

— Less favorable scores with larger glenoid bone loss 

• Burkhart et al Arthrosc 20076 

— 102 patients treated with a Modified Latarjet with glenoid 

bone loss 

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406 




— All had “inverted pear” Glenoid (arthroscopically measured) 

- 5 of 102 patients àα recurrence (4.9%) 

— Boileau et al Arthrosc 20073 - Arthroscopic Bristow 

procedure; transfer of coracoid with conjoint and a repair 

of the capsulolabral structures - 8% failures of 36 patients 

total 

— Provencher et al Arthrosc 2008 - Anatomic osteochondral 

allograft reconstruction for glenoid bone deficiency 

using distal tibia allograft - Basic science work has 

demonstrated excellent congruence and similar radius of 

curvature across numerous specimens 

• Pagnani et al AJSM 2008 

— 103 patients followed after open shoulder instability repair 

(mean age 20) 

— 84% Hill-Sachs (27% engaging, 57% nonengaging) 

— 14% anterior glenoid deficiency (4% with more that 20% 

defect) 

— Overall recurrence 2%; HIGHER if had a “engaging” Hill- 

Sachs 

— If large glenoid defect lost 12 degrees motion vs 5 degrees ER 

losses 

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• Weng AJSM 2009 

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bone graft 

— Femoral head allograft and anteroinferior capsular shift 

— Followed 4. 5years, 9 patients 

— Serial radiographs – all with union at 6 months after surgery 

— Overall good results – 1 subluxation and 1 dislocation 

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18. Mologne TS, Michio H, Zhao K, An KN, Provencher MT. The Addition of 

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ADDITIONAL READING AND RESOURCES 

1. Piasecki D, Ghodadra N, Bach BR, Romeo AA, Provencher MT. The diagnosis 

and management of glenoid bone loss in recurrent anterior shoulder 

instability. Journal of the American Academy of Orthopaedic Surgeons 2009; 

17(8):482-493. 

2. Seroyer S, Nho S, Provencher MT, Romeo AA. Four-Quadrant Approach 

to Capsulolabral Repair: An Arthroscopic Roadmap to The Glenoid. 

Arthroscopy (In Press). 

3. Detterline AJ, Provencher MT, Ghodadra N, Bach BR, Verma N, Romeo AA. A 

novel measurement of anterior glenoid bone loss; correlation measurements 

of the inverted pear glenoid. Arthroscopy 2009. In print. 

4. Grumet R, Ghodadra N, Romeo AA, Bach BR Jr., Provencher MT. Recurrent 

shoulder instability with glenoid bone loss. Orthopaedic Knowledge Update, 

Online 7(9); http://www5.aaos.org/oko/description.cfm?topic=SHO032. 

Accessed September 2, 2009. 

5. Provencher MT, Ghodadra N, LeClere L, Bach BR, Solomon DJ, Romeo 

AA. Anatomical osteochondral glenoid reconstruction for recurrent 

glenohumeral instability with glenoid deficiency using a distal tibia allograft. 

Arthroscopy 2009;25(4)446-452 

6. Kang RW, Frank R, Nho S, Ghodadra N, Verma NN, Romeo AA, Provencher 

MT. Complications Associated with Anterior Shoulder Instability Repair. 

Arthroscopy 2009; 25(8):909-920. 

7. Provencher MT, Detterline AJ, Ghodadra N, Romeo AA, Bach BR, Cole BJ, 

Verma N. Measurement of glenoid bone loss: A comparison of measurement 

error between 45° and 0° bone loss models and with different posterior 

arthroscopy portal locations. American Journal of Sports Medicine 2008; 

36(6):1132-1138. 

8. Schroder DT, Provencher MT, Mologne TS, Cox JS. The modified 

Bristow Procedure for anterior shoulder instability: 26-year outcomes 

in Naval Academy Midshipmen. American Journal of Sports Medicine 

2006;34(5):778-786. 

9. Mologne TS, Provencher MT, Menzel KA, Bell SJ. Arthroscopic stabilization of 

patients with glenoid bone deficiency. American Journal of Sports Medicine 

2007;35(8)1276-1283. 

10. Provencher MT, Ghodadra N, Romeo AA, Solomon DJ. Characterization 

of anterior shoulder instability. AAOS Annual Meeting Multimedia 

Presentation, New Orleans, LA, 2010. 

11. Ghodadra N, Grumet R, Mologne TS, Bach BR, Romeo AA, Provencher MT. 

The diagnosis and management of glenoid bone loss. AAOS Annual Meeting 

Scientific Exhibit, New Orleans, LA, 2010. 

12. Provencher MT. Pearls and pitfall in the surgical treatment of recurrent 

instability of the shoulder – techniques and bailouts. AAOS Annual Meeting 

Multimedia Presentation, Las Vegas, NV 2009. 

13. Provencher MT, Solomon DJ. The diagnosis, measurement, and treatment 

of shoulder instability in patients with glenoid bone loss. AAOS Annual 

Meeting Multimedia Presentation, Las Vegas, NV 2009.

408 

arthroSCopiC treatmeNt oF poSterior iNStability 

Jeffrey S. Abrams, MD 

Posterior and posteroinferior instability occur when excessive 

posterior humeral translation becomes painful and disabling. 

Although once thought to be uncommon, it can be found in 

athletes and other individuals who participate in repetitive overhead 

activities and contact sports. The gold standard of treatment should 

include correction of dynamic and static factors that limit posterior 

translation. A particular technique becomes a “gold standard” when 

success rates are improved, fewer complications occur, and the 

technique is reproducible amongst many treating physicians. 

Classifications 

a. Subluxation versus dislocation 

Dislocation is a relatively uncommon occurrence that is often 

the result of seizure due to the 3 E’s: ethanol, epilepsy, and 

electricity. The more common patient is a subluxator, i.e., the 

humerus translates posterior to the glenoid and then reduces 

without assistance. 

b. Subluxation classification 

• Voluntary: 

— Habitual 

— Muscular contraction 

• Involuntary 

— Positional: forward flexion 

— Symptoms reproduced with load-and-shift (occult) 

c. Onset of symptoms 

• Traumatic – unidirectional 

• Atraumatic/overuse – symptomatic direction MDI, 

posteroinferior 

Indications for arthroscopic approach 

• Recurrent posterior subluxation that remains symptomatic in 

spite of attempting a nonoperative stabilization program. 

• Involuntary: painful symptoms reproduced by 

(a) forward flexion, adduction 

(b)posterior load-and-shift exam 

Contraindications of arthroscopic approach 

• Voluntary subluxators: Habitual and subluxators due to 

muscular contraction should be treated with nonoperative 

programs 

• Significant bone abnormality, i.e., excessive glenoid retroversion, 

should be considered for glenoid osteotomy and open 


Role of load-and-shift translation tests: 

• Awake patients reproduce symptoms 

• EUA compare translation to asymptomatic side 

• Examination: 

— Posterior translation 

(a) neutral 

(b) flexed, internally rotated to see if restraint improves 

— Sulcus in neutral and reevaluate with shoulder in external 

rotation 

Arthroscopic Posterior Repair: (personal figures) 

• Posterior portal (2 cm inferior to angle of acromion and spine 

of scapular). 

• Anterior portal between lateral margin of acromioclavicular 

joint and coracoid. 

• Additional posterior portals inferior and lateral for suture 

anchors. 




Portals 

Complete diagnostic exam from both portals. Visualizing from the 

anterior portal, the inferior capsule is probed and roughened with 

a shaver. Suture anchors can be placed along the posterior inferior 

glenoid rim through an accessory portal. Suture anchors are used 

when labrum is detached, inadequate to create capsule plication, 

or in cases where the soft tissue can be transferred over an articular 

glenoid defect. Sutures can be retrieved through the capsule and 

under the labrum to create a pleat. Capsule plication can reduce 

inferior and posterior pouches. Suture anchors can be placed in the 

humeral head when capsule is avulsed. 

Visualizing from posterior portal, anchor repair of anterior labrum 

or Type II SLAP lesions. In cases where there is no additional labral 

pathology and a sulcus sign exists, rotator interval is reduced with 

sutures between the middle and superior glenohumeral ligaments. 

Labral tear Anchor 

Shuttle Repair 

Capsule pouch Plication 

Postoperative 

• Sling for 4-6 weeks 

• External rotation, shrugs 

• At 4 weeks, supine forward flexion 

• At 8 weeks, cuff and scapular strengthening

• At 3 months, advance strengthening 

• Noncontact sports, 4 months 

• Contact sports, 6 months 

Arthroscopic findings (49 patients) 

Most patients have enlarged posterior pouches (48), labral tears or 

detachments (26), glenoid articular defects (4), posterior capsule tear 

or humeral head detachment (2). In addition, coexistent pathology 

in the anterior and superior quadrant included SLAP lesions (4), 

anterior labral and capsule tears (13), articular partial-thickness 

rotator cuff tears (4), and enlarged rotator intervals (common in 

MDI). 

409 

Chondral changes SLAP tear reverse HAGL 

Results 

1. Abrams, JS (OCNA 2004). In 49 patients (2/3 traumatic) with 

2 recurrences (4%); 4 stable, but pain, stiffness after 6 months, 

requiring more than 6 months to resolve; 85% return to 

athletics; 90% throwing sports; 6 of 7 workmen’s compensation 

cases; 88% success. 

2. Wolf EM, Eakin CL (Arthroscopy 1998). 14 patients 

REFERENCES/BIBLIOGRAPHY 

1. Abrams JS. Arthroscopic repair of posterior instability and reverse humeral 

ligament avulsion lesions. Orthop Clin N Am 34:475-483, 2003. 

2. Abrams JS. Arthroscopic treatment of posterior instability. In Tibone JE, 

Savoie FH III, Shaffer BS, eds: Shoulder Arthroscopy, Springer, 2003, pp 97- 

103. 

3. Antoniou J, Duckworth DT, Harryman DT II. Capsulolabral augmentation 

for the management of posteroinferior instability of the shoulder. J Bone 

Joint Surg 82(A):12201230, 2000. 

4. Bell RH, Noble JS. An appreciation of posterior instability of the shoulder. 

Clin Sports Med 10:887-900, 1991. 




(9 traumatic, 5 overuse) repaired. All had enlarged pouches, 12 

had labral tears, 2 had anterior labral tears. One recurrence; 9 of 

10 returned to sport and 86% success. 

3. Kim SH, Ha KI, Park JH, et al (JBJS 2003). 27 patients 

(traumatic) repaired with one recurrence. All patients had 

enlarged posterior inferior pouches and most with labral tears 

or stripping. 

Conclusions 

Stabilization can predictably be performed in patients with recurrent 

posterior subluxation due to loss of soft tissue restraint. Multiple 

labral and capsular lesions can be discovered arthroscopically 

and repaired in addition to managing the enlarged posterior and 

inferior pouch. Improved stabilization rates can be attributed to 

proper patient selection, arthroscopic recognition, and correction of 

capsular and labral insufficiency that can limit humeral translation. 

The new gold standard recognizes and corrects the primary and 

secondary lesions. 

The gold standard of posterior repair: 

1. Reduced rate of recurrence of subluxation 

2. Reduced rate of complications; i.e., coracoid impingement 

3. Direct repair, rather than indirect shift, of capsule deformity 

4. Recognition and repair of coexistent lesions opposite the 

posteroinferior lesions (circle concept) 

5. Capsular plication of the rotator interval when indicated 

5. Harryman DT, Sidles JA, Harris SL, et al. Role of the rotator interval capsule 

in passive motion and stability of the shoulder. J Bone Joint Surg (Am) 

74:53-66, 1992. 

6. Hawkins RJ, Koppert G, Johnson G. Recurrent posterior instability 

(subluxation) of the shoulder. J Bone Joint Surg (Am) 66:169-174, 1984. 

7. Kim SH, Ha KI, Park JH, et al. Arthroscopic posterior labral repair and 

capsule shift for traumatic unidirectional recurrent posterior subluxation of 

the shoulder. J Bone Joint Surg (Am) 85(A):1479-1487, 2003. 

8. Nobuhara K, Ikeda H. Rotator interval lesion. Clin Orthop 223:44-50, 1987. 

9. Weber SC, Caspari RB. A biomechanical evaluation of the restraints to 

posterior shoulder dislocation. Arthroscopy 5:115-121, 1989. 

10. Wolf EM, Eakin CL. Arthroscopic capsule plication for posterior shoulder 

instability. Arthroscopy 14:153-163, 1998.

410 

deCiSioN-makiNg iN biCepS aNd Slap iNJurieS 

Richard K.N. Ryu, MD 

I. Anatomy 

a. Originates from posterior-superior labrum and supraglenoid 

tubercle 

b. Intraarticular / extra-synovial 

c. Widest at origin and progressively narrows 

d. Stability in groove provided by coracohumeral and superior 

glenohumeral ligaments primarily; tuberosities and 

transverse humeral ligament less important 

e. Proximal third with higher degree of innervation; substance 

P and calcitonin gene-related peptides present (rich 

sympathetic sensory network) 

f. Angular orientation of biceps in relationship to HH 

(adaptive) diminishes arm elevation capability; ? increased 

risk of biceps instability 

g. Vascularity arises from the capsule and periosteum, not 

from underlying bone; like meniscus, periphery with greater 

vascularity. h. Superior attachment of the biceps-labrum 

complex (BLC) labrum has three variations: (Stoller) 

1. Continuous with the articular surface where there is no 

cleft 

2. Attached medial to glenoid with hyaline cartilage 

beneath the free edge (meniscoid) 

3. Meniscoid attachment where a large cleft (sulcus) is 

present between the labral edge and the underlying 

articular cartilage 

i. Buford” normal variant where MGHL derives from the 

superior labrum with the anterior-superior labrum absent ( 

occurs in 1.5% ) 

j. Senescence pattern seen with superior labrum; separation 

as well as fraying can be a normal aging pattern without 

symptoms 

1. Pfahler JSES 2003: Senescence and natural course of 

labral degeneration. Micro and macroscopic analysis of 

NORMAL shoulders stratified by age concept of “agedependent” 

course of the labral attachments. 3 stages : 

i. < 10 years old circumferential attachment 

ii. 30-50 years old fissuring and recesses appear 

iii. >60 years old circumferential tearing, fissuring and 

detachment 

II. Biceps Function 

a. Humeral head depressor ? 

i. Larger size in chronic massive cuff tears may reflect 

chronic inflammation rather than hypertrophy 

ii. EMG does not support humeral head depressor theory; 

several studies indicate minimal role of biceps in the 

throwing shoulder 

iii. Position of biceps over HH in full external rotation may 

contribute to depressor function 

b. Shoulder Stabilizer 

i. Cadaveric biomechanical studies indicate enhanced 

glenohumeral stability with biceps contraction as 

resistance to torsional forces improved; resistance to 

superior HH migration with biceps activity also noted 

ii. EMG data does support; throwers with anterior instability 

patterns demonstrate greater EMG biceps activity 

iii. Elbow function may dictate contribution of biceps to 

HH/GH stability 

c. Does the biceps play a role in shoulder function? If so, is it 

clinically significant? Function or lack thereof forms basis for 




treatment alternatives and patient selection 

III. Biceps Pathology (non-SLAP) 

a. Need to consider “isolated” (less common) or associated 

pathology, i.e. RC pathology 

b. Etiologies: 

i. Impingement phenomenon 

ii. Intrinsic tendon degeneration 

iii. Instability, traumatic or associated with subscapularis tear 

iv. Traumatic 

v. Combination 

c. Categories: 

i. Partial tears (degneration and/or associated with cuff 

pathology 

ii. Complete ruptures (usually secondary to chronic partial 

with progression vs acute trauma) 

iii. Synovitis (“lipstick”synovitis per Gross) 

iv. “Hourglass” deformity (Boileau) of intra-articular 

segment ( chronic inflammation leads to thickened 

segment which cannot traverse the bicipital groove; 

tendon fails to glide as shoulder is rotated; segment 

“bunches up” as shoulder taken through ROM; patients 

lose terminal 10-20 degrees of FF 

v. Instability (usually in association with subscapularis 

injury; can occur as a result of acute trauma 

1. Instability can be medial (most common) with injury 

to medial sling (and subscapularis ); theoretically 

can reduce with internal rotation but clicking and 

popping usually not the associated with dislocation 

and relocation when medial 

2. Instability can be lateral with disruption of 

anterior superior cuff and lateral expansion of the 

coracohumeral ligament; lateral instability can be 

associated with a dislocation-relocation phenomenon 

as the arm is externally rotated 

vi. Combination with instability and partial tearing 

common 

IV. SLAP Pathology 

a. Classification: 

i. Type I: degenerative fraying at the base of the anchor 

ii. Type II: detachment of the superior labrum from the 

glenoid/supraglenoid tubercle 

iii. Type III: bucket-handle tear of the superior labrum 

sparing the biceps attachment iv.Type IV: bucket-handle 

tear of the superior labrum extending in the substance of 

the biceps and possibly into the anchor as well 

v. Type V: type II detachment contiguous with a Bankart 

lesion anterior and inferior 

vi. Type VI: type II detachment with a flap tear of the 

superior labrum 

vii.Type VII: type II detachment with extension along 

anterior labrum extending into the middle glenohumeral 

ligament 

viii. Type VIII: type II detachment contiguous with a 

posterior Bankart lesion 

ix. Type IX: type II with extension both anterior and 

posterior in which circumferential labral detachment is 

present 

x. Type X: type II detachment with non-contiguous 

posterior Bankart

411 

1. Characteristics 

Types 1-IV are basic types 

Types V –X are complex subtypes 

Type II most commonly encountered 

Type 1 requires no treatment 

Type II, III. IV, V associated with instability 

b. Associated Pathology: Isolated SLAP lesions are uncommon 

i. Snyder 43% associated rotator cuff partial or complete 

tear; 15% with instability 

ii. Maffet 48% associated rotator cuff pathology; 20% 

instability 

iii. Pagnani 18% with concomitant rotator cuff surgery 

iv. Stetson: of 140 patients with confirmed SLAP lesion, only 

26 without associated pathology 

1. Leads to critical question: 

If reported success rate with SLAP repair in 

CONJUNCTION with associated pathology, how can 

we know that the SLAP lesions was symptomatic in the 

first place given the difficulty with physical findings, 

imaging confirmation and clinical presentation? 

c. Mechanism of injury 

i. Andrews 1985: traction-type “pulling” injury; biceps 

overload 

ii. Snyder 1990: compression with arm flexed and abducted 

iii. Morgan/Burkhart 2002: “Peel-back” mechanism 

iv. Currently no one specific “mechanism of injury”; 

clearly superior labrum can be injured from a variety of 

forces; certain activities e.g. throwing can be linked to a 

particular set of forces which create a predictable lesion 

V. History and Physical Examination for Biceps (non-SLAP) 

a. History is usually compatible with that given by those with 

impingement type symptoms although the pain may be 

more anterior and radiate into the biceps (possibly the 

hand); popping and snapping moving from internal to 

external rotation may signify instability 

b. Physical findings can overlap as biceps pathology is 

commonly encountered in conjunction with rotator cuff 

disease 

i. Tenderness over bicipital groove (best palpated in 10-20 

degrees of internal rotation and 8-10 cm distal to tip of 

acromion; assess “ groove “ tenderness with palpation 

ii. Yergason or Speed test can be sensitive but not very 

specific 

iii. Some motion loss, esp internal rotation, may be noted; 

loss of forward flexion may indicate “hour-glass” type 

phenomenon 

iv. Differential injections can be helpful. Subacomial 

injection should not improve isolated biceps pathology. 

Intraarticular injection should improve biceps pain; can 

also use CT guided injection into the groove 

VI. Diagnostic Testing: 

a. Plain films are not very useful in most cases. Avulsion 

fragments from the tuberosity may indicate instability. 

b. MR arthrogram can be helpful to assess the biceps including 

morphology, position and whether contrast flows through 

bicipital groove (lack thereof may suggest chronic synovial 

thickening and a diseased tendon) 

c. Ultrasound especially useful in determining bieps 

dislocation; intra-articular pathology not well identified with 




this modality 

d. Arthroscopic evaluation may be the final assessment when 

biceps pathology is suspected, but not confirmed with 

noninvasive testing; Imperative that tendon is inspected 

thoroughly by pulling biceps into the joint and evaluating 

that portion usually hidden within the bicipital groove 

VII. History and Physical Examination for SLAP lesions 

a. Overlapping symptoms can make diagnosis difficult e.g. 

impingement-type symptoms and instability 

• Stetson: ISOLATED SLAP 

i. Positive impingement sign 52% 

ii. Pop/snap 43% 

iii. Anterior apprehension 39% 

iv. Biceps tension 35% 

b. Snyder: Speed test and O’Brien test most helpful in 

establishing biceps involvement; also recommends 

compression-rotation test ( analogous to McMurray’s) 

to trap unstable fragment; No single test or combination 

diagnostic of a SLAP tear 

c. Multiple tests described to diagnose SLAP lesions; overall the 

reported tests have low specificity and sensitivity (Kim JBJS, 

Oh AJSM 2008) 

d. Gobezie, et.al AJSM 2008: Inter and Intraobserver Variability 

in Diagnosis and Treatment of SLAP Tears 

• 73 EXPERT surgeons queried with video clips on diagnosing 

and treating SLAP lesions: 

i. Substantial variability 

ii. Difficulty distinguishing Type I and II 

iii. Results: 

1. Normal labrum 66.7% correct (D x and Tx both) 

2. Type 1 SLAP 60.3% “ “ 

3. Type II SLAP 51.9% “ “ 

4. Type III SLAP 23.3% “ “ 

5. Type IV SLAP 60.3% “ “ 

VIII. Diagnostic imaging for SLAP lesions: 

a. MR primary non-operative means to confirm the diagnosis; 

use of gadolineum essential 

b. Caution regarding normal variants e.g. Buford complex, 

sublabral foramen; be aware of BLC variants 

c. Presence of spinoglenoid cyst should raise the possibility of 

a SLAP lesion (analogous to meniscal tear and cyst) 

1. Arthroscopy remains the “gold” standard in confirming 

the diagnosis Salient arthroscopic features: 

i. For obvious lesions e.g. Types II and IV, careful 

probing reveals displaced fragment and extent of 

biceps involvement 

ii. As traction is applied to biceps tendon, the anchor 

pulls away from the superior glenoid; if more than 5 

mm displacement‡• likely a legitimate Type II SLAP 

lesion 

iii. Probing of the labrum allows “lifting” off of the 

superior labrum IN CONJUNCTION with irregular 

appearance of the underlying hyaline cartilage, + 

granulation tissue, significant fissuring and fraying 

iv. Dynamic assessment arthroscopy: arm is taken out of 

traction and placed in the ABER position; progressive 

external rotation and horizontal extension leads to 

“peel-back” of the posterior-superior labrum which 

can be visualized directly

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Glenoid Labrum. J Shoulder Elbow Surg 4; 243-248, 1995 

12. Nam, EK, Snyder SJ. The Diagnosis and Treatment of Superior Labrum 

Anterior Posterior (SLAP) Lesions. Am J Sports Med 31;798-810, 2003 

13. Maffet, MW, Gartsman, GM, Moseley, B. Superior Labrum-Biceps Tendon 

Complex Lesions of the Shoulder Am J Sports Med 23; 93-98, 1995 

13. Burkhart, SS, Morgan, CD The Peel-Back Mechanism: It’s Role in Producing 

and Extending Posterior Type II SLAP Lesions and Its Effect on SLAP Repair 

Rehabilitation. Arthroscopy 14; 637-640, 1998 

14. Franchesci, F., Longo, UG, Ruzzini, L., et.al. No Advantages in RepairingA 

Type II Superior Labrum Anterior and Posterior (SLAP) Lesion When 

Associated with Rotator Cuff Repair in Patients Over Age 50: A Randomized 

Controlled Trial 

15. Kim, SH, Ha, KI, Ahn, JH, et.al. Results of Arthroscopic Treatment of Superior 

Labral Lesions J Bone Joint Surg 84;981-985, 2002

16. Stetson, WB, Snyder,SJ, Karzel, RP, et.al. Long-Term Clinical Follow-Up of 

Isolated SLAP Lesions of the Shoulder. Presented at the 65th Annual Meeting 

of the American Academy of Orthopaedic Surgeons, March, 1998 

17. Oh, JH., Kim, WS, Gong, Hs. Et.al., The Evaluation of Various Physical 

Examinations for the Diagnosis of Type II Superior Labrum Anterior and 

Posterior Lesion Am J Sports Med 36: 353-359, 2008 

18. Vangsness, CT, Jorgenson, SS, Watson, T., et.al. The Origin of the Long Head 

of the Biceps From the Scapula and Glenoid Labrum: An Anatomical Study 

of 100 Shoulders J Bone Joint Surg 76B;951-954, 1994 

19. Rodosky, MW, Harner, CD, Fu, FH. The Role of the Long Head of the Biceps 

Muscle and Superior Glenoid Labrum in Anterior Stability of the Shoulder. 

Am J Sports Med 22; 1121-130, 1994 

20. Paxinos, A, Walton, J, Rutten, S, et.al. Arthroscopic Stabilization of Superior 

Labral (SLAP) Tears With Biodegradeable Tack: Outcomes to 2 Years. 

Arthroscopy 22: 627-34, 2006 

21. Blaine,TA, Edwards, S, Lee, JA, et.al Improved Outcomes with Non-Operative 

Treatment of Superior Labral Tears (SLAPS) Presented at 26th AANA Annual 

Meeting 2007, San Francisco, Ca 

22. Sassmanhausen, G, Sukay M, Mair, SD Broken or Dislodged Poly-L-Lactic 

Acid Boioabsorbable Tacks in Patients After SLAP Lesion Surgery Arthroscopy 

22: 615-619, 2006 

23. Bicknell RT, Parratte,S., Chuinard, D., et.al. Arthroscopic Treatment of Type II 

SLAP Lesions: Biceps Tenodesis as an Alternative to Re-insertion Presented at 

26th AANA Annual Meeting, San Francisco, Ca. 2007 

413 




24. Gobezie, R., Zurakowski, D., Lavery, K., et.al. Analysis of Interobserver and 

Intraobserver Variablity in the Diagnosis and Treatment of SLAP Tears Using 

the Snyder Classification. Am J Sports Med 36:1373-1379, 2008 

25. Weber, SC. Surgical Management of the Failed SLAP Repair. Presented at 

Closed Meeting ASES, Santa Barbara, Ca, 2008 

26. Katz, LM, Miller, S., Hsu, S., et.al Factors of Failure and Outcomes of Failed 

SLAP Repairs ( submitted manuscript) 

27. Coleman, SH, Cohen, DB, Drakos, MC, et.al. Arthroscopic Repair of Type II 

Superior Labral Anterior Posterior Lesions with and Without Acromioplasty. 

Am J Sports Med35: 749-753, 2007 

28. Oh, JH, Kim, SH, Oh, CH, et.al. Tecurrence of SLAP Lesion Does Not Affect 

Outcome After Rotator Cuff Repair. AOSSM Specialty Day, New Orleans, La., 

March 13, 2010 

29. Nho, SJ, Frank, RM, Reiff, S., et.al Retrospective Analysis of Arthroscopic 

Superior Labrum Anterior to Posterior (SLAP) Repair: Prognostic Facotrs 

Associated with Failure. AOSSM Specialty Day, New Orleans, La., March 13, 

2010 

30. Neri, BR, Vollmer, EA, Kvitne, RS Isolated Type II Superior Labral Anterior 

Posterior Lesions: Age-related Outcome of Arthroscopic Fixation. AJSM 37; 

937-942, 2009 

31. Alpert, JM, Wuerz, T., O’Donnell, T., et.al. The Effect of Age on the Outcomes 

of Arthroscopic Repair of Type II Superior Labrum Anterior Posterior Lesions: 

Minimum Two Year Follow-Up. AOSSM Specialty Day, New Orleans, La., 

March 13, 2010

414 

aC JoiNt reCoNStruCtioN iN 2011: Five CardiNal queStioNS 

For optimal deCiSioN makiNg 

LCOL John “JT” Tokish, MD, MC, USAF 

Introduction: 

Reconstruction of the AC joint after separation has undergone 

a resurgence in recent years. Biomechanical evaluation has led to 

the criticism of long standing techniques, and the development of 

new stronger and less invasive ones. In light of this data, the reader 

may find a review of 5 of the most debated questions surrounding 

reconstruction—and a review of the literature for each, helpful in the 

decision making process. 

1) Should we operate on Grade 3 injuries? 

As the AC joint separation has been examined more closely, the 

question of the grade 3 separation has become more debated. 

Proponents state that with early minimally invasive techniques, 

the results can be very satisfying. An in-depth review of the 

literature, including several systematic reviews may shed light on 

this question: 

Author Jnl/ year Study measure Outcome Conclusions 

Ceccarelli 2 JOT 2008 Systematic 

review 

Tamaoki 12 Chocrane 

2008 

Systematic 

Review 

phillips 9 CORR 1998 Systematic 

review 

1172 patients 

Larsen 7 Acta Orthop 

Belg 1987 

prospective 

Cohort 

Schlegel 10 AJSM 2001 prospective 

Cohort of 

conservative 

treated 

Tibone 14 AJSM 1992 Retrospective 

cohort 

pain, subjective 

scores, xrays 

Combined 3 

RCT’s 

satisfactory 

results: 88% op 

vs 87% non op; 

deformity op 3%, 

non op 37% 

persistent 

symptoms in 8% 

op group vs. 10% 

non op group 

At 1 yr, 17% 

decrease in 

bench press, only 

affected 20% of 

patients 

At 2 years, 

no strength 

differences 

No diffence 

in operative 

vs. non-op 

treatment 

No difference at 

one year, higher 

complication 

rate in operative 

No diff in 

outcomes, 

higher infection 

in op tx, but less 

deformity 

No difference 

between op/ 

non-op group 

20% failure 

rate with nonop 

outcome 

From these studies, it appears that most patients should be managed 

non-operatively with the grade 3 injury, with similar outcomes and 

lower complications after non operative treatment. Other factors 

such as where an athlete is in his/ her season, hand dominance, and 

athletic event may be taken into consideration. 

2 If we operate how good do we have to be? 

AC joint reconstruction is often touted as having “more than 60 

described operations”, but with arthroscopic advances, there is 

no doubt this number is likely to climb significantly. Whenever 

one considers adopting a new technique, one should consider 

what the normal anatomy and physiology ideal reconstruction 

should be. As an Air Force Officer, I am always trying to be as 

good as my Navy colleagues. Several studies have evaluated this 

question and are included below : 




Author Source Structure 

tested 

Harris 6 AJSM 2000 Native 

Ligament 

Costic AJSM 2004 Native 

Ligament 

Grutter 5 AJSM 2005 Native 

Ligament 

Walz 15 AJSM 2008 Native 

Ligament 

CC lig 

load (N) 

Stiffness 

(N/mm) 

Failure Mode 

500 103 Midsubstance/ 

avulsion 

560 61 midsubstance 

tear 

815 88 

598 99 

Given that there have been more than 60 operative techniques 

described for reconstruction of the CC ligaments, one should always 

consider the normal anatomy as the gold standard. Thus, a relative 

gold standard might be to require a novel reconstruction technique 

to stand up to a failure load of over 500 N and a stiffness of 60 N. 

3) How do described techniques match up against this gold 

standard? 

This question really examines how the “gold standard” Weaver 

Dunn behaves biomechanically, and compares it to more 

modern techniques. 

Author Source Structure tested CC lig 

load (N) 

Harris 6 AJSM 2000 Weaver dunn Recon 145 8 

deshmukh 4 AJSM 2004 Weaver dunn recon 177 NR 

Grutter 5 AJSM 2005 Weaver dunn recon 483 36 

Costic 3 AJSM 2004 SemiT 2 clav holes 1 coracoid 

hole 

Lee 8 AJSM 2008 SemiT around coracoid- 

1clavicle hole tied to self 

Grutter 5 AJSM 2005 FCR around coracoid, 2 clav 

holes and thru acromion 

406 23 

523 NR 

774 59 

Walz 15 AJSM 2008 2 tight ropes for acute recon 982 80 

Stiffness 

(N/mm) 

It is difficult to discern the biomechanical data on cc ligament 

reconstruction given the differences in testing techniques, and the 

emerging understanding of the importance of cyclical testing. Even 

the study by Grutter, which showed a strength of 483 for the Weaver 

Dunn procedure, was significantly weaker than the normal ligament 

in the same study (815 N). Perhaps the biomechanics were best 

summarized as follows: 

• The Weaver Dunn is only 1/4 -1/2 as strong as the native cc 

ligaments and cannot be recommended without a form of 

augmentation 

• Free graft reconstruction can approximate the native ligament 

in strength at time zero, but may not approximate the normal 

stiffness of the ligament 4) What are the clinical results of 

surgical reconstruction? In spite of the biomechanical data, the 

ultimate litmus test is in the clinical literature. Several well done 

studies have evaluated various surgical techniques, including 

some preliminary outcomes studies with modern techniques

415 

Study JNL/ Year Study details Outcome of Import 

Weinstein 16 AJSM 1995 augmented weaver 

dunn in acute vs. 

chronic groups 

Bostrom 

Windhamre 1 

JSES 2010 Weaver dunn + pdS vs. 

Wd + hook plate 

Tauber 13 AJSM 2009 Wvr dunn vs. Auto Semi 

T in chronics 

Shin 11 AJSM 2009 Case series single 

tunnel semiT, around 

coracoid, augmented 

with ethibond 

Nicholas AJSM 2008 Small retrospective 

case series, semiT graft 

REFERENCES 

clinical result 96% healed 

acutely, vs 77% fixed 

chronic (3 weeks) 

Hook plate hurt worse 

with motion, but no diff 

in SpAdi, quick dash or 

subjective shoulder 

Wd: ASES +12 (86) SemiT: 

+22 (96), xray: Wd 4mm 

vs. ST 1mm > uninjured 

side 

21 patients, 20 G&E, 

constant 85, UCLA 30, 

85% maintained reduction 

9 patients, ASES 96, no 

loss reduction 

1. Bostrom Windhamre HA, von Heideken JP, Une-Larsson VE, Ekelund AL. 

Surgical treatment of chronic acromioclavicular dislocations: a comparative 

study of Weaver-Dunn augmented with PDS-braid or hook plate. J Shoulder 

Elbow Surg. Oct;19(7):1040-1048. 

2. Ceccarelli E, Bondi R, Alviti F, Garofalo R, Miulli F, Padua R. Treatment of 

acute grade III acromioclavicular dislocation: a lack of evidence. J Orthop 

Traumatol. Jun 2008;9(2):105-108. 

3. Costic RS, Labriola JE, Rodosky MW, Debski RE. Biomechanical rationale for 

development of anatomical reconstructions of coracoclavicular ligaments 

after complete acromioclavicular joint dislocations. Am J Sports Med. Dec 

2004;32(8):1929-1936. 

4. Deshmukh AV, Wilson DR, Zilberfarb JL, Perlmutter GS. Stability 

of acromioclavicular joint reconstruction: biomechanical testing of 

various surgical techniques in a cadaveric model. Am J Sports Med. Sep 

2004;32(6):1492-1498. 

5. Grutter PW, Petersen SA. Anatomical acromioclavicular ligament 

reconstruction: a biomechanical comparison of reconstructive techniques of 

the acromioclavicular joint. Am J Sports Med. Nov 2005;33(11):1723-1728. 

6. Harris RI, Wallace AL, Harper GD, Goldberg JA, Sonnabend DH, Walsh WR. 

Structural properties of the intact and the reconstructed coracoclavicular 

ligament complex. Am J Sports Med. Jan- Feb 2000;28(1):103-108. 

7. Larsen E, Hede A. Treatment of acute acromioclavicular dislocation. Three 

different methods of treatment prospectively studied. Acta Orthop Belg. 

1987;53(4):480-484. 

8. Lee SJ, Keefer EP, McHugh MP, et al. Cyclical loading of coracoclavicular 

ligament reconstructions: a comparative biomechanical study. Am J Sports 

Med. Oct 2008;36(10):1990- 1997. 




From these studies, it appears that SemiT autograft is a promising 

reconstructive option. Fixation, arthroscopic options, augmentation, 

and autograft vs. allograft remain questions to be studied. 

5) Should we resect the distal clavicle or not? 

Classic teaching was that a dislocated AC joint could have 

significant chondral damage, and that reducing the joint may 

lead to AC joint Arthropathy, and therefore, most reconstructive 

techniques recommended that it be resected. This was 

challenged, however, by Costic et al (JOR 2003) who noted that 

resection of the AC joint may increase forces on a cc ligament 

reconstruction. More recently, however, Kowalsky et al (AJSM 

2010) specifically studied the effect of resection of the distal 

clavicle on in situ CC ligament graft forces and found that an in 

tact AC joint was only marginally protective of a CC ligament 

reconstruction, and that peak forces after resection remained far 

below the failure loads of CC ligament reconstruction. 

There is no clinical study that directly compares resection vs. 

preservation of the distal clavicle in the setting of CC ligament 

reconstruction. 

9. Phillips AM, Smart C, Groom AF. Acromioclavicular dislocation. 

Conservative or surgical therapy. Clin Orthop Relat Res. Aug 1998(353):10- 

17. 

10. Schlegel TF, Burks RT, Marcus RL, Dunn HK. A prospective evaluation of 

untreated acute grade III acromioclavicular separations. Am J Sports Med. 

Nov-Dec 2001;29(6):699-703. 

11. Shin SJ, Yun YH, Yoo JD. Coracoclavicular ligament reconstruction for 

acromioclavicular dislocation using 2 suture anchors and coracoacromial 

ligament transfer. Am J Sports Med. Feb 2009;37(2):346-351. 

12. Tamaoki MJ, Belloti JC, Lenza M, Matsumoto MH, Gomes Dos Santos 

JB, Faloppa F. Surgical versus conservative interventions for treating 

acromioclavicular dislocation of the shoulder in adults. Cochrane Database 

Syst Rev. (8):CD007429. 

13. Tauber M, Gordon K, Koller H, Fox M, Resch H. Semitendinosus tendon 

graft versus a modified Weaver-Dunn procedure for acromioclavicular joint 

reconstruction in chronic cases: a prospective comparative study. Am J Sports 

Med. Jan 2009;37(1):181-190. 

14. Tibone J, Sellers R, Tonino P. Strength testing after third-degree 

acromioclavicular dislocations. Am J Sports Med. May-Jun 1992;20(3):328- 

331. 

15. Walz L, Salzmann GM, Fabbro T, Eichhorn S, Imhoff AB. The anatomic 

reconstruction of acromioclavicular joint dislocations using 2 TightRope 

devices: a biomechanical study. Am J Sports Med. Dec 2008;36(12):2398- 

2406. 

16. Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU. Surgical 

treatment of complete acromioclavicular dislocations. Am J Sports Med. 

May-Jun 1995;23(3):324-331.

416 

multiple ligameNt iNJured kNeeS: 

CaSeS aNd CoNtroverSieS (bb) 

Moderator: Mark D. Miller, MD, Charlottesville, VA 

Following brief introductory lectures, each speaker will present knee MLI cases from their practice. At strategic intervals, the 

speakers will stop, quiz the panel and the audience (via ARS) regarding management. Controversies will including timing, 

repair vs reconstruction, rehabilitation, etc. 


Mark D. Miller, MD, Charlottesville, VA 

II. ACL-PCL Options 

Darren L. Johnson, MD, Lexington, KY 

III. LCL/MCL/Corner 

Claude T. Moorman III, MD, Durham, NC 

IV. MLI Complications 

Christopher D. Harner, MD, Pittsburgh, PA 

V. Case Presentations 

All Faculty 

VI. Discussion, Questions and Answers 




Anatomy & Biomechanics 

• The knee 

— Diarthrodial Joint 

— Simultaneous rotation and translation 

• Ligaments/Static Stabilizers 

— Anterior Cruciate Ligament (ACL) 

– Tibia => LFC 

– 33 mm x 11 mm 

– 2200 N (anterior) 

– 2 Bundles: 

~ AM (tight in flexion) 

~ PL (tight in extension) 

~ Middle Geniculate A. 

— Medial Collateral Ligament (MCL) 

– MFC => Tibia 

– 4000 N (valgus) 

– Superficial 

~ Tibial Collateral Lig 

– Deep 

~ Medial capsular Lig 

~ Attachment to meniscus (Coronary Ligaments) 

— Posteromedial Corner 

– Sartorius 

– Superficial MCL, POL, SM 

– Deep MCL 

— Posterior Cruciate Ligament (PCL) 

– MFC => Tibia sulcus 

– 38 mm x 13 mm 

– 2500 N (posterior) 

– 2 Bundles (PAL): 

– AL (tight in flexion) 

– PM (tight in extension) 

– Meniscofemoral Ligs: 

– Humphry (anterior) 

– Wrisberg (posterior) 

– Middle Geniculate A. 

— Lateral Collateral Ligament (LCL) 

– LFC => Fibula 

– Cord-Like 

– 750 N (varus) 

– Tight in Extension 

– Capsule’s most distal extent is just posterior to the fibula 

— Posterolateral Corner 

– Superficial: Biceps, ITT 

– Deep: LCL, Popliteus, Popliteofibular lig. 

History & Physical Examination 

• History 

417 

Feature Significance 

pop/swelling ACL 

dashboard pCL 

Fall pF Foot pCL 

Fall dF Foot patella 

Locking Meniscus 

pain w/ stairs patella 

• Palpation 

— Acute vs. Chronic 

kNee mil: iNtroduCtioN 

Mark D. Miller, MD 




— Gentlefirm 

— Tenderness/localized swelling 

– anterior-patella 

– posterior-meniscal 

— Collateral ligaments: proximal/distal 

— Patella: proximal/distal facets 

— Tendon: quadriceps/patella 

— Posterior Knee 

— Range-of-Motion: Active/passive 

— Ligamentous laxity 

– Laxity vs. Instability 

– Degree 

– Grade I: micro. disruption (

• PCL: Posterior Drawer, “sag,” “ski slope” sign 

• PCL & PLC: Posterolateral Drawer 

• PLC: 30˚ and 90˚ External Rotation Asymmetry, external 

rotation recurvatum 

• MCL: Valgus Stress 30˚ and 0˚ 

• LCL: Varus Stress 30˚ and 0˚ 

• KT-1000/2000 

— Objective Measurement of ACL Laxity 

— Instrumented Lachman 

— Somewhat Examiner Dependent 

— >3mm side-to-side difference is Abnormal 

— Man-Max vs. 30 lbs. 

— Posterior 

– PCL measurement 

– Classification of multiple ligament injured knee 

Classification of the Multiple Ligament Injured Knee 

• Classification basis 

— Position of the tibia in relation to the femur 

— Direction of the instability (in knees that spontaneously 

reduced) 

• Classification 

— Anterior 

— Posterior 

— Lateral 

— Medial 

— Rotation instability 

– Anteromedial 

– Anterolateral 

– Posteromedial 

– Posterolateral 

— Probable 

• Anterior Knee Dislocation: 

— Most common type 

— Primary mechanism of injury is forced hyperextension of the 

knee 

— Progression of injuries: Posterior 

capsuleACLPCLInjury to popliteal artery 

• Posterior Knee Dislocation: 

— Second most common type 

— Primary mechanism of injury: Motor Vehicle Accident 

(dashboard strikes the anterior tibia while the knee is flexed, 

this translates the tibia posteriorly on the femur) 

— Requires more force than anterior dislocation 

— PCL always ruptured 

— +/- ACL injury 

— Collateral ligament injury possible with varus or valgus stress 

— Popliteal Artery may be injured 

• Lateral and Medial Knee Dislocations 

— Rare 

— Mechanism of injury: varus/valgus stress while foot is fixed 

— Commonly involves disruption of both collateral ligaments 

and at least one cruciate ligament 

— More ligamentous injury that Anterior and Posterior 

dislocations 

— Often causes Multidirectional 

Instability 

— Neurologic injury to peroneal nerve 

is common 

• Probable Dislocation 

— Multiple-ligament-injured knees 

presenting in reduced position 

— Mechanisms 

– Spontaneous Reduction 

– Subluxation as initial injury 

418 




Initial Management of Knee Dislocation 

• If dislocatedreduce the knee 

• Once reducedcheck the vascular and neurologic status of the 

extremity 

— Pulses present: 

– If knee was dislocatedconsider arteriogram to r/o 

intimal tear 

– If knee was locatedobservation period and MRI 

– Pulses absentArteriogram/Vascular consult 

~ Vascular repair +/- ligament reconstruction or external 

fixator 

Definitive Management of Knee Dislocation 

• Surgical indications: 

— Acute 

– Vascular injury--#1 priority 

– Open fracture/dislocation 

– Compartment syndrome 

— Timing of repair controversial 

– Corners, avulsions, Capsular injuries relatively acute 

— Post-op rehab 

– Brace in extension 

– Early ROM 

• Knee Arthroscopy 

— Confirmatory 

— Beware of compartment syndrome risk 

– Dry scope 

– “Egress incision” 

• Multi-ligament Repair and Reconstruction 

— Graft Choices 

— ACL reconstruction 

– Tibial tunnel placement 

– Femoral tunnel placement 

~ “Anatomic”—between bundles 

— PCL Injury Treatment 

– Bony Avulsion—ORIF 

– Isolated PCL 

~ Nonoperative 

~ Favored by some surgeons if Posterior Drawer 

improves with Internal Rotation 

~ Quad Rehab 

~ Extension Brace for 2-4 wks for Grade III injuries

419 

– Late Chondrosis (MFC and Patella) 

— Combined Injuries 

– Reconstruction 

– Arthroscopic (Transtibial) 

– Tibial Inlay 

– Two-bundle 

Anterolateral graft tensioned in 90o and 

posteromedial tensioned in 30o of flexion 

– Post-op: Immobilize in extension, protect vs gravity, 

Quad rehabilitation 

— MCL Injury 

– Primary repair 

– Modified Bosworth Technique 

— LCL/PLC Injury Treatment 

– Partial--Grade I & II Instability with a good end point 

~ Nonsurgical Treatment--3 week immobilization in 

extension 

– Complete Acute 

~ Primary repair best 

~ Augment with allo/auto graft 

– Complete Chronic 

~ Reconstruct Popliteus and LCL 

– Post-op rehabilitation--Protect vs ER and varus 

REFERENCES AND SUGGESTED READING 

1. Hoover N.W., Injuries of the popliteal artery associated with fractures and 

dislocations. Surg Clin North Am, 1961. 41: p. 1099-112. 

2. Meyers M.H. and Harvey J.P., Jr., Traumatic dislocation of the knee joint. A 

study of eighteen cases. J Bone Joint Surg Am, 1971. 53(1): p. 16-29. 

3. Shields L., Mital M., and Cave E.F., Complete dislocation of the knee: 

experience at the Massachusetts General Hospital. J Trauma, 1969. 9(3): p. 

192-215. 

4. Seebacher J.R., Inglis A.E., Marshall J.L., and Warren R.F., The structure of the 

posterolateral aspect of the knee. J Bone Joint Surg Am, 1982. 64(4): p. 536- 

41. 

5. Hughston J.C., Andrews J.R., Cross M.J., and Moschi A., Classification of 

knee ligament instabilities. Part II. The lateral compartment. J Bone Joint 

Surg Am, 1976. 58(2): p. 173-9. 

6. Warren L.F. and Marshall J.L., The supporting structures and layers on the 

medial side of the knee: an anatomical analysis. J Bone Joint Surg Am, 1979. 

61(1): p. 56-62. 

Our Experiences at UVA 




Reconstruction Combo # % 

ACL+pLC 50 29.6% 

ACL+pCL+pLC 33 19.5% 

pCL+pLC 32 18.9% 

ACL+pCL+MCL 17 10.1% 

ACL+MCL 12 7.1% 

ACL+pCL 9 5.3% 

ACL+pCL+pLC+MCL 9 5.3% 

Other* 7 4.1% 

Total 169 

Other* 7 4.1% 

ACL+pLC+MCL 2 1.2% 

pCL+pLC+MCL 2 1.2% 

pCL+MCL 2 1.2% 

pLC+MCL 1 0.6% 

7. LaPrade R.F., Gilbert T.J., Bollom T.S., Wentorf F., and Chaljub G., The 

magnetic resonance imaging appearance of individual structures of the 

posterolateral knee. A prospective study of normal knees and knees with 

surgically verified grade III injuries. Am J Sports Med, 2000. 28(2): p. 191-9. 

8. Whiddon D.R., Zehms C.T., Miller M.D., Quinby J.S., Montgomery S.L., 

and Sekiya J.K., Double compared with single-bundle open inlay posterior 

cruciate ligament reconstruction in a cadaver model. J Bone Joint Surg Am, 

2008. 90(9): p. 1820-9. 

9. Sisto D.J. and Warren R.F., Complete knee dislocation. A follow-up study of 

operative treatment. Clin Orthop Relat Res, 1985(198): p. 94-101. 

10. Halinen J., Lindahl J., Hirvensalo E., and Santavirta S., Operative and 

nonoperative treatments of medial collateral ligament rupture with early 

anterior cruciate ligament reconstruction: a prospective randomized study. 

Am J Sports Med, 2006. 34(7): p. 1134-40. 

11. Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant 

assessment of posterior cruciate ligament and posterolateral corner injuries. 

Evaluation of isolated and combined deficiency. J Bone Joint Surg Am. 

2008;90(8):1621-1627. 

12. Schenck RC Jr. The dislocated knee. Instr Course Lect. 1994;43:127-136.

420 

multiple ligameNt iNJured kNeeS: CaSeS aNd CoNtroverSieS 

Darren L. Johnson, MD 

High energy combined knee ligament injuries in high school/ 

collegiate athlete represents a small minority of all knee ligament 

injuries seen. When they do happen it represents a serious event 

both emotionally and physically to the injured athlete. They are 

often career performance altering or even ending depending upon 

the severity of the event/injury pattern. A high index of suspicion 

must be taken for high energy mechanisms, i.e. contact football/ 

soccer/rugby/field hockey or particularly gymnastics. 

Treatment principles in the first 48¡ are directed around the 

neurovascular status of the extremity and close monitoring for the 

potential development of compartment syndrome. 

While plain radiographs are crucial to R/O large fractures, 

osteochondral injuries, fibular avulsion fractures of the posterolateral 

complex, and make sure a concentric reduction is present. High 

quality MRI scans to evaluate the ligaments, menisci and articular 

cartilage is of paramount importance. 

Over the last twenty years we have learned, the hard way in some 

cases, that true anatomic repair of what has been injured offers the 

athlete the best chance to return to their sport at the same level of 

performance they had before their injury. 

Combined ligament injuries that involve the ACL or PCL with lateral 

sided injuries are generally repaired in the first two weeks of injury. 

The majority of the lateral side injury is pulled off/avulsed “en-bloc” 

if you will from the proximal fibula/tibia and easily repaired with 

anchors in the bone at the level of the joint line. Anatomic repair 

is crucial to allow for immediate motion and the return of normal 

kinematics. Augmentation of the acute repair using autogenous 

or allograft tissue is controversial with lack of Level 1 evidence 

to support either/or. Often the quality of the primary repair will 

determine if augmentation is required. 

Medial sided injury of the MCL are often femoral based/not avulsed 

and do not involve the POL. These usually heal satisfactorily 

with conservative treatment then followed by cruciate ligament 

reconstruction. Medial sided injuries that are tibial based with 

avulsion and retraction with involvement of the posterior oblique 

ligament/capsule require anatomic repair concurrently with cruciate 

ligament reconstruction. This allows for immediate motion and 

restoration of normal kinematics. 

This is a devastating injury to the high school or collegiate athlete. If 

one is to return to their sport without a performance drop, anatomic 

repair and immediate return is a requirement. It often requires a year 

of time before the athlete feels confident in their knee to return at a 

high level. 

Critical to optimal outcome is anatomic repair/reconstruction of 

all injured structures. It is important that the operative surgeon 

fully understands gross/arthroscopic/radiographic landmarks of all 

ligament structures, particularly the ACL and PCL. The single most 

important determinant of outcome under control of the operating 

surgeon while in the operating theatre is anatomic placement of the 

graft ligament substitutes. 

Graft Selection 

• Autograft: BPTB, QHS, Quad Tendo 

• Allograft: Achilles Tendon, BPTB 

• Tissue Quality/Tissue Bank 

• Disease Transmission 

• “Knee Biology” 




ACL/PCL Reconstruction 

Anatomic ACL: (SB, DB, Matched): (see video) 

• Need to know bony/arthroscopic landmarks 

• Residents Ridge is superior border of ACL at 90¡ Flexion 

• Bifurcate Ridge separates the AM and PL Bundle 

• Bifurate Ridge is perpendicular to Residents Ridge 

Tibial Insertion is entirely in front of the tibial spine 

• On lateral x-ray no part of the tunnel should touch the spine!! 

Transtibial vs. Medial Portal ( 2 incisions) 

• TT: tibial tunnel too posterior 

• Femoral tunnel non-anatomic 

• vertical/anterior 

Medial Portal allows one to entirely reproduce normal anatomy on 

the femoral side independent of tibial anatomy. 

Pitfalls in Traditional ACL Reconstruction (see pictures) 

Femoral insertion sites orientation changes with knee flexion: The 

femoral AM and PL insertion sites are horizontally oriented when 

the knee is close to 90 degrees of flexion, while they are vertically 

oriented in knee extension. The important concept is often neglected 

in ACL reconstruction. 

The use of clock face reference: The knee is a 3 dimensional structure. 

The clock concept is easy to use. However, it is inaccurate in describing 

the location of femoral tunnel placement and lead to non-anatomic 

tunnel position. 

Inability to observe the femoral insertion site well by using the 

anteromedial portal: The anteromedial portal provides a superior 

view of the lateral wall of the notch and the femoral insertion site 

of ACL than the anterolateral portal, which is sufficient in observing 

the tibial insertion site. 

Graft impingent: It is concept created by us because of non-anatomic 

tunnel placement. The native ACL does NOT impinge with notch 

and PCL. As long as the tunnels were placed in an anatomic fashion 

there will be no impingement. However, if the tunnel is placed nonanatomically 

(as indicated by arrow below), impingement may 

occur. 

PCL Anatomic Placement (see Video) 

Bony Avulsion Tibia ORIF 

• Single versus DB 

• SB in MLI 

• Graft selection critical: LOTS OF COLLAGEN 

Tunnel Placement versus Inlay 

• Must be anatomic! 

• Tibia use PTTMM Landmark 

• X-ray confirmation of drill/pin 

• NV bundle is slightly lateral 

Femoral Tunnel must be high in notch 

• At 90˚ of Flexion 

• Edge of tunnel at Apex of notch 

Order of Tunnel Drilling 

• ACL/PCL Femoral Tunnel 

— Inside-out via Accessory Portals 

• PCL Trans-tibial tunnel 

— Finish by Hand 

• ACL Tibial Tunnel

Order of Graft Passage/Fixation 

• PCL Graft First: Fix Femur 

• ACL Graft Second: Fix Femur 

• PCL Tibial side fix at 90˚ (step-off) 

• ACL Graft Fix at 0˚ 

REFERENCE 

1. Wilson TC, Satterfield WH, Johnson DL Medial Collateral Ligament “Tibial” 

Injuries: Indication for Acute Repair. Orthopaedics 27(4):389-393, 2004 

2. Stevenson, WW, Johnson, DL Management of Acute Lateral Side Ligament 

Injuries of the Knee. Orthopaedics: 29(12):1089-1093, 2006. 

421 




3. Chabbra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic, 

Radiographic, Biomechanical and Kinematic Evaluation of the Anterior 

Cruciate Ligament and its Two Functional Bundles. J Bone Joint Surg Am 

2006;88(Supp 4):2-10. 

4. Mario Ferretti, M.D., Max Ekdahl, M.D., Wei Shen, M.D., Ph.D., and 

Freddie H. Fu, M.D. Osseous landmark of the femoral attachment of the 

anterior cruciate ligament : an anatomic study. Arthroscopy: The Journal of 

Arthroscopic and Related Surgery, Vol 23(11), Nov. 2007: pp 1218-1225.

422 

multiple ligameNt kNee iNJury (mlki) – mCl/pmC aNd lCl/plC 

Claude T. Moorman III, MD 

Injury Pattern 

• ACL/PCL/Posterolateral injury 

• ACL/PCL/Medial side injury 

Injury Pattern 

• ACL/PCL/Posterolateral injury 

• ACL/PCL/Medial side injury 

MRI 

• Very helpful 

• Roadmap 

• Tissue quality 

• Beware sensitivity lateral 

side 

PLRI 

Imaging vs Exam 

Trust Your Hands! 

Graft Selection 

• Autograft vs Allograft 

• Ease of harvest 

• Reliable tissue quality 

• No disease transmission 

variables 

• Moorman 

— Auto BTB ACL 

— Auto Semitendinosis PLRI 

— Allograft Achilles PCL 

Surgical Decision Making Principals 

• Address all instability Patterns 

• Cannot ask a single ligament to 

stabilize a multiplanar deformity 

Surgical Decision Making Principals 

• ACL/PCL reconstruction 

• MCL generally addressed if GII/GIII 

• MCL often amenable to repair 

• PLRI often needs augment/reconst. 

SURGICAL TECHNIQUE 

• Anterior incision 

• Autograft tissue harvest 

ACL/PCL 1st 

• Allograft Achilles graft PCL (Fanelli) 

• Patellar Tendon graft ACL 


• PCL guide 

• 11 mm dia 

• “PCL FACET” (Kaseta) 

• Posterior PCL footprint 

MCL Layer Anatomy 

Management of MCL 

• Low threshold for repair 

• Same incision 

• O’Brien, Warren 6/17 ACL failures Medial side laxity 

MCL Management 

• 8/10 repair 

• Severe cases consider Achilles allograft vs hamstring auto or allo 





• Medial Side: 

— Dissection to MCL origin- site of MRI lesion 

— ID of superficial / deep MCL fibers 


• Proximal MCL tissue peeled off of epicondyle 

• Placement of three Mitek super anchors 

• Imbrication of deep / superficial fibers 


• Plication of posterior capsule to posterior aspect of capsule 

• Closure over drain of Medial side and Quad Tendon 

Severe Blow-out 

• Grade III+ 

• AMRI 

• “Barn-Door” opening 

• Add Collagen 

• Achilles Allograft 

MCL Reconstruction 

• Reef posteromedial capsule 

• Posterior oblique 

ACL/PCL/PLRI 

• Central Pivot Management the same 

• PLRI 

— Repair an option early 

— Augmentation 

— Reconstruction 

• Combined 

• Fibular-based 

Fibular-Based PLRI Reconstruction 

• It’s Easy! 

• It makes anatomical/mechanical sense 

• It is a practical solution for most orthopaedists 

• It works! 

Anatomy 

• Maynard, O’Donohughe Award 1994 

• Popliteofibular ligament 

• Femur-fibula 

Anatomy 

• Steve Bernstein Study 

• AOSSM 1997 

• LCL/Popliteus Surgically Important Structures 

— LCL Varus 

— Popliteus ER

Rotational Moment 

Fibular-Based Reconstruction 

• 10mm more lateral 

• Mechanical advantage 

• Why God chose this position 

Anatomy 

Biomechanics 

• LCL(7mm area) 

• Popliteofibular 

Ligament(7mm area) 

• Single-strand Semitendinosus 

• (7mm each limb) 

WHAT DO I DO? 

• FIGURE 8 FIBULAR-BASED 

• SEMITENDINOSIS 

AUTOGRAFT 

• ACUTE AND CHRONIC 

• INCORPORATE NATIVE 

TISSUE 

Lateral Incision 

Tunnel Convergence 

in Combined ACL and 

Posterolateral Corner 

Reconstruction Shuler, 

Jasper, Rauh, Mulligan 

and Moorman 

Arthroscopy, 22:193- 

98, 2006 

Safe Zone 

Conclusions 

Beware of Tib/Fib 

Instability 

• Does not preclude 

Fibular-based 

resonstruction 

• Key is recognition and stabilization 

• 6.5mm screw into tibia 

• May proceed with PLRI reconstruction 

Aftercare 

• Controlled Arthrofibrosis 

• Locked in Extension 2 wks 

• Hinged Knee Brace 

REHABILITATION 

• Slower progression than ACL 

• Crutch use up to 8 wks 

• Avoid active FLX 

• MUA 20% at 6wks 

Questions for the Literature 

• Operate? 

• Repair vs Reconstruction? 

• PLRI? 

REFERENCES 

1. Barnes CJ, Pietrobon R, Higgins LD. Does the pulse examination in patients 

with traumatic knee dislocation predict a surgical arterial injury? A metaanalysis. 

Journal of Trauma. 2002;53(6):1109-1114. 

2. Richter M, Bosch U, Wippermann B, Hofmann A, Krettek C. Comparison of 

surgical repair or reconstruction of the cruciate ligaments versus nonsurgical 

treatment in patients with traumatic knee dislocations. The American Journal 

of Sports Medicine. 2002;30:718-727. 

423 




Literature Review 

• Richter, et al. AJSM 30:718-27, 2002 

• 63pts (49 Repair,14 Reconst.,26 Nonoperative) f/u 8.2 yrs 

• Better Scores 

— Repair/ 


—

6. Dedmond BT, Almekinders LC. Operative versus nonoperative treatment 

of knee dislocations: a meta-analysis. American Journal of Knee Surgery. 

2001;14(1):33-38. 

7. Mariani PP, Santoriello P, Iannone S, Condello V, Adriani E. Comparison of 

surgical treatments for knee dislocation. American Journal of Knee Surgery. 

1999;12(4):214-221. 

424 




8. Chhabra A, Cha PS, Rihn JA, Cole B, Bennett CH, Waltrip RL, Harner CD. 

Surgical management of knee dislocations. Surgical technique. The Journal 

of Bone and Joint Surgery. 2005;87 Suppl 1(Pt 1):1-21.

425 

CompliCatioNS oF multiligameNtouS kNee iNJurieS: 

evaluatioN, maNagemeNt, aNd “pearlS” 

Christopher D. Harner, MD, Timothy L. Miller, MD 

Overview 

I. General Principles of Management 

II. Complications–Evaluation, Management, and “Pearls” 

III. Case Examples 

I. General Principles of Management 

A. Definition–Spectrum of Injury 

i. Single cruciate injury (ACL or PCL) +/– Collaterals 

ii. Bicruciate +/– Collaterals • “Dislocation” 

iii. Partial ligamentous injuries (Grade I or II) 

B. Injury Classification 

i. Timing of Injury 

— Acute 

— Chronic 

ii. Anatomical Classification (Grade of Injury) 

— Cruciates 

— Collaterals 

— Meniscus 

iii. Associated Injuries 

— Tendon 

— Bone 

— Neurovasculature 

C. Operative Management 

i. Plan out carefully. 

ii. Perform cases electively. 

iii. Perform in an inpatient setting, and admit patients 

overnight. 

iv. Perform when rested/ during daylight hours. 

v. Delay and/ or stage surgery if necessary. 

II. Complications–Evaluation, Management, and “Pearls” 

A. Pre-Operative Issues 

i. Irreducible Dislocation (This is an “on field” issue in 

most cases.) 

• Fractures 

• Soft Tissue Interposition 

ii. Vasculature (Artery AND Vein.) 

a. Arterial 

• Spasm 

• Intimal Injury 

• Complete Tear 




b. Venous (DVT) 

iii. Nerve (Sensory, Motor, Complete) 

B. Pre-Operative Planning 

i. History/ Physical Exam (Time dependent!) 

• Neurovascular Exam (Including the vein.) 

• Swelling/ Soft Tissue Envelope/ Skin Quality 

• Alignment/ Deformity 

• Ligamentous Examination (Usually very limited.) 

ii. Associated Injuries 

• Patellar Tendon 

• MCL 

• Joint Capsule 

• Meniscus 

iii. Imaging 

• X-Rays (AP/ Lateral) 

• Arteriogram/ CT Angiogram 

• Venous Duplex Ultrasound (Initial visit and 1 day 

pre-op.) 

• MRI 

• Intra-Operative Fluoroscopy for EUA and Tunnel 

Placement 

iv. Operative Plan 

• Exam Under Anesthesia 

• External Fixation (Usually not necessary.) 

• Arthroscopy (Not always possible.) 

• Soft Tissue Repair 

• Ligamentous Reconstruction (May need both repair 

and reconstruction.) 

• Incision Placement 

v. Timing of Surgery–(Case dependent.) 

• Early Reconstruction (0-14 days) 

• Late Reconstruction (> 14 days) 

• Staging 

vi. Equipment/ Graft Availability 

• Autograft 

• Allograft 

vii.Patient Counseling 

• Realistic Expectations 

• Functional/ Occupational Requirements 

Pre-Operative Pearls: 

• Be specific about the diagnosis, including associated injuries. 

• Be prepared for any and all complications!

• Reduce knee dislocations on the field if possible to decrease the 

risk of damage to neurovascular structures and the joint. 

• When in doubt regarding vascular status, obtain a CT-angiogram 

or arteriogram. 

• Obtain a venous duplex Doppler ultrasound to rule out DVT. 

• Do not overlook associated fractures and tendon injuries (i.e. 

patellar tendon). 

• Use an external fixator only when necessary. Most knee 

dislocations do not require external fixation. 

• Often skin and soft tissue envelope is significantly swollen as 

with pilon, ankle, and calcaneus fractures, requiring delayed or 

staged surgery. 

• Delayed or staged procedures are acceptable in many cases 

(collaterals first, cruciates later). 

• Certain injury patterns (e.g. posterolateral corner, MCL) should 

be treated within 7 to 10 days. 

• Exam in the office is often very limited. MRI may be deceiving. 

• Use EUA in OR as final determining factor for ligamentous 

injury. (I often use fluoroscopy for the EUA, especially for 

anterior-posterior laxity.) 

C. Intra-Operative Complications 

i. Bleeding 

ii. Compartment Syndrome 

iii. Iatrogenic Neurovascular Injury 

iv. Bone Tunnel Fracture/ Tunnel Convergence 

Intra-Operative Pearls: 

• Careful pre-operative planning is critical. 

• Know what structures are to be repaired or reconstructed. 

• Use fluoroscopy to perform EUA. Compare injured limb to the 

non-injured limb 

• There are many partial injuries (e.g. PCL). Do not rely on the 

MRI. 

• Know the expected approach (Open/ Arthroscopic/ Combined). 

• Plan skin incisions around previous incisions and soft tissue 

envelope. 

• Know different graft options. Your preferred graft may not be 

the best option. 

• Perform cases in an inpatient setting, and do as the first or only 

case of the day. 

• Minimize use of a tourniquet. 

• Be aware of developing iatrogenic compartment syndrome. 

• Use intra-operative fluoroscopy for tunnel placement. 

• Expose the Common Peroneal Nerve for all Posterolateral 

Corner procedures. 

• Decompress the nerve if necessary, and define the extent of 

injury. 

D. Post-Operative Complications 

i. Wound Breakdown/ Skin Slough 

ii. Infection–Cellulitis is common. Be aggressive with suspected 

infection. 

iii. DVT/ PE–low molecular weight heparin, Aspirin (Always 

prophylax postoperatively.) 

426 




iv. Arthrofibrosis (The #1 complication in my practice.) 

v. Recurrent Instability 

Foot drop (Foot drop splint for 4 weeks to prevent 

plantarflexion contracture) 

vi. Pain 

Post-Operative Pearls: 

• Anticipate potential problems and complications, especially 

during the first 4 weeks post–operatively. 

• Admit patients for the first post-operative night. 

• Evaluate patients in follow-up 3 times during the first month 

post-op. 

• Give appropriate pre-operative and post-operative antibiotics. 

• Maintain a high index of suspicion for infection during the first 

4 weeks post-op. 

• Limit range of motion in the first 4 weeks post-op. Brace or 

splint the lower extremity in full extension. 

• Know the patient’s expected level of compliance. (Keep the first 

4 weeks simple!) 

• Have a high index of suspicion for DVT. (Check venous 

Dopplers post-op.) 

• Use prophylactic anticoagulation. Use low molecular weight 

heparin in all high risk patients. Aspirin in low risk patients. (I 

consider oral contraceptive pills to be a risk factor.) 

• Use footdrop splint for patients with peroneal nerve injury. 

• Avoid tight, constrictive braces and dressings around the 

peroneal nerve. 

• Know pre-operative neurovascular status. 

• Nerve blocks for post-op pain control are very useful. Always 

check neurovascular status before initiation of anesthesia. 

• Avoid use of CPM machines as well as early aggressive 

rehabilitation protocols. 

III. Case Examples 

1) Intra-Operative Vascular Injury 

2) Iatrogenic Compartment Syndrome 

3) Post-Operative Arthrofibrosis 

4) Intra-Operative Mortality 

5) Missed Patellar Tendon Rupture with Fixed Posterior 

Subluxation 

6) Missed Medial Tibial Plateau Fracture 

IV. Conclusions 

• Multiligamentous knee injuries are relatively uncommon. 

• Because of the severity of this injury and the potential for 

devastating complications, it is necessary to understand the 

principles of evaluation and management. 

• Complications may occur in the pre-operative, intra-operative, 

and post-operative time frames. 

• Evaluation consists of a brief history, thorough neurovascular 

evaluation, ligamentous examination, and radiographic studies. 

• Angiography should be used whenever knee dislocation is 

suspected to evaluate for the presence of a popliteal artery injury.

• Initial management includes prompt reduction and 

stabilization followed by reassessment of the neurovascular 

status of the limb and post-reduction radiographs. 

• Emergent surgery is indicated in patients with open dislocation, 

compartment syndrome, vascular injury, and irreducible 

dislocation. 

• Definitive management of the knee with multiple ligament 

injuries remains a controversial topic. 

• Satisfactory results can be achieved with early reconstruction of 

References 

1. Almekinders LC, Dedmond BT: Outcomes of the operatively treated knee 

dislocation. Clin Sports Med 2000;19: 503-518. 

2. Almekinders LC, Logan TC: Results following treatment of traumatic 

dislocations of the knee joint. Clin Orthop 1992;284:203-207. 

3. Cole BJ, Harner CD: The multiple ligament injured knee. Clin Sports Med 

1999;18:241-262. 

4. Fanelli GC, Edson CJ, Orcutt DR, HarrisJD, Zijerdi D: Treatment of combined 

anterior cruciate-posterior cruciate ligament-medial-lateral side knee injuries. 

J Knee Surg 2005;18:240-248. 

5. Fanelli GC, Harris JD: Surgical treatment of acute medial collateral ligament 

and posteromedial corner injuries of the knee. Medicine and Arthroscopy 

Review 2006;14:78-83. 

6. Fanelli GC, Orcutt DR, Edson CJ: The multiple-ligament injured knee: 

Evaluation, treatment, and results. Arthroscopy 2005;21:471-486. 

7. Harner CD, Baek GH, Vogrin TM, Carlin GJ, Kashiwaguchi S, Woo SL-Y: 

Quantitative analysis of human cruciate ligament insertions. Arthroscopy 

1999;15:741-749. 

8. Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ: Surgical 

management of knee dislocations. J Bone Joint Surg Am 2004;86:262-273. 

9. Irrgang JJ, Fitzgerald GK: Rehabilitation of the multiple-ligament-injured 

knee. Clin Sports Med 2000;19:545-571. 

10. Jones RE, Smith EC, Bone GE: Vascular and orthopedic complications of 

knee, J Bone Joint Surg Am 1988;70:88-97. 

11. Khanna G, Herrera DA, Wolters BW, Dajani KA, Levy BA: Staged protocol for 

high energy knee dislocation: Initial spanning external fixation versus hinged 

knee brace. 2008. 

12. Levy BA, Dahm DL, Herrera DA, MacDonald PB, Dajani KA, Stuart MJ: Acute 

repair of posteromedial and posterolateral corners in multiligament knee 

injury is not indicated. 2008. 

13. Levy, B. et al., Controversies in the Treatment of Knee Dislocations and 

Multiligant Reconstruction, JAAOS 2009 vol. 17,4: 197-206. 

427 




both the ACL and PCL using allograft tissue along with allograft 

reconstruction of complete LCL injuries, repair or allograft 

reconstruction of injured posterolateral structures, and early 

repair of complete MCL injuries. 

• Although technically challenging, adequate knee stability, ROM, 

and knee function can be obtained after anatomic repair or 

reconstruction and appropriate postoperative rehabilitation of 

the multiple ligament injured knee. 

14. Muller W: The Knee: Form, Function, and Ligament Reconstruction. Berlin, 

Germany: Springer-Verlag, 1984, pp 158-202. 

15. Owens BD, Neault M, Benson E, Busconi BD: Primary repair of knee 

dislocations: Results in 25 patients (28 knees) at a mean follow-up of four 

years.J Orthop Trauma 2007;21:92-96. 

16. Palmer I: On the injuries to the ligaments of the knee joint: A clinical study. 

Acta Chir Scand 1938;53:1-28. 

17. Reckling FW, Peltier LF: Acute knee dislocations and their complications. J 

Trauma 1969;9:181-191. 

18. Richter M, Bosch U, Wippermann B, Hofmann A, Krettek C: Comparison of 

surgical repair or reconstruction of the cruciate ligaments versus nonsurgical 

treatment in patients with traumatic knee dislocations.AmJ Sports Med 2002; 

30:718-727. 

19. Rihn J. et al Acutely Dislocated Knee: Evaluation and Treatment, JAAOS, 

2004, 12,5: 334-346. 

20. Schenck RC Jr, Hunter RE, Ostrum RF, Perry CR: Knee dislocations. Instr 

Course Lect 1999;48:515-522. 

21. Thompson KJ, Stannard JP, Robinson JT, Lopez R, McGwin G Jr, Volgas 

DA: Stabilization of knee dislocations using a hinged external fixator: A 

prospective randomized study, in Proceedings of the 73rd Annual Meeting 

of the American Academy of Orthopaedic Surgeons. Rosemont, IL: American 

Academy of Orthopaedic Surgeons, 2006, pp 783–784. 

22. Tzurbakis M, Diamantopoulos A, Xenakis T, Georgoulis A: Surgical 

treatment of multiple knee ligament injuries in 44 patients: 2-8 years followup 

results. Knee Surg Sports Traumatol Arthrosc 2006;14:739-749. 

23. Varnell RM, Coldwell DM, Sangeorzan BJ, Johansen KH: Arterial injury 

complicating knee disruption. Am Surg 1989;55(12):699-704. 

24. Wascher DC, Becker JR, Dexter JG, Blevins FT: Reconstruction of the anterior 

and posterior cruciate ligaments after knee dislocation: Results using freshfrozen 

nonirradiated allografts. Am J Sports Med 1999;27:189-196.

428 

advaNCeS aNd ChalleNgeS iN 

the maNagemeNt oF eXtremity 

blaSt iNJurieS (q) 



SympoSia TRAUMA 

Moderator: Romney C. Andersen, MD, Stafford, VA 

Advances, techniques and challenges in managing complex bone and soft tissue injuries associated with blast injuries, which 

are applicable to military and civilian trauma. 

I. Advances and Challenges in the Management of Extremity Blast Injuries 

Romney C. Andersen, MD, Stafford, VA 

II. Dealing with Segmental Tissue Loss 

David Dromsky, MD, San Marino, CA 

a. Muscle/tendon volumetric muscle loss, reconstructing 

b. Nerve: grafting, tendon transfers, conduits 

c. Bone defects: Transport/distraction osteogenesis, massive grafting, vascularized autograft 

III. Follow-up Debate: Segmental Tibial Bone Defects: Bone Transport Versus vs vascularized fibula autograft 


James R. Fricke, MD, San Antonio, TX 

IV. Questions and Answers 

V. Strategies for Preserving / Optimizing Limb Length in Traumatic Amputations 


a. Most distal level of soft tissue viability 

b. Upper v lower extremity priorities 

c. Fractures proximal to the level of amputation 

d. Atypical skin flaps/turn-up plasty/flap coverage 

VI. Timing of Wound Closure/Coverage in Large Open Wounds 

James R. Fricke, MD, San Antonio, TX 

a. How do you know when it is safe to cover/close wounds? 

b. Surveillance cultures 

c. Subjective wound appearance 

d. Timing of flap coverage: is sooner better, or should it wait for inflammation to decrease 

e. Cytokine mapping/future directions 

VII. Questions and Answers on Last Two Sections 

VIII. Preventing and Dealing with Post-Traumatic Arthrofibrosis of the Knee 


a. Causes of traumatic arthrofibrosis: extra-articular vs intra-articular injury 

b. Prevention: physical therapy and ranging joints in OR with multiple trips 

c. Management: manipulation vs open management 

d. Indications for arthroscopic vs open releases 

e. Walter Reed data 

IX. Advanced Bracing Strategies in Rehabilitation of Blast-Injury Limb Reconstruction 

Joseph R. Hsu, MD, San Antonio, TX 

a. Innovative bracing options to deal with weakness secondary to volumetric muscle or tendonloss, instability 

secondary to loss of stabilizing soft tissues or bone deformity 

X. Questions on Final Sections and Panel Discussion

429 

orthopaediC trauma 

mythbuSterS ii (u) 




Moderator: Robert F. Ostrum, MD, Camden, NJ 

This symposium explores the myths and controversies surrounding the management of orthopaedic trauma patients by 

examining the literature and evidence based medicine with case studies to elucidate recommendations for treatment. There is 

no need to have participated in Mythbusters I. 

I. Intra-artcular Fractures: Just Get Bone Stock 

A discussion of timing, temporary fixation, incisions and results of intra-articular fractures treated with open reduction and 

internal fixation. 

Robert F. Ostrum, MD, Camden, NJ 

II. Calcaneus Fractures: Nonoperative Care is Equal to Operative Treatment 

Discusses outcomes of nonsurgical and operative management of calcaneus fractures with an emphasis on indications 

Paul Tornetta, III, MD, Boston, MA 

III. Bone Graft Substitutes: It Doesn’t Really Matter What I Use 

Is an overview of the classes of bone graft substitutes with their indications and results 


IV. Case Presentations with Discussion and Floor Questions 

Robert A Probe, MD , Temple, TX 

V. Proximal Tibia Fractures: These Should Not be Nailed 

A detailed discussion of indications, surgical technique, and results of intramedullary nailing of proximal tibia fractures 

Paul Tornetta, III, MD, Boston, MA 

VI. Limb Salvage is Better than Amputation 

This presentation compares and contrasts the outcomes of patients treated by amputation and limb salvage for mangled lower 

extremities 

Robert A Probe, MD , Temple, TX 

VII. Hip Dislocations: Timing of Reduction Doesn’t Make Any Difference in Outcome 

This is a review of the literature and results with respect to the timing of reduction of hip dislocations 


VIII. Case Presentations with Discussion and Floor Questions 

Robert F. Ostrum, MD, Camden, NJ

INTRA-ARTICULAR FRACTURES 

430 

iNtra-artiCular FraCtureS; piloN FraCtureS; 

CalCaNeuS FraCtureS 

Robert F. Ostrum, MD 

Myth: Intra-articular Fractures: Just get bone stock 

• Is there literature to support the theory that patients with 

intra-articular fractures will do poorly even if we operate 

appropriately? 

Myth: Patients with bad intra-articular fractures will require a 

later reconstructive procedure REGARDLESS of treatment 

• Surgeons try to do minimal operation as they “know” that no 

matter what they do the patient will need something else later 

on 

Myth: Surgical intervention in comminuted intra-articular 

fractures has a high complication rate and may leave patient 

with no good salvage plan or infection 

• Non-operative treatment will lead to equal results to surgical 

intervention, with less complications and is therefore a better 

option 

Tibial Plateau Fractures 

I. Reasons why tibial plateau fractures don’t commonly go onto 

total knee arthroplasty 

a. 70% of the total knee joint load passing through the medial 

tibiofemoral compartment during walking. 

b. Lateral tibial plateau has thickest cartilage at 6 mm 

c. Meniscus protects cartilage from degeneration 

d. Articular reduction may not be as important as restoration 

of mechanical alignment and knee stability to varus/valgus 

stress 

e. High energy fractures at 8 year follow-up only 6.5% (2/31) 

had severe arthrosis 

f. Primary osteoarthritis much more common than posttraumatic 

arthritis of the knee 

g. Severity of injury and articular reduction had an effect on 

INTRA-ARTICULAR FRACTURES REFERENCES 

1. Weigel DP, Marsh JL. High-energy fractures of the tibial plateau. 

Knee function after longer follow-up. J Bone Joint Surg Am. 2002 

Sep;84-A(9):1541-51. 

2. Andriacchi TP: Dynamics of knee malalignment. Orthop Clin North Am 

1994, 25:395-403 

3. Huch K, Kuettner KE, Dieppe P.Osteoarthritis in ankle and knee joints. 

Semin Arthritis Rheum. 1997 Feb;26(4):667-74. 

4. Honkonen SE. Degenerative arthritis after tibial plateau fractures. J Orthop 

Trauma. 1995;9(4):273-7. 

5. Lansinger O, Bergman B, Korbner l. Tibial Condylar fractures. A twenty year 

follow-up. J Bone Joint Surg Am 1986;68:13-9. 

6. Volpin G, Dowd GS, Stein H. Degenerative arthritis after intra-articular 

fractures of the knee. Long-term results. J Bone Joint Surg Br, 1990;72:634-8. 

7. Saleh KJ, Sherman P, Katkin P. Total knee arthroplasty after open reduction 

and internal fixation of fractures of the tibial plateau: a minimum five-year 

follow-up study. J Bone Joint Surg Am. 2001 Aug;83-A(8):1144-8. 

8. Weiss NG, Parvizi J, Trousdale RT, Total knee arthroplasty in patients 

with a prior fracture of the tibial plateau. J Bone Joint Surg Am. 2003 

Feb;85-A(2):218-21. 




function 

II. Total knee uncommon after tibial plateau fracture, but high 

complication rate 

a. Mayo Clinc 1988-1999: 13,821 TKAs performed while 62 

were for previous tibial plateau fracture (0.45 %) 

b. 26% postoperartive complications, 21% reoperation 

PILON FRACTURES 

I. Post-traumatic arthritis of the ankle develops many years 

after injury 

a. Mean was 20.9 years 

b. Negative correlation between fracture severity and latency of 

OA 

c. Shorter latency with complications 

d. Open fractures higher incidence of OA than closed fractures 

e. Is it the articular damage or high complication rate ? 

f. Staged protocol for ORIF in severe fractures led to less 

arthritis and fewer fusion 

II. Post-traumatic arthritis more common than primary 

osteoarthritis in ankle 

a. knees post-traumatic DJD = 9.8% while in ankle posttraumatic 

DJD = 79.5% 

b. Rates of post pilon ORIF arthrodesis are from 5-30% 

CALCANEUS FRACTURES 

I. Nihilistic approach for displaced intra-articular calcaneus 

fractures does not yield good results 

a. non-op patients 1.5x more likely to have pain than op 

treated 

b. non-op 6x more likely to have fusion 

c. single surgeon series of over 600 cases, 6% fusions 

d. subtalar fusion after ORIF had better result than fusion after 

non-op treatment 

PILON FRACTURES REFERENCES 

1. Horisberger M, Valderrabano V, Hintermann B Posttraumatic ankle 

osteoarthritis after ankle-related fractures J Orthop Trauma. 2009 

Jan;23(1):60-7. 

2. Brown, Thomas D PhD; Johnston, Richard C MD Posttraumatic 

Osteoarthritis: A First Estimate of Incidence, Prevalence, and Burden of 

Disease Journal of Orthopaedic Trauma: November/December 2006 - 

Volume 20 - Issue 10 - pp 739-744 

3. M. Blauth, L. Bastian, C. Krettek Surgical Options for the Treatment of Severe 

Tibial Pilon Fractures: A Study of Three Techniques. Journal of Orthopaedic 

Trauma Vol. 15, No. 3, pp. 153–160 © 2001 

4. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B Etiology 

of ankle osteoarthritis. Clin Orthop Relat Res. 2009 Jul;467(7):1800-6. 

CALCANEUS FRACTURES REFERENCES 

1. Radnay CS, Clare MP, Sanders RW. Subtalar fusion after displaced intraarticular 

calcaneal fractures: does initial operative treatment matter? J Bone 

Joint Surg Am. 2009 Mar 1;91(3):541-6. 

2. Randle JA, Kreder HJ, Stephen D, Williams J, Jaglal S, Hu R. Should calcaneal 

fractures be treated surgically? A meta-analysis. Clin Orthop Relat Res. 2000 

Aug;(377):217-27. 

3. Csizy M, Buckley R, Tough S, et al: Displaced intra-articular calcaneal 

fractures: Variables predicting late subtalar fusion. J Orthop Trauma 

2003;17:106–112.

431 

myth: CalCaNeuS FraCtureS: 

NoNoperative Care iS equal to operative treatmeNt 

1. Natural history 

a. Factors affecting outcome 

i. Shortening 

ii. Impingement / abutment 

iii. Subtalar incongruity 

b. Timing of recovery 

2. Surgical management 

a. Risks 

i. Infection (factors) 

ii. Loss of reduction 

iii. Late complications 

BIBLIOGRAPHY 

1. Bajammal, S., Tornetta, P., Sanders, D., & Bhandari, M. (2005). Displaced 

intra-articular calcaneal fractures. Journal of orthopaedic trauma , 19 (5), 

360-4. 

2. Buckley, R., Tough, S., McCormack, R., Pate, G., Leighton, R., Petrie, D., et 

al. (2002). Operative compared with nonoperative treatment of displaced 

intra-articular calcaneal fractures: a prospective, randomized, controlled 

multicenter trial. The Journal of bone and joint surgery American volume , 

84-A (10), 1733-44. 

3. Csizy, M., Buckley, R., Tough, S., Leighton, R., Smith, J., McCormack, R., et al. 

(2003). Displaced intra-articular calcaneal fractures: variables predicting late 

subtalar fusion. Journal of orthopaedic trauma , 17 (2), 106-12. 

4. DeWall, M., Henderson, C., McKinley, T., Phelps, T., Dolan, L., & Marsh, 

J. (2010). Percutaneous reduction and fixation of displaced intra-articular 

calcaneus fractures. Journal of orthopaedic trauma , 24 (8), 466-72. 

5. Folk, J., Starr, A., & Early, J. (1999). Early wound complications of operative 

treatment of calcaneus fractures: analysis of 190 fractures. Journal of 

orthopaedic trauma , 13 (5), 369-72. 

6. Gougoulias, N., Khanna, A., McBride, D., & Maffulli, N. (2009). Management 

of calcaneal fractures: systematic review of randomized trials. British medical 

bulletin , 92, 153-67. 

7. Harvey, E., Grujic, L., Early, J., Benirschke, S., & Sangeorzan, B. (2001). 

Morbidity associated with ORIF of intra-articular calcaneus fractures using 

a lateral approach. Foot & ankle international / American Orthopaedic Foot 

and Ankle Society [and] Swiss Foot and Ankle Society , 22 (11), 868-73. 

8. Hedlund, L., Maki, D., & Griffiths, H. (1998). Calcaneal fractures in diabetic 

patients. Journal of diabetes and its complications , 12 (2), 81-7. 

9. Howard, J., Buckley, R., McCormack, R., Pate, G., Leighton, R., Petrie, D., 

et al. (2003). Complications following management of displaced intraarticular 

calcaneal fractures: a prospective randomized trial comparing open 

reduction internal fixation with nonoperative management. Journal of 

orthopaedic trauma , 17 (4), 241-9. 




Paul Tornetta, III, MD 

b. Benefits 

i. Decreased arthrosis 

c. Restored external anatomy 

3. Salvage 

4. Comparative studies 

a. Patient selection 

b. Goals 

c. Reality 

5. Exceptions / New horizons 

a. Tongue 2C 

b. Perc management 

10. Kingwell, S., Buckley, R., & Willis, N. (2004). The association between 

subtalar joint motion and outcome satisfaction in patients with displaced 

intraarticular calcaneal fractures. Foot & ankle international / American 

Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society , 25 

(9), 666-73. 

11. Radnay, C., Clare, M., & Sanders, R. (2010). Subtalar fusion after displaced 

intra-articular calcaneal fractures: does initial operative treatment matter? 

Surgical technique. The Journal of bone and joint surgery American volume , 

92 Suppl 1 Pt 1, 32-43. 

12. Sanders, R. (1992). Intra-articular fractures of the calcaneus: present state of 

the art. Journal of orthopaedic trauma , 6 (2), 252-65. 

13. Sanders, R., Fortin, P., DiPasquale, T., & Walling, A. (1993). Operative 

treatment in 120 displaced intraarticular calcaneal fractures. Results using a 

prognostic computed tomography scan classification. Clinical orthopaedics 

and related research (290), 87-95. 

14. Swanson, S., Clare, M., & Sanders, R. (2008). Management of intra-articular 

fractures of the calcaneus. Foot and ankle clinics , 13 (4), 659-78. 

15. Thermann, H., Krettek, C., HŸfner, T., Schratt, H., Albrecht, K., & Tscherne, 

H. (1998). Management of calcaneal fractures in adults. Conservative versus 

operative treatment. Clinical orthopaedics and related research (353), 107- 

24. 

16. Thordarson, D., & Krieger, L. (1996). Operative vs. nonoperative treatment of 

intra-articular fractures of the calcaneus: a prospective randomized trial. Foot 

& ankle international / American Orthopaedic Foot and Ankle Society [and] 

Swiss Foot and Ankle Society , 17 (1), 2-9. 

17. Tornetta, P. (1996). Open reduction and internal fixation of the calcaneus 

using minifragment plates. Journal of orthopaedic trauma , 10 (1), 63-7. 

18. Tornetta, P. (2000). Percutaneous treatment of calcaneal fractures. Clinical 

orthopaedics and related research (375), 91-6. 

19. van Tetering, E., & Buckley, R. (2004). Functional outcome (SF-36) of 

patients with displaced calcaneal fractures compared to SF-36 normative 

data. Foot & ankle international / American Orthopaedic Foot and Ankle 

Society [and] Swiss Foot and Ankle Society , 25 (10), 733-8. 

20. Zwipp, H., Tscherne, H., Thermann, H., & Weber, T. (1993). Osteosynthesis 

of displaced intraarticular fractures of the calcaneus. Results in 123 cases. 

Clinical orthopaedics and related research (290), 76-86.

432 

myth: boNe graFt SubStituteS: 

it doeSN’t really matter what i uSe 

J. Tracy Watson, MD 

Specific categories of agents for specific indications , efficacy based 

on available levels of evidence. 

1) Osteoinductive Bone Substitutes 

a) Autologous Bone…considered the GOLD STANDARD… 

i) There are few reports that actually provide the evidence 

for the clinical efficacy of autograft. 

b) Allogeneic Bone and Demineralized Bone Matrix 

i) No reports that carefully evaluate the osteoinductive 

properties of allograft bone. 

ii) Animal studies have documented DBM’s osteoinductive 

effects, there is a paucity of clinical information with 

similar findings. 

(1)Only one prospective controlled study showing 

equivalent rates of spinal fusion in the same patients 

treated with autograft versus a 2:1 ratio composite 

DBM(gel)/autograft, suggesting potential use DBM as 

a bone-graft extender. Only anecdotal information is 

available regarding similar applications in long bone 

fractures and nonunions. 

(2)Evidence of differential potencies of DBM 

preparations based on the manufacturer and 

manufacturing process. 

c) Bone Morphogenetic Proteins 

i) Urist, Johnson and colleagues first used the protein in 

clinical settings. Uncontrolled retrospective series (Level 4 

evidence) had encouraging results and stimulated further 

investigation in this area. 

ii) Two recombinant BMPs have been developed for clinical 

use; rhBMP-2 and rhBMP7 Each has been evaluated 

in randomized, controlled trials in trauma patients 

and these studies provide data that qualify as Level 1 

evidence. 

(1)Clinical use for diaphyseal open tibia fractures, long 

bone nonunion, and spinal fusion. 

2) Osteoconductive Bone Graft Substitutes 

a) Allograft 

i) Level 4 evidence exists for use of cortical allograft in 

reconstructive and trauma surgery of the humerus and 

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femur. Further research is needed to determine the ideal 

material for encouraging bone formation with these 

applications. 

ii) Calcium ceramic synthetic substitutes 

(1) Bone formation by providing an osteoconductive 

matrix for host osteogenic cells to create bone under 

the influence of host osteoinductive factors, for use in 

metaphyseal defects 

(2)Recommendations for use 

(a) CaPO4: Level B for use as an adjunct to internal of 

external fixation in fractures of the tibial plateau, 

intertrochanteric hip fractures and calcaneous 

fractures. Level A for use in distal radius fractures 

(b)CaSO4: Level B for use as a resorbable antibiotic 

bead in infected nonunions 

(i) Level C for use as an adjunct to internal 

fixation in tibial plateau fractures 

(ii)Allograft: Level C : no significant published 

evidence for use in non spinal skeletal Fractures 

(iii) Hydroxyapatite Level A for use in tibial 

plateaus as an adjunct to internal fixation 

3) Materials With Osteogenic Properties 

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milliliter of iliac aspirate contains approximately 40 million 

nucleated cells 1500 of which are CTPs..Clinical use with 

concentration and implantation for Fx and nonunions. 

i) Human data is limited, only case reports treating a 

limited number of patients demonstrating successful 

treatment in spinal fusion and nonunion patients (Level 

4). 

b) Use of Platelet – Rich Plasma and Related Peripheral Blood 

Concentrates 

i) Level 1 evidence in the Basic science literature to strongly 

support the positive effects and cellular stimulation by 

these adjuvants as a mechanism for bone repair. 

(1)Published prospective comparative studies are 

currently lacking. 

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experimental study in dogs. Clin Orthop.1991 Jul ;( 268):294-302. 

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Ortho Research 13:655-663, 1995. 

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Joint Surg Am. 2007 Mar;89(3):649-58. Review. 

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Factor Enhancement for Bone Grafts. June 1998, J Ortho Research 85(6) 

13:655-663, 1995. 

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a collagen-calcium phosphate graft material. A randomized clinical trial. J 


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morphogenetic protein 2 for treatment of open tibial fractures. A prospective, 

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Applications. J Orthop Trauma 22: 6: 432-439. 2008. 

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434 

myth: proXimal tibia FraCtureS: Should Not be Nailed 

Paul Tornetta, III, MD 

1. Problems with proximal fracture nailing 

a. Valgus malalignment 

b. Anterior angulation 

c. Knee pain? 

2. Solutions 

a. Nailing in relative extension 

b. Portal location 

c. Blocking screws 

BIBLIOGRAPHY 

1) Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullary tibial 

nailing: It’s incidence, etiology and outcome. J Orthop Trauma 1997; 11(2): 

103-105. 

2) Keating JF, Orfaly R, O’Brien PJ. Knee pain after tibial nailing. J Orthop 

Trauma 1997;11(1): 10-13. 

3) Court-Brown CM, Christie J, McQueen MM. Closed intramedullary tibial 

nailing. J Bone Joint Surg [Br] 1990; 72-B(4): 605-611. 

4) Alho, A, et al. Locked intramedullary nailing for displaced tibial shaft 

fractures. J Bone Joint Surg [Am] 1990; 72-B(5): 805-809. 

5) Koval KJ, Complications of reamed intramedullary nailing of the tibia. J 

Orthop Trauma 1991; 5(2): 184-189. 

6) Court-Brown CM, McQueen MM, Quaba AA, Christie J. Locked 

intramedullary nailing of open tibia fractures. J Bone Joint Surg [Br] 1991; 

73-B(6): 959-964. 

7) Haddad FS, et al. The AO undreamed nail: Friend or foe. Injury 1996; 27(4): 

261-263. 

8) Hooper GJ, Keddell RG, Penny ID. Conservative management or closed 

nailing for tibial shaft fractures. J Bone Joint Surg [Br] 1991; 73 (B): 83-85. 

9) Blachut PA, et al. Interlocking intramdullary Nailing with and without 

reaming for the treatment of closed fractures of the tibial shaft. A 

prospective, randomized study. J Bone Joint Surg [Am] 1997; 79A: 640-646. 

10) Bone LB, Johnson KD. Treatment of tibial fractures by reaming and 

intramedullary nailing. J Bone Joint Surg [Am] 1986; 68A: 877-887. 

11) Bhattacharyya T, et al. Knee pain after tibial nailing. Clin Orthop Rel Res 

2006; 449: 303-307. 

12) Karladani AH, et al. Displaced tibial shaft fractures: A prospective 

randomized study of closed intramedullary nailing versus cast treatment in 

53 patients. Acta Orthop Scand 2000; 71: 160-167. 

13) Devitt AT, et al. Patello-femoral contact forces and pressures during 

intramedullary tibial nailing. Intern Orthop 1998; 22(2): 92-96. 

14) Orfaly R, Keating JF, O’Brien PJ. Knee pain after tibial nailing: Does the entry 

point matter? J Bone Joint Surg [Br] 1995; 77-B: 976-977. 




3. Plates 

a. Risks 

b. Benefits 

4. High quality and Comparative studies 

5. Recommendations 

15) Tiovanen JAK, et al. Anterior knee pain after intramedullary nailing of 

fractures of the tibial shaft: A prospective, randomized study comparing two 

different nail-insertion techniques. J Bone Joint Surg [Am] 2002; 84: 580- 

585. 

16) Tornetta P, et al. Intra-articular anatomic risks of tibial nailing. J Orthop 

Trauma 1999; 13(4): 247-251. 

17) Vaisto O, et al. Anterior knee pain and thigh muscle strength after 

intramedullary nailing of tibial shaft fractures: A report of 40 consecutive 

cases. J Orthop Trauma 2004; 18(1): 18-23. 

18) Dogra AS, Ruiz AL, Marsh DR. Late outcome of isolated tibial fractures 

treated by intramedullary nailing: The correlation between disease-specific 

and generic outcome measures. J Orthop Trauma 2002; 16(4): 245-249. 

19) Freedman EL, Johnson EE. Radiographic analysis of tibial fracture 

malalignment following intramedullary nailing. Clin Orthop 1995; 315: 25- 

33. 

20) Buehler KC, Green J, Woll TS, et al. A technique for intramedullary nailing of 

proximal third tibial fractures. J Orthop Trauma 1997;11:218-23. 

21) Nork SE, Barei DP, Schildhauer TA, et al. Intramedullary Nailing of Proximal 

Quarter Tibial Fractures. J Orthop Trauma 2006;20(8):523-8. 

22) Tornetta P 3rd, Collins E. Semiextended position of intramedullary nailing of 

the proximal tibia. Clin Orthop 1996;328:185-9. 

23) Krettek C, Stephen C. Schandelmaier P, et al. The use of poller screws as 

blcokgin screws in stabilizating tibial fractures treated with small diameter 

intramedullary nails. J Bone Joint Surg 1999;(81B): 963-8. 

24) Ricci WM, O’Boyle M, Borrelli J, et al. Fractures of the proximal third of the 

tibial shaft treated with intramedullary nails and blocking screws. J Orthop 

Trauma 2001;15:264-270. 

25) Long GJ, Cohen BE, Bosse MJ, et al. Proximal third tibial shaft fractures: 

should they be nailed? Clin Orthop. 1995;315:64-74. 

26) Gustilo RD, Anderson JT. Prevention of infection in the treatment of one 

thousand and twenty-five open fractures of long bones: Retrospective and 

prospective analysis. J Bone Joint Surg Am. 1976;58:453-458. 

27) Vallier HA, Le TT, Bedi A. Radiographic and clinical comparisons of distal 

tibia shaft fractures (4 to 11cm proximal to the plafond): Plating versus 

intramedullary nailing. J Orthop Trauma. 2008;22:307-311.

435 

myth: limb Salvage iS better thaN amputatioN 

Robert Probe, MD 

I. Reconsideration of value of limb salvage 

A. Caudle & Stern (JBJS 1987) 

1. 62 Open Tibial Shaft fractures 

2. Seperated IIIB injuries into those with closure before or after 

7 days 

3. Conclusions: 

a. Soft Tissue cover should be accomplished within 7 days 

of injury 

b. “Type-IIIC: “Primary amputation should be seriously 

considered as a reliable and dependable means of 

restoring function of the limb…” 

II. Guideline Development 

A. Predictive Salvage Index (PSI) 

1. Howe, 1987 Annals of Surgery 

B. Mangled Extremity Score (MESS) 

1. Johansen et al 1990 

2. Tissue injury, ischemia, shock, age 

C. Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, 

Shock, and Age of Patient Score (NISSSA) 

1. McNamara et al 1994 

D. Limb Salvage Index 

1. Russel et al 1991 2. 26 limbs requiring revascularization 

E. Hannover Fracture Scale (97) 

TABLE I Components of Lower-Extremity Injury-Severity Scoring Systems 

MESS LSI PSI NISSA HFS-97 

Age x x 

Shock x x 

Warm ischemia time x x x x x 

Bone injury x x x 

Muscle injury x x 

Nerve injury x x 

deep Vein injury x x x 

Skeletal/soft Tissue injury x 

Contamination x x x 

Time to treatment x 

III. Guideline Performance 

A. When applied to the LEAP study group: 

1. All demonstrated low sensitivity (ability to accurately 

predict amputation) 

2. Demonstrated good specificity (ability to predict salvage) 

3. Show no correlation with functional outcomes of 

salvaged limbs 

4. Usefulness lies in the suggestion of salvage attempts for 

those patients with low scores 

IV. Patient Outcomes (Amputation vs Salvage) 

A. Outcomes following amputation 

1. MacKenzie et al, JBJS-A (2004) 

a. 161 patients with traumatic above ankle amputation 

b. Principle outcome: Sickness impact profile 

c. Results: 

i. Above and below knee amputations demonstrated 

similar Sickness Impact Profiles. 

ii. Both Above and below knee amputees scored 

higher than through knee amputees 




iii. Self-reported walking speeds highest with BKA 

B. Retrospective comparason of amputation vs salvage 

1. Georgiadis et al. JBJS-A (1993) 

a. Subjects were open tibial fractures with soft-tissue 

loss iv 16 patients with successful limb salvage v 18 

patients with traumatic below the knee amputation 

b. Limb salvage group 

i. More time to achieve full weight bearing 

ii. Less willing to work 

iii. Higher cost 

iv. More likely to consider themselves disabled 

v. More difficulty with daily activities 

C. LEAP: Bosse et al, NEJM 2002 

1. At 2 years, no significant difference in Sickness Impact 

Profile 

a. Amputation 12.6 

b. Limb salvage 11.8 

2. Predictors of poor outcome 

a. Major complication 

b. Low educational level 

c. Non-white race 

d. Poverty 

e. Uninsured 

f. Active litigation 

3. Return to work 

a. Amputation 53% 

b. Limb Salvage 49% 

D. Meta-analysis conclusions: Busse et al, JOT 2007 

1. Total cost higher for limb salvage (B) 

2. Long-term functional outcomes are equivelent 

3. 50% self reported disability in both groups 

4. Demographic factors have stronger correlation than 

treatment Outcome Variables 

E. No correlation with initial Injury Severity Scores. Ly et al, 

JBJS-A, 2008 

F. Surgeon controlled variables 

1. Webb et al, JBJS-A (2007) 

a. 156 patients, 105 Type III diaphyseal tibial fractures 

b. Variables with no effect: timing of debridement, 

timing of cover, timing of bone graft 

c. Variables with an adverse effect: 

i. Definitive treatment with external fixation 

d. Patients undergoing external fixation who also had 

a muscle flap for wound coverage had more physical 

impairment and a worse functional outcome than did 

patients who had an amputation. 

G. Outcome over time: MacKenzie et al, JBJS 2005 

1. SIP scores declined for both the salvage group and the 

amputation group after 2 years 

2. The absence of difference between groups remained at 7 

years following injury. 

V. Conclusions 

A. Given current technologies and social strategies, results are 

comparable between amputation and reconstruction 

B. Given the poor outcomes for both treatment options, 

continued efforts should be given to improved treatment 

strategies and technologies 

C. Non medical factors should be an integral part of future 

strategies to optimize functional outcomes

BIBLIOGRAPHY 

1. Bosse MJ, Melissa L. McCarthy, Alan L. Jones, Lawrence X. Webb, Stephen H. 

Sims,Roy W. Sanders,Ellen J. MacKenzie and the Lower Extremity Assessment 

ProjectThe Insensate Foot Following Severe Lower Extremity Trauma: An 

Indication for Amputation? J Bone Joint Surg Am. 2005;87:2601-2608. 

2. Busse, DC, MSc, Craig L. Jacobs, DC, Marc F. Swiontkowski, MD,Michael 

J. Bosse, MD, and Mohit Bhandari, MD. Complex Limb Salvage or 

EarlyAmputation for Severe Lower-Limb Injury: A Meta-Analysis of 

Observational Studies JOrthop Trauma _ Volume 21, Number 1, January 

2007 

3. CaudleRJ and PJ Stern. Severe open fractures of the tibia. J Bone Joint Surg 

Am. 1987;69:801-807. 

4. Georgiadis GM, FF Behrens, MJ Joyce, AS Earle and AL Simmons. Open tibial 

fractures with severe soft-tissue loss. Limb salvage compared with below-thekneeamputation. 

J Bone Joint Surg Am. 1993;75:1431-1441. 

5. Hansen, ST. The type-IIIC tibial fracture. Salvage or amputation; comment. J 

Bone Joint Surg Am. 1987;69:799-800. 

436 




6. Lawrence X. Webb, MD, Michael J. Bosse, MD, Renan C. Castillo, MS, Ellen J. 

MacKenzie, PhD. Analysis of Surgeon-Controlled Variables in the Treatment 

of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures. J Bone Joint 

Surg Am.2007;89:923-8 

7. MacKenzie EJ, Michael J. Bosse, Andrew N. Pollak, Lawrence X. Webb, Marc 

F. Swiontkowski, James Kellam, Douglas G. Smith, Roy W. Sanders, Alan L. 

Jones,F.Adam J. Starr, Mark P. McAndrew, Brendan M. Patterson, Andrew R. 

Burgess andRenan C. Castillo, Trauma. Results of a Seven-Year Follow-up 

Long-Term Persistenceof Disability Following Severe Lower-Limb J Bone 

Joint Surg Am. 2005;87:1801-1809. 

8. Patterson, Thomas G. Travison and Melissa L. McCarthy Andrew R. Burgess, 

Marc F.Swiontkowski, Roy W. Sanders, Alan L. Jones, Mark P. McAndrew, 

Brendan M. Ellen J.MacKenzie, Michael J. Bosse, Renan C. Castillo, Douglas 

G. Smith, Lawrence X.Webb, James F. Kellam, Amputation Functional 

Outcomes Following Trauma-Related Lower-Extremity. J Bone Joint Surg Am. 

2004;86:1636-1645. 

9. Swiontkowski, Roy W. Sanders, Alan L. Jones, Mark P. McAndrew, Brendan 

M.Patterson, Melissa L. McCarthy, Michael J. Bosse, Ellen J. MacKenzie, James 

F.Kellam, Andrew R. Burgess, Lawrence X. Webb. A Prospective Evaluation of 

theClinical Utility of the Lower-ExtremityInjury-Severity Scores J Bone Joint 

Surg Am. 2001;83:3.

437 

myth: hip diSloCatioNS: timiNg oF reduCtioN doeSN’t make 

aNy diFFereNCe iN outCome 

J. Tracy Watson, MD 

Basic Science Evidence: Posterior Hip Dislocations: A Cadaveric 

Angiographic Study, Yue, J.J. et.al. JOT: 10 (7), 447-454. 1996. 

These extraosseous changes do not consistently result in changes in 

the intraosseous blood flow possibly due to collateral circulation. 

Relocating the femoral head in a traumatic posterior hip dislocation 

may provide earlier blood flow to the femoral head by relieving 

tension across the femoral and circumflex vessels. 

Blood supply of the head of the femur in traumatic hip 

dislocation. Surg Gynecol Obstet. Duncan CP, et.al Surg Gynecol 

Obstet. Feb;144(2):185-91. 1977 

Disturbance of circulation is most severe and worsens with continued 

dislocation to a maximum at 24 hours. Early reduction enhances 

early and complete recovery of blood supply. Reduction > 12 hours 

or longer does not improve the extent of the circulatory recovery of 

the femoral head. 

Circulatory and vascular changes in the hip following traumatic 

hip dislocation, Shim SS. Clin Orthop Relat Res. (140):255-61. 

1979. 

Compression, traction and spasm of intact vessels are reversible by 

early reduction. Posttraumatic inflammatory changes, thrombosis, 

fibrosis and occlusion may cause AVN. Early reduction restores 

anatomy and extra and intraosseous circulation. 

Effect of hip dislocation on the blood supply to the femoral 

head. An experimental study in rabbits. Sapkas G,et.al. Acta 

Orthop Scand. 54(2):204-9, 1983 

The initially decreased femoral head blood flow progressively 

increased, in time from reduction. Traumatic dislocation is rarely be 

the 1˚ cause of AVN. 

Blood flow changes to the femoral head after acetabular fracture 

or dislocation in the acute injury and perioperative periods. Yue 

J.J, et.al. J Orthop Trauma. 15(3):170-6. 2001. 

Mean dislocation time was 9.1 hours in Pts. with low flow SPECT 

scan. VS. 4.5 hrs for pts with normal SPECT scans (Sig) 




Clinical Evidence: 

Stewart MJ, et.al…AVN 21.2% overall ….Reduced < 3 days..15.5% 

AVN, reduced < 21days..40%..AVN.... Osteoarthritis....48%. 

Brav et. al…AVN ….Reduction within 12 hrs..22% AVN, Reduction 

> 12hrs..52% AVN. Osteoarthritis…..26%. 

Hunter GA, …AVN…Reduction ASAP < 24hrs..2% AVN, 

Osteoarthritis…26%. 

Upadhyay et.el… Reduction within 8-12 hrs…..6% and 8% AVN (2 

studies) Osteoarthritis…24%. 

Hougaard and Thomsen… AVN …Reduction within 6 hrs..4% 

AVN, reduction > 6hrs..58% AVN……. Osteoarthritis….31%.....< 6 

hrs..30%, > 6hrs 58%. 

Yang RS et.al,….AVN… Reduction < 12 hrs…no difference from 

reduction at 12-24 hrs Osteoarthritis....19%. 

Dreinhofer et.al…AVN,…Reduction within 1 hr or within first 6 

hrs..no difference AVN…12%...All posterior…… Osteoarthritis.. 

Anterior..11%, Posterior..26%. 

Sahin V et.al…AVN…Reduction < 12hr…20% AVN, Osteoarthritis 

30%, Reduction > 12 hr…..80% AVN, Osteoarthritis 70% 

Myth: Hip dislocations: Timing of reduction doesn’t make any 

difference in outcome……BUSTED!!! With caveats’ 

Outcomes contingent on the development of arthritis and / or AVN. 

(time dependent) The long-term prognosis of simple hip dislocations 

reported excellent / good in 48% to 95%. Anterior dislocations have 

a better long-term prognosis than posterior dislocations. Associated 

injuries have a negative prognostic effect on the clinical result. 

Poorer results in patients with multiple severe injuries. Increased 

rates of arthritis with increasing length of follow-up. Heavy labor 

occupations after injury at increased risk for a poor outcome. The 

most important prognostic sign not necessarily time to reduction 

but direction of dislocation and overall severity of all injuries and 

specifically associated hip pathology.

438 

imagiNg iNterpretatioN oF 

oNCologiC muSCuloSkeletal 

CoNditioNS: uNderStaNd 

what you See!! (i) 



SympoSia TUMOR 

Moderator: Carol D. Morris, MD, New York, NY 

This Symposium will review the basics of image interpretation of musculoskeletal tumors and assist the practicing surgeon in 

understanding what the x-rays, CT scans, and MRI actually reveal. 

OBJECTIVES: 

1. Understand how to interpret commonly ordered radiographic studies (x-ray, MRI, CT scan) as they relate to bone 

and soft tissue tumors. 

2. Understand the imaging appearance of common musculoskeletal lesions. 

3. Understand what imaging findings require referral to an orthopaedic oncologist. 


Carol D. Morris, MD, New York, NY 

II. Basics of MRI Interpretation 

David Panicek, MD, New York, NY 

III. Extremity Bone Tumors 

Theodore W. Parsons, MD, Detroit, MI 

IV. Extremity Soft Tissue Tumors 

Carol D. Morris, MD, New York, NY 

V. Spine Tumors 

Joseph H. Schwab, MD, Boston, MD 

VI. Discussion, Questions and Answers 

All Faculty

439 

imagiNg iN muSCuloSkeletal tumorS: 

baSiCS oF mri iNterpretatioN 

David M. Panicek, MD 

Learning Objectives 

• Review factors that affect the MRI appearance of 

musculoskeletal tumors 

• Illustrate an approach to characterizing musculoskeletal tumors 

at MRI 

• Describe some MRI pitfalls 

Various extrinsic and intrinsic factors affect the appearance of 

musculoskeletal tumors at MRI. 

Extrinsic factors 

The most important extrinsic factor affecting the appearance of a 

tumor is the particular MR pulse sequence selected. A pulse sequence 

represents the physical means by which protons in the patient are 

interrogated to produce images that emphasize various properties 

of each of the different tissues present. Pulse sequences can be 

considered as being loosely analogous to the various stains used by 

pathologists; each has a different purpose. The two major classes of 

pulse sequences are spin echo and gradient echo. 

T1-weighted spin-echo images are often described as “anatomy” 

images, as they depict normal structures with fine detail. T1weighted 

images are critical in demonstrating bone tumors against 

a background of fatty marrow, distinguishing normal marrow and 

tumor, and showing the presence of fat or hemorrhage within a 

mass. T2-weighted sequences, also referred to as fluid-sensitive 

sequences, produce “pathology” images. Fat suppression is essential 

with T2-weighted images to distinguish tumor from surrounding 

marrow edema and fatty marrow, all of which otherwise can show 

high signal. 

Proton density images, although widely used in imaging of trauma 

and internal derangement, are of limited utility in musculoskeletal 

tumor imaging because the signal intensities of tumor, edema, 

and surrounding normal fatty marrow are often similar, thereby 

decreasing the conspicuity of the lesion. 

STIR(shorttauinversionrecovery)images,aformofspinechoimages, 

exhibit uniform fat suppression across the entire image, but are not 

recommended for characterization or staging of musculoskeletal 

tumors. Many lesions appear similarly bright on STIR sequences, 

limiting characterization; and the actual extent of tumor spread 

is often overestimated due to signal from even minimal amounts 

of peritumoral edema. STIR sequences are useful, however, in the 

presence of metallic hardware, as they produce fat-suppressed, fluidsensitive 

images that are much less prone to metallic artifacts. 

Pre- and post-gadolinium fat-saturated T1-weighted spin-echo 

images frequently are helpful in tumor assessment. The presence 

of enhancement within a lesion indicates that the lesion is not a 

cyst, but generally does not distinguish benign from malignant 

etiologies. Enhancement may increase the conspicuity of a small 

tumor recurrence within a background of post-treatment changes. 

Gradient-echo images can be obtained more quickly than most 

spin-echo images, but provide different tissue contrast. In tumor 

imaging, gradient-echo images obtained with long echo times (TEs) 

are utilized to assess for regions of very low signal that appear larger 

than on other sequences; this finding, called “blooming,” indicates 

the presence of metal (such as iron in hemosiderin) and allows the 

differential diagnosis to be narrowed considerably. Assessment of 

pigmented villonodular synovitis/giant cell tumor of the tendon 




sheath should include long-TE gradient-echo images. Flow-sensitive 

gradient-echo images can be used to assess for narrowing or 

thrombosis of vessels. 

An MR image usually includes a printed series descriptor that names 

the particular pulse sequence used (unless this option is turned 

off by the person displaying the image). If such a descriptor is not 

included in an image, the type of spin-echo pulse sequence usually 

can be inferred from the combination of TR (repetition time), TE 

(echo time), and for STIR, TI (inversion time) printed on the image. 

Some typical ranges for these parameters at 1.5 Tesla are as follows: 

TR (msec) TE (msec) TI (msec) 

T1-weighted 400-700 9-15 - 

T2-weighted 2000-6000 60-120 - 

Proton density 1800-5000 10-30 - 

STIR 2000-6000 20-50 140-160 

The selection of various pulse sequences, imaging planes, gadolinium 

contrast, slice thickness, and other scan parameters for a particular 

patient constitutes the scan protocol, which is tailored by the 

radiologist to optimally answer the questions posed by the referring 

physician. The more specific the question(s) posed in the MRI 

request, the greater the likelihood of receiving the correct answer(s). 

Intrinsic factors 

The key intrinsic factors that affect the appearance of tumors at MRI 

are the chemical and tissue compositions of the tumor. MRI has 

excellent ability to identify various chemicals, such as methemoglobin, 

hemosiderin, and water. Similarly, MRI excels in demonstrating the 

presence of fat (both macroscopic and microscopic), and often can 

demonstrate the presence of collagen or myxoid matrix within a 

lesion. 

Approach to characterizing soft tissue masses at MRI 

Characterization of soft tissue masses in the musculoskeletal system 

as benign or malignant often will be incorrect if one relies solely 

on traditional imaging features such as sharpness of the margin, 

presence of local invasion, large size, and internal homogeneity 

of the lesion. However, if a soft tissue mass demonstrates certain 

characteristic imaging features, a specific diagnosis frequently can be 

made (e.g., cyst, ganglion, lipoma, fat necrosis, giant cell tumor of 

tendon sheath, hemangioma, desmoid/fibromatosis, benign nerve 

sheath tumor, subacute hematoma, elastofibroma). Lacking such 

characteristic imaging features, the possibility of malignancy should 

not be dismissed. 

A specific diagnosis can often be suggested based on the basis of 

the chemical composition of the lesion (e.g., water, hemosiderin, 

methemoglobin) and/or its tissue composition (e.g., fat, collagen, 

myxoid matrix). 

Malignant lesions that are prone to being misinterpreted as benign 

include those sarcomas that are predominantly cystic, hemorrhagic, 

or myxoid. Extensive cystic change or hemorrhage within a sarcoma 

may overshadow the solid tumor elements present. Solid elements 

must be carefully sought and viewed as suspicious for cancer until 

proven otherwise; gadolinium-enhanced imaging is essential in this 

assessment.

Myxoid liposarcoma also may look deceptively cyst-like on standard 

T1-weighted and T2-weighted MR images. The presence of subtle 

fatty streaks within the lesion may be a clue to the correct diagnosis 

of myxoid liposarcoma. Even more importantly, enhancement 

within the lesion — ranging from fine and lacy to intense and 

coalescent — is typically evident after intravenous contrast material 

administration, and is an invaluable finding to prevent misdiagnosis 

of myxoid liposarcoma as a ganglion or other cyst. 

Another specific type of myxoid sarcoma, myxofibrosarcoma, is 

increasingly recognized by pathologists as one of the most common 

fibrous sarcomas of the extremities in the elderly. This tumor, even 

early on, has an unusual, infiltrative growth pattern along fascial 

and vascular planes, resulting in wispy streaks or “tails” of edemalike 

signal that extend for considerable distances from the primary 

sarcoma. These tails represent tumor; due to this atypical growth 

pattern, even low-grade myxofibrosarcoma tends to recur relentlessly, 

with subsequent recurrences being of higher grade. 

Approach to characterizing bone tumors at MRI 

Radiographs remain critical in the characterization of many bone 

lesions, and should not be neglected in the initial evaluation. 

The first task at MRI is to avoid misinterpreting normal marrow 

as tumor. Normal marrow in adults may appear heterogeneous 

at MRI, particularly in the pelvis, due to mixing of red and yellow 

marrow. Fat is present normally in both red and yellow marrow, 

being much more abundant in the latter. Features suggesting red 

marrow include a feathery appearance on T1-weighted images, and 

frequently a relatively symmetrical distribution. Red marrow shows 

signal intensity higher than that of muscle on T1weighted images. 

Bone tumors (primary or metastatic) replace the normal marrow, 

and typically show signal similar to that of muscle on T1-weighted 

images. Most bone tumors show sharply defined boundaries with 

normal marrow at MRI; this sharpness should not be misinterpreted 

as representing a narrow zone of transition, a criterion only applicable 

to radiographs. 

MRI generally does not depict calcifications unless they are large 

or very dense, limiting the utility of MRI in characterizing calcified 

tumor matrix. 

On fat-suppressed T2-weighted images, hyaline cartilage lesions 

(enchondroma, low-grade chondrosarcoma) often can be identified 

due to the presence of multiple small lobules with very high 

signal intensity (due to the high water content of hyaline cartilage 

lobules). 

440 




Blood-fluid (fluid-fluid) levels have been reported in a wide range 

of soft tissue and bone tumors, benign and malignant. A bone 

lesion composed solely of blood-fluid levels is consistent with an 

aneurysmal bone cyst. If thick septa or soft tissue nodules are present 

as well, other diagnoses must be considered, such as telangiectatic 

osteogenic sarcoma, or a secondary aneurysmal bone cyst engrafted 

on another bone tumor. Gadolinium-enhanced images are useful 

in assessing for soft tissue elements within an otherwise cystic bone 

lesion. 

The presence of flow voids (curvilinear black regions representing 

small, high-flow vessels) within a bone lesion at MRI suggests the 

lesion is a metastasis from a primary renal cancer. 

Lytic bone metastases generally show moderately increased signal 

throughout on fat-suppressed T2-weighted images, whereas blastic 

lesions often show such signal only in a peripheral rim (“halo”). 

This “halo,” when present, can be particularly helpful in diagnosing 

a blastic metastasis, which otherwise generally shows low signal on 

all pulse sequences. 

The differential diagnosis for benign bone lesions surrounded by 

extensive marrow edema includes osteoid osteoma/osteoblastoma, 

chondroblastoma, Langerhans cell histiocytosis, and osteomyelitis. 

As a general (but not absolute) guideline, the greater the extent 

of surrounding marrow edema, the more likely the bone lesion is 

benign. Marrow edema may be present around malignant bone 

tumors, as well, in which case it constitutes the reactive zone of the 

tumor. 

Calcific tendinitis can produce erosions in subjacent bone and an 

associated marrow edema pattern. Recognition of the overlying 

tendinous abnormality will help prevent misinterpretation of the 

subjacent bony changes as a metastasis. 

After chemotherapy and/or radiotherapy, CT and MRI may produce 

seemingly incongruous results for a bone tumor: CT may show 

persistent lytic and/or blastic changes while MRI shows normal fatty 

marrow in the same region. This apparent inconsistency results from 

the fact that the two imaging modalities demonstrate fundamentally 

different tissues. The CT findings are due to the secondary changes 

induced in trabecular and cortical bone of the host, whereas the MRI 

findings are due to signal from the tumor itself replacing marrow 

and from the surrounding marrow. In other words, MRI directly 

demonstrates tumor in the marrow, and CT only shows secondary 

bony effects of the tumor. Those secondary changes at CT may 

persist for months or even years despite, after successful therapy, 

reconstitution of fatty marrow in the region formerly occupied by 

the tumor.

The ability to interpret lesions of bone utilizing plain radiographs 

generally stems from one of two approaches: 

1. The “Aunt Minnie” approach as espoused by Dr. William 

Enneking. This is a general recognition of a certain pattern or 

appearance on radiographs, and given enough experience or 

exposure to large volumes of lesions, is generally quite accurate. 

(“I know my Aunt Minnie and I recognize her when I see her” is 

the analogy). 

2. The biologic approach, as refined by Dr. Gwilym Lodwick. This 

provides for some understanding of the biologic behavior of 

the lesion, and the biologic response of the bone. This method 

of interpretation is not so dependent on experience, but 

rather allows for the development of a differential diagnosis 

based upon an understanding of why an image has a certain 

appearance. 

In reality, a combination of the two approaches is ideal, and generally 

allows for the establishment of a reasonably accurate diagnosis based 

upon plain radiographs of bone. Clearly the more experienced the 

observer, the more comfortable he/she becomes in understanding 

and recognizing bone lesions. Several Key points should be kept in 

mind: 

• Plain Radiographs are the GOLD STANDARD when it comes to 

establishing the diagnosis of bone lesions. While other imaging 

modalities are extremely helpful, and aid in the diagnosis, they 

should never supplant good quality, bi-planar radiographs. 

• Lodwick Classification (biologic behavior, zone of transition) 

helps determine the lesional activity and the bone’s response 

to the presence of the lesion, if any. This classification is 

essentially: 

— Type I: Geographic Lesion 

IA: sclerotic margins 

IB: Well defined Margins 

IC: Poorly defined margins 

— Type II: Moth Eaten Lesion (confluence of small lytic areas in 

bone) 

— Type III: Permeative Lesion (diffuse, tend to preserve outline 

of the bone but show diffuse destruction) 

Generally, the increasing type corresponds with an increasing 

aggressiveness of the lesion. Type I lesions, particularly when well 

marginated, tend to be more indolent in nature. For example, a Nonossifying 

Fibroma, a common metaphyseal lesion with a sclerotic 

margin, is a great example of a type IA lesion. Myeloma, with its 

focal destructive confluence, but lacking margination, is a common 

example of a type II lesion. Classic high grade Osteosarcoma, with 

its aggressive and diffuse presentation, is a common example of a 

type III lesion. 

• Dr. Henry Mankin’s “Big Four” can help identify malignant vs. 

benign lesions based on four radiographic observations. This is 

another example of how understanding the biologic activity of a 

lesion can aid in the diagnosis. 

— Size of the lesion (big is bad, small is good) 

— Cortical destruction (present or not?) 

— Presence or absence of margination (zone of transition). 

— Presence or absence of a soft tissue mass. 

A large lesion with all these characteristics is likely to be aggressive, 

whereas a small lesion that lacks most of these findings is more 

likely benign. Note that there are exceptions! Infection may have 

441 




eXtremity boNe tumorS 

Theodore W. Parsons III, MD, FACS 

aggressive features (but is ‘benign’), while some metastatic lesions 

may look indolent (but are malignant)! Some benign lesions (giant 

cell tumor, chondroblastoma, aneurysmal bone cyst) may have 

aggressive features! 

• Location of the lesion helps establish the diagnosis. For 

example: 

— Chondroblastoma and giant cell tumor typically occur in the 

epiphyses or apophyses of long bones 

— Osteofibrous dysplasia and adamantinoma are classically 

tibial lesions 

— Nonossifying fibroma is eccentric and cortically based, and 

occurs in the metaphysis of long bones (typically in the 

lower extremity) 

— Simple bone cysts are centrally located, often in the proximal 

humerus or femur 

• Age of the patient is helpful in establishing the diagnosis. 

Certain tumors have a predilection for certain age groups. While 

there are always exceptions to the rule, this is another useful 

tool. For example: 

— Simple bone cysts, non-ossifying fibromas, 

chondroblastomas, Ewings sarcomas are seen in older 

children and teenagers 

— Multiple myeloma, chondrosarcoma, metastatic carcinoma 

are seen in older adults 

• Matrix mineralization within a lesion is a helpful diagnostic 

clue: 

— Stippled, “popcorn”, or “rings and arcs” calcifications 

indicate a chondroid tumor 

— Amorphous, “cloudlike” mineralization is typical of 

osteosarcoma or blastic metastases such as prostate 

carcinoma 

— Fibrous dysplasia typically demonstrates a “ground-glass” 

appearance 

— Bone infarcts often reveal a swirling, “smoke up the chimney” 

mineralized pattern 

After the evaluation of plain films, additional imaging studies may 

be helpful in clarifying the diagnosis. In general, these include the 

following: 

• Bone scintigraphy is particularly useful in determining whether 

a bone lesion is active or indolent (with a few exceptions). 

Slowly growing or inactive lesions typically demonstrate 

minimal radiopharmaceutical uptake, whereas active lesions, 

both benign and malignant, typically demonstrate intense 

radiopharmaceutical uptake. [Remember that the uptake 

represents the bone’s response to the presence of the lesion!] 

— Transition from a previously mild uptake to intense uptake 

in a known lesion is generally an ominous sign (malignant 

transformation). 

— Provides sensitive screening for metastatic disease 

– Note that renal cell, myeloma, thyroid carcinoma, may 

show little uptake…do not completely rely upon bone 

scan in these cases! 

— Helpful in identification of radiographically occult lesions 

— Computed Tomography (CT) is particularly useful at 

identification of mineral density in subtle lesions, or 

identification of cortical integrity 

— Differentiation of chondrogenic (calcifications) from 

osteogenic (cloudlike bone formation) lesions 

— Visualizing faint calcifications in liposarcomas or synovial

442 

sarcomas 

— CT is helpful in evaluating axial skeletal lesions (pelvis, 

spine) where the bony anatomy is complex 

— Remains the modality of choice for pelvic/abdominal 

adenopathy 

— Useful for planning/conducting biopsies of lesions or RF 

ablation 

— For evaluating primary source in metastatic lesions to bone 

- CT of chest, abdomen, pelvis as screening imaging 

— Magnetic Resonance Imaging (MRI) MRI is an excellent 

modality for obtaining fine detail in most lesions, and is 

an excellent tool in identifying anatomic involvement and 

extent of lesional boundaries. Here are a few simple keys 

useful in this modality: 

— T1 weighted images are best for evaluation of bone marrow 

– Marrow replacement from tumor or infection tends to be 

at least as dark as adjacent muscle 

— T1 weighted images are typically only bright from the 

following: 

– Fat, met hemoglobin, gadolinium, proteinaceous fluid, 

melanin, and particulate calcium 

– Reduced venous flow, surgical packing or hemostatic 

agents may also be bright in the post-op MRI on T1 

weighted images (generally seen in post-operative 

patients) 

— T2 weighted images reflect free water, and clearly identify 

most tumors, cystic lesions, joint or synovial fluid, and 

edema 

– Densely fibrous lesions may be low on T1 and T2 images 

— Fluid-fluid (layering of different density material) levels 

are common in aneurysmal bone cyst, telangiectatic 

osteosarcoma, and synovial sarcoma. 

– Other lesions (simple cyst with bleed, chondroblastoma, 

giant cell tumor, even fibrous dysplasia may reveal fluidfluid 

levels). 

— Gadolinium T1 weighted images reveal hyperemia of tissues, 

and may “overcall” tissue involvement by tumor. 




– “Rim enhancement” around a lesion is common with 

cystic lesions, rarely with centrally necrotic lesions 

Gradient Echo images may be used to confirm the presence of subtle 

calcification or chronic blood products (e.g. pigmented villonodular 

synovitis), due to its sensitivity to signal loss from these tissues 

(“bloom artifact”) 

Putting it all together in the clinical setting: When confronted 

with the lesion of bone, the diagnosis develops as the result of a 

confluence of information that the surgeon should obtain as part of 

the “work up”. Following this simple pattern, and utilizing the ‘keys’ 

noted above, typically results in an appropriate differential diagnosis, 

which in turn facilitates appropriate care for these patients. Referral 

to a musculoskeletal oncologist, in cases of suspected primary 

malignancy, or in cases of uncertainty, is generally a wise choice. 

1. Take a careful history from the patient. Pay attention to pain 

patterns, constitutional symptoms, family history, rapidity of 

symptom onset, etc. 

2. Physical examination of the involved area. Remember to look 

for regional adenopathy, and look for potential masses in the 

paired organs (breast, thyroid, etc) 

3. Order appropriate lab studies, including CBC, SPEP/UPEP, 

Thyroid function, PSA, UA, chem panel, etc. 

4. Obtain appropriate radiographs to analyze the lesion and its 

appearance as noted in the discussion above. 

5. Consider other supporting studies as indicated: Bone Scan, CT, 

MRI, etc. This additional information may be very helpful. 

Remember that XR/CT of the lungs, or screening CT of chest/ 

abdomen/pelvis may be necessary. 

6. Finally, tissue diagnosis may be necessary in the lesion that is 

aggressive, or whose diagnosis is not clear on imaging. While 

the general orthopaedic surgeon may feel comfortable dealing 

with metastatic carcinoma, most other biopsies of aggressive 

lesions should be done under the direction of a musculoskeletal 

oncologist.

• Demographics 

— Benign soft tissue tumors 

– 300 per 100,000 

– >60 different types of benign masses 

— Soft tissue sarcomas 

– 1.4 per 100,000 

ª 8 per 100,00 in persons >80 yo 

• Physical Examination is key for generating a differential 

diagnosis 

Clinical presentation of extremity soft tissue masses 

Benign Malignant Comments 

Pain Rare Rare 

Uncommon in the absence of 

nerve or bone invasion 

Size 5cm 

Location 

443 

Superficial 

(subcutaneous) 

Mobility Mobile Fixed 

Consistency Soft Firm 

Growth Stable Enlarging 

eXtremity SoFt tiSSue tumorS 

Carol D. Morris, MD, MS 

deep to fascia 2/3 of STS are deep 

Synovial sarcoma and clear cell 

sarcoma can be notoriously slow 

growing 

• Imaging modalities 

— X-ray 

– Useful for looking at mineralization pattern 

– Identifies bone involvement 

— MRI 

– By far the most useful diagnostic tool for soft tissue 

masses 

– Excellent definition of size and boundaries 

– Gadolinium helpful for distinguishing cystic vs. solid 

masses 

ANY HERTEROGENOUS, DEEP, >5CM MASS IS A MALIGNANCY 

UNTIL PROVEN OTHERWISE! 

— CT scan 

– Indicated in patients in whom MRI is incompatible 

– Best results with contrast 

– Excellent for characterizing mineralization pattern 

– i.e. peripheral mineralization as seen in myositis 

ossificans 

— Ultrasound 

– Helpful for distinguishing cystic vs. solid masses 

• Common Benign Soft Tissue Tumors 

— Elastofibroma 

– Almost exclusively subscapular in location 

— Desmoid 

– Iso- to hypo-intense on T1 

– Infiltrative pattern, ill-defined borders on MRI 

— Myxoma 




– Homogenous signal which is hypointense on T1 and 

bright on T2 often with associated peritumoral edema 

— Lipoma 

– Should have the same appearance as subcutaneous fat on 

ALL MRI sequences 

– No enhancement 

— Hemangioma 

– Plain x-ray helpful for identifying phleboliths 

– MRI with classic serpentine pattern, heterogenous signal 

intermixed with fat 

— Giant cell tumor of tendon sheath 

– Hypointense on both T1 and T2 weighted images 

– 20% with bone involvement 

— Schwannoma 

— Neurofibroma 

– Tail sign on coronal or sagittal MRI images 

– Target sign on axial MRI images 

• Common soft tissue malignancies 

— Liposarcoma 

– Most common STS in late adulthood 

– Low grade liposarcomas tend to have remnants of typical 

fat signal on MRI 

– High grade liposarcoma may not have any signal 

characteristics c/w fat 

— MFH 

— Synovial sarcoma 

– Vast majority are peri-articular with the knee being the 

common site 

– Peak age 20-40 yo 

– 20% demonstrate calcifications on imaging 

— Fibrosarcoma/Myxofibrosarcoma 

– Extensive edema-like high signal along fascial planes 

— Leiomyosarcoma 

— Malignant peripheral nerve sheath tumor 

– >50% arise in patients with neurofibromatosis-1 

– May see the tail of a nerve entering or exiting the mass 

— Rhabdomyosarcoma 

– Most common STS in children less than 10 yo 

— Angiosarcoma 

– Can be confused with chronic hematoma 

— Epithelioid sarcoma 

– Most common STS in the hand 

— Extraskeletal osteogenic sarcoma 

– Typically presents with mineralization in the soft tissues 

– Rare compared to skeletal osteogenic sarcoma 

— Ewing’s /PNET 

– More common in adults where as bony Ewing’s is more 

common in children 

— Alveolar soft-part sarcoma 

— Others (non-sarcomas) 

– Lymphoma 

– Melanoma 

– Metastatic disease

1. Pseuodotumor Conditions of the Vertebrae 

Degenerative Conditons of the Spine 

• Schmorl’s Nodes and other common non-malignant 

conditions of the spine 

Hamartomas and Failures of Involution 

• Hemangiomas and Notochordal Rests 

Paget’s Disease and other metabolic pseudotumors of the 

vertebrae 

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PAPERS 

445 

adult reconstruction hiP 

pApeR No. 031 

Hip Resurfacing Arthroplasty in Patients with Varus 

Deformity of the Femoral Neck-Shaft Angle 

Graeme S Carlile, MBChB, MRCS, Tavistock, United Kingdom 

Christopher Wakeling, MBChB, MRCS 

Mark Norton, MD, Truro, Cornwall, Uk, United Kingdom 

Edwin Darren Fern, MBChB, Truro, Cornwall, United Kingdom 

Hip resurfacing arthroplasty (HRA) in patients with a varus deformity 

of the femoral neck-shaft angle (NSA) is associated with poorer 

outcomes. Our experience has not reflected this. We examined the 

Oxford Hip Scores (OHS), Harris Hip Scores (HHS) and outcomes 

of patients with varus hips against a normal cohort to ascertain any 

significant difference. We identified 179 patients. Measurement of 

the femoral neck-shaft angle was undertaken from antero-posterior 

radiographs pre-operatively. The mean NSA was 128.5 degrees (SD 

6.3). Patients with a NSA of less than 122.2 were deemed varus 

and those above 134.8 valgus. These parameters were consistent 

with published anatomical studies. The varus cohort consisted of 

23 patients, mean NSA 118.7 (range 113.6-121.5), mean follow up 

49 months (range 13-74). Mean OHS and HHS were 16 and 93.5 

respectively. Complications included two cases of trochanteric nonunion; 

no femoral neck fractures, early failures or revisions. Normal 

cohort consisted of 125 patients, mean NSA 128 degrees, mean 

follow up 41 months (range 6-76). The OHS and HSS were 18.8, 

88.9 respectively. Complications included five trochanteric nonunions 

and one revision due to an acetabular fracture following a 

fall. Statistical analysis demonstrated no statistical difference between 

the cohorts OHS (p=0.583) or HHS (p=0.139). Our experience in 

patients with a varus femoral neck has been positive. Our analysis 

has demonstrated no statistical difference in hip scores between the 

cohorts. We have not yet experienced any femoral neck fractures, 

which we believe is due to the use of the Ganz trochanteric flip and 

preservation of blood supply. 

pApeR No. 032 

Neck Narrowing In Hip Resurfacing Is Associated With 

Wear 

George A Grammatopoulos, MRCS, Oxford, United Kingdom 

David Langton, Gateshead, United Kingdom 

Katrien Backers, PhD, Ghent, Belgium 

Hemant G Pandit, FRCS, Oxford, United Kingdom 

Adrian Taylor, MD, Oxford, United Kingdom 

Sion Glyn-Jones, MA MBBS, Oxford, United Kingdom 

Koen Aime DeSmet, MD, Gent, Belgium 

David W Murray, MD, Oxford, United Kingdom 

Richie H S Gill, MD, Oxford, United Kingdom 

Neck narrowing (NN) following Metal-on-Metal-Hip-Resurfacing- 

Arthroplasty (MoMHRA) is a recognized phenomenon that has been 

reported to exceed 10% in up to 27% of cases. It is more prevalent 

among females and patients with small components. NN is thought 

to occur secondary to a number of processes. MoMHRA wear can 

be measured in-vivo by measuring metal ions in blood. Our aim 

was to establish whether NN is associated with increased wear. A 

cohort of 214 patients with unilateral MoMHRA (139M:79F) was 

studied. All patients had Prosthesis-Junction-Ratio (PJR) measured 

postoperatively (PJRpost) and at latest follow up (PJRfollow) 

(4.3yrs, SD:1.9). For a subset of 53 patients (30M:23F), consecutive 

HJR measurements at three intervals (post-op, within first two years 

(intermediate) and last follow up) were made. Metal ion levels were 

measured at last follow up. Cr levels >5.1ppb and Co levels >4.4ppb 

were considered high (Gill et al). For the whole cohort, NN was 

3.8% (SD:4.3). Females (4.7%,SD:5.8) had significantly greater NN 

than males (2.4%,SD:29) (p=0.001). Patients with high ions had 

significantly greater NN than patients with low ions (10%, SD:8.3 

vs. 2.3%, SD 2.3) (p10% was seen in 16 hips 

(7.5%). The risk ratio of high ions if NN >10% was 113 (p10% is associated with high wear. We 

recommend that patients with progressive NN after the first two 

years and hips with NN >10% should be investigated further. 

pApeR No. 033 

Retrieval Analysis of 240 Metal-on-Metal Hip 

Components: Stemmed Versus Resurfacing Hip 

Arthroplasty 

Alister Hart, FRCS, London, United Kingdom 

Ashley Matthies, BSc 

Richard Underwood, PhD, London, United Kingdom 

Philippa Cann, PhD, London, United Kingdom 

Kevin Ilo, London, United Kingdom 

Syed Nawaz, MRCS, Stanmore, United Kingdom 

John Skinner, FRCS, London, United Kingdom 

Martyn Porter, MD, Wigan, United Kingdom 

Metal-on-Metal (MOM) hip resurfacing has a higher failure rate 

compared to metal-on-polyethylene total hip replacements. 

The mechanism of failure in many hip resurfacings is clinically 

unexplained but is thought to involve high wearing components 

and a reaction to metal wear debris. Although stemmed total hip 

replacements use the same bearing surface as hip resurfacing, it is 

unknown whether they fail by a similar mechanism involving high 

wear and the production of metal wear debris. An out of roundness 

machine was used to analyse wear of 240 failed current generation 

MOM hip components. We compared wear rate between two equally 

sized matched groups: Stemmed total hip replacements (n=120) and 

hip resurfacings (n=120). All hips included in this study were couples. 

The location and depth of the wear scar was mapped to investigate 

the role of edge loading. The groups were matched for gender 

and head size. Cup inclination and version angles were measured 

from plain radiographs and computer tomography scans and the 

effect of cup position was investigated. There was no significant 

difference in the median linear wear rate between stemmed total hip 

replacement and hip resurfacing for both acetabular (p=0.5125) and 

femoral (p=0.0695) components. The two groups had comparable 

median (resurfacing/stemmed) cup inclination (48/49), head size 

(47/48) and gender ratios (2:3 in both groups). Edge loading was 

the predominant mechanism of wear in both groups but occurred 

more often in hip resurfacing (67%) compared to stemmed total hip 

replacement (57%). Neck retention increases the head to neck ratio 

in hip resurfacing and therefore the risk of impingement. We suggest 

this as a possible mechanism leading to edge loading. There was no 



PaPers, Posters & scientific exhibits AR Hip

significant difference in wear rate between two large groups of MOM 

stemmed total hip replacements and hip resurfacings. This suggests 

that the clinical problems associated with high wearing components 

are likely to occur in all large diameter MOM hips. 

pApeR No. 034 

A survey of Canadian resurfacing Working Group 

Experience: Rates of conversion from RSA to THR 

James N Powell, MD, Calgary, AB Canada 

Paul E Beaule, MD, Ottawa, ON Canada 

Emil H Schemitsch, MD, Toronto, ON Canada 

Pascal-Andre Vendittoli, MD, Montreal, QC Canada 

Robert Barry Bourne, MD, London, ON Canada 

John Antoniou, MD, Montreal, QC Canada 

Jason Werle, MD, Calgary, AB Canada 

Etienne Belzile, MD, Quebec, QC Canada 

Frank C Smith, FRCSC, CHB, MB, Hamilton, ON Canada 

The purpose of the study was to determine the rate of conversion 

from resurfacing arthroplasty (RSA) to total hip replacement 

(THR) in a number of Canadian centers performing resurfacings. 

Retrospective review was undertaken in 12 Canadian Centers to 

determine the rate of revision and reason for conversion from RSA 

to THR. Averages and cross-tabulation with Chi-squared analysis was 

performed on a subset of 1,494 cases. A total of 2,729 resurfacings 

were performed up to December 2008. A total of 252 hips had a 

minimum of five-year follow up. The survivorship of this group 

was 97.4%. Sixty-eight patients underwent conversion to THR. Four 

resurfacing systems were used. Of the 68 where the reason for failure 

is reported: 21 were for femoral neck fracture, 25 were for loosening, 

12 were for deep infection, three pseudotumors and seven for other 

reasons. The cumulative conversion rate is 2.5%. The survivorship is 

not significant between genders p=0.46. Surgeon experience proved 

to be a significant factor in conversion rates. The revision rate to date 

with this new technology suggests that with increasing experience 

hip resurfacing arthroplasty remains an acceptable option for the 

treatment of hip arthritis. 

pApeR No. 035 

Failure Causes And Modes Of Modern Metal-On-Metal 

Hip Resurfacing Implants 

Edward Ebramzadeh, PhD, Los Angeles, CA 

Patricia A Campbell, PhD, Los Angeles, CA 

Zhen Lu, Los Angeles, CA 

Karren M Takamura, BA, Los Angeles, CA 

Harlan C Amstutz, MD, Los Angeles, CA 


Failure modes of metal-metal resurfacings have not been adequately 

documented; consequently, associated risk factors have not been 

established. A total of 308 retrievals of nine modern metal-metal 

designs were included. Service varied between one and 105 months. 

Wear was measured using a coordinated measuring machine (CMM). 

Metal allergy was diagnosed using tissue histological reaction (aseptic 

lymphocytic vasculitis-associated lesions or ALVAL) and clinical 

history. Failure was most frequently due to acetabular loosening 

(73); femoral loosening (62); neck fracture (61); malpositioning 

(30) or others. Femoral wear rate was greater (median 13µm) with 

>55 degree cup abduction compared to

equired for a THA. The amount of acetabular bone loss or gain was 

evaluated based on the manufacturer’s recommended press-fit for 

the commonly used HRA cups. A total of 180 consecutive patients 

undergoing a primary cementless THA had their femoral neck sized 

at the time of THA as if they were to undergo a HRA. The acetabulum 

was then reamed to prepare it for an acetabular component based 

on the preoperative templating and the intraoperative findings. The 

final reaming and reamer size used was independent of the femoral 

neck sizing. After preparing the acetabulum, a press-fit porous 

coated hemispherical cup was implanted in all cases. Overall, for a 

HRA cup that uses a 0 mm press-fit, 71% of the hips would have lost 

more acetabular bone stock and 15% would have gained bone stock 

compared to a conventional THA. For a 1 or 2 mm press-fit cup, 

57% hips and 41% of the hips would have lost additional acetabular 

bone stock while 28% and 44% of the hips would have maintained 

more bone stock than if they underwent a standard THA respectively. 

There were 20 hips that would be considered ideal for HRA - males 

under 65 years old with cam impingement and did not require 

screws for their cups. In this group, additional acetabular bone loss 

between 3-4 mm occurred in 80%, 65% and 65% of the hips, while 

less bone would have been reamed away in 20%, 20% and 35% of 

the hips with a 0 mm, 1mm and 2 mm press-fit respectively. This 

study allows the direct comparison of acetabular bone removal in 

THA and HRA in the same patients. The results demonstrate that 

the degree of acetabular bone loss or gain following HRA versus 

conventional THA is not identical and depends on the amount of 

press-fit required by the implant design. 

pApeR No. 038 

uThe Incidence Of Adverse Tissue Reactions In A 

Multicentre Study Involving 4226 Hip Resurfacings 


Thomas Joyce, PhD 

Simon Jameson, Middlesbrough, United Kingdom 

Sonali Natu, MD 

Maarten Van Orsouw, MD 

James Holland, MD, Newcastle, United Kingdom 


Antoni Nargol, FRCS, Yarm, United Kingdom 

There have recently been a number of reports of adverse reactions 

in the periprosthetic tissues of hips resurfaced with MoM bearing 

surfaces.We sought to establish the incidence of joint failure 

secondary to adverse reaction to metal debris (ARMD). Three 

implants were used in the study: Design A: Fourth generation device 

with low clearance. Design B: Third generation device. Design C: 

Fourth generation device with low clearance. Patients in prospective 

studies under the care of three surgeons at three centers resurfaced 

between January 1998 and January 2009 were included. Patients 

were assessed at annual clinic visits. Failures secondary to ARMD 

were recorded. Serum ion results from failed patients were compared 

to those from the asymptomatic cohort (n=881). Retrieved explants 

underwent analysis using a coordinate measuring machine. Total 

number of patients was 4226 (10-142 months). There were 58 

failures secondary to ARMD. Median CrCo concentrations in the 

failed group were significantly higher than in the control group. 

Survival analysis showed a failure rate in Design A patients of 9.8% 

at five years, compared to 25 degrees), or having an aspherical head (FAI; a angle 

>50degrees). Statistical analysis was performed to examine the 

association of each abnormality with gender. Seventeen percent 

of the male femora and 47% of the female femora were classified 

as “normal” (p=0.0077). Almost one half had a posterior slip, 8% 




were retroverted and 28% displayed a “cam” (FAI) type deformity 

of the head-neck junction. The relative proportions of each form of 

abnormality were statistically indistinguishable between male and 

female femora (56% vs 57% for slip, 13% vs 10% retroverted and 

31% vs 33% for FAI). This study demonstrates that the morphology 

of the proximal femur is innately variable. Current criteria defining 

the “normal” femur cause the majority of bones to be classified as 

“abnormal.” The “ideal” femur is much less common in males than 

females, and small degrees (2-3 mm) of posterior slip are common in 

both genders. Caution is advised in evaluating the patient in terms of 

lifestyle, symptoms and functional demands, before recommending 

femoral osteochondroplasty for preservation of “the hip at risk.” 

pApeR No. 041 

The Comparison Of Old Patients After Periacetabular 

Osteotomy And Younger About Joint Remodeling 

Kouichi Kinoshita, MD, Fukuoka, Japan 

Masatoshi Naito, MD, Fukuoka, Japan 

Yoshinari Nakamura, MD, Fukuoka, Japan 

Takahiro Ida, MD, Osaka, Japan 

Hirotaka Karashima, MD, Fukuoka-City, Japan 

Satoshi Kamada, MD, Fukuoka, Japan 

Nobuhiro Kashima, MD, Fukuoka, Japan 

Yoshitsugu Tanaka, MD 

The purpose of this study is to compare a remodeling of the 

acetabulum and clinical results in patients 46 years of age or older 

after curved periacetabular osteotomy (CPO) with those in patients 

under 46 years of age. We investigated 66 patients (78 hips) after 

CPO at one institution. The older group consisted of 19 patients 

(21 hips) who had a mean age at the time of surgery of 53 years 

and a mean duration of follow up of 5.6 years, and the younger 

group consisted of 47 patients (57 hips) who had a mean age at the 

time of surgery of 29 years and a mean duration of follow up of 5.8 

years. Clinical follow up was based on the Harris Hip Score (HHS). 

Length of sourcil and sclerotic zone angle (SZ) were measured on 

AP radiographs preoperatively, postoperatively. In the older group, 

the mean HHS improved from 75 points preoperatively to 95 points 

at the time of final follow up (p < 0.01). The mean length of sourcil 

improved from 26 mm to 33 mm (p < 0.01). The mean SZ improved 

from 58° to 74° (p < 0.01). In the younger group, the mean HHS 

improved from 79 points to 95 points (p < 0.01). The mean length 

of sourcil improved from 25 mm to 31 mm (p < 0.01). The mean SZ 

improved from 53° to 64° (p < 0.01). Remodeling of the acetabular 

in elderly patients after CPO was not inferior in comparison with 

younger patients. 

pApeR No. 042 

Adverse Events After Hemiarthroplasty for Hip 

Fracture: A National Medicare Sample 

Noah Epstein, MD, Stanford, CA 

Yun Wang, PhD 

Carlos Uquillas, MD, New York, NY 

William J Maloney MD, Redwood City, CA 

James H Herndon, MD, Boston, MA 

James I Huddleston, III MD, Redwood City, CA 

Adverse event (AE) reporting has become recognized as an important 

method for improving patient safety and monitoring healthcare 

quality. The aim of this study was to identify the rates of AEs, 

mortality, length of stay (LOS) and readmission among Medicare 

beneficiaries in the first 30 days following hemiarthroplasty for a 

hip fracture. The Medicare Patient Safety Monitoring System was a 

448 

national surveillance project created in 2001 under the leadership 

of the Centers for Medicare & Medicaid Services to determine the 

rates of specific medical AEs within the hospitalized Medicare 

population. Data were collected from medical record abstraction 

and claims on 676 patients who underwent hemiarthroplasty for 

hip fracture between 2002 and 2004. A total of 96 patients (14%) 

experienced an AE while hospitalized. The most common AEs were 

urine tract infection (7%), pneumonia (4%), major bleeding (3%) 

and cardiovascular adverse events (3%). Congestive heart failure was 

associated with a significantly increased chance of experiencing an 

AE while hospitalized (OR=1.75, CI 1.08-2.82, p=0.02). The 30day 

post-discharge mortality rate was 5.0%. There was a significant 

difference (p=0.02) in the mortality rate between the patients who 

experienced an AE (10%) compared to those who did not experience 

an AE (4%) during the index hospitalization. Experiencing an AE 

increased the chance of death during the index hospitalization > 

2-fold (p=0.05). The rates of AEs are comparable to rates reported 

in several hip fracture populations. The rate of in-house and 30-day 

mortality is also comparable to other studies. However, in patients 

who experience an AE, the mortality rate remains high. These data 

may provide an opportunity for improvement in patient safety in 

this population. 

pApeR No. 043 

10-Year Outcome of PAO with and without Correction 

of Femoroacetabular Impingement 

Christoph Emanuel Albers, MD, Bern, Switzerland 

Simon D Steppacher, MD, Bern, Switzerland 

Moritz Tannast, Bern, Switzerland 

Reinhold Ganz, MD, Guemligen, Switzerland 

Klaus Siebenrock, MD, Bern, Switzerland 

The surgical technique of the Bernese periacetabular osteotomy 

(PAO) for treatment of developmental dysplasia of the hip (DDH) has 

changed since the recognition of the femoroacetabular impingement 

concept. More attention has been paid to the proper reorientation 

of the acetabular fragment and to a concomitant femoral headneck 

osteoplasty to achieve an impingement-free range of motion. 

The aims of this study were to compare (1) the minimum 10-year 

survivorship (2) the clinical and radiographic outcome with/without 

implementation of these modifications and (3) to detect predictive 

factors indicating a poor outcome. A retrospective comparative study 

between an early series (operated between 1984-1987, 75 hips) 

and a current series (1997-2000, 90 hips) of PAOs was performed. 

The cumulative 10-year survivorship of the hip was calculated with 

endpoints defined as total hip arthroplasty, poor clinical outcome 

or progression of osteoarthritis. Cox-regression analyses were 

performed to detect predictors for poor outcome. A significantly 

increased 10-year survivorship was found for the current series. 

There were significantly more hips with progression of osteoarthritis 

in the early series. A significantly higher accuracy and precision 

of the reorientation of the acetabulum was found for the current 

series. Twenty predictors for poor outcome were found including 

demographic, preoperative radiographic factors and factors related 

to the surgical accuracy. The correct acetabular reorientation to 

achieve sufficient but not excessive coverage improves the long-term 

results after PAO. The impingement-free range of motion should 

be assessed intraoperatively by routine arthrotomy. If necessary, an 

additional osteochondroplasty should be performed to correct an 

aspherical femoral head-neck junction. 




pApeR No. 044 

Topographical Cartilage Thickness Variation in Patients 

with Femoroacetabular Impingement 


Christoph Emanuel Albers, MD, Bern, Switzerland 



Femoroacetabular impingement (FAI) is a pathologic condition of 

the hip that leads to osteoarthrosis (OA). The goal of the surgical 

hip dislocation is to correct the bony malformations to prevent 

the progression of OA. We investigated the topographical cartilage 

thickness variation in patients with FAI and early stage OA using 

an ultrasonic probe during surgical hip dislocation. We performed 

a prospective case-series of 30 patients (33 hips) that underwent 

surgical hip dislocation. The mean age at operation was 30.6 (18 

- 48) years. Indication for surgery was symptomatic FAI with 3 hips 

(9%) with pincer-type, 7 hips (21%) with cam-type, and 23 hips 

(70%) with mixed-type of FAI. Cartilage thickness was measured 

intraoperatively using an A-mode 22 MHz ultrasonic probe at 8 

locations on the acetabular cartilage. The thickest acetabular cartilage 

was found in the weight bearing zone (range 2.8 - 3.5mm), whereas 

the thinnest cartilage was in the posterior acetabular horn (1.0 - 2.2 

mm). In all hips, cartilage was thicker in the periphery area compared 

to the central area. In the anterior and posterior acetabular horn, 

the anterior area, and the superior area (central parts) a significantly 

decreased cartilage thickness in pincer-type compared to cam-type 

of FAI was found (p46 mm 

and head defects < than 1 cm (ideal) were compared to 632 nonideal 

hips. UCLA, HHS and SF-12 scores were calculated. Changes 

in surgical technique were made by hip #300. Two-tailed paired 

student t-tests were used to compare parametric data and p-value 

14.8) and mean Cr concentrations were 2.07 microg/L (0.51-9.16). 

When analyzed by femoral head size, Co and Cr concentrations 

were significantly different (p=0.0025 and p

pApeR No. 065 

Inflammatory Cytokines are Elevated in Patients with 

Adverse Reactions to Metal-on-Metal THA’s 

Scott T Ball, MD, San Diego, CA 

Robert Scott Meyer, MD, San Diego, CA 


William Bugbee, MD, La Jolla, CA 

Joshua Hillman, MS 

David Boyle, MS, La Jolla, CA 

Gary S Firestein, MD 

Recently, there has been growing concern about adverse reactions 

to metal debris (ARMD) in patients with metal-metal (MM) hip 

replacements. To our knowledge, there have been no reports 

characterizing the cytokines driving the underlying inflammatory 

response. In this case control study, 10 patients were identified 

with suspected ARMD from MM implants. At revision, soft tissue 

specimens were analyzed histologically for cell types and wear 

debris. Peri-articular fluid was obtained and analyzed for cobalt and 

chromium levels using inductively coupled plasma dynamic reaction 

cell mass spectrometry. This fluid was also profiled for cytokine 

expression by Luminex assay. Two types of ‘control’ cases were 

collected. Hip synovial fluid from six osteoarthritis (OA) patients 

served as a baseline control, and three patients undergoing revision 

for osteolysis from polyethylene wear (poly) served as controls for 

adverse reaction to other prosthetic material. In the ARMD cases, 

cytokine levels were markedly elevated demonstrating a significant 

inflammatory response. Notably, levels of IL-6, IL-8 and IP-10 were 

more than 15 fold higher than in the poly group and were more 

than 40 fold higher than OA controls. Additionally, TNF-±, VEGF 

and MCP-1 were elevated above control groups. With this number 

of cases, no correlation was found between Co and Cr levels and 

cytokine levels. The findings of this study demonstrate an underlying 

inflammatory reaction in ARMD cases that is much more intense 

than what is observed in poly wear cases. This may help to explain 

the soft tissue destruction which is sometimes seen in ARMD cases. 

pApeR No. 066 

Pathologically Confirmed Metal-on-Metal THA Adverse 

Local Tissue Reactions from One Center 

Kevin B Fricka, MD, Alexandria, VA 

C Anderson Engh Jr, MD, Alexandria, VA 

William G Hamilton, MD, Alexandria, VA 

Charles A Engh, Sr MD, Alexandria, VA 

There has been substantial use of metal-on-metal (MOM) bearings 

in total hip arthroplasty (THA) over the last decade. There appears 

to be a subset of patients who develop a local tissue reaction to the 

MOM bearing. We report our experience with this complication. 

Our institution has performed 1327 MOM THAs since 2001. A 

total 13 patients (seven of our own, six outside institutions) were 

revised secondary to a MOM reaction. All histology was confirmed 

by a single independent pathologist with expertise in MOM bearing 

surface pathology. Pre-operative lab evaluation and advanced 

imaging, gross inspection of the wound at the time of revision and 

histological analysis were available for each case. The average time 

to revision was 32 months (13-65). Cup position averaged 48° 

abduction (26°-78°) and 14° anteversion (-6°-37°). Advanced 

imaging (CT/MRI) was obtained in 11/13 patients. All patients had 

elevated cobalt/chromium levels (15.7 mcg/L and 3.64 mcg/L). ESR/ 

CRP levels were elevated in 10/13 patients. Synovial fluid analysis 

showed four patients with no intact cells and metal debris while 

eight patients had a median white blood cell count of 5,148. All 

451 

histological specimens were consistent with local tissue MOM 

reactions and three patients had pseudotumors. Follow-up from 

revision ranged from one to 107 months. Revisions included eight 

cup/liner/ball exchanges, two two-stage reimplantations, two liner/ 

ball exchanges and one resection arthroplasty. Adverse reactions to 

MOM bearings appear as a spectrum of disease and can be difficult 

to differentiate from infection. From our experience, we present an 

algorithm for diagnosis and treatment to minimize delay in treating 

this potentially devastating complication. 

pApeR No. 067 

Clinical And Wear Analysis Of 276 Failed Large 

Diameter Metal-On-Metal Hip Components 






Justin Peter Cobb, MD, London, United Kingdom 

Sarah Muirhead-Allwood FRCS, London, United Kingdom 



The most common clinical category of failure of current generation 

metal-on-metal (MOM) hip arthroplasties is unexplained. There has 

been only one large retrieval study (Morlock et al.) which revealed 

that cup components (n=32) had high wear rates and high inclination 

angles. We build on this by: increased numbers of components; 

increased clinical variables studied; and the use of multivariate 

statistical analysis. We aimed to determine which variables were 

significant predictors of cup and head rates. We studied a consecutive 

series of 138 head and cup couples of explanted MOM hips. Data pre, 

intra and post operatively enabled us to categorize cause of failure 

into infection, loosening, unexplained (non-infected; well fixed, 

satisfactory alignment) and other. We also recorded the following: 

age, gender, head size, hip type, cup inclination angle, blood cobalt 

levels, blood chromium levels, presence of edge loading, head wear 

rate, cup wear rate. Analysis of covariance was used for statistical 

analysis. There were 92 females and 46 males. The median cup wear 

rate was 4.51 microns/year (interquartile range 0.15 to 20.69). There 

was a strong positive relationship between cup and head wear rate 

(rs=0.843, p

pApeR No. 068 

The Occurrence of Edge Loading in Metal on Metal 

Hips: Low Clearance is a New Risk Factor 


Angelos Zografos, MEng 




Ferdinand Lali, PhD 



It is generally accepted that risk factors for edge loading acetabular 

cups are steep inclination and low cup coverage (articular arc). This 

paper describes a study of 160 explanted large diameter metal-onmetal 

(MoM) (320 components) to establish the size and location 

of wear scars and the occurrence and causes of edge loading. The 

wear of the explanted head and cups was measured using roundness 

machine. Finite element analysis and contact mechanics was used 

to calculate the size and position of any wear scar; this combined 

with information about cup design, clearance and position was used 

to examine the factors that effect edge loading. , Edge loading was 

found in 67% of cups and was associated with a seven times increase 

in linear wear rate. A total of 49% of ‘well positioned’ cups, within 

the Lewinnick’s safe zone, were edge loaded. Analysis showed that 

when the theoretical contact patch extended over the rim of the cup, 

the dramatic increase in contact pressure and probable disruption to 

the lubrication mechanism leads to increased wear at the rim of the 

cup. The distance from the edge of the contact patch to the rim is 

calculated theoretically for all the explanted hips and correlated with 

the occurrence of edge loading. Low clearance resulted in a larger 

contact patch and increased the risk of edge loading. For cups with 

low inclination angles (three-year revision rate experience, consistent with the 10-year 

benchmark). Compared to the three-year NICE entry benchmark, 10 

studies showed satisfactory implant survival percentages. Nine used 

the BHR implant, the other study used the Cormet 2000 implant. 

The quality of evidence is low according to the GRADE classification. 

Future research has to address the most important failure mode for 

HRA trying to explain the large variation in the frequency of femoral 

neck fractures. 




pApeR No. 071 

Large Diameter Modular Metal-on-Metal Total Hips: 

Assessing Soft Tissue Adverse Events 

William P Barrett, MD, Renton, WA 

Kirk Kindsfater, MD, Fort Collins, CO 

James Lesko, PhD 

The performance of large mono-block metal-on-metal (MOM) 

systems has come under general scrutiny. Failures secondary to soft 

tissue reactions, possibly attributable to metal wear debris, have 

been reported. Clinical symptoms often appear within two years 

postoperatively and include persistent or recurring pain and soft 

tissue reaction. Infection work-up is typically negative. This study 

investigated whether similar concerns exist for MOM articulations 

in large diameter modular hip systems. Between July 2001 and 

February 2008, 1,055 large diameter (minimum 36 mm diameter 

heads) modular MOM total hips were implanted in four prospective 

studies at 36 centers. The same acetabular system was used in all 

cases. A total of 720 hips (289 females, 431 males) had minimum 

two-year follow-up (mean 3.3 years, range 2-8 years). Mean age was 

57. Primary diagnosis was osteoarthritis in 637 (88.5%) cases. Four 

cases were revised for pain without evidence of infection. One case 

revealed metalosis without the typical ALVAL soft tissue reaction. 

Two cases showed an ALVAL-type reaction. A fourth case revealed a 

pseudotumor and necrotic material typically associated with metal 

wear debris. The incidence of revision due to soft tissue adverse 

events is estimated from these four revisions out of 720 cases to be 

0.56% (95% C.I. 0.15% to 1.42%). In this series of second generation 

modular, large head MOM prostheses, the incidence of revisions 

due to soft tissue adverse events was less than 0.6%. This compares 

favorably to published reports on the incidence of revisions for soft 

tissue adverse events in large mono-block MOM systems. 

pApeR No. 072 

Practical Guidelines In The Interpretation Of Serum 

Versus Whole Blood Metal Ion Concentrations 

Jose MH Smolders, MD, Lent, Netherlands 

Pepijn Bisseling, MD, Arnhem, Netherlands 

Annemiek Hol, MsC, Arnhem, Netherlands 

Job L C Van Susante, MD,PHD, Arnhem, Netherlands 

There is a clear correlation between a malfunctioning metal-onmetal 

joint arthroplasty and increased cobalt and chromium levels 

in whole blood and serum. Interpretation of these values becomes 

increasingly important for clinicians; however, the relation between 

both is difficult to understand. Also, practical tools for clinical use 

are lacking. From an ongoing trial comparing two metal-bearing hip 

implants, chromium and cobalt levels were determined both for 

serum and whole blood in 191 and 213 samples, respectively, using 

high resolution inductively-coupled plasma mass spectrometry. 

The agreement between blood and serum levels was assessed with 

normalized scatter plots, mean difference, regression analysis and 

the Bland and Altman limits of agreement. There was a highly 

significant correlation between blood and serum levels for both 

cobalt (p=0.936) and chromium (p=0.937). Due to the variability 

seen in the Bland and Altman plots between serum and whole 

blood concentration, they cannot be used interchangeably. Limits 

of agreements for cobalt are +71% to -41%, and +6% to -94% for 

chromium. Regression analysis provided a formula for conversion 

from serum to blood of 0.29 + 0.89*serum] for cobalt (ng/mL) and 

0.21 + 

453 

pApeR No. 073 

Serum Metal Ion And Ultrasound Assessment Of 

Asymptomatic Metal-On-Metal Hip Replacement 

Donald S Garbuz, MD, Vancouver, BC Canada 

Dan Williams, MRCS, MSc, Truro, United Kingdom 

Nelson Victor Greidanus, MD, Vancouver, BC Canada 

Bassam A Masri, MD, Vancouver, BC Canada 

Clive P Duncan, MD, Vancouver, BC Canada 

There is a postulated association between increased serum metal 

ions and pseudotumor formation in patients with metal-on-metal 

hip replacements. The primary aim of this study was to assess the 

prevalence of pseudotumor in 29 asymptomatic patients with a large 

femoral head (LFH) metal-on-metal hip implant. This was compared 

to the prevalence of pseudotumor in 21 matched asymptomatic 

patients with a hip resurfacing (HRA) and 23 matched asymptomatic 

patients with a standard metal-on-polyethylene (MOP) total hip. 

A secondary objective was to assess possible correlation between 

increased serum metal ions and pseudotumor formation. Ultrasound 

examination of the three groups was performed at a minimum follow 

up of two years. Serum metal ions were measured in the metal-onmetal 

LFH and HRA groups at a minimum of two years. There were 

eight solid or cystic masses in the LFH group with a mean size of 55.7 

(8 to 176) cm3. In the HRA group there were three masses with a 

mean size of 18.7 (6.1 to 25.9) cm3. In the MOP group there was one 

solid mass measuring 6.1 cm3. Mean serum cobalt and chromium 

ion levels in the LFH group were 6.57 (0 - 58.78) µgL and 4.55 (0 

- 50.47) µgL compared to 0.46 (0 - 3.57) µgL and 0.55 (0 - 3.77) 

µgL in the HRA group. This study demonstrates a significantly higher 

prevalence of pseudotumors in patients with large head metal-onmetal 

total hips. The higher levels of metal ions in this group suggest 

that elevated metal ions may lead to pseudotumor formation. 

pApeR No. 074 

uOutcomes and Pathomechanics of Adverse Local 

Tissue Reactions (ALTR) in Metal-Metal Bearings 

John Vincent Tiberi, MD, Torrance, CA 

Fabrizio Billi, PhD, Los Angeles, CA 

Michael Kertzner, Calabasas, CA 

Mylene A Dela Rosa, Los Angeles, CA 

Thomas P Schmalzried, MD, Los Angeles, CA 

The benefits of metal-metal bearings include low wear, absence 

of gross material failures (i.e., fracture), favor of large diameters 

and allow resurfacing. However, metal-metal bearings have been 

associated with adverse local tissue reactions (ALTR). The goals of the 

current study are to identify the prevalence of revision surgery in hips 

with a >36 mm metal-metal bearing and associated risk factors. A 

total of 585 hips (501 patients) received metal-on-metal arthroplasty 

(469 resurfacing and 116 total hip arthroplasty) from October 2000 

through May 2008 by the senior author. A posterior approach was 

used in all cases. In total, 451 hips (77%) were in men. Mean age and 

BMI were 50.7 (range 14.7-81.9) and 27.25 (range 17.0-44.7). Mean 

follow-up was 5.0 years (range 2-11 years). Acetabular component 

position was assessed with edge detection software. ALTR was defined 

as any peri-prosthetic tissue reaction that necessitated revision with 

well-fixed components. There were no revisions for instability. There 

were no loose stems and no revisions of modular sockets. There were 

no femoral neck fractures or operations for periprosthetic fracture. 

One hip was revised for infection. Nine hips in eight patients required 

aseptic revision (1.5%). The Conserve® Plus SR (Wright Medical; 

Memphis, TN) was revised in two of 232 (0.9%) hips: one for ALTR 

(high wear, metallosis) and one for osteonecrosis of the femoral head. 




Thirty-one Cormet 2000 SR (Corin; Cirencester, Gloucestershire, 

UK) hips and 59 Summit® (DePuy) total hip replacement (THR) 

femoral components with the Pinnacle (DePuy) modular acetabular 

component had no revisions. The ASR-XL (DePuy; Warsaw, IN) was 

revised in three of 57 hips (5.3%); one for pseudotumor and two for 

failure of osseointegration. The ASR (DePuy) surface replacement 

was revised in four of 205 (2%), two for pseudotumor and two 

for failure of osseointgration. In all, seven of 262 (2.7%) ASR hips 

were revised. Four hips (0.7%; three SR, one THA) were revised for 

ALTR; all were females and all had 50 mm O.D. sockets. All had 

a low lateral opening angle (mean 38.7°, range 31.8°-46.8°) but 

increased acetabular anteversion (mean 25.4° v. 16.4°; p=0.05). 

CT scan analysis of the THR indicated 22° femoral anteversion; 

combined anteversion of 45°. Retrieval analyses with CMM and SEM 

revealed edge wear, consistent with subluxation in extension. Large 

diameter bearings have solved the instability issue. The outcomes 

of both THR and SR were generally good, although the prevalence 

of revision associated with the ASR acetabular component was 

increased. This component is no longer used. The overall occurrence 

of ALTR necessitating revision was comparatively low. Retrieval 

analyses indicate edge wear and subluxation with a mechanical 

common denominator: increased (combined) anteversion. Even 

with a low lateral opening angle, a combined anteversion of >40° is 

associated with an increased risk of ALTR. On this basis, resurfacing, 

female gender and small component size are associated variables. 

The primary causal factor is the pathomechanics of subluxation in 

extension leading to an aberrant wear mechanism. 

pApeR No. 075 

Metal Ions And Outcome In Resurfacing Hip 

Arthroplasty (RHA) Versus Total Hip Arthroplasty (THA) 

Job L C Van Susante, MD,PHD, Arnhem, Netherlands 

Jose MH Smolders, MD, Lent, Netherlands 

Annemiek Hol, MsC, Arnhem, Netherlands 

W J Rijnberg, MD, Arnhem, Netherlands 

The resurfacing hip arthroplasty (RHA) has gained popularity over 

the past 10 years due to the bone preserving nature and increased 

stability of the implant. A true benefit in clinical parameters over 

the regular total hip arthroplasty (THA) has not been proven to date 

and concerns arise about local soft-tissue necrosis from increased 

metal ion levels (pseudotumors). A randomized trial comparing 

RHA with THA on these parameters was initiated. Sixty-seven 

patients (

fracture of the prosthesis. Six patients had non-mechanical failure 

modalities (one septic loosening and three multiple dislocations). A 

total of 104 patients had a well fixed prosthesis with no dissociation 

or fracture of the components. The Harris Hip Score mean in the 

office follow up patients is 85.8. Of the patients in the follow up 

group, it was found that this prosthesis has a 19.4 percent failure 

rate requiring a revision operation. When those pending or lost to 

follow up are included and assumed not to have hardware failure, 

the failure rate is 11.2 percent. Increasing body mass index and offset 

were shown to be significant risk factors for mechanical failures of 

the Alfa II modular hip system. The Alfa II modular stem hip system 

demonstrates a high failure rate at short-term follow up. 

pApeR No. 183 

Revision Total Hip Arthroplasty In Patients 80 Years Or 

Older 

Anne Lubbeke-Wolff, MD, DSc, Geneva 14, Switzerland 

Constantinos Roussos, MD 

Werner Koehnlein, MD 

Pierre J Hoffmeyer, MD, Geneve 4, Switzerland 

We aimed at evaluating outcomes after revision total hip arthroplasty 

(THA) in patients over 80 years and to compare these to outcomes in 

patients under 80 years. We reviewed all revisions performed in our 

institution from 3/1996 to 12/2008 and compared complications, 

mortality, clinical outcomes and satisfaction between the two age 

groups. Peri-operative information and complications were collected 

prospectively, and clinical outcome data were obtained both pro- 

and retrospectively. The Merle d’Aubigné score, Harris Hip score 

and patient satisfaction were assessed. A total of 325 revisions were 

included, 84 (25.8%) in patients >80 and 241 in patients 80 years were more often revised for periprosthetic fractures 

and recurrent dislocation. Mean follow up was 4.3 years. Mortality 

(>80 vs. 12 year follow up and complete ascertainment of revision and 

mortality. We used Medicare claims data to assemble a cohort of 

58,521 patients >65 years old who had primary THR in 1995-96. We 

followed this cohort in claims through 2008 and identified patients 

who had claims indicating revision THR. We used Cox proportional 

455 

hazard models to examine the association of revision rate with age, 

sex, race, Medicaid eligibility (a proxy for low income), diagnosis, 

comorbidity, surgeon and hospital THR volume. At surgery the cohort 

had mean age 74 ± 6, 64% were female and 56% were operated 

upon by surgeons who performed fewer than 12 THRs/year in the 

Medicare population. Over 12 to 13 year follow up, 32,680 patients 

died and 4,830 had revision THR. Factors independently associated 

with rate of revision THR included age 65-75 (versus > 75; hazard 

ratio (HR) 1.45, 95% CI 1.36, 1.55), male sex (HR 1.23, 95% CI 1.16, 

1.30), non-osteoarthritis diagnosis (HR 1.15, 95% CI 1.06, 1.25) 

and surgeon THR volume < 12 cases/year (HR 1.22, 95% CI 1.13, 

1.33). Medicaid eligibility, comorbidity and hospital volume were 

not independently associated with revision rate. These first national, 

population-based estimates of the rate of revision following THR 

over 12 years confirm the risk associated with younger age, male 

sex and low surgeon volume. As THR is performed increasingly in 

younger patients, these findings underscore the need for further 

research on revision rates in those < 65. 

pApeR No. 185 

Bone Graft Substitutes For Gap Healing And Bone 

Growth Into Porous Implants 

J Dennis Bobyn, PhD, Montreal, QC Canada 

Letitia Lim, MD, Montreal, QC Canada 

Michael Tanzer, MD, Montreal, QC Canada 

Revision surgery is often complicated by loss of bone stock and 

bone-implant gaps that reduce stability and the potential for biologic 

fixation. The purpose of this study was to assess the potential of 

bone graft substitute materials for enhancing the healing of boneimplant 

gaps and the osseointegration of porous metal implants. 

Intramedullary implants were fabricated with a 5 mm diameter 

central porous titanium rod and 11 mm solid end and central 

spacers to create a scenario with a 3 mm gap between host bone 

and porous material. The implants were bilaterally inserted into 

the proximal metaphyses of canine femora and humeri in the same 

animal in procedures staged eight weeks apart. At each period of 

four and 12 weeks implant gaps were left empty (n=6) or filled with 

demineralized bone matrix (DBM) (n=6), devitalized DBM (n=3) or 

a polymer-allograft composite (PAC) material (n=3). Bone formation 

within the gap regions and porous implants was quantified using 

high resolution microCT scanning and backscattered scanning 

electron microscopy. At four weeks, gaps with DBM were already 

filled (9.0%±6.7%) with numerous islands of new bone. By 12 

weeks, gap filling with new bone increased to 22.3%±5.2% (host 

bone density = 19.0%±5.0%) and bone trabeculae within the gap 

were contiguous with surrounding host bone. The PAC material 

started with 20.4% mineralized bone content; at four and 12 weeks 

PAC-filled gaps contained 17.2%±2.2% and 23.1%±3.3% bone by 

volume, respectively, with evidence of incorporation and remodeling 

by 12 weeks. In contrast, the empty (5.2%±0.7% at four weeks; 

2.6%±1.5% at 12 weeks), devitalized DBM-filled (5.1%±5.9% at 

four weeks; 6.1%±3.5% at 12 weeks) showed markedly less new 

bone healing. At 12 weeks gap filling with new bone was significantly 

greater in gaps filled with DBM and PAC compared to those filled 

with devitalized DBM or left empty (p

pApeR No. 186 

Risk For Aseptic Revision In Over 25,000 Primary Total 

Hips Differs By Gender 

Monti Khatod, MD, Santa Monica, CA 

Liz Paxton, MA, San Diego, CA 

Christopher F Ake, PhD, Corona Del Mar, CA 

Robert S Namba, MD, Corona Del Mar, CA 

T Ted Funahashi, MD, Irvine, CA 

Cunlin Wang, Silver Spring, MD 

Art Sedrakyan, PhD, New York, NY 

Thomas Gross, MD, PhD 

Danica Marinac-Dabic, MD, PhD, Rockville, MD 

Gender differences in risk of total hip arthroplasty (THA) revision 

have not been fully examined. THA patient demographics, implant 

characteristics, surgical techniques, surgeon and hospital annual case 

volume and outcomes were prospectively recorded in a communitybased 

registry (2001-2009). Kaplan Meier survival curves, log rank 

tests and Cox regression were applied to assess cumulative implant 

survival rates and relative risk of THA revision. A total of 25,377 

primary THA cases were performed. Primary cases were predominantly 

female (57.4%), 44.4% under age of 65. Osteoarthritis was the 

most common diagnosis (90.6%). At five years follow up, overall 

cumulative survival was 97.4%: survival for males and females was 

97.7% vs. 97.1% (p=0.06). Cox regression revealed the following 

risk factors for aseptic revision: diagnosis other than osteoarthritis 

(OA) (p=0.007), metal-on-conventional ultra high molecular weight 

polyethylene (UHMWPE) surface (p=.006) and femoral head size 

pApeR No. 189 

Revision Hip Arthroplasty for Instability: Constraint 

May Not be The Answer 

Aaron Carter, Washington, DC 

S M Javad Mortazavi, MD, Wyncote, PA 

Mr Eoin C Sheehan, Tullamore, Ireland 

James J Purtill, MD, Philadelphia, PA 

Matthew Austin, MD, Philadelphia, PA 

Peter F Sharkey, MD, Media, PA 


Constrained liners that were used as treatment for instability 

following THA were reviewed. The hypothesis of this study was that 

constrained liners are likely to fail if correctable causes for instability 

are not addressed. Results found that failure rate of constrained 

components are unexpectedly high. Increased rate of dislocation 

is associated with younger and healthier patients or patients with 

previous history of revision. Using our prospective institutional 

revision database, all hips that had undergone revision THA for 

instability and received constrained liners between 2000 and 2007 

were identified. Detailed retrospective review of the database and 

medical records were obtained to extract relevant information. 57 

hips in 56 patients received constrained liners. Average follow up 

was 5.04 years (range 24-119 months). Failure rate of constrained 

liners was 29.8% (12 dislocations, 5 acetabular loosening). 25% of 

liners that also had cup revision failed compared to 36% that only 

had a liner exchange (p=0.4). In the liner exchange group, there was 

no difference in failure rate for cemented compared to uncemented 

liners (p=0.8). Younger age (p=.04), lower Charlson index (p=.01), 

and history of previous revision surgeries (p=.05) were associated 

with higher dislocation rate. Constrained liners could be effective 

in the treatment of instability following THA, however failure rates 

are higher than previously expected. When considering constrained 

liners the surgeon must consider the limitations of these components 

especially in a more active patient population. These components 

are more likely to fail in younger patients with few comorbidities or 

patients with previous revision surgery. 

pApeR No. 190 

Do Paprosky Type III & IV Femoral Defects Have a 

Higher Failure Rate Following Revision THA? 


Rasesh R Desai, MD, Cincinnati, OH 

Kirby Hitt, MD, Temple, TX 

Fredrick Francis Jaffe, MD, New York, NY 

Jianhua Shen, Mahwah, NJ 

John R Schurman II, MD, Wichita, KS 

Purpose of this study was to compare results of patients with 

Paprosky Type I, II femoral defects vs. IIIA, B and IV defects in patients 

undergoing revision hip arthroplasty. There were 64 patients in the 

group with type I and II defects with an average age of 68 years. There 

were 52 patients with Paprosky Type IIIA, IIIB and IV defects with 

an average age of 67 years. The minimum follow up was two years. 

Clinical and radiographic analysis were performed and statistics 

using chi square and Wilcoxon rank-SUM tests. The same modular 

femoral implant with distal fixation was used in all patients. Type 

III and IV group had greater pre-op leg length discrepancy, increased 

intra-op blood loss and OR time which was statistically significant. 

There were no differences in the post op Harris Hip Score between the 

groups. There were four intraoperative femoral fractures in the Type 

III & IV group (8%), whereas there were zero in Type I & II group, 

p

pApeR No. 192 

Treatment of Pelvic Discontinuity with a Custom 

Triflange Acetabular Component 

Michael J Taunton, MD, Rochester, MN 

Thomas K Fehring, MD, Charlotte, NC 

Paul K Edwards, MD, Tampa, FL 

Thomas L Bernasek, MD, Tampa, FL 

Ginger E Holt, MD, Nashville, TN 

Michael J Christie, MD, Nashville, TN 

Pelvic discontinuity is an increasingly common complication of total 

hip arthroplasty. The purpose of this review is to report the use of 

custom triflange implants in patients with pelvic discontinuity. This 

is a retrospective multi-center cohort study. Inclusion criteria includes 

any patient who had a revision total hip arthroplasty (THA) using 

a custom triflange acetabular component for pelvic discontinuity 

with minimum two year follow up. Demographic data collected 

includes: age, gender and body mass index (BMI). Operative reports 

and clinical data were reviewed. A radiographic evaluation was 

performed to evaluate healing of the discontinuity and fixation of 

the implant. Between 1992 and 2008, 77 discontinuities were treated 

with a custom triflange component. Eleven were lost to follow up, 

leaving 66 for review. There were reoperations in 21 (38%). There 

were three failures (4.5%) as defined by revision or resection of the 

triflange component. One (1.5%) was revised for aseptic loosening. 

Upon radiographic review, 38 (57.5%) of triflange components 

were stable with a healed pelvic discontinuity. This retrospective 

multi-center review of custom triflange acetabular components 

had survival free of aseptic loosening in 65/66 hips. Instability 

was a common complication, given the subset of patients, most of 

which had multiple previous reconstructions prior to revision to 

a triflange component. In this difficult group of patients, triflange 

implants provided predictable fixation and consistent healing of the 

discontinuity at a cost equivalent to other treatment methods. 

pApeR No. 193 

Femoral Impaction Grafting Improves Survival Of 

Revisions With Extensive Defects And Large Stems 

Matthias Dominik Wimmer, MD, Bonn, Germany 

Sascha Gravius, MD 

Deml Moritz, MD 

Rudolf Ascherl, MD, Rochester, MN 

Ulrich Noeth, Philadelphia, PA 

Nadine Kraska, MD 

Dieter Wirtz, MD, Bonn, Germany 

We present long-term results of a prospective controlled multicenter 

study with an uncemented modular titan revision prosthesis with 

distal diaphyseal anchorage with or without metaphyseal bone 

stock augmentation. A total of 243 cementless stem revisions were 

performed in matched patients. Seventy patients (28.8%) received a 

metaphyseal bone augmentation; 173 other patients (71.2%) without 

metaphyseal bone augmentation served as controls. The clinical 

outcome was evaluated by the Harris Hip Score (HHS). Additionally 

x-rays were evaluated focusing on stability, periprosthetic bone 

remodeling, defect regeneration and the presence of radiolucent 

lines. The follow up period was 4.38 ± 1.79 y (2.10 ± 9.62 y). 

Preoperatively no significant differences were found concerning age, 

body mass index, score of the American Society of Anaesthesiologists, 

femoral bone defects as differentiated by Paprosky I - III and the 

HHS (p>0.05). Postoperatively no significant differences concerning 

the HHS and the intra- and postoperative complication rate occurred 

(p>0.05). A significant reduction of the proximal femoral bone 

458 

atrophy due to femoral stress-shielding (5.71% vs. 17.9%; p17 mm and femoral 

bone defects >Paprosky II C. The revision rate after augmentation was 

clearly reduced (2.86% vs. 6.36%). X-rays showed increasing axial 

subsidence for controls (6.9% vs. 2.9%; p=0.16). The encouraging 

results we found accentuate the need for metaphyseal bone defect 

augmentation for femoral bone defects larger than Paprosky II C and 

stem diameters >17 mm. Subsequently improved bone regeneration 

indicates increasing physiological load transmission and minimized 

femoral stress-shielding as a requirement for a prolonged prosthesis 

lifetime. 

pApeR No. 194 

Modern Proximally Tapered Uncemented Stems Can be 

Safely Used in Dorr Type C Femoral Bone 


Todd Kelley, MD, Cincinnati, OH 

Mary Jo Adams, BSN, Towson, MD 

Dorr Type C femoral bone is felt to be a difficult morphology for stem 

fixation in total hip replacement (THR). Modern proximally tapered 

uncemented hip systems have wide variability in terms of sizing and 

offsets. We report on our experience with the use of such a system 

in a group of Type C bone patients. Between 9/2001 and 5/2004, 

we implanted 431 consecutive uncemented tapered stems. Of this 

group, 60 femurs were classified as having Type C bone. Average age 

of the patients in this group was 67 and body mass index was 27. 

Patients were followed for an average of 6.4 years (range 4-9 years). 

Radiographs were reviewed by two experienced radiographers. Harris 

Hip Scores (HHS) were calculated. At final follow up, all stems were 

clinically stable. All stems were radiographically osseointegrated. 

Five of the stems showed any subsidence, none more than 3 mm. Of 

the 60 femurs, seven were placed into varus and seven into valgus. 

No patient complained of thigh pain. No femur showed significant 

stress shielding. HHS scores at final follow up averaged 92 (range 

72 to 100). We could document no problems using this modern 

proximally tapered uncemented stem in Type C femoral bone at midterm 

follow up. Assuming the surgeon is able to obtain adequate 

initial fixation, as evidenced by the minimal subsidence seen in this 

group, this type of stem provides durable and predictable fixation 

despite the morphology of the femur. 

pApeR No. 195 

An Algorithmic Approach to the Unstable Total Hip 

Arthroplasty 

Glenn Wera, MD, Cleveland, OH 

Nicholas Ting, MD, Cleveland, OH 

Mario Moric, MS 


Scott M Sporer, MD, Wheaton, IL 

Craig J Della Valle, MD, Chicago, IL 

Recurrent instability is among the most common reasons for 

revision of a total hip arthroplasty. Despite the frequency of this 

complication, there is a paucity of information available that 

defines the etiologies of instability and strategies for treatment. 

Seventy-five consecutive patients with recurrent instability of the 

hip were classified into six types based on the primary etiology of 

instability: Type I malposition of the acetabular component, Type II 

malposition of the femoral component, Type III abductor deficiency, 




Type IV impingement, Type V late wear of the polyethylene liner, 

or Type VI unknown etiology. Types I and II were treated with 

revision of the malpositioned component. Types III and VI were 

treated with a constrained acetabular liner. Type IVs were revised by 

removing sources of impingement and the use of a large diameter 

femoral head. Type Vs were treated with an exchange of the worn 

polyethylene liner and a large diameter femoral head. The most 

common causes of instability were abductor insufficiency (36%) 

and cup malposition (33%). At a mean of 35.3 months (range, 

24 to 78 months) 11 patients re-dislocated (14.6%). Nine of these 

11 failures were patients who were classified as Type III (abductor 

insufficiency) or Type VI (unknown etiology), and were treated with 

a constrained liner, five of which had been cemented into a wellfixed 

shell. Patients with abductor insufficiency (Type III) had the 

highest risk of failure (55%). By addressing the underlying cause of 

instability at revision surgery, our treatment protocol had an 85% 

overall rate of success. The highest risk of failure was in patients with 

abductor insufficiency with a revision for other etiologies having a 

success rate of 93%. 

pApeR No. 346 

Total Hip Replacement For The Treatment Of Acute 

Femoral Neck Fractures 

Giles Hugo Stafford, FRCS, Norfolk, United Kingdom 

Susan Charman, BSc, London, United Kingdom 

Michael J Borroff, Leeds, West Yorkshire, United Kingdom 

Claire Newell, BSc 

John Keith Tucker, FRCS, Norwich, United Kingdom 

In the majority of patients who have suffered a sub-capital fractured 

neck of femur (#NOF), the functional results of hemi-arthroplasty 

are acceptable as a significant proportion of these patients are 

medically unfit and/or have a sedentary lifestyle. The results of hip 

hemi-arthroplasty have however been shown to be not as good 

as total hip replacement (THR) in competent, medically fit (ASA 

1-2), high demand, active patients. As a result, there is evidence for 

increasing use of THR for certain patients with displaced sub-capital 

#NOF. We identified 1,302 of 157,232 Hospital Episode Statistic 

(HES) linked patients between April 2003 and November 2008 in 

the 6th Annual National Joint Registry of England and Wales (NJR), 

who had been recorded as having total hip replacement for acute 

#NOF. Revison rates at five years were analyzed using Kaplan-Meier 

and Cox regression methods. Co-morbidity, 30 day mortality and 

length of stay were also analysed. The mean age was 71 years (29-96 

years) and 966 (76%) were female. The overall cumulative revision 

rate following total hip replacement for femoral neck fracture was 

1.5% (95% CI: 0.9%, 2.4%) at one year and 2.0% (95%CI: 1.3%, 

3.1%) at three years and 2.0% (95% CI: 1.3%, 3.1%) at five years. 

The mean (95% CI) length of stay in hospital was 16 days. Length of 

stay varied significantly by age and physical status (both p

RSA examinations, Harris Hip, UCLA, WOMAC, SF-12 scores were 

obtained at 10 days, six months and annually thereafter with the 

furthest patients evaluated at five years. The rate of subsidence 

was highest in the first six months, and thereafter stabilized with 

minimal further subsidence. Patients with body mass index (BMI) 

< 30 exhibited less mean subsidence compared to those with BMI 

>30 at all time points. Mean UCLA, WOMAC, Harris Hip and SF- 

12PCS and MCS scores were improved compared to preoperative 

scores. Outliers with stem subsidence of greater than 1.5 mm had 

higher pain scores and lower WOMAC function scores and warrent 

careful RSA follow up. Data at six months-median show mean stem 

rotation: 0.13 deg., mean stem translation: 0.05; at one year-rotation: 

0.13 deg., translation: 0.05 mm; at two years-rotation: 0.07 deg., 

translation: 0.06 mm; at three years-rotation: 0.13 deg., translation: 

0.04 mm; at four years-rotation: 0.13 deg., translation: 0.05 mm. 

This cementless, tapered stem demonstrates excellent stability 

among young THR patients at four years. Subsidence occurs during 

the first six months and thereafter is minimal (not measurable), even 

in stems that subside the most during the first six months. There is 

no measurable rotation of the stems. The subsidence of this stem is 

comparable to or less than that previously reported for cemented 

stems with clinically successful long-term follow up. 

pApeR No. 349 

Prevention Of Dislocation In Revision THA: Randomized 

Clinical Trial Of 36/40 mm Versus 32 mm Head 





Eric R Bohm, MD, Winnipeg, MB Canada 


Allan E Gross, MD, FRCSC, Toronto, ON Canada 

Dislocation after revision total hip is a common complication. 

The purpose of this study was to assess whether a large femoral 

head (36/40 mm) would result in a decreased dislocation rate 

compared to a standard head (32 mm). A randomized clinical 

trial was undertaken to assess the effect of large femoral heads on 

dislocation after revision total hip. Patients undergoing revision 

hip arthroplasty at seven centers were randomized to 32 mm head 

or 36/40 mm head. Patients were stratified according to surgeon. 

Primary endpoint was dislocation. Rates were compared with 

Fisher’s exact test. Secondary outcome measures were quality of life: 

WOMAC, SF-36 and satisfaction. One-hundred eighty-four patients 

were randomized; 94 in the 32 mm head group and 90 in the large 

head group. Baseline demographics were similar in the two groups. 

Patients were followed from two to five years postoperatively. In the 

large head group, dislocation rate was 1.1% (1/90) vs. 8.5% (8/94) 

for the 32 mm head (p=0.035). In this study there was no difference 

in quality of life between the two groups. This randomized clinical 

trial demonstrates that a large femoral head (36/40 mm) can 

significantly reduce dislocation rate in patients undergoing revision 

total hip. As a result of this study the authors now routinely use large 

heads in all revision hip arthroplasty. 

460 

pApeR No. 350 

What Works Best, a Cemented or Cementless Primary 

THA? Minimum 17-year Followup of a RCT 

Kristoff Corten, MD, Pellenberg, Belgium 


Kory Charron, London, ON Canada 

Keegan Peter Au, MD, Ottawa, ON Canada 

Cecil H Rorabeck, MD, London, ON Canada 

Total hip arthroplasty (THA) has been associated with high survival 

rates, but debate remains concerning the best fixation mode of THA. 

We conducted a randomized controlled trial (RCT) with 250 patients 

with a mean age of 64 years between October 1987 and January 

1992 to compare the results of cementless and cemented fixation. 

Patients were evaluated for revision of either of the components. 

One hundred twenty-seven patients had died (51%) and 12 (4.8%) 

were lost to follow up. The minimum 17-year follow-up data (mean, 

20 years; range, 17-21 years) of 52 patients of the cementless group 

and 41 patients of the cemented group were available for evaluation. 

Kaplan-Meier survivorship analysis at 20 years revealed lower survival 

rates of cemented compared with cementless THA. The cementless 

tapered stem was associated with a survivorship of 99%. Age younger 

than 65 years and male gender were predictors of revision surgery. 

Radiographic comparison showed mild stress shielding around the 

cemented (95%) and cementless (88%) stem. More extensive stress 

shielding was found around 12% of the cementless stems but this 

did not lead to an increased prevalence of osteolysis. The efficacy 

of future RCTs can be enhanced by randomizing patients within 

specific patient cohorts stratified to age and gender in multicenter 

RCTs. Including only younger patients might improve the efficacy of 

a future RCT with smaller sample sizes being required. A minimum 

10-year follow-up period should be anticipated, but this can be 

expected to be longer if the difference in level of quality between the 

compared implants is smaller. 

pApeR No. 351 

Long Term Follow Up of a Modular Hydroxyapatite, 

Proximally Coated Femoral Stem 

Neil R Bergman, MD, Melbourne, VIC Australia 

David E Rothem, MD 

Ilan S Freedman, MD, North Caulfield, VIC Australia 

Hydroxyapatite coatings were added to titanium alloy femoral stems 

to increase the rate and extent of bone ongrowth onto uncemented 

femoral stems in hip arthroplasty. This stem also increased proximal 

metaphyseal loading with a tapered design and added a distal 

centralizer to increase endosteal contact and decrease thigh pain. 

This is the first study to report on the long-term performance of 

this design. Forty-six patients (53 hips) who underwent cementless 

primary hip replacement with this hydroxyapatite coated stem 

with average 15.4 year follow were investigated. The acetabular 

component used was either a dual geometry or a peripherally 

enlarged uncemented shell. In all cases, 26 mm femoral heads 

were used. Prospectively collected preoperative, post operative and 

last visit Harris Hip Scores were analyzed. The status of biological 

fixation of each femoral component was radiologically and clinically 

assessed. No patients in this series required femoral stem revision. 

Twelve hips (23%) underwent revision of the acetabular component; 

10 for periacetabular osteolysis or aseptic loosening and two for hip 

dislocation. All patients had clinically and radiologically well fixed 

femoral stems at last follow up. The average Harris Hip Score had 

improved from a mean of 43 preoperatively to a mean of 86 at most 

recent follow up. With femoral revision as the end point, the survival 




of this modular proximal hydroxyapatite coated stem at average 15.4 

year follow up was 100%. This study is the longest follow up of this 

more flexible stem. Hydroxyapatite proximal coating has facilitated 

superior outcomes than those reported for earlier generation 

implants. 

pApeR No. 352 

Tapered Uncemented HA Femoral Stems: 15-22 Year 

Survivorship 

James A D’Antonio, MD, Sewickley, PA 

William N Capello, MD, Indianapolis, IN 

William L Jaffe, MD, New York, NY 

Rudolph Gerbrand Geesink, MD,PhD, Maastricht, Netherlands 

Collarless, tapered, titanium alloy stems of several designs have had 

great success for 10-15 years follow up. They have demonstrated 

high survivorship for fixation with low incidence of thigh pain. 

A multicenter study began in 1988 and four surgeons continue 

to follow 178 patients (182 hips) with minimum 15 year and 

maximum 22 year follow up (average 17 years). The patients had an 

average age of 51.8 years and 50% were males. Thirty-three patients 

are deceased and 30 withdrew prior to 15 years. Follow up includes 

Kaplan-Meyer survivorship, revisions for any reason, complications 

and radiographic analysis which included periprosthetic bone 

remodeling. Clinically the patients have demonstrated excellent 

early restoration of function, a 2% incidence of thigh pain and an 

average Harris Hip Score of 90.2 at last follow up. Thirteen stems 

(5%) have been revised but only one stem revised for aseptic 

loosening (0.4%). The reasons for femoral revision include: deep 

joint infection; periprosthetic fracture; and discretionary revision at 

the time of acetabular revision. For the patients who were deceased 

and the 30 who withdrew prior to 15 years, all of those patients had 

stable stems at last follow up. Radiographic review demonstrates one 

stem that is fibrous stable, the remainder are bony stable, 30% have 

minimal bony remodeling, 37% have distal cortical hypertrophy 

and 33% have cortical hypertrophy combined with cortical porosity. 

Our 15-22 year experience with an HA coated tapered titanium alloy 

stem has demonstrated excellent clinical scores, low incidence of 

thigh pain and progressive bone remodeling in 70% of the patients. 

pApeR No. 353 

Modified Superior Approach for THA with Percutaneous 

Assistance: Technique and Early Results 

James Chow, MD, Phoenix, AZ 

William B Kurtz, MD, Nashville, TN 

Harbinder S Chadha, MD, Chula Vista, CA 

Brad L Penenberg, MD, Beverly Hills, CA 

Stephen B Murphy, MD, Boston, MA 

The supercapsular and percutaneously-assisted approaches to total 

hip arthroplasty (THA) each have had over six years of clinical success 

with published results rivaling those of other minimally-invasive 

hip approaches. In an effort to streamline these techniques, increase 

the ease of instruction and decrease necessary tooling, elements of 

both techniques were combined. This paper describes a superiorlybased 

minimally-invasive approach in which the interval between 

the piriformis and minimus is exploited. A longitudinal incision in 

the superior capsule is used to prepare the femur in-situ. Acetabular 

preparation is done through this incision and an additional 

percutaneous portal. A total of 110 (57 female, 53 male) consecutive 

THAs (108 primaries and two revisions) done by the same surgeon 

were entered into this study. No IV narcotics and no hip precautions 

were used. Patients were encouraged to walk one mile/day at seven 

461 

days. Follow up was two years, with data continuing to be collected. 

Average age was 63.82 (SD=12.56); average body mass index was 

29.23 (SD=5.94). Harris Hip Scores (HHS) and UCLA data were 

obtained at pre-op, six month, 12 month and 24 month intervals. 

Radiographic data was recorded and analyzed by a third party for 66 

consecutive THAs. Mean operative duration was 80 minutes (range 

40-141), mean blood loss was 328 mLs (range 100-900) and mean 

incision length was 7.4 cm (range 5-12). Mean hospital stay was 

1.7 days. No instability, neurovascular injuries, infections or perioperative 

mortalities occurred. Mean HHS were 45.44 (SD=15.49) at 

pre-op, 89.93 (SD=10.91) at six months and 87.26 (SD=14.97) at 12 

months. Mean UCLA were 3.98 (SD=1.17) at pre-op, 5.52 (SD=1.37) 

at six months and 5.67 (SD=0.58) at 12 months. Radiographically, 

mean acetabular component inclination was 40.13 degrees (SD=6.30) 

with all femoral & acetabular components well-seated. One posttraumatic 

posterior dislocation occurred, requiring re-operation to 

a hooded liner and primary repair of capsule and external rotator 

musculature. Early results of this modified minimally-invasive 

approach demonstrate safety and reliability in the short-term, with 

results better or comparable to those reported by studies regarding 

other hip approaches. Clinical results are comparable to those 

published for both original techniques from which this technique 

was derived. Radiographic results are consistent, and are comparable 

to those reported with other approaches. Longer term follow up is 

necessary, and is currently being collected. 

pApeR No. 354 

Long-term outcome of Infected Hip and Knee 

Arthroplasty treated with DAIR 

Rajesh Rout, MD, Oxford, United Kingdom 

Jonathon Campion, FRCS, Oxford, United Kingdom 

James Ferguson, MRCS 

William Jackson, FRCS, Oxford, United Kingdom 

Andrew J Price, FRCS, Oxford, United Kingdom 

Implant related infection is a complex problem associated with 

significant morbidity and mortality. This study considers the long 

term (10-year follow up) outcome of patients undergoing the 

Debridement, Antibiotics and Implant Retention (DAIR) procedure. 

Fifty-six study patients undergoing DAIR had data prospectively 

collected. Two controls per infection case were matched for age, 

sex, type and date of surgery. Data was collected with regards to 

their premorbid state and surviving patients were contacted with 

questionnaires (Oxford scores; SF-12). There were 31 total hip and 

25 total knee replacements in the DAIR group (matched to 62 and 50 

cases respectively). There was no preoperative significant difference 

in age, ASA grade or combined Charlson score. Post operatively 

there was no significant difference in the mean Oxford hip/knee 

scores (36.2 vs 35.0). There was a significant difference (p

pApeR No. 355 

A Randomized Clinical Trial of an Intra-Articular 

Technique Versus Epidural Infusion in THR 

Rajesh Malhotra, MS, New Delhi, India 

Tushar Gupta, MBBS 

Bhavuk Garg, MS Ortho 

Anjan Trikha, MD, New Delhi, Delhi India 

Vijay Kumar, MD, New Delhi,India, Delhi India 

We compared pain relief after total hip arthroplasty (THA) using 

periarticular intraoperative injection along with single dose post 

operative injection of local anesthetic with the well-established 

practice of epidural infusion. Seventy patients undergoing elective 

THA under combined spinal anesthesia were randomly assigned 

to receive either (1) continuous epidural infusion (group B) or 

(2) infiltration around the hip joint with a mixture of 100 ml of 

bupivacaine (2 mg/ml) + 1 ml ketorolac (30 mg/ml) and 0.5 ml 

epinephrine (1mg/ml) at the conclusion of surgery combined with 

one postoperative intraarticular injection of 20 ml of bupivacaine 

0.5% + 1 ml ketorolac (30 mg/ml)+ 0.5 ml epinephrine (1 mg/ml) 

through an intraarticular catheter (group A). All patients received 

acetoaminophen 1 gm eight hourly for 72 hours and injection 

ketoralac 30 mg every six hourly IV (15 mg if >65 yr 30 mg if 7) was treated by injection 

fentanyl 20 µg bolus at 10 min. interval till VAS reduced to 4 after 15 min. then injection fentanyl 20 µg bolus was given at 

10 min. interval till VAS

age, gender, cost of implant, length of stay, year of index procedure, 

diagnosis, revision and revision reason for both groups. Analysis 

was done using Wilcoxon rank sum tests, Pearson’s chi-square tests, 

Kaplan Meier methods and Cox regression. Overall cumulative 

revision rates (CRRs) remain similar between the two groups 

(p=0.20). After adjusting for confounders, uncemented implants 

did show a reduced risk of revision; uncemented implants were 0.55 

times as likely to be revised when compared to cemented implants 

(p

ecent films and treatment of active decay. Upon return to the TJA 

practice, the incidence of dental pathology was documented. One 

hundred consecutive TJA were seen and cleared by a dentist prior to 

TJA. Twenty-three (23%) of 100 patients were treated for active decay 

prior to being cleared for their arthroplasty procedure. Further, 66 

total procedures were performed, indicating that the treated patients 

had, on average, 2.9 carious teeth per patient. Utilizing this pathway, 

no patient developed TJA infection. A routine pathway in the TJA 

patient population, that included pre-operative dental clearance, 

demonstrated a true incidence of dental pathology of 23%, and 

treated patients had, on average, 2.9 carious teeth per patient. This 

information should help dentists and TJA surgeons understand the 

pervasiveness and significance of dental pathology in the arthroplasty 

population. 

pApeR No. 467 

uA Controlled-Release Antibiotic Delivery Bone Graft 

for Use in Revision Joint Replacement 

Amanda E Brooks, PhD, Salt Lake City, UT 

Bruce G Evans, MD, Salt Lake City, UT 

David Grainger, PhD 

Paul C Hogrebe, BS 

David C Evans, GED 

Infection remains a major complication in total joint revision surgery 

with rates ranging from 8-15%. Successful solutions to biomaterialassociated 

infection best extend beyond bulk material modifications 

to integrate locally delivered pharmaceuticals with wound and defect 

filler materials appropriate for large bone defects with prominent 

avascular spaces. Coating clinically familiar allograft bone tissue 

with an application-tailored, antibiotic releasing polymer shell may 

be such a solution in certain applications. To address this hypothesis 

we have combined clinically familiar components (allograft bone 

filler, degradable polycaprolactone (PCL), polyethylene glycol 

(PEG), tobramycin) to create a novel medical device. Using a layer 

by layer assembly allograft bone was coated with tobramycin-loaded 

PEG and PCL (n=6). The ratio and concentration of the polymers 

were modified to minimize bolus jettison of drug and extend the 

release of tobramycin. Each allograft fragment or micron-sized 

particulate was incubated in phosphate buffered saline for six 

weeks at 37C. Tobramycin release was assessed via 1) a custom 

fluorescence assay and 2) evaluation of the minimal inhibitory 

concentration. Tobramycin-loaded layers of PCL and PEG were able 

to control tobramycin release over the clinically relevant six-week 

timeframe preferred to treat peri-operative contamination and avoid 

infections. Tobramycin remained bioactive effectively killing E.coli 

clinical isolates (10^5 CFU). In addition to releasing bactericidal 

concentrations of tobramycin over four to six weeks, antibioticloaded 

allograft bone has beneficial osteoconductive potential, 

likely resulting in decreased revision and joint replacement surgical 

infections with improved new bone formation. 

pApeR No. 468 

uCalorimetry Of Synovial Fluid For Rapid Diagnosis Of 

Septic Arthritis 

Alec Cikes, MD, Lausanne, Switzerland 

Olivier Borens, MD, Lausanne, Switzerland 

Andrej Trampuz, MD, Lausanne, Switzerland 

Synovial fluid (SF) has limited sensitivity (e.g. Gram stain) or are 

slow (e.g. cultures). We evaluated the potential of SF calorimetry for 

rapid diagnosis of septic arthritis in native and prosthetic joints by 

detection of bacterial heat production. We prospectively included 

adult patients with acute arthritis, in whom arthrocenthesis was 

464 

performed. Septic arthritis was diagnosed by positive Gram stain 

and/or SF culture. In parallel, 1 ml SF was inoculated in 2 ml TSB 

and incubated at 37°C in an isothermal calorimeter (detection limit 

0.25 µW). Detection was defined until heat flow reached e10 µW. 

Eighty-nine episodes of arthritis were included (median age 66.6 y, 

range 24-98 y), of which eight (9%) were septic and 81 (91%) were 

non-septic, including gout (n=15), undifferentiated arthritis (n=14), 

pseudogout (n=13), osteoarthritis (n=13), reactive arthritis (n=11) 

or other conditions (n=15). The causative organism was detected by 

calorimetry in all eight episodes of septic arthritis after a mean of 

4.3 h (range, 2.8-7.5 h). Figure shows the heat flow characteristics; 

conventional SF cultures required 24-48 h for growth. S. aureus 

(n = 3), S. agalactiae (n=2), S. gallolyticus (n=1), viridans group 

streptococci (n=1) or no organism (n=1) grew. Calorimetry of SF 

allowed accurate discrimination between septic and non-septic 

arthritis within eight hours. Faster diagnosis of septic arthritis might 

prompt earlier treatment and improve their outcome. 

pApeR No. 469 

uEarly Diagnosis Of Infection By Microbial Heat 

Production In Sonication Fluid Of Removed Implants 



Julia Steinrucken, MD 

Martin Clauss, MD, Liestal, Switzerland 

Andrej Trampuz, MD, Lausanne, Switzerland 

Establishing the diagnosis of implant-associated infections is 

often difficult, because of variable clinical presentations and lack 

of uniform diagnostic criteria. Sonication of removed orthopedic 

devices was shown to have superior sensitivity and specificity for 

infection. We evaluated the value of microcalorimetry as a quick and 

reliable tool in the diagnosis of infection in sonication fluid from 

removed implants. Between 10/2009 and 02/2010, we prospectively 

included all removed orthopaedic devices at our institution, which 

were subjected to sonication. Periprosthetic tissue cultures were 

performed as standard procedure. The removed device was sonicated 

in Ringer solution (40 kHz, 1 minute) and the resulting fluid was 

cultured and centrifuged (3000 x g, 10 minutes). The resulting 

pellet was resuspended in 3 ml tryptic soy broth for isothermal 

microcalorimetry (sensitivity of 0.25 µW). The detection time until 

increase of 20 µW was calculated. A 48-channel batch calorimeter 

was used to measure the heat flow at 37°C controlled at 0.0001°C. 

Thirty-two cases were included (19 males, mean age ± SD was 64 

± 16 years). Twenty-six cases were arthroplasties (12 hip, 10 knee, 

one shoulder and one ankle prostheses, two spacers) and six cases 

osteosynthesis material (five screws, one cement-nail). Thirteen 

cases (41%) were infected, of which 11 (85%) were positive in 

periprosthetic tissue cultures and 10 (77%) in sonication culture. 

By microcalorimetry, 12 cases (92%) were positive with a mean 

detection time of 11.4 h (range, 0.2 h-20.9 h). Microcalorimety of 

sonication fluid showed superior sensitivity for the diagnosis of 

infection with detection time of

pApeR No. 470 

Does Vitamin E Addiction Affect Bacterial Adherence 

On UHMWPE? 

Alessandro Bistolfi, Torino, Italy 

Michele Boffano, Tornino, Italy 

Pierangiola Bracco, Torino, Italy 

Luigi Costa, Prof, Torino, Italy 

Giuliana Banche, Torino, Italy 

Valeria Allizond, Torino, Italy 

Anna Maria Cuffini 

Elena Brach Del Prever, Prof, Turin, Italy 

Ultra-high molecular weight polyethylene (UHMWPE) is a 

fundamental biomaterial for arthroprostheses. Prosthetic infections 

are rare but imply invasive and expensive treatments. Various studies 

showed that some bacteria are able to produce a biofilm and to 

adhere to the surface, thus obstructing antibiotics and umoral 

immunity intervention. We hypothesized a correlation between the 

characteristics of the surface of the UHMWPE and the adhesion. We 

compared sperimental cylinders of standard GUR 1050 UHMWPE 

and vitamin E-added (0,1%) UHMWPE incubated with a biofilmproducing 

bacterial strain (Staphylococcus epidermidis ATCC 35984). 

After incubation the cylinders were centrifuged at 12000 rpm for one 

minute to release the attached bacteria that were quantified by TSA 

plate counts. The experiments were assayed in triplicate and repeated 

a minimum of three times. A statistical analysis on results (T-Student 

test) was conducted. After seven hours of incubation, adhesion rates 

were similar, with no statistically relevant differences. A significant 

(p

pApeR No. 473 

Is Smoking a Risk Factor for Complications After 

Elective Primary Total Knee/Hip Arthroplasty? 

Jasvinder Singh, MD, Vestavia, AL 

Thomas Houston, MD 

Brent A Ponce, MD, Birmingham, AL 

Grady Maddox, MD, Birmingham, AL 

Michael J Bishop, Seattle, WA 

Joshua Richman, Birmingham, AL 

Elizabeth Campagnna, MS 

William G Henderson, PhD, Aurora, CO 

Mary Hawn, MD, FACS, Birmingham, AL 

Smoking has been linked to complications following many surgical 

procedures. The effect of smoking on veterans’ outcomes after 

elective primary total hip and total knee replacement (THR/TKR) has 

not been studied. All elective primary THR/TKR surgeries performed 

from 2002 to 2008 in the VA and assessed in the National Surgical 

Quality Improvement Program, (n=33,294) were studied. Patients 

were stratified by pre-operative smoking status into current, prior 

and never smoker. Multivariable logistic regression was used to assess 

adjusted risk of complications and death. Analyses were adjusted for 

age, race/ethnicity, ASA class, work relative value unit (RVU) and 

year. Surgical site infection (SSI) was additionally adjusted for wound 

classification. Current smokers (n=7,984) were younger (58 versus 

66 years) while prior smokers (n=6,297) had higher ASA class (ASA 

class 3/4, 72% versus 63%) compared to never-smokers (n=19,013) 

(p

pApeR No. 476 

Does Bridging With Low Molecular Weight Heparin 

Actually Lower The Rate Of Pulmonary Embolism? 

James Matthew Saucedo, MD, Chicago, IL 

Jason Wayne Savage, MD, Chicago, IL 

Erik Brian Eller, MD, Evanston, IL 

Mahesh Polavarapu, Chicago, IL 

S David Stulberg, MD, Chicago, IL 

Pulmonary embolism (PE) is a potentially devastating complication 

in total joint arthroplasty (TJA). While the standard of care dictates 

some form of chemoprophylaxis, there is currently no clear consensus 

on the best pharmacologic protocol. In this study we explore the rate 

of PE in primary total joint arthroplasty using three post-operative 

anti-coagulation protocols. Between April 2008 and December 2009, 

there were 2,376 primary total hip and total knee arthroplasties (THA 

and TKA) performed at a single institution. The rate of documented 

PE was obtained from our anti-coagulation dosing service, and the 

medical records were reviewed. We collected demographic data and 

stratified patients according to anti-coagulation protocols, which 

included warfarin alone, warfarin and enoxaparin, and warfarin and 

dalteparin. All were on an identical perioperative protocol, including 

anesthesia, weight-bearing status and mobilization. The rate of PE 

among patients undergoing either THA or TKA was 1.18%. The 

rates of PE among those on the various anti-coagulation protocols 

were: warfarin 0.83%, warfarin and enoxaparin 1.35%, warfarin and 

dalteparin 1.36%. Mechanical prophylaxis (sequential compression 

devices) was used on all patients. Our data series reflects a higher 

rate of PE among those on a protocol of warfarin plus low-molecular 

weight heparin (LMWH) as compared with warfarin alone. This is 

counter-intuitive, as the practice of adding a LMWH bridge to warfarin 

is based on the physiologic understanding that there is a brief hypercoagulable 

state after initiating warfarin alone. While there are likely 

other variables involved, our results call into question the utility of 

adding a LMWH bridge. 

pApeR No. 477 

uIn vitro Effect Of Rivaroxaban, A New Anti-Coagulant, 

Compared To Enoxaparin On Osteoblasts 

Gandhi Nathan Solayar, MD, Dublin 9, Ireland 

Pauline Walsh, BSc, PhD, Dublin, Ireland 

Kevin James Mulhall, MD, Dublin 03, Ireland 

Current treatments for the prevention of thromboembolism include 

heparin and low-molecular weight heparins (LMWHs). A number of 

studies have suggested that long-term administration of these drugs 

may negatively affect bone and some have associated their use with the 

risk of developing osteoporosis. Rivaroxaban (Xarelto) is a new antithrombotic 

drug for the prevention of venous thromboembolism in 

adult patients undergoing elective hip and knee replacement surgery. 

This study aimed to investigate the possible effects of rivaroxaban on 

osteoblast proliferation, function and gene expression compared to 

enoxaparin, a commonly used LMWH. Human osteoblast cells were 

cultured in the presence of varying concentrations of rivaroxaban 

(0.013-13 µg/ml) or enoxaparin (0.1-10 international units/ml). 

The MTS assay was used to assess the effect of drug treatments on 

cell proliferation. Alkaline phosphatase activity and osteocalcin 

expression were used to measure osteoblast function. Changes 

in mRNA expression of the transcription factor, Runx2, and the 

osteogenic factor, BMP-2, were measured by real-time polymerase 

chain reaction (PCR). Rivaroxaban and enoxaparin treatment did not 

adversely affect osteoblast proliferation. However, both drugs caused 

a significant reduction in alkaline phosphatase activity (p

pApeR No. 479 

Comparative Assessment Of Surgical Management Of 

Recurrent Dislocation After Total Hip Arthroplasty 

Ehsan Saadat, BS, San Francisco, CA 

Glenn Diekmann, MD, Los Angeles, CA 

Steven Takemoto, PhD, San Francisco, CA 

Michael D Ries, MD, San Francisco, CA 

The objective of this study was to investigate the relative success of 

interventions used in revision total hip arthroplasty (THA) to treat 

recurrent dislocations, and patient characteristics associated with 

success or failure of surgical intervention. This was a retrospective 

study conducted with approval from the Committee for Human 

Research at a large tertiary-care medical center. All cases of 

symptomatic recurrent dislocation from 1998 to 2008 requiring 

operative intervention under the direction of the senior author 

were reviewed. Minimum follow up was two years. Rates of success 

(achievement of a stable hip) were calculated using univariate and 

multivariate regression analyses. A total of 66 patients (69 hips) 

were identified. Fifty-one (74%) were successfully managed with 

one revision, nine (13%) required two revisions and nine (13%) 

required three or more revisions for successful management of 

recurrent dislocations. Success rates for constrained acetabular liner, 

large femoral head (diameter >36mm), trochanteric advancement 

and correction of malposition were 67%, 68%, 87% and 91% 

respectively. In multivariate analysis, correction of malposition 

and trochanteric advancement were most successful, with odds 

ratios of 8.5 (CI 0.6 to 123.8) and 3.1 (CI 0.7 to 14.3), respectively. 

Previous hip infection and obesity were strongly associated with 

failure of first attempt at surgical management (OR 12.0, p-value 

0.007 for infection; OR 3.5, p-value 0.12 for body mass index >30). 

Correction of malposition and trochanteric advancement are more 

successful than constrained acetabular liner or large femoral head in 

management of recurrent dislocations. Previous hip infection and 

obesity are major negative prognostic factors for success of revision 

THA for dislocation. 

pApeR No. 480 

Risk Factors for PJI & Postoperative Mortality following 

THA in Medicare Patients 

Kevin John Bozic, MD, MBA, San Francisco, CA 

Edmund Lau, MS, Menlo Park, CA 

Kevin Ong, PhD 

Steven M Kurtz, PhD, Philadelphia, PA 

Harry E Rubash, MD, Boston, MA 

Thomas Parker Vail, MD, San Francisco, CA 

Daniel J Berry, MD, Rochester, MN 

Patient-related risk factors for postprosthetic joint infection (PJI) 

and postoperative mortality in elderly total hip arthroplasty (THA) 

patients are poorly understood. The purpose of this study was to 

identify specific co-morbidities associated with increased risk of 

PJI and postoperative mortality in Medicare THA patients. The 

Medicare 5% sample was used to calculate the relative risk of PJI 

and mortality as a function of baseline medical co-morbidities in 

40,919 primary THA patients between 1998 and 2007. The impact of 

30 co-morbid conditions on PJI and mortality were examined using 

Cox regression, controlling for age, sex, race, Census region, public 

assistance and all other baseline co-morbidities. Adjusted hazard 

ratios were constructed for each condition, and Wald’s X2 statistic 

ranked the degree of association of co-morbid conditions with PJI or 

postoperative death. The most significant independent risk factors 

for PJI (in order of significance, p

edge loading occurs with the hip flexed such as when rising from 

a chair. This study compares the wear rates of anterosuperior and 

posterior edge loading. All alumina bearings revised at one center 

were collected over 12 years (1998-2010). A chromatically encoded 

confocal measurement machine with a resolution of 20 nanometers 

was used to measure the sphericity and surface topography of the 

femoral heads. Each case was analyzed for the type of edge loading. 

The orientation and location of the stripe wear on the head was used 

to differentiate between posterior and anterosuperior edge loading. 

Fifty-six alumina femoral heads were collected with median time 

to revision 2.7 years. Fourty-eight (86%) cases had edge loading 

wear comprised of 28 (50%) with posterior edge loading, 11 (20%) 

with anterosuperior edge loading, six (11%) with both posterior 

and anterosuperior edge loading and three (5%) with unknown 

orientation. The average volumetric wear rate for anterosuperior 

edge loading was 1.5 mm3/yr, and the average volumetric wear rate 

for posterior edge loading was 0.7 mm3/yr (p=0.05). Anterosuperior 

edge loading has a higher wear rate than posterior edge loading. 

Edge loading occurs during different activities, and may be related 

to cup position. 

pApeR No. 528 

Outcome Of Ceramic Bearing Surfaces In Primary 

Conventional THA: Analysis Of 40448 Procedures 

Richard De Steiger, MD, Victoria, Australia Australia 

Stephen Graves, MD, Adelaide, South Austalia Australia 

David Davidson, MD, University Of Adelaide, South Australia 

Philip Ryan, FAFPHM, Adelaide, SA Australia 

Lisa Miller, BSc 

Kara Cashman, BSc (HONS), Adelaide, SA Australia 

Concerns regarding wear and peri-prosthetic lysis have led to an 

increasing use of ceramics as a bearing surface in conventional total 

hip arthroplasty (THA). This study analyses data on over 40,000 

procedures undertaken on patients with a diagnosis of osteoarthritis. 

The data was obtained from a comprehensive national database 

that prospectively recorded these procedures over a 10-year period. 

Analyses were undertaken to examine the impact of age, gender, 

femoral head size and prostheses as well as determining the reasons 

for revision. The principal outcome measure was time to first revision 

using Kaplan-Meier estimates of survivorship. There have been 27,310 

ceramic-on-ceramic (CoC) and 13,138 ceramic-on-polyethylene 

(CoP) procedures recorded for conventional THA. The cumulative 

percent revision at nine years for CoC is 4.0 (3.6-4.4) and for CoP 

5.9 (5.0-6.9). There have been 47 revisions for implant breakage, 33 

for acetabular components and 14 for femoral heads. This gives a 

recorded incidence of breakage of 1/1,000 which is greater than that 

reported in the literature. Satisfactory outcomes can be achieved for 

ceramic bearing surfaces in conventional THA which are similar to 

metal on polyethylene. There is a slightly increased risk of revision 

for implant breakage. 

pApeR No. 529 

Alumina Ceramic Bearings for Total Hip Arthroplasty: 

Minimum 10-Year Follow-up 

James A D’Antonio, MD, Sewickley, PA 

Alumina ceramic bearings are scratch resistant and have superior 

lubrication and wear resistance compared to other bearings. In 1996 

a prospective, randomized, controlled, multicenter trial comparing 

alumina ceramic bearings to metal-on-conventional polyethylene 

was initiated. Five surgeons from five centers now continue to follow 

278 patients (289 cases) at and beyond 10 years. Three patient 

cohorts were randomized: group I had ceramic bearings with a 

469 

porous titanium cup; group II with a roughened HA cup; group 

III, a control metal-on-polyethylene with a porous titanium cup. 

There is no difference in the demographics between the patients 

who received alumina ceramic bearings and those who received the 

metal-on polyethylene controls. Follow up includes Kaplan-Meyer 

survivorship, revisions for any reason, radiographic analysis and 

complications including squeaking. The clinical performance with 

Harris Hip Score was no different for the study groups. Survivorship 

revision for any reason at 12 years is 96.8% for the alumina ceramic 

cases compared to 91.3% for the control metal-on-polyethylene cases 

(p=0.0046). There have been no revisions for aseptic loosening in 

any patient cohort. The only ceramic bearing surface failure occurred 

at nine years when a peripheral rim fracture fragment led to a liner 

revision. Osteolysis was noted in 17.6% of the control group and 

in none of those patients receiving the ceramic bearing. Occasional 

squeaking has occurred in two ceramic patients (0.9%). Alumina 

ceramic bearings for THA in a young and active patient population 

have performed well out to 12 years with a high survivorship and 

low rate of complications. 

pApeR No. 530 

Seven to Eleven Year Follow-Up of Highly Cross-linked 

Polyethylene Liners in Total Hip Arthroplasty 

Bryan T Jarrett, Boston, MA 

Charles R Bragdon, PhD, Boston, MA 

Michael Doerner, BA 

Meridith Greene, Boston, MA 

Henrik Malchau, MD, Boston, MA 

Highly cross-linked polyethylene (HXLPE) has become one of the 

most widely utilized bearing surfaces for total hip arthroplasty (THA). 

This study presents the long-term clinical and wear results of HXLPE 

at a minimum of seven years. We identified 386 primary THAs (363 

patients) using HXLPE liners coupled with either 26 mm, 28 mm 

or 32 mm femoral heads. Clinical evaluation included the Harris 

Hip, WOMAC, EQ-5D, SF-36 and UCLA activity scores. In addition 

to plain radiograph assessment, the Martell Hip Analysis Suite was 

used to measure head penetration over time which was compared 

using a t-test at the longest follow-up time point. We obtained follow 

up on 214 patients (230 hips, 217 with survey follow up, 171 with 

radiographic follow up) consisting of 99 females and 115 males with 

an average age at surgery of 59 years (28-84). Thirty-four patients 

died, 46 were lost to follow up, 45 are pending follow up and 24 

patients were revised, none for polyethylene wear or liner fracture. 

No osteolysis was found on plain radiographs. Average survey scores 

(±stdev) were HHS: 87.19±15.74, WOMAC pain: 1.81±3.28, EQ-5D 

HSI: 0.82±0.22, SF-36 physical: 46.37±10.65 and UCLA: 6.13±2.04. 

The average femoral head penetration rate of HXLPE was significantly 

different from that of conventional polyethylene (18.3±65 µm/year 

versus 113.4±131.3µm/year, p

pApeR No. 531 

The In vivo Volumetric Wear Of Highly Cross-Linked 

Polyethylene In Total Hip Arthroplasty (THA) 

Geraint Emyr Rhys Thomas, MA, MBBS, MRCS, Oxford, 

United Kingdom 

David J Beard, DPhil, Oxford, United Kingdom 

Adrian Taylor, MD, Oxford, United Kingdom 

Peter McLardy-Smith, FRCS, Oxford, United Kingdom 

Roger Gundle, Oxford, United Kingdom 

Barbara Marks, Oxford, United Kingdom 

Harinderjit Singh Gill, PHD, Oxford, United Kingdom 



The use of highly cross-linked polyethylene (HXLPE) is now 

commonplace for total hip arthroplasty (THA). Hip simulator 

studies and short-term in vivo measurements suggest that the wear 

rate of some types of HXLPE is significantly less than conventional 

ultra high molecular weight polyethylene (UHMWPE). The aim of 

this study was to measure the volumetric wear of HXLPE compared 

to UHMWPE liners in a prospective, double-blind randomized, 

controlled trial using radiostereometric analysis (RSA). Fifty-four 

subjects were randomized to receive hip replacements with either 

UHMWPE liners or HXLPE liners. All subjects received a cemented 

stem and uncemented acetabular component. Clinical outcomes 

were assessed and the 3D penetration of the head into the socket was 

determined for a minimum of seven years using RSA. Volumetric 

wear rate was calculated, with attention to the direction of wear as 

well as cup abduction and version. At a minimum of seven years 

post-operatively, the volumetric wear rate was significantly lower in 

the group treated with HXLPE (4.30 mm3/yr SE 3.17 mm3/yr) than 

it was in the UHMWPE group (25.75 mm3/yr SE 3.02 mm3/yr) (p < 

0.001). The direction of wear was supero-lateral in both groups. This 

study demonstrates that HXLPE has significantly reduced volumetric 

wear in vivo. This may decrease the incidence of failure due to aseptic 

loosening. It may also allow the use of larger, more stable metal on 

polyethylene couples. 

pApeR No. 532 

A Prospective, Randomized Study of Crosslinked and 

Non-crosslinked Poly for THA at 10-Year Follow-up 


Robert Hopper, PhD, Alexandria, VA 

Sarah Beykirch, Alexandria, VA 

Henry Ho, MSC, Alexandria, VA 

Supatra Sritulanondha, Alexandria, VA 

Charles A Engh, Sr MD, Alexandria, VA 

Crosslinked liners were introduced with the promise that they would 

substantially reduce polyethylene wear and therefore osteolysis 

and reoperation. In 1999, our institution initiated a prospective 

randomized study to compare the outcome of total hip arthroplasty 

patients with either non-crosslinked (conventional) liners or liners 

that had been crosslinked with 5 Mrad of gamma-irradiation and 

heat treated to eliminate free radicals (crosslinked). This study 

reports 10-year outcome, comparing head penetration, osteolysis 

and revision rates. Patient enrollment included 114 conventional 

liners and 116 crosslinked liners. Mean age at surgery was 62.0 for 

the conventional liners and 62.5 for the crosslinked liners (p=0.70). 

Implant survivorship was evaluated using the Kaplan-Meier method. 

Polyethylene wear was measured with Martell’s Hip Analysis Suite 

software and osteolysis was evaluated radiographically. There have 

470 

been five liner exchanges related to wear and osteolysis among the 

conventional group and none among the crosslinked group. Using 

revision for wear-related complications as an endpoint, survivorship 

at 10-years was 93.3±5.8% for conventional and 100% for crosslinked 

liners (p=0.03, log rank). The mean linear wear rate was 0.23 mm/ 

yr for conventional and 0.04 mm/yr for cross-linked (p

three years would show no difference in wear damage than liners 

implanted for a shorter period of time. The 76 analyzed liners were 

obtained from our Institutional Review Board-approved implant 

retrieval system. A previously described wear grading protocol was 

used, which looked at three areas of the liner: articular surface, 

backside and rim. For the articular surface, eight damage modes 

were graded on a 0 to 3 scale for a maximum damage score of 96. 

The average articular surface wear grade was 21.5 + 5 (range 11 to 

38). Thirty-five liners had screw hole creep and 48 liners had rim 

impingement. Incipient rim cracks without fracture were identified 

in five XLPE liners. In liners implanted >3 years (nine liners), the 

mean wear score was 22.8+6. In those implanted 3 years showed no difference in 

surface wear scores compared to those with LOI

atios adjusted for case mix differences (AOR). There were no 

significant differences between the two groups for PE (AOR=0.94; 

95% CI 0.75-1.17), DVT (AOR=0.84; 0.70-1.03), major bleed 

(AOR=0.95; 0.77-1.17) and RTT for infection (AOR=1.06; 0.76- 

1.46). There were significantly fewer deaths in the LMWH group 

(aspirin 0.65%, LMWH 0.51%, AOR=0.77; 0.61-0.98). In this large, 

matched group of THR patients, a small but statistically significant 

survival benefit was seen at 90 days following surgery when LMWH 

was used as thromboprophylaxis. Rates of symptomatic venous 

thrombo embolism events were not significantly different between 

the groups. Residual confounding cannot be fully excluded. 

pApeR No. 538 

Irrigation and Debridement for Periprosthetic 

Infections: Does the Organism Matter? 


Susan Marie Odum, Charlotte, NC 

Adolph V Lombardi Jr, MD, New Albany, OH 

Mr Benjamin Zmistowski, Philadelphia, PA 

Nicholas M Brown, BS, Davenport, IA 

Jeffrey TP. Luna, MD, Saugus, MA 

Keith Fehring, MD, Richmond, VA 

The success of open debridement with component retention 

(ODCR) varies depending upon host factors, organism virulence 

and time to treatment. Historical data reveals a failure rate of 68% 

increasing to 82% in patients with resistant organisms. Limited series 

report improved success if the infecting organism is a Streptococcal 

organism. The purpose of our study was to determine the failure 

rate of ODCR in periprosthetic Streptococcus infections versus other 

organisms. A multi-center review of periprosthetic infections from 

1987 to 2008 at four institutions was performed. Selection criteria 

included treatment with ODCR for infected primary arthroplasty. 

Failure of ODCR was defined as the need for any additional 

surgery due to infection. A total of 211 patients met inclusion 

criteria, 42 infected with Streptococcus and 169 infected with other 

organisms. At minimum two-year follow up, 106 of 211 patients 

failed (50%). Twenty-four of 42 Streptococcus failed (57%) and 

82 of 169 other organisms failed (48.5%). This difference was not 

significant (p=0.20). Open debridement with component retention 

is an attractive low morbidity treatment option for periprosthetic 

infection. However, the reported failure rate is high. Anecdotally, 

it has been assumed that those infected with streptococcus have a 

better prognosis following irrigation and debridement than those 

infected with other organisms. The data presented here does not 

support ODCR even if the infecting organism is streptococcus. 

Caution must be exercised when choosing this surgical approach to 

treat periprosthetic infections. 

pApeR No. 539 

Is The INR Cutoff Of 2.0 An Arbitrary Value? 

Patricia L Hansen, BS, Middletown, DE 


Camilo Restrepo, MD, Philadelphia, PA 



Richard H Rothman, MD, Philadelphia, PA 

There is a discrepancy in published data regarding the influence that 

anticoagulation has on the prevalence of pulmonary embolism (PE) 

following joint arthroplasty. Despite recommendations of reaching 

a post-operative international normalized ratio (INR) level of 2-3, 

recent studies have shown that aggressive anticoagulation (INR>2) 

472 

can lead to hematoma formation and the risk of subsequent 

infection. The hypothesis of this study was that administration of 

oral anticoagulants aiming for INR >2 does not provide absolute 

protection against PE. Using our institutional database, 629 

patients undergoing evaluation for PE (CT, VQ scan or pulmonary 

angiography) following orthopedic procedures between 2004 and 

2008 were identified. Of these, 173 patients had proven PE and 456 

were negative for PE. All patients at our institution receive warfarin for 

prophylaxis aiming for an INR level of 2.0. There were no significant 

differences between mean INR values in patients with or without PE 

on the date of scan (p=0.63) or the five days prior (p values from 

0.13 to 0.99). The percentage of patients who had an INR>2.0 with 

PE was not different from the percentage of patients who had an 

INR>2.0 without PE on POD 0-3 (p values from 0.20 to 0.42). In 

this study, we did not observe a clinically relevant difference in INR 

values of patients with and without PE. Additionally, we did not 

observe a difference in the proportion of patients with an INR>2.0 

with and without PE. Given this evidence, INR>2.0 did not appear 

to significantly protect against PE in our cohort. Due to the known 

risks associated with anticoagulation, the INR cutoff of 2.0 should 

be reconsidered. 

pApeR No. 540 

uIncreased Complication Rates Following THA And 

TKA In Morbidly Obese Patients 

Richard J Friedman, MD, Charleston, SC 

Susanne Hess, MD 

Scott D Berkowitz, MD, Montville, NJ 

Martin Homering, PhD, Wuppertal, Germany 

The incidence of morbid obesity and total joint arthroplasty are 

rising, yet it is controversial whether morbid obesity is a risk 

factor for increased complications following total hip (THA) and 

total knee arthroplasty (TKA). To determine the effects of morbid 

obesity (body mass index (BMI) >= 40) on the early (up to six to 

eight weeks) postoperative complication rate following surgery, 

data from the multinational RECORD clinical trial program on 

rivaroxaban for the prevention of venous thromboembolism (VTE) 

in THA and TKA were retrospectively analyzed. A total of 12,355 

patients (6,870 THA and 5,485 TKA) were reviewed to identify 

complication rates in those with a BMI >= 40 (3.6%) compared to 

normal weight (BMI < 25, 24.3%), overweight (BMI 25-29, 39.8%) 

and obese (BMI 30-39, 32.3%). Explorative analyses compared the 

rates of adjudicated VTE, bleeding and investigator reported adverse 

events by BMI groups. The morbidly obese patients were younger 

than the other groups, especially for TKA. Operative times were 

similar between all the groups. The overall complication rate was 

higher with a BMI >= 40 for both THA and TKA. Specifically, there 

were increases in erythema, peripheral edema, bacterial infections, 

respiratory disorders, neurologic complications, gastrointestinal 

complications and cardiac arrhythmias. These data support a 

correlation between morbid obesity and increased complications 

following THA and TKA. With this information, surgeons can have 

a more informed discussion with their patients about the potential 

risk of postoperative complications in morbidly obese patients. 




pApeR No. 706 

Correlation Between Radiographic Measures of 

Acetabular Morphology with 3D Femoral Head 

Coverage 

Andrew E Anderson, PhD, Salt Lake City, UT 

Benjamin Hansen, MD, Durham, NC 

Lucas Anderson, MD, Salt Lake City, UT 

Michael D Harris, BS 


Relationships between radiographic measures of acetabular 

morphology and 3D coverage of the femoral head are unknown. In 

this study, radiographic measurements of acetabular morphology 

were correlated to coverage. Retrospective Institutional Review Board 

approved study with 16 retroverted subjects (positive cross-over sign) 

and 26 controls (negative cross-over). Radiographic measurements 

of: posterior wall sign (PWS), posterior wall distance (PWD), lateral 

center edge angle (LCEA), acetabular index (AI), extrusion index 

(EI), coxa profunda and acetabular angle (AA) quantified by two 

orthopaedic surgeons on an AP radiograph. Three-dimensional 

hip models were constructed from CT images to quantify femoral 

head coverage. Radiographic measures were averaged between 

observers and correlated to total and regional (posterior/anterior) 

femoral head coverage (Pearson’s r, or Spearman’s rho). Correlation 

assumed strong when r or rho >0.5. Mann-Whitney tests used to 

compare 3D femoral head coverage between groups (significant if 

p

CTL images and a CT scan were included. Acetabular version 

measurements using serial CTL radiographs available from six week 

postoperative and annual follow-up intervals were compared to 

measurements from pelvic CT scans. Pearson’s regression analysis was 

performed to assess correlation between CTL and CT measurements. 

Acetabular anteversion measurements by CTL averaged 26.1 degrees 

(range: -2 to 48.3º). Anteversion assessed by CT averaged 28.8 

degrees (range: -7 to 54º). Pearson’s regression analysis indicated 

strong correlation (r- 0.82; p

of the fractured components was similar to those that did not fail. 

SEM analysis indicated that failures were due to fatigue. Evidence of 

corrosion was common in this retrieval series. Fractured components 

were severely corroded, although the failure mechanism was not 

a direct result of the corrosion. The prevalence and severity of the 

interfacial corrosion in this series suggests potential release of 

metallic ions or debris into the surrounding joint space. 

pApeR No. 712 

What Is The Benefit Of Introducing New Hip And Knee 

Prostheses? 

Stephen Graves, MD, Adelaide, South Austalia 

Rajan Anand, MBBS, Adelaide, South Australia 

Richard De Steiger, MD, Victoria, Australia 





New joint replacement prostheses are being continually introduced 

into the market. The underlying purpose is to improve patient 

outcomes. This study was undertaken to determine how many new 

prostheses were associated with improved patient outcomes. Data 

was obtained from a comprehensive national database. Analysis 

was undertaken on all hip and knee prostheses introduced into 

the market between January 1, 2003 and the December 31, 2007. 

Outcome analysis was undertaken only on new prostheses used on 

at least 100 occasions. They were compared to the combined result 

of the three best performing established hip and knee prostheses 

that had a minimum follow up of five years. The principle outcome 

measures were the rate of revision per observed component years and 

time to first revision using Kaplan-Meier estimates of survivorship. 

Most prostheses introduced into the market during the study period 

were used on less than 100 occasions. Of those that had been used 

in a sufficient number of procedures, 30% (10 out of 33) of the hip 

replacements and 29% (eight out of 28) of the knee replacements 

had a significantly higher risk of revision than the established 

prostheses. None of the newer prosthesis had a lower risk of revision 

than the established prostheses. This study indicates that there was 

no benefit to the introduction of new prostheses into this national 

market during the five year study period. Importantly 30% of the 

new prostheses were associated with a significantly worse outcome 

compared to the better established prostheses. 

pApeR No. 713 

Hip and Knee Osteoarthritis: Shared Decision Making 

and Factors Affecting Patient Treatment Choice 

Laura Bozzuto, AB, Hanover, NH 

Catharine Clay, Hanover, NH 

Ivan M Tomek, MD, Lebanon, NH 

Stephen R Kantor, MD, Lebanon, NH 

Stephen Kearing, MS 

Shared decision making enhances patient-centered care by educating 

patients about evidence-based treatment options, setting realistic 

expectations for outcomes and by eliciting personal values related to 

the decision. This prospective observational study sought to identify 

factors involved in patient choice about treatments for hip and 

knee osteoarthritis. Patients with hip (n=84) or knee osteoarthritis 

(n=149) who were deemed candidates for replacement by their 

orthopaedic surgeon (1) completed a pre-video questionnaire, (2) 

watched a video decision aid (DA) that reviewed treatment options 

and (3) completed a follow-up questionnaire. Chart review was used 

475 

to determine if patients followed through with their choice in the 

subsequent three months. Fewer patients were unsure about their 

treatment preference after viewing the DA (19% before vs. 13% 

after) and understood key facts associated with the decision (Hip: 

83%, Knee: 81%). Patients who had decided on treatment before the 

DA tended to retain their preferred option (92%). Patients tended 

to follow through with their post-DA choice (82% leaning toward 

surgery and 92% leaning toward non-surgical) within three months. 

Symptom severity, SF-12 PCS, and personal value scores (get pain 

relief, avoid surgery) were significant predictors of patient choice 

and treatment follow through (p d 0.05). After watching the DA, 

most patients understood treatment options, benefits and risks, were 

clear about their personal values and followed through with their 

chosen treatment. Clinical factors and personal patient values were 

both associated with treatment follow through. Decision support 

programs that elicit these factors may guide patients in making better 

quality osteoarthritis treatment decisions. 

pApeR No. 714 

Patients Feel that Orthopaedic Surgeons are 

Undercompensated for Total Hip and Knee 

Replacement 

Jared R H Foran, MD, Golden, CO 

Neil P Sheth, MD, Charlotte, NC 

Brett Russell Levine, MD, Chicago, IL 



Aaron Glen Rosenberg, FACS, MD, Chicago, IL 

Joshua J Jacobs, MD, Chicago, IL 


Medical economics and physician reimbursement have become 

increasingly crucial issues in the United States over the past decade. 

The purpose of this study was to evaluate patient perception of 

orthopaedic surgeon reimbursement for total hip (THA) and 

knee (TKA) arthroplasty. A total of 634 consecutive patients in an 

arthroplasty practice were surveyed. Patients were asked what they 

believed a surgeon should be paid for performing THA and TKA. The 

survey explicitly stated that the patient response should only include 

the surgeon’s fee (including the 90-day global period) and NOT the 

cost of hospitalization, operating room expenses, etc. Patients were 

then asked to estimate what Medicare actually reimbursed for each 

of these procedures. Finally, the survey revealed the true average 

national Medicare reimbursement rate for THA ($1,378) and TKA 

($1,430), and patients were asked if this was ‘much lower,’ ‘somewhat 

lower,’ ‘about right,’ ‘somewhat higher,’ or ‘much higher’ than what 

a surgeon should earn. On average, patients thought that surgeons 

should receive $18,501 for THA and $16,822 for TKA. Patients 

estimated actual Medicare reimbursement to be $11,151 for THA 

and $8,902 for TKA. Seventy percent of patients stated that Medicare 

reimbursement was ‘much lower’ than what it should be, and only 

1% felt that it was higher than it should be. Patients perceived the 

value of THA and TKA to be nearly an order of magnitude greater 

than current Medicare reimbursement. Many patients commented 

that given this discrepancy, surgeons may drop Medicare, which may 

decrease access to quality hip and knee replacements. 




pApeR No. 715 

A Comprehensive Program can Reduce Hospital 

Readmission Rates after Total Joint Arthroplasty 

Charles J Jordan, MD, Tenafly, NJ 

Ryan F Michels, New York, NY 

James D Slover, MD, New York, NY 

Joseph A Bosco, III MD, New York, NY 

Hospital readmission within 30 days of discharge is an important 

quality indicator of healthcare delivery. However, few studies have 

examined the impact of a comprehensive program designed to 

reduce readmission rates. The purpose of this study is to examine 

the effect of a comprehensive program designed to reduce 30-day 

hospital readmission rates after total joint replacement in a large, 

academic medical center. In 2007, we initiated a comprehensive 

program designed to reduce the rate of readmissions of patients who 

have undergone total hip and total knee arthroplasty. This program 

consisted of four main components: 1) Institution of infrastructure 

to enable outpatient workup of venous thromboembolism (VTE); 

2) System-wide efforts to decrease surgical site infection (SSI) rate; 

3) Early follow up with primary care physicians after discharge; 4) 

Education efforts to increase physician awareness of the financial 

and quality-related ramifications of readmissions following hip and 

knee replacement. We then analyzed our rates of readmission for 

any reason for patients with total knee and total hip replacements 

within 30 days of surgery. These rates were calculated for two 

years before our initiative was instituted (2005-2006), and for the 

three years since the program was initiated (2007-2009). We then 

compared these rates to determine if our initiative was successful 

in reducing readmission rates. Standard statistical analysis was 

performed comparing our readmission rates before and after the 

start of our initiative. Readmission rates for the two years preceding 

our intervention (2005 and 2006) were 3.70 and 3.29 for total hip 

replacement (THR) and total knee replacement (TKR) per 100 cases 

respectively. In the three years following our intervention these rates 

fell to 1.78 and 1.98 for THR and TKR per 100 cases respectively. This 

represents a 47.2% reduction of readmission for THR and 39.8% 

for TKR in our study. Both these results were statistically significant 

(p

abstracted from the medical records of 1,802 Medicare beneficiaries 

who underwent THA from 2002-2007 in the Medicare Patient 

Safety Monitoring System. To adjust for patient characteristics and 

comorbidities, the hierarchical generalized linear modeling approach 

was used to assess the odds of a change in the rates of LOS and 

readmission during the study period. The overall rate of readmission 

in the 30 days after discharge was 123/1,802 (6.8%). The 10 most 

common reasons for readmission were: congestive heart failure 

(21%), chronic ischemic heart disease (16%), cardiac dysrhythmias 

(11%), osteoarthrosis (10%), pneumonia (9%), general symptoms 

(8%), disorders of fluid, electrolyte and acid-base balance (7%), 

chronic bronchitis (7%), diabetes mellitus (6%) and disorders of 

the urethra and urinary tract (5%). There was no difference in the 

rate of readmission from 2002-2004 (7.1%) to 2005-2007 (6.3%) 

(OR 0.90, 95% CI 0.63-1.30, p=0.58). The overall mean LOS was 

4.2 ± 2.2 days. There was a significant reduction in LOS from 2002- 

2004 (4.4 ± 2.5 days) to 2005-2007 (3.8 ± 1.7 days) (OR 1.28, 

95%CI 1.25-1.31, p

posteR No. p002 

Efficacy of Mechanical Prophylaxis Against Venous 

ThromboEmbolism (VTE) in Major Joints Arthroplasty 

Mohammed Atef Diab, MD, Dorchester, United Kingdom 

Peter Ward, MD, Dorchester, United Kingdom 

Kerry Lim, MBBCh 

Ian W Barlow, FRCS, Dorchester, United Kingdom 

Orthopaedic surgeons are increasingly challenged to find 

a prophylaxis regimen that protects patients from venous 

thromboembolism (VTE) with minimizing adverse outcome such 

as bleeding. The constituents of an optimal regimen that prevents 

thromboembolic complications after total hip and knee replacement 

remain controversial. Today with better pain management, rapid 

mobilization of patients postoperatively and shorter hospital stays, 

some authors questioned whether routine chemoprophylaxis is 

necessary, especially because of the potential for complications such 

as bleeding, prolonged wound drainage and hematomas. The purpose 

of the present study was to evaluate the efficacy of the mechanical 

prophylaxis alone against symptomatic VTE following total hip 

and knee arthroplasty. This is a retrospective study which involved 

1,100 total joint arthroplasty in 970 patients who had undergone 

primary and revision total hip and knee arthroplasty between 2004- 

2009 in the same institution. All patients, except those who were 

already receiving warfarin for cardiovascular problems but including 

those who had a known history of the so-called classic risk factors 

for VTE, were considered for entry into the study. All radiology 

requests for each patient checked through PACS (patient’s archived 

computerized system). Investigation included venogram, duplex 

scan, CT pulmonary angiogram (CTPA) only if within three months 

of the joint replacement. All patients are treated intraoperatively 

and postoperatively with knee level elastic compression stockings, 

foot and calf intermittent pneumatic compression sleeves. Regional 

anesthesia was used in most patients and all patients were mobilized 

from bed within 24 hours after surgery. There were 531 primary total 

hip replacement (THR), 37 revision THR, 470 primary total knee 

replacement (TKR) and 23 revision TKR. Routine screening for VTE 

was not used in this study; only symptomatic VTE was investigated. 

The mean age of the patients was 69 years. We investigated 109 

symptomatic patients out of 1,100 joints arthroplasty using duplex 

scan in 50, venogram in 28 and CTPA in 31 patients. We only reported 

and treated above knee symptomatic DVT and pulmonary embolism 

(PE), below knee DVT were not treated or included in this study. 

Eight patients (0.76%) developed symptomatic above knee DVT and 

10 patients (0.9%) developed symptomatic PE. One patient had fatal 

PE (0.09%). Wound hematoma developed in four patients (0.4%). 

Only one patient required surgical drainage; the other three treated 

conservatively. The present study showed the efficacy of mechanical 

prophylaxis against symptomatic VTE. Our results of 0.7% 

symptomatic DVT and 0.9% symptomatic PE compares favorably 

with results of many studies using pharmacological prophylaxis 

like warfarin and low molecular weight heparin. Although some 

patients developed wound hematomas, the 0.4% figure is much less 

compared with figures (2.5%-5.8% in some studies) recorded with 

pharmacological prophylaxis. No patients developed other bleeding 

complications. This result should be viewed with the knowledge that 

our study included patients with the so-called classic high risk factors 

for the development of VTE. The lower prevalence of symptomatic 

VTE complications in our study suggests that mechanical prophylaxis 

alone may be sufficient even in high risk groups with the advantage 

of much less bleeding complications. 

478 


uZoledronic Acid (ZOL) Infusion Reduces Femoral 

Bone Loss Following Total Hip Arthroplasty (THA) 

David Forrest Scott, MD, Spokane, WA 

Jennifer Woltz, Seattle, WA 

Christine Loiseau, BS, Spokane, WA 

Significant proximal femoral remodeling occurs after total hip 

arthroplasty (THA), with regions of bone loss and hypertrophy. 

Fifty-one patients (mean age, 61.2 yrs; range, 33-84 yrs) participated 

in a prospective, blinded, randomized, placebo-controlled study. 

Zoledronic acid (ZOL) 5 mg intravenous infusion (n=27) or saline 

placebo (n=24) was administered at two weeks and one year after 

primary cementless THA. Dual energy X-ray absorptiometry (DXA) 

scans of the seven femoral region Gruen zones were performed 

preoperatively and three to seven days, six weeks, six months, and 

one and two years postoperatively. Two-year data were available for 

a subset of pts (ZOL, n=18; placebo, n=16). A single type of implant/ 

articulation was used for all cases. Harris hip scores were recorded 

to assess post-arthroplasty pain and functionality. There were no 

statistical differences in age, gender or body mass index between 

groups. Bone mineral density (BMD) in Gruen zone 1 decreased 

2.8% at two years in the placebo group, but increased 16.8% in 

the ZOL group (P

and 202 (range 23-563) days, respectively. Some 6.4% of initially 

culture-negative patients became MSSA-positive after an average 

of 253 (range 16-573) days. Two patients (0.37%) became newly 

MRSA-positive. Staphylococcus aureus decolonization with intranasal 

mupirocin and topical chlorhexidine was effective but not 

persistent in a significant proportion of patients. A small number of 

previously-uncolonized patients became colonized. Staphylococcus 

aureus screening and decolonization protocols must be repeated 

prior to any re-admission, regardless of prior colonization status. 


Hip Arthroplasty after Intramedullary Hip Screw 

Fixation 

Stephen J Incavo, MD, Houston, TX 

Jesse Exaltacion, MD, Cebu, Cebu, Philippines 

Philip C Noble, PhD, Houston, TX 

Vasilios Mathews, MD, Houston, TX 

Brian S Parsley, MD, Houston, TX 

We are unaware of any series of hip arthroplasty after intramedullary 

fixation of intertrochanteric hip fractures. We retrospectively 

reviewed our experience with these cases. There were four males 

and 12 females with an average age of 74 years (range: 53-87 years). 

The indications for hip arthroplasty were nonunion with failed 

fixation in 10, avascular necrosis in four and progression of hip 

arthritis in two. Of note, nine of 16 patients ultimately developed 

a nonunion of the greater trochanter after hip arthroplasty. The 

greater trochanter was considered a separate fracture fragment in 

only five of 16 cases. In these five cases, no trochanteric grip plates 

were used for postop fixation (three bolts, two heavy sutures) and 

none united. Postoperative trochanteric fracture occurred in four 

cases. A trochanteric slide osteotomy was performed in four cases 

stabilized by cerclage wires or trochanteric grip plates and all of 

these cases progressed to trochanteric union. After intramedullary 

nail treatment, the greater trochanter is at risk for fracture due to the 

lateral entry site of the lag screw or to bone loss of the medial greater 

trochanter from the large proximal diameter of the nail. Careful 

handling of the trochanter and the use of trochanteric grip plate with 

or without trochanteric slide osteotomy is recommended. 


Femoral Neck Fractures Following Hip Resurfacing 

Arthroplasty 

Gulraj Matharu, BSc, Birmingham, United Kingdom 

Mr Matthew Revell, Birmingham, United Kingdom 

Paul Pynsent, PhD 

Femoral neck fractures are one of the main causes of failure 

following hip resurfacing arthroplasty with a prevalence of 1-3% 

quoted in the literature. The aim of this study was to determine the 

prevalence of femoral neck fractures and time to fracture in patients 

undergoing hip resurfacing arthroplasty at a tertiary referral center, 

and to assess the complication rate following revision arthroplasty. 

All patients undergoing hip resurfacing arthroplasty at our center 

who subsequently underwent revision arthroplasty for a femoral 

neck fracture were identified from our database. Case notes were 

analyzed and demographic data, details of primary and revision 

arthroplasty and any complications following revision arthroplasty 

were extracted. Between October 1997 and December 2009, 3,435 

hip resurfacing arthroplasty procedures were performed. Femoral 

neck fractures occurred in 30 patients giving a prevalence of 0.87%. 

Mean age was 63.0 years, and 50% (n=15) were female. Median time 

to fracture was 64 days (range three days to 11.2 years). All fractures 

were treated by single stage revision. Postoperative complications 

479 

were classified as local (superficial wound infection; n=1, 3.3%), 

mechanical (aseptic loosening; n=3, 10%) and systemic (pulmonary 

embolism; n=1, 3.3%). Two patients underwent further surgery for 

aseptic loosening; one had revision of the acetabular component 

and one had revision of the femoral component. Two patients 

died during follow up for reasons unrelated to surgery. The largest 

published single center series of femoral neck fractures following 

hip resurfacing arthroplasty known to the authors are presented. 

The low prevalence of fractures reported in our series highlights the 

good results that can be achieved by experienced surgeons routinely 

performing resurfacing procedures. However, complication rates 

following revision arthroplasty are not negligible and surgeons 

should guide patients with this in mind. 


Morselized Autografting for Acetabular Roof Defects in 

THA for DDH with HA-Coated Cementless Cup 

Tamon Kabata, MD, Kanazawa, Ishikawa, Japan 

Takuya Nakamura, MD, Toyama, Japan 

Toru Maeda, MD, Kanazawa, Japan 

Kazunori Tanaka, MD 

Hironori Yoshida, MD 

Yoshitomo Kajino, MD, Kanazawa, Ishikawa, Japan 

Kyo-Ichi Ogawa, MD 

Shintaro Iwai, MD 

Hiroyuki Tsuchiya, MD, Kanazawa, Japan 

Reconstruction of superolateral acetabular roof defects is a critical 

problem in primary total hip arthroplasty (THA) for developmental 

dysplasia of the hip (DDH). Morselized autografting is an easy 

procedure that also facilitates remodeling. However, its risk of 

mechanical failure, long-term clinical results and graft incorporation 

to the implants are not known. The purpose of this study was to 

assess the outcome of primary THA with a hydroxyapatite (HA)coated 

cementless cup and morselized autograft to augment 

acetabular roof defects in patients with DDH. A total of 173 hips in 

155 DDH patients with moderate to severe acetabular roof defects 

reconstructed by morselized autograft with HA-coated cups were 

included in this study. Magnitude of the defects was evaluated by 

socket center-edge angle (Sugano, 1995): 31 hips were between -10 

and 0 degrees, 49 hips were between 1 and 10 degrees, and 93 hips 

were between 11 and 20 degrees. Mean follow-up duration was 49 

months. All cups were stable and obtained bone ingrown fixation 

to the host bone even though socket center-edge angle was around 

0 degrees. Reorientation of the bone trabeculae in the graft was 

observed within 12 months in all hips. Radiolucent lines at the graftcup 

interval were seen only in nine hips. Cup surfaces appeared to 

be osteointegrated to the graft in most cases. HA-coated cups with 

morselized autografting showed excellent stability and sufficient 

bone stock recovery. Remodeling of the graft was speedy, and bone 

ongrowth fixation appeared to be obtained at the graft-cup interval. 





Porous Tantalum Components in the revision of Failed 

Acetabular Cups -5 YEAR FU 

Ana Isabel Perez Torres, MD, Gijon, Spain 

Mariano Fernandez-Fairen, MD, Barcelona, Spain 

Antonio Murcia-Mazon, MD, Gijon, Spain 

Professor Antonio Murcia Asensio, Pruvia-Llanera, Spain 

Antonio Merono, MD, Gijon, Spain 

Agustin Blanco Pozo, MD, Burgos, Spain 

Jorge Ballester, Barcelona, Spain 

The primary purpose of this study was to analyze the minimum 

five-year clinical and radiographic results obtained in a consecutive 

series of 263 cases of failed acetabular components in total hip 

arthroplasties revised by means of the trabecular metal (TM) 

acetabular system. The secondary purpose was to consider these 

results in relation to the acetabular bone deficiency present at the 

time of revision. Between July 2000 and December 2002, 263 

consecutive patients across five centers underwent to a revision 

surgery of a failed acetabular component in which TM acetabular 

components were used. Study involved 150 women and 113 men 

with a mean of 69.5 years. Clinical evaluations were performed using 

the Harris hip score (HHS), the WOMAC and UCLA activity scale. 

Implant and screw position, polyethylene wear, radiolucent lines, 

gaps, and osteolysis were assessed. Preoperatively, acetabular bone 

deficiency was categorized using the classification of Paprosky et al. 

Statistical analysis was performed using nonparametric correlations. 

The overall mean follow up was 73.6 months and no patient was lost 

to follow up The overall mean follow up was 73.6 months and no 

patient was lost to follow up. The preoperative HHS rating improved 

from 43.6 ± 11.4, to 82.1 ± 10.7. WOMAC score from 42.9 ± 15.4 

to 80 ± 19 at one-year follow up and 78.0 ± 15.8 at the last review. 

The median UCLA score was 3 pre-revision, rising to 6 at the last 

evaluation. There was no evidence of new osteolysis foci. None of 

the patients was re-revised for loosening. There were eight cases of 

hip dislocation (3%). The cumulative prosthesis survival was 99.2% 

at five years. No correlation found between the degrees of acetabular 

bony defect and the magnitude of clinical results. In addition, the 

use of component augments allowed us to minimize the volume of 

morsellized allograft used for defect repair. Continued follow up of 

this cohort will be essential to determine the long-term performance 

of tantalum in revised acetabular components with tougher definition 

criteria of migration and loosening. In conclusion, the analysis of 

this consecutive series of acetabular revisions with the TM acetabular 

component demonstrates promising midterm results similar to 

those reported by other authors. We report reproducible results 

in obtaining a stable and durable acetabular revision composite 

without deterioration through minimum of five years. 


Does a Longer Wait for Surgery Affect Patient 

Satisfaction After Total Hip Arthroplasty? 

Todd Blumberg, BS, Houston, TX 

Adam Brekke, Houston, TX 

Uche Osadebe, San Antonio, TX 

Gregory William Stocks, MD, Houston, TX 

Kenneth B Mathis, MD, Houston, TX 

Ryan Nunley, MD, Saint Louis, MO 


Satisfaction after total hip arthroplasty (THA) is thought to be 

dependent on several factors, including pre-op diagnosis, ethnicity, 

body mass index (BMI), education-level, age and expectations. 

480 

One factor that has not been explored is whether the duration of 

hip symptoms prior to joint replacement affects satisfaction with 

the outcome of the procedure. A total of 143 primary, unilateral 

THA patients (51% male, average age: 63 years) were enrolled in 

this study with Institutional Review Board approval. At a minimum 

follow up of one year (avg: 2.1 yrs), each patient completed a selfadministered 

“hip function questionnaire” consisting of 124 items 

regarding demographics, satisfaction, expectations, symptoms 

and functional abilities. To assess the effect of delaying operative 

treatment, patients were divided into three groups according to the 

period from the onset of symptoms until THA: (i) 2 yrs). Patient satisfaction did not vary with gender, age, 

BMI, diagnosis or ethnicity but was dependent on the length of time 

between onset of hip problems and the joint replacement operation. 

At approximately two years post-op, 17% of the early surgery group 

was dissatisfied with their outcome vs. 8% of the 1-2yr group (p=.01) 

and 8% of the >2yr group (p

width and head/neck ratio, a smaller spherical bearing surface and 

reduced neck offset from the medullary canal. Therefore, surgical 

treatment limited to localized re-contouring of the head/neck 

profile may fail to address significant components of the underlying 

abnormality. 


Optimal Orientation of Hip Resurfacing Components 

Minimizes Impingement During Functional Activities 

Matthew T Thompson, Houston, TX 

Steven Schroder, MD, Long Beach, CA 

Molly M Usrey, Houston, TX 


The risk of edge-loading after hip resurfacing is a function of the 

positioning of the prosthetic components and the kinematic demands 

of each patient. This study was performed to determine whether the 

range of motion (ROM) of the resurfaced hip can be optimized by 

coupling the anteversion of the acetabular cup with the anteversion 

of the proximal femur. Ten patient-specific 3D computer models of 

the normal hip were generated from CT scans. Femoral anteversion 

and other morphologic parameters were measured for each patient. 

CAD models of a standard resurfacing system (3 mm cup) were 

virtually implanted in 45 degrees of abduction, and 20 degrees of 

anteversion. Hip ROM was measured through virtual simulations of 

six functional activities known to induce impingement. The virtual 

maneuvers were repeated with each acetabular component realigned 

in 10 and 0 degrees of anteversion. Comparisons were made 

between total cup+femoral anteversion and minimum acceptable 

values of hip motion in performing each functional maneuver. The 

average femoral anteversion was 11.4°±7.1° (range: 1.0° to 19.3°). 

Combined cup and femoral anteversion correlated directly with 

flexion (r2=0.50, p

signal changes with histopathology from retrieved tissue. Seventeen 

patients undergoing revision THA obtained preoperative MRIs. 

Tissue was obtained from specific anatomic sites correlating with 

MRI. Histopathology and MRI images were reviewed blinded, by 

an experienced pathologist and radiologist, respectively. Patients 

were divided into three groups. Group I: control tissue from patients 

undergoing exchange to constrained liner within 12 months of index 

arthroplasty. Group II: osteolysis tissue from patients undergoing 

revision THA. Group III: tissue from patients with symptomatic 

metal on metal articulations. Histopathology was graded using the 

modified Mirra classification. Distinct MRI signal patterns were 

observed for each group. Group I exhibited low signal intensity 

without discernible debris. Histopathology was in 100% concordance 

with absence of particulate debris. Group II exhibited two patterns, 

one of a non-homogenous intermediate signal which was interpreted 

as involving polymeric debris (polymethylmethacrylate (PMMA) 

and polyethylene) with a concordance of 57%. All tissue samples 

contained polyethylene debris, however 43% also contained 

metal. The second pattern observed was mixed low/intermediate 

signal interpreted as involving both metallic and polymeric debris. 

Concordance was 86%. Again all samples contained polyethylene, 

but 14% did not contain metal. Group III had a distinct signal 

pattern described as homogenous high signal interspersed with 

fine intermediate signal. The histopathology revealed lymphocytic 

infiltrate without microscopic metal debris with 100% concordance. 

MRI was able to distinguish between tissue containing particulate 

debris and normal periprosthetic tissue without debris. 


Infected THA: Do We Need Two-Stage Revision in All 

Cases? 

Horim Choi, MD, Boston, MA 

Hany Bedair, MD, Newton, MA 

Young-Min Kwon, MD, PhD, Boston, MA 

Sandra Bliss Nelson, MD 

Andrew A Freiberg, MD, Boston, MA 


This study compares the clinical outcome between patients 

receiving the second stage re-implantation of a planned two-stage 

revision arthroplasty and those in whom articulating spacer was 

retained as a long-term treatment for infected total hip arthroplasty 

(THA). Forty-three infected THAs were treated with implantation 

with an articulating spacer consisting of a cemented cup and 

cemented femoral stem. Twenty-one hips underwent a second stage 

reimplantation (re-implantation group) and 22 hips did not have 

a second surgery and retained the spacer (spacer group) as a final 

treatment. The mean follow up for the re-implantation and spacer 

groups was 65 months (range, 20-109) and 56 months (range, 14- 

108), respectively. In the re-implantation group, there were two 

subsequent revisions (two/21): one for septic failure of spacer and 

another for aseptic loosening of a re-implanted cementless stem. In 

the spacer group, there were three revisions (three/22) of the spacer: 

two hips had a recurrent infection at 27 and 36 months, and the 

third hip showed symptomatic loosening of the spacer stem at 74 

months follow up. At the latest follow up, average Harris hip score 

was 69, 78 points and the UCLA activity score was 3.9, 4.2 points 

for the re-implantation and spacer group, respectively. There was 

one patient on antibiotic suppression in the re-implantation group, 

and four in the spacer group. The results of this study suggest that 

long-term retention of temporary spacer for infected THA may lead 

to a successful treatment outcome comparable to that of two-stage 

revision arthroplasty. 

482 


Preoperative Templating and Intraoperative 

Radiograph Comparison for Primary Total Hip 

Arthroplasty 

Harpal Singh Khanuja, MD, Cockeysville, MD 

Robin Nestor Goytia, MD, Bellaire, TX 

Maria S Goddard, MD, Winston Salem, NC 

Tarun Bhargava, MD, Wichita, KS 

Lynne C Jones, PhD, Baltimore, MD 

During total hip arthroplasty, intraoperative anatomic landmarks 

are compared with preoperative radiograph templating to ensure 

appropriate restoration of the hip center of rotation, offset and 

leg length. Postoperative radiographs are used to assess the final 

reconstruction. The authors report whether an intraoperative hip 

radiograph aids in assessment of the reconstruction. Seventy-five 

total hip arthroplasties performed between November 2006 and 

January 2008, utilizing intraoperative radiographs, were evaluated 

prospectively. Cases that used intraoperative fluoroscopy were 

excluded. Preoperatively, films were templated using acetate templates. 

The intraoperative film was taken with the acetabular component and 

femoral trial in place and compared to the templated radiograph. All 

aspects of the restoration were assessed including acetabular version, 

leg length and component size. Subsequent changes were recorded 

in the operative report. At three-month follow up, restoration was 

re-assessed with a low anterior-posterior pelvis radiograph. In 50 

cases (66.67%), unanticipated adjustments were made after review 

of the intraoperative radiograph. In 12 cases (16%), no changes were 

made; in the remaining cases, an anticipated change was made after 

radiographic confirmation. In 44 cases (57%) femoral component 

size or position was changed primarily for leg length and in 28 

cases (37%) adjustments were made to the acetabular component 

position. At final follow up, average postoperative acetabular version 

and inclination were 13.46 ± 6.10º and 40.74 ± 5.55º, respectively. 

Mean postoperative leg length discrepancy was 1.95 ± 4.90 mm. 

Intraoperative radiographs provide a valuable tool for evaluating 

proper component position, size, and leg length. In over 60% of 

cases, unanticipated changes were made based on this intraoperative 

radiograph. 


High Incidences of Bony Abnormality in Impingement 

Patient With or Without Acetabular Labral Tear 

Yong-chan Ha, Prof, Seoul, Republic of Korea 

Jae-heon Jeong, MD, Seoul, Republic of Korea 

Young-Kyun Lee, MD, Seongnam-Si, Republic of Korea 

Hyung-min Ji, MD, Seongnam, Republic of Korea 

Kyung-Hoi Koo, MD 

Ki-Choul Kim, MD, Pohang City, Gyeongsangnamdo, Republic of 

Korea 

Bun-Jung Kang, MD, Pohang, Gyeongsangnamdo, Republic of 

Korea 

Tae-young Kim, Prof, Anyang, Republic of Korea 

Mechanical symptoms in the hip joint are well known to be 

related to labral tears and anterior acetabular chondral defects. It 

is also well recognized that acetabular labral tears rarely occur in 

the absence of an osseous abnormality. However, no study has yet 

evaluated the prevalences of osseous abnormalities in patients with 

mechanical symptoms. The purpose of this case-control study was to 

determine prevalences of structural bony abnormalities predisposing 

femoroacetabular impingement by comparing patients with and 




without mechanical symptoms. We performed this comparative 

study on 151 patients (151 hips; mean patient age 44.8 years; 

range 16-73 years) with mechanical symptoms, who underwent 

multi-detector computed tomography (MDCT) arthrography (the 

symptomatic group), and 151 age, gender, site (left or right) and 

time (at diagnosis) matched control patients who were performed 

MDCT due to urete stone (the asymptomatic group). Acetabular 

evaluations, which included cranial and central anteversion 

measurements and anterior and lateral center edge angles, were 

performed in a standardized manner. Femoral parameters evaluated 

included alpha angle and neck shaft angles. In addition, we evaluated 

the incidences and characteristics of structural bone abnormalities 

in labral tear group with mechanical symptoms. One hundred and 

twenty one hips (80.1%) among the 151 symptomatic hips and 

82 hips (54.3%) among the 151 asymptomatic hips had at least 

one structural bony abnormality predisposing femoroacetabular 

impingement (p

Patients who lived alone were more likely to experience severe pain 

(52% vs. 43% THA, 45% vs. 36% TKA, p45) compared with 63 nonobese 

patients (BMI 45 (24%), than for patients with BMI


Wear and Surface Damage of Retrieved Ceramic-on- 

Ceramic Acetabular Liners 

Jonathan H Lee, MD, New York, NY 

Dan Chen, MS, New York, NY 

Timothy M Wright, PhD, New York, NY 


Geoffrey H Westrich, MD, New York, NY 

Ceramic-on-ceramic bearings are associated with negligible wear; 

however, concerns exist regarding metal transfer, fracture and 

squeaking. We classified amount and type of damage of retrieved 

ceramic-on-ceramic liners. Nine surgeons revised 15 aluminaon-alumina 

total hip arthroplasties (THA). Liners were evaluated 

for damage and graded: Grade 1 (no markings), Grade 2 (some 

metal transfer present, light markings or 1”’); Grade 

4 (metal transfer 3 lines >1’”); Grade 5 

(metal transfer >20% of surface area). Femoral head damage was 

graded and compared to its paired acetabular liner. Clinical records 

were analyzed to correlate liner damage to body mass index (BMI), 

duration of implantation, position, femoral head wear, neck taper, 

gender and failure mode. Mean patient age was 56.5 years, mean 

implant duration 38.7 months, mean BMI 27.6, average abduction 

angle 49.4°, mean femoral head wear grade 3.4 and mean acetabular 

liner wear grade 2.4. Failure modes were liner breakage, infection, 

loss of fixation, squeaking, instability and fracture. Wear grade of 

the femoral head was the only characteristic significantly correlated 

with wear grade of the acetabular shell (R-squared=0.4, F=0.02). 

Acetabular wear was seen exclusively along the equator in 73% of 

the liners with the remainder exhibiting equatorial as well as polar 

wear. Femoral head wear was predominantly located from the 

equator to the superior pole. Retrieved ceramic liners were analyzed 

and corelations were assessed between clinical and acetabular wear 

grade. Significant correlation was observed between ceramic head 

and liner damage. 

posteR No. p025 AlteRNAte pApeR 

Improved Statistical Analysis of Radiographic Wear 

Data from Total Hip Replacements 

Bryan T Jarrett, Boston, MA 

David P Nicholls, PhD 

David Zurakowski PhD, Boston, MA 

John M Martell, MD, Chicago, IL 

Charles R Bragdon, PhD, Boston, MA 


No consensus exists on how to correctly analyze longitudinal 

wear data from clinical radiographs. A group of 224 patients who 

received total hip replacements (THRs) using 26-40 mm head sizes 

with minimum seven years follow up were identified (with 69 

conventional and 155 cross-linked polyethylene liners). Postoperative 

radiographs were analyzed using Martell Hip Analysis Suite resulting 

in head penetration values. Based on this data, we compared results 

of a previously used model (simple linear regression) to a mixed 

model regression approach using STATA and SPSS packages. Due to 

the longitudinal data, inconsistent and varying lengths of follow up, 

unequal number of radiographs per patient and variable wear across 

time and individuals, a mixed model analysis was chosen with fixed 

effects (factors affecting wear) and random slope and intercept terms 

(accounting for variation across time and individuals). Both models 

showed a significant difference in wear rate between conventional 

and cross-linked polyethylene (linear regression model: 128.5 µm/ 

485 

year conventional and 7.8 µm/year cross-linked; mixed model: 120.7 

µm/year conventional and 10.0 µm/year cross-linked, p

distance ambulated, assistive device used and time to discharge. 

Duration of surgery was 72.7 ±17.4 minutes in the THA group and 

109.9 ± 20.0 minutes in the SRA group (p

and required staged revision and two hematomas that resolved in 

the DJD group. There were five patients who required post-operative 

transfusions in the ORIF group and none in the DJD group. There 

were five dislocations in the ORIF group (two required revision to a 

constrained liner) and no dislocations in the OA group. Harris hip 

scores at pre-op, six months post-op and latest follow up were (44.8 

ORIF vs. 56.8 DJD; p

were discharged by POD#2. Long-term outcomes data demonstrate 

similar clinical results between ASI-THA and standard THA when 

comparing UCLA activity scores, SF-36 data, visual analogue pain 

scale and HHS. Complication rates were similar in both groups. In 

this study, minimally invasive ASI-THA demonstrates similar longterm 

outcomes, complications and revision rates when compared to 

standard THA, while significantly shortening the hospital stay. 


Diabetes Mellitus, Hemoglobin A1c and the incidence 

of Total Joint Arthroplasty Infection 

Richard Iorio, MD, Burlington, MA 

Andrew J Marcantonio, DO, Wellesley, MA 

Lawrence Specht, MD, Burlington, MA 

Kelly M Williams, PA-C, Burlington, MA 

John F Tilzey, MD, Burlington, MA 

William L Healy, MD, Burlington, MA 

Elevated hemoglobin A1c levels are a marker for blood glucose 

control in diabetes mellitus (DM). Patients with DM have a higher 

incidence of infection after total joint arthroplasty (TJA) than patients 

without DM. The purpose of this study was to identify if patients 

with elevated HbA1c levels have a higher incidence of infection after 

TJA than patients with well controlled HbA1c levels. From 12/1/04 

to 12/21/09, 3,468 patients underwent 4,241 primary or revision 

total hip arthroplasty (THA) or total knee arthroplasty (TKA) at one 

institution and were followed prospectively with a TJA data base. 

Review of data base records, morbidity and mortality reports and 

charts were conducted to identify patients with diabetes mellitus 

and/or infection after TJA. HbA1c levels prior to TJA operation were 

examined to evaluate if there was a correlation between control of 

HbA1C and infection after TJA. There were 49 total infections (29 

deep, 20 superficial) after TJA: 13 (3.71%) in patients with DM 

(n=350) and 36 (0.93%) in patients without DM (n=3891) (p


The Value Of Three-Dimensional Computerised 

Planning Of THA 

Elhadi Sariali, MD, Paris, France 

Yves Catonne, MD, Paris, France 

Raphael Mauprivez, MD 

A high precision of three-dimensional (3D) computerized planning 

of total hip arthroplasty (THA) was recently reported. However, 

there is no comparative study analysing the value of 3D planning 

comparatively to the planning made on X-rays using 2D templates. 

A prospective comparative randomized study was carried out 

from 2008 to 2009, and included two groups of 32 patients who 

underwent THA for primary osteoarthritis. One surgeon performed 

all the procedures using a direct anterior approach. In one group, 

the planning was made on calibrated X-Rays using 2D templates. 

In the other group, a 3D planning was performed based on CT-scan 

using the Hip-Plan software. Post operatively, the final hip anatomy 

was analyzed on X-Rays for the 2D group and on CT-scan for the 

3D group. In the 3D group, the duration of the surgical procedure 

was 18% shorter and the bleeding was 34% lower. The prediction 

rate of the stem and the cup sizes were respectively of 100% and 

97% in the 3D group. In the 2D group, these rates were 43%. When 

combining both components, the prediction rate was 97% in the 3D 

group and 16% in the 2D group. The center of rotation, the femoral 

offset and the length were restored with a twice higher precision in 

the 3D group. This higher precision was probably due to the accurate 

analysis of the hip anatomy; the problems that may be encountered 

were detected before surgery. Clinical benefits for the patients were 

also proved. This technique is now our gold standard procedure. 


Computer-Assisted Femoral Offset Correction In Cam- 

Type Impingement A Feasibility Study 

Timo M Ecker, MD, Berne, Switzerland 

Marc Puls, PhD 


Johannes Dominik Bastian, MD, Bern, Switzerland 

Marius Keel, MD, Berne, Switzerland 



Arthroscopic treatment of cam-type femoroacetabular impingement 

is an emerging trend. Outcome may be compromised by inadequate 

resection of lesions due to limited overview of the surgical site. 

Navigation of a surgical reaming device might improve accuracy of 

the procedure. Three-dimensional models of 18 identical sawbone 

femora with a distinct cam impingement and five cadaver hips were 

created. For the sawbones, three preoperative plans were constructed 

with a novel computerized planning tool. Two orthopaedic surgeons 

each performed three osteochondroplasties per plan using a 

navigated burr. For each cadaver hip, a single plan and procedure 

was performed. In all cases, the reaming process was tracked and 

visualized by the navigation application in real time. Postoperatively, 

3D models of the treated specimens were created. The differences in 

three-dimensional alpha angles and offset ratio between the planned 

and treated models were measured, as well as the surface distances. 

Accuracy and inter- and intraobserver correlation was assessed. 

Alpha angle and offset ratio could be accurately transferred from 

plan to realtime, as shown by an evenly distributed Bland-Altman 

plot. Inter- and intraobserver statistics showed excellent correlation. 

Alpha angle accuracy was similar among obervers (p = 0.486) and 

the different treatment plans (p = 0.194). Both observers reached 

489 

the planned offset ratios with similar accuracy (p = 0.2). Planning 

and conduction of navigated offset correction using a surgical 

reaming device is feasible and accurate. Transfer and integration 

into arthroscopic procedures might improve results and safety of 

surgery. 


Prevalence of HCV Infection in the Veteran Total Joint 

Arthroplasty Population 

Nicholas John Giori, MD, Palo Alto, CA 

Briana Calore, MD, Cooperstown, NY 

Hepatitis C (HCV) infection can damage a surgeon’s health and career. 

Many orthopedic residents train at Veterans’ Affairs (VA) hospitals. 

We sought to determine the prevalence of hepatitis C in veteran total 

joint arthroplasty (TJA) patients and the risks of contracting HCV 

for surgeons performing TJA on veterans. The surgeon’s risk per case 

of contracting HCV = (HCV prevalence in the patient population) * 

(intraoperative sharps injury rate/case) * (HCV transmission rate/ 

exposure). TJA patients were tested preoperatively for hepatitis C 

(antibody and HCV RNA) over 22 consecutive months from 2007 

to 2009, and estimated other rates from the literature. A total of 381 

of 408 (93.4%) primary TJA patients were tested. Some 8.4% were 

HCV antibody positive. Another 4.5% were viremic during surgery. 

Various studies support a sharps injury rate of 2.3%. Estimated 

HCV transmission from antibody positive patients is 1.8%, while 

transmission from viremic patients ranges from 9.9% to 19.8% 

depending on viral load. Given the viral loads in our viremic 

patients, the mean risk of disease transmission from our viremic 

patients was 14.2%. HCV antibody prevalence in VA TJA patients is 

nearly five times the general population. Nearly one in 20 veterans 

undergoing TJA are viremic and infectious with HCV. Using accepted 

rates of sharps injuries and disease transmission, the estimated rate 

of HCV transmission per surgeon-year ranges from 0.007 to 0.029. A 

career VA surgeon doing 200 cases/year for 30 years has a cumulative 

risk of 21%-88% of contracting HCV. Medications currently in FDA 

trials may present an option to treat viremic patients preoperatively 

to mitigate these risks. 


Preoperative Alcohol Misuse is Associated with 

Surgical Complications following TJA 

Nicholas John Giori, MD, Palo Alto, CA 

Alex HS Harris, PhD, MS 

The risks of preoperative alcohol misuse in total joint arthroplasty 

(TJA) patients are unknown, yet alcohol misuse is common and 

is associated with increased complication risk following other 

procedures. We asked whether TJA patients with alcohol misuse, as 

measured by a preoperative standardized alcohol screening score, 

were at increased risk of postoperative complications. The AUDIT-C 

is an alcohol misuse screen given annually to Veterans’ Affairs (VA) 

patients, yielding a 0-12 score with higher scores signifying greater 

and more frequent alcohol consumption. In a sample of 185 male 

VA TJA patients from one institution who had AUDIT-C scores 

recorded in the 12 months preceding surgery and who reported at 

least some alcohol use, we estimated the association between preoperative 

AUDIT-C scores and number of surgical complications in 

age and comorbidity adjusted negative binomial regression analyses. 

Of the 185 TJA patients reporting at least some drinking in the past 

year (mean age 63), 17% had AUDIT-C scores suggestive of alcohol 

misuse. AUDIT-C scores were significantly related to number of 

complications in negative binomial regression analysis (exp(beta) 

= 1.29, p = 0.035), signifying a 29% increase in the expected mean 




number of complications with every additional AUDIT-C point. 

Complications following TJA are exponentially related to alcohol 

misuse, as measured by AUDIT-C. The AUDIT-C has three simple 

questions that can be incorporated into a preoperative evaluation and 

can alert the treatment team to patients with increased postoperative 

risk. Preoperative alcohol misuse screening, and preoperative 

interventions for heavy drinkers, may be indicated for TJA patients. 


Outcome of Metal on Metal articulation in primary 

Conventional THA: Analysis of 17,775 procedures 




Australia 




Despite the increasing use of metal on metal (MoM) articulations in 

conventional total hip arthroplasty (THA), there is little data on the 

outcome of this approach. This study compares the risk of revision 

of over 17,000 MoM to almost 90,000 metal on polyethylene (MoP) 

procedures undertaken on patients with a diagnosis of osteoarthritis 

(OA). The data was obtained from a comprehensive national 

database that prospectively recorded these procedures over a 10-year 

period. Analyses examining the impact of age, gender, femoral head 

size and prosthesis as well as determining the reasons for revision 

were undertaken. The principle outcome measure was time to first 

revision using Kaplan-Meier estimates of survivorship. MoM has a 

significantly greater risk of revision compared to MoP. This is true 

in all age groups including younger patients. This increased rate of 

revision is due to greater rates of loosening and metal sensitivity. 

At five years metal sensitivity accounts for at least four revisions in 

every 1,000 procedures. The risk of revision in MoM is increased in 

females. Increasing head size increases the risk of revision with MoM 

which is always greater than MoP of equivalent head size with the 

exception of >28 mm where there was no difference. The outcome 

of different MoM prostheses varied but the least revised prostheses 

were MoP and most individual MoM prostheses had a much higher 

rate of revision. The use of MoM increases the risk of revision in 

conventional THR. This data suggests there is no benefit to use MoM 

in conventional THR particularly if head sizes >28 mm are used. 


Total Hip Arthroplasty Following Acetabular Fractures 

Ahmed Mohammed Abdel-aal, MD, Assiut, Egypt 

Yaser Emam Khalifa, Assiut, Egypt 

Hatem MA Bakr, MD, Assiut, Egypt 

Fractures of the acetabulum are complicated by post-traumatic 

arthritis in a considerable percentage of patients. Arthritis seems 

inevitable even in well reduced and fixed fractures, following highimpact 

injury and joint damage. Hip arthroplasty requires attention 

to restoration of the normal acetabular position and managing 

bone defects. The indications for total hip arthroplasty (THA) 

after acetabular fracture as well as short-term postoperative results 

are presented in this study. Forty-two THA were performed after 

acetabular fractures during a period of seven years. The average age 

of patients was 53 years (range 28 - 72 years). There were 31 males 

and 11 females. The average time from the fracture to the index 

operation was 14 months (range 3-52 months). Open reduction/ 

internal fixation (ORIF) had been performed in 17 patients and 

the remaining patients were treated conservatively. Non cemented 

490 

multiple-holed cups were used in 34 hips and reconstruction with 

bone graft, mesh and cemented cups were used in eight hips. The 

average postoperative follow up was 3.8 years. The Harris hip score 

increased from an average of 43 points preoperative to an average of 

89 points at the time of the last follow up. Complications included 

ectopic ossification (14%), cup migration (7%) and infection 

(2%). The five-year survival rate with revision as the end point 

was 97%. THA after acetabular fractures is a successful operation. 

Complications are higher than after THA for primary osteoarthritis, 

particularly cup migration and ectopic ossification. 


Performance of the ASR in Resurfacing and 

Conventional Primary THA: Analysis of 5563 

Procedures 







The ASR prosthesis is a metal on metal (MoM) articulation that has 

been extensively used worldwide for conventional and resurfacing 

total hip arthroplasty (THA). It was released with little clinical data 

supporting its use. This study reports the outcome of over 5,500 

procedures using the prosthesis in both primary conventional and 

resurfacing THA. Analysis of 1,167 ASR resurfacing and 4,406 ASR 

conventional large femoral head THA reported to a large national 

database over a six-year period. The outcomes were compared to 

all other resurfacing and conventional hip procedures. Analysis was 

performed on demographics, primary diagnosis, reason for revision 

and types of revision. The principle outcome measure was the 

time to first revision using age and gender adjusted Kaplan-Meier 

estimates of survivorship. Resurfacing ASR prosthesis had over twice 

the risk of revision compared to all other resurfacing prostheses 

(HR=2.32 (1.84-2.92) p


Acetabular Alignment and Primary Arc of Motion in 

THA for 28mm, 32mm, 36mm and 40mm Femoral 

Heads 

Yona Kosashvili, MD, Rishon Le Zion, Israel 

Dan Omoto, MD, Mississauga, ON Canada 

David Backstein, MD, Toronto, ON Canada 

Dror Lakstein, MD, Givataim, Israel 

Oleg Safir, MD, Toronto, ON Canada 

Yaron Bar Ziv, MD, Rishon Lezion, Israel 


Impingement is a main cause for dislocation in total hip arthroplasty 

(THA). This study examined the influence of acetabular cup 

alignment on the primary arc of motion (PAOM) for minus (-3.5), 

skirtless (+3.5) and skirted (+10.5) neck lengths with 28 mm, 32 

mm, 36 mm and 40 mm femoral heads. The resulting PAOM was 

evaluated in respect to the recommended post THA range of motion 

required for activities of daily living. THA was performed in a pelvic 

saw bone model. The acetabulum was positioned in 30°/45°/60° 

abduction and 0°/15°/30° anteversion, respectively. The PAOM was 

determined using a digital inclinometer for each of the acetabular 

positions and 12 femoral heads mentioned above. The PAOM 

examination included flexion, extension, internal rotation (IR), 

external rotation (ER), abduction, adduction and IR at 90° of flexion. 

The best PAOM was found in 45° abduction and 15°-30° anteversion 

as well as 60° abduction and 0° anteversion. Combinations of 

excessive abduction and anteversion as well as horizontalization and 

retroversion resulted in the worst PAOM. Skirtless heads significantly 

outperformed skirted (p=0.016) and minus (p=0.05) heads. Only 

40 mm heads significantly outperformed the 28 mm and 32 mm 

(p=0.001, p=0.005, respectively). Cup alignment is optimal in 45° 

of abduction and 15°-30° of anteversion, since PAOM is largest in 

this alignment without the potential downside of edge loading and 

excessive polyethylene wear. Within the previously defined safe zone 

for cup alignment of abduction >45° and anteversion >15° as well 

as abduction

greater trochanter. After implantation of the prosthetic components, 

the anterior part of the gluteus medius muscle was reattached with 

absorbable thread using five or six double stitches at its origin. 

Four radiopaque metal markers were attached to each side of the 

suture. The distance between the two markers was measured on 

postoperative radiographs, and failure rate of the procedure was 

evaluated. Abductor muscle strength was investigated before and 

after THA. In three of the 20 hips (15%), the attachment of the 

repaired gluteus medius muscle failed postoperatively. Independent 

of gluteus medius muscle attachment, the abductor muscle strength 

recovered postoperatively. The failure rate of repaired gluteus medius 

muscle in this study was lower than that in previous reports, and 

abductor muscle strength recovered more than 80% of the normal 

contralateral side postoperatively in one year. 


uTen Years Follow-Up Of 100 Ceramic On Ceramic 

Total Hip Arthroplasty 

Christophe J Chevillotte, MD, Lyon, France 

Vincent Pibarot, MD, Lyon Cedex 03, France 

Jean-Paul Carret, MD, Lyon, France 

Jacques Bejui-Hugues, MD, LATINA, LAZIO Italy 

Olivier Guyen, MD, Lyon, France 

Alumina ceramic on ceramic (COC) is nowadays a common 

arthroplasty bearing material because of its efficacy in terms of 

wear and osteolysis. However, limited data are available concerning 

long-term follow up. The aim of this study was to evaluate the 

first 100 cementless COC total hip arthroplasty (THA) performed 

at our institution with more than 10 years of follow up. Clinical 

evaluation was performed using Harris hip score. Radiological 

evaluation was performed by two surgeons, looking for osteolysis, 

implant loosening and heterotopic bone. Four patients were lost to 

follow up. Harris Hip score significantly improved at latest follow 

up. Radiological analysis showed calcar resorption for 75 patients 

and one cup loosening. One patient sustained a revision five years 

postoperatively for cup loosening. Seven dislocations (six early, one 

late) and two subluxations have been reported. High dislocation rate 

can be explained by variable experience of the surgeons involved in 

an accademic center. Moreover, a 28 mm head diameter was used 

as no greater diameter was available at the time of the study. Since 

the study period, we introduced in our practice the routine use of a 

navigation system to optimize positioning of the implants, and the 

use of larger head diameters (32 mm and 36 mm) with significantly 

improved results on stability. Based on these results, we advocate the 

use of uncemented hydroxyapatite coated ceramic on ceramic THA 

in young and active patients in our current practice. 


Subject-specific Finite Element Analysis on Stress 

Distribution after Periacetabular Osteotomy 

Yutaka Inaba, MD, Yokohama, Japan 

Naomi Kobayashi, MD, Yokohama, Japan 

Hiroyuki Ike, MD, Yokohama Kanagawa, Japan 

Hyonmin Choe, MD 

Takashi Ishida, MD 

Naoyuki Iwamoto, MD, Yokohama, Japan 

Youhei Yukizawa, MD 

Hiroshi Fujimaki, MD, Yokohama, Japan 

Tomoyuki Saito, MD, Yokohama, Japan 

Clinical results of rotational acetabular osteotomy (RAO) for 

dysplastic hip have been reported; however, there are few studies 

492 

which evaluated change of stress distribution in the hip joint after 

RAO. Purposes of this study were 1) to evaluate stress distribution 

in the acetabulum and femoral head before and after RAO, and 2) 

to examine radiologic parameters which correlate to improvement 

of stress maldistribution after RAO. This study series included 17 

dysplastic hips of 13 patients who underwent RAO. Finite element 

(FE) models of the pelvis and femur were obtained from pre- and 

postoperative CT data using Mechanical Finder (Research Center of 

Computational Mechanics Inc., Tokyo, Japan), software that creates 

FE models showing individual bone shape and density distribution. 

The mechanical properties of the bone were determined from CT 

density values, using equations proposed by Keyak et al. Lateral 

center-edge (CE) angle, acetabular roof angle (ARA), Sharp angle 

and acetabular head index (AHI) were measured on pre- and 

postoperative X-rays as radiologic parameters. Correlations between 

stress and these radiologic parameters were analyzed. Preoperative 

stresses in the acetabulum and femoral head were distributed 

unequally, and stress distribution was equalized and the peak 

stress decreased after RAO. Among radiologic parameters, CE angle 

and ARA correlated significantly with reduction of stress in the 

acetabulum (p


Peripheral Blood Stem Cell Transplantation Results in 

the Treatment for Osteonecrosis 

Young Wook Lim, MD, Seoul, Republic of Korea 

Yong Sik Kim, MD, Seoul, Republic of Korea 

Soon Yong Kwon, MD, Seoul, Republic of Korea 

Doo Hoon Sun, MD 

Yoon Jong Jang, MD, Seoul, Republic of Korea 

Jae Young Lee, MD 

We tried multiple drilling and stem cell transplantation derived 

from peripheral blood to treat the early stages of osteonecrosis of 

the femoral head and to minimize patient morbidity. We then report 

the clinical and radiological results of peripheral blood stem cell 

transplantation and core decompression. Thirty-eight patients (63 

hips) who had undergone surgery were divided in two groups based 

upon which treatment they had received: (1) multiple drilling and 

stem cell transplantation derived from peripheral blood stem cell 

transplantation, and (2) core decompression, curettage and bone 

graft. The clinical and radiological results of the two groups were 

compared. We defined failure as the need for additional surgery, or a 

Harris hip score of less than 75. After a minimum five-year followup, 

in group 1, 80% (four/five) of patients with Stage IIa disease, 60% 

(six/10) of patients with Stage IIb disease and 46.2% (six/13) of 

patients with Stage III disease had no additional surgery. In group 

2, 66.7% (6/9) of patients with Stage IIa disease, 66.7% (6/9) of 

patients with Stage IIb disease and 60% (three/five) of patients 

with Stage III disease had no additional surgery. Survival rates of 

patients with Ficat Stages I or II lesions were greater than survival 

rates for patients with Stage III lesions. There was no difference of 

survival rate between two groups. We found that there was not a 

significant difference between the two groups. The same results were 

found between peripheral blood stem cell transplantation and the 

conventional method of core decompression. 


Effect of Proximal Stem Surface Roughness on Initial 

Mechanical Stability 

Ichiro Nakahara, Suita, Japan 

Shunichi Bandoh, PhD, Suita, Japan 

Masaki Takao, MD, Suita, Japan 

Takashi Sakai, MD, Suita, Japan 

Takashi Nishii, MD, Osaka, Japan 

Hideki Yoshikawa, MD, Osaka, Japan 

Nobuhiko Sugano, MD, Suita, Japan 

The surface roughness of stems with a surface coating theoretically 

contributes to initial mechanical stability by increasing friction 

against the bone. We evaluated the effect of differences in surface 

roughness due to different surface treatments with the same stem 

design on the initial stability. Proximally titanium plasma-sprayed 

femoral stems (PS stem) and proximally grit-blasted stems (GB 

stem) were compared. The stem design was identical with an 

anatomic short tapered shape for proximal fixation. The optimum 

size of PS stem was implanted in one side of 11 pairs of human 

cadaveric femora and the same size of GB stems was implanted in 

the other side. The specimens were fixed to the jig of a universal 

testing machine and vertical load tests were conducted under 1 mm/ 

minute of displacement-controlled conditions until periprosthetic 

fracture occurred. The same size of PS or GB stem was successfully 

implanted in all 11 pairs without fracture. No significant difference 

was detected in the distances of subsidence until fracture occurred. 

The load applied for 1 mm of stem subsidence and the load at 

493 

fracture in the PS stem were significantly larger than those in the GB 

stem. The plasma-sprayed surface had a less slippery interface than 

the grit-blasted surface. Both femora of a pair fractured at the same 

level of hoop stress, which was induced by the same amount of stem 

subsidence but at significantly different loads. The scratching effect 

against the femoral canal due to the rougher surface of the plasmaspray 

works advantageously for initial mechanical stability. 


In Vivo Wear Comparison of Longevity and Crossfire in 

THA 

Ichiro Nakahara, Suita, Japan 

Nobuo Nakamura, MD, Osaka, Japan 

Hidenobu Miki, MD, Osaka, Japan 

Masaki Takao, MD, Suita, Japan 

Takashi Sakai, MD, Suita, Japan 

Takashi Nishii, MD, Osaka, Japan 

Hideki Yoshikawa, MD, Osaka, Japan 

Nobuhiko Sugano, MD, Suita, Japan 

Wear resistance of highly cross-linked polyethylene (HXLPE) has been 

demonstrated. However, the influence of different manufacturing 

process of removing free radicals on the clinical head penetration 

rate has not been well reported. This study compared in vivo head 

penetration between the annealed HXLPE and remelted HXLPE five 

years after total hip arthroplasty (THA). The annealed HXLPE was 

crossfire treated with 7.5 Mrad gamma irradiation with a subsequent 

annealing below the melting temperature and sterilized by 2.5 

Mrad gamma irradiation in nitrogen. The other remelted HXLPE 

was longevity treated with 10 Mrad electron-beam irradiation with 

a subsequent remelting and sterilized by gas plasma. Forty-seven 

primary cementless THAs using each of HXLPE and a 32 mm cobaltchromium 

head were retrospectively reviewed in postoperative 

five years. Two-dimensional head penetration was measured using 

the Hip Analysis Suite on annual x-rays. There were no significant 

differences between the groups in the first year head penetration 

(crossfire; 0.33±0.14 mm, longevity; 0.35±0.11 mm) and in the 

steady-state wear rate (crossfire; 0.002 mm/y, longevity; -0.003 

mm/y). The first year head penetration, which was mainly attributed 

by creep, was not different between the groups despite of a concern 

with the reduced mechanical strength of remelting. Although the 

process of annealing and the gamma irradiated sterilization also had 

a concern with oxidative degradation of polyethylene by residual free 

radicals, no difference in the steady-state wear rate was seen between 

the groups. At the mid-term follow-up, no in vivo differences in head 

penetration were detected between the annealed HXLPE sockets and 

remelted HXLPE sockets. 


Satisfactory Levels of Sporting Activities after 

Periacetabular Osteotomy 

Nobuhiro Kashima, MD, Fukuoka, Japan 





Kouichi Kinoshita, MD, Fukuoka, Japan 

Yoshitsugu Tanaka, MD 


Daisuke Kuroda, MD, Fukuoka City, Japan 

The expected level and participation in sporting activities after 

periacetabular osteotomy (PAO) have not been well researched. The 




time of life from the teens to the late thirties tends to be a period 

of high activity in daily life. Therefore, we investigated the sporting 

activities after PAO in patients aged under 40 years. Among patients 

under 40 years who underwent PAO for osteoarthritis secondary to 

dysplasia from 1995 to 2006, we evaluated 47 hips in 43 patients 

who were followed up for more than two years. Questionnaires 

were used to determine the types of sports and competitive levels 

that the patients were capable of participating in. Clinical outcomes 

were evaluated by the Harris hip score. The mean Harris hip score 

improved from 80 points preoperatively to 95 points postoperatively. 

Before surgery (BS), 35 of the 43 patients (81%) participated in sports 

such as table tennis (17%), athletic sports (14%), volleyball (11%), 

tennis (11%) and basketball (9%). After surgery (AS), 25 of the 43 

patients (58%) reported that they were able to participate in sports 

such as walking (60%) and golf (8%) (BS=81%, AS=58%, p=0.06). 

Seven patients were able to return to participating in their primary 

sports, including high-impact sports such as baseball and volleyball, 

following PAO. After PAO, most patients were able to participate in 

recreational sports such as walking and swimming. Patients with 

high levels of athletic activity preoperatively can expect to return to 

their primary sports postoperatively and maintain satisfactory levels 

of sporting activity. 


Straight Tapered Stems with Grit-Blasted Diaphyseal 

Surface in Cementless Total Hip Arthroplasty 

Woo Suk Lee, MD, Seoul, Republic of Korea 

Bo-Hyun Hwang, MD 

Ju Hyung Yoo, MD, Seoul, Republic of Korea 

Kwan Kyu Park, MD, Seoulgi-Do, Republic of Korea 

Ick-Hwan Yang, MD, Pittsburgh, PA 

Chang-Dong Han, MD, Seoul, Republic of Korea 

Tapered femoral stem permits the loading of proximal femur 

and reduces proximal stress shielding in cementless total hip 

arthroplasty (THA). Diaphyseal biologic fixation may induce better 

osteointegration and eliminate thigh pain. The objective of our 

study was to evaluate the five-year outcomes of straight cementless 

femoral stems having the combination of tapered geometry with 

a distal grit-blasted surface. Ninety-four cementless primary THAs 

were performed using a straight tapered stem with proximal porouscoating 

and distal grit-blasted surface. All patients were younger than 

65 years of age at the time of the surgery and were treated with third 

generation ceramic-on-ceramic articulation. After a minimum of five 

years of followvup (range, five to seven years), 78 arthroplasties in 

72 patients could be reviewed retrospectively. The mean Harris hip 

score was 93.5 points at the final follow up. The mean UCLA activitylevel 

score was 6.3 points. Two hips (2.6%) had thigh pain that was 

unrelated to other problems. All femoral stems were fixed by bone 

ingrown radiographically. There were no significant periprosthetic 

osteolysis and stem subsidence. Ten hips (12.8%) demonstrated 

femoral cortical hypertrophy. Cancellous condensation above the 

distal polished tip occurred in 45 (57.7%). Femoral cortical thinness 

due to stress shielding was moderate in eight (10.3%) and severe in 

five (6.4%). The results of straight tapered stems with grit-blasted 

diaphyseal surface were encouraging at intermediate follow up. 

Further long-term studies are necessary to detect a clinical problem 

with regard to stress shielding. 

494 


RCT Comparison of Oxinium & CoCr Heads Against 

XLPE and Conventional Polyethylene in THR using RSA 

Richard W McCalden, MD 

Doug Naudie, MD, London, ON Canada 


Steven J MacDonald, MD, London, ON Canada 

David W Holdsworth, London, ON Canada 

Xunhua Yuan, PHD, London, ON Canada 

This study reports on the early clinical performance and wear 

(measured with radiostereometric analysis (RSA)) of a randomized 

controlled trial (RCT) comparing Oxinium (Ox) and CoCr heads 

on highly cross-linked polyethylene (XLPE) and conventional 

polyethylene (CPE). Forty patients were randomized to receive either 

an Ox or CoCr head against either XLPE or CPE (i.e., 10 patients in 

each group). All patients had identical total hip replacements (THR) 

where tantalum beads were inserted for wear analysis. RSA wear 

analysis was performed immediately post-op, at six weeks, three and 

six months and then yearly. Patients were followed prospectively 

using validated clinical outcome scores (WOMAC, SF-12, Harris Hip 

scores) and radiographs. , Total 3D femoral head penetration at two 

years for each group was: CoCrXLPE (0.068±0.029 mm); OxXLPE 

(0.115±0.038 mm); CoCrCPE (0.187±0.079 mm); and OxCPE 

(0.242±0.088 mm). Thus, OxCPE was significantly higher than 

OxXLPE and CoCrXLPE but not CoCrCPE (p=0.001, p>0.0001 and 

p=0.094, respectively). In other words, head penetration was higher 

with CPE compared to XLPE but there was no significant difference 

between Ox and CoCr heads. Similarly, regardless of head type (i.e., 

combining poly types), there was a significant difference in 3D head 

penetration at two years between CPE and XLPE ( CPE 0.213±0.086; 

XLPE 0.093±0.041, p>0.0001). The early results of this RCT, using 

RSA as the wear analysis tool, indicate a significant improvement 

in wear with XLPE compared to CPE with no clear advantage to 

Oxinium over CoCr. Longer follow up is required to determine 

steady-state wear rates (after bedding-in) and allow comparison 

between bearing groups. 


Metal-on-Metal Revisions: A Review of Causes, 

Outcomes and a High Incidence of Early Failure 

David W Fabi, MD, San Diego, CA 

Brett Russell Levine, MD, Chicago, IL 




Mark A Hartzband, MD, Franklin Lakes, NJ 

Gregg R Klein, MD, Paramus, NJ 

Harlan B Levine, MD, Tenafly, NJ 

Metal-on-metal (MOM) total hip arthroplasty (THA) has become 

an increasingly popular option for contemporary alternative bearing 

surfaces. However, early failures due to aseptic loosening, metal 

hypersensitivity reactions, pseudotumor formation and component 

seizing are being realized. The purpose of this study is to investigate 

the timing, common modes of failure and incidence of MOM 

THA revisions. A retrospective review of 77 consecutive patients 

who underwent revision of a failed MOM THA for any reason was 

performed. The average age of the patients was 57.61 ± 10.8 years 

(range 31-84 years), with 40 being male and 37 being female. Clinical 

and radiographic data points were gathered to include: causes of 

failure, patient factors, time to revision and original implants used. 

The most common reason for metal-on-metal failure was acetabular 




loosening with a rate of 57.1% (44/77 patients). Other reasons in 

descending order were infection (13.0%), metal hypersensitivity 

(6.5%), failed resurfacing (6.5%), fracture (5.2%), loose stem 

(3.9%), dislodged liner (3.9%), seizing (1.3%), cup malposition 

(1.3%) and femoral stem fracture (1.3%). Early failure of MOM 

THAs was noted, with 62.9% of these revisions being performed 

within two years of the index operation and 81.5% within three years. 

Further, 90.9% (70/77) of these revisions had been performed over 

the short timespan of two years. Two pseudotumors were observed 

among these patients with additional 25% of patients experiencing 

significant soft tissue metallosis. Our study demonstrates a relatively 

high incidence of MOM THA revisions at early follow up. Component 

loosening is a common mode of failure. Phenomena relatively 

unique to MOM bearing such as pseudotumor, metal sensitivity and 

metallosis are being observed in a significant percentage of MOM 

failures. It is imperative for the surgeon to be cognizant of the fact 

that the proposed advantages of MOM THA are not without their 

potential detrimental sequelae. 


Surgical Treatment of Femoroacetabular Impingement 

in Patients 35 years and Older 

John C Clohisy, MD, Saint Louis, MO 

Lauren St John, Saint Louis, MO 

Geneva Baca, Saint Louis, MO 

Joint preservation surgical techniques have been popularized for the 

treatment of femoroacetabular impingement (FAI), and encouraging 

clinical results have been reported for most patients. Nevertheless, 

patients older than 35 years with FAI present a treatment-decision 

challenge and there is limited published information regarding the 

clinical results of surgery. The purpose of this study was to determine 

the clinical outcomes of joint preservation surgery for symptomatic 

FAI in patients 35 years and older. We performed a retrospective 

review of 96 hips in 88 patients who underwent surgical treatment 

for symptomatic FAI by one surgeon. Surgical approach varied 

according to patient and deformity characteristics, and included open 

dislocation (11%), all arthroscopic (13%) and arthroscopic with 

limited open (76%). Hip function was evaluated with the modified 

Harris Hip score. There were 42 females and 46 males. The mean age 

was 44 years, body mass index 25.8 kg/m2, and the average follow 

up was 23 months (range, 8-68). At the last follow up, the mean 

modified HHS for the entire group improved from 60.6 to 76.9 

points (p80, 14% 

between 70 and 79 and 39%

(p>0.05) regarding overall postoperative arthroplasty infections. 

Superficial soft tissue infection developed in nine/616 patients, 

zero/278 in group A vs. nine/338 in group B (2.99%) (p

were found for intraobserver reliability (0.99 vs. 0.89 and 0.92). 

Classification of pelvic tilt using the sacrococcygeal and coccyx had 

moderate levels of interobserver agreement (kappa 0.40-0.61), and 

misclassified 18.6-28.6% of radiographs. The SI based measurements 

misclassified 2.6-8.6% and had excellent reliability (K 0.83-0.94). 

For radiographs classified as having poor visualization, the reliability 

of measurements based on the sacrococygeal and coccyx decreased 

(fair-substantial), while SI measures were not affected (excellent). 

All three parameters had excellent agreement for pelvic rotation. The 

reliability of the inferior SI joint midpoint is superior to that of the 

sacrococcygeal and coccyx as a marker of pelvic tilt. 


Randomised Controlled Trial Comparing Cemented 

Stem Behaviour Following Large MOM and MOP THA 

Ajay Malviya, MD, Newcastle Upon Tyne, United Kingdom 

Jayasree Ramaskandhan, MSc 

Russell Bowman, MSc 

Elizabeth Anne Lingard, MD, Newcastle Upon Tyne, 



There is a concern that larger size head may put additional torque on 

the stem and lead to increased stress on the cement-implant interface. 

This study aims to compare the proven elements of conventional 

hip replacement (cemented stem fixation) in combination with 

large metal on metal (MOM) versus conventional metal on poly 

(MOP) bearing surface. One hundred patients were randomized to 

receive either a MOP bearing (28 mm head) or MOM bearing (large 

head) with a cemented femoral stem. All patients were assessed 

pre-operatively and at three months, one year and two years post 

operatively. There were 50 patients in each arm of the study with 

both groups similar in terms of age, gender, diagnosis, body mass 

index and preoperative scores. Using EBRA software femoral stem 

subsidence at two years was 1.27 mm for MOM group as compared 

to 1.4 mm for MOP group (p=0.73). At two years, significant 

(p0.05) was observed between the 

two groups in terms of all the scores. MOM group scored significantly 

higher in overall patient satisfaction (p=0.01) at two years. There was 

no detectable difference between the stem behavior using the large 

MOM bearing compared to the standard 28 mm MOP bearing as 

identified by EBRA up to two years, despite differences in sliding 

distances and torques between these bearings. 


Does Charnley Category Influence Modern Hip Specific 

Outcome Measures? 

Peter David Henry Wall, MBChB, MRCS, West Midlands, 


Munier Hossain, FRCS, MSc, Manchester, United Kingdom 

J Glynne Andrew, MD, Bangor, Gwynedd, United Kingdom 

It was recognized over 30 years ago that the functional outcome of 

total hip arthroplasty (THA) was worse for patients with additional 

disease affecting walking ability. The Charnley Category (CC) was 

developed to separate patients on this basis. Joint specific measures 

are designed to be minimally influenced by co-mobidity. We aimed 

to establish whether the CC has a measurable effect on modern joint 

specific outcome measures such as the Oxford Hip Score (OHS). We 

497 

reviewed the database of a prospective multi-center study carried 

out between January 1999 and January 2002 to investigate the 

relationship between CC and OHS both preoperatively and after 

THA. We recorded the OHS preoperatively and at five years after 

surgery. A total of 1,113/1,589 were followed up at five years. Preoperative 

OHS was significantly worse in CC-B (mean 45.75, 95% CI 

44.78- 46.71) and CC-C groups (mean 46.32, 95% CI 45.42-47.21) 

compared to the CC-A group (mean 42.9, 95% CI 42.39-43.41). All 

groups demonstrated significant improvement in OHS following 

surgery (p


Assessing Acetabular Component Anteversion: A 

Comparison of Three Methods 

John Vincent Tiberi, MD, Torrance, CA 

Nicholas Pulos, BA, Philadelphia, PA 

Michael Kertzner, Calabasas, CA 

Lauren Wisk, Los Angeles, CA 

Mylene A Dela Rosa, Los Angeles, CA 


Anteversion has been linked to range of motion and stability, 

wear, squeaking of ceramics and ion levels with metal-metal. Cup 

position has historically been assessed on a true lateral radiograph 

using the film edge as a reference. Edge detection software, EBRA, 

provides a valid method of assessment on digital films but is not 

available to all practitioners. We hypothesize that the assessment 

of component position on true lateral radiographs would be more 

consistent by using an anatomical measurement reference. We 

analyzed 52 hips in 51 patients implanted with the same prostheses 

with at least three post-operative radiographs taken at different 

times. On a true lateral radiograph, cup position was assessed by 

the method of Woo and Morrey (a surrogate for anteversion) and a 

new method using the ischial tuberosity as an anatomical reference: 

the ischiolateral method. Both methods utilize a line parallel to the 

face of the acetabular component. Woo and Morrey describe the 

angle this line makes with the horizontal plane of the radiograph 

(external reference) and the ischolateral method describes the angle 

made with a perpendicular to the long axis of the ischium (internal 

reference). Anteversion was also measured with the EBRA software. 

Fifty randomly selected radiographs were re-evaluated by the original 

observer at a separate setting and assessed by a second observer. 

Inter- and intra-observer reliability for each method were evaluated 

by the intra-class correlation coefficient. The ischio-lateral (2.15°) 

and EBRA (2.06°) methods had lower mean standard deviations 

than the Woo and Morrey method (3.65°, p

developed at our institution specifically aimed at evaluating patterns 

and amounts of osteolysis. Twenty patients were identified as having 

loose cups preoperatively by CT. Intraoperative findings confirmed 

this in 18 cases. Twenty-four patients were identified as having fixed 

cups preoperatively by CT. Intraoperative findings confirmed this in 

23 cases. Sensitivity, specificity, positive predictive value and negative 

predictive value of CT scan in detecting loose acetabular components 

were 94.7%, 92.0%, 90.0% and 95.8% respectively. CT scans can be 

of great value in assessing osteolysis after hip arthroplasty. We have 

found that careful review of CT scans can result in high sensitivity 

and specificity when diagnosing loose acetabular components when 

radiographs cannot confirm this. 


Hyponatremia Following Hip and Knee Replacement 

Surgery- Incidence and Associated Risk Factors 

Alexander P Sah, MD, Fremont, CA 

Postoperative hyponatremia is a relatively frequent, but commonly 

overlooked, perioperative disorder. Symptoms can include nausea, 

lethargy, confusion and weakness which can easily be attributed 

to perioperative medications or anesthesia effects. However, 

hyponatremia can also lead to encephalopathy, cerebral edema and 

demyelination with too rapid correction. The purpose of this study is 

to determine the frequency and associated risk factors of developing 

hyponatremia after joint replacement. A total of 280 consecutive 

patients undergoing total hip and knee replacement were followed 

perioperatively with daily basic metabolic panels. Lactated ringers 

solution was given intraoperatively and followed by normal and 

half-normal saline maintenance intravenous fluids. Hyponatremia 

was corrected with medical management including fluid restriction, 

temporary cessation of hydrochlorothiazide if taken, and normal 

saline infusion. Hyponatremia occurred in 81/280 (29%) of 

patients. Hyponatremia was mild (130-134) in 70.3%, moderate 

(125-129) 22.2%, and severe (less than 125) 7.3%. Nearly all 

patients with preoperative hyponatremia, 14/15 (93.3%) developed 

postoperative hyponatremia. Patients had higher risk of developing 

hyponatremia if taking HCTZ or ACE-inhibitors perioperatively 

(p

MC3T3-E1 cells attached and proliferated well on these surfaces. 

The extracellular matrix was synthesized and mineralized on all 

surfaces. Although the number of cells attached on the NaTi surface 

was less than that of the other surfaces initially, they produced better 

intercellular connections, extracellular matrix and mineralization. 

Cells on the surfaces of all implants expressed (++) and u staining 

for osteocalcin, osteopontin and bone sialoprotein. Expression 

increased with BMP 2 and BMP 7 stimulation. In conclusion, a new 

method of NaTi coating was customized. MC3T3-E1 cells initially 

proliferated slowly on this surface but the number of cells caught 

up with the other surfaces on day 14. Intercellular connections, 

extracellular matrix production and mineralization however were 

excellent on NaTi surfaces. Osteocalcin, osteopontin and bone 

sialoprotein expressed equally well on all surfaces. Both BMP 2 and 

BMP 7 stimulated cells and their protein synthesis. In conclusion, 

a new method of NaTi coating was customized. MC3T3-E1 cells 

initially proliferated slowly on this surface but the number of 

cells caught up with the other surfaces on day 14. Intercellular 

connections, extracellular matrix production and mineralization, 

however, were excellent on NaTi surfaces. Osteocalcin, osteopontin 

and bone sialoprotein expressed equally well on all surfaces. Both 

BMP 2 and BMP 7 stimulated cells and their protein synthesis. 


Revision Hip Arthroplasty for Instability: Constraint 

May Not be The Answer 

Aaron Carter, Washington, DC 


Mr Eoin C Sheehan, Tullamore, Ireland 



Peter F Sharkey, MD, Media, PA 


Constrained liners that were used as treatment for instability 

following total hip arthroplasty (THA) were reviewed. The hypothesis 

of this study was that constrained liners are likely to fail if correctable 

causes for instability are not addressed. Results found that failure 

rate of constrained components are unexpectedly high. Increased 

rate of dislocation is associated with younger and healthier patients 

or patients with previous history of revision. Using our prospective 

institutional revision database, all hips that had undergone revision 

THA for instability and received constrained liners between 2000 and 

2007 were identified. Detailed retrospective review of the database 

and medical records were obtained to extract relevant information. 

Fifty-seven hips in 56 patients received constrained liners. Average 

follow up was 5.04 years (range 24-119 months). Failure rate of 

constrained liners was 29.8% (12 dislocations, five acetabular 

loosening). A total of 25% of liners that also had cup revision failed 

compared to 36% that only had a liner exchange (p=0.4). In the liner 

exchange group, there was no difference in failure rate for cemented 

compared to uncemented liners (p=0.8). Younger age (p=.04), lower 

Charlson index (p=.01) and history of previous revision surgeries 

(p=.05) were associated with higher dislocation rate. Constrained 

liners could be effective in the treatment of instability following 

THA, however failure rates are higher than previously expected. 

When considering constrained liners the surgeon must consider the 

limitations of these components especially in a more active patient 

population. These components are more likely to fail in younger 

patients with few comorbidities or patients with previous revision 

surgery. 

500 


uRim Loaded MoM Hip Prostheses: Volumetric Wear is 

Increased by Increasing Bearing Diameter 


Thomas Joyce, PhD 

James Lord, MSc, Newcastle Upon Tyne, United Kingdom 

Harry Grigg, BSc, Newcastle Upon Tyne, Tyne and Wear, 


Dominic Meek, MD FRCS 


Antoni Nargol, FRCS, Yarm, United Kingdom 

Metal on metal (MoM) joints are manufactured to encourage fluid 

film lubrication. In theory, larger diameter bearings facilitate fluid 

film generation. However we have frequently observed the highest 

blood ion levels in patients with larger diameter prostheses. We 

analyzed our series of explanted paired MoM hip arthroplasty 

components using a coordinate measuring machine. From this data, 

total volumetric wear was calculated using a validated program. 

A complete data set for each retrieved hip was available including 

femoral size, UCLA activity score and age. Spearman rank correlation 

was used to identify significant relationships between volumetric 

wear and the variables listed above. Significant variables were 

forwarded for multiple regression analysis (MRA). A non contacting 

profilometer was used to obtain surface roughness measurements 

and lambda ratios were calculated using these values. There were 43 

paired components in total (39 revised for adverse reaction to metal 

debris, two infections, two avascular necrosis. Annual wear rates 

ranged from 1.15 to 95.5 mm3. Femoral diameter correlated with 

wear (r = 0.579 p

(14%) than in hips that received liner exchange (34%) (p=0.004). 

A total of 32% of hips with history of previous revision dislocated 

compared to 15% of hips that dislocated after primary revision 

(p=.05). Unconstrained 28 mm heads had the highest dislocation 

rate (44%) compared to larger head sizes (11.8%) (p=.0004). 

Multivariate analysis found that the odds of failure increased fourfold 

if an unconstrained 28 mm head was used (p=.02). Revision to 

address instability following THA appears to be effective. However, 

there is a relatively high rate of failure. Liner exchange rather than 

cup revision, history of previous revision and using smaller femoral 

heads are associated with this higher failure rate. Optimization of 

these factors during surgery can help to decrease the risk of failure in 

this complex group of patients. 


Early Failure of DePuy ASR XL Total Hip Arthroplasty 

Garen Steele, MD, Wrightsville Beach, NC 



Matthew C Nadaud, MD, Knoxville, TN 

Large diameter metal on metal articulations in total hip arthroplasty 

offer the theoretical advantage of better stability and increased range 

of motion compared to smaller diameter bearings. The ASR XL total 

hip arthroplasty system by DePuy offers a large diameter metal head 

paired with a metal acetabular cup, which was initially designed for 

hip surface replacements. An alarming number of early failures have 

prompted the need to evaluate clinical and radiographic outcomes 

of patients with the DePuy ASR XL implant system. The purpose 

of this study is to evaluate the clinical and radiographic outcomes 

of patients with the DePuy ASR XL implant system. A prospective 

consecutive series of 131 patients at two different institutions who 

underwent total hip arthroplasty with the DePuy ASR XL system 

was evaluated. All surgeries were performed by fellowship trained 

arthroplasty surgeons. Patients with a minimum two-year follow 

up were included in the study. Failure rates, Harris Hip Scores 

and radiographs were evaluated. Of the 131 patients included in 

this study, 16 failed at an average of only 1.6 yrs (.18-3.4 yrs). Ten 

patients were revised for aseptic loosening, three for metallosis, two 

for infection and one for periprosthetic fracture. The DePuy ASR XL 

with a failure rate of 12.2% is the second recently reported one piece 

metal-on-metal total hip system with a significant failure rate at early 

follow up. This particular class of implants has inherent design flaws 

that lead to early failure. 


T2*-mapping in Patients with Femoroacetabular 

Impingement at 3.0T MRI: A Feasibility Study 

Sebastian Apprich, MD, Bern, Switzerland 

Marcel Dudda, MD 



Tallal C Mamisch, MD, Bern, Switzerland 

To perform an in vivo evaluation comparing articular cartilage in 

patients with symptomatic femoroacetabular impingement (FAI) 

and healthy volunteers using T2*-mapping at 3.0 Tesla over time. 

Twenty-two patients (mean age: 28.1a) with clinical signs of FAI and 

Tönnis-grade d1 on anterior-posterior x-ray view and 35 healthy age 

matched volunteers were examined at a 3T whole body scanner using 

a flexible body coil. Image protocol consisted of sagittal and coronal 

orientated gradient-multi-echo sequence using six echoes (TR 125, 

TE 4.41/8.49/12.57/16.65/20.73/24.81, scan time 4.02 min.) for 

quantification T2*-maps, both measured at beginning and end of 

501 

the scan (time between: 40 min, respectively). Region of interest 

analysis was manually performed at three consecutive slices on the 

sagittal/coronal view on the acetabular cartilage. Mean T2*-values 

were compared using analysis of variance. Whereas quantitative 

mean T2*-values did not reveal significant differences between 

patients and volunteers, neither for sagittal (23.49 ms vs. 23.95 ms; 

p 0.644) or coronal images (19.53 ms vs. 19.54 ms; p 0.987), at 

the first measurement, a highly significant difference (pd0.004) was 

found for both measurements with time after unloading of the joint 

(sag.: 23.09 ms vs. 26.64 ms; cor.: 19.10 ms vs. 22.67 ms). Over time 

we found decreasing mean T2* values (sag -0.41 ms; cor -0.43 ms) 

for patients, in contrast to increasing mean T2*-relaxation times 

(sag 2.68 ms; cor 3.12 ms) in volunteers (p

variation within the asymptomatic population. The purpose of this 

study is to report the range of alpha (±)-angles in the asymptomatic 

population and anticipate the potential ratio-of-prevalence of FAI risk 

within the population. We retrospectively examined 420 randomly 

selected patients (840 hips), who underwent a thin-section pelvic 

computed tomography at our institution for other medical conditions 

from January 2005 to August 2009. The prevalence of possible FAI 

was assessed by measuring ±-angle of each hip on anteroposterior 

(AP) pelvic survey images taken during CT scanning. The CT images 

were then evaluated to confirm the presence of bump on the axial CT 

views. Sixty-seven hips were excluded due to inadequate imagings. 

All hips were classified according to the Copenhagen Osteoarthritis 

Study which was 1) Men: pathological (>83° alpha angle), borderline 

(69° to 82° alpha angle) and normal ( 57° alpha angle), borderline (51° to 

56° alpha angle) and normal (20 Year Comparison of Cemented and Cementless 

Femoral Stems In Primary Total Hip Replacement 


Cecil H Rorabeck, MD, London, ON Canada 

The purpose of this study was to compare the >20 year outcomes 

of cemented versus cementless femoral stems in primary total hip 

replacements (THR). The >20 year survivorships of four commonly 

used cemented femoral stems (Charnley, Exeter, HD-2, Mallory 

Head) were compared to three cementless stems (AML, PCA, 

Mallory Head) to determine which mode of fixation provided the 

best long-term outcomes. At >20 year follow up, cemented femoral 

stem survivorships varied between 81% and 97%. Cemented stems 

fabricated from stainless steel or a cobalt chrome alloy (Charnley 

92 to 95%, Exeter 97%, HD-2 96%) performed better than those 

made from a titanium alloy (Mallory Head 81%). At >20 year follow 

up, cementless stem survivorship varied from 96% to 99%. Fixation 

seemed equally good for extensively porous-coated (AML 98%), 

anatomic (PCA 96%) and tapered (Mallory Head 99%) cementless 

stems. Acetabular issues such as wear, osteolysis and loosening were 

the leading cause of revision for both the cemented and cementless 

THRs studied. This >20 year comparison of several commonly used 

primary THR femoral stems has demonstrated that: 1) Cementless 

femoral stem fixation is equal if not superior to the best cemented 

stem results, 2) Stainless steel and cobalt chrome alloy cemented 

stems perform better than those made from a titanium alloy, 3) Both 

proximally porous-coated (anatomic and tapered) and extensively 

porous-coated cementless stems provide durable fixation, 4) The 

bearing couples, not fixation, have been the Achilles heel of the 

THRs studied. 

502 


Total Joint Replacement in Patients with Rheumatoid 

Arthritis in US from 1992-2005 

Marc Wilson Hungerford, MD, Baltimore, MD 

Amit Jain, BS, Portland, OR 

Benjamin Eric Stein, MD, Baltimore, MD 

Richard L Skolasky, Jr Prof., Baltimore, MD 


Rheumatoid arthritis (RA) often progresses to joint degeneration 

requiring total joint arthroplasty (TJA). Recently, disease modifying 

anti-rheumatic drugs (DMARDs) have been shown to be efficacious in 

the treatment of RA. The aim of this study was to determine whether 

the proportion of RA patients undergoing primary TJA procedures 

of the major joints decreased during the period 1992-2005 in the 

United States. The Nationwide Inpatient Sample (NIS) collects 

data prospectively from a stratified sample of 20% of community 

hospitals in the U.S. Using this database, the total numbers of total 

joint arthroplasties for knee (TKA), hip (THA), shoulder (TSA) and 

elbow (TEA) performed in the U.S. were determined for 1992-2005. 

The numbers of procedures for patients with rheumatoid arthritis 

were also ascertained. Weighted analysis was performed to account 

for the stratified sampling used in the NIS to calculate national 

estimates and to analyze trends over time. From 1992-2005, there 

were 4,164,465 TKA, 2,416,563 THA, 125,810 TSA and 21,816 TEA 

performed in the U.S. For RA patients, there were 153,501 (3.7%) 

TKA, 77,736 (3.2%) THA, 8,725 (6.9%) TSA and 6,097 (27.9%) 

TER. While hospitalizations increased by 92% from 186,813 in 

1992 to 358,261 in 2005, the proportion of total joint replacement 

performed in RA patients decreased: TKA (20.7%; p

of peroxides were lower in the seminal plasma than in the blood 

plasma of these patients. Importantly, the ejaculate volume, the 

sperm density, the total sperm count, the pH and the percentage of 

cells with normal morphology were in the range of the WHO criteria 

for fertile population and also in the range of reference patients in 

the city of measurements. Results were also comparable to what was 

observed in a group of five control men matched for age. Also, there 

were no significant correlations between sperm or blood peroxide 

levels and the sperm parameters as well as between sperm or blood 

ion levels and the sperm parameters. Results of the present study 

strongly suggest that the raise of Co and Cr had no detrimental effect 

on sperm parameters of young patients of child fathering age with 

MoM THA. 


The Effect of Total Hip Arthroplasty (THA) Surgical 

Approach on Gait 

Daniel Varin, B.Sc. 

Mario Lamontagne, Ottawa, ON Canada 

Paul E Beaule, MD, Ottawa, ON Canada 

The anterior approach to the hip is thought to allow better gait 

after total hip arthroplasty since it spares the gluteus medius and 

minimus. It was hypothesized that it would result in closer to normal 

three-dimensional (3D) kinematics and kinetics. Ten months 

after THA, we performed 3D gait analysis on 20 THA patients 

that had an anterior approach (ANT), 20 with a lateral approach 

(LAT) and 20 healthy matched control participants. A nine-camera 

motion analysis system and two force plates were used to obtain 

kinematic (from 45 reflective markers on their body) and kinetic 

data respectively. Peak joint angles, range of motion and moments 

were averaged for three trials per participants, then for each group 

and were compared using multiple analyses of covariance. Both 

THA groups had reduced hip extension (ANT: -12º, p=0.007; LAT: 

-10º, p


Alumina Head/Liner vs. Alumina Head/UHMW 

Polyethylene Liner: 5-Year Results of a Randomized 

Trial 

Andrei Manolescu, MD, Edmonton, AB Canada 

Lauren Beaupre, PhD, Edmonton, AB Canada 

Donald William Cooper Johnston, MD, Edmonton, AB Canada 

Kelvin J Russell, MD 

James F McMillan, MD, Edmonton, AB Canada 

Donald Weber, MD, Edmonton, AB Canada 

Thomas H Greidanus, MD, Edmonton, AB Canada 

Wynne M Rigal, MD, Edmonton, AB Canada 

Primary total hip arthroplasty (THA) has had mixed long-term results 

in younger subjects primarily due to wear of the polyethylene liner 

and loosening of femoral component. The primary study purpose 

was to compare pain, function and stiffness over the first five years 

between subjects younger than 60 years who received either an 

alumina liner/alumina femoral head or an ultra high molecular 

weight (UHMW) polyethylene liner/alumina head at time of 

primary THA. Secondarily, we compared re-operation rates over five 

years between groups. This was a randomized, controlled trial (RCT) 

in which subjects less than 60 years of age, with non-inflammatory 

osteoarthritis (OA) and who were booked for primary THA were 

enrolled and randomized preoperatively and re-evaluated one and 

five years postoperatively. At each assessment, subjects completed 

the WOMAC Osteoarthritis Index (WOMAC); complications and 

re-operations were also recorded. Ninety-two young hip patients 

were enrolled in the study; the median age was 52.4 (SD 6.8) and 

50 (54%) were male. Preoperative WOMAC pain, function and 

stiffness scores were similar between groups (p>0.05). Five-year 

follow-up data was available for 78 (85%) patients. Both groups 

showed substantial improvement in pain, function and stiffness 

within one year that was maintained out to five years; there were 

no statistically significant difference between groups (p>0.05). Four 

subjects required re-operation within five years; no re-operation was 

related to liner type. Our RCT found very good five-year functional 

recovery and pain relief with no differences seen between groups. 

The re-operation rate was low and not related to liner type. Longerterm 

follow up is required to determine if liner type affects longterm 

survival of THA in young patients. 


Dislocation Rates of Total Hip Arthroplasties Inserted 

with Large Femoral Heads 

Michael Aaron Robinson, MD, Fleming Island, FL 

Lindsey Bornstein, New York, NY 

Brandon Mennaer, BS, New York, NY 


Bryan J Nestor, MD, New York, NY 



Improvements in bearing surfaces has allowed us to reduce liner 

wear and use the advantages of increased size of the femoral head 

to reduce the prevalence of dislocation. The objective of this study 

is to further explore the relationship between femoral head size and 

risk of postoperative dislocation. This is a retrospective review of 

all patients who underwent a total hip arthroplasty and received a 

32 or 36 mm femoral head between January 2003 and June 2007 

by four arthroplasty surgeons. All procedures were performed 

through a posterior approach with posterior repair. There was a 

504 

minimum of two years follow up. Data on 589 patients (679 hips) 

were available for analysis. Data on diagnosis, age and gender was 

collected. A questionnaire was given to all patients to keep track of 

instability and dislocations. Radiographic analysis was done with 

post operative x-rays: acetabular vertical height, (medial) acetabular 

offset, femoral offset and abduction angle. Analysis comparing 

clinical and radiographic data was performed between patients with 

and without dislocations. The prevalence of dislocation was 1.3% 

(9/679). Follow up averaged 3.4 years (range 2-6.6). Analysis showed 

that a decrease of the combined postoperative offset (lateral offset 

+ medial offset measurements) was associated with a statistically 

significant increase in the risk for dislocation (p=0.04). There was 

an increased incidence of dislocation in acetabular cups greater then 

58 mm (odds ratio 10.7, p


In vivo Oxidation Of Highly Cross-Linked Polyethylene 

Bearings 

Barbara H Currier, MChE, Hanover, NH 

Ashley J Martin 

Jennifer Caitlin Huot, Hanover, NH 

Douglas Van Citters, PhD, Hanover, NH 

Daniel J Berry, MD, Rochester, MN 

Highly cross-linked (HXL) ultra high molecular weight polyethylene 

(UHMWPE) bearings have carefully prescribed stabilization 

protocols (annealing, remelting or addition of antioxidants) to 

prevent oxidative degradation. Oxidation has been reported in 

both annealed and remelted HXL retrievals. The effectiveness of 

the stabilization methods in preventing in vivo oxidation and the 

ability to forecast future performance of HXL bearings requires 

analysis of all types of HXL retrievals. A total of 120 retrieved HXL 

UHMWPE bearings (annealed, remelted, antioxidant-stabilized, 

in vivo time 0 - 10 years) were evaluated for oxidation by Fouriertransform 

infrared spectroscopy, rated for clinical damage, and 

selected bearings were analyzed for free radical concentration (FRC) 

using EPR spectroscopy. Retrievals of annealed HXL bearings and 

antioxidant HXL have measurable FRC. Remelted HXL bearings have 

no measurable FRC. Fifty percent of retrieved HXL bearings exhibit 

subsurface articular oxidation in vivo. Subsurface articular oxidation 

may change the wear resistance of acetabular liners and could lead 

to fatigue failure of HXL tibial inserts given sufficient time. Careful 

monitoring of longer term in vivo performance of HXL UHMWPE 

bearings is critical to assessing these potential concerns. 


uDoes The Design Of Frequently Used Hip Resurfacing 

Components Affect Cement Fixation? 

Rudi Bitsch, MD, Heidelberg, Germany 

Beate Obermeyer, BSc 

Johannes S Rieger, MSc 

Sebastian Jaeger, MSc, Heidelberg, Germany 


National joint replacement registry data showed that component 

designs have been associated with failures of hip resurfacing 

arthroplasties. We used a well established experimental setup to 

analyze the effects of the inner geometry of five different femoral 

resurfacing components on cement fixation. Highly standardized 

open-cell reticulated carbon foam was demonstrated to closely 

simulate human femoral heads as prepared for resurfacing. 

We used this femoral resurfacing model to obtain real-time 

measurements of pressure and temperature and measure cement 

penetration and distribution as a function of the inner geometry 

of five different femoral hip resurfacing components. Statistical 

analyses were performed using the Kruskal-Wallis test, p

emodelling (Moore). Average patient age at acetabular revision was 

65 years, while 14 male and 24 female patients were included at an 

average follow up time of 35 months. The HHS improved from 46 

to 81 points. Four patients sustained a dislocation postoperatively 

(three closed reductions and one revision). One further acetabular 

revision was necessary seven months after implantation, because 

of loosening of the cup. Two further shaft revisions were necessary. 

Radiographs: 62% showed at revision defects as graded 2B and 28% 

3A by Paprosky. At latest radiographic follow up, all of augments 

appeared stable without change of position and showed signs of 

bony integration. Seventeen (45%) patients showed a superolateral 

buttress. Two patients (5%) showed radiolucent lines around the cup. 

The overall luxation rate was 11%. Trabecular metal augmentation in 

combination with local impaction grafting and an all polyethylen 

cup allows for adequate fixation and shows good tendency of bone 

remodeling three years after implantation. 


The Effect Of Risedronate On Periprosthetic Bone 

Resorption After Total Hip Arthroplasty 

Olof Skoldenberg, MD, Danderyd, Sweden 

Mats Salemyr, MD, Bromma, Sweden 

Henrik Boden, MD, PhD, East Lansing, MI 

Torbjorn E Ahl, Dandoeryd, Sweden 

Per Y Adolphson, MD, Danderyd, Sweden 

The aim of this trial was to investigate the effect of risedronate given 

once weekly on femoral periprosthetic bone resorption after total 

hip arthroplasty (THA) in patients with osteoarthritis of the hip. 

We enrolled 73 patients between 40 and 70 years of age scheduled 

for THA in a single-center, randomized, double-blind, placebocontrolled 

trial. Subjects received either 35 mg of risedronate (n=36) 

or placebo (n=37) once weekly for six months. The primary end 

point was change in bone mineral density (BMD) in femoral Gruen 

zones 1 and 7. BMD scans were taken postoperatively and at three, 

six, 12 and 24 months. Secondary end points included migration 

of the stem and clinical outcome. In the placebo group we found a 

continuous bone loss in zones 1 and 7 which amounted to 18% at 

24 months. Bone loss was less with risedronate during the treatment 

period but the difference between the groups was not statistically 

significant at 24 months. Patients with a low pre-operative BMD of 

the hip lost significantly more bone during the study. The migration 

of the stem, the clinical outcome and the frequency of adverse events 

did not differ between the groups. In patients with osteoarthritis, six 

months of risedronate treatment orally once weekly is effective in 

reducing femoral periprosthetic bone resorption up to 12 months 

after THA with a trend towards effect up to 24 months. Future 

studies of bisphosphonate treatment after THA should focus on 

patients who have both osteoarthritis and a low BMD of the hip. 

(ClinicalTrials.gov number, NCT00772395). 

506 


Minimum 2 Year Outcome & Survivorship of the 

Birmingham Hip Resurfacing System in the United 

States 

Ryan Nunley, MD, Saint Louis, MO 

Christopher D Nelson, DO, Carroll, IA 


John Sargent Rogerson, MD, Madison, WI 

Peter J Brooks, MD, Cleveland, OH 

Edwin P Su, MD, New York, NY 

Robert L Barrack, MD, Saint Louis, MO 

Previous data on survivorship of the Birmingham Hip Resurfacing 

(BHR) system come from the design surgeons and large national 

databases outside the United States. The purpose of this study was 

to determine the survivorship of this implant at two to four-year 

follow up in the United States. A multicenter, retrospective review of 

1,265 patients treated with a BHR implant at six high volume total 

joint centers with established joint registries from June 2006 until 

August 2008 was undertaken. Charts were reviewed and patient 

demographics, Harris Hip Scores (HHS) and radiographic findings 

were recorded. Patients without a two-year follow up clinic visit were 

contacted by phone. All patients were asked about complications, 

re-operations or failure of their implants. There were 1,118 patients 

with minimum two-year follow up. Average age was 52.6 years and 

74.2% were males. Average HHS improved from 55.7 pre-operatively 

to 97.4 (p

Mann-Whitney-Test. The test was two-sided and a p value of 0.05 

was considered significant. For the trabecular metal-bonecement 

interface the mean maximum tensile force was 424.08N (SD=96.81N, 

range: 234.40-559.30N) and the tensile strength 14.85N/mm^2 

(SD=3.36N/mm^2, range: 8.18-19.39 N/mm^2). For the bonebonecement 

interface the mean maximum tensile force was 169.73N 

(SD=74.18N, range: 65.40-274.75N) and the tensile strength 

6.28N/mm^2 (SD=2.89N/mm^2, range: 2.43-10.19 N/mm^2). The 

difference was statistically significant with p

were obtained from each PPS, with the first taken preoperatively to 

serve as a control. Cultures were incubated at 36°C for 24-48 hours 

in 5% CO2. Plates were examined, colonies were quantitated and 

all different colony types were subcultured to blood agar plates 

and incubated for 24 hours at 36°C. Isolated pure colonies were 

worked up according to the Gram stain results. Isolated S. aureus 

was classified as methicillin resistant or susceptible. Cultures were 

collected from 61 THA and 41 TKA. Fifty (49.02%) were found 

positive for bacterial contamination, 29/61 THA (47.54%) and 

21/41 TKA (51.22%). At least eight different species of bacteria 

were detected, including Coagulase-Negative Staphylococci (78%), 

Micrococcus sp. (22%), MSSA (12%), Bacillus sp. (7%) and MRSA 

(1%). Company literature indicates an average bacterial filtration 

efficiency of 99.4%. Therefore, if one challenges the PPS with 103- 

105 organisms, the estimated breakthrough of escaping organisms 

would be approximately 6-600. The patient’s own bacteria becoming 

disassociated and relocated, plus bacteria from other sources could 

add to the potential bioburden of the exterior of the PPS. Although 

the PPS is effective in isolating the surgeon from the patient large 

number appear to be contaminated at the initiation or conclusion 

of elective primary joint arthroplasty. 


Femoral Retroversion As A Cause Of Femoroacetabular 

Impingement: A Biomechanical Model 

Jibanananda Satpathy, MD, Richmond, VA 

Jai Jani, MD, Chicago, IL 

John R Owen, PE, Richmond, VA 

William A Jiranek, MD, Richmond, VA 

Jennifer S Wayne, PhD, Chesterfield, VA 

Jason Ray Hull, MD, Richmond, VA 

Our biomechanical model confirms femoral neck retroversion can be 

an important cause of pincer type impingement. Femoroacetabular 

impingement (FAI) has been associated with osteoarthritis in young 

patients. Limited studies have suggested femoral neck retroversion 

may be a cause of impingement. Our aim was to create a biomechanical 

model for FAI based on the concept of femoral retroversion, and to 

assess the associated pattern of impingement and effect on hip joint 

contact stresses. Fresh frozen cadaveric pelvi with intact femora and 

hip joints (three hips) were thawed at room temperature. Femoral 

neck version was measured using axial radiographs. Soft tissues were 

removed except for the acetabular labrum. Each hip was separately 

tested on Instron material testing equipment using custom 

mounting fixtures. Fuji films (low-pressure 2.5 to 10 MPa) were used 

for pressure measurement. Femoral neck retroversion was simulated 

via a subtrochanteric osteotomy. Each hip was loaded to 300 

pounds in 90 degrees of flexion for combinations with and without 

internal rotation and retroversion. Compared to the nonrotated 

and nonretroverted state, peak color density increased 15% in the 

hip’s posteromedial region with internal rotation alone, 36% with 

retroversion alone and 56% with combined internal rotation and 

retroversion. Conversion of densities to pressures showed 33% of 

peak pressure readings exceeded 10MPa for rotation alone, 40% for 

retroversion alone and 67% for combined rotation and retroversion. 

We produced a novel cadaveric biomechanical model of FAI to assess 

the impingement pattern and contact stresses in the hip joint. The 

observed pattern of increased hip joint contact stresses correlates 

with the osteoarthritis pattern seen clinically in pincer type FAI. 

508 


Reconstruction of Severe Acetabular Bone Loss 

(Paprosky Type-III) using Acetabular Cages 

Amit Sharma, MD, New Orleans, LA 

Jonathan N Sembrano, MD, Minneapolis, MN 

Edward Y Cheng, MD, Minneapolis, MN 

Acetabular cage reconstruction in Paprosky type III defects have 90% 

and 75% revision-free survival at five and 10 years, respectively. Use 

of bone graft is associated with better survival. Severe acetabular 

defects in total hip arthroplasty (THA) are challenging and treatment 

options include jumbo/bilobed/triflanged/custom/trabecular metal 

cups, reconstructive cages ± structural allografts and/or metal 

augments. We focused solely on the most severe acetabular defects 

(Paprosky type III) treated with reconstruction cages and report the 

mid to long-term results. Forty-six hips (41 patients) underwent 

acetabular reconstruction with a cage for type III (28 IIIa, 18 IIIb) 

acetabular defects with mean follow up 6.7 years (range 2-13). 

Defining an endpoint as cage revision, the implant survival was 

assessed using Kaplan-Meier analysis and independent prognostic 

factors were analyzed using multivariate regression. Radiographs 

were reviewed for cage loosening and migration. Outcome scores 

were obtained at final follow up. Five and 10-year survivorship for 

the acetabular cages was 90.0% (95% CI 82-99) and 75% (95% CI 

54-97), respectively. Of the 46 cages implanted, six were revised; 

aseptic loosening (four), infection (one) and recurrent dislocation 

(one). Cage survival was no different between Paprosky type IIIa or 

IIIb. The addition of morcelized and/or structural bone graft showed 

significantly improved survival (p = 0.0004) compared to a cage 

alone. At final follow up SF-36 scores were 44.3 (physical) and 58.8 

(mental), and WOMAC total score was 68.4. Reconstruction with 

an acetabular cage is a viable option with 75% of cages remaining 

revision-free at 10 years. The use of bone graft is recommended 

for improved survival of the cage in these cases with severe bone 

deficiency of the acetabulum. 


Infection In Revision Total Joint Arthroplasty (TJA): The 

Role Of Nutrition Screening 

Justin Brothers, MD, Danville, PA 


Patricia L Hansen, BS, Middletown, DE 

Patients undergoing revision total joint arthroplasty should have 

their nutrition status evaluated and optimized prior to revision 

surgery. Malnourished patients have an increased risk of infection. 

The relationship between infection and malnutrition has been well 

documented. However, there is much debate regarding which labs are 

the best indicator of malnutrition and at what thresholds. All patients 

undergoing revision total joint arthroplasty by the senior author 

underwent nutrition screening. We performed a retrospective review 

of this data for all patients who underwent revision surgery between 

April 2006 and December 2009. Preoperative nutrition lab values of 

patients later requiring irrigation and debridement were compared 

to those of aseptic patients. A total of 506 revisions were performed. 

Revisions for 58 acute periprosthetic infections and 47 acute traumas 

were excluded, leaving 401 patients. Twenty-four (6.0%) developed 

infection which required surgical intervention. A total of 3.5% of 

patients with a total lymphocyte count (TLC) >1,500 cells/mm3 

became infected requiring washout compared to 9.1% with a TLC 

of

prealbumin and TLC and increased C-reactive protein and erythrocyte 

sedimentation rate are associated with an increased rate of infection 

in revision surgery. For this reason, we believe nutrition screening 

in preadmission testing is warranted and steps should be taken to 

correct malnourished patients before surgery. 


The Effect Of Diabetic Control In Total Joint 

Arthroplasty Outcomes 

Carlos J Lavernia, MD, Coral Gables, FL 

Juan S Contreras, Miami, FL 

Jose Carlos Alcerro, MD, Miami, FL 

Mark Rossi, PhD, Miami, FL 

Poor glucose control in diabetic patients undergoing total joint 

arthroplasty may play a key role in determining outcomes 

postoperatively. Low and high HbA1c values have been associated 

with increased mortality and cardiovascular complications in diabetic 

patients. Our objective was to study the effects of diabetic control 

in the outcomes after total joint arthroplasty (TJA). A total of 121 

consecutive primary TJA were performed in type 2 diabetic patients. 

Patients were stratified into quartiles based on their preoperative 

HbA1c levels. Patient-oriented outcomes (QWB, SF-36, WOMAC), 

complications, length of stay (LOS) and hospitals costs were 

compared between groups. ANOVA and independent t-test were used 

to compare outcomes. At 2.7 years (range: two to five years), there 

were no significant differences between quartiles. A trend for worse 

scores in the lowest 25% and highest 25% quartiles was identified 

for the QWB (LQ25%: 0.627; IQ50%: 0.637; HQ25%: 0.627), 

SF-36 role physical (LQ25%: 71; IQ50%: 78; HQ25%: 77), social 

functioning (LQ25%: 72; IQ50%: 78; HQ25%: 76), and mental 

health component (LQ25%: 55; IQ50%: 57; HQ25%: 55), WOMAC 

function (LQ25%: 7; IQ50%: 3; HQ25%: 5) and total (LQ25%: 8; 

IQ50%: 4; HQ25%: 7). LOS and hospital costs were higher in both 

the lowest 25% and the highest 25% quartiles. After controlling for 

all confounders, this inverted U-shaped pattern remained similar. 

There was no difference in complications between quartiles. All 

perceived outcomes improved significantly two years after surgery. 

We found that type 2 diabetic patients with hypoglycemia and 

hyperglycemia as measured by preoperative HbA1c levels have a 

tendency towards worse outcomes after TJA. Poor glucose control in 

diabetic patients undergoing TJA may play a key role in determining 

outcomes postoperatively. 


Modern Ceramic on Ceramic Total Hip Arthroplasty in 

Patients Under 50: Minimum 10 Year Follow-up 

Jason Hsu, MD, Philadelphia, PA 

Stuart D Kinsella, BA, Philadelphia, PA 

Christine Kaminski, BA 

Jonathan P Garino, MD, Villanova, PA 


Modern ceramic on ceramic total hip arthroplasty in active patients 

under the age of 50 is durable at minimum 10-year follow up with 

low rates of complications. Recent reports of early failures of metal on 

metal (MOM) total hip arthroplasty (THA) have introduced doubts 

to its ability to be a viable long-term hard-on-hard bearing surface for 

THA. Like MOM THA, ceramic on ceramic (COC) THA has excellent 

in-vitro wear characteristics, but there is little information about its 

long-term track record in vivo. The purpose of this study is to evaluate 

the long term outcomes of COC THA in active patients under age 

50. We retrospectively reviewed 110 consecutive COC THAs in 88 

509 

patients performed by a single surgeon from 1997 to 2000. All THAs 

were performed as part of investigational device exemption (IDE) 

evaluations. There were 54 men and 34 women with an average age 

of 38.8 years. Of the 110 COC THAs, 51 were performed for avascular 

necrosis (AVN) of the hip, 46 for osteoarthritis (OA), eight for 

developmental dysplasia and five for inflammatory or posttraumatic 

arthritis. The patients underwent primary THA using three COC 

hip designs: Reflection/Spectron (Smith and Nephew), Encore 

Ceramic Hip (Encore) and Transcend/Perfecta (Wright Medical). 

All of the femoral stem components were cemented designs while 

all acetabular components were uncemented cup designs. Clinical 

outcomes were evaluated using the Harris Hip score, and serial 

radiographs were evaluated for signs of component loosening. The 

mean follow up was 11.2 years (range, 10.0-13.2 years). One patient 

died, and another was lost to follow up. The mean Harris Hip score 

was 94.1 (SD 11.6). There were no implants with subsidence or 

circumferential radiolucent lines. Five patients had failures of their 

COC THA (one for head fracture, one for ceramic liner fracture, one 

for instability, two for aseptic loosening). Two patients complained 

of squeaking. At a minimum 10-year follow up, the survivorship 

of the COC THA was 95.5%. Modern COC THA in active patients 

under the age of 50 is durable at minimum 10-year follow up with 

low rates of complications. 


Risk Factors For Early Mortality Following Modern 

Uncemented Total Hip Arthroplasty 


Michael C Aynardi, MD, Philadelphia, PA 

Christina L. Jacovides, Philadelphia, PA 

Orhan Bican, MD, Philadelphia, PA 


Kelley Kirkpatrick, BS 

This study confirms some of the previously identified factors 

associated with mortality (i.e., older age, high morbidity). As the 

number of total hip arthroplasties (THA) performed worldwide 

continues to grow, the identification of risk factors for early mortality 

and careful preoperative optimization has become increasingly 

important. The aim of this study was to evaluate the incidence of 

early mortality and identify risk factors for early death following 

modern uncemented THA. A retrospective review of all THAs 

performed at our institution between 2000 and 2006 identified 

patients who died within 90 days of surgery. These were matched 3:1 

to control patients by surgeon and day of surgery. Causes of death 

for case patients were established. Demographics, comorbidities, 

postoperative complications, labs and medications were compared 

between the two groups. We identified 38 early mortalities, for an 

overall mortality rate of 0.46%. Cardiac related causes of death 

were most common (42%), followed by respiratory complications 

(16%) and cerebrovascular incidents (8%). Previously identified 

risk factors such as older age, higher comorbidity index, lower body 

mass index, hyperglycemia, peripheral vascular disease, coronary 

artery disease, dementia, anemia and acute renal failure were 

confirmed. Newly identified risk factors for early mortality included 

postoperative shortness of breath, an abnormal preoperative EKG 

or echocardiogram, perioperative electrolyte imbalances, increased 

postoperative transfusion volume, use of general anesthesia and 

Medicare insurance. Smoking and postoperative acute myocardial 

infarction trended toward significance. This study confirms risk 

factors associated with mortality and identifies new significant risk 

factors. Future reductions in mortality will be made by addressing 

reversible comorbidities prior to elective surgery and by good 

preoperative optimization. 





The “Abductor Sparing” Anterolateral Approach (G3) in 

MIS THA: A Prospective RCT 






Michael Tanzer, MD, Montreal, QC Canada 

Abdul Aziz, BSc, Vancouver, BC Canada 

Samir Chihab, MD, Vancouver, BC Canada 

Aslam Anis, PhD, Vancouver, BC Canada 

The MIS Anterolateral approach is not superior to alternate MIS 

surgical approaches when evaluating outcomes of quality of life, 

complications and health resource utilization. The purpose of this 

study was to evaluate the clinical effectiveness and outcomes of the 

‘abductor sparing’ MIS Anterolateral approach (MIS Watson Jones/ 

G3) in comparison to the MIS Direct Lateral and MIS Posterolateral 

approaches in primary total hip arthroplasty. A multicenter, 

prospective, randomized controlled trial was designed to evaluate for 

the superiority of the new MIS Anterolateral approach (MIS Watson 

Jones/G3). The sample size calculation was performed for alpha .05, 

power .90, to evaluate for effect size 0.5 in WOMAC using repeated 

measures analyses with baseline WOMAC as covariate. A total of 

156 patients consented to participate in the trial and patients were 

assigned to MIS Anterolateral approach or alternate MIS approach 

(MIS Direct Lateral or MIS Posterolateral). Patients were subjected to 

standardized anaesthetic and perioperative management protocols 

and were evaluated at standardized intervals to evaluate endpoints 

of early recovery (three months) as well as endpoints of 12 and 24 

months respectively. The primary outcome of interest was WOMAC, 

however secondary outcomes included SF-36, as well as parameters 

of health resource utilization and complications. Univariate and 

multivariate analyses were perfomed. Patient groups were found to be 

similar at baseline with regards to demographics and baseline quality 

of life outcomes (p>.05). Multivariate and repeated measures analyses 

demonstrated no superiority of the MIS Anterolateral approach 

on outcomes of WOMAC and other quality of life measures in 

comparison to MIS Direct Lateral and MIS Posterolateral approaches 

(p>.05). Healthcare resource utlization was also similar with length 

of stay, blood transfusion requirements and complications (p>.05). 

Our multicenter, prospective, randomized clinical trial demonstrates 

that the MIS Anterolateral approach is not superior to alternate 

MIS surgical approaches when evaluating outcomes of quality 

of life, complications and health resource utilization. Surgeons 

should consider these outcomes, complications and other relevant 

advantages and disadvantages of select surgical approaches when 

deciding on a technique for use in their orthopaedic practice. 


Intra-operative Computed Radiography(CR) in Total Hip 

Arthroplasty(THA) Improves Results 

William Seth Bolling, MD, Beverly Hills, CA 

Brad L Penenberg, MD, Beverly Hills, CA 

Michelle Riley, PA, Beverly Hills, CA 

A portable computed radiography device enables the surgeon to 

rapidly obtain a high quality pelvis radiograph during total hip 

arthroplasty and permits more accurate intra-op adjustments of 

component alignment, leg length and offset. A portable computed 

radiography (CR) device makes it possible to rapidly obtain a high 

quality AP or PA pelvis radiograph during total hip arthroplasty 

510 

(THA). When compared to historical controls this technique permits 

more accurate intra-operative adjustments of component alignment 

and fit, leg length and offset. A consecutive retrospective review of 

467 total hips was carried out. A high quality AP or PA pelvis film 

was obtained with the patient in the lateral decubitus position during 

surgery. This low cost CR unit, including PACS, processes the film 

directly in the room within 60 seconds. It also auto-corrects settings, 

eliminating repeats for ‘technician error.’ Corrections to stem size, 

cup position, screw length and position, leg length and offset were 

made based on this intra-op x-ray. Post op film was used for final 

assessment. Mean abduction angle was 43° (35-48). Adjustment was 

performed in 25% of cases. Apposition was within 3 mm 100% of 

the time. Cup was re-seated in three hips. Femoral component was 

neutral in 87% and 3-5 degrees of varus in 13%. Femoral component 

was upsized 55% of the time. Leg length discrepancy was less than 5 

mm in 100% of hips. Offset was within 3 mm of the normal side in 

264 pts in whom this was measurable. Operative time averaged one 

hour and five minutes. The use of intra-operative CR offers a costeffective, 

user-friendly technique to improve precision of component 

placement in THA. 


Overdiagnosis of Pulmonary Embolus: How to Avoid a 

Potentially Catastrophic Problem? 


Brian Winters, MD, Mount Laurel, NJ 

Patrick Curry 




Mark Solarz, BS, Philadelphia, PA 

We have seen a 34% decrease in the incidence of orders for MDCT, 

59% for V/Q scan and 39% for total investigations (p


Endoscopic Illiopsoas Release for Tendon Impingement 

after Total Hip Replacement 


Tracy Kinsey, RN, Athens, GA 

Endoscopic release of the iliopsoas tendon from the lesser trochanter 

after total hip replacement effectively relieved symptoms of tendonitis 

for patients of this case series. Iliopsoas tendonitis after total hip 

arthroplasty (THA) appears to be a more frequent problem with 

acetabular designs for hard on hard bearings and very large femoral 

heads. We conducted an Institutional Review Board approved review 

of a case series of 15 patients who underwent endoscopic release 

of iliopsoas tendonitis to determine whether the floroscopic guided 

technique was feasible and efficacious. An automated chart review 

was undertaken to identify patients treated for iliopsoas tendonitis 

after THA between 6/04 and 6/08. Records were reviewed to asses time 

to onset, implants utilized, treatment used and clinical outcomes at 

two minimum years post procedure. Between June 2004 and June 

2008, 15 patients at our clinic underwent endoscopic iliopsoas 

release from one to eight years post total hip replacement. Twelve of 

the patients failed floro or ultrasound guided corticosteroid injection 

prior to being offered surgical treatment. Cross table lateral x-rays 

revealed overhanging acetabular metal anteriorly in 10 of 15 cases. 

There was one case where there was no anterior acetabular metal 

anterior, but the femoral head was quite large. At a minimum of 

two years after the tendon release there have been no recurrences of 

symptoms or problems with hip flexor weakness. Endoscopic release 

of the iliopsoas tendon from the lesser trochanter was a viable and 

effective treatment for patients with post THA iliopsoas tendonitis 

in this case series. 


Primary THA Comparing Anterolateral Approach versus 

Posterolateral Approach with a Capsular Repair 


Jacob Lantry, MD, Stony Brook, NY 

Lawrence A Schaper, MD, Louisville, KY 

Jessica I Curry, MS, Louisville, KY 

Matthew Thomas Hummel, MD, Cincinnati, OH 

Dale Baker, Louisville, KY 

Total hip arthroplasty using a posterior approach with a capsular 

repair has a comparable dislocation rate to an anterolateral 

approach with a decreased incidence of limp. Purpose of this study 

is to compare short term outcomes of primary total hip arthroplasty 

(THA) using two different approaches. Study is a retrospective 

review of two cohorts of patients undergoing primary THA, between 

1/2001 and 12/2005. Group I consisted of 281 consecutive primary 

THAs using an anterolateral approach. Group II consisted of 327 

consecutive THAs performed using a posterior approach modified 

with a posterior capsular repair. Cohorts were compared with respect 

to pain and function scores, operative data (estimated blood loss 

(EBL), operating room (OR) time) and complications. Statistical 

analysis was performed using paired t-tests and chi square tests. 

Group I had 135 females and 120 males with an average age of 63 

years and body mass index (BMI) of 30. Group II had 167 females 

and 127 males with an average age of 61 years and BMI of 31. No 

statistically significant differences in the number of complications in 

either group with respect to fracture, infection or dislocation. Group 

I had an incidence of moderate limp and severe limp of 9% and 13% 

respectively; and the posterior cohort, Group II, had a limp in

single surgeon cohort of 130 primary cemented Charnley femoral 

components, all well-fixed at minimum 20-year radiographic 

follow-up, were classified into one of three groups based on gross 

radiographic remodeling: distal hypertrophy, endosteal loss, or 

normal. Remodeling was analyzed with respect to gender, age at 

surgery, BMI, and postoperative activity level. Femoral diameter, and 

medial and lateral cortical widths were measured at four defined 

points. The distal cortical hypertrophy group had a younger age at 

time of surgery. There was no significant difference between the three 

groups in regards to gender, activity level, or BMI. The distal cortical 

hypertrophy group showed a greater increase in medial cortical 

thickness and endosteal width at the midstem, implant tip, and 2.5 

cm distal to the tip. The endosteal loss group showed a significantly 

decreased lateral cortical thickness at the lesser trochanter, midstem, 

and distal points. Remodeling characteristics are difficult to predict as 

the only demographic variable that correlated with remodeling type 

was younger patient age with distal cortical hypertrophy. This study 

should provide comparison for other long term studies to determine 

whether bone remodeling is different with cementless designs. 


Kalamchi and MacEwen group I Ischemic Changes 

Have Unfavorable Effects on Hip Morphology in DDH 

Hakan Omeroglu, MD, Prof, Eskisehir, Turkey 

Yucel Tumer, MD, Izmir, Turkey 

Ali Bicimoglu, MD, Ankara, Turkey 

Haluk Agus, MD, Prof, Izmir, Turkey 

Group I ischemic changes retard acetabular development and have 

quantitative unfavorable effects on lateral femoral head coverage and 

proximal femoral anatomy in DDH. Besides, the healing process is 

considerably long. 


A New Classification And Consistency Analysis In Adult 

Developmental Hip Dysplasia 

Emre Togrul, MD, Adana, Turkey 

Mahir Gulsen, Prof.Dr., Adana, Turkey 

Adem Gundogan, MD, Adana, Turkey 

Can Gocuk, MD, Adana, Turkey 

With this new classification pathologies have been divided into 3 

classes based on obturator foramen, asetebulum, the femoral neck 

and trochanter minor. This method has established interobserver 

and intraobserver consistency thereby confirming the efficacy of the 

classification 


Evaluation Of Neurological Complications Of Closed 

Wedge High Tibial Valgization Osteotomy Technique 

Burak Yalcin, Istanbul, Turkey 

Rifat Erginer, MD, Istanbul, Turkey 

Feray Savrun, Prof, Istanbul, Turkey 

Mehmet Can Unlu, MD, Istanbul, Turkey 

Prof Muharrem Babacan, Istanbul, Turkey 

We conducted an electrophysiological study to evaluate fibular nerve 

lesions of closed wedge high tibial valgization osteotomy. We found 

that this procedure is safe with no electrophysiological difference 

two months after surgery. 

512 

SCIENTIFIC EXHIBITS 

scieNtific exHibit No. se01 

The Immunopathology of ALVAL 


Piriya Sutthirunjwong, MD, Santa Monica, CA 

Scott C Nelson, MD, Redlands, CA 

Tim Tan, BS, Los Angeles, CA 

Mariam Al-Hamad, BS, Los Angeles, CA 

Yael Korin, PhD, Los Angeles, CA 

Clara Magyar, PhD, Los Angeles, CA 

Elaine Reed, PhD, Los Angeles, CA 

‘ALVAL ‘(Aseptic lymphocytic vasculitis associated lesions), was 

coined to describe lymphocyte-dominated histological features in 

failed metal-on-metal (M-M) hips suspected to have metal allergy. 

The term is often misused as a diagnosis for unexplained pain, or 

pain from wear-induced swelling and there is considerable confusion 

as to its meaning. To improve the reporting of periprosthetic tissue 

features around M-M hips, this exhibit will demonstrate and explain 

ALVAL, review the pathology of high wear and metal allergy. A 

virtual microscope with examples of how a scoring method and 

lymphocyte markers can be used to discriminate metal allergy from 

high wear reactions will be featured. A 10-point scoring method 

developed by the authors was applied to tissues from 50 M-M hips 

revised for pain and suspected metal allergy, acetabular malposition, 

or implant loosening. The wear of the components was determined 

from direct measurements. Immunohistochemical staining for 

lymphocytes, macrophages and plasma cells was performed on 9 

cases with suspected allergy, 12 cases with high implant wear, and 5 

cases with low wear and loosening. The results were quantified using 

image analysis. Cases with normal wear but revised for suspected 

allergy had higher ALVAL scores compared with those with higher 

wear or loosening. The allergy cases typically had more T cells, more 

plasma cells and fewer macrophages. Tissue organization and degree 

of synovial preservation also differed. To improve understanding of 

histology of M-M hips, a scoring method for ALVAL was developed. 

ALVAL score, and markers for T and B cells helped differentiate 

responses associated with high wear from those with suspected 

metal allergy. 


The High Performance Modular Hip: Curse or Comfort? 

A Seth Greenwald, DPhil Oxon, Cleveland Heights, OH 

J David Blaha, MD, Ann Arbor, MI 

Michael Dunbar, MD, PhD, Halifax, NS Canada 


Joshua J Jacobs, MD, Chicago, IL 

Christine S Heim, Cleveland, OH 

Modularity in total hip arthroplasty design has received increased 

citation in the clinical literature. The cited advantages of these systems 

include off-the-shelf flexibility for custom proximal and distal 

canal filling, restoration of offset while accommodating femoral 

deformity, limb length inequality and bone loss. However, in-vivo 

device breakage has been reported at neck and mid-stem metalmetal 

interconnections. This exhibit describes extensive clinical and 

laboratory comparisons which highlight features that account for 

the failure of these devices. A meta-analysis was performed on the 

authors’ personal clinical experiences of more than 1,500 modular 

hip arthroplasties as well as a review of the FDA MAUDE database 

tracking device mechanical failure leading to revision. The incidence 




and location of fractures were recorded over a timeframe ranging 

from 2 to 9 years postoperatively. These fractures were compared to 

the structural failure patterns observed through laboratory testing. 

The findings within this population suggest that patient habitus, 

restoration of offset and anatomical device placement are the major 

contributors to the 3% population failure rate observed clinically. 

Fretting between metallic interconnecting surfaces was identified 

as the link between the laboratory and clinical findings. Both neck 

and mid-stem femoral modularity have enabled contemporary stem 

designs to accommodate situations of skeletal pathology encountered 

in total hip arthroplasty patients. Their increased prevalence has led 

to device structural failure, most often encountered at metal-metal 

interconnections. This extensive database describes their clinical 

effectiveness and strongly points to the importance of technical 

proficiency and the need for preclinical laboratory evaluation where 

device-specific endurance limits are determined. 


Understanding Why Metal-on-Metal Hip Fail: The 

London Implant Retrieval Centre 




Barry Sampson, MD, London, United Kingdom 

Adam Mitchell, MD, London, United Kingdom 

Keshthra Satchithananda, FRCR, London, United Kingdom 


Justin Peter Cobb, MD, London, United Kingdom 


The UK and Australian joint registries have shown a high early failure 

rate of some types of metal-on-metal hip resurfacings. It is unknown 

whether the mechanism of failure will be similar to stemmed 

large diameter metal-on-metal hips. It is also uncertain whether 

the main limitation in their use is surgeon / component position 

related or design / manufacturer related. We will present the findings 

of our multi-disciplinary research centre set up to increase our 

understanding of how metal on metal hip / hip resurfacing implants 

fail. We prospectively recruited 320 patients with failed MOM hips. 

We collected pre, intra and post op data to determine the clinical 

category of failure (infection, loosening, dislocation, malalignment, 

fracture, unexplained). We measured pre-revision blood metal ion 

levels using ICP-Mass Spectrometry. Additionally, in a proportion 

of patients CT was used for component position analysis and MRI 

was used for soft tissue analysis. A published wear analysis protocol 

was used: a roundness machine was used and recorded more than 

1 million points per hip component to an accuracy of less than 1 

micron. We found no significant difference in wear rates between 

manufacturer types. The majority were unexplained clinical failures 

(well fixed, not infected and well aligned). Edge loading was present 

in approximately two thirds of hips. When compared to CT measured 

component positions of well functioning MOM hips we found no 

significant increase in malaligment of the failures. Blood metal ions 

levels were significantly greater in the failures when compared to 

88 patients with well functioning unilateral MOM hips. ALVAL was 

found in all types of failure. Cup edge loading was the commonest 

finding from wear analysis of failed MOM hips. In the majority of 

cases this did not arise from high cup inclination angles. At least 50% 

of failures had metal ion levels greater than 7 parts per billion. Blood 

metal ion screening may be more useful than Plain radiographs in 

detecting the risk of failure of MOM hips. 

513 


Total Joint Arthroplasty Aseptic Revision Risk Factors: 

Analysis of a US Registry with 72,000 Cases 


Maria Carolina Secorun Inacio, MS, San Diego, CA 




William Timothy Brox, MD, Fresno, CA 

Eric J Yue, MD, Carmichael, CA 

Factors affecting outcomes of Total Joint Arthroplasty (TJA) in the 

United States are poorly understood. Total hip (THA) and knee 

(TKA) arthroplasty patient demographics, surgical information, 

surgeon and hospital volume, implant characteristics and revision 

were recorded in a Total Joint Replacement Registry (2001-2009). 

Descriptive, survival, and multivariate analyses are presented. 

47429 primary TKA cases were performed. The patients were 

predominantly female (63%) with 38%

found on the Medline and EMBASE bibliographic databases that 

were related to total hip arthroplasty and all interfaces (including 

metal-on-metal, ceramic-on-ceramic, ceramic-on-metal, and metalon-highly-cross-linked 

polyethylene). Data regarding the incidence, 

recognition, and treatment or pseudotumors was collected for each 

study. Additionally, all patients operated on between 2000 and 2008 

at a high- volume institution will be reviewed to assess the incidence 

of pseudotumor in various bearing surfaces. The reported prevalence 

of hypersensitivity reactions following THA has ranged from less 

than 1% to as high as 10%. Based on the current literature, symptoms 

may come on within months or even years after surgery with some 

patients remaining relatively asymptomatic despite development of 

a pseudotumor. There were 25 studies that reported pseudotumors, 

which occurred predominantly in women. The reported treatments, 

such as mass excision of the pseudotumor or complete revision 

with removal of components, have mostly resulted in excellent 

outcomes. At our institution, there have been two patients who 

developed aseptic lymphocytic vasculitis-associated lesions, which 

were both associated with metal-on-metal articulations. Both of 

these patients did well following excision revision arthroplasty. 

The level of evidence of the reports assessing metal hypersensitivity 

and pseudotumors is low, and there is a need for more prospective, 

randomized studies. Although the results of our patient cohort 

as well as other reports in the literature suggest that these are rare 

complications, awareness of this potential complication is important 

its recognition and treatment. This exhibit will demonstrate the risk 

factors, methods for pre-operative patient evaluation, and treatment 

for metal hypersensitivity reactions. 


Inflammatory Pseudotumours Associated with Metalon-Metal 

Hip Replacement 



George A Grammatopoulos, MRCS, Oxford, United Kingdom 

Peter McLardy-Smith, FRCS, Oxford, United Kingdom 

Duncan Whitwell, FRCS, Oxford, United Kingdom 


Roger Gundle, Oxford, United Kingdom 

NA Athanasou, Oxford, United Kingdom 


Inflammatory pseudotumours(IPT) are a serious complication 

of MoM large diameter hip replacement. This exhibit describes a 

programme of IPT related research. We have examined the incidence 

(revisions for symptomatic IPT over 1,419 cases) and prevalence 

(screened 201 random asymptomatic cases), factors linked to 

development, clinical diagnosing modalities, histopathology, wear 

measurement comparing IPT retrieved components to fracture 

cases, in vivo wear mechanisms (motion analysis), in vitro cellular 

response to MoM wear debris. Our incidence of revision for IPT was 

4% overall at 8 years, this was 9% in females; factors significantly 

linked were female gender, age under 40, small component size. 

The prevalence of asymptomatic IPT was 4% overall, nearly 10% 

in females; serum metal ion levels were significantly (p

surgical treatment for PJI remain largely unknown. At our institution 

a prospective database is in place that collects detailed data on all 

patients undergoing joint arthroplasty, particularly those receiving 

revision arthroplasty. The database contains data on 1545 patients 

who have undergone revision arthroplasty of which over 550 patients 

have been treated for periprosthetic joint infection. This scientific 

exhibit will present the result of analysis of the prospective database 

to identify factors that are associated with failure of surgical treatment 

for PJI. Based on the findings of various studies performed at our 

institution and a meta-analysis of the available literature pertinent to 

surgical treatment of PJI, we have designed a surgical algorithm. This 

scientific exhibit will present the findings of institutional and other 

studies. In addition, the effectiveness of the surgical algorithm in 

minimizing this dreaded complication will be discussed. There were 

a number of factors that adversely affected the outcome of surgical 

treatment for PJI regardless of the type of procedure. Based on this 

analysis we introduce a prognostic classification that takes into 

account the host type (Cierny-Mader classification), the organism 

profile, and the type of surgical intervention. Patients with a high 

number of comorbidities infected by resistant organisms face a near 

50% failure rate with two-stage exchange arthroplasty. Other factors 

found to be significant predictors of failure included malnutrition, 

anemia, atrial fibrillation, long-term treatment with anticoagulation, 

low lymphocyte count, hyperglycemia, and high Charlson index. 

This scientific exhibit presents prognostic classification that predicts 

the outcome of surgery for PJI. This allows the treating surgeon to 

present a realistic prognosis for each patient. More importantly, 

identification of the factors leading to failure preoperatively may 

allow for reversal in order to improve outcome. 


Revision of a Ceramic Hip for Fractured Ceramic 

Components 

Francesco Traina, MD, Bologna, Italy 

Enrico Tassinari, MD, Bologna, Italy 

Marcello De Fine, MD, Bologna, Italy 

Barbara Bordini, MD, Bologna, Italy 

Aldo Toni, MD, Bologna, Italy 

The main drawback of ceramic components is the risk of failure. From 

1990, we have recorded 40 failures on 8022 primary ceramic hips 

(0.5%). Since it is a rare event, a revision of a ceramic fracture could 

be a difficult procedure.The amount of ceramic debris produced in 

the failure is a paramount factor for choosing the correct revision 

procedure. Due to this, a revision for a fractured ceramic liner is 

different from a revision for a fractured ceramic head; a revision 

for a post-traumatic failure is different from a revision for recurrent 

dislocation. Furthermore, in spite of most attempts to removal all 

of the ceramic debris, complete clearance of the articular space is 

difficult. With the retention of ceramic debris, there is an increase 

risk of developing significant third body wear of polyethylene or 

metal. The use of another ceramic hip would be the best choice 

to resist to abrasive wear. On the other hand, it is well known that 

third body particles are also responsible of ceramic hip squeaking; 

moreover, the abrasion of the taper of the stem or the cup could 

lead to a higher risk of a second ceramic failure. The aim of this 

study was to examine the results of revision total hip replacement 

performed specifically to treat a fracture of a ceramic component, 

to identify technical factors that affected the outcomes, to propose 

some tips and tricks to perform an easier ceramic revision, and to 

draw a guideline for the treatment of a ceramic failure. 

515 


Management of Hypoxia Following Total Joint 

Arthroplasty 






William B Morrison, MD, Philadelphia, PA 

Richard H Rothman, MD, Philadelphia, PA 

Hypoxia is a relatively common event following total joint 

arthroplasty (TJA). As a result of better nursing care and the liberal 

use of intrathecal opioids in recent years, a strict postoperative 

surveillance consisiting of frequent pulse oximetry measurements 

has been implemeneted. This exhibit will present the findings 

of numerous single instituional prospective studies aimed at 

elucidating the etiology of hypoxia following TJA, the mode of 

presentation of pulmonary embolus, and identification of hypoxic 

situations that warrant medical work up. Over the last 5 years we 

have implemented a protocol for hypoxia that instructs the residents 

and nurse practitioners in systematic approach to work up of 

hypoxic patients. Over the last 5 years, 12,000 joint arthroplasty 

has been performed at out institution. Using this protocol we have 

been able to avoid overdiagnosis of pulmonary embolus and to 

7,000 patients undergoing TJA at this institution were followed 

prospectively. Patients presenting with hypoxia, being defined 

as oxygen saturation < 90% on pulse oximetry, were identified. 

Detailed data on these patients were collected. Specific effort was 

made to identify presenting symptoms or signs that were indicative 

of an important clinical even such as PE, and distinguish this from 

benign cases. The potential association between the size and location 

of PE and the mode of presentation was also sought. All patients 

presenting with hypoxia received medical work up which initially 

included examination by an internist, chest x-ray, arterial blood gas 

sampling, and ECG. Patients with significant findings on any of these 

parameters were subjected to further work up that included multidetector 

CT scanning. Hypoxia is a relatively common event (24.5%) 

following TJA. Over 2/3 of patients presenting with hypoxia have a 

single episode of desaturaturion. Only 1/3 of patients present with 

a longer desaturation or a greater drop in saturation. Hypoxic events 

lasting greater than 5 minutes, or >10% drop on pulse oximetry, or 

being refractory to oxygen therapy were commonly associated with a 

clinically significant event. Although close monitoring of all patients 

with hypoxia is warranted, only those with persistent or dramatic 

oxygen desaturation may require further investigation. Based on the 

findings of this study we propose an algorithm for the management 

of hypoxia following total joint arthroplasty. 


Gluteus Maximus Transfer for Abductor Deficiency in 

Total Hip Arthroplasty 

Leo A Whiteside, MD, Saint Louis, MO 

Chronic avulsion or inflammatory destruction of the abductor 

portions of the gluteus medius and minimus in association with 

total hip arthroplasty causes severe limp and often pain. This study 

describes a reconstruction technique using the gluteus maximus. To 

treat abductor deficiency, the anterior half of the gluteus maximus 

muscle was transferred to the greater trochanter and sutured under 

the vastus lateralis. Suturing in abduction and VY repair of the 

gluteus maximus was done to ensure tight repair. Eleven hips (11 

patients) with complete loss of abductor attachment had repair and 




econstruction during total hip arthroplasty or later as a secondary 

procedure, and were followed for 10-36 months. Preoperatively 

all patients had abductor lurch, positive Trendelenburg sign, and 

no abduction of the hip against gravity. Postoperatively 10 hips 

(10 patients) have strong abduction of the hip against gravity, no 

abductor lurch, and negative Trendelenburg sign. One hip (1 

patient) has weak abduction against gravity, negative Trendelenburg 

sign, and slight abductor lurch. Surgical technique is important, but 

gluteus maximus transfer can restore abductor function in total hip 

arthroplasty with a high success rate. 


Femoracetabular Impingement in Collegiate Football 

Players: Radiographic and Physical Exam Findings 

Ashley L Kapron, BS, Salt Lake City, UT 


Stephen K Aoki, MD, North Salt Lake, UT 

Lee Garrit Phillips, MD, Salt Lake City, UT 

Mr Robert Toth, Salt Lake City, UT 

David Petron, MD, Salt Lake City, UT 

Lucas Anderson, MD, Salt Lake City, UT 


Due to increased loading of the hip during sport, the prevalence of 

femoroacetabular impingement (FAI) in athletes may be greater than 

the normal population. This comprehensive study used radiographic 

measures to identify morphologic abnormalities associated with FAI 

in an athletic population. Additionally, physical exams commonly 

used in the clinical diagnosis of FAI were evaluated to quantify 

their ability to predict underlying abnormalities in asymptomatic 

subjects. Prospective, IRB approved study of 67 male collegiate 

football players. Both hips (n=134) were evaluated for radiographic 

signs of pincer and cam femoroacetabular impingement (FAI) on AP 

and frog-lateral films. Each subject’s past and present hip condition 

was assessed with a questionnaire based on hip outcome score. 

Standard clinical exams, including the impingement and FABER 

exam, were performed. Maximum hip range of motion in flexion 

(supine) and internal/external rotation (supine, sitting, and prone) 

measured using a goniometer. The correlation between each range 

of motion and radiographic measure was determined by a randomeffects 

linear regression model 90% (120 hips) had at least 1 sign 

of cam or pincer FAI. Max hip internal rotation in the supine and 

prone position was significantly correlated to two measures of cam 

femoroacetabular impingement (alpha angle and head-neck offset). 

Morphologic abnormalities associated with cam/pincer FAI were 

common in these athletic males. The prevalence was substantially 

higher than previously reported values for normal populations. 

Supine and prone internal rotation can predict radiographic findings 

of cam FAI in athletic males with repeatable radiographic and 

physical measures. Screening athletes may identify hips at risk for 

the development of osteoarthrosis due to FAI. 


Improving Cup Positioning Using a Mechanical 

Navigation Instrument 



Jens Kowal, PhD, Boston, MA 

Acetabular component malpositioning is the most common reason 

for instability and wear resulting in revision total hip arthroplasty 

(THA). The current study aimed to assess a novel mechanical 

navigation device which was designed to simply and efficiently 

516 

indicate appropriate cup orientation during surgery. The accuracy 

was compared to a series of hip arthroplasties performed using CTbased 

computer-assisted cup placement. The study group consisted 

of 70 THAs performed using the mechanical device. The control 

group consisted of 146 THAs performed using CT-based computer 

navigation. Postoperative cup positioning was measured using a 

validated 2D/3D-matching method. An outlier was defined outside 

a range of ± 10 degrees from the planned inclination or anteversion. 

In the study group the mean accuracy for inclination was 1.3 ± 

3.4 (-6.6 ‘ 8.2) and 1.0 ± 4.1 (-8.8 ‘ 9.5) for anteversion with no 

outliers for either parameter. In the control group the accuracy for 

anteversion (3.0 ± 5.8 -11.8 - 19.6]; p=0.6%) and the percentage 

of outliers (6.8%; p=3.3%) differed significantly. The accuracy for 

inclination (3.5 ± 4.1 


Technical Challenges, Pre-operative Planning and 

Outcomes of THA in Down Syndrome Patients 

Michael G Zywiel, MD, Mississauga, ON Canada 


John J Callaghan, MD, Iowa City, IA 

Yona Kosashvili, MD, Rishon Le Zion, Israel 

Aaron J Johnson, MD, Baltimore, MD 


Michael A Mont, MD, Baltimore, MD 

Down’s syndrome is associated with a number of musculoskeletal 

abnormalities, including ligamentous laxity, hypotonia, and altered 

anatomy including hip dysplasia. As the life expectancy of patients 

with this syndrome continues to increase, a greater number of 

otherwise active patients are presenting with end-stage arthritic 

disease of the hip. The purpose of this scientific exhibit is to review 

the technical challenges and pre-operative planning, and assess the 

overall survival rates and clinical and radiographic outcomes of total 

hip arthroplasty in patients with Down’s syndrome. We reviewed 

all total hip arthroplasties performed by four subspecialty hip 

surgeons and identified twenty-five hips in 20 patients with Down’s 

syndrome. These patients had a mean age of 35 years (range, 17 to 

54 years) and a mean follow-up of 105 months (range, 25 to 292 

months). Cementless acetabular components with screw fixation 

were used in all cases, and cementless femoral components were 

used in all but one hip. Constrained liners were implanted in 8 cases 

to enhance stability. Clinical outcomes were assessed using Harris 

Hip Scoring, and radiographic evaluation for component fixation 

and migration was performed. All of the operated hips are doing 

well at the most recent follow-up. Five hips required revision surgery 

following the index procedure. Two femoral components were 

revised, one following a peri-prosthetic fracture and the second for 

aseptic loosening. Two acetabular components were revised, one 

for recurrent dislocation, and the second for acetabular wear and 

symptomatic metallosis. Additionally, one patient underwent twostage 

revision for infection. The overall survival with loosening as 

an endpoint was 84% at final follow-up. The mean Harris Hip score 

improved from 42 points (range, 19 to 66 points) pre-operatively, to 

83 points (range, 55 to 100 points) at final follow-up. No hips had 

evidence of loosening on final radiographic evaluation. Total hip 

arthroplasty provided good clinical results in patients with Down’s 

syndrome at a mean follow-up time approaching 10 years. While 

five patients did require revision for various reasons, all were doing 

well at final follow-up. While these patients can be more challenging 

to treat due to a higher incidence of hip dysplasia, joint laxity, and 

sometimes difficulty complying with hip precautions, awareness of 

the technical challenges, appropriate pre-operative planning, and 




good surgical technique with selective use of acetabular constraint 

appears to reliably provide patients with excellent pain relief and 

improved function. 


Creation of a Comprehensive Hip Preservation Service: 

Moving Beyond the Open Versus Scope Debate 


Jill Erickson, PA, Salt Lake City, UT 


The field of hip preservation surgery has grown substantially over 

the past decade coincident with the recognition that most young 

adult hip problems are associated with altered hip morphology. 

Although open hip procedures such as surgical dislocation (SD) and 

periacetabular osteotomy (PAO) have proven efficacy, arthroscopic 

treatment has increasingly become an attractive alternative to open 

hip approaches. In an effort to circumvent the ‘either/or’ approach, 

our center established a comprehensive service incorporating both 

arthroscopic and open hip surgery tailored to specific operative 

indications. The hypothesis was that the service would better address 

patient demand, define operative indications, and improve clinical 

outcome. In 2008 hip arthroscopy was formally incorporated into 

the Hip Preservation Service. Indications for operative intervention 

included FAI, dysplasia, and prearthritic hip disease. All operative 

hip preservation cases were shown at a multidisciplinary indications 

conference. Clinical outcome was measured with the HHS, SF- 

36, Lower Extremity Function Score (LEFS), Rapid Assessment of 

Physical Activity Score (RAPA) and conversion to THA. The mean 

age of all patients was 28 years (range 13-59). From 2008-2010, 147 

hip arthroscopy and 106 open procedures were performed (59 SD, 

47 PAO). The HHS improved from 76 to 91 (p

PAPERS 

518 

adult reconstruction Knee 

pApeR No. 001 

Five Year Results Of An RCT Comparing Mobile And 

Fixed Bearing Total Knee Replacement 


There is conflicting evidence about the merits of using mobile 

bearings at total knee replacement (TKR), partly because most 

randomized controlled trials (RCTs) have not been adequately 

powered. A pragmatic multicenter RCT involving 116 surgeons in 

34 UK centers was begun in 1999. Within a partial factorial design, 

539 patients were randomly allocated to mobile or fixed bearings. 

The primary outcome measure was the Oxford Knee Score (OKS); 

secondary measures included SF-12, EQ-5D, costs, cost-effectiveness 

and need for further surgery. There was no significant difference 

between the groups preoperatively. At five years, the mean OKS 

was approximately 33 in both groups. There was no significant 

difference between trial groups in OKS at five years (-1.21 95% CI 

-3.20, 0.96) or any of the other outcome measures. There was no 

significant difference in the proportion of patients with knee-related 

re-operations. In this appropriately powered RCT over the first five 

years after TKR, functional outcomes and re-operation rates appear 

to be the same whether mobile or fixed bearings are used. 

pApeR No. 002 

Rotating Platform Knees Did Not Result in Better Knee 

Flexion, Function, or Durability at 5-Years 

Michael Kalisvaart, MD, Rochester, MN 

Mark W Pagnano, MD, Rochester, MN 

Robert T Trousdale, MD, Rochester, MN 

Michael J Stuart, MD, Rochester, MN 

Arlen D Hanssen, MD, Rochester, MN 

Rotating-platform knee designs are intellectually appealing because 

of the contention that they can self align and thus accommodate 

small mismatches in the rotational position of the tibial and 

femoral components after total knee arthroplasty (TKA). Others 

have suggested a durability advantage with these designs over time. 

We carried out a randomized clinical trial to determine if there was 

a clinically important difference in function, motion or durability 

between rotating platform and fixed-bearing TKA. This prospective 

randomized study of 240 primary TKA used a single posteriorstabilized 

femoral component and included three groups of 80 

patients: all-polyethylene fixed bearing, a modular metal-backed fixed 

bearing and rotating platform. The three groups were dynamically 

balanced with a computerized randomization process that accounted 

for age, gender, BMI, surgeon and implant and thus there were no 

significant differences in the demographic characteristics between 

the groups. Patients returned for examination and radiographs 

at three months, one year, two years and five years. Function, as 

measured by Knee Society scores, at both two years (90, 91 and 91) 

and five years (88, 89 and 88) was not significantly different among 

the all-polyethylene, modular metal-backed and rotating platform 

groups, respectively. Stair climbing scores at two years and five years 

(39, 40 and 39) were not significantly different among the three 

groups. Range of motion at both two years (111°, 111° and 109°) 

and five years (110°, 109° and 109°) was not significantly different 

among the three groups. There were five revisions: one in the allpolyethylene 

group (patella fracture), two in the modular metalbacked 

group (aseptic loosening) and two in the rotating platform 

group (infection). In this randomized clinical trial, the rotating 

platform design did not result in better knee flexion, function or 

durability at five years compared with a posterior-stabilized, fixedbearing 

knee. 

pApeR No. 003 

Comparable Clinical Outcomes of a Fixed Versus 

Mobile Bearing Posteriorly Stabilized TKA 


Tracy Kinsey, RN, Athens, GA 

Theresa D’Errico, Mahwah, NJ 

Jianhua Shen, Mahwah, NJ 

We report the results of a multi-center randomized clinical trial (RCT)/ 

Investigational Device Exemption comparing a mobile bearing (MB) 

posterior stabilized cemented total knee arthroplasty (TKA) device 

to a fixed bearing (FB) device of the same design. With Institutional 

Review Board approval, 507 primary TKA of 416 patients from 14 

U.S. centers were randomized to FB or MB devices from November 

2001 to August 2007. WOMAC, SF-12, Knee Society Scores and range 

of motion were compared at six, 12 and 24 months post-op. Kaplan- 

Meier survivorship was compared using the log rank test. Retrieved MB 

device components underwent independent laboratory analysis. The 

study had >80% power to detect sub-clinical differences of outcome 

assessment scores. There were no differences (all p>.05) of mean 

clinical assessment scores or of mean score changes from baseline 

at any post-operative interval; 95% confidence intervals furthermore 

excluded clinically significant differences for most outcomes (i.e., 

clinical outcomes were statistically equivalent). At 2 to 7.5 years 

followup, 19/252 MB and 12/255 FB knees had undergone revision 

of any component. Survival was 94.7% for MB and 89.7% for FB 

(p=0.260). Two MB and no FB tibial components were revised for 

loosening. There was one case of MB insert dislocation. Three of 12 

retrieved MB inserts demonstrated mild abrasive wear on the articular 

surface, and only one on the undersurface. This adequately powered 

multicenter RCT revealed no evidence of clinically significant benefit 

of the MB design. Though survivorship was not statistically different, 

more revisions were observed in the MB group. 

pApeR No. 004 

Cemented Rotating Platform Total Knee Replacement: 

A Minimum Twenty Year Follow-Up Study 

John J Callaghan, MD, Iowa City, IA 

Christopher W Wells, BA, Bloomington, IN 

Steve S Liu, MD, Iowa City, IA 

Devon D Goetz, MD, West Des Moines, IA 

Richard C Johnston, MD, Iowa City, IA 

The purpose of this study was to address the question ‘What is the 20year 

durability of a mobile-bearing knee replacement and how does 

it compare to the durability of fixed-bearing knees at this length of 

follow up?’ This study was prospective in design and retrospectively 

reviewed. A total of 119 consecutive total knee arthroplasties were 

performed by a single surgeon in 86 patients and were followed for 

a minimum of 20 years. Average age of the patients was 70 years 

(range 37-88). Of this, 34 patients were males and 52 were females. 



PaPers, Posters & scientific exhibits AR KNee

At minimum 20-year follow up, 20 patients (26 knees) were known 

to be living, 64 patients (91 knees) were deceased, one patient (one 

knee) was lost to follow up and one patient (one knee) refused to 

participate, although he stated he was never revised. All patients 

received a cemented rotating platform mobile-bearing design. The 

living patients were evaluated clinically for the need of revision 

and with the Knee Society Score (KSS), the Hospital for Special 

Surgery Score and the WOMAC Score. Radiographs were evaluated 

for loosening and osteolysis. No knee had a revision of an implant. 

Two knees required reoperation for perioprosthetic fracture without 

revision of the components. One additional knee required a liner 

exchange for hematogenous infection. One knee has demonstrated 

radiographic loosening of the femoral component. Over the 20-year 

follow up, six knees have demonstrated osteolysis, two of which 

were extensive. Clinically, the average KSS were 89 (clinical) and 67 

(functional). The average HSS score was 80, and the average scaled 

WOMAC score was 19. Considering that gamma irradiated in air 

polyethylene was utilized in these cases, the durability of this cohort 

of total knee replacements has been excellent. These results are 

comparable or better than other 20-year studies with fixed-bearing 

designs. 

pApeR No. 005 

Prospective Randomized Comparison Of High Flex And 

Standard Rotating Platform TKA 

William G Hamilton, MD, Alexandria, VA 


Supatra Sritulanondha, Alexandria, VA 

Most manufacturers have high flex total knee designs available, with 

variable reports regarding their ability to improve postoperative 

flexion. The goal of this study was to determine if the rotating platform 

high flex (RP-F) design provides improved flexion compared to the 

standard rotating platform (RP) total knee arthroplasty. A total of 142 

patients were prospectively randomized to receive either a posterior 

stabilized RP-F or RP design. All protocols were similar between 

groups. Maximum supine active flexion was measured with both a 

goniometer and cross table lateral x-ray pre-op, at one month and 

12 months post-op. Pre-op and one year Knee Society, Oxford and 

satisfaction scores were measured and compared between groups. 

Complications were carefully recorded throughout. There were no 

differences in the demographics, Knee Society, Oxford or satisfaction 

scores at any interval between groups. There was no difference in the 

maximum flexion measured with goniometer or x-ray at any interval 

between groups (one year clinical flexion RP 123.7 degrees, RP-F 124 

degrees; p=.89; one year x-ray flexion RP 117.6 degrees, RP-F 117.6 

degrees; p=.998). There was no difference between groups comparing 

the improvement in pre-operative to one year postoperative flexion 

(RP-F 5.4 degrees, RP 3.3 degrees; p=0.29). There were 10 patients 

with post-op patellar crepitus, with a trend towards more in the RP-F 

group but not statistically significant with the numbers available 

(RP-F 8 patients, RP 2 patients, p=0.097). There was no difference 

in range of motion or clinical outcomes using a high flex rotating 

platform design, with a trend towards a higher incidence of patellar 

crepitus seen using this design. Due to these results, coupled with 

the increased bone resection and higher cost, we no longer routinely 

use the RP-F design. 

519 

pApeR No. 006 

Initial Experience of the Journey-Deuce 

Bicompartmental Knee Prosthesis 

Brian Palumbo, MD, Clearwater, FL 

Eric Henderson, MD, Tampa, FL 

Paul K Edwards, MD, Tampa, FL 

Brandon Burris, MD, Tampa, FL 

Sergio Gutierrez, PHD, Tampa, FL 

Aditya Ancha, BA, Clearwater, FL 

Stephen J Raterman, MD, Tampa, FL 

We sought to identify the following: (1) Early clinical results 

after implantation of the Deuce prosthesis and (2) post-operative 

assessment of radiolucencies. From January 2008 to January 2009, 

36 Journey-Deuce bicompartmental knee arthroplasties (BKAs) 

were implanted in 32 patients. The mean time to last follow up 

was 21 months. All cases were performed at a single institution by 

one surgeon. Medical records were reviewed retrospectively and 

patients were contacted via telephone and WOMAC, functional-KSS, 

pain scale and satisfaction surveys were performed. Independent 

radiographic review was performed on all implants to evaluate for 

post-operative radiolucencies. Operations were performed on 24 

females and 14 males with a mean age of 66 years. While 61% of tibial 

implants demonstrated progressive radiolucencies, no association 

with clinical outcome was observed. Bone scans were performed 

on eight patients due to persistent knee pain. In all cases isolated 

increased radiotracer uptake at the tibial bone-cement interface was 

observed. The mean KSS was 65.4. In detail, 31% of patients had an 

excellent result, 17% had a good result, 14% had a fair result and 

39% had a poor result. The mean WOMAC score was 75.8. Only 

19% of knees were painless. A total of 44% of patients stated that 

they were completely satisfied with their surgery while 25% rated 

their satisfaction as partial, and 31% stated that they were unsatisfied 

with the procedure. Additionally, 53% stated they would not repeat 

the procedure again. Conversion to total knee arthroplasty (TKA) was 

performed for persistent pain in five knees (14%) and the mean time 

to conversion was 19 months. Intraoperatively, all tibia base plates 

were grossly loose and were easily explanted. One patient was found 

to have a fractured tibial baseplate intraoperatively. Implantation of 

the Deuce BKA provides unreliable pain relief and functional results. 

A survival rate of 86% at 21 months is unacceptable in comparison 

to reported results of TKA. We report one catastrophically failed 

device in our series of 36 cases. 

pApeR No. 007 

Fixed Bearing Unicompartmental Knee Arthroplasty at 

a Minimum of 15 Years 

Jared R H Foran, MD, Golden, CO 


Richard A Berger, MD, Chicago, IL 


Jorge O Galante, MD, Chicago, IL 

Unicompartmental knee arthroplasty (UKA) has increased in 

popularity with scant evidence of continued longevity into the 

second decade of use. The purpose of this paper is to report the 15year 

to 20-year results of a consecutive series of unicompartmental 

knee arthroplasties. Sixty-two consecutive cemented, modular, fixedbearing 

UKA in 51 patients were studied prospectively. The cohort 

consisted of 34 females and 17 males with a mean age of 68 years 

(range, 51 to 84). Patients were deemed candidates for UKA based 

on the criteria of Kozinn and Scott. One patient was lost to follow 

up and 35 patients died leaving 19 knees in 15 patients evaluated 




at a mean of 19 years (range, 15-21 years); all deceased patients had 

well-functioning knees at the time of death. The mean Hospital for 

Special Surgery (HSS) knee score improved from 55 points (range, 

30-79) preoperatively, to 78 points (range, 23-100) at latest follow 

up (p-value=.003). No knees had radiographic evidence of loosening 

or osteolysis. Four of the 62 knees were converted to total knee 

arthroplasties (TKA); three for symptomatic patellofemoral arthritis 

and one for lateral compartment arthritis. Kaplan-Meier survival 

analysis revealed 15-year survivorship of 91% with revision for any 

reason as an endpoint (95% confidence interval 80% - 96%) and 

a projected 20-year survivorship of 85% (95% confidence interval 

73% - 92%). The 15-year to 20-year survivorship of this cohort was 

comparable to many reports of TKA. These results may not apply 

to broadened indications for UKA particularly in a younger patient 

population. 

pApeR No. 008 

Mobile Unicompartmental Knee Arthroplasty: 

Prospective Independent Study. Five To 11 Years 

Follow-Up 

Mr Lukas Lisowski, Amsterdam, Netherlands 

Dr Michel Van den Bekerom, Amsterdam, Netherlands 

Andrzej Lisowski, MD, Heerlen, Netherlands 

The use of unicompartmental knee arthroplasty (UKA) in the 

treatment of medial osteoarthritis of the knee has rapidly increased 

over the recent years. We report the outcome of the first mobile 

UKAs with a minimal five-year follow up (FU) years performing a 

minimal invasive surgical technique. Between 1999 and 2005, 138 

consecutive medial UKAs were implanted by a single surgeon. Nine 

patients deceased prior to their five-year assessment. The mean FU 

to date was 7.2 years (range 5 to 11.5 years), and the mean age was 

69.8 years. Pain, function and radiography were evaluated pre- and 

post-operatively and the survival of the arthroplasty was analyzed. 

The mean Knee Society score at latest FU was 90.9 (57.0-100). The 

Oxford Knee score was 38.5 (4-48). Eight knees with persisting pain 

complaints were successfully treated by arthroscopic procedures. Six 

knees were revised to total knee arthroplasty of which three because 

of failure of using strict selection criteria. The eight-year cumulative 

survival rate was 95%. Ninety-six knees were available at five years 

for fluoroscopic evaluation and radiolucency beneath the tibial 

component was found in 21% (N=20:5 complete and 15 partial). 

None of these patients had pain complaints. This study shows a high 

survival rate of this mobile UKA. The presence of radiolucency had 

no influence on functional outcome, survival and pain complaints. 

When strict indication criteria are followed, an excellent, and in our 

opinion reliable and durable, functional and radiological outcome 

can be expected in the medium term. 

pApeR No. 009 

Long Term Outcome (30 years) Following TKA after 

HTO in Young Patients With Varus Deformity 

Philippe Hernigou, PhD, Creteil France, France 

Alexandre Poignard, MD 

Charles Henri Flouzat-Lachaniette, MD 

Knee replacement is a satisfactory pain-relieving procedure in 

young patients, although survival may be poor. Isolated valgus 

osteotomy, with total knee arthroplasty (TKA) at a later stage is one 

of the solutions for young patients. This two-step strategy would 

require either no overcorrection in the previous osteotomy to avoid 

jeopardizing later the arthroplasty, and subsequently poor pain relief 

unless the TKA has been performed; either overcorrection osteotomy 

520 

that will improve pain relief to a better extent but will make the knee 

replacement hazardous because of the proximal tibial deformity. 

However, no result with a very long follow up has been reported. 

This paper studies the results of these two operations with a follow 

up of more than 30 years after the osteotomy. Total knee arthroplasty 

following high tibial osteotomy (HTO) for the treatment of arthritis 

have specific technical difficulties. The aim of this study was to 

compare function, quality of life (QOL) and survival outcomes 

of TKA in patients who had a previous HTO (opening or closed 

wedge technique) with TKA performed for primary arthritis. All the 

patients operated in our institution between 1985 and 1990 for 

the first operation (HTO) and between 1992 and 2000 for the TKA 

arthroplasty (HTO TKA group) were included in this retrospective 

study and compared to a randomly chosen group of patients operated 

on for primary arthritis (PA group) during the same period. A total 

of 143 patients (average age 45, range 34-58 at HTO) were included 

in the HTO TKA group (70 after opening wedge technique, 73 after 

closed wedge) and 150 in the PA group. All implants were the same 

and cemented (postero-stabilized arthroplasties). The preoperative 

and postoperative deformities were measured on weight-bearing 

radiographs of the whole limb (hip-knee-ankle angle) before 

and after each operation. Knee Society knee and function score 

improvement and QOL results for the five categories of the Knee 

Osteoarthritis Outcome Score were significantly lower in the HTO 

group (p

height and posterior slope of the proximal tibia were measured 

in preoperative and postoperative plain radiographs. Interval 

from surgery to weightbearing and radiographic union, range of 

motion and various functional knee scores were done for clinical 

assessment. Fibular head height significantly changed in Group 

T (11.4 to 3.1mm, p0.05). Lateral closing wedge high 

tibial osteotomy with fibular shaft osteotomy showed the minimal 

change of fibular head height and the possibility of larger correction 

in varus deformity without any complications including peroneal 

nerve palsy, compared with tibiofibular division. LCWO with fibular 

shaft osteotomy served a stable, effective and safe procedure in varus 

deformed unicompartmental osteoarthritic knees. 

pApeR No. 011 

The Influence of the Prosthesis Design on Outcomes of 

TKA: Minimum 5-Year Follow-up 

Sang-Min Lee, MD, Seoul, Republic of Korea 

Sang Cheol Seong, MD, Seoul, Republic of Korea 

Sahnghoon Lee, MD, Pittsburgh, PA 

Jak Jang, MD, Seoul, Republic of Korea 

Joon Kyu Lee, MD 

Sang Ho Shim, MD, Seoul, Republic of Korea 

Myung Chul Lee, MD, Seoul, Republic of Korea 

The purpose of this study was to compare the outcomes of standard 

cruciate-retaining (CR), posterior stabilized (PS) and high-flexion 

posterior stabilized (HF-PS) total knee arthroplasties (TKA) at a 

minimum five-year follow up. One-hundred-eighty-eight primary 

TKAs in 138 patients with three different types of prostheses with 

similar design evolved by a single company were included in the 

study. They were followed up for a mean of 7.1 years (range, 5-9.5 

years). Forty-eight knees had TKA with a standard CR design, 45 

with a standard PS design and 95 with a high-flexion PS design. 

Range of motion, American Knee Society (AKS) Score, Hospital 

for Special Surgery (HSS) Score, Western Ontario and McMaster 

Universities Osteoarthritis (WOMAC) Index scores and radiographic 

outcomes were evaluated. There was no difference in preoperative 

demographics, clinical and radiographic data among groups. The 

average range of motion was 112.5° in CR, 116.5° in PS and 118.7° 

in HF-PS knees (p=0.213). There was no significant difference 

in clinical outcomes including AKS knee scores (94.2:95.6:93.5, 

p=0.358), AKS function scores (87.3:89.8:88.0, p=0.710), HSS scores 

(90.7:91.1:89.2, p=0.314) and WOMAC index scores (16.1:14.2:12.2, 

p=0.238). Neither tibiofemoral angle (5.2:6.0:4.9, p=0.174) nor 

patellar tilt angle (0.2:0.1:1.7, p=0.622) showed difference among 

groups. Revision rates (2.1%:6.6%:6.3%, p=0.510), as well as aseptic 

loosening and complications, were not different. After a minimum 

follow up of five years, TKAs with three different types of prostheses 

with similar design resulted in comparable outcomes with regard to 

the range of motion, clinical and radiographic parameters. 

521 

pApeR No. 012 

Medial-Lateral Stability Post Total Knee Arthroplasty 

Affects Function: Results From A Joint Registry 

Renyi Benjamin Seah, MBBS, Singapore, Singapore 

Ngai-Nung Lo, MD, Singapore, Singapore 

Seng-Jin Yeo, FRCS, Singapore, Singapore 

Shi-lu Chia, MBBS, Singapore, Singapore 

Pak Lin Chin, FRCSEd, Singapore, Singapore 

Hwei Chi Chong, Singapore, Singapore 

One of the prerequisites of a successful total knee arthroplasty (TKA) 

is stability on varus-valgus stress. Our objective was to analyze the 

effect of medial-lateral instability on functional outcome and quality 

of life after TKA. Prospectively collected patient data was obtained 

from the Joint Registry of a tertiary institution (Singapore General 

Hospital) for all TKAs performed between 2004 and March 2008 

with a follow up of two years. Medial-lateral laxity (Group 1: 10°) was assessed by five independent 

researchers. Only Charnley A patients were included. A total of 

1,500 patients undergoing 1,507 arthroplasties (mean age=66.9 

years) were assessed and divided into three groups based on mediallateral 

laxity. (Groups 1: n=416, Group 2: n=878, Group 3: n=213). 

Majority of patients were female (80.7%) and had knee flexion 

greater than or equal to 90 degrees (96.2%). Knee Society Function 

Score (KSS-function), Oxford Knee Score (OKS) and SF-36 quality 

of life scores were obtained with self-administered questionnaires. 

This study reported a significant benefit of having a stable knee 

(medial-lateral laxity 35kg/m2) scheduled to undergo bariatric surgery, with clinical 

and radiographic evidence of knee OA, were invited to participate 

in this investigation. Western Ontario and McMaster Universities 

Osteoarthritis Index (WOMAC) and Knee Injury and Osteoarthritis 

Outcome Score (KOOS) surveys were administered preoperatively, 

and six and 12 months post-surgery. Patient weights were recorded 

at baseline and each follow-up appointment. Statistical analysis was 

performed with the Univariate procedure with Students T test, Sign 




and Signed Rank tests to assess changes from baseline. Patients were 

not prescribed exercise programs, medications or injections during 

the study. Weight loss at six and 12 months following bariatric 

surgery was found to be statistically significant (p < 0.0001). All 

variables from both the KOOS and WOMAC surveys at six and 12 

months improved to a significantly significant (p < 0.05) degree 

relative to baseline. This study demonstrates that isolated weight 

loss via bariatric surgery in obese patients with symptomatic, 

radiographically confirmed knee osteoarthritis results in significant 

improvements in knee pain, stiffness and function. Further study of 

overweight but less obese patients is warranted, as we believe that 

earlier weight loss could represent a more economical approach to 

non-operative treatment than prescription medications, injections 

and surgery for many patients. Recognizing the economic impact 

of knee arthritis in the United States, even minor reductions in the 

number of knee arthroplasty procedures would result in significant 

cost savings. 

pApeR No. 014 

Total Knee Arthroplasty In Morbidly Obese Patients 

Treated With Bariatric Surgery: A Comparative Study 

Erik P Severson, MD, Crosby, MN 

James Andrew Browne, MD, Charlottesville, VA 

Jasvinder Singh, MD, Vestavia, AL 


David G Lewallen, MD, Rochester, MN 

The purpose of this study was to test the hypothesis that patients 

undergoing weight loss surgery prior to total knee arthroplasty 

(TKA) will have fewer perioperative complications and have better 

functional results when compared to those undergoing TKA while 

morbidly obese, and prior to weight loss surgery. A retrospective 

review was undertaken using an institutional registry. In an 

attempt to identify the timing of when bariatric surgery and TKA 

is optimized in relation to each other, subjects were divided into 

three groups. Group 1 underwent TKA prior to bariatric surgery. 

Group 2 underwent TKA < 2 years after bariatric surgery and Group 

3 underwent TKA > 2 years after bariatric surgery. There were a total 

of 125 TKAs with follow up ranging from a minimum of 22 months 

to 14 years. Group 1 had 39 TKAs, group 2 had 25 TKAs and group 

3 had 61 TKAs. The operative time for group 3 was significantly 

less than the operative time for group 1 (p = < 0.001) as well as 

group 2 (p = 0.022). The overall complication rate among all 125 

knees was 15.2% (19/125). Although there was a trend toward a 

higher complication rate seen in group 1, it did not meet statistical 

significance (p = 0.08). No transfusions were required in group 1 

compared to 3/25 in group 2 (p = 0.06) and 6/61 in group 3 (p = 

0.08). The overall revision rate was 5.6% (7/125), with no significant 

difference between groups. This study analyzed if weight loss surgery 

prior to TKA would mitigate the risk to the patient. The findings in 

this study suggest that although operative time is less in group 3 

and transfusion rates are lower in group 1, the patients experience 

similar elevated rates of perioperative complications regardless of 

the temporal relationship between weight loss surgery and TKA. 

These results compare adversely to prior published outcomes in 

non-bariatric patients using the same institutional registry. 

522 

pApeR No. 015 

Does Periarticular Injection Bring Additional Benefits in 

Contemporary Pain Control Protocols? 

In Jun Koh, MD 

Chong Bum Chang, MD, Seongnamsi, Gyunggido, Republic of 

Korea 

Kil Jae Lee, MD 

Kyung-Hag Lee, MD, Seongnam-Si, Gyeonggi-do, Republic of 

Korea 

Byung June Chung, MD, Seoul, Republic of Korea 

Sae Kwang Kwon, MD, Bucheon-Si, Republic of Korea 

Eun Seok Seo, MD, Sungnam-Si, Gyenggi-do, Republic of Korea 


Tae Kyun Kim, MD, Seongnam-si, Gyeonggi-do, Republic of 

Korea 

Although the analgesic effects of periarticular multimodal 

drug injection (PMDI) have been well documented, there is 

little information about additional benefits of adding PMDI to 

contemporary multimodal pain control protocols which have 

proved to provide excellent pain relief. These randomized, controlled 

trials attempted to determine whether PMDI brings additional pain 

relief in patients covered by spinal anesthesia, continuous femoral 

nerve block (FNB), IV-PCA and preemptive oral medication. It also 

attempted to identify predictors for pain relief effects from patientrelated 

factors including demographics (age, gender, height, weight, 

BMI) and preoperative status (ROM, American Knee Society score, 

WOMAC score, SF-36 score). A total of 87 patients undergoing TKA 

were randomized into two groups: the PMDI group who received 

periarticular injection and the No-PMDI group who did not. 

All patients administrated preemptive analgesic medication and 

received spinal anesthesia, continuous FNB, IV-PCA and Ketoprofen 

IM injection as acute pain rescuer. There were 45 knees in the 

PMDI group and 42 knees in the No-PMDI group. Comparisons 

between the two groups were made for pain level (operation night, 

postoperative (PO) 1D, 4D, 7D), consumption of PCA and acute 

pain rescuer, functional recovery (ability to straight leg raise (SLR), 

maximal flexion), patient satisfaction, incidences of side effects and 

complications. Multivariate regression analyses to identify predictors 

were conducted. , The pain level was significant lower at operation 

night (VAS 2.3 vs. 6.4, p

pApeR No. 121 

Pre-Admission Chlorhexidine Cloth Prep Reduces 

Surgical Site Infections In Knee Arthroplasty 


Jacqueline A Daley, MLT, Baltimore, MD 


Antonia Woehnl, MD 


The treatment of peri-prosthetic infections often requires multiple 

surgical procedures, imposing a sizeable burden on the patient, 

surgeon and hospital. Most surgical infections occur as a result 

of colonization with the patient’s native flora, and efforts have 

been focused on minimizing this source of contamination. The 

purpose of this study was to evaluate the incidence of surgical site 

infections in knee arthroplasty patients who used a pre-admission 

cutaneous surgical preparation protocol, and to compare these 

results to a cohort of patients who underwent standard in-hospital 

skin disinfection only. Participating patients who were scheduled to 

undergo knee arthroplasty were given six clorhexidine gluconateimpregnated 

cloths, with printed instructions for their use, the 

evening before and morning of surgery. Compliance with this 

protocol was confirmed at the time of hospital admission and 

entered into the institution’s infection control database. Records for 

all hip arthroplasties performed between January 2007 and March 

2010 were reviewed to determine the incidence of deep incisional 

and periprosthetic infections. Overall, the pre-admission protocol 

was used in 312 hip arthroplasties. A lower incidence of surgical 

site infection was found in patients who used the pre-admission 

protocol, compared with patients who used the in-hospital protocol 

alone. Two surgical site infections occurred in 312 patients (0.6%) 

who used the advance protocol, compared with 31 site infections 

in 1,336 knee arthroplasties (2.3%) performed in patients who did 

not use the pre-admission cutaneous preparation. When combined 

with hip arthroplasty patients, there were a total of three infections 

out of 715 patients who complied with the protocol, compared 

with 49 infections out of 2,938 patients who did not comply with 

the protocol (p=0.019). A pre-admission cutaneous chlorhexidine 

protocol reduced the incidence of surgical site infection compared 

with patients who underwent in-hospital skin preparation only. 

Further study is warranted to develop and evaluate strategies for 

maximizing surgeon and patient compliance with this protocol. This 

study confirms prior, underpowered preliminary studies that have 

suggested this as an effective method to prevent infection. 

pApeR No. 122 

Successful Identification of Infecting Pathogens in 

Culture-Negative Cases of PJI 


Bahar Adeli, BA, Philadelphia, PA 

Kwang Am Jung, MD, Philadelphia, PA 

Michael G Ehrlich, MD, Providence, RI 


Diagnosis of periprosthetic joint infection (PJI) poses many 

challenges, one of which is the difficulty of isolating the infecting 

organism in a proportion of patients. In recent years a sophisticated 

modality has been introduced. This technology uses a series of 

polymerase chain reactions (PCR) with organism-specific primers 

to identify known pathogens and virulence genes. We investigated 

its usefulness in identifying infecting organisms in cases of known 

or suspected PJI. We prospectively collected 45 synovial fluid 

specimens from patients undergoing revision total knee or hip 

523 

arthroplasty. All specimens were analyzed using this technology. 

Patients were classified as infected or uninfected based first, on 

the surgeon’s impression and, second, on the strict criteria for PJI 

that was developed at our institution. Among 45 patients, 16 were 

infected and 35 uninfected according to the treating surgeon’s 

judgment, while 18 were infected and 27 uninfected using our 

diagnostic criteria. We successfully (1) isolated the same pathogen 

as conventional culture in all 10 patients with culture positive PJI, 

(2) isolated a pathogen in four of eight patients with culture negative 

PJI and (3) identified the mecA gene for methicillin-resistance 

in all four patients with cultures positive for methicillinresistant 

organisms as well as in two patients not previously known to be 

infected by methicillinresistant organisms. It appears that multiplex 

PCR technology is a valuable tool for investigating suspected PJI. It is 

able to isolate an organism in patients with culture negative PJI and 

can provide additional information regarding the presence of the 

mecA gene. Since identification of an infecting organism allows for 

more effective and focused therapeutic strategies, we believe this can 

be effectively utilized in patients with culture negative PJI or a high 

suspicion for infection. 

pApeR No. 123 

Serum and Synovial Fluid Tests for Periprosthetic 

Infection in Patients with Inflammatory Arthritis 

Cara A Cipriano, MD, Chicago, IL 


Andrew W Michael, MD, Hummelstown, PA 




Serum erythrocyte sedimentation rate (ESR) and C-reactive protein 

(CRP) and synovial fluid white blood cell (WBC) count and 

differential are effective in diagnosing periprosthetic joint infection 

(PJI); however their utility in patients with inflammatory arthritis 

is unknown. The purpose of this study is to determine the utility of 

these tests in patients with inflammatory arthritis. A total of 1,179 

consecutive revision hip and knee arthroplasties were prospectively 

evaluated for PJI. Some 308 cases were excluded due to acute postoperative 

or hematogenous infection. A total of 810 patients had 

non-inflammatory and 61 had inflammatory arthritis. Receiver 

operating characteristic (ROC) curves were used to establish optimal 

ESR, CRP, WBC and % neutrophil values for diagnosis of PJI, and 

the area under the curve (AUC) was calculated to determine overall 

accuracy. The optimal thresholds for predicting PJI were ESR 30 mm/ 

hr, CRP 17 mg/L, WBC 2,667, and differential 75% neutrophils in 

inflammatory arthritis, and ESR 32 mm/hr, CRP 15 mg/L, WBC 4,000, 

and 78% neutrophils in non-inflammatory arthritis. The efficacy of 

these tests was similar in both populations; AUC for inflammatory 

ESR=85.0%, CRP=85.1%, WBC=93.8%, differential=93.6% and 

for non-inflammatory ESR=84.9%, CRP=88.5%, WBC=94.5%, 

differential=95%. There was no significant difference between groups 

(ESR p=0.861, CRP p=0.549, WBC p=0.8315, differential p=0.7021). 

The rate of PJI was significantly higher in patients with inflammatory 

arthritis (33.3% vs.18.8%) arthritis (p-value=0.013). These results 

suggest that the ESR, CRP, synovial fluid WBC count and differential 

are useful in diagnosing PJI in patients with inflammatory as well as 

non-inflammatory arthritis with similar optimal cut-off values. 




pApeR No. 124 

CRP in joints: A Molecular Marker for Periprosthetic 

Joint Infection? 





William J Hozack, MD, Philadelphia, PA 

The goal of our study was to determine whether the accuracy of the 

serum C-reactive protein (CRP) assay for detection of periprosthetic 

joint infection (PJI) could be improved by measuring CRP in 

synovial fluid rather than in blood serum. Such an assay could 

improve the accuracy of diagnosis of PJI without significant added 

cost to hospitals. Synovial fluid specimens were collected from 53 

patients undergoing revision total knee arthroplasty. CRP levels were 

measured using an individual CRP enzyme-linked immunosorbent 

assay (ELISA) (16 samples; eight infected, eight uninfected) and 

a multiplex immunoassay platform (53 samples; 17 infected, 36 

uninfected). Results from preoperative serum CRP assays conducted 

by the hospital laboratory were collected for comparison. Sensitivity, 

specificity and receiver operating characteristic (ROC) curve analyses 

were performed for each assay, with diagnosis of infection based 

on institutional criteria. CRP concentrations differed significantly 

between infected and uninfected joints in all three assays. The area 

under the curve was 0.965 for the individual ELISA, 0.931 for the 

multiplex assay and 0.872 for the serum CRP assay. Sensitivity and 

specificity were 87.5% and 87.5% for the individual ELISA, 93.3% 

and 88.9% for the multiplex assay and 80% and 89.7% for the 

serum CRP assay. Measuring CRP in synovial fluid rather than in 

serum appears to improve the test’s diagnostic strength, especially 

its sensitivity. Although this finding should be confirmed in a larger 

cohort, if the serum CRP assay can be adapted for use in synovial 

fluid, we believe such an assay holds great promise as a new, 

potentially low-cost, diagnostic marker for PJI. 

pApeR No. 125 

Periprosthetic Joint Infection: Are Patients with 

Multiple Prosthetic Joints At Risk? 

S. Mehdi Jafari, MD, Tehran, (Islamic Republic of) Iran 

David Casper, MD, Philadelphia, PA 




Risk of PJI at our institution remains below one percent for total joint 

arthroplasty. For those patients that do suffer from PJI, often they 

have other prosthesis in place. It is not known if these patients are 

at higher risk of developing infection in their other prosthetic joint 

and more importantly what strategies should be taken regarding 

evaluation of the other asymptomatic concurrent prosthetic joint. 

Using our prospective institutional database, patients with PJI who 

had other prosthetic joints in place at the time of presentation were 

identified. There were 56 patients with a mean age of 62.7 (range: 

31-89) years. The cohort consisted of nine patients with ipsilateral 

joints replaced, 37 with multiple knees, 17 with multiple hips and 

nine with a contralateral hip and knee. Five patients had three joints 

replaced and two had all four joints replaced. Out of 56 patients, 11 

patients (19.6%) developed infection in multiple joints. Of these 

11, eight were multiple knees, two were multiple hips and one was 

ipsilateral joint infections. Five of these infections were separated 

by less than six months (three simultaneously). Four patients were 

infected by phenotypically identical organisms. A previously aseptic 

524 

prosthetic joint has an increased risk for infection when another 

prosthetic joint develops infection. 

pApeR No. 126 

Molecular Markers for Diagnosis of Periprosthetic 

Joint Infection 





Despite the impressive battery of tests available for diagnosing 

periprosthetic joint infection (PJI), no gold standard has yet been 

identified. The goal of our study was to improve the surgeon’s ability 

to accurately diagnose PJI. Working from results of previous studies 

that have observed differential expression of inflammatory-response 

genes in cases of PJI, we extend this work to the protein level by 

comparing concentrations of inflammatory proteins in synovial 

fluid of known infected and uninfected arthroplasties. We analyzed 

53 synovial fluid samples from patients undergoing revision knee or 

hip arthroplasty. Samples were diagnosed as infected (17 samples) 

or uninfected (36 samples) based on clinical and laboratory criteria. 

Proteomics analysis was conducted to determine concentrations of 

46 inflammatory proteins in each sample. We used receiver operating 

characteristic (ROC) curve analysis to identify proteins that could 

serve as accurate markers for PJI. Of 46 proteins tested, 16 had an 

area under the curve (AUC) greater than 0.80, suggesting strong 

diagnostic capabilities. Of these proteins, we further identified 4 

(±2- macroglobulin, and interleukins 6, 8, and 1²) which could be 

used to diagnose infection with greater than 90% sensitivity and 

specificity. Interleukin-6 had the highest combined sensitivity and 

specificity at 100% and 97.2% respectively at a threshold of 4270 pg/ 

ml. This prospective study utilizing biomarker immunoassays has 

demonstrated promising results for the use of molecular markers 

in diagnosis of PJI. The study identified four agents that could 

potentially be used as diagnostic markers for PJI. As part of our 

ongoing study, we hope to confirm both the diagnostic strength and 

thresholds of these proteins. Future studies will focus on designing 

assays with these proteins in mind in order to produce clinically 

useful diagnostic tests for PJI. 

pApeR No. 127 

Surgical Wound Infections in Total Knee Replacement: 

A Comparison of Common Definitions 

Mohamed Sukeik, MD, London, United Kingdom 

Elizabeth Ashby, MRCS, Cambridgeshire, United Kingdom 

Paul Sturch, MBBS, Middlesex, United Kingdom 

Fares Sami Haddad, FRCS, London, United Kingdom 

APR Wilson, MRCP 

Wound surveillance has been reported to result in a significant fall 

in the incidence of wound sepsis in total knee arthroplasty (TKA). 

However, there is currently little guidance on the definition of surgical 

wound infection that is best used for surveillance. The purpose 

of this study was to assess the agreement between three common 

definitions of surgical wound infection as a performance indicator 

in TKA; (a) the Centers for Disease Control (CDC) 1992 definition, 

(b) the Nosocomial Infection National Surveillance Service (NINSS) 

modification of the CDC definition and (c) the ASEPSIS scoring 

method applied to the same series of surgical wounds. A prospective 

study of 500 surgical wounds in patients who underwent knee 

arthroplasties between May 2002 and December 2004 from a single 

tertiary center were assessed according to the different definitions of 




surgical wound infection. A total of 500 wounds were assessed in 

482 patients. Mean age of patients was 70+/-11 years, 61.6% were 

females, duration of surgery was 101+/-49 minutes and mean follow 

up was 35.2+/-25.7 months. The most commonly isolated species 

were Coagulase negative staphylococci (33.3%), Staphylococcus 

aureus (25%) and Pseudomonas aeruginosa (16.6%). The mean 

percentage of wounds classified as infected differed substantially 

with different definitions: 5.8% with the CDC definition, 3.6% 

with the NINSS version and 2.2% with an ASEPSIS score >20. When 

superficial infections (according to CDC category) were included, 

5.2% (26) of all observed wounds received conflicting diagnoses, 

and 1.4% (7) were classified as infected by both ASEPSIS and CDC 

definitions. When superficial infections were excluded, the two 

definitions estimated about the same overall percentage infection 

(2.2% and 2.6% respectively), but there were almost three times as 

many conflicting infection diagnoses (n = 14) as concordant ones (n 

= 5). Distinctions in surgical wound infection definitions contribute 

to notable differences in how infections are classified after TKA. Even 

small changes made to the CDC definition, as with the NINSS version, 

caused major variation in estimated percentage of wound infection. 

A single definition used consistently can show changes in wound 

infection rates over time at a single center. However, differences in 

interpretation prevent comparison between different centers. 

pApeR No. 128 

Dilute Betadine Lavage Prior to Closure for Preventing 

Acute Deep Periprosthetic Joint Infection 


Cara A Cipriano, MD, Chicago, IL 




Infection is a devastating complication following total joint 

arthroplasty. Prior work has shown that a dilute betadine lavage 

prior to wound closure decreases the rate of infection following 

orthopaedic spine procedures. The purpose of this study was to 

evaluate the efficacy of a dilute betadine lavage in preventing 

early deep post-operative infection following total hip (THA) and 

knee (TKA) arthroplasty. Dilute (0.35%) betadine lavage for three 

minutes prior to wound closure was introduced in June 2008. A total 

of 1,862 consecutive cases (630 THA and 1,232 TKA) performed 

prior to initiation of this protocol were compared to 688 consecutive 

cases (274 THA and 414 TKA) after, for the occurrence of acute 

postoperative infections (within the first 90 days post-operatively). 

Infections were defined as gross purulence encountered within the 

joint at the time of surgical exploration or a deep culture positive for 

bacterial growth. A chi-squared analysis was performed to compare 

the rates of infection with and without the use of betadine lavage. 

Eighteen acute post-operative infections (0.97%) were identified 

prior to the use of dilute betadine lavage and one (0.15%) since 

(p = 0.018). There were no significant differences in the age (63.7 

vs. 63.4; p = 0.59), percentage of females (66.2% vs. 66.9%; p = 

0.74), or primary diagnosis of osteoarthritis (89.4% vs. 90.6%; p 

= 0.38) between the two groups. These results suggest that dilute 

betadine lavage prior to surgical closure may be an inexpensive, 

effective means of reducing acute post operative infection following 

total joint arthroplasty. 

525 

pApeR No. 129 

Staphylococcus Aureus Decolonization Protocol 

Decreases Surgical Site Infections 

Scott R Hadley, MD, New York, NY 

Igor Immerman, MD, New York, NY 

Gregory Katz, New York, NY 

Faith Skeete, New York, NY 


Michael Phillips, MD, New York, NY 


Patients colonized with methicillin-resistant Staphylococcus 

aureus (MRSA) and methicillin-sensitive S aureus (MSSA) are at 

an increased risk of surgical site infections (SSI). We investigated 

the effects of implementation of an institution wide screening and 

decolonization protocol on the rates of SSIs in patients undergoing 

primary knee and hip arthroplasty from 2007 to 2009. The treatment 

group consisted of patients seen at pre-admission testing (PAT) prior 

to undergoing primary hip or knee arthroplasty. They were screened 

for MSSA and MRSA colonization, and provided a five-day course of 

nasal mupirocin and a single pre-operative chlorhexidine shower. 

Patients colonized with MRSA received vancomycin peri-operative 

prophylaxis. Patients not seen at PAT did not receive decolonization 

protocol and constituted a concurrent control group. All patients 

were followed one year for post-operative infection; SSIs were 

classified using the Centers for Disease Control criteria. Statistical 

analysis performed using Fisher’s exact test. Of the 2,058 patients 

in this study, 1,644 patients underwent PAT treatment protocol and 

414 were in the control group. There were six deep SSIs (1.45%) in 

the control group and 21 (1.28%) in the treatment group (p=0.809). 

The total hip arthroplasty treatment subgroup had a lower rate 

of deep SSI (1.19% 9/756) than its control group (2.38% 4/168) 

(p=0.27). There were trends towards decreased deep SSIs in the PAT 

treatment groups. Due to the low rate of infection in primary total 

joint surgery this study did not enroll a sufficient number of patients 

for statistical significance. However, we believe the trend supports 

MRSA and MSSA screening and decolonization in primary hip and 

knee arthroplasty. 

pApeR No. 130 

Alignment and BMI, Factors Associated with Total Knee 

Replacement Failures 

Robert Andrew Malinzak, MD, Mooresville, IN 

Kenneth Davis, MS, Indianapolis, IN 

Jeffery L Pierson, MD, Carmel, IN 

Michael E Berend, MD, Mooresville, IN 

John B Meding, MD, Mooresville, IN 

Merrill A Ritter, MD, Indianapolis, IN 

The purpose of this study was to determine the importance of 

tibiofemoral alignment and both femoral and tibial component 

positions upon failure of a total knee replacement and whether the 

“correction” of one component for another malaligned component 

to produce a neutral overall alignment is favorable. To define the 

range of neutral that is associated with the least amounts of failures, 

and the effect of body mass index (BMI) and alignment on implant 

survival. We retrospectively reviewed the pre-operative BMI and 

the post operative overall coronal tibiofemoral and tibial and 

femoral component alignments in 6,070 knees. Cox regression was 

performed on failures (excluding infection) with all patient-related 

factors including overall alignment, component positions and BMI. 

The tibial component position of 8° were the primary component angles most likely 




to be the cause of failure (p

pApeR No. 134 

Variable Cartilage Depth Prevents Precise 

Measurement Of Posterior Condylar Offset On Pre-Op 

X-Rays 

Henry D Clarke, MD, Phoenix, AZ 

Restoration of posterior condylar offset (PCO) of the femur may play 

an important role in determining flexion after total knee arthroplasty 

(TKA). Measurements of PCO on pre- and post-operative x-rays have 

demonstrated that reductions of 1 to 5 mm can reduce maximal 

flexion by 5 to 10 degrees. However, other reports don’t support these 

findings. While true lateral x-rays allow accurate measurement of the 

post-operative PCO, as the prosthesis can be accurately identified, preoperative 

measurement of PCO may be inaccurate as the thickness 

of remaining cartilage on the posterior condyles is not included. This 

Institutional Review Board approved, retrospective study included 

140 consecutive patients who underwent primary TKA. The medial 

and lateral posterior condylar bone cuts were performed in the 

usual manner. The resected specimen was sectioned in the sagital 

plane and the cartilage thickness was measured at the mid portion 

to the nearest millimeter. The mean cartilage thickness was 1.7 mm 

(range, 0 to 4 mm) on the medial posterior condyle and 2.0 mm 

(range, 0 to 5 mm) on the lateral posterior condyle. The thickness 

of remaining cartilage on the posterior condyles is between 0 and 5 

mm. This variability is not accounted for on pre-operative x-rays and 

likely contributes to conflicting reports on the effect of changes in 

PCO and post-operative flexion; a 2 mm reduction of radiographic 

PCO may actually represent up to a 7 mm reduction. In future 

studies of PCO, the remaining cartilage thickness must be measured 

intra-operatively and the pre-op radiographic measurement must be 

adjusted by this thickness. 

pApeR No. 135 

Does Cyclical Loading Affect Antibiotic Elution and 

Strength of Articulating Cement Knee Spacers? 

Benedict Rogers, MBBS, Woking, United Kingdom 

Fiona Middleton, MRCS 

Natalie Shearwood-Porter, Meng 

Anne Roques, PhD, Woking, United Kingdom 

Neil Bradley, FRCS, Godalming, United Kingdom 

Martin Browne, PhD, Southampton, United Kingdom 

Two-stage revision surgery for infected total knee replacement is 

considered optimal treatment with articulating antibiotic cement 

spacers being employed during the first stage to eradicate infection 

while maximizing soft tissue function. This study investigates the 

effect of cyclic loading of cement spacers on antibiotic elution. 

Femoral and tibial cement spacers containing vancomycin at 

constant concentration (1 g per 40 g pack), and tobramycin of 

varying concentration (1.2 to 3.6 g per 40 g pack) were cyclically 

loaded (0-45 degrees of flexion) against each other in Ringer’s 

solution under a maximum compressive load of 250N. We also 

loaded simulated ambulation on crutches for 35,000 cycles, with 

test interruptions simulating rest periods. Triplicate aliquots were 

taken and the variation in antibiotic concentration was measured. 

Unloaded samples were used as controls for statistical comparison. 

Post immersion compression tests were performed at 0 degrees of 

flexion. Tobramycin elution increased proportionately to its cement 

concentration and was significantly higher (p

pApeR No. 243 

Revision TKA Using Short Cemented Stems: Minimum 

10 year Follow Up 


Charles L Nelson, MD, Voorhees, NJ 

Paul A Lotke, MD, Gladwyne, PA 

There is ongoing controversy about the best way to obtain stable 

component fixation during revision total knee arthroplasty (TKA). 

The purpose of this study is to evaluate the long-term results of 

revision TKA using short cemented stemmed components. Between 

1984-1999, 350 consecutive revision TKA were performed by a 

single surgeon using short cemented stemmed components. There 

were 195 women and 155 men with a mean age of 72 years (range 

50-88). The cause for revision surgery was aseptic loosening in 211 

knees, instability in 25, patella/extensor mechanism problems in 

54, infection in 50 and miscellaneous in 10. All failed total knee 

replacements (TKR) were revised using a TCIII constrained knee 

implant (Depuy, Warsaw IN) with short cemented stem extensions. 

The clinical outcomes were evaluated using the Knee Society (KS) 

clinical and functional scoring systems and radiographs were 

evaluated for radiolucent lines and component loosening. The 

minimum follow up was 10 years (range 10-15 years). A total of 98 

patients died and 32 patients were lost to minimum 10 year follow 

up. Five patients in this group had undergone subsequent surgery 

following revision TKA (two infection, one fracture, one aseptic 

loosening and one instability). The remaining 220 patients had 

complete records and were followed for an average of 12.5 years 

(range 10-16 years). At last follow up, the KS clinical score averaged 84 

(range 38-99) and the mean functional score was 50 (10-75). Stable 

non-progressive radiolucent lines were present in 36 knees and eight 

knees had progressive radiolucent lines. Reoperations occurred in 21 

knees (10 infections, two tibial loosening, three femoral loosening, 

two instability, two patellar maltracking/clunk and one fracture). At 

a mean 12.5 years, the survivorship of the revision knee prosthesis 

was 90%. Revision TKA using short cemented stemmed components 

provided durable results at an average 12.5 year follow up. 

pApeR No. 244 

Outcome of 177 Knees Revised for Osteolysis with 

Minimum 5-Year Evaluation 


Nancy L Parks, Alexandria, VA 

Gerard Anderson Engh, MD, Alexandria, VA 

The purpose of this study is to describe the five-year outcome of 

total knees revised for osteolysis. A total of 177 total knee revisions 

were performed for osteolysis as a primary or secondary diagnosis. 

The mean age at revision was 68 years, and the mean time in situ 

was 7.8 years. Seventy-two knees underwent a complete revision, 57 

had only a tibial revision, 46 had an isolated polyethylene exchange 

and two were femoral revisions. Rerevisions and complications 

were documented along with standard clinical and radiographic 

evaluations. A survivorship analysis was done. Statistical analysis 

was done to evaluate the influence of revision type and osteolysis on 

outcome. Twenty-nine patients died with the knee intact and 21 were 

lost before five-year follow up. A total of 104 cases had minimum 

five-year follow up (range 5-17) and had not been rerevised. Twentythree 

cases had a subsequent revision. The most common reason 

was osteolysis or wear in 11 and loosening in five cases. There were 

an additional 12 complications that did not involve the implants. 

Five-year survivorship with component re-revision as an endpoint 

was 88%. Neither the type of index revision (p=0.11), the amount 

of bone loss (p=0.36) or reason for the initial revision (p=0.07) 

528 

was a predictor of failure. Revisions for wear and osteolysis are 

challenging. The most common mode of failure is continued wear 

and osteolysis followed by component loosening. Improvements in 

the design of revision total knee systems and development of wear 

resistant polyethylene have the potential to increase the survivorship 

of these surgeries. 

pApeR No. 245 

Clinical Results of Hybrid Technique Revision Total 

Knee Arthroplasty 

Joseph Greene, MD, Louisville, KY 


Shaun Reynolds, MD, Louisville, KY 

Michael Massini, MD, Ann Arbor, MI 

The number of revision total knee arthoplasties (TKA) performed in 

the United States continues to rise annually. It remains controversial 

whether fluted intramedullary stems used in revision TKA should 

be cemented or press fit. We believe that uncemented fluted 

intramedullary stems have survivorship rates at least comparable, if 

not higher, than cemented stems. We retrospectively analyzed 119 

patients’ midterm survivorship rate of revision total knee arthroplasty 

using hybrid stem fixation. Sixty-four men and 55 women were 

included with an average age of 67 (range, 47-87). Revision was 

performed predominantly for aseptic loosening (78) and infections 

(28). Average follow up was 62 months (range, 46-80). A total of 

58 tibial offsets and 28 femoral offsets were utilized to optimize 

intramedullary stem fixation. Average preoperative Knee Society pain 

score improved from 39 to 68 postoperatively (p

in 13, loosening in 10 and wear-osteolysis in four knees. Patients 

were followed clinically and radiographically using the Knee Society 

score systems. The patients were followed for a mean of 3.3 years 

(range, 2-5.7 years). The mean Knee Society pain score improved 

from 48 points preoperatively to 79 points postoperatively and the 

function score improved from 19 points to 47 points. There was one 

femoral cone, with a hinged prosthesis, revised for loosening and 

one knee, with both femoral and tibial cones, removed for infection 

(3.7%). All 24 tibial cones and eight of nine femoral cones showed 

osseous integration without loosening. One patient had reoperation, 

plating for femoral shaft fracture, and one had a wound reclosure 

for dehiscence. There was a high chance of success (defined as no 

re-revision) and a low rate of infection in these 27 difficult knee 

arthroplasty revisions with severe tibial and femoral bone loss. With 

two to five year follow up, these results are promising but longer-term 

follow up is required. The authors continue to use this technique for 

revision knee arthroplasty with severe bone loss. 

pApeR No. 247 

Revision Total Knee Replacement with Porous Coated 

Metaphyseal Sleeves 

Michael R Pagnotto, MD, Rochester, MN 

Catherine Julia Fedorka, MD, Philadelphia, PA 

Richard Louis McGough, MD, Pittsburgh, PA 

Lawrence S Crossett, MD, Pittsburgh, PA 


Porous coated metaphyseal sleeves are designed to fill bone defects 

and facilitate osseointegration. This study evaluated two-year results 

of porous coated metaphyseal sleeves in total knee revisions (TKR). 

A retrospective review was conducted on all patients who had a 

press fit tibial and/or femoral metaphyseal sleeve TKR from October 

1, 2003 to October 1, 2008. Preoperative bone loss was classified 

according to the Anderson Orthopaedic Research Institute (AORI) 

classification system. Charts were reviewed and patients were 

contacted to determine clinical outcome. Postoperative radiographs 

were evaluated for implant stability and evidence of ingrowth. Fiftyeight 

mobile bearing TKR were performed with a press fit metaphyseal 

sleeves (57 tibial and 33 femoral). Average age was 67 years (range, 

41-90). Indications included 27 infections, 16 loosening, six lysis, 

five pain and four for instability. Pre-op AORI classification on the 

tibial side was one type 1, 33 type 2a, three type 2b and 21 type 3. On 

the femoral side, they were six, nine, 36, and seven respectively. Four 

patients were lost to follow up leaving 54 patients and 53 tibial and 

32 femoral sleeves. Average follow up was 25 months (range, 5-68). 

At final follow up, 80 of 85 (94%) sleeves remained (49/53 tibial 

and 31/32 femoral) in place. Three sleeves were revised for infection 

and two for loosening. All 80 of the remaining 80 sleeves showed 

radiographic evidence of ingrowth. Modular porous coated press fit 

metaphyseal sleeves may be used to fill AORI type 2 and 3 defects 

and provide for stable ingrowth at two years. 

pApeR No. 248 

Revision TKA Using Trabecular Metal Spacers -Short 

Term Results 

Daniel Kendoff, MD, Hamburg, Germany 

Christian Schmitz, MD 

Wolfgang Klauser, MD, Hamburg, Germany 

Knee revision surgery is a challenging procedure especially in the 

presence of bone defects. We report preliminary results of revision 

procedures where trabecular metal spacers were used to fill the 

bony defects in severe revision cases. We retrospectively reviewed 

52 patients (average age 69.2 years) clinically using the Hospital 

529 

for Special Surgery (HSS) score and radiographically at average 34 

month after surgery. Bony defects were classified using the Anderson 

Orthopaedic Research Institute AORI classification (Engh, 1999). 

Classification of bony defects showed type 2 and 3 defects on the 

femoral or tibial side in the majority of cases. Reason for revision 

was aseptic loosening of total knee arthroplasty (TKA) in 51 cases; in 

17 cases, trabecular metal (TM) spacers were used both femoral and 

tibial side, in 18 cases only on the femoral side and in 17 cases on 

the tibial side. In six cases in addition to the TM spacer, impaction 

grafting was used using homologous bone grafts. , At latest follow 

up (average follow up time 34 months), average range of motion 

was 0-1-98 degrees for extension/flexion. HSS score increased from 

35 to 76 postoperatively. At latest radiographic follow up, all of the 

spacers appeared stable without change of position and showed 

signs of bony integration. Complications: periprosthetic fracture in 

two cases, re-infection of a TKA in one septical case, one implant 

change to a nail-arthrodesis after TKA, while the TM spacer was 

stable and showed complete osseointegration during revision. TM 

spacers appear to offer an excellent solution in knee revision surgery 

in the presence of major bony defects. 

pApeR No. 249 

Use Of Porous Stepped Metaphyseal Sleeves During 

Revision Total Knee Arthroplasty 

Rohit Maheshwari, FRCS, Edinburgh, United Kingdom 

Issaq Ahmed, MRCS, Edinburgh, United Kingdom 

Phil Walmsley, FRCS 

Ivan Brenkel, FRCS, Fife, United Kingdom 

Revision knee arthroplasty is an increasingly common procedure. 

These operations can be challenging with the need to deal with 

bone defects, ligament instability and fixation. Current treatment 

options for tibial and femoral bone loss in the revision setting 

include cement, morselized or structural allograft, metal wedges and 

augments and custom or hinge/tumour prosthesis. The aim of this 

study is to describe the initial results obtained using unique femoral 

and tibial metaphyseal sleeves as an alternate treatment for tibial and 

femoral bone loss following total knee replacements. Porous stepped 

metaphyseal sleeves were implanted during 20 revision total knee 

replacements in 11 men and nine women who had an average age 

of 73.3 years at the time of the procedure. The indications included 

aseptic loosening in 19 cases and second stage reimplantation in 

one case. Bone defects in tibia and femur were classified intra 

operatively according to Anderson Orthopaedic Research Institute 

(AORI) classification. All patients were followed clinically and 

radiographically. The average hospital stay was nine days (five to 20 

days). There were no periprosthetic fractures or complications related 

to the insertion and impaction of the sleeves. The patients were 

followed for an average of 16 months (12 to 26 months). Clinical 

examination exhibited good muscle strength and had no evidence 

of instability to varus/valgus and flexion/extension testing on their 

last clinic visit. The average range of motion in the knee was 0 to 

95 degrees. Radiographs demonstrated reestablishment of joint line, 

neutral mechanical axis (average five degrees valgus) and signs of 

stable osteointegration. No cases of progressive osteolysis, loosening 

or subsidence were noted. Unique femoral and tibial stepped 

metaphyseal sleeves compensate for cavitary defects, compressively 

load the metaphyseal bone avoiding excessive bone resection and 

offer biologic fixation leading to implant stability. 




pApeR No. 250 

Revision Total Knee Arthroplasty Using Metaphyseal 

Sleeves At Short-Term Follow-Up 

S. Mehdi Jafari, MD, Tehran, (Islamic Republic of) Iran 

Catelyn Coyle, BS 

Ronald Huang, Philadelphia, PA 


Fabio Orozco, MD, Egg Hbr Twp, NJ 

Alvin C Ong, MD, Linwood, NJ 

Management of bone loss during total knee revision (TKR) is 

challenging. Metaphyseal sleeves have been introduced recently to 

address this issue. This study presents the short-term outcome of TKR 

in which metaphyseal sleeves were utilized. From September 2006 

to present, 268 TKRs have been performed at our institution. A Total 

Condylar 3 (TC3) prosthesis or an S-ROM hinge with metaphyseal 

sleeve was used in 103 knees with minimum two-year follow up. The 

indications for revision were aseptic loosening, 59 (57.2%); taged 

reimplantation, 21 (20.5%); instability, 16 (15.5%); periprosthetic 

fracture, four (3.9%); and correction of malpositioned components, 

three (2.9%). Eleven (10.6%) hinged prostheses were used. Using the 

Anderson Orthopaedic Research Institute (AORI) classification, there 

were four (3.9%) type 2A, 96 (93.2%) type 2B and three (2.9%) type 

3 tibial defects. There were six (5.8%) type 1, 80 (77.7%) type 2B 

and 17 (16.5%) type 3 femoral defects. At average follow up of 2.5 

years (range, 2-3.7 years), the average Knee Society function and pain 

scores significantly improved (p

tibial component. An extensive literature search was performed to 

identify studies comparing fixation techniques in a single cruciate 

retaining total knee arthroplasty (TKA) design. All aspects of the 

systematic review were performed independently by two reviewers 

according to the Cochrane Handbook. Meta-analysis was performed 

with Mantel-Haenszel random effects pooling. There were 154 

unique hits. Three of these studies including 323 TKA were included. 

The revision rate of the uncoated tibial component due to aseptic 

loosening is 3.65 times higher than the cemented component; or 

3.65 95% CI 1.12 to 11.93]. The number needed to treat is 14 in 

favor of the cemented tibial component for this TKA design. 

pApeR No. 254 

Minimum 6-year Follow-up In The Use Of Uncemented 

Stems In Revision TKR 



Revision total knee replacement (TKR) almost always utilizes a stem 

to enhance fixation and off-load stresses at the damaged metaphyseal 

interfaces. Stem fixation can be either cemented or pressfit and there 

are advantages to both. We report our experience with minimum sixyear 

follow up on a series of revision TKR treated with uncemented 

stems. Forty-four revision TKRs were performed in 43 patients using 

uncemented stems for adjuvant fixation. The minimum follow up 

was six years (range six to 11 years). No patients were lost to follow 

up. Average canal fill on the lateral X-ray was 80% on the femur and 

82% on the tibia. There were two revisions for aseptic loosening, 

one at seven years and one at 10 years. A halo was seen on 72% of 

femoral stems and 66% of tibial stems. Knee Society Scores increased 

from an average of 44 to 91 at final follow up. Non-septic loosening 

in this group was 4.6% (two of 43). No patient complained of 

end of stem pain. The appeal of uncemented stems is their relative 

ease of insertion and re-revision if needed. The presence of ‘halos’ 

around these stems does not appear to be clinically significant. At 

minimum six-year follow up, uncemented stems are an effective way 

of enhancing fixation in the revision TKR setting. 

pApeR No. 255 

Success of Revision Knee Arthroplasty for Stiffness 

Thomas Robert Turgeon, MD, Winnipeg, MB Canada 

David Hedden, MD, Winnipeg, MB Canada 


Colin Burnell, MD, Winnipeg, MB Canada 

Stiffness following total knee replacement can be a debilitating 

complication hampering function and resulting in pain for patients. 

Surgeons are often reluctant to offer revision surgery due to concerns 

about the recurrence of stiffness. This study reviews the success rate of 

revision knee arthroplasty for stiffness. The outcomes of 26 subjects 

were retrospectively reviewed following revision with a principal 

diagnosis of stiffness. Subjects were assessed pre-operatively and then 

annually after surgery with the SF-12, Western Ontario and McMaster 

Universities Osteoarthritis Index (WOMAC) and Knee Society Score 

(KSS) including range of motion. The mean pre-operative flexion arc 

was 69° and increased to 91° (p=0.002) at a mean of 2.2 years. Mean 

KSS pain scores improved from 10 to 34 (p

a commodity. Patients who choose to regionalize are less likely to 

experience a post-operative surgical infection or complication than 

those who do not even after adjustment for hospital volume. 

pApeR No. 288 

Histologic Evidence of Mechanoreceptor Retention in 

Posterior Cruciate Retaining TKA 


Aaron Creek, Memphis, TN 

Michelle Mary, Memphis, TN 

John Leicester Williams, PhD, Memphis, TN 

David E Komatsu, PhD, Stony Brook, NY 

The presence of mechanoceptors in the cruciate ligaments of the 

knee has been long-reported. But to our knowledge, no one has 

looked at posterior cruciate ligaments that have been retrieved 

from well-performing, cruciate-retaining total knee arthroplasty 

(TKA) specimens. In this study we look at the qualitative evidence 

of retained mechanoreceptors in the human posterior cruciate 

ligament (PCL) from patients that have had total knee arthoplasty 

with retention of the PCL. Six cruciate retaining TKA specimens 

were identified from a retrieval program and six PCLs were obtained 

during TKA from osteoarthritis (OA) patients after consent. The 

whole en bloc PCL specimens were harvested for the study. These 

specimens were then sectioned to a thickness of 8 microns and 

mounted on lysine-coated microscope slides. The sections were then 

subjected to immunohistochemistry with neurofilament protein 

(NFP), and S-100 protein. These were used to label the central axon, 

the periaxonic Schwann-related cells and the perineurial-related 

cells of the proprioceptors. The quantity of mechanoreceptors 

were then compared between the two groups. Five out of six of the 

PCLs in this series were intact. From the implant lot numbers and 

identified manufacturers the shortest functioning time of an implant 

in the series was estimated at 10 years. All five PCL specimens 

revealed evidence of positive stained elements with both S100 

protein and NFP immunohistochemical staining. Morphologically, 

these elements appear to correspond to pacini and lamellar types 

of mechanoreceptors. No difference in number or location of 

mechanoreceptors in the OA group was found. Controversy over 

the retention of the PCL in primary TKA has continued for years. 

This study is the first to show that when the PCL is retained that it 

can maintain mechanoreceptors with innervations that may aid in 

function after a TKA. 

pApeR No. 289 

The Synovial Fluid Adiponectin-Leptin Ratio Predicts 

Pain With Knee Osteoarthritis 

Rajiv Gandhi, MD, Toronto, ON Canada 

Mark Takahashi, MD, Toronto, ON Canada 

Holly Smith, BSc 

Randy Rizek, MD, Toronto, ON Canada 

Nizar Mahomed, MD, Toronto, ON Canada 

Obesity is well known to be a risk factor for the incidence and 

progression of prevalent osteoarthritis (OA). There is increasing 

evidence that visceral and sub-cutaneous truncal white adipose 

tissue (WAT) is an active endocrine organ that secretes cytokines 

and adipokines. We asked what is the relationship between these 

hormones and patient-reported knee OA pain. We collected 

demographic data, Short Form McGill Pain scores, WOMAC pain 

scores and synovial fluid (SF) samples from 60 consecutive patients 

with severe knee OA at the time of joint replacement surgery. SF 

samples were analyzed for leptin and adiponectin using specific 

532 

ELISA. Non-parametric correlations and linear regression modeling 

were used to identify the relationship between the adipokines and 

pain levels. The correlations between the individual adipokines and 

the pain scales were low to moderate and consistently less than that for 

the corresponding adiponectin/leptin (A/L) ratio. Linear regression 

modeling showed that the A/L ratio was a significant predictor of a 

greater level of pain on the MPQ-SF(p=0.03) but not the WOMAC 

pain scale(p=0.77). In conclusion, a greater A/L ratio predicted lower 

knee OA pain as measured by the MPQ-SF, but not on the WOMAC 

pain scale. This finding was above that of the individual adipokine 

levels alone. Some authors have suggested that leptin may have a 

proinflammatory role while adiponectin an anti-inflammatory role 

in synovial joint diseases. Further work to elucidate these pathways 

may present a target for novel therapeutics in knee OA. 

pApeR No. 290 

Steroid Modulation On Cytokine Release And 

Desmosine Level In Bilateral Total Knee Replacement 

Thomas P Sculco, MD, New York, NY 

Kethy Jules-Elysee, MD 

SE Wilfred, BA 

Stavros G Memtsoudis, MD, PhD, New York, NY 

David Kim, MD 

Michael Urban, MD, New York, NY 

Jacques YaDeau, MD, New York, NY 

Alexander Stewart McLawhorn, MD, MBA, New York, NY 

IL6 is a marker of inflammation in both sepsis and surgery. In 

the orthopedic patient population, higher levels have been linked 

to acute respiratory distress syndrome, postoperative confusion, 

depression and fever. Furthermore, IL6 is one of the major cytokines 

released in all patients undergoing joint replacement surgery. We 

had found a statistically significant decrease in IL6 in bilateral total 

knee replacement patients (BTKR) receiving two doses of 100 mg 

hydrocortisone eight hours apart. However, by 24 hours, IL6 levels 

were equal in both placebo and study group. In this study, we looked 

to see whether giving three doses to patients undergoing BTKR 

would maintain lower levels of IL6 at 24 hours and affect outcome. 

In addition, we also looked to see an effect on levels of desmosine 

(found to be a marker of lung injury in patients undergoing BTKR). 

This study was a double blind randomized placebo controlled 

study powered in order to detect at least a 25% decrease in IL6 from 

baseline. Hydrocortisone (100 mg) or placebo was given at three 

doses, each eight hours apart to the study group and placebo group 

respectively. Urine for desmosine levels were obtained on day zero, 

one and three postoperatively. Blood for cytokines were drawn at 

baseline, six hours, 10 hours, 24 hours and 48 hours postoperatively. 

After Institutional Review Board approval, a total of 28 patients (13 

study, 15 control) were enrolled. Both groups had similar baseline 

characteristics. Average age was 65. IL6 increased in both groups, but 

was statistically higher in the control group at all time points. Peak 

IL6 levels at 24 hours were four times higher in the control group. 

Pain scores measured as visual analog scores (VAS) were significantly 

lower in the study group as was the incidence of fever (p=0.03). 

Range of motion at the knee was statistically higher in the study 

group (p=0.04). Urine desmosine levels doubled by 24 hours in 

the control group, but remained unchanged in the study group. No 

infection was noted three months postoperatively. Hydrocortisone 

(100 mg) given over three doses, each eight hours apart, was effective 

at decreasing and maintaining a lower degree of inflammation as 

measured by IL6. It decreased incidence of fever, lowered VAS scores 

and improved range of motion. The lower values of desmosine in the 

study group suggest that this may also be protective of lung injury. 




pApeR No. 291 

Benefits of Prolonged Postoperative COX-2 Inhibitor 

Administration on TKA Recovery 

Michael E Berend, MD, Mooresville, IN 

Paul Diesfeld, PA-C, Saint Louis, MO 

Angela LeMarr, RN, Saint Louis, MO 

Mary E Reedy, RN, Saint Louis, MO 

Perioperative use of selective COX-2 inhibitors has demonstrated 

decreased in hospital narcotic requirements and improved knee 

motion following primary total knee arthroplasty (TKA). The 

purpose of this study was to determine what benefits resulted from 

an additional six weeks of COX-2 inhibitor treatment. A doubleblind, 

placebo-controlled study enrolled 107 TKA patients who met 

Institutional Review Board inclusion criteria. All patients received 

celecoxib preoperatively and during hospitalization. At hospital 

discharge, patients were randomized to receive celecoxib or placebo 

for six weeks. Narcotic use, knee flexion, Knee Society Score (KSS), 

Oxford Knee Score (OKS) and SF-12 scores were determined 

preoperatively and at three, six, 12 and 24 weeks and one year postop. 

Visual analog scores (VAS) documented pain at rest, at night and 

with activities at each time point. Statistical analyses of longitudinal 

data were performed using mixed model repeated measures analysis 

of variance (ANOVA). Total narcotic count was less in the celecoxib 

group compared with the placebo group, 76 ± 55 vs. 138 ± 117 

respectively, p=0.003. VAS improved more for the celecoxib group 

at rest (p=0.01), at night (p=0.02) and with activities (p=0.04). 

Through 12 weeks, the celecoxib group had improved KSS knee 

scores (p=0.0005), KSS function scores (p=0.03), OKS (p=0.02) and 

SF-12 physical composite scores (p=0.005). Improvement in knee 

flexion with celecoxib was greater at each time point through one 

year, p=0.04. This prospective double-blind study demonstrated that 

a COX-2 selective inhibitor for six weeks after TKA led to a more rapid 

and less painful recovery. Celecoxib patients required less narcotics 

than placebo controlled patients. Despite taking nearly twice the 

narcotic, placebo patients still had more pain at rest, at night, and 

with activities. Patients taking celecoxib had improved knee function 

through three months as measured by the KSS, OKS and SF-12 PCS. 

Improvement in knee flexion remained greater through one year of 

follow up. 

pApeR No. 292 

Total Knee Replacement Implant Classification Using 

Neural Networks 

Mohamed Mahfouz, PhD, Knoxville, TN 

Nicholas Battaglia, BS, Knoxville, TN 

Emam Abdel Fatah, Knoxville, TN 

Sumesh M Zingde, Knoxville, TN 

Richard D Komistek, PhD, Knoxville, TN 

Cruciate retaining (CR) and bi-cruciate/posterior stabilizing 

(BCS/PS) are two commonly used contradicting philosophies in 

TKA design. The CR knee intends to promote greater anatomical 

function and motion; whereas the PS and BCS knees use a 

cam-post system aimed at mechanically ‘guiding’ normal knee 

kinematics. The objective of this paper was to investigate whether 

PS and CR knees exhibit different kinematic behavior. Feed-forward 

backpropagation neural networks were employed to identify knee 

implant types from full extension to maximum flexion kinematics. 

Three-dimensional kinematic data was collected for 1,200 subjects 

(PS, PCR and BCS) performing a deep knee bend maneuver under 

fluoroscopic surveillance. Kinematic data was captured for medial/ 

lateral anteroposterior translation (MAP/LAP); medial/lateral 

533 

superoinferior translation (MSI/LSI); lift-off; axial tibiofemoral 

rotation; and three-dimensional relative transformations of the 

implant components. The data was classified utilizing a feed-forward 

backpropagation neural network. The results showed that a neural 

network can reach a maximum training and testing classification 

rate of 93.0% and 91.5%, respectively. Furthermore, it was found 

that the neural network could classify the system using only the 

medial anteroposterior translation with a maximum training and 

testing classification rate of 84.1% and 81.7%, respectively. This 

study showed that neural networks can be utilized to classify knee 

implants by their in vivo kinematics with a relatively high success 

rate. Furthermore, these findings showed that MAP translation is one 

of the most discriminating features of the system, which is consistent 

with previous research. Furthermore, the three different design 

philosophies exhibited distinct kinematic patterns which were each 

significantly different than those reported previously for normal 

knees. It is clear that even through considerable effort put forth by 

industry and academia to improve implant kinematics, an optimal 

design that mimics normal knee motion does not yet exist. 

pApeR No. 293 

Bone Ingrowth in Retrieved Porous Tantalum Tibial 

Trays 

Josa Hanzlik, MS 

Judd Day, PhD, Philadelphia, PA 

Daniel MacDonald, Philadelphia, PA 

Gregg R Klein, MD, Paramus, NJ 

Mark A Hartzband, MD, Franklin Lakes, NJ 

Harlan B Levine, MD, Tenafly, NJ 


Porous tantalum has recently been introduced to encourage bone 

growth in total joint arthroplasty. The goal of this study was to 

characterize the extent of bone growth in retrieved porous tantalum 

tibial components. Seventeen porous tantalum tibial trays were 

retrieved. The average age of the patient was 58.4±8.9 years. The 

average implantation time was 1.5±1 years (0.5 to 3.1 years). Porous 

tantalum tibial trays were revised for: instability (52.9%), infection 

(17.7%), femoral loosening (11.8%), malalignment (5.9%), pain 

(5.9%) and arthrofibrosis (5.9%). All were implanted at least 0.5 

years, allowing sufficient time for bone ingrowth. The extent of gross 

bone coverage was determined using a point counting technique. 

Bone ingrowth was observed on an average of 60±15% (Range: 

29-83%) of the total area. No correlation was observed between 

implantation time and bone ingrowth. Generally, ingrowth was 

more prevalent in the central region of the implant than the posterior 

region of the condyles. Porous tantalum tibial trays displayed bone 

ingrowth that covered approximately 60% of the backside surface, 

comparing favorably to other reported materials. These findings 

are likely underestimated due to damage to the bone-implant 

interface during removal. It is noteworthy that none of the implants 

were revised for tibial loosening. The outlook for porous tantalum 

remains encouraging in light of this study’s results; however, further 

studies are warranted to further characterize the depth and extent of 

bone ingrowth. 




pApeR No. 294 

An Economic Algorithm for Evaluation of the Painful 


Gabriel Levi, MD, Chicago, IL 

Giles R Scuderi, MD, New York, NY 

The excellent results of total knee arthroplasty (TKA) have been 

well documented in the literature. However, as the number of TKAs 

increases, so is the number of patients that present with failed TKA. 

The diagnostic work-up for painful TKA does create an economic 

burden and a cost analysis is useful in controlling the expenses 

associated with evaluating this increasingly expensive problem. A 

cost analysis was performed on a previously published diagnostic 

algorithm for the painful TKA. A literature search was performed 

for the statistical values for accuracy, specificity, sensitivity, positive 

predictive value and negative predictive value of each diagnostic 

study in the algorithm. Based on these values and the Medicare fee 

schedule for each diagnostic study, the cost-effectiveness and valueadded 

proposition of each diagnostic study were determined. A 

statistical analysis of the economic model was performed and each 

diagnostic study was weighted for its economic and clinical value. 

The most cost effective diagnostic modalities are: history and physical 

examination, knee radiographs, blood tests (CBC with differential, 

ESR and CRP) and knee aspiration. Nuclear imaging, CT scan and 

MRI, while providing supportive information are economically 

burdensome and should be considered in specific situations where 

the mechanism of failure is elusive or when the study will have 

an impact on the reconstructive procedure. In most situations, the 

evaluation for a painful TKA can be accomplished with a history 

and physical examination, knee radiographs, blood tests and knee 

aspiration. The cost effectiveness of additional imaging studies 

should be considered in this current healthcare environment. 

pApeR No. 295 

In vivo Function of Posterior Cruciate Ligament before 

and after Cruciate-Retaining TKA 

Kartik Varadarajan, MS, Boston, MA 

Bing Yue, Shanghai, China 


Guoan Li, PhD, Boston, MA 

Although the posterior cruciate ligament (PCL) is thought to play 

a major role in cruciate-retaining total knee arthroplasty (CR- 

TKA), little information is available regarding its in vivo function. 

Therefore, the goal of this study was to investigate the in vivo 

function of the PCL before and after TKA, during weight-bearing 

knee flexion. Eleven osteoarthritis (OA) patients and 22 normal 

control subjects were recruited. MRI scans were used to create 3D 

knee models, including the anterolateral (AL) and posteromedial 

(PM) PCL bundles insertions. The bone models were matched to 

dual-plane fluoroscopic images acquired, before and after surgery. 

The elongation of the PCL bundles relative to their length at full 

knee extension, and their axial plane orientations were measured. 

Beyond 75° flexion, the PCL elongation was greater (p

knee score mean was 86 at last follow up. Twenty out of 152 UKA 

(13%) had been revised. One knee was revised for progression of 

pigmented villonodular synovitis (PVNS). Thirteen knees failed with 

tibial components subsidence/loosening, which commonly began 

as progressive cystic degeneration beneath the tibial component. 

Six knees were revised elsewhere. Five-year survivorship was 97%; 

survivorship at 10 years was 78%. At mean 9.5 year follow up, 

this UKA demonstrated 78% survivorship. The dominant mode 

of failure was subsidence/loosening of the all-polyethylene fixedbearing 

tibial component, with a troubling number of this failure 

mode occurring between seven and 10 years. We will continue to 

follow this cohort closely. The principles of small incision, minimal 

quadriceps dissection, local injection and early mobilization have 

been incorporated into all current UKA patients. 

pApeR No. 298 

Custom Guides for Primary Total Knee Arthroplasty 

Adolph V Lombardi Jr, MD, New Albany, OH 

Keith R Berend, MD, New Albany, OH 

Roger H Emerson, Jr MD, Dallas, TX 

Michael D Skeels, DO, New York, NY 

Joanne B Adams, BFA, CMI, New Albany, OH 

Bethany C Gulick, RT 

Efforts to enhance technique in primary total knee arthroplasty 

(TKA) while avoiding negative aspects of navigation have fueled 

development of patient-specific guides generated from MRI or 

CT. We review our experience to date with TKA performed using 

patient-specific guides and compare the accuracy to standard 

technique via both radiographic and cadaveric studies. Two 

surgeons performed bilateral TKA on nine cadavers, using standard 

instrumentation on one side and custom guides contralaterally. 

TKA were evaluated postoperatively with CT for accuracy of 

femoral and tibial resection and femoral rotation. To date, 316 

patients (364 knees) have undergone primary TKA at one center 

using patient-specific guides. From this series, 91 custom-guided 

TKA were matched to 91 contemporaneous TKA performed with 

standard instrumentation. Postoperative standard AP radiographs 

were evaluated via calibrated picture archiving and communication 

system (PACS) by independent observer for femorotibial, femoral 

component and tibial component alignment. Long alignment 

radiographs were evaluated for 71 custom-guided TKA. Outliers 

were defined as >3° from goal. Accuracy for standard versus customguided 

cadaveric TKA femoral alignment averaged 2.1°±1.8° versus 

1.5°±1.4°, for rotation averaged 1.6°±1.1° versus 1.0°±0.6° and 

for tibial alignment averaged 1.3°±0.8° versus 1.5°±0.7°, which 

are not significantly different with numbers available. There were 

four outliers overall in the standard group versus one using customguides 

(NS). In the radiographic comparison, femorotibial, femoral 

component and tibial component alignment were all significantly 

more accurate using custom guides. Furthermore, there were more 

outliers in the standard group (6.6%; 18/273) than the customguided 

group (1.5%; 4/273; p=0.002). Review of long alignment 

series revealed restoration of mechanical axis to within 3° in all 

cases. Disposable patient-specific custom guides improve accuracy 

of alignment and component rotation in primary TKA. They provide 

ease and speed of use, efficiency in implant sizing and inventory, 

without cumbersome equipment or violation of the intramedullary 

canal, and are compatible with minimally invasive techniques. 

535 

pApeR No. 299 

Inappropriate Use of Magnetic Resonance Imaging of 

the Knee by Referring Physicians 

Harpal Singh Khanuja, MD, Cockeysville, MD 

Maria S Goddard, MD, Winston Salem, NC 

Simon Mears, MD, Baltimore, MD 


Currently, healthcare accounts for 15% of the gross domestic 

product in the United States. Identifying areas of reducing healthcare 

expenditures is essential. Patients with knee pain referred to 

orthopedists may already have magnetic resonance imaging (MRI) 

studies ordered by their primary provider. The purpose of this 

study was to investigate the appropriateness of knee MRI studies 

ordered by referring physicians. This prospective study evaluated 

108 consecutive patients (27 men, 80 women and one unrecorded) 

with a new onset of knee pain presenting to the Orthopaedic Clinic, 

between February and April 2009. Questionnaires were completed 

by the orthopaedic surgeon at the time of each encounter. Questions 

included whether patients presented with MRI studies, if there was 

a need for additional imaging and whether an MRI was necessary 

to obtain a diagnosis. Sixty-six patients (61%) were referred by their 

primary care physicians, 25 patients (23%) by other physicians, 

10 patients (9%) were self-referred. The referring physician was 

unknown for seven patients. Thirty-three patients (31%) presented 

with MRIs studies, 18 (55%) of which were considered unnecessary, 

as the diagnosis was possible with history, physical examination 

and radiographs alone. Two of six MRI studies ordered by referring 

orthopeic physicians were not necessary. Of the 75 patients (69%) 

who presented without an MRI study, only four required further 

MRI evaluation. The most common final diagnosis for this cohort 

was osteoarthritis in 41 patients (38%), followed by patellofemoral 

syndrome in 14 patients (13%) and meniscal tears in eight patients 

(7%). Although MRIs are useful in many diagnoses of knee 

pathology, they are an expensive screening tool. In this cohort, MRI 

was only warranted in 20% of cases, and 55% of MRIs ordered by 

referring physicians were unnecessary. It is important that clinicians 

be educated on the indications for MRI, and universal standards be 

developed. 

pApeR No. 300 

Do Current High Flexion Posterior Stabilized TKA 

Designs Increase Knee Flexion? - A Meta Analysis 

Takanobu Sumino, MD, Boston, MA 


Kartik Varadarajan, MS, Boston, MA 

Young-Min Kwon, MD, PhD, Boston, MA 

Guoan Li, PhD, Boston, MA 

It remains debatable whether the design changes in current highflexion 

(H-F) total knee arthroplasty (TKA) facilitate increased 

postoperative knee flexion, with conflicting results being reported 

by individual studies. Therefore, the goal of this work was to utilize 

a meta-analysis approach to integrate available published data from 

various studies into a common framework. In particular we examined 

whether current posterior stabilized (PS) H-F TKA designs provide 

increased range of knee motion. We conducted a systematic review 

of literature published between 1966 and 2010 through Medline and 

EMBASE. The inclusion criteria were: primary TKA study, follow up 

duration greater than one year, use of PS type prosthesis and reporting 

of maximal pre- and postoperative knee flexions along with standard 

deviations. We estimated the weighted mean differences between 

preoperative and postoperative flexions via random effect modeling. 




Eighteen articles were reviewed. These articles included a total of 

2,622 knees; 2,104 knees in the conventional group (seven prostheses 

designs) and 518 knees in the H-F group (two prostheses designs). 

The overall mean differences postoperative flexion was found to be 

4.70° higher than the preoperative flexion in the conventional group 

(p 74 mm). Investigators remained blinded throughout the 

study period. We compared the categorized VAS scores to patients’ 

KS and FS at an endpoint of two-year postoperatively. Thirty-two 

(66.7%) patients graded the painful stimulus as mild, 11 (22.9%) 

as moderate and five (10.1%) as severe. Patients with severe VAS had 

significantly (p=0.04) worse KS compared to patients with mild and 

moderate VAS (55±20.5 versus 81.5±11.1 and 84.8±13, respectively). 

Similarly, patients with severe VAS had significantly (p=0.027) worse 

FS compared to patients with mild and moderate VAS (34±20.7 

versus 75.2.5±17.3 and 77±17.4, respectively). Four (80%) of the 

patients with the severe VAS had poor KS and all five patients with 

severe VAS had poor FS. Patients who rate the sphingomanometric 

painful stimulus as severe on VAS are expected to have substantially 

lower KS and FS. 

pApeR No. 407 

Lower Prevalence of Anterior Knee Pain in Total Knee 

Arthroplasty with Circumpatellar Electrocautery 

Hans Peter W Van Jonbergen, MD, Deventer, Netherlands 

Vanessa AB Scholtes, PhD, Amsterdam, Netherlands 

Albert van Kampen, MD, Nijmegen, Netherlands 

Rudolf W Poolman, MD,PhD, Aerdenhout, Netherlands 

Anterior knee pain is reported to occur in 4-49% of patients 

following primary total knee arthroplasty (TKA). Although 56% of 

orthopedic surgeons employ circumpatellar electrocautery in TKA, 

the effect of this practice on the prevalence of anterior knee pain 

536 

remains unresolved. The purpose of the study was to determine 

the prevalence of anterior knee pain after TKA without patellar 

resurfacing using circumpatellar electrocautery compared to no 

circumpatellar electrocautery. In 2008, a prospective, outcome 

assessor and patient blinded, randomized clinical trial was initiated. 

Three-hundred patients with primary osteoarthritis of the knee 

underwent posterior stabilized TKA without patellar resurfacing. After 

cementing the femoral and tibial components, randomization was 

performed with 150 knees additionally treated with circumpatellar 

electrocautery (experimental procedure), and 150 knees with no 

additional electrocautery (control procedure). At one-year follow up, 

the prevalence of anterior knee pain was assessed using the Clinical 

Anterior Knee Pain Rating system. After exclusion of patients who 

had contralateral TKA within the study period, clinical follow up of 

one year was available for 262 knees, 131 knees with circumpatellar 

electrocautery and 131 knees without. The overall prevalence of 

anterior knee pain at one-year follow up was 26% (95% CI: 20% to 

31%), with 19% (95% CI: 12% to 26%) in the intervention group, 

and 32% (95% CI: 24% to 40%) in the control group (p = 0.02). 

In patients with primary knee osteoarthritis having TKA without 

patellar resurfacing, the use of circumpatellar electrocautery resulted 

in a lower prevalence of anterior knee pain at one-year follow up 

compared to no circumpatellar electrocautery. 

pApeR No. 408 

Gap Balancing Technique Improves Outcome in Total 

Knee Arthroplasty, Compared to Measured Resection 

Hee-Nee Pang, MBBS, MRCS 





Soft tissue balance in total knee arthroplasty (TKA) is accomplished 

by one of two methods, measured resection or gap balancing 

technique. The objective of this study was to compare the functional 

outcome of measured resection technique and computer assisted 

gap balancing technique in TKA. We randomized 140 consecutive 

patients undergoing TKA into two groups. The measured resection 

technique was performed in the control group and the gap balancing 

technique in the study group. Outcome assessment was made at six 

months and two years postoperatively by documenting the range 

of motion, the presence of flexion contractures, hyperextension, 

clinical laxity, postoperative radiological films, Knee Society Score, 

Oxford Knee Questionaire and SF-36 questionaire. Both patients 

and reviewers were blinded as to the study group. At two years, there 

were significantly more patients (five patients, 7%) in the control 

group with flexion contractures of more than 5 degrees (p=0.05). 

One patient (1%) in the control group and none in the study group 

had postoperative hyperextension more than 10 degrees. At six 

months follow up, the study group demonstrated better outcomes in 

function score (p=0.040) and total Oxford score (p=0.031). At twoyear 

review, the study group had better outcome in the total Oxford 

score (0.030). The gap balancing technique was able to achieve more 

precise soft tissue balance with better knee scores in TKA, compared 

to the measured resection technique in this randomized controlled 

trial. 




pApeR No. 409 

An RCT Comparing Fixed to Mobile Bearing TKA: Any 

Difference in Post Operative Gait and Motion? 


Kevin Deluzio, MSC, Kingston, ON Canada 

Barbara Shay, PhD 

John F Rudan, MD, Kingston, ON Canada 

It is not clear what benefit mobile bearing total knee arthroplasty 

(TKA) designs have on functional outcomes following surgery. 

We undertook a blinded, randomized, controlled trial to examine 

differences in gait and motion using a single TKA system that could 

accommodate either fixed or mobile bearing design. One hundred 

and nine (109) patients (114 knees) were enrolled - 57 females and 

52 males, with an average age of 64.7 years. A total of 53 knees were 

randomized to fixed bearing design, with the remaining 61 allocated 

to the mobile bearing group. Patients underwent pre- and one-year 

post-operative gait and motion assessment. Parameters examined 

included kinetic/kinematic knee joint analysis and spatiotemporal 

parameters of gait. Composite WOMAC, Knee Society Scores (KSS) 

and SF-36 PCS scores improved significantly in both groups following 

surgery; however no differences in these scores were detected 

between the groups. Similarly, gait analysis revealed improvements 

in gait speed, knee adduction moment and knee flexion moment in 

both groups; however, no differences could be detected between the 

groups. While mobile bearing designs may offer some theoretical 

benefits over fixed bearing designs, we were unable to confirm any 

functional difference use with specific gait and motion analysis. 

pApeR No. 410 

Total Joint Replacement in Patients Requiring 

Perioperative Cardioprotective Clopidogrel Bisulfate 

James V Bono, MD, Boston, MA 

Claire E Robbins, PT, DPT, MS, GCS, Franklin, MA 

Carl T Talmo, MD, Boston, MA 

Mehran Aghazadeh, MD, Boston, MA 

Many patients requiring chronic Clopidogrel Bisulfate following 

cardiac stent placement are also candidates for total joint arthroplasty 

(TJR). There is concern among surgeons that these patients are at risk 

for bleeding and hematoma following TJR, and the issue remains 

controversial in the orthopedic community. The objective of this study 

was to identify and report on complications from use of Clopidogrel 

in the perioperative period following TJR. We retrospectively 

reviewed 738 prescription orders in 429 patients with a history of 

Clopidogrel use, identifying 127 patients who underwent TJR with 

use of Clopidogrel Bisulfate in the immediate pre- and postoperative 

period in addition to routine thromboembolic priophylaxis. A 

detailed review of the medical records was performed to identify the 

incidence of complications or adverse events. Of the 127 TJR, 75 were 

total knee arthroplasty (TKA) and nine had a postoperative suction 

drain. There were two cases of hematoma requiring reoperation, one 

in a TKA at postoperative day 16 and one in a total hip arthroplasty 

on postoperative day 30. These results support the safety of TJR 

in patients requiring Clopidogrel Bisulfate for cardio-protection 

following stent placement with a small increase in risk of bleeding 

and hematoma formation. 

537 

pApeR No. 411 

20 Year Survival of Cruciate Retaining Total Knee 

Arthroplasty in Patients with Rheumatoid Arthritis 

Matthew D Miller, MD, Los Gatos, CA 



Aaron Glen Rosenberg, FACS, MD, Chicago, IL 

Jorge O Galante, MD, Chicago, IL 

Controversy in the literature persists regarding posterior cruciate 

ligament (PCL)-retaining total knee arthroplasty (TKA) in patients 

with rheumatoid arthritis, with some studies demonstrating late 

posterior instability leading to revision. The purpose of this study is 

to report 20-year results of a cruciate retaining TKA in patients with 

rheumatoid arthritis. Seventy-two PCL-retaining TKA’s in fifty-one 

consecutive patients with rheumatoid arthritis were prospectively 

studied. All procedures were performed with the Miller-Galante I 

prosthesis (cemented and cementless). Thirty-five patients (fortyeight 

knees) died before the twenty year follow-up, and two patients 

(two knees) were lost to follow-up, leaving fifteen patients with 

twenty-two knees for review. Patients were evaluated clinically 

and radiographically at a mean of twenty-two years (range, twenty 

to twenty-five years). Three knees in two patients were clinically 

unstable (4.2%), two of which required revision at 16 and 21 years 

follow up. The major indications for revision in this group included 

patellofemoral failures related to metal backed patellar design (8), 

periprosthetic fracture (4), and infection (4). The mean HSS knee 

score improved from 39 (+/-14.8) to 82 (+/-12) at last follow up 

for all knees (p

pApeR No. 414 

Clinical Results of PCL-Retaining TKA were inferior to 

PCL-Substituting TKA after Tibial Osteotomy 

Yukio Akasaki, MD, PhD, Fukuoka, Japan 

Shuichi Matsuda, MD, Fukuoka, Japan 

Ken Okazaki, MD, Fukuoka, Japan 

Yasutaka Tashiro, MD, PhD 

Shingo Fukagawa, MD, Fukuoka, Japan 

Hiroaki Mitsuyasu, MD 

Yukihide Iwamoto, MD, Fukuoka, Japan 

This study evaluated clinical results of total knee arthroplasty 

(TKA) after failed total knee arthroplasty. Total knee arthroplasty 

was performed in 20 knees after high tibial osteotomy. The mean 

age at surgery was 71.6 years (56-82) and the mean duration after 

osteotomy was 10.4 years (3-23). Eight knees were replaced with the 

Kirschner Performance posterior cruciate ligament (PCL)-retaining 

knee system and 12 knees were replaced with the NexGen PCLsubstituting 

knee system. The mean follow-up period was 8.0 years 

(4-11), and the mean preoperative Knee Society score was 66.1 

points and the postoperative score was 88.1 points. No loosening of 

the implant was identified and no revision surgery was performed. 

The knee score of the PCL-retaining knee was 81.9 points, and was 

significantly lower than that of PCL-substituting knee (92.2 points). 

The posterior stability of the PCL-retaining knee was measured at 75 

degrees by KT-2000, and the posterior displacement was increased 

from 5.2 mm to 12.1 mm during postoperative period. Clinical and 

radiographic results were satisfactory in the knees with TKA after 

failed high tibial osteoromy. However, clinical results of the PCLretaining 

knees were inferior to that of the PCL-substituting knees 

due to increased instability. The results of this study suggest that 

PCL-substituting knees are recommended for knees after high tibial 

osteotomy. 

pApeR No. 415 

ACL Reconstruction And Unicompartmental Knee 

Replacement: 8 Year Survivorship 


Cathy Jenkins, MSc, Oxford, United Kingdom 

Barbara Marks, Oxford, United Kingdom 





Christopher A F Dodd, FRCS, Oxford, United Kingdom 


The options for treatment of the young active patient with 

unicompartmental symptomatic osteoarthritis (OA) and preexisting 

anterior cruciate ligament (ACL) deficiency are limited. This 

study presents a series of 51 patients with ACL reconstruction and 

Oxford unicompartmental knee arthroplasty (UKA) (ACLR group) 

performed over past nine years (mean follow up four years). The 

mean age was 51 years (range: 36 to 65). This consecutive series of 

patients was matched with a group of patients with intact ACL and 

who had undergone medial Oxford unicondylar knee replacement 

(UKR) for osteoarthritis (ACLI group). A sub-set of patients (n=10) 

from each group and a group of normal knees underwent in vivo 

kinematic analysis. At last follow up, the mean outcome scores for 

the ACLR and ACLI groups were: Oxford Knee Score 41 (32-48) 

and 40 (31-48), objective Knee Society Scores 92 (80-100) and 

89 (80-100), and functional Knee Society Scores 90 and 90 (85- 

538 

100) respectively. Three patients in the ACLR group (one each for 

infection, bearing dislocation and progression of OA) and two in 

the ACLI group needed revision. The survival at eight years was 90%. 

No patients in either group had radiological evidence of component 

loosening. Kinematics in the ACLI and ACLR group were similar to 

that of the normal knee. This study has demonstrated that combined 

ACL reconstruction and Oxford UKA provide good medium-term 

clinical, radiological and kinematic results. The mobile bearing used 

in the Oxford knee minimizes wear and our radiographic study has 

seen no suggestions of loosening. 

pApeR No. 416 

All Polyethylene Tibial Component in Young, Active 

Patients: Minimum 10 Years Followup 

Morteza Meftah, MD, New York, NY 

Amar S Ranawat, MD, New York, NY 

Chitranjan S Ranawat, MD, New York, NY 

We previously reported mid-term results of all polyethylene tibial 

components for total knee replacement (TKR) in younger, active 

patients. This is a follow-up report of the same group of patients 

with special reference to survivorship and activity level. Between 

November 1992 to June 2000, 53 patients younger than 60 years old 

(74 knees) that underwent cemented all-poly tibial component were 

included. All patients were followed prospectively using clinical and 

radiographic criteria as defined by the Knee Society. At minimum 10 

years follow up, five patients were deceased, four were lost to follow 

up and two refused to participate in the study, leaving 42 patients 

(59 knees) for final analysis. Good to excellent results were achieved 

in 96% of patients. Kaplan-Meier survivorship at 10 years for revision 

due to mechanical reasons and for all failures was 100% and 97% 

respectively (one case of infection and one revision for fracture). There 

were no cases of malalignment, aseptic loosening, excessive wear or 

osteolysis. The mean WOMAC score was 31 ± 14, Knee Society Scores 

improved from an average of 48 to 97. Sixty-two percent of patients 

were participating in sport activities such as running, gym exercises 

and playing tennis or golf. Anterior knee pain was present in 9% 

of cases. The incidence of noise and asymptomatic crepitation was 

14%. There was no case of painful crepitation requiring scar excision. 

Long-term follow up of all-poly TKR demonstrates excellent clinical 

and radiographic results in younger, active patients, as 62% continue 

to participate in sport activities. 

pApeR No. 417 

Recurvatum Deformity Following Primary Total Knee 

Replacement: What Is Acceptable ? 

Mashfiqul Arafin Siddiqui, MBBS, MRCS, Singapore, Singapore 

Sivaiah Potla, MD 

Hwei Chi Chong, Singapore, Singapore 



Keng Jin Darren Tay, FRCS 



The aim of the study was to assess knee function and quality of 

life in patients with recurvatum at two years after primary total 

knee replacement (TKR). Data was obtained from our hospital 

joint registry from 2004 to 2008. This is a prospective study with 

a minimum follow up of two years. We assessed patients degree of 

recurvatum, Oxford knee scores (OKS), Knee Society scores (KSS) 

and SF 36 quality of life (QOL). We performed 5,400 TKRs of which 

1,952 (73.2%) patients had zero degree extension (grade 0) and 




715 patients (13.2%) were recurvatum. We classified recurvatum 

into grade 1(1-5 degrees ), grade 2 (6-10 degrees) and grade 3 (> 10 

degrees ). A total of 504 patients, 191 patients and 20 patients were 

grades 1, 2 and 3 respectively. Patients with grade 1 had worse knee 

score compared to grade 0 (p0.05). Moreover, there was no significant difference with the 

proportion of recovered patients at each follow-up period between 

the two groups (p>0.05). Although there was theoretical advantage 

with patellar non-eversion in TKA, we found no significant difference 

between the two groups throughout follow-up periods in terms of 

numeric data of quadriceps force and power. Therefore, the choice 

of patellar eversion in TKA would not result in inferior influences 

on quadriceps recovery and it would rather provide better surgical 

field and easier operation than patellar non-eversion in midvastus 

approach. 

pApeR No. 419 

The Outcome of Fixed and Mobile-bearing 

Unicompartmental Arthroplasty at a Minimum Fifteenyear 

Jean-Noel A Argenson, MD, Marseille, France 

Jean-Manuel Aubaniac, MD, Marseille, France 

Sebastian Parratte, MD, Marseille, France 

There is still controversy whether there is a clinical difference 

between fixed or mobile bearing unicomparmental knee arthoplasty 

(UKA). The objective of this study was to compare the clinical and 

radiological long-term outcome and the survivorship of fixed and 

539 

mobile metal-backed cemented UKA. The study included 156 knees 

in 147 patients operated on by the same surgeon following the same 

selection protocol between 1989 and 1992. Seventy-nine knees 

received a fixed-bearing UKA (FB group) and 77 patients a mobilebearing 

UKA (MB group). Mean age of the patients (63 years old), 

gender and body mass index (BMI) were comparable in the two 

groups. At a minimum of 15-year follow up, the mean Knee Society 

function and knee scores were respectively 82 and 88 points in the 

FB group and 81 and 89 points in MB group (NS). Radiographically, 

the number of radiolucencies was statistically higher in the MB group 

(69% vs 24%, p

pApeR No. 586 

Readmission and Length of Stay After TKA in a 

National Medicare Sample 2002-2007 

James I Huddleston, III MD, Redwood City, CA 

Yun Wang, PhD 

James H Herndon, MD, Boston, MA 


Evaluation of hospital readmissions after total knee arthroplasty 

(TKA) may provide an opportunity for improved patient safety 

and cost reduction. The purpose of this study was to investigate 

the rates and reasons for readmission after TKA from 2002-2007. 

We hypothesized that a reduction in length of hospital stay (LOS) 

would lead to an increase in the rate of readmission. Data were 

abstracted from the medical records of 4,057 Medicare beneficiaries 

who underwent TKA from 2002-2007 in the Medicare Patient 

Safety Monitoring System. To adjust for patient characteristics and 

comorbidities, the hierarchical generalized linear modeling approach 

was used to assess the odds of a change in the rates of LOS and 

readmission during the study period. The overall rate of readmission 

in the 30 days after discharge was 228/4,057 (5.6%). The 10 most 

common reasons for readmission were: congestive heart failure 

(21%), chronic ischemic heart disease (14%), cardiac dysrhythmias 

(13%), pneumonia (11%), osteoarthrosis (9%), general symptoms 

(7%), acute myocardial infarction (7%), care involving other 

specified rehabilitation procedure (6%), diabetes mellitus (6%) and 

disorders of fluid, electrolyte, and acid-base balance (6%). There was 

no difference in the rate of readmission from 2002-2004 (5.5%) to 

2005-2007 (5.8%) (OR 1.08, 95% CI 0.88-1.32, p=0.46). The overall 

mean LOS was 3.9 ± 1.9 days. There was a significant reduction in 

LOS from 2002-2004 (4.1 ± 2.0 days) to 2005-2007 (3.8 ± 1.7 days) 

(OR 1.27, 95% CI 1.25-1.29, p

performed MDCT scans on 48 consecutive THA/TKA patients on 

the first postoperative day. Patients underwent routine postoperative 

care and data were collected regarding the development of symptoms 

such as tachycardia, fever, chest pain or shortness of breath. All CT 

scans were kept blinded until completion of study recruitment and 

then read by two independent chest radiologists for findings of 

acute PE. Our cohort included 27 TKA patients and 21 THA patients. 

None of the 48 patients had any symptoms of PE. Among the TKR 

patients, 11 (41%) of the CT scans were read as positive for an acute 

PE compared with 1 (5%) of the THR patients (p=0.004). All of the 

patients diagnosed with an asymptomatic PE were discharged from 

hospital without developing any clinical symptoms suggestive of 

venous thrombosis. One TKA patient, who had a negative CT scan 

on the first postoperative day, was diagnosed with symptomatic 

PE the following day. The majority of the asymptomatic embolic 

burden found in our study was in the segmental and sub-segmental 

arteries of the lung. Our study demonstrates a high rate of abnormal 

MDCT early following lower extremity arthroplasty, the clinical 

significance of which may be benign. This finding is also important 

in the interpretation of MDCT obtained after a clinical suspicion of 

PE in these patients. 

pApeR No. 590 

A Modified V-Y Turn Down Flap To Repair The Ruptured 

Quadriceps Tendon After Total Knee Arthroplasty 

Shao-Min Shi, MD, Milwaukee, WI 

James T Ninomiya, MD, Milwaukee, WI 

Rupture of the quadriceps tendon is a serious complication after 

total knee arthroplasty but has received little attention. We describe 

a modified technique and evaluate the results after repair of this 

problem. Between 2005 and 2009, 11 patients who had quadriceps 

tendon rupture after total knee arthroplasty were operated on 

in our institution. Patients were treated by a V-Y turn down flap 

reconstruction. We modified this method by harvesting full thickness 

of the quadriceps tendon as a flap, releasing vastus medialis and 

lateralis muscles distally and then suturing both muscles together to 

reinforce the tendon without wires. Average follow-up period was 24 

months (range 12-54 months) in this group. Patients were evaluated 

by the mean knee score. Nine patients who were judged had excellent 

results and two had good results. The mean knee score generated 

from the questionnaire and clinic evaluation was 90 (range 75-100). 

After surgery, all of the patients had been able to ambulate and 

satisfied with their surgical results. The range of motion was 0-120 

degrees; only two patients had a measurable extensor lag of 5 degrees 

in the repaired limb. No rerupture occurred. The modified technique 

provides an effective and reliable option for reconstruction of the 

ruptured quadriceps tendon after total knee arthroplasty. 

pApeR No. 591 

Risk Factors For Postoperative Complications In Total 

Knee Arthroplasty; 5-Year Case Series 

Kosei Kawakami, MD, Tokyo, Japan 

Katsunori Ikari, MD, Tokyo, Japan 

Takuji Iwamoto, MD 

Asami Tokita, MD 

Koichiro Yano, MD 

Yu Sakuma, MD 

Ryo Hirosima, MD 

Shigeki Momohara, Tokyo, Japan 

The purpose of the present study was to determine the risk factors for 

acute surgical site infection (SSI) and for developing postoperative 

541 

deep vein thrombosis (DVT) after undergoing total knee arthroplasty 

(TKA). A retrospective study was carried out in 392 consecutive 

patients undergoing TKA during a five-year period from January 2005 

to December 2009 (mean age 63 years, 350 females, 340 rheumatoid 

arthritis). Diagnosis of acute SSI was based on the 1999 Centers 

for Disease Control and Prevention (CDC) recommendations. 

Multivariate logistic regression analysis was performed to analyze 

the risk factors for acute SSI and postoperative DVT (dependent 

variables: gender, age, body mass index, rheumatoid arthritis, the 

presence of diabetes mellitus, cigarette smoking, past history of DVT, 

revision surgery, operative time, preoperative CRP level, preoperative 

D-dimer level and the use of non-steroidal anti-inflammatory drugs, 

anti-platelet agents, prednisone, immunosuppressive DMARDs and 

biological agents). Of all the patients, 5.9% (23/392) developed 

superficial SSI requiring the use of antibiotics and 1.0% (4/392) 

developed deep SSI, which necessitated surgical treatment by 

removal of the artificial joint prosthesis. Multivariate logistic 

regression analysis showed that operative time (P=0.003) and the 

use of biological agents (P=0.0004) were the risks for acute SSI after 

TKA. One hundred and twenty cases (30.6%) were DVT positive. 

Multivariate logistic regression analysis showed that operative time 

(P=0.03), the use of biological agents (P=0.003), age (P=0.01), the 

presence of diabetes mellitus (P=0.03) were the risks for DVT after 

TKA. Operative time and the use of biological agents were the risks 

for acute SSI and DVT after TKA. Higher age and the presence of 

diabetes mellitus were the risks for DVT after TKA. 

pApeR No. 592 

Aseptic tibial loosening in the Oxford Knee : Incidence, 

Diagnosis & Management 


Benjamin JL Kendrick, MRCS 

Nicholas J Bottomley, MRCS, Oxford, United Kingdom 

Simon Abram, BA, Oxford, United Kingdom 




Christopher A F Dodd, FRCS, Oxford, United Kingdom 


Incidence of tibial loosening in the Oxford unicompartmental knee 

arthroplasty (UKA) has not been previously reported. Diagnosis 

can be difficult and the causes are poorly understood. All patients 

undergoing a phase 3 medial Oxford UKA in a single institution 

between 1998 and 2010 were prospectively followed. Patients 

are assessed at regular intervals and undergo fluoroscopy assisted 

radiographs. These help in proper comparison between subsequent 

x-rays. Patients needing further revision arthroplasty with intraoperative 

confirmation of aseptic tibial loosening had their medical 

notes and radiographs reviewed. Assessment included component 

sizing, cement thickness and evidence of excessive saw cuts on postop 

radiographs. Thickness and distribution of any radiolucency was 

assessed on the final radiograph before revision. A total of 2,200 

patients were included in the study. Nine patients had proven tibial 

loosening at revision. Post-operative radiographs confirmed correct 

sizing with all components seated on the posterior cortex. No tibial 

component was undersized medially and the maximal overhang was 

3 mm. Seven patients had evidence of significant overcutting of the 

vertical saw cut. Four patients had evidence of minimal overcutting of 

the horizontal saw cut. In all cases, complete radiolucencies beneath 

all tibial components with a depth greater than 2 mm in all regions 

were noticed. The incidence of proven aseptic tibial loosening in 

the Oxford UKA is 0.004%. A potential cause of an increased risk 




of tibial loosening is an overly deep saw cut when performing the 

initial vertical cut. Fluoroscopy aligned radiographs are an essential 

tool in diagnosing tibial loosening. 

pApeR No. 593 

Safety of Simultaneous Bilateral Total Knee 

Arthroplasty (B-TKA) Versus Staged Bilateral TKA 

(S-TKA) 

John Patrick Meehan, MD, Sacramento, CA 

Richard H White, MD, Sacramento, CA 

Beate Danielson, PhD 

Sunny H Kim, PhD, Sacramento, CA 

Dan Tancredi, PhD, Sacramento, CA 

Amir A Jamali, MD, Sacramento, CA 

The literature remains equivocal as to the saftey of performing bilateral 

total knee arthroplasty (B-TKA) versus staged bilateral total knee 

arthroplasty (S-TKA), with most studies being retrospective single 

surgeon or single institution case series. Most studies also contain 

bias not adjusted for in their analysis, and compare B-TKA with 

unilateral TKA (U-TKA). The objectives of this study are to compare 

the observed and standardized risk of specific adverse outcomes in 

patients undergoing B-TKA versus S-TKA, using a statistical model 

which eliminates the surgeon and patient bias. Utilizing the California 

Patient Discharge Database (PDD), we performed a retrospective 

comparison of adverse outcomes in patients who underwent B-TKA 

and and patients in whom the first of two sequential or staged TKA 

operations (S-TKA1 and S-TKA2) took place between 1997 and 

2006. Categorical data was analyzed using chi-quare testing. For 

each specific complication, logistic regression models were generated 

that compared the risk after B-TKA and S-TKA-1 and S-TKA2. These 

models were used to calculate a standardized expected number of 

complications that would occur if UTKA, B-TKA and S-TKA were 

performed on a standardized population (age, race, sex, hospital, 

etc.) and clinical characteristics (obesity, diabetes, hypertension), 

allowing a direct comparison which adjusted for these risk factors. 

The risk-adjusted odds of M.I., OR=1.6; 95% CI:1.2-2.2, a composite 

of coronary artery disease variable, OR=1.7; 95% CI:1.2-2.2, 

pulmonary embolism, OR=1.4; 95% CI:1.1-1.8, and peri-operative 

cardiac complications, OR=1.3; 95% CI:1.1-1.6, was significantly 

higher for B-TKA than S-TKA. For infection and mechanical failure, 

the risk adjusted odds were significantly lower for B-TKA, OR=0.6, 

95% CI:0.5-0.7, and OR=0.62, 95% CI:0.5-0.8 compared to S-TKA. 

Simultaneous B-TKA has a 50-60% higher risk-adjusted odds of 

dying, myocardial infarction or pulmonary embolism compared to 

S -TKA. Simultaneous B-TKA has a 48% lower incidence of major 

joint infection, and a 26% lower incidence of mechanical failure 

compared to S-TKA. Surgeons should consider performing B-TKA in 

persons with symptomatic bilateral knee osteoarthritis and low risk 

for underlying cardiovascular disease. 

pApeR No. 594 

Long Term Migration Is Different In Cemented, HA- 

Coated And Uncoated Total Knee Arthroplasty (TKA) 

Bart G Pijls, MD 

Edward R Valstar 

Bart L Kaptein, PhD 

Marta Fiocco, PhD 

Rob G H H Nelissen, MD, Leiden, Netherlands 

Failed or suboptimal fixation may lead to continuous migration, 

subsequent loosening and eventually revision. The aim of the present 

study is to evaluate the effect of three fixation types on long-term 

542 

migration of tibial components in total knee arthroplasty (TKA). 

Sixty-eight knees were randomized to HA-coated, uncoated and 

cemented components. All knees have been prospectively followed 

for an average of 7.6 years (range three months to 16 years) by 

radiostereometric analysis (RSA) to evaluate migration. During RSA, 

analyses observers were blinded for the non-coating and HA-coating, 

but were not blinded for the use of cement. A linear mixed effects 

model has been used to take into account the repeated measurement 

design of the study and to correct for confounders. A total of 759 

RSA analyses compose the present study. The median migration, 

expressed in maximal total point motion (MTPM) at 10 years is 1.74 

mm for non-coated group, 0.88 mm for the HA-coated group and 

0.59 mm for the cemented group; p < 0.001. The median subsidence 

at 10 years is 0.30 mm for the non-coated group, 0.03 mm for the 

HA-coated group and 0.04 mm for the cemented group; p = 0.005. 

The uncoated tibial components show significantly more migration 

than HA-coated and the cemented tibial components. HA-coating 

significantly reduces the amount of migration in uncemented tibial 

components. This beneficial effect of HA is still present at 10-year 

follow up. Some 86% of the migration occurs in the first postoperative 

year emphasizing the early predictive properties of RSA. 

pApeR No. 595 

The Increased Use of Operating Room Time in Obese 

Patients During Primary Total Knee Arthroplasty 


Naomi Gadinsky, Research Coor., New York, NY 

Jacob B Manuel, MD, Austin, TX 

Stephen Lyman, PhD, New York, NY 

Obesity is associated with a variety of health problems including 

increased need for total knee arthroplasty (TKA) and complications 

related to surgery. However, the relationships between body mass 

index (BMI) and standard intraoperative time measurements recorded 

during primary TKA are unknown. We retrospectively reviewed 454 

consecutive primary posterior stabilized TKAs implanted by one 

surgeon at our institution from 2005-2009. Patients were grouped 

by World Health Organization BMI class: Normal Weight 18.5-25, 

Overweight 25-30, Obese Class I 30-35, Obese Class II 35-40, Obese 

Class III >40. Five standard intraoperative time measurements (total 

room time, anesthesia induction time, tourniquet time, closing 

time, surgery time) were compared across BMI groups. Operative 

times by BMI category were analyzed using one way ANOVA with 

a post hoc least squares difference test if the overall ANOVA model 

was statistically significant (p

pApeR No. 596 

Early Failure of Posterior Stabilized High Flexion Knee 

Prosthesis with Unique Femoral Cam Design 

Woon-hwa Jung, MD, Masan, Gyeongsangnam-do, Republic of 

Korea 

Jae-heon Jeong, MD, Seoul, Republic of Korea 

Hyung-min Ji, MD, Seongnam, Republic of Korea 

Yong-chan Ha, Prof, Seoul, Seoul, Republic of Korea 

Ho Joong Jung, Seoul, Seoul, Republic of Korea 

Young-Kyun Lee, MD, Seongnam-Si, Republic of Korea 

Bun-Jung Kang, MD, Pohang, Gyeongsangnamdo, Republic of 

Korea 

Kyung-Hoi Koo, MD 

Several designs of posterior stabilized high flexion knee prostheses 

have been introduced to improve the range of knee motion; few 

have reported early loosening of the prosthesis. We experienced 

early failure including dislocation and femoral component 

loosening in the posterior stabilized total knee arthroplasty (TKA) 

with anterodistally positioned femoral cam design. The purpose 

of this study was to compare two different designs of the posterior 

stabilized high flexion knee prostheses. From May 2007 to July 

2008, 212 knees (159 patients) underwent posterior stabilized TKA 

with anterodistally positioned femoral cam design (Group I) and 

209 knees (168 patients) underwent posterior stabilized TKA with 

posteroproximally positioned femoral cam design (Group II). All 

patients were then evaluated on average 24 months postoperatively. 

The patients were assessed clinically and radiographically using the 

knee-rating systems of the Knee Society. Postoperative complications 

were also evaluated in both groups. There were early failures in 18 

knees (8.4%) of group I during the follow-up period. Dislocations 

in 11 knees (5.1%) and loosening of femoral component in seven 

knees (3.3%) occurred during normal daily activities from 12 to 

31 months (mean, 22.6 months) postoperatively. However, there 

was neither dislocation nor loosening of group II (p=0.001). Age 

(p=0.868), gender (p=0.124), preoperative conditions (p=0.678) 

and diagnosis (p=0.832) were not different between two groups. A 

high rate of early failure in the group I was observed during shortterm 

follow up. Although several factors are related to early failure 

after posterior stabilized TKA, we consider that early failures seem 

to be due to a difference in femoral component design, especially in 

terms of position of femoral cam. 

pApeR No. 597 

Complications of Indwelling Femoral Nerve Catheters 

Following TKA: Cause for Concern? 

Justin M LaReau, MD, Hinsdale, IL 


Carl T Talmo, MD, Boston, MA 

Claire E Robbins, PT, DPT, MS, GCS, Franklin, MA 

Multimodal analgesia is currently the standard of care in the 

perioperative period for total knee arthroplasty (TKA). Regional 

anesthesia with continuous indwelling femoral nerve catheters 

reduces postoperative pain and facilitates motion. The objective of 

this study was to identify and report on complications of femoral 

nerve catheters at one high-volume orthopedic specialty hospital. 

The in-hospital complications database was reviewed for all adverse 

events related to the use of indwelling femoral nerve catheters over a 

one-year period including 2000 cases of TKA. A detailed retrospective 

review was performed to identify risk factors for complications from 

femoral nerve catheters. We identify commonality of risk among 

the cases and steps to improve patient care. Six complications 

543 

were identified for a rate of 0.3%. Serious complications included 

compartment syndrome, vascular injury, a loss of a catheter tip within 

a patient and three postoperative falls. Clinical errors included: 

failure to monitor a patient placed in a continuous passive motion 

machine on post-operative day one and a wrong-side femoral nerve 

block placement. Although the complication rate of femoral nerve 

catheter use appears low, the incidence of serious complications was 

cause for concern. Using this data, awareness of the potential risks of 

femoral nerve catheter use in the perioperative period was increased 

at our institution and changes in the perioperative pain protocol were 

implemented to improve patient safety with subsequent reduction 

in postoperative catheter associated complications. 

pApeR No. 598 

Radiological Analysis of Failed Revision Total Knee 

Arthroplasty with Cementless Stems 

Saurabh Khakharia, MD, Moultrie, GA 


Restoring bone loss is a challenge in revision total knee arthroplasty 

(TKA). Routine use of stem extensions enhances fixation; however, 

inadequate stem fixation and inability to restore bone loss can 

lead to early failure. This study conducted a radiological analysis of 

failed revision TKA with cementless femoral stems. A retrospective 

review of 102 revision TKA was performed. Of 102 revision knees, 

eight knees were re-revision TKA for procedures performed at 

outside institutions and 93 knees had revision for failed primary 

TKA. Radiological analysis of the eight failed re-revision knees was 

performed. The method of femoral fixation and management of 

bone loss at the index revision TKA was analyzed. The reason for 

failure was aseptic in seven knees and septic in one knee. Five out 

of eight (62%) revision knees with cementless stem were observed 

to fail in varus on the femoral side as on anterior/posterior (AP) 

radiographs. Of the five failed revision knees, four knees had 

Anderson Orthopaedic Research Institute (AORI) Grade F2B bone 

loss and one knee had AORI Grade 3 bone loss. Bone loss at the index 

revision was managed with metaphyseal cement and the cementless 

femoral stems were undersized and no canal filling. At the time of rerevision, 

modular femoral augmentation was utilized to restore the 

metaphyseal bone in all cases and the femoral stems were cemented 

in seven knees and press-fit cementless diaphyseal engaging stem 

in one knee. Appropriate femoral augmentation should be used in 

patients with AORI Grade 2 and 3 bone loss to restore the distal 

femoral metaphysic and support the femoral component. Failure to 

augment the metaphyseal bone loss and secure diaphyseal fixation 

will lead to implant failure and subsidence into varus. Cemented 

stems can provide durable fixation and should be employed in 

patients with severe metaphyseal bone loss. 

pApeR No. 599 

Symptomatic Patellar Osteonecrosis Following Socalled 

Minimally Invasive Knee Arthroplasty 

John T Dearborn, MD, Fremont, CA 

Patellar osteonecrosis is an uncommon complication but currently 

has no solution. Avoiding intraoperative patellar eversion protects 

patellar perfusion but whether that practice reduces the incidence of 

osteonecrosis is unknown. We reviewed the incidence of symptomatic 

patellar osteonecrosis in a consecutive series of 3,615 primary knee 

replacements performed by the same surgeon from 1998 to 2009. 

A standard medial arthrotomy with patellar eversion was used until 

February 2004 (571 knees), and thereafter a limited arthrotomy with 

lateral displacement of the patella was used in all patients. A total of 

3,044 knees in the non-everted group met the six-month minimum 




follow up. Symptomatic osteonecrosis occurred in 25 knees (0.69%) 

in 22 patients overall. All presented within six months with anterior 

knee pain in combination with patellar sclerosis with eventual 

patellar fracture and/or fragmentation. The incidence was similar in 

the everted (0.88%) and non-everted groups (0.66%). Only three 

knees with patellar necrosis had lateral retinacular releases. Five 

patients required secondary surgical procedures (three tantalum 

augmentation patellar components, one patellar allograft and 

one internal fixation) with an 80% failure rate. Of the 18 patients 

interviewed two years after the index arthroplasty, only 12 were 

satisfied with the outcome of the original procedure and would go 

through with it again. Symptomatic patellar osteonecrosis is an usual 

but significant complication. It occurs in the absence of lateral release, 

and at the same rate with and without patellar eversion. Surgical 

intervention has a high failure rate. When it occurs, osteonecrosis 

greatly affects patient satisfaction. 

pApeR No. 600 

Predictors of Early Adverse Outcomes in Geriatric 

Patients After Total Knee and Hip Arthroplasty 

Carlos A Higuera, MD, Lakewood, OH 

Karim Ahmed Elsharkawy, MD, Lakewood, OH 

Alison K Klika, MS, Cleveland, OH 

Wael K Barsoum, MD, Bay Village, OH 

POSTERS 


Distal Femoral Fresh Osteochondral Allografts: Follow 

Up At A Mean Of 22 Years 

Guy Raz, MD, Toronto, ON, Canada 

Oleg Safir, MD, Toronto, ON Canada 

David Backstein, MD, Toronto, ON Canada 


Paul T H Lee, MD, Leicester, United Kingdom 

Oren Ben Lulu, MD, Toronto, ON Canada 

Farid Guirguis, MD, Thornhill, ON Canada 

A knee osteochondral defect in young active patients represents 

a challenge to the orthopedic surgeon. Earlier studies on fresh 

osteochondral allograft transplantation have shown this tissue to 

be immunologically privileged, and consist of hyaline cartilage with 

surviving chondrocytes up to 25 years post implantation. Our study 

examines the long term outcome of the use of fresh allografts for posttraumatic 

and osteochondritis dissecans defects in the distal femur. 

Since 1978 until 1995 we enrolled 63 patients in a prospective study 

of fresh osteochondral allografts. Five international patients which 

were lost to follow up were excluded. Indications for the procedure 

were: patients younger than 50 years of age having post-traumatic, or 

osteochondritis dissecans unipolar defect larger than three centimeter 

in diameter and one centimeter in depth. Fifty-eight patients age 11 

- 48 (mean 28) were followed for 15 - 32 years (mean 21.8 years). 

Thirteen of the 58 grafts had required further surgery, with three 

having graft removal and 10 converted to total knee arthroplasty. 

Three patients died during the study due to unrelated causes and 

are included in the survivorship curve. Kaplan-Meier survivorship 

analysis showed: 91%, 84%, 69% and 59% graft survival at 10, 

15, 20 and 25 years, respectively. Patients with surviving grafts had 

good function, with a mean modified Hospital for Special Surgery 

544 

score of an average 86 at 20 years or more following the allograft 

transplantation surgery. Late osteoarthritic degeneration as was 

seen on radiographs was associated with lower Hospital for Special 

Surgery scores representing patients with poorer clinical outcome. 

The authors confirm the value of fresh osteochondral allograft 

as a long-term solution for articular defect in the knees of young 

patients. We recommend the use of fresh osteochondral allograft for 

treatment of large osteochondral defects in the distal femur of young 

and active patients. 


Improved Outcomes After High Flexion TKA- 

A Randomised Control Trial With 5 Year Follow Up 

Chusheng Seng, MBBS, MRCS 

James Wee, MBBS, MRCS (Edin) 

Seng-Jin Yeo, FRCS, Singapore 

Ngai-Nung Lo, MD, Singapore 

Sri Subanesh, MBBS 

Hwei Chi Chong, Singapore 

Pak Lin Chin, FRCSEd, Singapore 

Shi-lu Chia, MBBS, Singapore 

A five-year follow up in a prospective double blinded randomized 

control trial comparing the improved clinical outcomes between the 

high flexion knee arthroplasty group and the conventional group. 

Seventy-six patients were enrolled. Forty-one patients underwent the 

high flexion total knee arthroplasty (TKA) and 35 underwent the 

conventional TKA. We compare the flexion range, Knee Society scores 

(KSS), Oxford knee scores (OKS) and SF-36 scores between the two 

groups pre-operatively through to the five-year follow up. , Consistent 

and sustainable increase in flexion angle for the high flexion group 

throughout the five-year follow up (128 vs. 117 degrees), which is 

statistically higher than the conventional group. Statistical difference 

in the physical functioning (63 vs. 53), general health (79 vs. 62) and 

vitality scores (74 vs. 62) of SF-36 between the two groups at the fiveyear 

follow up, with the high flexion group showing better scores. 

No differences between the KSS and OKS between the two groups. 

High-flexion implants are capable of producing a sustainable and 

consistently higher knee flexion angle post-TKA when compared to 

conventional implants. This has resulted in better outcomes in the 

physical function, general health and vitality components of the SF- 

36, which we feel would be beneficial to a select group of patients 

who require higher degrees of knee flexion in their daily activities 

and would thus appreciate the gains in physical function that the 

high-flexion implant delivers. Therefore, we propose that careful 

history-taking and patient selection should be performed preoperatively 

to identify patients who would benefit the most from 

high-flexion implants. 


Complications Of An Unicompartmental Knee 

Arthroplasty: A 10-Years Prospective Independent 

Study 

Mr Lukas Lisowski, Amsterdam, Netherlands 

Dr Michel Van den Bekerom, Amsterdam, Netherlands 

Andrzej Lisowski, MD, Heerlen, Netherlands 

The interest in unicompartmental knee arthroplasty (UKA) for medial 

osteoarthritis using a minimally invasive surgical technique (MIS) 

increased rapidly over the last 10 years. The use of this procedure 

is still controversial regarding recent reports of high failure rates. 

Aim of this study was to analyze the cause of complications and 

the rate of revision during the first 10 years of experience. Between 




1999 and 2009, 276 consecutive medial UKAs were implanted by a 

single surgeon. The mean follow up (FU) was 54 months and mean 

age was 70 years (range 49-91). One year postoperatively 17 patients 

(7.3%) experienced moderate or severe pain. Of these patients with 

a UKA in place only two patients (0.7%) had moderate pain at final 

FU. Eleven patients underwent an arthroscopic procedure for pain 

related to intra-articular causes. Revisions occurred in nine patients: 

three knee were revised due to pain complaints with failure of proper 

selection criteria, three because of dislocation of the meniscal insert, 

two due to progression of lateral compartment osteoarthritis and one 

because of cobalt allergy. The majority of revisions occurred due to 

failure of using proper selection criteria (1.1%) or by technical errors 

(0.7%). Pain complaints have been recognized and successfully 

treated by means of arthroscopic surgery in 2.9% of the knees. We 

recommend this procedure as a well-established treatment option of 

unicompartmental osteoarthritis of the knee joint if strict indication 

criteria are followed, proper surgical technique is used and careful 

follow-up of the patients is established. 


Revision After Total Knee Arthroplasty And 

Unicompartmental Knee Arthroplasty In Medicare 

Population 

Brian M Curtin, MD, Charlotte, NC 


Joseph Greene, MD, Louisville, KY 




The relative risk of revision and associated risk factors following 

total or unicondylar knee arthroplasty (TKA or UKA) in the Medicare 

population were compared. We hypothesized that Medicare patients 

undergoing UKA would have a significantly higher revision rate within 

the first five years. The Medicare 5% national sample database was 

used to identify TKA (CPT 27447) and UKA (CPT 27446) patients 

between 2001-2007. Kaplan-Meier survivorship was determined 

with revision as an endpoint. Multivariate Cox regression was 

used to compare the revision risk for TKA and UKA, adjusting for 

demographics, comorbidities (Charlson index in 12 months prior 

to index surgery), socio-economic status (Medicare buy-in status) 

and Census region. A total of 61,767 TKA and 2,848 UKA patients 

were identified. UKA patients were at increased risk for revision at 

two years (adjusted odds ratio of 2.32; p

high tibial osteotomy (overall revision rate 6.9%). In group B, 34 

patients required patello-femoral replacement, or UKR or TKR and 

17 patients required osteotomy (overall revision rate 31.1%). This 

difference was significant (p < 0.01). At latest follow up, the mean 

MCS was significantly higher in Group A (72.5 versus 51.8, p < 0.01). 

Patients with early radiographic of evidence of OA are unlikely to 

gain maximum benefit from ACI. The results suggest that ACI does 

not prevent patients from progressing in their arthritic process and 

hence requiring joint replacement. 


Short Term Results Of Low Contact Stress Mobile 

Bearing Unicompartmental Patellofemoral Arthroplasty 

Buchi R B Arumilli, MRCS, Manchester, United Kingdom 

Philip Hirst, MD, Wilmslow, United Kingdom 

Aaron Ng, MD, Manchester, United Kingdom 

David J Ellis, FRCS 

The cemented mobile bearing metal backed low contact stress 

patellofemoral arthroplasty (LCS PFA) is a newer design allowing 

patella to articulate with the trochlear component as well as the 

femoral component in total knee replacement (TKR). Twenty-one 

patients who underwent 24 (three bilateral) unicompartmental PFA 

for isolated patellofemoral osteoarthritis were included. Average age 

was 51 (40-58) years. The Oxford knee score was used to assess the 

results. At the latest follow-up of 2.7 (0.5 to 4) years, nine patients 

showed excellent improvement in their knee scores, five patients 

showed fair improvement and seven patients very little. There were 

nine revisions in seven patients either due to mechanical problems 

or due to persistent symptoms. We had three patients with early 

mechanical complications who underwent revision. The revision 

rate at two years was 33%. The revision rate for cemented mobile 

bearing LCS PFA seems to be very high and the issue is mainly with 

the patellar component (at the metal polyethylene interface). The 

Australian Orthopaedic joint registry report 2008 showed a higher 

revision rate for the same implant at 5%. We strongly advocate 

PFAs to be analyzed separately in all the National Joint Registries to 

highlight any persistent issues with new PFAs early. 


Articulating Spacer with Autoclaved Femoral 

Component for Infected TKA: Minimum 6 Year Follow 

Up 

John Anthony Anderson, MD, New York, NY 

Lazaros A Poultsides, MD, New York, NY 

Danilo Bruni, MD 


Thomas P Sculco, MD, New York, NY 

This study analyzed 17 patients (17 knees) with chronic deep total 

knee arthroplasty (TKA) infection in order to assess the long-term 

effectiveness of an articulating spacer in eradicating infection and 

also allowing the patient to mobilize. Very few studies have long-term 

results on this important technique. During 1997-2004, all patients 

underwent two-stage articulating spacer surgery, whereby the original 

femoral component was removed, autoclaved and then replaced. 

The tibial component was removed, and a new polyethylene tibial 

component was utilized. Antibiotic methylmethacrylate composite 

was used with these prosthetic spacers. The cement composite was 

almost completely hardened before putting the components against 

bone, to allow for easy subsequent removal. The second-stage 

procedure occurred at a mean interval of 11 weeks (range: four to 

39 weeks) after insertion of the spacer. The majority of prostheses at 

546 

reimplantation were constrained implants. Immediate mobilization 

was encouraged between stages and after reimplantation. Patients 

were assessed at a minimum of six years (mean 94 months; range: 73- 

144 months) post reimplantation, and modified Hospital for Special 

Surgery (HSS) knee scores were calculated. Two patients (12%) 

with diabetes had refractory re-infection, both more than two years 

after the re-implantation procedure. One, a woman with multipleresistant 

organisms, subsequently required external fixation, fusion, 

then amputation. The other, a 320-pound diabetic man required 

two further explantations and re-implantations using this method. 

Average range of motion for those with no re-infection just prior to 

re-implantation was 4 degrees to 110 degrees, and 3 degrees to 112 

degrees at latest follow up. HSS scores for those with no re-infection 

averaged 80 points (Range: 60-100) at latest follow up. A two-stage 

re-implantation technique that utilizes an articulating spacer for 

infected TKA results in effective treatment of infection and excellent 

range of knee motion between stages, and at long-term follow up. 


Chronic Antibiotic Suppression Reduces the 

Recurrence Rate of Periprosthetic Knee Infections 

Antonia Chen, MD, Pittsburgh, PA 


Claudia Ramirez, BS 

Matthew Tetreault, BA 

Nalini Rao, MD, Pittsburgh, PA 

Periprosthetic joint infection (PJI) is the most common cause 

of revision in total knee arthroplasty (TKA) and usually requires 

two-stage reimplantation with six weeks of antibiotics prior to 

reimplantation. This study examines factors that may reduce recurrent 

PJIs in TKA. Twenty-nine patients (16M/13F) were treated by twostage 

revision for PJI between 2006 and 2008 at a single institution. 

Infection was documented from clinical presentation, positive 

aspirates or positive intraoperative tissue cultures. There were a total 

of 29 TKA PJIs (19R/10L) with nine recurrences at two-plus year 

follow up. Of the nine recurrences, two had MSSA, one had MRSA, 

one had MRSA and GBS, one had MSSA and streptococcus viridans, 

two had coagulase negative staphylococcus, one had klebsiella and 

one had pseudomonas aeruginosa. Antibiotic therapy was managed 

by a single musculoskeletal infectious disease specialist. Long-term 

suppression was defined as antibiotic treatment greater than six 

weeks after reimplantation. Continuous variables were analyzed 

by the Mann-Whitney U Test and nominal variables were analyzed 

by Fisher’s Exact Test. The recurrence rate for periprosthetic knee 

infections was 31.0%. There was significant association between 

long-term antibiotic suppression and recurrences (p


UKA after Spontaneous Osteonecrosis of the Knee at 

11 years Follow-up 

Thomas Jan Heyse, MD, Marburg, Germany 

Ahmed Khefacha, Paris, France 

Professor Susanne Fuchs-Winkelmann, Marburg, Germany 

Philippe Edmond Cartier, MD, Neuilly Sur Seine, France 

Safety and efficacy of unicompartmental knee arthroplasty (UKA) 

in osteoarthritis has been shown in large patient series. It has been a 

matter of discussion whether or not spontaneous osteonecrosis of the 

knee (SONK) can successfully be treated with UKA. A retrospective 

approach included 52 cases of UKA for SONK of the femoral 

condyles. Four implants were revised (7.7%), and seven patients 

had died. Four patients (7.7%) were lost to follow up. Patients with 

the implant still in place underwent clinical examination including 

clinical scores (KSS and WOMAC) and radiographs. Satisfaction of 

patients was recorded in four categories. Average follow up was 10.9 

± 4.8 (4 - 25) years. Average age at operation was 66.6 ± 9.7 years. 

Two knees were mobilized within three weeks after the operation 

due to stiffness. The KSS score increased from a preoperative 85 ± 

30 to 173 ± 27 (p < 0.0001) at latest follow up. WOMAC was 7.7 ± 

11.4 at latest follow up. Most patients were satisfied (21.6%) or very 

satisfied (75.7%) with the outcome of this surgical procedure. One 

patient was dissatisfied (2.7%). This study shows that spontaneous 

osteonecrosis of the knee (SONK) can successfully be treated with 

UKA with a good mid- to long-term follow up. 


UKA in the Middle-Aged 

Thomas Jan Heyse, MD, Marburg, Germany 

Ahmed Khefacha, Paris, France 

Philippe Edmond Cartier, MD, Neuilly Sur Seine, France 

Unicompartimental knee arthroplasty (UKA) is known to be a 

viable procedure allowing preservation of the intact compartments 

delivering excellent long-term follow up. Revisions to total knee 

arthroplasty (TKA) are considered to be easy and can usually be 

done with primary implants, which makes UKA especially attractive 

to the younger and active patient. The purpose of this study was 

to report the outcome in patients younger than 60 years. From all 

UKA implanted between 1993 and 2005, 251 patients

postoperative (‘P) were analyzed. Oversizing was observed on the tibia 

(MLT=1.18±2.9, APTL=3.08±3.1) and the femur (MLANT=2.5±4.7, 

APM=1.1±2.6). Undersizing on the tibia (APTM=-1.58±2.4) and on 

the femur (APL=-0.81±3.2, MLDIST=-1.24±4.4. MLPOST=-2.93±4.2 

and MLPC=-1.68±4). A strong correlation was found between 

oversizing and ‘P in all dimensions excepted APTM and APM. 

Thresholds (T) were defined above which, ‘P was significantly 

lower (T, ‘P if inferior to T/ ‘P if superior to T, p-value). APL: 1 mm, 

35.1±20/23.9±16, 0.0083. MLANT: 0 mm, 39.2±20/29.7±18, 0.029. 

MLPOST: 1.5 mm, 33.2±19.7/22.8±15.4, 0.041. MLT: 2.5 mm, 

34.8±18.8/26.7±19.9, 0.034. APTL: 4 mm, 35.2±19.5/27.4±18.9, 

0.036. For two ML dimensions on the femur, the limit was an 

undersized component: MLDIST: -4.5 mm, 42.9±21/29.4±18, 0.006. 

MLPC: -4 mm, 38.2±19.4/29.9±19.2, 0.045. Surgeons are often 

unable to avoid oversizing in every dimension and slight overhangs 

can compromise the result. 


High Flexion Knees Are We Getting What We Are Paying 

For? 

Clifford W Colwell Jr, MD, La Jolla, CA 

Kenny Mai, MD, Hanford, CA 

Christopher Verioti, DO, Flint, MI 

Kace A Ezzet, MD, San Diego, CA 

Steven Copp, MD, La Jolla, CA 

Range of motion (ROM) following total knee arthroplasty (TKA) 

remains one of the most important factors in patient satisfaction 

following this surgical procedure. Because of relatively poor 

improvement in this measure with early design, newer high flexion 

designs by multiple manufacturers have been marketed. The purpose 

of our study was to compare ROM of the newer designs with previous 

designs. Clinical measurement with goniometer and radiographic 

measurement were obtained by three independent orthopedists. 

Gravity-assisted ROM, where patients maximally bend their own 

knees and active-assist ROM, where patients’ knees are bent by the 

surgeon maximally until stopped by anterior knee discomfort or 

inhibited by posterior soft tissue impingement were recorded and 

compared with the measurement from lateral radiographs obtained 

with knees in the same two positions. One hundred and eight 

patients (144 knees) were included in the study, with a mean gravityassisted 

ROM preoperatively of 110 degrees and postoperatively of 

113 degrees clinically and 112 degrees radiographically. Postoperative 

active-assist ROM were 117 degrees clinically and 121 degrees 

radiographically. Preoperative Knee Society function and score were 

52 and 55, respectively, and improved to 78 and 90, respectively, 

after surgery. Measurements obtained by three examiners were highly 

correlated, especially when radiographs were used for measurement. 

Three of the five prostheses were designed with high-flexion features; 

however, no difference in ROM was found between the previous 

designs and the high flexion designs. Although the newer designs 

allow for greater flexion, the actual flexion falls far short of the claim 

of the manufacturers. In addition, the ROM reported can depend 

significantly on the method of measurement used. Preoperative 

ROM remains the common denominator of postoperative ROM in 

all designs. 

548 


The Effect of Intra-articular Injection of Tranexamic 

Acid after Total Knee Arthroplasty 

Takashi Azuma, MD, Sakai City Osaka Pref, Japan 

Yoshinori Kadoya, MD, Sakai, Japan 

Kim Mitsunari, MD, Takarazuka City, Japan 

Yoshio Tokuhara, MD 

Kunio Takaoka, MD, Ikeda-City Osaka, Japan 

The blood conservation method after total knee arthroplasty (TKA) 

is controversial. The aim of this study was to evaluate the usefulness 

intra-articular injection of tranexamic acid without closed-suction 

drainage in comparison to re-infusion auto-transfusion system. A 

total of 160 patients (mean age = 74.2 years, 139 female, 21 male; 154 

osteoarthritis (OA), six rheumatoid arthritis (RA)) who underwent 

primary TKA were investigated. Eighty patients were treated with 

a re-infusion auto-transfusion system (Group I) and remaining 

80 patients received an intra-articular injection of tranexamic acid 

without closed-suction drainage (Group II). The postoperative 

hemoglobin and hematocrit values, range of motion (ROM), 

circumferentia of the thigh and calf; visual analog score (VAS) and 

functional recovery were compared. The postoperative hemoglobin 

and hematocrit values at one week were significantly higher in Group 

II. No significant differences were noted for ROM, circumferentia 

and incidence of wound complications. VAS score at rest was same 

between the groups but that during walking was significantly higher 

in Group II. As for the functional recovery (time for straight-leg raises, 

T-cane gait or stair-climbing), the patients in Group II had tendency 

to have slower recovery. Intraarticular injection of tranexamic acid 

without closed-suction drainage was shown to be effective and at least 

comparable in conserving blood and maintaining hemoglobin and 

hematocrit values when compared to re-infusion auto-transfusion 

system. This method has other advantages such as patient comfort, 

early mobilization and cost. These merits, however, should carefully 

be weighed against increased swelling, walking pain and slightly 

slower functional recovery. 


Revision Total Knee Arthroplasty in Patient Less than 

55 Years of Age 


Selena Eunice, MSPH, Saint Louis, MO 

Robert L Barrack, MD, Saint Louis, MO 


James A Keeney, MD, St Louis, MO 

Total knee arthroplasty (TKA) revision is a relatively uncommon 

procedure in patients less than 55 years of age, and there is minimal 

literature regarding clinical outcomes in this patient population. 

The purpose of this study was to determine the early clinical 

outcomes, radiographic fixation and complications/failures of TKA 

revision in patients less than 55 years of age. Our institutional adult 

reconstruction database with 600 revision TKAs was queried to 

identify patients less than 55 years of age who underwent revision 

TKA. Forty-nine knees (8.2% of all revisions) were identified and 

analyzed retrospectively at an average 4.7 year follow up (range, 

2-9.4). Average age was 42 years (range, 42-55). Seventeen were males 

(18 knees) and 28 females (31 knees). All TKAs were performed with 

metaphyseal cementation and cementless stems. Knee function was 

determined with the Knee Society score and standard radiographic 

analysis was performed. The average Knee Society score improved 

by 35.2 points (p

average 9.5 degrees (p=0.04). Six complications (12% of cases) were 

identified and included two dislocations, three manipulations and 

one deep infection. Two of these required surgery. All implants were 

well-fixed at the most recent follow-up visit and no implants were 

revised for loosening. Revision TKA in patients

analysis included age, co-morbidities (diabetes mellitus (DM), 

hypertension, hypercholesterolemia) smoking, previous history 

of stroke, antiplatelet medication, nature of surgery (computerassisted 

orthopaedic surgery vs. convention, primary vs. revision, 

unilateral vs. bilateral) and obesity. To compare incidence, vascular 

bypass surgeries of CS, NS, GS, URO department were compared. 

Six out of 1,214 (0.49%) patients suffered from stroke after TKA. All 

patients underwent primary TKA and all were female. Their mean 

age was 70.8 years. Three cases were bilateral TKA. Detection-andcare 

duration was mean 2.5 days. Most of them initially showed 

motor weakness or dysarthria. Four of them had diabetes mellitus, 

two had previous cerebrovascular accident and three were detected 

arteriovenous shunt (cardiac or peripheral) after stroke evaluation. 

DM, old age (more than 75), anti-platelet medication history, 

smoking, hypercholesterolemia were considered as high risk factors 

(OR= 58.2,22.4,37.1,52.8,32.5). Femoral or intracranial artery 

bypass surgeries had similar incidence of stroke (0.70, 0.51%). 

Incidence of stroke after TKA was 0.49% & similar to that of femoral 

or intracranial surgery. DM, old age, anti-platelet medication Hx, 

smoking and hypercholesterolemia were considered as high risk. 


Cell Count And Differential Of Aspirated Joint Fluid In 

Diagnosis Of Prosthetic Joint Infection 

Jiri Gallo, MD, Olomouc, Czech Republic 

Jana Zapletalova, PhD 

Ivana Cechova, MD, Olomouc, Czech Republic 

Milan Kolar, MD, PhD, Olomouc, Czech Republic 

There is no single reliable test to confirm the diagnosis of prosthetic 

joint infection (PJI). Several studies have demonstrated that cell 

count of aspirated joint fluid (AJF) may be a reliable tool in the 

preoperative diagnosis of PJI. To determine whether AJF analysis 

is a valuable tool in the preoperative detection of PJI in total joint 

arthroplasties, we conducted a prospective study. Patients were 

diagnosed with PJI if they met previously published criteria. Receiver 

operating characteristic curves were constructed for single and 

combined diagnostic data. The cutoff values of the leukocyte count, 

neutrophil and lymphocyte percentages for optimal balance between 

true and false positivity rates in the diagnosis of PJI were determined. 

We investigated the AJF in 43 patients with PJI and 77 controls. 

The median leukocyte count (20,500 compared with 500 cells/ml) 

and neutrophil percentage (87% versus 36%) were significantly (p 

2,150 leukocytes/ml, 

>69.5% and

2007. HTO was almost exclusively used for patients younger than 65 

years. The rate of conversion to knee arthroplasty was similar to what 

has been seen for unicompartmental knee arthroplasty. 


Comparison of Osteoarthritis after ACL Reconstruction: 

Patellar versus Hamstring Autograft 

Eun Kyoo Song, MD, Hwasungun, 160 Ilsimri, Hwasuneup, 

Republic of Korea 

Jong-Keun Seon, MD, Hwasun, Jeollanamdo, Republic of Korea 

Ju-Kwon Park, MD 

Mun Su Jeong, MD, Jeonnam, Hwasungun, Republic of Korea 

Mr Woo Bin Jung, Gwangju, Republic of Korea 

Kyung-Do Kang, MD 

We compared the incidence and risk factors for osteoarthritis (OA), 

after a minimum nine-year follow-up of anterior cruciate ligament 

(ACL) reconstruction, between using patellar tendon autograft 

and hamstring autograft. Fifty-three cases of ACL reconstruction 

using a patellar tendon and 40 cases using a hamstring tendon 

were evaluated with a minimum nine-year follow up. Radiographic 

evaluation, clinical outcome and laxity testing and the instrumented 

laxity testing were examined in relation to the development of 

osteoarthritis. Osteoarthritis was detected in 24 patients (45.3%) in 

the BPTB group and in 14 patients (35.0%) in the HT group. Among 

the various factors, an accompanying meniscal injury (BPTB group 

odds ratio (OR): 9.917; p12 months (the 

BPTB group OR: 3.273; p=0.037; the HT group OR: 5.625; p=0.021) 

and a patient’s age at reconstruction of >25 years (the BPTB group 

OR: 6.218; p=0.003; the HT group OR: 4.278; p=0.048) were all 

found to be significant independent predictors of osteoarthritis. 

However, no statistically significant correlations were found between 

the development of osteoarthritis and the clinical outcome or the 

radiographic stability in both groups. The overall incidence of 

osteoarthritis after ACL reconstruction using patellar and hamstring 

autografts was 41%. The frequency of OA was high for patients with 

accompanying meniscal injury, for patients with a protracted time 

from injury to reconstruction over 12 months and for patients who 

were more than 25 years old at reconstruction. 


Comparison of the Treatment of Infected Total Knee 

Arthroplasty: Static vs. Mobile Cement Spacer 








This study was undertaken to compare the clinical results of two-stage 

revision total knee arthroplasty (TKA) between static and mobile 

cement spacer in infected TKA. From July 2000 to February 2007, 

36 infected TKAs were treated with two-stage reimplantation using 

antibiotic-impregnated cement spacers (AICS) and followed up at 

least more than two years. Static spacers were used in 20 knees and 

mobile spacers in 16 knees. Range of motion (ROM), Hospital for 

Special Surgery (HSS) score and was evaluated prior to second stage 

revision TKA. Range of motion (ROM), HSS, Knee Society score (KSS) 

were evaluated at last follow up. In static group, 17 (85%) knees 

were revised successfully (one amputation, two fusion). In mobile 

551 

group, 15 (94%) knees were revised successfully (one fusion). These 

reinfection rates were not significantly different (p=0.698). Prior to 

second stage revision, in static group, ROM was 9.0° (0 to 20) and 

HSS score was 48.2 (31 to 52). In mobile group, ROM was 92.0° (65 

to 140) and HSS score was 57.2 (46 to 71) (p


Renal Function After Antibiotic-impregnated Spacer 

Placement for Infected Total Knee Arthroplasty 

John Koethe, ND, Nashville, TN 

Ginger E Holt, MD, Nashville, TN 

Cathy Jenkins, MA 

Sydney Hester, MD 

Bryan Shepherd, PhD 

Patty Wright, MD 

Geraldine Miller, MD 

Andrew A Shinar, MD, Nashville, TN 

The use of an antibiotic-impregnated cement spacer during the 

revision of an infected total knee arthroplasty (TKA) is associated with 

impaired renal function in case reports, but data on the incidence 

of acute kidney injury (AKI) following spacer placement is limited. 

We reviewed cases of antibiotic-impregnated spacers placed between 

January 1998 and November 2009 at our institution. AKI was defined 

as a >50% rise in serum creatinine from baseline to a level >1.4 mg/ 

dL within 90 days of the procedure. Logistic regression was used to 

assess associations between AKI and covariates. Eighty-five subjects 

met inclusion criteria; median age was 63 and median baseline 

creatinine was 0.91 mg/dL. Spacers contained aminoglycosides 

(93%), vancomycin (82%) and other antibiotics (6%), and all 

subjects received concomitant intravenous antibiotics (vancomycin 

and/or a beta-lactam n=82] or an aminoglycoside alone 


Etology of OA Based on Meniscus and Implications to 

Treatment 

Peter S Walker, PhD, New York, NY 

Sally Arno, MSc, New York, NY 

Sherry Liang, BS 

Gokce Yildirim, MSc 

Jonathan Samuels, MD 

Svetlana Krasnokutsky, MD 

Clinical evidence shows that injuries to the anterior cruciate ligament 

(ACL) or meniscus can lead to osteoarthritis (OA). Our hypothesis 

is that if the radial stiffness of the meniscus becomes reduced, the 

contact stresses on the cartilage will increase to cause progressive 

wear and OA. 3-D models of the femoral and tibial cartilage layers 

were constructed from 48 MRI scans of a patient cohort with OA 

at various stages, and from eight normal knees. The layers were 

divided into functional areas, and the thicknesses and volumes 

computed. Clinical and radiographic data were obtained. From the 

color-coded thickness maps, the central band of the distal femur, 

normally the thickest cartilage, steadily reduced until complete wearthrough. 

On the tibia, wear occurred on the cartilage not covered 

by the meniscus, then extended medially as wear progressed. 

Regression plots of (femoral distal medial volume)/(femoral distal 

lateral volume) versus (tibial medial volume)/(tibial lateral volume) 

showed parallel wear. Other plots showed predominance of central 

band wear, and low wear on the posterior femur. There was some 

correlation of wear with the Kellgren-Lawrence, but no correlation 

with Womac or SF36. Tibial wear at the medial side correlated with 

medial femoral subluxation. The wear patterns were consistent with 

weight-bearing in the central region not covered by the meniscus, 

implying the meniscus was ineffective in spreading the loads over 

a wide area. As deformity progressed, the femur subluxed medially, 

further stretching and extruding the meniscus. The wear patterns 

could be treated by early intervention components in many cases. 

552 


Magnetic Resonance Imaging Evaluation of Rotational 

Alignment in Painful Total Knee Arthroplasty 

Akira Murakami, MD, Boston, MA 

Thomas Hash, MD, Raleigh, NC 

Matthew Hepinstall, MD, New York, NY 


Bryan J Nestor, MD, New York, NY 

Hollis Potter, MD, New York, NY 

The purpose of this study was to demonstrate the utility of magnetic 

resonance imaging (MRI) in evaluation of rotational alignment in 

patients with painful total knee arthroplasty (TKA), unexplained 

by routine radiographs. Fifty patients were evaluated for painful 

TKA with MRI. These patients were compared to 16 asymptomatic 

controls. Two radiologists measured femoral and tibial component 

rotation, as well as a comparison of tibial to femoral component 

rotation. Inter-rater reliability was evaluated using one-way random 

intraclass correlation coefficient (ICC). Significant differences 

between measures between cases and controls were evaluated using 

an independent samples t-test. There was very high interobserver 

agreement for measurements of femoral component rotation (ICC 

= 0.811 for anatomic total elbow arthroplasty (TEA) and 0.696 for 

surgical TEA). Increased internal rotation of the femoral component 

was observed in painful TKAs relative to the controls. Mean surgical 

TEA angle in painful TKAs (Observer #1: 0.3º, SD 2.8; Observer #2: 

0.7º, SD 3.3) and in controls (Observer #1: -1.6º, SD 3.3; Observer 

#2: -2.0º, SD 3.7). This difference was statistically significant 

(

clinical infection was 15.5 months before resection. Thirty-seven 

patients underwent delayed reimplantion following antibiotic 

therapy and 21 patients with poor operative risks remained with the 

semi-permanent spacer for a mean of 11.4 months. A total of 81.1% 

were free from recurrent infection for a mean of 29.4 months. A 

total of 18.9% had a reinfection which required open debridement. 

Average flexion was 95.9° (range, 40-130°) with four patients 

having extensor lags averaging 27.5°. Twenty-one patients with poor 

operative risks remained with the semi-permanent spacer for a mean 

of 11.4 months. During the spacer phase, all patients had pain free 

ambulation with the stability of a fusion without bone loss or loss 

of limb length. Debridement after resection of a chronically infected 

TKA often leaves large bony and soft tissue deficiencies rendering 

conventional static and mobile spacers unsuitable due to instability. 

Incorporating an intramedullary rod in a hockey puck spacer block 

provides pain free, independent ambulation before reimplantation. 

This technique provides 1) stability and function simulating a fusion, 

2) eliminates use of braces, 3) avoids loss of limb length, 4) rod 

does not increase reinfection rates, 5) large surface area and higher 

elution of antibiotics, 6) stability for wound coverage procedures 

like flaps, 7) can be semi-permanent in select cases where medical 

complications delay reimplantation. 


Total Knee Design Based On Anatomic Medial Stability 

Peter S Walker, PhD, New York, NY 

Yonah Heller, BS 

Luis Vasquez, MS 

Gokce Yildirim, MSc 

MRI and fluoroscopic studies of knee specimens and test subjects 

have determined that for a full flexion range, the medial anterior/ 

posterior (AP) displacement is small, while the lateral femoral 

condyle is mobile and moves posterior in high flexion. This medial 

stability-lateral mobility concept is proposed as a rational approach 

to total knee arthroplasty (TKA) design for restoring normal knee 

mechanics and a natural feel to the patient. A test machine was 

constructed which applied a sequence of forces and moments to knee 

models, from which motion paths were measured. The mechanics of 

normal knee specimens was determined and expressed as neutral 

path of motion and laxity about the neutral path. Reconstructions 

using 3-D CAD software determined the motion patterns. Anatomic 

knees showed small medial femoral AP displacements and small AP 

laxities about the neutral path. The lateral side displaced posteriorly 

with flexion and showed large laxities. Standard CR and PS designs 

did not reproduce this differential medial-lateral behavior, and also 

showed paradoxical motion. The cam-post reduced AP and rotary 

laxities below normal values. The guided motion design reproduced 

anatomic mechanics more closely, with AP stability and lateral 

mobility. However, the cam-post still limited the laxities at higher 

flexion. In the quest for a TKA which feels like a normal knee, 

restoring anatomic mechanics may be key. This study showed how 

guided motion design features could help achieve this goal, and 

provided methods for design and pre-clinical evaluation. However, 

including a cam-post was not optimal to fully restore anatomic 

mechanics. 

553 


Efficacy of Multimodal Perioperative Analgesia 

Protocol with Periarticular Drug Injection in TKA 


Todd Kelley, MD, Cincinnati, OH 


Pain control is necessary for a successful postoperative rehabilitation 

and outcome following a total knee arthroplasty. The purpose 

of the study is to investigate the early postoperative pain control 

and rehabilitation course for patients receiving an intraoperative 

periarticular injection of medications consisting of an a2-adrenergic 

agonist (clonidine), a nonsteroidal anti-inflammatory (ketorolac), 

a long acting local anesthetic (ropivacaine) and epinephrine, to 

provide analgesia following total knee arthroplasty (TKA). Forty-eight 

patients who underwent TKA were randomized in a double blinded 

controlled study to receive one of four different intraoperative 

periarticular injections. Group A contained ropivacaine, epinephrine, 

ketorolac and clonidine. Group B contained contained ropivacaine, 

epinephrine and ketorolac. Group C contained ropivacaine, 

epinephrine and clonidine. The control Group D contained 

ropivacaine and epinephrine. All patients received a spinal anesthetic 

and preoperative celecoxib and oxycodone SR. Visual analog pain 

scores (VAS) and nursing pain assessments were recorded every four 

hours for 48 hours. Additional narcotic use and any side effects were 

documented. Knee range of motion, pain scores and ambulation 

distance were recorded for each physical therapy session. , Group A 

had significantly improved postoperative range of motion on days 

one and two over Group D (p

then maximal flexion and extension under gravity were measured for 

each knee using a navigation system. Average maximal flexions were 

134.3° in standard cruciate retaining knee, 136.2° in high-flexion 

knee and 136.4° in gender specific knee. All knees did not show any 

significant intergroup differences in intra-operative maximal flexion 

as well as extension between two groups (p>0.05). High-flexion and 

gender specific designs in cruciate retaining total knee arthroplasty 

showed a subtle increase in intra-operative range of motion without 

any significant differences compared with a standard design. 


Long-term Results and Survivorship Analysis of 

Implants in Revision Total Knee Arthroplasty 

Dae Kyung Bae, MD, Seoul, Republic of Korea 

Sang Jun Song, Seoul, Seoul, Republic of Korea 

Jung Ho Kang, MD, Seoul, Republic of Korea 

The purpose of this study is to evaluate the long-term clinical and 

radiological results, investigate the long-term survival rate of implants 

after revision total knee arthroplasty (TKA) and analyze the factors 

that contribute to the survival rate of implants. From December 1982 

to March 2007, 232 revision TKAs were performed in 195 patients. 

The mean follow-up period was 8.1 years (range, 2.0-18.5 years). 

For clinical assessment, the Knee Society clinical rating system was 

used, and survivorship analysis was done according to the life-table 

method. In order to evaluate factors influencing survival rate, the 

Mantel-Cox log rank test was used with variables including patient 

age, cause of revision, cementation technique and use of bulk 

allograft. The mean Knee Society knee and function score improved 

from 39.1 and 33.2 preoperatively to 86.9 and 74.0 at last follow 

up. The five, eight, 10 and 13-year survival rates were 97.1%, 92.1%, 

88.2% and 81.4%, respectively. The survival rate was lower in the 

patients younger than 65 years (p=0.007). There was no significant 

difference in survival rate according to cause of revision, cementation 

technique and use of bulk allograft. Clinical results and long-term 

survivorship of revision TKA were satisfactory. Overall survivorship 

decreased over time and annual failure rate markedly increased 10 

years after revision TKA. More frequent follow-up visits after the 10year 

period are needed to better detect complications. 


Role of Cartilage-Specific MRI in Pre-Operative 

Assessment of Patients Proceeding to UKR 

Vineet Batta, MD, Ascot, United Kingdom 

Shahid Mehmood, MRCS, Banbury, United Kingdom 

Ashish Gulati, MS, DNB, Oxford, United Kingdom 


Nicholas J Bottomley, MRCS, Oxford, United Kingdom 




Establishing a full-thickness cartilage in the lateral compartment and 

functionally intact anterior cruciate ligament (ACL) is vital before 

proceeding with unicondylar knee replacement (UKR). The aim of 

this study is to assess whether MRI is a useful adjunct in predicting 

suitability for UKR, as compared to standard and stress radiographs. 

We identified 50 patients with a knee found suitable for UKR based 

on their standard and stress radiographs. These patients underwent 

an additional cartilage-specific MRI scan to identify the status of 

ACL and the lateral compartment. The final decision regarding the 

suitability for UKR was based on the intra-operative observation. The 

mean age of patients was 65.1 years (49-79). Review of MRIs showed 

554 

that in 44 (88%), the MRI scan agreed with the X-ray findings. 

These patients all underwent UKR after suitability was confirmed 

intra-operatively. In six (12%) patients, the MRI scan was able to 

demonstrate significant lateral compartment arthritis in five patients 

and ACL damage in another. These findings were confirmed by direct 

observation at the time of surgery and a total knee replacement (TKR) 

was performed. Stress radiographs, if used alone, may not detect a 

proportion of knees with full-thickness cartilage loss in the lateral 

compartment. Despite doubts suggested in previous literature, our 

study suggests that cartilage-specific MRI can be a useful adjunct in 

the determining the status of the lateral compartment and ACL prior 

to UKR. It may be particularly useful for the younger population 

with osteoarthritis who would consent for UKR but not TKR. 


Risk Of Spinout In3800 Rotating Platform Knees At 

Minimum Of 5-Years 


Wayne M Goldstein, MD, Morton Grove, IL 


Douglas A Dennis, MD, Denver, CO 



Rotating platform technology for total knee replacement has 

been available for 30-plus years. While there are many theoretical 

advantages to these implants, a persistent fear has been the risk 

of ‘spinout’ or bearing dislocation. We reviewed a large series of 

consecutive rotating platform patients at multiple centers to evaluate 

this problem. A total of 2,289 patients (3,151 knees) at four different 

centers were treated with an identical rotating platform total knee 

replacement system. This consecutive group was prospectively 

followed. The average age of the group was 64 (range 19 to 88). 

The group was 60% female. Preoperative deformity and range 

of motion (ROM), postoperative alignment and ROM and Knee 

Society Scores were prospectively recorded. A total of three knees in 

three patients out of 3,151 knees sustained a bearing spinout at an 

average four-year follow up. One of these patients (who dislocated 

at four weeks following a fall) was successfully treated with closed 

reduction and bracing. The other two patients (who dislocated at 

three and four months respectively) were treated with conversion 

to a posterior stabilized fixed bearing design. For the group overall, 

the average postoperative ROM was 2 to 120 degrees and the average 

postoperative alignment was 3.1 degrees of valgus. Postoperative 

knee score improved from 42 to 90. With appropriate surgical 

technique, the risk of bearing spinout is very low in this large series 

at minimum five-year follow up. Surgeons should feel confident that 

this is a rare complication of using this rotating platform device. 


Novel Protocol For Outpatient Management Of Warfarin 

Prophylaxis Following Total Joint Arthroplasty 

Thomas L Bernasek, MD, Tampa, FL 

Ted William Parcel, DO, Denver, NC 

Kenneth A Gustke, MD, Temple Terrace, FL 

Steven Thomas Lyons, MD, Tampa, FL 

Tammy King, Tampa, FL 

Katheryne Downes, MPH, Tampa, FL 


The study evaluates a formula-based Warfarin dosing protocol for 

total joint patients. This retrospective study evaluates postoperative 

patients on a Warfarin protocol for deep vein thrombosis (DVT) 




prophylaxis attempting to maintain international normalized ratio 

(INR) between 1.9 and 3.0. A total of 494 post-operative patient flow 

sheets were evaluated from date of discharge through completion of 

Warfarin therapy. Exclusions included patients monitored by primary 

physicians or cardiologists, those discharged to nursing facilities 

(n=68), patients with insufficient data (n=16) and noncompliant 

patients (n=63). A total of 282 patients were available for analysis. 

During a minimum of a 21-day course of therapy, 50% of patients 

fell within target range and 40% of patients fell within + 0.3 of 

the therapeutic range. Eight patients (3%) were re-admitted to the 

hospital, two for pulmonary embolism and six for unknown cause. 

Three patients (1%) received a Vitamin K injection for elevated 

INR values. Eleven patients (4%) required physician adjustment to 

dosage. This formula maintained INR values + 0.3 units in 90% of 

patients. A total of 4% of patients required manual adjustment of 

their Warfarin dose. 


Use Of An All-Poly Tibial Component In Obese Patients 

Does Not Affect Survivorship 7 Years 


Kimberly K Tucker, MD, Oro Valley, AZ 


In the United States, the number of obese patients has increased 

markedly over the last four decades and this trend continues. Metal 

backed total knee replacement (TKR) has been shown to be an 

effective treatment modality for osteoarthritis of the knee in obese 

patients. The purpose of this study is to review our experience with 

use of an all-poly tibia in obese patients. Between 1996 and 2002, 

378 all-polyethylene tibial components were placed in 273 patients. 

Of these, 125 all-poly tibias in 90 patients had a body mass index 

>30 and were thus characterized as being obese. Average age of the 

cohort was 76 years (range 61-90). All TKRs were crutiate-retaining, 

tricompartmental knees. Patients were followed for a minimum 

seven years (average 10.3 years). Of the original 90 patients and 

125 knees, 24 patients (33 knees) were deceased and 13 patients 

(17 knees) were lost to follow up. Final study group was 53 patients 

and 75 knees. Patients were evaluated using the Knee Society Scoring 

System (KSS) and serial radiographs were evaluated. At a minimum 

seven-year follow up (range 7-14 years), KSSs had improved from 

46.4 to 93.2. Radiograhic analysis revealed radiolucencies in 25% 

of knees. All radiolucencies were


Wear Rate in a Series of 60 Rotating Platform Knee 

Bearings 

John H Currier, MS, Hanover, NH 

John P Collier, DE, Hanover, NH 

Michael B Mayor, MD, Hanover, NH 

Barbara H Currier, MChE, Hanover, NH 

Jennifer Caitlin Huot, Hanover, NH 

Douglas Van Citters, PhD, Hanover, NH 

Rotating platform (RP) knees aim to address the problems of 

loosening and rotational mal-alignment, but a potential disadvantage 

is the addition of the large backside articular surface. Measurement 

of retrieved components provides insight into the wear rate of this 

RP design. A series of 60 retrieved RP knee bearings were analyzed 

for damage and measured (through-thickness) for total wear. Average 

in vivo duration was 31 months (range 0.4 to 105). A total of 23% 

(14/60) were curved articular design; 77% (46/60) were stabilized 

articular design. Linear wear ranged from -0.04 to 0.25 mm (mean 

0.07), and increased with time in vivo (Spearman’s rho = 0.716, 

p 0.05 mm/yr). The dual, linear 

motion articulations of the RP design resulted in a low wear rate and 

associated debris generation. 


Patellar Thickness and Range Of Motion in Primary 

Total Knee 


Jose Carlos Alcerro, MD, Miami, FL 

Juan S Contreras, Miami, FL 

Mark Rossi, PhD, Miami, FL 

Overstuffing of the joint after total knee arthroplasty (TKA) is thought 

to be a cause of limited flexion. Our objective was to study the effects 

of patellar thickness on postoperative range of motion (ROM) and 

patient satisfaction. Two hundred patients undergoing primary 

TKA were studied. Patellar thickness was measured intraoperatively 

before and after patellar resection. Patients were divided according 

to postoperative total patellar thickness. Each patient was assessed 

preoperatively and at minimum two year’s mark for passive and 

active ROM. Difference in knee active flexion (KAF), knee passive 

flexion (KPF), knee active extension (KAE) and knee passive 

extension (KPE) were assessed using ANOVA. A Pearson product 

moment was also calculated to assess the relationship between levels 

of preoperative patellar thickness with the four ROM assessments. 

Independent t-tests were used to assess for differences in the KAF 

and KPF. There was no significant difference between groups based 

on preoperative patellar thickness for each of the ROM assessments 

(p range: 0.22 to 0.41). Results were similar at follow up for all 

postoperative patellar thickness (p range: 0.47 to 0.69). Patellar 

thickness was poorly correlated to ROM preoperatively (range: 0.001 

to 0.11) and postoperatively (range: 0.07 to 0.09). Postoperative KAF 

and KPF along with postoperative patellar thickness did not differ 

among those individuals who had 110° of KPF before the 

procedure. Maintaining a patellar resection between ±3.5 mm of its 

initial patellar thickness provides satisfactory results and does not 

556 

affect postoperative range of motion after primary total knee. 


Knee Arthroplasty Rehabilitation: Comparing 

Conventional Therapy to a Music Rehabilitation Video 

David A Fisher, MD, Indianapolis, IN 

Edward J Hellman, MD, Indianapolis, IN 

Sanford S Kunkel, MD, Indianapolis, IN 

Joseph C Randolph, MD, Indianapolis, IN 

Rising costs and limited access to services has led to the search for 

equally effective alternative treatments, including post-operative knee 

rehabilitation. We conducted a prospective, randomized controlled 

trial to see if patients who used a music exercise video following their 

knee surgery would demonstrate equivalent outcomes, satisfaction 

and decreased costs compared to conventional physical therapy. 

We randomized 100 patients undergoing total knee (58) and unicompartmental 

arthroplasty (42) into a video group or control 

group. The video group used a music exercise video following their 

surgery. The control group followed conventional in-home or outpatient 

physical therapy. Knee Society scores were determined at preop, 

six-week and six-month intervals, along with patient satisfaction 

ratings. The scorekeepers were blinded as to treatment group. 

Physical therapy costs were extrapolated. Six-month Knee scores 

were 90.9 (+/-8.7) and 92.1 (+/-9.1) for the control and video groups 

respectively (p=.5841). Improvement from pre op knee scores were 

+38.7 (+/-13.6) and +38.1 (+/-15.1)(p=.2442) respectively, and were 

statistically equivalent within 0.5 standard deviation (p=.0459). 

Function score was 82.1 (+/-16.7) and 77.4 (+/-19.3) at six months 

(p=.3778) respectively. Overall patient satisfaction was 4.7 (+/-0.5) 

and 4.7 (+/-0.5) and were statistically equivalent within 0.5 points 

(p

A control activity dataset was collected on 25 healthy subjects. , The 

knee monitoring system successfully provided monitoring data that 

delineated progress in ROM and compliance with the rehabilitation 

program to varying degrees. Patients tolerated the device throughout 

all collection sessions. A relationship between compliance and 

progress was evident based on the completion of the prescribed 

rehabilitation protocol. As expected, ROM and knee excursion 

events increased with time postop. Knee activity and ROM at day 10 

was positively related to maximal ROM at the final time point. Given 

expected increases in TKA procedures, development of an efficient 

and efficacious method to monitor patient progress and compliance 

during the postoperative period is critically needed. Our study 

demonstrates the feasibility of monitoring patient activity, progress 

with ROM and compliance with the postoperative rehabilitation 

program after TKA. 


Return to Theatre following Lower Limb Arthroplasty 

Before and After the Introduction of Rivaroxaban 

Cyrus D. Jensen, MB BS, MRCS, New Castle Upon Tyne, 


Andrew Steval, MB BS 

Paul Francis Partington, MD, Newcastle Upon Tyne, 


Mike R Reed, MBBS MD, Northumberland, United Kingdom 

Scott Muller, MBBS MD, FRCS, Northumberland, 


Rivaroxaban has been recommended for routine use as a 

thromboprophylactic agent in patients undergoing lower limb 

arthroplasty. Trials supporting its use have not fully evaluated the 

risks of wound complications caused by rivaroxaban. This study of 

1,048 total hip/knee replacements observes the return to theater 

(RTT) rates and infection rates before and after the change from a low 

molecular weight heparin (tinzaparin) to rivaroxaban as the chemical 

thromboprophylactic agent of choice in lower limb arthroplasty 

patients. During a 13-month period, 489 consecutive lower limb 

arthroplasty patients received post-operative tinzaparin. The next 559 

consecutive patients received rivaroxaban as thromboprophylaxis 

against venous thromboembolism (VTE.) Nine of the 489 patients in 

the control (tinzaparin) group (1.8%, 95% CI 0.9-3.5%) returned to 

theater with wound complications within 30 days post-operatively, 

compared with 22 out of 559 patients in the rivaroxaban group 

(3.94%, 95% CI 2.6-5.9%.). This increase was statistically significant 

(p

the 90-days showed significantly lower in Group 1 than in Group 2 

(p = 0.001). The most common side effect with regional anesthesia is 

hypotension which might lead to impairment of coronary perfusion 

and result in myocardial ischemia. Prolonged supine on bed for 

six hours to prevent postdural puncture headache and hematoma 

might cause formation of thrombus. The attacks of hypotension or 

formation of thrombus after SA might inflict the risk factors of CHD. 

Patients underwent TKA had potentially increased risks of CHD in 

SA compared with GA. 


MRI Findings of Osteonecrosis of the Knee: Differences 

of Steroid-Induced and Idiopathic ON 

Koh Shimizu, MD, Chiba, Japan 

Sara Shimizu, MD, Chiba, Japan 

Masatsugu Yamagata, MD, Ichihara, Japan 

Junichi Iwasaki, MD, Ichihara City, Chiba, Japan 

An universally accepted cause of idiopathic necrosis has yet to be 

established. Fracture has been suggested to be the cause of idiopathic 

necrosis from pathological findings; however, these studies did 

not include MRI findings. We aim to investigate the cause of 

osteonecrosis (ON) by detailed MRI analysis and to evaluate the 

difference between steroid-induced and idiopathic necrosis. MRI 

and X-ray analyses were performed in 301 knees of 185 patients (250 

steroid-induced ON knees, 51 idiopathic ON knees). Average age was 

39 years in steroid-induced and 71 years in idiopathic ON. Bilateral 

ON were observed in 114 of 136 patients with steroid-induced and 

in two of 49 patients with idiopathic ON. In steroid-induced cases, 

multiple necroses were common (132/136 patients) and most of 

the lesions demonstrated a “band pattern” and necroses occurred 

most frequently in the lateral femoral condyle, 79%; followed by the 

femoral diaphysis, 53%; medial femoral condyle, 46%. In idiopathic 

cases, multiple necroses were rare (three/49 cases) and most of the 

lesions demonstrated a “diffuse pattern” and necroses occurred 

most frequently in the medial condyle, 98%, but the shape of which 

was very similar to steroid-induced ON. In idiopathic ON, fracture 

was not evident in MRI findings. Steroid-induced ON is thought to 

be caused by obliteration of terminal vessels of the bone marrow. 

Idiopathic ON is thought to develop from mechanical stress applied 

to an ischemic environment; moreover, no evidence of fracture was 

evident on MRI. 


Early MRSA-infected TKA can be Treated with 

Successful Clinical Results Comparable to non-MRSA 

Ab-Rahman Shaifuzain, MBBS, Kota Bharu, KELANT Malaysia 


AS M Mashfiqul, FRCS 




Moi-Lin Lingg, MBBS 

Methicillin-resistant Staphylococcus aureus (MRSA) is becoming an 

increasingly common pathogen following joint prosthesis surgery. 

Previous studies show poorer outcomes following MRSA infection 

of joint replacement. We compared treatment outcomes of early 

MRSA infections (0.05). Overall 

successful surgical outcome of MRSA group was 92% and the non- 

MRSA group 77% (p>0.05). There was no significant difference in 

the KSS and SF-36 scores when compared between the two groups of 

successfully treated TKAs (p>0.05). Results suggest that early MRSAinfected 

TKA patients respond poorer to debridement and prosthesis 

retention. Staged reimplantation may be a better primary treatment 

option. Ultimately, successful surgical and functional outcomes are 

comparable to that of non-MRSA infected TKA patients. 


The Demographic Influence On Oxford Knee Scoring: 

Fact Or Fiction? 

Ali Ghoz, MB BCH MRCS MRCS(Ed), Leeds, West Yorkshire, 


Bassel El-Osta, MB BCh, London, United Kingdom 

Christopher Mark Andrews, Mr, North Yorkshire, 


The Oxford Knee Score (OKS) is a validated scoring system. Studies 

have suggested that the score is influenced by demographic differences 

between patients. The aim of this study was to further assess this 

using a large number of patients. Preoperative, three months and 

one, two, five and 10 years postoperative OKS were collected from 

1,636 patients from six distinct demographic locations undergoing 

total knee replacement (TKR) over 12 years under the care of seven 

consultants. The scores were analyzed to test whether age, postcode, 

sex, time or consultant had any significant effects on the outcome. 

No significant difference in outcome was found between the six 

locations. This was also the case when different consultants were 

compared. In this study, female patients had higher scores at both 

three and 12 months (significance p=0.011 and 0.044 respectively). 

Age of patient was also found to be of borderline significance when 

determining the post-operative scores. There was minimal change 

in the OKS over time. This large patient sample study shows that 

the Oxford Knee Score in post-operative patients is not as heavily 

influenced by demography as previously suggested. The results show 

that patients who are older and/or male will have better outcomes 

from TKR. Individual surgeons do not significantly affect the outcome 

although some surgeons may have better results when age of patient 

is taken into account. Finally, post code, life style and time have no 

significant influence on the outcome. 





Incidence, Predictors And Effects Of Postoperative 

Flexion Contracture In TKA For Asian Patients 

In Jun Koh, MD, Sungnam-Si, Gyenggi-do, Republic of Korea 


Korea 



Korea 


Hyung Joon Cho, MD, Seongnam, Gyeonggi-do, Republic of 

Korea 




Korea 

Postoperative flexion contracture (FC) can compromise the functions 

of a replaced knee and be the cause of residual anterior knee pain 

after total knee arthroplasty (TKA). In our practice for Korean 

patients who typically present with severe FC and yet maintained 

maximum flexion, it is frequent to have much larger flexion gap than 

extension gap despite rigorous soft tissue balancing and additional 

distal femur resection. In theory, a PE insert to fit the flexion gap in 

a knee with a larger flexion gap may lead to postoperative FC and 

one to fit the extension gap may lead to postoperative FC. Therefore, 

surgeons often face a challenging scenario between the risk for 

residual FC and the risk for flexion instability when selecting a PE 

insert for a knee with a larger flexion gap than extension gap. To 

provide helpful clues for the challenging scenarios, we attempted to 

determine the incidence and predictors for postoperative FC and to 

explore how detrimental the occurrence of FC is to the functions of 

a replaced knee. A retrospective review of 911 TKAs for osteoarthritic 

patients was carried out to identify the knees with a postoperative 

FC (5° or greater). To determine the predictors for the occurrence of 

postoperative FC, multivariate regression analyses were done for the 

demographic factors (gender, age, body mass index), preoperative 

status (motion arc, AKS scores, PF scores, WOMAC, SF-36) and 

surgical factors (difference in extension and flexion gaps, whether 

posterior cruciate ligament retained or substituted, implant type - 

fixed bearing vs. mobile bearing, whether unilateral or bilateral 

procedures, postoperative coronal limb alignment, degree of 

posterior slope of tibial component). Clinical outcomes were 

compared between the knees without and with FC. Of the 911 knees, 

there were 26 knees (2.9%) with five or more of FC (5° in eight, 10° 

in 15 and 15° in three). Mulitivariate regression analyses found that 

preoperative FC (odds raio=1.38 per 5° increase) and anterior knee 

pain (odds ratio=1.85 per one point decrease) were the predictors for 

the occurrence of postoperative FC. Compared to the knees with no 

postoperative FC, the knees with postoperative FC had less maximum 

flexion (125 vs. 133, p = 0.009), poorer AKS knee score (91 vs. 95, 

p

temperature to a peak corresponding to the level of ESR at the range 

of 2.5- 4.5°C. At 26-week follow up, both groups still had a mean 

of 1.0°C elevated temperature; however, there were significantly 

similarly improved KS clinical score (p


Navigation Does Not Improve Radiographic Sagittal 

Alignment of a Femoral Component in TKA 


Yong-Bum Park, MD, Seoul, Republic of Korea 


Korea 


Korea 






Korea 

Despite well-known improvement in coronal alignment of the 

femoral component, variable results have been published on 

the sagittal alignment of the femoral component after total 

knee arthroplasty (TKA). During computer-assisted TKA, sagittal 

alignment of a femoral component is established by mechanical axis 

identified by navigation system, but radiographic sagittal alignment 

is measured with reference to anatomical axes of the distal femur. 

We asked whether the application of navigation technology could 

improve radiographic alignment of the femoral component in 

the sagittal plane. In 196 knees undergoing TKA (navigated=97, 

conventional=99), femoral component flexion angles with reference 

to two anatomical references were measured on lateral radiographs. 

Anatomical data of patients including deviation between anatomical 

and mechanical axis, femoral bowing and femoral length were 

measured in preoperative radiographs. Univariate and multivariate 

regression analyses were carried out to identify the influencing factors 

on the sagittal alignment of the femoral component. No difference 

was found in radiographic sagittal alignment of femoral component 

in navigation and conventional group, having wide ranges of data 

in both groups. Deviation between anatomical and mechanical axis 

and femoral bowing were strongly associated with sagittal alignment 

of femoral component in navigation TKA. This study demonstrates 

that image-free navigation does not improve radiographic sagittal 

alignment with reference to anatomical references. We also found 

that deviations between mechanical axis and anatomical references 

of the femur inherently cause the variability of femoral component 

position in postoperative radiographic evaluation. Future studies are 

warranted to elucidate the clinical implications of the lack of sagittal 

alignment improvement in navigated TKAs. 


Anterior Border Of The Tibia Can Be Used As Reference 

For Extramedullary Alignment Guide In TKA 

Shuichi Matsuda, MD, Fukuoka, Japan 

Shingo Fukagawa, MD, Fukuoka, Japan 

Hiroaki Mitsuyasu, MD 

Ken Okazaki, MD, Fukuoka, Japan 

Yasutaka Tashiro, MD, PhD 

Yukihide Iwamoto, MD, Fukuoka, Japan 

Anterior border of the tibia has been used reference for installing 

an extramedullary guide in total knee arthroplasty (TKA). However, 

it has not been fully evaluated about appropriate references on the 

anterior border of the tibia for accurate positioning of the guide. A 

total of 101 osteoarthritic knees in 85 patients with varus deformities 

were included for this study. Computed tomographic images of 

561 

the entire tibia were obtained prior to TKA. Measurements were 

performed using three-dimensional imaging software. We identified 

six anatomical landmarks: the medial border, medial one-third of 

the patellar tendon attachment, and the most anterior points of the 

tibia at the level of the proximal one-fourth, proximal one-third, 

distal one-third and distal one-fourth. The relationship between the 

lines connecting the two of these points and the mechanical axis was 

evaluated in the coronal plane. The mean angles between each of 

the eight determined axes and the mechanical axis varied from 3.2° 

varus to 2.1° valgus. The line connecting the medial one-third of the 

patellar tendon attachment and the distal one-fourth of the anterior 

border was highly consistent and almost parallel to the mechanical 

axis (0.0 ± 0.7°). The line connecting medial third of the patellar 

tendon attachment and the distal one-fourth of the anterior border 

of the tibia was almost parallel to the mechanical axis. This axis can 

be a candidate for reference of extramedullary guide in total knee 

arthroplasty. 


Do We Know What Makes a Good Total Knee? 


Paul A Lotke, MD, Gladwyne, PA 

Surgeons generally agree on what they want to achieve when doing 

a total knee arthroplasty (TKA). However, we do not know which 

goals are correct, important or irrelevant. We asked if a surgeon can 

accurately predict success of a TKA at the time of surgery. We reviewed 

1,100 consecutive primary TKAs performed by a single surgeon. The 

surgeon intra-operatively recorded his impression of the quality of 

surgical success and the degree of difficulty on 1-10 point scales. At 

an average of 48 months (24-60) these scores were correlated to the 

clinical outcomes with the Knee Society (KS) clinical and functional 

scores. There were 142 patients with success scores of less than 

eight points. Of these, 15 were analyzed separately because there 

scores were less than 6.5 and all associated with clear and obvious 

deficiencies which would affect outcomes. There was no difference 

in the final clinical outcomes, nor degree of difficulty scores, between 

the 954 patients with more than, and the 127 patients with less 

than eight points on the intra-operative success scores. The mean 

KS clinical and functional scores for these 127 patients were 90 

(50-98) and 89 (40-95) respectively (p=0.62, p=0.47). There was a 

difference, however, in the clinical outcomes in the 15 patients with 

intra-operative success scores less than 6.5 points (mean KS clinical 

88 (65-90) (p=0.04) and functional 67 (30-80)(p

the symptoms associated is unclear. In a prospective pilot study, we 

hypothesized that significant weight loss via bariatric surgery will 

provide a beneficial clinical effect to patients with knee pain in the 

setting of osteoarthritis. Ten morbidly obese patients with knee pain 

and radiographic osteoarthritis were evaluated prior to undergoing 

gastric bypass surgery and were followed for one year after surgery. 

Visual analogue scale (VAS) pain scores, International Knee 

Documentation Committee (IKDC) scores and Western Ontario 

and McMaster University Osteoarthritis Index (WOMAC) and Short 

Form (SF-12) questionnaires were compared preoperatively and 

at one year postoperatively. The patients in our study, on average, 

lost 51 pounds at one year postoperatively following gastric bypass 

surgery. VAS scores improved from 4.7 preoperatively to 3.8 at one 

year postoperatively. WOMAC physical function and pain subscores 

both improved from 9.4 and 37 to 6.8 and 29.8, respectively. 

The average SF-12 score improved from -18.7 to -0.3 at one year 

postoperatively. The average IKDC score did not improve following 

surgery, decreasing from 49 to 43.7. With surgery-assisted weight 

loss, patients may experience improvement in knee pain. However, 

there appears to be irreparable damage from being morbidly obese 

that may limit improvement in knee pain despite significant weight 

loss. 


Blood Loss Reduction In Total Knee Arthroplasty: 

Tranexamic Acid vs Mechanical Flexion Technique 

Dr Pierluigi Antinolfi, Perugia, PG Italy 

Bernardo Innocenti, PhD, Leuven, Belgium 

Auro Caraffa, MD, Sarnan, IT Italy 

Giuliano Cerulli, MD, Perugia, Italy 

Total knee arthroplasty (TKA) may be associated with considerable 

postoperative blood loss and several techniques are commonly 

applied to reduce its volume. A prospective comparative randomized 

study was performed comparing the reduction in blood loss between 

a control group (no treatment) and a group of patients following 

either a local administration of tranexamic acid or a mechanical 

post-operative knee flexion. A second objective was to evaluate the 

impact of the techniques on the transfusion needs in patients. Only 

primary TKA patients were considered in this study; the same TKA 

was implanted in all the patients. Exclusion criteria were: tranexamic 

acid allergy, the use of pharmacological anticoagulant therapy, 

previous knee surgery and renal failure. For each patient the following 

parameters were investigated: the blood loss volume, the hemoglobin 

and hematocrit concentrations and the blood transfusion needs. 

The results show that the administration of systemic tranexamic 

acid reduces both the blood loss (with 40.5%) and the transfusion 

needs (with 57%) significantly (p0.05). Moreover, 

this treatment did not reduce the transfusion needs compared to 

the control group. Incidence of complications was not influenced 

by any of the treatments. The use of tranexamic acid, compared 

to mechanical knee flexion, significantly reduces blood loss and 

transfusion needs, without wound complications or symptomatic 

deep vein thrombosis (DVT). 

562 


Revision Knee Arthroplasty Using Morselized Bone 

Graft With Cementless Stemmed Prostheses 

Sammy A Hanna, MRCS, London, United Kingdom 

William Aston, FRCS, London, United Kingdom 

Nicholas De Roeck, FRCS 

David Powles, MD, FRCS 

Dealing with bone loss in revision knee arthroplasty is a challenging 

problem despite the array of reconstructive options available to 

surgeons to address this. The aim of this study was to analyze the 

results of using morselized loosely-packed cancellous bone graft in 

combination with stemmed cementless total knee components in a 

group of patients with a failed primary knee replacement associated 

with moderate to severe bone loss. We identified and retrospectively 

reviewed 56 patients (56 knees), who had undergone revision knee 

surgery at our institution between 1999 and 2006. All had a failed 

primary total knee replacement with an Anderson Orthopaedic 

Research Institute (AORI) grade (F1/2/3, T1/2/3) bone loss. Postoperative 

plain radiographs were assessed for the presence of nonprogressive 

radiolucencies, progressive radiolucencies, component 

migration and graft incorporation. Functional outcome was carried 

out pre and post-operatively using the Oxford Knee Score (OKS) 

system. There were 26 males and 30 females with a mean age of 68.3 

years at the time of operation. The mean follow up was 6.7 years 

(three to 10). The mean Oxford knee score significantly improved 

from 21.4 (36%) pre-operatively to 40.8 (68%) post-operatively 

(p

adiographs were reviewed for signs of loosening. All patients were 

followed for a minimum of two years. The mean follow up was 4.8 

years. At last follow up, the mean Oxford knee score was 34.2 (19- 

48). Seven knees (23%) in six patients required revision: three knees 

for infection (10%), two knees for aseptic loosening (7%), one knee 

for patellar instability (3%) and one knee for periprosthetic fracture 

(3%). The five-year survivorship for patients with TKA under age 

40 was 77%. Our results show increased complications and failure 

rate after total knee arthroplasty in this patient population. Implant 

survivorship in this series is lower compared to previously published 

series for primary total knee arthroplasty under the age of 55. Patients 

undergoing total knee arthroplasty under the age of 40 should be 

cautioned of the higher risk of failure and complications. 


The Pharmacokinetics Of Cefazolin Bone Concentration 

In TKA After Tourniquet Inflation 

Koji Yamada, MD, Tokyo, Japan 

Fumiaki Tokimura, MD, Tokyo, Japan 

Hiroshi Okazaki, MD, Topkyo, Japan 

Toshikazu Tsuboi, MD, Tokyo, Japan 

Yasuo Oohori, MD, Tokyo, Japan 

Toru Iga, MD 

Sakae Tanaka, MD, PhD, Tokyo, Japan 

Hiroyuki Oka, MD 

Ko Matsudaira, MD, PhD 

Little is known about the effect of air tourniquet in antibiotic 

bone concentrations. The aim of this study was to investigate the 

pharmacokinetics of cefazolin bone concentration in total knee 

arthroplasty (TKA) after tourniquet inflation. Consecutive patients 

who had symptoms for the indication of primary TKA were 

screened for the study eligibility. Two grams of cefazolin was given 

intravenously before the incision. Two bone samples were collected 

from all subjects. Cancellous bone from posterior femoral condyle 

(PFC) and tibial plateau (TP) were obtained. All samples were 

taken before the tourniquet deflation. Those who had possibility 

of abnormal bone concentration, and who were given extra dose 

before the samples taken, were excluded. Samples were transported 

and assayed at the same laboratory. A total of 27 patients were 

enrolled. The mean bone concentration was 17.8±12.0 mg/g in PFC 

and 16.1±11.0 mg/g in TP, with no significant difference (P=0.71 

by Wilcoxon test). No apparent trend toward time dependency 

was observed when the results in two regions were combined 

(Y=16.6584+0.00498X, R2


Microarray Analysis Of The Fat Pad In Knee OA And The 

Relationship With The Metabolic Syndrome 

Rajiv Gandhi, MD, Toronto, ON Canada 

Mark Takahashi, MD, Toronto, ON Canada 

Carl Virtanen 

J Rod Davey, MD, Toronto, ON Canada 

Khalid Syed, MD, Toronto, ON Canada 

Nizar Mahomed, MD, Toronto, ON Canada 

The role of the infra-patellar fat pad (IFP) in the knee joint 

inflammatory process of osteoarthritis (OA) is not well understood. 

The primary objective of this study was to examine the difference 

in gene expression patterns between diseased and control IFP 

samples. Twenty-nine disease IFPs and five control samples were 

harvested at the time of knee surgery. Total RNA was then extracted, 

labeled and hybridized to Illumina whole genome expression arrays 

(Human HT-12 v3 expression beadchip). Arrays were scanned and 

intensity of hybridization quantified. Arrays were checked for quality 

based on metrics in R/Bionconductor and subsequently imported 

into Genespring for further analysis. Individual probes displaying 

consistently low quality or signal intensity across all samples were 

removed from further study. Unsupervised analysis of all remaining 

probes and all samples using both principal components analysis or 

two-way hierarchical clustering showed groupings based on tissue 

source and disease. Deeper statistical analysis enabled us to find sets 

of genes that displayed differences between the two fat types. The 29 

IFPs demonstrated an elevation in the expression of adipokines such 

as adiponectin and leptin. Further, a statistically significant increased 

expression was seen for genes of adipogenesis that have relations 

to metabolic syndrome, such as peroxisome proliferator-activated 

receptor-³ ( PPAR-³), diacylglycerol acyltransferase 2 (DGAT2), 

cluster of differentiation (CD 36) and thyroid hormone responsive 

spot (THRSP) in the diseased fat pads as compared to the controls. 

Interestingly, a subset of five patients in the OA group appeared to 

consistently be more similar in gene expression to normal tissue. 

In conclusion, microarray analysis showed that the IFP from knees 

with OA demonstrate an increased expression of proinflammatory 

genes as compared to control samples, which may contribute to 

the disease process. In particular, we found an increased expression 

of the PPAR-³ gene in the disease IFP and this may represent a 

novel therapeutic target in OA. Interestingly, many of the genes 

upregulated in the disease IFP have relationships to the components 

of the metabolic syndrome and may suggest a metabolic pathway 

connecting these chronic diseases. Future work should be directed 

towards understanding the potential relationship between metabolic 

diseases such as diabetes, insulin sensitizing medications and joint 

inflammation in OA. 


Comparison of Kinematics & Outcome after Posterior 

Stabilized and Ultracongruent Mobile Bearing TKA 








Recently highly conforming ultracongruent total knee arthroplasty 

(TKA) has been reintroduced with improved wear characteristics 

and lower complications. The purpose of the study was to assess 

564 

kinematics and clinical outcome of posterior stabilized (PS) 

and ultracongruent (UC) rotating-platform mobile bearing TKA. 

Ninety patients with primary osteoarthritis of the knee were 

randomized to undergo computer assisted TKA with PS (n=45) or 

UC (n=45) prostheses and were followed up for a minimum two 

years. The passive kinematic evaluation was performed before and 

after implantation with a navigation system. Three parameters of 

tibiofemoral relationship (anterior/posterior translation, varus/ 

valgus alignment and rotation) were recorded from 0° to 130° of 

flexion. The patients were clinically and radiographically evaluated 

at final follow up. Paradoxical anterior translation of the femur was 

observed from 0° to 70° of flexion in PS (8.6 mm) and 0° to 85° 

in UC knees (10.2 mm, p=0.125). The distance of femoral roll-back 

was 6.6 mm and 6.5 mm, but never reached the starting point. 

Paradoxical internal rotation of the femur was found from 0° to 60° 

of flexion in PS (9.5°) and 0° to 46° in UC knees (6.0°, p=0.019). 

UC knees showed more external rotation of the femur during flexion 

from 0° to 130° (7.8:12.7, p=0.048). There was no significant 

difference in the maximal flexion (121.5°:121.9°, p=0.934), AKS 

knee scores (89.6:92.9, p=0.274), AKS function scores (75.0:82.0, 

p=0.234) and WOMAC index scores (20.7:15.9, p=0.135). There 

was no progressive radiolucent line or loosening in all knees. UC 

TKA showed similar anteroposterior translation and more femoral 

external rotation of earlier onset when compared to PS TKA. There 

was no difference in clinical outcome between two designs. UC TKA 

showed comparable kinematic and clinical results to PS TKA. 


Partial Release of the PCL and its Kinematic Changes 

During Cruciate Retaining TKA 


John Medige, PhD, Buffalo, NY 

Deepthi Rachala, MS 

Thomas Duquin, MD, Buffalo, NY 

Debate continues as to whether total knee arthroplasty (TKA) 

kinematics is better with a posterior cruciate ligament (PCL) 

substituting (PS) or retaining (CR) design. This study looked at 

the kinematics of the knee with varying levels of PCL release off of 

the tibia to better understand what happens if the PCL undergoes 

iatrogenic partial release during TKA surgery and whether this roll 

back can be tracked utilizing a computer navigation system. Six 

fresh frozen cadaveric specimens were utilized and had the midshaft 

of the femur mounted in a testing jig. The anatomical registration 

was undertaken for utilization of an infrared tracking system. The 

anterior and posterior origin and insertion of the PCL was digitized 

and then the knee flexed through a quadriceps driven open chain 

mechanism with 45N of static hamstring load. The kinematic profile 

was recorded for the intact, anterior cruciate ligament deficient knee 

as well as after release of the anterior one third, anterior two thirds 

and complete release of the PCL for comparison. Results showed 

that with progressive release of the PCL that the anterior points of 

the PCL origin and insertion increased to a maximum with complete 

release. This was not found to be statistically significant until two 

thirds and complete release of the PCL had occurred (p=0.03 and 


Bacterial Contamination of Surgical Scrubs; A 

Nosocomial Infection Risk? 

Chad A Krueger, MD, Fort Sam Houston, TX 

Clint Murray, MD, Fort Sam Houston, TX 

Katrin Mende, PhD 

Charles H Guymon, MA, Fort Sam Houston, TX 

Tad L Gerlinger, MD, San Antonio, TX 

The bacterial load within an operating room can contribute to perioperative 

infections. Our goal was to determine the bacterial burden 

and milieu of post-call scrubs. Thirty pairs of scrubs were swabbed 

in 10 locations (right and left axilla, inside and outside break 

pocket, crotch, pant line, inside and outside pant pocket, left and 

right thigh) on a per call basis. Samples were obtained prior to scrub 

wear and after 24 hours of continuous wear during call. All swabs 

were screened for aerobic gram-positive and gram-negative bacteria 

using standard microbiologic techniques. Bacteria underwent 

antimicrobial resistance testing and genetic relatedness by pulsedfield 

gel electrophoresis. A total of 41% (123 locations) of pre-call 

scrub samples were contaminated in comparison to 89% (268) of 

post-call scrubs samples (p

two million cycles, all 12 polyethylene components were weighed 

and analyzed. The results showed no statistical difference between the 

6 and 8 mm components. A separate analysis comparing specifically 

6 vs. 8 mm lateral and 6 vs. 8 mm medial also revealed no statistical 

differences. There were no significant differences between the 6 and 

8 mm polyethylene components at two million cycles with respect 

to wear. This theoretically allows the surgeon to resect less bone at 

the index procedure thereby preserving more of the patients host 

bone. It was also appreciated that with the thinner components, 

the peripheral rim of the polyethylene contained the least amount 

of material. Following this study, it is recommended to repeat the 

study with the tibial component in several degrees of mal-rotation to 

assess the integrity of this rim with respect to mechanical strength. 


Does Pre-Coating Total Knee Tibial Implants Affect The 

Risk Of Aseptic Revision? 

Stefano Alec Bini, MD, San Francisco, CA 

Yuexin Chen, BS, San Francisco, CA 



Pre-coating has been marketed as advantageous to long-term 

survivorship of cemented total knee implants. We hypothesize 

that pre-coating the tibia offers no clinical advantage in short-term 

survivorship. Using a community based arthroplasty registry, we 

assessed the early, non infection related revision rates of two tibial 

tray components that are identical except that one is pre-coated 

(PC) and one is not pre-coated (NPC). In a Cox regression model 

we adjusted for diagnosis, age, gender, BMI, ASA score and femoral 

coupling design (high flex vs. standard and cruciate retaining vs. 

substituting). Between 2001 and 2009, 13,810 PC and 2,705 NPC 

tibial trays were implanted. At three-year follow up, cumulative 

survival of NPC tibias was higher than PC (99.5 vs. 98.7%, p

(within 40 days), acute hematogenous infections and chronic 

infections with 65, 42, and 33 joints in each subgroup, respectively. 

The average follow up was 36.6 months. Treatment failure was defined 

as the need for any subsequent surgical intervention for infection. 

Successful I&D was performed in 66 (47.1%) of the 140 joints. 

Successful treatment occurred in 47.7% (31/65), 59.5% (25/42) 

and 30.3% (10/33) for acute postoperative, acute hematogenous 

and chronic infections respectively. Multivariate analysis provided 

both chronic PJI and methicillin-resistant organisms as predictors of 

failure (p=0.012 and p=0.017). No difference in success is observed 

between acute hematogenous and acute postoperative infections 

treated with I&D. Further, acute infections treated with I&D had a 

near two-fold likelihood of success compared to chronic infections. 

However, the success rate of this treatment is low regardless of timing 

and should be saved for a select group of healthy patients with a 

sensitive organism. 


A Novel In Vivo Technique To Measure Patella Tracking 

Following Total Knee Replacement 

Andrew P Monk, MRCS, Oxford, United Kingdom 

David R Simpson, PhD, Oxford, United Kingdom 

Minsi Chen, PhD, Oxford, United Kingdom 

Stephen J Mellon, PhD 

Max Gibbons, FRCS, Oxford, United Kingdom 


Harinderjit Singh Gill, PHD, Oxford, United Kingdom 


Total knee replacement (TKR) is the standard treatment for endstage 

osteoarthritis when conservative measures have failed. Previous 

attempts to study coronal plane patellofemoral kinematics have 

suffered from the patella being obscured by the components and/or 

metal artifact. The aim of this study was to assess whether there was 

any significant difference in the patellofemoral kinematics between 

normal and replaced knees using ultrasound in combination with 

a motion capture laboratory. Thirty patients were recruited into 

two groups; normal healthy volunteers (normal), and TKR patients 

with and without the patella resurfaced (TKR). A 12-camera motion 

capture system was used to capture images of markers mounted on 

subjects’ legs and an ultrasound probe, providing coordinates for the 

patella and bony landmarks on tibial and femoral segments, during 

a squat exercise. At each flexion angle, patellofemoral kinematics 

were described relative to both the femur and tibia in six degrees of 

freedom. The accuracy of the motion capture system is +/-0.29 mm. 

The accuracy of this technique registering the ultrasound images 

within the motion capture system is 2.54 mm. Early data shows 

medio-lateral movement of the patella between 0 and 90 degrees 

relative to the tibia was 6.09 mm for the normal group, and 1.12 

mm for the TKR group. The two groups showed different tracking 

patterns. Patella tendon angles: 11.4 degrees (normals), 4.1 degrees 

(TKR). Patella flexion angle: 8.56 degrees (normals), 6.97 degrees 

(TKR). Patella tilt: 9.8 degrees (normals), 3.53 degrees (TKR). Patella 

spin: 13.4 degrees (normals), 5.64 (TKR). We present a new, accurate, 

reliable in vivo technique for measuring six degrees of freedom 

patellofemoral kinematics. Our data suggest that many aspects of 

patellofemoral kinematics are absent following TKR whether or not 

the patella is resurfaced. 

567 


mRNA? Xpression Analysis Of Bcl2, Bax And Bcl2l12 

Apoptotic Genes In Osteoarthritis 

Georgios I Karaliotas, MD, MSc, Athens, Greece 

Konstantinos Mavridis, BSc 

Andreas Scorilas, Prof 

George Babis, MD, Athens, Greece 

Since osteoarthritis is primarily characterized by articular cartilage 

degeneration and chondrocyte loss, many studies have focused on 

the suggestion that cell death plays a pivotal role during disease 

progression. Although the role of apoptosis in cartilage pathobiology 

has not yet been fully clarified, the apoptotic BCL2 gene family 

is thought to be involved in the development of degenerative 

osteoarthritis. The purpose of the present study was the analysis 

of the mRNA expression pattern of classical members of the BCL2 

family, as well as of the recently cloned BCL2L12 in osteoarthritic 

cartilage. Eighty-five cartilage tissue samples were collected from 

patients undergoing reconstructive orthopaedic procedures. 

Utilizable total RNA was isolated from 28 samples and cDNA was 

produced via reverse transcription. The expression analysis of the 

apoptotic genes under study was conducted employing quantitative 

real-time PCR. The apoptosis-related genes BCL2, BAX and BCL2L12 

were found to be expressed, at the mRNA level, in cartilage tissue. 

The expression analysis revealed certain differences in the mRNA 

levels of BCL2, BAX and BCL2L12 between osteoarthritic (n=23) 

and non-osteoarthritic (n=5) cartilage specimens. More specifically, 

in osteoarthritic samples both the mRNA levels of the pro-apoptotic 

gene BAX and the novel gene BCL2L12 were elevated, whereas the 

ones of the anti-apoptotic gene BCL2 were downregulated compared 

to the non-osteoarthritic cartilage. Our preliminary results seem to 

implicate apoptosis further in the pathogenesis of osteoarthritis, 

through molecular mechanisms that include the aberrant expression 

of BCL2 gene family. Additional exploration of this procedure 

could reveal novel prognostic biomarkers and potential targets for 

therapeutic interventions in early stages of cartilage degeneration. 


Can Patient Self-Reporting Accurately Capture 

Complication Rates Following Total Knee Arthroplasty? 

Craig Dushey, MD, New York, NY 

Lindsey Bornstein, New York, NY 

Michael M Alexiades, MD, Manhattan, NY 


Inherent problems exist in calculating post-operative complication 

rates from single center registries (presentation at other hospitals) or 

from administrative ICD-9 coded databases (inaccurate recording by 

non-physician administrators). We examined the ability of patient 

self-reporting to overcome these limitations and accurately convey 

the rates of complications following total knee arthroplasty (TKA). 

Data from 3,278 patients from a prospective total joint registry was 

used to investigate the rates of complications in the first six months 

following primary TKA between May 2007 and February 2009. All 

patients reporting deep venous thrombosis (DVT), pulmonary 

embolism (PE) or major bleeding were identified through a mailin 

survey. Complications were verified by review of imaging records 

and direct communication with patients by a surgeon. Complication 

rates were then calculated and concordance between patient selfreport 

and surgeon assessment for each complication was measured. 

Surgeon verified rates of DVT, PE, and major bleeding were 1.52%, 

0.49% and 0.25% respectively. When compared to the complication 

rates as reported by patients, concordance was 86.2% for DVT, 




84.2% for PE and 32% for major bleeding. A total of 54.5% of 

complications were diagnosed and treated at the original operative 

hospital and 45.5% were diagnosed and treated at other institutions. 

Self-reported complications following TKA should be verified for 

accuracy by direct patient communication. Patient self-reporting 

was most accurate for determining the rate of DVT and PE and not 

as accurate for major post-operative bleeding. Our registry has the 

potential to overcome the limitations inherent in other methods of 

complication rate determinations for select complications. 


Clinical Results of Total Knee Arthroplasty in Patients 

with Skeletal Dysplasia 

Raymond H Kim, MD, Denver, CO 



Jeffrey D Kim, BS 


Patients with skeletal dysplasia have multiple skeletal abnormalities 

which can also affect the knee. The purpose of this study was to evaluate 

the clinical results of total knee arthroplasty (TKA) in a series of 

patients with five forms of skeletal dysplasia: pseudoachondroplasia, 

achondroplasia, multiple hereditary exostosis, spondyloepiphyseal 

dysplasia and osteogenesis imperfecta. Twenty-three total knee 

arthroplasties were performed on 14 patients between 1986 and 

2008. Preoperative diagnoses included pseudoachondroplasia in 

four patients (seven knees), achondroplasia in three patients (five 

knees), multiple hereditary exostosis in three patients (five knees), 

spondyloepipshyseal dysplasia in two patients (four knees) and 

osteogenesis in two patients (two knees). Clinical notes, operative 

records and radiographic data were reviewed. Minimum follow 

up was two years (average, 6.7 years; range, 2-24 years). At average 

follow-up of 6.7 years, no implants were radiographically loose. 

Average Knee Society Scores improved from 34.7 (range 10 to 60) 

to 83.5 (range 40 to 90) and Knee Society function scores improved 

from 49.8 (range 20 to 60) to 92.6 (range 60 to 100). Average flexion 

contractures improved from 4.3° (range 0 to 26°) to 2.0° (range 0 

to 10°) and flexion itself improved from 98.3° (range 45 to 130°) 

to 99.1° (range 80 to 120°). To our knowledge, this is the largest 

series reviewing clinical outcomes of total knee arthroplasty in 

skeletal dysplasia patients. Despite limited improvements in range 

of motion, total knee arthroplasty in patients with skeletal dysplasia 

can provide substantial pain and improved function. 


Evaluation of TKA Performed With and Without 

Computer Navigation: A Bilateral TKA Study 

Derek R Johnson, MD, Parker, CO 


Kirk Kindsfater, MD, Fort Collins, CO 

Raymond H Kim, MD, Denver, CO 

Obtaining accurate anatomic and mechanical alignment in total 

knee arthroplasty (TKA) is correlated with improved long-term 

results. Whether computer-assisted total knee arthroplasty (CAS- 

TKA) more reliably produces a neutral mechanical and anatomic 

alignment and improves functional outcomes over traditional 

total knee arthroplasty (T-TKA) remains debatable. This report 

evaluates the results of CAS-TKA vs. T-TKA in a series of patients who 

underwent bilateral TKA performed at the same surgical operation. 

Sequential bilateral TKA were performed on 54 patients utilizing 

CAS-TKA in one knee and T-TKA in the contralateral knee by two 

568 

fellowship-trained surgeons. A review and statistical analysis of 

prospectively collected data was performed after a mean follow 

up of 2.6 years. There were no differences between CAS-TKA and 

T-TKA with regard to Knee Society Score (KSS) (p=0.30), range of 

motion (ROM) (p=0.66), mean anatomic alignment (5.67º vs. 

5.21º, p=0.11), femoral component angle (5.48º vs. 5.33º, p=0.55), 

tibial component angle (89.90º vs. 89.66º, p=0.30) or mechanical 

axis (0.20º vs. 0.12º, p=0.80). There were significantly fewer 

alignment outliers in the CAS-TKA group with respect to anatomic 

alignment (3.7% vs. 17.0%, p=0.02), tibial component angle (0% 

vs. 7.5%, p=0.04), and mechanical axis alignment (6.1% vs. 20.4%, 

p=0.04). At early follow-up duration, there were no differences with 

regards to KSS, ROM or mean alignment between the two groups 

performed by high-volume, fellowship-trained total joint specialists. 

Use of computer navigation resulted in fewer outliers with regards 

to alignment. Long-term follow up will be required to assess the 

significance of these alignment variants. 


Comparison Of The Tibiofemoral Rotational Alignment 

After Mobile Bearing And Fixed Bearing TKA 



Dongwook Kim, MD, Seoul, Republic of Korea 






No anatomical landmark could be used as a reliable reference 

for the rotational alignment of the proximal tibia. The anatomic 

landmark for anteroposterior (AP) axis of the proximal tibia and its 

variability was investigated to evaluate whether a certain landmark 

could be used as a reference axis for proximal tibia after rotating 

platform mobile bearing (RP-MB) and fixed bearing (FB) total knee 

arthroplasties (TKAs). Eighty primary osteoarthritic knees were 

randomized to undergo RP-MB (Group A, n=40) or FB (Group B, 

n=40) TKAs and followed up for 37 and 36 months, respectively. 

The anteroposterior axes were defined for the distal femur, proximal 

tibia, ankle and each TKA component and their angles from the 

distal femoral AP axis were measured on reconstructed CT scans. 

Clinical and radiographic outcomes were evaluated at final follow 

up. The rotational position of the proximal tibia changed after RP- 

MB TKA (p=0.014) while it did not after FB TKA (p=0.133). The 

mean postoperative alignment of the tibia was different between 

the two groups (Group A: Group B = -2.9: -0.14, p=0.01) and its 

variability was significantly greater in group A (P


Computer Assisted Total Knee Arthroplasty For 

Significant Tibial Deformities 

Ritesh Shah, MD, Chicago, IL 

Lalit Puri, MD, Glenview, IL 

Gregory Strohmeyer, MD, Albuquerque, NM 

The success of a primary total knee arthroplasty (TKA) is partly 

dependent on mechanical axis restoration and soft tissue balancing. 

In the presence of proximal tibial bony deficiencies, restoring proper 

implant and extremity alignment remains a significant challenge. 

Quantification of tibial plateau deformities has been performed by 

radiographic templating and manual intra-operative measurement. 

Alternatively, computer assisted total knee replacement (CAS TKR) 

may allow tibial plateau deformities to be quantified prior to 

performing tibial osteotomies. In this prospective study, we describe 

the use of computer navigation to quantify the amount of bone loss 

on the medial or lateral tibial plateau and assess the need for and use 

of metallic tibial augmentation. A total of 439 consecutive primary 

CAS TKR were performed by one surgeon. Navigation instruments 

quantified the tibial deformities by inputting the lowest point on 

the deformed tibial plateau and the mid-point on the non-deformed 

tibial plateau. Inclusion criteria were patients undergoing CAS 

TKR in whom the measured difference between the medial tibial 

plateau and lateral tibial plateau exceeded 13 mm and the tibial 

deformity involved greater than one-third of the tibial plateau. All 

tibial deformities greater than 13 mm utilized tibial augmentation. 

We noted the navigated measured bony defect size, size of tibial 

wedges, prostheses used and polyethylene size. Radiographs were 

reviewed to measure the joint line restoration and final mechanical 

limb alignment. Twelve knees (2.7%) had tibial deformities greater 

than 13 millimeters and required tibial plateau metallic wedge 

augmentation. The mean measured tibial plateau discrepancy 

was 18 mm; six knees required a 5 mm tibial wedge and six knees 

required a 10 mm tibial wedge. The mean polyethylene size used 

was 11 mm. Mean overall post-operative mechanical alignment was 

0.08 degrees of valgus. Mean joint line restoration was 2.8 mm. CAS 

TKR is helpful in accurately measuring severe tibial deformities, 

predicting tibial augment thickness and restoring the mechanical 

alignment and joint line. 


Inflammatory Response of Human Articular 

Chondrocytes to Wear Debris 

Lige Kaplan, MD, Royal Oak, MI 

Carly Gratopp 

Erin Ann Baker, MS, Royal Oak, MI 

Kevin Baker, MS, Royal Oak, MI 

Unicompartmental knee arthroplasty (UKA) systems are commonly 

revised due to progression of arthritis characterized by cartilage 

degeneration. Retrieval studies have revealed significant mechanical 

damage to UKA components capable of generating particulare 

debris. The goal of this study is to investigate the potential role of 

implant wear in the biologic destruction of cartilage through in 

vitro analyses. Normal human articular chondrocytes (nHAC) from 

the knee were cultured on top of cross-linked ultra high molecular 

weight polyethylene (UHMWPE), cobalt-chromium-molybdenum 

(CoCrMo) or Ti6Al4V particles (0.1 or 1.0 mg/mL) in 24-well culture 

plates. Cell morphology was monitored at 24-hour intervals by phase 

contrast microscopy. Production of TNF-a, IL-1b, IL-10 was assayed 

by ELISA at one, three, five and seven days. Viability was compared 

between the materials and doses after seven days by mean transit 

569 

time assay. After 24 hours of culture, cells entered a phagocytotic 

phase with active uptake of particles within cell membranes. Cell 

detachment was apparent in CoCrMo and UHMWPE-treated wells. 

Expression of inflammatory cytokines was dose, time and materialdependent. 

IL-10 was expressed at the highest levels, followed by 

IL-1b and TNF-alpha. Cell viability was both material and dose 

dependent, with the largest reductions in viability coming from 

CoCrMo-treated wells (73.6%), followed by UHMWPE (43.7%) 

and Ti6Al4V (4.4%). Material and dose-dependent changes in cell 

morphology, cytokine expression and cell viability suggests that 

wear debris may have the potential to induce degenerative changes 

in cartilage adjacent to UKA components. 


The Financial Impact Of Our Innovative Joint 

Replacement Program In Our Regional Medical Center 

Jon R Cook, PT, Cottonwood, AZ 

Jack W Wylie, MD, Cottonwood, AZ 

Paul Prefontaine, PT 

A product line profitability analysis (PLPA) which is generated 

from the Medicare cost report is a method used to evaluate the 

financial solvency of hospital joint replacement programs (JRP). 

However, cost reports include a large amount of indirect cost 

which can overestimate the cost of treating this population. This 

discrepancy may underestimate the financial contribution JRPs 

make to their institutions. We compared PLPA to direct cost and 

total reimbursement for JRP cases in our regional medical center. 

Fifty-three cases over a period of 10 months were randomly selected 

for analysis of the direct cost of performing their joint replacement 

surgery. This included an itemized tracking of cost including preop 

education, surgical procedure including implant, social services, 

nursing, lab, radiology, rehab, pharmacy and dietary, among others. 

We then compared our findings to the total reimbursement and 

the PLPA for the same cohort. The average cost was $8,759 and 

the average reimbursement was $18,485 giving average revenue of 

$9,727 per case. The PLPA calculated an average cost of $18,141 and 

$18,509 average reimbursement leading to $369 average revenue 

per case. Due to a large indirect cost which is greater than the direct 

cost, the PLPA calculated a significantly higher cost per case, which 

led to lower revenue. Such an underestimation of revenue can 

lead institutions to make adverse decisions on a JRP’s solvency or 

program development. Since indirect costs are constant, a decision 

to eliminate a JRP based solely on PLPA solvency would only further 

indebt the hospital. 


Accuracy Of Implant Placement Using Customized 

Patient Instrumentation 

Hideki Mizuuchi, MD, La Jolla, CA 

Shantanu Patil, MD, La Jolla, CA 

Darryl D D’Lima, MD, La Jolla, CA 

William Bugbee, MD, La Jolla, CA 

Alignment and positioning of implants is important in total 

knee arthroplasty (TKA). Customized patient instrumentation 

(CPI) is an innovation that combines preoperative planning with 

customized cutting jigs. We compared the postoperative implant 

alignment of patients undergoing surgery with CPI to standard 

TKA instrumentation. Twenty-five consecutive TKA using CPI were 

analyzed. Preoperative CT scans of the patients’ lower extremity 

were segmented using MIMICS. Limb alignment and mechanical 

axes were computed. Based on the preoperative planning protocol, 

virtual implantation of implant CAD models was done using Rhino. 




Postoperative coronal and sagittal view radiographs were obtained. 

Using 3D-image-matching software, relative positions of the femoral 

and tibial implant were obtained from radiographs. Lowest contact 

point between femur and tibial inserts was calculated, imported 

into Rhino and compared to virtual surgical placement. Twentyfive 

TKAs implanted using standard instrumentation were analyzed. 

For CPI, difference in alignment from the preoperative plan was 

calculated. For the standard TKA group, targeted alignment was 90° 

in both planes for the femur and 90° coronal for the tibia. In the 

CPI group, mean absolute difference between planned and actual 

femoral placement was 0.7° (SD 0.5) in the coronal plane and 1.2° 

(SD 0.9) in the sagittal plane. For the traditional instrumentation 

group, difference from ideal placement for the femur was 1.5° (SD 

1.6) in the coronal and 2.3° (SD 1.3) in the sagittal plane. This 

was statistically significant at P< 0.001. In the CPI group, mean 

difference for the tibia was 0.9° (SD 0.6) in the coronal plane, as 

compared to 1.8° (SD 1.6) in the standard instrumentation group. 

(NS) CPI achieved accurate implant positioning that was superior to 

traditional total knee instrumentation. 


Patellofemoral Kinematics for Obese, Overweight and 

Normal Weight TKA Subjects 

Matthew Anderle, Parker, CO 

Sumesh M Zingde, Knoxville, TN 


John P Mueller, PhD, Knoxville, TN 

Duarte Y Ho, BS 


The objective of this study was to compare in vivo 2D patellofemoral 

kinematics in total knee arthroplasty (TKA) subjects by body mass 

index (BMI). A total of 266 TKA subjects were analyzed using 

fluoroscopy and a 2D measurement software package to determine 

patellofemoral angle (PA) relative to the femur and the normalized 

patellofemoral contact position (PC) from the distal end of the 

patella during a deep knee bend from full extension to maximum 

flexion. Each subject was classified as obese, overweight or normal 

weight using a standard BMI scale. Implant type analysis was also 

conducted on the mobile bearing, fixed bearing, posterior stabilized, 

bi-cruciate stabilized, cruciate retaining, anterior cruciate retaining 

and medial pivot groups. From full extension to maximum flexion 

the obese (n=82), overweight (n=123) and normal weight (n=61) 

groups averaged 74.0º, 75.3º and 80.4º of patellofemoral rotation. 

The obese group’s PA was significantly higher at full extension than 

normal weight group (3.2º vs 1.1º, p=0.0344). A similar trend was 

seen in every implant type group analyzed. From full extension 

to maximum flexion, the obese, overweight and normal weight 

groups experienced 0.34, 0.34 and 0.32 times patella length of PC 

translation. When analyzed by implant type, only the mobile bearing 

group showed a significant difference (normal weight compared to 

overweight at 60º, p=0.0409) at any contact point increment. All 

other implant type groups were similar at each increment, across 

the three BMI categories, within the same implant group. It can be 

concluded that BMI does play a factor in patellofemoral kinematics, 

particularly in patellofemoral angle. 

570 


Patient and Surgical Factors Associated with Primary 

TKA Outcomes in the United States 


Maria Carolina Secorun Inacio, MS, San Diego, CA 




Eric J Yue, MD, Carmichael, CA 

Factors associated with total knee arthroplasty (TKA) outcomes are 

unclear. TKA patient demographics, surgical information, surgeon 

and hospital volume, implant characteristics and subsequent revision 

procedures were recorded in a total joint replacement registry (TJRR). 

Descriptive, survival and multivariate analyses are presented. A total 

of 47,429 primary TKA cases were performed between 2001 and 

2009. The patients were predominantly female (63%) with 38%

in 70.5% (12/17) GN compared to 78.3% (58/74) of MSGP and 

63.2% (48/72) of MRGP. These results indicate that PJI due to GN is 

a complex complication to treat with limited success. It appears that 

debridement and prosthesis retention has a high failure rate in all 

PJI especially those caused by GN organisms. Two-stage revision was 

more successful in MSGP than GN, while MRGP provides the most 

problematic PJI. 


Patients with TKA still wish for further improvements 

in important issues 


Korea 

Kenny Won Jae Lee, MD, Saskatoon, SK Canada 

Yeon Gwi Kang, MD, Seongnam-Si, Gyeonggi-Do, Republic of 

Korea 


Korea 

Jae Ho Yoo, MD, Seoul, Seoul, Republic of Korea 




Korea 


Total knee arthroplasty (TKA) has been well documented to be an 

excellent treatment option for patients with advanced knee diseases, 

but a substantial proportion of patients are not fully satisfied with 

treatment outcomes after TKA, which indicates that contemporary 

TKA needs to be improved in various areas. The authors formulated 

nine issues that they considered to be important from the perspective 

of patients after TKA and attempted to determine how much patients 

after TKA are satisfied with the nine issues and to explore what 

patients wish for further improvements with regard to the nine 

issues. In addition, they also sought to indentify factors influencing 

patient wishes including the extent of patient satisfaction with the 

nine issues. A total of 210 consecutive patients who returned for 

TKA follow up were given a self-administered questionnaire to 

assess the levels of satisfaction and wishes in the nine issues. Sociodemographic 

data and various knee scores were obtained as well. 

Extents of patient satisfaction and wishes for further improvements 

with regard to the nine issues were evaluated using a 0-10 visual 

analog scale. Correlation analyses were performed to determine 

whether socio-demographic factors, functional outcomes by the 

clinical outcome scales and the extent of satisfaction are associated 

with patient wishes for further improvements in the nine issues. The 

highest patient satisfaction was with the occurrence of perioperative 

complications, followed by pain relief, expected implant longevity, 

restoration of routine daily activities, incision cosmetic, ability to 

perform recreational sports activities, hospital fee, postoperative 

pain management and ability for high flexion activities. Notable 

proportions (greater than 20%) of patients expressed a low level 

(VAS 0-3) of satisfaction with ability of high flexion activities (55%), 

postoperative pain management (40%), incision cosmetic (33%), 

ability to perform recreational sports activity (28%), hospital fee 

(24%) and restoration of routine daily activities (21%). Patients 

expressed high levels (higher than VAS 8) of wishes for further 

improvements in most of the nine issues, and the top three issues 

were restoration of daily activities, pain relief and ability for high 

flexion activities. Levels of patient satisfaction with the nine issues 

were not associated with patient wishes for further improvements, 

and a few sociodemographic factors including younger age and high 

household income were found to be associated with higher wishes. 

571 

This study demonstrates that notable proportions of patients are not 

fully satisfied with the nine important issues and wish for further 

improvements, particularly for restoration of daily activities, pain 

relief and ability for high flexion activities. Patients with a certain 

sociodemographic features, such as younger age and high household 

income, wish for further improvement more than those without the 

features. 


Robotic Arm Guidance to Improve Lateral 

Unicompartmental Accuracy and Outcomes 

Martin William Roche, MD, Fort Lauderdale, FL 

Lateral unicompartmental knee arthroplasty (UKA) utilizing 

mechanical instrumentation makes it difficult to routinely allow 

the surgeon to achieve optimized lateral joint kinematics. Results 

are influenced by the surgical approach, and knowledge of the 

differing anatomic and biomechanical properties of the lateral 

compartment. The patient with lateral compartment disease is more 

commonly female, and may present with soft tissue laxity, femoral 

hypoplasia and joint line obliquity. An intelligent cutting tool to 

allow optimized surgical outcomes was introduced, to determine 

the ability to achieve the desired pre-op plan, with the ability to 

adjust intra-op through a minimally invasive approach. Ten patients 

with various lateral compartment arthritic pathologies underwent 

a lateral UKA utilizing a computer assisted robotic arm technology 

through a minimally invasive lateral approach. The surgery was 

performed with CT based imaged navigation. The bony preparation, 

implant to implant articulation, joint gap balancing and mechanical 

axis were defined intra-op based on the patient’s specific kinematics. 

The surgeon assisted robotic preparation of the defined surgical 

parameters were performed under haptic guidance. All 10 patients 

were female, and underwent successful lateral UKA surgery with this 

novel technology. The mechanical axis was corrected an average of 

three degrees. The post-op weight bearing x-rays when compared to 

pre-op showed less than 1 mm change in the medial joint space. The 

average bony resection on the tibia was 3 mm and average posterior 

slope was six degrees. At six weeks, all patients had improved their 

range of motion by an average of five degrees and walked unassisted. 

The use of a haptically enabled robotic arm, utilizing virtual implant 

placement, accurate alignment and soft tissue balance through a 

direct lateral approach, allows bony resection and implant placement 

to be done through a minimal incision with precision and safety. 


Wide Variability in Tibial Tubercle Location: 

Implications for Aligning the Tibia in TKA 

Stephen M Howell, MD, Sacramento, CA 

Justin Chen, BS, Sacramento, CA 

Maury L Hull, PhD, Davis, CA 

Understanding the relationship between the tibial tubercle and its 

medial-lateral location on the tibia in the varus and valgus knee 

is important for aligning the internal-external rotation of the tibia 

on the tibial component and avoiding a poor functional outcome 

in total knee arthroplasty. The purpose of this study was to test the 

hypotheses that 1) the variability of the medial-lateral location of 

the tibial tubercle is wide enough to cause a clinically important 

error in rotational alignment of the tibia, 2) the variability of the 

location is not different in the varus and valgus knee, and 3) the 

medial border and the medial one-third of the tibial tubercle do 

not align with the anterior-posterior axis of the kinematically 

aligned tibial component. The study was performed in 115 knees 

in 111 consecutive subjects treated with total knee arthroplasty for 




end-stage osteoarthritis. The medial-lateral location of the medial 

border of the tibial tubercle from the medial tibia was measured 

from a magnetic resonance image (MRI) of the knee obtained in 

a kinematic projection where the image plane is perpendicular to 

the flexion-extension axis. The perpendicular distances between 

the medial border and the medial one-third of the tibial tubercle 

and the anterior-posterior axis at the center of the tibial component 

were measured from a three-dimensional model of the knee with 

the femoral and tibial components kinematically aligned. The 

medial border of the tibial tubercle varied 32 to 47 mm from the 

medial tibia. The location of the tibial tubercle was not different in 

the varus and valgus knee (p = 0.5872). The medial border of the 

tibial tubercle averaged -3 mm medial and did not align with the 

anterior-posterior axis of the tibial component (p

or more components had to be cemented based on intraoperative 

assessment of bone quality and other reasons, and in seven patients, 

constrained components had to be used instead; these two groups 

were excluded from the study. The subvastus approach was used in 

each knee, followed by routine rehabilitation and weight-bearing 

with an assistive device for four weeks after surgery. Radiographs and 

clinical assessment were performed at 6.5 years (range five to seven 

years). Seventeen femoral components had been revised for lack of 

bone ingrowth, one patella was revised for loosening after trauma 

and two knees had been resected for late deep sepsis. Two tibial 

components had subsided into 3 degrees of varus when compared to 

their position immediately after surgery; neither one had migrated 

further. Three additional tibial components were revised to address 

late medial instability after multiple falls. Fourteen patellae showed 

bony disintegration that was asymptomatic; in each case the 

prosthetic component was stable, with an intact extensor mechanism. 

Clinical outcome scores improved significantly over preoperative 

measurements. Excluding cases of sepsis, the revision rate in this 

series was 5%. Unlike other reports of cementless primary knees, 

most premature failures were related to the femoral component 

which failed to ingrow in 17 cases, rather than failures of cementless 

tibial fixation. Tibial and patella components, both of which had a 

porous tantalum metal porous surface, achieved excellent fixation in 

the present series. These data suggest that improvements in femoral 

component design, possibly in the type of porous surface, could 

improve the outcomes of cementless fixation of primary total knees 

of the design used in the present series. 

posteR No. oRs2 

Gender Differences in Human Knee Function During 

Maneuvers Associated with Non-Contact ACL Injury 

Daniel L. Miranda, Providence, RI 

Michelle M.Gosselin, Providence, RI 

Elizabeth L.Brainerd, Providence, RI 

Joseph J.Crisco, Providence, RI 

Braden C.Fleming, Providence, RI 

The purpose of this study was to investigate the gender differences 

in human knee function during maneuvers associated with noncontact 

ACL injury. This study involved designing and evaluating 

an experimental setup capable of collecting externally marked leg 

kinematic and ground reaction force (GRF) data while imaging 

the knee using high-speed biplanar fluoroscopy during a jump-cut 

maneuver. All procedures were approved by the IRB. After obtaining 

informed consent, 10 healthy volunteers, 5 males (age: 25.8±4.2 

years) and 5 females (age: 24.6±2.3 years) wearing athletic wear 

were outfitted with 23 retro-reflective surface markers on a single leg. 

The jump-cut maneuver performed during data collection was based 

on an activity designed to mimic maneuvers associated with noncontact 

ACL injury. Marker tracking was performed for 10 jump-cut 

trials at 250Hz using a 4-camera Qualisys Oqus system. GRF data was 

collected at 5,000Hz using a Kistler force plate. Biplanar fluoroscopy 

data was time-synchronized and collected at 250Hz during 3 of the 

trials.We found significant differences among males and females in 

both GRF at the impact transient and change in knee flexion angle 

from contact to max flexion. No significant differences among 

males and females were observed for knee flexion angle at contact. 

The observed gender differences in knee flexion angle suggest that 

women land and cut with less knee bend. This is supported by the 

larger GRF at the impact transient observed in female subjects. It 

is our hope that the synchronously recorded biplanar fluoroscopy 

data, once processed and analyzed, will increase our accuracy and 

ability to measure sub-millimeter knee bone translations at impact. 

573 



Revision of Re-infected Total Knee Arthroplasty after 

Previously Failed Revision for Infection 

Tariq Ali Nayfeh, MD, Ellicott City, MD 

Leo A. Whiteside, MD, Saint Louis, MO 

Revision of failed revision total knee arthroplasty is challenging, 

especially in cases with infection. When knees fail multiple times 

due to infection, amputation often is the only alternative. This study 

reviews a consecutive series of these cases treated with an aggressive 

regimen. Eighteen patients presented with reinfection after previously 

failed revision for infection. The time from the original total knee 

arthroplasty until reinfection was 49±23 months. The infecting 

organism was methicillin-resistant Staphylococcus aureus (11 knees, 

11 patients), methicillin-resistant Staphylococcus epidermidis (2 

knees, 2 patients), methicillin-sensitive Staphylococcus aureus (2 

knees, 2 patients), and mixed Streptococcus faecalis and Escherichia 

coli (3 knees, 3 patients). Twelve knees received thorough debridement 

and one-stage cementless reimplantation and 6 knees had similar 

debridement and insertion of a cement spacer with final revision 

later. All knees then had six weeks of direct intraarticular infusion of 

vancomycin via Hickman catheter. Two knees failed. One reinfected 

knee was amputated, and one was redebrided, revised, and retreated 

with intraarticular antibiotic infusion. Revision of reinfected total 

knee arthroplasty after previous revision for infection can be treated 

successfully in most cases with thorough debridement, revision in 

one or two stages, and intraarticular antibiotics. 


Revisiting UKA: with a 35-Years Experience, Medial and 

Lateral UKA Are Two Different Operations 


Alexandre Poignard, MD, France 

Charles Henri Flouzat-Lachaniette, MD, France 

Between 1975 and 2010, 1235 uni compartmental knee replacements 

have been performed in our hospital. 857 knees were medial uni 

compartmental knee replacements and 378 knees were lateral uni 

compartmental knee replacements. Of these1235 knees, 255 knees 

were available for a follow-up of more than 20 years. These 1235 

knees were subjected to long leg views to assess the mechanical axis 

and HKA ankle (Hip knee Ankle angle). The aim of this exhibit is to 

describe the evolution of the technique during the last 35 years; to 

report and explain our failures in the first period (between 1975 and 

1985); to describe the actual technique with modern fixed bearing 

implants, and tricks to avoid over correction or under correction; to 

report our experience with assisted computer navigation; to describe 

the analysis of the pre-operative radiographs to select patients for this 

surgery; to discuss the relative indications of osteotomy, UKA and 

TKA; to explain why medial and lateral UKA should be considered 

as two different operations. The femorotibial angle measured as 

the hip knee ankle angle was divided into seven axial alignment 

parameters: The femoral condylar femoral shaft angle ; The femoral 

condylar tibial plateau angle; The tibial plateau tibial shaft angle; 

The femoral shaft horizontal angle; The tibia shaft horizontal angle; 

The femoral condylar horizontal angle ;The tibial plateau horizontal. 

In lateral arthroplasties , before and after the operations, the 

femorotibial angle correlated with the tibial shaft horizontal angle 

(R=0.77; p

In postoperative lateral arthroplasties, the more valgus the knee 

the more the tibial shaft shifted toward the valgus direction, which 

was not true for the femoral shaft. In medial arthroplasties the 

postoperative femorotibial angle is influenced by the axial alignment 

of the femur and the tibia toward horizontal. The postoperative 

femoral shaft horizontal angle tends to be constant regardless of the 

degree of correction in lateral arthroplasties, suggesting that in the 

postoperative valgus knees the shift of the femoral shaft toward the 

valgus direction was limited. The authors assumed that this was to 

prevent the knee from knocking against the other leg. The authors 

recommend relying both on the preoperative femoral and tibial axial 

alignment parameters to determine the amount of correction and the 

position of the implants in medial arthroplasties and only on the 

tibial axial alignment parameter in lateral arthroplaties. The slope 

of the distal femoral articular surface should also be considered in 

a different manner when preoperative planning medial and lateral 

arthroplasties. This study evaluated also the creep and true wear in 

retrieved implants: All the polyethylene components were retrieved 

from 11 to 244 months after their implantation. The retrieved 

implants were placed in a coordinate measuring machine. Using this 

system, a three dimensional scaled image was used to calculate the 

total penetration of the femoral implant in relation with true wear 

and creep. To separate plastic deformation from true wear, the volume 

of true wear was calculated by wheighing the tibial components and 

comparing the results with non implanted components. Difference 

between the penetration determined by the coordinate machine 

and penetration determined by wheighing was considered to be in 

relation with creep. Total linear penetration rates ranged from 0.2 

to 2.6 mm/year (mean 0.19 mm/year) and was significantly less in 

lateral (mean 0.14 mm/year) than in medial implants (mean 0.25 

mm/year). Linear penetration rates in relation with wear ranged 

from 0.1 to 1.4 mm/year (mean 0.13 mm/year), and penetration 

in relation with creep ranged from 0.1 to 1.9 mm/year (mean 0.12 

mm/year). Creep was less important in knees with metalback as 

compared with full PE implants. We found that an increase of the 

postoperative deformity was in relation (p = 0.03) with an increase 

of creep and an increase of true wear for medial implants. But an 

increase of the postoperative deformity was not in relation (p = 

0.34) with an increase of creep or an increase of true wear for lateral 

implants. The postoperative deformity had a high influence on the 

penetration rate of the femoral condyle in the polyethylene of medial 

unicompartmental fixed bearing tibial implants. This phenomenon 

was not observed for the lateral fixed bearing implants and wear was 

significantly (p= 0.01) less in lateral than in medial implants. This 

phenomenon may be in relation with different kinematics in the two 

compartments. Indications for uni compartmental knee replacement 

include uni compartmental disease (either medial or lateral), no 

evidence of substantial patella femoral arthritis, and an intact, 

functioning anterior cruciate ligament. In our series the radiographic 

changes in the patello femoral joint were considered relevant only 

if they produced clinical symptoms. Alignment in excessive varus in 

medial uni compartmental knee replacements resulted in accelerated 

wear and tibial component subsidence. Moreover in our view if 

the knee required significant soft tissue release a uni compartment 

knee replacement may be an inappropriate procedure. Lateral uni 

compartmental arthroplasty is much less common than medial uni 

compartmental knee replacement. The slope of the lateral tibial 

plateau is lesser than the medial tibial plateau and hence the wear 

pattern is posterior as opposed to antero medial in case of medial 

compartment. Lateral compartment replacements should hence be 

placed with tibial resection made with less posterior slope. Care 

should be taken to prevent alteration of alignment while performing 

lateral uni compartmental knee replacements. Majority of the 

revisions in our experience were in lateral compartment disease, due to 

574 

accelerated degeneration in the uninvolved compartment, secondary 

to alterations in the alignment. The maintenance of alignment in uni 

compartmental knee replacement is of paramount importance in 

preventing progression of osteoarthritis in the normal compartment 

and wear in the prosthesis. Appropriate alignment can be reproduced 

in majority (99%) of the medial uni compartmental knees with 

adequate care before and during surgery. Lateral uni compartmental 

knee replacement require more care partly because they are rarely 

performed and in our experience more likely to result in an altered 

alignment. Only 4% of the knees with unacceptable altered alignment 

required conversion to TKA during the last 10 years. 


Treatment Algorithm for Osteonecrosis of the Knee 




Antonia Woehnl, MD, Baltimore, MD 

Peter M Bonutti, MD, Effingham, IL 

David R Marker, Baltimore, MD 

Ronald Emilio Delanois, MD, Baltimore, MD 

Osteonecrosis of the knee is a devastating disease that often 

progresses to joint destruction and may require knee arthroplasty. 

Three separate disease entities of the knee have been described: 

spontaneous, secondary, and post-arthroscopic osteonecrosis. A 

wide range of treatment modalities have been reported, including 

observation, medication, core decompression, arthroscopic 

debridement, chondroplasty, osteotomy, and total knee arthroplasty. 

The purpose of this exhibit was to describe and assess the efficacy 

of a multiple modality treatment algorithm for osteonecrosis of 

the knee. Between February 2000 and June 2007, 40 patients (64 

knees) were surgically treated at our institution for osteonecrosis of 

the knee. All patients were followed for a minimum of two years. 

Treatment was based on the classification of disease as determined 

by radiographs, magnetic resonance imaging and clinical symptoms. 

The following algorithm was used: 1) no symptoms - observation; 

2) associated pain and loss of function ‘ arthroscopy and/or core 

decompression (repeated if necessary); 3) associated mechanical 

symptoms (catching) or internal derangement (cartilage tear, flap, or 

free bodies) - arthroscopy with or without chondroplasty (repeated 

if necessary); 4) joint destruction - unicompartmental or total knee 

arthroplasty as indicated by the size and location of the articular 

defect. Forty patients (64 knees) underwent less than one year of 

observation before requiring surgical intervention due to progression 

of pain. Using the treatment algorithm, 26 knees were initially treated 

with core decompression alone, 16 with arthroscopy alone, 14 with 

arthroscopy plus core decompression, and eight with total knee 

arthroplasty. Core decompression alone or core decompression plus 

arthroscopy were successful in preventing disease progression in 86% 

of patients. Six patients progressed despite multiple interventions 

and required unicompartmental or total knee arthroplasty. Patients 

who underwent knee arthroplasty had substantial improvements in 

their knee pain and function scores at final follow-up. These results 

support the use of the algorithm for treating osteonecrosis of the 

knee. Core decompression may be an effective treatment for early 

stage osteonecrosis, while arthroscopy with or without chondroplasty 

may improve the outcomes of knees that have meniscal or cartilage 

tears. Knee arthroplasty is an effective treatment for knees that have 

progressed to joint destruction. This exhibit will demonstrate the 

complete treatment algorithm, will present published reports that 

address various aspects of the algorithm, will provide outcomes 

from two centers that have used the algorithm, and will demonstrate 

each treatment method with pictures and videos. 





Customizing the TKA: Surgical Technique or Implant 

Design? 

Dr Jason J Davis, Clawson, MI 


Recent trends in implant design have taken individual differences 

in knee anatomy to justify implant modification. Unique female 

knee morphology led to gender-specific prostheses which opened 

the door for a patient-specific ideology. Basic surgical strategies to 

customize the fit of the standard implant still remain paramount. 

The female knee movement leading up to the current era of 

implants is reviewed. Surgical pearls have been collected from over 

20 arthroplasty surgeons at one orthopaedic specialty hospital who 

consistently perform over 2400 TKA’s per year. Roughly 60% of the 

TKA patient population is female. Selected pearls for customization 

are presented. It is essential to understand your implant, then your 

gap tendencies, based on cruciate design. Reproduction of sagittal 

balance is mastered by your understanding of anterior and posterior 

referencing instrumentation. Efforts to downsize the femur to avoid 

overhang are then featured. Using a gap balancing method to control 

your femoral rotation will balance your knee in the coronal plane 

with minimal soft tissue manipulation. Finally, methods to restore 

proper tibial rotation and patellofemoral tracking are explored. In 

the current era of economic constraint, surgeons are becoming more 

responsible for the financial responsibility of their surgical workflow. 

Implant selection will not replace the need for meticulous surgical 

skill. The concept of ‘customizing’ total knee arthroplasty may have 

more to do with anatomic technique than with implant design. By 

utilizing some of the principles outlined here, surgeons can take 

steps to ensure proper sizing and balance of the individual TKA. 


TKA after HTO (A 30-years Experience): How to Plan 

and Resolve the Problems? 

Charles Henri Flouzat-Lachaniette, MD 


Alexandre Poignard, MD, France 

Knee replacement is a satisfactory pain relieving procedure in young 

patients, although survival may be poor. Isolated valgus osteotomy, 

with TKA at a later stage is one of the solutions for young patients 

with virus deformity. This two-step strategy would require either 

no overcorrection in the previous osteotomy to avoid jeopardizing 

later the arthroplasty, and subsequently poor pain relief unless 

the TKA has been performed; either overcorrection osteotomy that 

will improve pain relief to a better extent but will make the knee 

replacement hazardous because of the proximal tibial deformity. 

Total knee arthroplasty (TKA) following high tibial osteotomy (HTO) 

for the treatment of arthritis have specific technical difficulties. This 

paper studies the technical problems during surgery, the way to plan 

these problems, the safety of a posteriorstabilized knee in this 

situation, and the results of these two operations with a follow up 

of more than 30 years after the osteotomy.The aim of this study was 

to compare function, quality of life (QOL) and survival outcomes 

of TKA in 359 patients who had a previous HTO (opening or 

closed wedge technique) with TKA performed for primary arthritis. 

All the patients operated in our institution between 1985 and 

1995 for the first operation (HTO) and between 1992 and 2000 

for the TKA arthroplasty (HTO TKA group) were included in this 

retrospective study and compared to a randomly chosen group of 

100 patients operated on for primary arthritis (PA group) during the 

same period. All implants were the same and cemented (posteriorstabilized 

arthroplasties). The advantages and results of TKA after 

575 

opening wedge osteotomy (234 knees) were compared to TKA 

following closed wedge osteotomy (125 knees).The preoperative 

and postoperative deformities were measured on weight-bearing 

radiographs of the whole limb (hip-knee-ankle angle) before and 

after each operation. Complications and technical difficulties during 

total knee arthroplasty (TKA) following high tibial osteotomy were: 

Location of the skin incision, difficulty with operative exposure, 

patella eversion, and abnormal patellar tracking. Above all, proximal 

tibia deformity due to the previous osteotomy was commonly 

observed in high tibial osteotomy, and tibial component alignment 

during subsequent TKA was difficult to achieve. Tibial plateau offset 

from the shaft and valgus deformity of the proximal tibia were 

common after high tibial osteotomy. In TKA following failed high 

tibial osteotomy, the postoperative mechanical axis never intersects 

the center of the tibial component because of the deformed proximal 

tibia, particularly when the tibia has been resected perpendicular 

to the tibial shaft axis. Therefore, the authors advocate resection of 

the tibia referencing the predicted postoperative mechanical axis 

instead of the tibial shaft axis, especially in TKA following failed high 

tibial osteotomy. Advantages and inconvenients of intramedullary, 

extramedullary guidess, and computer assisted navigation for 

the tibial component are explained.KS knee and function score 

improvement and QOL results for the five categories of the Knee 

Osteoarthritis Outcome Score were significantly lower in the HTO 

group (p

lateral translation of the epiphysis. This situation is the opposite 

to that normally observed in an arthritic genu varum. This creates 

further difficulty during knee joint arthroplasty secondary to tibial 

osteotomy, and in our series, we found this defect to be severe in 32 

cases. Therefore, after a tibial osteotomy, regardless of the technique 

previously used, the thickness of bone resected from the lateral 

region of the tibia must be very small to reestablish the anatomical 

position of the lateral articular line. This precaution helps to reduce 

the possibility of instability or the use of excessively thick tibial 

inserts, which might in turn lead to an increase in the rate of patella 

infera. So, when planning a joint arthroplasty secondary to proximal 

tibial osteotomy, variations of the tibial anatomy necessarily related 

to the previous operation should be taken into account. However, 

our results confirmed the clinical impression that “no bridges are 

burned” by performing a high tibial osteotomy, despite significant 

lower functional, and QOL results. This two-step strategy (isolated 

valgus osteotomy, with posterior-stabilized TKA at a later stage) 

allowed obtaining good results with 94% survivorship 30 years after 

the first operation (HTO) and 15 years after the arthroplasty 


Overview of New Technologies in Total Knee 

Arthroplasty: Current Options and Future Directions 

Peter M Bonutti, MD, Effingham, IL 



Antonia Woehnl, MD, Baltimore, MD 

Ronald Emilio Delanois, MD, Baltimore, MD 


Uma Maduekwe, MD, Chicago, IL 

Qais Naziri, MD, Baltimore, MD 

Numerous technologies have been developed and utilized in an 

attempt to improve the outcomes of knee arthroplasties, or to 

address particularly challenging cases. Some have been associated 

with successful results, while others have not shown any benefits over 

previously-established technologies. The purpose of this exhibit will 

be to discuss some emerging technologies, including the rationale 

and the evidence for or against each one. A comprehensive search of 

the literature was performed using the Medline database to find peerreviewed 

reports on emerging technologies in total knee arthroplasty. 

Innovative approaches to knee arthroplasty were reviewed, including 

minimally-invasive approaches, new prosthetic and tool designs, 

as well as anterior cruciate ligament sparing approaches. Also 

reviewed were the use of computer assissted navigation in total knee 

arthroplasty, the intra-operative use of robotics to ensure precise and 

accurate bone cuts, and the use of cutom-designed bone guides and 

prostheses based upon magnetic resonance images of the knee. Our 

institution and others have successfully utilized minimally invasive 

surgical approaches, computer-assissted navigation, and customdesigned 

cutting guides. All of these novel surgical approaches will be 

described and demonstrated in-depth with regard to current results, 

potential advantages and pitfalls. For the use of computer-assisted 

navigation, recent innovations in the technology, current outcomes 

compared with non-navigated arthroplasties, cost-benefit analyses, 

and recommendation regarding the use of navigation for high- and 

low-volume surgeons will be featured. The use of robotics to guide 

the cuts during unicompartmental and total knee arthroplasty will 

be discussed, as well as the potential benefits, the current results, 

and future applications. Finally, the use of custom-designed bone 

guides and custom prostheses developed from magnetic resonance 

imaging templates will be discussed with respect to potential 

advantages and disadvantages, cost-benefit analysis, and current 

576 

results including patient-subjective evaluation, function, range of 

motion, and kinematics. New knee technologies might provide 

potential improvements in outcomes of total knee arthroplasty. This 

exhibit will demonstrate the advantages, disadvantages, indications, 

and contraindications of all of the new technologies described 

previously, based upon the evidence in the published literature as 

well as the data from our institutions. Videos, diagrams, and models 

will be utilized to demonstrate each technology. In addition, we will 

assess possible modifications, improvements, and advances, and 

how they might affect total knee arthroplasty in the future. 


Three-dimensional Morphology of the Knee, an Ethnic 

Study 



Emam Abdel Fatah, Knoxville, TN 

Lower limb morphology differences have always received attention in 

orthopaedics in relation to implant design. In this study, the intrinsic 

shape differences of the knee joint between differing populations 

were analyzed by a novel automatic feature detection algorithm. 

A set of automated measurements were defined based on highly 

morphometric variant regions, which then allowed for a statistical 

framework when analyzing different populations’ knee joints. Onethousand 

adult knee CT scans were captured (80 African American 

AA]; 80 East Asian EA]; 840 Caucasian). Three-dimensional surface 

models were created for each bone and were added to 3D statistical 

bone atlases. Statistical shape analysis was conducted with a process 

combining principal components analysis and multiple discriminate 

analysis. A set of measurements were conducted on both the femur 

and tibia including the AP and ML dimensions, radii of curvature of 

lateral and medial condyles and AP condylar angle. 


Clinical Validation of a Non-Invasive System Dedicated 

to Quantify Pivot-Shift 

Stefano Zaffagnini, MD, Bologna, Italy 

Nicola Lopomo, MSc, PhD, Bologna, Italy 

Cecilia Signorelli, MS, Bologna, Italy 

Giovanni Giordano, MD, Cesena, Italy 

Simone Bignozzi, Bologna, Italy 

Giulio Marcheggiani Muccioli, MD, Bologna, Italy 

Tommaso Bonanzinga, MD, Bologna, Italy 

Maurilio Marcacci, MD, Bologna, Italy 

Pivot-Shift (PS) test is becoming the benchmark in knee instability 

assessment Kocher 2009], the main problem in its use is the 

impossibility of clearly quantifying test outcome. This study aimed 

to clinically validate a non-invasive system able to quantitatively 

evaluate this dynamic instability highlighted by PS test. PS tests were 

analysed on 50 consecutive patients, that shown a generic problem 

to the knee, in out-patients’ clinic, 3 times both on left and right 

limb. The surgeon, who performed the study, was blinded to the 

medical history before the execution of the test. An 3D-accelerationsensor 

was skin-fixed, by an apposite strap, nearness of the joint. We 

estimated the maximum (MAX) and the minimum (min) value of 

the acceleration, their difference (Diff) and a derivate value index 

of the smoothness of the test itself (in physics called “jerk”). The PS 

recognition was automatically performed. Student t-test (P = 0.05) 

was used to explore the statistical differences between limbs (healthy 

and injured). Pathologic limbs, confirmed by the tester, compared 

to the healthy limb, revealed a lower min value of acceleration 




(8.23±0.51m/s2 vs 8.56±0.34m/s2, p=0.0097 ), a higher jerk 

(24.68±12.30m/s3 vs13.57±6.28 m/s3, p=0.0001) and a higher diff 

(4.06±1.12m/s2 vs 2.890.93± m/s2, p=0.0004). 


HTO Versus UKA: A Review of the Literature 

Federico Dettoni, MD, Torino, Italy 

Davide E Bonasia, MD, Torino, Italy 

Filippo Castoldi, MD, Torino, Italy 

Matteo Bruzzone, MD, Torino, Italy 

Davide Blonna, MD, Torino, Italy 

Gianluca Collo, MD, Torino, Italy 

Roberto Rossi, MD, Torino, Italy 

This review examined the literature regarding High Tibial Osteotomy 

(HTO) and Unicompartmental Knee Arthroplasty (UKA), focusing 

on indications for the two treatments, survivorship and functional 

outcomes of the two procedures, as well as revision to Total Knee 

Arthroplasty (TKA) after failed HTO or UKA. We searched the 

Literature for studies dealing with indications, outcomes and 

complications for HTO and UKA. Particularly papers comparing 

HTO and UKA were critically analysed. HTO and UKA share the 

same indications in selected cases of medial unicompartmental 

knee arthrosis. These include patients: 1) 55 to 65 years old; 2) 

moderately active; 3) non-obese; 4) with mild varus malalignment; 

5) no joint instability; 6) good range of motion; and 7) moderate 

unicompartmental arthrosis. Few studies comparing the outcomes 

of HTO and UKA are present in the literature. These studies show 

slightly better results for UKA, in terms of survivorship and functional 

outcome. Nevertheless, the differences are not remarkable, the study 

methods are not homogeneous and most of the papers report about 

closing wedge HTO. For these reasons, no definitive conclusion can 

be drawn. Total Knee Arthroplasty represents the revision option 

for both treatments and yields satisfactory functional outcomes and 

survivorship. Whether a TKA performed after a failed HTO or UKA 

perform worse than primary TKA is still controversial. With correct 

indications, both HTO and UKA produce durable and predictable 

outcomes in the treatment of medial unicompartmental arthrosis of 

the knee. There is no evidence of superior results of one treatment 

over the other. 


Change in the Position of the Popliteal Artery with Knee 

Flexion After Total Knee Arthroplasty 

Mitsuhiro Takeda, MD, Gyoda, Saitama, Japan 

Yoshinori Ishii, MD, Gyoda Saitama, Japan 

Noguchi Hideo, MD, Gyoda-Shi, Japan 

In the preoperative knee, 90° flexion allows the popliteal artery (PA) 

to move safely backward from the tibia. However, the behavior of 

the PA during flexion of the prosthetic knee is poorly understood. 

we evaluated the position of the PA in flexed knees that received 

either PCL-retaining (PCLR) or PCL-sacrificing prostheses (PCLS). 

Twenty-two patients (44 knees) received PCLR in one knee and PCLS 

in the other. The average follow up was 61 months. Twenty-two agematched 

knees served as controls. Noninvasive color-flow duplex 

scanning was used to determine the distance ‘X’ between the PA and 

the posterior margin of the tibia. This distance was measured with 

the knee in 0, 30, 45, 60, and 90° flexion. The mean distance X was 

8.2, 7.9, 7.8, 7.4, and 7.4 mm in PCLR knees and 8.5, 8.3, 8.3, 7.9, 

and 7.7 mm in PCLS knees, respectively. No significant differences 

were found among the angles in each group or between the groups 

at each angle. In control knees, the mean distance X was 4.9, 5.2, 

6.0, 6.2, and 7.8 mm, respectively; X at 90° flexion was significantly 

577 

greater than X at 45°. In contrast to the control group, the PA did not 

move posteriorly with flexion in either type of prosthetic knee. Thus, 

90° flexion may not be the safest position for PCLR or PCLS surgery. 

Using color-flow duplex scanning to preoperatively evaluate flexioninduced 

changes in position of the PA could help determine the 

optimal flexion angle to use during surgery to prevent PA injuries. 


Correcting Varus/Flexion Deformity during Total Knee 

Arthroplasty: The Inside-Out Technique 


Yossef C Blum, MD, New York, NY 

Amar S Ranawat, MD, New York, NY 

Chitranjan S Ranawat, MD, New York, NY 

Traditional method of correcting a fixed flexion/varus deformity was 

described in 1979, which required detachment of the posteromedial 

capsule from the tibia and semimembranosus tendon, partial or 

complete. The tight superficial medial collateral ligament (SMCL) 

was released subperiosteally. To address the risks of over release, 

hematoma formation and elevation of joint line, the Inside-Out 

technique was evolved. Our hypothesis is that this technique 

effectively corrects varus and flexion contracture while reducing these 

complications. This method requires femoral and tibial resection 

at 90 degree of the mechanical axis, and creation of a balanced 

rectangular extension gap. This is achieved by transverse capsulotomy 

of the posteromedial capsule at the level of the tibial resection in 

full extension. The semimembranosus insertion is not released. The 

tight SMCL is pie-crusted and with serial manipulations a balanced 

extension gap is achieved. The flexion balance gap is achieved by 

the ‘parallel to tibial cut technique’ of posterior condyles.Forty-five 

patients with severe biplanar deformity, with varus > 15 degrees 

and flexion contracture > 10 degrees underwent TKR with Inside- 

Out technique. The mean age was 73.3 years. Results were assessed 

according to WOMAC and Knee Society Scores. The mean Knee 

Society Score and WOMAC were 95 and 29 respectively. The mean 

coronal plane alignment was 5.5 degrees. There were no cases of 

instability or residual flexion contracture. The Inside-Out technique 

is very effective in correcting biplanar deformity without over or 

under release, hematoma or elevation of joint line. 


Preclinical Computational Models Can Predict 

UHMWPE Damage Patterns in TKA 

Edward Morra, MSME, Cleveland, OH 


Patient habitus, design and materials, as well as technical proficiency 

represent a triad of factors which influence the material damage 

patterns observed following TKA. Laboratory simulator wear testing 

is generally criticized because of poor clinical correlation. This 

exhibit describes a computational modeling experience dating back 

fifteen years for both fixed and mobile TKA systems where predicted 

UHMWPE damage patterns have correlated with clinical outcomes. 

The finite element (FE) model simulates the loading environments 

that occur in the knee during activities of daily living. The use of reverse 

engineered component geometries generated from three dimensional 

laser scans of sterilized implantable quality components allows 

detection of poor fit between manufactured component articulations. 

The articulations of the femoral component on the polymer tibial 

insert plateau produces surface and subsurface stress results that 

are associated with abrasive wear, delamination and fracture of 

the insert. The results are compared with an overlay of wear scar 

patterns realized from clinical component retrievals for specific knee 




systems. Both expected and unusual FE model predictions of stress 

were validated by retrieval evidence, demonstrating the robustness 

of the method. Validated computational modeling has proven to be 

a correlative methodology, predictive of material damage patterns 

observed in clinical retrievals. The database encompasses more than 

forty five contemporarily used fixed and mobile bearing knee systems. 

Its effectiveness is appreciated as a surrogate to costly physical testing 

for the prediction of in-vivo material damage patterns seen in knee 

arthroplasty. 


Investigation of Three-Dimensional In Vitro Knee 

Kinematics Using a Custom In Vitro Model 

J David Blaha, MD, Ann Arbor, MI 

David Kent DeBoer, MD, Nashville, TN 

C Lowry Barnes, MD, Little Rock, AR 

Paul M Stemniski, MS, Arlington, TN 

Sarah L Lancianese, PhD, Ann Arbor, MI 

Richard Obert, MS, Arlington, TN 

Michael E Carroll, Arlington, TN 

A custom machine to test knee functional kinematics (open and closed 

chain) has been developed incorporating the entire extremity (hip to 

ankle). The scientific exhibit will present the device and kinematic 

profiles of knees during open chain and closed-chain squat exercise 

in untouched, ACL deficient and total knee arthroplasty conditions. 

Lower limbs with radio-opaque markers were CT scanned, converted 

to CAD models and analyzed using a motion analysis system. 3D 

kinematics are determined as virtual animations, contact points, and 

rotation profiles through 0 115° for intact, ACL deficient and TKA (CS 

and PS). The model reveals kinematic differences in closed but not 

open-chain motion with increased AP motion in ACL deficient state 

but return toward normal with TKA. Because the model compares 

the same knee in multiple conditions variability is reduced and this 

combination of open and closed-chain models provides a suitable 

test to determine the effectiveness of an implant design (e.g., CS/PS) 

in restoring kinematics to closer approximate the normal knee. In 

the scientific exhibit, this data as well as knee kinematics determined 

from additional TKA designs, increased weight, internal and external 

foot rotation, and deep squat, will be presented with multimedia 

graphics in the form of 3D animations, contact point analysis, and 

kinematic profiles. 

578 






Tissue Reactions to Prosthetic Metal Wear Debris: 

Studies of Osteolysis, Pseudotumor and ALVAL 

Mark W Kovacik, Akron, OH 

Thomas F Bear, MD, Cuyahoga Falls, OH 

Richard A Mostardi, PhD, Akron, OH 

Ivan A Gradisar Jr, MD, Trappe, MD 

Rex D Ramsier, PhD, Akron, OH 

James M Jamison, PhD, Akron, OH 

Edward T Bender, PhD, Akron, OH 

Deborah R Neal, BS, Akron, OH 


The deleterious tissue responses (i.e., osteolysis, pseudotumors, 

ALVAL) associated with micro-metallic wear debris released by joint 

replacement components of metal/polyethylene or metal-on-metal 

prostheses are still not fully understood and are under most recent 

scrutiny. This exhibit presents clinical and laboratory experiences 

that address the possible role that metal implant and wear debris 

surface chemistry may contribute in these adverse responses. A metaanalysis 

was performed and included: 1) review of clinical joint 

replacement cases; 2) metallurgical studies, using energy dispersive 

spectroscopy (EDS) and x-ray photoelectron spectroscopy (XPS) to 

determine surface chemistry of micro-metal wear debris particles 

harvested in-vivo; and 3) nuclear transcription factor (NFkB) and 

cytokine/chemokine expression of synovial fibroblasts following 

prosthetic micro-metal particulate exposure. Heightened cellular upregulation 

of NFkB and downstream inflammatory factor expression 

differs with differing elemental surface chemistries of micro-metal 

particles; a more deleterious cellular response occurs in the presence 

of metal particles having increased surface cobalt content. Increased 

transcriptional expression of inflammatory proteins and cellular 

necrosis in the presence of micro-metal particles has long been related 

to bone resorption. Since it is only the surfaces of the prosthetic 

materials to which the cellular milieu may interact, elevated cobalt 

levels at these surfaces may be directly responsible for triggering 

the osteolytic and ALVAL responses commonly seen in tissues 

surrounding the implants. This exhibit describes the consequences 

of elemental surface segregation caused by various manufacturing 

and sterilization processes used for prosthetic implants as well as 

their associated osteolytic and ALVAL potentials. 

579 

basic research 


The Science of Rotator Cuff Repairs: Translating Basic 

Science into Clinical Recommendations 

Sandeep Mannava, Winston Salem, IL 

Christopher Tuohy, MD, Winston-Salem, NC 

Thorsten M Seyler, MD, Winston-Salem, NC 

Joel Stitzel, PhD, Winston Salem, NC 

Solomon Hayon, BS, Winston Salem, NC 

Patrick W Whitlock, MD, Winston Salem, NC 

Thomas L Smith, PhD, Winston-Salem, NC 

Katherine R Saul, PhD, Winston Salem, NC 

Rotator cuff tears are a common cause of upper-extremity disability, 

particularly in elderly patients over 50 years of age. For chronic, 

full-thickness, rotator cuff tears, repair surgery can be technically 

challenging due to large gap distances and increased stiffness of 

the muscle-tendon unit. In contrast, acute rotator cuff tears are 

associated with lower repair tensions, less fibro-fatty infiltration of 

the muscle, and better functional outcomes. This scientific exhibit 

demonstrates how animal models can be used to understand rotator 

cuff muscle function in the acute and chronic tear setting and how 

these results can be translated into clinical recommendations using 

computational modeling. In vivo muscle function, electromyography 

(EMG), and passive muscle-tendon unit properties were studied 

before and after supraspinatus tenotomy in a rodent rotator cuff 

injury model (acute vs chronic; NIA rodent colony: old vs young). 

Chemical denervation (botulinum neurotoxin A, BoNT-A) and Fungs 

QLV model were used to assess neural contributions to in vivo stressrelaxation 

biomechanical properties. Then, a series of simulation 

experiments were conducted using a validated computational 

human musculoskeletal shoulder model to assess both passive and 

active tension of rotator cuff repairs based on surgical positioning. In 

vivo muscle function was impaired at the tensions required to repair 

a chronically torn rotator cuff (45% reduction from maximal twitch 

amplitude, p

epair, post-operative healing, and rehabilitation. Thus, changing 

patient instructions on post-operative arm positioning and ranges 

of motion will reduce repair site tension. Current research efforts 

in our laboratory are focused on reducing repair tension by using 

tissue-engineered constructs to bridge the large distances formed 

after chronic tears. 


Sex in Your Orthopaedic Practice - AAOS Women’s 

Health Issues Advisory Board 

Julie A Switzer, MD, Saint Paul, MN 

Sheila Marie Algan, MD, Oklahoma City, OK 

Elizabeth A Arendt, MD, Minneapolis, MN 

This exhibit provides information for the practicing orthopedist 

regarding epidemiology of common musculoskeletal conditions 

and how male and female patients may present differently. Studies 

have shown that training can enhance women’s balance and 

decrease falls - in athletics and in older age; this exhibit will also 

focus on the importance of training and rehabilitation and the effect 

on improving and enhancing balance. This exhibit will explore the 

biological and social differences in presentation between male and 

female patients for various common musculoskeletal conditions. Sex 

differences will be examined in three areas of orthopaedic interest 

and common disorders, diseases, and injuries will be addressed: 

CMC arthritis Shoulder instability Frozen shoulder Hip Dysplasia 

Femero-acetabular implingement Hip Arthritis An interactive display 

on balance exercises and on rehabilitation programs for athletes and 

elders will also be a part of the exhibit. 

580 


Current Hot Topics in Orthopaedic Research - 

Orthopaedic Research Society 

Daniel A Grande, PhD, Manhasset, NY 

Clark T Hung, PhD, New York, NY 

James L Cook, DVM, PhD, Columbia, MO 

Fred R T Nelson, MD, Detroit, MI 


Robin Poole, Lancaster, ON Canada 

Hubert T Kim, MD, San Francisco, CA 

Joseph A Buckwalter, MD, Iowa City, IA 

Dawn M Elliott, PhD, Philadelphia, PA 

Nadeem O Chahine, PhD, Manhasset, NY 

Thomas W Bauer, MD, PhD, Cleveland, OH 

Jason Calhoun, MD, Columbus, OH 

Louis J. Soslowsky, PhD, Philadelphia, PA 

Stavros Thomopoulos, PhD, St. Louis, MO 

Orthopaedic research continues to progress rapidly as new 

methodologies become available. Members of the Orthopaedic 

Research Society conduct investigations on a wide range of topics 

aiming to obtain knowledge and understanding of the etiology of 

musculoskeletal diseases and to improve diagnosis and treatment 

of such conditions. Current orthopaedic research involves the 

most updated research strategies and methodologies and is carried 

out at multiple levels of experimentation, including cell biology, 

biochemistry, molecular biology, biomaterials, biomechanics, 

and advanced imaging. Exciting and most promising areas of 

research activity include studies of the bone tendon interface 

biology and repair in health, disease and injury; the mechanisms 

of musculoskeletal pain; new knowledge of cartilage injury and 

prevention; studies focusing on the concept of the joint as an organ; 

tissue engineering using stem cells focusing on the development 

of scaffolds and delivery of cytokines or growth factors; and new 

understanding of intervertebral disc biology. 



PaPers, Posters & scientific exhibits bAsic ReseARcH

PAPERS 

pApeR No. 046 

Treatment of The Stress Positive SE4 Ankle Fracture: 

Incidence of Syndesmotic Injury Decision Making 

Paul Tornetta III, MD, Boston, MA 

Thomas W Axelrad, MD, New York, NY 

William R Creevy, MD, MBA, Boston, MA 

It has been demonstrated that only one-third of patients with an 

isolated SE pattern fibula fracture who present with an aligned 

mortise have instability on stress examination. The purpose of this 

study is to report on a large series of stress (+) isolated SE type fibula 

fractures, as regards the ability to gain anatomic union, and to report 

the rate of syndesmotic instability in the operative cases. We treated 

99 patients (aged 19-76, avg 43) with stress (+) isolated SE type 

fibula fractures to union. The medial clear space was measured on 

the presentation, stress and final united radiographs. The decision 

for surgical or nonsurgical management was made by the patient and 

surgeon after a discussion. Syndesmotic instability for the operative 

cases was defined as medial widening and talar subluxation on an 

intraoperative stress film after fibular fixation. Of 99 cases, 43 were 

treated in a cast and 56 were treated operatively. Some 24 (43%) 

of the operative cases demonstrated intraoperative syndesmotic 

instability. The presentation medial clear space (MCS) measurements 

were not different for any group, however the stress radiograph 

MCS was statistically different for all groups (p

was used to estimate unadjusted (univariate) and adjusted relative 

rates (multiple regression) for fasciotomy based on injury factors 

(zone, injury severity score, arrival time), patient age, gender and 

race, hospital trauma level. Analyses were done using the GLIMMIX 

procedure in SAS 9.2. A total of 18,676 patients in the databank 

were identified as sustaining an isolated foot injury in zones 1-4. 

Of these, only 364 (1.95%) of patients underwent fasciotomies of 

the foot for presumed FCS. For the entire cohort, 79% between 18- 

64 years old; 71% were caucasion and 68% were male. Fasciotomy 

rates were 84.3% and 79.0% for 18-64 year olds who did vs. did not 

receive a fasciotomy (p

three study groups. The mean reaction time was increased for the 

SLC and CAM groups as compared with reaction time in the control 

group. The mean braking time was increased in the CAM and LFA 

groups as compared with braking time in the control group. Total 

brake-response time while wearing immobilization or utilizing a 

left-foot driving adapter is significantly increased, or worsened, as 

compared with the response time while wearing normal footwear. 

This information may prove valuable to physicians when counseling 

patients on safe return to driving. 

pApeR No. 053 

Reliability and Validity of 5 Lower Extremity Outcome 

Measures in Ankle Arthroplasty and Arthrodesis 

Ellie Pinsker, Toronto, ON Canada 

Timothy Rudolf Daniels, MD, Toronto, ON Canada 

Taucha Inrig, RN, Toronto, ON Canada 

Kelly Warmington, Toronto, ON Canada 

Dorcas Beaton, OT, Toronto, ON Canada 

A number of outcome measures have been used to assess hindfoot 

surgical interventions, but they vary in content and have not been 

directly compared. Some have not been psychometrically validated 

in this patient population. This study will directly compare 

measurement properties of five self-report lower extremity measures, 

and evaluate their reliability and validity in light of patient preferences. 

A cross-sectional survey of pre- and post-operative ankle arthrodesis 

and arthroplasty patients (n=142). Patients completed the patientreported 

section of AOFAS, FFI, LEFS, SMFA and WOMAC on two 

occasions. The survey also included SF-12, EQ-5D and measures of 

instrument preference, satisfaction, and current status. Scores were 

in the mid-range of the scales. Internal consistency was high for all 

scales and subscales - 0.83-0.96; ICC (2,1) 0.81-0.96). Correlations 

between scales ranged from 0.50 (WOMAC Stiffness subscale and 

FFI Activity Limitations subscale) to 0.96 (FFI Disability and FFI 

Overall). Higher correlations occurred between subscales from the 

same instrument and similar subscales from different instruments. 

Construct validity showed moderate-high correlations to NRSs 

of pain, stiffness and daily activity. Highest correlations (>= 0.75) 

occurred in pain NRS and WOMAC Pain/FFI/AOFAS; stiffness NRS 

and WOMAC Stiffness/WOMAC Physical Function; daily activity 

NRS and all instruments except WOMAC Stiffness/FFI Pain/SMFA 

Emotional Status. Direct comparison of measures revealed similarity 

between scales in terms of construct validity and internal consistency. 

Patient preferences endorsed these scales as useful, but insufficient 

in telling their full story. Foot specific instruments offered no clear 

advantage over lower extremity instruments in terms of validity and 

reliability in this patient population. 

pApeR No. 054 

uFluoroscopic Examination of a Meniscal Bearing 

Ankle Replacement to Assess Meniscal Motion 

Gerard Martin Bourke, FRACS, Melbourne, VIC Australia 

Meniscal bearing ankle replacements are designed to reduce contact 

stresses at the bone prosthesis interface by moving in all planes. This 

study attempts to define whether there is a difference in motion 

weight bearing compared to non weight bearing using video 

fluoroscopy. A total of 39 total ankle replacements in 38 patients 

were examined using a fluoroscopic mini C arm. All patients were at 

least six months following surgery and sub talar fusions were present 

in some cases. Examination consisted of a seated non weight bearing 

and standing weight bearing fluoroscan taking the ankle through 

a full range of motion. A lateral video scan was then examined to 

determine the movement of the meniscal bearing using the metal 

583 

markers within the polyethylene. In no case was antero posterior 

motion of the meniscal bearing seen, either weight bearing or non 

weight bearing. Coronal motion of the tibia on the talus was seen in 

weight bearing especially if there was an ipsilateral sub talar fusion. 

The meniscus in a meniscal bearing ankle arthroplasty becomes fixed 

to the tibial component soon after surgery. All motion therefore 

occurs at the talar polyethylene interface which is designed primarily 

for antero posterior movement and not rotation, translation or 

coronal plane motion. This has implications regarding prosthetic 

design especially as coronal movement is seen at the tibio-talar 

interface in weight bearing. If a prosthesis has no scope for coronal 

motion then increased stress will be placed on the polyethylene and 

bone prosthesis interface. This may lead to premature polyethylene 

wear or loosening. 

pApeR No. 055 

10 to 14 Years Survivorship of a Current 3-Component 

Total Ankle Prosthesis 

Samuel Brunner, MD, Liestal, Switzerland 

Markus Knupp, MD, Liestal, Switzerland 

Lukas Zwicky, MSc 

Beat Hintermann, MD, Liestal, Switzerland 

Despite numerous encouraging reports on outcome of total ankle 

replacement (TAR) at short- to mid-term, little is known about 

long-term survivorship. The goal of this study was to determine the 

survival at long-term of a current three-component ankle prosthesis 

in a controlled series of patients operated by a single independent (no 

conceptor) surgeon. Between 1996 and 2000, 72 patients (77 ankles) 

underwent TAR using a three-component, single hydroxyapatite 

coated ankle prosthesis. In all, 13 patients (14 ankles) were lost (12 

patients 13 ankles] died, one patient 1 ankle] moved overseas). All 

patients were clinically and radiologically assessed after 11.8 (10.1- 

14.2) years, and survivorship analysis was calculated. Revision of a 

metallic implant or conversion into ankle arthrodesis was taken as 

the endpoint. 

pApeR No. 056 

Correction of Moderate and Severe Coronal Plane 

Deformity with the STAR Prosthesis 

Sudheer C Reddy, MD, Boyds, MD 

Roger A Mann, MD, Oakland, CA 

Jeffrey Adam Mann, MD, Oakland, CA 

Devin R Mangold, BS, Walnut Creek, CA 

Prior studies demonstrated a correlation between the degree of 

preoperative coronal plane deformity and ankle replacement failure. 

Patients with moderate (10-20 degrees) and severe (>20 degrees) 

deformity who underwent replacement utilizing the Scandinavian 

Total Ankle Replacement (STAR) prosthesis from 2000-2009 were 

evaluated. A total of 130 consecutive patients (133 ankles) were 

identified. Of those, 44 patients (45 ankles) had at least 10 degrees of 

preoperative coronal plane deformity on weight-bearing radiographs. 

There were 29 males and 15 females. Average age was 66 years. 

Average follow up was 38 months (range 3-98). None were lost to 

follow up. Patients were evaluated pre-operatively and on initial and 

final post-operative examination. Nineteen ankles had 20 degrees or 

greater of deformity (eight varus, 11 valgus). Twenty-six had between 

10 and 20 degrees of deformity (11 valgus, 15 varus). There were 

28 incongruent and 17 congruent joints. Average talar pre-operative 

deformity was 17.9 degrees (range 10-29), while average initial postoperative 

deformity was 3.5 degrees (range 0-12). Average final postoperative 

deformity was 4.7 degrees (range 0-14). Pre-operative and 

final correction of deformity was statistically significant (p

was accomplished solely by soft-tissue procedures’ deltoid release or 

lateral ligament reconstruction. Twelve patients underwent deltoid 

ligament release. One underwent a lateral ligament reconstruction. 

No significant difference was noted between initial and final 

post-operative correction. Recurrence, defined as a change of > 4 

degrees in coronal alignment compared to the initial post-operative 

radiographs, occurred in only five patients (11%), one of whom 

had severe deformity. Correction of moderate/severe coronal plane 

deformity with the STAR prosthesis is achievable with soft-tissue 

balancing procedures with favorable results. 

pApeR No. 057 

Correlation of Component Position with Gait and 

Clinical Outcomes After Total Ankle Arthroplasty 

Samuel Bruce Adams, Jr MD, Towson, MD 

Nicholas Adam Viens, MD, Durham, NC 

James Keith DeOrio, MD, Durham, NC 

Mark E Easley, MD, Durham, NC 

James Albert Nunley II, MD, Durham, NC 

Robin M Queen, PhD, Durham, NC 

The importance of component alignment in hip and knee 

arthroplasty has been exhaustively studied. However, the optimal 

position of the tibial and talar components in total ankle arthroplasty 

(TAA) is unknown. The purpose of this study was to correlate 

several radiographic measurements, describing the location of these 

components, with gait mechanics and clinical outcome scores. 

Forty patients who underwent unilateral TAA without concomitant 

procedures were included. Preoperative and one-year postoperative 

gait analysis and clinical outcomes assessments (VAS for pain, 

AOFAS, SMFA, FADI) were performed. Coronal tibial implant angle, 

sagittal tibial implant angle, anterior talar translation, coronal talar 

implant angle, sagittal talar implant angle and the horizontal and 

vertical center of talar implant rotation in relation to the radiographic 

vertex of the lateral process of the talus were obtained from oneyear 

postoperative radiographs. Spatial-temporal gait variables 

and clinical outcome scores were correlated with the radiographic 

measurements using Pearson Correlations (p

pApeR No. 060 

Complications and Reoperations following Total Ankle 

Arthroplasty: Review of 70 cases 

John G Anderson, MD, Grand Rapids, MI 

Rohan Ashok Habbu, MS, MBBS, St Paul, MN 

Michelle A. Padley, Grand Rapids, MI 


Total ankle arthroplasty (TAA) has a steep learning curve and 

incidence of complications and failures still remains substantial. 

The objective of the present study was to assess the complication 

and reoperation rates following TAA with second generation 

prosthesis. The study also evaluated the predictors of complications 

and described the reoperations following failures or complications. 

It also assessed the survivorship of the implant. Between 2000 and 

2006, there were 90 TAA of which 67 patients (70 ankles) satisfied 

the criteria for the study (primary TAA and at least three years of 

followup). Ankles which failed earlier than the required three years 

were included in the analysis. These 67 patients were followed for 

mean 55 (range, 36 to 108) months. Mean age at surgery was 59 

(range, 28 to 84) years. Indications for TAA included post-traumatic 

arthritis (47/67), degenerative arthritis (10/67), rheumatoid arthritis 

(6/67) and others (4/67). Serial radiographs were assessed for loss 

of alignment and radiolucencies. Complications, reoperations 

and failures were noted. Survivorship was assessed with Kaplan- 

Meier survival curve. Intraoperative complications included five 

fibular fractures and three medial malleolar fractures, of which 

seven required stabilization. Seven out of these eight patients 

with an intraoperative fracture were early half (first 30 TAA) of the 

group (p

pApeR No. 093 

uTalar Osteochondral Lesions Repair By Arthroscopic 

ACI. 5y Clinical and MRI T2-Mapping Evaluation 

Sandro Giannini, MD, Bologna, Bologna Italy 

Milva Battaglia, MD, Bologna, BO Italy 

Roberto Buda, Bologna, Italy 

Francesco Di Caprio, MD, Bologna, Italy 

Deianira Luciani, MD, Bologna, Bologna Italy 

Marco Cavallo, MD, Bologna, Italy 

Alberto Ruffilli, MD, Bologna, Bologna Italy 

Francesca Vannini, MD, Bologna, BO Italy 

Ideal treatment of osteochondral lesions of the talus (OLT) is still 

controversial. The aim of this study is to review the five years follow 

up clinical and MRI results of arthroscopic autologous chondrocytes 

implantation (ACI) in the treatment of OLT. From 2001 to 2004, 

46 patients age 31.4±7.6 years affected by OLT received arthroscopic 

autologous chondrocytes implantation. Lesion size was 1.6±0.9 cm2. 

All patients were evaluated clinically (American Orthopaedic Foot 

and Ankle Society), radiographically and by MRI (Mocart score) preoperatively 

and up to a mean follow up of 63.2±14.5 months. MRI 

T2 mapping evaluation was performed in 20 patients. Pre-operative 

score was 57.2±14.3. At 12 months, it was 86.8±13.4 (p < 0.0005), 

while at final follow-up it was 92.7±11.4 (p

S1 with that of S2. From 1991 to 2000, 104 ankles in 94 patients 

were treated with the S1 method. The average follow up period was 

4.6 years. The average age at surgery was 26.7 years old. From 2001 to 

2008, 73 ankles in 66 patients were treated with the S2 method. The 

average follow up period was 2.1 years. The average age at surgery 

was 25.5 years old. The average AOFAS Score improved from 65 

to 95 in S1, and improved from 60 to 98 at the latest follow up. 

The average talar tilt improved from 13.5±5.6 to 5.2±3.2 degrees 

in S1, and improved from 12.9±5.1 to 5.4±2.8 degrees in S2. There 

was no significant statistical difference between two series. Both 

reconstruction methods for lateral ankle ligaments preserved good 

range of motion and provided sufficient stability. Anatomical graft 

placement should be most important surgical focus. 

pApeR No. 097 

A Hybrid Anatomic Lateral Ankle Reconstruction in 

Athletes: ATFL Autograft with Plication of the CFL 

Christopher D Murawski, New York, NY 

John G Kennedy, MD, New York, NY 

The lateral ankle sprain is the single most common sports injury 

worldwide. Surgical strategies for addressing lateral instability 

include anatomic reconstruction and checkrein procedures. 

Concerns over inadequate reparative tissue, scarring and over 

tightening of the subtalar joint have prompted the introduction of 

a hybrid reconstruction. Using a peroneal tendon autograft fixed 

to the isometric points of the anterior talofibular ligament (ATFL) 

and plicating rather than substituting the calcaneofibular ligament 

(CFL) provide the benefits of both techniques while reducing 

the drawbacks of both. The current study hypothesis is that the 

hybrid reconstruction will provide excellent functional recovery 

with few complications. Between January 2006 and June 2009, 57 

patients underwent a hybrid lateral ankle ligament reconstruction 

technique. Each patient included in the present study failed a threemonth 

conservative triple-phase therapy program. All patients were 

followed for a minimum of one year after surgery and were treated in 

identical fashion. Surgery included substituting the native ATFL with 

a 4 cm split peroneus longus autograft in addition to a vest-overpants 

plication of the CFL. All patients had pre- and post-operative 

Foot and Ankle Outcome Scores (FAOS) and Short Form-36v2 

scores. Pre- and post-operative MRIs were compared to detect ankle 

and subtalar arthrosis. A total of 93% of patients were satisfied with 

the procedure and would recommend it to a friend. FAOS scores 

increased significantly pre- to post-operatively from 58 to 89 points 

(p < .05). SF-36v2 scores also increased significantly from 67 points 

pre-operatively to age adjusted normal levels (p < .05). Two of 57 

patients had pre-operative grade II cartilage loss in the posterior facet 

of the subtalar joint. In one case, this had advanced to grade III at 

two years follow up. Two additional patients had grade I changes 

in the subtalar joint at two years and one patient demonstrated 

grade II changes in the ankle joint at one-year follow-up. All patients 

reported competing at some level of athletic sport prior to surgery. 

Five of 57 patients did not return to pre-operative sporting levels. 

All five patients had mechanical stability but all had functional 

instability. The incidence of functional instability was 22% overall 

and persistence of functional instability was a predictor of failure 

to return to sports. Complications included a painful hypertrophic 

peroneal tendon, two cases of superficial peroneal nerve neurapraxia 

and a post-operative sinus tarsi syndrome. Traditional anatomic 

reconstructions of the lateral ligament complex have demonstrated 

good outcomes. Nevertheless, significant scarring and overtightening 

of the ankle joint can occur. Checkrein procedures have 

also produced concerns with over tightening of the ankle and 

subtalar joints. The hybrid procedure described herein uses the most 

587 

advantageous concepts from both procedures while reducing the 

risk of these drawbacks. The current study has demonstrated that 

mechanical stability is restored without compromising joint forces. 

Functional stability training is critical to facilitate a full return to 

sports. 

pApeR No. 098 

Factors Influencing Union After Arthroscopic Ankle 

Arthrodesis 

Ichiro Yoshimura, MD, Fukuoka, Japan 


Kazuki Kanazawa, MD 


Tomohiro Nomura, MD 

Tomonobu Hagio, MD 

Arthroscopic ankle arthrodesis is an established technique for 

select patient populations. This study aimed to investigate factors 

influencing ankle union. We reviewed 35 patients (16 male, 21 female; 

mean age at operation 63.0 years, range 40 to 81) who underwent 

37 arthroscopic ankle arthrodesis operations for osteoarthritis 

(n=33), and rheumatoid arthritis, avascular necrosis, drop foot and 

hemophiliac arthritis (one each). The fixation methods were three 

cross transmalleolar screws (6.0 mm cannulated cancellous screws) 

in 12 (ML3), two cross screws in four (ML2), three trans-medial 

malleolar parallel screws in 15 (M3) and two trans-medial malleolar 

parallel screws in six (M2). Arthroscopic ankle arthrodesis produced 

radiographic fusion in 36 of the 37 ankles (97.3%). The average time 

to fusion was 74±9 days in ML3, 92±11 days in ML2, 64±7 days in 

M3 and 80±6 days in M2. The AOFAS score was 81.3±7.6 in ML3, 

83.5±8.7 in ML2, 86.7±6.8 in M3 and 83.3± 8.0 in M2. The average 

time to fusion was 66±4 days for a correction angle 10 degrees, measured on anteroposterior 

ankle radiographs (p=0.08). In obese patients, time to ankle fusion 

was significantly longer (BMI>25; 92±8 days, BMI

one recurrence (3%), which was treated with repeat excision. An 

additional patient was re-operated for failure to excise the coalition 

completely. Eleven patients (28%) underwent a subsequent surgery 

to correct the alignment of the foot. To the best our knowledge, none 

of the patients excluded due to short follow up had repeat surgery 

or recurrence. A symptomatic talocalcaneal coalition can be treated 

with excision and fat graft interposition and achieve good-excellent 

results in 85% of patients. Patients should be counseled that a subset 

may require further surgery to correct malalignment. 

pApeR No. 100 

Naviculocunieform Fusion: Outcomes and Predictors of 

Nonunion 

Scott Nemec, DO, Petoskey, MI 

Rohan Ashok Habbu, MS, MBBS, St Paul, MN 


John G Anderson, MD, Grand Rapids, MI 

Naviculocunieform joint (NC) fusion forms a vital adjunct in 

midfoot reconstruction. Few studies have focused on outcomes 

following this procedure. The aim of the study was to evaluate the 

outcomes of NC fusion and determine predictors for NC nonunion. 

Seventy four patients (78 feet) with naviculocunieform fusion with 

mean followup of 49 (range, 24 to 84) months were included in this 

retrospective study. Eight of the 78 feet had isolated NC fusion while 

the rest had additional procedures. The indications for NC fusion 

included primary arthritis in 61 feet, posttraumatic arthritis in 11 

feet, Charcot arthropathy in four feet and rheumatoid arthritis in two 

feet. The most common symptom in all feet was pain. There were 12 

men and 62 women (four bilateral cases). The mean age at surgery 

was 61 (range, 35 to 80) years. The mean body mass was index (BMI) 

was 32. Outcomes were assessed with help of pain scores (on a scale 

of one to 10), modified AOFAS midfoot score (subjective evaluation 

only, maximum score of 85) and patient satisfaction. Sixty two 

(83%) out of 74 patients were satisfied with the final result. Pain 

score improved from a preoperative mean of 6.8 to postoperative 

mean of 2.9 (p

statistically significant (p = 0.318). Of the patients with allograft, 

three of those with a nonunion had the allograft bone mixed with 

an iliac crest aspirate (3/28, 10.7%), while two did not (2/30, 6.7%). 

This difference was also not statistically significant (p = 0.583). The 

average graft size in patients with union was 7.51 mm. In those 

patients who had a nonunion, the average size was 8.86 mm. This 

difference was statistically significant (p = 0.008). Nonunion was a 

relatively uncommon occurrence in these patients as a whole; the 

allograft patients had a trend towards a higher risk of nonunion, but 

this trend was not significant. The requirement of a more aggressive 

deformity correction does appear to be a risk factor for nonunion. 

pApeR No. 103 

3-D Computer Image Modeling in the Determination of 

at-Risk Structures for Calcaneal Osteotomies 

Erin M Prewitt, MD, Akron, OH 

David B Kay, MD, Akron, OH 

Timothy Marks, BS 

Michael Askew, Akron, OH 

Leann Speering, Akron, OH 

Improvements in radiographic computer imaging have provided 

means to obtain 3-D anatomical visualizations of anatomy, 

pathology and orthopaedic injuries. The OsiriX software program is 

a free DICOM viewer that allows patient-specific surgical planning 

and post-surgical evaluation. This software has been applied to 

many fields of medicine but has not been studied in orthopaedics. 

The purpose of this study is to evaluate the accuracy of the OsiriX 

software for application to foot and ankle surgery. The accuracy of the 

OsiriX software was evaluated by two separate methods. First, a 3-D 

model was created with radiopaque objects and measurements were 

taken with calipers. These measurements were then compared with 

those derived from an OsiriX virtual 3-D model. Second, to apply 

the OsiriX software to the clinical setting, 3-D virtual models were 

created from CT scans of two cadaver feet. The medial displacement 

and Evan’s calcaneal osteotomies were performed on the cadaver and 

virtual 3-D feet. Measurements were obtained between the medial 

at-risk structures and the medial calcaneal cortex at the osteotomy 

sites for both the cadaver specimens and the virtual images. The 

mean difference between the physical measurements vs. OsiriX 

measurements for the inanimate model was -0.047 + 0.68 mm. The 

mean difference between the physical and OsiriX measurements in 

the cadaver specimens was 0.124 + 0.934 mm. We have shown that 

the measurements obtained through the OsiriX program are reliable 

and can be used in the clinical or research setting. Virtual surgery 

and computer imaging opens new possibilities for developing 

novel surgical procedures, better understanding of the 3-D nature of 

anatomy, evaluation of surgical corrections and individualization of 

patient care. Ease of use and accessibility make the OsiriX software a 

valuable tool for orthopaedic surgeons. 

589 

pApeR No. 104 

The Treatment of Achilles Tendinopathy with Tendon 

Debridement and Flexor Hallucis Longus Transfer 

Frances Faro, MD, Denver, CO 

Gregory P Guyton, MD, Baltimore, MD 

Brent G Parks, MSC, Baltimore, MD 

Lew C Schon, MD, Baltimore, MD 

Mayu Toner, BS 

Anand Mahesh Vora, MD, Lake Forest, IL 

Gary Aghazarian, BS, Baltimore, MD 

Jennifer Shores, RN, Baltimore, MD 

Degeneration of the Achilles tendon is a common cause of heel 

pain. Surgical debridement of the dysfunctional tendon substance is 

a common treatment. Augmentation of the debrided Achilles with 

a flexor hallucis longus (FHL) tendon transfer has been recently 

described. The purpose of this study was to prospectively evaluate 

the outcomes of this surgery over a minimum of two years. This 

study was an Institutional Review Board-approved prospective study 

of 48 patients who underwent Achilles debridement and flexor 

hallucis longus (FHL) tendon transfer for Achilles tendinopathy. 

Preoperatively, they were clinically evaluated to determine hallux 

and ankle range of motion, and the ability to do a single leg heel rise 

(SLHR). Patients also completed the SF-36, AOFAS Hindfoot and 

Visual Analog Scale (VAS) surveys. Evaluations were repeated at the 

three, six, 12 and 24 month postoperative timepoints. Forty-eight 

patients were included in the study. Patients averaged 54±10 years 

old and had an average BMI of 33.8±6.8. Prior to surgery, 63% were 

unable to do an SLHR. At the two-year time point, passive hallux and 

ankle range of motion were not significantly different. One hundred 

percent of patients assessed were able to do an SLHR; additionally, 

there was no significant difference between the operative and 

nonoperative leg calf circumference. The VAS overall pain intensity 

had decreased from 6.7±2.3 to 0.8±2.0 and the VAS overall pain with 

activity had decreased from 7.9±1.8 to 1.8±2.0. The SF-36 physical 

(34±8 to 49±9) and mental (49±12 to 54±9) scores increased as did 

the AOFAS hindfoot score (54±15 to 92±15). Debridement of the 

Achilles tendon with FHL transfer provides reliable outcomes with 

improved pain and function at the two-year timepoint following 

surgery. 

pApeR No. 105 

Early Weight Bearing and Accelerated Rehabilitation 

Program after Achilles tendon repair 

Justin M Weatherall, MD, New York, NY 

Nirmal C Tejwani, MD, New York, NY 

The purpose of this study is to compare the outcomes of early 

functional weight bearing after a minimally invasive or standard 

approach for surgical repair of Achilles tendon. We conducted a 

retrospective review of 45 consecutive patients with follow up of at 

least six months who underwent repair of an acute closed Achilles 

tendon rupture. The first group, consisting of 22 patients (Group 

A), was treated with a minimally invasive posterolateral approach. 

The second group, consisting of 23 patients (Group B), was treated 

with a standard posteromedial approach. At two weeks post op, 

the patients were allowed to weight bear as tolerated in a CAM 

boot with a 20 degree heel wedge. At six weeks the CAM boot was 

discontinued and the patient was placed in a regular shoe with a heel 

lift. We examined the rate of re-rupture, sural nerve injury, wound 

complication, post-op ROM (range of motion) at six weeks and three 

months, and calf strength at three to six months. There were zero reruptures 

in both groups. In Group A, only one (4.5%) developed a 



PaPers, Posters & scientific exhibits foot & ANKle

superficial wound infection, which resolved with oral antibiotics by 

three months. Three of 22 (14%) patients developed a sural nerve 

palsy, and two of the three palsies resolved by three months with one 

still present at six months. At six months, all patients had strength 

of 4/5 to 5/5. The average incision length was 2.5 cm. In Group B, 

two patients (8.6%) developed a superficial wound infection and 

three (13%) developed a superficial wound dehiscence; all resolved 

with either oral antibiotics or local wound care by eight months. 

At three months, all patients except one had strength of 4/5 to 5/5. 

The average length of the incision was 7.2 cm. Early functional 

weight bearing after a minimally invasive posterolateral or standard 

posteromedial approach is an effective and safe method for treating 

acute ruptures of the Achilles tendon. 

pApeR No. 496 

uEffect of PDGF-Coated Suture Repair on Achilles 

Tendon Healing in a Rat Model 

Joshua Dines, MD, Great Neck, NY 

Stephen H Cummings, MD, New Hyde Park, NY 

Pasquale Razzano, MS, Manhasset, NY 

Nadeen Chahine, PhD 

Daniel A Grande, PhD, Manhasset, NY 

Sutures coated with platelet derived growth factor (PDGF) were 

employed in an Achilles tendon repair model. PDGF has been shown 

to play a role in tendon healing through increased chemotaxis and 

proliferation of fibroblasts. The aim of this study was to compare the 

quality of tendon repair at four weeks post treatment with varying 

concentrations of PDGF-coated sutures against uncoated suture 

repairs. We hypothesized that an increasing dosage of PDGF would 

result in improved tendon healing histologically and biomechanically. 

A 4-0 vicryl suture was coated with varying concentrations of PDGF 

(0.3, 1.0 and 10.0 mg/ml) using a dip-coating process previously 

described. Four groups of sutures were employed in this study. The 

control group was made up of suture impregnated with acetate, 

the carrier molecule used with PDGF coated groups. Rat Achilles 

tendons were transected and repaired primarily. Tendons were 

repaired with one of the four suture types. Tendons were harvested at 

four weeks postop and sent for biomechanical analysis (n=8/Group) 

or histological analysis (n=4/Group). Histology sections from each 

specimen stained with H&E slides were then imaged and analyzed 

by two blinded observers. Samples were scored using the Soslowsky 

scale for collagen organization and angiogenesis. Uniaxial tensile 

biomechanical analysis was performed on each specimen providing 

load and extension data. The raw data was analyzed for the Young’s 

modulus, ultimate tensile strength and elastic toughness of each 

specimen. The biomechanical results demonstrated a significant 

difference in ultimate tensile stress between control (1.0 ± 0.2 

MPa) and high dose PDGF groups (1.9 ± 0.5 MPa and 2.1 ± 0.5 

MPa). Tensile Young’s modulus was significantly higher in PDGF 10 

group (7.22, SD 3.79) than all the other groups. This demonstrated 

a positive dose response and improved strength with PDGF coated 

sutures. The histological analysis demonstrated no significant 

differences in collagen score or angiogenesis between control and 

PDGF groups. This data demonstrate that PDGF coated suture 

improves material properties of repaired tendons in a positive, dosedependent 

fashion. Ultimate tensile stress improved in a dose-related 

fashion in tendons repaired with PDGF impregnated suture. Though 

there were no significant histological differences, the biomechanical 

data provides promise that growth factor coated sutures can improve 

and/or accelerate healing time in Achilles tendon repairs. 

590 

pApeR No. 497 

Biomechanical Study Of Flexor Digitorum Longus 

Tendon Transfer For Tibialis Posterior Insufficiency 

Mahesh Pimple, FRCS 

Ziad Harb, MRCS 

Aroon Baskaradas, MRCS, Frimley, United Kingdom 

Matthew C Solan, FRCS, Godalming Surrey, United Kingdom 

Tibialis posterior insufficiency is a common cause of acquired flat 

foot deformity in adults. Tibialis posterior is the main invertor of the 

hindfoot. It also acts as a primary dynamic stabilizer of the medial 

longitudinal arch by locking the midfoot and preventing abnormal 

forefoot abduction. Its dysfunction therefore leads to excessive 

hindoot foot eversion and forefoot abduction causing a planovalgus 

deformity. Flexor digitorum longus transfer is commonly used for 

balancing deforming forces in correctible flat foot deformity; usually 

in conjuction with a bony procedure. This study aims to find out 

how flexor digitorum longus (FDL) transfer compares to the tibialis 

posterior in producing inversion and abduction of the foot. Eight 

cadaveric legs were used. The tibia had been sectioned below the level 

of the tibial tuberosity. All soft tissue attachments were preserved. A 

vertical hole was drilled in the navicular bone from dorsal to plantar. 

FDL tendon was sectioned at the knot of Henry and passed plantar 

to dorsal through the tunnel and sutured to itself. The proximal 

musculotendinous junctions of the tibialis posterior tendon and 

FDL were exposed. Sutures were used to obtain secure fix in the 

tendinous portion and passed through the center of the muscle belly 

to maintain the line of pull of the muscles. The sutures were passed 

over a pulley system to accept load. The tibia was clamped securely 

in a jig so that the leg was lying horizontal with the sole facing the 

cameras and the proximal cross-section facing the pulleys. The ankle 

and subtalar joints were taken through full range of movements to 

relieve any stiffness and the tendons were cyclically loaded a few 

times to relieve the crimp in the tissues. Reflective markers were 

placed on the heel, head of first metatarsal and fifth metatarsal. Two 

motion capture cameras were used to track the movements of these 

three markers. A load cell was used to measure the adductor force 

generated over the head of the first metatarsal. The tendon excusion 

was noted by measuring movement of a marker on the tendon 

as compared to a fixed point. The native tibialis posterior tendon 

was loaded first. Readings were taken at load 0Newtons(N), 10N, 

20N, 30N and finally 0N again after removal of load. Force over 

the first metatarsal head was also measured at these loads using a 

load cell. The transferred FDL was now loaded in similar manner 

and measurements taken. The specimen or the jig was not handled 

in between these two sets of measurements for the two tendons. 

Statistical testing by paired t-test showed no difference between 

the tibialis posterior and FDL transfer with respect to the range of 

inversion, adduction force developed over the medial aspect of the 

first metatarsal and the tendon excursion. One of the fundamental 

principles of tendon transfer is that the tendon chosen as a donor 

must be strong enough to perform its new function in its altered 

position. A few studies have questioned the rationale of FDL transfer 

for tibialis posterior insufficiency. FDL is not considered as strong 

as tibialis posterior. In addition, its non-anatomical attachment 

over the inferior surface of navicular bone may further weaken its 

inversion action. However, our cadaveric study shows that FDL 

transfer is as effective as tibialis posterior in inverting the heel and 

adducting the forefoot. Clinically, a muscle will lose one grade of 

strength following transfer and a combined bony procedure such as 

a medial displacement calcaneal osteotomy could compensate by 

increasing the biomechanical advantage. In conclusion, our study 

shows that FDL transfer is effective in generating inversion and 

forefoot adduction similar to the native tibialis posterior tendon. 




pApeR No. 498 

Plantar Pressure Analysis in Forefoot After Different 

Amount of Lateral Column Lengthening 

Irvin Oh, MD, Hornell, NY 

Benjamin R Williams, New York, NY 

Daniel Choi, MS, New York, NY 

Carl W Imhauser, PhD, New York, NY 

Scott Ellis, MD, New York, NY 

Jonathan T Deland, MD, New York, NY 

Although lateral column lengthening of the calcaneus offers powerful 

correction of talonavicular subluxation in flatfoot deformity, 

increased postoperative plantar lateral pressures have been reported. 

The aim of this study was to investigate whether even small changes 

in correction (2 mm) affect lateral forefoot plantar pressures. Our 

hypothesis was that increasing lateral column lengthening by 2 mm 

would significantly increase lateral plantar pressures. Ten cadaveric 

feet were axially loaded using 6 degrees of freedom robot. Each 

specimen was tested with all soft tissues intact, after creating a 

flatfoot, and after 6, 8 and 10 mm of lateral column lengthening. For 

each condition, kinematic plantar pressure data were obtained with 

an axial force of 400N and pull through the Achilles of 311N. The 

flatfoot condition increased the medial/lateral ratio of mean average 

pressure (p

or gross inspection. Negative controls were classified as grade 0, 

and were defined as patients with a VAS of 0. Patients with none or 

mild synovitis/chondrosis were classified as grade 1. Patients with 

moderate/severe synovitis/chondrosis, osteochondritis dissecans, 

anterior impingement syndromes or loose body were classified 

as grade 2. Positive controls undergoing total ankle arthroplasty 

(TAA) were graded as 3. There were 36 patients, 21 males and 15 

females (mean age 45, range 18-76) and a mean pre-procedure VAS 

of 4.7. There were four positive, and 11 negative controls. Of the 

21 undergoing arthroscopy, six were grade 1 and 15 grade 2. The 

grade of intra-articular pathology was significantly related to age, 

preoperative VAS, FAC, IL-6, and MCP-1 (p < 0.05). FAC and MCP-1 

were significant predictors of pathology (p < 0.05). The mean values 

of the inflammatory marker MCP-1 in pg/ml were 49.8 (±8.0) for 

minimal pathology and 133.9 (±33.0) significant pathology. The 

mean values of FAC in optical density at 450 nm were 2.83 (±1.16) 

for minimal pathology and 9.62 (±2.23) for significant pathology. 

There are differences in FAC and MCP-1 with increasing grades 

of severity of intraarticular pathology. This may play a role in 

determining necessity of arthroscopy in equivocal candidates. 

pApeR No. 502 

uRandomized, Double-Blind Placebo-controlled Study 

of Hyaluronan Treatment of Ankle Osteoarthritis 

Henry DeGroot, MD, Newton Center, MA 

Sofia Uzunishvili, MD 

Robert Weir, MD 

Bruna Gomes, BS 

Treatment options for arthritis of the ankle are more limited than 

those for arthritis in the knee and hip. Surgical options include 

arthrodesis and arthroplasty, which are reserved for very advanced and 

severe cases. The safety and efficacy of hyaluronan (HA) injection for 

knee arthritis has been demonstrated in numerous well-controlled 

studies. In the USA, the FDA has not yet approved HA for use in the 

ankle. This study compares the therapeutic effect of a single intraarticular 

hyaluronan injection with a single intra-articular normal 

saline injection (placebo) for osteoarthritis of the ankle. This study 

is a randomized, prospective, double-blind (blinded observer), 

saline solution-controlled, parallel experimental design. Our power 

analysis showed that with an estimated population effect size of 0.4, 

a probability of alpha error (significance) of 0.05 and a required 

power (1-beta) of 0.95, the total required sample size would be 57 to 

62 patients with ankle osteoarthritis (Kellgren and Lawrence grade 

1 or more) were randomized to two groups. A single intra-articular 

hyaluronan injection or saline injection was given to each patient. 

The primary outcomes measure was the American Orthopaedic Foot 

and Ankle Society (AOFAS) score. Secondary outcome measures were 

ankle osteoarthritis score (AOS), patient reported pain (VAS) and 

quality of life (SF-12). Outcomes data were gathered at six weeks after 

the injection. Data were analyzed using the SPSS software package. 

Seventy-six patients were screened, of which 62 met study criteria 

and were enrolled. Seven patients withdrew for various reasons, 

leaving 55 patients who completed the entire study process. Analysis 

of the data indicated that two groups were similar at baseline across 

all measures. No adverse effects were observed in either group. A 

mild positive treatment effect was observed, based on the AOFAS 

scores. In the hyaluronan injection group, AOFAS scores increased at 

six weeks compared to baseline by approximately 7% (p

warranted PSB as anesthesia for foot and ankle surgery between 

January and May 2009 was conducted. The time for an orthopaedic 

surgeon to administer the block, visual analog score (VAS) at postanesthesia 

care unit (PACU) discharge and block duration were 

evaluated. These values were compared to historical controls where 

an anesthesiologist administered the nerve blocks. Fifty patients had 

PSB performed by an orthopaedic surgeon utilizing ESLGA. For this 

cohort, the average time to administer the block, VAS in PACU and 

average block duration were: 3.8±1.2 min., 1.4±2.1 and 15.8±7.1 

hours, respectively. These are compared to 10.6±4.6 min., 0.9±1.3 

and 18.2±7.3 hours in the 14 patient control group that had their 

PSB performed by an anesthesiologist utilizing APUG. The only 

parameter with statistical significance between the two groups was 

time to administer the block (p

institution. These results were originally published showing 90% 

success rates and only 3% requiring surgical excision at a mean follow 

up of 10.5 months. The authors concluded that alcohol injection 

was comparable to results for surgical excision. The purpose of our 

study was to reveiw this group of patients at an average of five years 

follow up. We were able to review 45 of this original cohort with an 

average of five-year follow-up (range 33-73 months). The modified 

Johnson score and visual analogue scales were used to assess the 

patients and compare these results to five-year results available in 

the literature for surgical management. Our results indicated that by 

five years, 36% had undergone surgical treatment and another 16% 

had return of symptoms. Only 29% remained symptom free. Results 

at five years showed statistically significant differences (P=0.0001) 

compared to surgical management with 67.8% complete resolution 

of symptoms with surgery and 33% in the alcohol injection group. 

Injection with alcohol sclerosant for MN has been marketed as a 

definitive management option, comparable to surgical excision. 

Our investigation illustrated that although short-term results are 

encouraging; alcohol injection does not offer permanent resolution of 

symptoms for most patients and can be associated with considerable 

morbidity. Our investigation provides the only long-term data for 

alcohol injection treatment of MN. 

pApeR No. 508 

Treatment of Advanced Hallux Rigidus with 

Cheilectomy and Poximal Phalangeal Osteotomy 

Martin J O’Malley, MD, New York, NY 

Harpreet Singh Basran, MD, Crystal Lake, IL 

Yang Gu, BS 

Jonathan T Deland, MD, New York, NY 

Hallux rigidus refers to the degenerative arthritis of the first 

metatarsophalangeal (MTP) joint. As the process proceeds, the 

proliferic bony response results in increased bulk as well as a 

creation of a dorsal ridge that impinges the dorsilflexion of the 

proximal phalanx. Historically, advanced hallux rigidus (Coughlin 

Grade III and IV) has been treated with arthrodesis of the MTP joint. 

The purpose of this study is to review patient outcomes following 

cheilectomy and proximal phalangeal osteotomy for advanced hallux 

rigidus. The operative notes for all patients treated with cheilectomy 

and proximal phalangeal osteotomy for hallux rigidus between 

2000 and 2007 (319 patients) were reviewed and a subgroup of 93 

patients (103 feet) were identified who had advanced hallux rigidus 

as manifested by greater than two-thirds loss of articular cartilage on 

the metatarsal head. The outcome was the need for further surgery 

(i.e., arthrodesis), patient satisfaction as well as comparison of pre 

and postoperative AOFAS (American Orthopaedic Foot and Ankle 

Society) scores and ranges of motion. Review of operative notes 

showed a total of 93 patients (103 feet) had advanced intraoperative 

findings of greater than two-thirds loss of articular cartilage, with 

an average of 75% loss of articular cartilage. Thirty-nine feet were 

Coughlin radiographic Grade III and 64 feet were Grade 4. Results 

showed that there was a significant increase in postoperative range 

of motion, with average increase of 26.2 degrees from preoperative 

average of 34.5 degrees to 60.7 degrees postoperative (p

to 20.1°±3.6 (p

score. After AAD the number of patients participating in sports 

decreased. However, this change was not statistically significant. 


Bisphosphonates, Graft Augmentation and Rigid 

Arthrodesis for the collapsed Charcot Midfoot 

Joe Wagener, MD, Liestal, Switzerland 

Markus Knupp, MD, Liestal, Switzerland 

Alexej Barg, MD 

Beat Hintermann, MD, Liestal, Switzerland 

In midfoot neuroarthropathy (Charcot), surgical reconstruction of 

the arch with internal fixation is plagued with a high failure rate 

due to weakening of bone, bone loss and implant failures. We thus 

established a treatment concept that included 1) bisphosponate 

medication to normalize the bone metabolism, 2) allograft 

augmentation to compensate for bone loss and 3) intramedullary 

screw fixation to respond best to load forces to the arch. The goal is 

to report on the preliminary results after a minimal follow up of two 

years. A series of 16 consecutive Charcot neuroarthropathic feet (15 

patients; females, six; males, nine; age, 45 - 77 years]) with breakdown 

of the arch and imminent risk for ulceration were treated with 

these modalities. After five to 10 days, full contact cast was applied 

and weight-bearing was allowed as tolerated until union was achieved 

radiographically. After a mean follow-up of 33.6± 8.5 months, 14 of 

16 feet (87.5%) were stable with no recurrence of Charcot process. 

Of these, union was achieved after 4.3 (2.7-8.0) months in 13 feet. 

In one foot, extension of the arthrodesis to tibiotalar fusion was 

needed due to progression, and healing was thereafter uneventful. 

In the remaining two feet (12.5%), infection occurred that needed 

hardware removal before complete bone healing occurred (one 

patient), and below knee amputation was performed (one patient) 

respectively. 


The Role Of Talar Cheilectomy In Ankle Arthrosis 

Sarah Hanslow, MD, Gorokan, NSW Australia 

Patricia Kramer, PhD, Seattle, WA 

Stephen K Benirschke, MD, Seattle, WA 

Sigvard T Hansen Jr, MD, Seattle, WA 

Ankle arthrosis is a debilitating condition with limited treatment 

options in the younger subset of patients. Ankle arthrodesis leads to 

degeneration of adjacent joints, particularly the subtalar joint and 

ankle arthroplasty is not indicated in the younger active patient. 

We postulate that ankle cheilectomy provides adequate pain relief 

to defer other definitive surgical management. A retrospective chart 

review was conducted of all open ankle cheilectomies performed 

by two surgeons between 2003 and 2009. Data collected included 

demographic, aetiology, pain relief, change in range of movement, 

complications and further surgery required. Variable parameters 

were assessed at six weeks, six months and one year. The chart 

review identified 84 patients. Four were excluded due to inadequate 

availability of data. Of the remaining patients, 36 had >one year of 

follow up. The average age of these patients was 45.6 (20-67) years, 

and 58% of patients were male. Of these patients with >one year 

follow up, 56% had pain relief not requiring further intervention that 

continued on average for at least 2.5 years. The range of movement 

increased by an average of 10 degrees. The surgical complication 

rate was 6% (two patients), one patient developed a deep vein 

thrombosis and subsequent pulmonary embolism while a second 

patient developed a sural nerve neuropraxia, which resolved. Ankle 

cheilectomy is a procedure without significant complications, which 

provides pain relief and increases range of movement in younger 

596 

patients with ankle arthrosis. The procedure may be repeated if the 

anterior talar osteophytes recur and has the benefit of not interfering 

with future surgical management in the form of arthroplasty or 

arthrodesis. 


Biomechanical Comparison Of 4 Achilles Tendon 

Repairs: In vitro Study In Bovine Achilles Tendons 

Cristian Ortiz, MD, Santiago, Chile 

Pablo Mococain, MD 

Felipe Reinares, MD 

Julian Alonso, MS, RM, Chile 

Gonzalo Labarca, MS 

Sergio Arellano, MS, RM, Chile 

Andres Keller, MD, Santiago, Chile 

Emilio Wagner, MD, Santiago, Chile 

Operative treatment for acute Achilles tendon ruptures is generally 

recommended. Minimally invasive procedures have been designed 

in order to decrease soft tissue complications. Any repair should be 

able to withstand early postoperative motion. Our objective was 

to evaluate the strength of a mini open repair with and without 

modifications in bovine Achilles tendons. Twenty fresh bovine 

Achilles tendon were incised 4 cm proximal to the calcaneal insertion, 

then were randomly repaired using either a mini open technique 

(Dresden technique), modified oblique Dresden technique 

(Oblique technique), modified triple strand Dresden technique 

(Triple technique) and Krackow repair (Krackow). All tendons 

were repaired using a number 2 polyblend suture. Each tendon was 

loaded to failure. Force at 5 mm gap formation, peak load to failure 

and the failure mechanism were registered. Gapping resistance was 

significantly greater for the triple repair (246.1 N to initial gapping) 

versus the Dresden (180 N, p=0.012) and the Krackow repair (101 N, 

p

scale and Sefton grading system. The measurement of talar tilt angle 

and anterior talar translation was performed through anterior and 

varus stress radiographs. At the last follow up, the Karlsson scale had 

improved significantly from preoperative average 45.4 points to 90.5 

points in single anchor group, from 46.2 points to 91.3 points in 

double anchor group. There were eight excellent, 10 good and two 

fair results according to the Sefton grading system in single anchor 

group, and nine excellent, eight good, three fair results in double 

anchor group. Therefore, 18 cases (90%) in single anchor group and 

17 cases (85%) in double anchor group achieved satisfactory results. 

Talar tilt angle had improved significantly from preoperative average 

15.7° to 6.1° in single anchor group, from 16.8° to 4.2° in double 

anchor group. There was significant difference in postoperative 

talar tilt angle between single and double anchor group. Significant 

differences in clinical and functional outcomes were not found 

between single and double suture anchor technique. On stress 

radiographs for evaluation of mechanical stability, modified- 

Brostrom procedure using double anchor showed less talar tilt angle 

than single anchor technique. 


Cost-Effectiveness Of Plate Fixation For Unstable But 

Undisplaced Lateral Malleolus Fractures 

Gerard Slobogean, MD, MPH, Vancouver, BC Canada 

David Sanders, MD, London, ON Canada 

We sought to determine the parameters when open reduction 

and internal fixation (ORIF) might be considered a cost-effective 

treatment compared to casting for unstable but undisplaced isolated 

lateral malleolus fractures. A single payer governmental perspective 

was used to create a decision tree modeling the results of a multicentre 

trial comparing ORIF versus nonoperative treatment for isolated 

fibular fractures. Utilities were obtained from the subjects’ Short- 

Form-6D scores and used to calculated Quality Adjusted Life Years 

(QALYs). Probabilities for each strategy were taken from the one-year 

trial endpoint. Costs were obtained from the Ontario case costing 

initiative. Sensitivity analysis was performed for all model variables 

to determine when ORIF is a cost-effective treatment. Nonoperative 

management was the preferred treatment during the one-year timehorizon. 

The nonoperative treatment strategy had an average cost of 

$2,128±$1,984 for an average gain of 0.72±0.00 QALYs. ORIF had an 

average cost of $6,343 ±$893 for an average gain of 0.74±0.02 QALYs. 

The incremental cost effectiveness ratio for the ORIF treatment was 

$216,106/QALY. ORIF becomes the preferred treatment at extreme 

values for its costs (0.80). 

From a single payer governmental perspective, short-term followup 

does not support the cost-effectiveness of ORIF for unstable 

undisplaced isolated fibular fractures. Long-term follow-up and 

additional modeling from a societal perspective remain necessary. 


Postoperative Pain Following Surgical Treatment of 

Ankle Fractures: A Prospective Study 

Ariel Williams, MD, Baltimore, MD 

Kenneth Hunt, MD, Redwood City, CA 

Rosanna Duester, PA-C 

Loretta Chou, MD, Redwood City, CA 

Fixation of fractures has been reported to have a substantial incidence 

of post-operative pain. Patients frequently require large amounts of 

narcotics and are at risk for long-term use of pain medications. Few 

prospective studies in the literature investigate patient expectations 

with regard to postoperative pain. We prospectively evaluated 46 

patients undergoing open reduction internal fixation of ankle 

597 

fractures regarding their pain experience. Two Short-Form McGill Pain 

Questionnaires (SF-MPQ) were administered preoperatively, one for 

current pain and the other for anticipated postoperative pain. The 

SF-MPQ was repeated at three days and six weeks post-operatively. 

There were significant correlations between preoperative VAS and 

anticipated VAS and between anticipated VAS and actual VAS at 

three days and six weeks. There was a weak but significant correlation 

between anticipated Total Pain Rating Index (TPRI) and actual TPRI 

at three days. Pain was significantly higher for trimalleolar fractures at 

three days and six weeks compared to other fracture types. Fractures 

involving injuries to the syndesmosis had significantly higher pain 

rating on a VAS at three days. Pain control after open repair of 

ankle fractures can be problematic. Appropriately managing patient 

expectations and medication use during this period is critical. We 

found that preoperative pain and anticipated pain were predictive 

of pain at three days and six weeks postoperatively. Further study 

is needed to determine whether these data apply to other foot and 

ankle procedures. 


Immediate Weight-Bearing After Complete Achilles 

Detachment/Repair for Calcific Tendinosis 

Santiago A. Lozano Calderon, MD, Mount Kisco, NY 

Robert Li, BS, Flushing, NY 

James R McWilliam, MD, Harrison, NY 

Early mobilization and weight bearing following surgical repair for 

calcific insertional Achilles tendinosis (CIAT) is safe and provides 

satisfactory results. Under an Institutional Review Board approved 

study and after informed consent, 68 patients undergoing surgical 

treatment for CIAT after failed conservative for three months, were 

enrolled in this investigation. Postoperatively, patients were placed 

in a short leg cast and allowed to bear weight for two weeks, followed 

by six weeks in a below knee ankle brace where they performed 

gentle resistance exercises. Physical therapy was then started eight 

weeks postoperatively. Patients were evaluated functionally at two 

and eight weeks and six, 12 and 24 months after surgery using the 

American Orthopaedic Foot and Ankle Society (AOFAS) score. Early 

mobilization and weight bearing following surgery for insertional 

achilles tendinosis yielded 85% good to excellent results at the latest 

follow up, with only six wound complications and one partial tendon 

rupture (8% complication rate). Early weight bearing and range 

of motion after surgical repair for CIAT proportionate satisfactory 

results at two years as per the AOFAS score and does not increase 

wound complication or tendon rupture rates. 


uA Phase 3 Trial of EXPAREL , an Extended Release 

Bupivacaine Local Analgesic, in Bunionectomy 

Erol Onel, MD, Parsippany, NJ 

Stephen Daniels, DO 

Michael Golf, DPM, Austin, TX 

Gary Patou, MD 

This FDA-approved, Phase 3 clinical trial compared EXPAREL(TM), 

an experimental extended release liposomal bupivacaine-based 

analgesic, to placebo for the prevention of pain after bunionectomy 

procedures. After obtaining Institutional Review Board approval, 

193 consenting patients undergoing bunionectomy were randomly 

assigned to receive either a single injection of placebo (n=96) or 

120 mg EXPAREL (n=97) administered via wound infiltration at 

the conclusion of the surgical procedure. The severity of pain was 

assessed after surgery at specified predetermined time points using a 

numeric rating scale (NRS) at rest for pain with 0 = no pain and 10 = 




worst possible pain. The NRS scores were used to calculate the area 

under the curve (AUC) from immediately post op (time 0) through 

multiple postoperative time points. Other endpoints included 

number of patients requiring no parenteral opioid analgesic (rescue) 

medications, number of patients who were pain free (NRS=

grafting procedures for lesions over 1 cm. There are currently no 

biomechanical data supporting this size threshold. Our purpose was 

to determine the effect of OLT defect size on stress concentration, 

rim stress and location of peak stress. We created progressively 

larger medial OLTs (6 mm, 8 mm, 10 mm, 12 mm) in eight 

fresh frozen cadaveric lower extremities. With a calibrated digital 

electronic pressure sensor in the tibiotalar joint, an axial load of 

700 N was applied and pressure recorded in neutral and 15 degrees 

plantarflexion with each defect size. Average and peak stresses, rim 

stress and location of peak stress were determined. The distance 

between peak stress and the defect rim was significantly decreased 

with increasing defect size. Total tibiotalar contact area was 

significantly decreased with increasing defect size and with ankle 

plantarflexion. While peak joint stress and peak rim stress were not 

affected by defect size or plantarflexion, average stress and average 

rim stress were significantly increased by plantarflexion. There was 

no significant difference in peak stress or rim stress with increasing 

OLT diameter. However, reduction in contact area and shift in the 

location of peak stress with increasing defect size may contribute 

to articular cartilage degeneration in patients with OLTs. There does 

not appear to be a threshold defect size, but rather a linear effect on 

joint stresses. 


Surgical Treatment Of Neglected Idiopathic Clubfoot 

After Walking Age In Developing Countries 

Cesare Faldini, MD, Bologna, Italy 


Stavroula Pagkrati, MD, Bologna, Italy 

Matteo Nanni, MD, Bologna, BO Italy 

Danilo Leonetti, MD, Bologna, BO Italy 

Francesco Acri, MD, Bologna, BO Italy 

Maria Teresa Miscione, MD, Bologna, BO Italy 

Dunia Francesconi, MD, Bologna, BO Italy 

Sandro Giannini, MD, Bologna, Bologna Italy 

Several conservative or minimally invasive surgical techniques have 

been described to correct idiopathic clubfoot diagnosed at birth. 

However, surgical treatment of neglected clubfoot is a challenge if 

the deformity is observed after walking age without any previous 

treatment. The aim of this study is to review a series of 24 walking 

patients with neglected congenital idiopathic equinovarus clubfoot 

surgically treated by combined posteromedial release and cuboid 

osteotomy. Forty neglected congenital idiopatic equinovarus clubfeet 

in 24 children (age range three to seven years, mean four years) were 

observed. Skeletal maturity, grade and stiffness of the deformity were 

carefully assessed. Surgical procedure consisted in posteromedial 

release combined with cuboid wedge osteotomy in order to shorten 

the lateral column of the foot. Postoperative treatment consisted 

of plastercast for six weeks then talovalgus splints during night, 

insoles and physiotherapy up to the end of growing age. Patients 

were evaluated at an average follow up of five years (range three to 

eight years). Four feet with delayed healing of the skin were dressed 

until healing. Excellent correction was achieved in 18 feet, good in 

14, fair in eight and poor in none. Further surgery was performed in 

three feet to complete the correction of residual varus deformity. The 

treatment of never previously treated neglected congenital clubfoot 

is a demanding surgery after walking age. Posteromedial release 

combined with cuboid osteotomy allowed to obtain satisfactory 

correction of neglected congenital idiopathic equinovarus clubfoot 

with low rate of complications. 

599 


The Ponseti Technique Heel Cord TenotomyDoes Local 

or General Anesthesia Provide the Best Outcome? 

Eric Edmonds, MD, San Diego, CA 

Tracey Bastrom, MA, San Diego, CA 

Scott J Mubarak, MD, San Diego, CA 

Charles Douglas Wallace, MD, San Diego, CA 

The current study compared the outcomes between percutaneous 

tendo Achilles lengthening performed under local (LTAL) versus 

general (GTAL) anesthesia in the treatment of idiopathic clubfoot 

utilizing the Ponseti method. A retrospective review was performed 

of all infants treated for clubfoot between 2003 and 2008 at our 

institution by a single surgeon who prefers LTAL and by other 

surgeons who prefer GTAL. Exclusion criteria included: nonidiopathic 

clubfeet, non-Ponseti technique or no TAL after Ponseti 

casting. Details related to their clubfoot severity, casting, follow 

up and treatment course and progression were recorded. The data 

was analyzed using Chi-squared and ANOVA. One-hundred-thirty 

infants met inclusion criteria: 111 LTAL and 19 GTAL. There was no 

statistical difference between LTAL and GTAL, respectively, for the 

mean age at first cast (30.2 vs 30.1 days), follow-up duration (22.1 vs 

21.5 months), the percent of good correction at TAL (80% vs 74%) 

and the number of relapses (27% vs 10.5%). No statistical difference 

was noted between the total cost of treatment: LTAL $6,803 ($859- 

$40,114) versus GTAL $4,755 ($1,138-$10,621). The LTAL group 

had more severe clubfeet than those treated with GTAL (p=0.03). 

Furthermore, the number of pre-TAL casts applied differed between 

the LTAL (4.7) and GTAL (5.4) which likely represents delay of 

GTAL due to OR scheduling (p=0.012). Our results yielded excellent 

outcomes in 89.5% of the GTAL group and 73% of the LTAL group 

with an overall mean cost of treatment difference of $2,048 more in 

the LTAL group. 


Nerve Structures at Risk during Tibialis Anterior 

Tendon Transfer 

John E Herzenberg, MD, Baltimore, MD 

Christof Radler, MD 

Monique C Gourdine-Shaw, DPM, Columbia, MD 

Tibialis anterior tendon transfer (TATT) is a common procedure for 

clubfoot. It includes passage of needles/sutures from the dorsum 

of the foot through the plantar surface. Neurovascular damage 

is possible. We conducted a cadaveric study to determine how to 

minimize this risk. Tibialis anterior tendon transfer (TATT) was 

performed on the lateral cuneiform in 12 cadaveric feet (three feet 

per group). Tendon was passed through a lateral cuneiform drill 

hole using sutures through the plantar aspect of the foot. Drill 

holes were created perpendicular to dorsal cuneiform (Group A), 

perpendicular to plantar surface (Group B), tilted 15° in frontal and 

sagittal planes (Group C) and aimed at the geometric middle of the 

foot (Group D). Sutures were pulled through drill holes using Keith 

needles. Distance between nerves and drill hole was measured. Keith 

needles were passed 20 times per foot; damage to nerve structures 

was noted. Group A: Drill hole was 1.7 mm from medial plantar 

nerve. Average distance to bifurcation was 5 mm. Group B: Hole 

was 0.3 mm from lateral plantar nerve with 25.3 mm to bifurcation. 

Group C: Hole was 1.7 mm from lateral plantar nerve bifurcation. 

Group D: Hole was 7.7 mm from medial plantar nerve and 4.3 mm 

from lateral plantar nerve. Needles pierced nerve structures in group 

A (12 instances), group B (20 instances), group C (six instances) and 

group D (one instance). To prevent neurovascular damage, the drill 




should be aimed at the middle of the foot. Blunted Keith needles 

might prevent damage to nerves. 


Alternative Distal Lower Extremity Amputations in 

Patients with Diabetic Foot Ulcers 

Matthew L Brown, Rochester, NY 

Judith F Baumhauer, MD, MPH, Rochester, NY 

Amar Patel, MD, Overland Park, KS 

Wan Tang, PhD 

Below-knee amputations (BKA) are performed for recalcitrant or 

infected ulcers of the midfoot, hindfoot or ankle. This procedure 

results in decreased ambulatory status due to increased energy and 

oxygen demands. Partial foot amputations have less energy and 

oxygen demands and theoretically suggest improved functional 

outcome. The purpose was to examine mortality, index amputation 

failure rates and functional outcome in patients treated with partial 

foot amputations compared to BKA. Retrospective chart review 

identified transmetatarsal, Chopart, partial or total calcanectomy 

amputations for osteomyelitis or non-healing ulcers in diabetics. BKA 

was used for comparison. Patient demographics, co-morbidities, ASA 

and HbA1C were obtained. Primary outcomes were death and time 

to a more proximal amputation. Mortality rates based on survival 

analysis methods were calculated for each cohort at one, three and 

five years. Living patients were contacted to assess functional status 

using a validated instrument. BKA: 18 patients, eight deaths (44%), 

.45 five-year mortality rate, one proximal reamputation, 2.8/6.0 mean 

ambulatory score (MAS). Transmetatarsal: 21 patients, seven deaths 

(33%), .30 five-year mortality rate, two proximal reamputations, 

4.3/6.0 MAS. Chopart: 11 patients, five deaths (45%), .36 five-year 

mortality rate, six proximal reamputations, 4.3/6.0 MAS. Partial 

Calcanectomy: 17 patients, 10 deaths (59%), .69 five-year mortality 

rate, seven proximal reamputations, 4.3/6.0 MAS. Total Calcanectomy: 

16 patients, 11 deaths (69%), .59 five-year mortality rate, five 

proximal reamputations, 3.3/6.0 MAS. BKA is associated with high 

morbidity and mortality, which suggests investigating the advantage 

of partial foot amputations. In regards to mortality rates, only 

transmetatarsal amputations at one and three years were statistically 

lower. Partial foot amputations at the other levels examined failed to 

show statistically improved survival. Transmetatarsal and Chopart’s 

amputations had the longest durability, with mean time to failure 

exceeding two years, suggesting that these amputation levels may 

provide some ambulatory advantage over the other amputations by 

providing an end bearing limb. 


Evaluation of Patient Outcomes Following Mini 

Fragment Fixation of Talar Neck Fractures 

Mary A Herzog, MD, Grand Rapids, MI 

Clifford B Jones, MD, Grand Rapids, MI 

Debra Sietsema, PhD, Grand Rapids, MI 

James R Ringler, MD, Grand Rapids, MI 

Talar neck fractures are uncommon and result from high energy 

mechanisms. The purpose of this study was to evaluate the outcomes 

of talar neck fractures treated with mini fragment fixation. Over a 

five-year period from March 2002 through June 2007, 83 talar neck 

fractures in 79 skeletally mature patients were treated with mini 

fragment fixation at a level one trauma center and retrospectively 

identified. Outcomes included pain at final assessment, ankle 

motion, return to previous activity and complications. Demographic 

data, fracture type, instrumentation used and radiographic arthrosis 

were recorded. Gender was near equal distribution (38 males, 48.1% 

600 

and 41 females, 51.9%) with more right talus injuries (44, 53%) than 

left (39, 47%). Average age was 35 years (range 18-77). Hawkin’s 

classification was: II (39, 47%), III (30, 36%) and IV (14, 17%). 

Open injuries were 15 (18.1%). Isolated injuries were 15 (18.1%) 

and 68 had associated injuries (81.9%). Hardware complications 

were two migration, 10 broken and eight irritating. Radiographic 

ankle arthritis was 31 (38.4%) and subtalar arthritis was 38 (46.3%). 

Complications of avascular necrosis (AVN) 20 (24%), nonunion one 

(2%) and hardware loosening two (3.9%) were noted. Secondary 

surgeries were 18 (22%) with BKA one, TAA one and hardware 

removal 16. Pain was noted to be: none 19 (23%) and mild (1- 

3/10) pain 63 (76%). Pain is related to subtalar arthrosis (r=0.525, 

p

educing forefoot pain, but the literature reports complications. An 

alternative, the oblique sliding proximal to distal osteotomy (PD) 

assures that the metatarsal head would slide superiorly, reducing 

plantar pressure. The purpose of this study is to characterize the 

relationship between the amount of second metatarsal shortening, 

osteotomy type, and plantar pressure. We performed six DP and 

six PD second metatarsal osteotomies on twelve paired cadaveric 

feet. The second metatarsals were shortened by 0mm, 2mm, 4mm, 

and 6mm. Dynamic in vitro robotic gait simulation was based 

on in vivo gait data and performed at 50% body weight and one 

sixth physiologic velocity. Three trials were obtained for metatarsal 

length. Regression lines for peak pressure (PP) and pressure time 

integral (PTI) and metatarsal shortening were calculated with linear 

mixed effects models. Second metatarsal PP and PTI were negatively 

correlated with metatarsal shortening (p

POSTERS 


National Association of Orthopaedic Technologists 

(NAOT) 

Cynthia Henderson, OTC, CO, Oklahoma City, OK 

Sean B Conkle, OTC, Bethlehem, PA 

Nicole T Williams, OTC, Greeley, CO 

Robyn Masseth, OTC, Indianapolis, IN 

Established in 1982, the NATIONAL ASSOCIATION OF 

ORTHOPAEDIC TECHNOLOGISTS (NAOT) is dedicated to the 

pursuit of excellence through the continued educational development 

of orthopaedic allied health care professionals who specialize in 

casting, splinting and bracing. 


American Society of Orthopaedic Physician’s 

Assistants (ASOPA) 

Jason S Mazza, OPA-C, Trinity, FL 

Frank E Greaves, OPA-C, OTC, Houston, TX 

Gail Sue Keating, OPA, Indianapolis, IN 

ASOPA is an organization for physician extenders who specialize in 

orthopaedic Board-certified surgery. ASOPA members are usually 

employed by a Board-certified orthopaedic surgeon or by an 

orthopaedic facility. The organization’s primary purpose is to enhance 

the quality of patient care by providing professional development 

to orthopaedic physician’s assistants through continuing education, 

certification, networking, publications and meeting with peers and 

other allied health professionals. 


The American Fracture Association (AFA) 

Diana Deane Carr, MD, Sebring, FL 

Judy L Wright, MD, Bloomington, IL 

Alfonso E Pino, MD, Dublin, TX 

Jose G Ramon, MD, Edwardsville, IL 

The American Fracture Association was founded in 1938 to improve 

fracture care. We are particularly interested in practical solutions for 

the difficult cases seen by community orthopedists. We also have 

many international learning opportunities via our international 

members and our membership in SLAOT (Society of Latin American 

Orthopedic Societies). 

602 

General 



PaPers, Posters & scientific exhibits GeNeRAl

PAPERS 

pApeR No. 271 

The Use of Sodium Hyaluronate in Treatment of First 

Carpal Metacarpal Joint Arthritis 

Germaine R Fritz, DO, Milford, MI 

John Toth, DO, Scottsdale, AZ 

Danny C Holland, DO, Oak Park, CA 

The purpose of this study was to determine the safety and effectiveness 

of an intraarticular injection of sodium hyaluronate compared with 

administration of a physiological saline control for the relief of 

pain associated with arthritis of the first carpal metacarpal (CMC) 

joint. This study was a prospective, single-center, randomized, 

placebo controlled, double-blind study approved by the Food and 

Drug Administration. Patients were randomized to receive 5 mg of 

sodium hyaluronate or placebo of normal saline in the same volume 

(0.5 ml) per each injection, one week apart for three weeks, into 

the first carpal metacarpal joint. After the last injection, patients 

returned for follow up at months one, three, six and 12. Outcome 

measurements include pain relief, safety, grip strength, key pinch, 

pulp pinch, adduction, palmar abduction, joint crepitus, DASH and 

x-rays. Statistical analysis was performed using Fisher’s exact, paired 

and two sample t-tests. Twenty-seven patients were enrolled in the 

study, 20 (74%) patients completed the study. Eight (30%) were 

male, 19 (70%) were female. Mean age at enrollment was 57 years 

(range 42 to 72 years). Thirteen patients received the hyaluronate 

and 14 patients received the placebo. Three adverse events were 

related to the study which was pain in the extremity. Self-evaluation 

of pain was slightly better in the hyaluronate group at six and 12 

months though differences were not statistically significant. DASH 

was slightly better at one and three months in the hyaluronate group 

though differences were not statistically significant. Pain at rest was 

similar in both groups, while pain with activity improved in both 

placebo and hyaluronate groups. Range of motion of the thumb, 

including adduction and palmar abduction, changed slightly over 

the year with placebo and hyaluronate but the differences were not 

statistically significant. Grip strength, key pinch and pulp pinch 

were similar over the year without statistical differences. There was 

improvement in crepitus in both groups. Patients reported similar 

results in global improvement in both groups. The majority of 

patients reported good or very good tolerance of the treatment in 

both groups. X-ray classification was reported at Stage III or IV in 

a majority of both groups before and after the treatment. The use 

of hyaluronate joint fluid therapy in first CMC joint arthritis is safe 

but failed to produce evidence of a clinically statistical benefit over 

placebo. 

pApeR No. 272 

A US-Guided Injection Targeting the EPB of de 

Quervains Disease With Septation is Very Effective 

Kensuke Kume, ME, Hiroshima, Japan 

Kanzo Amano, MD 

Susumu Yamada, MD, Hiroshima, Japan 

Hiroyuki Ohta, PhD, Hiroshima, Japan 

Intrasheath steroid injection is one of the best therapeutic approaches 

to de Quervain’s disease (dQD). Although sometimes (from 15% 

603 

hand and Wrist 

to 20%), this is not so for efficacy. Failure is probably due to the 

presence of septation of the first compartment. We hypothesize that 

US-guided injection targeting the external fixation bridging (EFB) 

may be effective for dQD with septation. Twenty-eight wrists were 

included and all patients were confirmed dQD with septation of first 

compartment. All patients were candidates for surgery. They were 

randomized to single intrasheath injection of either US-guided or 

conventional technique. Baseline assessments and questionnaires 

one month after injection related to subjective symptoms (wrist 

pain by 100 mm visual analog scale (VAS)), number of surgeries and 

adverse events possibly related to treatment. The primary endpoint 

was a reduction in wrist pain from baseline to one month, analyzed 

using a Mann-Whitney U test and repeated measures analysis. At one 

month, a significant reduction in pain was observed in both groups, 

while VAS pain for US group was a significant decrease. Baseline 

VAS pain for US group was mean 80.3 (SD 19.6) mm, one month 

after injection 25.6 (15.1) mm (p

normalized to the contralateral leg. Statistical significance was 

evaluated using ANOVA testing. At 12 weeks, the average normalized 

maximum isometric tetanic force at evaluation was 52.0 +/- 2.9% 

for Group A, 34.1 +/- 4.2% for Group B and 51.3 +/- 3.3% for Group 

C. There was no statistical difference between Groups A and C, but 

there was statistical difference when Group A was compared to B and 

Group C compared to B. The average normalized compound muscle 

action potential was 104.8 +/- 8.1% for Group A, 86.1 +/- 4.9% 

for Group B and 90.9 +/- 4.3% for Group C.(p>0.05). The average 

normalized tibialis anterior muscle weight was 52.0 +/- 2.0% for 

Group A, 47.5 +/- 1.6% for Group B and 51.9 +/- 3.0% for Group 

C.(p>0.05). Matched diameter acellular nerve allograft demonstrated 

equal functional recovery at 12 weeks when compared to the control 

group, and superior functional recovery to the cabled sural nerve 

autograft. These results suggest that acellular nerve allografts may 

be the best option for small nerve defects, but large defect sizes and 

longer recovery time periods should be investigated. 

pApeR No. 274 

Unusual Causes Of Carpal Tunnel Syndrome - 

Space Occupying Lesions 

Tuoh Wu, MD, Yonghe City, Taiwan 

Chun-Ho Chen, MD, Taipei, Taiwan 

Jui-Sheng Sun, MD, Taipei City, Taiwan 

Pei-yu Chen, MD, Taipei, Taiwan 

Yi-Chen Li, MD, Taipei, Taiwan 

Chien-Feng Fang, MD 

Hsiang-Yao Huang, MD, Taipei, Taiwan 

Chung-Chien Lee, MD 

Carpal tunnel syndrome (CTS) caused by space occupying lesion was 

a rare condition and more complicated than idiopathic CTS. From 

January 1999 to December 2008, 764 cases received surgery under 

the diagnosis of CTS. In these, 25 patients who underwent operation 

for CTS caused by space occupying lesions were studied. CTS was 

diagnosed by clinical examinations and electrodiagnostic studies. 

The average age was 57.28 years (range: 26 to 94 years old). In the 

patients with local swelling or palpable mass, ultrasonography or 

magnetic resonance imaging (MRI) were taken. All the patients were 

treated by conventional open release of transverse carpal ligament 

and removal of the lesions. The pathological reports included 

Tophaceous gout in 10 cases, tenosynovitis in seven cases and 

tumors in eight cases. All the patients have CTS caused by gout were 

male. For the patients with tumor, there were median nerve neuroma 

in two cases, ganglion cyst in two cases, lipoma in three cases and 

fibroma of tendon sheath in one case. The neurological symptoms 

subsided after operation in all cases. In the patients with gout, one 

had wound infection and another one had recurrence. Carpal tunnel 

syndrome caused by space occupying lesion was a rare condition 

and more complicated than idiopathic CTS. Misdiagnosis may lead 

to inadequate treatment and the symptoms may remain. 

pApeR No. 275 

Thumb Metacarpophalangeal Joint Capsulodesis as an 

Adjunct to Basal Joint Arthroplasty 

Dima Raskolnikov, BS, New York, NY 

Neil White, MD, FRCSC, Edinburgh, United Kingdom 

Ioannis Zouzias, MD, New York, NY 

Eric F Swart, MD, New York, NY 

Melvin Paul Rosenwasser, MD, New York, NY 

Patients with advanced basal joint arthritis may suffer from 

a characteristic hyperextension deformity of their thumb 

604 

metacarpophalangeal (MCP) joints. The purpose of this study is to 

provide long-term follow-up on a group of patients who were treated 

with a novel technique of thumb MCP joint capsulodesis as an 

adjunct to basal joint arthroplasty. We retrospectively evaluated 14 

patients who had received basal joint interposition arthroplasty with 

concomitant MCP capsulodesis. Objective evaluation included thumb 

range of motion, grip strength and key pinch strength. Subjective 

evaluation included patient-based scores on the Disabilities of the 

Arm, Shoulder and Hand (DASH) questionnaire, visual analog scale 

(VAS) pain scores and a study-specific questionnaire. At an average 

of 5.43 years after surgery (range, 2.2 to 11.5 years), average MCP 

hyperextension was 15.0°, with all but three patients hyperextending 

to less than 20°. Thirteen of 14 patients were able to oppose their 

thumbs against the distal end of the fifth metacarpal. Average 

grip and pinch strength were 23.4 kg and 3.5 kg, respectively. The 

average DASH score was 10.3. Patients reported minimal pain and 

were all satisfied with the procedure. No complications or revision 

procedures were reported. Basal joint arthroplasty combined with 

the described volar plate step-cut technique for thumb MCP joint 

capsulodesis provides excellent long-term results for patients with 

basal joint arthritis and severe MCP hyperextension, although 

precise indications for the procedure remain poorly defined. This 

new procedure is safe and has a low complication profile. 

pApeR No. 276 

Do Intercarpal Ligament Injuries Predict Outcome After 

Distal Radius Fractures? 

Peter Tang, MD, New York, NY 

Anthony Ding, MD, San Francisco, CA 


Despite improvements in operative fixation of distal radius fractures, 

outcomes remain variable and difficult to predict. The advent of 

wrist arthroscopy as a diagnostic modality has demonstrated that 

intercarpal ligament injuries in patients with distal radius fractures 

are more common than were initially suspected. To date, no studies 

have evaluated the relationship between ligament injuries and long 

term patient-based outcomes. Twenty-seven patients with distal 

radius fractures were enrolled in this prospective prognostic study. 

At the time of initial fracture surgery, patients were arthroscopically 

evaluated for injuries to the scapholunate interosseous ligament 

(SLIL), triangular fibrocartilaginous cartilage complex (TFCC) 

or to the articular cartilage. One year after surgery, patients were 

assessed using the Disabilities of the Arm, Shoulder, and Hand 

(DASH) questionnaire, pain visual analog scale (VAS), as well as 

using objective physical exam parameters including range of motion 

and grip strength. A multivariate linear regression model was then 

constructed to evaluate the effect of these ligament injuries on the 

DASH, pain, range of motion and grip strength. A total of 47% of 

patients had SLIL injuries, 53% had TFCC injuries and 40% had 

injuries to the articular cartilage. Controlling for AO fracture type, 

none of these injury factors were significant predictors of DASH 

scores at one year. None of them correlated with VAS scores or 

physical exam parameters as well. Intercarpal ligament injuries and 

cartilage damage are common in patients with distal radius fractures, 

although they do not predict outcome at one year. 



PaPers, Posters & scientific exhibits HANd & WRist

pApeR No. 277 

Thumb Deformity In Patients With Rheumatoid 

Arthritis, A Five-Year Follow-Up 

Shogo Toyama, Kyoto, Japan 

Daisaku Tokunaga, MD, Kyoto, Japan 

Tatsuya Hojo 

Hiroyoshi Fujiwara, MD, Kyoto, Japan 

Ryo Oda, MD, Kawaramachi-Hirokoji 

Kiamigyo-ku, Kyoto, Japan 

Hiroaki Kobashi, Kyoto, Japan 

Kan Imai, MD 

Hisashi Okumura, MD, Kyoto City, Japan 

Toshikazu Kubo, MD, Kyoto, Japan 

The hands and fingers are affected at high incidence rate in patients 

with rheumatoid arthritis (RA). Deformity of thumb occurs in high 

incidence, resulting in functional deficiency of hand function. We 

studied the frequency, functional deficiency and a successive changes 

regarding various types of thumb deformities in RA. We assessed 67 

patients, 134 hands of RA with deformity of fingers functionally in 

our institution in 2004 and 2009. The average age at the baseline 

was 62 (35-79) years old and the duration of the disease averaged 19 

(4-41) years. Fifty patients were able to follow up, five hands of five 

patients that had surgical procedures were excluded from the study. 

Thus, 95 hands of 50 subjects were studied. The average age was 60.9 

(39-79) years old and the duration of the disease at the baseline 

averaged 17.9 (4-41) years. Disease activity of the rheumatoid 

arthritis was categorized using DAS score, showing low disease 

activity in 21 cases, moderate in 18 cases and high in six cases. The 

classifications of thumb deformities were carefully determined using 

classification by Stein. Hand evaluations were made using the total 

opposition test of the modified Kapandji index (MKI), scores of 

activities of daily living (ADL) by Japanese Society for Surgery of the 

Hand (JSSH) and the joint space narrowing score on plain X-rays 

of the hand. One finger after desis of IPJ of the thumb before the 

time of baseline was excluded. Deformities of thumb at the baseline 

were type I: 50.0%, type II: 6.4%, type III: 2.1, type IV: 3.2%, type V: 

0%, type VI: 8.5%, type MP: 6.4% and type CM: 9.6%. Deformities 

of thumb at five-year follow up were type I: 46.8%, type II: 8.5%, 

type III: 4.2%, type IV: 4.2%, type V: 0%, type VI: 8.5%, type MP: 

8.5% and type CM: 8.5%. The total opposition test of MKI (10pt 

maximum) was 5.8 pt at the baseline and worsened significantly 

(p

median nerve neurectomy appears a useful adjunct to STP with ulnar 

motor branch neurectomy and wrist fusion in the prevention of an 

intrinsic TIP deformity in the non-functional hand. 

pApeR No. 280 

Operative Treatment for Painful Osteoarthritis of the 

DIP Joint 

Osami Suzuki, MD, Hiroshima, Japan 

Toru Sunagawa, Hiroshima, Japan 

Yuko Nakashima, MD 

Rikuo Shinomiya, MD, Hiroshima-Shi, Japan 

Mitsuo Ochi, MD, PhD, Hiroshima, Japan 

Arthrodesis of the distal interphalangeal (DIP) joint can be a reliable 

method to treat painful osteoarthritis. However, it’s considered 

that complete loss of DIP motion may limit activity of daily living 

(ADL). We performed the combination of osteophytectomy and 

synovectomy of the joint from 1995 for alleviating pain while 

preserving motion of the joint. The purpose of this study is to 

report the clinical outcome of this procedure. Fifty-two joints of 37 

patients (33 women and four men, mean age 54 years) with painful 

osteoarthritis of the finger DIP joints and the thumb interphalangeal 

(IP) joints were enrolled in this study. Forty-five joints were treated by 

the combination while seven were treated by arthrodesis. We assessed 

the clinical outcome subjectively and objectively at an average of 3.2 

years after surgery. In cases of arthrodesis, there were no complaints 

about pain and appearance of DIP joints, however most of patients 

felt some functional disability when they used the involved hand. 

Meanwhile, preoperative pain completely disappeared in 70% of 

joints by the combination, and only one case needed arthrodesis 

because of persisting pain. Extension lag by this procedure averaged 

11 degrees and the range of motion of the joint was 34 degrees on an 

average. About 70% of DIP joints recovered satisfying appearance and 

function. The combination of osteophytectomy and synovectomy 

has more advantage for improving the ADL than arthrodesis. This 

procedure can be one of the effective treatments for the painful 

osteoarthritis of DIP joint. 

pApeR No. 281 

Early Outcomes Of Saddle Pyrolytic Carbon 

Hemiarthroplasty For Trapeziometacarpal Arthritis 

Saurabh Odak, MBBS, MRCS 

Ann Birch, MD, Wigan, United Kingdom 

Krishna Swamy, MBBS, FRCS 

Ian A Trail, MD, Lancs, United Kingdom 

Trapeziometacarpal (TMC) joint arthritis is a frequently encountered 

painful and disabling condition predominantly affecting females. 

Arthroplasty of the trapeziometacarpal joint is a well described 

surgical treatment. We present our early results with a minimum of 

one-year follow up of carbon hemiarthroplasty performed for the 

treatment of TMC joint arthritis in our center. Twenty-two thumbs 

in 22 patients (18 females, four males) with a mean age of 53 

years (range 47-76 years) were assessed. Indications for the surgery 

were primary osteoarthritis in 20, rheumatoid arthritis in one and 

seronegative inflammatory arthritis in one patient. A total of 19 

patients were available for follow up. The mean follow-up period 

was 59.73 months (range 12-91 months). There was a significant 

improvement noted in pain scores post-operatively (p value = 0.05). 

However no such improvement was noted in range of movements, 

grip strength, apposition (key holding) strength and tripod strength. 

Radiologically the implant was noted to be subluxed in four patients; 

however none of them were symptomatic. Five patients (26%) needed 

606 

a revision procedure at a mean of six months (range 2-11 months). 

Of these, three had persistent symptoms, one developed Complex 

Regional Pain Syndrome (CRPS) and in one patient the implant 

was noted to be persistently unstable after sustaining traumatic 

dislocation. Pyrolytic carbon has a certain role for the treatment of 

TMC joint arthritis. The high revision rate noted in our series could 

be accountable to the pre-operative patient selection and surgical 

technique. We did not encounter any implant associated problems. 

Majority of the patients in the non-revised group were satisfied with 

this procedure. A further long-term follow-up study would be more 

conclusive. 

pApeR No. 282 

Neglected Bennett’s Fracture Dislocation in Manual 

Laborers Managed by K-wires and Tension Bands 

Mostafa Mahmoud, MD, Cairo, Egypt 

Sherif El Shafie, MB BCh, Cairo, Egypt 

During open procedures of resection arthroplasty and arthrodesis of 

the thumb, it was observed that most of the metacarpo-phalangeal 

articular surface is intact. It was also noted that a degree of weakness 

and a limited range of motion were reported with such procedures 

respectively. This case series evaluates the results of open reduction 

and internal fixation using K-wires and tension bands with 

neglected Bennett’s fracture dislocation, as an alternative to resection 

arthroplasty and arthrodesis that result in a degree of weakness and a 

limited range of motion respectively. Ten patients with more than 12 

weeks duration, average 16 weeks, Bennett’s fracture dislocation were 

evaluated for their range of motion, pain, grip strength and pinch 

strength. Arthrosis and subluxution were evaluated by radiographs 

and CT. All patients were males with an average age of 30.2 years 

(range 20-44). Through a radial approach, fixation was performed 

using K-wires and tension band after undoing the fracture. Excess 

callus was used as an insitu graft for the metaphyseal defect. Mean 

follow up period was 16 months (12-36). Union was achieved in all 

10 patients and nine patients returned to their previous occupation. 

Visual analog score improved from 6 to 2. Palmar abduction 

improved from 15° to 40°, and radial abduction improved from 

22° to 39° (25°-47°). At final follow up, radiographs showed 

marginal osteophyte formation in two patients. Neglected Bennett’s 

fracture dislocation can be effectively managed by open reduction 

and internal fixation using K-wires and tension band, without 

compromise in strength or range of motion. 

pApeR No. 283 

Results Of Palmaris Longus Interposition Tendon 

Grafting For Neglected Extensor Tendon Injuries 

Prakash Kotwal, MS 


Neglected extensor tendon injuries are difficult to treat. The purpose 

of our study is to evaluate the clinical and functional outcome of 

palmaris longus interposition tendon grafting for neglected extensor 

tendon injuries. Between Jan. 2004 to Dec. 2008, 56 neglected 

extensor tendon injuries (12 in zone 5, 26 in zone 6, 18 in zone 

7) were reconstructed using autogenous palmaris longus tendon as 

a free interposition graft. The mean duration since injury was 4.1 

months. In each case, the evaluation was based on both subjective 

and objective criteria, including the range of MCP joint flexion 

after surgery, the extension lag at the Metacarpo-phalangeal joint 

before and after surgery, and the ability of the patient to work. The 

average of follow-up was 14.1 months (range, 12 to 32 months). 

The average range of metacarpophalangeal (MCP) joint flexion after 

reconstruction was 68 degrees. The extension lag at the metacarpo- 




phalangeal joint significantly improved from a preoperative mean of 

36 degrees (range, 25 degrees - 60 degrees) to a postoperative mean 

of 14 degrees (range, 0 degrees - 25 degrees). Subjectively all patients 

were satisfied with the clinical results, and achieved a return to their 

level of ability before tendon rupture. One patient sustained rupture 

of graft and was re-reconstructed using opposite side palmaris 

longus interposition graft. Extensor tendon reconstruction using 

autogenous palmaris longus tendon as a free interposition graft 

is a viable and effective option to treat neglected extensor tendon 

injuries with good clinical functional result. 

pApeR No. 284 

The Under-Recognition of Radiocarpal Dislocations 

Asif Ilyas, MD, Wayne, PA 

Chris Williamson, MD, Philadelphia, PA 

Chaitanya S Mudgal, MD, Boston, MA 

Radiocarpal dislocations are uncommon injuries and their incidence 

often quoted to be approximately 0.2% of all wrist injuries. The 

diagnosis of a radiocarpal dislocation can be difficult to make and it 

is often missed. Accurate diagnosis is needed for proper treatment. 

We hypothesized that (1) the incidence of radiocarpal dislocations is 

higher than previously reported, and (2) that an accurate diagnosis is 

not always made. Radiographs were reviewed of all patients presenting 

to an academic trauma center with a diagnosis of a distal radius 

fracture or wrist dislocation over a five-year period. A radiocarpal 

dislocation was defined as a dislocation or subluxation of the entire 

carpus of the hand relative to the distal radius. The injury could be 

entirely soft tissue or be associated with a marginal rim or styloid 

fracture. Radiology reports were reviewed for all cases for accuracy 

of identification. In addition, patient demographics and risk factors 

were also assessed. Over the study period, radiocarpal dislocations 

represented 2.7% of all wrist fractures and dislocations. The average 

patient age was 34.5 years and 92% were male. All were the result 

of high energy injuries. An associated fracture was identified in 10 

cases while two were strictly soft tissue injuries. A dorsal-directed 

dislocation was identified in 83% of cases. The dislocation was 

accurately diagnosed in 58% of cases by radiology report. We found 

radiocarpal dislocations to be much more common than expected. 

They are most often dorsally directed and associated with a fracture. 

Greater vigilance is needed to avoid misdiagnosis. These injuries 

occur most often in young males and are usually the result of high 

energy injuries. 

pApeR No. 285 

Immobilization in Supination Following Surgical 

Treatment of Galeazzi Fractures: Is it Necessary? 

Min Jung Park, MD, MSc, Philadelphia, PA 

Nick D Pappas, III MD, Philadelphia, PA 

David J Bozentka, MD, Philadelphia, PA 

The goal of this study was to investigate whether immobilization in 

supination is necessary to prevent recurrent distal radio-ulnar joint 

(DRUJ) instability in patients with Galeazzi fracture-dislocations 

whose DRUJ stabilizes immediately following operative fixation 

of the radius. We performed a retrospective chart review of 13 

consecutive patients who were immobilized in either supination 

or a neutral position following surgical treatment of a Galeazzi 

fracture-dislocation in which the DRUJ was noted to be stable 

immediately after fixation of the radius. Group I consisted of seven 

patients who were immobilized in supination for a period of four 

weeks, while Group II, six patients immobilized in neutral for two 

weeks. Patients were followed for an average of 18 weeks postoperatively. 

No significant difference was noted between the two 

607 

groups with respect to age, medical co-morbidities, hand dominance 

or worker’s compensation status. None of the patients in either 

group demonstrated DRUJ instability during the follow up period 

or required additional surgeries. At final follow up, patients in the 

two groups had comparable forearm pronation and supination 

(p = 0.93). This study demonstrates that there is no clear benefit 

from immobilizing patients in supination for Galeazzi fracturedislocations 

who demonstrate a stable DRUJ following operative 

fixation of the radius. Limited immobilization for two weeks in 

neutral does not appear to predispose these patients to post-op 

DRUJ instability. 

pApeR No. 331 

Radiographic Outcomes of Volar Locked Plating for 

Distal Radius Fractures 

Megan Mignemi, MD, Nashville, TN 

Ian R Byram, MD, Nashville, TN 

Carmen Wolfe, BA 

Elizabeth A Koehler, MS 

John J Block, MD, Nashville, TN 

Martin I Jordanov, MD, Nashville, TN 

Donald H Lee, MD, Nashville, TN 

Volar locked plating (VLP) has become the standard of care for 

many types of distal radius fractures. The purpose of this study is to 

assess the ability of VLP to restore normal radiographic parameters 

for articular step-off, volar tilt, radial inclination, ulnar variance 

and radial height. A retrospective review was performed of 186 

consecutive patients who underwent VLP with a single plate for distal 

radius fractures over a three-year period by three senior surgeons. 

Anteroposterior and lateral radiographs from the time of injury, 

post-reduction, initial post-operative follow up and minimum sixweek 

post-operative follow up were independently reviewed by two 

musculoskeletal radiologists and a senior orthopaedic resident. 

Measurements for volar tilt, radial inclination, ulnar variance and 

radial height were recorded, and each fracture was classified according 

to the AO and Frykman systems. Articular step-off was categorized as 

either greater than or equal to 2 mm or less than 2 mm. Logistic 

regression was used to determine the association between return to 

historical anatomic norms and fracture type, age, gender and preoperative 

measurements. Articular congruence of less than 2 mm 

was observed in 91.9% of patients after VLP. Normal volar tilt (11.0° 

+/- 4.6°) was restored in 45.9% of patients with an average of 6.7°. 

Normal radial inclination (22.0° +/- 2.5°) was achieved in 43.8% of 

patients, with an average of 21.2°. Normal ulnar variance (0.7mm 

+/- 1.5mm) was achieved in 53.0% of patients, with an average of 

0.4 mm. Normal radial height (14.0mm +/- 1.0mm) was restored 

in 14.1% of patients, with an average of 10.8 mm. Correction of 

ulnar variance was significantly associated with fracture type 

according to Frykman classification (p=0.021), and restoration of 

volar tilt was significantly associated with fracture type according to 

AO classification (p=0.019). VLP for distal radius fractures corrects 

articular step-off to less than 2 mm but is less likely to restore normal 

radiographic measurements for volar tilit, radial inclination, ulnar 

variance and radial height. 




pApeR No. 332 

Supination, Pain, and Strength are Important 

Determinants of Disability After Distal Radius Fracture 


Aldo Riesgo, BS 

Kate W Nellans, MD, New York, NY 

Dima Raskolnikov, BS, New York, NY 

Melvin Paul Rosenwasser, MD, New York, NY 

Patients suffering from distal radius fractures often have variable 

outcomes, despite near-anatomic restoration of classically assessed 

radiographic parameters (volar tilt, ulnar variance, radial inclination). 

In these patients, the relationship between radiographic outcomes, 

objective exam-based parameters and patient-perceived disability 

remains unclear. Our group maintains a prospective observational 

registry of patients undergoing operative fixation of distal radius 

fractures. Radiographic assessment is performed and physical exam 

parameters measured at each visit, and patient-based outcomes are 

quantified with the Disabilities of the Arm, Shoulder, and Hand 

(DASH) questionnaire and pain visual analogue scale (VAS). A 

multi-variate linear regression model was constructed to evaluate 

the association of range of motion, grip strength and VAS score to 

the DASH score. Data from 190 patients at 611 total clinic visits were 

analyzed. Pain (p < .001), grip strength (p < .001) and supination (p 

< 0.01) were all significant predictors of the DASH, controlling for all 

other predictors. These three variables alone predict 56% of the DASH 

score. Flexion/extension, radial/ulnar deviation and pronation had 

no significant correlation to DASH scores. In addition, time since 

surgery was also not a significant predictor of DASH score. Pain, 

strength and supination are important determinants of patient-rated 

outcomes after distal radius fractures. Restoration of supination 

depends specifically on the anatomy of the distal radial-ulnar joint 

(DRUJ), a factor not encompassed in the classical radiographic 

parameters assessed after distal radius fractures. Future assessments 

of outcomes after distal radius fracture may benefit from a system 

that takes DRUJ anatomy into account. 

pApeR No. 333 

The Influence of Anatomic Reduction At One Year 

Following Intra-Articular Distal Radius Fractures 

Marc Joseph Richard, MD, Durham, NC 

David Simms Ruch, MD, Durham, NC 

Priyesh Patel, MD, Elgin, IL 

Periklis Papapetropoulos, MD, Pittsburgh, PA 

Robert J Medoff, MD, Kailua, HI 

Fraser J Leversedge, MD, Durham, NC 

Anatomic reduction and stabilization of the volar lunate facet 

fragment of multifragmentary intra-articular fractures of the distal 

radius is critical to achieve satisfactory functional and radiographic 

outcomes. We prospectively acquired data on 157 patients with AO 

type C3 distal radius fractures. All patients were treated with either 

external fixation or internal fixation using either a dorsal plate or 

a fixed angle volar plate. Patient data was collected at three, six 

and 12 months post surgical intervention including radiographic 

evaluation, range of motion, grip strength, Gartland and Werley 

scores and the DASH outcome score. Each clinical follow up included 

standard postero-anterior, lateral and inclined lateral radiographs. 

The radiographs were evaluated for the tear drop angle, volar tilt, 

radiolunate angle, carpal translation, articular step-off and articular 

gap. The palmar lunate facet was determined to be displaced if: 1) 

the posteroanterior radiograph demonstrated >2 mm of depression 

of the lunate facet relative to the radial styloid fragment, and relative 

608 

to a line parallel to the head of the ulna combined with 2) evidence 

of depression of the volar lip of the distal radius on the lateral and 

the inclined lateral view. Based on these radiographic parameters, 

two groups were designated with group I being patients with 

significant residual articular depression of the palmar lunate facet 

(>2 mm) and group II consisting of patients with less than 2 mm 

of articular depression. Group I contained 41 patients and Group 

II consisted of 116 patients. Descriptive statistics for all continuous 

variables were computed. For these variables, the significance of the 

difference in medians for Group I and Group II was assessed using 

the Wilcoxon rank sum test. Patients without displacement had a 

significantly higher median value of extension (65) than those with 

residual displacement (45) (p=0.002). Median supination for those 

without displacement (78) was significantly higher than for those 

with displacement (67) (p=0.004). Gartland and Werley scores for 

those with displacement were significantly higher than for those 

without displacement. Reduction of the palmar lunate facet correlates 

with improved clinical outcomes both at the radiocarpal joint and 

at the distal radial-ulnar joint, and impacts functional outcome as 

noted by improved Gartland and Werley scores at one year. While 

previous studies have reported the implications of the significance 

of the lunate facet of the distal radius, no published studies correlate 

the significance of the palmar lunate facet reduction to clinical and 

functional outcomes. 

pApeR No. 334 

Early Versus Late Motion Following Volar Plating of 

Distal Radius Fractures 

David G Dennison, MD, Rochester, MN 

Char Blanchard, Rochester, MN 

Bassem T Elhassan, MD, Rochester, MN 

Alexander Yong Shik Shin, MD, Rochester, MN 

Distal radius fractures are very common and the trend in fixation has 

included the use of locked volar plating. The amount of splinting 

that is required after surgery and the effect that splinting has upon 

the outcome of the wrist is not clear. Our aim was to compare the 

outcome (strength, motion and outcome scores) of patients treated 

with an early versus late motion protocol after volar plating. Thirtythree 

adult patients with distal radius fractures were prospectively 

and randomly enrolled into an early versus late motion study which 

included volar plating of a distal radius fracture. Early motion was 

defined as initiation of an active and passive motion protocol by 14 

days after surgery and delayed motion was initiated at five weeks. 

Fractures were defined as intra-articular and extra-articular, and 

those with, and without, ulnar styloid fracture. Volar plating was 

completed through an FCR approach in all cases. Outcome measures 

(Disabilities of the Arm, Shoulder and Hand - DASH/Patient Rated 

Wrist Evaluation - PRWE), motion (flexion-extension, radial-ulnar 

deviation, pronation-supination) and strength (appositional and 

oppositional pinch and grip) were measured through one year. Wrist 

motion and DASH and PRWE scores were all significantly different at 

six weeks (p

pApeR No. 335 

Bone Cement Augmentation After Volar Locking Plate 

For Distal Radius Fractures Of Elderly Patients 

Jae Kwang Kim, MD, Seoul, Republic of Korea 

Young Do Koh, MD, PhD, Yangcheongu, Seoul, Republic of Korea 

Seung Yup Lee, MD 

Jeong Suh Kim, MD, Seoul, Republic of Korea 

The purpose of this randomized study was to determine whether 

calcium phosphate bone cement (CPC) augmentation has any 

benefit over volar locking plate fixation alone in elderly (> 65 years) 

patients with an unstable distal radius fracture (DRF). Forth-eight 

patients (50 DRFs) were recruited for this study. Mean patient age 

was 73 years (range, 65 to 89). Surgical procedures were randomized 

between volar locking plate fixation alone (Group 1) and volar 

locking plate fixation with CPC injection (Group 2). The patients 

were assessed clinically at three and 12 months postoperatively. 

Clinical assessments included grip strength, wrist range of motion, 

wrist pain, modified Mayo wrist scores and disabilities of arm, 

shoulder and hand scores. Radiographic evaluations were performed 

immediately after surgery and one-year follow up visits, and degrees 

of radiographic reduction were assessed by measuring radial 

inclination, volar angulation and ulnar variance. The volar locking 

plate fixation (Group 1) and the volar locking plate fixation plus 

CPC (Group 2) groups were comparable with regard to age, gender, 

fracture type, injury mechanism and bone mineral density. No 

significant differences were observed between the groups in terms 

of clinical outcomes at three or 12-month follow ups. Furthermore, 

no significant inter-group differences were observed in terms of 

radiographic outcomes immediately after surgery or at one-year 

follow-up visits. Furthermore, no complication-related differences 

were observed. The calcium phosphate bone cement augmentation 

of metaphyseal defects after volar locking plate fixation was found 

to offer no benefit over volar locking plate fixation alone, even in 

elderly patients with an unstable distal radius fracture. 

pApeR No. 336 

Correction of Malunited Distal Radial Fractures Using 

Volar Locked Plates Without Bone Grafting 



Study the effectiveness of the use of volar locked plates in the 

correction of malunited fractures of the distal radius without the 

use of bone grafting, to achieve proper reduction, alignment and 

stability of the wrist joint. The study was performed on 30 wrists 

in 26 patients with dorsal malunited distal radius treated with fixed 

angle volar locked plate without bone grafting. Their mean age was 

35 years. Mean duration since fracture was 10 months. Twenty-two 

wrists in 19 patients were available for follow up with a mean follow 

up duration of 18 months. Union occurred in all patients. Mean 

radial inclination was restored from 2° to 18°. Mean radial height 

was restored from -4 mm to -1 mm. Dorsal tilt improved from 32° 

to 5°. Mean preoperative DASH score improved from 35 to 10, VAS 

improved from five to two, and grip strength from 75% to 90%. One 

patient suffered from transient median nerve neuritis that resolved 

within three months, one patient suffered from reflex sympathetic 

dystrophy which was resolved by aggressive physiotherapy and 

residual ulnar side wrist pain requiring ulnar shortening was 

encountered in two patients. Fixation with a volar locked plate is an 

effective method for the management of malunited fractures of the 

distal radius and bone grafting is not needed. 

609 

pApeR No. 337 

Distal Scaphoid Resection for Arthritis Secondary to 

Scaphoid Nonunion: A Twenty Year Experience 

Matthew M Malerich, MD, Bakersfield, CA 

Louis W Catalano III, MD, New York, NY 

The results of distal scaphoid resection arthroplasty for the treatment 

of degenerative arthritis secondary to scaphoid nonunion were 

presented at the 1995 American Society for Surgery of the Hand 

meeting. At that time, the average follow up was 49 months and the 

audience requested follow up data. The objective of this study was to 

demonstrate that satisfactory results would be maintained at longer 

follow up. Eighteen of the original 19 patients were re-reviewed at 

follow up between 11-21 years with a mean of 15 years. Repeat followup 

examinations and radiographs were performed on all patients at 

follow up. Of the 18 patients, 17 remain satisfied with the procedure. 

Range of motion was maintained at the same degree compared to 

the 1995 study. The flexion-extension arc was 90 degrees; radialulnar 

deviation arc was 39 degrees. Grip strength decreased 20% 

but did so symmetrically. No change in the radiolunate joint angle 

or revised carpal height ratio was documented. Approximately onethird 

of patients did have some degree of capitolunate joint space 

narrowing that was new and asymptomatic. Radiolunate and residual 

radial scaphoid joints did not develop arthrosis. One patient from 

the study underwent a proximal row carpectomy. Long-term results 

are good. A total of 94% of patients remained satisfied. Some 30% 

of patients developed capitolunate joint space narrowing that was 

asymptomatic. No further wrist collapse occurred. No additional 

joints developed arthritis. 

pApeR No. 338 

Percutaneous Fixation of Scaphoid Nonunion Without 

Using Bone Graft 



Scaphoid nonunions with extensive bone resorption at the nonunion 

site were traditionally indicated for open bone grafting and internal 

fixation. We study the feasibility of isolated percutaneous fixation 

of the scaphoid without bone grafting in a series of established 

nondisplaced nonunions with substantial gaps. A consecutive 

series of 30 patients, 28 males and two females with nondisplaced 

established nonunion of the scaphoid and extensive resorption were 

treated by rigid fixation alone without bone grafting with a headless 

cannulated screw inserted by a volar percutaneous technique. Union 

was achieved in all patients at an average of 11.7 weeks as evidenced 

radiologically. Patients were followed up for an average of 24 months 

and at final follow up clinical evaluation revealed less pain on wrist 

motion and the mean visual analogue score improved from 4 to 1. 

Mayo Modified Wrist score was poor in 16, fair in 12 and good in 

two patients; this improved to 26 excellent and four good. Selected 

nondisplaced scaphoid nonunions with extensive resorption and 

gapping of 2 mm or more possess the biological ability, but lack the 

mechanical stability, for bone healing to proceed without the need 

for bone graft, which can be achieved percutaneously. 

pApeR No. 339 

Bicolumnar Fusion for Scaphoid Nonunion Advanced 

Collapse Without Bone Graft 



Various modalities have been previously used in the management of 

scaphoid nonunion advanced collapse (SNAC) to provide pain relief 




yet preserving wrist function. Based on the carpal biomechanical 

concepts, the motion between the capitate and the hamate is negligible 

and the motion between the lunate and the triquetrium does not 

occur when the midcarpal movements are blocked, we assumed that 

fusing the capitohamate and the lunotriquetral joints unnecessary. 

We study the effectiveness of fusing only the joints as a salvage 

procedure for SNAC wrists. The procedure was performed on seven 

patients, six males and one female with an average age of 36 years 

(range 30-56) and an average duration of symptoms 15 years (range 

5-20). Capitolunate and triquetrohamate joints were fused using 

screws without the use of bone grafts. Below elbow cast was applied 

for eight-12 weeks post-operatively Union occurred in all cases, 

average visual analogue score improved from 4 to 1, postoperative 

Mayo wrist score was excellent in five and good in two patients. Six 

patients returned to their previous occupations. Bicolumnar fusion 

without fusing the capitolunate and the triquetrohamate joint is an 

effective salvage operation of SNAC wrist providing pain relief and 

preservation of wrist function. 

pApeR No. 340 

Staged Reduction Of Neglected Transscaphoid 

Perilunate Dislocation: A Report Of 16 Cases 



Transscaphoid perilunate dislocation is a rare injury and therefore it 

is easily missed at the initial treatment. Once ignored, an alternative 

treatment such as proximal row carpectomy is indicated, but 

surgical outcome is not as good as that of an early reduction. Also 

late reduction (>3 months) is not possible and needs extensive 

dissection. We present an alternative technique of staged reduction 

with better outcome. Sixteen cases (14 males and two females) 

with neglected transscaphoid perilunate dislocation (>3 month 

old) were treated with staged reduction. In first stage an external 

fixator was applied across the wrist and distraction was done at 1 

mm/day. Second surgery was done through dorsal approach and we 

were able to reduce all the fractures and dislocations. Herbert screws 

and K wires were used for fixation. The mean duration between two 

surgeries was 2.4 weeks (range two to four weeks). Thirteen cases 

had excellent results, one had fair result. Two patients developed 

reflex sympathetic dystrophy and had poor results. Staged reduction 

should be considered for neglected transscaphoid perilunate 

dislocations. If properly executed, a good functional pain free range 

of motion is the usual outcome. 

pApeR No. 341 

Percutaneous transtrapezial approach to scaphoid 

fractures does not lead to ST degeneration 

Roger P van Riet, MD, Wilrijk, Belgium 

Ghislain Geurts, MD 

Geert Meermans, MD, Berchem, Belgium 

Frederik Verstreken, MD, Deurne, Belgium 

Biomechanical studies have shown that a long, centrally placed 

screw is favorable in scaphoid fracture fixation. A volar percutaneous 

transtrapezial approach was developed to facilitate central screw 

placement. The purpose of this study was to evaluate radiographic 

changes at the scaphotrapezial (ST) joint at long term follow up in 

patients where this approach was used. Results were graded with 

the visual analogue scale (VAS) and modified Mayo wrist score. 

Radiographs of both hands, comprising an anteroposterior, lateral, 

and 45 degrees pronated oblique view were obtained. Degenerative 

changes at the ST joint were staged according to the modified Eaton 

& Glickel classification. Thirty-four patients with an average age of 34 

610 

years were followed at a mean of 6.1 years (four to nine). Union was 

obtained in all at an average time of 6.4 weeks (six to 10). There were 

no significant differences in VAS score and range of motion, between 

the operated and nonoperated side (p>0.05). The mean Mayo wrist 

score was 93 (80-100). Three patients showed stage 2 osteoarthritis 

of the ST-joint. In two of these, stage 2 osteoarthritis was found in 

both the injured and uninjured side. One patient had asymptomatic 

stage 2 osteoarthritic changes at the injured side. The advantages of 

the volar percutaneous transtrapezial approach include central screw 

placement, without the need for manipulation of the wrist. From 

the present study it can be concluded that the volar percutaneous 

transtrapezial approach to fix scaphoid fractures does not lead to 

significant radiographic degenerative changes in the ST joint, at a 

follow up of more than six years. 

pApeR No. 342 

Traumatic Ulnar Translocation of the Carpus: Early 

Diagnosis and Treatment 

John C Berschback, MD, Chicago, IL 

David Mark Kalainov, MD, Chicago, IL 

Sohail Husain, MD, Salem, NH 

Thomas A Wiedrich, MD, Chicago, IL 

Mark S Cohen, MD, Chicago, IL 

Daniel J Nagle, MD, Chicago, IL 

Ulnar translocation of the carpus occurs when the entire carpus 

translates medially along the distal radius. The injury is rare; 

consequently, the diagnosis may be unintentionally missed or 

delayed. We present 11 cases of posttraumatic ulnar translocation 

of the carpus and review our results following early recognition and 

treatment. Eleven cases (10 patients) of traumatic ulnar translocation 

of the carpus were identified: seven were ligamentous injuries alone 

and four were ligamentous injuries in association with fractures. 

Treatment included wrist immobilization (one), ligament repair 

(five), fracture fixation alone or in combination with ligament repair 

(three), radioscapholunate fusion (one) and diagnostic arthroscopy 

(one). Six patients were examined at a mean of 5.5 years after injury. 

Information for four others was obtained from medical records at 

a mean of 11 months following injury. Intercarpal alignment and 

post traumatic arthritis were assessed using established radiographic 

criteria. Eight of 10 patients described intermittent wrist pain and all 

patients demonstrated loss of normal wrist flexion and/or extension 

at final assessment. A 3 mm scapholunate gap was measured 

in two cases, and ulnar translocation of the carpus was evident 

in all patients. Degenerative arthritis involving the radiocarpal 

articulation developed in 45% of injured wrists. Posttraumatic ulnar 

translocation of the carpus can result from ligamentous injury alone 

or in association with fracture. Restricted wrist motion is expected, 

intermittent wrist pain may persist and degenerative arthritis of the 

radiocarpal interval may develop. Early ligament or fracture repair 

does not assure restoration of normal radiocarpal alignment. 

pApeR No. 343 

Long Term Outcomes Of Ulnar Head Prosthetic 

Replacement 

Sanjeev Kakar, MD, Rochester, MN 

Russell P Swann, MD, Rochester, MN 

Kevin I Perry, MD, Rochester, MN 

Alexander Yong Shik Shin, MD, Rochester, MN 

Steven L Moran, MD, Rochester, MN 

Hypothesis: Ulnar head endoprostheses restore stability and 

functionality to the upper limb after degenerative joint disease 




or resection arthroplasty of the distal radioulnar joint (DRUJ). A 

retrospective review was conducted analyzing the outcome of all 

ulnar head prosthesis implanted within our institution over a 10-year 

period. All patients presented complaining of pain and functional 

disability due to instability or arthrosis of the DRUJ. Standardized 

preoperative and postoperative assessments included a patient rated 

pain score, forearm range of motion, grip strength and Mayo wrist 

score. Preoperative and postoperative radiographs were examined to 

determine whether implant survival was associated with patient pre 

and postoperative characteristics. Sixty-nine patients were followed 

for a median of 49 months (range: 16 to 126 months). Eighty-nine 

percent of prosthesis were uncemented. Pain scores decreased by a 

mean of 2.2 (± 1.8) points, and Mayo wrist scores improved a mean 

of 26 (±13) points after surgery. Mean grip strength improved by 2 (± 

11) Kg from preoperative measurements. There were no statistically 

significant differences with respect to pre and postoperative wrist 

and forearm range of motion. Kaplan-Meier analysis demonstrated 

81% survival at six years. Distal ulna arthroplasty restored stability 

and function to patients with DRUJ impingement or arthrosis. 

Thirty-two percent of patients, however, required additional surgical 

procedures after primary ulnar endoprosthesis placement. 

pApeR No. 344 

Scaphoid Hemi-Resection & Arthrodesis of the Radio- 

Carpal Joint for Isolated Radio-Carpal Arthritis 

William H Seitz Jr, MD, Cleveland, OH 

Recessed arthrodesis of the radiocarpal joint with distal scaphoid 

hemiresection can reduce pain and provide functional motion 

through the mid carpal joint. Twenty-four patients with radiocarpal 

arthritis (eight patients following failed treatment of complex distal 

radius fractures, eight patients with scapholunate advanced collapse, 

four patients with scaphoid nonunion with advanced collapse 

and four patients following failure of treatment for transcaphoid 

perilunate fracture dislocation) were treated with a procedure 

to recess the lunate and proximal pole of scaphoid into the 

metaphyseal bone of the distal radius, resection of the distal. Onehalf 

of the scaphoid was also performed to allow enhanced motion 

of the capitate head within the mid carpal joint as a ‘universal joint.’ 

Fixation of the lunate and proximal scaphoid was achieved through 

flexibile tension plates. Controlled early active motion was begun 

one week after surgery (patients have been followed for an average 

of 3.8 years, range two to five years). All 24 patients developed a 

stable union at the arthrodesis site. None had hardware problems 

and there were no infections. Range of motion increased from an 

average preoperative total arc of flexion-extension of 32° to a total 

arc of flexion extension of 68° (range 42° to 110°). Pain ratings 

on a visual analog scale decreased from an average of 8.7 to 1.2. 

Twenty-two of 24 patients demonstrated a significant increased 

ability in their activities of daily living. Of the 10 patients who had 

been gainfully employed prior to surgery, nine had returned to 

work at their regular job. Patients who participated in recreational 

activities and had been prevented from doing so prior to surgery 

(tennis, golf, fishing, bowling) were able to resume their recreational 

athletic activities. One patient had persistent stiffness and was not 

pleased with his limited motion but had significant pain relief. One 

patient developed mid carpal arthritis and was converted to a total 

wrist arthroplasty. Radiographic analysis has shown deterioration of 

the mid carpal articular surfaces in only this one patient. Scaphoid 

hemiresection and limited arthrodesis of the radio-carpal joint is a 

viable motion sparing procedure for isolated radiocarpal arthritis. 

Although there are limitations in the total degree of movement, the 

motion which persists is functional, pain relief has been substantial 

and the short term (two to five year) follow up suggests minimal 

611 

deterioration. This procedure is technically straight forward and 

appears to be a viable alternative to total wrist arthrodesis when 

the mid carpal joint is reasonably spared. Revision to total wrist 

arthroplasty remains a viable salvageable procedure. The key to 

enhanced motion through the mid carpal joint is resection of the 

distal one-half of the scaphoid. 

pApeR No. 345 

Modified Sauve-Kapandji Procedure for Rheumatoid 

Wrist: Results of Follow up for More Than 5 Years 

Akira Kawabata, MD, Osaka, Japan 

Hideki Tsuboi, MD 

Takeshi Egi, MD, Nishinomiya, Japan 

Kenrin Shi, MD, Osaka, Japan 

Satoru Fujita, MD, Takarazuka, Japan 

Hideo Hashimoto, MD 

Eiji Takeuchi, MD, Osaka, Japan 

Susumu Saito, MD, Toyonaka, Japan 

Kazuhiro Masada, MD, Osaka, Japan 

We report the results after more than five years of follow up 

of rheumatoid arthritis patients with distal radioulnar joint 

abnormalities who underwent the modified Sauvé-Kapandji 

procedure. This procedure involves resecting the distal part of the 

ulna, rotating the resected portion by 90° and inserting it into 

the distal part of the radius. We followed 27 patients (32 wrists; 

mean age at operation, 59.7 years) for more than five years (mean 

follow-up period, 92 months). We assessed the pain, grip strength 

and range of wrist motion. The carpal height ratio (CHR), carpal 

translation index (CTI) and palmar carpal subluxation ratio (PCSR) 

were calculated from the radiographs. The wrist pain had reduced in 

all cases. The mean range of wrist motion was as follows: extension, 

flexion, pronation and supination of 39°, 37°, 78° and 67° at 

preoperative stage and 40°, 23°, 86° and 85° at final follow up, 

respectively. The average grip strengths at preoperative stage and final 

follow up were 95 mmHg and 87 mmHg, respectively. Preoperative 

radiography showed that CHR, CTI and PCSR were 0.45, 0.32 and 

0.23, respectively; at the final follow up, they were 0.44, 0.34 and 

0.25, respectively. Statistically, pronation and supination increased 

significantly, while wrist flexion decreased. Other parameters were 

not significantly different. We have previously reported that this 

procedure ensured pain reduction, improvement in forearm rotation 

and prevention of ulnar translation of the carpal bones after a mean 

postoperative follow up of 48 months. These improvements were 

maintained even five years after surgery. 

pApeR No. 556 

Biomechanical Evidence For Immediate Mobilization of 

the Brachioradialis After Tendon Transfer 

Jan Friden, MD, PhD, Goteborg, Sweden 

Richard L Lieber, PhD, La Jolla, CA 

Matthew Charles Shillito, MD, San Diego, CA 

Samuel R Ward, PhD, La Jolla, CA 

Brachioradialis (BR)-to-flexor pollicis longus (FPL) tendon transfer is 

often used to restore key pinch after cervical spinal cord injury. Current 

postoperative recommendations include elbow immobilization in a 

flexed position to protect the BR-FPL anastomosis. The purpose of 

this study was to measure the BR-FPL tendon tension across a range 

of wrist and elbow joint angles to determine its acute vulnerability 

to joint motion. BR-to-FPL tendon transfers were performed on 

fresh frozen cadaveric arms (n=8) and the BR-FPL tendon was 

instrumented with a buckle transducer. Arms were ranged over four 




wrist angles from 45° of flexion to 45° of extension and eight elbow 

angles from 90° of flexion to full extension, measuring tension in 

the BR-FPL anastomosis at each angle. Subsequently, the BR-FPL 

tendon constructs were elongated to failure. Over the normal wrist 

and elbow range of motion, BR-FPL tendon tension was under 20 N. 

Two-way ANOVA with repeated measures revealed a significant effect 

of wrist joint angle (p

examined, 13 patients had normal thumb ROM, average pinch 

strength was 7 lbs for the affected hand and 9 lbs for the unaffected 

contralateral hand. Average key grip was 9 lbs for the affected hand 

and 11 lbs for the unaffected contralateral hand. X-rays showed 

inflammatory changes in the proximal metacarpal in eight of 14 

patients. A total of 27.7% of Artelon implants placed needed to be 

removed due to local tissue reaction and pain; those patients who 

did not develop a reaction to Artelon had good outcome. Patients 

who reacted to Artelon did so relatively early with an average time 

of 12 weeks. X-rays demonstrated significant amount of reaction in 

the proximal metacarpal joint most likely as a consequence of the 

reaction caused by the Artelon implant. 

pApeR No. 560 

uErythropoietin Enhances Functional Recovery After 

Peripheral Nerve Repair: Our Experience 



Erythropoietin (EPO) is a naturally occurring hormone with 

multiple effects on a number of different cell types. Recent data 

have suggested neuroprotective and perhaps even neurotrophic 

roles for erythropoietin. We evaluated the role of erythropoietin 

after peripheral nerve repair. Fourteen patients, who underwent 

primary peripheral nerve repair (March 2009-May2009), were given 

erythropoietin 4000 I.U. subcutaneously twice a week for 12 weeks. 

Ulnar nerve repair was done in four patients at the level of elbow; at 

the level of wrist in five cases. Median nerve was repaired at the level 

of wrist in four cases and two cases underwent digital nerve repair. 

All cases were followed up for one year. Twelve out of 14 cases had 

excellent outcome and got complete recovery. Two cases had partial 

motor and sensory recovery. The average time to recovery in elbow 

lesions was 9.2 months: 6.4 months in wrist lesions. It was also seen 

that progression of Tinel sign as well as recovery was faster following 

use of erythropoietin. No adverse effect related to erythropoeitin was 

seen. Our results demonstrated that EPO is able to enhance nerve 

regeneration and promote functional recovery after peripheral nerve 

repair 

pApeR No. 561 

Prevalence of CTS, Wrist Arthritis and Rhizarthritis in 

Paraplegic Patients Compared to Controls 

Michael Akbar, MD, Heidelberg, Germany 

Sepehr Doustdar, MD 

Thomas Bruckner, Dipl.Math. 

Carl Hans Fuersenberg, MD 

Marc-Andre Weber, MD, Heidelberg, Germany 

Martin Jung, MD 

Musculoskeletal injuries of the hand in paraplegic patients can result 

from overuse and/or incorrect use of wheelchairs. With improved 

long-term survival of these patients who exclusively depend on their 

upper extremities for weight-bearing activities such as transfers and 

wheelchair propulsion, they are particularly susceptible for hand 

pathologies. The purpose of this study was to compare the functional 

and structural changes in weight-bearing hand of paraplegic patients 

who are wheelchair dependent for more than 30 years with ablebodied 

volunteers. This was a case-control-study with 56 (112 hands) 

patients who had been paraplegic and wheelchair dependent for a 

mean of 34.7 years. These patients were matched for gender, age, 

occupation and hobbies to a group of 56 (112 hands) able-bodied 

volunteers. The mean age for the paraplegic patients was 53.4 years 

and 52.1 years for the matched volunteers. The handedness was 

distributed equally in both groups. Hands from both groups were 

613 

evaluated using MRI. All films were analyzed by two board-certified 

radiologists who were blinded to the study. Prospectively collected 

outcome measures included a standardized clinical examination 

protocol, the DASH-Score and visual analog scale (VAS) pain scores. 

The hand function according to the DASH Score was significantly 

worse in paraplegic patients compared to able-bodied volunteers 

(p

pApeR No. 563 

Prospective Comparison of Post-Operative Outcomes: 

Two-Incision Versus Open Carpal Tunnel Release 

Tiffany Castillo, Atherton, CA 

Jeffrey Yao, MD, Redwood Shores, CA 

Patients who undergo two-incision carpal tunnel release (CTR) with 

preservation of subcutaneous nerves seem to experience less severe 

short-term post-operative symptoms and quicker recovery of strength 

and sensation compared to patients who undergo traditional open 

CTR. Twenty-eight patients were randomized to undergo twoincision 

or open CTR by a single surgeon. The sample size was set to 

ensure a power of 80% to detect a 15% difference in mean Brigham 

and Women’s Carpal Tunnel Questionnaire (BWCTQ) function or 

symptom scores. Pre-operatively, patients completed a Disabilities 

of the Arm, Shoulder and Hand (DASH) Questionnaire, BWCTQ, 

grip and pinch strength measurements and Semmes-Weinstein 

monofilament sensory testing. Questionnaires and measurements, 

along with scar tenderness and pillar pain evaluations were repeated 

two weeks, six weeks and six-plus-months post-operatively. Twentyeight 

patients (16 open, 12 two-incision) completed the study. 

There was no significant difference in demographics or pre-operative 

measurements between groups. All patients reported improved postoperative 

carpal tunnel symptoms and hand function. There was no 

significant difference between groups in two weeks, six weeks and sixplus-months 

post-operative DASH or BWCTQ scores, scar tenderness 

or pillar pain. There was a trend toward a greater increase in grip 

strength in the open CTR group (p=0.30) and a greater increase in 

pinch strength in the two-incision CTR group (p=0.10). Patients who 

undergo two-incision CTR demonstrate similar but not improved 

post-operative recovery and improvement in grip and pinch strength 

compared to those who undergo traditional open CTR. Thus either 

technique may be offered as an efficacious treatment for carpal 

tunnel syndrome. 

pApeR No. 564 

Biophysical Stimulation Induce Demyelination: An In- 

Vitro Study of Chronic Compressive Neuropathy 

Michael Y Lin, MD, Irvine, CA 

Laura Frieboes, PhD 

Maryam Forootan, BS 

Winnie Palispis, BS 

Ranjan Gupta, MD, Orange, CA 

Entrapment neuropathy occurs when the peripheral nerve is 

chronically subjected to mechanical forces. Increasing evidence 

implicates the extracellular matrix (ECM) as transducers of 

biophysical stimuli, relaying signals through bridging proteins to 

activate intracellular signal cascades. Integrins, as heterodimeric 

transmembrane molecules that bind the ECM, are attractive 

candidates to mediate changes in the ECM in response to chronic 

nerve compression (CNC). To better understand the pathophysiology 

of entrapment neuropathies, we sought to define the involved 

molecular events. We designed a bioreactor to study the role of 

pressure, hypoxia and ischemia on myelinating neuronal/Schwann 

cell co-cultures. Hydrostatic pressure, dissolved oxygen and glucose 

were manipulated independently and maintained constantly. 

Demyelination was assayed via immunolabeling of myelin basic 

protein, whereas Schwann cell proliferation and apoptosis were 

respectively assessed with BrdU and TUNEL labeling. Additionally, 

the activation of integrin signal cascades was assayed via Western 

Blots of the total and phosphorylated levels of Paxillin FAK Pyk2 

and Src. Mechanical loading of neural tissue induces Schwann 

614 

cell proliferation without cytotoxicity. However, hydrostatic 

pressure, ischemia and glucose deprivation independently caused 

demyelination. Furthermore, the affects of the individual stimuli were 

additive and in combinations incrementally destabilized myelin. 

Biophysical stimuli also down-regulated Paxillin phosphorylation at 

Tyr31 and transiently upregulated Src phosphorylation. Preliminary 

studies implicate FAK and PYK2 as upstream molecular signals 

because silencing both FAK and PYK2 reversed Src activation, as does 

functional inhibition of integrin receptors with blocking antibodies. 

Myelin is exquisitely sensitive to biophysical stimuli, and the 

resulting demyelination is associated with the activation of integrin 

signaling cascades. Our results argue for a role of ECM as sensors of 

CNC-induced environmental cues. By better defining the molecular 

pathways involved with the pathogenesis of entrapment neuropathy, 

we move closer to developing novel therapeutic adjuncts to improve 

patient recovery. 

pApeR No. 565 

Surgical Interventions to Reduce Neuroma Formation 

in a Rat Model 

Steve K Lee, MD, New York, NY 

Daniel Alfonso, MD, New York, NY 

Eric Eisemon, MD, Brooklyn, NY 

Edward Lin, MD, New York, NY 

Jack Choueka, MD, Lawrence, NY 

Nader Paksima, DO, New York, NY 

Neuroma formation may be a source of disabling pain. We hypothesize 

that burying nerve ends in muscle is more effective than other 

methods in decreasing neuroma formation with less inflammation, 

and decreased inflammatory markers. To our knowledge there is no 

direct comparison of commonly used methods utilizing an animal 

model. Twenty-five rats underwent resection of one centimeter of 

the sciatic nerve. The rats were divided equally into five groups 

with different interventions at the proximal nerve end: 1) in situ, 

2) burying the nerve end in muscle, 3) cauterization, 4) ligation 

and 5) a collagen nerve tube. After eight weeks, the diameter of the 

proximal nerve end was measured. The specimens were stained with 

hematoxylin and eosin (H&E) and assigned to one of five grades 

of inflammation. The immunohistochemical specimens were 

compared for relative quantities of p-ERK, and TGF beta. The average 

diameter of nerve ends buried in muscle was significantly smaller 

compared to the diameter of nerve ends treated by ligation or with 

a closed collagen tube. Burying nerve ends in muscle showed less 

inflammation in histological staining. Larger neuromas with more 

inflammation showed greater intensity of staining for p-ERK and 

TGF beta. Neuroma formation may be decreased by burying nerve 

ends in muscle as compared to cauterization, ligation, or placing a 

collagen nerve cap. When muscle is not available, cauterization is 

preferable to ligation or a closed collagen nerve cap. p-ERK and TGF 

beta do appear to be part of the cascade for neuroma formation and 

may be useful markers or points of intervention for future studies. 




pApeR No. 566 

Contribution of Flexor Pollicis Longus (FPL) to Pinch 

Strength- An In-Vivo Study 

Tom Goetz, MD, Vancouver, BC Canada 

Anthony Costa, MD, Vancouver, BC Canada 

Satyam Rajnikant Patel, MD, Vancouver, BC Canada 

Gerard Slobogean, MD, MPH, Vancouver, BC Canada 

Andrew Travlos, MD 

Kishore Mulpuri, MD, Vancouver, BC Canada 

Pinch strength has been shown to be an important predictor of the 

ability to grip objects and perform functional hand-related tasks. 

The flexor pollicis longus (FPL) muscle plays an essential role in 

directing thumb tip force and contributes a proportion of overall 

pinch strength. The relative contribution of FPL to pinch strength 

is unknown however. The purpose of this study was to estimate 

the contribution of FPL to pinch strength in-vivo using an or 

electromyographic (EMG) guided, selective motor blockade, testretest 

protocol. Eleven healthy volunteers were recruited to participate 

in this study. Baseline pinch strength was recorded for all participants 

using three different pinch techniques: key pinch, three-point chuck 

grasp, and tip pinch. EMG-guided selective lidocaine blockade 

of the FPL muscle was carried out and post-block pinch strength 

measurements recorded. All three types of pinch strength showed 

a significant difference between pre and post block measurements 

(p

patients treated for scaphoid nonunion using a non-vascularized 

bone graft from the dorsal and distal aspect of the radius (group 

I), relative to 46 patients treated by means of a conventional nonvascularized 

bone graft from the iliac crest (group II). All nonunions 

were stabilized with single Herbert screw. Bone fusion was achieved 

in 87.1% of group I and 86.5% of group II patients. Functional 

results were good to excellent in 76.0% of the patients in group I and 

72.5% in group II. The average grip power, as well as wrist flexion 

and extension, were similar in both groups. However, the donor site 

morbidity was much higher in group II (four cases of hematoma, six 

cases of chronic pain and one anterior superior iliac spine avulsion 

fracture). No complication was seen in group I. We conclude that 

nonvascularized distal radius bone grafting yields similar union rate 

as well as functional outcome as compared to iliac crest bone graft 

with no donor site morbidity. 

pApeR No. 570 

Arthroscopic Wafer Resection for Ulnar Impaction 

Syndrome: Prediction of Outcomes 


Eric Keefer, MD, New York, NY 

Georgia Panagopoulos, PhD 

Syngil Steven Yang, MD, New York, NY 

Ulnar impaction syndrome (UIS) is a degenerative condition 

characterized by pain, swelling and limitation of range of motion 

related to excessive load bearing across the ulnocarpal joint. Our 

objective was to evaluate the results of arthroscopic wafer resection for 

ulnar impaction at our institution and identify preoperative factors 

that could predict outcomes. Between 1998 to 2005, 26 patients 

were diagnosed with ulnar impaction syndrome and underwent 

arthroscopic wafer resection. The diagnosis of UIS was made based 

on magnetic resonance imaging (MRI) findings of positive variance 

or signs of impaction such as sclerosis or cystic changes in distal 

ulna or proximal lunate. Spearman’s rho correlation coefficient was 

calculated between variables (age, previous history of fracture, MRI 

signs and ulnar variance) and outcomes (post-op strength, pain 

relief). None of the patients had ulnar negative variance. All patients 

with a history of previous radius fracture (five patients, 19%) were 

ulnar positive. Twenty-two out of 26 patients (84.6%) had either 

good or excellent pain relief. We found significant correlation 

between MRI findings of cystic changes, edema or sclerosis and postop 

pain relief. Previous fractures were correlated with presence of 

ulnar variance and negatively correlated with MRI signs. Patients 

who had pre-operative MRI scan findings of ulnar impaction had 

significantly better results with arthroscopic wafer procedure in 

terms of pain relief. 

POSTERS 


Lateral Tilt Wrist Radiograph: A Technique to Position 

the Wrist 

Kristofer S Matullo, MD, Ambler, PA 

David G Dennison, MD, Rochester, MN 

Lateral tilt radiographs are useful following volar locked plate 

fixation of distal radius fractures to assess the radiocarpal joint, the 

subchondral bone congruity and the volar tilt. The purpose of our 

study was to define the reliability of our positioning method using 

the patient’s opposite hand to position the injured wrist. Twenty- 

616 

four wrists (24 patients) were retrospectively identified that all had 

a distal radius fracture treated with locked volar plating as well as a 

post-operative lateral tilt radiograph. The lateral tilt wrist radiograph 

was obtained by positioning the injured wrist at a height determined 

by the contralateral hand being placed under the ulnar wrist crease. 

Radiographs were blindly reviewed by two reviewers (authors) 

to determine if the radiocarpal joint and subchondral bone were 

visualized and if any screws appeared to cross the radiocarpal 

joint. Fifteen normal volunteers were also placed into this lateral 

tilt position to measure the inclined forearm angle. Twenty-three 

patients (96%) had radiographs with acceptable visualization of 

the subchondral bone. The concordance of the subchondral bone 

visualization was 100% (95% CI 85.5-100%). The mean angle with 

lateral tilt positioning was 18° from horizontal (range 15°-23°; SD 

2.4°). The lateral tilt view, using the contralateral hand to position 

the wrist, produced radiographs with reliable visualization of the 

distal radius subchondral bone in 96% of our cases. Visualization 

of the subchondral bone in the region of the radial aspect of the 

scpahoid fossa requires more tilt than achieved with this technique. 


Investigation Of Trabecular Morphology Using Micro- 

CT In Trapeziometacarpal Arthritis 

Arthur T Lee, MD, New York, NY 

Ariel Williams, MD, Baltimore, MD 

Derek P Lindsey, MS, Palo Alto, CA 

Robert Cheng, MS 

Amy L Ladd, MD, Palo Alto, CA 

The pathologic mechanism of trapeziometacarpal (TMC) joint 

arthritis, and the most common sites of wear within the joint 

remain controversial (1-5). Current literature supports significant 

bony remodeling primarily in the arthritic trapezium rather than the 

metacarpal (6-9). Bone remodels under stress according to Wolff’s 

law. Analysis of trapezial trabecular morphology provides preliminary 

correlation of architecture and load transmission, potentially 

reflecting pathomechanics of osteoarthritis in the TMC joint. With 

Institutional Review Board approval, 13 normal cadaveric trapeziae 

and 16 Eaton stage III-IV trapeziae were harvested for comparison. 

Specimens were scanned with micro-CT imaging. Utilizing software, 

each specimen was divided into four quadrants: volar ulnar, volar 

radial, dorsal radial and dorsal ulnar. Trabecular bone morphologic 

parameters were measured including bone volume ratio, three 

dimensional connectivity, trabecular number and trabecular 

thickness. The osteoarthritic and normal specimen quadrant 

measurements were compared by analysis of variance with post hoc 

Bonferroni/Dunn correction. There was no significant difference in 

trabecular morphologic parameters between the osteoarthritic and 

normal specimens (p=0.44). However, when collectively comparing 

the volar ulnar quadrant of osteoarthritis and normal specimens, 

they displayed 28% and 35% higher bone volume fraction, 

trabecular number and connectivity than the dorsoradial and volar 

radial quadrants (p

quadrant is a feature of functional activity in both normal and 

osteoarthritic subjects, providing further biomechanical information 

about this complex joint. 


Flouroscopic Evaluation of DRUJ Screw Penetration 

after Distal Radius Fixation: A Cadaveric Study 

Asif Ilyas, MD, Wayne, PA 

Nathan Daniel Bodin, MD, Philadelphia, PA 

Inadvertent screw violation of the distal radioulnar joint (DRUJ) is 

a potential complication of distal radius fixation. The semi-circular 

anatomy of the sigmoid notch makes radiographic visualization 

difficult. The purpose of this study was to (1) evaluate surgeons’ 

ability to accurately identify intra-articular placement of screws in 

the DRUJ, and (2) to evaluate the efficacy of two new radiographic 

views in identifying intra-articular screw placement. Three implants: 

a volar plate, a radial plate and an intramedullary nail were placed in 

cadaveric wrists. The length of screw closest to the DRUJ was placed 

at three lengths relative to the articular surface of the sigmoid notch: 

extra-articular, 2 mm intra-articular. 

Three views were taken of each implant at each screw length including 

posteroanterior and two new oblique views: 20° over-pronated and 

20° over-supinated views. All images were randomly presented to 

hand surgeons, general orthopaedists and orthopaedic residents to 

assess their ability to determine screw position. Overall accuracy of 

identifying screw position was 73% among all raters (n=18). Greatest 

accuracy was achieved on the 20° over-pronated oblique view, but 

the posteroanterior view provided the greatest accuracy between all 

implants and raters (p


Giant Cell Tumor of Tendon Sheath: Whom to Give 

Postoperative Radiotherapy 



Giant cell tumor of the tendon sheath is a solitary benign soft tissue 

tumor of the limb. We present our prospective experience of 106 cases, 

over a period of 22 years, to assess the effectiveness of prophylactic 

radiotherapy in postoperative period. We also present a classification 

system to help in selecting patients for postoperative radiotherapy. 

Between 1986 and 2008, we treated 106 patients with giant cell 

tumor of the tendon sheath of the hand. There were 77 females 

and 29 males with a mean age of 31.2 years. All patients presented 

with gradually progressive swelling. Pain was present in three cases. 

All patients were investigated preoperatively with plain X-rays. MRI 

was done in 36 cases. A preoperative diagnosis of giant cell tumor 

of the tendon sheath was made in 98 patients preoperatively. Eight 

patients were diagnosed on histopathological examination. We 

developed a classification system to identify the patients for risk of 

recurrence and consequently selection of patients for postoperative 

radiotherapy. Group 1(a) and 2(a) were identified as low risk groups 

and comprised of 56 patients. None of the patients in this group 

received postoperative radiotherapy and no patient had recurrence 

among them. All other patients (50 patients) were considered to be 

high risk and given postoperative radiotherapy. Among them, four 

had recurrence. A total recurrence rate of 3.7% was found in our 

study, which is favorably comparable to reported incidences of 25- 

45%. In our series, we gave radiotherapy only to high risk patients 

and had a recurrence rate of only 3.7%. Even in the high risk group 

alone to whom postoperative radiotherapy was given, recurrence rate 

was 8%. This indicates the role of radiotherapy as well as importance 

of our classification system to identify the patients for high risk of 

recurrence. 


Hybrid and Volar Locking Plate Fixation in Normal and 

Osteoporotic Distal Radius Models 

Derek Amanatullah, MD, Sacramento, CA 

Shima Sokol, MD, Mineola, NY 

Shane Curtiss, Sacramento, CA 

Robert Morris Szabo, MD, MPH, Sacramento, CA 

Information is lacking to direct the specific application of hybrid 

fixation to the distal radius. The purpose of this study is to determine 

if a hybrid plate construct is stronger by allowing compression to 

bone than a standard locking plate construct in a distal radius 

fracture model. Twenty-eight normal, osteoporotic and over drilled 

osteoporotic left distal radius sawbones were divided into paired 

groups of 14. Within each group, the sawbones were plated with 

either a volar locking plate using all locking screws or a hybrid 

construct. A 1 cm dorsal wedge osteotomy was created with the apex 

2 cm from the volar surface of the lunate facet. Axial compression 

was delivered at 1 N/s over three cycles from 20 N to 100 N to 

establish stiffness. Each sample was failed at 1 mm/s until 5 mm of 

permanent deformation occurred. Our results show no difference 

in construct stiffness and load at failure between the all-locking 

and hybrid constructs in the normal, osteoporotic, or overdrilled 

osteoporotic models (p > 0.05, power = 0.8). All specimens failed 

at the osteotomy site with loss of height. Hybrid constructs provide 

similar stiffness and stability compared to all-locked constructs in 

the fixation of a comminuted distal radius fracture model. This 

was true regardless of bone quality and with as few as three locking 

screws inserted in the distal fragment. 

618 


Factors Associated Pillar Pain After Limited-Open 

Carpal Tunnel Release 

Jae Kwang Kim, MD, Seoul, no, Republic of Korea 

Young Do Koh, MD, PhD, Yangcheongu, Seoul, Republic of Korea 

Seung Yup Lee, MD 

Jeong Suh Kim, MD, Seoul, Republic of Korea 

This prospective study was performed to investigate the association 

between the intensity of pillar pain and (1) patient satisfaction after 

open carpal tunnel release (CTR), (2) psychological distress and 

(3) patient-assessed outcome. Eighty-three idiopathic carpal tunnel 

syndrome patients (102 hands) treated by open CTR were enrolled in 

this study. All patients completed the Brigham and Women’s (Boston) 

carpal tunnel questionnaire (BCTQ) preoperatively. We also accessed 

level of depression using the Center for the Epidemiological Study 

of Depression (CES-D), and pain anxiety using the Pain Anxiety 

Symptoms Scale (PASS) preoperatively. In addition, three months 

after surgery, patients were asked to provide a 10-point Likert scale 

for patient satisfaction and pillar pain, to complete the BCTQ a 

second time and to undergo grip strength testing. Mean BCTQ-S 

score decreased from 2.7 ± 1.2 preop to 1.7 ± 0.9 at three months 

postop (p


High Fusion Rates and Patient Satisfaction after Four 

Corner Fusion with Mid to Long Term Results 

Julia A Kenniston, MD, Foxboro, MA 

David J Bozentka, MD, Philadelphia, PA 

Scaphoid excision and four corner fusion (4CF) has been an accepted 

motion preserving salvage procedure for mid-carpal degenerative 

changes, with the majority of indications as scapholunate advanced 

collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC) 

wrists. This fusion was originally described with the use of Kirschner 

wires (K-wires) and has expanded to the use of staples, headless 

screws and circular fusion plates without long-term results from the 

traditional methods of K-wire fixation. The purpose of the current 

study is to evaluate our experience with 4CF using K-wire fixation 

and determine the mid to long-term outcome from this procedure 

and to assess radiographic fusion and effect of lunate alignment. 

We retrospectively reviewed a consecutive cohort of patients who 

underwent scaphoid excision and four corner fusion with K-wire 

fixation between 1999 and 2009. There were a total of 22 procedures 

in 21 patients performed over this time period by the senior author 

with eight patients lost to follow up leaving 14 wrists available 

for evaluation. The mean follow-up time was 63 months with a 

maximum of 134 months (range, 15-134). Median and mean Quick 

Disabilities of the Arm, Shoulder and Hand (QDASH) scores were 

10.3 and 17.9 respectively and the median and mean Mayo wrist 

scores were 65 and 59.6. Thirteen of the 14 cases were satisfied with 

the procedure and all 14 reported they would repeat the surgery, 

including the one patient who stated he was unsatisfied with the 

surgery as he developed a complete non-union with radiocarpal 

arthrosis. All other patients developed a union at the capitolunate 

interval. Interestingly, complete radiographic fusion of the four 

corners was only evident in 53.8% of patients, and 38.5% of patients 

lacked fusion in the lunotriquetral interval. Despite this, there was 

no effect on patient satisfaction, DASH, Mayo wrist scores, arc of 

motion or grip strength. Radiographic analysis also revealed lunate 

position to be within 15 degrees of neutral in all patients. There was 

no bearing on the total arc of motion regardless of lunate position. 

Scaphoid excision and four corner fusion using K-wire fixation 

has reliable mid to long term results with high patient satisfaction 

rates. There were high capitolunate fusion rates with good results 

regardless of lunotriquetral interval fusion or lunate position within 

15 degrees of neutral. Scaphoid excision and 4CF is a reasonable 

option for patients with midcarpal degenerative changes. 


Bioactive Sutures for Tendon Repair: Efficacy of 

Delivering Stem Cells in-vivo 

Jeffrey Yao, MD, Redwood Shores, CA 

Tatiana Korotkova 

Don Young Park, MD, Mountain View, CA 

Varun Kashyap Gajendran, MD, Redwood City, CA 

R Lane Smith, PhD, Stanford, CA 

Rat bone-marrow derived mesenchymal stem cells (MSCs) may 

successfully adhere to suture material and be successfully delivered 

into acellularized tendon in vitro. However, it is currently unclear 

if these cells survive implantation into live animals, are targeted by 

the host immune system and whether these cells may repopulate 

the acellular zone seen around a tendon repair site in vivo. Rat 

bone marrow derived MSCs were isolated and labeled with PKH26 

fluorescent dye to distinguish between implanted and host cells. 

Polyester sutures were seeded with MSC and cultured for three days. 

619 

Open transection of Sprague-Dawley rat hind tendons and subsequent 

repair with MSC-implanted suture was performed in six animals, with 

six control (standard suture repair) animals. Cast immobilization 

of the rat hind limbs prevented loading of the repairs. The repaired 

hind tendons were harvested and sectioned at seven and 14 days. The 

specimens were evaluated for any host inflammatory response and 

implanted cell viability was evaluated with fluorescent microscopy. 

Rat hind tendons repaired with PKH26-labeled MSC demonstrated 

detectable MSC lineage utilizing fluorescent microscopy (whereas 

the controls did not), and no significant inflammatory response was 

stimulated. Thus, implanted MSC were successfully delivered to the 

tendon repair site and survived the acute phase of inflammation and 

healing. MSCs will adhere on to suture and survive the implantation 

process into a live rat hindpaw tendon in vivo. Implanted MSCs 

survive the acute phase of healing at the tendon repair site and 

appear immunoprivileged. These cells may biologically augment 

current tendon repair. 


DIPJ Arthrodesis Using Axial Screw With Variable 

Thread Pitch (Mini Acutrak) 

Sujith Konan, MRCS, London, United Kingdom 

Aditi Das, MBBS 

Emma Taylor, MD, London, United Kingdom 

Elliott Sorene, FRCS, Middlesex, United Kingdom 

Distal interphalangeal joint (DIPJ) or thumb interphalangeal joint 

arthrodesis is a recognised treatment for restoring joint stability and 

hand function in patients with osteoarthritis. The aim of this study 

was to review the clinical outcome and complications in patients 

who underwent DIPJ fusion using an axial screw with variable 

thread pitch; the Mini-Acutrak screw (Acumed, LLC, Hillsboro, 

OR, USA). Twenty-eight cases (24 patients) of DIPJ arthrodesis was 

performed using the axial Mini-Acutrak screw as day surgery under 

general anaesthesia. The indication for arthrodesis was osteoarthritis 

in 21 cases and trauma in seven cases. Patients were followed up 

until radiological union was confirmed and desired functional result 

was achieved. Patient satisfaction, the Quick Disability of the Arm, 

Shoulder and Hand (quick-DASH) score and radiographs at final 

follow up were assessed at final follow up. All patients tolerated 

the procedure well. Excellent results were achieved in 24 patients 

(86%) with good to excellent patient reported satisfaction and quick 

DASH score of 0 for symptom score, work and performance module. 

Radiological union was confirmed in all these cases at three-month 

follow up. Four complications were noted. One case of distal bone 

fracture and one case of screw migration were treated conservatively 

and did not affect the final outcome. One patient had screw cutout 

and required revision to k-wire. One patient required screw removal 

for infection at four weeks but progressed to union with conservative 

management. The use of axial mini-acutrak screw for DIPJ arthrodesis 

is associated with excellent clinical and functional results and less 

morbidity compared to the use of k-wires. 





Immunomodulation Of Mesenchymal Stem Cells In 

Composite Tissue Allotransplantation 

Ryosuke Ikeguchi, MD, Kobe, Japan 

Ryosuke Kakinoki, MD, Kyoto, Japan 

Hiroto Mitsui, MD 

Moritoshi Furu, MD, PhD, Kouka-Shi Shiga, Japan 

Tomoki Aoyama, MD, PhD, Kobe, Japan 

Keiichi Kawanabe, Kobe, Japan 

Junya Toguchida, MD, PhD 

Takashi Nakamura, MD, Kyoto, Japan 

Hand transplantations have revolutionized the reconstruction field 

for patients with hand defects. However, immunosuppressants are 

essential for maintaining human hand transplant survival despite 

lethal side effects such as infections, drug toxicity and malignancies. 

Recent studies indicate that mesenchymal stem cells (MSCs) have 

some immunomodulatory properties to suppress T cell mediate 

responses that cause graft rejection. The purpose of this study 

is to evaluate the effect of intravenous donor MSC infusion for 

immunomodulation in the rat composite tissue allotransplantation 

model. Orthotopic rat hind limb transplantation was performed 

using donor Wister rats and recipient Lewis rats. The recipient rats 

were randomly divided into two experimental groups: in group 

FK, 0.2 mg/kg/day intramuscular tacrolimus were administered to 

recipient rats for seven consecutive days (days 0’6); in group MSC, 

recipient rats were injected intravenously with 2×106 donor MSCs 

on day six with 0.2 mg/kg/day tacrolimus administered for seven 

days. Graft survival was assessed by daily inspection and histological 

study. Recipients’ immunological reactions were evaluated by serum 

ELISA, RNA assays and mixed lymhocyte reactivity assays. The graft 

survival of group MSC was significantly prolonged in comparison 

with that of group FK. Cytokine expression analysis of grafted 

limbs showed that MSC treatment significantly decreased proinflammatory 

cytokine expression. An in vitro mixed lymphocyte 

reaction showed MSCs inhibiting T cell proliferation. MSCs induce 

T cell hyporesponsiveness and prolong graft survival in the rat 

composite allotransplantation model. MSCs demonstrate some 

immuno-modulatory properties that can be accomplished without 

the need for significant recipient immunosuppression. 


Collagenase Clostridium Histolyticum Therapy for 

Dupuytrens Contracture in Europe, Australia and US 

Nebojsa V Skrepnik, MD, Tucson, AZ 

Philip Waller, MD, Houston, TX 

Harvey Kushner, PhD 

Dat Nguyen, PharmD 

Two studies in the U.S. and Europe/Australia investigated the 

efficacy/safety of injectable collagenase clostridium histolyticum 

(CCH) in patients with Dupuytren’s contracture. These prospective, 

nine-month, open-label studies used identical protocols. Patients 

with Dupuytren’s contracture and a fixed-flexion contracture (20°- 

80° for PIP joints; 20°-100° for MP joints) were selected. Five total 

injections were allotted per patient. At the investigator’s discretion, 

affected joints could receive £3 CCH injections (0.58 mg) per cord, 

with manipulation done the following day, and a 30-day follow up. 

Clinical success was defined as a reduction in contracture to 0°-5° 

of normal extension, 30 days after the last injection. A total of 201 

patients with 188 MP, 104 PIP joints at 14 U.S. sites (JOINT I), and 

386 patients with 345 MP, 244 PIP joints at 20 European/Australian 

sites (JOINT II) received CCH. Clinical success was achieved in 

620 

67.0% of MP and 26.9% of PIP joints from JOINT I, and 70.8% 

of MP and 41.0% of PIP joints from JOINT II. In both studies, the 

average number of injections per cord was 1.4. The mean percentage 

decrease in degree of joint contracture from baseline to 30 days after 

last injection was 66.8% in JOINT I, and 75.4% in JOINT II. Mean 

increase in range of motion was 28.3° ± 20.2º in JOINT I and 26.7° 

± 16.9º in JOINT II. Two patients had SAEs, but no tendon ruptures 

or systemic reactions were noted. CCH is a nonsurgical treatment 

option for Dupuytren’s contracture that is highly effective and well 

tolerated. 


Four Corner Fusion and Proximal Row Carpectomy: 

Comparison of Wrist Motion and Tendon Forces 

Daniel DeBottis, Syracuse, NY 

Frederick W. Werner, Syracuse, NY 

Levi G. Sutton, Syracuse, NY 

Brian Harley, Syracuse, NY 

Controversy exists whether a proximal row carpectomy (PRC) is a 

better procedure than scaphoid excision with 4-corner fusion (4CF) 

for preserving motion in the painful posttraumatic arthritic wrist. Six 

fresh-frozen cadaver forearms were tested for range of motion in the 

intact wrist, followed by 4CF and then PRC. Wrists were positioned 

statically and then moved dynamically through 4 ranges of motion 

using a wrist joint motion simulator while physiological forces were 

applied to the 5 wrist flexor/extensor tendon groups.Wrist motion 

statistically decreased following both the 4CF and the PRC. Wrist 

flexion decreased on average 13.1° after 4CF and 11.8° after PRC, 

while extension decreased on average 19.6° after 4CF and 11.8° after 

PRC. During flexion-extension, circumduction and dart throw, the 

average ECU force was statistically greater after 4CF compared to 

after PRC. The peak ECU force had a trend to be smaller with the 

PRC compared to intact wrist. During wrist circumduction, the peak 

ECRB forces were less after the PRC compared to intact while the 

FCU forces were greater. The measured passive wrist range of motion 

decreased after both 4-corner fusion and PRC, which is consistent 

with the clinical situation. Larger peak tendon forces were required 

to achieve identical wrist motions with the 4-corner fusion when 

compared to the intact wrist. Smaller forces were observed for 

the PRC. This may help explain why PRC may allow early clinical 

improvement and ease of motion. 



Magnetic Resonance Imaging of the Hand and Wrist: 

Techniques and Spectrum of Disease 

Ashvin Kumar Dewan, MD, Baltimore, MD 

A Jay Khanna, MD, Baltimore, MD 

Abhinav Bobby Chhabra, MD, Keswick, VA 

Mark W Anderson, MD, Charlottesville, VA 

Lance Michael Brunton, MD, Gibsonia, PA 

Magnetic resonance imaging (MRI) can image pathologic processes 

of the hand and wrist. MRI allows for high-resolution evaluation 

of osseous structures and soft tissue structures including ligaments, 

tendons, nerves, and muscles. Multiple imaging techniques and 

pulse sequences exist for evaluation. The purpose of this scientific 

exhibit is to educate and update orthopaedic surgeons on current 

MRI techniques and illustrate the spectrum of hand and wrist 




disease detectable by MRI. Medline was searched using keywords 

MRI and hand or wristfor studies less than 5 years old evaluating 

MRI techniques. These papers, the authorsexperience, and textbooks 

reviewing hand and wrist MRI provided the information to prepare 

this exhibit. This exhibit describes the essentials and applications 

of the following techniques: 1. Conventional, non-Gadolinium 

enhanced MRI 2. Gadolinium enhanced MRI 3. Magnetic resonance 

arthrography 4. Magnetic resonance angiography The classic MRI 

appearances of the following are demonstrated: 1. Occult Fractures 

; 2. TFCC Injury ; 3. Interosseous Ligament Injury; 4. Extrinsic 

Carpal Ligament Injury; 5. Thumb UCL Injury; 6. Tendon Injuries; 

7. Ulnar Impaction Syndrome; 8. Tendon Disorders; 9. Carpal 

Instability; 10. Infectious Conditions; 11. Kienbocks Disease; 12. 

Preiser’s Disease ; 13. Post-traumatic Scaphoid Osteonecrosis; 14. 

Rheumatoid Arthritis; 15. Compression Neuropathies; 16. Soft 

Tissue Masses. MRI is a valuable, non-invasive method of evaluating 

the hand and wrist. This exhibit will make the orthopaedic surgeon 

aware of various MRI techniques available and allow him or her to 

recognize the MR appearance of the most commonly seen hand and 

wrist pathologies. 


Treatment of Symptomatic Neuromas of the Dorsal 

Radial Sensory Nerve using a Nerve Conduit - 

American Association of Hand Surgery 

Joshua Matthew Abzug, MD, Woodbury, NJ 

Sergio Rodriguez, MD, Buenos Aires, Argentina 

John S Taras, MD, Philadelphia, PA 

A Lee Osterman, MD, King Of Prussia, PA 

Established symptomatic neuromas of the dorsal radial sensory 

nerve are difficult problems for which no ideal treatment exists. 

Procedures have includes efforts to inhibit axonal outgrowth such 

as synthetic containment and efforts to protect the neuroma from 

noxious stimulation such as ablation and implantation. This paper 

studied the role of neurolysis and wrapping of the neuroma in a 

resorbable collagen conduit. 21 patients, 7B,14B with an average age 

of 33 years (20-52) met the entry criteria: intractable DRSN pain ; 

failure of time , desensitization, and neuroleptic medication; positive 

electrical studies or a surgically documented DRSN injury. All had 

DRSN neurolysis and wrapping of the neuroma segment with a 

NeuraGen® Nerve Guide. Results were evaluated clinically, by visual 

analog scale, and by DASH questionnaire. The dominant hand was 

involved in 52%. 11 patients had previous surgery to the radial wrist 

including 4 direct injuries and repair to the DRSN; 7 cases of indirect 

injury including Dequervain’s release, CMC arthroplasty, lipoma 

resection, ORIF distal radius fracture, and dog bite. The 10 closed 

injuries related to crush injury, percutaneous needles, radial fracture, 

and casting . 17/21 has preop electrical studies. All had preop pain 

management including desensitization and neuroleptics, 17/21 had 

lidocaine, 12/21 had steroid injection. 2 patients were on narcotic 

medication .The median time from original injury to surgery was 8 

months (4-37).The condition was work related in 5 and litigation 

active in 4.’Mean FU was 2.8 years ( 1.2-4.5). No patient was lost 

to FU. 90% (19/21) were improved and 95% would repeat the 

surgery. In 19/ 21 hypersensitivity was improved and patients were 

postoperatively able to tolerate watchbands, bracelets and sleeves. 

Pre and postop 2PD and Semmes monofilament measurements 

were variable and not significantly different but all sensory maps 

identified the DRSN distribution and tended to improve. Subjectively 

preop numbness decreased in 66%.’Preop TInels decreased from 

100% to 38%. Visual analog scales(0-10) improved both at rest and 

in activity: rest 5’0.7; activity 7’1.8. Dash improved 71+/-22 to 29+/- 

621 

18. Wrist ROM Improved in flexIon, radial and ulnar deviation. Grip 

strength improved 61% ‘ 92%. Key and Tip pinch showed similar 

data: 55%’84%, 62%’88%. Work return : 6 not working rtw usual 

job; 2 not working rtw modified; 1 modified rtw regular job; 7 

working stayed working; 5 not working outside home. 4 high level 

athletes were able to return to their sport In summary, neurolysis and 

wrapping with a resorbable collagen tube is effective in significantly 

improving the symptomatic neuroma of the DRSN. It is simple to 

perform, avoids ablation of the nerve and the harvesting of other 

tissues. One drawback is the expense of the conduit.’ 


Distal Radius Osteoarticular Allografts Reconstruction: 

Surgical Technique and Results 

Luis Alberto Aponte-Tinao, MD, Buenos Aires, Argentina 

Lucas Eduardo Ritacco, MD, Buenos Aires, Argentina 

German Luis Farfalli, MD, Buenos Aires, Argentina 

Miguel Angel Ayerza, MD, Buenos Aires, Argentina 

Domingo Luis Muscolo, MD, Buenos Aires, Argentina 

The purpose of this study was to describe the technical details 

and results of distal radius osteoarticular allografts after tumor 

resections. Distal radius osteoarticular allografts in 14 patients 

were retrospectively reviewed and followed for a mean of 6 years. 

There were 11 female and 3 males and the diagnoses included 

giant cell tumor (11) and osteosarcoma (3). Complications and 

range of motion were recorded and patients were evaluated with 

the Musculoskeletal Tumor Society scoring system. Details of 

surgical technique included: 1) accurate allograft selection; 2) 

tumor resection; 3) allograft preparation; 4) rigid internal fixation; 

5) careful soft-tissue reconstruction of the joint. Key points for 

successful fixation are allograft selection, absolute stability and 

satisfactory soft-tissue reconstruction at the time of surgery that 

allows aggressive rehabilitation. One allograft needed to be removed 

due to a deep infection. From the remaining 13 patients, one patient 

developed a nonunion that was treated with autologous bone graft. 

At final follow up, the average arc of motion of all thirteen patients, 

was 110° (average flexion 57° and average extension 54°) with 

average pronation of 69° and average supination of 52°. Average 

MSTS functional score was 26 points with a range between 23 and 

30. Neither fracture nor resorption of the allograft was recorded. 

The reconstruction of distal radius after tumor resections, preserving 

wrist stability and function is limited. Distal radius osteoarticular 

allografts is a reliable alternative and showed an acceptable range of 

motion with a good MSTS functional score. 




PAPERS 

pApeR No. 166 

The Treatment of Pediatric Tibial Shaft Fractures with 

an Extended Cast and Early Weight-bearing 

Mauricio Silva, MD, Playa Vista, CA 

Michael Eagan, MD, Playa Vista, CA 

Melissa Wong, Montebello, CA 

Daniel Dichter, BA 

Edward Ebramzadeh, PhD, Los Angeles, CA 

Lewis Evan Zionts, MD, Pacific Palisades, CA 

There is no general agreement as to how best to immobilize tibial 

shaft fractures in children. We randomized 81 children, aged four 

to 14 years, who had closed tibial shaft fractures, into two groups. 

Group I patients (n=40) received a long-leg cast (LLC) with the knee 

flexed 60° and were asked not to bear weight. Group II patients 

(n=41) received a LLC with the knee flexed 10° degrees and were 

asked to bear weight as tolerated. All patients were switched to short 

leg walking casts at four weeks. Patients were followed at one, four, 

six, 12, and 24 weeks post-injury. We compared time to healing, 

overall alignment, shortening and physical disability as determined 

by the Activities Scale for Kids - Performance (ASK-P) questionnaire. 

At 12 weeks, all fractures had healed. The two groups did not differ 

in coronal alignment (1.6° vs. 0.54° of varus, p=0.12), sagittal 

alignment (0.7° vs. 0.3° of recurvatum, p=0.11) or shortening 

(0.08 vs. 0.55 mm, p=0.1). The ASK-P showed that both groups had 

overall improvement in physical functioning over time. However, at 

six weeks, Group II had better overall scores (65.2 vs 72.9 points, 

p=0.03), better standing skills (49.7 vs. 60.4 points, p=0.01) and 

tended to show better locomotion (64.8 vs. 69.5 points, p=0.17). 

Initial immobilization of a tibial shaft fracture in either flexion 

or extension of the knee resulted in no difference in radiographic 

outcome. Those patients immobilized in extension enjoyed better 

early function than those immobilized in flexion. 

pApeR No. 167 

The Kickstand Technique to Promote Elevation and 

Wound Care of Pediatric Lower Extremity Injuries 


Derek Michael Kelly, MD, Memphis, TN 

James H Beaty, MD, Memphis, TN 

S Terry Canale, MD, Germantown, TN 

William C Warner Jr, MD, Germantown, TN 

External fixation is a common form of treatment of pediatric lower 

extremity fractures, especially high-energy fractures with signifiant 

soft tissue injury. The use of a kickstand attachment to an external 

fixator ensures elevation and provides access for the monitoring 

and care of soft tissues. A two-year Institutional Review Boardapproved 

retorospective review of children treated with a kickstand 

attachment to a previously applied external fixator was performed. 

Patient charts were reviewed for demographic information, fracture 

types, associated injuries and surgical procedures. Skin pressure 

complications were rated using the National Pressure Ulcer Advisory 

Panel Classification. The kickstand was used eight times on seven 

patients who sustained high energy trauma. There were seven males 

and one female (mean age 11.8 years). All kickstands were placed 

622 

Pediatrics 

at the time of the initial procedure using standard external fixation 

equipment already present in the operating room (mean weight .45 

kg) and none required further modification. There were four open 

tibia fractures and three closed tibia fractures. Four of eight patients 

had multiple fractures and one patient had a leg compartment 

syndrome. The mean number of secondary procedures was two 

(range 1-11). One patient who underwent bone transport had a 

second kickstand placed at the time of his bone transport procedure. 

No patients had other skin pressure modalities used and no patients 

at final follow up had any complications related to skin pressure or 

the kickstand itself. The use of external fixation in the treatment of 

high-energy trauma in children is well established and allows for 

management of soft tissue injuries and neurovascular monitoring. 

The efficacy of a kickstand modification has been described in adult 

patients but not previously in children. This light-weight, easy to 

apply kickstand was successful in allowing management of soft 

tissue injuries and preventing skin pressure complications. It also 

eliminated the need for splint and cast changes which can be painful 

and anxiety provoking, especially in children. 

pApeR No. 168 

Compartment Syndrome in Pediatric Tibial Shaft 

Fractures: Incidence and Multivariate Risk Factors 

Ben Shore, MD, Boston, MA 

Michael P Glotzbecker, MD, Waban, MA 


Travis H Matheney, MD, Boston, MA 

Pediatric tibial shaft fractures (TSF) account for 15% of long bone 

fractures in children. Compartment syndrome (CS) is difficult to 

diagnose in children, often leading to disastrous outcomes. This 

study investigated the incidence of CS in TSF and its associated 

risk factors. This study involved a detailed five-year retrospective 

chart review of TSF treated at a major pediatric hospital. CS was 

diagnosed clinically or by intra-compartment pressure. Multivariate 

logistic regression analysis tested age, gender, mechanism of injury, 

time to surgery, fracture type and treatment intervention as possible 

risk factors for CS. There were 216 TSF in 212 children (160 males, 

52 females; mean age 13.6 years, range 8-18 years). A total of 132 

(61%) fractures were treated with closed reduction and casting, 36 

with external fixation, 21 with flexible intramedullary nails and 27 

with locked intramedullary nails. There were 23 cases of CS (10.6%). 

Multivariate predictors of CS included age 14 years and older (21/96 

= 22%, p < 0.001) and motor vehicle accident (MVA) (12/57 = 21%, 

p = 0.002). Incidence of CS was 44% among patients 14 and older 

who sustained MVA (11 of 25). Gender, AO fracture type, time to 

surgery and surgical fixation were not predictive of CS. This is the 

first large study to report the incidence of CS from TSF. The incidence 

of 10.6% is higher than previously reported and much higher in 

patients 14 years of age and older and involved in an MVA. Surgeons 

should be especially aware and suspicious of CS in children with 

these risk factors. 



PaPers, Posters & scientific exhibits pediAtRics

pApeR No. 169 

Significant Rate of Misuse of the Hare Traction Splint 

in Pediatric Trauma 

Margot C Daugherty, MSN, MEd, RN, EMT-P, Cincinnati, OH 

Charles T Mehlman, DO, MPH, Cincinnati, OH 

Tom E Lemaster, MSN, MEd, RN, EMT-P 

Heather N Evans, BA 

Richard Falcone Jr, MD, MPH 

This study assessed the rate of misapplication of the Hare traction 

device among children evaluated at a pediatric trauma center. All 

patients three to 16 years old who presented to our pediatric Level 

I trauma center with a femur fracture between 2001 and 2007 were 

included. X-rays were reviewed by a multidisciplinary team for 

proper placement of the device according to application instructions. 

A total of 114 (25%) arrived with a Hare traction splint in place. The 

average age was 10.4 ± 3.5 years with a median injury severity score 

(ISS) of 9 (range of 4 - 42). Sixty-one percent (n=71) of the 116 Hare 

traction splints were applied incorrectly. Of the misplaced splints, 

56 had one identified placement problem and 15 had two or more 

problems. The rate of incorrect splint application was highest among 

children three to nine years old (72% vs. 54%, p=0.04) and among 

those with ISS>15 (69% vs. 60%, p=0.52). In pediatrics, the Hare 

traction splint is rarely utilized and often misplaced and should be 

replaced with simpler methods of immobilization. 

pApeR No. 170 

Skin Complications and Costs in Children Treated with 

Hip Spica Casts for Femur Fractures 

Rachel L DiFazio, MS, RN, cPNP, Beverly, MA 

Judith Anne Vessey, PhD 


Michael Timothy Hresko, MD, Boston, MA 

Travis H Matheney, MD, Boston, MA 

Spica cast immobilization remains the treatment of choice for femur 

fractures in children aged six months to six years. The incidence 

of skin complications and their associated charges have not been 

well described. This study’s purposes were to: 1) determine the 

rate of skin complications in children treated with spica casts for 

femur fractures, 2) identify predictors and 3) calculate the charges 

associated with skin complications. Health records for all patients 

treated with immediate spica casting for a femur fracture at a major 

tertiary care children’s hospital from 2003-2009 were reviewed and 

relevant data were abstracted. Descriptive statistics and univariate and 

multiple logistic regression analyses were used to compare children 

with and without skin complications and to identify predictors of 

skin complications. Overall charges for skin complications leading 

to a cast change and early bi-valving and lining were calculated. Of 

the 300 spica cast applications in 297 patients, 77 subjects (28%) 

had skin complications. Twenty-four (31%) of these 77 patients 

underwent a cast change in the operating room, 34 (44%) required 

early bi-valving and lining and 19 (25%) required cast trimming 

and skin care. Predictors of skin complications included; child 

abuse as mechanism of injury, younger age and cast time > 40 days. 

Gender, weight, fracture location and total number of clinic visits 

were not statistically significant predictors of skin complications. 

The median charge for patients that required cast changes for skin 

complications was $12,719 ($8,632-$53,768), while the median 

charge for bi-valving and lining was $416.51 ($403.32-$449.00). 

Spica cast treatment is associated with numerous skin complications 

and additional charges. Victims of child abuse may benefit from 

additional clinical oversight. Future research needs to investigate 

623 

patient education and casting interventions that reduce skin 


pApeR No. 171 

Overgrowth After Femoral Shaft Fractures In Infants 

Treated With A Pavlik Harness 

William L Hennrikus Jr, MD, Hershey, PA 

John Mahajan, BS 

Fractures of the femur in children age two to 12 years heal with an 

expected overgrowth response. However, in infants, age less than 

one, the overgrowth response is variable and some authors have 

suggested that overgrowth does not occur. The purpose of this paper 

is to determine if overgrowth occurs when treating femur fractures 

in infants using a Pavlik harness. The charts and radiographs of 30 

patients age less than one year old treated with a Pavlik harness for 

a femoral shaft fracture were reviewed. Seven patients were lost to 

follow up or had less than 18 months follow up and were excluded 

from the study. For the remaining 23 patients, a teleoroentgenogram 

-- one film with a single exposure for the entire lower limbs to 

measure limb lengths -- was performed 18 or more months after 

the injury. In addition each patient was examined for range of 

motion, rotation, gait and thigh circumference. Fifteen boys and 

eight girls were studied. Fourteen right femurs and nine left femurs 

were fractured. The average age at injury was five months (range 

1d-11 months). The average time in the Pavlik was 26 days (range 

14 to 44 days). Twelve of 23 patients underwent a nucleic acid test 

evaluation. The average radiographic shortening at injury was 7 mm 

(range 1-18mm). Ten fractures were transverse and 13 were oblique. 

The average final radiographic femoral length was 2 mm longer on 

the injured leg (range 5 mm short to 5 mm long). Fourteen of 23 

fractures demonstrated overgrowth averaging 5 mm (range 1 to 18 

mm). Range of knee and hip motion was equal in all patients. Gait 

was symmetrical for age in all patients. Minor -- less than 10 degree 

-- changes in hip rotation were noted in two patients. Overgrowth 

following femur fractures in infants occurred in the majority of 

cases. Overgrowth does reliably occur in infants with up to 2 cm 

shortening. Pavlik harness treatment of femur fractures in 23 children 

less than one year of age resulted in no case of significant leg length 

inequality, gait change or rotational issues. 

pApeR No. 172 

What Is The Morbidity Rate Of Supracondylar Elbow 

Fractures In Children? 

Sumeet Garg, MD, Denver, CO 

Amanda Lindsley Weller, MD, Dallas, TX 

Nicholas D Fletcher, MD, Atlanta, GA 

Michael Soon Kwon, MD, Dallas, TX 

Annalise Noelle Larson, MD, Saint Paul, MN 

Jonathan R Schiller, MD, Providence, RI 

Christine Ann Ho, MD, Dallas, TX 

Lawson A B Copley, MD, Dallas, TX 

Established morbidity rates for supracondylar elbow fractures in 

children are based on either small cohorts of patients and/or data 

collected over a prolonged period of time. Our purpose was to 

retrospectively review the morbidity and demographics of type 3 

extension and flexion type supracondylar fracture at a high volume 

pediatric trauma center over a four-year period. The patient cohort 

was identified retrospectively through the use of CPT code 24538 in 

the billing database from 2004-2007. Emergency, operative, inpatient 

and outpatient records were reviewed to determine morbidity at 

presentation as well as operative and post-operative complications 




and their resolution. Over four years, 1,298 patients had an 

operatively treated supracondylar elbow fracture. Some 67% (873) 

had type 3 fractures, 31% (399) had type 2 fractures and 2% (25) had 

flexion type fractures. Children with type 2 fractures were excluded 

from morbidity and complication analysis. Age at injury averaged 

5.9 years (SD 2.6 years) with a nearly even gender distribution (54% 

male, 46% female). There was no palpable pulse in 4.2% (54) of 

patients at presentation. Only 15 patients had open injuries (1.1%) 

and 18 developed either superficial or deep infection (1.4%). Nerve 

palsy occurred in 5.5% (72) with a mean time to resolution of 52 

days. Children with absent pulse at presentation had a significantly 

higher rate of nerve injury than those who had a palpable pulse 

(32% vs 7%). There was no difference in time to resolution between 

those with palsy identified pre or post-operatively. Time to surgery 

averaged 16 hours from injury; longer time to surgery was not 

associated with an increased morbidity rate. As age increased, the 

rate of nerve injury and need for therapy due to stiffness increased. 

Type 3 and flexion type supracondylar elbow fractures have a higher 

rate of morbidity than has previously been described. This study 

establishes benchmark morbidity and complication rates based on a 

high volume practice over a four-year period of time. 

pApeR No. 173 

Type 2 Supracondylar Fractures: Does Time to Surgery 

Matter? 

Annalise Noelle Larson, MD, Saint Paul, MN 

Amanda Lindsley Weller, MD, Dallas, TX 

Sumeet Garg, MD, Denver, CO 

Nicholas D Fletcher, MD, Atlanta, GA 

Michael Soon Kwon, MD, Dallas, TX 

Jonathan R Schiller, MD, Providence, RI 


Due to changing referral patterns, increasing numbers of pediatric 

supracondylar humerus fractures are treated at tertiary centers. To 

expedite patient flow, Type 2 fractures are sometimes pinned in 

a delayed fashion or in an outpatient setting. We hypothesized 

that delay in surgical treatment of Gartland Type 2 supracondylar 

humerus fractures would not affect the generally excellent outcome 

following closed reduction and percutaneous pinning. We performed 

a retrospective review of a consecutive series of 1,298 supracondylar 

fractures treated operatively at a tertiary referral center over four 

years. Thirty one percent (399 fractures) were Gartland Type 2 

fractures. Mean patient age in the Type 2 group was five years (range 

1 to 15). Some 46% were pinned within 24 hours, 24% pinned from 

one to five days and 26% pinned five days or more after the injury. 

A total of 4% of patients sustained a complication, but there was 

no association with complication and time to surgery. There were 

no compartment syndromes, vascular injuries or permanent nerve 

injuries. Six patients had open fractures (1.5%). Three patients 

sustained nerve injuries, and all underwent surgery within 24 hours 

of injury. One patient developed an ulnar motor and sensory nerve 

palsy after fixation with crossed K-wires. This resolved by seven weeks 

postoperatively. Two patients presented with an anterior interosseous 

nerve palsy - one resolved one week after surgery, the other by eight 

weeks postoperatively. Six patients (1.5%) were referred to physical 

therapy for persistent elbow stiffness. Satisfactory outcomes are 

possible even with delayed treatment of Type 2 supracondylar 

humerus fractures. Further prospective work is necessary to see if 

operative time or techniques differ or if there are subtle functional 

benefits with emergent treatment of Type 2 supracondylar humerus 

fractures. 

624 

pApeR No. 174 

Torsional Strength Of Pin Configuration In 

Supracondylar Fractures: Does Pin Diameter Matter? 

Anupam Pradhan, MD, Hershey, PA 

William L Hennrikus Jr, MD, Hershey, PA 

Gregory S Lewis, PhD 

April D Armstrong, MD, Hershey, PA 

Closed reduction and percutaneous pin fixation is the current 

treatment technique of choice for displaced supracondylar fractures 

of the distal humerus in children. Previous biomechanical studies 

have demonstrated that the maximum stability for fracture fixation is 

provided by crossed pins placed from the medial and lateral condyles. 

However, to our knowledge, none of the previous biomechanical 

studies were standardized for pin diameter. The purpose of this paper 

is to determine if pin diameter affects the torsional strength of the 

supracondylar fracture treated by closed reduction and percutaneous 

pinning. Pediatric sawbone humeri were used. Each sawbone 

humerus was osteotomized transversely at the mid- olecranon fossa 

level with a 2 mm ossillating saw to simulate a Gartland type III 

fracture. The osteotomy was then reduced and stabilized with pins 

using a hand held power wire driver. Four pin configurations were 

compared: two lateral, three lateral, one lateral and one medial, 

and two lateral and one medial pins. Bi-cortical fixation of both 

fragments was achieved with each pin. Lateral pins were placed in 

divergent fashion. Crossed pins were separated by more than 2 mm 

at the osteotomy site. Next, an axial torsion machine was utilized 

to test the torsional strength of each construct. The fixed specimens 

were subjected to a torsional load producing internal rotation of 

the distal fragment. Rotation in degrees and the corresponding 

torque were measured. We applied a torsional rotation of 1 dec/sec 

for a total of 30 degrees of rotation. The stability provided by 1.25 

mm and 1.6 mm smooth pins were compared. Torque required to 

produce 15 degrees rotation and 25 degrees rotation was significantly 

greater using larger diameter pins in all models tested. For example; 

for the two lateral pin model, the torque required to produce 15 

degrees rotation was .27 for the small pins and .39 for the large pins 

(31% greater torque). Similarly: two lateral pin model/25 degrees 

torque: small pins - .36 vs. large pins - .54 (33%). Three lateral pin 

model/15 degrees torque: small pins - .46 vs. large pins - .61 (26%). 

Three lateral pin model/25 degrees torque: small pins - .70 vs. large 

pins - .85 (17%). One lateral and one medial pin model/15 degrees 

torque: small pins - .61 vs. large pins - .83 (26%). One lateral pin and 

one medial pin model/25 degrees torque: small pins - 1.03 vs. large 

pins - 1.28 (20%). Two lateral and one medial pin model/15 degrees 

torque: small pins - .91 vs. large pins - 1.48 (39%). Two lateral and 

one medial pin model/25 degrees torque: small pins - 1.02 vs. large 

pins - 1.53 (33%). Best pin model stability at 15 and 25 degrees 

torque for both small and large pins demonstrated that two lateral 

and one medial pin were most stable, followed by one lateral and 

one medial pin, three lateral pins, and lastly two lateral pins. To our 

knowledge, this is the first biomechanical study examining the effect 

of pin diameter on supracondylar fracture stability. Size does matter. 

In a synthetic pediatric humerus model of supracondylar humerus 

fractures, larger diameter pins (1.6 mm) provided significantly 

increased stability compared to small diameter pins (1.25 mm) in 

all four pin configurations tested. 




pApeR No. 175 

The Location of the Medial Humeral Epicondyle in 

Children Based off Common Radiographic Landmarks 

Joshua Klatt, MD, Salt Lake City, UT 


Treatment of displaced medial humeral epicondyle fractures in 

children is somewhat controversial. The degree of displacement 

suffers from significant intra-observer variability. In this anatomic 

descriptive study, we describe the location of the medial epicondyle 

in relation to common radiographic landmarks of the elbow. 

We reviewed elbow radiographs of children aged four to 15 with 

proximal radial and/or ulna fractures. A total of 171 adequate studies 

were identified and studied. On the anteroposterior radiograph, a 

line was drawn down the center of the humeral shaft with a second 

line drawn perpendicular to this at the level of the inferior margin 

of the olecranon fossa. The tangential distance was determined from 

the center of the medial epicondyle apophysis to the olecranon fossa 

line. On the lateral radiograph, a line was drawn down the posterior 

cortex of the humerus. The tangential distance was determined 

from the center of the medial epicondyle apophysis to the posterior 

cortical line. Some 54% were female and 44% were male. There 

were at least 10 patients in every age group from four to 15. On 

the anteroposterior radiographs, the average location of the center 

of the medial epicondyle was 0.5 mm inferior to the olecranon 

line (standard deviation: 2.0 mm). On the lateral radiographs, the 

average location of the center of the medial epicondyle was 1.2 mm 

anterior to the posterior humeral line (standard deviation: 1.2 mm). 

The anatomic location of the medial epicondyle can be determined 

using common radiographic landmarks. This may be helpful in 

assessing fracture displacement in medial epicondyle fractures in 

children. 

pApeR No. 176 

Prospective Longitudinal Evaluation of Elbow Motion 

Following Pediatric Lateral Condyle Fractures 

Nicholas Bernthal, MD, Venice, CA 

Christopher Max Hoshino, MD, Torrance, CA 

Daniel Dichter, BA 

Melissa Wong, Montebello, CA 

Mauricio Silva, MD, Playa Vista, CA 

A prospective, longitudinal evaluation of range of motion was 

performed in a large population of children undergoing treatment 

for a lateral condyle fracture (LCF). A total of 141 LCFs, with mean 

age of 5.2 years (0.2-14.9) and mean follow up of 29 weeks (7-116), 

were evaluated. Based on the amount of displacement, patients 

were treated with casting, percutaneous pinning or open reduction 

and pinning. Relative arc of motion (RAM) was calculated as a 

percentage of motion of the normal, contralateral elbow. At the time 

of cast removal, the mean RAM was 44%, reaching 84% by week 

12. RAM reached 87%, 90%, 93% and 97% by weeks 18, 24, 36 

and 48, respectively. LCF treated without surgery had significantly 

lower RAM from the time of cast removal (7%, p=0.005) and up to 

18 weeks after the injury (11%, p

pApeR No. 178 

Pelvic Fractures In Children: A Modification Of A Pre- 

Existing Classification 

Ben Shore, MD, Boston, MA 

Catherine Bevan, MD, Melbourne, VIC Australia 

Cameron Palmer, MD 

Michael Johnson, MD, North Melbourne, VIC Australia 

Ian P Torode, MD, Parkville, VIC Australia 

The Torode classification system for pediatric pelvic fractures (PPF) 

was published in 1985, based on plain film interpretation alone. 

Today CT scanning has become common in the evaluation of PPF. 

The purpose of this study was to investigate whether this classification 

is predictive of outcomes, morbidity and or mortality. PPF were 

recorded on a prospectively identified hospital registry of all trauma 

admissions. The X-rays and CT scans were reviewed and classified. 

Correlation was made with age, gender, mechanism, associated 

injuries, intensive care unit (ICU) stay, operations and discharge 

outcome. Blood product usage was obtained from a haematology 

database. A total of 124 patients were identified with PPF, comprising 

0.79% of trauma admissions between July 2000 and June 2008. 

Radiology was available for 115 patients (58 males, and 57 females): 

grade I = 5, grade II = 16, grade IIIA = 43, grade IIIB = 39, grade 

IV =12 patients. Six patients died; with an overall mortality of 5% 

(two patients from each of the groups IIIA (5%), IIIB (5%) and IV 

(16%), Cochran-Armitage trend test p=0.004). Blood product usage 

increased with Torode grade: I = 0%, II = 25%, IIIA = 16%, IIIB = 

41%, IV = 58%, p=0.02. Median ICU stay increased across the grades: 

I =0, II =1.0, IIIA = 2.4, IIIB = 3.3, IV = 6.9 days. The modified Torode 

classification is predictive for significant morbidity and death in the 

setting of multi-trauma. CT scanning helps identify posterior pelvis 

fractures which are predictive of increased blood product use and 

increased ICU requirement. 

pApeR No. 179 

The Surgeon Learning Curve for Type III Supracondylar 

Humerus Fractures in Children 

Raymond Liu, MD, Cleveland Heights, OH 

Joanna Helena Roocroft, MA 


Burt Yaszay, MD, San Diego, CA 

Supracondylar fractures are the most common pediatric elbow 

fractures, and have been increasingly referred to regional pediatric 

orthopaedic trauma centers. We reviewed all supracondylar fractures 

operatively treated by pediatric orthopaedic fellows from 2003- 

2009. Flexion type and open fractures were excluded. Presence of 

backup attending, surgery time and fluoroscopy time were recorded. 

Type II fractures were used solely to track the number of cases for 

each fellow. Non-ideal radiographic results on type III fractures were 

defined by: Baumann angle outside the range of 64°-81° and/or 

an anterior humeral line not intersecting the capitellum. Staff cases 

from 2005-2007 served as a control. Twenty-one fellows surgically 

treated 479 total fractures (23 per fellow), with 213 type III. There 

were no significant changes in surgery or fluoroscopy time between 

the four academic quarters. Staff supervision was highest the first 

quarter (39%) and decreased to a baseline by the second quarter 

(12%). This correlated with an increase in non-ideal radiographic 

results between cases 7 and 15, from 21% to 33%, after which the rate 

decreased. There were four compartment syndromes, one infection, 

one postoperative ulnar nerve palsy and no malunions requiring 

osteotomy, with no significant differences between fellows and staff. 

Fellows became essentially independent by the second academic 

626 

quarter. A notable increase in suboptimal results began at case 7 and 

reversed at case 15, with no difference in true complications. Overall, 

we define a relatively short learning curve for pediatric orthopaedic 

fellows treating type III supracondylar humerus fractures. 

pApeR No. 180 

Fractures at Pediatric Implants: A 15-year Review 

Paul D Sponseller, MD, Baltimore, MD 

Gurkan Erkula, MD, Baltimore, MD 

Arabella I Leet, MD, Baltimore, MD 

Michael Craig Ain, MD, Owings Mills, MD 

Amit Jain, BS, Portland, OR 

Implants are routinely used to treat fractures and to stabilize 

osteotomies in children. Their role as stress risers is often a concern, 

especially after years of growth. Implant related fractures (IRF) are 

mentioned briefly in literature. We report a comprehensive survey of 

their incidence and characteristics at our institution. A retrospective 

analysis of records and images in a pediatric population from 

1995 and 2009 was carried out. We tabulated all implants inserted 

at each skeletal location and identified IRF cases and risk factors. 

Demographics, type of implant and the location of the fracture were 

recorded. During the study period, 7,584 implants were inserted 

and 1,844 implants were removed. There were 25 cases of IRF in 22 

patients. Mean age at fracture was 11.8±4 years, with average 2.8±2.6 

years between insertion and fracture. Patient diagnoses leading 

to original surgery were cerebral palsy in nine, syndromes in five, 

fracture in four, hip dysplasia in two and spina bifida and slipped 

capital femoral epiphysis in one patient each. Overall IRF risk was 

3.3 per 1,000 implants with 0.56 per 1000 implants at the arm, 

forearm and hand; 8.9 per 1,000 implants at the femur and hip; and 

0.95 per 1,000 implants at the leg, ankle and foot. Fractures were 15 

times more likely to occur at the hip and femur compared to other 

locations combined (p

hooks plowed intra-operatively resulting in bone damage. The 

average time to loss of fixation was 19 months for both implants. 

There were no complications involving neurologic or vascular injury 

directly related to a hook or screw. Pedicle screws in growing rods 

have significantly less complications than hooks (p

in the tethered group (54.9±7.7µm, 11.1±2.1µm) vs. controls 

(85.7±16.3µm, 16.5±1.9µm) respectively (p

pApeR No. 398 

Significant Differences among Patients in Lenke Curve 

Types 

Paul D Sponseller, MD, Baltimore, MD 

The use of Lenke curve types (for surgical planning, research and 

perhaps future genetic study) raises an important question: do Lenke 

types distribute in a homogeneous way, or are there significant 

differences in gender, age, frequency, magnitude at surgery, etc? We 

studied nearly 2000 surgical patients to answer this. Parameters of 

1,912 adolescent idiopathic scoliosis (AIS) patients 75°); most smaller curves were LT 1 & 5. The 

largest mean curve was Type 4 (78o)*, followed by 3 (63°), 2 (60°), 

6 (59°), 1 (52°)* and 5(46°)* (* comparisons p75°, 14.6 for curves 50- 

75°, and 15.2 for curves

pApeR No. 401 

The Role of Preoperative Cardiac Screening Studies in 

Adolescent Idiopathic Scoliosis Surgery 

Roger F Widmann, MD, New York, NY 

Lisa Ipp, MD 

Patrick Flynn, MD 

John S Blanco, MD, New York, NY 

Oheneba Boachie-Adjei, MD, New York, NY 

Jeanine Kozich, MD, New York, NY 

Daniel William Green, MD, New York, NY 

Roger F Widmann, MD, New York, NY 

Prevalence of asymptomatic cardiac disease in adolescents with 

adolescent idiopathic scoliosis (AIS) has never been reported. 

We have documented significant cardiac findings in a cohort of 

asymptomatic patients with AIS. Retrospective chart review of all presurgical 

AIS patients from 2000-2007 was completed. Demographic 

information including age at surgery, sex, curve magnitude, fusion 

type, instrumentation and surgical course were compiled. Patients 

with neuromuscular scoliosis or known/suspected cardiac disease 

were excluded. Records of the pre-surgical screening 12 lead EKG, 

two dimensional (2D); Doppler and M-mode echocardiograms were 

analyzed. Charts of 215 patients with AIS who were indicated for 

surgery were reviewed. Three patients were excluded because the 

studies were not ordered. All patients were examined by a general 

pediatrician at the time of the pre-surgical clearance visit and had 

normal cardiac examinations. Of the 212 subjects (age 12-18), 154 

(73%) were female and 58 (27%) were male. A total of 141 (67%) of 

these patients had normal EKGs and echocardiography findings. In 

32 (15%) subjects with EKG abnormalities, 28 (88%) had ‘normal 

variant readings,’ as outlined by the American Hospital Association 

statement on screening EKGs in attention-deficit hyperactivity 

disorder (ADHD) patients (Vetter, et. al) and four subjects’ EKGs 

met LVH by voltage criteria. However, echocardiograms were within 

normal limits in these patients. Significant echocardiogram findings 

(table 1) revealed two subjects with atrial septal defects (that delayed 

spine surgery) and seven (3.3%) subjects with aortic root and/or 

valve abnormalities. Pre-surgical population abnormalities ranged 

from mild to severe, and in two cases, affected the surgical timing. 

In the adolescent patient with severe scoliosis indicated for surgery, 

novel findings of aortic abnormalities were identified in 3.3% of our 

patient population (7/212). Interestingly, the incidence of mitral 

valve prolapse in our study was only 4.7% which is lower than 

described in prior studies, (14%-26%, Dhuper and Hirschfield) and 

closer to the rate in the general population of 3.2% (Dhuper). In a 

study which examined the prevalence of heart disease in randomly 

selected healthy adolescents with previously unknown cardiac disease 

(Steinberger, et. al), the authors found a rate of 3.6% (13/357) of 

cardiac anomalies. Interestingly, none of these patients were found 

to have aortic root or valve abnormalities. The aortic root and valve 

abnormalities appear to be unique findings in patients with severe 

AIS, and likely point to a long suspected collagen vascular component 

in this disease. Echocardiograms may be indicated in patients with 

AIS. Further studies will need to clarify the relationship between AIS 

and occult cardiac disease. 

630 

pApeR No. 402 

Intraoperative versus Postoperative Radiographs 

Following Instrumentation for Idiopathic Scoliosis 

Sanjeev Sabharwal, MD, Chatham, NJ 

Alexios Apazidis, MD, Patchogue, NY 

Caixia Zhao, MD 

Heidi Hullinger, MD, New York, NY 

Michael Vives, MD, Newark, NJ 

While intraoperative radiographs following surgical correction of 

adolescent idiopathic scoliosis are often performed, the validity of 

such imaging has not been well documented. The purpose of our 

study was to compare the frontal plane correction as measured on 

intraoperative supine radiographs following posterior segmental 

instrumentation with similar measurements made using postoperative 

full-length standing radiographs. Additionally, we sought to 

evaluate whether the type and extent of spinal instrumentation 

affected the magnitude of discrepancy between the intraoperative 

and postoperative radiographs. Frontal plane Cobb angles of all 

thoracic and thoracolumbar/lumbar curves were measured on the 

intraoperative supine (IO), initial postoperative (IPO) and final 

postoperative (FPO) standing radiographs. A total of 74 patients with 

adolescent idiopathic scoliosis underwent surgical correction with 

posterior segmental instrumentation using either all pedicle screw 

(21 patients) or hybrid constructs (53 patients). The main thoracic 

curve was instrumented in all patients, proximal thoracic curve in 

61 and thoracolumbar/lumbar curve in 20 patients. The mean Cobb 

angle was 57° preoperatively, 17° (IO), 18° (IPO) and 20° (FPO) 

for the main thoracic, 27° preoperatively, 14° (IO), 15° (IPO) and 

16° (FPO) for proximal thoracic and 42° preoperatively, 12° (IO), 

14° (IPO) and 14° (FPO) for thoracolumbar/lumbar curves. There 

was a strong correlation between the IO and IPO measurements for 

the proximal thoracic, main thoracic and thoracolumbar/lumbar 

curves (r=0.73, 0.83 and 0.84, respectively, p12 years. Associated injuries were classified as 

abdominal trauma, thoracic trauma, closed head injury, other spinal 

fracture, appendicular skeletal fracture or neurologic injury. Of 




special interest was the frequency of noncontiguous spinal fractures. 

Overall, 80% had associated injuries; 46% had multiple spinal 

fractures, 36% of which were at noncontiguous levels. Children aged 

0-3 years had the highest number of associated injuries (87%), as 

well as the most frequent orthopaedic injuries (33%) and neurologic 

injuries (29%). Older children (four-12 years and >12 years) had 

similar numbers of associated injuries (77%), but juveniles (4- 

12 years) had fewer orthopaedic injuries (5% vs 24%). Spinal 

fractures in children, especially those aged 0-3 years, frequently are 

indications of associated injuries. Nearly half of pediatric spinal 

fracture patients have additional spinal fractures, over a third of 

which are noncontiguous. Imaging studies should include the entire 

spinal column to avoid missing these fractures. 

pApeR No. 404 

Age-Related Patterns of Spine Injury in Children 

Involved in All Terrain Vehicle (ATV) Accidents 


Michael J Beebe, MD, Salt Lake City, UT 

Norfleet Buckner Thompson, MD, Memphis, TN 

Aaron Creek, Memphis, TN 

Matthew G. Yantis, MD 



All-terrain vehicle (ATV) accidents are a significant source of 

morbidity for children and their use continues to increase. The 

purpose of this study is to characterize ATV-related spine injuries in 

children and adolescents. An Institutional Review Board-approved 

retrospective review of ATV-related spine injuries over a five-year 

period at two pediatric trauma centers was performed. Records were 

evaluated for demographic factors, spine/associated injuries, surgical 

procedures and hospital charges. Patients were divided into age 

groups (16 yrs). There were 52 spine injuries in 29 patients 

(1.8/pt) with a mean age of 15.8 years (range 6-18 yrs). There were 

14 females (48%) and 15 males (52%). Multiple spine injuries were 

common: 45% of patients had >1 spine injury (range 1-5). There 

were seven cervical (14%), 22 thoracic (42%), 16 lumbar (31%) and 

seven sacral fractures (14%). Compression/burst fractures were the 

most common fracture type (31%). There was one mortality (3%). 

Six patients (21%) had closed head, six (21%) had intrabdominal 

and three (10%) had thoracic injuries. Nine (31%) had one, six 

(21%) had two and one patient (3%) had three major associated 

injuries. Older children had a lower pediatric trauma score (p=.004) 

and were more likely to have a thoracic spine fracture (p=0.012). 

Lumbar spine fractures (p

internal foot progression angle was the most frequent kinematic 

abnormality seen in follow up in 63% of patients, although 62% of 

feet had improvement in the degree of intoeing. Kinetic data showed 

increased ankle power and moment post-operatively which was 

significantly greater in the split transfers compared to full. There was 

a 6% occurrence of new onset footdrop post-operatively, all in the 

full transfer group. Pre-operative pedobarographs had the greatest 

peak pressures in the lateral mid- and forefoot while post-operative 

peak pressures were shifted to the hindfoot and more medially along 

the foot, indicating correction of forefoot supination. After anterior 

tibialis tendon transfer, normal sagittal ankle motion was seen in 

31% of feet. Patients after transfer did have increased mean ankle 

power and moment and increased medial pressures in the fore-, 

mid- and hindfoot. 

pApeR No. 422 

Reliability Of The Dimeglio Classification For Clubfoot 

Armando Torres-Gomez, MD, Mexico City, DF Mexico 

Nelson Cassis, MD, Mexico City, DF Mexico 

Gilberto Rios, MD 

Ricardo Velutini, MD 

Juan-Carlos Falcon, MD, MSc 

Dimeglio’s classification for clubfoot has become the most widely 

used system for grading this deformity. We sought to report the 

reliability of the Dimeglio system for congenital clubfoot in terms 

of intraclass correlation coefficients (ICCs) considering three raters 

during the process and the homogeneity of the scale in terms of 

Cronbach’s alpha. We designed a prolective observational study, 

with randomly selected patients and three fixed raters (observers) 

to assess the reliability and homogeneity of Dimeglio’s classification 

for clubfoot. From March 31 2009 to June 31 2010, we evaluated 144 

feet (subjects) with clubfoot deformity. A special collection sheet 

was designed for this study; it included diagrams of the Dimeglio 

classification with guides to scores, closed responses and coding of 

each observer to permit a blind analysis. Sample size was calculated 

using Bonnet’s formula; based upon obtained reliabilities, the 

number of raters (three), the desired width of the confidence interval 

(w = 0.08) and statistical significance (Z-alpha = 1.96) for a twotailed 

alpha level of 0.05. A sample of 130 subjects was obtained. 

Sampling was achieved with stratified randomization to obtain a 

platykurtic distribution of scores (k = -0.38). Each observation was 

codified for analysis purposes. Statistical analysis: we used a two-way 

random effects Analysis of Variance (ANOVA) mixed effects model; 

mean squares were used to calculate the intraclass correlation 

coefficients ICC2 (C,1) for consistency and ICC2 (C,2) for agreement. 

We calculated all the possible split-half reliabilities of the scale 

(internal consistency and homogeneity) in terms of Cronbach’s 

alpha, for all the observations and for each observer. The intraclass 

correlation coefficients (95% CI) for consistency ICC2 (C,1) was 

0.8554 (0.8087 to 0.9022, p=0.013) corresponding to the intra-rater 

reliability. The ICC (A,1) was 0.8521 (0.8049 to 0.8993, p=0.098), 

equivalent to the inter-rater reliability. Observations without a data 

collection sheet, where raters did not have an immediate reference to 

the classification, yielded a lower reliability of ICC2 (C,1) = 0.7872 

and ICC (A,1) = 0.5424. Cronbach’s alpha resulted in 0.8149, which 

denoted homogeneity of Dimeglio’s classification. Dimeglio’s 

classification is reliable. We recommend incorporating a collection 

sheet into medical files to increase reliability. The classification of 

Dimeglio, the most cited classification system for clubfoot, has 

excellent reliability and an ability of 85.54% to differentiate the 

deformities of clubfeet. 

632 

pApeR No. 423 

A Comparison of Children with Clubfoot Who 

Underwent Surgical or Ponseti Treatment 


Julie Coplan, DScPT 

Chris Church, PT 

Dijana Poljak 

John D Henley, PhD 

Roland Starr, MS, Baltimore, MD 

Mohan Belthur, MD, Houston, TX 

Ahmed Mohamed Thabet, MD, Benha, Egypt 

Freeman Miller, MD, Wilmington, DE 

No long-term clubfoot studies have compared surgery versus 

Ponseti method using gait analysis, pedobarographs and outcome 

instruments. Two groups underwent clubfoot treatment (minimum 

five-year follow up) and were evaluated retrospectively: posteromedial 

release (PMR) surgery group (n=26, feet=43, ages 5-11 years) and 

Ponseti group (n=22, feet=35, ages 5-10 years). Ponseti group had an 

average of 5.0 casts (range, 3-8 casts); 18 of 22 patients underwent 

Achilles tenotomy. Five feet in Ponseti group relapsed and required 

additional casting. Three required surgery (two anterior tibialis tendon 

transfers, one Achilles lengthening). Physical exam measurements, 

pedobarographs, gait analysis and outcome measurements were 

obtained. Results were compared with published values for normal 

feet. Operative group had reduction in dorsiflexion (-0.6±8.6°; 

p

patients by CPT code having foot arthrodesis or osteotomy. Eightytwo 

patients met the inclusion criteria. Patients were classified into 

three groups, GA, PNB/NS and PNB/US, with analysis of variance 

and Z-tests being used to compare means and proportions between 

groups. There was no statistical difference in the body weight and 

type of procedure performed in the GA (N=22), PNB/NS (N=39) 

and PNB/US (N=21) groups. The PNB/US group had the lowest 

verbal analog pain scores for the first six hours (p = .049), the 

highest proportion of patients who were pain free for eight and 12 

hours (p

pApeR No. 428 

Limb Reconstruction or Amputation for Severe Fibular 

Deficiency: A Two-Center Comparison 

Dror Paley, MD, West Palm Beach, FL 

John G Birch, MD, Dallas, TX 

Stacy C Specht, MPA, Baltimore, MD 

Anne Morton, PhD 

Shan G Ward, PhD 

Kirsten Tulchin, MS 

Roland Starr, MS, Baltimore, MD 

Don R Cummings, CP LP, Dallas, TX 

Terry-Elinor R Reid, Riverdale, MD 

Children with severe fibular deficiency may undergo amputation or 

limb reconstruction. Twenty children who underwent amputation 

at one center were compared with 22 children who underwent limb 

reconstruction at a second center. Average evaluation age was nine 

years (range, five to 15 years) and included psychosocial status, 

quality of life (QOL) characteristics and patient/parent satisfaction 

surveys and gait analysis with timed 25-yard dash. Parents of males 

who underwent amputation perceived a lower QOL for their child 

(p38ºC, 

hematocrit 12,000/ml and C-reactive 

protein >13mg/L. The probability of MRSA osteomyelitis is directly 

proportional to the number of multivariate predictors: 92% for all 

four predictors, 45% for three, 10% for two, 1% for one and 0.1% 

for zero predictors (chi-square = 76.63, p

pApeR No. 431 

Pathologic Fractures In Children With Staphylococcus 

Aureus Osteomyelitis 

Jacob Weinberg, MD, Houston, TX 

Mohan Belthur, MD, Houston, TX 

Alejandro Verdugo, MD, Mexico City, DF Mexico 

Sherri B Birchansky, MD, Pearland, TX 

Edward O Mason, PhD 

Kristina G Hulten, PhD, Houston, TX 

Sheldon L Kaplan, MD 

William A Phillips, MD, Houston, TX 

E O’Brian Smith, PhD 

Osteomyelitis is a common musculoskeletal infection in children that 

can weaken the normal structure of the affected bone, placing it at 

risk for a pathological fracture. We studied risk factors for pathologic 

fractures in children with Staphylococcus aureus (S. aureus) 

osteomyelitis. Seventeen children who developed a pathologic 

fracture secondary to osteomyelitis between 2001 and 2009 were 

identified at a tertiary care pediatric hospital. A retrospective 

review and analysis of the clinical records, imaging studies, and 

microbiology was performed. These patients were compared to 49 

children with S. aureus osteomyelitis without fractures matched for 

age, site of infection, sex and antibiotic susceptibility. Pulsotypes 

were determined by pulsed field gel electrophoresis and polymerase 

chain reaction (PCR) detected the genes encoding for Panton- 

Valentine leukocidin (PVL). Statistical analysis (SPSS 18) was used 

to assess risk factors associated with fracture occurrence. Patients 

in the fracture group presented with osteomyelitis at an average of 

eight years of age (range two-17 years). Fifteen of 17 patients with 

pathological fractures had methicillin-resistant S. aureus (MRSA), 

and two had methicillin-susceptible S. aureus (MSSA) isolates. The 

control group had a similar ratio of these organisms. The mean time 

to fracture from disease onset was 72 days (range 20-150 days). The 

most common sites of fracture were the femur (n=9) and fibula 

(n=3). At hospital admission, temperature, inflammatory markers 

(WBC, ESR, CRP), BMI and days to presentation were similar in both 

groups. The length of hospitalization, number of surgical procedures, 

duration of antibiotics (oral, IV, and combined) and total number 

of complications were statistically different between the fracture 

and the control groups. Baseline MRI studies demonstrated a 

significantly higher incidence of subperiosteal abscess with relatively 

larger abscess circumference in the fracture patients. A sharper zone 

of abnormal marrow enhancement was also more common in 

these patients. The USA300-0114 pulsotype was more commonly 

associated with fracture microbiology, as compared to other 

USA300 variants or non-USA300 pulsotypes. S. aureus osteomyelitis 

is a serious infection that may predispose children to pathologic 

fractures. Children who undergo prolonged initial hospitalizations 

and multiple surgical procedures are at increased risk for fracture, as 

are patients with USA300-0114 pulsotype; in addition, MRI shows 

relatively larger subperiosteal abscess circumference and sharper 

zone of abnormal marrow enhancement pattern. Protected weightbearing 

is recommended in these children. 

635 

pApeR No. 432 

Musculoskeletal Infection in Patients Under 24 Months 

of Age 

Joseph T Lanzi, Jr MD, Waipahu, HI 

Robert Lane Wimberly, MD, Dallas, TX 

Lawson A B Copley, MD, Dallas, TX 

David A Podeszwa, MD, Dallas, TX 


Philip L Wilson, MD, Dallas, TX 

Richard H Browne, PhD, Dallas, TX 

We are aware of no significant orthopaedic literature specifically 

studying musculoskeletal infection in patients younger than 24 

months of age. Recently, an increase in the hospital volume and 

orthopaedic management of infection has been published. We 

assume an increased severity of illness in younger patients. Our 

hypothesis is the younger musculoskeletal infection patient will 

have increased laboratory markers, a broader spectrum of infectious 

organisms and prolonged hospital stays compared to an older 

cohort. We performed a retrospective chart review of 297 pediatric 

patients with musculoskeletal infections over two years at a single 

institution. Patients were divided into two groups based upon age 

at presentation: Group A patients were 0-24 months of age and 

Group B patients were 24 months-18 years of age at admission. 

We further divided Group A by six-month intervals to assess for 

differences in the youngest of patients. Parameters reviewed include 

admission white blood cell count (WBC), C-reactive protein (CRP), 

sedimentation rate (ESR), length of stay (LOS), culture results 

and antibiotic course. Statistical analysis was performed between 

the groups. Eighty-two patients comprised Group A and Group B 

numbered 215. Overall, the admission WBC counts for Group A 

and Group B were 14.48 and 11.76 (p=.0005) and the CRP values 

were 5.54 and 7.37 (p=.035), respectively. Some 37.8% of Group A 

patients were culture positive with a variety of organisms including 

methacillin resistant Staphylococcus aureus. When examining 

Group A in six month intervals, the youngest cohorts, 0-6 months 

of age, were culture positive in 67% and trended to the longest 

hospital stay of 10.8 days. We have found, through analysis of a large 

pediatric patient population, significant differences in admission 

inflammatory markers for children under 24 months of age. Further 

evaluation of the youngest patients confirmed a variety of isolated 

organisms and prolonged hospitalizations. 

pApeR No. 433 

Diagnosis and management of Dysplasia Epiphysealis 

Hemimelica 

Jennifer Kreshak, MD, Bologna, Emilia-Romagna Italy 

Nicola Fabbri, MD, Bologna, Italy 

Mark C Gebhardt, MD 

Marco Alberghini, MD, Bologna Emilia-Romagna, Italy 

Daniel Vanel, MD 

Onorfio Donzelli, MD 

Mario Mercuri, MD, Bologna, Italy 

Dysplasia epiphysealis hemimelica (Trevor’s disease) is a rare 

skeletal developmental disorder characterized by asymmetric 

osteocartilaginous overgrowth of one or more epiphyses, most 

commonly affecting the lower extremity. Retrospective study of 

41 patients seen at one institution between 1964-2009 with a 

histologic diagnosis of dysplasia epiphysealis hemimelica. Clinicoradiographic 

features were reviewed with updated follow up and 

functional results. There were 33 males and eight females; 39 

diagnosed before age 20, with a peak in the first decade. All patients 




had symptoms, most consisting of deformity and/or functional 

limitation with little or no pain. Ankle and knee were the most 

frequent locations, with disease most commonly occurring in the 

medial aspect of the joint (35). Thirty-seven had involvement of 

the lower extremity, four the upper extremity, one both; only two 

patients had bilateral findings. Multiple epiphyseal involvement 

was present in 13 patients. Excision and/or epiphyseal reshaping of 

the joint were performed in all patients, with selective periarticular 

osteotomy at a later age in six. Multiple surgeries were performed in 

eight patients with one post-operative complication (supracondylar 

femur fracture). At last follow up, 95% of the patients were without 

major limitation or pain. Dysplasia epiphysealis hemimelica is a 

rare and poorly understood condition, more common in boys with 

medial involvement of a lower extremity joint and early onset of 

symptoms. Absence of severe pain, despite residual stiffness, seems 

to play a role in patients’ acceptance of limitation. Close monitoring 

and surgical management were successful in preventing severe 

functional limitations in this retrospective study. 

pApeR No. 434 

Growth Plate Flow and Metabolism Screening Using 

MR: A New Application for Specialized MR Sequences 

Juan Manuel Shiguetomi-Medina, Aarhus C, Denmark 

Hans Stodkilde-Jorgenson, MD, DMSci 

Ole Rahbek, MD, Aarhus, Denmark 

Bjarne Moller-Madsen, MD, MSCI, Aarhus, Denmark 

Magnetic resonance imaging (MRI) can be used for studies of joint 

cartilage as well as bone growth plates. A number of MR derived 

parameters present aspects of viability and growth patterns: the 

apparent diffusion constant (ADC) is dependent on intracellular 

as well as extracellular water movements and as such related to cell 

viability and cell apoptosis. The ADC provides early signs of ischemic 

lesions; diffusion tensor images provide information on structure of 

the tissue and finally measurements of water concentration identify 

the areas with highest osteoblast activity. Normal pig tibiae were 

studied. Tomography, MR T1 and T2 sequences were performed and 

compared. Apparent diffusion coefficient and surface tension images 

were also performed and analyzed. Finally, methylmethacrylate 

embedding histology was performed using hematoxylin-eosin, 

toluidine blue and safranin stains. MR ADC and surface tension 

images are able to provide an overview of the cell metabolism 

measuring the movement and freedom of the water in the different 

tissues. These measurements can be interpretated as flow and 

metabolism respectively. Bony structures seen in high resolution MR 

images resemble those seen in histological sections. A number of 

MR derived sequences can be applied to cartilage-like tissue such 

as growth plate. These sequences provide images that correspond to 

flow and cell-metabolism. MR imaging provides enough evidence 

and information about the structure and behavior of the growth 

plate to propose a standardized protocol for MRI ADC and tension 

surface images. This should provide more information about growth 

disturbance causes and characteristics. 

pApeR No. 435 

Orthopaedic Surgeons are Less Likely to See Children 

Now Than 10 Years Ago, Regardless of Insurance 

Coleen S Sabatini, MD, San Francisco, CA 

Kira F Skaggs 

David Lee Skaggs, MD, Los Angeles, CA 

The purpose of this study is to assess availability of timely orthopaedic 

care to children in California. Ten years earlier an identical study 

in the same location found timely access to orthopaedic care was 

636 

available in 100% of offices polled to a child with private insurance 

versus 2% of offices to a child with Medicaid. 1] Fifty orthopedic 

offices were randomly contacted by phone to request an appointment 

for a fictitious 10-year old with an arm fracture. Each office was 

contacted twice with an identical scenario, once with the office 

told that the child had private insurance and once with Medicaid. 

Access to appointments based on insurance status was compared, 

as well as to access rates 10 years earlier. Of the 50 offices randomly 

selected, we were able to successfully reach 45. An appointment 

with an orthopaedist was offered within seven days to a child with 

private insurance by 42% (19/45) of the offices and 2% (1/45) of 

offices to a child with Medicaid (p

on 3T machine at baseline and one-year follow up. We analyzed on 

MR-images, the femoral morphology and epiphyseal changes related 

to age, status of the epiphyseal scar and location on the femur. We 

assessed on seven radial positions around the femoral neck, rotating 

from anterior to posterior, (1) head-radius, (2) neck-radius, (3) tiltangle, 

(4) epiphyseal-extension and the (5) alpha angle. Looking at 

the influence of age, we saw that as we expected, head and neck radius 

increase was highly significant (p

to the retained hardware. Retained pediatric hardware at the time of 

THA was associated with increased operative time, intra-operative 

fractures and hospital stays. Retained hardware was directly related 

to two of the four intraoperative fractures. Consideration should 

be given to removing hardware as a child to avoid the increased 

complexity of potential future surgery. 

pApeR No. 546 

Outcome of Legg-Calve-Perthes Disease Patients With 

Onset Before Six Years Of Age 

Junichi Nakamura, MD, Chiba, Japan 

Shunji Kishida, MD, Chiba, Japan 

Yoshitada Harada, MD, Yachiyo-City, Japan 

Koya Kamikawa, MD, Chiba, Japan 

Seiji Ohtori, Chiba, Japan 

Kazuhisa Takahashi, MD, Chiba City, Japan 

Munenori Takeshita, MD, Chiba City, Japan 

Tomonori Shigemura, MD, Chiba City, Japan 

Makoto Takazawa, MD, Chiba City, Japan 

The prognosis of Legg-Calve-Perthes disease (LCPD) in young patients 

had been accepted as favorable. The purpose of this study was to 

clarify the outcome of LCPD patients with onset before six years of 

age. From 1989 to 2007, of 332 LCPD patients, 71 patients were before 

six years at onset. We excluded four hips which were affected after six 

years of age in bilateral LCPD and nine hips of which epiphyisis had 

not been completely repaired. Then we retrospectively studied the 

remaining 74 hips in 62 LCPD patients with Image J 1.41v (National 

Institutes of Health, USA) and with SPSS 16.0. Mean age at onset 

was 4.0 years. Waldenström classification at presentation was initial 

stage in 51 hips, fragmentation stage in 21 hips and healing stage in 

two hips. Lateral pillar classification was group A in 11 hips, group B 

in 11 hips, group B/C in 13 hips and group C in 39 hips. Treatment 

methods were restriction of activity alone in 30 hips, a few weeks of 

hospitalized traction in 26 hips, A-cast in 12 hips, brace in 26 hips 

and operation in 10 hips. Modified Stulberg classification was class I 

in 16 hips, II in 9 hips, IIIa in 20 hips, IIIb in 21 hips and IV in eight 

hips at the mean age of 13.2 year. Correlation among following three 

measurements was noted (p=0.001); % sphericity (mean 72.6%), 

AHI (mean 73.2%), and ATD (mean 14.9 mm). Poor outcome was 

observed even in patients before six years of age with large necrotic 

area and subluxation. 

pApeR No. 547 

Validity and Reliability of Measuring Femoral 

Anteversion and Neck-Shaft Angle in Cerebral Palsy 

Chin Youb Chung, MD,PhD, Seoul, Republic of Korea 

Park Moon Seok, MD, Sungnam, Republic of Korea 

Lee Kyoung Min, MD 

Kwon Dae Gyu, MD 

In Ho Choi, MD, Seoul, Republic of Korea 

Proximal femoral deformity is a common problem in patients with 

cerebral palsy, which often needs surgical correction. The aim of the 

study was to determine the validity and reliability of the methods 

commonly used to measure the proximal femoral geometry in 

patients with cerebral palsy. Thirty-six consecutive patients (mean 

age 11 years, range from six to 20 years) with cerebral palsy were 

included. The validity and the interobserver reliability using three 

orthopaedic surgeons were evaluated for the physical examination 

determined by comparing the results of a trochanteric prominence 

angle test (TPAT), hip internal rotation (IR) and hip external rotation 

(ER) in the prone position with the femoral anteversion measured 

638 

on 2D CT. The validity, and the intra- and interobserver reliability 

were assessed by comparing the neck shaft angle on the hip 

internal rotation radiograph with that measured on the multiplanar 

reformatted CT image. TPAT showed excellent concurrent validity 

(r=0.862, p

pApeR No. 549 

uOutcomes of Minimally Invasive Multilevel Surgery 

for Children with Cerebral Palsy 

David A Yngve, MD, Galveston, TX 

Dana Wild, PT, PhD 

Raj Harry Shani, MD, Houston, TX 

Kelly D Carmichael, MD, Galveston, TX 

Christine P Baker, PT, EdD, Galveston, TX 

We describe minimally invasive lengthening of the gastrocnemius, 

hamstrings and hip adductors with 2-3 mm incisions and the use of 

ethanol block of the obturator nerve, using the selective percutaneous 

myofascial lengthening (SPML) procedure. The objective was to 

determine the short-term outcomes in terms of knee and ankle 

motion and the short-term and medium-term outcomes in terms 

of function. Twenty-seven ambulatory children with cerebral palsy, 

Gross Motor Functional Classification System II (56%), III (19%), IV 

(26%), mean age 8.7 years (range, four to eighteen years) at the time 

of surgery, had preoperative and postoperative videos, mean followup 

of 7.5 months. Function was determined by the Functional 

Mobility Scale preoperatively and at mean follow ups of 7.5 and 

35 months. The mean preoperative maximum knee extension in 

stance decreased 12.3°, from 21.9° to 9.6° (p

70 consecutive adolescent (16 years of age and under) patients who 

underwent hip arthroscopy were retrospectively analyzed. Subjective 

data included modified Harris hip score (MHHS), and patient 

satisfaction with outcome (10=very satisfied, 1=very unsatisfied). 

Average age at time of surgery was 15 years (range 13-16), 31% were 

males and 69% were females. CAM impingement was found in 10% 

of patients, pincer type in 15% and mixed-type in 75%. LT were seen 

in all patients, and 83% of these were repaired; the remaining were 

debrided. Limited femoral osteoplasty was done in 56 patients and 

rim trimming was performed in 55 patients. The average follow up 

was three years (range, 2-5 years). Average preoperative MHHS was 

60 (range, 31-85), and it improved to an average of 93 (range, 68- 

100). The median patient satisfaction was 10 (range, 5-10). After 

the index procedure, eight patients needed revision arthroscopy. All 

revisions were females. Median satisfaction with outcome following 

revision was 9 (range 7 to 10). Arthroscopic treatment of FAI and 

LT in the adolescent population is a safe procedure with excellent 

clinical outcomes. Females had a higher revision rate but were 

satisfied after revisions. 

pApeR No. 553 

Quality of Life in Patients with Fibular Hemimelia: 

Lengthening and Amputation 


L Alberto Harfush-Nasser, MD, Mexico City, DF Mexico 


Alex Betech, MD, Naucalpan, MEX Mexico 

Fibular hemimelia represents a challenge for the orthopaedic 

surgeon; several treatments are available. Treatment is aimed at 

restoring the function of the extremity and improving the quality of 

life (QoL) of these patients. Management for mild cases includes shoe 

lifts; limb lengthening and alignment procedures, epiphysiodesis or 

shortening of the contralateral leg. In more severe cases, there are 

two main therapeutic modalities: early amputation with prosthetic 

fitting, or limb lengthening and reconstruction. Which treatment is 

the best or the right one has been a debate between different authors 

and institutions, and continues to be in discussion. The purpose 

of our study was to assess the outcome of two different treatment 

methods for fibular hemimelia: lengthening and amputation, 

in terms of quality of life assessed by the Short Form-36 (SF-36) 

questionnaire. We present a cohort based, prolective study, with 

patients with fibular hemimelia treated at our institution in a 10year 

period, between January 1995 and December 2005. From 552 

patients with longitudinal deficiency of the lower limbs, 91 patients 

had the diagnosis of fibular hemimelia. These patients were divided 

into two groups: A) treated by tibial lengthening (30 patients) and 

B) treated by amputation and prosthetic fitting (61 patients). Two 

patients from group A and nine from group B were excluded due to 

incomplete medical records or follow up. Ten patients from group 

A and 28 from group B did not respond the questionnaire and were 

thus, eliminated. The study was performed with 42 patients, 18 from 

group A (mean age = 16.01 SD = 2.89); and 24 from group B (mean 

age = 11.09 SD = 4.47). The SF-36 questionnaire (to assess quality 

of life), was applied on our study group. A non-parametric test, the 

two tailed Mann-Whitney U test was used to assess differences in 

SF-36 scores between groups (level of significance set at 0.05). In 

terms of SF-36 scores, group A patients reported a median of 100 

(90.55 to 100), while group B patients reported a median of 89.44 

(63.61 to 98.88). This difference in medians between the two groups 

differed significantly (Mann-Whitney U = 21.00, n1 = 18, n2 = 24, p 

= 0.0000) Our study demonstrated that children treated with either 

lengthening or amputation for fibular hemimelia, both reported a 

good quality of life. However patients who were amputated scored 

640 

lower than those that were lengthened. Both treatment groups are 

different; the decision of whether to lengthen or to amputate a 

patient is based upon functionality of the foot. 

pApeR No. 554 

Bone Marrow Edema Patterns of the Knee in 

Symptomatic Pediatric Patients 

Sommer Hammoud, MD, New York, NY 

Christopher Kepler, MD, Philadelphia, PA 



Symptomatic pediatric patients referred for magnetic resonance 

imaging (MRI) commonly present with traumatic bone marrow 

edema patterns. This observational study has grouped these into six 

mechanistic patterns: hyper-extension; anterior tibial translation; 

patellar dislocation; varus or valgus load; direct contusion; and 

extensor mechanism overload. MRI referrals of symptomatic patients 

aged three-18 were captured. A total of 314 MRIs performed with a 

standard protocol at one institution were reviewed. Images and reports 

were reviewed and traumatic bone marrow edema patterns were 

analyzed. A traumatic bone marrow edema pattern was identified in 

95/314 studies. Patients with closed physes as well as bone marrow 

edema secondary to osteochondral lesion and discernable fracture 

line were excluded. Bone marrow edema patterns were grouped into 

one of six patterns in the remaining 60 patients. The average age was 

12.2 years. The most frequent pattern was patellar dislocation (n=19) 

followed by extensor mechanism overload (n=16) and anterior 

tibial translation (n=9). Bone marrow edema signal intensity on fatsuppressed 

sequences was classified as severe in 92% of cases. Bone 

marrow edema patterns are found in symptomatic pediatric patients 

with relatively high frequency. We speculate that the high strength 

of pediatric knee ligaments and tendons relative to epiphyseal bone 

contributes to the high rate of bone marrow edema patterns seen 

on MRI in the symptomatic pediatric patient. We propose that the 

majority of bone marrow edema patterns follow six specific patterns 

which can help the clinician recognize the mechanism of injury and 

thus, associated pathology. 

pApeR No. 555 

Rebound after Removal of Guided Growth Screw-Plate 

Devices 

Louise Reid Boyce Nichols, MD, Lutherville Timonium, MD 


Guided growth with the screw-plate system has become increasingly 

popular in young patients. When used in young patients, the screwplate 

device must be removed before skeletal maturity. We analyzed 

cases in which rebound deformities occurred after removal of screwplate 

devices. We reviewed cases of hemiepiphysiodesis about the 

knee performed at a single institution between 2005 and 2009. 

Measurements were obtained from preoperative and 10-month 

post-removal radiographs. Rebound was considered to be a change 

of greater than 3 degrees in the lateral distal femoral angle or medial 

proximal tibial angle after screw-plate removal. Thirty-one screwplates 

(23 patients) were inserted: 17 in medial distal femora and 14 

in medial proximal tibiae. Etiologies included 16 congenital cases 

and 15 developmental cases. Diagnoses included congenital femoral 

deficiency (three), fibular hemimelia (seven), both congenital 

femoral deficiency and fibular hemimelia (four), Marfan syndrome 

(one), chromosomal deletion (one), poliomyelitis (one), and 

idiopathic angulation (six). Eighteen (58%) of 31 cases experienced 

rebound. All 10 cases of congenital distal femoral valgus rebounded 

(p=.006). Two (40%) of five congenital proximal tibiae rebounded. 




In the developmental cases, three (43%) of seven femora and three 

(38%) of eight tibiae rebounded. Average age at removal was 10.6 

years (range, 6.1’13.9 years). Relapse after screw plate removal is a 

significant problem, particularly in the valgus femur. Risk factors for 

relapse may include younger age, congenital etiology and insertion 

of femoral plates. 

POSTERS 


Evaluation of Proposed Selection Criteria for Psoas 

Lengthening in Individuals with Cerebral Palsy 

Walter Huu Truong, MD, Toronto, ON Canada 

Tom F Novacheck, MD, Saint Paul, MN 

Adam Rozumalski, MS 

Cammie Beattie, PT, Toronto, ON Canada 

Michael H Schwartz, PhD, Minneapolis, MN 

No selection criteria have been agreed upon for psoas lengthening 

surgery. A retrospective, case controlled study was performed on 

children with cerebral palsy (CP) who underwent a single event 

multi-level surgery (SEMLS) and met two-out-of three of the 

following proposed selection criteria after gait analysis: 1) maximum 

hip extension no greater than 8° of flexion, 2) maximum pelvic tilt 

greater than 24°, and 3) pelvic tilt range of motion greater than 8°. 

One group had a psoas lengthening surgery as part of their SEMLS 

(psoas group) and one group did not (control group). The Gait 

Deviation Index (GDI), Pelvis and Hip Deviation Index (PHiDI) and 

Gross Motor Function Classification System (GMFCS) levels were 

compared. A total of 87 sides met two-out-of-three of the proposed 

selection criteria; 32 in the psoas group and 55 in the control group. 

Both groups showed improvement in function after SEMLS. There 

was a significantly greater improvement in GDI for the psoas group 

in patients with GMFCS levels 3 and 4 (+12.9 versus +7.7, p=0.02). 

Odds ratio for poor outcomes in PHiDI for the control group, 

compared to the psoas group, was 5.1 (95% CI 1.37 - 18.95), which 

was significant. Patients that met the proposed selection criteria 

did functionally better if psoas surgery was included as part of their 

SEMLS, especially if they were classified as GMFCS levels 3 and 4. The 

risk of no improvement in hip function after SEMLS was significantly 

greater if the parameters were met and psoas lengthening was not 

performed. 


MRI Analysis Of Normal And Dysplastic Glenohumeral 

Morphology In Children With Birth Palsy 

Michael L Pearl, MD, Los Angeles, CA 

Eric K Lee, MD 

Paul Didomenico, MD 

Lauren Peng, MD 

Spencer Woolwine, CS, Glendale, CA 

Brachial plexus birth palsy (BPBP) frequently results in severe 

glenohumeral deformity. Several classification systems exist, 

measurement of version and PHHA are common. Reliability data 

are lacking. The purpose of this study was to compare normal and 

abnormal MRI findings in BPBP and evaluate the inter-observer 

reliability of commonly used measures. Twenty-one bilateral MRI 

scans of children with internal rotation contractures (mean age 3.8, 

ER -13°) were evaluated by four independent reviewers trained in 

a protocol specific for slice selection and placement of reference 

641 

axes. Reviewers measured version, PHHA and assigned classification 

to two established systems: System A, (five categories) and System 

B, (seven categories). Inter-observer reliability was evaluated with 

intraclass (ICC)/Pearson correlations and percent agreement. System 

A was further analyzed after simplification to three categories. Mean 

retroversion and PHHA was 5.7° and 48.3%, respectively for the 

normal shoulder; 28.2° and 26.9% for the involved. Intraclass 

correlation coefficient (ICC) for version ranged from 0.49 to 0.91, 

pair-wise Pearson correlations from 0.36 to 0.79. ICC for PHHA 

similarly ranged from 0.45 to 0.90. For classification systems A and 

B, there was 81% and 67%, respectively. Reducing classification A 

to three categories increased agreement (90%). Reviewers were 

inconsistent in image slice selection for all but three/42 sequences. 

Despite rigorous instructions for making measurements, interobserver 

variability challenges the reliability of reported values 

without further diligence to methodology. Numerical measures 

falsely convey precision in clinical situations that may be better 

represented by descriptive classification. 


Osteogenesis Imperfecta Bone: Correlation of 

Histologic Structure With Radiographic Appearance 

Frederic Shapiro, MD, Boston, MA 

Kathleen Maguire, BA 

Evelyn Flynn, MA 

The strength of osteogenesis imperfecta (OI) bone depends on 

its histologic structure but radiographic appearance is currently 

used for clinical guidelines. This study correlates these parameters. 

Femoral and tibial cortical bone (41 samples) was assessed from 

17 OI patients type II, 4 and type III (osteotomy), 13]. Histologic 

grading: i) cortical compaction 75%]; ii) lamellar 

pattern [discontinuous, continuous]; and iii) percentage woven and 

lamellar bone [Grade 1: all woven; Grade 2: woven and lamellar- 

-2a woven > lamellar, 2b woven = lamellar, 2c woven < lamellar; 

Grade 3: all lamellar--3a partially compacted, 3b fully compacted]. 

Radiographic grading: i) cortical thickness: thin, thick; ii) long bone 

shape: bowed, straight. Histology: Compaction: 75%--22%. Lamellar pattern: all discontinuous. 

Percentage woven and lamellar bone: Grade 1--18%, Grade 2--82% 

(2a 10%, 2b 18%, 2c 54%), Grade 3--0%. Radiology: Cortices: thick 

58 %, thin 42%. Shape: bowed 84%, straight 16%. Correlations: All 

lamellar bone was discontinuous (short segments at random angles 

to adjacent segments). Cortical compaction: 75%, 

thick, usually straight. Percentage woven and lamellar: Grades 1, 

2a and 2b--thin cortices; Grade 2c--thick cortices; Grades 1, 2a-bowed; 

Grade 2b--bowed or straight; Grade 2c--straight. Type III OI 

cortical bone has woven and lamellar tissue with lamellae always 

discontinuous. Bone tissue compaction >75% and lamellar > woven 

bone accumulations correlate with thicker cortices and straighter 

bones. Histologic structure of OI bone is an important parameter in 

relation to radiographic deformation. 


An Accelerated Ponseti Method vs. The Standard 

Ponseti Method 

Paul Richard Harnett, MB, ChB, London, United Kingdom 

Jim Harrison, MBBS 

Robert Freeman, MBBS, Oswestry, United Kingdom 

Sometimes patients are forced to travel long distances to have their 

CTEV (congenital talipes equinovarus) treated with the standard 

proven Ponseti method. In some cases the journey may take days. 




In addition, keeping a plaster clean and dry for one week can be 

challenging and may result in loss of position. We hypothesized 

that a two-day interval would be equally effective as weekly plaster 

changes. We conducted a prospective randomized controlled trial 

comparing the standard Ponseti casting method with an accelerated 

method for the treatment of idiopathic CTEV. The standard weekly 

plaster changes method was accelerated to three times per week. We 

treated a total of 40 consecutive patients (61 feet). The initial median 

Pirani score was 5.5 (95%CI 4.5-6.0) in the accelerated group and 

5.0 (95%CI 4.0 - 5.0) in the control group. The scores decreased by 

an average 4.5 in the accelerated group and 4.0 in the control group. 

There was no significant difference in the final Pirani score between 

the two groups (Chi squared p-value = 0.308). The median number 

of treatment days in plaster was 16 in the accelerated group and 42 

in the control group (P

treated 479 total fractures (23 per fellow), with 213 type III. There 

were no significant changes in surgery or fluoroscopy time between 

the four academic quarters. Staff supervision was highest the first 

quarter (39%) and decreased to a baseline by the second quarter 

(12%). This correlated with an increase in non-ideal radiographic 

results between cases seven and 15, from 21% to 33%, after which 

the rate decreased. There were four compartment syndromes, one 

infection, one postoperative ulnar nerve palsy and no malunions 

requiring osteotomy, with no significant differences between fellows 

and staff. Fellows became essentially independent by the second 

academic quarter. A notable increase in suboptimal results began 

at case #7 and reversed at case #15, with no difference in true 

complications. Overall, we define a relatively short learning curve 

for pediatric orthopaedic fellows treating type III supracondylar 

humerus fractures. 


All-Epiphyseal ACL Reconstruction Improves Knee 

Stability: An In Vitro Study 

Matthew Stonestreet, MD, Akron, OH 

Kerwyn Jones, MD, Akron, OH 

Marcus Kirkpatrick, MD 

Kushal Shah, BS 

Caroline Frampton, BS 

Melanie Morscher, Akron, OH 

John J Elias, PHD, Akron, OH 

An all-epiphyseal approach to anterior cruciate ligament (ACL) 

reconstruction in pediatric patients is performed to restore knee 

stability without disturbing the physis. The influence of allepiphyseal 

ACL reconstruction on knee stability was evaluated 

in vitro. Ten cadaver knees were tested with the ACL cut and with 

an all-epiphyseal ACL reconstruction. The knees were placed on a 

testing frame and loaded with quadriceps (600 N) and hamstrings 

(200 N) loading at 0°, 15°, 30° and 45° of flexion. An anatomical 

coordinate system was set on the femur, and a sensor was fixed to 

the tibia to characterize tibiofemoral kinematics. Thin (0.1 mm) 

dynamic pressure sensors were inserted under the menisci and fixed 

to the tibia to characterize the center of force on the tibia. Paired 

t-tests were used to compare all data between the reconstructed 

and cut conditions at all angles. Reconstruction shifted the center 

of force anteriorly on the tibia. On the medial plateau, the anterior 

shift was approximately 3 mm, which was significant at all angles. 

On the lateral plateau, the anterior shift was approximately 2 mm 

from 15° to 45°, with the changes being significant for these flexion 

angles. Reconstruction significantly translated the tibia posteriorly at 

all angles and significantly reoriented the tibia into varus at 30° and 

45°. The reconstruction significantly shifted the tibia laterally and 

rotated the tibia externally for some conditions. The all-epiphyseal 

ACL reconstruction improves knee stability. Reconstruction primarily 

pulled the tibia posteriorly and also reversed other kinematic changes 

associated with ACL injury. 

643 


The Effects of Hypothyroidism on the Proximal Femoral 

Physis in Miniature Swine 

Jason C Tank, MD, Akron, OH 

Robin Jacquet, Akron, OH 

Elizabeth Lowder, Akron, OH 

Dylan Childs, MD, Akron, OH 

William J Landis, Akron, OH 

Todd F Ritzman, MD, Akron, OH 

Walter Horne, DVM 

Melanie Morscher, Akron, OH 

Dennis S Weiner, MD, Akron, OH 

Hypothyroidism has been associated with slipped capital femoral 

epiphysis (SCFE). Studies of hypothyroidism at a cellular level 

are limited, but the condition and its potential tissue effects in 

miniature swine could serve as a model for human comparison. 

This work intended to establish a defined hypothyroid state in 

immature miniature swine and evaluate specific molecular, cellular 

and extracellular responses of their growth plates to the hypothyroid 

condition. Two male, 10-week-old Sinclair miniature swine were 

given 6-propyl-2-thiouracil (PTU) in their water and two other like 

animals (controls) were provided water without PTU. Animal blood 

levels of thyroid stimulating hormone (TSH), triiodothyronine 

(T3) and thyroxin (T4) were monitored weekly. After 15 weeks, 

proximal femoral physes were harvested for histology, laser capture 

microdissection and quantitative reverse transcription-polymerase 

chain reaction analysis. Compared to controls, swine provided PTU 

had increased TSH and decreased T3 and T4 levels, features consistent 

with a hypothyroid state. Compared to controls, hypothyroid swine 

exhibited structurally altered physes and had statistically significant 

decreased gene expression levels of aggrecan (p < 0.05) and type X 

collagen (p < 0.1), trends toward decreased expression of type II 

collagen and SOX9 and no change in matrix metalloprotease-13 

expression. This is the first model establishing hypothyroidism 

in miniature swine. On control comparison, hypothyroid swine 

physes changed in the molecular and biochemical character of 

their proteoglycans and collagens in addition to their cellular and 

extracellular matrix architecture. These differences may provide 

insight into human growth plate disorders such as SCFE. 


Is Radiographic Evaluation Necessary in Children With 

a Clinical Diagnosis of Sever Disease? 


James Nick Rachel, MD, Memphis, TN 

John Barton Williams, BA 



Sever disease is usually diagnosed clinically, and radiographic 

evaluation considered unnecessary. To evaluate the need for 

radiographic evaluation with a clinical diagnosis of calcaneal 

apophysitis, we determined the frequency of abnormal radiographic 

findings in children with this clinical diagnosis. Clinical records 

and radiographs of children between the ages of four and 17 years 

with a chief complaint of heel pain were reviewed. Patients with an 

insidious onset of heel pain were included; those with acute trauma 

and a diagnosis of Achilles tendinitis were excluded. Radiographs 

were reviewed by three orthopaedists (blinded to the clinical 

diagnosis) to determine if any radiographic abnormalities were 

present. Review identified 98 patients (134 feet) with a mean age 

of 10.8 years. Positive radiographic findings (lateral radiographs) 




were identified in five patients (five feet): three calcaneal unicameral 

bone cysts (UBC), one distal tibial nonossifying fibroma and two 

calcaneal stress fractures (one patient had both a calcaneal UBC and 

a stress fracture in the same foot). The rate of abnormal radiographic 

findings in the 96 patients was 5.1% (3.75% in the 133 feet). The 

abnormal radiographic findings seen in 5.1% of children usually 

led to more aggressive treatment including close radiographic 

follow up or immobilization. Despite concern about exposure to 

ionizing radiation and the cost of medical imaging, routine lateral 

radiographs appear to be justified for screening of pediatric patients 

with heel pain. If a diagnosis of calcaneal apophysitis is made 

without obtaining radiographs, a lesion requiring more aggressive 

treatment could be missed. 


Acetabular Retroversion in Slipped Capital Femoral 

Epiphysis 

Harish Sadanand Hosalkar, MD, San Diego, CA 

Luis Moraleda, MD, Madrid, Spain 

Robert Hyun Cho, MD, Los Angeles, CA 


Kai Ziebarth, Bern, Switzerland 


Dennis R Wenger, MD, San Diego, CA 

The true etiology of slipped capital femoral epiphysis (SCFE) remains 

an enigma. Previous reports have mainly focused on abnormalities 

of the proximal femur. Our purpose was to identify any variations on 

the acetabular side, particularly related to version and orientation. 

We retrospectively reviewed radiographs of a 100 consecutive 

children with SCFE. Retroversion on plain radiographs was defined 

based on the cross-over sign and/or the presence of ischial-spine 

sign. All radiographs were also measured using validated Hip2Norm 

software. There were 115 slips (85 unilateral and 15 bilateral). Of 

these 115 slips, there were 24 acute slips, 15 acute-on-chronic, and 

74 chronic and two were unclassified. There was a positive crossover 

sign in all the involved hips and 99% of the non-involved hips 

(p=0.24). The mean retroversion-index was 34.61% for the involved 

hips and 30.76% for the uninvolved hips (p=0.037). There was a 

positive posterior wall sign in 93 (80.1%) involved hips and 71 

(83.5%) in the un-involved hips (p=0.63). We noted acetabular 

retroversion in all patients with SCFE on the involved side. These 

findings were consistent on the other side as well and 15% did have 

sequential slip. At this point we can only hypothesize whether this 

is a primary anatomical variation or a secondary phenomenon. The 

relative over-coverage in anterosuperior zone can certainly potentiate 

the shear forces on the capital femoral epiphysis with axial loading. 

Additionally the positive posterior wall sign significantly noted 

in our series is now established to be a factor for progression of 

osteoarthritis. These are purely morphological findings and will 

need prospective evaluations and additional data to support the 

correlation as well as implications from a treatment perspective. 

644 


Complications of Hip Arthroscopy in Children and 

Adolescents 

Mininder S Kocher, MD, MPH, Boston, MA 

Benedict U Nwachukwu, Boston, MA 

Eric D McFeely, BA 

Adam Nasreddine, BS, Boston, MA 

James A Krcik, MD, Orland Park, IL 

Dr Jeremy S Frank, Hollywood, FL 

Hip arthroscopy has become an established procedure for certain hip 

disorders. Complications of hip arthroscopy have been characterized 

in adult populations, but complications in children and adolescents 

have not been well described. The purpose of this study was to 

characterize complications of hip arthroscopy in children and 

adolescents. The study design was a retrospective review of 218 hip 

arthroscopies in 175 patients 18 years old and younger over a nineyear 

period by a single surgeon at a tertiary-care children’s hospital. 

Patient demographics, indications for surgery and complications 

after surgery were recorded. Indications for surgery included: isolated 

labral tear (n=131), labral tear with concomitant hip disorder (n=37), 

Perthes disease (n=10), hip dysplasia (n=5), juvenile rheumatoid 

arthritis (n=3), loose bodies (n=3), osteochondral fracture (n=3), 

synovitis (n=2), avascular necrosis (n=1), chondral lesion (n=1), 

iliopsoas tendinitis (n=1) and slipped capital femoral epiphysis 

(n=1). The overall complication rate in the study population was 

1.8%. Complications of arthroscopy included: transient pudendal 

nerve palsy (n=2), instrument breakage (n=1) and suture abscess 

(n=1). No cases of proximal femoral epiphyseal separation, 

osteonecrosis or growth disturbance were noted. Hip arthroscopy in 

children and adolescents appears to be a safe procedure with a low 

complication rate similar to adults. 


A Nearly Radiation-free Approach to the Treatment of 

Developmental Dislocations of the Hip 

Meghan N Imrie, MD, Menlo Park, CA 

Stephanie Pun, MD, Stanford, CA 

Lawrence A Rinsky, MD, Palo Alto, CA 

James G Gamble, MD, PhD, Palo Alto, CA 

John D MacKenzie, MD, San Francisco, CA 

Awareness of exposure to ionizing radiation to both patients and 

surgeons during the course of orthopaedic treatment has been 

increasingly recognized. In the case of developmental dislocations 

of the hip (DDH), patients are subjected to radiation preoperatively, 

as part of diagnosis (pre-operative pelvic radiographs); 

intra-operatively (during hip arthrogram); immediately postoperatively 

(pelvic radiograph in spica cast versus three-dimensional 

confirmatory imaging, often CT scan); and in follow up (scheduled 

pelvic radiographs). We sought to reduce patient exposure during 

DDH treatment, focusing specifically on the intra-operative and 

immediate post-operative periods. Our hypothesis is that patients 

with developmental hip dislocations undergoing closed or open 

reduction without femoral or pelvic osteotomy can be comparably 

treated with radiation-minimizing techniques as with standard 

techniques. This was a retrospective review of all patients with hip 

dislocations treated with the ‘nearly radiation-free’ approach at 

our institution. To minimize intra-operative radiation, the minifluoroscan 

was used in place of a standard image intensifier to 

perform the hip arthrogram. To minimize radiation post-operatively 

while still confirming concentric reduction with three-dimensional 

imaging, all hips were imaged with a new technique of a non- 




sedate rapid sequence MRI within 24 hours of the closed or open 

reduction. Twelve patients with 12 dislocated hips were identified 

over an eight-month period. Average age at time of surgery was 

nine months (range three to 18 months). Four hips required open 

reduction with ligamentum teres transfer; eight hips were closed 

reduced. All hip arthrograms were done with a mini-fluoroscan 

and all were considered diagnostic. Post-operatively, rapid sequence 

MRIs were performed within 24 hours to confirm maintenance and 

quality of reduction in the spica cast. No patient required sedation or 

anesthetic; all MRIs were diagnostic and no scan had to be repeated. 

The average image acquisition time was 13 minutes, 29 seconds and 

all hips were located. Minimizing exposure to ionizing radiation to 

patients, but also surgeons and staff, is important wherever possible. 

By using a mini-fluoroscan for hip arthrogram, radiation exposure is 

cut by a reported 90%; confirming reduction post-operatively with a 

rapid sequence MRI rather than the frequently-used CT scan exposes 

the patient to no radiation. Neither technique compromises the 

quality of hip evaluation. 


Intercondylar Notch Dimensions & Growth Patterns in 

Young Pediatric Patients 





A narrow intercondylar notch has been implicated as a predisposing 

factor in anterior cruciate ligament injuries. Notch dimensions in 

young pediatric subjects have not been well characterized, which is 

the purpose of this observational study. A pediatric MRI database 

of 314 studies performed at our institution excluded patients with 

prior surgery or acute fracture. MRI measurements of femoral width, 

notch and anterior notch width were performed as per Anderson et 

al. A total of 132 MRIs were performed on patients 12 years of age or 

younger. Femoral width increased until age 14 (r=0.41, p


Remodeling Potential of Pediatric Completely 

Displaced Clavicle Shaft Fractures 

Charles T Mehlman, DO, MPH, Cincinnati, OH 

Doug Matey, DO, Tulsa, OK 

Completely displaced clavicle shaft fractures are considered to heal 

and remodel readily in children. The purpose of our study was to 

conduct a retrospective cohort study to better quantify healing and 

remodeling in terms of clavicle length and width (i.e., the bump) 

with a minimum of two years radiographic follow up. Radiographs 

of completely displaced clavicle shaft fractures were retrospectively 

reviewed at our institution between 2001 and 2006. Cases were 

excluded due to inadequate follow up or history of pathologic 

fracture. Fisher’s Exact test was used for data analysis and relative 

risks along with 95% confidence intervals are reported. Of the 419 

cases identified, 41 were found to meet inclusion criteria with an 

average age of 6.85 years (30 males, 11 females). More than half of 

the cohort were double shaft diameter). 

This translated to a 13 times higher risk (95% CI = 1.84, 99.10) of 

clavicle shortening and a seven times higher risk (95% CI = 0.95, 

62.63) of permanent bump in children ³10 years of age. Children 

³10 years of age do not reliably remodel their clavicle shaft fractures 

as compared to younger children. Although adult clavicle fractures 

have received abundant attention in recent years, additional research 

should be conducted in pediatrics. 


Limb Lengthening with a Submuscular Locking Plate 

Chang-Wug Oh, MD, Daegu, Republic of Korea 

Hae Ryong Song, MD, Seoul, Republic of Korea 

Hyun-Joo Lee, MD 

Byung Chul Park, MD, Daegu, Republic of Korea 

Lengthening over an intramedullary nail (IM) is a common technique 

to remove external fixators earlier. However, IM nails are difficult 

to use when bone has a narrow canal diameter or is deformed, or 

in the presence of joint contracture or an open physis in children. 

Thus, due to these restrictions and dangerous complications, there is 

a demand for a new technique. Ten patients (mean age, 18.5 years), 

who were difficult for lengthening over nail technique, underwent 

leg lengthening with a submuscular plate. After fixing a locking 

plate submuscularly on the proximal segment, an external fixator 

was fixed to lengthen the bone after corticotomy. Lengthening was 

performed at 1 mm/day. On reaching the target length, three or 

four screws were fixed on the distal segment with the removal of 

the external fixator. All patients achieved preoperative target length 

(mean, 4.0 cm). Mean duration of external fixation was 61.6 days. 

Mean external fixation index was 15.1 days/cm, which was less than 

one-third of the mean healing index. Complications were minor 

(eight problems, one obstacle), with 0.9 of complication rate. All 

patients achieved a satisfactory outcome without restriction of 

adjacent joints. Lengthening with a submuscular locking plate may 

successfully permit early fixator removal with fewer complications. It 

may be a useful alternative in children or when nailing is difficult. 

646 


Cost Effectiveness of the Ponseti Method vs Postero- 

Medial Release for the Treatment of Clubfoot 



Jacobo Saleme, MD 

Fernando Carlos, MSc, Mexico, DF Mexico 

Mauricio Disilvo, MD, FACS 

Clubfoot is one of the most frequent congenital musculoskeletal 

malformations. Diverse treatments have been used, from simple 

serial castings to complex soft tissue releases. At the present time, 

both the Ponseti technique and the surgical release or posteromedial 

release (PMR) are commonly used for the treatment of 

clubfoot deformity. We sought to find out which one of these two 

treatment options for clubfoot is more cost-efficient in terms of cost 

per corrected foot. We hypothesized that the Ponseti method is costeffective. 

A cost-effectiveness analysis was performed using clinical 

and economic assumptions. Considering those values, deterministic 

and probabilistic models were built, the cost-effectiveness ratio was 

calculated. The incremental cost-effectiveness ratio was computed. 

The present analysis is performed from the institution’s perspective. 

The temporal horizon for both costs and benefits was considered of 

one year. The effects are measured in terms of corrected feet. Two 

analyses of sensitivity are presented: 1. A deterministic approach. 

In this case a one-way sensitivity analysis was performed. 2. A 

probabilistic technique was also applied. A Monte Carlo simulation 

was performed with 1,000 samples. A cost-effectiveness analysis 

is presented with the information obtained. We observed that the 

Ponseti method is most cost-effective than the PMR in terms of 

cost per foot corrected. In the first model, there is an incremental 

cost of $1,465.74 USD per corrected foot; while in the second, the 

incremental cost is $985.48 USD per corrected foot. The incremental 

cost-effectiveness ratio per effect unit is: $-7.63 USD per corrected 

foot. Sensitivity Analysis: deterministic model. In all settings, the 

PMR is a dominated intervention. Probabilistic model. The costeffectiveness 

analysis resulted from this strategy demonstrates 

that the PMR is a dominated intervention. We concluded that the 

Ponseti method for the treatment of clubfoot is cost-effective when 

in comparison to the postero-medial release. The PMR is a clearly 

dominated strategy, even under the sensitivity analysis. 


Use Of The O-Arm Intraoperative Computerized 

Tomography Scanner In Pediatric Spinal Surgery 

Patrick O’Toole, MD, Dublin 16, Ireland 

Sachin Kulkarni, MD 

Lauren Tomlinson, BA 

John P Dormans, MD, Philadelphia, PA 

The use of pedicle screws in the treatment of spinal deformity has 

increased. Insertion of pedicle screws is not without potential risks 

especially in the thoracic spine. The intraoperative computerized 

tomography scanner, or O-arm, allows better visualization to 

facilitate better screw placement. We retrospectively reviewed data on 

all patients, who utilized the O-arm, that underwent posterior spinal 

surgery using thoracic and lumbar pedicle screws. Patients either 

had screws placed freehand with screw placement checked using the 

O-arm once all the screws were inserted (non-real time group), or 

those who were scanned using the O-arm in real time as the screws 

were placed (real time group). A total of 54 patients were included in 

this study. The average age was 14.24 years, with a range of 4.5 to 21.9 

years. Adolescent idiopathic scoliosis was the underlying diagnosis in 




the majority of patients (70.4%). There were 12 patients in the nonreal 

time group and 42 patients in the real time group. The final total 

number of pedicle screws placed in both groups was 882, with an 

average of 16.3 screws per patient. Significantly less screws required 

replacement in the real time group compared to the non-real time 

group, (p value

PAPERS 

648 

Practice ManaGeMent/non-clinical 

pApeR No. 106 

Paying Surgeons Less Has Cost More: A 10 Year 

Review Of Knee Arthroplasty 

Peter Derman, BS, Philadelphia, PA 

Joseph Bernstein, MD, Haverford, PA 

The Balanced Budget Act of 1997 mandated reductions in physician 

reimbursement. Yet because total spending is not governed 

exclusively by the per-case reimbursement (but also ancillary costs 

and the amount of work performed), increases in work volume 

can negate any potential savings to be produced by lowering fees. 

To assess this effect, a review of costs and spending for total knee 

replacement was undertaken. An annual data set comprising the size 

of the Medicare population, the number of orthopedic surgeons, the 

Medicare per-case reimbursement to doctor and hospital and the 

number of knee replacements performed was compiled from public 

sources for the decade spanning 1996-2005. Inflation-adjusted 

physician reimbursement decreased 41%, from $2,847 to $1,685. 

Nonetheless, spending on physician fees increased, as annual output 

grew from 253,841 to 498,169. This corresponded to an increase in 

the rate of knee replacements from 17.9 per surgeon annually to 30.6; 

and an increase in the number of knee replacements per thousand 

Medicare beneficiaries from 7.6 annually to 13.9. Considering 

hospital payments alone, the growth in surgical volume generated 

more than $5 billion of excess spending. The stated goals of the 

Balanced Budget Act may have been undermined by the physician fee 

cuts enshrined by the act, as surgeons have apparently compensated 

for lower fees by working more. If constraining total spending is the 

desired goal, the Centers for Medicare & Medicaid Services might 

consider increasing the per-case surgical reimbursement, or, more 

radically, abandoning fee-for-service payments altogether. 

pApeR No. 107 

Patient Education And Early Intensive Physiotherapy 

Decreases Hospital Stay After Primary THA 



The aim of our study was to determine the role of patient education 

regarding hospital stay and intensive early physiotherapy on 

length of hospital stay after total hip arthroplasty (THA) in an 

elderly population. Patients undergoing elective primary THA at 

our tertiary referral hip reconstruction unit were counseled preoperatively 

regarding early hospital discharge (within three to four 

days). Intensive physiotherapy was initiated on the day after surgery, 

focusing on safe mobilization at home with two crutches and ability 

to ascend and descend stairs. Routine outpatient physiotherapy was 

provided for all patients at discharge. Fifty patients from this study 

group were compared to 50 patients (control) undergoing elective 

primary THA prior to introduction of this accelerated hospital 

discharge program. The average hospital stay decreased to 3.5 days 

(range two to four days) in the study group from six days (three 

to eight days) in the control group. There was no difference in the 

type of anaesthetic, ASA grade, age or sex distribution of patients in 

the two groups. At six-week follow up, no difference was noted in 

patient satisfaction between the study and control groups. Patient 

education had led to better satisfaction with decreased hospital 

stay in the study group. No difference was noted in immediate and 

early complications in the two groups. Under comparable clinical 

circumstances, implementation of patient education regarding 

the advantages of early mobilization and decreased hospital stay 

along with accelerated and focused physiotherapy decreases average 

hospital stay elective primary THA. 

pApeR No. 108 

A Surgical Waste Audit of Total Knee Arthroplasties 

Nathan Stall, BSc, London, ON Canada 

Jennifer Bondy, BSc, Toronto, ON Canada 

Yoan Kagoma, BS, London, ON Canada 

Doug Naudie, MD, London, ON Canada 

Operating rooms (ORs) contribute substantially to healthcare waste 

at high costs to the environment and hospital spending. ORs are 

estimated to generate 20-33% of hospital waste, and prosthetics and 

implants represent 17% of our institution’s ecological footprint. 

In order to investigate waste production associated with total knee 

arthroplasties (TKAs), we performed a surgical waste audit. A waste 

audit is a quantitative and qualitative assessment tool used to 

evaluate waste management. We conducted a waste audit of five TKAs 

in February 2010. Waste was categorized into six streams: regular 

solid waste, recyclable plastics, biohazard waste, linens, sharps and 

blue sterile wrap. Volume and weight of each stream was quantified. 

Canadian Joint Replacement Registry data (2007-2008) was used to 

estimate annual weight and volume totals of waste from all TKAs 

performed in Canada excluding Quebec. The average surgical waste 

per TKA was 29.4 pounds, of which 19.0 pounds (64.5%) was 

normal solid waste, 5.6 pounds (19.2%) was biohazard waste, 3.6 

pounds (12.1%) was blue sterile wrap, 0.6 pounds (2.2%) were 

recyclables and 0.6 pounds (2.0%) were sharps. Plastic wrappers, 

disposable surgical linens and personal protective equipment 

contributed considerably to total waste. Non-recyclable waste from 

all 38,922 TKRs performed in Canada in 2007-2008 was estimated 

at 560.1 tons by weight and 1.1 million cubic feet by volume. TKAs 

produce substantial amounts of surgical waste. The emergence of 

environmentally-friendly surgical products and waste management 

strategies may allow ORs to reduce the negative impacts of waste 

production without compromising patient care. 

pApeR No. 109 

Correlation of Patient’s Expectations with Constant 

Score and SF-36 

Sara Martinez-Martos 

Carlos Torrens, MD, Castelldefels, Spain 

Victoriano Marlet, Sant Boi, Spain 

Lautaro Candioti, MD, El Prat De Llobregat, Spain 

Joan Miquel 

Eva Correa 

Enrique Caceres, Prof, Barcelona, Spain 

Constant scale and the quality of life questionnaire SF-36 are 

objective measures of patient assessment widely used in the 

evaluation of shoulder pathology. The patient’s subjective assessment 

and the expectations that he would expect following conservative or 

surgical treatment is an important fact to consider. The aim of this 

study is to analyze the correlation between patient expectations with 



PaPers, Posters & scientific exhibits pRActice

the functionality of the shoulder, by the Constant functional scale 

and the quality of life questionnaire SF-36. From September 2008 

until December 2008, we included 258 patients consecutively that 

attended our outpatient pathology in the shoulder unit, with a mean 

age of 47.38 years. They were evaluated by Constant functional scale, 

the quality of life scale SF-36 and the expectations questionnaire of 

New York Special Surgery expectations form. Patients were classified 

according to their age, gender, employment status, educational level, 

affected extremity, previous surgery and diagnosis at the time of 

the consultation (184 had rotator cuff pathology, 29 glenohumeral 

arthrosis, 18 old fractures, 15 instability in their shoulder and 12 

mixed pathology). The expectations of the patient were classified 

into four groups according the pain, function, strength and 

activities of daily living (ADL). We analyzed the correlation between 

expectations with the quality of life scale SF-36 and the functional 

scale of Constant by the Spearman correlation coefficient. Mean 

Constant score of the series is 61,58. Poor correlation was found 

between patient´s expectations with the Constant score and SF-36 

values. Pain, function, strength and DLA expectations poorly correlate 

with total Constant score (0,205, 0,160, -0,023, 0,070), with U.S. 

standard physical component (0,073, 0,102, 0,078, 0,167) and with 

U.S. standard mental component (-0,074, -0,162, -0,088, -0,081). 

Elderly people have greater expectations even when their Constant 

score is high (0.242), while young patients have more expectations 

when their Constant score is low. When comparing diagnosis, the 

patients with old fractures have higher negative correlation between 

Constant score and the physical component of SF-36 with patient´s 

expectations (-0.321, -0.360) meaning that for low Constant score 

values patients have more expections. Patient’s expectations in pain, 

function, ADL and strength are poorly correlated with the functional 

evaluation of their shoulder deficits and their perception of quality 

of life. Patients with bad objective function or pain do not expect 

more than patients with good objective shoulder function. Older 

patients, even if their Constant score is high, have more expectations 

than younger people. 

pApeR No. 110 

Costs and Cost Management Strategies for Hip and 

Knee Replacement Implants 

Kevin John Bozic, MD, MBA, San Francisco, CA 

Alexis Pozen 

Samuel Tseng, Berkeley, CA 

James Robinson, PhD, Berkeley, CA 

Hospitals are pursuing various strategies to gain greater alignment 

with physicians and better purchasing relationships with device 

manufacturers. The purpose of this study was to quantify the patient, 

hospital and market characteristics associated with variation in implant 

and total procedure costs, and assess the effectiveness of hospital 

strategies for implant cost containment. Clinical, demographic and 

economic data were collected on 10,280 unilateral primary total 

knee replacement (TKR) patients and 5,096 unilateral primary total 

hip replacement (THR) patients at 61 hospitals in 2008. Device costs 

and total procedure cost per case were determined, and multivariate 

statistical analyses were used to evaluate the independent effects of 

implant vendor concentration, annual procedure volume, hospital 

size, teaching status, hospital market structure and population size 

in the local market on implant costs and total procedure costs. 

Average implant costs per case ranged from $3,380 to $10,744 for 

TKR procedures and from $3,828 to $10,640 for THR procedures. 

Higher volume hospitals experienced lower implant costs per case, 

but concentration of purchases among a small number of implant 

vendors was associated with higher implant costs per case for both 

TKR and THR procedures (both p

to nearest non-LVH street distance were calculated. For patients who 

did not have a non-LVH located closer than the hospital of service, 

the median, 75th, 90th, 95th percentile and maximum distances to 

the nearest non-LVH were calculated. During 2001, 3,214 hospitals 

provided 183,800 TKR to Medicare patients nationally. While 43% of 

these hospitals were LVH; only 9.8% of all TKR surgeries performed 

were provided at the LVHs. Among the states with highest number 

of Medicare TKR procedures, California had the highest proportion 

of LVHs (57%) and the highest proportion of procedures performed 

at LVHs (19.8%). However, if access were restricted to non-LVH, 

95% of the LVH patients served in populous states would not need 

to commute more than 60 miles to the nearest non-LVH. However, 

up to 10-25% patients in less densely populated states would be 

required to travel greater than 100 miles to the nearest non-LVH. 

Greater number of TKR procedures and smaller proportion of rural 

population were both associated with lower proportion of TKRs 

being performed at LVHs (p < 0.0001). For most patients, restricting 

access to non-LVH would not result in unmanageable travel 

distances. However, travel distances in less densely populated states 

could exceed 100 miles. This burden might dissuade patients from 

considering TKR. Restricting access to a highly effective procedure 

(even if outcomes are slightly poorer at LVH) may not be optimal 

policy. Policies considering restricting access to LHVs ought to 

consider the disproportionate impact on certain regions and consider 

waivers for these areas. 

pApeR No. 113 

Readmission After Orthopaedic Surgery: Causes and 

Accuracy of Administrative Data 

Richard A McCormack, MD, New York, NY 

Ryan F Michels, New York, NY 

Nicholas Ramos, BA 

Lorraine Hutzler, BA 



The rate of unplanned 30-day readmissions to the hospital after 

discharge is considered a barometer of quality of care. While the 

readmission rate can be calculated using administrative data, the 

accuracy of this data is variable and defining which readmissions 

are unplanned and preventable is often difficult. The purpose 

of this study is to review readmissions to a single hospital and 

to understand the causes for readmission. Using the hospital’s 

administrative database of patient records from 2007 to 2009, all 

patients who were readmitted to the hospital within 30 days of a 

previous hospitalization were identified. Readmissions were broadly 

categorized as planned (a staged or rescheduled procedure or a direct 

transfer) or unplanned. Unplanned readmissions were defined as 

either surgical or nonsurgical complications (medical conditions not 

directly related to the procedure). A total of 490 readmissions were 

identified, of which 144 (29.4%) were planned (64 rescheduled 

procedures, 67 staged procedures and 13 direct transfers). A total 

of 346 readmissions (70.6%) were unplanned, with the majority 

of unplanned readmissions (199, 57.5%) resulting from infection. 

Nonsurgical complications accounted for 63 readmissions (11.6% 

of all readmissions and 18.2% of all unplanned readmissions), 

with the majority from systemic (17 patients, 27.0% of nonsurgical 

complications) and gastrointestinal (13 patients, 20.6% of nonsurgical 

complications) conditions. Nineteen patients were readmitted for 

uncontrolled pain and 16 patients for a revision. The average length 

of stay of the readmission was 8.0 days (5.2 days for planned and 

9.1 days unplanned). Planned readmissions must be eliminated 

when using administrative data to calculate preventable readmission 

rates after surgery. The majority of unplanned readmissions were 

650 

due to complications; including surgical site infections and venous 

thromboembolism. The high number of nonsurgical complications 

highlights the importance of monitoring the patient closely once they 

have been discharged. It is clear that reducing readmissions requires 

a reduction in postoperative complications and close monitoring of 

the patient upon discharge. 

pApeR No. 114 

Economic Simulation of Rigid Locked Nails vs. 

Titanium Elastic Nails for Pediatric Femur Fracture 

Suneel B Bhat, MPhil, Philadelphia, PA 

Matthew Robert Garner, MD, New York, NY 

Jack M Flynn, MD, Philadelphia, PA 

David Andrew Spiegel, MD, Philadelphia, PA 

Both rigid locked nails (RLN) and titanium elastic nails (TENs) are 

utilized for femur fractures in older children and adolescents. This 

study compares the charges associated with RLNs versus TENs with 

either routine implant removal or removal only when symptomatic. 

We retrospectively reviewed femur fractures treated with either RLNs 

or TENs between 2000 and 2007. A unique stochastic decision tree 

model based on probabilities derived from our data was developed 

and a modified Monte Carlo simulation conducted with identical 

theoretical populations aged 10 to 14 modeled from 2007 Census 

data. Individually simulated patients accrued age-stratified incidence 

of femur fracture, charges for nail placement, removal, and any 

other associated surgical charges, and the simulation outputs were 

statistically analyzed. Average charges per 100,000 patient years 

were $547,035 (95% CI $506,489 to $587,580) for routinely 

removed TENs, $520,636 (95% CI $480,957 to $560,315) for TENs 

removed only symptomatically, and $429,032 (95% CI $391,908 

to $466,155) for RLNs. Analysis of variance of all three groups and 

t-test between each of the mean per case charges were significant at 

p

y non-operative fracture care. We then specifically analyzed the 

most common fractures we managed non-operatively and recorded 

the number of visits for each fracture type to our clinic within the 

90 day global period. Multiply injured patients and those from 

outside our catchment area who sought follow up care at another 

facility were excluded. A comparison was made between collections 

from closed treatment codes (using local Medicare reimbursement 

rates for CPT codes) and potential reimbursement lost due to visits 

during the 90 day global period. A subsequent visit code 99213 was 

used as the value of visits in the post-operative period potentially 

lost during to the 90 day global period. A total of 19,815 RVUs 

were generated by the trauma service during the 2008 fiscal year. 

Non-operative (closed) fracture care generated 2,725 (14%) of 

total RVUs. An analysis of the non-operative fracture cases revealed 

that pubic ramus, proximal humerus, distal radius, clavicle, lateral 

malleolus, proximal tibia and humeral shaft fractures accounted for 

more than 50% (1,410) of RVUs generated. We believe these are also 

fractures that need to be followed most closely in the post-fracture 

period. The average amount of reimbursement from closed fracture 

care less potential lost revenue from non-billable subsequent visits is 

summarized in the last column. Closed fracture care is an important 

part of an orthopaedic trauma practice. There are financial concerns 

that closed treatment of fractures may not be the most economically 

advantageous practice due to the 90 day global period. We found 

that in the most common fractures we treat which require close 

follow up, it is still financially beneficial to bill for closed fracture 

care initially and thus forfeiting all potential collections in the 90 

day global period. 

pApeR No. 116 

Turnover Time In Arthroscopic Shoulder Surgery: 

A Reduction Of 18% By Three Simple Strategies 

Prof George A C Murrell, MD, Kogarah, NSW Australia 

Quinton Yang 

The aim of the study was to determine if three strategies: parallel 

anesthetic induction, improving first case start times and dedicating 

porters to surgical theaters could reduce turnover times. A prospective 

interventional clinical study of operating room processes was 

conducted over a 10-week observation period, then a two-week 

education period, followed by a 10-week intervention period in a 

day surgery facility during arthroscopic shoulder surgery. Three 

intervention strategies were used: (1) parallel anesthetic induction, 

defined as performing the anesthetic induction on the next patient 

during the intra-operative period of the currently anesthetized 

patient, (2) a dedicated porter system, where the porter remained 

with the same theater for the entire turnover period and (3) starting 

the first case within 10 minutes of scheduled start time. The major 

outcome was turnover time the time between end of skin closure 

of the first patient to knife to skin of the next patient in the same 

theater. Minor outcomes included porter time (wheel out to wheel 

in), first case start times and cost savings. Intervention of the three 

strategies reduced turnover time by nine minutes (18%), from 51 ± 

10 mins (mean ± SD) to 42 ± 9 mins. Porter times were reduced by six 

minutes (27%). First case start times improved by 12 minutes. Total 

time savings per day was 61 minutes. The reduction in turnover time 

and improvements in first case start times resulted in a minimum net 

financial benefit of $430 per day to the day surgery facility. Parallel 

anesthetic induction, improving first case start times and dedicating 

porters to theaters significantly decreased turnover time. 

651 

pApeR No. 117 

The Effects of Health Insurance Status on the Rate of 

Upper Extremity Elective Surgery 

Tim James McGlaston, BS, Boston, MA 

Kenneth Robert Gundle, MD, Seattle, WA 

Arun J Ramappa, MD 

Health insurance status is associated with access to medical 

care as well as health outcomes. The purpose of this study was 

to determine effect of health insurance status on rate of upper 

extremity elective surgery. Over a 3.75 year period, 7,577 patients 

diagnosed with upper extremity injuries were identified at a single 

institution. Their demographics, insurance status and plan of care 

were reviewed. Insurance categories included private insurance, 

workers’ compensation, military-related (TriCare), Medicare, 

Medicaid (MassHealth), government-subsidized health care plan 

(Commonwealth Care), Free Care (Health Safety Net) and self-pay. 

After adjusting for age, gender and diagnosis, the proportion of 

patients who underwent elective surgery was calculated for each type 

of insurance. Of patients with private insurance, 21% underwent 

elective upper extremity surgery. The adjusted rate of surgery (AROS) 

for workers compensation and patients with military-related 

insurance was significantly higher (35%, p=0.001; and 35%, p

pApeR No. 119 

The Prevalence of Defensive Orthopaedic Imaging: A 

Prospective Practice Audit in Pennsylvania 

Robert Andrew Miller, BS, Philadelphia, PA 

Norma Rendon, Philadelphia, PA 

Jack M Flynn, MD, Philadelphia, PA 

Defensive medicine is ubiquitous, but poorly understood. There 

has only been one previously published study of defensive 

practices among orthopaedic surgeons. Our study was designed 

to prospectively capture and analyze the current rate and cost of 

defensive imaging among orthopaedists in a single state. Members 

of the Pennsylvania Orthopaedic Society were asked to voluntarily 

and anonymously record a consecutive series of patient imaging 

decisions (in any setting: clinic, ED, inpatient). Each orthopaedist 

was asked to record their demographic information and the modality, 

region and indication for each order. Demographics were analyzed 

using Chi-squared test for independence and costs were analyzed 

using economic models. Defensive imaging composed 324 of 

1,642 (19.7%) orders recorded by 56 orthopaedists. MRI composed 

161 (49.7%) of defensive orders. By modality: 128/1,119 (11.4%) 

radiographs, 161/425 (37.9%) MRIs, 13/40 (33.0%) CT scans, 13/23 

(56.5%) bone scans and 9/17 (52.9%) ultrasounds were ordered for 

defensive reasons. Defensive imaging was responsible for $93,422 

of $267,166 (35.0%) of total imaging charges, based on Medicare 

dollars. Defensive MRIs were responsible for $80,532, or 86.2% of 

defensive costs and 30.1% of total costs. A lawsuit within the last 

five years and practice over 15 years predicted an increased incidence 

of defensive orders (p

treatment recommendations requires the inclusion of patient choice 

and opinion as central components of the process. The vast majority 

of respondents in our study do not feel that the quality of their care 

will be diminished due to industry funding of educational events or 

for surgeon tuition and/or travel expenses. Disclosure is important 

to people. 

pApeR No. 453 

Level of Evidence of Presentations at American 

Academy of Orthopaedic Surgery Annual Meetings 

Pramod Babu Voleti, MD, Philadelphia, PA 

Derek J Donegan, MD, Philadelphia, PA 


The American Academy of Orthopaedic Surgery (AAOS) Annual 

Meeting is a major international forum for scientific exchange and 

education. The AAOS Program Committee works continuously to 

improve the scientific quality of material presented at this meeting 

each year. One measure of quality is the level of evidence on which 

each study is based. The purpose of this study is to evaluate the level of 

evidence of papers and posters presented at the 2004, 2007 and 2010 

AAOS Annual Meetings. Abstracts obtained from the AAOS Annual 

Meeting Proceedings from 2004 (290 papers and 466 posters), 

2007 (525 papers and 541 posters) and 2010 (720 papers and 569 

posters) were analyzed by three reviewers. The level of evidence of 

each presentation was determined based on the evaluation system 

adopted by the AAOS. The results were subdivided according to 

orthopaedic subspecialty and type of presentation (paper vs. poster). 

With each successive year, there was a substantial increase in the 

percentage of Level I studies (2.9% in 2004, 5.1% in 2007, 7.2% in 

2010), Level II studies (18% in 2004, 23% in 2007, 29% in 2010) 

and Level III studies (26% in 2004, 29% in 2007, 33% in 2010), with 

a concomitant decrease in the percentage of Level IV studies (54% 

in 2004, 43% in 2007, 31% in 2010). These trends were consistent 

across all orthopaedic subspecialties and in both the paper and poster 

subgroups. In 2010, Level I studies comprised 8.8% of papers and 

5.2% of posters and Level II studies comprised 31% of papers and 

26% of posters. Among subspecialty categories in 2010, Hand and 

Wrist had the largest percentage of Level I studies (9.7%) and Foot 

and Ankle had the smallest percentage of Level I studies (4.5%). The 

level of evidence of studies presented at the AAOS Annual Meeting is 

steadily increasing - a mark of continual improvement in the quality 

of the scientific program. 

pApeR No. 454 

Testing for the Presence of Positive-Outcome Bias in 

Peer Review: A Randomized Controlled Trial 

Seth S Leopold, MD, Seattle, WA 

Gwendolyn Beth Emerson, MD, Minneapolis, MN 

Winston J Warme, MD, Bellevue, WA 

Fredric M Wolf, PhD, Seattle, WA 

James D Heckman, MD, Manchester, VT 

Richard A Brand, MD, Philadelphia, PA 

If positive-outcome bias (POB) exists, it threatens the integrity of 

evidence-based medicine. We sought to determine whether POB is 

present during peer review by testing whether peer reviewers would 

1) recommend publication of a ‘positive’ version of a fabricated 

manuscript over an otherwise-identical ‘no-difference’ version; 2) 

identify more purposefully placed errors in the no-difference version; 

and 3) rate the methods section in the positive version more highly 

than the identical methods section in the no-difference version. 

Two versions of a well-designed randomized controlled trial that 

653 

differed only in the direction of the finding of the principal study 

endpoint were submitted for peer review to The Journal of Bone 

& Joint Surgery American and Clinical Orthopaedics and Related 

Research; 238 reviewers were randomly allocated to review either 

a positive or a no-difference version of the manuscript. Reviewers 

were more likely to recommend the positive version of the test 

manuscript for publication than the no-difference version (97.3% 

vs. 80%; p = 0.005). Reviewers detected more errors in the nodifference 

manuscript than in the positive version (0.85 vs. 0.41; p 

< 0.001). Reviewers awarded higher methods scores to the positive 

manuscript than to the no-difference manuscript (8.24 vs. 7.14; p 

= 0.005), even though the methods sections in the two manuscript 

versions were identical. POB was present during peer review. A 

fabricated manuscript with a positive outcome was more likely to be 

recommended for publication than was an otherwise-identical nodifference 

manuscript. POB can result in inappropriate inflation of 

apparent treatment effects when the literature is subjected to metaanalysis. 

pApeR No. 455 

Utility of AAOS OITE Scores in Predicting ABOS Part I 

Outcomes 

David Swanson, PhD 

Kathleen Holtzman, BA, BS 

Deniz Bucak, BS, Philadelphia, PA 

Amy Sawhill, BA 

Carol Morrison, PhD 

Shepard R Hurwitz, MD, Chapel Hill, NC 

G Paul De Rosa, MD, Chapel Hill, NC 

John Lawrence Marsh, MD, Iowa City, IA 

This collaborative study investigated the utility of scores on the AAOS 

Orthopaedic In-Training Exam (OITE) for identification of residents 

at risk for failing ABOS Part I. Scores of the 3,132 examinees taking 

ABOS Part I for the first time between 2002 and 2006 were matched 

against AAOS records from the 1997 to 2006 OITE administrations; 

at least one OITE score was located for 92% of ABOS examinees. After 

normalizing OITE percentile ranks to place scores from different 

administrations on roughly the same scale, descriptive statistics for 

and correlations between ABOS and OITE performance in each year 

of training were computed, and regression analyses were conducted 

to predict Part I scores and pass/fail results from OITE performance. 

Mean OITE scores increased significantly as residents progressed 

through training, as did correlations between OITE and Part I scores, 

reaching a maximum of 0.53 in the 3rd and 4th years in training. 

Logistic regression results indicated that residents with OITE scores 

in the bottom decile during the 2nd, 3rd or 4th year in training were 

five-15 times more likely to fail Part I than those scoring in the top 

half of the OITE score distribution in the same training year. OITE 

scores are good predictors of ABOS Part I outcomes, particularly in 

later years of residency training, and OITE performance can be used 

effectively by program directors for identification of residents at risk 

for failing Part I. 




pApeR No. 456 

Introduction of Multimedia on ABOS Part I: A Controlled 

Trial of the Impact on Item Characteristics 

Kathleen Holtzman, BA, BS 

Randall Evan Marcus, MD, Cleveland, OH 

Harry N Herkowitz, MD, Royal Oak, MI 

Regis J O’Keefe, MD, Rochester, NY 

David Swanson, PhD 

Jean D’Angelo, BA 

Carol Morrison, PhD 

Shepard R Hurwitz, MD, Chapel Hill, NC 

With the phase-in of computer-based administration of ABOS Part 

I in 2009, three new multimedia item formats were introduced. 

Interspersed with scored test material on the 2009 ABOS Part I exam, 

12 video-based arthroscopy items, 23 video-based physical exam 

items and six CT/MR items in two formats were compared with 

unscored content-matched controls, and responses were analyzed 

for 718 first-time examinees. Results from use of the formats on 

the July 2010 Part I exam will also be presented. Compared with 

content-matched text controls, video-based arthroscopy items were 

slightly easier (mean % correct), more discriminating (mean itemtotal 

correlation) and required an average of 26 more seconds for 

examinee responses. Relative to text controls, video-based physical 

finding items were slightly more difficult, less discriminating and 

required 23 more seconds for responses. Compared with matched 

single-slice controls, multi-slice and stacked CT/MR items were 

similar in item difficulty (% correct), more discriminating and 

required 50 more seconds for responses. Examinee responses to 

end-of-test survey items indicated that they preferred more authentic 

presentation of clinical findings, though there were some difficulties 

with the user interface for CT/MR formats. Review of study results by 

ABOS led to approval of two multimedia formats for scored use on 

Part I because of the increased authenticity with which they assess 

important skills in orthopaedic practice. 

pApeR No. 457 

On-Line Case Simulation: The Ability To Screen, 

Identify And Initially Manage Inflammatory Arthritis 

Veronica Marie Rita Wadey, MD, Toronto, ON Canada 

Heather McDonald-Blumer, MD, Toronto, ON Canada 

Alfred Cividino, MD, Hamilton, ON Canada 

David Levy, MD 

Jean Wessel, PhD 

Dr Deborah Kopansky-Giles, Toronto, ON Canada 

Jody McIlroy, PhD 

Douglas Archibald, PhD(c), Toronto, ON Canada 

The ability to screen, identify and initially manage patients with 

inflammatory arthritis was identified as a priority item at the 

2005 National Summit on Standards for Arthritis Prevention and 

Care. The purpose of this project was to complete the content and 

its accompanying assessment tools proposed for an interactive 

technology-learning resource pertaining to inflammatory arthritis. 

Subject matter experts were recommended by their professional 

associations to develop content for the gait, arms, legs and spine 

(GALs) screening for arthritis and a Sore Hands, Sore Feet (SHSF) 

case simulation. Evaluation templates were developed. A storyboard 

with instructional designs for an interactive educational experience 

and assessment tool was completed and a technology template was 

constructed. Eighty Canadian healthcare providers were invited to 

review this on-line content. Each participant was provided access to 

654 

the MSK Health website learning modules. Pre/post test measures 

were used. Sixty-two percent (49/80) of the invitees participated in 

the study. There was a statistically significant increase in scores from 

the pre-test for GALS (M = 49%, SD = .23) to the post-test scores 

(M=79%, SD = .20), p

completed the survey. Some 49% (292) had never used a reference 

manager. Of the 299 using a reference manager, 87% (257) used 

Endnote, 12% (37) RefWorks and 4% (13) RefMan. The perceived 

difficulty in following journal guidelines among experienced users 

was significantly less (p

practice location and setting and their intended work output (e.g. 

years in practice and days of work per week). Generational and 

gender differences were also examined. An online, self-administered 

survey was emailed to U.S. PGY3+ residents querying them about 

their fellowship specialty choice and their intended career plans. 

The survey was tested in a pilot study of 20 orthopedic trainees and 

modified accordingly. A power analysis was performed, determining 

that 335 respondents were needed to achieve a 95% confidence level 

for p

There were 16 male and 49 female patients, with an average age of 

80.3 (between 57 and 95) years old. Osteosynthesis was performed 

in 37 patients, and 28 patients underwent bipolar hemiarthroplasty. 

A liaison clinical pathway played the role of a progress report during 

hospitalization and a referral request consisting of the following 

patient information: (1) general and preoperative information; (2) 

general condition on discharge; (3) walking and basic movements. 

The Functional Independence Measure (FIM) scores at admission and 

discharge and the admission periods for the treatment in convalescent 

stage (in our hospital) were examined. After introduction of a liaison 

clinical pathway, the FIM score was 78.7±30.2 points at the admission 

to our hospital and 93.8 ±29.5 points at discharge, with a significant 

improvement (p


Orthopaedic Surgery Delivery in Rural American 

Hospitals: A survey of rural hospital administrators 

Derek Weichel, MD, Tampa, FL 

Many rural American residents prefer to receive their medical care 

locally. There is a lack of information on how rural hospitals provide 

orthopaedic care to their communities. The purpose of this study was 

to determine how orthopaedic surgical services are provided in rural 

America. All hospitals in Florida, Montana, Nebraska, West Virginia 

and Arizona that were located in zip codes that met the criteria 

for being a rural town according to the rural urban commuting 

area codes were included. A survey covering many different topics 

including community and hospital demographics, orthopaedic 

surgical staffing and the types of orthopaedic surgical services 

offered was sent to the hospital administrators. A total of 145 of 

223 rural hospitals completed the survey. Thirty percent had at least 

one full time orthopaedic surgeon. Some 25% did not provide any 

orthopaedic surgical services. A total of 18% had an orthopaedic 

surgeon on call for the emergency room (ER) every night. Sixty-five 

percent never had an orthopaedic surgeon on ER call. A total of 33% 

stated that they were currently recruiting an orthopaedic surgeon. 

Some 52% stated that it is more difficult to recruit an orthopedic 

surgeon when compared to a general surgeon and only 4% felt it 

was easier to recruit an orthopaedic surgeon. A total of 71% of the 

administrators stated that there is a need for additional orthopaedic 

surgical services in their community. Some 77% of the hospitals 

do perform both inpatient and outpatient surgeries and 75% have 

anesthesia available 24 hours per day. For those hospitals that do not 

have a full time orthopaedic surgeon, members of those communities 

must travel an average of 55 miles for emergency orthopaedic surgical 

care. There are many rural American communities that have limited 

or no access to orthopaedic surgical services. While many of the 

rural hospital administrators feel that there is a need for additional 

orthopaedic surgical services in their communities, it is difficult to 

recruit orthopaedic surgeons to these rural areas. 


Variations in Acute Care Length of Stay After 

Orthopedic Surgery 

Nelson Fong SooHoo, MD, Los Angeles, CA 

John D Fitzgerald, MD, PhD, MPH 

Haoling H Weng, MD 

Susan L Ettner, PhD 

The purpose of this study is to report variations in the length of stay 

following acute hospitalization for orthopaedic surgical procedures. 

The effect of changes in Medicare reimbursement policies on the 

length of stay is analyzed. The length of stay following surgical 

fixation for hip fractures, elective total hip replacement and elective 

total knee replacement was analyzed using time series analysis of 

a 100% sample of Medicare patients undergoing these procedures 

in the years 1996 through 2001. Variations in the month-tomonth 

length of stay are analyzed at the county, state and Censusregion 

levels. Length of stay following hip fractures and total joint 

replacement was trending downward in all regions examined until 

the implementation of the Medicare Short Stay Transfer Policy in 

1998 created disincentives to early discharge. There was limited 

regional variation in the length of stay with the exception of longer 

times seen in New York state. The exemption of New York from the 

Medicare Prospective Payment System until 1997, as well as a lower 

rate of managed care penetration, contributed to the longer length 

of stay in New York compared to other states. Medicare payment 

polices have had significant impacts on trends in the length of stay 

658 

following surgical treatment of hip fractures and elective total joint 

replacement. 


Clinical And Biochemical Characteristics After Intra- 

Articular Injection Of Osteoarthritis 

Masaki Shimizu, MD, Maebashi, Gunma, Japan 

Hiroshi Higuchi, MD, Maebashi-Shi, Japan 

Kenji Takagishi, Prof, Maebashi, Japan 

Tetsuya Shinozaki, Maebashi-shi, Japan 

Tsutomu Kobayashi, MD, Gunma, Japan 

Kazuhika Hatayama, MD 

Intra-articular injections of sodium hyaluronate (Na-HA) and 

corticosteroid (CS) are used for the treatment of osteoarthritis, and 

the clinical usefulness has been reported. Some studies have discussed 

the effectiveness of injection therapy in terms of the clinical results, 

but no cohort studies have performed evaluations of effectiveness 

based on changes in joint biomarkers. This prospective randomized 

study compared the efficacy of Na-HA and CS injections based on 

clinical scores and levels of biochemical markers for osteoarthritis. 

A total of 51 patients with knee osteoarthritis received intra-articular 

injections of either Na-HA or CS and were followed for six months 

after treatment. Pain and inflammatory scores were evaluated at the 

baseline, at five weeks and at six months. We also measured joint 

fluid levels of hyaluronan (HA), chondroitin 6-sulfate, chondroitin 

4-sulfate, matrix metalloproteinase (MMP)-9 and tissue inhibitor of 

MMP-1 at the baseline and at five weeks. In both groups, injection 

therapy significantly improved pain/inflammation scores with time 

(P

also analyzed. Seventeen cases were recognized as SSI (2.1%); nine 

cases were superficial and eight cases were deep infections. Steroids 

administration showed a statistically significant risk of SSI; on the 

other hand, methotrexate administration was a negative risk factor 

of SSI. The dose of oral steroids at the time of surgery clearly showed 

a positive dose-dependent correlation with the rate of SSI. After 

introducing the strict guideline of CDC, reported incidences of SSI 

became higher (approximately 2%). In those reports, more than 

half the cases of SSI occurred in superficial lesions. The results of 

current study were similar to recent reports. As for risk factors, the 

administration of steroids was a risk of SSI; in contrast, administration 

of MTX was a negative risk factor of SSI. 


Orthopaedic Call Coverage at Level II Centers 

Robert H Blotter, MD, Marquette, MI 

Robert Winn 

Jody McCollum, MPAS 

Several studies have looked at trends of orthopaedic call availability 

since the Emergency Medical Treatment and Active Labor Act 

(EMTALA) in 2003 and found it a problem, some even calling it a 

crisis. No one has looked exclusively at level II trauma centers, which 

may be at increased risk because of their exposure to complex patients 

without the benefit of resident manpower. A 15-question survey was 

mailed to the nursing director at all 127 level II trauma centers in 

September 2009. Sixty-three surveys were returned for a response 

rate of 49.6%. Statistical analysis was performed by determination 

of the correlation coefficient and comparison by t-test. The average 

years accredited, as a trauma center was 10.3 years. A total of 82% 

of the centers transferred less than 5% of their cases. The average 

number taking call was 7.75 and 72.6% were compensated for call 

monetarily. Trauma call coverage was significantly more difficult 

today than five years previously (p

asis to all people working with orthopaedic patients, including 

the physicians, and all team members are expected to provide work 

plans for making improvements based on these reports. 


Clinical Pathway Can Improve Quality of Care in 

Patients Undergoing TKA 


Korea 




Korea 






Korea 

Clinical pathways are management plans that display goals for 

patients and provide the sequence and timing of actions necessary 

to achieve these goals with optimal efficiency. We aimed to evaluate 

the effectiveness of a clinical pathway for patients who underwent 

total knee arthroplasty (TKA). We performed retrospective 

comparisons between 50 unilateral TKA patients who were 

managed on a clinical pathway in 2008 (clinical pathway group) 

and 50 patients who underwent the same procedure in 2007 prior 

to the pathway’s implementation (control group). The major 

comparative outcomes included length of hospital stay, total costs, 

readmission rates and postoperative complications. In addition, we 

conducted a questionnaire survey of 17 residents and 21 nurses for 

advantages and disadvantages, and overall satisfaction of the TKA 

clinical pathway using a 10-point visual analog scale. The clinical 

pathway group had significantly shorter length of hospital stay (p 


Developing a New Pre-Clinical Orthopedic Curriculum: 

Being an Agent of Change 

Charles S Day, MD, MBA, Boston, MA 

Yangyang Yu, BA 

Albert C Yeh, Cambridge, MA 

Ronald Arky, MD, Boston, MA 

Ms Lori Newman 

David Roberts, MD 

The inadequacy of orthopedic education at medical schools has been 

well documented in literature. This study describes the framework of 

a systematic approach to instituting curricular change and developing 

an orthopedic curriculum at a medical school. At a single academic 

medical school, a new orthopedic curriculum was instituted in a 

seven-step process, based on John P. Kotter’s stepwise approach to 

successfully leading and implementing change. The eight distinct steps 

included: identifying the existing orthopedic curriculum, assessing 

the existing orthopedic curriculum, identifying key supporting 

educators, initiating reform, lobbying for course additions, designing 

course content, leading faculty development and evaluating the 

implemented changes. In 2005, 40 hours of orthopedic education 

were identified, which was 25 hours below the national average 

in preclinical curricula. Students were then surveyed to assess the 

current curriculum, which revealed a significant deficiency in basic 

musculoskeletal knowledge. These results were presented to medical 

educators and, in response, a musculoskeletal task force was created 

to develop four-year education objectives. Ten course directors were 

contacted to lobby for the addition of time dedicated to orthopedic 

education to the pre-clinical curriculum. After successful addition 

of time into three courses, courses were designed according 

to the previously developed education objectives. Orthopedic 

faculty members were then recruited from affiliated hospitals and 

underwent faculty training. To evaluate the changes, the first class of 

students to undergo the new curriculum was surveyed with the same 

survey materials. Curriculum integration involves demonstrating a 

need for change, proposing feasible innovation, garnering internal 

and external support, developing appropriate human resources and 

providing ongoing evaluation. 



FDA Today: Latest Regulatory Perspectives Regarding 

Metal-on-Metal Joint Replacement 

Michael C Owens, Silver Spring, MD 

Elizabeth Frank, MS, Rockville, MD 

Deepa Gavini, MS, Silver Spring, MD 

John Bowsher, PhD, Silver Spring, MD 

Ron Kaczmarek, MD, Gaithersburg, MD 

Barbara Buch, MD, Silver Spring, MD 

Metal-on-metal (MOM) hip joint replacements have seen almost 

five decades of clinical use worldwide. However, recent reports of 

adverse event data on MOM total joint replacements from multiple 

countries have led to growing concerns. These growing concerns lead 

to an increased regulatory scrutiny because of FDAs responsibility to 

promote and protect the public health. The purpose of our scientific 

exhibit is to provide updates on the latest regulatory perspectives 

regarding MOM joint replacement, from pre-market to post-market 

activities. From a pre-market perspective, the exhibit will address 

661 

current practices regarding how a clinical study should be designed 

and conducted to collect adequate data to support a marketing 

application. Current clinical trial design considerations will be 

covered, with a special focus on joint replacement devices with a 

MOM articulation. In addition, the applicability of these clinical 

trial design considerations and MOM technology for cervical and 

lumbar total disc replacements will also be discussed. From a postmarket 

perspective, the exhibit will outline current adverse event 

reporting trends for MOM joint replacement devices. Our exhibit 

will also discuss what type of information is important to capture 

on an adverse event report. Finally, the exhibit will outline postapproval 

study design considerations, with a special focus on devices 

with MOM articulations. n/a 


The Patient Protection and Affordable Care Act: Impact 

on You and Your Patients 

Richard C Mather, III MD, Durham, NC 

Carolyn Hettrich, MD, MPH, Nashville, TN 

Samir Mehta, MD, Philadelphia, PA 

Bruce D Browner, MD, Farmington, CT 

President Obama ushered in a new era of U.S. health care by signing 

the Patient Protection and Affordable Care Act (PPACA). This 2400+ 

page document brings significant changes to orthopaedic surgeons 

and our patients. However, understanding how we will be affected 

is challenging given the breadth and complexity of the bill. In this 

scientific presentation, we aim to summarize the legislation to 

its most impactful points and discuss legislative action since the 

bill’s passage. After analyzing this health care reform package, we 

summarize the relevant provisions likely to affect the practice of 

orthopaedic surgeons. We organize this by three distinct sections: 

how the bill affects orthopaedic surgeons, patients, and legislative 

action since the bill’s passage. We will provide a post-exhibit quiz 

and an website for review. Pertinent facets of the legislation include 

the Independent Payment Advisory Board and increased use of 

comparative effectiveness research. We explain how insurance 

coverage will be expanded to cover all Americans and outline the 

quality initiatives created by the bill. We provide political updates 

since the bill’s passage, including reform of the sustained growth 

rate and discuss efforts to repeal or revise portions of the bill. The 

PPACA is a difficult to understand piece of legislation with broad 

and significant effects. In this scientific presentation, we summarize 

the bill’s most impactful points for orthopaedic surgeons and their 

patients and review legislative action since the bill’s passage. 


Evidence-Based Practice Committee (EBPC) Scientific 

Exhibit 

William Timothy Brox, MD, Fresno, CA 

Evidence-Based Orthopaedic Practice is an essential component of 

contemporary patient care. Evidence has always been part of decision 

making and recommendations to patients, it now has even greater 

importance with the advent of quality evaluation, payer financial 

decisions, and regulatory oversight. The purpose of this exhibit is 

to:a)’Summarize the principles of evidence-based medicine, b)’To 

provide an overview of the AAOS activities in evidence-based 

medicine, and c)’To present recently approved evidence-based 

guidelines.Evidence-based practice is the balance and integration 

of three key components: a)’The best available research evidence, 

b)’Clinical expertise, and c)’Patient value preferences. Identifying 

and summarizing the best available research evidence is a major task 

including formulating answerable questions, appropriately gathering 




the evidence, appraising the evidence, implementing the evidence, 

and evaluating the process. This task is performed by a variety of 

organizations, and the AAOS is providing key leadership in this 

process on musculoskeletal topics. The AAOS is actively involved in 

Evidence-Based Orthopaedic Practice through the Evidence ‘Based 

Medicine Committee, the Guidelines and Technology Assessment 

Oversight Committee, the Council on Quality Assessment, and 

Technology (CORQAT) and the AAOS Department of Research 

and Scientific Affairs. AAOS develops evidence-based guidelines, 

technology overviews, and educational programs on evidence-based 

medicine topics. These committees also provide information on 

evidence-based medicine for other activities including testimony 

and advocacy before government agencies, payer groups, and 

the public.Four recently approved Guidelines are featured in this 

exhibit including:a)’Treatment of Glenohumeral Joint Arthritis, b)’ 

Treatment of Distal Radius Fractures, and c)’ Diagnosis and Treatment 

of Achilles Tendon Rupture. d)’ The Diagnosis of Periprosthetic 

Joint Infections of the hip and knee Integration of the principles of 

evidenced based medicine is critical to optimize patient care and for 

long term survival in orthopaedic practice. 


Integration of Lean Manufacturing Principles Optimizes 

TJR Perioperative Efficiency and LOS 

Vivek Mohan, MD, Newport Beach, CA 



Dhiren S Sheth, MD, Irvine, CA 

Hamid Sabet, Raynham, MA 

Fixed resources demand increased operational efficiency to 

provide high quality of care for the projected increase of total joint 

replacement (TJR) patients. The incorporation of ‘lean’ manufacturing 

practices in the Operating Room (OR) and on the Orthopaedic floor 

may lead to efficient patient care. A surgeon initiated consortium 

of health care providers utilized ‘lean’ re-engineering principles 

to optimize management of TJR patients . Simulation exercises 

identified improvement opportunities and created a collaborative 

environment for change management across the continuum of 

inpatient care. OR workflows and inpatient carepaths incorporated 

JCAHO standards and ensured SCIP compliance. Total cycle time 

from conceptual development to implementation was 6 mths for 

the OR efficiency and 4 mths for the LOS carepath. Perioperative 

efficiency protocols yielded average turn-around-times (TATs) of 

16 minutes at 6 months post-implementation, which represents 

approximately 40% reduction from pre-implementation. Surgeons 

and support staff expressed high levels of satisfaction with operating 

room workflows, quality of care, and team-building factors. Since 

adoption, average LOS for the inpatient carepath was 2.4 days, with 

an associated skilled nursing facility (SNF) utilization of 16%. This 

represents a 29% reduction from pre-implementation LOS (3.4 

days) and yielded a higher proportion of patients going home (84%) 

Integrating ‘lean’ manufacturing principles optimized perioperative 

TATs (16 mins) and increased staff satisfaction. Implementing a timebased 

carepath consistently reduced LOS for primary TJR patients 

to 2.4 days (29% reduction). An associated 50% reduction in SNF 

utilization was concomitantly seen. The ‘Lean’ concepts utilized 

were: parallel processing, waste elimination, protocol creation, and 

standardization. 

662 


Modifiable Risk Factors in Orthopaedic Infections - 

AAOS Patient Safety Committee 

Bobbi A Farber, MD, Columbus, GA 

Richard Parker Evans, MD, Little Rock, AR 

Laura J Prokuski, MD, Scottsdale, AZ 

Paul M Huddleston, MD, Rochester, MN 

Calin Stefan Moucha, MD, New York, NY 

This Scientific Exhibit will review the current state of infection in 

orthopaedic surgery in relation to modifiable risk factors emphasizing 

topics such as the post operative management of glucose in diabetes 

patients, preoperative control of remote infections, treatment 

of patients with poor oral hygiene, treatment of urinary tract 

infections, and malnutrition. It will also review the effects of obesity, 

smoking and HIV on infection rates. A critical examination of 

preoperative infection control and prevention will review methods 

of identification of modifiable risk factors in the preoperative 

period as well as treatment prior to surgical intervention. Further, 

postoperative management of glucose, management of malnutrition 

preoperative and postoperative, and management to decrease 

risks of infection to patients with HIV, obesity, and Rheumatoid 

Arthritis will be addressed. The exhibit will emphasis Patient Safety 

Committee links to Antibiotic Prophylaxis for Bacteremia in Patients 

with Joint Replacement, SSI prevention, Society of Thoracic Surgeons 

guide to postoperative glucose control, Body Mass Index calculation, 

and malnutrition calculations. The audience will appreciate current 

trends of updated knowledge of this subject area. The importance 

of current and future mechanisms for SSI reporting and feedback 

surveillance of increasing rates of antimicrobial resistant organisms 

will be reviewed and emphasized. 


SOPs: Professional Relationships and Musculoskeletal 

Services - AAOS Committee on Professionalism 

Murray J Goodman, MD, Salem, MA 

David E Attarian, MD, Durham, NC 

Richard A Brown, MD, La Jolla, CA 

Dale R Butler, MD, Grass Valley, CA 

Thomas W Currey, MD, Chattanooga, TN 

William John Hopkinson, MD, Maywood, IL 

Tamara Lynn Martin, MD, Boston, MA 

Vincent J Silvaggio, MD, Pittsburgh, PA 

Richard E Strain Jr, MD, Davie, FL 

The Committee on Professionalism (COP) is charged with 

educating the AAOS Fellowship about the minimum Standards of 

Professionalism expected of all Fellows. There are six SOPs. The 

COP also reviews all formal complaints (Grievances) filed by one 

Fellow against another and forms a Hearing Panel to evaluate the 

charges and make disciplinary recommendations to the AAOS 

Board of Directors. The exhibit will focus on minimum standards 

concerning the provision of musculoskeletal services to patients as 

well as relationships among healthcare professionals. Using posters 

and video, the exhibit will cite the SOPs and provide examples of 

appropriate and inappropriate behavior. Recent revisions enacted 

to the Expert Witness SOP will also be cited. The exhibit will also 

summarize the Professional Compliance Program by illustrating 

the formal grievance process and recapping the Professional 

Compliance actions taken to date by the AAOS Board of Directors. 

Current statistics for AAOS Grievances will be presented as well. 

Through the use of this exhibit, AAOS Fellows will be informed and 

updated about the Professional Compliance Program and the AAOS 




Standards of Professionalism. 


Liability Associated with Never Events - AAOS Medical 

Liability Committee 

Douglas W Lundy, MD, Marietta, GA 

Thomas B Fleeter, MD, Reston, VA 

Andrew David Markiewitz, MD, Cincinnati, OH 

Dale R Butler, MD, Grass Valley, CA 

Theodore J Clarke, MD, Denver, CO 

Elliott H Leitman, MD, Wilmington, DE 

Subramanyan Jayasankar, MD, Weston, MA 

Stuart L Weinstein, MD, Iowa City, IA 

David Seligson, MD, Louisville, KY 

In 2002, the National Quality Forum derived a list of Serious 

Reportable Events that has been renamed ‘Never Events’. These events 

include complications that the Centers for Medicare and Medicaid 

Services believes should not happen during hospitalizations, and 

they will no longer reimburse facilities for the additional costs 

associated with care arising from these events. “Never events’ include 

such conditions as wrong-site surgery, stage III or IV pressure ulcers, 

retained foreign bodies after surgery, falls in the hospital, and most 

recently, deep vein thrombosis or pulmonary emboli after total joint 

arthroplasty. Orthopaedic surgeons are at significant medicolegal 

risk when a ‘never-event’ occurs to one of their patients while under 

the surgeon’s care. The AAOS and the Joint Commission have 

already instituted methods to avoid wrong site-surgery and extensive 

efforts have been undertaken to eliminate retained foreign bodies 

and reduce post-operative pulmonary embolism. The AAOS Medical 

Liability Committee reviews the ‘never events ‘that are most likely to 

be encountered by the orthopaedic surgeon, methods to avoid these 

events, and strategies to employ when one of these conditions occurs 

to our patients. 


Viewing Care Delivery Through the Eyes of Patients 

and Families Using Reality TV and Shadowing 

Anthony M DiGioia III, MD, Pittsburgh, PA 

Timothy J Levison, MS, Pittsburgh, PA 

Viewing all care through the eyes of patients and families improves 

safety, quality and efficiencies following total joint replacement 

surgery as well as deliver exceptional care experiences. This study 

demonstrates the utilization of various observation tools, from 

high-tech digital video recording to low-tech patient and family 

shadowing, to capture real-time care experiences and reports on the 

resulting innovative care delivery, quality and safety improvements. 

These observations are the first steps to transform care experiences as 

well as define not only the flow of care from the patients’ perspective 

but also identify critical Touchpoints between patients and Care 

Givers. Using these observation tools enabled us to continuously 

monitor care experiences, clinical outcomes and care delivery over 

the patients entire length of stay. Results highlighted the number of 

various Care Giver interactions, frequency of contacts and duration 

of each interaction, along with staff flow efficiencies and patients’ 

family involvement in care delivery. Data analysis for the 2.6 day 

average length of stay showed the average patient interacted with 28 

unique Care Givers during 183 total contacts, while spending 91% 

of the time in their room with 15% of that time receiving direct 

bedside care. These observation techniques demonstrated the extent 

of valuable data available when care experiences are viewed through 

the eyes of patients and their families. Using these observation tools, 

663 

combined with the PFCC Methodology, we were able to identify 

areas of process improvement through the full cycle of care that 

enabled rapid and sustainable results. 




PAPERS 

pApeR No. 616 

Computer-Animations Improve Measurement of 

Function in Patients With Hip or Knee Osteoarthritis 

Vanessa AB Scholtes, PhD, Amsterdam, Netherlands 

Rudolf W Poolman, MD,PhD, Aerdenhout, Netherlands 

Caroline Terwee, PhD 

Charlotte Coopmans, MSc 

Wilfred Peter, PT, Postbus 58271 Amsterdam, Netherlands 

Roorda Leo, MD, PhD 

Jaap Harlaar, PhD 

Henrica CW De Vet, Prof, PhD 

Functional limitations of patients with hip or knee osteoarthritis 

(OA) can be measured by self-report questionnaires or performancebased 

tests. Both methods have advantages and disadvantages. 

Questionnaires are influenced by factors like pain, fatigue and patients’ 

interpretation of the questions. Performance-based tests require 

personal contact and are time-consuming and a burden for patients. 

We aimed to develop a new computer-animated questionnaire. The 

computer-animation questionnaire was developed in cooperation 

with a specialized company, based on movement analyses of a 

person performing seven different daily activities. Different videos 

of each activity were made with two to five levels of difficulty. For 

each activity, patients choose the video that best indicated their way 

of activity performance. We compared this new questionnaire with a 

validated paper questionnaire (WOMAC) and validated performance 

tests (walking, timed-up-and-go, timed-stair-test). Outcomes of 

33 patients with hip or knee OA were correlated on each form of 

measurement. The computer-animation questionnaire showed a 

higher correlation with the performance tests than the WOMAC 

questionnaire (0.75 vs. 0.49). Patients were enthusiastic about this 

new measurement instrument. Almost all patients preferred it over 

paper questionnaires and performance-based tests. The computeranimation 

questionnaire might be a good alternative instrument to 

measure functional limitations of patients with hip or knee OA. This 

method can easily be used in other patient populations as well and 

can be administered by the Internet. 

pApeR No. 617 

Preoperative Narcotic Medication Has Minimal 

Postoperative Effect in Total Joint Arthroplasty (TJA) 



James Shen, MD 

Melissa Stewart, BS 

The role of preoperative narcotic medication use in recovery after 

primary total joint arthroplasty (TJA) has not been well studied. 

This study investigates the effects of preoperative narcotics on 

postoperative recovery. A prospective case series of 128 consecutive 

patients and 136 TJAs from 2008 to 2009 was examined. The study 

population had three preoperative narcotic medication categories: 95 

TJAs took no narcotics preoperatively (average age 63.4 yrs; 43M/52F; 

36 hips/59 knees; 49R/46L); 35 TJAs took short acting narcotics 

(average age 61.2 years, 7M/28F, 20 hips/15 knees, 18R/17L); and six 

TJAs received long acting narcotics (average age 63.1 years, 5M/1F, 

664 

rehabilitation 

two hips/four knees, 1R/5L). Short acting narcotics included drugs 

with half-lives less than four hours taken on a four to six hour dosing 

schedule. Long acting narcotics included medications with half-lives 

longer than four hours and were dosed on a 12+ hour schedule. Pain 

levels were determined by the 0-10 visual analog scale. Length of 

stay (LOS) was determined by operative start time until the time of 

discharge. Early physical therapy was defined as treatment on the day 

of surgery (POD 0). Continuous variables were analyzed by one-way 

ANOVA and categorical variables were analyzed by chi-squared tests. 

In the immediate post-operative period, pain scores were significantly 

different in patients who were on preoperative narcotics compared to 

those who were not taking narcotic medication (p=0.03, no narcotics 

4.5±1.6, short acting 5.3±1.9, long acting 5.5±1.4). However, there 

were no differences between length of stay (p=0.29, no narcotics 

3.4 days±1.7, short acting 3.4±1.5, long acting 4.5±2.1) or early 

rehabilitation (p=0.96, no narcotics POD 0 17.9%, short acting 

POD 0 20%, long acting 16.7%). Patients who receive preoperative 

narcotic medication have more pain postoperatively, but this does 

not affect length of stay or postoperative rehabilitation. 

pApeR No. 618 

Physical Therapy on Day of Total Joint Arthroplasty 

(TJA) Surgery Reduces Length of Hospital Stay 



Melissa Stewart, BS 

Alma Heyl, CCRC 

Studies demonstrate decreased length of stay (LOS) with multiple 

changes to perioperative care after total joint arthroplasty (TJA). 

These multimodality protocols involve changes to pre-operative 

education, analgesia and physical therapy (PT). The isolated effect of 

instituting PT on the day of surgery (POD 0) has not been studied. 

Our study compared the LOS between patients who received PT on 

POD 0 and patients who received PT on post-operative day one. A 

prospective cohort study was performed on 128 consecutive patients 

(53 males, 75 females, average age of 62.3) who underwent 136 

primary TJAs (58 hips, 78 knees) from September 2008 to September 

2009. There were 68 right and 68 left procedures. Patient selection 

for POD 0 rehabilitation was random and was dependent on timing 

and staff availability. On POD 0, 60 remained in bed, 51 were out 

of bed to a chair with nursing and 25 received PT. Of the 25 joints 

that received PT, 22 ambulated in the hall and three moved to a 

chair. A total of 24% hip and 14% knee arthroplasties received POD 

0 PT. The initial PT session was recorded for activity performed. The 

LOS was determined by the operative start time until the time of 

discharge, after all patients met standardized discharge criteria. LOS 

differed between those receiving PT on POD 0 (2.8±0.8 days) versus 

patients receiving PT on POD 1 (3.7±1.8 days) (p=0.02). Those who 

were out of bed to chair with PT on POD 0 stayed 2.9±0.6 days, 

and those who ambulated with PT stayed 2.8±0.8 days. Patients that 

remained in bed on POD 0 stayed an average of 3.9±1.8 days, and 

patients who were out of bed to a chair with nursing staff stayed 

3.6±1.7 days. All patients who received PT on POD 0 got out of bed, 

while none of the remaining patients ambulated on POD 0. There 

was no difference in physical therapy treatment based on body mass 

index, nausea/vomiting, vital signs or pain levels. Physical therapy 

intervention on POD 0 shortened hospital LOS, regardless of the 

intervention performed. 



PaPers, Posters & scientific exhibits ReHAbilitAtioN

pApeR No. 619 

Iliopsoas Muscle Atrophy Pre and Post THA -MRI 

Analysis of 500 Cases 

Koh Shimizu, MD, Chiba, Japan 

Sara Shimizu, MD, Chiba, Japan 

Masatsugu Yamagata, MD, Ichihara, Japan 

Junichi Iwasaki, MD, Ichihara City, Chiba, Japan 

Muscle atrophy of the iliopsoas in patients with hip osteoarthritis 

has not been noticed clinically, although it is a very important and 

strong muscle which flexes the hip joint and supports the lumbar 

spine and pelvis. Also, it has not been evaluated enough how the 

atrophic muscles will recover after total hip arthroplasty (THA). 

This study was performed to determine the incidence and severity of 

muscle atrophy of the iliopsoas muscle, compared with that of the 

gluteus medius muscle, before and after THA. Preoperative MRI of 

500 THA patients with severe osteoarthritis of the unilateral hip was 

used for evaluation of the psoas, iliacus and gluteus medius muscles. 

A total of 207 of the 500 patients were followed by MRI more than 

three years after THA, and recovery of the muscles were investigated. 

T1 weighted images in coronal and transverse sections were analyzed 

by SIGNA. Transverse diameters in coronal sections and the area in 

transverse sections of bilateral muscles were measured to calculate 

the percentage of muscle atrophy. Preoperatively, average decrease 

ratio of the transverse diameter in coronal sections was 31% in the 

psoas, 30% in the iliacus and 23% in the gluteus medius muscle. 

Preoperative decrease ratio of area in transverse sections was 51% in 

the psoas, 42% in the iliacus and 35% in the gluteus medius muscle. 

After THA, average decrease ratio of the area was 45% in the psoas, 

39% in the iliacus and 31% one year postoperatively and 34% in 

the psoas, 35% in the iliacus and 25% three years postoperatively. 

This MRI study revealed greater muscle atrophy in the iliopsoas 

as compared to the gluteus medius muscle in patients with hip 

osteoarthritis preoperatively. Recovery of the atrophic muscles was 

not sufficient even after THA, although the decrease ratio improved 

slightly. The lack of improvement may be speculated to be the result 

of inactivity during the preoperative painful OA years, and the lack 

of activity even after successful THA. Post THA rehabilitation should 

include hip flexion exercises in order to build the iliopsoas muscle 

and hip abduction exercises in order to build the gluteus medius 

muscle. 

pApeR No. 620 

Development and Validation of a Discriminating 

Functional Hip Score 


Jenni Tahmassebi, MSc, Great Missenden, Bucks, 



The aim of this study was to validate a user friendly discriminating 

functional hip scoring system developed in our unit for use in 

younger, ‘high demand’ patients undergoing hip arthroplasty surgery. 

The commonly used hip outcome scores have a ceiling effect and 

discriminate poorly at the highest functional levels. The functional 

hip score uses a series of five tasks, which are graded on a hierarchical 

unweighted scale. We studied a cohort of 38 subjects without any hip 

symptoms and 72 patients undergoing total hip arthroplasty (THA) 

for osteoarthritis of the hip. Pre-procedure and post-procedure 

scores were collected in the latter cohort of patients. Short form- 

36 (SF-36) and the Western Ontario and McMaster Universities 

Osteoarthritis Index (WOMAC) scores were used to validate our 

functional scoring system. A statistically significant improvement 

665 

following total hip arthroplasty was demonstrated by the functional 

hip score (p

in 17 patients having a THA revision. The impact of Co2+ on human 

neutrophils killing against two strains of Staphylococus epidermidis 

was determined by counting surviving bacteria. The effect of Co2+ 

on superoxide production by neutrophils was measured with a 

cytochrome c reduction assay. To test whether Co2+ blocks Hv1 

activity, we measured neutrophils intracellular alkalinization 

following an acute acid load. The effect of Co2+ on Hv1 proton 

currents from activated neutrophils was determined by patch clamp 

recordings. The mean Co2+ concentration in periprosthetic tissues 

was 71 µM (3-410 µM). Micromolar concentrations of Co2+ (1- 

10 and 100 µM) inhibit proton currents, impair the extrusion of 

cytosolic acid and decrease superoxide production in neutrophils. 

As a result, Co2+ reduces the ability of neutrophils to kill two strains 

of Staphylococcus epidermidis. At micromolar concentrations in 

peri prosthetic tissues, Co2+ inhibits proton channels and might 

therefore promote bacterial infections in patients with MM THA. 

pApeR No. 623 

Atorvastatin is Beneficial for Muscle Reinnervation 

After a Complete Sciatic Nerve Section in Rats 

Dominique Rouleau, MD, Montreal, QC Canada 

Jonah Hebert-Davies, MD, Montreal, QC Canada 

Frederic C Cloutier, MD, Montreal, QC Canada 

Pierre H Beaumont, MD, Montreal, QC Canada 

Eric Beaumont, PhD, Montreal, QC Canada 

Nerve regeneration and functional recovery are often incomplete 

after peripheral neurotmetic lesion. The aim of this study was to 

determine if the systemic administration of atorvastatin is effective in 

promoting functional muscle reinnervation. Female Sprague-Dawley 

rats were used in this study. A complete right sciatic nerve section 

using scissors was done. End-to-end microsuture repair (0-180°) 

was performed in every nerve and fibrin glue was added. Two groups 

were studied: 1) sutures (S) + fibrin glue (F) only; 2) S+F+Atorvastatin 

administration for fourteen (14) days. The left uninjured hindlimb 

was used for the 3) control group. Five months later, the sciatic nerve 

and the gastrocnemius muscle were dissected to perform in vivo 

electrophysiological measurements. Sixteen (16) rats were used in 

this study. Electromyographic activity (EMG) and muscle force were 

measured following the nerve stimulation proximal to the lesion site 

and compared between groups. The group with suture and fibrin 

glue alone 1) (0,77mV; 28,56g) was significantly lower compared 

to the atorvastatin group 2) (2.91mV; 85.1g) and the control group 

3) (3,29mV; 77,14g). Five months after a neurotmetic lesion, the 

recovery is incomplete when using suture and fibrin glue only. 

Furthermore, the systemic administration of atorvastatin for fourteen 

(14) days post lesion is beneficial in reestablishing the muscle force 

and the EMG at the uninjured level. 

pApeR No. 624 

Safety and Efficacy of Repeat Treatment with Single 

dose Hylan G-F 20 in OA of the knee 

Raghu Raman, MRCS, Normanton, West Yorkshire, 


Geoffrey V Johnson, FRCS, Hull, United Kingdom 

Nicky Day 

Arup Dutta, FRCS 

Hemant Sharma, MRCS,MS, Hessle, United Kingdom 

Christopher Shaw, FRCS 

Pain and symptom relief from viscosupplementation is variable 

ranging from three-12 months necessitating a repeat course of 

treatment. There is a paucity of clinical evidence addressing the 

666 

efficacy and safety of repeat courses of this treatment. The aim 

of this study was to assess the safety and efficacy of repeat intraarticular 

injections of single dose hylan GF-20 (Synvisc, 6 ml) in the 

treatment of osteoarthritis (OA) of the knee. In this independent 

study, patients who had previous viscosupplementation treatment 

to the knee were offered repeat treatment after a minimum of six 

months after the initial course. The inclusion criteria were pain 

score of >6 on a VAS (0-10) in the target knee and one course of 

previous viscosupplementation (single (6 ml) or multi dose hylan 

G-F 20 (3x2 ml) treatment. As an extension of our previous study, 

we identified 195 consecutive patients, who were prospectively 

reviewed by blinded independent assessors at pre injection, one 

week, six weeks, and three, six and 12 months after repeat treatment 

with single dose hylan G-F 20 (6 ml). The primary outcome variable 

was knee pain on VAS at six months. Functional outcome was 

assessed using WOMAC, Oxford knee score and EuroQol EQ-5D. 

All adverse events (AE), including injection and treatment related 

AE in the target knee were recorded at one week and six weeks after 

treatment. Mean follow up was 12 months. A total of 103 patients 

received single dose (6 ml) at initial treatment and the rest had multi 

dose (3x2 ml) hylan G-F 20. The mean time from primary course 

of treatment was 46.1 months (44.2 - multiple dose hylan G-F 20 

group, 47.3 - single dose hylan G-F 20 group). Knee pain on VAS 

improved from 6.9 to 3.8 at six months (p=0.02) and to 4.9, p>0.05 

at 12 months. Significant improvements from the baseline in the 

WOMAC pain and function subscales and Oxford knee scores at 

three, six and 12 months were recorded. Sub group analysis showed 

no statistically significant difference between patients with previous 

single or multi dose treatments. Overall adverse events were recorded 

in 13% (14% in initial course). Treatment and/or injection related 

minor AE in the target knee were observed in 3.8% (3.1% in the 

single - single dose group and 3.9% in the multiple - single dose 

group). Previous treatment regime did not influence the incidence 

of AE in the patients. None of the patients had serious AE. There 

is a significant reduction of pain and improvement in function 

following treatment of symptomatic OA of the knee with repeat 

injections of singe dose hylan G-F 20. The magnitude of pain relief 

and the longevity of symptom control were comparable with the 

results from the first course of treatment. Repeat injections of singe 

dose hylan G-F 20 are well tolerated as shown by the low rate of AE. 

From this study, it appears that repeat injections of single dose hylan 

G-F 20 can be both safely and effectively administered in patients 

with symptomatic OA of the knee. 

pApeR No. 625 

Hip Findings in Elite Female Soccer Athletes Differ by 

Level of Experience 

Robert H Brophy, MD, Saint Louis, MO 

Devyani Hunt, MD, St Louis, MO 

Tedd Yemm, PT 

Kathryn Fong, BS 

Monica Rho, MD, Chicago, IL 

Heidi Prather, DO, Saint Louis, MO 

Elite female soccer athletes are at risk for hip related disorders. 

Little is known about baseline physical examination findings in this 

population. The purpose of this study was to test the hypothesis 

that passive hip range of motion (ROM) and strength differ by level 

of experience in these athletes. Female athletes from an elite youth 

soccer club, a college and a professional team were evaluated prior to 

their competitive seasons. Passive hip ROM and abduction strength 

was measured on each athlete. Data were compared for the grade/ 

middle school, high school, college and professional players. A total 

of 172 athletes (62 grade/middle school, 54 high school, 20 college 




and 36 professional) with a mean age of 17 years (range 10-30) 

participated. Professional players had reduced flexion for both hips 

(p

pApeR No. 629 

Immunological Response to Bolus vs Multiple 

Injections of Synvisc in a Murine Biocompatibility 

Model 

Syed Sami, MD, Canton, MI 

Nancy M Jackson, Southfield, MI 

Amanda Esquivel, PhD, Warren, MI 

Dr Jeffrey Flynn, Southfield, MI 

Weiping Ren, MD 

David C Markel, MD, Southfield, MI 

Although local reactivity to Synvisc has been studied, no study has 

been done which compares the reactivity of Synvisc in single vs. 

multiple injections using both systemic and local parameters. Thus, 

the objective of our study was to use the murine biocompatibility 

model to study the inflammatory response to Synvisc after various 

treatment protocols. Air pouches were established subcutaneously 

in the dorsum of 50 BALB/c mice. Ten mice were randomly placed 

into each group, and the pouches were injected with: phosphatebuffered 

saline (PBS, negative control), 5 mg ultra-high molecular 

weight polyethylene particles (to simulate synthetic joint wear debris, 

positive control), 0.5 ml Synvisc (one injection/week for three weeks, 

harvested 14 days after last injection), and 1.5 ml Synvisc bolus 

(harvested either 14 or 28 days after last injection). At the time of 

sacrifice, sera and air pouch tissues were collected. Serum antibody 

titers to Synvisc were determined by enzyme-linked immunosorbent 

assay. Inflammatory gene expression of air pouch tissue was 

quantified by polymerase chain reaction. Inflammation was also 

evaluated by histological analysis of wall thickness and cellularity 

in several locations on the H&E-stained pouch. Inflammation was 

observed with all Synvisc treatments, as pouch wall thickness and 

cellular density were increased, relative to PBS (P


Effectiveness of a Laterally Wedged Insole for 

Dysplastic Hips 

Akira Maeyama, MD, Fukuoka, Japan 


Takahiko Kiyama, MD, Fukuoka, Japan 




Effective conservative treatments for adult dysplastic hips have not 

been reported in detail, while various surgical treatments have been 

performed. The purpose of this study was to assess the effects of a 

laterally wedged insole, which is used as a conservative treatment for 

dysplastic hips. Sixty-three outpatients (91 hips) with hip arthritis 

secondary to dysplasia and normal knee joints were randomly 

allocated into a laterally wedged insole group (44 hips; Group I) and 

a neutrally wedged insole group (47 hips; Group II). Both groups 

were matched for age, sex, obesity index, disease duration, X-ray 

grade, pain and radiographic findings. Pain was evaluated using the 

visual analog scale (VAS) before application of the insole (baseline 

data) and after eight weeks of insole application for both groups. The 

effects of both types of insoles on hip instability were investigated by 

triaxial accelerometry. Data acquired by accelerometry while walking 

were used to analyze hip instability. After eight weeks of insole 

application, the VAS scores were significantly improved in group I 

compared with the baseline data (p

management of TKR. The purpose of this study was to examine 

outpatient physical therapy (PT) utilization in patients undergoing 

primary TKR surgery. PT records from patients participating in the 

Joint Action clinical trial were included in the study. Records from 

patients who attended outpatient PT, completed their course of 

care and their study six-month assessment were eligible for review. 

Records from 65 patients who underwent primary TKR were eligible 

for review. Forty-four records were reviewed from 18 facilities. 

Twenty-one records were not reviewed because the facilities did not 

respond to requests for the records. Frequency and duration of PT 

and total number of visits were recorded using a previously reported 

survey (Describing Variability of Physical Therapy Practice Following 

Total Knee Replacement in Montgomery County, Pennsylvania). 

“Usual care” was operationally defined as more than 50% 

agreement. “Consensus” was operationally defined as more than 

85% agreement. No agreement existed on initiation of outpatient PT 

(one to >seven weeks postoperatively). Average number of visits was 

15 (SD 6.4). No agreement existed on total number of visits (five to 

34) or on when to discontinue PT (16 weeks postoperatively). 

No agreement exists in outpatient PT utilization. Patients still have 

functional limitations one year after TKR. Research is needed to 

determine if variability in post-operative rehabilitation utilization 

contributes to patient outcomes. 


Measurement of Leg Motion Complexity for 

Quantification of Gait Impairment in Knee OA 

Yuki Tochigi, MD,PhD, Iowa City, IA 

Neil Segal, MD, Iowa City, IA 

Tanawat Vaseenon, Meung, Chaing-Mai, Thailand 

Thomas D Brown, PH D, Iowa City, IA 

A concept called the ‘loss of complexity’ hypothesis regards decreased 

complexity in biological systems as a characteristic of pathologic 

conditions. This concept is consistent with the clinical observation 

that patients with a lower-limb joint disorder exhibit monotonic 

leg motion patterns to protect the symptomatic site from loading 

(i.e., limp). This study aimed to test if measurement of complexity 

in leg motion patterns during walking would allow identifying gait 

impairment associated with lower limb disorder. The hypothesis 

was that subjects with symptomatic knee osteoarthritis (OA) 

would walk with more monotonic (i.e., less complex) leg motion 

patterns compared to age-matched asymptomatic control subjects. 

Elderly volunteers (range: 60-79 years), including 51 subjects with 

symptomatic knee OA and 17 asymptomatic control subjects, were 

recruited with Institutional Review Board approval. Leg motions 

during long-distance corridor walking were measured using a lightweight 

wireless tri-axial accelerometer device, attached bilaterally 

just above each ankle. The collected 3-D acceleration time-series data 

were analyzed using a chaotic non-linear measure “sample entropy 

(SampEn),” which quantified the complexity (stride-to-stride 

variability) of time-series data. Complexity of leg motion pattern 

was significantly lower in the OA subjects (p

of families would treat a second child born with clubfoot deformity. 

Parent education seems to be important for a successful outcome. 

Internet influence parent decisions in treatment. Parents report 

routine and discipline as crucial in children compliance with the 

abduction brace. Parents report a generally positive impression on 

Ponseti treatment for their children and reinforce their necessity of 

sharing responsibility for good outcomes. 


uNovel Biodegradable Regenerative Type Neural 

Interface with Regenerated Peripheral Nerve Fibers 

Xiaofeng Jia, MD, PhD, Baltimore, MD 

Dan Lewitus, MS 

Jacob Vogelstein, PhD 

Gehua Zhen, MD, Baltimore, MD 

Young-Seok Choi, PhD, Baltimore, MD 

Joachim Kohn PhD, Piscataway, NJ 

The two main factors limiting the functionality of prosthetic upper 

limbs are the lack of a high-bandwidth information channel 

conveying the user’s movement intent and the lack of a high-resolution 

sensory feedback pathway from the artificial limb. Next-generation 

neuroprosthetic limbs will require a reliable long-term neural 

interface to residual nerves in the peripheral nervous system (PNS). 

We have developed novel biocompatible materials and a fabrication 

technique to create high site-count microelectrodes for stimulating 

and recording from regenerated peripheral nerves. Our electrodes are 

based on a biodegradable tyrosine-derived polycarbonate polymer 

system with suitable degradation and erosion properties and a 

fabrication technique for deployment of the polymer in a porous, 

degradable, regenerative, multi-luminal, multi-electrode conduit. 

The in vitro properties of the polymer and the electrode were tuned 

to retain mechanical strength for over 24 days and to completely 

degrade and erode within 220 days. The fabrication technique 

resulted in a muti-luminal conduit with at least 10 functioning 

electrodes maintaining impedance of recording sites in the singledigit 

kOhm values. Additionally, an in vivo study showed that neural 

signals could be recorded from these devices starting at four-weeks 

post-implantation and that signal strength increased over time. Our 

biodegradable regenerative-type neural interface is a good candidate 

for chronic high fidelity recording electrodes for integration in 

regenerated peripheral nerves. This work was sponsored by the Johns 

Hopkins University Applied Physics Laboratory under the Defense 

Advanced Research Projects Agency 2009 Revolutionizing Prosthetics 

program; contract N66001-06-C-8005. The views, opinions, and/ 

or findings contained in this article/presentation are those of the 

author/presenter and should not be interpreted as representing the 

official views or policies, either expressed or implied, of the Defense 

Advanced Research Projects Agency or the Department of Defense. 

Distribution Statement A (Approved for Public Release, Distribution 

Unlimited). 

671 


Influence of Psychological Distress on Function and 

Pain After Hip and Knee Replacement Surgery 

Thoralf R Liebs, Kiel, Germany 

Wolfgang Herzberg, Wedel, Germany 

Martin Russlies, MD, L¿beck, Germany 

Wolfgang Ruther, MD, Hamburg, Germany 

Joerg Haasters, MD, Kappeln, Germany 

Joachim Hassenpflug, MD, Kiel, Germany 

It has been discussed that psychological distress may have a role 

on pain and function after hip or knee replacement surgery. It 

was the aim of this study to evaluate the independent influence of 

preoperative psychological distress on function and pain after hip 

or knee replacement surgery. This analysis is based on prospectively 

collected data from three multicenter randomized controlled trials 

evaluating different rehabilitation measures after hip or knee 

replacement surgery. A total of 1,198 patients (494 with knee and 

704 with hip replacement surgery) were included in the analysis. We 

have used the preoperative scale “’mental health” of the SF-36 to 

determine its association with postoperative function and pain, as 

measured by the WOMAC (Western Ontario McMasters Universities 

Arthritis Index), at three, six, 12 and 24 postoperative months. We 

adjusted for several covariates. Preoperative ‘mental health’ of the 

SF-36 was statistically significantly associated with postoperative 

function and pain. The parameter estimate of the mental health score 

on postoperative function ranged between 0.179 and 0.264 after hip 

arthroplasty and between 0.162 and 0.278 after knee arthroplasty, 

indicating that for each point increase in the mental health index, 

WOMAC function changed by e.g., 0.179 points. Regarding 

postoperative pain, the parameter estimates ranged between 0.138 

and 0.169 after hip arthroplasty and between 0.148 and 0.193 after 

knee arthroplasty. Patients with preoperative psychological distress 

demonstrated statistically significant associations with increased 

postoperative pain and poorer physical function, after both knee 

and hip replacement surgery. 




PAPERS 

pApeR No. 076 

Lesser Tuberosity Osteotomy vs. Subscapularis 

Tenotomy In Shoulder Arthroplasty: A Multicentre RCT 

Peter Lapner, MD, Ottawa, ON Canada 

Kimberly Bell, BA, Ottawa, ON Canada 

George S. Athwal, MD, London, ON Canada 

Controversy exists regarding the optimal technique of subscapularis 

mobilization during shoulder arthroplasty. The purpose of this 

multicenter randomized double-blind study was to compare the 

functional outcomes and healing rates of the lesser tuberosity 

osteotomy (LTO) to the subscapularis tenotomy (ST). Patients 

undergoing shoulder arthroplasty were randomized to receive either 

a LTO or ST. The primary outcome was to compare subscapularis 

strength, as measured by an electronic hand-held dynamometer at 

12 months. Secondary outcomes included range of motion, Western 

Ontario Osteoarthritis of the Shoulder, Constant and American 

Shoulder and Elbow Surgeons scores. A sample size calculation 

determined that 80 patients provided 80% power with a 50% effect 

size to detect a significant difference between groups. Baseline 

demographic data did not differ between groups including age 

(p=0.69), sex (p=0.77), affected side (p=0.59) and arthroplasty type 

(hemiarthroplasty or total, p=0.77). Strength comparison between 

groups revealed no statistical differences at any time interval 

(p=0.744, baseline, p=0.449, three months, p=0.203, six months, 12 

months, p=0.45). Statistically significant improvements occurred in 

both groups from baseline to 12 month time points in all clinical 

outcome scores (p

clinical and radiological outcomes. Full radiographic and clinical 

follow up greater than five years was available for 518 total shoulder 

arthroplasties performed for primary osteoarthritis in 10 surgical 

centers. Secondary cuff failure was diagnosed radiographically by 

moderate or severe superior subluxation. At average 104 months 

(60-219), the rate of secondary cuff failure was 17% and was 

significantly correlated with preoperative fatty infiltration of the 

supraspinatus (p

were taken for subsidence in each arthroplasty. RSA analysis showed 

median total humeral component subsidence at six months to be 

0.07±0.07 mm (-0.46-0.67 mm). When compared to six months, 

subsidence increase at 12 months was -0.01±0.04 mm (-0.20-0.41 

mm] and subsidence increase at two years was 0.03±0.10 mm 

(-0.59-0.65 mm). There was no significant change in the median 

humeral subsidence between six months, one year or two years. 

The early results from our study indicate that uncemented humeral 

components are stable and experience little subsidence within the 

first two years after implantation. To our knowledge, this study is the 

first quantitative analysis of humeral component stability. Longerterm 

follow up will be necessary to understand the longer-term 

stability of these components. 

pApeR No. 083 

Regionalization of Elective Total Shoulder Arthroplasty 


Huong Do, MS, New York, NY 

Robert G Marx, MD, New York, NY 

Patients at higher volume centers have improved outcomes after total 

shoulder arthroplasty (TSA) and many other surgical procedures, 

leading some policy experts to call for regional centers of excellence. 

This study aims to evaluate the frequency of regionalization of 

TSA, which patients regionalize and what effect regionalization 

has on patient outcomes. Patients who underwent a TSA in 13 

U.S. states between 1990 and 2006 were identified using statewide 

hospitalization databases. We identified patients who stayed in their 

local hospital service area (HSA) or who left to have surgery at a higher 

volume hospital than available locally. In-hospital complications 

were identified and a logistic regression model was used to identify 

the effect of regionalization on the risk of these complications. A 

total of 40,937 patients (56% female; mean age 68) underwent TSA. 

Of these, 54% left their local HSA and 36% went to a higher volume 

hospital. Patients who regionalized were more likely to be younger 

(p

value (SSV) was 77%. All patients were satisfied with the outcome 

following surgery. Radiographic tuberosity healing was observed in 

all but one case where there was partial lysis. 

pApeR No. 086 

The Relationship Between Scapular Notching And 

Reverse Shoulder Arthroplasty Prosthesis Design 

Marc S Kowalsky, MD, Hartsdale, NY 

Derek S Shia, MD, Portland, OR 

Leesa M Galatz, MD, Saint Louis, MO 

Jay D Keener, MD, Saint Louis, MO 

Inferior scapular notching is a known radiographic complication 

of reverse shoulder arthroplasty (RSA). The purpose of this study is 

to determine the impact of prosthesis design on the incidence and 

severity of notching. Eighty-eight patients (mean age 72.2 years) who 

underwent reverse shoulder arthroplasty with a minimum of oneyear 

follow-up (mean 30 months) were retrospectively reviewed. 

Patients were grouped based on prosthesis design: Prosthesis 1 

(46%), Prosthesis 2 with standard liner (Prosthesis 2 STD, 35%) and 

Prosthesis 2 with retentive liner (Prosthesis 2 RET, 19%). Notching 

on final radiographs was graded using the Sirveaux and a novel 

classification system. The presence of heterotopic ossification was 

also noted. The incidence of notching was significantly higher with 

Prosthesis 1 (92%) compared to Prosthesis 2 STD (58%) and RET 

(71%) (p < 0.05). Using both grading systems, the incidence of highgrade 

notching and the average grade were significantly higher with 

Prosthesis 1 compared to Prosthesis 2 STD and RET (p < 0.05). Using 

the novel grading system, there was a higher incidence of notching 

involving the baseplate with Prosthesis 1 (68%) compared to 

Prosthesis 2 (33%) (p < 0.05). While overall there was no significant 

difference in heterotopic ossification between the two prostheses, 

Prosthesis 2 RET demonstrated the highest incidence (94%) (p < 

0.05). A higher incidence and severity of notching were observed 

with Prosthesis 1. This may be due to the higher inclination angle of 

this prosthesis. In addition to surgical technique, attention should 

be paid to prosthesis design in mitigating risk of scapular notching. 

pApeR No. 087 

Reverse Shoulder Arthroplasty for Instability After 

Anatomic Arthroplasty 

Matthew P Abdel, MD, Rochester, MN 

Steven J Hattrup, MD, Phoenix, AZ 

John William Sperling, MD, MBA, Rochester, MN 

Robert H Cofield, MD, Rochester, MN 

Cole Robert Kreofsky, BS 

Joaquin Sanchez-Sotelo, MD, Rochester, MN 

Instability after shoulder arthroplasty is difficult to correct. Reverse 

shoulder arthroplasty represents an attractive option. However, the 

results of such procedures are largely unknown. The purpose of 

this study was to determine the results of revision of the unstable 

anatomic shoulder arthroplasty to a reverse prosthesis. Between 2004 

and 2007, 33 unstable anatomic shoulder arthroplasties were revised 

to a reverse design. Outcomes evaluated included visual analog 

scores (VAS) for pain, range of motion, Neer rating and shoulder 

stability. The mean age was 71 years, with 58% of the patients being 

female. The average follow up was 26 months. The average time 

from the index arthroplasty to revision was 26 months (range, 4-164 

months). Pain scores improved significantly (preoperative VAS 7.2 ± 

1.6; most recent VAS 2.2 ± 1.9; p = 0.001). There was a statistically 

significant increase in active forward elevation from 40.2º ± 27.3º to 

97.0º ± 36.2º (p = 0.001). There was no difference in internal (p = 

675 

0.93) or external (p = 0.40) rotation. At last follow up, 31 shoulders 

(94%) were deemed stable. The remaining two patients experienced 

dislocations, one at 2.5 weeks postoperatively and the other at 

three months postoperatively. According to the Neer rating system, 

there were 13 excellent, 10 satisfactory and 10 unsatisfactory results. 

Revision of an unstable shoulder arthroplasty to reverse prosthesis is 

associated with a high rate of postoperative stability, improved pain 

relief and gains in active elevation. Overall results are excellent or 

satisfactory in approximately 70% of the patients. 

pApeR No. 088 

Survivorship Of The Reverse Shoulder Arthroplasties 

(RSA) With A Minimum Follow Up Of 10 Years 

Luc Favard, MD, Tours, France 

Ghassan Alami, MD, Montreal, QC Canada 

Allan Young, PhD, Woollahra, NSW Australia 

Daniel Mole, MD, Nancy Cedex, France 

Francois Sirveaux, PhD, Nancy, France 

Pascal Boileau,MD, Nice, France 

Gilles Walch, MD, Lyon, France 

The goal of this study was to analyze the survivorship of reverse 

shoulder arthroplasties (RSA) with a minimum 10 years follow 

up. Between 1992 and 1999, 145 RSAs have been implanted 

in 138 patients. It was a mulicentric study. Initial etiologies were 

gathered as follows: group A (92 cases) cuff tear arthropaties (CTA), 

osteoarthritis (OA) with at least two involved cuff tendons and 

massive cuff tear (MCT) with pseudoparalysis; group B (39 cases) 

failed hemiarthroplasties (HA), failed total shoulder arthroplasties 

(TSA) and fracture sequelae; and group C (14 cases) varied. Survival 

curves were established with the Kaplan-Meier technique. Two 

endpoints were retained: implant revision defined by glenoid 

or humeral replacement or removal, or conversion to HA; a poor 

clinical outcome defined by an absolute Constant score of less than 

30. At the time of review, 47 patients had died with their prosthesis 

in place and 30 were lost to follow up. There were 12 revisions, 

six for infections, three for glenoid loosening, one for dislocation, 

one for glenoid dissociation (by unscrewing) and one for humeral 

loosening. The survival curve to prosthetic removal showed an 

overall survivorship of 92% at 10 years. Segmentation according to 

etiology showed a 97% survivorship for group A and 88% for group 

B. This difference was not significant. No patients of group C had 

a minimum follow up of 10 years because they died or were lost 

to follow up. The survival curve to a Constant score of less than 30 

showed an overall survivorship of 90% at 10 years. Segmentation 

according to etiology showed a significant difference at 10 years in 

favor of group A (92%) compared to group B (86%) with a break 

of the curve after nine years for group B. Our results show that the 

overall survivorship of the reverse shoulder prosthesis to removal is 

good even 10 years after implantation, in particular if it had been 

implanted for CTA, OA or MCT. However, functional results did 

deteriorate progressively after nine years, especially if it had been 

implanted for revision (HA or TSA). Therefore, extreme caution 

must be observed in relation to the indications for reverse shoulder 

arthroplasty, especially in younger patients. 



PaPers, Posters & scientific exhibits sHouldeR & elboW

pApeR No. 089 

Reverse Shoulder Arthroplasty: Review of 

Complications According to Surgical Indication 

Richard J Hawkins, MD, Greenville, SC 

Jason C Clark, MD, Moline, IL 

Frederick Suh Song, MD, Princeton, NJ 

Enthusiasm for the use of reverse shoulder arthroplasty in the 

treatment of cuff tear arthropathy, failed hemiarthroplasty, 

irreparable cuff tears, failed total shoulder arthroplasty and proximal 

humerus fractures has continued to grow despite the concerns about 

high complication rates. The goal of this study was to look at the 

complication rate in relation to the indication for reverse shoulder 

arthroplasty. A total of 137 reverse shoulder arthroplasties performed 

for various indications including primary cuff tear arthropathy (44 

shoulders), failed prior rotator cuff repair (35 shoulders), acute 

proximal humerus fractures (21 shoulders), proximal humerus 

fracture malunion and nonunion (nine shoulders) and major 

revision arthroplasty (19 failed hemiarthroplasty, seven failed total 

shoulder arthroplasty) were reviewed for complications. Overall, the 

complication rate was 20%. Complication rate varied depending 

on the pathology: primary cuff tear arthropathy (14%), prior failed 

rotator cuff repair (20%), acute proximal humerus fracture (19%), 

proximal humerus malunion or nonunion (22%) and major revision 

arthroplasty (27%). This study showed an overall complication rate 

of 20% for reverse shoulder arthroplasty. A number of these shoulders 

with complications (59%) required further surgical management. 

Reverse shoulder arthroplasty for primary cuff tear arthropathy had 

a complication rate of 14%. Rates almost twice that high should be 

anticipated by the surgeon and relayed to the patient prior to surgery 

for indications such as failed prior rotator cuff repair, acute fractures, 

fracture malunion and nonunion and major revision arthroplasty. 

pApeR No. 090 

Reverse Shoulder Arthroplasty for the Treatment of 

Acute Proximal Humerus and Glenoid Fractures 

Yousef Shishani, MD, Cleveland, OH 

Christopher McCrum, BS 

John Paul Wanner, BS 

Christopher J Lenarz, MD, Beachwood, OH 

Robert J Nowinski, DO, Columbus, OH 

Thomas Bradley Edwards, MD, Houston, TX 

Reuben Gobezie, MD, Cleveland, OH 

Historically, three- and four-part fractures of the proximal humerus in 

elderly patients have been difficult to treat. Several surgical methods 

have been described for these fractures including hemiarthroplasty, 

total shoulder arthroplasty, fixed-angle locking plates and reverse 

shoulder arthroplasty. Little literature exists on reporting the 

outcomes for reverse arthroplasty in the treatment of these fractures. 

This study evaluates the clinical outcomes of elderly patients with 

acute three- and four-part proximal humerus fractures using a 

reverse total shoulder replacement. A multi-center retrospective 

study of 39 patients who were treated for acute three- and fourpart 

proximal humerus (n=35) and/or glenoid (n=4) fractures was 

performed. The average age of these patients was 75 years (range 54- 

94 yrs) and the mean follow up was 19 months. Three of the patients 

had previous rotator cuff repair (RCR) surgery and had the reverse 

arthroplasty at a mean of 60.75 months (S.D. ± 80.2, range 11-180) 

after their RCR. Outcome measures used to evaluate these patients 

included preoperative and postoperative American Shoulder and 

Elbow Surgeons Score (ASES), range of motion, visual analog scale 

(VAS) for pain and complications. The patients showed a significant 

676 

improvement in ASES scores from 24.5 points preoperatively (S.D. 

±21.8, range 0-68) to 69.2 points postoperatively (S.D. ±14.0, 

range 32-98)(p

week in steroid groups (IS, TS) compared to no steroid groups (IN, 

TN)(p

compared to two patients in group 2. In MRI assessment, none 

developed retears in group 1 and two patients had retears in group 

2. Arthroscopic repair of articular-sided partial-thickness rotator 

cuff tears provided satisfactory functional improvements and pain 

relief regardless of repair techniques. However, transtendon repair 

techniques had advantages in preservation of the intact portion of 

the rotator cuff despite slow postoperative recovery. 

pApeR No. 156 

Effect of Dihydrotestosterone on Cultured Human 

Tenocytes from Intact Supraspinatus Tendon 

Laura Ruzzini, MD, Rome, rome Italy 

Umile Guiseppe Longo, MD, Rome, Italy 

Francesco Franceschi, MD, Rome, Lazio Italy 

Professor Nicola Maffulli, London, United Kingdom 

Vincenzo Denaro, MD, Rome, Italy 

The role of hormones in the pathogenesis of tendinopathy is not well 

recognized, even though the use of anabolic steroids is correlated with 

a higher incidence of spontaneous tendon ruptures. The aim of this 

study was to investigate the effects of dihydrotestosterone (DHT) on 

human tenocyte cultures from the intact supraspinatus tendon of male 

subjects. Cultured human tenocytes were seeded into culture plates 

at a density of 5 × 104 cells per well and incubated for 24 hours. 10-9 

M to 10-7 M DHT or Dulbecco’s Modified Eagle’s Medium (DMEM) 

only (control) was added to the culture plate wells. Cell morphology 

assessment and cell proliferation tests were performed 48 hours, 72 

hours and 96 hours after DHT treatment. DH T-treated tenocytes 

showed an increased proliferation rate at DHT concentration higher 

than 10-8 M. Differences in cell numbers between control and DHTtreated 

cells were statistically significant (p < 0.05) after 48 hours 

and 72 hours of treatment with DHT concentrations of 10-8 M 

and 10-7 M. The tenocytes treated with DHT (10-8 M and 10-7 M) 

became more flattened and polygonal compared to control cells that 

maintained their fibroblast-like appearance during the experiment at 

each observation time. In conclusion, in vitro, progressive increasing 

concentration of DHT at doses greater than 10-8 M had direct effects 

on male human tenocytes, increasing cell number after 48 hours and 

72 hours of treatment, and leading to a dedifferentiated phenotype 

after 48 hours of treatment. This effect can be important during 

tendon-healing and repair, when active proliferation is required. 

pApeR No. 157 

Symptoms of Pain Do Not Correlate with Rotator Cuff 

Tear Severity 

Warren Dunn, MD, MPH, Nashville, TN 

Laura Ruzzini, MD, Rome, rome Italy 

Angel An, MS, Nashville, TN 

Dr Michael S Khazzam, Milwaukee, WI 

For many orthopaedic disorders, symptoms correlate with disease 

severity (e.g. osteoarthritis). Many people have asymptomatic 

rotator cuff tears. Additionally, patients may be satisfied with their 

results following failure of cuff tear surgery. The purpose of this 

study was to determine if pain is related to the severity of rotator cuff 

disease. A prospective multi-center cohort study design examined 

the effectiveness of physical therapy in subjects with full-thickness 

rotator cuff tears seen on MRI. Baseline data was used to examine 

the relationship between severity of cuff disease and pain. Severity 

was measured by tear size, retraction, superior head migration and 

fatty atrophy. Pain was measured on the 10 cm visual analog score 

(VAS) item in the patient reported ASES. A linear multiple regression 

model was fit using the continuous VAS score as the dependent 

678 

variable. Tear severity and patient factors were the independent 

variables. The cohort is 48% female with a median age of 61. The 

dominant shoulder was involved in 69% of the cohort. The median 

baseline VAS was 4.4. Subjects with symptoms 0.25). Severity of cuff 

pathology as measured by size, retraction and fatty atrophy is not 

associated with pain. Factors associated with pain are comorbidities, 

education and race. 

pApeR No. 158 

Arthroscopic Partial Rotator Cuff for Management of 

Massive Rotator Cuff Tears: Long-term Follow-up 

Stephen C Weber, MD, Sacramento, CA 

Surgical options for the patient with a massive rotator cuff tear 

remain limited. Tendon transfers offer significant perioperative 

morbidity, and procedures such as interval tendon slides have raised 

concerns about the vascularity of the remaining tendon, with a 

recent study showing only 25% of patients with interval slides had 

solid healing on MRI follow up. Xenograft and allograft patches 

have shown significant complications and mixed results. Burkhart 

(1994) and others pioneered the concept of partial rotator cuff 

repairs as an arthroscopic-assisted procedure, with good preliminary 

results. The procedure, however, is difficult, especially to access the 

infraspinatus and subscapularis from a deltoid split. Presented here 

is the first report of all-arthroscopic partial rotator cuff repair in the 

treatment of massive, unrepairable rotator cuff tears. Eighty patients 

with large or massive rotator cuff tears were evaluated. All patients 

were Thomazeau class 2 to 3 for atrophy, and Goutallier class 2 to 

4 for fatty infiltration. All patients had primary closure attempted; 

interval slides or other heroic techniques were avoided. If solid 

closure without tension could not be obtained by primary repair, 

but a portion of the cuff could be solidly reapproximated, partial 

rotator cuff repair with acromioplasty, preserving the coracoacromial 

ligament, was performed. All patients were reexamined, with UCLA, 

SST and ASES scores obtained, and follow up radiographs and MRI 

scans were obtained and compared to preoperative studies. Sixty 

five patients had repair of the infraspinatus only, with 15 patients 

combined infraspinatus and subscapularis. Follow up was a minimal 

24 months (average 40.7 months). Good or excellent results were 

obtained in 88% of cases based on UCLA scores, with SST scores 

averaging 10.11 and ASES scores 86.2. No complications occurred, 

specifically no hardware issues, infections or neurologic injuries. All 

procedures were performed successfully as an outpatient procedure. 

Pain scores showed the most significant decrease, with functional 

scores based on ASES and Constant scores showed less improvement. 

External rotation strength improved 1.2 grades. No patient developed 

anterosuperior instability, and no patients developed cuff tear 

arthropathy. Radiographs at final follow up showed no evidence of 

vertical migration. MRI scanning showed no progression of atrophy 

and interval healing of the repaired segment in 68%. Good results 

can be obtained with arthroscopic partial rotator cuff repair for large 

and massive rotator cuff tears. Arthroscopic exposure of the rotator 




cuff is much simpler that with mini-open technique, and direct 

suturing of the available tendons is possible without damaging the 

deltoid. While not approaching the results of complete arthroscopic 

repair, this technique represents a reasonable, low-morbidity salvage 

option for the patient with a rotator cuff tear that is not primarily 

repairable. 

pApeR No. 159 

The Effects of Mesenchymal Stem Cells on Rotator Cuff 

Muscle In a Chronic Injury Model in Sheep 

Struan H Coleman, MD, New York, NY 

John R Ehteshami, MD, New York, NY 

John D Kisiday, PhD, Fort Collins, CO 

Russell F Warren, MD, New York, NY 

A Simon Turner, DVM, Fort Collins, CO 

We use a chronic rotator cuff injury and repair model in sheep 

to test the hypothesis that the injection of stem cells directly into 

muscle at the time of surgical repair will improve muscle function 

and decrease fat content. Twenty-four adult female sheep were used. 

Infraspinatus muscle specimens were analyzed for fat content. The 

force generated with stimulation was recorded intra-operatively. 

The tendon was wrapped in a dura substitute and then repaired six 

weeks after release. The muscle was injected at the time of surgical 

repair with cell medium (eight), marrow derived stem cells (eight) 

and muscle derived stem cells (eight). Animals were sacrificed after 

three months and tested. At the initial surgery, the muscle generated 

an average load of 37.68 lbs. After six weeks of detachment, the 

average load was 18.66 lbs., a 50.5% decrease. Three months after 

repair and injection, the average loads increased by 14% (control), 

29% (muscle MSC) and 40% (marrow MSC), (p

pApeR No. 162 

Effect of Acromioplasty in Arthroscopic Repair of Small 

to Medium Sized Rotator Cuff Tears 

Sang-Jin Shin, MD, Seoul, Republic of Korea 

Jaedoo Yoo, Prof, Seoul, Republic of Korea 

Nam Hoon Do, MD 

Yeo-Hon Yun, MD, Seoul, Republic of Korea 

Ki Young Chang, MD, Seoul, Seoul, Republic of Korea 

The effectiveness of subacromial decompression is still on debate 

although subacromial decompression is routinely performed 

in rotator cuff repair. This study prospectively assessed the role 

of acromioplasty in arthroscopic repair of small to medium 

sized rotator cuff tears. Forty-one consecutive patients with 

small to medium sized rotator cuff tears received arthroscopic 

subacromial decompression with rotator cuff repair (group 1) and 

43 consecutive patients received arthroscopic rotator cuff repair 

without acromioplasty (group 2). Postoperative pain was measured 

by visual analogue scale and functional outcomes were evaluated 

using Constant and UCLA scores. Tendon healing was evaluated by 

MRI at six months after operation. Average follow up period was 

28 months. Postoperative visual analogue pain score was higher in 

group 1 in immediate postoperative period, however, there were no 

significant differences between the two groups at final follow up. 

Constant scores in both groups improved significantly at final follow 

up (from 53 to 89 in group 1 and 47 to 85 in group 2). In group 1, 

36 patients revealed good or excellent results in UCLA score and 38 

patients in group 2. Rotator cuff retear rate was 10% in group 1 and 

13% in group 2. Three patients in group 1 and one patient in group 

2 developed postoperative adhesive capsulitis. No correlations were 

found between clinical outcomes and acromioplasty Arthroscopic 

repair of small to medium sized rotator cuff tears provided improved 

functional outcomes and pain relieves regardless of acromioplasty. 

Acromioplasty did not affect clinical outcomes in rotator cuff 

repair. 

pApeR No. 163 

uDevelopment of Nanostructured Scaffolds as 

Therapeutic Replacement Options for Rotator Cuff 

Disease 

Erica Taylor, MD, Charlottesville, VA 

Lakshmi Sreedharan Nair, PhD 

Syam Prasad Nukavarapu, PhD, Farmington, CT 

Cato T Laurencin, MD, PhD, Farmington, CT 

Current rotator cuff repair modalities yield less than optimal results, 

making achievement of alternative treatment options desirable. 

Tissue-engineering is an emerging therapeutic approach to mimic 

the micro-architecture and biomechanics of a normal rotator cuff, 

while supporting new tissue growth. The objective of this study was 

to explore the evolution of nanostructured scaffolds and develop an 

innovative tissue-engineered polymeric device to support healing of a 

torn rotator cuff and enhance regenerative repair. An electrospinning 

method was adopted to fabricate a bioresorbable poly(85 lactic 

acid-co-15 glycolic acid) (PLAGA) nanofiber scaffold for rotator cuff 

augmentation. Scaffolds were seeded with rabbit patellar tendon 

cells and in vitro material properties were characterized, including 

matrix architecture, tenocyte proliferation and biomechanical 

strength. An original in vivo rat rotator cuff model was developed 

for interval biomechanical evaluations following augmentation 

of a supraspinatus repair with the scaffold. Fabrication of an 

optimized nanofiber PLAGA polymeric matrix was accomplished. 

In vitro cell assays demonstrated the scaffold’s ability to support 

680 

significant proliferation, persistent viability and formation of a 

biomechanically strong cellular network. A rodent rotator cuff 

repair model was created, with histological inspection confirming 

a time-dependent degradation of the bioresorbable scaffold as 

the supraspinatus repair increased significantly in biomechanical 

strength. The proposed nanostructured scaffold has shown promise 

as a potential replacement option for a torn rotator cuff. Optimized 

in vitro material characteristics and successful in vivo biological 

performance for tendon regeneration have been demonstrated. 

The results of this project will advance development of an ideal 

rotator cuff augmentation graft with properties suitable for tendon 

replacement technology. 

pApeR No. 164 

Complications After Arthroscopic Revision Rotator Cuff 

Repair - A Multi Center Study 

Nata Parnes, MD, Carthage, NY 

Michael DeFranco, MD, New York, NY 

Jessica Wells, Cambridge, MA 

Laurence D Higgins, MD, Boston, MA 

Jon J P Warner, MD, Boston, MA 

The rate of satisfactory results after primary arthroscopic rotator 

cuff repair has been reported to be greater than 90%. However the 

complication rate of patients undergoing this procedure is 10.6%. 

The results of arthroscopic revision rotator cuff repair (ARRCR) have 

generally been inferior to those of primary repair. The purpose of this 

multicenter retrospective study was to determine the complication 

rate of ARRCR. Ninety-four patients were identified who underwent 

ARRCR performed by the two senior authors. The mean age was 52 

years (range 44-72). Sixty-four patients underwent one revision rotator 

cuff repair (RCR), 23 patients underwent two revisions and seven 

patients underwent three or more revisions. We documented tear 

size, number of tendons involved and type of additional procedures 

performed. Nineteen patients (20.21%) developed a complication 

after ARRCR (12 males, seven females, mean age was 53) within 90 

days postoperatively. These complications include: failure to heal in 

nine patients (9.57%), stiffness in seven patients (7.44%), infection 

in two patients (2.1%) and nerve injury in one patient (1%). A 

direct correlation was found between the complication rate and the 

number of revision surgeries: 14% after one revision; 17.4% after two 

revisions; 33% after three revisions; 50% after four or more revisions. 

The complication rate after arthroscopic revision rotator cuff repair is 

about twice the published rate for primary rotator cuff repair. There 

is a direct correlation between the complication rate and the revision 

number. The most common complication was recognized as failure 

to heal and that was related to poor tissue quality. 

pApeR No. 165 

uFunctional Outcome of Reverse Shoulder 

Arthroplasty versus Hemiarthroplasty in Cuff Tear 

Arthropathy 

Simon Young, MD, Auckland, New Zealand 

Peter Poon, MD, Auckland, New Zealand 

Cuff tear arthropathy remains a challenging problem to the 

shoulder arthroplasty surgeon. Poor results of conventional total 

shoulder arthroplasty in cuff deficient shoulders have meant 

hemiarthroplasty has been the traditional preferred option. Recently 

reverse total shoulder arthroplasty (RSA) has gained popularity 

due to a clinical perception of an improved functional outcome. 

This is despite a lack of comparative data particularly in relation to 

modern hemiarthroplasty prostheses. The aim of this study was to 




compare the functional results of hemiarthroplasty versus RSA in the 

management of cuff tear arthropathy. Patients were identified from 

the New Zealand National Joint Registry and matched for age, sex 

and American Society of Anesthesiologists (ASA) scores. Functional 

outcome was assessed using the Oxford shoulder score (OSS) 

collected prospectively at six months and five years post surgery, 

together with mortality and revision rates. The OSS is a validated 

outcome score known to correlate well with the Constant score. 

One-hundred-two primary shoulder hemiarthroplasties performed 

for cuff tear arthropathy were matched against 102 RSAs performed 

for the same diagnosis. There were 51 males and 51 females in 

each group, with a mean age of 71.6 in the hemiarthroplasty 

group and 72.6 in the RSA group. Mean ASA score was 2.2 in both 

groups. Twenty-eight hemiarthroplasty and 30 RSA patients had 

undergone previous soft tissue procedures. Patients were followed 

for a minimum of two years (range 2-10). The median OSS was 31 

in the hemiarthroplasty group and 39 in the RSA group (p

0-10)(p=.00004). Preoperative ASES score improved from 19.6 (S.D. 

±15.8, range 0-53) to 41.5 (S.D. ± 7.8, range 30-53) postoperatively 

(p

at an implant price below $14,875, RSA is cost-effective relative to 

HHR. Using currently available cost and outcome data, RSA could be 

a cost-effective alternative to HA for rotator CTA over a wide range 

of patient ages. The cost-effectiveness of RSA is dependent on the 

health utility gained from the operation and the utility lost due to 

complications from the operation, and further head-to-head studies 

evaluating the clinical and quality-of-life outcomes of these two 

treatments are warranted. 

pApeR No. 367 

Midterm Results of Biologic Resurfacing of the Glenoid 

in Young Patients with Glenohumeral Arthritis 

Eric J. Strauss, MD, New York, NY 

Michael Salata, MD, Cleveland, OH 

Kevin C McGill, MPH, Chicago, IL 

Gregory P Nicholson, MD, Chicago, IL 

Brian J Cole, MD, Chicago, IL 

Nikhil N Verma, MD, Chicago, IL 

Anthony A Romeo, MD, Chicago, IL 

The purpose of this study is to evaluate the clinical outcomes of 

biological interposition arthroplasty of the glenohumeral joint using 

either a lateral meniscus allograft (LMA) or a human acellular dermal 

tissue matrix (HADTM) in combination with hemiarthroplasty or 

humeral head resurfacing. Forty-five consecutive patients with a 

mean age of 42.2 years (range 18.1-60.2 years) underwent either 

hemiarthroplasty (38 cases) or humeral head resurfacing (seven 

cases) combined with biologic resurfacing of the glenoid. Preoperative 

diagnoses included symptomatic glenohumeral arthrosis 

(31 patients), capsulorrhaphy arthropathy (two patients), avascular 

necrosis (one patient) and chondrolysis (one patient). There were 

30 males and 11 females with the dominant extremity involved 

in 24 patients (58.5%). LMA was used in 31 cases and HADTM 

interposition was used in 10 cases. At a mean follow up of 2.8 years, 

41 patients (91.1%) were available for evaluation. The overall clinical 

failure rate was 51.2% (21 of 41 patients). Failure was defined as 

actual or recommended conversion to TSA, revision surgery for graft 

removal, patient reported disabling pain/loss of function and/or 

post-operative ASES score of < 50. The LMA cohort had a failure rate 

of 45.2% with a mean time to failure of 3.4 years. Those treated with 

a HADTM had a failure rate of 70.0% with a mean time to failure 

of 2.2 years. Nine patients (22%) failed treatment within two years 

of the procedure. None of the treatment failures were attributed 

to problems associated with the humeral head implant. Biologic 

resurfacing of the glenoid with LMA or HADTM in combination 

with hemiarthroplasty or humeral head resurfacing results in a high 

rate of clinical failure at midterm follow up. Our results suggest 

that biologic resurfacing of the glenoid may have a minimal and 

as yet undefined role in the management of glenohumeral arthritis 

in the young active patient over more traditional methods of 

hemiarthroplasty or total shoulder arthroplasty. 

pApeR No. 368 

Effects of Tilt and Glenosphere Eccentricity on 

Baseplate Forces in a Reverse Shoulder Model 

Sergio Gutierrez, PHD, Tampa, FL 


The purpose of this study was to determine: 1) the relative forces 

at the baseplate-bone interface in glenospheres with centers of 

rotation located concentrically and eccentrically to the center of 

the baseplate-bone attachment and 2) if forces at the baseplatebone 

interface can be optimized (off-center loading minimized) 

683 

by altering tilt of the baseplate. A validated computer model was 

used to compare concentric glenospheres with neutral offset to 

eccentrically offset glenospheres (6 mm inferior or 6 mm lateral) 

in three baseplate tilts: 15° inferior, neutral or 15° superior. A 

baseplate, simulated bone, screws and humeral component were 

modeled, and forces underneath the baseplate were calculated 

from the superior and inferior portions of the baseplate as the arm 

was abducted through 90° of glenohumeral motion. Center of 

rotation offset affects the uniformity of forces across the baseplatebone 

interface. For lateral and concentric glenospheres, inferior 

tilt provides the most even distribution of forces (mean difference 

in force between superior and inferior portion of baseplate: 11.3 

N, and 24.7 N respectively) and superior tilt provides the most 

uneven distribution of forces (109.3 N and 78.7 N, respectively). 

For inferior eccentric glenospheres, inferior tilt provides the most 

uneven distribution of forces (58.7 N) and neutral tilt provides the 

most even distribution of forces (27.7 N). Although inferior tilting 

of the baseplate is recommended for concentric and laterally offset 

glenospheres, this same recommendation may be detrimental to 

inferiorly offset glenospheres and warrants further investigation. 

pApeR No. 369 

Glenoid Morphology Rather Than Version Predicts 

Humeral Subluxation 

Lisa Tibor, MD, Mammoth Lakes, CA 

Heinz R Hoenecke Jr, MD, San Diego, CA 

Brennen L Lucas, MD, La Jolla, CA 


Glenoid retroversion is thought to play an important role in stability 

both before and after arthroplasty in the arthritic shoulder. Thus, 

many authors recommend glenoid reaming intraoperatively to correct 

retroversion and improve stability. Genetic analysis has revealed that 

glenoid vault and scapular development are controlled by different 

genes and environmental factors, resulting in diverse glenoid 

morphologies. We therefore analyzed the relative contribution of 

glenoid morphology and version to humeral head position. A total 

of 121 shoulder CT scans obtained preoperatively for shoulder 

arthroplasty were measured by two orthopaedic shoulder fellows. 

Humeral subluxation and glenoid version were measured on the 

axial image at the middle of each glenoid. Glenoid morphology was 

characterized as biconcave, worn, displaced, dysplastic, angled or 

neutral. The strength of the correlation between humeral subluxation, 

glenoid version and glenoid morphology was analyzed. Glenoid 

version did not correlate with humeral subluxation (R2=0.02). The 

distribution of glenoid morphology was: angled (13), biconcave 

(32), displaced (15), dysplastic (one), neutral (two), worn (58). The 

highest frequency of posterior subluxation was noted in biconcave 

glenoids. Shoulders with other glenoid morphologies were more 

likely to have anterior or central positioning of the humerus. The 

mean subluxation ratio for biconcave glenoids was 0.56 and was 

significantly different from all other morphologies (p

pApeR No. 370 

uSodium Hyaluronate (SUPARTZ?) for the Treatment of 

Glenohumeral Osteoarthritis 

Young W Kwon, MD, PhD, New York, NY 

David L Gilliam, MD, Little Rock, AR 

Gerald Eisenberg, MD 

Joseph D Zuckerman, MD, New York, NY 

Non operative treatments for glenohumeral osteoarthritis (GH- 

OA) are limited and associated with unpredictable outcomes. 

Sodium hyaluronate (HA) is an intra-articular (IA) viscosupplement 

therapy that has been effective in treating osteoarthritis of the knee. 

Therefore, we sought to evaluate the safety and the efficacy of HA in 

the treatment of GH-OA. A double blind, randomized, phosphate 

buffered saline (PBS) controlled multicenter trial enrolled 300 

patients with GH-OA. Both groups (150 HA, 150 PBS) received three 

weekly IA injections, and were evaluated over 26 weeks. Primary and 

secondary outcome measurements were visual analog scale (VAS) 

for pain, and the percentage of OMERACT-OARSI high responders. 

In the HA and PBS Intent To Treat patients, there was a mean 

improvement from baseline in VAS scores of 19.88 mm and 16.29 

mm at week 26, respectively, after treatment. Between groups, the 

least squares mean difference was 2.84 mm in favor of the HA group. 

Similarly, the percentage of OMERACT-OARSI high responders in 

the HA group was higher (40.8% vs. 34.9%). However, neither of 

these differences was statistically significant (p=0.1121 and 0.0690, 

respectively). In a subset of patients without concomitant shoulder 

pathologies, the differences of VAS and OMERACT-OARSI high 

responder rates between groups were 4.0 mm and 8.37%, respectively. 

These differences reached statistical significance. However, due to 

the number of protocol deviations, strict interpretation of these 

results was not possible. Safety analyses showed comparable rates of 

adverse events between groups, and neither group reported serious 

or unanticipated treatment related adverse events. No statistically 

significant differences in efficacy or safety were found between HA 

and PBS treated patients with GH-OA. Although a subset of HA 

patients did show signs of efficacy, no definitive conclusions could 

be drawn due to confounding factors. 

pApeR No. 371 

Arthroscopic Treatment of Early Gleno-Humeral Arthritis 

Giuseppe Porcellini, MD, Cattolica, RN Italy 

Fabrizio Campi, MD, Cattolica, RN Italy 

Chandra Sekhar Bodanki, MS, Cattolica RN, Italy 

Eugenio Cesari, MD, Cattolica, RN Italy 

Paolo Paladini, MD, Cattolica, RN Italy 

Several surgical options are available to manage primary shoulder 

arthritis, including arthroscopic joint debridement and arthroscopic 

resurfacing using graft or engineered membranes. Aim of this study 

is to highlight differences between these surgical approaches at two 

years of follow up. Twenty-four consecutive patients affected by 

early gleno-humeral arthritis were enrolled for the study. Group A 

(control group, 13 patients, 45.8%) were treated with debridement, 

capsular release and microfracture, Group B (11 patients, 54.2%) 

with the same procedure adding interposition of hyaluronic acid 

engineered membrane. All the patients has a pre-operative imaging 

study with X-ray and MRI and were evaluated by SST and Constant 

score. Inclusion criteria were: arthritis at Samilson stage I or II, loss 

of forward elevation less than 40 degrees and of external rotation 

less than 30 degrees. Cartilaginous defects were classified as focal, 

total and mono-polar or bi-polar. Follow up examination were done 

at three, six, 12 and 24 months from surgery (mean 31 months). 

X-rays were taken at two years of follow up. Twenty-one patients 

684 

(87.5%) had good outcomes. Three patients (12.5%) had poor 

outcomes related to progression of arthritis. Range of motion (ROM) 

recovery, Constant pain sub-score and SST were always higher in 

patients of B group (p

the positive effect of injection on pain but great controversy exists 

as to the accuracy of injection by palpation and the importance 

of accuracy with regard to pain and function. We used a blinded, 

longitudinal observational design of effectiveness in an effort to 

determine the accuracy of intraarticular injections and the effect 

of that accuracy on pain and functional outcomes in patients with 

various shoulder pathologies. Of the 103 blinded injections, 54 

injections were identified by fluoroscopy as ‘in’ the capsule, whereas 

49 were identified as ‘outside’ the capsule, an accuracy rate of 52.4%. 

In the four-week follow up, regardless of group assignment or accuracy 

of the injection, patients improved significantly (p

of three-part fractures and 0% (zero/five) of two-part fractures. 

Similarly, radiographic PTA (including AVN) was observed in 37% 

(10/27) of fractures. PTA was observed in 60% (six/10) of four-part 

fractures, 33% (four/12) of three-part fractures and 0% (zero/five) 

of two-part fractures. Mean ASES score at the latest follow-up was 82 

for all patients (77 for patients with AVN and 84 for patients without 

AVN). Intermediate follow up of patients with percutaneously treated 

proximal humerus fractures demonstrates an increased incidence of 

AVN and PTA over time, with some cases presenting as late as eight 

years postoperatively. This increased incidence over time suggests 

longer-term follow up may be necessary for patients treated with this 

technique. Despite the development of AVN over time, there did not 

appear to be a significant degradation of subjective outcomes. 

pApeR No. 602 

Shoulder Arthroplasty for Proximal Humeral Non-unions 


Justin Jacobson, MD, Missoula, MT 

John William Sperling, MD, MBA, Rochester, MN 


Robert H Cofield, MD, Rochester, MN 

Shoulder arthroplasty is often used as a salvage operation for 

proximal humeral fracture non-unions, with frequent unsatisfactory 

functional results. The goal of this study is to assess the outcome 

of shoulder arthroplasty for proximal humeral non-unions at our 

institution. From 1976 to 2007, 85 patients underwent shoulder 

arthroplasty for proximal humeral non-union. Those with less than 

two-year follow up were excluded, leaving 63 patients. There were 46 

females and 17 males with a mean follow up of nine years. The initial 

fracture pattern was two-part in 35 patients (56%), three-part in 17 

(27%) and four-part in 11 (17%). Hemiarthroplasty was performed 

in 51 (81%) and total shoulder arthroplasty in the remaining 12 

(19%). Average active elevation and external rotation improved from 

46 and 26 to 104 and 50 degrees at final follow up (p=0.0001). VAS 

pain scores improved from 8 to 4 at final follow up (p=0.0001), and 

there were 10 (17%) excellent, 18 (30%) satisfactory and 32 (53%) 

unsatisfactory results using the modified Neer score. No differences 

were found between the hemi and total arthroplasty groups. 

Complications occurred in 24 (39%) patients with 10 re-operations 

including five revisions. Kaplan-Meier survivorship analysis for 

revision was 97% (94.3,100) at one year and 93% (88.0,99.2) at five, 

10 and 20 years. Shoulder arthroplasty for proximal humeral fracture 

non-unions results in modest improvement in pain and function 

with unsatisfactory results in greater than half of patients. Difficulty 

in obtaining anatomic positioning of components and tuberosity 

healing in arthroplasty for proximal humeral non-unions results in 

compromised outcomes. 

pApeR No. 603 

Intercellular Adhesion Molecule-1 Is Increased in the 

Frozen Shoulder and Down-regulated by Steroid 

Yang-Soo Kim, MD, Seoul, Republic of Korea 

Jung Man Kim, MD, Seoul, Republic of Korea 

Ji-Hoon Ok, MD, Seoul, Republic of Korea 

Yun-Kyoung Lee 

The object of this study was to evaluate the expression of ICAM-1 

in the frozen shoulder and the effect of steroid on its expression. 

Twenty-six glenohumeral joint capsule tissues (17 frozen shoulders, 

nine controls) were obtained intraoperatively and evaluated ICAM- 

1 expression using oligo-array technique, real-time RT-PCR and 

immunohistochemical staining. The expression of ICAM-1 in the 

joint fluid was determined using western blotting and the expression 

686 

in the blood serum was determined using ELISA. The capsule cells 

from the patients with frozen shoulders and controls were cultured 

and treated with steroids. ICAM-1 expression was evaluated in 

cultured capsular cells following one day and three days after steroid 

treatment using real-time RT-PCR. The expression of ICAM-1 was 

significantly increased in glenohumeral joint capsule of frozen 

shoulder (1.72) than controls (0.69) and also significantly increased 

in joint fluid of frozen shoulder (1.70) than control (0.48) (p

pApeR No. 605 

Efficacy Of Different Corticosteroid Injection Site For 

The Treatment Of Adhesive Capsulitis 

Sang-Jin Shin, MD, Seoul, Republic of Korea 

Jaedoo Yoo, Prof, Seoul, Republic of Korea 

Nam Hoon Do, MD 

This study prospectively compared the clinical outcomes in patients 

who had idiopathic adhesive capsulitis treated with a single 

corticosteroid injection in three different locations of the shoulder. 

One hundred and fifty patients with limited shoulder motion under 

120° forward flexion, 30° external rotation and internal rotation 

below L3 level were randomly assigned to four groups based on 

corticosteroid injection location; group 1, intraarticular combined 

with subacromial injection; group 2, intraarticular injection; group 

3, subacromial injection; and group 4, medication only. A single 

injection of corticosteroid was done under ultrasound guidance. Pain 

relief was measured by visual analogue scale and functional outcomes 

were evaluated using ASES score. Patients with corticosteroid 

injections showed faster pain relief than medication group up to 

six months after injection (p

(p

the community radiologists (p

pApeR No. 615 

Bristow-Latarjet Repair versus Bankart. A 17-year 

follow-up of 185 Shoulders 

Lennart Hovelius, MD, Gavle, Sweden 

Ola Vikerfors, MD, Vasteras, Sweden 

Bjorn Sandstrom, MD, Gavle, Sweden 

Anders Olofsson, MD 

Olle Svensson, MD, Umea, Sweden 

Hans Rahme, MD, Uppsala State, Sweden 

During 1988-1995, 88 consecutive shoulders had a Bankart repair 

(B) and 97 consecutive shoulders a Bristow-Latarjet repair (B-L) in 

two different Swedish hospitals. Mean age at surgery was 27.8 years 

for the B-L group and 27.4 years for the Bankart. In 2008- 2009, 

all shoulders had a follow up by letter/telephone. The patients 

answered a questionnaire and completed the WOSI (Western Ontario 

Shoulder Index), DASH (Disability Arm Shoulder Hand) and SSV 

(Simple Shoulder Value). All patients had a follow up after 13-22 

years (mean 17). , In the B-L group, one shoulder and in the B group, 

five had revision surgery due to recurrence (P=0.08). Thirteen/97 of 

B-L shoulders had redislocation/subluxation after index operation 

compared to 25/87 in the B group (P=0.017). Ninety-four/96 

Bristow shoulders were very satisfied/satisfied compared to 71/80 in 

the B series (P=0.01). Mean WOSI score was 88 for B-L shoulders 

and 79 for B shoulders (P=0.002). B-L shoulders also scored better 

with respect to DASH (P=0.002) and SSV (0.007). Patients had 11o 

loss of outward rotation with the arm at the side after B-L repair 

compared to 19o after Bankart (P=0.012). Ten/88 shoulders with 

original Bankart with tunnels though the glenoid rim had less 

redislocation(s)/subluxation(s) than shoulders done with anchors 

(P=0.048). Shoulders with Bristow-Latarjet repair had better results 

than Bankart repairs done with anchors with respect to postoperative 

stability and subjective evaluation. Shoulders with original Bankart 

repair were more stable than repairs done with anchors. 

pApeR No. 676 

Radiation Therapy for Heterotopic Ossification 

Prophylaxis Acutely After Elbow Trauma 

Nady Hamid, MD, St Louis, MO 

Nomaan Ashraf, MD, New York, NY 

Michael J Bosse, MD, Charlotte, NC 

Patrick Michael Connor, MD, Charlotte, NC 

James F Kellam, MD, Charlotte, NC 

Stephen H Sims, MD, Charlotte, NC 

Douglass E Stull, MD, Lawrence, KS 

Kyle James Jeray, MD, Greenville, SC 

Robert Hymes, MD, Falls Church, VA 

Heterotopic ossification (HO) around the elbow can result in pain, 

loss of motion and impaired function. We hypothesized that a single 

dose of radiation therapy (RT) could be safely administered acutely 

after elbow trauma, would decrease the number of elbows that would 

require surgical excision of HO and potentially improve clinical 

results. A prospective, randomized study was conducted at three 

medical centers. Patients with intra-articular distal humerus fractures 

or fracture dislocation of the elbow with proximal radius and/or 

ulna fractures were enrolled. Patients were randomized to either 

receive single-dose radiation therapy of 700 centigray immediately 

postoperatively (within 72 hours) or nothing (control group) for HO 

prophylaxis. Clinical and radiographic assessment was performed at 

six weeks, three months and six months postoperatively. All adverse 

events and complications were documented prospectively. This study 

was terminated prior to completion due to unacceptably high adverse 

690 

events reported in the treatment group. Data was available on 45 of 

the 48 patients enrolled in this study. When investigating the rate 

of complications, there was a significant difference in the frequency 

of nonunions between the two groups. Of the nine nonunions in 

this series, eight were in the treatment group. The nonunion rate in 

the treatment group was 38% (eight/21). This showed a significant 

difference compared to the control group which had a 4% (one of 

24) nonunion rate (p=0.0072). There were no significant differences 

between the groups with regard to incidence of HO, post-operative 

range of motion or Mayo Elbow Performance Score noted at the time 

of study termination. This study demonstrated that post-operative 

single-dose radiation therapy for HO prophylaxis may play a role in 

increasing the rate of fracture and olecranon osteotomy nonunion 

when used acutely after elbow trauma. Clinical efficacy of RT could 

not be determined based on the sample size. Further research 

is needed to determine the role of limited field radiation for HO 

prophylaxis after elbow trauma. 

pApeR No. 677 

MRI Appearance Of Distal Biceps Tendon Repair And 

Comparison With Functional Outcome 

Christopher C Schmidt, MD, Pittsburgh, PA 

Veronica A Diaz, MD, Stuart, FL 

David M Weir, BS, Pittsburgh, PA 

Carmen Latona, MD, Pittsburgh, PA 

Mark C Miller, PHD, Pittsburgh, PA 

The purpose of this study was to determine whether MRI appearance 

of a repaired distal biceps tendon correlated with functional outcome. 

Nineteen patients with distal biceps repairs to cortical bone using 

an endobutton underwent MRI of the involved elbow an average 

of 4.1 years after repair. A musculoskeletal radiologist and upper 

extremity fellow characterized each MRI independently with respect 

to integrity, tendon heterogeneity and heterotopic bone. Seventeen 

patients underwent isometric supination strength testing at three 

forearm positions, and 19 patients completed disabilities of the arm, 

shoulder, and hand (DASH) and visual analog scale (VAS) scores. 

All repairs healed to cortical bone. There was wide variability in the 

appearance of the repaired tendon. MRI characterization showed 

substantial inter-observer reliability for repair integrity (kappa, k = 

1.0), tendon heterogeneity (k = 0.79) and presence of heterotopic 

bone (k =0.89). The greatest strength deficit occurred with the 

forearm in 60° of supination (average 67% of uninjured side p

pApeR No. 678 

1 vs. 2 Incision Technique for the Repair of Distal 

Biceps Tendon Ruptures: A RCT 

Ruby Grewal, MD, London, ON Canada 


Joy C MacDermid, PhD, London, ON Canada 

Ken Faber, MD, London, ON Canada 

Darren Sean Drosdowech, MD, FRCSC, London, ON Canada 

Graham J W King, MD, London, ON Canada 

This study evaluated the functional and clinical outcomes of the 

single vs. double incision technique for distal biceps tendon repair. 

Patients with acute distal biceps ruptures (n=90) were randomized 

to receive either a single (S) incision (n=48) repair using suture 

anchors or a double (D) incision repair (n=42) using trans-osseous 

drill holes. Patients were followed at three, six, 12 and 24 months 

following surgery. The primary outcome was the American Shoulder 

and Elbow Surgeon’s (ASES) elbow score. Secondary outcomes 

included complication rates and Disabilities of the Arm Shoulder 

and Hand (DASH) score. Generalized linear modeling was used 

to assess differences in outcome measures between groups over 

time. Continuous variables were assessed with a student’s t-test 

and categorical variables with a Chi-square test. All patients were 

male, there were no significant differences between mean ages (S: 

45.3 years, D: 44.9 years), percentage of dominant hands affected 

(S: 69%, D: 62%) or workers compensation cases (S: 33%, D: 23%) 

between groups. There were no differences in overall mean outcomes 

between the two groups over time ASES pain: 10.5 (p=0.9), ASES 

function: 28.8 (p=0.5), DASH: 16.7 (p = 0.9)]. Comparison of final 

isometric strength regained at two years (expressed as a percentage 

of the unaffected arm) revealed that there were no overall differences 

in final extension (S: 104%, D: 106%, p = 0.6), pronation (S: 99%, 

D: 103%, p = 0.6) or supination (S: 98%, D: 92%, p = 0.4) between 

groups. A marginal advantage in mean isometric flexion strength 

regained was seen with the double incision technique (D: 104% 

vs. S: 94%, p= 0.01). The single incision technique resulted in a 

higher overall complication rate, primarily due to a high number 

of early transient neurapraxias (S: 19/48, D: 3/42, p

pApeR No. 681 

Ulnar Collateral Ligament Injuries of the Elbow in 

Professional Football Quarterbacks 

Christopher Dodson, MD, Philadelphia, PA 

Nicholas R Slenker, MD, Philadelphia, PA 

Steven Brad Cohen, MD, Media, PA 

Michael G Ciccotti, MD, Philadelphia, PA 

Peter F DeLuca, MD, Philadelphia, PA 

Background: Ulnar collateral ligament (UCL) injuries of the elbow 

can cause significant pain and disability in the overhead thrower. 

Most studies in the literature have focused on baseball players and 

demonstrated that surgical reconstruction is the most reliable way to 

allow these athletes to return to their previous level of performance. 

Little is known about whether or not surgical reconstruction is 

necessary for other types of elite throwing athletes. We hypothesize 

that professional football quarterbacks with UCL injuries of the elbow 

can return to competitive play after nonoperative management. The 

NFL Injury Surveillance System (NFLISS) was reviewed for any UCL 

injuries of the elbow in quarterbacks from 1994 to 2008 including 

the type and mechanism of injury, player demographics, method of 

treatment and time to return to play. A total of 10 cases of UCL injuries 

in quarterbacks were identified starting in 1994. Nine cases were 

treated nonoperatively, and the mean return to play was 26.4 days. 

UCL injuries of the elbow are uncommon injuries in professional 

quarterbacks. This group of overhead athletes can be successfully 

treated nonoperatively, in contrast to baseball players, who more 

commonly need surgical reconstruction to return to competitive 

play. The difference between the two groups of overhead athletes is 

most likely secondary to biomechanics and demand. 

pApeR No. 682 

Inflammation Is Present In Early Human Tendinopathy 

Neal L Millar, MD, South Lanarkshire, United Kingdom 

Axel Hueber, MD 

James H Reilly, PhD 

Umberto Giuseppe Fazzi, FRCS, Glasgow, United Kingdom 

Prof George A C Murrell, MD, Kogarah, NSW Australia 

Professor Iain B McInnes 

The cellular mechanisms of tendinopathy remain unclear particularly 

with respect to the role of inflammation in early disease. We have 

previously identified increased levels of inflammatory cytokines in 

an early human model of tendinopathy and sought to extend these 

studies to the cellular analysis of tissue. The purpose of this study 

was to characterize inflammatory cell subtypes in early human 

tendinopathy. We explored the phenotype and quantification 

of inflammatory cells in torn and control tendon samples. Torn 

supraspinatus tendon and matched intact subscapularis tendon 

samples were collected from 20 patients undergoing arthroscopic 

shoulder surgery. Control samples of subscapularis tendon were 

collected from 10 patients undergoing arthroscopic stabilization 

surgery. Tendon biopsies were evaluated immunohistochemically 

by quantifying the presence of macrophages (CD68 and CD206), T 

cells (CD3), mast cells (Mast cell tryptase) and vascular endothelium 

(CD34). Subscapularis tendon biopsies obtained from patients 

with torn supraspinatus tendon exhibited significantly greater 

macrophage, mast cell and T cell expression compared to either 

torn supraspinatus samples or control subscapularis derived tissue 

(p

0.14°±7.08° in extension and 0.50°±6.89° in flexion for the expert 

surgeon, -3.6°±8.9° in extension and -4.2°±8.13° in flexion for 

the experienced PA, -3.88°±10.62° in extension and 0.32°± 9.05° 

in flexion for the fellow and -12.63° ± 18.67° in extension and 

-4.82°±16.6° in flexion for the study coordinator with no clinical 

experience in the elbow. Goniometric measurements taken from 

photographs are accurate and reliable for measuring the active 

range of motion of the elbow if used by someone experienced with 

elbow contractures. This finding is important because it validates 

an objective measure of patient outcome without requiring the 

patient to travel back to a tertiary care center, where most contracture 

surgeries are done. 

pApeR No. 685 

A Retrospective Analysis of Radial Head Replacement 

with a Bipolar Radial Head System 

Mark Zunkiewicz, MD, Troy, OH 

Jill Clemente, MS, Pittsburgh, PA 

Mark C Miller, PHD, Pittsburgh, PA 

Robert R Gray, MD, Chicago, IL 

Mark S Cohen, MD, Chicago, IL 

Mark E Baratz, MD, Pittsburgh, PA 

This study was designed to evaluate the early results of a bipolar 

radial head prosthesis with a smooth, unfixed, telescoping stem. 

We hypothesized that this implant design would effectively restore 

stability to elbows with a comminuted radial head fracture and 

valgus instability. Thirty-seven patients sustaining a comminuted, 

unreconstructable radial head fracture underwent resection of the 

radial head followed by replacement arthroplasty with a bipolar 

implant. At final follow up, we obtained the Mayo Elbow Score 

(MES), VAS, DASH, and bilateral multiplanar range of motion 

measurements for each patient. Radiographs of bilateral wrists and 

elbows were obtained to compare medial and lateral ulnohumeral 

joint space and proximal radial migration in the operative versus 

the non-operative extremity. Change in stem angulation from postop 

radiographs to final follow-up radiographs was noted. If present, 

lucency about the stem, arthritic change at the radiocapitellar joint 

and heterotopic ossification was recorded. Twenty-nine patients (30 

implants) were available for final follow up at an average of 34.0 

(24-48) months. The average MES, VAS and DASH were 92.1, 1.4 

and 13.8 respectively. Range of motion analysis revealed statistically 

but not clinically significant differences between operative and 

nonoperative sides for flexion/extension and pronation/supination. 

Measurement of medial and lateral ulnohumeral spaces revealed 

re-establishment of a congruent elbow joint with our treatment. 

In most cases, there was little appreciable arthritic change at the 

radio-capitellar joint and minimal migration of the implant in the 

proximal radial shaft. Our analysis demonstrates that a bipolar radial 

head prosthesis with a smooth stem and telescoping neck effectively 

restores stability to elbows with a comminuted radial head fracture 

and valgus instability. To date, this is the largest reported outcome 

analysis of bipolar radial head replacement in the literature. 

pApeR No. 686 

Arthroscopic Ulnohumeral Arthroplasty Versus Simple 

Debridement For Elbow Arthritis 

Bryan C Fagan, MD, Tupelo, MS 

Larry D Field, MD, Jackson, MS 

Felix H Savoie, III MD, New Orleans, LA 

Primary arthritis of the elbow is an uncommon entity that can cause 

disabling pain and functional limitations. The therapeutic arsenal 

693 

for the treatment of primary arthritis of the elbow in young, active 

patients is somewhat limited. Arthroscopic debridement both 

with and without concurrent ulnohumeral arthroplasty have been 

shown to be effective. A retrospective chart review of 35 patients 

who underwent elbow arthroscopy for primary osteoarthritis of 

the elbow was completed. Twenty patients underwent arthroscopy 

with debridement alone; 15 patients underwent arthroscopy with 

debridement and ulnohumeral arthroplasty. Preoperative motion, 

pain and Mayo Elbow Performance Index scores for both groups 

were compared. For those undergoing arthroscopic debridement 

only, the average follow up was 37 months (range, 8 to 57 months). 

Preoperatively, mean flexion was 115° (range, 100-130) and mean 

extension loss was 26° (range, 7°-70°). Postoperatively, mean 

flexion was 129°(range, 110°-145°) and mean extension loss was 8° 

(range, 0° - 25°). The total arc of motion averaged 89° preoperatively 

and 121° postoperatively. Mayo Elbow Performance Index scores 

improved from an average of 57 preoperatively to 90 postoperatively. 

The mean subjective pain level improved from 6.6 preoperatively to 

1.4 postoperatively. For those undergoing arthroscopic debridement 

with combined ulnohumeral arthroplasty, the average follow up was 

34 months (range, 10-60 months). Preoperatively, the mean flexion 

was 102° (range, 90°-130°) and mean extension loss was 31°(range, 

10°-50°). Postoperatively, mean flexion was 128° (range, 110°- 

145°) and mean extension loss was 6° (range, 0°-25°). The total 

arc of motion averaged 71° preoperatively and 122° postoperatively. 

Mayo Elbow Performance Index scores improved from an average of 

55 preoperatively to 83 postoperatively. The mean subjective pain 

level improved from 6.6 preoperatively to 2.7 postoperatively. When 

comparing the two techniques, a statistically significant difference 

was found for the average arc of motion improvement. Those patients 

undergoing ulnohumeral arthroplasty had an average change of 53° 

compared to 28° for those undergoing debridement only (p=0.033). 

The change in Mayo Elbow Performance Index scores and subjective 

pain level were not found to be statistically significant. Based on these 

results, ulnohumeral arthroplasty may provide greater improvement 

in postoperative arc of motion. Both techniques improved patients 

to a functional range of motion; however, ulnohumeral arthroplasty 

may provide better results in patients with more restricted motion. 

pApeR No. 687 

Stress Shielding Around Radial Head Prostheses 

Cholawish Chanlalit, MD, Bangkok, Thailand 

James S Fitzsimmons, BSc, Rochester, MN 

David R Shukla, MB, B Ch, Rochester, MN 

Shawn W O’Driscoll, MD, Rochester, MN 

Stress shielding is known to occur around rigidly fixed implants. 

Nothing is reported concerning radial head prostheses. Charts and 

radiographs of 86 radial head prostheses inserted or removed by 

the senior author between 1999 and 2009 were reviewed. Exclusion 

criteria included infection, loosening, or followup

The seven with circumferential exposure of the stem (stage IIb) 

averaged 3 mm (1-10) of exposed stem. Importantly, stress shielding 

never extended to the bicipital tuberosity. Stress shielding around 

radial head prostheses is common. Though not severe enough to 

cause implant failure, these findings merit consideration of partially 

coated implants. 

pApeR No. 688 

The Long-Term Effect Of Corticosteroid In The 

Acromioclavicular Joint: A Prospective Study 

Roger P van Riet, MD, Wilrijk, Belgium 

Tom Goehre, MD, Berlin, Germany 

Simon Bell, MD, Brighton, VIC Australia 

Corticosteroids are routinely used in the treatment of a symptomatic 

acromioclavicular (AC) joint. Diagnostic injection with anaesthetic 

has been described as the gold standard in the detection of AC 

pathology. The anesthetic effect and therefore the location of the 

steroids, is monitored by repeating clinical tests, positive prior to the 

injection. Despite the widespread use of steroids, the effect of such 

an infiltration is poorly documented. In this prospective review of 

patients, we studied the long-term effects of an intra articular injection 

of local anaesthetic and steroid into the AC joint. Fifty-eight patients 

with isolated AC joint symptoms were included in this prospective 

study. All patients were examined using a standard protocol. A 

corticosteroid and local anaesthetic injection was administered into 

the AC joint space. All tests were repeated following the injection. 

Patients were examined at one month after the injection and at final 

follow up. ASES and UCLA shoulder scores were calculated. One 

month following the injection, symptoms had satisfactorily resolved 

in 16 patients (28%). Apart from one patient who had a temporary 

increase in pain, no other patients had any adverse reaction. Final 

follow up of these patients was performed at an average of 42 months 

(40-44). One patient had arthroscopic surgery for recurrence of the 

symptoms. Four of the remaining 15 patients reported occasional 

mild pain. Average ASES score was 94 points (70-100). The average 

UCLA score was 34 (28-35). All patients had a UCLA satisfaction 

score of 5 out of 5. From the present study it can be concluded that 

an injection of corticosteroid in the AC joint is of benefit in the short 

term, in just under a third of patients. Almost all patients with a 

good response however, avoid a surgical procedure in the longer 

term. Since the injection is cheap and with a low complication rate, 

it would seem reasonable to offer a cortisone injection to patients 

presenting with AC related symptoms. 

pApeR No. 689 

Biomechanical Comparison of an Intramedullary and 

Extramedullary Free-Tissue Graft AC Reconstruction 

Pooya Javidan, MD, Dearborn, MI 

Rishi Garg, MD, Arcadia, CA 

Gregory J Adamson, MD, Pasadena, CA 

Thay Q Lee, PhD, Long Beach, CA 

Several different surgical techniques have been described to address 

the coracoclavicular (CC) ligaments in acromioclavicular (AC) joint 

injuries. However, very few techniques focus on reconstructing the 

AC ligaments despite its importance in providing stability. The 

purpose of our study was to compare the biomechanical properties 

of two free-tissue graft techniques that reconstruct both the AC and 

CC ligaments in cadaveric shoulders, one with extramedullary AC 

reconstruction and the other with intramedullary AC reconstruction. 

We hypothesized that the intramedullary AC reconstruction will 

provide greater anteroposterior translational stability and improved 

load to failure characteristics than the extramedullary technique. 

694 

Six matched cadaveric shoulders underwent translational testing at 

10N and 15N in the anteroposterior and superoinferior directions 

under acromioclavicular joint compression loads of 10N, 20N 

and 30N. After the AC and CC ligaments were transected, one of 

the specimens was randomly assigned the intramedullary freetissue 

graft reconstruction while its matched pair received the 

extramedullary graft reconstruction. Both reconstructed specimens 

then underwent repeat translational testing as well as load to 

failure testing via superior clavicle distraction at a rate of 50 mm/ 

min. Intramedullary reconstruction provided significantly greater 

translational stability in the anteroposterior direction than the 

extramedullary technique in all loading conditions except at 10 N 

of translation with 30 N of compression. There were no significant 

differences in translational stability in the superoinferior direction for 

any loading condition. The intramedullary reconstructed specimens 

demonstrated improved load to failure characteristics, however only 

ultimate load to failure and energy absorbed to clinical failure was 

significant. Intramedullary reconstruction of the AC joint provides 

greater stability in the anteroposterior direction and improved load 

to failure characteristics than the extramedullary technique. 

pApeR No. 690 

Activities after Total Elbow Arthroplasty 

Jonathan D Barlow, MD, Rochester, MN 

Shawn W O’Driscoll, MD, Rochester, MN 

Bernard F Morrey, MD, San Antonio, TX 

Scott P Steinmann, MD, Rochester, MN 


There is limited information about activities performed by patients 

after total elbow arthroplasty. Knowledge of these activities may help 

understand the true functional gains obtained after replacement. All 

patients who underwent a primary or revision total elbow arthroplasty 

at a single institution during 2006 and 2007 were contacted by 

our Research Survey Center and queried regarding performance of 

multiple activities. The UCLA score and Mayo Elbow Performance 

Score (MEPS) was also assessed. One hundred and twelve surveys 

were analyzed. There were 29 males and 83 females with a mean 

age of 65 years. Sixty-four were primary and 48 were revision elbow 

arthroplasties. The mean MEPS was 77.4 points (range, 15 to 100 

points). The mean UCLA activity score was 4.7 points (range, 1 to 

10 points). High demand activities were performed by 45 patients 

(40%), and moderate demand activities were performed by an 

additional 60 patients (54%). The most common moderate demand 

activities were carrying groceries and gardening. The most common 

high demand activities were shoveling snow and shoveling dirt. 

Higher MEPS, higher UCLA and male gender were predictive of higher 

demand activities (p

POSTERS 


Radial Nerve Palsy Following Humeral Revision In Total 

Elbow Arthroplasty 

Thomas Throckmorton, MD, Germantown, TN 

Peter Constantine Zarkadas, MD, North Vancouver, BC Canada 



Revision for failed total elbow arthroplasty is increasingly common. 

The radial nerve is at risk during humeral component revision. 

The purpose of this study was to define the incidence of treatment 

and outcome of radial nerve palsy following humeral implant 

revision. The Total Joint Database at our institution was searched 

for all humeral component revisions between 1988 and 2007. The 

search was then refined to identify patients with radial nerve palsies 

discovered following this procedure. Several variables, including the 

use of power and/or ultrasound instruments, formal radial nerve 

exposure and the use of electrodiagnostic testing were analyzed. 

Seven out of 258 (2.7%) humeral component revisions, with an 

average follow up of 84 months (range 24 to 233), were complicated 

by radial nerve palsy. Only three out of seven patients ultimately 

regained function. No nerve recovery occurred in three out of four 

patients where power instruments were used for cement removal, 

and in the one patient where ultrasound technology was employed. 

However, two of the three patients who underwent formal exposure 

of the radial nerve at the time of revision had return of function. 

Six patients had electrodiagnostic studies data obtained at least six 

weeks after the revision procedure, which was predictive of ultimate 

nerve status in five (83%) patients. Five out of seven (71%) patients 

were subjectively improved overall from the joint replacement at 

final follow up. Radial nerve palsy is an uncommon complication 

following humeral revision in total elbow arthroplasty but is not 

necessarily associated with full recovery. In patients who develop 

this complication, and where power instruments or ultrasound 

technology were used for cement removal, return of function is less 

likely. Electrodiagnostic testing is predictive of ultimate neurological 

outcome. If injury occurs after formal exposure and protection of 

the radial nerve, recovery is possible. We therefore conclude that 

palpation and presumption of radial nerve security is inadequate 

in this setting. We recommend formal exposure, visualization 

and protection of the radial nerve during humeral component 

revision. Patient satisfaction remains relatively high despite this 

complication. 


uReverse Shoulder Prosthesis for Acute 4-Part 

Fracture: Reliable Tuberosity Healing 

Jonathan Chad Levy, MD, Fort Lauderdale, FL 

Results of hemiarthroplasty for complex four-part proximal humerus 

fractures in the elderly have been unreliable. While patients often 

achieve pain relief, return of above shoulder level function can be 

challenging, as tuberosity nonunion, malunion and/or resorption is 

quite common. The reverse shoulder replacement has been advocated 

as a reliable off-label alternative for these patients. Preliminary 

studies have suggested that tuberosity healing is critical for achieving 

external rotation strength following reverse shoulder arthroplasty. 

From May 2008 to March 2009, eight patients over the age of 75 

presented with complex four-part fractures of the proximal humerus. 

Five patients sustained four-part fracture dislocations and three 

patients sustained four-part fractures without dislocation. All were 

695 

treated with a reverse shoulder replacement with tuberosity repair 

using a wedged horseshoe graft taken from the excised humeral head. 

Humeral lengthening was minimized to prevent excessive tension 

on the tuberosity repair. Average age was 86 (range 78-91), with six 

females and two males. Average follow up was 10 months (10-15 

months). Average active forward elevation was 114 (range 80-150) 

and active external rotation was 18 (range 0-30). Manual muscle 

strength was five/five in seven patients with tuberosity healing, and 

four/five with tuberosity non-union. VAS pain scores averaged 0.6 

(range 0-2), VAS function averaged 8.5 (range 7-10), ASES pain 

47.1 (range 45-50) and ASES function 40 (range 31-50). Subjective 

satisfaction was excellent for five patients, satisfactory for one 

patient, and good for two patients. Radiographic analysis revealed 

a tuberosity union rate of 87% (seven/eight patients). There were 

no cases of inferior scapular notching. The patient with tuberosity 

non-union subsequently sustained a mid-acromion fracture which 

healed without clinical consequence. One patient developed nonbridging 

hetertopic bone formation. Reverse shoulder arthroplasty 

is a reliable off-label treatment alternative for elderly patients (over 

age 75) with complex four-part fractures and fracture-dislocations. 

Tuberosity healing is reliable in these patients utilizing a wedge 

horeshoe graft. 


Fully Uncemented Polyethylene Glenoid: Preliminary 

Results 

Francis De Neve, Med Student 

Lieven De Wilde, Gent, Belgium 

Carl J Basamania, MD, Shoreline, WA 

Cemented glenoid still is the golden standard in total shoulder 

arthroplasty. Because initial research showed significantly stronger 

pull-out with an uncemented fluted peg than a fully cemented keel 

glenoid in a canine model, an uncemented anchor peg glenoid was 

implanted in patients. The purpose of this study is to investigate 

whether our short-term results in uncemented anchor peg glenoid 

implants are clinically and radiologically comparable to previous 

publications. We studied 35 consecutive patients, with one drop 

out, with a minimum follow up of 17 months. We evaluated our 

patients with the Constant Murley score, the Western Ontario 

Osteoarthritis of the Shoulder index and the SF-12 score. Finally, a 

follow-up study of the glenoid with a CT-scan was also performed 

to evaluate the bone ingrowth of the anchor peg glenoid. Clinical: 

The mean absolute Constant Score was 72 (pain: 12.3; activities 

of daily living: 17.5; range of movement: 34.2; power: 8.2). The 

WOOS score was 388/1,900, where a minimal score reflects good 

functioning. Radiological: One or more bony flange(s) in the anchor 

were identified in 25 cases, in six cases no loosening signs around the 

pegs, glenoid or anchor were seen and in three cases loosening was 

seen around the central anchor, in one of these three cases loosening 

was seen around the pegs. The clinical and radiological evaluation of 

the uncemented anchor peg glenoid is promising, with results that 

are clinically comparable to a classical cemented pegged glenoid. 


Characteristic Retear of Arthroscopic Double Row 

Suture Anchor (DR) Method for Rotator Cuff Tear 

Kenji Hayashida, MD, Osaka, Japan 

Makoto Tanaka, MD, Osaka, Japan 

Kota Koizumi, MD, Osaka, Japan 

To elucidate characteristic retear pattern of double row (DR) method 

and its incidence. The 47 patients with complete rotator cuff tears, 

who were treated with DR method under arthroscopy and assessed 




epair condition by MRI after about 12 months of operation, were 

included in the present study. The average age at operation was 65 

years old (42-82). The average follow-up period was 26 months (24- 

32 months). A retear was found in 13 shoulders and the pattern of 

retear was classified into four groups, as follows: the partial retear 

of deep layer, the partial retear of superficial layer at medial anchor, 

the complete retear at medial anchor with a well preserved tendon 

foot print and the complete retear from foot print. The partial retear 

of superficial layer and the complete retear at medial anchor were 

characteristic in DR method and the incidence was seven of 13 retear 

cases and seven of all 47 patients in the present study. A partial retear 

of superficial layer and a complete retear at medial anchor with a 

well repaired tendon on foot print could be the characteristic tear 

of double row suture anchor method. These characteristic retear 

patterns occupied 54% of retear cases (seven of 13) and the incidence 

was 15% of all patients (seven of 47). 


Distal Humeral Hemiarthroplasty Short Term Results 


Scott P Steinmann, MD, Rochester, MN 

Despite historical reports of distal humeral hemiarthroplasty (DHH) 

for fracture, there is little in the current literature regarding modern 

implants and distal humeral replacement in young patients. The 

goal of this study was to determine the short-term outcomes of distal 

humeral hemiarthroplasty. Between 1975 and 2009, 13 elbows (13 

patients) underwent distal humeral hemiarthroplasty and were 

followed for a mean of 2.95 years. The mean age at the time of 

surgery was 54 years. The indications for surgery were post-traumatic 

(12), and advanced rheumatoid arthritis with contracture (one). 

Clinical outcome was graded using the Mayo Elbow Performance 

Score (MEPS). Radiographs were graded for implant loosening, 

radial head and olecranon wear. DHH resulted in statistically 

significant improvements in pain, extension (mean improvement, 

33.2 degrees), flexion (mean improvement, 28 degrees) and total 

arc of motion (from 46 to 206 degrees, p=0.001). The intraoperative 

arc of motion was greater than that at final evaluation, but this was 

not significant (from 121.7 to 106 degrees, p>0.05). The mean final 

MEPS was 72.7 points, with two excellent, four good, three fair and 

two poor results. Radiographs showed implant loosening (three), 

anterior radial head wear (four), radiocapitellar degeneration (one) 

and moderate olecranon wear (one). Complications included deep 

infection (one), stitch abscess (one), contracture (three), heterotopic 

ossification (two) and delayed medial column fracture (one). There 

were two revisions. DHH for traumatic sequelae offers a reasonable 

short term result, with significant improvements in motion, pain 

relief and function. 


Measurement Of The Glenoid Track In Vivo, Investigated 

By The 3D Motion Analysis Using Open MRI 

Yasushi Omori, MD, Suita, Japan 

Nobuyuki Yamamoto, MD, Sendai, Miyagi, Japan 

Hayato Koishi, Osaka, Japan 

Makoto Tanaka, MD, Osaka, Japan 

Kazuma Futai, MD, Suita, Osaka, Japan 

Akira Goto, MD, PhD, Rochester, MN 

Kazuomi Sugamoto, MD, Osaka, Japan 

Eiji Itoi, MD, Sendai, Japan 

Engaging Hill-Sachs lesion is one factor thought to be related to 

recurrent anterior glenohumeral instability. To our knowledge, no 

anatomic or biomechanical studies to date have clarified which 

696 

size of Hill-Sachs lesion is critical. Recently, we proposed a new 

concept, ‘glenoid track,’ to evaluate risk of engagement with glenoid 

in a cadaveric study. The purpose of this study was to investigate the 

glenoid track in vivo using a non-invasive motion analysis system 

developed in our laboratory. We examined 16 right shoulders of 

16 healthy volunteers, mean age of 26 years with wide gantry MRI. 

MRI was taken in seven static supine positions with the arm from 

0° to maximum abduction keeping maximum external rotation 

and horizontal extension. Using our motion analysis system, threedimensional 

models of scapula and humerus were created from the 

MRI data. Then, the movement was calculated by the voxel-based 

registration of each model, and motion of glenoid on the humeral 

head was analyzed. The images clearly demonstrated that the glenoid 

shifted from infero-medial to supero-lateral portion of the humeral 

head in live shoulders the same way as observed in the cadaveric 

shoulders. The distance from the foot print to the medial margin 

of the glenoid track was 19.9 mm ± 3.7 mm (mean ± SD), which 

was equivalent to 83% ± 10% of the glenoid width. We confirmed 

the existence and the size of the glenoid track in vivo. We believe 

that this new concept can be used to evaluate the risk of Hill-Sachs 

lesion. 


Significant Neuroanatomic Changes Resulting From 

The Latarjet Procedure 

Michael T Freehill, MD, Palo Alto, CA 

Umasuthan Srikumaran, MD, Braintree, MA 

Kristin Archer, PhD, Nashville, TN 

Edward G McFarland, MD, Lutherville, MD 

Steve A Petersen, MD, Lutherville, MD 

Latarjet procedures for glenoid deficiency resulting in glenohumeral 

joint instability has gained an increase in popularity. Our hypothesis 

was the Latarjet results in significant alterations in anatomic 

relationships of neurovascular structures in the shoulder. Four 

cadaveric forequarters (eight shoulders) were utilized for the study. 

Pre and post-Latarjet measurements were made by two investigators 

utilizing EKG calipers and digital ruler in two arm positions: (1) 0° 

abduction (Abd) and neutral rotation and (2) 30° Abd and 30° 

external rotation (ER). Measurements were made from the midanterior 

glenoid rim to musculocutaneous nerve (MCN), axillary 

nerve (AXN) and axillary artery (AXA) along both medial-lateral 

(x) and superior-inferior (y) axis. A glenoid defect was created and 

Latarjet procedure was performed. The dissection was photographed 

to further assess relationship changes between structures before 

and after the Latarjet. Statistical analysis was performed using 

standardized statistical software. Statistical significance was set at 

pd0.05. Intra-rater reliability for each tester was above 0.80 except 

for one measurement (0.73). After the Latarjet procedure, significant 

changes in location of the MCN were found along the (y-axis) in both 

the neutral and 30°Abd/30°ER positions, (pd0.02). The change in 

location of both MCN and AXN after the Latarjet consistently resulted 

in the MCN lying directly on top of the AXN. The observations in the 

neuroanatomic relationships of the musculocutaneous and axillary 

nerves following a Latarjet procedure provide essential information 

in the event of future revision surgery. 





Radiocapitellar Pressure Differences in Bipolar versus 

Monopolar Radial Heads 

Prasad J Sawardeker, MD, Miami, FL 

Check C Kam, MD, Miami, FL 

Winston Elliott, Miami, FL 

Jeffrey Dean Martins, Miami, FL 

Loren L Latta, PhD, Plantation, FL 

Elizabeth A Ouellette, MD, North Miami Beach, FL 

There has been considerable recent interest in bipolar radial head 

components however very few studies have been done to compare 

it to traditional monopolar radial head implants. We examined 

the effects of implant design on radiocapitellar joint pressures. 

Eight fresh-frozen, cadaveric arms were utilized. Radial heads were 

resected and a bipolar, metal radial head prosthesis was implanted. 

Appropriately sized implants were used to restore axial length of the 

native radial head. Arms were cyclically loaded with the forearm in 

neutral. Radiocapitellar forces were measured using pressure sensors. 

Then, a metal washer was inserted in situ to convert the bipolar radial 

head into a rigid monopolar device and testing was repeated. Bipolar 

radial heads produced radiocapitellar pressures (0.36 N/mm2) that 

were significantly lower than the rigid, monopolar implant (0.68 N/ 

mm2) (p

infection in one. Reoperations were performed in three shoulders; 

resection for deep infection in one, open reduction internal fixation 

for a distal fracture in one and bone grafting with internal fixation 

for allograft resorption in one. Pain ratings (on a scale of 1 to 5) 

decreased from a mean of 4.5 preoperatively to 2.4 postoperatively. 

The mean active elevation increased from 81 degrees preoperatively 

to 110 degrees postoperatively; the mean external rotation increased 

from 28 degrees to 47 degrees. Excellent or satisfactory results were 

achieved in 22 of 38 shoulders according to the modified Neer 

rating system. Radiolucent lines were identified in six cases, but no 

components met criteria to be considered radiographically “at risk” for 

clinical loosening. Intermediate or long stem humeral components 

are useful in obtaining a secure distal fit in cases involving diaphyseal 

fracture, significant bone loss or in patients with a large humeral 

canal. Caution should be taken to avoid intraoperative fractures 

distally. Outcomes are often determined by proximal soft tissue 

integrity and not affected by long stem placement. Neither clinical 

nor radiographic follow up show these components to be at high 

risk for loosening. 


The Long-Term Outcome of Total Elbow Arthroplasty in 

Juvenile Rheumatoid Arthritis 





Total elbow arthroplasty (TEA) is commonly considered for endstage 

juvenile rheumatoid arthritis (JRA). Little is known regarding 

its long-term outcome, which could be affected adversely by the 

musculoskeletal pathology in this young population. The goal of this 

study was to determine the long-term outcome of TEA in JRA elbows. 

Between 1983-2005, 29 elbows (24 patients) underwent TEA for JRA 

using a linked-semiconstrained implant and followed for a mean 

of nine years. Clinical outcome was graded using the Mayo Elbow 

Performance Score (MEPS). Survivorship analyses were performed 

using the Kaplan-Meier method. The results were compared with a 

series of TEA in adult-onset rheumatoid arthritis (RA). , TEA resulted 

in statistically significant improvements in pain, extension (15 

degrees), flexion (17 degrees) and total arc of motion (from 65 to 

99 degrees), (p=0.001). The intraoperative arc of motion was greater 

than at final evaluation (from 121 to 99 degrees, p=0.001). Fourteen 

elbows (48%) were noted to have small bone size, requiring implant 

modification in four cases. Complications included revision surgery 

(six) and superficial infection (one).The mean final MEPS (84+/- 

11) was not significantly different that in RA patients (87+/-14), 

(p=0.22). With the numbers available there were no statistically 

significant differences in implant survival between JRA and RA at 

one year (100% vs 99.6%), five years (96.2% vs 95.6%) and 10 years 

(78.2% vs 91.7%). TEA in JRA is associated with a reasonable longterm 

survival and a high rate of satisfactory functional results that 

are similar to RA. 


Anconeus Interposition for Proximal Radioulnar 

Synostosis 

David Gay, MD, Palm Coast, FL 

Aaron Daluiski, MD, New York, NY 

Sophia Paul, BA 

Robert N Hotchkiss, MD, Riverside, CT 

Proximal radioulnar synostosis is a rare debilitating condition 

that often results in an individual having difficulties performing 

698 

tasks of daily living. There have been limited reports of successful 

treatment of this condition. Since 1997, we have been addressing 

this condition by posterior excision of the synostosis and anconeus 

interposition. In this study we present the results of this treatment. 

Sixteen adult patients who had undergone a proximal radioulnar 

synostosis resection and anconeus interposition were identified, 

and their records were reviewed. All patients had a minimum follow 

up of 12 months, and the average follow up was 46 months. Ten 

patients’ synostosis resulted from a fracture or dislocation of the 

elbow, and six were related to a previous distal biceps repair. There 

was not a significant difference between the fracture/dislocation 

patients and the biceps repair group with respect to age (p=0.61) 

or follow-up duration (p=0.76). The fracture/dislocation group had 

undergone a significantly higher number of surgeries (p=0.046). 

All patients had an increase in their pronation-supination arc and 

no patient had a loss of motion in the flexion-extension plane. 

The mean preoperative pronation-supination arc of 12 +/- 26 

degrees increased to 138 +/- 49 degrees (p

0.51, 0.39 and 0.6, respectively. Certain biomarkers predominate 

in osteoarthritic shoulders when compared to non-OA shoulders; 

mainly Connexin 43, ADAMTS5, Col I, Cox-2, Chondroitin, TIMP- 

3 and iNOS biomarkers. Of these, Connexin 43 had the greatest 

fold increase in expression in OA shoulders compared to non-OA 

shoulders, and was found to be significantly correlated to these other 

biomarkers. This novel study will provide the basis to determine 

potentiators and inhibitors of shoulder arthritis. 


Causative Factors and Outcome in 17 Patients with 

Glenohumeral Chondrolysis 

Samer S Hasan, MD, PhD, Cincinnati, OH 

Cassie M Fleckenstein, Cincinnati, OH 

Glenohumeral chondrolysis is a devastating condition characterized 

by the rapid dissolution of glenohumeral cartilage and resultant 

joint destruction. Excessive intra-articular use of thermal heat, 

suture anchors that are prominent or loose and the use of an intraarticular 

pain pump (IAPP) delivering local anesthetics have all 

been implicated as causative factors. The objective of this study is 

to report on the presentation, clinical findings and treatment of 

glenohumeral chondrolysis. Between November 2007 and February 

2010, 29 patients presented with glenohumeral chondrolysis related 

to one or more of the causative factors noted above. Seventeen 

patients have been followed since their initial presentation, with the 

remainder presenting for evaluation only, at the suggestion of their 

attorneys. Seven of 17 patients were male and mean age at the time 

of their index surgery was 28.6 (range 15-55) years. Two patients 

developed chondrolysis as a result of prominent suture anchors 

and 15 as a result of an IAPP delivering bupivacaine. Two patients 

underwent placement of an IAPP following a closed manipulation 

for adhesive capsulitis and 13 underwent IAPP placement following 

arthroscopic labrum repair or capsular plication using one to seven 

suture anchors. Onset of symptoms related to chondrolysis, such as 

increased pain, stiffness and crepitation, occurred at a mean eight 

months (range 1-32 months) following the index procedure. Twelve 

patients underwent one or more additional arthroscopic procedures, 

typically for debridement and chondroplasty, and in some cases, 

capsular release. A loose suture anchor was found in one joint at 

arthroscopy, which was removed. Eleven patients had radiographs 

documenting joint space obliteration at most recent follow up or at 

the time of prosthetic shoulder arthroplasty. At most recent follow 

up, seven patients had undergone three total shoulder replacements 

and four humeral head resurfacing procedures. Four other patients 

were contemplating prosthetic shoulder arthroplasty. For those 

undergoing shoulder replacement, range of motion recovered 

modestly so that active forward elevation improved from 111° to 

137° (p

orthopaedic surgeons independently reviewed the subjects’ one-year 

postoperative radiographs on two occasions at least six weeks apart, 

to obtain intrarater and interrater data. The severity of radiographic 

notching was graded according to the classification of Nerot. The two 

groups were also compared with regards to their outcome measures 

(Constant and ASES) and range of motion. Minimum one-year 

postoperative radiographs and follow-up data were available on 

42/52 subjects (81%). Follow-up time did not differ between groups 

(p=0.723). One subject had died and nine subjects were lost to follow 

up. Twenty patients were in the inferior tilt group and 22 patients 

were in the control group. The raters demonstrated good intrarater 

(intraclass correlation coefficients = 0.88 and 0.97, respectively) and 

interrater (intraclass correlation coefficient = 0.94) agreement. Fifteen 

of 20 patients (75%) in the inferior tilt group and 19 of 22 patients 

(86%) in the control group had notching scores of one or greater. Ten 

of 20 patients (50%) in the inferior tilt group and 11 of 22 patients 

(50%) in the control group had notching scores of two or greater. The 

groups did not differ significantly on the notch ratings when averaged 

across raters (p=0.936) nor did they differ significantly for any single 

scoring occasion of any rater. The improvement in outcome measures 

and range of motion were not significantly different between groups; 

all measures improved significantly over time (p

significant improvement of their clinical signs and symptoms, they 

had an inferior outcome. 


Heterotopic Ossification After Elbow Fractures and 

Fracture-Dislocations of the Radius and Ulna 

Antonio Maria Foruria de Diego, MD, PhD, Madrid, Spain 

Salvador Augustin, MD, Madrid, Spain 



The goal of our study was to determine the incidence, risk factors, 

location, severity and functional implications of heterotopic 

ossification (HO) after surgical treatment of elbow fractures and 

fracture-dislocations of the proximal radius and ulna. From 2004 

to 2008, 134 elbow fracture or fracture-dislocations involving the 

proximal radius or ulna were treated surgically at a single institution. 

The records and radiographs obtained before surgery, immediately 

after surgery, three months after surgery and at most recent follow 

up were reviewed to determine the incidence of HO and analyze 

its location morphology and associated clinical features. There 

was radiographic evidence of HO in 51 elbows (38%). Ligament 

involvement usually developed in combination with HO in other 

locations. The most common locations were the olecranon fossatriceps 

tendon and the proximal radius. HO was categorized as 

immature granular in 22 elbows, mature discrete HO in 20 elbows, 

mature extensive in six elbows and bone bridging in three elbows. 

Risk factors for the development of HO included male gender, severe 

chest trauma, dislocation, open injury and associated distal humerus 

fracture. Surgical removal of HO was performed in 15 elbows. HO 

is identified in approximately 40% of the fractures and fracturedislocations 

of the proximal radius and/or ulna treated surgically. 

It may lead to additional surgery for functional limitations in 30%. 

Male gender and a higher energy injury may increase the risk of this 

complication. 


Biplane X-ray Analysis Of In-Vivo Shoulder Function 

After Rotator Cuff Repair: Two-Year Results 

Vasilios Moutzouros, MD, Novi, MI 

Michael Bey, PhD, Detroit, MI 

Terrence R Lock, MD, Ypsilanti, MI 

Patricia A Kolowich, MD, Detroit, MI 

Rotator cuff treatment is implicitly designed to restore normal 

glenohumeral joint (GHJ) function, but the extent to which surgery 

restores GHJ function is unknown. The objective of this study was to 

compare in-vivo GHJ mechanics and shoulder strength between the 

repaired (REP) and contralateral (CONTRA) shoulders of rotator cuff 

repair patients, and dominant shoulder of control (CTL) subjects. 

Using dynamic, biplane x-ray analysis, we measured in-vivo GHJ 

contact patterns during abduction from rotator cuff repair patients 

(n=22, tested two years post surgery) and asymptomatic volunteers 

(n=33). Isometric shoulder strength was measured during elevation 

(ELEV), abduction (ABD), internal rotation (IR) and external 

rotation (ER) and clinical outcomes were assessed with the Western 

Ontario Rotator Cuff (WORC) index. Overall joint position was 

different between shoulders, with the humerus of the REP shoulders 

located more superiorly on the glenoid than both the CONTRA and 

CTL shoulders (p

shoulder group had a greater percent improvement. Both pre- and 

post-operatively, isometric shoulder strength decreased as the degree 

of flexion increased, which is different from a normal shoulder 

where torque remains steady as range of motion increases. While 

patients undergoing anatomical shoulder arthroplasty were stronger 

than reverse shoulder arthroplasty patients both pre- and postoperatively, 

both groups experienced similar amounts of strength 

gains following surgery. 


Cost Analysis of Failed Shoulder Stabilization 

Jonathan Godin, BA, Fenton, MI 

Jack Gerard Skendzel, MD, Ann Arbor, MI 

Jon K Sekiya, MD, Ann Arbor, MI 

The purpose of this study was to determine the cost of failed 

shoulder stabilization and subsequent surgery needed to definitively 

stabilize these patients. Given the burden of disease, combined with 

the increasing focus on cost- and comparative-effectiveness research, 

there is a need for more information to guide resource allocation 

decisions within this area of orthopedics. We retrospectively reviewed 

the medical records and billing information of 19 consecutive 

patients treated at our institution for recurrent shoulder instability 

during a 36-month period. Using the billing records for each 

case, a cost-minimization analysis was conducted from a societal 

perspective. The actual costs of index stabilization and revision 

stabilization procedures for our cohort of 19 patients amounted to 

$1,437,833. The costs of revision surgeries conducted for this cohort 

by a single surgeon at our institution amounted to $527,870. The 

hypothetical costs of primary arthroscopic stabilization and open 

stabilization for a similar cohort of 19 patients leading to permanent 

repair equal $417,383 and $618,175, respectively. The incremental 

difference between actual costs and hypothetical costs of primary OA 

allograft stabilization for patients with bony defects is $278,394. For 

patients with bony defects, an open repair with failure rate of 44.9%, 

or an arthroscopic repair with failure rate of 62.8%, is cost neutral to 

a primary open repair with OA allograft. In addition, an open repair 

with failure rate of 14.6%, or an arthroscopic repair with failure rate 

of 42.3%, is cost neutral to a primary Latarjet repair. Failed shoulder 

stabilization bears high costs to society, even without considering 

the psychological costs to patients. We must identify and refine 

diagnostic and prognostic factors to better determine the appropriate 

treatment modality for patients with shoulder instability. 


Muscle Recruitment Patterns During Arm Elevation 

With A Reverse Total Shoulder Replacement (rTSA) 

Young W Kwon, MD, PhD, New York, NY 

Jangwhon Yoon, PhD, PT, New York, NY 

Vivek Pinto, Astoria, NY 

Page Dunning, Tampa, FL 


Ali Sheikhzadeh, MD, New York, NY 

In patients with rotator cuff arthropathy, reverse total shoulder 

arthropathy (rTSA) has been used to improve pain and restore 

function. This clinical success is believed to be due to the anatomic 

changes in the rTSA construct that provides mechanical advantage for 

the deltoid muscles. This theoretical change, however, has not been 

confirmed and little information is available regarding the muscle 

recruitment pattern in rTSA shoulders. Seven healthy subjects and 

seven patients with rTSA were recruited. All rTSA patients received 

the implant as the primary arthroplasty at least six months prior to 

testing, were able to elevate the arm to at least 120 degrees and had 

702 

an average ASES score of 90.1 +/- 9.4. During elevation along the 

scapular plane with zero, two and four pounds of handheld weight, 

muscle recruitment pattern and shoulder kinematics were analyzed 

using magnetic motion capture device and surface electromyography. 

In comparison to healthy subjects, increased recruitment was noted 

in the anterior deltoid, middle deltoid and trapezius muscles of the 

rTSA shoulders (p


Diagnostic Performance And Reliability Of Ultrasound 

For Fatty Degeneration Of Rotator Cuff Muscles 

Lindley B Wall, MD, Saint Louis, MO 

Hyun Min Kim, MD, Columbia, MO 

Leesa M Galatz, MD, Saint Louis, MO 

Karen Steger-May, MD, Saint Louis, MO 

Nirvikar Dahiya, MD, St Louis, MO 

Sharlene A Teefey, MD, Saint Louis, MO 

William D Middleton, MD, Saint Louis, MO 

Daniel Wessell, MD, PhD 

Ken Yamaguchi, MD, Saint Louis, MO 

Fatty degeneration of the rotator cuff muscles is a negative prognostic 

factor in rotator cuff repair surgery. We investigated diagnostic 

performance and reliability of ultrasonography in identifying and 

grading fatty degeneration of the rotator cuff muscles using MRI as 

the reference standard. Eighty patients were prospectively enrolled 

and underwent both MRI and ultrasonography of the shoulder. The 

supraspinatus, infraspinatus and teres minor muscles were graded 

in MRI for fatty degeneration by four independent raters using 

the Goutallier system. Ultrasonography of the three muscles was 

performed and graded by radiologists in real time with a three-point 

scale. The percent agreement (i.e., accuracy), sensitivity and specificity 

of ultrasound were determined. Agreement between the ultrasound 

and MRI grades and inter-observer reliability of the two modalities 

was determined. The percent agreement of ultrasound was 92.5% 

for the supraspinatus and infraspinatus, and 87.5% for teres minor. 

Sensitivity was 84.6%, 95.6% and 87.5%, respectively. Specificity 

was 96.3%, 91.2% and 87.5%, respectively. Agreement between the 

MRI and ultrasound was substantial for the supraspinatus (0.63) 

and infraspinatus (0.67) and moderate for teres minor (0.56). Interobserver 

reliability of MRI was substantial for the supraspinatus 

(0.76) and infraspinatus (0.77) and moderate for teres minor 

(0.66). For ultrasound, the inter-observer reliability was excellent the 

supraspinatus (0.82) and infraspinatus (0.91) and substantial for 

teres minor (0.75). Ultrasonography has a comparable diagnostic 

performance to MRI for fatty degeneration of the rotator cuff muscles 

and can be used as a reliable and economical diagnostic modality in 

rotator cuff muscle pathologies. 


Multicenter Review Of Infected Shoulder Prosthesis. 

Where Do We Stand? 


Luk Verhelst, MD, Gent, Belgium 

Jose A Stuyck, Pellenberg, Belgium 

Carlo Romano, MD, Milano, MI Italy 


Despite a large number of reports describing the management of 

infected hip and knees arthroplasties, little information is available 

on how to deal with infected shoulder arthroplasties. Our goal 

is to present pooled results from three European centers in order 

to propose guidelines for treatment algorithms and evaluate the 

outcome after infection. Between 1999 and 2009, 33 patients were 

diagnosed with an infected shoulder prosthesis in three different 

European orthopaedic departments. This retrospective study 

includes 19 women and 14 men with a mean age of 61.2 years (43- 

78 years). Indications for prosthetic shoulder replacement were: 

degenerative arthritis in 11 patients, post-traumatic arthritis in 18 

patients, rheumatologic in one and tumor in three. We found 23 

hemi, six reverse, three standard total implants, as well as one tumor 

703 

implant. Infection was considered early in six patients, delayed in 

15 patients and late in 12. All of the patients underwent surgical 

revisions. In six patients surgical debridement was performed (with 

replacement of the mobile parts in three). Resection arthroplasties 

were performed in three patients. In 24 patients a cemented spacer 

was implanted. Cultures from samples taken during surgery showed 

Staphyloccocal infection in 24 samples. Ten infected shoulder joints 

showed more than 1 germ. Eight patients had negative cultures 

although they showed clinical signs of infection. We found six 

patients with a propionibacterium acnes infection. After surgery, 

all the patients where treated with adapted antibiotics for a long 

duration of time. In the spacer group, 10 patients were managed with 

reimplantation of a RTSA, one with a standard TSA and four with a 

hemi-arthroplasty. For nine patients, a permanent cemented spacer 

was used. Eradication of the infection was achieved in 32 out of 33 

patients (97%). One patient with a mixed MRSA/pseudomonas 

infection had persistent infection after two repeated debridements. 

There were four dislocations of spacers or prosthesis. Two fractures 

around the implanted stem were found. Function was generally poor 

and the Constant shoulder score went from 24 preoperatively to 33 

points postoperatively at follow up. General satisfaction was good to 

excellent in 26 patients (78%). Seven patients were not satisfied or 

disappointed. Functional results after infected shoulder arthroplasty 

revisions are generally poor, although general satisfaction is good 

to excellent in about two-thirds of the patients. Propionibacterium 

acnes is present in 18% of infections and should be actively 

assessed. Newer and more sensitive diagnostic tools like sonication, 

calorimetry and malditof should helpful in decreasing the number of 

false negative microbial samples. As opposed to cemented spacers in 

hips and knee, shoulder spacers can be left in place for long periods 

of time, and even be used as a definitive implant. 


Open and Arthroscopic Supra- and Infraspinatus 

Repairs are Equivalent 

Christian Gerber, MD, Zurich, Switzerland 

Atul Sukthankar, MD, Volketswil Zurich, Switzerland 

Patrick Oliver Zingg, MD, Zurich, Switzerland 

Christian Pfirrmann, MD, Zurich, Switzerland 

Marco Zanetti, MD 

Bernhard Jost, MD, Zurich, Switzerland 

It is unknown whether arthroscopic repair of supra- and infraspinatus 

repairs can be carried out with the same structural and clinical results 

as open repairs. Forty-one patients with FT SS and/or IS tears without 

prior surgery were randomized to arthroscopic (single row) or open 

(transosseous) tendon repair. Physical examination, Constant 

scoring (CS) and MR-arthrography were performed preoperatively 

and at final follow up in all patients. There were 21 open and 20 

arthroscopic repairs. At two years, the respective mean gains were 42 

and 42 points in subjective shoulder value, 22 and 21% in relative 

CS, four and seven (out of 15) in pain points, 15 and 14 degrees of 

active elevation and 2.5 and 1.5 kg in abduction strength. There was 

one FT retear and three partial retears in each group. Fatty infiltration 

increased in SS and IS insignificantly in both groups. Two patients 

in the open and one in the arthroscopic group had to be revised. In 

this prospective randomized trial, the clinical AND structural results 

of arthroscopic repair of one to two tendon tears were not inferior to 

those of open repair. 





Elbow Ulnar Collateral Ligament Reconstruction Using 

Hamstring Allograft in Young Throwing Athletes 

James A Hurt, III MD, New Orleans, LA 

Jeffrey Jon-Michael Yaste, MD, Asheboro, NC 


Larry D Field, MD, Jackson, MS 

Currently, several graft options have been described for reconstruction 

of the ulnar collateral ligament (UCL) of the elbow. Palmaris longus, 

gracilis, plantaris, extensor toe grafts and even achilles tendon 

autografts have been well documented. To our knowledge, no clinical 

study exists reporting outcomes using allograft. Hamstring allografts 

provide a robust graft without donor site morbidity such as pain, 

scarring and potential neurovascular injury. The purpose of this study 

was to evaluate our series of consecutive UCL reconstructions using 

hamstring allograft in young (


Effectiveness of Physical Therapy in Treating 

Atraumatic Full Thickness Rotator Cuff Tears 

John E Kuhn, MD, Nashville, TN 

Warren Dunn, MD, MPH, Nashville, TN 

The purpose of this study is to assess the effectiveness of a nonoperative 

physical therapy program in treating atraumatic full 

thickness rotator cuff tears using a multi-center prospective cohort 

design. All patients with atraumatic full thickness tears and no 

other pathology were offered an opportunity to enroll in the study. 

Subjects completed a questionnaire collecting data on demographics, 

symptom characteristics, co-morbidities and patient related outcomes 

(SF-12, ASES, WORC, SANE score, Marks Activity Scale). Physicians 

recorded physical examination and imaging data. Patients began a 

a systematic review-based physical therapy program and returned at 

six and 12 weeks. At those visits patients could chose one of three 

outcomes: 1) cured (no formal follow up scheduled), 2) improved 

(continue therapy with scheduled reassessment in six weeks) or 3) 

no better (arthroscopic rotator cuff repair scheduled). Patients were 

contacted by telephone at one and two years to determine if they 

had undergone surgery since their last visit. A Wilcoxon signed rank 

test with continuity correction was used to compare initial, six week 

and 12 week outcome scores. As of May 1, 2010, 396 patients were 

enrolled. Significant improvement at six and 12 weeks was seen for 

the ASES, WORC, SANE scores. Patients who decided to have surgery 

generally did so in the first six weeks of treatment. Overall, patients 

elected to undergo surgery less than 10% of the time. Non-operative 

treatment using this physical therapy protocol is effective for treating 

atraumatic full thickness rotator cuff tears in >90% of patients. 


Anatomical Evaluation of a Flip-button Type Device for 

Distal Biceps Tendon Repairs 

Douglas D Duncan, MD, Winchester, VA 

Gerard F Lancaster, MD, Grosse Pointe Park, MI 

Jefferey E Michaelson, MD, Novi, MI 

David C Markel, MD, Southfield, MI 

Stephen E Lemos, MD, PhD, Warren, MI 

The purpose of this study is to evaluate the proximity of a flip-button 

type device to the posterior interosseous nerve (PIN) during a oneincision 

technique repair of the distal biceps tendon using human 

cadaveric models. Ten cadaver elbows from six cadaver specimens 

were used. The biceps tendon was identified with an anterior 

incision, traced to its insertion and then transected at the insertion 

to represent a rupture. With the forearm supinated, a Beath pin was 

drilled at a 0° angle perpendicular to the table starting at the radial 

tuberosity. A dorsal incision was used to identify the PIN. The bicep 

tendon was repaired with the flip-button device, ensuring the device 

lay in line with the radial shaft. The closest point from the device to 

the PIN was then measured using digital calipers. The Beath pin was 

then drilled aimed 20° directly proximal toward the radiocapitellar 

joint (RCJ); then re-drilled at 30° aimed distal. Measurements were 

taken as described above. The data from each group were compared 

using students paired t-test. The average distance from the device to 

the PIN with the straight posterior insertion was 8.94 mm, 11.86 mm 

with 20° proximal and 0.55 mm with 30° distal angles. The average 

difference was -3 mm between the straight insertion and 20° proximal 

groups. The average distance was 8.4 mm between the straight and 

30° distal insertions. The distance between the flip-button and the 

PIN was significantly greater when inserting the device posterior 20° 

toward the RCJ than when utilizing the straight insertion technique 

705 

(p=0.0061). The difference was more statistically significant between 

the straight and distal insertions with a p

the fascial sling. Extra-fascial accessory innervation of teres minor 

begins on average 30 mm (range, 15-48 mm) medial to the muscle’s 

lateral insertion. Preliminary results of surgical decompression 

of the primary nerve to teres minor are encouraging. Two percent 

of 2,031 consecutive shoulder ultrasounds showed isolated teres 

minor atrophy. Compression of the primary nerve to teres minor 

may be exacerbated in patients with a separate fascial compartment 

surrounding the muscle. A fascial sling is the potential site of greatest 

compression and tethering of this nerve. Additional lateral extrafacial 

nerves to teres minor may be spared in cases of compression of 

the primary nerve. Teres minor syndrome, a previously unrecognized 

clinical entity, is described. 


Comparison of the Accuracy of 2-D and 3-D Imaging 

and Modeling of Radial Head Fractures 

David C Ring, MD, Boston, MA 

Thierry Guitton, MSc, Amsterdam, Netherlands 

Kim M Brouwer, MSC, Boston, MA 


This investigation tests the hypothesis that classification and 

characterization of fractures of the radial head is more accurate with 

3D than 2D computed tomography images and radiographs, using 

a prospective study design with intraoperative inspection as the 

reference standard. Treating surgeons and first assistants completed a 

questionnaire assigning a type according to the Broberg and Morrey 

modification of Mason’s classification, evaluating important fracture 

characteristics, and selecting preferred management four times: 

Initially based upon radiographs and 2D images alone, a second 

time based on radiographs, 2D and 3D-CT images, a third time on 

radiographs, 2D, 3D-CT and 3D physical models, and a final time 

after surgery based on intra-operative visualization of the fracture. 

The agreement between surgeon and first assistant as well as the 

sensitivity and specificity were calculated for 2D-CT and radiographs, 

3D-CT, and 3D physical models as compared to the intraoperative 

direct observation. The addition of 3D-CT reconstructions and 3D 

models to standard radiographs and 2D-CT scans improved the 

reliability of fracture classification according to the Broberg and 

Morrey modification of the Mason classification (kappa values, 

2DCT = 0.23, 3DCT = 0.26 and 3D model = 0.37; all p

and internal rotation were also similar between the two groups. 

Repairing or not repairing the subscapularis during reverse shoulder 

arthroplasty using the reverse shoulder prosthesis has no significant 

effect on complication or dislocation rate. Visual analog pain scale 

scores and gains in range of motion were also similar between the 

two groups. 


Biomechanical Comparison of Three Rotator Cuff 

Repair Constructs after Healing in an Animal Model 

Akash Gupta, BA 

Ryan Quigley, BS, Irvine, CA 

Joo Han Oh, MD, Seongnam, Gyeonggi-do, Republic of Korea 

Kyung-Chil Chung, MD, Irvine, CA 

Michelle H McGarry, MD, Long Beach, CA 

Ranjan Gupta, MD, Orange, CA 

James E Tibone, MD, Los Angeles, CA 

Thay Q Lee, PhD, Long Beach, CA 

Recent studies investigating rotator cuff repairs have shown that the 

double row (DR) and transosseous equivalent (TOE) techniques 

provide improved contact area and pressure between the rotator cuff 

tendon and footprint and improved biomechanical characteristics 

compared to single row (SR). The purpose of this study was to 

biomechanically compare the healing characteristics of SR, DR and 

TOE techniques using a chronic and retracted rabbit subscapularis 

rotator cuff tear model. We hypothesized that repair with TOE and 

DR will show improved biomechanical properties over SR after 

healing. Twenty-one New Zealand white rabbits were used for three 

repair groups: SR, DR and TOE. A two-stage surgical procedure 

was performed. The left subscapularis tendon was first transected 

and was allowed to retract to simulate a chronic rotator cuff tear. 

Following six weeks, rotator cuff tendon repair was then performed 

using either the SR, DR or TOE technique using microanchors. 

During both surgical procedures, the contralateral shoulder was 

used as a sham control. Rabbits were then permitted 12 weeks of 

healing, and then euthanized. Repaired and control humeri with 

attached subscapularis were then used to quantify biomechanical 

characteristics. Analysis of variance was used to compare groups 

with significance set at p

to type IIB and 57% to type IIC according to Morgan. The overall 

prevalence of pulley lesions was just under 3%. Type I biceps pulley 

lesions classified according to Habermeyer were present in 44%, 

type II in 34%, type III in 13% und type IV in 9%. Isolated SLAP 

without pulley lesions were present in 157 cases (86%), isolated 

pulley without SLAP lesions in 62 cases (71%), a coincident presence 

was evaluated in 25 cases (10%, p=0.003). A total of 65% of isolated 

biceps pulley lesions and 34% of isolated SLAP lesions were 

associated with preoperative shoulder-trauma. The typical trauma 

mechanism for both lesions was the fall on the arm. Some 32% of 

pulley lesion occured during fall on the flexed and internal rotated 

arm, while 13% of SLAP lesions occured during fall on the abducted 

and external rotated arm. A positive correlation of SLAP lesions and 

anterior shoulder instability (p=0.001) but a negative correlation 

of pulley lesions and shoulder instability (p=0.004) was seen. An 

association of glenohumeral chondral lesions with SLAP lesions 

(p0.05). There is no difference in biomechanical properties 

of biceps tenodesis with regard to screw length or diameter at both 

proximal and distal tenodesis locations. The results may serve as a 

guide to the orthopaedic surgeon performing proximal BT in selecting 

appropriate interference screw. When possible, we recommend using 

the smallest screw size available to minimize risk of stress fracture at 

tenodesis site. 


Chronic AC Dislocation: Arthroscopic Treatment With 

CC Ligament Autograft And Double-Button Fixation 

Yannick Roussanne, MD, Montpellier, France 

Olivier Gastaud, MD, Nice, France 

Nicholas Brassart, Cagnes Sur Mer, France 

Pascal Boileau,MD, Nice, France 

The purpose of this study was to evaluate the clinical and radiographic 

results after arthroscopic transfer of the coraco-acromial ligament 

(CAL) with an attached acromial osseous fragment into the clavicle 

for severe (Rockwood types III-V) acromio-clavicular dislocation 

(ACD). Twenty-two patients presenting with symptomatic and severe 

(Rockwood types III-V) ACD were treated with an all-arthroscopic 

reconstruction of their coraco-clavicular ligaments. The surgical 

technique consisted of transferring the acromio-clavicular ligament 

into a cavity burred into the distal clavicle, along with an attached 

osseous fragment cut from the anterior acromion (bone-tendonbone 

graft, Weaver-Dunn-Chuinard technique). A four-strand, 

non-absorbable suture, mounted on two titanium buttons (the 

‘double-button’) was used to retain the coraco-clavicular reduction 

and protect the transferred graft during its healing. The patients were 

followed prospectively with radiographs and CT scans, with a mean 

follow up of 19 months (9-36). Among these patients, six presented 

with a recurrent ACD after having been initially treated with an open 

coraco-clavicular pinning. One patient had a superficial infection 

that went on to heal with no sequelae. The mean Constant score 

was 86 points (65-100) at last follow up. All patients returned to 

work within six months of surgery and were very satisfied with the 

cosmetic result as well as with the resolution of their symptoms 

(pain, arm fatiguability and paresthesias). All patients also returned 

to their previous athletic activities, including contact and overhead 

sports. The arthroscopic transfer of the CAL is a reliable technique 

for the treatment of ACD of Rockwood types III-V. This technique 

even allows the successful revision of failed open acromio-clavicular 

stabilizations. Arthroscopy has a clear advantage in treating a 

pathology in which cosmetic concerns are among the reasons for 

which patients seek treatment. Transferring an osseous fragment 

along with the CAL allows the achievement of bone-to-bone 

healing. 





Natural History Of Untreated Rotator Cuff Tear: 

Radiological And Clinical Study 

Alessandro Ciompi, MD, Roma, RM Italy 

Angelo De Carli, MD, Rome, Italy 

Antonio Vadala, MD, Rome, Italy 

Carlo Iorio, MD 

Andrea Ferretti, Rome, Italy 

The natural history of rotator cuff tears is not widely known. 

The aim of this study is to analyze the clinical and radiological 

evolution of conservative treatment of rotator cuff tears. Thirtyeight 

patients conservatively treated after a diagnosis of rotator cuff 

tear documented by MRI (T0-MRI) were enrolled in this study. At 

T0 there were 19 full-thickness tears (group C), 12 partial-articular 

(group A) and seven partial-bursal (group B) cuff tears. All patients 

underwent a new MRI (T1), clinical examination and scoring scales 

at follow up. The mean follow up was 62 months. Classifying all 

patients depending on the T0-MRI diagnosis (group A, B or C), we 

found a significant trend toward a complete tear in six cases (85.7%) 

(p


Pitfalls of Overstuffing in Radial Head Arthroplasty, A 

Cadaveric Study 

Prasad J Sawardeker, MD, Miami, FL 

Check C Kam, MD, Miami, FL 

Winston Elliott, Miami, FL 

Edward L Milne, Miami Beach, FL 


Elizabeth A Ouellette, MD, North Miami Beach, FL 

Successful results following radial head arthroplasty can be 

significantly impaired if the implant is incorrectly sized. We examine 

the effects of alteration of axial length of the radial head prosthesis 

and force conveyed at the radiocapitellar joint. Seven fresh-frozen 

cadaveric arms were utilized. Radial heads were resected and a 

monopolar, metal radial head prosthesis was implanted. Adjustments 

of radial head length were made in 2 mm increments to create an 

understuffed (-2), neutral (0) and overstuffed (+2, +4) effect. Forearms 

were cyclically loaded with the forearm in neutral, in 60 degrees of 

pronation, and in 60 degrees of supination. Radiocapitellar forces 

were measured using Tekscan sensors with radial head length set at 

-2 mm, 0, +2 mm and +4 mm and comparisons were made with the 

neutral (0) radial head. Radiocapitellar forces with the forearm in 

neutral in arms that were understuffed (-2), neutral (0), overstuffed 

(+2, +4) were 24.07 +/- 9.65N, 30.21 +/- 9.63N, 37.45 +/- 13.09N, 

46.47 +/- 9.25N. There was a stepwise increase in force transmitted 

with progressive radial head lengthening. Radiocapitellar forces 

were essentially 1.5 times greater with radial head overstuffing (+4) 

compared to neutral (0). Radiocapitellar forces were significantly 

elevated in forearms that were pronated in comparison to forearms 

in neutral and in supination for each adjusted radial head length. 

Replicating axial length of native radial heads plays a critical role in 

restoring native radiocapitellar forces and may effectively reduce wear, 

early arthritis and implant loosening after radial head arthroplasty. 


Interfragmentary Suture Fixation for Displaced Acute 

Type II Distal Clavilce Fractures 

Xavier A Duralde, MD, Atlanta, GA 

Scott Pennington, MD, Atlanta, GA 

Douglas H Murray, MD, Atlanta, GA 

Open reduction/internal fixation (ORIF) of Type II distal clavicle 

fractures remains a challenge because of distal comminution and the 

significant deforming forces created by the weight of the shoulder 

girdle. Current fixation options struggle with distal fixation and 

often require violation of the acromioclavicular (AC) joint or the 

subacromial space. We hypothesize that a suture technique utilizing 

coracoclavicular fixation to neutralize the deforming force of the 

shoulder girdle along with interfragmentary suture fixation leads to a 

high degree of fracture union. We retrospectively reviewed the results 

of 19 consecutive patients who presented to our clinic between 

1998 and 2010 with displaced acute type II distal clavicle fractures 

treated with suture technique. Patient age ranged between 24 and 

76 (mean 44.5), with 14 men and five women. Eleven of 19 patients 

had comminution of the distal fragment. All patients were treated 

with a uniform surgical technique, consisting of circumferential 

coracoclavicular fixation and interfragmentary suture fixation of 

the distal fracture fragment(s). All patients were kept in a sling 

for six weeks, followed by protected active range of motion. Mean 

time between injury and surgery was 9.8 days (3 -21) and mean 

radiographic and clinical follow up was 259 days. All patients went 

on to bony union. There were no cases of significant loss of reduction 

710 

or malunion. No patients developed significant stiffness or loss of 

function. There were no complications requiring reoperation and 

no patients developed acromioclavicular arthrosis or impingement. 

Suture fixation for ORIF of Type II distal clavicle fractures is a safe 

and effective technique that obtains secure reduction and fixation 

with reliable results. It obviates the need for hardware removal and 

avoids violation and injury to the AC joint and subacromial space. 


The Influence of Arm and Shoulder Position on The 

Belly-Press, Lift-Off and Bear-Hug Tests 

Andrew T Pennock, MD, San Diego, CA 

W Wesley Pennington, MS 

Michael Torry, PHD, Normal, IL 

Michael Decker, Vail, CO 

Suketu B Vaishnav, MD, San Francisco, CA 

Matthew T Provencher, MD, San Diego, CA 

Peter J Millett, MD, MSc, Vail, CO 

Thomas R Hackett, MD, Vail, CO 

Testing the integrity of the subscapularis includes the belly-press, 

lift-off and bear-hug evaluations. While these tests have been widely 

applied to clinical practice, there is considerable variation in the arm 

positioning within each clinical exam. The purpose of this study 

was to determine the ideal arm and shoulder positions for isolating 

the subscapularis muscle while performing each examination. 

The activity of seven muscles (upper and lower subscapularis, 

suprapsinatus, latissimus dorsi, teres major, triceps, pectoralis major) 

was monitored in 20 healthy subjects. EMG data was collected and 

compared across each exam at varying arm positions: bear-hug (ideal 

position, 10° superior, 10° inferior to the shoulder line), belly-press 

(ideal position, maximum external rotation and maximal internal 

rotation) and lift-off (ideal position, 5° superior, 5° inferior to the 

midlumbar spine). Regardless of arm and shoulder position, the 

upper and lower subscapularis muscle activities were significantly 

greater than all other muscles while performing each exam (p

(HHA) and partial resurfacing arthroplasty (PRA). Seven cadaveric 

upper extremities were tested on an active shoulder simulator. 

The protocol involved testing the intact specimen, Bankart lesion 

and repair and two Hill-Sachs (H-S) lesions (30%,45%) with the 

remplissage, HHA and PRA. Survivability of the construct (extension 

to engagement) and range-of-motion (ROM) were measured. All 

unrepaired H-S lesions engaged during abduction and external 

rotation. No remplissage or HHA specimens engaged. With PRA, 

three of seven and five of seven specimens partially engaged in 

30% and 45% H-S lesions, respectively. In adduction, the 30% 

H-S remplissage significantly reduced mean ROM 19.7°±8.3° 

(p=0.017), while the HAA and PRA did not (p=1.0). The 45% H-S 

remplissage reduced ROM a mean of 22.3°±14.0 (p=0.12) without 

significance, while the HHA (p=0.58) and PRA (p=1.0) did not. In 

abduction, the 30% H-S remplissage (p=0.25), HHA (p=0.5) and 

PRA (p=1.0) demonstrated no significant reduction in ROM. The 

45%H-S remplissage reduced motion without significance a mean 

of 27.6°±20.9° (p=0.28) and the HHA significantly reduced ROM a 

mean of 14.0°±4.7° (p=0.004). The PRA demonstrated no significant 

reduction in ROM (p=1.0). The remplissage, HHA and PRA all 

enhanced shoulder stability. In the PRA group, partial engagement 

into the remaining bone defect was identified. The remplissage and 

HHA consistently eliminated engagement, however, the remplissage 

did so at the expense of motion. 


Contralateral Elbow Radiographs can Reliably 

Diagnose Radial Head Implant Over-Lengthening 


Dominique Rouleau, MD, Montreal, QC Canada 



Radial head implant over-lengthening, a common cause of capitellar 

wear and clinical failure, is difficult to diagnose using radiographs of 

the injured elbow. The purpose of this study was to determine if a novel 

measurement technique based on contralateral elbow radiographs 

could be used to accurately estimate the magnitude of radial head 

implant over-lengthening. Part I of this study examined the sideto-side 

consistency of this radiographic measurement technique. 

Part II of this study validated the technique using a simulated overlengthening 

cadaveric model. Part I: A side-to-side comparison of the 

radiographic measurement technique was performed in 50 patients 

(100 radiographs). Part II: Radial head prostheses of varying lengths 

(0, +2 mm, +4 mm, +6 mm, +8 mm) were implanted in four paired 

cadaveric specimens. Radiographs were obtained and measurements 

were performed by two examiners blinded to implant size to 

determine if contralateral radiographs can provide a valid estimate 

of the magnitude of implant over-lengthening. Intra and inter-rater 

reliability was determined. No significant side-to-side differences 

(p0.90). 

The inter-rater agreement between two separate surgeons was also 

excellent, with the 95% lower confidence interval exceeding 0.90 

in all cases. A novel measurement technique based on contralateral 

elbow radiographs can be used to reliably calculate the magnitude of 

radial head implant over-lengthening. 

711 


Scapular Notching In The Primary Reverse Total 

Shoulder Arthroplasty 

Adam Warren, MD, San Francisco, CA 

James D Kelly, II MD, San Francisco, CA 

Reverse total shoulder arthroplasty using the Grammont style of 

prosthesis is associated with the development of scapular notching. 

Caudal positioning is purported to reduce the incidence of notching. 

We developed and published a technique, the 12 mm rule, to assist 

in maximal caudal placement of the glenoid component. The 

purpose of this retrospective study is to evaluate the incidence of 

radiographic notching among patients undergoing this surgery with 

this technique. Forty-five consecutive Grammont style shoulder 

glenoid components were placed in a maximally inferior position 

using the 12 mm rule. The surgery was performed by a single 

surgeon (JK) at a single institution. Notching was evaluated by plain 

radiographs. They were obtained postoperatively at week one, six, 

12, 26, 52 and then yearly thereafter. Patients with minimum twoyear 

follow up were selected for this analysis. Twenty-six of 45 (58%) 

shoulders developed scapular notching. Eleven of 26 were grade I, 

eight of 26 were grade II and seven of 26 were grade III. All patients 

showed improved function by Constant and ASES score. There was 

no difference between the patients with and without notching. 

Maximal inferior placement of the glenoid component utilizing the 

12 mm rule does not prevent scapular notching. However, use of 

this technique has no observable adverse consequences and results 

in reproducible good and excellent results. Notching rates using this 

technique are similar to previously published studies. The presence 

of notching in a patient with a caudally placed glenosphere has no 

observable negative predictive value. 


Distraction Arthoplasty of the elbow in younger 

patients with Rheumatoid Arthritis 

Kimberly Carney Young, MD, Ithaca, NY 


Disabling elbow arthritis in the young active rheumatoid patient 

presents a surgical challenge due to high functional demand with 

implant TER demonstrating high rates of catastrophic failure. Using 

disease-modifying antirheumatic drug (DMARD) medications, 

fewer joints are often afflicted. Because the adjacent joints are more 

functional, use and weight (lifting) restrictions recommended 

with implant TER are less likely to be followed. This leads often to 

implant failure with loosening, osteolysis and extremely challenging 

revision surgery. This study reports the outcome of interposition 

arthroplasty of the rheumatoid elbow offered as an alternative in 

this select group of patients. Between 1994-2009, 14 patients (15 

elbows) with rheumatoid arthritis (RA), average age of 46 years (30- 

64) were treated with complete synovectomy, interposition using 

Achilles tendon allograft and hinged fixation. The medial cruciate 

ligament and lateral ulnar collateral ligament were protected during 

surgery. Pain (VAS), ROM and DASH scores were recorded, before 

and after surgery. Patients were not restricted from any particular 

activity or lifting weight limit. No patients were lost to follow up; 

with a mean follow up of 5.0 years (one-16). No patient required or 

requested conversion to TER. All patients reported relief from pain, 

average pre-op pain (scale 0-10) was 6.0 at rest and 8.0 with activity 

and post operatively decreased to 0 at rest and 0.5 with activity. The 

average total range of motion improved from 70 degrees pre-op to 

105 degrees post-op. DASH score improved from 44.2 (25-63.5) 

pre-op to 13.9 (0.8-43.4) post-op. No patients had a worse DASH 

score. Post operative radiographs did not show bony resorption or 




loss of joint space. No patient reported or demonstrated instability. 

There were three complications: hematoma (one), pin track 

infection (two). Interposition arthroplasty in selected patients with 

rheumatoid arthritis may offer durable, reliable pain relief and 

improved functional use. This cohort of patients was able to return 

to many activities not generally recommended after implant TER. 

The option for conversion to primary TER is still available at a later 

time, if needed. 


A Predictive Model of Shoulder Instability After a First- 

Time Anterior Shoulder Dislocation 


Lori A. Orlando, MD 

Drew Henderson, MSIV, Durham, NC 

J. Todd R. Lawrence, MD, Wynnewood, PA 

Dean C Taylor, COL, MD, Durham, NC 

Management of a first-time anterior shoulder dislocation (FTASD) 

involves important clinical and policy decisions. Predictive disease 

modeling can improve the quality of information disseminated in 

treatment discussions. In this paper, we describe a general purpose, 

publicly available model and illustrate its potential as a tool for 

management of a FTASD. A Markov decision model of the natural 

history of a FTASD was constructed. Outcome probabilities and 

effectiveness were derived from the literature or estimated by expert 

opinion where necessary. Outcomes were the Western Ontario 

Shoulder Instability index (WOSI) and the probability of a patient 

experiencing recurrent instability, undergoing surgical stabilization 

and having a stable shoulder at 10 years. The model was both 

internally and externally validated. Specific outcomes were examined 

for specific cases. The model was effectively externally validated 

against two studies, a Swedish prospective cohort of Hovelius et al 

and Botonni et al.’s military cohort. It can produce detailed outcome 

predictions for individuals; for example, an 18-year-old man has a 

77% risk of dislocation in year one and a 32% chance of having a 

stable shoulder in 10 years. Detailed and specific information about 

prognosis is critical in the management of a FTASD. Disease modeling 

lends itself well to these needs and allows improved shared decisionmaking. 

Our model was externally validated and can predict specific 

outcomes. As a publically available resource, it will allow physicians 

to accurately predict the expected outcome of a procedure based on 

patient demographics and their own surgical success rates. 


Cell Viability in Human Rotator Cuff Explants 


Connor Raymond LaRose, MD, Durham, NC 

Farshid Guilak, PhD, Durham, NC 

Claude T Moorman III, MD, Durham, NC 

Alison P Toth, MD, Durham, NC 

Human rotator cuff tendon can have poor healing potential after 

surgical repair, but the cell viability of rotator cuff tendons has 

not been determined. We aimed to characterize the cell viability 

of rotator cuff tendons and their pathologic states. We performed 

a live-dead assay (Invitrogen Molecular Probes) using a confocal 

laser scanning microscope on 20 human rotator cuff explants (two 

normal). We recorded age, sex and body mass index in addition to 

the following tear characteristics: size, full or partial thickness, tissue 

quality, retraction, location and presence of other pathology. Five 

locations were examined: the medial, lateral, anterior and posterior 

edges and the midsubstance. Cell viability was assessed as minimal, 

moderate and maximum live cells. No difference in cell viability was 

712 

observed between the different tear types. Areas of cell death were 

observed in all tendons. High cell viability was seen in both full 

thickness and partial tears. The medial edge of the tendons showed 

demonstrated minimal increase in tenocyte viability compared to 

the lateral edge. The normal control tendons showed the largest 

numbers of live cells. This study describes a novel evaluation of 

human rotator cuff tendon. We found consistent cell death in all 

tendons, with acute and chronic tears both exhibiting areas of high 

cell death and viability. Debridement of 3-5 mm of tendon from 

the lateral edge does not consistently increase the number of live 

tenocytes at the repair. Diminished cell viability may explain the 

overall poor healing rates of rotator cuff tears, but cannot explain 

differences between tear types. 


Functional Outcome of Radial Head Fractures Managed 

with Open Reduction and Internal Fixation 

Jeffrey Pike, MD, Vancouver, BC Canada 





Limited information is available regarding the functional outcomes 

of radial head fractures managed with open reduction and internal 

fixation (ORIF). Fifty-two patients, with a mean age of 44±12 years, 

who were treated with radial head ORIF were evaluated at a mean of 

4.4±2.4 years. Thirty were isolated radial head fractures (Group A), 

13 (Group B) were associated with a complex fracture-dislocation 

(terrible triad variants), and five (Group C) were associated with a 

proximal ulnar fracture (Monteggia/trans-olecranon variants). Fourtyfour 

were partial articular fractures and eight were complete articular 

fractures. Outcomes were assessed with physical and radiographic 

examination, and validated self-reported questionnaires. The 

average PREE score (Patient Rated Elbow Evaluation) for Groups 

A, B and C were 7.6±13.1, 12.3±13.4 and 10±8.5, respectively. The 

average MEPI (Mayo Elbow Performance Score) for Groups A, B and 

C were 89±13, 85±11 and 91±8, respectively. For Groups A, B and C 

respectively, the prevalence of radiographic radiocapitellar arthritis 

was 30%, 46% and 20%. The average flexion/extension arc for 

Groups A, B and C were seven to 132°, six to 134° and 10 to 132° 

respectively. Secondary surgery was performed in 17% of cases, most 

commonly for decreased motion. Three comminuted fractures failed 

ORIF and required conversion to radial head arthroplasty. Patients 

with radial head fractures, including those associated with complex 

fracture-dislocations, can achieve excellent functional outcomes with 

low self reported pain and disability when treated with ORIF, despite 

radiographic evidence of mild post-traumatic arthritis. 


Hemiarthroplasty (HHR) For Fracture-Dislocation Of 

The Proximal Humerus Yields Poor Results 

Mike Greiwe, MD, Edgewood, KY 

Elizabeth Cody, BS, New York, NY 

Comron Saifi, BS, New York, NY 

Christopher S Ahmad, MD, New York, NY 

Louis U Bigliani, MD, New York, NY 

William N Levine, MD, New York, NY 

Hemiarthroplasty (HHR) for the management of four-part fractures 

is reliable for pain relief and patient satisfaction, but post-operative 

motion remains unpredictable. The purpose of this study was to 

investigate what effect concurrent dislocation has on post-operative 




outcomes following HHR for four-part proximal humerus fracturedislocations. 

From January 2001 through January 2009, all patients 

who received HHR for the acute treatment of Neer four-part proximal 

humeral fracture-dislocations were retrospectively reviewed. Twelve 

of 14 patients were available for clinical follow up at an average 

of 35 months (range 12-61). Clinical outcomes (ASES, SST and a 

self-assessment ROM evaluation) and post-op radiographs were 

used for evaluation. Clinical: There was a 25% incidence of nerve 

injury. A bimodal distribution of range of motion was identified in 

the fracture-dislocation group. Seven patients had >130° of forward 

elevation (FE) (average 158°±15°). Five patients had poor FE

SCIENTIFIC EXHBITS 


Rotator Cuff Tear Arthropathy: Evaluation, Diagnosis 

and Treatment 

Denis Nam, MD, New York, NY 

Travis G Maak, MD, New York, NY 

Bradley Raphael, MD, Santa Monica, CA 



A common cause of shoulder arthritis is cuff tear arthropathy (CTA). 

Rotator cuff pathology can alter the biomechanical properties of the 

glenohumeral joint resulting in uneven wear. Nevertheless, only a 

small percentage of these patients will develop a massive tear causing 

enough destabilization to develop CTA. Many hypotheses have been 

postulated, but the etiology has been an area of speculation. Despite 

detailed understanding of the underlying pathology, controversy 

exists regarding the treatment protocol for these patients. Total 

shoulder arthroplasty (TSA) or hemiarthroplasty have reliable 

improvement in pain levels, function, and patient satisfaction. 

However, a high rate of glenoid loosening after TSA in these patients 

remains a concern. This concern has stimulated a recent trend toward 

exploring reverse or constrained total shoulder arthroplasty in these 

patients. This exhibit reviews the clinical and diagnostic approach 

to patients with CTA. A literature review describes the extent of 

the problem as well as controversies regarding a patient with CTA. 

History, physical examination, anatomic considerations, imaging, 

classification systems, and treatment options are outlined. Surgical 

techniques and indications are discussed with an emphasis on 

relevant biomechanical advantages and risks related to conventional 

and reverse TSA in the setting of CTA. An algorithmic approach 

based on the patient’s medical condition, functional goals, deltoid 

musculature, cuff and CA arch integrity is provided. Intraoperative 

photographs and diagrammatic representations assist in clearly 

delineating treatment options based on specific clinical scenarios. 

This approach aids in the selection of an appropriate technique 

aimed at improving patient outcome. 


Arthroscopic Management of Lateral Epicondylitis: 

Technique and Outcomes 

Duretti Fufa, MD, New York, NY 

Haydee C. Brown, MD, New York, NY 


Alison Kitay, MD, New York, NY 

Moira Margaret McCarthy, MD, New York, NY 

Lauren Elizabeth Lamont, MD, New York, NY 

Alexia Hernandez-Soria, MD, New York, NY 

John Dougald MacGillivray, MD, New York, NY 


Lateral epicondylitis, or tennis elbow, is a common diagnosis 

treated by internists, general orthopaedists as well as hand, sports 

medicine and shoulder/elbow specialists. It is reported to affect 

1-3% of adults annually. While in most cases, the process is selflimiting 

and can be treated with conservative measures, in a subset 

of cases, it will be recurrent and/or recalcitrant and require surgical 

intervention. Traditionally, an open debridement is performed 

in this case. Recently, with increasing use of and indications for 

elbow arthroscopy, arthroscopic debridement has emerged as 

an alternative to open debridement. This scientific exhibit will 

714 

focus on indications for and techniques involved in arthroscopic 

management of lateral epicondylitis. We will specifically focus on: 

(1) the anatomic considerations of the extensor carpi radialis brevis 

(ECRB) origin and maintenance of elbow stability, (2) arthroscopic 

techniques employed by the lead authors of the exhibit (R.S.H and 

J.D.M) and (3) evidence both from the literature and our institutions 

experience comparing open and arthroscopic management of lateral 

epicondylitis. Surgical techniques will be demonstrated through 

intraoperative photographs and video and correlated with diagrams 

of pertinent anatomy. Common complications of arthroscopic 

treatment as well as surgical pearls for avoiding these complications 

will also be discussed. The literature suggests that the results of 

arthroscopic debridement are comparable to open debridement. The 

evidence is mixed, however, and few studies directly comparing open 

and arthroscopic management exist. We will systematically review 

and summarize the available literature as well as the experience at our 

institution. In particular, we will focus on rates of complication, early 

relief of symptoms, return to work and recurrence. The goal of this 

scientific exhibit is to review the role of arthroscopic management of 

lateral epicondylitis. In doing so, we will describe and demonstrate 

surgical techniques for this procedure and provide a review of the 

current literature to support its use. 


Can We Improve the Reliability of the Constant-Murley 

Score? 


Michele Scelsi, MD, Torino, Italy 

Alessandra Tellini, MD, Alpignano-Turin, Italy 


Enrico Bellato, MD, Torino, Italy 

Eleonora Marini, MD, Torino, Italy 


The Constant-Murley (CS), ASES and Oxford scores are widely used 

tools for outcomes evaluation in shoulder surgery. Several studies 

investigated their reliability. However the reliability is usually express 

in coefficients not easy to interpret and tested in healthy volunteers. 

The first aim of this scientific exhibit is to show the real reliability 

of the three scores testing the reliability in patients with shoulder 

disfunctions . The second aim is to test the hypothesis that the 

reliability of the CS can be improved when the score is administered 

using a severe protocol (Standardized Constant-Murley score, S-CS). 

Using a video we will also show how to improve the reliability of the 

Constant Score. The scores were administered by two orthopaedic 

surgeons, with different level of expertes in using the CS, to fiftyfive 

patients. The same patients were evaluated one to four weeks 

later by the same two observers. The data were elaborated using the 

Bland and Altman method. After the evaluation of the errors the 

S-CS score was formulated and than tested. The CS showed the worst 

intra rater (error: 4±21points) and inter rater reliability (error: 4±24 

points), compare to the Oxford and ASES scores that were more 

stable overtime. The use of the S-CS showed a better inter-rater and 

intra-rater reliability compared to the CS. The use of high quality 

scores is mandatory in the era of the evidence based medicine. The 

S-CS showed benefits compared to the CS, ASES and Oxford score. 





Salvage of Failed Shoulder Instability with 

Osteochondral Allografts 

Jack Gerard Skendzel, MD, Ann Arbor, MI 

Jon K Sekiya, MD, Ann Arbor, MI 

Recurrent shoulder instability can be due to multiple factors, 

including technical errors, failure to recognize associated injuries, 

glenoid bone loss and Hill-Sachs lesions. Numerous surgical 

techniques for the treatment of failed shoulder stabilizations have 

been described, however, in certain patients a sizeable glenoid 

or humeral head osteochondral defect exists that requires novel 

reconstruction methods. Non-anatomic procedures are associated 

with significant risks, including advanced arthritis, persistent 

instability, and difficult revision surgery. This exhibit reviews 

the biomechanics, clinical outcomes, and surgical technique 

of osteochondral allograft reconstruction for failed shoulder 

stabilizations due to large humeral head and glenoid osteochondral 

defects. We will review the pathoanatomy of these osteochondral 

defects in failed shoulder surgery. The indications for osteochondral 

allograft use are discussed, including a “critical limit” of glenoid 

and humeral head bone loss. The current literature and our own 

case-series reporting clinical outcomes of osteochondral allografts 

will be reviewed. The surgical technique will be detailed with video 

illustration highlighting important steps including pre-operative 

planning and defect evaluation with CT scans. In addition, the 

surgical approach with exposure of the defect and the fashioning of 

an appropriate osteochondral graft for implantation will be shown. 

Patients with recurrent instability and significant glenoid or humeral 

head bone loss may not be adequately treated by standard surgical 

techniques, possibly leading to further bone loss and lengthening of 

capsular structures. We believe the benefits of osteochondral allograft 

reconstruction are its ability to re-create normal shoulder anatomy 

and lessen the risk of recurrent instability through restoration of 

normal biomechanical function. 


The Human Gun: Management of the Biceps from Stem 

to Stern 

Paul Shupe, MD, San Diego, CA 

Lucas McDonald, MD, San Diego, CA 

Christopher B Dewing, MD, San Diego, CA 


Injury to the biceps muscle-tendon unit encompasses a variety of 

pathology from the shoulder to the elbow coinciding with the origin 

and insertion of this muscle. From the low demand weekend warrior 

to the high demand laborer/competitive athlete, biceps injuries 

occur in a large and diverse group of patients. As such, there are a 

variety of important disorders of the biceps that must be recognized 

and evaluated in order to optimize patient care. The purposes of 

this scientific exhibit are to identify injuries of the biceps from stem 

to stern from the shoulder to the elbow, review patient history and 

common presenting complaints, the physical examination, describe 

associated conditions, and outline treatment options. This exhibit 

will review the spectrum of injury to the biceps from proximal to 

distal, starting first with the shoulder to include: SLAP tears, long 

head biceps tendonopathy, biceps tendon instability or rupture, 

and concluding at the elbow with partial and distal biceps tendon 

ruptures. Through the use of audiovisual aids, including video, we 

will present the characteristic findings on history, physical, and 

imaging of a patient with biceps pathology. Using MRI studies, 

arthroscopic images, and cadaveric photographs, we will review 

normal and abnormal biceps anatomy. After a review of our own 

715 

clinical data and a systematic review of the current literature, we will 

discuss a logical approach to comprehensive management of these 

patients with appropriate images and video (biceps tenotomy, open 

subpectoral biceps tenodesis, SLAP debridement, SLAP repair, distal 

biceps tendon repair). We will also outline the pearls and pitfalls 

associated with these techniques, including postoperative pain, 

stiffness, and neurovascular compromise. The expected outcomes for 

patients with biceps pathology have been promising. These results 

nonetheless indicate the selection of the ideal intervention for each 

patient must be individualized to meet their functional need. 


Surgical Approach for Elbow Hemiarthroplasty: 

Advantges and Limits 

Enrico Guerra, MD, Bologna, Italy 

Roberto Rotini, MD, Bologna, Italy 

Enrico Guerra, MD, Bologna, Italy 

Alessandro Marinelli, MD, Casalecchio Di Reno, Italy 

Graziano Bettelli, MD, Bologna, Italy 

Marco Nigrisoli, MD, Bologna, Italy 

Distal humerus fractures are increasingly frequent in patients older 

than sixty. Open reduction and internal fixation is always the first 

treatment option, but it must have sufficient stability to allow 

early range of motion. Even if Total Elbow Arthroplasty (TEA) is 

a well accepted indication in elderly patients with comminuted 

intrarticular fractures, the complications mostly in the ulnar 

component of the implant are not uncommon (loosening, 

periprosthetic fracture, infection). Distal Humeral Hemiarthroplasty 

(DHH) is a new treatment option for unreconstructable combined 

capitellar and lateral trochlear fractures, with or without medial 

trochlear involvement. Even if the existing follow-up of is too short 

to confirm real advantages compared to TEA, the Distal Humeral 

Hemiarthroplasty should have expanded indications, including 

also adults patients, and should show lower complications, as 

infection and loosening. DHH requires specific prosthetic design, 

both medial and lateral columns intact or reconstructed, intact or 

stable reconstructed radial head and coronoid process and intact 

or reparable MCL and LCL. The correct approach can make the 

difference between success or failure Four emblematic case of distal 

humerus fracture, chosen for different surgery approach: Triceps 

on, TRAP, Olecranon Osteotomy, and Triceps Splitting.The approch 

was choosen depending on the tipe of the fracture. There were all 

man with the dominant upper limb affected. Each patient has been 

followed for at least 2 ys (min 2, max 3,5). Mepi score, exstension/ 

flexion strenth and elbow stability has been measured at different 

time after surgery. All patiens had Mepi score 95 at the end. Triceps 

on and Olecranon osteotomy had faster and more complete recovery 

of extension strenth compared to the other limb. Triceps on had a 

mild elbow unstability at follow up DHH is a performing procedure. 

To decide the correct orientation and length of the implant the 

surgeon needs broad exposure, but on the other side has to respect 

or rebuild collateral ligament validity. Nowadays four approach are 

described for DHH: Triceps on: no triceps deficiency but extremely 

aggressive on collateral ligament with minor intraoperative vision 

TRAP (Triceps Reflecting Anconeus Pedicle): sovra/intercondilar 

fractures violates bony lateral and/or medial column, by the fracture 

rime the implant is possible and this approach allow internal fixation 

at the end, respecting ligament attached to the fractured condoles. 

Olecranon Osteotomy: great vision respecting ligament and triceps 

insertion but technically demanding and concerning for possible 

olecranon non-union Triceps Splitting: A little less aggressive on 

triceps insertion than trap approach, but let an easier and more 

functional ligament reconstruction. The Authors report a complete 




leterature rewiew and their experience with all of these differente 

approaches considering advantages and disadvantages found out 

during surgery. They propose an algorithm to help the surgeon to 

choose the correct approach in this difficult procedure 


Massive Rotator Cuff Tears: An Algorithmic Approach 

To Treatment 

Shane Nho, MD, Chicago, IL 

Demetris Delos, MD, New York, NY 


Michael B Cross, MD, New York, NY 


Massive rotator cuff tears pose a significant clinical challenge and 

are associated with less predictable results as well as poorer clinical 

outcomes compared to smaller rotator cuff tears. In order to optimize 

outcomes, a thorough comprehension of these types of tears and their 

diagnosis is necessary, along with an understanding of the advanced 

surgical techniques often required to treat them. This exhibit will 

review the characteristic changes in biology and biomechanics 

associated with massive rotator cuff tears and demonstrate an 

appropriate patient evaluation. Determining whether a tear is 

repairable is critical and will be emphasized. Tears that are repairable 

will often require advanced soft-tissue releases and fixation methods, 

including double-row and transosseous-equivalent suture bridges. 

Irreparable tears may be addressed with palliative surgical treatment, 

salvage treatment utilizing tendon transfers, or shoulder arthroplasty, 

including Cuff Tear Arthropathy (CTA) prosthesis for joints that are 

diseased or reverse total shoulder replacement.Diagrams and figures 

demonstrating the various surgical techniques as well as shoulder 

arthroplasty models will be available. An algorithm for treatment 

will be presented. This exhibit will introduce the viewer to an 

algorithmic approach for diagnosing and categorizing massive cuff 

tears, as well as the various treatment modalities available which will 

enhance understanding of a complex topic. Massive rotator cuff tears 

are a significant clinical challenge but outcomes may be improved 

with enhanced understanding and appropriate treatment. 

716 




PAPERS 

pApeR No. 016 

Efficacy of Multi-Level ACDF Versus ACCF for Multi- 

Level Cervical Spondylotic Myelopathy 

Kwang-Bok Lee, MD, Jeonju, Chonbuk, Republic of Korea 

Kyung Jin Song, MD, Jeonju, Jeonbuk, Republic of Korea 

Cyrus Emil Taghavi, MD, Sacramento, CA 

Ji-Hoon Song, MD, Suncheon-Si, Jorye Dong, Republic of Korea 

Hoon Park, MD 

The optimal surgical option for multilevel cervical spondylotic 

myelopathy (CSM) remains controversial. In addition, few 

comparative studies have been conducted on anterior cervical 

discectomy and fusion (ACDF) and corpectomy and fusion (ACCF) 

for multilevel CSM. The purpose of this study is to evaluate the 

efficacy of ACDF versus ACCF for multilevel CSM. A total of 40 

patients who underwent multilevel ACDF or ACCF suffering from 

CSM into two groups; Group A (n=25) underwent ACDF; Group B 

(n=15) underwent ACCF. Clinical outcomes (Japanese Orthopedic 

Association (JOA) score, visual analogue score (VAS)), perioperative 

parameters (hospital stays, blood loss, operation times), radiological 

parameters (fusion rate, segmental height, cervical lordosis) and 

complications were compared. There was no significant difference 

between group A and B in JOA score and VAS. There are significant 

differences between groups in hospital stay (p=0.031), blood 

loss (p=0.001) and operation time (p=0.024). Both group A 

and B showed a significant increase in the cervical lordosis after 

operation and reached satisfactory fusion rates (88.0% and 93.3%, 

respectively). There is no significant difference in the incidence of 

complications between groups. Both multilevel ACDF and ACCF 

provide good clinical results and a similar fusion rate for CSM. 

However, multilevel ACDF results in better radiologic parameters, 

shorter hospital stays, smaller blood loss and a shorter operation 

time than ACCF. Therefore, multilevel discectomy and fusion will 

become a good alternative for corpectomy and fusion in patients 

with multilevel CSM. 

pApeR No. 017 

Do Stand-Alone Spacers with Integrated Screws 

Provide Stability in Multi-level Cervical Arthrodesis? 

Haines Paik, MD, Fairfax, VA 

Mario J Cardoso, MD, Chicago, IL 

Anton E Dmitriev, Washington, DC 

Ronald Arthur Lehman, MD, Potomac, MD 

Rachel E Gaume, BS 

Divya Ambati, A, Fairfax, VA 

Michael Rosner, MD, Washington, DC 

Postoperative complications after anterior cervical fusions have 

been attributed to anterior cervical plate profiles and necessary wide 

operative exposure for insertion. Consequently, low-profile standalone 

interbody spacers with integrated screws have been developed. 

While they have demonstrated similar biomechanical stability to the 

anterior plate in single-level fusions, their role as stand-alone devices 

in multilevel reconstructions has not yet been established. Thirteen 

human cadaveric cervical spines (C2-T1) were non-destructively 

tested with a custom six-degree-of-freedom spine simulator under 

717 

sPine 

axial rotation (AR), flexion-extension (FE) and lateral bending 

(LB) loading. After intact analysis, eight single-levels (C4-5 & C6- 

7) from four specimens were instrumented and tested with: 1) 

anterior cervical plate (ACP) and 2) stand-alone spacer (SAS). Nine 

specimens were tested with: 1) C5-7 SAS, 2) C5-7 ACP, 3) C4-7 ACP, 

4) C4-7 ACP & posterior fixation, 5) C4-7 SAS and 6) C4-7 SAS & 

posterior fixation. Full range of motion (ROM) data was obtained 

and analyzed by loading modality utilizing mean comparisons with 

repeated measures analysis of variance. Paired t-tests were used for 

post-hoc analysis with Sidak’s correction for multiple comparisons. 

No significant difference in ROM was noted between ACP and SAS 

for single-level fixation (p>0.05). However, the ACP as compared to 

the SAS did provide superior stability. Compared to intact, the ACP 

significantly decreased ROM for both two and three level anterior 

constructs (p0.05). The ACP considerably reduced ROM 

as compared to the SAS for both two and three-level constructs 

(p

vocal cord paresis which resolved after six months. Notably, we had 

no significant surgical complications in the posterior group. Our 

study showed that patients with multilevel disease treated with 

laminoplasty do well and compare favorably with patients with 

only single or dual level disease treated with an anterior approach. 

Notably posterior surgery was associated with shorter operating 

time, better improvement of JOA score at six months and a tendency 

towards lesser complications. As such, we believe that careful patient 

selection for either the anterior or posterior approach based on the 

pathology of the myelopathy and radiological findings will result in 

comparable improved clinical outcomes post-operatively. 

pApeR No. 019 

Neurological Complications Of Laminoplasty For 

Ossification Of The Posterior Longitudinal Ligament 

Atsushi Seichi, MD, Shimotsuke, Japan 

Atsushi Kimura, MD, Shimotsuke, Japan 

Hirokazu Inoue, MD 

Yuichi Hoshino, MD, Shimotsuke, Japan 

Perioperative neurological complication rates of laminoplasty for 

cervical ossification of the posterior longitudinal ligament (OPLL) 

have not been well described. The purpose of this retrospective 

multi-institutional study was to clarify the incidence of neurological 

deficits after cervical laminoplasty for OPLL. Subjects comprised 

consecutive 581 patients at 27 institutions between 2005 and 

2008. Postoperative neurological complications within two weeks 

after laminoplasty were analyzed in detail. C2-7 Cobb angle and 

occupying rate of OPLL were investigated. Open-door laminoplasty 

was conducted in 237 patients, double-door laminoplasty in 311 and 

other types of laminoplasty in 33. Deterioration of lower-extremity 

function occurred after laminoplasty in 18 patients (3.1%). Causes 

of deterioration were epidural hematoma in three patients, spinal 

cord herniation through injured dura mater in one, incomplete 

laminoplasty due to vertebral artery injury while making a trough 

in one and unidentified in 13. Prevalence of unsatisfactory recovery 

not reaching preoperative level by six-month follow-up was 7/581 

(1.2%). Mean occupying rate of OPLL for patients with deteriorated 

lower-extremity function was 51.2±13.6%, significantly higher than 

the 42.3±13.0% for patients without deterioration (95% confidence 

interval of the difference, 3.0-15.0%). No significant difference in 

C2/7 lordotic angle was seen between groups. As a whole, the greater 

the occupying rate of OPLL, the higher the risk of postoperative 

neurological sequelae. Although most neurological deterioration can 

be expected to recover to some extent, the frequency of short-term 

neurological complications was higher than the authors expected. 

pApeR No. 020 

Prognostic Factors for Neurologic Improvement in 

Cervical Spondylotic Myelopathy 

Christopher George Furey, MD, Cleveland, OH 

Sanford E Emery, MD, MBA, Morgantown, WV 

Kasra Ahmadinia, MD, Cleveland, OH 

Jung U Yoo, MD, Portland, OR 

Henry H Bohlman, MD, Cleveland, OH 

It is generally agreed that cervical spondylotic myelopathy is best 

treated with surgery. It is less clear which factors are associated with 

post-operative neurologic improvement. The goal of this study was 

to evaluate multiple clinical and radiographic variables and their 

relationship with the neurologic improvement following surgical 

management of cervical spondylotic myelopathy. A consecutive 

series of 120 patients (77 males and 43 females) with multilevel 

718 

cervical spondylotic myelopathy who underwent surgery over a 

seven-year period (1999-2005) were evaluated. Nurick scores were 

obtained pre- and post-operatively. Neurologic improvement was 

defined as a drop in Nurick score. Variables were evaluated using 

Logistic Regression Analysis. The Nurick score improved from a preoperative 

mean of 3.6 to a post-operative mean of 2.8. A total of 91 

patients (76%) improved at least one Nurick grade, 19 (16%) were 

unchanged and 10 (8%) worsened one grade. Factors significantly 

different in those patients with neurologic improvement included: 

age < 65 years at the time of surgery, Nurick grade 3 or less preoperatively, 

duration of symptoms less than 12 months, absence of 

diabetes or cardiac disease which had required surgical intervention 

and no history of smoking. Radiographic features significantly 

different in those patients with neurologic improvement included 

the absence of signal change on T2 weighted image and cord 

flattening to less that 40% of normal anterior-posterior diameter. 

Among the factors not significantly different included the type of 

surgical procedure performed, the occurrence of a perioperative 

complication or the need for additional surgery. The severity and 

duration of myelopathy can be predictive of the extent of neurologic 

improvement following surgery for cervical spondylotic myelopathy. 

While surgery should be offered to most, if not all patients, those 

with more advanced myelopathy at the time of presentation (Nurick 

Grade 4 or 5) and those with symptoms present for greater than a 

year may be less likely to improve neurologically. 

pApeR No. 021 

High Resolution Diffusion Tensor Imaging in Cervical 

Spondylotic Myelopathy 

Alpesh Ashwin Patel, MD, Salt Lake City, UT 

Michael David Daubs, MD, Salt Lake City, UT 

Darrel S Brodke, MD, Salt Lake City, UT 

Seong Eun Kim, PhD, Salt Lake City, UT 

Eun Kee Jeong, PhD 

Conventional magnetic resonance (MR) imaging, while offering 

anatomic information of the spine, provides little insight into the 

integrity of the spinal cord in patients with cervical spondylotic 

myelopathy (CSM). Diffusion tensor imaging (DTI), an imaging 

modality utilized in other central nervous system disorders, may 

provide further insight into the integrity of white matter tracts 

within the cervical spinal cord. To date, DTI of the cervical cord has 

been limited by low spatial resolutions. The purpose of this study 

is to investigate the feasibility and validity of high resolution DTI 

in the setting of CSM. Thirty patients were prospectively identified. 

Fourteen control patients and 16 patients with CSM were included. 

The diagnosis of CSM was based upon symptoms, physical 

examination and diagnostic imaging confirming cervical spinal cord 

compression. Subjects with CSM were classified according to both 

the Nurick and modified Japanese Orthopedic Association (mJOA) 

scales. Canal diameter and evidence of T2-weighted spinal cord 

signal at each disc space between C2-3 and C7-T1 were recorded. 

A novel DTI sequence (2D ss-IMIV) was performed on a 3T MRI 

system. DTI measurements, blinded to the results from conventional 

MRI, included fractional anisotropy (FA), trace and radial and axial 

diffusivity (»). The average age of the control patients was 42 years 

compared to 57.4 (37-73) among study patients. The average Nurick 

grade was 2.9 (2-4) and the average mJOA score was 11.8 (6-15). 

On average, canal stenosis was present over 3.5 levels (2-5) with 

canal diameter measuring 7.6 mm (5.2-9.9) in areas of spinal cord 

compression and 13.2 mm (10-15) in areas without compression. 

Compared with controls, FA values (0.489 vs. 0.591), trace values 

(1.69 vs. 1.96), axial diffusivity » (0.906 vs. 1.16) and axial/radial 

» ratio (2.33 vs. 3.07) were decreased. This was found in patients 



PaPers, Posters & scientific exhibits spiNe

with or without T2 spinal cord signal change (Figure 1,2). DTI 

measurements suggest a loss of normal, longitudinal white matter 

integrity (decrease FA and » ratio, increased radial diffusivity) in 

CSM. This was identified not only in areas with T2-weighted spinal 

cord signal change but also in myelopathic patients with normal 

spinal cord signal on conventional MRI. High-resolution DTI may 

provide greater diagnostic information about the integrity of the 

cervical spinal cord compared with conventional MRI in the setting 

of CSM. 

pApeR No. 022 

Differentiating C8 Radiculopathy From Ulnar 

Neuropathy: How Knowledgeable Are Spine Surgeons? 

K Daniel Riew, MD, Saint Louis, MO 

Lukas P. Zebala, MD, Saint Louis, MO 

Jacob M Buchowski, MD, Saint Louis, MO 

Dong-Ho Lee, MD, Seoul, Republic of Korea 

Many spine surgeons have a difficult time differentiating C8 

radiculopathy (C8R) from ulnar neuropathy (UN). Most only test 

grip strength and don’t know which intrinsic hand muscles are C8- 

T1 innervated. We tested spine surgeons regarding C8R versus UN. 

A total of 24 experienced cervical spine surgeons completed the 

following questionnaire. 1. Cutting the ulnar nerve at the elbow 

results in numbness of: A) ulnar forearm, small+ring fingers B) Only 

ulnar forearm C) Only small+ring fingers 2. Which of the following 

are weak with C8R without UN: flexor digiti minimi brevis, flexor 

pollicis brevis, abductor digiti minimi, abductor pollicis brevis, 

adductor pollicis, opponens digiti minimi, opponens pollicis, medial 

lumbricals, lateral lumbricals, dorsal interossei, palmar interossei. 

Only 15/24 (58%) surgeons correctly answered #1 (C). None of the 

24 correctly identified all four C8-T1 innervated muscles without 

naming additional muscles. One named all four, but also named six 

others incorrectly. One identified two muscles; another, two correct 

and one incorrect. 

pApeR No. 023 

Mortality in Elderly Patients following Operative and 

Non-Operative Management of Odontoid Fractures 

Barrett Ivory Woods, MD, Pittsburgh, PA 

Justin Hohl, MD, Pittsburgh, PA 

Robert Hartman, MS 

Brett Braly, MD, Pittsburgh, PA 

Ishaq Syed, MD, Winston Salem, NC 

William F Donaldson III, MD, Pittsburgh, PA 

James Kang, MD, Pittsburgh, PA 

Joon Yung Lee, MD, Pittsburgh, PA 

Odontoid fractures account for approximately 20% of all cervical 

spine fractures and represent the most common cervical spine 

fracture in patients over 70. Despite the frequency, there is little 

published literature regarding mortality and clinical outcome of 

odontoid fractures in the elderly. The purpose of this study was to 

analyze the mortality of elderly patients following operative and 

non-operative management of odontoid fractures. We performed a 

retrospective review of all odontoid fractures in patients 75 years of 

age or older at our institution over the past 15 years. Comorbidities 

were stratified using the Charlson comorbidity index. Mortality 

was determined at one and five years. A total of 96 patients were 

identified of which 75 met inclusion criteria. The average age of the 

patients who survive operative management (77.9) was significantly 

different from those who died (83.1) (p= .004). The average age 

between those who survived (83) and died (85) following non- 

719 

operative management was not significantly different (p=0.22). 

The average Charlson comorbidity score for those operated on 

(2.37) was not significantly different from the non-operative group 

(2.46), (p=0.45). However the patients that survived surgery had a 

significantly lower Charlson score (1.53) than those that died (3.22) 

after surgery (p=0.05). There was no significant difference in Charlson 

scores between patients who lived and died following non-operative 

management (p=0.175). Concomitant injury was present in 66% 

of patients who died following surgery and 53.5% of the patients 

that died after non-operative treatment (p=0.47). There was no 

significant difference in one (p=0.42) or five (p=0.21) year mortality 

between the operative and non operative cohorts. Patients treated 

operatively lived significantly longer after injury (29.8 months) than 

those treated non-operatively (8.6 months) (p=0.04). Respiratory 

failure accounted for the most common cause of death in both the 

non-operative (46%) and operative (33%) cohorts. There was not 

a significant difference in overall mortality between patients who 

received operative or non-operative treatment at one or five years. 

However the operative group did appear to live significantly longer 

after injury than the non-operative group. Prospective randomized 

studies are needed to validate these conclusions. 

pApeR No. 024 

Spinal Cord Injury Associated with Type II Odontoid 

Fractures: A Retrospective Cohort Analysis 

Amar Arun Patel, BS, Philadelphia, PA 

Harvey Smith, MD, Bellaire, TX 

Kristen E Radcliff, MD, Margate City, NJ 

Todd J Albert, MD, Philadelphia, PA 

James Harrop, MD 

D Greg Anderson, MD, Moorestown, NJ 

Alan S Hilibrand, MD, Philadelphia, PA 


Alexander Vaccaro, MD, PhD, Gladwyne, PA 

Neurologic deficits associated with type II odontoid fractures are 

extremely rare and thought to portend a poor prognosis. This study 

is a retrospective analysis of acute type II odontoid fractures with 

neurologic deficit presenting to a regional spinal cord injury referral 

center. A prospectively collected database was reviewed for acute 

type II odontoid fractures with a presenting neurologic deficit from 

June 1985 to July 2008. Demographic information including age, 

length of stay, date of death, mechanism of injury, displacement, 

comorbidities, associated injuries, ASIA grade, treatment and 

complications was collected. Results of this study were compared 

to data from a previously published cohort of 188 neurologically 

intact patients presenting to the same institution during the same 

time interval. Twenty patients were identified with an acute type 

II odontoid fracture with neurological deficit. The incidence of 

neurological deficits among all type II odontoid fractures was 9.6%. 

Patients with deficits presented with younger mean age (p

pApeR No. 025 

Utility of Advanced Imaging in Diagnosing Cervical 

Arterial Injury after Blunt Trauma in Children 

Stephen R Tolhurst, MD, Ann Arbor, MI 

Kelly L Vanderhave, MD, Ann Arbor, MI 

Michelle S Caird, MD, Ann Arbor, MI 

Frances A Farley, MD, Ann Arbor, MI 

The incidence of cervical vascular injury (CVI) following blunt 

cervical trauma in children and adolescents is low, but the potential 

for harm with missed injury is high. Screening for CVI has increased 

with recent advances in noninvasive angiography including 

computed tomographic angiography (CTA) and magnetic resonance 

angiography (MRA). We evaluate the utility of screening for CVI 

in children and adolescents with cervical spine trauma. Clinical 

and radiographic records of consecutive patients ages 4-18 years 

with blunt cervical spine trauma from 1998-2008 were reviewed. 

Patient demographics, cervical spine injury pattern, neurological 

findings and treatment were recorded. A total of 62 patients with 

blunt cervical spine trauma were identified. Due to injury pattern 

(high velocity injuries, subaxial fracture/dislocations and fractures 

into the foramina transversaria), 19 patients underwent noninvasive 

angiography to evaluate for CVI. There were 12 males and 

seven females with a mean age of 13.5 years. The most common 

mechanism of injury was MVC (n=11). Six patients underwent MRA, 

11 CTA and two had both studies. Seven patients had a CVI. Two 

patients had ipsilateral hemiparesis, and four had complete SCI. 

Five of seven patients had changes made in their treatment based 

on findings consistent with CVI, one treated with heparin and four 

treated with aspirin. Anticoagulation was contraindicated in the 

remaining two patients. No delayed-onset ischemic neurological 

events occurred. After blunt cervical spine trauma, certain fracture 

patterns increase the risk of CVI. CVI is common, with a minimum 

incidence of 7/62 or >10% of pediatric patients with blunt cervical 

spine injury. More than one third of patients studied with high risk 

criteria had injury. Advanced imaging with noninvasive angiography 

(CTA/MRA) should be strongly considered in pediatric patients with 

cervical spine trauma. The presence of CVI often prompts a change 

in management. 

pApeR No. 026 

uRoutine Use of Posterior Arch Screws for C1 Fixation: 

Feasibility and Related Complications 

Jin-Sup Yeom, MD, PhD, Sungnam, Gyungki-do, Republic of 

Korea 

Won Noh, MD 

Ngoc Quyen Nguyen, MD, Hanoi, Hai Ba Trung Viet Nam 

Dinesh Kafle, MD 

Kun-woo Park, MD, Seongam-si, Gyeonggi-do, Republic of Korea 

Bong-Soon Chang, MD, Seoul, Republic of Korea 

Choon-Ki Lee, Seoul, Republic of Korea 


Whenever feasible, C1 posterior arch screws have advantages over 

lateral mass screws, including improved fixation, decreased C2 root 

irritation and venous bleeding. We evaluated the feasibility of, and 

complications related to, posterior C1 arch screws. In this singlesurgeon 

study, 82 C1 arch screws were attempted in 42 consecutive 

patients (18 men, 24 women). Prospective database, clinical records, 

questionnaires regarding occipital neuralgia and post-operative 

intravenous CT-angiography were analyzed by uninvolved surgeons. 

The height of 50 posterior arches was smaller than 4 mm on 

preoperative CT angiography. Posterior arch screws could be inserted 

720 

in all cases, including nine with poticuli posticus and seven with 

persistent first intersegmental arteries. There were no vertebral artery 

injuries during surgery or on postoperative CT-angiography. The 

posterior arch was perforated cranially by five, caudally by 28 and 

craniocaudally by 13 screws. Among the 16 patients with preoperative 

occipital neuralgia, nine had complete resolution and seven had 

alleviation of the pain at the last follow up. Among 26 patients 

without preoperative occipital neuralgia, seven developed new 

neuralgia and four had persistent pain (VAS 1 to 4) at the last follow 

up. Routine use of C1 posterior arch screw was feasible even in those 

with small posterior arch height, ponticulus posticus and persistent 

first intersegmental artery. Vertebral artery injury was preventable by 

mobilization before screw insertion. Cortical perforation was often 

inevitable. Occipital neuralgia was not infrequent, but its cause was 

not clear. 

pApeR No. 027 

Anatomy of Lamina in the Subaxial Cervical Spine with 

the Special Reference to Translaminar Screws: CT and 

Cadaveric Analysis with Screw Simulation 

Woojin Cho, MD, Charlottesville, VA 

Jason T Le, BS 

Adam L. Shimer, MD, Charlottesville, VA 

Brian C Werner, MD, Charlottesville, VA 

Michael Iwanik, PhD 

John A Glaser, MD, Charleston, SC 

Francis H Shen, MD, Charlottesville, VA 

Translaminar screws were initially developed for C2 fixation. Since 

then, their usage has expanded to include the subaxial cervical spine, 

and thoracic and lumbar spine. To our knowledge, special anatomy for 

inserting translaminar screws in the subaxial cervical spine have not 

been studied. A total of 18 cadaveric spines were harvested from C3 

to C7 and 1 mm CT scans and 3D reconstructions obtained. Bilateral 

translaminar screw entry points and trajectories were simulated at 

each level from C3 to C7. Constructs were selected to achieve maximal 

bony purchase with one screw, designated the primary screw. The 

contralateral screw, designated the secondary screw, was selected to 

achieve the optimal allowable diameter possible while avoiding a 

simulated cortical breach, which was not always necessarily the best 

purchase diameter. Initial screw diameters selected were 3.5 mm; 

however, in the event that a narrower portion was encountered, then 

a 3.0 mm diameter screw was utilized instead. The crossing area of 

both screws were calculated geometrically. Maximal thickness of 

the lamina was considered in determining the diameter of screws. 

Whenever possible 3.5 mm screws were selected in both lamina 

(3.5/3.5 mm); however if a 3.5 mm screw was utilized as the primary 

screw, but the permissible range (P) for the secondary screw was less 

than 3.5 mm, then a hybrid construct was utilized (3.5/3.0 mm). In 

cases where P was less than 3 mm, then both screws were studied at 

3 mm (3.0/3.0 mm). Screw diameters that optimized trajectory and 

bony purchase, while remaining within the permissible range, were 

analyzed, tabulated and recorded. On CT, along the trajectory of the 

screws, the image was cut and measured in terms of screw length, 

the narrowest portion of the lamina, vertical angle and horizontal 

angle in both primary and secondary screws. On the individually 

separated cervical spine segments in cadavers (11 out of 18), we 

performed caliper measurements on the same portions which were 

measured on CT. It could not be exactly the same portions, however, 

due to the three dimensional characteristics of the specimens. For 

C3, only one specimen allowed two screws (3/3 mm), while the 

remaining specimens permitted a unilateral primary screw (3.5 or 3 

mm) only. For C4, 50% of specimens allowed two screws (3.5/3 mm 




or 3/3 mm), but the rest allowed only a unilateral primary screw(3.5 

or 3 mm). For C5, 43% allowed two screws (3.5/3.5 mm, 3.5/3 mm, 

or 3/3 mm). For C6, 88% of specimens allowed two screws (3.5/3.5 

mm, 3.5/3 mm or 3/3 mm). For C7, all levels allowed two screw 

(3.5/3.5 mm, 3.5/3 mm, 4/4 mm, 4/3 mm, 4.5/3 mm, 4.5/3.5 mm 

or 4/3.5 mm). On CT, the average lengths of the 1° and the 2° screws 

are 26.14 mm and 24.01 mm respectively. The average vertical and 

horizontal angles were 22.26° and 40.66° in 1° screw, and 3.45° 

and 45.59° for the 2° screw. On cadavers, the average lengths of 

the 1° and the 2° screws are 22.58 mm, 23.44 mm respectively. The 

average vertical and horizontal angles were 23.67° and 54.44° in 

1° screw, and 2.28° and 54.89° for the 2° screw. This is a report of 

the anatomy of the lamina in the subaxial cervical spine with the 

special reference to translaminar screws. It was analyzed with CT 

and cadaveric spines along with simulated screw trajectories. Further 

study is obviously needed for the feasibility of translaminar screw 

insertion in the actual subaxial cervical spine. 

pApeR No. 028 

Distraction In The Occipito-Cervical Spine In Patients 

With Dissociative Injuries 

Peleg Ben-Galim, Houston, TX 

Rani Lador, MD, Tel-Aviv, Israel 

Niv Dreiangel, MD, Tel Aviv, Israel 

Charles A Reitman, MD, Houston, TX 

John Hipp, PhD, Houston, TX 

Prior literature reviews have concluded that although evidence exists 

that currentcervical spine immobilization techniques can reduce 

head motion in healthy volunteers, there is no evidence that these 

techniques can limit motion or maintain normal alignment within 

the occipito-cervical region in the presence of severed issociative 

injuries. It is also known that secondary injuries are relatively common 

in patients with dissociative injuries. However, evidence in support 

of potential intervention strategies to minimize secondary injuries is 

limited. The purpose of this study was to better understand potential 

mechanisms for distraction in the occipito-cervical region in blunt 

trauma patients as documented in multiple clinical case series. This 

is an analysis of a small case series from a large level-I trauma center 

of patients with occipito-cervical dissociative injuries. Quantitative 

measurement of the gaps between the occiput and C1 or between C1 

and C2 were assessed using FDA recommended QMA software. Review 

of the available literature on occipito-cervical dissociative injuries to 

identify possible mechanisms for the abnormal gaps described in 

many studies between the occiput and C1 or between C1 and C2 are 

presented. Twenty-nine peer-reviewed publications were identified 

where abnormal intersegmental separation was shown or described 

in patients with occipito-cervical dissociative injuries. In all patients 

from the current case series, abnormal distraction was measured from 

images taken during patient management. An association between 

in-line stabilization or application of a rigid cervical collar and 

exacerbated abnormal distraction between segments of the unstable 

upper cervical spine were identified. Numerous clinical studies have 

shown or report abnormal separation between the occiput and C1 or 

between C1 and C2 in patients with dissociative injuries, although 

explanations for the distraction were rarely provided. Observations 

from a small case series suggest that cervical stabilization procedures 

including in-line stabilization and application of a collar should 

be further investigated to achieve the goal of protecting against 

secondary injuries in patients with severe occipito-cervical injuries. 

721 

pApeR No. 029 

Biomechanical Analysis of Rod Material and Diameter 

for Cervicothoracic Ankylosing Spondylitis 

Justin Scheer, San Francisco, CA 

Jessica Anne Tang, BS 

Vedat Deviren, MD, San Francisco, CA 

Jenni M Buckley, PhD 

Murat Pekmezci, MD, San Francisco, CA 

Robert Trigg McClellan, MD, San Francisco, CA 

Christopher Ames, MD, San Francisco, CA 

Ankylosing spondylitis frequently results in spinal sagittal plane 

deformity. A combination of osteotomy and spinal fixation is used 

to treat severe cases to restore spinal balance and horizontal gaze. 

The specific model of instrumented opening wedge osteotomy 

(OWO) in autofused ankylosing spondylitis has not been studied 

biomechanically. The goal of this study is to characterize the 

structural stiffness of the effects of posterior spinal rod diameter 

and material type across the cervicothoracic junction in spines with 

ankylosing spondylitis. Ten human spines (C3-T6) each underwent 

an OWO at C7-T1. To simulate the anterior auto-fusion and long 

lever arms characteristic of ankylosing spondylitis, anterior cervical 

plates were placed from C4-C7 and T1-T3 using fixed angle screws. 

Lateral mass screws were inserted bilaterally from C4-C6 and pedicle 

screws from T1-T3. Three different posterior spinal fusion rods were 

tested for each specimen: 3.2 mm Titanium (Ti), 3.5 mm Ti and 3.5 

mm cobalt-chrome (CoCr). Non-destructive pure moment flexion/ 

extension (FE), lateral bending (LB) and axial rotation (AR) tests 

were conducted to 3.0 Nm in each anatomical direction. 3D motion 

tracking was used to measure the primary range-of-motion (ROM) 

across the osteotomy site (C7-T1). The 3.5 mm Ti and 3.5 mm CoCr 

rods were significantly stiffer in FE compared to the 3.2 mm Ti rod 

(25.2%±16.4% and 48.1%±15.3%, respectively, p

in addition to a subfascial drain in obese patients. In 2008, we 

additionally began placing 500 mg of vancomycin powder into 

the wound prior to closure. We analyzed the infection rates of 

three groups: Group C (control patients prior to 8/2004), Group 

AD (alcohol foam and drain) and Group VAD (vancomycin). We 

retrospectively, independently reviewed all posterior cervical spine 

surgeries (n=972) performed by one surgeon from 1995-2010, 

including foramenotomies, laminectomies, laminoplasties, fusions 

and/or osteotomies. There were 483 patients in Group C, 330 in 

AD and 159 in VAD. Group C (n=483) had nine postoperative 

deep infections (1.86%). Higher infection rates were found in 

smokers (p=0.005), rheumatoids (p=0.027), obese BMI>30kg/m2 

(p=0.005), instrumented fusions (p=0.014), revisions (p=0.002) and 

>4 vertebral levels (p=0.017) but not diabetes (p=0.2). Group AD 

had 1/330 infections, significantly decreased versus C (p=0.0419). 

VAD had 0/159 infections, trending towards a decrease compared 

to Group C (p=0.07). Combining new measures since August 2004 

(Groups AD/VAD to C) resulted in a substantial infection decline 

(p=0.009). No complications were associated with vancomycin 

powder administration. In the present study, the addition of intrawound 

vancomycin powder to a pre-prep with alcohol foam and 

multiple drains in obese patients decreased the infection rate to 

0/159 posterior cervical spine surgeries. We recommend the routine 

use of our protocol for all posterior cervical operations. Such 

techniques may become even more important as Medicare refuses 

reimbursement for nosocomial infections. 

pApeR No. 256 

Does a Multilevel Laminectomy with a Single Level PLF 

Increase the Risk of Adjacent Segment Disease 

Brian J Neuman, MD, Philadelphia, PA 

David T Anderson, MD, Philadelphia, PA 





Little is known about the longer-term stability of a multilevel 

laminectomy adjacent to a single-level fusion. The purpose of this 

study was to evaluate whether a multi-level decompression in the 

setting of a single level fusion would increase a patient’s risk of 

developing adjacent segment disease (ASD). A retrospective chart 

review of 183 consecutive patients who underwent a single-level 

posterior lumbar fusion (PLF) for spondylolithesis with stenosis was 

performed. A total of 142 patients had a minimum of 24-month 

follow up, averaging 54 months. Fifty-eight patients had a PLF with 

additional levels decompressed above the fusion, and 84 patients 

underwent a single level laminectomy and PLF. The incidence of ASD 

and reoperation rate was calculated, and a Fisher’s exact test was used 

to compare each subgroup. ASD was defined as the development of 

new radiculopathy or claudication referable to a motion segment 

adjacent to the lumbar arthrodesis with symptom duration greater 

than six weeks. A total of 22.4% (N=13/58) of patients who had 

a PLF with multilevel laminectomy developed ASD with a 5.2% 

(N=3/58) reoperation rate. Among patients who had a PLF with 

a laminectomy only at the fusion level, the incidence of ASD was 

14.3% (N=12/84) and the reoperation rate was 7.1% (N=6/84). 

There was neither a significantly higher incidence of ASD (p=0.26) 

or reoperation rate (p=0.74) between the multilevel laminectomy 

and single level laminectomy groups. Concomitant decompression 

of additional levels above a single level PLF did not significantly 

increase the risk of ASD or additional surgery compared to single 

level laminectomy and PLF. 

722 

pApeR No. 257 

Does the Facet Joint Violation by Transpedicular Screw 

Cause Adjacent Segment Degeneration? 

Hyoung Yeon Seo, MD, Gwangju, Republic of Korea 

Jae Yoon Chung, MD, Gwangju, Republic of Korea 


Gi Heon Park, MD 

The facet joint violation by transpedicular screw is a possible 

risk factor for adjacent segment degeneration (ASD) in patients 

undergoing lumbar fusion. We randomized 75 patients undergoing 

lumbar fusion into two groups. The ASD group was 35 patients who 

received lumbar fusion in the superior segment because of ASD 

after one or two segment fusions of the lower lumbar spines. The 

average interval between the first surgery and the superior segment 

surgery was 8.3 years. The control group was 40 randomly selected 

patients, who received lumbar fusion and had no complications for 

the average of seven years. We reviewed the CT scan where non-fused 

facet joints and proximal screws were both shown. No points were 

given when the screw clearly avoided the facet joint, one point was 

given when the screw head was either in contact with the facet joint 

or when the screw was suspected to have invaded the facet joint and 

two points were given when the screw had clearly invaded the facet 

joint. We evaluated both left and right sides and gave a total sum 

of the points. The demographics known to increase the risk of ASD 

were similar between the two groups. The average degree of facet 

joint invasion at the superior adjacent segment after transpedicular 

instrumentation was 1.8 for the ASD group. This was higher than 

the control group whose average was 1.1. The difference between the 

two groups was significant (p

and abnormal motion or mobile spondylolisthesis at any lumbar 

level (kappa

at last follow up, their lordosis at L4/5 at last follow up still was 

significantly different from their lordosis at L4/5 before surgery. 

Lumbar lordosis did not significantly change. Mean JOA score was 

13.4 before surgery and 24.5 at the last follow up; mean recovery 

ratio was 71.2%. Adjacent segment degeneration occurred in 40.5% 

of patients, almost all of which occurred in the cranial adjacent 

segment. Three patients (8.1%) required reoperation due to adjacent 

segment degeneration, at 76 months, on average, after their initial 

surgery. After PLIF at L4/5, 40.5% of subjects developed adjacent 

segment degeneration, and 8.1% required reoperation for it. 

pApeR No. 262 

Infection Rate with the Use of Antibiotics for 24 hours 

versus the Duration of a Drain 

Richelle C Takemoto, MD, New York, NY 

Justin J Park, MD, New York, NY 

Pedro Ricart Hoffiz, MD, New York, NY 

Jeffrey Andrew Goldstein, MD, New York, NY 

Jeffrey M Spivak, MD, New York, NY 

Yong H Kim, MD, New York, NY 

John A Bendo, MD, New York, NY 

Thomas J Errico, MD, New York, NY 

Baron Lonner, MD, New York, NY 

There are no studies in the body of literature which have looked 

at the utilization of antibiotics for 24 hours when a drain is in 

place versus continuing the antibiotics for the entire duration that 

the drain is in place. Most of the literature has evaluated joint 

arthroplasty patients in terms of the use of drains and the duration 

of antibiotics. No study has evaluated these two variables together. 

A total of 199 patients who underwent multilevel thoracolumbar 

spine surgery requiring a post-operative drain were enrolled and 

randomized into two groups: one group receiving 24 hours of 

perioperative antibiotics and one group receiving antibiotics for 

the duration that the drain was in place. Data collected included 

demographics, medical co-morbidities, type of spine surgery and 

surgical site infection. Six/110 (5.4%) in the 24 hours of antibiotic 

group developed a surgical site infection while 13/89 (14.6%) in the 

antibiotic for the duration of the drain were found to have a surgical 

site infection. The differences between each group were significant 

(p=0.029). There were no significant differences between the groups 

with respect to demographics, surgical time, type of surgery, drain 

output or length of stay. Continuing peri-operative antibiotics for 

the entire duration a drain is in place after spine surgery does not 

decrease the rate of surgical site infections. 

pApeR No. 263 

Obesity And Surgical Outcomes For Lumbar Spinal 

Canal Stenosis 

Toshihiko Sakakibara, MD 

Zhuo Wang, MD, Tsu, Japan 

Koji Akeda, MD, PhD, Tsu, Japan 

Akihiro Sudo, Prof., Tsu, Japan 

Yuichi Kasai, MD, Mie Prefecture, Japan 

The purpose of this study is to determine the influence of body 

mass index (BMI) on outcomes of surgery for lumbar spinal canal 

stenosis. The subjects comprised 413 patients who had underwent 

posterolateral fusion in a single intervertebral disc space with spinal 

instrumentation using a pedicle screw and rod system. Obesity levels 

were classified into three groups according to BMI: > or = 35, severely 

obese group (n=41); 25 to

controversy remains as to whether this correlates with outcome after 

DLSS. Retrospective study of 36 patients, average age 74 years, who 

underwent DLSS under an orthopaedic spinal surgeon. The dural 

cross-sectional area (DCSA) was measured at the most stenotic disc 

level on MRI using digital imaging software. Patients completed the 

Swiss Spinal Stenosis (SSS) score via telephone at a minimum of one 

year follow up. This simple, reproducible, internally consistent, valid 

and responsive outcome measure includes symptom severity, physical 

function and postoperative satisfaction scales, which are expressed as 

a score out of 100. Eight patients had mild/moderate stenosis (DCSA 

> 75 mm2), 28 patients had severe stenosis (DCSAd 75 mm2); 34 

patients (94%) reported an improvement in symptom severity (pain 

and neuroischaemic) with an average improvement of 19/100 (SSS). 

Thirty-five patients (97%) reported an improvement in pain with an 

average improvement of 29/100. Thirty patients (83%) reported an 

improvement in physical function with an average improvement of 

19/100. Thirty-three patients (92%) were very satisfied, two patients 

were somewhat satisfied, one patient was somewhat dissatisfied. 

There was no statistically significant correlation (p

pApeR No. 268 

Is SubjectiveOutcome better and persistent with 

Microendoscopic Discectomy than Open Discectomy? 


Arvind Jayaswal, MS 

In the current prospective, randomized study, the subjective 

outcome of open discectomy procedure was compared with those 

of microendoscopic discectomy (MED) at various intervals of time. 

One hundred and twelve patients who had objective evidence of a 

single level, central or paracentral herniation of a lumbar disc caudal 

to the first lumbar vertebra were randomized into two groups; Group 

1 (55 patients) was managed with microendoscopic discectomy, 

and Group 2 (57 patients), with open (fenestration/ laminotomy) 

discectomy. Analysis of the outcomes of both procedures was based 

on the patient’s self-evaluation before and after the operation through 

Oswestry scoring, and the patient’s ability to return to a functional 

status. The patients were followed at one week, six weeks, six months 

and for a minimum of one year postoperatively and the results were 

statistically analyzed. On the basis of the patient’s preoperative and 

postoperative self-evaluation and the patient’s ability to return to 

work or to normal activity, 53 patients (96 percent) in Group 1 and 

54 patients (95 percent) in Group 2 were considered to have had a 

satisfactory outcome. The overall satisfaction score was statistically 

significantly higher after the endoscopic microdiscectomies than 

after the laminotomies and discectomies in immediate postoperative 

period (one and six weeks) as assessed through Oswestry scoring 

and became statistically insignificant at six months and one year. 

The data from this randomized, prospective study suggest that better 

subjective outcome with MED is more significant in first six weeks 

and become insignificant at six months and one year. 

pApeR No. 269 

Microsurgical Lumbar Laminoplasty: Bilateral Lumbar 

Microdecompression via Unilateral Laminotomy 



Joon-Hyung Kim, BS 

Russel C Huang, MD, New York, NY 

Laminectomy is the standard procedure for lumbar spinal canal 

decompression. Microsurgical lumbar laminoplasty (MLL) is 

a less disruptive technique for bilateral lumbar decompression 

via a unilateral laminotomy. During MLL, the spinous process, 

supra-spinous ligaments, contralateral paraspinal muscles and the 

majority of the lamina are preserved. The technique is intended to 

maximally preserve spinal stability while performing a complete 

decompression of the spinal canal and subarticular lateral recess. 

Ninety-seven patients underwent bilateral decompression of lumbar 

stenosis at 172 levels; L1-2 three, L2-3 26, L3-4 52, L4-5 72, L5-S1 

19 levels. All patients had symptomatic lumbar spinal canal stenosis 

and had failed conservative treatment. A unilateral laminotomy 

was used to decompress the central canal, ipsilateral and contralateral 

subarticular recess under microscope magnification. Perioperative 

data and complications were recorded. Spine outcome 

measures were recorded pre-operatively and at subsequent followups. 

Twelve patients had associated degenerative scoliosis, 43 had 

listhesis, four had adjacent level degeneration next to the previously 

instrumented fusion levels and 45 had associated disc herniation 

requiring microdiscectomy. There were 56 males and 41 females. 

Mean follow up was 6.0±4.6 months (6 weeks-17 months). The 

values for pre-operative and post-operative outcome scores are 

given in Table 1. Mean estimated blood loss was 182±131 cc. A 

total of 85% of patients had resolution of the leg pain, and 38% 

726 

of patients had improvement in back pain. Eighteen patients had 

simultaneous non-instrumented fusion and 13 had instrumented 

fusion. There were six dural tears, one post-operative epidural 

hematoma requiring surgical evacuation, two post-operative deep 

infections and three recurrent disc herniations requiring further 

decompression. MLL is a viable option for lumbar decompression, 

especially in patients with degenerative scoliosis and listhesis. The 

procedure is technically demanding, however, the complication rate 

is acceptably low. Posterior osseo-musculo-ligamentous structures 

are preserved relative to laminectomy. 

pApeR No. 270 

Epidural Steroid Injections Affect The Outcome Of 

Lumbar Disk Herniation. A SPORT Subgroup Analysis 




Wenyan Zhao, PhD, Hanover, NH 

Jon D Lurie, MD, Lebanon, NH 


Tor Tosteson, ScD 

James N Weinstein, DO, MS, Lebanon, NH 


The purpose of this study was to determine whether epidural 

steroid injections (ESI) affect the outcome of treatment of lumbar 

disc herniation. The study population included patients enrolled in 

SPORT for treatment of lumbar disk herniation who received ESIs 

(non-ESI) compared to patients who did not receive ESIs (non- 

ESI) pre-enrollment or during treatment. There were 423 non-ESI 

patients and 769 ESI patients. At baseline, the patients who were 

treated with ESIs had an increased incidence of depression (14% vs. 

8%, p=0.002) and a lower percentage of patients with symptoms 

less than six months (76% vs. 82%, p=0.024). The ESI patient 

group had lower baseline SF36 BP, SF36 PF, SF36 MCS. There was 

an average 5.8 minute increased operative time in the ESI group 

(79 vs. 73.2, p=0.038). After adjustment for baseline differences, 

there was significantly less improvement in the surgically treated 

ESI patients compared to non-ESI patients in SF36 BP (48.2 vs. 

43.3, p

pApeR No. 436 

Assessment of Factors Predictive Of Post-Operative 

Infection in 941 Spinal Deformity Patients 

Baron Lonner, MD, New York, NY 

Kushagra Verma, MD, Philadelphia, PA 

Laura E Dean, Philadelphia, PA 

David Vecchione, MD, Miami, FL 

Antonio D C Valdevit, Hoboken, NJ 

Kathryn E Kean, BA 

Post-operative infection occurs following spinal surgery in 1 to 

15% of cases varying with patient factors and type of procedure 

performed. This study aimed to identify patient and surgery related 

factors associated with increased risk of infection from a single 

surgeon database. This was a retrospective review of 941 patient 

records from a single-surgeon database of deformity patients treated 

from 2000-07. Demographic (age, gender, body mass index (BMI), 

comorbidities), surgical (prior surgery, approach, type and number 

of procedures, etc.), radiographic and peri-operative complications 

were assessed. Infection was classified as deep, superficial or possible. 

Deep infection always required operative irrigation and debridement, 

while superficial infection was treated non-operatively. Patients 

restarted on antibiotics for wound drainage without fever, positive 

culture or abnormal laboratory values were categorized as a possible 

infection. There were 13 deep (1.4%) and 17 superficial infections 

(1.8%). Patients were treated with an anterior (n=193), posterior 

(n=590) or combined (n=140) approach with the following 

procedures: spinal fusion (n=873), growth rod distraction (n=23), 

revision (n=145), vertebral column resection (n=32) and osteotomy 

(n=162). Predictors of infection were: age, BMI, number of levels, 

Lenke 3-4, osteotomy and number of comorbidities (p

pApeR No. 439 

uRelating Current to Distance in the Detection of 

Motor Nerves 

Stephen Bartol, MD, Detroit, MI 

Christopher D Wybo, MS, Royal Oak, MI 

The efficacy of stimulated electromyography (EMG) for locating nerves 

is based on the inferred relationship between the electrical signals 

and the distance from the stimulus source to the nerve. Detection of 

EMG signals may vary however, with electrode placement, electrical 

contact and tissue conductivity and the source to nerve distance 

cannot be quantified. Mechanomyography (MMG) measures the 

mechanical response of muscle to stimulus and is not subject to 

variations in electrical signal conduction or signal detection. The 

purpose of this study was to quantify the acceleration of muscle 

contraction (MMG signal) in response to electrical stimulus and to 

determine its relationship to the distance from the stimulus source to 

the motor nerve. Custom mechanomyography accelerometer sensors 

were placed over the lower limbs of three anaesthetized sheep. The 

lumbar plexus was exposed by a direct lateral approach and a gauge 

used to fix the distance from a nerve to the stimulator probe. Three 

nerves were studied at eight distances: 0-6 mm and 10 mm. A 100 µs 

square-wave pulse was applied to each nerve at 2 Hz for 5 seconds 

using constant current. Current levels of 1-6 mA in 0.5 mA increments 

were studied and tests repeated three times in each animal for a total 

of 7,920 stimulation scenarios. MMG sensor signal was plotted as a 

function of stimulus current amplitude showing a direct relationship 

(R2 = 0.9747; range: 0.9169 - 0.9971). MMG signal was then plotted 

as a function of distance with resulting curves describing an inverse 

relationship between sensor signal and distance at each current level 

(R2 = 0.9965; range: 0.9518 to 0.9839). Our findings describe the 

relationship between MMG signals, the level of stimulation current 

and the distance from the stimulation source to the nerve. MMG 

signal responses vary directly with both stimulus amplitude and 

the distance from the stimulus probe to the nerve. With a known 

stimulus amplitude, the distance to the nerve can be inferred based 

on the measured MMG sensor signal response. MMG sensors using 

accelerometer technology are a sensitive indicator of distance to a 

nerve when the level of stimulating current is known. MMG is a 

reliable alternative to EMG based systems for locating, mapping and 

avoiding nerves in minimally invasive surgery and in other surgical 

procedures where the nerve cannot be directly visualized. 

pApeR No. 440 

Complication Rate in Spinal Cord Injury Patients After 

Scoliosis Correction Using Pedicle Screws 

Joseph John King, III MD, Philadelphia, PA 

Steven W Hwang, MD, Jamaica Plain, MA 

Anthony Fine, BS 

Christopher E Swanson, MD, Philadelphia, PA 

Roald Jon Llado, MD, Philadelphia, PA 

Jason Nydick, DO, TAMPA, FL 

Gbolabo Olabiyi Sokunbi, MD, Philadelphia, PA 

Patrick John Cahill, MD, Philadelphia, PA 

Amer Samdani, MD 

Few studies highlight the outcomes and complications of patients 

with spinal cord injury (SCI) patients undergoing posterior spinal 

fusion (PSF) to correct scoliosis. In most series, SCI patients make up 

a small percentage of patients and their outcomes are combined with 

other etiologies of neuromuscular scoliosis. This study evaluates the 

complications of spinal deformity surgery in patients with SCI using 

pedicle screws. A retrospective review was performed at a single 

728 

institution identifying all SCI patients that underwent PSF with 

primarily pedicle screw fixation for scoliosis between 2002-2009. 

Medical records were reviewed for demographic, operative and 

clinical information. Complications were as follows: intraoperative 

complications (new neurologic injury and dural tear), minor medical 

complications (decubitus ulcers and cardiovascular/respiratory 

complications), major medical complications (sepsis, ARDS and 

any medical complication necessitating a procedure), minor surgical 

complications (superficial wound complication and asymptomatic 

hardware failure) and major surgical complications (pseudoarthrosis, 

deep wound complication and progressive/ new deformity). Twentyeight 

patients (19 male, nine female) were identified with an average 

age at SCI of 7.9 years with 43% of injuries involving a motor vehicle 

accident. Average age at surgery was 15.4 years (range 10-20 years) 

with an average of 16 levels fused (range 6-18). Eighty-nine percent 

underwent a fusion to the pelvis and 7% were two-stage surgeries. 

Average surgical time was 520 minutes (335-735 minutes). Average 

estimated blood loss was 2813 mL (range 1-10L). Mean preoperative 

Cobb angle was 54 degrees, with the most recent Cobb angle being 

18 degrees for a 70% correction. Mean follow-up was 2.4 years 

(range six months to 5.9 years). Overall, 46% of patients experienced 

a perioperative complication (19 complications in 13 patients). 

Intraoperative complication rate was 11% (three complications 

in three patients) which included dural tear in two patients (7%) 

and optic nerve injury in one. No new spinal neurologic changes 

occurred. Five patients (18%) had minor medical complications. 

Four patients (14%) had major medical complications with the 

most common being a new pressure ulcer (two patients). Minor 

surgical complication rate was 14% (four patients) with the most 

common being superficial wound complications (three patients). 

Major surgical complication rate was 18% (six complications in 

five patients) with deep wound infection being the most common 

(four patients, 14%). Five major operations relating to the PSF were 

performed on four patients (14%). Correction of scoliotic deformity 

by PSF in spinal cord injury patients carries a high complication rate. 

However, the majority of complications are easily managed and do 

not require prolonged treatment. Patients and surgeons should be 

aware of these potential complications so a risk benefit analysis can 

be performed prior to surgical intervention. 

pApeR No. 441 

Upper fusion level in Adult Spinal Deformity: 

Effectiveness of Classification in guiding treatment 

Frank J Schwab, MD, New York, NY 

Jean-Pierre C Farcy, MD, New York, NY 

Virginia Lafage, New York, NY 

Ashish Patel, MD, Brooklyn, NY 

Steven D Glassman, MD, Louisville, KY 

Keith H Bridwell, MD, Saint Louis, MO 

Adult spinal deformity (ASD) is complex due to the range of 

deformity patterns and clinical presentation. The ASD Classification 

(Schwab, et al.) permits a relevant description of patients based upon 

health related quality of life measures, but outcomes based upon 

fusion level (upper instrumented vertebra: UIV) by classification 

has not been reported. The purpose was to determine if the ASD 

Classification is effective in guiding selection of the UIV. This is a 

retrospective review of a multicenter ASD prospective database. The 

study included 1,071 patients, 166 male and 903 female, (mean 

age 59.6yo, SD=12) with minimum one-year follow up. Inclusion 

criteria were long fusion with lower instrumented level of L5 or S1 

and UIV of L1 or above. Patients were classified according to: ASD 

Classification, UIV and outcomes measures. An analysis of variance 

was applied to detect differences between groups based upon 




outcomes changes for the following UIV groups: T1-3, T4-6, T9-11, 

T12-L1. Distribution by UIV was: T1-3 n=206, T4-6 n=242, T9-11 

n=466, T12-L1 n=157. No significant difference was noted in terms 

of global balance or lumbar lordosis modifiers across UIV groups. By 

SF-12, SRS pain and SRS activity scores, the T1-3 UIV demonstrated 

the least improvement. By SRS mental score, T12-L1 UIV had greater 

improvement than T1-3 and T9-11 groups. For patients with marked 

sagittal malalignment, T4-6 UIV showed greater improvement than 

other UIV groups. The T9-11 UIV group never outperformed all other 

UIV groups for any of the classification categories. In this large multicenter 

prospective study, the application of the ASD Classification 

demonstrates significant differences in health-related quality of life 

outcomes by proximal fusion level for long fusions. These findings 

lay an important foundation for the development of treatment 

algorithms for surgical planning. 

pApeR No. 442 

Optimal Lowest Instrumented Vertebra for Thoracic 

Adolescent Idiopathic Scoliosis 

Yongjung J Kim, MD, New York, NY 

Lawrence G Lenke, MD, Saint Louis, MO 


Oheneba Boachie-Adjei, MD, New York, NY 

Jean-Luc Clement, MD, Nice, France 

Samuel Kang-Wook Cho, MD, Palisades Park, NJ 

Charla R Fischer, MD, New York, NY 

The purpose of this study is to determine the optimal lowest 

instrumented vertebra (LIV) without adding on or distal junctional 

kyphosis following posterior segmental spinal instrumented fusion 

(PSSIF) of thoracic adolescent idiopathic scoliosis (AIS) with lowest 

instrumented vertebra at L2 or above. A radiographic assessment of 

521 thoracic major AIS patients (average 14.7 years) who underwent 

PSSIF with a minimum two-year follow up (average 4.1 years, range 

2-16.7 years) was performed. Adding-on (AO) was defined as the 

distance from the center of the lowest instrumented vertebra to the 

center sacral vertical line >3 cm or coronal disc angle below the lowest 

instrumented vertebra >10 degree and distal junctional kyphosis 

(DJK) was defined as sagittal disc angle below lowest instrumented 

vertebra > 10 degree at the ultimate follow up. The prevalence of 

AO or DJK at the ultimate follow up was 14% (72/521). Stable LIV 

(center sacral line (CSL) between medial walls of the LIV pedicles) 

had 9% (27/285), Stable-1 LIV (between Stable +1 and +3) 15% 

(28/192) and Stable-2 LIV (No touch of LIV by CSL) 19% (17/44, 

p=0.000). Open triradiate cartilage had 43% (6/14 vs. closed one 

13%, p=0.001). Neutral LIV had 11% (42/376), Neutral-1 (one 

vertebra proximal to NV) 15% (8/55) and Neutral-2 (at least two 

verteba proximal to NV) 24% (22/90, p=0.000). The prevalence of 

AO or PJK at the ultimate follow up following posterior segmental 

spinal instrumented fusion of AIS with lowest instrumented vertebra 

at L2 or above was 14%. Open triradiate cartilage, less touching of 

LIV by CSL and more proximal to NV were identified as risk factors. 

729 

pApeR No. 443 

The Biomechanical Consequences of Rod Reduction on 

Pedicle Screws: Should it be Avoided? 






Rod contouring is frequently required to allow for appropriate 

alignment of pedicle screw-rod constructs. When residual mismatch 

is still present, a rod persuasion device is often utilized to achieve 

further rod reduction. Despite its popularity and widespread use, 

the biomechanical consequences of this technique have not been 

evaluated. Fifteen three-level, human cadaveric thoracic specimens 

were prepared and DEXA scanned. Osteoporotic (n=6) and normal 

(n=9) specimens were instrumented with 5.0 mm diameter pedicle 

screws with variable lengths (35-45 mm). Titanium 5.0 mm rods 

were contoured and secured to the pedicle screws at the proximal 

and distal levels. For the middle segment, the rod on the right side 

was intentionally contoured to create a 5 mm residual gap between 

the inner bushing of the pedicle screw and the rod (Figure 1). A 

rod persuasion device was then utilized to engage the set screw. The 

left side served as control with perfect screw/rod alignment. After 

30 minutes, constructs were disassembled and vertebrae individually 

potted. The implants were pulled in-line with the screw axis with 

peak POS measured in Newtons (N). For the proximal and distal 

segments, pedicle screws on the right side were taken out and reinserted 

through the same trajectory to simulate screw depth 

adjustment as an alternative to rod reduction. Pedicle screws reduced 

to the rod generated a 48% lower mean POS (495±379N) relative to 

the controls (954±237N) (p=0.00). Nearly half (n=7) of the pedicle 

screws had failed during the reduction attempt with visible pull-out 

of the screw. Following reduction, decreased POS was observed in 

both normal (p=0.02) and osteoporotic bone (p

specimens received a C7 osteotomy, seven with OWO and seven with 

PSO. All 14 specimens also were tested with Ti 3.5 mm and 4.5 mm 

spinal rods. Non-destructive pure moment flexion/extension (FE), 

lateral bending (LB) and axial rotation (AR) tests were conducted 

to 4.5 Nm. 3D motion tracking was used to monitor primary rangeof-motion 

across the entire fixation site (C4-T3) and the osteotomy 

(C6-T1). Independent of osteotomy type, the 4.5 mm rods exhibited 

a significant increase in stiffness compared to the 3.5 mm rods in 

all bending modes (p

fusion levels utilizing the PA and lateral radiographs. They were then 

shown the corresponding bend films and asked to again select fusion 

levels. The responses were evaluated to quantify changes in the 

decision making for fusion level selection. Average change in fusion 

level was 20% of cases (range: 6% to 40%). In eight, the change 

was to selective fusion compared with two that became non-selective 

fusions. Most adjustments were at the lowest instrumented vertebra 

(LIV) compared to upper instrumented vertebra (UIV), 51 vs. 12. A 

total of 40% of LIV changes were between L3 and L4. Bend films 

resulted in fewer fusion levels in 80% of cases, saving on average 1.4 

levels. Bending films for operative AIS patients with moderate curves 

appear to influence decision making in one of five cases. Depending 

on experience and undefined individual criteria for fusion level 

selection, this study suggests radiation exposure may be minimized 

by eliminating one of the bends and only keeping the appropriate 

bend for determining the caudal fusion level when in doubt. 

pApeR No. 448 

A Genome Wide Association Study Identifies IL17RC as 

an Adolescent Idiopathic Scoliosis Locus 

John P Dormans, MD, Philadelphia, PA 

Struan F Grant, PhD 

Norma Rendon, Philadelphia, PA 

Haitao Zhang, PhD, Hatfield, MD 

Frank D Mentch, MS 

Cecilia E Kim, BA 

Rosetta M Chiavacci, BSN, Philadelphia, PA 

Hakon Hakonarson, MD, PhD 

There is strong evidence for a genetic component to idiopathic 

scoliosis. Classical candidate gene studies have only achieved limited 

success in identifying genetic determinants of idiopathic scoliosis. 

Genome wide association studies (GWAS) have been revolutionizing 

the field of complex disease in the last five years, revealing multiple 

novel loci underpinning common disorders, including diabetes, 

asthma and autism. To date, no GWAS has been reported for 

scoliosis. We therefore elected to perform a GWAS of adolescent 

idiopathic scoliosis (AIS) on subjects recruited from the Department 

of Orthopedic Surgery at the Children’s Hospital of Philadelphia. 

We genotyped ~550,000 single nucleotide polymorphisms (SNPs) 

with the Illumina Human Hap550 Genotyping BeadChip on our 

study population of 137 adolescent idiopathic scoliosis cases of 

European ancestry and 2,126 controls. Following adjustment for 

local ancestry, four SNPs on chromosome 3p25.3 reached the strict 

threshold for genome wide statistical significance. The top signal at 

this locus, rs708567, is a common missense mutation (S111L) within 

the “interleukin 17 receptor C” (IL17RC) gene (P=1.18x10-9). The 

risk associated allele C confers an odds ratio of 2.28 i.e. more than 

doubles the risk of presenting with AIS. A GWAS has identified an 

IL17RC missense mutation (S111L) as an AIS locus. Efforts are now 

underway to replicate this association further, test it for association 

in additional sub-forms of idiopathic scoliosis and to test its 

functional role in the pathogenesis of the trait. This finding presents 

the potential opportunity for diagnostic applications and for novel 

therapeutic intervention for AIS. 

731 

pApeR No. 449 

Posterior Only Vertebral Column Resection vs. Anterior/ 

Posterior Vertebrectomy in Spinal Deformity 

Joshua Pahys, MD, Philadelphia, PA 





Matthew M Kang, MD 


Linda A Koester 

Posterior only vertebral column resection (VCR) is an alternative to 

combined anterior/posterior vertebrectomy (A/P-V) for the treatment 

of severe spinal deformity. We examined a matched cohort of 

patients with severe scoliosis and/or kyphosis, with a minimum two 

year follow up, treated by posterior only VCR vs. A/P-V. The surgical 

databases of two spine surgeons at one institution from 1994- 

2007 were reviewed. Patients were matched based on age at surgery 

(within 10 years), diagnosis, curve pattern, vertebra(e) resected 

(within one), levels fused (within five) and minimum two year 

follow up. A total of 34 VCR patients were identified that matched 

to 34 A/P-V patients. Comparing VCR vs. A/P-V groups: mean age at 

surgery: 22.3yrs/23.0yrs (p=0.89); vertebrae resected: 1.6/1.6; levels 

fused: 11.6/10.4 (p=0.27); average preop coronal Cobb: 71.9°/65.3° 

(p=0.52); average preop sagittal Cobb: 95.5°/75.7° (p=0.026). Final 

coronal Cobb correction for VCR vs. A/P-V groups were similar: 

(p=0.8), while VCR final sagittal Cobb correction was superior: 

53.0% vs. 40.0% (p=0.017). Total estimated blood loss was lower 

on average in the VCR group, 1,237 mL vs. 1,435 mL, although not 

statistically significant (p=0.5). The VCR group had a significantly 

shorter total operating room time: 534 min vs. 662 min (p=0.004) 

and total length of stay 9.9 vs. 21.0 days (p=0.004). Complications 

for VCR vs. A/P-V groups included: wound infections 2.9% vs. 8.8% 

(p=0.31); subsequent revision surgery, 2.9% vs. 8.8% (p=0.31); and 

transient motor deficits, 2.9% vs. 5.9% (p=0.49), respectively. There 

were no permanent neurologic deficits for VCR, and one permanent 

foot drop for A/P-V (p=0.5). Total SRS scores improved from preop 

to final follow up for VCR, (p=0.007), compared to A/P-V, (p=0.07). 

As compared to an A/P vertebrectomy for severe spinal deformity, a 

posterior VCR demonstrated shorter operative time and hospital stay, 

as well as improved sagittal correction and SRS scores at a minimum 

two year follow up. 

pApeR No. 450 

Is Thoracolumbar Scoliosis Associated With 

Obstructive Lung Disease? 

Viral Jain, MD, Cincinnati, OH 

Gary L McPhail, MD 

Robert E. Wood, MD 

R Paul Boesch, MD, Cincinnati, OH 

Steven Agabegi, MD, Cincinnati, OH 

Eric Wall, MD, Cincinnati, OH 

Alvin Howell Crawford, MD, Cincinnati, OH 

It is well known that restrictive lung disease can be associated 

with severe scoliosis. This study identifies that obstructive lung 

disease (OLD), in which a patient cannot exhale gas quickly from 

the airways, is commonly associated with scoliosis. We queried 

a pulmonary database for children with scoliosis who underwent 

pulmonary function testing (PFT) from 2005-2009. Patients with 

congenital, idiopathic or syndromic thoracolumbar scoliosis with a 

Cobb angle of > 40 degrees were included. Patients with other causes 




of OLD such as asthma and cystic fibrosis were excluded. OLD was 

defined per the American Thoracic Society criteria with FEV1/FVC 

ratio below the 95% confidence interval as compared to standard 

reference values. The reference population was used as a control group 

and neuromuscular scoliosis patients were used as a case-control 

group. A total of 222 scoliosis patients met inclusion criteria. The 

median Cobb angle was 50 degrees (range 40-146). The prevalence 

of obstructive lung disease in scoliosis patients was 37.2% (83/222). 

The odds ratios for OLD in cases versus the reference population 

was 23.3 and versus case-controls was 11.3. There is a statistically 

significant difference when comparing cases (83/222 cases have 

OLD) vs. control reference population (250/10,000 pts with OLD); 

the odds ratio is 23.3 with a 95% CI (confidence interval) of 17.2612 

to 31.4186. One-third of scoliosis patients with thoracolumbar 

scoliosis and a Cobb angle of > 40 degrees have obstructive lung 

disease. It is possible that scoliosis, particularly compression of a 

mainstem bronchus by a thoracic spinal deformity, may be a cause 

of this obstruction. 

pApeR No. 661 

urhBMP-2 versus Iliac Crest Bone Graft in Upper 

Thoracic to Sacrum Fusion in Adult Spinal Deformity 







Christine Baldus, MD, Saint Louis, MO 

A prior study showed bone morphogenetic protein (BMP) to have 

similar outcomes and pseudarthrosis to iliac crest bone graft (ICBG) 

in thoracic (30% at T2-T5) to sacrum fusion. This study reports 

outcomes of BMP versus ICBG in upper thoracic (T2-T5) to sacrum 

fusion in primary adult spinal surgery. Inclusion criteria for BMP 

group was minimum 5 mg BMP and 1.7 fixation points/level. 

Nineteen consecutive BMP (2003-2007) and 16 consecutive ICBG 

(no BMP) patients (1995-2002) with surgery at one hospital are 

included. Average follow-up was 2.7 years (range, 2-3.9 yrs) in BMP 

and 7.6 years (range, 3.5-11.5 yrs) in ICBG groups. Pseudarthrosis 

was diagnosed as rod breakage, screw loosening or implant pullout. 

Groups were similar at preop in gender (all F), smokers, body mass 

index (26 vs. 26, p=0.9) and major curve Cobb (MCC, 59° vs. 61°, 

p=0.8). BMP group was older than ICBG (62 vs. 52 yrs, p=0.001) 

group. Sixteen ICBG patients had more anterior fusions (average 

six levels) than 19 BMP patients (average one level, p

hBMP-7 was associated with a smaller inflammatory volume than 

rhBMP-2 was at each dose, the only statistically significant difference 

was seen in the 20 µg treatment group. In the 20 µg treatment group, 

rhBMP-7 was found to be associated with a significantly smaller 

granuloma mass and inflammatory zone area. Both rhBMP-2 and 

-7 trigger dose-dependent inflammatory reactions. Compared 

to rhBMP-2, rhBMP-7 is associated with smaller inflammatory 

volumes; however, this difference was only significant in the highestdose 

treatment group (20 µg). 

pApeR No. 664 

Effect of Platelet-rich Plasma-Serum on the 

Intervertebral Disc Degeneration: A Preclinical Study 

Koji Akeda, MD, PhD, Tsu, Japan 

Shuji Obata, MD 

Koichi Masuda, MD, La Jolla, CA 

Ryo Morimoto, MD 

Yumiko Asanuma, MD, PhD, Tsu, Japan 

Yuichi Kasai, MD, Mie Prefecture, Japan 

Akihiro Sudo, Prof., Tsu, Japan 

Platelet-rich plasma (PRP) has been clinically used as an autologous 

source of growth factors for tissue regeneration. The purpose of this 

study was to determine the effects of the serum isolated from PRP 

(PRP-serum) on the progression of disc degeneration in the rabbit 

anular needle puncture model. Twelve New Zealand white rabbits 

received an anular puncture in two noncontiguous discs to induce 

disc degeneration. Fresh blood was drawn to isolate autologous 

PRP. PRP and PPP (platelet-poor plasma) were prepared using two 

centrifugation techniques. After clot formation by adding autologous 

serum, the PRP- and PPP-serum was isolated from the clotted 

PRP and PPP by centrifugation. Four weeks after the surgery, PBS, 

PPP- or PRP-serum was injected into the punctured discs. Lateral 

X-rays of the lumbar spine were taken every two weeks. MRI (T2quantification) 

and histological analyses were performed 12 weeks 

after the initial puncture. The anular puncture induced a consistent 

disc narrowing within four weeks. PRP-serum induced a statistically 

significant restoration of disc height (PRP vs. PPP and PBS, p

integrity or ASIA score. There were 32 patients with >20 degrees 

kyphosis and 14 patients with or < 20° kyphosis, there was no difference in PLC 

integrity or ASIA score. The results of this study indicate that 50% 

LOVBH or kyphosis >20° are not predictive of ligamentous injury in 

thoracolumbar burst fractures and are therefore of little importance 

in clinical decision making. The posterior ligamentous complex 

and neural elements should be directly assessed with MRI if there is 

clinical concern. 

pApeR No. 667 

Robotic Guided Vertebral Cement Augmentation: 

A Major Radiation Reduction Tool 

Yair Barzilay, MD, Jerusalem, Israel 

Joshua Schroeder, MD 

Amir Hasharoni, MD, Tel-Aviv, Israel 

Meir Liebergall, MD, Jerusalem, Israel 

Leon Kaplan, MD, Jerusalem, Israel 

The risk of radiation induced cancer among orthopedic and spine 

surgeons is up to five times the risk of the general population. 

The risk of developing breast cancer is three fold higher in female 

orthopedic surgeons. According to the literature, one level vertebral 

augmentation is associated with a minimum of 180 seconds of 

radiation exposure in free hand technique and a minimum of 90 

seconds with navigation systems. This study reports the radiation 

measurements in robotic-assisted vertebral augmentation. Fortysix 

vertebral augmentations (one to five levels) were performed 

in 27 patients. Average age was 67 (29-92), 21 females and six 

males. Twenty of the fractures were osteoporotic, seven pathologic. 

Augmentation (Jamshidi) needles insertion to the vertebrae was 

robotically guided. Pulsed fluoroscopy monitored every 0.25 cc 

of cement injected. In multiple level augmentation, two surgeons 

injected cement into adjacent vertebrae with simulations fluoroscopy 

control. Data collection included procedure, robotic and radiation 

time measurements. Mean procedure time was 119 minutes (49- 

350). Robotic guidance required 37 minutes on average (10-93). 

Mean total radiation time per level (required for registration, needle 

insertion and augmentation) was 46.1 seconds (patient’s exposure); 

while mean needle positioning and augmentation related radiation 

time per level was 37.8 seconds (operating room (OR) staff 

exposure). Robotic guided vertebral augmentation, the use of pulsed 

fluoroscopy and simultaneous cementation of two vertebrae by two 

surgeons reduces the radiation exposure of patients, surgeons and 

OR staff by 60% compared to reports in the literature. 

pApeR No. 668 

Percutaneous Short Segment Spinal Instrumentation in 

One-Level Unstable Burst Fractures 

K Samer F Shamieh, MD, Shreveport, LA 

Patrick Allen Massey, MD, Shreveport, LA 

Gabriel James Hommel, MD, Columbus, GA 

Debi P Mukherjee, Sc.D, Shreveport, LA 

Richard Evan McCall, MD, Shreveport, LA 

Minimally invasive spine surgery with short-segment instrumentation 

has recently been advocated for the treatment of traumatic one-level 

unstable thoracolumbar burst fractures. A retrospective three-month 

evaluation of patients treated with percutaneous instrumentation 

without fusion was done. From 2008-2009, 18 consecutive patients 

were treated with short segment (one level cephalad and one level 

caudad) percutaneous polyaxial pedicle screws without fusion. All 

patients sustaining traumatic one-level thoracolumbar unstable 

734 

burst fractures without neurologic injury were included in the study 

following the criteria of thoracolumbar injury classification score. 

Radiographic outcomes were assessed on the basis of change in 

angulation and change in vertebral body height after three months. 

There was no significant difference in vertebral height (mm) between 

the injury measurements and the immediate post-surgical CT 

measurements (21.4±6.0 vs. 22.8 ± 4.7, p = 0.05). However, vertebral 

heights after three months (30.9 ± 5.2) were significantly different 

between the post injury (21.4 ± 6.0) and post op values (22.8 ± 4,7). 

No statistically significant difference in radiographic outcomes was 

noted between the injury kyphotic angulation (9.7±6.9 vs. 8.5±5.0 

p = 0.54) and vertebral body height loss (71.9± 16.9 vs. 74.0± 14.3 

p = 0.69) when compared to three months postoperatively. Short 

segment fixation in unstable one-level thoracolumbar fractures 

corrected vertebral body height immediately after surgery. However, 

the three-month data showed that this construct was unable to 

maintain sagittal balance (vertebral height). It appeared that the 

constructs failed at the polyaxial screw-saddle interface as evidenced 

by the unaltered position of the screw in bone. 

pApeR No. 669 

The Effect of Pedicle Screw Countersinking on Pull-Out 

Resistance in the Thoracic Spine 






Daniel Kang, MD, Chevy Chase, MD 

The biomechanical fixation strength afforded by pedicle screws has 

been strongly correlated with bone mineral density (BMD). It has 

been postulated in the osteoporotic spine, that countersinking, or 

‘hubbing,’ the head of the pedicle screw against the dorsal cortex 

provides a load-sharing effect thereby limiting cephalocaudad 

toggling and improving the pull-out resistance of the pedicle screw. 

Twenty-two human cadaveric thoracic vertebrae were acquired and 

DEXA scanned. Osteoporotic (n=16) and normal (n=6) specimens 

were instrumented with a 5.0 x 35 mm pedicle screw on one side in a 

standard fashion. In the contralateral pedicle 5.0 x 30 mm screw was 

inserted with countersinking of the screw into the dorsal lamina. A 

difference in screw length was utilized to achieve equivalent depth/ 

chordlength. Following 2,000 cycles of cephalocaudad toggling 

screws were pulled out with the tensile force oriented in-line with 

the midline of the spine and peak POS measured in newtons (N). 

‘Hubbed’ screws resulted in significantly lower POS (290.5±142.4 

N) compared to standard pedicle screws (511.5±242.8N)(p=0.00). 

This finding was evident in both normal and osteoporotic vertebrae 

based on independent subgroup post hoc analyses (p

pApeR No. 670 

uThe Effects of Cement Augmentation Technique and 

Volume on Pedicle Screw Fixation in Osteopenic Bone 

Todd Joseph Lansford, MD, Kansas City, KS 

Terence McIff, PhD, Kansas City, KS 

Douglas C Burton, MD, Kansas City, KS 

Cement augmentation of pedicle screws improves fixation in 

osteopenic spines. To avoid complications of cement extravasation 

during open pedicle injection and the difficulty of extracting 

fenestrated screws, a novel fenestrated tap (NFT) was created, which 

leaves a threaded cement track upon removal. This cemented tract 

allows the insertion of a standard pedicle screw into the augmented 

vertebral body. The NFT was fabricated by drilling fenestrations in the 

distal one-third of standard pedicle screws. Vertebral augmentation 

involved placement of the NFT and injection of either 2 ml or 3 ml 

of polymethylmethacrylate bone cement (PMMA). Prior to cement 

hardening, the NFT was removed and replaced with a standard 

pedicle screw. On the contralateral side, open injection technique 

was utilized. The screws in 21 osteopenic lumbar vertebral bodies 

were subjected to cephalocaudal toggling. The torque required 

for the removal of screws was completed on an additional eight. 

Visualization of cement extravastion into the pedicle was noted. 

There was a significant 51% greater resistance to toggle (p

pApeR No. 673 

Hedgehog Signaling and BMP2-induced Osteogenic 

Differentiation In Vitro and Spine Fusion In Vivo 

Jared Johnson, MD, Los Angeles, CA 

Jeong-hyun Yoo, MD, PhD, Koyang, Kyunggi, Republic of Korea 

Vicente Meliton, MS 

Woo Kim, PhD 

Jeffrey C Wang, MD, Santa Monica, CA 

Renata Pereira, PhD 

Theodore J Hahn, MD 

Farhad Parhami, PhD 

We examined the effect of cyclopamine (Cyc), a specific Hedgehog 

(Hh) signaling inhibitor, on BMP2-induced osteogenic differentiation 

of bone marrow stromal cells (MSC) in vitro, and BMP2-mediated 

bone formation and spinal fusion in rats in vivo. M2-10B4 MSC cells 

were treated with control vehicle or 50 ng/mL BMP2 with or without 

2 ¼M cyclopamine. Twenty-six Lewis rats were divided into four 

groups and underwent posterolateral intertransverse process spinal 

fusion with implantation of a collagen sponge carrier containing 

control vehicle, 5¼g BMP2, 5¼g BMP2 + 2 mg Cyc or Cyc alone. Bone 

formation and fusion was assessed by radiograph, manual palpation 

of excised spines, Micro CT and histology. Cyc significantly inhibited 

BMP2-induced mRNA expression of the osteogenic differentiation 

markers osterix, alkaline phosphatase (ALP) and bone sialoprotein, 

as well as ALP activity, suggesting a role for basal Hh signaling in 

BMP2-induced osteogenic differentiation of MSC. In vivo, no fusions 

or new bone formation were found in control or Cyc treated rats. All 

specimens from BMP2 treated rats demonstrated complete fusion 

with robust bone formation. Bone formation in rats that received 

BMP2+Cyc, although greater than that seen in control or Cyc treated 

animals, was significantly inhibited when compared to BMP2 

treated rats, with none of the specimens showing complete fusion. 

Hh and BMP signaling are important for osteoblast generation and 

bone formation. However, the role of basal Hh signaling in BMPinduced 

osteogenic differentiation has not been defined. These 

findings suggest an important role of Hh signaling in BMP2-induced 

osteogenesis in vitro and in vivo. 

pApeR No. 674 

uOsteogenic Differentiation In vitro And Spinal Fusion 

In vivo Induced By Novel Oxysterol Molecules 


Vicente Meliton, MS 


Michael Jung, PhD 

Sotirios Tetradis, PhD, DDS 

Theodore J Hahn, MD 

Francine Farouz, PhD 

Scott Thies, PhD 

Farhad Parhami, PhD 

Here we report on the synthesis and characterization of two novel 

oxysterol molecules, Oxy34 and Oxy49, which induce osteogenic 

differentiation of bone marrow stromal cells (MSC) in vitro and 

induce bone formation and spine fusion in vivo. M2-10B4 (M2) 

MSC were treated in vitro with 0.1-5 uM of Oxy34 or Oxy49. In 

vivo 60 Lewis rats were divided into six groups and underwent 

posterolateral intertransverse spinal fusion at L4-5 with bilateral 

implantation of a collagen sponge carrier containing: 1) control 

vehicle, 2) 5 ug rhBMP2, 3) 0.2 mg Oxy34, 4) 2 mg Oxy34, 5) 20 

mg 0xy34 or 6) 20 mg Oxy49. At four, six and eight weeks, bone 

736 

formation was assessed by plain radiographs. Definitive fusion in all 

specimens was then determined at nine weeks by manual palpation 

and MicroCT of the excised spines. In vitro treatment induced the 

mRNA expression of early and late osteogenic differentiation markers 

and robust mineralization. In vivo, manual assessment and micro 

CT showed fusion in 0/10 Group 1, 10/10 Group 2 (eight bilateral/ 

two unilateral), 0/10 Group 3, five/10 Group 4 (three bilateral/ 

two unilateral), 10/10 Group 5 (eight bilateral/two unilateral) and 

10/10 Group 6 (eight bilateral/two unilateral). Bone morphogenetic 

proteins (BMPs) although effective in promoting osseous growth and 

spinal fusion, have limitations in their use because of higher costs 

and possible adverse effects, including ectopic bone formation and 

inflammatory reaction, particularly in the cervical spine. Oxy34 and 

Oxy49 are potent novel osteoinductive molecules that may provide a 

new alternative for clinical stimulation of bone formation. 

pApeR No. 675 

uNanostructured TCP In Rabbit Posterolateral Fusion 

Compared To Commercial Osteobiologics 

William R Walsh, PhD, Randwick, NSW Australia 

Florence Degroot, PhD 

Nicky Bertollo, PhD, Randwick, NSW Australia 

Frank Vizesi, PhD 

Nicholas J Hancock, FRCS 

Joost De Bruijn, PhD 

Erik M Erbe, PhD, San Diego, CA 

Nanostructured osteobiologics attract higher levels of proteins 

from the body and present a new option for high performance 

bone grafting without the need for cells or proteins to be added 

ex-vivo. The rabbit posterolateral fusion model is an accepted 

tool for assessing graft performance and was to compare several 

commercially available products with a novel osteobiologic. Sixty 

New Zealand white rabbits were assigned to six groups following 

ethical approval for single level fusion in an established model. The 

test groups were autograft, empty, BMP2, bioactive TCP, silicated HA 

and a novel nanostructured tricalcium phosphate (TCP) combined 

with a biodissolvable polymer carrier. MicroCT, mechanical testing 

and histology were performed at 12 weeks. Protein adsorption was 

conducted in vitro. Radiographic review revealed 85% fusion for 

autograft, 0% for empty and 100% for BMP2. Fusion was difficult 

to assess by plain radiographs in calcium phosphates due to nonresorbed 

graft material while micro CT demonstrated new bone in 

the nanostructured TCP, bioactive TCP and silicated HA groups. The 

nanostructured TCP was mechanically superior (P

pApeR No. 736 

Lessons Learned After 9 Years Clinical Experience With 

Three Different Nucleus Replacement Devices 

Luiz Pimenta, MD, Sao Paulo, SP Brazil 

Leonardo Oliveira, MD, Sao Paulo, SP Brazil 

Luis Marchi, MS, Sao Paulo, SP Brazil 

Etevaldo Coutinho, MD, Sao Paulo, SP Brazil 

The nucleus replacement devices have been developed for treating 

moderate forms of degenerative disc disease, trying to fill the gap 

between discectomy and fusion. The surgical goals are pain relief, 

maintenance of the disc height and flexibility at the index and adjacent 

levels. Prospective, non randomized, single center clinical study with 

125 patients presenting moderate forms of degenerative disc disease. 

Radiographic (anterior/posterior, lateral and dynamic) and clinical 

outcomes were collected preoperatively, one week and one, three, 

six, nine and annually through nine years postoperatively. The VAS 

and ODI questionnaires were used to assess pain and functional 

outcomes. Eighty patients had PDN disc prosthesis, 26 patients with 

PNR (Trans1) and 19 patients using the NUBAC (Pioneer) device. 

The surgical techniques for each device were performed following 

the prosthesis indications. After nine years follow up, the global 

retrieval incidence was 48.8% (61/125). From these patients, 15 

(57.7% of the specific device) had PNR failures, eight (42.1% of 

the specific device) experienced NUBAC retrievals and 38 (47.5% of 

the specific device) had PDN flaws. The failures included significant 

loosening of the disc height at the operated level, displacement, 

silicon inside de canal and migration. All patients underwent fusion 

as a retrieval surgery. The retrieval rate in our series is very high. It 

shows that the end-plate reaction in a long period of time happens, 

resulting in important subsidence and mechanic back pain. The 

device expulsion was another cause of pain and second surgery, as 

shown in the literature. 

pApeR No. 737 

Cervical Disc Replacement: Five Year Follow-Up From 

The U. S. Prospective Randomized Bryan Trial 

Rick C Sasso, MD, Indianapolis, IN 

Paul A Anderson, MD, Madison, WI 

John G Heller, MD, Atlanta, GA 


The published two-year results of the pivotal FDA investigational 

device exemption trial of cervical arthroplasty compared to anterior 

cervical discectomy with fusion (ACDF) for treating single-level 

degenerative cervical disc disease revealed a statistically superior 

overall success rate in the arthroplasty group. The purpose of this 

study is to evaluate the currently available data at half of a decade to 

determine their consistency over time and to assess complications 

and revision surgeries. A total of 463 patients were enrolled in a 

prospective, randomized, controlled, multi-center study with a 1:1 

randomization scheme; 242 in the arthroplasty group and 221 in 

the control group. No statistical differences were seen between the 

groups for demographics and preoperative measures. As of May 28, 

2010, five-year follow-up data were available for 193/242 (79.8%) 

of the arthroplasty patients and 159/221 (71.9%) of the control 

patients. The study’s primary outcome measure, overall success, as 

well as secondary functional outcome measures (NDI, SF-36, arm 

and neck pain scores), were collected at pre-defined time points out 

to 60 months postoperatively. At 60 months postoperatively: overall 

success rate: 160/193 (82.9%) for the arthroplasty group, 119/159 

(74.8%) for the control group, p=0.043;NDI score: 15.9 arthroplasty, 

19.1 control, p=0.020; neck pain score: 23.8 arthroplasty, 28.8 

737 

control, p=0.031 (change from preop: -51.3 arthroplasty, -45.2 

control, p=0.031); and SF-36 PCS: 47.3 arthroplasty, 44.0 control, 

p=0.006 (change from preop: 14.4 arthroplasty, 11.8 control, 

p=0.006); cumulatively up to 60 months: second surgery at index 

level: 11 (4.5%) arthroplasty, 11 (5.0%) control; possibly related 

AEs: nine (3.7%) arthroplasty, 14 (6.3%) control; possibly devicerelated 

and serious (grade 3 or 4) adverse events (AE): four (1.7%) 

arthroplasty, nine (4.1%) control. Based on currently available data, 

excellent results continue out to five years postoperatively in both 

the arthroplasty and ACDF groups. Continued statistically significant 

differences are present for overall success that favor the arthroplasty 

cohort at 60 months, as was seen at 24 months postoperatively. The 

NDI, SF-36 PCS and neck pain scores also showed improvement 

in the arthroplasty group that was statistically significant at 60 

months compared to the control group. Second surgery and adverse 

events were very low in both groups with no statistically significant 

differences between groups at half a decade postoperatively. 

pApeR No. 738 

Retrieval Analysis of ProDisc? Cervical Total Disc 

Replacements 

Sean Lefloch, BS, New York, NY 


Kai Zhang 

Stelios A Koutsoumbelis, MD, New York City, NY 

Celeste Abjornson, PhD, New York, NY 

Frank P Cammisa Jr, MD, New York, NY 


The goal of this study was to examine components retrieved from 

patients who had undergone cervical total disc replacement (TDR) 

and who subsequently required revision surgery that included 

removal of the implant components. The objectives were to identify 

wear patterns on the metallic inlays and polyethylene (PE) bearing 

surfaces and to examine the plasma sprayed endplate surfaces for 

evidence of bony fixation. ProDisc-C® TDRs from revision surgeries 

were received from outside institutions. The retrieval collection 

includes 19 ProDisc-C® TDRs. PE and metallic components were 

examined using light stereo-microscopy. The devices were retrieved 

because of trauma, infection or continued pain; not associated with 

component malfunction. PE wear patterns tended to be asymmetrical, 

with machine marks visible at the periphery. Mild scratching was 

evident on 11 of 19 implants. Mild backside wear was observed 

on five of eight implants. Evidence of impingement on metallic 

endplates, PE inlays or both was observed in 16 cases. Wear on the 

modular interfaces between the PE insert and the metal backing was 

mild, indicative of micromotion. Bony on growth was appreciated 

on 85% on the superior endplates and 65% of the inferior endplates. 

Impingement and PE wear was seen on a significant number of 

the retrieved components. As more retrieved implants become 

available, correlations between wear and impingement findings and 

demographic and radiographic data will be explored. Fixation in 

these implants did not appear to be a problem. Future work includes 

quantifying deviations from CAD models and determining extent of 

backside polyethylene wear. 




pApeR No. 739 

Biologic Effect of Metallic Wear Debris on 

Chondrocytes Harvested from the Annulus Fibrosus 

Edward Ratcliffe Anderson, III MD, San Antonio, TX 

Garrick Wayne Cason, MD, Ooltewah, TN 


Carly Gratopp 


The influence of metallic wear debris, similar to that shed by spine 

instrumentation in vivo, on intervertebral disc chondrocytes is 

currently unknown. An in vitro study characterizing the effect 

of metallic debris on human annulus fibrosus chondrocytes is 

presented. Annulus fibrosus tissue, collected from interbody fusion 

procedures, was minced and incubated in defined minimum 

essential medium (DMEM) and collagenase. Cells were separated 

from the tissue and cultured on top of 316L, CoCrMo or Ti6Al4V 

particles in 24-well culture plates. Cell morphology was monitored 

at 24 hour intervals. Production of TNF-a, IL-1b, IL-6 and IL-8 

and caspase-3 was assayed by ELISA. Viability was compared after 

seven days by MTT assay. After 24 hours of culture, cells entered 

a phagocytotic phase with active uptake of particles within cell 

membranes. Chondrocytes exposed to 316L stainless steel became 

more spherical in shape, while CoCrMo- and Ti6Al4V-treated cells 

maintained an elongated fibrochondrocytic appearance. Expression 

of inflammatory cytokines and apoptosis markers was dose, time and 

material-dependent. The MTT assay performed at seven days showed 

that 316L particles reduced viability the most, followed by CoCrMo 

and Ti6Al4V at each dose. As previously demonstrated, phagocytosis 

of metal particles leads to expression of proinflammatory cytokines, 

which may perpetuate local inflammatory and degenerative changes. 

Observed changes in cell morphology, pro-inflammatory cytokine 

expression and cell viability suggests that metallic wear debris may 

have the potential to induce degenerative changes in adjacent disc 

tissue. 

pApeR No. 740 

Biological Activities Of PEK Particles In Epidural Space 

Korush Kabir, MD, Bonn, Germany 

Jens Schwiesau 

Christoph Burger, MD, Bonn, Germany 

Robert Pflugmacher, MD, Bonn, Germany 

Thomas Grupp, MD 

Dieter Wirtz, MD, Bonn, Germany 

Total disc arthroplasty (TDA) is designed to preserve motion. The 

clinical significance of wear debris was reported in total disc arthroplasty. 

Our goal was to evaluate the biological response of polyetherketone 

(PEK) wear debris in epidural space. Thirty-six female rabbits were 

randomly allocated to three groups: PEK, UHMWPE-particles and 

sham. The particles were implanted into the epidural space of the 

cervical region by percutaneous technique (fluoroscopic guidance). 

Neurobehavioral observations were conducted at pretreatment, on 

day one-14 postinjection, then weekly. Cervical spine tissue sections 

were examined for histopathological inflammation in response to 

the particles after three and six months. Except two in PEK group, 

none of the animals showed any neurological or musculo-skeletal 

abnormality. The neurological deficits presented immediately after 

injection and did not progress. There was no evidence of systemic 

toxicity. Histopathological examination revealed that polarizing, 

crystalline wear debris was seen in the vertebral canal of examined test 

injection sites surrounded by inflammatory cells. The inflammation 

and angiogenesis was limited to the epidural space around the 

738 

particles. There was no evidence of osteolysis and changes of the 

dura mater. In conclusion, we have established a percutaneous 

technique to implant wear debris in the cervical epidural space in a 

rabbit model to simulate the biological consequences of debris after 

TDA. PEK and UHMWPE show similar histopathological changes 

in the cervical epidural space. The inflammation was limited to the 

epidural space around the particles. We propose that PEK could be 

an alternative bearing material in total disc arthroplasty. 

pApeR No. 741 

Cost-Effectiveness of Cervical Disc Replacement 

Sheeraz Qureshi, MD, New York, NY 

Steven McAnany, MD, New York, NY 

Andrew C Hecht, MD, New York, NY 

In recent years, there has been increased interest in the use of 

cervical disc replacement (CDR) as an alternative to anterior cervical 

discectomy and fusion (ACDF). While ACDF is a proven intervention 

for patients with myelopathy and radiculopathy, there are inherent 

limitations specific to the procedure. CDR was designed to preserve 

motion, avoid the limitations of fusion and theoretically allow for a 

quicker return to activity. A number of recent systematic reviews and 

randomized controlled trials have been published demonstrating 

positive clinical results for CDR but there are no studies demonstrating 

which strategy is more cost-effective. The purpose of this study 

was to evaluate the cost effectiveness of CDR and ACDF using the 

power of decision analysis. Additionally, we aimed to identify the 

most critical factors affecting both cost and effectiveness and define 

thresholds for durability and function to focus and guide future 

research. A surgical decision model was created for the treatment 

of single-level cervical disc disease with associated radiculopathy. 

The literature was reviewed to identify possible outcomes and their 

likelihood following CDR and ACDF. Health state utility factors 

were determined from the literature and assigned to each possible 

outcome and effectiveness was expressed in units of quality-adjusted 

life years (QALY). Using ICD-9 procedure code and data from the 

Nationwide Inpatient Sample (NIS), median cost of hospitalization 

was obtained by multiplying hospital charges by the hospital specific 

cost-to-charge ratio. Gross physician costs were determined from 

the mean Medicare reimbursement for each CPT code. Uncertainty 

in both the cost and effectiveness numbers were assessed using 

sensitivity analysis. In the reference case, the model assumed a 20year 

duration of the CDR prosthesis. Although both ACDF and 

CDR were found to be cost-effective at all time points (based on 

willingness to pay $50,000/QALY), CDR resulted in higher average 

QALYs gained at a lower cost to society if both strategies survived 

for 20 years ($3,103/QALY for CDR versus $4,435/QALY for ACDF). 

Sensitivity analysis determined that CDR needed to survive at least 

13.99 years in order to be considered a more cost-effective strategy 

than ACDF. Sensitivity analysis also demonstrated that CDR must 

provide a utility state of at least 0.838 in order to be cost-effective. 

Both cervical disc replacement and anterior cervical discectomy 

and fusion were shown in this reference case to be cost-effective 

procedures. Given the results found in the sensitivity analysis, 

cervical disc replacement must remain functional for at least 14 

years in order to establish greater cost-effectiveness as compared to 

anterior cervical discectomy and fusion. Since the current literature 

has not yet demonstrated with certainty the actual durability and 

long-term functionality of CDR, future long-term studies will be 

required to validate this analysis. 




pApeR No. 742 

Effect of Methylprednisolone Infusion on the 

Expression of CNTF in a Rat Spinal Cord Injury Model 

Daniel J Del Gaizo, MD, Chicago, IL 

Ronald D Graff, PhD, Chapel Hill, NC 

Sameer Mathur, MD, Cary, NC 

Ciliary neurotrophic factor (CNTF) is known to have both 

neuroprotective and regenerative qualities. The expression and 

concentration of CNTF has been shown to increase in the spinal cord 

after an acute spinal cord injury (SCI). Although controversial, many 

emergency centers continue to administer the National Acute Spinal 

Cord Injury Study (NASCIS) high dose IV methylprednisolone (MP) 

bolus/infusion to patients presenting within eight hours of an acute 

SCI. This study was designed to evaluate the effect of the NASCIS MP 

infusion protocol on the expression of the neuroprotective cytokine, 

CNTF. Thirty Long Evans rats were subjected to a standardized SCI. 

The animals were randomized to receive either the rat dose equivalent 

(RDE) of the NASCIS MP infusion protocol or an equivalent volume 

of normal saline (NS). Three animals in each group were sacrificed 

at six, 12, 24, 48 and 72 hours post SCI. An additional three 

animals were sacrificed immediately after injury to serve as baseline 

control. RT-PCR was used to quantify the expression of CNTF in the 

injured spinal cord of each animal at sacrifice. CNTF expression was 

significantly decreased in the animals that received IV MP at both 

12 (p.0006) and 24 (p.0008) hours post injury when compared to 

animals that received an equivalent volume of IV NS. The NASCIS 

MP protocol inhibited the expression of CNTF. By inhibiting the post 

injury increased expression of the neuroprotective cytokine CNTF, 

the NASCIS MP protocol may have a detrimental effect in patients 

with acute spinal cord injury. 

pApeR No. 743 

Effects of Epidural Steroid Injections on Blood Glucose 

Levels in Patients with Diabetes Mellitus 

Jesse L Even, MD, Nashville, TN 

Kirk A McCullough, MD, Nashville, TN 

Yanna Song, PhD 

Clinton J Devin, MD, Nashville, TN 

Epidural steroid injections (ESI) are commonly used in the 

treatment of multiple spinal disorders. Corticosteroid injections 

have been evaluated in the total joints and hand literature showing 

systemic effects to diabetics. There has not been a clinical study to 

evaluate if ESI cause systemic effects in diabetics. Diabetic patients 

who were scheduled for an ESI were given an opportunity to enroll 

in our Institutional Review Board approved study. We collected the 

patient’s most recent hemoglobin A1c (hA1c) and then asked them 

to track their blood glucose numbers at least twice per day for two 

weeks prior to and after their ESI. We noted a statistically significant 

increase in blood glucose levels in diabetic patients (N=30) after 

epidural steroid injection. The mean blood glucose level prior to ESI 

injection was 157.97 ± 45.71 and after ESI it was 304.00 ± 112.63. 

This represents an average 146.03 ± 88.5 increase in blood glucose 

levels after injection, which was significantly higher than 0 (p=0.0001, 

Wilcoxon singed-rank test). Using a nonlinear mixed effect model 

the estimated half life of this increase was 1.54 days (95% CI 0.86, 

7.37), meaning that the patients were back within their normal 

standard deviation mean glucose levels within two days of injection. 

The Spearman correlation when evaluating the association between 

pre injection hA1c levels and maximum blood glucose change was 

0.174 (p=0.502) indicating there is no correlation between pre 

injection hA1c levels and systemic response to ESI. Epidural steroid 

739 

injections were noted to cause a significant increase in the blood 

glucose levels in diabetics. There was no correlation between pre 

injection diabetic control, represented by hA1c levels, and post 

injection response. Diabetics who are candidates for ESI should 

be counseled that a blood glucose increase may be apparent post 

intervention but effects should not last longer than approximately 

two days. 

pApeR No. 744 

Can Ketamine Prevent Post-Op Pain In Opiate- 

Dependent Patients - A Plaebo-Controlled Blind PRC 

Study 

Dilip K Sengupta, MD, Hanover, NH 

Randy W Loftus, MD 

William A Abdu, MD, Lebanon, NH 

Ketamine has been shown to be useful in the reduction of acute 

postoperative pain and analgesic consumption. Little is known 

regarding its efficacy in opiate-dependent patients with a history 

of chronic pain. We hypothesized that ketamine would reduce 

postoperative opiate consumption and improve surgical outcomes in 

this patient population. This was a randomized, prospective, doubleblinded 

and placebo controlled trial involving opiate-dependent 

patients with a history of chronic back pain scheduled to undergo 

major lumbar SPINE surgery. A total of 102 patients were enrolled 

over a two-year period (February 2007 to April 2009). Patients in 

the treatment group were administered 0.5 mg/kg of intravenous 

ketamine prior to the surgical incision followed by an infusion at 

10 mcg/kg/min started prior to incision and terminated at wound 

closure. Patients in the placebo group received saline of equivalent 

volume. The anesthetic was controlled in both groups, and patients 

were followed for 48 hours post-operatively and seen again at the 

first post-surgical visit. The primary outcomes were pain intensity 

as measured by morphine consumption and average reported visual 

analog scales in the acute postoperative period (up to 48 hours) 

and at the first post-surgical visit (six weeks). Secondary outcomes 

included hemodynamic changes, duration of post-anesthesia care 

unit and hospital stay and differences in adjunctive and conservative 

treatments at six weeks as compared to preoperative patient 

reports. Total morphine consumption (morphine equivalents) was 

significantly reduced in the treatment group at 24 and 48 hours and 

at six weeks. The average reported pain intensity as indicated by the 

visual analog scale was significantly reduced in the post-anesthesia 

care unit and at six weeks but was no different in the first 48 hours. 

There were no differences in known ketamine or opiate-related sideeffects 

between groups. Intraoperative use of preventative, low-dose 

racemic ketamine reduces opiate consumption and reduces pain 

intensity both in the acute postoperative period and at six weeks after 

surgery in opiate-dependent patients undergoing painful surgery. 

This benefit is without an apparent increase in side effects. 

pApeR No. 745 

Surgical Treatment Of Aneurysmal Bone Cysts Of The 

Spine 

Addisu Mesfin, MD, Baltimore, MD 

Edward F McCarthy Jr, MD, Baltimore, MD 

Khaled M- Kebaish, MD, Baltimore, MD 

Aneurysmal bone cysts (ABC) are rare, benign, highly vascular 

pseudotumors of unknown etiology. The objective of this study is 

to report our experience with the surgical management of ABCs of 

the spine in pediatric and adult patients. A retrospective review of 

patients diagnosed with ABCs of the spine (excluding the sacrum) 




at our institution was performed. From 1995-2006, 17 patients were 

identified; 14 of the 17 patients underwent surgical management at 

our institution. Three of the 17 patients were managed at outside 

institutions. From the 14 patients managed at our institution, nine 

had greater than two-year follow up. The location of the ABCs, 

recurrence rates, presenting symptoms, treatment and complications 

were documented for these nine patients. The cervical spine, at 56%, 

was the most common location with 22% in the lumbar and 22% in 

the thoracic spines. Mean age of presentation was 17.2 (five-32). The 

average follow up was 49.6 month (24-88). All patients underwent 

either resection and combined anterior and posterior spinal 

fusion (67%) or resection and posterior spinal fusion (33%). Two 

recurrences within three months were noted. Pain was the presenting 

symptom in 100% of cases. Four complications were noted. ABCs 

of the spine can be successfully treated with surgical resection and 

in this study, no recurrence was noted in 78% of patients after a 

minimum of two-year follow up. Most of the patients developed 

symptoms before age 18 and all presented with pain. The cervical 

spine was the most frequently involved site. 

pApeR No. 746 

MRI Is a Reliable, Accurate, and Safe Alternative to CT 

Scan for Evaluation of Pedicle Morphology 

Adam Laurance Wollowick, MD, New York, NY 

Beverly Thornhill, MD 

Terry David Amaral, MD, Bronx, NY 

Etan Sugarman, MS, Bronx, NY 

Vishal Sarwahi, MD, Bronx, NY 

Understanding pedicle morphology is important for the safe 

placement of pedicle screws. Currently, the gold standard modality 

to assess pedicle morphology is CT scan. However, CT scans carry 

an increased risk of radiation exposure. We have evaluated MRI as a 

potential alternative to CT scan for assessing the bony architecture 

of pedicles. A total of 765 pedicles in 24 spinal deformity patients 

were reviewed independently by a bone radiologist and a spine 

surgeon. Pedicle morphology was classified as: Type A (normal 

pedicle): >4mm cancellous channel, Type B: 2-4 mm channel, Type 

C: cortical channel, and Type D:

lytic spondylolisthesis, lumbar fusion for degenerative disc disease 

exclusion criteria, revision surgery, development of postoperative 

complications, diagnosis of deformity/trauma/infection/tumor. The 

patient data was also collected from the review of medical records. 

The preoperative, six week, six month and one year postoperative 

ODI/NDI scores were used for analysis apart from the preoperative 

SF-36 PCS and MCS scores. The last available assessment was 

determined and used for subsequent analysis to maximize the 

number of patients in each group. The total number of patients 

included 404 patients (ACDF 89, DDD 43, HNP 91, Spondy 140, 

Stenosis 41) who satisfied the inclusion criteria. Normative data 

for baseline and final ODI/NDI scores are presented. While the 

preoperative diagnosis and the ODI/NDI score is an indicator of 

postoperative outcome, a specific threshold value does not seem to 

exist for any of the conditions which would predict SCB. Greater 

baseline ODI, greater age at surgery and lower ODI is associated with 

greater improvement in final ODI whereas smoking and worker’s 

compensation status adversely affects final scores. 

pApeR No. 749 

The Impact of Spinal Disorders on Health-related 

Quality of Life 

Anthony De Giacomo, MD, Hacienda Heights, CA 

Sheri Rocha, BS 

Serena S Hu, MD, San Francisco, CA 


Steven Takemoto, PhD, San Francisco, CA 

Shane Burch, MD, San Anselmo, CA 

Sigurd H Berven, MD, San Francisco, CA 

Spinal conditions have a significant and measurable impact on 

health-related quality of life. The relative impact of common spinal 

disorders on health status remains unknown. The purpose of this 

study is to quantify the effect of different spinal diagnoses on health 

status. Prospective, observational study of consecutive adolescent 

and adult preoperative patients from a single institution. Predictor 

variables were diagnosis, comorbidities, age and gender. Outcome 

variables were SF-36 physical and mental composite scores. Data 

analysis used multivariate linear regression to determine the 

association between diagnosis and health status, controlling for age, 

gender and comorbidities. A total of 933 patients had 14 different 

spinal diagnosis: lumbar spondylolisthesis (n=119), cervical stenosis 

(n=89), cervical degenerative disc disease (DDD) (n=89), lumbar 

stenosis (n=120), lumbar DDD (n=84), lumbar disc herniation 

(n=95), adult scoliosis (n=155), adolescent scoliosis (n=10), 

thoracic kyphosis (n=43), flatback deformity (n=26), pseudarthrosis 

(n=80), compression fracture (n=22), tumor (n=23) and infection/ 

osteomyelitis (n=eight). Multivariate linear regression, demonstrated 

that adolescent scoliosis, thoracic kyphosis and cervical DDD were 

associated with significantly higher physical component scores 

(PCS). Flatback deformity, lumbar stenosis and lumbar DDD were 

significantly associated with lower PCS scores. Flatback deformity 

and adolescent scoliosis were significantly associated with higher 

mental component scores (MCS), where as thoracic kyphosis was 

associated with a lower MCS score. Spinal disorders have a significant 

impact on patient quality of life. There are significant differences 

in the impact of specific disorders on physical and mental health 

status. Preoperative spine patients present with health status that is 

more severely compromised than many other common medical and 

surgical conditions. 

741 

pApeR No. 750 

Cost-Utility Analyses in Spinal Care: A Systematic 

Review 


Sean Wilkinson, BA 






The purpose of this study was to systematically review the existing 

literature on the cost-utility of various aspects of spinal care. We 

searched the Tufts Medicinal Center Cost-Utility Analysis (CUA) 

registry from 1976 to 2008 for CUA articles related to spinal care. 

Data from the CUA registry were analyzed. Each article was reviewed 

in detail. The cost-utility ratios in each article were identified, with 

costs expressed in 2008 U.S. dollars. Twenty-six cost-utility studies 

on spinal care were identified. There was wide variation among the 

studies in methodological practices. There were 15 operative, nine 

nonoperative and two imaging studies. Study subjects included: 

lumbar spine (n=21), cervical spine (n=3), scoliosis (n=1), lumbar 

and cervical spine (n=1). Nineteen of the studies were based on 

clinical data from prospective randomized studies, five on decision 

models and two on prospective observational data. Of the lumbar 

studies, 13 addressed low back pain, six disc herniation, two lumbar 

stenosis/degenerative spondylolisthesis and one imaging. Of the 

cervical studies, two addressed the surgical treatment of degenerative 

disease, one nonoperative treatment for neck pain and one imaging. 

Forty-nine cost-utility ratios were reported in the 26 articles. 

Fifteen/49 (30.6%) of the ratios were cost saving, 22/49 (44.9%) 

were less than $100,000/QALY gained and 12/49 (24.5%) were 

greater than $100,000/QALY gained. The average quality grade of the 

papers on a seven-point Likert scale was 4.5, with a range of 2 to 6.5. 

Only four/26 (15.4%) of the studies contained the four key criteria 

of cost-effectiveness research recommended by the U.S. Panel on 

Cost-Effectiveness in Health and Medicine. Twenty-six CUA studies 

and 49 cost-utility ratios have been published on various aspects of 

spinal care over the last 30 years. Certain aspects of spinal care have 

been shown to be cost-effective. Further efforts, however, are needed 

to better define the value of many aspects of spinal care. 

POSTERS 


Fibronectin and Aggrecan Complex Predicts Functional 

Outcome after Lumbar ESI 

Gaetano J Scuderi, MD, Redwood City, CA 

S Raymond Golish, MD, PHD, Ridgefield, WA 

Lewis Hanna, PhD, Jupiter, FL 

Robert Bowser, PhD, Redwood City, CA 

Pasquale X Montesano, MD, Roseville, CA 

Eugene Carragee, MD, Redwood City, CA 

There is a need for biomarkers predicting response to epidural 

steroid injection (ESI) for patients with herniated nucleus pulposus 

(HNP). We have previously investigated molecular markers of 

disc degeneration. We attempted to determine if a novel complex 

of fibronectin and aggrecan predicts clinical response to ESI for 

the indication of radiculopathy from lumbar HNP. This study 




was a single center, prospective, consecutive case series of patients 

undergoing epidural lavage prior to treatment of radiculopathy due 

to lumbar disc herniation. This study included 26 patients with 

radiculopathic pain and MRI positive for HNP who elected epidural 

steroid injection. Epidural lavage was performed immediately prior 

to injection. The lavage fluid was assayed for the fibronectin-aggrecan 

complex using a heterogeneous enzyme-linked immunosorbent 

sandwich assay (ELISA). The results were compared with the interval 

improvement in the physical component score of the SF-36 after 

injection compared with baseline. The mean improvement from 

baseline PCS in patients with the fibronectin-aggrecan complex 

was 22.9 (standard deviation 12.4) and without the complex was 

0.64 (standard deviation 3.97; p

level fusions and 19 two-level fusions. Seven cortical breaches were 

identified for a rate of 2.52%. Seven patients had involvement of the 

superior level facet for an incidence of 11.48%. One patient required 

revision for a malpositioned pedicle screw. This study revealed a low 

rate of superior segment facet violation and cortical violation after 

minimally invasive TLIF. This rate of superior level facet involvement 

is significantly lower than previously reported after open procedures, 

between 24% and 32%. This rate also demonstrated a significant 

learning curve with significantly higher rate in the surgeon’s initial 

experience. The rate of cortical violation is similar to previous reports 

in the literature with a low revision rate. 


Soft Tissue Damages In Adult Patients With Cervical 

Spinal Cord Injury Without Major Bony Injury 

Takashi Maeda, Iizuka, Japan 

Takayoshi Ueta, Iizuka, Japan 

Eiji Mori, MD 

Itaru Yugue, MD, Iizuka Fukuoka, Japan 

Osamu Kawano, MD 

Tsuneaki Takao, MD 

Hiroaki Sakai, MD 

Keiichiro Shiba, MD, Iizuka, Japan 

No evidence has been shown as to whether the extraneural soft 

tissue damages in patients with cervical spinal cord injury (SCI) 

without major bony injury are associated with cervical segmental 

instability and clinical prognosis. The purpose of this study is to 

evaluate soft tissue damages detected on MRI, as well as segmental 

instability judged by flexion-extension radiographs of those patients 

with SCI who had no or little bony injury. We also evaluated if these 

soft tissue damages relate to clinical prognosis. Eighty-eight patients 

who admitted to our hospital within two days after trauma were 

included in this study. Flexion-extension radiographs were taken 

under the supervision of spine surgeon. Area of prevertebral edema 

detected on MRI was measured using imageJ software. Forty-two 

patients showed instability at the injured segment judged according 

to the criteria of White and Panjabi. On MRI, ALL disruption and 

disc injury were apparent in 44 and 37 patients respectively. Various 

degrees of prevertebral edema were demonstrated in 76 patients. 

There was a significant relationship between segmental instability 

and MRI findings of the soft tissue damages. Interestingly, ASIA 

motor score was significantly associated with both segmental 

instability and MRI findings, but not with cervical canal diameter. 

A considerable proportion of the patients with cervical SCI without 

obvious bony injury were shown to have various soft tissue damages 

and cervical segmental instability at the early stages of the injury. 

Clinical prognosis greatly depended on these soft tissue damages 

rather than pre-existent cervical canal stenosis. 


The Pathway Of Vertebral Metastases Extending To The 

Adjacent Vertebral Body: A Histologic Study 

Takeshi Sasagawa, MD, Kanazawa, Japan 

Norio Kawahara, MD, Kananzawa, Japan 

Hideki Murakami, MD, Kanazawa, Japan 

Satoru Demura, MD 

Katsuhito Yoshioka, MD 

Katsuro Tomita, MD, Kanazawa, Japan 


Each vertebra can be regarded as a compartment surrounded by 

several anatomically characterized barriers. However, in some 

743 

cases the tumor extends outside the barriers. The pathway of 

the vertical extension to the adjacent vertebrae is unclear. The 

vertical extension of a metastatic spinal tumor is important in the 

preoperative decision making of the cranio-caudal surgical margin. 

The objective was to investigate the pathway of the vertical extension 

of metastatic vertebral tumors. We examined 20 en bloc resected 

metastatic vertebral bodies where the tumors had extended outside 

the vertebral body. 5^8 sagittal sections including the pedicle, the 

lateral part of the posterior longitudinal ligament (PLL) and the 

central part of the PLL were prepared from each resected specimen. 

The sections were stained with haematoxylin-eosin and elastica 

van Gieson. Histologic examination focused on the pathways of 

the tumor vertical extension at each barrier tissues and the degree 

of tumor extension along each pathway. The vertical extension of a 

tumor was observed at the anterior longitudinal ligament (ALL) in 

six cases, at the central part of the PLL in 14 cases, at the lateral part 

of the PLL in 20 cases, at the cartilaginous endplate in three cases, at 

the periosteum on the lateral side of vertebral body in seven cases. 

The tumor had extended the farthest at the lateral part of PLL in 18 

cases, at lateral side of the vertebral body in one case and through 

the disc in one case. Metastatic vertebral tumors most commonly 

extend vertically between the lateral part of the PLL and the posterior 

aspect of the disc. 


Hernia Recurrence After Discectomy. Incidence And 

Risc Factors 

Sara Martinez-Martos 

Maite Ubierna, Montcada, Barcelona, Spain 

Enrique Caceres, Prof, Barcelona, Spain 

Ana Garcia De Frutos, MD 

Guillem Salo, MD, Barcelona., Spain 

Antonia Matamalas, MD 

Risk factors for hernia recurrence are not clear. There is controversy 

in the surgical treatment of hernia recurrence. The aim of our work 

is to study the incidence of herniation recurrence after discectomy at 

one level, and identify risk factors for its occurrence. Retrospective 

review of 239 patients diagnosed with herniated disc that underwent 

for surgery after failure of the conservative treatment during at 

least six weeks. It was assessed preoperatively age, level and type 

of hernia, Modic changes on MRI, the degree of degeneration 

according to Pfirrmann’s classification, job physical activity and 

sport. The Oswestry Disability Index (ODI), physical activity, work 

and sports was also measured postoperatively. Hernia recurrence 

was considered the recurrence of symptoms after a minimum of 

six months free interval and associated with an image consistent 

with disc herniation in MRI performed with gadolinium. We 

collected complete information on 201 patients. A total of 60.2% 

were male. The median age was 42.9 years (19-76). The level of 

involvement is L5-S1 in 61.8% and in L4-L5 of 31.2%. Monitoring 

is between 12 months and seven years. In any case the MRI signal 

corresponding was a healthy disc (Pfirrmann). A total of 52.7% of 

patients continued treatment with epidural injection before surgery. 

The mean Oswestry index is 12.7 (0-96). Males have a lower rate 

resulted in Oswestry index, and non-working population has the 

worst results (p = 0.00). Some 19.3% (35) were diagnosed with 

symptomatic hernia recurrence and confirmed by MRI at the same 

level. Seven of them improved with conservative treatment or 

epidural infiltration. Twenty-eight required surgery (11 arthrodesis, 

13 discectomies and four sequestrectomies). No statistical differences 

observed between type of treatment with the ODI. No correlation 

between hernia recurrence and gender, type and level of the hernia, 

disc degeneration, type of surgery and sports activities. We observed 




that younger patients (


Does the Rotation of the Spinal Cord Predict 

Postoperative C5 Nerve Palsies? 

Michelle Aubin, MD, Worcester, MA 

Mark Eskander, MD, Worcester, MA 

Chris Balinger, MD, Worcester, MA 

Jeffrey K Lange, MD, Worcester, MA 

Nicholas Lewing, BS 

Caitlin Howard, AB, New Orleans, LA 

Patrick J Connolly, MD, Worcester, MA 

Jason C Eck, DO, Worcester, MA 

Louis George Jenis, MD, Newton, MA 

C5 nerve palsy is a common complication of cervical spine surgery. 

This study evaluates if spinal cord rotation seen on MRI is a predictor 

for the development of postoperative C5 nerve palsy. Retrospective 

review of 177 patients degenerative disorders of the cervical spine with 

preoperative MRIs who underwent anterior cervical decompression 

and fusion (ACDF) at C4-5 or C5-6. MRI measurements included 

area for the cord (AC), space available for cord (SAC) and rotation 

of the cord (RC) relative to the vertebral body. Measurements were 

taken at the site of surgical decompression. Medical records were 

reviewed for postoperative C5 palsy, defined as manual muscle 

testing of three or less. Linear regression analysis was used to 

evaluate correlations of these MRI measurements with postoperative 

C5 nerve palsy. A total of 50% female, mean age 49.8 years and 6.8% 

incidence of postoperative C5 nerve palsy. AC, SAC and RC means 

and standard deviations are 1.5 +/-0.4 cm2, 9.6 +/-1.8 mm, and 2.8 

+/-3.0° respectively. Pearson’s correlations showed that AC (r =-0.11 

(p=0.18)) and SAC (r=-0.13 (p=1)) did not correlate with C5 palsy. 

Cord rotation showed statistically significant correlation with the 

development of postoperative C5 nerve palsy (r=0.81 (p4 mm cancellous channel, Type B: 2-4 mm 

cancellous channel, Type C: >2 mm cortical channel and Type 

D:

demonstrated predictable healing rates and reoperations. The goal of 

this study was to compare and evaluate the number of complications 

requiring reoperation in elderly versus younger patients. During a 

seven-year period of time (2002-2009), all patients undergoing 

instrumented lumbar posterolateral fusion consenting to utilizing 

of rhBMP-2 (INFUSE) were retrospectively evaluated as a quality 

analysis within a large orthopaedic surgery private practice. Patient 

demographics, body mass index, comorbidities, number of levels, 

associated interbody fusion and types of bone void filler (BVF) were 

analyzed. The age of patients were subdivided into 65 yo (elderly). A total of 1,269 consecutive patients were 

evaluated with 42% males and 58% females. Average age was 59 yo 

with 779 (61.4%) 65. Number of levels fused 

was: one (478, 38%), two (525, 41%), three, (182, 14%), four (64, 

5%), five (13, 1%) and six (7, 0.6%). No difference in levels fused 

was noted. Complications requiring reoperation was: acute seroma 

formation with neural compromise requiring decompression 29 

(22/779, 2.8% 65), delayed reossification of 

foraminotomy requiring decompression seven (5/779, 0.6% 65), infection requiring debridement 47 (35/779, 

4.1% 65), and redo instrumented fusion for 

symptomatic nonunion 33 (19/779, 2.4% 65). 

No statistical differences were noted within the two groups except 

more medical comorbidities in the elderly group (p

of cervical trauma with concern for arterial injury. Thirty-six (22.64%) 

were found to have an injury following arterial imaging. There was 

a statistically significant correlation with displaced cervical injuries 

(p

y expanded I-VEP and maintained by effective bony fusion inside 

and outside of the I-VEP. Also, the preservation of the end plate 

diminished the risk of subsidence of the I-VEP into the adjacent 

segments. I-VEP seems reliable and safe in the treatment of patients 

with symptomatic OVF. 


Surgical Outcome of Drop Foot Caused by Degenerative 

Lumbar Disorders 

Yoshihiro Takamori, Fukuoka, Japan 

Jun Arimizu, Jonan-Ku, Japan 

Teruaki Izaki, MD, Fukuoka, Japan 


Takahiko Kiyama, MD, Fukuoka, Japan 

We conducted a retrospective study on the surgical outcome in 

patients with drop foot due to degenerative lumbar disorders, and 

assessed the factors influencing surgical outcome. There were 467 

patients who underwent lumbar spine surgery for degenerative 

lumbar disorders, 26 of whom (5.6%) presented with drop foot. 

The mean age at surgery was 60.3 years, and mean follow-up period 

was 24.9 months. The manual muscle test can be used to determine 

the muscular strength of the tibialis anterior. Drop foot is then 

defined as a score below three out of five. The mean duration of 

drop foot symptoms before surgery was 29.5 days. The correlated 

factors studied were age at surgery, preoperative grade of muscle 

strength, diabetes mellitus, grade of leg pain and duration of palsy 

before surgery. Of the patients, 61.5% recovered from drop foot after 

surgery. Postoperative muscle recovery in patients with lumbar disc 

herniation was significantly superior to that in patients with lumbar 

spinal stenosis. Significant factors that determine surgical outcome 

are age at surgery, diabetes mellitus and preoperative grade of leg 

pain (P

implant’s inherent stability and the minimal disruption of stabilizing 

ligaments associated with LTIF, this technique may allow more 

aggressive restoration of indirect foraminal decompression. Patients 

were eligible for inclusion if they had underwent LTIF with or 

without posterior instrumentation and had both preoperative and 

postoperative CT scan at our institution with multiplanar images. 

From preoperative and postoperative CT scans, we measured disc 

heights, neural foraminal area between adjacent level pedicles, 

cage position measured from the anterior and posterior border of 

the adjacent inferior vertebral body. Preoperative and postoperative 

Oswestry Disability Index (ODI) and Short Form-12 (SF-12) 

scores for included patients were recorded. ODI and SF-12 scores 

were matched with the foraminal areas from the most severely 

affected side or an average of the two foraminal areas if both sides 

were equally affected. Average foraminal area increases averaged 

36.2 mm2 which represents 35% of preoperative area (p

myelography-assisted group require additional decompression 

due to residual filling defects. Significant improvement was noted 

in the myelography-assisted group with lower score (six vs. 10, p = 

0.049) and more improvement (44% vs. 22%, p = 0.005) in ODI. 

This group also had significantly higher JOA scores (27.5 vs. 24, p = 

0.043) with a higher improvement rate (73.2% vs. 92.8%, p = 0.013). 

Higher ratios in ‘significant improvement’ (100% vs. 80%) for ODI 

and ‘success’ (100% vs. 95%) and ‘good to excellent results’ (95% 

vs. 75%) for JOA scores were also noted in the myelography-assisted 

group. This novel protocol provided a practical method for precise 

localization of stenosis and verification of adequate decompression; 

hence improved the treatment result of MEDL. 


Coronal and Sagittal Plane Alignment after XLIF in the 

treatment of Degenerative Scoliosis 

Luiz Pimenta, MD, Sao Paulo, SP Brazil 

Leonardo Oliveira, MD, Sao Paulo, SP Brazil 

Luis Marchi, MS, Sao Paulo, SP Brazil 

Etevaldo Coutinho, MD, Sao Paulo, SP Brazil 

The traditional treatments to degenerative scoliosis consist in open 

surgeries, with high incidence of morbidity. Here we present a lateral 

retroperitoneal minimally invasive approach for the treatment of 

adult scoliosis. Symptomatic adult scoliosis deformity presents as a 

difficult problem to solve. Traditional treatments include anterior and 

posterior open approaches. A prospective, non-randomized, single 

center clinical trial with 60 patients, mean age 66.95 (50-87 years), 

that underwent extreme lateral interbody fusion (XLIF) procedure 

to treat degenerative scoliosis. Lateral, anterior/posterior, flexionextension 

X-rays, neurological examination and clinical outcome 

assessments using Oswestry and VAS scores were performed at the 

preoperative, one, six week, three, six, 12, 24, 36, 48 and 60 months 

postoperative intervals. The extreme lateral approach was done 

through the retroperitoneal space and through psoas muscle avoiding 

vascular lesions. A partial discectomy was done and the end-plate 

cleaned preserving anterior longitudinal ligament (ALL), keeping the 

spine more stable than the traditional anterior surgery. The operated 

levels ranged from four to seven levels, including T10-T11 to L4-L5. 

The procedures were performed without complication in an average 

121 minutes and with less than 50 cc blood loss. Ten patients had 

four levels of fusion; two patients had five levels and two patients 

with seven levels of arthrodesis. VAS pain scores improved from an 

average 8.33 at pre-op to 3.47 at five years, standard deviation 1.49 

and 1.34 respectively. Oswestry scores improved from an average 

51.2 at pre-op to 29.52 at five years with standard deviation of 13.42 

and 13.47 respectively. Coronal and sagittal alignments improved 

from average Cobb angles of 16.4 degrees at pre-op and 7.5 degrees 

at five years, and average lordosis angles of 17.1 degrees at pre-op 

to 34.2 degrees at five years. Using the XLIF approach we were able 

to treat long thoracolumbar deformities in a minimally invasive 

way targeting the pain improvement after surgery without the risks 

and morbidity associated with big corrections. Our intent was pain 

improvement and stabilization. We found reasonable coronal and 

sagittal correction in addition to successful clinical improvements in 

pain and function in long thoracolumbar reconstructions. 

750 


uPosterior Cervical and Cervicothoracic Fusions with 

rhBMP-2: Complications and Fusion Rates 


Ian G Dorward, MD 

Geoffrey Stoker, BS 




RhBMP-2 has been shown to increase fusion rates in the lumbar 

spine, but little is known regarding its efficacy and associated 

complications in posterior cervical fusions. We independently 

evaluated 57 consecutive patients with minimum two-year follow up 

who underwent posterior cervical, occipitocervical or cervicothoracic 

instrumented fusion augmented with rhBMP-2. Fusion was 

determined by bony bridging on CT scans, absence of lucency 

around instrumentation and/or absence of motion on flexion/ 

extension films. Fifty-seven patients with mean age 56.7 ± 13.2 years 

and mean follow up of 37.7 ± 20.6 months were analyzed. A total 

of 84.2% had undergone previous cervical surgery and 42.1% had 

a preexisting nonunion. Fusions spanned 5.63 ± 2.66 levels; 19% 

involved the occiput, while 63% crossed the cervicothoracic junction. 

Mean rhBMP-2 dose was 21.1 ± 8.7 mg. Compression-resistant 

matrix was used in 44% of cases, iliac crest in 30%, and allograft in 

67%. Six patients (10.5%) experienced nonunion; only two required 

reoperation. In all cases of nonunion, the instrumentation crossed 

the occipitocervical or cervicothoracic junction. However, no factors 

were statistically associated with nonunion. Fourteen patients 

(24.6%) suffered complications, with seven patients requiring 

additional surgery. Three patients had superficial infections and 

one had a deep infection requiring irrigation and debridement. 

Visual Analog Scale (VAS) scores improved from 6.8 ± 1.8 to 3.9 

± 3.1 (P

Additionally, the footprint of the lateral TDR device capitalizes on 

the biomechanical support of the ring apophysis. Prospective, non 

randomized clinical trial to evaluate the safety and effective of the 

lateral total disc replacement implanted by the XLIF approach. 

Patients included 16 males and 20 females, average age 43 years (24- 

60). A TDR device designed for implantation through a true lateral, 

retroperitoneal, transpsoas approach (XLIF) was implanted in 36 

patients with discography-confirmed 1- or 2-level degenerative disc 

disease (DDD). Clinical and radiographic outcomes assessments 

were prospectively collected. Surgeries included 14 1-level, three 

2-level and 19 hybrid TDR/ALIF cases. The surgery was performed 

through a 4 cm lateral incision in an average of 134 minutes (90-300) 

and with an average 58 cc blood loss (30-150). There was no intra-op 

or post-op complications. Postoperative x-rays showed good device 

placement, with restoration of disc height, foraminal volume and 

sagittal balance. All patients were up and walking within 12 hours of 

surgery. VAS pain scores improved from an average of 9.3 at pre-op 

to 2.27 after three years. Oswestry Disability Index improved from 

an average of 57 at pre-op to 16.5 after three years. Mid-term results 

of a laterally placed TDR device demonstrate maintenance of pain 

relief and functional improvement. The benefits of this technique 

-- minimal morbidity, avoiding mobilization of the great vessels, 

preserving the anterior longitudinal ligament, biomechanically stable 

orientation and broader revision options -- suggest a promising new 

direction for TDR procedures. 


Facet Joint Biomechanics At The Treated And Adjacent 

Levels After Total Disc Replacement 

Vikas Vanarsi Patel, MD, Denver, CO 

Sergiu O Botolin, MD, Denver, CO 

Christian Puttlitz, PhD, Fort Collins, CO 

Todd H Baldini, Denver, CO 

Anthony Petrella, PhD 

Evalina L Burger, MD, Aurora, CO 

Celeste Abjornson, PhD, New York, NY 

Total disc replacement (TDR) provides an alternative to fusion that 

is designed to preserve motion at the treated level and restore disc 

height. However, the effects of TDR on spine biomechanics at the 

treated and adjacent levels are not fully understood. Seven freshfrozen 

human cadaveric lumbar spines were potted at T12 and L5 

and installed in a six-DOF displacement-controlled testing system. 

Displacements of 15° flexion/extension, 10° right/left bending and 

10° right/left axial rotation were applied. Contact pressure, peak 

contact pressure, force, peak force and contact area for each facet 

joint were recorded at L2-L3 and L3-L4 both before and after TDR at 

L3-L4. The data were analyzed with ANOVAs/t-tests. Axial rotation 

had the most impact on all measures in intact spines. During lateral 

bending and axial rotation, TDR resulted in a significant increase 

in facet forces at the level of treatment and a decrease in contact 

pressure, peak contact pressure and peak force at the level superior 

to the TDR. With flexion/extension, there was a decrease in peak 

contact pressure and peak contact force at the superior level. Our 

study demonstrates that rotation is the most demanding motion for 

the spine. We also found an increase in facet forces at the treated 

level after TDR. In general, our findings suggest there is an increase 

in loading of the facet joints at the level of disc implantation and an 

overall unloading effect at the level above. 

751 


uBiomechanical Evaluation of a Standalone Lumbar 

Interbody Cage with Integrated Screws 

Martin B Kornblum, MD, Livonia, MI 

Frank M Phillips, MD, Chicago, IL 

Alexander W Turner, PhD, San Diego, CA 

Michael Zatushevsky, MD 

Bryan Cornwall, PhD, San Diego, CA 

Anterior lumbar interbody fusion (ALIF) devices with integrated 

fixation provide the opportunity to increase fusion construct stability, 

potentially allowing for standalone use. In this cadaveric study, the 

biomechanical stability of a standalone device was evaluated against 

more traditional ALIF constructs using a multi-directional flexibility 

protocol. Eight fresh-frozen lumbar spines were thawed, dissected 

and potted at L2 and the sacrum (average age 56 years, range 34 to 

63; all male). Specimens were tested in moment control at ±7.5 Nm 

in flexion-extension, lateral bending and axial rotation. Conditions 

tested were: intact, cage at L4-5 (0 screws); cage (0 screws) + anterior 

plate; cage (0 screws) + bilateral pedicle screws; cage (three screws); 

cage (three screws) + spinous process plate; and cage (four screws). 

Range of motion (ROM) at L4-5 was measured optoelectronically. 

The standalone cage with supplemental integrated screw fixation 

was significantly more rigid than the cage alone (p 0.05), although there 

was a small trend towards more motion in flexion-extension and 

axial rotation with three screws. The cage with screws (three or four) 

was not significantly different (p >0.05) from the cage (0 screws) and 

anterior plate or the cage (three screw) and spinous process plate 

in lateral bending or axial rotation. The cage with three screws and 

spinous process plate provided the most rigid construct in flexionextension. 

Bilateral pedicle screws were most rigid in lateral bending 

and axial rotation. The standalone cage with integrated screws 

showed improved stability over a standalone cage without screws, 

and comparable stability to traditional ALIF constructs, particularly 

in lateral bending and axial rotation. Clinical evaluation will further 

support the efficacy of this device for this application. 


Kyphoplasty And Vertebroplasty: Trends In Use In 

Ambulatory And Inpatient Settings 

Vadim Goz, BA, New York, NY 

Steven Koehler, New York, NY 

Natalia Egorova, PhD, MPH 


Andrew C Hecht, MD, New York, NY 

Vertebral compression fractures (VCFs) are a substantial health 

concern. Kyphoplasty (KP) and vertebroplasty (VP) are vertebral 

augmentation procedures (VAPs) used to treat VCFs. The purpose 

of this study was to compare VP and KP patient demographics and 

evaluate inpatient and outpatient utilization trends. Hospitalizations 

for VP and KP were identified from California, New York and Florida 

inpatient and ambulatory discharge databases from 2005-2008. 

ICD-9 diagnosis codes for pathologic, dorsal and lumbar fracture 

of vertebrae were cross-referenced with ICD-9 procedure codes and 

CPT procedure codes to select the population. Patients under 40 

years of age, or those that had both procedures were excluded. The 

final population contained 61,851 VAPs (35,805 KPs and 26,046 

VPs). KP showed increased inpatient and outpatient utilization. 

VP utilization remained at a low level of six/100,000 capita. KP 

patients had more comorbidities than VP patients. In Florida in 




2008, radiologists performed the majority of VPs (52.3%) and 

orthopaedists performed the most KPs (35.45%). Post-operative 

complication rates were significantly different; 0.79% of KPs had 

cardiac complications versus 0.57% of VPs (p = 0.0073). Respiratory 

complications occurred in 0.83% of KPs and 0.49% of VPs (p

heterotopic bone in the canal or neural foramen (20). Early surgery 

prior to six weeks preop was complicated by excessive bleeding. This 

was less evident after three months post op. All patients operated 

after six months showed evidence of bone formation in the canal. 

Average follow up was 22 months (range 12-50). Most patients 

had immediate relief of symptoms but it did not persist in several 

patients. Six patients required more than one surgery for reformation 

of bone in the canal. The off label use of rhBMP-2 in PLIF and TLIF 

surgery may lead to heterotopic bone, cage migration and extensive 

scarring. Revision surgery is complex but may lead to resolution of 

symptoms in these individuals. 


Selective Thoracic Fusion in Lenke 1C Curves: 

Prevalence and Criteria 

Charles H Crawford, III MD, Louisville, KY 


Daniel J Sucato, MD, Dallas, TX 

B Stephens Richards III, MD, Dallas, TX 

John B Emans, MD, Boston, MA 

Michael G Vitale, MD, New York, NY 

Mark A Erickson, MD, Aurora, CO 

James O Sanders, MD, Rochester, NY 


Classification systems for adolescent idiopathic scoliosis (AIS) 

have been developed to help surgeons identify curve types and 

select appropriate fusion levels. Selective thoracic fusion has been 

advocated for the so-called ‘false double major’ curve (Lenke 1C, 

King II). Despite this recommendation, many surgeons continue to 

perform non-selective fusions for this curve type. It is unknown to 

what extent these classification systems and other factors influence 

the surgeon’s selection of fusion levels. A prospective multicenter 

database included 264 patients with surgically treated 1C curves. 

Patients were divided into two groups: selective thoracic fusion group 

(ST) included patients with the lowest instrumented vertebra (LIV) 

at or cephalad to L1, and nonselective group (NS) included patients 

with the LIV at or caudal to L3. Preoperative radiographic, clinical 

(scoliometer) and SAQ/SRS questionnaire data were analyzed and 

compared between the groups. Only 138/264 (49%) underwent an 

ST fusion. Gender ratio (90% vs. 86% female), average age (14.7 vs. 

14.8 years) and preop main thoracic (MT) Cobb angles (56.0º±9.9 

vs. 55.3º±11.4) were not significantly different between groups (ST 

vs NS). However, the average thoracolumbar/lumbar (TL/L) preop 

Cobb angle was significantly smaller in the ST group (42.1º±8.6 vs. 

47.0º±9.0; p

caused by mainstem airway compression from the spine. This study 

has important implications for surgical approaches to patients with 

scoliosis and obstructive lung disease. 


Defensive Medicine The Impact of Preventable Spinal 

Imaging 

Mark F Kurd, MD, Gladwyne, PA 


James D McDermott, BA, Philadelphia, PA 


Ravi Kumar Ponnappan, MD, Linwood, NJ 




The Government Accountability Office reported that Medicare 

spending from 2000 to 2006 for imaging services increased from 

$6.89 to $14.11 billion. Despite the interest of policy makers in this 

issue, there is little medical literature evaluating the appropriateness 

of medical imaging utilization. This study was designed to assess 

the prevalence and predictors of unnecessary spinal imaging. At the 

time of abstract submission, 75 consecutive patients presenting for 

initial consultation to a spine surgeon completed a self-administered 

questionnaire. Data collected included demographic information, 

relevant medical and surgical history and information on previous 

spinal studies. After a history and physical exam, the attending spine 

surgeon determined whether each spinal study the patient had 

undergone was necessary and what effect the study had in making 

the diagnosis and treatment plan. Twenty-eight percent of patients 

surveyed were found to have at least one unnecessary imaging study. 

Twenty percent of patients with an unnecessary study had multiple 

unnecessary studies. The only significant predictor of unnecessary 

studies was a history of spine surgery (p=0.016). Age, sex, income, 

education, health insurance, duration of symptoms, number of 

doctor visits, location of pathology and prescribing physician were 

not predictive of having an unnecessary study. Greater than one in 

four patients presenting to a spine surgeon undergo preventable 

medical imaging. This exposes patients to unnecessary risk and 

the healthcare system to millions of dollars of wasteful spending. 

Revisiting of imaging guidelines for patients presenting to medical 

care for back pain may be warranted. 


Two-Year Post-Op Follow-Up On A Less Invasive Far 

Lateral Approach In Advanced Adult Spine Deformity 

Gregory M Mundis, MD, La Jolla, CA 

Behrooz A Akbarnia, MD, La Jolla, CA 

Pooria Salari, MD 

Ramin Bagheri, MD, La Jolla, CA 

Anterior reconstruction of the spine in adult deformity is a widely 

accepted approach to improve fusion rate and achieve coronal 

and sagittal deformity correction. We present our experience using 

the less invasive far lateral interbody fusion (LIF) to achieve these 

goals. This was a retrospective review of adult deformity patients 

undergoing LIF. Of 58 patients, 16 met the inclusion criteria: Cobb 

>30°, initial surgery for scoliosis and minimum two-year follow 

up with complete data. Exclusion criteria included add-on disease 

and primary diagnosis other than scoliosis. Clinical, radiographic 

and outcomes data were analyzed. There were 15 females and one 

male. Average age was 56 (23-84) years, seven were idiopathic and 

nine were degenerative scoliosis. Average comorbidites were 2.6 

754 

per patient. Main curve improved from 47° to 19° (p

lack of significant differences in satellite rod orientation suggests 

that positioning of the satellite rods is not an important factor to 

consider in strengthening the revision. 


Defining Two Components of Shoulder Imbalance: 

Clavicle Tilt and Trapezial Prominence 

Peter O Newton, MD, San Diego, CA 

Takashi Ono, MD 


The current study sought to identify two features of shoulder 

asymmetry (clavicle tilt and trapezial prominence) and how they 

relate to different underlying radiographic parameters. A total of 113 

pre-operative patients with right main thoracic Lenke 1 and 2 AIS 

curves were investigated to evaluate the correlations between clinical 

and radiographic findings of shoulder imbalance. The following 

parameters were defined and evaluated from pre-op clinical 

photographs: clavicle angle (tilt), trapezial angle, ratio of left to right 

trapezial area. These were correlated with radiographic measures of 

T1 tilt, first rib angle, curve magnitude, coronal balance and thoracic 

apical deviation. There were 82 Lenke 1 and 31 Lenke 2 curves with 

an average thoracic Cobb of 52.1 degrees. The clinical clavicle angle 

had a modest correlation with proximal thoracic curve size, T1 tilt, 

coronal balance and thoracic apical deviation (r value, 0.43, 0.42, 

0.41 and 0.41, respectively). In contrast, medial shoulder trapezial 

prominence correlated well with the radiographic measures of T1 tilt 

and the 1st rib angle (trap angle: 0.70 and 0.68; trap area ratio: 0.58 

and 0.60, respectively). Our analysis suggests there are two distinct 

regions (lateral and medial) of shoulder height asymmetry. Medial 

differences, reflected in trapezial prominence, relate principally 

to deformity created by upward tilted proximal ribs, and thus T1 

tilt. Lateral differences in shoulder symmetry correlate weakly with 

radiographic measures of spinal deformity. This suggests correction 

of the trapezial prominence by leveling T1 may be more predictable 

compared to leveling clavicle tilt following corrective scoliosis 

surgery. 


In Vivo Kinematics between Pre-operative and Postoperative 

Fusion of the Lumbar Spine 

Christopher Carr, Knoxville, TN 

Joseph S Cheng, MD, MS, Nashville, TN 

Adrija Sharma, Knoxville, TN 



Joseph W Mitchell, Knoxville, TN 

Chris Little, Knoxville, TN 

Fusion of the spine decreases overall motion and is thought to 

induce more stress at adjacent levels, leading to the development 

of further problems and additional surgeries. The objective of this 

study is to analyze the in-vivo motions of the vertebrae in the fused 

spine at pre-operative and post-operative stages to understand the 

effects of fusion on adjacent levels. Six subjects undergoing fusion 

were evaluated using fluoroscopic surveillance while performing 

flexion/extension of the lumbar spine. Three of the subjects required 

fusion at L4-L5 and three subjects were required fusion at L5-S1. 

In-vivo, 3D kinematics at each vertebral level were recovered using 

a previously described 3D-to-2D image registration technique and 

comparative changes were analyzed for each subject. On average, 

pre-operative and post-operative in-plane rotations achieved by 

subjects fused at L4-L5 were 30.8° and 23.1°, respectively, while 

755 

subjects having a fusion at L5-S1 averaged 28.9° of rotation about 

the FE axis pre-operatively and 27.9° post-operatively. All subjects 

experienced a substantial increase in rotation at one of the superior 

levels following fusion. Out-of-plane rotations tended to decrease 

following fusion for the L5-S1 group, but the L4-L5 group revealed 

sporadic out-of-plane rotational magnitudes. Single level fusion 

increases overall stiffness of the lumbar spine and results in increased 

motion at adjacent levels, yet unfortunately, the effect on specific 

adjacent levels is not clear. Abnormal motion patterns appear to 

remain dominant with decreased magnitudes at pathological and 

fused levels, possibly leading to degeneration at levels where the 

abnormal kinematics are occurring. 


Advanced Healing of the Intervertebral Disc using 

Anabolic Growth Factors and a Catabolic Inhibitor 

Matthew Alan Pifer, MD, Royal Oak, MI 

Leonard K Kibuule, MD, Southlake, TX 

Tristan Maerz, BS 


Diane Studzinski, Royal Oak, MI 


High reherniation rates following discectomy are thought to be 

associated with poor healing. Tissue engineering techniques can 

augment the healing of the intervertebral disc by supplying a blend 

of regenerative cytokines. Normal human articular chondrocytes 

(nHAC) were treated with the following combinations of 

transforming growth factor-²3 (TGF- ²3), bone morphogenetic 

protein-4 (BMP-4) and tissue inhibitor of matrix metalloproteinase-2 

(TIMP-2): 1) TGF- ²3; 2) BMP-4; 3) TIMP-2; 4) TGF- ²3 + BMP-4; 5) 

TGF- ²3 + TIMP-2; 6) BMP-4 + TIMP-2; 7) TGF- ²3 + BMP-4 + TIMP- 

2. Gene expression of Collagen1a1, Collagen2a1, Collagen10a1, 

and Aggrecan, and glycosaminoglycan (GAG) concentrations were 

assessed at 24 hrs, 72 hrs and seven days. Immunocytochemistry 

staining was performed at 72 hrs. TGF-²3 (1), TGF-²3 + BMP-4 (4), 

TGF-²3 + TIMP-2 (5) and TGF-²3 + BMP-4 + TIMP-2 (7) significantly 

upregulated Collagen1a1, Collagen2a1, and Collagen10a1. BMP- 

4 (2) and BMP-4 + TIMP-2 (6) upregulated Aggrecan expression. 

Treatment with TGF-²3 + BMP-4 (4) and TGF-²3 + BMP-4 + TIMP-2 

(7) showed markedly high GAG content compared to the control. 

Immunocytochemistry staining showed increased fluorescent signal 

from cells treated with TGF-²3 (1) and TGF-²3 + BMP-4 + TIMP-2 (7). 

The use of anabolic growth factors and a catabolic inhibitor molecule 

proved efficacious in upregulating extracellular matrix markers. 

Healing an intervertebral disc could be accomplished by the delivery 

of both anabolic growth factors and catabolic inhibitors. Articular 

chondrocytes have been previously used as an intervertebral disclike 

cell and future investigations will include the use of annulus 

fibrosus and nucleus pulposus cells. 


Functional Assessment of Human Fetal Neural Stem 

Cells Following Spinal Cord Injury in Rats 

Robert E Mayle, MD, San Jose, CA 

Ivan Cheng, MD, Redwood City, CA 

R Lane Smith, PhD, Stanford, CA 

Christopher Cox, MD, Stanford, CA 

Ian Corcoran-Schwartz, Palo Alto, CA 

Injury to the spinal cord is devastating, resulting in functional 

deficits that leave patients with significant impairments. The injured 

adult mammalian central nervous system does not support readily 




apparent re-growth of damaged axons. Four groups were identified 

for this study: two experimental and two control. A moderate spinal 

cord contusion at the T10 level was incurred. Experimental subjects 

received a subdural injection of human neural stem cells (hNSCs) 

adjacent to the site of injury, or an intrathecal injection of hNSCs 

through a separate laminotomy made in the mid-lumbar spine, 

distal to the site of injury. Control subjects received an injection of 

control media alone. Functional assessment was measured using 

the BBB Locomotor Rating Score following injury and then weekly 

for six weeks. Compared to controls, subjects that received hNSCs 

have improved functional recovery. The ability to achieve similar 

significant functional recovery through an intra-thecal injection of 

hNSCs distal to the site of spinal cord injury (SCI) may considerably 

affect clinical treatment of SCI. Proper usage of stem cell therapy 

shows early promise in the improvement of functional recovery 

following spinal cord injury. 


Prevalence and Outcomes of Coronal Decompensation 

in Multilevel Spinal Fusion for Adult Deformity 








Christine Baldus, MD, Saint Louis, MO 

We report the prevalence and outcomes of coronal decompensation 

in a consecutive series of multilevel spinal fusions for adult 

scoliosis. A consecutive series of 148 patients with adult idiopathic/ 

degenerative scoliosis who underwent a multilevel primary posterior 

spinal fusion (>5 levels fused) at a single institution from 2002-2007 

with minimum two-year follow up were reviewed. There were 133 

females/15 males; mean age at surgery 48.2 years. Posterior fusion 

alone was performed in 66 patients (44.6%), while 82 patients 

(55.4%) had a combined posterior/anterior fusion. Five patients 

(3.7%) had coronal imbalance (CI) of >4 cm from the C7 plumb to 

the center sacral vertical line (CSVL) at two months postop. All CI 

patients had double major curve patterns, increased lumbar flexibility 

on bending and no preop CI. Compared to the coronally balanced 

(CB) patients, CI patients had longer posterior fusions (14.0 vs. 10.0 

levels, p=0.014), presence of pre/postop pelvic obliquity (p=0.027, 

p=0.02, respectively) and similar preop coronal balance (p=0.46). 

All CI patients were fused to L4 or below compared to 25.9% of 

CB patients (p=0.33). CI patients had a larger coronal imbalance 

at initial followup (p

mean operative time and ICU stay. Chi-square analysis demonstrated 

that the complication group exhibited a higher percentage of 

staging procedures (46% vs. 37%, p=0.011), a higher percentage of 

anterior/posterior approach (56% vs. 32%, p=0.011) and a greater 

prevalence of postoperative anemia (16.7% vs. 6.4%, p=0.04). 

We report an incidence of 7.6% in major complications among 

953 consecutive patients. Improved understanding of risk profiles 

and procedure-related parameters may assist in pre-operative riskbenefit 

surgical discussions and pre-emptive approaches to reduce 

major complications. Patients should be counseled that a major 

complication is more likely to occur in revision, staged and anterior/ 

posterior surgery. 


Diagnosis and Treatment of Craniocervical Dissociation 

in 48 Consecutive Survivors 

Abilio Antunes Reis, MD, Glen Allen, VA 

Richard Jackson Bransford, MD, Seattle, WA 

Tom Penoyer, MD 

Jens R Chapman, MD, Seattle, WA 

Carlo Bellabarba, MD, Seattle, WA 

Craniocervical dissociation (CCD) is an uncommon and frequently 

fatal injury with few reports in the literature of survivors. Advances 

in automobile safety and improved emergency medical services 

have resulted in increased survival. Timely diagnosis and treatment 

are imperative for optimal outcome. Regrettably, the presence of 

multiple life threatening injuries, low clinical suspicion, and lack of 

familiarity with the upper cervical radiographic anatomy frequently 

lead to missed or delayed diagnosis. This paper represents the largest 

series of surgically treated CCD survivors. The goal of this study is 

to determine if any improvements have been made in the timely 

diagnosis of CCD while performing a complete patient evaluation. 

Following Institutional Review Board approval, a search of the 

Harborview Medical Center (HMC) trauma registry was conducted 

for all surgically treated CCD patients between 1996 and 2008. 

Forty-eight consecutive cases were identified. A retrospective review 

of the radiological and clinical results with emphasis on timing of 

diagnosis, modality used for diagnosis, clinical effect of delayed 

diagnosis, potential clinical or imaging warning signs and response 

to treatment was performed. Thirty-one patients treated from 2003 

to 2008 were compared to 17 patients that were treated from 1996 

to 2002 and reported previously. All patients sustained high-energy 

injuries and were evaluated according to standard ATLS protocols. 

Once CCD was identified or suspected, provisional stabilization 

was applied and MRI evaluation performed. Definitive surgical 

management with rigid posterior instrumentation and fusion 

was performed as soon as physiologically possible. Craniocervical 

dissociation was identified on initial cervical spine imaging in 26 

patients (84%). The remaining five patients (16%) were diagnosed 

by cervical spine MRI. Twenty-three patients (74.2%) were diagnosed 

within 24 hours of presentation, seven (22.6%) were diagnosed 

between 24 and 48 hours and one (3.2%) experienced a delay of 

greater than 48 hours (table 1). In comparison, four (24%) of the 

previously treated 17 patients were diagnosed on initial cervical 

spine imaging. Four patients (24%) were diagnosed within 24 

hours of presentation, nine (52%) were diagnosed between 24 

and 48 hours, and four (24%) experienced a delay of greater than 

48 hours. There were no cases of craniocervical pseudarthrosis or 

hardware failure during a mean nine-month follow-up period. Four 

patients expired during their hospital course. The mean American 

Spinal Injury Association (ASIA) motor score of 47 improved to 

60, and the number of patients with useful motor function (ASIA 

Grade D or E) increased from eight (26%) preoperatively to 17 

757 

(55%) postoperatively. Improvements have been made in the time 

to diagnosis of CCD in recent years. Increased awareness and the 

routine use of CT scan as part of the initial advanced trauma life 

support evaluation account for this progress. Expedited diagnosis 

has decreased preoperative neurological deterioration. However, 

differences in length of follow up between the two groups preclude 

conclusions about its effect on long-term neurological outcome. 


Pedicle Subtraction Osteotomy for Cervicothoracic 

Kyphosis: Technique and Report of 10 Cases 


Justin Scheer, San Francisco, CA 

Christopher Ames, MD, San Francisco, CA 

Historically, the Smith-Peterson osteotomy has been used to 

restore cervical spinal sagittal balance. Cervicothoracic (CT) pedicle 

subtraction osteotomy (PSO) offers more controlled closure and 

greater biomechanical stability but is infrequently reported in 

literature. The study details the CT PSO technique with 10 cases and 

correlates clinical kyphosis (chin brow vertical angle (CBVA)) with 

radiographic measurements. Ten patients underwent PSO (nine at 

C7, one at T1) for severe cervical kyphotic deformities. Pre- and postop 

sagittal plane radiographic (n=10) and CBVA (n=7) measurements 

were made. Patient outcomes were assessed using Neck Disability 

Index (NDI), SF36 and Visual Analogue Pain Scale (VAS). Technique: 

Facet release and C6-C7 and C7-T1 facetectomy were performed. The 

C7 and C8 nerve roots were identified and traced out the foramen. 

The osteomtomy was carried lateral and the C7 pedicle isolated. The 

C7 vertebral body (VB) lateral wall was resected with a Penfield 1 

retractor and visualized to the anterior VB margin. The C7 pedicle was 

skeletonized and removed with a Lempert-Leksell. Sequential lumbar 

taps were used to decancellate the C7 VB; osteotomes and downpushing 

curettes were used to create a 30 deg wedge. The C7 lateral 

wall, then the medial column, was removed. The Mayfield was used 

to lift the head (after loosening) and close the osteotomy. Results are 

averages (n=10): age - 72yrs, estimated blood loss - 1,110 cc, surgical 

time - 4.3 hrs, hospital stay - 9.9 days, follow-up time - 5 mo, preop 

cervical sagittal imbalance - 8.0±1.4 cm, immediate post-op - 3.5±1.8 

cm, overall correction - 4.5±1.5 cm (43.6%), PSO correction - 18.8 

deg, CBVA correction - 38 deg. There was no correlation between 

pre-op C2-T1 radiographic kyphosis and pre-op CBVA (R squared = 

0.0021). There was a large correlation with PSO correction angle and 

post-op CBVA (R squared = 0.36). NDI decreased significantly (51.1 

to 38.6, p=0.03), and VAS (7.6 to 3.4, p=0.0083). PCS increased by 

18.4% (30.2 to 35.8) with no neurological complications. CT PSO 

is safe and effective for managing CT kyphotic deformity. It yields 

excellent correction of cervical kyphosis and CBVA with controlled 

closure and improvement in HRQOL scores even at early time points. 

Currently, the authors prefer PSO at the CT level for treatment of 

chin-on-chest deformity. 


Inferior Vena Cava Filters Prevent Emboli in High-Risk 

Patients Undergoing Major Spinal Surgery 

Justin Dazley, MD, Stony Brook, NY 

Reese Wain, MD 

Ryan Vellinga, BS, Hauppauge, NY 

Benjamin Cohen, MD, Garden City, NY 

Marc A Agulnick, MD, Franklin Square, NY 

This study was undertaken to demonstrate the efficacy of prophylactic 

inferior vena cava (IVC) filters in preventing potentially fatal venous 

thromboembolic event (VTE) in high-risk patients undergoing major 




spinal surgery. All patients undergoing major spinal surgery, with IVC 

filters placed for VTE prophylaxis from 2006 to 2009, were reviewed. 

Patients with two or more risk factors for VTE were included and 

reviewed for perioperative VTE, as well as complications related to use 

of the IVC filter. Cavograms obtained at the time of attempted filter 

retrieval identified intercepted emboli, inferring the prevention of a 

pulmonary embolism (PE). The incidence of intercepted emboli, as 

well as PE, in our series was compared with rates of PE documented 

in the literature for similar high-risk populations undergoing similar 

procedures. Approximately 17% of patients reviewed had thrombus 

present at attempted filter retrieval. An additional 17% of IVC filters 

were unable to be retrieved as they had shifted position within the 

inferior vena cava. No patients experienced symptomatic PE. One 

patient developed a DVT requiring pharmacologic treatment. One 

patient with a retained filter developed a lower extremity phlebitis 

requiring treatment. There were no other complications related to 

IVC filter use. This series shows that IVC filters are safe, as well as 

efficacious in preventing VTEs in patients undergoing spinal surgery. 

The observed rate of PE is consistent with the rate of PE in similar 

populations documented in the literature; however, our study 

demonstrates objectively that IVC filters prevent embolic events in 

this patient population. Emboli intercepted by filters more accurately 

estimate PEs prevented, and may prove to be a standard for future 

efforts to assess the efficacy of these devices, as their role in spine 

surgery continues to be defined. 


Lateral Lumbar Fusion (LLIF) Vs. Standard Fusion 

Approaches: Analysis Of Segmental Lordosis Change 

Jonathan N Sembrano, MD, Minneapolis, MN 

Ryan David Horazdovsky, MD, Minneapolis, MN 


Edward Rainier G Santos, MD, Minneapolis, MN 

Bieta Azmoudeh, BS, Minneapolis, MN 

David W Polly Jr, MD, Minneapolis, MN 

Potential advantages of minimally-invasive lateral lumbar interbody 

fusion (LLIF) include reduced morbidity and blood loss, decreased 

post-op pain and faster recovery. Improvement in sagittal alignment 

is considered an important goal in lumbar fusion. There are no 

studies comparing restoration of sagittal parameters utilizing the 

LLIF approach versus standard approaches. This is a comparative 

x-ray analysis of four lumbar fusion approaches. In a two-year period, 

245 levels in 167 patients were fused: LLIF (43 patients; 63 levels); 

anterior lumbar interbody fusion (ALIF) (41 patients; 67 levels); 

transforaminal lumbar interbody fusion (TLIF) (56 patients; 74 

levels); and posterior spinal fusion (PSF) (30 patients; 41 levels). The 

following parameters were measured on pre- and post-op standing 

radiographs: segmental lordosis; overall lumbar lordosis (L1-S1); 

anterior and posterior disk heights. Comparison of measurement 

changes between groups were performed using student’s t-test. 

All interbody procedures produced significantly greater lordosis 

change compared to posterior fusion alone (ALIF p=0.007; TLIF 

p=0.019; LLIF p=0.03). The three interbody approaches were not 

significantly different (ALIF vs. TLIF p=0.15; ALIF vs. LLIF p=0.28; 

TLIF vs. LLIF p=0.80). Only ALIF showed significant improvement 

in overall lumbar lordosis (p=0.0017). LLIF anterior disk height 

increase is intermediate between ALIF and TLIF. LLIF posterior disk 

height increase is similar to ALIF and superior to TLIF and PSF. LLIF 

provides similar segmental sagittal contour change compared to 

other interbody fusion approaches (ALIF and TLIF), and significantly 

greater compared to posterior fusion alone. Overall lumbar lordosis 

remains unchanged after LLIF. Posterior disk height increase is 

significant and may provide basis for indirect decompression. 

758 


uAnalysis of Pedicle Screw Design for Cement 

Augmentation in Osteoporotic Vertebrae 

Theodore J Choma, MD, Columbia, MO 

Ferris Pfeiffer, PhD 

Surgeons are increasingly considering pedicle screw instrumentation 

in osteoporotic patients for a variety of spinal conditions. The 

optimal screw design and cement characteristics are as yet unknown 

when cement augmentation is considered. Fifty human osteoporotic 

(with average bone mineral density 0.581 g/cm3) cadaveric 

thoracolumbar vertebrae were instrumented with pedicle screws 

from a single vendor. Screw geometry varied by being solid-core or 

cannulated with multiple side fenestrations over the distal one-third 

of the screw. Two different (one being more viscous than the other) 

commercially available polymethylmethacrylate (PMMA) cements 

were tested for augmentation. Pullout testing was performed on 

all screws. Extraction torque was tested on 24 additional vertebrae. 

Non-augmented screws had the lowest mean force to failure (159 

N). Solid core screws augmented with PMMA prior to insertion 

demonstrated 525 N failure force. PMMA injected though distally 

fenestrated screws produced 690 N failure force. Peak insertion 

torque for all screws averaged 6.99 in-lb. Extraction torque for nonaugmented 

screws was not significantly different, but was higher 

(10.33 in-lbs for solid core and 15.61 in-lbs for distally fenestrated, 

p

levels were C2-3 and C3-4. Twenty-seven percent of patients had >1 

congenital fusion level. In the KFS population, the surgical level was: 

1-level cephalad to the congenital fusion (17%), 1-level caudal to the 

congenital fusion (66%), in between two congenitally-fused areas 

(17%). The KFS group had a tendency of more myeloradiculopathy, 

and the control group had a tendency towards more radiculopathy. 

However, both tendencies were not significantly different. MRIs of 10 

KFS and 22 control group were available. There was no difference in 

the area of both spinal cord and canal of the operative levels. There 

were no differences between KFS and well-matched control group 

in terms of age of onset, presentation, revision rate, complication 

rates, surgical outcomes and cross sectional spinal cord and canal 

dimensions. 


Outcomes And Complications Of Pedicle Subtraction 

Osteotomy For Sagittal And/Or Coronal Deformity 

George N Jada, Kingston, ON Canada 

Ahmed Salem Mohamed, MD, Baltimore, MD 

Philip R Neubauer, MD, White Hall, MD 

Richard L Skolasky, Jr Prof., Baltimore, MD 

Khaled M- Kebaish, MD, Baltimore, MD 

Pedicle subtraction osteotomy (PSO) is a widely used procedure 

in surgeries of spinal deformity. However, there is limited research 

into the outcomes and complications associated with PSO in older 

populations. This a retrospective study of 63 consecutive patients 

who underwent PSO for the treatment of sagittal and/or coronal 

deformities. All patients included were older than 40 years. All patients 

completed a minimum 24 months of follow up. Complications were 

classified as major or minor. Radiographic and functional outcome 

data (SRS-22, ODI) were collected prospectively. The average patient 

age was 58.3 (42-78), with 41 females and 22 males. Preoperative 

diagnoses included 33 patients (52.38%) with sagittal imbalance, 

three patients (4.76%) with coronal deformity and 27 patients 

(42.86%) with both sagittal and coronal imbalance. There was total 

of 87 PSO surgeries in 63 patients, 71 were lumbar, 12 thoracic, two 

cervical and two sacral. There was improvement in all SRS-22 domains 

from preoperative to final follow up, with the most improvement 

in the lumbar/sacral PSO patients. There was no mortalities, eight 

neurological complications, none were permanent, two infection, 

one deep and one superficial. There was one pseudoarthrosis at 

an osteotomy level. Overall 28.57% of patients experienced major 

complications and 57.14% had minor complications. Increased age 

was correlated with increased complications (r=0.85). There was a 

correlation between the occurrence of complications and the degree 

of preoperative sagittal deformity (r=0.39). Furthermore, a greater 

correction in the sagittal deformity was associated with greater risk 

of complications (r=0.23). Pedicle subtraction osteotomy is now 

widely used for the correction of sagittal and/or coronal deformities. 

It is a technically challenging procedure which has an increased risk 

of complications in older patients. Nevertheless, patients showed 

significant improvement in functional outcomes in spite of these 

complication. The significance of this study is that although older 

patients may be at an increased risk of perioperative complications 

following pedicle subtraction osteotomy for deformity correction, 

their functional outcome is substantially improved. 

759 


Complication Rates Utilizing rhBMP-2 for Instrumented 

Lumbar Posterolateral Fusions 


Martin Hoffman, MD, Grand Rapids, MI 


rhBMP-2 (INFUSE) has been utilized off label for instrumented 

lumbar posterolateral fusions for many years. Many series have 

demonstrated predictable healing rates and reoperations. The 

goal of this study was to evaluate the number of complications 

requiring reoperation for symptomatic failed fusion and hyper 

responsive neural compressions. During a seven-year period of 

time (2002-2009), all patients undergoing instrumented lumbar 

posterolateral fusion consenting to utilizing of rhBMP-2 (INFUSE) 

were retrospectively evaluated as a quality analysis within a large 

orthopaedic surgery private practice. Patient demographics, body 

mass index (BMI), comorbidities, number of levels and types 

of bone void filler (BVF) were analyzed. Complications were 

determined to be reoperation secondary to failed symptomatic 

fusion, hyper reaction resulting in compressive fluid collections, 

hyper formation of bone resulting in neural compression and 

infections. A total of 1,269 consecutive patients were evaluated with 

42% males and 58% females. Average age was 59 yo and BMI was 

30. Number of levels fused was: one (478, 38%), two (525, 41%), 

three (182, 14%), four (64, 5%), five (13, 1%) and six (7, 0.6%). 

Complications requiring reoperation were 78/1269 (6%): Seroma 

with acute neural compression 29 (2.3%), excess bone formation 

with delayed neural compression seven (0.5%), infection requiring 

debridement 10 (0.8%) and symptomatic nonunion requiring redo 

fusion and instrumentation 33 (2.6%). Seroma formation was not 

associated with interbody fusion or prior rhBMP exposure and was 

associated with acute exacerbation of radicular pain and transient 

neural involvement of varying degrees. Bone reformation at the 

laminectomy and foraminotomy sites occurred in a delayed fashion 

associated with a solid union, progressive worsening of radicular 

pain, and were successfully treated with repeat neural compression 

only. Nonunion was not related to smoking, number of levels fused 

or age. All nonunions were successfully treated with redo surgical 

instrumentation and rhBMP application. Neural compression 

acutely with fluid or delayed with osseous formations and nonunions 

associated with rhBMP2 require further evaluation. 


Quality of Life among Lumbar Fusion and Joint 

Arthoplasty Patients in the Elderly Population 

Ian Cowgill, MS 

Zachary Allen Child, MD, Albuquerque, NM 

Jean Hanson, RN, PhD, Albuquerque, NM 

Meghan A Erdman, MS 

Scott Traver Lovald, PhD, MBA, Philadelphia, PA 

Paul S Robinson, Albuquerque, NM 

Beverly E Diamond, DSW 

Clinical outcomes from operative treatment of lumbar spinal 

disorders in the elderly are not well documented. The object of this 

study was to determine if quality of life of elderly lumbar spinal surgery 

(LSS) patients is different from those of total knee (TKA) and hip 

arthroplasty (THA), which are considered the standard benchmarks 

for operative restoration of quality of life. Preoperative and twoyear 

postoperative SF-36 Physical (PCS) and Mental Component 

Scores (MCS) from 20 centers were compared for TKA (N=49), THA 

(n=46) and LSS (n=105)(decompression/fusion) patients age 65 yrs 




and older. The two-year scores were analyzed in a series of univariate 

models and in a multivariate ANCOVA. The ANCOVA controlled for 

preoperative scores and included age, gender, BMI and comorbidity. 

For PCS, the LSS group improved less and remained significantly 

lower (38.6 ±10.3; p

professionals. and sponsor spine conferences for patients. 


Simvastatin Improves Spinal Fusion In Rats 

Bora Bostan, MD, Tokat, Turkey 

Taner Gunes, MD, Tokat, Turkey 

Murat Asci, MD, Tokat, Turkey 

Cengiz Sen, Tokat, Turkey 

Mehmet Halidun Kelestemur, Assc Prof, Kayseri-Talas, Turkey 

Mehmet Erdem, MD, Tokat, Turkey 

Resit Dogan Koseoglu, MD, Tokat, Turkey 

Unal Erkorkmaz, PhD, Tokat, Turkey 

Aim of the Study: Statins stimulate bone formation by inducing the 

expression of BMP-2 (Bone morphogenetic proteins). In the present 

study, we investigated the effects of orally administered simvastatin 

on spinal fusion in rats. Methods: Twenty rats were randomized into 

two groups as spinal fusion group (SF) (n=10) or a spinal fusion and 

oral simvastatin administered group (SFS) (n=10). Simvastatin was 

administered orally 120 mg/kg/day in the SFS group. A spinal fusion 

model was performed between L4-L6 representing two levels in each 

rats, and at the end of 12 weeks, the rats were killed. Results: Manual 

palpation revealed two moderate fusions in the SF group, whereas 

the treatment group revealed no signs of pseudoarthrosis. An average 

three-point bending force causing failure of fusion revealed results 

of 148.80±39.403 Newtons and 123.80±28.479 Newtons in SFS and 

SF groups, respectively (p>0.05). Histological examination revealed 

better fusion grades in the SFS group with a mean of 9.30 ±0.949 than 

with the SF group with an average grade of 6.80 ±2.044 (p=0.003). 

Radiographic examination revealed grade C fusion in two levels and 

grade A fusion in 18 levels in the SF group whereas grade C fusion 

in one level and grade A fusions in 19 levels were detected in the 

SFS group. Conclusion: Our results suggest that if bioavailability of 

simvastatin in bone can be adjusted by lowering its clearance in the 

liver, it can be used as an adjunct to spinal fusion procedures in an 

elderly population with high cholesterol levels. 



Mortality Risk for Operated and Non-Operated 

Vertebral Fracture Patients in the Medicare Population 

Avram A Edidin, PhD, Portola Valley, CA 

Kevin Ong, PhD, Philadelphia, PA 



Sigurd H Berven, MD, San Francisco, CA 

Mortality risk has been shown to increase following the onset of 

vertebral compression fractures (VCFs). However, the difference in 

survival for VCF patients following non-operative and operative 

(kyphoplasty or vertebroplasty) treatments has not been examined. 

Operated and non-operated VCF patients were identified from the 

100% Medicare national sample in 2005 to 2008 and followed for 

up to 4 years. Patients with previously diagnosed pathological and 

traumatic VCFs in the prior year were excluded. Overall survival 

was estimated by the Kaplan-Meier method, and the differences 

in mortality rates (operated vs. non-operated; vertebroplasty vs. 

kyphoplasty) were assessed by Cox regression (adjusted for patient 

demographics and comorbidities, e.g., arterial disease, chronic 

obstructive pulmonary disease, cancer, diabetes, hip fracture, 

761 

hypertension, ischemic heart disease, heart conduction disorders, 

pneumonia, pulmonary heart disease, stroke, and wrist fracture). 

182,946 patients that underwent vertebroplasty or kyphoplasty 

had a higher survival rate of 57.3% at 48 months following VCF 

diagnosis compared to 50.4% for the 676,032 non-operated patients. 

Vertebroplasty or kyphoplasty patients were 32% less likely to die 

than non-operated VCF patients (adjusted OR=0.68; p

Newtons for 2600 cycles at a rate of 1 Hertz. Continuous load and 

deformation data were acquired at 100 cycle intervals. For each 

screw design, a non-linear exponential fit of the screw deflection 

versus cycle number was conducted. The resulting parameters of 

Plateau (stabilization point) and rate of deflection increase (decay) 

were extracted and averaged. An analysis of variance with a posthoc 

Tukey comparison was utilized to infer statistical differences 

in performance between designs. The non-linear exponential fit 

resulted in R-squared values in excess of 0.9 . Both deflection rate 

(decay) and Plateau were found to be good indicators of screw 

performance by displaying statistically significant differences among 

the designs. Both deflection rate (decay) and Plateau were found to 

differ depending on the particular design of the screw. The fitting of 

dynamic toggle data resulted in non-linear R-squared values close 

to unity, indicating that using this methodology to evaluate screw 

performance is reproducible. These parameters may be used to aid in 

the performance evaluation of future screw designs. 


The Role of Sagittale Balance and Spinopelvic 

Parameters in Spine Deformity 

Michael Akbar, MD, Heidelberg, Germany 

Markus Eichler, MD, Heidelberg, Germany 

Cornelia Putz, MD, Heidelberg, Germany 

Bernd Wiedenhofer, MD, Heidelberg, Germany 

One of the most critical relationships in the human spine that sets 

parameters for the sagittal balance is the lumbosacral pelvis. Recent 

studies report that the sagittal plane balance is mediated by the 

following independent factors: sacral slope, pelvic tilt (or pelvis 

retroversion used to maintain an upright posture in the setting 

of spinal deformity), pelvic incidence (morphologic parameter 

directly linked to sagittal morphotypes), and lumbar lordosis. The 

purpose of this exhibit is to present our over 10-year experience 

with treating spinal deformity taking the sagittal profile and the 

spinopelvic parameter into account and underline the meaning and 

consequences of the sagittal profile for the spine. Between January 

2000 and December 2009, more than 5000 patients were treated 

with a spondylodesis of the spine. The patients had congenital, 

traumatic and degenerative spinal disorders. About 1500 patients 

were included in this study. The authors reviewed the clinical 

records and radiographs of all patients included in the study. The 

postoperative outcome (VAS, HQOL and ODI) was correlated with 

the sagittal profile and the spinopelvic parameter. From 2000 to 

2009, 1500 patients were treated with a spondylodesis for different 

types of spinal disorders. The postoperative results in the different 

spinal disorder groups show that the sagittal profile and the pelvic 

tilt (PT) play a significant role and have a significant influence on 

outcome and function. In patients with severe spinal deformity 

(neurogenic hyperkyphosis) the extent of restoration of the sagittal 

profile correlated with postoperative complications like failure 

of instrumentation (rode breakage and rode penetration). It has 

become evident that good clinical outcome in the treatment of 

spinal deformity requires proper alignment. Pelvis parameters 

play an essential role not only in terms of spine morphotypes but 

also in regulating standing balance and postoperative alignment. 

Thus, optimal treatment of a patient with spinal deformity requires 

integration of the pelvis in the preoperative evaluation and treatment 

plan.This scientific exhibit will report our over 10-year experience 

with different spinal disorders, review treatment principles, and 

emphasize the role of the sagittal balance for postoperative outcome, 

function and failure of instrumentation. 

762 




PAPERS 

763 

sPorts Medicine and arthroscoPY 

pApeR No. 196 

Prospective Randomized Trial ACI vs Mosaicplasty in 

the Adult Knee. 10 Year Results 

Leela C Biant, FRSCEd, Edinburgh, United Kingdom 

Sridhar Vijayan, BSC, MBBS 

George Bentley, CHM FRCS, Oxford, United Kingdom 

Autologous chondrocyte implantation (ACI) and mosaicplasty 

(MP) are two methods of repair of symptomatic articular cartilage 

defects in the adult knee. This study represents the only longterm 

comparative clinical trial of the two methods. A prospective, 

randomized comparison study of ACI versus MP in 100 patients 

with a symptomatic articular cartilage lesions of the knee. Pain and 

function were assessed for minimum 10 years using the modified 

Cincinnati score, Bentley Stanmore Functional rating system and 

visual analogue scores. ‘Failure’ was determined by pain, a poor 

outcome score and arthroscopic evidence of graft disintegration. 

Patients had a mean age at index operation of 31. There was a long 

mean pre-op duration of symptoms of seven years, and an average 

of 1.5 operations (excluding arthroscopy) had been performed on 

the defect prior to the cartilage repair surgery. The aetiology of the 

articular cartilage defects was mainly trauma. Five patients were 

lost to follow up. Twenty-three of the 42 MP patients and 10/58 

ACI patients failed (p

in the knee. Fifty-three patients were treated with hyaluronan-based 

MACT product. Patient characteristics at baseline were as follows 

(mean±standard deviation): 22 female, 31 male, age 32±12 years, 

body mass index (BMI) 24.5±3.8 kg/m2 and defect size 4.4±1.9 

cm2. Fifty patients had single defects and three had multiple defects 

(41 medial femoral condyle, six lateral femoral condyle, two patella, 

one tibia). Primary inclusion criteria (stable ligaments, regular 

knee alignment (±3°), singular defect within otherwise healthy 

adjacent cartilage, age

pApeR No. 203 

Long-Term Assessment Of Cartilage Repair After 

Microfracture Therapy Using Morphological Mr 

Imaging 

Arvind Gabriel Von Keudell, MD, Boston, MA 

Joerg Atzwanger, MD, Brooklyn, NY 

Rosemarie Forstner, MD, Salzburg, Austria 

Herbert Resch, MD, Salzburg, Austria 

Thomas Hoffelner, MD, Salzburg, Austria 

Michael Mayer, MD, Salzburg, Austria 

Recent literature revealed good short-term results after 

microfracturing (MFX) of isolated focal cartilage defects in the knee. 

Study purpose was a long-term evaluation of patients who received 

MFX through a multimodal approach, correlating clinical scores 

and morphological pre- and postoperative MRI. Between 2000 and 

2007, 158 patients were treated with MFX for focal femoral or tibial 

defects at our department. Patients with instabilities, secondary 

surgical intervention, patellofemoral lesions, plica mediopatellaris 

or more than one cartilage defect site and age >55 were excluded. 

Fifteen patients were included. Minimum post-operative follow 

up (FU) was 18 months (18-78 m). Mean age at surgery was 45 

years (27- 54), mean FU-interval 48±2 months (18-78 m). Male to 

female ratio was 9:6. For clinical assessment the Knee Injury and 

Osteoarthritis Outcome (KOOS) and Lysholm scores were used, 

radiological evaluation was performed with X-ray and 3T-MRI. 

Clinical knee function was rated good to excellent in one patient, 

fair in two and poor in 10 patients. Two of 15 patients received full 

knee replacement due to insufficient cartilage repair through MFX 

during FU period. Evaluation of pre- and postoperative MRI showed 

good cartilage repair tissue in one (7.7%), moderate repair in two 

(15.4%) and poor fill in 10 patients (76.9%). In these 10 patients, 

defect size increased. Average defect size preoperatively was 187 

mm2 (12-800 mm2) and postoperatively 294 mm2 (40- 800 mm2). 

The KOOS pain averaged 60 (39-94), KOOS symptoms 60.6 (21- 

100), KOOS ADL 69 (21-91), KOOS Sports 35.7 (5-60) and KOOS 

QUL 37.2 (6-81). The average Lysholm score was 73.9 (58-94). Ten 

patients showed a varus leg axis deviation (Ø 5.9°), three had a 

neutral alignment. The alignment correlated positively with KOOS 

and especially with the Lysholm score. Our study demonstrated that 

MFX as a treatment option for cartilage defect in the knee did not 

show the anticipated clinical and radiological long-term results. In 

12/15 patients the cartilage defect size had increased after MFX, in 

two/15 indicating full-knee replacement. Especially those with a 

leg malalignment > 6 degrees were more prone to suffer from an 

increase in defect size. In our cohort the clinical scores correlated 

with the radiological findings. 

pApeR No. 204 

T1rho MRI Can Detect Early Cartilage Changes in 

Knees of Asymptomatic Collegiate Female Athletes 

Sebastian Charles Peers, MD, Royal Oak, MI 

David Keyes, MD 

Anil Shetty, PhD, Royal Oak, MI 

David Marcantonio, MD 

Erin Ann Baker, MS, Royal Oak, MI 


Dr Yang Xia, Rochester, MI 

Joseph Guettler, MD, Bingham Farms, MI 

The purpose of this study was to determine if young impact athletes 

were pre-disposed to knee arthritis later on in life, and whether 

765 

T1rho MRI could pick up very early pathologic cartilage changes. 

Ten impact (basketball players) and 10 non-impact (swimmers) 

female collegiate athletes, all participating within the season of their 

respective athletic schedule, underwent MRI. Sagittal condylar cuts 

and axial patellofemoral cuts were obtained. Gross examination 

of MRIs was performed. Frequency charts, representing pathologic 

cartilage matrix changes, were also created from parametric maps 

to determine the distribution of T1rho relaxation times within the 

three knee compartments. A comparison of the depth-dependent 

changes was also performed. Findings were compared between the 

impact and nonimpact groups. Gross examination of MRIs showed 

damage to the patellofemoral cartilage of four impact athletes, 

while no gross structural changes were appreciated in the nonimpact 

group. T1rho relaxation times in the patellofemoral and 

lateral compartments were not significantly different between the 

two groups. However, there were statistically significant changes in 

the medial compartment of the impact group. Depth-dependent 

differences between the two groups were also observed. T1rho MRI 

can be utilized to detect early degenerative changes in the articular 

cartilage of otherwise asymptomatic young impact athletes. These 

findings may have significant implications relating to the potential 

risk for arthritis in this group, and future modifications in lowerimpact 

training and practice regimens may be necessary. 

pApeR No. 205 

uUse of a Biphasic Scaffold for the Treatment of 

Isolated Osteochondral Defects of the Knee 

Frank Petrigliano, MD, Los Angeles, CA 

Hsiu Su, MD 

Li Foong Foo, MD 

Ian Solsky, BS 

Thomas L Wickiewicz, MD, New York, NY 

Scott Alan Rodeo, MD, New York, NY 




The purpose of this study was to report the subjective outcomes of 

patients treated with a biphasic scaffold for isolated osteochondral 

defects of the knee and describe the morphology and incorporation 

of the scaffold using cartilage-sensitive MRI. Thirty patients (31 

knees) underwent biphasic scaffold implantation. The follow up 

interval to subjective evaluation was 32.8 months (range: 24-48) 

and MRI was 20.8 months (range: 12-40). Subjective outcomes were 

assessed using the Activity of Daily Living score (ADL), Marx Activity 

Scale and International Knee Documentation Committee (IKDC) 

Patient Subjective Knee Evaluation. Implants were evaluated for 

cartilage signal, interface morphology, displacement, hypertrophy, 

subchondral edema, bony overgrowth, percentage fill and degree of 

incorporation. ANOVA and linear regression analysis were performed 

with Bonferroni correction; p

MRI appearance, clinical outcome did not correlate with implant 

morphology. 

pApeR No. 206 

Characterization of the Bond Formed Between Native 

and Engineered Cartilage and Subchondral Bone 

Tamara Pylawka, MD, Hershey, PA 

J Spence Reid, MD, Hershey, PA 

Henry J Donahue, PhD, Hershey, PA 

Gregory S Lewis, PhD 

Sprague Hazard, MD 

Timothy Shane Johnson, MD 

Current articular cartilage repair techniques partially rely on the 

integration of cartilage to bone with scar tissue. Thus the bond 

formed between native cartilage and subchondral bone as well 

as engineered cartilage and subchondral bone is important in 

determining the usefulness of cartilage engineering as a potential 

therapeutic technique. However, limited information regarding this 

subject exists. Our goal was to characterize the bond formed between 

native cartilage and subchondral bone as well as engineered cartilage 

and subchondral bone using histology, immunohistochemistry and 

biomechanical testing. Chondrocytes were isolated from different 

porcine anatomic sources (articular, auricular and costal), suspended 

in fibrin gel polymer (80x106 chondrocytes/mL) and sandwiched 

between discs of articular cartilage and subchondral bone. A drop 

of this suspension was placed between a disk of articular cartilage 

and subchondral bone forming 40 tri-layer constructs for each 

chondrocyte type (40 articular, 40 auricular and 40 costal), resulting 

in 120 experimental constructs. These tri-layer constructs were then 

implanted in athymic mice for six and 12 weeks, then subjected 

to gross analysis, biomechanical testing, standard histological 

evaluation and immunohistochemical (Type II collagen) testing. 

Control groups consisted of fibrin glue only with no cells added. 

The ultimate stress and failure energy was significantly more at 

12 weeks compared to six weeks for each cell type. Each cell type 

had a significantly higher ultimate stress and failure energy when 

compared to their respective control groups but not when compared 

to each other. Using immunohistochemistry, we demonstrated that 

sample constructs taken from each group expressed type II collagen 

suggesting not only chondrocyte viability but preserved synthetic 

function. Safranin-O revealed the presence of glycosaminoglycans 

in the newly formed tissue. Alternative anatomical chondrocyte 

sources (auricular or costal) are biomechanically similar during axial 

tension to failure compared to articular chondrocytes and may be 

viable repair tissue sources. 

pApeR No. 207 

Co-Cultures Of Adult-Juvenile Chondrocytes Compared 

With Adult-Juvenile Chondral Fragments 

Davide E Bonasia, MD, Torino, Italy Italy 

James A Martin, PhD 

Antongiulio Marmotti, MD, Torino, TO Italy 

Richard Amendola, Post Grad, Torino, Italy 


Annunziato Amendola, MD, Iowa City, IA 

The goal of this study is to evaluate in vitro the chondrogenesis of 

adult/juvenile co-cultures of both chondrocytes (part 1) and minced 

cartilage fragments (part 2). Cartilage sources consisted of three 

adult and three juvenile donors. In part 1, per each donor, juvenile 

cells were mixed with adult ones in five different proportions: 100, 

50, 25, 12.5 and 0% of adult with, respectively, 0, 50, 75, 87.5, 

766 

100% of juvenile chondrocytes. At six weeks, proteoglycan assay, 

lactate assay, safranin-O, anti-collagen II, anti-link-protein immunofluorescence 

staining and Bern scoring of the neo-cartilage were 

performed. In part 2, cartilage fragments were manually minced (

pApeR No. 209 

Supraphysiological Temperatures Are Necessary for 

Bupivacaine Chondrotoxicity 

Nelson Mead, BS, New Orleans, LA 

Jessica Ryu, BA 

Sen Liu, MD 

Dongxia Ge, MD, MS 


Zongbing You, MD, New Orleans, LA 

Justin Lucas, BS 

Recent studies have implicated bupivacaine as the primary etiology 

of chondroysis of the shoulder. We believe the etiology to be 

multifactorial, and have designed a study to evaluate the effect of 

exposure to various temperatures encountered in arthroscopic 

surgery to determine whether there is an additive effect. Initially, we 

incubated bovine articular chondrocytes in either 20°C, 37°C, 40°C, 

42°C, 45°C, 47°C or 50°C for 15, 30 or 60 minutes to determine 

the effect of temperature on chondrocyte viability. We then cultured 

a separate population of cells and divided them into experimental 

groups that were incubated in either 37°C, 45°C or 50°C for either 

30 or 60 minutes. These experimental groups were subsequently 

treated with either 0.5% bupivacaine or saline for 60 minutes. 

Using flow cytometry, we were able to determine the percentages 

of live/dead cells and necrotic/apoptotic cells. Bovine articular 

chondrocytes exhibited significantly more cell death at temperatures 

exceeding 45°C, regardless of the time of exposure (p

otational stability. However, no consensus has been reached on the 

advantages of this technique over the single bundle technique. We 

hypothesized that double bundle ACL reconstruction can provide 

better clinical outcome than single bundle reconstruction. Fiftysix 

patients with ACL injury in one knee were recruited with 27 

allocated to the double bundle ACL reconstruction group and 29 

to the single bundle ACL reconstruction group. Clinical outcomes 

including Lysholm knee and Tegner activity scores were similar in 

the two groups at three-year follow up (p>0.5). Furthermore, stability 

results of Lachman test, pivot shift test and radiological findings 

at three-year follow up failed to reveal any significant inter-group 

differences (p>0.05). Notchplasty rate was different between two 

groups: double bundle (25.9%) and single bundle group (58.6%) 

(p

laxity was measured before and after reconstruction at 0°, 30°, 

60°, and 90°. 3D CT was checked postoperatively to evaluate the 

tunnel position. Both steps of surgical treatment (SB and DB) 

significantly reduced anteroposterior (AP) translation and rotation 

postoperatively. However, total rotation was significantly smaller 

in DB group at 60° postoperatively (p=.045) and the amount of 

postoperative decrease in rotation was also greater in DB group at 

30° (p=.033). O’clock position and high-low position was different 

among SB, DB anteromedial (DB AM) and DB posterolateral (DB 

PL) femoral tunnels (SB vs PL, p=.012; AM vs PL, p=.003), whereas 

the deep-shallow position was not different. In regard to the 

relationship between the tunnel position and stability, posteriorly 

placed PL tibial tunnel and deep SB and AM femoral tunnel was 

correlated with postoperative increase in rotation. Clinical outcome, 

including manual stability, KT-1000, Tegner activity score, Lysholm 

and IKDC score, was not different between the two groups. Double 

bundle ACL reconstruction showed similar anteroposterior laxity 

but superior rotational stability to single bundle ACL reconstruction 

measured by navigation. Tunnel positions had some correlation 

with the laxity, indicating fine tuning in tunnel placement may be 

needed to improve the stability, but overall clinical outcome was not 

different between groups, which should be further elucidated. 

pApeR No. 321 

Delayed Bone Tunnel Communication In The Femur 

After Anatomical Double Bundle ACL Reconstruction 

Masayuki Inoue, MD, Sapporo, Japan 

Norimichi Shimamoto, MD, Sappro, Japan 

Tsuyoshi Asano, MD, Sapporo, Japan 

Masatake Matsuoka, MD, Sapporo, Japan 

Shin Onodera, MD, Hokkaido Sapporo, Japan 

Kazunori Yasuda, MD, Sapporo, Japan 

After anatomical double bundle anterior cruciate ligament (ACL) 

reconstruction, there are some cases that did not exhibit tunnel 

communication just after surgery and yet exhibit it at one year 

after surgery. Tunnel communication will cause huge bone loss, 

which will be a serious problem at revision ACL surgery. The aim 

of this study is to clarify risk factors that may cause delayed tunnel 

communication in the femur. One hundred and ten patients (62 

male, 48 female, mean age 27) who underwent anatomical double 

bundle ACL reconstruction were evaluated. At one week and at one 

year after surgery, all patients received multi planner reconstructed 

CT that enabled detailed evaluation of bone tunnels at any direction. 

We evaluated the width of the septum between two tunnels, the 

position of the tunnel outlet and the angle of the tunnels. We also 

investigated the age and gender of the patients. Seventeen knees 

exhibited delayed tunnel communication. The incidence of delayed 

communication was significantly higher in cases whose septum was 

less than 2 mm-thick at surgery (P

(p=0.10). Contralateral ACL rupture occurred in significantly more 

PT patients (26%) than HT patients (12%) (p=0.03). Significant 

differences have developed at 15 years after surgery which were not 

seen at earlier reviews. Compared to the HT Group, the PT group 

had significantly worse outcomes with respect to radiological 

osteoarthritis, range of motion and functional tests but no significant 

difference in laxity was identified. There was a high incidence of 

ACL injury after reconstruction, to both the reconstructed and the 

contralateral knee. 

pApeR No. 324 

Current Trends in ACL Reconstruction Among 

Professional Team Physicians 

Rajeev Pandarinath, MD, Washington, DC 

Michael G Ciccotti, MD, Philadelphia, PA 

Peter F DeLuca, MD, Philadelphia, PA 

Robert W Frederick, MD, Villanova, PA 

Anterior cruciate ligament (ACL) reconstruction is one of the most 

commonly performed sports medicine procedures. There is wide 

variation among surgeons in every aspect of the procedure. Although 

autograft patellar tendon is historically considered the ‘gold standard’ 

graft for ACL reconstruction, there are many graft choices available. 

In addition, there are a number of options for tunnel placement 

and drilling technique, fixation choices and final tensioning of the 

graft. The purpose of this study was to poll surgeons responsible for 

treating professional athletes to determine what options are most 

commonly used, and if there are any trends in treatment for this 

highly functioning population. An online survey was distributed 

to orthopedic surgeon members of professional team physician 

organizations for Major League Baseball, the National Football 

League, the National Hockey League and the National Basketball 

Association. Forty-seven physicians responded to the survey, 

representing 46% of all teams polled (122). Responses were collected 

and tabulated. Patellar tendon autograft was the most common 

graft used (66%). If allografts were used, non-irradiated grafts were 

strongly preferred (75%). Metal (38%) and bio-composite (28%) 

interference screws were most commonly used in the femoral tunnel. 

In the tibial tunnel, metal interference screws (40%) were the most 

commonly used, followed by bio-composite screws (17%). Onehalf 

of physicians preferred a femoral starting point of 10 o’clock/2 

o’clock depending on the laterality of the knee. Transtibial femoral 

tunnel drilling was more common than using the anteromedial 

portal. Ligaments were tensioned at 15 degrees of flexion on average, 

with full extension as the most common position for tensioning. 

Some 90% of surgeons preferred a single bundle technique. A total 

of 75% of surgeons routinely used a tourniquet for at least part of 

the reconstruction, with 50% leaving the tourniquet inflated for 

the entire case. There are a number of widely accepted methods for 

ACL reconstruction, many of which are used in high-level athletes. 

Patellar tendon autografts are most commonly used, typically with 

metal or bio-composite fixation. There are a number of preferred 

starting points for the femoral tunnel, with 10 o’clock being the most 

common. The single bundle technique continues to be used by the 

overwhelming majority of professional team physicians. 

770 

pApeR No. 325 

Performance after ACL Reconstruction in Womens 

National Basketball Association Athletes 

Kelly Scott, BA, New York, NY 

Surena Namdari, MD, MSc, Philadelphia, PA 

Andrew Hill Milby, MD, Philadelphia, PA 

Keith D Baldwin, MD, Philadelphia, PA 


Anterior cruciate ligament (ACL) tears are more common in female 

compared to male athletes. Performance outcomes and attrition rates 

associated with this injury/surgery in Women’s National Basketball 

Association (WNBA) athletes are unclear. The purpose of this study 

was to compare athletes who underwent ACL reconstruction with 

preinjury and with matched controls to determine differences 

in performance. A retrospective review of 18 WNBA players who 

underwent ACL reconstruction between 1998 and 2008 was 

conducted. Performance data for two seasons preceding and 

following the index surgery were collected. Data were obtained from 

36 matched controls. Within-group and between-group comparisons 

were performed to assess significance of changes in athletic 

performance between the pre- and post-index seasons, and the odds 

ratio of return to play following surgery. Twenty-two percent (4 of 

18) of WNBA athletes who underwent ACL reconstruction never 

returned to play in the WNBA. Within-group comparisons revealed 

that shooting percentage (p=0.04) and steals per 40 minutes of 

play (p=0.03) were reduced postoperatively. No other performance 

variables were significantly different in absolute terms or per 40 

minutes of play. Changes in these performance variables from the 

pre-index to post-index seasons were not significantly different from 

those of the control group. Cases had lower odds of remaining in 

the WNBA after the index year when compared to controls (OR 0.7, 

p=0.72). After ACL reconstruction, 22% of athletes did not return 

to a sanctioned game. For those returning, performance decreased 

in several categories, although the changes were not statistically 

significant relative to the comparison group. 

pApeR No. 326 

The Evaluation Of Donorsite After ACL Reconstruction 

With Use Of Quadriceps Tendon Autograft 








We evaluated donorsite after anterior cruciate ligament (ACL) 

reconstruction with use of quadriceps tendon-bone autograft by 

means of questionnaire, dynamometer and electromyography. Three 

hundred and eighteen ACL reconstructions with use of quadriceps 

tendon-bone autograft were included in the study and the mean 

follow up period was 48 months (range, 24 to 131 months). 

Donorsite evaluation included physical exam, questionnaire about 

anterior knee pain, quadriceps and hamstring muscle strengths by 

Cybex II isokinetic testing, electromyographic study and radiographic 

measurment of patellar position. Side-to-side difference by KT- 

1000 arthrometry was less than 5 mm in 90.5% and pivot shift 

was grade 0 in 76%. Only 6% of patients complained of more 

than minimal kneecap symptom during normal daily activities, 

but 50% complained of more than moderate anterior knee pain 

during long period sitting and kneeling. Donorsite tenderness was 



PaPers, Posters & scientific exhibits spoRts med/ARtHRo

absent in 92%. Insall-salvati ratio and congruence angle did not 

change postoperatively. Extension peak torque of quadriceps muscle 

at 180Ú/s measured by cybex was 80% of contralateral side at two 

years after surgery. Nerve conduction study showed the improvement 

of compound muscle action potential at six months and one year, 

which were well correlated with the recovery of quadriceps muscle 

strengths. Donorsite morbidity was minimal after ACL reconstruction 

using quadriceps tendon-bone autograft: mild or little anterior knee 

pain; minimal tenderness; recovery of quadriceps muscle strengths; 

and electromyographic evidence well correlated with the muscle 

strengths. Quadriceps tendon is considered a reliable graft alternative 

in ACL surgery. 

pApeR No. 327 

ACL Reconstruction Does Not Restore Load Sharing 

Between Menisci and Articular Cartilage 

Craig S Mauro, MD, Pittsburgh, PA 

Carl W Imhauser, PhD, New York, NY 

Antonia Zaferiou, BE 

Thomas L Wickiewicz, MD, New York, NY 

Alterations in joint contact mechanics may contribute to osteoarthritis 

after anterior cruciate ligament (ACL) tear and reconstruction. 

The purpose of this study was to determine the effect of ACL tear 

and reconstruction on load sharing between menisci and articular 

cartilage. Nine cadaveric knees were loaded using a robot in intact, 

ACL-deficient and single-bundle ACL-reconstructed states under a 

134 N anterior force (AF) at 30° and a combined 8 N-m/4 N-m 

valgus/internal rotation load (VI) at 5°, 15°, 30°. After determining 

knee kinematics, a pressure measurement sensor (Tekscan) was 

sutured beneath the menisci. Kinematics were replayed with the 

menisci in three conditions (intact, lateral meniscectomy, medial 

meniscectomy) and the contact force across the compartments was 

measured. Load sharing across the compartments was the ratio of in 

situ force with each meniscal perturbation to the in situ force with 

the menisci intact. With ACL deficiency, load sharing in the meniscus 

increased by 175% in the medial compartment with AF, and in the 

lateral compartment with VI between 24% and 46%. With ACL 

reconstruction, load sharing in the medial meniscus was similar to 

the intact knee with AF, but load sharing in the lateral meniscus with 

VI at 5° was lower than the intact knee by 41%. Under anterior loads, 

the medial meniscus bears proportionately more load with ACL 

deficiency, while load sharing is restored in the medial compartment 

with ACL reconstruction. Under rotational loads, the lateral meniscus 

bears proportionately more load with ACL deficiency; however, the 

lateral articular surface bears proportionately more load following 

ACL reconstruction. 

pApeR No. 328 

Semitendinosus Tendon Regeneration After Acl 

Reconstruction: Can We Use It Once More? 

Vladan Stevanovic, MD, Belgrade, Serbia 

Agnica Petkovic, MD 

The surprising observation has been made, supported by clinical 

and MRI findings, that the semitendinosus tendon can regenerate 

after being harvested in its whole length and thickness for anterior 

cruciate ligament (ACL) reconstruction. Is it biologicaly and 

functionaly adequate to use it once more? Two groups of randomized 

patients (150) followed two years after harvesting semitendinosus 

or semitendinosus and gracilis tendons in ACL reconstruction. 

Clinical, ultrasound and MRI examination, interventional biopsies 

and hystological and imunnohystochemical tests were done after 

patient’s approval. Surgical exploration was done in three patients 

771 

for macroscopic verification. A total of 70% showed regeneration of 

their semitendinosus tendons. The neotendons all inserted below 

the knee joint where they had fused with the gracilis tendon and 

above the joint when the gracillis was harvested too. The isokinetic 

strength of the hamstrings and quadriceps was not significantly 

lower in the operated leg than in the nonoperated leg. After biopsy 

macroscopically, histologically and immunohistochemically the 

regenerated tendons closely resembled normal ones with focal scarlike 

areas. In one patient regenerated tendon was used for medial 

patellofemoral ligament reconstruction. The semitendinosus muscle 

can recover and the tendon has a great potential to regenerate after 

its removal. Our data showed that those tendons can even be used 

again for autograft ligaments reconstruction. 

pApeR No. 329 

Pain Management with Local Multimodal Drug 

Injection for Patients Undergoing ACL Reconstruction 



Korea 




Korea 



Korea 



Korea 

This study aimed to determine the efficacy and safety of multimodal 

drug injection for pain control after anterior cruciate ligament (ACL) 

reconstruction using bone patellar tendon bone (BPTB) graft. A 

hundred patients were randomly assigned to five study groups (20 

patients in each group): Group 1: No injection; Group 2: Intraarticular 

(IA) injection of ropivacaine alone; Group 3: IA injection 

of multimodal drug cocktail; Group 4: Extra-articular (EA) injection 

of multimodal drug cocktail; Group 5: IA and EA injection of 

multimodal drug cocktail. Multimodal drug cocktail consists of 150 

mg of ropivacaine, 5 mg of morphine, 30 mg of ketorolac, 200 mg 

of epinephrine, and 375 mg cefuroxime. EA injection was performed 

at infrapatellar fat pad, graft harvest sites, arthroscopic portal sites, 

periosteum around the tibial tunnel and incision sites. Comparisons 

among five groups were performed in terms of pain levels at 

operation night, postoperative one day (PO 1D), 2D and 14D, 

pain levels with reference to preoperative expectation (PO 1D, 2D 

and 14D), patient satisfaction for the pain management (PO 14D) 

and incidences of side effects. The IA, and IA and EA multimodal 

drug injection groups (group 4 and 5) had significantly less pain at 

operating night than other three groups (p < 0.001). The overall pain 

levels among the groups 1, 2 and 3, and between groups 4 and 5 had 

no significant differences. The patients in groups 4 and 5 were more 

likely to experience same or less pain than preoperative expectation 

on PO 1D (p=0.050). However, the levels of patient satisfaction 

evaluated on PO 14D were not significantly different among 

groups. There were no patients reporting multimodal drug-related 

side effects. This study demonstrates that the multimodal cocktail 

injection, particularly EA injection, is an effective and safe method 

for reducing early postoperative pain after BPTB ACL reconstruction. 

In particular, this method would be valuable for outpatient-based 

ACL reconstruction. 




pApeR No. 330 

Effective Use of MRI in the Evaluation of Knee Pain: An 

Evidence Based Algorithm 

Eric D Fornari, MD, Boston, MA 

Elizabeth G Matzkin, MD, Newton, MA 

Jason C Saillant, MD, Boston, MA 

Isi Obadan, MD, Framingham, MA 

Rafael Cavalcanti, BS, Boston, MA 

Knee pain is one of the most common complaints of patients 

presenting to both primary care and orthopedic physicians. Despite 

its prevalence, many clinicians continue to have trouble evaluating 

knee pain. The purpose of this study was to determine clinical 

findings that can be used in an algorithm to determine which 

patients require an MRI for further evaluation of their knee pain. 

A retrospective review was performed of all knee MRIs ordered at 

Tufts Medical Center between October 2006 and October 2008. 

Inclusion criteria were patients >18 years old as well as evaluation 

by a member of the adult orthopedic department. Subjects who 

needed an MRI (297) differed significantly from those who did not 

(179) with respect to five independent predictors: duration of knee 

pain, joint laxity, joint line tenderness, joint effusion and extent of 

radiographic degenerative findings. Multivariate analysis determined 

a very strong relationship between an increasing number of predictors 

and the proportion of subjects who needed an MRI. The predicted 

probability of needing an MRI is 25% for one predictor, 43% for 

two, 56% for three, 72% for four and 95% if all five are present. Also, 

orthopedic physicians had significantly more appropriately ordered 

MRIs than their primary care counterparts. Our study derived an 

evidence-based algorithm using five clinical predictors (duration 

of symptoms, effusion, laxity, joint line tenderness and degree of 

radiographic degenerative change) to determine the need for MRI 

in the evaluation of knee pain. Furthermore, standard radiographs, 

ideally including weight-bearing views, should routinely be obtained 

prior to considering more invasive and costly imaging modalities. 

pApeR No. 481 

Outcome of Anatomic Transphyseal ACL 

Reconstruction in Tanner Stage 1 & 2 Patients with 

Open Physes 

Leo A Pinczewski, FRACS, Wollstonecraft, NSW Australia 

Justin Phillip Roe, MD, Sydney, New South Wales Australia 

Alison Kok, Sydney, NSW Australia 

Dr Lucy J Salmon, Sydney, NSW Australia 

Duncan Ferguson, MD, Auckland, New Zealand 

Catherine Hui, MD, Calgary, AB Canada 

Anterior cruciate ligament (ACL) injuries are being seen with 

increasing frequency in children. The aim of this study was to 

determine the outcome of anatomic transphyseal ACL reconstruction 

in tanner stage 1 and 2 patients with open growth plates at a 

minimum of two years after surgery. Between 2007-2008, 16 

prepubescent skeletally immature patients underwent anatomic 

transphyseal ACL reconstruction using soft tissue grafts. All patients 

were tanner stage 1 and 2 and all had open growth plates. Outcomes 

were assessed at a minimum of two years after surgery and included: 

limb alignment, limb length, instrumented testing with KT-1000 

and International Knee Documentation Committee (IKDC) score. 

Mean age at the time of surgery was 12 years (8-14). Graft choices 

included: living-related donor hamstring tendon allograft (n=14), 

hamstring tendon autograft (n=1) and fresh frozen allograft (n=1). 

Mean IKDC subjective score was 96 (84-100). Ninety-three percent 

of patients had

ACL origin to the popliteal insertion and to the lateral epicondyle. 

Distances were then calculated for both the lengths of these tunnels 

and the shortest distance from the physis to these tunnels. Statistical 

analysis was then performed to compare these distances across the 

age groups and between sexes. 3D MRI physeal reconstruction was 

then employed to confirm that the chosen anatomic landmarks 

spared the physes after femoral tunnel placement. Male and female 

femoral tunnel distances from the ACL origin to the popliteus 

insertion (tunnel A) and the tunnel length from the ACL origin to 

the lateral epicondyle (tunnel B), significantly differed across all age 

groups (p

was done with the aim of assessing the amount of femoral and 

tibial enlargement. Femoral tunnel diameter increased from 9.05+/- 

0.09 mm to 9.35+/-0.13 mm in group A, and from 9.03+/-0.12 

mm to 9.37+/-0.4 mm in group B (p:0.47). Tibial tunnel diameter 

increased from 9.06+/-0.31 mm to 10.3+/-0.81 mm in group A, and 

from 9.03+/-0.12 mm to 9.14+/-0.4 mm in group B (p:0.14). No 

significant differences were detected in either the femoral or tibial 

side between the two groups. In all patients of group A except for 

one, a significant presence of calcification inside both the femoral 

and tibial tunnels was observed. The use of the nanohydroxyapatite 

bone graft substitute does not seem to be efficient in preventing 

significant tunnel enlargement. Even though its use could still 

promote bone-graft integration, it has no effect on the amount of 

tunnel enlargement. 

pApeR No. 487 

Platelet-Rich Plasma: Does It Help Reducing Tunnel 

Widening After Acl Reconstruction? A Ct Study 


Raffaele Iorio, MD, Rome, Italy 

Ludovico Caperna, MD, Rome, Italy 

Daniele Paravani, MD 

Matteo Ferretti, MD, Rome, RM Italy 

Angelo De Carli, MD, Rome, Italy 


In the last years, growth-factors have been used to improve the rapidity 

of the tendon-to-bone healing process in anterior cruciate ligament 

(ACL) reconstruction with hamstrings. The aim of the study was to 

evaluate the efficacy of platelet-rich plasma (PRP) on the tunnel 

walls and assess their role in reducing the bone tunnel phenomenon. 

Twenty consecutive male patients operated for ACL reconstruction, 

in which a 9 mm tunnel was performed on femoral and tibial sides, 

were enrolled in this prospective study. They were randomly assigned 

to group A (10 patients, PRP group) and group B (10 patients, control 

group). All patients were clinically and radiologically followed up 

at a mean of 12 months. CT evaluation was done with the aim of 

assessing the amount of femoral and tibial enlargement. Femoral 

tunnel diameter increased from 9.03+/-0.12 mm to 9.8+/-0.3 mm 

in group A, and from 9.06+/-0.07 mm to 9.38+/-0.5 mm in group B 

(p>0.05). Tibial tunnel diameter increased from 9.04+/-0.23 mm to 

10.9+/-0.21 mm in group A, and from 9.08+/-0.07 mm to 10.14+/- 

0.4 mm in group B (p>0.05). No clinical differences were detected 

among the two groups. The use of PRP does not seem to be efficient 

in preventing significant tunnel enlargement. Even though its use 

may be useful in promoting bone-graft integration, it does not seem 

to be effective in reducing the tunnel enlargement phenomenon. 

pApeR No. 488 

PCL Reconstruction Combined With Anatomical 

Reconstruction Of Posterolateral Corner Insufficiency 

Dr Duck-Hyun Choi, Seoul, Republic of Korea 

Sung-Jae Kim, MD, Seoul, Republic of Korea 

Yong-Min Chun, MD, Seoul, Seoul, Republic of Korea 

Sung-Hwan Kim, MD, Seoul, Republic of Korea 

Byoung-Yoon Hwang, MD 

There is a paucity of clinical studies comparing single- and doublebundle 

posterior cruciate ligament (PCL) reconstruction combined 

with a posterolateral corner reconstruction. The purpose is to compare 

the clinical outcomes of single- and double-bundle transtibial 

PCL reconstruction combined with anatomical reconstruction of 

posterolateral corner insufficiency. The study population consisted 

774 

of 42 patients, and for whom a minimum of two years of follow-up 

data were available. We compared clinical outcomes of two surgical 

techniques: a single-bundle technique (23 patients, single-bundle 

group) or a double-bundle technique (19 patients, double-bundle 

group), each combined with reconstruction of the lateral collateral 

ligament and popliteus tendon for posterolateral corner insufficiency. 

There was no difference between the single- and double-bundle 

groups in the mean side-to-side difference of posterior translation 

measured with Telos stress radiography (4.2 ± 1.7 vs. 3.9 ± 1.6 mm), 

and rates greater than 5 mm were 22% in single-bundle group and 

21% in double-bundle group. Regarding the posterolateral rotatory 

laxity, there were no differences between the two groups in the 

mean side-to-side difference in the dial test (5.3° ± 2.7° vs. 5.1° 

± 2.4° at 30°; 6.7° ± 2.7° vs. 6.7° ± 2.4° at 90°), or in varus stress 

radiography(1.2 ± 1.2 mm vs. 1.3 ± 1.4 mm). The Lysholm knee 

scores were 85.7 ± 7.6 in the single-bundle group and 87.7 ± 7.3 

in the double-bundle group. There was no difference between the 

groups in International Knee Documentation Committee knee score. 

The rates of abnormal and severely abnormal categories in IKDC 

were 30% in single-bundle group and 26% in double-bundle group. 

Double-bundle PCL reconstruction combined with posterolateral 

corner reconstruction does not appear to have advantages over singlebundle 

PCL reconstruction combined with posterolateral corner 

reconstruction with respect to the clinical outcomes or posterior 

knee stability. 

pApeR No. 489 

Comparison Of Three Posterior Cruciate Ligament 

Reconstruction Techniques 

Young-Bok Jung, MD, Seoul, Seoul, Republic of Korea 

Sang Hak Lee, MD, Seoul, Republic of Korea 

Ho Joong Jung, Seoul, Seoul, Republic of Korea 

Siti Tahir, Kuala Lumpur, Malaysia 

Posterior cruciate ligament (PCL) injuries have the potential for 

intrinsic healing and several magnetic resonance imaging studies have 

reported that the PCL healed with continuity but also with residual 

laxity. Identification of concomitant injuries of the posterolateral 

corner (PLC) is important to optimize surgical and clinical outcomes. 

PCL injuries have many varieties of the PCL remnant depending on 

the situation. The purpose of this study was to compare the clinical 

results at a two-year follow up with three techniques: (1) the remnant 

PCL-augmenting procedure with transtibial tunnel technique in the 

acute or subacute stage, 2) tensioning of remnant PCL using modified 

tibial inlay technique with single bundle reconstruction in chronic 

stage and 3) PCL double bundle reconstruction. The records of 89 

patients who had primary PCL reconstruction with posterolateal 

corner sling (modified Larson technique) between April 2004 and 

March 2008 were analyzed retrospectively. Thirty-four patients were 

treated with PCL remnant preserving augmenting anterolatral bundle 

(ALB) reconstruction using transtibial tunnel technique in acute and 

subacute stage of the injury (group 1); 40 patients were treated with 

remnant tensioning and ALB reconstruction with modified inlay 

technique in chronic stage (group 2); and 15 patients were treated 

with double bundle reconstruction using modified inlay technique 

(group 3). An Achilles tendon allograft was used in PCL double 

bundle reconstruction and an autogenous hamstring tendon were 

used in the other two groups. PLC reconstruction was performed 

with autogenous hamstring tendon through fibular head tunnel in 

all patients. Double bundle reconstruction was done if there was no 

remnant PCL or very weak PCL remnant by MRI and arthroscopic 

finding in subacute or chronic stage. Each patient was evaluated 

on the basis of the International Knee Documentation Committee 

(IKDC) and the Orthopadische Arbeitsgruppe Knie (OAK) scores, 




the mean side-to-side difference in tibial translation as measured on 

Telos stress radiographs and a maximal manual displacement test 

with a KT-1000 arthrometer. The mean side-to-side differences in 

posterior tibial translation were reduced from G1, 10.1± 2.5 mm; 

G2, 10.6 ± 2.4 mm; G3, 12.8 ± 3.2 mm preoperatively to G1, 2.3 

± 1.4 mm; G2, 2.3 ±1.5 mm; G3, 4.0 ± 2.5 mm at last follow up 

on the stress radiographs (p=0.022). The final IKDC score was in 

G1, A in 21 (62%), B in nine (27%), C in three (9%) and D in one 

(3%); in G2, A in 16 (40%), B in 21 (53%), C in three (7%); in 

G3, A in three (20%), B in nine (60%), C in two (13%), D in one 

(7%). The average OAK score improved from 71.7 ± 9.2 to 85.0 ± 

6.7 in G1, from 65.8 ± 10.4 to 87.8 ± 7.6 in G2, from 71.3 ± 12.7 

to 83.0 ± 5.8 in G3. Posterior instability recurred more than 10 mm 

compared to contralateral side one case each in G1 and G3. Excellent 

posterior stability and good clinical results were achieved with the 

anterolateral band reconsuction preserving injured remnant PCL in 

acute and subacute and remnant PCL tensioning in chronic stage. 

Double bundle reconstruction group did not have the same result as 

remnant tensioning or remnant well preserving group. PCL remnant 

requires posterior stability to get good clinical results. 

pApeR No. 490 

High Prevalence of Abnormal MR Findings of LCL and 

Popliteus Tendon in the Knees Without Instability 


Korea 

Ja-Young Choi, Seoul, Republic of Korea 






Korea 



Korea 

Because of well known difficulty in diagnosis of chronic posterolateral 

corner (PLC) injury of the knee, MRI has received attention as a useful 

diagnostic tool for PLC injury. However, in our practice, abnormal 

MR findings of the PLC structures, particularly abnormal signal 

intensity and abnormal thickening of the lateral collateral ligament 

(LCL) and the popliteus tendon (PT), were frequently found in the 

patients without knee instability. We aimed to determine prevalence 

of alterations in the signals and thicknesses of the LCL and the PT on 

the MRI in the subjects without clinical evidence of knee instability, 

and to analyze the factors associated with the abnormal MR findings. 

MRI in 120 subjects (79 men, 41 women; mean age, 36.8 years; 

range, 14-62 years) who had not any kind of knee instability were 

evaluated to assess the LCL and the PT in terms of signal alteration 

and thickness. Demographics, Kellgren-Lawrence OA grading and 

mechanical alignment of the knee were assessed to determine the 

factors associated with the abnormal MR findings of the LCL and the 

PT. The signal alterations of the LCL and the PT were found in 33.3% 

and 28.9%, respectively, while the abnormal thickening of the LCL 

and the PT were found in 32.5% and 7.6%, respectively. In the logistic 

regression analyses, degrees of varus alignment (mean = varus 1.5°) 

was found to be the only predictor for the LCL signal alteration (OR 

= 0.81, 95% CI = 0.66 - 0.98) and abnormal thickening (OR = 0.73, 

95% CI = 0.59 - 0.90). Among the factors evaluated, any factors were 

not associated with the alterations of the PT. Even in the subjects 

without knee instability, signal alteration and abnormal thickening 

of the LCL and/or the PT on the MRI are frequently found. The 

775 

mechanical alignment of the knee in the coronal plane was found to 

be the predictor of the alterations of the LCL. Our findings should be 

considered when the results of MR features of the LCL and the PT are 

being considered for the diagnosis of the chronic PLC injury. 

pApeR No. 491 

Accuracy of Magnetic Resonance Imaging of the Knee 

in the Community Setting 

H Jolene Clark, Salt Lake City, UT 

William A Grana, MD, MPH, Tucson, AZ 

Gregory Thomas Evangelista, MD, Scottsdale, AZ 

Robert E Hunter, MD, Salida, CO 

Magnetic resonance imaging (MRI) is routinely used as a diagnostic 

modality for knee problems. The purpose of this study was to 

determine the accuracy, sensitivity and specificity of MRI in the 

evaluation of meniscal pathology compared to clinical evaluation 

when the MRI facility and the radiologist are not preselected. A 

retrospective study of 288 arthroscopies of the knee were compared 

to evaluate accuracy of diagnosis of medial or lateral meniscal 

pathology by MRI study without controlling selection of MRI facility 

or training of the interpreting radiologist as occurs in a community 

orthopaedic practice, and the clinical evaluation by an orthopaedic 

surgeon. Patients were divided into three groups: those who had an 

MRI performed and interpreted at a single institution (SI = academic 

center with two fellowship trained musculoskeletal radiologists), 

those who had an MRI performed and interpreted at a community 

facility (CF = variable group of institutions and radiologists in the 

community) and those who had no MRI but only a clinical evaluation 

(CE) by one of two senior orthopaedic surgeons. The sensitivity, 

specificity and accuracy of the diagnosis of medial meniscal 

pathology (MM) at a single institution (SI) were 90%, 59%, 76%, 

respectively; in the community (CF) for the same measurements 

were 73%, 68%, 70%, respectively; and by an orthopedic surgeon’s 

clinical evaluation (CE) were 93%, 55%, 73%, respectively. For 

lateral meniscal pathology (LM) the results were: SI 75%, 76%, 81%; 

CF 60%, 88%, 79%; and CE 45%, 90%, 79%. Sensitivity for MM 

was greater than for LM but specificity of diagnosis was better for LM 

by both MRI and CE. While not statistically significant, SI tended 

toward increased sensitivity in the diagnosis of MM and LM but 

show less specificity than the CF. The total number of false-positive 

diagnoses that resulted in surgery (i.e. no intra-articular pathology) 

was four/288 (1.39%) patients. The overall accuracy for MM by MRI 

was 73% vs. 73% for CE. The overall accuracy for MRI for LM was 

78% vs. 79% for CE. Routine MRI may not be more beneficial or 

helpful than clinical evaluation when there is no preselection of MRI 

facility and interpreting radiologist. 

pApeR No. 492 

Repair and Failure Rates of Injured Menisci Amongst 

Patients Undergoing ACL Reconstruction 

Daniel K Williams, MD, Indianapolis, IN 


Gregory B Maletis, MD, Baldwin Park, CA 

Brent R Davis, MD, Irvine, CA 

Yuexin Chen, BS, San Francisco, CA 

Rick P Csintalan, MD, Irvine, CA 

Stefan Fornalski, MD, San Clemente, CA 

Recent studies have shown meniscus repair rates with concomitant 

anterior cruciate ligament (ACL) reconstruction to be between 15% 

and 20%. Success rates of meniscus repair in conjunction with 

anterior cruciate ligament reconstruction have been reported to be 




greater than 90%. We hypothesize that when compared to published 

averages, a higher rate of meniscus repair in patients undergoing 

anterior cruciate ligament reconstruction will lead to a higher rate 

of repair failure. All patients who had a meniscus tear undergoing 

an anterior cruciate ligament reconstruction were evaluated from a 

large community based anterior cruciate ligament registry. Patients 

were evaluated from one of three separate sites participating in the 

registry. All patients had at least two-year follow up. Initial meniscal 

repairs and reoperations of failed repairs were reviewed via operative 

reports. There were a total of 650 meniscus tears in 500 patients 

undergoing anterior cruciate ligament reconstruction. Two hundred 

and twenty eight meniscus repairs were performed for a repair rate 

of 35.1%. After a minimum of two-year follow up, 23 menisci 

were reported as having failed (needing a repeat arthroscopy for 

meniscal symptoms). The overall failure rate of the meniscus repairs 

was 10.1%. Meniscus repair, when performed in conjunction with 

anterior cruciate ligament reconstruction, has a high rate of success. 

A higher rate of meniscal repair does not appear to increase the need 

for reoperation of the repaired meniscus. 

pApeR No. 493 

Cost Effectiveness Analysis of the Diagnosis of 

Meniscus Tears 


Dustin Hambright, BA 

Michael P Bolognesi, MD, Durham, NC 

William E Garrett, Jr MD, Durham, NC 

Lori A. Orlando, MD 

Tally E Lassiter Jr, MD, Oneonta, NY 

In the adult presenting with knee pain, a meniscus tear is a common 

diagnosis, and knee arthroscopy is the most performed orthopaedic 

procedure in the U.S. Diagnostic imaging represents the fastest 

growing segment of costs in the health system and identifying cost 

effective diagnostic strategies is critical to achieve efficient healthcare 

delivery. In this study, we investigated the cost effectiveness of 

diagnostic approaches to meniscus tears of the knee. A simple 

decision model reflecting the diagnostic algorithm faced by clinicians 

was constructed for a cost-utility analysis evaluating the value of the 

addition of MRI to history and physical exam (H&P) for traumatic 

or degenerative tears presenting to either a primary care or sports 

medicine clinic. Outcome probabilities and effectiveness were derived 

from the literature or estimated by expert opinion where necessary. 

Costs were estimated from the societal perspective. Strategies were 

compared using the incremental cost effectiveness ratio (ICER). 

History and physical exam alone are widely preferred for suspected 

degenerative meniscus tears with ICERs for the other strategies 

ranging from $140,000-$600,000+, well above the willingness to 

pay of $50,000/quality-adjusted life year (QALY). For traumatic tears 

in the primary care clinic, the MRI to confirm a positive diagnosis 

was preferred with an ICER of $40,565/QALY. MRI for all patients 

was not preferred in any reasonable clinical scenario. H&P is the 

preferred strategy for the suspected degenerative meniscus tear for 

all practitioners. MRI to confirm a positive is preferred for traumatic 

tears. Consideration should be given to implementing alternative 

diagnostic strategies. 

pApeR No. 494 

Meniscal Allograft Transplantation- 10 Year Follow-up 

Thomas R Carter, MD, Phoenix, AZ 

Michael Rabago, PA, Phoenix, AZ 

While meniscal allografts can benefit symptomatic patients, longterm 

studies are lacking with the durability and protective abilities 

776 

questioned. The purpose of this study is to evaluate results of 

patients 10 years after receiving meniscal allografts. Forty-one of 

our initial 47 (87%) meniscal allograft recipients for symptomatic 

knees were available for prospective study. The average age at 

implantation was 34.8 years (range 19-50yrs). The outerbridge 

grade of chondromalacia at implantation: I-2, II-20, III-19. Eight 

grafts were isolated with concurrent ACL-28; osteotomy-three; ACL/ 

osteotomy-one; and MCL-one. The clinical outcomes were recorded 

at two and 10 years, including degree of symptoms, satisfaction, graft 

survivorship and plain radiographs. Forty of the 41 (97%) patients 

noted improvement in symptoms at two years, with 33 (80%) at 

10 years. All but two stated they would undergo the procedure 

again. Seven patients required partial meniscectomies, with four 

beyond seven years, for a 10-year graft survivorship of 83%. Thirtyfour 

patients had plain X-rays available for pre-op, two years and 

10 years comparison. At two years, two showed mild progression of 

arthritis. At 10 years, 14 had no change, 15 mild and five moderate 

to advanced progression. Meniscal allografts are able to provide 

subjective improvement at long-term follow up. Graft durability has 

been a concern, but our study showed over 80% graft survivorship 

at 10 years. The ability to delay the progression of arthritis is still 

of question and needs further study, but the grafts are not able to 

uniformly prevent arthritis. 

pApeR No. 495 

Prospective Evaluation of Meniscal Allograft 

Transplantation Procedure: Minimum 7 Year Follow-Up 


Erika L Daley, BS 

Sarvottam Bajaj, BE, Chicago, IL 

James Kercher, MD, Atlanta, GA 

Eric J. Strauss, MD, New York, NY 

Paul B Lewis, MD, Chicago, IL 


Meniscal transplantation is an accepted method of treatment for 

meniscal deficient patients. Although mid-term results have been 

promising, there is limited long-term clinical follow-up data. The 

purpose of this study is to report post operative outcomes of meniscal 

allograft transplantation at a minimum of seven year follow up. 

Clinical results from 20 patients (mean age 32.2) who underwent 

meniscal transplantation (10 medial and 10 lateral) were evaluated 

at a mean follow up of 8.23 years. Post-operatively, patients were 

assessed using the International Knee Documentation Committee 

(IKDC), Tegner-Lysholm, Knee Injury and Osteoarthritis Outcome 

Score (KOOS) and San Francisco-12 (SF-12). The mean IKDC score 

improved from 46.84 to 60.95 (p

pApeR No. 571 

Treatment Of Shoulder Impingement Syndrome: 

Subacromial Injection Of Ketorlac Versus 

Triamcinolone 

Kyong Su Min, MD, Tacoma, WA 

Edward D Arrington, MD 

Paul M Ryan, MD, Lakewood, WA 

Subacromial impingement syndrome is commonly treated with 

corticosteroid injections; however, corticosteroids have been associated 

with tendon rupture, subcutaneous atrophy and articular cartilage 

changes. There has been evidence to support that NSAID injections 

are effective in treating impingement. This study hypothesizes that 

an injection of ketorlac is as effective as triamcinolone in treating 

subacromial impingement syndrome. Patients diagnosed with 

subacromial impingement syndrome that met the inclusion and 

exclusion criteria were included in this double-blinded randomized 

controlled clinical trial. The Steroid syringe contained 6 cc of 1% 

lidocaine with epinephrine and 40 mg triamcinolone; and the 

NSAID syringe contained 6 cc of 1% lidocaine with epinephrine and 

60 mg ketorlac. After a single injection, the patients were evaluated 

and instructed to follow up in four weeks. The mean improvement 

in the UCLA Shoulder Assessment Score was 7.15 for the NSAID 

group and 2.13 for the Steroid group (p-value: 0.03). The NSAID 

group showed an increase in forward flexion strength (NSAID: 0.26, 

Steroid: -0.07; p-value: 0.04) and patient satisfaction (NSAID: 2.94, 

Steroid; p-value: 0.03). In this study, a single injection of ketorlac is 

more effective than triamcinolone in the treatment of subacromial 

impingement. Arguably, the relief provided by both ketorlac and 

triamcinolone is a function of their anti-inflammatory action. By 

decreasing pain, the patient is able to strengthen the rotator cuff, and 

thereby increase the subacromial space. We believe that ketorlac is an 

effective alternative to triamcinolone because it appears to increase 

shoulder function and does not risk the potential side-effects of 

corticosteroids. 

pApeR No. 572 

Predictors Of Pain And Function In Symptomatic, 

Atraumatic Full-Thickness Rotator Cuff Tears 

Grant L Jones, MD, Columbus, OH 

Joshua Harris, MD, Columbus, OH 

Angela D Pedroza, MPH 

The prevalence of full-thickness rotator cuff tears increases with 

age. Many patients are asymptomatic. Thus, not all of these patients 

require surgical repair. It is unclear which factors definitively 

contribute to patients’ pain and function. The purpose of this study 

was to determine what non-modifiable and non-surgically modifiable 

factors contribute to pain and function with symptomatic, atraumatic 

full-thickness rotator cuff tears. A prospective, non-randomized 

cohort study reporting time-zero data of patients enrolled in a nonoperative 

treatment program for symptomatic, atraumatic rotator 

cuff tears by the Multi-center Orthopaedic Outcomes Network 

(MOON) shoulder group. Based on ASES (American Shoulder and 

Elbow Surgeons) scores and WORC (Western Ontario Rotator Cuff) 

indices, several variables were analyzed. A total of 389 subjects were 

enrolled. The following variables significantly affected the WORC 

and ASES scores: Sex (females had higher score; p=.001), education 

level (higher education, higher score; p

pApeR No. 574 

Post-Operative Goals After Shoulder Surgery: Is Pain 

Relief or Strength More Important to Patients? 


James Kercher, MD, Atlanta, GA 

Sarvottam Bajaj, BE, Chicago, IL 

Erika L Daley, BS 

Billy Keith Parsley, MD, Kingsport, TN 

Anthony A Romeo, MD, Chicago, IL 


Stephen S Burkhart, MD, San Antonio, TX 

Scoring systems currently used to evaluate the shoulder (ASES, 

SPADI, UCLA and Constant scores) place substantial weight on 

pain relief and range of motion. It is our hypothesis that the relative 

value of strength may not be weighted appropriately in these surveys 

and thus may not accurately represent a patient’s post-operative 

expectations. Our purpose was to determine the relative importance 

of improvements in strength relative to pain relief in patients 

undergoing shoulder surgery. Patients with suspected shoulder 

pathology pre-operatively completed a newly devised questionnaire 

to determine how they would rate the importance of post-operative 

improvements in strength versus pain relief. Baseline data was 

obtained related to current pain and weakness, as well as hand 

dominance, occupation, level of sports participation, gender and 

age. Post-operative expectations were surveyed by asking whether 

they would prefer a strong shoulder with mild pain, or a weak 

shoulder with no pain. A total of 128 patients with suspected rotator 

cuff pathology were analyzed for this study. Overall, 84% of patients 

preferred a strong shoulder with mild pain, and only 16% preferred a 

weak shoulder with no pain. Sub-group analysis reported all groups 

favoring a strong shoulder with mild to moderate pain. Historically, 

post-operative pain relief has been a primary indicator for rotator 

cuff surgery. However, the majority of patients indicated that they 

prefer a strong shoulder following surgery even with some persistent 

pain. The results of this survey reflect that patient preferences for 

improvement in strength may not be adequately emphasized preoperatively 

or when using contemporary outcome measures. 

pApeR No. 575 

Which Repair For Partial Thichness Rotator Cuff Tears? 

Francesco Franceschi, MD, Rome, Lazio Italy 

Rocco Papalia, MD, Rome, Italy 

Angelo Del Buono, MD 

Alessio Palumbo, MD, Roma, Italy 

Sebastiano Vasta, MS 



The incidence of partial thickness rotator cuff tears (PTRCTs) is 

unclear because of its difficult diagnosis, while its definition and 

classification are well established. The surgical treatment focuses on 

partial thickness tendon rupture itself that is approached with repair 

in arthroscopic surgery. There is no agreement on which surgical 

treatment must be chosen. However several studies reported good 

results using both trans-tendon technique and lesion completing 

and subacromial repair. Sixty patients with a partial thickness rotator 

cuff tear (detected by arthro-MRI and confirmed by intra-operative 

measurement using cuff- meter device) underwent arthroscopic 

repair with suture anchors. They were divided into two groups of 

30 patients according to repair technique: trans-tendon technique 

(group 1) or lesion completing and subacromial repair (group 2). 

Results were evaluated by use of the UCLA score, shoulder and 

778 

hand (DASH) and normalized Constant score and muscle strength 

measurement. On analyzing the outcomes at a one-year follow up, 

we considered the following independent variables: baseline scores; 

age; gender; dominance; location; preoperative thickness of rotator 

cuff tear; treatment of biceps tendon. Univariate and multivariate 

statistical analyses were performed to determine which variables 

were independently associated with the outcome. Significance was 

set at P < .05. Of the patients, six (10%) were lost to follow up. 

Comparison between groups did not show significant differences for 

each variable considered. Overall, according to the results, the mean 

DASH scores, UCLA scores and SF-36 scores improved significantly 

in both groups postoperatively, with no significant difference 

between the groups. Muscle strength was 13.6 ± 5.7 lb. in group 1 

and 13.2 ± 7.0 lb. in group 2. Univariate and multivariate analysis 

showed that only age, gender and baseline strength significantly and 

independently influenced the outcome. Differences between groups 

1 and 2 were not significant. At short-term follow up, arthroscopic 

partial thickness of rotator cuff repair with trans-tendon technique 

showed no significant difference in clinical outcome compared with 

lesion completing and subacromial repair. 

pApeR No. 576 

Complications Associated With The Use Of 

Bioabsorbable Implants About The Shoulder 

Daniel D Buss, MD, Edina, MN 

Leroy Pearce McCarty, III MD, Edina, MN 

Michael Q Freehill, MD, Edina, MN 

Literature describes sterile bony abscess formation, as well as 

occurrence of glenohumeral synovitis and chondrolysis, in 

association with poly-L-lactic acid (PLLA) implants. Previous reports 

have included small cohorts and described intra-articular use of 

such implants. We report a large series of patients with a biologically 

mediated reaction following utilization of PLLA implants to address 

intra-articular or rotator cuff pathology. After Institutional Review 

Board approval, 47 patients were retrospectively identified from 

the research database. Inclusion criteria involved a pathology 

report showing polarizing material and giant cell reaction and/or 

the presence of macroscopic, extra-osseous anchor material. All 

index procedures were performed by outside institutions. Mean 

age at index procedure was 34 years (range 16-62). Mean period 

between index and debridement procedures was 47 months. Eleven 

(23%) required more than one revision surgery. Index procedures 

included intra-articular stabilization procedures (n=29) and rotator 

cuff repairs (n=18). Average number of anchors used for labral 

stabilizations was 2.8 and 2 for rotator cuff repair. Osteolytic 

changes were apparent per plain films and/or MRI. Pathology from 

all cases revealed a synovitic process in the glenohumeral and/or 

subacromial space. Polarizing material was present on pathology 

for 34 (72%) cases. Twenty-two (47%) had macroscopic material 

present. Grade three or four chondral damage was present in 26 

(55%) patients. A recurrent rotator cuff tear occurred in all patients 

whose index procedure included a rotator cuff repair. PLLA implants 

can generate biologically mediated adverse reactions in some 

patients, as evidenced by development of reactive synovitic changes 

with chondral damage or recurrent rotator cuff pathology. 




pApeR No. 577 

The Effect of Platelet-Rich Fibrin Matrix on Rotator Cuff 

Tendon Healing 




Ronald S Adler, MD, PhD, New York, NY 

Andrew D Pearle, MD, Rye, NY 


Platelet-rich fibrin matrix (PRFM) is an autologous fibrin matrix that 

allows for sustained release of cytokines from platelets. The purpose 

of this study was to evaluate the effect of PRFM on rotator cuff tendon 

healing. A prospective trial of 67 patients randomized to receive 

PRFM (36 patients) or no implant (31 patients) during arthroscopic 

rotator cuff repair was performed with minimum one-year follow 

up. The primary outcome was ultrasound evaluation of tendon 

healing at six and 12 weeks. Secondary outcomes included ASES 

and L’Insalata scores as well as strength testing. Statistical analysis 

was performed with p=0.05. Overall, there were no differences in 

tendon-to-bone healing between the two groups. Repairs were intact 

in 24/36 (67%) in the PRFM group and 25/31(81%) in the control 

group. There were no significant differences in healing by ultrasound 

at six and 12 weeks, including no differences in vascularity at the 

peribursal, peritendinous and musculotendinous regions of the 

tendon. No differences in ASES, L’Insalata and strength outcomes 

were noted between the groups. Platelet-rich fibrin matrix applied 

to the tendon-bone interface during rotator cuff repair had no 

effect on tendon healing and tendon vascularity, strength or clinical 

outcome. These results may be due to variability in platelet recovery, 

platelet activation and kinetics of cytokine release from the PRFM. A 

weakness of this study is the absence of PRFM platelet concentration 

and the relatively small number of patients studied. Further study is 

required to evaluate the role of PRFM in rotator cuff repair. 

pApeR No. 578 

Platelet-Rich Plasma Augmentation For Arthroscopic 

Rotator Cuff Repair 

Roberto Castracini, MD, Rome, Italy 

Umile Guiseppe Longo, MD, Rome, Italy 

Massimo De Benedetto, MD 

Nicola Panfoli, MD 

Piergiorgio Pirani, MD, Mombaraccio, PU Italy 

Raul Zini, MD, Pesaro, Italy 



The rotator cuff has limited ability to heal back to its insertion on the 

humerus following repair. Growth factors augmentation has been 

proposed to be able to enhance healing in such procedure. The aim 

of this randomized controlled trial is to assess the efficacy and safety 

of the addition of growth factor augmentation during rotator cuff 

repair. Eighty-eight patients with a rotator cuff tear were randomly 

assigned by a computer-generated sequence to receive arthroscopic 

rotator cuff repair without (n=45) or with (n=43) augmentation 

with platelet-rich plama (PRP). The primary endpoint was the 

difference in change from baseline to 16 months in the Constant 

score between the two groups. The secondary endpoint was the 

integrity of the repaired rotator cuff, as evaluated by MRI. Analysis 

was on an intention to treat basis. All the patients completed follow 

up at 16 months. There was no statistically significant difference in 

total Constant score when comparing arthroscopic rotator cuff repair 

with or without PRP. There was no statistically significant difference 

779 

in MRI tendon score when comparing arthroscopic rotator cuff 

repair with or without PRP. Our study does not support the use of 

autologous PRP for augmentation of a rotator cuff repair to improve 

the healing of rotator cuff tears 

pApeR No. 579 

The Effect Of Mechanical Load On Tendon-To-Bone 

Healing 

Carolyn Hettrich, MD, MPH, Nashville, TN 

Selom Gasinu 

Patrick Birmingham, MD, Wauwatosa, WI 

Brandon S Beamer, MD, Boston, MA 

Mark Stasiak, New York, NY 

Alice JS Fox, MSc, New York, NY 

Xiang-Hua Deng, MD, New York, NY 


Joint motion is commonly prescribed following tendon repair 

surgeries such as rotator cuff repairs; however, the ideal rehabilitation 

program to optimize tendon-to-bone healing is unknown. We 

hypothesized that delayed loading would result in a mechanically 

stronger and better organized tendon-to-bone interface compared to 

immobilized and immediately loaded animals. A total of 278 Sprague 

Dawley rats underwent unilateral patellar tendon detachment and 

repair followed by placement of a custom designed external fixator. 

Rats were assigned to: 1. immobilization, 2. immediate postoperative 

loading or 3. delayed onset loading (4- or 10-day delay). Tendon 

loading was controlled using a specially designed motorized device 

to apply 3 Newtons (low load) or 6 Newtons (high load) of axial 

tensile load to the healing bone-tendon complex at 0.17 Hz for 

50 cycles per day. Rats were sacrificed at four, 10, 21, or 28 days 

post-operatively for histomorphometric, immunohistochemical, 

radiographic, molecular and biomechanical analyses. Immobilized 

animals had significantly better mechanical properties than the 

immediate and delayed loading groups (p

(SST) and visual analog scale for pain (VAS), subjective shoulder 

value (SSV) Short Form 12 (SF12). The two groups were compared 

using chi-square and t-tests. The mean age in the SLAP/RCR group 

was 49 years compared to 59 in the RCR group (p

pApeR No. 584 

Does the Remplissage Procedure Decrease Shoulder 

Range of Motion? An In-vitro Biomechanical Study 

Ilia Elkinson, MD, Wellington South, New Zealand 

James A Johnson, PhD, London, ON Canada 

Josh W Giles, BESc, London, ON Canada 


Harm-Willem Boons, MD, Nijmegen, Netherlands 

Louis Ferreira, MSc, London, ON Canada 


Remplissage may be performed as an adjunct to Bankart repair to 

address an engaging Hill-Sachs (HS) defect. It has been reported 

that the Remplissage procedure may restrict range of motion. The 

purpose of this biomechanical study was to examine the effects of the 

Remplissage procedure on shoulder motion and stability. Cadaveric 

forequarters (n=7) were mounted on a custom biomechanical testing 

apparatus which applied simulated loads independently to the rotator 

cuff muscles and the anterior, middle and posterior deltoid. The 

testing conditions included: intact shoulder, Bankart lesion, Bankart 

repair, two HS defects (15%,30%) with and without Remplissage. 

Joint motion and translation were recorded with an optical tracking 

system. Outcomes measured were internal/external glenohumeral 

rotation (IE-ROM) in adduction and 90° combined abduction and 

stability of the construct (joint stiffness and translation). In 15% 

HS defects, the Remplissage did not significantly reduce IE-ROM in 

adduction (14.4°±9.6°p=0.1]) or abduction (5.1°±12.4° 

pApeR No. 585 

A Biomechanical Comparison and Three Single and 

Two Double loaded anchors for Bankart Repair 

Stephen A Hoover, Jr MD, Chapel Hill, NC 

Paul Weinhold, PhD, Chapel Hill, NC 

Robert Alexander Creighton, MD, Chapel Hill, NC 

Jeffrey T Spang, MD, Chapel Hill, NC 

Authors have reported post-operative glenoid fracture through suture 

anchor drill holes after shoulder instability surgery. Manufacturers 

have now produced double-loaded suture anchors. The use of 

double-loaded suture anchors may allow equivalent biomechanical 

results when compared to single-loaded anchors while limiting the 

number of glenoid drill holes in arthroscopic instability surgery. Nine 

matched pair cadaveric shoulders had a surgically created Bankart 

lesion repaired with either two double-loaded or three single-loaded 

suture anchors. Each 21 mm lesion was created using a standardized 

template. Three single-loaded anchors were placed at the proximal, 

middle and distal margins of the lesion while two double-loaded 

anchors were placed 7 mm and 14 mm from the ends of the lesion. 

Constructs were mounted on a servohydraulic testing machine using 

a cryoclamp. A differential variable reluctance transducer was used to 

record labrum displacement. The construct was then preconditioned 

at 10 N for 10 cycles (1 Hz), and then pulled to failure. Measured 

outcomes included utimate tensile load (UTL), labrum displacement 

at failure, load at 2 mm of displacement, energy at failure, energy at 

2 mm of displacement and stiffness of repair. The double-loaded 

suture anchors had a higher UTL (944N to 783N, p

pApeR No. 633 

Mid-Term Results Of Surgical Repair Of Proximal 

Hamstring Tendon Tears 



The purpose of this study was to investigate the outcome of surgical 

repair of proximal hamstring tendon tears at mid-term follow up. 

Forty-six patients were treated with surgical repair and intensive 

physiotherapy program after complete tears of the proximal 

hamstring tendon. The average time between injury and surgical 

referral was two weeks (one day to three weeks). MRI was used to 

confirm the tear and plan surgical repair in all cases. Primary repair 

using suture anchors to approximate the torn tendon to the ischial 

tuberosity was undertaken in all cases. Intensive physiotherapy was 

commenced in all cases with gradual increase in knee flexion based 

on the severity of the tear and the surgeon’s assessment of the surgical 

repair at the time of surgery. Patient satisfaction and return to sports 

were used as measures of outcome. The average hospital stay was 

one day. Apart from local numbness around the scars, there were 

no post-operative complications noted in this group. High patient 

satisfaction was noted in all patients at final follow up (one year) 

which was also noted at four years. The average time to return to 

sports was six months (five months to nine months). No re-tears 

were noted in any patients. In cases where dynamometer isokinetic 

muscle testing was undertaken, comparable results for operated 

and non-operated contra lateral sides were noted after six months. 

At mid-term follow up, early surgical repair and physiotherapy has 

been noted to be associated with a good outcome and enables an 

early return to sports after complete tear of the proximal hamstring 

tendons. 

pApeR No. 634 

Poor Correlation Between Pain And Radiographic 

Findings In FAI 


Anil Ranawat, MD, New York, NY 

Ben Schulz, MD 

Sebastian F Baumbach, MD, Wien, Austria 


Michael Leunig, MD, Zurich, Switzerland 

The primary diagnosis of femoroacetabular impingement (FAI) is 

based on clinical symptoms, physical exam findings and radiographic 

abnormalities. Our objective was to determine if patient derived pain 

score correlates to radiographic findings and which radiographic 

finding was most predictive of symptomatic FAI patients. One 

hundred prospective patients with unilateral FAI symptoms based 

on clinical and radiographic findings were included in this study. All 

patients filled out a WOMAC pain questionnaire. Two independent 

blinded surgeons assessed antero-posterior and lateral radiographs for 

33 radiographic parameters of FAI. Correlations between pain scores 

and radiographic findings were calculated. A matched radiographic 

analysis was performed comparing symptomatic versus asymptomatic 

hips as well as males versus females. Weak positive correlations 

were identified between increasing pain scores with radiographic 

findings of posterior wall dysplasia, presence of a shallow socket 

and a more lateral acetabular fossa relative to the Ilioischial Line. A 

symptomatic hip had a lower neck shaft angle, greater distance from 

ilioischial line to acetabular fossa and larger distance from cross 

over sign to superolateral point of the acetabulum when compared 

to the asymptomatic hip in the same patient. Symptomatic hips in 

males had more joint space narrowing, femoral osteophytes, higher 

782 

alpha angles and larger, more incongruent femoral heads. Females 

had more medial acetabular fossa relative to the ilioischial line and 

smaller femoral head extrusion index. There is no single strong 

radiographic predictor of symptoms in FAI. 

pApeR No. 635 

Hip Range of Motion is correlated to Radiographic 

Findings of FAI in Collegiate Football Players 

Ashley L Kapron, BS, Salt Lake City, UT 



Lee Garrit Phillips, MD, Salt Lake City, UT 

Mr Robert Toth, Salt Lake City, UT 

David Petron, MD 


Physical exams are commonly used to evaluate patients with 

femoroacetabular impingement (FAI). It is unknown if exams can 

detect FAI in asymptomatic subjects. Prospective, Institutional 

Review Board approved study of 65 male collegiate football players. 

Both hips (n=130) were evaluated by two orthopaedic surgeons for 

radiographic signs of FAI. The alpha angle (AA) and head neck offset 

(HNO) were measured on frog-lateral films. Center edge angle, 

acetabular angle, cross-over ratio, and anteroposterior alpha angle 

were measured on anteroposterior films. Maximum hip range of 

motion in flexion (supine) and internal/external rotation (supine, 

sitting and prone) were measured using a goniometer. Forty-nine 

players went to one of two stations, staffed by two clinicians (one 

examined, one measured). Sixteen players went to both stations 

(repeatability). For all combinations of observers, correlation between 

each range of motion and radiographic measure was determined 

by a random-effects linear regression model (significance p

measured using CT and MRI. The average alpha angle measured 

using the MRI was 60.12 and with the CT was 65.71. No significant 

difference was noted between the two sets of measurements using 

the t-test (p =0.4). Comparison of alpha angles measured on CT vs. 

MRI showed a high intra class correlation coefficient of 0.82. MRI 

showed cartilage lesions over the CAM lesion and labral tears in all 

cases. MRI scans can reliably predict alpha angle as a measure of 

CAM type FAI. They provide useful information about cartilage and 

labral pathology. The higher average alpha angles noted on CT scans 

may suggest greater accuracy and this may particularly be useful in 

the presence of severe pathology or for post procedure evaluation. 

pApeR No. 637 

Comparison of Radiographs and CT Imaging in 

detecting Femoral Head-neck Junction Malformations 

Jeffrey Nepple, MD, Shrewsbury, MO 

John M Martell, MD, Chicago, IL 

Harish Sadanand Hosalkar, MD, San Diego, CA 


David A Podeszwa, MD, Dallas, TX 

Ernest L Sink, MD, Aurora, CO 

Daniel J Sucato, MD, Dallas, TX 

Ira Zaltz, MD, Royal Oak, MI 


Three-dimensional imaging (CT and MRI) is the gold standard 

for detection of femoral head-neck junction malformations in 

femoroacetabular impingement (FAI), yet plain radiographs are 

used to screen for FAI. The purpose of this study was to compare 

the utility of plain radiographs with CT scanning in the detection 

of femoral head-neck malformations. We performed a retrospective 

review of 41 consecutive surgical patients with preoperative CT scans 

and plain radiographs (anterior/posterior (AP), 45 degree Dunn, 

frog lateral, cross-table lateral). Twenty-eight were female, 13 male 

and diagnoses included cam FAI (56.1%), combined cam-pincer 

FAI (36.6%), DDH (4.9%) and normal structural anatomy (2.4%). 

Radial CT reformations of the head-neck junction were generated 

at the 12, 1, 2, and 3 o’clock positions spanning the superior to 

anterior neck. Alpha angles were measured with a computer-assisted 

program. Alpha angle thresholds of 50 and 63 degrees were utilized as 

markers of any or severe deformity, respectively. The maximum alpha 

angle on plain radiographs was greater than that of CT reformats in 

61.0% of cases. The complete radiographic series was 85.7-90.0% 

sensitive to detecting deformity on CT. Exclusion of the crosstable 

lateral did not affect the sensitivity (85.7-87.7%). The Dunn view 

was most sensitive (71.4-80.0%). The frog lateral showed the best 

specificity (90.9-100%). Plain radiographs detect deformity seen on 

CT scan, and in some cases may overestimate the alpha angle. The 

combination of an AP pelvis, 45 degree Dunn and frog lateral has 

excellent sensitivity in detecting head-neck malformations. 

pApeR No. 638 

Radiologic Predictors of THR following Arthroscopy for 

Femoroactabular Impingement 

John Carlisle, MD, Overland Park, KS 

Marc J Philippon, MD, Vail, CO 

Bruno Goncalves Schroder Souza, MD, Juiz De Fora, MG Brazil 

Karen K Briggs, MPH, Vail, CO 

Some studies stress the importance of standardizing plain radiographs 

to identify femoroacetabular impingement (FAI). Current literature 

has little data regarding use of radiographs to predict patient 

outcomes following hip arthroscopy. This study looks at the impact 

783 

of common osteoarthritis (OA) radiographic features and patient 

outcomes following FAI surgery. This study was Institutional Review 

Board approved. A total of 115 preoperative anterior/posteriorpelvis 

radiographs were retrospectively reviewed from patients 

having undergone hip arthroscopy for labral tears, secondary to 

FAI. Minimum three-year postoperative outcome data was used. 

Radiographic data points collected included Kellgren-Lawrence 

OA score and Tonnis OA classification. Radiographic assessment of 

sclerosis, cyst formation and osteophyte presence was performed at: 

lateral acetabular margin, acetbular fossa, infermedial acetabular 

floor, lateral femoral head-neck junction, superior weightbearing 

aspect of the femoral head, medial aspect of femoral head and 

inferior aspect of femoral head. Radiographs were reviewed by a 

single surgeon. Another surgeon reviewed a subset of radiographs for 

interobserver reliability. A total of 29/115 patients progressed to total 

hip arthroplasty (THA). Pearson-Chi Square testing found factors 

that positively correlated with higher THA rates, including acetabular 

sclerosis (p=0.001), osteophyte formation at lateral femur head-neck 

junction (p=.011), inferomedial acetabular floor (p=.009), acetabular 

fossa(p=.012). Maximal Kellgren-Lawrence (p=.006) and Tonnis 

scores (p=.002) correlated with an increased THA risk. Contrarily, 

sclerosis of femoral weightbearing surface (p=.31), lateral acetabular 

rim osteophytes (p=.107) and femoral or acetabular side cysts did 

not correlate with increased THA risk. Preoperative radiographs 

are an effective prognostic tool in patients undergoing arthroscopy 

for FAI. Specifically, presence of significant joint space narrowing, 

acetabuar sclerosis or medial acetabular osteophyte formation (fossa 

or floor) were suggestive of future THA. 

pApeR No. 639 

Vascular Safe Zones in Hip Arthroscopy 

Frank McCormick, MD, Needham, MA 

Conor P Kleweno, MD, Cambridge, MA 


Scott David Martin, MD, Boston, MA 

Hip arthroscopy is growing in incidence and utility due to advances in 

technique, improved technology and increased demand. Identifying 

vascular safe zones using anatomic and intra-capsular landmarks 

provides a valuable intra-operative guide to reduce risk of damage 

to the femoral head blood supply during femoral neck osteoplasty 

and psoas tendon release. We analyzed 76 consecutive contrast 

enhanced magnetic resonance scans obtained for patients with in an 

Institutional Review Board approved study. High resolution threedimensional 

scans were reconstructed to visualize the vasculature. 

We traced the medial femoral circumflex artery (MFCA) course from 

the anterior thigh to the femoral head. Specific attention was paid 

to its proximity to the psoas tendon at the site of release and the 

associated retinacular vessels in relation to femoral neck course. MRI 

imaging revealed that the MFCA inserts on the posterior-superior 

femoral neck, just posterior to the lateral synovial fold, from 10:30 

to 12:00 o’clock position, then diverges medially via two to five 

retinacular vessels on the posterior superior femoral head-neck 

junction from 10:30 to 12:00 o’clock position (mean 11:15 +/- 1.8 

standard deviation), before diving into subcondral bone an average 

of 5.0 mm lateral to the osteochondral junction. We observed an 

average MFCA location of 15 mm (SD 0.37mm) medial to the 

medial cortex of the femoral neck at a mean 50% distance (SD 8%) 

between the lesser trochanter and inferior femoral head/acetabular 

junction. Based on our data, we define the following safe zones: 

Femoral Neck Safe Zone is on the anterior half of the femoral neck; 

Psoas Tendon Release Safe Zone is proximal or distal to the middle 

third of the medial hip capsule. 




pApeR No. 640 

The “Pop” Sign of the Hip: Association with 

Arthroscopic Intra-Articular Findings 

Benjamin Domb, MD, Chicago, IL 

Craig Joseph McAsey, MD, Maywood, IL 

Itamar Botser, Chicago, IL 

Thomas Waddell Smith, Westmont, IL 

J W Thomas Byrd, MD, Nashville, TN 

The authors noted that with application of traction to the hip under 

anesthesia, some hip joints initially remain reduced, and then 

demonstrate a sudden release of the femoral head from the suction 

seal of the acetabulum. This was termed the ‘pop’ sign. The authors 

hypothesize that the presence of the pop sign reflects an intact suction 

seal, while its absence indicates a disruption of the suction seal, 

possibly associated with labral tear. The purpose of this study is to 

examine the association between an absent pop sign and arthroscopic 

intra-articular findings. A total of 239 consecutive hip arthroscopies 

were prospectively evaluated. Exclusion criteria were hips with 

arthritis, loose bodies or dysplasia. Intraoperative arthroscopic 

findings were documented, including location and pattern of labral 

tear, grade and size of chondral damage and ligamentum teres 

tear. Findings were statistically compared to the prescence or absence 

of pop sign. The pop sign was positive for 69 hips, and negative for 

153 hips. All patients included in the study had labral tears. Larger 

tears were more likely to have an absent pop sign (P

epair group (p

pApeR No. 647 

Operative Treatment Of Recalcitrant Patellar 

Tendinopathy: Minimum 2-Year Follow-Up 

Sanaz Hariri, MD, Menlo Park, CA 

Edgar Savidge, PT, DPT, OCS 

Kaitlin M Carroll, BS 

Michael M Reinold, PT, Boston, MA 

James E Zachazewski, PT, Foxborough, MA 

Thomas James Gill, MD, Boston, MA 

Patellar tendinopathy presents as anterior knee pain, particularly in 

the jumping athlete. Operative treatment may be considered for the 

few who continue to have symptoms despite a one-year minimum 

of conservative treatment. We propose that a technique combining 

arthroscopic (debridement of the inferior patellar pole and lysis 

of adhesions) and open (tenotomy, patella tendon debridement, 

tendon fenestration and inferior patellar pole microfracture) 

procedures will relieve the pain and allow these patients to return 

to their pre-injury activity level. We describe a surgical technique to 

address chronic patellar tendinopathy and report minimum twoyear 

follow up of patients who have had this surgery performed by a 

single surgeon. The patients completed a survey detailing their pre- 

and post-operative symptoms and activities. Over a period of 8.6 

years, the senior surgeon performed 63 consecutive cases of primary 

patellar tendon debridements in 59 patients without previous knee 

surgeries. Thirteen patients (13 knees) were lost to follow up. There 

was a 79% follow-up rate. The average age at surgery was 31 (SD 12, 

range 14-64). The average follow up was 42 months (SD 18, range 

23-92 months). Post-operatively, visual analog pain scores decreased 

by an average of five points (SD 3, range +1 to -10, p

pApeR No. 650 

Risk of Acute Compartment Syndrome in Tibia 

Fractures Sustained During Athletic Competition 

Tyler Conway Wind, MD, Charleston, SC 

Stuart M Saunders, MD, Winston-Salem, NC 

William R Barfield, PhD, Charleston, SC 

James F Mooney III, MD, Charleston, SC 

Langdon A Hartsock, MD, Charleston, SC 

Acute compartment syndrome (ACS) is a potentially devastating 

complication of tibia fractures. Generally high energy mechanisms 

are thought to lead to an increased risk of compartment syndrome. 

However, we recently noted several patients who developed 

compartment syndrome after low energy mechanisms during athletic 

competition. Based upon this observation, we hypothesized that 

tibia fractures resulting from athletic competition have an increased 

risk of compartment syndrome. A retrospective review of 626 

consecutive tibia fractures treated by our department between July 

2006 and June 2009 was performed. We recorded the mechanism 

of fracture and whether or not ACS developed. Soccer and football 

injuries were analyzed as specific groups. Chi square testing was 

used to analyze our results. Thirty-four patients (5.4%) developed 

ACS, which is consistent with published literature. Nine patients 

sustained an injury while playing soccer (1.4% of patients) while 11 

patients (1.7%) were injured playing football. Five of the nine soccer 

players (55%; p

pApeR No. 653 

Retention of Biomotor Skills Learned from a Haptic 

Arthroscopic Knee Simulator 

Kostas Economopoulos, MD, Tempe, AZ 

Alexander C McLaren, MD, Phoenix, AZ 

Ryan McLemore, PhD, Phoenix, AZ 

Traditional methods of surgical training have relied upon 

apprenticeship and judgment by skilled experts to determine when 

a trainee is skilled enough to begin more independent learning. 

Recent advances in virtual reality and haptics have enabled the 

construction of virtual surgical simulators in which residents can 

obtain basic surgical skills before advancing to patient care. With 

the development of these new tools, new metrics are necessary to 

measure and document performance. Studies have shown that 

virtual reality (VR) simulators can differentiate the skill level between 

novice and experienced arthroscopists. However, the most reliable 

metrics for determining mastery of specific skills or tasks in VR 

simulators have not been defined. While long-term skills tracking is 

likely to require significant simulation and development of metrics 

for various arthroscopy tasks, a key question to be answered is how 

long residents retain biomotor skills learned from a simple VR task. 

The purpose of this study was to determine the short-term retention 

of biomotor skills a resident gains by training on a VR simulator. We 

hypothesized that biomotor skills learned from a VR knee simulator 

would be retained over a six-week period. A cohort study of seven 

orthopaedic residents at a single residency program was performed. 

All participants were either first, second or third year residents in 

the program. Using a virtual reality knee simulator, each resident 

was tested on probing the medial meniscus of the right knee. The 

medial compartment was broken up into three zones consisting of 

the posterior horn, medial body and anterior horn. Tasks in each 

zone consisted of visualizing the proper zone, placing the probe 

in the correct field of vision, probing the superior aspect of the 

meniscus and finally pulling on the undersurface of the meniscus in 

the appropriate zone. Each zone was timed and all cartilage injuries 

were documented. Participants underwent pretesting using the VR 

knee simulator to obtain a baseline of their arthroscopic biomotor 

skills. After pretesting, subjects underwent technical skills training 

using the right knee medial compartment training module of the 

VR knee simulator. Participants were allowed unlimited training 

until they were able to obtain 100% on the timed training module. 

Following training, participants were retested minutes after, two 

weeks after and six weeks after training. Subjects were not allowed 

to use the knee simulator outside of the experimental protocol 

during the six week period. All participants were able to complete 

the four tasks in all three zones each time they were tested. The 

average time to complete all four tasks dropped below the pretest 

time at all post tests in all three zones. In the posterior horn zone, 

the average time to complete the tasks dropped from a pretest time 

of 81.7 seconds (SD ±37.3) to an average of 20.1 seconds (SD ±7.3) 

post training. The middle body times dropped from a pretest average 

value of 34.1 seconds (SD ± 19.6) to 15.5 seconds (SD ± 7.7) after 

training. Anterior horn zone times dropped from 30.6 seconds (SD 

± 16.3) pretest to 13.1 seconds (SD ± 5.4). Likewise, the number 

of cartilage injuries decreased below the pretest number for all 

zones following simulator training. Posterior zone injuries dropped 

from a pretest value of 9.7 to an average of 2.4 injuries following 

simulator training. Following training, middle body cartilage 

injuries dropped from an average of three injuries at pretest to 1.1. 

In the anterior zone, cartilage injuries decreased from an average of 

two to 0.4 at pretest and following training respectively. Residents 

showed markedly decreased time to complete the experimental 

tasks following simulator training. Residents also showed markedly 

788 

decreased incidence of cartilage injury after they completed training. 

These results indicate that residents retain motor skills learned in 

virtual arthroscopy, and suggest that both time and cartilage injury 

may be reasonable metrics to investigate further as response variables 

in more complicated surgical tasks. 

pApeR No. 654 

uArthroscopic Technique Using a Percutaneous Device 

vs Open Surgery for Displaced Patella Fractures 

Daniel Pizarro Luna, MSc, MD, Mexico, DF Mexico 

Juan Carlos De La Fuente, MD, Mexico City, DF Mexico 

There is a high rate (25%) of complications in the surgical treatment 

of patella fractures. Our objective was to compare the percutaneous 

patellar osteosynthesis system (PPOS) technique with arthroscopic 

view versus open surgery for patella fractures. This is a randomized 

controlled trial at a referral orthopedic and trauma center involving 

16 patients with displaced patellar fractures. Intervention: 

stabilization and fixation of patellar fractures with PPOS arthroscopy 

view or open surgery. Main outcome measurements: knee flexion 

and extension angles, pain, surgical time and assessment of knee 

function based on the Knee Society Clinical Rating Scale (KSCRS). 

Comparison of PPOS and open surgery groups respectively at four 

weeks showed the following: pain, 4.2 ± 1.3 vs. 7.2 ± 2.4, p

two post-procedure through routine MRIs to assess progression of 

OA. Athroscopy, MR and OCT images were compared. The results 

show OCT’s arthroscopic capabilities in humans and demonstrate its 

ability to determine abnormalities earlier than MRI and arthroscopy. 

In vivo arthroscopic OCT imaging of the human joint represents a 

new potentially powerful method for identifying early OA. Results 

of the year three MRIs of this study will be critical in assessing the 

clinical course of abnormalities detected by OCT. 

pApeR No. 656 

Do Patients With Medial Pathology Of The Knee Always 

Have Medial Knee Pain? 

Jane Campbell, Galway, . Ireland 

Paraic A Murray, MD, Galway City, Ireland 

Pain is the primary motivation for patients to seek medial advice. 

It has been noted in clinical practice that patients with medial 

pathology alone do not always present with medial knee pain. 

This study endeavored to ascertain the association between medial 

pathology and medial knee pain. This was a single centered study 

of prospective cohort design. From a possible 856 patients awaiting 

arthroscopy, 215 were identified as meeting the inclusion criteria and 

were invited to participate in the study. Patients with traumatic knee 

injuries were excluded; 213 patients consented to be included. The 

participating subjects located area of their symptoms on a diagram 

showing the four aspects of the knee. The primary outcome measure 

was findings at arthroscopy, which was recorded on the International 

Knee Documentation Form (IDKC). Medial pathology included 

medial meniscal tears, articular lesions of the medial femoral 

condyle or the medial tibila plateau or an inflamed infero-medial 

plica. Statistical analysis was carried out using the Statistical Package 

for Social Sciences. A total of 193 (135 males, 58 females) subjects 

completed the study. Fifty-five subjects had pathology located on 

the medial compartment of the knee only. Of these 85% (47) had 

medial pain, however only 27% (15 cases) had medial pain alone. 

Five cases had lateral pain only, one case had posterior pain only and 

the remaining (44 cases) had a combination of pains. Some 14.5% 

(eight) had no medial pain what-so-ever. Pearson’s Chi Square 

test for association found no significant association between the 

presence of medial knee pain and isolated medial knee pathology. 

There is a certain assumption that pain location is directly related 

to underlying pathology. However we found through this study that 

this is not always the case. 

pApeR No. 657 

Outcomes Of Arthroscopic Meniscectomy Are Best 

Predicted By Osteoarthritis Grade 

Faisal Mirza, MD, FRCSC, San Francisco, CA 

Benjamin Warren Halligan, MD, Fremont, CA 

Barbara Elspas, MPH 

Knee arthroscopy and meniscectomy is commonly done in patients 

with varying degrees of osteoarthritis (OA). We asked whether 

symptom duration, arthritis grade or tear type could predict oneyear 

outcomes. Sixty-seven subjects with a mean age of 51 years 

scheduled for knee arthroscopy for meniscal tears were enrolled 

from May 2005 to January 2009. Forty-five subjects were available 

for final review. History of acute injury within 12 months of 

presentation, preoperative Kellgren-Lawrence arthritis grade and 

preoperative MRI appearance of meniscus tear (degenerative or not) 

was recorded for each patient. Baseline preoperative and one-year 

postoperative WOMET and WOMAC scores were used to evaluate 

surgical outcomes with paired t-test and regression analysis. WOMET 

and WOMAC scores improved significantly in the entire cohort 

789 

at one year (p

three-fold increase in risk compared to under 30 minutes (p

evaluation of rotational instability is vital for assessing and improving 

current ACL reconstruction procedures which already solved anterior 

instability. The acceleration of the instability measured by triaxial 

accelerometer could provide quantitative parameters to evaluate the 

magnitude of the instability. The present study demonstrated that 

DB reconstruction can restore rotational instability better than SB in 

terms of the rotational instability. 


uComparison of Pyrocarbon to Co-Cr for 

Hemiarthroplasty:Effect of Biomaterial on Opposing 

Cartilage 

Stephen D Cook, PhD, Metairie, LA 

Deryk G Jones, MD, New Orleans, LA 

Samantha L Salkeld, MSE, Metairie, LA 

Laura P Patron, MS, Metairie, LA 

Peter Strzepa, MSME, Austin, TX 

Resurfacing an osteoarthritic joint is the treatment strategy for 

patients for which biologic options are not viable. The articular 

cartilage opposing a metallic hemi-arthroplasty implant becomes 

damaged and eventually succumbs to the altered surface mechanics 

and wear properties of the prosthetic device. Pyrocarbon has been 

shown to significantly improve survival of acetabular cartilage as 

compared to cobalt-chromium (Co-Cr) and other biomaterials in a 

canine hip endoprosthesis model. The purpose of this study was to 

evaluate in vivo changes in the tibia articular cartilage and meniscus 

to a pyrocarbon implant placed in the medial femoral condyle as 

compared to an identical Co-Cr alloy implant. A 6 mm diameter 

pyrocarbon and Co-Cr articulating implants were placed bilaterally 

in the medial condyles of nine dogs. Groups of three animals were 

sacrificed at 12, 24 and 52 weeks postoperative. Radiographic, gross 

and histologic analyses (modified Kirker-Head scale and modified 

ICRS-Histological Visual Scale) were performed. In addition to 

cartilage adjacent to the implants, both the medial and lateral 

menisco-tibial tissues were evaluated. Cartilage damage observed 

with Co-Cr at 12 and 24 weeks were not observed or observed to a 

lesser degree with pyrocarbon at 52 weeks. At all time periods, mean 

scores for pyrocarbon were superior to Co-Cr (p

examination, nonarthritic hip score (NAHS), Western Ontario and 

McMasters Universities (WOMAC) score and radiographs to assess the 

alpha-angle. Postoperative evaluation included pain score assessment 

with a visual analog scale and satisfaction assessment. At follow up, 

the mean NAHS rose from 49.2 to 71.2 and the WOMAC increased 

from 67.2 to 72.8. Alpha angles were reduced from 75 to 51.3 

degrees. Presence of internal rotation impingement sign decreased 

from 97% to 47%. Patient satisfaction was 80%. Two patients 

required a repeat bursectomy or hip arthroscopy. Twelve patients 

progressed to arthroplasty. Arthroscopic femoral neck resection in 

patients with cam-type FAI results in improved clinical outcomes, 

decreased physical symptoms and a high patient satisfaction at a 

mean follow up of 32 months. A reduced alpha angle is maintained, 

providing adequate offset of the head-neck ratio. Patients who failed 

hip arthroscopy and progressed to arthroplasty were older and 

tended to have more arthritis on preoperative radiographs and lower 

clinical scores. 


Incidence of Bony Abnormalities in Patients With and 

Without Acetabular Labral Tears 

Jason Archibald, MD, Baltimore, MD 

James S Keene, MD, Madison, WI 

Erica Knavel, BS 

Donna G Blankenbaker, MD, Madison, WI 

Arthur A DeSmet, MD, Madison, WI 

Prior studies have found that 79-85% of people with labral tears 

have bony abnormalities of the hip joint. However, there have been 

no studies that have compared the incidence of boney abnormalities 

in a matched group of patients without labral tears. Conventional 

radiographs of 50 patients who did not have acetablular labral tears 

(NLT patients) on magnetic resonance arthrograms of their hip 

performed at our institution were compared with those of a matchedgroup 

of 50 patients who had labral tears (LT patients) documented 

at hip arthroscopy by the senior author. The anteroposterior 

and lateral radiographs of these 100 patients were examined for 

abnormal findings defined as: Tonnis angle ³15°; center-edge angle 

(CEA) 0.05). The incidence of each type of bony abnormality in the 

NLT and LT patients was: Tonnis angle 6.7% vs. 6.0%; CEA 3% vs. 

8%; retroversion 12% vs. 14.6%; cross-over sign 13% vs. 14%; neckshaft 

angle 10% vs. 18%; head-neck offset 7% vs. 42%; and alpha 

angle 13.4% vs. 34%, respectively. The only significant differences 

between the groups (p

36 (p=0.0259 for PHI and p=0.0036 for MHI) scores compared with 

PMM group at minimum 10-year follow up. Radiographic evaluation 

showed a significantly lower medial joint line height (p=0.0002) 

and side-to-side difference (p=0.0003) narrowing in MCMI group 

respect to PMM group at final follow up. Improvements in pain 

relief, activity level, objective IKDC score and joint-line preservation 

are detectable with the use of MCMI at a minimum 10-year follow 

up. This data support the use of meniscal scaffold to treat irreparable 

partial meniscal lesions. 


Arthroscopic Rotator Cuff Repairs: Functional and 

Radiographic Results at 5 Years 

Lawrence Gulotta, MD, New York, NY 

Shane Nho, MD, Chicago, IL 

Christopher Dodson, MD, Philadelphia, PA 

David W Altchek, MD, New York, NY 

John Dougald MacGillivray, MD, New York, NY 

The purpose of the present study is to report the preliminary data 

of patients undergoing arthroscopic rotator cuff repair at five years. 

A total of 193 patients underwent all-arthroscopic rotator cuff 

repairs. Patients were evaluated pre-operatively, and one, two and 

five years post-operatively for physical examination, manual muscle 

testing, ASES questionnaires and ultrasonography. Outcomes were 

compared between timepoints using a paired student’s t-test with 

a significance set at pfour 

weeks) of the ACL has the same functional outcome as early (


Prospective Comparative Study on ACL Reconstruction 

using the Double and Single bundle Techniques 








Double bundle anterior cruciate ligament (ACL) reconstruction 

is aimed to reproduce the normal ACL anatomy and improve 

knee joint rotational stability. However, no consensus has been 

reached on the advantages of this technique over the single bundle 

technique. We hypothesized that double bundle ACL reconstruction 

can provide better intraoperative stability and clinical outcome than 

single bundle reconstruction. Forty patients with ACL injury in one 

knee were recruited with 20 allocated to the double bundle ACL 

reconstruction group and 20 to the single bundle ACL reconstruction 

group. Intraoperative stabilities at 30° of knee flexion were compared 

between the two groups using a navigation system. Clinical 

outcomes including Lysholm knee scores, Tegner activity scores, 

Lachman and pivot shift test results and radiographic stabilities were 

also compared between the two groups after a minimum of twoyear 

follow up. Intraoperative anterior and rotational stabilities after 

ACL reconstruction in the double bundle group were significantly 

better than those in single bundle group (p=0.020 and p0.5). Furthermore, stability 

results of Lachman test, pivot shift test and radiological findings 

at two-year follow up failed to reveal any significant inter-group 

differences (p>0.05). Although double bundle ACL reconstruction 

produces better intraoperative stabilities than single bundle ACL 

reconstruction, the two modalities were found to be similar in terms 

of clinical outcomes and postoperative stabilities after a minimum 

of two-year follow up. 


Intra-Articular Bupivacaine Is Superior To Portal 

Bupivacaine For Analgesia After Hip Arthroscopy 

Joseph Baker, MD, Cork, Ireland Ireland 

Ciara Megan McGuire, MD, Dublin, Ireland 

Daniel Byrne, PhD, Santry Demsne, Dublin, Ireland 

Kim Hunter, FRCA 

Nick Eustace, FRCA 

Kevin James Mulhall, MD, Dublin, Ireland 

Although hip arthroscopy is increasingly used, the optimal analgesic 

management following hip arthroscopy is yet to be determined. 

Furthermore, concern exists over the use of intra-articular local 

anaesthetic following arthroscopic procedures. We aimed to 

compare the efficacy of intra-articular adminstration with peri-portal 

infiltration of bupivacaine following hip arthroscopy. We performed 

a randomized, double-blinded trial comparing intra-articular 

administration of bupivacaine with peri-portal infiltration of 

bupivacaine. All patients received a standardized general anaesthetic 

and post-operative oral analgesic regime. At the completion of 

surgery, patients were randomized to receive bupivacaine (0.25%, 10 

ml) by either the intra-articular or peri-portal route. Post-operative 

morphine requirements and visual analogue scale (VAS) pain scores 

794 

were assessed as primary outcome measures. Student’s t-tests and 

ANOVA were used to assess for differences. Fifty-nine patients 

completed the trial (M35:F24). There was no gender difference 

between the groups. Patients receiving intra-articular bupivacaine 

(n=31) required less intravenous morphine for rescue analgesia after 

surgery (mean 0.3 mg vs. 2.5 mg, p=0.007). At one and two hours 

post-surgery, the mean VAS pain scores were similar, however at six 

hours the mean was significantly lower in the intra-articular group 

(1.3 vs. 2.2, p=0.031). No patients represented after surgery due to 

pain control problems. Intra-articular bupivacaine provided superior 

analgesic control following hip arthroscopy. Fewer morphine 

requirements can results in lower incidence of post-operative nausea 

and vomiting. This may allow earlier, more effective rehabilitation 

following surgery. 


The Validation of a Functional Assessment Tool for the 

Upper Extremity in the Youth Overhead Athlete 

Guillem Gonzalez-Lomas, MD, Newark, NJ 

Reza Jazayeri, MD, Woodland Hills, CA 

Francis G Alberta, MD, Glen Rock, NJ 

Karen J Mohr, PT, Los Angeles, CA 

Lewis A Yocum, MD, Los Angeles, CA 

Neal S ElAttrache, MD, Los Angeles, CA 

Frank W Jobe, MD, Los Angeles, CA 

Current shoulder and elbow scoring systems may not be sensitive 

to subtle changes in performance in overhead athletes. Recently, a 

functional assessment instrument has been devised to specifically 

evaluate the performance and function of adult overhead athletes. 

No similar validated upper extremity tools exist for the youth 

overhead throwing population. A total of 153 competitive overhead 

youth athletes (age 11-18) completed the questionnaire as well as 

two established upper extremity questionnaires (the DASH and 

the DASH Sports Module). The athletes were asked to complete all 

questionnaires at a second time point separated by at least six weeks. 

The athletes were self-assigned into injury categories: (I) playing 

without pain; (II) playing with pain; (III) not playing due to pain. 

The novel score, the DASH and the DASH Sports Module were then 

evaluated for reliability, validity and responsiveness. Reliability was 

measured by testing both internal reliability (Cronbach coefficient 

±) and test-retest correlation (Pearson correlation coefficient (r) and 

root mean square (RMS) difference). Validity was tested by correlating 

the median KJOC score with arm status, using the non-parametric 

Kruskal-Wallis test to compute p values. Responsiveness testing was 

performed by comparing scores before and after an intervention or 

before and after an injury. Of the 153 athletes, 136 were healthy 

and 17 were injured. The new score showed high correlation with 

the DASH score and DASH Sports Module (DSM). The new score 

correctly stratified overhead athletes by injury category (p


Intercondylar Notch Size And Non-Contact ACL Injuries 

At The United States Naval Academy 

Korboi N Evans, MD, Bethesda, MD 

John-Paul H Rue, MD, Annapolis, MD 

Jeffrey R Giuliani, MD, Kensington, MD 

David E Gwinn, MD, Crownsville, MD 

John H Wilckens, MD, Annapolis, MD 

Several potential risk factors for anterior cruciate ligament (ACL) 

injuries have been proposed. The goal of this study is to document 

the incidence of ACL injuries at the United States Naval Academy 

and to evaluate pre-injury radiographic measurements (notch width) 

and body mass index (BMI) as possible risk factors for these injuries. 

An Institutional Review Board (IRB)-approved, retrospective review 

of a database from an existing IRB-approved study was performed. 

The database contained measurements from prospectively obtained 

standard AP/lateral knee radiographs, as well as baseline height, 

weight, age, sex and documented ACL injury for two consecutive 

incoming classes at the United States Naval Academy in 1999 

and 2000 and followed prospectively for four years. Radiographic 

measurements including notch width, femoral notch width index 

(notch width divided by condyle width), eminence width index and 

the notch width/eminence width ratios were calculated for both 

the injured and uninjured subjects utilizing standard radiographic 

measurements. Inclusion criteria for the retrospective review included 

having initial radiographic measurements, height and weight, no 

previous ACL injury and documentation of subsequent injury or 

lack of injury during the four years of observation. Exclusion criteria 

included missing any of the inclusion criteria. A total of 1,687 

study participants met the inclusion criteria and were observed 

for four years. The overall incidence of ACL injury was 2.9% (12 

female, 37 male). The average BMI for the ACL injured group was 

25.6 kg/m2 compared to 24.4 kg/m2 overall. While an association 

of ACL injury with a femoral notchwidth of


Increasing Suture Number Increases Repair Strength 

In A Rotator Cuff Repair Model 

Patrick Jost, MD, New York, NY 

Mahmoud Michael Khair, MD, New York, NY 


Anne Mary Kelly, MD, Uniondale, NY 



Increasing the number of sutures crossing the repair site of a finger 

flexor tendon leads to higher failure loads, less gap formation and 

better outcomes. Whether the same is true for rotator cuff repairs 

has not been proven. We hypothesize that increasing the number 

of sutures in a sheep rotator cuff model decreases gap formation 

under cyclic loading. Sheep infraspinatus tendons were repaired 

with two, four or six mattress sutures (N = 6, 7 and 5). Two 5.5 

mm metal corkscrew suture anchors were used in all specimens with 

one, two or three sutures per anchor. Specimens were pretensioned 

at 10N for 60 seconds and then cyclically loaded for 200 cycles from 

10N to 180N at 0.2 Hz. Failure was defined as gap formation of 10 

mm or greater. Student’s t test was used to determine differences 

between each group. An ANOVA test was used to compare the three 

experimental groups. The average gap formation for the tendons 

repaired with two, four and six sutures were 5.42 mm, 3.53 mm and 

1.34 mm, respectively. The six-suture repair showed significantly less 

gap formation than the four-suture repair (p=0.040) and the twosuture 

repair (p=0.050). Comparing all groups showed that as suture 

number increased, gap formation decreased (p=0.059). Increasing 

the number of sutures crossing a sheep rotator cuff tendon repair 

decreases gap formation under cyclic loading, ultimately providing 

a stronger repair. 


A Comparison between Clinical Results of Selective 

Bundle And Double Bundle ACL Reconstruction 

Young-Jin Seo, Prof, Seoul, Republic of Korea 

Yonsik Yoo, Chuncheon, Gangwon-Do, Republic of Korea 

The purpose of this study was to compare the two-years followup 

clinical results of anatomical double bundle anterior cruciate 

ligament (ACL) reconstruction with a selective reconstruction 

of either anteomedial (AM) or posterolateral (PL) bundle while 

keeping the relatively healthy ACL bundle left. We followed up 50 

patients for minimum two years after their ACL reconstruction, of 

which 12 were double bundle ACL reconstructions (group A) and 25 

were AM bundle reconstructions (group B) and 13 were PL bundle 

reconstructions (group C). We compared those three groups with 

patient’s subjective feeling of instability, Lysholm score, radiological 

stress view, Lachmann test and pivot shift test. At the last follow up, 

the mean side-to-side instrumented laxity was 2.08 ± 1.67 mm in 

group A, 2.20 ± 1.41 mm in group B, 2.00 ± 1.41 mm in group C, 

which improved significantly after surgery. The Lysholm knee score 

improved significantly improved from 52 ± 7.64 to 83.4 ± 8.46 in 

group A, from 57 ± 15.04 to 83.2 ± 9.60 in group B, from 62±15.22 to 

87.5 ± 7.32 in group C. There was no statistically significant difference 

between three groups. Both double bundle ACL reconstruction and 

selective bundle ACL reconstruction showed improved joint stability 

and Lysholm scores postoperatively. If properly indicated, selective 

bundle ACL reconstruction can be a treatment option for patients 

with partial ACL injuries. 

796 


Intra-Bursal Versus Inter-Scalene Post-Operative Pain 

Control For Arthroscopic Shoulder Surgery 

Rajesh Magattil, MRCS, Lexington, KY 

Darren Patten 

Srinath Kamineni, MD, Lexington, KY 

Post-operative pain following arthroscopic shoulder surgery can 

impair final functional outcome, since good quality rehabilitation 

is dependent on good pain control. Various methods of analgesia 

have been described, and we routinely used inter-scalene analgesia. 

We hypothesized that inter-scalene analgesia provided better pain 

control than intra-bursal analgesia. We prospectively collected data 

over a consecutive two-year period, with the first year patients (n=65) 

all having inter-scalene and the second year patients (n=79) having 

intra-bursal catheters. The interscalene 16F catheters were placed 

with the patient anaesthetised and an electrical Touhy needle. The 

intra-bursal 16F catheters were placed at the end of the arthroscopic 

shoulder operation, under direct vision, exiting from the posterior 

portal. Pain parameters collected were pain scores, visual analogue 

scales, analgesia usage and whether or not the patients were 

comfortably able to go home the same day as surgery. Pain and 

visual analogue scores showed no statistical differences between 

the two groups. Analgesia usage was greater in the inter-scalene 

group than the intra-bursal group, but was not statistically different. 

Thirty-two/65 (49%) of patients with inter-scalene catheters and 

75/79 (95%) of patients with intra-bursal catheters were able to 

comfortably go home on the day of surgery, 28/33 (84%) of the 

inter-scalene patients were hospitalized due to post-operative pain 

or anxiety regarding arm paralysis (n=12 pain and n=16 anxiety) 

and five/33 (15%) due to anaesthetic or medical problems. Two/ 

four (50%) of hospitalized intra-bursal patients had post-anaesthetic 

complications, and two/four (50%) had pre-operative medical 

problems. Inter-scalene analgesia is widely published as the most 

effective route for post-shoulder surgery pain control. Our data does 

not support this view, and intra-bursal analgesia administration was 

found to be more effective at returning a comfortable patient home 

on the day of surgery. Our practice now routinely utilizes intra-bursal 

catheters for post-operative bolus analgesia. 


Glenoid Bone Loss and Clinical Application of the 

Dominic T Gomez-Leonardelli, MD, Coronado, CA 

Paul D Metzger, MD, San Diego, CA 

Brian Barlow, MD, San Diego, CA 

William Joseph Peace, MD, Alexandria, VA 



The optimal treatment of Hill-Sachs injuries is difficult to determine 

and is potentiated by the finding that a Hill-Sachs injury becomes 

more important in the setting of glenoid bone loss. The “glenoid 

track” concept was developed to biomechanically quantify the effects 

of a combined glenoid and humeral head bony defect on stability, 

and is thought to be important to determine if a Hill-Sachs lesion 

is at high risk of engaging the glenoid, thus changing potential 

treatment options. However, this concept has yet to be clinically 

verified in regards to existing Hill-Sachs classification systems and 

clinical findings. The purposes of this study were to correlate the 

amount of glenoid bone loss with the extent of Hill-Sachs injury and 

clinically verify the “glenoid track” concept. In addition, we sought 

to investigate correlation among multiple Hill-Sachs grading scores 

with demographic variables such as time of instability and number 

of dislocations/instability events, and determine the mean value of 




Hill-Sachs size across multiple scoring systems. A total of 205 patients 

treated for recurrent shoulder instability over a two-year period were 

reviewed. Of these shoulders, 173 (80.8%) had an adequate MRI/ 

MRA for evaluation. Therefore a total of 140 (80.9%) patients had 

Hill-Sachs lesions and were included in the final radiographic analysis 

and grading of lesions with a mean age of 27.6 (SD 6.9), mean length 

of instability 43.4 months (SD 58.7) and a mean of 7.2 dislocations 

(SD 16.9). Hill-Sachs lesions were quantified radiographically 

based on Rowe Grade, the Flatlow percentage of articular cartilage 

involved, the Francheschi Grade, the Richards and Hall degrees of 

lesion involvement on axial cuts and the percentage of articular 

cartilage involvement on sagittal oblique images. The “glenoid 

track” was measured and if the size of the humeral head lesion and 

glenoid bone loss was large enough (84% relative to each other), 

then the humeral head was said to be outside the “glenoid track” 

and at high risk for engaging and this number (percent) of patients 

recorded. Three independent examiners investigated all radiographic 

and demographic parameters. The mean Rowe length was 19.1 (SD 

3.2) mm and depth was 5.1 mm (SD 2.0); mean Richards arc was 

7.1 degrees (SD 4.2); mean Francheschi score was 1.9 (SD 0.8); and 

mean glenoid bone loss was 7.6%. A total of 22 (15.7%) patients 

were determined to be outside the “glenoid track” and at higher risk 

of humeral-glenoid engagement. From regression analysis, patient 

age and number of dislocations were jointly predictive of being 

outside the “glenoid track” (p=0.015), number of dislocations was 

predictive of glenoid bone loss (p=0.01) and number of dislocations 

predictive of percentage articular cartilage involvement on saggital 

oblique MRI (P=0.015). More dislocations also correlated with 

larger Hill-Sachs lesions as well as larger extent of combined glenoid 

and humeral bone loss. The “glenoid track” concept is a potentially 

useful clinical tool to determine risk of engaging lesion in the setting 

of combined Hill-Sachs injury and glenoid bone loss. Patient age 

and number of dislocation/subluxation events is predictive of the 

presence of lesions outside of the “glenoid track” and may guide 

clinical work-up and treatment algorithms for patients experiencing 

recurrent anterior shoulder instability. 


Intra-Articular Hyaluronic Acid Durolane ® Versus 

Bupivacaine Following Knee Arthroscopy 

Gandhi Nathan Solayar, MD, Dublin 9, Ireland Ireland 

Gandhi Nathan Solayar, MD, Dublin 9, Ireland Ireland 

Joseph Baker, MD, Cork, Ireland Ireland 

Daniel Byrne, PhD, Santry Demsne, Dublin Ireland 

Raymond Moran, FRCS, Dublin 9, Ireland 

Kevin James Mulhall, MD, Dublin 03, Ireland 

Intra-articular local anaesthetic (LA) is commonly administered 

following knee arthroscopy for the purpose of pain relief. However, 

recent reports have suggested that LA agents may be harmful to 

articular cartilage. Durolane®, a stabilized hyaluronic acid (HA), is 

licensed for intra-articular viscosupplementation as a treatment for 

the symptoms of osteoarthritis. In this study we aimed to compare 

the analgesic effects of Bupivacaine and Durolane® administered 

intra-articularly immediately post knee arthroscopy. We randomized 

98 patients to receive either 10 ml of Bupivacaine (0.5%) or 10 ml of 

Durolane® via intra-articular injection immediately following knee 

arthroscopy. They were prospectively followed pre-operatively, at one 

day, one week, two weeks and six weeks post-surgery. Both patients 

and observers were blinded to the treatment group. Statistical 

analysis of visual analogue scores (VAS) at rest and weight bearing, 

as well as Western Ontario/MacMaster index scores for function were 

performed. A sub-group analysis based on arthroscopic osteoarthitic 

scores, meniscal debridement and the presence of osteochondral 

797 

defects were also conducted. The mean VAS improvement at rest 

was 1.06 in the Bupivacaine group and 0.75 in the Durolane® group 

(p=0.263). The mean VAS improvement on weight bearing was 2.29 

in the Bupivacaine group and 2.27 in the Durolane® group (p=0.962). 

Functional WOMAC scores improved by 15.21 in the Bupivacaine 

group and 15.73 in the Durolane® group (p=0.846). The various 

sub-group analyses revealed no statistically significant differences 

in VAS and functional WOMAC scores for both Bupivacaine and 

Durolane® groups. Intra-articular injection of the stabilized HA 

Durolane® was as effective as Bupivacaine in providing analgesia 

following knee arthroscopy performed for a number of conditions. 

HA injection can be considered as an alternative analgesic agent to 

LA following knee arthroscopy if the operating surgeon is concerned 

about the potential chondrotoxic effect of LA. 


A Meta-Analysis Comparison of Single Row vs. Double 

Row Arthroscopic Rotator Cuff Repair 

M. Russell Giveans, PhD, Minneapolis, MN 

Shahin Sheibani-Rad, MD, Flint, MI 

Arthroscopic rotator cuff repairs are increasing in frequency. 

Although clinical results from arthroscopic repair have been 

encouraging, recurrent tears continues to be a feared complication 

from the procedure. To date, there is no general consensus as to 

which method is a better technique in terms of clinical outcomes. The 

purpose of this meta-analysis was to compare the arthroscopic single 

row and double row configurations in terms of clinical outcomes 

between the two techniques with respect to 1) Constant scores, 2) 

UCLA scores and 3) American Shoulder and Elbow Surgeons scores 

(ASES). We performed a thorough search of the Medline, Ovid, 

EMBASE, Cochrane Library databases and PubMed for Englishlanguage 

articles published from January 1990 to November 2009. 

A manual reference check of all accepted papers and recent reviews 

was performed to supplement the electronic searches and to identify 

any additional potentially relevant studies. We also performed an 

online search, as well as a manual search of the American Academy 

of Orthopaedic Surgeons (AAOS) abstracts from 2007-2009 annual 

meetings. Studies had to meet the inclusion criteria set forth by the 

authors. In order to determine if there was a difference in the effect 

size of pre-to-post change for single row compared to double row, 

Cohen’s D statistics, as a measure of effect size, were calculated for 

both groups. To further enhance our understanding of the differences 

found between these two groups across publications, weighted 

means and standard deviations were then calculated based upon 

reported sample size. Of the total 182 articles reviewed for eligibility, 

nine studies met the inclusion. There was a single level I study, 

two level II studies, two level III studies and four level IV studies. 

Across all studies that assessed clinical outcomes, there were a total 

of 740 patients (418 males, 322 females). The mean age was 52.6 

years (19-87). The mean follow-up time was 30.9 months (12-60). 

The indication for surgery was a failure of conservative treatment 

for three to four months in patients with a chronic tear, and more 

immediate repair for patients with an acute tear. The most common 

tear pattern was crescent type lesions, followed by U-shaped lesions. 

In those studies that included data on tear size, there were 61 

patients with a tear 1.45). This measure of effect 

size between single row and double row was found to be statistically 

similar (p>.05) for Constant-Murley and UCLA. However, for ASES, 

we found a significantly greater effect size for the double row group 




as compared to the single row group (p = .027). When looking at 

the weighted change in score from pre-op to post-op, we found 

no difference in the UCLA score. For the ASES score, we found 

the change in double row patients (52.6) to be statistically greater 

than the change in single row patients (45.8)(p


Outcomes of Meniscus Repair At a Minimum Five Year 

Follow-up: A Meta-analysis 

Jeffrey Nepple, MD, Shrewsbury, MO 

Rick W Wright, MD, Saint Louis, MO 

Numerous studies have documented the short-term outcomes of 

various techniques for meniscal repair, but few have reported longterm 

outcomes. Late failure of meniscal repair up to five years has 

been reported. We performed a meta-analysis to better define the rates 

of meniscal repair failure at a minimum five years postoperatively 

in the literature. We performed a systematic review of the literature 

to identify studies with a minimum follow up of five years after 

meniscal repair. Twelve studies (13 groups) met the inclusion 

criteria, including five using open, three inside-out, one outside-in, 

two all-inside (meniscal arrow) and one mixed inside-out/all-inside 

(meniscal arrow) repair techniques. The primary outcome measure 

was clinical failure or reoperation for symptomatic meniscal repair 

failure. Subgroup analysis including medial/lateral, ACL status and 

acute/chronic meniscal tears were performed. The overall pooled 

failure rate for the population was 23.3% (120/514). Pooled failure 

rates were 22.2% (28/126) with open, 22.4% (34/152) with insideout, 

23.9% (21/88) with outside-in and 25.0% with (37/148) allinside 

(meniscal arrow) repair techniques. The failure rate of medial 

meniscal repair was 24.6% and lateral meniscal repair was 21.8%. 

The failure rate of meniscal repair in the setting of an intact ACL 

was 23.6%, compared to 27.8% with ACL reconstruction. Rates of 

failure of meniscal repair after five years are 22.2-25.0% irrespective 

of the technique of meniscal repair. Rates of failure were similar 

between medial/lateral meniscal tears and ACL status. More longterm 

studies are needed to define the ultimate outcome of meniscal 

repair, specifically with modern all-inside techniques. 


Incidence of Elbow Dislocations in the United States 

Population 

Jason W Stoneback, MD, Aurora, CO 

Joshua Bengtson Sykes, MD, Memphis, TN 


Brett D Owens, MD, West Point, NY 

Jennifer Moriatis Wolf, MD, Farmington, CT 

There is minimal information regarding the epidemiology of simple 

elbow dislocations. The purpose of this study is to report the estimated 

incidence of elbow dislocations in the United States, utilizing the 

National Electronic Injury Surveillance System Database (NEISS). 

The NEISS database includes 100 hospitals representing random 

sampling of all patients presenting to U.S. emergency departments. 

The database was queried for elbow dislocation events. NEISS data 

for 2002 to 2006 was used for raw and weighted injury counts. 

Incidence rates with 95% confidence intervals (CI) were calculated 

by age group and gender, using U.S. census data. A total of 1,068 

elbow dislocations were identified, representing a weighted estimate 

of 36,751 acute dislocations nationwide. A calculated incidence of 

5.21 dislocations per 100,000 person-years (95% CI, 5.20-5.22) was 

noted. The highest incidence of elbow dislocations occurred in those 

aged 10-19 years (6.87 per 100,000, 95% CI, 6.86-6.88, 39%). The 

incidence rate ratio comparing dislocations in males to females was 

1.02 (5.26/100,000 in males, 5.16/100,000 in females). In patients 

10 years or older, 464 injuries (43.4% of total dislocations) were 

sustained in sports. Males dislocated elbows in football, wrestling 

and basketball. Females sustained elbow dislocations most 

frequently in gymnastics and skating. The estimated incidence of 

799 

elbow dislocations in the U.S. population is 5.21 per 100,000 person 

years, using a national database. Adolescent males are at highest risk 

for dislocation. Nearly half of acute elbow dislocations occurred in 

sports, with males at highest risk with football, and females at risk 

with gymnastics and skating. 


Characterization of Orthopaedic Surgeries Upon 

Completion of a Combat Deployment 

Gens Pierce Goodman, DO, El Paso, TX 

Jason R Dutton, DO, El Paso, TX 

Andrew Schoenfeld, MD, Canutillo, TX 

Brett D Owens, MD, West Point, NY 

Philip J Belmont, Jr MD, El Paso, TX 

Analysis of the orthopaedic surgery consultations and surgical 

procedures required by soldiers upon return from a combat 

deployment has not been previously performed. A descriptive 

epidemiologic study characterizing the number and type of 

orthopaedic surgical consultations and orthopedic procedures 

required by soldiers in a U.S. Army Brigade Combat Team returning 

from a combat deployment to Operation Iraqi Freedom was 

performed. A centralized casualty database and the military electronic 

medical records system were used. Factors analyzed included age, 

sex, military rank, distribution of wounds and mechanism of 

injury. A total of 4,122 soldiers deployed with the Brigade Combat 

Team were under investigation. In total, 4,087 soldiers survived, 

and 3,787 soldiers endured the duration of the 15-month combat 

deployment. Upon completion of the deployment, 710 orthopaedic 

surgical consultations were evaluated. Among these consultations, 

166 (23.4%) required surgical procedures. Senior enlisted soldiers 

accounted for 40% of the population at risk, yet accounted for 54% 

of the total surgeries. Males (153/3525), when compared to females 

(13/323), had no difference in the risk of requiring surgery. The most 

common surgical procedures performed included: knee arthroscopy 

(27), shoulder stabilization (19), superior labrum anterior-posterior 

lesion (13), anterior cruciate ligament reconstruction (12) and 

lateral ankle stabilization (six). Combat operations often result in 

devastating musculoskeletal injuries, many of which require medical 

evacuation from theater. However, many soldiers with injuries 

which can be evaluated and treated in an ambulatory setting while 

deployed, in order to conserve the fighting strength, often times 

require surgical intervention upon completion of the deployment. 


A Comparison of Glenoid Bone Loss Measurement 

Techniques: Axial CT vs 3D CT Sagittal Reconstruction 

Andrew S Bernhardson, MD, San Diego, CA 

James R Bailey, MD, San Diego, CA 


The stabilizing structures of the glenohumeral joint include static 

and dynamic elements. Loss of a main static stabilizer, glenoid 

bone, can have a profound effect on stability. The imaging study of 

choice to evaluate glenoid bone loss is a CT. Previously axial CTs 

have been used to determine the amount of bone loss. Recently 3D 

reconstructions of the glenoid with humeral head subtraction allow 

creation of an enface view of the glenoid. The purposes of this study 

were to measure both axial CT and 3D sagittal CT reconstruction 

images with known bone loss at time of surgery to determine the 

most reliable and accurate means of calculating bone loss. Over a 

two-year period, a total of 106 patients with existing preoperative 

shoulder CTs with both axial images and a 3D sagittal reconstruction 

were used. Bone loss was determined by measuring three selected 




axial images for glenoid AP distance below the coracoid process 

and determining what percentage of the assumed glenoid was lost 

on each image. The 3D sagittal images were measured by placing a 

circle over the lower two-thirds of the glenoid approximating the 

unaffected native glenoid and any bony segment absent from the 

circle was measured as bone loss. The average bone loss at time of 

axial CT was 19.4%. The bone loss measured in the same group 

of patients using 3D CT sagittal reconstruction was 12.02%. This 

patient group underwent shoulder arthroscopy and was found to 

have an average glenoid bone loss of 10.3%. Glenoid bone loss is an 

important factor affecting post-operative stability. There is a need to 

assess the amount of glenoid bone present in patients undergoing 

shoulder arthroscopy for stabilization. Knowledge preoperatively 

of increased bone loss can aid in surgical planning and the best 

method for determining glenoid bone loss is a 3D CT with sagittal 

reconstructions. 


Validation Of A Prognostic Classification System For 

Acetabular Cartilage Lesions 


Faizal Rayan, MBBS,MRCS,DORTHO, Kettering, 


Geert Meermans, MD, Berchem, Belgium 

Johan Witt, MD, London, United Kingdom 


In recent years, there has been a significant advancement in our 

understanding of femoro-acetabular impingement and associated 

labral and chondral pathology. Surgeons worldwide have 

demonstrated the successful treatment of these lesions via arthroscopic 

and open techniques. The aim of this study is to validate a simple and 

reproducible classification system for acetabular chondral lesions. 

In our classification system, the acetabulum is first divided into six 

zones as described by Ilizalithurri VM et al Arthroscopy 24(5) 534- 

539]. The cartilage is then graded as 0 to 4 as follows: Grade 0 - 

normal articular cartilage lesions; Grade 1 softening or wave sign; 

Grade 2 - cleavage lesion; Grade 3 - delamination and Grade 4 - 

exposed bone. The site of the lesion is further typed as A, B or C based 

on whether the lesion is one-third distance from acetabular rim to 

cotyloid fossa, one-third to two-thirds distance from acetabular rim 

to cotyloid fossa and >two-thirds distance from acetabular rim to 

cotyloid fossa. For validating the classification system, six surgeons 

reviewed 14 hip arthroscopy video clips. All surgeons were provided 

with written explanation of our classification system. Each surgeon 

then individually graded the cartilage lesion. A single observer then 

compared results for observer variability using kappa statistics. 


Influence of Laceration and Interference Screw 

Fixation on Tensile Strength of Soft-Tissue Grafts 

Robert Javier Villarreal, MD, Providence, RI 

Wendell M Rogan Heard, MD, Providence, RI 

David Paller, MS 

Keith Oster Monchik, MD, Providence, RI 

Steve Brian Behrens, MD, Providence, RI 

Alison M Biercevicz, BS, Houston, TX 

Paul Fadale, MD, Providence, RI 

Innovations in interference screw design for soft-tissue anterior 

cruciate ligament (ACL) reconstruction have resulted in 

bioabsorbable screws capable of providing fixation strength similar 

to that of metal screws without the previously reported problem of 

800 

screw breakage. Previous research has reported significant differences 

in graft laceration and pullout load between metallic screws and first 

generation biocomposite screws. Currently, comparative assessment 

of graft integrity with current generation biocomposite screws has 

not been performed. The objective of this study was to evaluate the 

influence of graft laceration from screw insertion on mechanical 

properties of the graft. A total of 24 bovine knees (12 matched pairs) 

were used to create tibial bone discs 35 mm in length. A 7.5 mm 

extraction drill created a bone tunnel in each sample. Samples were 

then serially dilated to 9 mm in preparation for a 9 mm porcine 

tendon graft instrumented with one of four commercially available 

10x35 mm biocomposite screws--BCP/PLDLA (biphasic calcium 

phosphate/poly-DL-lactic acid), ²-TCP/PLGA (beta-tricalcium 

phosphate/poly(lactic-co-glycolic acid) and two screws made of 

HA/PLLA (hydroxyapatite/poly-L-lactic acid) - each with a different 

thread design. Samples were tensile loaded to failure at 200 mm/ 

min. A one factor ANOVA was used to test for statistical significance. 

No graft showed macroscopic evidence of laceration following screw 

insertion and there were no statistically significant differences for yield 

load (p=0.41), maximum load (p=0.35) or stiffness (p=0.68) among 

the different screw types. The results suggest that all biocomposite 

screws tested are acceptable for ACL reconstruction with respect to 

their potential for causing damage to the soft tissue graft. 


Stress Fractures in High School Athletes 

Andrew D Goodwillie, MD, New Brunswick, NJ 

Eric Nussbaum, ATC, Freehold, NJ 

Charles J Gatt, Jr MD, New Brunswick, NJ 

This study reports the epidemiology of stress fractures in the 

adolescent athlete. This surveillance highlighted the frequent 

occurrence of this injury and the gender differences that exist. Between 

September 2007 and December 2010, stress fractures in adolescent 

athletes were prospectively submitted to an online database by local 

high-school athletic trainers. For every radiographically confirmed 

stress fracture, each athletic trainer was instructed to complete a 

standardized online form that detailed each athlete’s demographics, 

fracture pattern, clinical presentation, sport, level of participation, 

training intensity and various dietary habits. The database created 

is reported and analyzed in this study. A total of 230 stress fractures 

were reported in 189 athletes (74 males; 115 females) from 57 high 

schools. The tibia (48%) was the most frequently involved bone, 

followed by the metatarsal (19%), fibula (10%), spine (6%), pelvis 

(4%), hindfoot (4%) and femur (4%). Varsity athletes sustained the 

majority of the fractures (53%) within this study. The most common 

sports that caused fractures in males were track (26%), football 

(23%) and cross-country (19%), and in females track (28%) and 

cross country (23%). Male athletes sustained fractures at an older 

age (15.97 yrs vs. 15.46 yrs, P=0.004), higher grade (10.56 vs. 10.14, 

P=0.001), and at a higher body-mass index (BMI) (22.4 vs. 20.8, 

P


Surgical Hip Dislocation for FAI in Athletes Younger 

Than 21 Years of Age 

Michele R D’Apuzzo, MD, Rochester, MN 


Rafael Jose Sierra, MD, Rochester, MN 

We report the treatment of femoroacetabular impingement (FAI) 

through a surgical hip dislocation in athletes younger than 21 years 

of age. Seventeen athletes (19 hips) diagnosed with FAI were treated 

through a surgical dislocation between 2003 and 2007. Eleven males 

and six females composed with an average age of 18 years were 

included. An athlete was defined as a patient who played team or 

individual based sports more than three times a week for more than 

one hour a day. Intraoperative findings were classified according to 

the Beck classification of labral pathology and the Outerbridge grade 

classification of cartilage damage. Time to pain relief and return 

to sports were documented. The average time from surgery was 35 

months (range 15-66 months). The average length of follow up was 

15 months (range 1-35 months). Labral pathology was identified 

in all except two hips. The Outerbridge classification was 0 in four 

hips, 1 in two hips, 2 in eight hips and 3 in five hips, respectively. 

Fourteen hips had severe or constant pain while five had intermittent 

pain preoperatively. Fifteen hips were pain free at last follow up and 

the average time to a pain-free hip was three weeks. There were no 

intraoperative or postoperative complications. Hardware was removed 

in 30%. Some 95% of patients returned to previous athletic activities 

at an average time of 21 weeks. Four of 19 hips had limitations in 

athletic activities secondary to pain. Surgical hip dislocation is a 

safe operative intervention in young patients with FAI. The surgical 

procedure is clearly more invasive than hip arthroscopy but in this 

young patient population with significant hip damage, rehabilitation 

does not seem to defer dramatically with that reported by arthroscopic 

techniques. Return to previous athletic activities is high. 


5-Year Follow-Up of Surgical Hip Dislocation for the 

Treatment of Femoroacetabular Impingement 



Carmen Huemmer, MD 


Femoroacetabular impingement (FAI) leads to hip pain and 

osteoarthrosis. The gold standard of treatment is the surgical hip 

dislocation with labrum reattachment performed since 2001. We 

investigated the five-year outcome of this procedure and calculated 

predective factors for poor outcome. We retrospectively evaluated 97 

hips (75 patients) that underwent surgical dislocation at a mean age 

of 32 ± 8.3 (range, 15-50) years. The average follow up was 6.0 ± 0.6 

(5.0-7.1) years. Preoperatively, the mean Merle d’Aubigné (MDA) 

score was 15.3 ± 1.4 (8-18) and the mean Tönnis osteoarthosis (OA) 

score was 0.22 ± 0.46 (0-2). Failure was defined as conversion to 

a total hip arthroplasty (THA), a MdA score of less than 15 and a 

progression of OA at follow up. The cumulative survivorship at five 

years was 93.8% (95% confidence interval, 89.0-98.6%). At follow 

up, the MDA score was significantly increased to 17.2 ± 1.2 (12-18) 

(p=0.02) and the Tönnis score did not significantly increase to 0.29 

± 0.55 (0-2) (p=0.56). Failures (15 hips, 15%) included seven hips 

(7%) that converted to a THA, seven hips (7%) with progression of 

OA and one hip (1%) with a MDA score of less than 15 at follow up. 

Surgical hip dislocation has the potential to prevent the progression 

of osteoarthrosis and to decrease hip pain in patients with FAI. 

801 


Outcomes Of Arthroscopic Bankart Repair With Suture 

Anchors In Contact Versus Non-Contact Athletes 

Dr Massimo Petrera, Toronto, ON Canada 

Matthew Tsuji, MD, Toronto, ON Canada 

John Theodoropoulos, MD, North York, ON Canada 

Open repair of Bankart lesions has been considered the gold 

standard for the treatment of anterior instability in contact athletes. 

The purpose of this study was to evaluate the outcomes of the 

arthroscopic shoulder stabilization with suture anchors in contact 

versus non-contact athletes. A search in senior author’s database 

was performed; 125 patients were identified, 38 (19 contact athletes 

and 19 non-contact) were evaluated at minimum 24 months follow 

up. All patients underwent arthroscopic labral repair with suture 

anchors. Recurrence rate and functional outcomes according to 

ASES score, WOSI and SF-12 were evaluated. Statistical analysis was 

performed using chi-square and t-student test with 95% confidence 

interval (CI), significance level set at P

(71%) could ambulate and participate in activities. Although 71% 

of patients did not wear an AFO, only 29% of patients did not limp. 

The donor deficits included weak toe flexion (29%) and reduced 

calf circumference (57%). Generally, 57% of patients were satisfied 

and 71% would recommend surgery. Nerve transfers for foot drop 

give inconsistent results. Although 36% of patients achieved M3+ 

recovery, the remaining patients regained minimal motion and 

risked the morbidity of the procedure. 


Clonal Populations of Human Embryonic Stem Cells 

have Increased Potential for Cartilage Repair 

Tsaiwei Olee, PhD 

Nicholas Glembotski, BS 

Hal Sternberg, PhD 

Michael West, PhD 


Human embryonic stem cells (hESC) are an attractive renewable 

resource for cell based regenerative medicine. Unfortunately, during 

culture and expansion, hESC differentiate into heterogeneous cell 

types and are not as chondrogenic as primary human chondrocytes. 

We tested the hypothesis that select clonal progenitor cells have 

greater potential for cartilage repair. A library of over 140 distinct 

clones was generated by differentiating hESC under different 

culture conditions after confirming their homogeneity. Clones were 

ranked by gene expression levels of type II collagen and aggrecan. 

Chondrogenecity in the highest ranking clones was tested by 

staining for glycosaminoglycan and type II collagen in standard 

pellet culture. The potential for repair was assessed by placing 

clonal cell pellets in surgically created cartilage defects in human 

cartilage explants for one month. hESC, primary human articular 

chondrocytes (hAC) and adult adipose derived stem cells (hASC) 

were used for comparison. Gene expression levels and matrix stains 

in selected clonal cell lines were higher than in heterogeneous hESC 

and ASC, and approached levels seen in hAC. In cartilage explants, 

the repair tissue resembled articular cartilage and was well integrated 

with surrounding host tissue. Currently available human embryonic 

cell lines are heterogeneous but can contain distinct subpopulations 

that have variable chondrogenic potential. By using stable and easy 

to expand clonal progenitor cell lines we have improved upon the 

quality of the chondrogenic repair relative to using the heterogeneous 

population. This approach broadens the use of defined embryonic 

cell types for cartilage repair and tissue engineering. 


The Intraosseous and Extraosseous Vascular Anatomy 

of the Fifth Metatarsal 

Kathleen E McKeon, MD, Saint Louis, MO 

Sandra E Klein, MD, Chesterfield, MO 

Jeffrey Einer Johnson, MD, Chesterfield, MO 

Jeremy J McCormick, MD, Chesterfield, MO 

Stress fractures of the fifth metatarsal are often refractory to conservative 

management, in part due to the pattern of intraosseous vascularity. 

Previous articles have described a nutrient artery that penetrates the 

cortex distal to the tuberosity and supplies the diaphysis of the fifth 

metatarsal, but these studies have not described the origin of this 

nutrient artery. The major arteries of the distal limb of seven fresh 

adult human cadavers were injected with India ink and Ward’s blue 

latex. The extraosseous blood supply was examined after chemical 

debridement with sodium hypochlorite. The intraosseous blood 

supply of the fifth metatarsal was elucidated in three specimens with 

802 

a modified Spalteholz technique. As previously described, the fifth 

metatarsal receives multiple branches from both dorsal and plantar 

metatarsal arteries to form a dense periosteal plexus throughout. 

The central portion of the diaphyseal column is supplied by a 

nutrient artery arising from the fourth plantar metatarsal artery 

and penetrating the cortex from the medial surface. These findings 

support the previous descriptions of a nutrient artery which supplies 

the diaphysis of the fifth metatarsal, and determine that it arises 

from the fourth plantar metatarsal artery. The nutrient artery should 

be carefully preserved during surgical approaches to the forefoot. 

This study is ongoing, with 40 additional specimens under review. 

The blood supply to the diaphysis of the fifth metatarsal arises from 

a nutrient artery given off by the fourth plantar metatarsal artery. 


Immediate Strength of Ulnar Fixation in Two Ulnar 

Collateral Ligament Reconstruction Techniques 

Atiba Jackson, MD, W Burlington, IA 

Jason P Dieterle, DO, Stillwater, MN 

Tristan Maerz, BS 


Denise Koueiter 

Christopher Andrecovich, BS, Royal Oak, MI 

Kyle Anderson, MD, Birmingham, MI 

Ulnar collateral ligament (UCL) rupture used to be a career-ending 

injury. To date, numerous techniques have been developed to 

mimic the strength and isometricity of the native ligament to allow 

for the prompt return to activity. The objective of this study was to 

develop an ulnar fixation testing protocol and assess the strength 

and stiffness of the ulnar fixation of two UCL reconstructions. Six 

matched pairs of cadaveric human upper extremities were dissected 

to isolate the site of ulnar fixation utilized during ulnar collateral 

ligament reconstruction. An ulnar fixation testing protocol was 

developed and used to test the ultimate strength of the ulnar fixation 

of six specimens reconstructed using the traditional bone tunnel 

technique and six specimens reconstructed using a cortical button 

and interference screw modality called the tension slide technique. 

The bone tunnel technique showed a statistically significantly higher 

ultimate strength in torsional torque (mean 17.90 N”m, P=0.009) 

and stiffness (mean 27.67 N”m/rad, P=0.002) compared to the 

tension slide technique (strength: mean 8.95 N”m, stiffness: 11.67 

N”m/rad). Statistics were performed using the Mann-Whitney Rank 

Sum Test. The success of a UCL reconstruction depends on several 

factors including immediate strength. The ulnar fixation of the 

bone tunnel technique presents a stronger modality compared to 

the tension slide technique. Higher immediate strength allows for 

the earlier return to activity. Assessing the cyclic loading response 

and/or in vivo healing may further elucidate the efficacy of these 

constructs. 





Patellar Tendon Bone Autograft In Acl Surgery: Do The 

Bone Plugs Heal Within The Tunnels? A Ct Study 



Jacopo Conteduca, MD, ROME, RM Italy 

Andrea Redler, MD 

Luigi Valeo, MD 

Giuseppe Argento, MD 

Fabio Conteduca, MD, Roma, Italy 


Anterior cruciate ligament (ACL)-reconstruction using bone-patellar 

tendon-bone autograft (BPTB) is one of the most common surgical 

techniques. The main advantage of this technique is the reported 

earlier integration of the bone plugs in the bone tunnels. The aim of 

the study is to evaluate the incorporation grade of bone-graft inside 

the tibial bone tunnel. In this prospective study, we evaluated 16 

consecutive patients undergoing ACL reconstruction with BPTB by 

using CT scan images. The radiological evaluation was performed 

10 months postoperatively. Images from each completed scan 

were analyzed for percentage of incorporation of the bone graft by 

a blinded expert radiologist. Results were classified in four stages. 

Grade III: complete incorporation of the bone plug; grade II: >50% 

of incorporation; grade I: 40) treated with arthroscopic suture bridge rotator cuff 

repair following a full-thickness, fully reducible rotator cuff tear were 

imaged using ultrasonography and evaluated by subjective functional 

testing and quantitative strength testing with a dynamometer. To 

date, one-year follow up results show a mean active flexion of 161.6 

degrees, mean active external rotation of 79.6 degrees, mean active 

internal rotation of 54 degrees, and a mean pain score of 0.16 versus 

pre-operative active flexion of 147.5 degrees, active external rotation 

of 65 degrees, active internal rotation of 50 degrees and a pain score 

of 3.75. One-year mean scaption strength is 36.07 N, mean external 

rotation strength is 51.08 N and mean internal rotation strength 

is 72.61 N. None of the patients exhibited a tear at the repair site. 

Results to date indicate an increase in motion, a decrease in pain 

803 

and sound strength following suture bridge rotator cuff repair. By 

creating a strong, anatomic construct, arthroscopic suture bridge 

rotator cuff repair is a clinically successful technique with a low 

incidence of retearing. 


Design and Evaluation of a Novel Fiber-Reinforced 

Synthetic Meniscal Replacement 

Saadiq F El-Amin, III MD, Springfield, IL 

Natalie Kelly, Ithaca, NY 

Julianne Holloway, BS 

Yan Ma, PhD 

Anthony Lowman, PhD 

Giuseppe Palmese, PhD 

Suzanne A Maher, PhD, Manhattan, NY 


Surgical options for the treatment of damaged menisci are limited. 

We have developed a fiber-reinforced synthetic meniscal substitute 

consisting of drawn ultra-high molecular weight polyethylene 

embedded in a polyvinyl-alcohol hydrogel matrix. Our objective 

was to assess the ability of the substitute to distribute loads across 

the knee during gait as a function of fiber content; our goal was 

to match the performance of an allograft. Meniscal substitutes 

were manufactured using resin transfer molding at 10% and 30% 

wt polyethylene; resulting in tensile moduli of 90 MPa and 250 

MPa, respectively. Four human cadaveric knees were subjected to 

physiological gait loads on a knee joint simulator. Medial tibial 

plateau contact pressures were dynamically recorded for: (i) intact, 

(ii) meniscectomized, (iii) meniscus re-implanted to simulate a 

‘pseudo-allograft’, (iv) 10%wt substitute and (v) 30% wt substitute 

implanted knees. The generalized estimating equations method was 

used to compare peak contact pressure magnitude and contact area 

for each condition. Meniscectomy led to significantly higher contact 

pressures compared to all other conditions. Allograft or substitute 

implantation did not restore contact mechanics to that of the intact 

knee. Contact mechanics were not significantly affected by substitute 

fiber content. The contact mechanics of the substitute implanted 

knees, regardless of fiber content, matched that of the pseudoallograft 

implanted knees. All groups evaluted failed to restore 

normal joint contact pressure and area compared to the intact knee. 

The geometry and mode of fixation of the substitutes are now being 

modified so that their contact mechanics more closely mimics that 

of the intact knee. 


uGait Analysis In Anterior Cruciate Ligament Injury 

Using A Novel Device 

Mhd Alsawaf, MD, Taylor, MI 

Cynthia A Bir, Detroit, MI 

David McKeon Prior, MD, Kalamazoo, MI 

Lawrence G Morawa, MD, Dearborn, MI 

Kelli Crawford, PA-C, Dearborn, MI 

Several studies have been performed to evaluate gait in patients with 

anterior cruciate ligament (ACL) injury compared to normal subjects. 

Typically these studies use traditional motion analysis laboratories. 

A novel marker-less, camera-less motion capture has recently been 

validated. This biomechanics assessment system uses an array of 13 

sensors containing accelerometers, gyroscopes and magnetometers. 

Its use in the clinical setting is presented. Test subjects were divided 

into a normal control group (n=10) and ACL-deficient group (n=10). 

ACL injury was confirmed by history, physical examination and 




imaging studies. Objective measurements of sagittal plane motion 

were determined using a knee laxity testing device for both groups. 

Gait analysis was performed during walking (20 feet), step up and 

step down activities. Data was extracted from the sensors to provide 

flexion-extension and percentage of body weight bearing at the 

knee joint. The data reveal an average of 68 + 8.8 degrees of flexionextension 

in the control population during walking with an average 

difference between the right and left knees of 3.1 degrees. Data from 

the patient population demonstrated 69 + 4.3 degrees of flexionextension 

in the unhealthy limb and 75 + 3.1 degrees in the contralateral 

side resulting in an average statistical difference of 6.3 degrees. 

The biomechanics assessment system demonstrated that the step up 

and step down task for the ACL subjects resulted in the healthy leg 

consistently bearing over 100% of the body weight regardless of the 

initiating leg. This novel assessment of biomechanics system can 

provide valuable information in the clinical setting. 


uRepair Of Cartilage Defects With Human 

Mesenchymal Stem Cells And Hydrogel In Rabbits 

Chul Won Ha, MD, Seoul, Republic of Korea 

Choong-Hee Lee, MD 

Sang-Eun Nha, MD 

This study investigated the cartilage regeneration effects of human 

umbilical cord blood derived mesenchymal stem cells (hUCB- 

MSCs) plus sodium hyaluronate using an articular cartilage defect 

model in rabbits. Full-thickness chondral defects, 3 mm wide × 3 

mm deep, were created in the trochlear groove of the right femur 

in 53 healthy New Zealand White (NZW) rabbits. The control 

group had only a chondral defect in the trochlear groove and four 

study groups administered directly into the defect (0.2 ml/cm2). 

The MSCs concentration ranged between 0.1 and 1.5 x 107 cells/ 

mL were applied. At four, eight and 16 weeks after surgery, cartilage 

repair was evaluated macroscopically and histologically using a 

semiquantitative grading scale. The mean scores of the gross and 

histological evaluation grade in the experimental groups were 

significantly superior to those in the control group at eight and 16 

weeks (P


Hip Arthroscopy for Legg-Calve-Perthes Disease: 

Minimum Two-Year Follow-up 

Carl R Freeman, MD, Erie, PA 

Kay S Jones, RN, Nashville, TN 

J W Thomas Byrd, MD, Nashville, TN 

Legg-Calve-Perthes disease is a common childhood disorder that 

leads to painful sequelae in adulthood with few options other 

than arthroplasty. The purpose of this study is to report the results 

of arthroscopy in this population. All patients undergoing hip 

arthroscopy are prospectively assessed with a modified Harris hip 

score at three, six, 12, 24, 60, 120 and 180 months. A cohort of 

20 consecutive patients (21 hips) were identified with Legg-Calve- 

Perthes disease that had undergone arthroscopy with at least twoyear 

follow up and represent the substance of this report. There was 

100% follow up at an average of 56 months (range 24-180 months). 

The average age was 26 years (range 7-58) with 13 males and seven 

females. Findings during arthroscopy included 16 labral tears, 15 

hypertrophic or torn ligamentum teres, seven femoral and six 

acetabular chondral lesions, five loose bodies, three osteochondral 

defects and one cam lesion. The average improvement was 25.3 points 

(preop 56.7; postop 82). All patients were improved, although this 

improvement was negligible in two patients who underwent repeat 

arthroscopy. There were no complications. This is the largest reported 

series of arthroscopy for Legg-Calve-Perthes disease and reflects that 

it does have a role in the management of painful sequelae. Successful 

outcomes can often be expected with minimal morbidity. Reduced 

symptoms and improved quality of life are reasonable expectations, 

although this data does not suggest that it alters the natural history 

of the disease process. 


Biomechanical Comparison of Secondary Tibial 

Fixation in Anterior Cruciate Ligament Reconstruction 

James Patrick Leonard, MD, Skokie, IL 

Alex Romero, MD, Santa Monica, CA 

Mark R Hutchinson, MD, Chicago, IL 

Farid Amirouche, MD, Chicago, IL 

Tibial fixation remains the weak link in anterior cruciate ligament 

(ACL) reconstruction. Our study evaluates suture anchors compared 

to suture post screws as means of secondary fixation, providing a 

‘back-up’ point should the primary means of fixation fail. Ten 

cadaveric tibias were randomly assigned into two groups: either 

secondary fixation with a suture anchor device or suture post 

screw. Each group utilized a cadaveric hamstring tendon graft with 

interference screw fixation to the tibia. A testing machine was used 

to quantify the amount of force to failure of the tibial fixation. The 

suture post screw group failed at significantly higher force of 563.0N 

compared with 263.8N for the suture anchor group (p

lesion, length of follow-up and associated surgeries on the result was 

found. No differences were found between the results obtained with 

different surgeries except a slight tendency of better improvement in 

the result following autologous chondrocyte implantation (p

a minimum two year follow-up. This systematic review will outline 

the results in the current literature on graft failure rate, activity level 

and functional assessment, as well as posterior knee laxity. 


Treatment of Posteromedial Corner Injuries: Indications 

and Complete Review of Results 


Davide E Bonasia, MD, Torino, Italy 

Matteo Bruzzone, MD, Torino, Italy 

Federico Dettoni, MD, Torino, Italy 

Antongiulio Marmotti, MD, Torino, Italy 



There are different surgical techniques for treating posteromedial 

corner knee injuries. We have reviewed the literature on the anatomy 

of the poster medial peripheral ligamentous structures of the knee 

and their surgical techniques and results. This exhibit will present 

a complete review of posteromedial corner reconstruction and 

repair techniques and their outcomes. We evaluated both repair and 

reconstruction techniques to certify the outcomes. Detailed technical 

steps will be presented in an interactive format for the most commonly 

encountered scenarios. The objective of this scientific exhibit is to 

present a review of current posteromedial corner reconstruction and 

repair techniques and provide a thorough review of their published 

outcomes. With the information presented, participants will be able 

to critically assess their own surgical technique, in order to improve 

the care of their own patients. The information would serve as the 

basis for future biomechanical studies to investigate the contribution 

of the posteromedial structures to joint stability. 


Peripheral Nerve Blocks in the Perioperative Pain 

Management of Orthopaedic Patients 


Umasuthan Srikumaran, MD, Braintree, MA 

John H Wilckens, MD, Annapolis, MD 

Michael T Freehill, MD, Palo Alto, CA 

The increasing use of peripheral nerve blocks (PNBs) in orthopaedic 

surgery has paralleled the rise of procedures performed in the 

ambulatory surgery setting. PNBs are now commonly used to 

provide effective perioperative pain management. An understanding 

of the indications, risks, and patient benefits associated with PNBs 

is important for the practicing orthopaedic surgeon. The purpose 

of this exhibit is to provide a concise and pertinent review of the 

use of peripheral nerve blocks (PNBs) in various orthopaedic 

procedures with specific focus on indications, complications, and 

patient outcome measures. A review of the literature and reference 

textbooks on commonly performed PNB procedures in orthopaedic 

surgery. The authors focused on the most commonly used PNBs 

in both upper and lower extremity surgery. The use of PNBs in 

orthopaedic surgery is fast becoming a mainstay of perioperative 

pain management strategy. The goal of this exhibit is to advance the 

orthopaedic surgeons working knowledge of these procedures in 

order to facilitate the decision making process regarding their use. 

807 


The Meniscal Tear in the Varus Knee: A 

Multidisciplinary Approach 

Michael B Cross, MD, New York, NY 


Denis Nam, MD, New York, NY 

Christopher John Dy, MD, New York, NY 

Anil Ranawat, MD, New York, NY 

Andrew D Pearle, MD, Rye, NY 

Keith R Reinhardt, MD, New York, NY 


A meniscal tear is a common clinical problem encountered by 

orthopaedic surgeons. However, the diagnosis and appropriate 

management of a meniscal tear in a patient with varus alignment 

is complex, and often under appreciated. We will first describe the 

common etiologies for meniscal tears, and present the likelihood of 

progression and incidence based the etiology. We will then describe 

the classification of the varus knee (i.e. single, double, triple varus), 

and the anatomic structures injured with each. Meniscal tears can 

occur in isolation but often present with a myriad of other articular 

derangements such as chondral defects, knee degeneration, bone 

attrition, tibial subluxation, and insufficiency of the ACL or PCL. 

Understanding the contribution of meniscal pathology to pain and 

dysfunction in the setting of concomitant internal derangement is 

challenging and will be presented algorithmically. The diagnostic 

workup in a patient with a varus knee and meniscal tear, including 

radiographs, standing alignment xrays, MRI, bone scan and gait 

analysis, will be clearly presented. The management of meniscal 

tears in the varus knee requires a multidisciplinary approach, and 

is dependent on multiple factors including the patient’s age. We 

will provide an evidence based algorithm of management options 

depending on the clinical situation. Treatment options include 

NSAIDs, bracing, orthotics, injections, meniscal repair, partial 

meniscectomy, meniscal transplant, cartilage resurfacing, osteotomy, 

unicompartmental knee arthroplasty, and total knee arthroplasty. We 

will provide orthopaedic surgeons a simplified algorithm, based on 

results in the literature, for appropriately managing meniscal tears in 

patients with varus alignment. 


Ulnar Collateral Ligament Reconstruction in Throwing 

Athletes: A Review of Current Concepts 

Kristofer Jones, MD, New York, NY 

Daryl C Osbahr, MD, Birmingham, AL 

Mark Schrumpf, MD, New York, NY 

Joshua Dines, MD, Great Neck, NY 

David W Altchek, MD, New York, NY 

Repetitive overloading from throwing can cause ulnar collateral 

ligament (UCL) insufficiency resulting in disabling elbow pain. 

Until Jobe described a novel technique to reconstruct the UCL, these 

injuries were, in many cases, career-ending. Since that time, various 

modifications to the surgical technique have resulted in return to 

play in up to 90% of throwing athletes. Despite the reported clinical 

success with UCL reconstruction, postoperative complications have 

been shown in up to 10% of patients, and subgroups exist with less 

impressive outcomes, including high school athletes, patients with 

a history of prior elbow surgery and concomitant flexor-pronator 

injuries. The intent of this exhibit is to: 1) Review relevant elbow 

anatomy, biomechanics and pathophysiology 2) Evaluate preoperative 

prognostic factors influencing outcome 3) Discuss surgical 

techniques with supplemental video, intra-operative photographs, 




and diagrammatic visual aids 4) Present clinical outcomes based 

on patient and technique specific factors 5) Outline complications 

relating to operative and post-operative variables 6) Describe a novel 

athlete-specific treatment algorithm. UCL reconstruction typically 

results in successful return to sport; yet several questions still exist 

relating to optimal surgical technique, potential co-morbidities, 

athlete-specific treatment factors, and longevity of return to play. 

This exhibit will provide important data to assist surgeons managing 

throwing athletes with UCL pathology through patient counseling, 

surgical technique considerations, athlete-specific treatment 

algorithms, and future research considerations to further improve 

outcomes. 


Allograft Salvage Procedure in Multiple ACL Revision 

Surgery 

Roberto Buda, Bologna, Italy 

Francesco DiCaprio, Bologna, Italy 

Alberto Ruffilli, MD, Bologna, Italy 

Alberto Ferruzzi, MD, Bologna, Italy 


Sandro Giannini, MD, Bologna, Italy 

Multiple ACL revisions represent an extremely demanding surgery, 

due to the presence of enlarged or malpositioned tunnels, hardware, 

injuries to the secondary stabilizers and difficulties in retrieving 

autologous tendons. An anatomical ACL reconstruction is not always 

possible. We analyzed the results in a series of patients operated 

with over the top reconstruction (OTTR) and lateral extra-articular 

plasty to the Gerdys tubercle (LP) using Achilles (AT) or tibialis 

posterior tendon (TPT) allografts. From 2002 to 2008, twentyfour 

male athletes with a mean age of 30.8 years were operated. 

20 of the patients had two, while four patients had three previous 

reconstructions. IKDC score and KT evaluation were used at a mean 

3.3 years follow-up (27 years). The mean IKDC subjective score at 

follow-up was 81.3. The IKDC objective score rated A or B in 84% 

of the patients. Of the 20 good results, 17 patients resumed sport 

activity at the pre-injury level. KT side-to-side difference averaged 

3.5 mm in the TPT, versus 3.2 mm in the AT group. No significant 

differences were noted between the AT and TPT group. Multiple ACL 

revision surgery is a salvage procedure, with average good results, 

but not equivalent to primary ACL reconstruction. Patients should 

be advised that a return to sports may not be feasible. OTTR+LP is an 

established technique that permits to overcome difficult anatomical 

situations, with cortical fixation providing good immediate stability 

and avoiding tunnel fixation and bone grafting. Long tendon grafts 

as AT and TPT are needed. 


Complications in Medial Patellofemoral Ligament 

(MPFL) Reconstruction 

Miho Jean Tanaka, MD, Baltimore, MD 

Andrew J Cosgarea, MD, Lutherville, MD 


Jack T Andrish, MD, Cleveland, OH 

John P Fulkerson, MD, Farmington, CT 

The role of medial patellofemoral ligament (MPFL) reconstruction 

in reestablishing the stability of the patellofemoral joint has been 

increasingly reported in recent years. While the long term outcomes 

of these new procedures are still unavailable, in this scientific 

exhibit, we review the literature and highlight the common technical 

errors and the potential complications that result from MPFL 

808 

reconstructions. The purpose of this exhibit is to review the multiple 

factors that are crucial for successful MPFL reconstruction, including 

patient selection, technique, tunnel placement, graft isometry and 

determining the need for concurrent realignment procedures. The 

reported causes of failure in the literature will be reviewed, as will 

the biomechanical rationale that should be used in guiding surgical 

management. The principles of surgical management include a 

thorough understanding of proper patient selection, as well as the 

interaction between the roles of the bony and soft tissue restraints 

of the patella. Tunnel positioning is extremely crucial in recreating 

the appropriate patellofemoral alignment. Creating a logical 

treatment algorithm based on pathoantomy can elucidate the 

need for concurrent distal realignment surgeries. These guidelines 

can help avoid the majority of reported complications, including 

patellofemoral arthrosis, graft impingement, and graft failure. 

Patellar fractures, overtightening and recurrence have been reported 

as well. MPFL reconstructions are becoming more popular in the 

armamentarium of the sports surgeon. This exhibit emphasizes the 

potential pitfalls, alternatives and complications in this increasingly 

popular procedure. 


Allograft in Sports Medicine: Growing Applications, 

Surgical Indications and Clinical Outcomes 

Alexander Weber, MD, Ann Arbor, MI 



Allograft tissue is used for a growing number of applications in the 

treatment of ligament, tendon, meniscus and cartilage injuries not 

only in the knee but increasingly in the shoulder, elbow, hip and 

ankle. The purpose of this exhibit is to provide a comprehensive 

review of traditional applications of allograft tissue as well as to 

introduce innovative applications within sports medicine. The first 

objective will include a literature review discussing the indications 

and clinical outcome data for common applications of allograft 

tissue including ACL reconstruction, cartilage repair and meniscal 

transplantation. The emphasis of this section will be on patient 

selection and allograft clinical performance compared to alternative 

treatment options. The discussion of the second objective, innovative 

applications of allograft tissue, will focus on patient selection, surgical 

technique and clinical outcome data when available. In addition, 

we will also review our institutional experiences with novel allograft 

options for various tendon and ligament repairs/reconstructions, 

shoulder instability and the treatment of Hill-Sachs defects. As 

an educational example this section will contain a case report in 

which the senior author performed bilateral shoulder stabilizations 

augmented with Achilles allograft. As the use of allograft tissue in 

sports medicine becomes increasingly prevalent this exhibit will 

provide timely data on current indications and clinical outcomes for 

commonly used allograft tissue. Furthermore, by presenting some of 

the more novel applications we intend to provide educational value 

to the membership as they make decisions regarding allograft tissue 

usage in their clinical practice. 





Practical Guide to Anatomic Single- and Double- 

Bundle Anterior Cruciate Ligament Reconstruction 

Carola F Van Eck, MD, Pittsburgh, PA 

Bryson Lesniak, MD, Miami, FL 

Verena M Schreiber, MD, Pittsburgh, PA 

C Niek Van Dijk, MD, Abcoude, Netherlands 

Freddie H Fu, MD, Pittsburgh, PA 

Anatomy is the foundation of orthopedic surgery and the advancing 

knowledge of the anterior cruciate ligament (ACL) anatomy has led 

to the development of improved modern reconstruction techniques 

that approach the anatomy of the native ACL. We aimed to develop 

a guidline to anatomic ACL reconstruction. Current literature 

on the anatomy of the ACL and its reconstruction techniques, as 

well as surgical experience was used to develop an extended and 

detailed guideline to perform anatomic ACL reconstruction. A 

video demonstration following a flowchart pattern was created. 

This audiovisual material educates the surgeon on the anatomic 

ACL reconstruction technique. Principles, pearls, pitfalls and 

relevant literature of this complex surgery are discussed in a concise, 

interactive fashion. Multiple surgical options including singlebundle 

and double-bundle reconstruction are being discussed using 

high quality pictures and videos. While there is still much to learn 

about anatomic ACL reconstruction methods, we believe this is a 

helpful exhibit for surgeons. We continue to modify the guideline as 

more information about the anatomy of the ACL, and how to more 

closely reproduce it becomes available. 


Platelet Rich Plasma: Applications in Sports Medicine 


Alexander Weber, MD, Ann Arbor, MI 


Platelet rich plasma (PRP) is an autologous blood product that 

can be injected locally to treat musculoskeletal injuries. Since its 

introduction to the orthopaedic community it has enjoyed increasing 

popularity. However, clinical data is limited and clear indications 

for sports medicine purposes are yet to be defined. This exhibit will 

introduce the reader to PRP, its preparation, the rationale behind 

its use, contemporary results, and its potential clinical applicability 

in sports medicine. We will review the historical antecedents to 

PRP that led to its development, the biologic underpinnings of the 

therapy, and current and historical data so as to assist the reader 

into better understanding the rationale for PRP use and its effects. 

Current sports medicine applications for PRP will be reviewed, 

including tendinopathy, acute tendon and ligament injuries, muscle 

injuries, and surgical repair augmentation (i.e. rotator cuff repair 

augmentation, meniscus repair augmentation). The exhibit will 

utilize images of PRP being prepared as well as images of repairs 

augmented with PRP. We will review the current level of evidence 

for PRP use in various joints/tissues and present the results to the 

reader in the form of diagrams and tables. Expert recommendations 

for PRP use will be presented as well. Platelet-rich plasma (PRP) 

is being increasingly used to treat musculoskeletal injuries despite 

limited evidence and clear indications. This exhibit will introduce 

the reader to the most up-to-date science behind PRP in order to 

allow for educated decisions regarding its use. 

809 




PAPERS 

pApeR No. 136 

uRecombinant Human Bone Morphogenetic Protein-2 

(rhBMP-2) and Its Effect on Murine Sciatic Nerve 

David Stephen Margolis, MD, Tucson, AZ 

Eileen Wan-Ying Wu, MD, Richmond, VA 

Lisa Marie Truchan, MD, Tucson, AZ 

With the proven efficacy of bone morphogenetic protein (BMP) 

to treat open tibia fractures and promote spine fusion, there has 

been an increase in its off-label use. Recent studies have shown that 

BMPs play a role in nerve development and regeneration. Little is 

known about changes that result when BMP is used in the vicinity of 

peripheral nerves. The purpose of this study is to characterize changes 

that occur in peripheral nerves following exposure to recombinant 

human bone morphogenetic protein-2 (rhBMP-2). rhBMP-2 on an 

absorbable collagen sponge carrier was implanted directly on the 

sciatic nerves of male adult Wistar rats. The contralateral control 

nerve was surgically exposed, but no BMP was implanted. One 

and three weeks following surgery the nerves were harvested and 

stained using hematolyxin and eosin, Sevier-Munger and toluidine 

blue. Qualitative histological analysis was performed to evaluate 

inflammatory and structural changes. BMP induced ectopic bone 

formation in muscle tissue in all animals after three weeks, but did 

not cause bone formation within the nerve. Axonal swelling and 

splitting of the myelin sheath were observed in experimental and 

control nerves in 70% of the mice at one week. Axonal swelling was 

still present at three weeks, but only one animal showed splitting 

of the myelin sheath at three weeks. Axonal dropout was observed 

in three of the 20 nerves (15%) treated with BMP, with one nerve 

showing axonal dropout at one week, and two nerves demonstrating 

axonal dropout at three weeks. rhBMP-2 may adversely affect the 

axons of peripheral nerves by causing axonal dropout. Axonal 

swelling and splitting of the myelin sheath may be a result of surgical 

manipulation as this was observed in control and experimental 

nerves. The ectopic bone formed by placement of BMP is located 

in muscle tissues and does not form within the peripheral nerve. 

Although there was ectopic bone present in all animals by three 

weeks, axonal dropout may be a direct effect of rhBMP-2, as it was 

observed prior to ectopic bone formation. 

pApeR No. 137 

uBone Healing Of rhBMP-7 Is Enhanced By 

Combination With BMP Binding Peptide In A Femur 

Defect Model 

Jen-Chung Liao, MD, Kweishian, Taoyuan, Taiwan 

Shiau-Tzu Tzeng, MD, Taipei, Taiwan 

Kwang-Bok Lee, MD, Jeonju, Chonbuk, Republic of Korea 

Gun Keorochana, MD, Bangkok, Thailand 



RhBMP-7 is available commercially and approved by the United 

States Food and Drug Administration (FDA) for clinical use in 

human long bone defects. However, a large dose of rhBMP-7 (3.5 

mg) is required to overcome a long bone nonunion, which means 

the cost is still very high in clinical use. Furthermore, local adverse 

810 

trauMa 

effect such as unwanted ectopic bone formation has been reported. 

BMP binding peptide (BBP) can be extracted from bone matrix 

protein. We tested our hypothesis that BBP can enhance bone healing 

of rhBMP-7 and that BBP can reduce doage of rhBMP-7 required to 

achieve a successful union. We employed a rat femoral defect model 

to test the effect of BBP on rhBMP-7 induced bone healing. Two 

doses of BBP (500 ug and 100 ug) were tested with various amounts 

of rhBMP-7 (2 ug and 5 ug) and the results were compared with the 

positive control group (10 ug rhBMP-7). Bone healing was evaluated 

by radiology, manual palpation, microcomputed tomography and 

histology. A 10 ug rhBMP-7 acquired a consistent 100% bone union 

rate and a matured bone marrow formation in histology. When 1,000 

ug BBP is combined with 2 ug rhBMP-7 or 5 ug rhBMP-7, significant 

differences are seen in radiographic scores, manual palpation and 

bone volume when compared to 2 ug rhBMP-7 or 5 ug rhBMP-7 

alone. The combination administration of 1,000 ug BBP and 5 ug 

rhBMP-7 also achieved 100% fusion rate, induced a larger amount of 

bone formation and yielded similar maturity of bone marrow when 

compared with 10 ug rhBMP-7 group. BBP is an 18.5 kD fragment 

of the bone matrix peptide. This peptide contains a cystatin-like 

domain which has an affinity to TGF-B and BMPs because its cystatin 

domain contains a region similar to the TGF-B receptor II homology 

1 domain. This study demonstrated that BBP can enhance the bone 

healing of rhBMP-7. Improved containment of the graft material 

imparted by the addition of BBP may result in lesser amounts of 

rhBMP-7 needed to achieve union in the clinical setting. 

pApeR No. 138 

Bone Morphogenetic Proteins: Comparison of 

Osteogenic, Angiogenic, and Migratory Potentials 

Jessica Dale Cross, MD, Fort Sam Houston, TX 

Christopher Rathbone, PhD 

Joseph C Wenke, PhD, San Antonio, TX 

Bone morphogenetic proteins (BMP) other than those clinically 

available may be osteogenic or important for other processes in fracture 

healing. The purpose of this study is to evaluate six different BMPs’ 

effects on proliferation, osteogenesis, angiogenesis and migration 

in vitro. Adipose derived stem cells, C2C12 mouse myoblasts and 

C3H10T1/2 cells were cultured with recombinant human BMPs 2, 4, 

5, 6, 7 or 9 at five doses between 10 ng/ml and 500 ng/ml. Cells were 

lysed at day 3 and day 7 for alkaline phosphatase assay. Human bone 

marrow-derived stem cells were cultured with the BMPs and the cell 

culture supernatants were collected. We assayed vascular endothelial 

growth factor (VEGF) to test for angiogenesis, stromal derived 

growth factor-1 (SDF-1) for migration, basic fibroblast growth factor 

(b-FGF)for early osteogenesis and osteocalcin for late osteogenesis. 

BMP9 resulted in the highest alkaline phosphatase levels in C2C12 

cells and adipose stem cells at mid and high range doses. BMP6 was 

effective at the highest dose. BMP4 up regulated VEGF expression. 

BMP5 increased SDF-1 expression. BMP2 increased b-FGF expression, 

while the other BMPs down regulated it. BMP4 and 9 resulted in 

high osteocalcin expression, while BMP2 did not affect this late 

osteogenic marker. There was no difference in proliferation. BMP9 

and 6 were the most osteogenic. BMP4 is important for angiogenesis 

and BMP5 is important for promoting migration. BMP2 is important 

early in osteogenesis while the other BMPs tested may be a negative 

regulator of early osteogenic differentiation. 



PaPers, Posters & scientific exhibits tRAumA

pApeR No. 139 

Sorted Mesenchymal Stem Cells and Platelet Rich 

Plasma Augmentation for Distal Tibial Fractures 

Meir Liebergall, MD, Jerusalem, Israel 

Zulma Gazit, PhD 

Joshua Schroeder, MD 

Yoram Zilberman, PhD 

Shaul Beyth, MD, Jerusalem, Israel 

Amal Khoury, MD, Jerusalem, Israel 

Yoram A Weil, Jerusalem, Israel 

Anat Daskal, MSc, Jerusalem, Israel 

Rami Mosheiff, MD, Jerusalem, Israel 

Distal tibia fractures have a high rate of nonunion. A protocol for 

the use of rapidly isolated mesenchymal stem cells (MSC) has been 

developed that may expedite fracture healing. The purpose of this 

study was to evaluate the safety and efficacy of early minimally 

invasive intervention in the treatment of these fractures. A total of 24 

consecutive patients underwent surgery for extra-articular distal tibia 

fractures. After surgery, an informed consent was signed and patients 

were randomized for routine follow up or early intervention. No 

differences were found between the two groups at baseline. In the 

intervention group, about one month after fixation, 50 ml of bone 

marrow from the iliac crest and 100 ml of blood were collected. MSCs 

were positively selected with magnetic CD105+ antibodies, using 

the CliniMACS. Blood was centrifuged for platelet reach plasma 

(PRP). Mix of MSC, PRP and demineralized bone matrix (DBM) was 

injected into the fracture site. Fracture healing was concluded based 

on clinical and radiographic parameters. Samples of the composite 

graft were also implanted subcutaneously in immunodeficient 

mice as a biological control. No complications occurred during the 

secondary intervention. Average time to union was 71 days in the 

intervention group and 130 days in the control group (P

fractures demonstrated significantly higher torsional stiffness versus 

controls (EPC=30.3±5.0 Nmm/deg, Control=0.9±0.1 Nmm/deg; p 

value = 0.000). When biomechanically compared to contralateral 

intact limbs, the EPC treated limbs had similar torsional stiffness 

(p=0.996), but significantly lower torsional strength (p=0.000) and 

smaller angle of twist (p=0.002). These results suggest that local EPC 

therapy significantly enhances fracture healing in an animal model. 

The biomechanical results show that control animals develop a 

mechanically unstable non-union. In contrast, EPC therapy results 

in fracture healing that restores the biomechanical properties of the 

fractured bone closer to that of the intact bone. 

pApeR No. 142 

uEffect Of Teriparatide On Bone Regenerate After 

Distraction Osteogenesis 

Masood Umer, MD, Karachi, SINDH Pakistan 

Tashfeen Ahmad, MD, Karachi, Pakistan 

Sadia Habib, MSc 

Rasham Rehman, MSc 

The parathormone analogue teriparatide (PTH 1-34) has been 

used clinically to increase bone mass and reduce fracture risk in 

osteoporosis; there is increasing evidence that it may promote 

fracture healing. Our objective was to determine the effect of 

teriparatide on new bone formation in a rat model of distraction 

osteogenesis. Twelve male Sprague-Dawley rats (weight ~250 gm) 

were allocated to two treatment groups, teriparatide and saline, both 

given subcutaneously for three weeks. Femoral distraction was done 

at a rate of 0.4 mm/day for three weeks, followed by a further four 

weeks for consolidation. New bone formation was assessed using 

X-ray, DEXA and histology. Xray: In the control group there was no 

new bone formation in two of the six rats, while in the teriparatide 

group all rats showed new bone formation. Scoring according to 

modified Lane and Sandhu system confirmed higher score in the 

teriparatide group. DEXA: The area (size) of new bone formed 

adjacent to the margins of the osteotomy site as well as the total 

bone mineral content of that new bone was significantly higher 

(p

in the adult patient exposed to blunt trauma can suffer fissuring 

of the articular cartilage with progressive breakdown of the joint 

surface leading to irreversible arthritis. We have mimicked trauma 

to articular cartilage in a porcine experimental model to contrast 

the biochemical effects in adult and juvenile specimens in the hope 

that techniques may be developed to potentiate cartilage healing. 

Twenty-four samples of adult and juvenile porcine cartilage were 

exposed to trauma or were kept as controls. Following a period 

of incubation, Type II Collagen and Sox9 mRNA expression were 

measured using real time RT-PCR and Western blot. Juvenile articular 

cartilage synthesises large amounts of Type II Collagen mRNA and 

protein compared to adult cartilage. Following trauma, synthesis of 

Type II Collagen and Sox 9 increased in juvenile cartilage, but not in 

adult cartilage. The stability of mRNA also improved. Human adult 

cartilage has poor healing potential following trauma. Isolation of 

the factors in juvenile cartilage which potentiate Sox9 and Type II 

Collagen production may permit techniques to be adapted for the 

minimally invasive stimulation of cartilage healing in adult human 

patients. 

pApeR No. 146 

The Mitochondrial Contribution to Chondrocyte 

Apoptosis Following Mechanical Injury 

Eric A Eisner, MD, La Jolla, CA 

Joseph Borrelli, Jr MD, Dallas, TX 

Richard Hotchkiss, MD, Saint Louis, MO 

Chris Davis, BS 

Scott McClure, BS 

John Shelton, BS, Dallas, TX 

The mechanism by which chondrocytes undergo apoptosis in response 

to mechanical injury is unclear. This study sought to elucidate the 

role that the mitochondria (intrinsic pathway) play in chondrocyte 

apoptosis following mechanical injury. Using a previously validated 

xiphoid process injury model, the xiphoid process of eight week 

old wild type B6 mice (n=12) and Bim/Bid double knockout mice 

(n=13) were injured. Three well-described, independent means of 

assessing apoptosis (H&E, TUNEL, activated caspase-3) were used to 

analyze all cartilage specimens at 48 hours post-operatively. Detailed 

analysis of the injured B6 mice specimens demonstrated numerous 

chondrocytes undergoing apoptosis, while the injured knockout mice 

specimens contained considerably fewer apoptotic chondrocytes. 

H&E stained injured B6 specimens contained numerous cells with 

classic morphologic features of apoptosis. In contrast, the knockout 

mice specimens contained few cells with these characteristics. 

TUNEL was used to quantify the amount of chondrocyte apoptosis 

in each of the specimens. The B6 uninjured specimens were found to 

have 2.4% apoptotic cells, while the injured specimens had 13.7% 

apoptotic cells. The uninjured knockout mice specimens were found 

to have 1.7% apoptotic cells, while the injured knockout specimens 

had 6.3% apoptotic cells. The activated caspase-3 analysis confirmed 

that the majority of dying cells were indeed undergoing apoptosis, as 

evidenced by activation of caspase-3. Overall, the injured knockout 

mice specimens had a statistically significant 54% decrease (p=0.027) 

in chondrocyte apoptosis compared to injured B6 specimens. There 

was no statistically significant difference in apoptosis rate between 

the uninjured B6 and knockout specimens. Reduction of the 

mitochondrial contribution to apoptosis by elimination of Bim and 

Bid activity significantly reduced apoptosis at 48 hours post-injury. 

Based upon these findings, it appears that the intrinsic pathway 

is the primary mechanism for chondrocyte apoptosis following 

mechanical injury. 

813 

pApeR No. 147 

Cell Death Following Blunt Trauma In An Experimental 

Model Of Intra-Articular Fracture 

Justin K Greisberg, MD, New York, NY 


Geoffrey Konopka, MPH 

Thomas R Gardner, MCE, New York, NY 

Sean Kelly 

Post-traumatic arthritis remains a problem after high energy intraarticular 

fractures. Previous studies have identified chondrocyte 

death in humans and animal models following blunt trauma. 

None of the described animal models combine fracture shearing 

with rapid compression that is part of a high energy articular injury 

in humans. In this study, we describe the first true in vivo animal 

articular fracture model and propose that cell death will increase 

over time following fracture, and that caspase activity will increase 

as well. A drop tower applied rapid compression to the patellae of 

mature rats to create an intra-articular distal femur fracture. Animals 

were sacrificed at one hour, 24 hours and 72 hours after injury. 

A live-dead assay was performed with confocal microscopy. The 

prevalence of apoptosis was assessed with TUNEL assay and caspase 

immunofluorescent staining. Consistent distal femur fractures were 

created in the animals. Live-dead and TUNEL assays found cell death 

increased over time, and was most prevalent adjacent to the fracture 

and in more superficial levels of cartilage. The prevalence of activated 

caspase increased over time as well. Both impact and shearing forces 

appear to increase cell death. The increase in caspase activity and 

TUNEL staining suggests programmed cell death (apoptosis) may 

play a role in chondrocyte loss following trauma. Future research will 

better characterize the role of apoptosis; if cell death following blunt 

trauma is preventable, then treatments can be devised to block cell 

death and work toward the prevention of post-traumatic arthritis. 

pApeR No. 148 

Release Of Growth Factors In PRP Activated With 

Thrombin 

Joaquin Carrasco, PhD, Valencia, Spain 

Daniel Lluch Bonete, MD, Valencia, Spain 

Francisco Gomar, MD, Valencia, Spain 

The development of platelet-rich plasma (PRP) has generated great 

expectations in bone surgery. PRP is designed to release growth factors 

from autologous manner. We extracted from sheep peripheral blood 

in tubes of 4 ml with 0.32 ml of CDA (Citra). We prepared PRP 

in 1800, 2000 and 2200 rpm for 10’, and a second centrifugation 

at 3500 rpm for 8’ to concentrate platelets. The samples were used 

for platelet count, and for activation with 1000 units of thrombin 

(Sigma) and 10% CaCl2 per ml. Aliquots were taken from the gel 

on the 10’, 60’ and 180’ after activation and frozen at - 70 C, for 

determination of PDGF and TGF b1 by ELISA (R & D system). We 

determined the release of platelet-derived growth factor (PDGF) and 

transforming growth factor b1 (TGF) in time. After activation, PDGF 

increases of up to 1.7 times, and TGF b1 increases eight times. PDGF 

was released 93.88% in 10’. TGF b1 was released only 65% in 10 ‘. A 

linear relationship between platelets/ growth factors released were 

obtained (r2 = 0.885). The PDGF is released mainly in 10 minutes. 

The release of TGF b1 is slower and continuing the first three hours 

after application. 




pApeR No. 149 

Expression Of VEGF Gene Isoforms In A Rat Segmental 

Bone Defect Model Treated With EPCs 


Ru Li, MD, Toronto, ON Canada 

Erion Qamirani, MD, Toronto, ON Canada 

Kivanc Israel Atesok, MD, Toronto, ON Canada 

Xiaomei Wang, PhD 

Angiogenesis and osteogenesis are essential for bone growth, 

fracture repair and bone remodeling. Vascular endothelial growth 

factor (VEGF) has an important role in bone repair by promoting 

angiogenesis and osteogenesis. In our previous study, endothelial 

progenitor cells (EPCs) promoted bone healing in a rat segmental 

bone defect as confirmed by radiological, histological and microCT 

evaluations; EPC treatment of fractures resulted in a significantly 

higher strength by biomechanical examination. In addition, cellbased 

VEGF gene transfer has been effective in the treatment of 

segmental bone defects in a rabbit model. Purpose of this study: 

Evaluation of VEGF gene expression after EPC local therapy for a rat 

segmental bone defect. Rat bone marrow-derived EPCs were isolated 

from the rat bone marrow by the Ficoll-paque gradient centrifuge 

technique. The EPCs were cultured for seven to 10 days in endothelial 

cell growth medium with supplements (EGM-2-MV-SingleQuots, 

Clonetics) and collected for treatment of the rat segmental bone 

defect. EPCs were identified by immunocytochemistry staining with 

primary antibodies for CD34, CD133, FLK-1 and vWF. A total of 

56 rats were studied. A 5 mm segmental bone defect was created in 

the middle one third of each femur followed by mini plate fixation. 

The treatment group received 1x106 EPCs locally at the bone defect 

and control animals received saline only. Seven control and seven 

EPC treated rats were included in each group at one, two, three 

and 10 weeks. Animals were sacrificed at the end of the treatment 

period, and specimens from the fracture gap area were collected 

and immediately frozen. Rat VEGF mRNA was measured by reverse 

transcriptase-polymerase chain reaction (RT-PCR) and quantified. 

All measurements were performed in triplicate. Cultured EPCs at 

one week showed positive staining for CD34, CD133, Flk-1 and 

vWf markers. The EPC group had a greater VEGF expression than the 

control group at week one, two and three but not at week 10. Three 

VEGF isoforms were detected in this rat model: VEGF120, VEGF164 

and VEGF188. VEGF120 and VEGF164 levels peaked at two weeks, 

while VEGF188 levels peaked at three weeks. All three VEGF isoform 

levels were low at 10 weeks. EPC-based therapy for a segmental bone 

defect results in increased VEGF expression during the early period of 

fracture repair. In addition, the specific VEGF isoform may be a key 

regulator of the bone healing process. These findings demonstrate 

that EPCs promote fracture healing by increasing VEGF levels and 

thus stimulating angiogenesis, a process that is essential for early 

callus formation and bone regeneration. 

pApeR No. 150 

PINP Expression During Femoral Fracture Healing In 

Mice 

Travis Burgers, PhD, Grand Rapids, MI 

Marlon O Coulibaly, MD, Bochum, Germany 

James Mason, Grand Rapids, MI 


Bart Williams, PhD 


Femoral shaft (FS) fractures are common, and an incidence of 1-25% 

makes FS non-unions (FSNUs) a frequent clinical problem. To date, 

814 

no early and reliable detection measures for fracture healing or the 

timely diagnosis of FSNUs are available. In this study, the feasibility 

of procollagen type I amino-terminal propeptide (PINP) was 

examined as a bone formation marker for FS fracture healing. We 

hypothesized that PINP expression increases as callus size increases 

during fracture healing in mice. A closed mid-diaphyseal femoral 

fracture was induced in C57Bl/6 mice after retrograde insertion of 

a 25G intramedullary pin under sterile conditions; a non-fracture 

group served as a control. Blood draws for serum PINP measurement 

and radiographic image analysis were performed at days seven, 11, 

17 and 23 post-fracture. MANOVA analyses and student’s t-tests 

were used to determine statistical significance at p

pApeR No. 212 

Complication Risk following Treatment of Acetabular 

Fractures in the Medicare Population 


Craig S Roberts, MD, Louisville, KY 





The purpose of this study was to determine the incidence of and 

evaluate risk factors for complications and mortality following 

closed and open treatment of acetabular fractures in the Medicare 

population. A 5% national sample of Medicare records from 1998 to 

2007 was reviewed for the treatment of acetabular fractures, 35 ICD- 

9-CM complication codes and six CPT reoperation codes, in order 

to assess complications within 90 days and within one year. There 

were a total of 1,286 fractures treated closed and 359 with open 

reduction/internal fixation (ORIF) reviewed (99 post wall, 111 one 

column, 149 complex). Multivariate Cox regression was performed 

to compare complication rates and risk factors. The incidence of 

acetabular fractures in the Medicare population has increased by 29% 

since 1998. The ORIF group had higher incidence of complications: 

cardiac 7% vs 4.7%, p

from the femoral head are directed toward the posterior aspect of 

the acetabulum. At 40% of the sit-to-stand cycle, maximum hip 

flexion angle of 98.9° is seen with femoral head force application 

posteriorly at an area one third the size and with three times the 

pressure of single leg stance. The purpose of this study was to 

compare joint stability during single leg stance (SLS) relative to sitto-stand 

(STS) maneuver using a posterior wall acetabular fracture 

model. Seven side-randomized fresh frozen cadaveric hemi-pelvic 

specimens with proximal femurs were dissected of all soft tissues 

except for the acetabular labrum. Posterior wall acetabular fractures 

were created in 5 mm increments. The percent of resected posterior 

wall was calculated using the distance from cotyloid fossa (PWR) and 

the resected posterior wall area (PWRa). A 1,200 N load was applied 

to the acetabulum simulating the STS manuver (15° abduction, 90° 

flexion) and SLS (15° abduction, 0° flexion). The average distance 

from the roof needed to dislocate the hip was 5.2 mm ± 5 mm 

in the SLS position and 15.5 mm ± 2.7 mm in the STS position 

(p=0.001). The average PWR causing hip dislocation was 48%±19% 

in STS and 85%±14% in SLS (p=0.008). The average PWRa needed 

to dislocate the hip was also significantly less (p=0.005) for the STS 

group (45.4%±14.4%) than the SLS group (82.4%±12.8%). The hip 

joint is significantly more unstable in sit-to-stand maneuver than 

in single leg stance in simulated posterior wall acetabular fractures. 

Patients with posterior wall fractures affecting more than 45.4% of 

the articular surface area, or that are within 15 mm from the dome 

of the acetabulum may be susceptible to instability during activities 

of daily living. 

pApeR No. 216 

Reliability of Computed Tomography Assessment of 

Hip Stability in Posterior Wall Acetabular Fracture 

Jeffrey Maurice Reagan, MD, Saint Louis, MO 

Berton R Moed, MD, Saint Louis, MO 

Exam under anesthesia (EUA) is considered the gold standard for 

diagnosis of dynamic hip stability status. However, computed 

tomography (CT) assessment of fracture fragment size and position 

may be able to identify clinically unstable hips that require operative 

fixation. The purpose of this study is to determine if there is sufficient 

observer consistency in this CT assessment for prediction of hip 

stability status in posterior wall acetabular fractures. CT scans of 10 

patients with posterior wall acetabular fractures were evaluated for 

stability with a previously described subtraction method. CT scans 

were reviewed twice with a one month washout period by three 

junior orthopaedic residents (year two), three senior residents (year 

five) and three traumatologists who perform acetabular fixation. 

Stability predictions were compared to EUA status and intraclass 

correlation coefficients were calculated. Intra- and interobserver 

reliability were both excellent (> 0.80) regardless of experience level. 

Eliminating the indeterminate predictions, sensitivity was calculated 

at 88% and specificity was 98% after comparison with EUA. However, 

inappropriate nonoperative treatment would have occurred in 8% 

of cases. By additionally eliminating certain fracture variables from 

consideration (such as nondisplaced fracture lines and fractures in a 

posterior superior location), sensitivity and specificity increased to 

100% with no potential treatment errors. This method for assessing 

hip stability is reliable and reproducible. However, as a diagnostic 

tool, it should not be used to evaluate fractures in a posterior 

superior location or those having any additional nondisplaced 

fracture lines. Patients with measurements in the indeterminate 

range (20%-50%) or those having confounding variables (e.g., a 

posterior superior location, additional nondisplaced fracture lines or 

marginal impaction) are candidates for dynamic stress fluoroscopy 

under anesthesia. 

816 

pApeR No. 217 

Propensity for Hip Dislocation is Higher During Sit-to- 

Stand Maneuvers Than Gait in a Cadaver Model 

Erik McDonald, Santa Cruz, CA 

Meir Tibi Marmor, MD, Foster City, CA 

Jenni M Buckley, PhD 

Amir Matityahu, MD, San Francisco, CA 

Current clinical guidelines for surgical intervention of acetabular 

fractures are limited in that they only reflect acetabular loading 

patterns during gait or standing. A report by the National Center for 

Health Statistics has revealed that in 2005, 39.9% of adults spent 

most of their time sitting as the usual daily activity. The vectors 

of the forces projected from the femoral head to the acetabulum 

when moving from sitting to standing (STS) or standing to sitting 

are markedly different than during standing, single leg stance (SLS) 

or walking activities. Seven side randomized fresh frozen cadaveric 

hemi-pelvic specimens with proximal femurs were dissected of all 

soft tissues except for the acetabular labrum. Transverse acetabular 

fractures were created in 5 mm increments from distal to proximal. 

The roof arc angle and reduction of articular surface area were 

measured. A 1,200 N load was applied to the acetabulum simulating 

most demanding load during the sit-to-stand motion (15° abduction, 

90° flexion) and single leg stance (15° abduction, 0° flexion). The 

average roof arc angle (RAA) needed to dislocate in the SLS position 

was 71.9° in the iliac oblique (IO), 46.1° in the anterior-posterior 

(AP) and 25.2° in the obturator oblique (OO) X-ray. The average 

RAA needed to dislocate in the STS position was 101.4° IO, 90.9° 

AP and 67.3° OO X-ray views. There was a significant difference in 

the RAAs between the SLS and STS in all Roentgenograms (p

failure in the reduced (r = 0.76, p=0.04), but not in the unreduced 

specimens (r = -0.09). This data taken together reveals that more 

frictional stability can be generated by lag screw compression in a 

reduced SI joint than in an unreduced joint. 

pApeR No. 219 

Economic Analysis of Surgical Pelvic and Acetabular 

Fracture Treatment at a Level 1 Trauma Center 

Jesse T Torbert, MD, Baltimore, MD 


Michael Mercincavage, BS, MAd, CPHQ 


Surgical treatment of pelvic/acetabular fractures may be financially 

beneficial to a health system. However, hospital charges and collections 

likely surpass those of the orthopaedic trauma surgeon responsible 

for managing the injury. A retrospective review was performed of all 

operatively managed pelvic and acetabular injuries over two years in 

a health system that did not provide this service previously. Hospital 

contribution margin (CM) and profit were calculated. Factors 

impacting CM and profit were analyzed. Metrics were compared to 

other surgical services within the health system. Hospital charges and 

collections were compared to the orthopaedic surgeon’s charges and 

collections. Sixty-five patients were included. The average hospital 

CM for surgical pelvic/acetabular patients was +$18,188/patient, 

greater than the majority of surgical services. However, calculated 

hospital profit was -$14,279/patient. The length of stay and indirect 

costs were highest in the pelvic/acetabular surgical patients, which 

negatively affected calculated profit. Shorter length of stay and 

worker’s compensation insurance significantly increased hospital 

profits, while higher diagnosis related group (DRG) and Medicare 

severity diagnosis related groups (MSDRG) weights (measures of 

patient illness/injury severity) significantly increased CM. Hospital 

charges/collections far outweighed orthopaedic surgeon professional 

fee charges/collections (50 fold and 30 fold, respectively). Surgically 

managing pelvic/acetabular injuries can have a profound impact 

on CM for a hospital. The hospital collections for the treatment of 

these patients are in excess of the direct costs by $18,188/patient; 

therefore the hospital does benefit significantly. Indirect costs, which 

the surgeon has no control over and are somewhat arbitrarily set, are 

high in this population. Hospital charges/collections far outweigh 

the surgeon’s. When advocating for the necessary resources to treat 

pelvic/acetabular fractures, surgeons should be aware of the hospital’s 

financial position. 

pApeR No. 220 

Monitoring Transcranial Electric Motor Evoked 

Potentials during Acetabular/Pelvic Fracture Surgery 

Manny D Porat, MD, Philadelphia, PA 

Nitin Goyal, MD, Philadelphia, PA 

Alvin C Ong, MD, Linwood, NJ 

Fabio Orozco, MD, Egg Hbr Twp, NJ 

Daniel M Schwartz, PhD, Philadelphia, PA 

Anthony K Sestokas, MD, Springfield, PA 

Pelvic and acetabular fractures can be devastating injuries, often 

complicated by neurologic dysfunction. Although studies have 

reported on the application of neuromonitoring with somatosensory 

evoked potentials (SSEPS) or electromyography (EMG) to reduce 

iatrogenic nerve injury, both neuromonitoring modalities have met 

with mixed success. We report on the use of transcranial electric motor 

evoked potential (tceMEP) monitoring for improved detection of 

impending sciatic nerve injury during pelvic and acetabular fracture 

817 

surgery. Multimodality neuromonitoring (tceMEP, SSEP, EMG) was 

performed on 54 patients who underwent open reduction/internal 

fixation (ORIF) for acetabular or pelvic fractures between 2003 

and 2010. tceMEP amplitude loss >65% served as the surgical alert 

criterion for evolving neural injury. Of 53 patients monitored, five 

(9.4%) awoke with new onset neurologic deficit. The criterion for 

significant tceMEP amplitude loss was exceeded in four of these five 

patients, with no evidence of substantial improvement following 

surgical intervention and through closing. One patient, whose 

baseline tceMEP amplitudes were small and labile due to anesthetic 

depth, did not show a significant change, but emerged with a new 

deficit. Sensitivity for tceMEP detection of developing sciatic nerve 

injury, therefore, was 80%. Because of the low or questionable 

sensitivity of SSEP and EMG monitoring during ORIF for nerve 

injury detection, neither has enjoyed widespread acceptance. This 

preliminary investigation suggests that tceMEP monitoring, unlike 

its SSEP and EMG counterparts, is uniquely sensitive for identifying 

emerging sciatic nerve injury, and prompts the surgeon to institute 

rapid rescue intervention which either reverses or limits any adverse 

effects. 

pApeR No. 221 

Does Body Mass Index Affect Hemorrhage In High- 

Energy Pelvic And Acetabular Fractures? 

Brent J Morris, MD, Nashville, TN 

Justin E Richards, MD, Nashville, TN 

Oscar Guillamondegui, MD, MPH, Nashville, TN 

Kyle Sweeney, BS 

Marc A Tressler, DO, Hendersonville, TN 

William Obremskey, MD, Nashville, TN 

Philip James Kregor, MD, Nashville, TN 

We evaluated the “Cushion Effect” of obesity, through body mass 

index (BMI), on pelvic and acetabular fractures and the relationship 

to peritraumatic hemorrhage. Retrospective review of radiographic, 

demographic and initial 24-hour transfusion data on 244 consecutive 

isolated pelvic and/or acetabular fractures. No patients were treated 

operatively in the first 24 hours and had no other Apache Index Score 

> 2. Thus, the majority of blood loss was due to pelvic or acetabular 

injury. BMI was described as normal:

hemorrhage in isolated pelvic trauma, even for fracture patterns “less 

likely to bleed.” 

pApeR No. 222 

Radiographic Determinants of Early Failure in Posterior 

Wall Acetabular Fractures 

Swapnil B Shah, MD, Oakland, CA 

Robert V O’Toole, MD, Baltimore, MD 

Theodore T Manson, MD, Bel Air, MD 

Jason Warren Nascone, MD, Baltimore, MD 

Marcus F Sciadini, MD, Baltimore, MD 

This study was designed to investigate which factors play a significant 

role in clinical failure of operatively treated posterior wall acetabular 

fractures. Our hypothesis was that the patient’s native anatomy 

(including acetabular version) and the actual fracture pattern are 

predictive of clinical outcome. Forty-five patients at a level I trauma 

center who received open reduction internal fixation of a posterior 

wall acetabular fracture from 2004 to 2009 and had at least a oneyear 

follow up were retrospectively examined. Their charts, axial 

computed tomography scans and plain films were reviewed. The 

following 18 variables were recorded: age, history of dislocation, 

marginal impaction, comminution, femoral head injury, incarcerated 

fragments, involvement of the subchondral arc, proximal to distal 

fracture extension, use of laterally placed spring plates, transverse 

plane acetabular anteversion, anterior acetabular sector angle 

(AASA), posterior acetabular sector angles (PASA) at both the level 

of the fovea and the level of greatest wall involvement, the percent 

change in PASA due to the fracture at both the level of the fovea 

and level of greatest wall involvement and size of fracture measured 

by the Calkins, Keith and Moed methods. Failure of treatment 

(n=18) was defined as the patient receiving a total hip arthroplasty 

(n=5) or developing post-traumatic arthritis that was clinically 

determined to need a total joint (n=13). Comparisons were made 

using Fisher’s exact and student’s t-tests. Fracture extension into the 

subchondral arc was the only variable predictive of clinical failure 

(67% in failures vs. 26% in non-failures p=0.01). Acetabular version 

and all other parameters were not predictive of failure. Involvement 

of the subchondral arc appears to be the most important predictor 

of failure of operative treatment of posterior wall fractures. Native 

anatomy, fracture size and the presence of marginal impaction did 

not play a significant role in predicting failure. 

pApeR No. 223 

Clinical Aspects And Outcomes Of Straddle Pelvic 

Fractures 

Nikolaos K Kanakaris, MD, Leeds, United Kingdom 

Fragiskos Xypnitos, MD, Epsom/Uk, United Kingdom 

John Charopoulos, MD, Leeds, United Kingdom 

Peter Giannoudis, MD, Leeds, United Kingdom 

The straddle fractures represent a distinct anatomical pattern of pelvic 

trauma. Their specific clinical characteristics, associated trauma and 

clinical outcome remain mostly underreported and ambiguous. 

Over a three-year period, straddle fractures were identified from a 

prospective database of a tertiary-referral-hospital. For all cases, 

excluding children < 16 years and pathologic-fractures, demographic 

characteristics, associated trauma, ISS-05, transfusion requirements, 

surgical procedures, post-operative course, complications and 

clinical outcome were recorded over a median follow up of 19 

months (12-36). All fractures were classified by the two senior 

authors separately. Out of 280 pelvic fractures, 31 (11%) straddle 

fractures were identified. The median age was 38 years (17-88) 

818 

and male/female ratio 1.38. Half of them were classified as lateralcompression 

(51.6%), 19.4% as anteroposterior-compression 

and 29% combined mechanism of injury. Nine cases had an 

intraarticular extension. Median injury severity score was 21 (9-57), 

while 71% had a serious (AIS>2) associated thoracic injury, 48.4% 

- head-injury, 38.7% - abdominal-injury, 51.6% - lower-extremityfracture 

and 38.7% - significant urogenital injuries. Six underwent 

acute embolization, and the mean transfusion rates over the initial 

72 hours were 7.5 units - cRBC, 2.3 units - FFP, 0.5 units - PLTs. All 

cases were treated operatively; either with open reduction/internal 

fixation (ORIF) (14 cases), closed reduction and percutaneous screw 

fixation (10 cases), while an external fixator was used in 21 cases. The 

median length-of-stay was 21 days (1-106). The mortality rate was 

6.5%. Eight superficial infections (pin sites of the external fixators), 

two deep sepsis of pfannestiel wounds, as well as one asymptomatic 

non-union of an inferior pubic rami were recorded. Five cases 

underwent further surgery for late urogenital repair and four cases 

have chronic incontinence and sexual dysfunction symptoms. 

Straddle fractures represent a severe type of pelvic trauma. They are 

associated with severe mostly thoracic, head and extremity trauma 

as well as severe urogenital complications. These injuries suggest 

pelvic ring haemodynamic and mechanical instability that requires 

surgical stabilization in the acute and delayed reconstructive setting. 

They are easily identifiable at the initial radiological investigations 

and should alert the clinician for multidisciplinary assessment and 

early referral. 

pApeR No. 224 

Nonoperative Immediate Weightbearing of Minimally 

Displaced Lateral Compression Sacral Fractures 


Gillian Soles, MD, Medford, MA 

John Lien, MD, Ann Arbor, MI 

The purpose of this study is to compare the initial and follow up 

radiographs of patients with minimally (

pApeR No. 225 

Are Conventional Inlet and Outlet Radiographs 

Obsolete in Evaluation of Pelvis Fractures? 

Murat Pekmezci, MD, San Francisco, CA 

Utku Kandemir, MD, San Francisco, CA 

Saam Morshed, MD, San Francisco, CA 

The new generation multi-detector computed tomography (CT) 

scanners allow generation of virtual x-rays from the data acquired to 

evaluate the pelvic fractures. Special software allows the technicians 

to obtain the appropriate orientation that is required for adequate 

inlet and outlet views, which would eliminate repeat trips to the 

radiography suite to acquire adequate x-rays. The purpose of this 

study is to compare the quality virtual x-rays and conventional x-rays 

that are used in evaluating pelvis fractures. A retrospective database 

review was performed to identify patients who were operated on with 

a diagnosis of pelvis fracture identified. The inclusion criteria were 

unstable pelvic fracture, age >18, complete set of antero-posterior 

(AP) pelvis, inlet and outlet x-rays and multi-detector pelvis CT scan. 

Virtual AP pelvis, inlet and outlet views are generated from the CT 

data. Two fellowship trained orthopedic trauma surgeons reviewed 

the virtual and conventional studies separately in association with CT 

scans and graded the quality of the studies on a custom developed 

questionnaire. Each fracture was classified separately based on 

Orthopedic Trauma Association classification. Twenty patients 

were eligible for the study. The AP pelvis view quality was similar 

for both conventional and virtual images except for the tilt of the 

pelvis. The inlet and outlet views quality was better in all domains 

in the virtual x-ray group when compared to the conventional x-rays. 

The percentage of adequate inlet and outlet views were higher in the 

virtual x-ray group when compared to the conventional x-ray group. 

The intraobserver agreement was fair to good with Orthopedic 

Trauma Association classification (kappa: 0.24 and 0.43) whereas 

interobserver agreement was poor (kappa:0.17). The results show 

that the virtual inlet and outlet views consistently provided higher 

rates of adequate x-rays when compared to the conventional x-rays. 

Replacement of the conventional views with the virtual inlet and 

outlet views would decrease the radiation exposure to the patient, 

overall cost and prevent repeat x-rays in order to achieve adequate 

views. 

pApeR No. 301 

Improving Results in Treatment of Intertrochanteric Hip 

Fractures 

Harris S Yett, MD, Weston, MA 

Treatment of intertrochanteric hip fractures has been associated in all 

published series with high rates of complications. This series of 315 

consecutive patients treated by a single surgeon in a single hospital 

had a low rate of complications. Key surgical measures included 

attainment of anatomic or near-anatomic reduction, selection of 

often under-appreciated but critically important external rotation to 

achieve proper reduction in certain sub-classes of fracture, reduction 

and fixation of the detached lesser trochanter when possible and 

appropriate uasage of the sliding hip screw (which was used exclusively 

in this series). Complication rates were low: one hardware failure, no 

non-unions, no infections and two re-operations (one for hardware 

failure and one wash-out of a sterile hematoma). Comparing the 

rate of treatment failure or re-operation in this series (0.64%) to 

eight other reviewed series having similar demographics with more 

than 200 patients published over the past 21 years (failures or reoperations 

rates of 2.6% to 9.4%), there is a significant difference in 

outcome (p

pApeR No. 303 

Functional Outcomes in Cardiovascular Patients 

Undergoing Surgical Hip Fracture Repair (FOCUS) 


Jeffrey L Carson, MD, New Brunswick, NJ 

Michael L Terrin, MD, MPH 

William B Macaulay, MD, New York, NY 

Courtland G Lewis, MD, Hartford, CT 

Kevin A Hildebrand, MD, Calgary, AB Canada 

Lauren Beaupre, PhD, Edmonton, AB Canada 

Jay Magaziner, MD, Baltimore, MD 

Functional outcomes in cardiovascular patients undergoing surgical 

hip fracture repair (FOCUS) is a randomized controlled trial 

designed to determine whether higher blood transfusion thresholds 

improve functional recovery and reduce mortality and morbidity 

after hip fracture repair. A total of 2,016 patients 50 years of age or 

older, who underwent surgery for hip fracture had a history of risk 

factors for cardiovascular disease, and had postoperative anemia 

(Hgb less than 10 g/dL) were randomized from 47 centers. Patients 

were allocated to a transfusion threshold of 10 g/dL, or to receive 

transfusion when anemia symptoms occurred or Hgb level was less 

than 8 g/dL. In-hospital mortality, cardiac events, complications 

and length of stay were compared between the groups. Functional 

outcome, defined as the ability to walk across a room unaided, was 

compared at 30 and 60 days. The mean age of study subjects was 81.8 

± 8.8 years, and 75.7% were female. The 1,007 patients in the liberal 

group were transfused a total of 1,866 units of blood for an average 

hemoglobin of 9.2 g/dL, while the 1,009 patients in the restrictive 

group received a total of 652 units for an average hemoglobin of 

7.9 g/dL. Composite outcomes did not differ between the groups. 

In the 10 g/dL group, 34.7% were dead or unable to walk without 

human assistance and for the symptomatic group 35.2% (p=0.80). 

The symptomatic approach to transfusion greatly reduced blood 

demands with no discernible effect on mortality or function. 

pApeR No. 304 

Primary Determinants of Intra-operative Radiation 

Exposure during Proximal Femur Fracture Fixation 

Edward Rodriguez, MD, Medfield, MA 

Michael Baratz, MD, Brookline, MA 

Yue-Yung Hu, MD 

Aron Chacko 

Paul Appleton, MD, Cohasset, MA 

We aimed to evaluate intra-operative radiation use during surgical 

fixation of proximal femur fractures and to determine the primary 

determinants of total dose used. We hypothesized that body mass 

index (BMI), severity and location of the fracture, technique/implant 

used, patient positioning, time of day and skill of the operative staff 

were independent determinants of intra-operative radiation use. 

Total fluoroscopy time, peak kilovoltage (KVP), mili-ampere (mAmp) 

and cumulative dose (mrad-cm2) were recorded prospectively for 

84 patients with proximal femur fractures undergoing repair with 

either a cephalomedullary nail (63), a compression hip screw device 

(11) or percutaneous fixation with cannulated screws (10) by two 

trauma fellowship trained surgeons at our institution. Fluoroscopy 

was performed by hospital employed radiation technicians using a 

GE OEC C-arm. Patient records were then retrospectively reviewed 

to determine, for each case: fracture location and type (based on 

Orthopaedic Trauma Association (OTA) classification), laterality, age, 

BMI, surgical position, presence of resident assistants and level of their 

training, implant used, time of surgery (day vs. night) and treating 

820 

surgeon. Univariate and multivariate analyses were performed using 

the Wilcoxon and ANOVA tests and linear regression to determine 

which of these factors were significant determinants of total radiation 

exposure. Mean radiation doses for each case type are tabulated. After 

adjusting for other covariates, an increase of 47.9 +/- 12.1 mrad-cm2 

was seen per each point increase in BMI across all cases (p = .0004). 

Intertrochanteric fractures repaired with a short cephalomedullary 

nail used 493.5 +/- 195.1 more mrad-cms than those repaired with 

a compression screw system (p=.01). Within the cephalomedullary 

nail group, surgeries done in the lateral position used 899.8 +/- 

202.4 mrad-cm2 more than those done supine (p < 0.0001), and 

subtrochanteric fractures used 770.1 +/- 225.1 mrad-cm2 more than 

intertrochanteric and femoral neck fractures (p=0.0012). Surgeries 

done after 6 pm used an average of 871.4 +/- 302.4 more mrad-cm2 

than surgeries done during normal daytime hours (p = 0.0056). 

One surgeon used an average of 529.5 +/- 159.4 mrad-cm2 more 

than the other (p = 0.0016). No significant differences were seen in 

regards to patient sex, age, severity of fracture (OTA type), laterality 

or level of training of resident(s) assisting in the case. The amount 

of intra-operative radiation exposure used in surgical fixation of 

proximal femur fractures is primarily determined by BMI, patient 

position, surgical technique used, timing of surgery and individual 

surgeon performing the case. Surprisingly, OTA fracture type and the 

level of training of assisting residents do not seem to be significant 

determinants of total radiation used. 

pApeR No. 305 

Neck Reconstruction (AIIMS Box Technique): An 

Answer To Large Femoral Neck Defects 


BN V Upendra, MS 

Arvind Jayaswal, MS 

Large femoral neck defects pose a great challenge for orthopedic 

surgeons and are frequently associated with neglected femoral neck 

fractures, post infective sequale and failed implants around femoral 

neck. We present our technique (AIIMS Box Technique) of neck 

reconstruction aiming to preserve the natural femoral head and 

restoring the function of hip in cases of large femoral neck defects. 

A total number of 52 patients (age range 20 to 56 years with an 

average of 38 years) with large femoral neck defects were treated 

from January 1990 to May 1997 and were followed for a minimum 

of 10 years (range 10 to 17 years). Neck defect was converted into a 

box using osteal flaps (base from greater trochanter, anterior wall 

from head, quadratus femoris muscle pedicle graft posteriorly). 

This box was filled with cancellous bone autograft along with three 

cancellous screw fixation. Union occurred in all patients in a mean 

time of 16 weeks (range 12-20 weeks). One patient in our series had 

avascular necrosis (AVN) of femoral head. Eighteen out of 52 results 

were classified as excellent, 28 good and six fair. No patient had poor 

result. Good functional mobility including squatting was seen in all 

but two patients. Complications included coxa vara in two patients 

and hardware problems in four patients. Our study shows that large 

femoral neck defects can be managed successfully with preservation 

of vascularity of femoral head. This procedure can be considered an 

alternative to excisional or replacement arthroplasty, particularly in 

young adults. 




pApeR No. 306 

A Biomechanical Analysis of Cephalomedullary Nail 

Lag Screw Position in the Femoral Head 

Paul Robert Kuzyk, MD, FRCSC, MSc, Toronto, ON Canada 

Rad Zdero, PhD 

Suraj Shah, BSc, Toronto, ON Canada 

Michael Olsen, Toronto, ON Canada 

James P Waddell, MD, Toronto, ON Canada 


Minimizing tip-apex distance (TAD) has been shown to reduce 

clinical failure of extramedullary sliding hip screws used to 

fix peritrochanteric fractures. The purpose of this study was 

to determine if such a relationship exists for the position of a 

cephalomedullary nail lag screw in the femoral head. Unstable fourpart 

peritrochanteric fractures were created in 30 synthetic femurs 

and repaired with Long Gamma 3 Nails using one of five lag screw 

positions: 1) superior, 2) inferior, 3) anterior, 4) posterior, 5) central. 

Radiographic measurements including TAD and calcar referenced 

tip-apex distance (CalTAD) were calculated from anteroposterior 

and lateral radiographs. Specimens were tested for axial, lateral and 

torsional stiffness, and then loaded to failure in the axial position. 

ANOVA was used to compare means of the five treatment groups. 

Linear regression analysis was used to compare stiffness and loadto-failure 

(dependant variables) with radiographic measurements 

(independent variables). The inferior lag screw position had 

significantly greater mean axial stiffness than superior (p

pApeR No. 309 

The Natural History of Atypical Femoral Insufficiency 

Fractures (AFIFs) Multicenter Study- 

Kwang Woo Nam, MD, Jeju, Jeju, Republic of Korea 

Kyung-Jae Lee, MD, Daegu, Republic of Korea 

Seok-hyun Kweon, Prof, Iksan, Jeonbuk, Republic of Korea 

Dr Je Hyun Yoo, Anyang, Republic of Korea 

Hee Joong Kim, MD, Seoul, Seoul, Republic of Korea 

Jeong Joon Yoo, MD, SEOUL, Republic of Korea 

Kee Hyung Rhyu, MD, Seoul, Seoul, Republic of Korea 

Kwang Jun Oh, MD, Seoul, Republic of Korea 

Seung Beom Han, MD, Seoul, Republic of Korea 

Several recent papers have reported atypical femoral insufficiency 

fractures (AFIFs) in long-term users of bisphosphonate. However, the 

contemporary literature listed limitations such as small number of 

cases, vague definition of AFIFs, lack of incomplete fracture and lack 

of bilaterality or multiplicity. We intended to look into the clinical 

course of AFIFs by increase of sample size through multicenter study 

and also investigated the fate of the untreated incomplete AFIFs. We 

gathered patient data from the geriatric hip fracture groups at each 

institution. We focused on radiographycally documented AFIFs. 

The inclusion criteria were no trauma history, the subtrochanetric 

or diaphyseal fracture of femur and characteristic radiologic features 

compatible with AFIFs. The characteristic radiologic features were 

as follows: simple and transverse, unicortical beak and cortical 

thickening in case of complete AFIFs; cortical thickening with or 

without microfracture lines confirmed by bone scan, CT or MRI. 

We classified the direction of cortical thickening into two types: 

intramedullary and outer cortical. Fifty cases of 30 female patients 

were included (subtrochanteric fractures 26 and diaphyseal fractures 

24). Incomplete AFIFs were 38 cases and complete AFIFs were 12 

cases at the initial presentation. All but three patients had been 

taking bisphosphonates for mean of 4.2 years. Age, multiplicity, 

the direction of cortical thickening, bisphosphonate use and lower 

bone mineral density (BMD) were significantly different between 

subtrochanteric and diaphyseal AFIFs. Thirty-two incomplete AFIFs 

except six cases of prophylactic stabilization were followed up 

without surgery. Fourteen of 32 incomplete AFIFs progressed to 

complete and displaced fractures with mean interval of 8.4 months. 

Duration of bisphosphonate medication and cortical thickening to 

outer cortex were significant predictors for fracture progression in the 

Cox analysis adjusted for other variables. Incomplete atypical femoral 

insufficiency fractures can be carefully observed without prophylactic 

surgery. However, if the longer duration of bisphosphonate use 

(especially >5 years) and the cortical thickening on outer cortex 

exist, it is better to perform prophylactic stabilization. 

pApeR No. 310 

Surgical Approach Does Not Affect Union of 

Supracondylar Femur Fractures Treated with Plate 

Fixation 

Jonathan Michael Gross, MD, Rochester, NY 

Fernando Serna, MD, Rochester, NY 

Kyle Lybrand, BS 

Xing Qiu, PhD, Rochester, NY 

Catherine A Humphrey, MD, Rochester, NY 

John T Gorczyca, MD, Rochester, NY 

Although there have been several series demonstrating the efficacy 

of open and sub-muscular surgical techniques in the treatment of 

supracondylar femur fractures, there are few series that compare 

822 

open versus limited open approaches. The purpose of this study 

was to determine whether a limited incision sub-muscular surgical 

approach provided an advantage to fracture healing over a traditional 

open vastus elevating approach. We retrospectively reviewed 99 

supracondylar femur fractures (OTA /AO classification 33A and 33C) 

in 95 patients, who had complete demographic and radiographic 

data, and who were treated by an orthopedic traumatologist with 

plate fixation from January 1, 2001 through January 1, 2009. The 

primary outcome was the need for a second surgery to achieve 

fracture union. Secondary outcomes were age of the patient at the 

time of fracture, diabetes, smoking, open versus closed fractures, 

plate length, proximal screw number and density and open versus 

sub-muscular surgical approach. Of the 99 fractures, 51 utilized a submuscular 

approach and 48 an open approach. There were 22 (22%) 

fractures that required a second surgery to achieve union; 12 with 

an open approach and 10 with a sub-muscular approach. Analysis 

with a Fisher’s Exact test demonstrated that only open fractures (p = 

0.034), diabetes (p = 0.013) and a plate length of less than 10 screw 

holes (p = 0.011) were associated with a second surgery. The odds 

ratios for these three factors were respectively 2.912, 0.116 and 9.052. 

The p value for open versus sub-muscular approach was 1. In this 

study, when performed by an orthopedic trauma specialist, limited 

incision sub-muscular plating did not provide an advantage over 

traditional open vastus elevating approach for healing distal femur 

fractures. Surgical approach should not compromise adequacy of 

reduction and fixation. This study raises questions about the clinical 

significance of minimally invasive surgery to achieve fracture union. 

pApeR No. 311 

Distal Locking in Femoral Nailing of 52 Patients 

without X-ray Guidance- A Multi-Center Study 

Arturo C Canete, MD, Quezon City, Metro Manila, Philippines 

Godfredo V Dungca III, MD 

Regidor B Deleon III, MD 

Daniel V Dungca, MD 

Jereme B Atupan, MD, Metro Manila, Philippines 

Joaquin C Pandanan, MD 

Wilfredo B Pacheco, MD, Quezon City, Philippines 

Abigail Trinidad Jao, BS, MEM-BME 

Distal locking of femoral nail continues to be a challenge due to 

problems in accuracy and radiation exposure. This study was 

conducted to determine effectiveness of a new distal locking 

technique without x-ray guidance. This is a prospective series of 52 

patients, indicated for femoral locked nailing. Distal locking was 

performed with the use of an automated device which was inserted 

into the nail canal, and deploys a flexible nitinol cable drill through 

the lateral screw holes. Upon switching the device on, drilling of a 

pilot hole at the lateral femoral cortex is initiated. Using the pilot hole 

as reference, drilling back through the nail and medial cortex were 

accomplished without x-ray guidance. Drill-back technique evolved 

as it was being optimized. Confirmation of screw insertion was done 

by a probing technique, and double-checking with x-ray. Assessment 

of success rate and average time for locking and monitoring for 

adverse events were conducted. Out of the 52 patients, 50 were 

successfully locked using the device. Successful locking was achieved 

in 96% on first attempt, and 100% on the second. Average time 

for complete distal locking was 14 minutes. Two cases were locked 

using other methods due to technical problems, which were rectified 

sucessfully. No device related adverse events were encountered. Use 

of this innovative device was 96% effective on first attempt and 100% 

on the second. This device is easy to use, saves time, is relatively safe 

and minimizes radiation exposure to surgical team and patient. 




pApeR No. 312 

Location of Gunshot Wound Femur Fracture Predicts 

Arterial Injury 

Ida Leah Gitajn, MD, Boston, MA 

Paul William Perdue, Jr MD, Brooklyn, NY 

John McCall Hardcastle, V MD, New York, NY 


Gunshot wound fracture is a unique category of gunshot wound 

injuries which may have a special relationship to arterial injury. The 

purpose of the present study was to evaluate whether location of 

gunshot wound femur fracture predicts arterial injury. This would 

provide a clinician with an easy-to-obtain clinical feature that can 

be used to drive management. We hypothesized that fracture in the 

distal portion of the femur is likely to be a marker for arterial injury 

since the femoral artery is tethered to the femur at the adductor 

hiatus or Hunter’s canal. The records of 96 patients with gunshot 

wound femur fractures who were evaluated at a level-I trauma center 

were reviewed. Outcome measure consisted of presence or absence 

of arterial injury. Stored plain films were used to measure length of 

femur and distance to proximal and distal fracture lines. Location of 

proximal and/or distal fracture lines in the distal third of the femur 

was associated with presence of arterial injury (p < 0.05). Odds ratio 

for presence of arterial injury when proximal fracture line was in 

the distal third of the femur is 5.21 (95% CI from 1.49 to 18.19, p 

Sixty-six patients, 59 females and seven males with an average age of 

78 (66-100) years had no history of bisphosphonate therapy. Eleven 

patients (14% of remaining cohort), 10 females and one male with 

an average age of 75.5 (67-94) years, had received bisphosphonate 

therapy for greater than two years prior to admission. All 11 patients 

in the bisphosphonate group had sustained a low energy fall from 

a standing height or less. In the non-bisphosphonate group, 63 

patients had a mechanism of fall from standing and three patients 

had a mechanism of motor vehicle accident. In nine of the 11 (82%) 

patients in the bisphosphonate group, the radiographs resembled 

the previously described transverse shaft fractures that have been 

observed in patients on chronic bisphosphonate therapy. From 

2000-2005, only three/36 (8%) of femoral shaft fractures occurred 

in patients on chronic bisphosphonate therapy. From 2006- 

2009, eight/41 (19.5%) patients sustained a transverse femoral 

shaft fracture while on bisphosphonate therapy, demonstrating a 

substantial increase in the incidence of this injury pattern in patients 

taking bisphosphonates. Although bisphosphonate therapy has 

been shown to decrease the incidence of lumbar and femoral neck 

fractures, our series corroborates the worrisome evidence found 

by other authors that bisphosphonate use is associated with lowenergy, 

transverse fractures of the femoral shaft. Moreover, our data 

demonstrate a trend in the increased incidence of these fractures. 

In a patient population at risk for low energy fractures, prolonged 

pharmacologic therapy with biphosphontates may place these 

patients at an additional risk for fractures of the diaphyseal femur. 

pApeR No. 376 

Reamer Irrigator Aspirator System: Early Experience 

Nikolaos K Kanakaris, MD, Leeds, United Kingdom 

Suribabu Gudipati, MBBS, MRCS, Wakefield, United Kingdom 

Dan Morell, MBBS, BS, Leeds, United Kingdom 

Peter Giannoudis, MD, Leeds, United Kingdom 

The indications of the reamer irrigator aspirator (RIA) system include 

acute cases (minimization of second hit), osteomyelitis (debridement 

of intramedullary canal), autologous grafting (harvesting of 

morselized autograft), oncology (intramedullary canal lesion biopsy 

and prophylactic nailing). Since January 2008, data from the cohort 

of patients where the RIA system was used in a single center were 

prospectively collected. Epidemiological, in-hospital, post-discharge 

follow-up data and intraoperative direct medical costs were included 

in this series stratified as to its four basic indications. RIA was used 

in 64 patients in 71 different occasions (mean age 53 years, (19- 

80)). These included 10 polytrauma patients with thoracic and/or 

neurosurgical associated injuries, 11 pathological fractures/ pending 

fractures, 20 osteomyelitis for debridement and 23 for harvesting of 

autologous graft (atrophic and/or recalcitrant nonunions). At those 

where the by-products of reaming were collected, for diagnostic or 

grafting purposes, the mean volume was 60 ml (40-90 ml). One 

intraoperative complication was recorded (dismantling of the reamer 

head from the RIA tube assembly attributed to user’s error). In the 

limited follow-up period of this series no fractures, hematomas, 

compartment syndrome, heterotopic ossification, postoperative 

pain or limitation of patients’ mobility associated to the RIA 

technique were recorded. The mean direct medical cost of its use 

was £355 (312-740). The RIA system was proven versatile, with short 

learning curve, and highly effective especially for the cases of bone 

harvesting and intramedullary debridement (septic and oncology 

cases). Further evidence from prospective randomized clinical trials 

is anticipated to elicit its safety and efficacy to the impressing variety 

of its indications. 

824 

pApeR No. 377 

Complications Associated with the use of the Reamer- 

Irrigator-Aspirator Device 

Amer J Mirza, MD, Portland, OR 

Jayme Hiratzka, MD, Beaverton, OR 

Darin M Friess, MD, Portland, OR 

Tahnee Groat, MPH 

Thomas J Ellis, MD, Columbus, OH 

The Reamer-Irrigator-Aspirator (RIA) is a novel femoral canal 

reaming device currently indicated for use for harvesting autologous 

bone graft, management of femoral or tibial osteomyelitis and as an 

alternative to traditional non-irrigated reaming for canal preparation 

in intramedullary nail placement procedures for femoral shaft 

fractures. The purpose of this study was to evaluate operative time, 

blood loss and adverse events with the early use of the RIA device. A 

retrospective review of patients undergoing a RIA procedure at one 

Level 1 trauma center between January 2004 and December 2009 

was performed. Patient records were reviewed for operative time, 

reamer size, estimated blood loss, equipment failure, iatrogenic 

cortical perforation of the femoral shaft and medical complications 

in the immediate postoperative period. Operative times and blood 

loss were compared in femoral nailing procedures between patients 

in which a RIA device was used versus traditional pressure sensitive 

sentinel reamers. Unpaired t-tests were calculated with a level of 

significance P

pApeR No. 378 

Comparison of Five Protocols for Contaminated Bone 

Grafts in Regards to Sterility and Cell Viability 

Jennifer M Bauer, Cleveland Heights, OH 

Raymond Liu, MD, Cleveland Heights, OH 

Thomas J Kean, PhD 

James E Dennis, PhD 

William J Petersilge, MD, Cleveland, OH 

Allison Gilmore, MD, Shaker Heights, OH 

On occasion, a bone graft or fracture fragment can drop on the 

operating room (OR) floor and become contaminated. In cases 

where retention of the contaminated graft is desired, an optimal 

protocol balancing sterility and cell viability has not been 

established. Discarded bone samples were taken from 20 total 

knee arthroplasty operations and uniformly contaminated using 

a bacterial broth grown from the OR floor. Each set underwent 

five different decontamination procedures: autoclave; mechanical 

agitation and serial washes of normal saline; 2% chlorhexidine 

gluconate; and 10% povidone-iodine both left wet and allowed to 

dry for 10 minutes. Positive and negative controls were utilized. Ten 

sets were then cultured to determine sterility, and 10 underwent 

live/dead trypan blue staining to determine cell viability. Autoclave, 

chlorhexidine gluconate and dry povidone-iodine sterilized all 

samples; wet povidone-iodine sterilized four of 10 (40%); and 

saline sterilized none. While all decontamination methods reduced 

cell count to some degree, autoclave and chlorhexidine gluconate 

left no viable cells. Dried povidone-iodine sterilization maintained 

significantly less live cells than controls (21%, p

crest bone graft procedure if needed were used to evaluate the long 

term morbidity of the bone graft harvest. Thirty (20 men and 10 

women, avg. age 46 (29-65)) were evaluated at average follow up 

of seven years after ICBG for nonunions (24) or fusions (six). There 

were no postoperative wound complications. Four (13%) of the 30 

patients reported pain lasting more than two weeks after the harvest. 

Their average VAS was 7.5 (range, 6 to 8) during that time. However, 

no patient had any pain at final followup (VAS = 0 for all patients). 

Three of the four patients who had pain for more than two weeks 

after graft harvest expressed that they would not elect to have another 

bone graft and would seek alternative graft sources. All other patients 

would consent to another bone graft if recommended. Three patients 

(10%) reported some scar numbness, but none complained of thigh 

numbness (LFCN). Twenty-eight patients (93.3%) were satisfied 

with the cosmetic result. No patient had any limitations in activity 

related to the harvest site. Anterior inner table iliac graft harvesting 

resulted in minimal morbidity and no pain or functional limitations 

at an average of seven years after the index procedure. 

pApeR No. 382 

The Critical Sized Defect in the Tibia: Is it Critical? 

Results from the SPRINT Trial 


Marc F Swiontkowski, MD, Minneapolis, MN 

There is no clear definition of a critical sized defect of the tibia. We 

defined it as a fracture gap at least 1 cm in length and involving 

over 50% of the cortical diameter. We explored if the presence of 

a ‘critical-sized defect’ predicted reoperation, and which other 

factors predict reoperation in patients with the critical defect. The 

patient based outcomes of these patients were compared to patients 

without a critical defect. Patients enrolled in the SPRINT trial with 

a critical sized defect were evaluated for secondary interventions to 

gain union. Other factors predicting the need for reoperation were 

studied. We also compared the patients with critical sized defects 

to the larger cohort of patients without a defect with respect to 

demographics, injury mechanism, fracture characteristics and 

patient-based outcome. Tibial diaphyseal defects of greater than 

or equal to 1 cm and >50% cortical circumference healed without 

additional surgery in 47% of cases. Fewer reoperations were required 

in patients treated with a reamed nail (p=0.04). The mean of the 

SF-36 physical component summary in patients with a critical sized 

defect was poorer than the overall cohort (p=0.02, difference = 5.2, 

95% confidence interval 0.8 to 9.6). This definition of a critical sized 

defect is not ‘critical’ in terms of predicting reoperation, as 47 % 

of cases healed without additional intervention. However, patients 

with these bone defects had a higher rate of reoperation and worse 

patient based outcomes compared to the overall cohort of tibial 

fracture patients. Further investigation is recommended. 

pApeR No. 383 

Do Surgeon and Center Volumes Impact the Outcomes 

of Closed Tibia Fractures? 

Marc F Swiontkowski, MD, Minneapolis, MN 

Our hypothesis was that closed tibia fractures treated with 

intramedullary nails are impacted by surgeon and center volumes. 

Data from 813 patients with closed tibia fractures were obtained 

from the SPRINT study. Using multiple regression, we examined the 

effect of center and surgeon volume (categorized as high, moderate 

or low), and geographic differences by country (Canada, USA and 

the Netherlands) on health-related quality-of-life at one year and the 

revision surgery to gain union. Our measures of quality-of-life were 

the Short-Form 36 Health Survey Questionnaire (SF-36 PCS) and the 

826 

Short Musculoskeletal Function Assessment (SMFA). Patients treated 

by moderate volume surgeons had a reduced risk of re-operation 

versus patients treated by low volume surgeons (odds ratio =0.54, 

95% CI = 0.33 to 0.89, p=0.02). No effects of surgeon volume were 

seen for the other outcomes. Patients treated at moderate volume 

centers had poorer quality of life at one year than patients treated at 

low volume centers, based on the SMFA Bother score (difference = 

7.33, 95% CI = 2.65 to 12.01). This effect was not seen with the other 

outcomes. Patients with isolated fractures have better quality-of-life 

at one year, based on all three measures, p

were included in this prospectively designed observational study. 

A short musculoskeletal functional assessment (SMFA) evaluation 

was given at three months and six months and a musculoskeletal 

functional assessment (MFA) was administered at 12 months and 

then every 12 months thereafter. Range of motion and a pain score 

were obtained at every office visit. AOFAS and ACFAS scores were 

obtained at every visit beginning at 12 weeks. The Bother Index and 

all other subscales of the SMFA, and the ACFAS and AOFAS scores 

showed gradual improvement to 52 weeks, but then hit a plateau. 

The range of motion improved to 12 months, but then began to 

decline between 12 months and 36 months. Minimum pain reported 

improved out to 36 months, but maximum pain improved only to 

12 months and then remained steady. Most of the improvement 

in range of motion, pain and in subjective scores occurs within the 

first 12 months after surgery. By 36 months, some patients begin to 

decline in function. This information can be used to help patient 

and employers predict return to premorbid employment. 

pApeR No. 386 

A Surgical Procedure For Fracture Healing With 

Superior Soft Tissue Preservation 

Koji Watanabe, kanazawa, Japan 

Hidenori Matsubara, MD, Kanazawa, Japan 

Kei Takato, MD 

Munetomo Takata, MD, Kanazawa, Japan 

Nomura Issei, MD 


The Taylor Spatial Frame (TSF) is a modern multiplanar external 

fixator that combines ease of application and computer accuracy 

for fracture reduction. Fractures can be reduced during surgery and 

postoperatively using the TSF method, and it represents a novel and 

revolutionary concept for fracture treatment. Use of TSF results in 

superior preservation of the soft tissue surrounding the fracture site 

compared to other surgical procedures. This study was conducted to 

retrospectively determine the efficacy and complications associated 

with TSF in fracture treatment. Thirty-one patients with femoral and 

tibial fractures were included. The mean age was 48.3 years. Ten 

fractures were closed, four were Gustilo Type I, four were Type II 

and 13 were Type III. According to the AO/OTA fracture classification 

of fracture patterns, 15 fractures were type A, nine were type B and 

seven were type C. Statistical analysis was performed using ANOVA. 

All fractures except one united over a mean of 25.6 weeks (range, 8.4- 

59.6 weeks). Concerning soft tissue damage, patients with Gustilo 

type III fractures experienced statistically prolonged fracture healing 

(p

outcome variable was surgical site infection as defined by Centers 

for Disease Control criteria and assessed prospectively by blinded 

research personnel. Bivariate and multiple logistic regression 

analyses of the database were performed to determine whether the 

NNISS and SENIC scores have any predictive value for infection 

and to identify factors that correlate with infection. The injury and 

treatment characteristics were used to identify risk factors for surgical 

site infection. We found that there is little correlation between the 

surgical infection scores used in general surgery (NNISS, SENIC or a 

combination score) and infection rate (odds ratios ranged between 

1.2 and 1.6, with p>0.3 for all). The relative odds of infection among 

patients with AO C3 or Sanders 4 fractures compared to injuries 

with lower fracture classifications was 7.2 (95% CI : 2.0 to 26.6, 

p=0.003). Increased operative time was also a risk factor, with an 

increased odds of infection of 17% per 30 minutes of additional 

operative time (95% CI : 1% to 38%, p=0.05). A score assigning two 

points for C3 or Sanders 4, and one point for surgical time > 200 

minutes predicted 2.3 times increased odds of infection per point 

in the score (95% CI : 1.4 to 3.8, p=0.001). The NNISS and SENIC 

scores were not useful in assessing risk of infection after operative 

treatment of calcaneus, plateau and pilon fractures. We propose a 

new score that incorporates fracture classification and operative time 

as risk factors for infection. Further studies are needed to validate 

this scoring system. 

pApeR No. 389 

Radiographic Outcomes Of Ring External Fixation For 

Malunion And Nonunion 

John Strudwick Lewis, Jr MD, Durham, NC 

Tyler Steven Watters, MD, Durham, NC 

Robert Kamiel Lark, MD, Durham, NC 

Robert D Fitch, MD, Durham, NC 

Ring external fixation devices such as the Ilizarov External Fixator 

(IEF) and Taylor Spatial Frame (TSF) allow powerful correction 

of limb deformity in a less invasive manner. This study analyzed 

the radiographic outcomes of ring external fixation for deformity 

correction in the setting of mal/nonunions, with secondary 

emphasis comparing efficacy of the TSF to the IEF. A retrospective 

review was performed for 54 patients treated with ring external 

fixation for malunion/nonunion by a single surgeon over a 10-year 

period. Patient demographics, preoperative radiographic measures 

in the coronal and sagittal plane and limb length discrepancies 

were recorded. Primary outcome measures included time to union, 

radiographic correction of deformity and leg length discrepancy 

and complications from treatment. Fifty patients (93%) achieved 

radiographic union with two patients requiring further fixation and 

two patients electing to undergo amputation. The pre-operative 

coronal plane deformity averaged 13 degrees (range 0-41) while 

the sagittal plane deformity averaged 11 degrees (range 0-49). At 

the time of frame removal, the average coronal plane correction 

was within 3 degrees of anatomic (p

pApeR No. 692 

uPRCT of Subacromial Injections Following Proximal 

Humeral Fractures 

Amgad Ihab Nakhla, MSc, FRCS, London, United Kingdom 

Marie-Clare Johnson, GDP, MMACP 

Andrew Forester, FRCS, London, United Kingdom 

Patients suffer prolonged stiffness and pain following proximal 

humeral fractures. Our prospective randomized controlled trial 

(PRCT) shows that a subacromial injection of local anesthetic and 

triamcinolone three weeks post injury accelerates rehabilitation and 

improves shoulder range of motion. We randomized 36 patients with 

conservatively treated proximal humeral fractures to one of three 

groups. Group A received local anesthetic and triamcinolone, group 

B received local anesthetic only and group C received saline. Both 

the patient and physiotherapist assessing them were blinded to the 

nature of the injection. All patients were followed up at one month 

and six months following the injection. They were all given the same 

exercises by the physiotherapist. All patients were examined for 

range of motion and impingement, scored on Oxford shoulder score 

and recorded on visual analogue scale at every occasion. Patients in 

Group A and B had immediate increase of 40 degrees of abduction on 

average compared to 15 degrees improvement in Group C. Groups 

A and B had higher Oxford shoulder scores at one month following 

injections compared to Group C. Group A had longer lasting effects 

than Group C at the final six months review. This double blinded 

PRCT show that subacromial injection of triamcinolone and local 

anesthetic three weeks following proximal humeral fractures is an 

effective treatment option to speed recovery and increase range of 

motion. 

pApeR No. 693 

Small Fragment Fixation of Humeral Shaft Fractures 

Lisa K Cannada, MD, Clayton, MO 

Courtney Fahnhorst, BA 

J Tracy Watson, MD, Saint Louis, MO 

There are several patients whose bone is too small for 4.5 mm plate. 

The purpose of our study is to report the clinical results of 3.5 mm 

plates for humeral shaft fractures. Patients who were treated a 3.5 

mm plate were included in the study. The average patient age was 38 

(range 18-83). The average injury severity score (ISS) was 14 (range: 

5-34). There were 16 patients with Orthopaedic Trauma Association 

(OTA) 12-A, 13 with 12-B and six with 12-C fracture types. Thirtythree 

patients healed at an average of 3.9 months after surgery. Two 

patients required revision plating with bone grafting for non-union 

and healed. Thirty of 35 patients healed with callus formation. There 

were 13 (37%) of patients whose humerus fractures were stabilized 

to facilitate poly trauma mobilization. All patients were allowed full 

weight bearing on their extremity after surgery. The average follow 

up was seven months. Genetic and ethnic differences exist which 

may limit traditional techniques of humeral shaft fixation secondary 

to anatomic mismatch of the plate to bone diameter. In our study, 

there were no hardware failures in patients treated with 3.5 mm 

plates when cortical apposition was achieved to support the fixation 

montage. Secondary bone healing with callous occurred in 80% 

of the cases. In spite of immediate weight bearing allowed in our 

patients, the stiffness in our constructs was significant enough to 

permit fracture healing. This study supports a 3.5 mm plate may be 

used for humeral shaft fractures and immediately loaded when this 

is appropriate for the patient’s anatomy. 

829 

pApeR No. 694 

Are Two Plates Necessary for Fractures of the Distal 

Humerus? 

Jeffrey Dean Watson, MD, Tampa, FL 

Edward H Becker, III MD, Parkville, MD 

Hyunchul Kim, MS, College Park, MD 

Michael Shorofsky, BS, Baltimore, MD 

Daniel M Lerman, MD, New York, NY 


W Andrew Eglseder, MD, Baltimore, MD 

Anand M Murthi, MD, Baltimore, MD 

The purpose of this study is to compare the biomechanical stability 

of a standard precontoured two-plate locked construct to a single 

custom designed laterally placed locked plate for extra-articular 

supracondylar distal humerus fractures. Extra-articular supracondylar 

humerus fractures were created on matched pairs of non-osteoporotic 

cadaveric humerii. Specimens were plated with either a custom single 

locked plate placed posterolaterally or two precontoured locked 

plates placed orthogonally. Both constructs were instrumented in a 

hybrid manner with a combination of locked and unlocked screws. 

Each sample underwent cyclic loading in flexion and varus to failure. 

Average cycles to failure, force to failure, displacement and mechanical 

stiffness were compared. The single plate construct demonstrated a 

stiffness of 1072 N compared to 722 N for the two-plate construct 

(p=0.06). Average cycles to failure for the single plate construct were 

3,586, while the two-plate construct failed at an average of 2,771 

cycles (p=0.42). Force to failure averaged 428 N for the single plate 

and 380 N for the two-plate construct (0.56). All constructs failed 

through the plate-bone interface without failure of the hardware. A 

single plate custom designed specifically for fractures of the distal 

humerus is biomechanically equivalent with two precontoured 

plates also designed for the distal humerus. This is the first study 

to demonstrate a single plate as equivalent to a two-plate construct. 

This may be clinically significant because the single plate technique 

potentially reduces surgical time and exposure to the posterior and 

medial aspects of the elbow. Decreased exposure, especially to the 

medial elbow, may reduce iatrogenic injury. 

pApeR No. 695 

Incidence And Risk Factors Of Heterotopic Ossification 

Following Major Elbow Trauma 

Keith C Douglas, MD, Nashville, TN 

Lisa K Cannada, MD, Clayton, MO 

Stella Lee, BA 

Daniel Brian Dean, MD, Saint Louis, MO 

Kristin Archer, PhD, Nashville, TN 

William Obremskey, MD, Nashville, TN 

Heterotopic ossification (HO) is a complication of major elbow 

trauma with poorly defined incidence and risk factors. A total of 156 

patients who underwent operative intervention for a distal humerus 

fracture or an elbow fracture dislocation and had at least three 

months of follow up were retrospectively reviewed. The risk factors 

for radiographic HO and for surgical excision of HO were evaluated 

using separate multiple variable logistic regression analyses. Brooker 

class 3 or 4 HO occurred following 18/125 (14%) distal humerus 

fractures, 15/69 (22%) Orthopaedic Trauma Association (OTA) 

type C distal humerus fractures and 11/31 (35%) ulnohumeral 

fracture dislocations. Surgical excision of HO was performed after 

12/125 (10%) distal humerus fractures, 10/69 (14%) OTA type C 

distal humerus fractures and 8/31 (26%) ulnohumeral fracture 

dislocations. Severe elbow injury (OTA type C distal humerus fracture 




or ulnohumeral fracture dislocation, p

pApeR No. 699 

Internal vs External Fixation of Distal Radius Fractures: 

A prospective randomized controlled trial 





Few randomized trials have evaluated whether internal fixation offers 

superior outcomes to external fixation in the treatment of distal 

radius fractures (DRF). The purpose of this pragmatic randomized 

controlled trial (RCT) was to compare functional outcomes seen 

with open reduction/internal fixation (ORIF) to closed reduction, 

percutaneous pinning and external fixation (ExFix) in the treatment 

of DRF. Fifty-two patients with DRF failing closed reduction and 

casting were randomized to ORIF (n=26) or ExFix (n=26). For 

pragmatic reasons, the choice of internal fixation was left to the 

surgeon’s discretion early recruitment: dorsal plates (n=8), later 

recruitment: volar locked plates (n=18)]. Outcomes were measured 

at six weeks, three, six and 12 months and included: the Patient 

Rated Wrist Evaluation (PRWE), range of motion and grip strength. 

Generalized linear modeling using repeated measures was used to 

identify differences in outcome scores between fixation types over 

time. Other continuous variables were analyzed using the student’s 

t-test. The groups were equal with respect to age, gender, number 

with dominant hand injured and workers compensation claims. 

Generalized linear modeling using repeated measures indicated that 

there were significant differences for fixation and time in PRWE scores 

(Figure 1). The overall mean advantage for ORIF on PRWE scores 

was 9.95 (p=0.04) (Figure 1). However the ExFix group had a higher 

mean baseline PRWE score, indicating that despite randomization, 

this group may have had a more severe initial injury. Although this 

study was not designed to differentiate between fixation method, 

a subgroup comparison identified significantly better PRWE scores 

with volar plates compared to both external fixation (p=0.01) and 

dorsal plating (p = 0.04) (Figure 2). There were no significant 

differences for any measured impairment between the two groups. 

However, we did observe a trend towards greater grip strength 

(p=0.05), wrist extension (p=0.06) and supination (p=0.09) in the 

ORIF group at three months, and greater supination (p=0.07) and 

radial deviation (p=0.09) at one year. Of note, these differences were 

of little clinical significance (i.e.

pApeR No. 702 

uReducing Construct Stiffness can Improve Fracture 

Healing With Locked Plating Constructs 

Michael Bottlang, PhD, Portland, OR 

John Lawrence Marsh, MD, Iowa City, IA 

Trevor Lujan, PhD, Portland, OR 

Josef Doornink, MS 

Daniel C Fitzpatrick, MD, Eugene, OR 

Peter Augat, PhD, Murnau, Germany 

Brigitte von Rechenberg, MD, Zurich, Switzerland 

Steven Michael Madey, MD, Portland, OR 

Locked bridge plating relies on secondary bone healing, which 

requires interfragmentary motion for callus stimulation. This 

study evaluated whether locked plating (LP) permits sufficient 

interfragmentary motion to promote fracture healing. It furthermore 

evaluated if healing can be improved with a modified locked plating 

approach termed far cortical locking (FCL) that promotes controlled 

interfragmentary motion. Using an established ovine fracture 

healing model, a 3 mm tibial osteotomy was stabilized with LP or 

FCL constructs in 12 sheep. FCL constructs were designed to provide 

84% lower stiffness than LP constructs and permitted nearly parallel 

gap motion. Fracture healing was monitored on weekly radiographs. 

After sacrifice at week nine, healed tibiae were analyzed by computed 

tomography, mechanical testing in torsion and histology. At week 

nine, the FCL group had a 36% greater callus volume (p=0.03) and 

a 44% higher bone mineral content (BMC, p=0.013) than the LP 

group. Callus in LP specimens was asymmetric, having 49% less 

BMC at the near cortex adjacent to the plate than at the far cortex 

(p=0.003). Callus in FCL specimens was symmetric (p=0.91). FCL 

specimens healed to be 54% stronger (p=0.023) and sustained 156% 

greater energy to failure (p

A) and 100 Burgess combat-related transtibial amputations (group 

B). The primary outcome measure was the need for re-operation 

following definitive closure. At a mean follow up of two years (range, 

9-48 months), there was a 53% overall re-operation rate. The overall 

complications were neuroma excision (18%), myodesis failure 

(4%), heterotopic ossification excision (15%) and scar revision 

(7%). A significantly higher rate of overall complications (p>0.008) 

was noted in the bone bridge group. Additionally, there were an 

increased number of non-infectious complications in the bone 

bridge group (p=0.02). A positive selection bias was also noted for 

performing bone bridge amputations late (p = 0.0002) and outside 

the zone of injury (p

trauma patients. Our hypothesis was that clavicle fractures are 

associated with a high rate of death in geriatric patients sustaining 

high energy trauma. Patients injured from high energy trauma 

(motor vehicle collisions, falls from height, no low energy falls) with 

at least one orthopaedic injury were identified from a prospectively 

collected database at a level I trauma center between January 2004 

and July 2009. Our study group was patients age 65 years or greater 

(n=611) with at least one orthopaedic injury and the control group 

was those younger than 65 years (n=6564). All patients with and 

without clavicle fractures were identified. Our primary outcome was 

in-patient mortality recorded in a prospective database. Analysis 

was performed using Fisher’s Exact test and Student T test. The 

mortality rate for geriatric patients with clavicle fractures after high 

energy trauma was 23% (23/101), which was roughly double the 

rate observed in geriatric patients without clavicle fractures (12%, 

63/510, p= 0.02). The death rate in young patients with clavicle 

fractures (6.9%, 54/776) is also higher than those without clavicle 

fractures (4.6%, 266/5788, p=0.006), although as would be expected, 

these death rates are lower than the geriatric group (p

Three patients had positive blood cultures AFTER their orthopaedic 

intervention, which demonstrates the systemic complications, 

associated with these critically ill patients. The ISS was a poor 

predictor of deep infection as many patients with minimal injuries 

developed respiratory complications leading to a prolonged TICU 

stay and positive blood cultures. These patients may be under greater 

stress, negative nitrogen balance and poor nutrition making them 

more susceptible to nosocomial infection. It appears safe to operate 

on multiply injured patients with positive blood cultures when the 

‘window of opportunity’ and clinical parameters are optimal. This, 

however, may not prevent subsequent postoperative sepsis and deep 

wound infection. 

pApeR No. 726 

IVC Filter Placement in Orthopaedic Trauma Patients: 

Clinical Judgement or Clinical Guidelines? 

Andre Nicolas Gay, MD, Philadelphia, PA 


Surena Namdari, MD, MSc, Philadelphia, PA 


Indications for inferior vena cava (IVC) filter placement in 

polytrauma patients are debated and often performed via clinical 

management guidelines (CMG). The goals of our study were to 

determine how often CMG were followed versus how often clinical 

judgement (CJ) was used, to determine the effectiveness of each 

method, and to define factors leading to filter placement outside 

of CMG. A retrospective review of our institution’s trauma database 

of blunt orthopaedic trauma patients admitted from 1997 to 2007 

was performed. CMG dictates very high risk patients receive IVC 

filters. CMG IVC filter patients were compared to CJ IVC filters and 

control subjects. Data were analyzed by univariate and multivariate 

statistics. The overall prevalence of thromboembolic disease in 

4,279 blunt trauma patients was 6.8%. A total of 603 received IVC 

filters. Some 47.5% of patients had IVC filters placed via CMG versus 

52.5% by CJ. The prevalence of thromboembolism in CMG patients 

was 28.6%, compared to 52.4% in CJ patients. The sensitivity of 

CMG for patients at risk was 25.2%, and the specificity was 95.4%, 

compared to 68.3% and 96.5% for CJ. Older age (p

provides the first detailed report of musculoskeletal combat casualty 

wound incidence rates for a large combat-deployed manuever unit. 

The complex orthopaedic injury patterns found in this investigation, 

including the high incidence of major amputation and fractures, have 

important implications for the future, as the burden of ongoing care 

for combat injured soldiers must be borne by the federal government, 

military treatment facilities and the Veterans’ Administration. 

pApeR No. 729 

Does a Single Incision Fasciotomy Result in Adequate 

Decompression of the Deep Posterior Compartment 

Max Robert Berdichevsky, MD, Brooklyn, NY 

Ashish Patel, MD, Brooklyn, NY 

Hebah El-Gendi, MS 

Ariel Goldman, MD, Roslyn Heights, NY 

The parafibular single-incision fasciotomy technique has several 

potential advantages over the ‘conventional’ dual-incision technique: 

decreased iatrogenic trauma, skin bridge avoidance and reductions 

in wound complications. However, the deep posterior compartment 

is difficult to decompress using the single-incision approach. This 

study aims to evaluate (1) if the single incision technique can 

adequately decompress the deep posterior compartment and 

(2) the impact of incision length on decompression. Ten paired, 

intact cadaveric lower limbs were available. Three pairs (n=6) were 

infused with saline to create a compartment syndrome model for 

the deep posterior compartment. Decay analysis showed steadystate 

pressures five minutes after discontinuation of saline infusion; 

identifying the appropriate time window for fasciotomy testing. 

The remaining seven pairs (n=14) were infused and subsequently 

fasciotomies were performed: Group 1 received 14 cm incisions and 

Group 2 received 20 cm incisions. Paired student t-test was used 

to analyze differences in compartment decompression between 

incision lengths. Compartmental pressures measured a mean 43.6 

mmHg prior to incisions. No difference in compartment pressures 

(decay curve), prior to incisions, was observed between groups 

(p=0.54). Immediate post incision pressure measured 12.9 mmHg 

for both groups. No difference in immediate post-incision pressure 

was observed between groups (p=0.59). Mean compartment 

pressures reduced from 12.9 mmHg to 2.8 mmHg over the next 

five minutes. The parafibular single-incision fasciotomy technique 

adequately decompressed the deep posterior compartment. The 14 

cm fasciotomy incision performed as well as the 20 cm incision. In 

cases of extensive soft tissue compromise, the limited single-incision 

fasciotomy technique may be used for adequate lower extremity 

compartment decompression. 

pApeR No. 730 

Resuscitation in Polytrauma Open Fractures Impacts 

Infection Rates More Than the Timing of Operative 

Debridement 

Johnny M Gibbs, MD, Bedford, TX 

Robert N Reddix, Jr MD, Fort Worth, TX 

Daniel Ziegler, MD, Ft Worth, TX 

Terry E Rives, PhD 

Our study was designed to evaluate the timing of operative 

debridement with consideration of patient resuscitation status 

in polytrauma. Our first hypothesis was that early operative 

management does not independently decrease the risk of 

postoperative wound infections in this patient population. Our 

second hypothesis was that under-resuscitation of the polytrauma 

patient during perioperative surgical debridement may increase the 

836 

risk of postoperative wound infections in open fractures, regardless 

of operative timing. Utilizing our institutions trauma registry, we 

identified trauma activations from January 11, 2005 thru December 

16, 2007 with a documented open fracture that required operative 

irrigation and debridement. We retrospectively reviewed the patient 

medical records to identify Gustilo-Anderson open fracture grade, 

fracture type and location, timing of initial operative intervention, 

and perioperative resuscitation markers. Specifically, we targeted 

initial and perioperative vital signs including blood pressure and 

heart rate, perioperative base deficit and pH and intraoperative urine 

output as resuscitation markers. In addition we collected data on 

polytrauma severity with use of the injury severity score (ISS) and 

intensive care unit admission as criteria. Our outcome of interest 

was the development of a postoperative wound infection of any 

type. Statistical analysis was performed on timing of surgery and 

infection rate with a level of significance set at p

morbidities to the affected limb and whole body. To our knowledge 

this is the largest and most comprehensive study of multiligamentous 

knee injuries to date. We identified 102 patients (106 knees) with 

multiligamentous knee injuries and/or knee dislocations by ICD- 

9 diagnoses within a large regional trauma referral center from 

2000-2008. Ligamentous injury patterns were verified by MRI 

and confirmed by a single fellowship-trained sports medicine 

orthopaedic surgeon. Isolated ACL/MCL injuries were excluded. Data 

were obtained from the medical record using a predefined protocol 

to include trauma and orthopaedic examinations, radiographic 

findings and ancillary studies. All vascular injuries, nerve injuries, 

associated fracture patterns and whole body morbidities were noted. 

The mean age was 27 years; 74% were male. Thirty-one percent of 

patients were dislocated on arrival. Four patients (4%) had bilateral 

multiligamentous knee injuries. Motorcycle collision (29%), motor 

vehicle accident (23%), pedestrians struck by a motor vehicle (23%) 

and sports injuries (8%) were the most common mechanisms of 

injury. Injury patterns included ACL/PCL/PLC (43%), ACL/PCL/MCL 

(17%), ACL/PLC (17%), PCL/PLC (7%), ACL/PCL/PLC/MCL (5%) 

and ACL/PCL (5%). Twenty-six percent of patients had ipsilateral 

tibial plateau fractures and 19% suffered ipsilateral femoral fractures. 

Arterial injury (21%), peroneal nerve injury (26%) and compartment 

syndrome (16%) were common injuries to the affected limb. Severe 

closed head injury was present in 9%, symptomatic pulmonary 

embolism in 5% intra-abdominal injury in 15% and 2% expired. In 

our trauma center, nearly half of all multiligamentous knee injuries 

involved the ACL/PCL/PLC and 26% had associated ipsilateral tibial 

plateau fractures. Peroneal nerve injury (26%) was more common 

than previously reported in the literature (5-20%), while vascular 

injury was similar to prior studies. We found a substantial incidence 

of associated morbidities to the whole body. These results prove that 

concomitant injuries are common among patients presenting with 

multiligamentous knee injuries. 

pApeR No. 732 

The Fate of Patients With a SurprisePositive Culture 

After Nonunion Surgery 


Dana Olszewski, MD, Boston, MA 


Martin Hoffman, MD, Grand Rapids, MI 


Charlton Stucken, MD, Boston, MA 


William M Ricci, MD, St Louis, MO 

Michael J Gardner, MD, Saint Louis, MO 

The purpose of this study is to review a series of patients who had a 

‘surprise’ positive culture result (unexpected at the time of nonunion 

surgery) from definitive surgery for nonunion with regards to 

postoperative treatment and ultimate result. All patients treated for 

nonunion at three level one trauma centers who were considered 

at risk for indolent infection and had cultures taken at the time of 

definitive nonunion surgery were evaluated for organism, antibiotic 

regimen and result. Of 666 consecutive nonunions, 456 (68%) 

had cultures sent at the time of definitive surgical management 

for a history of prior surgery or open fracture. Ninety-four (21%) 

had a ‘surprise’ positive culture. The definitive procedures were 

intramedullary (IM) nail (45), open reduction/internal fixation 

(ORIF) (42), ex fix (one) and bone graft alone (six). Forty-five 

(52%) of the patients who had internal stabilization also had local 

augmentation with graft and/or bmp. Coag Neg Staph (45), MRSA 

(12) and MSSA (seven) were the most common bacteria isolated. 

837 

Seven had multiple organisms. Infectious disease consultants were 

involved in all cases. Eight cultures were considered probable 

contaminants and no additional antibiotics were given. The other 

86 patients were treated with six to eight weeks of culture specific 

antibiotics (77) or with a slightly shorter duration (nine). Five of 

the eight patients with presumed contaminants healed, three have 

a persistent nonunion, of which two are infected and one was 

amputated. Of the 86 treated with antibiotics, 79 (92%) healed, 

five (6%) developed a recurrent nonunion and two (2%) became 

grossly infected. Ultimately 12 (15%) of the 79 who healed had 

their hardware removed after union. In patients with a history of 

prior surgery or open fracture, we found that 21% had positive 

intraoperative cultures from the definitive nonunion surgery. All but 

those felt to be contaminants were treated with antibiotics, leading 

to a post-reconstruction infection rate of 2.2%, all with the same 

organisms cultured at the definitive procedure. The use of culture 

specific antibiotics seems justified based on the overall low rate of 

infection in this complex patient population. 

pApeR No. 733 

Negative Pressure Wound Therapy Reduces the 

Effectiveness of Antibiotic Beads 

Daniel J Stinner, MD, San Antonio, TX 

Joseph R Hsu, MD, San Antonio, TX 


Negative pressure wound therapy (NPWT) is commonly used as 

an effective wound management technique. Adjunctive treatments, 

to include the addition of local antibiotics, offer an attractive 

alternative to NPWT alone, but there is concern that the antibiotics 

will be removed from the wound milieu. This study evaluates the 

ability of antibiotic-impregnated polymethylmethacrylate (PMMA) 

beads used in conjunction with NPWT to minimize infection in 

contaminated wounds compared to the standard antibiotic bead 

pouch. A complex musculoskeletal wound was created on the 

hindlimb of 20 goats and contaminated with S. aureus (lux) bacteria. 

The bacteria are genetically engineered to emit photons, allowing for 

quantification with a photon-counting camera system. The wounds 

were débrided and irrigated six hours after inoculation. Goats were 

assigned to two different treatment groups: a control group using an 

antibiotic bead pouch and an experimental group using NPWT in 

conjunction with antibiotic beads. The wounds were evaluated 48 

hours after contamination and the bacteria within the wounds were 

quantified. NPWT effluent levels of antibiotic were measured at six, 

12, 24, 36 and 42 hours after treatment was initiated. The bacterial 

load was significantly minimized in wounds treated with the 

antibiotic bead pouch when compared to treatment with NPWT and 

antibiotic beads (p

pApeR No. 734 

Lidocaine Analgesia for Removal of Wound VACs: A 

Randomized Double Blinded Placebo Controlled Trial 

Thomas Christensen, MD, Salt Lake City, UT 

Troy Thorum, RN 

Erik Kubiak, MD, Salt Lake City, UT 

Vacuum assisted closure (VAC) is a wound management technique 

utilized frequently within orthopaedics. While facilitating closure 

of many types of orthopaedic related wounds, its frequent bedside 

removal can be a source of great pain for patients. The purpose 

of this investigation is to evaluate the pain relief achieved from 

topical lidocaine application during VAC removal. We prospectively 

randomized patients, aged 18 and older, who required at least two 

VAC changes for any type of extremity wound, excluding diabetic and 

neoplastic wounds. In a double-blinded fashion, topical lidocaine 

(1%) was compared to normal saline (0.9% NaCl) when injected 

into the VAC sponge to reduce VAC-removal pain. The crossover 

intervention technique, whereby each patient received two VAC 

changes, once each with lidocaine and saline, served to control for all 

possible patient characteristics. Randomization determined whether 

lidocaine or saline was given first or second. Patients were evaluated 

for pain scores, narcotic requirement and wound characteristics. , A 

total of 11 patients (all males; mean age, 38 years) were enrolled for 

a total of 21 VAC changes (mean wound size 133 cm2). Controlling 

for pre-VAC change pain, the lidocaine intervention was associated 

with 2.4 points less on the 0-10 visual analog scale (VAS) for 

pain (p-value


The Impact of Morbid obesity on Acetabular Fracture 

Waleed Fouad Mourad, MD, New York, NY 

Satya Pakianathan, MD, PhD 

Zhen Zhang, MS 

Rania Ayman Shourbaji 

Walid Waked, MD 

Srinivasan Vijayakumar, MD 

Mathew Graves, MD 

George V Russell Jr, MD, Jackson, MS 

To compare the incidence of heterotopic ossification (HO) between 

patients with body mass index (BMI) /=40 after operative treatment of traumatic acetabular 

fractures (TAF) that are followed by radiation therapy (RT). This 

is a single institution retrospective chart review of medical records 

and radiographs of 419 patients. All patients with well-documented 

BMI measurements underwent open reduction and internal fixation 

(ORIF) followed by RT ± indomethacin. All patients received single 

fraction of 700 cGy to mid-plane using 6-18 MV photons with 

fields that included the soft tissues around the proximal femur and 

acetabulum without bone shielding. All RT were given postoperatively 

within 72 hours. The patients were divided into two groups based on 

their BMI: Group (A) patients with BMI /=40. All patients were assessed post-operatively at fixed 

time intervals. HO was assessed during scheduled follow up with 

standard X-ray (AP/PA & Judet views). BMI was used as a surrogate 

measure of morbid obesity to test its ability to predict the risk of HO 

formation despite RT. The incidence of HO among all patients was 

21.2% (89/419) while among those in group A with BMI /=40 (21of 45) patients developed HO (46.7%). 

The difference between the rates of HO in the two groups was 29%. 

Chi-square test and multivariate logistic regression analysis on HO 

versus morbid obesity status, adjusting for other factors (i.e. age, 

gender, race and indomethacin) confirm the positive and direct 

association between HO formation and morbid obesity status, 

p

fractures. 


Outcome Assessment in Orthopaedic Trials: Is it Good 

Enough? 

Nicole Simunovic, Hamilton, ON Canada 

Sheila Sprague, Hamilton, ON Canada 

Gordon Guyatt, MD, Hamilton, ON Canada 

PJ Devereaux, MD,MSc, Hamilton, ON Canada 

Stephen Walter, PhD, Hmailton, ON Canada 


Mohit Bhandari, MD, Hamilton, ON Canada 

The approaches used to limit bias in outcome assessment in 

orthopaedic trials remain unclear. We aimed to assess the reporting and 

process of outcomes assessment practices in the current orthopaedic 

trauma literature. We searched eight high-impact-factor medical and 

orthopaedic journals manually and using the MEDLINE electronic 

database for reports of randomized controlled trials published from 

2005 to 2008 pertaining to the surgical treatment of trauma-related 

injuries. Two reviewers independently determined study eligibility 

and extracted relevant data from included trials. Of the 7,910 citations 

identified during our search, 47 randomized controlled trials, which 

included a total of 4,706 patients, met our inclusion criteria. Of 47 

studies, 39 (83%) provided a statement to describe some process 

of outcome assessment and 29 (74%) reported using an unblinded 

individual as the outcome adjudicator. Four studies (10%) reported 

using a second assessor to verify outcome measurements, and three 

studies (8%) reported the use of an adjudication committee to reach 

endpoint decisions via consensus. No included study provided a 

rationale for the use of their chosen approach to adjudication. The 

most commonly adjudicated outcomes included fracture healing 

(15 studies), reoperation rate (six studies) and general clinical 

assessment of post-operative complications and limb function (30 

studies), mainly by orthopaedic surgeons. Blinding of outcome 

assessors was not performed or unclear in 38 studies (81%). Despite 

the importance of the outcome assessment process in orthopedic 

trauma trials, key aspects of outcome assessment are insufficiently 

reported. 


uShockwave On Bone Healing And Systemic Nitric 

Oxide (NO), TGF-?1, VEGF and BMP-2 in Non-Unions 

Ching-Jen Wang, MD, Kaohsiung, Taiwan 

Jih-Yang Ko, MD, Niao Sung Hsiang, Taiwan 

Kuender D Yang, MD, Kaohsiung Hsien, Taiwan 

Feng-Sheng Wang, PhD 

This study investigated the effects of extracorporeal shockwave 

treatment (ESWT) on bone healing and the systemic concentrations 

of nitric oxide (NO), TGF-b1, VEGF and BMP-2 in long bone nonunions. 

Forty-two patients with 42 established non-unions of femur 

and tibia were enrolled in this study. Each long bone non-union was 

treated with 6,000 impulses of shockwave at 28 kV (= 0.62 mJ/mm2 

energy flux density) in a single session. Ten milliliters of peripheral 

blood were obtained for measurements of serum NO level and 

osteogenic growth factors including TGF-b1, VEGF and BMP-2; serum 

levels of calcium, alkaline phosphatase, calcitonin and parathyroid 

hormone before treatment and at one day, one, three and six months 

after treatment. The evaluations for bone healing included clinical 

assessments and serial radiographic examinations. At six months, 

bony union was radiographically confirmed in 78.6%, and persistent 

non-union in 21.4%. The serum NO level, TGF-b1, VEGF and BMP-2 

840 

were significantly elevated at one month after ESWT. Patients with 

successful bony union after ESWT showed significantly higher serum 

NO level, TGF-b1, VEGF and BMP-2 at one month after treatment as 

compared to patients with persistent non-union. ESWT is effective 

in the treatment of long bone non-union. Shockwave-promoted 

bone healing was associated with significant increases in serum 

NO level and osteogenic growth factors. The elevations of systemic 

concentration of NO level and the osteogenic factors may reflect a 

local stimulation of shockwave in bone healing in long bone nonunions. 


Bacteria on External Fixators, Which Prep is Best? 

Daniel J Stinner, MD, San Antonio, TX 

Michael John Beltran, MD, San Antonio, TX 

Brendan David Masini, MD, Schertz, TX 



There are no established guidelines for the surgical prep of an 

external fixator in the operative field. This study investigates the 

effectiveness of different prep solutions and methods of application. 

We hypothesized that there would be a similar reduction in bacteria 

counts regardless of prep solution or method of application. Forty 

external fixator constructs, consisting of a rod, pin and pin to bar 

clamp, were immersed in a broth of S. aureus (lux) for 12 hours. 

Constructs were then randomized into four treatment groups: 

chlorhexadine gluconate (CHG) (4%) scrub, CHG (4%) spray, 

betadine (BD) (10%) scrub and BD (10%) spray. Each construct 

was imaged with a specialized photon capturing camera system 

yielding the quantitative and spatial distribution of bacteria both 

before and after the prep. Each pin to bar clamp was loosened and 

moved two centimeters down the construct, simulating an external 

fixator adjustment and reimaged. Spatial distribution of bacteria and 

total bacteria counts were compared. There was a similar reduction 

in bacteria following surgical prep when comparing all four groups 

independently (p=0.19), method of application (spray vs. scrub, 

p=0.27) and different solutions (CHG vs. BD, p=0.41). Although 

bacteria were evident in newly exposed areas following external fixator 

adjustment, most notably within the loosened pin to bar clamp, 

it did not result in an increase in bacteria counts (all four groups, 

p=0.11; spray vs. scrub, p=0.18; CHG vs BD, p=0.99). Although there 

was no increase in bacteria counts following the simulated external 

fixator adjustment, it did expose additional bacteria previously 

unseen. While there was no difference in surgical prep solution or 

method of application, consideration must be given to performing 

an additional surgical prep of the newly exposed surface following 

loosening of each individual ex-fix component as this may further 

minimize potential bacteria exposure. 


The Influence of Hemorrhagic Anemia on Fracture 

Healing 

Thomas F Varecka, MD, Minneapolis, MN 

Lindsay Wiesner, BS 

Severe trauma frequently results in blood volume depletion. Little 

literature exists about how anemia affects bone healing. Anemia, 

and resultant transfusion thresholds, have recently been redefined as 

Hemoglobin (Hgb)

1997-2007. Patients were reviewed for development of anemia 

(Hgb d10 gm% vs 8 gm%), need for and quantity of transfusions, 

fracture healing. In total, 627 patients with 700 fractures were 

analyzed; 107 additional patients were excluded. Statistically 

significant reductions in healing were noted at both definitions of 

anemia. Tibial healing was most profoundly influenced: non-union 

rates of 30.6% at Hgb

should be considered when trying to prevent future fractures and 

calculating overall costs associated a particular surgical procedure. 


Age Matters: A Comparison Of Distal Radius Fractures 

In Young Adult And Elderly Patient Populations 

Joshua C Fox, MD, Dallas, TX 

Adam Jennings Starr, MD, Dallas, TX 

Rahul Banerjee, MD, FACS, Dallas, TX 

Adam Z Neustein, BS, Dallas, TX 

Acute fractures of the distal radius are among the most common 

bony injuries treated by orthopaedic surgeons. The purpose of this 

study was to compare and contrast the patterns of distal radius 

fractures seen at a level I trauma center in two populations, young 

adults and the elderly. Utilizing the trauma registry, all distal radius 

fractures treated at our level I trauma center between January 1, 

2006 and January 1, 2008 were identified and reviewed. Of these 

patients, two groups were selected based on age. The groups were 

young adults (ages 18-35 years) and the elderly (age >59 years). 

Over this two-year period, 131 young adults (132 wrists) and 67 

elderly (69 wrists) were treated at our institution for distal radius 

fractures. Electronic medical records from emergency department 

visits and digital radiographs of injury films were examined to 

determine demographic information and mechanism of injury and 

to classify fracture patterns according to the AO-OTA classification 

system. The patients in the young adult group were more likely to 

have been injured by a high-energy mechanism (50% vs. 18.8%). 

In contrast, most patients in the elderly group were injured in a fall 

from standing. The rate of open fractures was higher in the young 

adult group (5.3% vs. 1.4%) and the fractures in this group were 

more likely to have a more severe AO-OTA classification (45.1% 

vs. 21.7% AO-OTA type C). The proportion of female patients was 

3.4 times higher in the elderly group (86.6% vs. 25.2%). Our data 

provides demographic and epidemiological information for distal 

radius fractures seen at a level I trauma center in two specific patient 

cohorts. Younger patients tend to have high energy injuries, such as 

motor vehicle collisions, and the injury pattern more commonly 

involves the articular surface. In the elderly population, fractures are 

usually the result of low-energy falls and the resulting fractures are 

more commonly extra-articular. In the younger population men are 

more commonly affected than women, while in the elderly, women 

sustain this injury with higher frequency. This is important when 

analyzing the multitude of articles relating to treatment of distal 

radius fractures. Elderly patients and young adults have different 

injuries and different mechanisms that all fall into the discussion 

of distal radius fracture, and these groups should not be grouped 

together in analysis of treatments and results. 


Inter- and Intraobserver Reliability of Hip Stability after 

Posterior Wall Acetabular Fracture 

Adrian Thomas Davis, MD, Saint Louis, MO 

Berton R Moed, MD, Saint Louis, MO 

Hip stability status after posterior wall acetabular fracture involving 

20% to 50% of the posterior wall is difficult to determine. However, 

noted experts have professed that hip stability can be accurately 

determined by careful review of good quality anterior/posterior 

and oblique plain radiographs and a CT scan. The purpose of this 

study was to evaluate the interobserver and intraobserver reliability 

and accuracy of fellowship-trained orthopaedic traumatologists in 

determining hip stability in these fractures. Plain radiographs and 

axial CT images of 15 fractures involving 20% to 50% of the posterior 

842 

wall were reviewed by four expert, fellowship-trained orthopaedic 

traumatologists specializing in acetabular fractures. A determination 

of hip stability status was made for each fracture at two time points 

based on these images along with any history of dislocation of the 

hip at the time of injury. These determinations were compared to 

the findings of examination under anesthesia (EUA), which served 

as the gold standard. Although intraobserver reliability was good 

(0.65), interobserver reliability was poor (0.12). In addition, percent 

correct was only 53.3% for the initial reading and only 51.7% for 

the second. For the initial reading, sensitivity and specificity were 

100% and 12.5%, respectively. For the second reading, the sensitivity 

and specificity were 57.1% and 46.9%, respectively. Orthopaedic 

traumatologists expert in acetabular fracture care cannot adequately 

determine hip stability status for fractures involving 20% to 50% of 

the posterior wall using plain radiographs and CT. EUA is vital in 

determining hip stability status for these fractures. 


Open Distal Radius Fractures: Implications of Time to 

Debridement and Fixation Type 

John Kurylo, MD, Boston, MA 

Thomas W Axelrad, MD, New York, NY 


Andrew Jawa, MD, Boston, MA 

There is a scarcity of literature regarding complications and methods 

of treatment of open distal radius fractures. The purpose of this 

study is twofold: to compare patterns of open and closed injuries; 

and to evaluate the effect of delayed debridement and the choice of 

initial fixation on the rates of infection, malunion and nonunion. 

Forty consecutive patients with 41 open distal radius fractures were 

identified from a prospectively collected database. Nine patients 

without adequate follow up were excluded. Among the 32 injuries, 

10 had early (6 

hours). Twenty fractures were treated with external fixation (Group 

1), seven with plating (Group 2) and five with planned conversion 

from external fixation to plating (Group 3). There were 19 Guistillo 

and Anderson grade 1, 11 grade 2, and two grade 3A injuries. Each 

open fracture was matched with three closed-fracture controls. Each 

fracture was assessed for displacement, dorsal comminution and 

associated ulna fractures. Open fractures were more likely to be 

displaced (p

through an institutional fracture database. Patient demographic data, 

comorbidities, mechanism of injury, associated injuries, fracture 

type, treatment and mortality information were assessed. Data was 

analyzed with SPSS 17.0 statistics software. From a prospectively 

collected fracture database, there were 1,123 acetabular fractures 

treated between 2004 and 2009. There were 156 patients (14%) 

aged 65 years or older. In these senior patients, 70% had either an 

associated both-column or anterior column/posterior hemitransverse 

(AC/PHT) fracture pattern. Not surprisingly, 82% of the patients 

had significant medical comorbidities. Fifty-seven patients (36.5%) 

underwent open reduction and internal fixation using standard 

reduction techniques and surgical implants. Skilled nursing facilities 

were utilized after their initial hospitalization in 77% of patients. 

Fifty-one patients (33%) died within one year, and 75% of those 

were dead within 90 days of their acetabular fracture. Of the 51 that 

died during the study period, 84% had non-operative treatment. For 

those patients treated with traction alone, there was a 79% one-year 

mortality and a nearly 50% mortality rate at 90 days. Of the 105 

surviving patients, 91% underwent operative treatment. Acetabular 

fractures in senior patients occur uncommonly, but when they do 

occur there is a very high incidence of associated both column and 

AC/PHT fracture patterns. Routine fixation constructs and implants 

can be used effectively. The 90-day and one-year mortality rates are 

surprisingly high, especially in those senior patients treated without 

surgery. 


Treatment of Proximal Femur Fractures using an 

Extended-Short Nail 

Russel C Wright, BS, Burbank, CA 

Stephan Vahe Yacoubian, MD, Burbank, CA 

Raymond B Raven III, MD, Burbank, CA 

Yuri Falkinstein, MD, Burbank, CA 

Shahan V Yacoubian, MD, Burbank, CA 

This study was performed to evaluate the effectiveness of extendedshort 

(ES) nails for the treatment of intertrochanteric (IT) fractures. 

ES nails are long cephalomedullary nails which can be locked at the 

same distance as the distal locking hole of a short intramedullary 

(IM) nail. This study retrospectively reports on the two-year patient 

outcome of the first 150 consecutive patients undergoing IT fracture 

fixation with ES nails. In total, 150 consecutive patients presenting 

with IT fractures were admitted through the emergency department of 

a single community hospital, consented for surgery and subsequently 

followed for two years. The operative technique for the ES nail 

system consists of operative closed reduction with use of a fracture 

table and follows standard trochanteric-entry cephalomedullary 

nailing methods with canal reaming. Locking screws were targeted 

and inserted at the mid-femur at the nail’s ES hole. Before the twoyear 

postoperative examination, 38 (25.3%) patients had died and 

19 (12.7%) patients were lost to follow up for various reasons. 

Among the 93 patients available at two years, 54 (58.1%) had 

returned to their prefracture patient activity score. There were two 

postoperative periprosthetic fractures, two wound infections and 

three postoperative hematomas. No nonunions, implant failures, 

cutouts or fixation failures occurred. The hybrid design of the ES nail 

combines the mechanical characteristics of long IM nails with the 

surgical ease of use offered with short IM nails. This unique nail type 

obviates the freehand technique for targeting distal locking screws, 

leading to reduced operative time and radiation exposure. The ease 

of use, low rate of complication, high rate of union and favorable 

rate of return to prefracture patient activity level suggests this nail 

type to be a viable option in the management of hip fractures. 

843 


Infection Following External Fixation in Tibial Plateau 

Fractures: Is Pin SitePlate Overlap a Cause 

Catherine N Laible, MD, New York, NY 

Emily Earl-Royal, BA 

Roy Davidovitch, MD, New York, NY 

Kenneth A Egol, MD, New York, NY 

Michael Walsh, PhD, New York, NY 

It is common practice to place external fixator pins away from the 

field of future internal fixation in the setting of temporary external 

fixation. This practice is driven by the theory that pin site colonization 

is a potential source of infection at the time of definitive fixation. To 

our knowledge, no prior published study has looked at this potential 

association. The purpose of this study was to determine whether or 

not overlap between temporary external fixator pins and definitive 

plate fixation correlates with infection in high energy tibial plateau 

fractures. We performed a retrospective clinical review of an existing 

database of patients who received immediate placement of knee 

spanning external fixation followed by delayed internal fixation 

for high-energy tibial plateau fractures treated at our institution 

between 2000 and 2008. Seventy-nine patients with unilateral tibial 

plateau fractures formed the basis of this report. The mean age of 

the cohort was 47 years. Sixty patients (76%) were men and 19 

(24%) were women. There were 62 (79%) Schatzker VI fractures, 

15 (19%) Schatzker V fractures, one (1%) Schatzker IV fracture, and 

one (1%) Schatzker II fracture. There were 17 (21%) open fractures 

and 62 (79%) closed fractures. Of the 79 fractures treated, six (7.6%) 

developed deep infections requiring serial irrigation and debridement 

procedures and intravenous antibiotics. Radiographs were reviewed 

to assess for the presence of overlap between the temporary external 

fixator pins and the definitive plate. Fisher exact and t-test analyses 

were performed to compare those patients who had overlap and 

those who did not, and were used to determine whether this was 

a factor in the development of a post-operative infection. Six knees 

in six patients developed deep infections requiring serial irrigation 

and debridement procedures and intravenous antibiotics. Of these 

six infections, three were in patients with closed fractures and three 

in patients with open fractures. Two of these six infections followed 

definitive plate fixation that overlapped the external fixator pin 

sites, with an average of 4.2 cm of overlap. In the four patients who 

developed an infection and had no overlap, the average distance 

between the tip of the plate to the first external fixator pin was 6.3 

cm. There was no correlation seen between infection and distance 

from pin to plate, pin-plate overlap distance, time in external fixator, 

open fracture, classification of fracture, sex of the patient, age of 

the patient or healing status of fracture. Fears of definitive fracture 

fixation site contamination from external fixator pins do not appear 

to be clinically grounded. When needed we recommend the use 

of a temporary external fixation construct with pin placement that 

provides for the best reduction and stability of the fracture, regardless 

of plans for future surgery. 





Articular Exposure with the Swashbuckler Versus a 

Mini-Swashbuckler Approach 


James Alan Blair, MD, San Antonio, TX 

Jeannie Huh, MD, San Antonio, TX 

Jess McKarns Kirby, MD, Davidson, NC 


We aim to quantify the articular exposure obtained with a 

Swashbuckler approach to the distal femur and compare this to a 

“Mini-Swashbuckler” approach. Forty surgical approaches in 20 

fresh-frozen hemipelvis specimens were performed using a Miniswashbuckler 

approach followed by a traditional Swashbuckler. 

Key anatomic landmarks, including the posterior femoral condyles, 

intercondylar notch and medial articular margin, were either 

directly visualized or palpated with a tonsil clamp. Calibrated digital 

photographs were taken from the surgeon’s viewing perspective 

after each approach. The digital images were then analyzed using 

a computer software program, ImageJ (NIH, Bethesda, MD), to 

calculate the articular surface square area exposed. The Miniswashbuckler 

exposed 87% of the articular surface compared to the 

Swashbuckler approach(29.48 cm2 vs. 34.03 cm2, p

(460 out of 7,349), and with osteonecrosis was 11.1% (41 out of 

369). In all cases, callus and granulation tissue were histologically 

observed along the fracture line. A SIF was diagnosed histologically 

in 6.5% of the surgically removed femoral heads. 


Bag of Bones Treatment of Comminuted Distal 

Humerus Fractures: Is It Relevant in 2011? 

Peter S Vezeridis, MD, Boston, MA 


Alexander Michael Vezeridis, BA, Boston, MA 

James T Monica, MD, Chestnut Hill, MA 

Significantly comminuted distal humerus fractures present a 

challenging therapeutic dilemma. Non-operative treatment - the 

bag of bones approach - was first described over 70 years ago. We 

tested the hypothesis that non-operative treatment of comminuted 

distal humerus fractures results in acceptable functional outcome, 

particularly in patients with multiple comorbidities. Patients treated 

with initial definitive non-operative management for a comminuted 

distal humerus fracture between 2007 and 2010 were reviewed. 

Demographic data, mechanistic data and functional outcomes 

were analyzed. Patients with 12 months or greater follow up were 

administered outcomes instruments. Five patients (three males, two 

females) were treated with the bag of bones approach, with brief 

immobilization and early range of motion. Average age was 73 years. 

All injuries occurred after fall from standing. Medical comorbidities 

included atrial fibrillation on coumadin, diabetes mellitus, 

osteoporosis and morbid obesity. Two patients had previous surgery 

on the ipsilateral extremity. One patient was hospitalized for 

septic shock shortly after injury. At six months post-injury, average 

flexion was 127.5°, extension was -30°, supination was 82.5° and 

pronation was 86°. One patient developed heterotopic ossification 

but elbow range of motion remained functional. No patients 

required pain medications at latest follow up. For three patients at 

average 20.7 months follow up, average Mayo Elbow Performance 

Score was 95/100 (100 optimal), Oxford Elbow Score was 45.7/48 

(48 optimal) and QuickDASH Score was 7.5/100 (0 optimal). Nonoperative 

treatment for comminuted intra-articular distal humerus 

fractures results in acceptable functional outcome in elderly patients 

with multiple comorbidities. This treatment continues to be relevant 

in 2011 and should be considered for patients with higher surgical 

risk. 


uThe Effect of a Single Dose of Ketorolac on 

Heterotopic Ossification in a Rat Model 

Laurence Kempton, MD, Charlotte, NC 


Carola Pechey, Detroit, MI 

Elisabeth Michels 

James John Verner, MD, Beverly Hills, MI 

The purpose of this study was to determine whether a single dose 

of ketorolac inhibits heterotopic ossification (HO). Our hypothesis 

was that a local dose of ketorolac would inhibit HO greater than a 

systemic dose, which would inhibit HO greater than a saline control. 

Demineralized bone matrix was implanted into gluteal pouches 

in 31 Sprague Dawley rats. Ten rats were injected with saline both 

locally and intraperitoneally (control). Eleven rats were injected with 

saline locally and ketorolac intraperitoneally (systemic’ group). Ten 

rats were injected with ketorolac locally and saline intraperitoneally 

(local group). Half the rats were sacrificed at four weeks and the rest at 

845 

eight weeks. The implants were recovered, and their ash weights were 

measured in order to determine the extent of mineralization. Mean 

percent-mineralization at the four-week time point was 20.04% in 

the control group, 27.89% in the systemic group and 29.40% in the 

local group. Mean percent-mineralization at the eight-week time 

point was 42.69% in the control group, 45.25% in the systemic 

group and 43.14% in the local group. Statistical analysis at each time 

point revealed no significant differences between groups. Neither 

local nor systemic administration of a single dose of ketorolac had a 

noticeable effect on HO formation at the four and eight-week time 

points. This suggests that fracture healing may not be inhibited by 

a single perioperative dose of ketorolac. Also, a single injection of 

ketorolac is not likely adequate for HO prophylaxis. 


A Cost Utility Analysis Of Hemiarthroplasty And 

Internal Fixation In Femoral Neck Fractures 

Gudrun Waaler, MSc 

Eline Aas, PhD, Oslo, Norway 

Hemiarthroplasty is the most common treatment of displaced 

femoral neck fractures in the elderly. We preformed a cost utility 

analysis to assess the cost effectiveness of hemiarthroplasty compared 

to internal fixation. In total, 222 patients above 60 years of age 

were randomized to internal fixation with two parallel screws or a 

bipolar cemented hemiarthroplasty. Mainly due to cognitive failure 

or death, 56 patients failed to complete the EQ-5D questionnaire at 

any follow up, hence 166 patients, 124 women (75%), mean age 82 

years were available for analysis. Quality of life was assessed with the 

EQ-5D at four, 12 and 24 months, and used to calculate patients’ 

quality adjusted life-years (QALYs) during the two-year period. 

Resource use in hospital, rehabilitation, community-based care and 

nursing home was identified, quantified and valued. The cost for the 

initial hospital stay was lower for the internal fixation group, but due 

to reoperations (45 vs. nine; p

fluoroscopic guide without bone graft. Seventeen of the 18 fractures 

from the TN group and all fractures from the SP group went on to 

union. Time to union was similar in both groups. There was no 

complication except one deep infection and resulted nonunion after 

TN. All patients showed excellent clinical results of Flynn’s criteria. 

The average operative time was 104 minutes for SP and 94.7 minutes 

for TN (P = 0.095). The average fluoroscopy time was 87% greater 

for the SP group (109 seconds) than for the GT group (58 seconds) 

(P


Dynamization of the Taylor Spatial Frame 

Christopher August Iobst, MD, Key Biscayne, FL 

Anthony Khoury, BS 

Zach Ingwer, BS 

Edward L Milne, Miami Beach, FL 

David N Kaimrajh, Miami, FL 


There have not been any attempts to study dynamization of the 

Taylor Spatial Frame. A modifed shoulder bolt with 2 mm extra 

length was created as a method of dynamizing the Taylor Spatial 

Frame. The objective of this study was to define what type of motions 

occur with sequential unlocking of struts, and to see if the use of 

a modified shoulder bolt applied to the ring can control the shear 

motions while allowing the desired axial motion at the fracture/ 

osteotomy site. Dynamized Ilizarov threaded rods were used as a 

control. Five sawbones tibias had Taylor Spatial Frames applied and 

a 5 cm gap was created just below the tibial tubrical. Axial load was 

applied from 20 N tension to -200 N compression aligned to the 

position of the predicted resultant force at heal strike. Six degrees 

of freedom of motion between the proximal and distal fragments 

was measured with a Selspot system for loading with all struts 

tight, then for progressive unlocking of each strut, followed by the 

application of a modified shoulder bolt at each struts connection 

to the proximal ring which can allow sliding of up to 2 mm and 

finally the application of Ilizarov rods locked to the rings. Coronal 

and sagittal shear motions were combined by vector summation to 

create a total shear motion at the gap. Shear translations were 1.3 ± 

1.1 mm for locked struts, 13.7 ± 12.1 mm with one strut unlocked, 

1.7 ± 0.9 mm with the modified shoulder bolts and 0.7 ± 0.2 mm 

for the Ilizarov posts. The vertical translations were 1.1 ± 0.3 mm for 

locked struts, 15.5 ± 4.3 mm for one strut unlocked, 3.15 ± 0.9 mm 

for the modified shoulder bolts and 0.23 ± 0.06 mm for the Ilizarov 

rods. The 2 mm dynamization shoulder bolts were able to increase 

the axial motion of the Taylor Spatial Frame by approximately 2 

mm which was a statistically significant degree while also reducing 

the shear movement. Other techniques for dynamizing the Taylor 

Spatial Frame, such as loosening struts, should be avoided due to the 

large amounts of shear that occur at the fracture/osteotomy site. 


Correlated Biomechanical and Histological Changes in 

a Remodelable Bone/Polymer Biocomposite Implant 

Moussa Hamadouche, MD PhD, Paris, France 

Christophe Nich, MD, Paris, France 

Dr Bertrand David, Châtenay-Malabry Cedex, France 

Karim Oudina, MS 

Valentin Myrtille, MS 

Herve Petite, PhD 

The aim of this study was to correlate the histological and mechanical 

properties over time in a remodelable bone graft substitute in a 

rabbit defect model. A biocomposite of bioresorbable polymer and 

mineralized cortical allograft bone fibers was implanted during 

its moldable phase in 6 x 4.5 mm defects, in the distal femurs of 

New Zealand white rabbits. Animals were sacrificed immediately 

after implantation, and at eight, 16 and 24 weeks. Specimens 

dedicated to compressive testing were loaded and UCS calculated. 

Other specimens were embedded in polymethylmethacrylate for 

non-decalcified histology. Cross-sections were prepared to 120 mm 

thickness allowing for histomorphometric measurement of bone 

tissue in the defect. The biocomposite graft progressively remodeled 

847 

into newly formed bone from the periphery towards the center of 

the defect. Histomorphometric analysis revealed that bone fraction 

increased from 27.7% (representing bone of the composite) 

immediately after implantation to 36.7% at eight weeks and 74.5% 

at 16 weeks (significant, p

and epidemiology of patients with orthopaedics injuries transferred 

to a Level-I trauma center. Prospective data was supplemented 

through chart review on all patients transferred to a Level-I trauma 

center with orthopaedic injuries (N=546) from January 1, 2007 to 

December 31, 2007. The accepting orthopaedic trauma surgeon 

evaluated the appropriateness of transfer by visual analog scale (VAS). 

In addition to VAS scores, demographics and appropriateness were 

collected on each patient transferred to the trauma center requiring 

orthopaedic trauma service involvement. The authors considered 

16.5% of the cohort inappropriate transfers, 49.3% appropriate and 

the remaining 34.2% were designated as intermediate. The transfers 

came from an emergency department physician in 81% of cases, an 

orthopaedic surgeon in 14% of cases, and 5% via general surgeon 

or internist. One hundred forty-eight cases transferred primarily 

due to orthopaedic injuries had an available orthopaedic surgeon 

on call at the original institution. Sixty percent were transferred due 

to orthopaedic injury complexity, but only 39% of the 148 were 

evaluated by an actual orthopaedic surgeon prior to transfer. Lack 

of orthopaedic coverage at the referring hospital accounted for 27% 

of transfers. A total of 16.5% of transfers were deemed completely 

inappropriate by the accepting orthopaedic traumatologist. Most 

transfers, both appropriate and inappropriate, were attributed to 

either complete lack of orthopaedic coverage or a lack of expertise 

at the referring center. 


Divergent Trends between Typical and Atypical Hip 

Fractures in the US Elderly, 1996-2007 

Timothy Bhattacharyya, MD, Bethesda, MD 

Zhong Wang, PhD 

Increasing numbers of atypical hip fractures have been reported. Large 

studies have argued that the subtrochanteric fractures are quite rare. 

The true trend in incidence is unknown. To compare trends between 

atypical and typical hip fractures between men and women 65 years 

or older, we conducted cross-sectional studies from 1996 to 2007 on 

619,044 hospitalizations in the Nationwide Inpatient Sample with a 

primary surgical procedure and a primary diagnosis of either a typical 

closed hip fracture in femoral neck and intertrochanteric regions or 

an atypical closed fracture in the subtrochanteric region. National 

estimates and sex-specific, age-adjusted rates of hip fractures were 

measured. Between 1996 and 2007, the annual national estimate 

for typical hip fractures decreased 12.8% from 263,623 to 229,942. 

Among women, age-adjusted rates of typical hip fractures decreased 

by 31.6% (from 1,020.5 to 697, four fractures per 100,000) and 

among men, by 20.5% (from 424.9 to 337.6 fractures per 100,000). 

In contrast, national estimates for atypical hip fractures increased 

31.2% from 8,273 to 10,853. Joinpoint regression analysis indicated 

that trends in age-adjusted rates for atypical hip fractures remained 

unchanged among men (p=0.34), but increased 20.4% among 

women from 28.4 (95% confidence interval CI], 27.7-29.1) in 1999 

to 34.2 (96% CI, 33.4-34.9) fractures per 100,000 in 2007. The 

annual percentage increase was 2.1% (95% CI, 1.3-2.8, p

clean orthopaedic surgery with the frequency of contamination 

tending to increase towards the end of the operations. 


Treatment of Nonunion of Femoral Neck Fracture by 

Valgus Osteotomy in 33 Cases 

Masoud Norouzi, Tehran, (Islamic Republic of) Iran 

Dr Mohammad Nasir Naderi, Tehran, (Islamic Republic of) Iran 

In spite of advances in treatment, femoral neck fractures are 

complicated fractures with a relatively high incidence of nonunion. 

Between 1990 and 2004, 33 patients with nonunion of femoral neck 

fractures were treated by valgus osteotomy in our department. The 

mean age of patients at the time of operation was 38 years (range 

from 16 to 60 years). Reasons for non-union were implant failure in 

21 and osteomalacia in two patients. The remaining 10 patients were 

treated non-operatively. Average neck-shaft angle was 109 (78-125) 

degree and the average shortening of the involved limb was 2.5 (0.5- 

4.5) centimeters. After subtrochantric valgus osteotomy, fracture 

healing occurred in 32 of 33 patients. The average time for healing 

was five months (range three to eight months). Pain and limitation 

of motion improved remarkably and the majority of patients did 

not need to use crutches. Post-operatively neck-shaft angle was 140 

(125-160) degrees and shortening reduced to an average of one 

centimeter. Partial avascular necrosis of the femoral head developed 

in five patients after six to 12 months. Valgus osteotomy of the femur 

is a suitable procedure for treatment of femoral neck nonunion in 

young patients, easy to perform with relatively good results. 


Influences of Rotation on Neck-Shaft Angle 

Measurements in the Varus Malreduced Proximal 

Femur 

Meir Tibi Marmor, MD, Foster City, CA 

Robert Trigg McClellan, MD, San Francisco, CA 

Amir Matityahu, MD, San Francisco, CA 

Varus and shortening are the most common malreductions seen 

in proximal femoral fractures, and may lead to poor functional 

outcome. It is assumed that in order to quantify the neck-shaft 

angle (NSA) of the femur, x-ray measurements have to be performed 

with the leg internally rotated to compensate for proximal femoral 

external rotation and version. Since in most of the our patients, we 

cannot verify the rotation of the leg when x-rays were taken, the 

purpose of this study was to define the utility of in situ neck-shaft 

angle measurements on the anterior posterior (AP) x-ray. First, CT 

scans of 20 patients (40 hips) undergoing abdominal CT scans were 

assessed for the in-situ rotation of the femoral neck relative to the 

scanner bed. Then, NSA of three saw-bones with intertrochanteric 

osteotomies were measured after they were subjected to anatomic 

reduction (AR), varus malreduction of 20° (VM), and shortening 

malreduction of 10 mm (SM). The proximal femurs were then 

rotated in 5° intervals from 45° of internal rotation (IR) to 50° 

of external rotation (ER) and x-rays performed. Two independent 

trauma trained orthopaedic surgeons measured the femoral NSA 

using well-established techniques. The rotation of the neck of 

the femur relative to the CT scanner bed in the 40 hips averaged 

23.4±9.9° of external rotation. The measured NSA was 128° for the 

AR femur, 107.5° for the VM femur and 127.5° for the SM femur. 

NSA measurements varied less than 5° with less than 30° of rotation 

in the proximal femur but drastically increased with continued ER or 

IR for all groups. At 50° of ER, the average NSA was 137.5° for the AR 

femur, 115.5° for the VM femur and 139.5° for the SM femur. At 40° 

of IR, the average NSA was 143.5° for the AR femur, 116.0° for the 

849 

VM femur and 134.5° for the SM femur. The measured NSAs, when 

the femur is rotated, were correlated to the angles predicted from the 

following formula: NSA= 90 + tan-1vertical height/(offset*cos(beam 

angle))]. 


The Preoperative Diagnosis of Infection in Nonunions 


Charlton Stucken, MD, Boston, MA 

Dana Olszewski, MD, Boston, MA 


The purpose of this study is to report on the utility of a standardized 

protocol to rule out infection in high risk nonunion patients, 

and to evaluate the efficacy of each component of the protocol. A 

protocol of preoperative tests (WBC, CRP, ESR), a combined white 

cell/sulfur colloid scan and intraoperative gm stain and biopsy 

were performed in high risk nonunion patients. Infection was 

diagnosed based on positive intra-operative cultures, a finding of 

gross infection or infection in the immediate postoperative period. 

Ninety-three patients with 95 nonunions and available records for 

the above protocol were surgically treated for nonunion. Thirty of 

the 95 nonunions were ultimately diagnosed as being infected. The 

utility of the protocol components are seen below: Test - Sensitivity 

Specificity -PPV-NPV White Cell Scan - 19%, 92%, 50%, 72% ESR 

>30; 58%, 80%, 58%, 80% CRP >1.0; 61%, 75%, 54%, 75% WBC 

>11,000; 22%, 89%, 50%, 70% Path WBC >3; HPF 40%, 81%, 

40%, 81%. Using a combination of the risk factors (elevated WBC, 

ESR, CRP and (+) scan), the PPV for 0, 1, 2 and 3 risk factors being 

positive were 22%, 36%, 57% and 83% respectively. Eliminating the 

more expensive nuclear scan, leaving only WBC, ESR and WBC, the 

PPV for 0, 1, 2 and 3 risk factors were 25%, 27%, 58% and 100%. 

In the face of prior surgery or history of open fracture, quiescent 

infection is common. None of the tests that we performed on this 

difficult population of patients was independently accurate We 

recommend simple blood tests and intra-operative WBC/HPF for 

the pre- and intraoperative workup of quiescent infection in high 

risk nonunions. 


The Effect of Locking Plugs on the Strength of a 

Locking Plate Construct in an Osteoporotic Model 

Brad Matthew Picha, MD, Dayton, OH 

Michael J Prayson, MD, Dayton, OH 

Tarun Goswami, DSc 

Locking plates are becoming increasingly more popular as tools of 

fixation in fracture care. When a plate spans a region of comminution 

this creates an area of increased stress. This area may be predisposed 

to early failure. Filling these holes with locking plugs may help to 

reduce the point stress and thereby help to decrease plate failure. The 

purpose of this study was to examine the biomechanical strength of 

a 10-hole LCP plate in an osteoporotic bone model with and without 

locking plugs inserted at the fracture site. The plates were tested 

under torsion and axial load using a 2 centimeter osteotomy gap. 

Each group was subdivided with the experimental group containing 

locking plugs at the osteotomy site while same number of constructs 

in the control group did not. For the axial group, the specimens 

were initially placed through 30,000 cycles at a load of -50N to 

-350N. After cyclic testing the specimens were loaded to failure. For 

the torsion testing, specimens were initially placed through 30,000 

cycles at a load of -3 Nm to +3 Nm with a frequency of 2 Hz. The load 

to failure was then attained. There were no statistically significant 

differences observed in either the axial load group or the torsional 




load group for displacement, load to failure and stiffness. There were 

however, meaningful trends evident in displacement and stiffness 

measurements. This biomechanical study failed to demonstrate 

statistically significant biomechanical improvements. Meaningful 

trends were evident which support further investigation. 


uThe Effect of a Removable Venous Filter during 

Medullary Canal Pressurization: A Canine Study 

Joseph M Caldwell, II MD, Akron, OH 

William Lanzinger, MD 

Mark C Leeson, MD, FACS, Akron, OH 

Dennis Wright, MD, FACS 

Kimberly Stakleff, PhD, Akron, OH 

The rate of acute respiratory distress syndrome (ARDS) is higher in 

trauma patients with acutely treated femoral shaft fractures with 

reamed intramedullary (IM) nailing (Pape et al). This is thought to 

be due to the liberation of bone marrow fat particles during reaming, 

which then travel to the lung and cause damage to the parenchyma. 

The purpose of this study is to 1) demonstrate the ability of a clinically 

applicable and retrievable venous filter to capture such particles and 

2) how such a device affects lung function after reamed IM nailing. A 

total of 12 canine test subjects were used, four control and eight test 

subjects. The subjects were anesthetized and a Swan-Ganz catheter, 

arterial line and the removable venous filter were introduced. The 

femoral and tibial canals were then reamed and an IM nail was 

placed in each. Various pulmonary and cardiac effects were then 

measured and recorded at timed intervals up to 60 minutes after the 

procedure. The filter and a lung sample were retrieved for analysis. 

On gross inspection, the retrieved filters did indeed capture bone 

marrow debris that was liberated. There was a statistically significant 

difference (p=0.0476) in the change in pH at 60 minutes after IM 

nailing (control = -0.052, experimental = -0.013). Also, a significant 

difference was noted in the change in serum bicarbonate (meq/dl) 

between the two groups. The control group had a change of -3 and 

-1.8 at 10 and 60 minutes, respectively. The experimental group had 

a change of +0.6 and +1.2 at those intervals (p=0.0238, 0.0167 at 

10 and 60 minutes, respectively). The oxygen saturation levels were 

lower in the control group at the 10 and 15 minute intervals. In this 

canine model, the filters did capture and allow retrieval of embolic 

debris from reamed IM nailing of lower extremity long bones and 

had a protective effect on pulmonary function after the procedure. 

We propose that the multiply injured patient at risk for pulmonary 

complications and ARDS with long bone fractures could benefit 

from such filters prior to intramedullary fixation. 


The Effect of Femoral Lateral Locked Plate Position in 

the Setting of a Well-Fixed Proximal Stem 

Dan Kemper, MD, Salt Lake City, UT 

Daniel Scott Horwitz, MD, Salt Lake City, UT 

Erik Kubiak, MD, Salt Lake City, UT 

Thomas F Higgins, MD, Salt Lake City, UT 


Lateral locking plates are used to treat periprosthetic femur fractures 

distal to a well-fixed stem. There is concern for a potential stress riser 

as the gap decreases between the proximal plate and distal stem, but 

the relationship between the plate and stem with regards to length 

is unknown. This study analyzed the effect of construct length on 

cortical strain between a femoral lateral locking plate and a well-fixed 

cemented stem in a fall loading model. Eight composite femurs with 

850 

cemented stems were instrumented with progressively increasing 

lengths of fixation. Cortical surface strains in the inter-prosthetic 

region were measured using uniaxial strain gauges. Femurs were 

loaded to simulate a fall from height. Load to failure was performed 

in three different groups (four specimens per group): 8 cm gap 

between implants, 2 cm gap and overlapped using a four-point 

bending model. Paired T-tests, corrected for multiple comparisons, 

compared changes in strains, load to failure and stiffness between 

groups (significance=p0.34). Inter-prosthetic cortical strain was reduced and 

loads to failure greatly increased by overlapping a well-fixed proximal 

femoral stem with a lateral locking plate. We recommend bypassing 

the proximal stem and overlapping implants whenever possible. 


Pain, Function And Complications After Operations 

With A Sliding Hip Screw Or A Nail - A RCT 

Kjell Matre, MD, Bergen, Norway 

Jonas Meling Fevang, MD, Bergen, Norway 

Leif Ivar Havelin, MD, Bergen, Norway 

Tarjei Vinje, MD 

Jan-Erik Gjertsen, MD, PhD 

Birgitte Espehaug, PhD, Bergen, Norway 

Ove Nord Furnes, MD, Bergen, Norway 

Nailing of trochanteric fractures is increasing worldwide. This trend, 

however, is not supported by documentation of better clinical results 

compared to the sliding hip screw (SHS). Therefore, in the present 

study, we compared one recently launched nail with the SHS. In this 

prospective, randomized multicenter study with 697 patients, we 

compared one new nail with the SHS regarding postoperative pain, 

functional mobility and complications. Patients older than 60 years 

with trochanteric and subtrochanteric fractures were included in five 

hospitals. Day five, and three and 12 months postoperatively, pain 

was measured using a Visual Analogue Scale (VAS) and the Timed Up 

and Go test (TUG-test) was performed to evaluate functional mobility. 

A total of 328 patients were evaluated at day five postoperatively. At 

mobilization, patients treated with the nail had less pain compared 

to the SHS (VAS 47 vs. 53). There was no difference in pain at rest or 

in early functional mobility. The length of postoperative hospital stay 

was also similar for the two groups (8.5 and 8.4 days respectively). 

At three (457 patients) and 12 months (374 patients) there was no 

difference in pain or TUG-test performance. At discharge, three and 

12 months, the overall reoperation rate for the groups was similar. In 

this prospective randomized trial we found less pain at mobilization 

for patients operated with a nail at day five postoperatively compared 

to the SHS. No difference in pain or function was evident at later 

follow ups. There was no difference in reoperation rates between the 

groups. 





Fate of Combat Nerve Injury 


Travis C Burns, MD, Tarrytown, NY 

Tobin Eckel, MD, Silver Spring, MD 

Benjamin Potter, MD, Washington, DC 



Determine whether multiple projectile penetrating injury (MPPI) 

is associated with poorer rates of motor and sensory improvement 

compared to single projectile projectile injury (SPPI) in combatrelated 

Type III open tibia fractures. Retrospective study at three 

U.S. military medical centers between March 2003 and September 

2007 to identify service members who sustained a type III open tibia 

fracture with a peripheral nerve injury. Thirty-two patients with 43 

peripheral nerve injuries met inclusion criteria and were available 

for follow up at an average of 20 months. There was no difference in 

improvement based on mechanism of injury. At an average follow 

up of 20 months, 89% of motor nerve injuries were functional, 

while sensory nerve injuries had function in 93% of patients. Fifty 

and 27% of motor and sensory injuries demonstrated improvement, 

respectively (p=0.043). With the numbers available there was no 

difference in motor or sensory improvement based on mechanism 

of injury, fracture severity or location, soft tissue injury or specific 

nerve injured. In the subset of patients with an initially impaired 

sensory exam, full improvement was related to fracture severity 

and location (p

mice showed greater inflammatory gene expression of IL-1 and 

TNF-a in the synovial tissue, including a 720-fold increase in IL-1b 

expression and 13-fold increase in TNF-a, and significantly higher 

levels of IL-1b in the serum (p=0.002) following articular fracture 

compared to MRL/MpJ mice. C57BL/6 mice showed higher levels 

of cytokines in the synovial fluid of fractured limbs and markedly 

increased numbers of activated macrophages in synovial tissue 

beginning three days post-fracture compared to MRL/MpJ mice. 

Control C57BL/6 mice exhibit significantly increased intra-articular 

and systemic inflammation following articular fracture compared to 

MRL/MpJ mice. The MRL/MpJ mice reduced inflammatory response 

after injury may protect them from the development of PTA. 


Acute Compartment Syndrome of the Thigh in Combat 

Casualties 

Brendan David Masini, MD, Schertz, TX 

Amber E Ritenour, MD 

Adam Wesley Racusin, MD, Round Rock, TX 


Tad L Gerlinger, MD, San Antonio, TX 


Acute compartment syndrome (ACS) of the thigh is a rare clinical 

entity and blast injury mechanisms may put soldiers at specific risk. 

The spectrum of this disease and functional outcome in combat 

casualties has not been reported. We hypothesize that mortality, 

functional outcome and fasciotomy morbidity are similar to civilian 

reports and related to injury severity score (ISS). A chart review 

at Landstuhl Regional Medical Center, Germany was performed 

for casualties who underwent fasciotomies for ACS in Iraq or 

Afghanistan between January 2005 and August 2006. Those who 

had fasciotomies for ACS of the thigh were evaluated for wounding 

patterns and clinical characteristics. Outcomes evaluation was by SF- 

36, Short Musculoskeletal Function Assessment questionnaire and a 

fasciotomy specific symptom questionnaire. Thirty patients (9% of 

all ACS) had 40 fasciotomies of the thigh. A total of 87% of casualties 

were by blast mechanism. Overall mortality was 23%. Average ISS was 

22 (1-75). Some 27.5% of thighs had femur fractures with average 

ISS 20 and 0% mortality. Twelve had >40% total body surface area 

burns with average ISS 34 and mortality of 58%. Eleven patients 

with 15 injured thighs treated with fasciotomy were evaluated for 

outcome at avg. 36 months from injury. SFMA scores demonstrated 

and average disability index of 38.6 ± 5.4 (11-62) and an average 

bother index of 32 ± 4.3 (6-45). The average SF-36 scores physical 

summary 38.4±2.5 (28-51) and mental summary 44.9±5.4 (16-66). 

Fasciotomy symptoms reported in order of frequency were sensation 

changes, dry skin, tethering, edema, discoloration, pruritis, fascial 

herniations and symptomatic heterotopic ossification. A total of 18% 

had surgical site infections. Eight incisions were closed primarily, 

six with skin graft and one by secondary intention. There were four 

amputations in three patients. Soldiers exposed to blast trauma are 

an at-risk population for thigh ACS. Mortality was 47% in patients 

with ISS>25 and 0% for ISS

flexion contracture (p=0.001) and female gender (p=0.002) were 

both independent predictors of worse DASH scores (p=0.016). 

Poorer Oxford Elbow scores (p=0.002) and overall satisfaction 

ratings (p=0.005) were predicted by reduced flexion-extension arc 

of movement. Patients report good long-term functional outcomes 

after simple dislocations of the elbow. These are not entirely benign 

injuries. There is a high rate of residual pain and stiffness. Functional 

instability is less common and does not often limit activities. 


The Effect Of Operative Time On Surgical Site Infection 

In Tibial Plateau Fractures 

Matthew Colman, MD, Pittsburgh, PA 

Adam Wright, MD, Pittsburgh, PA 

James J Irrgang, PhD, Pittsburgh, PA 

Hans-Christoph Pape, MD, Aachen, Germany 

Gary S Gruen, MD, Pittsburgh, PA 

Peter Siska, MD, Pittsburgh, PA 

Ivan Seth Tarkin, MD, Pittsburgh, PA 

This study was undertaken to determine whether operative time 

during plate osteosynthesis of proximal tibia fractures in trauma 

patients has an effect on the incidence of postoperative surgical site 

infection. We performed a retrospective analysis of 318 consecutive 

unicondylar and bicondylar tibial plateau fractures treated with open 

plate osteosynthesis at our institution’s level I trauma center during 

a recent five-year period. Exclusion criteria included fractures treated 

with external fixation, percutaneous fixation or those fractures where 

multiple procedures were performed as part of the operative time. 

We recorded operative times, fracture pattern and open fracture 

grades. A group with postoperative infection as defined by the need 

for a subsequent debridement procedure was compared to a group 

which did not become infected. Student’s t-test and multivariate 

logistic regression analysis were performed to determine statistical 

significance. A total of 318 tibial plateau fractures (158 unicondylar, 

160 bicondylar) were analyzed. We found an overall postoperative 

surgical site infection rate of 7.9% (unicondylar vs. bicondylar 5.7% 

vs. 10.0%, p=0.15). The mean operative time in the infection group 

was 2.8 hours vs. 2.2 hours in the non-infected group (p=0.001). 

In addition, multivariate logistic regression analysis identified 

longer operative time as an independent predictor of surgical site 

infection (OR 1.8, 95% CI 1.2 to 2.8, p=0.005). Closed fractures 

were independently protective against surgical site infection (OR 0.1, 

95% CI 0.05 to 0.4, p


Hip Impingement - it’s Not Just About OA, Abnormal 

Morphology Increases Acetabular Fracture Risk 

David J Hak, MD, Denver, CO 

Edwin Darren Fern, MBChB, Truro, Cornwall, United Kingdom 

Mark Norton, MD, Truro, Cornwall, Uk, United Kingdom 

Jules Arthur Dumais, MD, Lubbock, TX 

Gavin Bartlett, MBBS, Truro, United Kingdom 

Abnormal bony morphology in patients with hip impingement is 

characterized by contact between the femoral head neck junction and 

acetabular rim. We hypothesized this increased bony constraint may 

predispose to acetabular fracture in high energy trauma. We studied 

100 patients sustaining acetabular fractures and compared them to 

100 similar patients sustaining lateral compression pelvic fractures 

following high energy trauma. CT scans and post-op x-rays were 

analyzed with the following measurements: center edge angle (CEA), 

sourcil angle and alpha angle of the femur. Standard criteria were 

used to define acetabular dysplasia, cam and pincer impingement. 

Statistical analysis was performed using SPSS. A significantly 

higher percentage of patients in the acetabular fracture group had 

x-ray evidence of hip impingement (71 vs. 18, p

data when known were similar to prior reports (28 ineffective, 52 

effective, 79 unknown). Ineffectiveness was associated with failure to 

stop the distal pulse commonly, failure to control hemorrhage and 

device breakage rarely. Prehospital effectiveness (76%) was less than 

emergency department (ED) effectiveness (86%) indicating that ED 

devices may be more effective than prehospital devices. The EMT 

was the only emergency department (ED) device in the trial, and it 

was the most effective tourniquet probably because of its pneumatic 

design and great width. However, even when ED personnel used 

prehospital devices such as the CAT and SOFTT, users could adjust 

the devices or put them side-by-side in use to improve effectiveness 

greater than prehospital users which indicated that more user 

knowledge was associated positively with higher effectiveness. The 

effectiveness of single devices was 82% but increased to 92% when 

two or more tourniquets were used side-by-side which underscores 

the importance of width particularly when one realizes that side-byside 

use is only done when hemorrhage control has failed with one 

device. First aid device wear and tear seems important to best care 

but they are rarely analyzed. Compelled to fix the most preventable 

cause of death on the battlefield, limb exsanguination, the U.S. Army 

Institute of Surgical Research formed a program to develop emergency 

tourniquets and solved the problem. How tourniquets work, i.e., high 

trans-mural arterial pressure gradient, is not how they work best, as 

the intra-neural gradient has to be low to be safe. Thus, a moderate 

pressure gradient over a safe width seems best. The scientific key is 

a tissue pressure gradient below a threshold that injures nerves, e.g., 

500 mmHg. The pressure in or under the tourniquet is not the key to 

optimal use. The key is the pressure in tissues about the arteries, and 

the nerve is the tissue most vulnerable to pressure gradients. These 

facts indicate that a refinement of tourniquet training and doctrine is 

due, and new device designs should incorporate these new findings 

in order to improve on the performance of current tourniquets and 

techniques. The data show that there is an uncommon need for onehanded 

tourniquet application, and even if every applier of the 16 

casualties with bilateral upper extremity tourniquets did use only 

one hand, the potential survival benefit is clinically small, infrequent 

and currently statistically insignificant. Obviously one-handed 

application is more important in those few cases in the field at the 

point of injury during self-application when one upper extremity 

is injured, but one-handed application is less important in aid 

stations, ambulances or EDs. The current work reinforces a growing 

body of knowledge indicating that tourniquet width and design 

are associated with safety and effectiveness. Using a comprehensive 

approach, the emergency tourniquet program worked with many 

organizations successfully to change first aid in combat. 


Mortality in Female War Veterans of Operation 

Enduring Freedom and Operation Iraqi Freedom 

Jessica Dale Cross, MD, Fort Sam Houston, TX 

Anthony E Johnson, MD, Fort Sam Houston, TX 


Michael J Bosse, MD, Charlotte, NC 

James R Ficke, MD, San Antonio, TX 

The care of female war veterans as a distinct population has not 

received much attention in the literature despite the dramatic 

increase in females serving in Operations Enduring (OEF) and Iraqi 

Freedom (OIF). The purpose of this study is to determine whether 

the casualty rates for females serving in OEF and OIF differ from 

their male counterparts. We calculated the percentage of all deaths 

by gender for OIF and OEF from the Defense Manpower Statistics 

of casualties between October 2001 and October 2009. We searched 

the Joint Theatre Trauma Registry for female casualties of this time 

855 

period and described their injury characteristics. Female veterans 

comprised 1.89% of all casualties, 1.99% of all casualties in OIF, and 

1.13% of all casualties in OEF. In OIF, the percent death for women 

was 14.47% versus 12.04% for men (P

females with a mean age of 44.1 (19-65) and body mass index 

(BMI) of 26.2 (18-41). Five (22.7%) patients had an associated 

femoral shaft fracture. Mechanism of injury was low-energy falls 

(12/22, 54.5%) and high-energy injuries (10/22, 45.5%). AO/OTA 

fracture classification included nine/22 (40.9%) B2 and 13 (59.1%) 

B3 fracture pattern. Primary fracture treatment consisted of 17/22 

(77.3%) ORIF and five/22 (22.7%) CRIF and secondary surgery for 

FNNU was 10 intertrochanteric osteotomies and eight arthroplasties. 

Complications included leg length shortening (17/22, 77.3%), 

secondary OA (9, 40.9%), heterotopic ossification (eight Brooker I, 

three Brooker II), AVN (7/22, 31.8%) and infection (1/22, 4.5%). 

Functional status was Daily 32.5, Emotional 32.0, Arm-Hand 11.3, 

Mobility 36.6, Dysfunction 28.5, Bother 25.6, Physical Component 

Summary (PCS) 31.0, and Mental Component Summary 56.8. Pain 

requiring medication was present in 14 cases (63.4%). Mobility 

assistive devices were utilized in four patients and 14 patients were 

limping. Specialized shoe wear was needed by five/22 (22.7%). 

Return to work status was 14/22 (63.6%) full return, six (27.3%) 

with restrictions and two (9.1%) did not return to previous level of 

activity. FNNU functional status was significantly reduced compared 

to normative values (Dysfunction t=3.715, Bother t=2.411, PCS 

t=7.112) with significance at p0.05). 

Ulnar diaphyseal fracture pattern and injury severity did not predict 

healing and outcome. However, non-operative treatment of displaced 

fractures were at high risk for complications. 


Operative Fixation vs. Reconstruction with THA for 

Acetabular Fractures in the Elderly Population 

Dr Michael J Weaver, Boston, MA 

Micah Miller, BS 

R M Smith, MD, Boston, MA 

Mark S Vrahas, MD, Boston, MA 

The purpose of this study is to compare the short-term outcomes of 

open reduction and internal fixation (ORIF) and acute reconstruction 

with total hip arthroplasty (THA) in the management of acetabular 

fractures in patients over 65 years old. We reviewed a consecutive 

series of patients of 65 years or older treated over a seven-year 

period at our institution with either ORIF or reconstruction with a 

THA for an acute acetabular fracture. Patients were interviewed and 

radiographs were examined. Validated outcome scores including the 

Harris Hip Score and SF36 were collected. Seventy-three patients 

were included in the study, 33 treated with ORIF and 40 treated with 

THA. Mean follow up was 21 months. The mean age in the ORIF 

group was 73 (65-88) while the mean age in the THA group was 79 

(68-89). One-year mortality was similar between those treated with 

ORIF (15%) and THA (23%, p=0.43). There was a trend towards a 

higher rate of reoperation in the ORIF group (30%) compared to 

the THA group (15%, p=0.12). Seven (21%) of the patients treated 




initially with ORIF went on to develop post-traumatic arthritis and 

underwent eventual THA. There was a trend towards improved 

Harris hip scores in those treated with THA (mean 82) compared to 

ORIF (63, p=0.06). There was a significantly better SF36 bodily pain 

scores in the THA group (mean 48) compared to the ORIF group 

(39, p=0.04). There was also a trend towards improved physical 

summary scores in the THA group (mean 43) compared to the ORIF 

group (35, p=0.15). ORIF and reconstruction with THA are options 

in the treatment of acute fractures of the acetabulum in the elderly 

population. THA appears to compare favorably to ORIF, with a 

similar rate of complication, but with improved pain scores. There 

is a significant rate of conversion of ORIF to THA. Both treatments 

are associated with high rates of morbidity and mortality in this 

population. 


The Effect Of Room Entry On Contamination Of 

Yankaeur Suction Catheter Tips On Continous Suction 

Matthew L Klima, DO, Moreno Valley, CA 

Gregory S Tennant, DO, Newport Coast, CA 

Room entry can provide a source of potentially contaminated 

room air into the operating room environment. This source can 

be eliminated by reducing the number of entries, or by changing 

the catheter tip before a known interval of exposure. A total of 42 

Yankaeur catheter tips were hooked up to continous suction of 

operating room air using sterile technique. At the time internal of 

zero, two, four, six and 12 hours, the catheter tips were harvested and 

sent for aerobic culture. The tips were divided into three groups based 

off of the number of room entries (low, medium and high number 

of room entries). A total of three tips per interval were harvested. 

The tips were swabbed on blood agar and monitored for 72 hours 

for growth. Low room entries was defined as less than 15 entries 

per hour, medium was 15-30 entries per hour (with one external 

door opening) and high was greater than 30 entries per hour (with 

four external door openings). A total of 42 tips were cultured, three 

tips per time interval. The catheter tips were categorically negative 

for culture after 72 hours. The negative culture tips all reveal that 

continous room suction of up to 12 hours will not provide a source 

of contamination for that tip. Even at the highest levels of air 

contamination (greater than 30 room entries per hour to include 

four openings of the external door), the suction tips failed to grow 

any organism. Room entry alone as an independent variable is not 

responsible for contamination of a suction tip, and switching of the 

suction tip during a case where there an increased number of room 

entries is not warranted by this study. 


Outcomes Of Arthroscopic Release After Proximal 

Humerus Fixation 

Okechukwu A Anakwenze, MD, Philadelphia, PA 

Vamsi Kancherla, MD 

G Russell Huffman, MD, Philadelphia, PA 

Pre-contoured locked plating of proximal humerus fracture 

is commonly used in treating proximal humerus fractures. 

Biomechanically, the treatment allows early mobilization. 

However, post-traumatic stiffness and functional disability remains 

problematic. Forty-three patients were treated with plating of humerus 

fractures by a single surgeon over a three-year period. Surgical and 

demographic factors associated with post-fixation adhesive capsulitis 

were assessed. When indicated, patients underwent a circumferential 

arthroscopic capsular release. Pre and post release function, range 

of motion and functional outcome were assessed. Nine patients 

857 

underwent an arthroscopic shoulder release after fixation with a 

locked, pre-contoured plate with a mean follow up of 35 months (11- 

59) after surgical release. The mean patient age was 56 (24-79). The 

mean time from fixation to contracture release was 257 days (100- 

602). Mean patient follow up from date of fracture to final follow 

up was 34.9 months (11-59), with an average follow of 32 months 

(five-55) after capsular release. The predominant factor associated 

with need for contracture release was female gender (seven of nine 

patients). There were no cases of avascular necrosis and one case of 

varus malreduction in the entire cohort. Prior to arthroscopic release, 

mean forward elevation (FE), abduction and external rotation (ER) 

was 111°, 78° and 32° respectively. At final follow up, after CR, mean 

FE, abduction and ER increased by 43° (P

inferior iliac pelvic external fixator to create groups 4-6. Eighteen 

instrumented pelvic models (n=3 per group) were tested with right 

ilium fixed to simulate a physiologic single-leg stance. Torque and 

axial load were applied to center of S1 superior endplate with no 

other external constraints on its 3D motion. Five cycles of ± 10 

Nm torque was initially applied then sequentially increased by ± 5 

Nm until permanent deformation was detected (by an offset of 5 

degrees at zero torque at end of a cycle). Five cycles of axial load 

from 15 to 50 N compression was next applied then sequentially 

max compression was increased 50N until permanent deformation 

was detected (by an offset of 2 mm when a cycle returned to 15 N). 

This was followed by axial loading to catastrophic failure. 3D relative 

motion across the sacral and rami fractures and of screws relative 

to bone was measured with an optical tracking system. Construct 

torsional and axial flexibility coefficients were determined during 

the fifth cycle of loading. Student T (two tail, unequal variance) was 

used to determine significance, P

Research Society (ORS) bring together the nation’s top civilian and 

military orthopaedic trauma surgeons and researchers for a two-day 

symposium AAOS lobbies for orthopaedic research dollars as well. 

The first program, OETRP, issues grants for peer-reviewed intramural 

and extramural orthopaedic trauma research. The purpose of OETRP 

is to complement and broaden the research in orthopaedic trauma. 

The second program, PRORP, was established to quickly develop 

focused basic and clinical research through direct grants to research 

institutions. The goal is to help military surgeons address the leading 

burden of injury and loss of fitness for military duty by finding new 

limb-sparing techniques. The results have been the country’s leading 

medical symposium (EWI) on the issues facing wounded warriors, 

and two groundbreaking federally-funded research programs 

(OETRP and PRORP) that will provide data on how to address the 

leading burden of injury. The projects of the Extremity War Injuries 

Project Team represent some of AAOS’ greatest contributions to our 

fighting men and women, and the doctors who treat them. 


Plaster: Our Orthopaedic Heritage 

Kathleen A McHale, MD, Alexandria, VA 

Martha K Lenhart, MD, Silver Spring, MD 

Marlene DeMaio, MD, Portsmouth, VA 

Casting is a dying art in adult orthopaedics as modern internal 

and external fixation replace external immobilization. Proper 

casting technique is paramount. While synthetic casting has some 

advantages over plaster, the plaster bandage is the time honored 

material in orthopaedics. This exhibit outlines the history, the 

chemistry, the advantages and disadvantages, and indications 

of casting. The differences in immobilization materials and 

technique will be demonstrated on the video . Modern materials 

and applications of plaster, i.e., amputation stump wrapping will 

be presented. History. Casting and splinting are ancient. Modern 

development was spurred by management of war wounds. 

(deChuliac, Pare) Calcium sulfate (plaster of Paris) was introduced 

in 1798. Mathijsen devised plaster bandages (splints) in 1852. By 

1927, crinoline rolls dipped in plaster treated with binding agents 

facilitated application. Synthetic casting (45% polyurethane resin, 

55% fiberglass) was introduced in the 1970s. Chemistry. Casting 

materials create an exothermic reaction while curing after dipping. 

Plaster: (CaSO4)2 + 3H2O ---> 2(CaS04.2H20) + HEAT Fiberglass: 

Prepolymer + H20 ---> 02 + polyurethane polymer + HEAT Burns 

are associated with water temperatures > 24 deg Celsius, ply (layers) 

> 8, and inadequate ventilation. Maximum water temperature must 

be less with fiberglass. Advantages. Plaster: tucks, use larger rolls; 

requires less tension than fiberglass; no gloves; absorbs fluids; can 

peel off (does not require saw). Fiberglass: cleaner, water resistant. 

Disadvantages. Plaster: poor in humidity. Fiberglass: poor storage in 

heat. The chemistry and physical properties of the casting materials 

drive the indications and application techniques as shown on the 

video. Early wrapping and shrinking of amputation stumps is ideal 

with plaster usage. Understanding of casting materials is important, 

especially with staged management and prevention of burns. 

859 


Atypical Femur Fracture and Its Association with Long- 

Term Oral Term Oral Bisphosphonate Use 

Richard M Dell, MD, Cypress, CA 

Denise Greene, RNP, Cypress, CA 


Eric Eisemon, MD, Brooklyn, NY 

David Laurence Boardman, MD, Clackamas, OR 

Joan C Lo, MD, Oakland, CA 

Annette L Adams, PhD, Pasadena, CA 

It is important to properly diagnosis and treat atypical femoral 

subtrochanteric and shaft fractures to ensure the best outcomes. 

A retrospective analysis of all femoral subtrochanteric and shaft 

fractures was carried out in a large california Health Maintenance 

Organization.. Charts and imaging studies were reviewed on all 

patients 45 years and older with the ICD9 codes for a femoral 

fracture between 1/1/2007 and 12/31/2009 to identify cases of with 

radiographic findings of an atypical femur fractures 102 patients 

(99 women, 3 men) had the characteristic radiographic findings. 

61% of the fractures occurred in the shaft region and 39% in the 

subtrochanteric region. 25% of the patients had either a complete 

fracture or stress fractures on the contralateral femur. The average age 

was 72 years old (range 45 to 92). Prodromal pain was reported by 

70% of the patients. Five patients had not taken a bisphosphonate 

and 97 patients were on oral bisphosphonates with an average 

duration of use of 5.5 years. There appears to be an associate between 

atypical femur fractures and long term oral bisphosphonate use in a 

small percentage of patients. 


Do the Outcomes Justify Changes in Treatment 

Patterns Following Hip Fractures? 


Colin Carroll, BS, Louisville, KY 

Craig S Roberts, MD, Louisville, KY 



Judd Day, PhD, Philadelphia, PA 


Kevin Ong, PhD, Philadelphia, PA 

This study evaluated temporal trends in treatmentpatterns for hip 

fractures and compared post-operative complication andmortality 

risks. Intracapsular and Intertrochanteric hip fractures were 

identified from Medicare claims data (1998-2007) 5% sample 

usingICD-9-CM diagnosis; ORIF, hemiarthroplasty, and THA 

patients were included. Dislocation, DVT, infection, mechanical 

complications, PE,and cardiac complications were computed 

up to 90 days and mortality,mal-union/non-union, conversion 

to arthroplasty, and re-operation for up to 1 year. Cox regression 

compared complications between treatments, adjusting for patient 

demographics. : Intracapsular fx: 40,852 patients (33.7% ORIF, 

59.2%hemiarthroplasty, 7.0% THA) were identified. From 1998- 

2007, there was a 22% decline in incidence of intracapsular hip 

fx’s. Hemiarthroplasty increased compared with ORIF. Compared 

with ORIF patients, adjusted risks for hemiarthroplasty patients 

were higher for dislocation (+98%)and infection (+53%) at 90 

days. One-year mortality rates for ORIF,hemiarthroplasty, and THA 

patients were 26.1%, 27.7%, and 14.4%. Intertrochanteric fx: 9,157 

IM nail and 27,687 plate fixation procedures for intertrochanteric 

fx’s were identified; IM nail use increased from 3.3% to 63.1%. 

IM nail patients had higher adjusted risk of PE at 90 days (+39%; 




p=0.003) and mortality at 1 year (+9%;p5 mm in 4 patients. The Hybrid 

External fixator was removed at an average of 17.5 weeks. Full 

weight bearing was achieved at a mean of 7.8 weeks. There were no 

intraoperative injuries to nerves or major vessels. Using the outcome 

scale of Ovadia and Beals, good-excellent results were achieved in 

67% (n=36) subjectively and 77% (n=41) objectively. Two poor 

results occurred in patients with a varus malunion. External fixation 

is a satisfactory method of treatment for fractures of the distal tibia 

and is associated with fewer complications than internal fixation, 

because it limits the amount of soft tissue. 




PAPERS 

861 

tuMor and Metabolic disease 

pApeR No. 226 

uEvaluation of Fracture Complications With 

Denosumab (RANKL Inhibitor) in Postmenopausal 

Osteoporosis 

Joseph M Lane, MD, New York, NY 

Mohit Bhandari, MD, Hamilton, ON Canada 

Ethel Siris, MD, New York, NY 

Steven Cummings, MD 

Pei-Ran Ho, MD, Thousand Oaks, CA 

Andrea Wang 

Cesar Libanati, MD 

Silvano Adami, MD, New York, NY 

Complications associated with fractures can negatively influence 

a patient’s prognosis. In FREEDOM, denosumab, an antibody to 

RANKL, significantly reduced the risk of new vertebral, hip and 

nonvertebral fractures (Cummings NEJM 2009;361:756). In this 

prespecified analysis, we evaluated complications associated with 

nonvertebral fractures, including those related to fracture healing, 

in denosumab-treated patients. FREEDOM was a three year, 

double-blind trial in 7,868 postmenopausal women with low bone 

mineral density randomized to six monthly denosumab 60 mg 

or placebo. Nonvertebral fractures were radiologically confirmed. 

Complications associated with the fracture/surgical management 

or fracture healing were reported by the investigator on case report 

forms. Healing was ‘delayed’ if not completed within six months. 

In total, 667 patients (364 placebo, 303 denosumab) reported 851 

nonvertebral fractures. The most common fracture locations were 

the radius (26%), humerus (11%) and foot (9%). Significantly fewer 

denosumab patients suffered complications associated with fracture/ 

surgical management vs. placebo patients (five vs. 20, respectively, 

relative risk reduction: 70%, p=0.0093). This finding was consistent, 

regardless of whether a patient had surgery for the fracture, (surgery: 

3/65 5%] denosumab vs. 12/100 

pApeR No. 227 

Impact of Zoledronic Acid on severe vertebral 

fractures: Results from HORIZON-Pivotal Fracture Trial 

Rosanna Lisa Wustrack, MD, San Francisco, CA 

Ego Seeman, Prof, Heidelberg, Australia 

Christina Bucci-Rechtweg, MD 

Lisa Palermo, PhD 

Dennis Black, San Francisco, CA 

Vertebral fractures are the most common osteoporotic fractures with 

an annual incidence of 750,000. Once-yearly infusion of zoledronic 

acid (ZOL) 5 mg has been shown to decrease the risk of vertebral, hip 

and other osteoporotic fractures, as well as mortality following hip 

fractures. We assessed the effects of ZOL on severe vertebral fractures 

during a three-year period. HORIZON-pivotal fracture trial (PFT) is 

a large, international placebo-controlled trial in postmenopausal 

osteoporotic women, comparing once-yearly ZOL (n=3,077) to 

placebo (PBO) (n=3,045). This analysis included women who had 

lateral radiographs at baseline, 12, 24 and 36 months. Fracture 

severity was graded by semi-quantitative (SQ) analysis on a scale 

from 0 (normal) to 3 (severe). The endpoints were maximum SQ 

grade change in a single incident fracture and an index of overall 

severity calculated by summing all SQ grade changes in an individual 

over three years of the trial. The number of new severe fractures and 

sums SQ change were compared between the ZOL and PBO group. 

Treatment with ZOL reduced the number of patients with one or 

more severe vertebral fractures by 67% (3.4% in PBO vs. 1.1% in 

ZOL, p

pApeR No. 229 

uEfficacy of Zoledronic Acid in the Treatment of 

Benign Osteolytic Bone Lesions 

Sudhir Garg, MD, Chandigarh, India 

Purnima Aggarwal, MD, Chandigarh, India 

Anshul Goel, MBBS 

Rohit Jindal, MD 

Fibrous dysplasia, unicameral bone cyst, allograft bone chips (ABC), 

giant cell tumors (GCT), etc. are often extensive. Surgical procedures 

such as curettage and bone grafting are associated with low cure rate 

and high recurrence rate. The aim of this study was to find out the 

efficacy of zoledronic acid as a therapeutic or as an adjuvant agent in 

the treatment of these extensive benign osteolytic tumours or tumor 

like conditions. Thirty-one patients (19 female, 12 male) from eight 

years to 42 years, were treated with intravenous zoledronic acid. 

In 17 patients (fibrous dysplasia - 10, nonossifying fibroma - four, 

unicameral bone cysts - three), zoledronic acid alone was used as a 

therapeutic agent. In 14 patients (ABC - three, GCT - 11), it was used 

as an adjuvant agent after curettage. Four patients presented with 

pathological fracture. In all patients, 4 mg zoledronic acid was given 

at two monthly intervals. Maximum of six injections were given 

in eight patients. Patients were evaluated using visual analog pain 

scale and x-rays. At last follow up (six-40 months), in 15 patients 

treated with zoledronic acid alone, there was thickening of cortices 

and reduction in the size of the lesions. Pain score decreased from 

an average of eight to two or lower. All four fractures healed. In two 

patients, both with fibrous dysplasia, there was progression in size 

of the lesion. In all 14 patients, where it was used as an adjuvant 

to surgery, there was also early thickening of bone cortices. There 

was no local recurrence in this group. There was no adverse reaction 

to the drug in any of the patients. Benign osteolytic lesions such as 

fibrous dysplasis, ABC and GCT require extensive surgical procedures 

and copious amount of bone graft. Still they have a high rate of 

recurrence. Zoledronic acid is a third generation bisphosphonate. 

It is 100 times more potent than pamidronate as an anti-osteolytic 

agent. Our study suggests that zoledronic acid not only helps to 

stabilize these lesions but also resulted in pronounced healing in 

the majority (>90%) of patients. If obviates the need for surgery. It 

also reduced recurrence rate in aggressive benign bone tumors such 

as ABC or GCT when used as an adjuvant treatment. 

pApeR No. 230 

Comparison of Ultrasound Fusion and Computed 

Tomography Guided Biopsy in Musculoskeletal 

Neoplasia 

Jad Khalil, MD, Birmingham, MI 

Michael P Mott, MD, Detroit, MI 

Marnix Van Holsbeeck, MD, Detroit, MI 

Trevor Banka, MD, Farmington, MI 

Theodore W Parsons, MD, FACS, Detroit, MI 

Fusion of ultrasonic imaging to diagnostic magnetic resonance 

imaging (MRI) or computed tomography (CT) allows for as accurate 

of needle placement as traditional CT-guided biopsy without the 

need for repeated CT or MRI scans. Additionally, scheduling ease 

and patient comfort /satisfaction are improved as time-consuming 

diagnostic imaging studies are not repeated. Sixty consecutive 

patients undergoing biopsies for the diagnosis of musculoskeletal 

masses diagnosed by CT/MRI were randomized into two groups. 

From these diagnostic imaging studies, the most desirable area for 

biopsy was identified. Group 1 underwent biopsies via ultrasound 

(US) fusion where the CT or MRI images were integrated into an 

862 

ultrasound framework to direct accurate needle placement using 

ultrasound. Group 2 patients underwent conventional CT-guided 

biopsies with CT scan of the region of interest repeated at the time 

of the biopsy. Accuracy of the histologic specimen, complication 

rates and patient satisfaction were determined. Biopsies obtained 

by US fusion technology provided diagnostic accuracy equal to that 

of the control CT-guided procedures. The complication rates were 

minimal and similar in the two groups. Patients in the US fusion 

group expressed higher satisfaction and lower discomfort with the 

procedure. US fusion technology provides a means to obtain high 

yield, quality musculoskeletal biopsies with an accuracy equal to 

that of traditional CT-guided biopsies. Performing the procedure in 

an US suite allowed for ease of scheduling and resulted in higher 

patient satisfaction. 

pApeR No. 231 

Ability to Obtain Molecular Genetics from Percutaneous 

Biopsy of Extremity Sarcomas 

David M King, MD, Pewaukee, WI 

Donald A Hackbarth Jr, MD, Milwaukee, WI 

Guillermo Carrera, MD, Milwaukee, WI 

Keith E Baynes, MD, Milwaukee, WI 

Vladimir Osipov, MD 

Percutaneous biopsy has been shown to be accurate and reliable with 

low morbidity in the diagnosis of extremity sarcomas. Molecular 

genetics continues to evolve as a diagnostic tool for sarcoma. 

As new sarcoma therapies become available and as molecular 

genetics advances the science of sarcoma, precise diagnosis will 

become even more important. We asked the question of whether 

percutaneous biopsy techniques allow the same opportunity for 

molecular genetic analysis for extremity sarcoma as open biopsy. 

We retrospectively identified all patients who presented to our 

institution with undiagnosed extremity sarcomas from 2002 

until March of 2010. Biopsy type was identified (open, tru-cut 

percutaneous by the musculoskeletal oncologist vs. image-guided 

percutaneous by musculoskeletal radiology). Attempts and results 

of molecular genetic data were documented and compared between 

the three techniques. Patients with osteosarcoma or chondrosarcoma 

diagnoses were excluded as no attempt was made to obtain molecular 

genetic information in those patients. A total of 119 patients were 

eligible for the study. Forty-three patients underwent image-guided 

percutaneous biopsies by the radiologists, 48 had tru-cut biopsies 

performed by the musculoskeletal oncologists and 28 open biopsies 

were performed. The decision to pursue molecular genetic data was 

at the discretion of the pathologist. Fourteen out of 48 tru-cut, 14 out 

of 28 open and 12 out of 43 image-guided percutaneous specimens 

were sent for genetic analysis. Eleven out of 12 (92%) image-guided, 

13 of 14 (93%) open and seven of 14 (50%) tru-cut biopsies yielded 

genetic information. Open and image-guided percutaneous biopsy 

techniques reliably allowed for the acquisition of molecular genetic 

information of extremity sarcomas. Tru-cut biopsy was less reliable. 

The ability of image-guided techniques to obtain molecular genetic 

data may be due to improved sampling of viable areas of the tumor. 



PaPers, Posters & scientific exhibits tumoR

pApeR No. 232 

A High Serum Levels Of VEGF Predict Poor Prognosis 

For Patients With Osteosarcoma 

Mitsunori Kaya, MD, Sapporo, Japan 

Takuro Wada, MD,PhD, Sapporo, Japan 

Satoshi Nagoya, MD, Sapporo, Japan 

Tomotsu Soma, MD 

Mikito Sasaki, MD, Sapporo, Japan 

Masanobu Kano, MD 

Makoto Emori, MD 

Toshihiko Yamashita, MD, Sapporo, Japan 

Vascular endothelial growth factor (VEGF) is an important mediator 

of tumor angiogenesis. A high serum VEGF level has been shown to 

predict poor survival in several cancers, but its prognositic value in 

osteosarcoma is still under investigation. We conducted a prospective 

study to evaluate the prognostic significance of pretreatment 

serum VEGF levels on survival of patients with osteosarcoma. 

Pretreatment serum VEGF levels were measured by an enzymelinked 

immunosorbent assay in 15 patients with osteosarcoma. The 

patients were divided into two groups (high and low VEGF) and 

the incidence of remote metastasis and overall survival rate were 

compared between the two groups. Serum VEGF levels were compared 

between groups categorized by various clinicopathologic features 

including gender, age, sensitivity to preoperative chemotherapy, 

tumor size and the serum VEGF level at diagnosis using the Mann- 

Whitney test. The curve for overall survival was drawn according to 

the Kaplan-Meier method and differences were analyzed by applying 

the log-rank test. The median serum VEGF level was 1069.4 pg/ml 

(range: 156.2-5,700pg/ml). No significant relationship was observed 

between the serum VEGF levels and sex, age, tumor size or the 

response to preoperative chemotherapy. Patients with serum VEGF 

>1,000pg/ml had significantly worse survival than those with serum 

VEGF

while CTRA alone recommended surgery in 40% (n=33) of lesions. 

The results suggest that more than 25% of the clinical treatment 

recommendations would potentially be altered by use of CTRA. 

Treatment plans were similar in cases where there was either marked 

bony destruction or minimal bone involvement. 

pApeR No. 235 

Dendritic Cell Immunotherapy Is Feasible For Patients 

With Malignant Bone And Soft Tissue Tumors 

Hideji Nishida, MD, Kanazawa City, Japan 

Toshiharu Shirai, MD, Kanazawa, Japan 

Katsuhiro Hayashi, MD, Kanazawa, Japan 

Akihiko Takeuchi, MD, Kanazawa, Japan 

Hidenori Matsubara, MD, Kanazawa, Japan 

Yoshikazu Tanzawa, MD, Kanazawa, Japan 

Shinji Miwa, MD 


This study was undertaken to evaluate the safety and feasibility of 

autologous tumor lysate-dendritic cell (DCs) immunotherapy for 

patients with malignant bone and soft tissue tumors who failed 

other standard treatments. Nineteen patients were enrolled and 

immunized with DCs. Patient tumors comprised 14 bone tumors 

(osteosarcoma nine], chondrosarcoma one], fibrosarcoma 

pApeR No. 236 

Malignant Sarcoma of the Pelvic Bones 

Muhammad Umar Jawad, MD, Palo Alto, CA 

Abdul Ahad Haleem, MD, Overland Park, KS 

Sean P Scully, MD, PhD, Hubert, NC 

Treatment of malignant sarcomas of the pelvis poses a challenge 

for local disease control and oncologic outcome. Many reports have 

described the dismal outcomes. Most studies are retrospective series 

coming out of single centers, thus biased towards patient selection 

and are of limited statistical power. We have utilized the Surveillance, 

Epidemiology and End Results (SEER) database to analyze 1,185 

pelvic sarcoma cases from 1987-2006. Kaplan Meier and Cox 

regression have been used to analyze the significance of prognostic 

factors. The analysis was repeated for different histopathological 

subtypes to determine specific prognostic factors in each case. 

Incidence of pelvic sarcoma in 2006 was 89 per 100,000 persons 

and it has significantly increased since 1973 (ptwo-fold induction of key OB markers. Wnt pathway activation or 

osteogenic medium induced a marked increase in the OPG/RANKL 

ratio and loss of GCTSC OC-inducing activity. Conversely, treatment 

with BMP-2 resulted in a decreased OPG/RANKL ratio, and 




enhanced OC formation in monocyte co-cultures. Surprisingly, the 

induction of OB differentiation by BMP or Wnt pathway activation 

produced differential effects on OC-inducing activity. This effect 

may be attributed to the differential effects of the Wnt and BMP 

pathways on OPG/RANKL production. The ability to manipulate the 

osteoclastogenic phenotype of GCTSC provides a novel approach 

for treatment and insight into the mechanisms by which OB lineage 

cells regulate osteoclastogenesis. 

pApeR No. 239 

Melanoma Metastatic To Bone 

Matthew Colman, MD, Pittsburgh, PA 

John M Kirkwood, MD, Pittsburgh, PA 

Mark A Goodman, MD, Pittsburgh, PA 

Alma Heyl, CCRC 

Richard Louis McGough, MD, Pittsburgh, PA 

Melanoma metastatic to bone is rare and carries a dismal prognosis 

with survival in the four to six month range. Although the literature 

suggests that resection of isolated visceral metastatic disease improves 

survival, the role of resection and reconstruction of isolated osseous 

metastases is unclear. We present the largest series of melanoma 

metastatic to bone, reporting on survival and treatment outcomes. 

We conducted a retrospective review of 2,442 consecutive cases of 

melanoma presenting to our tertiary cancer center over the past 

12 years. We identified 130 cases with pathologically confirmed 

bony disease. Patient demographics, stage, treatment profiles and 

mortality were recorded. We used Kaplan-Meier curves and nonparametrric 

tests to evaluate statistical significance. Median time 

from diagnosis of primary melanoma to bony metastases was 

72 months. After this diagnosis, overall median survival was 5.4 

months. A total of 43% of skeletal metastases were axial, 21% 

appendicular and 36% both. Some 25% presented with a fracture, 

two-thirds of which were compression fractures of the spine, with no 

difference in survival. A total of 62% of patients were treated nonoperatively 

with median survival of 5.0 months. Of those treated 

surgically, 64% received a debulking or stabilization operation, with 

median survival of 5.3 months. Some 36% received a wide resection 

and reconstruction with a contamination rate of 37% and median 

survival of 12.5 months. Log-rank Kaplan Meier survival analysis 

confirmed the overall survival benefit to wide resection (p=0.045). 

Medical co-morbidities and the use of adjuvant chemotherapy or 

radiotherapy had no effect on overall survival. Poor prognosticators 

for overall survival included axial spine involvement, concomitant 

liver or lung disease and absence of chemotherapy given for the 

initial high-risk primary melanoma. Melanoma metastatic to bone 

is a rare, devastating clinical entity. While stabilization of impending 

or unstable spine and long bone fractures is indicated and palliative 

debulking procedures may be considered, they are unlikely to 

improve survival. Bony disease which can be resected to dramatically 

reduce or eliminate known disease burden may provide hope for 

improved survival. 

865 

pApeR No. 240 

Teleangiectatic osteosarcoma: a review of 87 cases 

Prof Pietro Ruggieri, Bologna, BO Italy 

Andrea Angelini, MD, Bologna BO, Italy 


Giovanni Guerra, MD 

Gabriele Drago, MD 

G Douglas Letson, MD, Tampa, FL 

Mario Mercuri, MD, Bologna, Italy 

Telangiectatic osteosarcoma (TOS) is a rare subtype of osteosarcoma. 

We review our experience to characterize its prevalence, treatment, 

relapse and survivorship at long term follow up. Eighty-seven 

patients aged from four to 60 years (mean 20 years) were treated 

from 1985 to 2008. Lesions affected the femur (38), humerus (20), 

tibia (19), fibula (four), pelvis (three), foot (two) and radius (one). 

Eight patients had metastatic disease at diagnosis. Seventy-eight 

patients were treated with neoadjuvant chemotherapy with three 

or more drugs according to different protocols; nine had surgery 

as first treatment. Limb salvage surgery was performed in 71 cases, 

amputation in 14 and rotationplasty in one. One patient died 

before surgery. Prognostic factors were evaluated with Kaplan-Meier 

analysis. At a mean follow up of eight years, overall survival was 

81%, 65% and 65% at two, five and 10 years respectively. Fifty-two 

patients were disease-free, three were alive with disease, 29 died with 

disease and three died of other causes. Thirteen local recurrences 

were observed. Twenty-three patients developed lung (20) or bone 

(three) metastases. Pathologic fracture did not significantly influence 

survivorship. Prognostic influence of age of the patients was evaluated 

at three different cut-off (15, 20 and 25 years-old): younger patients 

had better survivorship, without statistical significance. Metastatic 

disease significantly influenced survivorship (p

Three patients refused participation in the long-term follow-up study. 

Mean MSTS score was 79 (range 64-88). SF-36 score was obtained in 

20 patients (age > 16); male patients showed a trend toward greater 

activity and vitality. Compared to age-group norms, rotationplasty 

scores were lower for physical activity level (p

pApeR No. 515 

Impact of Close Surgical Margin on Local Recurrence 

and Survival in Osteosarcoma 

Richard D Lackman, MD, Philadelphia, PA 

Xin Li, MD, Jinan, China 

Vincent Michael Moretti, MD, Chicago, IL 

Adedayo O Ashana, BA, Philadelphia, PA 

For soft tissue sarcoma patients, several authors have suggested that 

a close surgical margin is associated with poor outcomes. However, 

there is a dearth of similar studies in osteosarcoma patients with 

neoadjuvant chemotherapy. This study investigates the impact 

of close surgical margin on local recurrence (LR) and overall 

survival (OS). We reviewed all cases of osteosarcoma treated at our 

institution. Forty-seven patients (28 males and 19 females) met 

inclusion criteria. Median age was 22 years (range 12-76). Fortry 

were MSTS stage 2B and seven were 3B. Pathologic types included 

38 osteoblastic and nine others. Tumor locations included 26 

distal femur, five proximal tibia, five pelvises, two humerus, two 

proximal femur, two distal tibia, two fibula, one total femur, one 

rib and one radius. Forty-one patients were treated with resection 

and six underwent amputation. Positive surgical margin was defined 

as tumor present at surgical margin. Close margin was defined as 

tumor present less than 5 mm from the surgical margin. Negative 

margin was defined as no tumor present within 5 mm of the surgical 

margin. All patients received preop chemotherapy and 42 patients 

underwent postop chemotherapy. Median follow up was 61 months 

(range 10-133). As of last follow up, 22 patients had died and seven 

had LR. Twenty-nine patients had negative margins, six had positive 

margins and 12 had close margins. In univariate analysis, positive 

margin had a greater risk of LR than negative margin (p=0.009). 

Although close to statistical significance, patients with positive 

margins had more LR than those with close margins (p=0.058). 

There was no difference in LR between close and negative margins 

(p=0.972). In multivariate analysis, only positive margin increased 

the risk of LR (P=0.017). In univariate analysis of marginal status 

to OS, there was no statistical difference between the three groups. 

Similarly, multivariate analysis showed no correlation of marginal 

status to OS. Compared with negative margins, close margins did 

not lead to increased LR. Similarly, there was no difference in OS 

between these two groups. These data suggest that close margins, as 

defined in our study, may be just as acceptable as negative margins 

in terms of patient outcomes. More patients and longer follow up 

are necessary to further evaluate the impact of margin status on local 

control and survival in osteosarcoma. 

pApeR No. 516 

Local Recurrence and Survival in Stage III Sarcomas 

without Resection of the Core Biopsy Tract 

Odion Binitie, MD, Tampa, FL 

Shawn Tejiram, bsC 



David Cheong, MD, Tampa, FL 

Core needle biopsies of sarcomas have been shown to be a safe and 

effective diagnostic tool, however the efficacy of resecting the biopsy 

tract in the setting of adjuvant therapy has not been evaluated. Fortyone 

adult patients with deep, larger than 5 cm, high grade soft tissue 

sarcomas of the upper or lower extremity treated at one institution 

were retrospectively reviewed. All the patients underwent a core 

needle biopsy. Resection was performed with wide margins. The 

biopsy tract was not resected during the definitive surgery. Patients 

867 

received neo-adjuvant and or adjuvant treatment with chemotherapy, 

external beam radiation, brachytherapy or participated in a vaccine 

trial. Surgical outcomes, local recurrence and survival were reviewed. 

Median follow-up was 42 months (range 7-117). Five-year survival 

was 61%, three-year survival 73.3%. Local recurrence rate was 

9.75%. Thirty-seven patients received either preoperative and/or 

postoperative radiation; three (8.1%) of these had a local recurrence. 

Nine patients (21.9%) had microscopic positive margins at resection. 

Eleven patients (26.8%) developed metastasis after diagnosis, three 

presented with metastasis. Median duration from diagnosis to 

metastasis was six months. Logistic regression demonstrated positive 

margins to have a significant effect on five-year survival rates. This 

study demonstrates no increase in local recurrence rates or reduction 

in survival, compared to published results, when resection of the core 

biopsy tract was not performed. It shows that in patients with stage 

III soft tissue sarcomas who received adjuvant therapies in addition 

to surgical resection, there was no adverse effect from excluding the 

biopsy tract from the definitive surgical resection. 

pApeR No. 517 

Quantitative Margin vs. Local Recurrence for Extremity 

Bone Sarcomas 

David M King, MD, Pewaukee, WI 

Donald A Hackbarth Jr, MD, Milwaukee, WI 

Andrew Kirkpatrick, BS, Wauwatosa, WI 

The optimal soft tissue and bone quantitative resection margin 

for extremity bone sarcomas is unclear in the literature. We 

retrospectively reviewed our widely resected bone tumor patients to 

determine whether resection quantitative margin had a significant 

impact on local control. A retrospective chart review identified 

patients who had primary wide resections for extremity or pelvic 

bone sarcomas at our institution from 2001-2008. Spine tumors, 

Grade I chondrosarcomas, resections of metastatic disease sites 

and primary amputations were excluded. The closest quantitative 

resection margin was determined from the pathology reports and 

categorized as positive, 5 mm. Potential 

confounders were evaluated including chemotherapy, development 

of metastatic disease, tumor necrosis, biopsy location and type 

and follow-up information. Minimum follow up was 24 months. 

Eight local recurrences were noted in the 66 patients with negative 

resection margins (12%). Six of 22 (27%) of patients with 5 mm 

margins recurred. Local recurrence in the osteosarcoma and Ewing’s 

sarcoma patients presented in conjunction with the development of 

metastatic disease. Mean follow up was 48 months. Close

cell lines. The effects on apoptosis in OS cells were analyzed via flow 

cytometry, Western Blots and IHC staining. To analyze osteogenic 

differentiation in both MSCs and OS cell lines, we performed assays 

for the early marker alkaline phosphatase (ALP), the late markers 

osteocalcin (OCN), osteopontin (OPN) and alizarin red. In OS cells, 

IGFBP5 induced the expression of the late apoptotic marker, cleaved 

caspase 3. It also induced both early apoptotic markers stained with 

annexin and propidium iodide by more than three-fold. IGFBP5 

increased the number of cells arresting in the G1 phase of the cell 

cycle (p-value

disease, eight cases of limb deformity, six cases of fracture and three 

cases of osteomyelitis. The types of the implants were 27 spinal 

instrumentations, 18 plates for osteosynthesis, 16 tumor prostheses 

and external fixation pin, seven hip prostheses and two nail/ 

cannulated screw. Iodine-supported implants were used to prevent 

infection for 54 patients under immunosuppressive condition and 

to treat active infection for 32 patients. White blood cell (WBC) and 

C-reactive protein (CRP) were measured pre- and post-operatively in 

all patients. To confirm whether iodine from the implant influenced 

the body, thyroid hormone levels in the blood were examined. 

Both examinations were conducted sequentially for one year. After 

the operation, radiological evaluations were performed regularly. 

Infection was perfectly prevented in all 54 cases. Furthermore, 

infection was cured in all other 32 cases. Among patients with active 

infection, one showed late hematogenous infection two years after 

revision surgery and one was suspected iodine allergy. In all cases, 

there were no signs of infection at the time of final follow up. WBC 

and CRP levels were returned to normal within four weeks after 

surgery. Abnormalities of thyroid gland function were not detected. 

Loosening of the implants was not shown in any patient. There were 

two patients with mechanical implant failure, which were recovered 

by re-implantation. Excellent bone ingrowth and ongrowth were 

found around hip and tumor prostheses. No problems were detected 

even when iodine-supported titanium was implanted at infectious 

lesion as the infection was subsided due to the antibacterial activity 

of the implant. Moreover, iodine-supported implants may prevent 

infections post-operatively for compromised hosts. There were no 

cytotoxicity and adverse effects detected. This iodine coating can be 

applied for all titanium implants and is very effective for preventing 

and treating infection related to orthopedic surgery. 

pApeR No. 522 

Intra-operative Navigation for Minimally Invasive 

Resection of Periarticular and Pelvic Tumors 

Nicholas Paul Webber, MD, Milwaukee, WI 

R Lor Randall, MD, Salt Lake City, UT 

Karl Wu, MD, Taipei, Taiwan 

Kevin Jones, MD, Salt Lake City, UT 

Russell A Ward, MD, Temple, TX 

Approaching symptomatic benign, metastatic and some low grade 

primary malignant tumors is often a difficult undertaking due to their 

typically precarious locations. The treatment with regard to surgical 

approach and preservation of functional peritumoral anatomy is a 

formidable opponent when biopsying and treating these tumors. 

We present a series of cases where intraoperative ‘stealth navigation’ 

was used to successfully treat five patients with periarticular tumors 

located in precarious anatomic locations. All of the patients in this 

case series with the peri-articular tumors had an excellent postoperative 

Musculoskeletal Tumor Society Functional Score (range 

26- 29) after surgery. There were no surgical related complications. 

One of the five patients had tumor recurrence months after first 

operation and was treated successfully with repeated operation 

without complications noted. The use of paired point imaging with 

image fusion (intraoperative computed tomography scanning with 

navigation synched to the image) has made approaching tumors 

through a minimally invasive and astoundingly accurate technique 

a reality. The advantages of these minimally invasive techniques are 

many, especially with regard to tumors that would otherwise require 

extensive dissection, soft tissue stripping, joint dislocation and insult 

to periarticular blood supply. 

869 

pApeR No. 523 

Unplanned Excision of Soft Tissue Sarcomas What is 

the Effect on Patient Outcome? 

Peter Ferguson, MD, Toronto, ON Canada 

Anthony M Griffin, MSC, Toronto, ON Canada 

Jay Wunder, MD, Toronto, ON Canada 

Patients are often referred to tertiary care centers after unplanned 

excision of soft tissue sarcomas. In situations where the tumor is 

small and superficial, the situation can often easily be salvaged by reexcision 

of the tumor bed. However, if the original tumor is large, deep 

to fascia or directly adjacent to bone or neurovascular structures, the 

salvage procedure often becomes more complex. The purpose of this 

study is to evaluate the effect of unplanned excision of high-risk soft 

tissue sarcomas on patient outcome. We reviewed our prospectively 

collected sarcoma database from the years 1989 to 2006. Patients 

who underwent definitive resection of a soft tissue sarcoma at our 

center were included. The primary categories were patients who had 

and had not undergone initial unplanned resection of their tumor 

prior to referral for definitive management at our center. Patients 

who had tumors that were less than 5 cm in diameter, superficial 

to fascia and not overlying bone or neurovascular structures were 

excluded. A total of 1,034 patients met inclusion criteria. Of these, 

385 (37%) patients had undergone a prior unplanned excision prior 

to referral, while 649 (63%) patients underwent definitive resection 

at our center without prior unplanned excision. There was a higher 

percentage of high grade (61% vs. 50%) and deep tumors (88% vs. 

65%) in the unplanned excision group, and the mean tumor diameter 

was also smaller in the unplanned excision group (5.9 cm) than the 

control group (10.6 cm). There was no difference between the groups 

in terms of rate of amputation, necessity for flaps for coverage and 

local recurrence-free survival. Complications were more common in 

the control group (34%) than the unplanned excision group (20%, 

p

extremity STS. Lymphoedema severity (Stern 1964) has been 

prospectively collected from our soft tissue sarcoma population. The 

patient’s demographics, tumor characteristics, surgical procedures, 

radiotherapy dosage, complications and functional outcomes (MSTS 

1987, TESS) were also prospectively collected. Lymphoedema severity 

and functional outcomes were recorded at the same time, with 

an average follow-up interval of 35 months (range 12-60). Charts 

were also retrospectively abstracted for body mass index (BMI) and 

medical comorbidities. There were 289 evaluable STS patients (158 

males). Mean age was 53 (range 16-88). Mean BMI was 27.4 (range: 

15.8-52.1). A total of 209 had lower extremity tumors and 80, upper 

extremity. Mean tumor size was 8.1 cm (range 1.0-35.6 cm). Seventysix 

had no adjuvant radiation, 180 had 50 Gy and 32 received 66 Gy. 

The incidence of lymphoedema was found to be 28.8% (206 none, 58 

mild, 22 moderate, three severe, zero very severe). Mean MSTS score 

was 32 (range: 11-35) and TESS, 89.4 (range: 32.4-100). Radiation 

dose was significantly correlated with tumor size >5 cm (p=0.0001) 

and TESS score (p=0.001), but not MSTS score (p=0.090). For analysis, 

we grouped cases with lymphoedema grades 0-1 and 2-3. Univariate 

analysis found significant correlations between the severity of 

lymphoedema and tumor size >5 cm (p=0.011), deep location (no 

patient with a superficial tumor had severe lymphoedema, p=0.001) 

and radiation dosage 50 vs 66 Gy (p=0.010), but not between upper 

vs. lower extremity (p=0.092). We found no significant association 

between the incidence of lymphoedema and hypertension (p=0.36) 

or smoking (p=0.63). A logistic regression analysis identified tumor 

size (odds ratio 3; 95% confidence interval: 1.2-7.6) and radiation 

dosage (odds ratio 5.7; 95% confidence interval: 1.8-17.9) as the two 

factors which predicted lymphoedema. Nine percent of STS patients 

in our cohort developed severe (Stern grade 2) post-treatment 

lymphoedema. Tumor size >5 cm was associated with an increased 

occurrence of lymphoedema but not tumor location. Radiation dose 

was associated with severity of lymphoedema and appeared to be 

one of the few variables on which clinicians can have influence. 

Otherwise, high-risk patients could be targeted for prophylactic 

intervention and/or prospective trials. 

pApeR No. 525 

DVT Prophylaxis with Dalteparin for Malignant Tumor 

Resection 

Patrick P Lin, MD, Houston, TX 

Hyun-Guy Kang, MD, Goyang-Si, Gyeonggi-Do, Republic of 

Korea 

Robert L Satcher Jr, MD, Houston, TX 

Bryan Scott Moon, MD, Houston, TX 

Valerae O Lewis, MD, Houston, TX 

The efficacy of low molecular weight heparins for prophylaxis against 

venous thromboembolic events has been well-established. Their 

use in patients undergoing major tumor resections of the limbs has 

been limited by concerns for the possiblity of increased bleeding and 

wound complications. The goal of the present study is to determine 

the efficacy and safety of dalteparin in patients undergoing excision 

of moderate to large sized (5-20 cm) tumors of the lower extremities. 

A prospective study was performed of 25 patients with primary 

sarcomas and 25 patients with metastatic disease. All patients 

underwent limb-sparing surgery and excision of tumors, which 

were 5-20 cm in size and located in the lower extremities. Patients 

were screened with bilateral doppler ultrasound before surgery and 

prior to discharge home at 5-14 days after surgery. Dalteparin was 

administered at a dose of 5,000 units subcutaneously daily starting 

12-24 hours after surgery. A case-controlled cohort of patients who 

did not receive chemoprophylaxis was chosen from historical data to 

compare surgical complications. Patients were matched for disease, 

870 

site, tumor size and surgical operation. Of the 50 patients who 

completed the study, one patient (2%) developed a post-operative 

deep venous thrombosis (DVT). No patient developed a symptomatic 

pulmonary embolism and no patient died of pulmonary embolism 

within three months of surgery. The rate of surgical complications, 

including hematoma formation, seroma, deep infection, dehiscence 

and bleeding were not significantly different between the study 

group and the case controlled cohort. The rate of DVT in patients 

treated with dalteparin compared favorably with published historical 

controls, which have shown a rate of 14% in patients treated with 

mechanical prophylaxis. We did not detect a significant increase in 

surgical complications. The maximal size of tumors in this study, 

however, was 20 cm, and no pelvic resections were included. The 

optimal use of dalteparin in these very large resections is still not 

well defined. The results of this preliminary study suggest that 

dalteparin is safe and efficacious as prophylaxis against DVT in 

patients undergoing moderate to large sized tumor resection. 

POSTERS 


Clinical Benefits of Supplementing Radiotherapy with 

Chemotherapy in Soft Tissue Sarcoma (STS) 




Michael Delacruz, MD 

Vasthi Wilson, MD 

The management of soft tissue sarcomas (STS) remains controversial. 

Radiotherapy (XRT) or chemotherapy is often utilized preoperatively, 

but the clinical benefits of these modalities remain unclear. 

Information regarding the combined utilization of both radiotherapy 

and chemotherapy prior to surgery is especially limited. This 

study investigates whether supplementing preoperative XRT with 

neoadjuvant chemotherapy provides any clinical benefit to patients 

with STS. We searched our database for patients with pathologically 

confirmed STS treated with both preoperative XRT and surgical 

resection since 1998. Complete medical records and a follow up 

of greater than 12 months, or until patient death, were required 

for study inclusion. Outcome measures included overall survival 

(OS), disease free survival (DFS), amount of tumor shrinkage after 

radiotherapy and amount of histologic tumor necrosis at the time 

of surgery. OS was defined as the time from patient presentation 

until death or end of follow up. DFS was defined as the time from 

definitive surgery until development of local tumor recurrence/ 

metastatic disease or end of follow up. Survival analyses were 

performed with Kaplan-Meier and group comparisons were made 

using Student’s t-tests. Forty patients were included in this study. 

Mean follow up was 34.1 months. Twenty-nine patients had received 

preoperative XRT and 11 patients had received both preoperative 

XRT and neoadjuvant chemotherapy. The group receiving both 

XRT and chemotherapy had a two-year OS of 90%, which was not 

significantly different from the two-year OS of 92% for radiotherapy 

alone (p = 0.33). The group receiving both XRT and chemotherapy 

had a two-year DFS of 80%, which was not significantly different 

from the two-year DFS of 71% for radiotherapy alone (p = 0.94). 

The amount of tumor shrinkage in the group receiving both XRT 

and chemotherapy (mean, 37.4%) was significantly greater than 

the amount of shrinkage in the group receiving XRT alone (mean, 

-33.0%) (p=0.01). No significant difference was noted in the amount 




of histologic tumor necrosis between the two groups (means of 

62% vs. 49%) (p=0.36). Supplementing preoperative XRT with 

neoadjuvant chemotherapy provides no survival benefits to patients 

with STS, but the combination leads to significantly smaller tumors 

than XRT alone. This finding may be utilized by multi-specialty teams 

to shrink large sarcomas that would otherwise be unresectable. 


Monobutyrin - A Novel Factor Linking Fat Gain and 

Bone Loss 

Rachel W Li, MD, PhD, Canberra, ACT Australia 

Paul N Smith, MD, Deakin West, ACT Australia 

Monobutyrin secreted from adipocyte inhibited osteoblasts (OB). 

This indicates an existence of bone-fat interaction and a potential 

therapeutic target for reducing osteoporotic fracture risk. Human 

primary OBs derived from eight healthy and eight osteoporotic 

patients were cultured with monobutyrin. Cell proliferation, alkaline 

phosphatase (ALP), mineralization and confocal microscopy assays 

were used for functional assessments of OBs. Quantitative RT-PCR 

and flow cytometry were used for osteogenic gene profiling, cytokine 

production and phosphorylation of histone H3. Monobutyrin 

significantly inhibited OB cell proliferation (p

at a major oncologic referral center who had undergone either 

internal or external hemipelvectomy for tumor between June 2002 

and December 2007. Nineteen patients previously treated operatively 

with either a Type II periacetabular internal (INT, n=5), external (EXT, 

n=14) hemipelvectomy, or hip disarticulation (combined with EXT 

group) were evaluated using the Toronto Extremity Salvage Score 

(TESS), MSTS and SF-36. There were 16 (84%) males and 3 (16%) 

females with a mean age at operation of 48.7 ± 16.6 (range from 18 

to 69). Follow up was 30.7 ± 19.1 (range five to 70 months). Overall 

mean MSTS was 41.2 (range from 6.7 to 83.3), and TESS was 56.6 

(range 31.8 to 88). SF-36 physical function results were lower than 

the general population. Mental health condition was comparable 

to the normal population. The three measurements, TESS, MSTS 

and PF subscale of the SF-36, were all positively correlated. There 

were no significant influences of post-surgery time on MSTS, TESS 

or PF. However, the age of the patient at operation has a negative 

correlation with the physical function. The younger the patients, the 

higher the TESS and PF scores. Hemipelvectomies (either internal or 

external) have profound impact on patient lives as illustrated by low 

TESS, SF-36 and MSTS scores. TESS, MSTS and PF were all positively 

correlated indicating that the patient and physician tabulated scores 

correlate with one another in our study. The age of the patient at 

operation had a negative correlation with the physical function in 

that the younger the patients, the higher the TESS and PF scores. The 

time out from surgery did not affect scores. 


Aseptic Loosening Rates In Distal Femoral 

Endoprostheses: Does Surgical Technique Matter? 

Patrick F Bergin, MD, Indianapolis, IN 

Jenna B Noveau, BS 

Robert Mikael Henshaw, MD, Washington, DC 

James S Jelinek, MD 

Distal femoral replacement provides immediate functionality in 

limb salvage procedures. However, long-term results have been 

plagued by high rates of aseptic loosening with only resection length 

of the distal femur being predictive of failure. We propose a large 

stem, line-to-line reaming method of cemented stems to reduce 

the incidence of aseptic loosening. All distal femoral replacements 

performed at one institution were evaluated including revisions. The 

age, gender, oncologic diagnosis, length of follow up, chemotherapy 

and radiation treatments, and radiographic parameters were 

recorded. Patients with at least five-year follow up, no infection 

history and no radiation therapy were placed into a separate cohort. 

Two Kaplan-Meier survival curves were created. The first used any 

cause of stem removal as the endpoint for failure. The second 

specifically used aseptic loosening as the endpoint. Radiographs were 

reviewed to calculate the femoral resection percentage, stem size and 

ratio of diaphyseal to stem diameter. They were also reviewed in a 

blinded fashion by a musculoskeletal radiologist to assess for early 

signs of aseptic loosening. The Student’s t-test was used to assess for 

significant differences in the selected cohort between clinically stable 

patients and those patients revised for aseptic loosening. Bivariate 

analysis was performed for the entire patient population to look 

for risk factors predictive of loosening. Multiple logistic regression 

analysis was performed to find independent risk factors that lead to 

loosening. A total of 104 stems in 93 patients were evaluated with an 

average follow up of 5.5 years. Overall implant survival using Kaplan- 

Meier curves was 73.3% at 10 years but fell to 46.1% at 20-year follow 

up. Survival using aseptic loosening as the failure mode was 94.6% at 

10 and 15 years and 86.5% at 20-year follow up. Thirty-four patients 

with an average follow up of 12.5 years were placed into a separate 

cohort as described. Comparing patients with stable versus loose 

872 

implants in this cohort showed significant differences in stem size 

and bone/stem size ratio. There was no statistical difference between 

the resection percentages in this cohort. Using bivariate analysis of 

the entire patient population, similarly only stem size and bone/ 

stem ratio influenced survival. Resection percentage approached 

significance, but in multivariate analysis, only the bone/stem ratio 

was found to be an independent risk factor for aseptic failure. Aseptic 

loosening rates in cemented distal femoral replacement vary greatly 

among cohorts. Resection of more than 40% of the distal femur has 

previously been shown to predict loosening of the prosthesis. We 

present evidence that using a large stem with full canal fill and a 

small cement mantle is the most protective factor against failure. 

This surgical technique compared with a smaller stem technique can 

reduce historical loosening rates and shows less than 15% loosening 

at 20-year follow up. In this cohort, cemented endoprostheses with 

large canal-filling stems provides excellent stability in limb salvage 

reconstructions. 


Low-Energy Femur Fractures And Alendronate 

Aimee Perreira, MD, Honolulu, HI 

Kevin P Christensen, MD, Honolulu, HI 

Cori Hirai, BS, Honolulu, HI 

There is growing concern and circumstantial evidence for an 

association between low-energy femoral diaphysis fractures and longterm 

bisphosphonate use. The aims of this study are to: 1) review all 

low-energy femoral shaft fractures treated at our institution over the 

past three years, and 2) identify patient factors associated with this 

fracture pattern. This is a retrospective review of low-energy femoral 

shaft fractures presenting to our institution from January 1, 2006 to 

December 31, 2009, who were treated by the orthopaedic trauma 

service. Exclusion criteria includes age less than 50 years old and 

all pathologic, periprosthetic, pertrochanteric or distal 1/3 femur 

fractures. Pertrochanteric fractures that were excluded were used as a 

control for comparison. Fractures with lateral cortical thickening, a 

transverse pattern and a medial spike were grouped as ‘classic fracture 

pattern.’ Data collected includes subject demographics, medical 

history and available laboratory values. Fracture characteristics were 

described, and involvement of the contralateral side was noted. A 

total of 114 fractures were identified, 73 of which were excluded. 

Twenty-seven of these were pertrochanteric fractures and were used 

as a control. Fifty-two fractures in 41 subjects met inclusion criteria. 

Thirty-five subjects demonstrated classic findings compared to zero 

in the control. There was no difference in sex, body mass index or 

ethnicity between the two groups (p >0.05). Secondary causes of 

osteoporosis were present in 59% of subjects. Those with classic 

findings were younger than the control (69.7 versus 80.2 years, p 

Future prospective studies are needed to identify other risk factors 

associated with this unique fracture pattern, evaluate the safety of 

long-term bisphosphonate therapy and determine a method of 

radiographic screening for the population at risk. 


Diversity Of Angiogenesis Among Malignant Bone 

Tumors 

Tadahiko Kubo, MD, PhD, Hiroshima, Japan 

Shoji Shimose, MD, PhD, Hiroshima, Japan 

Toshihiro Matsuo, MD, PhD, Hiroshima, Japan 

Mitsuo Ochi, MD, PhD, Hiroshima, Japan 

Jun Fujimori, MD 

Several reports demonstrated that angiogenesis assessed by microvessel 

density (MVD) correlated with patient prognosis in a variety 

of cancers, whereas the data regarding the relevance of angiogenesis 

and prognosis in malignant bone tumors are scant and controversial. 

The aim of this study is to examine MVD in malignant bone tumors 

to clarify the role of angiogenesis in prognosis and therapeutic 

strategies. We reviewed 63 patients with non-metastatic malignant 

bone tumors, including osteosarcoma, chondrosarcoma and Ewing’s 

sarcoma, treated between 1980 and 2007. Biopsy or pretherapeutic 

surgical specimens were stained with anti-CD34 antibody. MVD was 

calculated according to the Weidner’s method. The median follow-up 

period was six years four months. The median values of MVD were 

40.9, 7.8 and 43.0 in osteosarcoma, chondrosarcoma and Ewing’s 

sarcoma, respectively. In osteosarcoma, high MVD, AJCC stage IIA, 

good histological response to chemotherapy correlated significantly 

with better disease-free survival (P


Effects Of Metabolic Acidosis On Fracture Healing: An 

Experimental Study 

Eduardo Nilo Novais, MD, Boston, MA 

Ana Christina Simoes-Silva, MD, PhD 

Marco Antonio Percope-Andrade, MD, Belo Horizonte, Brazil 

Regina Pereira, MD, PhD 

Guilherme Soares, MD 

There is substantial evidence that acidosis exerts profound adverse 

effects on bone metabolism. Studies in vitro and in vivo have shown 

that metabolic acidosis (MA) increases bone resorption and reduces 

bone formation as it suppresses osteoblastic activity and stimulates 

osteoclastic activity. MA is a usual feature present in metabolic bone 

diseases associated with renal disorders. Children with chronic 

renal diseases often present with widened and irregular epiphysealmetaphyseal 

junctions and angular deformities of the lower limbs. 

Management of long bone deformities and fractures associated 

with these situations may be troublesome. The purpose of this 

study is to evaluate the impact of MA on fracture healing in rats. 

We investigated the effects of MA on fracture healing in acidotic rats 

(AC) and in non-acidotic (C) controls. Chronic MA was induced by 

ingestion of ammonium chloride added to tap water as the unique 

source of liquid for the animals. After two weeks of acid-load (AC) 

or tap water (C) ingestion, a fracture of the right tibia was produced. 

Four weeks later, fracture healing was evaluated by radiological and 

histological standard parameters. Blood pH, sodium, potassium, 

chloride, calcium and phosphate were measured in both groups 

throughout the study Rats of the AC group were in a state of evident 

metabolic acidosis when the fracture was performed. However, at 

the end of the experimental period (day 42), they presented normal 

blood pH and bicarbonate levels. Fracture healing in AC animals was 

significantly altered as compared to C group both by radiographic 

and histological evaluation. Serum phosphate was significant lower 

in AC rats in the end of the study. This study showed a higher 

frequency of delayed fracture healing and nonunion in the presence 

of MA and emphasized the important role of bone buffering in 

acid base homeostasis. To our knowledge this is the first study that 

demonstrates in vivo effects of sustained metabolic acidosis on the 

fracture healing process. 


Perioperative and Late Infections in Osteosarcomas 

Treated with Endoprosthetic Reconstruction 


Xin Li, MD, Jinan, China 



Over the past few decades, there has been an improvement in survival 

outcomes in patients with osteosarcoma and a corresponding increase 

in the percentage of limb-sparing surgeries done in this population. 

With increased long-term survival, the incidence of infection has 

become more important in the treatment of these patients. The 

goal of this study is to assess the rate of infection in osteosarcoma 

patients treated with resection and prosthetic reconstruction. We 

retrospectively reviewed all cases of osteosarcoma treated with limb 

salvage surgery involving primary endoprosthetic reconstruction 

at our institution. Peri-operative infection was defined as infection 

within two months of surgery and any infection after two months 

was categorized as late. Sixty-seven patients (40 males and 27 

females) met inclusion criteria. Mean age was 33 years (range 10- 

78). Tumor locations included distal femur (39 patients), proximal 

874 

tibia (14), proximal femur (eight), proximal humerus (three), 

total humerus (two) and proximal radius (one). Fifty-nine patients 

had chemotherapy. Four patients had radiotherapy. All patients 

were given intra-operative intravenous antibiotics (first-generation 

cephalosporin), continued for three days postoperatively and 

then given orally for five days. Allergic patients were instead given 

intravenous vancomycin followed by clindamycin. Mean follow up 

was five years (range 1-9). Total infection rate was 6.0%. Only one 

patient (1.5%) had peri-operative infection. This occurred in a 78 

year old female following proximal tibial replacement with total 

knee arthoplasty, gatrocnemius flap and skin graft. Three patients 

(4.5%) had late infections. One occurred in a 22 year-old female, 52 

months after distal femur replacement with total knee arthroplasty. 

Another occurred in a 12 year-old male, nine months after distal 

femur replacement with total knee arthroplasty. The third late 

infection occurred in a 68 year-old male, 14 months after proximal 

tibia replacement with total knee arthroplasty. Three (75%) of 

the four total infections resolved with surgical debridement and 

antibiotics. The reported incidence of infection following sarcoma 

resection and endoprosthetic reconstruction varies greatly in the 

literature. Some authors report total infection rates as high as 

20% but ours was significantly lower at 6.0%. Our peri-operative 

infection rate was especially remarkable at only 1.5%, which may 

be due to our antibiotic regimen being longer than that generally 

recommended for routine total joint replacement. This series also 

exhibited a high rate of eradication of peri-prosthetic infection with 

surgical debridement and antibiotics, suggesting it may be a variable 

alternative for treating this complication in the osteosarcoma 

population. 


Validity of an Automatic Measure Protocol for Allograft 

Selection in a 3-D Virtual Bone Bank System 

Luis Alberto Aponte-Tinao, MD, Buenos Aires, Argentina 

Lucas Eduardo Ritacco, MD, Buenos Aires, Argentina 


Miguel Angel Ayerza, MD, Buenos Aires, Argentina 

Domingo Luis Muscolo, MD, Buenos Aires, Argentina 

Christof Seiler, PhD 

Mauricio Reyes, PhD 

Lutz P Nolte, PhD, Bern, Switzerland 

Ostearticular allograft is one of the possible treatments in wide 

surgical resections with large defects. In the context of bone 

databanks, performing best allograft selection is of great relevance. 

Current approaches are time consuming hindering these points in 

practice. We report a validation study of a software able to perform 

automatic bone measurements used to automatically assess the 

distal femur sizes across a databank, from six pre-defined anatomical 

landmarks. Featuring a fast and accurate, yet easy to employ, method 

for bone allograft selection. A total of 170 distal femur surfaces 

were reconstructed from CT data and measured manually using a 

measure protocol taking into account the transepicondyle distance 

(A), anterior-posterior distance in medial condyle (B) and lateral 

condyle (C). Intra and inter-observer studies were conducted and 

regarded as ground truth measurements. The same bone surfaces 

were then measured using an automatic software. Manual and 

automatic measures were compared using, a statistic description 

(means, maximal and minimal differences), intraclass correlation 

coefficient and illustrated with Bland and Altman graphics. A single 

operator was tested for intraobserver repeatability while using 

the above-mentioned A-B-C protocol twice on the bone surfaces, 

obtaining an intraclass correlation coefficient of 0.99 for all measures. 




Interobserver consistency of two separate observers was quantified 

as well for the same cohort, leading to an intraclass correlation 

coefficient of 0.99 for A measure, and of 0.98 for B and C measures. 

For the automatic measurements, the correlation coefficients between 

observer one and automatic method, were of 0.99 for A measure 

and 0.96 for B and C measures. The average time needed to perform 

the measurements was of 16 hours for both manual measurements, 

and of three minutes for the automatic method. The proposed 

methodology is presented as a key element towards effective and fast 

allograft selection, advancing the state of the art over current timeconsuming 

and labor-intensive solutions. The results demonstrate 

the high reliability and, most importantly, high repeatability of the 

proposed approach, which suggests an improvement of the available 

material in the databank, considerable speed-up on the planning 

and ultimately better surgery outcomes. 


The Effect of Osteoporosis Screening and Treatment on 

the Rate of Proximal Humerus Fracture 

Anshuman Singh, MD, San Diego, CA 

Richard M Dell, MD, Cypress, CA 


Annette L Adams, PhD, Pasadena, CA 

Ronald Anthony Navarro, MD, Rolling Hills, CA 

Osteoporosis is a quantitative loss in bone mineral density which 

causes fragility fractures of the spine and long bones. As the 

population ages, this represents an increasing burden on our society 

in terms of patient morbidity, lost productivity and expense to the 

healthcare system. The reduction in hip fracture cost and morbidity 

by osteoporosis screening and treatment has been well documented; 

we lack data regarding the effect of such programs on proximal 

humerus fracture. Beginning in 2002, a comprehensive screening and 

treatment program was initiated with the goal of screening all high 

risk individuals with dual x-ray absorptiometry scan and treating 

individuals with prior fragility fracture or T-score of 2.5 or worse 

with bisphosphonates. Institutional Review Board approval was 

obtained for a multicenter retrospective review of shoulder fractures 

in all patients aged 60 years old and older between 2002 and 2007. 

Fracture cases were screened using a comprehensive longitudinal 

electronic administrative database serving over three million 

individuals, identified by ICD-9 codes. Accuracy of this coding was 

regularly confirmed. The database includes fracture data, patient 

demographics, age, co-morbidities and history of previous fracture. 

A total of 15.5% of the study group was 60+ years old (N=525,758), 

which approximates the U.S. population. In terms of demographic 

risk factors for proximal humerus fracture, females have a hazard 

ratio of 3.1, diabetics 1.5 and Caucasians 2.0 (all p

crystal violet staining and results demonstrated a consistent increase 

in OS proliferation induced by LPAAT-B. LPAAT-B over-expression 

promoted OS migration as demonstrated by complete wound 

closure at 36 hours. In the orthotopic animal model of OS, LPAAT-B 

over-expression was shown to significantly increase OS growth 

(p


Radiological Evaluation of the Hip Joint Following 

Endoprosthetic Replacement of the Proximal Femur 

Michael Drexler, MD, Tel Aviv, Israel 

Eyal Amar, MD, Tel Aviv, Israel 

Shlomo Dadia, MD 

Isaac Meller, MD, Tel Aviv, Israel 

Jacob Bickels, MD, Rehovot, Israel 

Endoprosthetic replacement of the proximal femur involves removal 

of large amounts of bone and surrounding soft-tissues and is 

associated with a considerable load on the remaining acetabulum. 

We radiologically evaluated the changes occurring around the affected 

hip joint. Follow-up imaging studies of 41 consecutive patients 

who underwent either proximal or total femur endoprosthetic 

replacement and in which an acetabular cup has not been placed 

were retrospectively reviewed. The radiological evaluation included 

the extents of acetabular protrusion, degenerative changes of the 

acetabulum and heteroptopic bone formation around the prosthetic 

hip joint. The mean follow-up period was 76.8 months (range one 

to 190 months). Protrusion of the prosthetic head was documented 

in 14.6% (six patients), degenerative acetabular changes in 9.7% 

(four patients), and grade 1 heterotrophic bone formation in 24.4% 

(10 patients). The degenerative articular changes and heterotopic 

bone formation were not associated with clinical symptoms. 

Radiological evidence of protrusion, degeneration and heterotopic 

bone formation occur in the minority of the patients who undergo 

endoprosthetic replacement of their proximal femur. The extent of 

these changes and the lack of clinical symptoms do not justify the 

routine placement of an acetabular cup in these cases. 


Surgery And Malignant Change Around The Shoulder In 

Hereditary Multiple Exostoses 

Nicholas D Clement, MRCS Ed, Edinburgh, United Kingdom 

Cho Ng, MBBS, Edinburgh, United Kingdom 

Daniel Porter, MD, Edinburgh, United Kingdom 

Patients with hereditary multiple exostoses (HME) in association 

with palpable shoulder exostoses are more severely affect by their 

disease. We describe the epidemiology and risk of surgery around 

the shoulder in HME. A total of 172 patients were identified from 

a prospective database of 78 families with HME. Demographic 

details, deformity and functional scores, standing height, number 

of exostoses, site, genotype (EXT1 & EXT2), surgical excision and 

malignant change were recorded. Non-parametric tests were used 

to compare patients with shoulder exostoses (clavicle, scapular, 

humerus) to those without. There were 5,361 palpable exostoses, 

of which 14% were of the shoulder and were present in 145 

(84.3%) patients. There was a younger mean age (26.8 years verses 

37.9 years) and a male predominance in those individuals with 

shoulder exostoses (p=0.0005). Patients with shoulder exostoses 

had significantly worse disease (p

profile and additionally a lifestyle-questionnaire. Referring to the 

age and gender matched Z-score we found six cases of osteopenia 

(six/17) and five of osteoporosis (five/17) in Ewing’s sarcoma in 

the lumbal spine and four times osteopenia (four/18) and one time 

osteoporosis (one/18) in osteosarcoma. In the femur seven Ewing’s 

sarcoma patients were dropping below osteopenic (seven/17) and 

three below osteoporotic levels (three/17) while six osteosarcoma 

patients presented with osteopenia (six/18) and seven osteoporosis 

(seven/18). BMD (bone mineral density)-reduction occurred in both 

types of tumor, independent of chemotherapeutic scheme, sex and 

tumour localization which reveals the importance of prophylactic 

screening and osteoprotective medication also in childhood cancer. 


Adamantinoma of Bone 

Eduardo Nilo Novais, MD, Boston, MA 

Franklin H Sim, MD, Rochester, MN 

Peter S Rose, MD, Rochester, MN 

Carrie Inwards, MD, Rochester, MN 

Armita Bahrami, MD, Rochester, MN 

Doris Wenger, MD, Rochester, MN 

Mathew Most, MD, Sutton, MA 


Adamantinoma (AD) of the long bones is a rare, low-grade, malignant, 

slow-growing primary bone tumor with a strong predilection for the 

midshaft of the tibia, with or without involvement of the ipsilateral 

fibula. The purpose of this study is to define the clinical presentation, 

diagnostic and therapeutic options, prognosis for local recurrence, 

metastasis and survival in patients with adamantinoma. Forty-two 

consecutive patients with an adamantinoma were evaluated. Thirtyfive 

patients had an AD of the tibia (five of which also involved the 

fibula). Othe locations of the tumor were: femur (two), ulna (two), 

fibula (two), radius (one) and humerus (one). Thirty-four patients 

were treated initially with a limb sparring surgery and eight with an 

amputation. Most common presentation was pain and swelling. The 

mean age at presentation was 13 years (range 7-79). With a mean 

follow up of 13 years, the overall survival of the entire series was 

78.6%. Eight (19%) patients had recurrent local disease, nine (21%) 

developed lung and lymph node metastasis. Nine patients died of 

their disease and the majority of them were initially treated with 

an amputation (p=0.04). No statistical differences were observed in 

others risk factors for recurrent or metastatic disease. Adamantinoma 

of bone is a malignant lesion with metastatic potential. As adjuvant 

radiation and chemotherapy have not been effective in the treatment 

of AD, surgical management is necessary with the goal of clear 

margins. Historically amputation has been one option for the 

treatment of AD. However, in our series amputation did not improve 

the survival rate and we currently recommend wide en bloc resection 

with wide margins and reconstruction. All patients require long-term 

follow up for surveillance of local recurrence or distance metastasis. 


Does the Addition of Zoledronic Acid to Bone Cement 

Reduce Local Progression of Bone Metastases? 

Jeffrey TP. Luna, MD, Saugus, MA 

Niraj Kalore, MD, Birmingham, AL 

Yang Zhang, MS, Minneapolis, MN 

Edward Y Cheng, MD, Minneapolis, MN 

Zoledronic acid (ZA) reduces osteoclast activity and has antineoplastic 

effects. We studied whether or not packing with ZA 

impregnated bone cement (ZA+PMMA) after curettage of metastatic 

878 

bone cancer would lower local tumor progression. Seventy-three 

consecutive patients who underwent intralesional excision of an 

extremity bone metastasis were included in a case-control study. 

Group A (n=38), the tumor cavity was packed with ZA+PMMA; 

group B (n=35), PMMA alone was used. Time to local progression 

(TLP) was compared between groups A and B. Confounding factors 

such as gender, primary cancer histology, surgical site, pathologic 

fracture, visceral metastases, internal fixation, radiation therapy 

and chemotherapy, presence of multiple bone metastases and 

concomitant use of intravenous ZA were analyzed. Although 

univariate analysis did not show significance between the two groups, 

regression analysis revealed that the independent factors related to 

reduced TLP were ZA+PMMA (p=0.0024), use of internal fixation 

(p=0.0066) and presence of multiple bone metastases (p=0.0360). 

Final proportional hazard modeling based on backwards selection 

and likelihood ratio testing showed that for patients with multiple 

bone metastases, the chance of having local progression with local 

use of PMMA alone on their surgical site was 9.9 times greater when 

compared to those treated with ZA+PMMA (hazard ratio = 9.914 

with 95% CI: 1.128-87.125). The addition of zoledronic acid to bone 

cement for packing bone defects after excision of metastatic bone 

disease is associated with reduced time to local tumor progression. 


Effect Of Mitomycin C On Postoperative Adhesion 

Surgery: An Experimental Study In Rats 

Baris Kocaoglu, MD, Istanbul, Turkey 

Ismail Agir, MD, Istanbul, Turkey 

Ufuk Nalbantoglu, MD, Istanbul, Turkey 

Mustafa Karahan, MD, Istanbul, Turkey 

Metin Turkmen, Prof, Istanbul, Turkey 

The purpose of this study was to investigate the effect of Mitomycin-C 

on reduction of peritendinous fibrotic adhesion formation after 

tendon repair. Achilles tendons of twenty Wistar-Albino rats were 

cut and repaired with modified Kessler technique. In Group I, an 

injection of Mitomycin-C was placed between the tendon and skin 

of the right leg. In group 2, an identical volume of sterile normal 

saline was injected in the left side in a similar fashion. All rats 

received weekly both Mitomycin-C and saline for 4 weeks starting 

from the day of operation. Animals were sacrificed at postoperative 

day 30. The peritendinous fibrous tissue formation, inflammatory 

reaction and tendon healing were evaluated. Tensile strength of the 

repaired tendons was also measured biomechanically. Microscopic 

determination of adhesion formation and inflammation were less 

in Group I. There was also no significant difference in the tensile 

load required to rupture the repaired tendon between groups I and 

2. Our study showed that Mitomycin-C may provide a simple and 

inexpensive means of preventing postoperative adhesions. 


The Effect Of Pentoxyfillin At The Healing Of Segmental 

Bone Defects And Angiogenesis 

Gokhan Cakmak, Asst. Prof., Antalya, Turkey 

Ismail Cengiz Tuncay, MD, Ankara, Turkey 

Ali Engin Ulusal, MD, Balikesir, Turkey 

Handan Ozdemir, Assoc Prof, Ankara, Turkey 

The effect of pentoxyfillin at the healing of segmental bone defects 

and angiogenesis. 





The Local Treatment Of Soft Tissue Sarcomas 

Requiring Bone Resection 

Murat Hiz, MD, Istanbul, Turkey 

Sinan Ustundag, MD, Istanbul, Turkey 

Mehmet Can Unlu, MD, Istanbul, Turkey 

Fatih Ozyer, MD, Van, Turkey 

Yuksel Tenekecioglu, MD, Istanbul, Turkey 

Sergulen Dervisoglu, Prof, Istanbul, Turkey 

Bone resection and reconstruction is included in the surgical local 

tumour control of 25 large soft tissue sarcomas adjacent to bone 

or bony invasion that received neoadjuvant chemotherapy and 

irradiation after throuogh imaging. 

posteR No. bos1 

Gladden Society - The Pathophysiology of Health Care 

Disparities 

Raymond O Pierce Jr, MD, Indianapolis, IN 

Several Muscloskeletal Disparties have been found to have a common 

pathway, due to ethnic differences in the function and reactions 

of endothelial cell. Literature review dealing with Endothelial 

dysfuctions found in certain ethnic groups which results in 

differences in incidence, burden of disease and outcomes of known 

musculoskeletal Disparities. Endothelial dysfunction was found to be 

one of the primary etiological factors in the incidence and outcomes 

in Strokes and Low Birth Weight Babies, and is also involved in the 

non healing of diabetics ulcers and the aggressive nature of some 

Prostate Cancers. A common pathway has been demonstrated in 

some Musculoskeletal Disparites which is validated by cell culture 

studies showing biological differences in certain Ethnic groups. 


Role of GLI2 in Growth of Human Osteosarcoma 

Takao Setoguchi, Kagoshima, Japan 

Hiroko Nagao, Kagoshima, Japan 

Masataka Hirotsu, Kagoshima, Japan 

Yukihiro Matsunoshita, Kagoshima, Japan 

Naoya Kawabata, Kagoshima, Japan 

Takuya Yamamoto, Kagoshima, Japan 

Setsuro Komiya, Kagoshima, Japan 

Hedgehog pathway is critical for many processes during embryonic 

development. Recent studies have demonstrated constitutive 

activation of Hedgehog pathway in various types of malignancies. 

To explore the involvement of aberrant Hedgehog pathway in the 

pathogenesis of osteosarcoma, we investigated the expression and 

activation of Hedgehog pathway in osteosarcoma and examined 

the effect of GLI2 inhibition. In addition, we examined the effect 

of forced expression of constitutive-active GLI2. We performed 

real-time PCR using osteosarcoma cell lines and osteosarcoma 

biopsy specimens. We evaluate the effect of GLI2 inhibition or overexpression 

by MTT assay, colony formation assay, cell cycle analysis, 

and xenografts models. Real time PCR showed over-expression of 

Hedgehog pathway molecules in osteosarcoma. Knock down of 

GLI2 by RNAi prevents osteosarcoma growth by cell cycle regulation 

in vitro. Forced expression of constitutive active GLI2 promote 

mesenchymal stem cell growth by cell cycle regulation. Xenograft 

models demonstrated significant inhibition of tumor growth by 

GLI2 knockdown by shRNA. Kaplan-Meier analysis showed that GLI2 

knockdown conferred a significant survival benefit. These findings 

suggest that inhibition of GLI2 prevents osteosarcoma growth in 

879 

vitro and in vivo.We previously reported that inhibition of SMO, a 

Hedgehog receptor, prevents osteosarcoma growth in vitro and in 

vivo (Hirotsu M.et al. Molecular Cancer 2010). Our new findings 

confirm that the Hedgehog pathway is functionally activated in 

osteosarcoma. Our findings suggest that inactivation of GLI2 may be 

an attractive target for the treatment of patients with osteosarcoma. 



Current Concepts in the Treatment of Fatty Tumors of 

Soft Tissue - Musculoskeletal Tumor Society 

Michael P Mott, MD, Detroit, MI 

Theodore W Parsons, MD, FACS, Detroit, MI 

Carol D Morris, MD, New York, NY 


Valerae O Lewis, MD, Houston, TX 

H Thomas Temple, MD, Miami, FL 

J David Pitcher, Jr MD, Miami, FL 

Fatty Tumors of soft tissue comprise more than half of all soft tissue 

tumors. The wide variety of lesions within this subgroup can present 

a confusing picture to the practicing surgeon, and an understanding 

of appropriate treatment options can help avoid complications in 

patient management. This exhibit represents the experience of seven 

seasoned musculoskeletal tumor surgeons in 5 institutions across 

North America. It reflects the collective experience of many hundreds 

of cases of fatty tumors of soft tissue. The presentation, evaluation, 

and treatment options of the various common fatty lesions will be 

presented in a manner that will aid the practicing orthopaedic surgeon 

to more effectively treat patients afflicted with these soft tissue masses. 

It will present the imaging and clinical characteristics of these lesions 

along with available treatment options. Several example cases will 

be presented for illustrative purposes. The exhibit will conclude with 

a summary of current recommendations for care based upon the 

considerable collective experience of the authors. Specific histologydriven 

treatment regimens for fatty tumors of soft tissue can result 

in favorable outcomes for patients that suffer from these common 

lesions. Fatty lesions of soft tissue range from benign lipoma and 

its variants, to atypical lipomatous tumors, to well-differentiated 

liposarcomas, to high grade liposarcomas. Appropriate treatment 

requires the recognition, evaluation, and eventual treatment of these 

common lesions depending upon histology, size, and location. An 

appropriate algorithm for evaluation and treatment of these tumors 

is presented to aid the practicing orthopaedic surgeon in caring for 

these patients. 





Gender Disparities in the Diagnosis and Treatment of 

Osteoporosis 

Lauren Elizabeth Lamont, MD, New York, NY 

Joseph M Lane, MD, New York, NY 

Aasis Unnanuntana, MD, New York, NY 

Moira Margaret McCarthy, MD, New York, NY 

Christopher John Dy, MD, New York, NY 

Haydee C. Brown, MD, New York, NY 

Duretti Fufa, MD, New York, NY 

Alison Kitay, MD, New York, NY 

Osteoporosis in aging females and males remains an underrecognized 

and under-treated disease, resulting in significant 

morbidity and mortality. Despite the prevalence of osteoporosis 

across both genders, females are more likely than males to be 

diagnosed and treated. Consequently, at presentation, men have 

reached an advanced stage of osteoporosis. Moreover, there is an 

increased 1 year mortality in males (37.1%) compared with females 

(26.4%) in patients who present with hip fracture. There are distinct 

gender factors related to the pathophysiology and treatment of 

osteoporosis that influence clinical outcomes. Sex-specific differences 

in bone biology and morphology may affect the pathophysiology 

of osteoporosis and the choice of implant used in fracture fixation. 

Additionally, estrogen metabolism may play a key role in both 

fracture prevention and healing. Current screening guidelines differ 

between males and females and may influence the severity at which 

osteoporosis is recognized. This exhibit will highlight the gender 

disparity in the diagnosis, treatment and outcomes of osteoporosis. 

We will present data from a prospective descriptive study of patients 

presenting with hip fracture at our institution. Data at time of hip 

fracture includes prior screening for osteoporosis, prior fracture, prior 

and current treatment. We will also discuss and display radiographic 

examples of surgical techniques for osteoporotic fracture fixation as 

well as biologics for augmentation of bone healing. This information 

is essential to propagate in the orthopaedic community given the 

delayed presentation of men with osteoporosis. 


Leading Technology for In Vivo Fluorescent Sarcoma 

Imaging 

Katsuhiro Hayashi, MD, Kanazawa, Japan 

Norio Yamamoto, MD, Kanazawa Ishikawa, Japan 

Toshiharu Shirai, MD, Kanazawa, Japan 

Hideji Nishida, MD, Kanazawa City, Japan 

Akihiko Takeuchi, MD, Kanazawa, Japan 

Hiroaki Kimura, MD, Kanazawa, Japan 

Robert M Hoffman, PhD, San Diego, CA 


Naturally fluorescent proteins have revolutionized biology by 

enabling what was formerly invisible to be seen clearly. The green 

fluorescent protein (GFP) gene is frequently used as a reporter of 

expression and a biosensor in living animals. However, in orthopedic 

research, fluorescent proteins have only been used in a limited fashion. 

We have developed fluorescent real-time imaging for sarcoma cells 

by means of multi-color fluorescent cell lines and transgenic mice. 

Sarcoma cells were labeled with GFP or red fluorescent protein (RFP). 

Color-coded cells were transplanted into bone, soft tissue, spinal 

cord or blood vessels and their dynamics were observed in live mice. 

Transgenic mice were also used as the host in which GFP was driven 

by a stem cell marker nestin. Nascent blood vessels expressed GFP in 

880 

this model and tumor angiogenesis was imaged after transplantation 

of RFP sarcoma cells. Fluorescence imaging readily distinguished 

the color-coded cell lines and their differential ability to survive at 

the primary sites as well as metastasizing in live mice. Imaging of 

sarcoma cell trafficking in vessels revealed critical steps of metastasis. 

In transgenic mice, nascent blood vessels in the growing tumors were 

visualized and doxorubicin significantly decreased the mean nascent 

blood vessel density in the tumors. Lung metastasis was observed 

directly under fluorescent light. Real time in vivo imaging of sarcoma 

cells enabled visualization of their dynamics, including cell mobility, 

invasion, metastasis and angiogenesis. This technique will contribute 

not only to tumor biology but also to whole orthopedic research. 


Defining Personalized Medicine in Orthopaedics - 

AAOS Orthopaedic Device Forum 


Barbara D Boyan, PhD, Atlanta, GA 

Michael E Trice, MD, Baltimore, MD 

Michael J Yaszemski, MD, PhD, Rochester, MN 


Jack E Lemons, PhD, Birmingham, AL 

Personalized medicine uses a patient’s unique genetics, anatomy, 

or medical history to predetermine the most appropriate treatment 

modality. This exhibit discusses the issues within orthopaedic surgery 

where the future of personalized medicine has the best chance to 

create the highest impact on patient outcomes. The Orthopaedic 

Device Forum present personalized medicine opportunities in 

orthopaedics to educate the Fellowship on its potential for their 

patients. Areas of genomics, clinical and surgical examples are 

featured in multiple subspecialty areas of orthopaedic surgery. To 

date, there are few peer-reviewed publications in orthopaedic surgery 

which document discerned advantages of personalized medicine 

opportunities. An algorithm has been developed which defines both 

the pros and cons of this newly faceted aspect of musculoskeletal 

care. With the advent of new and improved technology, the face 

of orthopaedic surgery will continue to change. In the field of 

oncology the personalized medicine approach has involved genetic 

markers and directed immune therapy but now the possibility of 

directing patient’s own stem cell therapy or approaching surgical 

parameters in a unique patient function approach are all possible. 

Examples of personalized medicine in arthroplasty include demand 

matching, custom designed implants, advances in patient-specific 

cutting blocks and computer assisted techniques to customize the 

surgical parameters utilized to implant the components. This exhibit 

introduces the promise of this field and its impact in orthopaedic 

surgery. 


Combined Technique for Correction of Lower Extremity 

Deformities Caused by Metabolic Bone Diseases 

Prof Mehmet Kocaoglu, Istanbul, Turkey 

Levant Eralp, Istanbul, Turkey 

Fikri Erkal Bilen, MD, Istanbul, Turkey 

Halil I Balci, MD, Istanbul, Turkey 

We are presenting the results of the fixator assisted nailing and 

lengthening over nail for the treatment of lower extremity deformities 

caused by metabolic bone diseases. Between 2001 and 2009, 43 

lower extremity segments (27 femora and 16 tibiae) of 18 (5 male, 

13 female) patients with diagnosis of 16 hypophosphatemic rickets 

and two renal osteodystrophy, a mean age of 25.6 years (range, 




14-57) were acutely corrected, and the segment was stabilized by 

intramedullary locked nail. Three segments with shortening were 

subsequently lengthened by distraction osteogenesis. The mean 

follow-up time was 70 months (range, 28-130). In varus knees, the 

mechanical axis deviation (MAD) improved by an average of 57 mm, 

the lateral distal femoral angle (LDFA) improved by an average of 19 

degrees, and the medial proximal tibial angle (MPTA) improved by 

an average of 10 degrees postoperatively. In valgus knees, the MAD 

improved by an average of 48 mm, the LDFA improved by an average 

of 15.6 degrees, and the MPTA improved by an average of 10 degrees 

postoperatively. The mean external fixation time was 78.9 days, and 

for the lengthened segments the mean external fixation index was 

14.34 days/cm and the average bone healing index was 38.32 days/ 

cm. This combined technique provided good patient comfort, early 

mobilization and weight bearing due to the strong fixation provided 

by the locked IM nail. The usage of the intramedullary nail also 

prevented the recurrence of the deformity and refracture in the midterm 

follow-up period. 

881 




MEC01 

A Modified Approach to Bernese Periacetabular 

Osteotomy Maintaining Rectus-Femoris Tendon 

Insertion 

Joaquin Lara, MD, Santiago, Chile 

Luis Emilio Moya, MD, Santiago, Chile 

Juanjose Valderrama, MD, Santiago, Chile 

Javier Besomi, MD, Santiago, Chile 

Dante Parodi, MD, Santiago, Chile 

Pablo Villavicencio, Medical Student, Santiago, Chile 

Bernese periacetabular osteotomy (PAO) is the gold standard in 

the treatment of hip dysplasia. We present a modification of the 

Bernese PAO designed to improve and accelerate postoperative 

rehabilitation. The original technique, published by Ganz, et al 

in 1988, described a complete detachment of the rectus femoris 

tendon and tensor fascialata muscle, which had to be reattached 

at the end of the surgery. With this procedure, the patient had to 

refrain from active movement for six weeks. Our technique uses a 

shorter anterior approach with no detachment of the rectus femoris 

tendon, and the abductor musculature remains in its anatomical 

position. This modification allows the patient to begin active 

movement the first day after surgery, preserves the strength to walk, 

and shortens the limping period. The scar is also shorter and more 

aesthetically pleasing, which may be important to women patients. 

Our video shows how the osteotomy can be performed successfully 

using the shorter approach and the soft-tissue mobile-window 

concept, including a complete depiction of the modified technique, 

its advantages, and the accelerated rehabilitation program. The 

video also provides a detailed description of the original Bernese 

PAO technique, surgical indications and contraindications for the 

procedure, and a radiological study. Our modification of the Bernese 

PAO provides a successful osteotomy with adequate reorientation of 

the acetabulum and coverage of the femoral head in young patients 

with hip dysplasia. Rehabilitation time is shortened, and patients are 

able to begin active exercises soon after surgery. 

MEC02 

Medial Plantar Release in Nonreducible Congenital 

Equinovarus Foot 


Francesco Acri, MD, Bologna, Italy 

Stavroula Pagkrati, MD, Bologna, Italy 

Maria Teresa Miscione, MD, Bologna, Italy 



Idiopathic congenital clubfoot, also called equinovarus deformity 

or talipes equinovarus, is a difficult deformity to treat. Treatment of 

clubfoot begins at birth, with manipulation of the foot increasing 

gradually, depending on the stiffness of the deformity. Some feet are 

very rigid, and manipulation produces little evident change. Such feet 

are usually small and stubby. After manipulation, the patient receives 

a plaster cast and frame. If the clubfoot is not treated by the time 

the child reaches walking age, he/she will be able to stand only on 

the lateral aspect of the foot. Weight bearing on a club foot worsens 

the varus and supination deformities, which causes instability 

and makes walking painful. Some patients may require surgery if 

conservative treatment fails or the child reaches walking age without 

treatment. Our video shows the step-by-step surgical treatment of 

a nonreducible idiopathic equinovarus deformity in a child treated 

between 2 and 6 years of age with medial plantar release. The surgical 

procedure consisted of lengthening the medial tendons of the foot, 

882 

performing a capsulotomy of the talo-navicular joint, repositioning 

the navicular bone on the talar head, and performing capsulotomy 

of the naviculo-cuneiform joints to reduce the varus deformity. 

Lastly, we lengthened the Achilles tendon. Medial plantar release is 

a recognized surgical technique in the treatment of clubfoot, but its 

indication should be reserved for children who have already reached 

walking age who have a nonreducible deformity or those for whom 

conservative treatment has failed. Other patients should continue to 

receive conservative treatment over a long period. 

MEC03 

Scapulothoracic Fusion: Indications, Technique and 

Outcome 

Jon J. P. Warner, MD, Boston, MA 

Jessica Wells, BA, Cambridge, MA 

Danny Goel, MD, Vancouver, Canada 

James Romanowski, MD, Columbus, OH 

Ifedayo Kuye, BA, Boston, MA 

Laurence D. Higgins, MD, Boston, MA 

In this video, we describe the clinical and technical aspects of 

patients undergoing scapulothoracic fusions. The video begins with 

the clinical findings observed in patients with scapular winging 

who have failed conservative treatment and are not candidates 

for tendon transfer. We demonstrate multiple etiologies, including 

fascioscapulohumeral dystrophy and combined nerve palsy and 

clavicular insufficiency. Next, we give a detailed account of the 

surgical technique and dissection. Key components include patient 

positioning, surgical landmarks, incisions, muscular dissection, 

bony preparation, and hardware placement. We provide additional 

material to assess for potential intraoperative complications, 

including evaluation of pleural injury. The video concludes with 

a description of postoperative rehabilitation and a review of the 

outcomes of all patients who underwent scapulothoracic fusions 

from 2004-2010. 

MEC04 

Pediatric Anterior Cruciate Ligament Reconstruction 

Davide E. Bonasia, MD, Torino, Italy 


Brian R. Wolf, MD, Iowa City, IA 


Our video begins with a brief introduction outlining the 

controversies, possible treatments, complications, clinical 

examination, and imaging of anterior cruciate ligament (ACL) 

rupture in pediatric patients. We then describe the most commonly 

used techniques for pediatric ACL reconstruction, which include: 

physeal-sparing techniques, partial transphyseal techniques, and 

complete transphyseal techniques. Next the video gives a step-bystep 

description of pediatric ACL reconstruction using a partial 

transphyseal technique with proximal over-the-top positioning of 

the semitendinosus autograft. The 10-step surgical procedure we 

describe includes: 1) set-up and examination under anesthesia; 

2) graft harvesting; 3) graft preparation; 4) arthroscopic knee 

balance; 5) proximal approach to the lateral femur; 6) over-thetop 

positioning; 7) tibial-tunnel drilling; 8) proximal fixation of 

the graft; 9) distal fixation of the graft and final examination of the 

knee; and 10) postoperative management. Finally, we report the 

outcomes of conservative and surgical treatments, highlighting the 

level of evidence of the available studies, the controversies regarding 

the indications, and the technical errors commonly correlated with 

growth disturbance. 



MultiMedia education 2011

MEC05 

Anterior Hip Arthroplasty Approach Utilizing Operative 

Fracture Table and Fluoroscopy 

Nicholas A. Abidi, MD, Capitola, CA 

This video outlines patient positioning and the surgical technique 

used in the anterior supine intermuscular (ASI) surgical approach to 

primary total hip arthroplasty (THA). The video focuses on setting 

up the patient and positioning him/her on the fracture table. It also 

demonstrates the use of fluoroscopy for component postioning and 

illustrates how the design of the fracture table can assist in accurate 

placement during ASI primary THA. 

MEC06 

Northern or Superior PATH Approach for Hip 

Arthroplasty 

Patrick A. Meere, MD, New York, NY 

Sean Thompson, MD, New York, NY 

Carlos M. Alvarado, MD, New York, NY 

We describe the northern or superior percutaneous acetabular total 

hip (PATH)® approach for hip arthroplasty. The technique involves 

piriformis tendon release-only exposure with in-situ femoral 

preparation and percutaneous acetabular preparation. We position 

the patient in a lateral decubitus position. The incision is over the 

course of the piriformis with the leg flexed at 45°. Next, we divide 

the gluteus maximus bluntly proximal to the trochanteric bursa 

and release the piriformis. The interval between the piriformis and 

gluteus minimus is exploited to allow for an L superior capsulotomy. 

This method preserves the external rotators and the anterior and 

posterior capsule. Blunt retractors protect the neck while a slot 

is prepared in the superior femoral head. This allows for in-situ 

reaming and broaching on the femoral side, in a manner similar 

to a nail preparation. The thigh-foot angle sets the anteversion, 

and the depth of broaching relies on the greater trochanter. We 

perform the osteotomy after optimized broaching from the top. 

No dislocation is necessary. We then prepare the acetabulum using 

the PATH® method. This preserves all external rotators. Reduction 

uses modular neck components. Intraoperative radiographs confirm 

that accuracy is satisfactory. The closure involves the piriformis, 

superior capsule, gluteus maximus fascia, and superficial layers. This 

technique minimizes the risk associated with dislocation ie, femoral 

neurovascular compression and spiral fracture. The preservation of 

the external rotators minimizes the risk of dislocation and allows 

for an anticipated faster recovery. The technique is easily extensible 

to a regular posterior approach and therefore very safe in case of 

technical difficulties. 

MEC07 

Partial Thickness Tears of the Gluteus Medius: 

Technique for Trans-Tendinous Endoscopic Repair 

Benjamin Domb, MD, Chicago, IL 

Itamar Botser, MD, Chicago, IL 

Rima Nasser, MD, Chicago, IL 

Tears in the gluteus medius and minimus tendons have recently 

emerged as important causes of recalcitrant greater-trochanter pain 

syndrome. The purpose of this study was to review the anatomy, 

pathology, and existing repair techniques of the gluteus medius 

and to describe the rationale and surgical steps for endoscopic 

trans-tendinous repair. Advances in endoscopic surgery of the hip 

have created opportunities to better evaluate and treat pathology 

in the peritrochanteric compartment. We review the literature on 

trochanteric pain syndrome and gluteus medius tendon injuries and 

883 

analyze existing techniques for endoscopic and open gluteus tendon 

repair. We also explore potential challenges in the restoration of 

abductor function. Partial thickness undersurface tears of the gluteus 

medius are common pathological entities. Although these tears are 

otherwise analogous to partial thickness tears of the rotator cuff, the 

lack of arthroscopic access to the deep side of the gluteus medius 

tendon represents a unique technical challenge. We describe a 

novel endoscopic trans-tendinous repair technique to address the 

difficulty in visualizing —and therefore recognizing and repairing — 

undersurface tears of the gluteus medius. 

MEC08 

Revision Arthroplasty with Use of a Total Femoral 

Replacement 

Calin Stefan Moucha, MD, New York, NY 

James C. Wittig, MD, New York, NY 

Camilo E. Villalobos, MD, New York, NY 

Brett Hayden, BA, Clifton Park, NY 

Richard A. Greendyk, BS, New York, NY 

Benjamin A. Lerner, AB, Fairfield, CT 

The number of patients who require revision surgery for a failed 

total hip arthroplasty is increasing at a rapid rate. While multiple 

reconstructive options are available in the majority of cases, on 

rare occasions the femoral bone stock is so deficient that standard 

revision implants cannot be securely fixed in the remaining bone. 

This program demonstrates a surgical technique that utilizes a total 

femoral replacement prosthesis for revision arthroplasty of a highly 

deficient femur. The patient, who is young and morbidly obese, has 

previously undergone a total knee replacement and 18 surgeries 

on his femur. After an extensive, negative-infection workup, a total 

femoral replacement procedure was selected for this patient. The 

video shows the extensile exposure, the resection of the femur, the 

removal of a stemmed, well-fixed tibial arthroplasty component, and 

reconstruction using the total femoral prosthesis. Highlights include 

protection of the neurovascular structures and the appropriate 

implant positioning for ultimate stability and functionality. The 

authors suggest that the implant and surgical technique shown 

in this case are valuable additions to the orthopaedic surgeon’s 

armamentarium for treating patients with these difficult revisions. 

MEC09 

Revision of the Femoral Component in Total Hip 

Arthroplasty 


After failure of either a cemented or noncemented total hip 

replacement, femoral bone stock almost always is denuded of 

cancellous bone, and the proximal cortical structure is insufficient 

to achieve secure axial and torsional load-bearing. To achieve the 

best fixation, the bone in the metaphysis and the diaphysis of 

the femur must be firmly engaged with the femoral component. 

Torsional loading is the most important cause of loosening of 

the femoral component after revision total hip replacement, and 

therefore it is the most important issue to address in fixation. Axial 

load bearing is equally important, but achieving axial fixation is a 

much simpler biomechanical and surgical problem to solve. Initial 

rigid torsional load-bearing capacity up to 25 Nm of torsional load 

is a prerequisite for an implant to achieve a high degree of success. 

In a revision situation, this can be achieved only by an implant that 

develops mechanical interlock with the diaphyseal cortical bone. 

A long tapered rectangular or fluted stem is the simplest geometric 

component to fit in the proximal femur, and such a component 

satisfies the criteria for adequate axial and torsional load-bearing 




capacity as well. This video uses surgical footage and illustrations 

to describe my preferred surgical technique to reconstruct the femur 

in revision total hip arthroplasty. The clinical results of 45 hips with 

major femoral bone loss showed that 1 hip failed due to loosening, 

and 3 hips had mild thigh pain at 3 years after surgery. 

MEC10 

Cup Revision Through the Direct Anterior Approach 

Michael M. Nogler, MD, Oberperfuss, Austria 

William J. Hozack, MD, Philadelphia, PA, 

Helga Fritsch, MD, Innsbruck, Austria 

Eckart Mayr, MD, Philadelphia, PA 

Martin Krismer, MD, Innsbruck, Austria 

The direct anterior approach (DAA), which exploits the interval 

between tensor fasciae latae and sartorius, has become a widely used 

approach for primary total hip arthroplasty (THA). As with any other 

approach to the hip, it is not limited to primary arthroplasty but can 

also be used for revision arthroplasty of the acteabular component. 

We have developed concepts for revision procedures using DAA in 

patients with failed primary THA. Our method does not require use 

of a special traction table. In this narrated video, we demonstrate 

how a cup revision can be performed successfully through a DAA. 

The video uses sequences filmed intraoperatively, as well as extensive 

cadaver preparation to demonstrate revision following a prior DAA 

and revision following prior non-DAA approaches. The video also 

demonstrates cup exposure and possible extensions, cup removal, 

and cup reconstruction with and without cement. To clarify specific 

information, the video uses labeled overlays. 

MEC11 

Stem Revision Through the Direct Anterior Approach 

Michael M. Nogler, MD, Oberperfuss, Austria 

William J. Hozack, MD, Philadelphia, PA 

Helga Fritsch, MD, Innsbruck, Austria 

Eckart Mayr, MD, Philadelphia, PA 

Martin Krismer, MD, Innsbruck, Austria 

The direct anterior approach (DAA), which exploits the interval 

between tensor fasciae latae and sartorius, has become a widely used 

approach for primary total hip arthroplasty (THA). Since access to 

the cup is quite direct, it is obvious that this approach can be used 

for cup revision, but it can also be used for endo-femoral revisions 

of the femoral component, and it can extend to reach the diaphysis 

for more complex trans-femoral procedures. We have developed 

concepts for revision procedures in patients with failed THA that 

employ the DAA but do not require the use of a special traction table. 

In this narrated video, we demonstrate the revision of the femoral 

component. The technique emphasizes the extension of the approach 

in order to reach areas distal to the lesser trochanter and expose the 

diaphysis of the femur. The video contains intraoperative footage 

and includes extensive cadaver preparation to demonstrate exposure 

of the proximal femur, endo-femoral retrieval of the component, 

endo-femoral reconstruction with noncemented systems, and endofemoral 

reconstruction with bone-impaction grafting. The video also 

covers anatomic considerations and extensions and includes labeled 

overlays to demonstrate specific information. 

884 

MEC12 

Understanding Acetabular-Component Positioning 

Justin Dazley, MD, Stony Brook, NY 

James D. Capozzi, MD, Garden City, NY 

Ryan M.Vellinga, BS, Hauppauge, NY 

The purpose of our video is to aid in the interpretation of 

postoperative radiographs in total hip arthroplasty (THA), especially 

with regard to acetabular-component positioning. The video reviews 

several common scenarios of intraoperative incorrect patient 

positioning during THA. Using a simulation with a human model, 

the video shows a patient who is appropriately positioned, a patient 

falling forward, a patient falling backward, and a vertically placed 

acetabular component. A pelvic-bone model demonstrates the 

underlying bony anatomy for each scenario. Radio-opaque markers 

placed on the bone model help correlate the described situation 

with the corresponding radiograph. A pelvic-bone model with an 

acetabular component in place shows the effects of intraoperative 

positioning on the acetabular component. The video also discusses 

how to interpret radiographic findings in the various scenarios. 

MEC13 

Anatomy, Function, and Surgical Access to the Iliotibial 

Band in Total Knee Arthroplasty 


Marcel Roy, PhD, Saint Louis, MO 

When the iliotibial band (ITB) causes deformity in the valgus knee, 

it must be released or elongated during total knee arthroplasty (TKA) 

to establish normal stability. We created this video to delineate the 

attachments of the ITB about the knee, to determine the function 

of its parts in flexion and extension, and to establish a safe release 

of the ITB in the valgus knee. The dissection of 20 human cadaver 

knees established that the ITB has a broad anterior attachment to the 

quadriceps, patella, and patellar tendon. The central portion attaches 

to Gerdy’s tubercle on the tibia. The posterior portion attaches to 

the biceps femoris and fibular head. The posterior portion of the 

ITB tightens in extension. The anterior portion tightens in flexion 

and holds the central portion anteriorly, giving the ITB some lateral 

stabilizing effect in flexion. The posterior portion of the ITB closely 

overlies the lateral collateral ligament (LCL). In flexion, the posterior 

portion of the ITB slackens but remains close to the LCL. Release 

of the posterior ITB from inside would damage the LCL and the 

popliteus tendon. Complete release of the ITB can be done outside 

the joint without damaging the lateral ligaments. Selective posterior 

release also can be done from outside, leaving the anterior portion 

intact and the underlying ligaments undisturbed. Our findings 

suggest that complete ITB release cannot be done safely from inside 

the knee joint and is best done from outside. Partial ITB release may 

also be done from outside the knee joint. 

MEC14 

Computer-Assisted Open-Wedge High Tibial Osteotomy 

Silvio Giannetti, MD, Rome, Italy 


Antonio Vadalà, MD, Rome, Italy 

Fabio Conteduca, MD, Rome, Italy 

Andrea Ferretti, MD, Rome, Italy 

Open-wedge high tibial osteotomy is an established technique 

for the treatment of symptomatic varus malaligned knees. In this 

surgical video, we describe the use of a navigation-system device in 

a patient undergoing surgery for medial knee compartment arthritis. 

We show the surgical planning of the operation, and then we describe 




in details the use of the software and its intraoperative reliability. At 

the end of the video, we show radiographic varus angle correction. In 

conclusion, we recommend the use of this type of navigation system 

because it is easy to use and very reliable for the correction of both 

the final mechanical axis and the tibial slope. 

MEC15 

Direct Intra-articular Antibiotic Infusion for Treatment 

of Methicillin-Resistant Staphylococcus Aureus in 



Michael Peppers, PharmD, Saint Louis, MO 

Marcel Roy, PhD, Saint Louis, MO 

Tariq Ali Nayfeh, MD, Ellicott City, MD 

Resistant organisms are difficult to eradicate in infected total knee 

arthroplasty. This video evaluates the effectiveness of single-stage 

revision and direct antibiotic infusion for this condition. We treated 

18 knees (18 patients) with methicillin-resistant Staphylococcus 

aureus between January 2001 and January 2007 with a one-stage 

revision protocol that included débridement, noncemented revision 

of total knee components, and intra-articular infusion of 500 mg 

vancomycin via Hickman catheter once or twice daily for 6 weeks. We 

used no intravenous antibiotics after the first 24 hours. We monitored 

serum vancomycin levels to maintain levels between 3 and 10 µg/ 

mL. The mean serum vancomycin peak concentration was 6 ± 2 µg/ 

mL and the mean serum vancomycin trough concentration was 3 

± 1 µg/mL at 2 weeks postoperatively. We measured knee synovial 

fluid peak and trough vancomycin levels in two knees. Synovial fluid 

peak concentrations were 10,233 µg/mL and 20,167 µg/mL and 

trough concentrations were 724 µg/mL and 543µg/mL, respectively. 

Minimum followup was 27 months (range, 27 to 75 months). 

Mean followup was 62 months, (range, 27 to 96 months). At 2-year 

followup, mean Knee Society score was 83 ± 9. No radiographic 

evidence of implant migration has occurred. One knee reinfected 

with methicillin-resistant S aureus and required reoperation at 5 

months. We found a necrotic bone segment, debrided and revised 

the knee, and readministered the antibiotic infusion protocol. The 

knee remained free of infection at 42 months postoperatively. We 

conclude one-stage revision and 6-week intra-articular vancomycin 

administration safely and effectively treats methicillin-resistant S 

aureus-infected total knee arthroplasty. 

MEC16 

Surgical Exposure and Bone Reconstruction in 

Revision Total Knee Arthroplasty 


This video illustrates my technique for surgical exposure and 

reconstruction of failed total knee arthroplasty. Reconstitution of 

bone stock is a primary concern at revision surgery. Fixation often 

is difficult because the cancellous bone has been depleted, so 

it is tempting to cement the implant to diaphyseal cortical bone. 

However, revision with cement ultimately destroys more bone stock. 

Rather, techniques that use a noncemented porous-coated stem 

to engage the isthmus, and then bone graft to fill the defects, can 

provide adequate fixation as well as the opportunity to reconstruct 

the bone stock around the knee. Seating the implant on the patient’s 

own bone stock controls axial migration, and the stem prevents the 

implant from tilting into the defect. Screw-and-peg fixation can add 

stability to the construct, thereby allowing the cavitary deficiencies 

to be filled with morselized bone. This bone grafting technique 

promotes rapid healing and reconstitution of bone stock without 

the technical difficulty and late collapse associated with massive 

885 

allograft replacement. Since 1984, I have tried to fix the implants 

to the patient’s remaining bone structure using osteointegration 

techniques and to graft the remaining cavitary defects with non-weight 

bearing allograft. Initially, I thought that noncemented fixation of 

the components would be tenuous and that repeat revision would 

be necessary to achieve durable fixation with the improved bone 

stock. However, I have found that repeated revision due to failure 

of fixation has not been necessary because the construct has been 

reliably durable. 

MEC17 

Patellar Fracture Fixation Utilizing Minimal Hardware 

E. Barry McDonough, MD, Morgantown, WV 

Patellar fractures are uncommon injuries occurring most often as the 

result of direct blows to the anterior aspect of the knee. Traditional 

methods of fixation include tension-band wiring with heavy 

gauge wire. While this technique provides stable fixation, there are 

complications associated with this method. Hardware prominence 

can cause soft-tissue issues, and some studies have reported wire 

breakage or migration, either of which can lead to problems. 

This video provides a new technique to minimize complications 

associated with traditional wire fixation. 

MEC18 

Robotic Arm Guidance to Improve Lateral 

Unicompartmental Knee Arthroplasty Accuracy 

Martin William Roche, MD, Fort Lauderdale, FL 

John H. Velyvis, MD, Saint Helena, CA 

Lateral unicompartmental knee replacements account for approximately 

10% of the unicompartmental procedures performed today. 

Good results depend on patient selection, implant design, and 

surgical technique. The surgical approach and the orthopaedic 

surgeon’s familiarity with the anatomy and biomechanics of the 

lateral joint also affect whether the surgery achieves optimized lateral 

joint kinematics. Patients with lateral compartment disease are often 

women presenting with soft-tissue laxity, femoral hypoplasia, and 

joint-line obliquity. There are a number of technical difficulties 

associated with treatment in these patients. The laxity presents a 

risk of overcorrecting the mechanical axis during surgery. Another 

problem is that the use of mechanical instrumentation often makes 

it difficult to place the desired tibial-implant cut. To compensate 

for the screw-home mechanism, internal rotation of the tibial 

component is required to allow central tracking on the femoral 

component from extension into deep flexion. In comparison to the 

medial side, the tibial cut should be smaller and the slope less steep. 

The femoral cuts are more difficult because patellar impingement 

with knee flexion can affect the mechanical jigs. To optimize implant 

articulation, the femoral component usually requires more nearly 

vertical positioning that is lateral on the femoral condyle. Our video 

shows how the use of robotic-arm-assisted lateral unicompartmental 

knee arthroplasty aids in virtual implant positioning, intraoperative 

achievement of the desired mechanical alignment, and optimized 

soft-tissue balancing. Through a direct lateral approach, the 6° 

of freedom in the robotic arm make it possible to achieve boney 

resection and implant placement through a minimal incision with 

precision and safety. 




MEC19 

Unicompartmental Knee Replacement: Surgical 

Technique 


This video incorporates surgical footage and a detailed explanation of 

the surgical technique that I use when performing unicompartmental 

knee replacement. To ensure optimal clinical results, the video 

describes principles of instrument alignment, bone preparation, and 

component alignment. It also presents outcomes of 89 knees in a 

12-year period. None have failed because of loosening or anterior 

cruciate ligament instability. One failed due to osteoarthritis in the 

lateral compartment, and three that failed because of polyethylene 

wear underwent revision. 

MEC20 

Interactive Functional Anatomy of the Foot and Ankle 

Phinit Phisitkul, MD, Iowa City, IA 

Tanawat Vaseenon, Iowa City, IA 

Gladys Chan, MD, Salt Lake City, UT 

John E. Femino, MD, Iowa City, IA 


The foot and ankle are sophisticated structures that are subject 

to high impact, even during normal activities. Not surprisingly, 

both acute and chronic overuse injuries are common and often 

disabling. Successful treatment of foot and ankle injuries requires 

precise knowledge of the functional anatomy of the lower limb. 

Our interactive video demonstrates important clinically correlated 

anatomy of the foot and ankle. The demonstration and discussion 

topics include: Achilles tendinopathies, peroneal tendons, lateral 

ankle ligaments, subtalar joint impingement, subtalar ligamentous 

structures, ankle syndesmosis, the deltoid ligament, and the Lisfranc 

joint. 

MEC21 

Guidelines for Surgical Treatment of Hallux Rigidus 



Gianluca Grandi, MD, Bologna, Italy 

Danilo Leonetti, MD, Bologna, Italy 

Matteo Nanni, MD, Bologna, Italy 

Francesco Acri, MD, Bologna, Italy 

The treatment of hallux rigidus — a painful limitation of dorsiflexion 

of the first metatarsophalangeal joint —remains a controversial topic 

in orthopaedic surgery. In the past, most authors have recommended 

resection arthroplasty of the first metatarsophalangeal joint, but 

more recently, others have presented good results with cheilectomy, 

various types of osteotomies and arthrodeses, or bioreabsorbable 

implants. This video presents our recently published guidelines 

for surgical treatment of hallux rigidus, based on our review of 

111 consecutive feet that underwent surgery. The video shows 

step-by-step clinical and radiographic evaluation, classification, 

an algorithm for treatment, and various surgical techniques. We 

used labeling factors to classify feet for treatment. Feet with hallux 

rigidus without arthritis underwent plantar release; feet with grade 

1 hallux rigidus underwent distal decompressive osteotomies; feet 

with grade 2 hallux rigidus underwent cheilectomy; feet with grade 3 

hallux rigidus underwent arthrodesis or resection arthroplasty using 

bioreabsorbable implants. We allowed immediate weight bearing 

with talus shoes for 4 weeks. We examined the feet clinically and 

radiographically for an average follow-up of 6 years. The mean 

clinical preoperative AOFAS score was 42+14; at follow-up, it was 

886 

81+9. The mean preoperative metatarsophalangeal range of motion 

was 27+17°; at follow-up, it was 75+8°. Surgical treatment of hallux 

rigidus depends on its pathoanatomy, and optimal results hinge on 

the precise evaluation of labeling factors. 

MEC22 

Treatment of Flexible Flatfoot in Children: Joint- 

Preserving Surgery with Subtalar Arthroereisis in 

Conjunction with Soft Tissue Procedures 

Antongiulio Marmotti, MD, Torino, Italy 



Margherita Germano, MD, Torino, Italy 


Gianluca Collo, MD, Torino, Italy 

Mattia Cravino, MD, Torino, Italy 

Alessia Tron, MD, Torino, Italy 

Rainero Del Din, MD, Perosa Argentina, Italy 

Flexible flatfoot in children is one of the most common disorders in 

pediatric orthopaedic practice. The patient should undergo careful 

evaluation to ascertain the extent of flexibility. A radiograph is 

unnecessary if the flexible flatfoot is asymptomatic. Such patients do 

not require treatment, but they should undergo clinical monitoring 

for changes in status. In a small percentage of patients (less than 

10%), symptoms will develop in middle-to-late childhood (from 

8 to 9 years old). Symptoms are often related to sports activities, 

and they may present as foot and lower-limb fatigue, pain in the 

hindfoot and in the medial midfoot, or both. When conservative 

measures fail to relieve the pain in symptomatic children, jointpreserving 

deformity-correcting surgery is indicated. The goal of 

surgical treatment is to correct heel valgus and pronation of the 

subtalar joint; laxity in the talonavicular joint and the medial 

column; posterior tibial tendon weakening; and a too-short Achilles 

tendon, if present. Corrective treatment includes extra-articular 

subtalar arthroereisis in conjunction with soft-tissue procedures, 

such as spring ligament plication (medial plication); posterior 

tibial tendon tensioning repair; and percutaneous Achilles tendon 

lengthening, if needed. After corrective surgery to reduce heel valgus 

and medial laxity, patients typically have a painless return to sports 

activities. Our video shows the various steps of this treatment for 

pediatric flexible flatfoot, both as performed by a senior surgeon and 

as demonstrated on a cadaveric model. 

MEC23 

Scaphoidectomy and Four-Corner Fusion 

Robert M. Orfaly, MD, Portland, OR 

Scaphoidectomy and four-corner fusion is a widely accepted treatment 

of scapholunate advanced collapse (SLAC) and scaphoid nonunion 

advanced collapse (SNAC) in wrists. With the introduction of circular 

plates in 1999, the expectation was that they would effectively bind 

the carpal bones together until solid fusion could be achieved. 

However, early reports suggested higher complication rates including 

nonunion, dorsal hardware impingement, and screw breakage or 

back-out. More recent studies have demonstrated superior results 

with few complications. This video demonstrates several technical 

steps that are necessary to achieve consistent success with circular 

plates. Proper seating of the plate is important. To avoid hardware 

prominence, the surgeon should seat the plate entirely below the 

dorsal cortices. Even with relatively generous reaming, deep seating 

requires removal of only a small percentage of the surface area 

between the carpal bones. Another advantage of deep seating the 




plate is that it facilitates proper screw placement. With superficial 

plate placement, the surgeon can only achieve adequate screw 

fixation by using a horizontal trajectory, which may shift the bone 

away from the center and increase the gap at the fusion site. Deep 

seating permits vertical screw orientation and excellent fixation. The 

bone will draw toward the center of the plate, thus decreasing the 

gap at the fusion site. Other details that will promote a successful 

outcome include: taking care to preserve congruent bony surfaces, 

performing complete decortication of the volar and dorsal portions 

of the articular surfaces, and undertaking external compression of 

the bone during provisional fixation. Following these dictates can 

lead to a stable construct with excellent potential for solid fusion. 

MEC24 

All-epiphyseal Anterior Cruciate Ligament 

Reconstruction in Skeletally Immature Patients 


Neeraj M. Patel, MBS, Philadelphia, PA 

Stephanie R. Cody, BS, Philadelphia, PA 

J. Todd R. Lawrence, MD, Wynnewood, PA 

Prompt treatment of anterior cruciate ligament (ACL) injuries 

in skeletally immature patients can minimize the risk of future 

chondral and meniscal damage. However, the presence of the 

open physis in this patient population presents a unique surgical 

challenge. A number of modified techniques have recently emerged 

as potential options for ACL repair in prepubescent patients. We 

describe, to our knowledge, the only reported ACL reconstruction 

technique that keeps the graft and fixation entirely in the epiphysis 

while placing the graft within the native ACL footprint. The 

technique is as follows: The surgeon creates standard anteromedial 

and anterolateral arthroscopic portals and then places a guide wire 

in the distal femoral epiphysis, parallel to the physis, to the center 

of the femoral attachment point of the ACL. The next step is to drill 

a tunnel in the epiphysis of the lateral femoral condyle. Using a 

retrograde drill, the surgeon then drills a tibial tunnel from insideout 

to 3 mm from the tibial physis. Intraoperative CT scanning with 

three-dimensional reconstruction will confirm the precise location 

of the femoral and tibial tunnels, after which the surgeon can pull an 

autologous quadrupled hamstring graft through the femoral tunnel 

and into the tibial tunnel. Fixation of the graft is achieved with a 

retrograde interference screw in the tibia and an interference screw 

in the femur. Although the procedure requires long-term follow-up, 

we have found excellent results in our patients that have undergone 

all-epiphyseal ACL repair. This method provides a novel technique 

that avoids fixation, drill holes, or tensioning of the graft across the 

physis and thus minimizes the risk of growth disturbance. 

MEC25 

Transepiphyseal, Physeal Sparing Anterior Cruciate 

Ligament Reconstruction 


Controversy surrounds treatment of anterior cruciate ligament 

tears in children and adolescents. In this video, I briefly discuss the 

rationale for treating high risks prepubescent patients with a relatively 

anatomic transepiphyseal physeal-sparing ACL reconstruction. I also 

demonstrate the procedure and give the results of patients treated 

with the technique. 

887 

MEC26 

Congenital Hip Dislocation: Open Reduction Through a 

Medial Approach With Video Assistance 

Antonello Montanaro, MD, Rome, Italy 

Turturro Francesco MD, Rome, Italy 

Luca Labianca, MD, Rome, Italy 

Vincenzo Di Sanzo, MD, Rome, Italy 

Silvio Giannetti, MD, Rome, Italy 


Ludloff introduced the medial approach for the open reduction 

of congenital dislocation of the hip in 1908. Open reduction is 

the treatment of choice when closed reduction has failed. Studies 

suggest that the medial approach is best suited for children between 

the ages of 7 months and 18 months because there is a higher risk 

of avascular necrosis in infants younger than 7 months. The surgeon 

may undertake the medial approach either anteromedially or 

posteromedially, depending on the choice of path to the adductor 

brevis. There are three well-known surgical techniques for the medial 

approach: the Weinstein approach (an anteromedial approach), the 

Ludloff approach (an anteromedial approach), and the Ferguson 

approach (a posteromedial approach). The Ferguson posteromedial 

approach has several advantages, which include minimal dissection 

and blood loss; a direct approach to common obstacles to reduction, 

such as the psoas tendon, capsular constriction, and the transverse 

acetabular ligament. However, there are also surgical disadvantages, 

which include a poor view of the acetabulum because of the 

narrow surgical field. Also, the Ferguson approach does not permit 

capsulorraphy, which is required in older patients. We prefer the 

Ludloff approach with video assistance to improve the view of the 

acetabulum and help us evaluate how the various structures can 

affect the final results. 

MEC27 

Femoral Head Re-Orientation in SCFE Through a 

Surgical Hip Dislocation 


Alessandro Massè, MD, Torino, Italy 

Alessandro Aprato, MD, Orbassano, Italy 

Luigino Turchetto, MD, Musile Di Piave, Italy 

Guido Grappiolo, MD, Pietra Ligure, SV, Italy 

Antonio Campacci, MD, Arbizzano, Italy 

Since the senior author reported that it is safe to surgically dislocate 

adult hips to deal with impingement problems without the risk 

of avascular necrosis, surgeons have expressed interest in open 

treatment of severe slipped capital femoral epiphysis using this 

surgical approach to anatomically realign the slip. The additional 

technique of the extended retinacular flap permits the performance 

of an open subcapital reorientation of the epiphysis. Advantages of 

this technique are the possibility of restoring the correct hip anatomy 

through an open procedure, the ability to perform an acetabular 

condroplasty at the same time, and the opportunity to perform a 

trochanteric advancement to avoid pelvic-trochanteric impingement. 

The disadvantages of this procedure are that it is demanding surgery 

with the risk of avascular necrosis of the head when not executed 

carefully and exactly following the original description. 




MEC28 

Physical Examination of the Elbow: A Cadaver Insight 

to Better Understand How the Tests Work 



Michele Scelsi, MD, Torino, Italy 


Andrea Ferro, MD, Rivoli, Italy 

The physical examination of the elbow remains an unsolved problem 

for many orthopaedic surgeons. We believe the reason for this can 

be found in a lack of familiarity with the elbow’s anatomy as well as 

the relative rarity of elbow diseases. The aim of this video is to show 

another way to look at the physical examination of the elbow through 

a dynamic view of the anatomic structures involved in the tests. In 

this video, we demonstrate how to correctly perform tests for medial 

instability, subluxating medial triceps, distal biceps tendon rupture, 

posterolateral instability, and posterolateral and anterolateral plica. 

Most of the tests use a cadaver specimen and drafts. The video also 

contains a simulation with a healthy volunteer, with emphasis on 

avoiding false positive and false negative results. 

MEC29 

Latissimus Dorsi and Teres Major Transfers for 

External Rotation With Reverse Shoulder Arthroplasty 

Geraldo Motta, MD, Rio De Janeiro, Brazil 

Marcus Vinicius Galvao Amaral, MD, Rio De Janeiro, Brazil 

Marcio Theo Cohen, MD, Rio de Janeiro, Brazil 

Martim Teixiera Monteiro, MD, Rio de Janeiro, Brazil 

Bruno Lobo Brandão, MD, Rio de Janeiro, Brazil 

Rickson Moraes, MD, Rio De Janeiro, Brazil 

Massive rotator cuff tears or muscles infiltrated by fat cause a patient 

to lose the ability to lift the affected arm and rotate the shoulder, 

move the hand away from the body, or place the hand to the mouth 

or head. To place the hand to the mouth or head, a person must have 

external rotation with forward flexion. Reverse shoulder arthroplasty 

restores active forward flexion, but it does not enhance external 

rotation. Boileau et al described a modification of the L’Episcopo 

procedure that transfers both the latissimus dorsi and teres major 

behind the posterior humerus and restores active external rotation. 

In our video, we show this procedure combined with the reverse 

shoulder arthroplasty performed through a single deltopectoral 

approach. We followed all ten patients with cuff-tear arthropathy 

both clinically and radiographically for a minimum of 12 months. 

The mean increase in active elevation was 1000, and in active 

external rotation, it was 300. The Constant score improved from 18 

to 64. After surgery, all patients were able to lift their hands to their 

mouths. A neurologic complication occurred in one patient who 

developed a transient radial palsy. Our results show that latissimus 

dorsi and teres major transfer with concomitant reverse shoulder 

arthroplasty can be done through a single deltopectoral approach, 

which will effectively restore active external rotation and forward 

flexion in cuff-tear arthritis. 

MEC30 

Reverse Shoulder Arthroplasty Through Two Surgical 

Approaches 

Alicia Karin Harrison, MD, Minneapolis, MN 


Reverse shoulder arthroplasty represents a treatment option to 

decrease pain and improve function for patients who previously 

888 

had few treatment options available. Reverse shoulder arthroplasty 

is evolving as the indications and contraindications continue to be 

re-evaluated. This procedure can be performed through two different 

surgical approaches: the superior approach and the deltopectoral 

approach. Each approach has advantages and disadvantages, so 

the details of a patient’s individual case should determine which 

approach is best for each patient. In this video, we explore the 

indications and contraindications for each approach, demonstrating 

the variables specific to each surgical technique. 

MEC31 

Salvage Technique for Failed Reverse Total Shoulder 

Arthroplasty: The Yoke Technique 

Eric D. Bava, MD, Dallas, TX 

Sumant G. Krishnan, MD, Dallas, TX 

Phillip W.Bennion, MD, Phoenix, AZ 

Wayne Z.Burkhead, Jr, MD, Dallas, TX 

Failure of a reverse total shoulder arthroplasty presents an extremely 

difficult problem for even the most experienced surgeon. This video 

introduces a novel technique for salvage of a failed reverse total 

shoulder arthroplasty. A clinical case demonstrates revision of the 

failed reverse shoulder prosthesis to a hemiarthroplasty using the 

yoke technique in a patient with a failed glenosphere baseplate and 

inadequate glenoid bone stock to support a prosthetic component. 

This technique uses an Achilles tendon allograft to resurface the 

remaining glenoid bone and stabilize the proximal humerus. The 

allograft provides a smooth surface for the hemiarthroplasty to 

articulate, and it recreates the capsuloligamentous structures of the 

shoulder, which prevents anterosuperior escape. 

MEC32 

Pectoralis Major Tendon Ruptures 

Peter J. Millett, MD, MSc, Vail, CO 

Carl Wierks, MD, Holland, MI 

Our video reviews pectoralis major ruptures and demonstrates a 

technique for repair with suture anchors. Ruptures of the pectoralis 

major tendon can occur from a violent abduction, external rotation 

movement of the arm, or a strong eccentric contraction of the muscle. 

Body builders and people who engage in contact sports typically 

suffer these tear injuries. The sternal head is more commonly torn 

than the clavicular head. We recommend surgical repair in young, 

active patients. Operative treatment results in superior outcomes 

when compared to nonoperative treatment, even in patients with 

chronic tears. Suture-anchor restoration of the torn tendon to its 

native insertion site can provide excellent results. However, the 

surgeon must recognize that frequently the sternal head is retracted 

deep to the intact clavicular head. This instructional video depicts the 

relevant surgical anatomy and demonstrates a technique for repair. 

MEC33 

Total Shoulder Arthroplasty 


Suketu B. Vaishnav, MD, San Francisco, CA 

Glenohumeral osteoarthritis can cause severe pain and loss of 

function in patients with advanced disease. Surgery may be the best 

option to alleviate pain and restore function when nonoperative 

measures fail. Total shoulder arthroplasty (TSA) is the most effective 

method for treating advanced glenohumeral osteoarthritis, though 

the technique is a challenging one that requires skill to perform well. 

Highlights of this video include a lesser tuberosity osteotomy for 

glenohumeral joint exposure, with subsequent repair using a novel 




technique in which we use cerclage to position fixation sutures 

around the stem of the implant and lesser tuberosity bone fragment. 

This provides strong, stable fixation with bone-to-bone healing. We 

show a free-hand cutting technique for the humeral osteotomy and 

demonstrate the cut along the anatomic neck, along with relevant 

landmarks. We also describe a “double hammock” inferior capsular 

release that improves glenoid exposure and helps to restore motion 

postoperatively. Also, by preserving the mid-portion of the inferior 

glenohumeral ligament, the double hammock release offers protection 

for the axillary nerve inferiorly. We achieve glenoid resurfacing 

by using a hybrid glenoid component that combines the advantages 

of both the peg and keel components in one device. The video also 

demonstrates a careful cement-pressurization technique used in 

our procedure. We accomplish anatomic humeral reconstruction 

by using a modern fourth-generation-adaptable implant, which 

intraoperatively accommodates to anatomic variations in the 

proximal humerus. Once we reconstruct the proximal humerus 

anatomically through adjustments to the inclination angle, version, 

and head offset on the prosthesis, the correct glenohumeral center of 

rotation and appropriate rotator-cuff function is restored. Lastly, we 

demonstrate excision and tenodesis of the long head of the biceps 

tendon. When performed successfully, TSA has excellent durability, 

and it can result in complete pain relief and restoration of normal 

function. 

MEC34 

Comprehensive Operative Management of Midshaft 

Clavicle Fractures: Plate and Intramedullary Fixation 


Hinrich J.D. Heuer, MS, Luebeck, Germany 

Suketu B. Vaishnav, MD, San Francisco, CA 

Clavicle fractures are common, and they affect the diaphysis in 

approximately 80% of cases. Classic teaching based on studies 

by Neer and Rowe shows that midshaft fractures heal well when 

treated without surgery. However, treatment options have lately 

become controversial. Hill et al were among the first to show higher 

nonunion rates with nonoperative treatment, and subsequent 

studies suggested that operative fixation may result in better clinical 

outcomes. In recent years, several studies demonstrated better 

results with operative treatment, especially for displaced fractures. 

This video summarizes the current thinking on midshaft clavicle 

fractures with a focus on the mechanism of injury, classification, 

indications for surgery, and complications of surgery. Additionally, 

the video describes the advantages of the most frequently used 

methods for surgical treatment and gives our recommendations for 

postoperative care and rehabilitation. The video also demonstrates 

the two most common surgical fixation techniques: plate fixation 

and intramedullary fixation. Superior plate fixation has become 

popular with the advent of anatomically preshaped plates that 

have the highest load-to-failure rate. Intramedullary fixation is the 

other alternative fixation method. While not as popular as plating, 

intramedullary fixation has distinct advantages, which we also 

highlight in this video. We have included many surgical pearls and 

pitfalls for these two procedures, which should help the novice 

and the experienced traumatologist, shoulder specialist, or general 

orthopaedic surgeon in the management of midshaft clavicle 

fractures. We hope these pearls will translate into more successful 

surgical practice and better postoperative outcomes. 

889 

MEC35 

Posterior Shoulder Instability 

Adam Blair Yanke, MD, Chicago, IL 

Geoffrey Van Thiel, MD, Chicago, IL 

Lance E. LeClere, MD, San Diego, CA 



Posterior shoulder instability is an increasingly recognized aspect 

of shoulder pathology. It is typically present in younger patients 

who participate in sporting activities with their arms flexed in front 

of their bodies. Specific physical tests for posterior instability will 

result in accurate diagnoses. After ruling out bony pathology with 

radiographs and CT scan, one can complete an MRI or MRA to 

elucidate the soft- tissue pathology. If the patient and physician agree 

to operative management, this population can be successfully treated 

by arthroscopic stabilization. The technique involves identifying 

the tear type, preparing the tear for repair, and repairing the tear. 

After repair, a strict postoperative rehabilitation program ensues. 

The senior author has reported 88% improvement and increased 

return to sport function with arthroscopic stabilization of posterior 

shoulder instability. 

MEC36 

Ultrasound-Guided Placement of a Localization Wire 

for Arthroscopic Treatment of Calcific Tendonitis 

Matthew J. Kelly, MD, Camp Hill, PA 

Patrick H. Lam, Sydney, Kogarah, NSW, Australia 

Lisa Briggs, Sonographer, Maroubra, NSW, Australia 

Brett M. Andres, MD, Portland, OR 

Ali Razif, MD, Camp Hill, PA 

George A. C. Murrell, MD, Kogarah, NSW, Australia 

Surgical decompression of calcific tendonitis of the shoulder can be 

difficult because identification of the lesion is problematic, as the 

lesion is usually within the supraspinatus and cannot be directly 

visualized. We demonstrate a technique to identify and mark the 

calcific lesion using portable 2-D ultrasound-guided placement 

of a breast-biopsy localization wire, followed by arthroscopic 

decompression of the calcific lesion. After identifying the calcific 

lesion with portable ultrasound, we advance the introducer needle 

of the breast-lesion localization wire into the calcific lesion. The 

localization wire, with two barbs at its tip, advances through 

the introducer needle into the lesion where the barbs secure it. 

Following diagnostic arthroscopy, we place the arthroscope into the 

subacromial space. We identify the localization wire and follow it to 

the calcific lesion. We debride the lesion with an arthroscopic shaver, 

removing as much calcific material as possible. We then examine 

the supraspinatus tendon. If a significant defect is present, we repair 

it. Analysis of 13 shoulders (7 male shoulders, 6 female, average 

age 48.8 years) 6 months after surgery showed there was subjective 

improvement (determined from a questionnaire) and objective 

improvement (determined by examination of range of motion and 

strength). Five of eight shoulders re-examined by ultrasound had no 

residual calcific lesions, and all eight rotator cuffs were intact. We 

describe a technique of ultrasound-guided arthroscopic removal of 

calcific tendonitis lesions of the supraspinatus. Our early-term results 

show subjective and objective improvement in pain and function. 




MEC37 

Arthroscopic Management of Os Acromiale 

Robert J. Meislin, MD, New York, NY 

Michael Patrick Hahn, MD, Stockton, CA 

Symptomatic os acromiale is a clinical entity whose surgical 

management has traditionally been through open approaches, with 

varying levels of deltoid reflection off the acromial. We present our 

arthroscopic technique of internal fixation of os acromiale using 

partially threaded cannulated screws. 

MEC38 

Unilateral Transforaminal Posterior Lumbar Interbody 

Fusion 


Matteo Nanni, MD, Bologna, Italy 

Mohammadreza Chehrassan, MD, Bologna, Italy 

Luca Boriani MD, Bologna, Italy 

Alberto Di Martino, MD, Rome, Italy 


Unilateral transforaminal posterior lumbar interbody fusion is a 

surgical technique in which the surgeon achieves anterior-column 

support through a unilateral posterolateral approach and posteriorcolumn 

stabilization with pedicle screw fixation. Interbody fusion is 

indicated for anterior-column deficiency with chronic pain related 

to severe spinal stenosis, degenerative scoliosis, spondylolisthesis, 

and severe instability. These conditions require decompression of 

stenotic segments and elimination of motion, which are achieved by 

a solid arthrodesis that includes restoration of segmental lordosis. 

Interbody fusion techniques associated with posterior-column 

stabilization can restore normal sagittal contour while indirectly 

decompressing the neuroforamen. Depending on the pathoanatomy 

of the disorder of the lumbar spine, the surgeon should precisely plan 

the number of vertebrae to be fused, and for each level, the need for 

posterolateral fusion, interbody fusion, or both. Our video shows 

this unilateral transforaminal posterior interbody fusion surgical 

technique in a 62-year-old patient, suffering from chronic back pain 

associated with intractable radiculopathy of L3 right root. Following 

clinical and radiographic findings (X-ray, CT scan), we performed L2 

through L4 posterolateral arthrodesis associated with decompression 

and unilateral transforaminal interbody fusion at right L3-L4 space. 

Together with a precise technique, the key to successful outcomes 

for degenerative disorders of the lumbar spine is patient selection. A 

precise evaluation of clinical symptoms (radiculopathies, low-back 

pain) and strict correlation with imaging is crucial to choosing the 

extent of posterior stabilization and position and the number of 

transforaminal lumbar interbody fusions. 

MEC39 

Office-Based Ultrasonography of the Shoulder: A Howto 

Guide for the Orthopaedic Surgeon 

Dave Angelillo, MD, Westbury, NY 

Michael S. Day, MPhil, New York, NY 

Laith M. Jazrawi, MD, New York, NY 

Leon Rybak, MD, New York, NY 

Ultrasound is an imaging modality that uses sound frequencies in 

the range of 3 to 25 MHz emitted and received by an ultrasound 

transducer or probe to produce an image based on the composition 

of tissue with differential acoustic properties. Clinicians frequently 

use ultrasound to aid diagnosis in a variety of settings because of its 

versatility, availability, noninvasiveness, and relatively modest cost. 

890 

The modality enjoys high patient acceptance and a lack of medical 

contraindications. Ultrasound has gained increased popularity 

in orthopaedic surgery in recent years. However, musculoskeletal 

ultrasound techniques are not part of the training programs of most 

practicing orthopaedic surgeons. The purpose of this video is to 

introduce the basic concepts of shoulder ultrasonography for the 

orthopaedic surgeon wishing to incorporate this imaging modality 

into the office setting. 

MEC40 

Proximal Biceps Tenodesis: Surgical Options and 

Techniques 

Brett H. Young, MD, New York, NY 

Laith M. Jazrawi, MD, New York, NY 

Michael S. Day, MPhil, New York, NY 

Young W. Kwon, MD, PhD, New York, NY 

Andrew S. Rokito, MD, New York, NY 

Shoulder pain often arises in the long head of the biceps. Pathology 

of the biceps tendon includes isolated tendinitis or tendinosis, tears 

of the superior labrum from anterior to posterior (SLAP tears), 

subluxation, and fraying. There is almost always concomitant 

pathology. The two most common techniques for surgical 

management are biceps tenotomy and biceps tenodesis. Our video 

demonstrates detailed surgical techniques for subpectoral biceps 

tenodesis and arthroscopic percutaneous soft-tissue tenodesis. We 

also give an overview of the techniques for all arthroscopic tenodeses 

that use an interference screw. We provide step-by-step instructions, 

the results from our series, and a review of the literature. 

MEC41 

Minimally Invasive Hamstring Harvest Through a 

Posterior Incision 

Patrick A. Smith, MD, Columbia, MO 

The minimally invasive hamstring harvest is a clear-cut method 

of tendon identification and release that can be accomplished 

through a small posterior incision with minimal soft-tissue trauma. 

The hamstring harvest is done without any real change in position 

from the standard anterior cruciate ligament reconstruction. The 

surgeon maintains the knee in a flexed position with the hip rotated 

externally. The tendons are palpated in the area of the posteromedial 

knee crease and a 2 cm oblique incision is made just medial 

to the anatomic midline. The semitendinosus and gracilis tendons 

are superficial at this level and are easy to recognize after simple 

dissection of the fascia. Fascial attachments are also easy to see at this 

level. Their release decreases the chances of untimely subtraction. This 

technique is perfect for autograft harvest for the all-inside anterior 

cruciate ligament technique. Results are uniformly consistent, and 

the technique is less invasive than standard open techniques. 

MEC42 

Quadriceps Tendon Autograft for Anatomic Anterior 

Cruciate Ligament Reconstruction 

Freddie H. Fu, MD, Pittsburgh, PA 

Volker Musahl, MD, Pittsburgh, PA 

Carola F. Van Eck, MD, Pittsburgh, PA 

Corey A. Gilbert, MD, Odenton, MD 

There are many published clinical studies on techniques and 

outcomes of single- and double-bundle anterior cruciate ligament 

(ACL) reconstruction. Orthopaedic surgeons have used different 

graft tissues, including allografts and autografts, with good results. 

In this video, we outline the use of autograft quadriceps tendon as 




an alternative graft choice for anatomic single- and double-bundle 

ACL reconstruction, and we discuss the application of an anatomic 

ACL reconstruction concept. The quadriceps tendon is longer and 

thicker than the patellar tendon, and it attaches to the patella on a 

wider base. The ultimate load is similar to that of the patellar tendon. 

Clinical studies have reported that the quadriceps tendon has less 

donor site morbidity and produces less anterior knee pain compared 

with patellar tendon autograft. The combination of the large size 

and decreased donor side morbidity makes the quadriceps tendon a 

valuable alternative for anatomic double-bundle ACL reconstruction. 

The surgical technique for double-bundle reconstruction consists of 

one oval-shaped femoral tunnel and two round tibial tunnels. The 

surgeon places bone block on the femoral side and fixes it with an 

endobutton. The two soft-tissue ends are placed on the tibial side and 

fixed with biointerference screws. For single-bundle reconstruction, 

the quadriceps graft can be used with or without a bone block. 

MEC43 

Medial Patellofemoral Ligament Reconstruction for 

Recurrent Lateral Patellar Instability 

Tal S. David, MD, San Diego, CA 

Jesse Abeler, ATC, OTC, Highlands Ranch, CO 

The medial patellofemoral ligament (MPFL) has increasingly 

become recognized as the most important passive stabilizer against 

lateral patellar displacement in early knee flexion. Injury to this 

structure is common after a single lateral patellar dislocation, and 

it is the principal lesion following this type of injury. Due to the 

inconsistent healing capacity of the MPFL, recurrent lateral patellar 

instability following dislocation is not uncommon. In these cases, 

MPFL reconstruction may be advisable. This video reviews the 

clinical presentation and physical exam findings of patients with 

recurrent patellar instability. The video also defines the indications, 

contraindications, surgical technique, rehabilitation protocol, and 

outcomes of MPFL reconstruction. 

MEC44 

Intra-articular Arthroscopic Recession of the Iliopsoas 

Tendon: Medial Protection Technique 

Allston J. Stubbs, IV MD, Winston-Salem, NC 

Hip pain often accompanies iliopsoas pathology such as tendonitis/ 

bursitis, contracture, and mechanical snapping. Pathologic iliopsoas 

conditions can occur with both native hip disease and hip arthroplasty. 

In the setting of chronic iliopsoas pathology, surgical management 

may be an option to alleviate symptoms and reduce mechanical 

stress across the lumbar spine, proximal femur, and anterosuperior 

acetabular rim. Surgical techniques are available to release or recess 

the iliopsoas muscle tendon unit at various anatomic locations. 

Traditionally, these approaches, both open and arthroscopic, have 

focused on release of the iliopsoas tendon from its insertion on the 

lesser trochanter. A more recent approach involves an arthroscopic 

release of the iliopsoas at the level of the hip joint, a release that 

is more proximal than the traditional one. Arthroscopic release at 

the level of the hip joint is technically demanding, and it poses a 

theoretical risk of iatrogenic injury to the femoral neurovascular 

structures, which is a significant complication. The two primary 

modes of intra-articular arthroscopic iliopsoas release or recession 

involve tenotomy either from the peripheral compartment or from 

the central compartment. One such central- compartment technique 

is the medial protection technique, which protects the femoral 

neurovascular structures from iatrogenic injury. This video details 

the medial protection technique with a two-portal hip arthroscopy 

method. We present a complete surgical case and a discussion of the 

891 

technical pearls and pitfalls. 

MEC45 

Hip Arthroscopy for Trauma: Arthroscopic 

Osteosynthesis of Femoral Head Fractures 

Dean K. Matsuda, MD, Los Angeles, CA 

This video presents a new application for hip arthroscopy, which was 

once thought to be limited to diagnostic use and foreign/loose body 

removal. The video demonstrates the arthroscopic reduction and 

internal fixation of displaced femoral-head fractures in two trauma 

patients, one with an isolated supra-foveal osteochondral fracture 

and another with a more common fracture-dislocation. The video 

describes the rationale for the procedure, preoperative planning, and 

contingency plans. There is intraoperative footage of key steps in the 

arthroscopic osteosynthesis of these fractures, an introduction to a 

“chopstick” maneuver for arthroscopic reduction, and a discussion 

of a “clamshell” osteochondral fracture requiring arthroscopic 

manipulation prior to osteosynthesis. To enrich the learning 

experience, the video also includes material on postoperative care 

and rehabilitation, results of 1- and 2-year clinical outcomes, and 

relevant comparative imaging studies. 

MEC46 

Chondrosarcoma of the Proximal Femur: Limb-Sparing 

Resection and Prosthetic Reconstruction 



Andrew M. Silverman, BS, New York, NY 



The proximal femur is a common site for primary sarcomas and 

is the site of involvement for ~13% of all chondrosarcomas. This 

video details a limb-sparing radical resection of the proximal femur 

performed for a large chondrosarcoma, followed by reconstruction 

with a modular, segmental, proximal-femur tumor prosthesis. The 

chondrosarcoma infiltrated the head and greater trochanter of the 

femur, as well as the proximal shaft. Additionally, it demonstrated 

cortical breakthrough with a moderately sized extraosseous soft 

tissue component. We describe the surgical procedure in detail 

with strong emphasis on dissection and mobilization of the sciatic 

nerve. We further emphasize multiple muscle rotations, which are 

used to allow optimal function and to cover the prosthesis with soft 

tissue to minimize complications. Limb-sparing radical resection 

of the proximal femur followed by reconstruction with a modular 

segmental proximal femur tumor prosthesis and multiple muscle 

transfers is a safe and reliable method for treating tumors in this 

location. 

MEC47 

Intermuscular Liposarcoma of the Posterior Thigh: 

Radical Resection and Sciatic Nerve Preservation 



Benjamin A.Lerner, AB, Fairfield, CT 

Richard A.Greendyk, BS, New York, NY 



This video demonstrates radical resection of an intermuscular 

myxoid liposarcoma of the posterior thigh in a 39-year-old patient. 

The tumor was compressing and displacing the sciatic nerve. The 




preoperative MRI strongly suggested that the tumor was arising 

from the patient’s biceps femoris muscle. Intraoperative exploration, 

however, showed that the tumor was actually growing from an 

intermuscular location, displacing the biceps femoris muscle 

medially. The surgical procedure included radical resection of the 

intermuscular tumor as well as the use of multiple muscle rotation 

flaps for soft-tissue closure. We used these flaps to close the defect and 

provide adequate soft tissue coverage for the sciatic nerve in order to 

minimize postoperative wound complications. The video strongly 

emphasizes sciatic nerve dissection, mobilization, and preservation 

prior to tumor removal. This reconstruction technique is a safe and 

reliable method for treatment of soft-tissue tumors in this location. 

MEC48 

Intra-articular Proximal Humerus Resection and 

Prosthetic Reconstruction for a Pathologic Fracture 






Our video presents a patient with a pathologic fracture of his right 

proximal humerus due to metastatic renal-cell carcinoma. The 

imaging studies demonstrated a pathologic fracture of the proximal 

humerus with a large soft tissue component. We performed an intraarticular 

resection of the right proximal humerus and used a modular, 

segmental, proximal-humerus tumor prosthesis for reconstruction. 

To stabilize the prosthesis, we used both static and dynamic 

methods. To provide multidirectional stability, we reconstructed 

the glenohumeral ligaments with a GORE-TEX® aortic graft. We 

performed multiple muscle transfers and rotational flaps for dynamic 

stabilization as well as to power the shoulder girdle and cover the 

entire prosthesis with soft tissue. The goal of the reconstruction 

was to provide a pain-free and stable shoulder girdle for optimal 

hand and elbow function without compromising rotation. In our 

video, we particularly emphasize that a meticulous dissection of 

the brachial plexus and axillary blood vessels is necessary for a safe 

and reliable resection. This patient has been pain-free and has had 

normal elbow and hand function. There have been no dislocations, 

and the shoulder has remained stable. 

MEC49 

Limb-Sparing Total Scapula and Proximal Humerus 

(Tikhoff-Linberg) Resection and Reconstruction 






Martin M. Malawer, MD, Mclean, VA 

In this video, we detail the case of a 60-year-old man who presented 

with a fungating squamous cell carcinoma involving his shoulder 

girdle. The patient lost an extensive amount of soft tissue overlying 

the scapula, clavicle, and proximal humerus. These bony structures 

were grossly involved by the tumor in several locations. The patient 

underwent a radical resection of the left scapula and the proximal 

humerus including the deltoid, rotator cuff muscles, and portions of 

the trapezius and the clavicle in lieu of a forequarter amputation. We 

used a modular proximal-humerus tumor prosthesis to act as a spacer 

and to permit stabilization of the extremity to optimize hand and 

elbow function. We stabilized the prosthesis to the second rib and 

892 

clavicle. We also performed multiple muscle transfers and rotational 

flaps to restore elbow function, stabilize the prosthesis, and cover 

it with soft tissues. All margins were free of neoplasm. The video 

discusses the importance of a meticulous dissection of the brachial 

plexus and axillary blood vessels to achieve a safe and reliable 

resection. In this patient, we used static and dynamic methods of 

soft tissue reconstruction to stabilize the prosthesis and cover it with 

soft tissue to optimize function and minimize complications. This 

patient has a stable shoulder girdle and can use his hand and elbow. 

He has minimal discomfort. 

MEC50 

Osteosarcoma of the Distal Femur: Radical Resection 

and Reconstruction with a Distal Femur Tumor 

Prosthesis 







The distal femur is a common site of primary and metastatic bone 

tumors. The traditional treatment for tumors of the distal femur has 

been high above-knee amputation. Today, with earlier diagnosis and 

induction chemotherapy, limb-sparing resection and reconstruction 

with endoprosthetic replacement has proven to be an effective 

treatment. The prosthesis has an excellent long-term survival rate, 

good reliability, low complication rates, and minimal problems 

with breakage or dysfunction. This video describes limb-sparing 

resection of an osteosarcoma involving the distal femur and knee 

joint. A modular segmental distal-femur tumor prosthesis is used to 

reconstruct the knee joint. The video emphasizes the importance of 

meticulous neurovascular dissection and preservation and multiple 

muscle transfers to optimize function and minimize complications. 

Distal femur endoprosthetic reconstruction is a safe and reliable 

technique of functional limb sparing that provides good function 

and local tumor control. 

MEC51 

Primary Malignant Fibrous Histiocytoma of the 

Proximal Tibia: Limb-Sparing Resection with a 

Prosthesis and Soft Tissue Reconstruction 







Our video reports on a patient who underwent limb-sparing resection 

of the proximal tibia for a primary malignant fibrous 

histiocytoma of bone. We used a modular, segmental proximal-tibia 

endoprosthesis to reconstruct the bony defect and knee joint. This 

video details an extensile anteromedial parapatellar approach to 

the proximal tibia and knee joint, with emphasis on neurovascular 

dissection to enable a safe and reliable resection. To optimize knee 

function, we also reconstructed the extensor mechanism of the knee 

following bony reconstruction with the prosthesis. We created a 

medial gastrocnemius muscle flap and rotated it anteriorly over the 

prosthesis to achieve adequate coverage and to optimize function 

and minimize complications. Proximal tibia and knee joint resection 




followed by reconstruction with a modular, segmental, proximal-tibia 

endoprosthesis is a safe and reliable method for limb preservation in 

patients with high-grade tumors of the proximal tibia. 

MEC52 

Radical Resection of the Distal Humerus and 

Reconstruction with a Distal Humerus Tumor 

Prosthesis 





Benjamin A.Lerner, AB, Fairfield, CT 

The distal humerus is a relatively rare site for developing a tumor. 

Limb-sparing resection and reconstruction is challenging due to the 

close proximity of several critical neurovascular structures as well 

as the paucity of surrounding soft tissues. We describe an anterior 

approach for resecting tumors involving the distal humerus and 

reconstruction with an endoprosthetic replacement. We use a modular, 

segmental, distal-humeral replacement with a hinged elbow joint for 

reconstruction. In our video, we emphasize meticulous dissection of 

the brachial artery and veins and ulnar, musculocutaneous, lateral 

antebrachial cutaneous, median, and radial nerves to enable a safe 

and reliable resection. We believe the anterior approach is optimal 

to obtain excellent exposure for dissection and mobilization of these 

neurovascular structures. We perform multiple muscle transfers, 

including a flexorplasty, to optimize function and completely cover 

the endoprosthesis with soft tissue to minimize complications. Limbsparing 

resection for tumors involving the distal humerus through 

an anterior approach, followed by reconstruction with a modular 

distal-humerus tumor prosthesis and multiple muscle transfers is a 

safe and reliable method for treating tumors in this location. 

MEC53 

Radical Sacrectomy and Reconstruction for a High- 

Grade Primary Sarcoma of the Sacrum 






Richard A. Greendyk, BS, New York, NY 


This video details a radical sacrectomy and reconstruction for a 

high-grade primary sarcoma. Sarcomas of the sacrum are extremely 

rare. Resection of sacral tumors is risky because it entails resection 

of multiple sacral-nerve roots. These surgeries often have multiple 

postoperative complications. Our patient, a 43-year-old woman, 

presented with a tumor arising from the right side of her sacrum. The 

tumor had a large soft-tissue component, which extended anteriorly 

into the retroperitoneum as well as the piriformis muscle, which it 

entirely replaced. The tumor also extended through the sciatic notch 

into the upper buttock compartment, compressing the sciatic nerve 

in this location. We undertook resection and reconstruction through 

three approaches. We used a lateral approach to identify, dissect, and 

mobilize the sciatic nerve. We then employed an anterior approach 

to expose the anterior aspect of the sacrum from the level of L5 to 

S4. In this approach, we mobilized and protected the rectum and 

neurovascular structures, osteotomized the sacrum, and performed 

a right nephrectomy because of chronic hydronephrosis. After 

allowing the patient to recover for 96 hours, we approached the 

893 

sacrum posteriorly. In this approach, we placed fixation in order 

to create an ilio-lumbar fusion. We dissected the sacral-nerve roots 

that could be salvaged and mobilized them away from the tumor. 

We then removed the sacrum with the tumor en bloc. All margins 

were free of disease. To cover the sacral defect, we reconstructed the 

sacrum with bilateral paraspinous muscle flaps and bilateral gluteus 

maximus muscle flaps. 




NAME AAOS EVENT NAME AAOS EVENT 

Aarabi, Shahram ..................................Paper 503 

Aas, Eline ...................................... Poster P479 

Abbaspour, Aziz ..................................Paper 143 

Abdel Fatah, Emam. ...........Paper 292, Scientific Exhibit SE23 

Abdel-aal, Ahmed Mohammed .................... Poster P042 

Abdel, Matthew P .................................Paper 087 

Abdu, William A ..................................Paper 744 

Abeler, Jesse .....................Multimedia Education MEC43 

Abella, Linda .....................................Paper 471 

Aberle, Nicholas S. ................................Paper 241 

Abidi, Nicholas A ................Multimedia Education MEC05 

Abjornson, Celeste .....................Paper 738, Poster P376 

Aboulafia, Albert J. ................................Paper 234 

Abram, Simon....................................Paper 592 

Abrams, Jeffrey S .................................Symposia A 

Abzug, Joshua Matthew ..................Scientific Exhibit SE37 

Acri, Francesco. ..........Multimedia Education MEC02, MEC21, 

Poster P220 

Adami, Silvano ...................................Paper 226 

Adams, Annette L ............Poster P534, Scientific Exhibit SE76 

Adams, Joanne B ...................... Paper 298, Poster P203, 

Scientific Exhibit SE07 

Adams, Mary Jo .........Paper 194, 254, Poster P142, P146, P148 

Adams, Samuel Bruce ..................... Paper 048, 057, 058 

Adamson, Gregory J ...............................Paper 689 

Adeeb, Samer. ....................................Paper 691 

Adeli, Bahar ..........Paper 122, 124, 126, Scientific Exhibit SE08 

Adili, Anthony. .................................Poster BOS2 

Adler, Ronald S ...................................Paper 577 

Adolphson, Per Y ............................... Poster P093 

Adwar, Sean .................................... Poster P023 

Afable, Richard ..................................Symposia L 

Agabegi, Steven ........................Paper 450, Poster P384 

Agar, Gabriel .....................................Paper 406 

Agarwal, Animesh .........Paper 211, 212, 213, 214, 215, 216, 217, 

218, 219, 220, 221, 222, 223, 224, 225 

Aggarwal, Ajay .................................. Poster P205 

Aggarwal, Purnima ................................Paper 229 

Aghazadeh, Mehran ............................... Paper 410 

Aghazarian, Gary. .................................Paper 104 

Agir, Ismail .....................................Poster P561 

Agnew, Samuel G ................................Symposia L 

Agochukwu, Uzondu Francis ........................Paper 504 

Agrawal, Meenakshi ...............................Paper 426 

Agulnick, Marc A. ............................... Poster P397 

Agus, Haluk .................................... Poster P562 

Ahl, Torbjorn E ................................. Poster P093 

Ahlmann, Elke R ..................................Paper 228 

Ahmad, Christopher S ...Paper 366, 607, Poster P344, Symposia H 

Ahmad, Tashfeen. .................................Paper 142 

Ahmadinia, Kasra .................................Paper 020 

Ahmed, Issaq. ................................Paper 249, 612 

Ahn, Christine. ................................. Poster P270 

Ain, Michael Craig ............Paper 180, Scientific Exhibit SE40 

Akasaki, Yukio. ...................................Paper 414 

Akbar, Michael .... Paper 561, Poster P405, Scientific Exhibit SE59 

Akbarnia, Behrooz A. .........Paper 391, 392, Poster P255, P386, 

Symposia T 

Ake, Christopher F ................Paper 080, 186, Poster P198, 


Akeda, Koji ..................................Paper 263, 664 

Akelina, Yelena ...................................Paper 273 

894 

Akelman, Edward .......Paper 556, 557, 558, 559, 560, 561, 562, 

563, 564, 565, 566, 567, 568, 569, 570 

Al-Hamad, Mariam. .....................Scientific Exhibit SE01 

Alami, Ghassan ...................................Paper 088 

Alberghini, Marco .................................Paper 433 

Albers, Christoph Emanuel .....................Paper 043, 044 

Albert, Todd J. ...................Paper 024, 256, 270, 666, 750, 

Poster P361, P385, Symposia R, Y 

Alberta, Francis G ............................... Poster P420 

Alcerro, Jose Carlos. ..........Paper 717, Poster P026, P102, P152 

Alden, Kris John ................................ Poster P140 

Aleto, Thomas J. ................................ Poster P205 

Alexander, Peter G. ................................ Paper 210 

Alexiades, Michael M .......................Poster P018, P189 

Alfonso, Daniel ...................................Paper 565 

Algan, Sheila Marie. .....................Scientific Exhibit SE32 

Alizadehkhaiyat, Omid. ...........................Poster P321 

Allan, D Gordon ..................................Paper 062 

Allgier, Allison. ...................................Paper 628 

Allison, Daniel C. .................................Paper 228 

Allizond, Valeria ..................................Paper 470 

Almeida, Luiz Henrique .......................... Poster P295 

Almqvist, Fredrik. ............................... Poster P165 

Alonso, Julian ...................................Poster P211 

Alosh, Hasson .........................Paper 627, Poster P308 

Alsawaf, Mhd. .................................. Poster P450 

Alshryda, Sattar ...................................Paper 536 

Alsop, Helen ................................... Poster P176 

Altchek, David W ............Poster P415, Scientific Exhibit SE68 

Althausen, Peter L .......Paper 376, 377, 378, 379, 380, 381, 382, 

383, 384, 385, 386, 387, 388, 389, 390 

Alvarado, Carlos M ...............Multimedia Education MEC06 

Alzolibani, Abdullatif ............................ Poster P264 

Amanatullah, Derek ............................. Poster P233 

Amano, Kanzo. ...................................Paper 272 

Amar, Eyal ..................................... Poster P540 

Amaral, Marcus Vinicius Galvao ....Multimedia Education MEC29 

Amaral, Terry David ....................Paper 746, Poster P358 

Ambati, Divya ............................Paper 017, 443, 669 

Amendola, Annunziato ..........Multimedia Education MEC04, 

MEC20, Paper 092, 207, 651 

Amendola, Luca ........................Scientific Exhibit SE57 

Amendola, Richard ................................Paper 207 

Ames, Christopher ........... Paper 029, 444, Poster P387, P396 

Ames, S Elizabeth .................................Paper 258 

Amin, Osama Ahmed. ........................... Poster P264 

Amirouche, Farid. ............................... Poster P455 

Amstutz, Harlan C ............................Paper 035, 045 

An, Angel ........................................Paper 157 

Garcia De Frutos, Ana. ........................... Poster P352 

Anakwe, Raymond E ............................. Poster P504 

Anakwenze, Okechukwu A. ........................Poster P518 

Anand, Ashish ...................................Poster P416 

Anand, Rajan. ....................................Paper 712 

Ancha, Aditya ....................................Paper 006 

Anderle, Matthew ............................... Poster P197 

Andersen, Romney C ...................Paper 705, Symposia Q 

Anderson, Allen F . . . . . Multimedia Education MEC25, Symposia Z 

Anderson, Andrew E ...............Paper 635, 706, Poster P496, 


Anderson, D Greg ............. Paper 024, 666, 750, Poster P385 

Anderson, David T ................................Paper 256 

Anderson, Donald D ....................Scientific Exhibit SE79 

author IndEx


Anderson, Edward Ratcliffe ..............Paper 739, Poster P363 

Anderson, John Anthony ..........................Poster P118 

Anderson, John G .............................Paper 060, 100 

Anderson, Kyle ............................Poster P446, P448 

Anderson, Lucas ..............Paper 706, Scientific Exhibit SE12 

Anderson, Mark W ......................Scientific Exhibit SE36 

Anderson, Megan E. ...............................Paper 234 

Anderson, Paul A .................................Paper 737 

Anderson, Robert B. ................Paper 050, 505, Symposia K 

Andrecovich, Christopher ........................ Poster P446 

Andres, Brett M ..................Multimedia Education MEC36 

Andrew, J Glynne ............................... Poster P065 

Andrews, Christopher Mark ....................... Poster P160 

Andrews, James R ................................Symposia Z 

Andrish, Jack T .........................Scientific Exhibit SE70 

Angelillo, David .................Multimedia Education MEC39 

Angelini, Andrea .......................Paper 240, Poster P539 

Anis, Aslam .....................................Poster P105 

Ansari, Aneel .....................................Paper 709 

Antinolfi, Pierluigi ...............................Poster P171 

Antonellis, Anne ..................................Paper 704 

Antoniou, John ........................Paper 034, Poster P082 

Aoki, Chie ..................................... Poster P068 

Aoki, Stephen K. .....Paper 175, 635, Scientific Exhibit SE12, SE15 

Aoyama, Tomoki. ............................... Poster P239 

Apazidis, Alexios ..................................Paper 402 

Aponte-Tinao, Luis Alberto ..............Paper 513, Poster P533, 


Appleton, Paul ...............Paper 115, 304, Poster P218, P509 

Apprich, Sebastian .............................. Poster P077 

Aprato, Alessandro ...............Multimedia Education MEC27 

Archer, Kristin .........................Paper 695, Poster P292 

Archibald, Douglas ................................Paper 457 

Archibald, Jason .................................Poster P412 

Arden, Nigel ................................... Poster P327 

Arellano, Sergio. .................................Poster P211 

Arendt, Elizabeth A. .....................Scientific Exhibit SE32 

Argenson, Jean-Noel A .............................Paper 419 

Argento, Giuseppe .....................Paper 486, Poster P447 

Ariizumi, Takashi ............................... Poster P523 

Arimizu, Jun ................................... Poster P366 

Arky, Ronald ................................... Poster P275 

Armitage, Bryan M ................................Paper 307 

Armstrong, April D ................................Paper 174 

Armstrong, Douglas G ........................... Poster P482 

Arno, Sally ..................................... Poster P138 

Arnoczky, Steven P .............................. Symposia C 

Arrington, Edward D. ..............................Paper 571 

Arumilli, Buchi R B ...............................Poster P117 

Asano, Tsuyoshi ..................................Paper 321 

Asanuma, Yumiko. ................................Paper 664 

Ascherl, Rudolf ...................................Paper 193 

Asci, Murat. .................................... Poster P560 

Ashana, Adedayo O. .......................Paper 514, 515, 519, 

Poster P521, P530, P532 

Ashby, Elizabeth ..................................Paper 127 

Ashraf, Nomaan ..................................Paper 676 

Ashton, Fiona ....................................Paper 612 

Asik, Mehmet ..........................Scientific Exhibit SE35 

Askew, Michael ...................................Paper 103 

Asopa, Vipin .....................................Paper 145 

Aspros, Dimitrios .................................Paper 265 

Assal, Mathieu. ...................................Paper 091 

895 

Aston, William ................................. Poster P172 

Atalar, Ata Can. .........................Scientific Exhibit SE35 

Atanda, Alfred .................................. Poster P246 

Atay, Ozgur Ahmet .............................. Poster P569 

Atay, Tolga ..................................... Poster P568 

Atesok, Kivanc Israel ...........................Paper 141, 149 

Athanasou, NA .........................Scientific Exhibit SE06 

Athwal, George S. ........................Paper 076, 584, 678, 

Poster P337, P338, P343, P434 

Atlaf, Farhaan ....................................Paper 462 

Attarian, David E. .......................Scientific Exhibit SE46 

Atupan, Jereme B. ................................. Paper 311 

Atzwanger, Joerg ..................................Paper 203 

Au, Keegan Peter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 350 

Aubaniac, Jean-Manuel. ............................Paper 419 

Aubin, Michelle. .......Paper 348, Poster P035, P353, P356, P357 

Auerbach, Joshua D ............................. Poster P400 

Augat, Peter ......................................Paper 702 

Augustin, Salvador .............................. Poster P306 

Austin, Luke. ....................................Poster P317 

Austin, Matthew .............Paper 189, 250, Poster P073, P075, 

P101, P107, Scientific Exhibit SE10 

Axelrad, Thomas W. ....................Paper 046, Poster P469 

Ayers, David Christopher ..........Paper 348, Poster P035, P280, 

Symposia AA 

Ayerza, Miguel Angel ...................Paper 513, Poster P533, 


Aynardi, Michael C ...............................Poster P104 

Aziz, Abdul .....................................Poster P105 

Azmoudeh, Bieta. ............................... Poster P398 

Azuma, Takashi ................................. Poster P125 

Babacan, Muharrem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P567 

Babis, George. .................................. Poster P188 

Baca, Geneva ................................... Poster P058 

Bach, Bernard R. ..................................Paper 606 

Backers, Katrien. ..................................Paper 032 

Backstein, David .........Paper 251, 406, Poster P044, P062, P111 

Backus, Sherry I ...................................Paper 558 

Badalamente, Marie ...............................Paper 568 

Badarudeen, Sameer ...............................Paper 459 

Bae, Dae Kyung ........................Paper 418, Poster P144 

Bae, Donald S ..................................Symposia D 

Bae, Hyun W .................................Paper 662, 672 

Bae, Ki-Cheor. ...................................Poster P318 

Bae, Won ...................................... Poster P393 

Baer, David G ...................................Poster P510 

Bagheri, Ramin ................................. Poster P386 

Bahrami, Armita ................................ Poster P544 

Bailey, James R ................................. Poster P436 

Baird, Glen Olsen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 427 

Bajaj, Sarvottam .................Paper 160, 200, 208, 495, 574 

Baker, Alex ..................................... Poster P542 

Baker, Charlie ....................................Paper 701 

Baker, Christine P .................................Paper 549 

Baker, Dale. .....................................Poster P109 

Baker, Erin Ann ........Paper 204, Poster P194, P345, P363, P448 

Baker, Joseph ..............................Poster P419, P428 

Baker, Kevin. ................Paper 204, 739, Poster P194, P345, 

P363, P390, P446, P448, P478 

Bakr, Hatem MA ................................ Poster P042 

Bal, B Sonny ................................... Poster P205 

Balaguer, Eric. ....................................Paper 559 

Balci, Halil I. ..................... Scientific Exhibit SE35, SE85 

author IndEx


Baldini, Todd H. ................................ Poster P376 

Baldus, Christine. ......................Paper 661, Poster P392 

Baldwin, Keith D. ............Paper 219, 279, 325, 613, 627, 726, 

Poster P308 

Balfour, George Walter ...Paper 271, 272, 273, 274, 275, 276, 277, 

278, 279, 280, 281, 282, 283, 284, 285 

Balinger, Chris. ................................. Poster P356 

Ball, Scott T ......................................Paper 065 

Ballester, Jorge .................................. Poster P008 

Banche, Giuliana. .................................Paper 470 

Banci, Lorenzo ................................. Poster P409 

Bandiera, Stefano .......................Scientific Exhibit SE57 

Bandoh, Shunichi ............................... Poster P052 

Banerjee, Rahul ................................. Poster P467 

Bangert, Yannic ................................. Poster P092 

Banka, Trevor. ....................................Paper 230 

Banta, Charles J .........Paper 736, 737, 738, 739, 740, 741, 742, 

743, 744, 745, 746, 747, 748, 749, 750 

Bar Ziv, Yaron .........................Paper 406, Poster P044 

Baratz, Mark E ....................................Paper 685 

Baratz, Michael ...................................Paper 304 

Barfield, William R ................................Paper 650 

Barg, Alexej .......................Paper 059, 651, Poster P209 

Barlow, Brian ................................... Poster P427 

Barlow, Ian W .................................. Poster P002 

Barlow, Jonathan D. ...............................Paper 690 

Barnes, C Lowry ........................Scientific Exhibit SE29 

Barnett, Clint D. .......................Paper 061, Poster P229 

Barnett, Steven L .................................Poster P021 

Barnwell, Jonathan C ..............................Paper 567 

Barrack, Robert L. ................. Poster P027, Paper 420, 708, 

Poster P088, P094, P126, Symposia E, V 

Barrett, William P .................................Paper 071 

Barrington, John W. ...........................Paper 297, 466 

Barrington, Thomas ...............................Paper 466 

Barsoum, Wael K. ..................Paper 111, 600, Poster P096 

Bartelt, Robert Boyd ............................. Poster P097 

Bartlett, Craig Scott ......Paper 691, 692, 693, 694, 695, 696, 697, 

698, 699, 700, 701, 702, 703, 704, 705 

Bartlett, Gavin .................................. Poster P508 

Bartley, Carrie ....................................Paper 447 

Bartol, Stephen ...................................Paper 439 

Barzilay, Yair .....................................Paper 667 

Basamania, Carl J ............................... Poster P288 

Basiglini, Luca ....................................Paper 486 

Baskaradas, Aroon. ................................Paper 497 

Basran, Harpreet Singh. ............................Paper 508 

Bastian, Johannes Dominik ....................... Poster P038 

Bastrom, Tracey. .....................Paper 179, 394, 447, 671, 

Poster P221, P247, P388 

Batta, Vineet ................................... Poster P145 

Battaglia, Milva ...................................Paper 093 

Battaglia, Nicholas ................................Paper 292 

Bauer, Andrea S ...................................Paper 696 

Bauer, Jennifer M. .................................Paper 378 

Bauer, Thomas W .......................Scientific Exhibit SE33 

Baumbach, Sebastian F. ............................Paper 634 

Baumhauer, Judith F. ............................ Poster P223 

Bava, Eric D .....................Multimedia Education MEC31 

Baydar, Metin Lutfi .............................. Poster P568 

Baykal, Barbaros Yakup .......................... Poster P568 

Baynes, Keith E ...................................Paper 231 

Bayramoglu, Alp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P569 

896 

Beach, William R. ................................Symposia X 

Beall, Doug ......................................Paper 672 

Beals, Timothy C..................................Paper 651 

Beamer, Brandon S ................................Paper 579 

Bear, Thomas F .........................Scientific Exhibit SE30 

Beard, David J .....................Paper 415, 531, Poster P187 

Beaton, Dorcas ...................................Paper 053 

Beattie, Cammie .................................Poster P241 

Beaty, James H. ...................................Paper 167 

Beauchamp, Christopher Paul .......................Paper 133 

Beaule, Paul E .....Paper 034, 359, Poster P083, Symposia J, ORSI 

Beaumont, Eric ...................................Paper 623 

Beaumont, Pierre H ...............................Paper 623 

Beaupre, Lauren ...................Paper 303, 691, Poster P086 

Becker, Edward H .........................Paper 694, 700, 731 

Bedair, Hany ....................................Poster P015 

Bedi, Asheesh ................Paper 644, Scientific Exhibit SE63 

Beebe, Michael J ..................................Paper 404 

Begum, Farhana ..................................Paper 691 

Behrens, Steve Brian ....................Paper 581, Poster P438 

Beitcher, Bob ................................. Symposia 152 

Bejui-Hugues, Jacques. ........................... Poster P048 

Belkora, Jeff ......................................Paper 458 

Bell, John-Erik ....................................Paper 366 

Bell, Kimberly ................................Paper 076, 154 

Bell, Rebecca ................................... Poster P329 

Bell, Simon ......................................Paper 688 

Bellabarba, Carlo ............................... Poster P395 

Bellato, Enrico. .........................Scientific Exhibit SE51 

Bellemans, Johan ..........................Poster P422, P430 

Belmont, Philip J. ......................Paper 728, Poster P435 

Belthur, Mohan ...............................Paper 423, 431 

Beltran, Michael John ..................Poster P462, P473, P498 

Belzile, Etienne ...................................Paper 034 

Ben Lulu, Oren ..................................Poster P111 

Ben-Galim, Peleg. .........................Paper 028, 260, 721 

Bender, Edward T .......................Scientific Exhibit SE30 

Bendo, John A ....................................Paper 262 

Benedict, Shaike ..................................Paper 406 

Benirschke, Stephen K ............................Poster P210 

Benjamin, James B .............................. Poster P127 

Benke, Michael T. ............................... Poster P347 

Benner, Rodney W. .............................. Poster P149 

Bennion, Phillip W ...............Multimedia Education MEC31 

Bentley, George ........................Paper 196, Poster P116 

Berdichevsky, Max Robert. ..........................Paper 729 

Beredjiklian, Pedro K ..............................Paper 562 

Berend, Keith R ......Paper 061, 298, 406, 407, 408, 409, 410, 411, 

413, 414, 415, 416, 417, 418, 419, 420, 

Poster P203, P204, Scientific Exhibit SE07, 

Symposia E, P 

Berend, Michael E .......Paper 130, 286, 287, 288, 289, 290, 291, 

292, 293, 294, 295, 296, 297, 298, 

299, 300, 413, Symposia B, P 

Berger, Richard A. ......................Paper 007, Poster P164 

Bergin, Patrick F ................................ Poster P526 

Bergman, Neil R ..................................Paper 351 

Beris, Alexandros. ............................... Poster P060 

Berkowitz, Scott D. ................................Paper 540 

Berlet, Gregory Charles. .......................... Poster P225 

Berlin, Orjan K ...................................Paper 704 

Bernard, Matthew S. ............................. Poster P149 

Bernasek, Thomas L ....................Paper 192, Poster P147 

author IndEx


Bernat, Nicholas ..................................Paper 314 

Bernhardson, Andrew S .......................... Poster P436 

Bernstein, Joseph .................................Paper 106 

Bernthal, Nicholas ................................Paper 176 

Berry, Daniel J ............Paper 480, Poster P089, Symposia E, S 

Berschback, John C ................................Paper 342 

Bert, Jack M .....................................Symposia X 

Bertelsen, Alexander . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P294 

Bertollo, Nicky ...................................Paper 675 

Bertumen, J ......................................Paper 735 

Berven, Sigurd H ... Paper 749, Scientific Exhibit SE56, Symposia Y 

Besomi, Javier ...................Multimedia Education MEC01 

Betech, Alex ......................................Paper 553 

Bettelli, Graziano .......................Scientific Exhibit SE54 

Betz, Brad W .....................................Paper 541 

Betz, Randal R ...................................Poster P371 

Bevan, Catherine. .................................Paper 178 

Bey, Michael ....................................Poster P307 

Beykirch, Sarah ...................................Paper 532 

Beyth, Shaul. .....................................Paper 139 

Bezwada, Hari ..........Paper 121, 122, 123, 124, 125, 126, 127, 

128, 129, 130, 131, 132, 133, 134, 135 

Bhadra, Arup K ...................................Paper 632 

Bhandari, Mohit .....................Paper 226, 387, 464, 630, 

Poster BOS2, P460, P519 

Bhargava, Tarun. .................................Poster P016 

Bhat, Suneel B ............................Paper 114, 118, 482 

Bhatia, Nitin N ...................................Paper 233 

Bhatia, Sanjeev ...................................Paper 606 

Bhattacharyya, Timothy .......................... Poster P488 

Biant, Leela C ....................................Paper 196 

Bican, Orhan ....................................Poster P104 

Bicimoglu, Ali .................................. Poster P562 

Bickels, Jacob. .................................. Poster P540 

Biercevicz, Alison M ............................. Poster P438 

Bigliani, Louis U .......................Paper 607, Poster P344 

Bignozzi, Simone .......................Scientific Exhibit SE24 

Bilen, Fikri Erkal ........................Scientific Exhibit SE85 

Billi, Fabrizio. ....................................Paper 074 

Bilotta, Victor Joseph ..............................Paper 356 

Binette, Francois ................................ Poster P393 

Bini, Stefano Alec ............................... Poster P183 

Binitie, Odion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 516 

Bir, Cynthia A .................................. Poster P450 

Birch, Ann .......................................Paper 281 

Birch, John G. ....................................Paper 428 

Birchansky, Sherri B ...............................Paper 431 

Birjandinejad, Ali ............................... Poster P459 

Birmingham, Patrick. ..............................Paper 579 

Bishop, Allen T ........................Paper 051, Poster P443 

Bishop, Michael J .................................Paper 473 

Bisseling, Pepijn ..................................Paper 072 

Bistolfi, Alessandro ................................Paper 470 

Bitsch, Rudi ...............................Poster P090, P095 

Black, Dennis ....................................Paper 227 

Black, James Clinton. ..............................Paper 483 

Black, Kevin P ....................................Paper 013 

Blackbourne, Lorne H. ............................Poster P510 

Blaha, J David .................... Scientific Exhibit SE02, SE29 

Blaine, Theodore A ......Paper 676, 677, 678, 679, 680, 681, 682, 

683, 684, 685, 686, 687, 688, 689, 690 

Blair, James Alan ................................ Poster P473 

Blair, Jamie L ................................... Poster P184 

897 

Blake, Kim ..................................... Poster P274 

Blalock, Ryan. ....................................Paper 626 

Blanchard, Char ..............................Paper 334, 334 

Blanco Pozo, Agustin ............................ Poster P008 

Blanco, John S. ...................................Paper 401 

Blankenbaker, Donna G ...........................Poster P412 

Blatt, Theodore ............................... Symposia 152 

Block, John J .....................................Paper 331 

Blonna, Davide ........Multimedia Education MEC28, Paper 684, 

Scientific Exhibit SE25, SE51, SE65 

Blotter, Robert H ...........................Poster P269, P269 

Blum, Yossef C .........................Scientific Exhibit SE27 

Bluman, Eric Michael ..............................Paper 504 

Blumberg, Todd. ................................ Poster P009 

Blumenfeld, Thomas J ...Paper 061, 062, 063, 064, 065, 066, 067, 

068, 069, 070, 071, 072, 073, 074, 075 

Boachie-Adjei, Oheneba. ............Paper 401, 442, Poster P348 

Boardman, David Laurence ...............Scientific Exhibit SE76 

Bobyn, J Dennis ..................................Paper 185 

Bodanki, Chandra Sekhar ..........................Paper 371 

Boden, Henrik. ................................. Poster P093 

Boden, Scott D .................................Symposia W 

Bodette, Teresa. ................................. Poster P033 

Bodin, Nathan Daniel ........................... Poster P228 

Boesch, R Paul. ........................Paper 450, Poster P384 

Boese, Christoph. ............................... Poster P132 

Boettner, Friedrich. .............................. Poster P084 

Boffano, Michele. .................................Paper 470 

Boghosian, Ghassan ............................. Poster P182 

Bohay, Donald R Paper 060, 091, 092, 093, 094, 095, 096, 097, 098, 

099, 100, 100, 101, 102, 103, 104, 105 

Bohlman, Henry H ............................Paper 020, 665 

Bohm, Eric R . . . . . . . . . . . . . . . . . . . . . . . . Paper 252, 255, 349, 409 

Bohne, Walther Hartmuth ..........................Paper 499 

Boileau, Pascal. .......Paper 084, 085, 088, 361, 362, Poster P330 

Bojan, Alicja ...................................Poster BOS2 

Bolling, William Seth .............................Poster P106 

Bolognesi, Michael P ..........................Paper 246, 493 

Bonanzinga, Tommaso. .......Poster P414, Scientific Exhibit SE24 

Bonar, Fiona ....................................Poster P301 

Bonasia, Davide E ......Multimedia Education MEC04, Paper 207, 

Scientific Exhibit SE25, SE65 

Bond, Jeffrey R. ................................. Poster P097 

Bondy, Jennifer ...................................Paper 108 

Bonete, Daniel Lluch ..............................Paper 148 

Bonnevialle, Nicolas ...........................Paper 361, 362 

Bonnin, Michel ................................. Poster P123 

Bono, Christopher M ............................ Poster P355 

Bono, James V ............ Paper 410, 597, Scientific Exhibit SE20 

Bonutti, Peter M .................. Scientific Exhibit SE19, SE22 

Boohaker, Hikel Alfred ............................. Paper 611 

Boons, Harm-Willem ...................Paper 584, Poster P337 

Booth, Robert E. .................................Symposia B 

Bordini, Barbara ........................Scientific Exhibit SE09 

Borens, Olivier ....................Paper 468, 469, Poster P314 

Boriani, Luca Multimedia Education MEC38, Scientific Exhibit SE57 

Boriani, Stefano. ........................Scientific Exhibit SE57 

Bornstein, Lindsey ...............Poster P018, P020, P087, P189 

Borrelli, Joseph ...................................Paper 146 

Borroff, Michael J ......................Paper 346, Poster P022 

Bos, Ellis ........................................Paper 070 

author IndEx


Bosco, Joseph A. .........Paper 113, 129, 616, 617, 618, 619, 620, 

621, 622, 623, 624, 625, 626, 627, 

628, 629, 630, 715, Poster P004 

Bosio, Santiago ...................................Paper 400 

Bosscher, Frederiek .............................. Poster P156 

Bosse, Michael J. ...................Paper 380, 676, Poster P511 

Bostan, Bora ................................... Poster P560 

Bostrom, Mathias P G. ...Paper 466, 467, 468, 469, 470, 471, 472, 

473, 474, 475, 476, 478, 479, 480, 

Poster P087, P118 

Botolin, Sergiu O ............................... Poster P376 

Botser, Itamar .....Multimedia Education MEC07, Paper 640, 645 

Botte, Michael J ...................................Paper 278 

Bottlang, Michael .................................Paper 702 

Bottomley, Nicholas J ...................Paper 592, Poster P145 

Boublik, Martin. ................................ Poster P332 

Bouliane, Martin ..................................Paper 691 

Boulton, Christina B. ............................ Poster P509 

Bourke, Gerard Martin .............................Paper 054 

Bourne, Robert Barry. ..............Paper 034, 350, Poster P056, 

P080, P127, Symposia B 

Bowen, Thomas R .................................Paper 716 

Bowers, Lyndsay N ......................Scientific Exhibit SE23 

Bowman, Russell. ............................... Poster P064 

Bowser, Robert. ................................. Poster P346 

Bowsher, John ..........................Scientific Exhibit SE41 

Boyan, Barbara D .......................Scientific Exhibit SE84 

Boyce Nichols, Louise Reid .........................Paper 555 

Boyle, David .....................................Paper 065 

Bozentka, David J ......................Paper 285, Poster P236 

Bozic, Kevin John ... Paper 110, 451, 452, 453, 454, 455, 456, 457, 

458, 458, 459, 460, 461, 462, 463, 464, 465, 

480, Scientific Exhibit SE16, Symposia L, Y 

Bozzuto, Laura ...................................Paper 713 

Bracco, Pierangiola ................................Paper 470 

Brach Del Prever, Elena. ............................Paper 470 

Bradley, Gary W. ........Paper 586, 587, 588, 589, 590, 591, 592, 

593, 594, 595, 596, 597, 598, 599, 600 

Bradley, Neil .....................................Paper 135 

Bragdon, Charles R ...................Paper 082, 348, 530, 704, 


Braley, Brett .................................... Poster P362 

Braly, Brett .......................................Paper 023 

Brand, Jefferson C ......................Paper 120, Poster P274 

Brand, Richard A..................................Paper 454 

Brandao, Bruno Lobo .............Multimedia Education MEC29 

Branemark, Rickard ...............................Paper 704 

Bransford, Richard Jackson ....................... Poster P395 

Brassart, Nicholas ......................Paper 085, Poster P330 

Brekke, Adam .............................Poster P009, P127 

Brenkel, Ivan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 249 

Brennan, Kindyle L .............................. Poster P466 

Brennan, Michael L. ............................. Poster P466 

Brezinski, Mark ...................................Paper 655 

Brickwede, Hans-Peter ........................... Poster P273 

Bridwell, Keith H. ................Paper 441, 442, 446, 449, 661, 


Briggs, Karen K ...............................Paper 552, 638 

Briggs, Lisa. .....................Multimedia Education MEC36 

Briggs, Tim. .....................................Poster P116 

Brink, Ole .....................................Poster BOS2 

Brix, Martin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 199 

Brodke, Darrel S ..................................Paper 021 

898 

Brody, Gordon A ........Paper 271, 272, 273, 274, 275, 276, 277, 

278, 279, 280, 281, 282, 283, 284, 285 

Brooks, Amanda E. ................................Paper 467 

Brooks, Peter J .................................. Poster P094 

Brophy, Robert H .............................Paper 625, 626 

Brothers, Justin ..................................Poster P101 

Brouwer, Kim M ................................ Poster P323 

Brown, Haydee C. .............Paper 642, Scientific Exhibit SE34, 

SE50, SE64, SE82 

Brown, Kate ......................................Paper 379 

Brown, Kate V ....................................Paper 379 

Brown, Matthew L. .............................. Poster P223 

Brown, Nicholas M .......Paper 007, 123, 128, 132, 187, 411, 538, 


Brown, Richard A .......................Scientific Exhibit SE46 

Brown, Thomas D. ..........Poster P281, Scientific Exhibit SE79, 

Symposia ORSI 

Browne, James Andrew. .................Paper 014, Poster P136 

Browne, Martin ...................................Paper 135 

Browne, Richard H ................................Paper 432 

Browner, Bruce D .......................Scientific Exhibit SE42 

Brox, William Timothy. ............ Scientific Exhibit SE04, SE43 

Bruckner, Thomas .................................Paper 561 

Bruni, Danilo ...................................Poster P118 

Brunner, Samuel ..................................Paper 055 

Brunton, Lance Michael . . . . . . . . . . . . . . . . . .Scientific Exhibit SE36 

Bruzzone, Matteo ................. Scientific Exhibit SE25, SE65 

Bucak, Deniz .....................................Paper 455 

Bucci-Rechtweg, Christina ..........................Paper 227 

Buch, Barbara ..........................Scientific Exhibit SE41 

Buchowski, Jacob M ................Paper 022, 661, Poster P374 

Buckley, Jenni M . . . . . . . . . . .Paper 029, 215, 217, 444, Poster P387 

Buckley, Richard E. ................................Paper 724 

Buckwalter, Joseph A. .....Scientific Exhibit SE33, Symposia ORSII 

Buda, Roberto ...........Paper 093, Scientific Exhibit SE61, SE69 

Bueno, Rogerio Serpone .......................... Poster P295 

Bugbee, William ..............Paper 065, 197, 202, Poster P196, 


Bullough, Peter G ............................... Poster P476 

Buly, Robert L .................................. Poster P409 

Bunn, Janice Y ....................................Paper 258 

Burch, Shane ......................Paper 266, 749, Poster P404 

Burger, Christoph .................................Paper 740 

Burger, Evalina L ................................ Poster P376 

Burgers, Travis ....................................Paper 150 

Burke, Mary F ....................................Paper 080 

Burkhart, Stephen S ...............................Paper 574 

Burkhead, Wayne Z. ............. Multimedia Education MEC31, 

Symposia M 

Burnell, Colin ................................Paper 252, 255 

Burns, Travis C. ................................. Poster P498 

Burris, Brandon ...................................Paper 006 

Burton, Douglas C .....................Paper 670, Poster P394 

Burton, Lucas J ...................................Paper 241 

Busch, Michael T.................................Symposia Z 

Buscio, Tiziana ................................... Paper 510 

Buss, Daniel D. ...................................Paper 576 

Butler, Dale R .................... Scientific Exhibit SE46, SE47 

Byram, Ian R .....................................Paper 331 

Byrd, J W Thomas ......................Paper 640, Poster P454 

Byrne, Daniel. .............................Poster P419, P428 

Byun, Young Soo. ............................... Poster P480 

Caborn, David N. ............................... Poster P423 

author IndEx


Caceres, Enrique .......................Paper 109, Poster P352 

Cahill, Patrick John. .....Paper 391, 392, 393, 394, 395, 396, 397, 

398, 399, 400, 401, 402, 403, 404, 405, 440 

Caird, Michelle S. .................................Paper 025 

Cakmak, Gokhan ............................... Poster P564 

Calabro, Teresa ................................. Poster P539 

Calbucci, Lucia ..................................Poster P012 

Caldwell, Joseph M. ............................. Poster P495 

Calhoun, Jason H . . . . . . . . . . . . . . . . . . . . . . .Scientific Exhibit SE33 

Callaci, John .....................................Paper 140 

Callaghan, John J ..................... Paper 004, Poster P062, 

Scientific Exhibit SE14, Symposia S 

Callewaert, Barbara. ............................. Poster P422 

Calore, Briana .................................. Poster P039 

Camacho-Galindo, Javier ...........................Paper 360 

Cammisa, Frank P. .................Paper 738, 747, Poster P369 

Camp, John ......................................Paper 505 

Campacci, Antonio ...............Multimedia Education MEC27 

Campagnna, Elizabeth .............................Paper 473 

Campbell, Jane ...................................Paper 656 

Campbell, Joel. ...................................Paper 208 

Campbell, Patricia A .......Paper 035, 065, Scientific Exhibit SE01 

Campi, Fabrizio ..................................Paper 371 

Campion, Jonathon ...............................Paper 354 

Canale, S Terry. ...................................Paper 167 

Candioti, Lautaro .................................Paper 109 

Canesin Dal Molin, Eugenio ...................... Poster P282 

Canete, Arturo C .................................. Paper 311 

Cann, Philippa .......Paper 033, 067, 068, Scientific Exhibit SE03 

Cannada, Lisa K ......................... Paper 380, 693, 695 

Capello, William N. ...............................Paper 352 

Caperna, Ludovico ................................Paper 487 

Capo, Jason ......................................Paper 505 

Capozzi, James D ................Multimedia Education MEC12 

Caraffa, Auro ....................................Poster P171 

Cardoso, Mario J ..................................Paper 017 

Carey, Jason P ....................................Paper 691 

Carillon, Yannick ............................... Poster P123 

Carlile, Graeme S .................................Paper 031 

Carlisle, John. ....................................Paper 638 

Carlos, Fernando. ............................... Poster P259 

Carluzzo, Fulvio ........................Scientific Exhibit SE80 

Carmichael, Kelly D ...............................Paper 549 

Carney Young, Kimberly. ......................... Poster P340 

Caroom, Cyrus Theodore. ........................ Poster P229 

Carpenter, James E ...............................Poster P312 

Carr, Andrew J .................................. Poster P327 

Carr, Christopher ............................... Poster P389 

Carr, Diana Deane .............................. Poster P559 

Carr, John Austin. .................................Paper 550 

Carragee, Eugene. ............................... Poster P346 

Carrasco, Joaquin .................................Paper 148 

Carrera, Guillermo ................................Paper 231 

Carret, Jean-Paul ................................ Poster P048 

Carrington, Richard ..............................Poster P116 

Carrino, John Anthony. .......................... Poster P383 

Carroll, Colin ..........................Scientific Exhibit SE77 

Carroll, Kaitlin M .............................Paper 580, 647 

Carroll, Michael E .......................Scientific Exhibit SE29 

Carson, Jeffrey L ..................................Paper 303 

Carson, William ................................ Poster P520 

Carter, Aaron ....................Paper 189, Poster P073, P075, 


899 

Carter, Thomas R. .................................Paper 494 

Cartier, Philippe Edmond ...................Poster P120, P121 

Cartner, Jacob ................................Paper 701, 703 

Carulli, Christian ................................Poster P061 

Caruso, Salvatore .......................Scientific Exhibit SE80 

Casagrande, Danielle ............................ Poster P299 

Casey, William J ..................................Paper 133 

Cashman, Kara ...............Paper 528, 712, Poster P041, P043 

Caskey, Paul M ...............................Paper 427, 437 

Cason, Garrick Wayne ..................Paper 739, Poster P363 

Casper, David .........................Paper 125, Poster P078 

Cassas, Kyle ......................................Paper 373 

Cassinelli, Ezequiel H. .............................Paper 665 

Cassis, Nelson .....................Paper 422, 553, Poster P259 

Castillo, Renan C ........................ Paper 388, 698, 735 

Castillo, Tiffany. ..................................Paper 563 

Castoldi, Filippo .........Multimedia Education MEC22, MEC28, 

Scientific Exhibit SE25, SE51, SE51, SE65 

Castracini, Roberto ................................Paper 578 

Catalano, Louis W. ................................Paper 337 

Catonne, Yves .............................Poster P036, P037 

Catton, Charles ...................................Paper 524 

Cavalcanti, Rafael .................................Paper 330 

Cavallo, Marco ............... Paper 093, Scientific Exhibit SE61 

Cavanagh, Peter. ................................ Poster P154 

Cechova, Ivana ..................................Poster P131 

Cerulli, Giuliano .................................Poster P171 

Cesari, Eugenio ...................................Paper 371 

Cetin, Gokben Nesrin. ........................... Poster P568 

Cevolani, Luca. ................................... Paper 510 

Chacko, Aron ................Paper 115, 304, Poster P218, P509 

Chadha, Harbinder S ..............................Paper 353 

Chafik, Dara ................................... Poster P322 

Chahine, Nadeen .............Paper 496, Scientific Exhibit SE33 

Chamberlain, Aaron Mark ........................ Poster P294 

Chambers, Hank G ................................Paper 550 

Chambers, Lauchlan. ..............................Paper 039 

Chan, Gilbert. ....................................Paper 484 

Chan, Gladys. ......... Multimedia Education MEC20, Paper 651 

Chan, Keith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P411 

Chandra, Rajesh ..................................Paper 426 

Chang, Bong-Soon ................................Paper 026 

Chang, Chong Bum ......................Paper 015, 329, 490, 

Poster P161, P167, P200, P272 

Chang, Edward ..................................Poster P317 

Chang, Ki Young ..............................Paper 155, 162 

Chanlalit, Cholawish ..............................Paper 687 

Chapman, Jens R. .................... Poster P395, Symposia G 

Chaput, Christopher D. .......................... Poster P466 

Charkin, Susan ............................... Symposia 152 

Charman, Susan ...................Paper 346, 537, Poster P022 

Charopoulos, John ................................Paper 223 

Charron, Kory ....................................Paper 350 

Chehrassan, Moahmmadreza ......Multimedia Education MEC38 

Chen, Albert C. ................................. Poster P393 

Chen, Antonia. .................... Paper 617, 618, Poster P119 

Chen, Chun-Ho ..............................Paper 274, 500 

Chen, Dan .......................Paper 738, Poster P024, P424 

Chen, Justin. ................................... Poster P202 

Chen, Lan ..................................... Poster P303 

Chen, Minsi. ................................... Poster P187 

Chen, Pei-yu .................................Paper 274, 500 

Chen, Po Quang ................................ Poster P365 

author IndEx


Chen, Yuexin ..........................Paper 492, Poster P183 

Cheng, Edward Y. .................Paper 234, Poster P100, P545 

Cheng, Ivan .....................................Poster P391 

Cheng, Joseph S ................................ Poster P389 

Cheng, Robert .................................. Poster P227 

Cheong, David ...................................Paper 516 

Cherf, John .....................................Symposia L 

Cheung, Sunny ...................................Paper 573 

Chevillotte, Christophe J ......................... Poster P048 

Chhabra, Abhinav Bobby. ................Scientific Exhibit SE36 

Chia, Shi-lu ..............Paper 012, 408, 417, Poster P112, P159 

Chiarello, Eugenio ................................ Paper 510 

Chiari, Catharina .............................Paper 199, 347 

Chiavacci, Rosetta M. ..............................Paper 448 

Chihab, Samir ...................................Poster P105 

Child, Zachary Allen. ............................ Poster P403 

Childs, Dylan .............................Poster P249, P256 

Chin, Matthew S ..................................Paper 541 

Chin, Pak Lin. ............Paper 012, 408, 417, Poster P112, P159 

Chinchilli, Vernon ................................Paper 013 

Chiu, Vanessa ....................................Paper 458 

Cho, Byung Ki ...................................Poster P212 

Cho, Chul-Hyun .......................Paper 374, Poster P318 

Cho, Hyung Joon .................Paper 329, Poster P161, P167 

Cho, Kye-Youl ....................................Paper 418 

Cho, Robert Hyun. ...............................Poster P251 

Cho, Samuel Kang-Wook ..............Paper 030, 442, 446, 449, 

Poster P392 

Cho, Woojin ........................Paper 027, 446, 449, 661, 

Poster P374, P392, P400 

Choe, Hyonmin ...........................Poster P049, P068 

Choi, Daniel .....................................Paper 498 

Choi, Duck-Hyun .................................Paper 488 

Choi, Euisung ...................................Poster P212 

Choi, Horim ....................................Poster P015 

Choi, In Ho ..................................Paper 095, 547 

Choi, Ja-Young ...................................Paper 490 

Choi, Leera .....................................Poster P021 

Choi, Young-Seok ............................... Poster P284 

Choma, Theodore J. ............................. Poster P399 

Chong, Hwei Chi .................. Paper 012, 417, Poster P112 

Chou, Loretta ............................. Poster P214, P219 

Choueka, Jack ....................................Paper 565 

Chow, James .....................................Paper 353 

Chow, Roxanne ...................................Paper 691 

Christensen, Kevin P. ............................ Poster P527 

Christensen, Thomas ..........................Paper 734, 734 

Christie, Michael J. ................................Paper 192 

Christofilopoulos, Laurent-Panayiotis. ................Paper 622 

Chu, Constance R ............................Symposia ORSII 

Chubinskaya, Susanna G ...........................Paper 208 

Chun, Yong-Min . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 488 

Chung, Byung June. .Paper 015, 329, 490, Poster P161, P167, P272 

Chung, Chin Youb ............................Paper 095, 547 

Chung, Dae-Huk. .................................Paper 583 

Chung, Jae Yoon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 257 

Chung, Kyung-Chil. ............................. Poster P326 

Chung, Seok Won .................................Paper 153 

Church, Chris ....................................Paper 423 

Chutkan, Norman Barrington ..........Paper 436, 437, 438, 439, 

440, 441, 442, 443, 444, 445, 

446, 447, 448, 449, 450 

Ciccotti, Michael G ............................Paper 324, 681 

900 

Cikes, Alec ........................Paper 468, 469, Poster P314 

Ciompi, Alessandro ..............................Poster P331 

Cipriano, Cara A ......................... Paper 123, 128, 132 

Citak, Musa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P156 

Cividino, Alfred. ..................................Paper 457 

Civinini, Roberto ................................Poster P061 

Claes, Steven AJ ................................. Poster P422 

Clanton, Thomas O ......... Paper 646, 647, 648, 649, 650, 651, 

652, 653, 654, 655, 656, 657, 

658, 659, 660, Symposia K 

Clark, Heather Jolene ..............................Paper 491 

Clark, Jason C .........................Paper 089, Poster P325 

Clarke, Henry D ..............................Paper 133, 134 

Clarke, Theodore J. ......................Scientific Exhibit SE47 

Clauss, Martin ....................................Paper 469 

Clavert, Philippe ..................................Paper 085 

Clay, Catharine ...................................Paper 713 

Clement, Jean-Luc. ................................Paper 442 

Clement, Nicholas D .......................Poster P541, P542 

Clemente, Jill. ....................................Paper 685 

Clohisy, John C ..............Paper 637, 708, Poster P027, P058, 

P059, P062, P063, P088, P126, 

Scientific Exhibit SE14, Symposia J 

Cloutier, Frederic C. ...............................Paper 623 

Cobb, Andrew ................................Paper 709, 709 

Cobb, Justin Peter ..Paper 067, Poster P176, Scientific Exhibit SE03 

Cody, Elizabeth ........................Paper 607, Poster P344 

Cody, Stephanie .................Multimedia Education MEC24 

Coe, Marcus P ....................................Paper 366 

Coetzee, J Chris ..................................Symposia K 

Cofield, Robert H ......... Paper 078, 087, 364, 602, Poster P296 

Cohen, Benjamin ............................... Poster P397 

Cohen, Bruce E ...................................Paper 505 

Cohen, Marcio Theo..............Multimedia Education MEC29 

Cohen, Mark S. ...............................Paper 342, 685 

Cohen, Steven Brad. ...............................Paper 681 

Colaco, Henry B ..................................Paper 265 

Colangeli, Marco. ................................. Paper 511 

Colantonio, Fabio. ......................Scientific Exhibit SE80 

Cole, Ashley. ....................................Poster P481 

Cole, Brian J. ............Paper 160, 200, 208, 367, 495, 574, 609 

Cole, Peter A .....................................Paper 307 

Coleman, Jill .....................................Paper 471 

Coleman, Struan H. ...........................Paper 159, 643 

Collier, John P. .................... Paper 296, 711, Poster P151 

Collo, Gianluca. ................Multimedia Education MEC22, 


Colman, Matthew ......................Paper 239, Poster P505 

Colwell, Clifford W. ......... Paper 286, 287, 288, 289, 290, 291, 

292, 293, 294, 295, 296, 297, 298, 

299, 300, Poster P124, P150 

Comfort, Thomas Krebs ............................Paper 358 

Conditt, Michael A ....................Poster P010, P032, P156 

Conkle, Sean B ................................. Poster P557 

Conner, Chad Stephen ............................Poster P411 

Connolly, Patrick J ....................Poster P353, P356, P357 

Connor, Patrick Michael. ...........................Paper 676 

Conteduca, Fabio ...............Multimedia Education MEC14, 

Paper 486, Poster P447 

Conteduca, Jacopo .....................Paper 486, Poster P447 

Contreras, Juan S. ............Paper 717, Poster P026, P102, P152 

Contreras, Richard ................................Paper 608 

Conway, Janet Donohue. .................Scientific Exhibit SE39 

author IndEx


Cook, Chad ......................................Paper 373 

Cook, James L ..........................Scientific Exhibit SE33 

COOK, Jon R. .................................. Poster P195 

Cook, Stephen D. ............................... Poster P408 

Cook, Todd .................................... Poster P458 

Cooke, Nicholas ..................................Paper 069 

Coombs, Richard RH ..............................Paper 145 

Cooper, Ross ................................... Poster P448 

Coopmans, Charlotte ..............................Paper 616 

Coplan, Julie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 423 

Copley, Lawson A B ...........................Paper 172, 432 

Copp, Steven ................................... Poster P124 

Corcoran-Schwartz, Ian ...........................Poster P391 

Cordill, Ronda. ...................................Paper 437 

Cornwall, Bryan ................................ Poster P377 

Correa, Adrian J. ..................................Paper 228 

Correa, Eva ......................................Paper 109 

Correia, Rickson Guedes De Moraes. Multimedia Education MEC29 

Corten, Kristoff ...................................Paper 350 

Cortez, Doug ................................... Poster P485 

Cosgarea, Andrew J ......................Scientific Exhibit SE70 

Costa, Anthony ...................................Paper 566 

Costa, Christopher R ....................Scientific Exhibit SE05 

Costa, Luigi ......................................Paper 470 

Costouros, John George ............................Paper 080 

Coulibaly, Marlon Osman . . . . . . . . . . . . . . . Paper 047, Poster P513 

Coulibaly, Marlon O. ...................Paper 150, Poster P515 

Court-Brown, Charles M ......................... Poster P504 

Coutinho, Etevaldo. .........Paper 736, Poster P373, P375, P379 

Cowgill, Ian.................................... Poster P403 

Cox, Christopher. ................................Poster P391 

Coyle, Catelyn ....................................Paper 250 

Coyne, Ellen ................................... Poster P368 

Craig, Edward V. ................................Symposia M 

Craig, Matthew ...................................Paper 315 

Cravino, Mattia ..................Multimedia Education MEC22 

Crawford, Alvin Howell .................Paper 450, Poster P384 

Crawford, Charles H. ............................ Poster P382 

Crawford, Kelli ................................. Poster P450 

Crawford, Lindsay Michele. .........................Paper 421 

Crawford, Scott Nicholas ...........................Paper 177 

Creek, Aaron ............................ Paper 288, 403, 404 

Creevy, William R . . . . . . . . . . . . . . . . . .Paper 046, 732, Poster P493 

Creighton, Robert Alexander ........................Paper 585 

Crichlow, Renn J ................................ Poster P487 

Crist, Brett D ..........................Paper 302, Poster P520 

Crosby, Lynn A .........Paper 151, 152, 153, 154, 155, 156, 157, 

158, 159, 160, 161, 162, 163, 164, 165 

Cross, Jessica Dale. ...........Paper 138, Poster P185, P507, P511 

Cross, Michael B ...........................Poster P156, P162, 


Cross, William Wood ............................ Poster P470 

Crossett, Lawrence S ...............................Paper 247 

Cruz, Aristides I. ..................................Paper 548 

Csintalan, Rick P ..................................Paper 492 

Cuffini, Anna Maria ...............................Paper 470 

Cumberland, William. ...Paper 181, 182, 183, 184, 185, 186, 187, 

188, 189, 190, 191, 192, 193, 194, 195 

Cummings, Don R ................................Paper 428 

Cummings, Stephen H .............................Paper 496 

Cummings, Steven ................................Paper 226 

Currey, Thomas W ......................Scientific Exhibit SE46 

Currier, Barbara H. ................Paper 296, Poster P089, P151 

901 

Currier, John H .................... Paper 296, 711, Poster P151 

Curry, Jessica I ...................................Poster P109 

Curry, Patrick. ............................. Poster P107, P361 

Curtin, Brian M ..................................Poster P114 

Curtiss, Shane .................................. Poster P233 

Cushner, Fred D ........ Paper 001, 002, 003, 004, 005, 006, 007, 

008, 009, 010, 011, 012, 013, 014, 015 

Cuttica, Daniel J ................................ Poster P225 

D’Alleyrand, Jean-Claude ...........................Paper 735 

D’Angelo, Jean. ...................................Paper 456 

D’Antonio, James A. ...........................Paper 352, 529 

D’Apuzzo, Michele R ............................ Poster P440 

D’ERRICO, THERESA ..............................Paper 003 

D’Lima, Darryl D ...........Paper 369, Poster P150, P196, P444, 


D’Orazio, Luca ...................................Paper 198 

Dabis, Hossam ...................................Paper 709 

Dadia, Shlomo ................................. Poster P540 

Dae Gyu, Kwon ...............................Paper 095, 547 

Dahiya, Nirvikar .................................Poster P313 

Dahl, Annette W .......................Paper 242, Poster P133 

Dahm, Diane Lynn ..Paper 481, 482, 483, 484, 485, 485, 486, 487, 

488, 489, 490, 491, 492, 493, 494, 495, 660 

Dai, Joseph Michael ............................. Poster P349 

Daigl Cattaneo, Monica ............................Paper 724 

Daikos, George ................................. Poster P060 

Daines, Michael T ............................... Poster P327 

Dal Molin, Danilo Canesin ....................... Poster P282 

Dal Molin, Eden ................................ Poster P282 

Dale, Paul A. ..........................Paper 120, Poster P274 

Daley, Erika L. .......................Paper 160, 200, 495, 574 

Daley, Jacqueline A ................................Paper 121 

Daluiski, Aaron ................................. Poster P298 

Dalury, David F ....Paper 194, 254, Poster P142, P146, P148, P190 

Damron, Timothy A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 234 

Dancy, Lindsay ...................................Paper 735 

Choi, Daniel ................................... Poster P069 

Daniels, Stephen .................................Poster P216 

Daniels, Timothy Rudolf ...........................Paper 053 

Danielson, Beate ..................................Paper 593 

Daou, Samira ....................................Paper 622 

Das, Aditi ...................................... Poster P238 

Daskal, Anat .....................................Paper 139 

Daubs, Michael David .............................Paper 021 

Daugherty, Margot C. ..............................Paper 169 

Davey, J Rod. ..........................Paper 589, Poster P177 

David, Bertrand. ................................ Poster P484 

David, Tal S .....................Multimedia Education MEC43 

Davidovic, Nadav .................................Paper 406 

Davidovitch, Roy. ......................Paper 372, Poster P472 

Davidson, David ..............Paper 528, 712, Poster P041, P043 

Davis, Adrian Thomas ........................... Poster P468 

Davis, Brent R ....................................Paper 492 

Davis, Brian .................................... Poster P154 

Davis, Charles M ................................ Poster P085 

Davis, Chris ......................................Paper 146 

Davis, Jason J. ..........................Scientific Exhibit SE20 

Davis, Kenneth ........................Paper 130, Poster P370 

Davis, Rebecca. ...................................Paper 424 

Davis, William Hodges. ............................Paper 505 

Dawkins, Ross ....................................Paper 403 

Day, Charles S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P270, P275 

Day, Judd ....................Paper 293, Scientific Exhibit SE77 

author IndEx


Day, Michael S. .......... Multimedia Education MEC39, MEC40 

Day, Nicky .......................................Paper 624 

Dazley, Justin. ........Multimedia Education MEC12, Poster P397 

De Benedetto, Massimo ............................Paper 578 

De Bruijn, Joost. ..................................Paper 675 

De Carli, Angelo .......................Paper 487, Poster P331 

De Fine, Marcello .......................Scientific Exhibit SE09 

De Giacomo, Anthony .............................Paper 749 

De La Fuente, Juan Carlos ..........................Paper 654 

De La Rocha, Adriana ..............................Paper 544 

De Neve, Francis ................................ Poster P288 

De Roeck, Nicholas. ............................. Poster P172 

De Steiger, Richard ............Paper 528, 712, Poster P041, P043 

De Vet, Henrica CW ...............................Paper 616 

De Wilde, Lieven. ............................... Poster P288 

De Young, Allison .............................Paper 197, 202 

Dean, Daniel Brian ................................Paper 695 

Dean, Laura E ....................................Paper 436 

Dearborn, John T .................................Paper 599 

Debi, Ronen .....................................Paper 406 

DeBoer, David Kent .....................Scientific Exhibit SE29 

Decker, Michael. ................................ Poster P336 

DeFranco, Michael ................................Paper 164 

Degroot, Florence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 675 

DeGroot, Henry ..................................Paper 502 

Dehoux, Emile ...................................Paper 697 

Del Buono, Angelo ................................Paper 575 

Del Din, Rainero .................Multimedia Education MEC22 

Del Gaizo, Daniel J ................................Paper 742 

Dela Rosa, Mylene A. ...................Paper 074, Poster P067 

Dela Torre, Katrina ................................Paper 644 

Delacruz, Michael ...................... Paper 519, Poster P521 

Delamarter, Rick B ................................Paper 662 

Deland, Jonathan T. .......................Paper 102, 498, 508 

Delaney, Kevin ...................................Paper 559 

Delanois, Ronald Emilio .........................Poster P181, 


Deleon, Regidor B. ................................ Paper 311 

Dell, Richard M. .............Poster P534, Scientific Exhibit SE76 

Della Rocca, Gregory John ......................Paper 302, 464 

Della Valle, Craig J ......Paper 007, 123, 128, 132, 187, 195, 349, 

411, 714, Poster P057, P186, Symposia E, P 

Delos, Demetris. ..............Paper 577, Scientific Exhibit SE55, 

SE63, SE67, SE71, SE73 

DeLuca, Peter A ...................................Paper 548 

DeLuca, Peter F ...............................Paper 324, 681 

Deluzio, Kevin. ...................................Paper 409 

DeMaio, Marlene .......................Scientific Exhibit SE75 

Demaurex, Nicolas ................................Paper 622 

Demetracopoulos, Constantine. ...........Scientific Exhibit SE34 

Demiryurek, Deniz .............................. Poster P569 

Demura, Satoru. ....................... Paper 261, Poster P351 

Denaro, Vincenzo ........................ Paper 156, 575, 578 

Deng, Xiang-Hua. .................................Paper 579 

Dennis, Douglas A ...............Poster P146, P190, P191, P197 

Dennis, James E ..................................Paper 378 

Dennison, David G. ....................Paper 334, Poster P226 

Dent, Ricardo E ...................................Paper 387 

DeOrio, James Keith ...................... Paper 048, 057, 058 

Derman, Peter ....................................Paper 106 

DeRosa, G Paul ...................................Paper 455 

Dervisoglu, Sergulen. ............................ Poster P565 

Desai, Rasesh R ...................................Paper 190 

902 

Desloovere, Kaat ................................ Poster P422 

DeSmet, Arthur A ................................Poster P412 

DeSmet, Koen Aime .......................Paper 032, 035, 038 

Dettoni, Federico ................. Scientific Exhibit SE25, SE65 

Devereaux, PJ. .................................. Poster P460 

Devin, Clinton J .......................Paper 743, Poster P362 

Deviren, Vedat. ..........Paper 029, 444, 749, Poster P387, P396 

Dewan, Ashvin Kumar ...................Scientific Exhibit SE36 

Dewing, Christopher B. ..................Scientific Exhibit SE53 

Di Caprio, Francesco ..............................Paper 093 

Di Martino, Alberto ..............Multimedia Education MEC38 

Di Martino, Alessandro ............................Paper 198 

Di Matteo, Berardo ................................Paper 198 

Dipaola, Christian ............................Paper 451, 452 

Di Sanzo, Vincenzo. ..............Multimedia Education MEC26 

Di Sette, Priscilla ..................................Paper 486 

Diab, Mohammed Atef. .......................... Poster P002 

Diamond, Beverly E ............................. Poster P403 

Diaz, Veronica A ..................................Paper 677 

DiCaprio, Francesco .....................Scientific Exhibit SE69 

DiCesare, Paul E ........ Paper 031, 032, 033, 034, 035, 036, 037, 

038, 039, 040, 041, 042, 043, 044, 045 

Dichter, Daniel ...............................Paper 166, 176 

Dickson, Kyle F ...................................Paper 213 

Didomenico, Paul. .............................. Poster P242 

Diekmann, Glenn .................................Paper 479 

Diesfeld, Paul ....................................Paper 291 

Dieterle, Jason P ................................ Poster P446 

DiFazio, Rachel L .................................Paper 170 

DiGioia, Anthony M. ....................Scientific Exhibit SE48 

DiGiovanni, Benedict F ...........................Poster P207 

DiGiovanni, Christopher W. ........................Paper 049 

Dikmen, Goksel ........................Scientific Exhibit SE35 

Dillon, Erica .....................................Paper 573 

Dines, David M .................................Symposia M 

Dines, Joshua ................Paper 496, Scientific Exhibit SE68 

Ding, Anthony. ...................................Paper 276 

DiPaola, John ............Paper 106, 107, 108, 109, 110, 111, 112, 

113, 114, 115, 116, 116, 117, 118, 119, 120 

Dirusso, Jessice M ............................... Poster P280 

Disilvo, Mauricio ............................... Poster P259 

Dmitriev, Anton E .........................Paper 017, 443, 669 

Do, Huong. ..............Paper 083, 287, 658, 659, Poster P020 

Do, Nam Hoon. .....................Paper 155, 162, 604, 605 

Doan, Josh. ...........................Paper 394, Poster P364 

Dodd, Christopher A F .........................Paper 415, 592 

Dodson, Christopher ...................Paper 681, Poster P415 

Doerner, Michael .................................Paper 530 

Domayer, Stephan. ................................Paper 199 

Domb, Benjamin ..Multimedia Education MEC07, Paper 640, 645 

Donahue, Henry J .................................Paper 206 

Donaldson, William F .............................Paper 023 

Donegan, Derek J .................................Paper 453 

Donegan, Ryan P. ............................... Poster P332 

Donzelli, Onorfio .................................Paper 433 

Doornink, Josef. ..................................Paper 702 

Dopirak, Ryan M. ..............................Symposia 151 

Doral, Mahmut Nedim. .......................... Poster P569 

Dormans, John P. ......................Paper 448, Poster P260 

Dorotka, Ronald . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 199 

Dorr, Lawrence D ............................... Poster P032 

Dorward, Ian G ................................. Poster P374 

Dosanjh, Sonia ...................................Paper 464 

author IndEx


Douglas, Keith C ..................................Paper 695 

Doustdar, Sepehr. .................................Paper 561 

Dowd, Thomas Charles ............................Paper 052 

Downes, Katheryne. ............................. Poster P147 

Downie, Brian ...................................Poster P312 

Doyle, Mike S .........................Paper 120, Poster P274 

Doyle, Shevaun Mackie ............................Paper 405 

Drago, Gabriele. .......................Paper 240, Poster P539 

Dragoo, Jason L. ..................................Paper 631 

Dreese, James C. ....Paper 196, 197, 198, 199, 200, 201, 202, 203, 

204, 205, 206, 207, 208, 209, 210, 731 

Dreiangel, Niv ................................Paper 028, 721 

Drew, Brian ......................................Paper 630 

Drew, Jacob M ....................Paper 348, Poster P035, P357 

Drexler, Michael ................................ Poster P540 

Dromsky, David M ..............................Symposia Q 

Drosdowech, Darren Sean ..........................Paper 678 

Dudda, Marcel. ................................. Poster P077 

Dudley, Thomas Edward ................Paper 120, Poster P274 

Duester, Rosanna ................................Poster P214 

Dumais, Jules Arthur ............................ Poster P508 

Dunbar, Michael ........................Scientific Exhibit SE02 

Duncan, Clive P ...................Paper 073, 349, Poster P105 

Duncan, Douglas D ............................. Poster P320 

Dungca, Daniel V ................................. Paper 311 

Dungca, Godfredo V. .............................. Paper 311 

Dunn, Warren . . . . . . . . . . . . . . . . . . . . . . . . . Paper 157, Poster P319 

Dunning, Page. ..................................Poster P311 

Duquin, Thomas. ............ Paper 078, 602, Poster P179, P297 

Duralde, Xavier A ............................... Poster P335 

Dushey, Craig .................................. Poster P189 

Dutta, Arup ......................................Paper 624 

Dutton, Jason R. ................................ Poster P435 

Dvorak, Marcel F. .............................Paper 451, 452 

Dy, Christopher John .............. Scientific Exhibit SE67, SE82 

Dyer, George S. ...................................Paper 696 

Eagan, Michael ...................................Paper 166 

Earl-Royal, Emily. ............................... Poster P472 

Easley, Mark E ........................... Paper 048, 057, 058 

Ebrahimpour, Prouskeh .......................... Poster P020 

Ebramzadeh, Edward ..........................Paper 035, 166 

Eck, Jason C. .........................Poster P353, P356, P357 

Mayr, Eckart. .............Multimedia Education MEC10, MEC11 

Eckel, Tobin. ................................... Poster P498 

Ecker, Timo M .................................. Poster P038 

Economopoulos, Kostas. ...........................Paper 653 

Edidin, Avram A ........................Scientific Exhibit SE56 

Edmonds, Eric ...................................Poster P221 

Edwards, Christopher ..............................Paper 013 

Edwards, Paul K. ..............................Paper 006, 192 

Edwards, Thomas Bradley ....Paper 090, Poster P302, Symposia M 

Efe, Turgay ..................................... Poster P132 

Egi, Takeshi ......................................Paper 345 

Eglseder, W Andrew ...........................Paper 694, 698 

Egol, Kenneth A. ...................Paper 144, 372, Poster P472 

Egorova, Natalia ................................ Poster P378 

Ehrlich, Michael G ................................Paper 122 

Ehteshami, John R ................................Paper 159 

Eichler, Markus .........................Scientific Exhibit SE59 

Einhorn, Thomas A. .......................Symposia ORSII, W 

Eisemon, Eric. ................Paper 565, Scientific Exhibit SE76 

Eisenberg, Gerald .................................Paper 370 

Eisner, Eric A .....................................Paper 146 

903 

Ejnisman, Leandro ................................Paper 552 

Ekholm, Carl ...................................Poster BOS2 

Ekkernkamp, Axel ............................... Poster P273 

El Chemaly, Antoun ...............................Paper 622 

El Miligui, Yasser H. ........................Poster P360, P380 

El Shafie, Sherif ......................Paper 282, 336, 338, 339 

El-Amin, Saadiq F ............................... Poster P449 

El-Gendi, Hebah ..................................Paper 729 

El-Osta, Bassel .................................. Poster P160 

El-Sharkawi, Mohammad Mohammad. ........Poster P360, P380 

ElAttrache, Neal S ............................... Poster P420 

Elfatori, Salah ....................................Paper 359 

Elhassan, Bassem T .....................Paper 334, Poster P465 

Elias, John J .................................... Poster P248 

Elkinson, Ilia ..........................Paper 584, Poster P337 

Eller, Erik Brian ...................................Paper 476 

Elliott, Dawn M. ........................Scientific Exhibit SE33 

Elliott, Winston. ...........................Poster P293, P334 

Ellis, Andrew R ..................................Poster P010 

Ellis, David J ....................................Poster P117 

Ellis, Scott ...................Paper 498, Scientific Exhibit SE34 

Ellis, Thomas J. ...................................Paper 377 

Ellison, Brad .....................................Paper 420 

Elsharkawy, Karim Ahmed ..........................Paper 600 

Elspas, Barbara ...................................Paper 657 

Emans, John B. ....................Paper 396, 671, Poster P382 

Emerson, Gwendolyn Beth .........................Paper 454 

Emerson, Roger H .............................Paper 297, 298 

Emery, Sanford E. .................................Paper 020 

Emori, Makoto ...................................Paper 232 

Encalada, Ivan .................................... Paper 610 

Endo, Naoto ..............................Poster P261, P523 

Endres, Terrence J .................Paper 047, Poster P513, P515 

Engh, C Anderson. ........Paper 005, 066, 244, 532, Poster P094 

Engh, Charles A. ..............................Paper 066, 532 

Engh, Gerard Anderson ...............Paper 244, Symposia B, P 

Entezari, Vahid ...................................Paper 234 

Epie, Geoffrey ....................................Paper 709 

Epstein, David M. ............................... Poster P004 

Epstein, Noah ....................................Paper 042 

Eralp, Levent ...........................Scientific Exhibit SE85 

Erbe, Erik M. .....................................Paper 675 

Ercakmak, Burcu ................................ Poster P569 

Erdem, Mehmet ................................ Poster P560 

Erdman, Meghan A.............................. Poster P403 

Erginer, Rifat ................................... Poster P567 

Erickson, Jill ...... Paper 061, Poster P030, Scientific Exhibit SE15 

Erickson, Mark A. ............................... Poster P382 

Erkorkmaz, Unal. ............................... Poster P560 

Erkula, Gurkan ........................Paper 180, Poster P383 

Errico, Thomas J ..................................Paper 262 

Eskander, Mark ........Paper 348, Poster P035, P353, P356, P357 

Espehaug, Birgitte ..........................Poster P497, P500 

Esposito, Christina Ilona ................Paper 527, Poster P045 

Esquivel, Amanda .................................Paper 629 

Essner, Aaron. .............................Poster P181, P182 

Ethington, Arthur ................................Poster P481 

Ettner, Susan L. ................................. Poster P266 

Eunice, Selena . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P126 

Eustace, Nick ....................................Poster P419 

Evangelista, Gregory Thomas. .......................Paper 491 

Evans, Bruce G. ...................................Paper 467 

Evans, Christopher H .............................Poster P431 

author IndEx


Evans, Heather N .................................Paper 169 

Evans, Korboi N .................................Poster P421 

Evans, Richard Parker ....................Scientific Exhibit SE45 

Evans, David C ...................................Paper 467 

Even, Jesse L. ..........................Paper 743, Poster P362 

Exaltacion, Jesse ................................ Poster P005 

Ezzet, Kace A ................................... Poster P124 

Fabbri, Nicola ................................Paper 433, 511 

Faber, Ken ..............Paper 584, 678, 699, Poster P337, P343 

Fabi, David W .................................. Poster P057 

Fabing, Meredith. .................................Paper 077 

Fabricant, Peter David. .............................Paper 405 

Fadale, Paul .................................... Poster P438 

Fagan, Bryan C ...................................Paper 686 

Falcon, Juan-Carlos. ...............................Paper 422 

Falcone, Richard ..................................Paper 169 

Faldini, Cesare. ..........Multimedia Education MEC02, MEC21, 

MEC38, Paper 510, Poster P220, 


Falkinstein, Yuri .................................Poster P471 

Fang, Chien-Feng .............................Paper 274, 500 

Farber, Bobbi A .........................Scientific Exhibit SE45 

Farber, Daniel C ........Paper 496, 497, 498, 499, 500, 501, 502, 

503, 504, 505, 506, 507, 508, 509, 510 

Farcetta, Mariana Custodio ....................... Poster P283 

Farcy, Jean-Pierre C ................................Paper 441 

Farfalli, German Luis .............Paper 513, Poster P533, P544, 


Farid, Yasser .................................... Poster P140 

Faris, Philip M ....................................Paper 413 

Farjoodi, Payam .............Poster P278, Scientific Exhibit SE62 

Farley, Frances A ..................................Paper 025 

Farng, Eugene ................................Paper 039, 719 

Fahnhorst, Courtney. ..............................Paper 693 

Farnsworth, Christine L ................... Paper 393, 394, 543 

Faro, Frances .....................................Paper 104 

Farouz, Francine ..................................Paper 674 

Farshad, Mazda ...................................Paper 151 

Favard, Luc. ..............................Paper 079, 085, 088 

Fayad, Tony Elias. .................................Paper 636 

Fazzi, Umberto Giuseppe. ..........................Paper 682 

Fedenko, Alexander N .............................Paper 228 

Fedorka, Catherine Julia............Paper 247, Poster P186, P199 

Feeley, Brian T ................................Paper 161, 573 

Fehring, Keith ....................................Paper 538 

Fehring, Thomas K ......Paper 192, 538, Poster P076, P085, P146, 

Symposia B, E 

Fehringer, Edward V .............................Symposia M 

Femino, John E ........Multimedia Education MEC20, Paper 092 

Ferguson, Duncan. ................................Paper 481 

Ferguson, James ..................................Paper 354 

Ferguson, Peter ...............................Paper 523, 524 

Ferkel, Richard D. .................................Paper 094 

Fern, Edwin Darren. ....................Paper 031, Poster P508 

Fernandez-Fairen, Mariano ....................... Poster P008 

Ferreira, Joel. ....................................Poster P514 

Ferreira, Louis .........................Paper 584, Poster P337 

Ferretti, Andrea ..........Multimedia Education MEC14, MEC26, 

Paper 486, 487, Poster P331, P447 

Ferretti, Matteo ...................................Paper 487 

Ferro, Andrea. ...................Multimedia Education MEC28 

Ferruzzi, Alberto ........................Scientific Exhibit SE69 

Fevang, Jonas Meling .......................Poster P497, P500 

904 

Ficke, James R ............Paper 052, Poster P511, Symposia N, Q 

Field, Larry D. .........................Paper 686, Poster P316 

Filardo, Giuseppe .........Paper 198, 208, Scientific Exhibit SE61 

Fine, Anthony ....................................Paper 440 

Fine, Kenneth M .................................. Paper 210 

Finn, Henry A .................................. Poster P140 

Fiocco, Marta. ....................................Paper 594 

Firestein, Gary S ..................................Paper 065 

Fischer, Charla R ..................................Paper 442 

Fisher, Anthony Colin. ............................Poster P321 

Fisher, Charles G ..............................Paper 451, 452 

Fisher, David A ................................. Poster P153 

Fisher, Steven. ................................ Symposia 152 

Fisk, Erica. .......................................Paper 727 

Fitch, Robert D ...................................Paper 389 

Fitz, Wolfgang . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Symposia P 

Fitzgerald, John D......................Paper 112, Poster P266 

Fitzpatrick, Daniel C. ..............................Paper 702 

Fitzsimmons, James S..............................Paper 687 

Flatow, Evan L ..................Multimedia Education MEC30, 

Paper 601, Symposia H, M 

Fleck, Erin E. ................................... Poster P166 

Fleckenstein, Cassie M ........................... Poster P300 

Fleeter, Thomas B .......................Scientific Exhibit SE47 

Fletcher, Nicholas D ...........................Paper 172, 173 

Flint, Kathy J.. .................................. Poster P370 

Flouzat-Lachaniette, Charles Henri .............. Paper 009, 191, 


Flynn, Evelyn. .................................. Poster P243 

Flynn, Jeffrey .....................................Paper 629 

Flynn, Jack M. ................Paper 114, 119, Poster P255, P371 

Flynn, Patrick. ....................................Paper 401 

Foad, Susan ......................................Paper 628 

Fong, Kathryn ....................................Paper 625 

Foo, Li Foong. ....................................Paper 205 

Foran, Jared R H ...............Paper 007, 187, 714, Poster P164 

Ford, Kevin Ray ...................................Paper 649 

Forester, Andrew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 692 

Fornalski, Stefan ..................................Paper 492 

Fornari, Eric D. ...................................Paper 330 

Fornfeist, Douglas S ............................. Poster P229 

Forootan, Maryam ............................Paper 557, 564 

Forsberg, Jonathan Agner ...........................Paper 705 

Forstner, Rosemarie. ...............................Paper 203 

Foruria de Diego, Antonio Maria. .................. Poster P306 

Fowler, John R ................................Paper 315, 613 

Fox, Alice JS ......................................Paper 579 

Fox, Joshua C. .................................. Poster P467 

Fragomen, Austin Thomas ..........................Paper 313 

Fraitzl, Christian R .............................. Poster P028 

Frampton, Caroline ............................. Poster P248 

Franceschi, Francesco ..........................Paper 156, 575 

Francesconi, Dunia .............................. Poster P220 

Frank, Elizabeth L .......................Scientific Exhibit SE41 

Frank, Jeremy S ................................. Poster P252 

Frank, Rachel. .................................. Poster P329 

Frankle, Mark A ............. Paper 361, 362, 363, 364, 365, 365, 

366, 367, 368, 368, 369, 370, 371, 

372, 373, 374, 375, Poster P309, P311 

Franklin, Patricia. ................... Poster P280, Symposia AA 

Frederick, Robert W. ...............................Paper 324 

Freedman, Brett. .................................Poster P481 

Freedman, Ilan S ..................................Paper 351 

author IndEx


Freehill, Michael Q ...................Paper 576, Symposia 152 

Freehill, Michael T ..... Poster P292, Scientific Exhibit SE62, SE66 

Freeman, Carl R. ................................ Poster P454 

Freeman, Heather . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Poster P410 

Freeman, Robert ................................ Poster P244 

Freeman, Theresa ............................... Poster P078 

Freiberg, Andrew A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Poster P015 

Freitag, Per. .....................................Poster P271 

Fricka, Kevin B. ...................................Paper 066 

Friden, Jan .......................................Paper 556 

Frieboes, Laura ...............................Paper 557, 564 

Friedlaender, Gary E .....Paper 226, 227, 228, 229, 230, 231, 232, 

233, 234, 235, 236, 237, 238, 239, 240 

Friedman, Daniel .................................Paper 524 

Friedman, Richard J ...............................Paper 540 

Friel, Nicole A ....................................Paper 208 

Friend, Jennifer K .................................Paper 048 

Friess, Darin M ...................................Paper 377 

Frihagen, Frede ............................Poster P479, P535 

Fritsch, Helga. ............Multimedia Education MEC10, MEC11 

Fritz, Germaine R .................................Paper 271 

Froelich, John Marshal ............................Poster P271 

Frostick, Simon ..................................Poster P321 

Fu, Freddie H. ...........Multimedia Education MEC41, MEC42, 

Poster P407, Scientific Exhibit SE72 

Fuchs-Winkelmann, Susanne. ................Poster P120, P132 

Fuersenberg, Carl Hans .................Paper 561, Poster P405 

Fufa, Duretti ...........Scientific Exhibit SE34, SE50, SE64, SE82 

Fuji, Takeshi. .....................................Paper 707 

Fujimaki, Hiroshi ............................... Poster P049 

Fujimori, Jun ..............................Poster P524, P528 

Fujita, Satoru .....................................Paper 345 

Fujiwara, Hiroyoshi ...............................Paper 277 

Fukagawa, Shingo ......................Paper 414, Poster P168 

Fulkerson, John P .......................Scientific Exhibit SE70 

Funahashi, T Ted..........Paper 080, 186, 492, 621, Poster P534, 


Funovics, Philipp Theodor ..........................Paper 520 

Furey, Christopher George ......................Paper 020, 665 

Furman, Bridgette D ..............................Poster P501 

Furnes, Ove Nord ..........................Poster P497, P500 

Furu, Moritoshi ................................. Poster P239 

Futai, Kazuma ...................................Poster P291 

Daggy, Joanne ....................................Paper 727 

Gabriel, Keith Robert .............................Poster P271 

Gad, Bishoy V .................................... Paper 111 

Gadinsky, Naomi .................................Paper 595 

Gajendran, Varun Kashyap. ....................... Poster P237 

Galante, Jorge O ..............................Paper 007, 411 

Galatz, Leesa M ...............Paper 086, 601, Poster P313, P322 

Gallagher, Kieran R ...............................Poster P116 

Gallo, Jiri .......................................Poster P131 

Galoian, Karina ...................................Paper 512 

Galoyan, Armen ..................................Paper 512 

Gamble, James G. ............................... Poster P253 

Gandhi, Rajiv. .....................Paper 289, 589, Poster P177 

Ganley, Theodore J ..............Multimedia Education MEC24, 

Paper 482, Symposia Z 

Gantsoudes, George D .............................Paper 099 

Ganz, Reinhold ....Multimedia Education MEC27, Paper 043, 634 

Garabekyan, Tigran. ...............................Paper 445 

Garbis, Nickolas G ................................Paper 609 

Garbuz, Donald S ..................Paper 073, 349, Poster P105 

905 

Garcia, Grant .................................Paper 613, 613 

Garcia, Ryan .....................................Paper 665 

Gardner, Michael J ................................Paper 732 

Gardner, Thomas R ............................Paper 147, 273 

Garg, Bhavuk. ......Paper 268, 283, 305, 340, 355, 474, 560, 569, 

710, 720, Poster P232, P235, P305, P489 

Garg, Rishi .......................................Paper 689 

Garg, Rohit ......................................Paper 558 

Garg, Sudhir .....................................Paper 229 

Garg, Sumeet .................................Paper 172, 173 

Garino, Jonathan P .........................Poster P103, P122 

Garner, Matthew Robert ............................Paper 114 

Garras, David N. ..................................Paper 562 

Garrett, William E .................................Paper 493 

Garvin, Kevin L ............. Paper 121, 122, 123, 124, 125, 126, 

127, 128, 129, 130, 131, 132, 133, 

134, 135, 241, Symposia B 

Gasbarrini, Alessandro ...................Scientific Exhibit SE57 

Gasinu, Selom. ...................................Paper 579 

Gastaud, Olivier ................................ Poster P330 

Gatt, Charles J .................................. Poster P439 

Gaume, Rachel E ..........................Paper 017, 443, 669 

Gausden, Elizabeth. ...............................Paper 747 

Gavini, Deepa ..........................Scientific Exhibit SE41 

Gay, Andre Nicolas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 726 

Gay, David ..................................... Poster P298 

Gazit, Zulma .....................................Paper 139 

Ge, Dongxia. .....................................Paper 209 

Gebhardt, Mark C .........................Paper 234, 433, 511 

Gee, Albert Ooguen ............................. Poster P122 

Geerts, William H .................................Paper 589 

Geesink, Rudolph Gerbrand ........................Paper 352 

Gehrke, Thorsten. ............................... Poster P092 

Gehrmann, Robin Michael. .........................Paper 375 

Genuario, James ................................ Poster P332 

George, Michael S .......Paper 571, 572, 573, 574, 575, 576, 577, 

578, 579, 580, 581, 582, 583, 584, 585 

Gerber, Christian. ...................... Paper 151, Poster P315 

Gerlinger, Tad L ............................Poster P180, P502 

Germano, Margherita .............Multimedia Education MEC22 

Geurts, Ghislain ..................................Paper 341 

Ghate, Raju S ................................... Poster P175 

Ghayem Hassankhani, Ebrahim ................... Poster P459 

Ghermandi, Riccardo ....................Scientific Exhibit SE57 

Ghodadra, Neil S .................................Paper 606 

Ghomrawi, Hassan ................................Paper 658 

Ghoz, Ali ...................................... Poster P160 

Giakas, Giannis ...................................Paper 318 

Giannetti, Silvio ......... Multimedia Education MEC14, MEC26 

Giannini, Sandro ........Multimedia Education MEC02, MEC21, 

MEC38, Paper 093, 510, Poster P012, P220, 


Giannoudis, Peter ..............Paper 211, 223, 376, Poster P499 

Gibbons, Christopher T ............................Paper 722 

Gibbons, Max .................................. Poster P187 

Gibbs, Johnny M. .................................Paper 730 

Gibson, Anthony. ............................... Poster P404 

Gie, Graham Allan ...............................Poster P110 

Gilbert, Corey A ..........Multimedia Education MEC41, MEC42 

Giles, Josh W ..........................Paper 584, Poster P337 

Gill, Harinderjit Singh ..................Paper 531, Poster P187 

Gill, Richie H S .......Paper 032, 415, 592, Scientific Exhibit SE06 

Gill, Thomas James. ...........................Paper 580, 647 

author IndEx


Gilliam, David L ..................................Paper 370 

Gilmore, Allison ..................................Paper 378 

Gilula, Louis A. ...................................Paper 672 

Gioe, Terence J. ......Paper 406, 407, 408, 409, 410, 411, 413, 414, 

415, 416, 417, 418, 419, 420, 588, Symposia E 

Giordano, Giovanni ..........Poster P414, Scientific Exhibit SE24 

Giori, Nicholas John. ..............Paper 657, Poster P039, P040 

Girardi, Federico Pablo. .................Paper 747, Poster P369 

Gitajn, Ida Leah. ..................................Paper 312 

Giuffre, Jennifer L ......................Paper 051, Poster P443 

Giuliani, Jeffrey R ................................Poster P421 

Giveans, M. Russell .....................Paper 646, Poster P429 

Gjertsen, Jan-Erik ..........................Poster P497, P500 

Glaser, David L ..........Paper 076, 077, 078, 079, 080, 081, 082, 

083, 084, 085, 086, 087, 088, 089, 090 

Glaser, Diana A ......Paper 393, 394, 543, 551, Poster P245, P364 

Glaser, John A ....................................Paper 027 

Glassman, David Michael ..........................Paper 438 

Glassman, Steven D .................. Paper 441, Symposia T, Y 

Glazebrook, Mark ......................Paper 503, Symposia K 

Glembotski, Nicholas. ........................... Poster P444 

Glos, David ......................................Paper 429 

Glotzbecker, Michael P. ............................Paper 168 

Glyn-Jones, Sion ..........Paper 032, 531, Scientific Exhibit SE06 

Gobezie, Reuben ......................... Paper 082, 090, 363 

Gocuk, Can .................................... Poster P566 

Goddard, Maria S ......................Paper 299, Poster P016 

Godin, Jonathan .................................Poster P310 

Goehre, Tom .....................................Paper 688 

Goel, Anshul . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 229 

Goel, Danny ....................Multimedia Education MEC03 

Goetz, Devon D ..................................Paper 004 

Goetz, Thomas ...................................Paper 566 

Gohlke, Frank ....................................Paper 079 

Goldberg, Michael J ..............................Symposia F 

Goldman, Ariel ...................................Paper 729 

Goldring, Steven R ................................Paper 238 

Goldstein, Jeffrey Andrew. ......Paper 262, Scientific Exhibit SE58 

Goldstein, Wayne M ............................. Poster P146 

Goldwyn, Elan Michael ............................Paper 698 

Goletz, Ty Henry ..........Paper 106, 107, 108, 109, 110, 111, 112, 

113, 114, 115, 116, 116, 117, 118, 119, 120 

Golf, Michael. ...................................Poster P216 

Golish, S Raymond .....................Paper 501, Poster P346 

Gomar, Francisco .................................Paper 148 

Gomes, Bruna ....................................Paper 502 

Gomes, Joao Ellera ................................Paper 509 

Gomez-Leonardelli, Dominic T. ................... Poster P427 

Gonzalez Della Valle, Alejandro M ...................Paper 535 

Gonzalez, Bernal. .................................Paper 360 

Gonzalez Ugalde, Humberto ........................Paper 360 

Gonzalez-Lomas, Guillem ........................ Poster P420 

Gonzalez-Thompson, Miguel ....................... Paper 610 

Gonzalez, Ruben. ............................... Poster P423 

Gooch, Hubert Lee ......Paper 256, 257, 258, 259, 260, 261, 262, 

263, 264, 265, 266, 267, 268, 269, 270 

Goodman, Gens Pierce. .................Paper 728, Poster P435 

Goodman, Mark A ................................Paper 239 

Goodman, Murray J .....................Scientific Exhibit SE46 

Goodman, Stuart Barry. ..........................Symposia W 

Goodwillie, Andrew D ......................Poster P439, P439 

Gorab, Robert S ..................................Poster P021 

Gorczyca, John T .................................. Paper 310 

906 

Gordon, Wade T ................................Symposia Q 

Gortz, Simon. ................................Paper 197, 202 

Goswami, Tarun ................................ Poster P494 

Goto, Akira .....................................Poster P291 

Goto, Hideyuki ...................................Paper 319 

Gotze, Christian ................................ Poster P084 

Goubau, Yannick. ............................... Poster P430 

Goulding, Krista .................................Poster P519 

Gourdine-Shaw, Monique C ...................... Poster P222 

Goyal, Amrit .....................................Paper 426 

Goyal, Nitin. .....................................Paper 220 

Goytia, Robin Nestor .............................Poster P016 

Goz, Vadim .................................... Poster P378 

Grabowski, Gregory ...............................Paper 258 

Gradisar, Ivan A. ........................Scientific Exhibit SE30 

Graff, Ronald D. ..................................Paper 742 

Grainger, David ...................................Paper 467 

Grammatopoulos, George A ....Paper 032, Scientific Exhibit SE06 

Grana, William A .................................Paper 491 

Grande, Daniel A .............Paper 496, Scientific Exhibit SE33 

Grandi, Gian Luca. ...............Multimedia Education MEC21 

Grant, Struan F ...................................Paper 448 

Grappiolo, Guido ................Multimedia Education MEC27 

Gratopp, Carly. ...................Paper 739, Poster P194, P363 

Graves, Mathew. ...........................Poster P456, P457 

Graves, Stephen. ..............Paper 528, 712, Poster P041, P043 

Gravius, Sascha ...................................Paper 193 

Gray, Robert R ....................................Paper 685 

Gray, Tinker .....................................Poster P410 

Greaves, Frank E ................................ Poster P558 

Green, Andrew ...................................Paper 581 

Green, Daniel William . . . . . . . . . .Paper 401, 405, 554, Poster P254 

Green, Stuart A .........................Scientific Exhibit SE39 

Greenbaum, Jordan N ............................Poster P018 

Greendyk, Richard A. ............Multimedia Education MEC08, 

MEC47, MEC53 

Greene, Denise .........................Scientific Exhibit SE76 

Greene, Joseph ........................Paper 245, Poster P114 

Greene, Meridith. ............. Paper 082, 348, 530, Poster P035 

Greenwald, A Seth. ...........Scientific Exhibit SE02, SE08, SE16, 

SE28, SE30, SE60, SE84, Symposia W 

Gregg, Paul J .....................................Paper 537 

Greidanus, Nelson Victor ............Paper 073, 349, Poster P105 

Greidanus, Thomas H. ........................... Poster P086 

Greisberg, Justin K ...... Paper 046, 047, 048, 049, 050, 051, 052, 

053, 054, 055, 056, 057, 058, 059, 060, 147 

Greiwe, Mike ......................Paper 366, 607, Poster P344 

Grewal, Ruby ......................Paper 678, 699, Poster P343 

Griesser, Michael. ............................... Poster P525 

Griffin, Anthony M ................................Paper 523 

Grigg, Harry. ................................... Poster P074 

Grimm, Nathan L ................................Poster P417 

Grimshaw, Charles Simpson ....................Paper 214, 380 

Groat, Tahnee ....................................Paper 377 

Grogan, Thomas J ............................. Symposia 152 

Gross, Allan E .....Paper 251, 349, Poster P044, P062, P105, P111, 

Scientific Exhibit SE14, Symposia W 

Gross, Jonathan Michael ........................... Paper 310 

Gross, Thomas. ...................................Paper 186 

Grossman, Joshua D. ............................ Poster P358 

Gruebl, Alexander .................................Paper 347 

Gruen, Gary S .................................. Poster P505 

Grumet, Robert C .................................Paper 208 

author IndEx


Grupp, Thomas ...................................Paper 740 

Gruson, Konrad Izumi .............................Paper 601 

Gryzlo, Stephen. ..................................Paper 680 

Gu, Yang ........................................Paper 508 

Guanche, Carlos .................................Poster P411 

Guda, Teja .......................................Paper 379 

Gudipati, Suribabu ................................Paper 376 

Guelcher, Scott ...................................Paper 379 

Guerra, Enrico .................... Scientific Exhibit SE54, SE54 

Guerra, Giovanni .................................Paper 240 

Guerrero, Marcos ............................... Poster P453 

Guettler, Joseph. ..................................Paper 204 

Guevara, Benjamin G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 403 

Guilak, Farshid ............................Poster P342, P501 

Guillamondegui, Oscar ............................Paper 221 

Guirguis, Farid. ..................................Poster P111 

Guitton, Thierry ................................ Poster P323 

Gulati, Ashish .................................. Poster P145 

Gulick, Bethany C .................................Paper 298 

Gulotta, Lawrence ................................Poster P415 

Gulsen, Mahir .................................. Poster P566 

Gundle, Kenneth Robert. ................Paper 117, Poster P263 

Gundle, Roger ................ Paper 531, Scientific Exhibit SE06 

Gundogan, Adem ............................... Poster P566 

Gunes, Taner ................................... Poster P560 

Gupta, Akash. .................................. Poster P326 

Gupta, Ranjan .....................Paper 557, 564, Poster P326 

Gupta, Rishi R ....................................Paper 388 

Gupta, Tushar ....................................Paper 355 

Gupta, Vikas .....................................Paper 426 

Gurdezi, Sabahat. .................................Paper 507 

Gurske de Perio, Jennifer ...........................Paper 131 

Gustke, Kenneth A .............................. Poster P147 

Gutierrez, Sergio ..............................Paper 006, 368 

Guyatt, Gordon................................. Poster P460 

Guyen, Olivier. ................................. Poster P048 

Guymon, Charles H ............................. Poster P180 

Guyton, Gregory P ................................Paper 104 

Gwinn, David E. .................................Poster P421 

Ha, Chul Won ...................................Poster P451 

Ha, Eun-Young ........................Paper 374, Poster P318 

Ha, Yong-chan. ....................Paper 472, 596, Poster P017 

Haasters, Joerg. ................................. Poster P285 

Habbu, Rohan Ashok ..........................Paper 060, 100 

Habermeyer, Dr Peter ............................ Poster P328 

Habib, Sadia .....................................Paper 142 

Hackbarth, Donald A ..........................Paper 231, 517 

Hackett, Thomas R .............................. Poster P336 

Haddad, Fares Sami ..............Paper 107, 127, 536, 620, 633, 

636, 641, Poster P437 

Haddad, Steven L ...Paper 046, 047, 048, 049, 050, 051, 052, 053, 

054, 055, 056, 057, 058, 059, 060, Symposia K 

Hadley, Scott R ........................Paper 129, Poster P004 

Hafez, Moustafa Ismail. ............................Paper 145 

Hagio, Tomonobu ................................Paper 098 

Hahn, Michael P .................Multimedia Education MEC37 

Hahn, Theodore J .............................Paper 673, 674 

Hak, David J ................................... Poster P508 

Hakimiyan, Arnavaz ...............................Paper 208 

Hakki, Sam ......................................Paper 356 

Hakki, Sema ................................... Poster P072 

Hakonarson, Hakon ...............................Paper 448 

Halanski, Matthew ................................Paper 541 

907 

Haleem, Abdul Ahad ..............................Paper 236 

Halliburton, Carolina. .............................Paper 400 

Halligan, Benjamin Warren .........................Paper 657 

Halstead, Mark ...................................Paper 626 

Hamadouche, Moussa ........................... Poster P484 

Hambright, Dustin ................................Paper 493 

Hamid, Nady. ....................................Paper 676 

Hamilton, William G ..........................Paper 005, 066 

Hammond, Kyle E ................................Paper 483 

Hammoud, Sommer. ..............Paper 554, 642, Poster P254, 


Han, Chang-Dong. .............................. Poster P055 

Han, Seung Beom .................................Paper 309 

Hancock, Nicholas J ...............................Paper 675 

Hanel, Douglas P ...............................Symposia O 

Hanna, Lewis. .........................Paper 501, Poster P346 

Hanna, Sammy A ......................Paper 462, Poster P172 

Hansen, Benjamin ................................Paper 706 

Hansen, Patricia L ..................Paper 357, 539, Poster P101 

Hansen, Sigvard T ................................Poster P210 

Hanslow, Sarah ..................................Poster P210 

Hanson, Beate ....................................Paper 724 

Hanson, Jean. .................................. Poster P403 

Hanssen, Arlen D .......Paper 002, 133, Poster P136, Symposia B 

Hanzlik, Josa .....................................Paper 293 

Hara, Toshiaki ....................................Paper 707 

Harada, Yoshitada. .....................Paper 546, Poster P279 

Harb, Ziad .......................................Paper 497 

Hardcastle, John McCall. ...........................Paper 312 

Harfush-Nasser, L Alberto ..........................Paper 553 

Harigane, Kengo ................................ Poster P268 

Hariri, Sanaz .................................Paper 463, 647 

Harisboure, Alain .................................Paper 697 

Harlaar, Jaap .....................................Paper 616 

Harmsen, William. ................................Paper 364 

Harner, Christopher D .......................... Symposia BB 

Harnett, Paul Richard ............................ Poster P244 

Harris, Alex HS ................................. Poster P040 

Harris, Joshua ....................................Paper 572 

Harris, Michael D .................................Paper 706 

Harris, Mitchel B ..................... Poster P355, Symposia G 

Harris, Steven M ...............................Symposia 151 

Harrison, Alicia Karin ... Multimedia Education MEC30, Paper 601 

Harrison, Jim. .................................. Poster P244 

Harrop, James ................................Paper 024, 666 

Hart, Alister ..........Paper 033, 067, 068, Scientific Exhibit SE03 

Hart, Deborah .................................. Poster P327 

Hart, Nathan .....................................Paper 582 

Hart, Robert A .................................. Poster P394 

Harter, Gary Dean. ................................Paper 716 

Hartman, Robert ..................................Paper 023 

Hartsell, Zane ....................................Paper 703 

Hartsock, Langdon A ..............................Paper 650 

Hartzband, Mark A .....................Paper 293, Poster P057 

Haruhiko, Satonaka ...............................Paper 652 

Harvey-Kelly, Katherine F ......................... Poster P499 

Hasan, Samer S ................................. Poster P300 

Hasan, Saqib ....................Multimedia Education MEC39 

Hasanzadeh, Zabeolla .............................Paper 143 

Hash, Thomas .................................. Poster P139 

Hasharoni, Amir ..................................Paper 667 

Hashim, Zaid. .................................. Poster P503 

Hashimoto, Hideo ................................Paper 345 

author IndEx


Hashimoto, Tomoyuki .............................Paper 259 

Hashimoto, Yusuke. ..............................Poster P115 

Hassenpflug, Joachim. ........................... Poster P285 

Hatano, Hiroshi ................................ Poster P523 

Hatayama, Kazuhika. ............................ Poster P267 

Hatten, H Paul ...................................Paper 672 

Hattrup, Steven J ..................................Paper 087 

Havelin, Leif Ivar. ..........................Poster P497, P500 

Hawasli, Ammar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 030 

Hawkes, David ..................................Poster P321 

Hawkins, Richard J .................Paper 089, 373, Poster P325 

Hawkinson, Nicola .............................. Poster P394 

Hawn, Mary. .....................................Paper 473 

Hayashi, Hiroyuki. ................................Paper 261 

Hayashi, Katsuhiro ................ Paper 235, 521, Poster P537, 


Hayashida, Kenji ................................ Poster P289 

Hayda, Roman A ................................Symposia N 

Hayden, Brett. ....Multimedia Education MEC08, MEC46, MEC47, 

MEC48, MEC49, MEC50, MEC51, MEC52, MEC53 

Haydon, Rex ..........................Paper 518, Poster P536 

Hayon, Solomon. .......................Scientific Exhibit SE31 

Hays, Peyton ..........................Paper 348, Poster P035 

Hazard, Sprague ..................................Paper 206 

Hazlerigg, Alexandra. ..............................Paper 709 

He, Tong-Chuan .......................Paper 518, Poster P536 

Healey, John H ...................................Paper 238 

Healy, William L ................Poster P034, P085, Symposia B 

Heard, Wendell M Rogan ......................... Poster P438 

Hecht, Andrew C. ......................Paper 741, Poster P378 

Heckman, James D ................................Paper 454 

Heckman, Kimberly ...............................Paper 748 

Hedden, David ...............................Paper 252, 255 

Hegedus, Eric. ....................................Paper 373 

Hegmann, Jo Ellen .............................. Poster P556 

Heim, Christine S .......................Scientific Exhibit SE02 

Helfet, David Leonard .............................Paper 724 

Heller, John G ....................................Paper 737 

Heller, Yonah. ...................................Poster P141 

Hellman, Edward J .............................. Poster P153 

Hellman, Michael ............................... Poster P079 

Helmy, Hany F ...................................Paper 062 

Hemery, Xavier ...................................Paper 697 

Hemmer, Stefan ................................ Poster P405 

Henderson, Cynthia ............................. Poster P557 

Henderson, Drew ......................Paper 246, Poster P341 

Henderson, Eric. ..................... Paper 006, 240, 516, 520 

Henderson, William G .............................Paper 473 

Henley, John D ...................................Paper 423 

Henley, M Bradford ..............................Symposia F 

Henn, R Frank ....................................Paper 580 

Hennrikus, William L ...............Paper 171, 174, Poster P482 

Henshaw, Robert Mikael. ......................... Poster P526 

Hepinstall, Matthew ............................. Poster P139 

Hebert-Davies, Jonah ..............................Paper 623 

Herkowitz, Harry N .......... Paper 456, 739, Poster P363, P390 

Herman, Martin Joseph ...........Paper 391, 392, 393, 394, 395, 

396, 397, 398, 399, 400, 401, 

402, 403, 404, 405, Symposia R 

Hernandez-Soria, Alexia. ........... Scientific Exhibit SE50, SE64 

Herndon, James H ........................Paper 042, 586, 718 

Hernigou, Philippe ...Paper 009, 191, Scientific Exhibit SE18, SE21 

908 

Herrick, Richard T.......Paper 331, 332, 333, 334, 335, 336, 337, 

338, 339, 340, 341, 342, 343, 344, 345 

Herzberg, Wolfgang ............................. Poster P285 

Herzenberg, John E. ................Paper 423, 555, Poster P222 

Herzog, Mary A ................................. Poster P224 

Hess, Susanne ....................................Paper 540 

Hester, Sydney. ................................. Poster P137 

Hetsroni, Iftach ...................................Paper 659 

Hettrich, Carolyn .............Paper 579, Scientific Exhibit SE42 

Heuer, Hinrich JD ................Multimedia Education MEC34 

Heumann, Peter ................................ Poster P273 

Hewett, Timothy E ................................Paper 649 

Heybeli, Nurettin ............................... Poster P568 

Heyl, Alma. ..................................Paper 239, 618 

Heyse, Thomas Jan ....................Poster P120, P121, P132 

Heyworth, Benton E ...............................Paper 405 

Hideo, Noguchi. ........................Scientific Exhibit SE26 

Higgins, Laurence D ....Multimedia Education MEC03, Paper 164 

Higgins, Thomas F .............................. Poster P496 

Higuchi, Hiroshi ................................ Poster P267 

Higuera, Carlos A ......................Paper 600, Poster P096 

Hildebrand, Kevin A ...............................Paper 303 

Hilibrand, Alan S ................Paper 024, 256, 270, 666, 750, 


Hillman, Joshua ..................................Paper 065 

Hillstrom, Howard ................................Paper 558 

Himes, Ryan .....................................Paper 140 

Hintermann, Beat ..................Paper 055, 059, Poster P209 

Hipp, John. ..............................Paper 028, 260, 721 

Hirai, Cori ..................................... Poster P527 

Hirakawa, Kazuo. ............................... Poster P046 

Hiratzka, Jayme. ..................................Paper 377 

Hirosima, Ryo ....................................Paper 591 

Hirst, Philip. ....................................Poster P117 

Hitt, Kirby .......................................Paper 190 

Hiz, Murat ..................................... Poster P565 

Hjerstedt, Karen ..................................Paper 471 

Ho, Christine Ann. ....................... Paper 172, 173, 432 

Ho, Duarte Y ................................... Poster P197 

Ho, Henry .......................................Paper 532 

Ho, Jessica Mayan .................................Paper 260 

Ho, Pei-Ran ......................................Paper 226 

Hoang, Bang H ...................................Paper 233 

Hoekstra, H J .....................................Paper 070 

Hoenecke, Heinz R ................................Paper 369 

Hoffelner, Thomas ................................Paper 203 

Hoffman, Martin. .................Paper 732, Poster P359, P402 

Hoffman, Robert M. ..........Poster P537, Scientific Exhibit SE83 

Hoffmeyer, Pierre J ........................Paper 091, 183, 622 

Hofmann, Aaron Adam ...........................Symposia B 

Hofstaetter, Jochen G ............................ Poster P208 

Hogrebe, Paul C ..................................Paper 467 

Hohl, Justin ...........................Paper 023, Poster P362 

Hojo, Tatsuya. ....................................Paper 277 

Hokama, Jorge ...................................Paper 400 

Hol, Annemiek ...............................Paper 072, 075 

Holdsworth, David W. ........................... Poster P056 

Holland, Danny C ................................Paper 271 

Holland, James ...................Paper 038, Poster P064, P074 

Holloway, Julianne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P449 

Holmes, Laurens ................................ Poster P246 

Holt, Ginger E .........................Paper 192, Poster P137 

Holtzman, Kathleen ...........................Paper 455, 456 

author IndEx


Holzer, Nicolas ...................................Paper 091 

Homering, Martin. ................................Paper 540 

Hommel, Gabriel James. ...........................Paper 668 

Honsawek, Sittisak .............................. Poster P163 

Hooper, Gary John ......Paper 346, 347, 348, 349, 350, 351, 352, 

353, 354, 355, 356, 357, 358, 359, 360 

Hoover, M ..................................... Poster P280 

Hoover, Stephen A ................................Paper 585 

Hopkinson, William John ................Scientific Exhibit SE46 

Hopper, Robert ...................................Paper 532 

Hoque, Martha ..................................Poster P012 

Horazdovsky, Ryan David ........................ Poster P398 

Hori, Kazuichiro ..................................Paper 652 

Horibe, Shuji .....................................Paper 201 

Horinouchi, Yutaka ............................. Poster P354 

Horne, Walter .................................. Poster P249 

Horneff, John G ................................ Poster P464 

Hornicek, Francis J ................................Paper 520 

Horodyski, MaryBeth ............................ Poster P368 

Horwitz, Daniel Scott ............................ Poster P496 

Hosalkar, Harish Sadanand ................Paper 543, 551, 637, 

Poster P063, P245, P251 

Hoshino, Christopher Max .........................Paper 176 

Hoshino, Yuichi .......................Paper 019, Poster P407 

Hossain, Munier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P065 

Hotchkiss, Richard ................................Paper 146 

Hotchkiss, Robert N ....Poster P298, P340, Scientific Exhibit SE50 

Hotta, Tetsuo. .................................. Poster P523 

Houman, Justin. ..................................Paper 662 

Houston, Thomas .................................Paper 473 

Hovelius, Lennart .................................Paper 615 

Howard, Caitlin ................................ Poster P356 

Howell, Stephen M .....................Paper 420, Poster P202 

Hozack, William J ........ Multimedia Education MEC10, MEC11, 

Paper 124, Symposia E 

Hresko, Michael Timothy. ..........................Paper 170 

Hsieh, Adam H ...................................Paper 700 

Hsieh, Jui-Yang ............................Poster P157, P365 

Hsu, Jason ................................Poster P103, P173 

Hsu, Joseph R ......... Paper 052, 733, Poster P304, P462, P473, 

P498, P502, P507, Symposia Q 

Hsu, Patricia A. ................................. Poster P324 

Hsu, Wellington .........Paper 016, 017, 018, 019, 020, 021, 022, 

023, 024, 025, 026, 027, 028, 029, 030 

Hu, Serena S .....................................Paper 749 

Hu, Yue-Yung ....................................Paper 304 

Huang, Hsiang-Yao ............................Paper 274, 500 

Huang, Ronald ...................................Paper 250 

Huang, Russel C .......................Paper 269, Poster P369 

Huddleston, James I .......................Paper 042, 586, 718 

Huddleston, Paul M .....................Scientific Exhibit SE45 

Hueber, Axel .....................................Paper 682 

Huebner, Janet L .................................Poster P501 

Huemmer, Carmen. ..............................Poster P441 

Huffman, G Russell. ..............................Poster P518 

Hughes, Alexander P. ..............................Paper 747 

Huh, Jeannie ..............................Poster P304, P473 

Hui, Catherine. ...................................Paper 481 

Hui, Emily .......................................Paper 388 

Huk, Olga ..................................... Poster P082 

Hull, Jason Ray ................................. Poster P099 

Hull, Maury L .................................. Poster P202 

Hullinger, Heidi ..................................Paper 402 

909 

Hulten, Kristina G. ................................Paper 431 

Hummel, Matthew Thomas ........................Poster P109 

Humphrey, Catherine A ............................ Paper 310 

Hung, Clark T ..........................Scientific Exhibit SE33 

Hungerford, Marc Wilson .........................Poster P081 

Hunt, Devyani. ...................................Paper 625 

Hunt, Kenneth. ...............Paper 050, 505, Poster P214, P219 

Hunter, Kim. ....................................Poster P419 

Hunter, Robert E ..................................Paper 491 

Huon, Tomy S ....................................Paper 080 

Huot, Jennifer Caitlin ..............Paper 711, Poster P089, P151 

Hurley, Patrick E .......................Paper 120, Poster P274 

Hurst, Jason Michael. ..................Poster P204, Symposia P 

Hurst, Lawrence C. ................................Paper 568 

Hurst, Simon A ................................. Poster P176 

Hurt, James A ...................................Poster P316 

Hurwitz, Shepard R. ..............Paper 455, 456, Symposia 151 

Husain, Sohail. ...............................Paper 342, 342 

Hussain, Nasir. .................................Poster BOS2 

Hutchinson, Mark R ............................. Poster P455 

Hutt, Jonathan R..................................Paper 709 

Hutzler, Lorraine. .................................Paper 113 

Hwang, Bo-Hyun ............................... Poster P055 

Hwang, Byoung-Yoon. .............................Paper 488 

Hwang, Steven W .................................Paper 440 

Hymes, Robert. ...................................Paper 676 

Ichinose, Tsuyoshi. .............................. Poster P333 

Ida, Takahiro .................Paper 041, 098, Poster P047, P054 

Idusuyi, Osaretin B ...............................Poster P271 

Iga, Toru. .................................Poster P174, P490 

Iguchi, Hirotaka ..................................Paper 319 

Iida, Takahiro ...................................Poster P115 

Ikari, Katsunori ...................................Paper 591 

Ikawa, Tessyu. ...................................Poster P115 

Ike, Hiroyuki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P049, P068 

Ikebuchi, Mitsuhiko ..............................Poster P115 

Ikeguchi, Ryosuke ............................... Poster P239 

Ikemoto, Roberto ............................... Poster P295 

Ilizaliturri Sanchez, Victor Manuel ...................Paper 360 

Ilo, Kevin ............................... Paper 033, 067, 068 

Ilyas, Asif .........................Paper 284, 679, Poster P228 

Imai, Kan ........................................Paper 277 

Imhauser, Carl W .............................Paper 327, 498 

Immerman, Igor .......................Paper 129, Poster P004 

Imrie, Meghan N. ............................... Poster P253 

Inaba, Yutaka. .............................Poster P049, P068 

Inacio, Maria Carolina Secorun ...............Poster P198, P413, 


Incavo, Stephen J. ............................... Poster P005 

Ingwer, Zach ................................... Poster P483 

Innes, Alan. .................................... Poster P262 

Innocenti, Bernardo ..............................Poster P171 

Innocenti, Massimo ..............................Poster P061 

Inoue, Hirokazu ..................................Paper 019 

Inoue, Masayuki ..................................Paper 321 

Inoue, Shinichi ................................. Poster P354 

Inrig, Taucha .....................................Paper 053 

Inwards, Carrie ................................. Poster P544 

Iobst, Christopher August ........................ Poster P483 

Iorio, Carlo .....................................Poster P331 

Iorio, Raffaele ..................Multimedia Education MEC14, 

Paper 486, 487, Poster P447 

Iorio, Richard .............................Poster P034, P085 

author IndEx


Iosifidis, Michael. .................................Paper 318 

Ipp, Lisa .........................................Paper 401 

Irrgang, James J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P505 

Ishida, Takashi. ............................Poster P049, P068 

Ishii, Katsushi .................................. Poster P268 

Ishii, Yoshinori .........................Scientific Exhibit SE26 

Israelite, Craig L. ................................ Poster P122 

Issei, Nomura ....................................Paper 386 

Itoi, Eiji ........................................Poster P291 

Iwai, Shintaro .................................. Poster P007 

Iwaki, Hiroyoshi .................................Poster P115 

Iwamoto, Naoyuki .........................Poster P049, P068 

Iwamoto, Takuji ..................................Paper 591 

Iwamoto, Yukihide ......Paper 308, 414, Poster P150, P168, P476 

Iwanik, Michael. ..................................Paper 027 

Iwasaki, Junichi. .......................Paper 619, Poster P158 

Iwinski, Henry J. ..............................Paper 424, 445 

Izaki, Teruaki ................................... Poster P366 

Izuka, Byron H ...................................Paper 177 

Jackson, Atiba .................................. Poster P446 

Jackson, Mark P. ..................................Paper 526 

Jackson, Nancy M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 629 

Jackson, William ...............Paper 354, 415, 592, Poster P145 

Jacobs, Craig .....................................Paper 630 

Jacobs, Joshua J ...............Paper 714, Scientific Exhibit SE02, 

Symposia ORSII 

Jacobs, Michael A .................................Paper 062 

Jacobson, Justin. ............. Paper 078, 602, Poster P290, P297 

Jacofsky, David Joseph .............................Paper 218 

Jacofsky, Marc C ..............................Paper 132, 218 

Jacovides, Christina L.. .....Paper 122, 124, 126, Poster P104, P107 

Jacquet, Robin .............................Poster P249, P256 

Jada, George N ..................................Poster P401 

Jaeger, Sebastian ...........................Poster P090, P095 

Jafari, S. Mehdi ..............Paper 125, 250, Poster P184, P464, 


Jaffe, Fredrick Francis ..............................Paper 190 

Jaffe, William L ...................................Paper 352 

Jain, Amit. ............................Paper 180, Poster P081 

Jain, Viral .............................Paper 450, Poster P384 

Jaiswal, Parag Kumar .............................Poster P116 

Jamali, Amir A. ...................................Paper 593 

Jameel, Omar ....................................Paper 397 

James, Philip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Poster P071 

Jelinek, James S ................................. Poster P526 

James, Stephen E. .................................Paper 265 

Jameson, Simon ...................Paper 038, 537, Poster P071 

Jamieson, Miranda .............................. Poster P032 

Jamison, James M .......................Scientific Exhibit SE30 

Janey, Jim. .......................................Paper 630 

Jang, Jak ........ Paper 010, 011, 320, 322, 326, Poster P178, P192 

Jang, Sung-Won. ..................................Paper 063 

Jang, Yoon Jong. .................................Poster P051 

Jani, Jai. ....................................... Poster P099 

Jao, Abigail Trinidad. .............................. Paper 311 

Jarrett, Bryan T. ........................Paper 530, Poster P025 

Jarrett, Claudius ................................ Poster P170 

Javidan, Pooya. ...................................Paper 689 

Jawa, Andrew. .................................. Poster P469 

Jawad, Muhammad Umar ..........................Paper 236 

Jayasankar, Subramanyan. ................Scientific Exhibit SE47 

Jayaswal, Arvind ..............................Paper 268, 305 

Jazayeri, Reza. .................................. Poster P420 

910 

Jazrawi, Laith M ......... Multimedia Education MEC39, MEC40 

Jeans, Kelly. ......................................Paper 421 

Jaberi, Mehrad M .................................Paper 478 

Jenis, Louis George . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P356 

Jenkins, Cathy .................................. Poster P137 

Jenkins, Cathy ....................................Paper 415 

Jenkins, Matthew V ................................ Paper 210 

Jenkins, Paul John. .............................. Poster P504 

Jensen, Cyrus D. .......................Paper 722, Poster P155 

Jensen, Kelly ................................... Poster P482 

Jeong, Eun Kee ...................................Paper 021 

Jeong, Jae-heon ....................Paper 472, 596, Poster P017 

Jeong, Mun Su. ............Poster P130, P134, P135, P143, P418 

Jeray, Kyle James ..................................Paper 676 

Ji, Hyung-min .....................Paper 472, 596, Poster P017 

Jia, Xiaofeng ................................... Poster P284 

Jiang, Ching Chuan ............................. Poster P157 

Jindal, Rohit .....................................Paper 229 

Jinnah, Riyaz H ..................................Symposia P 

Jiranek, William A. .............................. Poster P099 

Jo, Sungkweon. ...................................Paper 316 

Jobe, Frank W .................................. Poster P420 

Jobin, Charles M ................................ Poster P303 

Joensson, Anders. ...............................Poster BOS2 

Joglekar, Siddharth B ..............................Paper 748 

Johnson, Aaron J. ................ Paper 121, Poster P062, P181, 


Johnson, Anthony E .........................Poster P185, P511 

Johnson, Darren L. ............................. Symposia BB 

Johnson, Derek R ................................Poster P191 

Johnson, Geoffrey V ...............................Paper 624 

Johnson, James A ......................Paper 584, Poster P337 

Johnson, Jared. .......................... Paper 137, 673, 674 

Johnson, Jeffrey Einer ...................Paper 101, Poster P445 

Johnson, Marie-Clare ..............................Paper 692 

Johnson, Mia. ....................................Paper 646 

Johnson, Michael .................................Paper 178 

Johnson, Timothy Shane ...........................Paper 206 

Johnston, Casey D ................................Paper 646 

Johnston, Charles Eugene ..........................Paper 391 

Johnston, Donald William Cooper ................. Poster P086 

Johnston, Richard C ...............................Paper 004 

Johnston, Katherine ............................. Poster P280 

Jones, Carroll Payne ...............................Paper 505 

Jones, Clifford B .........................Paper 047, 150, 732, 

Poster P224, P359, P402, P513, P515 

Jones, Deryk G. ................................. Poster P408 

Jones, Grant L ....................................Paper 572 

Jones, Kay S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P454 

Jones, Kerwyn ......Paper 166, 167, 168, 169, 170, 171, 172, 173, 

174, 175, 176, 177, 178, 179, 180, Poster P248 

Jones, Kevin. .....................................Paper 522 

Jones, Kristofer .........................Scientific Exhibit SE68 

Jones, Lynne C. ...................Paper 299, Poster P016, P081 

Joo, Jong-Hwan. ..................................Paper 181 

Yoo, Yonsik .................................... Poster P425 

Jordan, Charles J .............. Paper 715, Scientific Exhibit SE78 

Jordanov, Martin I. ................................Paper 331 

Jorgensen, Anton Yang .............................Paper 437 

Joshi, Rohan .....................................Paper 366 

Jost, Bernhard ...................................Poster P315 

Jost, Patrick .................................... Poster P424 

Joyce, Thomas .....................Paper 038, 069, Poster P074 

author IndEx


Ju, Kevin L .......................................Paper 430 

Jules-Elysee, Kethy. ................................Paper 290 

Jung, Ho Joong ...............................Paper 489, 596 

Jung, Kwang Am ...............Paper 122, 124, 126, Poster P079 

Jung, Martin. .....................................Paper 561 

Jung, Michael. ....................................Paper 674 

Jung, Woo Bin .............Poster P130, P134, P135, P143, P418 

Jung, Woon-hwa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 596 

Jung, Young-Bok . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 489 

Jungkind, Donald ............................... Poster P098 

Kabata, Tamon ................................. Poster P007 

Kabir, Korush. ....................................Paper 740 

Kaczmarek, Ron. ........................Scientific Exhibit SE41 

Kadoya, Yoshinori. .............................. Poster P125 

Kadrmas, Warren R ..............................Symposia N 

Kaeding, Christopher C .. Paper 646, 647, 648, 649, 650, 651, 652, 

653, 654, 655, 656, 657, 658, 659, 660 

Kaehr, David M ................................. Poster P487 

Kafle, Dinesh .....................................Paper 026 

Kagoma, Yoan ....................................Paper 108 

Kaider, Alexandra .................................Paper 347 

Kaimrajh, David N .............................. Poster P483 

Kajino, Yoshitomo .............................. Poster P007 

Kakar, Sanjeev ....................................Paper 343 

Kakihana, Masataka ...............................Paper 096 

Kakinoki, Ryosuke. .............................. Poster P239 

Kalainov, David Mark ..............................Paper 342 

Kalisvaart, Michael ................................Paper 002 

Kalore, Niraj ................................... Poster P545 

Kam, Check C .............................Poster P293, P334 

Kamada, Satoshi ............ Paper 041, Poster P047, P054, P277 

Kamath, Atul F ................................. Poster P122 

Kamikawa, Koya .......................Paper 546, Poster P279 

Kamineni, Srinath. .............................. Poster P426 

Kaminski, Christine ..............................Poster P103 

Kanakaris, Nikolaos K. ..........Paper 211, 223, 376, Poster P499 

Kanayama, Masahiro ..............................Paper 259 

Kanazawa, Kazuki .................................Paper 098 

Kancherla, Vamsi. ................................Poster P518 

Kandemir, Utku. ..................................Paper 225 

Kane, Patrick .....................................Paper 357 

Kaneko, Takeshi ................................ Poster P046 

Kaneko, Tetsuya. ................................ Poster P333 

Kaneko, Tomonori ................................Paper 096 

Kang, Bun-Jung ....................Paper 472, 596, Poster P017 

Kang, Daniel .....................................Paper 669 

Kang, Hyun-Guy ..................................Paper 525 

Kang, James ......................................Paper 023 

Kang, Jung Ho .................................. Poster P144 

Kang, Kyung-Do . .Paper 257, Poster P130, P134, P135, P143, P418 

Kang, Matthew M ......... Paper 030, 446, 449, 661, Poster P392 

Kang, Richard W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P452 

Kang, Yeon Gwi. ................................ Poster P200 

Kanim, Linda E A .................................Paper 662 

Kanj, Wajdi ......................................Paper 482 

Kano, Masanobu. .................................Paper 232 

Kantor, Stephen R .................................Paper 713 

Kaper, Bertrand Paul .....Paper 451, 452, 453, 454, 455, 456, 457, 

458, 459, 460, 461, 462, 463, 464, 465 

Kaplan, Leon .....................................Paper 667 

Kaplan, Lige. ................................... Poster P194 

Kaplan, Sheldon L. ................................Paper 431 

Kappe, Thomas ................................. Poster P028 

911 

Kapron, Ashley L. .............Paper 635, Scientific Exhibit SE12 

Kaptein, Bart L. ...................................Paper 594 

Karahan, Mustafa ................................Poster P561 

Karaliotas, Georgios I ............................ Poster P188 

Karas, Spero G ..........Paper 676, 677, 678, 679, 680, 681, 682, 

683, 684, 685, 686, 687, 688, 689, 690 

Karashima, Hirotaka. ........ Paper 041, Poster P047, P054, P277 

Karbach, Lauren E .................................Paper 260 

Kardosh, Rami. ...................................Paper 406 

Karlen, Judson W .................................Paper 314 

Karol, Lori A .....................................Paper 421 

Karrholm, Johan Nils ..............................Paper 704 

Kasai, Yuichi .................................Paper 263, 664 

Kashima, Nobuhiro ...............Paper 041, Poster P047, P054 

Kasinova, Monika ............................... Poster P280 

Kasraeian, Sina ...................................Paper 228 

Kato, Satoshi .....................................Paper 261 

Kato, Yuki ..................................... Poster P407 

Katonis, Pavlos ................................. Poster P367 

Katz, Gregory. .........................Paper 129, Poster P004 

Katz, Jeffrey N ................................Paper 184, 286 

Kaufman, Annette .................................Paper 503 

Kawabata, Akira. ..................................Paper 345 

Kawahara, Norio ....................... Paper 261, Poster P351 

Kawakami, Kosei ..................................Paper 591 

Kawanabe, Keiichi. .............................. Poster P239 

Kawano, Osamu ................................ Poster P350 

Kawashima, Hiroyuki ............................ Poster P523 

Kay, David B .....................................Paper 103 

Kaya, Mitsunori ...................................Paper 232 

Kean, Kathryn E. ..................................Paper 436 

Kean, Thomas J ...................................Paper 378 

Kearing, Stephen ..................................Paper 713 

Kearney, Sean Patrick ..............................Paper 427 

Kearns, Kenneth ................................ Poster P098 

Keating, E Michael ......Paper 241, 242, 243, 244, 245, 246, 247, 

248, 249, 250, 251, 252, 253, 254, 255, 413 

Keating, Gail Sue. ............................... Poster P558 

Kebaish, Khaled M-. ....................Paper 745, Poster P401 

Keck, Johannes ...................................Paper 542 

Keefer, Eric .......................................Paper 570 

Keel, Marius. ................................... Poster P038 

Keeling, John Joseph. ..............................Paper 705 

Keenan, Mary Ann E .......... Paper 279, 627, Poster P276, P308 

Keene, James S. ..................................Poster P412 

Keener, Jay D ......................Paper 086, 601, Poster P322 

Keeney, James A. ..................Paper 708, Poster P088, P126 

Kelem, Rose ......................................Paper 471 

Kelestemur, Mehmet Halidun ..................... Poster P560 

Kellam, James F. ..................................Paper 676 

Keller, Andres ...................................Poster P211 

Keller, Julie M ....................................Paper 723 

Kellett, Catherine .................................Paper 461 

Kelley, Todd ...........................Paper 194, Poster P142 

Kelly-Pettersson, Paula ............................Poster P512 

Kelly, Anne Mary. ............................... Poster P424 

Kelly, Bryan T. ..................... Paper 642, 644, Symposia J 

Kelly, Derek Michael ........... Paper 167, 403, 404, Poster P250 

Kelly, James D .................................. Poster P339 

Kelly, John D .....................................Paper 613 

Kelly, Matthew J .................Multimedia Education MEC36 

Kelly, Michael .................................. Poster P033 

Kelly, Michael A. .................................Symposia B 

author IndEx


Kelly, Natalie ..........................Paper 534, Poster P449 

Kelly, Sean .......................................Paper 147 

Kemp, Graham ..................................Poster P321 

Kemper, Dan ................................... Poster P496 

Kempton, Laurence. ............................. Poster P478 

Kendoff, Daniel. .......................Paper 248, Poster P092 

Kendrick, Benjamin JL .............................Paper 592 

Kenji, Oguro ................................... Poster P432 

Kennedy, John G ..................................Paper 097 

Kennedy, William R ...............................Paper 062 

Kenniston, Julia Anne. ........................... Poster P236 

Kenter, Keith ............Paper 076, 077, 078, 079, 080, 081, 082, 

083, 084, 085, 086, 087, 088, 089, 090 

Kenyu, Iwasaki ...................................Paper 308 

Keorochana, Gun .................................Paper 137 

Kephart, Curtis J .................................. Paper 210 

Kepler, Christopher. ..........Paper 269, 554, Poster P254, P369, 


Kercher, James ........................... Paper 200, 495, 574 

Kern, Brian Scott ..................................Paper 094 

Kertzner, Michael ......................Paper 074, Poster P067 

Keyes, David .....................................Paper 204 

Khair, Mahmoud Michael ........................ Poster P424 

Khakharia, Saurabh ...............................Paper 598 

Khalifa, Yaser Emam ............................. Poster P042 

Khalil, Jad .......................................Paper 230 

Khan, Bushra. ....................................Paper 471 

Khan, Shah Alam .................................Paper 237 

Khanna, A Jay .................... Scientific Exhibit SE36, SE62 

Khanna, Monica ..................................Paper 589 

Khanuja, Harpal Singh ..................Paper 299, Poster P016 

Khatod, Monti. ..................Paper 186, Poster P183, P198, 


Khatri, Dharmesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 720 

Khazzam, Michael S ....................Paper 157, Poster P520 

Khefacha, Ahmed ..........................Poster P120, P121 

Khodadadi, Akbar. ................................Paper 143 

Khoury, Amal ....................................Paper 139 

Khoury, Anthony. ............................... Poster P483 

Kibuule, Leonard K .............................. Poster P390 

Kienle, Karl-Philipp. ...............................Paper 542 

Kijek, Theresa ...................................Poster P312 

Kilic, Ayhan ......................................Paper 273 

Killeen, Kathleen. .................................Paper 358 

Kim, Cecilia E ....................................Paper 448 

Kim, David ......................................Paper 290 

Kim, Dong-Soo ..................................Poster P212 

Kim, Dongwook ................................ Poster P192 

Kim, Hee Joong. ..................................Paper 309 

Kim, Hubert T ................ Paper 161, Scientific Exhibit SE33 

Kim, Hye Ran ....................................Paper 153 

Kim, Hyeon Joo. ..................................Paper 631 

Kim, Hyun Min. ...........................Poster P313, P322 

Kim, Hyunchul ...............................Paper 694, 700 

Kim, Jae Kwang ...................Paper 335, Poster P230, P234 

Kim, Jaehon M ................................. Poster P206 

Kim, Jeffrey D .................................. Poster P190 

Kim, Jeong Suh ...................Paper 335, Poster P230, P234 

Kim, Joon Yub. ...................................Paper 153 

Kim, Joon-Hyung .................................Paper 269 

Kim, Jun Shik .........................Paper 181, Poster P001 

Kim, Jung Man ...............................Paper 152, 603 

Kim, Kang-Il .....................................Paper 418 

912 

Kim, Ki-Choul .........................Paper 472, Poster P017 

Kim, Paul D. ................................... Poster P303 

Kim, Paul R .................................... Poster P475 

Kim, Raymond H ..........................Poster P190, P191 

Kim, Sae Hoon ...................................Paper 153 

Kim, Seong Eun. ..................................Paper 021 

Kim, Seung-Ho ...................................Paper 583 

Kim, Stephen. ....................................Paper 534 

Kim, Sung-Hwan. .................................Paper 488 

Kim, Sung-Jae ....................................Paper 488 

Kim, Sun-Mi .....................................Paper 153 

Kim, Sunny H ....................................Paper 593 

Kim, Tae Kyun ...........................Paper 015, 329, 490, 

Poster P161, P167, P200, P272 

Kim, Tae-young ........................Paper 472, Poster P017 

Kim, Woo. .......................................Paper 673 

Kim, Yang-Soo. .......................... Paper 152, 153, 603 

Kim, Yong Sik ...................................Poster P051 

Kim, Yong-Min ..................................Poster P212 

Kim, Yong H .....................................Paper 262 

Kim, Yongjung J ..................................Paper 442 

Kim, Young-Hoo .......................Paper 181, Poster P001 

Kim, Young Jo ..........Paper 637, 639, Poster P059, P063, P077, 

Symposia J, ORSI 

Kimura, Atsushi. ..................................Paper 019 

Kimura, Hiroaki .............Poster P537, Scientific Exhibit SE83 

Kindsfater, Kirk ........................ Paper 071, Poster P191 

King, Akilah B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P348 

King, David M ................................Paper 231, 517 

King, Graham J W ............ Paper 678, 699, Poster P338, P343 

King, Joseph John .............................Paper 440, 519 

King, Tammy ................................... Poster P147 

Kinoshita, Kouichi ................Paper 041, Poster P047, P054 

Kinsella, Stuart D ..........................Poster P103, P173 

Kinsey, Tracy ......................Paper 003, 587, Poster P108 

Kiran, Amit .................................... Poster P327 

Singisetti, Kiran ...................................Paper 064 

Kirby, Jess McKarns .........................Poster P304, P473 

Kircher, Joern. .................................. Poster P328 

Kirkpatrick, Andrew ...............................Paper 517 

Kirk, Kevin L .....................................Paper 052 

Kirkpatrick, Kelley. ...............................Poster P104 

Kirkpatrick, Marcus. ............................. Poster P248 

Kirkwood, John M ................................Paper 239 

Kirmanj, Faraj ....................................Paper 356 

Kishida, Shunji ........................Paper 546, Poster P279 

Kisiday, John D ...................................Paper 159 

Kissenberth, Michael John ..........................Paper 373 

Kitay, Alison. ...........Scientific Exhibit SE34, SE50, SE64, SE82 

Kivirahk, Diana L .................................Paper 278 

Kiyama, Takahiko ..........................Poster P277, P366 

Klatt, Brian A ..............Paper 247, 617, 618, 618, Poster P119 

Klatt, Joshua .....................................Paper 175 

Klauser, Wolfgang .................................Paper 248 

Kleiber, Brian D. .................................. Paper 101 

Klein, Gregg R . . . . . . . . . . . . . . . . . . . . . . . . . Paper 293, Poster P057 

Klein, Sandra E ........................Paper 101, Poster P445 

Kleweno, Conor P. ................................Paper 639 

Klika, Alison K. ....................Paper 111, 600, Poster P096 

Klima, Matthew L ................................Poster P517 

Knavel, Erica ....................................Poster P412 

Knox, Jeffrey B. ................................. Poster P349 

Knupp, Markus ....................Paper 055, 059, Poster P209 

author IndEx


Ko, Jih-Yang. ....................................Poster P461 

Kobashi, Hiroaki. .................................Paper 277 

Kobayashi, Masaaki ...............................Paper 319 

Kobayashi, Naomi .........................Poster P049, P068 

Kobayashi, Tsutomu ........................Poster P267, P333 

Koc, Nursen. ................................... Poster P072 

Kocak, Tugrul. .................................. Poster P028 

Kocaoglu, Baris ..................................Poster P561 

Kocaoglu, Mehmet ......................Scientific Exhibit SE85 

Kocher, Mininder S ........Symposia R, Z, Paper 430, Poster P252 

Kodikal, Gautam. ................................Poster P416 

Koehler, Elizabeth A ...............................Paper 331 

Koehler, Steven ................................. Poster P378 

Koehnlein, Werner ................................Paper 183 

Koester, Linda A ..................................Paper 449 

Koethe, John ................................... Poster P137 

Koguchi, Atsushi ................................ Poster P432 

Koh, In Jun .............................Paper 015, 329, 490, 

Poster P161, P167, P200, P272 

Koh, Kyoung-Hwan ...............................Paper 683 

Koh, Young Do ...................Paper 335, Poster P230, P234 

Kohn, Joachim ................................. Poster P284 

Koike, Tatsuya ....................................Paper 506 

Koishi, Hayato. ..................................Poster P291 

Koizumi, Kota .................................. Poster P289 

Kok, Alison ..................................Paper 323, 481 

Kolb, Alexander. ..................................Paper 347 

Kolessar, David J ..................................Paper 716 

Kolowich, Patricia A ..............................Poster P307 

Komatsu, David E .................................Paper 288 

Komistek, Richard D. ..............Paper 292, Poster P197, P389 

Kon, Elizaveta ................ Paper 198, Scientific Exhibit SE61 

Konan, Sujith. ...................Paper 107, 620, 633, 636, 641, 


Konopka, Geoffrey ............................Paper 147, 273 

Koo, Kyung-Hoi .......................Paper 596, Poster P017 

Koo, Kyung Hoe ..................................Paper 472 

Kopansky-Giles, Deborah. ..........................Paper 457 

Koptan, Wael MT. ..........................Poster P360, P380 

Korin, Yael .............................Scientific Exhibit SE01 

Korkusuz, Feza ................................. Poster P072 

Korkusuz, Petek. ................................ Poster P072 

Kornblum, Martin B ............................. Poster P377 

Korotkova, Tatiana .............................. Poster P237 

Kosashvili, Yona .............Paper 251, 406, Poster P044, P062, 


Kose, Nusret. ................................... Poster P563 

Koseoglu, Resit Dogan ........................... Poster P560 

Kotilingam, Dhanasekaran. .........................Paper 213 

Kotwal, Prakash. .....................Paper 283, 340, 560, 569, 

Poster P232, P235, P305 

Kotwal, Suhel .................................. Poster P140 

Kotzamelos, Dimitrios .............................Paper 318 

Koueiter, Denise ................................ Poster P446 

Koutsoumbelis, Stelios A .......................Paper 738, 747 

Kovachevich, Rudy ................................Paper 133 

Kovacik, Mark W ........................Scientific Exhibit SE30 

Kowal, Jens ............................Scientific Exhibit SE13 

Kowalsky, Marc S. .................................Paper 086 

Koyonos, Loukas ................................ Poster P186 

Kolar, Milan. ....................................Poster P131 

Kozich, Jeanine ...................................Paper 401 

Kozin, Scott H ................................Symposia D, R 

913 

Kraay, Matthew J ........Paper 241, 242, 243, 244, 245, 246, 247, 

248, 249, 250, 251, 252, 253, 254, 255 

Krag, Martin Hans. ................................Paper 258 

Kragh, John F. ...................................Poster P510 

Kramer, Patricia. .................................Poster P210 

Kraska, Nadine ...................................Paper 193 

Krasnokutsky, Svetlana ........................... Poster P138 

Kraszewski, Andrew ...............................Paper 558 

Kraus, Virginia Byers ..............................Poster P501 

Krcik, James A .................................. Poster P252 

Krebs, Viktor Erik ..........................Poster P096, P154 

Kregor, Philip James ...............................Paper 221 

Kreofsky, Cole Robert ..............................Paper 087 

Kreshak, Jennifer ..............................Paper 433, 511 

Krieg, James C .................................. Poster P470 

Krishnan, Sumant G ..............Multimedia Education MEC31 

Krishnaney, Ajit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 267 

Krismer, Martin ...........Multimedia Education MEC10, MEC11 

Krueger, Chad A ...........................Poster P180, P304 

Kruse, Lisa M ................................... Poster P322 

Krych, Aaron J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 660 

Krywicki, William J ................................Paper 716 

Kubiak, Erik. .....................Paper 734, Poster P030, P496 

Kubo, Tadahiko. ...........................Poster P524, P528 

Kubo, Toshikazu ..................................Paper 277 

Kuhl, Mitchell D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P487 

Kuhn, John E ....................................Poster P319 

Kuklis, Matt .................................... Poster P154 

Kulkarni, Abhaya V ................................Paper 630 

Kulkarni, Sachin ................................ Poster P260 

Kumar, Ashok ....................................Paper 237 

Kumar, Vijay ..............Paper 355, 474, 710, 720, Poster P489 

Kume, Kensuke ...................................Paper 272 

Kunkel, Sanford S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P153 

Kurata, Tsutomu ................................ Poster P432 

Kurd, Mark F ................................... Poster P385 

Kurdziel, Michael ............................... Poster P345 

Kuroda, Daisuke ...........................Poster P047, P054 

Kurtz, Anton .....................................Paper 258 

Kurtz, Steven M ............... Paper 212, 293, 480, Poster P114, 


Kurtz, William B ..................................Paper 353 

Kurylo, John ................................... Poster P469 

Kushner, Harvey ................................ Poster P240 

Kuye, Ifedayo ....................Multimedia Education MEC03 

Kuzyk, Paul Robert ................................Paper 306 

Kwak, Steve ......................................Paper 094 

Kweon, Seok-hyun ................................Paper 309 

Kwon, John Y ...................................Poster P218 

Kwon, Michael Soon. ..........................Paper 172, 173 

Kwon, Sae Kwang .................................Paper 015 

Kwon, Soon Yong ................................Poster P051 

Kwon, Young-Min ......................Paper 300, Poster P015 

Kwon, Young W. ................Multimedia Education MEC40, 


Kyoung Min, Lee ..............................Paper 095, 547 

Labarca, Gonzalo ................................Poster P211 

Labianca, Luca. ..................Multimedia Education MEC26 

Labib, Sameh A ................................. Poster P170 

Lachiewicz, Paul F. ...................Paper 246, Symposia E, V 

Lackie, Debra. ...................................Poster P481 

Lackman, Richard D ..Paper 514, 515, 519, Poster P521, P530, P532 

Ladd, Amy L ........................Poster P227, Symposia O 

author IndEx


Lador, Rani ..................................Paper 028, 721 

Lafage, Virginia ........................Paper 441, Poster P394 

Laflamme, George Yves. .......................... Poster P475 

Lafosse, Laurent. ................................Symposia M 

Lage, Daniel. ................................... Poster P270 

Laible, Catherine N. ............................. Poster P472 

Lakstein, Dror .........................Paper 251, Poster P044 

Lali, Ferdinand ...................................Paper 068 

Lam, Patrick H. ..................Multimedia Education MEC36 

Lamont, Lauren Elizabeth ..........Scientific Exhibit SE34, SE50, 

SE64, SE82 

Lamontagne, Mario. ............................. Poster P083 

Lancaster, Gerard F .............................. Poster P320 

Lancianese, Sarah L. .....................Scientific Exhibit SE29 

Landgraeber, Stefan. ............................. Poster P066 

Landis, William J. ..........................Poster P249, P256 

Landon, Glenn C .........Paper 706, 707, 708, 709, 710, 711, 712, 

713, 714, 715, 716, 717, 718, 719, 720 

Lane, Joseph M ...........Paper 226, 313, Scientific Exhibit SE82 

Lange, Jeffrey K ............................Poster P353, P356 

Langfitt, Maxwell K ................................Paper 380 

Langton, David ...... Paper 032, 038, 064, 069, Poster P071, P074 

Lansford, Todd Joseph .............................Paper 670 

Lansky, David ...................................Symposia F 

Lantry, Jacob ....................................Poster P109 

Lanzi, Joseph T ...................................Paper 432 

Lanzinger, William .............................. Poster P495 

Lapinsky, Anthony S ............................. Poster P353 

Lapner, Peter .................................Paper 076, 154 

LaPorte, Dawn. ................................. Poster P278 

LaPrade, Robert F .......Paper 196, 197, 198, 199, 200, 201, 202, 

203, 204, 205, 206, 207, 208, 209, 210 

Lara, Joaquin ....................Multimedia Education MEC01 

LaReau, Justin M ..................................Paper 597 

Lark, Robert Kamiel ....................Paper 389, Poster P245 

LaRose, Connor Raymond ........................ Poster P342 

Larson, Annalise Noelle . . . . . . . . . . . . . . . Paper 172, 173, 544, 545 

Larson, Christopher .....................Paper 646, Symposia J 

Lassiter, Tally E ...................................Paper 493 

Latona, Carmen. ..................................Paper 677 

Latta, Loren L. ........................Poster P293, P334, P483 

Latteier, Michael J .......................Scientific Exhibit SE07 

Lau, Edmund. .....................Paper 212, 480, Poster P114, 


Lauing, Kristen ...................................Paper 140 

Laurencin, Cato T .................................Paper 163 

Lavernia, Carlos J .................Paper 717, Poster P026, P102, 

P147, P152, Symposia E 

Lawhorn, Keith W .......Paper 631, 632, 633, 634, 635, 636, 637, 

638, 639, 640, 641, 642, 643, 644, 645 

Lawrence, J. Todd R. .............Multimedia Education MEC24, 


Lawson, Bryan K ..................................Paper 696 

Le Duff, Michel Jean ...............................Paper 045 

Le, Jason T .......................................Paper 027 

Leaver, Ryan W ..................................Poster P417 

Lebl, Darren R .................................. Poster P355 

LeBrun, Christopher T .............................Paper 698 

LeClere, Lance E .................Multimedia Education MEC35 

Leduc, Stephane ................................ Poster P475 

Lee, Arthur T ..............................Poster P219, P227 

Lee, Choon-Ki ....................................Paper 026 

Lee, Choong-Hee. ................................Poster P451 

914 

Lee, Chung-Chien .................................Paper 274 

Lee, Donald H ....................................Paper 331 

Lee, Dong-Ho .....................Paper 022, 030, Poster P400 

Lee, Elaine ..................................... Poster P393 

Lee, Eric K ..................................... Poster P242 

Lee, Gwo-Chin Paper 243, 325, 453, Poster P103, P122, P169, P173 

Lee, Gye Wang ....................................Paper 475 

Lee, Ho Hyung ................................. Poster P096 

Lee, Hyun-Il. .....................................Paper 063 

Lee, Hyun-Joo .............................Poster P258, P480 

Lee, Hyung-joon .................................Poster P212 

Lee, Jae Young ...................................Poster P051 

Lee, Joe. .........................................Paper 233 

Lee, Jonathan H. ...........................Poster P024, P084 

Lee, Joon Kyu. ... Paper 010, 011, 320, 322, 326, Poster P178, P192 

Lee, Joon Yung. ........................Paper 023, Poster P362 

Lee, Kenny Won Jae. ............................. Poster P200 

Lee, Keun Bae .................................. Poster P029 

Lee, Ki Seok ......................................Paper 550 

Lee, Kil Jae ....Paper 015, 329, 490, Poster P161, P167, P200, P272 

Lee, Kwang-Bok. ..........................Paper 016, 137, 663 

Lee, Kyung-Hag .....Paper 015, 329, 490, Poster P161, P200, P272 

Lee, Kyung-Jae .....................Paper 309, 374, Poster P318 

Lee, Lorrin SK ....................................Paper 177 

Lee, Myung Chul. Paper 010, 011, 320, 322, 326, Poster P178, P192 

Lee, Paul T H ....................................Poster P111 

Lee, Sahnghoon. . Paper 010, 011, 320, 322, 326, Poster P178, P192 

Lee, Sang Hak ....................................Paper 489 

Lee, Sang-Min ... Paper 010, 011, 320, 322, 326, Poster P178, P192 

Lee, Seung Yup ...................Paper 335, Poster P230, P234 

Lee, Stella. .......................................Paper 695 

Lee, Steve K ...........................Paper 565, Poster P324 

Lee, Sung-Yoon ..................................Poster P318 

Lee, Thay Q ...........................Paper 689, Poster P326 

Lee, Tong Joo .....................................Paper 475 

Lee, Woo Suk. .................................. Poster P055 

Lee, Young-Kyun ......... Paper 374, 472, 596, Poster P017, P318 

Lee, Yun-Kyoung ..............................Paper 152, 603 

Leeson, Mark C ................................. Poster P495 

Leet, Arabella I. ...............Paper 180, Scientific Exhibit SE40 

Lefloch, Sean .....................................Paper 738 

Lehman, Ronald Arthur ....................Paper 017, 443, 669 

Leighton, Ross K ........Paper 061, 062, 063, 064, 065, 066, 067, 

068, 069, 070, 071, 072, 073, 074, 075, 

376, 377, 378, 379, 380, 381, 382, 383, 

384, 385, 386, 387, 388, 389, 390 

Leinberry, Charles F ...............................Paper 562 

Leiter, Jeff. .......................................Paper 154 

Leithner, Andreas ............................... Poster P543 

Leitman, Elliott H .......................Scientific Exhibit SE47 

LeMarr, Angela ...................................Paper 291 

Lemaster, Tom E ..................................Paper 169 

Lemma, Mesfin A ............................... Poster P278 

Lemons, Jack E .........................Scientific Exhibit SE84 

Lemos, Stephen E ............................... Poster P320 

Lenarz, Christopher J ..........................Paper 082, 090 

Lenhart, Martha K .......................Scientific Exhibit SE75 

Lenhoff, Mark ....................................Paper 558 

Lenke, Lawrence G ...............Paper 396, 442, 446, 449, 671, 

Poster P382, P392, Symposia T 

Leo, Roorda ......................................Paper 616 

Leonard, James Patrick ........................... Poster P455 

Leonards, James .................................. Paper 111 

author IndEx


Leonetti, Danilo ......Multimedia Education MEC21, Poster P220 

Leopold, Seth S ...................................Paper 454 

Lerman, Daniel M. ................................Paper 694 

Lerner, Benjamin A. ......Multimedia Education MEC08, MEC46, 

MEC47, MEC48, MEC49, MEC50, 

MEC51, MEC52, MEC53 

Lertwanich, Pisit .......................Paper 552, Poster P407 

Lesko, James .....................................Paper 071 

Lesniak, Bryson .........................Scientific Exhibit SE72 

Letson, G Douglas. ....Paper 240, 516, 520, Scientific Exhibit SE81 

Leunig, Michael. ........................Paper 634, Symposia J 

Levack, Brian .....................................Paper 462 

Leversedge, Fraser J ......Paper 331, 332, 333, 333, 334, 335, 336, 

337, 338, 339, 340, 341, 342, 343, 344, 345 

Levi, Gabriel .....................................Paper 294 

Levin, Paul. ........Paper 136, 137, 138, 139, 140, 141, 142, 143, 

144, 145, 146, 147, 147, 148, 149, 150 

Levine, Brett Russell ................Paper 187, 714, Poster P057 

Levine, David S ...................................Paper 102 

Levine, Harlan B .......................Paper 293, Poster P057 

Levine, William N .......Paper 366, 607, Poster P344, Symposia H 

Levison, Timothy J ......................Scientific Exhibit SE48 

Levitz, Seth .................................... Poster P324 

Levy, Bruce A ............ Paper 051, 316, 317, 318, 319, 320, 321, 

322, 323, 324, 325, 326, 327, 328, 329, 

330, 485, 660, Poster P097, P443 

Levy, David ......................................Paper 457 

Levy, Jonathan Chad. .......................Poster P287, P287 

Lewallen, David G. ...................Paper 014, Symposia E, V 

Lewing, Nicholas. ............................... Poster P356 

Lewis, Courtland G ................................Paper 303 

Lewis, Gregory S ..............................Paper 174, 206 

Lewis, John Strudwick ..................Paper 389, Poster P501 

Lewis, Paul B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 495 

Lewis, Valerae O .............. Paper 525, Scientific Exhibit SE81 

Lewitus, Dan ................................... Poster P284 

Li, Bing. .........................................Paper 379 

Li, Guoan. ...................................Paper 295, 300 

Li, Rachel W. ................................... Poster P522 

Li, Robert .......................................Poster P215 

Li, Ru .......................................Paper 141, 149 

Li, Xin. ...........................Paper 514, 515, Poster P532 

Li, Yi-Chen. ..................................Paper 274, 500 

Li, Zhongyu John .................................Paper 567 

Liang, Sherry ................................... Poster P138 

Liao, Jen-Chung ..................................Paper 137 

Libanati, Cesar. ...................................Paper 226 

Lichtenberg, Sven ............................... Poster P328 

Lieber, Richard L ..............................Paper 550, 556 

Liebergall, Meir ...............................Paper 139, 667 

Lieberman, Isador H. .................. Paper 267, Symposia W 

Lieberman, Jay R ............Paper 039, Poster P088, Symposia E 

Lieberman, Jeremy A. ............................ Poster P404 

Liebs, Thoralf R ................................. Poster P285 

Lien, John .......................................Paper 224 

Light, Terry R ...........Paper 556, 557, 558, 559, 560, 561, 562, 

563, 564, 565, 566, 567, 568, 569, 570 

Lillmars, Steven A .................................Paper 716 

Lim, Byung-Ho ...................................Paper 063 

Lim, Kerry ..................................... Poster P002 

Lim, Letitia ......................................Paper 185 

Lim, Moojoon ....................................Paper 317 

Lim, Seung-Jae. ...................................Paper 063 

915 

Lim, Tae Kang ....................................Paper 683 

Lim, Young Wook ................................Poster P051 

Lin, Edward ..................................Paper 144, 565 

Lin, Hui-Wen. .................................. Poster P157 

Lin, Michael Y ................................Paper 557, 564 

Lin, Patrick P .....................................Paper 525 

Lindbom, Daniel. ................................Poster P512 

Lindsey, Derek P ..................Paper 582, Poster P219, P227 

Line, Breton G .................................. Poster P394 

Lingard, Elizabeth Anne .......................... Poster P064 

Lingg, Moi-Lin. ................................. Poster P159 

Link, Thomas. ....................................Paper 573 

Linklater, James. ..................................Paper 323 

Linovitz, Raymond J ...............................Paper 672 

Lippert, William ..................................Paper 628 

Lisowski, Andrzej ......................Paper 008, Poster P113 

Lisowski, Lukas ........................Paper 008, Poster P113 

Litchfield, Robert B .............................. Poster P337 

Little, Chris .................................... Poster P389 

Little, Kevin James. ................................Paper 429 

Liu, Bin .........................................Paper 655 

Liu, Chuan-ju ....................................Paper 144 

Liu, Fang ...................................... Poster P206 

Liu, Raymond .....................Paper 179, 378, Poster P247 

Liu, Sen .........................................Paper 209 

Liu, Shing-Hwa ................................. Poster P529 

Liu, Steve S. ......................................Paper 004 

Liu, Wanjun. ................................... Poster P206 

Liu, Xuhui .......................................Paper 161 

Liublinska, Victoria. ............................. Poster P023 

Llado, Roald Jon ..................................Paper 440 

Lo, Joan C .............................Scientific Exhibit SE76 

Lo, Ngai-Nung. ...........Paper 012, 408, 417, Poster P112, P159 

Lock, Terrence R .................................Poster P307 

Loftus, Randy W ..................................Paper 744 

Logishetty, Rajani .................................Paper 069 

Lohmander, Stefan .............................. Poster P133 

Loiseau, Christine ............................... Poster P003 

Lombardi, Adolph V......Paper 061, 298, 538, Poster P203, P204, 

Scientific Exhibit SE07, Symposia B, P 

Longo, Umile Guiseppe ........................Paper 156, 578 

Lonner, Baron .....................Paper 262, 436, Poster P371 

Lonner, Jess H ........................Poster P127, Symposia P 

Lopomo, Nicola .............Poster P414, Scientific Exhibit SE24 

Lord, James .................................... Poster P074 

Lorich, Dean G ...................................Paper 724 

Losina, Elena .................................Paper 184, 286 

Lotke, Paul A . . . . . . . . . . . . . . . . . . . . .Paper 243, Poster P122, P169 

Lovald, Scott Traver. ............................. Poster P403 

Lowder, Elizabeth ............................... Poster P249 

Lowman, Anthony .............................. Poster P449 

Lozano Calderon, Santiago A. . . . . . . . . . . . . . . . . Poster P215, P217 

Lu, Zhen. ........................................Paper 035 

Lubbeke-Wolff, Anne ..........................Paper 091, 183 

Lucas, Brennen L ..................................Paper 369 

Lucas, Justin. .....................................Paper 209 

Luciani, Deianira. .............................Paper 093, 510 

Luhmann, Scott J. .................................Paper 446 

Lujan, Trevor .....................................Paper 702 

Luna, Daniel Pizarro. ..............................Paper 654 

Luna, Jeffrey TP.. .......................Paper 538, Poster P545 

Lundy, Douglas W. ......................Scientific Exhibit SE47 

Lurie, Jon D ...........................Paper 270, Poster P361 

author IndEx


Luther, Gaurav Aman ..............................Paper 518 

Luu, Hue H ...........................Paper 518, Poster P536 

Lybrand, Kyle. .................................... Paper 310 

Lyman, Stephen ......Paper 083, 287, 595, 658, 659, Poster P139 

Lynch, Scott A ....................................Paper 013 

Lyon, Russ ..................................... Poster P404 

Lyons, Steven Thomas ........................... Poster P147 

Ma, ChunBong Benjamin. ..........................Paper 573 

Ma, Yan ..........................Paper 535, 658, Poster P449 

Maak, Travis G. .........Scientific Exhibit SE49, SE55, SE63, SE67 

Macaulay, William B ....................Paper 303, Symposia P 

Maccagnan, Elena ................................Poster P012 

MacDermid, Joy C. .................Paper 678, 699, Poster P338 

MacDonald, Daniel ...............................Paper 293 

Macdonald, David ...............................Poster P110 

MacDonald, Peter Benjamin ........................Paper 154 

MacDonald, Steven J. ..................Poster P056, Symposia B 

MacGillivray, John Dougald. ...Poster P415, Scientific Exhibit SE50 

Machen, Michael Shaun .......................... Poster P406 

Mackay, Nicola ...................................Paper 461 

MacKenzie, John D .............................. Poster P253 

Maddox, Grady ...................................Paper 473 

Madey, Steven Michael .............................Paper 702 

Maduekwe, Uma ........................Scientific Exhibit SE22 

Maeda, Takeshi ................................. Poster P350 

Maeda, Toru. ................................... Poster P007 

Maenza, Ruben . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 400 

Maerz, Tristan ........................Poster P390, P446, P448 

Maeyama, Akira. ...........................Poster P277, P407 

Maffulli, Nicola. ......................... Paper 156, 575, 578 

Magattil, Rajesh. ................................ Poster P426 

Magaziner, Jay ....................................Paper 303 

Magosch, Petra ................................. Poster P328 

Maguire, Kathleen ............................... Poster P243 

Magyar, Clara. ..........................Scientific Exhibit SE01 

Mahajan, John. ...................................Paper 171 

Mahboubian, Shahab ..............................Paper 313 

Maher, Suzanne A ............................... Poster P449 

Maheshwari, Rohit ................................Paper 249 

Mahfouz, Mohamed. .................. Paper 292, Poster P389, 


Mahmoud, Mostafa ..................Paper 282, 336, 338, 339 

Mahomed, Nizar. ..................Paper 289, 589, Poster P177 

Mahoney, Ormonde M. ..Paper 003, 587, Poster P108, Symposia B 

Mai, Kenny .................................... Poster P124 

Majewski, Martin ................................Poster P431 

Makowski, Anna Lena. .............................Paper 559 

Malawer, Martin M ..............Multimedia Education MEC49, 

MEC50, MEC51 

Malchau, Henrik ............ Paper 082, 184, 348, 530, 533, 704, 

Poster P015, P025, P035 

Malerich, Matthew M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 337 

Maletis, Gregory B. .....................Paper 492, Poster P413 

Maley, Margaret M .............................Symposia 150 

Malhotra, Rajesh ...........Paper 355, 474, 710, 720, Poster P489 

Malinzak, Robert Andrew. ......................Paper 130, 413 

Malkani, Arthur L .......Paper 190, 212, 245, 586, 587, 588, 589, 

590, 591, 592, 593, 594, 595, 596, 597, 598, 599, 600, Poster P109, 

P114, Scientific Exhibit SE77 

Maloney, William J ............Paper 042, 586, 718, Poster P126, 

Symposia F, ORSII 

Malvitz, Thomas A ...... Paper 001, 002, 003, 004, 005, 006, 007, 

008, 009, 010, 011, 012, 013, 014, 015 

916 

Malviya, Ajay .............................. Poster P064, P071 

Mamisch, Tallal C ........Paper 542, Poster P077, Symposia ORSI 

Mandell, Peter J. .................................Symposia S 

Manfrini, Marco .................................. Paper 511 

Mangold, Devin R. ................................Paper 056 

Mann, Gideon. ...................................Paper 659 

Mann, Jeffrey Adam ...............................Paper 056 

Mann, Roger A. ...................................Paper 056 

Mannava, Sandeep ......................Scientific Exhibit SE31 

Manning, David W .............................. Poster P166 

Manolescu, Andrei .............................. Poster P086 

Manson, Theodore T. ..................... Paper 222, 698, 735 

Manuel, Jacob B .......................Paper 595, Poster P014 

Manzano, Givenchy ...............................Paper 161 

Maples, Dayle L. ..................................Paper 541 

Maran, Nidu .....................................Paper 018 

Marburger, Robert .................................Paper 725 

Marcacci, Maurilio .....................Paper 198, Poster P414, 


Marcantonio, Andrew J. .......................... Poster P034 

Marcantonio, David ...............................Paper 204 

March, Gerard ....................................Paper 359 

Marcheggiani Muccioli, Giulio ....................Poster P414, 


Marchi, Luis. ...............Paper 736, Poster P373, P375, P379 

Marcus, Randall Evan ..............................Paper 456 

Mardones, Rodrigo M. ........................... Poster P453 

Marecek, Geoffrey ..........................Poster P069, P175 

Margolis, David Stephen ...........................Paper 136 

Marinac-Dabic, Danica. ............................Paper 186 

Marinelli, Alessandro ....................Scientific Exhibit SE54 

Marini, Eleonora ........................Scientific Exhibit SE51 

Marion, Chad ....................................Paper 607 

Mariscalco, Michael W .............................Paper 267 

Markel, David C .......................Paper 629, Poster P320 

Marker, David R ........................Scientific Exhibit SE19 

Markiewitz, Andrew David. ...............Scientific Exhibit SE47 

Marks, Barbara ...............................Paper 415, 531 

Marks, Michelle. .................................Poster P371 

Marks, Timothy ...................................Paper 103 

Marlet, Victoriano .................................Paper 109 

Marmor, Meir Tibi. .................Paper 215, 217, Poster P492 

Marmotti, Antongiulio ...........Multimedia Education MEC22, 

Paper 207, Scientific Exhibit SE65 

Marsh, John Lawrence .....Paper 455, 702, Scientific Exhibit SE79 

Martell, John M. ............Paper 637, Poster P025, P059, P063 

Martin, Ashley J. ................................ Poster P089 

Martin, James A. ..................................Paper 207 

Martin, Sadie .....................................Paper 278 

Martin, Scott David. ...........................Paper 639, 655 

Martin, Tamara Lynn ....................Scientific Exhibit SE46 

Martin, William. .................................Symposia S 

Martinez-Martos, Sara. ..................Paper 109, Poster P352 

Martini, Rodrigo Klafke ............................Paper 509 

Martins, Jeffrey Dean ............................ Poster P293 

Maruo, Keishi .................................. Poster P354 

Marvin, Julianne ................................ Poster P357 

Marwah, Simran ................................ Poster P503 

Marx, Robert G . . Paper 083, 287, 658, 659, Scientific Exhibit SE64 

Mary, Michelle. ...................................Paper 288 

Masada, Kazuhiro .................................Paper 345 

Mashfiqul, AS M ................................ Poster P159 

Masini, Brendan David. .....................Poster P462, P502 

author IndEx


Mason, Edward O .................................Paper 431 

Mason, James ....................................Paper 150 

Mason, James ....................................Paper 536 

Masri, Bassam A ...................Paper 073, 349, Poster P105 

Masse, Alessandro ................Multimedia Education MEC27 

Masseth, Robyn. ................................ Poster P557 

Massey, Patrick Allen. ..............................Paper 668 

Massini, Michael ..................................Paper 245 

Masuda, Koichi ........................Paper 664, Poster P393 

Matamalas, Antonia ............................. Poster P352 

Matassi, Fabrizio .................................Poster P061 

Matey, Doug ................................... Poster P257 

Matharu, Gulraj. ...................Paper 036, 188, Poster P006 

Matheney, Travis H ............................Paper 168, 170 

Mather, Richard C ................Paper 493, Poster P341, P342, 


Mathews, Vasilios ............................... Poster P005 

Mathis, Kenneth B. .............................. Poster P009 

Mathur, Sameer...................................Paper 742 

Matityahu, Amir ...................Paper 215, 217, Poster P492 

Matre, Kjell ...............................Poster P497, P500 

Matsen, Frederick A. ..................Poster P294, Symposia M 

Matsubara, Hidenori. ..........................Paper 235, 386 

Matsuda, Dean K. ...............Multimedia Education MEC45, 

Paper 631, 632, 633, 634, 635, 636, 637, 

638, 639, 640, 641, 642, 643, 644, 645 

Matsuda, Shuichi .................Paper 414, Poster P150, P168 

Matsudaira, Ko ............................Poster P174, P490 

Matsuo, Toshihiro. .........................Poster P524, P528 

Matsuoka, Masatake ...............................Paper 321 

Matsushita, Takashi. ............................. Poster P432 

Matthies, Ashley ......................... Paper 033, 067, 068 

Matullo, Kristofer S. ............................. Poster P226 

Matzkin, Elizabeth G ..............................Paper 330 

Mauprivez, Raphael ............................. Poster P037 

Mauro, Craig S ...................................Paper 327 

Mavridis, Konstantinos. .......................... Poster P188 

Mavrogenis, Andreas. ............................ Poster P539 

May, Megan ......................................Paper 484 

Mayer, Mark. ................................... Poster P448 

Mayer, Michael ...................................Paper 203 

Mayerson, Joel. ...Paper 511, 512, 513, 514, 515, 516, 517, 518, 519, 

520, 521, 522, 523, 524, 525, Poster P525 

Mayle, Robert E ..................................Poster P391 

Mayman, David Jacob ........................... Poster P162 

Mayor, Michael B .................. Paper 296, 711, Poster P151 

Mazza, Jason S. ................................. Poster P558 

McAdams, Timothy R ..............................Paper 582 

McAnany, Steven ..................................Paper 741 

McAndrew, Mark Philip ...........................Poster P271 

McAsey, Craig Joseph ..............................Paper 640 

McCalden, Richard W. ........................... Poster P056 

McCall, Richard Evan ..............................Paper 668 

McCarthy, Edward F ...............................Paper 745 

McCarthy, James J ............Scientific Exhibit SE39, Symposia R 

McCarthy, Joseph C ...........................Paper 040, 463 

McCarthy, Moira Margaret ..........Scientific Exhibit SE34, SE50, 

SE64, SE82 

McCarthy, Richard E ............................. Poster P255 

McCarty, Leroy Pearce. .............................Paper 576 

McClellan, Robert Trigg ....... Paper 029, 444, Poster P387, P492 

McClung, Anna ...................................Paper 399 

McCLURE, Scott ..................................Paper 146 

917 

McCollom, Vance .................................Paper 672 

McCollum, Jody ................................ Poster P269 

McCormack, Richard A. ............................Paper 113 

McCormick, Frank ................................Paper 639 

McCormick, Jeremy J ...................Paper 101, Poster P445 

McCrum, Christopher. .........................Paper 090, 363 

McCullough, Kirk A ....................Paper 743, Poster P362 

McDonald-Blumer, Heather. ........................Paper 457 

McDonald, Erik. ..............................Paper 215, 217 

McDonald, Lucas .......................Scientific Exhibit SE53 

McDonough, E Barry .............Multimedia Education MEC17 

McFarland, Edward G ............................ Poster P292 

McFeely, Eric D ................................. Poster P252 

McGarry, Michelle H. ............................ Poster P326 

McGill, Kevin C. ......................... Paper 160, 367, 609 

McGinnis, Mark ................................ Poster P423 

McGlaston, Tim James ..................Paper 117, Poster P263 

McGough, Richard Louis .......................Paper 239, 247 

McGrail, Linda ...................................Paper 716 

McGuire, Ciara Megan ............................Poster P419 

McHale, Kathleen A .....................Scientific Exhibit SE75 

McIff, Terence ....................................Paper 670 

McIlroy, Jody .....................................Paper 457 

McInnes, Iain B ...................................Paper 682 

McIntyre, Louis F. ................................Symposia X 

McKee, Michael D ...............................Symposia H 

McKeon, Kathleen E ............................. Poster P445 

McLardy-Smith, Peter .......... Paper 531, Scientific Exhibit SE06 

McLaren, Alexander C. .............................Paper 653 

McLawhorn, Alexander Stewart ......................Paper 290 

McLemore, Ryan ..................................Paper 653 

McMillan, James F. .............................. Poster P086 

McNally, Thomas A. .....Paper 736, 737, 738, 739, 740, 741, 742, 

743, 744, 745, 746, 747, 748, 749, 750 

McPhail, Gary L. .......................Paper 450, Poster P384 

McPherson, Edward J ..............Paper 061, Poster P013, P128 

McPherson, Laura ..........................Poster P013, P128 

McQueen, Margaret M ........................... Poster P504 

McRae, Sheila ....................................Paper 154 

McDermott, James D ............................ Poster P385 

McSweeney, Sean .................................Paper 589 

McWilliam, James R ........................ Poster P215, P217 

Mead, Nelson ....................................Paper 209 

Mears, Simon ....................................Paper 299 

Medige, John ................................... Poster P179 

Meding, John B .....Paper 130, 413, 526, 527, 528, 529, 530, 531, 

532, 533, 534, 535, 536, 537, 538, 539, 540 

Medoff, Robert J ..................................Paper 333 

Medvecky, Michael .............................. Poster P304 

Meehan, John Patrick ..............................Paper 593 

Meek, Dominic ................................. Poster P074 

Meere, Patrick A. .................Multimedia Education MEC06 

Meermans, Geert. ......................Paper 341, Poster P437 

Meftah, Morteza ......Paper 416, 570, 634, Scientific Exhibit SE27 

Mehbod, Amir A ..................................Paper 748 

Mehle, Susan Clay. ............................Paper 358, 588 

Mehlman, Charles T ................Paper 169, 628, Poster P257 

Mehmood, Shahid .............................. Poster P145 

Mehr, David R ....................................Paper 302 

Mehta, Samir ............Paper 219, 627, 726, Poster P308, P464, 


Meislin, Robert J .................Multimedia Education MEC37 

Melis, Barbara ................................Paper 361, 362 

author IndEx


Meliton, Vicente ..............................Paper 673, 674 

Meller, Isaac. ................................... Poster P540 

Mellon, Stephen J ............................... Poster P187 

Memtsoudis, Stavros G. ........................Paper 290, 535 

Mende, Katrin .................................. Poster P180 

Menendez, Lawrence R. ............................Paper 228 

Mennaer, Brandon .............................. Poster P087 

Mentch, Frank D ..................................Paper 448 

Mercer, Deana .................................. Poster P294 

Mercincavage, Michael .............................Paper 219 

Mercuri, Mario ............Paper 240, 433, 511, 520, Poster P539 

Mereddy, Praveen .................................Paper 064 

Merono, Antonio ............................... Poster P008 

Mesfin, Addisu ...................Paper 745, Poster P278, P383 

Meskey, Thomas ..................................Paper 735 

Mesko, J Wesley. ........Paper 181, 182, 183, 184, 185, 186, 187, 

188, 189, 190, 191, 192, 193, 194, 195 

Messina, Adam ...................................Paper 701 

Metkar, Umesh ................................. Poster P355 

Metzger, Paul D. ................................ Poster P427 

Meyer, Dominik Christoph .........................Paper 151 

Meyer, Robert Scott ................................Paper 065 

Meyer, Susan .....................................Paper 632 

Meyers, Kathleen. .................................Paper 499 

Micera, Giovanni. ................................Poster P012 

Michael, Andrew W ...........................Paper 123, 182 

Michaelson, Jefferey E. ........................... Poster P320 

Michaelsson, Karl .................................Paper 264 

Michaud, Linda J. .................................Paper 628 

Micheli, Lyle J ...................................Symposia Z 

Michels, Elisabeth ............................... Poster P478 

Michels, Ryan F ...............................Paper 113, 715 

Miclau, Theodore ...Paper 136, 137, 138, 139, 140, 141, 142, 143, 

144, 145, 146, 147, 148, 149, 150, Symposia W 

Middeldorp, Saskia ................................Paper 253 

Middleton, Fiona .................................Paper 135 

Middleton, Scott ................................ Poster P504 

Middleton, William D ............................Poster P313 

Mignemi, Megan. .................................Paper 331 

Mihalko, William Michael .....Paper 131, 288, Poster P149, P179, 


Miki, Hidenobu ................................ Poster P053 

Milbrandt, Joseph C ...............................Paper 062 

Milbrandt, Todd A. ............................Paper 424, 445 

Milby, Andrew Hill ................................Paper 325 

Millar, Neal L. ....................................Paper 682 

Moller-Madsen, Bjarne .............................Paper 434 

Miller, Bruce S ...................................Poster P312 

Miller, Daniel James . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 397 

Miller, Freeman ...................................Paper 423 

Miller, Geraldine ................................ Poster P137 

Miller, Lisa ...................Paper 528, 712, Poster P041, P043 

Miller, Mark C ................................Paper 677, 685 

Miller, Mark D. ................................ Symposia BB 

Miller, Matthew D. ................................ Paper 411 

Miller, Micah ....................................Poster P516 

Miller, Robert Andrew. .............................Paper 119 

Miller, Stuart D .........Paper 496, 497, 498, 499, 500, 501, 502, 

503, 504, 505, 506, 507, 508, 509, 510 

Millett, Peter J ..................Multimedia Education MEC32, 

MEC33, MEC34, Poster P336 

Millis, Michael B ...........................Poster P059, P063 

Milne, Edward L ...........................Poster P334, P483 

918 

Min, Byung Woo .................................Poster P318 

Min, Kyong Su. ...................................Paper 571 

Minoda, Yukihide ................................Poster P115 

Miquel, Joan .....................................Paper 109 

Mirza, Amer J. .........................Paper 377, Poster P464 

Mirza, Faisal .....................................Paper 657 

Miscione, Maria Teresa Multimedia Education MEC02, Poster P220 

Mitchell, Adam .........................Scientific Exhibit SE03 

Mitchell, Joseph W .............................. Poster P389 

Mitsugi, Naoto ................................. Poster P268 

Mitsui, Hiroto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P239 

Mitsunari, Kim ................................. Poster P125 

Mitsuyasu, Hiroaki .....................Paper 414, Poster P168 

Miwa, Shinji .....................................Paper 235 

Miyao, Masunao . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Poster P261 

Mizuuchi, Hideki ..........................Poster P150, P196 

Mochida, Yuichi ................................ Poster P268 

Mococain, Pablo .................................Poster P211 

Moed, Berton R ....................Paper 214, 216, Poster P468 

Mohamed, Ahmed Salem. .........................Poster P401 

Mohamed, Saqr. ................................ Poster P264 

Mohan, Vivek ................ Paper 621, Scientific Exhibit SE44 

Mohr, Karen J .................................. Poster P420 

Moineau, Gregory .............................Paper 084, 085 

Mole, Daniel .....................................Paper 088 

Molinari, Massimo ...............................Poster P414 

Molli, Ryan ............................Scientific Exhibit SE07 

Molloy, Anne. ....................................Paper 471 

Molloy, Robert M ............................... Poster P182 

Momohara, Shigeki ...............................Paper 591 

Monchik, Keith Oster ............................ Poster P438 

Monica, James T ................................ Poster P477 

Monk, Andrew P ................................ Poster P187 

Mont, Michael A ................. Paper 121, Poster P062, P181, 


Montanaro, Antonello ............Multimedia Education MEC26 

Montao, Aldo Campusano. ....................... Poster P453 

Monteiro, Martim Teixiera .........Multimedia Education MEC29 

Montesano, Pasquale X .......................... Poster P346 

Moon Seok, Park. .............................Paper 095, 547 

Moon, Bryan Scott ....Paper 511, 512, 513, 514, 515, 516, 517, 518, 

519, 520, 521, 522, 523, 524, 525, 525 

Moon, Kyoung Ho ................................Paper 475 

Moon, Young-Wan ................................Paper 063 

Mooney, James F ..................................Paper 650 

Moor, Molly. ................................... Poster P245 

Moore, Andrew M ................................Poster P207 

Moore, Drew Douglas. ........................... Poster P345 

Moorman, Claude T . . . . . . . . . . . . . . . . . Poster P342, Symposia BB 

Moraga, Claudio ..............................Paper 081, 363 

Moraleda, Luis. ..................................Poster P251 

Moran, Raymond ............................... Poster P428 

Moran, Steven L ..................................Paper 343 

Morawa, Lawrence G ............................ Poster P450 

Morell, Dan ..................................Paper 211, 376 

Moretti, Vincent Michael ...................Paper 514, 515, 519, 

Poster P521, P530, P532 

Morgan, Joseph A .............................Paper 485, 660 

Mori, Eiji ...................................... Poster P350 

Moric, Mario ............................ Paper 123, 128, 195 

Morimoto, Ryo ...................................Paper 664 

Morita, Tetsuro ................................. Poster P523 

Moritz, Deml. ....................................Paper 193 

author IndEx


Moriyama, Tokuhide ............................ Poster P354 

Moroni, Antonio. ................................Poster P012 

Morra, Edward. .........................Scientific Exhibit SE28 

Morrey, Bernard F . . . . . . . . . . . Paper 690, Poster P286, P297, P306 

Morris, Brent J ....................................Paper 221 

Morris, Carol D .............. Scientific Exhibit SE81, Symposia I 

Morris, Michael James ......................Poster P203, P204 

Morrison, Carol. ..............................Paper 455, 456 

Morrison, William B .....................Scientific Exhibit SE10 

Morscher, Melanie. ....................Poster P248, P249, P256 

Morshed, Saam ...................................Paper 225 

Mortazavi, S M Javad ....Paper 189, 357, Poster P073, P075, P104, 


Morton, Anne ....................................Paper 428 

Mosca, Vincent Stephen ..Paper 421, 422, 423, 424, 425, 426, 427, 

428, 429, 430, 431, 432, 433, 434, 435 

Mosheiff, Rami ...................................Paper 139 

Mosher, Timothy J. ................................Paper 013 

Most, Mathew .................................. Poster P544 

Mostardi, Richard A .....................Scientific Exhibit SE30 

Motley, John .....................................Paper 626 

Mott, Michael P. .............. Paper 230, Scientific Exhibit SE81 

Motta, Geraldo ..................Multimedia Education MEC29 

Moucha, Calin Stefan ............Multimedia Education MEC08, 


Mounir-Soliman, Loran ............................ Paper 111 

Mourad, Waleed Fouad .....................Poster P456, P457 

Mouttet, Alexandre .............................. Poster P036 

Moutzouros, Vasilios .............................Poster P307 

Mowinckel, Petter ............................... Poster P535 

Moya, Luis Emilio. ...............Multimedia Education MEC01 

Moylan, Kyle C ...................................Paper 302 

Mroz, Thomas Edward .............................Paper 267 

Mubarak, Scott J .......................Paper 099, Poster P221 

Mudgal, Chaitanya S. ..............Paper 284, Poster P323, P477 

Mueller, John P ................................. Poster P197 

Muirhead-Allwood, Sarah ...............Paper 067, Poster P091 

Mukherjee, Debi P ................................Paper 668 

Mulhall, Kevin James ..............Paper 477, Poster P419, P428 

Muller, Scott ..........................Paper 722, Poster P155 

Mullis, Brian .....................................Paper 727 

Mulpuri, Kishore. .................................Paper 566 

Mundis, Gregory M. ...............Paper 392, Poster P386, P394 

Murachovsky, Joel ............................... Poster P295 

Murakami, Akira ................................ Poster P139 

Murakami, Hideki. ..................... Paper 261, Poster P351 

Muratoglu, Orhun K...............................Paper 533 

Murawski, Christopher D. ..........................Paper 097 

Murcia Asensio, Antonio ......................... Poster P008 

Murcia-Mazon, Antonio. ......................... Poster P008 

Murphy, James. ...................................Paper 665 

Murphy, Stephen B .......Paper 353, Scientific Exhibit SE02, SE13 

Murray, Clint ................................... Poster P180 

Murray, David W. ................Paper 001, 032, 415, 531, 592, 

Poster P145, P187, Scientific Exhibit SE06 

Murray, Douglas H .............................. Poster P335 

Murray, Michael R. ................................Paper 680 

Murray, Paraic A ..................................Paper 656 

Murray, Trevor G ................................ Poster P096 

Murrell, George A C .............Multimedia Education MEC36, 


Murthi, Anand M ......................Paper 694, Poster P299 

Murty, A N .......................................Paper 722 

919 

Musahl, Volker ...........Multimedia Education MEC41, MEC42 

Musapatika, Dana Lynn .......................... Poster P487 

Muschler, George F ..............................Symposia W 

Muscolo, Domingo Luis. ................Paper 513, Poster P533, 


Musib, Mrinal ...................................Poster P019 

Myer, Gregory Donald .............................Paper 649 

Myerson, Andy ...................................Paper 278 

Myrtille, Valentin. ............................... Poster P484 

Myung, Karen ................................Paper 391, 438 

Nabb, Colin. ................................... Poster P400 

Nadaud, Matthew C ............................. Poster P076 

Naderi, Mohammad Nasir .........................Poster P491 

Nagaya, Yuko. ....................................Paper 319 

Nagle, Daniel J ...................................Paper 342 

Nagoya, Satoshi. ..................................Paper 232 

Nair, Lakshmi Sreedharan ..........................Paper 163 

Naito, Masatoshi. ..Paper 041, 098, Poster P047, P054, P277, P366 

Nakahara, Ichiro ......................Poster P050, P052, P053 

Nakamura, Hiroaki. ....................Paper 506, Poster P115 

Nakamura, Junichi .....................Paper 546, Poster P279 

Nakamura, Nobuo .............................. Poster P053 

Nakamura, Takashi .............................. Poster P239 

Nakamura, Takuya .............................. Poster P007 

Nakamura, Yoshinari ........ Paper 041, Poster P047, P054, P277 

Nakashima, Yuko .................................Paper 280 

Nakata, Katsuya. ..................................Paper 707 

Nakhla, Amgad Ihab. ..............................Paper 692 

Nalbantoglu, Ufuk ...............................Poster P561 

Nam, Denis ........... Poster P162, Scientific Exhibit SE49, SE67 

Nam, Kwang Woo.................................Paper 309 

Namba, Robert S. ................. Paper 186, 621, Poster P198, 


Namdari, Surena. ........Paper 325, 627, 726, Poster P276, P308 

Nandipati, Chaitanya ..............................Paper 393 

Nanni, Matteo ...........Multimedia Education MEC21, MEC38, 

Poster P220, Scientific Exhibit SE57, SE61 

Nargol, Antoni ................Paper 038, 064, 069, Poster P074 

Nascone, Jason Warren. ........................Paper 222, 698 

Nasreddine, Adam .............................. Poster P252 

Nasser, Rima ....................Multimedia Education MEC07 

Natu, Sonali. .................................Paper 038, 069 

Naudie, Doug .........................Paper 108, Poster P056 

Nauth, Aaron. ....................................Paper 141 

Navarro, Ronald Anthony ...............Paper 080, Poster P534 

Nawaz, Syed ..........................Paper 033, Poster P116 

Nayfeh, Tariq Ali ................Multimedia Education MEC15, 


Nayyar, Samir ...................Multimedia Education MEC39 

Nazarian, Ara. ....................................Paper 234 

Naziri, Qais ............................Scientific Exhibit SE22 

Neal, Deborah R ........................Scientific Exhibit SE30 

Nehrer, Stefan ....................................Paper 199 

Neil, Michael John .............................. Poster P129 

Neiss, Geraldine ..................................Paper 396 

Nelissen, Rob G H H ..........................Paper 253, 594 

Nellans, Kate W. ..................................Paper 332 

Nelson, Andrea ........................Paper 120, Poster P274 

Nelson, Charles L ......................Paper 243, Poster P122 

Nelson, Christopher D ........................... Poster P094 

Nelson, Eric W. ........................Paper 120, Poster P274 

Nelson, Fred R T ........................Scientific Exhibit SE33 

Nelson, Sandra Bliss ..............................Poster P015 

author IndEx


Nelson, Scott C .........................Scientific Exhibit SE01 

Nemec, Scott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 100 

Nepple, Jeffrey. .............Paper 637, Poster P059, P063, P433 

Nestor, Bryan J. .......................Poster P014, P087, P139 

Neubauer, Philip R ...............................Poster P401 

Neuman, Brian J ..................................Paper 256 

Neustein, Adam Z ............................... Poster P467 

Neven, Enrico .................................. Poster P422 

Newell, Claire .........................Paper 346, Poster P022 

Newhoff, Drew K .................................Paper 092 

Newman, Lori .................................. Poster P275 

Newton, Peter O . . . . . . . . . . . . . . . . .Paper 393, 394, 396, 447, 671, 

Poster P364, P371, P388 

Neyton, Lionel ...............................Paper 361, 362 

Ng, Aaron ......................................Poster P117 

Ng, Cho ........................................Poster P541 

Ng, Vincent .................................... Poster P203 

Ngcelwane, Mthunzi. .....Paper 016, 017, 018, 019, 020, 021, 022, 

023, 024, 025, 026, 027, 028, 029, 030 

Ngo, Trung. ......................................Paper 630 

Nguyen, Dat ................................... Poster P240 

Nguyen, Ngoc Quyen ..............................Paper 026 

Nha, Sang-Eun ..................................Poster P451 

Nho, Shane .................Poster P415, Scientific Exhibit SE55 

Nho, Yoon-Mi .........................Paper 374, Poster P318 

Nich, Christophe. ............................... Poster P484 

Nicholls, Alexander S ............................ Poster P327 

Nicholls, David P ............................... Poster P025 

Nicholson, Gregory P ...............Paper 160, 367, Poster P452 

Nickisch, Florian ..................................Paper 651 

Nieuwenhuijse, Marc J .............................Paper 253 

Nigrisoli, Marco ........................Scientific Exhibit SE54 

Nikolaou, Vassilios .............................. Poster P082 

Ninomiya, James T ................................Paper 590 

Nirenstein, Lana ................................ Poster P358 

Nishida, Hideji ................... Paper 235, 521, Poster P537, 


Nishii, Takashi. .......................Poster P050, P052, P053 

Nistri, Lorenzo ..................................Poster P061 

Nitri, Marco.....................................Poster P414 

Noble, Philip C .............Paper 040, Poster P005, P009, P010, 

P011, P127, Symposia ORSII 

Noeth, Ulrich ....................................Paper 193 

Nogler, Michael M ........Multimedia Education MEC10, MEC11 

Nogueira, Monica Paschoal . . . . . . . . . . . . . . . . . . . . . . . Poster P283 

Noh, Won .......................................Paper 026 

Nohutcu, Rahime ............................... Poster P072 

Nolan, Elizabeth M. ....................Paper 077, Poster P345 

Nolte, Lutz P ................................... Poster P533 

Nomura, Tomohiro ...............................Paper 098 

Noonan, Vanessa. .............................Paper 451, 452 

Nork, Sean E ................................... Poster P470 

Norouzi, Masoud ................................Poster P491 

Northam, Casey ..................................Paper 567 

Norton, Mark .........................Paper 031, Poster P508 

Novacheck, Tom F. ...............................Poster P241 

Novais, Eduardo Nilo .......................Poster P531, P544 

Noveau, Jenna B ................................ Poster P526 

Novicoff, Wendy .................................Poster P271 

Nowinski, Robert J ............................Paper 090, 363 

Nozaki, Masahiro .................................Paper 319 

Nti, Akosua A ....................................Paper 184 

Nuber, Gordon W .................................Paper 680 

920 

Nukavarapu, Syam Prasad ..........................Paper 163 

Nunley, James Albert ..................... Paper 048, 057, 058 

Nunley, Ryan ......Paper 420, 708, Poster P009, P027, P088, P094 

Nunn, Thomas ....................Paper 393, 394, Poster P364 

Nuss, Katja MR ...................................Paper 151 

Nussbaum, Eric ................................. Poster P439 

Nwachukwu, Benedict U ......................... Poster P252 

Nydick, Jason. ....................................Paper 440 

O’Brien, Joseph R ............................... Poster P347 

O’Connor, Daniel P ............................. Poster P302 

O’Connor, Mary I ......................Paper 463, Poster P085 

O’Donnell, Thomas FX. ............................Paper 580 

O’Donnell, Turlough ............................ Poster P129 

O’Driscoll, Shawn W ..................... Paper 684, 687, 690 

O’Keefe, Regis J ...................................Paper 456 

O’Malley, Martin J. ............................Paper 102, 508 

O’Shea, Kieran. ...............................Paper 084, 085 

O’Sullivan, Brian. .................................Paper 524 

O’Toole, Patrick. ................................ Poster P260 

O’Toole, Robert V ....Paper 222, 312, 388, 694, 698, 700, 723, 735 

Oag, Hannah CL ................................ Poster P327 

Oatis, Carol A .................................. Poster P280 

Obadan, Isi ......................................Paper 330 

Obata, Shuji .....................................Paper 664 

Obermayer-Pietsch, Barbara. ...................... Poster P543 

Obermeyer, Beate ..........................Poster P090, P095 

Obermeyer, Thomas S. .............................Paper 140 

Obert, Richard. .........................Scientific Exhibit SE29 

Obremskey, William.......................Paper 221, 380, 695 

Ochi, Mitsuo .....................Paper 280, Poster P524, P528 

Oda, Masafumi ...................................Paper 707 

Oda, Ryo ........................................Paper 277 

Odak, Saurabh ...................................Paper 281 

Odum, Susan Marie ...............Paper 538, Poster P076, P146 

Offley, Sarah ................................... Poster P368 

Ogawa, Kyo-Ichi ................................ Poster P007 

Ogawa, Masato ...................................Paper 096 

Ogose, Akira ................................... Poster P523 

Oh, Chang-Wug ...........................Poster P258, P480 

Oh, Chung Hee. ..................................Paper 153 

Oh, Irvin ........................................Paper 498 

Oh, Joo Han ..........................Paper 153, Poster P326 

Oh, Kwang Jun ...................................Paper 309 

Oha, Fumihiro ...................................Paper 259 

Ohl, Xavier. ......................................Paper 697 

Ohori, Yasuo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P490 

Ohta, Hiroyuki ...................................Paper 272 

Ohtori, Seiji. ..........................Paper 546, Poster P279 

Ok, Ji-Hoon. .................................Paper 152, 603 

Oka, Hiroyuki .............................Poster P174, P490 

Okada, Fumiaki. ................................ Poster P354 

Okano, Tadashi ...................................Paper 506 

Okazaki, Hiroshi. ..........................Poster P174, P490 

Okazaki, Ken ..........................Paper 414, Poster P168 

Okumura, Hisashi. ................................Paper 277 

Olee, Tsaiwei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P444 

Oliveira, Daniel. ..................................Paper 356 

Oliveira, Leonardo ..........Paper 736, Poster P373, P375, P379 

Olofsson, Anders. .................................Paper 615 

Olsen, Michael ...................................Paper 306 

Olson, Steven A. .................................Poster P501 

Olszewski, Dana . . . . . . . . . . . . . . . . . . . . . . . Paper 732, Poster P493 

Olysav, David J ..................................Poster P271 

author IndEx


Omeroglu, Hakan ............................... Poster P562 

Omilanowski, Ted M ............................ Poster P154 

Omori, Yasushi ..................................Poster P291 

Omoto, Dan ................................... Poster P044 

Onder, Ercument. ............................... Poster P072 

Onel, Erol ......................................Poster P216 

Ong, Alvin C ................. Paper 220, 250, 478, Poster P184 

Ong, Crispin C ...................................Paper 372 

Ong, Kevin. .......................Paper 212, 480, Poster P114, 


Ono, Takashi ................................... Poster P388 

Onodera, Shin. ...................................Paper 321 

Onyedika, Ikechukwu. ........................... Poster P280 

Oohori, Yasuo .................................. Poster P174 

Oral, Ebru .......................................Paper 533 

Orchowski, Joseph R. ............................ Poster P349 

Ordes, Debbie .................................. Poster P556 

Orfaly, Robert M ................Multimedia Education MEC23, 

Paper 691, 692, 693, 694, 695, 696, 697, 

698, 699, 700, 701, 702, 703, 704, 705 

Orlando, Lori A. .......................Paper 493, Poster P341 

Orozco, Fabio ................ Paper 220, 250, 478, Poster P184 

Orr, Justin D .....................................Paper 052 

Ortiz, Cristian ...................................Poster P211 

Osadebe, Uche ................................. Poster P009 

Osawa, Toshihisa ............................... Poster P333 

Osbahr, Daryl C ........................Scientific Exhibit SE68 

Osei, Daniel. .....................................Paper 405 

Osipov, Vladimir. .................................Paper 231 

Osterman, A Lee ........................Scientific Exhibit SE37 

Ostrum, Robert F. ......................Paper 725, Symposia U 

Osuch, Daniel .........................Paper 348, Poster P035 

Otani, Masafumi. .................................Paper 319 

Otsuka, Takanobu. ................................Paper 319 

Oudina, Karim ................................. Poster P484 

Ouellette, Elizabeth A. .............Paper 559, Poster P293, P334 

Ounpuu, Sylvia ...................................Paper 548 

Owen, John R .................................. Poster P099 

Owens, Brett D .............Paper 728, Poster P406, P434, P435 

Owens, Christopher J ............................ Poster P296 

Owens, Lesa. ....................................Poster P481 

Owens, Michael C. ......................Scientific Exhibit SE41 

Ozdemir, H. Mustafa ............................ Poster P569 

Ozdemir, Handan ............................... Poster P564 

Ozeki, Satoru. ....................................Paper 096 

Ozsoy, Mehmet Hakan ........................... Poster P569 

Ozturk, Abdullah ............................... Poster P072 

Ozturk, Adnan. ................................. Poster P072 

Ozyer, Fatih .................................... Poster P565 

Paccola, Cleber A Jansen ...........................Paper 724 

Pacelli, Lorenzo. ..................................Paper 278 

Pacheco, Wilfredo B ............................... Paper 311 

Pacicca, Donna M .......Paper 541, 542, 543, 544, 545, 546, 547, 

548, 549, 550, 551, 552, 553, 554, 555 

Padgett, Douglas E ......Paper 466, 467, 468, 469, 470, 471, 472, 

473, 474, 475, 476, 478, 479, 480, 642, 

Poster P014, P024, P087, Symposia V 

Padley, Michelle A. ................................Paper 060 

Pagkrati, Stavroula ....Multimedia Education MEC02, Poster P220 

Pagnani, Michael J ...... Paper 601, 602, 603, 604, 605, 606, 607, 

608, 609, 610, 611, 612, 613, 614, 615 

Pagnano, Mark W ...........Paper 002, Poster P032, Symposia B 

Pagnotto, Michael R ...............................Paper 247 

921 

Pahys, Jenny R ....................................Paper 030 

Pahys, Joshua. ............ Paper 030, 446, 449, 661, Poster P392 

Paik, Haines. .............................Paper 017, 443, 669 

Pakianathan, Satya .........................Poster P456, P457 

Paksima, Nader ...................................Paper 565 

Pala, Elisa. ............................Paper 520, Poster P539 

Paladini, Paolo ...................................Paper 371 

Palermo, Lisa. ....................................Paper 227 

Paletta, George A. ................................Symposia Z 

Paley, Dror. ......................................Paper 428 

Palispis, Winnie. ..............................Paper 557, 564 

Paller, David ..........................Paper 581, Poster P438 

Palmer, Cameron .................................Paper 178 

Palmese, Giuseppe .............................. Poster P449 

Palumbo, Alessio .................................Paper 575 

Palumbo, Brian ...................................Paper 006 

Panagopoulos, Georgia. ............................Paper 570 

Pandanan, Joaquin C .............................. Paper 311 

Pandarinath, Rajeev ...............................Paper 324 

Pandit, Hemant G. ............Paper 032, 415, 592, Poster P145, 


Pandya, Nirav Kiritkumar. ..........................Paper 551 

Panfoli, Nicola ...................................Paper 578 

Pang, Hee-Nee. ...................................Paper 408 

Panicek, David ..................................Symposia I 

Pankovich, Arsen M .....................Scientific Exhibit SE78 

Panteliadis, Pavlos ...............................Poster P110 

Pao, Jwo-Luen .................................. Poster P372 

Papalia, Rocco ....................................Paper 575 

Papapetropoulos, Periklis. ..........................Paper 333 

Pape, Guido. .....................................Paper 079 

Pape, Hans-Christoph. ............Paper 721, 722, 723, 724, 725, 

726, 727, 728, 729, 730, 731, 732, 

733, 734, 735, Poster P505 

Pappas, Nick D ...............................Paper 279, 285 

Paprosky, Wayne Gregory. .................Paper 187, 195, 714, 

Poster P057, Symposia W 

Paravani, Daniele .................................Paper 487 

Parcel, Ted William .............................. Poster P147 

Parhami, Farhad ..............................Paper 673, 674 

Parikh, Shital. ................................Paper 425, 484 

Park, Byung Chul ..........................Poster P258, P480 

Park, Daniel K .................................. Poster P164 

Park, Don Young. ............................... Poster P237 

Park, Gi Heon ....................................Paper 257 

Park, Hoon ......................................Paper 016 

Park, Jae-Hyun ...................................Paper 583 

Park, Jangwon ....................................Paper 181 

Park, Jeong Min. ..................................Paper 317 

Park, Ju-Kwon .............Poster P130, P134, P135, P143, P418 

Park, Justin J .....................................Paper 262 

Park, Kun-woo. ...................................Paper 026 

Park, Kwan Kyu ................................. Poster P055 

Park, Kyoung Jin .................................Poster P212 

Park, Kyung Soon ............................... Poster P029 

Park, Min Jung. ...............................Paper 285, 613 

Park, Sang Eun ...................................Paper 317 

Park, Yong-Bum. ................................ Poster P167 

Park, Youn Soo ...................................Paper 063 

Parks, Brent G ....................................Paper 104 

Parks, Michael Lloyd. ..............................Paper 534 

Parks, Nancy L. ...................................Paper 244 

Parmar, Raviinder .................................Paper 478 

author IndEx


Parnes, Nata. .....................................Paper 164 

Parodi, Dante ...................Multimedia Education MEC01 

Parratte, Sebastian. ................................Paper 419 

Parsley, Billy Keith. ................................Paper 574 

Parsley, Brian S ........................Paper 463, Poster P005 

Parsons, Bradford .................................Paper 601 

Parsons, Theodore W ..........Paper 230, Scientific Exhibit SE81, 

Symposia I 

Partington, Paul Francis ............Paper 722, Poster P071, P155 

Parvizi, Javad .......Paper 122, 124, 125, 126, 189, 357, 478, 539, 

Poster P073, P075, P078, P079, P098, P104, P107, 

P184, P186, P199, P464, Scientific Exhibit SE08, 

SE10, Symposia E, ORSII, V 

Paryavi, Ebrahim. .................................Paper 388 

Pasku, Dritan. .................................. Poster P367 

Pasquier, Gilles ................................. Poster P036 

Patel, Alpesh Ashwin ..............................Paper 021 

Patel, Amar .................................... Poster P223 

Patel, Amar Arun. .................................Paper 024 

Rajendra, Patel’Anay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P069 

Patel, Ashish .................................Paper 441, 729 

Patel, Jay J ......................................Poster P021 

Patel, Neeraj ....................Multimedia Education MEC24 

Patel, Priyesh .....................................Paper 333 

Patel, Satyam Rajnikant ............................Paper 566 

Patel, Shelain. ....................................Paper 265 

Patel, Vikas Vanarsi .............................. Poster P376 

Patella, Silvio. ....................................Paper 198 

Patil, Shantanu ................................. Poster P196 

Patou, Gary .....................................Poster P216 

Patron, Laura P ................................. Poster P408 

Patten, Darren .................................. Poster P426 

Patzer, Thilo. ................................... Poster P328 

Paul, Sophia ................................... Poster P298 

Pavlou, George ..................................Poster P110 

Pawelek, Jeff. ..........................Paper 392, Poster P255 

Paxton, Liz. .....................Paper 186, Poster P183, P198, 


Peace, William Joseph. ........................... Poster P427 

Pearl, Michael L. ................................ Poster P242 

Pearle, Andrew D ................Paper 577, Poster P156, P162, 


Pechey, Carola .................................. Poster P478 

Pedroza, Angela D. ................................Paper 572 

Peers, Sebastian Charles ............................Paper 204 

Pekmezci, Murat . . . . . . . . . . . . . . Paper 029, 225, 444, Poster P387 

Pelet, Syephane ...................................Paper 384 

Penenberg, Brad L ......................Paper 353, Poster P106 

Peng, Lauren ................................... Poster P242 

Penn-Barwell, Jowan G. .......................... Poster P485 

Pennington, Scott ............................... Poster P335 

Pennington, W Wesley ........................... Poster P336 

Pennock, Andrew T. ........................Poster P336, P336 

Penoyer, Tom. .................................. Poster P395 

Pensy, Raymond A. ................................Paper 698 

Peppers, Michael .................Multimedia Education MEC15 

Percope-Andrade, Marco Antonio ...................Poster P531 

Perdue, Paul William ..............................Paper 312 

Pereira, Regina. ..................................Poster P531 

Pereira, Renata. ...................................Paper 673 

Pereira, Tatiana Soares ........................... Poster P283 

Pereles, Daniel. ...................................Paper 648 

Pericle, Tony ....................................Symposia X 

922 

Perino, Georgio. .................................Poster P014 

Perra, Joseph H ..................................Symposia T 

Perreira, Aimee ................................. Poster P527 

Perrien, Daniel ...................................Paper 379 

Perry, Kevin I .....................................Paper 343 

Peter, Wilfred. ....................................Paper 616 

Peters, Christopher L. .... Paper 061, 346, 347, 348, 349, 350, 351, 

352, 353, 354, 355, 356, 357, 358, 

359, 360, 635, 706, Poster P030, 

Scientific Exhibit SE12, SE15, Symposia B 

Petersen, Steve A ................................ Poster P292 

Petersilge, William J ...............................Paper 378 

Petit, Alain ..................................... Poster P082 

Petite, Herve ................................... Poster P484 

Petkovic, Agnica ..................................Paper 328 

Petrella, Anthony ............................... Poster P376 

Petrera, Massimo. ............................... Poster P442 

Petrigliano, Frank .................................Paper 205 

Petrisor, Brad ......................Paper 387, 630, Poster P519 

Petron, David ................Paper 635, Scientific Exhibit SE12 

Petty, Damon H. .................................. Paper 611 

Petty, Emily .................................... Poster P245 

Pfeiffer, Ferris. .............................Poster P399, P520 

Pfirrmann, Christian. .............................Poster P315 

Pflugmacher, Robert ...............................Paper 740 

Philbin, Terrence ................................ Poster P225 

Philippon, Marc J .............................Paper 552, 638 

Phillips, Frank M. ............................... Poster P377 

Phillips, Lee Garrit ............Paper 635, Scientific Exhibit SE12 

Phillips, Michael .......................Paper 129, Poster P004 

Phillips, William A ................................Paper 431 

Phisitkul, Phinit .......Multimedia Education MEC20, Paper 092 

Pibarot, Vincent ................................ Poster P048 

Picha, Brad Matthew. ............................ Poster P494 

Pierce, Raymond O ..............................Poster BOS1 

Pierson, Jeffery L ..................................Paper 130 

Pifer, Matthew Alan ............................. Poster P390 

Pijls, Bart G ..................................Paper 253, 594 

Pike, Jeffrey .................................... Poster P343 

Pimenta, Luiz ..............Paper 736, Poster P373, P375, P379 

Pimple, Mahesh ..................................Paper 497 

Pinczewski, Leo A .............................Paper 323, 481 

Pinney, Stephen J ................................Poster P207 

Pino, Alfonso E ................................. Poster P559 

Pinsker, Ellie .....................................Paper 053 

Pinsky, Jonathan ..................................Paper 471 

Pinto, Vivek .....................................Poster P311 

Pirani, Piergiorgio .................................Paper 578 

Pirker-Fruhauf, Ulrike M ......................... Poster P543 

Pitcher, J David .........................Scientific Exhibit SE81 

Pizzutillo, Peter D .......Paper 541, 542, 543, 544, 545, 546, 547, 

548, 549, 550, 551, 552, 553, 554, 555 

Plancher, Kevin D . . . . . . . Paper 481, 482, 483, 484, 485, 486, 487, 

488, 489, 490, 491, 492, 493, 494, 495 

Plaskos, Christopher. ............................ Poster P162 

Ploumis, Avraam L .............................. Poster P060 

Podeszwa, David A .................Paper 432, 637, Poster P059 

Poignard, Alexandre .......................... Paper 009, 191, 


Polavarapu, Mahesh ...............................Paper 476 

Polishchuk, Daniil ................................Paper 375 

Poljak, Dijana ....................................Paper 423 

Pollak, Andrew N .......................Scientific Exhibit SE74 

author IndEx


Polly, David W. ................................. Poster P398 

Ponce, Brent A ....................................Paper 473 

Ponnappan, Ravi Kumar. ......................... Poster P385 

Poole, Robin ...........................Scientific Exhibit SE33 

Poolman, Rudolf W ............Paper 070, 407, 616, Poster P519 

Poon, Peter ......................................Paper 165 

Porat, Manny D. ..................................Paper 220 

Porcellini, Giuseppe ...............................Paper 371 

Porter, Daniel .............................Poster P541, P542 

Porter, Martyn . . . . . . . . . . . . Paper 033, 067, Scientific Exhibit SE03 

Potla, Sivaiah. ....................................Paper 417 

Potter, Benjamin Kyle ...................Paper 705, Poster P498 

Potter, Hollis ...........Paper 205, 554, Poster P014, P139, P254 

Poultsides, Lazaros A ...................Paper 535, Poster P118 

Powell, James N ..................................Paper 034 

Powles, David .................................. Poster P172 

Pozen, Alexis ..................................... Paper 110 

Pradhan, Anupam. ................................Paper 174 

Prata Nascimento, Luis Gustavo ................... Poster P295 

Prather, Heidi ....................................Paper 625 

Prayson, Michael J. .............................. Poster P494 

Prefontaine, Paul. ............................... Poster P195 

Prevezas, Nikolaos ................................ Paper 211 

Prewitt, Erin M ...................................Paper 103 

Price, Andrew J ................Paper 354, 415, 592, Poster P145 

Prifti, Dritan .....................................Paper 062 

Prior, David McKeon ............................ Poster P450 

Pritsch, Tamir .................................. Poster P465 

Probe, Robert A .................................Symposia U 

Prokuski, Laura J ........................Scientific Exhibit SE45 

Provencher, Matthew T ...........Multimedia Education MEC35, 

Paper 606, Poster P329, P336, P427, P436, 

Scientific Exhibit SE53, Symposia A, N 

Puigdevall, Miguel ................................Paper 400 

Pulos, Nicholas ................................. Poster P067 

Puls, Marc ..................................... Poster P038 

Pun, Stephanie ................................. Poster P253 

Pupello, Derek ........................Paper 365, Poster P309 

Purdue, Ed ............................Paper 238, Poster P014 

Puri, Lalit ..................Paper 460, Poster P069, P175, P193 

Puri, Rajeev D ....................................Paper 182 

Purtill, James J. .........Paper 189, 539, Poster P073, P075, P107, 


Putti, Amit B ................................... Poster P262 

Puttlitz, Christian ............................... Poster P376 

Putz, Cornelia . . . . . . . . . . . . . . . . . . . . . . . . . .Scientific Exhibit SE59 

Pylawka, Tamara ..............................Paper 013, 206 

Pynsent, Paul. .....................Paper 036, 188, Poster P006 

Qamirani, Erion ..................................Paper 149 

Qanirani, Erion ...................................Paper 141 

Queen, Robin M ......................... Paper 048, 057, 058 

Qiu, Xing ........................................ Paper 310 

Quigley, Ryan .................................. Poster P326 

Qureshi, Sheeraz ................Multimedia Education MEC53, 


Rabago, Michael ..................................Paper 494 

Rabenhorst, Brien . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 544 

Rachala, Deepthi................................ Poster P179 

Rachel, James Nick .............................. Poster P250 

Racusin, Adam Wesley ........................... Poster P502 

Radcliff, Kristen E ..... Paper 024, 256, 270, 666, 750, Poster P361 

Radler, Christof ................................. Poster P222 

Ragone, Vincenza ............................... Poster P409 

923 

Rahbek, Ole. .....................................Paper 434 

Rahimi, Mohammad ............................ Poster P459 

Rahman, Luthfur. ................................Poster P091 

Rahme, Hans .....................................Paper 615 

Rajaratnam, Sam ..................................Paper 526 

Rajdl, Eduardo. ................................. Poster P453 

Raju, PPJ ........................................Paper 064 

Rakhra, Kawan. .............................. Symposia ORSI 

Raman, Raghu .........................Paper 624, Poster P503 

Ramappa, Arun J .......................Paper 117, Poster P263 

Ramaskandhan, Jayasree ......................... Poster P064 

Rambani, Rohit ................................. Poster P503 

Ramesh, Palanisamy ...............................Paper 507 

Ramirez, Claudia. ................................Poster P119 

Ramon, Jose G. ................................. Poster P559 

Ramos, Nicholas ..................................Paper 113 

Ramsier, Rex D .........................Scientific Exhibit SE30 

Rana, Sumit Hamendra .......................... Poster P393 

Ranawat, Amar S .............. Paper 416, Scientific Exhibit SE27 

Ranawat, Anil ................Paper 634, Scientific Exhibit SE67 

Ranawat, Chitranjan S .........Paper 416, Scientific Exhibit SE27, 

Symposia B, V 

Randall, R Lor ....................................Paper 522 

Randelli, Filippo ................................ Poster P409 

Randolph, Joseph C ............................. Poster P153 

Rao, Nalini. .....................................Poster P119 

Raphael, Bradley ........................Scientific Exhibit SE49 

Raschke, Michael. ............................... Poster P506 

Rashidifard, Christopher H .........................Paper 655 

Raskolnikov, Dima ............................Paper 275, 332 

Rasquinha, Vijay J ................................Poster P019 

Rastegar, Farbod ................................ Poster P536 

Rastogi, Shishir ...................................Paper 237 

Raterman, Stephen J ...............................Paper 006 

Rathbone, Christopher ..................Paper 138, Poster P507 

Rathjen, Karl E. ...................................Paper 421 

Ravazzolo, Giovanni. .............................Poster P414 

Raven, Raymond B ...............................Poster P471 

Ravi, Krishna Cidambi ........................... Poster P364 

Raviraj, Adala. ...................................Poster P416 

Rayan, Faizal ................................... Poster P437 

Raz, Guy. .......................................Poster P111 

Razaei, Yadollah ..................................Paper 143 

Razif, Ali. .......................Multimedia Education MEC36 

Razzano, Pasquale. ................................Paper 496 

Reagan, Jeffrey Maurice. ............................Paper 216 

Realyvasquez, John ................................Paper 519 

Realyvasquez, Juan A ............................ Poster P530 

Rechtine, Glenn R ............................... Poster P368 

Reddix, Robert N. ......................Paper 730, Poster P458 

Reddy, Sudheer C .................................Paper 056 

Redler, Andrea .................................. Poster P447 

Reed, Elaine. ...........................Scientific Exhibit SE01 

Reed, Mike R .................Paper 537, 722, Poster P071, P155 

Reedy, Mary E ....................................Paper 291 

Rees, Harold Wharton .............................Paper 133 

Regalbuto, Ricky ..................................Paper 273 

Rehman, Rasham .................................Paper 142 

Reichel, Heiko .................................. Poster P028 

Reid, J Spence ....................................Paper 206 

Reid, Terry-Elinor R. ...............................Paper 428 

Reilly, James H. ...................................Paper 682 

Reinares, Felipe ..................................Poster P211 

author IndEx


, Poster P257 

Reinhardt, Keith R. ................ Scientific Exhibit SE64, SE67 

Reinhart, Donnie M ...............................Paper 541 

Reinold, Michael M. ...............................Paper 647 

Reis, Abilio Antunes ............................. Poster P395 

Riesgo, Aldo. .....................................Paper 332 

Reisman, William ................................Poster P481 

Reitman, Charles A ................................Paper 028 

Ren, Weiping .....................................Paper 629 

Rendon, Norma ..........................Paper 118, 119, 448 

Repicci, John A ..................................Symposia P 

Resch, Herbert ....................................Paper 203 

Restrepo, Camilo. ........Paper 125, 357, 539, Poster P078, P079, 


Rettig, Arthur C ...................................Paper 632 

Reveal, Gregory T ............................... Poster P487 

Revell, Matthew. ...................Paper 036, 188, Poster P006 

Reyes, Mauricio ................................. Poster P533 

Reynolds, Sarah. .................................Poster P413 

Reynolds, Shaun ..................................Paper 245 

Rhee, Peter C .....................................Paper 364 

Rho, Monica .....................................Paper 625 

Rhyu, Kee Hyung .................................Paper 309 

Ricart Hoffiz, Pedro. ...............................Paper 262 

Ricci, William M ..........................Paper 701, 703, 732 

Richard, Marc Joseph ..............................Paper 333 

Richards, B Stephens. ............................ Poster P382 

Richards, Justin E .............................Paper 221, 380 

Richardson-Frazzitta, Meagan ..................... Poster P345 

Richman, Joshua. .................................Paper 473 

Rieger, Johannes S. .........................Poster P090, P095 

Ries, Michael D ...................................Paper 479 

Riew, K Daniel. ......Paper 022, 026, 030, 737, Poster P374, P400 

Rigal, Wynne M. ................................ Poster P086 

Rihn, Jeffrey. ........................Paper 024, 270, 666, 750, 

Poster P361, P385, Symposia Y 

Rijnberg, W J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 075 

Riley, Clayton H ................................ Poster P302 

Riley, Michelle. ..................................Poster P106 

Ring, David C ...............Poster P231, P323, Symposia AA, O 

Ringler, James R .............Paper 047, Poster P224, P513, P515 

Rinsky, Lawrence A .............................. Poster P253 

Rios, Gilberto ....................................Paper 422 

Ritacco, Lucas Eduardo. .......Poster P533, Scientific Exhibit SE38 

Ritenour, Amber E. .............................. Poster P502 

Ritter, Merrill A ...............................Paper 130, 413 

Ritzman, Todd F ................................ Poster P249 

Rives, Terry E . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 730, Poster P458 

Rizek, Randy .....................................Paper 289 

Robbins, Claire E. .............................Paper 410, 597 

Roberge, David ...................................Paper 524 

Roberts, Craig S ..............Paper 212, 721, 722, 723, 724, 725, 

726, 727, 728, 729, 730, 731, 732, 733, 

734, 735, Scientific Exhibit SE77 

Roberts, David. ................................. Poster P275 

Roberts, Matthew .................................Paper 102 

Roberts, Timothy. .................................Paper 535 

Robertsson, Otto. ......................Paper 242, Poster P133 

Robinson, James .................................. Paper 110 

Robinson, Michael ................................Paper 612 

Robinson, Michael Aaron. ........................ Poster P087 

Robinson, Paul S. ............................... Poster P403 

Robinson, Yohan. .................................Paper 264 

924 

Rocha, Sheri. .................................Paper 266, 749 

Roche, Martin William . . . . . . . . . . . Multimedia Education MEC18, 

Poster P201, Symposia L 

Rodeo, Scott Alan .............Paper 205, 577, 579, Poster P424, 

Scientific Exhibit SE71, SE73, Symposia C, ORSII 

Rodine, Robert. ...................................Paper 630 

Rodriguez, Carlos M ....................Paper 717, Poster P026 

Rodriguez, Edward ............Paper 115, 304, Poster P218, P509 

Korduba-Rodriguez, Laryssa. .................Poster P181, P182 

Rodriguez, Sergio .......................Scientific Exhibit SE37 

Roe, Justin Phillip .............................Paper 323, 481 

Roebuck, Margaret M .............................Poster P321 

Rogal, Michael J. ...............................Symposia 151 

Rogers, Ann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 013 

Rogers, Benedict ..................................Paper 135 

Rogerson, John Sargent. .......................... Poster P094 

Rojpornpradit, Thana ............................ Poster P163 

Rokito, Andrew S ................Multimedia Education MEC40 

Romano, Carlo ..................................Poster P314 

Romanowski, J R .................Multimedia Education MEC03 

Romantini, Matteo .............................. Poster P539 

Romeo, Anthony A ....Paper 160, 367, 574, 606, 609, Poster P329 

Romero, Alex. .................................. Poster P455 

Roocroft, Joanna Helena ............Paper 099, 179, Poster P247 

Roques, Anne .....................Paper 135, 527, Poster P045 

Rorabeck, Cecil H ......................Paper 350, Poster P080 

Rose, David .................................... Poster P324 

Rose, Peter S. ................................... Poster P544 

Rosenberg, Aaron Glen. ..............Paper 411, 714, Symposia B 

Rosenwasser, Melvin Paul. ...........Paper 275, 332, Poster P303 

Rosner, Michael. ..................................Paper 017 

Ross, F Patrick ....................................Paper 238 

Rossi, Mark ...............................Poster P102, P152 

Rossi, Roberto ...........Multimedia Education MEC04, MEC22, 

Paper 207, Scientific Exhibit SE25, SE65 

Roth, Alan .......................................Paper 648 

Rothem, David E. .................................Paper 351 

Rothman, Richard H. ...................Paper 539, Poster P078, 


Rotini, Roberto .........................Scientific Exhibit SE54 

Rouleau, Dominique ...................Paper 623, Poster P338 

Rounds, Tracy ....................................Paper 120 

Roussanne, Yannick ....................Paper 084, Poster P330 

Roussos, Constantinos .............................Paper 183 

Rout, Rajesh. .....................................Paper 354 

Routt, Milton L ................................. Poster P470 

Roy, Louis ..................................... Poster P475 

Roy, Marcel ............. Multimedia Education MEC13, MEC15 

Roye, David Price .................................Paper 397 

Rozbruch, S Robert ................................Paper 313 

Rozumalski, Adam ...............................Poster P241 

Rubash, Harry E ......................... Paper 295, 300, 480 

Rubery, Paul T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P368 

Rubin, Todd A ....................................Paper 666 

Ruch, David Simms ...............................Paper 333 

Rudan, John F ....................................Paper 409 

Rue, John-Paul H. ................................Poster P421 

Ruffilli, Alberto ..........Paper 093, Scientific Exhibit SE61, SE69 

Ruggieri, Pietro ....................Paper 240, 520, Poster P539 

Ruh, Erin ...................................... Poster P027 

Ruiz Suarez, Michell ............................... Paper 610 

Rush, Jeremy K ...................................Paper 052 

Russell, George V. ..........................Poster P456, P457 

author IndEx


Russell, Kelvin J. ................................ Poster P086 

Russell, Thomas A. ................................Paper 701 

Russlies, Martin ................................. Poster P285 

Ruther, Wolfgang. ............................... Poster P285 

Ruzzini, Laura ................................Paper 156, 157 

Ryan, Paul M .....................................Paper 571 

Ryan, Philip..................Paper 528, 712, Poster P041, P043 

Rybak, Leon. ....................Multimedia Education MEC39 

Ryu, Jessica ......................................Paper 209 

Ryu, Richard K N. ................................Symposia A 

Saadat, Ehsan ....................................Paper 479 

Sabatini, Coleen S. ................................Paper 435 

Sabet, Hamid. ................ Paper 621, Scientific Exhibit SE44 

Sabharwal, Sanjeev ................................Paper 402 

Sacks, Janice T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P556 

Sacks, Stanley E ................................. Poster P556 

Saddiki, Rachid ...................................Paper 697 

Saeki, Kazuhiko. ................................ Poster P407 

Safir, Oleg ....................... Paper 251, Poster P044, P111 

Sah, Alexander P .................................Poster P070 

Sah, Robert .................................... Poster P393 

Saha, Subrata. ...................................Poster P019 

Sahin, Hacer ................................... Poster P506 

Saifi, Comron .................................. Poster P344 

Saillant, Jason C ..................................Paper 330 

Saito, Susumu ....................................Paper 345 

Saito, Tomoyuki ......................Poster P049, P068, P268 

Saiz, Paul ..............Paper 661, 662, 663, 664, 665, 666, 667, 

668, 669, 670, 671, 672, 673, 674, 675 

Sakai, Hiroaki .................................. Poster P350 

Sakai, Takashi ........................Poster P050, P052, P053 

Sakakibara, Toshihiko. .............................Paper 263 

Sakdinakiattikoon, Manoon ...................... Poster P163 

Saklatvala, Jeremy .................................Paper 145 

Sakuma, Yu ......................................Paper 591 

Salari, Nima. ...........................Scientific Exhibit SE62 

Salari, Pooria ..........................Paper 392, Poster P386 

Salata, Michael ............... Paper 200, 367, 609, Poster P452 

Saleh, Khaled J ..................................Poster P271 

Saleme, Jacobo ................................. Poster P259 

Salemyr, Mats .................................. Poster P093 

Salkeld, Samantha L ............................. Poster P408 

Salmon, Lucy J. ...............................Paper 323, 481 

Salo, Guillem. .................................. Poster P352 

Salonen, David ...................................Paper 589 

Saltzman, Charles L ...............................Paper 651 

Saltzman, Matthew .....................Paper 680, Poster P294 

Salvati, Eduardo Agustin ...........................Paper 535 

Salvo, Davide. ....................................Paper 091 

Sama, Andrew A .......................Paper 747, Poster P369 

Samdani, Amer ...................................Paper 440 

Samejima, Yashuito ............................. Poster P432 

Sami, Syed .......................................Paper 629 

Sammarco, Vincent James .....Paper 091, 092, 093, 094, 095, 096, 

097, 098, 099, 100, 101, 102, 103, 104, 105 

Sampson, Barry .........................Scientific Exhibit SE03 

Samuels, Jonathan .............................. Poster P138 

San Giovanni, Thomas P ...........................Paper 501 

Sanchez-Sotelo, Joaquin. ...Paper 078, 087, 602, 690, Poster P286, 

P297, P306 

Sanden, Bengt ....................................Paper 264 

Sanders, David ....................Paper 303, 382, Poster P213 

Sanders, James O. ............................... Poster P382 

925 

Sandhu, Harvinder S. ............................Symposia W 

Sandstrom, Bjorn .................................Paper 615 

Sanhudo, Jose A ..................................Paper 509 

Santos, Edward Rainier G ......................... Poster P398 

Sariali, Elhadi .............................Poster P036, P037 

Sarwahi, Vishal ........................Paper 746, Poster P358 

Sasagawa, Takeshi ................................Poster P351 

Sasahara, Jun ................................... Poster P432 

Sasaki, Mikito ....................................Paper 232 

Sasso, Rick C ..........................Paper 737, Symposia G 

Sassoon, Adam ...................................Paper 364 

Satcher, Robert L ..................................Paper 525 

Satchithananda, Keshthra. ................Scientific Exhibit SE03 

Sato, Yukata. ....................................Poster P261 

Satonaka, Haruhiko ...............................Paper 652 

Satpathy, Jibanananda ........................... Poster P099 

Saucedo, James Matthew .......................Paper 460, 476 

Saul, Katherine R. .......................Scientific Exhibit SE31 

Saunders, Stuart M ................................Paper 650 

Savage, Jason Wayne ...............................Paper 476 

Savidge, Edgar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 647 

Savoie, Felix H .....................Paper 209, 686, Poster P316 

Savrun, Feray ................................... Poster P567 

Sawardeker, Prasad J ........................Poster P293, P334 

Sawhill, Amy .....................................Paper 455 

Sawyer, Jeffrey R .............. Paper 167, 403, 404, Poster P250 

Sayeed, Siraj A ...................................Poster P181 

Scelsi, Michele. .................Multimedia Education MEC28, 


Schaffer, Jonathan L ............................. Poster P154 

Schaper, Lawrence A ..............................Poster P109 

Scharfstein, Daniel ................................Paper 388 

Scharschmidt, Thomas J .......................... Poster P525 

Schaufele, Michael ................................Paper 672 

Scheer, Justin ................ Paper 029, 444, Poster P387, P396 

Schemitsch, Emil H ..........Paper 034, 070, 141, 149, 301, 302, 

303, 304, 305, 306, 306, 307, 308, 309, 

310, 311, 312, 313, 314, 315, 464, 

Poster BOS2, P460, P519 

Scher, David M ...................................Paper 405 

Scherl, Susan A .........Paper 166, 167, 168, 169, 170, 171, 172, 

173, 174, 175, 176, 177, 178, 179, 180 

Schiller, Jonathan R. ...........................Paper 172, 173 

Schleck, Cathy D ..................................Paper 364 

Schlegel, Theodore F. ............................ Poster P332 

Schmalzried, Thomas P ............Paper 074, Poster P067, P090 

Schmidt, Christopher C ............................Paper 677 

Schmitt, Jan O. ................................. Poster P132 

Schmitz, Christian ................................Paper 248 

Schneckener, Charlotte-Dorothe . . . . . . . . . . . . . . . . . . . . . Paper 347 

Schneider, Robert ......................Paper 405, Poster P476 

Schoenfeld, Andrew ....................Paper 728, Poster P435 

Schofer, Markus. ................................ Poster P132 

Scholtes, Vanessa A ............................Paper 407, 616 

Schon, Lew C. ....................................Paper 104 

Schoones, Jan W ..................................Paper 253 

Schreiber, Verena M .....................Scientific Exhibit SE72 

Schroder, Steven ..................................Paper 040 

Schroder, Steven ............................Poster P010, P011 

Schroeder, Joshua .............................Paper 139, 667 

Schroer, William C ................................Paper 291 

Schroerlucke, Samuel Ray. ..........................Paper 392 

Schrumpf, Mark ........................Scientific Exhibit SE68 

author IndEx


Schuh, Reinhard ................................ Poster P208 

Schulte, Caitlin ..................................Poster P371 

Schulz, Ben ......................................Paper 634 

Schurman, John R. ................................Paper 190 

Schwab, Frank J .........Paper 397, 441, Poster P394, Symposia T 

Schwab, Joseph Hasbrouck ........................Symposia I 

Schwantes, Bernd ............................... Poster P092 

Schwartz, Daniel M. ...............................Paper 220 

Schwartz, Jeffrey M .......Paper 316, 317, 318, 319, 320, 321, 322, 

323, 324, 325, 326, 327, 328, 329, 330 

Schwartz, Michael H ..............................Poster P241 

Schwarz, Dana M .................................Paper 241 

Schwarzkopf, Ran ............................... Poster P023 

Schwiesau, Jens ...................................Paper 740 

Sciadini, Marcus F........................ Paper 222, 698, 723 

Scolaro, John Alan .............................. Poster P464 

Scoon, Joanna ....................................Paper 643 

Scorilas, Andreas ................................ Poster P188 

Scott, David Forrest. ............................. Poster P003 

Scott, Kelly. ......................................Paper 325 

Scott, W Norman ............................... Poster P127 

Scuderi, Gaetano J. .....................Paper 501, Poster P346 

Scuderi, Giles R ..............Paper 294, 598, Poster P127, P190, 

Scientific Exhibit SE23, Symposia B, P 

Sculco, Thomas P ......................Paper 290, Poster P118 

Scully, Sean P. ....................................Paper 236 

Seah, Renyi Benjamin. .............................Paper 012 

Sedrakyan, Art ....................................Paper 186 

Seeger, Joern Bengt .............................. Poster P095 

Seeman, Ego .....................................Paper 227 

Sees, Julieanne P ..................................Paper 725 

Segal, Lee S ......................................Paper 314 

Segal, Neil ......................................Poster P281 

Segalman, Keith A. .............................. Poster P324 

Sehn, Jennifer .................................. Poster P400 

Seichi, Atsushi ....................................Paper 019 

Seiler, Christof. ................................. Poster P533 

Seitz, William H ..................................Paper 344 

Sekiya, Jon K ................Poster P310, Scientific Exhibit SE52 

Seligson, David ..........Paper 212, Scientific Exhibit SE47, SE77 

Soles, Gillian .....................................Paper 224 

Sembrano, Jonathan N. .....................Poster P100, P398 

Sen, Cengiz .................................... Poster P560 

Seng, Chusheng. ....................... Paper 018, Poster P112 

Sengupta, Dilip K .................................Paper 744 

Seo, Eun Seok ...............Paper 015, Poster P161, P167, P272 

Seo, Hyoung Yeon. ................................Paper 257 

Seo, Young-Jin .................................. Poster P425 

Seok, Chang-Woo .................................Paper 583 

Seon, Jong-Keun ......Poster P029, P130, P134, P135, P143, P418 

Seong, Sang Cheol ...Paper 010, 011, 015, 320, 322, 326, 329, 490, 

Poster P161, P167, P178, P192, P200, P272 

Serna, Fernando .................................. Paper 310 

Sestokas, Anthony K ...............................Paper 220 

Sethi, Anil ......................................Poster P381 

Severson, Erik P. ..................................Paper 014 

Sewell, Mathew ...................................Paper 462 

Sexton, Shaun Alan. ...............................Paper 526 

Seyler, Thorsten M. ......................Scientific Exhibit SE31 

Shah, Kushal ................................... Poster P248 

Shah, Nirav .................................... Poster P088 

Shah, Ritesh. ................................... Poster P193 

Shah, Suken A .....................Paper 396, 671, Poster P371 

926 

Shah, Suraj. ......................................Paper 306 

Shah, Swapnil B ..................................Paper 222 

Shaifuzain, Ab-Rahman .......................... Poster P159 

Sham, Jonathan. ..................................Paper 519 

Shamieh, K Samer F ...............................Paper 668 

Shani, Raj Harry ..................................Paper 549 

Shapiro, Frederic ................................ Poster P243 

Sharkey, Peter F ..........................Paper 189, 357, 478, 

Poster P073, P075, P186, P199 

Sharma, Adrija. ................................. Poster P389 

Sharma, Amit .............. Paper 269, Poster P100, P369, P398 

Sharma, Hemant. ......................Paper 624, Poster P503 

Sharma, Vinod Kumar .............................Paper 426 

Sharrock, Nigel E. .................................Paper 535 

Shaw, Christopher. ................................Paper 624 

Shawen, Scott ....................................Paper 705 

Shay, Barbara. ....................................Paper 409 

Shea, Kevin G ...................................Poster P417 

Shearwood-Porter, Natalie ..........................Paper 135 

Sheehan, Eoin C ............ Paper 189, Poster P073, P075, P199 

Sheibani-Rad, Shahin ............................ Poster P429 

Sheikhzadeh, Ali .................................Poster P311 

Shelbourne, K Donald ............................Poster P410 

Shelton, John. ....................................Paper 146 

Shen, Francis H ...................................Paper 027 

Shen, James ......................................Paper 617 

Shen, Jianhua ................................Paper 003, 190 

Shepherd, Bryan ................................ Poster P137 

Sheppard, Zachary R. ..............................Paper 429 

Sherman, Seth .................................. Poster P162 

Sheth, Dhiren S ............... Paper 621, Scientific Exhibit SE44 

Sheth, Neil P .....................................Paper 714 

Shetty, Anil ......................................Paper 204 

Shi, Kenrin. ......................................Paper 345 

Shi, Shao-Min ....................................Paper 590 

Shia, Derek S .....................................Paper 086 

Shiba, Keiichiro. ................................ Poster P350 

Shibusawa, Kazuyuki ............................ Poster P333 

Shigemura, Tomonori. ..................Paper 546, Poster P279 

Shigenobu, Keiichi ................................Paper 259 

Shiguetomi-Medina, Juan Manuel. ...................Paper 434 

Shillito, Matthew Charles. ..........................Paper 556 

Shim, Sang Ho .................. Paper 010, 011, 320, 322, 326, 


Shim, Shang Mi. ..................................Paper 153 

Shimamoto, Norimichi ............................Paper 321 

Shimer, Adam L. ..................................Paper 027 

Shimizu, Koh. .........................Paper 619, Poster P158 

Shimizu, Masaki ................................ Poster P267 

Shimizu, Sara .........................Paper 619, Poster P158 

Shimizu, Tohru ................................. Poster P538 

Shimose, Shoji. ............................Poster P524, P528 

Shin, Alexander Yong Shik .......Paper 051, 334, 343, Poster P443 

Shin, Jin Hyup. ...................................Paper 583 

Shin, Sang-Jin ...................Paper 155, 162, 316, 604, 605 

Shin, Sangmin Ryan ...............................Paper 381 

Shinar, Andrew A ............................... Poster P137 

Shinjiro, Takata ...................................Paper 143 

Shinomiya, Rikuo .................................Paper 280 

Shinozaki, Tetsuya .............................. Poster P267 

Shirai, Toshiharu. ............Paper 235, 521, Poster P537, P538, 


Shishani, Yousef ......................... Paper 082, 090, 363 

author IndEx


Shitara, Hitoshi ................................. Poster P333 

Shon, Hyun-Chul ................................Poster P212 

Shore, Ben ...................................Paper 168, 178 

Shores, Jennifer ...................................Paper 104 

Shorofsky, Michael ............................Paper 694, 700 

Shortt, Michael D.. .............................. Poster P406 

Shourbaji, Rania Ayman. ....................Poster P456, P457 

Shrader, Michael Wade .........................Paper 218, 314 

Shufflebarger, Harry L. ..............Paper 396, 671, Poster P371 

Shukla, David R. ..................................Paper 687 

Shuler, Michael S. ................................Poster P481 

Shupe, Paul ............................Scientific Exhibit SE53 

Siddiqui, Mashfiqul Arafin. .........................Paper 417 

Sides, Brenda .....................................Paper 446 

Sidhwa, Feroze ...................................Paper 503 

Siebenrock, Klaus ........................Paper 043, 044, 542, 

Poster P038, P077, P251, P441 

Siegel, Judith .....................................Paper 218 

Sierra, Rafael Jose ..........................Poster P097, P440 

Sietsema, Debra .........................Paper 047, 150, 732, 

Poster P224, P359, P402, P513, P515 

Signorelli, Cecilia .......................Scientific Exhibit SE24 

Sijbesma, Thea ...................................Paper 070 

Silva, Mauricio. ...............................Paper 166, 176 

Silvaggio, Vincent J ......................Scientific Exhibit SE46 

Silverman, Andrew M ............Multimedia Education MEC46, 



Silvis, Matthew ...................................Paper 013 

Sim, Franklin H. ................................ Poster P544 

Simoes-Silva, Ana Christina ........................Poster P531 

Simpson, David R ............................... Poster P187 

Sims, Stephen H ..................................Paper 676 

Simunovic, Nicole. .........................Poster P460, P474 

Sinapi, Fabrizio ..................................Poster P012 

Singh, Anshuman ............................... Poster P534 

Singh, Jagwant. ................................. Poster P503 

Singh, Jasvinder. ..............................Paper 014, 473 

Sink, Ernest L. ....................Paper 637, Poster P059, P063 

Siris, Ethel .......................................Paper 226 

Sirugo, Fabio ...........................Scientific Exhibit SE80 

Sirveaux, Francois ......................Paper 088, Symposia M 

Siska, Peter. .................................... Poster P505 

Skaggs, David Lee .........................Paper 391, 435, 438 

Skaggs, Kira F. ....................................Paper 435 

Skeels, Michael D .................................Paper 298 

Skeete, Faith. ..........................Paper 129, Poster P004 

Skendzel, Jack Gerard .........Poster P310, Scientific Exhibit SE52 

Skinner, John. ................Paper 033, 067, 068, Poster P116, 


Skolasky, Richard L ......................... Poster P081, P401 

Skoldenberg, Olof. .........................Poster P093, P512 

Skrepnik, Nebojsa V ............................. Poster P240 

Slabaugh, Mark A ............................... Poster P329 

Slenker, Nicholas R ................................Paper 681 

Slikker, William. .................................Poster P219 

Slobogean, Gerard .....................Paper 566, Poster P213 

Slough, Jennifer. ................................ Poster P482 

Slover, James D ...........Paper 113, 129, 715, Poster P004, P023 

Slutsky, David Joseph ............................Symposia O 

Smit, Milton J ....................................Paper 182 

Smith, E O’Brian ..................................Paper 431 

Smith, Frank C ...................................Paper 034 

927 

Smith, Harvey ....................................Paper 024 

Smith, Holly .....................................Paper 289 

Smith, Julie Macaulay. .............................Paper 461 

Smith, Karen ..........................Paper 037, Poster P031 

Smith, Lucas .....................................Paper 550 

Smith, Paul N .................................. Poster P522 

Smith, R Lane .............................Poster P237, P391 

Smith, R M. .....................................Poster P516 

Smith, Thomas L. ............. Paper 567, Scientific Exhibit SE31 

Smith, Thomas Waddell ........................Paper 640, 645 

Smith, Wade Russell ...............................Paper 716 

Smolders, Jose MH ............................Paper 072, 075 

Smolinski, Patrick J. ............................. Poster P407 

Smucker, Joseph Douglas ......... Paper 436, 437, 438, 439, 440, 

441, 442, 443, 444, 445, 446, 

447, 448, 449, 450 

Snearly, Christine ............................... Poster P149 

Sneller, Michael A .......................Scientific Exhibit SE07 

Snyder, Benjamin Matthew .........................Paper 366 

Snyder, Brian .....................................Paper 234 

Soares, Guilherme. ...............................Poster P531 

Sodl, Jeffrey F. ....................................Paper 608 

Soileau, Elizabeth S. ...............................Paper 246 

Sokol, Shima ................................... Poster P233 

Sokunbi, Gbolabo Olabiyi. .........................Paper 440 

Solan, Matthew C .................................Paper 497 

Solarz, Mark ....................................Poster P107 

Solayar, Gandhi Nathan ............Paper 477, Poster P428, P428 

Solomon, Daniel Jordan .........Multimedia Education MEC35, 

Poster P427 

Solsky, Ian .......................................Paper 205 

Soma, Tomotsu ...................................Paper 232 

Song, Eun Kyoo. ......Poster P029, P130, P134, P135, P143, P418 

Song, Frederick Suh ....................Paper 089, Poster P325 

Song, Hae Ryong. ............................... Poster P258 

Song, Ji-Hoon ....................................Paper 016 

Song, Kyung Jin. ..............................Paper 016, 663 

Song, Sang Jun ................................. Poster P144 

Song, Yanna. .....................Paper 743, Poster P362, P367 

SooHoo, Nelson Fong ..........Paper 039, 112, 719, Poster P266 

Sorene, Elliott .................................. Poster P238 

Soroceanu, Alexandra..............................Paper 503 

Soslowsky, Louis J .......................Scientific Exhibit SE33 

Souder, Christopher D ........................... Poster P466 

Souza, Bruno Goncalves Schroder. ...................Paper 638 

Spandidos, Demetrios ........................... Poster P367 

Spang, Jeffrey T ...................................Paper 585 

Spangehl, Mark J ..................................Paper 133 

Specht, Lawrence. ............................... Poster P034 

Specht, Stacy C ...................................Paper 428 

Spector, Tim D. ................................. Poster P327 

Speering, Leann. ..................................Paper 103 

Sperling, John William ........Paper 078, 087, 151, 152, 153, 154, 

155, 156, 157, 158, 159, 160, 161, 162, 

163, 164, 165, 364, 602, Poster P296, 

Symposia M 

Spiegel, David Andrew .............................Paper 114 

Spinner, Robert Jay .....................Paper 051, Poster P443 

Spitzer, Andrew I. .................................Paper 459 

Spivak, Jeffrey M ..................................Paper 262 

Sponseller, Paul D. ....Paper 180, 395, 396, 398, 671, Poster P383, 

Scientific Exhibit SE40, Symposia T 

author IndEx


Sporer, Scott M ................. Paper 123, 128, 132, 182, 187, 

195, 471, 714, Poster P057 

Sprague, Sheila ..........Paper 387, 464, 465, Poster BOS2, P460 

Sprowson, Andy ..................................Paper 722 

Spyropoulos, Giannis ..............................Paper 318 

Sridhar, Michael S ............................... Poster P170 

Srikumaran, Umasuthan .........................Poster P292, 


Srinath, Arjun ....................................Paper 424 

Sritulanondha, Supatra. ........................Paper 005, 532 

St John, Lauren ................................. Poster P058 

St Pierre, Patrick ........Paper 571, 572, 573, 574, 575, 576, 577, 

578, 579, 580, 581, 582, 583, 584, 585 

Stabile, Cara Marie ................................Paper 655 

Staddon, Arthur P ............................... Poster P530 

Stafford, Giles Hugo ....................Paper 346, Poster P022 

Stakleff, Kimberly ............................... Poster P495 

Stall, Alec C ......................................Paper 388 

Stall, Nathan .....................................Paper 108 

Stange, Richard ................................. Poster P506 

Stannard, James P .............................Paper 385, 390 

Stans, Anthony A. .................................Paper 545 

Starman, James ...................................Paper 380 

Starr, Adam Jennings. ............................ Poster P467 

Starr, Roland .................................Paper 423, 428 

Stasiak, Mark .....................................Paper 579 

Steele, Garen ................................... Poster P076 

Steensma, Matthew. ...............................Paper 238 

Steger-May, Karen ..........................Poster P088, P313 

Stein, Benjamin Eric . . . . .Poster P081, Scientific Exhibit SE66, SE70 

Steinbach, Lynne S ................................Paper 573 

Steinmann, Scott P .....................Paper 690, Poster P290 

Steinmetz, Michael P ..............................Paper 267 

Steinrucken, Julia .................................Paper 469 

Stelzeneder, David ................................Paper 199 

Stemniski, Paul M .......................Scientific Exhibit SE29 

Stengel, Dirk ................................... Poster P273 

Steppacher, Simon D .........Paper 043, 044, Poster P038, P441, 


Sternberg, Hal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P444 

Steval, Andrew. ................................. Poster P155 

Stevanovic, Vladan ................................Paper 328 

Stewart, Melissa. ..............................Paper 617, 618 

Stewart, Rena .................................Paper 385, 390 

Stimac, Jeffrey ...................................Poster P010 

Stinner, Daniel J .......................Paper 733, Poster P462 

Stitzel, Joel. ............................Scientific Exhibit SE31 

Stocks, Gregory William ..................... Poster P009, P010 

Stodkilde-Jorgenson, Hans. .........................Paper 434 

Stoecklein, Holbrook ..............................Paper 558 

Stoker, Geoffrey. ................................ Poster P374 

Stone, Austin V ...................................Paper 429 

Stoneback, Jason W ............................. Poster P434 

Stonestreet, Matthew ............................ Poster P248 

Stover, Michael David. .............................Paper 140 

Strain, Richard E ........................Scientific Exhibit SE46 

Strauss, Eric ............................. Paper 367, 495, 609 

Streubel, Philipp Nicolas ...........................Paper 732 

Stringer, Keith ....................................Paper 429 

Strohmeyer, Gregory ............................. Poster P193 

Strose, Eric ..................................... Poster P295 

Strzepa, Peter. .................................. Poster P408 

928 

Stuart, Michael J .....Paper 002, 485, 616, 617, 618, 619, 620, 621, 

622, 623, 624, 625, 626, 627, 628, 629, 630, 660 

Stubbs, Allston J .................Multimedia Education MEC44 

Stucken, Charlton ......................Paper 732, Poster P493 

Studzinski, Diane ............................... Poster P390 

Stulberg, Bernard N ...............................Paper 062 

Stulberg, S David. ......................Paper 476, Poster P069 

Stull, Douglass E ..................................Paper 676 

Sturch, Paul ......................................Paper 127 

Stuyck, Jose A ...................................Poster P314 

Su, Brian W ......................................Paper 666 

Su, Edwin P ........Paper 031, 032, 033, 034, 035, 036, 037, 038, 

039, 040, 041, 042, 043, 044, 045, Poster P094 

Su, Hsiu .........................................Paper 205 

Subanesh, Sri. ...................................Poster P112 

Sucato, Daniel J. .................Paper 396, 399, 544, 637, 671, 

Poster P059, P063, P382 

Sudo, Akihiro ........................... Paper 263, 652, 664 

Suero, Eduardo M ......................Paper 499, Poster P156 

Sugamoto, Kazuomi .................... Paper 707, Poster P291 

Sugano, Nobuhiko ....................Poster P050, P052, P053 

Sugarman, Etan........................Paper 746, Poster P358 

Sugi, Michelle T. ..................................Paper 372 

Sugioka, Yuko ....................................Paper 506 

Sugita, Takashi. ................................. Poster P524 

Suk, Michael .....................................Paper 724 

Sukeik, Mohamed. ............................Paper 127, 536 

Sukthankar, Atul .................................Poster P315 

Sumino, Takanobu ................................Paper 300 

Sun, Doo Hoon. .................................Poster P051 

Sun, Jui-Sheng. ...................................Paper 274 

Sunagawa, Toru ...................................Paper 280 

Sunberg, Martin ..................................Paper 242 

Sutter, Grant ................................... Poster P324 

Sutthirunjwong, Piriya ...................Scientific Exhibit SE01 

Suzuki, Kou ......................................Paper 096 

Suzuki, Osami. ...................................Paper 280 

Svensson, Olle. ...................................Paper 615 

Swaims, Chad .................................. Poster P406 

Swamy, Krishna. ..................................Paper 281 

Swann, Russell P ..................................Paper 343 

Swanson, Christopher E ............................Paper 440 

Swanson, David ..............................Paper 455, 456 

Swart, Eric F ..............Paper 147, 275, 276, 332, Poster P303 

Sweeney, Kyle ....................................Paper 221 

Sweet, Fred A .....................................Paper 030 

Swiontkowski, Marc F. ..............Paper 382, 383, Poster P474 

Switzer, Julie A. .........................Scientific Exhibit SE32 

Syed, Ishaq. ......................................Paper 023 

Syed, Khalid. ..........................Paper 589, Poster P177 

Sykes, Joshua Bengtson. .....................Poster P149, P434 

Szabo, Robert Morris ............................ Poster P233 

Szuszczewicz, Edward. ........................... Poster P033 

Taborek, Alex. .................................. Poster P393 

Tachibana, Toshiya .............................. Poster P354 

Tada, Masahiro ...................................Paper 506 

Taghavi, Cyrus Emil ...........................Paper 016, 663 

Tahernia, Amir David ..............................Paper 672 

Tahir, Siti ........................................Paper 489 

Tahmassebi, Jenni .................................Paper 620 

Tajika, Tsuyoshi. ................................ Poster P333 

Takagishi, Kenji ............................Poster P267, P333 

Takahashi, Mark .......................Paper 289, Poster P177 

author IndEx


Takahashi, Kazuhisa ....................Paper 546, Poster P279 

Takamori, Yoshihiro ............................. Poster P366 

Takamura, Karren M ...........................Paper 035, 045 

Takao, Masaki ........................Poster P050, P052, P053 

Takao, Tsuneaki. ................................ Poster P350 

Takaoka, Kunio ................................. Poster P125 

Takata, Munetomo ................................Paper 386 

Takato, Kei .......................................Paper 386 

Takazawa, Makoto. .....................Paper 546, Poster P279 

Takeda, Hideaki. ................................ Poster P432 

Takeda, Mitsuhiro .......................Scientific Exhibit SE26 

Takemae, Takashi ................................Poster P261 

Takemoto, Richelle C ..............................Paper 262 

Takemoto, Steven .............................Paper 479, 749 

Takeshita, Munenori ....................Paper 546, Poster P279 

Takeuchi, Akihiko .........Paper 235, 521, Scientific Exhibit SE83 

Takeuchi, Eiji .....................................Paper 345 

Taki, Naoya .................................... Poster P268 

Talmo, Carl T. ................................Paper 410, 597 

Talwalkar, Vishwas R. ..........................Paper 424, 445 

Tampere, Thomas ............................... Poster P165 

Tan, Eric ...............................Scientific Exhibit SE40 

Tan, Seang Beng ..................................Paper 018 

Tan, Tim. ..............................Scientific Exhibit SE01 

Tan, Virak. ...................................Paper 375, 375 

Tanaka, Kazunori ............................... Poster P007 

Tanaka, Makoto. ...........................Poster P289, P291 

Tanaka, Miho Jean ......................Scientific Exhibit SE70 

Tanaka, Sakae .............................Poster P174, P490 

Tanaka, Yoshinari .................................Paper 201 

Tanaka, Yoshitsugu . . . . . . . . . . . . . . . .Paper 041, Poster P047, P054 

Tanavalee, Aree ................................. Poster P163 

Tancredi, Dan ....................................Paper 593 

Tang, Jessica Anne. .................Paper 029, 444, Poster P387 

Tang, Peter ...................................Paper 273, 276 

Tang, Wan ..................................... Poster P223 

Tank, Jason C. .............................Poster P249, P256 

Tannast, Moritz ..... Paper 043, 044, 551, Poster P038, P251, P441 

Tanzawa, Yoshikazu ...............................Paper 235 

Tanzer, Michael ...............Paper 037, 185, Poster P031, P105 

Taras, John S ............... Scientific Exhibit SE37, Symposia O 

Tarkin, Ivan Seth ................................ Poster P505 

Tashiro, Yasutaka. ......................Paper 414, Poster P168 

Tassinari, Enrico ........................Scientific Exhibit SE09 

Tatman, Penny. ...............................Paper 358, 588 

Taunton, Michael J ................................Paper 192 

Tawada, Kaneaki ..................................Paper 319 

Tay, Keng Jin Darren ...............................Paper 417 

Taylor, Adrian ................................Paper 032, 531 

Taylor, Dean C. ..................................Poster P341 

Taylor, Emma .................................. Poster P238 

Taylor, Erica ......................................Paper 163 

Taylor, Samuel Arthur ....................Scientific Exhibit SE63 

Teefey, Sharlene A ................................Poster P313 

Tejiram, Shawn ...................................Paper 516 

Tejwani, Nirmal C. ................................Paper 105 

Tellini, Alessandra. .......Multimedia Education MEC22, MEC28, 


Temple, H Thomas .............Paper 512, Scientific Exhibit SE81 

Tenekecioglu, Yuksel. ............................ Poster P565 

Tennant, Gregory S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Poster P517 

Terek, Richard M ..................................Paper 234 

Terrin, Michael L ..................................Paper 303 

929 

Terry, Michael A. ..................................Paper 680 

Terwee, Caroline ..................................Paper 616 

Tetradis, Sotirios ..................................Paper 674 

Tetreault, Matthew ...............................Poster P119 

Thabet, Ahmed Mohamed ..........................Paper 423 

Thakur, Nikhil Anand. .............................Paper 049 

Tham, Seng Choe .................................Paper 573 

Thang, Christine K ................................Paper 662 

Theodoropoulos, John ........................... Poster P442 

Theriault, Benoit ..................................Paper 384 

Thies, Scott ......................................Paper 674 

Thomas, Dimitri M ................................Paper 728 

Thomas, Geraint Emyr Rhys. ........................Paper 531 

Thomas, Thad ..........................Scientific Exhibit SE79 

Thomopoulos, Steve .....................Scientific Exhibit SE33 

Thompson, Darby. ................................Paper 648 

Thompson, George H ............................ Poster P255 

Thompson, Matthew ............................ Poster P032 

Thompson, Matthew T ............. Paper 040, Poster P010, P011 

Thompson, Norfleet Buckner. ...................Paper 403, 404 

Thompson, Sean ......Multimedia Education MEC06, Poster P023 

Thornhill, Beverly ......................Paper 746, Poster P358 

Thornhill, Thomas S ...............................Paper 286 

Thorum, Troy ....................................Paper 734 

Throckmorton, Thomas .......................... Poster P286 

Tiberi, John Vincent ....................Paper 074, Poster P067 

Tibone, James E. ................................ Poster P326 

Tibor, Lisa .......................................Paper 369 

Tilzey, John F. .................................. Poster P034 

Timmesfeld, Nina ............................... Poster P132 

Timperley, John. .................................Poster P110 

Timucin, Muharrem ............................. Poster P072 

Ting, Nicholas ....................................Paper 195 

Tintle, Scott M ....................................Paper 705 

Tis, John E .............................Scientific Exhibit SE40 

Tjoumakaris, Fotios Paul ...........................Paper 613 

Tobola, Allison ...................................Paper 373 

Tochigi, Yuki ..........................Paper 092, Poster P281 

Todd, Dane ......................................Paper 483 

Todd, Michael S. ................................ Poster P406 

Togawa, Daisuke ..................................Paper 259 

Togrul, Emre ................................... Poster P566 

Toguchida, Junya. ............................... Poster P239 

Tokimura, Fumiaki .........................Poster P174, P490 

Tokish, John Michael .............................Symposia A 

Tokita, Asami. ....................................Paper 591 

Tokuhara, Yoshio ............................... Poster P125 

Tokunaga, Daisaku ................................Paper 277 

Tolhurst, Stephen R. ...............................Paper 025 

Tolo, Vernon T. ...................................Paper 438 

Tome, Yasunori ................................. Poster P537 

Tomek, Ivan M ...................................Paper 713 

Tomita, Katsuro. .................................Poster P351 

Tomlinson, Lauren .........................Poster P255, P260 

Tompkins, Bryan J. ............................Paper 427, 437 

Toner, Mayu. .....................................Paper 104 

Tongue, John R ..................................Symposia S 

Toni, Aldo .............................Scientific Exhibit SE09 

Torbert, Jesse T. ...................................Paper 219 

Tornetta, Paul ...........Paper 046, 218, 224, 381, 701, 703, 732, 

Poster P469, P493, P514, Symposia U 

Torode, Ian P .....................................Paper 178 

Torrance, David ...................................Paper 630 

author IndEx


Torrens, Carlos ...................................Paper 109 

Torres-Gomez, Armando ............Paper 422, 553, Poster P259 

Torres, Ana Isabel Perez .......................... Poster P008 

Torry, Michael .................................. Poster P336 

Tosteson, Anna ...................................Paper 366 

Tosteson, Tor .....................................Paper 270 

Toth, Alison P .................................. Poster P342 

Toth, John .......................................Paper 271 

Toth, Robert. .................Paper 635, Scientific Exhibit SE12 

Totsch, Martin .................................. Poster P066 

Tow, Benjamin Phak Boon ..........................Paper 018 

Toyama, Shogo ...................................Paper 277 

Trail, Ian A .......................................Paper 281 

Traina, Francesco. ....Multimedia Education MEC02, Poster P220, 


Trammell, Terry Ralph ........................... Poster P370 

Trampuz, Andrej ..............................Paper 468, 469 

Transfeldt, Ensor E ................................Paper 748 

Trappey, George Joseph .......................... Poster P302 

Travlos, Andrew. ..................................Paper 566 

Tressler, Marc A ...................................Paper 221 

Trice, Michael E ................... Scientific Exhibit SE60, SE84 

Trikha, Anjan. ....................................Paper 355 

Trnka, Hans Joerg ............................... Poster P208 

Trojani, Christophe. ...............................Paper 361 

Tron, Alessia ....................Multimedia Education MEC22 

Trousdale, Robert T ................ Paper 002, 014, Poster P032, 

P097, P440, Symposia B 

Truchan, Lisa Marie. ...............................Paper 136 

Truong, Walter Huu ..............................Poster P241 

Truumees, Eeric .........Paper 256, 257, 258, 259, 260, 261, 262, 

263, 264, 265, 266, 267, 268, 269, 270 

Tsarouhas, Alexandros ..................Paper 318, Poster P367 

Tseng, Samuel .................................... Paper 110 

Tsiridis, Elefterios ................................Poster P110 

Tsuboi, Hideki. ...................................Paper 345 

Tsuboi, Toshikazu ..........................Poster P174, P490 

Tsuchiya, Hiroyuki ........Paper 235, 261, 386, 521, Poster P007, 

P351, P537, P538, Scientific Exhibit SE83 

Tsuji, Koji. ..................................... Poster P046 

Tsuji, Matthew. ................................. Poster P442 

Tsujii, Masaya ....................................Paper 652 

Tuan, Rocky S .................................... Paper 210 

Tuccar, Eray .................................... Poster P569 

Tucker, John Keith. .....................Paper 346, Poster P022 

Tucker, Kimberly K .............................. Poster P148 

Tuke, Mike ............................Paper 527, Poster P045 

Tulchin, Kirsten. ..............................Paper 421, 428 

Tulloch, Chris ....................................Paper 069 

Tumer, Yucel ................................... Poster P562 

Tuncay, Ismail Cengiz. ........................... Poster P564 

Tuohy, Christopher ......................Scientific Exhibit SE31 

Turchetto, Luigino. ...............Multimedia Education MEC27 

Turcotte, Robert Emile .............................Paper 524 

Turgeon, Alexis ...................................Paper 384 

Turgeon, Thomas Robert .......................Paper 252, 255 

Turkmen, Metin .................................Poster P561 

Turner, A Simon ..................................Paper 159 

Turner, Alexander W ........................Poster P347, P377 

Turner, Joseph ..........................Scientific Exhibit SE58 

Turturro, Francesco ...............Multimedia Education MEC26 

Twigg, Stacy L .................................. Poster P452 

Twyman, Roy. ....................................Paper 709 

930 

Tyler, Wakenda ...................................Paper 238 

Tzeng, Shiau-Tzu. .................................Paper 137 

Ubierna, Maite ................................. Poster P352 

Uchida, Atsumasa .................................Paper 652 

Uemura, Kazushi. .................................Paper 652 

Uemura, Takeshi ..................................Paper 652 

Ueta, Takayoshi ................................. Poster P350 

Ulusal, Ali Engin ................................ Poster P564 

Umer, Masood. ...................................Paper 142 

Umlas, Marc Evan .......Paper 526, 527, 528, 529, 530, 531, 532, 

533, 534, 535, 536, 537, 538, 539, 540 

Underwood, Richard .....................Paper 033, 067, 068, 


Unlu, Mehmet Can. ........................Poster P565, P567 

Unnanuntana, Aasis .....................Scientific Exhibit SE82 

Unruh, Kenneth P. ................................Paper 380 

Upasani, Vidyadhar V ..............................Paper 394 

Upendra, BN V ...................................Paper 305 

Uquillas, Carlos. ..................................Paper 042 

Urban, Michael ...................................Paper 290 

Urch, Scott E ....................................Poster P410 

Usrey, Molly M .............................Poster P010, P011 

Ustundag, Sinan ................................ Poster P565 

Uzunishvili, Sofia .................................Paper 502 

Vaccaro, Alexander ...............Paper 024, 256, 270, 666, 750, 

Poster P361, P385, Symposia G 

Vadala, Antonio. ................Multimedia Education MEC14, 

Paper 486, 487, Poster P331, P447 

Vaidya, Rahul. ...................................Poster P381 

Vail, Thomas Parker ..............Paper 246, 480, Symposia B, E 

Vaishnav, Suketu B .......Multimedia Education MEC33, MEC34, 

Poster P336 

Vakis, Antonis .................................. Poster P367 

Valderrama, Juanjose .............Multimedia Education MEC01 

Valdevit, Antonio D C. .........Paper 436, Scientific Exhibit SE58 

Valeo, Luigi .................................... Poster P447 

Valero Gonzalez, Fernando ......................... Paper 610 

Valstar, Edward R. .............................Paper 253, 594 

Van Citters, Douglas . . . . . . . . . . . Paper 296, 711, Poster P089, P151 

Van den Bekerom, Michel ...............Paper 008, Poster P113 

Van der Bracht, Hans ............................ Poster P430 

Van Der Linde, Just A ..............................Paper 614 

Van Der Maas, Jaap .............................. Poster P165 

Van Der Meulen, Jan. ..............................Paper 537 

van der Weegen, Walter A P C .......................Paper 070 

Van Dijk, C Niek ........................Scientific Exhibit SE72 

Van Eck, Carola F ........Multimedia Education MEC41, MEC42, 


Van Holsbeeck, Marnix. ............................Paper 230 

Van Jonbergen, Hans Peter W .......................Paper 407 

van Kampen, Albert ...............................Paper 407 

Van Orsouw, Maarten ..............................Paper 038 

van Riet, Roger P ..............................Paper 341, 688 

Van Susante, Job L C ...........................Paper 072, 075 

Van Thiel, Geoffrey ..............Multimedia Education MEC35, 


Vance, Michael. ...................................Paper 337 

Vanderhave, Kelly L. ...............................Paper 025 

Vanel, Daniel. ....................................Paper 433 

Vannini, Francesca ........ Paper 093, 510, Scientific Exhibit SE61 

Varadarajan, Kartik ............................Paper 295, 300 

Varecka, Thomas F .............................. Poster P463 

Varin, Daniel ................................... Poster P083 

author IndEx


Varley, Eric S. .................................Paper 394, 543 

Varsalona, Roberto ......................Scientific Exhibit SE80 

Varvarousis, Dimitrios N. ......................... Poster P060 

Vaseenon, Tanawat ..............Multimedia Education MEC20, 


Vasquez, Luis ....................................Poster P141 

Vasta, Sebastiano. .................................Paper 575 

Vaughn, Jeffrey M .................................Paper 314 

Vaz, Carlos. .................................... Poster P282 

Vecchione, David. .................................Paper 436 

Vellinga, Ryan ........Multimedia Education MEC12, Poster P397 

Velutini, Ricardo ..................................Paper 422 

Velyvis, John H ..................Multimedia Education MEC18 

Vendittoli, Pascal-Andre ............................Paper 034 

Verdonk, MD, Phd, Peter ......................... Poster P165 

Verdonk, Rene .................................. Poster P165 

Verdugo, Alejandro ................................Paper 431 

Verhelst, Luk ..............................Poster P314, P430 

Verioti, Christopher ............................. Poster P124 

Verma, Kushagra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 436 

Verma, Nikhil N ..Paper 160, 200, 367, 495, 574, 609, Poster P329 

Verner, James John .............................. Poster P478 

Verstreken, Frederik. ...............................Paper 341 

Vessey, Judith Anne. ...............................Paper 170 

Vezeridis, Alexander Michael . . . . . . . . . . . . . . . . . . . . . . Poster P477 

Vezeridis, Peter S ................................ Poster P477 

Viens, Nicholas Adam. .........................Paper 057, 058 

Vieth, Volker ................................... Poster P506 

Vijayakumar, Srinivasan .....................Poster P456, P457 

Vijayan, Sridhar. ..................................Paper 196 

Vikerfors, Ola ....................................Paper 615 

Villalobos, Camilo E. .....Multimedia Education MEC08, MEC46, 

MEC47, MEC48, MEC49, MEC50, MEC51, MEC52, MEC53 

Villano, Marco. ..................................Poster P061 

Villarreal, Robert Javier. .......................... Poster P438 

Villavicencio, Pablo ..............Multimedia Education MEC01 

Villegas, Diego. ................................. Poster P453 

Vinje, Tarjei ...............................Poster P497, P500 

Virani, Nazeem ................................. Poster P309 

Virtanen, Carl .................................. Poster P177 

Vitale, Michael G. ...Paper 397, 421, 422, 423, 424, 425, 426, 427, 

428, 429, 430, 431, 432, 433, 434, 435, Poster P382 

Vives, Michael ......Paper 402, 661, 662, 663, 664, 665, 666, 667, 

668, 669, 670, 671, 672, 673, 674, 675 

Vizesi, Frank .....................................Paper 675 

Vogelstein, Jacob ................................ Poster P284 

Voleti, Pramod Babu. ..............................Paper 453 

Volgas, David A ...............................Paper 385, 390 

Volpato, Gian Paolo ............................. Poster P453 

Von Keudell, Arvind Gabriel ........................Paper 203 

von Rechenberg, Brigitte. ...........................Paper 702 

Vora, Anand Mahesh. ..............................Paper 104 

Vosseller, James Turner .............................Paper 102 

Vrahas, Mark S. ............................Poster P206, P516 

Vranceanu, Ana-Maria ............................Poster P231 

Waaler, Gudrun................................. Poster P479 

Wada, Takuro. ....................................Paper 232 

Waddell, James P. .................................Paper 306 

Wade, Charles ...................................Poster P510 

Wadey, Veronica Marie Rita .........................Paper 457 

Wagener, Joe ................................... Poster P209 

Wagner, Emilio ..................................Poster P211 

Wagner, Eric R .........................Paper 518, Poster P166 

931 

Wain, Reese .................................... Poster P397 

Waked, Walid .............................Poster P456, P457 

Wakeling, Christopher .............................Paper 031 

Wakitani, Shigeyuki ...............................Paper 506 

Walch, Gilles . . . . . . . . . . . . . . . . . . . . Paper 079, 081, 088, 362, 363 

Walker, Janet .................................Paper 424, 445 

Walker, John J.. ................................. Poster P406 

Walker, Matthew H ................................Paper 365 

Walker, Peter S. ............................Poster P138, P141 

Wall, Eric .................... Paper 429, 450, 484, Poster P384 

Wall, Lindley B ..................................Poster P313 

Wall, Peter David Henry .......................... Poster P065 

Wallace, Charles Douglas ..........................Poster P221 

Waller, Philip. .................................. Poster P240 

Walloe, Anders ................................. Poster P535 

Walmsley, Phil. ...................................Paper 249 

Walsh, Michael ................................. Poster P472 

Walsh, Pauline. ...................................Paper 477 

Walsh, William R ..................Paper 527, 675, Poster P045 

Walter, Stephen ................................. Poster P460 

Walter, William K ..................Paper 526, 527, Poster P045 

Walter, William Lindsay . . . . . . . . . . . . .Paper 526, 527, Poster P045 

Walters, Thomas J ................................Poster P510 

Wang, Andrea ....................................Paper 226 

Wang, Chen-Chie .................................Paper 500 

Wang, Ching-Jen .................................Poster P461 

Wang, Chung-Li ..................................Paper 500 

Wang, Cunlin ....................................Paper 186 

Wang, Feng-Sheng. ...............................Poster P461 

Wang, Jaw-Lin .................................. Poster P372 

Wang, Jeffrey C ......................Paper 137, 663, 673, 674 

Wang, Joon Ho ................................. Poster P407 

Wang, Lingjun ....................................Paper 228 

Wang, Lushun ....................................Paper 018 

Wang, Ting-Ming. .................................Paper 500 

Wang, Vincent .................................. Poster P329 

Wang, Xiaomei ...................................Paper 149 

Wang, Yun ...............................Paper 042, 586, 718 

Wang, Zhenhai ................................. Poster P206 

Wang, Zhong ................................... Poster P488 

Wang, Zhuo. .....................................Paper 263 

Wanner, John Paul ....................... Paper 082, 090, 363 

Wannomae, Keith K ...............................Paper 533 

Ward, Peter .................................... Poster P002 

Ward, Russell A ...................................Paper 522 

Ward, Samuel R. ..................................Paper 556 

Ward, Shan G ....................................Paper 428 

Warme, Winston J ......................Paper 454, Poster P294 

Warmington, Kelly ................................Paper 053 

Warner, Cory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 241 

Warner, Jon J P ....Multimedia Education MEC03, Paper 164, 363 

Warner, William C ............ Paper 167, 403, 404, Poster P250 

Warren, Adam .................................. Poster P339 

Warren, Russell F. .............Paper 159, 205, 577, Poster P449, 


Wasserman, Scott M ...............................Paper 387 

Watanabe, Kenichi ...............................Poster P115 

Watanabe, Koji ...............................Paper 386, 521 

Watanabe, Nobuyuki ..............................Paper 319 

Waterman, Brian ................................ Poster P406 

Waters, Peter M .................................Symposia D 

Watson, J Tracy .....................Paper 693, Symposia U, W 

Watson, Jeffrey Dean ......................Paper 694, 700, 731 

author IndEx


Watters, Tyler Steven ...........................Paper 246, 389 

Wayne, Jennifer S ............................... Poster P099 

Weatherall, Justin M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 105 

Weaver, DeWayne Lynn ............................Paper 727 

Weaver, Michael J ................................Poster P516 

Webber, Nicholas Paul .............................Paper 522 

Weber, Alexander ..................Scientific Exhibit SE71, SE73 

Weber, Donald ................................. Poster P086 

Weber, Kristy L. ..................................Symposia F 

Weber, Marc-Andre ................................Paper 561 

Weber, Robert .................................. Poster P229 

Weber, Stephen C .......Paper 158, 601, 602, 603, 604, 605, 606, 

607, 608, 609, 610, 611, 612, 613, 614, 615 

Wee, James. .....................................Poster P112 

Weesner, Marshall .................................Paper 425 

Wegman, Brian ................................. Poster P205 

Wegner, Alexander .............................. Poster P084 

Weichel, Derek ................................. Poster P265 

Weigel, Dennis P.......................Paper 120, Poster P274 

Weil, Yoram A ....................................Paper 139 

Weiland, Andrew J ......................Scientific Exhibit SE63 

Weinberg, Jacob ..................................Paper 431 

Weiner, Bradley K .................................Paper 260 

Weiner, Dennis S. ..........................Poster P249, P256 

Weinhold, Paul ...................................Paper 585 

Weinstein, James N. ....................Paper 270, Poster P361 

Weinstein, Stuart L ...........Scientific Exhibit SE47, Symposia S 

Weir, David M ....................................Paper 677 

Weir, Robert. .....................................Paper 502 

Weiss, Michael. ............................... Symposia 152 

Weisstein, Jason Scott ....Paper 226, 227, 228, 229, 230, 231, 232, 

233, 234, 235, 236, 237, 238, 239, 240 

Welge, Jeffrey A ...................................Paper 425 

Weller, Amanda Lindsley .......................Paper 172, 173 

Wells, Christopher W ..............................Paper 004 

Wells, Jessica ..........Multimedia Education MEC03, Paper 164 

Wells, Lawrence. ..................................Paper 118 

Weng, Haoling H ............................... Poster P266 

Wenger, Dennis R ......................Paper 543, Poster P251 

Wenger, Doris .................................. Poster P544 

Wenke, Joseph C .... Paper 138, 379, 733, 733, Poster P462, P485, 

P498, P502, P507, P511 

Wera, Glenn. .....................................Paper 195 

Werkema, Judi. ...................................Paper 471 

Werle, Jason. .....................................Paper 034 

Werlen, Stefan ....................................Paper 542 

Werner, Brian C ...................................Paper 027 

Wessel, Jean ......................................Paper 457 

Wessell, Daniel ..................................Poster P313 

West, Michael .................................. Poster P444 

Westrich, Geoffrey H. ............. Paper 595, Poster P018, P020, 

P024, P087, P189 

White, Gregory R. .................................Paper 314 

White, Neil ......................................Paper 275 

White, Richard E ..........Paper 706, 707, 708, 709, 710, 711, 712, 

713, 714, 715, 716, 717, 718, 719, 720 

White, Richard H. .................................Paper 593 

White, Tom ......................................Paper 507 

Whiteside, Leo A .........Multimedia Education MEC09, MEC13, 

MEC15, MEC16, MEC19, 


Whitesides, Thomas E. ............................Poster P481 

Whitlock, Patrick W .....................Scientific Exhibit SE31 

932 

Whitwell, Duncan. ......................Scientific Exhibit SE06 

Whyne, Cari. .....................................Paper 141 

Wiater, J Michael .......................Paper 077, Poster P345 

Wich, Michael .................................. Poster P273 

Wickiewicz, Thomas L .........................Paper 205, 327 

Widmaier, James C ................................Paper 716 

Widmann, Roger F ........................Paper 401, 401, 405 

Wiebelhaus, John .................................Paper 241 

Wiedenhoefer, Bernd ............................ Poster P405 

Wiedenhofer, Bernd .....................Scientific Exhibit SE59 

Wiedrich, Thomas A ...............................Paper 342 

Wierks, Carl .....................Multimedia Education MEC32 

Wieskoetter, Britta. .............................. Poster P506 

Wiesner, Lindsay ................................ Poster P463 

Wijdicks, Coen A. .................................Paper 307 

Wilckens, John H .......Poster P421, Scientific Exhibit SE62, SE66 

Wild, Dana ......................................Paper 549 

Wilfred, SE. ......................................Paper 290 

Willems, W Jaap ..................................Paper 614 

Williams, Ariel. ............................Poster P214, P227 

Williams, Bart ....................................Paper 150 

Williams, Benjamin R. .............................Paper 498 

Williams, Dan ....................................Paper 073 

Williams, Daniel K ................................Paper 492 

Williams, Frank ............................... Symposia 152 

Williams, Gerald R ..........Paper 601, Poster P317, Symposia M 

Williams, John Barton ........................... Poster P250 

Williams, John Leicester ............................Paper 288 

Williams, Johnathan. ............................ Poster P466 

Williams, Kelly M ............................... Poster P034 

Williams, Nicole T .............................. Poster P557 

Williams, Riley Joseph ....... Paper 205, 361, 362, 363, 364, 365, 

366, 367, 368, 369, 370, 371, 

372, 373, 374, 375, 577 

Wilkinson, Sean ..................................Paper 750 

Williamson, Chris. ................................Paper 284 

Willis, Matthew Parker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 365 

Wilson, APR. .....................................Paper 127 

Wilson, Philip L ..................................Paper 432 

Wilson, Vasthi ......................... Paper 519, Poster P521 

Wimberly, Robert Lane .............................Paper 432 

Wimmer, Matthias Dominik ........................Paper 193 

Wind, Tyler Conway ...............................Paper 650 

Windhager, Reinhard ..............................Paper 520 

Winn, Robert ................................... Poster P269 

Winter, Robert B ..................................Paper 748 

Winters, Brian ...................................Poster P107 

Wirth, Michael A................................Symposia M 

Wirtz, Dieter .................................Paper 193, 740 

Wisk, Lauren ................................... Poster P067 

Witt, Johan .................................... Poster P437 

Wittig, James C ..........Multimedia Education MEC08, MEC46, 



Woehnl, Antonia. ...Paper 121, Scientific Exhibit SE05, SE19, SE22 

Wolf, Brian R ....................Multimedia Education MEC04 

Wolf, Fredric M ...................................Paper 454 

Wolf, Jennifer Moriatis ........................... Poster P434 

Wolfe, Carmen ...................................Paper 331 

Wolfe, Scott W. ...................................Paper 558 

Wolff, Aviva ......................................Paper 558 

Wolinsky, Philip R. .......Paper 301, 302, 303, 304, 305, 306, 307, 

308, 309, 310, 311, 312, 313, 314, 315 

author IndEx


Wollowick, Adam Laurance ...Paper 746, Poster P358, Symposia T 

Woltz, Jennifer. ................................. Poster P003 

Won, Man Hee ...................................Paper 475 

Wong, Melissa ................................Paper 166, 176 

Wood, Robert E. .......................Paper 450, Poster P384 

Woodcock, Jessica .................................Paper 545 

Woods, Barrett Ivory ...............................Paper 023 

Woodward, Chase. ................................Paper 680 

Woolwine, Spencer .............................. Poster P242 

Worden, Alicia. ...............................Paper 141, 679 

Wright, Adam .................................. Poster P505 

Wright, Dennis ................................. Poster P495 

Wright, Elizabeth A. ...............................Paper 184 

Wright, John .....................................Paper 286 

Wright, Judy L .................................. Poster P559 

Wright, Patty ................................... Poster P137 

Wright, Rick W ................................. Poster P433 

Wright, Russel C .................................Poster P471 

Wright, Timothy M ........... Paper 534, 738, Poster P024, P424 

Wu, Chung-Ding. ..........................Poster P157, P365 

Wu, Eileen Wan-Ying ..............................Paper 136 

Wu, Karl .....................................Paper 522, 522 

Wu, Tuoh. .......................................Paper 274 

Wunder, Jay ..................................Paper 523, 524 

Wustrack, Rosanna Lisa ........................Paper 227, 266 

Wyatt, Ronald W B ...............................Poster P413 

Wybo, Christopher D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 439 

Wylie, Jack W. .................................. Poster P195 

Xerogeanes, John W ...............................Paper 483 

Xia, Yang ........................................Paper 204 

Xu, Yinghua. ....................................Poster P301 

Xypnitos, Fragiskos ................................Paper 223 

Yacob, Alem. ....................................Poster P312 

Yacoubian, Shahan V .............................Poster P471 

Yacoubian, Stephan Vahe ..........................Poster P471 

YaDeau, Jacques ..................................Paper 290 

Yagi, Mitsuru . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P348 

Yalcin, Burak ................................... Poster P567 

Yamada, Katsuhisa ................................Paper 259 

Yamada, Koji ..............................Poster P174, P490 

Yamada, Susumu. .................................Paper 272 

Yamagata, Masatsugu ...................Paper 619, Poster P158 

Yamaguchi, Ken. ................Poster P313, P322, Symposia H 

Yamaguchi, Tamonori. ........................... Poster P393 

Yamako, Go. .....................................Paper 707 

Yamamoto, Atsushi. ............................. Poster P333 

Yamamoto, Nobuyuki ............................Poster P291 

Yamamoto, Norio ............Poster P537, Scientific Exhibit SE83 

Yamamoto, Takuaki ....................Paper 308, Poster P476 

Yamamura, Mitsuyoshi. ............................Paper 707 

Yamashita, Takayuki ...............................Paper 267 

Yamashita, Toshihiko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 232 

Yamauchi, Kensuke. ............................. Poster P537 

Yan, Alan Yong ................................. Poster P278 

Yang, Ick-Hwan ................................. Poster P055 

Yang, Kuender D .................................Poster P461 

Yang, Quinton. ...................................Paper 116 

Yang, Rong-Sen ................................. Poster P529 

Yang, Syngil Steven ................................Paper 570 

Yanke, Adam Blair. ...............Multimedia Education MEC35 

Yano, Koichiro. ...................................Paper 591 

Yantis, Matthew G. ................................Paper 404 

Yao, Jeffrey. ...........................Paper 563, Poster P237 

933 

Yaste, Jeffrey Jon-Michael ..........................Poster P316 

Yasuda, Kazunori. .................................Paper 321 

Yasui, Natsuo. ....................................Paper 143 

Yasunaga, Yuji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P524 

Yaszay, Burt ..................Paper 179, 447, Poster P247, P371 

Yaszemski, Michael J. ........Scientific Exhibit SE84, Symposia W 

Yates, Adolph J ................................Symposia 151 

Yeh, Albert C ................................... Poster P275 

Yemm, Tedd. .....................................Paper 625 

Yeo, Seng-Jin .............Paper 012, 408, 417, Poster P112, P159 

Yeom, Jin-Sup ....................................Paper 026 

Yett, Harris S .....................................Paper 301 

Yeung, Eric .......................................Paper 526 

Yew, Andy .......................................Paper 018 

Yian, Edward .................................Paper 080, 608 

Yildirim, Gokce ............................Poster P138, P141 

Yngve, David A ...................................Paper 549 

Yocum, Lewis A ................................. Poster P420 

Yonetani, Yasukazu ................................Paper 201 

Yonick, David ....................................Paper 140 

Yoo, Jae Ho ................. Paper 329, 490, Poster P200, P272 

Yoo, Jae-Chul. ....................................Paper 683 

Yoo, Jaedoo . . . . . . . . . . . . . . . . . . . . . Paper 155, 162, 316, 604, 605 

Yoo, Je Hyun .....................................Paper 309 

Yoo, Jeong-hyun ..................................Paper 673 

Yoo, Jeong Joon. ..................................Paper 309 

Yoo, Ju Hyung .................................. Poster P055 

Yoo, Jung U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 020 

Yoon, Jangwhon .................................Poster P311 

Yoon, Taek Rim ................................. Poster P029 

Yorgova, Petya ....................................Paper 396 

York, Sally ............................Paper 463, Poster P085 

Yoshida, Hironori ............................... Poster P007 

Yoshida, Taku ...................................Poster P115 

Yoshikawa, Hideki ...........Paper 707, Poster P050, P052, P053 

Yoshimura, Ichiro .................................Paper 098 

Yoshioka, Katsuhito ..............................Poster P351 

Yoshiya, Shinichi. ............................... Poster P354 

You, Zongbing. ...................................Paper 209 

Young, Allan .............................Paper 079, 081, 088 

Young, Brett H. ..................Multimedia Education MEC40 

Young, Simon ....................................Paper 165 

Yu, Warren D ................................... Poster P347 

Yu, Yangyang ................................... Poster P275 

Yuan, Brandon J ................................ Poster P097 

Yuan, Xunhua .................................. Poster P056 

Yue, Bing ........................................Paper 295 

Yue, Eric J. ..................Poster P198, Scientific Exhibit SE04 

Yue, Wai Mun ....................................Paper 018 

Yugue, Itaru .................................... Poster P350 

Yukizawa, Youhei ..........................Poster P049, P068 

Yun, Yeo-Hon ................................Paper 155, 162 

Yurgin, Nicole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 387 

Zachazewski, James E ..............................Paper 647 

Zadnik Newell, Mary ..............................Paper 388 

Zadzilka, Jayson D ................................Paper 062 

Zaferiou, Antonia .................................Paper 327 

Zaffagnini, Stefano ...........Poster P414, Scientific Exhibit SE24 

Zaltz, Ira. ................... Paper 637, 644, Poster P059, P063 

Zanetti, Marco ...................................Poster P315 

Zapletalova, Jana. ................................Poster P131 

Zarkadas, Peter Constantine. ...................... Poster P286 

Zarrabian, Mohammad ............................Paper 251 

author IndEx


Zatushevsky, Michael ............................ Poster P377 

Zavala, John Alexander. ............................Paper 373 

Zdero, Rad .......................................Paper 306 

Zebala, Lukas P.. .................Paper 022, 030, 446, 449, 661, 


Zehetgruber, Harald ...............................Paper 347 

Zeidman, Seth .................................. Poster P368 

Zeitler, Evan. ....................................Poster P501 

Zell, Jason .......................................Paper 233 

Zellers Fortuna, Kristine .......................... Poster P482 

Zen, Yo. ....................................... Poster P538 

Zeni, Amer. .................................... Poster P487 

Zhang, Haitao ....................................Paper 448 

Zhang, Hongbin ..............................Paper 451, 452 

Zhang, Kai .......................................Paper 738 

Zhang, Yang. ................................... Poster P545 

Zhang, Zhen ..............................Poster P456, P457 

Zhao, Caixia .....................................Paper 402 

Zhao, Li .........................................Paper 662 

Zhao, Qianqian. ..................................Paper 727 

Zhao, Wen ..................................... Poster P206 

Zhao, Wenyan .........................Paper 270, Poster P361 

Zhen, Gehua ................................... Poster P284 

Zheng, Kathy .....................................Paper 655 

Zhu, Jinjun ..................................Paper 420, 708 

Zicat, Bernard A. ...................Paper 526, 527, Poster P045 

934 

Ziebarth, Kai .......................... Paper 551, Poster P251 

Ziegler, Daniel. ...................................Paper 730 

Zilberman, Yoram. ................................Paper 139 

Zingde, Sumesh M .....................Paper 292, Poster P197 

Zingg, Patrick Oliver ..............................Poster P315 

Zingmond, David .............................Paper 039, 719 

Zini, Raul ........................................Paper 578 

Ziogas, Argyrios. ..................................Paper 233 

Zionts, Lewis Evan ................................Paper 166 

Ziran, Bruce ..............Paper 211, 212, 213, 214, 215, 216, 217, 

218, 219, 220, 221, 222, 223, 224, 225 

Zlowodzki, Michael Pawel . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 307 

Zmistowski, Benjamin .....Paper 125, 357, 538, 539, Poster P186, 


Zmitzkowski, Benjamin ............................Paper 601 

Zografos, Angelos .................................Paper 068 

Zonno, Alan .....................................Paper 581 

Zouzias, Ioannis ..................................Paper 275 

Zuckerman, Joseph D ..........................Paper 370, 372 

Zukor, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poster P082 

Zunkiewicz, Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paper 685 

Zupko, Karen. ................................ Symposia 152 

Zurakowski, David .............Paper 168, 170, 430, Poster P025 

Zwicky, Lukas ....................................Paper 055 

Zywiel, Michael G ......................Paper 121, Poster P062, 


author IndEx

KEYWORD AAOS EVENT KEYWORD AAOS EVENT 

AC Joint / Bankart Repair / Slap. ........Papers 160, 609, 611, 612, 

614, 615, 688, 689, 

Posters P328, P330, P335, P341 

ACL Deficient ......................Papers 321, 324, 327, 482, 

Posters P406, P407, P418, P421, 

P422, P425, P435, P450, 

Scientific Exhibits SE65, SE67, SE69 

ACL Graft Selection / Placement Fixation.........Papers 318, 319, 

320, 321, 322, 323, 324, 326, 327, 328, 

481, 483, 485, Posters P407, P416, 

P418, P430, P432, P438, P447, P455, 

Scientific Exhibits SE72 

ACL Outcomes .........Papers 316, 317, 318, 320, 321, 322, 323, 

324, 325, 326, 328, 329, 481, 482, 485, 

486, 649, Posters P406, P407, P410, 

P416, P418, P422, P425, P438, P447, 


Allograft/Vascular Fibular Grafts ........Papers 513, Posters P533, 


Anatomy / Biomechanics .....Papers 010, 131, 134, 250, 288, 298, 

409, Posters P115, P123, P138, P141, 

P150, P162, P168, P179, P181, P185, P197, 

Scientific Exhibits SE23, SE24, SE26, SE29 

Anatomy and Basic Science ...Papers 040, 044, 466, 539, 706, 707, 

710, 720, Posters P010, P017, P031, 

P036, P037, P038, P044, P050, P052, 

P064, P066, P067, P072, P079, P090, 

P099, Scientific Exhibits SE08 

Ankle Instability ........Papers 092, 096, 505, Posters P212, P218 

Arthritis ..............................Scientific Exhibits SE32 

Arthroplasty. ..........................Scientific Exhibits SE30 

Arthroplasty / Primary / Revison and Arthrodesis ......Papers 076, 

077, 078, 079, 080, 081, 082, 083, 084, 

085, 086, 087, 088, 089, 165, 361, 362, 

363, 364, 365, 366, 367, 368, 369, 370, 

371, 372, 602, 606, 607, 610, 685, 

Posters P286, P287, P288, P294, P296, P300, 

P302, P309, P311, P314, P317, P325, P337, 

P339, P344, P345, Scientific Exhibits SE49 

Articular Cartilage ...........Papers 196, 197, 198, 199, 200, 201, 

202, 203, 204, 205, 206, 207, 208, 209, 

210, 327, 576, 631, 636, 640, 651, 655, 

656, Posters P408, P410, P437, P441, 

P444, P451, P451, 


Avascular Necrosis. ............... Papers 037, 472, Posters P051 

Back Pain / Other ...........Papers 258, 264, 265, 266, 269, 441, 

664, 667, 672, 673, 674, 736, 743, 744, 

747, 748, 750, Posters P352, P365, P367, 

P368, P375, P378, P379, P381, P383, 

P385, P393, P401, P403, P404 

935 

Basic Science .......... Papers 027, 124, 126, 131, 136, 137, 138, 

140, 141, 142, 143, 145, 146, 147, 148, 

148, 149, 149, 150, 260, 273, 288, 289, 

292, 296, 306, 378, 379, 443, 448, 556, 

557, 558, 565, 566, 662, 663, 664, 669, 

673, 674, 675, 691, 694, 700, 701, 703, 

721, 724, 727, 729, 733, 734, 739, 740, 

742, Posters P115, P138, P154, P171, 

P174, P177, P185, P187, P188, P194, 

P197, P227, P237, P239, P346, P352, 

P364, P367, P376, P390, P393, P404, 

P462, P476, P478, P481, P483, P484, 

P485, P486, P501, P506, P507, P510, P517, 

P520, Scientific Exhibits SE75, SE79 

Basic Science / Tumor / Infection ......Papers 174, 393, 405, 429, 

430, 431, 432, 433, 434, 541, 542, 543, 

550, Posters P243, P249, P256, 


Bearing Surfaces ............Papers 031, 033, 034, 035, 036, 038, 

044, 061, 062, 063, 065, 066, 067, 069, 

071, 072, 073, 074, 075, 189, 191, 350, 

470, 526, 527, 528, 529, 531, 532, 533, 

Posters P006, P008, P012, P019, P024, 

P029, P032, P041, P045, P053, P057, 

P071, P073, P074, P086, P091, P091, 

P094, P103, Scientific Exhibits SE01, 

SE03, SE05, SE06, SE07 

Benign ........................Papers 229, 230, 237, 238, 522, 

Posters P530, P541, P542, 


Biceps. ............... Papers 609, 677, 683, Posters P318, P320, 


Bilateral Procedures ..............Papers 290, Posters P117, P191 

Biomechanics .........................Scientific Exhibits SE31 

Biomechanics / Anatomy .....Papers 017, 022, 029, 443, 444, 669, 

670, 738, Posters P347, P369, P376, 

P377, P379, P387, P393, P399, 


Blood Loss .........................Papers 357, 359, 536, 539, 

Posters P027, P037 

Bone. ................................Scientific Exhibits SE32 

Bone Graft / Fusion. .........Papers 018, 260, 661, 662, 663, 673, 

674, 675, 745, Posters P353, P359, 

P360, P374, P381, P402 

Carpal Tunnel .......... Papers 274, 557, 561, 563, Posters P230, 


Carpus / Metacarpal / Phalanges ...Papers 271, 277, 278, 280, 282, 

284, 337, 338, 339, 340, 341, 342, 558, 

559, 561, 568, 569, Posters P227, P229, 


Cartilage. .............................Scientific Exhibits SE32 

Cartilage Transplantation. ........Papers 196, 197, 198, 199, 200, 

202, 206, 207, 208, Posters P444, P451, 


Cemented ..................... Papers 709, Posters P090, P095 

Cemented Total Hip Arthroplasty ......Papers 035, 181, 350, 358, 

531, 709, Posters P042, P080, P081 

Cervical ...............Papers 016, 017, 018, 019, 020, 021, 022, 

023, 024, 025, 026, 027, 028, 029, 030, 

444, 663, 737, 738, 740, 741, 748, 750, 

Posters P347, P350, P354, P355, P356, 

P357, P374, P395, P396, P400 

Clavicle Fractures ................Papers 085, 604, Posters P335 

Keyword IndEx


Compartment Syndrome/Limb Salvage ..... Papers 312, 389, 729, 

734, 735, Posters P462, P481, P498, 

P502, P510, Scientific Exhibits SE74, SE75 

Complications. .........Papers 018, 019, 024, 026, 028, 030, 031, 

035, 036, 038, 039, 042, 061, 064, 065, 

066, 069, 073, 074, 075, 182, 183, 187, 

188, 190, 192, 256, 263, 270, 346, 357, 

437, 438, 439, 440, 442, 467, 468, 469, 

470, 471, 475, 478, 479, 480, 529, 536, 

537, 539, 540, 666, 667, 670, 715, 718, 

739, 745, Posters P002, P004, P006, 

P014, P018, P023, P030, P034, P039, P040, 

P047, P048, P057, P060, P062, P069, P071, 

P086, P097, P098, P101, P104, P105, P107, 

P348, P349, P352, P354, P356, P357, P359, 

P361, P362, P368, P370, P371, P374, P380, 

P381, P392, P394, P397, P400, P401, P402, 

P405, Scientific Exhibits SE01, SE02, SE04, 

SE05, SE06, SE08, SE09, SE10, SE11 

Computer / Technology ..............Papers 120, 456, 457, 459, 

Posters P262, P264, P273, P274 

DRUJ / TFCC ...................Papers 285, 333, 343, 345, 570, 

Posters P228, Scientific Exhibits SE36 

Deformities ............Papers 171, 391, 392, 393, 394, 399, 400, 

421, 423, 426, 427, 428, 433, 434, 546, 

551, 553, 555, Posters P241, P242, P243, 

P244, P245, P251, P255, P258, P260, 


Degenerative Disc Pain / Disease. ......Papers 016, 256, 259, 263, 

264, 265, 269, 270, 664, 736, 739, 743, 

748, 749, Posters P346, P349, P352, 

P363, P363, P367, P373, P375, P376, 

P379, P386, P390, P400, P403 

Diagnostic Imaging. ...Papers 086, 369, Posters P288, P302, P313, 

P315, P323, P327, P331, P333, P339 

Disc Herniation. ....... Papers 022, 267, 268, 269, 270, 737, 741, 

Posters P346, P352, P366, P367, P390, 

P393, P403 

Dislocations. ...........................Papers 182, 349, 479, 



Distal Radius .......... Papers 276, 284, 285, 331, 332, 333, 334, 

335, 336, 344, Posters P226, P228, P233 

Distal Radius/Forearm/Elbow .........Papers 694, 695, 696, 697, 

698, 699, Posters P467, P469, P477, P482, 


Economic / Cost Analysis. ......Papers 106, 107, 110, 111, 112, 114, 

115, 116, 118, 119, 120, 451, 452, 453, 463, 

Posters P263, P265, P266, P269, P271, 

P272, P273, P274, Scientific Exhibits SE42, 

SE43, SE44, SE48 

Education .................Papers 107, 108, 452, 453, 455, 456, 

457, 458, 459, 460, 461, 463, 464, 465, 

Posters P262, P264, P270, P271, P275, 


Elbow / Hand ............ Papers 652, Posters P431, P434, P446, 

Scientific Exhibits SE66, SE68 

Elbow / Tendon Injuries / Contracture / ...................... 

Radial Tunnel Syndrome Papers 677, 678, 681, 684, 686, 

Posters P298, P303, P305, P306, P316, 


936 

Elbow Basic Science / Biomechanics .... Posters P293, P303, P304, 

P306, P316, P318, P321, P324, P334, 

P338, P340 

Endoscopic Spinal Surgery .........Papers 267, 268, Posters P372 

Epidemiology/Procedural/Outcomes ....Papers 139, 211, 212, 220, 

223, 301, 302, 303, 304, 309, 310, 377, 

381, 384, 388, 389, 390, 693, 696, 697, 

721, 723, 726, 727, 728, 731, 734, 

Posters P458, P465, P466, P467, P469, 

P470, P476, P479, P482, P488, P489, P490, 

P498, P499, P502, P504, P508, P509, P510, 

P511, P512, P513, P515, P515, P517, P518, 


Extensor Mechanism. ....................Papers 297, 587, 590, 

Posters P136, P172, P203 

Femoral ...................Papers 187, 193, 194, 351, 352, 360, 

709, Posters P001, P006, P038, P052, 

P055, P059, P068, P080, P090, 


Femur/Patella ..............Papers 137, 144, 145, 150, 304, 305, 

308, 309, 310, 311, 312, 313, 314, 377, 

386, 704, Posters P459, P459, P461, 

P464, P471, P473, P480, P502, P509, 

P513, P519, Scientific Exhibits SE76 

Foot / Ankle. ...............Papers 167, 385, 388, 390, 421, 422, 

423, 424, 425, 428, 646, 651, 724, 

Posters P244, P250, P259, P431, P445, 


Forefoot ...................Papers 050, 499, 505, 505, 506, 507, 

508, 509, Posters P220, P222, P223 

Fracture Healing ........... Papers 137, 138, 139, 140, 142, 144, 

147, 150, 301, 309, 310, 376, 379, 380, 

385, 386, 387, 389, 691, 693, 701, 702, 

Posters P456, P457, P458, P459, P463, 

P464, P471, P472, P477, P478, P480, P482, 

P484, P485, P494, P501, P503, P506, P509, 


Fractures. ..................Papers 046, 047, 049, 050, 091, 504, 

Posters P206, P213, P214, P218, P224 

Frozen Shoulder / Shoulder Contractures. ... Papers 371, 373, 374, 

603, 605, 608, 

Posters P301, P308, P333 

Giant Cell ..............Papers 229, 237, 238, 512, Posters P526 

Hallux Valgus. ......... Papers 506, 510, Posters P207, P207, P216 

Hemiarthroplasty ...... Papers 078, 080, 165, 364, 366, 367, 602, 

607, Posters P290, P294, P296, P337, P344 

Hindfoot / Ankle. ...........Papers 046, 048, 053, 054, 055, 056, 

057, 058, 059, 060, 091, 093, 094, 095, 

096, 097, 098, 099, 101, 102, 103, 104, 

105, 497, 501, 502, 504, Posters P208, 

P208, P210, P211, P215, P217, P218, 

P219, P220, P222, P223, P224, 


Hip ...................... Papers 633, 634, 635, 636, 637, 638, 

639, 640, 641, 642, 643, 644, 645, 

Posters P409, P411, P412, P419, P437, 

P440, P441, P453, P454 

Hip / Ddh Rehab. ...... Papers 541, 542, 543, 544, 545, 546, 547, 

551, 552, Posters P241, P251, P252, P253, 


Hip Dysplasia ......... Papers 041, 043, 706, Posters P007, P046, 

P049, P054, P058, P059, P062, 


Keyword IndEx


Hip Fractrure ...........Papers 217, 301, 302, 303, 306, 307, 308, 

309, 722, Posters P456, P457, P460, P466, 

P471, P475, P476, P479, P488, P489, P490, 

P492, P496, P497, P500, P507, P512, 


Humerus .............. Papers 691, 692, 693, 695, Posters P465, 


Iliac Crest Bone Graft ............................. Papers 661 

Imaging ...................Papers 230, 231, 234, 237, 519, 522, 

Posters P521, P540, P544, 


Impingement. .............. Papers 160, 373, 374, Posters P333, 


Infected Total Hip Arthroplasty ........Papers 354, 466, 467, 468, 

469, 470, 471, 480, 538, 715, 

Posters P004, P015, P034, P060, P084, 


Infection / Metabolic Disease / Tumor ......Papers 030, 262, 436, 

437, 438, 665, 745, 747, Posters P351, 


Infectious. .....................Papers 521, Posters P532, P538 

Injuries. ...................Papers 206, 325, 484, 571, 577, 582, 

632, 633, 641, 642, 643, 646, 648, 650, 

652, 654, Posters P406, P408, P417, P421, 

P422, P431, P434, P437, P439, P443, 

P445, P452, Scientific Exhibits SE62, 

SE63, SE64, SE65, SE68, SE73 

Instrument / Pedicle Screw. .......Papers 256, 257, 259, 261, 263, 

264, 440, 661, 668, 669, 670, 

Posters P349, P354, P359, P360, P364, 


Instrumentation ............Papers 018, 027, 029, 259, 260, 441, 

442, 443, 444, 667, 668, 738, 739, 745, 

747, Posters P347, P348, P354, P359, 

P363, P365, P370, P377, P387, P402, 


Internal/External Fixation .... Papers 211, 212, 218, 220, 222, 223, 

301, 306, 311, 376, 383, 386, 389, 691, 

693, 694, 699, 700, 701, 702, 728, 734, 

Posters P456, P457, P459, P462, P469, 

P471, P472, P473, P480, P480, P483, 

P490, P492, P494, P496, P518, P520, 


Knee ..............................Papers 426, 427, 550, 554, 

Posters P248, P254, Scientific Exhibits SE39 

Knee / Hip / Osteoarthritis / Total Hip Arthroplasty ....Papers 616, 

617, 618, 619, 620, 621, 622, 625, 

Posters P277, P278, P279, P280, 

P281, P282, P285 

Knee Arthroscopy .......Papers 198, 199, 203, 209, 210, 317, 318, 

319, 320, 325, 326, 482, 483, 484, 486, 

487, 488, 491, 493, 647, 652, 653, 654, 

655, 656, 657, 658, 659, 660, 

Posters P406, P407, P413, P414, P422, 

P423, P425, P428, P430, P433, P438, 

P447, P451, Scientific Exhibits SE60, SE61, 

SE64, SE65, SE66, SE69, SE70, SE71, SE72 

Lumbar Fusion .............Papers 256, 257, 259, 260, 261, 263, 

264, 662, 673, 674, 675, 747, 

Posters P359, P361, P363, P368, P369, 

P377, P381, P386, P387, P389, P398, 


937 

MRI / Imaging ..............Papers 203, 204, 483, 486, 487, 490, 

491, 493, 573, 632, 634, 636, 637, 638, 

639, 655, 657, Posters P410, P412, P414, 

P447, Scientific Exhibits SE55, SE72 

Meniscal Repair / Transplants .....Papers 491, 492, 494, 495, 655, 

Posters P414, P433, P449, 


Meniscus ..................Papers 327, 482, 491, 493, 494, 495, 

653, 655, 656, 657, Posters P408, P410, 


Metastatic. .................Papers 230, 233, 234, 235, 239, 512, 

518, 523, 525, Posters P521, P526, 

P535, P536, P545 

Miscellaneous ..........Papers 013, 015, 035, 037, 042, 048, 051, 

052, 059, 072, 075, 100, 103, 124, 125, 

126, 142, 148, 182, 219, 229, 230, 233, 

236, 239, 253, 272, 281, 293, 299, 353, 

355, 377, 378, 468, 472, 498, 500, 501, 

504, 505, 507, 514, 515, 522, 525, 557, 

560, 562, 565, 570, 586, 586, 594, 616, 

618, 620, 621, 623, 624, 626, 627, 627, 

627, 627, 628, 630, 703, 705, 710, 714, 

717, 718, 724, 726, 727, Posters P008, 

P013, P023, P031, P038, P050, P052, P062, 

P070, P079, P106, P107, P108, P111, P116, 

P134, P140, P147, P158, P160, P165, P166, 

P170, P175, P184, P185, P186, P195, P209, 

P210, P211, P216, P220, P221, P225, P227, 

P231, P232, P235, P238, P276, P276, P276, 

P278, P279, P283, P284, P285, P457, P473, 

P474, P477, P487, P498, P501, P511, P517, 

P523, P523, P523, P523, P527, P530, 

P531, P532, P535, P539, P542, P544, 

Scientific Exhibits SE05, SE10, SE14, 

SE15, SE19, SE22, SE34, SE37, SE84 

Muscle ...............................Scientific Exhibits SE31 

Nerve ................................Scientific Exhibits SE31 

Neuromuscular .................Papers 547, 548, 549, 549, 550, 


New Technique / Device. .....Papers 017, 027, 438, 439, 449, 662, 

667, 670, 736, 737, 738, 740, 741, 

Posters P364, P365, P368, P372, P373, 

P375, P377, P379, P386, P387, P396, P398 

Nonunion/Malunion ....Papers 138, 140, 142, 144, 150, 305, 310, 

376, 380, 381, 384, 389, 691, 702, 732, 

Posters P461, P463, P477, P485, P491, 

P492, P493, P509, P513, P519 

Novel Techniques/Imaging .......Papers 145, 146, 220, 224, 225, 

304, 305, 311, 376, 379, 692, 698, 733, 

734, Posters P462, P468, P471, P473, 

P481, P482, P492, P493, P494, P506, 


Osteochondral Transplantation. ...........Papers 197, 198, 202, 


Osteolysis .................Papers 063, 181, 191, 467, 529, 532, 

Posters P014, P019, P046, P053, P066, 


Osteolysis acetabular .......Papers 181, Posters P014, P069, P092, 


Osteoporosis ...................Papers 226, 227, 667, 670, 672, 

Posters P365, P373, P378, P399, P522, 

P527, P529, P531, P534, P543, 


Keyword IndEx


Osteosarcoma ..............Papers 232, 235, 236, 240, 511, 512, 

514, 515, 517, 518, 525, Posters P524, 

P525, P526, P528, P532, P536, 

P537, P539, P540, P541, 


Osteotomy. ............Papers 009, 010, 041, 043, 044, 242, 414, 

Posters P049, P054, P058, P111, P132, 

P133, Scientific Exhibits SE15, SE21, SE25 

Outcomes .............Papers 018, 020, 022, 023, 024, 026, 028, 

031, 035, 038, 039, 041, 042, 043, 044, 

045, 061, 071, 074, 075, 107, 109, 110, 113, 

115, 183, 184, 188, 189, 190, 193, 257, 

261, 263, 264, 265, 266, 268, 269, 270, 

346, 349, 351, 353, 356, 358, 441, 442, 

446, 449, 454, 457, 458, 461, 462, 471, 

473, 478, 479, 480, 526, 528, 530, 532, 

536, 540, 661, 665, 668, 672, 707, 712, 

715, 718, 737, 738, 743, 744, 745, 748, 

749, 750, Posters P001, P006, P007, P008, 

P009, P011, P015, P021, P022, P023, P025, 

P027, P030, P031, P033, P035, P036, P041, 

P043, P047, P051, P054, P055, P056, P057, 

P058, P062, P064, P065, P073, P075, P078, 

P082, P083, P086, P091, P092, P093, 

P094, P098, P100, P101, P102, P104, P105, 

P261, P263, P271, P346, P348, P361, P362, 

P365, P366, P369, P372, P374, P378, P380, 

P381, P383, P385, P386, P397, P400, P401, 


SE13, SE14, SE43, SE45, SE46, 

SE47, SE48, SE56, SE57, SE59 

PCL Reconstruction ..... Papers 488, 489, Scientific Exhibits SE64 

Patello-femoral .........................Papers 204, 484, 654, 


Pediatric. ..................Papers 142, 314, Posters P480, P482 

Pediatric Spine. ........Papers 025, 437, 438, 440, 442, 445, 446, 

448, 449, 450, 671, 746, Posters P348, P358, 

P364, P371, P380, P383, P384, P388 

Pelvis and Acetabulum ....Papers 211, 212, 213, 214, 215, 216, 217, 

218, 219, 220, 221, 222, 223, 224, 225, 

722, Posters P456, P457, P468, P470, 

P499, P507, P508, P514, P516, P520 

Perioperative Complications .......... Papers 212, 220, 301, 303, 

378, 388, 695, 696, 705, 722, 725, 726, 

727, 732, 733, 735, Posters P456, P462, 

P485, P490, P495, P502, P505, P507, 


Periprosthetic Fractures ....................Posters P464, P496 

Plantar Fasciitis .................................Posters P207 

Polyethelene ...............Papers 181, 470, 530, 531, 532, 533, 

Posters P019, P025, P035, P046, P053, 


Primary Total Hip Arthroplasty Cementless ...Papers 061, 181, 182, 

194, 347, 348, 350, 352, 353, 356, 358, 

360, 474, 529, 532, 707, 710, 711, 718, 

Posters P001, P003, P007, P029, P033, 

P036, P037, P042, P048, P052, P053, 

P055, P068, P075, P078, P080, P081, P086, 

P091, P093, P104, P105, P107, P109, 


SE13, SE14, SE16 

938 

Prosthetic/Allograft Combo/Reconstructions. .........Papers 520, 

Posters P532, P540, 


Quality Control. .........Papers 107, 108, 109, 112, 113, 116, 451, 

452, 453, 454, 457, 461, 462, Posters P266, 


SE43, SE44, SE46, SE47, SE48 

Radial Head Reconstruction. .Papers 685, Posters P293, P334, P338 

Radiographic Analysis. ...... Papers 032, 062, 064, 187, 193, 348, 

351, 352, 530, 531, 706, 707, 708, 

Posters P001, P014, P016, P017, P025, 

P026, P028, P036, P037, P038, P046, 

P048, P056, P059, P063, P064, P067, 

P068, P069, P077, P078, P079, P088, 


Reconstruction/Limb Salvage Techniques. ....Papers 237, 511, 513, 

517, 520, 521, 523, 524, 

Posters P525, P526, P532, P538, P540, S 


Reconstructive ............. Papers 273, 275, 278, 279, 283, 284, 

285, 337, 343, 556, 558, 559, 

Posters P227, P229, P238, P239 

Rehabilitation ..........Papers 013, 291, 418, Posters P142, P153, 


Research / Basic ..........................Papers 108, 109, 459 

Research / Clinical .......Papers 109, 113, 114, 115, 116, 117, 118, 

451, 454, 454, 457, 458, 459, 461, 465, 

Posters P263, P267, P268, P273, 


Revision / Acetabular Component. ..... Papers 036, 066, 068, 071, 

074, 183, 184, 185, 189, 191, 192, 467, 

479, 534, Posters P008, P013, P061, 

P066, P069, P073, P092, P100, 


Revision / Femoral Component. ....... Papers 036, 068, 071, 183, 

184, 185, 187, 190, 193, 467, 479, 

Posters P066, Scientific Exhibits SE08, SE09 

Revision / Periprosthetic Fractures. ..Papers 188, Posters P030, P110 

Revision Total Knee Arthroplasty. ......Papers 122, 123, 124, 126, 

132, 133, 135, 241, 243, 244, 245, 246, 

247, 248, 249, 250, 251, 252, 254, 255, 

293, 294, 598, Posters P114, P117, P118, 

P119, P122, P126, P128, P129, P136, 

P137, P140, P144, P172, P199, P203, 


Rotator Cuff. ...............Papers 571, 572, 573, 574, 575, 576, 

577, 578, 578, 579, 580, 581, 

Posters P415, P424, P426, P429, P431, 


Rotator Cuff / Basic Science .......Papers 152, 156, 159, 161, 163, 

609, 682, Posters P295, P321, P322, 

P326, P336, P342 

Rotator Cuff / Clinical .......Papers 089, 151, 153, 154, 155, 157, 

158, 160, 162, 164, 165, 366, 373, 374, 

611, 682, Posters P288, P289, P307, P312, 

P313, P315, P319, P322, P325, P327, 

P331, P332, P333, 


Keyword IndEx


Scoliosis / Deformities .......Papers 259, 438, 440, 441, 442, 445, 

446, 447, 448, 449, 450, 661, 671, 746, 

749, Posters P348, P358, P364, P370, 

P371, P373, P380, P382, P383, P384, 

P386, P388, P392, P394, P397, P401, 


Scoliosis / Spine ............Papers 391, 392, 393, 394, 395, 396, 

397, 398, 399, 400, 401, 402, 403, 404, 


Shoulder ............................Papers 692, Posters P518 

Shoulder / Instability ........Papers 209, 210, 571, 574, 575, 576, 

579, 580, 581, 583, 584, 585, 652, 

Posters P420, P426, P427, P435, P436, 


Shoulder Basic Science / Biomechanics. ..... Papers 086, 151, 152, 

159, 368, 374, 375, 603, 606, 609, 611, 

680, Posters P291, P299, P301, P307, 

P321, P322, P329, P333, P336, P337, 


Shoulder Instability / Clinical Applications ...... Papers 087, 090, 

363, 367, 601, 606, 609, 610, 611, 612, 

613, 615, 680, Posters P291, P292, 

P300, P308, P310, P328, P337, P341, 


Soft Tissue Sarcomas. ........Papers 230, 231, 233, 235, 512, 516, 

519, 523, 524, 525, Posters P521, 

P523, P524, P525, P526, P540, 


Spinal Cord Trauma .........Papers 021, 024, 025, 028, 440, 666, 

742, Posters P350, P360, P362, P378, 

P391, P395, P404 

Spine ...............................Papers 721, Posters P490 

Spondylolisthesis / Spondylolysis ......Papers 256, 258, 261, 266, 

743, 747, 748, Posters P361, P366, 


Stability / Minimally Invasive Surgery. ...............Papers 353, 

Posters P001, P007, P013, P021, 

P027, P033, P033, P105 

Tendon. ..............................Scientific Exhibits SE31 

Tendon Disorders .......Papers 102, 104, 105, 496, 497, 498, 503, 

Posters P211, P215, P217, P222 

Tendons .................. Papers 272, 278, 279, 283, 556, 566, 

Posters P237, Scientific Exhibits SE36 

Thromboembolic ...............Papers 476, 477, 478, 535, 536, 

537, 539, 715, Posters P002 

Tibial Plateau. ..........................Papers 145, 388, 735, 

Posters P458, P472, P501, P505 

Tibial Shaft / Plafond ....... Papers 143, 143, 380, 382, 384, 385, 

386, 388, 390, 705, 729, 735, 

Posters P461, P463, P481, P498, P503, 


Total Elbow Arthroplasty / Elbow Reconstruction ......Papers 684, 

685, 687, 690, Posters P286, P290, 

P297, P306, P316, P338, P340 

939 

Total Hip Arthroplasty .......Papers 031, 033, 034, 037, 039, 045, 

062, 063, 064, 065, 068, 069, 070, 071, 

072, 073, 074, 075, 182, 184, 185, 186, 

187, 188, 193, 346, 347, 348, 349, 350, 

351, 353, 357, 358, 359, 360, 470, 472, 

473, 526, 527, 528, 530, 531, 536, 537, 

707, 708, 709, 711, 712, 713, 714, 716, 716, 

717, 718, 719, Posters P002, P003, P005, 

P014, P015, P016, P018, P019, P020, P021, 

P022, P023, P024, P025, P026, P027, P031, 

P032, P035, P039, P041, P042, P043, P045, 

P046, P047, P048, P050, P052, P053, P056, 

P057, P062, P064, P065, P066, P069, P070, 

P076, P081, P082, P083, P085, P087, P088, 

P090, P093, P096, P100, P102, P103, P105, 


SE02, SE04, SE05, SE09, SE11, SE13, 

SE14, SE16 

Total Knee Arthroplasty / Other Clinical Conditions. ...Papers 004, 

009, 013, 014, 015, 245, 292, 294, 300, 

406, 410, 412, 595, 597, Posters P115, 

P125, P128, P130, P149, P151, P153, 

P157, P160, P161, P162, P163, P167, 

P180, P183, P184, P185, P186, P190, 


SE20, SE23, SE25, SE29 

Total Knee Arthroplasty Blood Transfusions. ... Posters P125, P171 

Total Knee Arthroplasty Complications ..........Papers 121, 122, 

123, 125, 126, 127, 128, 129, 131, 132, 

133, 246, 253, 255, 287, 290, 294, 407, 

410, 586, 588, 590, 591, 593, 596, 597, 

598, 599, Posters P114, P119, P125, P128, 

P130, P131, P144, P146, P155, P157, P160, 

P166, P172, P173, P174, P175, P179, P180, 

P183, P186, P189, P199, P202, P203, 


Total Knee Arthroplasty Components... Papers 003, 004, 005, 011, 

131, 245, 247, 248, 250, 253, 293, 295, 

296, 300, 409, 416, 587, 588, 594, 

Posters P122, P123, P124, P128, P129, 

P139, P141, P146, P148, P149, P150, 

P152, P162, P167, P178, P181, P182, 

P183, P187, P192, P196, P202, P205, 


Total Knee Arthroplasty General Outcome ....Papers 004, 005, 011, 

012, 013, 014, 128, 130, 248, 251, 252, 

286, 287, 288, 291, 294, 295, 296, 300, 

406, 407, 409, 413, 414, 417, 417, 417, 

417, 417, 586, 588, 589, 593, 599, 

Posters P114, P119, P123, P124, P126, 

P127, P142, P144, P148, P149, P151, 

P154, P154, P160, P161, P166, P167, 

P169, P173, P178, P180, P183, P187, 

P191, P200, P202, P203, P205, 


Total Knee Arthroplasty Infection ......Papers 121, 122, 123, 126, 

127, 128, 129, 135, 247, 287, 294, 593, 


P155, P159, P172, P174, P180, P199, 


Keyword IndEx


Total Knee Arthroplasty Kinematics ........Papers 004, 005, 134, 

251, 292, 295, 408, 418, 420, 

Posters P141, P143, P152, P178, P197, 


Total Knee Arthroplasty Novel Techniques ...Papers 006, 133, 245, 

246, 248, 297, 298, 407, 

Posters P136, P140, P149, P193, P196, 


Total Knee Arthroplasty Patella ....Papers 006, 407, 418, 588, 599, 

Posters P122, P152, P187, P197 

Total Knee Arthroplasty Posterior Cruciate Ligament ...Papers 295, 

300, 411, 414, 594, Posters P178, P179, 


Total Knee Arthroplasty Results ........Papers 001, 002, 003, 004, 

005, 009, 011, 012, 013, 127, 128, 133, 

134, 241, 242, 247, 252, 253, 255, 288, 

291, 295, 298, 408, 409, 411, 414, 416, 

420, 586, 594, 596, 599, Posters P112, 

P122, P124, P127, P132, P140, P142, 

P143, P151, P154, P159, P163, P166, P167, 

P173, P178, P180, P181, P183, P187, P190, 

P191, P192, P195, P196, P198, P205, 


SE28, SE29 

Total Knee Arthroplasty Technique .....Papers 134, 241, 245, 247, 

255, 298, 407, 408, 411, Posters P122, 

P150, P162, P163, P168, P191, 


SE22, SE27 

Total joint ............................Scientific Exhibits SE30 

Trauma. ...................Papers 078, 085, 090, 364, 371, 372, 

602, 615, 676, 679, 687, Posters P287, 

P290, P296, P298, P303, P304, P306, 

P316, P328, P335, P341, P343 

Trauma / Fractures ..........Papers 166, 167, 168, 169, 170, 171, 

172, 173, 174, 175, 176, 177, 178, 179, 

180, 403, 404, 405, 426, 427, 429, 431, 

435, 543, Posters P245, P246, P247, P251, 


Unicompartment Arthroplasty ........Papers 006, 007, 008, 297, 

415, 419, 592, Posters P113, P114, P117, 

P120, P120, P121, P129, P138, P145, 

P145, P156, P164, P176, P182, P194, 


Upper Extremity .......Papers 172, 173, 174, 175, 176, 177, 179, 

Posters P242, P245, P247, 


Viscosupplement. ............Papers 624, 627, 629, Posters P279 

940 

Keyword IndEx

Annual Meeting Proceedings - American Academy of Orthopaedic ...

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