Front Matter - The Journal of Bone & Joint Surgery

In a pivotal head-to-head study,* 

EUFLEXXA Performs 

EUFLEXXA : Fastest-Growing HA Brand 1 

For Good Reasons 

Proven Efficacy in Only 3 Injections 

Months of effective relief 2 

Mean WOMAC Pain Subscale Score 

(0-100 mm VAS) 

60 

50 

40 

30 

20 

10 

0 

1st Injection 

2nd Injection 

3rd Injection 

0 2 4 6 8 10 12 

Weeks of Treatment 

Synvisc ® 

EUFLEXXA 

SEVERE 

PAIN 

MODERATE 

PAIN 

MILD PAIN 

PAIN-FREE 

* Ina 

pr 

osp 

spect 

ective, randomi 

zed, double-blind, 

head-t dt d-to-head 

study vs Synvi 

visc 

® (N=321) 

† 

Patients were asked to meas 

ure levels of pain relief 

at Week 12 using a visual analog subscale of 

0-10000 mm on the 5 WOMAC pain subscale questions. 

Patients with an averageage 

score 

of

UNIQUE NATIONAL 

HCPCS CODE 

Q4085 

BRIEF SUMMARY 

Please consult package insert for full Prescribing Information. 

INDICATION 

EUFLEXXA (1% sodium hyaluronate) is indicated for the treatment 

of pain in osteoarthritis (OA) of the knee in patients who have failed to 

respond adequately to conservative non-pharmacologic therapy and 

simple analgesics (e.g., acetaminophen). 

CONTRAINDICATIONS 

• Do not use EUFLEXXA to treat patients who have a known hypersensitivity 

to hyaluronan preparations 

• Do not use EUFLEXXA to treat patients with knee joint infections, 

infections or skin disease in the area of the injection site 

WARNINGS 

• Mixing of quaternary ammonium salts such as benzalkonium chloride with 

hyaluronan solutions results in formation of a precipitate. EUFLEXXA 

should not be administered through a needle previously used with medical 

solutions containing benzalkonium chloride. Do not use disinfectants for 

skin preparation that contain quaternary ammonium salts 

• Do not inject intravascularly because intravascular injection may cause 

systemic adverse events 

PRECAUTIONS 

General 

• Patients having repeated exposure to EUFLEXXA have the potential for 

an immune response; however, this has not been assessed in humans 

• Safety and effectiveness of injection in conjunction with other intra-articular 

injectables, or into joints other than the knee has not been studied 

• Remove any joint effusion before injecting 

• Transient pain or swelling of the injected joint may occur after intra-articular 

injection with EUFLEXXA 

• Do not use after expiration date 

• Protect from light 

• Do not re-use—dispose of the syringe after use 

• Do not use if the blister package is opened or damaged 

Information for Patients 

• Transient pain and/or swelling of the injected joint may occur after intraarticular 

injection of EUFLEXXA 

• As with any invasive joint procedure, it is recommended that the patient 

avoid any strenuous activities or prolonged (i.e., more than 1 hour) 

weight-bearing activities such as jogging or tennis within 48 hours 

following intra-articular injection 

• The safety and effectiveness of repeated treatment cycles of EUFLEXXA 

have not been established 

ADVERSE EVENTS 

Adverse event information regarding the use of EUFLEXXA as a treatment 

for pain in OA of the knee was available from two sources; a multicenter 

clinical trial conducted in Germany and a single center clinical trial that was 

conducted in Israel. 

Multicenter Clinical Investigation 

This clinical investigation was a prospective randomized, double blinded, 

active control (commercially available hyaluronan product) study conducted 

at 10 centers. Three hundred twenty-one patients were randomized into 

groups of equal size to receive either EUFLEXXA (n=160) or the active 

control (n=161). A total of 119 patients reported 196 adverse events; this 

number represents 54 (33.8%) of the EUFLEXXA group and 65 (44.4%) of 

the active control group. There were no deaths reported during the study. 

Incidences of each event were similar for both groups, except for knee joint 

effusion, which was reported by 9 patients in the active control group and 

one patient in the EUFLEXXA treatment group. A total of 160 patients 

received 478 injections of EUFLEXXA. There were 27 reported adverse 

events considered to be related to EUFLEXXA injections: arthralgia – 

11 (6.9%); back pain – 1 (0.63%); blood pressure increase – 3 (1.88%); 

joint effusion – 1 (0.63%); joint swelling – 3 (1.88%); nausea – 1 (0.63%); 

paresthesia – 2 (1.25%); feeling of sickness of injection – 3 (1.88%); skin 

irritation – 1 (0.63%); tenderness in study knee – 1 (0.63%). Four adverse 

events were reported for the EUFLEXXA group that the relationship to 

treatment was considered to be unknown: fatigue – 3 (1.88%); nausea – 

1 (0.63%). 

Single Center Study 

In a single-center, single-blinded, placebo controlled, prospective, 

two parallel treatment arm clinical trial a total of 49 (25 EUFLEXXA, 

24 placebo) patients were randomized into two treatment groups in a ratio 

of 1:1 EUFLEXXA or placebo. A total of 65 adverse events were reported 

by 17 (68%) of the patients in the EUFLEXXA group and 15 (63%) in 

the placebo group. Of the 65 total events reported, 20 were regarded as 

treatment related. Knee pain, hypokinesia of the knee, knee swelling, and 

rash were considered to be treatment related adverse events. 

DETAILED DEVICE DESCRIPTION 

Each syringe of EUFLEXXA contains: 

Sodium hyaluronate 

Sodium chloride 

Disodium hydrogen phosphate dodecahydrate 

Sodium dihydrogen phosphate dihydrate 

Water for injection 

20 mg 

17 mg 

1.12 mg 

0.1 mg 

q.s. 

HOW SUPPLIED 

EUFLEXXA is supplied in 2.25 ml nominal volume, disposable, pre-fi lled 

glass syringes containing 2 ml of EUFLEXXA. Only the contents of the syringe 

are sterile. EUFLEXXA is nonpyrogenic. 3 disposable syringes per carton. 

CAUTION 

Product contact parts of the syringe contain natural rubber latex, 

which may cause allergic reactions. 

DIRECTIONS FOR USE 

• Store at 2°-25°C (36º-77ºF). Protect from light. Do not freeze. 

If refrigerated, remove from refrigeration at least 20-30 minutes 

before use. 

• EUFLEXXA is administered by intra-articular injection into the knee 

synovial capsule using strict aseptic injection procedures. The full content 

of the syringe is injected into the affected knee at weekly intervals for 

3 weeks, for a total of 3 injections. 

• If refrigerated, twenty to thirty minutes before use, remove the product 

box from the refrigerator, remove the blister pack from the box and allow 

the syringe to come to room temperature. Be sure to return any syringes 

not intended for use to the refrigerator. 

Toll free number for providers and patients to call with questions: 

1-(888)-FERRING (1-(888)-337-7464). 

MANUFACTURED FOR: 

FERRING PHARMACEUTICALS INC. 

PARSIPPANY, NJ 07054 

MANUFACTURED BY: 

Bio-Technology General (Israel) Ltd. 

Be’er Tuvia Industrial Zone, Kiryat Malachi 83104, Israel 

Issue date: 05/2006 

References: 1. IMS data, March 2007 2. Kirchner M, Marshall D. A double-blind randomized controlled trial 

comparing alternate forms of high molecular weight hyaluronan for the treatment of osteoarthritis of the knee. 

Osteoarthritis Cartilage. 2006;14:154-162. 

©2007 Ferring Pharmaceuticals Inc. 8/07 EUF-75698A 

Downloaded From: http://jbjs.org/ on 01/27/2014


THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG VOLUME 89-A · NUMBER 9 · SEPTEMBER 2007 

September 2007 

The Journal of Bone & Joint Surgery · American Volume 

SCIENTIFIC ARTICLES 

1887 

Hallux Valgus and First Ray Mobility. Michael J. Coughlin, MD, and Carroll P. Jones, MD 

A Prospective Study 

1899 

Intermediate and Long-Term Outcomes of 

Total Ankle Arthroplasty and Ankle Arthrodesis. 

A Systematic Review of the Literature 

A video supplement to this article has been developed 

by the American Academy of Orthopaedic Surgeons and JBJS 

1906 

Removal of Painful Orthopaedic 

Implants After Fracture Union 

1913 

Patients’ Preoperative Expectations 

Predict the Outcome of Rotator Cuff Repair 

1920 

Minimally Invasive Hip Arthroplasty: 

What Role Does Patient 

Preconditioning Play? 

1928 

Clinical and Structural Outcomes 

of Nonoperative Management 

of Massive Rotator Cuff Tears 

1935 

Ultraviolet Lighting During Orthopaedic 

Surgery and the Rate of Infection 

1941 

The Effect of Kneeling During Spine 

Surgery on Leg Intramuscular Pressure 

S.L. Haddad, MD, J.C. Coetzee, MD, R. Estok, RN, BSN, 

K. Fahrbach, PhD, D. Banel, BA, and L. Nalysnyk, MD, MPH 

Reuven B. Minkowitz, MD, Siraj Bhadsavle, MD, 

Michael Walsh, PhD, and Kenneth A. Egol, MD 

R. Frank Henn III, MD, Robert Z. Tashjian, MD, 

Lana Kang, MD, and Andrew Green, MD 

Aidin Eslam Pour, MD, Javad Parvizi, MD, FRCS, 

Peter F. Sharkey, MD, William J. Hozack, MD, and 

Richard H. Rothman, MD, PhD 

P.O. Zingg, MD, B. Jost, MD, A. Sukthankar, MD, 

M. Buhler, MD, C.W.A. Pfirrmann, MD, and C. Gerber, MD 

Merrill A. Ritter, MD, Emily M. Olberding, BS, and 

Robert A. Malinzak, MD 

Bryan T. Leek, MD, R. Scott Meyer, MD, John M. 

Wiemann, MD, Adnan Cutuk, MD, Brandon R. 

Macias, BS, and Alan R. Hargens, PhD 

How to Reach Us 

Editorial and business offices: 20 Pickering Street, Needham, MA 02492-3157. Telephone: (781) 449-9780 

www.jbjs.org · e-mail: mail@jbjs.org · Editorial Fax: (781) 449-9787 · Advertising Fax: (781) 449-3485 · Subscription Fax: (781) 449-9742 

The Journal of Bone & Joint Surgery (ISSN: 0021-9355) (American Volume) is issued monthly. 

The 2007 U.S. subscription price, payable in advance, is $162.00. Single copies, $30.00. 

The Journal of Bone & Joint Surgery, periodicals postage paid at Boston, Massachusetts, and at additional mailing offices. 

Postmaster: Send address changes to The Journal of Bone & Joint Surgery, 20 Pickering Street, Needham, MA 02492-3157. 

The Journal of Bone and Joint Surgery ® , JB&JS ® , and JBJS ® are registered in the U.S. Patent and Trademark Office. 

COPYRIGHT © 2007 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED. ALL RIGHTS RESERVED. 

➤ 


EXOGEN ultrasound treatment has the highest 

heal rate for non-unions, including patients with 

certain comorbidities 1 

The EXOGEN Ultrasound Bone Healing System is like no other: 

•Highest heal rate for non-unions – 86% 1 

•Accelerates healing of indicated* fresh fractures – 38% 2 

•Unique fracture healing ultrasound technology 

•Works in just 20 minutes a day 

1 

Highest rate of healing reported among pre-market approval submissions to FDA based on variable fracture types, sites and 

conditions. See EXOGEN – PMA 900009 – 10/05/1994, EXOGEN – PMA 900009, Supplement – 02/23/2000, Bioelectron – PMA 

P850022 – 02/18/1986, EBI – PMA P790002 – 11/06/1979, Orthofix/AME – PMA P850007 – 02/21/1986, Orthologic – PMA P910066 

– 03/04/1994, EBI – PMA P790005 – 01/25/1980. 

2 Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF. Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed 

ultrasound. J Bone Joint Surg Am. 1994 Jan;76(1):26–34. 

Orthopaedic Trauma & Clinical Therapies 

Smith & Nephew, Inc. 1450 Brooks Road, Memphis, TN 38116 USA 

Telephone: 1-901-396-2121, Information: 1-800-821-5700, Orders and Inquiries: 1-800-836-4080 

www.smith-nephew.com www.exogen.com 

Summary of Indications for Use: The EXOGEN 4000+, or any other 

EXOGEN Bone Healing System, is indicated for the non-invasive 

treatment of established non-unions † excluding skull and vertebra. 

* In addition, they are indicated for accelerating the time to a healed 

fracture for fresh, closed, posteriorly displaced distal radius fractures 

and fresh, closed or Grade I open tibial diaphysis fractures in skeletally 

mature individuals when these fractures are orthopaedically managed 

by closed reduction and cast immobilization. 

Contraindications: There are no known contraindications for the EXOGEN 

device. Warnings and precautions pertaining to the treatment of either 

condition may be found at www.exogen.com or by calling 1-800-836-4080. 

† 

A non-union is considered to be established when the fracture site 

shows no visibly progressive signs of healing. Rx only. 

Trademark of Smith & Nephew. 

Reg. US Pat. & TM Off. 

©2007 Smith & Nephew, Inc. 






1948 

Lateral Unicompartmental Knee Alexander P. Sah, MD, and Richard D. Scott, MD 

Arthroplasty Through a Medial Approach. 

Study with an Average Five-Year Follow-up 

A video supplement to this article will be 

available from the Video Journal of Orthopaedics 

1955 

Anatomic Factors Related to the 

Cause of Tennis Elbow 

1964 

Locking Compression Plate Fixation 

of Vancouver Type-B1 Periprosthetic 

Femoral Fractures 

1970 

The Quality of Reporting of Orthopaedic 

Randomized Trials with Use of a 

Checklist for Nonpharmacological Therapies 

1979 

Comparison of Arthrodesis and 

Metallic Hemiarthroplasty of the 

Hallux Metatarsophalangeal Joint 

1986 

Synovectomy of the Hip in Patients 

with Juvenile Rheumatoid Arthritis 

1993 

Long-Term Results of Surgery for 

Forearm Deformities in Patients with 

Multiple Cartilaginous Exostoses 

2000 

The Anatomy of the Medial 

Part of the Knee 

2011 

The in Vivo Isometric Point of the 

Lateral Ligament of the Elbow 

Robert E. Bunata, MD, David S. Brown, MD, 

and Roderick Capelo, MD 

M.A. Buttaro, MD, G. Farfalli, MD, M. Paredes 

Núñez, MD, F. Comba, MD, and F. Piccaluga, MD 

Simon Chan, BSc, and Mohit Bhandari, MD 

Steven M. Raikin, MD, Jamal Ahmad, MD, 

Aidin Eslam Pour, MD, and Nicholas Abidi, MD 

Hans-Dieter Carl, Dr. med, Annemarie Schraml, Dr. med, 

Bernd Swoboda, Prof. Dr. med, and Gerd Hohenberger, Dr. med 

Shosuke Akita, MD, Tsuyoshi Murase, MD, Kazuo 

Yonenobu, MD, Kozo Shimada, MD, Kazuhiro Masada, MD, 

and Hideki Yoshikawa, MD, PhD 

Robert F. LaPrade, MD, PhD, Anders Hauge Engebretsen, 

Medical Student, Thuan V. Ly, MD, Steinar Johansen, MD, 

Fred A. Wentorf, MS, and Lars Engebretsen, MD, PhD 

Hisao Moritomo, MD, PhD, Tsuyoshi Murase, MD, PhD, 

Sayuri Arimitsu, MD, Kunihiro Oka, MD, Hideki 

Yoshikawa, MD, PhD, and Kazuomi Sugamoto, MD, PhD 

➤ 






2018 

Blood Supply to the First Metatarsal 

Head and Vessels at Risk with 

a Chevron Osteotomy 


J.J. George Malal, MBBS, DOrtho, MS(Ortho), DNB(Ortho), 

MRCS, J. Shaw-Dunn, BSc, MBChB, PhD, FRCS, AIAS, 

and C. Senthil Kumar, FRCS(Tr&Orth) 

2023 

Evaluation of Oxidation and Fatigue 

Damage of Retrieved Crossfire 

Polyethylene Acetabular Cups 

2030 

The Location in Cartilage of 

Infectious Retrovirus in Cats Infected 

with Feline Leukemia Virus 

Barbara H. Currier, MChE, John H. Currier, MS, Michael B. Mayor, 

MD, Kimberly A. Lyford, BA, John P. Collier, DE, and Douglas W. 

Van Citters, PhD 

Steven P. Arnoczky, DVM, Cheryl Swenson, DVM, PhD, 

Monika Egerbacher, DVM, PhD, Keri Gardner, MS, Oscar 

Caballero, MS, and Meghan Burns, DVM 

CASE REPORTS 

2037 

Epidural Hematoma Causing Paraplegia Joon Y. Lee, MD, Ahmad Nassr, MD, and Ravi K. Ponnappan, MD 

After a Fluoroscopically Guided Cervical 

Nerve-Root Injection. A Case Report 

2040 

Surgical Treatment of a Tear of the 

Pectoralis Major Muscle at Its 

Sternal Origin. A Case Report 

2044 

Invasive Group-A Streptococcal 

Infection in an Allograft 

Recipient. A Case Report 

2048 

Epidural Hematoma Secondary to 

Removal of an Epidural Catheter After a 

Total Knee Replacement. A Case Report 

Michael K. Shindle, MD, Abtin H. Khosravi, MS, Brett M. Cascio, 

MD, E. Gene Deune, MD, and Edward G. McFarland, MD 

Ellen H. Lee, MD, Dayna Ferguson, MD, Daniel Jernigan, MD, MPH, 

Melissa Greenwald, MD, Timothy Coté, MD, Jon E. Bos, MPH, 

Jeannette Guarner, MD, Sherif Zaki, MD, PhD, Anne Schuchat, MD, 

Bernard Beall, PhD, and Arjun Srinivasan, MD 

Sokratis E. Varitimidis, MD, Konstantinos Paterakis, MD, 

Zoe H. Dailiana, MD, Michalis Hantes, MD, and Stavroula 

Georgopoulou, MD 

CURRENT CONCEPTS REVIEW 

2051 

Management of Distal Radial Fractures 

Neal C. Chen, MD, and Jesse B. Jupiter, MD 

A translation of this article is available at jbjs.org. 

➤ 


NEW 

Designed by 

John L. Stanton, MD, FACS 

Designed to work as “tissue pushers”, helping to enhance exposure by 

allowing the surgeon or an assistant to push forward the opposite side of 

the wound while retracting (or not) the nearer side 

Stanton 

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Product No’s: 

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Posterior-Inferior 

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Designed for Total Hip Surgery 

Designed by 

Wayne M. Goldstein, MD 

Stanton Forward 

Ragnell Retractor 


4510-01 [Shallow – 13mm] 

4510-02 [Deep – 19mm] 

The posterior-inferior 

retractor is placed with 

the point at 6 o’clock 

and the retractor’s 

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ischium. The remaining 

blade of this retractor 

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Blade Width: 45mm 

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NEW STYLE 

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with and 

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Makes it easier in 

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SELECTED INSTRUCTIONAL COURSE LECTURE 

2064 

Operative Carpal and Hand Injuries in Children 

Peter M. Waters, MD 

THE ORTHOPAEDIC FORUM 

2075 

AOA Symposium 

Gainsharing in Orthopaedics: 

Passing Fancy or Wave of the Future? 

Douglas R. Dirschl, MD, Joane Goodroe, D. McCarty Thornton, and Gary W. Eiland 

2084 

Follow-up on Misrepresentation of 

Research Activity by Orthopaedic Residency 

Applicants: Has Anything Changed? 

Emmanuel K. Konstantakos, MD, Richard T. Laughlin, MD, 

Ronald J. Markert, PhD, and Lynn A. Crosby, MD 

ETHICS IN PRACTICE 

2089 

Physician Advertising: 

Evaluation of a Sample Advertisement 

James D. Capozzi, MD 

SPECIALTY UPDATE 

2092 

What’s New in Orthopaedic Research 

Lawrence V. Gulotta, MD, Chisa Hidaka, MD, Suzanne A. Maher, PhD, 

Matthew E. Cunningham, MD, PhD, and Scott A. Rodeo, MD 

Follows Table of Contents 

Instructions to Authors 

DEPARTMENTS 

2102 

Book Reviews 

Adv 32, 48, 64, 74, 80, 86, 92, 98, 104, 112, 118 

Abstracts from The Journal of Bone and Joint Surgery [Br] 


The marriage of the Uni 

and the PFJ 

A partnership like no other 

*smith&nephew 

JOURNEY DEUCE 

Bi-Compartmental Knee System 

• Retention of the ACL and PCL for more normal kinematics 

• Retention of the unaffected lateral compartment 

• Replacement of the diseased medial and patellofemoral compartments – 

which could represent up to 70% of TKA performed* 

Contact your Smith & Nephew sales representative for more information 

Orthopaedic Reconstruction 

Smith & Nephew, Inc. 1450 Brooks Road, Memphis, TN 38116 USA 

Telephone: 901-396-2121, Information: 1-800-821-5700, Orders/Inquiries: 1-800-238-7538 

www.smith-nephew.com 

* Rolston, L; Sprague, J; Tsai, S; Salehi, A. A Novel Bone/Ligament Sparing Prosthesis for the Treatment of Patellofemoral and Medial Compartment Osteoarthritis. 2006 AAOS Annual Meeting, Poster #P181. 

Trademark of Smith & Nephew. US Pat. & TM Off. 



E XCLUSIVELY ON JBJS. ORG! 

SEPTEMBER 2007 

STREAMING VIDEO OF THE MONTH 

September 1-30 

VJO/JBJS Featured Streaming Video: “Functional Treatment of Fractures,” featuring 

Augusto Sarmiento, MD, and Loren L. Latta, PhD (“A Functional Below-the-Knee Brace 

for Tibial Fractures: A Report on Its Use in One Hundred Thirty-Five Cases” JBJS, 

March 1970, and “A Functional Below-the-Knee Brace for Tibial Fractures: A Report on 

Its Use in One Hundred and Thirty-Five Cases,” JBJS September [Suppl 2, Pt 2] 2007) 

WEEKLY VIDEO RELEASES FROM THE VIDEO 

JOURNAL OF ORTHOPAEDICS AND JBJS 

August 28 - October 2 

“Chevron Osteotomy for 

Correction of Hallux 

Valgus” featuring Mark S. 

Myerson, MD 

VIDEO SUPPLEMENTS FROM THE AMERICAN 

ACADEMY OF ORTHOPAEDIC SURGEONS AND JBJS 

“The Agility Total Ankle 

Arthroplasty” with Frank 

L. Alvine, MD, Steven L. 

Haddad, MD, and Charles 

L. Saltzman, MD 

September 4 - October 9 

“Stabilized Subcutaneous 

Anterior Ulnar Nerve Transposition” 

featuring Steven Z. 

Glickel, MD, O. Alton Barron, 

MD, and Richard G. Eaton, MD 


“Operative Treatment of DDH 

with Open Reduction and Salter 

Osteotomy” featuring Stuart L. 

Weinstein, MD, and Dennis R. 

Wenger, MD 


“Elbow Arthroscopy: Avoiding 

Complications” featuring 

Bernard F. Morrey, MD 

“Distraction Plating of Distal 

Radial Fractures with Metaphyseal 

and Diaphyseal 

Comminution” with David 

S. Ruch, MD 

“Cementation of Constrained 

Liner into Secure Cementless 

Acetabular Shells: A Two to 

Twelve-Year Follow-Up Study” 

with John Callaghan, MD 

“The Vastus-Splitting Approach 

for Primary Total 

Knee Arthroplasty” with 

Vincent D. Pellegrini Jr., MD 


“Ankle Arthrodesis for Posttraumatic 

Arthritis” featuring 

Charles L. Saltzman, MD 

“Arthroscopic Débridement 

of Acetabular Labral Tears” 

with John C. Clohisy, MD 




ON JBJS.ORG (CONTINUED) 

COMMENTARY AND PERSPECTIVE 

• Mark Easley, MD, on “Hallux Valgus and First Ray 

Mobility. A Prospective Study,” by Coughlin and Jones 

(JBJS, September 2007) 

• Thomas J. Gill, MD, on “Patients’ Preoperative 

Expectations Predict the Outcome of Rotator Cuff 

Repair,” by Henn et al. (JBJS, September 2007) 

• Mark W. Pagnano, MD, on “Minimally Invasive 

Hip Arthroplasty: What Role Does Patient Preconditioning 

Play?” by Pour et al. (JBJS, September 2007) 

ONLINE CME ANNOUNCEMENT 

JBJS is pleased to announce that our online quarterly 

CME examination has been approved by the ABOS as 

a Self-Assessment Examination (SAE). 

Earn 10 of your 20 required SAE credits with the 

successful completion of the JBJS online quarterly 

general CME exam. 

IMAGE QUIZ 

• Suprapubic Pain Following 

Strenuous Physical Activity 

IMAGE-QUIZ LIBRARY 

• A Cervical Spine Injury 

Secondary to a Motor-Vehicle 

Accident 

• Enlarging Painless Mass in a Four-Year-Old Girl 

• Painless Shoulder Mass in a Fifty-Six-Year-Old 

Woman 

• An Unusual High-Energy Injury to the Ankle 

• Pathologic Fracture of the Humerus During 

Pregnancy 

• Hip Pain in a Seventeen-Year-Old Girl 

• Destructive Fibular Lesion in a Ten-Year-Old Boy 


INSTRUCTIONS TO AUTHORS 


Instructions to Authors 

The Journal of Bone and Joint Surgery welcomes articles that contribute to orthopaedic 

knowledge from all sources in all countries. • Articles are accepted only for exclusive 

publication in The Journal of Bone and Joint Surgery. Previously published articles, even 

those in peer-reviewed electronic publications, are not accepted by The Journal. • Publication 

does not constitute official endorsement of opinions presented in articles. • Published 

articles and illustrations become the property of The Journal. • If the Editor-in- 

Chief of The Journal requests additional data forming the basis for the work, the authors 

will make the data available for examination in a timely fashion. • All manuscripts dealing 

with the study of human subjects must include a statement that the subjects gave 

Informed Consent to participate in the study and that the study has been approved by 

an institutional review board or a similar committee. All Case Reports must include a 

statement that each subject was informed that data concerning the case would be submitted 

for publication. All studies should be carried out in accordance with the World 

Medical Association Declaration of Helsinki, as presented in The Journal (1997;79-A: 

1089-98). Patient confidentiality must be protected according to the U.S. Health Insurance 

Portability and Accountability Act (HIPAA). • All clinical trials submitted for consideration 

should have been registered in a public trials registry. • All manuscripts dealing 

with experimental results in animals must include a statement that the study has been 

approved by an animal utilization study committee. The authors should also include 

information about the management of postoperative pain for both animal and human 

subjects. • Reports of randomized controlled trials (RCTs) should follow the checklist 

developed by the CONSORT Group (www.consort-statement.org), published in JAMA 

2001;285:1987-91. In the preparation of a manuscript, authors should, in general, follow 

the recommendations in “Uniform Requirements for Manuscripts Submitted to Biomedical 

Journals: Writing and Editing for Biomedical Publication” by the International 

Committee of Medical Journal Editors, October 2004 (www.icmje.org). • On occasion, 

reviewers, associate editors, and/or deputy editors may have a conflict of interest or a 

competing interest with regard to the subject matter of a manuscript. Such conflicts are 

disclosed to the Editor-in-Chief, who has no known conflicts of interest or competing 

interests and who makes the final decision regarding acceptance or rejection of all 

manuscripts submitted to The Journal. 

Submission of Manuscript 

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requiring authors to submit and track 

manuscripts electronically. Authors must register 

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You will be e-mailed a confidential username 

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system and submit your manuscript. 

When you submit an article, the following 

items must be included: 

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and the authors’ names in the order in 

which they should appear. Provide a 

complete mailing address for each author. 

Clearly designate the corresponding author 

and his/her mailing address, telephone 

number, fax number, and e-mail address. 

2. Blinded Manuscript: The Journal of Bone 

and Joint Surgery has a policy of blinded 

peer review. The manuscript must not 

contain any mention of the authors’ 

names or initials or the institution at 

which the study was done. Page headers 

can include the title but not the authors’ 

names. Manuscripts not in compliance 

with The Journal’s blinding policy will be 

returned to the corresponding author. 

3. IRB Approval: A copy of the letter granting 

approval from the institutional review 

board or the animal utilization 

study committee is required. You must 

reference the manuscript title and corresponding 

author on the fax cover sheet or 

in an accompanying letter. 

4. Copyright Transfer and Author Agreement: 

Material appearing in The Journal is 

covered by copyright. All authors must sign 

a Copyright Transfer and Author Agreement 

form upon submission of the manuscript 

to The Journal. The form must reference 

the manuscript title, assigned JBJS 

manuscript number, and corresponding 

author. This form must be submitted by 

post mail, by fax, or in PDF format online. 

5. Potential Conflict of Interest Statement: 

Authors of manuscripts must sign 

a Conflict of Interest Statement at the time 

of submission of each manuscript. The 

form must reference the manuscript title 

and assigned JBJS manuscript number. 

This statement has no bearing on the editorial 

decision to publish a manuscript. 

That decision will continue to be based 

solely on the value of the article to the 

readers of The Journal. The signature of 

each author is required. No article will be 

published until the completed conflict of 

interest form has been incorporated into 

the record kept on that manuscript in The 

Journal office. The statements selected by 

the author or authors will be printed at the 

end of the published article. 

Forms required for manuscript submission 

can be found at jbjs.org. 

When you submit an article, the following 

items are optional: 

1. Cover Letter 

2. Acknowledgment: If included, it must be 

attached as a separate file, not included in 

the text of the manuscript. 

3. Figures and/or Tables: Figures must be 

submitted electronically. Each figure 

and/or table must be labeled separately 

and submitted as a separate electronic 

file. No more than 30 figures may be 

submitted. Tables should be submitted 

in their original file format. Refer to the 

section entitled Illustrations for figure 

format requirements. 

The Journal discourages submission of illustrations 

that have been published elsewhere. 

When such illustrations are deemed 

essential, the author must include a letter, 

from the original holder of the copyright, 

granting permission to reprint the illustration. 

Give full information about the previous 

publication, including the page on 

which the illustration appeared. 




Preparation of Manuscript 

Manuscripts should be a maximum of 5000 

words. They must be double-spaced with 

wide margins. Pages must be numbered 

sequentially. An article should consist of: 

1. A structured abstract of no more than 

325 words, consisting of five paragraphs, 

with the headings Background (which 

states the primary research question), 

Methods, Results, Conclusions, and Level of 

Evidence (for clinical articles) or Clinical 

Relevance (for basic-science articles). For 

the Level of Evidence section, describe the 

study type and assign a level-of-evidence 

rating to the primary research question, 

according to the criteria in the table in the 

Instructions to Authors. Do not include an 

abstract with case reports. 

2. The body should consist of: 

Introduction: State the problem that 

led to the study, including a concise 

review of only the relevant literature. 

State your hypothesis and the purpose 

of the study. 

Materials and Methods: Describe 

the study design (prospective or retrospective, 

inclusion and exclusion criteria, 

duration of study) and the study 

population (demographics, duration 

of follow-up). 

Statistical Methods should be described 

in detail. Use of the word significant 

requires reporting of a p value. 

Ninety-five percent confidence intervals 

are required whenever the results of 

survivorship analysis are given in the 

text or graphs. Use of the word correlation 

requires reporting of the correlation 

coefficient. 

The Journal encourages the use of validated 

outcome instruments. The use of 

both a generic (general) health outcome 

measure and a joint-specific, limb-specific, 

or condition-specific instrument is 

encouraged. If an outcome system leads 

to a categorical ranking (excellent, good, 

etc.), the aggregate score for each patient 

should be provided. 

Results: Provide a detailed report on 

the data obtained during the study. Results 

obtained after less than two years of 

follow-up are rarely accepted. All data in 

the text must be consistent throughout 

the manuscript, including any illustrations, 

legends, or tables. 

Discussion: Be succinct. What does your 

study show? Is your hypothesis affirmed or 

refuted? Discuss the importance of this article 

with regard to the relevant world literature; 

a complete literature review is 

unnecessary. Analyze your data and discuss 

their strengths, their weaknesses, and 

the limitations of the study. 

3. Illustrations accompanying your manuscript 

must be submitted electronically 

and be in TIFF or EPS format. Do not 

import images into other software programs. 

No more than 30 images may be 

submitted. 

Any digital manipulation of an image— 

color, contrast, brightness, etc.—must be 

applied to the entire image and may not 

result in misrepresentation of the original 

image. Enhancement or alteration of part 

of an image, without clear and explicit disclosure 

in the legend, is unacceptable. 

Image files should be named appropriately 

and include the number of the figure (e.g., 

Figure1.tif, Figure2.eps, etc.). When completing 

the online submission form, remember 

to enter the name and number 

of the figure (Figure 1, Figure 2, etc.) into 

the “description” field. This description 

should match the name of the image file. 

Color images must be RGB (not CMYK). 

We cannot alter or vouch for the quality 

of color reproductions. 

In accordance with HIPAA, remove any 

writing that could identify the patient 

(e.g., names, initials, patient numbers). 

When using a digital camera to create 

your images, if possible, set the camera 

to save in TIFF format (not JPEG), set the 

resolution to a minimum of 300 ppi (pixels 

per inch), and set the size of the image 

to 5 × 7 in (127 × 178 mm). 

The resolution of your electronic images 

is critical and is directly linked to 

how well they will appear when printed. 

Color and grayscale images, such as 

radiographs, must have a minimum 

resolution of 300 ppi, and line-art drawings 

must have a minimum resolution 

of 1200 ppi. An original image size of 

5 × 7 in (127 × 178 mm) is preferred. 

For questions regarding electronic submission 

of images, contact the Desktop 

Publishing Department at dtp@jbjs.org. 

4. Legends must be included for all illustrations 

and listed in order. Explain what 

each illustration shows. Give the magnification 

of all photomicrographs. Define all arrows 

and other such indicators appearing 

on the illustration. If an illustration is of a 

patient who is identified by a case number, 

include that case number in the legend. 

How to contact us: 

The Journal of Bone and Joint Surgery 

20 Pickering Street, Needham, Massachusetts 02492-3157 

telephone: 781.449.9780 • fax: 781.449.9787 • e-mail: mail@jbjs.org 

5. A bibliography, of references made in the 

text. Abstracts or meeting transactions 

more than three years old should not be 

cited. The references should be numbered 

according to the order of citation in the 

text (not alphabetically) and should be in 

PubMed/Index Medicus format (for an example, 

go to the National Center for Biotechnology 

Information [NCBI] web site 

www.ncbi.nlm.nih. gov/entrez/query.fcgi and 

search for specific reference citations). All 

references must be cited in the text. 

Style 

Use “Uniform Requirements for Manuscripts 

Submitted to Biomedical Journals: 

Writing and Editing for Biomedical Publication” 

by the International Committee 

of Medical Journal Editors, October 2004 

(www.icmje.org) for standard format. For 

style guidelines, use “Scientific Style and 

Format. The CBE Manual for Authors, Editors, 

and Publishers, 6th ed.,” published by 

Cambridge University Press. 

The following style conventions should be 

kept in mind: 

1. The numerator and denominator should 

be included for all percentages. Round off 

percentages when the denominator is less 

than 200. Percentages should not be used 

when the value of n is less than twenty. 

2. All measurements should be given in metric 

or SI units, which are abbreviated. 

3. No other abbreviations or acronyms 

should be used. 




Authorship 

The order of names reflects only the preference 

of the authors. Each author must have 

contributed significantly to one or more 

aspects of the study: its design, data acquisition, 

analysis and interpretation of data, 

drafting of the manuscript, critical revision 

of the manuscript, statistical analysis, and/ 

or study supervision. Each author should 

be able to defend and assume full responsibility 

for the content of the manuscript, regardless 

of the specific contributions. No 

more than six authors should be listed; individuals 

who have contributed to only one 

segment of the manuscript or have contributed 

only cases should be credited in an acknowledgment 

footnote. If there are more 

than six authors, an accompanying letter of 

transmittal must detail why the authors 

have taken exception to these recommendations 

and should state how each author 

has contributed to the manuscript, with 

use of the criteria listed above. 

If a research group is designated as the 

author of an article, one or more group 

members who fully meet the above criteria 

for authorship should be listed in the article’s 

byline, followed by “on behalf of the 

[name of group].” The other group members 

should be listed in an acknowledgment 

section at the end of the article. 

Alternatively, the byline can include only 

the name of the group, followed by an asterisk 

corresponding to a list that specifies 

the authors who fully meet the above criteria 

for authorship and that also mentions 

the other group members. 

Letters to The Editor 

The Journal welcomes readers’ comments on 

published articles. Letters will be accepted and 

edited at the Editor’s discretion and will be 

published electronically on jbjs.org. Selected 

letters and author responses will be published 

in the print journal on a quarterly basis. Instructions 

for submitting a Letter to the Editor 

are available on our website (click “Instructions 

to Authors” and then click “Instructions 

for submitting a Letter to the Editor”). 

Review of Manuscripts 

Manuscripts are evaluated by the editorial 

staff of The Journal and are sent to outside 

reviewers. The time between receipt of a 

submitted manuscript and the decision 

regarding its publication has averaged six 

weeks, but it can be longer. 

Levels of Evidence for Primary Research Question 1 

Therapeutic Studies⎯ 

Investigating the 

Results of Treatment 

Level I • High-quality randomized controlled trial 

with statistically significant difference 

or no statistically significant difference 

but narrow confidence intervals 

• Systematic review 2 of Level-I randomized 

controlled trials (and study results 

were homogeneous 3 ) 

Level II • Lesser-quality randomized controlled 

trial (e.g.,



A CONCISE FORMAT FOR REPORTING THE 

LONGER-TERM FOLLOW-UP STATUS OF 

PATIENTS MANAGED WITH TOTAL HIP 

ARTHROPLASTY 

This format is to be used when the original fulllength 

article was published in The Journal of 

Bone and Joint Surgery. 

Length limit: Six manuscript pages, excluding 

references and figures. 

Follow-up intervals: No less than five years since 

the previous publication and preferably at five or 

ten-year intervals, as long as no interim changes 

have occurred that require expedited reporting. 

Abstract 

State, in a maximum of 150 words, why you are 

reporting the results at this interval and your 

major findings. 

Background 

Briefly summarize and cite the original study 

published in The Journal of Bone and Joint Surgery. 

Describe the original: 

• patient cohort 

• type of arthroplasty and critical aspects of surgical 

and cementing or cementless techniques 

• type of series (Was this a selected or unselected 

series? A consecutive series? Were 

the operations performed by a single surgeon? 

By multiple surgeons? At multiple institutions? 

Were data acquired prospectively 

or retrospectively?) 

Methods 

List, but do not describe, the methods used to 

assess clinical and radiographic results and 

cite the appropriate reference. 

For reporting clinical results: 

• you may use the same assessment scheme 

employed in your previous report—e.g., Harris, 

Hospital for Special Surgery, Iowa, Mayo Clinic, 

or Merle d’Aubigné-Postel rating system 

• you are strongly encouraged to include the 

WOMAC scores for the current cohort 

• you are encouraged to use the clinical and 

radiographic nomenclature described by 

Johnston et al. (J Bone Joint Surg Am. 

1990;72:161-8) for other pertinent data 

• you must perform survivorship analyses (with 

calculation of confidence limits) using end 

points that are appropriate to your cohort 

Results 

The results should include: 

• the original number of patients/hips studied 

and the number of patients/hips studied 

since the last report 

• the number of patients/hips who died, the 

number of patients/hips who were lost to 

follow-up, and the number of patients/hips 

currently being studied 

• the number of patients/hips in the updated 

series who were examined, the number who 

responded to questionnaires, and the number 

with available radiographs 

• the number of patients/hips in whom the primary 

joint replacement is still intact 

• basic demographic characteristics of the cohort, 

especially any that might affect results 

(age, diagnosis, gender, height, weight, and 

level of activity) 

• the number of arthroplasties revised for any 

reason. If the revised arthroplasties are included 

in the current series, report the status 

in this group separately 

• complications since the last report, including 

infection, dislocation, stem breakage, osteolysis, 

wear, and so on 

For survivorship analysis, the following end 

points should be used: 

(1) revision for any cause—e.g., aseptic loosening, 

osteolysis, component breakage, or 

infection 

(2) revision for aseptic loosening of the femoral 

component 

(3) revision for aseptic loosening of the acetabular 

component 

(4) definite radiographic loosening of the femoral 

component, according to the criteria of 

Harris et al. (J Bone Joint Surg Am. 

1982;64:1063-7) for cemented stems and 

the criteria of Engh et al. (J Bone Joint Surg 

Br. 1987;69:45-55) for uncemented stems. 

If your results cannot be evaluated with 

these criteria, cite the appropriate reference 

for your rating criteria 

(5) definite radiographic loosening of the acetabular 

component, according to the criteria 

of Hodgkinson et al. (Clin Orthop. 

1988;228:105-9)—i.e., migration or >1 

mm of radiolucency in all DeLee and 

Charnley zones. If your results cannot be 

evaluated with these criteria, cite the appropriate 

reference for your rating criteria 

Conclusions 

The conclusions should include: 

• major factors limiting the longevity of the 

prosthesis at the time of this follow-up 

• recommendations regarding the continued 

use of the prosthesis if it is still available 

• if the prosthesis is not still available, lessons 

applicable to the current successor or 

to similar designs 

A CONCISE FORMAT FOR REPORTING THE 

LONGER-TERM FOLLOW-UP STATUS OF 

PATIENTS MANAGED WITH TOTAL KNEE 

ARTHROPLASTY 

This format is to be used when the original fulllength 

article was published in The Journal of 

Bone and Joint Surgery. 

Length limit: Six manuscript pages, excluding 

references and figures. 

Follow-up intervals: No less than five years since 

the previous publication and preferably at five or 

ten-year intervals, as long as no interim changes 

have occurred that require expedited reporting. 

Abstract 

State, in a maximum of 150 words, why you are 

reporting the results at this interval and your 

major findings. 

Background 

Briefly summarize and cite the original study 

published in The Journal of Bone and Joint Surgery. 

Describe the original: 

• patient cohort 

• type of arthroplasty and critical aspects 

of surgical and cementing or cementless 

techniques 

• type of series (Was this a selected or unselected 

series? A consecutive series? Were 

the operations performed by a single surgeon? 

By multiple surgeons? At multiple 

institutions? Were data acquired prospectively 

or retrospectively?) 

Methods 

List, but do not describe, the methods used to 

assess clinical and radiographic results and 

cite the appropriate reference. 

For reporting clinical results: 

• you may use the same assessment scheme 

employed in your previous report—e.g., Hospital 

for Special Surgery or Knee Society rating 

system 

• you are strongly encouraged to include the 

WOMAC scores for the current cohort 

• you are encouraged to use the clinical and 

radiographic nomenclature described by 

Insall et al. (Clin Orthop. 1989;248:13-4) and 

Ewald (Clin Orthop. 1989;248:9-12) for other 

pertinent data 

• you must perform survivorship analyses (with 

calculation of confidence limits) using end 

points that are appropriate to your cohort 

Results 

The results should include: 

• the original number of patients/knees studied 

and the number of patients/knees studied 

since the last report 

• the number of patients/knees who died, the 

number of patients/knees who were lost to 

follow-up, and the number of patients/knees 

currently being studied 

• the number of patients/knees in the updated 

series who were examined, the number who 

responded to questionnaires, and the number 

with available radiographs 

• the number of patients/knees in whom the 

primary joint replacement is still intact 

• basic demographic characteristics of the cohort, 

especially any that might affect results 

(age, diagnosis, gender, height, weight, and 

level of activity) 

• the number of arthroplasties revised for any 

reason. If the revised arthroplasties are included 

in the current series, report the status 

in this group separately 

• complications since the last report, including 

infection, loosening, component breakage, 

osteolysis, wear, instability, and so on 

For survivorship analysis, the following end 

points should be used: 

(1) revision for any cause—e.g., aseptic loosening, 

osteolysis, component breakage, instability, 

or infection 

(2) revision for aseptic loosening of the femoral 

component 

(3) revision for aseptic loosening of the tibial 

component 

(4) revision for aseptic loosening of the patellar 

component 

Conclusions 

The conclusions should include: 

• major factors limiting the longevity of the 

prosthesis at the time of this follow-up 

• recommendations regarding the continued 

use of the prosthesis if it is still available 

• if the prosthesis is not still available, lessons 

applicable to the current successor or 

to similar designs 


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PUBLISHED IN TWO VOLUMES 

AMERICAN VOLUME 

Editor and Chairman, Board of Editors: JAMES D. HECKMAN 

Editors Emeriti: PAUL H. CURTISS JR., 

Deputy Editors Emeriti for Research: ALBERT H. BURSTEIN, 

HENRY R. COWELL LAWRENCE C. ROSENBERG 

ROBERT W. BUCHOLZ, Deputy Editor for Adult Reconstructive 

Surgery and Trauma 

CHARLES R. CLARK, Deputy Editor for Adult Reconstruction and Spine 

THOMAS A. EINHORN, Deputy Editor for Current Concepts Reviews 

VERNON T. TOLO, Deputy Editor for Pediatric Orthopaedics 

VINCENT D. PELLEGRINI Jr., Deputy Editor for Surgical Techniques 

ROBERT POSS, Deputy Editor for Electronic Media 

DEMPSEY S. SPRINGFIELD, Deputy Editor for Instructional Course Lectures 

PAUL TORNETTA III, Deputy Editor for AOA Publications 

american editorial board 

PETER STERN, Deputy Editor for the Upper Extremity 

KEN YAMAGUCHI, Deputy Editor for the Upper Extremity 

MARC F. SWIONTKOWSKI, Deputy Editor for Outcome Studies and Trauma 

BERTRAM ZARINS, Consulting Editor for Sports Medicine 

JAMES G. WRIGHT, Associate Editor for Evidence-Based Orthopaedics 

JAMES D. CAPOZZI, Coordinator of Ethics in Practice 

BRENT GRAHAM, Deputy Editor for Methodology and Biostatistics 

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ELENA LOSINA, Deputy Editor for Methodology and Biostatistics 

JOHN G. BIRCH, Dallas, Texas 

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SETH S. LEOPOLD, Seattle, Washington 

BASSAM A. MASRI, Vancouver, British Columbia, Canada 

JAMES P. MCAULEY, London, Ontario, Canada 

ROBERT M. SZABO, Sacramento, California 

EDWARD M. WOJTYS, Ann Arbor, Michigan 

the journal of bone and 

joint surgery incorporated 

Board of Trustees 

MICHAEL A. SIMON, Chairman 

BERNARD A. RINEBERG, Vice-Chairman 

JAMES H. HERNDON, Treasurer 

CECIL H. RORABECK, Secretary 

JAMES D. HECKMAN, Editor 

DAN M. SPENGLER 

VERNON T. TOLO 

EDWARD N. HANLEY Jr. 

STUART L. WEINSTEIN 

the american orthopaedic association 

President: PETER STERN 

6300 North River Road 

Rosemont, Illinois 60018 

the american academy of 

orthopaedic surgeons 

President: JAMES H. BEATY 

6300 North River Road 

Rosemont, Illinois 60018 

ANTHONY CATTERALL, Chairman 

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NEIL THOMAS, Secretary 

JAMES SCOTT, Editor 

FRANK HORAN, Editor Emeritus 

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british council of management 

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ROBERT MARSHALL 

JOHN GETTY, President, B.O.A. ex officio 

british orthopaedic association 

JOHN GETTY, President 

At the Royal College of Surgeons 

35-43 Lincoln’s Inn Fields, London WC2A 3PN 

australian orthopaedic association 

JOHN HARRIS, President 

Ground Floor, William Bland Centre, 

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Sydney, New South Wales 2000 

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Suite 360, Westmount, Quebec H3Z 2Y5 

board of consulting editors 

for research 

THOMAS W. BAUER, Deputy Editor for Research 

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TERRANCE D. PEABODY, Chicago, Illinois 

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BRITISH VOLUME 

Editor: JAMES SCOTT 

Editor Emeritus: FRANK HORAN 

british editorial board 

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JOHN GETTY, President, B.O.A., ex officio 

NICOLA MAFFULLI, Editorial Secretary, B.O.A. 

GEORGE BENTLEY, London, England (EFORT) 

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CY FRANK, Calgary, Canada 

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ROBERT GRIMER, Birmingham, England 

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JOE W.M. HARPER, Leicester, England 

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new zealand orthopaedic association 

MURRAY FOSBENDER, President 

P.O. Box 7451, Wellington South, New Zealand 

south african orthopaedic association 

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P.O. Box 25846, Langehovenpark 9330, Bloemfontein 

irish orthopaedic association 

FRANK DOWLING, President 

Cappagh National Orthopaedic Hospital, Finglas, Dublin 11 

european federation of 

national associations of orthopaedics 

and traumatology - efort 

WOLFHART PUHL, President 

Technoparkstrasse 1, CH-8005 Zürich, Switzerland 

western orthopaedic association 

President: GERARD L. GLANCY 

154-A West Foothill Boulevard, #107 

Upland, California 91786 

eastern orthopaedic association 

President: SCOTT D. BODEN 

110 West Road, Suite 227 

Towson, Maryland 21204 

mid-america 

orthopaedic association 

President: TIMOTHY C. FITZGIBBONS 

20 Second Avenue, S.W. 

Rochester, Minnesota 55902 

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BRIGITTE SCAMMELL (B.O.R.S.) 

GEORGE SIKORSKI, Perth, Australia 

SUSAN STOTT, Auckland, New Zealand 

DAVID WARWICK, Southampton, England 

ANDREW WILLIAMS, London, England 

JOHAN WITT, London, England 

british orthopaedic research society 

B. CATERSON, President 

c/o BOA 

35-43 Lincoln’s Inn Fields, London WC2A 3PN 

european orthopaedic research society 

NICO VERDONSCHOT, President 

Weiner Medizinische Akademie für ärztliche Fortbildung und Forshung, 

Vienna Academy of Postgraduate Medical Education and Research, 

Alserstrasse 4, 1. Hof, DION, A-1090 Wien 

canadian orthopaedic research society 

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4150 Ste. Catherine Street West 

Suite 360, Westmount, Quebec H3Z 2Y5 

British Office 

22 Buckingham Street, London WC2N 6ET, England 

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Published in the United Kingdom by 

The British Editorial Society of Bone & Joint Surgery 



EDITORIAL STAFF 

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PREP SCHOOL 

LESSON NO. 2 

COVERAGE 

AREA 

Some surgical prep applicators 

cover a lot more ground 

than others. 

How much does it cost to cover 450 sq. in.? 

With 3M DuraPrep Surgical Solution (Iodine 

Povacrylex [0.7% available iodine] and Isopropyl 

1 

26 mL applicator 

of DuraPrep 

Solution 

x 

$ _____________ 

(per applicator cost) 

= 

$ _____________ 

2.58 

26 mL applicators 

of ChloraPrep 

Antiseptic Prep 

x 

$ _____________ 

(per applicator cost) 

= 

$ _____________ 

Alcohol, 74% w/w) Patient Preoperative Skin 

Preparation, you can cover at least a 15” x 30” area 

(450 sq. in.) with a single 8630 applicator. That’s 

more than twice the area (13.2” x 13.2”, or 174 sq. in.) 

of the large 26mL ChloraPrep ® Antiseptic Skin Prep 

applicator. Want the facts? Ask your 3M representative 

for a Prep School Lesson Book or call the 3M Health Care 

Helpline at 1-800-228-3957. 

© 3M 2007. All Rights Reserved. DuraPrep and 3M are trademarks of 3M. ChloraPrep is a registered trademark of Enturia. 


For MIS and Navigation Assisted 

Hip Arthroplasty 

US Patent No. 7,100,225 

MorphBoard ® Positioning System 

• Multiple peg lengths for greater versatility and 

better stability 

• Lightweight, modular components make set up and 

storage easy 

• Modular system converts from standard to bariatric 

patients by a simple turn of the center board component 

• Disposable pads and sleeves protect patient from 

cross contamination 

Universal Lateral Positioner 

• Independently adjustable and removable 

anterior arms for more accurate contact with 

iliac crests 

• Patented Hyperflexion Plate allows up to 

120º of flexion during ROM testing 

• Removable Inferior arm to accommodate 

any patient anatomy 

• Storage case, w/casters for easy handling, 

keeps components organized and accessible 

US Patent No. 6,003,176 

Also from IMP… 

De Mayo Hip Positioner 

• Simple, adjustable lateral decubitus positioning 

• Easy nursing setup for large and obese patients 

SlimLine Abduction Pillow 

• Assures greater patient comfort and easier 

nursing care after hip surgery 

Contact your local IMP 

representative or call 800-467-4944 

IMP... THE OPERATIVE WORD IN 

PATIENT POSITIONING 

IMP and MorphBoard are registered trademarks, and Universal 

Lateral Positioner, De Mayo Hip Positioner and Slimline are 

trademarks of Innovative Medical Products, Inc. 

7173 ©2007 Innovative Medical Products, Inc. 

All rights reserved. 8/07 

Innovative 

Medical Products, Inc. 

AGLOBAL LEADER IN PATIENT POSITIONING 

87 Spring Lane, Plainville, CT 06062 

PH: 860-793-0391 FAX: 860-793-8975 

Toll Free: PH: 800-467-4944 FAX: 888-229-1452 

www.impmedical.com 


Stepping forward with locking technology. 

Acumed has taken locking technology 

one step further with the forefoot 

and midfoot plating system. Engineered 

with a new counterbore/countersink 

design, the locking screws “disappear” 

down into the plate. By adding this 

technology to the anatomically 

contoured, low profile plates, 

Acumed has provided yet another 

innovative solution that’s truly 

steps ahead of the rest. 

(888) 627-9957 www.acumed.net 

Downloaded From: http://jbjs.org/ on 01/27/2014 

AcUMEDr


Could you be treating 

your total knee 

candidates with an 

Oxford ® Partial Knee? 

• Less postoperative pain 1 * 

• Less bone removal 1 * 

• More natural motion 1 * 

• Clinically proven at 10, 15 and 20 years 2 

Oxford ® Partial Knee 

Contact your local Biomet Distributor for more 

information about the most widely used partial 

knee in the world. 

* Compared to total knee replacement 

1. Kim, K.T. et al. A Prospective Analysis of Oxford Phase 3 Unicompartmental 

Knee Arthroplasty. Orthopedics. 30(5 Suppl): 15–18, 2007. 

2. Price, A.J. et al. 20-year survival and 10-year clinical results of the 

Oxford uni knee arthroplasty. Paper No. 046. 73rd Annual AAOS 

Meeting. Chicago, IL. 2006. 

Biologics • Bracing • Microfi xation • Orthopedics • Osteobiologics • Spine • Sports Medicine • Trauma • 3i 

biomet.com • 800.348.9500 x 1501 

©2007 Biomet Orthopedics, Inc. Oxford ® is a registered trademark of Biomet Manufacturing Corp. 



The Science of Increased Motion 13 

High flexion knee system designed for mobility 

with stability through 150 degrees of motion. 

Flared Posterior Condyles 

• Open design accommodates 20 degrees 

of internal/external rotation throughout 

range of motion. 7 

Rotary Arc Insert 

• Precision-machined surface facilitates 

internal/external rotation. 

Anatomic Radius (10º – 110º) 

• Designed to maintain collateral 

ligament stability throughout the range 

of motion. 8 

• Centered at the transepicondylar axis - 

the optimal flexion axis of the knee. 9 

Anatomic Patellofemoral Track 

• The Triathlon Knee patellofemoral track shares the same 

design as preceding Stryker total knee systems, bringing over a 

decade of excellent clinical performance and the industry’s 

lowest revision rate (0.3%) 10 to date to this knee system. 

Over 100,000 implanted in just two years... 

To learn more about the Motion, Fit and Wear of Triathlon, please visit: www.stryker.com 

7. Stryker test data RD-03-041 and RD-04-027. 

8. Stryker initiated Dynamic Computer Simulations of Passive ROM and Oxford Rig Test, Stephen Piazza, 2003. 

9. Churchill, D.L., Incavo, S.J., Johnson, C.C., Beynnon, B.D. The Transepicondylar Axis Approximates the Optimal 

Flexion Axis of the Knee, Clinical Orthopaedics. Nov. 1998 (356): 111-8. 

10. Robertson, O., Knutson, K., Lewold, S., Lidgren, L. The Swedish Knee Arthroplasty Register, Outcome with Special 

Emphasis on 1988-1997. Department of Orthopedics, University Hospital. 

13. Greene, K.A. Range of Motion: Early Results from the Triathlon Knee System, Stryker Literature Ref # LSA56., 2005. 

Triathlon 

Stryker Orthopaedics 325 Corporate Drive, Mahwah, NJ 07430 www.stryker.com 

A surgeon must always rely on his or her own professional clinical judgment when deciding to use which products and/or 

techniques on individual patients. Stryker is not dispensing medical advice and recommends that surgeons be trained in 

orthopaedic surgeries before performing any surgeries. 

The information presented in this brochure is intended to demonstrate the breadth of Stryker product offerings. Always refer to 

the package insert, product label and/or user instructions before using any Stryker product. Products may not be available in all 

markets. Product availability is subject to the regulatory or medical practices that govern individual markets. 

Please contact your Stryker representative if you have questions about the availability of Stryker products in your area. 

Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks 

or service marks: Triathlon, X3, N 2 \Vac. All other trademarks are trademarks of their respective owners 

or holders.7 


Experience 

Reserve your 

AAOS Annual Meeting 

Hotel Room on 

August 16th! 

the very best in orthopaedic education, research, and technology 

On Thursday, August 16, hotel room reservations 

for the AAOS 75th Annual Meeting become available 

online to AAOS Members only. 

Choose from a wide selection of San Francisco hotels—priced at special rates 

negotiated for the AAOS Annual Meeting. We know housing is important to 

you. Act early to take advantage of this member benefit. 

On October 3, Members-Only Early Registration opens online. 

Watch for email alerts* in advance of these opening dates, bringing you the 

Members Only website addresses. 

*Does the AAOS have your latest email address? If not, please go to www.aaos.org, click on 

Member Services, then My Profile, then Email Address. Or just email us your address at 

meeting@aaos.org. 

AAOS 75 th Annual Meeting 

San Francisco, California 

March 5 – 9, 2008 


The Science of Better Fit 

Designed with a wide range of sizing options, based on 

the anatomical differences of men and women. 6 

The Triathlon Knee System addresses smaller anatomies, 

often found in female patients, heavily concentrated in 

the region shown, while still accommodating larger male 

patients. 

• Broad range of size offerings are based on an anthropometric 

measurement study 6 for improved interplay between implant 

geometry and anatomic structure for women and men. 

• The Triathlon design incorporates a variable aspect ratio to 

adequately fit the female anatomy while still accommodating the 

male population. 6 

• The many design aspects of the implant accommodate surgical 

realities. 

7-Degree Anterior Flange 

• The unique 7-degree anterior flange 

design of the Triathlon Knee System is 

designed to provide the flexibility to 

downsize the femoral component while 

avoiding the incidence of notching. 

This feature culminates in the potential 

to provide patients with a more 

customized fit. 


6. Hitt, K., et al. Anthropometric Measurement of the Human Knee: correlation to the Sizing of Current Knee 

Arthroplasty Systems, JBJS, Vol. 85-A, Supplement 4, 2003. 


Triathlon 











or holders.7 


Adv 32 

JBJS [Br] Abstracts Now Available 

Hip 

Reduction of the potential for thermal damage during hip resurfacing 

H. S. Gill, P. A. Campbell, D. W. Murray, and K. A. De Smet 

J Bone Joint Surg Br 2007 89-B: 16-20 

Resurfacing arthroplasty of the hip is being used increasingly 

as an alternative to total hip replacement, especially for young 

active patients. There is concern about necrosis of the femoral 

head after resurfacing which can result in fracture and loosening. 

Most systems use a cemented femoral component, with 

the potential for thermal necrosis of the cancellous bone of the 

reamed femoral head. We used thermal probes to record temperatures 

close to the cement-bone interface during resurfacing 

arthroplasty. 

The maximum temperature recorded at the cement-bone 

interface in four cases was approximately 68°C which was 

higher than that reported to kill osteocytes. A modified surgical 

technique using insertion of a suction cannula into the lesser 

trochanter, generous pulsed lavage and early reduction of the 

joint significantly reduced the maximum recorded cancellous 

bone temperature to approximately 36°C in five cases (p = 

0.014). 

We recommend the modified technique since it significantly 

reduces temperatures at the cement-bone interface. 

Trauma 

Conservative treatment of isolated fractures of the medial malleolus 

D. Herscovici, Jr, J. M. Scaduto, and A. Infante 


Between 1992 and 2000, 57 patients with 57 isolated fractures 

of the medial malleolus were treated conservatively by 

immobilisation in a cast. The results were assessed by examination, 

radiography and completion of the short form-36 questionnaire 

and American Orthopaedic Foot and Ankle Society 

ankle-hindfoot score. 

Of the 57 fractures 55 healed without further treatment. 

The mean combined dorsi- and plantar flexion was 52.3° (25° 

to 82°) and the mean short form-36 and American Orthopaedic 

Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 

100), respectively. At review there was no evidence of medial 

instability, dermatological complications, malalignment of the 

mortise or of post-traumatic arthritis. 

Isolated fractures of the medial malleolus can obtain high 

rates of union and good functional results with conservative 

treatment. Operation should be reserved for bi- or trimalleolar 

fractures, open fractures, injuries which compromise the skin or 

those involving the plafond or for patients who develop painful 

nonunion. 

Knee 

Validation of the short-form WOMAC function scale for the evaluation 

of osteoarthritis of the knee 

K. G. Auw Yang, N. J. H. Raijmakers, A. J. Verbout, W. J. A. Dhert, and 

D. B. F. Saris 


This study validates the short-form WOMAC function 

scale for assessment of conservative treatment of osteoarthritis 

of the knee. Data were collected before treatment and six and 

nine months later, from 100 patients with osteoarthritis of the 

knee to determine the validity, internal consistency, test-retest 

reliability, floor and ceiling effects, and responsiveness of the 

short-form WOMAC function scale. The scale showed high correlation 

with the traditional WOMAC and other measures. The 

internal consistency was good (Cronbach : 0.88 to 0.95) and an 

excellent test-retest reliability was found (Lin’s concordance correlation 

coefficient ( c): 0.85 to 0.94). The responsiveness was 

adequate and comparable to that of the traditional WOMAC 

(standardised response mean 0.56 to 0.44 and effect size 0.64 to 

0.57) and appeared not to be significantly affected by floor or 

ceiling effects (0% and 7%, respectively). 

The short-form WOMAC function scale is a valid, reliable 

and responsive alternative to the traditional WOMAC in the 

evaluation of patients with osteoarthritis of the knee managed 

conservatively. It is simple to use in daily practice and is therefore 

less of a burden for patients in clinical trials. 


THE JOURNAL OF 

BONE AND JOINT SURGERY 

www.jbjs.org.uk

The Science of Reduced Wear 

High performance through improved design 

kinematics combined with X3 Advanced Bearing Technology. 1 

The Triathlon Knee System is designed to 

reduce rotational stresses, increase overall 

contact area, and minimize backside wear. 

• Through the Rotary Arc design, anatomic radius, 

and flared posterior condyles, the Triathlon Knee 

System balances conformity with constraint to 

mimic natural knee kinematics and the potential 

for enhanced wear properties. 2,3,7 

Wear Test Results: Triathlon Knee 

System with X3 versus Competitive 

Premium Bearing Technology 1 

X3 Advanced Bearing Technology 

• Structural Contact Fatigue Strength better than 

conventional polyethylene 11 

Locking tabs 

to secure wire 

Insert guide 

• Improved Wear Performance 2,3 

• Oxidation Resistance 4,5 

Same as virgin polyethylene 

Anti-Rotation Island 

designed to minimize 

insert micromotion 

and creep 

Improved Locking Mechanism Design 

• Full periphery locking rim and locking wire. 

• Anti-rotation island. 

• Reduce micromotion and promote 

ease of insertion. 12 



1. Stryker Orthopaedics Test Report: RD-06-013. 

2. Stryker Orthopaedics Triathlon CR Tibial Inserts made from X3 UHMWPE, 5530-G-409 show a 68% reduction in 

volumetric wear rate versus the same insert fabricated from N 2 \Vac gamma sterilized UHMWPE, 5530-P-409. The insert 

tested was Size 4, 9mm thick. Testing was conducted under multiaxial knee simulator (multi-station MTS knee joint 

simulator [a]) for five million cycles using appropriate size CoCr counterfaces, a specific type of diluted calf serum 

lubricant and the motion and loading conditions, representing normal walking, outlined in ISO/DIS 14243-3. 

Volumetric wear rates were 17.7 ± 2.2 mm 3 /10 6 cycles for standard polyethylene inserts and 5.7 ± 1.5 mm 3 /10 6 cycles for 

test samples. Test inserts were exposed to a gas plasma sterilization process. In vitro knee wear simulator tests have not 

been shown to quantitatively predict clinical wear performance. 

[a] A. Essner, A. Wang, C. Stark and J. H. Dumbleton. A simulator for the evaluation of total knee replacement 

wear, 5th World Biomaterials Congress, Toronto, Canada, May 1996, pg 580. 

3. Stryker Orthopaedics Triathlon PS Tibial Inserts made of X3 UHMWPE, 5532-G-409 show a 64% reduction in 

volumetric wear rate versus the same insert fabricated from N 2 \Vac gamma sterilized UHMWPE, 5532-P-409. The insert 

tested was Size 4, 9mm thick. Testing was conducted under multiaxial knee simulator (multi-station MTS knee joint 

simulator) for five million cycles using a size 7 CoCr counterfaces, a specific type of diluted calf serum lubricant and 

literature or fluoroscopy based motion and loading conditions representing stair climbing [b,c]. Volumetric wear rates 

were 3.6 ± 0.61 mm 3 /10 6 cycles for standard polyethylene inserts and were 1.3 ± 0.44 mm 3 /10 6 cycles for test samples. 

Test inserts were exposed to a gas plasma sterilization process. In vitro knee wear simulator tests have not been shown to 

quantitatively predict clinical wear performance. 

[b] R. Riener, M. Rabuffetti and C. Frigo. Stair ascent and descent at different inclinations, Gait and Posture 15: 

2002, pp. 32-44. 

[c] JB. Morrison. Function of the knee joint in various activities, Bio-medical Engineering, 4: 1969, pp. 573-580. 

4. X3 UHMWPE maintains mechanical properties after accelerated oxidative aging. No statistical difference was found for 

Tensile Yield Strength, Ultimate Tensile Strength and Elongation as measured per ASTM D638 before and after exposure 

to ASTM F2003 accelerated aging (5 Atmospheres (ATM) of oxygen at 70°C for 14 days). Tensile Yield Strength was 23.5 

± 0.3 MPa and 23.6 ± 0.2 MPa, Ultimate Tensile Strength was 56.7 ± 2.1 MPa and 56.3 ± 2.3 MPa, and Elongation was 

267 ± 7% and 266 ± 9% before and after accelerated oxidative aging, respectively. 

5. X3 UHMWPE resists the effects of oxidation. No statistical difference was found for Tensile Yield Strength, Ultimate 

Tensile Strength, Elongation, Crystallinity and Density as measured per ASTM D638, D3417 and D1505 before and after 

ASTM F2003 accelerated aging (5 ATM of oxygen at 70°C for 14 days). Tensile Yield Strength was 23.5 ± 0.3 MPa and 

23.6 ± 0.2 MPa, Ultimate Tensile Strength was 56.7 ± 2.1 MPa and 56.3 ± 2.3 MPa, Elongation was 267 ±7%and266± 

9%, Crystallinity was 61.7 ± 0.6% and 61.0 ± 0.5%, and Density was 939.2 ± 0.1 kg/m3 before and after accelerated 

oxidative aging, respectively. 

7. Stryker test data RD-03-041 and RD-04-027. 

11. Contact fatigue testing was conducted on accelerated aged sequentially crosslinked and annealed (X3) UHMWPE and 

control materials. Testing involved translating a 22mm CoCr femoral head across 5mm thick samples at 0.5 Hz under a 

200 N load for a contact stress of 62 MPa. Control materials were nitrogen packed and gamma-radiation sterilized and 

air packed and gamma-radiation sterilized UHMWPE’s. X3 samples were unsterilized. All contact fatigue samples were 

ASTM F2003 accelerated aged (5 ATM of oxygen at 70°C for 14 days). Testing induced cracking in control materials in as 

little as 0.5 million cycles while proposed material samples showed no signs of pitting, cracking (surface or subsurface) 

after 5 million cycles. Control material cracks progressed to gross material loss (delamination). 

The results of the in-vitro delamination tests have not been shown to correlate with clinical delamination mechanisms. 

12. Stryker Test Report. Multi-Axis Dynamic Fatigue Test MTP101.0-02. 

Triathlon 











or holders.7 


2006 Corporate Associates 

Platinum Level ($200,000 & above) 

Gold Level 

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LINK ® BetaCone TM 

Hip Prosthesis System 

This device is deared for use without bone cement in the United States. 

LINK ORTHOPAEDICS · 300 Roundhill Dr. · Rockaway, NJ 07866 · USA 

Phone 1-973-625-1333 (U.S. and Canada) · Phone 1-973-625-4445 

e-mail: link@linkorthopaedics.com 

Distributed in U.S. and Canada by Exactech, Inc. · FL 32653 Gainesville · Phone 1-800-392-2832 

Manufactured: WALDEMAR LINK GmbH & Co. KG · www.linkhh.de · Germany 

www.betacone.com 

Next 

generation 

hip prosthesis 

providing excellent 

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to reduce “stress-shielding“ 

Time has come for change! 


“ DYONICS ELECTROBLADE Resector makes 

quick work of subacromial decompressions.” 

LAWRENCE LEMAK, MD 

LEMAK Sports Medicine Institute, Birmingham, Alabama 

 

Exclusively from Smith & Nephew, the DYONICS ELECTROBLADE Resector 

streamlines subacromial decompressions by delivering simultaneous soft 

tissue resection and hemostasis. This reduces instrument exchanges, 

minimizes bleeding and enhances visualization. Please contact us to learn 

more about how DYONICS products can simplify your procedures. 

Endoscopy 

Smith & Nephew, Inc. 

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Certain marks are Reg US Pat and TM Office. 

©2007 Smith & Nephew, Inc. All rights reserved 

Printed in USA 06/07 2071 Rev. A 


Dislocation 

concerns? 

Lifestyle Recovery 

Technologies 

Helping you to help patients maximize ROM and 

enhance stability. 

LFIT Anatomic 

CoCr Femoral 

Head with 

X3 Liner 

UHRBipolar 

Femoral Head 

Secur-Fit Max 

Femoral Hip 

Stem 

Trident 

Constrained 

Insert 

Formore information,contactyourlocal Stryker sales representative at 

1-866-447-3627 or visit www.stryker.com 

Lifestyle Recovery Technologies, LFIT AnatomicCoCr Femoral Head, 

X3 Liner,UHRBipolar Head,Trident Constrained Insert 

Stryker Orthopaedics 

325 Corporate Drive, Mahwah, NJ 07430 

Asurgeon is the best person to decide with the patient which treatments andproducts are right for them. 

Surgeons must always rely on their ownclinicaljudgement when deciding which treatments andprocedureto 

use with patients. Copyright © 2006 Stryker. Stryker Corporation orits divisions or other corporate affiliated 

entities own, use or have appliedfor the following trademarks:LFIT, Lifestyle Recovery, Secur-Fit, Stryker, 

Trident, UHR, X3. 


IMPORTANT SAFETY INFORMATION: 

*Because of its clotting mechanism, Thrombin-JMI ® must not be injected or otherwise allowed to enter large blood vessels. Extensive intravascular clotting or even 

death may result. Thrombin-JMI ® should be given to a pregnant woman only if clearly indicated. Safety and efficacy in children have not been established. 

The use of topical bovine thrombin preparations has occasionally been associated with abnormalities in hemostasis ranging from asymptomatic alterations in 

laboratory determinations, such as prothrombin time (PT) and partial thromboplastin time (PTT), to severe bleeding or thrombosis which rarely have been fatal. 

These hemostatic effects appear to be related to the formation of antibodies against bovine thrombin and/or factor V which in some cases may cross react with 

human factor V, potentially resulting in factor V deficiency. Repeated clinical applications of topical bovine thrombin increase the likelihood that antibodies against 

thrombin and/or factor V may be formed. Consultation with an expert in coagulation disorders is recommended if a patient exhibits abnormal coagulation 

laboratory values, abnormal bleeding or abnormal thrombosis following the use of topical thrombin. Any interventions should consider the immunologic basis of 

this condition. Patients with antibodies to bovine thrombin preparations should not be re-exposed to these products. 

Please see brief summary of full Prescribing Information for Thrombin-JMI ® on adjacent page. 


Gets to the Site 

of the Bleeding 

Your Trusted Thrombin-on-the-Spot for Fast, Active Hemostasis 

•Hemostasis achieved within 3 minutes in 71% of patients undergoing spinal surgery who were treated with 

Thrombin-JMI ® -soaked Absorbable Gelatin Sponge, USP 1 

•A biologically active agent that works directly at the end of the coagulation cascade 2 

Multiple Delivery Options for Hemostasis— 

Where You Want It, When You Need It 

• Thrombin-JMI ® Pump Spray Kit to cover broad oozing areas 

• Thrombin-JMI ® Syringe Spray Kit for difficult-to-reach bleeding sites* 

•Thrombin-JMI ® Vials for direct application or use in conjunction with certain passive hemostatic agents 

Thrombin-JMI ® is indicated as an aid to hemostasis whenever oozing blood and minor bleeding from capillaries 

and small venules is accessible. In various types of surgery, solutions of Thrombin-JMI ® may be used in conjunction 

with an Absorbable Gelatin Sponge, USP for hemostasis. 

Makes Contact. Takes Action. 

Thrombin-JMI is a registered trademark of King Pharmaceuticals Research and Development, Inc., a wholly owned subsidiary of King Pharmaceuticals ® , Inc. 

Copyright © 2006 King Pharmaceuticals ® , Inc. All rights reserved. JMI4276 12/2006 


THROMBIN, TOPICAL U.S.P. 

(BOVINE ORIGIN) 

THROMBIN-JMI ® 

BRIEF SUMMARY of Full Prescribing Information 

 

Thrombin, Topical (Bovine) must not be injected! Apply on 

the surface of bleeding tissue. 

INDICATIONS AND USAGE 

THROMBIN-JMI ® is indicated as an aid to hemostasis whenever 

oozing blood and minor bleeding from capillaries and small 

venules is accessible. 

In various types of surgery, solutions of THROMBIN-JMI ® may 

be used in conjunction with an Absorbable Gelatin Sponge, USP 

for hemostasis. 


THROMBIN-JMI ® is contraindicated in persons known to be sensitive 

to any of its components and/or to material of bovine origin. 

WARNING 

The use of topical bovine thrombin preparations has 

occasionally been associated with abnormalities in 

hemostasis ranging from asymptomatic alterations in 

laboratory determinations, such as prothrombin time 

(PT) and partial thromboplastin time (PTT), to severe 

bleeding or thrombosis which rarely have been fatal. 

These hemostatic effects appear to be related to the formation 

of antibodies against bovine thrombin and/or factor 

V which in some cases may cross react with human 

factor V, potentially resulting in factor V deficency. 

Repeated clinical applications of topical bovine thrombin 

increase the likelihood that antibodies against 

thrombin and/or factor V may be formed. Consultation 

with an expert in coagulation disorders is recommended 

if a patient exhibits abnormal coagulation laboratory values, 

abnormal bleeding, or abnormal thrombosis following 

the use of topical thrombin. Any interventions should 

consider the immunologic basis of this condition. 

Patients with antibodies to bovine thrombin preparations 

should not be re-exposed to these products. 

Because of its action in the clotting mechanism, THROM- 

BIN-JMI ® must not be injected or otherwise allowed to enter 

large blood vessels. Extensive intravascular clotting and 

even death may result. 

PRECAUTIONS 

General — Consult the Absorbable Gelatin Sponge, USP labeling 

for complete information for use prior to utilizing the thrombin 

saturated sponge procedure. 

Pregnancy — Category C – Animal reproduction studies have 

not been conducted with THROMBIN-JMI ® . It is also not known 

whether THROMBIN-JMI ® can cause fetal harm when administered 

to a pregnant woman or can affect reproduction capacity. 

THROMBIN-JMI ® should be given to a pregnant woman only if 

clearly indicated. 

Pediatric Use — Safety and effectiveness in children have not 

been established. 

ADVERSE REACTIONS 

Allergic reactions may be encountered in persons known to be 

sensitive to bovine materials. Inhibitory antibodies which interfere 

with hemostasis may develop in a small percentage of 

patients. See Warning. 

 

 

 

 

 

 

 

 

Distributed By: 

Jones Pharma Incorporated, Bristol, VA 24201 

Manufactured by: 

GenTrac, Incorporated, Middleton, Wisconsin 53562 

U.S. License No. 977 

Rev. 5/05 

Jones Pharma Incorporated and GenTrac, 

Incorporated Jones Pharma are Incorporated wholly owned subsidiaries and GenTrac, of 

King Incorporated Pharmaceuticals are wholly ® , Inc. owned subsidiaries of 

King Pharmaceuticals ® , Inc. 

References: 1. Renkens KL Jr, Payner TD, Leipzig TJ, et al. A 

multicenter, prospective, randomized trial evaluating a new 

hemostatic agent for spinal surgery. Spine. 2001;26:1645- 

1650. 2.Thrombin-JMI [package insert]. Middleton, Wis: 

GenTrac, Inc; 2005. 

 



The Main Event 

The comprehensive meeting on hip resurfacing 

October 25 - 27, 2007 

Loews Miami Beach Hotel 

Miami, Florida 

Register online at www.orthomeetings.com 

Chairmen 

Derek McMinn, FRCS 

Edgbaston, Birmingham 

United Kingdom 

Ronan Treacy, FRCS 

Edgbaston, Birmingham 

United Kingdom 

Trademark of Smith & Nephew. Reg. US Pat. & TM Off. 

10 Years 

1997-2007 

BIRMINGHAM HIP Resurfacing 




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See brief summary on page 18 


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Photo © www.KarlGrobl.com 

 

 

 


Take the guesswork out of 

shoulder reconstruction. 

Only the HemiCAP ® system can recreate both the non-spherical and spherical curvatures 

of the humeral head using 3D intraoperative mapping without changing 

head height, version or tension of the soft tissue envelope. 

Map it and HemiCAP ® 

it! 

X-rays courtesy of John Macy, M.D., Burlington, VT, USA 

28 forge parkway, franklin, ma 02038 tel +1 508 520 3003 fax +1 508 528 4604 web arthrosurface.com 


Adv 48 


Trauma 

The undiagnosed Essex-Lopresti injury 

P. Jungbluth, T. M. Frangen, S. Arens, G. Muhr; and T. Kälicke 

From BG-Kliniken Bergmannsheil Bochum, Bochum, Germany 

J Bone Joint Surg (Br) 2006;88-B:1629-33 

The Essex-Lopresti injury is rare. It consists of fracture of the 

head of the radius, rupture of the interosseous membrane and 

disruption of the distal radioulnar joint. The injury is often 

missed because attention is directed towards the fracture of the 

head of the radius. We present a series of 12 patients with a 

mean age of 44.9 years (26 to 54), 11 of whom were treated 

surgically at a mean of 4.6 months (1 to 16) after injury and 

the other after 18 years. They were followed up for a mean of 

29.2 months (2 to 69). Ten patients had additional injuries 

to the forearm or wrist, which made diagnosis more difficult. 

Replacement of the head of the radius was carried out in ten 

patients and the Sauve-Kapandji procedure in three. Patients 

were assessed using standard outcome scores. The mean postoperative 

Disabilities of the Arm, Shoulder and Hand score was 

55 (37 to 83), the mean Morrey Elbow Performance score was 

72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 

80). The mean grip strength was 68.5% (39.6% to 91.3%) of 

the unaffected wrist. 

Most of the patients (10 of 12) were satisfied with their 

operation and in 11 the pain was relieved. When treating the 

chronic Essex-Lopresti injury, we recommend accurate realignment 

of the radius and ulna and replacement of the head of the 

radius. If this fails a Sauve-Kapandji procedure to arthrodese 

the distal radioulnar joint should be undertaken to stabilise the 

forearm while maintaining mobility. 

Hip 

going resurfacing (57%; 36) had an offset ratio 0.15 pre-operatively 

and required greater correction of offset at operation than 

the rest of the group. In the non-arthritic hips the mean offset 

ratio was 0.137 (0.04 to 0.23), with the offset ratio correlating 

negatively to an increasing angle. An offset ratio 0.15 had a 

9.5-fold increased relative risk of having an angle 50.5°. Most 

hips undergoing resurfacing have an abnormal femoral head/ 

neck offset, which is best assessed in the sagittal plane. 

Knee 

Determining the rotational alignment of the tibial component at 

total knee replacement 

A COMPARISON OF TWO TECHNIQUES 

M. Ikeuchi, N. Yamanaka, Y. Okanoue, E. Ueta, and T. Tani 


We prospectively assessed the benefits of using either a rangeof-movement 

technique or an anatomical landmark method to 

determine the rotational alignment of the tibial component during 

total knee replacement. We analysed the cut proximal tibia 

intraoperatively, determining anteroposterior axes by the rangeof-movement 

technique and comparing them with the anatomical 

anteroposterior axis. 

We found that the range-of-movement technique tended to 

leave the tibial component more internally rotated than when 

anatomical landmarks were used. In addition, it gave widely 

variable results (mean 7.5°; 2° to 17°), determined to some 

extent by which posterior reference point was used. Because of 

the wide variability and the possibilities for error, we consider 

that it is inappropriate to use the range-of-movement technique 

as the sole method of determining alignment of the tibial component 

during total knee replacement. 

The femoral head/neck offset and hip resurfacing 

P. E. Beaulé, N. Harvey, E. Zaragoza, M. J. Le Duff, and F. J. Dorey 


Because the femoral head/neck junction is preserved in hip 

resurfacing, patients may be at greater risk of impingement, 

leading to abnormal wear patterns and pain. We assessed femoral 

head/neck offset in 63 hips undergoing metal-on-metal hip 

resurfacing and in 56 hips presenting with non-arthritic pain 

secondary to femoroacetabular impingement. Most hips under- 




www.jbjs.org.uk

Ankle Fusion has an 

Improved Alternative 

The 4th generation Agility LP Ankle is a 

new member of the Agility Total Ankle System 

that provides: 

• New cutting blocks to provide precise, 

reproducible tibial, fibular and talar cuts 

• Broader cortical coverage of the cut talus 

• System has 90% survivorship with revision 

option 1 

• Over 20 years of clinical experience 2,3,4 

For more information, contact 

your local DePuy representative. 

© 2007 DePuy Orthopaedics, Inc. All rights reserved. 

References: 

1. Data on file at DePuy Orthopaedics, Inc. 

2. Kronemyer, B.: Results of First 100 Agility Total Ankle Arthroplasties 

Encouraging. Orthopedics Today, July 1997, Vol. 17, No. 7: 16-17. 

3. Alvine, F. G.: Total Ankle Arthroplasty: New Concepts and Approach. 

Contemporary Orthopaedics, April 1991, Vol. 22, No. 4: 397-403. 

4. Pyevich, M. T.; Saltzman, C. L. and Callaghan, J. J.: Total Ankle Arthroplasty: 

A Unique Design. JBJS, October 1998, Vol. 80-A, No. 10: 1410-1420. 


Features of BONE FOAM 

• Radiolucent for 

C-Arm imaging 

• Saves 10-20 minutes each case 

• Consistent and 

stable 

• Strategic design for each extremity 

• 100% latex freee 

• Durable stain resistant coating 

• Sterile bags available ailable to fit most pieces 

• Fire retardant 

• Washable for infection control 

TO 

ORDER 

612.338.1400 

www.bonefoam. com 

sales@excelmedsolutions.com 

lmedsolutions.co 

om 

Before 

BONE FOAM 

BONE FOAM 

Before 

Upper Extremity 

Block & Wedge 

ORIF of Distal Humerus, 

Olecranon, Ulna 

"The upper extremity 

pieces have an offset 

down arm tunnel that 

makes it perfect for C-Arm 

imaging." 

Upper Extremity Block 

ORIF of Distal Humerus 

and Olecranon 

"The upper extremity ty 

block helps to reduce and 

hold reduction through 

surgery." ry." 

Before 

BONE FOAM 

BONE FOAM 

Leg Cradle 

Cylindrical i 

Bumps 

ORIF of Tibial Plateau 

and Distal Femur 

"Bone Foam cylinders 

help me quickly bump 

and prop up any 

extremity." 

The Ramp/Leg Elevator 

ORIF of Patella, Tibia, Ankle, 

Midfoot ot and Forefoot oot FX 

"The leg Elevator helps me 

save time by positioning oning 

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operative leg above 

the 

nonoperative leg so 

lateral 

C-Arm Imaging is 

consistant and fast." 

Before 

BONE FOAM 

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Retrograde 

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Small, Medium, Large: 

To get the right angle 

Knee Wedges 

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reduction. 

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Why One Million 

Gamma Nails 

Have Been Implanted 

Worldwide 

First † 

Pioneered by visionaries 

Finest 

Improved through experience 

Preferred †† 

Most trusted and implanted device of its type 

Surgeons have embraced Stryker’s Gamma 

technology and have implanted over one 

million worldwide.* This extraordinary 

statistic speaks to the trust surgeons across 

the globe place in Gamma Nails, and to 

the Gamma Nail innovators who strive 

for excellence. 

Nearly two decades ago, Stryker introduced 

the first † generation of Gamma Nail 

to the world market. Today, the third 

generation intramedullary sliding lag 

screw nail continues to define the industry 

standard. 

Gamma Locking Nail System 

The unmistakable advantages of the 

Gamma Nail Family 

• Over 17 years of clinical experience 

• New smaller implant with streamlined 

instrumentation 

• Minimally invasive surgery with the 

possibility for less bone removal 

• Three entry options for beginning 

the procedure 

• Potential for earlier weight bearing** 

Stryker is proud to work side-by-side with 

trauma and orthopaedic surgeons to herald 

in the future of orthopaedic fracture 

treatment. 

To see a Live Gamma3 procedure performed 

on a cadaver by Drs. Christopher Born, 

James Maxey and Robert Probe, please 

visit www.or-live.com/Gamma3/1458 

For more information, visit 

www.stryker.com/gamma or contact 

your Stryker Trauma Representative. 

* Includes Gamma, Gamma-Ti, and Gamma3 

** Early weight bearing as appropriate for the patient 

and determined by the Surgeon. References available 

upon request. 

† Based on trademark filing with the United States Patent 

and Trademark Office, US Registration # 2819616. 

†† Millennium Research Group, US Markets for Trauma 

Devices, February 2005, Intramedullary Hip Screw 

Market. 


A surgeon is the best person to decide with the patient which treatments and products are right for them. Surgeons must always rely on their 

own clinical judgment when deciding which treatments and procedures to use with patients. Copyright © 2007 Stryker. All rights reserved. 




T-Pin for Distal Radius Fracture Fixation 

FLOSEAL [Hemostatic Matrix] Indications 

FLOSEAL [Hemostatic Matrix] is indicated in surgical 

procedures (other than ophthalmic) as an adjunct to 

hemostasis when control of bleeding by ligature or 

conventional procedures is ineffective or impractical. 

Important Safety Information 

FLOSEAL must not be injected into blood vessels, or 

allowed to enter blood vessels. Do not apply in the 

absence of active bleeding. Extensive intravascular 

clotting and even death may result. 

Do not use FLOSEAL in the closure of skin incisions 

because it may interfere with the healing of the 

skin edges. 

Do not use FLOSEAL in patients with known allergies to 

materials of bovine origin. 

FLOSEAL is made from human plasma. It may carry a 

risk of transmitting infectious agents, e.g., viruses, and 

theoretically, the Creutzfeldt-Jakob disease (CJD) agent. 

RX only: For safe and proper use of this device, please 

refer to full device Instructions For Use. 

 

Mini-incisions 

Local anesthesia 

Placed over guide wires 

Allows early wrist ROM 

Break-off driver/easy insertion 

Enrolling surgeon consultants 

Technique guide available at 

www.unionsurgical.com 

834 Chestnut Street 

Suite G-114 

Philadelphia, PA 19107 

(215) 925-5208 Phone 

tpin@unionsurgical.com 


IN THE TREATMENT OF OSTEOARTHRITIS (OA) KNEE PAIN 

NO VISCOSUPPLEMENT 

STANDS UP TO PAIN BETTER 

SYNVISC® (hylan G-F 20) is indicated for the treatment of pain in osteoarthritis (OA) 

of the knee in patients who have failed to respond adequately to conservative 

nonpharmacologic therapy and simple analgesics,eg,acetaminophen. 

In clinical trials,the most commonly reported adverse events were transient local 

pain,swelling,and/or effusion in the injected knee.In some cases,these symptoms 

have been extensive.Other side effects such as rash have been reported rarely. 

SYNVISC is contraindicated in patients with known hypersensitivity to hyaluronan 

Please see accompanying Prescribing Information. 

products or patients with infections in or around the knee.Use caution when using 

SYNVISC in patients allergic to avian proteins,feathers,or egg products;who have 

evidence of venous or lymphatic stasis in the leg to be treated; or who have severe 

inflammation in the knee joint to be treated.Patients should be advised to avoid 

strenuous or prolonged weight-bearing activities after treatment.Strict 

adherence to aseptic technique must be followed to avoid joint infection.The safety 

and effectiveness of SYNVISC in children and in pregnant or lactating women have 

not been established.It is unknown whether SYNVISC is excreted in human milk. 


UNIQUE NATIONAL 

HCPCS CODE 

Q4084 

BRIEF SUMMARYFOR THE PHYSICIAN (CONSULT PACKAGE INSERT FOR FULL PRODUCT INFORMATION) 

CAUTION: Federal law restricts this device to sale by or on the order of a physician (or properly 

licensed practitioner). 

INDICATIONS Synvisc is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients 

who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics, 

e.g., acetaminophen. 

CONTRAINDICATIONS • Do not administer to patients with known hypersensitivity (allergy) to hyaluronan 

(sodium hyaluronate) preparations. • Do not inject Synvisc in the knees of patients having knee joint 

infections or skin diseases or infections in the area of the injection site. 

WARNINGS • Do not concomitantly use disinfectants containing quaternary ammonium salts for skin 

preparation because hyaluronan can precipitate in their presence. • Do not inject Synvisc extra-articularly 

or into the synovial tissues and capsule. Local and systemic adverse events, generally in the area of the 

injection, have occurred following extra-articular injection of Synvisc. • Intravascular injections of Synvisc 

may cause systemic adverse events. 

PRECAUTIONS General • The effectiveness of a single treatment cycle of less than three injections of 

Synvisc has not been established. • The safety and effectiveness of Synvisc in locations other than the 

knee and for conditions other than osteoarthritis have not been established. • Do not inject anesthetics or 

other medications into the knee joint during Synvisc therapy. Such medications may dilute Synvisc and 

affect its safety and effectiveness. • Use caution when injecting Synvisc into patients who are allergic to 

avian proteins, feathers, and egg products. • The safety and effectiveness of Synvisc in severely inflamed 

knee joints have not been established. • Strict aseptic administration technique must be followed. 

• STERILE CONTENTS. The syringe is intended for single use. The contents of the syringe must be used 

immediately after its packaging is opened. Discard any unused Synvisc. • Do not use Synvisc if package 

is opened or damaged. Store in original packaging (protected from light) at room temperature below 

86°F (30°C). DO NOT FREEZE. • Remove synovial fluid or effusion before each Synvisc injection. 

• Synvisc should be used with caution when there is evidence of lymphatic or venous stasis in that leg. 

Information for Patients • Provide patients with a copy of the Patient Labeling prior to use. • Transient 

pain, swelling and/or effusion of the injected joint may occur after intra-articular injection of Synvisc. 

In some cases the effusion may be considerable and can cause pronounced pain; cases where swelling 

is extensive should be discussed with the physician. • As with any invasive joint procedure, it is 

recommended that the patient avoid any strenuous activities or prolonged weight-bearing activities 

such as jogging or tennis following the intra-articular injection. 

Use in Specific Populations •Pregnancy: The safety and effectiveness of Synvisc have not been 

established in pregnant women. •Nursing mothers: It is not known if Synvisc is excreted in human milk. 

The safety and effectiveness of Synvisc have not been established in lactating women. • The safety and 

effectiveness of Synvisc have not been established in children. 

ADVERSE EVENTS 

Adverse Events Involving the Injected Joint 

Clinical Trials: A total of 511 patients (559 knees) received 1771 injections in seven clinical trials of 

Synvisc. There were 39 reports in 37 patients (2.2% of injections, 7.2% of patients) of knee pain and/or 

swelling after these injections. Ten patients (10 knees) were treated with arthrocentesis and removal of 

joint effusion. Two additional patients (two knees) received treatment with intra-articular steroids. Two 

patients (two knees) received NSAIDs. One of these patients also received arthrocentesis. One patient was 

treated with arthroscopy. The remaining patients with adverse events localized to the knee received no 

treatment or only analgesics. 

Postmarket Experience: The most common adverse events reported have been pain, swelling and/or 

effusion in the injected knee. In some cases the effusion was considerable and caused pronounced pain. 

In some instances, patients have presented with knees that were tender, warm and red. It is important to 

rule out infection or crystalline arthropathies in such cases. Synovial fluid aspirates of varying volumes 

have revealed a range of cell counts, from very few to over 50,000 cells/mm 3 . Reported treatments 

included symptomatic therapy (e.g., rest, ice, heat, elevation, simple analgesics and NSAIDs) and/or 

arthrocentesis. Intra-articular corticosteroids have been used when infection was excluded. Rarely, 

arthroscopy has been performed. The occurrence of post-injection effusion may be associated with 

patient history of effusion, advanced stage of disease and/or the number of injections a patient receives. 

Reactions generally abate within a few days. Clinical benefit from the treatment may still occur after 

such reactions. 

The clinical trials described above included 38 patients who received a second course of Synvisc 

injections (132 injections). There were twelve reports in nine patients (9.1% of injections, 23.7% of 

patients) of knee pain and/or swelling after these injections. Reports of two additional clinical trials in 

which patients received repeated courses of Synvisc treatment have appeared during the post-marketing 

period. One of these trials included 48 patients who received 210 injections during a second course of 

Synvisc treatment 1 ; the other contained 71 patients who received 211 injections during a second course 

of Synvisc treatment. A total of 157 patients have received 553 injections in the three clinical trials of 

repeated courses of Synvisc treatment. The reports in these trials describe a total of 48 reports of adverse 

events localized to the injected knee in 35 patients that occurred after injections that patients had received 

during their second course of treatment. These adverse events accounted for 6.3% of injections in 22.3% 

A division of Genzyme Corporation 

55 Cambridge Parkway 

Cambridge, MA 02142 

1-888-3SYNVISC 

www.synvisc.com 

of patients as compared to 2.2% of injections in 7.2% of patients in a single course of Synvisc injections. 

In addition, reports of two retrospective studies during the post-marketing period have described adverse 

events localized to the injected knee that have occurred after 4.4% and 8.5% of injections that patients had 

received during one or more repeated courses of Synvisc treatment. 2,3 Intra-articular infections did not 

occur in any of the clinical trials and have been reported only rarely during clinical use of Synvisc. 

OTHER ADVERSE EVENTS 

Clinical Trials: In three concurrently controlled clinical trials with a total of 112 patients who received 

Synvisc and 110 patients who received either saline or arthrocentesis, there were no statistically 

significant differences in the numbers or types of adverse events between the group of patients that 

received Synvisc and the group that received control treatments. 

Systemic adverse events each occurred in 10 (2.0%) of the Synvisc-treated patients. There was one case 

each of rash (thorax and back) and itching of the skin following Synvisc injections in these studies. These 

symptoms did not recur when these patients received additional Synvisc injections. The remaining 

generalized adverse events reported were calf cramps, hemorrhoid problems, ankle edema, muscle pain, 

tonsillitis with nausea, tachyarrhythmia, phlebitis with varicosities and low back sprain. 

Postmarket Experience: Other adverse events reported include: rash, hives, itching, fever, nausea, 

headache, dizziness, chills, muscle cramps, paresthesia, peripheral edema, malaise, respiratory difficulties, 

flushing and facial swelling. There have been rare reports of thrombocytopenia coincident with Synvisc 

injection. These medical events occurred under circumstances where causal relationship to Synvisc is 

uncertain. (Adverse events reported only in worldwide postmarketing experience, not seen in clinical trials, 

are considered more rare and are italicized.) 

DETAILED DEVICE DESCRIPTION 

Each syringe of Synvisc contains: 

Hylan polymers (hylan A + hylan B) ..........................................16 mg 

Sodium chloride ........................................................................17 mg 

Disodium hydrogen phosphate ................................................0.32 mg 

Sodium dihydrogen phosphate monohydrate ..........................0.08 mg 

Water for injection ....................................................................q.s. to 2.0 mL 

HOW SUPPLIED 

Synvisc is supplied in a 2.25 mL glass syringe containing 2 mL Synvisc. 

Product Number: 58468-0090-1 3 disposable syringes 

The contents of the syringe are sterile and nonpyrogenic. 

DIRECTIONS FOR USE 

Synvisc is administered by intra-articular injection once a week (one week apart) for a 

total of three injections. 

Precaution: Do not use Synvisc if the package has been opened or damaged. Store in original packaging 

(protected from light) at room temperature below 86°F (30°C). DO NOT FREEZE. 

Precaution: Strict aseptic administration technique must be followed. 

Precaution: Do not concomitantly use disinfectants containing quaternary ammonium salts for skin 

preparation because hyaluronan can precipitate in their presence. 

Precaution: Remove synovial fluid or effusion before each Synvisc injection. 

Do not use the same syringe for removing synovial fluid and for injecting Synvisc, but the same needle 

should be used. 

Take particular care to remove the tip cap of the syringe and needle aseptically. 

Twist the gray tip cap before pulling it off, as this will minimize product leakage. 

Inject Synvisc into the knee joint through an 18 to 22 gauge needle. 

To ensure a tight seal and prevent leakage during administration, secure the needle tightly while firmly 

holding the luer hub. 

Precaution: Do not over tighten or apply excessive leverage when attaching the needle or removing the 

needle guard, as this may break the tip of the syringe. 

Do not inject anesthetics or any other medications intra-articularly into the knee while administering 

Synvisc therapy. This may dilute Synvisc and affect its safety and effectiveness. 

Precaution: The syringe containing Synvisc is intended for single use. The contents of the syringe must 

be used immediately after the syringe has been removed from its packaging. Inject the full 2 mL in 

one knee only. If treatment is bilateral, a separate syringe must be used for each knee. Discard any 

unused Synvisc. 

This brief summary is based upon the current circular, 70230602, revised November 15, 2004. 

References: 1. Raynauld JP, Bellamy N, Goldsmith CH, Tugwell P, Torrance GW, Pericak D, et al. (2002). 

An evaluation of the safety and effectiveness of repeat courses of hylan G-F 20 for treating patients with 

knee osteoarthritis. Osteoarthritis Research Society International, 2002 OARSI World Congress on 

Osteoarthritis, Sydney, Australia [Paper reference #PS128]. Presentation on File. 2. Leopold SS, Warme WJ, 

Pettis PD and Shott S. (2002). Increased frequency of acute local reaction to intra-articular Hylan G-F 20 

(Synvisc) in patients receiving more than one course of treatment. J Bone Joint Surg. 2002;84-A(9): 

1619-1623. 3. Waddell DD, Estey DJ and Bricker D. (2001). Retrospective tolerance of Hylan G-F 20 

using fluoroscopically-confirmed injection and effectiveness of retreatment in knee osteoarthritis. 

Proceedings of the American College of Rheumatology Annual Meeting 2001. Presentation on File. 

SYNVISC and GENZYME are registered trademarks of Genzyme Corporation. 

©2007 Genzyme Corporation. All rights reserved. Printed inUSA. S-00269.A 01/2007 


What factors affect ingrowth? 

the optimal 

combination 

Does porosity equal performance? 

Titanium vs. Tantalum? 

for fixation 

Bonus 

Demineralized For answers Bone to these Matrixquestions visit www.biomet.com/porousmetalfacts 

or contact your Biomet sales representative. 

Regenerex 

Porous Titanium Construct 

Clinically proven material. 

Advanced porous technology. 

Regenerex is a trademark of Biomet Manufacturing Corp. 

DrivenByEngineering 

800.348.9500 ext. 1501 • ©2007 Biomet Orthopedics, Inc. All Rights Reserved • www.biomet.com 



Now, viewing subspecialty 

procedures is as easy as this. 

Wouldn’t it be great if you could call up video procedures for 

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The Video Journal of Orthopaedics (VJO) and JBJS have greatly 

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BUILD YOUR OWN CUSTOM 

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In hip-replacement surgery*... 

Break Down the Risk 

NAFT † proves FRAGMIN ® is more effective than warfarin 

in early postop ‡ dosing 1 

• 72% relative risk reduction in proximal DVT with FRAGMIN (0.8%) 

vs warfarin (3.0%; P=0.03) §1 

• 45% relative risk reduction in total DVT with FRAGMIN (13.1%) 

vs warfarin (24.0%; P

FRAGMIN 

(dalteparin sodium injection) 

For Subcutaneous Use Only 

BRIEF SUMMARY: For full prescribing information, see package insert. 

SPINAL/EPIDURAL HEMATOMAS 

When neuraxial anesthesia (epidural/spinal anesthesia) or spinal puncture is employed, patients anticoagulated or 

scheduled to be anticoagulated with low molecular weight heparins or heparinoids for prevention of 

thromboembolic complications are at risk of developing an epidural or spinal hematoma which can result in 

long-term or permanent paralysis. The risk of these events is increased by the use of indwelling epidural catheters 

for administration of analgesia or by the concomitant use of drugs affecting hemostasis such as non steroidal 

anti-inflammatory drugs (NSAIDs), platelet inhibitors, or other anticoagulants. The risk also appears to be 

increased by traumatic or repeated epidural or spinal puncture. Patients should be frequently monitored for signs 

and symptoms of neurological impairment. If neurological compromise is noted, urgent treatment is necessary. 

The physician should consider the potential benefit versus risk before neuraxial intervention in patients 

anticoagulated or to be anticoagulated for thromboprophylaxis (also see WARNINGS, Hemorrhage and 

PRECAUTIONS, Drug Interactions). 

INDICATIONS AND USAGE 

FRAGMIN Injection is indicated for the prophylaxis of ischemic complications in unstable angina and non-Q-wave 

myocardial infarction, when concurrently administered with aspirin therapy (as described in CLINICAL TRIALS, 

Prophylaxis of Ischemic Complications in Unstable Angina and Non-Q-Wave Myocardial Infarction). 

FRAGMIN is also indicated for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary 

embolism (PE): 

• In patients undergoing hip replacement surgery; 

• In patients undergoing abdominal surgery who are at risk for thromboembolic complications; 

• In medical patients who are at risk for thromboembolic complications due to severely restricted mobility 

during acute illness. 

FRAGMIN is also indicated for the extended treatment of symptomatic venous thromboembolism (VTE) (proximal 

DVT and/or PE), to reduce the recurrence of VTE in patients with cancer. 


FRAGMIN Injection is contraindicated in patients with known hypersensitivity to the drug, active major bleeding, or 

thrombocytopenia associated with positive in vitro tests for antiplatelet antibody in the presence of FRAGMIN. 

Patients undergoing regional anesthesia should not receive FRAGMIN for unstable angina or non-Q-wave myocardial 

infarction, and patients with cancer undergoing regional anesthesia should not receive FRAGMIN for extended 

treatment of symptomatic VTE, due to an increased risk of bleeding associated with the dosage of FRAGMIN 

recommended for these indications. Patients with known hypersensitivity to heparin or pork products should not be 

treated with FRAGMIN. 

WARNINGS 

FRAGMIN Injection is not intended for intramuscular administration. FRAGMIN cannot be used interchangeably (unit 

for unit) with unfractionated heparin or other low molecular weight heparins. FRAGMIN should be used with 

extreme caution in patients with history of heparin-induced thrombocytopenia. 

Hemorrhage: FRAGMIN, like other anticoagulants, should be used with extreme caution in patients who have an 

increased risk of hemorrhage, such as those with severe uncontrolled hypertension, bacterial endocarditis, 

congenital or acquired bleeding disorders, active ulceration and angiodysplastic gastrointestinal disease, 

hemorrhagic stroke, or shortly after brain, spinal or ophthalmological surgery. Spinal or epidural hematomas can 

occur with the associated use of low molecular weight heparins or heparinoids and neuraxial (spinal/epidural) 

anesthesia or spinal puncture, which can result in long-term or permanent paralysis. The risk of these events 

is higher with the use of indwelling epidural catheters or concomitant use of additional drugs affecting 

hemostasis such as NSAIDs (see boxed WARNING and ADVERSE REACTIONS, Ongoing Safety Surveillance). 

As with other anticoagulants, bleeding can occur at any site during therapy with FRAGMIN. An unexpected drop in 

hematocrit or blood pressure should lead to a search for a bleeding site. 

Thrombocytopenia: In FRAGMIN clinical trials supporting non-cancer indications, platelet counts of 

Three of the major bleeding events that occurred by Day 21 were fatal, all due to gastrointestinal hemorrhage 

(two patients in the group treated with FRAGMIN and one in the group receiving placebo). Two deaths 

occurred after Day 21: one patient in the placebo group died from a subarachnoid hemorrhage that started on 

Day 55, and one patient died on day 71 (two months after receiving the last dose of FRAGMIN) from a 

subdural hematoma. 

Patients with Cancer and Acute Symptomatic Venous Thromboembolism 

Table 12 summarizes the number of patients with bleeding events that occurred in the clinical trial of patients with 

cancer and acute symptomatic venous thromboembolism. A bleeding event was considered major if it: 1) was 

accompanied by a decrease in hemoglobin of >2 g/dL in connection with clinical symptoms; 2) occurred at a critical 

site (intraocular, spinal/epidural, intracranial, retroperitoneal, or pericardial bleeding); 3) required transfusion of 

>2 units of blood products; or 4) led to death. Minor bleeding was classified as clinically overt bleeding that did not 

meet criteria for major bleeding. At the end of the six-month study, a total of 46 (13.6%) patients in the FRAGMIN 

arm and 62 (18.5%) patients in the OAC arm experienced any bleeding event. One bleeding event (hemoptysis in a 

patient in the FRAGMIN arm at Day 71) was fatal. 

Table 12: Bleeding Events (Major and Any) (As treated population) 1 

Study period FRAGMIN OAC 

200 IU/kg (max. 18,000 IU) s.c. FRAGMIN 200 IU/kg (max 18,000 IU) s.c. 

once daily x 1 month, then 150 IU/kg once daily x 5-7 days and OAC 

(max 18,000 IU) s.c. once daily x 5 months for 6 months (target INR 2-3) 

Number Patients with Patients with Number Patients with Patients with 

at risk Major Bleeding Any Bleeding at Risk Major Bleeding Any Bleeding 

n(%) n(%) n(%) n(%) 

Total during study 338 19 (5.6) 46 (13.6) 335 12 (3.6) 62 (18.5) 

Week 1 338 4 (1.2) 15 (4.4) 335 4 (1.2) 12 (3.6) 

Weeks 2-4 332 9 (2.7) 17 (5.1) 321 1 (0.3) 12 (3.7) 

Weeks 5-28 297 9 (3.0) 26 (8.8) 267 8 (3.0) 40 (15.0) 

1Patients with multiple bleeding episodes within any time interval were counted only once in that interval. However, 

patients with multiple bleeding episodes that occurred at different time intervals were counted once in each interval 

in which the event occurred. 

Thrombocytopenia: See WARNINGS: Thrombocytopenia. 

Other: Allergic Reactions: Allergic reactions (i.e., pruritus, rash, fever, injection site reaction, bulleous eruption) 

have occurred rarely. A few cases of anaphylactoid reactions have been reported. Local Reactions: Pain at the 

injection site, the only non-bleeding event determined to be possibly or probably related to treatment with FRAGMIN 

and reported at a rate of at least 2% in the group treated with FRAGMIN, was reported in 4.5% of patients treated 

with FRAGMIN 5000 IU once daily vs 11.8% of patients treated with heparin 5000 U twice daily in the abdominal 

surgery trials. In the hip replacement trials, pain at injection site was reported in 12% of patients treated with 

FRAGMIN 5000 IU once daily vs 13% of patients treated with heparin 5000 U three times a day. 

Ongoing Safety Surveillance: Since first international market introduction in 1985, there have been more than 

15 reports of epidural or spinal hematoma formation with concurrent use of dalteparin sodium and spinal/epidural 

anesthesia or spinal puncture. The majority of patients had postoperative indwelling epidural catheters placed for 

analgesia or received additional drugs affecting hemostasis. In some cases the hematoma resulted in long-term or 

permanent paralysis (partial or complete). Because these events were reported voluntarily from a population of 

unknown size, estimates of frequency cannot be made. 

Post-Marketing Experience: Skin necrosis has occurred rarely. There have been isolated cases of alopecia reported 

that improved on drug discontinuation. 

OVERDOSAGE 

Symptoms/Treatment: An excessive dosage of FRAGMIN Injection may lead to hemorrhagic complications. These 

may generally be stopped by the slow intravenous injection of protamine sulfate (1% solution), at a dose of 1 mg 

protamine for every 100 anti-Xa IU of FRAGMIN given. A second infusion of 0.5 mg protamine sulfate per 100 

anti-Xa IU of FRAGMIN may be administered if the APTT measured 2 to 4 hours after the first infusion remains 

prolonged. Even with these additional doses of protamine, the APTT may remain more prolonged than would usually 

be found following administration of conventional heparin. In all cases, the anti-Factor Xa activity is never completely 

neutralized (maximum about 60 to 75%). Particular care should be taken to avoid overdosage with protamine sulfate. 

Administration of protamine sulfate can cause severe hypotensive and anaphylactoid reactions. Because fatal 

reactions, often resembling anaphylaxis, have been reported with protamine sulfate, it should be given only when 

resuscitation techniques and treatment of anaphylactic shock are readily available. For additional information, consult 

the labeling of Protamine Sulfate Injection, USP, products. A single subcutaneous dose of 100,000 IU/kg of FRAGMIN 

to mice caused a mortality of 8% (1/12) whereas 50,000 IU/kg was a non-lethal dose. The observed sign was 

hematoma at the site of injection. 

Rx only 

U.S. Patent 4,303,651 

April 2007 FR080231 © 2007 Pfizer Inc. 

818 312 112 All rights reserved. Printed in USA/July 2007 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Adv 64 


Trauma 

Fractures of the distal third of the humerus with palsy of the radial 

nerve 

MANAGEMENT USING MINIMALLY-INVASIVE 

PERCUTANEOUS PLATE OSTEOSYNTHESIS 

A. Livani, W. D. Belangero, and R. Castro de Medeiros 

From the State University of Campinas, Sao Paulo, Brazil 

J Bone Joint Surg (Br) 2006;88-B:1625-28 

Fractures of the distal third of the humerus may be complicated 

by complete lesions of the radial nerve which may be 

entrapped or compressed by bone fragments. Indirect reduction 

and internal fixation may result in a permanent nerve lesion. 

We describe the treatment of these lesions by insertion of 

a bridge plate using the minimally-invasive percutaneous technique. 

Six patients were operated on and showed complete 

functional recovery. Healing of the fractures occurred at a mean 

of 2.7 months (2 to 3) and complete neurological recovery by a 

mean of 2.3 months (1 to 5). In one patient infection occurred 

which resolved after removal of the implant. 

gen 1 (sca-1+) and stem cell factor receptor, CD117 (c-kit+) 

in order to identify the endothelial precursor cell population. 

Immunomagnetically-enriched sca-1+ mononuclear cell 

(MNCsca-1+) populations were then cultured and examined 

for functional vascular endothelial differentiation. Bone marrow 

MNCsca-1+,c-kit+ counts increased almost twofold within 

48 hours of the event, compared with baseline levels, before 

decreasing by 72 hours. 

Sca-1+ mononuclear cell populations in culture from 

samples of bone marrow at 48 hours bound together Ulex 

Europus-1, and incorporated fluorescent 1,1'-dioctadecyl- 

3,3,3,’3'-tetramethylindocarbocyanine perchlorate-labelled 

acetylated low-density lipoprotein intracellularily, both characteristics 

of mature endothelium. 

Our findings suggest that a systemic provascular response of 

bone marrow is initiated by musculoskeletal trauma. Its therapeutic 

manipulation may have implications for the potential 

enhancement of neovascularisation and the healing of fractures. 

Upper Limb 

Research 

A systemic provascular response in bone marrow to musculoskeletal 

trauma in mice 

A. J. Laing, J. P. Dillon, E.T. Condon, J. C. Coffey, J. T. Street, J. H. 

Wang, A. J. McGuinness, and H. P. Redmond 


Post-natal vasculogenesis, the process by which vascular 

committed bone marrow stem cells or endothelial precursor 

cells migrate, differentiate and incorporate into the nacent 

endothelium and thereby contribute to physiological and pathological 

neurovascularisation, has stimulated much interest. Its 

contribution to neovascularisation of tumours, wound healing 

and revascularisation associated with ischaemia of skeletal and 

cardiac muscles is well established. We evaluated the responses 

of endothelial precursor cells in bone marrow to musculoskeletal 

trauma in mice. 

Bone marrow from six C57 Black 6 mice subjected to a 

standardised, closed fracture of the femur, was analysed for 

the combined expression of cell-surface markers stem cell anti- 

The outcome of peri-operative humeral condylar fractures after 

total elbow replacement in patients with rheumatoid arthritis 

H. Ito, T. Matsumoto, H. Yoshitomi, R. Kakinoki, and T. Nakamura 


We compared the outcome of peri-operative humeral condylar 

fractures in patients undergoing a Coonrad-Morrey semiconstrained 

total elbow replacement with that of patients with 

rheumatoid arthritis undergoing the same procedure without 

fractures. In a consecutive series of 40 elbows in 33 patients, 

13 elbows had a fracture in either condyle peri-operatively, and 

27 elbows were intact. The fractured condyle was either fixed 

internally or excised. We found no statistical difference in the 

patients’ background, such as age, length of follow-up, immobilisation 

period, Larsen’s radiological grade, or Steinbrocker’s 

stage and functional class. There was also no statistical difference 

between the groups in relation to the Mayo Elbow Performance 

Score, muscle strength, range of movement, or radiolucency 

around the implants at a mean of 4.8 years (1.1 to 8.0) followup. 

We conclude that fractured condyles can be successfully 

treated with either internal fixation or excision, and cause no 

harmful effect. 




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For more information on Simplex Bone Cements, contact your Stryker 

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Stryker Orthopaedics 325 Corporate Drive, Mahwah, NJ 07430 

A surgeon is the best person to decide with the patient which treatments and products are right for them. 

Surgeons must always rely on their own clinical judgement when deciding which treatments and procedure 

to use with patients. Copyright © 2007 Stryker. Stryker Corporation or its divisions or other corporate 

affiliated entities own, use or have applied for the following trademarks: Stryker, Simplex SpeedSet. 

A C DF G B E E B G FD C 


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See brief summary on page 110

Front Matter - The Journal of Bone & Joint Surgery

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