Jaaos Jan 2019

Review Article
Value-based Total Hip and Knee

Arthroplasty: A Framework for
Understanding the Literature
Abstract
Adam J. Schwartz, MD, MBA Since passage of the Patient Protection and Affordable Care Act of
Kevin J. Bozic, MD, MBA 2010, the current decade has witnessed an explosion of the value-
based total hip and knee arthroplasty literature. Total hip arthroplasty
David A. Etzioni, MD
and total knee arthroplasty are the most common inpatient surgeries
for Medicare beneficiaries, and thus, it is no surprise that total joint
arthroplasty is currently a prime target of efforts toward cost reduction
and quality improvement. The purpose of this review was to provide a
framework for understanding the rapidly growing quality and cost
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literature. Research efforts toward quality improvement are likely to be

effective when they address the structure, process, and most
importantly outcomes of total joint arthroplasty. Similarly, cost savings
should be evaluated with an understanding of existing accounting
From the Department of Orthopaedic
methods, relationships to the entire cycle of osteoarthritis care, and
Surgery (Dr. Schwartz), Division of the direct effect on the quality of care provided.
Colon and Rectal Surgery
(Dr. Etzioni), Mayo Clinic, Phoenix,
AZ, and the Department of
Orthopaedic Surgery, Dell Medical
School, The University of Texas at
Austin, Austin, TX (Dr. Bozic). T he success of total hip and total
knee arthroplasty (THA and
TKA) in the management of end-
in 2010, the federal government’s
involvement in tracking and reporting
quality measures for physicians and
Dr. Schwartz or an immediate family
member serves as a board member,
stage arthritis has placed tremendous hospitals dramatically expanded.3 The
owner, officer, or committee member economic strain on the United States fundamental concept of this approach
of the American Academy of healthcare system because demand for is that a focus on “value” (as defined
Orthopaedic Surgeons. Dr. Bozic or these procedures continues to grow at as optimizing patient-centered out-
an immediate family member serves
as a paid consultant to Carrum Health
exponential rates.1 According to the comes per healthcare dollar spent) will
and the Centers for Medicaid and Centers for Medicare and Medicaid avoid policies that result in arbitrary
Medicare Services; serves as an Services (CMS) website, in 2015, the cost-cutting measures in favor of in-
unpaid consultant to Harvard National Heath Expenditure (NHE) centivizing practitioners to provide
Business School; and serves as a
board member, owner, officer, or
grew 5.8% to $3.2 trillion, or $9,990 high-value care and to minimize or
committee member of the American per person, representing 17.8% of eliminate low-value care. As a result of
Joint Replacement Registry and the the gross domestic product.2 Of this these changes, the current decade has
Hip Society. Neither Dr. Etzioni nor total spending, Medicare and Medic- witnessed an explosion of data inves-
any immediate family member has
received anything of value from or has
aid accounted for the largest portion, tigating the quality and costs asso-
stock or stock options held in a making up 37% of the total NHE. ciated with TJA. Despite dramatic
commercial company or institution Because hip and knee replacement shifts in the current political environ-
related directly or indirectly to the procedures are the most common ment, a value-based approach to
subject of this article.
inpatient surgery for Medicare bene- healthcare delivery is likely to main-
J Am Acad Orthop Surg 2019;27:1-11 ficiaries, it is no surprise that total joint tain a strong influence on current and
DOI: 10.5435/JAAOS-D-17-00709 arthroplasty (TJA) is currently a prime future healthcare policy. The purpose
target of cost reduction efforts. of this review was to provide a
Copyright 2018 by the American
Academy of Orthopaedic Surgeons. With passage of the Patient Protec- framework for understanding this lit-
tion and Affordable Care Act (ACA) erature and the concept of value as it
January 1, 2019, Vol 27, No 1 1
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Value-based Total Joint Arthroplasty
Figure 1 Structure of Total Joint

Arthroplasty
The predominance of highly com-
partmentalized care in the United
States healthcare system has resulted
in a lack of unified goals among
stakeholders. Rather than a single
unified goal of achieving high value
for patients, divergence exists with
regard to performance measurement,
profitability, and cost containment,
among other targets. Recent efforts to
improve structural aspects of care
include the movement toward alter-
native payment models, unified care
delivery (the so-called teaming),8 and
Image showing a framework for understanding the value-based literature on total development of integrated practice
hip and knee arthroplasty. units (IPUs).9,10
In 2013, the Bundled Payments for
applies to the TJA episode of care the purposes of this article, we will Care Improvement (BPCI) initiative
(Figure 1). incorporate aspects of both the Do- was launched by the CMS, defining
nabedian and Porter frameworks for four models of evaluation.11 As a
quality, recognizing that patient out- separate but related value-based
Quality comes are the most direct and rele- payment model, the Center for Medi-
vant measure of quality of care. care and Medicaid Innovation in-
Defining Quality In their comprehensive review, troduced the Comprehensive Care
According to Porter,4 value in any Bumpass et al3 organized the major for Joint Replacement Program in 67
industry is most accurately defined quality stakeholders into public, pri- geographic locations.12 Although the
from the perspective of the customer, vate, and hybrid organizations. No- aim of these programs is to align
which in the case of health care is the ticeably absent from this list is the providers to achieve a common goal
patient. Rather than a single measure patient. Although the intention of these of reducing the episode cost of care
of success, Porter advocates for the use private and public entities is ultimately without compromising patient out-
of an Outcome Measures Hierarchy, to improve patient care, it is yet to be comes, only modest evidence sup-
with three primary components determined whether adherence to each ports that such programs achieve
including a measure of health status agency’s particular metrics actually these goals. In most publications,
achievement, a measure of the process achieves this goal. A stark example of complication rates, death rates, or
to achieve the health status, and a this, as pointed out by Bumpass et al, is readmissions are used as the sole
measure of sustainability. For exam- the study by Wang et al6 that measures of quality when comparing
ple, from the perspective of the patient, demonstrated that increased compli- bundled payment models to more
the quality of a TJA would entail ance with venous thromboembolism traditional payment systems. Iorio
measurement of pain and/or functional prophylaxis, a high-value measure, et al13 reviewed a model 2 bundled
improvement, measurement of the was associated with a higher risk of payment program at a large, tertiary,
process by which this improvement was surgical site infection, possibly because urban academic medical center and
achieved, and finally a measurement of of the higher likelihood of profound shorter length of stay, lower
sustainability of that improvement. longed drainage associated with readmission rate, and lower dis-
According to Donabedian,5 quality of aggressive venous thromboembolism charge to inpatient postacute care
care is the deployment of medical prophylaxis. This phenomenon un- facilities with the bundled program.
technology in a way that maximizes derscores the notion that quality of Similarly, Navathe et al14 in their
health benefits, while minimizing care cannot be fully assessed by review of 3,942 patients who par-
health risks. Quality may be assessed focusing on process and structure ticipated in the Acute Care Episode
from the perspective of structure, alone, but rather health outcomes (a predecessor to the BPCI focused
process, and outcome (Table 1). For achieved by patients.7 exclusively on the inpatient episode)
2 Journal of the American Academy of Orthopaedic Surgeons
Adam J. Schwartz, MD, MBA, et al
Table 1
Selected Recent Literature Regarding THA and TKA According to the Donabedian Matrix of Quality
Factor Author Year Design Major Findings
Structure Siddiqi et al15 2017 Systematic review Alternative payment models, such as the
BPCI and CJR, reduce costs, mainly
through reduction in length of hospital
stay, readmissions, and use of postacute
inpatient facilities
Qin et al16 2017 Retrospective review of NSQIP data Patients undergoing THA for femoral neck
(1,580 femoral neck fractures fracture have higher complication rates,
compared to matched controls) unplanned readmission, longer hospital
stays, and higher likelihood of discharge to
inpatient postacute care. The article
implies that an optimal structure of THA for
one diagnosis may not apply to another
diagnosis.
Navathe et al14 2017 Observational study of 3,942 patients Uncomplicated and complicated TJA
undergoing primary joint replacement expenditures decreased by 20.8% and
in ACE and BPCI model in one 13.8%, respectively, whereas patient
healthcare system illness severity remained stable. A large
portion of savings was through reduction
in postacute care spending, which was
noted only when this was included in the
bundle. Readmissions and emergency
department visits were reduced by 1.4%
and 0.9%, respectively.
Iorio et al13 2016 Single-institution review of costs of 721 Decreased LOS, readmissions, and
TJA in model 2 bundled payment discharge to inpatient facility compared to
system prior to bundled implementation.
Process Yao et al17 2017 Of a total of 50,376 THA and 71,293 TKA Risk stratification is important when
patients discharged to home identified attempting to facilitate home discharge
in the NSQIP database, 1,575 THA and versus inpatient postacute care. A formal
2,490 TKA experienced severe risk stratification protocol would be useful
complications or unplanned to prevent complications and
readmissions. Analysis of risk factors readmissions among home-discharged
performed. patients.
McLawhorn et al18 2017 NSQIP data used to compare 70,628 Discharge to inpatient postacute care
primary TKA patients discharged home facility associated with higher odds of
to 30,628 patients discharged to complications and readmissions. The
inpatient postacute care authors advocate for discharge to home
when feasible.
Sutton et al19 2016 NSQIP data used to compare early (0-2 Patient comorbidities and perioperative
d) discharge to standard (3-4 d) variables, such as longer procedure duration
discharge. and postoperative transfusion, were
independently associated with major
complications, whereas early discharge was
not. The authors advocate for early discharge
in appropriately risk-stratified patients.
Outcome Berliner et al20 2017 Retrospective review of 562 patients The authors found that patients with a
who underwent primary unilateral TKA. preoperative KOOS greater than 58 or
Preoperative KOOS and SF-12 version SF12v2 greater than 34 were less likely to
2 collected, and ROC analysis used to experience a clinically meaningful
determine threshold values of improvement in function after TKA. Better
preoperative PROM scores to predict mental and emotional health resulted in
meaningful improvement (defined as a higher threshold values for both KOOS
10-point improvement in the KOOS or and SF12v2.
5-point improvement in the SF12v2).
(continued )
ACE = acute care episode, BPCI = bundled payments for care improvement, CJR = care for joint replacement, KOOS = Knee Disability and
Osteoarthritis Outcome Score, LOS = length of stay, PROM = Patient-reported Outcome Measure, ROC = receiver operator curve, SF = short form,
THA = total hip arthroplasty, TJA = total joint arthroplasty, TKA = total knee arthroplasty
January 1, 2019, Vol 27, No 1 3
Table 1 (continued )
Selected Recent Literature Regarding THA and TKA According to the Donabedian Matrix of Quality
Factor Author Year Design Major Findings
Jain et al21 2017 83 patients who underwent primary TKA Higher preoperative expectations predicted
at 7 institutions prospectively followed greater postoperative improvement in
with functional measures and function but not satisfaction. The authors
measures of satisfaction (fulfillment of admit that the study was not powered to
expectations) detect a difference in satisfaction;
however, the finding highlights the notion
that many factors in addition to improved
pain and function play a role in
satisfaction, such as experience with
rehabilitation and socioeconomic status,
among others.
Rolfson et al22 2016 Workgroup consensus statement The authors define a standard set of
outcome measures for monitoring patients
with osteoarthritis across the entire
spectrum of care.
ACE = acute care episode, BPCI = bundled payments for care improvement, CJR = care for joint replacement, KOOS = Knee Disability and
Osteoarthritis Outcome Score, LOS = length of stay, PROM = Patient-reported Outcome Measure, ROC = receiver operator curve, SF = short form,
THA = total hip arthroplasty, TJA = total joint arthroplasty, TKA = total knee arthroplasty
and BPCI found markedly lower bundled payments and improved is a focus on patient preferences
average Medicare payments per patient outcomes. and values, and gearing treatment
episode, while patient illness severity Although payment models con- approaches to each individual
remained stable. Most reductions in tinue to evolve, the success of bundled condition. Previsit collection of
overall spending during both pro- payment programs has necessitated Patient-Reported Outcome Mea-
grams resulted from internal cost and, to some extent, even facilitated a sures (PROMs), medical history
reductions (51.2%), particularly shift toward team-based approaches elements, and provider review of
implant costs, and reduction in to the total joint episode of care. this material would provide ap-
postacute care spending (48.8%), The transformation from silo-based, propriate use of medical services
the latter observed after the intro- physician-centric models of care to and treatment options.10 Keswani
duction of the BPCI. Interestingly, patient-centered, value-based sys- et al10 identify three major ob-
and perhaps not surprisingly, the tems of care is a primary force behind stacles, which may hinder the im-
authors found that reduction in this shift. Nawaz et al8 outlined con- plementation of an IPU approach
postacute care spending was noted crete steps toward successful teaming to care: operational, technological,
only when it was included in the in orthopaedic surgery. The authors and payment/contracting. All three
bundle. Siddiqi et al15 performed a explain that teams most commonly represent future structural challenges
review of the literature analyzing the fail because of inherent structures to implementing a true value-based
effects of bundled payments in TJA. designed to “. . .execute the captain’s approach to care.
The main finding of the article is that commands,” rather than learning to
alternative payment models such as develop effective problem-solving
the BPCI, Care for Joint Replace- strategies. IPUs are an example of a Process of Total Joint
ment, and others have shown team-based approach in health care. Arthroplasty
promise in reducing costs, mainly by An IPU is a multidisciplinary team of The processes associated with THA
reducing length of stay, decreasing clinical and nonclinical providers and TKA have been constantly
readmission rates, and reducing the who treat conditions over the full refined over the past half-century.
use of inpatient postacute care ser- cycle of care.9 In the case of hip or From the perspective of the patient,
vices. The evidence supporting cost knee an IPU would ideally provide value is enhanced when the TJA out-
reduction in bundled models is fairly the patient with a single point of comes are improved while either
robust; however, the authors were access for the entire gamut of treat- lowering or maintaining costs. From
unable to demonstrate any literature ment options from physical therapy the perspective of the healthcare sys-
establishing a correlation between to surgery. Central to this concept tem, the adherence to evidence-based
processes of care increases the likeli- demonstrated no notable increase in addresses a clinically important issue
hood of maximizing health while odds of complications among early and can have a meaningful effect),
minimizing adverse outcomes. The discharges. The study points out, scientific acceptability (ie, the measure
distinction is important because the however, that patients discharged early is valid, reliable, and risk adjusted),
latter emphasizes the percentage tended to be healthier, and perhaps and usability (ie, the measure is easily
chance of success, whereas the former comparing these patients to patients used in clinical practice).7 Many cur-
is more reflective of absolute outcome.7 with more medical comorbidities leads rently available PROMs meet some
Most of the currently available liter- to biased results. The authors’ findings but not all of these criteria. In addi-
ature regarding the process of TJA support early discharge for appropri- tion, implementation of computerized
centers on the implementation of clini- ately risk-stratified patients. adaptive testing and item response
cal pathways. As an example, Walter Although reductions in hospital theory has called into question the
et al23 reported their experience in a stay duration may reduce cost, ill- efficacy of PROMs based on the
community hospital after 1,680 hip conceived mandated discharge regu- classical test theory, which largely
and knee arthroplasty procedures. lations may interrupt a clinical pathway uses static tests.27 Static PROMs have
After implementation of a low-cost and lead to additional notable waste the disadvantage of using the same
clinical pathway for total joint in the system, as demonstrated in the questions for every individual, rather
replacement, the authors found a study by Sibia et al.25 The authors than adjusting the questions admin-
notable reduction in length of stay, used data from the National Surgical istered based on patient responses (eg,
with no change in complication or Quality Improvement Program da- more or less active patients). The
readmission rates. Tessier et al24 re- tabase to demonstrate that extra days result is a higher respondent burden
viewed claims data for elective hip and spent in the hospital to satisfy CMS and greater likelihood to generate
knee arthroplasty in a cross-sectional regulations for patients discharged floor or ceiling effects with static in-
study of patients treated under a to rehabilitation (after the required struments than with more adaptive,
Medicare model 2 Bundled Payment 3-night stay in the hospital) may dynamic assessment tools.
for Care Improvement episode. Inde- result in $63 million of wasted In an ideal setting, all providers
pendent reviewers placed groups into expense to the healthcare system. An involved in treatment across a given
four categories based on whether they interesting contrast to this finding is diagnosis would maintain records with
had used a defined clinical pathway. the study by Slover et al,26 who found consistent outcome data elements. In
The study included 77,008 diagnosis- that keeping patients in the hospital 2016, the International Consortium
related group 469 and 470 Medicare for up to 5.2 days can be cost-effective for Health Outcomes Measurement
fee-for-service patients from 68 inde- in a bundled payment model if it Hip and Knee Osteoarthritis Working
pendent orthopaedic groups nation- allows for discharge to home rather Group established a set of patient-
wide. The authors found that than to a postacute inpatient facility. centered outcome measurements
compared to groups without defined Because of added cost of inpatient meant to allow for evaluation of
pathways, groups with defined post- care, along with the typically higher osteoarthritis treatments across the
acute clinical pathways showed con- readmission rates seen with patients entire disease spectrum.22 Unlike
sistent decreases in cost and utilization. discharged to inpatient postacute care traditional measures based on the
Cost savings were $3,189 per episode facilities, there is increased pressure to primary intervention (eg, TKA or
for THA, and $2,466 for TKA, and reduce utilization of postdischarge THA), this patient-centered set of
the authors concluded that this par- inpatient facilities after TJA. measures allows for analysis of pa-
ticular process change was a success. tients with multiple sites of osteo-
The introduction of evidence-based arthritis, regardless of disease severity,
clinical care pathways has been Outcomes of Total Joint treatment, or type of provider. The
demonstrated to affect cost savings Arthroplasty standard set includes a concise group
through reductions in length of hos- The ultimate measure of value is of outcome measures, along with
pital stay, postacute care utilization, achieving greater health for patients per baseline characteristics and risk fac-
and hospital readmissions. Sutton healthcare dollar spent, hence the rec- tors. The aim of a standard set such as
et al19 examined the National Sur- ognition of the importance of PROMs this is to provide meaningful com-
gical Quality Improvement Program in assessing the value of healthcare in- parisons of treatment value across
database and divided patients into terventions. The characteristics of high- healthcare systems.
two groups: early (less than 2 days) quality outcome measures of pain and A full picture of quality requires
and standard discharge (3 to 4 days). functional improvement after TJA more than a simple score based on a
Multivariate regression analysis include importance (ie, the measure static questionnaire, and factors
January 1, 2019, Vol 27, No 1 5
independent of the surgical proce- 17% of gross domestic product and the quantity of time the patient spends
dure may result in differences per- are expected to increase. Although with each resource. Akhavan et al29
ceived by the outcome tools. As an cost reduction alone may be a strat- compared the costs associated with
example, Jain et al21 explored the as- egy for improving value in some cir- primary TKA and THA using tradi-
sociation between patient expectations, cumstances, many high-value treatment tional cost accounting versus TDABC.
outcomes as measured by PROMs, options are currently, and are likely The authors found considerable
and satisfaction with their TJA. The to remain, quite expensive. Without differences between cost estimates,
authors found that higher preoper- an established relationship to effects with TDABC accounting for almost
ative expectations predicted greater on quality, strategies that target cost $10,000 difference for each proce-
improvement as measured by PROMs alone fall short of the goal of maxi- dure and approximately 50% dif-
(ie, UCLA activity score, SF-12 mizing value. According to Kaplan ference in cost by surgeon. The
physical component summary (PCS), et al,28 the present state of cost authors explain that traditional
and Knee Disability and Osteo- accounting in health care can be accounting methods lead to high cost
arthritis Outcome Score) but not summarized as follows: “Instead of estimates largely because of indirect
patient satisfaction (as measured by focusing on the costs of treating in- costs being “lumped” into total costs
the Hospital for Special Surgery Knee dividual patients with specific medi- in addition to unused capacity.
Replacement Fulfillment of Expect- cal conditions over their full cycle of In addition to the lack of stan-
ations Survey). The authors argue care, providers aggregate and ana- dardized accounting methods, another
that this finding highlights the concept lyze costs at the specialty or depart- fundamental weakness in any review
that satisfaction is not solely based on ment level.” Compounding this of the cost of osteoarthritis care is
pain and/or functional improvement confusion is the fact that often costs that a large proportion of spending
but is also likely influenced by struc- of care are publicly represented dif- likely goes undocumented. Although
tural and process factors. In a similar ferently depending on the entity’s the development and use of appro-
study, Berliner et al20 examined perspective. For instance, the cost priate use criteria in the field of hip
the ability of preoperative PROMs of a total hip replacement varies and knee osteoarthritis continue to
to predict achievement of the mini- greatly from the perspective of the grow, many unproven treatment
mal clinically important difference patient, the hospital/provider, the modalities continue to be used by
(MCID) in function after THA. Using third-party payer, or society at large healthcare practitioners.30 The NHE
distribution-based methods, the au- (Table 2). Yet frequently discussions estimates that 11% of total health-
thors determined an MCID value of and even literature in the field of care spending comes from out-of-
4.6 for the SF12v2 PCS, 6.0 for the health care do not specify from pocket expenses; however, these
SF12v2 mental component summary which perspective cost is being rep- estimates likely underestimate the
(MCS), and 9.1 for the Hip Disability resented, making it difficult to draw cost of unconventional osteoarthritis
and Osteoarthritis Outcome Score meaningful conclusions from the care because they are based primar-
(HOOS). The authors found a pre- data presented. The value equation ily on documented provider visits,
operative HOOS . 51.0, and SF12v2 mitigates this problem by tying cost insurance deductibles, premiums,
PCS . 32.5 predicted achievement of to patient-centered outcomes. and copays. In their review of the
MCID for all patients. These thresh- Traditional accounting methods Medical Expenditure Panel Survey,
old values were found to be depen- historically measure the costs of Kotlarz et al31 found that osteo-
dent on preoperative MCS scores individual departments, services, or arthritis was responsible for $36.1
(ie, a measure of mental and emo- support activities by assigning both billion total out-of-pocket ex-
tional health), with lower MCS scores direct (eg, wages, supplies) and indi- penditures among insured patients,
decreasing the likelihood of achieving rect costs (eg, office space, electricity again an estimate that likely falls
MCID after THA. bills). The latter costs are frequently short of the true cost of osteoarthritis
spread evenly across each depart- care. Sharif et al32 estimate that
ment’s billable activities using vari- among patients with osteoarthritis,
Cost ous factors (eg, number of patients, approximately 50% of nonemploy-
number of procedures, size of direct ment due to illness in the Canadian
Defining Cost and the Cycle costs). Time-dependent activity-based population was due to osteoarthritis,
of Osteoarthritis Care costing (TDABC) creates a pathway and the productivity cost of work loss
From the perspective of the United whereby each individual process step is expected to increase substantially in
States government, healthcare costs is represented by two parameters: (1) future years. Similarly, Dibonaventura
are estimated to represent more than the cost of each resource used and (2) et al33 found that patients with
Table 2
Selected Recent Cost Literature Regarding THA and TKA According to Perspective and Temporal Relation to
Surgery
Factor Author Year Design Perspective Major Findings
Preoperative Williams et al34 2017 Three protocols for Hospital, patient, From the patient and society
staphylococcus and society perspective, two-swab and
decolonization (four universal decolonization
swabs, two swabs, and were most cost-effective.
nasal swab alone) From the hospital
compared to no screening perspective, universal
and universal decolonization was the most
decolonization. commonly used, but single
swab remained the most
cost-effective strategy.
The study highlights the
importance of considering the
perspective of the entity
paying for diagnostic or
treatment modalities.
McLawhorn et al18 2016 Markov model used to Patient Patients who underwent TKA
compare immediate TKA alone had lower QALYs
with bariatric surgery 2 yr gained than patients who
prior to TKA for morbidly underwent bariatric surgery
obese patients. prior to TKA.
Intraoperative Elmallah et al35 2017 844 patients who Patient Estimated ICER for TKA and
underwent primary TKA THA versus baseline before
and 224 patients who surgery were $43,107 and
underwent primary THA at $39,453, respectively. The
7 institutions were authors argue that THA and
analyzed with SF-6D at TKA are cost-effective and
baseline and 1-yr follow- that the use of simple metrics
up. QALY estimated and such as SF-6D may facilitate
ICERs deduced for both these calculations.
groups.
Zygourakis et al36 2017 63 surgeons received Hospital Cost feedback to surgeons
standardized monthly resulted in 9.95% reduction in
scorecards showing surgical supply costs.
median surgical supply
direct cost for each
procedure compared to
186 control surgeons who
did not receive this
information
Haas et al37 2017 Retrospective study of 27 Hospital Presence of a hospital-
hospitals collecting data physician committee for
on average prosthetic implant vendor selection and
purchase price for primary negotiation was associated
TKA and THA, and factors with 17% and 23% lower
that might play a role in implant purchase prices for
variation in prices. TKA and THA, respectively.
Volume also played a role in
lowering TKA costs but not
THA costs. The range of
implant costs from the 10th
percentile to the 90th
percentile was in excess of
200%.
(continued )
ICER = incremental cost-effectiveness ratio, PJI = periprosthetic joint infection, POD = postoperative day, QALY = quality-adjusted life year, THA =
total hip arthroplasty, TJA = total joint arthroplasty, TKA = total knee arthroplasty
January 1, 2019, Vol 27, No 1 7
Selected Recent Cost Literature Regarding THA and TKA According to Perspective and Temporal Relation to
Surgery
Factor Author Year Design Perspective Major Findings
Collins et al38 2017 153 revision THAs analyzed Hospital Direct to hospital and fixed
and cost of implants implant pricing lowered the
determined as percentage cost of revision THA, saving
of total cost of more than $8,000 per case.
hospitalization. This The cost of revision implants
number was compared to represented 36% of the total
direct to hospital and fixed hospital cost.
implant pricing models.
Carnes et al39 2016 Markov model used to Patient, hospital, At a cost-differential of $1,003,
determine ceramic-on- and society ceramic heads were not cost-
polyethylene revision rate effective at any age
needed to be cost- compared to cobalt chromium
effective compared to heads. At a cost-differential of
metal on polyethylene. $325, ceramic heads were
cost-effective for patients
younger than 85 yr. The
authors conclude that
indiscriminant change to
ceramic heads may not be
cost-effective depending on
the differential in price of the
implant compared to cobalt
chromium heads.
Postoperative Sibia et al25 2017 NSQIP database used to Society Authors argue that many
determine discharge discharges on POD 3
destination and compared correspond to unnecessary
to institutional cost extra days in the hospital and
difference between POD 2 could potentially represent
and POD 3. $63 million in annual savings
to Medicare.
Slover et al26 2016 Decision analysis used to Society Extended hospital stays of up
examine how many days a to 5.2 d to allow for home
patient can remain in the discharge may be more cost-
hospital to avoid effective than earlier
postacute inpatient care. discharge with need for
inpatient rehabilitation. The
authors emphasize that the
study did not specifically
determine whether quality
would be affected by this shift
and that further study of the
strategy is necessary.
Shearer et al40 2015 Markov model used to Society Net monetary benefit for 10%
determine whether reduction in PJI was $278,
reductions in compared with $174 for
periprosthetic joint reductions in aseptic
infection and early loosening. The authors argue
readmission would have that strategies focused on PJI
greater influence on the reduction will enhance the
net monetary benefit for overall value of TJA greater
THA compared with than improvements to implant
equivalent reductions in longevity.
aseptic loosening.
ICER = incremental cost-effectiveness ratio, PJI = periprosthetic joint infection, POD = postoperative day, QALY = quality-adjusted life year, THA =
total hip arthroplasty, TJA = total joint arthroplasty, TKA = total knee arthroplasty
osteoarthritis experienced greater thors surmise that adhering to the and THA over a 1-year period. The
work impairment while at work, approach outlined by the American study revealed that the presence of a
poorer health status, and greater Academy of Orthopaedic Surgeons hospital-physician committee was
healthcare resource utilization. Clinical Practice Guidelines would associated with up to 23% reduction
Interest has grown in cost- potentially reduce the cost of non- in purchase prices. A study by Carnes
effectiveness analysis as a method to inpatient osteoarthritis treatment by et al39 highlights the importance of
elucidate how a given treatment both 45%. A limitation of the study is the cost analysis in the adoption of newer
extends and improves quality of life. reliance on accurately coded and technology and the role of perspective
Through comparison of incremental documented interventions; thus, the in drawing meaningful conclusions
cost-effectiveness ratio, the benefit of authors’ findings likely represent from the data. The authors used
individual treatments based on quality- notable underestimations in cost Markov decision modeling to show
adjusted life years (QALYs, defined estimates. that at a cost differential of $325
as a year of perfect health) may be as- Risk optimization before surgery when compared to metal-on-
certained. A commonly accepted value may represent a good example of in- polyethylene bearings, ceramic-on-
per QALY is $50,000,41 although this creasing costs, while simultaneously polyethylene bearings for THA were
number is debated, with some authors improving patient outcomes by a cost-effective for patients aged ,85
advocating for a tiered threshold de- greater degree, thus elevating the years, at a cost differential of $600
pending on perspective.42 In their overall value of the TJA episode of were cost-effective for patients aged
systematic review of the literature, care. Evidence currently exists that at ,65 years, and at a differential of
Nwachukwu et al identified 23 high- documents the cost-effectiveness of $1,003 were not cost-effective at all.
quality cost-utility studies related to smoking cessation, staphylococcal One could argue that the findings
hip and knee arthroplasty and identi- decolonization, and weight loss, should be followed up by a
fied only two studies that compared among other interventions. Paxton willingness-to-pay analysis because
TJA to nonsurgical intervention. One et al46 analyzed the Kaiser Perma- it is quite feasible that many patients
study identified TKA to be associated nente Total Joint Replacement Reg- would be willing to pay an out-of-
with an incremental cost-effectiveness istry to demonstrate that both pocket premium to eliminate the
ratio of $18,300 per QALY compared modifiable and nonmodifiable risk possibility of trunnionosis altogether.
to nonsurgical management43 and the factors for readmission exist for As a significant cost to the health-
other determined that TKA compared patients undergoing primary unilat- care system, postoperative hospital
to nonoperative management resulted eral THA. Modifiable patient risk readmissions represent a key target
in an age-weighted mean societal cost factors included obesity and medical for cost reduction by the CMS. The
savings of $18,930.44 comorbidities (such as pulmonary Medicare Hospital Readmissions
disease, hypothyroidism, and mental Reduction Program is an outgrowth
health), and structural risk factors of the ACA, establishing a model
Preoperative, Intraoperative, included hospital and surgeon volume. whereby hospitals and other provid-
and Postoperative Costs of Interestingly, the authors found a ing institutions will be responsible for
Total Joint Arthroplasty higher incidence of readmission readmissions for any reason within a
The costs of hip and knee osteoarthritis with higher volume surgeons, pos- period after surgery, ranging from 30
in the period of time leading up to TJA sibly because of referral patterns in to 90 days. Kurtz et al,48 in their
are significant. Bedard et al30 reviewed the Kaiser system. review of the Nationwide Read-
the Humana administrative claims The inpatient costs associated with mission Database, found that read-
database from 2007 to 2015 and THA and TKA are variable, ranging missions were more common in the
found that among 86,081 primary from $10,014 to $37,719. Major cost Medicare population compared to
TKA procedures, more than 65% of drivers are hospital charges (65%), the privately insured population,
patients had at least one treatment in implant costs (27%), and physician ostensibly because of the better
the year before TKA. Interestingly, fees (8%). Robinson et al47 found baseline health of the latter. The
only 3 of 8 treatments studied have a that most of the variation in the cost authors also found that over half of
strong recommendation for their use of total hip and knee replacement readmissions within 90 days were
based on the American Academy of surgery was related to implant costs. due to medical complications unre-
Orthopaedic Surgeons’ Clinical Prac- Haas et al37 retrospectively reviewed lated to the index procedure and that
tice Guidelines, representing only data from 27 relatively high-volume these readmissions tended to be
12% of non-inpatient knee osteo- hospitals regarding the prosthetic among the most costly. Despite this
arthritis treatment cost.45 The au- implant purchase prices for TKA finding, the data also revealed that
January 1, 2019, Vol 27, No 1 9
infections and other mechanical The third-party payer system that nhe-fact-sheet.html. Accessed May 17,
2017.
complications related to the proce- prevails in the United States imposes a
dure remain costly sources of read- challenging dynamic whereby value 3. Bumpass DB, Samora JB, Butler CA,
Jevsevar DS, Moffatt-Bruce SD, Bozic KJ:
mission after primary TJA. Strategies is determined by those paying and Orthopaedic quality reporting: A
that improve clinical pathways for frequently not the end-user of care. comprehensive review of the current
landscape and a roadmap for progress. JBJS
specific readmission diagnoses will Thus, it becomes commonplace to
Rev 2014;2:e5.
likely have a notable effect on cost, witness dramatic variations between
4. Porter ME: What is value in health care? N
primarily through length of stay patient and societal perception of Engl J Med 2010;363:2477-2481.
reduction. value.50 As Porter has aptly recog-
5. Donabedian A: Evaluating the quality of
Discharge to postacute inpatient nized, value in any industry is mea- medical care. Milbank Mem Fund Q 1966;
care after TJA has been associated sured by the consumer or the patient 44(suppl):166-206.
with higher costs, higher readmission in the case of health care. Regardless 6. Wang Z, Chen F, Ward M, Bhattacharyya
rates, and higher rates of postopera- of any shift in political climate or T: Compliance with surgical care
modifications to the ACA that may improvement project measures and
tive complications. Proposed strate-
hospital-associated infections following hip
gies to reduce these problems include be pending in future years, a value- arthroplasty. J Bone Joint Surg Am 2012;
preoperative education and prepara- based approach to health care is likely 94:1359-1366.
tion, enlistment of family support to remain a permanent fixture. As 7. MacLean C: Value-based purchasing for
at the time of discharge, and close shown throughout this review, a osteoarthritis and total knee arthroplasty:
What role for patient-reported outcomes?
collaboration with, and education growing body of evidence supports the J Am Acad Orthop Surg 2017;25(suppl 1):
of, inpatient rehabilitation facilities. continued use of TJA as a high-value S55-S59.
Schwarzkopf et al49 reviewed the treatment for end-stage hip and knee 8. Nawaz H, Edmondson AC, Tzeng TH,
California Hospital Discharge data osteoarthritis from all perspectives. Saleh JK, Bozic KJ, Saleh KJ: Teaming: An
approach to the growing complexities in
set and determined that the elderly health care: AOA critical issues. J Bone
Medicare population showed a higher Joint Surg Am 2014;96:e184.
Acknowledgments
likelihood of discharge to inpatient 9. Keswani A, Koenig KM, Bozic KJ: Value-
care facilities after TKA, echoing the This research was made possible in based healthcare: Part 1—designing and
findings of previous studies. Despite implementing integrated practice units for
part by the Mayo Clinic Robert D. the management of musculoskeletal disease.
strategies to discourage the use of and Patricia E. Kern Center for the Clin Orthop Relat Res 2016;474:
postacute inpatient care, it remains to Science of Health Care Delivery. 2100-2103.
be seen in a bundled payment model 10. Keswani A, Koenig KM, Ward L, Bozic KJ:
whether surgical treatment remains Value-based healthcare: Part 2—addressing
References the obstacles to implementing integrated
a viable option in these higher-risk practice units for the management of
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Evidence-based Medicine: Levels of Res 2016;474:2344-2348.
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Summary contents. In this article, reference 21 Froimson MI: Alternative reimbursement
is a level I study. References 1, 6, 13, models: Bundled payment and beyond:
AOA critical issues. J Bone Joint Surg Am
To define and analyze value in THA 20, 30, and 44 are level II studies. 2016;98:e45.
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12. Centers for Medicare & Medicaid services:
the multiple facets of cost and out- 37, 39-43, and 45-48 are level III Comprehensive care for joint replacement
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initiatives/CJR. Accessed May 17, 2017.
ity improvement are likely to be 22, 27, and 28 are level IV studies.
13. Iorio R, Clair AJ, Inneh IA, Slover JD,
effective when they address the struc-
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those published within the past 5 90-day total joint arthroplasty episode of
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ings, whether achieved during the
preoperative, postoperative, or intra- 1. Kurtz SM, Ong KL, Lau E, Bozic KJ: 14. Navathe AS, Troxel AB, Liao JM, et al:
Impact of the economic downturn on total Cost of joint replacement using bundled
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Joint Surg Am 2014;96:624-630.
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tionships to the entire cycle of osteo- 2. CMS National Health Expenditure Data of bundled payments and health care
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the quality of care provided. and-reports/nationalhealthexpenddata/ J Arthroplasty 2017;32:2590-2597.
16. Qin CD, Helfrich MM, Fitz DW, Hardt to minimize after-care costs for total joint 39. Carnes KJ, Odum SM, Troyer JL, Fehring
KD, Beal MD, Manning DW: The arthroplasty in a bundled payment TK: Cost analysis of ceramic heads in
Lawrence D. Dorr Surgical Techniques & environment? J Arthroplasty 2016;31: primary total hip arthroplasty. J Bone Joint
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postoperative outcomes between total hip
arthroplasty for fracture vs osteoarthritis. 27. Brodke DJ, Hung M, Bozic KJ: Item 40. Shearer DW, Youm J, Bozic KJ: Short-term
J Arthroplasty 2017;9S:S3-S7. response theory and computerized adaptive complications have more effect on cost-
testing for orthopaedic outcomes measures. effectiveness of THA than implant
17. Yao DH, Keswani A, Shah CK, Sher A, J Am Acad Orthop Surg 2016;24:750-754. longevity. Clin Orthop Relat Res 2015;
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28. Kaplan RS, Michael PE: The big idea: How 473:1702-1708.
after primary elective total joint
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Arthroplasty 2017;32:375-380. QALY threshold. Expert Rev
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42. Nwachukwu BU, Bozic KJ: Updating cost
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discharge within 2 Days following total 31. Kotlarz H, Gunnarsson CL, Fang H, Rizzo Cost-effectiveness of total knee arthroplasty
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or knee osteoarthritis: Consensus of the joint arthroplasty patients. J Arthroplasty
international consortium for health 2017;32:S91-S96. 47. Robinson JC, Pozen A, Tseng S, Bozic KJ:
outcomes measurement hip and knee Variability in costs associated with total hip
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Success of clinical pathways for total joint 2017;32:351-354. Kolisek FR, Manley MT: Which clinical
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Bosco J: What is the best strategy J Arthroplasty 2017;9:S141-S143. 2696-2699.
January 1, 2019, Vol 27, No 1 11
Review Article
Microinstability of the Hip—Gaining

Acceptance
Abstract
Marc R. Safran, MD The hip has generally been considered an inherently stable joint.
However, the femoral head moves relative to the acetabulum.
Although the bones are primarily important in hip stability, the
importance of the soft tissues has recently been demonstrated.
Symptomatic microinstability of the hip is defined as extraphysiologic
hip motion that causes pain with or without symptoms of hip joint
unsteadiness and may be the result of bony deficiency and/or soft-
tissue damage or loss. Recent work has helped improve the ability to
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ91WI%,7WH;2:-)*R341'3P9QV(OZPJM7V-(/R'3P38YR2< RQ
identify microinstability patients preoperatively. Initial management

begins with activity modification and strengthening of the
periarticular musculature. Failing nonsurgical management, surgical
intervention can be beneficial, focusing on treatment of the
underlying cause of microinstability, as well as associated intra-
From the Department of Orthopaedic articular pathology. Bony deficiency may be treated with a
Surgery, and the Department of redirectional osteotomy, whereas those with adequate bony
Sports Medicine, Stanford University, coverage may be treated with capsular plication, capsular
Redwood City, CA.
reconstruction, and/or labral reconstruction.
Dr. Safran or an immediate family
member has received royalties from
DJ Orthopaedics, Smith & Nephew,
and Stryker; is a member of a
speakers’ bureau or has made paid
presentations on behalf of ConMed
Linvatec, Medacta, and Smith &
T here has been increasing aware-
ness of microinstability of the
hip, although it remains a contro-
clinically, confirms that hip micro-
instability is a real entity, even without
bony deficiency (ie, hip dysplasia).
Nephew; serves as a paid consultant
to ConMed Linvatec, Cool Systems, versial topic. It has commonly been This manuscript reviews the recent
and Medacta; serves as an unpaid held that the hip is one of the most growing literature supporting the
consultant to Cool Systems, Cradle inherently stable joints in the body concept of hip microinstability, fo-
Medical, Ferring Pharmaceuticals, cusing on the relevant contributions
as a result of bony congruity and
Biomimedica, and Eleven Blade
Solutions; has stock or stock options stout supporting structures. Litera- of the anatomy to hip stability, the
held in Cool Systems, Cradle Medical, ture review of the 20th century lacks dynamics of hip motion, causes of hip
Biomimedica, and Eleven Blade discussion of hip microinstability, microinstability, evaluation of the
Solutions; has received research or patient with microinstability, and
institutional support from Ferring
even after a hip dislocation, whereas
Pharmaceuticals and Smith & recurrent dislocations were also quite treatment options.
Nephew; and serves as a board rare. Part of the lack of general
member, owner, officer, or committee acceptance of hip microinstability
member of the International Society of Contributors to Hip Stability
Arthroscopy, Knee Surgery, and as a clinical issue is the fact that the
Orthopaedic Sports Medicine and the hip has an apparent high degree of Microinstability of the hip is defined
International Society for the Hip. bony conformity and is deep within a as extraphysiologic hip motion that
J Am Acad Orthop Surg 2019;27: dense soft-tissue envelop in which causes pain with or without symp-
12-22 small amounts of increased motion toms of hip joint unsteadiness and
DOI: 10.5435/JAAOS-D-17-00664 (that may cause symptoms and/or may be the result of bony deficiency
intra-articular damage) may be hard and/or soft-tissue damage or loss.1
Academy of Orthopaedic Surgeons. to detect or quantify. Nonetheless, Many factors contribute to the sta-
mounting evidence, preclinically and bility of the hip.
Marc R. Safran, MD
Bony Stability Figure 1

Although the hip has generally been
considered a highly constrained ball
in socket joint, most studies have
suggested that it is really a gimbal
joint. Furthermore, under physiologic
loads, the weight-bearing surface un-
dergoes deformation—flattening and
widening—allowing for translation.
The acetabulum is a quasi-hemisphere
that covers approximately 170 of the
femoral head. The acetabular labrum
increases the acetabular volume by
approximately 20% and the surface
area by 25%.2 The acetabulum is
anteverted 15 to 20 and has 45
lateral tilt. When considering the hip
and stability, the importance of the
proximal femur is often discounted.
Approximately 130 of superior in-
clination of the femoral neck from
the shaft (ie, neck-shaft angle) and
approximately 10 of anteversion
exist; both play a notbale role in the
stability of the hip. This combination
of femoral and acetabular ante-
version and lateral inclination pro- Schematic showing the microinstability cycle that demonstrates the
vide good bony coverage posteriorly pathophysiology of symptomatic microinstability. Generally, femoral head
and thus inherent stability, allowing motion exists within the acetabulum. This phenomenon stresses the labrum and
capsuloligamentous structures. With continued extremes of motion and forces,
for more hip flexion and abduction the labrum may breakdown and/or the capsuloligamentous structures stretch
than extension and adduction. As a out. This phenomenon leads to more femoral head motion, which stresses the
result, greater reliance exists on soft- capsuloligamentous structures and labrum further. Eventually, patients will
tissue structures for anterior stabil- develop pain and through disuse, the muscular contributions to stability will
diminish, as the muscles weaken.
ity, especially in femoral adduction,
extension, and external rotation. In
hip dysplasia, with decreased ace- Table 1
tabular depth, increased anteversion, Hip Instability Examination Tests
increased acetabular roof inclina- Test Comment
tion, and increased femoral ante-
version, less bony stability exists, Anterior apprehension/HEER Sensitivity of 71% and specificity of 85%
which allows more anterior and Abduction-extension-external Sensitivity of 81% and specificity of 89%
rotation
superior/lateral femoral head migra-
tion, increasing the reliance on the Prone external rotation Sensitivity of 33% and specificity of 98%
soft tissues for stability. If all 3 tests mentioned earlier are 95% likelihood of microinstability
positive confirmed at surgery
Beighton signs Generalized ligamentous laxity. Does not
Ligaments necessarily correlate with hip
microinstability
There are four main capsu-
Log roll Assess iliofemoral ligament laxity
loligamentous structures and 1 non-
Axial distraction Distraction stability
capsular ligament in the hip. The
noncapsular ligament, ligamentum Posterior apprehension For posterior instability
teres (LT), has a unique pyramidal HEER = hyperextension external rotation
and somewhat flattened shape. This
January 1, 2019, Vol 27, No 1 13
Microinstability of the Hip
Table 2 Table 3
Imaging Findings for Hip Stability Intraoperative Findings of Hip
Instability
Plain radiographs
Center edge angle less than 20 or 25 Ease of distractibility
Lateral center edge angle less than 20 to 25 Labrum
Acetabular roof inclination greater than 10 Labral-chondral separation
Femoral head subluxation Straight anteriorly
Broken Shenton line Straight laterally
Cliff sign Chondral damage
Distal femoral neck sclerosis Acetabulum
Splits radiograph for vacuum sign and/or femoral head subluxation Wearing down pattern
Femoro-epiphyseal acetabular roof index 1 to 3 mm from the rim
MRI Straight anteriorly
Capsular integrity/defect Straight laterally
Thin anterior lateral capsule (,3 mm) Femoral head
Wide anterior capsular recess (.5 mm) Central
Accumulation of contrast in the posterior-inferior joint in $2 planes Ligamentum teres
Tear
Hypertrophy
ligament takes its origin from the limits hip external rotation in hip
transverse acetabular ligament and flexion, whereas both internal and
posterior-inferior acetabular fossa external rotations are limited by the
ments of the hip joint, helping main-
and inserts into the fovea capitis of ILFL in hip extension.
tain the negative intra-articular pressure
the femoral head. Hip flexion, ad- The PFL originates on the anterior
within the joint and creating a suction
duction, and external rotation result acetabulum and spirals inferiorly and
effect.9-11 This has been confirmed in
in tightening of the LT and have been posteriorly around the femoral head,
the lab, as 60% less force was required
shown to be secondary restraints in before blending with the other two
to distract the femoral head in the
that position.3,4 Furthermore, hyper- longitudinal capsular ligaments. The
presence of a labral tear.9,12,13
trophy or tearing of the LT has been PFL limits external rotation, espe-
seen in the setting of hip dysplasia and cially in hip extension. The ISFL
Dynamic Stabilizing Factors
hip instability.5,6 starts at the ischial acetabular margin
The iliofemoral (ILFL), pubofemoral and inserts at the base of the greater Dynamic factors include adhesion-
(PFL), and ischiofemoral (ISFL) liga- trochanter posteriorly. The ISFL cohesion, negative intra-articular pres-
ments are longitudinal thickening of limits posterior translation and hip sure, and muscular forces of the 17
the capsule that spiral around the internal rotation (iem in both flexion muscles that cross the hip that provide
femoral head and insert on the ace- and extension). compression of the femoral head into
tabulum directly, except for the PFL. The zona orbicularis is a capsular the acetabular concavity. In addition,
Sixty percent of the hip capsule com- thickening that encircles the femoral the iliopsoas musculotendinous unit
prises the hip capsuloligamentous neck, at the narrowest point of the may provide additional stability to
thickenings.7 The ILFL is the strongest capsule, and is important in limiting resist anterior femoral head translation
ligament in the body and is also called femoral head distraction.8 based on its anatomic location. Most of
the Y Ligament of Bigelow because of these individual factors have not been
its inverted Y shape with a single studied for their role specifically in the
proximal attachment at the base of Labrum hip joint; however, they provide sta-
the anterior inferior iliac spine. The As mentioned earlier, the intact bility in other joints, such as the shoul-
ILFL inserts on the anterior promi- labrum increases the surface area and der, and may function similarly in the
nence of the greater trochanter lat- volume of the acetabulum. This phe- hip.
erally and at the level of the lesser nomenon contributes to hip stability
trochanter on the anterior femur for and the distribution of joint stresses Femoral Head Motion
the medial attachment. The lateral during loading. Furthermore, the Although the bony anatomy has long
arm of the ILFL is a primary restraint labrum functions as a seal between been considered the primary factor in
for many hip motions.4 The ILFL the central and peripheral compart- the stability of the hip, recent studies
Marc R. Safran, MD
have demonstrated that the center of Figure 2

the femoral head (ie, centroid) moves
relative to the center of the acetabu-
lum. We have shown that the femoral
head moves on average 3.4 mm in the
medial-lateral plane, 1.5 mm in the
anterior-posterior plane, and 1.5 mm
in the proximal-distal plane as the
hip is taken through the extremes
of motion in a cadaver model.14
Charbonnier et al15 demonstrated
the femoral head subluxates an
average 2 mm when comparing MRIs
of asymptomatic professional ballet
dancers in the supine position versus an
MRI while in the splits position.
Recently, Mitchell and coinvestigators
described the splits radiograph that is
an AP pelvis radiograph with the legs
abducted in the splits position.16 They
found that 89% of 47 professional
ballet dancers had lateral subluxation
of their femoral head (ie, average Photograph showing the flexion, abduction and external rotation (FABERE) test.
1.4 mm), and 36% had a vacuum sign, With the patient supine, the leg being examined is brought into a “figure-of-4”
position. The distance from the lateral knee joint line to the table may give a clue
also indicating that microinstability of as to laxity (or stiffness). The clinician uses his fist as a measure. A distance less
the hip exists. More recently, dynamic than 3 inches from the lateral knee to the table may be a clue to laxity of the hip
in vivo femoral head motion relative joint.
to the acetabulum has been demon-
strated using biplanar fluoroscopy,
with translations between 0.69 and have generally divided patients into nation of these bony abnormalities
4.1 mm.17 six categories based on the underlying may result in anterior hip instability
Thus, femoral head centroid moves cause of instability or microinstability: and early degenerative changes because
relative to the acetabulum. Femoral (1) notable bony abnormalities or of these abnormal hip joint forces.
head motion may also be guided, and developmental dysplasia of the hip, (2) Connective tissue disorders are
limited, by the soft tissues, including connective tissue disorders, (3) post- often genetic disorders of soft-
the ligaments about the hip, labrum, traumatic, (4) microtraumatic (ie, usu- tissue elasticity/stiffness. Collagen
and muscles.14,18 Myers et al and ally associated with athletics), (5) disorders, such as Ehlers-Danlos
others demonstrated that the ILFL iatrogenic, and (6) idiopathic.1,6 syndrome, Marfan syndrome, or
plays a notable role in limiting hip Notable bony abnormalities may be Down syndrome, are associated with
external rotation and anterior femoral developmental, such as acetabular joint instability, including the hip. Lesser
head translation, whereas the acetab- dysplasia or posttraumatic (discussed degrees of connective tissue disorders
ular labrum is a secondary stabilizer later), which result in microinstability include benign hypermobility disorders.
for these motions.4,19 Repeated ex- because of the lack of bony support, Posttraumatic hip instability is rel-
tremes of femoral head motion may stressing the soft tissues (ie, labrum atively uncommon. However, the
lead to breakdown of the soft tissues, and ligaments) that may result in pathology of a hip dislocation in-
such as a labral tear, or stretch out the breakdown over time. Typical ana- cludes tearing of the ILFL and often a
ligaments of the hip, and continue in a tomic changes in developmental dys- posterior labral-chondral separation
downward spiral (Figure 1). plasia of the hip include a misshapen and tearing of the LT. There may also
femoral head, a shallow acetabulum be posterior acetabular rim fractures.
Causes with loss of anterolateral coverage, Because most hip dislocations are
increased acetabular lateral tilt, and posterior, if there is no associated
Atraumatic hip microinstability may excessive anteversion of the acetabu- bony damage, recurrent instability is
be caused by a variety of factors. We lum and proximal femur. The combi- uncommon; however, in those with
January 1, 2019, Vol 27, No 1 15
Figure 3 hip arthroscopy, making a capsu-

lotomy between the anterior and
anterolateral portals (ie, interportal
capsulotomy). Cutting the ILFL in-
creases femoral head translation,
especially in neutral flexion-
extension, and rotation (especially
in flexion), as well as increasing
hip range of motion and joint lax-
ity.19,20 Furthermore, the more of
the ILFL that is cut, the more easily
the hip can be distracted.21 Some
also extend the interportal capsu-
lotomy distally, in a “T” fashion
(T-capsulotomy). Making the inter-
portal capsulotomy cuts the ILFL by
necessity.7 The T-capsulotomy also
results in increased hip external
rotation compared with an intact
state and interportal capsulotomy.22
These capsulotomies, with or with-
out iliopsoas tenotomy, have been
Photograph showing the anterior apprehension test. The anterior apprehension associated with hip dislocations
test, also known as the hyperextension, external rotation test, is performed with postoperatively and likely lesser
the patient supine at the end of the examination table, with their buttocks just at
the edge of the table. The patient holds one knee toward their chest, whereas the
degrees of instability (ie, micro-
extremity to be examined is passively allowed to fall into hyperextension. The instability).6,23 Furthermore, Frank,
extremity being examined is then externally rotated by the clinician, which et al demonstrated that patients
stresses the anterior capsule and labrum, and should reproduce the patient’s who had closure of the whole
anterior pain or apprehension. Posterior pain with this maneuver may be the
result of posterior impingement. We have found that the anterior apprehension
T-capsulotomy did better than those
test has a sensitivity of 71% and specificity of 85% (Hoppe et al25). who just had closure of the longi-
tudinal portion (leaving the inter-
portal capsulotomy open).24 This
associated fracture, acetabular retro- potential cause of hip microtraumatic has been hypothesized to be the result
version with posterior wall insuffi- instability or even complete disloca- of reducing hip microinstability.
ciency, or extensive soft-tissue damage, tion. Pincer-type FAI was initially
posttraumatic recurrent instability may described as causing the contrecoup
exist. damage from a subluxation type Diagnosis
Microtrauma can occur from mechanism of the femoral head—neck
repeated extreme range of motion. junction levering on the over- The diagnosis of hip microinstability
External rotation of the lower extrem- covering anterior acetabulum. Re- can be difficult, especially if the
ity results in anterior translation of cently, several authors have reported patient does not have notable bony
the femoral head relative to the ace- that cam- or pincer-type FAI is abnormalities or connective tissue
tabulum, which may result in ante- associated with low-velocity hip disorder. The signs and symptoms
rior labral tears, and stretching of the subluxation or dislocation in most of may be quite subtle, and there is no
anterior capsuloligamentous struc- their cases. Thus, FAI anatomy with definitive preoperative diagnostic
tures. This condition is seen in ballet the hip at end range of motion can test, physical examination finding, or
dancers who continuously train to try load the acetabular labrum and imaging modality that is pathogno-
to get increased turnout of their leg, stretch the hip capsule, resulting in monic for hip microinstability, simi-
stretching the ILFL and stressing the instability—microtraumatic or true lar to the case of shoulder. Recent
anterior labrum, as well as in golfers, dislocation. research has identified some physical
who apply an axial load and rotate. More recently, iatrogenic hip insta- examination maneuvers and imaging
In addition, femoroacetabular im- bility has been identified after hip findings that may provide a clue to
pingement (FAI) may also be a arthroscopy. Many surgeons perform the clinician (Tables 1 and 2). In
Marc R. Safran, MD
addition to having a high index of Figure 4

suspicion, intraoperative findings
have been associated with hip mi-
croinstability to help confirm the
diagnosis (Table 3).
History
Patients with hip microinstability rarely
complain that their hip is actually
unstable or coming out of the socket.
Usually patients complain of pain deep
in the joint, such as the C sign, or deep
in the inguinal crease or groin.1,6 They
may complain of pain or apprehen-
sion, or giving way with certain
activities. This is particularly true with
rotational activities with an axial load
(ie, specifically external rotation), or
with hyperextension, such as when
their leg is behind them when walking.
Most patients will note an insidious
onset of hip pain, with gradual wors-
Photograph showing the abduction-extension-external rotation test. The abduction-
ening, although they may have had an extension-external rotation test is performed with the patient in the lateral decubitus
injury the initiated the pain. position, and the leg to be examined is abducted about 30, extended, and then
In the author’s practice, many pa- externally rotated. Then, an anteriorly directed force is applied to the posterior
tients who have failed hip arthros- greater trochanter. This should reproduce the patient’s symptoms. We have
found this test to have a sensitivity and specificity of 81% and 89%, respectively
copy have microinstability—either (Hoppe et al25).
iatrogenic (ie, from cutting the ILFL
or removal of the labrum) or had
mentous laxity. Hip strength and of 85%, whereas the abduction-
microinstability before the first sur-
range of motion should be tested, as extension-external rotation test
gery that was not addressed.
well as evaluation of other joints to rule has a sensitivity of 81% and a
out referred pain. Excessive hip internal specificity of 89%, and the prone
Physical Examination or external rotation (.60 in either external rotation test is sensitive
A thorough and complete physical direction) and/or lateral knee joint line 33% of the time but has a specificity
examination is important when the distance from the examination table of of 98%.25 If all three of these tests
diagnosis of hip microinstability is less than 3 inches with the leg in the are positive on clinical examination,
suspected because this is a dynamic figure-of-4 position may be suggestive there is a 95% likelihood that the
issue, and imaging is a static modality of hip joint laxity (Figure 2). patient will have intraoperative
to evaluate the hip. The goal of the Six specific provocative maneuvers confirmation of hip microinstability.
examination should be to reproduce are commonly described to evaluate
the patient’s symptoms, whether hip stability: the anterior apprehen-
Imaging
pain or apprehension, with range of sion test (Figure 3), the abduction-
motion, palpation and/or provoca- extension-external rotation test Radiographs
tive tests. (Figure 4), the prone external rota- Plain radiographs should include a
Although we have not found gener- tion test (Figure 5), the log roll test high-quality supine AP pelvis radio-
alized ligamentous laxity to correlate (Figure 6), the axial distraction test graph, a good lateral radiograph (ie,
with hip microinstability, certainly (Figure 7), and the posterior appre- not a frog lateral but a cross-table or
individuals with diffuse ligamentous hension test6 (Figure 8; Table 1). We Dunn view), and a false-profile view.
laxity have a greater likelihood of recently studied three of these tests.25 Radiographs should be studied for
having hip laxity and possibly, mi- This study demonstrated that the evidence of hip dysplasia, FAI, pre-
croinstability. As such, we test anterior apprehension test has a vious surgery, previous trauma, and
Beighton signs of generalized liga- sensitivity of 71% and a specificity degenerative changes. Acetabular
January 1, 2019, Vol 27, No 1 17
Figure 5 assessed on AP pelvis radiographs,

as greater than 10 is suggestive of
acetabular dysplasia, and angles of
more than 14 to 16 have been
associated with poorer outcomes of
hip arthroscopy, as has femoral
neck-shaft angle of greater than
139. AP pelvis radiographs should
also be assessed for acetabular
retroversion, as suggested by the
posterior wall sign and/or ischial
spine sign (Figure 9).
Some recent studies report radio-
graphic findings consistent with hip
microinstability (Table 2). We
describe the cliff sign, where there is
loss of sphericity of the femoral head
(Figure 10). In a study of 96 patients,
74% of those with a cliff sign had
hip microinstability, whereas only
7% of those who had no cliff sign
had microinstability.26 For the 20
Photograph showing the prone external rotation test. The prone external rotation women younger than 32 years who
test is performed with the patient prone, and thus, their hip is in neutral flexion- had a cliff sign, 100% had capsular
extension. The hip is then externally rotated, and the examiner applies an
anterior directed force to the posterior trochanter. Pain or apprehension felt
laxity. It has also been noted that
anteriorly is consistent with the diagnosis of hip instability, and we found that this patients with sclerosis distal on the
test to be sensitive 33% of the time but have a 98% specificity (Hoppe et al25). femoral neck likely have impingement
due to supraphysiologic motion,
possibly against the anterior inferior
Figure 6 iliac spine, as a sign of potential hip
microinstability. Other radiographic
signs include extrusion of the femo-
ral head, and a broken Shenton line,
usually seen in patients with
dysplasia.
Wyatt et al27 recently described
the femoro-epiphyseal acetabular
roof index as a clue to instability
for those with borderline dyspla-
sia.26 They evaluated that the angle
comprised two lines formed from
(1) the acetabular roof inclination and
(2) the femoral head physeal scar. A
Photograph showing the log roll test. The log roll test is performed while the positive value, indicating the roof is
patient is laying supine on the examination table. With the patient relaxed, supine at a steeper angle than the physeal
and knee in extension, the examiner internally rotates the foot fully and then scar, was consistent with instability.
removes their hand from the foot. The foot will passively rotate back in to external
rotation. If external rotation is greater than the contralateral side, and more
specifically, less than 20 foot-table angle, anterior hip laxity may be present. MRI
Magnetic resonance arthrography
(MRA) can be particularly helpful.
dysplasia is defined as a lateral and on the false-profile view of Postoperative instability may result
center edge angle of Wiberg of less Lequesne. Furthermore, the ace- in capsular defects, with dye extrav-
than 20 to 25 on the AP pelvis tabular roof inclination needs to be asation from the joint, which may
Marc R. Safran, MD
Figure 7 Figure 8
AP pelvis radiograph of a patient

with just the left hip demonstrating a
posterior wall sign and ischial spine
sign. The posterior wall sign is
present when the posterior
acetabular wall (white line) is medial
to the center of the femoral head
(white dot) and is suggestive of
posterior wall insufficiency as a
Photograph showing the axial distraction test. The axial distraction test is also result of acetabular retroversion.
performed with the patient supine on the examination table. The examiner places The dashed line with block white
their knee up against the patient’s ischium while the patient’s hip and knee are arrow highlights the left hip ischial
flexed approximately 30. With the patient relaxed as best as possible, the spine, which also is a clue to
examiner applies an axial load. The examiner evaluates whether the hip toggles, retroversion of the acetabulum.
whether it causes apprehension, and whether it generates pain. The right hip shows the center of the
femoral head (black dot) is at the
level of the posterior wall (white
arrow).
be a clue to hip instability.28,29 Fur- posterior-inferior joint on two or
thermore, Magerkurth et al28 iden- more planes.27
tified features on MRA in patients patient’s perineum against the post,
with hip laxity. Those investigators before applying fine traction. This
injected as much fluid into the hip as Intraoperative does not happen in patients without
patients would tolerate. They studied Intraoperatively, hip microinstability microinstability.
the area lateral to the zona orbicu- can be confirmed by (1) ease of dis- Evaluation of the location and
laris on axial sections. These authors tractibility and (2) location and pat- pattern of pathology in the joint can
found the space between the femoral tern of intra-articular pathology be helpful in determining whether hip
neck and capsule, the anterior hip (Table 3). Different fracture tables microinstability is present. Patients
joint recess, measured more than 5 mm have different pitch to the screw with microinstability have labral
in patients with laxity, whereas stable mechanism of traction. However, on damage straight anteriorly, or straight
patients did not have this wide recess. the fracture table (ie, Maquet Hip laterally, compared with patients with
Second, they found that the adjacent Interventions Table) used in our FAI, where the damage is most fre-
hip joint capsule anteriorly, but lateral center, hips with microinstability quently anterolateral.30 Furthermore,
to the zona orbicularis, was thin—less required less than 11 turns (44 mm) the damage initially is a labral-chondral
than 3 mm. In our evaluation of hip under general anesthesia with separation. There usually is associated
microinstability, we also found that paralysis to distract the femoral chondral wear, that is shallow (1 to
capsular thinning of less than 3 mm head 8 to 10 mm. The traction is 3 mm) and has a pattern of being worn
was associated with hip micro- applied after the patient is posi- down, as opposed to the abutment,
instability in females.26 Lastly, tioned against the perineal post. softening, and delamination of FAI.
Wyatt et al27 describe instability on Some patients will distract one to Other less frequent findings include
MRA as having a crescent shaped several millimeters just with body central femoral head chondral damage
accumulation of gadolinium in the weight applied to initially bring the and tearing or hypertrophy of the LT.
January 1, 2019, Vol 27, No 1 19
Figure 9 Figure 10 lent intra-articular visualization with

lower morbidity, comparative studies of
open and arthroscopic management of
hip microinstability are lacking.
When treating hip microinstability,
it is important to address concomi-
tant intra-articular pathology and
the hip capsule. As the labrum is
an important secondary stabilizer,
labral tears should be repaired if
possible.13 If labral repair is not
possible, consideration should be
given to labral reconstruction as an
adjunct to hip stabilization.13,31
There have been reported cases of
Schematic demonstrating capsular hip dislocation after arthroscopic
AP pelvis radiograph of a woman plication used by the author. The
with hip instability demonstrating cliff capsulotomy/capsulectomy without
iliofemoral is above, and the
sign. Note the femoral head is out of closure,23,32 as well as instability
ischiofemoral below. Thus, a partial
round. This sudden loss of sphericity without dislocation after hip arthros-
capsulectomy is performed straight
we have called the Cliff sign. This laterally, in an area of the capsule copy.33,34 It is recommended that any
sign has been seen in patients with devoid of ligaments. The capsule is
hip instability. patient undergoing hip arthroscopy
then closed with sutures, functioning
with capsular redundancy and/or
like a rotator interval closure of the
shoulder—not overconstraining symptomatic capsular laxity be
either ligament. considered for capsule repair and/or
Treatment plication.35-37 In addition, capsular
repair and/or plication should be
As with most orthopaedic maladies,
ally, a significant number of patients strongly considered in patients with
treatment options for the management
with hip microinstability can improve generalized ligamentous laxity or an
of patients with hip microinstability
and return to regular activities without underlying connective tissue disorder
include conservative/nonsurgical and
surgery, just by doing rehabilitation. who are undergoing arthroscopic
surgical options. Unfortunately, little
treatment of labral tears, cartilage
literature exists to guide management
damage, or FAI.6,36,38,39 Wylie re-
of this relatively new diagnosis. Surgical Management ported excellent outcomes in
For those patients who have no symptomatic patients undergoing
Nonsurgical Management improvement in symptoms after an hip capsular plication after failed hip
Initial management of the patient 8- to 12-week course of nonsurgical arthroscopy.34 For those patients
with hip microinstability is based on treatment, surgical intervention may who have capsular defects, open or
modifiable factors. Physical therapy be considered. In cases of notable arthroscopic capsular reconstruction
to strengthen the periarticular mus- bony deformity such as marked ace- should be considered if the defect
cles is of paramount importance— tabular dysplasia or acetabular retro- cannot be closed primarily.31
particularly the iliopsoas, gluteal version, open redirectional osteotomies Arthroscopic techniques to treat
musculature, and the adductors and of the acetabulum and/or proximal hip capsular redundancy and reduce
rotators, in addition to the core femur may be required. In the absence capsular volume include thermal
musculature. Activity modification of such bony abnormalities, much of capsulorrhaphy and suture plication.
to reduce symptomatic activities the literature would suggest that treat- Arthroscopic thermal capsulorrhaphy
should be adopted. Nonsteroidal anti- ment options should focus on the of the hip was first reported by
inflammatory medications can help labrum and/or hip capsuloligamentous Philippon40 in 12 patients with
with the pain, especially in helping the complex. Several techniques have been hip instability. All their patients re-
patient perform the strengthening described to reduce hip capsular volume, ported improvement at 6-week and
activities. No studies published report both by open and arthroscopic 6-month follow-up visits. The hip
the outcomes of nonsurgical manage- approaches, successfully treating atrau- capsular volume was reduced with
ment of hip microinstability, though matic hip microinstability. Although the use of thermal energy causing
the authors’ experience and anecdot- arthroscopy has the advantage of excel- tissue shrinkage. The concern of
Marc R. Safran, MD
chondrolysis and thermal necrosis of traumatic and atraumatic instability. Clin

the capsule led to the development
Summary Sports Med 2011;30:349-367.
and acceptance of arthroscopic hip 2. Tan V, Seldes R, Katz M, et al:

Symptomatic hip microinstability is Contribution of acetabular labrum to
suture capsular plication for the articulating surface area and femoral head
increasingly being recognized as a
management of hip microinstability coverage in adult hip joints: An anatomic
potential cause of pain and disability in study in cadavera. Am J Orthop 2001;30:
due to capsular laxity. Although
young patients. More recent research 809-812.
more technically demanding, this
studies have confirmed the importance 3. Martin H, Savage A, Braly B, et al: The
technique allows control of plication
of the periarticular soft tissues in the function of the hip capsular ligaments: A
tension and can easily be used during quantitative report. Arthroscopy 2008;24:
stability of the hip. The etiology of hip 188-195.
concomitant cartilage, labrum, or
microinstability includes bony abnor-
FAI procedures. Several authors 4. van Arkel RJ, Amis AA, Cobb JP, et al: The
malities, residual laxity after traumatic capsular ligaments provide more hip
have reported success with a variety
dislocation, connective tissue disorders rotational restraint than the acetabular
of arthroscopic suture plication labrum and the ligamentum teres: An
resulting in ligamentous laxity, repeti-
techniques.38,39,41 Larson et al38 experimental study. Bone Joint J 2015;
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Surgery should focus on treatment of orbicularis contribute to hip joint stability
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Review Article
Electrical Injuries of the Hand and

Upper Extremity
Abstract
Donald H. Lee, MD High-voltage electrical injuries are relatively rare injuries that pose
Mihir J. Desai, MD unique challenges to the treating physician, yet the initial management
follows well-established life-saving, trauma- and burn-related principles.
Erich M. Gauger, MD
The upper extremities are involved in most electrical injuries because
they are typically the contact points to the voltage source. The amount of
current that passes through a specific tissue is inversely proportional to
the tissue’s intrinsic resistance with electricity predominantly affecting
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ93;)H-IWJ0[Z*G;:KLV'];+&09/40TK7-M RQ
the skeletal muscle secondary to its large volume in the upper

extremity. Therefore, cutaneous burns often underestimate the true
extent of the injury because most current is through the deep tissues.
From the Department of Emergent surgical exploration is reserved for patients with
Orthopaedics, Vanderbilt University compartment syndrome; otherwise, initial débridement can be delayed
Medical Center, Nashville, TN. for 24 to 48 hours to allow tissue demarcation. Early rehabilitation,
Dr. Lee or an immediate family wound coverage, and delayed deformity reconstruction are important
concepts in treating electrical injuries.
Zimmer Biomet; is a member of a
presentations on behalf of Zimmer
Biomet; serves as a paid consultant to
Zimmer Biomet; and serves as a
committee member of the American
O n August 11, 1938, President
Franklin Delano Roosevelt
traveled to Barnesville, Georgia, to
or even death. The first reported death
secondary to commercially available
electricity was in 1879.2 Over the next
Academy of Orthopaedic Surgeons, speak about the beginning of electrical 100 years, there was an increase in the
the American Orthopaedic
service to rural customers. He stated incidence of fatal and nonfatal elec-
Association, the American Shoulder
and Elbow Surgeons, the American that “Electricity is a modern necessity trical injuries, with 1,157 deaths and
Society for Surgery of the Hand, and of life, not a luxury. That necessity 3% of admissions to major burn units
the Association of Bone and Joint ought to be found in every village, in documented in 1974.2 The percentage
Surgeons. Dr. Desai or an immediate
every home and on every farm in every of admissions to burn units with elec-
family member is a member of a
speakers’ bureau or has made paid part of the United States.”1 Harnessing trical injuries has remained between
presentations on behalf of AxoGen; electrical power and creating a reliable 3% and 5%,3-5 whereas the number of
serves as a paid consultant to distribution network is arguably one deaths secondary to electrical injury
Acumed; and serves as a board
of the most influential advances of has steadily decreased from 432 in
member, owner, officer, or committee
member of the American Society for humankind. It fundamentally altered 2002 to 305 in 2009.6 This phenom-
Surgery of the Hand. Neither how people work and spend their free enon can be partially attributed to the
Dr. Gauger nor any immediate family time. Without electricity, there would founding of the Occupational Safety
member has received anything of
be no fluoroscopy, electrocautery, or and Health Administration and im-
value from or has stock or stock
options held in a commercial company lights in the operating room. Franklin proved safety measures at the work-
or institution related directly or Delano Roosevelt foresaw the trans- place. Regardless of the strides that
indirectly to the subject of this article. formation of electricity from a luxury have been made at the workplace,
J Am Acad Orthop Surg 2019;27: to a necessity. Although there have most electrical injuries that require
e1-e8 been countless positive consequences medical attention are due to high-
DOI: 10.5435/JAAOS-D-17-00833 of the widespread distribution of elec- voltage electric shock from contact
tricity, the inherent energy involved in with commercial electrical power, with
Academy of Orthopaedic Surgeons. transporting it from source to desti- overhead power lines being the leading
nation has the potential to cause injury cause of on the job electrical deaths.7 A
January 1, 2019, Vol 27, No 1 e1
Electrical Injuries
Table 1
Electrical Terminology and Equations
Term Definition Term Definition
Arcing or Electric current that passes along ionized Hertz Unit of frequency for electromagnetic
dielectric gas created by an immense electric field. waves and is defined as one cycle
breakdown Mechanical contact is not required to per second
transfer current to the victim.
Conductor Any object or material that allows the flow Insulator Opposite of a conductor, no flow of
of charged particles. charged particles can occur.
Contact points Wounds sustained from mechanical contact Joule’s law Power (joule) = I2*R. Temperature
with an electric power source. A single skin increase from electric current.
contact point can serve as both entry and
exit points. Abandon usage of entrance
and exit wounds for AC.
Dielectric The field magnitude required for an arc to No-let-go Inability to release grip on an electric
breakdown initiate. Air’s breakdown strength is phenomenon source secondary to the volar
strength 2 million V/m. flexors overpowering the dorsal
extensors with simultaneous
contraction of the forearm muscles.
Electric current The flow of electric charge. Consists of Ohm’s law I = V/R. Current (I) through a
or electricity mobile ions in the human body conductor is proportional to the
(eg, sodium, chloride) driving force (V) and inversely
proportional to the object’s
resistance.
Electric shock Sudden, violent response to electric current Resistance Measure of the difficulty for electric
flow through any part of a person’s body. current to pass through a conductor.
Electrocution Death caused by electric shock. Voltage Potential difference in charge between
two points in an electric field. Driving
force behind electric current.
Electroporation Electrically driven process in which structural
defects ("pores") are formed in the cell’s bilayer
lipid membrane when the transmembrane
potential magnitude is too large.
few reports of MRI-related electrical related to electricity is complex, is a measure of the difficulty for
thermal injury with current induc- making a framework of consistent electric current to pass through a
tion by the pulsed magnetic gradient language essential for communica- conductor and is dependent on the
and/or the radiofrequency field are tion about electrical injuries7 (Table object. An insulator is the opposite
available.8 Although electrical in- 1). At the most basic level, elec- of a conductor in which no flow of
juries are relatively rare, the upper tricity is the flow of electric charge. charged particles can occur. A
extremities are involved in nearly For metallic conductors, this is in perfect insulator does not exist.
every case as the contact point to the the form of electrons, whereas in Instead, insulators are simply ma-
power source.7 Furthermore, elec- aqueous solutions such as the terials that have extremely high
trical burns to the upper extremities human body, electric charge is resistance. All insulators can be
have the highest rate of amputation transported via mobile ions. Elec- conductive if there is a large enough
among all causes of burns and tricity is therefore synonymous voltage. Ohm’s law is an integral
greater resource utilization than with electric current (I). A con- equation to understanding elec-
comparable total body surface area ductor is a term for any object or tricity by specifying the relation-
percentage cutaneous burns.9-11 material that allows the flow of ship between current, voltage, and
charged particles. Voltage (V) is the resistance. The law states that the
Terminology and Equations potential difference in charge current through a conductor is
between two points in an electric proportional to the driving force or
Understanding the concepts, termi- field and is the driving force behind voltage and inversely proportional
nology, and mathematical equations electric current.12 Resistance (R) to the object’s resistance.
e2 Journal of the American Academy of Orthopaedic Surgeons
Donald H. Lee, MD, et al
I 5 V=R Table 2
Electrophysiologic Responses to 60 Hz AC7,13
The resistance is determined by the
innate properties of the object and its Current Response
immediate surroundings, with the 1 mA Barely perceptible
current being the dependent variable 11 mA No-let-go threshold (female)
in the equation. This has important 16 mA No-let-go threshold (male)
implications in electrical injuries. The 20 mA Respiratory muscle paralysis
amount of current is the major com- 100 mA Ventricular fibrillation
ponent determining the physiologic 1,500 mA Nerve and muscle membrane
effects of electricity on the human permeabilization
body, with relatively small currents 2000 mA Cardiac standstill and internal organ
leading to potentially serious effects damage
(Table 2). By increasing the resis-
mA = amps
tance to current flow, the deleterious Common household circuit breaker is 15 to 30 amps.
effects on the human body can be
mitigated.
Electricity and magnetism were uni-
fied into a common theory in the power absorption by water mole- Power ðJouleÞ 5 I2 *R
cules and explain its utility in heating
19th century, with the electromag-
up leftover food. As the frequency
netic spectrum encompassing all
increases toward the visible spectrum
types of radiation or energy that can
(1014 to 1015 Hz), power absorption Pathophysiology and
be propagated as a wave with a par-
begins at the atomic level. Ionizing Patterns of Electrical Injury
ticular frequency. Hertz (Hz) is the
electromagnetic fields greater than
unit of frequency with 1 Hz equal to 1
1015 Hz cause the formation of free Ohm’s and Joule’s laws serve as the
cycle per second. It has been well
radicals.7 Damage in the low fre- foundation for understanding the
established that the most physio-
quency category from 0 Hz (DC) to pathophysiology of electricity on
logically responsive frequencies are
10,000 Hz is due to nonthermal biologic tissue, which in turn is vital
between 50 and 100 Hz.7,14-17
electrical destruction of the cell for recognizing patterns of injury in
Commercial power frequency in membrane potential (ie, electro- patients sustaining high-voltage elec-
the United States is AC at 60 Hz, poration) or thermal forces (ie, Joule tric shock. First of all, high voltage is
which happens to be in the range heating).7 Electroporation is the arbitrarily defined as .1,000 V,
in which heart and skeletal muscle process by which an increased whereas low voltage is ,1,000 V,
are most susceptible. Consequently, transmembrane potentially causes with voltage being the only variable
even low-voltage electrical injury structural defects in the cell mem- that is usually known at the time of
can result in fatal cardiac arrhythmias brane and allows the influx of water injury. What remains unpredictable
or muscular responses including and other solutes that lead to cellular is the amount of current penetrating
the “no-let-go” phenomenon.14-16 damage.18 The larger the cell, the the epidermis, which depends on the
At a threshold current of 16 milli- longer the induced transmembrane resistance and time in contact with
amps (mA), all the muscles in the potential; hence, the reason muscle the electrical lines. More than 99%
forearm simultaneously contract and nerve cells are the most sus- of the body’s resistance to current
with the stronger volar flexor mus- ceptible to this type of cellular flow is at the epidermis.13 The aver-
culature overpowering the extensors, injury.7,19,20 Joule heating is the age skin resistance of the human body
leading to the inability to release the temperature increase from elec- is 40,000 ohms.2 The palmar surface
electrified object. Nearly all cases of tric current and is responsible for of the hand is more resistant than
inability to let go involve AC.13 thermal burns in patients with the dorsum. Conditions at the
There are additional effects of elec- electrical injuries. Heat is generated time of contact can also determine
tricity on the body that are dependent as electricity flows through tissue, the body’s resistance with a cal-
on the frequency. In general, the with the increase in temperature loused palm having resistance up to
smaller the structure, the more it proportional to the current squared 1,000,000 ohms and a wet palm as
is affected at higher frequencies. Mi- and resistance as defined by Joule’s low as 300 ohms.2 Specialized boots,
crowaves (108 to 1011 Hz) lead to law. gloves, and other safety equipment
Electrical Injuries
Figure 1 can cause the victim to be propelled with the external appearance of
away from the source of electricity unharmed tissue in the forearm
by causing involuntary tetanic and arm, the so-called skip lesions
muscle contractions before direct (Figure 3). (3) The highest temper-
contact and/or a thermoacoustic atures were recorded at areas with the
blast due to rapid heating of the smallest cross-sectional diameter such
surrounding air with temperatures as the wrist. (4) Lastly, higher cur-
reaching up to 4,000C.7,12,21 Arcing rent densities were recorded at the
may also be the more common pre- origins and insertions of major
sentation of high-energy electrical in- muscle groups. As noted previously,
juries because eyewitnesses of electric the current and tissue resistance
shock frequently report that the correspond to the extent of Joule
victim is instantly “blown” or heating. Combine this information
“knocked” away.20,21 with primate experiments that dem-
Regardless of the mechanism of onstrate that muscle is the major
current transfer, once the epidermis conducting volume in the body and it
Photograph showing high-voltage
electrical injury with contact point on has broken down, electricity flows is understandable that the thermal
the hand. Local tissue necrosis in the through the body. It can be tempting properties of muscle dominate the
thenar eminence and palmar digital to consider only the cutaneous ther- thermal response.23 The skeletal
crease of the index finger indicate
mal burns because they are the most muscle initially transfers heat to the
the contact point. The full-thickness
epidermal destruction is a tubular obvious manifestation. The external neighboring bone, with the bone
shape consistent with electrical line damage underestimates the true ex- temperature remaining elevated for a
contact and precedes passage of tent of the injury and is one of the greater time causing a reciprocal
current throughout the body. Note
unique attributes of electrical shock heating of the muscle and ongoing
the clenched position of the fingers.
that makes it distinct from the more damage.22,23 Overall, this conglom-
common cutaneous thermal burns eration of findings indicates the
can limit the amount of current (Figure 2). The amount of current a important anatomic areas to con-
transferred by increasing resistance. specific tissue type will encounter sider when evaluating a patient with
At the contact point with the voltage depends on the tissue’s inherent upper extremity electrical injuries.
source, epidermal destruction and resistance, tissue volume, and cur- The pathway of electric current can
thermal damage will eventually occur rent pathway. Cortical bone has the be difficult to determine but tends to
to allow the passage of current greatest resistance to current, fol- correlate with local tissue damage
through the body (Figure 1). Two or lowed by cancellous bone, fat, ten- and has a strong effect on the injuries
more separate contact points suggest don, skin, muscle, vessel, and finally and overall survival. The most dan-
current flow through the body. Entry nerve.2 gerous pathway is parallel to the axis
and exit wounds are not appropriate Daniel et al22 used a primate upper of the body becauase it encompasses
terminology in these circumstances extremity as an experimental model all the organs including the heart,
because the standard 60 Hz alter- and made several clinically pertinent respiratory muscles, and central ner-
nating current changes polarity 120 observations regarding the flow of vous system.18 Current passing from
times per second. electricity and patterns of injury. The hand to hand through the thorax can
Although initially counterintuitive, authors found the following: (1) The have a mortality rate of up to 60%,
electric contact with a power source majority of the current travels through with only a 20% mortality rate for
can happen without any direct contact the largest conducting volume in current passage from leg to leg.12
by the victim. This type of injury is concentrations directly related to the
referred to as arc contact or dielectric cross-sectional diameter with the
breakdown and occurs when the predominant load carried in muscle. Initial Management
electric field strength creates an ion- (2) Greater currents were gener- Considerations
ized gas acting as an excellent con- ated where the composition of the
ductor of electricity with the current limb changes from relatively low- Appropriate medical management
breaking through the air to the vic- resistance muscle to high-resistance for victims of electrical shock starts
tim. Current flow begins at the time of tendon and bone. This helps explain at the injury scene by the first res-
arcing across the air gap. In contrast the damage to skin and muscle at the ponders. Power should be shut off
to the no-let-go phenomenon, arcing wrist, antecubital fossa, and axilla immediately to minimize the duration
of current flow from the source to the Figure 2 Figure 3

victim and to ensure that no one else
can be harmed. For the unresponsive
victim, Advanced Cardiac Life Sup-
port principles should be followed.
There is increased probability of
respiratory arrest and/or cardiac
dysrhythmia or arrest as the duration
of current flow increases. Of interest, Photograph showing extensive
although lung parenchyma usually electrical burns to the upper
remains unaffected, respiratory dys- Photograph showing cutaneous and extremity. The patient sustained
deep tissue injury in a patient bilateral upper extremity injuries. The
function secondary to the combined contralateral side is included in
sustaining upper extremity high-
effects of tetanic paralysis of respira- voltage electrical contact. The Figure 1. The small surface area of
tory muscles and damage to centers in patient presented with signs of the wrist combined with high-
the brain is common.12 In addition, compartment syndrome resistance tissues leads to focal
necessitating forearm fasciotomies heating and tissue destruction.
the victim should be assessed as a Although fasciotomies have already
and carpal tunnel release. The mid to
trauma patient, initiating standard distal volar forearm musculature is been performed, there is an area of
Advanced Trauma Life Support dusky and unhealthy appearing, healthy-appearing skin proximal to
protocols, because approximately indicative of current passage through the wrist with full-thickness skin
the deep tissue with involvement of necrosis in the proximal arm and
15% of electrical burn patients have axilla. This is an example of “skip
the muscle, highlighting one of the
other traumatic injuries caused by hallmarks of electrical injuries. Most lesions.”
falling from a height, violent te- soft tissue remained viable, and the
tanic muscle contractions, or being extremity was salvageable with
propelled away from the voltage repeat débridement and soft-tissue electric shock. It has been well estab-
coverage.
source.12,18 lished that patients with electrical
The presence of cutaneous thermal injury can have dysrhythmias, with
burns and deep tissue injury, particu- especially in the presence of gross atrial fibrillation being the most
larly to skeletal muscle, mandates hematuria, the recommended uri- common.9 All patients with electrical
aggressive fluid resuscitation. The nary output increases to 1 to injuries should have an ECG with 24
Parkland formula has limited utility in 2 mL21kg21hr, with some authors to 48 hours of cardiac monitoring
managing fluid resuscitation in pa- proposing the use of mannitol 12.5 recommended in the following cir-
tients with electrical injuries because to 25 g intravenous push for cumstances: (1) ECG abnormality, (2)
it is meant to establish the volume osmotic dieresis and two ampules cardiac dysrhythmia during transport
requirement for cutaneous burns and of sodium bicarbonate to alkalinize or in the emergency department, (3)
does not account for damage to deep the urine.18,19 documented cardiac arrest, (4) loss of
tissues. Patients with electrical burns The heart is a large muscle with its consciousness, and (5) patients with
will require more fluid than estimated own electrical conducting system that other standard indications.9,11,18,28
by the Parkland formula. Urinary is susceptible to electric shock by pro- Arrowsmith et al11 reported that all
output is considered the benchmark ducing direct myocardial damage or cardiac irregularities were present in
by most authors for adequate resus- inducing dysrhythmias or cardiac the emergency department or within
citation, with the recommendation of arrest. The resultant trauma to the several hours of hospitalization.
0.5 mL21kg21hr in a patient with myocardium is not the same as a true The overwhelming majority of pa-
normal vital signs without gross uri- myocardial infarction. Without any tients presenting with electric shock
nary pigmentation.18 Myoglobinuria- associated electrocardiogram (ECG) have involvement of the upper ex-
induced acute renal failure is one changes, no reliable correlation exists tremity, and a high index of suspicion
of the potential consequences of the between cardiac enzyme levels (eg, should exist for compartment syn-
predilection for electricity to damage creatine kinase muscle-brain, troponin drome. All patients should be closely
skeletal muscle. Although up to 70% and cardiac injury.9,18 It has been evaluated on arrival with serial ex-
of patients with electric injuries have proposed that elevated creatine kinase aminations if any concerns exist
evidence of myoglobinuria, hemodi- muscle-brain levels are most likely because tight compartments may
alysis is rarely necessary with ade- secondary to noncardiac muscle develop over the first 48 hours with
quate fluid resuscitation.24,25 If injury9,26,27 and should not be used to third-space fluid losses and ongoing
myoglobin is detected in the urine, detect cardiac injury in the setting of tissue damage.18 Unlike thermal
Electrical Injuries
burns that cause compression through cover the median nerve. If necessary, degree of damage sustained can, and
burn eschar and are treated with es- the incision can be extended should, be only a nebulous conjec-
charotomy, deep tissue necrosis and obliquely across the wrist to in- ture. Despite this statement, many
edema lead to increased compart- clude a carpal tunnel and a Guyon authors recommended immediate
mental pressure and can only be canal release. The extensor com- surgical débridement and compart-
successfully treated with formal fas- partment incision dorsally is more ment release in patients with upper
ciotomies. Compartment syndrome straightforward and begins 2 cm extremity electrical injuries.25,31-34
remains a clinical diagnosis with pain distal and 1 to 2 cm lateral to the This was the modus operandi for
on passive stretch and out of pro- lateral epicondyle, extending distally numerous years with the theory that
portion to the examination as the 8 to 10 cm toward the midline of the urgent decompression and débride-
quintessential signs. Diminished sen- wrist.18 A third incision on the ulnar ment would limit secondary tissue
sation, paralysis, and pulselessness aspect of the forearm may be needed loss.25 Amputation rates for upper
are late findings and may indicate a for electrical burns.3 Although recent extremity electrical injuries are typi-
missed compartment syndrome or studies suggest that a minimally in- cally reported between 35% and
primary neurovascular injury. In an vasive volar incision may be sufficient 40%18,34 (Figure 4). No evidence
unresponsive patient, taut and for forearm compartment release with exists that immediate surgical de-
incompressible compartments war- less morbidity and wound complica- compression reduces the need for
rant determination of compartment tions,3 it should not be attempted at amputation in any series and pa-
pressures. Standard diagnostic crite- the expense of an adequate release. tients who undergo their initial op-
ria include compartment pressure The release of hand compartments can eration after resuscitation require
greater than 30 mm Hg and a diabe accomplished through four strate- fewer surgeries than patients who are
stolic pressure–compartment pressure gically placed incisions. Two dorsal decompressed within 24 hours.18,25
difference of less than 30 mm Hg. incisions address the dorsal and pal- Currently, the severity of the injury
Emergent surgical intervention is mar interossei and are made in line and not the timing of surgical
mandatory for patients diagnosed with the second and fourth meta- débridement and decompression is
with compartment syndrome. carpals. The remaining two incisions the main factor in the necessity for
Detailed knowledge of the upper originate at the junction of the gla- amputation and the overall num-
extremity compartments and anat- brous and nonglabrous skin of the ber of surgeries. An evidence-based
omy is vital for complete release of thenar and hypothenar eminence. The guideline article provided four in-
the fascia and to avoid injury to cru- adductor pollicis is released through dications for immediate surgical man-
cial structures. The forearm has 4 the second metacarpal dorsal incision. agement with the recommendation for
compartments (ie, superficial volar, Along with release of the tight inpatients who do not meet the criteria
deep volar, dorsal, and mobile wad) vesting fascia, escharotomy should be being débrided on the 3rd to 5th
that can be addressed with two in- performed in the presence of circum- postinjury day9,18 (Table 3).
cisions, whereas there are 10 com- ferential burns. After the initial débridement, the
partments in the hand (ie, 4 dorsal patient should return to the oper-
interossei, 3 palmar interossei, the- ating room every 24 to 48 hours for
nar, hypothenar, and adductor pol- Surgical Treatment reassessment of tissue viability and
licis) that can be approached with repeat débridement. Serial débride-
four incisions. The forearm volar Surgical management in patients with ment should continue until only
incision should begin ulnar and end electrical injuries can be divided into healthy tissue remains, which can
ulnar with an intervening lazy S 3 phases: initial (ie, immediate to 48 be a greater challenge than previously
design. The incision starts 1 to 2 cm hours), maintenance (ie, 48 hours to thought. Sassoon et al35 recently
proximal to the medial epicondyle 3 months), and reconstruction (ie, evaluated the surgeon’s ability to
and curves radial toward the mobile 3 months to 3 years).29 The initial identify viable muscle using the four
wad reaching the midline of the phase was described in the previous C’s (ie, color, consistency, capacity
forearm at the junction of the middle section and focuses on resuscitation, to bleed, and contractility) during
and distal thirds of the forearm.3,18 stabilization, and recognition of in- débridement by comparing their
The incision then curves back to the juries requiring emergent surgical assessment with histopathologic
ulnar side of the palmaris longus at treatment. Lewis30 stated in 1958 specimens. Unfortunately, the sur-
the wrist to avoid injury to the pal- that in the early phase of any type of geon’s impression using the four C’s
mar cutaneous branch of the median electrical injury, any immediate de- differed from the histopathologic
nerve and allow a flap of tissue to terminations or predictions of the appearance in 72% of the specimens.
Figure 4 Table 3
Indications for Immediate Surgery9,18
1) Progressive neurologic dysfunction
2) Vascular compromise
3) Increased compartment pressure, compartment syndrome
4) Systemic clinical deterioration from suspected ongoing myonecrosis
Photograph showing the right upper dures required or hospital length of sion, maximal thumb palmar abduc-
extremity in a nonsalvageable stay.18,19,36 Overall, the available tion, metacarpal-phalangeal joint in
electrical injury requiring
transhumeral amputation. The diagnostic adjuncts are rarely used and 60 to 90 of flexion, and interpha-
patient had viable forearm epidermis add little, if anything, to the evaluation langeal joints in extension.4,29,40 Future
that was brought proximal for wound of a patient with electrical injuries. reconstructive surgeries can be limited
coverage. After adequate After all devitalized tissue is excised, with appropriate therapy and judicious
débridement and removal of necrotic
tissue, the proximal lateral arm still the resultant soft-tissue defect must be splinting. The last phase of manage-
required additional procedures of covered with healthy tissue. A multi- ment of electrical injuries is recon-
soft-tissue coverage emphasizing tude of options exist for wound cov- struction, which focuses on restoring
that the level of amputation should erage from simple (ie, direct closure) to sensory and motor function and can
be carefully considered to balance
the length of the extremity with the complex (ie, microvascular free tissue last up to several years.29 Hetero-
viability of the remaining soft tissue. transfer). The reconstructive elevator topic ossification is an additional late
emphasizes choosing the most appro- consequence of electrical injury that
priate method for wound coverage may require surgical management.
A distinct possibility exists that and not the least complex.37 For The methods of reconstruction are
surgeons are removing viable tissue example, exposed tendon, bone, outside the scope of this review but
with early, aggressive excision. Instead, and/or neurovascular structures may can involve nerve or tendon grafting
questionable tissue should be pre- be more optimally treated with free or transfer, additional free tissue
served and reassessed during subse- tissue transfer. Thus, it is important transfer, tenolysis, and scar revision.
quent débridements because injured to keep in mind that the success rate
tissue evolves rapidly. The longitudi- for free flaps in electrically injured
nal white structures in continuity patients is lower than that for pa- Summary
(eg, tendons, nerves) and bone with tients without an electrical injury,
attached soft tissues should also be potentially because of the propensity High-voltage electrical injuries are
retained. for microvascular thrombosis.34 rare yet potentially devastating
In light of the surgeon’s inherent Timing of wound coverage must also injuries that predominantly affect
fallibility in determining muscle via- be considered and should not be done young working class males and are a
bility, it would seem that there is a role prematurely. Ofer et al38 reported a major source of morbidity and mor-
for diagnostic adjuncts to aid in iden- 15% flap failure rate in electrically tality with significant socioeconomic
tifying nonviable deep tissue. Several injured patients and noted that all the effect. A firm grasp on the terminol-
modalities have been studied, includ- failures occurred within 5 to 21 days ogy and equations is a requisite for a
ing MRI with or without gadolinium after the initial trauma. Proponents better understanding of the patho-
and radionuclide scanning with exist for radical débridement, free physiologic effects of current flow
xenon-133 or technetium pyro- flap coverage, and immediate recon- through the body and clinical pat-
phosphate. MRI can detect tissue struction of the upper extremity terns of electrical injuries. Initial
edema secondary to cell membrane within 24 hours of an injury.39 In management relies on trauma, burn,
damage with the drawback of poor certain circumstances, this tactic may and life-saving protocols. The patient
sensitivity in areas with compromised be beneficial but is not advocated in should be taken emergently to the
perfusion.19 Gadolinium-enhanced patients with electrical injuries. operating room in the setting of com-
MRI improves the accuracy in During the maintenance phase, it is partment syndrome. Other organ
zones of tissue edema. Radionuclide critical to prevent joint contractures systems can be affected by electrical
scans have been shown to predict the and stiffness with a combination of injury, particularly the heart and
extent of soft-tissue damage but did therapeutic exercises and splinting kidneys, and should be evaluated in
not change the number of proce- with the wrist in 10 to 30 of exten- all patients presenting to the
Electrical Injuries
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Myocardial injury after electrical burns: Short
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Electrical injury and the frequency of injuries: A 20-year review. J Burn Care
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29. Sharma K, Bichanich M, Moore AM: A 3-
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13. Fish RM, Geddes LA: Conduction of 30. Lewis GK: Electrical burns of the upper
electrical current to and through the human extremities. J Bone Joint Surg Am 1958;40-
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14. Dalziel CF: Effect of frequency on let-go 31. d’Amato TA, Kaplan IB, Britt LD: High-
Evidence-based Medicine: Levels of currents. Trans Am Inst Electr Eng 1943; voltage electrical injury: A role for
evidence are described in the table of 62:745-750. mandatory exploration of deep muscle
compartments. J Natl Med Assoc 1994;86:
contents. In this article, reference 35 is a 15. Dalziel CF: Threshold 60-cycle fibrillating 535-537.
level II study. References 10 and 36 are currents. AIEE Transactions III (Power
Apparatus and Systems) 1960;79:667-673. 32. Achauer B, Applebaum R, Vander Kam
level III studies. References 2, 11, 24- VM: Electrical burn injury to the upper
34, and 38 are level IV studies. Refer- 16. Dalziel CF, Lee WR: Lethal electric extremity. Br J Plast Surg 1994;47:
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ences 1, 3-9, 12-23, 37, 39, and 40 are
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Thresholds and biophysical mechanisms. PW, Miller SH: Aggressive approach to the
Ann N Y Acad Sci 1994;720:21-37. extremity damaged by electric current. Am J
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18. Arnoldo BD, Purdue GF: The diagnosis and Surg 1985;150:78-82.
those published within the past 5 years.
management of electrical injuries. Hand 34. Pannucci CJ, Osborne NH, Jaber RM,
1. Roosevelt FD: Address at Barnesville, Clin 2009;25:469-479. Cederna PS, Wahl WL: Early fasciotomy in
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19. Sanford A, Gamelli RL: Lightning and
presidency.ucsb.edu/ws/?pid=15520. injury severity and deep venous thrombosis
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Accessed September 12, 2017. risk: An analysis of the national burn
120:981-986.
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with special reference to the upper
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extremity electrical trauma. Hand Clin 35. Sassoon A, Riehl J, Rich A, et al: Muscle
Surg 1977;134:95-101. viability revisited: Are we removing normal
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3. Friedstat J, Brown DA, Levi B: Chemical, muscle? A critical evaluation of dogmatic
electrical, and radiation injuries. Clin Plast 21. Edlich RF, Farinholt HM, Winters KL, Britt debridement. J Orthop Trauma 2016;30:
Surg 2017;44:657-669. LD, Long WB III: Modern concepts of 17-21.
treatment and prevention of electrical
4. Yakuboff KP, Kurtzman LC, Stern PJ: burns. J Long Term Eff Med Implants 36. Hammond J, Ward CG: The use
Acute management of thermal and 2005;15:511-532. of Technetium-99 pyrophosphate
electrical burns of the upper extremity. scanning in management of high voltage
Orthop Clin North Am 1992;23:161-169. 22. Daniel RK, Ballard PA, Heroux P, Zelt RG, electrical injuries. Am Surg 1994;60:
Howard CR: High-voltage electrical injury: 886-888.
5. American Burn Association: Burn Incidence Acute pathophysiology. J Hand Surg Am
and Treatment in the United States: 2016. 1988;13:44-49. 37. Janis JE, Kwon RK, Attinger CE: The new
Available at: http://ameriburn.org/who- reconstructive ladder: Modifications to the
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Accessed September 12, 2017. in electrical trauma. J Biomech Eng 1992; 2011;127(Suppl 1):205S-212S.
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6. Hnatov MV: Electrocutions associated with 38. Ofer N, Baumeister S, Megerle K, Germann G,
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Review Article
Translating Orthopaedic
Technologies Into Clinical Practice:
Challenges and Solutions
Abstract
Suzanne A. Maher, PhD Despite the wealth of innovation in the orthopaedic sciences, few
Richard Kyle, MD technologies translate to clinical use. By way of a 2-day symposium
titled “AAOS/ORS Translating Orthopaedic Technologies into
Bernard F. Morrey, MD
Clinical Practice: Pathways from Novel Idea to Improvements in
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ939:(MWLN4S9+\JY5KLD7820<6TJV0*YE%56)D16=0 RQ
Michael J. Yaszemski, MD, PhD Standard of Care Research Symposium,” key components of
successful commercialization strategies were identified as a
passionate entrepreneur working on a concept aimed at improving
patient outcomes and decreasing the cost and burden of disease; a
de-risking strategy that has due recognition of the regulatory
approval process and associated costs while maximizing the use of
institutional, state, and federal resources; and a well thought-out
and prepared legal plan and high quality, protected intellectual
property. Challenges were identified as a lack of education on the
scale-up and commercialization processes; few opportunities to
network, get feedback, and obtain funding for early stage ideas;
disconnect between the intellectual property and the business
model; and poor adoption of new technologies caused in part by un-
optimized clinical trials. By leveraging the network of professional
orthopaedic societies, there exists an opportunity to create an
enlightened community of musculoskeletal entrepreneurs who are
positioned to develop and commercialize technologies and
transform patient care.
From the Department of

D espite the wealth of innovation
in the orthopaedic sciences, few
technologies translate to clinical use.
this manuscript is to summarize that
meeting.
Biomechanics, Hospital for Special
Surgery, New York, NY (Dr. Maher), By way of a 2-day symposium, titled
Clinical Translation of
Hennepin County Medical Center, “AAOS/ORS Translating Ortho-
Minneapolis, MN (Dr. Kyle), and the Technologies in
paedic Technologies into Clinical
Mayo Clinic, Rochester, MN
Practice: Pathways from Novel Idea
Orthopaedics
(Dr. Morrey and Dr. Yaszemski),
and the University of Texas to Improvements in Standard of
Health Research, San Antonio, TX Care Research Symposium,” key Clinical Need for Innovative
(Dr. Morrey). stakeholders including orthopaedic Solutions
J Am Acad Orthop Surg 2019;27: surgeons, engineers, entrepreneurs, The economic burden of musculo-
e9-e16 patent attorneys, technology transfer skeletal injuries and degeneration is
DOI: 10.5435/JAAOS-D-17-00851 officers, and investors, identified key staggering, exceeding $874 billion in
components of successful commer- the United states alone and equivalent
Academy of Orthopaedic Surgeons. cialization strategies, specific to the to 4.9% of the gross domestic prod-
field of orthopaedics. The purpose of uct.1 Musculoskeletal problems are
Translating Orthopaedic Technologies Into Clinical Practice
Figure 1 Emerging Educational and

Mentoring Opportunities
There exist benefits and challenges to
working with established orthopaedic
industries versus running a life sciences
start-up company in terms of effort,
time, risk, control, monetary needs and
rewards, motivation, and exit strate-
gies (Figure 2). Fifty percent of start-up
companies fail within 4 years for
reasons that include underestimating
the time and cost of commercializa-
tion, particularly that required to
implement a robust plan to achieve
Worldwide Medtech Sales Forecast to reach $521.9 billion by 2022. Orthopaedics regulatory clearance, and the need
has estimated the sales growth of 14% and 8.5% of worldwide market sales. to focus on technologies that can
CAGR = Compound Annual Growth Rate (Reproduced with permission from
improve clinical outcomes.10-13 The
EvaluateMedTech World Preview 2017, Outlook to 2022 Evaluate Ltd.)
single most important reality at this
stage is whether the intellectual prop-
the leading cause of disability and ship is increasing,4,5 as is the impact of erty (IP) is a true “game changer” with
account for more than half of all physician driven innovations for clin- real value or a “cosmetic change.” To
chronic conditions in people older ical care.6 And yet, if not properly educate physicians and scientists on
than 50 years.2 While steady ad- organized and executed, even the best these issues and to expose them to the
vances are being made in under- and most innovative advances run importance of IP protection at the
standing the mechanisms that drive the risk of never being applied to earliest stages of ideation,14,15 educa-
the development and progression of patient care. Before embarking on a tional initiatives and infrastructure
these debilitating diseases, mecha- commercialization/entrepreneurial investments specific to the transla-
nisms to translate new findings into pathway, individuals must be armed tion of research to clinical care are
improved clinical care are opaque with sufficient information to enable emerging. Universities are creating
and time-consuming. As the world them to assess if they have the time, new curricula and infrastructure to
population ages, and the need for knowledge, and passion for such support entrepreneurship.8 Aside from
medical therapeutics grows, Figure 1, endeavors.7 Formal programs aimed didactic lectures and team-building
improving patient outcomes and at educating medical students about programs, Bedside-to-Bench-and-Back
decreasing the financial burden of commercialization of new technolo- programs are also emerging across
disease are essential features of any gies are emerging,8 but widespread the country, helped in large part by
future clinically relevant technologi- adoption, particularly in orthopae- the growing realization that the bar-
cal innovation.3
dics, is lacking and largely absent riers between basic and clinical re-
from resident/fellowship training searchers are hurting innovation, and
The Role of the Physician programs. This deficit causes ortho- by the opportunity to use federal
Physicians are in a unique position to paedic entrepreneurs to face uncer- funding to bridge those barriers
realistically assess the risk and oppor- tain pathways to commercialization (https://www.cc.nih.gov/ccc/btb/).
tunities and provide insights into tech- that can dampen enthusiasm and These programs provide a forum for
nological advances aimed at improving lead to costly mistakes and delays in interested parties to create entrepre-
patient care.3 Physician entrepreneur- their innovation directed endeavors. neurial teams consisting of medical
Dr. Maher or an immediate family member has stock or stock options held in AGelity Biomechanics and Hydro-Gen and serves as a board
member, owner, officer, or committee member of the Orthopaedic Research Society. Dr. Kyle or an immediate family member has received
royalties from DJ Orthopaedics and Exactech and serves as a board member, owner, officer, or committee member of the Hennepin Health
Foundation, the Orthopaedic Research and Education Foundation, and Excelen. Dr. Morrey or an immediate family member has received
royalties from Small Bone Innovations and Zimmer Biomet; is a member of a speakers’ bureau or has made paid presentations on behalf of
Stryker and Zimmer Biomet; is an employee of Tenex Health; serves as a paid consultant to Zimmer Biomet; and has stock or stock options held in
Tenex Health. Dr. Yaszemski or an immediate family member serves as a paid consultant to K2M, Medtronic and serves as a board member,
owner, officer, or committee member of the American Academy of Orthopaedic Surgeons and the Society of Military Orthopaedic Surgeons.
Suzanne A. Maher, PhD, et al
students, engineering students, busi- Figure 2

ness students, and law students,
who form start-up companies, and
who have already shown signs of
success.9 A number of classes/support
and educational resources are also
available to our field (eg, I-Corps,
LaunchPad Initiative, and E-lab).
Educating surgeons at all stages of
their careers about commercialization
pathways/entrepreneurship can have a
real and immediate impact on how
surgeons view translational opportu-
nities. Algorithms for commercial-
ization of ideas range from the
complex,25 where multiple pathways
to “exit” depend on the idea, team,
funding sources, and overall strategy
of the investors and their partners
(Figure 2), to more streamlined
approaches (https://marketing-in
sider.eu/marketing-explained/part-
iii-designing-a-customer-driven-mar
keting-strategy-and-mix/new-product-
development-process/).
Stages that technology development can go through that illustrates different exit
points. The monetary value of the idea/product increases, while the degree of
Key Components of control of the inventor can decrease as new management comes on board or as
the product is licensed. Funding sources are highlighted in white boxes and can
Successful vary depending on the stage of the technology and the development pathway
Commercialization that is chosen.
Strategies
sense of realism and self-questioning metrics that determine how commer-
Concepts With Due is needed. What is the soundness of cial entities are paid is changing.
Consideration of Market the business model and are the con- Industry is being graded on outcomes
Forces siderations being adequately con- and paid accordingly. This reality has
Knowing the burden of disease and sidered and addressed? Is there a put pressure on companies to either
the impact that your solution could product here that people will buy? cut costs or improve outcomes, and as
have is considered a requisite. In- Will people pay for your product such, innovations should focus on
ventors should consider the following and what benefit will they achieve? these goals. Excess and obsolescence
questions: Does your invention solve What are the challenges for reim- are key issues; revenue is only gener-
the problem or define it better? Is bursement for the product and reg- ated from boxes that are opened.
your technology “new” or is it just ulatory (US FDA) approval? What Innovation around the supply chain is
packaged as new? There is a need to do consumers pay for competing critical. If instruments are changed,
realize that as an inventor, you can products? Will your product affect for example, everything associated
fall in love with your own idea, but bundled payments? with the original instrument needs to
you need to be realistic on what Industry is more open than ever to be recalled at considerable cost. A
others think. Before deciding what pursuing creative ways to work with golden rule is that any new technology
pathway to move your invention start-up companies, while considering should improve clinical outcomes,
through, evaluating your idea with them as potential acquisition oppor- improve efficiencies, and reduce
others through pitching events and tunities, from following technology waste. Therefore as technology is
in-person interviews with customers development efforts, to buying IP developed, an awareness of barriers to
will provide useful information. A outright, to acquisition. However, the entry to the marketplace and how
January 1, 2019, Vol 27, No 1 e11
those barriers can be overcome (time University/Medical Center? Knowl- but time-consuming; they can take
and effort) is required. edge of these arrangements is critical several months to write and to obtain
so that agreements are structured all necessary registrations, and
People appropriately. 6 months before reviews are complete
and money is made available. (2)
Leader/Quarterback Strategic partners (angel investors,
In deciding to form a company, suc- De-risking Technology in a friends/family, venture capital [VC]
cess will, in large part, be dictated by Logical Way and Funding the funds) can provide grants and in-
the passion and single-mindedness of Associated Costs vestments, in return for future mon-
the inventor, her/his clarity of vision, If your technology is successfully etary rights that are typically a
and a sense of realization that his/her licensed, the discussion of de-risking multiple of the original investment.20
idea/product will evolve, as will the technology will largely take As such, in courting strategic part-
his/her role. Consider your person- place within the walls of the licensee. ners, the planned exit is critical. Angel
ality and motivation: Do you want to From the point of view of a start-up investors are accredited by the gov-
become an entrepreneur? If you are company, a list of questions must ernment and invest their own money,
a physician entrepreneur, you have be addressed throughout the de- typically in early stage companies, in
a Fiduciary Duty to your patient: a risking process: Can your product fields for which they oftentimes have
duty of loyalty (to avoid conflict of be manufactured/packaged/sterilized personal experience or connections.
interest and to act in patients’ best with sufficient shelf life19? Can your The value of angel investments can
interest) and a duty of care to pro- product be manufactured/supplied range $15K to $150K, but in the life
vide clarity (to be objective and to act at a cost to you that is consistent sciences, investments can be as high
rationally), and as such, your entre- with a sufficient margin for profit? In as $500K, while syndicates can invest
preneurial activities cannot conflict the case of software, is your code as high as $5M. By accepting an
with these pillars of responsibility.16 protected/Health Insurance Portabil- investment from an angel, you can
Will you inspire your team to achieve ity and Accountability Act (HIPAA) expect to give up 20% to 40% of
success17? If an academic decides compliant, can it be copied or mim- your company’s equity, oftentimes
to pursue orthopaedic innovation, icked? The FDA should be viewed as without any requirement to change
a surgeon champion is critical. Al- your partner. The regulatory classi- management. VC funds typically
though characteristics like directed fication of your product, the time to have a fixed life (10 years) and
aggressiveness play a role, a relentless approval, and the cost of approval in invest people’s money in late-stage
sprit, self-control, and an apprecia- the United states and/or overseas investor funding rounds.21 The role
tion for the team around you will help must be planned and appreciated. of VCs is to manage and invest a fund
ensure your success, while ensuring De-risking your technology is a so that clients get a good return on
life balance.18 step-wise process. With each step, the investment. Funding ranges are typi-
value of your idea/company will cally $30M, in return for upward of
Your Team increase, but as you secure funding, 50% ownership and a seat on the
The nucleus of innovation can come your percent ownership will decrease company’s board. VCs can, and will,
from preclinical research and/or from (you will own a smaller portion of a change management as needed and
point-of-care experience. But it is the larger “pie;” Figure 3). Sufficient will ask the following questions:
synergy of vested individuals from funding is of paramount importance, What is the ease of entry into the
these disparate fields who can merge and insufficient capitalization is one of space for your technology? What are
with business to drive projects the most common causes of a failed your management skills, people skills,
toward commercialization. Thus, the effort to commercialize. Sources of time availability, and commitment?
value of working with a team that you funding come in many forms: (1) Who are your competitors? Who are
trust and enjoy working with cannot Grants do not dilute your company you working with? What is your exit
be understated. Each member should (ie, you do not have to assign own- strategy? From your perspective, you
have clearly defined roles and a plan ership of your company to the need to consider if you really want to
in place for conflict resolution. Your awarding entity), but grants help work with a particular VC, as the
team is particularly important when to “credentialize” your technology relationship will last a long time and
working with academic centers. through the thorough review that you lose a great deal of control over
What contributions can the team grants receive (https://sbir.nih.gov/). decision-making. Beware of covenants
members provide and how is their Federal grants are highly competitive that are imposed with an influx of
contribution considered by their and, as such, highly prestigious, capital because this is one of the means
whereby capitalization can result in Figure 3

loss of control of the company.
Iron-clad Legalities
There is a need for all inventors/
entrepreneurs to read and understand
their employment policy, and to use an
attorney, as needed, to clarify what can
and cannot be done according to that
agreement. Recognizing that your
home institution has a claim to what
you know and leveraging this claim
can help you garner institutional sup-
port for your efforts. Indeed, keeping
ideas at your institution for as long as
possible can help you to maximize the
benefit from research grants that help
to de-risk your technology22 without
sacrificing equity.
Ideas can be accidentally divulged,
and it might then be difficult to prove
that the idea originated with you. At A graphical representation of how ownership of the idea/product/technology
all times, communication should be changes with each step in the de-risking process. In this illustration, the size of
circle equates to the value of the concept/company. The ideation phase can lead
controlled by labeling everything as
to intellectual property (IP) and possibly the issue of a patent. If the patent
confidential, emailing participants to prosecution costs are covered by your institution, they will use their Institutional
summarize the minutes of meetings, Royalty Sharing Policy to prescribe a dividend of any financial reward from that
and ensuring that you have arranged IP. If the IP is licensed to an established company and starts generating revenue,
a proportion of the income, as per the agreement with the licensee, will be
appropriate legal protection for your
divided accordingly. If the IP is licensed to a start-up company, the institution will
ideas. Indeed, the importance of pro- typically take an equity share (percent ownership of the company) and an
tecting ideas using patents cannot be agreement for sharing any revenue from sales. As investors are brought on
overstated. Provisional patents are board to enable you to continue to de-risk your technology, you will assign a
portion of the ownership of your company to those investors.
relatively inexpensive to submit to the
US patent office. Provisionals provide
12 months of protection to allow you become involved, all patents must their career, and throughout career
to generate data to support your key be in place. The FDA meeting, for development, about commerciali-
concepts and to find potential licensees example, is a public meeting, and zation pathways and to help them
before deciding if a full and more you cannot withhold information to connect with like-minded mentors.
costly patent is worth pursuing. Many from the FDA. In this manner, they can arm them-
inventors work under the principal of selves with the tools needed to
“file early and file often” to ensure that navigate the commercialization path-
all ideas are appropriately protected.
Challenges Specific to Our way, specifically on the following
The need to protect information Field topics:
should be balanced by the requirement 1. Ethical considerations of bal-
to share information to garner interest Education and Mentoring ancing multiple roles
in your technology. For initial meet- The lack of direct mentorship on com- 2. Business acumen in terms of
ings with industry/investors, confi- mercialization strategies from senior equity sharing, dilution, inves-
dentiality agreements may not be orthopaedic surgeon-entrepreneurs, tor profiling, and team building
needed because the goal of the first who have track records on this topic, 3. Terms of employee contracts
meeting is ultimately to generate directly and negatively impacts our and institutional commitment
enough interest so that you can have a progress in this arena. There exists as related to IP.
second meeting. As your technology a need to educate/expose orthopae- A forum for sharing ideas and
matures, and regulatory bodies dic residents and fellows, early in mentorship and for liaising with
January 1, 2019, Vol 27, No 1 e13
investors is necessary. Such gather- versities are also providing more direct house prior-art reviews. Mayo Clinic
ings not only will allow entrepreneurs access to business schools, pitch ses- Ventures, for example, has a range
to get feedback on their direction/ideas sions, and technology transfer offices of programs to maximize commer-
but also will allow for the growth of a that help to vet ideas in a more thor- cial viability and value by way of
community that has a vested interest in ough way than was ever possible before. seed funding opportunities at all
funding and nurturing the next genera- stages of development, ranging from
tion of entrepreneurs. As such, surgeons early stage proof-of-concept/clinical
Private practice
will be empowered to grow careers trials (Venture Innovation Program
Surgeons in private practice are en-
where their entrepreneurial roles are and Discovery Translation Program)
couraged to find a collaborator so that
allowed, encouraged, and supported. to late-stage VC funding. The
they are not isolated and have access to
ability of an institution to support
university resources. Advantages to
Networking and Fund-raising entrepreneurial/commercialization ef-
being in private practice include more
forts varies widely. The contributions
The mean cost for commercializing control over your IP. However, this
provided by the institution (eg, engi-
new musculoskeletal technology is control must be balanced with the need
neering support, legal support, and
$30 to $40 million. Increased expo- to have robust advice contracts using
market analysis), or lack thereof,
sure to angel investors, venture capi- legal counsel that you must find and
should help to drive the fiscal and
talists, and alternate funding sources pay for yourself. Private practice
contractual agreements for equity
and a better understanding of when surgeons are encouraged to seek in-
sharing in accordance with the
and how to approach these entities cubators and state-funded resources
amount of resources provided by the
are needed. At different stages of and in particular to reach out to state-
institution to advance the effort.
technology development, there is a funded schools, which often have a
need/opportunity to build relation- mandate to support local innovators.
ships at all levels, while strategizing Adoption of Technologies
for an exit either in partnership with
Academic Models The rapidity by which a truly useful
industry or a start-up company that
There currently exists no platform for innovation is adopted is surprising,
you subsequently sell (Figure 2). The
different institutions to learn from each often taking twice as long as antici-
process of pitching an idea is not
other about systems that worked and pated. Robust and meaningful clini-
trivial; it is critical to securing interest
approaches that failed. Instead, the cal data are critical, both from the
in your technology, publicity, net-
institutional “formula” to encourage point of view of obtaining regulatory
working opportunities, and ulti-
commercialization is driven by the approval and for adoption strategies
mately, investments. More directed
individuals at any given institution as such barriers to adoption should
feedback about how to pitch, how to
and as such is highly variable. This be strongly in focus when a clinical
assess market share, and how to
variability extends to the sharing study is being designed. The follow-
position your company for funding by
program for the individual bringing ing processes are at the forefront:
way of large-scale commercialization-
forth the IP and the academic institu- plan for dissemination of the data
centric meetings is needed.
tion. Many institutions have relatively generated before starting the study,
newly formed venture arms: Hospital include important stakeholders
Culture and Eco- for Special Surgery Innovation Center such as patients and payers, and
environment (founded in 2016), Yale Center involve well-regarded experts to
The importance of the institutional/ for Biotechnology and Innovation ensure the independence of evalua-
university culture and the city/state (founded in 2014), Pittsburgh Inno- tion of outcomes. Measure meaning-
culture toward nurturing and sup- vation Institute (founded in 2014), ful outcomes, consider the impact of
porting entrepreneurship was re- and Mayo Clinic Ventures (founded follow-up time, measure costs and
peatedly identified. The wealth of in 1986). Common activities across cost-effectiveness, and address issues
resources available to fund start-up institutions include “pitch” nights of implementation up front. The use
companies at the federal, state, and (where inventors/entrepreneurs can of multi-center trials and follow-up
city level is growing nationwide, make a high level presentation to get studies is a challenging but powerful
with tax breaks, low-cost rent feedback and generate interest in way to study the effectiveness of
space, and networking opportunities their ideas), helping to catalyze technologies.23,24 Challenges include
(eg, http://pfnyc.org/our-investments/). teams, creating infrastructure for inadequate sample size (leading to
Yet, orthopaedics as a field does not people to come together, and decid- inadequate power), randomization,
harness these resources effectively. Uni- ing whether to pursue IP using in- and the associated low rate of
consent to randomize because of Research Symposium. The faculty 7. Manbachi A, Kreamer-Tonin K, Walch P,
et al: Starting a medical technology venture
surgeon and patient preference. members that presented include Richard as a young academic innovator or student
Kyle, MD, Peter Amadio, MD, Regis entrepreneur. Ann Biomed Eng 2018;46:1-13.
O'Keefe, MD, PhD, Robert Hotchkiss, 8. Loftus PD, Elder CT, D’Ambrosio T,
Summary MD, Mary O'Connor, MD, Rocky Langell JT: Addressing challenges of
training a new generation of clinician-
Tuan, PhD, Tom Cirrito, PhD, Jill
Key components of successful com- innovators through an interdisciplinary
Anderson, JD, Benjamin Glenn, JD, medical technology design program: Bench-
mercialization strategies were identified to-bedside. Clin Transl Med 2015;4:15.
Darren Carney PhD, Daniel Estes,
as a combination of factors that
MBA, Douglas Padgett, MD, Lloyd 9. Maher S, Yaszemski M, Ransford EF:
included unique and passionate leaders Translating orthopaedic innovation to
Hey, MD, Jim Nevelos, PhD, Ellen
working on a strong idea interpreted in clinical use. AAOS Now August 2017.
MacKenzie, PhD, Kurt Spindler, Available at: https://www.aaos.org/
light of market needs, that is de-risked
MD, Martha Murray, MD, Anthony AAOSNow/2017/Aug/Research/
in a logical and meaningful way, with research02/?ssopc=1. Accessed October 2,
Ratcliffe, PhD, Ken Gall, PhD, Lisa
due recognition of the costs associated 2017.
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provided by AAOS, NIH (R13 11. Jackson WM, Nesti LJ, Tuan RS: Concise
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Research Article
Trampoline-Related Injuries: A
Comparison of Injuries Sustained
at Commercial Jump Parks Versus
Domestic Home Trampolines
Abstract
Jesse Doty, MD Introduction: The nature of trampoline injuries may have changed
Ryan Voskuil, MD with the increasing popularity of recreational jump parks.
Methods: A retrospective review was performed evaluating domestic
Caleb Davis, MD
trampoline and commercial jump park injuries over a 2-year period.
Rachel Swafford, MPH Results: There were 439 trampoline injuries: 150 (34%) at jump parks
Warren Gardner II, MD versus 289 (66%) on home trampolines. Fractures and dislocations
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ93:[KF(SG/-+5&95*Q6P0&\TF8KXX):JG/Q98 RQ
Dirk Kiner, MD accounted for 55% of jump park injuries versus 44% of home trampoline
injuries. In adults, fractures and dislocations accounted for 45% of jump
Peter Nowotarski, MD
park injuries versus 17% of home trampoline injuries. More lower
extremity fractures were seen at jump parks versus home trampolines
in both children and adults. Adults had a 23% surgical rate with jump
park injuries versus a 10% surgical rate on home trampolines.
Discussion: Trampoline-related injury distribution included a higher
percentage of fractures/dislocations, lower extremity fractures,
fractures in adults, and surgical interventions associated with jump
parks versus home trampolines.
Level of Evidence: Level III
A jump park, or trampoline park,

is an interconnected network of
trampolines designed specifically for
Recent estimates suggest that jump
park admission rates may be nearly
150,000 to 200,000 participants per
entertainment purposes, similar to a year.1
From the Department of Orthopaedic skateboard park or a bicycle park. Nearly all jump parks require an
Surgery, University of Tennessee Jump parks incorporate games, ob- injury liability waiver before admis-
College of Medicine Chattanooga, stacles, and variable geometric con- sion and many parks cite a 2002
Chattanooga, TN (Dr. Doty, figurations of trampolines to enhance report estimating a rate of two in-
Dr. Voskuil, Ms. Swafford,
Dr. Gardner, Dr. Kiner, and the jumper’s experience. They may juries per 1,000 home trampoline
Dr. Nowotarski), and University of include modifications of more tra- users.2 These data are used by the
Tennessee Health Science Center, ditional sports, such as basketball jump park industry to justify claims
Memphis, TN (Dr. Davis). goals, volleyball nets, or gymnastic of superior safety profiles compared
Correspondence to Dr. Doty: balance beams. Jump parks have with other sports such as soccer,
jessd90@hotmail.com gained traction locally, nationally, which has an injury rate of nearly 21
J Am Acad Orthop Surg 2019;27: and even globally in the past 5 years. per 1,000 players.3
23-31 In 2009, there were only a few In 2014, there were roughly 100,000
DOI: 10.5435/JAAOS-D-17-00470 operational jump parks. However, emergency department (ED) visits
by the end of 2014, there were related to trampoline use across the
Academy of Orthopaedic Surgeons. approximately 350 operating jump United States.4 A single urban trauma
parks in the United States alone.1 center reported approximately 31
January 1, 2019, Vol 27, No 1 23
Trampoline-Related Injuries
Figure 1 variables include sex, age, diagnosis,

mechanism, anatomic location, ad-
mission status, treatment, hospital
course, surgical intervention, and
complications. Data were stratified
into two groups to allow comparison
of patients sustaining an injury at a
commercial jump park and patients
sustaining an injury on a domestic
home trampoline. A two-tailed mid-P
exact test was used to analyze asso-
ciations between discrete variables,
with a significance level set at 0.05.
Unadjusted odds ratios (ORs) were
calculated to describe the prevalence
of injuries between groups.
Results
A total of 439 patients were identified
after being treated for trampoline in-
juries within a university healthcare
Graph showing the percentage of injuries by type of injury.
network. Of these trampoline in-
juries, 150 (34%) occurred at a
trampoline-related ambulance re- outcomes for those who participate commercial jump park, and 289
sponses annually.5 A potential rise in in recreational trampoline use, (66%) occurred on a private home
severe injuries at a time when jump including commercial jump park trampoline.
park popularity is skyrocketing has activities. Of the 150 jump park-related in-
increased media attention and ignited juries, 67 (45%) of these were
public interest about the serious nature strains/sprains, 80 (53%) were closed
of jump park injuries. Methods fractures or dislocations, and 3 (2%)
No published reports have exclu- were open fractures or dislocations
sively examined traumatic jump A retrospective chart review was (Figure 1). There were 109 (73%)
park-related injuries and comparing performed of patients who presented injuries to the lower extremities, 19
them with injuries attributed to home to one of the three EDs of an urban (13%) injuries to the upper extrem-
trampolines. Little to no public data level I trauma center after sustaining a ities, and 22 (14%) injuries to the
define adult trampoline injury rates. trampoline-related injury. The study spine, torso, or head (Figure 2). The
The purpose of this study was to population was determined by a average age of jump park injured
describe the epidemiology of jump hospital database query of Interna- patients was 15 years (range,
park-related injuries compared with tional Classification of Diseases 16 months to 51 years). Eighteen
domestic trampoline injuries, with (ICD)-9 and ICD-10 injury codes for (12%) of the commercial jump park
particular emphasis on the injury trampoline-related injuries (E005.3 injured patients required emergency
distribution in adults. This informa- and Y93.44). Data collection en- transportation by ambulance. Nine-
tion may lead to increased public compassed patients of all ages teen patients (13%) required surgical
awareness of the potential for serious during a 2-year period from January intervention, and thirteen patients
injuries and permanently disabling 2014 to December 2015. Reported (9%) had a hospital admission with
Dr. Doty or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex; serves as a
paid consultant to Arthrex, Globus Medical, and Wright Medical Technology; and has stock or stock options held in Globus Medical.
Dr. Nowotarski or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Synthes; and
serves as a paid consultant to Synthes. None of the following authors or any immediate family member has received anything of value from
or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Voskuil,
Dr. Davis, Ms. Swafford, Dr. Gardner, and Dr. Kiner.
Jesse Doty, MD, et al
an overnight stay (range, 1 to Figure 2

23 days).
One hundred eleven (74%) of the
patients injured at a jump park
reported that their mechanism of
injury was related to routine jumping
or an awkward landing on the nylon
weave mat surface. Twenty (13%)
patients reported getting caught in
the springs or striking the edge out-
side the nylon weave mat. Twelve
(8%) patients were injured from
falling off the trampoline or while
participating in park obstacles
(eg, foam pit, basketball goal).
Seven (5%) patients reported that
they were injured by a collision with
another participant on the trampo-
line (Figure 3).
The commercial jump park injury
group comprised 110 (73%) pedi-
atric patients (range, 16 months to
17 years) and 40 (27%) adult pa- Graph showing injury distribution: jump park versus home trampoline.
tients (range, 18 to 51 years). Sex
distribution was similar between age
groups, with 49 (45%) female and Figure 3
61 (55%) male pediatric patients
and 17 (43%) female and 23 (57%)
male adult patients. Most patients
with jump park injuries were male
children (41%).
Of the 110 pediatric patients, 65
(59%) had a fracture or joint dislo-
cation, whereas 18 of the 40 (45%)
adult patients sustained a fracture or
joint dislocation. In pediatric pa-
tients, there were 47 (72%) lower
extremity, 16 (25%) upper extrem-
ity, and 2 (3%) spine fractures/
dislocations (Figure 4). In adult pa-
tients, there were 17 (94%) lower
extremity, no upper extremity, and 1
(6%) spine fractures/dislocations
(Figure 5). Ten (9%) pediatric pa-
tients and nine adult patients (23%)
required surgical intervention (Ta-
bles 1 and 2). The odds ratio of the
necessity for surgical intervention for Graph showing the mechanism of injury.
adult patients versus pediatric pa-
tients was 2.88 (P = 0.04; 95%
confidence interval [CI], 1.043 to three times more likely than children Among notable jump park injuries,
7.893) (Table 3). Thus, adults to undergo surgery, which was a two adult patients and one pediatric
injured at the jump park were almost notable difference. patient sustained open fractures. This
January 1, 2019, Vol 27, No 1 25
Figure 4 patient, who underwent multiple

operations for a nonunion. Another
adult patient had a knee dislocation
with popliteal artery transection that
required four compartment fascioto-
mies and an arterial repair, leading to
multiple operations and a prolonged
hospital stay with multiple medical
sequelae including renal failure.
Private home trampolines ac-
counted for 289 (66%) of the total
439 trampoline injuries. Of note, 127
(44%) were fractures or dislocations,
125 (43%) were sprains, strains, or
contusions, 19 (7%) were lacer-
ations, 14 (5%) were closed head in-
juries, and 4 (1%) were other injuries.
There were no open fractures or dis-
locations (Figure 1). There were 130
(45%) injuries to the lower extrem-
ity, 97 (34%) injuries to the upper
extremity, and 62 (21%) injuries to
Graph showing pediatric fractures/dislocations by injury site. the spine, torso, or head (Figure 2).
The average age of home trampoline
injured patients was 10 (range, 1 to
Figure 5 65) years. Twenty-four (8%) of the
home trampoline injured patients
required emergency transportation
by ambulance. Twenty patients (7%)
required surgical intervention and
thirteen patients (4%) had a hospital
admission with an overnight stay
(range, 1 to 2 days).
One hundred seventy-one (59%) of
the patients injured on a home tram-
poline reported that their mechanism
of injury was related to routine
jumping or landing awkwardly on
the nylon weave mat surface.
Twenty-nine (10%) of the patients
reported getting caught in the springs
or striking the edge outside the nylon
weave mat. Forty-six (16%) of the
patients were injured from falling
off the trampoline. Forty-three (15%)
of the patients reported that they
were injured by a collision with
Graph showing adult fractures/dislocations by injury site. another participant on the trampo-
line (Figure 3).
Among the home trampoline injury
included a grade 3A ankle fracture- nuted intra-articular supracondylar group, 260 (90%) were pediatric
dislocation that required multiple femur fracture. Bilateral open tibia patients (range, 1 to 17 years) and 29
operations and a grade 3A commi- shaft fractures occurred in an adult (10%) were adult patients (range, 18
to 65 years). Sex distribution between Table 1

age groups was 122 (47%) female
Surgical Injuries in Pediatric Patients: Jump Park
and 138 (53%) male pediatric pa-
tients and 10 (34%) female and 19 Age Sex Mechanism Injury
(66%) male adult patients. Most pa- 2 F Foam pit Midshaft femur fracture
tients with home trampoline injuries
2 M Routine jumping Midshaft femur fracture
were male children (48%).
3 M Foam pit Midshaft femur fracture
Of the 260 pediatric patients, 123
4 F Routine jumping Supracondylar humerus fracture
(47%) had a fracture or dislocation,
9 M Routine jumping Distal femur fracture
whereas 5 of 29 (17%) adult patients
10 M Routine jumping Forearm fracture
sustained a fracture or dislocation.
11 F Routine jumping Bilateral forearm fractures
In pediatric patients, there were 41
(33%) lower extremity, 78 (64%) 12 F Routine jumping Bimalleolar ankle fracture/dislocation
upper extremity, and 4 (3%) spine, 14 M Routine jumping Tibia shaft fracture
torso, or head fractures/dislocations 15 F Routine jumping Knee dislocation
(Figure 4). In adult patients, there
were two (40%) lower extremity,
no upper extremity, and one each Table 2
(20%) of spine, torso, or head
Surgical Injuries in Adult Patients: Jump Park
fractures/dislocations (Figure 5).
Seventeen (7%) of the pediatric Age Sex Mechanism Injury
patients and three (10%) of the 19 M Landed on metal bar Open ankle fracture/dislocation
adult patients required surgical in- 22 M Routine jumping Distal tibial shaft fracture with articular
tervention (Tables 4 and 5). The extension
odds ratio of the necessity for sur- 27 M Routine jumping Trimalleolar ankle fracture
gical intervention for home tram- 28 F Routine jumping Subtalar dislocation and calcaneus fracture
poline injuries in adult patients 30 M Routine jumping Trimalleolar ankle fracture/dislocation
versus pediatric patients was 1.65 32 M Routine jumping Knee dislocation with popliteus tendon
(P = 0.45; 95% CI, 0.364 to 5.597) artery transection
(Table 2). Although a greater per- 33 M Routine jumping Supracondylar/intercondylar distal
centage of adults underwent surgery, femur fracture
this was not markedly higher than 34 F Routine jumping Trimalleolar ankle fracture/dislocation
children. 43 M Trampoline Bilateral open tibial shaft fractures
collapsed
Discussion
Comparing jump park and home on home trampolines (P = 0.02),
Although some studies have investi- trampoline injuries, several signifi- whereas children experienced a 59%
gated trampoline injuries in the cant notable differences may be fracture rate at jump parks versus
domestic setting for personal use, few observed. Fifty-five percent of ED a 47% rate on home trampolines
studies have evaluated commercial visits for jump park injuries were (P = 0.04).
jump park-related injuries. More- diagnosed as a fracture or disloca- For trampoline injuries at any site,
over, there is limited public information, whereas 44% of home trampo- our study found that children had a
tion regarding trampoline injuries in line ED visits were diagnosed as a significantly higher rate of fractures
adults, who seemingly have higher fracture or dislocation (P = 0.02) and dislocations than did adults
participation rates at jump parks (Table 6). When evaluating adult (51% versus 33%; P = 0.008)
than in the domestic setting. We think patients and pediatric patients inde- (Table 7). Fractures and dislocations
that our data support the notion of pendently, we found both groups accounted for 47% of pediatric in-
existence of a high potential for exhibited a higher rate of fractures or juries from home trampolines com-
severe disabling injuries involving dislocations when participating in a pared with 17% of adult injuries
jump parks at a time when the jump park versus on a home tram- (P = 0.002). For jump parks, 59% of
industry is rapidly expanding in the poline. Adults had a 45% fracture pediatric injuries were fractures/
recreation market. rate at jump parks versus a 17% rate dislocations, whereas 45% of adult
January 1, 2019, Vol 27, No 1 27
Table 3
Comparison Between Adult Patients and Pediatric Patients With Trampoline-related Injuries (All Trampolines, Jump
Parks, and Home Trampolines)
Location Adults Pediatrics P Valuea ORb CI
Any trampoline (N = 439) N = 69 (16%) N = 370 (84%) — — —

Lower extremity fractures/dislocations 19 (28%) 88 (24%) 0.504 1.22 0.669, 2.158
Surgical intervention 12 (17%) 27 (7%) 0.014 2.67 1.239, 5.521
Jump park (N = 150) N = 40 (27%) N = 110 (73%) — — —
Home trampoline (N = 289) N = 29 (10%) N = 260 (90%) — — —
Numbers in bold type denote statistically significant results, 95% CI.

CI = confidence interval, OR = odds ratio
a
Mid-P exact test (2-tailed)
b
Conditional maximum likelihood estimate of odds ratio (crude)
Table 4 presenting to a metropolitan ED

during 1991 to 1992. They reported
Surgical Injuries in Pediatric Patients: Home Trampoline
injuries in 217 patients, which is half
Age Sex Mechanism Injury the number of injuries described in
4 M Routine jumping Midshaft femur fracture our retrospective 2-year review (439
4 F Fell off trampoline Supracondylar humerus fracture trampoline injuries). This disparity
5 F Collided with another jumper Supracondylar humerus fracture may simply reflect divergent study
5 M Fell off trampoline Lateral condyle humerus fracture
populations, or our larger sample of
5 F Struck metal bar Supracondylar humerus fracture
injuries may be attributed to the
increasing popularity of jump parks
5 F Fell off trampoline Both-bone forearm fracture
in urban areas. Moreover, Larson
6 M Routine jumping Lateral condyle humerus fracture
and Davis reported a peak incidence
6 F Fell off trampoline Midshaft femur fracture
of trampoline injuries in July, which
7 F Fell off trampoline Supracondylar humerus fracture
aligns with our study’s high inci-
9 M Fell off trampoline Supracondylar humerus fracture
dence of home trampoline injuries in
9 M Routine jumping Supracondylar humerus fracture
the warmer months of April and
May. However, contrary to the peak
10 M Collided with another jumper Supracondylar humerus fracture
season for home trampoline injuries,
12 F Routine jumping Tilaux ankle fracture
our data showed that most jump
park injuries occurred in March.
14 M Routine jumping Both-bone forearm fracture
This finding may represent an in-
17 F Routine jumping Anterior cruciate ligament tear
teresting trend: children entertain
themselves on outdoor trampolines
in the warmer seasons, whereas a
injuries were fractures/dislocations. and children was found in the rate of broader population plays at jump
Regardless of the trampoline setting, surgical intervention when evaluat- parks in cooler seasons because
and although they had a lower rate ing home trampoline injuries (P = weather patterns may limit outdoor
of fractures and dislocations, adults 0.45), adults injured at jump parks activities (Figure 6).
had a significantly higher odds of experienced a significantly higher Loder et al7 reported data from the
undergoing surgical intervention for rate of surgical intervention than did national database of trampoline in-
their trampoline injuries versus children (P = 0.04). juries from 2002 to 2011. The injuries
children (17% versus 7%; OR, 2.67; Larson and Davis6 performed a in this database occurred exclusively
P = 0.01) (Table 3). Although no 2-year retrospective review of recon traditional home or free-standing
significant difference between adults reational home trampoline injuries individual trampolines. Including all
Table 5
Surgical Injuries in Adult Patients: Home Trampoline
Age Sex Mechanism Injury
28 M Routine jumping Orbital and zygomatic fracture

30 M Routine jumping Knee dislocation and medial patella facet cartilage injury
35 F Routine jumping Lateral meniscus tear
Table 6
Comparison Between Trampoline-related Injuries From Jump Parks and From Home Trampolines (All Patients,
Adult Patients, and Pediatric Patients)
Distribution Jump Park Home Trampoline P Valuea ORb 95% CI
All ages (N = 439) N = 150 (34%) N = 289 (66%) — — —

Total fractures and dislocations 83 (55%) 127 (44%) 0.020 1.58 1.061, 2.353
Lower extremity injuries 109 (73%) 130 (45%) ,0.0001 3.24 2.123, 5.007
Emergency transport 18 (12%) 24 (8%) 0.220 1.50 0.778, 2.875
Hospital admission 13 (9%) 13 (4%) 0.090 2.01 0.893, 4.531
Adults (N = 69) N = 40 (58%) N = 29 (42%) — — —
Pediatrics (N = 370) N = 110 (30%) N = 260 (70%) — — —
Lower extremity fractures/dislocations 47 (43%) 41 (16%) ,0.0001 3.97 2.397, 6.602

a
b
Conditional maximum likelihood estimate of OR (crude)
trampoline-related ED visits, 29% of jump park injuries (55%) involved lower extremity, compared with only
sustained a fracture, and 10% were a fracture or dislocation compared 7% of the home trampoline injuries
admitted to the hospital. Similarly, with a rate of 44% from home tram- (P = 0.001). In children, 43% of the
Larson and Davis6 reported that 39% polines (P = 0.02). jump park injuries were lower
of patients sustained a fracture and When reviewing injury type across extremity fractures, whereas only
7% of patients were admitted for all ages, the odds of a lower extremity 16% of the home trampoline injuries
observation. Likewise, we found an injury were significantly higher in were lower extremity fractures (P #
overall admission rate of approxi- those who were at jump parks than 0.0001). Loder et al,7 as well as
mately 6%, with only 4% of home those who were using home trampo- Larson and Davis,6 reported a higher
trampoline injuries and nearly 9% of lines (73% versus 45%; OR, 3.24; incidence of upper extremity than
jump park injuries requiring admis- P # 0.0001). Furthermore, both lower extremity injuries. Even when
sion (Table 6). Our data suggest a adults and children had higher rates combining jump park and home
higher total incidence of trampoline- of lower extremity fractures and trampoline injuries, we found a 54%
related fractures and dislocations at dislocations occurring from jump lower extremity, 26% upper ex-
48% compared with that of previ- parks than from home trampolines. tremity, and 19% spine/torso/head
ously reported studies. When further In adults, 43% of the jump park injury rate. These findings suggest
stratified, a significantly higher rate injuries were fractures involving the that higher-energy mechanisms of
January 1, 2019, Vol 27, No 1 29
Table 7
Comparison Between Adult Patients and Pediatric Patients With Trampoline-related Injuries (All Trampolines, Jump
Parks, and Home Trampolines)
Location Pediatrics Adults P Valuea ORb 95% CI
Any trampoline (N = 439) N = 370 (84%) N = 69 (16%) — — —

Jump park (N = 150) N = 110 (73%) N = 40 (27%) — — —
Home trampoline (N = 289) N = 260 (90%) N = 29 (10%) — — —

a
b
Conditional maximum likelihood estimate of OR (crude).
Figure 6 Pediatrics developed home trampo-

line rules and regulations based on
their evaluation of available pub-
lished research and statistics.9 Both
groups strongly recommend against
multiple persons on a trampoline at
the same time and suggest that
independent use may markedly
decrease the risk. These statements,
although based on home trampoline
use, suggest that there may be a
higher risk of injury at jump parks
where multiple jumpers across all
ages commonly participate simulta-
neously. In our study, 5% reported
that they were injured at the jump
park by collision with another par-
ticipant, with person-to-person con-
tact severe enough to cause
immediate injury (Figure 3). How-
Graph showing the seasonal incidence of trampoline injuries. ever, this may underrepresent the
dangers of multiple jumpers because
it did not include injuries obtained
injury may emanate from less coor- fractures in the jump park group and
by being bumped into obstacles,
dinated falls and high-flying acrobat- none in the home trampoline group
knocked off the trampoline, or being
ics experienced at jump parks. This also supports this notion.
pushed into a hazard.
finding may also contribute to the Children and adolescents repre-
Kasmire et al10 documented an
increased number of ED visits result- sented most jump park injuries with
increase in US ED visits for jump park-
ing from fractures and dislocations, as an average age of 15 years. In 2010,
well as the higher rate of surgical the American Academy of Ortho- related injuries from 581 visits in 2010
intervention for jump park injuries paedic Surgeons established a posi- to 6,932 visits in 2014. The same
than for home trampoline injuries tion statement on trampoline use authors reported no change in visits
(13% versus 7%; P = 0.052). Fur- in the domestic setting.8 Likewise, for home trampoline-related injuries.
thermore, the finding of three open in 2012, the American Academy of We believe that our reported findings
add further clarification to the tram- P , 0.0001) and is likely attributed to

poline public database and strengthen the increase in the number of adult
References
the American Academy of Orthopae- participants.
Evidence-based Medicine: Levels of
dic Surgeons position statement. Finally, most adult fractures and
evidence are described in the table
The difficulty of epidemiologic dislocations occurring at jump parks
of contents. In this article, reference
data collection in these particular involved the lower extremity (94%).
10 is a level III study. References
study groups may have contributed In addition, we noted a trend toward
2-4, 6, and 7 are level IV studies.
to the limitations of this study. The increased surgical necessity for adults
References 1, 5, 8, and 9 are level V
true incidence of trampoline injuries injured at jump parks (23%) com-
expert opinion.
remains inconclusive because the pared with children (9%). However,
number and frequency of individuals the need for surgical intervention was References printed in bold type are
who actually participated in tram- similar between age groups for home those published within the past 5
poline activities during the study trampolines (adults 10% versus years.
time frame is unknown. Further- pediatric 7%).
1. Sarris T: Indoor trampoline parks continue
more, a database query of ICD-9 to be one of the fastest growing indoor
and -10 codes may not have cap- entertainment attractions worldwide. Play
Meter Magazine April 2015:66-69.
tured all trampoline-related injuries Summary
if the cause of injury code was not 2. Smith GA: Injuries in the United States
related to trampolines, 1990-1995: A
included at the initial patient en- Fractures and dislocations, hospital national epidemic. Pediatrics 1998;101:
counter. Therefore, the prevalence of admissions, and surgical intervention 406-412.
trampoline-related injuries may secondary to jump park-related in- 3. Radelet MA, Lephart SM, Rubinstein EN,
actually be higher than that docu- juries can be seen in children and Myers JB: Survey of the injury rate for
children in community sports. Pediatrics
mented based on these data sets. adults. There were a higher percent-
2002;110:e28.
Although this health system includes age of total fractures, lower extremity
4. United States Consumer Product Safety
four EDs, and has the only regional fractures, open fractures, adult frac- Commission: NEISS Data Highlights 2014.
level I trauma center, some patients tures, and surgical fractures among www.cpsc.gov/en/Research-Statistics/
may have presented to outside hos- patients with commercial jump park NEISS-Injury-Data/. Accessed November
20, 2015.
pitals and walk-in clinics, thereby, injuries compared with patients who
making extrapolation of data lim- sustained home trampoline injuries. 5. Alltucker K, Hansen RJ, Berry J: Trampoline
parks face scrutiny over safety. The Arizona
ited based on geographic variations Commercial jump parks may con- Republic February 7, 2012. http://archive.
in healthcare delivery models. tribute to higher-energy mechanisms azcentral.com/arizonarepublic/news/articles/
20120207trampoline-parks-face-scrutiny-
To our knowledge, this is the first of trauma than previously suggested over-safety.html. Accessed August 10, 2016.
report evaluating trampoline-related based on data extrapolated from
6. Larson BJ, Davis JW: Trampoline-related
injuries in adults. Our data suggest domestic trampoline use. Our data injuries. J Bone Joint Surg 1995;77:
that there is a much higher rate of adult suggest that with the expansion of 1174-1178.
participation than previously consid- commercial jump parks, the inci- 7. Loder RT, Schultz W, Sabatino M:
ered, with 27% of jump park injuries dence, severity, and economic effect Fractures from trampolines: Results from a
national database, 2002 to 2011. J Pediatr
occurring in adults, as opposed to 10% of trampoline injuries may be un- Orthop 2014;34:683-690.
of home trampoline injuries occurring derestimated. Jump park partic-
8. America Academy of Orthopaedic
in adults (OR, 3.25; P = 0.00; 95% CI, ipants, legal guardians, and public Surgeons: Position Statement: Trampolines
1.919 to 5.552). Although the average policy-makers should have accessi- and Trampoline Safety. 2010. http://www.
age of patients with home trampoline bility to accurate safety profiles. This aaos.org/CustomTemplates/Content.aspx.
Accessed August 10, 2016.
injuries in our review was 10 years implication is of particular impor-
(68.82) (concurring with the average tance as healthcare costs continue to 9. American Academy of Pediatrics: AAP
Advises Against Recreational Trampoline
age of 10 years reported by Larson rise, and public safety is emphasized Use. 2012. https://www.aap.org/en-us/
and Davis in the early 1990s), we as a prevention mechanism. This about-the-aap/aap-press-room/pages/AAP-
Advises-Against-Recreational-Trampoline-
found that the average age of injury in report also highlights the need for Use.aspx. Accessed August 10, 2016.
jump park patients was 15 years further evaluation into the econom-
10. Kasmire KE, Rogers SC, Sturm JJ:
(610.54). This increase in age was ics and societal effect of jump park- Trampoline park and home trampoline
statistically significant (t = 4.97; associated injuries. injuries. Pediatrics 2016;138:e20161236.
January 1, 2019, Vol 27, No 1 31
Research Article
Risk Factors for Prolonged

Postoperative Opioid Use After
Spine Surgery: A Review of
Dispensation Trends From a State-
run Prescription Monitoring
Program
Abstract
Brett D. Rosenthal, MD Introduction: Opioid abuse and dependence have a detrimental
Linda I. Suleiman, MD effect on elective orthopaedic surgeries, yet pain control is an
important predictor of postoperative satisfaction. We aimed at better
Abhishek Kannan, MD
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ93:[KF(SG/7)L*8),U14=*T4&S=9:&IV)N2X.H RQ
defining risk factors for prolonged postoperative opioid requirements

Adam I. Edelstein, MD and risk factors for patients requiring higher doses of opioids after
Wellington K. Hsu, MD spine surgery.
Alpesh A. Patel, MD, FACS Methods: The Illinois Prescription Monitoring Program was queried to
analyze opioid dispensation patterns at 3 and 6 months postoperatively
for adult patients who had spine surgery at a tertiary care hospital by a
single surgeon over a 5-year period. Patients were divided into three
groups: group 1 patients had opioid dispensed to them 3 and 6 months
preoperatively, group 2 patients had opioid dispensed to them only at
3 months preoperatively, and group 3 patients did not have
preoperative opioid prescriptions. Demographic characteristics,
psychiatric history, smoking status, alcohol use, body mass index,
surgical region, and presence of multiple prescribers were abstracted.
Statistical analysis included multivariate modified Poisson regression,
linear regression, and chi-squared testing when appropriate.
Results: Patients in group 1 were at significantly increased risk
of continued opioid usage than those in group 2 (relative risk, 3.934;
95% confidence interval, 1.691 to 9.150; P = 0.0015) and those in
group 3 (relative risk, 4.004; 95% confidence interval, 1.712 to 9.365;
P = 0.0014) at 6 months postoperatively. Group 1 patients also had
larger quantities of opioid dispensed to them relative to patients in
group 2 or group 3 (P , 0.0001) at 6 months postoperatively.
Surgery, Northwestern University, Discussion: Use of opioid medications at 6 months preoperatively
Chicago, IL. is a risk factor for continued usage and at higher doses 6 months
Correspondence to Dr. Rosenthal: postoperatively.
brett.david.rosenthal@gmail.com Level of Evidence: Level III: retrospective cohort study
J Am Acad Orthop Surg 2019;27:
32-38
DOI: 10.5435/JAAOS-D-17-00304

Academy of Orthopaedic Surgeons. B ecause clinicians have been
directed to regard pain as the
“fifth vital sign,1” the prescribing of
opioids continues to increase.2 The
United States consumes 99% of the
global hydrocodone supply, and
Brett D. Rosenthal, MD, et al
chronic pain is present in one of important predictor of postoperative Illinois. A query was placed to iden-
every five US adults.2 Similarly, 20% satisfaction.8 tify dispensation of controlled sub-
to 55%3-5 of patients undergoing Risk factors for prolonged postop- stances to all patients who underwent
spine surgery use opioid medications erative opioid use after spine surgery spinal surgery by a single surgeon
preoperatively. Patients undergoing are not well reported in the scientific over the 5-year period between Jan-
elective spine surgery are at an literature. Identification of risk fac- uary 2008 and December 2014.
increased risk of opioid abuse and/or tors for requiring prolonged postop- Adult patients aged 18 to 80 years
dependence.6 Although opioid med- erative opioids would be beneficial undergoing spine surgical procedures
ications play an important role to practitioners both for managing were included in analysis. Patients
in perioperative pain management, patient expectations and for guiding were excluded if they were (1) not a
their prolonged use may indicate a medication changes. resident of Illinois (and thus not
failure to achieve the goals of surgery Previous studies into this subject included in the IPMP), (2) lacking
or may be a sign of addiction or matter have relied on patient surveys records of postoperative opioid use in
abuse. to assess each patient’s opioid use,3,4 IPMP, (3) underwent surgery for
Opioid abuse and dependence are which has inherent unreliability. infection, tumor, or trauma, or (4)
not without danger. As expected, Using a state-run controlled sub- requiring revision surgery within the
because of drug tolerance, preopera- stance monitoring program, we 6-month postoperative period from
tive opioid use is associated with an aimed at better defining risk factors the index procedure. Prescription
increased demand for opioids in the for prolonged postoperative opioid data from 3 and 6 months preoper-
immediate postoperative period.3 In requirements and risk factors for atively and postoperatively were
addition, patients with preoperative patients requiring higher doses of obtained. All patients who were
opioid use have worse self-reported opioids after spine surgery. We receiving controlled substances from
outcome scores as measured by the hypothesized that patients with long- providers outside of the treating sur-
12-Item Short-Form Health Survey, standing prescription dispensation of geon’s staff were categorized as
the EuroQol-5D, the Oswestry Dis- opioids preoperatively would require having multiple prescribers. For
ability Index, and the Neck Disability opioids for a more prolonged period comparison purposes, all opioid
Index.7 More concerning, however, is and at higher doses postoperatively prescription dosages were converted
that the incidence of postoperative compared with patients who were to morphine equivalents. Demo-
opioid independence is lower in this opioid naive. graphic data, psychiatric histories,
cohort.3 Patients with opioid abuse smoking status, alcohol use, body
and dependence have an increased mass index, and procedure details
risk of inpatient mortality (odds ratio, Methods were collected to better elucidate
4.8; 95% confidence interval [CI], 3.5 potential risk factors for prolonged
to 6.5) and aggregate morbidity (odds Institutional review board approval postoperative opioid requirements.
ratio, 3.5; 95% CI, 3.4 to 3.7) when was obtained before initiation of All data were abstracted from the
undergoing elective orthopaedic sur- this study. The Illinois Prescription electronic medical record, which are
geries.6 Unfortunately, a physician’s Monitoring Program (IPMP) is an shared among all specialties at this
attempts to prematurely wean pa- electronic tool that collects informa- tertiary care hospital. Patients were
tients from opioid medications can tion on controlled substance pre- divided into groups, depending on
prove counterproductive because scriptions, schedules 2 to 5, that were their duration of preoperative opioid
pain control is often the most dispensed by retail pharmacies in usage. Group 1 was the cohort of
Dr. Edelstein or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of
Orthopaedic Surgeons. Dr. Hsu or an immediate family member has received royalties from Stryker; is a member of a speakers’ bureau or
has made paid presentations on behalf of AONA; serves as a paid consultant to Allosource, AONA, CeramTec, Globus Medical, Graftys,
Medtronic Sofamor Danek, Mirus; RTI, Stryker, and Xtant; has received research or institutional support from Medtronic; and serves as a
board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the Cervical Spine Research
Society, the Lumbar Spine Research Society, and the North American Spine Society. Dr. Patel or an immediate family member has received
royalties from Amedica and Zimmer Biomet; serves as a paid consultant to Amedica, Pacira, and Zimmer Biomet; has stock or stock options
held in Amedica, Cytonics, Nocimed, nView Medical, and Vital5; and serves as a board member, owner, officer, or committee member of the
American Orthopaedic Association, the AO Spine North America, the Cervical Spine Research Society, the International Society for the
Advancement of Spine Surgery, the Lumbar Spine Research Society, and the North American Spine Society. None of the following authors
nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or
institution related directly or indirectly to the subject of this article: Dr. Rosenthal, Dr. Suleiman, and Dr. Kannan.
January 1, 2019, Vol 27, No 1 33
Risk Factors for Prolonged Postoperative Opioid Use
Table 1 had a spinal fusion as a component

of their procedure; 84 one-level fu-
Indications for Surgery
sions, 40 two-level fusions, 2 three-
No. of Percentage of Total level fusions, 7 four-level fusions, 2
Indication Cases Cases
five-level fusions, and 1 seven-level
Disc herniation 106 40.2 fusion were performed. Linear re-
Spondylolisthesis 43 16.3 gression analysis did not identify any
Cervical stenosis/(non–disc related) 44 16.7 statistically significant differences
radiculopathy/myelopathy/spondylosis in age (P = 0.66), body mass index
Lumbar stenosis/(non–disc related) 48 18.2 (P = 0.66), or number of levels
radiculopathy/spondylosis fused (P = 0.65) between cohorts.
Other 23 8.7 The surgical approaches used were
as follows: 69 (26.1%) anterior,
49 (18.6%) lateral, 145 (54.9%)
posterior, and 1 (0.3%) combined
Table 2
anterior/posterior.
Postoperative Narcotic Usage by Group On the basis of the available data,
3 Months Postoperatively 6 Months Postoperatively the distribution of preoperative opi-
Continued Usage Total Continued Usage Total oid usage was compared with post-
Group (Percentage of Group) Patients (Percentage of Group) Patients operative dispensation at 3 and
6 months (Table 2). Chi-squared
1 44 (88) 50 23 (52) 44
testing demonstrated that preopera-
2 58 (67) 87 10 (13) 80 tive opioid usage had a significant
3 66 (89) 74 7 (10) 67 effect on postoperative usage at both
time points (P3-month post-op = 0.0005
and P6-month post-op , 0.0001).
patients who received opioid at both were fitted to take advantage of the Within the 6 months before and
3 and 6 months preoperatively. direct risk ratio assessment of this subsequent to surgery, 91.1% of
Group 2 was the cohort of patients method. For multivariate analysis of patients had multiple prescribers. At
who received opioid at 3 months continuous outcomes, linear regres- 3 months preoperatively, patients
preoperatively but not at 6 months sion models were applied. A P value with multiple prescribers had a
preoperatively. Group 3 was the of 0.05 was chosen to determine the greater amount of opioid dispensed
cohort of patients who were not threshold of statistical significance to them (mean = 46.5 morphine
receiving opioid at 3 or 6 months for all analyses. equivalents; SD = 32.7; n = 226)
preoperatively. For stratification than patients with only a single
purposes, when performing our prescriber (mean = 14.2 morphine
regression analysis, alcohol use was Results equivalents; SD = 71.1; n = 18;
divided into four groups: 0 = none, P , 0.001).
1 = one to three drinks per week, A total of 264 patients met our At 3 months postoperatively,
2 = 4 to 10 drinks per week, and 3 = inclusion criteria, but because of multivariate analysis did not iden-
more than 10 drinks per week. limitations of the IPMP, data were tify any variable of interest as sig-
A statistician performed statistical incomplete at certain instances for nificantly affecting the RR of
analysis with Statistical Analysis some patients, accounting for the continued opioid usage (Table 3).
System (SAS version 9.3; SAS Insti- variance in the sample size for various With regard to dosage, however,
tute, 2011). For categoric variables, statistics. Fifty-five percent of pa- patients in group 2 received lower
comparisons were made using the tients were male. The mean age at the doses of opioid than those in group
chi-squared test. For continuous time of surgery was 50.87 6 15.08 3 (P = 0.0083); no other variables
variables, an independent sample years (range, 21 to 84 years). The of interest significantly affected the
Student t-test or analysis of variance indications for surgery are presented postoperative dose dispensed
test was used, where appropriate. in Table 1. The most common indi- (Table 4).
For multivariable analysis of binary cation for surgery was a disc herni- At 6 months postoperatively,
outcomes, relative risks (RRs) and ation (40%; 106 patients). One multivariate analysis identified
modified Poisson regression models hundred thirty-six patients (51.5%) patients in group 1 as having
significantly increased risk of con- Table 3

tinued opioid usage than patients in
RR of Continued Opioid Usage at 3 Months Postoperatively
group 2 (RR, 3.934; 95% CI, 1.691
to 9.150; P = 0.0015) and patients in 95% Confidence
Limits
group 3 (RR, 4.004; 95% CI, 1.712
to 9.365; P = 0.0014). No other Variable RR Lower Upper Pr . Chi-square
variables of interest were found to
Sex: female 0.9911 0.8691 1.1302 0.8936
significantly alter the RR of contin-
Smoking: none 0.9303 0.7317 1.1827 0.5551
ued opioid usage at 6 months post-
Psychiatric history: none 0.9951 0.8161 1.2134 0.9612
operatively (Table 5). Similarly, with
Approach: anterior 1.0047 0.8373 1.2055 0.9599
regard to dosage, patients in group
1 had larger amounts of opioid Marital status: single 1.0066 0.8609 1.1769 0.9347
dispensed to them relative to patients Group 1 versus 2 1.0469 0.89 1.2315 0.5801
in group 2 or group 3 (P , 0.0001) Group 2 versus 3 0.8685 0.7305 1.0325 0.1102
at 6 months postoperatively. No Group 1 versus 3 0.9092 0.7664 1.0786 0.2749
other variables were found to sig-
RR = relative risk
nificantly affect the dose dispensed
(Table 6).
On the basis of chi-squared anal-
ysis, postoperative opioid use at Table 4
both 3 and 6 months postoperative Opioid Dose Dispensed at 3 Months Postoperatively
did not demonstrate any statistically Parameter Estimate Standard Error Pr . Chi-square
significant dependence on the region
of the spine involved (eg, cervical, Intercept 84.3569 39.6544 0.0334
thoracic, lumbar) (P3-month = 0.223, Sex: female 1.1987 10.924 0.9126
P6-month = 0.609). Smoking: none 219.4808 14.5579 0.1808
Psychiatric history: none 8.8673 14.9159 0.5522
Approach: anterior 14.5484 13.1808 0.2697
Discussion Marital status: single 211.9447 10.6896 0.2638
Group 1 versus 2 20.2616 13.3145 0.1281
Our study demonstrates that pre- Group 2 versus 3 231.1783 11.8201 0.0083
operative opioid use is the strongest Group 1 versus 3 210.9167 13.4764 0.4179
predictor of persistent postopera- Age 20.1395 0.3583 0.6971
tive opioid use. Lawrence et al4 BMI 0.9013 0.9406 0.338
retrospectively reviewed patients Alcohol 215.3126 11.0356 0.1653
who had undergone an anterior Fusion level 6.857 6.949 0.3238
cervical discectomy and fusion and
had similar findings. Thirty-four BMI = body mass index
percent of patients with preopera- Bold indicates statistical significance, where P , 0.05
tive opioid use still took opioid

medications at 2 years postopera-
tively, whereas, only 7% of those tients with preoperative opioid use operative period. Their analysis also
without preoperative opioid use had such outcomes.4 demonstrated a higher dissatisfac-
still took opioids at 3 months Similar results have been identified tion rate among patients with pre-
postoperatively. Functional outcomes in the total joint arthroplasty litera- operative opioid use.9
were also worse among patients ture. Franklin et al9 identified a lower Spinal fusion surgery is typically
who had chronic opioid usage opioid independence rate among regarded as one of the most painful of
preoperatively. Eighty-six percent patients with preoperative opioid orthopaedic procedures.10 As such,
of patients who underwent an use. This finding suggests that the pain management is a critical ele-
anterior cervical discectomy and problem is not inherent to the nature ment of postoperative patient care.
fusion with no preoperative opioid of spine surgery. It is likely more Interestingly, in our analysis, the
use had good or excellent out- related to the inherent nature of number of levels fused (ie, 0, 1, 2)
comes, whereas only 51% of pa- opioid medications in the peri- was not a significant factor for
January 1, 2019, Vol 27, No 1 35
Table 5 agreement with the patient, which

aims at improving adherence, miti-
RR of Continued Opioid Usage at 6 Months Postoperatively
gating risk, obtaining informed
95% Confidence consent, and delineating prescribing
Limits
policies.14
Variable RR Lower Upper Pr . Chi-square Chronic use of opioids may be a
surrogate marker for psychosocial
Sex: female 1.2187 0.6358 2.336 0.5513
disturbances that precipitate as poorer
Smoking: none 0.5594 0.2586 1.2102 0.1401
perception of pain and treatment
Psychiatric history: none 0.8999 0.4111 1.9695 0.7918
outcomes. Fittingly, some previous
Approach: anterior 1.2176 0.5083 2.9164 0.6587
analyses have identified the presence
Marital status: single 1.131 0.6073 2.1062 0.6981 of a psychiatric diagnosis as a predic-
Group 1 versus 2 3.9338 1.6913 9.1497 0.0015 tor of preoperative opioid use15 and
Group 2 versus 3 1.018 0.3726 2.7815 0.9723 continued opioid use at 12 months
Group 1 versus 3 4.0044 1.7123 9.3647 0.0014 postoperatively.3 Interestingly, one
recent randomized double-blinded
RR = relative risk
Bold indicates statistical significance, where P , 0.05 trial identified preoperative adminis-
tration of duloxetine, which is tradi-
tionally used as an antidepressant
improved postoperative pain and
Table 6 function in patients undergoing spine
Opioid Dose Dispensed at 6 Months Postoperatively surgery regardless of the presence of a
Parameter Estimate Standard Error Pr . Chi-square previous diagnosis of depression.16
This finding suggests a complex inter-
Intercept 7.8646 21.5064 0.7146 relatedness between subtle psychiat-
Sex: female 4.3554 6.0786 0.4737 ric alterations and postoperative
Smoking: none 23.7271 7.9789 0.6404 pain, whether they meet criteria to be
Psychiatric history: none 21.7006 8.3928 0.8394 given a clinical diagnosis. Our anal-
Approach: anterior 4.0301 7.2767 0.5797 ysis, however, did not identify psy-
Marital status: single 2.0248 5.8693 0.7301 chiatric diagnoses as a statistically
Group 1 versus 2 38.818 7.3215 ,0.0001 significant predictor of prolonged
Group 2 versus 3 23.3772 6.5668 0.6071 opioid usage or elevated opioid
Group 1 versus 3 35.4408 7.4221 ,0.0001 dosage.
Age 0.0059 0.2014 0.9766 Unsurprisingly, different surgical
BMI 0.0309 0.4774 0.9483 procedures are associated with differ-
Alcohol 0.7867 6.0941 0.8973 ent opioid requirements postopera-
Fusion level 21.5968 3.8483 0.6782 tively. Within this series of patients, no
difference in opioid usage or dosage
BMI = body mass index patterns was identified on the basis of
Bold indicates statistical significance, where P , 0.05
whether an anterior, posterior, or lat-
eral approach was performed. Simi-
larly, no difference in usage was
determining the RR of continued them. This phenomenon mirrors identified on the basis of which spinal
usage or dosage dispensed at any what has been similarly shown in the region was operated on (eg, cervical,
postoperative time point. Both fail- orthopaedic trauma literature.12 thoracic, lumbar, sacral).
ure to adequately treat a patient’s Having multiple prescribers has Our study is novel in that it uses a
pain and the addictive nature of been shown to increase concurrent state-run prescription dispensation
opioid medications may be contrib- usage of controlled substance pre- database, which likely provides a
uting to the increasing rate of peri- scriptions, which is a risk factor for more accurate depiction of opioid
operative “doctor shopping.”11 In overdose.13 One strategy to mini- usage in our subjects than other
our analysis, the cohort with multi- mize multiprescriber dispensation of studies that rely on self-reported sur-
ple prescribers had significantly opioid medications is to preopera- veys. We have identified that patients
higher doses of opioid dispensed to tively make a controlled substance who receive opioids at both 3 and
6 months preoperatively are more explain why they continued to re- studies. References 5, 6, 10, and 13
likely to require opioids 6 months quire opioids after spinal surgery. are level V report or expert opinion.
postoperatively. In addition, the Additional limitations of this study
dosage they require will be higher at are inherent to its retrospective References printed in bold type are
the 6-month postoperative follow-up design, single institution, and single those published within the past 5
period. These findings validate our surgeon analysis. “Doctor shopping” years.
hypothesis, and this information will and opioid abuse patterns have been 1. Menendez ME, Ring D, Bateman BT:
prove invaluable to clinicians during identified as a geographically vari- Preoperative opioid misuse is associated
with increased morbidity and mortality
preoperative discussions that set able phenomenon,11 so this must be after elective orthopaedic surgery. Clin
patient expectations of recovery. In taken into account before wide- Orthop Relat Res 2015;473:2402-2412.
addition, we have identified that spread generalization of the findings 2. Hessler C, Boysen K, Regelsberger J,
having multiple prescribers of opioid reported herein. Vettorazzi E, Winkler D, Westphal M:
Patient satisfaction after anterior cervical
increases the dosage dispensed to discectomy and fusion is primarily driven
patients throughout the early post- by relieving pain. Clin J Pain 2012;28:
operative period. Practitioners must 398-403.
Conclusions
be highly attuned to this risk factor 3. Armaghani SJ, Lee DS, Bible JE, et al:
Preoperative opioid use and its association
because increased perioperative opi- Opioid medications play an impor-
with perioperative opioid demand and
oid usage can be detrimental by tant role in the management of pain postoperative opioid independence in
incurring increased morbidity and during the perioperative period, but patients undergoing spine surgery. Spine
(Phila Pa 1976) 2014;39:E1524-E1530.
mortality.6 their prolonged use may be detri-
Patients in group 2, interestingly, mental to the patient’s health and 4. Lawrence JTR, London N, Bohlman HH,
Chin KR: Preoperative narcotic use as a
were dispensed less opioid at may indicate a failure to achieve the predictor of clinical outcome: Results
3 months postoperatively than those goals of surgery. By querying a state- following anterior cervical arthrodesis.
Spine (Phila Pa 1976) 2008;33:2074-2078.
who were opioid naive preopera- run prescription monitoring pro-
tively (group 3). This phenomenon gram, risk factors for prolonged 5. Morone NE, Weiner DK: Pain as the fifth
vital sign: Exposing the vital need for pain
may reflect opioid prescriptions opioid usage and elevated opioid education. Clin Ther 2013;35:1728-1732.
in conjunction with a period of dosage were identified. Patients with
6. Kuehn BM: Opioid prescriptions soar:
nonsurgical/conservative treatment multiple prescribers tend to have Increase in legitimate use as well as abuse.
modalities that are often attempted increased dosage of opioid dispensed JAMA 2007;297:249-251.
before resigning to surgical manage- to them preoperatively. This same 7. Walid MS, Hyer L, Ajjan M, Barth ACM,
ment of spine pathology. After the cohort had greater opioid dosages Robinson JS: Prevalence of opioid
surgical procedure was completed, postoperatively at 3-month follow- dependence in spine surgery patients and
correlation with length of stay. J Opioid
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would be expected, and no longer dispensed to them 6 months preop- 8. Lee D, Armaghani S, Archer KR, et al:
required opioids for analgesia. It is eratively had a significantly greater Preoperative opioid use as a predictor of
unclear as to why opioid-naive pa- risk of prolonged opioid usage and adverse postoperative self-reported
outcomes in patients undergoing spine
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greater opioid at the 3-month post- 6 months postoperatively. By iden-
9. Franklin PD, Karbassi JA, Li W, Yang W,
operative time point, but regardless, tifying these risk factors, clinicians Ayers DC: Reduction in narcotic use after
this discrepancy was no longer sta- can more accurately set expectations primary total knee arthroplasty and
association with patient pain relief and
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postoperatively. independence when counseling their
10. Sinatra RS, Torres J, Bustos AM: Pain
One limitation of this study is that patients presurgically. management after major orthopaedic surgery:
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treatment of a spine-related pain B, Mir HR: Narcotic use and postoperative
doctor shopping in the orthopaedic trauma
issue. It is possible that some patients Evidence-based Medicine: Levels of population. J Bone Joint Surg Am 2014;96:
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sued to them for management of is a level I study. References 2-4, 7, 8, Preoperative narcotic use and its relation to
depression and anxiety in patients
other chronic pain conditions unre- 11, and 12 are level II studies. Ref- undergoing spine surgery. Spine (Phila Pa
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January 1, 2019, Vol 27, No 1 37
13. Dowell D, Haegerich T, Chou R: CDC for prolonged opioid use after major Pharmacoepidemiol Drug Saf 2014;23:
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2016. MMWR Recomm Rep 2016;65: 16. Hyer L, Scott C, Mullen CM, McKenzie LC,
1-49. 15. McDonald DC, Carlson KE: The ecology of Robinson JS: Randomized double-blind
prescription opioid abuse in the USA: placebo trial of duloxetine in perioperative
14. Clarke H, Soneji N, Ko DT, Yun L, Geographic variation in patients’ use of spine patients. J Opioid Manag 2015;11:
Wijeysundera DN: Rates and risk factors multiple prescribers (“doctor shopping”). 147-155.
Research Article
Median Nerve Ultrasonography

Measurements Correlate With
Electrodiagnostic Carpal Tunnel
Syndrome Severity
Abstract
Beverlie L. Ting, MD Introduction: The purpose of this study was to assess whether
Philip E. Blazar, MD median nerve ultrasonography (US) measurements correlate with the
severity scale of electrodiagnostic studies (EDS) of carpal tunnel
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ9&VFYUGE5%ZO;2&80M\R1*+H(Q955UYR[UK1X,;,QHQ;<6Q-4 RQ
Jamie E. Collins, PhD

syndrome (CTS).
Ariana N. Mora, BA Methods: A retrospective review was conducted of patients
Mohammad Kian Salajegheh, aged $18 years who underwent both median nerve US and EDS. US
MD measurements of the median nerve cross-sectional area at the distal
Anthony A. Amato, MD wrist crease and forearm were used to calculate the median nerve
Brandon E. Earp, MD wrist-to-forearm ratio. EDS severity was classified according to
guidelines from the American Association of Electrodiagnostic
Medicine.
From the Department of Orthopedic Results: A total of 112 wrists (n = 112) in 78 consecutive patients
Surgery (Dr. Ting, Dr. Blazar, with a mean age of 59 (range, 26 to 88) years were included.
Dr. Collins, Ms. Mora, and Dr. Earp),
and the Department of Neurology Increased cross-sectional area at the distal wrist crease and wrist-to-
(Dr. Salajegheh and Dr. Amato), forearm ratio were significantly correlated with increased EDS
Brigham and Women’s Hospital, severity (P , 0.0001).
Boston, MA.
Discussion: Median nerve US measurements not only distinguished
Correspondence to Dr. Earp:
bearp@partners.org
between normal and abnormal EDS but also correlated with the
category of EDS severity.
Dr. Blazar or an immediate family
member serves as a paid consultant
Level of Evidence: Diagnostic III
to Endo Pharmaceuticals. Dr. Earp or
an immediate family member has
stock or stock options held in Johnson
& Johnson and Pfizer; and serves as a
C arpal tunnel syndrome (CTS) is
the most common compressive
neuropathy of the upper extremity
with discomfort at the time of the
procedure.8
Recent interest has developed
Academy of Orthopaedic Surgeons.
None of the following authors nor any
with an estimated prevalence of 7.8% in ultrasonography (US) as a less
immediate family member has in working populations in the United invasive method to confirm CTS.9
received anything of value from or has States.1,2 It is estimated that over Several studies have refined ultraso-
stock or stock options held in a 500,000 carpal tunnel releases are nographic criteria for the diagnosis of
commercial company or institution
related directly or indirectly to the
performed each year in the United CTS and have confirmed that an
subject of this article: Dr. Ting, States.3 No consensus on confirma- increased cross-sectional area of the
Dr. Collins, Ms. Mora, Dr. Salajegheh, tory testing for the diagnosis of CTS median nerve at the distal wrist crease
and Dr. Amato. exists.4-6 (wCSA) correlates with the electro-
J Am Acad Orthop Surg 2019;27: Electrodiagnostic studies (EDSs) diagnostic diagnosis of CTS.9-16
e17-e23 are commonly used and have a Controversy exists in the published
DOI: 10.5435/JAAOS-D-17-00557 high degree of sensitivity and spec- literature regarding how US meas-
ificity to confirm the diagnosis of urements of the median nerve corre-
Academy of Orthopaedic Surgeons. CTS.7 However, electrodiagnostic late with the electrodiagnostic graded
procedures are often associated severity of CTS.9,11,13-15,17-22
January 1, 2019, Vol 27, No 1 e17
Median Nerve Ultrasonography Measurements
Figure 1 Neurology in the subspecialty, and

US was performed according to the
protocol described by Hobson-Webb
et al.12 The same US machine
(Esaoate MyLab25Gold) and trans-
ducer were used for all studies. A
linear 10- to 18-mHz transducer was
used at the 18-mHz setting, and at a
depth setting of 2 cm at the wrist and
2 to 3 cm at the forearm, based on
the limb size. Measurements were
done on raw images before capture
and conversion to image files. Opti-
mal images captured through a
continuous video clip were used.
Median nerve wCSA and forearm
cross-sectional area (fCSA) were used
to calculate the median nerve WFR
(Figure 1). The forearm measure-
ments were taken from 1/3 of the
distance between the distal wrist
crease and the elbow flexion crease
Median nerve ultrasonography (US) demonstrating a normal median nerve proximal to the distal wrist crease.
cross-sectional area at the distal wrist crease (wCSA) of 8 mm2 (A) and at the Values of wCSA ,12 mm2 and
forearm (fCSA) of 6 mm2 (B) compared with median nerve US with an increased WFR ,1.5 were considered normal.
median nerve wCSA of 20 mm2 (C) relative to the fCSA of 6 mm2 (D). Electrophysiologic measurements in-
cluded peak latency of the sensory
The purpose of this study was to institution and were referred for nerve action potential (SNAP, wrist-
examine whether median nerve US electrodiagnostic testing for clinical index finger, distance = 13 cm),
measurements correlate with EDS suspicion of CTS. Patients referred motor latency of the compound
severity in a population of patients in had clinical signs or symptoms of muscle action potential (CMAP,
the United States. We hypothesized CTS including paresthesias in the wrist-abductor pollicis brevis, dis-
that increased wCSA and increased median nerve distribution and/or tance = 7 cm), and CMAP amplitude
median nerve wrist-to-forearm cross- positive provocative maneuvers for (abductor pollicis brevis). All hands
sectional area (CSA) ratio (WFR) CTS. Patients who presented because below a temperature of 32C were
correlate with increased electro- of bilateral symptoms were referred warmed before electrodiagnostic
diagnostic graded severity of CTS. for testing of both hands, and each testing. EDS severity was classified
hand was counted as an independent according to the following guidelines
observation. Each patient had the from the American Association of
Methods same unmasked examiner perform Electrodiagnostic Medicine: pro-
both EDS and US examinations longed sensory or mixed nerve action
Patient Identification during one visit. Exclusion criteria potential distal latency 6 SNAP
After institutional review board were polyneuropathy, cervical radic- amplitude below the lower limit of
approval, we conducted a retrospec- ulopathy, previous ipsilateral carpal normal (mild), abnormal median
tive chart review of consecutive pa- tunnel release, and recent cortico- sensory latencies similar to mild CTS
tients aged $18 years who steroid injection for CTS within in addition to prolongation of median
underwent both median nerve US 1 month of the time of US. motor latency (moderate), and pro-
and EDS between August 2014 and EDS testing and US testing were longed median motor and sensory
January 2016 at a single institution performed by two attending neuro- distal latencies, with either an absent
in the United States. Patients initially muscular specialists, board-certified or mixed nerve action potential,
presented to one of five board- by both the American Board of Elec- or low amplitude or absent thenar
certified orthopaedic hand and trodiagnostic Medicine and the CMAP in addition to possible
upper extremity surgeons at a single American Board of Psychiatry and fibrillations, reduced recruitment,
Beverlie L. Ting, MD, et al
and motor unit potential changes Table 1

(severe).23
Patient Demographics Based on the Total Number of Observations (N = 112)
per Electrodiagnostic Studies (EDS) Graded Severity Grade (Normal, Mild,
Statistical Methods Moderate, and Severe)
The association between each sono- Parameter (%) Normal Mild Moderate Severe Overall
graphic measurement and EDS
No. of observations 12 28 53 19 112
severity was evaluated using a gen-
Mean age (yr) 53.6 53.2 59.5 70.7 59.2
eralized linear mixed model (analysis
No. of females 8 (67) 20 (71) 34 (64) 13 (68) 75 (67)
of variance), to account for the cor-
No. of males 4 (33) 8 (29) 19 (36) 6 (32) 37 (33)
relation between patients. Pairwise
Diabetes 1 (8) 4 (15) 8 (15) 8 (42) 21 (19)
comparisons were evaluated with the
Tukey honest significant difference Thyroid disorder 1 (8) 6 (22) 11 (21) 1 (5) 19 (17)
test. The EDS severity was first eval- Self-reported race — — — — —
uated as a nominal categorical vari- Asian — 1 (4) 1 (2) — 2 (2)
able and then the F-test was used to African American — 3 (11) 7 (13) 6 (32) 16 (15)
test for a linear trend across severity Hispanic 2 (17) 8 (29) 5 (9) 3 (16) 18 (16)
category. Correlations between US White 10 (83) 16 (57) 36 (68) 10 (53) 72 (64)
measurements and individual EDS Unknown — — 4 (8) — 4 (4)
measurements were assessed with the
Pearson correlation.
teria. The mean wCSA in normal, cally significant differences between
The receiver operating characteristic
mild, moderate, and severe CTS all groups, with the exception of mild
curve was used to evaluate possible
measured 9.4 6 2.8 mm2, 13.4 6 versus moderate (P = 0.4219) and
cut-point values of the sonographic
2.5 mm2, 15.8 6 3.8 mm2, and moderate versus severe (0.1940). The
measurement to discriminate between
18.2 6 3.9 mm2, respectively. The test for trend demonstrated a signifi-
levels of the gold-standard EDS sever-
mean WFR in normal, mild, mod- cant linear trend in the severity group
ity. The following contrasts were
erate, and severe CTS measured (P , 0.0001) (Figure 2, B).
evaluated: (1) normal versus abnor-
1.7 6 0.5, 2.5 6 0.8, 2.8 6 1.1, and Increased wCSA and WFR each
mal (mild/moderate/severe EDS), (2)
3.3 6 0.6, respectively. markedly correlated with prolonged
normal/mild EDS versus moderate/
Comparing patients with EDS- peak latency of the SNAP, pro-
severe EDS, and (3) normal/mild/
confirmed CTS with those with nor- longed motor latency of the CMAP,
moderate EDS versus severe EDS.
mal EDS, the mean wCSA was and decreased CMAP amplitude
The Youden24 index was used to select
15.58 6 3.83 mm2 versus 9.42 6 (Figure 3).
the optimal cut-point. Sensitivity and
2.81 mm2 (P value , 0.001). The We ran three analyses to assess the
specificity were calculated for each
mean WFR in patients with and discriminative ability of wCSA: (1)
contrast. Statistical significance was
without EDS-confirmed CTS was normal versus abnormal (mild/
indicated at a two-sided P , 0.05.
2.82 6 0.97 and 1.66 6 0.51, moderate/severe EDS), (2) normal/
respectively (P , 0.0001). mild EDS versus moderate/severe
Results An association between wCSA and EDS, and (3) normal/mild/moderate
EDS severity was found (P , 0.0001). EDS versus severe EDS. The area
A total of 112 wrists (n = 112) of 78 Pairwise comparisons demonstrated under the curve (AUC) for the ability
consecutive patients with an average statistically significant differences of wCSA to discriminate between
age of 59 (range, 26 to 88) years between all groups, with the excep- normal versus abnormal (mild/
were included. We included 24 men tion of moderate versus severe moderate/severe EDS) was 0.915.
and 54 women in the study (P = 0.1621), after adjustment for The optimal cutoff point based on the
(Table 1). multiple comparisons. The test for Youden index is 10.5 mm2, which
One hundred wrists had electro- trend demonstrated a significant corresponds to a specificity of 75%
diagnostic evidence of CTS (ie, 28 linear trend in the severity group and sensitivity of 97%. For normal/
mild, 53 moderate, and 19 severe), (P , 0.0001) (Figure 2, A). mild versus moderate/severe EDS the
whereas 12 subjects had normal EDS. A significant association between AUC was 0.811. The optimal cutoff
Of the 12 patients who had normal WFR and EDS severity was also point is 13.4 mm2, which corre-
EDS, 2 of those did not meet EDS observed (P , 0.0001). Pairwise sponds to a specificity of 70% and
criteria for CTS but did meet US cri- comparisons demonstrated statisti- sensitivity of 79.2%. Finally, to
January 1, 2019, Vol 27, No 1 e19
Figure 2 88.9%. Finally, to identify severe

EDS, the AUC was 0.804. The opti-
mal cut-point is 2.53, which corre-
sponds to a specificity of 57% and
sensitivity of 94.7%.
Discussion
Buchberger et al25 was the first to

report that swelling of the median
nerve could be observed in patients
with CTS using high-resolution ultra-
sonography. Neuromuscular US has
Distal wrist crease CSA (A) and wrist-to-forearm ratio (B) correlate with
electrodiagnostic grading of carpal tunnel syndrome severity. CSA = cross- consistently proven to be a useful
sectional area screening tool in the diagnosis of
CTS.9,10,12,14-16,25 However, it remains
unclear whether US measurements of
identify severe EDS, the AUC was EDS) was 0.895. The optimal cutoff the median nerve correlate with CTS
0.772. The optimal cutoff point is point is 1.45, which corresponds to a severity as graded by electrodiagnostic
16.4 mm2, which corresponds to a specificity of 58.3% and sensitivity of criteria.9-11,13,17,19-21,26-28 This is a
specificity of 80.6% and sensitivity 100%. For normal/mild versus clinically relevant question that re-
of 63.2%. moderate/severe EDS, the AUC was mains unanswered, especially in light
The AUC for the ability of WFR 0.731. The optimal cutoff point is of recent studies that have high-
to discriminate between normal ver- 2.055, which corresponds to a speci- lighted the cost-effectiveness and
sus abnormal (mild/moderate/severe ficity of 47.5% and sensitivity of efficiency of US examinations, which
Figure 3
Distal wrist crease cross-sectional area (A-C) and wrist-to-forearm ratio (D-F) correlates with electrodiagnostic measures of
prolonged peak latency of SNAP, prolonged distal motor latency of the CMAP, and reduced CMAP amplitude.
CMAP = compound muscle action potential, CSA = cross-sectional area, SNAP = sensory nerve action potential
often require , 90 seconds to per- EDS severity. They proposed spe- rather only composite severity grades
form per patient.29,30 Furthermore, cific US measurement cutoff values by EDS criteria.
patients often report discomfort with that could be used to differentiate In this study, we examine 112
EDS, and in our anecdotal experi- between mild, moderate, and wrists in patients who presented to
ence, there are select patients who severe CTS. They reported that orthopaedic hand surgery clinics of
refuse a repeat EDS examination wCSA cutoff values of 10, 13, and five surgeons at a metropolitan ter-
based on their prior experience with 15 mm 2 were optimal to discrimi- tiary care hospital in the United
EDS. Neuromuscular US offers a nate between normal versus States. We measured both distal
diagnostic alternative to EDS, which mild, mild versus moderate, and wCSA and WFR because previous
may be better tolerated and less moderate versus severe groups, studies have suggested that WFR is
expensive. respectively.10 more sensitive in the diagnosis and
There have been several studies Numerous subsequent studies have grading of EDS severity.19 WFR
examining the utility of US in diag- also shown that higher wCSA values measurements can also serve as an
nosis of CTS with conflicting con- are associated with increased EDS internal control for individual dif-
clusions. The difficulty in interpreting severity but are limited by relatively ferences in median nerve measure-
the results of these studies can be small study populations.11,17,18,33 ments because of age, sex, or BMI.36
attributed to a number of factors. Conversely, there exist a similar We also report specific sensory and
First, reference standards used for the number of studies that observe motor EDS measurements, rather
US-based diagnosis of CTS include no correlation between median than only composite EDS severity
various combinations of clinical nerve US measurements and EDS grades. Although select pairwise
examination, the CTS-6 diagnostic severity.13,14,20,34,35 Relatively few comparisons present in our study
tool, electrodiagnostic criteria, and studies conducted in the United were not statistically significant, the
surgical outcomes.20,29 Second, there States have examined median nerve overall trend was consistent with the
exists a wide variability in US pro- US and EDS severity, especially in observation that increasing wCSA
tocols used, median nerve measure- the orthopaedic literature. In 2006, and WFR was associated with
ments reported, diagnostic criteria Wiesler et al9 conducted a study in increasing EDS severity.
followed, and training of providers. 26 patients examining 44 wrists We found optimal cutoff points to
There are reports in the literature of measuring only wCSA and found discriminate between normal versus
orthopaedic surgeons, rheumatolo- that higher values of wCSA were abnormal 10.5 mm2 (wCSA) and
gists, radiologists, and neurologists associated with EDS severity. In 1.45 (WFR), normal/mild versus
all performing these diagnostic 2014, Fowler et al29 examined 55 moderate/severe 13.4 mm2 (wCSA)
tests.10,15,20 A recent study demon- subjects with CTS-6 diagnosed CTS and 2.06 (WFR), and normal/
strated that examiner experience and concluded that median nerve US mild/moderate versus severe groups
has a significant influence on intra- has high sensitivity and specificity 16.4 mm2 (wCSA) and 2.53 (WFR).
rater agreement.31 Furthermore, compared with EDS for CTS but the Both US measurements appear use-
many of these studies have been study did not specifically examine ful. The AUC was higher for wCSA
conducted within relatively homog- US correlation with EDS severity. versus WFR in discrimination
enous populations. Normative me- Outside the orthopedic literature between normal versus abnormal
dian nerve CSA values have been in the United States, Mhoon et al15 (0.915 versus 0.895) and normal/
shown to be influenced by body published a study in 2012 in mild versus moderate severe (0.811
mass index (BMI), age, sex, and the neurology literature of 192 versus 0.731). However, the AUC
ethnicity.19,32 These variables likely symptomatic wrists and 50 control was higher for WFR versus wCSA in
account for the wide range of wCSA wrists in patients who presented to an discriminating between not severe
cutoff values suggested for the electromyography laboratory and versus severe (0.804 versus 0.772).
diagnosis of CTS, which range from found no notable correlation between Further work should consider
6.5 to 11 mm2.9,13,15,21 US measurements and EDS severity. whether some combination of these
Although some studies have Limitations of the study included a measurements could help better dis-
found a correlation between median heterogeneous control population criminate across all four levels of
nerve CSA and electrodiagnostic with a variety of neuromuscular CTS severity.
graded severity of CTS, others have diagnoses, which could conceivably Other studies have reported cutoff
not.9,14,15,19-22,26,27 In 2004, El affect median nerve measurements. point in a similar range of
Miedany et al10 noted increased Furthermore, they did not report wCSA .9 mm2 and WFR .1.4 to
mean wCSA values with increasing specific EDS measurements, but differentiate between normal and
January 1, 2019, Vol 27, No 1 e21
abnormal US tests with high sensi- of interobserver and intraobserver 7. Jablecki CK, Andary MT, Floeter MK, et al:
Practice parameter: Electrodiagnostic studies
tivity, and wCSA .17 mm and reliability. A large multicenter study in carpal tunnel syndrome report of the
WFR .2.97 for high specificity to using the same EDS and US techni- American Association of Electrodiagnostic
diagnose CTS.15 Another study done ques and diagnostic criteria would Medicine, American Academy of Neurology,
and the American Academy of Physical
in an Asian population suggested help refine the results of this study Medicine and Rehabilitation. Neurology
wCSA cutoff values of 9.5, 12.05, and allow further analysis of the 2002;58:1589-1592.
and 14.15 mm2 and WFR cutoff influence of BMI, age, sex, and eth- 8. Al-Shekhlee A, Shapiro BE, Preston DC:
values of 1.34, 1.89, and 2.2, nicity on CSA measurements. Iatrogenic complications and risks of
nerve conduction studies and needle
respectively, which suggests that The results of our study demon- electromyography. Muscle Nerve 2003;
population-based differences in strate that median nerve US mea- 27:517-526.
median nerve US measurements may surements, specifically wCSA and 9. Wiesler ER, Chloros GD, Cartwright MS,
exist.19 WFR, show a notable association Smith BP, Rushing J, Walker FO: The use of
diagnostic ultrasound in carpal tunnel
Limitations of our study include its with EDS severity. Increased wCSA syndrome. J Hand Surg 2006;31:726-732.
retrospective nature and lack of a and WFR are significantly correlated
10. El Miedany YM, Aty SA, Ashour S:
formal control group. Second, each with sensory and motor EDS find- Ultrasonography versus nerve conduction
patient had the same unmasked ings. This study finds that US can be study in patients with carpal tunnel
examiner for both EDS and US ex- used as an additional diagnostic tool syndrome: Substantive or complementary
tests? Rheumatology 2004;43:887-895.
aminations, introducing potential for CTS, including determination of
11. Padua L, Pazzaglia C, Caliandro P, et al:
bias. Third, we did not collect data severity. Carpal tunnel syndrome: Ultrasound,
points to measure interobserver and neurophysiology, clinical and patient-
intraobserver reliability. Our study oriented assessment. Clin Neurophysiol
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January 1, 2019, Vol 27, No 1 e23
Research Article
Increasing Rate of Surgical Fixation

in Four- and Five-year-old Children
With Femoral Shaft Fractures
Abstract
Ram Kiran Alluri, MD Background: The purpose of this study was to identify temporal
Andrew Sabour, BS trends in the management of pediatric femoral shaft fractures in 4- and
5-year-old children.
Nathanael Heckmann, MD
Methods: The Kids’ Inpatient Database was used to extract data on
George F. Hatch, MD patients aged 4 and 5 years with closed femoral shaft fractures. The
Curtis VandenBerg, MD frequency of nonsurgical and surgical management was calculated,
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ9/L'3=GM*R;QO.J)QWU5\OS25$%RKZH RQ
and temporal trends were evaluated.

Results: Between 1997 and 2012, the absolute increase in surgical
fixation was 35% and 58% in 4- and 5-year-old patients, respectively.
The surgical rate increased every 3 years by 13.8% in 4-year-old
patients and 7.6% in 5-year-old patients. Significant associations were
From the Keck School of Medicine of
the University of Southern California, noted based on demographics, comorbidities, and hospital
Los Angeles, CA. characteristics with management decisions.
Correspondence to Dr. Alluri: Conclusions: A clear and significant increase was noted in internal
kiranalluri3839@gmail.com fixation for pediatric femoral shaft fractures in 4- and 5-year-old
Dr. Alluri or an immediate family children, and the lower age limit for surgical management of these
member has stock or stock options fractures is decreasing.
held in AxoGen, Stryker, and Zimmer
Biomet and has received nonincome Level of Evidence: Level III. Retrospective comparative study
support (such as equipment or
services), commercially derived
honoraria, or other non–research-
related funding (such as paid travel)
from Acumed, Arthrex, and Trimed.
Dr. Heckmann or an immediate family
P ediatric femur fractures are
among the most common injuries
treated by orthopaedic surgeons.1-3
exists regarding the best treatment
modality, and many surgeons follow
an age-based algorithm where pa-
member has stock or stock options
held in Masimo, Materialise NV, and
Treatment of these fractures depends tients younger than 6 months are
NuVasive. Dr. Hatch or an immediate on factors such as age, size and weight treated with a Pavlik harness and
family member is a member of a of a patient, fracture pattern, soft- patients aged between 6 months to 6
speakers’ bureau or has made paid tissue integrity, comorbidities, con- years are treated with spica casting,
presentations on behalf of Arthrex and
serves as a paid consultant to Arthrex.
current injuries, family preference, and typically without traction. Older
Neither of the following authors nor surgeon preference. Despite rare cases children aged between 6 and 10
any immediate family member has of significant morbidity, the over- years are often treated with flexible
received anything of value from or has whelming majority of pediatric pa- IM nailing, whereas children in this
stock or stock options held in a com-
mercial company or institution related
tients with femoral shaft fractures are age group with length unstable
directly or indirectly to the subject of expected to heal with normal function fracture patterns may be treated with
this article: Mr. Sabour and and radiographic alignment.4-6 submuscular plating. A lateral entry
Dr. VandenBerg. Treatment options for the man- rigid IM nail may be used in children
J Am Acad Orthop Surg 2019;27: agement of pediatric femoral shaft older than 10 years.7,8 The American
e24-e32 fractures include Pavlik harness Academy of Orthopaedic Surgeons
DOI: 10.5435/JAAOS-D-17-00064 application, spica casting, external Clinical Practice Guideline recom-
fixation, submuscular plating, and mends, with moderate strength,
Academy of Orthopaedic Surgeons. flexible or rigid intramedullary (IM) spica casting of most diaphyseal
nailing.7 Currently no consensus femur fractures in children aged
Ram Kiran Alluri, MD, et al
6 months to 5 years and, with limited Figure 1

strength, the use of flexible IM nails
in patients aged 5 to 11 years.9
The success of flexible IM nailing of
pediatric femur fractures has resulted
in a general transition away from
nonsurgical management toward
surgical intervention. 10-12 Specifi-
cally in younger patient cohorts, the
relative safety and efficacy of flexible
IM nail placement along with greater
ease of postoperative care compared
with spica casting have resulted in a
progressive trend toward surgical
management.13 The treatment of pre-
school children, aged 4 to 5 years, is
of particular interest and remains
controversial. A recent study demon-
strated no difference in clinical or
radiographic outcomes when com-
paring spica casting to flexible IM
nailing in this age group.4
The purpose of this study was to
identify nationwide temporal trends in
the management of pediatric femoral
shaft fractures in 4- and 5-year-old
children while identifying potential
demographic, surgical, and hospital
characteristics that may predict surgi-
cal versus nonsurgical management.
We hypothesized that the surgical
management of femoral shaft frac-
tures in patients between ages 4 and 5
years has progressively increased dur-
ing the period examined in this study.
Flow diagram showing patient selection (CR = closed reduction, CRIF = closed
reduction and internal fixation, OR = open reduction, ORIF = open reduction and
internal fixation). The number of patients listed represents weighted numbers.
Methods
The Kids’ Inpatient Database (KID) participating states. The Healthcare characteristics of the poststratified
is a national hospital discharge Cost and Utilization Project defines a hospitals.14 The weighting algorithm
database of patients younger than community hospital as a nonfederal, can allow for reliable estimates of
21 years. It is maintained by the short-term (less than 30-day stay) national volumes for a given diagnosis
Healthcare Cost and Utilization Project hospital that is accessible to the or procedure, and this algorithm has
and is the largest publicly available public. The KID database uses a been previously validated.15
pediatric database of inpatient hos- sample of pediatric discharges from Data from the 1997, 2000, 2003,
pitalizations in the United States. all hospitals in the sampling frame, 2006, 2009, and 2012 data sets were
The release of data sets on a triennial selecting 10% of “normal newborns” compiled and retrospectively re-
basis began in 1997, and these con- born in the hospital and 80% of other viewed. At the time of the study, the
tain information on approximately pediatric cases from each frame 2012 data set was the most recent
2 to 3 million pediatric inpatient hospital.14 The KID database pro- data set. Patients aged between zero
discharges occurring in community, vides sampling weights for obtaining and eight years were identified using
nonrehabilitation hospitals across national estimates, which are based on data filters. The primary purpose of
January 1, 2019, Vol 27, No 1 e25
Increasing Rate of Surgical Fixation in Four- and Five-year-old Children
Figure 2 The counts of inpatient admissions

were weighted using provided weights
from the KID database to generate
national estimates for the “CR” and
“IF” groups. All reported numbers
are national estimates based on the
weights provided by the KID data-
base. Statistical analysis comparing
demographic, surgical, and hospital-
level variables between the two
groups was performed using STATA
13.0 (StataCorp LP). Fisher exact
and chi-square analyses were per-
formed to compare categoric data
between treatment groups and
populations treated at different
hospital types. For continuous or
discrete variables, a Student t-test
was used. Surgical trends over time
Graph showing the comparison of CR versus IF between 1997 and 2012 for were analyzed using linear regres-
ages zero to 8 years. CR = closed reduction, IF = internal fixation
sion, and the P value of the slope
from the line of best fit was cal-
this study was to identify trends designated ICD-9-CM procedure culated. Categoric variables included
between nonsurgical and surgical codes, a bilateral procedure or revi- a prevalence percentage, whereas
management of femoral shaft frac- sion surgery, or having undergone an continuous/discrete variables included
tures in patients aged between 4 and 5 apparent OR without IF (ICD-9-CM an SD. P # 0.05 was considered
years. We included ages zero to 3 procedure code 7925) were excluded. statistically significant.
years and 6 to 8 years to serve as rel- Patients who underwent CR without
ative comparison groups because IF were designated as one group,
treatment in these age groups is “CR.” Patients who underwent either Results
less controversial with nonsurgical CRIF or OR of femur fracture with IF
management almost always recom- ORIF were combined into a second Between 1997 and 2012, 15,583
mended for the zero to 3 years age group, “IF.” Figure 1 illustrates our pediatric femoral shaft fractures
group and generally surgical manage- patient selection process. (71%) were treated with closed man-
ment for the 6 to 8 years age group.3,16 Closed femoral shaft fractures in agement and 6,417 (29%) were
After identifying all patients aged pediatric inpatients of ages 4 and treated with IF in children aged ,8
between zero and 8 years, we used 5 years were analyzed in detail in years. In patients aged less than 1 year,
the International Classification of terms of demographic, surgical, and 1,356 femoral shaft fractures (98%)
Diseases, Ninth Revision, Clinical hospital/institutional characteristics were treated with closed management,
Modification (ICD-9-CM) diagnos- provided by the KID database. Inpa- whereas in 8-year-old children, 1,234
tic code 82101 to identify patients tient variables such as “risk of mor- (73%) were treated with IF (Figure 2).
with a closed femoral shaft fracture. tality” and “severity of illness” were Linear regression demonstrated that
This subset of patients was again also analyzed. The “severity of ill- surgical fixation increased by 9.1%
filtered using an ICD-9-CM proce- ness” variable is based on a numeric (P , 0.0001) for every integral in-
dure code of either 7905, 7915, value ranging from 1 to 4, with 1 crease in age up to 8 years.
7925, or 7935 describing closed representing minor loss of function Over the 15-year period that this
reduction (CR) of femur fracture and 4 representing extreme loss of study examined, in 4-year-old
without internal fixation (IF), CR of function. The KID database assigns a patients, a total of 1,285 femoral shaft
femur fracture with IF (CRIF), open numeric severity of illness value at fractures (70%) were treated with
reduction (OR) of femur fracture the time of admission using an closed management and 554 (30%)
without IF, and OR of femur frac- algorithm that factors in the under- were treated with IF. In 1997, 300
ture with IF (ORIF), respectively. All lying comorbidities and primary and (87%) were treated with closed man-
patients with more than 1 of the secondary diagnoses. agement and 44 (13%) were treated
with IF (Figure 3). In 2012, 149 Figure 3

(52%) were treated with closed
management and 136 (48%) were
treated with IF (Figure 3). The abso-
lute increase in IF over the 15-year
period was 35%. Linear regression
demonstrated that surgical fixation
increased by 14% (P = 0.0003) every
three years from 1997 to 2012.
For the same 15-year period, in
5-year-old patients, a total of 904
femoral shaft fractures (53%) were
treated with closed management and
810 (47%) were treated with IF. In
1997, 334 (84%) were treated with
closed management and 64 (16%)
were treated with IF (Figure 4). In
2012, 62 (26%) were treated with
closed management and 178 (74%)
were treated with IF (Figure 4). Graph showing the comparison of CR versus IF between 1997 and 2012 for
patients of age 4 years. CR = closed reduction, IF = internal fixation
The absolute increase in IF over the
15-year period was 58%. Linear
regression demonstrated that sur-
gical fixation increased by 8% Figure 4
(P = 0.003) every 3 years from 1997
to 2012.
Combined analysis of demographic
variables from patients aged both 4
and 5 years demonstrated no differ-
ences in closed management versus IF
based on sex, race, or payment method
(Table 1). Patients from families with
higher median household incomes
were more likely to undergo closed
management (P = 0.048) (Table 1).
In both the 4- and 5-year-old patient
groups, patients with higher loss of
function were more likely to undergo
IF than receive closed management
(P , 0.001) (Table 2). No significant
difference was noted in the mortality
risk between the two treatment groups Graph showing the comparison of CR versus IF between 1997 and 2012 for
(P = 0.517) (Table 2). Discharge dis- patients of age 5 years. CR = closed reduction, IF = internal fixation
position was also similar (P = 0.182),
and more than 90% of children were
routinely discharged after closed (P , 0.0001) at $28,200 and ownership (P = 0.101) (Table 3). Both
management or IF. The length of $17,400, respectively (Table 2). the region and teaching status of the
stay was approximately 4 days Analysis of hospital variables hospital demonstrated significant
regardless of treatment modality (P = demonstrated no differences in closed differences. Teaching hospitals were
0.559) (Table 2); however, total management or IF for 4 and 5 year more likely than nonteaching hospi-
hospital charge was significantly olds based on the percentage of pedi- tals to use IF (P = 0.034) (Table 3).
higher for patients receiving IF atric discharges (P = 0.083), hospital Last, significant differences were
compared with closed management bed size (P = 0.249), or hospital noted between geographic regions
January 1, 2019, Vol 27, No 1 e27
Table 1 increase in IF compared with non-

surgical management among 4 -and
Comparison of Demographic Variables in Patients of Ages 4 and 5 Years
Undergoing Closed Reduction Versus Internal Fixation 5-year-old children with closed fem-
oral shaft fractures between 1997
Closed Internal
Demographics Reduction Fixation P Value and 2012. Several demographic,
surgical, and hospital variables
Sex (female) 559 (25.51%) 357 (26.16%) 0.759 were associated with variations in
Race 0.104 management. Although previous
White 1,070 (65.05%) 674 (63.67%) — studies have evaluated trends in
Black 237 (14.42%) 159 (15.02%) — pediatric femoral shaft fracture
Hispanic 222 (13.46%) 143 (13.54%) — management, this is the first study to
Asian or Pacific Islander 37 (2.22%) 9 (0.85%) — specifically assess 4- and 5-year-old
Native American 15 (0.91%) 11 (1.06%) — children, for which management is
Other 65 (3.93%) 62 (5.87%) — controversial.1,4,10,16-19
Primary payment method 0.074 The increased use of IF in 4- and
Medicare 1 (0.06%) 3 (0.20%) — 5-year-old children with closed femo-
Medicaid 742 (33.96%) 540 (39.72%) — ral shaft fractures is likely due to in-
Private, including HMO 1,217 (55.67%) 691 (50.88%) — creased utilization of flexible IM nails
Self-pay 125 (5.73%) 62 (4.59%) — in lieu of spica casting. Although the
No charge 0 (0.00%) 0 (0.00%) — database used for this study does not
Other payment 100 (4.58%) 63 (4.61%) — allow for assessment of the type of IF
Median household income 0.048 used, it can reasonably be assumed
0–25th percentile 579 (27.20%) 379 (28.43%) — that most of the 4 -and 5-year-old
26–50th percentile 531 (24.96%) 349 (26.16%) — patients receiving IF for a femoral
51–75th percentile 449 (21.10%) 331 (24.77%) — shaft fracture were treated with flexi-
76–100th percentile 569 (26.74%) 275 (20.64%) — ble IM nails.
Some studies have demonstrated
HMO = health maintenance organization
that spica casting can result in higher
rates of malunion, delayed hip and
knee range of motion, slower mobi-
Table 2
lization, and poorer functional out-
Comparison of Inpatient Variables in Patients of Ages 4 and 5 Years
comes compared with flexible IM
Undergoing Closed Reduction Versus Internal Fixation
nails.13,20,21 Aside from clinical and
Closed Internal radiographic outcomes, certain socio-
Inpatient Variables Reduction Fixation P Value
economic factors may affect femur
Severity of illness ,0.001 fracture management decisions. Out-
Minor loss of function 5 (0.44%) 0 (0.00%) — come surveys have revealed that flex-
Moderate loss of function 1,038 (92.76%) 897 (79.37%) — ible nails may decrease the burden of
Major loss of function 60 (5.33%) 202 (17.92%) — care on family members because spica
Extreme loss of function 16 (1.46%) 31 (2.71%) — casts can be difficult to take care of.22
Risk of mortality 0.517 Furthermore, spica casting may force
Minor likelihood of dying 1,063 (94.98%) 1,070 (94.69%) — parents to take increased time off work
Moderate likelihood of dying 30 (2.68%) 34 (3.01%) — to care for their child who may not be
Major likelihood of dying 25 (2.21%) 20 (1.78%) — allowed to return to school until the
Extreme likelihood of dying 1 (0.13%) 6 (0.52%) — cast is off.20,23 Although several re-
Length of stay 4.19 6 5.96 4.04 6 5.45 0.559 ported benefits of flexible nailing exist,
Total charge (dollars) 17,400 6 26,600 28,200 6 31,500 ,0.001 surgery carries a risk of general anes-
thesia complications, infection, blood
loss, and damage to surrounding
with respect to management: the Conclusions neurovascular structures along with
South and Midwest more frequently surgical scarring and postoperative
using IF compared with the West and This study using a national pediatric skin irritation. In addition, a second
Northeast (P , 0.0001) (Table 3). database demonstrated a significant surgery is usually required or
recommended to remove the flexible Table 3

nails.4,24 Although the data from this
Comparison of Hospital-Level Variables in Patients of Ages 4 and 5 Years
study show a clear increasing trend Undergoing Closed Reduction Versus Internal Fixation
toward the use of IF, the manage-
Closed Internal
ment of closed femoral shaft frac- Hospital Variablesa Reduction Fixation P Value
tures in 4- and 5-year-old children
still remains without consensus. % Of pediatric discharges 38.9% 6 30.8% 42.0% 6 33.2% 0.083
The lack of consensus can be Bed size of hospital 0.249
attributed to limitations of studies Small 202 (13.36%) 183 (15.28%) —
assessing this age group, along with Medium 387 (25.57%) 273 (22.78%) —
numerous patient characteristics, Large 924 (61.07%) 743 (61.94%) —
radiographic parameters, socioeco- Ownership of hospital 0.101
nomic variables, and surgeon prefer- Government/private 977 (75.06%) 711 (80.31%) —
collapsed category
ences influencing management
Government, nonfederal, 54 (4.12%) 43 (4.85%) —
decisions.4,6,13 A recent retrospective public
cohort study by Ramo et al4 Private, nonprofit, voluntary 148 (11.41%) 79 (8.87%) —
demonstrated similar clinical and Private, invest-own 58 (4.44%) 20 (2.25%) —
radiographic outcomes in 4- and 5- Private, collapsed category 65 (4.97%) 33 (3.71%) —
year-old patients treated with spica Region of hospital ,0.001
casting or flexible nails, but average Northeast 319 (20.54%) 169 (13.45%) —
follow-up was less than 1 year for Midwest 374 (24.02%) 399 (31.74%) —
both groups. A similar retrospective South 449 (28.85%) 395 (31.43%) —
study by Heffernan et al13 compar- West 414 (26.59%) 294 (23.38%) —
ing spica casting with flexible nails in Teaching status of hospital 0.034
children aged 2 to 6 years demon- Nonteaching 404 (31.05%) 224 (25.33%) —
strated similar time to union between Teaching 897 (68.95%) 661 (74.67%) —
the two groups, but the flexible nail
group had shorter times to inde- a
The percent of pediatric discharges is defined as the number of total pediatric patients
pendent ambulation and returned to discharged divided by the total number of patients discharged from a given hospital.
full activity earlier than the spica

casting group. Average follow-up in
this study was 1.2 6 1.5 years for the an elastic IM nail. Ultimately, no seen in median household incomes
spica group and 3.7 6 2.7 years for clear conclusion can be drawn from the 75th to 100th percentile,
the flexible nail group, which was a about the superiority of either where a 7% higher rate of CR was
point of concern brought up in the spica casting or flexible nailing of noted. Although this was statistically
commentary by Price.25 Price validly closed pediatric femoral shaft significant, the clinical significance is
argues that a minimum of 2-year fractures in 4- and 5-year-old chil- unknown. It is possible that patients
follow-up should be obtained to dren in the absence of well-defined from families with more economic
adequately assess for radiographic prospective studies with clinical and resources would prefer nonsurgical
overgrowth of the femur, which can radiographic outcomes and adequate treatment to avoid a first and pos-
occur for up to 3.5 years after midterm follow-up. sibly second surgery while having
treatment.26 The less than 2-year Our analysis of demographic vari- more means to care for a potentially
follow-up in the spica casting group ables for patients aged 4 and 5 years burdensome spica cast. On average,
and some patients in the flexible nail demonstrated no differences in race, families may require up to three
group in the study by Heffernan et al13 sex, or insurance status between weeks off to care for these patients
and the less than 1-year follow-up of children receiving closed treatment which can have a significant finan-
all patients in the study by Ramo et al4 versus IF. This is consistent with cial impact, particularly in single-
likely inadequately assess femoral similar studies in older children.18 provider homes.23
overgrowth. At the time of treatment, However, we demonstrated that With respect to surgical variables
overgrowth can be mitigated with patients from families with higher and patient selection criteria, our
spica casting by intentionally im- median household income were study demonstrated that 4- and
plementing a 1-cm overlap of the more likely to undergo closed treat- 5-year-old children with higher pre-
fracture, but this is not possible with ment. The greatest difference was operative loss of function were more
January 1, 2019, Vol 27, No 1 e29
likely to receive IF, whereas those due to postoperative pain control. however, that the distribution of
with lower loss of function were more Other studies examining older chil- fracture patterns remained relatively
likely to undergo closed manage- dren treated with spica casting have constant over the 15-year period
ment. This difference in treatment reported longer lengths of stay with studied, and therefore, our results
may be due to surgeons electing for IF spica casting, but this was mostly due demonstrating increased rates of IF
in patients with greater loss of func- to the use of traction.21,28 A second- for femoral shaft fractures in 4- and
tion, such as polytrauma patients, to ary analysis of our data demonstrated 5-year-old patients hold true. Simi-
facilitate postoperative rehabilitation that 4 and 5 year olds undergoing larly, this study categorized patients
or because spica casting in a patient CR received traction less than primarily on chronological age,
with multiple injuries can be techni- 10% of the time (see Appendix I, which may not account for variability
cally challenging. This finding is Supplemental Digital Content 1, in patient weight, body mass index,
consistent with previous studies in http://links.lww.com/JAAOS/A124). skeletal maturity, or other patient
which patients in this age group with Overall, the reported 4-day length of factors that could affect treatment
greater mechanisms of injury or stay for spica casting is higher than decisions. The use of current proce-
polytrauma were more likely to be to be expected. This is likely due to dural codes or ICD-10 codes may
treated with flexible nailing.4,13 the sampling process of the KID offset this limitation in the future,
From a financial standpoint, inpa- database, which captures only inpa- but are currently not available in any
tient charges were $10,800 higher in tient admissions. It is not uncommon national pediatric database.
the IF group. This was an expected for a spica cast to be placed in the Further limitations of the KID data
finding presumably due to implant emergency department, followed set include its utilization of only dis-
and operating room cost; many hip by discharge after a brief period of charge records to analyze patient
spica casts can be applied in a proce- observation; therefore, our data may data, and therefore, analysis of sur-
dure room or emergency department be overestimating the true length of gical or other clinically relevant var-
and do not require consumption stay for spica casting. iables is not feasible. In addition, this
of operating room resources.27 In Last, out study demonstrated several database analysis may have under-
addition, the actual final cost of differences based on hospital charac- reported the rates for CR because
flexible nailing may be higher because teristics. Teaching hospitals were more some institutions may perform CR
our study does not account for costs likely to use IF in 4- and 5-year-old and spica casting in an emergency
associated with removal of the nail, children. This may be secondary to department setting without inpatient
which can occur in greater than half teaching hospitals having pediatric admission; these instances would
of patients.13 Conversely, the final orthopaedic surgeons on staff who not be captured by the KID. More-
cost of spica casting could be higher may be more comfortable placing over, this study categorized patients
because of costs associated with ad- flexible nails in younger children as either having undergone CR or IF,
justing the cast, replacing the cast, or and managing them postoperatively. but data were not available regarding
having to covert to surgical manage- There may also be financial motive the type of IF used; the authors of
ment; these costs would not be cap- partially contributing to the trend for this study chose to refer to the IF
tured by the KID database. Previous surgical management in younger pa- group as primarily being flexible IM
studies have demonstrated no differ- tients; flexible IM nailing has a reim- nailing. There is likely a smaller per-
ence in cost between the two treat- bursement rate more than three times centage of the IF group that under-
ment options.21 higher than placement of a spica cast. went another form of IF, such as
Length of inpatient stay can also There are several limitations of this submuscular plating. In addition,
significantly influence hospital charg- study. First, we used a national data- it is possible that patients in the
es. In our study, the length of stay was base that is dependent on analyzing CR group actually received external
similar, 4 days, for both treatment ICD-9 codes to isolate procedures and fixation and not a spica cast, but
groups. The literature reports mixed diagnosis. This lends our data subject analysis demonstrated that this was
results when comparing length of stay to coding error and also prevents us less than 2% of patients (data not
between these two treatment modali- from differentiating between various presented). For the purposes of
ties. Jauquier et al6 reported that forms of IF. Perhaps the most signifi- this analysis, the authors did not feel
median hospital stay was 1 day for cant limitation of this study is that we that this potential heterogeneity of
spica casting and 4 days for patients could not assess fracture pattern, fixation choices changed the con-
receiving a flexible nail in patients which is a critical factor when decid- clusions of the study.
aged 1 to 4 years. The longer length ing to elect for nonsurgical or surgical Over a 15-year period, the man-
of stay with surgical treatment was management. It is a valid assumption; agement of pediatric femoral shaft
fractures in 4- and 5-year-old chil- 2. Sahlin Y: Occurrence of fractures in a MD, Agency Healthc Res Qual, 2003,
defined population: A 1-year study. Injury pp 1-30.
dren has progressively shifted. 1990;21:158-160.
Recently, more surgeons are electing 15. Agency for Healthcare Quality and
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for surgical management with IF, and Operative stabilization of pediatric femur Database comparative Analysis. https://
correspondingly less are using closed fractures. Orthop Clin North Am 1994;25: www.hcup-us.ahrq.gov/db/nation/kid/kid_
635-650. 2012_introduction.jsp. Accessed September
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Hooe BS, Snoddy MC, Jo CH: 16. Heyworth BE, Galano GJ, Vitale MA,
cause of this shift in management is Intramedullary nailing compared Vitale MG: Management of closed
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warrants further investigation. The fractures in four and five-year-old to 10: National practice patterns and
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5. Flynn JM, Garner MR, Jones KJ, et al:
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follow-up. Both spica casting and with the traditional spica cast. J 1987 and 2005. J Pediatr Orthop 2011;
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Immediate hip spica is as effective as, but
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2004;86:770-777.
10. Buckley SL: Current trends in the treatment
of femoral shaft fractures in children and 22. Lehmann CL, Anderson JT,
References adolescents. Clin Orthop Relat Res 1997; Hoernschemeyer DG, et al: Treatment of
338:60-73. femur fractures in children ages 2-6: A
multi-center prospective trial. Presented
Evidence-based Medicine: Levels of 11. Lascombes P, Haumont T, Journeau P: at the Pediatric Orthopaedic Society of
evidence are described in the table of Use and abuse of flexible intramedullary North America (POSNA) Annual
nailing in children and adolescents. Meeting, Hollywood, CA, April 30,
contents. In this article, references 5, J Pediatr Orthop 2006;26:827-834. 2014.
21, and 22 are level II studies. Ref-
12. Buechsenschuetz KE, Mehlman CT, Shaw 23. Hughes BF, Sponseller PD, Thompson
erences 1, 2, 4, 6, 12, 13, 16-20, and KJ, Crawford AH, Immerman EB: JD: Pediatric femur fractures: Effects of
26-28 are level III studies. References Femoral shaft fractures in children: spica cast treatment on family and
Traction and casting versus elastic stable community. J Pediatr Orthop 1995;15:
23 and 24 are level IV studies.
intramedullary nailing. J Trauma 2002; 457-460.
53:914-921.
References printed in bold type are 24. Levy JA, Podeszwa DA, Lebus G, Ho CA,
those published within the past 5 13. Heffernan MJ, Gordon JE, Sabatini CS, Wimberly RL: Acute omplications
et al: Treatment of femur fractures in associated with removal of flexible
years. young children: A multicenter intramedullary femoral rods placed for
comparison of flexible intramedullary pediatric femoral shaft fractures. J Pediatr
1. Hinton RY, Lincoln A, Crockett MM, nails to spica casting in young children Orthop 2013;33:43-47.
Sponseller P, Smith G: Fractures of the aged 2 to 6 years. J Pediatr Orthop 2015;
femoral shaft in children. Incidence, 35:126-129. 25. Price CT: The Conclusions Reached
mechanisms, and sociodemographic risk by MJ Heffernan et al, may be
factors. J Bone Joint Surg Am 1999;81: 14. Introduction to the HCUP Kids’ incorrect (MJ Heffernan, et al,
500-509. Inpatient Database (KID). Rockville, “Treatment of femur fractures in
January 1, 2019, Vol 27, No 1 e31
young children: A multicenter conservative treatment for femoral and Comparison of reduction, complications,
comparison of flexible intramedullary tibial shaft fractures in children. Chir and hospital charges. J Pediatr Orthop
nails to spica casting in young children Organi Mov 2008;91:13-19. 2010;30:813-817.
aged 2 to 6 years”). J Pediatr Orthop
2016;36:e38. 27. Mansour AA III, Wilmoth JC, Mansour 28. Reeves RB, Ballard RI, Hughes JL:
AS, Lovejoy SA, Mencio GA, Martus JE: Internal fixation versus traction and
26. Stilli S, Magnani M, Lampasi M, Immediate spica casting of pediatric casting of adolescent femoral shaft
Antonioli D, Bettuzzi C, Donzelli O: femoral fractures in the operating fractures. J Pediatr Orthop 1990;10:
Remodelling and overgrowth after room versus the emergency department: 592-595.
Research Article
Day of Admission is Associated

With Variation in Geriatric Hip
Fracture Care
Abstract
Matthew R. Boylan, MD, MPH Introduction: The transition to bundled payment reimbursement for
Aldo M. Riesgo, MD geriatric hip fractures has incentivized the identification of avoidable
inefficiencies in the cost and quality of care. Although a “weekend
Carl B. Paulino, MD
effect” has been described with regard to hip fracture mortality,
Nirmal C. Tejwani, MD
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ9*)()T[V,(L4934HU($8O,)3-LW-X':X,&$$Y4X::Q\H$J RQ
measures of efficiency according to the day of hip fracture admission

are currently unclear.
Methods: We identified 62,303 patients aged 65 years or older with
a primary diagnosis of femoral neck or intertrochanteric hip fracture
From the Department of Orthopaedic in the New York Statewide Planning and Research Cooperative
Surgery, NYU Langone Health System between 2009 and 2014. Outcome measures included
(Dr. Boylan, Dr. Riesgo, and
preoperative delay, postoperative length of stay (LOS), and cost
Dr. Tejwani), and the Department of
Orthopaedic Surgery, SUNY of admission.
Downstate Medical Center College of Results: Preoperative delay was longer for weekend admissions, but
Medicine (Dr. Paulino), New York, NY.
shorter for admissions on Wednesday, Thursday, and Friday.
Correspondence to Dr. Boylan: Postoperative LOS was longer for admissions on Tuesday,
matt.boylan@gmail.com
Wednesday, and Thursday. Discharge rates varied considerably
Dr. Paulino or an immediate family according to the day of admission, ranging from 12% to 43% by
member is a member of a speakers’
bureau or has made paid hospital day 4 and 53% to 72% by hospital day 6. No differences in cost
presentations on behalf of Depuy according to day of admission were found once preoperative delay
Synthes and Ethicon. Dr. Tejwani or and postoperative LOS were accounted for.
an immediate family member is a
member of a speakers’ bureau or has Discussion: Notable variation exists in hospitalizations for geriatric
made paid presentations on behalf of hip fracture depending on the day of admission. Our data suggest the
and serves as a paid consultant to
presence of a weekend effect, in which changes in staffing of surgical,
Zimmer Biomet and Stryker and
serves as a board member, owner, medical, and ancillary services lead to increased waiting times for
officer, or committee member of the surgery for new admissions and delays in discharge of early- and mid-
American Academy of Orthopaedic
Surgeons, the Foundation of
week admissions.
Orthopaedic Trauma, and the Level of Evidence: Level III, retrospective study
Orthopaedic Trauma Association.
Neither of the following authors nor
H
received anything of value from or has ip fracture is a common cause years, the Centers for Medicare &
stock or stock options held in a
of hospitalization in the geriat- Medicaid Services has included hip
related directly or indirectly to the ric population, accounting for more fracture care in alternative payment
subject of this article: Dr. Boylan and than 250,000 admissions in the United models, including Bundled Payments
Dr. Riesgo. States annually.1 Although notable for Care Improvement and Com-
J Am Acad Orthop Surg 2019;27: costs associated with hip fracture prehensive Care for Joint Replace-
e33-e40 surgery and rehabilitation exist, ment. Both of these initiatives replace
DOI: 10.5435/JAAOS-D-17-00143 treatment is highly cost-effective, the traditional fee-for-service reim-
giving patients an opportunity to bursement system with a single bun-
Academy of Orthopaedic Surgeons. recover their preinjury ambulatory dled payment that is shared among the
and functional status.2,3 In recent providers and facilities responsible for
January 1, 2019, Vol 27, No 1 e33
Variation in Geriatric Hip Fracture Care
delivering inpatient and postdischarge contain any protected health infor- across all outcomes. After exclusions,
care. For geriatric hip fracture pa- mation, this study was determined to we had a final cohort of 62,303 pa-
tients, inpatient services typically be exempt by our institutional review tients with a geriatric hip fracture
include orthopaedic surgery, hospi- board. This study had no sources of (Figure 1).
talist, social work, physical therapy, institutional or external funding.
radiology, and nursing. Postdischarge Timing of Admission and
care includes rehabilitation, home
Cases Surgery
services, and outpatient clinic visits.4
With alternative payment models We created an initial cohort of We extracted the date as well as the day
now linking reimbursement to qual- 89,841 admissions with the pri- and hour of the week that the admis-
ity and cost, a growing need to iden- mary International Classification of sion occurred. This represented when
tify inefficiencies of orthopaedic care Diseases, Ninth Revision (ICD-9), the patient was admitted to the hospi-
exists. In our experience, hip fracture diagnosis codes for closed femoral tal. We defined day admission from 7
care on the weekends can potentially neck fracture (ie, 820.00, 820.01, AM to 6 PM, and night admission from
be plagued by inefficiencies that can 820.02, 820.03, 820.09, 820.8) or 7 PM to 6 AM The time of presentation
result in delays for both surgery and closed intertrochanteric femur frac- to the emergency department was not
postoperative discharges. Although a ture (ie, 820.21). To ensure that only available. The date of surgery was
“weekend effect” has been described surgically managed hip fractures extracted, but the time of surgery was
with regard to mortality with hip were included, we retained only not available.
fractures,5 we hypothesize that a those patients with a primary pro-
similar effect exists with regard to cedure code of primary total hip Covariates
costs and length of stay (LOS). To arthroplasty (ie, 81.51), hemiarthro- We extracted patient demographics
assess the validity and potential im- plasty (ie, 81.52), or internal fixation including age (in years), sex (ie, male
plications of our observations, we of the hip (ie, 78.55, 79.15, 79.35). or female), race (ie, white or non-
used a large statewide database to We then excluded admissions with no white), insurance (ie, government or
conduct a retrospective cohort study identification code and patients with private/other), and year of ad-
and analyze the variation in hospi- repeat admissions, to identify 79,214 mission (ie, 2009 through 2014).
talizations for geriatric hip fracture unique patients with a hip fracture. Comorbidities were assessed using
according to the day of the week that To capture low-energy geriatric the Charlson and Deyo scoring method
the admission occurred. hip fractures, we excluded patients for ICD-9 coding.6
younger than 65 years and poly- We also extracted clinical covariates
trauma patients with a concomitant including fracture location and surgi-
Methods long-bone fracture or injury to the cal procedure. Fracture location was
head, spine, chest, abdomen, or defined using the primary ICD-9
Database pelvis. Patients who died during their diagnosis code and categorized as
The New York Statewide Planning admission were excluded because femoral neck (ie, 820.00, 820.01,
and Research Cooperative System these patients were not discharged 820.02, 820.03, 820.09, 820.8) or
(SPARCS) is a comprehensive health- from the hospital. Patients who intertrochanteric (ie, 820.21). Surgi-
care data reporting system established received surgery more than 7 days cal procedure was defined using the
by the New York State Department of after admission were also excluded primary ICD-9 procedure code and
Health (https://www.health.ny.gov/ because this condition may have was categorized as fixation (ie, 78.55,
statistics/sparcs/). This database con- represented a fracture that occurred 79.15, or 79.35) or arthroplasty (ie,
tains all hospital admissions that take after admission or an extremely 81.51 or 81.52).
place within New York State annu- medically unstable patient who would
ally. Each record includes patient not subject to typical discharge
demographics as well as details of the patterns. Patients with missing race Outcomes
clinical course, including medical were excluded because we could not We calculated the LOS in days for
diagnoses and surgical procedures. adjust for this variable in regression each admission. Preoperative delay
The database creates a unique iden- models. Patients with missing data represented the number of days
tification code for each patient, al- in outcome calculations including between admission and surgery, with
lowing researchers to retrospectively charges, cost:charge ratios, or date postoperative LOS representing the
follow patients. Because our version of surgery were excluded to main- number of days between surgery and
of the SPARCS database did not tain the same cohort of patients discharge. The day of admission was
Matthew R. Boylan, MD, MPH, et al
considered hospital day 0, with the Figure 1

unit of a “day” representing the
number of midnights that the patient
subsequently spent in the hospital.
Because calculations were based on
dates and not times, values were not
convertible to hours in this study.
We extracted the charge that was
billed by the hospital to the patient’s
insurer for the admission and ad-
justed values to 2016 United States
dollars ($) using inflation rates pro-
vided by the Consumer Price Index.
The relevant inflation rates were
10.112% for 2009, 10.487% for
2010, 8.704% for 2011, 5.375% for
2012, 3.238% for 2013, and 1.742%
for 2014. Cost values were derived
using hospital inpatient cost trans-
parency data provided by the New
York State Department of Health
(https://health.data.ny.gov/Health/
Hospital-Inpatient-Cost-Transparency-
Beginning-200/7dtz-qxmr/about). For
each All Patient Refined Diagnosis
Related Group (APR-DRG) and its
four Severity of Illness levels, we
defined the cost:charge ratio as the
mean cost of admission divided
by the mean charge of admission.
Cost:charge ratios were specific to
each APR-DRG and each Severity
Study cohort flowchart showing that some patients account for multiple
of Illness at a given hospital in a exclusions. THA = total hip arthroplasty
given calendar year between 2009
and 2014.
tive delay, postoperative LOS, and which we compared the likelihood
cost. Geometric means were selected of patients receiving surgery within
Statistical Analysis over arithmetic means because they 2 days of admission according to
To describe patient characteristics ac- are less influenced by outlier values. the day of admission. This analysis
cording to the day of admission, we To calculate the magnitude and sig- described unadjusted rates using pro-
used means with standard deviations nificance of differences for each out- portions with exact 95% Clopper-
for continuous variables and frequency come according to day of admission, Pearson confidence intervals and a
tables with proportions for categorical we used mixed effects linear regression multivariable-adjusted mixed effects
variables. We calculated the signifi- models that controlled for hospital logistic regression model. We also
cance of daily differences in each vari- and year of surgery as random effects constructed a secondary multivariable-
able using analysis of variance tests for variables and age, sex, race, insurance, adjusted regression model of cost,
continuous variables and chi-squared Deyo score, fracture location, surgi- where we added preoperative delay
tests for categorical variables. For the cal procedure, and time of ad- and postoperative LOS to the list of
P values we reported, we used the mission as fixed effects variables. fixed effects variables. We per-
Holm-Bonferroni method to correct Monday admissions were used as the formed logarithmic transformations
for multiple comparisons.7 reference group in all regression on each outcome variable to nor-
We used geometric means to models. We performed a secondary malize its right-skewed distribution,
report daily averages of preopera- analysis of preoperative delay in assigning a value of 0.001 to
January 1, 2019, Vol 27, No 1 e35
Table 1
Patient Characteristics, According to Day of Hip Fracture Admission
Day of Admission
Characteristic Monday Tuesday Wednesday Thursday Friday Saturday Sunday P Value
Patients, N 9,059 9,190 9,033 9,034 9,026 8,631 8,330 —

Age 0.560
Mean 83.4 83.6 83.6 83.5 83.5 83.6 83.4 —
SD 7.9 7.9 7.8 7.8 7.8 7.7 7.9 —
Sex 0.387
Male, % 27 26 26 25 26 25 25 —
Female, % 73 74 74 75 74 75 75 —
Race 0.125
White, % 86 86 87 87 87 87 87 —
Nonwhite, % 14 14 13 13 13 13 13 —
Insurance 0.734
Government, % 85 85 86 85 85 85 85 —
Private/other, % 15 15 14 15 15 15 15 —
Deyo score 0.255
Mean 1.43 1.44 1.44 1.42 1.41 1.39 1.43 —
SD 1.60 1.61 1.61 1.61 1.60 1.54 1.59 —
Fracture location ,0.001a
Femoral neck, % 50 50 47 49 50 47 47 —
Intertrochanteric, % 50 50 53 51 50 53 53 —
Surgical procedure ,0.001a
Fixation, % 64 64 65 64 63 66 65 —
Arthroplasty, % 36 36 35 36 37 34 35 —
Time of admission ,0.001a
Day, % 63 61 62 62 62 60 60 —
Night, % 37 39 38 38 38 40 40 —
THA = total hip arthroplasty

a
Significant difference
Percentages may not add to 100 because of rounding.
outcomes equal to zero days or Mean preoperative delay was

$0. We interpreted regression co-
Results 0.41 days, with a minimum of
efficients and 95% confidence inter- 0.34 days for Friday and a maximum
The mean number of geriatric hip
vals as percentage differences using the of 0.53 days for Saturday (see Figure,
fracture admissions per day of the week
formula 100 · (eb 2 1), where b is Supplemental Digital Content 1, http://
was 8,900, with a minimum of 8,330
the parameter estimate of a log- links.lww.com/JAAOS/A170). Com-
on Sunday and a maximum of 9,190 on
transformed outcome variable.8 For pared with Monday, the mixed effects
Tuesday. We found statistically signif-
the P values we reported from re- adjusted preoperative delay was 13%
gression models, we used the Holm- icant but clinically insignificant differ- shorter for Wednesday (P , 0.001),
Bonferroni method to correct for ences according to day of admission for 14% shorter for Thursday (P ,
multiple comparisons.6 fracture location (P , 0.001) surgical 0.001), and 18% shorter for Friday
We performed our statistical procedure (P , 0.001), and time of (P , 0.001). In contrast, the preop-
analysis using SAS version 9.4 (SAS admission (P , 0.001). No differences erative delay was 28% longer for
Institute). Figures were generated exist in age, sex, race, insurance, or Saturday (P , 0.001), 18% longer
using Microsoft Excel (Microsoft Deyo score according to day of for Sunday (P , 0.001), and not
Corporation). admission (Table 1). significantly different for Tuesday
(P = 0.017) (Figure 2). In our sec- Figure 2

ondary analysis, surgery was per-
formed within 2 days of admission
for 84% of patients, with a minimum
of 78% on Friday and 88% on
Wednesday (see Figure, Supple-
mental Digital Content 2, http://
links.lww.com/JAAOS/A171). Com-
pared with Monday, the mixed ef-
fects adjusted odds of having surgery
within 2 days of admission was 25%
higher for Wednesday (P , 0.001),
but 48% lower for Friday (P ,
0.001) and 38% lower for Saturday
(P , 0.001), with no significant dif-
ference for Tuesday (P = 0.353), Chart showing that preoperative delay was significantly longer for weekend
Thursday (P = 0.051), or Sunday (P = admissions, but significantly shorter for Wednesday, Thursday, and Friday
admissions.
0.489) (Figure 3).
Mean postoperative LOS was
4.43 days, with a minimum of
Figure 3
4.13 days for Saturday and a maxi-
mum of 4.83 days for Wednesday (see
Figure, Supplemental Digital Content
3, http://links.lww.com/JAAOS/A172).
Compared with Monday, the mixed
effects adjusted postoperative LOS
was 6% longer for Tuesday (P ,
0.001), 11% longer for Wednesday
(P , 0.001), and 5% longer for
Thursday (P , 0.001). In contrast,
postoperative LOS was 5% shorter for
Saturday (P , 0.001) and 3% shorter
for Sunday (P , 0.001) but was not
significantly different for Friday (P =
0.044) (Figure 4). Chart showing that surgery within 2 days of admission was less likely for Friday
The proportion of patients dis- and Saturday admissions, but more likely for Wednesday admissions.
charged by a given hospital day varied
greatly according to the day of
admission, with peak variation taking Content 9, http://links.lww.com/ discharged, compared with 53% of
place on hospital days 3 through JAAOS/A178; Figure 4G, Supple- Monday admissions. We noted that
6 (Figure 5; Figure 4A, Supple- mental Digital Content 10, http:// these four daily minimums each cor-
mental Digital Content 4, http:// links.lww.com/JAAOS/A179). By responded with Sunday discharge.
links.lww.com/JAAOS/A173; Figure hospital day 3, 17% of Tuesday Mean cost of admission was
4B, Supplemental Digital Content 5, admissions were discharged, com- $17,104, with a minimum of $16,698
http://links.lww.com/JAAOS/A174; pared with 2% of Thursday admis- for Saturday and a maximum of
Figure 4C, Supplemental Digital sions. By hospital day 4, 43% of $17,576 for Wednesday (see Figure 5,
Content 6, http://links.lww.com/ Monday admissions were discharged, Supplemental Digital Content 11,
JAAOS/A175; Figure 4D, Supple- compared with 12% of Wednesday http://links.lww.com/JAAOS/A180).
mental Digital Content 7, http:// admissions. By hospital day 5, 61% Compared with Monday, the mixed
links.lww.com/JAAOS/A176; Figure of Sunday admissions were dis- effects adjusted cost was 2% higher
4E, Supplemental Digital Content 8, charged, compared with 32% of for Tuesday (P = 0.002) and 3%
http://links.lww.com/JAAOS/A177; Tuesday admissions. By hospital day higher for Wednesday (P , 0.001). In
Figure 4F, Supplemental Digital 6, 72% of Saturday admissions were contrast, the cost of admission was
January 1, 2019, Vol 27, No 1 e37
Figure 4 of geriatric hip fractures in New York

State between 2009 and 2014, we
observed significant differences in
preoperative delay, postoperative
LOS, and cost according to the day of
the week that admission occurred.
Our data was strongly suggestive of
a weekend effect, characterized by
delays in surgery for weekend ad-
missions and delays in discharge for
postoperative patients. Costs were
similar across all days of admission
once preoperative delay and postop-
erative LOS were accounted for.
These findings have notable clini-
Chart showing that postoperative LOS was significantly longer for admissions on cal and economic implications for
Tuesday, Wednesday, and Thursday, but significantly shorter for Saturday and hospitals, providers, patients, and
Sunday admissions. LOS = length of stay
payers.
We acknowledge that our study has
Figure 5 several limitations. First, the SPARCS
database does not contain informa-
tion on patient characteristics, in-
cluding body mass index, smoking
status, ASA score, and preoperative
functional status; intraoperative ex-
posures, including duration of sur-
gery and type of anesthesia; or
postoperative outcomes, including
functional and ambulatory status.
Second, ICD-9 coding does not
report mechanism of injury, so we
were unable to identify patients who
sustained a ground-level fall versus a
higher-energy injury. However, to
mitigate this limitation, we excluded
patients with concomitant long-bone
fractures or traumatic injury to
Chart showing that the proportion of patients discharged by a given hospital day another body system. Third, the
is shown for the first 14 days of admission. For each hospital day, maximum SPARCS database reports the day
and minimum values according to the day of admission are also shown. The
and time of admission but only re-
purple line represents the difference between these extreme values.
ports the day of surgery, so our defi-
nition of preoperative delay was
not significantly different for admis- Sunday (P = 0.342) compared with limited to days instead of hours.
sion on Thursday (P = 0.016), Friday Monday admission (Figure 6). Fourth, costs were calculated using
(P = 0.410), Saturday (P = 0.331), or cost:charge ratios and were not
Sunday (P = 0.538). When we directly measured. Fifth, the SPARCS
adjusted for preoperative delay and Discussion database does not include records
postoperative LOS, the cost of from rehabilitation and nursing
admission was not significantly dif- The transition to bundled payment facilities, so we were unable to eval-
ferent for admission on Tuesday reimbursement for geriatric hip frac- uate the total costs of care over
(P = 0.422), Wednesday (P = 0.253), tures has incentivized the identifica- 30-day and 90-day postoperative
Thursday (P = 0.389), Friday tion of avoidable variations in the periods, which are incorporated into
(P = 0.040), Saturday (P = 0.034), or cost and quality of care. In this study bundled payments for hip fracture
under Bundled Payments for Care Figure 6

Improvement and Comprehensive
Care for Joint Replacement.
Our study showed that the time
between admission and hip fracture
surgery was significantly longer for
weekend admissions than for week-
day admissions. This finding is con-
sistent with previous studies of other
medical conditions, which have re-
ported weekend-related delays for
cardiac catheterization after acute
myocardial infarction and endoscopy
after acute gastrointestinal hemor-
rhage.9-13 Although hip fracture
surgery is less time-sensitive than
these potentially fatal medical con- Chart showing that cost was significantly higher for Tuesday and Wednesday
ditions, delay in surgery of longer admissions. However, cost was not significantly different for any day of
than 24 to 48 hours is a known risk admission once the model was adjusted for preoperative delay and
factor for adverse outcomes, most postoperative LOS. LOS = length of stay
notably mortality.14 In consideration
of this evidence, the American charge for hip fracture exist. First, additional day on the trauma service
Academy of Orthopaedic Surgeons most orthopaedic and hospitalist was $420 in 1998, which translates
gives a moderate-strength recom- services are staffed on the weekends to $700 in 2016.22,23 Furthermore,
mendation to perform hip fracture by on-call providers who have less expedited hip fracture care has been
surgery within 48 hours of admis- familiarity with patients and plans shown to be cost-effective when pa-
sion.15 Interestingly, surgery within and therefore may be reluctant to tients undergo surgery within 48
48 hours of hip fracture admission is clear them for discharge. Second, hours.24
considered a benchmark of hospital decreased staffing of social work, In summary, geriatric hip fracture
quality in Canada’s national health nursing, and rehabilitation services patients are subject to significant dif-
system.16 Delays in hip fracture can interfere with existing discharge ferences in their hospitalizations ac-
surgery are most frequently caused plans and delay the initiation of new cording to the day of the week that they
by lack of available surgical rooms, plans. Third, geriatric hip fracture are admitted. Given these findings, we
which is further exacerbated on patients are predominantly dis- encourage hospitals and providers to
weekends by limited staff availability charged to outside rehabilitation or pursue quality improvement initiatives
that must prioritize surgical emer- nursing facilities, which are also that remove variation from hip frac-
gencies.17,18 Limited weekend staff- short staffed on weekends and ture care and more broadly try to
ing of hospitalist and geriatric teams therefore are less likely to accept new eliminate hospital-wide inefficiencies
can also delay preoperative clearance patients.20 of weekend services. A number of
and medical optimization, especially Cost of admission followed a similar hospitals have already established
for patients who require additional pattern to LOS, with higher costs for clinical pathways for hip fracture ad-
testing or evaluation by consultants. early- and mid-week admissions and missions, using custom order sets,
LOS was highly dependent on lower costs for weekend admissions. hospitalist co-management, bench-
the day of admission, a finding that Secondary analyses suggested that mark surgical waiting times, acceler-
has also been reported for myocardial preoperative delay and postoperative ated postoperative rehabilitation, and
infarction.19 Specifically, admissions LOS contribute to the observed vari- early discharge planning to reduce
on Tuesday, Wednesday, and Thurs- ation in cost of admission. These unwanted variation and inefficiencies
day were more likely to stay in the findings are consistent with existing of care.25 Patients receiving care
hospital over the weekend because this literature on fracture admissions, within these pathways have been
corresponded with hospital days 3 which reported that variations in LOS observed to have superior clinical
through 6, the most common LOSs. account for nearly 30% of the direct outcomes compared with traditional
We suspect that three major factors variable expenses.21 Another study models, including reduced LOS,
driving the delays in weekend dis- reported that the direct cost of an fewer in-hospital complications, and
January 1, 2019, Vol 27, No 1 e39
decreased short-term mortality.25 hip fracture. Bone Joint J 2014;96-B: elderly. J Bone Joint Surg Am 2015;97:
373-378. 1196-1199.
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Adapting a clinical comorbidity index for Oppenheimer L: Reduced time to surgery
and providers nationwide, the need use with ICD-9-CM administrative improves mortality and length of stay
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multiple testing when reporting research 17. Vidán MT, Sánchez E, Gracia Y, Marañón E,
results: The Bonferroni vs Holm methods. Vaquero J, Serra JA: Causes and effects of
Am J Public Health 1996;86:726-728. surgical delay in patients with hip fracture: A
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(NHDS), National Center for Health for the hospital? An analysis of hospital
mortality from myocardial infarction. N
Statistics: Health Data Interactive, Health revenues and costs for treatment of
Engl J Med 2007;356:1099-1109.
Care Use and Expenditures. www.cdc.gov/ common fractures. J Orthop Trauma 2015;
nchs/hdi.htm. Accessed April 1, 2016. 12. Bell CM, Redelmeier DA: Waiting for 29:e219-e224.
urgent procedures on the weekend among
2. Gu Q, Koenig L, Mather RC, Tongue J: emergently hospitalized patients. Am J Med 22. Taheri PA, Butz DA, Greenfield LJ: Length
Surgery for hip fracture yields societal 2004;117:175-181. of stay has minimal impact on the cost of
benefits that exceed the direct medical costs. hospital admission. J Am Coll Surg 2000;
Clin Orthop Relat Res 2014;472: 13. Ananthakrishnan AN, Mcginley EL, 191:123-130.
3536-3546. Saeian K: Outcomes of weekend admissions
for upper gastrointestinal hemorrhage: A 23. Swart E, Vasudeva E, Makhni EC,
3. Koval KJ, Skovron ML, Aharonoff GB, nationwide analysis. Clin Gastroenterol Macaulay W, Bozic KJ: Dedicated
Meadows SE, Zuckerman JD: Ambulatory Hepatol 2009;7:296-302.e1. perioperative hip fracture comanagement
ability after hip fracture: A prospective programs are cost-effective in high-volume
study in geriatric patients. Clin Orthop 14. Moja L, Piatti A, Pecoraro V, et al: Timing centers: An economic analysis. Clin Orthop
Relat Res 1995:150-159. matters in hip fracture surgery: Patients Relat Res 2016;474:222-233.
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4. Hung WW, Egol KA, Zuckerman JD, Siu outcomes. A meta-analysis and meta- 24. Dy CJ, Mccollister KE, Lubarsky DA,
AL: Hip fracture management: Tailoring regression of over 190,000 patients. PLoS Lane JM: An economic evaluation of a
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term mortality following admission with a management of hip fractures in the effective? Injury 2016;47(suppl 1):S25-S27.
Research Article
Biomechanical Analysis of Fixation

Devices for Basicervical Femoral
Neck Fractures
Abstract
Joseph Johnson, MD Introduction: Basicervical femoral neck fractures are challenging
Matthew Deren, MD fractures in geriatric populations. The goal of this study was to
determine whether compression hip screw (CHS) constructs are
Alison Chambers, PhD
superior to cephalomedullary constructs for the treatment of
Dale Cassidy, MD basicervical femoral neck fractures.
'RZQORDGHG IURP KWWSMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.E+77,PTHQ91WI%,7WH;2:-)*R341&M<:\Q.<$JD]9KQW. RQ
Sarath Koruprolu, MS Methods: Thirty cadaver femurs were osteotomized and received a
Christopher Born, MD CHS with derotation screw, a long cephalomedullary nail (long Gamma
nail), or a short cephalomedullary nail (short Gamma nail). All constructs
were loaded dynamically in compression until dynamic failure.
Results: All failed CHS constructs demonstrated superior femoral head
cutout. In the long Gamma nail and short Gamma nail groups, constructs
failed by nail cutout through the medial wall of the trochanter or rotationally.
Normalized fluoroscopic distance was found to increase markedly with an
increasing cycle count when considering all treatment groups.
Conclusions: Given our results and those of previous studies, we
could not determine superiority of one implant and recommend that
surgeons select fixation constructs based on the individual patient’s
anatomy and the surgeon’s comfort with the implant.
B asicervical femoral neck frac-

tures are typically seen in geriat-
ric populations after low-energy falls.
fractures are less common than
intertrochanteric fractures and are
often misdiagnosed.6 Failure rates
In 1992, Cooper et al1 estimated for these fractures are thought to be
that 250,000 hip fractures occurred higher than intertrochanteric hip
Surgery, Loma Linda University,
in the United States alone. Given the fractures, with implant cutout, nail
Loma Linda, CA (Dr. Johnson), and increasing age of the United States breakage, and failure rates reported
the Department of Orthopedic population, they estimated that by as high as 54%.7-9 The goal of this
Surgery, Brown University, 2032, the number of these fractures study was to determine the biome-
Providence, RI (Dr. Deren,
Dr. Chambers, Mr. Koruprolu, and
would increase to 500,000 per year.1 chanically optimal construct for
Dr. Born), and Colorado Springs The goal of fixation of these frac- fixation of basicervical femoral neck
Orthopedic Group, Colorado Springs, tures within 48 hours has become fractures using human cadavers.
CO (Dr. Cassidy). widely accepted allowing for early Previous studies have examined the
Correspondence to Dr. Johnson: mobilization and weight bearing to role of various implants in the treatment
joey.johnson12@gmail.com prevent postoperative complications of these fractures. Recently, studies
J Am Acad Orthop Surg 2019;27: and allow maximal return to func- have focused primarily on compression
e41-e48 tion remains constant.2-5 hip screws (CHS) and cannulated
DOI: 10.5435/JAAOS-D-17-00155 Basicervical femoral neck fractures screw constructs, showing CHS
are a challenging fracture in geriatric devices with derotation screws to have
Academy of Orthopaedic Surgeons. populations. Data regarding their a biomechanical advantage.10,11
fixation are limited because these One recent study using sawbones
January 1, 2019, Vol 27, No 1 e41
Biomechanical Analysis of Fixation Devices
compared intramedullary and ex- gross anatomic defects and were mens from different groups were
tramedullary implants for treat- excluded if present. Specimens were randomly selected for instrumenta-
ment of basicervical femoral neck maintained at 220C until approxi- tion to prevent any learning curve
fractures, and although it showed an mately 24 hours before testing. The bias. To ensure anatomic reduction,
increased load to failure for the in- samples were thawed, and all residual all specimens were predrilled before
tramedullary fixation device, be- soft tissue was carefully removed. A osteotomy. The basicervical fracture
cause of multiple modes of failure in basicervical femur fracture was then in the CHS cohort was fixed with an
the treatment groups, this study lacked created using a thin bladed-straight appropriately measured lag screw,
sufficient power to detect differences sagittal saw, as described by Stafford 130 side plate, and a 6.5-mm ASNIS
in groups.12 The cephalomedullary et al, via a cut at the base of the III partially threaded screw of
nail is a reliable implant for treating femoral neck.17 Throughout prepa- appropriate length (Omega3/ASNIS;
unstable intertrochanteric fractures ration and testing, the specimens were Stryker) (Figure 1). The plate was
and may be a better alternative for kept moist with saline-soaked gauze. secured distally with two 4.5-mm
basicervical fractures. 13 Several cortical screws. Intramedullary nail
small case series have described the length and lag screw length were
use of cephalomedullary nails to Instrumentation measured for each femur, and a 120
treat basicervical fractures, despite The treatment groups investigated were cephalomedullary nail was used
the lack of preclinical research to the CHS (Omega3; Stryker) with a (Figure 1). The proximal set screw
support its use.8,14 derotation screw, long Gamma nail was placed to allow sliding of the lag
The goal of this study was to (LG), or short Gamma nail (SG) screw while preventing lag screw
determine whether a CHS construct (Stryker) with a center-center lag screw rotation as per the manufacturer’s
with a derotation screw is superior to position, as previously described by technical manual. A single distal in-
long and short intramedullary con- Baumgartner et al.18 A balanced terlocking screw in the dynamic
structs with regard to cycles to failure incomplete block design was used to position was placed for each nail to
and implant migration for the treat- randomly assign the specimens to one simulate clinical practice and allow
ment of basicervical femoral neck of the three comparison groups: CHS any additional fracture compression.
fractures in a cadaver model. with derotation screw versus long Anterior to posterior and lateral
cephalomedullary nail (CHS versus radiographs were obtained before
LG), CHS with derotation screw ver- dynamic testing to ensure proper
Materials sus SG (CHS versus SG), and LG implant placement and measure the
versus SG). A paired Student t-test was tip-apex distance. Before loading, all
Specimen Preparation used to test for differences in BMD fractures were compressed either
Thirty female femur samples older than between matched pairs. In addition, a using a compression screw in the CHS
75 years (mean age = 88.2 6 7.4 years; one-way analysis of variance was used group or the compression handle on
15 matched pairs) were used. Fresh to test for BMD differences between the Gamma nail guide.
frozen cadaver tissue is an appropriate the three different comparison groups
medium for evaluating biomechanical (ie, LG versus SG, SG versus CHS, and
properties because it most closely ap- CHS versus LG). No differences were Dynamic Compression
proximates in vivo biomechanical found in BMD between contralateral Testing
characteristics.15 CT and quantitative sides for the same matched pair or for After instrumentation, the distal
CT Mindways (Mindways Software) the three different comparison groups condyles were potted in a urethane
analyses were used to quantify bone (P = 0.991 and P = 0.891, respectively). compound and mounted on a double
mineral density (BMD) across the All instrumentation was performed gimble fixture facilitating uncon-
proximal femur for each sample.16 in general accordance with the In- trolled motion in the sagittal and
The specimens were screened for structions for Use Guidelines. Speci- coronal planes.13 The femurs were
Dr. Johnson or an immediate family member serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma
Association. Dr. Cassidy or an immediate family member serves as a board member, owner, officer, or committee member of the American
Association for Hand Surgery. Dr. Born or an immediate family member serves as a paid consultant to IlluminOss and Stryker; serves as an
unpaid consultant to BioIntraface; has stock or stock options held in BioIntraface and IlluminOss; has received research or institutional
support from Stryker; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic
Surgeons and the American College of Surgeons. None of the following authors nor any immediate family member has received anything of
value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article:
Dr. Deren, Dr. Chambers, and Mr. Koruprolu.
Joseph Johnson, MD, et al
potted such that the loading vector Figure 1

applied to the head of the femur was
in line with the intercondylar fossa.
The potted femoral condyles were
rigidly mounted to the base of an
Instron 8521S servohydraulic load
frame (Instron). Proximally, the head
of the femur was coupled with the
actuator using a custom concave
indenter (Figure 2). For all tests, the
loading vector was oriented at the
center of the femoral head, passing
through the intercondylar notch in
the coronal plane and the femoral
epicondyles in the sagittal plane.
Samples were loaded dynamically in Fluoroscopic images showing a compression hip screw with derotation screw
compression at 700 N (one-time and cephalomedullary nail constructs.
body weight of 70 kg) with a loading
profile of 70 to 700 N (R ratio of
10), with a test frequency of 1 Hz Figure 2
(sinusoidal wave) for a total of 500
cycles.19,20 On completion of 500
cycles, the loading magnitude was
increased by 350 N (1/2 times body
weight) and retested for an addi-
tional 500 cycles (R ratio of 10
sustained throughout testing). This
ramping load sequence was repeated
every 500 cycles until dynamic fail-
ure, reported as .15 mm of height
loss (plastic and elastic deformation)
from the start of dynamic testing at
700 N.13,21 Load and displacement
data were recorded digitally at a
frequency of 300 Hz. Displacement
was observed in real time as actuator
Photograph showing the testing apparatus with Instron and fluoroscopy testing
travel to assess deformation of the machines.
constructs and to determine whether
functional failure was reached. A
displacement change of .15 mm femur in real time during mechanical initial measurement at the beginning
from the beginning of testing was testing. Ragiographic videos were of the 700 N loading segment or
deemed a functional failure. Cata- captured at the beginning of testing 10 cycles. This normalized fluoroscopic
strophic failure was defined as the (700 N load profile) and at every 500 distance represents change in device
device clearly cutting out of the cycle increment until failure or 3,000 distance to superior femoral head wall
femoral head or the construct no cycles. For the cephalomedullary and over the course of the dynamic testing.
longer functioning structurally. CHS constructs, the perpendicular
distance between the tip of the lag
screw and the superior femoral head Cycles to Failure
Radiograph: Device Failure cortical wall was measured at each 500 All specimens that reached 3,000 cy-
Tracking cycle increment (Figure 3). All dis- cles were deemed run out. A gener-
A fluoroscope was oriented around the tances measured between the device alized estimation equation for log
test frame such that radiograph could and the superior femoral head cortex normal distributions was used to
be acquired in the AP direction for each were normalized (subtraction) to their access cycles to failure because
January 1, 2019, Vol 27, No 1 e43
Figure 3 252.32 g/cm 3 (range, 149.1 to

359.3 g/cm 3). As defined by the
t score, six specimens were normal
(T score, .21.0), 10 were osteo-
penic (T score, 21 to 22.5), and 14
were osteoporotic (T score, ,22.5).
Mode of Failure
Only two samples survived testing:
one instrumented with a short
cephalomedullary nail (SG) and one
with an LG. The mode of failure
between the fixation constructs was
different. In specimens instrumented
Images showing radiographic device cutout measurement. with a CHS, all constructs failed
by cutting out of the femoral
head (Figure 4). Although in speci-
Figure 4 was used to access normalized fluo-
mens instrumented with the long
roscopic distance, with the predictive
cephalomedullary device, three con-
factors for the treatment group
structs failed with the femoral head
(ie, CHS, LG, and SG), cycle count,
rotating around the lag screw, one
and specimen BMD. The interaction
failed with screw cutout of the
between the treatment group and
femoral head, whereas the other five
cycle count was included in the model
failed by nail migration through
to allow for differences in treatment
the medial wall of the trochanter
with an increasing cycle count. Tukey
(Figure 5). Similarly, in specimens
adjustment was used to maintain
instrumented with a short cepha-
family wise alpha at 0.05 across mul-
lomedullary device, two constructs
tiple comparisons for both models (ie,
failed rotationally and seven failed
cycles to failure and normalized fluo-
with medial wall nail migration.
roscopic distance). Sandwich estima-
tion was used to adjust for any model
Fluoroscopic image showing the Cycles to Failure
compression hip screw construct at
misspecification for both models (ie,
moment of failure, with lag screw unequal variances and covariances).22 The treatment group was not found
cutting out of the head. In all cases, statistical significance was to have a significant effect on speci-
set to P , 0.05 a priori. SAS was used men cycles to failure (P = 0.1469).
for all statistical analyses (version 9.4). BMD was found to have a significant
most specimens failed during testing effect on specimen cycles to failure in
(2 specimens of 30 were censored at which specimens with lower BMD
3,000 cycles, 1 LG and 1 SG). The had less cycles to failure (P = 0.024)
Results
predictive factors for the treatment (Figure 6). The interaction between
group (ie, CHS, LG, and SG) and BMD BMD and treatment group was not
Bone Mineral Density Testing
were used to assess cycles to failure in found to be significant (P = 0.1910).
the model, and the interaction between All 30 samples were screened for
the treatment group and BMD was anatomic defects and CT scanned
from the most proximal point of the Radiograph: Device Cutout
included to allow for differences in
femur to below the lesser trochanter. Data
treatment with increasing BMD.
These data were digitally analyzed by No difference was found for the
the quantitative CT program to normalized fluoroscopic distance
Normalized Fluoroscopic determine a T score and quantitative between treatment groups (P = 0.483)
Distance BMD in mg/cc. The average T score when considering all cycle counts.
Similarly, a generalized estimation was 22.27 (range, 0.25 to 24.51). Furthermore, BMD was not found to
equation for log normal distributions The average quantitative BMD was have a significant effect on normalized
fluoroscopic distance (P = 0.808)

across all cycle counts. Cycle count Figure 5
had a significant effect on normalized
fluoroscopic distance (P , 0.0001),
in which larger cycle counts were
found to have larger fluoroscopic
distances. Furthermore, the increase
in the normalized fluoroscopic dis-
tance with an increasing cycle count
was found to be significant with
the CHS and LG treatment groups
but not the SG group (P , 0.0001,
P = 0.0001, and P = 0.193, respec-
tively) (Figure 7). However, no
difference was found between the
increase in the normalized fluoro-
scopic distance between treatment
Fluoroscopic images showing the cephalomedullary nail construct migrating
groups (ie, CHS versus LG, CHS through the medial wall of the trochanter at moment of failure. Arrows highlight
versus SG, and LG versus SG; migration of the nail construct.
P = 0.064, 0.138, and 0.628, re-
spectively) (Figure 7), although the
difference between the increases in Figure 6
the normalized fluoroscopic distance
for the CHS and LG groups did
approach significance (Figure 7).
Conclusions
Our testing was unable to demon-
strate a difference in cycles to failure
or implant motion in the femoral
head associated with the method of
fixation. However, mode of failure
seemed to vary between treatment
groups. In our study, all the CHS
failures occurred by the screw cut-
ting out of the head, whereas
the intramedullary constructs had
only one cutout. The rest of our
intramedullary constructs failed by
having the nail migrate medially
through the medial wall of the tro- Graph showing the effect of bone mineral density on cycles to failure stratified by
the treatment group. BMD = bone mineral density, CHS = compression hip
chanter or by femoral neck rotational screw, LG = long Gamma nail, SG = short Gamma nail
failure. This mode of failure may have
been related to the amount of space
between the intramedullary device significant effect on cycles to failure, basicervical femoral neck fracture fix-
and the cortices of the cadaver with lower BMD being associated ation.10-12 However, only one such
femurs. This space may have allowed with earlier failure. study attempted to compare CHS
motion during load testing that re- Previous studies have been per- constructs with cephalomedullary
sults in cutout of the intramedullary formed that demonstrate the biome- constructs.12 This study was per-
device through the medial trochan- chanical superiority of CHS constructs formed in sawbones and, because of
teric border. In addition, BMD had a over cancellous screw constructs for sample size restrictions, was unable
January 1, 2019, Vol 27, No 1 e45
Figure 7 with multiple points of fixation into

the femoral neck have not been
studied in basicervical femoral neck
fractures, they have been evaluated in
intertrochanteric hip fractures. One
biomechanical study found them to
be more stable in a cadaver inter-
trochanteric fracture model to axial
loading and rotational forces than
cephalomedullary nails with one
point of fixation into the femoral
neck.23 The clinical superiority and
importance of these nails have not
been born out in the literature;
however, it may provide a better
solution to basicervical femoral neck
fractures that have less bony contact
and lower intrinsic stability.24-26
Our study has several limitations.
Specifically, this is an in vitro bio-
mechanical study and does not pro-
vide clinical follow-up on these
Graph showing the cycle count versus normalized fluoroscopic distance
stratified by the treatment group. CHS = compression hip screw, LG = long fractures. Thus, determining which, if
Gamma nail, SG = short Gamma nail any, of these failures would occur
before healing is difficult. However,
unlike previous studies, fresh frozen
to determine any differences between over-report the amount of motion seen cadaver bones were used because
its CHS, intramedullary fixation, in the intramedullary group because these are most biomechanically simi-
and external fixation groups.12 In rotational failure may be reported lar to living, in vivo human bone.16 In
contrast to the results of Imren similar to superior migration. addition, the rotational failures of
et al,12 none of our CHS constructs These rotational failures may have cephalomedullary constructs limit
failed rotationally, likely because of been related to lower BMD; however, the ability to interpret the fluoro-
our use of a derotation screw. We because of the sample size, this scopic data on screw movement in
included a derotation screw in our cannot be definitively stated. The the femoral head. However, to our
CHS construct group based on these implications for clinical use based on knowledge, this is the only study in
rotational failures and the results mode of failure are not clear. Lag the literature that evaluates the
of previous biomechanical analysis screw cutout can result in significant strength of fixation between CHS
showing improved strength and acetabular bone damage, whereas constructs, long cephalomedullary
rotational control with the addition migration through the medial wall of devices, and short cephalomedullary
of the derotation screw.10-12 the trochanter may have significant devices. In addition, some of the nail
We were not able to establish the effect on the abductor muscle tension. medialization seen in our LG and SG
superiority of one construct in terms of In addition, this failure results in the constructs may have been secondary
cycles to failure or movement of the loss of the bony architecture of the to unidirectional loading because
screw in the head of the femur. This femoral head, usually necessitating we did not use a multidirectional
study did, however, suggest that modes an arthroplasty revision procedure. loading system.27
of failure may be different in each Although our study demonstrated an One recent study by Watson
group. In the intramedullary groups, element of rotational instability of et al9 reviewed 11 basicervical fem-
there were five rotational failures our cephalomedullary groups, ceph- oral neck fractures treated with
(ie, three LG and two SG), which alomedullary nail designs with mul- cephalomedullary nails, 6 of which
limits our ability to interpret our data tiple secondary sites of fixation into failed. Five of the six failed by screw
about motion of the lag screw in the the femoral neck exist that may pre- cutout and collapse, causing the au-
head as detected by live fluoroscopy. vent some of these rotational failures. thors to caution against the routine
This phenomenon may cause us to Although cephalomedullary nails use of cephalomedullary nails for
treatment of these fractures.9 This pensation for this study. The authors fixation. J Bone Joint Surg Am 2016;98:
1097-1102.
rate of failure is much higher than have received funding in the form of
the rate of failure reported for simi- implant donation for this study from 10. Blair B, Koval KJ, Kummer F, Zuckerman
JD: Basicervical fractures of the proximal
larly treated intertrochanteric hip Stryker Trauma (Mahwah, NJ). This femur: A biomechanical study of 3 internal
fractures reported in the literature, study was supported in part by a fixation techniques. Clin Orthop 1994;
256-263.
demonstrating the unique challenges grant from the National Institutes of
posed by basicervical femoral neck Health (2P20 GM104937) (COBRE 11. Deneka DA, Simonian PT, Stankewich CJ,
Eckert D, Chapman JR, Tencer AF:
fractures.7,18 These results differ Bioengineering Core). Biomechanical comparison of internal
from ours, given that screw cutout fixation techniques for the treatment of
was noted only in one intra- unstable basicervical femoral neck
medullary sample. We also note that

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contents. In this article, reference 26 screw, and monoaxial external fixation in
not seem that CHS constructs pro-
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varus collapse between a single lag screw nail for intramedullary nailing of unstable screws and helical blades utilizing a new
and integrated dual screw intertrochanteric trochanteric fractures. Diagn Pathol 2014; oscillating test method. J Orthop Res 2011;
hip fracture fixation device using a 9:191. 29:760-766.
cadaveric hemi-pelvis biomechanical
model. J Orthop Trauma 2016;30: 26. Berger-Groch J, Rupprecht M, Schoepper S, 28. Kumar N, Kalra M: Evaluation of
164-169. Schroeder M, Rueger JM, Hoffmann M: Five- valgus intertrochanteric osteotomy in
year outcome analysis of intertrochanteric neglected fracture neck femur in young
24. Seyhan M, Turkmen I, Unay K, Ozkut AT: femur fractures: A prospective adults. J Clin Orthop Trauma 2013;4:
Do PFNA devices and Intertan nails both randomized trial comparing a 2-screw 53-57.
ORTHOPAEDIC VIDEO THEATER ABSTRACTS
Surgical Pearls in Total En Bloc Spondylectomy for Giant Cell Tumor of the
Mobile Spine – Award Winner
Noriaki Yokogawa, MD; Hideki Murakami, MD; Satoru Demura, MD; Satoshi Kato, MD;
Katsuhito Yoshioka, MD; Naoki Takahashi, MD; Takaki Shimizu, MD; Norihiro Oku, MD;
Hiroyuki Tsuchiya, MD
DOI: 10.5435/JAAOS-D-18-00627
Abstract: En bloc excision is strongly recommended for management of a spinal giant cell tumor (GCT)
because of the high local recurrence rate associated with intralesional excision. We perform total en bloc
spondylectomy (TES) with transpedicular osteotomy using a T-saw, which allows the posterior elements
of the spine to be removed en bloc and allows for easier dissection of the spinal cord and nerve roots.
Although T-saw transpedicular osteotomy often involves an intralesional procedure, we feel that TES with inclusion of the
tumor margin will result in curative resection. All 11 patients with a spinal GCT who underwent TES with intralesional T-saw
transpedicular osteotomy at our hospital between May 1994 and February 2015 had no local tumor recurrence or metastasis at
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a mean follow-up of 108 months (range, 24 to 216 months). Concern exists with regard to the highly invasive nature of TES for
management of a spinal GCT; therefore, the benefits of the procedure must be weighed against the associated perioperative
morbidity. Initially, TES frequently required more than 10 hours and often was associated with blood loss exceeding 2,500 mL.
The surgical techniques for TES have improved greatly as a result of the knowledge acquired and consideration of the surgical
anatomy, physiology, and biomechanics of the spine and the spinal cord. In five patients with a spinal GCT who recently
underwent TES, intraoperative blood loss was 252 6 171 mL without the need for blood transfusion, and no perioperative
complications occurred. This video shows current surgical techniques for TES of a spinal GCT, with a focus on safety and
reduction of intraoperative blood loss. Watch the video trailer: http://links.lww.com/JAAOS/A285.
© 2018 The Author(s). Published by Wolters Kluwer Health, Inc., on behalf of the American Academy of Orthopaedic Surgeons.
Video trailers that accompany these abstracts are available on www.jaaos.org.
January 1, 2019, Vol 27, No 1 e49
Review Article
Management of the Failed

Arthroplasty for Proximal Humerus
Fracture
Abstract
Djuro Petkovic, MD A variety of reasons exist for failure of arthroplasty performed for
David Kovacevic, MD management of proximal humerus fracture. Revision surgery for these
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failures is complex and has a high likelihood of inferior outcomes

William N. Levine, MD
compared with primary arthroplasty. Successful management
Charles M. Jobin, MD requires consideration of various modes of failure including tuberosity
malunion or resorption, rotator cuff deficiency, glenoid arthritis, bone
loss, component loosening, stiffness, or infection. Although revision
to a reverse shoulder arthroplasty is an appealing option to address
instability, rotator cuff dysfunction, and glenoid arthritis, there are
concerns with higher complication rates and inferior results compared
From the Center for Shoulder, Elbow with primary reverse replacement. Any treatment plan should
and Sports Medicine, Department of appropriately address the cause for failure to optimize outcomes.
Orthopedic Surgery, New York-
Presbyterian/Columbia University
Medical Center, New York, NY.
F
Dr. Kovacevic or an immediate family ailure of shoulder arthroplasty or component-related problems usu-
owner, officer, or committee member
for proximal humerus fracture ally results in good or excellent
of the American Academy of is a challenging clinical entity and can outcomes, whereas revision for soft-
Orthopaedic Surgeons and the require revision in up to 20% of pa- tissue reconstruction often has poor
American Orthopaedic Association. tients.1 Hemiarthroplasty and re- outcomes.5 Revision arthroplasty is
Dr. Levine or an immediate family
member serves as an unpaid
verse total shoulder arthroplasty especially challenging because of
consultant to Zimmer Biomet. (RTSA) are the most common types tissue loss, distorted tissue planes,
Dr. Jobin or an immediate family of arthroplasty for these fractures. implant debris, associated proximal
member is a member of a speakers’ Hemiarthroplasty for fracture has humerus and glenoid bone loss,
bureau or has made paid
presentations on behalf of Acumed,
inconsistent outcomes and is tech- possible need to explant a well-fixed
Wright Medical Group, and Zimmer nically difficult, leading many sur- stem, and occasionally infection. Ap-
Biomet; serves as a paid consultant to geons to adopt RTSA for irreparable propriate soft-tissue management,
Acumed and Zimmer Biomet; and fractures, especially in elderly pa- especially the subscapularis, during
serves as a board member, owner,
officer, or committee member of the
tients.2-4 Outcomes of revision ar- revision arthroplasty affects patient
American Shoulder and Elbow throplasty are consistently inferior to satisfaction and long-term implant
Surgeons. Neither Dr. Petkovic nor those of primary arthroplasty, and survival.
any immediate family member has success is dependent on the reason
for the primary arthroplasty failure.5
commercial company or institution Many revision arthroplasties are Clinical Presentation
related directly or indirectly to the performed for combined modes of
subject of this article. failure. Common complaints of patients
J Am Acad Orthop Surg 2019;27: Identifying the mode of failure with a failed arthroplasty for fracture
39-49 requires a thorough history, detailed care include pain, loss of motion,
DOI: 10.5435/JAAOS-D-17-00051 physical examination, radiographic weakness, and instability. The onset
imaging, laboratory testing, and a and timing of pain should be eluci-
Academy of Orthopaedic Surgeons. joint aspiration and biopsy to rule out dated. Pain that never improved after
deep infection. Revision for osseous the index procedure is concern for an
January 15, 2019, Vol 27, No 2 39
Failed Arthroplasty for Shoulder Fracture
indolent low-grade infection. Pain secondary to the trauma or may be Tuberosity Nonunion or
that developed after an interval iatrogenic from surgery and is more Resorption
period of months or years of minimal common in the deltoid-splitting
Tuberosity nonunion or resorption
symptoms may suggest the develop- approach.7
after hemiarthroplasty for fracture is a
ment of glenohumeral arthritis or
devastating complication that results in
rotator cuff dysfunction, the latter of
Specific Failures Types and rotator cuff dysfunction, weakness,
which can develop secondary to
Management pseudoparalysis, and occasionally in-
tuberosity malunion, nonunion, or
stability. Attempts to repair a tuberos-
resorption. Pain with mechanical
Tuberosity Malunion ity nonunion have a high likelihood of
symptoms of instability with eleva-
unsatisfactory results.9 Likewise, mus-
tion and extension may suggest Tuberosity malposition during hemi-
cle transfers for posterosuperior cuff
anterior instability, whereas poste- arthroplasty for fracture is common
deficiency after hemiarthroplasty are
rior instability is commonly found and responsible for worse clinical
not well described, though one study
during forward elevation and outcomes. Tuberosity malunion may
describes latissimus transfer in combi-
adduction. Pain with pseudopar- cause subacromial, subcoracoid, or
nation with anatomic hemiarthro-
alysis suggests rotator cuff dysfunc- bony internal impingement and com-
plasty.11 Although patients with little
tion. Pain with chronic stiffness both monly disrupts rotator cuff mechanics
pain can be treated nonsurgically, in
actively and passively may indicate because of altered muscle length rela-
symptomatic patients conversion to
capsular contracture, scar, oversized tionships. In cases of external im-
RTSA is often the only reasonable
components, or low-grade chronic pingement with a functional rotator
option. However, it is important to
deep infection.6 cuff, arthroscopic subacromial de-
note that without a functional poste-
Loss of passive motion is suggestive compression has been successful for
rior rotator cuff, external rotation will
of infection, suboptimal component greater tuberosity superior displace-
not be restored with a RTSA alone.
position, version, sizing, or disloca- ments up to 15 mm.8
tion. An oversized humeral head in- The management of symptomatic
creases the lateral humeral offset and tuberosity malunion not amenable to Rotator Cuff Tear
over tensions the rotator cuff causing arthroscopic management is chal- Rotator cuff tear after hemiarthro-
pain and stiffness.6 Infection should lenging. Osteotomy and repair of the plasty for fracture is commonly a late
always be considered in any painful malunited tuberosity is not recom- complication from degenerative cuff
or stiff shoulder arthroplasty, re- mended after hemiarthroplasty for tissue, mechanical impingement from
gardless of overt signs like loosening fracture because osteotomy healing is altered joint mechanics, or tuberosity
of components, draining sinus, swell- jeopardized. Tuberosity osteotomy malposition. Early cuff dysfunction is
ing, induration, and elevated inflam- has been used for fracture malunion frequently encountered when the
matory markers. and during concomitant arthroplasty tuberosity develops a nonunion or re-
Periprosthetic instability can occur for fracture malunion.9 Tuberosity sorbs, but this is rarely a true cuff tear.
with component-related and soft- osteotomy during arthroplasty has Evidence of proximal humeral migra-
tissue–related complications. An un- poor outcomes with worse results tion, acetabularization of the acro-
dersized or excessively retroverted than acute management of tuberos- mion, or rounding of the greater
humeral head can lead to posterior ity fractures. The decision to RTSA tuberosity indicates a chronic cuff tear
instability, whereas excessive ante- for tuberosity malunion depends on that is irreparable. In our experience,
version of the head or subscapularis the severity of rotator cuff dysfunc- repairs of degenerative tears after ar-
insufficiency can lead to anterior tion because of tuberosity malposi- throplasty are not likely to succeed.
instability. Commonly rotator cuff tion and impingement.10 Superior Even in the setting of anterior insta-
deficiency from tuberosity resorp- malposition of the tuberosity can bility from a subscapularis tear, repairs
tion or secondary tearing will lead to lead to impingement and loss of can be attempted if identified early,
weakness, pseudoparalysis, and elevation, and these patients can though expectations on functional
sometimes instability. Failure to re- potentially greatly improve with a outcomes should be tempered.12
gain active motion after hemi- RTSA. However, posterior malunion In acute tears, surgeons have at-
arthroplasty for fracture despite of the tuberosity can be problematic tempted repair around a shoulder
appropriate component and tuber- because it is associated with loss of prosthesis with poor results. In one
osity union may indicate neurologic external rotation. These patients study, only 20% success of rotator cuff
deficiency or rotator cuff failure. may not be served as well unless an repair was achieved after shoulder ar-
Nerve dysfunction is commonly associated tendon transfer is used. throplasty.13 Subscapularis tears are
Djuro Petkovic, MD, et al
Figure 1
Radiographs showing chronic instability after failed hemiarthroplasty for fracture. This is the status of a 61-year-old woman
who underwent hemiarthroplasty for fracture but developed anterior instability, bony Bankart fracture, and loss of fixation of
the greater tuberosity and was painfully stiff with pseudoparalysis for 8 months with AP (A) and axillary (B) radiographs.
Serum and aspiration infection workup was negative, so an arthroscopic biopsy for culture was performed which was
negative for infection. The patient underwent a single-stage revision to reverse replacement after CT scan demonstrated
good glenoid vault remaining without notable anterior bone loss (C). One-year follow-up radiographs AP (D) and axillary (E)
demonstrate no loosening of stem or baseplate but grade 1 scapular notching. Her range of motion was 85 of forward
elevation and 10 of external rotation, and pain control was excellent with visual analogue scale of 1.5 of 10.
sometimes repaired directly because arthroplasty for fracture. Eccentric sults.14 Similarly, disappointing
of anterior instability, but this may glenoid wear is found with an results have been observed with
only be successful in about half of unbalanced joint from rotator cuff revision arthroplasty after resur-
patients and may need augmenta- tear, tuberosity malunion, or com- facing hemiarthroplasty. 15 During
tion with pectoralis transfer or ponent malposition. The superior revision of a failed hemiarthroplasty
graft.12 Symptomatic chronic rota- glenoid is worn with posterosuperior to TSA with eccentric glenoid wear,
tor cuff tear after hemiarthroplasty cuff deficiency and proximal humeral soft-tissue balancing is difficult be-
for fracture is best treated with migration. Even with an intact cuff, cause tissue planes are scarred and
conversion to a RTSA. revision to total shoulder arthro- less compliant. Often, RTSA may be
plasty (TSA) has worse outcomes the only successful option with
Glenoid Arthritis and Bone than primary TSA for arthritis with chronic instability of a failed hemi-
Deficiency more stiffness, higher revision sur- arthroplasty (Figure 1).
The development of glenoid arthritis gery rate, up to 64% rate of glenoid Glenoid bone deficiency after TSA
is a common finding after hemi- erosion, and 47% unsatisfactory re- was classified by Antuna et al,16
January 15, 2019, Vol 27, No 2 41
Figure 2 Figure 3
Illustration of Antuna classification

of glenoid bone deficiency after
glenoid component removal.
This classification is determined
intraoperatively during revision
arthroplasty. It is first determined
where the defect is on the glenoid (ie,
central, peripheral, combined). Then,
the defect is classified as mild if it
involves less than one third of the
glenoid rim or surface, moderate if it Radiographs showing management of a periprosthetic fracture. An 85-year-old
involves between one third and two female sustained a periprosthetic fracture of her humeral shaft just distal to the
thirds, and severe if more than two stem of her well-fixed reverse shoulder arthroplasty (A). She failed a course of
thirds is compromised. several months of conservative treatment with a Sarmiento brace resulting in
nonunion. Surgical treatment was then performed, consisting of an
interfragmentary screw at the fracture site as well as application of an
which can help guide management anterolateral 4.5 mm compression plate fixed distally with bicortical screws and
options (Figure 2). Typically, mild proximally with a combination of unicortical screws and radiolucent cables where
the stem prevented longer screws (B).
and moderate deficiencies are ame-
nable to reimplantation of the gle-
noid component with or without
bone grafting. However, in those fracture location.17 Type A fractures a 16% intraoperative fracture rate
with severe central or combined require assessment of stem stability during removal of the prosthesis or
bone loss, it may not be possible to with surgical management depend- cement mantle. Risk factors of intra-
place a new glenoid component. ing on distal stem fixation. Type B operative fracture include female gen-
Options in severe cases of bone loss fractures typically have good stem der, patients with instability, and
include eccentric structural graft, an fixation but are at risk for nonunion previous hemiarthroplasty. In the set-
eccentric baseplate, eccentric ream- given the involvement of the stem tip ting of a well-fixed stem where ex-
ing, or placement of a hemiarthro- and cement. These fractures may be traction is difficult, fracture risk can be
plasty without a glenoid component. treated with a trial of nonsurgical decreased with a vertical osteotomy
care with a brace, and if healing fails and stabilization with cerclage cables.19
within 3 to 6 months, then surgical
Periprosthetic Fractures care with plate, cerclage, and possi-
Periprosthetic fractures are rare and ble strut allografting has demon- Stem Loosening and
are usually related to trauma or intra- strated excellent union rates (Figure Proximal Humeral Bone Loss
operative complications. Periprosthetic 3). Type C fractures may be treated Loosening of the humeral stem for any
humeral shaft fractures were classified like a typical humeral shaft fracture diagnosis, even after arthroplasty for
by Wright and Cofield with type A with good success with nonsurgical fracture, is rare.20 Loosening is more
fracture proximal to the stem tip, type management in a functional brace. common among failed total or reverse
B fracture at the tip and extending Care must be taken intraoperatively shoulder arthroplasty with possible
distally, and type C fracture distal to in removing a well-fixed stem during glenoid polyethylene debris, cement
the stem. Management depends on revision surgery. Wagner et al18 found particles, or metallosis responsible for
Figure 4
Radiographs showing humeral stem loosening, canal perforation, and proximal bone loss. This is the status of a 63-year-old
woman 12 years after hemiarthroplasty for a failed total shoulder glenoid component with stem loosening, canal perforation,
and notable proximal bone loss (A). Her workup was negative for infection except the radiographic findings and history of
failed surgery. B, Status after explantation, débridement, and long-stem custom antibiotic spacer placement. C, Nine months
after second-stage revision to reverse replacement with fibula structural autografting demonstrating osseous incorporation.
Photographs showing clinical range of motion forward elevation (D), only 2 months after revision reverse replacement with
90 forward elevation, 70 abduction, and internal rotation to L3.
osteolysis.21 If loosening is present, humeral component and thus pro- sion with allograft prosthetic re-
infection must be ruled out. Loosening mote loosening. placement, fibula strut autograft
often compromises humeral bone Management of a loose, aseptic (Figure 4, C), or monoblock stem
stock, and the stem tip may perforate stem may include conversion to a ce- without structural grafting23 (Figure
the humeral shaft (Figure 4). The mented stem if bone stock remains, 5, E). The addition of allograft bone
proximal humerus is often deficient longer stem implantation to gain increases the risk of infection and
in bone because of tuberosity repair better diaphyseal purchase,22 and nonincorporation, autograft pro-
and stress shielding seen with ce- either intramedullary or cortical vides biologic bony support but
mented humeral stems. Additionally, strut bone grafting. Management of has potential donor site morbidity,
metaphyseal bone loss can lead to proximal humeral bone loss after and metallic replacement overcomes
lack of rotational stability of the failed arthroplasty can include revi- bone deficiency but risks metallic
January 15, 2019, Vol 27, No 2 43
Figure 5
Radiographs showing chronic deep infection after hemiarthroplasty for fracture with Draining Sinus. This is the status of a 72-year-
old man 13 years after hemiarthroplasty for fracture with 5 years of pseudoparalysis with 40 degrees forward elevation and the
development of a chronic draining sinus for the last 6 months. A, Radiograph reveals cuff tear of the superior cuff and notable
proximal humeral bone loss. CT scan AP radiograph (B) and axillary (C) reveal Sirveaux E3 glenoid erosion. He underwent
débridement, removal of prosthesis and cement, and placement of antibiotic spacer seen in the radiograph (D) with cultures
growing P. acnes. He was treated with 6 weeks IV antibiotics and 6 weeks off antibiotics with normalization of his inflammatory
markers. AP radiograph (E) and axillary view (F) one year after revision to reverse replacement his radiographs reveal a well-
cemented stem and well-fixed baseplate without signs of loosening or infection. He did not receive allograft because of concern for
recurrent infection. His 1-year follow-up motion was acceptable at 100 forward elevation (G) and 10 external rotation.
stem breakage.23 Stephens et al24 (PMNs) per high-powered field of postoperative antibiotics until cul-
compared conversion to RTSA in (HPF). It is controversial how many tures are finalized.26
patients with and without bone loss PMNs are required per HPF to
and found no difference in outcome diagnose infection, though 7 to 10
scores but worse range of motion, PMNs per HPF for five or more Outcome of
higher rates of stem loosening, and HPFs demonstrated a sensitivity of Hemiarthroplasty Revision
subsidence in the bone loss group. 72%, and 100% specificity.29 Based to Reverse Replacement
They recommended a long-stem on a small retrospective cohort,
monoblock prosthesis to prevent arthroscopic biopsy culture results Hemiarthroplasty for fracture is a
humeral-sided failure. were found to have 100% sensitiv- technically demanding procedure
ity, specificity, positive predictive that is dependent on rotator cuff
value, and negative predictive value function and restoration of tuberos-
Infection compared with open biopsy results ity anatomy and proximal humeral
Infection is nearly always part of the as the benchmark (Figure 1, C). In geometry. The results of hemi-
differential diagnosis for a failed ar- contrast, fluoroscopically guided as- arthroplasty for fracture are highly
throplasty. Strong clinical signs like a pirations yield a sensitivity of 16.7%, dependent on the anatomic healing of
draining sinus, swelling and indura- specificity of 100%, positive predictive the tuberosities compared with those
tion, and elevated inflammatory value of 100%, and negative predic- of RTSA.4 In addition, a host of
markers are common in overt in- tive value of 58.3%.30 other common failures exist such as
fections, but often subclinical in- The optimal management for PSI glenoid arthritis, glenoid eccentric
fections exist (Figure 4). The surgeon remains controversial. Options include wear, deep infection, stiffness,
should attempt to rule out infection débridement and retention of com- instability, loosening, and compo-
before and during revision surgery, ponents in infections within 3 weeks nent malposition.1 Multiple ran-
although no benchmark tests exist to from the index surgery, single-stage domized control studies have found
completely rule out deep infection. revision with débridement and re- limited functional benefit to hemi-
Propionibacterium acnes is often the implantation, and a two-stage revi- arthroplasty for fracture in elderly
culprit identified in indolent peri- sion with débridement and antibiotic patients compared with nonsurgical
prosthetic shoulder infection (PSI), spacer followed by later reimplanta- management.2,3 The outcome after
though staphylococcal species are tion. Resection arthroplasty alone is a revision to RTSA was worse for
also relatively common.25 P acnes is salvage procedure for infection but failed hemiarthroplasty for fracture
difficult to isolate in routine labora- leaves the patient with inferior out- than for failed hemiarthroplasty for
tory cultures, and serum erythrocyte comes.25 Theoretic advantages of a arthritis.31
sedimentation rate (ESR), C-reactive single-stage revision are decreased The clinical outcome of revision to
protein (CRP), and white blood cell morbidity, less scarring, and better RTSA for failed hemiarthroplasty for
blood tests have poor sensitivity and function than two-stage surgery. The fracture is not frequently described. A
specificity for shoulder infections.26 main advantage of a two-staged re- study by Patel et al31 found encour-
Synovial aspirations with biomarkers vision with temporary antibiotic aging results after revision to RTSA.
such as a-defensin and interleukin-6 spacer is potentially improved rates With an average of 3.5 years of
hold promise to diagnose PSI.27 of infection eradication, though this follow-up, these failed hemiarthro-
Current diagnosis of PSI includes a has not been proven. A recent sys- plasty patients had a mean American
positive culture from an aspiration, tematic review found no statistical Shoulder and Elbow Surgeons score
arthroscopic biopsy, or open biopsy. difference in infection eradication of 64, forward elevation to 112, and
Cultures should be held for 21 days to between single- and two-stage re- visual analogue scale pain score of
isolate the growth of P. acnes. One visions, but with improved Constant 3.7, with a 7% complication rate
must be mindful, however, that scores in the former. Interestingly, of periprosthetic fracture. Patients
contaminants are more likely to grow 43% of patients undergoing two- should be educated and expectations
after 11 days of culture, whereas true staged revision elected to perma- should be realistic that results can be
positive cultures normally grow in nently live with the antibiotic spacer disappointing. Dezfuli et al32 com-
fewer days with a higher proportion because of acceptable function and pared primary reverse with revision
of positive cultures.28 Commonly, pain relief.25 Once revision surgery RTSA after previous hemiarthro-
frozen section pathology is sent for has been performed in the setting of plasty for fracture and predictably
cell count to determine the preva- possible infection, it is common to found worse outcome scores as
lence of polymorphonuclear cells maintain the patient on several weeks well as lower scaption strength and
January 15, 2019, Vol 27, No 2 45
external rotation range of motion in increasing polyethylene thickness,

the revision group. In the setting of a restoration of the lateral offset of the
Authors’ Preferred
previous modular stem hemiarthro- humerus by increasing the gleno- Techniques for Revision of
plasty for fracture that does not sphere diameter, or lengthening by Failed Arthroplasty for
require stem extraction, the results adding a spacer to the humeral stem. Fracture
are potentially encouraging in terms Inadequate soft-tissue forces and
When performing a revision of a
of low intraoperative complications, prosthetic compressive forces are the
failed arthroplasty for fracture, we
decreased surgical time, lower blood most important factors to increase
typically perform a comprehensive
loss, fewer subsequent revisions, and stability. Other factors to consider
improved clinical scores.33 include impingement from hetero- diagnostic workup to correctly iden-
topic ossification and liner failure.36 tify contributing failure modes. We
Management of baseplate failure first rule out PSI on all cases and
Failure of Reverse may include staged surgery with bone routinely obtain an ESR, CRP, and
Arthroplasty for Fracture autografting of the glenoid defect, peripheral CBC with differential. If
followed by revision baseplate fixa- either the ESR or the CRP is
Reverse arthroplasty for acute prox- tion.37 Single-stage revision of base- increased, or if concerning features
imal humerus fracture has become plate fixation is also possible when such as a loose humeral stem even
increasingly popular in select patients there is a contained defect with intact with normal labs are present, then we
older than 70 years because of a pre- medial vault or base of the scapular perform a fluoroscopic-guided arthro-
dictable return to good function spine for central long peg placement. centesis and send the fluid for gram
without the dependency on tuberos- Single-stage revision requires careful stain and culture. Typically, there is
ity healing. However, postoperative preoperative planning by obtaining a not enough fluid aspirated for cell
complication rates are as high as 45% CT with 3D reconstruction to define count. We routinely perform arthro-
in RTSA, with complication rates for screw trajectory, baseplate place- scopic or open biopsy to obtain cul-
fracture as high as 36%.1 These ment, and the need for structural ture results before revision if any part
complications, which are similar to allografting. If inadequate glenoid of the workup is worrisome for deep
other diagnoses managed with this vault remains for central fixation, infection. During revision surgery,
prosthesis, include dislocation, base- then the baseplate may be positioned we use frozen section and con-
plate failure, loosening, scapular to have the central post or screw gain sider .5 PMNs per HPF in any
notching, acromial fracture, deltoid fixation in the base of the scapular sample to be suggestive of infection
fatigue, nerve palsy from over leng- spine. In cases with more severe and subsequently implant an
thening or iatrogenic injury, and glenoid bone loss, experimental gle- antibiotic-impregnated cement spacer.
infection. Unique complications for noid component designs exist similar We typically use a deltopectoral
fracture include higher rates of het- to hip arthroplasty systems that use approach. We avoid an anterosuperior
erotopic ossification, reflex sympa- multiple points of fixation in the
deltoid-splitting approach for revision
thetic dystrophy, and periprosthetic scapula and have had success for
surgery because this approach is
fracture.34 Revision of a failed RTSA revision of the failed RTSA at 3-year
nonextensile and the axillary nerve
for fracture is dependent on the follow-up.38
may be difficult to identify in cases
mode of failure, but is especially Management options for PSI after
with notable scar, putting it at risk for
difficult if the glenoid bone stock is RTSA are complex as noted previ-
injury. When a hemiarthroplasty is
deficient. Additionally, clinical out- ously. One study found improved
comes are jeopardized if axillary function and symptomatic relief revised to an anatomic shoulder ar-
nerve dysfunction or notable deltoid without component loosening after throplasty, we typically perform a
deficiency is present.35 débridement and polyethylene ex- lesser tuberosity osteotomy if suffi-
Management of the unstable RTSA change compared with resection.39 cient bone stock exists. In the setting of
usually includes a closed reduction Although resection is a viable palli- poor bone quality, we perform a sub-
and 6 weeks of immobilization for ative option for failed arthroplasty to scapularis tenotomy. Lesser tuberosity
first time dislocation so long as there reduce shoulder pain, shoulder osteotomy is preferable because it im-
are no problems with component function will be detrimentally af- proves the glenoid exposure when the
version, fixation, or concern for infected. Resection of RTSA has worse soft tissues are less compliant during
fection. For recurrent dislocation, outcomes than resection after hemi- revision. When revision to a RTSA is
surgical intervention typically re- arthroplasty or anatomic shoulder done, we perform a subscapularis peel
quires increased soft-tissue tension, arthroplasty.40 technique.
If the humeral stem requires re- soft-tissue contracture that is com- deficient or noncompliant. In the
moval for infection, revision to mon to failed hemiarthroplasty, we setting of intraoperative anterior
reverse, or malposition, we prefer to routinely identify the axillary nerve instability, we assess for component
attempt stem removal without hum- anterior to the inferior subscapularis. mechanical impingement postero-
eral osteotomy. However, if the stem We attempt to maintain the teres inferiorly, because unreleased postero-
is well cemented and cannot be minor and infraspinatus attachment inferior capsule/soft tissue prevents
removed with proximal osteotomy to the greater tuberosity to help with proper rotation and lengthening. We
preparation using osteotomes, stem postoperative external rotation. It is also assess for soft-tissue tension
extractors, and slap hammers, then a reasonable to resect the supraspinatus including conjoint tendon tightness,
vertical humeral osteotomy is pre- tendon to allow for proper prosthetic axillary nerve tension, axial shuck,
ferred.19 Once the controlled oste- tensioning. and lateral dislocation force and may
otomy has been made and an Baseplate implantation requires consider a retentive polyethylene
osteotome is used to dislodge the careful attention to glenoid bone liner despite the risk for increased
intramedullary cement, we cerclage stock and type of glenoid erosion. notching. Other options can include a
wire the proximal humerus to prevent Superior glenoid erosion may require thicker or lateralized polyethylene, as
humeral fracture or further propaga- structural grafting or a superiorly well as a glenosphere with greater
tion of the controlled osteotomy eccentric baseplate to correct the diameter.
before attempted stem extraction. superior tilt to the glenoid. If notable Postoperatively, we keep RTSA
If an infection is diagnosed or pre- medialization of the glenoid joint line patients immobilized in an abduction
sumed, we prefer a prefabricated is present, a lateralized glenosphere sling for 4 to 6 weeks followed by
antibiotic spacer because the cement may help restore offset, improve the active assisted motion as tolerated.
head is smooth and may limit glenoid deltoid wrap over the proximal
erosion. If the spacer stem is not long humerus, and provide compression
enough, we will either fabricate our of the articulation. However, the soft Future Trends
own cement spacer with gentamicin- tissues are often poorly compliant,
Trends that will advance the man-
impregnated cement and a large bore and increasing lateral offset or leng-
agement of failed arthroplasty for
threaded Steinmann pin (Figure 4, B) thening may be difficult as a result of
fracture include increasing use of
or augment the prefabricated spacer the excessive soft-tissue tightness. In
RTSA for acute fractures, the use of
with an extended stem using a chest cases with contained glenoid defi-
pyrocarbon hemiarthroplasty heads
tube and a threaded Steinmann pin ciency with central erosion, we prefer
to reduce glenoid wear, enhance-
to create a shape and length suitable to use a long-post baseplate that has
ments in preoperative templating,
for the proximal humerus. A second purchase in and may even penetrate
and progress in infection prevention
batch of cement is commonly re- the medial vault cortical bone. Can-
and diagnosis. The management of
quired to fill the metaphyseal void cellous impaction bone grafting can
failed RTSA for fracture is especially
and provide rotational and axial be performed within the contained
complex because surgical solutions
fixation to the cement spacer. We deficiency. In situations with uncon-
are limited. Promising concepts
typically place the spacer in 30 to tained glenoid bone loss, we will
include staged glenoid bone grafting
40 retroversion and repair the place structural bone graft with
and cage-like scapular reconstructions
anterior tissues and/or subscapularis autograft from the iliac crest, femoral
for severe glenoid bone loss. Future
to prevent anterior dislocation of the head allograft, or consider metallic
research will likely focus on the suc-
spacer. In cases of infection, this augmented baseplate designs.
cesses and failures of glenoid struc-
repair should be done with mono- Humeral stem revision to RTSA
tural bone grafting, management of
filament suture. If patients have sat- typically requires cementation be-
periprosthetic joint infections, and
isfactory function and symptomatic cause of proximal humeral calcar and
implant designs that allow for
relief and the patient wants to avoid metaphyseal bone loss. If notable
increased modularity and convert-
surgery, it is appropriate to leave proximal humeral bone loss exists,
ibility between reverse and anatomic
these spacers in permanently. then we prefer long-stem fixation
reconstruction.
When revision to a RTSA is per- with structural autografting or me-
formed, we consider soft-tissue re- tallic replacement and try to avoid
leases of the capsule to ensure alloprosthetic reconstruction because Summary
adequate soft-tissue tensioning with of concern for infection risk. We
RTSA and to prevent postoperative typically do not repair the sub- Failure of shoulder arthroplasty for
dislocation. To safely release the scapularis because it is frequently fracture has a wide range of
January 15, 2019, Vol 27, No 2 47
etiologies, and management should proximal humeral malunions: Long-term 22. Owens CJ, Sperling JW, Cofield RH: Long-
results. J Shoulder Elbow Surg 2002;11: stemmed humeral components in primary
be tailored to the cause of failure. 122-129. shoulder arthroplasty. J Shoulder Elbow
Revision surgery is technically diffi- Surg 2014;23:1492-1498.
10. Willis M, Min W, Brooks JP, et al: Proximal
cult with outcomes that are predict- humeral malunion treated with reverse 23. Budge MD, Moravek JE, Zimel MN, Nolan
ably worse than primary arthroplasty. shoulder arthroplasty. J Shoulder Elbow EM, Wiater JM: Reverse total shoulder
Surg 2012;21:507-513. arthroplasty for the management of failed
Patient expectations should be ap-
shoulder arthroplasty with proximal
propriately treated, and preopera- 11. Jerosch J, Sokkar SM, Neuhaeuser C, humeral bone loss: Is allograft
Abdelkafy A: Humeral resurfacing
tive education is critical to patient arthroplasty in combination with latissimus
augmentation necessary? J Shoulder Elbow
Surg 2013;22:739-744.
satisfaction. dorsi tendon transfer in patients with
rotator cuff tear arthropathy and preserved 24. Stephens SP, Paisley KC, Giveans MR,
subscapularis muscle function: Preliminary Wirth MA: The effect of proximal humeral
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20. Cil A, Veillette CJ, Sanchez-Sotelo J, shoulder arthroplasty as primary versus
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AM: Dislocation following reverse total bone loss: Improved clinical outcome in 11 22:247-252.
January 15, 2019, Vol 27, No 2 49
Review Article
Management of Isolated Lateral

Malleolus Fractures
Abstract
Amiethab A. Aiyer, MD Isolated lateral malleolus fractures represent one of the most common
Erik C. Zachwieja, MD injuries encountered by orthopaedic surgeons. Nevertheless,
appropriate diagnosis and management of these injuries are not
Charles M. Lawrie, MD
clearly understood. Ankle stability is maintained by ligamentous and
Jonathan R. M. Kaplan, MD bony anatomy. The deep deltoid ligament is considered the primary
stabilizer of the ankle. In the setting of an isolated lateral malleolus
fracture, identifying injury to this ligament and associated ankle
instability influences management. The most effective methods for
assessing tibiotalar instability include stress and weight-bearing
radiographs. Clinical examination findings are important but less
reliable. Advanced imaging may not be accurate for guiding
management. If the ankle is stable, nonsurgical management
produces excellent outcomes. In the case that clinical/radiographic
findings are indicative of ankle instability, surgical fixation options
include lateral or posterolateral plating or intramedullary fixation.
From the Department of Orthopaedic Locking plates and small or minifragment fixation are important
Surgery, University of Miami Hospital,
Miami, FL (Dr. Aiyer and adjuncts for the surgeon to consider based on individual patient
Dr. Zachwieja), the Department of needs.
Orthopaedic Surgery, Washington
University School of Medicine, Saint
Louis, MO (Dr. Lawrie), and the
O
Orthopaedic Specialty Institute, rthopaedic surgeons frequently effects on outcomes. Sanders et al5
Orange, CA (Dr. Kaplan).
evaluate and manage ankle noted in a randomized, controlled
Dr. Aiyer or an immediate family fractures. Epidemiologic data report prospective study of 81 patients with
that isolated lateral malleolus frac- nondisplaced, unstable isolated lateral
to Medline and Paragon 28 and
serves as a board member, owner, tures are the most common ankle malleolus fractures, that nonsurgical
officer, or committee member of the fracture pattern (56% to 65% of all management resulted in an increased
American Orthopaedic Foot and Ankle risk of fracture displacement and de-
ankle fractures).1,2 However, con-
Society. Dr. Lawrie or an immediate
troversy remains in the orthopaedic layed union. Moreover, unstable frac-
family member serves as a paid
consultant to Medtronic. Dr. Kaplan or literature about the appropriate eval- tures that are managed nonsurgically
an immediate family member serves uation and management of this are associated with increased rates of
as a paid consultant to Medline and
ubiquitous injury. Current treatment posttraumatic ankle arthritis (PTAA).3
Paragon 28. Neither Dr. Zachwieja nor
paradigms are based on the stability Thus, determination of ankle stability
received anything of value from or has of the ankle mortise. Isolated lateral is the crux of optimal management for
malleolus fractures without lateral isolated lateral malleolar injuries.
related directly or indirectly to the subluxation of the talus are stable,
subject of this article. have a low chance of displacement, Anatomy
J Am Acad Orthop Surg 2019;27: and do well with nonsurgical man-
50-59 agement.3 Conversely, lateral malleolus The ankle is a complex joint that
DOI: 10.5435/JAAOS-D-17-00417 fractures that have an incongruent comprises the talus, medial and lat-
ankle mortise are considered unstable eral malleoli, and tibial plafond. In
Academy of Orthopaedic Surgeons. and require surgical fixation.4 Ap- addition to the osseous architecture
propriate management has notable of the ankle mortise, three groups of
Amiethab A. Aiyer, MD, et al
ligamentous structures provide ankle preventing external rotation and lat- lated lateral malleolus fracture at
static stability. The ligamentous eral displacement of the talus.9 The the level of the syndesmosis. SER-2
support of the medial ankle com- syndesmosis and lateral ligamentous injuries are lateral malleolus frac-
prises the deltoid ligament. The structures are secondary stabilizers. tures without ligamentous instabil-
deltoid ligament contains both Disruption of the deltoid ligament in ity. SER-4 injuries involve a lateral
a superficial and deep layer. The isolation, or in conjunction with the malleolus fracture, injury to the an-
deep layer originates from the inter- syndesmosis, leads to lateral trans- terior inferior tibiofibular ligament,
collicular groove and posterior lation of the fibula and external ro- posterior inferior tibiofibular ligament,
colliculus and inserts on the talus. tation of the talus, shifting the center and medial-sided structures, result-
The superficial layer originates from of contact pressure on the talus, and ing in an unstable ankle. Although
the anterior colliculus and inserts on decreasing the overall contact area. this remains the most commonly
the navicular, calcaneus (sustentaculum Hunt et al10 demonstrated this ele- used classification, it is important to
tali), talus, and spring ligament.6 vated total contact stress of the recognize that the original experi-
The tibiofibular syndesmosis pro- tibiotalar joint. Ultimately, this condi- mental technique that created these
vides a soft-tissue connection be- tion may increase the risk for articular injuries involved manual application
tween the distal tibia and fibula. cartilage damage and PTAA. of rotational forces to a fixed foot
It consists of the anterior inferior Injuries that destabilize the ankle and does not accurately re-create
tibiofibular ligament, posterior infe- joint generally require open reduc- in vivo injury mechanisms of com-
rior tibiofibular ligament, inferior tion and internal fixation to restore bined axial loading/rotational de-
transverse ligament, and interosseous normal joint kinematics. However, formation. Rodriguez et al14 found
ligament.7 The lateral ligamentous an injury without instability can be that the Lauge-Hansen classification
structures of the ankle consist of the managed conservatively with the was only 65% accurate in predicting
anterior talofibular ligament, calca- assumption that the biomechanics of radiographic fracture patterns based
neofibular ligament, and posterior ankle joint motion is not altered. Clini- on observed injury mechanisms.
talofibular ligament.6 cal studies have repeatedly demon- The Danis-Weber classification is
strated excellent results for nonsurgical based on radiographs and evaluates
management of stable ankle fractures.3 the position of the distal fibula frac-
Biomechanics Unfortunately, determining ankle sta- ture in relation to the syndesmo-
bility after an isolated lateral malleolus sis.12,13 Type A fractures occur
The trapezoidal shape of the talus fracture remains a diagnostic dilemma. below the level of the syndesmosis
influences ankle motion. During and are generally stable fracture pat-
dorsiflexion, the fibula rotates exter- terns. Type B fractures, which corre-
nally and translates laterally, accom- Classification and spond to the SER pattern described in
modating the anteriorly wide talar Diagnosis the Lauge-Hansen classification, orig-
dome. In plantarflexion, the nar- inate at the level of the syndesmosis
rower, posterior aspect of the talus is Fracture diagnosis begins with stan- (Figure 1) and may or may not be
within the mortise, leading to internal dard AP, lateral, and mortise radio- stable. Type C fractures occur above
rotation of the talus.7 The ankle is graphs of the ankle. Based on the level of the syndesmosis and are
considered stable when the talus radiographic findings, classifications often unstable injuries.15
moves in a normal physiologic pat- have been developed to describe the An ideal classification would help
tern through full range of motion mechanism of injury, predict soft- determine treatment. Unfortunately,
(ROM). In these conditions, most tissue injury, and determine the need neither of these systems has been
of the load is transmitted through for surgical intervention. The two shown to accurately predict insta-
the talar dome with the remainder most commonly used classifications bility or the need for surgical treat-
through the medial and lateral talar are the Lauge-Hansen11 and Danis- ment and have limited prognostic
facets.8 Injury that leads to an un- Weber systems.12,13 capabilities.16-18 In 2007, Michelson
stable ankle and nonphysiologic The Lauge-Hansen11 classification et al18 developed a classification
movement of the talus within the for ankle fractures was developed in based on the stability of the injury
tibial plafond markedly alters joint 1954 and is based on the position of pattern. Instability was defined as
forces and contact pressures. the foot at the time of injury and the injuries requiring a reduction, loss of
Under physiologic loading, the del- deforming force. Supination external reduction, lateral displacement of the
toid ligament is considered the pri- rotation (SER) injuries are the most talus leading to increased medial
mary static stabilizer of the ankle, common and may result in an iso- clear space (MCS), which represents
January 15, 2019, Vol 27, No 2 51
Isolated Lateral Malleolus Fractures
Figure 1
Lateral, AP, and mortise radiographs of a 28-year-old woman with an isolated lateral malleolus fracture without an
associated medial-sided injury. This scenario is consistent with an SER-2 injury. Note that the fibula fracture exits at the level
of the tibial plafond, which corresponds to a Weber B fracture. This condition was managed nonsurgically in a well-molded
short leg cast with a brief period of immobilization. SER = supination-external rotation
the distance from the superior- tients were successfully treated at the mortise view radiograph to mea-
medial aspect of the talus to the a minimum follow-up of 2 years. sure the MCS (Figure 3). Murphy
superior-lateral aspect of the medial For the remainder of this article, the et al20 reviewed 49 ankle radio-
malleolus at the level of the talar focus will be on evaluation and graphs without pathology and found
dome, and bimalleolar or trimalleolar management of isolated Weber B the mean MCS in males to be 3.8 6
injuries; stable injuries were those ankle fractures. 0.7 mm and in females 2.9 6
that did not meet the abovementioned 0.5 mm. Increased MCS is suggestive
criteria. After a literature review of all of deltoid ligament disruption and
articles pertaining to ankle fractures, Detecting Tibiotalar Instability ankle instability. The authors found
treatment, and outcomes, the authors In the setting of an isolated Weber B that tall patients and men were at
concluded that unstable ankle frac- lateral malleolus fracture, identifying risk for a false-positive diagnosis of
tures have improved outcomes with whether tibiotalar instability is pre- deltoid rupture. Currently, consen-
surgical intervention, whereas non- sent is critical in deciding between sus on the amount of MCS indicative
surgical treatment produces better surgical and nonsurgical manage- of instability is lacking. Using initial
results in stable ankle fractures. ment. Unstable fracture patterns with non–weight-bearing injury radio-
Pakarinen19 also evaluated a stability- lateral translation of the talus or talar graphs, Schuberth et al21 showed that
based classification. In this classifica- tilting on standard non–weight- for an MCS of 3 mm, 4 mm, $5 mm,
tion scheme, unstable injury patterns bearing radiographs are suggestive and $6 mm, the false-positive rate for
included high fibular fractures with of deltoid disruption and benefit from deltoid rupture was 88.5%, 53.6%,
positive stress tests, lateral malleolar open reduction and internal fixation 26.9%, and 7.7%, respectively, com-
fractures with talar shift or tilt on the (ORIF) (Figure 2). However, patients pared with direct arthroscopic visuali-
mortise or lateral radiographs, and with a reduced ankle mortise on zation of the ligament. This finding led
bimalleolar or trimalleolar injuries. radiographs require further investi- the authors to conclude that deltoid
Fractures not meeting these criteria gation. A multitude of methods have ligament integrity cannot be pre-
were considered stable. Unstable frac- been proposed to assess deltoid in- dicted by the MCS on initial injury
tures were managed with surgical jury and tibiotalar instability, in- radiographs.
treatment, and stable fractures were cluding stress radiographs, MRI, and Findings of physical examination
managed nonsurgically. The author physical examination alone. of medial-sided tenderness, swelling,
found that by using this classification One of the most common methods and ecchymosis are also unreliable at
scheme to determine treatment, pa- to assess tibiotalar instability is using determining instability. DeAngelis
Figure 2
A 19-year-old woman with isolated lateral malleolus Weber B fracture. A, Obvious medial clear space widening and lateral
subluxation of the talus are present on initial injury radiographs, indicating an unstable ankle mortise. B, The patient
underwent successful open reduction and internal fixation (ORIF).
January 15, 2019, Vol 27, No 2 53
Figure 3 Figure 4 external rotation stress radiographs,

gravity stress radiographs, or weight-
bearing radiographs. Manual exter-
nal rotation stress radiographs are
performed by manually internally
rotating the tibia approximately 10
while applying an external rotation
to the foot with the ankle in neutral
dorsiflexion (Figure 4). Studies have
suggested that an MCS greater than
4 or 5 mm indicates deltoid ligament
disruption. Park et al24 obtained
fluoroscopic mortise views of six
cadaveric ankles after destabilizing
the ankles according to the SER
mechanism. The authors found a sen-
sitivity, specificity, positive predictive
value, and negative predictive value of
100% for absolute MCS .5 mm with
applied dorsiflexion and external
rotation. However, clinical data sug-
gest otherwise. Schottel et al25 noted
that an MCS cutoff of greater than
5 mm produced a sensitivity and
specificity of only 66% and 77%,
respectively, for deltoid ligament tear
confirmed by MRI. Using an MCS
cutoff of 4 mm, the sensitivity was
Mortise radiograph showing 73% and the specificity was 46%.
measurement for medial clear space. An inherent problem with manual
stress examination is the reproducibility
Manual external rotation stress
radiographs are performed with the of the test. As noted by Park et al,24
et al22 evaluated 55 patients with ankle in neutral dorsiflexion, the tibia the position of the ankle when
Weber B lateral malleolus fractures internally rotated 10, and a manual external rotation stress is applied
and a normal MCS on initial radio- external rotation force applied. affects the predictive value of the
graphs. They found that medial-sided deep deltoid ligament status. The
tenderness as a marker of deltoid lig- fracture fragments, and female sex. authors found the highest specific-
ament injury had a sensitivity of 57% However, it is important to note that ity and positive predictive value for
and a specificity of 59%. the specificity of detecting a stable deep deltoid injury when the ankle
Nortunen et al23 assessed mor- lateral malleolus fracture in patients was held in a dorsiflexed position
phological factors on standard non– with posterior diastasis of ,2 mm and an external rotation force applied.
weight-bearing injury radiographs and only two fracture fragments was Another important consideration is
that may indicate stability. The au- 39% and 13%, respectively, indicat- that the amount of applied force nec-
thors evaluated 286 consecutive ing a very high false-negative rate essary has not been determined.
patients with an isolated lateral using these criteria.
malleolus fracture without evidence
of incongruity or medial widening Gravity Stress Radiographs
on standard injury radiographs. Manual External Rotation Alternatively, numerous studies have
Analysis revealed three independent Stress Radiographs suggested the use of gravity stress
radiographic variables that were pre- Currently, dynamic imaging with the radiographs to assess the competency
dictors of stability: maximum width use of stress radiographs remains the of the deep deltoid ligament.26-28
of the fracture line on the lateral standard practice to detect tibiotalar Gravity stress radiographs are per-
radiograph of ,2 mm, only two instability. Options include manual formed by placing the patient in the
lateral decubitus position with the lateral malleolar fracture, a normal Figure 5
injured side down. The most distal ankle mortise on non–weight-bear-
half of the leg is then placed over the ing static radiographs and a positive
end of the table, allowing the foot to external rotation stress test. These
fall into external rotation because of patients were then placed into a
gravity. A standard mortise radio- short leg walking cast. They returned
graph of the ankle is then taken to the clinic seven days after injury
(Figure 5). The gravity stress view and were evaluated with weight-
was first introduced by Michelson bearing radiographs. If the MCS
et al.26 Using eight cadaver speci- was less than or equal to 4 mm the
mens, superficial and deep deltoid patients continued nonsurgical treat-
transection combined with fibular ment. If the MCS was greater than
osteotomy produced a lateral talar 4 mm, the deltoid ligament was
shift of 2 mm or greater in all considered ruptured, and the patient
specimens when the gravity stress was offered surgical treatment. The Gravity stress radiographs are
view was performed. Proposed ben- authors noted that 8% of the patients performed with the patient in the
lateral decubitus position with the
efits of this technique include no had MCS widening at follow-up and
most distal half of the affected leg
radiation exposure to the physician were offered surgical treatment. At over the table. A bump is placed
and the constant force of gravity as 1-year follow-up, the average Amer- under the calf allowing the foot to fall
opposed to an unreproducible force ican Orthopaedic Foot and Ankle into external rotation.
applied by the practitioner. In addi- Society (AOFAS) score was 91 6
tion, the position of the ankle does 8.1, which is considered to be a good for determining management.30,31
not affect the effectiveness of the to excellent result. However, it should However, they may be influenced by
examination.29 Clinically, Schock be noted that the AOFAS is a non- the amount of weight being placed
et al27 and LeBa et al28 demon- validated scoring system. These by the patient. Gravity stress radio-
strated in their prospective studies findings are consistent with results graphs are not influenced by ankle
of patients with isolated SER fibula from Holmes et al;32 patients with a position, rely on the constant force
fractures that gravity stress radio- Weber B ankle fracture and an intact of gravity, and are less painful for
graphs are as effective as manual mortise on initial non–weight-bear- patients. Manual external rotation
stress radiographs, while being less ing radiographs were seen at 1-week stress radiographs are commonly
painful. follow-up and gravity stress views used and have reproducible results
were obtained. Using an MCS cutoff if performed by well-trained per-
of 7 mm, surgical treatment was sonnel. Although the superiority
Weight-bearing Radiographs recommended for those patients with of one imaging technique over the
Recent literature has questioned values greater than this. Fifty-one other has not been determined, treat-
whether a positive stress radiograph patients without MCS widening on ing clinicians must select the modality
indicates complete rupture of the gravity stress views were followed that is optimal for a given patient. Re-
deep deltoid ligament and conse- for 1 year with serial weight-bearing gardless of the modality used, evalua-
quent instability in patients with no radiographs to evaluate for MCS tion of the MCS is important to gauge
MCS widening on initial radio- widening. At final follow-up, the the presence of medial-sided injury.
graphs. Koval et al30 showed that 19 mean AOFAS Hindfoot score was Although the absolute value of the
of 21 patients with MCS .5 mm 93.2. All patients except one had MCS can be helpful for optimizing
on manual external rotation stress decreased MCS at 1 year, and clini- management, its utility may be limited
imaging and no lateral talar sub- cal fracture union was 100%. by magnification or the radiographic
luxation on static injury radiographs Overall, identifying stability of the technique. Comparing the MCS with
had a partial tear of the deep deltoid ankle can be assessed with manual the contralateral side or using the ratio
ligament on MRI; these patients were external rotation stress radiographs, of the superior clear space to the MCS
successfully treated nonsurgically. gravity stress radiographs, or weight- may correct for this effect.
This has led to the investigation of bearing radiographs. Weight-bearing
using weight-bearing radiographs to radiographs take into account the
evaluate ankle stability and dictate inherent stability of the ankle in Magnetic Resonance Imaging
management. Hoshino et al31 eval- neutral position and have been The utility of MRI is also limited.
uated 38 patients with an isolated shown to be an acceptable method Regardless of MCS, Nortunen
January 15, 2019, Vol 27, No 2 55
et al33 found that the deep deltoid union was found in this cohort. radiographs. It is important to con-
ligament was injured in all patients Although short-term follow-up dem- sider that this protocol represents the
with an SER fracture pattern. onstrates acceptable outcomes with practice of the senior authors. Pro-
Similarly, they noted that although nonsurgical management of stress- vided that the patient has decreased
the severity of deltoid ligament positive lateral malleolus fractures, pain and radiographs demonstrate
injury correlated with increased the long-term consequences of radio- healing/persistent ankle stability, for-
MCS, remarkable variability was graphic malalignment and wid- mal physical therapy can begin to
seen in measurements between ened MCS are notable. Yde and work on strengthening, gait training,
similar MRI findings. On the basis Kristensen34 demonstrated at a ROM, and stretching.
of these findings, the authors do follow-up of 3 to 10 years that SER-4
not recommend using MRI to aid ankle fractures with a nonanatomic
in clinical decision making. reduction managed surgically had a
Surgical Treatment
good functional result in 83% of Surgical management of unstable
patients, compared with 55% in isolated lateral malleolar ankle frac-
Management nonsurgically managed fractures. Sim- tures is addressed through open
ilarly, Tunturi et al35 demonstrated a reduction and internal fixation.
If the medial malleolus is fractured or strong association between fracture Multiple fixation methods have been
the talus is laterally translated on displacement and development of described, including lateral versus
injury radiographs, surgical treat- PTAA. Thus, we recommend surgi- posterolateral plating, nonlocked ver-
ment is advocated. Weber B fractures cal fixation of all stress-positive lat- sus locked plating, and intramedullary
that show no widened MCS or talar eral malleolus fractures to avoid fixation. In the lateral plating tech-
subluxation on stress imaging are long-term sequela. nique, a one-third tubular plate or an
considered stable and can be man- anatomic distal fibular plate is used.
aged nonsurgically. Management of Anatomic distal fibular plates are
lateral malleolus fractures without Nonsurgical Treatment precontoured to match the anatomy
joint subluxation on injury radio- If the ankle is found to be stable, lat- of the lateral malleolus and allow for
graphs, but signs of instability on eral malleolus injuries can be man- the placement of multiple screws in
stress examination, is less clear. Clas- aged nonsurgically with either a nonlinear configuration. A non-
sically, these patients were thought immediate weight bearing or a brief locking one-third tubular plate is
to benefit from surgical treatment. period of immobilization. Under- most commonly used, either in the
However, recent literature has sought standing the patients’ symptoms, neutralization or bridging mode. The
to investigate this idea. Egol et al17 including pain with weight bearing, former is applied in conjunction
noted that based on AOFAS scores, time elapsed since injury, bone with a lag screw, for interfrag-
100% (20/20) of patients with a quality, and risk factors for healing mentary compression between prox-
positive stress radiograph (MCS $ need to be considered. The senior imal and distal fragments of the
4 mm) and negative clinical signs of authors primarily use pain levels to fracture. Plate application in a bridg-
deltoid disruption (medial tender- guide treatment. If the pain is severe ing fashion is indicated when notable
ness, ecchymosis, and swelling) man- (Visual Analog Scale six or higher), comminution is present or in fracture
aged nonsurgically had good or patients are placed into a well- patterns not amenable to lag screw
excellent clinical results. Two pa- padded/molded cast and kept non– fixation. Length, rotation, and sagit-
tients had persistent widening of the weight bearing for 2 to 3 weeks and tal alignment can be accomplished
MCS at 7.4-month follow-up. Sanders then transitioned into a walking through plate-assisted reduction ma-
et al5 prospectively studied 81 pa- boot. Patients with decreased pain neuvers, such as a push screw tech-
tients with Weber B fractures and (Visual Analog Scale five or less) are nique or pulling the plate with a bone
positive stress examinations ran- placed into a walking boot or ankle hook. Fixation calls for at least two
domized to surgical or nonsurgical brace immediately, with emphasis on to three bicortical screws proximal
treatment. No functional differences ROM exercises. Patients return to the fracture and two to three
were found between the surgical and 6 weeks after injury to obtain repeat screws distal to the fractures, which
nonsurgical groups at 1-year follow- weight-bearing radiographs to assess are often unicortical because of prox-
up. However, 20% of the nonsur- the status of fracture healing. Alter- imity to the distal syndesmotic and
gical group did show radiographic natively, patients may be brought ankle joints. When using one-third
malalignment within 1 year after back at more frequent intervals to tubular plates, we prefer to use 4.0-
injury, and a higher rate of delayed gauge pain and obtain additional mm cancellous screws distally in
metaphyseal bone because of im- clude that lower-profile surgical im- healing complications, intramedullary
proved pullout strength and maxi- plants may be a suitable fixation tool, fixation is another stabilization
mum insertion torque.36 The primary pending more clinical investigation. technique. Fibular intramedullary
advantage of lateral plating with In highly comminuted fractures, nailing demonstrates greater resis-
one-third tubular plates is the de- patients with osteoporotic bone, or tance to torque to failure than tradi-
creased cost compared with locking short metaphyseal segments, locking tional fibular plating with a lag
plates. Disadvantages include surgical plates are often advocated. Locking screw42 and is a low-profile surgical
implant prominence and potential plates create a fixed-angle construct implant. Ramasamy and Sherry43
for intra-articular screw penetration. and rely on the strength of the screw report good and excellent results in
However, newer low-profile ana- head threading into the plates, 11 elderly patients treated with fib-
tomically contoured plates can help thereby enabling stability with uni- ular nailing for a Weber B ankle
avoid soft-tissue irritation that screw cortical fixation. This phenomenon is fracture. The authors note that this
placement into the distal fibula may in contrast to nonlocking constructs, technique requires only a 15-mm
cause. which rely on friction created skin incision and minimal soft-
Posterolateral plating of the fibula between the screw/plate and bone. tissue stripping, which is ideal for
takes advantage of an antiglide mode Both one-third tubular plates and this specific patient population. A
of fixation. Although this is biome- anatomic distal fibular plates are prospective, randomized controlled
chanically the most stable construct, available in locking designs. Al- trial of 100 patients elder than 65
there has been concern for per- though locking plates have been years with ankle fractures random-
oneal tendon irritation. Weber and found to provide superior fixation ized to undergo standard ORIF with
Krause37 retrospectively reviewed 70 strength in osteoporotic fractures traditional one-third tubular plating
patients who were treated with an throughout the body, Davis et al39 or fibular nailing demonstrated
antiglide plate for Weber B lateral evaluated the biomechanical prop- markedly fewer wound infections in
malleolus fractures. The authors erties of locking and nonlocking the fibular nail group, with similar
found that peroneal tendon irritation plates in Weber B fibula fractures functional outcomes and union rates.
was associated with a prominent or in a cadaver model. Evaluation of Moreover, although the fibular im-
oblique screw head in the most distal torsion, load to failure, and axial plant was more expensive than a
screw hole, specifically if it was a stiffness demonstrated no differences traditional plate, the overall cost of
posteroanterior lag screw. Thus, in between the two groups. In a retro- the management of the intramedullary
an effort to avoid peroneal irritation, spective clinical analysis of precon- nail was less expensive because of the
we recommend avoiding placing the toured locking distal fibular plates high rate of revision surgery in the
plate within 1 cm from the tip of the versus conventional one-third tubu- plating group.44
lateral malleolus. In addition, if a lar plates, Lyle et al40 found no
posteroanterior lag screw is re- difference in the complication rate
quired, we suggest placing a 2.0- or or revision surgery rate at 2-year Conclusion
2.4-mm screw under the plate or follow-up. Low-profile (2 mm thick-
using a 2.7-mm lag screw through ness or less) anatomically contoured For patients in whom an isolated
the plate. Bariteau et al38 evaluated plates with locking options are now lateral malleolar injury is suspected,
the biomechanical characteristics available and may aid in reducing evaluation begins with a history and
of minifragment and small fragment the risk of wound-healing compli- physical examination. Initial injury
fixation constructs for the distal cations or soft-tissue irritation pre- radiographs are reviewed, and if
fibula in an effort to identify fixation viously noted in the literature.41 obvious tibiotalar instability or
options with a lower risk for soft- However, distal fibular locking medial-sided injury is present, sur-
tissue irritation. The authors used plates had a mean cost greater than gical treatment is recommended.
osteoporotic synthetic fibular bone six times that of a one-third tubular In patients with an isolated lateral
models to compare the biomechani- plate. Although these lower-profile malleolus fracture without instability
cal strength between these two plating options are more expensive on injury radiographs, weight-
groups. They found no statistically initially, the initial surgical implant bearing radiographs are attempted.
significant difference in the mean cost may offset costs of revision sur- The radiographs are evaluated for
load to failure or mean stiffness gery secondary to surgical implant- alignment of the ankle, the MCS, the
between fixation constructs using related issues. presence or absence of lateral talar
either 2.4-mm screws or 3.5-mm In patients with poor soft-tissue subluxation, and the length/rotational
screws. This led the authors to con- envelopes or high risk for wound- alignment of the fibula. If osseous
January 15, 2019, Vol 27, No 2 57
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Capla EL, Koval KJ: Ankle stress test for
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January 15, 2019, Vol 27, No 2 59
Review Article
Optimizing Clinical Use of Biologics

in Orthopaedic Surgery:
Consensus Recommendations
From the 2018 AAOS/NIH U-13
Conference
Constance R. Chu, MD* Abstract

Scott Rodeo, MD* Concern that misinformation from direct-to-consumer marketing of
Nidhi Bhutani, PhD largely unproven “biologic” treatments such as platelet-rich plasma
Laurie R. Goodrich, DVM, PhD and cell-based therapies may erode the public trust and the
Johnny Huard, PhD responsible investment needed to bring legitimate biological
James Irrgang, PhD, PT therapies to patients have resulted in calls to action from
Robert F. LaPrade, MD, PhD professional organizations and governing bodies. In response to
Christian Lattermann, MD substantial patient demand for biologic treatment of orthopaedic
Ying Lu, MS, PhD conditions, the American Academy of Orthopaedic Surgeons
Bert Mandelbaum, MD convened a collaborative symposium and established a
Jeremy Mao, DDS, PhD* consensus framework for improving and accelerating the clinical
Louis McIntyre, MD evaluation, use, and optimization of biologic therapies for
Allan Mishra, MD musculoskeletal diseases. The economic and disease burden of
George F. Muschler, MD musculoskeletal conditions is high. Of the various conditions
Nicolas S. Piuzzi, MD discussed, knee osteoarthritis was identified as a “serious
Hollis Potter, MD condition” associated with substantial and progressive morbidity
Kurt Spindler, MD and emerged as the condition with the most urgent need for clinical
John M. Tokish, MD trial development. It was also recognized that stem cells have
Rocky Tuan, PhD* unique characteristics that are not met by minimally manipulated
Kenneth Zaslav, MD mixed cell preparations. The work group recommended
that minimally manipulated cell products be referred to as cell
William Maloney, MD*
therapy and that the untested and uncharacterized nature of these
Correspondence to Dr. Chu: treatments be clearly communicated within the profession, to
chucr@stanford.edu patients, and to the public. Minimum standards for product
J Am Acad Orthop Surg 2019;27: characterization and clinical research should also be followed. A
e50-e63
framework for developing clinical trials related to knee OA was
DOI: 10.5435/JAAOS-D-18-00305
agreed upon. In addition to recommendations for development of
Copyright © 2018 The Author(s).
high-quality multicenter clinical trials, another important
Published by Wolters Kluwer Health, Inc.
on behalf of the American Academy recommendation was that physicians and institutions offering
of Orthopaedic Surgeons.This is an biologic therapies commit to establishing high-quality patient
open-access article distributed under
the terms of the Creative Commons
registries and biorepository-linked registries that can be used for
Attribution-Non Commercial-No postmarket surveillance and quality assessments.
Derivatives License 4.0 (CCBY-NC-ND),
where it is permissible to download and
T
share the work provided it is properly he clinical use of biologics such as paced the evidence. This phenomenon
cited. The work cannot be changed in
platelet-rich plasma (PRP) and is due in part to the prevalence and
any way or used commercially without
permission from the journal. cell-based therapies to treat ortho- seriousness of musculoskeletal con-
paedic complications has greatly out- ditions, in part due to the lack of

Constance R. Chu, MD, et al
satisfactory conventional treatment Clinical Use of Biologics in Ortho- National Institutes of Standards and
options, and in part due to widespread paedic Surgery.”1 Participants included Technology, the Stanford Center for
direct-to-consumer marketing of academic and private practitioners, Innovative Study Design, and the
treatments that fall outside tradi- basic and clinical scientists from FDA. The goals of the symposium
tional regulatory pathways. To ad- academia, patients, representatives were (1) to establish a clear, col-
dress these concerns, on February 15, from the AAOS, the National In- lective impact agenda for improving
2018, through February 17, 2018, stitutes of Health (NIH), the the clinical evaluation, use, and
the American Academy of Ortho- American Orthopaedic Society for optimization of biologics in ortho-
paedic Surgeons (AAOS) convened Sports Medicine, the Arthroscopy paedics and (2) to develop a guidance
thought leaders from clinical medi- Association of North America, the document on clinically meaningful
cine, research, and government at International Cartilage Regenera- end points and outcome metrics to
Stanford University for a “think tion and Joint Preservation Society, accelerate the evaluation of biologics
tank” symposium on “Optimizing and keynote speakers from the for common orthopaedic conditions.
From Stanford University, Stanford, CA (Dr. Chu, Dr. Bhutani, Dr. Lu, Dr. Mishra, and Dr. Maloney), the Hospital for Special Surgery, New York,
NY (Dr. Rodeo and Dr. Potter), Colorado State University, Fort Collins, CO (Dr. Goodrich), the University of Texas Health Science Center,
University of Texas, Houston, TX (Dr. Huard), the University of Pittsburgh, Pittsburgh, PA (Dr. Irrgang and Dr. Tuan), the Steadman Clinic, Vail,
CO (Dr. LaPrade), the Brigham and Women’s Hospital, Boston, MA (Dr. Lattermann), Santa Monica Orthopaedic and Sports Medicine, Santa
Monica, CA (Dr. Mandelbaum), Columbia University, New York City, NY (Dr. Mao), Northwell Orthopaedic Partners, Sleepy Hollow, NY
(Dr. McIntyre), the Cleveland Clinic, Cleveland, OH (Dr. Muschler, Dr. Piuzzi, and Dr. Spindler), the Mayo Clinic, Phoenix, AZ (Dr. Tokish), Ortho
Virginia, Richmond, VA (Dr. Zaslav).
February 15-17, 2018 at Stanford University, Stanford California.
*Conference organizers
Dr. Rodeo or an immediate family member serves as a paid consultant to the Joint Restoration Foundation and has stock or stock options held in
Ortho RTI. Dr. Goodrich or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Allsource;
serves as a paid consultant to Allsource; has stock or stock options held in ART; has received research or institutional support from Allsource; and
serves as a board member, owner, officer, or committee member of the North American Veterinary Regenerative Medicine and the Orthopaedic
Research Society. Dr. Huard or an immediate family member serves as a board member, owner, officer, or committee member of the Orthopaedic
Research Society. Dr. Irrgang or an immediate family member serves as a board member, owner, officer, or committee member of the American
Physical Therapy Association. Dr. LaPrade or an immediate family member has received royalties from Arthrex, Ossur, and Smith & Nephew; serves
as a paid consultant to Arthrex, Ossur, and Smith & Nephew; has received research or institutional support from Arthrex, Smith & Nephew, Ossur, and
Linvatec; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports Medicine and the
International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. Dr. Lattermann or an immediate family member serves as a
paid consultant to Cartiheal, Novartis, Samumed, and Vericel; has stock or stock options held in Cocoon; has received research or institutional
support from Smith & Nephew; and serves as a board member, owner, officer, or committee member of the International Cartilage Repair Society and
the German-speaking Arthroscopy Society. Dr. Mandelbaum or an immediate family member has received royalties from Arthrex; serves as a paid
consultant to Arthrex, DePuy, Exatech; and serves as a board member, owner, officer, or committee member of the CONCACAF Medical Committee
and the Kerlan Jobe Institute. Dr. Mao or an immediate family member serves as an unpaid consultant to Mitogen and has stock or stock options held
in Mitogen. Dr. McIntyre or an immediate family member serves as a paid consultant to Active Implants, Ceterix, Flexion, and Smith & Nephew and
serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, Advocacy for Improvement in
Mobility, the Arthroscopy Association of North America; the Medical Society of the State of New York, the Westchester County Medical Society, and
Orthopaedic Practice Management Inc. Dr. Muschler or an immediate family member has received royalties from Fortus; serves as a paid consultant
to the National Institutes of Health; serves as an unpaid consultant to Parker Hannifin; and has received research or institutional support from Fortus.
Dr. Potter or an immediate family member serves as a paid consultant to Ortho RTI; has stock or stock options held in Imagen; has received research
or institutional support from GE Healthcare and GE/NBA; and serves as a board member, owner, officer, or committee member of the International
Society for Magnetic Resonance in Medicine. Dr. Spindler or an immediate family member has received royalties from NPhase; serves as a paid
consultant to Cytori-Scientific Advisory Board, Mitek, and the National Football League; has received research or institutional support from the
National Institutes of Health; and serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports
Medicine and the Orthopaedic Research Society. Dr. Tokish or an immediate family member has received royalties from Arthrex; is a member of a
speakers’ bureau or has made paid presentations on behalf of Arthrex and Mitek; serves as a paid consultant to Arthrex, DePuy, and Mitek; and
serves as a board member, owner, officer, or committee member of the Arthroscopy Association of North America. Dr. Tuan or an immediate family
member serves as a paid consultant to Orthocell and serves as an unpaid consultant to AbbVie and Recellerate. Dr. Zaslav or an immediate family
member is a member of a speakers’ bureau or has made paid presentations on behalf of Lifenet and Vericel; serves as a paid consultant to Cartiheal
and Lifenet; has stock or stock options held in Cartiheal and Orthospace; has received research or institutional support from Active Implants,
Aesculap/B.Braun, Organogenesis, and Zimmer Biomet; and serves as a board member, owner, officer, or committee member of the International
Cartilage Repair Society. Dr. Maloney or an immediate family member has received royalties from Stryker and Zimmer Biomet; has stock or stock
options held in Bristol-Myers Squibb, Flexion Therapeutics, Medtronic, Novartis, Pfizer, and TJO; and serves as a board member, owner, officer, or
committee member of the American Academy of Orthopaedic Surgeons. Dr. Mishra receives royalties from Zimmer-Biomet and DePuy. None of the
following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or
institution related directly or indirectly to the subject of this article: Dr. Chu, Dr. Bhutani, Dr. Lu, and Dr. Piuzzi.
January 15, 2019, Vol 27, No 2 e51

Optimizing Clinical Use of Biologics in Orthopaedic Surgery
concentrates. Blood products have sium directly addresses recent calls to

Musculoskeletal Diseases long been used clinically for a variety action, particularly the need for clear
Include Serious Conditions of needs where anticoagulated whole standards in the nomenclature
for Which Conventional blood is centrifuged to separate it into for cellular therapies and biologics,
Treatments Are Lacking plasma and packed red cell fractions. standards for measuring and re-
Manual preparation of a platelet porting the composition of these
Musculoskeletal pain and dysfunction
concentrate involves collection of the therapies and their clinical outcomes,
attributable to trauma, obesity, and
PRP lying just above the white blood and the establishment of registries
aging are a leading cause of physician
cell layer, followed by a second spin and clinical trial networks to accel-
visits, chronic pain, and disability in the
to permit further concentration erate rigorous assessment and opti-
United States.2 The economic burden
of the platelets. Consequently, cen- mization of regenerative therapies
of musculoskeletal diseases approaches trifuges have been an important for musculoskeletal diseases. The
$1 trillion annually in the United fixture in hospitals and blood banks consensus outcomes are summarized
States, comprising approximately for decades. below.
7.4% of the gross domestic prod- This clinical history has set the stage
uct.3 Although the disease burden for more recent widespread clinical use
is high, treatment options remain of PRP as a biologic therapy for Section I: Pathways to
limited. Progression of serious musculoskeletal conditions. Fur- Improve Accountability for
conditions such as osteoarthritis thermore, use of centrifuge-like devices Biologics Currently in
(OA) that eventually fail conven- and other mechanical methods to General Clinical Use
tional nonsurgical therapies lead prepare minimally manipulated
to chronic pain, disability, and autologous cell preparations has Recommendation 1: Define
difficulty with self-care and activ- been extended to fat, placenta, and Terminology to Clearly
ities of daily living. These circum- many other tissues. These un- Distinguish Uncharacterized
stances make patients vulnerable to characterized cell products have Minimally Manipulated
unsubstantiated claims in direct- been marketed as stem cells and
to-consumer advertising. 4,5
Autologous Cell Products
used to treat a long list of clinical
From Rigorously
conditions ranging from hair loss to
Characterized, Culture-
retinopathy and, most commonly,
Misrepresentation of orthopaedic applications.4 The high
expanded and Purified Stem
Uncharacterized and prevalence of painful and disabling Cell and Progenitor Cell
Unproven Minimally orthopaedic conditions such as knee Populations
Manipulated Products as OA has also resulted in an exponen- Stem cells have unique characteristics
Stem Cells May Erode tial increase in the marketing of that are not met by minimally manip-
Public Trust and unproven biologics to relieve chronic ulated cell-based therapies being widely
Compromise Development pain.4,5 marketed in the United States (Table 1).
of Legitimate Cell Therapies Concerns over misinformation The use of the term stem cells to de-
from direct-to-consumer marketing scribe minimally manipulated cell
Public awareness of biologics thought of unproven treatments have led to preparations is problematic and has
to have regenerative potential has recent calls to action from profes- created substantial confusion for
been accelerated by highly publicized sional organizations including the patients, physicians, and the general
use in professional athletes6 and by National Academy of Sciences, the public. As defined by the NIH,10
the national debate on embryonic International Society for Cellular “Stem cells differ from other kinds of
stem (ES) cells. These circumstances, Therapy (ISCT), the American Asso- cells in the body. All stem cells have
along with misrepresentation of un- ciation for the Advancement of Sci- three general properties: they are
characterized, minimally manipu- ence, and the AAOS.7-9 Each of these capable of dividing and renewing
lated cell preparations as “stem groups recognizes the potential value themselves for long periods; they are
cells,” have led to a widespread of cell therapies and the risk that unspecialized; and they can give rise
clinical use of unproven biologic the current environment may erode to specialized cell types.” Prime ex-
therapies.4,5 the public trust and responsible amples of stem cells are the ES cells
For decades, PRP served primarily investment that are needed to bring derived from early embryos or blas-
as an intermediary in the manual legitimate cellular and biological tocysts with the ability to generate
preparation of life-saving platelet therapies to patients. This sympo- progeny that can differentiate into

Table 1
Characteristics of Stem Cells, Culture-Expanded Connective Tissue Cells and Minimally Manipulated Cell Preparations
Cell Type Definition Examples
Stem cells10 Three minimum characteristics: (1) ES cells, induced pluripotent stem cells
capable of division and self-renewal
for long periods of time, (2)
unspecialized, and (3) can give rise
to specialized cell types
Culture-expanded connective tissue Culture-expanded tissue-derived cells MSCs, muscle-derived cells, adipose-
cells derived cells, cartilage-derived cells
Plastic adherent —
Tend to differentiate or undergo —
senescence with prolonged culture
Biological attributes and function —
dependent on and vary with tissue
source and culture conditions
Bioactivity varies between donors and —
batch, even with standardized
processing
Expansion makes cell banking and —
allograft sourcing an option
Requires prospective FDA-approved —
clinical trials
Minimally manipulated autologous cell Cleared for homologous use Bone marrow concentrate, adipose
preparations stromal or stromal vascular fraction,
placenta tissue fragments
Processing must not alter the relevant —
biological characteristics of cells or
tissues
Mixed cell populations, with variable —
composition
Stem or progenitor cells may be —
present at lower prevalence
Biological attributes and function —
highly variable
ES = embryonic stem, MSC = mesenchymal stromal cell
any tissue type. Use of ES cells is one in one million cells harvested from of osteochondral defects.17 Connec-
limited by ethical controversies and healthy tissues are stem or progenitor tive tissue progenitor cells are the
safety concerns. cells that are capable of differentiating heterogenous population of tissue-
Virtually all current cell therapies into one or more connective tissues resident cells that can be activated to
offered in the United States for such as bone, cartilage, and fat.12-14 proliferate and to generate progeny
musculoskeletal conditions involve the For adipose tissue, the potential stem that can be shown in vitro to differ-
transplantation of adult cells obtained and progenitor cells are thought to be entiate into one or more connective
through harvest and minimal manipu- pericytes embedded in the basement tissues.12-14,16,18 For many indications,
lation of native tissues (eg, blood, bone membrane of capillaries where enzy- laboratory manipulation and cul-
marrow, fat). These tissues contain matic digestion is needed to release ture expansion are needed to iso-
stem and progenitor cells. The con- these cells.15 The efficacy of cell ther- late and adequately enrich these cell
centration of these cells can be apies is also dependent on cell source, populations.
increased at the point of care using processing technique, and setting. For Contributing to the confusion re-
density separation or other means to example, bone marrow can be pro- garding stem cells, the substantial lit-
improve efficacy in some settings.11 cessed to increase the concentration of erature exists using the terminology of
However, stem and progenitor cells progenitors and improve bone or culture-expanded cells known as mes-
are the least abundant cell type in these cartilage repair.7,11,16 However, bone enchymal stem cell or mesenchymal
preparations. Depending on the tissue marrow concentration has not con- stromal cell, both abbreviated as
of origin, only one in one thousand to sistently been shown to improve repair “MSC.”7,19,20 To improve clarity, the
January 15, 2019, Vol 27, No 2 e53

ISCT defined MSC to be mesenchymal arations have identified the inherent of diseases for PRP and cell-based
“stromal” cells having the attributes variability of these products as a major therapies. Regarding MSC, the ISCT
of being plastic-adherent culture- hurdle to proper characterization standard can be used to communi-
expanded cells without hematopoi- and evaluation of their biological and cate whether the cells used meet the
etic cell markers that express specific clinical effects. Unlike conventional ISCT published standard.7
cell surface markers (ie, CD73, CD90, pharmaceuticals where a known con-
and CD105) and that show the ability centration of a bioactive substance is Future Directions
to differentiate into osteoblasts, adi- administered to achieve a targeted Characterization of minimally pre-
pocytes, and chondrocytes in vitro.7 biological effect, most biologics are pared biologics using transcriptomic,
Although there have been decades of complex mixtures of variable compo- proteomic, and metabolomic tech-
promising in vitro and animal research sition that are not easily assayed. This nologies, coupled with bioinformatic
exploring the capacity of culture- phenomenon is particularly evident analysis, is needed for further refine-
expanded MSC meeting these criteria for blood products such as PRP and ment of standards. Furthermore,
to secrete immunomodulatory factors for minimally manipulated autologous most of the several hundred platelet-
or contribute to new tissue formation, cell preparations where standards are harbored proteins and polypeptides
no MSC therapies have yet been lacking and where the biological status have not been intensively studied in
cleared by the FDA for human clin- of the donor and the preparation terms of their biologic activity.
ical application to musculoskeletal methods vary widely. Experimental analysis of previously
diseases. As the most studied biologic used in understudied and undiscovered
orthopaedics, PRP composition is platelet proteins may lead to discov-
Recommendations known to vary widely when blood ery of new target proteins with spe-
The consensus opinion is that the from the same individual is obtained at cific functional roles. In addition,
term stem cell has been overused to different times of day or is prepared such studies may in fact show that
encompass uncharacterized mini- using systems from different manu- certain “deleterious” components in
mally manipulated cell preparations, facturers.21-23 Furthermore, growth PRP may be removed or neutralized
as well as tissue-derived culture- factor and cytokine concentrations to enhance the therapeutic benefit of
expanded cell populations. It is rec- vary by donor age, health status, and PRP. For cell-based therapies, addi-
ommended that the use of minimally sex.23,24 Similarly, progenitor and tional laboratory work to define
manipulated cell products and tissue- MSC populations isolated from a progenitor subpopulations can be
derived culture-expanded cells be given donor also differ widely from used to refine the description and
referred to as cell therapy and that the one preparation to another and vary understanding of the cell pop-
untested and uncharacterized nature by age, sex, tissue source, harvest, and ulations used. Refined use of
of these treatments be clearly under- processing methods.12-16,19,21,22,25-28 nomenclature to distinguish between
stood by practitioners and clearly It is therefore necessary for scientific native stem and progenitor pop-
communicated within the profession, communications to become more rig- ulations and culture-expanded cell
to patients, and to the public. orous and standardized in reporting populations will provide critically
these variables.9,12,13,16 needed improvement to scientific
Future Directions and public communication.
Expert opinion and consensus work
Recommendations
groups can be convened to improve Recommendation 3:
It is recommended that Minimum
precision of terminology surround- Establish Registries for
Information for studies reporting Bio-
ing cell therapy. Establishment of Postmarket Monitoring and
logics (MIBO) checklists be used as a
standards and criteria for describing Quality Assessments of
guide for study design and reporting29
therapeutic cell populations will be Biologic Therapies
(Tables 2 and 3). For PRP and cell-
needed for clear scientific and clinical
based therapies, the MIBO include Registries provide opportunities to
communications.
specific items that reached a consensus collect standardized data on clinical
among a panel of experts through the status and clinical outcomes for a
Recommendation 2: Delphi process.29 These proposed variety of different interventions
Standardize Reporting minimum requirements would facil- performed in the clinical setting to
Requirements itate clinical and experimental in- treat the same disease or condition.
Examination of both minimally ma- vestigations into the mechanisms of Data from joint replacement and
nipulated and culture-expanded prep- action and efficacy in a broad range other clinical registries also contribute

Table 2
Minimum Reporting Standards for Clinical Studies Evaluating PRPa
Section or Topic Item Number Checklist Item
Study design 1 Study conducted in accordance with CONSORT (ie, RCT),

STROBE (ie, cohort, case-control, or cross-sectional), or
PRISMA (ie, meta-analysis) guidelines
2 Relevant institutional and ethical approval
Recipient details 3 Recipient demographics (including age and sex)
4 Comorbidities (including underlying diabetes, blood
dyscrasia, inflammatory condition, preexisting joint
pathology, and smoking status)
5 Current anti-inflammatory or antiplatelet medications
Injury details 6 Diagnosis (including relevant grading system and
chronicity)
7 Results of any preoperative imaging
8 Previous surgical or biologic treatments for current injury
Intervention 9 Intervention described sufficiently to enable replication
10 Surgical findings
Whole blood processing 11 Whole blood storage environment (including concentration
and volume of anticoagulant, temperature, and light
exposure)
Whole blood characteristics 12 Whole blood platelet, differential leukocyte, and red cell
analysis of all samples
PRP processing 13 PRP processing described sufficiently to enable replication
(including commercial kit details and spin protocol)
14 Platelet recovery rate of protocol
15 PRP storage temperature and light exposure
16 Time between blood drawing, PRP processing, activation,
and delivery
PRP characteristics 17 PRP format (eg, liquid, gel, membrane)
18 PRP platelet, differential leukocyte, and red cell analysis of
all samples
Activation 19 Activation described sufficiently to enable replication
(including volume and concentration of the activating
agent)
Delivery 20 Point of delivery (intraoperative and/or postoperative or
serial)
21 PRP delivery described sufficiently to enable replication
(including volume delivered, concomitant use of
stem cells or cytokines, and details of carrier or
scaffold)
Postoperative care 22 Rehabilitation protocol sufficiently described to enable
replication (including immobilization and physical
therapy)
23 Outcome assessments include functional outcomes and
recording of complications (including infection and need
for further surgery); if performed, radiographic outcomes,
physical examination findings, return to activities, and
satisfaction
CONSORT = Consolidated Standards of Reporting Trials, PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses,
PRP = platelet-rich plasma, RCT = randomized controlled trial, STROBE = STrengthening the Reporting of OBservational studies in
Epidemiology
a
This checklist could be used to guide authors, reviewers, and editors to ensure that submitted manuscripts report sufficient experimental detail to
enable results to be evaluated and experiments repeated.
Adapted with permission from Murray IR, Geeslin AG, Goudie EB, Petrigliano FA, LaPrade RF: Minimum information for studies evaluating biologics
in orthopaedics (MIBO). J Bone Joint Surg Am 2017; 99(10):809-819.
January 15, 2019, Vol 27, No 2 e55

to quality improvement initiatives and clinical outcome metrics to evaluate for a biologics registry. It was recom-
assessments. Furthermore, when used potential mechanisms of action and mended that further examination
consistently, a well-organized and clinical efficacy. of the feasibility for establishing a
complete registry represents a large An effective biologics registry would national registry for postmarket sur-
prospective cohort study. A registry require commitment from physicians, veillance and quality assessment of
can additionally be linked to a bio- clinics, and hospitals to include all biologics be performed.
repository to capture and preserve qualifying patients, appropriate in-
clinical samples for selective future centives for physician and patient
Future Directions
analysis. This design could be partic- participation, and a mechanism for
The collection and storage of bio-
ularly powerful to understand the financial support of the human re-
specimens into a biorepository and
influence of variable PRP composition sources required to capture and report
collection of imaging outcome met-
on clinical outcomes. clinical baseline and outcomes data.
The orthopaedic community has For quality assessments, preparation rics necessitate standardized proto-
established several registry models technique, device used, and clinical cols, which further increases the
that could provide pathways for laboratory data on the administered expense and the complexity. For more
postmarket monitoring and quality biologic will also need to be captured. immediate reliable generation of high-
control of the use of biologics in Using PRP as an example, white blood quality clinical data, it was the opinion
orthopaedics. These include registries cell and platelet counts in whole blood of the work group that multicenter
from the scale of a single institution, and in the administered PRP are the prospective clinical trials involving
an entire health system, to national minimum data needed to determine committed centers with appropriate
and international registries. Several whether the patient received leukocyte- volume and adequate follow-up, as
registry models have contributed rich or leukocyte-poor PRP and to well as willingness and ability to de-
important clinical data on practice what degree the platelets were con- velop and maintain biorepositories
patterns, provided early warning of centrated by the device used.9,29,31 and to follow standardized treatment,
potential issues related to a particular Similar minimal clinical laboratory imaging, and outcomes data collec-
implant or treatment strategy, or test data would need to be established tion protocols, were needed.
show potential for contributing clin- for cell-based treatments.9,12,13,16,29
ical evidence on the efficacy of PRP. Furthermore, tissue specimens may be
These include the American Joint also collected to assist in stratifying Section II: Accelerating the
Replacement Registry,30 the Kaiser patient disease state, as well as for Discovery, Development,
Registries,26 and the PRP Registry at performing biomarker, molecular, and and Delivery of 21st
the Veterans Hospital in Palo Alto, genomic analyses to synergize. These Century Cures
California. data may ultimately be required to
To address the disconnect between define which patient populations are The 21st Century Cures Act was
the variable composition of PRP from most likely to respond to therapy and enacted in December 2016 with pro-
different patients and clinical outcomes, to define the critical quality attributes visions to accelerate the development
a Biorepository-linked PRP Registry of a cellular or biologic therapy. and translation of promising new
established at the Veterans Hospital in therapies into clinical evaluation and
Palo Alto, CA, offers a model where use.32 This legislation increased fund-
patients receiving PRP injections for Recommendations ing for medical research, for combat-
treatment of knee OA complete patient- It is recommended that physicians, ing the opioid epidemic, and included
reported outcomes (PROs) before clinics, and institutions offering bio- measures to streamline approval of
treatment and at defined time points logic therapies commit to establishing new therapies for clinical trials. The
after treatment as part of the clinical high-quality patient registries that can law also provided a new expedited
care pathway. In parallel, a sample of be used for postmarket surveillance biologics product development pro-
the administered PRP is banked for and quality assessments. The AAOS gram called Regenerative Medicine
patients consenting to federally funded has expertise and processes in place to Advanced Therapy. Key elements of
research who additionally undergo assist with registry development and Regenerative Medicine Advanced
functional and structural assessments implementation. The American Joint Therapy include accelerated FDA
of gait analysis and advanced quanti- Replacement Registry is part of what approval for a regenerative medicine
tative MRI. This biorepository-linked will be a family of registries under the therapy that is intended to treat a
registry supports correlation of PRP AAOS umbrella. Data sets can be serious or life-threatening disease or
proteomics with PRO and quantitative customized for specific registries or condition and that shows a potential

to address unmet clinical needs for clinical needs. The AAOS/NIH U-13 that may also significantly vary from
that disease or condition. Biologics Symposium work group the human condition. Innovative
concurs with the Osteoarthritis studies in humans, using advanced
Recommendation 4: Research Society International white imaging and limited biopsies, can be
Designate Osteoarthritis as a paper entitled “Osteoarthritis: A used to study the underlying biologic
Serious Disease.”37 effects and thus help to identify the
Serious Medical Condition
desired treatment targets.
The FDA has indicated that a serious In addition to defining the desired
Future Directions
disease or condition is one that is “biologic” targets (eg, cell prolifera-
Many other musculoskeletal conditions
“associated with morbidity that has tion, anti-inflammatory, antifibrotic
such as chronic tendinopathy, degen-
substantial impact on day-to-day effect), clinical outcome milestones
erative disk disease, and osteoporosis
functioning.”33 The designation of are also important targets for PRP
also have substantial and progressive
“whether a disease or condition is therapy. For example, for acute
negative impacts on daily function,
serious is a matter of clinical judg- muscle injury, the primary goal may
morbidity, and mortality and should be
ment,” based on its impact on survival, be prevention of reinjury rather than
further evaluated for designation as
daily function, and the likelihood that faster return to sport. For rotator cuff
serious medical conditions.
such morbidity, if persistent or recur- repair, the goal may be to decrease
rent, has a high likelihood of pro- the rate of retear of the repaired
gression if left untreated. In addition, Recommendation 5: Clarify,
tendon. Finally, mediators of pain/
“An unmet medical need is a condition by Disease State, a
nociception have been advanced as
whose treatment or diagnosis is not Consensus Approach for therapeutic targets for the use of PRP
addressed adequately by available Biological Markers of Interest and cell-based therapies to treat
therapy.” and Clinical Trial Design degenerative conditions such as ten-
OA is a leading cause of disability Using PRP treatment as a model, an dinopathies and OA.
worldwide for which disease- important goal is to address the var- Once the biologic targets for a spe-
modifying treatments are lacking. iability in outcomes by identifying the cific tissue are identified, steps can be
Knee and hip OA reduces life expec- biologic targets for PRP. This is taken to match the “ideal” PRP for-
tancy with walking disability as a main needed to more precisely choose the mulation to the tissue. For example,
risk factor. Studies show that the optimal PRP formulation to focus multiple randomized controlled trials
walking disability from OA exceeds treatment for each specific tissue and and a meta-analysis have suggested
that of heart disease.34 The Framing- to ultimately reduce this variability. that leukocyte-rich PRP is an effi-
ham study also showed more depen- As an example, for rotator cuff ten- cacious treatment of lateral elbow
dency with knee OA than with heart don repair, the primary targets are tendinopathy,22,38 whereas leukocyte-
disease.35 OA has also been associated considered to be provision of signal- poor PRP seems effective for treat-
with an increased risk for premature ing molecules that drive cellular dif- ment of symptomatic knee OA.39 In
death primarily from cardiovascular ferentiation to reform the organized addition to identifying optimal PRP
disease. In a propensity-matched structure of the enthesis.38 Further formulations, additional studies are
landmark analysis to examine identification of biologic targets will needed to define the ideal dose and
whether total joint arthroplasty of the require improved understanding of timing of PRP application to aug-
hip and knee reduces the risk for the underlying cellular and molecu- ment soft-tissue healing. For exam-
serious cardiovascular events in pa- lar mechanisms of tissue degenera- ple, PRP may be more effective for
tients with moderate-severe OA, Ravi tion and repair for each disease state. rotator cuff repair if adminis-
et al36 showed that over a 7-year Such mechanistic information may tered days to weeks after surgery,
period, 8 total joints prevented 1 come from both animal and human once a responding cell population is
myocardial infarction. studies. Although acute soft-tissue present, rather than just at the time
injury can be reproduced in animal of surgery. It is also likely that the
Recommendations models, it is difficult to simulate particular PRP formulation should
On the basis of these data, the chronic conditions such as overuse be tailored to specific time points in
strength of the clinical evidence, and tendinopathy and chronic, slowly- the healing process because the bio-
the group discussion, the consensus developing OA. Another important logic targets are likely different at
opinion is that OA meets all the cri- limitation of animal models is the later healing phases.
teria for designation as a serious inability to precisely control the It will be important to collect com-
condition with significant unmet mechanical loading environment prehensive demographic and clinical
January 15, 2019, Vol 27, No 2 e57

data from patients to allow later anal- layed by a PRP administration if it is gous cells are already widely used in
yses of factors that may influence clin- performed during the early inflam- the United States. The existing stud-
ical outcome. In addition to standard matory phase because PRP contains ies do not show that these therapies
demographic information (eg, age, both anti- and pro-inflammatory are associated with substantial risk
sex), appropriate imaging should be factors. Furthermore, injection of of harm.12,39 Where a proposed ther-
used to allow quantitative grading of saline as a placebo may dilute the apy does not present significant safety
tissue structure and composition and to naturally occurring hematoma at the concerns, the focus can be directed
potentially provide insight into func- injury site and may lead to a negative toward phase II, III, and IV trials. For
tion. Adequate characterization of effect on healing. Standardized re- optimal evaluation of efficiency, pro-
early stages of OA may require MRI habilitation protocols should be spective multicenter trials with ran-
for accurate staging. A sample of the defined and followed. domization and placebo control are
treated tissue should be harvested for Robust statistical analyses will be need. Given the prevalence of OA and
later analysis of tissue composition and required to study the interactions the number of proposed biological
microstructure, which could then be between intervention (ie, leukocyte- treatments, randomization schemes
correlated with imaging characteristics, rich PRP, leukocyte-poor PRP), with a 3:1 or 4:1 ratio of treatment
with the goal being to identify imaging time point after injury, and injury groups to placebo will accelerate
biomarkers that predict outcome. grade or severity. Stratification progress.
Identification of imaging biomarkers in should also be performed with re-
the treated tissue may also inform the gard to sex and age. Last, it will be
The Role of MRI in Characterizing
choice of the type and dosing schedule important to consider identification
Disease State
of PRP. Ultimately, detailed tran- and stratification by important meta-
Although radiographs are helpful in
scriptomic and proteomic profiling of bolic and systemic factors that may
assessing the knee mechanical axis
the affected tissue may contribute to a affect treatment response, such as
and are reproducible for assessing
“precision medicine” approach to the diabetes, rheumatologic conditions,
joint space with appropriate tech-
use of PRP for soft-tissue injury. and chronic use of anti-inflammatory
nique, they are relatively insensitive
It is further recommended that vali- or antifibrotic medications (ie, NSAIDs
to focal chondral defects and are
dated outcome measures for each spe- or losartan).
inadequate for staging early disease.
cific tissue or anatomic region be
Because of its direct multiplanar
identified. Where validated patient- Recommendation 6: acquisition, tomographic nature,
reported instruments do not exist, the Establish the Framework and superior soft-tissue contrast,
most promising metrics should be for a Multicenter Knee MRI is necessary to evaluate carti-
identified by consensus expert opinion,
Osteoarthritis Clinical Trial lage morphology and has shown
followed by validation as a research
Consortium (Table 4) superior reproducibility compared
priority. In addition, the use of the
Of the conditions discussed, knee OA with arthroscopy.44,45 Recent ad-
NIH-funded Patient-Reported Out-
emerged as the clinical condition with vances in quantitative MR allow for
comes Measurement Information Sys-
the most urgent need for clinical trial assessment of cartilage relaxometry,
tem physical function instrument may
development. Treatment of end-stage targeting specific changes in proteo-
be a suitable alternative.40 Additional
knee OA with knee replacement is glycan content and collagen orien-
functional metrics that provide quan-
already the largest single line item in tation, respectively, that improves
titative data are also needed, such as
the Medicare budget, and demand is the sensitivity of MRI for changes of
gait analysis to measure functional
expected to substantially increase year early knee OA.
impairment in knee OA.41 The use of
wearable technologies may facilitate to year.43 The arthroplasty pop-
collection of these types of functional ulation treated for end-stage OA Future Directions
metrics.42 represents just a small fraction of the Characterization of the treated pop-
Finally, clinical trial design will massive underlying demand for ulation with respect to clinical,
require consideration of several regenerative and biological treatments structural, and biological attributes
important factors. An important to reduce pain and to prevent or delay and disease state (eg, subtype, grade)
factor in the design of a clinical trial progression of early knee OA. is important. In addition to cell and
for an acute soft-tissue injury is the protein composition, establishing
timing from injury to treatment. The Safety Considerations specimen biorepositories will facili-
native, usually successful, healing Treatment of knee OA with PRP tate genomic and molecular analyses
response may be interrupted or de- and minimally manipulated autolo- that can synergize with existing NIH

Table 3
Minimum Reporting Standards for Clinical Studies Evaluating Cell Therapiesa
Section or Topic Item Number Checklist Item
Study design 1 Study conducted in accordance with CONSORT (ie, RCT), STROBE
(ie, cohort, case-control, or cross-sectional), or PRISMA (ie,
meta-analysis) guidelines
2 Relevant institutional and ethical approval
Recipient details 3 Recipient demographics (including age and sex)
4 Comorbidities (including underlying diabetes, inflammatory
conditions, preexisting joint pathology, and smoking status)
5 Current anti-inflammatory medications
Injury details 6 Diagnosis (including relevant grading system and chronicity)
7 Previous treatments for current injury
Intervention 8 Surgical intervention described sufficiently to enable replication
9 Surgical findings
Donors 10 Donor age
Tissue harvest 11 Tissue harvest described sufficiently to enable replication (including
anatomic source, equipment, reagents, storage media, and
environment)
12 Tissue between tissue harvest and processing
Processing 13 Description of tissue processing that makes replication of the experiment
possible (including digestion solution concentrations and volumes,
duration, agitation and temperature of digestion phase, and name of
commercial system)
14 If performed, purification described sufficiently to enable replication
(including combination and concentration of antibodies,
equipment, and method of confirming purity.)
15 Yield with respect to volume of tissue processed
Cell culture 16 If performed, cell culture described sufficiently to enable replication
(including conditions and number of freeze-thaw cycles)
17 If performed, predifferentiation described sufficiently to enable
replication
MSC characteristics 18 MSC preparation and source described in title and abstract (eg,
BM-MSC, ADSC)
19 Cellular composition and/or heterogeneity
20 Immunophenotype and details of in vitro differentiation tested on
batch
21 Passage and percentage viability
Delivery 22 MSC delivery described sufficiently to enable replication (including
point of delivery, volume of suspension, and media used as vehicle)
23 If performed, details of codelivered growth factors, scaffolds, or
carriers
Postoperative care 24 Rehabilitation protocol sufficiently described to enable replication
(including immobilization and physical therapy)
Outcome 25 Outcome assessments include functional outcomes and recording of
complications (including infection and tumor); if performed,
radiographic outcomes, physical examination findings, return to
activities, and satisfaction
ADSC = adipose-derived stem cell, BM-MSC = bone marrow–mesenchymal stromal cell, CONSORT = Consolidated Standards of Reporting Trials,
MSC = mesenchymal stromal cell, PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PRP = platelet-rich plasma,
RCT = randomized controlled trial, STROBE = STrengthening the Reporting of OBservational studies in Epidemiology
a
This checklist could be used to guide authors, reviewers, and editors to ensure that submitted manuscripts report sufficient experimental detail to
enable results to be evaluated and experiments repeated.
Adapted with permission from Murray IR, Geeslin AG, Goudie EB, Petrigliano FA, LaPrade RF: Minimum information for studies evaluating biologics
in orthopaedics (MIBO). J Bone Joint Surg Am 2017; 99(10):809-819.
January 15, 2019, Vol 27, No 2 e59

Table 4
Framework for a Multicenter Knee OA Clinical Trial Consortium
Item
Number Outcome Measure Comments
1 Primary outcome: Patient-Reported Outcome Patient-reported pain for a minimum of 6 months

pain Measures (PROM)-KOOS pain after treatment was considered to be the most
important metric for initial assessment of
efficacy for biologic treatments of the knee. Pain
should be assessed before and after treatment
using a validated PROM such as the Knee injury
and Osteoarthritis Outcome Score (KOOS): pain
subscale.
2 Secondary outcome: PROM including function or activity Additional research into optimizing PRO measures
function level (eg, KOOS physical to detect differences in pain and physical function
function) after biological treatments for knee OA in large
cohorts and registry-based cohorts is needed.
Computer-adaptive tests to assess physical
function and pain interference, such as those
developed by the PROMIS network may have the
potential to more efficiently detect the effects of
biological treatments for individuals with knee OA
and other disease conditions.
— Activity monitors may be The use of wearable accelerometers and other
considered biosensors to monitor activity and other biological
processes may be considered for synergy with
other multisite initiatives such as Molecular
Transducers of Physical Activity Consortium
(MotrPAC) and for additional analyses against
standard outcome metrics and proteomic
analyses. Future options, perhaps based on the
application of high-content image analysis of
monitored patient motion, may be possible with the
application of artificial intelligence capabilities.
3 Structural outcome Radiographs: full-length standing Although the potential structure modifying effects of
(imaging) alignment, lateral, Merchant, and biologics in radiographic knee OA has not been shown,
standardized weight-bearing PA structural restoration is considered important for
flexion views (eg, Synaflexer assessing disease modification. Radiographic
[Synarc]) are recommended assessment consisting of full-length standing
alignment, lateral, Merchant, and standardized weight-
bearing PA flexion views (eg, Synaflexer)
— Morphologic MRI 3D pulse sequences are now readily available across
vendors and provide more efficient assessment of
cartilage morphology when applied to large OA
studies. Semiquantitative assessment of knee OA
has been shown to be reliable using a 3D fast spin
echo sequence compared with 2D techniques.44
— MOAKS scoring of morphologic The Whole-Organ MRI Score (WORMS) and, in
MRI particular, the newer MRI Osteoarthritis Knee Score
(MOAKS) may be used as continuous variables for
assessment of longitudinal changes in early knee OA
status. Both have shown good reproducibility and utility
in multicenter trials.45 With the exception of the tibial
cartilage area, measures of reliability for MOAKS
using kappa statistics ranged between very good to
near-perfect.48 These scoring systems may be used
as continuous variables for assessment of longitudinal
change in knee OA status.
(continued )
2D = two dimensional, 3D = three dimensional, ACL = anterior cruciate ligament, FGF = fibroblast growth factor, IGF = insulin growth factor, OA =
osteoarthritis, PDGF = platelet-derived growth factor, PRO = patient-reported outcome, PRP = platelet-rich plasma, TGF-b = transforming growth
factor beta, VEGF = vascular endothelial growth factor

Framework for a Multicenter Knee OA Clinical Trial Consortium
Item
Number Outcome Measure Comments
— Quantitative MRI may be Performance sites with expertise in quantitative MRI are
considered encouraged to use standardized protocols for
compositional evaluation of articular cartilage in studies
of preradiographic and early OA. With regard to
proteoglycan, T1 rho has been used at 3T and, while
slightly less specific for proteoglycan than gadolinium-
enhanced or sodium MRI, has shown good correlation
with a histologic standard.51 Collagen orientation is
best assessed using T2 or T2*.46,47,52 Ultrashort TE
(UTE) T2* techniques permit evaluation of deep
cartilage tissues and have been shown to assess
potentially reversible longitudinal changes after ACL
injury and subsequent reconstruction47 along with
correlation with walking mechanics and PROs.41
4 Laboratory Platelet or cell counts, differential Standardized sampling and analysis of the
concentration and prevalence of cells and platelets
need to be performed using a representative fraction
of the administered biologic.
— Proteomic analysis Biological attributes of PRP therapies already include
growth factors in the family of PDGF, IGF, TGF-b,
VEGF, and FGF and a large number of cytokines
(eg, interleukins) and chemokines. However,
insufficient knowledge exists as to which of these
factors, and/or combinations thereof, may act as the
true therapeutic agent(s). It is important to perform
as complete profiling of these factors as is currently
feasible and that specimens be banked for future
analysis when the knowledge base increases.
— Biorepository Separate representative sample of the administered
product should also be preserved future analysis.
Additional collection of samples such as serum, tissue,
and synovial fluid samples should be considered.
2D = two dimensional, 3D = three dimensional, ACL = anterior cruciate ligament, FGF = fibroblast growth factor, IGF = insulin growth factor, OA =
osteoarthritis, PDGF = platelet-derived growth factor, PRO = patient-reported outcome, PRP = platelet-rich plasma, TGF-b = transforming growth
factor beta, VEGF = vascular endothelial growth factor
areas of emphasis such as Helping to ating cost-effectiveness if proven to design and standardized report-
End Addiction Long-term, Molecular be efficacious. Key elements from a ing. 29 Elements recommended for a
Transducers of Physical Activity federally funded pre-post observa- knee OA clinical trial are summa-
Consortium, and precision medicine tional trial in Veterans that influ- rized in Table 4.
initiatives. enced the consensus trial design
include establishment of a bio- Recommendation 7: Explore
repository, targeted biospecimen
Accelerated Pathways for
Consensus Knee analysis, linkage of the resulting
FDA Approval of New Drug
Osteoarthritis Biologics compositional data with clinical
data, and PRO metrics along with
Applications for Biologics to
Clinical Trial Design
the use of MRI to establish and Treat Musculoskeletal
For evaluation of knee OA treat- stage OA disease and to assess Conditions
ments, the primary clinical research structural outcomes.41,44-48 The A patient panel highlighted the tre-
goals are to determine efficacy in MIBO checklists for PRP (Table 2) mendous need and demand for
relation to pain, function, and struc- and cell therapy (Table 3) should effective treatments to restore func-
ture, with additional goals of evalu- be used as a guide for clinical study tion and alleviate musculoskeletal
January 15, 2019, Vol 27, No 2 e61

pain. This is particularly true for with the conference and consensus 7. Dominici M, Nichols K, Srivastava A, et al:
Positioning a scientific community on
degenerative conditions such as OA statement development, and Erin unproven cellular therapies: The 2015
and tendinopathy. The clinical his- Ransford, Manager, Research Advo- International Society for Cellular Therapy
tory with minimally manipulated cacy, who assisted with all aspects of Perspective. Cytotherapy 2015;17:
1663-1666.
autogenous cell products and culture- conference development and coordi-
8. Sipp D, Caulfield T, Kaye J, et al:
expanded cells without genetic nation. This symposium was funded by
Marketing of unproven stem cell–based
modifications for musculoskeletal the American Academy of Orthopae- interventions: A call to action. Sci Transl
indications suggest that these treat- dic Surgeons, the Stanford University Med 2017;9:eaag0426.
ments can be considered “lower Department of Orthopaedic Surgery, 9. LaPrade RF, Dragoo JL, Koh JL, Murray
risk.” and NIH U-13 AR073668 (Chu). IR, Geeslin AG, Chu CR: AAOS research
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January 15, 2019, Vol 27, No 2 e63

Review Article
Chronic Medial Epicondyle

Avulsion: Technique of Fragment
Excision and Ligament
Reconstruction With Internal
Brace Augmentation
Abstract
Raffy Mirzayan, MD Medial epicondyle fracture nonunions of the elbow may lead to
Joseph D. Cooper, MD symptomatic instability in the high-demand or overhead athlete.
These injuries are challenging to treat surgically because of the small
residual bony fragment, the scarred and shortened chronically injured
ulnar collateral ligament (UCL), which prevents it from being mobilized
and reduced to its native position. To date, most described methods
aim at reducing the displaced fragment and achieving union with the
humerus. This usually can only be accomplished by releasing of the
scarred UCL to mobilize the fragment. The scarred and attenuated
residual ligament is then repaired to restore stability but is often
inadequate to sustain high-level valgus loads. We describe a
technique of excision of the bony fragment and UCL reconstruction
with allograft, augmented with internal brace to provide medial stability
to the elbow. The described method allows proper tensioning of the
graft and provides immediate and secure fixation.
From the Kaiser Permanente
Southern California (Dr. Mirzayan),
Baldwin Park, CA, and the
University of Southern California
Keck School of Medicine
(Dr. Cooper), Los Angeles, CA. M edial epicondyle fractures of
the elbow are common injuries
in children, accounting for 11.5% of
symptomatic, and all had a stable
valgus stress test; however, only
one patient was reported to be
Dr. Mirzayan or an immediate family
member is a member of a speakers’ fractures about the elbow.1 Non- a manual laborer, and none were
bureau or has made paid displaced and minimally displaced reported to be overhead athletes.2,8
presentations on behalf of Arthrex; fractures are generally treated with- More recently, patients with
has stock or stock options held in
AlignMed; and has received research
out surgery,1-5 whereas incarcerated higher demands and overhead ath-
or institutional support from Arthrex intra-articular fragments or markedly letes have been shown to have worse
and the Joint Restoration Foundation. displaced fragments require surgical outcomes in the setting of non-
Neither Dr. Cooper nor any immediate treatment.3,5-7 union with development of medial
family member has received anything
of value from or has stock or stock
Long-term follow-up studies by elbow pain and valgus instability.9-12
options held in a commercial company Farsetti et al8 evaluating 42 patients Therefore, a more aggressive ap-
or institution related directly or with 33 years of follow-up and proach is taken with this subset of
indirectly to the subject of this article. those by Josefsson and Danielsson2 patients having a lower threshold to
J Am Acad Orthop Surg 2019;27: evaluating 56 patients with 35 years perform surgery.
e64-e69 of follow-up have reported that When the medial epicondyle frag-
DOI: 10.5435/JAAOS-D-17-00446 50% to 90% of medial epicondyle ment has been chronically avulsed,
fractures treated nonsurgically went symptomatic patients become more
Academy of Orthopaedic Surgeons. on to nonunion.2,8 In these studies, difficult to treat surgically because of
only 11% of the nonunions were the scarred and shortened ulnar
Raffy Mirzayan, MD and Joseph D. Cooper, MD
collateral ligament (UCL) preventing Figure 1

the medial epicondyle bone fragment
from being mobilized and reduced to
its native anatomy. Many techniques
have been described to address these
symptomatic patients including open
reduction and internal fixation, ten-
sion band fixation of the remaining
fragment, and fragment excision with
ligament repair with and without
suture anchors.11,13-15 Unfortunately,
these methods focus mainly on bony
union of the medial epicondyle and
inadequately address the true issue in
these symptomatic patients, which is
instability. The UCL is scarred and
shortened in these chronic injuries
and not amenable to direct repair. In
addition, direct repair techniques do
not allow adequate tensioning.
We describe a technique of excision Intraoperative fluoroscopic images of the elbow with a chronic medial epicondyle
of the medial epicondyle fragment, avulsion fracture. A, AP view of the right elbow. B, Valgus stress applied showing
UCL reconstruction with gracilis gapping of the medial joint line due to ulnar collateral ligament insufficiency.
allograft, and internal brace augmen-
tation to restore stability of the medial length of 53.9 mm, and inserts 2.8 mm previously described for UCL re-
elbow. A variation of our technique distal to the ulnar articular margin at constructions in overhead athletes.22
has been described previously for the sublime tubercle.17,18,21 An allograft such as gracilis or
UCL injuries in overhead adult ath- semitendinosis tendon can also be
letes with intact medial epicondyles used but should be thinned to a
requiring reconstruction.16 Indications
folded diameter of no more than
Patients with symptomatic, chronic, 4.5 mm.
displaced nonunion of the medial
Anatomic and epicondyle who wish to undergo a
Biomechanical surgical procedure to restore stability Surgical Technique
Considerations to the elbow.
After induction of general anesthesia,
The UCL is composed of three separate the patient is positioned supine, and the
ligaments: anterior oblique, posterior Contraindications surgical extremity is placed on an arm
oblique, and transverse. The anterior board. The surgical table is rotated 90,
oblique is the primary restraint to val- Patients who have an asymptomatic placing the surgical arm away from
gus stress at the elbow from 30 to 90 nonunion who are able to perform the anesthesiologist for more working
of flexion and is the most commonly without deficiency or pain and patients area. An intraoperative valgus stress
injured.17,18 The posterior oblique with active infections or neuropathic test can be performed under anes-
contributes to stability from 90 to pain on the medial aspect of the elbow. thesia, confirming widening of the
120 of flexion.19 The transverse lig- Patients with previous ulnar nerve medial joint space (Figure 1). A well-
ament does not cross the elbow joint procedure should be carefully evalu- padded unsterile tourniquet is placed
and does not contribute to valgus ated, and the ulnar nerve dissected at on the proximal arm, and the
support of the elbow.20 the time of reconstruction. extremity is prepped and draped in the
The anterior oblique ligament is 5 to usual fashion.
9 mm wide and is the strongest liga- Graft Options The palmaris longus tendon can be
ment of the UCL.17-19 It originates on harvested, or a gracilis allograft is
the anterior-inferior edge of the medial A palmaris longus tendon, ipsilateral thawed and prepared on the back
humeral epicondyle, has an average or contralateral, can be used as table. The graft diameter should be at
January 15, 2019, Vol 27, No 2 e65
Chronic Medial Epicondyle Injury Repair
Figure 2 Figure 3
Photograph showing gracilis allograft

with Krackow suture stitched 15 to A, Medial elbow showing the medial epicondyle with a forceps grasping the
20 mm up each end. proximal end of the flexor/pronator mass. MABC = medial antebrachial
cutaneous nerve, UN = ulnar nerve with a vessel loop to identify and protect it
throughout the case, MEF = chronically displaced medial epicondyle fragment.
least 4.5 mm when doubled, and the B, Elevating the FPW with the medial epicondyle fragment excised to reveal the
graft length should be longer than origin of the UCLO. At the base of the FPW is the sublime tubercle and the
120 mm so that it will be at least insertion of the ulnar collateral ligament. FPW = flexor-pronator wad, UCLO =
ulnar collateral ligament.
60 mm in length when doubled
over.
Each tail end of the graft is sewn fragment is then excised using elec- pendicularly at this location. The
with #2 high-strength suture in a trocautery (Figure 3, B and C). guide pin is directed into the center of
Krackow fashion approximately 15 The UCL is followed down to the the trochlea, ensuring that it does not
to 20 mm up the graft (Figure 2). The sublime tubercle on the ulna (Figure 3, violate the olecranon or coronoid
graft is left under tension on the back D). A safe zone has been described as fossae. A 5-mm cannulated reamer is
table and kept moist. 1 cm distal to the insertion of the UCL, used over the guidewire to ream the
An Esmarch is used to exsanguinate and care must be taken not to extend humeral tunnel for the graft. The
the surgical extremity, and the tour- the exposure past this point.23 A tunnel length will be approximately
niquet is inflated. A 6-cm incision 3.2-mm spade-tipped guide pin is then 25 mm (Figure 4, A and B).
is made centered over the medial placed at the sublime tubercle and The FiberTape (Arthrex) is placed
epicondyle extending distally over angled distally to exit out of the lateral through the eyelet of a 4.75-mm Bio-
the sublime tubercle. The medial ulnar cortex (Figure 4, A). Care must Composite SwiveLock (Arthrex)
antebrachial cutaneous nerve is identi- be taken to avoid the proximal ra- along with the #2 FiberWire suture
fied, dissected, and protected through- dioulnar joint to not affect the rotation over which the graft was folded over
out the case. The ulnar nerve is of the forearm. The guide pin should on the humeral end of the graft. The
identified, dissected, and brought out be angled 30 distally and dorsally graft and FiberTape are introduced
of the cubital tunnel. A vessel loop is to protect the posterior interosseous into the humeral tunnel, and the
placed around the nerve to mobilize nerve as described by Lee et al.24 The tenodesis screw is advanced into the
it throughout the case (Figure 3, A). length of the tunnel should be assessed humeral tunnel for fixation (Figure
The medial epicondyle fragment using the calibration marks on the 5). The FiberTape sutures will later
is identified by palpation and by guide pin. The tunnel should be be secured into the ulnar tunnel to
following the muscle fibers of the approximately 30 mm in length. A act as an “internal brace.”
flexor/pronator mass. It is usually 5-mm cannulated reamer is then used The sutures from the free ends of
posterior and inferior to its origin on to ream the ulnar tunnel over the the graft are then placed through a
the humerus. The posteromedial guidewire to make a unicortical tun- BicepsButton (Arthrex). The suture
capsule and UCL are sharply incised nel (Figure 4, B). ends must be passed in opposite
from the floor of the cubital tunnel Attention is then turned to the directions into the button to allow
and dissected proximal and anterior humeral tunnel. The base of the the button to flip on the far cortex
to the fragment. The flexor-pronator medial epicondyle is identified and (Figure 6). The BicepsButton is passed
mass is left attached to the fragment, followed until it comes in contact through the far cortex of the ulnar
but the native UCL is peeled off with the medial condyle (ie, trochlea). tunnel with the insertion tool. The #2
the fragment. The medial epicondyle A 2.4-mm guide pin is drilled per- FiberWire sutures are pulled, and the
Figure 4 Figure 5
A, Photograph demonstrating a 3.2- A, The graft and FiberTape (Arthrex) have been placed into the humeral tunnel,
mm guidewire in the sublime tubercle and the BicepsButton (Arthrex) is shown loaded just before insertion into the
angled distally to exit out of the ulnar tunnel. B, Graft has been tightened into the ulnar tunnel with the
lateral ulnar cortex. A 2.4-mm BicepsButton. C and D, Biocomposite SwiveLock is used in both the ulnar and
guidewire is placed in the humeral humeral tunnel to provide additional graft fixation and fix FiberTape as an internal
cortex directed into the center of the brace.
trochlea, ensuring that it does not
violate the olecranon or coronoid
fossae. B, Photograph The elbow is then stressed again under mobilize the medial epicondyle frag-
demonstrating a 5-mm reamer that fluoroscopy to confirm that it is stable ment. The ulnar landmark is the sub-
has been used to complete the
tunnels. under valgus stress (Figure 8). lime tubercle. The guide pin should be
The wounds are thoroughly irri- directed 30 distal and 30 caudal.
gated. The fascial incisions are then Palpate the posterior ulnar cortex and
graft is reduced into the ulnar tunnel.
closed with a zero Vicryl suture. The aim the guide pin caudal to the pos-
The sutures are pulled and the graft
subcutaneous tissue is closed with a terior cortex. Intraoperative mini-
tensioned at 90 flexion. Knots are
#2-0 Vicryl suture. The subcuticular fluoro can be used to confirm proper
then tied using an arthroscopic knot
layer is closed with a running #3-0 pin placement and orientation. But-
pusher and advanced to the base of the
monofilament, and Steri-Strips are ton placement can also be verified
ulnar tunnel. The FiberTape limbs
applied. with fluoroscopy. The humeral
from the humeral tunnel are passed
A sterile dressing is then applied. tunnel landmark is the junction of
through the eyelet of a 4.75-mm Bio-
The patient is placed in a well-padded the medial epicondyle base with
Composite SwiveLock anchor and
posterior molded splint with the the medial condyle/trochlea. Before
inserted into the ulnar tunnel, where
elbow at 90 and the forearm in reaming, guide pins can be placed
the tenodesis screw will provide ad-
neutral rotation. into the sublime tubercle and the
ditional fixation of the graft, and the
FiberTapes will acts as an “internal origin of the humeral tunnel and a
brace” (Figure 5, C and D). Pearls and Pitfalls suture can be wrapped around both
The flexor-pronator mass is then pins to check for isometry.
repaired and fixed to the humeral ori- The ulnar nerve should be dissected and A pitfall would be to attempt this
gin using the free ends of the suture moved out of the groove to allow the in a mini-open approach and not
from the humeral anchor (Figure 7). release of the posteromedial capsule to moving the ulnar nerve out of the
January 15, 2019, Vol 27, No 2 e67
Chronic Medial Epicondyle Injury Repair
Figure 6 Figure 7 Figure 8
Photograph showing the biceps Photograph showing the completed

button with arrows that demonstrate repair with the flexor-pronator mass
the direction and position of the four secured over the humeral origin.
limbs.
groove to have access to the postero- Summary

medial capsule. Another pitfall is
Minimally displaced medial epi- Intraoperative stressed fluoroscopic
to attempt to repair the shortened image from the operating room
condyle fractures can frequently be
and scarred UCL because it is not a showing no further gapping of the
treated successfully without surgery.1-5
viable ligament and therefore needs medial elbow with applied valgus
Nonunion is common with nonsurgi- stress.
to be reconstructed. Care should
cal treatment; however it is frequently
be taken when reaming the ulnar
asymptomatic.2,8 High-demand pa-
tunnel to not “blow out” the far
tients and overhead athletes, however, did not address the core problem in
cortex and to keep the ulnar tunnel
are more likely to develop pain and these symptomatic patients, which is
unicortical.
symptomatic instability after a non- instability. When using this construct,
union.9-12 In these cases, or in cases in if you place the bony fragment at its
Postoperative which patients develop tardy ulnar anatomic origin, you are not ade-
Rehabilitation nerve symptoms due to the mass effect quately tensioning the native UCL,
of the medial epicondyle fragment, which is attenuated and damaged by
Postoperatively, the patient is immo- surgical management is a challenge years of being malpositioned because
bilized in a posterior 90 splint for 7 because of the small size of the bony of the nonunion. The only option to
to 10 days until their first postop- fragment, the scarred and shortened tension the ligament is to place the
erative visit. The wrist is not neces- chronically injured UCL, which pre- bony fragment eccentric to its origin,
sary to be immobilized to encourage vents it from being mobilized and which does not restore the native
early range of motion. The splint is reduced to its native position. anatomy, and still relies on a dam-
removed at the first visit, and active Smith et al12 proposed treatment by aged ligament for stability.
and active-assisted range of motions open reduction of the fragment with Although not specifically evaluated
are initiated with physical therapy. excision of the fibrinous nonunion with regard to medial epicondyle
No further brace or dynamic im- tissue and screw fixation with a 3.5- nonunions, the literature on UCL
mobilization device is used after mm or 4.5-mm screw. This technique repair is discussed with regard to
splint removal. The patient is ex- is technically challenging because the UCL tears. Initial studies showed that
pected to regain full range of motion bony fragment is often too small for repair of the native ligament had
in the first 3 to 4 weeks after surgery. this fixation method. In addition, five worse return to sport outcomes
Strengthening is initiated at 6 weeks patients required a second procedure compared with reconstruction.25,26
postoperatively. In overhead throw- for implant removal because of pain However, more recent data have
ers, an interval throwing program is at the screw site. indicated that repair may have sim-
started at 6 months postoperatively Sanjai et al11 describe a tension ilar outcomes to reconstruction
and progresses over 6 weeks. Most band construct instead of screw fix- with modern techniques.26,27 These
throwers are able to return to full ation. This addressed the problem studies support the repair of the
activities in 6 to 8 months. of prominent implant; however, it native ligament in acute tears of
an otherwise healthy ligament that 3. Wilson NI, Ingram R, Rymaszewski L, 17. Floris S, Olsen BS, Dalstra M, Søjbjerg JO,
Miller JH: Treatment of fractures of the Sneppen O: The medial collateral ligament of
is not scarred and shortened. This medial epicondyle of the humerus. Injury the elbow joint: Anatomy and kinematics. J
is in stark contrast to the medial 1988;19:342-344. Shoulder Elbow Surg 1998;7:345-351.
epicondyle nonunion population, 4. Robert M, Moulies D, Alain JL: Fractures 18. Dugas JR, Ostrander RV, Cain EL,
which has had a scarred UCL in a of the medial epicondyle in children Kingsley D, Andrews JR: Anatomy of the
[French]. Chir Pediatr 1985;26:175-179. anterior bundle of the ulnar collateral
nonanatomic location for years.
ligament. J Shoulder Elbow Surg 2007;16:
Other proposed methods have aimed 5. Kamath AF, Baldwin K, Horneff J, 657-660.
Hosalkar HS: Operative versus non-
at addressing these issues either by operative management of pediatric medial 19. Callaway GH, Field LD, Deng XH, et al:
combining screw fixation with suture epicondyle fractures: A systematic review. J Biomechanical evaluation of the medial
anchors to tension the ligament28 or by Child Orthop 2009;3:345-357. collateral ligament of the elbow. J Bone
Joint Surg Am 1997;79:1223-1231.
excising the fragment and repairing 6. Duun P, Ravn P, Hansen L, Buron B:
Osteosynthesis of medial humeral 20. Carrino JA, Morrison WB, Zou KH,
the native UCL.13 Although these
epicondyle fractures in children: 8-year Steffen RT, Snearly WN, Murray PM:
methods recognize the inherent issue follow-up of 33 cases. Acta Orthop Scand Noncontrast MR imaging and MR
of instability and aim to address it, 1994;65:439-441. arthrography of the ulnar collateral
ligament of the elbow: Prospective
they are similarly limited by either 7. Hines RF, Herndon WA, Evans JP: evaluation of two-dimensional pulse
repairing an attenuated ligament to Operative treatment of medial epicondyle sequences for detection of complete tears.
fractures in children. Clin Orthop Relat Res Skeletal Radiol 2001;30:625-632.
its anatomic origin or tensioning a 1987;170-174.
damaged ligament and placing it 21. Neill Cage DJ, Abrams RA, Callahan JJ,
8. Farsetti P, Potenza V, Caterini R, Ippolito E:
eccentric to its origin. Botte MJ: Soft tissue attachments of the
Long-term results of treatment of fractures
ulnar coronoid process. Clin Orthop Relat
We feel that this injury is symptom- of the medial humeral epicondyle in
Res 1995;154-158.
children. J Bone Joint Surg Am 2001;83:
atic because of instability and any 1299-1305. 22. Jobe FW, Stark H, Lombardo SJ:
means of repair without addressing Reconstruction of the ulnar collateral
9. Woods GW, Tullos HS: Elbow instability
this core issue are inadequate. Our and medial epicondyle fractures. Am J
ligament in athletes. J Bone Joint Surg Am
1986;68:1158-1163.
technique uses a hamstring allograft Sports Med 1977;5:23-30.
with an “internal brace” to replace the 10. Takeishi H, Oka Y, Ikeda M:
23. Smith GR, Altchek DW, Pagnani MJ,
Keeley JR: A muscle-splitting approach to
scarred native UCL. Our tunnel fix- Reconstructing an unstable medial elbow
the ulnar collateral ligament of the elbow:
complicated by medial epicondyle non-
ation method allows the graft to union: Case report. Tokai J Exp Clin Med
Neuroanatomy and operative technique.
be placed anatomically on both its Am J Sports Med 1996;24:575-580.
2001;26:77-80.
humeral and ulnar origins. In addi- 11. Shukla SK, Cohen MS: Symptomatic
24. Lee GH, Limpisvasti O, Park MC,
McGarry MH, Yocum LA, Lee TQ:
tion, using a button in the ulnar fix- medial epicondyle nonunion: Treatment by
Revision ulnar collateral ligament
ation allows full placement of the open reduction and fixation with a tension
reconstruction using a suspension button
band construct. J Shoulder Elbow Surg
graft into the tunnel to restore its 2011;20:455-460.
fixation technique. Am J Sports Med 2010;
38:575-580.
desired tension. 12. Smith JT, McFeely ED, Bae DS, Waters PM,
To our knowledge, this method of Micheli LJ, Kocher MS: Operative fixation 25. Conway JE, Jobe FW, Glousman RE, Pink M:
Medial instability of the elbow in throwing
fixation has not been described in the of medial humeral epicondyle fracture
athletes: Treatment by repair or
nonunion in children. J Pediatr Orthop
literature. Further biomechanical out- 2010;30:644-648.
reconstruction of the ulnar collateral ligament.
comes comparing these fixation meth-
13. Gilchrist AD, McKee MD: Valgus
ods could further prove the benefit of instability of the elbow due to medial 26. Erickson BJ, Bach BR, Verma NN,
Bush-Joseph CA, Romeo AA: Treatment
this technique. epicondyle nonunion: Treatment by
of ulnar collateral ligament tears of the
fragment excision and ligament repair—A
report of 5 cases. J Shoulder Elbow Surg elbow: Is repair a viable option? Orthop J
2002;11:493-497. Sports Med 2017;5:
References 2325967116682211.
14. Rodgers WB, Kharrazi FD, Waters PM,
Kennedy JG, McKee MD, Lhowe DW: The 27. Walters BL, Cain EL, Emblom BA,
References printed in bold type are Frantz JT, Dugas FR: Ulnar collateral
use of osseous suture anchors in the treatment
those published within the past 5 years. of severe, complicated elbow dislocations. ligament repair with internal brace
Am J Orthop 1996;25:794-798. augmentation a novel UCL repair technique
1. Beaty JH, Kasser JR: Rockwood and in the young adolescent athlete. Orthop J
Wilkins’ Fractures in Children. 15. Gallay SH, McKee MD: Operative Sports Med 2016;4(3 suppl 3):
Philadelphia, PA, Lippincott Williams & treatment of nonunions about the elbow. 2325967116S00071.
Wilkins, 2010. Clin Orthop Relat Res 2000;87-101.
28. Erdil M, Bilsel K, Ersen A, Elmadag M,
2. Josefsson PO, Danielsson LG: Epicondylar 16. Acevedo DC, Lee B, Mirzayan R: Novel Tuncer N, Sen C: Treatment of
elbow fracture in children: 35-year follow- technique for ulnar collateral ligament symptomatic medial epicondyle nonunion:
up of 56 unreduced cases. Acta Orthop reconstruction of the elbow. Orthopedics Case report and review of the literature.
Scand 1986;57:313-315. 2012;35:947-951. Int J Surg Case Rep 2012;3:467-470.
January 15, 2019, Vol 27, No 2 e69
Research Article
Outpatient Total Hip Arthroplasty in

the United States: A Population-
based Comparative Analysis of
Complication Rates
Abstract
Armin Arshi, MD Introduction: With healthcare expenditure in the national forefront,

Natalie L. Leong, MD outpatient arthroplasty is an appealing option in select patient
populations. The purpose of this study was to determine the
Christopher Wang, MD
complication rates associated with outpatient total hip arthroplasty
Zorica Buser, MD (THA) in comparison to standard inpatient THA.
Jeffrey C. Wang, MD Methods: We performed a retrospective review of the Humana
Nelson F. SooHoo, MD subset of the PearlDiver insurance records database to identify
patients undergoing THA (Current Procedural Terminology-27130
and Current Procedural Terminology-27132) as either outpatients or
inpatients from 2007 to 2016. Multivariate logistic regression adjusting
for age, gender, and Charlson Comorbidity Index were used to
calculate odds ratios of complications among outpatients undergoing
THA relative to inpatients undergoing THA.
Results: The query identified 2,184 patients who underwent outpatient
THA and 73,596 patients who underwent inpatient THA. The median
age was in the 65 to 69 age group and in the 70 to 74 age group for the
outpatient and inpatient cohorts, respectively (P , 0.001). Outpatients
undergoing THA had a significantly lower incidence of comorbid
hypertension (P , 0.001), cerebrovascular disease (P = 0.001),
obesity (P = 0.017), chronic obstructive pulmonary disorder (P =
0.045), and chronic kidney disease (P = 0.049). The incidence of both
From the Department of Orthopaedic outpatient THA (P = 0.001) and inpatient THA (P , 0.001) increased
Surgery, David Geffen School of over the study period. After adjusting for age, gender, and Charlson
Medicine at UCLA, Los Angeles, CA
(Dr. Arshi, Dr. SooHoo), the
Comorbidity Index, patients undergoing outpatient THA had
Department of Orthopaedic Surgery, comparable rates of all queried surgical complications, including
Rush University Medical Center, component revision, irrigation and debridement, and hip dislocation at
Chicago, IL (Dr. Leong), the
Department of Orthopaedic Surgery, 1 year. Rates of postoperative medical complications were also
Keck School of Medicine of the comparable between the two cohorts.
University of Southern California, Los Conclusion: Outpatient THA is increasing in frequency nationwide
Angeles, CA (Dr. C. Wang, Dr. Buser,
Dr. J. C. Wang). and has comparable postoperative complication rates. With its
potential to minimize arthroplasty care costs, outpatient THA is a safe
Correspondence to Dr. Arshi:
arminarshi@mednet.ucla.edu and effective option among appropriately selected patients.
61-67
DOI: 10.5435/JAAOS-D-17-00210

R ecent projections suggest that
the number of total joint
arthroplasty procedures performed
by at least twofold in the next 20 years.1
As concerns regarding healthcare
expenditure and economic burden
in the United States is expected to grow remain in the national forefront,
January 15, 2019, Vol 27, No 2 61
Outpatient Total Hip Arthroplasty
providing high quality and cost- approaches to minimize soft tissue (PearlDiver [www.pearldiverinc.com])
effective (value-based) arthroplasty disruption, perioperative regional was conducted for patients undergo-
care is critical to meeting this expected rather than general anesthesia, accel- ing THA as either an inpatient or
growth. Though joint replacement in erated rehabilitation, and short-term outpatient. This commercially avail-
general has traditionally been con- telephone follow-up.4,5 Indeed, prior able database consists of information
sidered an inpatient surgical proce- publications have correlated hospital about approximately 20 million pa-
dure, practitioners in the United States length of stay with cost in total joint tients with orthopaedic diagnoses
have seen a gradual decrease in arthroplasty, and cost analyses have compiled from records from Humana,
postoperative length of stay, mirror- demonstrated that same-day dis- the nationwide health insurance pro-
ing trends in other surgical special- charge following THA may decrease vider.15-18 Clinical diagnoses can be
ties.2,3 This decrease in duration of total payor cost by $4,000 to 7,000 queried by using patient billing codes,
hospitalization is attributable to imper patient.11,12 However, in spite of including those classified by Interna-
provements in surgical exposures with early interest and excitement in its tional Classification of Diseases (ICD)
less soft tissue damage, better post- potential benefits, outpatient arthro- and Current Procedural Terminology
operative pain management protocols plasty is still relatively uncommon in (CPT).
with regional and preemptive anes- the United States. Evidence regarding Patients undergoing THA were
thesia, early mobilization, and more safety and outcomes of outpatient identified by querying for patients
frequent use of rehabilitation facili- THA is limited to a few re- undergoing either CPT-27130 (ar-
ties.4 More recently, there has been ports,6,7,10,13,14 with the majority of throplasty, acetabular and proxi-
emerging interest in the feasibility data arising from single-surgeon series mal femoral prosthetic replacement
of outpatient arthroplasty wherein at high-volume centers and only one [THA], with or without autograft or
carefully selected candidates undergo prior investigation reporting on a allograft) or CPT-27132 (conversion
rapid recovery protocols with direct multi-institutional randomized study.9 of previous hip surgery to THA, with
hospital discharge as a mechanism for The purpose of this study was to or without autograft or allograft) as
increasing patient satisfaction and use a large multi-institution insurance the primary index procedure. Pa-
outcomes, minimizing costs for third- database to investigate trends in out- tients were then separated into inpa-
party payors, and possibly decreasing patient THA and to determine the tient and outpatient cohorts using
postoperative complications such as incidence and risk of perioperative service location modifiers “21”
hospital-acquired infections.5 medical and surgical complications (inpatient) and “22” (outpatient).
Outpatient joint arthroplasty has requiring reoperation relative to The service location modifier “22”
perhaps best been studied in the con- inpatient THA. Our initial hypotheses represents discharge occurring from
text of total hip arthroplasty (THA).6- were that the incidence of outpatient either a hospital or ambulatory sur-
10 Multiple authors in the last several THA has increased over the last sev- gery setting without an associated
years have reported that outpatient eral years and that the perioperative inpatient hospital admission and
THA is safe and effective in highly complication rates of outpatient and absolute length of stay less than 24
select cohorts of patients. The inpatient THA would be comparable. hours. Patient records were available
purported feasibility of ambulatory for THA performed during 2007 to
THA is based on the development Methods 2016, and the demographic data
of streamlined “clinical pathways,” for aggregate records included the
including structured preoperative A retrospective review of the Pearl- patient age (reported as 5-year bins),
patient education, minimally invasive Diver Patient Record Database gender, geographic location, year
Dr. C. Wang or an immediate family member has received royalties from Aesculap/B.Braun, Amedica, Zimmer Biomet, SeaSpine, and
DePuy Synthes; has stock or stock options held in Benvenue, Bone Biologics, Electrocore, Expanding Ortho, Flexuspine, FzioMed, NexGen
Healthcare, PearlDiver, Promethean Spine, and Surgitech; and serves as a board member, owner, officer, or committee member of
AOSpine International, the Cervical Spine Research Society, and the North American Spine Society. Dr. Buser or an immediate family
member serves as a paid consultant to AOSpine and Xenco Medical. Dr. J. C. Wang or an immediate family member has received royalties
from Amedica, Zimmer Biomet, SeaSpine, and DePuy Synthes; has stock or stock options held in Benvenue, Bone Biologics, Electrocore,
Expanding Ortho, Flexuspine, FzioMed, NexGen Healthcare, Paradigm Spine, PearlDiver, Promethean Spine, and Surgitech and Vertiflex;
and serves as a board member, owner, officer, or committee member of AOSpine International, the Cervical Spine Research Society, the
North American Spine Foundation, and the North American Spine Society. Dr. SooHoo or an immediate family member serves as a board
member, owner, officer, or committee member of the American Foot and Ankle Society. Neither of the following authors nor any immediate
family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly
or indirectly to the subject of this article: Dr. Arshi and Dr. Leong.
Armin Arshi, MD, et al
of procedure, and Charlson Co- Figure 1

morbidity Index (CCI). The CCI is a
well-validated prospective tool to
determine 1-year mortality based on
22 medical conditions.19 PearlDiver
records on the total number of
insurance records were used to
compute incidence per 100,000
Humana-insured patients as a sur-
rogate for population incidence.20,21
Inferential statistics comparing the
baseline age, gender, regional, and
medical comorbidity distributions of
the outpatient and inpatient cohorts
were computed using x2 analysis. A
two-tailed Student’s t-test was used
to compare the baseline CCI of the
two cohorts. A linear regression
model was used to determine the R2 Age distributions of Humana-insured patients undergoing total hip arthroplasty
coefficient to ascertain the trends for as either an outpatient (red) or inpatient (blue). For the inpatient cohort, the
median and mode age were both in the 70 to 74 age bin; for the outpatient cohort,
the annual incidence of procedures the median age was in the 65 to 69 cohort and the mode age was the 70 to 74
across the study period. Statistical cohort. The age distributions were not statistically equivalent (P , 0.001).
significance was defined as P , 0.05.
To determine the incidence of com-
renal failure, and respiratory failure sponding to an approximately 3:100
plications, the aforementioned co-
within 14 days; and acute myocardial ratio of outpatient to inpatient THA.
horts were queried to identify patients
infarction and cerebrovascular acci- For the inpatient cohort, the median
who had a series of major postopera-
dent within 30 days. Using the and mode age were both in the 70 to
tive surgical and medical complica-
PearlDiver statistical analysis pack- 74 age bin; for the outpatient cohort,
tions based on CPT and ICD-9 codes,
age, multivariate logistic regression the median age was in the 65 to 69
respectively. Surgical complication
with patient age, gender, and CCI as cohort and the mode age was the 70
categories (see Table, Supplemen-
covariates was performed to calculate to 74 cohort (Figure 1; see Table,
tal Digital Content 1, http://
adjusted odds ratios for each com- Supplemental Digital Content 3,
links.lww.com/JAAOS/A152)
plication category with outpatient http://links.lww.com/JAAOS/A154).
included excision of heterotopic
THA treated as the exposed group. The age distributions were not sta-
ossification (HO), acetabular/femoral
component revision, removal of tistically equivalent between the
prosthesis, irrigation and debride- outpatient and inpatient cohorts
Results
ment (I&D), hip dislocation, manip- (P , 0.001). Females comprised
ulation under anesthesia (MUA), A total of 2,184 patients who under- 57.7% of outpatient THA and
and periprosthetic fracture at both went outpatient THA between 2007 58.6% of inpatient THA patients
6 months and 1 year following and 2016 were identified from the identified; the gender distribution
the primary index THA. For HO Humana database. The comparison was statistically equivalent between
excision, component revision, and group was comprised of 73,596 pa- the two groups (P = 0.400). The
explantation of prosthesis, concomi- tients who underwent inpatient THA incidence of outpatient THA was not
tant CPT codes for I&D served as during the same period (see Table, equivalent between geographical re-
criteria to exclude infectious causes Supplemental Digital Content 3, gions (P , 0.001). The South region
of HO excision and arthroplasty http://links.lww.com/JAAOS/A154). had the highest incidence of outpa-
revision. Medical complication cate- Across the study period, the overall tient THA (13.0 cases per 100,000)
gories (see Table, Supplemental Dig- incidence of outpatient THA was and the Northeast region had the
ital Content 2, http://links.lww.com/ 10.5 cases per 100,000 Humana- lowest (1.2 cases per 100,000).
JAAOS/A153) included deep vein insured patients compared to 352.3 Outpatients undergoing THA
thrombosis and pulmonary embolism per 100,000 Humana-insured pa- had a significantly lower incidence of
within 60 days; pneumonia, acute tients for inpatient THA, corre- comorbid hypertension (P , 0.001),
January 15, 2019, Vol 27, No 2 63
cerebrovascular disease (P = 0.001), within 14 days (outpatient, 1.10%; Demographically, we found that
obesity (P = 0.017), chronic ob- inpatient, 1.49%), deep vein throm- the Humana-insured patients under-
structive pulmonary disorder (P = bosis within 60 days (outpatient, going outpatient THA were younger
0.045), and chronic kidney disease 1.28%; inpatient, 1.21%), and pul- when compared to those of the inpa-
(P = 0.049); they also had a lower monary embolism within 60 days tient comparison cohort. We also
frequency of diabetes mellitus, coro- (outpatient, 1.24%; inpatient, 1.22%) found that outpatients had fewer co-
nary artery disease, nonischemic were the most frequent complications morbidities and lower CCI when
heart disease, and peripheral vascular following THA in both cohorts. compared to inpatients undergoing
disease, which approached but did Pneumonia within 14 days, myocar- THA. The fact that outpatient THA
not reach statistical significance dial infarction within 30 days, and patients were younger and healthier
(see Table, Supplemental Digital cerebrovascular events within 30 days than their inpatient counterparts is
Content 4, http://links.lww.com/ of the index THA procedure occurred not surprising given the rigorous
JAAOS/A155). The mean CCI for in less than 1% of patients. There vetting criteria used to identify out-
outpatients and inpatients under- was no statistically significant dif- patient arthroplasty candidates.5
going THA was 2.23 6 2.82 and ference in any of the queried med- Indeed, patient eligibility for outpa-
2.69 6 2.86, respectively (P = 0.007). ical complication rates for patients tient THA is based on a thorough
The incidence of both inpatient THA undergoing outpatient THA versus evaluation of their medical co-
(R2 = 0.94; P , 0.001) and outpatient for those undergoing inpatient THA morbidities and general anesthetic
THA (R2 = 0.79; P = 0.001) showed a (P . 0.05). and perioperative risk, to which
statistically significant increase across older patients would be inherently
the study period. The relative inci- more susceptible. Furthermore, age
dence of outpatient THA when Conclusion is a known independent risk factor
compared with inpatient THA did for perioperative complications in
not show a statistically significant As of 2010, over 600,000 THA pro- arthroplasty.23 In their randomized
trend toward increase or decrease cedures were performed in the United controlled trial on outpatient THA,
across the study period (P = 0.098). States annually; this volume is ex- Goyal et al9 excluded patients
Among surgical complications, the pected to increase by 174% by older than 75 years of age for this
most common complications at 1 2030.1 With the increasing empha- reason. It is important to note that
year were component revision (out- sis on value-based care and bundled the age distribution of patients is
patient, 2.75%; inpatient, 2.33%), payments in arthroplasty, surgeons an important finding in such a
hip dislocation (2.01% outpatient; and healthcare administrators are population-level study as the pro-
1.67% inpatient), and I&D (outpa- showing increasing interest in out- portion of patients younger than 65
tient, 0.92%; inpatient, 1.27%) for patient THA (and other joint years are more frequently expected
both inpatient and outpatient THA replacement procedures) as a real- to become candidates for THA.1,24
(see Table, Supplemental Digital istic means for minimizing costs and This study also found the relative
Content 5, http://links.lww.com/ burden associated with the lengthy incidence of outpatient THA varied
JAAOS/A156). HO excision, ex- postoperative hospital courses by geographical region, with the
plantation of prosthesis, stiffness and increasing satisfaction in an incidence significantly higher in the
requiring MUA, and periprosthetic appropriately selected patient pop- South and Midwest regions than in
fractures occurred in less than 0.5% ulation.4,22 Due to the relatively recent the Northeast. This regional epide-
of patients undergoing THA in both emergence of outpatient THA in the miology is reflected in the outpa-
settings. When comparing the inpa- orthopedic literature, information on tient arthroplasty literature, wherein
tient and outpatient cohorts, the its national trends and complication nearly all early outcomes data to
odds ratio was not statistically sig- rates are limited, and its feasibility in date has emerged from the South and
nificantly different for any of the the greater orthopedic community Midwest.4,9,25,26 We anticipate that
queried complications (P . 0.05) outside of high-volume centers is this marked regional difference will
(see Table, Supplemental Digital unknown.6,7,9,14 To our knowledge, narrow down with a gradual adop-
Content 5, http://links.lww.com/ the present study reports the largest tion of outpatient arthroplasty as a
JAAOS/A156). Among the postop- cohort of patients across multiple practice more pervasively across the
erative medical complications que- institutions evaluating the trends United States.
ried, acute renal failure within and postoperative complications We also found that the incidence of
14 days (outpatient, 3.30%; inpa- associated with THA performed in outpatient THA cases performed
tient, 3.83%), respiratory failure the outpatient setting. has increased over the study period.
However, the relative frequency of statistically comparable rates of com- readmission and complication rates,
outpatient THA to inpatient THA ponent revision, surgical infections patients undergoing THA with a
has remained relatively stable at requiring I&D, hip dislocation, post- same-day discharge had a slightly
approximately 3%, suggesting that operative stiffness requiring MUA, higher complication rate compared
while the incidence of outpatient periprosthetic fractures, as well as with a propensity-matched cohort
THA is increasing, it has not postoperative cardiac, pulmonary, discharged on postoperative day one.
become a widely adopted alternative and renal complications compared to Similarly, Springer et al10 reported a
to traditional inpatient THA. The inpatients following THA (P . 0.05 slightly, although not statistically
earliest published case series on out- for all comparisons). This is despite significantly, higher rate of un-
patient THA dates back to 2004 concerns regarding limited access to planned 30-day hospital read-
wherein Berger et al27 reported a inpatient nursing and acute rehabili- missions following outpatient total
prospective series of 97 patients who tation services, postoperative analge- hip and knee arthroplasty. Conversely
were discharged on the day of sur- sia, and the guideline-recommended and perhaps more convincingly, a
gery following minimally invasive 24-hour course of postoperative recently published multi-institutional
THA; to achieve this, they utilized antibiotic prophylaxis in patients randomized-controlled trial of 220
regimented preoperative teaching, discharged on the same day.4 We patients demonstrated no difference
regional anesthesia, a minimally note that the postoperative medical in the number of reoperations, hos-
invasive approach, and preemptive and surgical complication rates found pital readmissions without reopera-
oral analgesia and antiemetic therapy in these cohorts are largely equivalent tion, emergency department visits
in select patients with few medical to those reported in the arthroplasty without readmission, or acute office
comorbidities, body mass index ,40, literature for both inpatients and visits between cohorts of patients
and low cardiovascular risk. Since outpatients.6,8,9 The lack of differ- undergoing outpatient and inpatient
then, several studies have emerged ence in complication rates noted in THA.9 Taken together, the findings
including several single-institution this study supports the use of outpa- of the present study, based on the
series,7,10,13,14 an analyses of the tient THA in appropriately selected largest known sample size with
American College of Surgeons’ patient populations as a means of population-level data, suggest that
National Surgical Quality Improve- lowering cost and improving patient outpatient THA is a safe and effective
ment Program database,6,8 and one satisfaction without compromising alternative to traditional THA in a
multi-institutional randomized con- patient safety.11,12 Although cost postoperative hospital with no sig-
trol trial,9 reflecting the observed analyses on outpatient arthroplasty nificant difference in complication
national increase in the volume of are limited to date, projections have rates.
THA in ambulatory surgery center estimated cost savings of $4,000 to To our knowledge, the present
and same-day discharge settings. 7,000 per patient, largely attributable study represents the largest group of
We note that despite this growing to the high cost associated with patients for whom the trends and
body of literature, these prior postoperative hospital care.28,29 In complication rates following THA
studies are limited in that they are their observational case–control in the ambulatory setting can be
performed exclusively at high-volume series, Aynardi et al11 demonstrated investigated and is only the third to
arthroplasty centers, which neither total cost savings of nearly $7,000 report multi-institutional data with
provide population-level trends nor for patients undergoing outpatient an inpatient comparison cohort.6,9
ascertain the feasibility of outpatient THA at their institution from 2008 to However, the current study design
THA in the general orthopedic com- 2011. Although prior studies have has several notable limitations. First,
munity where it may have a greatest reported generally excellent outcomes the PearlDiver database has limited
impact on the American healthcare following outpatient THA, only a few granularity and provides aggregate
enterprise. studies have directly compared rather than individual patient data
This study also found that THA postoperative readmission and com- by design for patient privacy con-
performed in the outpatient setting plication rates to ascertain the true cerns. Because the database is pri-
was associated with statistically cost–benefit balance and have only marily queried by CPT and ICD
equivalent odds ratios of major post- recently begun to emerge. In their codes, the available data on baseline
operative surgical and medical com- analysis of the National Surgical health characteristics—such as the
plications in comparison to cohorts of Quality Improvement Program regis- American Society of Anesthesiolo-
patients undergoing THA as an inpa- try, Otero et al6 found that while gists’ physical status classification—
tient with a postoperative hospital outpatient total and unicompartmen- are less comprehensive than are
course. Specifically, outpatients had tal knee arthroplasty had comparable available through conventional chart
January 15, 2019, Vol 27, No 2 65
review. We acknowledge that despite annually published “inpatient only” References 2, 3, 7, 13, 14, 16, 17, 18,
multivariate logistic regression con- list for prospective payment. The 20-22, 25-28 are level IV studies.
trolling for age, gender, and CCI, most recent proposal for the 2017 References 4 and 5 are level V studies.
these differences may serve as a con- edition includes a comment solicita-
founder that would potentially mask tion regarding whether total knee References printed in bold type are
differences in complication rates arthroplasty should be removed those published within the past 5 years.
between outpatient and inpatient from the inpatient only list in a 1. Kurtz S, Ong K, Lau E, Mowat F, Halpern
THA. Second, because of the limited subsequent year; no such solicitation M: Projections of primary and revision hip
and knee arthroplasty in the United States
data granularity, performing a query has been made regarding THA, from 2005 to 2030. J Bone Joint Surg Am
and analysis by hospital length of stay which generally has lower postop- 2007;89:780-785.
(eg, to compare same-day discharge erative complication rates. Based on 2. Memtsoudis SG, Della Valle AG, Besculides
versus “fast-track” versus traditional the results of this population-based MC, Gaber L, Laskin R: Trends in
demographics, comorbidity profiles, in-
2- to 3-day inpatient stay) is impos- analysis using a nationwide sample hospital complications and mortality
sible. Such a multi-tiered system and overview of the growing litera- associated with primary knee arthroplasty.
may be helpful in stratifying risk ture available on outpatient THA, J Arthroplasty 2009;24:518-527.
and appropriately determining ideal we recommend that THA be poten- 3. Jain NB, Higgins LD, Ozumba D, et al:
Trends in epidemiology of knee arthroplasty
patient settings for arthroplasty. In tially considered for prospective
in the United States, 1990-2000. Arthritis
the same vein, there is also concerns reimbursement by CMS in the out- Rheum 2005;52:3928-3933.
regarding definitional differences of patient setting in future. Indeed, this 4. Berger RA, Cross MB, Sanders S:
“outpatient arthroplasty” based on recommendation comes with caution Outpatient hip and knee replacement: The
billing codes, which usually but not for a careful consideration of ideal experience from the first 15 years. Instr
Course Lect 2016;65:547-551.
always includes overnight stay surgical candidates with minimal
,24 hours.30 Third, our study was medical comorbidities and a peri- 5. Lombardi AV, Barrington JW, Berend KR,
et al: Outpatient arthroplasty is here now.
also unable to determine the rate operative clinical pathway that may Instr Course Lect 2016;65:531-546.
of punitive emergency department help achieve equivalent patient out-
6. Otero JE, Gholson JJ, Pugely AJ, Gao Y,
visits and hospital readmission comes and complication rates. Bedard NA, Callaghan JJ: Length of
rates, which has been a fundamental In summary, this study demon- hospitalization after joint arthroplasty:
Does early discharge affect complications
concern in implementing outpatient strates that outpatient THA is and readmission rates? J Arthroplasty
arthroplasty.5,8,24 Finally, the data- associated with an equivalent rate of 2016;31:2714-2725.
base provides no information on postoperative surgical and medical 7. Klein GR, Posner JM, Levine HB,
functional outcome, which would complications compared to inpatient Hartzband MA: Same day total hip
be incorporated to determine the THA. Furthermore, the number of arthroplasty performed at an ambulatory
surgical center: 90-day complication rate on
effectiveness of outpatient THA outpatient THA procedures being 549 patients. J Arthroplasty 2016;32:
with more patient-driven data than performed in the United States has 1103-1106.
hospital readmission and major increased in recent years. THA per- 8. Lovecchio F, Alvi H, Sahota S, Beal M,
complication rates. formed in the outpatient setting Manning D: Is outpatient arthroplasty as
safe as fast-track inpatient arthroplasty? A
One of the primary incentives for appears to be a safe and effective propensity score matched analysis. J
establishing outpatient arthroplasty alternative, with the potential to Arthroplasty 2016;31:197-201.
as a viable alternative is the potential decrease payor cost associated with 9. Goyal N, Chen AF, Padgett SE, et al: Otto
to decrease healthcare costs associ- lengthy postoperative hospital courses aufranc award: A multicenter, randomized
study of outpatient versus inpatient total
ated with a high-volume procedure in patients carefully selected and hip arthroplasty. Clin Orthop Relat Res
that is expected to increase expo- treated with rigorous and comprehen- 2016;475:364-372.
nentially in coming years for an aging sive clinical pathways. 10. Springer BD, Odum SM, Vegari DN,
population. However, the Center for Mokris JG, Beaver WB: Impact of inpatient
Medicare and Medicaid Services versus outpatient total joint arthroplasty on
30-day hospital readmission rates and
(CMS) targets costly hospital com- References unplanned episodes of care. Orthop Clin
plications and readmissions in their North Am 2017;48:15-23.
fiscal algorithms, which could coun- Evidence-based Medicine: Levels of 11. Aynardi M, Post Z, Ong A, Orozco F, Sukin
termand cost savings among out- evidence are described in the table of DC: Outpatient surgery as a means of cost
reduction in total hip arthroplasty: A case-
patients if there is a disproportionate contents. In this article, reference 9 is a control study. HSS J 2014;10:252-255.
complication rate.29 As of 2016, level I study. References 19 and 29 are
12. Bertin KC: Minimally invasive outpatient
CMS continues to list THA (CPT- level II studies. References 1, 6, 8, 10- total hip arthroplasty: A financial analysis.
27130 and CPT-27132) under its 12, 15, 23 and 30 are level III studies. Clin Orthop Relat Res 2005;154-163.
13. Berger RA, Sanders SA, Thill ES, Sporer complications. Orthop J Sport Med 2016;4: 25. Berger RA, Sanders S, Gerlinger T, Della
SM, Della Valle C: Newer anesthesia and 2325967116662873. Valle C, Jacobs JJ, Rosenberg AG:
rehabilitation protocols enable Outpatient total knee arthroplasty with
outpatient hip replacement in selected 19. Charlson ME, Pompei P, Ales KL, a minimally invasive technique. J
patients. Clin Orthop Relat Res 2009; MacKenzie CR: A new method of Arthroplasty 2005;20:33-38.
467:1424-1430. classifying prognostic comorbidity in
longitudinal studies: Development and 26. Berger RA, Kusuma SK, Sanders SA, Thill
14. Dorr LD, Thomas DJ, Zhu J, Dastane M, validation. J Chronic Dis 1987;40: ES, Sporer SM: The feasibility and
Chao L, Long WT: Outpatient total hip 373-383. perioperative complications of outpatient
arthroplasty. J Arthroplasty 2010;25: knee arthroplasty. Clin Orthop Relat Res
501-506. 20. McCormick F, Harris JD, Abrams GD, 2009;467:1443-1449.
et al: Trends in the surgical treatment of
15. Arshi A, Kabir N, Cohen JR, et al: articular cartilage lesions in the United 27. Berger RA, Jacobs JJ, Meneghini RM, Della
Utilization and costs of postoperative States: An analysis of a large private-payer Valle C, Paprosky W, Rosenberg AG:
physical therapy after rotator cuff repair: A database over a period of 8 years. Rapid rehabilitation and recovery
comparison of privately insured and Arthroscopy 2014;30:222-226. with minimally invasive total hip
medicare patients. Arthroscopy 2015;31: arthroplasty. Clin Orthop Relat Res 2004;
2392-2399.e1. 21. Zhang AL, Kreulen C, Ngo SS, Hame SL, 239-247.
Wang JC, Gamradt SC: Demographic
16. Cohen JR, Bradley AT, Lieberman JR: trends in arthroscopic SLAP repair in the 28. Sibia US, MacDonald JH, King PJ:
Preoperative interventions and charges United States. Am J Sport Med 2012;40: Predictors of hospital length of stay in an
before total knee arthroplasty. J 1144-1147. enhanced recovery after surgery program
Arthroplasty 2016;31:2730-2735.e7. for primary total hip arthroplasty. J
22. Lovald S, Ong K, Lau E, Joshi G, Kurtz S, Arthroplasty 2016;31:2119-2123.
17. Nwachukwu BU, McCormick F, Malkani A: Patient selection in outpatient
Provencher MT, Roche M, Rubash HE: A and short-stay total knee arthroplasty. J 29. Bozic KJ, Stacey B, Berger A, Sadosky A,
comprehensive analysis of Medicare trends Surg Orthop Adv 2014;23:2-8. Oster G: Resource utilization and costs
in utilization and hospital economics for before and after total joint arthroplasty.
total knee and hip arthroplasty from 2005 23. Shin JI, Keswani A, Lovy AJ, Moucha CS: BMC Health Serv Res 2012;12:73.
to 2011. J Arthroplasty 2015;30:15-18. Simplified frailty index as a predictor of
adverse outcomes in total hip and knee 30. Bovonratwet P, Webb ML, Ondeck NT,
18. Arshi A, Cohen JR, Wang JC, Hame SL, arthroplasty. J Arthroplasty 2016;31: Lukasiewicz AM, Cui JJ, McLynn RP,
McAllister DR, Jones KJ: Operative 2389-2394. Grauer JN: Definitional differences of
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January 15, 2019, Vol 27, No 2 67
Research Article
Treatment Patterns and Outcomes

of Stable Hips in Infants With
Ultrasonic Dysplasia
Abstract
Harry K. W. Kim, MD, MS Introduction: No clear practice guideline exists for the management
Terri Beckwith, MPH, CCRP, of stable hip with ultrasonic dysplasia (UD). This study assessed the
CPH treatment patterns for stable UD and determined the outcomes of

Adriana De La Rocha, PhD, Pavlik harness (PH) treatment or observation (OB).
CCRP Methods: This is a prospective study of 80 infants (107 hips)
Erica Zepeda, RN, BSN,
aged #12 weeks at presentation diagnosed with stable UD.
CPNP-PC Results: Sixty-five hips were treated with PH, whereas 42 hips were
observed. Patients who were older at the time of initial sonogram and
Chan-Hee Jo, PhD
those with lower head coverage were more likely to be treated with PH.
Dan Sucato, MD, MS The mean head coverage was lower in the PH group, indicating more
severe UD. At a 2-year follow-up period, 93% of patients in the OB
From the Center for Excellence in Hip group and 87% in the PH group had a good radiographic outcome.
Disorders, Texas Scottish Rite Discussion: Head coverage and age at first sonogram had a
Hospital for Children, Texas Scottish
Rite Hospital for Children, Dallas, TX.
significant influence on the treatment decision for PH. A milder
ultrasonic hip dysplasia can be observed because 93% of the patients
Correspondence to Dr. Kim:
harry.kim@tsrh.org
who were observed had a good outcome.
Level of Evidence: Level II: prospective cohort study
Dr. Kim or an immediate family
member has received research or
institutional support from Medivir and
has received nonincome support
(such as equipment or services),
commercially derived honoraria, or
other non–research-related funding
D evelopmental dysplasia of the
hip (DDH) represents a spec-
trum of hip instability ranging from a
of newborn hips, stable UD is diag-
nosed within a few days of delivery. A
vast majority of the newborn hips
(such as paid travel) from 3D Matrix stable hip with ultrasonic dysplasia with UD in these centers has been
and Genentech. Dr. Sucato or an
immediate family member has
(UD) at one end to an unstable, dis- shown to normalize their hips
received royalties from Globus Medi- located hip at the other end. Pavlik without PH treatment.3-7 In other
cal and serves as a board member, harness (PH) is the treatment of centers, universal ultrasonography
owner, officer, or committee member choice for infants aged ,6 months screening of newborn hips is not
of the Pediatric Orthopaedic Society of
North America. None of the following
with a dislocated or a dislocatable performed, and the diagnosis of
authors or any immediate family hip. It improves hip stability and stable UD is generally made a few
member has received anything of acetabular development with a low weeks or more after the delivery. The
value from or has stock or stock op- risk of complications.1,2 Although optimal management of these pa-
tions held in a commercial company or
institution related directly or indirectly
good evidence exists in the literature tients in terms of observation (OB)
to the subject of this article: Ms. to support the use of PH treatment versus PH treatment remains un-
Beckwith, Dr. De La Rocha, Ms. Ze- for hips with clinical instability, the clear. In the recent clinical practice
peda, and Dr. Jo. optimal treatment for infants with a guideline published by the American
J Am Acad Orthop Surg 2019;27: clinically stable hip with UD, defined Academy of Orthopaedic Surgeons
68-74 as less than normal alpha angle and on the detection and nonsurgical
DOI: 10.5435/JAAOS-D-17-00233 femoral head coverage (FHC), re- management of DDH in infants aged
mains unclear. up to 6 months, only one study rated
Academy of Orthopaedic Surgeons. In European centers that perform as “low strength” by reviewers was
universal ultrasonography screening available to provide limited evidence
Harry K. W. Kim, MD, MS, et al
to support OB for infants with a Hip Ultrasonography (SAS Institute) and IBM SPSS 24
clinically stable hip with UD.8,9 All patients in the study had their Software (IBM).
Currently, no clear practice guid- initial hip sonogram performed after
ance exists in the literature in terms of 4 weeks of age to avoid overdiagnosis
who should be treated with a PH and
Results
of UD. Sonograms were obtained
who does not for patients with stable using the Siemens Acuson S3000, a Stable UD was the most common
UD. As a result, some physicians 5- to 7-MHz linear transducer, by a diagnostic spectrum of DDH seen at a
will routinely initiate PH treatment, staff ultrasonography technician. tertiary referral center. Of the 1,152
whereas others observe. Further- Patients were placed in a supine patients seen for DDH screening
more, no study has prospectively position, with a bolster underneath from 2008 to 2013, 188 (16.3%) had
assessed the treating patterns of the hip being examined. Coronal and stable hips with UD; 47 (4.1%)
pediatric orthopaedic surgeons for transverse images were obtained, with had dislocated but reducible hip
stable UD. The purposes of this study the hip being flexed at 90. Nonstress (Ortolani positive); 42 (3.6%) had
were to assess the treatment patterns and stress (Barlow maneuver) images dislocatable hip (Barlow positive),
of eight pediatric orthopaedic sur- were obtained. The alpha angle and 9 (0.8%) had hip laxity without dis-
geons for stable UD at a tertiary the percent FHC were measured, as location, and 6 (0.5%) had fixed
referral center and to determine the previously described.12,13 dislocation (Ortolani negative). The
outcomes of patients treated with a
remaining 856 patients (74.3%) had
PH or OB at a 2-year follow-up
normal hips. Patients with milder
period. Radiographic Assessment
UD (alpha angle $ 55) or who
The acetabular index (AI) 14 was had ,3 months of follow-up or who
measured on a standing AP pelvis presented after 12 weeks of age were
Methods
view by two pediatric orthopaedic excluded; this left a total of 80 (71
surgeons who were blinded to females/9 males) patients with 107
Study Design
treatment. The measurements were hips (57 left, 50 right hips) who met
This is an institutional review board– performed independently and as- the inclusion criteria. In the cohort of
approved prospective longitudinal sessed for interobserver reliability. 80 patients, the mean age at initial
cohort study of babies who were Acetabular dysplasia (poor out- presentation was 3.4 6 2.6 weeks
referred to a tertiary care institution come) was defined as greater than (range, 2.6 to 11.4 weeks), and the
for screening or treatment of DDH two SDs above the normal AI for mean age at the first hip ultraso-
between 2008 and 2013. Study pa- age, as described by Tonnis.15 nography was 6.5 6 1.5 weeks (4.2
tients were recruited from the clinics
to 11.4 weeks). Risk factors for hip
of eight staff pediatric orthopaedic
Statistical Analysis dysplasia included breech presenta-
surgeons. Data regarding the clinical
tion in 28 patients (35%) and first-
diagnosis, risk factors for DDH, The intraclass correlation coeffi-
born child in 43 patients (54%). Of
physical findings, ultrasonic find- cient was calculated to assess
the 107 hips analyzed, 54 hips had
ings, treatment, and final outcome the interobserver reliability for AI
bilateral UD.
were collected in a prospective measurements. A chi-square test
fashion. Inclusion criteria were in- was used to compare categoric var-
fants aged #12 weeks at presenta- iables, and where the sample size Observation Versus Pavlik
tion with at least 3 or more months was small, a Fisher exact test was Harness Treatment
of follow-up, normal hip examina- performed. Continuous variables A total of 65 hips (61%) with UD
tion, and ultrasonic hip dysplasia were first examined for normality, were treated with a PH, and the re-
defined as having an alpha angle10 and if normality was not present, maining 42 hips (39%) were
between 40 and 55 and FHC a nonparametric Mann-Whitney observed (Table 1). The mean age at
between 10% and 50%.11 Patients U test was used. A logistic regres- presentation was higher in the PH
were evaluated at 2 years for ace- sion model was used to determine group than in the OB group, but the
tabular dysplasia using a standing whether any variable influenced the difference was not statistically signif-
AP pelvis radiograph. Patients with physicians’ decision to treat with icant (OB, 2.9 6 1.7 weeks versus PH,
underlying syndromes, teratologic PH versus OB. For all tests, P , 4.2 6 3.1 weeks; P = 0.15). The mean
abnormalities, or who received pre- 0.05 was considered statistically age at initial sonogram was signifi-
vious treatment for DDH were significant. Statistical analysis was cantly higher in the PH group than in
excluded. performed using SAS version 9.4 the OB group (OB, 6.2 6 1.3 weeks
January 15, 2019, Vol 27, No 2 69
Treatment Patterns and Outcomes of Ultrasonic Hip Dysplasia
Table 1
Comparisons of Baseline Characteristics for Patients in the Ultrasonic Dysplasia Cohort
Factor Observation Pavlik P value
Categoric data
Female sex 29 (88%) 42 (89%) .0.99
Positive family history of DDH 4 (12%) 7 (15%) .0.99
Firstborn 20 (63%) 23 (50%) 0.28
Breech 12 (36%) 16 (34%) 0.83
Bilateral dysplasia 21 (64%) 31 (66%) 0.83
Continuous data
Age at presentation (wk) 2.9 6 1.7 (0.9-6.2)a 4.2 6 3.1 (1-11.4) 0.15
Age of initial sonogram (wk) 6.2 6 1.3 (4.2-9.9) 6.9 6 1.6 (4.2-11.4) 0.02
Total visits 4.6 6 1.2 (2-7) 8.4 6 2.5 (4-14) ,0.0001
Total sonograms 2.7 6 0.9 (1-5) 4.9 6 2.5 (2-11) 0.0001
Affected hip alpha angle () 49.7 6 3.5 (42-54) 49.0 6 3.4 (40-54) 0.20
Affected hip FHC (%) 38.6 6 6.8 (23-50) 32.1 6 9.2 (10-48) 0.0002
DDH = developmental dysplasia of the hip, FHC = femoral head coverage

a
Expressed as mean 6 SD (range).
versus PH, 6.9 6 1.6 weeks; P = FHC $ 50%). In the OB group, older age at first sonogram (odds
0.02). The PH group had a signifi- repeat ultrasonography was per- ratio = 1.67; 95% confidence inter-
cantly greater number of sonograms formed 4 to 8 weeks after the initial val, 1.16 to 2.39) and a lower per-
(OB, 2.7 6 0.9 versus PH, 4.9 6 2.5; ultrasonography. Two patients were cent FHC (odds ratio = 0.90; 95%
P = 0.0001) and clinic visits com- initially observed and then later confidence interval, 0.84 to 0.96)
pared with the OB group (OB, 4.5 6 treated with a PH when they were significantly influenced the treatment
1.3 versus PH, 8.3 6 2.4; P , found to have a persistent UD decision for PH treatment. The other
0.0001). A large overlap was seen in on a follow-up ultrasonography. variables, including the alpha angle,
terms of the distribution of the alpha None of the patients had any ad- family history, birth presentation,
angle and the FHC between the PH ditional treatments or evidence of birth order, and sex, did not influ-
group and the OB group (Figure 1). hip subluxation or dislocation at ence the treatment decision.
The mean alpha angle was similar the follow-up.
between the two groups (OB, Two-year Follow-up Results
49.7 6 3.5 versus PH, 49.0 6 Treatment Patterns for Stable Of the 80 patients (107 hips)
3.4; P = 0.20), but the PH group Ultrasonic Dysplasia included in the study, 51 patients
had a significantly lower mean per- The treatment pattern for stable (71 hips) returned for 2-year follow-
cent FHC compared with the OB UD varied between eight pediatric up. The mean age at follow-up was
group (OB, 38.6 6 6.8% versus PH, orthopaedic surgeons (Figure 2). 29 6 4.9 months (range, 20 to 47
32.1 6 9.2%; P = 0.0002), indicat- Two surgeons (surgeons 2 and 6) months). Twenty-seven hips were in
ing that patients with more severe treated almost all of their patients the OB group and 44 hips in the PH
UD were treated by PH. with PH, whereas two surgeons group. The demographic and hip
The mean duration of PH treatment (surgeons 3 and 5) had almost an ultrasonography parameters of this
was 9.2 6 3.7 weeks (range, 3 to equal split between OB and PH cohort seen at the 2-year follow-up
16 weeks). The patients were followed treatment, and four surgeons (sur- period were similar to the original
up with repeat hip ultrasonography, geons 1, 4, 7, and 8) treated more cohort of patients (Table 2). At a
and the PH treatment was dis- severe UD with PH. 2-year follow-up period, 93% of
continued without weaning in 35 Logistic regression was used to the hips in the OB group and 87%
hips and weaned off in 30 hips when determine whether any variable of the hips in the PH had a good
the ultrasonic parameters nor- studied influenced the surgeons’ radiographic outcome (Figures 3
malized (alpha angle $ 60 and the decision to treat with PH or OB. An and 4). Seven percent of the hips in
Figure 1
A, Histograms showing the frequency distribution of the alpha angle measured on the initial ultrasonography of the patients
in the observation (OB) and the Pavlik harness (PH) groups. A considerable overlap was found in the distribution curve of the
alpha angle between the OB and the PH groups. No significant difference was found between the two groups. B, Histograms
showing the frequency distribution of the femoral head coverage (FHC) measured on the initial ultrasonography of the
patients in the OB and the PH groups. A considerable overlap was found in the distribution curve of the FHC between the OB
and the PH groups. The graph indicates that patients with more severe degree of ultrasonic dysplasia were treated with PH.
A significant difference was found between the two groups (P = 0.0002).
the OB group and 13% of the hips represents the most common form whether the hips with less FHC
in the PH group were considered to of DDH treated with a PH. Our would also do well with OB alone or
have acetabular dysplasia based on findings show that the age at initial whether they should be treated with
age and sex-matched AI criteria ultrasonography and the percent PH. This uncertainty would be best
described by Tonnis.15 The mean AI FHC on the initial ultrasonography addressed with a randomized clinical
was 22.1 6 3.5 (range, 13 to 30) play a significant role in the treat- trial.
for the OB group and 20.9 6 4.7 ment decision for PH. Finding UD at As a result of this study, the senior
(range, 11 to 32) for the PH group an older age and lower FHC was author now observes patients with
(P = 0.19). The intraclass correla- more likely to lead to PH treatment. mild ultrasonic hip dysplasia defined
tion coefficient between the two To our knowledge, this is the first as percent FHC .35% and alpha
observers for AI was 0.74. study to prospectively investigate angle .50 on the initial hip ultra-
the treatment patterns of pediatric sonography obtained at or after
orthopaedic surgeons for stable UD 6 weeks of age. The timing of the
Discussion and the factors that influence treat- initial hip ultrasonography depends
ment decision. Our findings suggest on the age at presentation. If a
Our study focused on treatment that mild ultrasonic hip dysplasia patient presents before 6 weeks of
patterns and outcomes of stable UD can be observed because 93% of the age and is found to have a stable hip
diagnosed after the newborn pe- patients who were observed had a examination, the initial ultrasonog-
riod. The results show that stable good outcome at a 2-year follow up raphy is delayed until 6 weeks of age
UD is the most common spectrum period. The OB group had a mean to minimize overdiagnoses of mild
of DDH seen at a tertiary refer- alpha angle of 49º and percent FHC hip dysplasia. If a patient is found to
ral center. As a result, stable UD of 38%. It is unclear from this study have a mild dysplasia on the initial
January 15, 2019, Vol 27, No 2 71
Figure 2
A, Treatment patterns of eight pediatric orthopaedic surgeons assessed by the alpha angle. Each rectangular box represents a
surgeon, and each dot within the box represents a hip that was either observed (blue dot) or treated with a Pavlik harness (PH) (red
dot). OB represents observation (OB), and PH represents PH treatment. B, Treatment patterns of eight pediatric orthopaedic
surgeons assessed by femoral head coverage. Each rectangular box represents a surgeon, and each dot within the box represents
a hip that was either observed (blue dot) or treated with a PH (red dot). OB represents OB, and PH represents PH treatment.
Figure 3 unnecessary treatment of mild

ultrasonic hip dysplasia.
Although several studies have
examined the outcomes of stable UD
detected within 2 to 3 days of deliv-
ery,3-7 only one study has previously
reported the outcomes of stable UD
diagnosed after three weeks of age.
In the study, 44 infants (63 hips)
aged from 2 to 6 weeks were treated
with a PH (n = 38 hips) or by OB
(n = 25 hips).9 The study found no
significant difference in the AI
measurements between the OB and
PH groups at 3 months. The only
other study that assessed the out-
comes of stable UD diagnosed after
the newborn period was a retro-
spective study, which analyzed the
outcomes of 192 hips in 112 new-
Case example of a patient with stable bilateral ultrasonic dysplasia (UD) who born babies with the mean age of
was observed. A, Initial ultrasonographic images showing bilateral UD. B, AP presentation and initial ultrasonog-
radiograph of the pelvis obtained at a 2-year follow-up period. raphy at 12.7 days (range, 12 to
30 days).16 Forty-three hips were
hip ultrasonography, the patient is improvement is seen, the PH treat- treated with a PH, and 149 hips
followed up with a repeat hip ment is initiated at this point. This were observed. At a mean follow-up
ultrasonography 4 weeks later. If no stratified approach may decrease period of 15.9 months, no hip in the
PH group and only two hips (1.3%) Figure 4

in the OB group were considered
dysplastic with an AI .20.
The present study does have some
limitations. First, given the prospec-
tive cohort study design, the OB and
the PH groups were not identical in
terms of the severity of the ultrasonic
abnormalities; thus, a direct com-
parison of outcomes of PH versus OB
group cannot be made. It is important
to note that the primary purpose of
the study was to determine the treat-
ment patterns for ultrasonic hip dys-
plasia and their outcomes. With this
study design, we are able to conclude
that an older age at the initial ultra-
sonography and a lower percent FHC
are significant factors influencing the
treatment decision for PH, and a
milder form of ultrasonic hip dys-
plasia can be observed with good Case example of a patient with stable bilateral ultrasonic dysplasia (UD) who
expected outcome at a 2-year follow- was treated with a Pavlik harness. A, Initial ultrasonographic images showing
bilateral UD. B, AP radiograph of the pelvis obtained at a 2-year follow-up period.
up period.
Another limitation of the study is
that not all patients returned for a nature of this condition. We did exactly at the 2-year mark. Five
2-year follow-up visit. Our follow- compare the demographic parame- of the 51 patients returned earlier
up rate was 64% (66% by hip ters of the original cohort and a than 24 months. The minimum
follow-up). This phenomenon is 2-year follow-up cohort (Tables 1 follow-up duration was 20 months,
likely due to the mobility of young and 2) and found them to be sim- with a mean follow-up duration of
families and the asymptomatic ilar. Last, not all patients returned 29 6 4.9 months.
Table 2
Comparisons of Baseline Characteristics for Patients With 2-Year Follow-up
Factor Observation Pavlik P value
Categoric data
Female sex 17 (94%) 29 (88%) 0.64
Positive family history of DDH 0 2 (6%) 0.53
Firstborn 12 (67%) 17 (53%) 0.35
Breech 6 (33%) 11 (33%) .0.99
Bilateral dysplasia 14 (78%) 21 (64%) 0.36
Continuous data
Age at presentation (wk) 3.1 6 1.7 (0.9-5.9)a 4.1 6 3.1 (1-10.4) 0.47
Age of initial sonogram (wk) 5.9 6 1.3 (4.7-9.9) 6.7 6 1.4 (4.2-9.9) 0.011
Total visits 5.3 6 1 (3-7) 9.2 6 2.3 (5-14) ,0.0001
Total sonograms 2.8 6 0.9 (1-4) 5.3 6 2.7 (2-11) 0.0006
Affected hip alpha angle () 48.9 6 3.9 (42-54) 48.8 6 3.5 (40-54) 0.84
Affected hip FHC (%) 38.3 6 7.7 (23-50) 32.2 6 9.1 (10-46) 0.005
DDH = developmental dysplasia of the hip, FHC = femoral head coverage

a
Expressed as mean 6 SD (range).
January 15, 2019, Vol 27, No 2 73
The strengths of this study include 8. AAOS: Detection and Nonoperative

its prospective design, assessment of
References Management of Pediatric Developmental
Dysplasia of the Hip in Infants Up to Six
current treatment patterns of eight Months of Age: Evidence-based Clinical
References printed in bold type are Practice Guideline. Rosemont, IL, AAOS,
pediatric orthopaedic surgeons, and
those published within the past 5 2014.
inclusion of a well-defined patient
years. 9. Wood MK, Conboy V, Benson MK, Does
population with regard to the age at
early treatment by abduction splintage
presentation and the age at the initial 1. Grill F, Bensahel H, Canadell J, Dungl P, improve the development of dysplastic
Matasovic T, Vizkelety T: The Pavlik
ultrasonography. All the patients harness in the treatment of congenital
but stable neonatal hips? J Pediatr
Orthop 2000;20:302-305.
had their initial ultrasonography dislocating hip: Report on a multicenter
performed after 4 weeks of age to study of the European Paediatric 10. Graf R: Classification of hip joint
Orthopaedic Society. J Pediatr Orthop dysplasia by means of sonography. Arch
avoid overdiagnosis of UD. We also 1988;8:1-8. Orthop Trauma Surg 1984;102:
excluded the patients who were 248-255.
2. Nakamura J, Kamegaya M, Saisu T,
found to have milder alpha angle Someya M, Koizumi W, Moriya H: 11. Berman L, Klenerman L: Ultrasound
abnormalities of 55 to 59 degrees. Treatment for developmental dysplasia of screening for hip abnormalities [letter].
the hip using the Pavlik harness: Long-term Br Med J (Clin Res Ed) 1986;293:
Other strengths of the study are the results. J Bone Joint Surg Br 2007;89: 1309-1310.
use of two independent observers for 230-235.
12. Morin C, Harcke HT, MacEwen GD: The
the measurement of acetabular 3. Rosendahl K, Dezateux C, Fosse KR, infant hip: Real-time US assessment of
indices. et al: Immediate treatment versus acetabular development. Radiology 1985;
sonographic surveillance for mild hip 157:673-677.
dysplasia in newborns. Pediatrics 2010;
125:e9-e16. 13. Gerscovich EO: A radiologist’s guide to
Conclusions the imaging in the diagnosis and
4. Tegnander A, Holen KJ, Terjesen T: The treatment of developmental dysplasia
Treatment patterns for stable hip natural history of hip abnormalities of the hip. II: Ultrasonography:
detected by ultrasound in clinically Anatomy, technique, acetabular angle
with UD varied considerably in a normal newborns: A 6-8 year measurements, acetabular coverage of
tertiary referral center. The age at radiographic follow-up study of 93 femoral head, acetabular cartilage
children. Acta Orthop Scand 1999;70: thickness, three-dimensional technique,
initial ultrasonography and the 335-337. screening of newborns, study of older
amount of FHC had a significant children. Skeletal Radiol 1997;26:
5. Terjesen T, Holen KJ, Tegnander A: 447-456.
influence on the treatment decision Hip abnormalities detected by
for PH. Ninety-three percent of the ultrasound in clinically normal newborn 14. Massie WK, Howorth MB: Congenital
patients who were observed had a infants. J Bone Joint Surg Br 1996;78: dislocation of the hip. Part I: Method of
636-640. grading results. J Bone Joint Surg Am 1950;
good outcome at a 2-year follow-up 32-A:519-531.
period, suggesting that milder ultra- 6. Sampath JS, Deakin S, Paton RW: Splintage
in developmental dysplasia of the hip: How 15. Tonnis D: Normal values of the hip joint for
sonic hip dysplasia can be observed low can we go? J Pediatr Orthop 2003;23: the evaluation of x-rays in children and
with a good expected outcome. On 352-355. adults. Clin Orthop 1976:39-47.
the basis of the results of the study, a 7. Castelein RM, Sauter AJ, de Vlieger M, van 16. Sucato DJ, Johnston CE II, Birch JG,
randomized clinical trial is warranted Linge B: Natural history of ultrasound hip Herring JA, Mack P: Outcome of
abnormalities in clinically normal ultrasonographic hip abnormalities in
to evaluate the role of PH treatment newborns. J Pediatr Orthop 1992;12: clinically stable hips. J Pediatr Orthop
for stable UD. 423-427. 1999;19:754-759.
Research Article
Outcome of Surgical Treatment

of Hip Femoroacetabular
Impingement Patients with
Radiographic Osteoarthritis:
A Meta-analysis of Prospective
Studies
Abstract
Pengfei Lei, MD Introduction: In this study, the prognostic value of osteoarthritis (OA) on
William K. Conaway, BA the overall failure rate, pain, and function of surgical management of
femoroacetabular impingement (FAI) was evaluated via meta-analysis.
Scott D. Martin, MD
Methods: Relevant comparative studies were obtained from
PubMed, OVID, and Cochrane database up until April 2016. Studies
were selected according to the eligibility criteria. The study design,
participant characteristics, interventions, and outcomes were
reviewed after the assessment of methodological quality of each trial.
All data were analyzed by Review Manager 5.3.
Results: Seven studies were identified with 1,129 total patients, with
819 patients in the FAI group and 310 patients in the FAI with OA
group. Pooled analyses showed that the overall failure rate was
Orthopaedics, Xiangya Hospital, significantly higher in the FAI-OA group than in the FAI group (odds
Central South University, Hunan ratio, 8.50; 95% confidence interval, 4.44 to 16.26; P , 0.00001). In
Province, China (Dr. Lei), the
addition, the rate of conversion to total hip arthroplasty was
Department of Orthopaedics,
Massachusetts General Hospital, significantly higher in the FAI-OA group (37.3%) than in the FAI group
Boston, MA, the Department of (9.7%) (odds ratio, 19.42; 95% confidence interval, 7.00 to 53.85;
Orthopaedic Surgery, Brigham and
Women’s Hospital, Boston, MA, and
P , 0.00001).
the Department of Orthopaedics, Conclusions: We found that radiographic OA was correlated with
Harvard Medical School, Boston, MA higher failure rates, increased conversion to total hip arthroplasty, and
(Dr. Lei, Mr. Conaway, Dr. Martin).
worse outcomes after surgical management of FAI.
Correspondence to Dr. Lei: Level of Evidence: Level II
Pengfeilei@csu.edu.cn
None of the following authors or any
I n recent years, notable advances
have been made in the identifica-
tion and management of femo-
femoral and acetabular osteoplasty,
is now a commonly performed pro-
cedure with well-documented short-
subject of this article: Dr. Lei, Mr. roacetabular impingement (FAI). FAI term outcomes. Although most
Conaway, and Dr. Martin. is thought to be a prearthritic mech- patients can be treated successfully
J Am Acad Orthop Surg 2019;27: anism caused by repetitive abutment with hip arthroscopy, those with
e70-e76 of the femoral head and neck junction osteoarthritis (OA) have been found
DOI: 10.5435/JAAOS-D-17-00380 against the acetabular rim. It fre- to experience less predictable results.
quently occurs in athletically active The occurrence rate of OA is in-
Academy of Orthopaedic Surgeons. young adults and adolescents. Labral creased with aging. Numerous stud-
repair or débridement, along with ies have shown that the presence of
Pengfei Lei, MD, et al
OA negatively affects improvements Table 1

in pain and function after hip arthros-
Distribution of OA in Included Studies
copy or open hip surgery.1-3 However,
most of these studies predate modern Studies FAI Alone (n) FAI-OA (n)
management of FAI or are limited to Skendzel et al6 Joint space .2 mm (383) Joint space ,2 mm (63)
the small sample size.4 The degree of
Ribas et al7 Tönnis grade 0 (32) Tönnis grade 2 (24)
degenerative changes and associated
Ribas et al7 Tönnis grade 0 (32) Tönnis grade 1 (61)
preoperative findings that affect func-
Larson et al3 Tönnis grade 0-1 (169) Tönnis grade 2-3 (58)
tional improvements after FAI surgery
Philippon et al8 Joint space .2 mm (111) Joint space ,2 mm (42)
are not well defined. The purpose of
Gedouin and colleagues9,20 Tönnis grade 0 (75) Tönnis grade 1 (36)
our study was to compare failure
Stähelin et al10 Tönnis grade 0 (14) Tönnis grades 1-2 (8)
rates, pain, and function in patients
undergoing surgery without and with Gicquel et al11 Tönnis grade 0 (35) Tönnis grade 1 (18)
preoperative radiographic OA via a FAI = femoroacetabular impingement, OA = osteoarthritis
meta-analysis of prospective studies.
We tried to quantify the overall failure
rate and the rate of conversion to total
(4) OA defined by Tönnis grade or inadequate or partially reported, and
hip arthroplasty (THA) to assess the
joint space (Table 1); two indicated reported and adequate.
prognostic value of OA for surgical
(5) Comparison between FAI with The ideal total score is 24 for com-
management of FAI. To our knowl-
no or mild OA or joint space parative studies. Two independently
edge, this study was the first meta-
width .2 mm and FAI with working reviewers assigned a quality
analysis on this topic. The hypothesis
higher degree of Tönnis grade score to each component study. The
was that patients with radiographic
or joint space width #2 mm. agreement between the two reviewers
OA would report inferior outcomes
(6) Evaluation of the failure rate in was evaluated with both the correla-
and have increased rates of conversion
terms of conversion to THA, tion coefficient (r) for interrater
to THA.
dissatisfaction rate (according agreement and the intraclass cor-
to patient satisfaction score relation coefficient.
Methods on a scale from 1 to 10), or
additional revision; Data Collection
Search Strategy for Eligible (7) Minimum follow-up of at least
General demographic data were
Studies 6 months.
included for each study in our review.
Using the PubMed, OVID, and Data points of interest included study
Exclusion Criteria
Cochrane database, a search was con- population composition (eg, age, sex,
ducted for all relevant English-language Review articles, articles focusing purely follow-up time frame), surgical tech-
articles published before April on technique, and studies of nonsurgi- nique, conversion to THA or revision,
2016. The keywords used were cal management were excluded. Stud- conversion time frame, and clinical
“Femoroacetabular Impingement” ies dealing with hip arthroscopy but not outcome scores preoperatively and at
and “treatment or surgery.” The specifically management of FAI alone final follow-up. A number of outcome
authors screened every title and were excluded. Studies that dealt with scores were used including Western
abstract to identify appropriate the surgical management of FAI but Ontario and McMaster Universities
articles for this study. did not provide a comparison between Arthritis Index (WOMAC), modified
FAI with OA and FAI alone were also Harris hip score (mHHS), non-arthritic
Inclusion and Exclusion excluded. hip score (NAHS), hip outcome score–
Criteria activities of daily living, hip outcome
Articles were selected on the basis of Quality Assessment score–sports, visual analogue score
the following criteria: The methodological quality of each (VAS), and Short Form-12 (SF-12). If
(1) Adult patients who were diag- article was assessed with the Method- there were studies for which only a
nosed with FAI; ological Index for Nonrandomized subgroup of the participants met the
(2) Arthroscopic or open surgical Studies items.5 This scale is based on a inclusion criteria for the current
intervention; list of 12 criteria, each one conferring review, we would extract data only on
(3) Postoperative evaluation of 0 to 2 points. Zero indicated unre- this subgroup, provided that random-
function or patient satisfaction; ported, one indicated reported but ization had not been broken.
January 15, 2019, Vol 27, No 2 e71
Hip Femoroacetabular Impingement
Figure 1 Failure Rate

The failure was defined as those pa-
tients who required THA, revision
surgery, were dissatisfied, or have a
modified Harris hip score (HHS) or
NAHS of less than 70. All seven studies
included in this meta-analysis
reported failure rate–related data.
The failure rate was 45.2% (140 of
310) in the FAI-OA group and
13.2% (108 of 819) in the FAI
group, and the overall failure rate
was 22.0%. Pooled analyses showed
that the failure rate was significantly
higher in the FAI-OA group than in
the FAI group (OR, 8.50; 95% CI,
4.44 to 16.26; P , 0.00001), sug-
gesting that the presence of preop-
erative radiographic OA would
predict poor prognosis for FAI
Flowchart showing the selection flow for included studies in this meta-analysis. surgery. Because evidence of het-
OA = osteoarthritis
erogeneity existed between the
study estimates (I2 = 59%; P =
0.02), the random-effects model
Statistical Analysis these, 939 were excluded after was used (Figure 2).
Pooled cohort analysis was performed review of the abstract and title on The rate of conversion to THA
for comparison between the preopera- the basis of unrelated topic, no was also assessed in this meta-
tive radiographic OA group (FAI-OA) specific mention of FAI; no ran- analysis. For the included studies,
and the FAI without OA group (FAI) in domization; or foreign language. the rate of conversion to THA
terms of pain and functional improve- One hundred two full-text articles ranged from 86% to 13.8% in the
ment after surgery. Pooled analyses were retrieved and reviewed, with FAI-OA group, whereas in the FAI
were performed with Revman 5.3 (The seven comparative studies3,6-11 group, the range was from 0% to
Cochrane Collaboration, Interna- meeting the inclusion criteria 16%. Based on the result of pooled
tional). Mean differences were calcu- (Figure 1). The characteristics of analysis, the overall rate of conver-
lated for continuous outcomes, and the seven included studies were sion to THA was 37.3% (106 of
odds ratio (OR) for binary outcomes, summarized in Supplemental Table 284) in the FAI-OA group and 9.7%
along with 95% confidence intervals (see Supplemental Digital Content (75 of 770) in the FAI group. Pooled
(CIs). Statistical heterogeneity was 1, http://links.lww.com/JAAOS/ analyses showed that the rate of
tested using the chi-square test and the A134). A total of 1,129 patients conversion to THA was signifi-
I2 test. I2 . 50% was considered as were involved in this meta-analysis, cantly higher in the FAI-OA group
evidence of heterogeneity. A fixed with 310 patients included in the than in the FAI group (OR, 19.42;
effect model was used if there was no FAI-OA group and 819 patients 95% CI, 7.00 to 53.85; P ,
statistical evidence of heterogeneity; involved in the FAI group, respec- 0.00001) (Figure 3). The mean
otherwise, a random-effects model tively. Four studies were of high follow-up time ranged from 6 to
was used. P , 0.05 was considered quality with scores of 18 to 20 by 31.6 months.
statistically significant. evaluation with the Methodologi-
cal Index for Nonrandomized
Studies criteria. Quality scores for Postoperative Clinical
Results all included studies are shown in Assessment
Table 2. A summary of postopera- The WOMAC score was reported in
Study Characteristics tive results according to the differ- four studies, while for the study by
A total of 1,081 relevant titles were ent scoring systems in each study is Skendzel et al, WOMAC score was
identified by database query. Of shown in Table 3. displayed in a form different from
Table 2
Quality Assessment for all Eligible Studies According to the Methodological Index for Nonrandomized Studies
Score
Skendzel Ribas Larson Gedouin and Stähelin Philippon Gicquel
Items et al6 et al7 et al3 Colleagues9,20 et al10 et al8 et al11
A clearly stated aim 2 2 2 2 2 2 2

Inclusion of consecutive patients 2 2 2 2 2 1 1
Prospective collection of data 2 0 2 2 2 2 2
End points appropriate to the 2 2 2 2 2 2 2
aim of the study
Unbiased assessment of the 0 0 1 0 0 0 0
study end point
Follow-up period appropriate to 2 2 2 2 2 2 2
the aim of the study
Loss to follow-up less than 5% 2 1 2 2 2 0 1
Prospective calculation of the 0 0 0 0 0 0 0
study size
An adequate control group 2 2 2 2 2 2 2
Contemporary groups 2 2 2 2 2 2 2
Baseline equivalence of groups 1 1 1 1 1 1 1
Adequate statistical analysis 2 2 2 2 2 2 2
Total scores 19 16 20 19 19 16 17
Table 3
Postoperative Functional and Pain Outcomes According to Various Score Systems of Included Studies in This
Meta-analysis
Studies Functional and Pain Outcomes (FAI-OA versus FAI) P Value
Skendzel et al6 Change in mHHS: 8 versus 24 0.529

Change in HOS-ADL: 26 versus 15 0.035
Change in HOS-SS: 3.6 versus 34.8 0.005
Ribas et al7 Negative impingement test: 58.3% versus 93.7% NA
WOMAC score improvement: 58.3% versus 93.4% NA
Satisfactory results in DCSs: 58.3% versus 93.4% ,0.001
Larson et al3 Mean HHSs: 67 versus 88 ,0.001
HHS improvement: 3.7 versus 22.8 points NA
SF-12 improvement: 4.3 versus 20.9 points NA
VAS improvement: 2.6 versus 4.5 points NA
Stähelin et al10 NAHS: 56 6 19 versus 83 6 12.5 NA
VAS: 3.2 6 2.0 versus 0.6 6 0.6 ,0.05
Gedouin and colleagues9,20 WOMAC: 73.7 6 19 versus 87.5 6 13 ,0.001
Gicquel et al11 WOMAC: 77 6 18 versus 88 6 14 0.03
OA progression rate: 57% versus 24% 0.046
DCS = Dexeus combined score, FAI = femoroacetabular impingement, HHS = Harris hip score, HOS-ADL = hip outcome score–activities of daily
living, HOS-SS = hip outcome score–sports, mHHS = modified Harris hip score, NA = not available, NAHS = non-arthritic hip score, OA =
osteoarthritis, SF-12 = Short Form-12, VAS = visual analogue score, WOMAC = Western Ontario and McMaster Universities Arthritis Index
the other three studies, it was con- by Ribas et al, postoperative out- Tönnis grade 2 were separately
verted into a unified form (global comes of symptomatic FAI patients compared with that of the control
scale) for comparison. In the study presenting with Tönnis grade 1 or group presenting with Tönnis
January 15, 2019, Vol 27, No 2 e73
Figure 2
Forest plot showing pooled analyses of the failure rate between the FAI-OA group and FAI group. CI = confidence interval,
FAI = femoroacetabular impingement, M-H = Mantel-Haenszel, OA = osteoarthritis.
Figure 3
Forest plot showing pooled analyses of the rate of conversion to THA between the FAI-OA group and FAI group. CI =
confidence interval, FAI = femoroacetabular impingement, M-H = Mantel-Haenszel, OA = osteoarthritis, THA = total hip
arthroplasty.
Figure 4
Forest plot showing pooled analyses of the WOMAC score between the FAI-OA group and FAI group. CI = confidence
interval, FAI = femoroacetabular impingement, OA = osteoarthritis, WOMAC = Western Ontario and McMaster Universities
Arthritis Index.
grade 0. The WOMAC scores of results showed that the WOMAC FAI group (mean difference, 210.82;
the two comparison were both score in the FAI-OA group was 95% CI, 216.48 to 25.17; P =
pooled for meta-analysis, and the significantly lower than that in the 0.0002) (Figure 4).
For six studies, other postoperative large sample size are lacking. In In this study, the severity of OA was
outcomes, such as mHHS, HHS, addition, although most studies on defined according to Tönnis grade $1
SF-12, and VAS score, were also this topic have used Tönnis grade or or joint space width #2 mm. Pooled
evaluated in the FAI-OA and FAI joint space to define the degree of analyses showed that OA significantly
groups(Table 3). Skendzel et al showed OA, reports disagree on a stan- increased the failure rate after surgical
that change in hip outcome score– dardized definition. In this study, management (45.2% versus 13.2%;
activities of daily living and change in we evaluated the prognostic value P , 0.00001). In a systematic review
HOS-Sports were significantly lower in of OA on the overall failure rate by Saadat et al,12 which evaluated all
FAI patients with OA (P = 0.035 and functional outcomes of surgical factors associated with the failure for
and 0.005, respectively). Ribas et al7 management of FAI via meta-analysis. FAI treatment, OA was indicated as
found that FAI patients with OA To our knowledge, no meta-analyses the strongest predictor of surgical
showed inferior outcomes compared of prospective studies on this topic failure. Generally, a zero to 30% rate
with those without OA in terms of currently exist. of conversion to THA is reported after
satisfactory results in Dexeus com- Traditionally, plain radiographs conservative surgery for FAI.19,20 In
bined scores and mean HHSs (P , have been the benchmark for diag- regards of FAI with radiographic
0.001). In addition, Gicquel et al nosing and stratifying OA14 according OA, a 60% failure rate was reported
showed that the OA progression rate to grading systems such as the Tönnis in FAI patients with marked gener-
in FAI patients with OA was higher and Kellgren-Lawrence systems. De- alized chondral lesions in 20 patients
than those without OA (57% versus spite no unifying definition,15 joint with radiographic OA (Tönnis grades
24%; P = 0.046). After summarizing space narrowing is used to measure 1 to3) after arthroscopic treatment
the postoperative functional and the severity of OA,16 which has also with 3 years’ mean follow-up,2 sug-
pain outcomes, we found that in been found to predict conversion to gesting the influence of OA on the FAI
most of the included studies, the FAI THA after hip arthroscopy.17 Stan- surgical outcomes. Furthermore, a
patients with OA showed inferior dard MRI allows for assessment of 72% failure rate was reported in a
outcomes compared with those precise articular lesions associated cohort of 39 patients with OA who
without OA. with OA with higher sensitivity and underwent hip arthroscopy with
specificity compared with plain radi- a minimum 4-month follow-up.21
ography.14 Clinical and radiographic However, in our study, we found
Conclusions signs may lag behind several years that OA increased the failure rate to
biochemical changes leading to irre- 45.2%, which was much higher than
Many studies have supported the versible cartilage loss on MRI;18 that in the FAI without OA group.
efficacy of arthroscopic and open hence, MRI findings could predict Nevertheless, the failure rate for
treatment of FAI. Identifying which the onset of radiographic knee OA. arthroscopy is generally high, and it
patients will have less favorable or Larson et al reported that 66% of the may be necessary to refine clinical and
predictable outcomes is important patients who were defined as FAI radiographic indications for surgery.
for preoperative planning and setting without OA by plain radiograph had Pooled analysis of four studies
patient expectations. Many studies grade 3 or 4 chondromalacia intra- found that the WOMAC score in the
have associated cartilage degenera- operatively, suggesting that the false- FAI-OA group was significantly
tion with an increased risk of less negative rate of plain radiographic lower than that in the FAI group.
favorable outcomes. The presence of OA evaluation is high. In addition, After summarizing the reported other
OA established by preoperative plain Larson et al found that the group postoperative outcomes, such as
radiograph has been reported as an of patients with these high-grade mHHS, HHS, SF-12, and VAS score,
important negative prognostic factor defects performed inferiorly to we found that the existence of OA
for postoperative functional result in counterparts without lesions on decreased improvement in pain or
FAI patients.2,12,13 Generally, patients MRI. Given the sensitivity of MRI to function.
with Tönnis grade 1 and 2 coxarth- soft-tissue deformity, this imaging There were some limitations for this
rosis have had significantly poorer modality may be a better choice for meta-analysis. First, the Tönnis grade
results in terms of range of motion, preoperative OA assessment than or joint space width was not com-
visual analog scale score, and NAHS plain radiography. The prognostic prehensive enough to define the
than those without it.10 However, value of MRI findings such as sub- severity of OA. Plain radiographic
studies that evaluate the failure rate chondral edema, cysts, cartilage thin- could not precisely assess articular le-
of surgical interventions specifically ning, and cartilage flaps has not yet sions associated with OA. Second,
for the management of FAI with the been fully elucidated. among the included studies, Larson
January 15, 2019, Vol 27, No 2 e75
et al defined Tönnis grade 0 to grade 1 References printed in bold type are treatment of femoro-acetabular impingement:
A prospective study after a mean follow-up of
as FAI without OA group, whereas in those published within the past 5 4.6 (4.2-5.5) years. Orthop Traumatol Surg
the other studies, Tönnis grade 0 was years. Res 2014;100:651-656.
defined as FAI without OA group. In 1. Byrd JW, Jones KS: Prospective analysis of 12. Saadat E, Martin SD, Thornhill TS,
addition, different surgical approaches hip arthroscopy with 10-year followup. Brownlee SA, Losina E, Katz JN: Factors
were used to treat FAI for the included Clin Orthop Relat Res 2010;468:741-746. associated with the failure of surgical
treatment for femoroacetabular
studies. These differences may increase 2. Horisberger M, Brunner A, Herzog RF: impingement: Review of the literature. Am J
the heterogeneity of this meta-analysis. Arthroscopic treatment of femoral Sports Med 2014;42:1487-1495.
acetabular impingement in patients with
Third, we did not consider the influ- preoperative generalized degenerative 13. Philippon MJ, Briggs KK, Yen YM,
ence of age on OA progression and changes. Arthroscopy 2010;26:623-629. Kuppersmith DA: Outcomes following hip
arthroscopy for femoroacetabular
poor prognosis of postoperative 3. Larson CM, Giveans MR, Taylor M: Does impingement with associated
functional result of FAI for the insuf- arthroscopic FAI correction improve chondrolabral dysfunction: Minimum two-
function with radiographic arthritis? Clin year follow-up. J Bone Joint Surg Br 2009;
ficient data in this meta-analysis. Orthop Relat Res 2011;469:1667-1676. 91:16-23.
Finally, the quality of included stud-
4. Jerosch J, Schunck J, Khoja A: 14. Loeuille D: When should MRI for knee or
ies were low for randomized control Arthroscopic treatment of the hip in early hip osteoarthritis should be performed?
trials regarding this topic were lack- and midstage degenerative joint disease. [French]. Rev Prat 2012;62:625-629.
Knee Surg Sports Traumatol Arthrosc
ing. Additional high-quality evidence 2006;14:641-645. 15. Palmer DH, Ganesh V, Comfort T, Tatman
is required. Nevertheless, this meta- P: Midterm outcomes in patients with cam
5. Slim K, Nini E, Forestier D, Kwiatkowski F,
analysis revealed that the presence of Panis Y, Chipponi J: Methodological index
femoroacetabular impingement treated
arthroscopically. Arthroscopy 2012;28:
established OA emerged as an for non-randomized studies (minors):
1671-1681.
important negative prognostic factor Development and validation of a new
instrument. ANZ J Surg 2003;73:712-716. 16. Jayakar R, Merz A, Plotkin B, Wang D,
for functional result of FAI patients. Seeger L, Hame SL: Magnetic resonance
6. Skendzel JG, Philippon MJ, Briggs KK,
In conclusion, cartilage status is a arthrography and the prevalence of
Goljan P: The effect of joint space on
major prognostic factor, and we acetabular labral tears in patients 50
midterm outcomes after arthroscopic hip
years of age and older. Skeletal Radiol
would not recommend arthroscopy surgery for femoroacetabular impingement.
2016;45:1061-1067.
Am J Sports Med 2014;42:1127-1133.
in cases of evolved OA. In early
7. Ribas M, Ledesma R, Cardenas C, Marin- 17. Philippon MJ, Briggs KK, Carlisle JC,
arthritis, results are moderately good, Patterson DC: Joint space predicts THA
Pena O, Toro J, Caceres E: Clinical results
and it is not clear that arthroscopy after anterior mini-open approach for after hip arthroscopy in patients 50 years
and older. Clin Orthop Relat Res 2013;
does not accelerate deterioration of femoroacetabular impingement in early
degenerative stage. Hip Int 2010;20(suppl 471:2492-2496.
the hip and clinical symptoms when 7):S36-S42.
18. Amin S, LaValley MP, Guermazi A, et al:
performed in the setting of OA, and it
8. Philippon MJ, Schroder E, Souza BG, The relationship between cartilage loss on
may be considered on a case-by-case Briggs KK: Hip arthroscopy for magnetic resonance imaging and
basis, taking patient age into account. femoroacetabular impingement in patients radiographic progression in men and
aged 50 years or older. Arthroscopy 2012; women with knee osteoarthritis. Arthritis
28:59-65. Rheum 2005;52:3152-3159.
References 9. Gedouin JE, May O, Bonin N, et al: 19. Laude F, Sariali E, Nogier A:
Assessment of arthroscopic management of Femoroacetabular impingement
femoroacetabular impingement: A treatment using arthroscopy and anterior
Evidence-based Medicine: Levels of approach. Clin Orthop Relat Res 2009;
prospective multicenter study. Orthop
evidence are described in the table of Traumatol Surg Res 2010;96:S59-S67. 467:747-752.
contents. In this article, references 6, 20. Gedouin JE, Duperron D, Langlais F,
10. Stähelin L, Stahelin T, Jolles BM, Herzog
9, and 11 are level II studies. Refer- RF: Arthroscopic offset restoration in Thomazeau H: Update to femoroacetabular
ences 3, 5, 7, 12, and 17 are level III femoroacetabular cam impingement: impingement arthroscopic management.
Accuracy and early clinical outcome. Orthop Traumatol Surg Res 2010;96:
studies. References 1, 2, 4, 8, 10, 13, Arthroscopy 2008;24:51-57.e8. 222-227.
15, 16, and 18–21 are level IV
11. Gicquel T, Gedouin JE, Krantz N, May O, 21. Walton NP, Jahromi I, Lewis PL: Chondral
studies. Reference 14 is a level V Gicquel P, Bonin N: Function and degeneration and therapeutic hip
report or expert opinion. osteoarthritis progression after arthroscopic arthroscopy. Int Orthop 2004;28:354-356.
Research Article
Patient and Practice Trends in Total

Ankle Replacement and Tibiotalar
Arthrodesis in the United States
From 2007 to 2013
Abstract
Venus Vakhshori, MD Introduction: Both total ankle replacement (TAR) and tibiotalar
Andrew F. Sabour, BS arthrodesis (TTA) are used in the surgical management of ankle
arthritis. Over the past decade, TAR instrumentation, techniques, and
Ram K. Alluri, MD
implants have improved, making the procedure more reliable and
George F. Hatch III, MD reproducible, thus making TAR more common.
Eric W. Tan, MD Methods: The Nationwide Inpatient Sample database from 2007 to
2013 was used to obtain data on patients elder than 50 years who
underwent either TAR or TTA. Differences in temporal, demographic,
and diagnosis trends between TAR and TTA were analyzed.
Results: Between 2007 and 2013, 15,060 patients underwent TAR
and 35,096 underwent TTA. Patients undergoing TTA had
significantly more comorbidities (2.17 versus 1.55; P , 0.001). The
share of TAR performed increased significantly from 2007 (14%) to
2013 (45%) (P , 0.001). From 2007 to 2013, we found a 12-fold
increase in the odds of having a TAR for patients with posttraumatic
osteoarthritis (P , 0.001), a 4.9-fold increase for those with primary
osteoarthritis, and a 3.1-fold increase for patients with rheumatoid
arthritis (P , 0.001).
Conclusions: Over the past decade, the frequency of TAR has
increased, particularly in patients with posttraumatic arthritis and
osteoarthritis. Surgeons still perform TAR in healthier patients
compared with TTA; however, because surgeons become more
experienced with the technique, patients are undergoing TAR at a
markedly higher rate.
Level of Evidence: Level III: retrospective comparative study

Surgery, Keck School of Medicine of
the University of Southern California,
Los Angeles, CA.
E nd-stage arthritis of the ankle
joint results in notable pain, dis-
ability, and resultant socioeconomic
the historic treatment of choice.1
However, TTA has a unique set of
complications, including adjacent
Correspondence to Dr. Vakhshori: and medical costs. These patients are joint degeneration with continued
venus.vakhshori@med.usc.edu often initially treated with conserva- pain, disability, activity limitation,
J Am Acad Orthop Surg 2019;27: tive therapies including nonsteroidal and persistent gait alterations.1-5
e77-e84 anti-inflammatory medications, joint In the 1970s, total ankle replace-
DOI: 10.5435/JAAOS-D-17-00526 injections, activity modification, ment (TAR) was introduced. Early
bracing treatment, and physical designs were complicated by severe
Academy of Orthopaedic Surgeons. therapy. When these methods fail, osteolysis, loosening, impingement,
tibiotalar arthrodesis (TTA) has been infection, and soft-tissue breakdown
January 15, 2019, Vol 27, No 2 e77
Patient and Practice Trends in Total Ankle Replacement and Tibiotalar Arthrodesis
and therefore were not readily im- in a number of recent database stud- accepted relative contraindication
plemented in management of ankle ies.12-15 However, these studies have for TAR, because younger, more
arthritis.2,6 More recent implants not specifically evaluated the trends active patients may place excessive
developed in the 1980s and 1990s in TAR compared with TTA with demand on the implants, which may
more closely replicate the ankle’s respect to indications and patient result in premature failure or need
natural anatomy and biomechanics and hospital specific factors. The for revision.2,6
and thereby provide improved func- purpose of this study was to eluci- Subjects were categorized based
tion with decreased wear and loos- date these trends in the use of TAR on the surgical procedure. Hospital
ening.2,6 Advances in technology, compared with TTA in a nationwide variables including bed number, gov-
surgical instrumentation, and implant database. ernment (public) or private (investor-
design, including the introduction of owned or not-for-profit) ownership,
mobile bearing articulations and and location were identified. Bed size
partially conforming surfaces, allow Methods categories are determined by
decreased constraint and prosthesis- Healthcare Cost and Utilization Pro-
bone interface stress, improving re- Data ject and vary based on region of the
sults and reproducibility.6 Using the Nationwide Inpatient country and teaching or nonteaching
Compared with TTA, TAR has Sample (NIS), Healthcare Cost and status. Rural versus urban status is
similar clinical outcomes and compli- Utilization Project, Agency for based on 2000 US Census data.16
cations with some reports describing Healthcare Research and Quality Demographic variables, comorbidities,
an increased risk of revision surgery discharge records, a retrospective patient location, length of stay, median
and others with lower complication review was performed from 2007 to household income, and primary pay-
rates; however, no randomized con- 2013 to identify patients who ment method were assessed for each
trolled trials comparing the two have underwent a TAR or TTA. The NIS group. Specific comorbidities such as
been performed and many studies includes about 20% of the approxi- hypertension, depression, diabetes,
report unequal baseline character- mately 37 million annual discharges diabetes with complications (diabetes
istics.7-11 A systematic review of in the United States and is the largest with ketoacidosis, hyperosmolarity,
intermediate and long-term out- inpatient database in the United coma, renal manifestations, ophthal-
comes by Haddad et al8 reported States.16,17 Using International mic manifestations, neurologic mani-
that 68.5% of patients with TAR Classification of Diseases, 9th edi- festations, or peripheral circulatory
have excellent or good American tion (ICD-9) codes, patients who disorders), obesity (body mass index .
Orthopaedic Foot and Ankle Society underwent a primary procedure of 30), peripheral vascular disorders,
ankle-hindfoot scores, compared TAR (81.56) or ankle arthrodesis and renal failure were also identified.
with 68.0% of patients with TTA. A (81.11) were identified. Revision The frequency of concomitant pro-
recently published meta-analysis by procedures (81.59) and patients who cedures as indicated by ICD-9 pro-
Kim et al9 reports no difference in had both arthroplasty on one cedure codes was determined for
the American Orthopaedic Foot and extremity and TTA on the contra- each group. These variables were
Ankle Society ankle-hindfoot score, lateral extremity were excluded. All compared by surgical procedure over
Short Form-36 physical and mental patients included in the study had a the entire study period.
component scores, visual analog concomitant diagnosis of tibiotalar To determine temporal changes,
scale for pain and patient satisfac- arthritis. Patients who died during the frequency of TAR and TTA was
tion; however, patients with TAR their hospitalization were excluded assessed for each year of the data-
were 81% more likely to have a from our analysis. Patients younger base. The frequency of TAR was
revision surgery. than 50 years were excluded to avoid determined for patients with post-
Nonetheless, the use of TAR is selection bias favoring TTA because traumatic osteoarthritis, primary
rapidly increasing as demonstrated age above 50 years is a commonly osteoarthritis, rheumatoid arthritis,
Dr. Alluri or an immediate family member has stock or stock options held in Axogen, Medtronic, Stryker, and Zimmer Biomet and has
received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such
as paid travel) from Acumed, Arthrex, and Trimed. Dr. Hatch or an immediate family member is a member of a speakers’ bureau or has made
paid presentations on behalf of and serves as a paid consultant to Arthrex. Dr. Tan or an immediate family member is a member of a
speakers’ bureau or has made paid presentations on behalf of Arthrex and serves as a board member, owner, officer, or committee member
of the American Academy of Orthopaedic Surgeons and the American Foot Ankle Society. Neither of the following authors nor any
immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution
related directly or indirectly to the subject of this article: Dr. Vakhshori and Mr. Sabour.
Venus Vakhshori, MD, et al
and comorbid diabetes, hyperten- Figure 1

sion, and coronary artery disease for
2007 compared with 2013. Incidence
per capita was calculated using 2010
US Census data for patients elder
than 50 years.
Statistical Analysis
Univariate analysis compared patient
demographics, preoperative co-
morbidities, inpatient variables, and
hospital variables between groups.
The Student t-test compared contin-
uous variables. The Fisher exact test
or chi-square analysis compared
Graph showing annual incidence of total ankle arthroplasty compared with
categorical variables. Preoperative tibiotalar arthrodesis.
comorbidities with P , 0.05 and
prevalence .0.5% were included
in a logistic regression for multivar- 5.68 days) than in those with TAR surgery in patients receiving TAR
iate analysis. A P value ,0.05 was (2.28 6 1.41 days) (P , 0.001). In were implant removal (9.8%), gas-
considered significant. addition, the proportion of patients trocnemius recession (7.7%), and
with Medicare and private insurance subtalar fusion (5.8%), whereas for
receiving TAR (94.5%) was signif- those receiving TTA, the most
Results icantly higher than those receiving common concomitant procedures
TTA (87.4%), whereas the oppo- were implant removal (21.7%), sub-
From 2007 to 2013, an initial cohort site was true for Medicaid patients talar fusion (9.6%), and application
of 50,156 patients elder than 50 years (1.4% for TAR compared with of a tibia and/or fibula external
who underwent either TTA or TAR 5.8% for TTA) (P , 0.001). Sim- fixation device (4.5%) (Table 4).
was identified. TTA was performed ilarly, patients with higher than Analysis of primary diagnosis
in 35,096 patients (69.9%), and TAR median household income were demonstrated that from 2007 to
was performed in 15,060 patients more likely to receive TAR (P , 2013, we noticed a 12.1-fold increase
(30.1%). From 2007 to 2013, the 0.001) (Table 1). Further demo- in the odds of having a TAR in pa-
yearly incidence of TAR per capita graphic and hospital information tients with posttraumatic osteo-
increased 421% from 0.86/100,000 is presented in Tables 1 and 2, arthritis (P , 0.001), a 4.9-fold
to 3.66/100,000, whereas the inci- respectively. increase for those with primary
dence of TTA per capita de- With regard to patient-specific vari- osteoarthritis (P , 0.001), and a
creased 18% from 5.37/100,000 to ables, TAR was performed in healthier 3.1-fold increase for patients with
4.40/100,000 (P , 0.001) (Figure 1). patients who had an average of rheumatoid arthritis (P , 0.001).
As a percentage of total procedures 1.55 comorbidities, compared with Furthermore, patients with combined
performed, TAR increased from patients who underwent TTA who comorbid diagnoses of diabetes,
14% in 2007 to 45% in 2013 had an average of 2.17 comorbidities hypertension, and coronary artery
(P , 0.001). The patients in the (P , 0.001). Patients with alcohol disease were 4.7 times more likely to
TAR group were older (mean age, abuse, anemia, depression, diabetes receive TAR in 2013 compared with
65.5 6 8.68 years) than those in the with or without chronic complica- 2007 (P , 0.001) (Table 5).
TTA group (mean age, 63.7 6 8.95 tions, obesity, peripheral vascular
years) (P , 0.001). No significant disease, psychoses, and renal failure
difference was found in sex between were all more likely to receive TTA Conclusions
the two groups (48.9% female un- compared with TAR in univariate
derwent TTA, 50.0% female under- and multivariate analysis (P , 0.01 Ankle arthritis is a debilitating con-
went TAR; P = 0.32). for each comorbidity) (Table 3). dition that results in pain and
The length of stay was significantly The most common concomitant pro- decreased function. For patients refrac-
longer in patients with TTA (3.43 6 cedures performed at the time of tory to conservative management,
January 15, 2019, Vol 27, No 2 e79
Table 1
Demographic and Patient-specific Variables in Patients Receiving TTA and TAR
Arthrodesis (TTA), Arthroplasty (TAR),
Demographics N = 35,096 (%) N = 15,060 (%) P Value
Age (mean, yr) 63.7 6 8.95 65.5 6 8.68 ,0.001

Sex (female) 17,100 (48.9) 7,520 (50.0) 0.319
Race ,0.001
White 24,000 (84.6) 11,000 (88.4) —
Black 1,800 (6.3) 373 (3.0) —
Hispanic 1,480 (5.2) 441 (3.6) —
Asian or Pacific Islander 288 (1.0) 149 (1.2) —
Native American 118 (0.4) 63 (0.5) —
Other 699 (2.5) 414 (3.3) —
Primary payment method ,0.001
Medicare 17,500 (50.0) 8,140 (54.2) —
Medicaid 2,020 (5.8) 209 (1.4) —
Private 1,310 (37.4) 6,060 (40.3) —
Self-pay 383 (1.1) 89 (0.4) —
No charge or other 2,011 (5.7) 560 (3.7) —
Median household income ,0.001
0-25th percentile 7,910 (23.0) 2,570 (17.4) —
26-50th percentile 9,460 (27.5) 3,670 (24.9) —
51-75th percentile 8,880 (25.9) 4,010 (27.3) —
70-100th percentile 8,090 (23.6) 4,480 (30.4) —
TAR = total ankle replacement, TTA = tibiotalar arthrodesis
arthrodesis has long been an option Practice patterns have shifted in the The rise in TAR is multifactorial.
for this condition, but leads to last decade toward favoring arthro- Improved instrumentation and im-
noticeably altered gait mechanics plasty. From 1995 to 2004, arthro- plants resulting in improved clinical
and velocity, decreased range of desis was performed nearly 10 times outcomes and increased experience
motion, and resultant osteoarthritis more often than arthroplasty in Cal- with the procedure have contributed
of the adjacent joints. 1,3 Total ifornia.10 Our study demonstrates to this change in practice patterns. In
ankle arthroplasty aims to address a relative increase in the rate of the United States, the availability
the drawbacks of arthrodesis. After arthroplasty compared with arthro- of implant systems was extremely
arthroplasty, patients have im- desis, with arthroplasty accounting limited until just over a decade ago.
proved range of motion with less for 14% of the procedures for ankle Before 2005, the only Food and
load on surrounding joints and arthritis in 2007, to just under 50% Drug Administration-approved ankle
improved gait.2,4-6 Benefits of ar- by 2013. Terrell et al14 found an arthroplasty systems in the United
throplasty in the perioperative pe- increase in total ankle arthroplasty States were the Beuchel-Pappas TAR
riod have been reported and include from 0.63 per 10,000 in 2004 to (Endotec) introduced in the 1980s,
lower blood transfusion rates and 0.99 per 10,000 patients in 2009, a and the Agility Total Ankle System
lower rates of nonhome discharge.18 nearly 40% increase. This trend is (DePuy) prosthesis, approved in
However, arthroplasty is not with- also seen in the Medicare pop- 1992.2,20 The early outcomes of these
out its own limitations. Several ulation, in which the arthroplasty implants, especially the first-generation
studies have found similar patient volume increased over 12-fold from implants, were discouraging. Less
satisfaction and clinical outcomes 1991 to 2010, whereas arthrodesis comprehensive understanding of the
but increased risk of major surgical volume increased by only 36%, with ankle biomechanics, implant constraint
complications and revision surgery nearly 4 times as many US hospitals and bone-implant interface, and lim-
with arthroplasty.7-9,10,11,13,19 performing arthroplasty by 2010.12 ited surgeon experience led to high
Table 2
Hospital Variables and Length of Stay in Patients Receiving TTA and TAR
Hospital Variables N = 35,096 (%) N = 15,060 (%) P Value
Length of stay (mean, d) 3.43 6 5.68 2.28 6 1.41 ,0.001

Bed size of the hospital ,0.001
Small 4,920 (14.2) 3,060 (20.4) —
Medium 8,510 (24.5) 3,660 (24.4) —
Large 21,300 (61.3) 8,270 (55.2) —
Ownership of hospital ,0.001
Government (public) 18,580 (72.4) 5,448 (65.9) —
Private (investor-owned or not-for-profit) 7,080 (27.6) 2,822 (34.1) —
Hospital setting ,0.001
Rural 1,760 (6.8) 286 (3.5) —
Urban 23,900 (93.2) 7,980 (96.5) —
Table 3
Univariate and Multivariate Analysis of Preoperative Comorbidities in Patients Receiving TTA and TAR
Arthrodesis Arthroplasty Univariate Multivariate
Preoperative (TTA), N = 35,096 (TAR), N = 15,060 P OR (TAR/ P OR (TAR/ P
Comorbidities (%) (%) Value TTA) Value TTA) Value
Total comorbidities 2.17 6 1.69 1.55 6 1.31 ,0.001 — — — —

Alcohol abuse 578 (1.6) 122 (0.8) 0.001 0.49 ,0.001 0.48 ,0.001
Anemia 3,950 (11.3) 778 (5.2) ,0.001 0.43 ,0.001 0.63 ,0.001
Depression 4,760 (13.6) 1,730 (11.5) 0.004 0.83 ,0.001 0.88 ,0.001
Diabetes 6,560 (18.7) 1,810 (12.0) ,0.001 0.59 ,0.001 0.57 ,0.001
(uncomplicated)
Diabetes (with chronic 3,770 (10.7) 144 (1.0) ,0.001 0.08 ,0.001 0.10 ,0.001
complications)
Hypertension 22,600 (64.4) 8,830 (58.6) ,0.001 0.78 ,0.001 1.04 0.022
Hypothyroidism 4,270 (12.2) 2,050 (13.6) 0.043 1.14 ,0.001 1.24 ,0.001
Liver disease 637 (1.8) 197 (1.3) 0.089 0.72 ,0.001 0.91 0.265
Obesity 6,680 (19.0) 1,850 (12.3) ,0.001 0.59 ,0.001 0.71 ,0.001
Peripheral vascular 1,370 (3.9) 252 (1.7) ,0.001 0.42 ,0.001 0.66 ,0.001
disorders
Psychoses 1,040 (3.0) 284 (1.9) 0.001 0.63 ,0.001 0.69 ,0.001
Renal failure 3,110 (8.9) 424 (2.8) ,0.001 0.30 ,0.001 0.59 ,0.001
Rheumatoid arthritis/ 2,070 (5.9) 881 (5.9) 0.963 0.99 ,0.001 0.97 0.471
collagen vascular
disease
OR = odds ratio, TAR = total ankle replacement, TTA = tibiotalar arthrodesis
rates of complications and limited previous implant designs and in- Technology) in 2005, the Salto
functional benefits.21,22 Since 2005, strumentation, have been intro- Talaris Anatomic Ankle (Integra
current-generation ankle replace- duced including the INBONE Total LifeSciences) in 2006, the Scandina-
ments, which have improved on Ankle System (Wright Medical vian TAR (Stryker) in 2009, and the
January 15, 2019, Vol 27, No 2 e81
Table 4
Number and Frequency of Concomitant Procedures in Patients Receiving TAR and TAA
Concomitant Procedures N = 35,096 (%) N = 15,060 (%) P Value
Removal of implanted device from bone, tibia, 7,617 (21.7) 1,474 (9.8) ,0.0001
and fibula
Removal of implanted devices from bone, tarsals, 952 (2.7) 335 (2.2) 0.001
and metatarsals
Subtalar fusion 3,370 (9.6) 880 (5.8) ,0.0001
Tarsometatarsal fusion 398 (1.1) 102 (0.7) ,0.0001
Triple arthrodesis 194 (0.6) 129 (0.9) ,0.0001
Arthrodesis of other specified joints 349 (1.0) 220 (1.5) ,0.0001
Tendon transfer or transplantation 381 (1.1) 202 (1.3) 0.016
Gastrocnemius recession 635 (1.8) 1,165 (7.7) ,0.0001
Achilles tendon lengthening 409 (1.2) 166 (1.1) 0.583
Application of external fixator device, tibia, and 1,575 (4.5) 79 (0.5) ,0.0001
fibula
Application of external fixator device, ring system 1,165 (3.3) 21 (0.1) ,0.0001
Table 5
Change in Incidence for Patients Receiving TAR From 2007 to 2013 Based on Primary Diagnosis
Diagnosis % TAR (2007) % TAR (2013) Odds Ratio (2013/2007) P Value
Posttraumatic osteoarthritis 9.3 55.5 12.1 ,0.001

Primary osteoarthritis 25.6 62.9 4.9 ,0.001
Rheumatoid arthritis 25.5 51.4 3.1 ,0.001
Comorbid DM 1 HTN 1 CAD 12.6 40.3 4.7 ,0.001
CAD = coronary artery disease, DM = diabetes, HTN = hypertension, TAR = total ankle replacement
Zimmer Trabecular Total Ankle phenomenon may be due to patients In our study, the increase in rate of
(Zimmer Biomet) in 2013.20,23 The with Medicaid living in rural areas arthroplasty is most notable for pa-
improvements in technology, in- with limited access to tertiary centers tients with posttraumatic arthritis
creased reproducibility, and wider that perform arthroplasty or reim- who had a 12-times increase in the
range of options for arthroplasty bursement patterns discouraging the odds of undergoing arthroplasty in
have likely contributed to the recent use of arthroplasty because of cost.24-26 2013 compared with 2007. More
increase in TARs. Interestingly, the proportion of pa- modest increases were seen for
Our data show that in this cohort tients receiving arthroplasty at a arthroplasty in primary osteoarthritis
of patients (age . 50 years), arthro- small hospital is larger than those (4.9-fold increase) and rheumatoid
plasty is more commonly performed receiving arthrodesis at a small hos- arthritis (3.1-fold increase). Patients
in older, white patients in private pital; the opposite is true for large with primary osteoarthritis, post-
hospitals in urban settings compared hospitals. This is potentially due to traumatic arthritis, and rheumatoid
with arthrodesis. This finding is patients receiving arthrodesis being arthritis have all been reported to
consistent with other database studies more medically complex and conse- have good outcomes after total ankle
reporting that patients with Medicare quently being treated at large referral arthroplasty.27-29 This likely reflects
or private insurance are three times centers. Further research is needed to both increasing surgeon experience
more likely to undergo arthroplasty elucidate the reasons behind hospital and comfort with arthroplasty in
than do those with Medicaid.24 This size and treatment choice. varying circumstances in addition to
improved surgical instrumentation, monly in the outpatient setting, many

techniques, and implants. patients have at least an overnight
References
The data from our cohort suggest hospital stay, with an average
that arthroplasty was generally reported length of stays of two to
limited to healthier patients. Patients four nights.18,30-33 The move to-
contents. In this article, references 4,
with medical comorbidities were ward outpatient arthroplasty and
7, 24, and 26 are level II studies.
more likely to undergo arthrodesis arthrodesis is recent, and it is possi-
References 1, 3, 9, 10-12, 15, 18, 27,
than arthroplasty, and patients who ble that by not capturing outpatient
and 29-33 are level III studies. Ref-
received an arthrodesis had a higher procedures, our data are most likely
erences 5, 8, 13, 14, 19, 21, 22, and
number of average comorbidities. In understating the growth of arthro-
28 are level IV studies. References 2,
both univariate and multivariate plasty from 2007 to 2013. In addi-
6, 17, 20, 23, and 25 are level V
analysis, patients with alcohol abuse, tion, outcome data are not provided
report or expert opinion.
anemia, depression, diabetes, obe- in the NIS database, and therefore,
sity, peripheral vascular disease, no follow-up data exist to determine References printed in bold type are
psychoses, or renal failure were all clinical results of either intervention. those published within the past 5
more likely to receive arthrodesis. With respect to concomitant proce- years.
These differences likely reflect sur- dures performed, these are listed
1. Coester LM, Saltzman CL, Leupold J,
geon preference to perform arthro- in the NIS by ICD-9 procedure Pontarelli W: Long-term results following
desis over arthroplasty in medically code, which is less descriptive than ankle arthrodesis for post-traumatic
arthritis. J Bone Joint Surg Am 2001;83-A:
complex patients to potentially de- Current Procedure Terminology 219-228.
crease surgical time and risk of revi- codes. Finally, this database study
2. Bonasia DE, Dettoni F, Femino JE, Phisitkul
sion surgery.7,9 The increased length allows us to draw only correlative P, Germano M, Amendola A: Total ankle
of stay and rate of nonhome discharge associations, and we cannot con- replacement: Why, when and how? Iowa
Orthop J 2010;30:119-130.
in patients with arthrodesis may be clude the reasons behind trends
related to medical comorbidities and in practice patterns. However, this 3. Thomas R, Daniels TR, Parker K: Gait
analysis and functional outcomes following
patient demographics rather than the study does provide valuable infor- ankle arthrodesis for isolated ankle
particular procedure being performed. mation regarding national trends arthritis. J Bone Joint Surg Am 2006;88:
Although patients with more co- regarding the use of arthroplasty 526-535.
morbidities are more likely to receive compared with arthrodesis for ankle 4. Singer S, Klejman S, Pinsker E, Houck J,
Daniels T: Ankle arthroplasty and ankle
an arthrodesis, arthroplasty volume arthritis.
arthrodesis: Gait analysis compared with
is expanding. Furthermore, patients In conclusion, this study demon- normal controls. J Bone Joint Surg Am
with comorbid hypertension, diabe- strates an increased national inci- 2013;95:e191(1-10).
tes, and coronary artery disease had dence of TAR compared with TTA 5. Pedowitz DI, Kane JM, Smith GM, Saffel
seen a 4.7-fold increase in the rate of from 2007 to 2013. Patients who HL, Comer C, Raikin SM: Total ankle
arthroplasty versus ankle arthrodesis: A
arthroplasty in 2013 compared with may have previously not been candi- comparative analysis of arc of movement
2007. This increase is likely the result dates for arthroplasty are now more and functional outcomes. Bone Joint J
2016;98-B:634-640.
of improvements in the implant design likely to undergo the procedure. The
and outcomes and increased surgeon largest changes were seen in patients 6. Easley ME, Vertullo CJ, Urban WC,
Nunley JA: Total ankle arthroplasty. J Am
experience with arthroplasty, allow- with posttraumatic osteoarthritis, Acad Orthop Surg 2002;10:157-167.
ing surgeons to perform arthroplasty primary osteoarthritis, and rheuma-
7. Daniels TR, Younger ASE, Penner M, et al:
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It is important to recognize the is typically performed in healthier replacement and ankle arthrodesis: A
COFAS multicenter study. J Bone Joint
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8. Haddad SL, Coetzee JC, Estok R, Fahrbach
vational review of a national data- morbidities. Arthroplasty is more K, Banel D, Nalysnyk L: Intermediate and
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is subject to inaccuracies in coding. with Medicare or private insurance, arthroplasty and ankle arthrodesis: A
systematic review of the literature. J Bone
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9. Kim HJ, Suh DH, Yang JH, et al:
throplasty performed in an outpatient TAR and TTA are necessary to Total ankle arthroplasty versus ankle
setting is not captured. Although determine the ideal surgical proce- arthrodesis for the treatment of end-stage
ankle arthritis: A meta-analysis of
ankle arthroplasty and arthrodesis are dure for patients with end-stage ankle comparative studies. Int Orthop 2017;41:
slowly being performed more com- arthritis. 101-109.
January 15, 2019, Vol 27, No 2 e83
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ankle arthrodesis and total ankle total ankle arthroplasty from 2002 to 2011. patients with rheumatoid arthritis and
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Swedish Ankle Registry: Self-reported der Heide HJL: The mid-term outcome of
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JK: Total ankle arthroplasty outcome
population. Foot Ankle Int 2014;35: Orthop 1981;160:217-221.
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30. Mulligan RP, Parekh SG: Safety of
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York state. Orthopedics 2016;39:170-176. Osteoarthritis of the ankle: The role of traditional inpatient admission or overnight
arthroplasty. J Am Acad Orthop Surg observation. Foot Ankle Int 2017;38:
14. Terrell RD, Montgomery SR, Pannell WC,
2008;16:249-259. 825-831.
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total ankle replacement and ankle fusion in 24. Heckmann N, Bradley A, Sivasundaram L, 31. Basques BA, Bitterman A, Campbell KJ,
the United States. Foot Ankle Int 2013;34: Alluri RK, Tan EW: Effect of insurance on Haughom BD, Lin J, Lee S: Influence of
1486-1492. rates of total ankle arthroplasty versus surgeon volume on inpatient complications,
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Bone Joint Surg Am 2016;98:1453-1458. Spang JT, Lin F-C, Kamath GV: A regional 32. Gonzalez T, Fisk E, Chiodo C, Smith J,
16. HCUP National Inpatient Sample (NIS): assessment of medicaid access to outpatient Bluman EM: Economic analysis and patient
Healthcare Cost and Utilization Project orthopaedic care: The influence of satisfaction associated with outpatient total
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Research Article
Recurrent Fragility Fractures:

A Cross-sectional Analysis
Abstract
Debbie Y. Dang, MD, PhD Introduction: Despite growing rates of fragility fractures, there has
Samuel Zetumer, BA been a lack of research investigating the risk and characteristics of
recurrent fragility fractures.
Alan L. Zhang, MD
Methods: The Medicare Standard Analytic Files database was used
to identify patients from 2005 to 2009 who were older than 65 years,
had a diagnosis of osteoporosis or osteopenia, and sustained a
fragility fracture of the proximal humerus, distal radius, hip, ankle, or
vertebral column. The incidence and type of recurrent fragility fracture
were tracked over a 36-month period.
Results: A total of 1,059,212 patients had an initial fragility fracture
from 2005 to 2009. Of these patients, 5.8% had a subsequent fragility
fracture within 1 year for their initial fracture, 8.8% within 2 years, and
11.3% within 3 years. At 3-year follow-up, hip fractures were the most
common type of subsequent fracture, regardless of the initial fracture
type (6.5%, P , 0.001). Vertebral compression and proximal
humerus fractures (13.8% and 13.2%, respectively) were most likely
to be associated with a recurrent fragility fracture.
Conclusion: Patients who have any type of fragility fracture have a
notable risk of subsequent fractures within 3 years, especially hip
fractures. These patients should be evaluated and treated for
underlying risks factors, including osteoporosis and/or osteopenia.
Level of Evidence: Retrospective, level III
Surgery, University of California, San
Francisco, San Francisco, CA.
Correspondence to Dr. Zhang:
Alan.Zhang@ucsf.edu
Dr. Zhang or an immediate family
F ragility fractures that result from
low-impact events, such as a fall
from standing height, typically affect
tion, nor does it account for the
number of men hospitalized for a
fragility fracture. Thus, the total
member serves as a board member, the elderly and individuals with poor incidence of fragility fractures is ex-
of the American Orthopaedic Society
bone quality. There are increasing pected to be even higher. In fact, the
for Sports Medicine. Neither of the numbers of older adults in developed National Ambulatory Medical Care
following authors nor any immediate countries, and accordingly, there has Survey showed more than 4 million
family member has received anything been an increase in disease burden outpatient fragility fracture visits in
options held in a commercial company
from fragility fractures.1 In its most 2010 and 2011, more than 80% of
or institution related directly or recent review of musculoskeletal which were for nonhospital dis-
indirectly to the subject of this article: disease burden, the United States charges.2,3 This underscores the high
Dr. Dang and Mr. Zetumer. Bone and Joint Initiative notes there incidence of all fragility injuries—
J Am Acad Orthop Surg 2019;27: were 1.7 million hospitalizations due both those that require and those
e85-e91 to fragility fractures in women older that do not require hospitalization.
DOI: 10.5435/JAAOS-D-17-00103 than 55 years in 2011.2 This number For the individual, fragility frac-
does not account for the number of tures are associated with increased
Academy of Orthopaedic Surgeons. individuals who sustain a fragility morbidity and mortality. There is a
fracture not requiring hospitaliza- 6% in-hospital mortality rate and a
January 15, 2019, Vol 27, No 2 e85
Recurrent Fragility Fractures
Table 1 identified International Classification

of Diseases, 9th Revision (ICD-9)
ICD-9 Codes Used
codes.19 The SAF file used in this study
Factor Codes Used was derived from all inpatient and
Fractures (ICD-9-D-) outpatient records billed to Medicare
parts A and B from 2005 to 2012.
Ankle fractures 824.0, 824.2, 824.4, 824.6, 824.8
Distal radius fractures 813.40, 813.41, 813.42, 813.44, 813.45, 813.47
Hip fractures 820.00, 820.01, 820.02, 820.03, 820.09, 820.20, Study Population
820.21, 820.22
Records from 39 million patients in
Proximal humerus 812.00, 812.01, 812.02, 812.03, 812.09 the SAF database older than 65 years
fractures
were used for this study. To capture
Vertebral compression 805.2, 805.4
fractures fragility fracture and exclude trau-
Other diagnoses matic fractures, only patients aged 65
(ICD-9-D-) years or older with an osteoporosis or
Osteoporosis 733.00, 733.01, 733.02 osteopeniaICD-9 diagnosis code and a
Osteopenia 733.90 fracture code as a primary diagnosis
were considered to have had a fragility
ICD = International Classification of Diseases fracture. The codes used to capture
these values are shown in Table 1. We
30% 1-year mortality rate for those independent predictor of a future queried records from 2005 to 2009 for
who sustain a hip fracture.4 Patients fragility fracture.12,13 initial index fragility fractures so that
who survive a hip fracture do not From the existing literature, it is subsequent fragility fractures within a
fare well; they experience worse known that a history of fragility 3-year time frame would be captured
mobility, decreased independence, fracture predicts a future fragility in the data set. A second fracture was
poorer health status, increased rates fracture14-18; however, does the type defined as a fracture code occurring
of institutionalization, and lower of initial injury matter? What types after the same fiscal quarter as the first
quality of life compared with age- of subsequent fractures are predicted fracture and accompanied by a sepa-
matched controls.5-7 As few as 40% by a given index fracture? Are all rate hospitalization code.
of individuals recover their preinjury fragility fractures equally predictive
level independence; therefore, many, of future fracture? To answer these Data Collection and Analysis
if not most, require assistance with questions, we sought to conduct Patient records that met the criteria
activities of daily living after their a large cross-sectional analysis of for an initial fragility fracture between
injury.8 an elderly population in the United 2005 and 2009 were stratified by the
There has been great effort to define States. The purpose of this study was type of fragility fracture and tracked
the risks of sustaining a fragility to analyze the rate, location, and at 1-, 2-, and 3-year intervals. Patients
fracture so that future injuries and characteristics of recurrent fragility were stratified based on the anatomic
associated sequelae can be prevented. fractures in an at-risk population. location of initial and subsequent
The Fracture Risk Assessment Tool, fractures acquired within 3 years
developed through the World Health of follow-up. All-cause mortality at
Organization is the result of studies Methods
1 year after each fracture type was
of populations in North America, also recorded. Mortality was treated
Europe, Latin America, Asia, and Database
as a competing event when calculat-
Australia. Its function is to assess The PearlDiver Patient Records Data- ing the risk of refracture.
10-year fracture risk in individuals, base was used to query patients from
and it identifies multiple variables that the Medicare Standard Analytic Files
contribute to this risk.9-11 Among (SAF) database. Pearldiver (http:// Statistical Analysis
these are risk factors including www.pearldiverinc.com) is a com- Chi-squared analysis was used to test
country of residence, age, sex, family mercially available database mining for significant differences between
history, corticosteroid use, smoking, company that allows access to the the initial and subsequent fractures
and a history of fragility fracture. Of SAF file through Health Insurance based on the location of fracture and
the variables identified, a history of Portability and Accountability Act- the duration of follow-up. Differ-
previous fragility fracture is a strong, compliant patient queries with de- ences in patient mortality stratified by
Debbie Y. Dang, MD, PhD, et al
the fracture type was also examined. Table 2

P , 0.05 was considered statistically
Rate of Index Fracture and Osteoporosis Diagnosis
significant for all comparisons. All
computations were completed using Index Fracture Total Number (Incidencea)
STATA 14.2. Ankle 104,968 (11.5)
Distal radius 180,191 (19.7)
Proximal humerus 138,587 (15.1)
Results Hip 370,480 (40.4)
Vertebral compression 264,986 (28.9)
A total of 1,059,212 patients had an
initial fragility fracture between 2005 a
Incidence per 10,000 person-years.
and 2009. Of these patients, 35% had
sustained hip fractures (Table 2). At
1-year follow-up, 5.8% of patients
Figure 1
had a subsequent fracture, at 2-year
follow-up 8.8%, and 11.3% who
have a subsequent fragility fracture
within 3 years.
Of all initial fracture types, vertebral
fractures, followed by proximal
humerus (PH) fractures, were most
likely to be associated with a subse-
quent fracture. Among patients with a
vertebral compression (VC) fracture
or a PH fracture, 13.8% and 13.2%,
respectively, had a second fracture by
the third year of follow-up (P ,
0.001) (Figure 1). Despite this, hip
fractures were the most predictive of
mortality. The all-cause mortality rate
at 1-year follow-up after a fragility
fracture was 21.3% for hip fractures,
14.7% for VC fractures, 11.0% for
PH fractures, 8.5% for ankle frac-
tures, and 6.8% for distal radius (DR)
fractures (P , 0.001) (Figure 2). Graph showing the incidence of subsequent fracture after an initial fragility
By 3 years of follow-up, hip frac- fracture and the proportion of patients who acquire second fractures within the
first, second, and third years of follow-up. Patients are grouped by initial fracture
tures were the most common subse- type. DR = distal radius, PH = proximal humerus, VC = vertebral compression
quent fracture. This was true for
patients who initially sustained DR
fractures, hip fractures, PH fractures, sustain a particular type of second initial VC fracture were at highest
or VC fractures because hip fractures fracture at 3 years. risk of subsequent fracture. At 3 years
comprised 57.5% of subsequent frac- after their initial injury, hip fractures
tures by the third year after their initial were the most common type of sec-
fractures (P , 0.001) (Figure 3). For Discussion ond injury. These findings under-
patients who initially had ankle frac- score the importance of recognizing
tures, ankle fractures remained the We used a large cross-sectional that fragility fractures, in all loca-
most common type of second fracture cohort to analyze refracture rates tions, increase a patient’s risk of
at 2 years, and at 3 years, hip and and characteristics after an initial future morbid fractures. Orthopae-
ankle fractures occurred with equal fragility fracture. We found that 11% dic surgeons have the opportunity to
frequency (P . 0.05). For a given of patients will have a second fragility intervene once they see a patient with
index fracture, Table 3 provides the fracture within 3 years of their initial an initial fragility fracture, by eval-
relative percentage of patients who injury, and patients who have an uating the patient for underlying risk
January 15, 2019, Vol 27, No 2 e87
Figure 2 factors, treating these, and making

the appropriate referrals.20
Our findings are consistent with
previously reported refracture rates
in the literature. Berry et al15 found
that during a mean follow-up time of
4.2 years, 14.8% of patients with an
initial hip fracture sustained a second
hip fracture. Schroder et al14 found a
6.8% second hip fracture rate over a
16-year follow-up period; however,
their study was conducted nearly 25
years ago and may not reflect more
recent trends. In a study published in
2002, Robinson et al,21 prospec-
tively followed up patients in a single
institution after they sustained a
“low-energy” index fracture, which
was defined as “those that result
from a fall from or below standing
height, increase in incidence with
age, and occur more often in post-
Graph showing all-cause mortality 1 year after an initial fragility fracture and the menopausal women.” Specifically,
percentage of patients with each fracture type who do not survive the first year
after an initial fracture. DR = distal radius, PH = proximal humerus, they evaluated hip, DR, PH, and
VC = vertebral compression ankle fractures but not VC fractures
because of the low frequency of pre-
sentation at their institution. Com-
Figure 3 parable to our results, hip fractures
were the most common type of sec-
ond fracture, with a 13.2% overall
refracture rate. The current study,
however, is unique in that initial
fracture rates were correlated with
concomitant osteoporosis diagnoses,
more precisely identifying patients
with fragility fractures. To add to
this, the current study examined a
larger patient population across the
United States.
These findings indicate that VC
fractures, along with PH fractures,
were most correlated with the occur-
rence of a second fracture. Other
studies have demonstrated that VC
fractures are predictive of subsequent
vertebral fractures.22-24 In addition,
vertebral fractures are also predictive
of other types of fragility fractures,
Graph showing the subsequent fracture location within 3 years of an initial including hip fractures.25 The cur-
fragility fracture and the proportion of patients with initial fractures who acquire rent study affirms these findings and
subsequent fractures within 3 years of the first fracture, broken down by the adds to the literature by providing
locations of each fracture. DR = distal radius, PH = proximal humerus, perspective on how each initial frac-
VC = vertebral compression
ture type compares to others in its
correlation with a future injury. Our Table 3

findings indicate that PH fractures
Relative Proportion (%) of Second Fractures 3 Years After Each Type of the
have a similarly high correlation with First Fracture
second fractures. This, along with a
Second Fracture
recent study that found a low initiation
rate of osteoporosis treatment after a Ankle DR PH Hip VC
PH fragility fracture,26 highlights a
First fracture
potential population in which early
Ankle 38.5 5.1 6.5 39.9 10.0
intervention can prevent subsequent
DR 6.2 18.5 8.5 54.6 12.2
injury and morbidity. In fact, upper
PH 4.0 4.8 27.8 52.3 11.0
extremity fragility fractures are associ-
ated with high healthcare costs and Hip 2.8 5.2 7.5 72.9 11.6
mortality risk,27,28 and the findings of VC 3.0 3.5 5.9 48.2 39.4
this study further underscore the clini- DR = distal radius, PH = proximal humerus, VC = vertebral compression
cal significance of these injuries and the
need to view them as harbingers of
future injury. Treatment should there- and core strengthening. Such pro- The strengths of this study are the
fore not only be directed at healing grams can improve bone mineral large number of patients that the data
fractures but also aimed at preventing density.31,32 Other treatments have are able to capture and the ability to
the next fracture. aimed at improving overall bone stratify fracture types both on initial
Our findings further indicate that health through lifestyle modification and subsequent presentation. This
fragility fractures in any location, including smoking cessation, mod- study is, however, limited by several
even in those commonly thought to be eration of alcohol consumption, factors. First, to differentiate claims
less morbid, such as the DR or ankle, and fall prevention programs.33,34 for second fractures from claims
are sentinel events for more serious Finally, in addition to addressing related to the index fracture, a buffer
injuries, specifically hip fractures. a fracture, prospective workup of period was required. This method
From our data, it is estimated that metabolic anomalies after a first prevents detection of second frac-
more than half of patients who have a fragility fracture, regardless of fractures that occur within the same
second injury sustain a hip fracture ture location, can also help identify quarter as the first injury. Past studies
between 1 and 3 years after their first treatable conditions.35,36 have suggested that subsequent in-
injury. When excluding those with The reasons why ankle fractures juries occurring within this period
initial hip fractures, approximately behave differently than the other types account for approximately only
one third of patients with other types of fractures, or why DR fractures, one percent of second fractures;15,39
of index fragility fractures sustain a while also distal extremity fractures, therefore, they would unlikely change
hip fracture as their second injury. behave differently from ankle frac- the findings in this study. During the
This phenomenon implies that there is tures are unclear. It is possible that time frame studied in this article,
as much as a 3-year time period in there is a biological or biomechanical Medicare codes were time stamped
which interventions can be initiated to reason that predisposes patients based on fiscal quarter; we were
prevent a morbid refracture in a large with ankle fractures toward having therefore unable to have finer time
number of patients. another ankle fracture. In fact, others resolution of the data. Adding the
Known interventions such as vitamin have demonstrated that specific co- criterion for a separate hospitaliza-
D and calcium supplementation and morbid conditions increase a patient’s tion code allowed us to better,
diphosphonate treatment have been risk of ankle fractures.37,38 It is not though not perfectly, delineate indi-
shown to improve bone health and known whether the effect of these vidual fracture events. As a result,
even prevent fragility fractures.29,30 risk factors is different for individ- this can potentially give a slight
Furthermore, physical therapy beyond ual fracture locations. Alternatively, overestimation of recurrent frac-
treatment targeted toward the initial there may be differences in mech- tures. The second limitation is the
injury type can be initiated to improve anism of injury that make a patient inability to differentiate the laterality
overall function. For example, rather who has already had an ankle frac- of an injury based on ICD-9 codes. A
than working only with a therapist for ture prone to having another one. third limitation is the inability to
hand and wrist function after a DR This is the first time this finding has further stratify the patients based on
fracture, a patient can work with a been reported, and further investi- treatment of the initial fracture.
therapist for gait training, balance, gation is necessary. Because the data set includes all-
January 15, 2019, Vol 27, No 2 e89
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Hebel JR, Kenzora JE: Predictors of Zhang AL: Proximal humerus fragility
gility fractures, it is not known what functional recovery one year following fractures: Recent trends in nonoperative
intervention, if any, affects the inci- hospital discharge for hip fracture: A and operative treatment in the Medicare
dence of a subsequent injury. Finally, prospective study. J Gerontol 1990;45: population. J Shoulder Elbow Surg 2016;
M101-M107. 25:256-261.
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6. Haentjens P, Magaziner J, Colon-Emeric 20. Farmer RP, Herbert B, Cuellar DO, et al:
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CS, et al: Meta-analysis: Excess mortality Osteoporosis and the orthopaedic surgeon:
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1. Friedman SM, Mendelson DA: Fragility Second hip fracture in older men and
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2. United States Bone and Joint Initiative: The 16. Lonnroos E, Kautiainen H, Karppi P, humeral fractures. Shoulder Elbow 2014;6:
Burden of Musculoskeletal Disesases in the Hartikainen S, Kiviranta I, Sulkava R: 95-99.
United States (BMUS), ed 3. 2014. http:// Incidence of second hip fractures: A
www.boneandjointburden.org. Accessed population-based study. Osteoporos Int 29. Weaver CM, Alexander DD, Boushey CJ,
December 16, 2016. 2007;18:1279-1285. et al: Calcium plus vitamin D
supplementation and risk of fractures: An
3. Singer A, Exuzides A, Spangler L, et al: 17. Klotzbuecher CM, Ross PD, Landsman updated meta-analysis from the National
Burden of illness for osteoporotic fractures PB, Abbott TA III, Berger M: Patients Osteoporosis Foundation. Osteoporos Int
compared with other serious diseases with prior fractures have an increased 2016;27:367-376.
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Development and initial validation of a How well can a previous fracture for Clinical and Economic Aspects of
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year mortality in patients with hip study of 29,802 postmenopausal Musculoskeletal Diseases (ESCEO) and the
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31. Kemmler W, Bebenek M, Kohl M, von 34. Rebolledo BJ, Unnanuntana A, Lane JM: A 37. Smith JT, Halim K, Palms DA, Okike K,
Stengel S: Exercise and fractures in comprehensive approach to fragility Bluman EM, Chiodo CP: Prevalence of
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Osteoporosis Prevention Study (EFOPS). 8-13.
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Unmet needs and current and future 38. Cawsey S, Padwal R, Sharma AM, Wang
32. Kemmler W, Engelke K, von Stengel S: approaches for osteoporotic patients at X, Li S, Siminoski K: Women with severe
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Osteoporotic therapy after fragility 39. Curtis JR, Arora T, Matthews RS, et al: Is
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January 15, 2019, Vol 27, No 2 e91
Research Article
A Compatibility Guide for the

Orthopaedic Surgeon Planning to
Perform Hardware Removal
Surgery
Abstract
Matthew D. Riedel, MD Background: Removal of previously placed orthopaedic implants is a
Patrick K. Cronin, MD commonly performed procedure worldwide. Given the diversity of
orthopaedic implant manufacturers, surgeons may be uncertain
Philip B. Kaiser, MD
whether they have the appropriate screwdriver on site. The purpose of
John Y. Kwon, MD this study was to assess the compatibility of screw head and size
configurations from various orthopaedic manufacturers with two
commonly used universal screw removal sets.
Methods: Inclusion of orthopaedic implant manufacturers was
determined by market share based on industry-monitoring financial
firms. Screw size and drive type for the top grossing orthopaedic
From the Harvard Combined
Orthopaedic Residency Program implant manufacturers were collected and recorded. Screw and
(Dr. Riedel, Dr. Cronin, and screwdriver compatibility was assessed and compared with two
Dr. Kaiser), and the Department of commonly used universal screw removal sets.
Orthopaedic Surgery (Dr. Kwon), Beth
Israel Deaconess Medical Center, Results: In total, six orthopaedic implant companies with commonly
Boston, MA. implanted screws throughout the appendicular skeleton were
Correspondence to Dr. Riedel: included. The data were compiled in table format with noncannulated,
mdriedel@gmail.com cannulated, and locking screw offerings separated by the screw
Dr. Riedel or an immediate family size and manufacturer. Guidewire size compatibility for cannulated
member serves as a paid consultant offerings was also assessed.
to Paragon 28 and serves as a board
Conclusions: Given the ubiquity of implanted orthopaedic implant,
member of the Orthopaedic Trauma removal must be as safe, planned, and controlled as possible. The
Association. Dr. Kwon or an data in this article provide an inclusive, centralized resource for
received royalties from Paragon 28 surgeons looking to confirm the compatibility of previously implanted
and TriMed; serves as a paid screws and available removal equipment at their institution.
consultant to Medline, MedShape,
and Paragon 28; and has stock or
stock options held in MedShape.
Neither of the following authors nor
R emoval of orthopaedic implants
is a commonly performed proce-
dure, accounting for approximately
not be as straightforward as perceived
and can be fraught with complica-
tions and substantial cost to both the
5% of all orthopaedic surgeries.1,2 patient and healthcare system.5,6
related directly or indirectly to the Retained implants are removed for Implant removal is not a benign
subject of this article: Dr. Cronin and various reasons, including pain, in- procedure, with previous studies
Dr. Kaiser. fection, nonunion, prominence, after demonstrating complication rates
J Am Acad Orthop Surg 2019;27: intended or unintended growth mod- ranging from 3% to 40%.5,7 Imme-
e92-e95 ulation, planned removal of tempo- diate perioperative issues include
DOI: 10.5435/JAAOS-D-17-00658 rary fixation, and/or requirements anesthetic complications, broken
for additional procedures.3,4 Despite and/or retained implant, iatrogenic
Academy of Orthopaedic Surgeons. the frequency and relatively simple injury, time out of work, and pain.
objective, removal of implant may Patients are subject to other issues
Matthew D. Riedel, MD, et al
in the recovery period, including risk without the assurance of knowing appendicular skeleton were included
of wound complications, deep vein whether the universal set houses the in this comparative review.
thrombosis secondary to immobili- appropriate screwdriver required. Publicly available surgical technique
zation, risk of fracture through Furthermore, direct visualization of guides, typically in portable document
screw holes or defects/previous stress- the screw head (to determine which format, were retrieved from the World
shielded areas of bone, and further screwdriver is required) is not always Wide Web for each manufacturer by
lost time from work.5,7 Not surpris- possible intraoperatively. The lack typing the name and implant system
ingly, previous literature finds that of knowledge regarding whether the into a search engine. Each technique
surgical time and blood loss for surgeon is using the appropriate guide was thoroughly reviewed for
implant removal can be higher than screwdriver in such cases in which implant, screwdriver information, and
for the index procedure.8 direct visualization is not possible can guidewire (when appropriate), and, in
Given the potential difficulties with make removal exceedingly difficult. cases in which the obtained informa-
implant removal, it is important for Therefore, the purpose of this study tion was unclear or incomplete, surgi-
orthopaedic surgeons to be cognizant of was to assess the compatibility of screw cal representatives from each specific
variables, which may minimize com- head and size configurations from var- company were contacted to clarify the
plications, decrease surgical time, and ious orthopaedic manufacturers with screw size, guidewire size, screw drive
reduce surgeon frustration. Familiarity two commonly used universal screw type, and/or screwdriver size along
with commonly used implants (eg, removal sets to compile a reference with known compatibility options.
manufacturer, screw size, screw head to facilitate screw removal. A reference Screw and screwdriver compatibility
configuration), ensuring the presence for cannulated screws has also been was assessed and compared with
of on-site compatible systems, and included to document the compatibility two commonly used universal screw
knowledge/experience using broken of the guidewire size. removal sets as determined by the two
implant removal kits has been postu- highest grossing orthopaedic implant
lated to correlate with the success of companies, Johnson & Johnson
hardware removal procedures.9 Methods (J&J)/Depuy/Synthes and Stryker.
Most commonly, difficulties arise The data were compiled in table
when faced with removing screws No institutional institutional review format with noncannulated, cannu-
previously implanted by another sur- board approval was required for this lated, and locking screw offerings
geon without the knowledge of the study becuase no human or nonhuman for each included company being
exact screw size and head configura- subjects were necessary for completion reviewed and documented. Guide-
tion. Fortunately, despite the growing of the research included. All data and wire size compatibility for cannu-
number of implant manufacturers on analysis were compiled and completed lated offerings was also assessed and
the market, notable compatibility ex- using readily available and accessible documented.
ists among companies. Furthermore, information. Inclusion of selected or-
several orthopaedic device companies thopaedic implant manufacturers was
make universal screw removal sets determined by market share based on Results
with various screwdriver types/sizes industry-monitoring financial firms.10
to facilitate screw removal across a The top 10 highest grossing ortho- To facilitate the ease of implant iden-
breadth of systems. This is a particu- paedic implant companies in 2016 tification in the clinical scenario, the
larly important tool when a surgeon were Stryker, J&J/Depuy/Synthes, compiled tables have been separated
may be unaware of the manufacturer Zimmer Biomet, Medtronic, Smith & into noncannulated, cannulated, and
of a previously implanted screw and/or Nephew, Arthrex, NuVasive, Globus locking offerings. Results were tabu-
may not have that manufacturer’s Medical, Wright Medical Group, and lated to include the manufacturer
screwdrivers readily available. Al- Tornier (Wright Medical and Tornier name, screw diameter, screw purpose,
though identifying the previously had since merged).10 NuVasive, Med- manufacturer catalog number for
implanted implant before proceed- tronic and Globus Medical are exclu- screwdriver, and potential removal
ing to the operating room obviously sively spine implant suppliers and, set(s) for noncannulated, cannulated,
negates this issue, this is not always a given a likely decreased utility of and locking screws (see Table 1, Sup-
possibility. knowledge of screw configuration to plemental Digital Content 1, http://
However, although a universal set the general reader, were removed from links.lww.com/JAAOS/A141; Table 2,
may be available, it is not uncommon our analysis. In total, six orthopaedic Supplemental Digital Content 2, http://
for surgeons to proceed to the oper- implant companies with commonly links.lww.com/JAAOS/A142; Table
ating theater with some trepidation implanted screws throughout the 3, Supplemental Digital Content 3,
January 15, 2019, Vol 27, No 2 e93
Compatibility Guide for Hardware Removal Surgery
http://links.lww.com/JAAOS/A143). for some surgeons to reference if the average cost of a basic, uncompli-
These tables are further organized implant manufacturer is known cated orthopaedic implant removal
based on the implant outer thread preoperatively. surgery to be approximately $6,000,
diameter, allowing the surgeon to the data presented in this manuscript
measure the implant diameter on a may be an important resource and
properly calibrated radiograph and Discussion cost-saving measure for practicing
identify it using the appropriate table surgeons to implement in their pre-
based on the implant characteristics. Given the ubiquity of implanted operative planning.6 In addition to
Preoperatively obtaining historic sur- orthopaedic implant, removal must improved surgical efficiency, this
gical data on implant manufacturer be as safe, planned, and controlled as guide may further decrease costs by
and size remains the ideal option. possible. Both perioperative and limiting the number of equipment
While the suggested radiographic postoperative risks may cause sub- sets unnecessarily opened, thereby
measuring technique is not an abso- stantial morbidity to patients. Similar decreasing associated processing and
lutely reliable method, it should prove to other surgical procedures, multiple sterilization costs.
to be useful to the surgeon who does factors exist when performing removal Surgeon experience may play a
not have preoperative access to his- of implant, which may influence the role in the morbidity of implant
toric surgical reports or information success of the surgery, and appropriate removal. Langkamer and Ackroyd
about which manufacturer’s implants preoperative planning should always demonstrated a 47% lower com-
are to be removed. This method can be performed. Identifying the manu- plication rate when implant re-
help the surgeon estimate the ap- facturer of a patient’s existing implant moval was performed by experienced
proximate diameter of implant to be before removal is, of course, preferred; surgeons compared with moderately
removed (based on the reliability of however it is not always possible. experienced surgeons illustrating the
the radiograph calibration) and ensure Therefore, identifying likely compati- potential complexity of these proce-
the presence of proper screwdrive type ble screwdrivers preoperatively based dures.12,13 Others have shown that
and size associated with the particular on the implant size and head type is removal can be problematic for all
size nonlocking, cannulated, or lock- the next best option. providers because studies have
ing screw to be removed. The importance of having the correct demonstrated complication rates
Using these radiographically iden- screwdriver, while obvious and intui- ranging from 3% to 40% including
tifiable parameters, the surgeon may tive, cannot be underestimated. Bio- refracture, nerve or vessel injury,
identify the screw using the following mechanical studies have shown that hematoma, wound infection, and
tables and thereby determine which the maximal torque values decrease by ongoing pain.12,14
of the two commonly available 50% after a single slippage event dur- Although an orthopaedic implant
implant removal sets (ie, Synthes ing screw removal.9,11 Such slippage is sometimes removed by the index
Removal Set, Stryker Removal Set, or events are more common if an incor- surgeon, there are many cases when
either removal set) contains the rect screwdriver size or shape is used. implant removal is performed at an
appropriate driver. If the table in- Stripping or breakage of the screw outside institution by a different sur-
dicates that the necessary driver is not head can cause notable surgeon frus- geon without a readily accessible sur-
available in either removal set, the tration and increase the surgical time gical report, implant list, or product
catalog number of the driver pro- and cost because of the need for al- vendor with knowledge of the preex-
duced by the manufacturer is also ternative techniques for removal, isting implants. The data reported in
provided. These catalog numbers are which may be technically more chal- this study allow a surgeon to preop-
provided for all screws listed in the lenging and require additional equip- eratively identify what equipment
chart to allow surgeons to opt ment. In some cases, implant may be they will need to remove a patient’s
for a single driver if that option is broken preoperatively, identified as implant and to ensure that they have
available at their institution because broken intraoperatively, or sustain the proper instruments available.
many institutions will not have all iatrogenic breakage, adding to the This article can serve as a centralized
company’s drivers or removal instru- complexity of the procedure.9 Screw guide of such information to facilitate
mentation available. heads may be sheared off or stripped, screw removal whether preoperative
Table 4 (see Supplemental Digital screwdriver tips may fail, and cold knowledge of existing implants is
Content 4, http://links.lww.com/ welded screws may be encountered.9 available.
JAAOS/A144) represents the same Furthermore, increased surgical Limitations to this study include the
data cross-referenced by the manu- time translates to increased cost. In lack of inclusivity of all manufacturers
facturer. This layout may prove easier light of recent research that found the of orthopaedic implants. Because of
Matthew D. Riedel, MD, et al
the sheer number of manufacturers a guide and by no means a compre- 4. French HG, Cook SD, Haddad RJ:
Correlation of tissue reaction to corrosion
and their offerings, we chose to de- hensive definitive source. in osteosynthetic devices. J Biomed Mater
termine inclusion based on recent Res 1984;18:817-828.
market share data. Furthermore, the 5. Swiontkowski MF: Slipped capital femoral
data presented are current as of the Conclusion epiphysis: Complications related to internal
fixation. Orthopedics 1983;6:705-712.
date of submission; however, compa-
nies are continuously developing new Removal of previously placed ortho- 6. Nearly 68% of patients improve after
offerings and future products. We paedic implants is a commonly hardware removal, but surgery is costly.
Healio Orthopedic Today. Available at
appreciate that manufacturers make performed procedure worldwide. http://www.healio.com/orthopedics/trauma/
changes to their products as technol- Availability of compatible removal news/online/%7B1f854283-164c-4fda-b169-
instruments is important for the d53ee35e324c%7D/nearly-68-of-patients-
ogy evolves. However, the implants improve-after-hardware-removal-but-
included in this article are basic screw success of the procedure. The pur- surgery-is-costly. Accessed May 30, 2017.
offerings that have changed little pose of this article is to provide a 7. Jacobsen S, Honnens de Lichtenberg M,
across all manufacturers in recent centralized resource for surgeons Jensen CM, Tørholm C: Removal of
looking to confirm the compatibility internal fixation—the effect on patients’
years. Furthermore, alhtough com- complaints: A study of 66 cases of removal
panies may introduce new plating of previously implanted screws of internal fixation after malleolar
systems, for example, in general, and available removal equipment fractures. Foot Ankle Int 1994;15:170-171.
manufacturers try to make these im- at their institution. Preoperative 8. Brown OL, Dirschl DR, Obremskey WT:
plants compatible with their estab- identification of existing implant Incidence of hardware-related pain and its
effect on functional outcomes after open
lished screw options and types to size and characteristics certainly reduction and internal fixation of ankle
ensure compatibility and limit cost. makes this hardware removal guide fractures. J Orthop Trauma 2001;15:271-274.
We avoided including most “spe- much easier to use, however is not 9. Hak DJ, McElvany M: Removal of broken
cialty” implants, focusing more imperative. hardware. J Am Acad Orthop Surg 2008;
16:113-120.
so on commonly used implants in
basic small and large fragment type 10. EvaluateMedTech: World Preview 2016,
References Outlook to 2022. Available at: http://
offerings for this very reason. Al- www.evaluategroup.com/public/reports/
though we were thorough in our EvaluateMedTech-World-Preview-2016.
References printed in bold type are aspx. Accessed May 30, 2017.
assessment of available implants and
equipment, sample equipment was 11. Behring JK, Gjerdet NR, Mølster A: Slippage
between screwdriver and bone screw. Clin
not available to confirm test com- 1. Busam ML, Esther RJ, Obremskey WT:
Orthop Relat Res 2002;404:368-372.
Hardware removal: Indications and
patibility. Given that information
expectations. J Am Acad Orthop Surg 12. Langkamer VG, Ackroyd CE: Removal of
regarding compatibility was obtained 2006;14:113-120. forearm plates: A review of the complications.
from direct sources from the manu- J Bone Joint Surg Br 1990;72:601-604.
2. Rutkow IM: Orthopaedic operations in the
facturers, although not formally United States, 1979 through 1983. J Bone 13. Schepers T, Van Lieshout EM, de Vries
tested by the investigators, perfect Joint Surg Am 1986;68:716-719. MR, Van der Elst M: Complications of
syndesmotic screw removal. Foot Ankle Int
accuracy in compatibility cannot be 3. Anderson LD, Sisk D, Tooms RE, Park 2011;32:1040-1044.
confirmed. Therefore, readers should WI: Compression-plate fixation in acute
diaphyseal fractures of the radius and 14. Richards RH, Palmer JD, Clarke NM:
acknowledge that the information ulna. J Bone Joint Surg Am 1975;57: Observations on removal of metal implants.
presented in this article is to serve as 287-297. Injury 1992;23:25-28.
January 15, 2019, Vol 27, No 2 e95
Review Article
Meniscal and Chondral Pathology

Associated With Anterior Cruciate
Ligament Injuries
Abstract
Andrew N. Pike, MD Anterior cruciate ligament (ACL) ruptures are commonly associated
Jeanne C. Patzkowski, MD with meniscal and articular cartilage injuries, and the presence of
these defects influences both short- and long-term outcomes. Multiple

Craig R. Bottoni, MD
variables are predictive of this pathology including time from injury,
age, and sex. Revision ACL reconstructions demonstrate higher rates
of chondral injury than primary reconstructions. Menisci are important
secondary stabilizers of the knee in the setting of ACL deficiency, and
specific tear types are more consistently associated with ACL injury.
Successful outcomes with multiple treatment options for meniscal
tears in conjunction with ACL reconstruction have been reported.
Maintaining meniscal integrity may be protective of both joint surfaces
and graft stability in the long term; however, clear treatment
recommendations for tear subtypes remain ill defined. High-grade
chondral defects have the most consistent and potentially largest
negative effect on long-term patient-reported outcomes; however,
optimal treatment is also controversial with successful results
demonstrated with several modalities including benign neglect.

Surgery, Division of Sports Medicine,
Tripler Army Medical Center,
Honolulu, HI.
A pproximately 50% of primary
anterior cruciate
(ACL) ruptures and over 90% of
ligament Epidemiology
Dr. Bottoni or an immediate family The incidence of associated cartilage

failed reconstructions will have co-
member is a member of a speakers’ and meniscal pathology with ACL
existing cartilage and/or meniscal
bureau or has made paid tears varies widely in the literature.
presentations on behalf of Arthrex; pathology.1-4 Multiple factors con-
Recent studies suggest that between
serves as a paid consultant to Arthrex; tribute to joint surface injury in asso-
and has received research or one and two thirds of patients will
ciation with ACL tears, and the
institutional support from Arthrex, and present with an associated meniscal
the Musculoskeletal Transplant
appropriate management of these
concomitant lesions is an area of tear in conjunction with a primary
Foundation. Neither of the following
authors nor any immediate family ongoing study. Recent literature has ACL rupture1,3,5,6 and that approx-
member has received anything of provided insight into the biomechan- imately one fourth of patients will
value from or has stock or stock have combined medial and lateral
ical interaction between the ACL and
meniscal structures, garnering an tears.5 The rates of chondral injuries
or institution related directly or
indirectly to the subject of this article: improved understanding of injury with ACL ruptures are inconsistently
Dr. Pike and Dr. Patzkowski. patterns associated with ACL tears. reported because of variability in
J Am Acad Orthop Surg 2019;27: Many studies have demonstrated a grading and chronicity. Variation in
75-84 notable clinical association between defect classification also exists with
DOI: 10.5435/JAAOS-D-17-00670 chondral and meniscal pathology; the Outerbridge and International
however, optimal treatment of spe- Cartilage Restoration Society scales
Academy of Orthopaedic Surgeons. cific lesions remains an area of most commonly used. Regardless of
controversy. the system used, virtually all studies
February 1, 2019, Vol 27, No 3 75
Meniscal/Chondral Injuries in Anterior Cruciate Ligament Tears
Table 1
Variables Associated With Chondral and Meniscal Pathology in Primary Anterior Cruciate Ligament Tears
Factor Level of Evidence Patients Time From Injury Increasing Age Male Sex
Granan et al3 2 3,475 CD CD MT

— — MT — —
Slauterbeck et al5 2 1,104 MMT: .3 mo MMT, CD (MFC) MMT, LMT, CD
— — MMT/LMT/CD: .12 mo — —
Chhadia et al9 3 1,252 MMT, CD: .12 mo CD LMT, CD
Røtterud et al10,a 2 15,783 CD: .12 mo CD CD
Kluczynski et al1,b 3 541 MMT CD LMT, MMT
BMI = body mass index, CD = chondral defect, LMT = lateral meniscal tear, MFC = medial femoral condyle, MT = meniscal tear side unspecified,
MMT = medial meniscal tear
a
Grade 3, 4 CD; no MT reported.
b
Linear association with an increasing number of instability episodes up to 5.
distinguish between “low-grade” presence of a meniscal tear doubled pathology with ACL injuries. Such
(softening/fibrillations/slight fis- the likelihood of an associated variables include age and sex (Table 1)
suring) versus “high-grade” (deep articular cartilage defect.3 Addi- as well as body mass index and
fissuring/exposed subchondral bone) tional studies have reported that sport participation. Several studies
lesions, which correlates with grades medial meniscal tears are most prone have reported on increasing age as a
0 to 2 and 3 to 4 on either scale, to secondary injury with increasing risk factor for medial meniscal tears
respectively.2,3,6-8 A systematic review time from surgery.1,2,9,12 A delay as and chondral defects; however, au-
of ACL reconstructions performed little as 6 to 12 weeks from point of thors have also observed the positive
within 3 months of injury reported injury has been shown to markedly association between age and surgical
rates of chondral injury ranging from increase the rate of medial meniscal delay, which likely contributes to
16% to 46%.7 However, high-grade tears (8% to 19%), whereas delays this finding.5,9 However, in studies
defects were the lowest in frequency of greater than 1-year result in that specifically evaluate grades of
(16%), and other studies have re- increased number, size, and grade of chondral defects, older patients, on
ported rates of high-grade lesions to be chondral defects.1,5 Previous reports average, have higher-grade lesions
as low as 7% to 9% irrespective of have cited higher rates of lateral than younger patients.3,5,10 Males
chronicity.2,8 meniscal tears in acute injuries, but consistently demonstrate higher rates
with advancing chronicity, medial of meniscal tears than females.1,3,5,9,10
meniscal tear rates increase while Although less frequently reported,
Time from Injury lateral meniscal tears remain rela- obesity has been associated with
Several large level II and III observa- tively constant.1,12 Of note, the au- higher rates of chondral defects (odds
tional studies have reported on the thors’ definition of “chronicity” was ratio [OR], 2.63; CI, 1.10 to 6.28).1
timing of ACL reconstruction and the based on the occurrence of second- Sport participation is less clear with
observed incidence of associated ary episodes of instability and not some reports finding no increased risk
pathology1,3,5,9,10 (Table 1). Con- specific time intervals. Recent liter- for chondral or meniscal pathology.1
sistent findings include higher rates ature has also supported this obser- However, using soccer as a referent as
of both meniscal and chondral vation with the increasing number of the most common sport associated
pathology with increasing time from patient-reported instability episodes with ACL tears, a large multinational
initial injury to surgical reconstruc- having the highest association with cohort observed basketball to have
tion and have led some authors to the risk of secondary medial me- significantly higher rates of lateral
conclude that early ligamentous niscal tears but no association with meniscal tears (OR, 1.28; CI, 1.06
stabilization may prevent secondary lateral meniscal tears.1 to 154), chondral defects (OR, 1.23;
damage to the joint.3,11 A large level CI, 1.01 to 1.51), and combined
II prospective cohort found that meniscal/chondral lesions (OR, 1.38;
surgical delay increased rates of Patient Specific Variables CI, 1.11 to 1.72)13 and men’s team
meniscal tears and chondral lesions Patient demographics also influence handball to have an increased risk
by 1% per month and that the the type and degree of associated for lateral meniscal tears (OR, 1.27;
Andrew N. Pike, MD, et al
Table 2
Patient-reported Outcomes Based on Combined Chondral/Meniscal Pathology/Treatment
Patients (Mean
Level of Age and Medial Meniscal Chondral Defects
Factor Evidence Follow-up) (yr) Lateral Meniscal Tear Tear (Grade 3, 4)
Shelbourne 3 928 (23, 8.6) Worse outcomes: Worse outcomes: Worse outcomes: all
et al11 partial lateral partial medial locations: (IKDC)
meniscectomy: meniscectomy:
(IKDC) (IKDC)
Røtterud 2 8,4762,30 No statistically No statistically Worse outcomes: all
et al2 significant findings significant findings sizes, location
unspecified (KOOS-
all subscales)
Cox et al6,a 1 1,3076,23 Improved outcomes: Improved outcomes: Worse outcomes: MFC,
nontreatment: (IKDC, .50% medial LFC, MTP: (IKDC),
KOOS-all subscales) meniscectomy: MFC, LFC, MTP, LTP,
& .50% lateral (KOOS-pain) trochlea: (KOOS-
meniscectomy: multiple subscales) &
(IKDC, KOOS- MFC (Grade 4 only):
symptoms/activity) (Marx-K)
— — — Worse outcomes: —
,33% medial
meniscectomy:
(IKDC); medial
meniscal repair:
(IKDC, KOOS)
Dunn 1 1,4116,23 Improved outcomes: No statistically Worse outcomes: LTP
et al38,a nontreatment & .50% significant findings (SF-36)
lateral meniscectomy
(SF-36)
MARS 2 9892,26 Worse outcomes: Worse outcomes: Worse outcomes:
group4,b previous partial lateral previous partial trochlea (IKDC,
meniscectomy (IKDC, medial meniscectomy KOOS/WOMAC-6/8
KOOS/WOMAC-all (KOOS-symptoms, subscales), all other
subscales) pain, WOMAC- locations-various
stiffness) subscales
IKDC = International Knee Documentation Committee, KOOS = Knee injury and Osteoarthritis Outcome Score, LFC = lateral femoral condyle, LTP =
lateral tibial plateau, MFC = medial femoral condyle, MTP = medial tibial plateau, SF-36 = short-form 36, PCS = physical component summary
a
Separate reports on the same patient population.
b
Revision data.
CI, 1.10 to 1.48) and high-grade study comparing 508 primary with defects were associated with previ-
chondral defects (OR, 2.36; CI, 1.33 281 revision ACL reconstructions, ous partial meniscectomies of the
to 4.19).10,13 the revision cases had a significantly corresponding compartment regard-
higher incidence of high-grade de- less of primary or revision status.
fects involving the lateral femoral Similarly, a level II cohort evaluating
Failed Reconstructions condyle (OR, 1.73; CI, 1.02 to 2.93; 725 revision ACL reconstructions
Recurrent knee instability secondary P = 0.04) and patellofemoral com- found that a previous meniscectomy
to a failed ACL reconstruction often partment (OR, 1.70; CI, 1.01 to was associated with a grade 2 or higher
results in progression of secondary 2.84; P = 0.04) irrespective of me- defect in any compartment including
injury patterns with rates exceeding niscal status. However, rates of lat- patellofemoral (P , 0.0001).14 Fur-
those of primary reconstruction. The eral meniscal tears were lower in the thermore, after adjusting for age, par-
incidence of meniscal tears is as high revision group (OR, 0.54; CI, 0.39 to tial meniscectomies resulted in higher
as 75% and chondral injuries 67%, 0.75; P , 0.01), whereas medial rates of chondral injury compared
with over 90% of patients presenting meniscal tear rates were similar.15 with normal menisci (P , 0.0001) or
with either lesion type.4,14 In a level II Additionally, high-grade chondral previous meniscal repairs in either
February 1, 2019, Vol 27, No 3 77
compartment (P = 0.003) although (19.0 6 4.6 versus 13.9 6 4.3 mm; P , scopically creating a posterolateral
lateral meniscal repairs were more 0.05) and not Lachman maneuvers. root tear (including disruption of
protective of their respective articular Although total meniscectomies are meniscofemoral ligaments). Progres-
surfaces than medial meniscal repairs relatively uncommon, the study dem- sive increases in tibial translation
(P = 0.03). In a large level II study onstrates the roles of the medial and with pivot shift was noted from ACL
comparing 989 patients undergoing lateral menisci in anterior and rotatory intact (2.62 6 0.53 mm), to ACL
revision reconstruction with their re- stability, respectively. resection (6.01 6 0.51 mm; P =
spective primary reconstruction find- Additional laboratory investigations 0.0005), and to ACL resection/root
ings, rates of medial meniscal tears have evaluated specific tear types with tear (8.13 6 0.75 mm; P , 0.0001).
increased slightly, 38% to 45%, and similar findings. The effects of periph- However, the root tear did not
lateral meniscal tears increased 20% to eral longitudinal posterior horn medial change stability with simulated
37%. A complete analysis of chondral meniscal tears (mean 28 mm length Lachman maneuvers.19 In a similar
lesions was limited by the lack of pri- tear) in the setting of ACL deficiency study, isolated root tears with and
mary data; however, at the time of were evaluated.17 Findings included without meniscofemoral attachment
revision, 43% of patients had at least significant increases in anterior trans- resections were assessed in cadaver
grade 2 changes of the medial femoral lation with simulated Lachman ma- knees with simulated pivot shift,
condyle, 29% lateral femoral condyle, neuvers at flexion angles up to 60 internal rotation stress, and anterior
30% patellar, and 20% trochlear.4 (P , 0.05) but no differences with drawer all at varying degrees of knee
These studies suggest that although the pivot shift. Furthermore, the periph- flexion. The authors found a statis-
overall rates of chondral injury are eral tear resulted in the same degree tically significant 1-mm (P , 0.05)
higher in revision cases, intact or pre- of instability as a total medial increase in anterior tibial translation
served menisci at the time of primary meniscectomy. After meniscal repair, during pivot-shift testing at 20 and
reconstruction may decrease the inci- however, stability was restored to the 30 with combined ACL/lateral
dence of associated chondral lesions isolated ACL-deficient state. A similar meniscal root tears compared with
observed in failed reconstructions. Ad- cadaver study evaluated the effect isolated ACL deficiency. Conversely,
ditionally, patellofemoral chondrosis is of a posteromedial meniscocapsular the authors found a statistically sig-
markedly more likely to develop in defect with ACL insufficiency.18 nificant 1.1-mm (P , 0.05) increase
patients undergoing revision than in Maximal anterior translation (mean, in anterior translation with anterior
primary cases. 14 mm; P , 0.001) occurred with drawer at 30 and 60 between these
simulated Lachman maneuvers at groups. Furthermore, the lateral
30 flexion in knees with a postero- meniscal root insertion seemed to
Meniscal Tears medial meniscocapsular lesion. Repair protect against excess internal rota-
(arthroscopic, all-inside) of the tion at higher degrees of knee flexion
Biomechanics meniscocapsular defect restored regardless of ACL status. The au-
Interest in the mechanism of injury translation to that of the isolated thors concluded that injury to the
with ACL tears and the associated ACL-deficient state (mean, 10.1 mm; posterolateral root insertion may
stress imparted to supporting struc- P = 001). After patellar tendon liga- result in higher-grade pivot-shift find-
tures has led to several cadaver studies ment reconstruction, stability was ings clinically and meniscofemoral
evaluating the role of the menisci in further improved to 4.1 mm but was ligament status further contributes to
knee stability. The effect of to- then destabilized to 7.1 mm with re- rotational stability.20
tal meniscectomies in the setting sectioning of the meniscocapsular
of ACL deficiency was assessed with repair (P = 0.01). These studies suggest
simulated pivot shift and Lachman that the peripheral, posteromedial Tear Subtypes
maneuvers.16 A total medial meniscal complex contributes mark- Specific tear patterns are often
meniscectomy resulted in markedly edly to the anteroposterior stability of observed in conjunction with ACL
increased anterior tibial translation the knee in the ACL-deficient state. ruptures. Variables include the loca-
with Lachman maneuvers (11.4 6 The effect on stability of postero- tion and orientation of tears, as well
5.2 versus 5.9 6 3.1 mm; P , 0.001) lateral root avulsions with ACL tears as injury to capsular and root at-
compared with an ACL tear alone, has also been studied. A cadaver tachments. In terms of location, 95%
but no notable difference with pivot investigation evaluated simulated and 77% of medial and lateral
shift. Conversely, a total lateral pivot shift and anterior tibial trans- menisci, respectively, involve the
meniscectomy resulted in significantly lational forces at varying degrees of posterior horn.1 More specifically,
higher tibial translation with pivot shift knee flexion before and after arthro- the peripheral and central zones of
the posterior horns are the most As mentioned previously, there is Figure 1
common locations of tears, inde- also increasing interest in the con-
pendent of age or injury chronicity.5 tributions of the posterolateral
However, these zone-specific data meniscal root attachments in the
fail to report on root and capsular ACL-deficient knee. Association of
attachments, specifically. In terms of this injury in conjunction with ACL
orientation, posterior vertical, lon- tears is approximately 8% to 14%.20
gitudinal tears are commonly reported Conversely, posteromedial meniscal
acutely, with degenerative and hori- root avulsions are uncommonly
zontal patterns becoming more prev- observed with isolated ACL injury,
Seventy degrees arthroscopic view
alent in chronic cases.21-24 Unstable although they have increased asso- through the intercondylar notch of a
bucket-handle morphology is also ciation with multiligament injuries, posteromedial meniscocapsular
commonly recognized. In review of particularly those involving complete separation or “ramp” lesion.
over 2,000 ACL reconstructions, the medial collateral ligament ruptures.28
rates of medial and lateral bucket-
handle tears were 7% and 23%, had higher rates of revision surgery
respectively.22,23 Treatment (9.5%) compared with lateral (3%).24
A more recently investigated tear The diversity of meniscal tear patterns A level III review with 6-year follow-up
pattern is the aforementioned postero- encountered in the ACL-deficient knee of 208 meniscal tears left in situ with
medial meniscocapsular defect, or adds complexity to the treatment ACL reconstruction found that 97.8%
“ramp” lesion25 (Figure 1). The decision-making process, and ques- and 94.4% of lateral and medial tears
pathoanatomy is not entirely clear tions still exist regarding the optimal required no further intervention,
and possibly includes disruption of strategies for maximizing outcomes. respectively. Risk factors for failure
meniscotibial ligament attachments.26 Treatment options for meniscal tears included younger patient age (18.6
Authors have observed that this is an encountered during ACL reconstruc- versus 25.1; P = 0.26) and tear
underappreciated lesion with MRI tion include débridement, abrasion/ length .10 mm (11.5% versus 3.2%;
sensitivity in detecting ramp lesions trephination, repair, and benign P = 0.35).30 All failures laterally were
ranging widely, 0% to 77%.25 Two neglect. Acceptable outcomes have greater than 10 mm in length; how-
separate studies have reported an been reported with each of these op- ever, 1/3 of medial failures were
incidence of approximately 17% for tions; however, high-level compara- ,10 mm. A level III case control study
ramp lesions in association with tive studies are lacking. In revision assessed patients undergoing trephi-
ACL tears.26,27 In a consecutive cases with substantial meniscal defi- nation of a stable, peripheral medial
series of 302 patients, investigators ciency, allograft transplantation may meniscal tear during ACL recon-
found an overall 41% rate of medial be considered to improve both stabil- struction.21 At mean 5-year follow-
meniscal disruptions, of which 40% ity and chondral protection, but fur- up, no differences were observed
of these were ramp lesions (50/302; ther discussion is beyond the scope of in subjective patient outcomes or
16.6%). Of these capsular defects, this review. radiographic grading compared with
23% were diagnosed viewing through Several authors have suggested that nontear controls. However, the tear
the intercondylar notch, and an stable tear patterns are effectively cohort had a significantly higher rate
additional 17% required utilization treated with minimal or no interven- of revision surgery (16.3% versus
of a posteromedial portal—7% over- tion.21,24,29,30 Although the exact 5.8%; P , 0.0001). A level II pro-
all rate of “hidden” lesions.26 Al- definition of a “stable” meniscal tear spective randomized study compared
though the overall incidence of medial is somewhat ambiguous, common trephination/abrasion versus repair
meniscal tears increases with chronic- descriptors often include: non- of stable (11 to 14 mm) postero-
ity, the rates of ramp lesions with degenerative, nondisplaceable, incom- medial meniscocapsular lesions in 73
surgical delay are less clear with some plete, peripheral, longitudinal, and/or patients. At minimum 2-year follow-
authors suggesting no increased inci- length less than 10 to 15 mm.21,24,29,30 up, no differences were found in
dence beyond 6 weeks from the time A recent level IV systematic review patient-reported outcomes, objective
of injury,26 whereas other reports evaluated the results of benign neglect stability, or healing rates on follow-
observe increasing prevalence up to of stable meniscal tears during ACL up MRI (92% completely healed).29
24 months after injury.27 Further- reconstruction. Of 646 tears left in situ, Long-term clinical outcomes of
more, young males seem to sustain the the overall rate of revision surgery was unstable ramp lesions left in situ are
highest rates of ramp tears.27 5.4%. However, medial meniscal tears lacking; however, aforementioned
February 1, 2019, Vol 27, No 3 79
biomechanical data suggest a potential similar at 7 and 9-year follow-up, risk factors for graft failure (medial:
detrimental effect on long-term respectively. Pain scores were slightly hazard ratio, 15.1; CI, 4.7 to 48.5;
stability. worse with partial lateral meniscec- P , 0.001, lateral: hazard ratio, 9.9,
Approximately 20% to 30% of ACL tomies compared with repairs (P = CI, 3 to 33; P , 0.001).34
reconstructions include an associated 0.0478). Of all treatments, the worst
meniscal repair.31 Despite this, no overall outcomes were in patients with
prospective randomized studies have degenerative medial tears that were Chondral Defects
compared treatments/techniques in- repaired (P = 0.02). However, the
volving unstable meniscal tear pat- overall clinical success rates for repair Natural History
terns with ACL reconstruction. In a of nondegenerative tears exceeded Articular cartilage injury associated
level IV meta-analysis including 21 97% in both compartments.22,23 with ACL reconstruction possibly
studies and 1,126 patients, failure Treatment of posterolateral root has the greatest single effect on long-
rates of all-inside meniscal repairs avulsions in conjunction with ACL term subjective outcomes.11 How-
were significantly higher than inside- reconstructions remains unclear. ever, compared with meniscal
out (16% versus 10%; P = 0.016) Some investigators have recommended pathology, the volume of literature
despite shorter mean follow-up times repair based on the known biome- focused on treatment of chondral
(58 versus 76 months).31 Implant- chanical effect of these injuries in rela- defects in conjunction with ACL
related complications were also sig- tion to knee stability;19,20,28 however, reconstruction is significantly infe-
nificantly higher with all-inside clinical data supporting this are lim- rior. The medial femoral condyle is
devices. The authors proposed that ited. Although high-powered studies the most common location reported
the inside-out technique be the current are lacking, a single level III investi- overall; however, lateral femoral
benchmark with ACL reconstruction gation evaluating 33 patients at condyle defects are also reported in
but acknowledged the need for long- a mean follow-up of 10.6 years both acute and chronic cases5-7
term randomized studies with modern demonstrated no significant difference (Figure 3). In a large, level-III review
implants. A large level II cohort of in IKDC scores compared with a of 2,770 patients, 4.5% were found
4,691 patients with 2-year follow-up matched control group (84.6 6 14 to have an isolated high-grade
found that only medial meniscal re- versus 90.5 6 13; P = 0.09). However, chondral defect (treated with
pairs had significantly worse Knee the avulsion cohort had increased benign neglect, mean size 1.7 cm2) in
injury and Osteoarthritis Outcome lateral compartment joint space nar- the absence of meniscal pathology.
Score (KOOS) subscales compared rowing radiographically (1.0 6 1.6 Compared with a cohort without
with isolated ACL reconstructions versus 0 6 1.1 mm; P , 0.006).33 meniscal or chondral pathology, at
(Symptoms: b = 22.5; CI, 24.6 Markedly unstable root tears may mean follow-up 8.7 years, IKDC
to 20.5; P = 0.023, Quality of Life: be repaired with transosseous su- scores were statistically lower but
b = 23.8; CI, 26.8 to 21; P = 0.009). tures (Figure 2). differences were likely not clinically
However, all other treatments had no High-level clinical evidence on the significant (medial: 1.2; P = 0.0451,
effect, including any lateral meniscal effect of meniscal integrity on post- lateral: 3.1; P = 0.0047).35 A similar
intervention.32 The authors hypoth- operative stability is also lacking. study also compared untreated high-
esized that the respective negative One level III review of 482 patients at grade defects (mean size 2.1 cm2) at
and positive effects of partial mean 7.6 years postoperatively found 10- and 15-year follow-up with a
meniscectomies and repairs may not significantly higher KT-1000 side-to- matched control group. Findings
be evident with relatively short follow- side differences in patients with any included no subjective difference at
up. In terms of large, unstable tear medial meniscal resection compared 10 years and statistically, but again,
patterns, a comparison of inside-out with intact medial menisci (2.6 6 1.7 not likely clinically significant, lower
repair versus débridement of bucket- versus 2.0 6 1.5 mm; P = 0.0065), total IKDC scores at 15 years (79.6
handle tears in patients without but no differences in graft failures versus 83.7; P = 0.031).8
chondral damage has been evaluated were reported.11 In a recent level III Bone contusion patterns have long
with nonrandomized level III evidence. study with median follow-up been recognized in association with
Lateral tears were repaired more fre- 26 months, 118 patients were eval- ACL injury with questionable long-
quently (74% versus 36%) because of uated after anatomic single bundle term effect on articular cartilage.
higher rates of degenerative findings hamstring tendon autograft ACL The most common location for this
medially. In both groups, subjective reconstruction. The investigators finding is the lateral tibial plateau
outcomes (International Knee Doc- found that medial and lateral me- followed by the lateral femoral
umentation Committee [IKDC]) were niscal deficiency were the highest condyle.36 A recent review found no
correlation between severity or vol- Figure 2

ume of bony contusions with clinical
outcomes after ACL reconstruction.
However, 21% of lateral contusions
were associated with a “clinically
significant” chondral defect (defined
as Outerbridge $2) and resulted in
markedly worse outcomes at all
measured time points (Figure 4).
Notably, patients with these defects
were on average older (33.9 versus
26.4 years) and heavier (body mass
index, 27.8 versus 24.3) than iso-
lated contusion patients.36
Repair Techniques
High-level studies evaluating ACL
reconstruction with concurrent car-
tilage repair are lacking. Techniques Unstable lateral meniscal root tear, displaced into joint space (A). Root secured
described include chondroplasty, with racking stitch (B). Drill guide used to create a docking tunnel for repair (C).
microfracture, autologous chondrocyte Final repair with sutures secured through the tibia (D).
implantation, and osteochondral
autograft/allograft transplantation.
Reviews consistently report suc-
cessful outcomes; however, most of Figure 3
these studies are level IV case
series.7 In a level II, nonrandomized
comparison of microfracture,
débridement, or benign neglect of
full-thickness cartilage defects in 357
patients (mean age, 36) at the time of
ACL reconstruction, the authors
noted at 2-year follow-up that KOOS
subscales of Sports/Recreation and
Quality of Life were significantly
lower with microfracture (b = 28.6;
95% CI, 216.4 to 20.7, and
b = 27.2; 95% CI, 213.6 to 20.8)
regardless of age, defect size, or
associated meniscal pathology. No
notable difference between débride-
ment and benign neglect was found.37
A prospective, randomized level II
(nonblinded) study comparing os-
teochondral autograft transplanta-
tion, microfracture, and débridement
of high-grade defects (mean, 2.6 cm2)
in conjunction with ACL recon-
struction found at mean 36-month Massive lateral femoral condyle chondral defect associated with an acute
follow-up superior results with anterior cruciate ligament tear with a fragment displaced into posterior joint
osteochondral autograft transplan- space (A and B). Arthroscopic view of large full-thickness chondral loss (C).
Retrieval of loose body through intercondylar notch (D).
tation compared with microfracture
February 1, 2019, Vol 27, No 3 81
Figure 4 medial meniscal repairs and im-

Clinical Implications proved outcomes with nontreatment
of lateral meniscal tears.6,38 Addi-
Several studies have attempted to
tionally, repair or resecting more
qualify patient outcomes after ACL
than 50% of the lateral meniscus
reconstruction based on multiple
resulted in improved quality of life
patient and pathologic variables,
and activity scores, whereas resect-
including the presence of meniscal
ing more than 50% of the medial
and chondral lesions (Table 3).
meniscus improved pain scores.6
Scandinavian population-based stud-
Currently, an explanation for the
ies provide the greatest patient observation of improved outcomes
numbers; however, they have rela- in both nontreatment of lateral me-
tively poor follow-up and provide niscal tears or large resections of
limited details of treatment. One either meniscus is lacking. In the same
such study with 54% follow-up studies, the presence of chondral
Sixteen-year-old man with a typical reported 2-year outcomes based on defects negatively affected outcomes
lateral bony contusion pattern meniscal and chondral pathology.
associated with pivot-shift mechanism but varied based on the defect loca-
in anterior cruciate ligament injury. Of Only the presence of high-grade tion. A level-III review with longer
note, an associated subchondral chondral defects was associated mean follow-up of 8.6 years found
impaction injury is noted posterior to with worse KOOS outcomes at 2 that both meniscal resections and
the sulcus terminalis. years, although a subanalysis based chondral defects were associated
on meniscal tear treatment was not with worse subjective outcomes.11
(P = 0.024) or débridement (P = performed.2 Two level I prospective Data from revision reconstructions
0.018).39 No difference between investigations, both reporting on demonstrate similar findings with
microfracture and débridement was data from the same pool of patients previous meniscectomies and chondral
noted, although all modalities were with 6-year follow-up, found, com- defects, particularly trochlear, neg-
inferior to a control group with in- pared with uninjured menisci, worse atively affecting outcomes at 2-year
tact articular cartilage. patient-reported outcomes with follow-up.4
Table 3
Summary of Conclusions (Levels of Evidence)
Lateral meniscal tears are more often associated with acute, primary ACL tears and occur less frequently in chronic ACL
tears and failed reconstructions (III)
Increasing time from injury and increasing episodes of instability result in higher rates of chondral defects and medial
meniscal tears (II, III)
Meniscal tears and previous partial meniscectomies have higher associations with corresponding compartmental chondral
defects in both primary and revision ACL reconstructions (II)
Failed ACL reconstructions have higher rates of chondral injury than primary cases, which partially depends on meniscal
integrity. Rates of patellofemoral chondrosis are higher in revision cases (II)
Benign neglect of stable meniscal tears in association with ACL reconstruction leads to generally acceptable outcomes;
however, medial meniscal tears left in situ are associated with higher revision surgery rates than lateral tears (9.5%-16.3%
versus 3.0%-5.8%).3,4 Detailed outcomes comparing treatment modalities in specific tear subtypes are generally lacking.
Success rates for repair of unstable, nondegenerative meniscal tears is high, with better survival rates with inside-out
techniques compared with all-inside techniques (III, IV)
Emerging biomechanical and clinical data suggest that meniscal deficiency negatively affects graft integrity after ACL
reconstruction; however, this area needs further long-term clinical validation (III, IV)
Successful patient-reported outcomes have been demonstrated with multiple treatment modalities for chondral defects,4 as
well as benign neglect,3 when performed in conjunction with ACL reconstruction. However, the current level of evidence
and volume of literature are insufficient for clear treatment recommendations (II)
The presence of chondral defects consistently results in lower intermediate-to-long-term patient-reported outcomes. Lateral
meniscal tears in general have less negative effect on outcomes than do medial meniscal tears. (I, II)
ACL = anterior cruciate ligament
8. Widuchowski W, Widuchowski J, Koczy B,

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February 1, 2019, Vol 27, No 3 83
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Review Article
Diagnosing Sacroiliac Joint Pain
Abstract
Dinesh P. Thawrani, MD, FACS The sacroiliac joint (SIJ) is a diarthrodial joint that has been implicated
Steven S. Agabegi, MD as a pain generator in approximately 10% to 25% of patients with
mechanical low back or leg symptoms. Unique anatomic and
Ferhan Asghar, MD
physiologic characteristics of SIJ make it susceptible to mechanical
stress and also create challenges in the diagnosis of SIJ pain. A
variety of inciting causes for SIJ pain may exist, ranging from repetitive
low-impact activities such as jogging to increased stress after
multilevel spine fusion surgery to high-energy trauma such as in motor
vehicle accidents. Similarly, wide variability exists in the clinical
presentation of SIJ pain from localized pain or tenderness around the
SIJ to radiating pain into the groin or even the entire lower extremity.
No pathognomonic clinical history, physical examination finding, or
imaging study exists that aids clinicians in making a reliable diagnosis.
However, imaging combined with clinical provocative tests might help
to identify patients for further investigation. Although provocative
physical examination tests have not received reliable consensus, if
three or more provocative tests are positive, pursuing a diagnostic SIJ
injection is considered reasonable. Notable pain relief with intra-
articular anesthetic injection under radiographic guidance has been
shown to provide reliable evidence in the diagnosis of SIJ pain.
From the Department of Orthopedic
Surgery (Dr. Thawrani), Cincinnati VA
Medical Center, University of
Cincinnati College of Medicine, and
the Department of Orthopedic
Surgery, University of Cincinnati
T he etiology of low back pain is
often difficult to determine,
given overlapping clinical signs and
Anatomy
College of Medicine (Dr. Agabegi and
Dr. Asghar), Cincinnati, OH. symptoms originating from an enor- Bony and Ligamentous
mous number of pathophysiologic Anatomy
Dr. Asghar or an immediate family
member serves as a board member, and psychosocial causes. Investigators The SIJ is a true diarthrodial synovial
owner, officer, or committee member have shown that diagnostic studies, joint that serves as a connecting link
of the American Academy of history, and physical examination between the axial and appendicular
Orthopaedic Surgeons and the
American Orthopaedic Association.
can be combined to identify some skeleton. The anterior third of the
Neither of the following authors nor cases and ascertain that approxi- interface between the sacrum and
any immediate family member has mately 10% to 25% of time, low ilium is a true synovial joint, covered
received anything of value from or has back pain or leg pain originates by hyaline cartilage that provides a
from the sacroiliac joint (SIJ). gliding surface between the bones.
related directly or indirectly to the However, in the absence of trauma, The rest of the joint has fibrocartilage
subject of this article: Dr. Thawrani tumor, or metabolic diseases di- and is composed of an intricate set
and Dr. Agabegi. rectly affecting the SIJ, its role in of ligamentous connections, which
J Am Acad Orthop Surg 2019;27: generating low back pain is difficult give inherent stability to the joint.
85-93 to diagnose. Understanding the anat- The posterior capsule is rudimentary
DOI: 10.5435/JAAOS-D-17-00132 omy, function, and biomechanics of and is almost replaced by extensive
this particular joint is important to ligamentous structures. Overall, the
Academy of Orthopaedic Surgeons. understand the pathophysiology of articular surfaces are rough and
SIJ dysfunction. have many ridges and depressions
February 1, 2019, Vol 27, No 3 85
that minimize movement and en- mean rotation ranged between 1 and maximus, piriformis, biceps femoris,
hance stability. The coarse nature of 12 mm, and mean translation ranged and thoracolumbar fascia, as all of
the SIJ is considered to be an adap- between 3 and 16 mm, with the caveat these are functionally attached to the
tation to stress across this vertically that measurements differed based SIJ. The SIJ is in very close proximity
oriented joint located in axial spine, on patient position. Interestingly, a to the lumbosacral plexus.5,6 The
and therefore, it varies among in- roentgen stereophotogrammetric anal- sacral articular cartilage of the joint
dividuals and changes with age.1 ysis conducted by Sturesson et al4 is twice as thick as the iliac cartilage,
found no differences in either rota- whereas the subchondral iliac bone
Innervations tional or translational movements end-plate is 50% thicker than that of
between symptomatic and asymp- the sacrum. This finding may explain
The lateral branches of L4-S3 dorsal
tomatic joints. why degenerative changes on the
rami supply the posterior SIJ, whereas
The SIJs are the connecting link sacral side usually lag 10 to 20 years
some studies suggest contribution from
between the axial skeleton and lower behind those affecting the iliac sur-
L3 to S4 dorsal rami. The anterior
extremities. The literature is unclear face.13 In addition, the natural his-
joint is innervated by L2-S2.1 The SIJ
whether the primary function of tory of capsular structures of the SIJ
and lumbosacral plexus are in close
the SIJ is supportive or to provide is conversion into markedly rigid
proximity. Various patterns of ex-
mobility. However, with the avail- collagenous and fibrous ankylosis,
travasation of the fluid from SIJ to
able literature on SIJ anatomy (intra- leading to restricted motion by the
the nearby neural structures have
articular band of ligaments and sixth decade and inevitable erosion
been demonstrated: mainly posterior
surrounding thick ligaments) and and plaque formation by the eighth
extravasation into the dorsal sacral
motion (limited motion in all planes), decade of life.7,8
foramina, superior recess extravasa-
it is reasonable to conclude that the
tion at the sacral alar level to the L5
main function of this joint is stability,
epiradicular sheath, and ventral ex- Clinical Presentation
for transmission and dissipation of
travasation to the lumbosacral plexus.
truncal load to the lower extremities.
Because of the insufficient capsular History
Biomechanical studies found that
envelope around the SIJ the inflam-
because of their distinct anatomy and SIJ pain has numerous systemic
matory pain mediators can leak
location, the SIJ can only withstand and/or local etiologic factors; there-
through any of these pathways into
half the torsion and 1/20th of the fore, a thorough history of clinical
the neural structures. This mech-
axial compression load compared symptoms and a general medical
anism may explain the radicular leg
with lumbar spine, which may strain history are paramount in all patients
pain (sciatica) that is commonly seen
and injure the weaker anterior joint with suspected SIJ dysfunction. SIJ-
with SIJ pathology.2
capsule.1 related pathologies include trauma,
The SIJ has several unique ana- infection, or inflammatory diseases
Function and Biomechanics tomic characteristics that may render such as ankylosing spondylitis, Reiter
Ligaments around and within the it vulnerable to unusual stress and syndrome, rheumatoid arthritis, and
joint prevent separation of the joint strain. The SIJ is the largest axial joint psoriatic arthritis. Secondary con-
and provide movement of the pelvis in the body with an average surface ditions causing SIJ pain include spi-
along the various axes of the sacrum. area of 17.5 cm2. Only the anterior nal fusion, scoliosis, and leg-length
The SIJ rotates about all three axes, third of the interface between the discrepancy.9,10
although the movements are very sacrum and ilium is a true synovial The pain diagram is often helpful.
small. Several cadaveric studies conjoint, and the rest is composed of Fortin et al11 generated a pain referral
cluded that sagittal plane motion an intricate set of ligamentous con- map in asymptomatic volunteers after
often ranges between 1 and 4 and nections functioning as a connecting SIJ injection. A specified hypesthetic
translation between 0.5 and 2 mm. band limiting motion in all planes of area, approximately 10 cm caudally
Male patients tend to have transla- movement. The posterior capsule of and 3 cm laterally from the poste-
tional motion, whereas female patients the SIJ is absent or rudimentary. The rior superior iliac spine (PSIS), was
have more rotational motion.2,3 In joint is vertically oriented causing diagnosed immediately after the
women, the ligaments are weaker, more shearing forces across the joint, injection, which corresponds to the
allowing the mobility necessary for and these forces are concentrated in maximal pain. A typical patient with
parturition. Walker3 averaged reports the limited anterior synovial area. SIJ isolated SIJ dysfunction may char-
from various studies and found a mobility is affected by the action of acteristically localize pain just distal
wide range of motion in the SIJ, several muscles such as the gluteus and medial to the PSIS.12 However,
Dinesh P. Thawrani, MD, FACS, et al
the pain referral pattern from SIJ and Trendelenburg test. The SIJ in their study. They concluded that
does not seem to be limited to the should be palpated, and the maxi- SIJ etiology should be suspected in a
lumbar or buttock region. Slipman mum area of tenderness determined. patient in whom three or more pro-
et al8 found 18 different patterns of The Fortin finger test is considered vocative tests (out of six) reproduce
SIJ pain referral in their population. positive when the maximum point of the patient’s pain, which warrants
The most common symptom was tenderness is consistently within 2 cm further investigation to confirm the
buttock pain (94%) followed by inferomedial to the PSIS with one diagnosis of SIJ pain.18-21 If all six
lower lumbar pain (72%), and about finger. The reliability of this test was tests are negative, SIJ is excluded
14% reported of pain in the groin further confirmed by other inves- from the differential diagnosis of
area. Approximately 50% of pa- tigators.6,12,13 Straight leg raise test back or leg pain.19
tients also had pain in the lower and neurologic examination should Despite the above findings, studies
extremity; most common area was be performed to rule out spinal entirely disputing the use of provoc-
posterior and lateral thigh pain fol- pathology or nerve root stretch pain. ative tests in clinical practice exist. A
lowed by leg pain distal to the knee Several provocative tests14-16 are systematic methodological review of
(28%) and pain in the foot in 14%. described for the diagnosis of SIJ the literature performed by van der
Interestingly, they found younger pain, but data are lacking to sup- Wurff concluded that no evidence
patients to be more likely to report of port any single test as being highly exists showing the reliability of the
pain distal to the knee. This vari- sensitive.6 Some commonly per- clinical provocative tests.14 Other
ability can be attributed to several formed provocative tests for SIJ authors have come to the same
reasons including close anatomic pain, their sensitivity, specificity, conclusion.21
location of the lumbar plexus sup- reliability, and positive and nega- Several reasons exist as to why
plemented with poor capsular tive predictive values are summa- provocative tests are not reliable in
strength around the SIJ to the com- rized in Table 1. diagnosing SIJ pain. First, the range
plex nerve innervation of the SIJ, Dreyfuss et al6 studied 12 physical of motion of the SIJ is so limited that it
sclerotomal pain referral, or sec- diagnostic tests and found none of may be difficult to clinically repro-
ondary irritation of the adjacent them to be reliable in the diagnosis of duce and elicit the pain from motion.
structures.8 SIJ pain. van der Wurff et al17 The joint is anatomically confined
The patients’ history and clinical investigated a combination of mul- within a bony pelvic ring, and the
findings are often helpful to rule out tiple clinical tests in the diagnosis of intra-articular ligamentous band and
other pathologies that may mimic SIJ SIJ pain. They found that when three surrounding muscular and ligamen-
pain such as lumbar disc disease, or more provocation tests are posi- tous structures add notable stability.
tumor, hip joint pathology, myofascial tive, the probability is between 65% Dreyfuss et al22 conducted clinical
pain syndrome, and gastrointestinal, and 93% that the pain is related to provocation tests in asymptomatic
genitourinary, or gynecologic pa- the SIJ. With fewer than three posi- patients and found false-positive re-
thologies. Inflammatory disorders tive tests, the probability is between sults in more than 20% of volunteers
that also involve the SIJ should be 72% and 99% that the SIJ is not the and attributed this to the relative
investigated with appropriate radio- source of pain. When three or more hypomobility of a specific joint
graphs and laboratory tests in tests were positive, sensitivity was under test.
patients with doubtful history or 85%, specificity 79%, negative pre- Second, tests that presumably load
clinical findings suggestive of dictive value 87%, and positive the SIJ will also load and stress the
spondyloarthropathy. predictive value 77%. With only one structures surrounding the joint,
positive test, the specificity was only making it difficult to differentiate the
42% and the positive predictive origin of pain. The unique anatomy
Clinical Examination value was 59%. Similarly, Young of the SIJ, with weak anterior capsule
Physical examination of a patient et al18 supported that three or more and strong posterior ligaments, makes
with suspected SIJ dysfunction starts provocative tests are reliable for the it difficult to distinguish between
with an evaluation of gait pattern, diagnosis of SIJ pain. In addition, intra-articular and extra-articular
leg-length inequality, and lower they found that with SIJ pathology, pathologies. Several extra-articular
lumbar examination to rule out any patients rarely presented with mid- structures exist around the SIJ that
obvious deformity secondarily caus- line pain or pain above the L5 spi- can be pain generators, such as
ing SIJ symptoms. In addition, hip nous process. Pain exaggeration facet joint pain, iliolumbar syn-
joint pathology should be ruled out while rising from sitting position was drome, and superior cluneal nerve
with a range of motion examination also highly correlated with SIJ origin entrapment. Eskander et al23 found
February 1, 2019, Vol 27, No 3 87
Table 1
Describes Methods of Commonly Used Provocative Tests, Their Sensitivity, Specificity, Reliability, and Positive
and Negative Predictive Values8,13,16,18,37-42
Positive Negative
95% CI 95% CI Predictive Predictive
Test Method Sensitivity Specificity Reliability Value Value
FABER (flexion, Patient position: Supine 57-77 40%-100% 85%-96% 81 60

abduction, external
rotation) test/Patrick
test/figure-four test
The examiner places the — — — — —
patient’s leg so that the foot
of the test leg is on the top of
the knee of the opposite leg.
Then, the examiner slowly
pushes the knee toward the
table, while stabilizing the
opposite ASIS ensuring that
lower back is in neutral
position. A positive test is
indicated by the test leg’s
knee remaining above the
opposite straight leg with the
reproduction of the patient’s
exact pain. Anterior hip/
groin pain indicates an
iliopsoas strain or hip
disorder, SIJ pain indicates
SIJ dysfunction while
posterior hip pain suggests
posterior hip impingement.
Gapping test/distraction Position: Supine with affected 11%-60% 90-100 88%-94% 60 81
test side close to the side of the
table.
The examiner applies — — — — —
pressure to both ASIS in the
dorsal and lateral direction.
The test is positive when the — — — — —
patient’s exact pain is
reproduced.
Compression test/ Position: Side posture with the 0-19 90-100 74%-91% 52 82
approximation test affected side up and the back
toward the side of the
examiner. Hips are flexed to
approximately 45 and knee
to 90.
The examiner places folded — — — — —
hands over the lateral
prominent iliac crest and
apply a downward pressure.
reproduced.
(continued )
ASIS = anterior superior iliac spine, SIJ = sacroiliac joint
examination under fluoroscopy to than any other clinical provocative tion to localize the point of maxi-
be a more specific (80%) and with test. This fluoroscopically guided test mum tenderness to help rule out
higher positive predictive value (93%) was performed in the prone posi- some of these obvious surrounding
Describes Methods of Commonly Used Provocative Tests, Their Sensitivity, Specificity, Reliability, and Positive
and Negative Predictive Values8,13,16,18,37-42
Positive Negative
95% CI 95% CI Predictive Predictive
Test Method Sensitivity Specificity Reliability Value Value
Thigh thrust test/ Position: Supine with 36-88 50-100 82%-94% 58 92

femoral shear test contralateral leg extended
and ipsilateral leg flexed
approximately 90 at hip.
Then, the examiner slightly
adducts the femur. The
examiner’s one hand cups
the sacrum and the other
arm and hand wraps around
the flexed knee. The
examiner applies a graded
force through the long axis
of the femur, which causes
anterior to posterior shear to
the SIJ on the same side.
reproduced.
Gaenslen test/pelvic Position: Supine 21-71 26-72 82%-88% 47 76
torsion test
One leg lies over the edge of — — — — —
the table and other hip and
knee are flexed toward the
patient’s chest. The
examiner applies firm
pressure to the flexed knee
toward the chest and a
counter pressure to the knee
of the hanging leg toward
the floor.
reproduced.
Sacral thrust test/sacral Position: Prone. 3-63 29-100 66%-78% 56 80
base spring test
The examiner applies a — — — — —
pressure vertically
downward on the center of
the sacrum.
reproduced.
More than three — 92%-94% 78%-87% — 77 (95% CI: 87 (95% CI,
positive tests 62-92) 74-99)
ASIS = anterior superior iliac spine, SIJ = sacroiliac joint
structures. However, it gets more corticosteroid at the posterior inter- Murakami et al25 found similar re-
dubious when the pain generator is osseous ligaments and S1-3 lateral sults; the improvement rate after
the posterior SIJ ligaments rather branches in addition to the SIJ and periarticular injection was 96%,
than intra-articular pathology. Bor- found 47% increase in patients’ which was significantly higher
owsky and Fagen24 directed the response to the anesthetic block. than that after the intra-articular
February 1, 2019, Vol 27, No 3 89
Figure 1 only 12% to 46%. The positive pre-

dictive value and the negative pre-
dictive value of bone scans are 86%
and 72%, respectively. Because of
low sensitivity, bone scan should not
be included in the routine diagnostic
algorithm of SIJ pain. However, at
times compared with MRI, we found
bone scan to be more advantageous
because increased uptake often helps
to identify stress fractures, inflam-
matory changes, and infection or pri-
mary and metastatic tumors as well.
Bone scan is also helpful when a diag-
Arthrogram showing AP (A) and lateral SIJ (B) under fluoroscopic guidance nostic block cannot be performed.31,32
before injecting anesthetic agent. SIJ = sacroiliac joint In general, limited evidence exists
for the diagnostic accuracy of any
imaging modality in diagnosing SIJ
injection, which was 62%. These represent from mild erosion (grade 1) pain.26 The choice of radiographic
sults suggest that the prevalence of SIJ to ankylosis (grade 4) on plain investigation should depend on the
pain, when reported only by SIJ intra- radiographs according to the modi- clinical presentation and history of
articular injection response, may be fied New York criteria.27 So, starting the individual patient. We do not
underestimated. Furthermore, the with a plain AP pelvis is reasonable routinely obtain advanced imaging
clinical provocative tests may have a to only rule out any other obvious studies for the diagnosis of SIJ dys-
high false-positive result because of reasons for pain. However, the sig- function. These tests are more help-
the difficulty in distinguishing intra- moid shape and oblique orientation ful in ruling out other sources of
articular versus extra-articular pain by of the SIJ creates challenges in pain.
clinical examination. visualization by conventional radio-
Finally, the degree and duration of graphs. Cross-sectional studies such
force applied by the examiner per- as CT, MRI, and single photon Diagnostic Injections
forming the provocative tests may emission CT carry distinct advan- Because of the lack of reliable clinical
vary and is influenced by patients’ tages because of their ability to cre- and radiologic studies to diagnose SIJ
body habitus. At times, myofascial ate multiplanar visualization of the pain, the use of SIJ contrast enhanced
pain and dermatomal stretch also joint. CT scan shows erosive joint injections under fluoroscopic guid-
aggravate the low back pain giving changes and subchondral sclerosis. ance has become more common as a
false-positive results. Table 1 shows Elgafy et al reported that CT was diagnostic and therapeutic option.
the variability and range of reliability only 57.5% sensitive and 69% spe- To minimize unnecessary diagnostic
data of various tests as reported by cific in the diagnosis of SIJ pain. The injections, several investigators have
various investigators. Wide variation authors concluded that with clinical suggested that only patients with
exists in the sensitivity and specificity suspicion of a sacroiliac origin of three or more positive provocative
of each test, and generally, the tests pain, intra-articular injection is the clinical tests or patients with isolated
have low positive predictive value only means to confirm the diagno- localized SIJ pain and positive Fortin
and relatively higher negative pre- sis.28 MRI can detect early inflam- Finger tenderness be candidates for a
dictive value. Therefore, these tests mation and soft-tissue pathology of diagnostic SIJ injection.17,18,33
are more helpful in ruling out SIJ the SIJ in patients with spondy- Good evidence exists to support
dysfunction than in diagnosing this loarthropathy.29 Edema and early single or dual blocks for the diagnosis
condition. erosive changes across the SIJ iden- of SIJ as a pain generator when pain
tified on MRI are sometimes useful relief cutoff is set between 75% and
in the diagnosis or staging of spon- 100%.16,26 Evidence is fair when
Radiographic Tests dyloarthropathy.30 MRI can also the cutoff is set between 50% and
No imaging studies have been found rule out other sources of pain. 74%.17,33 Depending on the pain
to be accurate in diagnosing SIJ The specificity of nuclear bone response cutoff value and inclusion
pain.26 Inflammatory sacroilitis can scans is 90%, with the sensitivity of criteria designed in a particular
Figure 2
Flowchart showing the algorithm useful in a patient with suspected SIJ pain. LBP = low back pain, PSIS = posterior superior
iliac spine, PT = physical therapy, ROM = range of motion, SIJ = sacroiliac joint
February 1, 2019, Vol 27, No 3 91
study, the prevalence of SIJ pain is surrounding stability from various tive provocative tests, and possible
reported anywhere from 10% to ligaments posteriorly. These rare imaging findings may implicate the
as high as 62%.16,18,19,26,34,35 A characteristics make the SIJ vulnera- SIJ as the source of pain, and these
prevalence of greater than 50% was ble to various modes of stress. Pro- patients should be considered for an
reported in a well-selected pop- vocative clinical tests have low SIJ injection, which may be diag-
ulation.6,16,26 Most studies suggest sensitivity and specificity. Similarly, nostic and therapeutic. If the injec-
a point prevalence of approximately the unique anatomy, with oblique tion leads to at least 75% pain relief,
25%.16 Comparative local anesthetic orientation and uneven and sigmoid the SIJ is the likely pain generator.
blocks are also useful when the di- shape of the joint along with vari-
agnosis is still in doubt and/or the first able composition from synovium to
block response was false-positive. In fibrous to ligamentous structures, References
this scenario, repeated blocks are makes imaging the joint challenging
given at different occasions with dif- from a diagnostic standpoint. In References printed in bold type are
ferent anesthetic agents (with varying 2013, the American Society of Inter- those published within the past 5
duration of action) to ascertain the ventional Pain Physicians reported in years.
efficacy of the block.20 their evidence-based guidelines that 1. Cohen SP: Sacroiliac joint pain: A
Radiographic localization of the SIJ good evidence exists for the diagnosis comprehensive review of anatomy,
diagnosis, and treatment. Anesth Analg
by arthrography is important before of SIJ pain utilizing controlled com- 2005;101:1440-1453.
injecting the anesthetic agent, as di- parative local anesthetic blocks, fair
2. Fortin JD, Tolchin RB: Sacroiliac
agnostic specificity of the injection evidence for provocative testing, and arthrograms and post-arthrography
will be otherwise compromised limited evidence for the diagnostic computerized tomography. Pain Physician
2003;6:287-290.
(Figures 1 and 2). Rosenberg et al36 accuracy of imaging in identifying
showed that only 22% of patients painful SIJ.26 Similar results were 3. Walker JM: The sacroiliac joint: A critical
review. Phys Ther 1992;72:903-916.
received an intra-articular injection found in two different independent
when the injection was performed by systematic reviews of the available 4. Sturesson B, Selvik G, Udén A: Movements
of the sacroiliac joints: A roentgen
clinical palpation only. They per- literature conducted by Rupert et al stereophotogrammetric analysis. Spine
formed immediate postinjection CT and Simopoulos et al.16,33 (Phila Pa 1976) 1989;14:162-165.
scan and found that most injected However, enough evidence exists 5. Fortin JD, Vilensky JA, Merkel GJ: Can the
material was within 1 cm of the joint to support that the SIJ is a potential sacroiliac joint cause sciatica? Pain
Physician 2003;6:269-271.
in the posterior area medial to the pain generator that must be consid-
iliac bone and the remaining material ered within the differential diagnosis 6. Dreyfuss P, Michaelsen M, Pauza K,
McLarty J, Bogduk N: The value of
had leaked into the sacral neural of low back pain, buttock pain, and medical history and physical examination
foramen and epidural spaces. radicular pain. Because of the lack of in diagnosing sacroiliac joint pain.
The average SIJ volume in reliable clinical and radiologic tests, Spine (Phila Pa 1976) 1996;21:
2594-2602.
symptomatic patients is 1.08 mL physicians should use a combination
(range, 0.8 to 2.5). Therefore, ap- of provocative tests and diagnostic 7. Bowen V, Cassidy JD: Macroscopic and
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rior capsule to the neural structures performed meticulously under fluo- 8. Slipman CW, Jackson HB, Lipetz JS, Chan
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February 1, 2019, Vol 27, No 3 93
Review Article
Cervical Disk Arthroplasty
Abstract
Theodore D. Koreckij, MD Anterior cervical diskectomy and fusion has been and remains the
Sapan D. Gandhi, MD benchmark surgical management of cervical degenerative disk disease.
However, an increased use of cervical disk arthroplasty (CDA) has been

Daniel K. Park, MD
found in the past few years. The purported benefits of CDA included
preserved motion, less adjacent-level degeneration, and less morbidity.
Short-term results from randomized control trials clearly showed
noninferiority of CDA compared with fusion. With long-term comparison
data becoming available, results are equivalent and superior in many
metrics compared, favoring CDA. Concerns remain regarding the best
way to manage CDA failures. Nonetheless, appropriate patient selection
and adherence to strict surgical technique make CDA a viable treatment.
C ervical myelopathy and/or radi-

culopathy are among the most
common indications for cervical spi-
sion of degenerative cervical spine
pathology.3
Recently, motion-sparing interven-
nal surgery. Anterior cervical diskec- tion to the cervical spine has gained
tomy and fusion (ACDF) has been popularity as an alternative to tradi-
considered the “benchmark” surgical tional ACDF. In particular, cervical
intervention for decompression and disk arthroplasty (CDA) was de-
stabilization in the cervical spine. veloped with the goal of preserving
ACDF has extensive supporting liter- cervical range of motion (ROM), pre-
From Dickson-Diveley Midwest ature showing excellent results, with venting symptomatic ASD, and im-
Orthopaedic Clinic, Leawood, KS outcomes comparable with those of proving clinical outcomes. In addition,
(Dr. Koreckij), the Department of total hip arthroplasty.1 Although although ACDF is a largely successful
Orthopaedic Surgery, Beaumont
Hospital-Royal Oak, Royal Oak, MI ACDF is a successful surgery, adja- surgery, concerns about pseudarthrosis
(Dr. Gandhi), and Michigan cent segment disease (ASD), defined exist, particularly in smokers.4 CDA
Orthopaedic Institute, Southfield, MI as symptomatic radiculopathy and/or circumvents some of the challenges
(Dr. Park). myelopathy adjacent to a previous involved in obtaining bone graft and
Dr. Park or an immediate family successful spinal fusion severe enough ensuring fusion. As long-term data on
member serves as a paid consultant to warrant management, has an outcomes compared with ACDF,
to K2M and Stryker and has stock or
stock options held in Johnson and
incidence of 2.9% per year after complications, and cost analysis begin
Johnson. Neither of the following cervical fusion.2 It is important to to become available, the role of CDA
authors nor any immediate family highlight that ASD in this review will in clinical practice will become clearer.
member has received anything of be used in cases of clinically
symptomatic ASD as opposed to
or institution related directly or radiographic ASD. The cause of ASD Cervical Spondylosis
indirectly to the subject of this article: in the setting of anterior cervical Pathoanatomy and Natural
Dr. Koreckij and Dr. Gandhi. fusion remains a topic of some con- History
J Am Acad Orthop Surg 2019;27: troversy. The controversy revolves
e96-e104 around whether fusion of a cervical Degenerative changes in the cervi-
DOI: 10.5435/JAAOS-D-17-00231 spine segment creates increased stress cal spine are a ubiquitous and nat-
at adjacent segments, accelerating ural consequence of aging. In most
Academy of Orthopaedic Surgeons. degeneration at those levels, or that of the population, these changes are
ASD represents the natural progres- asymptomatic. However, degenerative
Theodore D. Koreckij, MD, et al
changes in the cervical spine can tients who have failed nonsurgical interface and may theoretically
become pathologic, presenting as axial treatment of cervical radiculopathy increase the risk of implant loosening
neck pain, cervical radiculopathy, and/or myelopathy secondary to one- and migration.9 The Bryan disk is an
and/or cervical myelopathy. Cervical level spondylosis.8 The Mobi-C (LDR) example of a single-piece design.
radiculopathy typically follows a prosthesis has been approved for two- Multipiece design refers to multiple
benign natural history. In a population level cervical spondylosis. Pathology separate pieces that are implanted and
based study by Radhakrishnan et al,5 causing symptoms (confirmed by articulate with one another. Prodisc-C
90% of patients initially diagnosed MRI) must be primarily anterior-based is an example of a multipiece pros-
with cervical radiculopathy were to be adequately addressed by CDA. thesis. The multipiece prosthesis has
asymptomatic or minimally affected by Contraindications include three or the theoretic advantage of distribut-
their symptoms at almost 6 years of more levels that require treatment, ing the stress through the prosthesis
follow-up, with approximately 26% of cervical instability, known allergy to through multiple pieces of the device.9
patients requiring surgical intervention implant materials, active local or Long-term data comparing single-
at some point in their disease course. In systemic infection, osteoporosis or piece and multipiece designs are scarce.
cervical radiculopathy, surgical inter- osteopenia, previous surgery at the Some second-generation CDA pros-
vention should be considered when level to be treated, posttraumatic theses have incorporated axial com-
nonsurgical management has failed. vertebral body deformity, segmental pression into implant design. The
In contrast, cervical myelopathy is kyphotic deformity, and notable fac- rationale of these disks is to allow for
generally accepted as a progressive et joint arthropathy.8 Patients should physiologic axial compression, al-
disorder that typically does not re- be counseled that despite appropri- though long-term literature showing
spond to nonsurgical management.6 ate review of preoperative imaging, any advantage over more conven-
Clarke and Robinson7 first described intraoperative findings may preclude tional CDA designs is sparse. This
the natural history of cervical mye- the placement of CDA, and they may CDA prosthesis design uses a poly-
lopathy in 1956 with their report of require ACDF instead. Endplate de- carbonate urethane nucleus with
120 patients in which 75% patients fects, inability to achieve adequate woven polyethylene annulus. The
deteriorated in a stepwise fashion with sizing or fixation of the arthroplasty Freedom (Axiomed) and M6-C (Spi-
intervening periods of stable symp- device, body habitus inhibiting nal Kinematics) are two examples of
toms, 20% with a gradual and steady adequate fluoroscopic imaging, or axial compression disks using visco-
decline, and 5% with a rapid decline. vascular/neurologic complications elastic cores. These prostheses are not
However, since this initial description, precluding safe and stable place- available in the United States.
determining how rapidly each indi- ment of the prosthesis may require Devices vary on the amount of
vidual patient will progress remains the surgeon to abort to an ACDF. constraint they possess. They can be
elusive. Nonsurgical treatment should In a series of 167 patients who classified as constrained, semicon-
be considered only in mild cases of underwent ACDF, Auerbach et al8 strained, and nonconstrained, de-
cervical myelopathy. Surgical inter- found that 43% of patients had in- pending on the degree of freedom
vention should be strongly considered dications for a CDA, whereas the allowed by the design. Constrained
in patients with moderate or severe other 57% had contraindications devices allow less than physiologic
cervical myelopathy with the under- precluding them from a CDA. They motion, semiconstrained devices
standing that surgery is aimed at concluded that a notable number of allow physiologic levels of motion,
halting progression and not all pa- patients who currently underwent and nonconstrained devices allow
tients will experience full recovery of ACDF would benefit from potentially greater than physiologic ROM. Non-
their neurologic function. For both improved outcomes from CDA. constrained devices depend on sur-
cervical radiculopathy and mye- rounding anatomic structures, such as
lopathy, ACDF remains one of the the posterior ligamentous complex
mainstays of surgical treatment, with Implant Design and the facet joints, to prevent ex-
CDA emerging as an alternative. tremes in ROM. Caution should be
Several factors are involved in CDA used when using nonconstrained
design. The prosthesis can be single- devices in the setting of previous spine
Indications and piece or multipiece designs. Single- surgery.10 Most of the CDA devices
Contraindications piece designs more closely resemble available are semiconstrained.
the native disk; however, all the stress For the most part, fixation of the
The current indications for CDA used through the disk are transmitted CDA device occurs through bony
in the FDA clinical trials include pa- through the vertebral body-prosthesis ingrowth at the prosthesis-endplate
February 1, 2019, Vol 27, No 3 e97
interface. Most of the devices and reducing the motion and stress results similar to Park et al,14 finding
approved for use in the United States seen by other levels in the cervical that the total contributions from the
possess a porous titanium-alloy spray spine. index and adjacent segments to total
coating to allow bony ingrowth. The Dmitriev et al11 analyzed intra- cervical ROM was consistent from
Prestige ST prosthesis used locking discal pressures after CDA and baseline to 2 years after CDA. In
screws that fix the device to the ver- ACDF in 10 cadaveric specimens. contrast, ACDF had reduced cervical
tebral body above and below. In They discovered that CDA preserved ROM at the surgical level, with
terms of materials used, most of the preoperative disk stress at adjacent markedly increased ROM at adja-
devices use ultra-high–molecular- levels. These findings were statisti- cent levels.
weight polyethylene on cobalt chro- cally different compared with the In a systematic review and meta-
mium alloy endplates (ie, Prodisc-C, increased intradiscal pressure found analysis exploring cervical kinemat-
Mobi-C, SECURE-C, PCM). The in the arthrodesis group. Chang ics after CDA by comparing with
Prestige ST and LP prostheses use et al12 reported similar findings in a those after ACDF, Anderson et al16
metal-on-metal articulations (ie, stain- biomechanical study of 18 cadaveric found no statistically significant dif-
less steel and titanium-ceramic alloy, specimens, comparing adjacent-level ference in in vivo cervical kinematics
respectively). The Bryan disk is a intradiscal pressure in CDA with at adjacent segments, specifically
single-piece prosthesis with tita- that in ACDF. adjacent segment angular motion,
nium endplates and polyurethane In contrast, in vivo studies have had adjacent segment translation, and
core. inconsistent results. In a prospective adjacent-level horizontal and vertical
Several factors could be considered randomized controlled trial (RCT), center of rotation.
when choosing a prosthesis. All of the Powell et al13 compared cervical Although in vitro studies examin-
approved devices in the United States kinematics of patients who under- ing cervical kinematics in CDA and
cause notable MRI artifact, with the went CDA with those of patients arthrodesis show the ability to
exception of the Bryan, which may who underwent ACDF via radio- maintain cervical ROM and protect
markedly limit postoperative evalu- graphic analysis. They found that adjacent segments from increased
ation of patients who have undergone adjacent segment sagittal angular stress, in vivo radiographic analyses
CDA. Most of the prostheses use, as motion was increased after both of cervical kinematics have been
described earlier, bony ingrowth at ACDF and CDA. They found no inconsistent.
the prosthesis-endplate interface, notable difference in sagittal motion
although the amount of bone resected at adjacent levels when comparing
varies from prosthesis to prosthesis. ACDF and CDA. They concluded Surgical Technique
Large keels/rails, such as the Bryan that although CDA preserved cervi-
disk, require notable bony resection, cal kinematics at the index level, no A standard Smith-Robinson approach
although they have the advantage of difference was found in motion at is used to expose the anterior cervical
having immediate press-fit. Those adjacent levels. spine. Strict hemostasis is ensured
prostheses with teeth or spikes, such In contrast, Park et al14 conducted a during the dissection to minimize risk
as PCM, require less bony resection; radiographic subanalysis of a proof heterotopic ossification (HO).
however, they may “settle” over the spective RCT comparing 272 patients After confirmation of the surgical
immediate postoperative period into undergoing single-level CDA with level, an anteroposterior view should
the endplates and may end up shift- 182 patients undergoing single-level also be taken to ensure that the center
ing before bony ingrowth takes ACDF. They found that, although of the disk space in the coronal plane
place. diminished, angular motion at the is identified and Caspar pin dis-
index level was preserved with CDA tractors place appropriately. Next,
at 1 year after surgery (8.0 to 6.2; diskectomy and decompression is
Kinematics of Cervical Disk P , 0.001). In addition, they done based on the surgeon’s prefer-
Arthroplasty reported that ACDF resulted in an ence. Adequate decompression of the
increase in the superior adjacent neural elements is ensured. Although
One of the goals of CDA is to improve angular motion at 1 year after sur- not imperative, the authors routinely
cervical spine kinematics compared gery (9.6 before surgery, 11 after remove the posterior longitudinal
with those obtained with fusion after surgery; P = 0.003), whereas CDA ligament to ensure adequate decom-
surgical intervention. More specifi- demonstrated preservation of pre- pression and aid in implant insertion.
cally, CDA aims at maintaining operative adjacent segment angular Before endplate preparation, a lateral
physiologic ROM at the index level motion. Auerbach et al15 published fluoroscopic image is taken to once
again ensure neutral sagittal align- disability index (NDI) scores, a underwent CDA compared with
ment of the index level. higher improvement in neurologic those in the 25 patients who under-
Next, the endplate is prepared for status, lower rates of revision surgery went ACDF at 10 years of follow-up.
prosthesis placement. The technique at the index level (4.8% versus Hisey et al21 reported the 5-year
for endplate preparation varies based 13.7%), and lower rates of revision clinical and radiographic outcomes
on the system and manufacturer of surgery for adjacent-level degenera- of the Mobi-C prosthesis (LDR)
the prosthesis. Prosthesis-specific tion (4.6% versus 11.9%). CDA and versus ACDF for one-level cervical
instrumentation varies and can ACDF patients had similar rates of spondylosis. They found that at
include keel preparation mills, end- return to work (approximately 60 months of follow-up, CDA and
plate mills, and rasps. Regardless of 73%). The CDA group maintained ACDF had similar rates of overall
specific instrumentation used for on average 6.75 of angular motion success, including similar improve-
endplate preparation, subchondral at 7 years. ments in NDI scores, visual analogue
bone violation should be avoided Gornet et al18 compared the 7-year scale neck and arm pain, and Short
to minimize the risk of prosthesis clinical and radiographic outcomes Form-12. They reported no differ-
subsidence. Prosthesis insertion is of the Prestige LP disc (Medtronic ence in adverse events or major
implant specific and can proceed per Sofamor Danek) in 280 patients with complications, although they found
the manufacturer’s recommendations. those of 265 historical ACDF control higher rates of revision surgery at the
Regardless of manufacturer, implant patients from a previous Prestige index level and adjacent level in the
position should be checked via fluo- ST trial. They reported a markedly ACDF group compared with that in
roscopy or intraoperative plain film higher rate of overall success in CDA the CDA group (12.3% and 11.1%
radiographs. Fixation can then be with the Prestige LP prosthesis versus 3.4% and 2.2%, respec-
done based on implant-specific in- compared with ACDF. Overall suc- tively). In addition, 5-year clinical
strumentation. Postoperative immobi- cess was defined as a 15-point outcomes of the Mobi-C prosthesis
lization is not required, although a soft improvement in the NDI, neuro- for two-level cervical spondylosis
collar can be considered for comfort in logic status improvement compared have been reported by Radcliff
the initial postoperative period. with baseline, maintenance of the et al.22 Although both CDA and
functional spinal unit disk height, no ACDF improved markedly from
serious adverse event associated with baseline at 5 years of follow-up, the
Outcomes the implant or surgical procedure, CDA group had a markedly greater
and no secondary surgical procedure improvement in NDI scores, Short
The literature examining CDA rep- classified as a treatment failure. This Form-12 scores, and overall satis-
resents some of the strongest studies definition of overall success was used faction of treatment with a lower
in terms of statistical power and study in most of the RCTs for CDA. rate of revision surgery. Radcliff et al
design in spine surgery to date. Each Sasso et al19 reported the 4-year also reported no difference in the
of the seven FDA-approved CDA pooled clinical and radiographic re- rate of adverse events between CDA
prostheses has level-I evidence sup- sults of the Bryan CDA (Medtronic and ACDF.
porting CDA’s equivalence, and in Sofamor Danek). In their prospec- Phillips et al23 analyzed the clinical
many metrics, superiority, to ACDF. tive, randomized, controlled trial, and radiographic outcomes in 293
In a prospective, RCT comparing 242 patients underwent CDA with patients in a prospective RCT ex-
276 patients undergoing CDA with the Bryan prosthesis, whereas 221 amining the use of PCM CDA
265 patients undergoing ACDF, underwent ACDF (Figure 1). Sasso (NuVasive) (n = 163) and ACDF
Burkus et al17 reported their 7-year et al reported a markedly higher rate (n = 130) in single-level cervical
clinical and radiographic outcomes of overall success, including a lower spondylosis. Similar to others, both
with the Prestige ST prosthesis NDI score, neck pain score, arm pain ACDF and CDA groups had mark-
(Medtronic Sofamor Danek). They score, and Short Form-36 physical edly improved outcomes compared
found that both Prestige ST and component score in the CDA group with baseline in every clinical mea-
ACDF patients improved compared compared with those in the ACDF sure at 5 years of follow-up. Patients
with baseline at 1.5 months, and group at 4 years. Sasso et al20 have who underwent CDA with a PCM
these improvements were sustained also published 10-year, single-site prosthesis had markedly better NDI
through 7 years. In addition, they data with the Bryan disk. They scores and more improvement in
found that compared with the ACDF report lower NDI scores, as well as neck pain scores than those who
group, the CDA group had a mark- lower revision surgery rates (9% underwent ACDF with a PCM
edly higher improvement in neck versus 32%), in the 22 patients who prosthesis. No difference was found
Figure 1
Radiographs showing preoperative flexion (A), preoperative extension (B), saggital T2 MRI (C), and axial T2 MRI (D) of a
40-year-old male with neck pain and right upper extremity radiculopathy secondary to a C5-6 disk herniation. After failing
nonsurgical treatment, he underwent a one-level CDA with a Prestige LP prosthesis (Medtronic Sofamor Danek). Postoperative
AP (E), neutral lateral (F), flexion (G), and extension (H) radiographs are shown. CDA = cervical disk arthroplasty
in arm pain, neurologic success, for ASD in the ACDF group com- single-level ACDF compared with
adverse events, or subsequent sec- pared with that in the CDA group that in the ACDF group in all the
ondary surgical interventions. They (ASD: 12.2% versus 5.8%). CDA trials within the same time
reported a markedly higher rate of Vaccaro et al25 reported 2-year frame. They recommended cau-
radiographic adjacent segment de- clinical outcomes of the SECURE-C tioned interpretation of differences
generation in the ACDF group com- (Globus Medical) prosthesis com- in revision surgery rates in the FDA
pared with that in the CDA group pared with those of ACDF. They CDA trials.
(50.9% versus 33.1%), although the reported a higher rate of overall
clinical significance of radiographic success at 2 years in patients who
degeneration is unclear. underwent CDA with SECURE-C Adjacent Segment Disease
Janssen et al24 reported the 7-year compared with patients who under-
clinical outcomes of the Prodisc-C went ACDF. In addition, they ASD has been an outcome measure of
prosthesis (DePuy Synthes) in 209 reported fewer subsequent surgical interest when evaluating CDA. Pre-
patients (CDA = 103; ACDF = 106). procedures in the CDA group. venting ASD is one of the key ratio-
They reported that both ACDF and Many meta-analyses have pooled nale for the development of CDA.
CDA were effective at improving data from available CDA RCTs and Verma et al33 conducted a meta-
neck pain and arm pain. No notable have largely found favorable out- analysis of early to midterm studies
difference was found between CDA comes in terms of clinical improve- (2 to 5 years of follow-up) compar-
with Prodisc-C and ACDF in any ment compared with ACDF for both ing secondary surgeries for ASD
clinical outcome measure including one- and two-level cervical spondy- after CDA with those for ASD after
NDI, Short Form-36, and visual losis.26-30 However, others have ex- ACDF. They found that in this time
analogue scale for neck pain and arm pressed concern at the potential for frame, no notable difference was
pain. No difference was found bias in the decision to revise surgery found in rates of secondary surgeries
between CDA and ACDF in terms of and the reporting of complications for ASD. However, they acknowl-
neurologic outcomes. They reported within an FDA CDA RCT.31,32 edged that their included studies
a markedly higher rate of revision Singh et al31 pointed out a much had a lower follow-up rate for ACDF
surgery, including revision surgery lower rate of revision surgery after a and that longer term data may
Table 1
Rates of Secondary Surgery for ASD After CDA and ACDF From Selected Long-term, Prospective Studies
Follow-up ASD After ASD After
Study/Year Disk (yr) CDA (%) ACDF (%) Difference?
Burkus et al,17 2014 Prestige ST 7 4.60 11.90 Yes

Gornet et al,18 2016 Prestige LP 7 9.60 8.30 No
Sasso et al,19 2011 Bryan 4 4.10 4.10 No
Hisey et al21/Jackson et al,34 2016 Mobi-C 5 2.20 11.10 Yes
Radcliff et al22/Jackson et al,34 2016 Mobi-C 5 3.40 11.40 Yes
Phillips et al,23 2015 PCM 7 0.60 14.60 Yes
Janssen et al,24 2015 Prodisc-C 7 5.80 12.20 Yes
Vaccaro et al,25 2013 SECURE-C 2 1.70 1.40 No
ACDF = anterior cervical diskectomy and fusion, ASD = adjacent segment disease, CDA = cervical disk arthroplasty
Table 2
Rates of Secondary Surgery for ASD After CDA and ACDF From Meta-analyses of Prospective Studies
Follow-up No. of ASD After ASD After
Study/Year (yr) Levels CDA (%) ACDF (%) Difference?
Zhu and colleagues,35,36 2016 21 1 3.10 5.30 Yes

Zhong et al,37 2016 2-7 1 or 2 3 8 Yes
Verma et al,33 2013 21 1 5.10 6.90 No
Xie et al,27 2016 21 1 4.20 7 Yes
ACDF = anterior cervical diskectomy and fusion; ASD = adjacent segment disease; CDA = cervical disk arthroplasty
show a difference in ASD not seen at secondary surgical procedures at prove clinical effectiveness but also
2-year follow-up. adjacent levels in a meta-analysis of cost-effectiveness. In this respect,
Because long-term data have over 1,800 patients who underwent ACDF has been not only successful at
become available, some differences in Bryan CDA. managing cervical spondylosis but
the rate of ASD have been reported Multiple meta-analyses since the also cost-effective.38 Concerns over
(Table 1). In the RCTs examining the availability of longer term data (ie, over higher initial costs of CDA compared
Prestige ST, Mobi-C, and Prodisc-C 5-year follow-up) have pooled data with those of ACDF and unclear
prostheses, a lower rate of secondary from all manufacturers of CDA and potential to prevent secondary sur-
surgical procedures was found for have found that CDA is associated with geries for ASD dampened initial
ASD.17,21,22,24,25,34 Phillips et al23 lower rates of revision surgery at adja- enthusiasm.39 However, because
found higher rates of radiographic cent levels compared with ACDF36,37 longer term data has become avail-
ASD at the cephalad level after (Table 2). The results from these meta- able, the potential to increase cost-
ACDF compared with that after analyses should be accepted with effectiveness by improved clinical
PCM. Mixed results have been caution because differences in CDA outcomes and lower costs secondary
reported with the Bryan disk, with design between manufacturers and to prevention of revision surgery for
the pooled multisite data from the inconsistency in the definition of ASD ASD has emerged.
RCT at 4-year follow-up reporting between studies could bias results. Ament and colleagues40,41 pre-
no difference in adjacent-level sec- sented their cost-effectiveness anal-
ondary surgeries, but single-site data ysis at both 2-year and 5-year
with 10-year follow-up reporting a Cost-effectiveness follow-up after a two-level CDA
markedly lower rate of secondary compared with a two-level ACDF.
surgeries for ASD.19,20 Zhu et al35 For an intervention to become part of They found that at 2-year follow-up,
reported no notable difference in clinical practice, it must not only CDA met the threshold of $50,000
per quality-adjusted life-years.40 At established that HO can result in cervical spondylosis. However, sur-
5-year follow-up after two-level decreased ROM at the surgical level, geons should remain cautious because
surgery, although CDA costs $1,687 Zhou et al44 were unable to deter- CDA becomes more commonplace, as
more than does ACDF, a notable mine from the current body of evi- the outcomes in randomized control
difference was found in the incre- dence whether it influences clinical studies may not hold true because in-
mental cost-effective ratio, suggesting outcome or rates of ASD in a sys- dications for CDA broaden from their
that CDA was more cost-effective tematic review and meta-analysis of well-defined parameters within those
long term than ACDF. the data. Additional studies on the studies.
Radcliff et al42 retrospectively re- extent and effect of HO after CDA Additional nonindustry-sponsored
viewed total costs paid by insurers in are still needed. randomized studies are needed to
patients who underwent a single- Alvin et al32 expressed concern about further corroborate the industry-
level ACDF versus CDA at approx- the wide prevalence of conflicts of sponsored IDE studies. In addition,
imately 2 years of follow-up. They interest (COI) in the reported incidence future studies should aim at reporting
found that after accounting for re- of complications in industry-funded long-term outcomes (ie, greater than
admission rates, revision surgery studies in their systematic review of 15-year follow-up), delineating the
rates, and 90-global window costs, the literature. They found that al- life-span of these prostheses, and
CDA patients had a markedly lower though no difference exists in quality better documenting the incidence of
total cost than ACDF patients of life measures between studies with specific complications after CDA and
($34,979 versus $39,820). Radcliff and without COI, there was a higher how best to manage them.
et al43 also reported their cost- rate of reported complications after
effectiveness analysis from the CDA in studies without COI than in
Prodisc-C CDA clinical trial, finding a studies with COI. References
mean per-patient cost saving of
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Orthopaedic Advances
Biologic Adjuvants for the

Management of Osteochondral
Lesions of the Talus
Abstract
MaCalus V. Hogan, MD, MBA Surgical techniques for the management of recalcitrant osteochondral
Justin J. Hicks, MD lesions of the talus have improved; however, the poor healing potential
of cartilage may impede long-term outcomes. Repair (microfracture)
Monique C. Chambers, MD,
MSL or replacement (osteochondral transplants) is the standard of care.
Reparative strategies lead to production of fibrocartilage, which,
John G. Kennedy, MD, FRCS
compared with the native type II articular cartilage, has decreased
mechanical and wear properties. The success of osteochondral
transplants may be hindered by poor integration between grafts and
host that results in peripheral cell death and cyst formation. These
challenges have led to the investigation of biologic adjuvants to
augment treatment. In vitro and in vivo models have demonstrated
promise for cartilage regeneration by decreasing inflammatory
damage and increasing the amount of type II articular cartilage.
Further research is needed to investigate optimal formulations and
time points of administration. In addition, clinical trials are needed to
investigate the long-term effects of augmentation.
O steochondral lesions of the

talus (OLT) pose clinical and
surgical challenges to orthopaedic
anti-inflammatory medication and
limiting physical activity. The success
rates of nonsurgical treatment, in
surgeons. Approximately two million minimally symptomatic patients, have
ankle sprains occur in the United been reported to be 86%, compared
States annually, with up to 50% of with 49% in moderately symptomatic
patients sustaining concurrent carti- patients based on acute symptoms
lage injury.1,2 Furthermore, ankle and not long-term cartilage healing.4
fractures are associated with a high Surgical management is indicated in
risk (up to 73%) for cartilage in- symptomatic patients and possibly in
jury.1 Chondrocytes are the primary patients with sizeable defects whose
cell type in cartilage and have little condition does not improve under
capacity for self-renewal because of conservative management.
From the University of Pittsburgh
School of Medicine (Dr. Hogan,
limited vascularity, making OLT Surgical management of OLT cur-
Dr. Hicks, and Dr. Chambers), and the management challenging. rently focuses either on reparative
Hospital for Special Surgery, New The optimal treatment modality for cell-based therapies such as micro-
York, NY (Dr. Kennedy). an OLT is unclear. Loveday et al,3 fracture or on replacement strategies
J Am Acad Orthop Surg 2019;27: in a Cochrane review, concluded such as autologous chondrocyte
e105-e111 that there is insufficient evidence implantation, matrix-induced autol-
DOI: 10.5435/JAAOS-D-16-00840 from current trials to determine which ogous chondrocyte implantation,
treatment strategies are best for or osteochondral autologous trans-
Academy of Orthopaedic Surgeons. managing OLT in adults. Nonsurgical plantations. Cell-based therapy in-
management involves nonsteroidal volves local recruitment or delivery of
Biologic Adjuvants for the Management of Osteochondral Lesions of the Talus
Table 1 ment of osteochondral defects of the

talus.10-12
Growth Factors and Their Known Function
Concerns with current treatment
Growth Factor Function modalities have led to recent studies
TGF-b1 Increased ECM synthesis. investigating the role of biologic
adjuncts in augmenting cartilage
Decreased catabolic signaling (IL-1 and MMP).
healing and the management of os-
Increased fibroblast proliferation and collagen synthesis.
teochondral lesions.
PDGF Increased proteoglycan synthesis. Increased production
of collagen.
VEGF Promotes new vessel growth.
BMP-7 (OP-1) Stimulates ECM synthesis.
Growth Factors and
Suppresses MMP and IL induced cartilage damage.
Platelet-rich Plasma
Not affected by age or presence of OA.
Growth factors are proteins that
IGF-1 Increased cell growth. stimulate the growth and develop-
Increased collagen synthesis of fibroblast. ment of tissue. Platelet-rich plasma
bFGF Increased production of collagen and angiogenesis. (PRP) is composed of a patient’s own
CTGF Increased cartilage regeneration and angiogenesis. concentrated platelets, which con-
tain over 1,500 growth factors
bFGF = basic fibroblast growth factor, BMP = bone morphogenetic protein, ECM = extracellular
matrix, FGF = fibroblast growth factor, IGF-1 = insulin growth factor 1, IL = interleukin, MMP = matrix located within the a-granules.13
metalloproteinase, OA = osteoarthritis, OP = osteogenic protein, PDGF = platelet-derived growth These growth factors have several
factor, TGF-b1 = transforming growth factor-b1, VEGF = vascular endothelial growth factor
functions including both cartilage
growth and extracellular matrix
synthesis, which in turn may have
cells with chondrocyte properties, Minced juvenile articular cartilage the potential to augment cartilage
whereas transplantation involves is a novel option for large or refrac- healing and repair (Table 1). It is
transferring cartilage explants or cells tory osteochondral lesions. This important to note that the compo-
to the defect site. Although midterm option entails the use of allograft sition of growth factors in PRP varies
studies report improved outcomes for cartilage harvested from donors less from person to person and even
these treatments, many patients still than 13-year old.10 It has been used between repeated preparations
experience persistent pain.5 This may since 2007 mostly in the knee within the same individual.14 Other
be due to biologic shortcomings and has been shown to contain up patient-specific factors and differences
inherent with each approach. Cell- to 10 times the cellular density of in commercial system preparation
based reparative therapies have pro- adult chondrocytes with improved methods can lead to variations in PRP
teoglycan depletion and chondrocyte ability to retain articular cartilage composition and can make interpre-
death at 1-year follow-up, and the fi- phenotype, theoretically leading tation of the literature challenging.14
brocartilage that is generated pos- to decreased production of fi- PRP is not only composed of con-
sesses inferior mechanical and biologic brocartilage.10 Early results from centrated platelets but also contains
properties compared with the native case reports and case series demon- leukocytes and reticulocytes. One
hyaline articular cartilage.6-8 With strate good-to-excellent clinical out- cannot ignore these ancillary factors
replacement strategies, concerns exist comes; however, more robust and because they can affect the function
regarding poor graft integration, cell long-term clinical studies are needed of PRP. For instance, high concen-
death, graft degeneration, and cyst to evaluate the efficacy of juvenile trations of leukocytes are associ-
formation.9 articular cartilage for the manage- ated with catabolic cytokines and
Dr. Hogan or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Miller Review
Course; has received research or institutional support from Amniox Medical; and serves as a board member, owner, officer, or committee
member of the J. Robert Gladden Society, Nth Dimensions Education Solutions, the Orthopaedic Research Society. Dr. Kennedy or an
immediate family member serves as a paid consultant to and has received research or institutional support from Arteriocyte and serves as a
board member, owner, officer, or committee member of the American Orthopaedic Foot and Ankle Society, the Arthroscopy Association of
North America, the European Society for Sports Traumatology, Knee Surgery, and Arthroscopy, the Ankle and Foot Associates, and the
International Society for Cartilage Repair of the Ankle. Neither of the following authors nor any immediate family member has received
anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of
this article: Dr. Hicks and Dr. Chambers.
MaCalus V. Hogan, MD, MBA, et al
Table 2
HA and PRP OLT Adjunct Outcomes
Biologic Study Patient Average
Study Adjunct Description Type Number Average Defect Size Follow-up Outcomes
Guney et al17 PRP Mfx alone; Mfx 1 Case 35 ,20 mm diameter 16.2 mo (range, PRP as an adjunct improved
PRP series 12-24 mo) outcomes scores
compared with Mfx alone.
Doral et al18 HA Mfx 1 HAinjection* RCT 57 ,20 mm diameter 2 yr post op Both groups had increased
Mfx alone outcome scores.
— *3 weekly HA — — — — Injection group outcome
injections starting at scores were inceased
3 wk postop compared with Mfx alone.
Gormeli et al19 HA or PRP Mfx 1 HA RCT 27 PRP: 1.28 (range, 15.3 mo (range, Both PRP and HA improved
0.52-1.4) 11-25) clinical outcomes.
— Mfx 1 PRP — — HA: 1.24 (range, — Single-dose PRP yielded
0.48-1.46) better results than
multidose HA.
— — — — Control: 1.18 (range, — —
0.46-1.38)
Shang et al20 HA Mfx alone vs Mfx 1 RCT 35 1.4 cm2 (SD 0.4 cm2) 10.5 6 1.2 mo MRI outcomes demonstrated
HA injections (3 a higher thickness index
injections over 14 d) (0.8 6 0.1 versus 0.7 6
0.1) and lower T2 index
(1.2 6 0.1 versus 1.4 6
0.1) in the injection
group compared with the
noninjection group
(P , 0.01).
— — — — — — AOFAS and VAS scores both
yielded higher level of
improvement in the
injection group (P , 0.05).
AOFAS = American Orthopaedic Foot and Ankle Society, HA = hyaluronic acid, Mfx = microfracture, PRP = platelet-rich plasma, RCT = randomized controlled trial,
VAS = visual analog score
proinflammatory signaling, which microfracture of OLT are promising, fluid. In water, HA forms a viscous
can be detrimental to tissue healing, reporting improved outcomes com- gel-like substance with nociceptive
compared with leukocyte-poor PRP, pared with surgical repair alone blocking properties that may play a
which in vitro exhibits anabolic ef- (Table 2). However, long-term, level role in osteoarthritis treatment.
fects promoting chondrogenesis.15 I randomized control trials are In vitro, HA has been found to pro-
As such, PRP may act as an adjunct needed. The optimal combination of mote cartilage regeneration through
to cartilage repair by decreasing platelets, leukocytes, and eryth- increased chondrocyte proliferation
inflammatory mediators, increasing rocytes among other components of and synthesis of proteoglycans while
collagen and proteoglycan synthesis PRP currently is unknown. A maxi- also preventing cartilage degradation
and degradation, as well as recruiting mal efficacious platelet concentra- and the production of deleterious
mesenchymal stem cells (MSCs), tion may also be present. Therefore, proinflammatory cytokines and matrix
which in turn undergo chondrogenesis it is critical that future studies metalloproteinases.21 The chon-
and synthesize type II collagen. properly characterize and report droprotective and regenerative ef-
A preclinical animal model in rab- PRP contents used, to optimize PRP fects of HA have been validated in
bits demonstrated that osteochondral as an adjunct to OLT surgery and animal models. Strauss et al22 demon-
defects treated with PRP demon- accurately interpret findings. strated that HA supplementation
strated improved histological scoring through three weekly intra-articular
with increased hyaline-like cartilage injections enhanced filling of the
and improved integration of the os- Hyaluronic Acid defects grossly and histologically in
teochondral graft at the cartilage rabbits after microfracture surgery.
interface.16 Clinical studies assessing Hyaluronic acid (HA) is a glycos- Kaplan et al23 created 10- · 10-mm
the efficacy of PRP as an adjunct to aminoglycan located within synovial partial-thickness articular cartilage
Figure 1 lesions in the medial condyle of

sheep followed by two HA in-
jections 7 days apart. Lesions were
evaluated at 12 weeks demon-
strating that early administration
of HA is chondroprotective.
Three recent studies comparing
OLT treatment using microfracture
surgery alone with microfracture
surgery supplemented with HA
demonstrate improved outcomes in
the HA group (Table 2). Compar-
ing a single-dose PRP injection
with a multidose HA injection regi-
men as adjunct to microfracture
surgery in OLT, the authors found
Magnetic resonance imaging (MRI) of the osteochondral lesion of the talus that both PRP and HA improved
(OLT). A, Coronal T2 showing medial talar dome OLT with surrounding marrow outcomes; however, PRP was rec-
edema. B, Sagittal T1 image showing medial central dome OLT with findings
ommended over HA because a single
consistent with unstable fragment.
injection yielded superior outcomes
(Table 2). Given the in vitro evidence
of chondroprotection and increased
Figure 2 cartilage regeneration as well as
improved outcomes scores clinically,
HA seems to be a viable adjunct to
OLT repair. Further studies are
needed to make more robust treat-
ment recommendations regarding
HA injections alone or even in
combination with PRP to supple-
ment cartilage regeneration.
Stem Cells
Embryonic Derived
Mesenchymal Cells
Embryonic-derived mesenchymal
cells (EMCs) are pluripotent stem
cells with the ability to differentiate
into all three primary germ layers:
endoderm (eg, lining of the gastroin-
testinal tract and lungs), mesoderm
(eg, muscle, bone, cartilage, blood),
and ectoderm (eg, nervous tissue).24
This pluripotency and unlimited self-
renewal distinguishes EMCs from
adult stem cells, which have limited
Osteochondral lesion of the talus (OLT) repair with iliac-crest bone marrow differentiating ability and are con-
aspirate concentrate (BMAC). A, OLT during initial insertion of BMAC, B, sidered multipotent. The utilization
insertion of prepared BMAC injection. C, OLT with BMAC in place after of EMCs for cartilage repair is in its
microfracture and débridement. D, OLT following final placement of BMAC and infancy. Currently, very few studies
Tisseell.
have been conducted to evaluate the
Table 3
Stem Cell Adjunct Outcomes
Average
Study Biologic Adjunct Description Average Defect Size Follow-up Outcomes
Kennday et al29 cBMA 1 OATs Case series. 72 patients 11.12 mm (range, 6-20 mm) 28.02 mo (range, Increased AOFAS score from 52.67
anterior to posterior 12-64 mo) to 86.19 and SF-12 from 59.40 to
88.63
— 10.74 mm (range, 7-20 mm) — Return to sports = 13 wk (range,
medial to lateral 11-20 wk)
Buda et al30 cBMA 1 scaffold Prospective. 64 (5.27 6 68 cm2) 54 mo Increased AOFAS score from 65.2
(collagen powder or patients with OLT (613.9) to 91.1 (68.7 at 24 mo
HA) (peak)
— — — Gradual decline and settled at 80.7
(614.1) at 72 mo
Kim et al31 MSC Retrospective. 65 108.7 (634.6 mm2) 21.8 mo (64.3) Mean VAS and AOFAS scores
patients. Mfx vs Mfx 1 improved in both groups.
MSC injection.
— — — Tegner activity scale improved in
the Mfx 1 MSC group (3.5 6 0.7
to 3.8 6 0.7)
— — — Large lesions (.109 mm2) and
existence of subchondral cysts
predicted unsatisfactory results
for the Mfx-only group
Gianni et al32 cBMA 1 scaffolded Case series. 49 patients 2.24 6 1.23 cm2 48 6 6.1 mo AOFAS score improved from 63.73
with OLT 6 14.13 to 82.19 6 17.04
— — — T2-mapping showed regenerated
tissue with T2 values of 35-45 ms,
similar to hyaline cartilage
AOFAS = American Orthopaedic Foot and Ankle Society, cBMA = concentrated bone marrow aspirate, HA = hyaluronic acid, Mfx = Microfracture, MSC = mesenchymal
stem cell, OATs = osteochondral autologous transplantation, OLT = osteochondral lesions of the talus, SF = short form, VAS = visual analog scale
ability of EMCs to repair os- preimplantation embryo. Further- optimal option for cartilage regener-
teochondral defects. EMC have been more, their ability to self-renew and ation because they are widely avail-
induced in vitro to form MSCs multilineage properties raise concern able and can be accessed easily during
including chondrocytes.25,26 Pilichi regarding tumorigenicity. surgery from the patient’s iliac crest
et al24 demonstrated that delivery of among other locations. Derived from
EMCs into osteochondral defects in adult tissue, MSCs also avoid the
sheep femoral condyles improved
Bone Marrow-derived Stem ethical concerns associated with
cartilage regeneration for up to Cells and Bone Marrow EMCs. Concentrated bone marrow
24 months. Cheng et al27 used EMCs Aspirate Concentrate aspirate (cBMA) is a source of MSCs
encapsulated in a fibrin gel and im- MSCs are adult stem cells that can be and is a potential biologic adjunct to
planted these cells into patellar found in bone marrow and other tis- OLT treatment modalities. In addi-
groove osteochondral defects. The sues. These stem cells are multipotent tion to MSCs, cBMA also contains
authors observed improved histo- with the ability to differentiate along platelets that contain growth factors
logic scoring and upregulation of connective tissue cell lineages, within the platelet a-granules, anal-
chondrogenic genes in groups including chondrocytes, osteoblasts, ogous to PRP (Table 1). These
receiving EMCs. Although promis- and myocytes. MSCs are thought to growth factors may potentially aug-
ing, the use of EMC-derived chon- be responsible for physiologic growth, ment the regenerative and reparative
drocytes for the clinical management wound healing, and replenishing cells capacity of MSCs. Another major
of cartilage defects is far off. Further lost during daily cell turnover and advantage of cBMA is that it can be
research is needed to characterize have been shown to be effective for obtained and prepared during the
their potential to repair damaged managing musculoskeletal tissue index procedure.
cartilage. In addition, the use of injury. Bone marrow stem cells are the Evidence supporting bone marrow
EMCs raises ethical concerns because most commonly used source of cells aspirate as an adjunct to cartilage
they are derived from the early-stage for cartilage regeneration. They are an repair has been demonstrated in
preclinical animal models (Figures 1 researchers to investigate the carti- and 19 are level I studies. References
and 2). In an equine model, Fortier lage regeneration potential of these 2, 3, 17, and 20 are level II studies.
et al28 compared microfracture alone cells. In vitro, chondrocytes derived References 1, 31, and 33 are level III
with microfracture with cBMA to from the synovial lineage retain studies. References 4, 5, 10, 11, 29,
manage full-thickness cartilage de- fibroblastic characteristics needed to 30, 32, 35, and 36 are level IV
fects of the lateral trochlear ridge. form hyaline cartilage. Studies com- studies. Reference 12 is a level V
Histological and MRI analysis indi- paring them with MSCs demonstrate expert opinion.
cated improved healing in the cBMA higher chondrocyte differentiation
group. Early studies suggest that potential.34 Application of synovial References printed in bold type are
these findings have translated to stem cells to OLT surgery is far from those published within the past 5
surgical repair of human OLTs. clinical application; however, their years.
Improved clinical outcome scores potential for future use is intriguing. 1. Hintermann B, Regazzoni P, Lampert C,
and radiographic findings have been Another novel source of stem cells is Stutz G, Gächter A: Arthroscopic findings
in acute fractures of the ankle. J Bone Joint
demonstrated in several clinical periosteum-derived cells. Periosteum- Surg Br 2000;82:345-351.
studies (Table 3). These findings may derived cells have the potential to
2. Waterman BR, Belmont PJ Jr, Cameron
be limited by defect size as Kim et al serve as chondroprogenitor cells and KL, Deberardino TM, Owens BD:
found that large lesions (.109 mm2) are currently appreciated for their Epidemiology of ankle sprain at the United
and subchondral cysts predicted dual lineage (bone and hyaline carti- States Military Academy. Am J Sports Med
2010;38:797-803.
unsatisfactory outcomes. Additional lage) potential. Further studies are
long-term randomized controlled needed to characterize conditions to 3. Loveday D, Clifton R, Robinson A:
Interventions for treating osteochondral
trials are needed. Reporting of defect induce cartilage growth.25 defects of the talus in adults. Cochrane
size and depth is critical to under- Database Syst Rev 2010:CD008104.
standing the efficacy of bone marrow 4. Klammer G, Maquieira GJ, Spahn S,
stem cell as an adjunct to OLT repair Summary Vigfusson V, Zanetti M, Espinosa N:
Natural history of nonoperatively treated
and will aid in the optimization of osteochondral lesions of the talus. Foot
The optimal management of OLT is
this method. Ankle Int 2015;36:24-31.
still undefined. An international con-
sensus meeting on the treatment of 5. Polat G, Erşen A, Erdil ME, Kızılkurt T,
Adipose-derived Stem Cells OLTs was recently held at the Uni-
Kılıço
glu Ö, Aşık M: Long-term results of
microfracture in the treatment of talus
Adipose tissue represents another versity of Pittsburgh (M.V.H.).35 The osteochondral lesions. Knee Surg Sports
source of MSCs capable of differen- results of this meeting as it pertains to Traumatol Arthrosc 2016;24:1299-1303.
tiating into chondrocytes. In vitro, biologics were reported.36 Concerns 6. Hjertquist SO, Lemperg R: Histological,
cartilage derived from adipose stem regarding the biologic shortcomings autoradiographic and microchemical
studies of spontaneously healing
cells has a high total collagen count of current reparative and replacement osteochondral articular defects in adult
but lower levels of type II collagen. A strategies still remain. Biologic ad- rabbits. Calcif Tissue Res 1971;8:54-72.
recent study by Kim et al33 compar- juncts using stem cells, growth fac- 7. Shapiro F, Koide S, Glimcher MJ: Cell
ing marrow stimulation in OLT with tors, HA, scaffolds, or a combination origin and differentiation in the repair of
full-thickness defects of articular cartilage. J
marrow stimulation augmented with thereof are potential interventions Bone Joint Surg Am 1993;75:532-553.
adipose stem cells demonstrated that may enhance the regeneration of
8. Mitchell N, Shepard N: The resurfacing of
improved clinical and MRI out- these defects. In vitro and preclinical adult rabbit articular cartilage by multiple
comes scores in the adipose stem cell animal models support this hypothe- perforations through the subchondral bone.
group compared with marrow stim- sis, and early clinical studies of bio- J Bone Joint Surg Am 1976;58:230-233.
ulation alone. Although encourag- logic augmentation are promising. 9. Huang FS, Simonian PT, Norman AG,
ing, the self-renewal capacity of Research exploring the efficacy of Clark JM: Effects of small incongruities
in a sheep model of osteochondral
adipose stem cells is not completely these biologic treatment modalities is autografting. Am J Sports Med 2004;32:
understood, and further studies are underway and may improve the out- 1842-1848.
needed to optimize the chondrogenic comes of OLT treatment in the future. 10. Giza E, Howell S: Allograft juvenile
potential of these cells. articular cartilage transplantation for
treatment of talus osteochondral defects.
Foot Ankle Spec 2013;6:141-144.
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Research Article
Validation of Patient-reported
Outcomes Measurement
Information System Computer
Adaptive Tests in Lumbar Disk
Herniation Surgery
Abstract
Surabhi Bhatt, BS Introduction: Inadequate validation, floor/ceiling effects, and time
Barrett S. Boody, MD constraints limit utilization of standardized patient-reported outcome
measures. We aimed to validate Patient-reported Outcomes
Jason W. Savage, MD
Measurement Information System (PROMIS) computer adaptive tests
Wellington K. Hsu, MD (CATs) for patients treated surgically for a lumbar disk herniation.
Nan E. Rothrock, PhD Methods: PROMIS, CATs, Oswestry Disability Index, and Short
Alpesh A. Patel, MD, FACS Form-12 measures were administered to 78 patients treated with
lumbar microdiskectomy for symptomatic disk herniation with
radiculopathy.
Results: PROMIS CATs demonstrated convergent validity with
legacy measures; PROMIS scores were moderately to highly
correlated with the Oswestry Disability Index and Short Form-12
physical component scores (r = 0.41 and 0.78, respectively).
PROMIS CATs demonstrated similar responsiveness to change
compared with legacy measures. On average, the PROMIS CATs
were completed in 2.3 minutes compared with 5.7 minutes for legacy
measures.
Discussion: The PROMIS CATs demonstrate convergent and
known groups’ validity and are comparable in responsiveness to
legacy measures. These results suggest similar utility and improved
efficiency of PROMIS CATs compared with legacy measures.
Levels of Evidence: Level II

Surgery, Northwestern University,
Evanston, IL (Ms. Bhatt, Dr. Boody,
Dr. Hsu, Dr. Rothrock, and Dr. Patel),
and the Center for Spine Health,
D elivery of health care has changed
dramatically over the past several
decades, with an increased interest in
have relied on clinical data such as
range of motion, muscle strength,
and neurologic deficits.1 Although
Cleveland Clinic, Cleveland, OH the assessment of the clinical outcomes these measurements provide valu-
(Dr. Savage).
of medical care. Advancements in able information, they do not include
Correspondence to Dr. Patel: technology and surgical techniques the patient’s point of view concern-
alpesh.patel@nm.org require feedback from patients to ing his or her physical function,
J Am Acad Orthop Surg 2019;27: define effectiveness and value. To pain, and quality of life. As the US
95-103 comprehensively evaluate the effect healthcare system places an increas-
DOI: 10.5435/JAAOS-D-17-00300 of care, there exists a need for reli- ing focus on the value of delivered
able, valid, and efficient measures. care, clinicians require improved
Academy of Orthopaedic Surgeons. Typically, treatment outcomes in patient outcome metrics that pro-
patients undergoing spine surgery vide more accurate patient-centered
February 1, 2019, Vol 27, No 3 95
Patient-reported Outcomes Measurement
functional assessments to both dem- PRO measures for respondents with a confirmed lumbar disk herniation with
onstrate the value and justify the wide range of chronic diseases and radiculopathy between the age of 18
costs for our clinical interventions.2 demographic characteristics.2 PROs and 95 years and the ability to read and
Recent developments in health care assess subjective experience in ways speak English were invited to partici-
have called for a greater emphasis distinct from physiologic outcomes.5 pate. Any patients who presented for
on evidence-driven, patient-centered Furthermore, to shorten the time revision surgery, with tumors, trauma,
care.3 Patient-reported outcome needed to complete data collection, or an infection were excluded from the
(PRO) instruments are widely used PROMIS uses computer adaptive study. Included patients underwent
to capture the patients’ health per- tests (CATs), which allow for precise surgical management for their lumbar
ception, well-being, quality of life, and valid scores with a small subset of disk herniation (subtotal diskectomy).
physical function, pain, and satisfac- questions from a large collection (ie, Each patient who agreed to participate
tion with care.4 The most commonly item banks). This approach greatly in the study provided informed consent
used legacy PRO measures in the lum- reduces the time needed to complete a and thereafter invited to complete
bar spine population include the measure, thereby potentially increas- the PRO assessment with a wireless
Oswestry Disability Index (ODI), the ing their utilization.1,6-11 Internet-enabled iPad. Assessment
Swiss Spinal Stenosis Questionnaire, The utility and validity of PROMIS Center an online data collection
the Oxford Spinal Stenosis Ques- CATs have been demonstrated in a tool was used for data collection
tionnaire, and the Maine-Seattle Back variety of medical and surgical fields, (www.assessmentcenter.net).
Questionnaire.1 These traditional displaying reliability, validity, flexi- Assessments were administered
paper-based PRO measures have bility, and inclusiveness in conditions preoperatively (visit 1) and postop-
drawbacks for everyday clinical use such as depression, cancer, chronic eratively at 6 weeks (visit 2) and
because they are time consuming, obstructive pulmonary disease, and 3 months (visit 3) using a secure
demonstrate disease bias, and may heart failure, among other patholo- individually assigned login and pass-
display inaccuracies when testing gies.2,12-16 The PROMIS CATs have word. Participants completed their
patients with either severe functional not been validated in patients with baseline assessment within the clinic,
disability or extreme functional surgical lumbar disk herniation.3 whereas all postoperative assess-
ability (ie, floor and ceiling effects, Accordingly, we sought to evaluate ments were completed over the phone
respectively).2 The floor limitations the validity (ie, convergent validity, or through Internet. Patients unable
of traditional PRO measures remain known groups’ validity, and respon- to (eg, limited hand mobility) or
of great concern given the severe siveness to change) of PROMIS CATs uncomfortable using the iPad were
disability that is typically encoun- in patients receiving surgical man- given the option to have the study
tered with surgical spine patients. agement for symptomatic lumbar coordinator read questions out loud
Ineffectively differentiating patients disk herniation. and enter the participant’s response.
with severe pain and disability has
impaired surgeons’ ability to capture
meaningful differences in clinical Methods Measures
outcomes. All three assessments included the
The Patient-reported Outcomes Design PRO measures as described below in
Measurement Information System After obtaining the appropriate insti- addition to a global rating of change
(PROMIS) developed a psychometri- tutional approvals, all surgical patients and a question regarding any effec-
cally sound and validated system of with a symptomatic, radiographically tive comorbid conditions.
Dr. Savage or an immediate family member serves as a paid consultant to Stryker. Dr. Hsu or an immediate family member has received
royalties from Stryker; is a member of a speakers’ bureau or has made paid presentations on behalf of AONA; serves as a paid consultant to
Allosource, AONA, CeramTec, Globus Medical, Graftys, Medtronic Sofamor Danek, Mirus, RTI, Stryker, and Xtant; has received research or
institutional support from Medtronic, serves as a board member, owner, officer, or committee member of the American Academy of
Orthopaedic Surgeons, the Cervical Spine Research Society, the Lumbar Spine Research Society, and the North American Spine Society.
Dr. Rothrock or an immediate family member has received research or institutional support from AO Patient Outcomes Center US. Dr. Patel
or an immediate family member has received royalties from Amedica and Zimmer Biomet; serves as a paid consultant to Amedica, Pacira
Pharmaceuticals, and Zimmer Biomet; has stock or stock options held in Amedica, Cytonics, Nocimed, nView Medical, and Vital5; serves
as a board member, owner, officer, or committee member of the American Orthopaedic Association, AO Spine North America, the Cervical
Spine Research Society, the International Society for the Advancement of Spine Surgery, the Lumbar Spine Research Society, and the
North American Spine Society. Neither of the following authors nor any immediate family member has received anything of value from or has
stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Ms. Bhatt and
Dr. Boody.
Surabhi Bhatt, BS, et al
Oswestry Disability Index physical functioning. The PROMIS Descriptive statistics were calcu-
The ODI, version D17 is a self- Pain Interference (PI) CAT v1.0 lated for all scores at baseline to
administered questionnaire designed measures the degree to which pain examine the level of impairment.
to assess limitations of various activi- interferes with a range of activities. Floor and ceiling effects were exam-
ties of daily living. It consists of 10 The item bank includes 41 items. The ined by determining the percentage of
sections, each of which is scored on a PROMIS Pain Behavior (PB) CAT patients who scored at the upper and
0-to-5 scale, five representing the v1.0 (item bank = 39 items) assesses lower limits for the respective out-
greatest disability. The index score is the self-reported expression of pain come instrument (Figures 1–3).
calculated by dividing the summed (eg, verbal and nonverbal indications Assessment time was calculated by
score by the total possible score, which of pain). For each PROMIS pain CAT, summing the response time for each
is then multiplied by 100 and ex- higher scores indicate more pain. item within a measure. This time was
pressed as a percentage. automatically captured by Assess-
ment Center. Convergent validity
Effective Comorbid Conditions
was evaluated using Pearson corre-
Twelve-Item Short Form Survey The effective comorbid conditions
lation coefficients between PROMIS
The 12-item Short Form survey question assesses the effect of other
CATs, the ODI, and SF-12 at base-
(SF-12) is a 12-item measure that as- health conditions on physical function
line. Correlation values of 0.0 to
sesses physical, social, and mental and pain. The question “Are your
0.19, 0.20 to 0.39, 0.40 to 0.59, 0.60
function. It is summarized into a answers to today’s questions being
to 0.79, and 0.80 to 1.0 are described
physical component (PCS) and men- affected by any conditions (ie, arthri-
as very weak, weak, moderate, strong,
tal component score (MCS). The tis, knee pain, heart disease, lung dis-
and very strong, respectively.
SF-12 scale uses a population mean ease) other than what you are being
To test discriminant (known-groups)
of 50 with a SD of 10, with higher seen for today?” is answered yes/no.
validity, patients were grouped by dis-
scores indicating better health. A
ease severity at baseline as measured by
meaningful health state classification
Global Rating of Change the ODI. PROMIS and SF-12 scores
SF-6D utility score was calculated
The Global Rating of Change question were compared between groups using
based on the SF-12 score. Individual
assesses one’s perception of change 2-sample t-tests.
respondents can be classified on any
between assessments (“How is your To evaluate responsiveness, the
of four to six levels of functioning or
neck or back condition since your PROMIS CAT and legacy measures
limitations for each of six domains.
last visit with us?”). Responses were were compared across time. Changes
“much better,” “slightly better,” in scores were calculated between each
Patient-reported Outcomes “about the same,” “slightly worse,” assessment point for all measures,
Measurement Information and “much worse.” This question was and the statistical significance was
System Physical Function, Pain used to evaluate responsiveness. evaluated using paired t-tests. Pear-
Interference, and Pain Behavior son correlation coefficients were
Computer Adaptive Test also calculated using the change
PROMIS CATs are administered using Statistical Analysis scores to evaluate validity over time.
an algorithm that uses previous ques- PROMIS CAT scores were exported Changes were interpreted relative
tion responses to prompt subsequent directly from the Assessment Center to minimal clinically important dif-
targeted, relevant questions to deter- system. SF-12 PCS, MCS were calcu- ference (MCID) thresholds reported
mine the patient’s level of function or lated using the QualityMetric Health in the literature. Although there
symptomatology. The measure ends Outcomes Scoring Software 4.5. ODI exist few publications for MCIDs
when a specified level of measurement scores were calculated according to for PROMIS PB, PI, and PF meas-
precision (standard error , 3.0) or 12 developers’ instructions as the per- ures, Amtmann et al15 recently
items have been answered. Reported centage of total possible points. For reported that an MCID of 3.5 to 5.5
scores use a T-score metric, with a some analyses, ODI scores were points in PROMIS PI scores may be
score of 50 points reflecting the gen- grouped in quintiles and classified considered meaningful in the low-
eral population mean (SD = 10). The into levels of disability: zero to back-pain patient population. Sim-
PROMIS Physical Function (PF) CAT 20% minimal disability, 21% to ilarly, few publications review
v1.2 is administered from a bank of 40% moderate disability, 41% MCIDs for legacy PROs for lumbar
121 potential items and assesses self- to 60% severe disability, 61% to disk herniations, so surrogate values
reported capability for physical activ- 80% extreme disability, and 81% to were drawn from previously described
ities. Higher scores indicate better 100% bed-bound. thoracolumbar spine conditions.
February 1, 2019, Vol 27, No 3 97
Figure 1 Because of variability in deriving

and reporting MCID thresholds,
clinicians should interpret reaching
MCID thresholds in isolation with
caution.23 Although no validated
MCID for PROMIS measures for
spine pathology have been pub-
lished, an acceptable estimate cur-
rently used is 50% of the reported
SD.24,27
Although we report MCIDs for
legacy measures, the use of MCIDs
was to attribute clinical correlation to
the size of the clinical effect reported
by the outcome measures. The aim of
this study was not to evaluate the
participants’ function and symptoms
but to evaluate the performance of
PROMIS measures in comparison
with legacy measures.
Responsiveness to clinical change
was further evaluated by stratifying
Graph showing the distribution of PROMIS PF scores aggregate across time patients by self-evaluation of post-
points. PF = physical function, PROMIS = Patient-reported Outcomes operative improvements in symptom
Measurement Information System relief. The ability of outcome metrics
to appropriately distinguish between
patients who reported feeling “much
Figure 2 better” against all other patient-
reported changes was evaluated.
The mean change from baseline
scores was tested using paired t-tests.
The standardized response mean =
mean change/SD of change was cal-
culated to quantify the relative level
of change within these groups.
Results
Of the 78 patients enrolled (mean
age = 41.6; SD = 13.4; 62% male;
Table 1), 83% completed the 6-
week postoperative assessment and
62% completed the 3-month post-
operative assessment. Patients largely
denied concomitant pathologies
Graph showing the distribution of PROMIS PB scores aggregate across time affecting their reported pain and
points. PB = pain behavior, PROMIS = Patient-reported Outcomes
Measurement Information System function outcomes, with 95% and
83% reporting no other conditions
affecting their answers on outcome
Available thoracolumbar spine lit- MCID18-20 and SF-12 PCS and measures at baseline and 3 month
erature reports a range of 6.8 to MCS improvement of 2.5 to 6.1 and assessments, respectively. At baseline,
14.9 point decrease in ODI as an 10.1, respectively, as an MCID.21,22 patients demonstrated impairments
in physical function and pain on all Figure 3

measures including PROMIS PF
(mean = 35.9; SD = 8.0), ODI
(mean = 42.4; SD = 19.0), SF-12 PCS
(mean = 34.5; SD = 8.8), PROMIS PI
(mean = 66.1; SD = 7.6), and
PROMIS PB (mean = 60.2; SD = 6.2).
Additionally, nearly half of the pa-
tients’ (48%) scores were in the
crippled or severely disabled range on
the ODI (Table 1).
The three PROMIS instruments took
an average of 2.3 minutes in total to
complete, with individual CAT com-
pletion times of 0.9 minutes for PB
(SD = 1.0), 0.6 minutes for PI (SD =
0.6), and 0.8 minutes for PF (SD =
0.8). These data compare favorably
with the completion times for the ODI
and SF-12, which took an average
of 5.7 minutes in total to complete,
with individual completion times Graph showing the distribution of PROMIS PI scores aggregate across time
points. PI = pain interference, PROMIS = Patient-reported Outcomes
of 2.7 and 3.0 minutes, respec- Measurement Information System
tively (Table 2). PROMIS outcome
measures demonstrated minimal
floor and ceiling effects at baseline
(Figure 4). The ODI and SF-12 Table 1
exhibited minimal ceiling effects in Patient Characteristics (n = 78)
this sample as well (Figure 5).
Median
Convergent validity was supported Factor Mean (SD) (Range)
with moderate to strong correlations
in the expected direction at baseline Age (yr) 41.6 (13.4) 39 (20-72)
between PROMIS CATs and legacy Sex (no. of pts)
measures. PROMIS PF, PI, and PB Male 48 62%
correlated strongly with ODI scores (r = Female 30 38%
20.78, r = 0.78, and r = 0.58, Race (no. of pts)
respectively, each P , 0.01). Similarly, Not provided 9 12%
SF-12 PCS was strongly correlated White 56 72%
with PROMIS PF (r = 0.61; P , 0.01). Black 4 5%
SF-12 MCS had a moderate correla- Asian 3 4%
tion with PROMIS PB and PI as well Other 6 8%
(r = 20.47 and r = 20.47, respectively; Ethnicity (no. of pts)
each P , 0.01). Correlations were of Not provided 9 12%
similar magnitude when examining the Not Hispanic or Latino 67 86%
change from baseline to month 3 Hispanic or Latino 2 3
(Table 3).
Baseline ODI (n = 1 missing)
This disk herniation patient pop-
No. of pts with minimal disability (0%–20%) 10 13%
ulation reported a substantial number
No. of pts with moderate disability (21%–40%) 30 39%
of individuals with severe disability as
No. of pts with severe disability (41%–60%) 21 27%
determined by the baseline ODI score
No. of pts crippled (61%–80%) 16 21%
(severe disability 27% and crippled
21%). To test discriminant (known- ODI = Oswestry Disability Index
groups) validity, patients were grouped
February 1, 2019, Vol 27, No 3 99
Table 2 (each P , 0.001), whereas PROMIS

PF increased 12.3 points over the
Time to Complete in Minutes
same period (P , 0.001). The other
Completion time (min) legacy measures demonstrated score
Factor N Mean SD Median changes consistent with the observed
trend seen with PROMIS CATs. ODI
PROMIS PB 76 0.9 1.0 1.0 scores decreased an average of 233.4
PROMIS PI 78 0.6 0.6 1.0 points. SF-12 PCS increased 14.5 and
PROMIS PF 78 0.8 0.7 1.0 MCS increased 8.6 points (each P ,
Oswestry Disability Index 71 2.7 1.3 2.0 0.001). These observed improve-
SF-12 75 3.0 1.8 3.0 ments in PROMIS and legacy mea-
sure scores are clinically relevant as
PB = pain behavior, PF = physical function, PI = pain interference, PROMIS = Patient-reported
Outcomes Measurement Information System, SF = Short Form well, with each of the PROMIS sub-
scores and the SF-12 PCS and ODI
legacy measures exceeding reported
Figure 4 MCID thresholds.
The sample was divided into sub-
groups based on self-reported change
(“much better” versus all others).
Comparing baseline with 6-week
follow-up (visit 1 versus visit 2),
the improved group reported im-
provement in PROMIS PB, PI,
and PF (213.0, 216.3, and 12.1,
respectively) and in SF-12 PCS
(13.5), SF-12 MCS (10.0), and ODI
(234.4; SD 19.6) (see Table 5,
Supplemental Digital Content 1,
http://links.lww.com/JAAOS/A135).
Standardized response means ranged
from 0.94 (MCS) to 2.03 (PI) for this
group, and from 0.53 (MCS) to 1.34
(PCS) for the group of patients who
were only slightly better, unchanged,
or worse. The difference in change
scores was statistically significant
Graph showing the change in Patient-reported Outcomes Measurement
Information System T-Scores and SF physical component score and mental (P , 0.05) only for PROMIS PI and
component score composite score over time. SF = Short Form PF and ODI, although sample sizes
were small.
by disease severity at baseline as mea- baseline by the 6-week and 3-month

sured by the ODI. Patients who were postoperative time points, respec- Discussion
severely or extremely disabled re- tively, with most improvements in
ported worse PROMIS, SF-12, and pain, disability, and function ap- This study demonstrates convergent
ODI scores compared with patients pearing early in the postoperative validity, responsiveness, and known
with minimal-moderate disability course and plateauing by the 3-month groups’ validity of the PROMIS PF,
(Table 4, all P , 0.01). Effect sizes follow-up (Figures 4, 6). Physical PI, and PB CATs in patients under-
were large and ranged from 0.77 function and pain also improved after going a lumbar disk herniation sur-
(MCS) to 1.60 (PROMIS PI). surgery across all measures as ex- gery through strong correlations with
After surgical management of the pected. Change scores for PROMIS other measures of the same con-
lumbar disk herniation(s), 85% and PB and PI had decreases of 13.1 and structs, ability to distinguish those
94% of patients reported ODI score 16.5, respectively, between baseline with notable clinical improvement
decreases of at least 10 points from and 3-month postoperative follow-up from others, and ability to distinguish
diagnostic groups. To our knowl- Figure 5

edge, this is also the first assessment
of the validity of PROMIS CATs for
PF, PI, and PB in patients with lumbar
disk herniation who were treated
surgically.
The PROMIS CAT allows efficient
and precise PRO measurements by
eliminating irrelevant or redundant
items.8 Unlike the classical test the-
ory that requires respondents to
complete all (or most) questions to
determine a test score, the PROMIS
CATs are able to obtain a patient’s
responses based on their function or
symptom level by customizing the
items that are administered.14 On
average, the three PROMIS CATs
were obtained in 2.3 minutes com-
pared with 5.7 minutes for the two Graph showing the Short Form-12 scores by Oswestry Disability Index severity
legacy measures (Table 2). The groups. MCS = mental component score, PCS = pain behavior score
notable reduction in time to com-
plete the PROMIS CATs is most
likely due to the fewer number of Table 3
questions that are administered Pearson Correlation Coefficients Between Measures
(range, 4 to 12 per CAT; median, 4)
Factor PROMIS PB PROMIS PI PROMIS PF
compared with the legacy measures
(range, 10 to 12). These findings are Baseline
strongly supported by two pub- ODI score 0.58a 0.78a 20.78a
lications by Papuga et al25 and SF-12 PCS 20.41a 20.59a 0.61a
Brodke et al.26 The study by Papuga SF-12 MCS 20.47a 20.47a 0.38a
et al25 demonstrated a strong corre- SF-6D utility 20.63a 20.80a 0.73a
lation of PROMIS CATs with ODI Change from baseline
scores in a population presenting for to month 3
routine clinic visits. Furthermore, ODI score 0.60a 0.73a 20.66a
they showed a markedly decreased SF-12 PCS 20.60a 20.77a 0.56a
time to complete the PROMIS CATs SF-12 MCS 20.20 0.05 0.17
compared with the legacy measures. SF-6D utility 20.61a 20.70a 0.63a
Brodke et al26 in a study of over
1,600 patients presenting for a clinic MCS = mental component score, ODI = Oswestry Disability Index, PB = pain behavior, PCS =
physical component score, PF = physical function, PI = pain interference, PROMIS = Patient-
visit also demonstrated a significant reported Outcomes Measurement Information System, SF = Short Form
correlation of PROMIS CATs with a
P , 0.01.
ODI and SF-36 scores as well as less
time to complete the CATs.
The PROMIS tools were also able
to accurately capture the patient’s model for PROMIS instruments al- ing self-reported health status infor-
physical and pain health status while lows for tracking completion times, mation available in real time during
avoiding floor and ceiling effects. This time and date stamps on responses, a clinical encounter. This informa-
ability is particularly important in the immediate scoring, and automated tion can be used by healthcare pro-
patient population we studied because tracking of missing data. Although viders to facilitate assessment of the
nearly half of the sample (48%) were CATs require a computer for admin- patient, treatment evaluation, or
crippled or severely disabled (Table 1). istration, their advantage in speed and planning. Patients could also use PRO
Using a website-based data collection measurement precision facilitate mak- information to track their personal
February 1, 2019, Vol 27, No 3 101
Table 4
PROMIS and SF-12 Scores at Baseline by Oswestry Disability Index Severity Group
Minimal-moderate Disability Severe Disability or Crippled
n = 40 n = 37
Factor Mean (SD) Mean (SD) P Value Mean Difference Effect Size
PROMIS
PB 57.2 (6.9) 63.2 (3.2) ,0.001 5.9 1.09
PI 61.5 (6.9) 70.7 (4.2) ,0.001 9.2 1.60
PF 40.4 (7.4) 31.1 (5.6) ,0.001 29.4 21.42
SF-12
MCS 50.4 (9.6) 42.8 (10.3) 0.001 27.6 20.77
PCS 38.6 (8.1) 30.0 (7.5) ,0.001 28.6 21.10
SF-6D 0.63 (0.11) 0.50 (0.07) ,0.001 20.13 21.36
MCS = mental component score, PB = pain behavior, PCS = physical component score, PF = physical function, PI = pain interference, PROMIS =
Patient-reported Outcomes Measurement Information System, SF = Short Form
Effect size = mean difference/pooled SD.
Figure 6 ment to capture clinically significant

outcomes. Parker et al28 suggested
12-month follow-up because they
found that 3 month ODI MCID for
lumbar surgery predicted 12-month
MCID thresholds with only 62.6%
specificity and 86.8% sensitivity.
However, for the validation pur-
poses of this study, lengthy follow-
up to assess treatment outcomes was
unnecessary. Although we report
MCIDs for legacy measures, the use
of MCIDs was to attribute the clin-
ical correlation to the size of the
clinical effect reported by the out-
come measures. The aim of this
study was not to evaluate the par-
ticipants’ function and symptoms
Graph showing the change in the Oswestry Disability Index over time. but to evaluate the performance of
PROMIS measures in comparison
health and facilitate communications thermore, all website-based admin- with legacy measures. Finally, our
with their surgeon. istrations of the PROMIS CATs study included only English-speaking
Although using PROMIS has sev- require the patient to have computer patients, and as such, the findings
eral benefits, our study also had lim- to complete the outcome measures. may not be generalizable to non–
itations. First, the small sample size The number of patients who com- English-speaking patients.
limits rigorous subgroup analysis. pleted their 1 year postoperative Despite potential limitations, we
However, we think that the statisti- follow-up assessment was markedly found that PROMIS can be incor-
cally significant correlations found lower, thus indicating that a large porated in a busy surgical practice
between multiple PROMIS and leg- number had been lost to follow-up. with minimal additional time and
acy PROs as well as the responsive- This finding is consistent with much resources required. In addition,
ness seen with PROMIS measures of the spine surgical literature. Addi- our results suggest good evidence
within the patient self-rated function tionally, the 3-month follow-up may of responsiveness, convergent, and
groups are clinically relevant. Fur- not be of sufficient time since treat- known group validity. We found the
real-time scoring and interpretation item bank in orthopaedic patients. J Orthop 18. Parker SL, Mendenhall SK, Shau DN, et al:
Res 2011;29:947-953. Minimum clinically important difference in
provided by PROMIS improved our pain, disability, and quality of life after neural
ability to capture accurate and mean- 5. Cella D, Yount S, Rothrock N, et al: The decompression and fusion for same-level
Patient-Reported Outcomes Measurement recurrent lumbar stenosis: Understanding
ingful functional outcome data. Information System (PROMIS): Progress of clinical versus statistical significance.
an NIH roadmap cooperative group during J Neurosurg Spine 2012;16:471-478.
its first two years. Med Care 2007;45(5
suppl 1):S3-S11. 19. Parker SL, Mendenhall SK, Shau D, et al:
Conclusions Determination of minimum clinically
6. Choi SW: Firestar: Computerized adaptive important difference in pain, disability, and
PROMIS CATs for PB, PI, and PF testing simulation program for polytomous quality of life after extension of fusion for
item response theory models. Appl Psychol
demonstrate responsiveness and con- adjacent-segment disease. J Neurosurg
Meas 2009;33:644-645.
Spine 2012;16:61-67.
vergent and known groups’ validity 7. Fitzpatrick R, Davey C, Buxton MJ,
among patients surgically treated for a 20. Parker SL, Adogwa O, Paul AR, et al: Utility
Jones DR: Evaluating patient-based
of minimum clinically important difference in
lumbar disk herniation. PROMIS outcome measures for use in clinical trials.
assessing pain, disability, and health state
Health Technol Assess 1998;2:1-74.
CATs perform comparably against after transforaminal lumbar interbody fusion
8. Fries JF, Bruce B, Cella D: The promise of for degenerative lumbar spondylolisthesis.
commonly used PRO measures and J Neurosurg Spine 2011;14:598-604.
PROMIS: Using item response theory to
require less time to complete. The improve assessment of patient-reported
21. Parker SL, Mendenhall SK, Shau DN, et al:
PROMIS CATs demonstrate advan- outcomes. Clin Exp Rheumatol 2005;23(5
Determination of minimum clinically
suppl 39):S53-S57.
tages compared with the standard important difference (MCID) in pain,
legacy instruments through improved 9. Revicki DA, Cella DF: Health status disability, and quality of life after revision
assessment for the twenty-first century: fusion for symptomatic pseudoarthrosis.
efficiency in measuring the treatment Item response theory, item banking and Spine J 2012;12:1122-1128.
effect. Because of these advantages, computer adaptive testing. Qual Life Res
1997;6:595-600. 22. Parker SL, Mendenhall SK, Shau DN, et al:
we suggest the PROMIS CATs can Determination of minimum clinically
be a useful, efficient, and practical tool 10. Weiss DJ: Computerized adaptive testing important difference (MCID) in pain,
for effective and efficient measurement in disability, and quality of life after revision
for tracking patient outcomes after counseling and education. Meas Eval fusion for same-level recurrent lumbar
surgical management of lumbar disk Couns Dev 2004;37:70-84. stenosis: Understanding clinical versus
herniation. statistical significance. J Neurosurg Spine
11. Godil SS, Parker SL, Zuckerman SL, et al: 2012;16:471-478.
Determining the quality and effectiveness of
surgical spine care: Patient satisfaction is not a 23. Copay AG, Martin MM, Subach BR,
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12. Jensen RE, Potosky AL, Reeve BB, et al:
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Evidence-based Medicine: Levels of Validation of the PROMIS physical
2010;10:291-296.
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evidence are described in the table of population-based cohort of cancer patients. 24. Norman GR, Sloan JA, Wyrwich KW:
contents. In this article, references Qual Life Res 2015;24:2333-2344. Interpretation of changes in health-related
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and 5 are level V reports or expert Validation of PROMIS ®physical function
2003;41:582-592.
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Orthop Relat Res 2013;471:3466-3474. PT. Correlation of PROMIS physical
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Patient-reported outcome measures in spine
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negative affect, physical function and social
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across a range of chronic conditions. J Clin Correlation of PROMIS scales and clinical simple? Possible limits to the universality of
Epidemiol 2016;73:89-102. measures among chronic obstructive the one half standard deviation. Med Care
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3. Marshall S, Haywood K, Fitzpatrick R: without exacerbations. Qual Life Res 2015;
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February 1, 2019, Vol 27, No 3 103
Research Article
Outcomes of Arthroscopic
Posterior Medial Meniscus Root
Repair: Association With Body
Mass Index
Abstract
Robert H. Brophy, MD Introduction: The purpose of this study was to assess the association
Robert D. Wojahn, MD of outcomes from posterior medial meniscus root repairs with patient
age, sex, and body mass index (BMI).
Olivia Lillegraven, BA
Methods: Patients who underwent arthroscopic posterior medial
Joseph D. Lamplot, MD meniscus root repair completed the Knee Injury and Osteoarthritis
Outcome Score (KOOS) and reported subsequent surgeries. The
association of patient factors with subsequent surgery and clinical
osteoarthritis (OA) based on the KOOS score was evaluated.
Results: Minimum 2-year follow-up was available on 22/25 patients
(88%). Two patients (9.1%) had subsequent surgeries, and 10
(45.5%) met the KOOS criteria for OA. A BMI over 35 kg/m2 was
associated with repeat surgery (25% versus 0%; P = 0.049) and
clinical OA (75% versus 28.6%; P = 0.035).
Conclusion: Although arthroscopic repair of posterior medial root
tears has good clinical outcomes and a low rate of subsequent
From the Department of Orthopaedic surgery, an elevated BMI level is associated with worse clinical
Surgery, Washington University
School of Medicine in St. Louis, St. outcomes and a higher rate of subsequent surgery.
Louis, MO.
Correspondence to Dr. Brophy:

brophyrh@wustl.edu
Dr. Brophy or an immediate family
M eniscus root tears are a subset
of meniscus tears with dis-
ruption of the posterior horn attach-
native anatomy and biomechanics of
the meniscus to potentially slow the
to Magellan Rx Management and
progression of degenerative changes.
serves as a board member, owner, ment to the tibial plateau, either as an In recent years, there has been an
officer, or committee member of the avulsion injury of the meniscus attach- increased recognition of the biome-
American Academy of Orthopaedic ment or a radial tear within 1 cm of the chanical consequences and accelerated
Surgeons and the American
insertion.1,2 The resulting disruption of joint degeneration resulting from pos-
Orthopaedic Association. None of the
following authors or any immediate the circumferential fibers of the menis- terior medial meniscus root tears
family member has received anything cus leads to a loss of hoop stress gen- (PMMRTs).3,5,6 Studies demonstrat-
of value from or has stock or stock eration crucial to meniscus function,3,4 ing relatively rapid joint degeneration
with biomechanical effects approach- after APM has caused a paradigm shift
indirectly to the subject of this article: ing a total meniscectomy.3,5,6 Arthro- from APM to meniscus root repair for
Dr. Wojahn, Ms. Lillegraven, and scopic partial meniscectomy (APM) PMMRT.12,13 Ozkoc et al13 reported
Dr. Lamplot. may provide moderate symptom relief, outcomes after APM of PMMRT,
J Am Acad Orthop Surg 2019;27: but it does nothing to slow or halt the demonstrating notable improvement
104-111 rapid joint deterioration and develop- in clinical outcomes but progression of
DOI: 10.5435/JAAOS-D-17-00065 ment of symptomatic osteoarthritis radiographic OA at a mean follow-up
(OA) that occurs without root re- of 4.7 years, suggesting that APM
Academy of Orthopaedic Surgeons. pair.3,6-11 Thus, root repair should be likely provides symptomatic relief but
considered when possible to restore the does not arrest the progression of OA.
Robert H. Brophy, MD, et al
Han et al12 corroborated these findings. Figure 1

Consequently, surgeons have begun
to treat PMMRTs with relative ur-
gency in an effort to restore the bio-
mechanical function of the meniscus
and to slow or arrest the onset or
progression of OA.
Surgical indications include a
symptomatic PMMRT that has failed
nonsurgical treatment, minimal ar-
thritic changes, and no significant
varus malalignment.14 A number of
surgical techniques, including suture
anchor repair and pullout suture
repair, have been described and
studied.7,15-18 Short- to medium-term
outcomes after posterior medial
meniscus root repair have been re-
ported in many Korean studies.4,19-24
However, these studies may not be
generalizable to a North American
population, which likely has different
demographic characteristics that may
Magnetic resonance images of posterior medial meniscus root tears. A,
affect outcomes. Specifically, because Coronal T2-weighted fat-suppressed magnetic resonance image demonstrating
the mean body mass index (BMI) a complete radial tear involving the posterior root of the medial meniscus
among US adults is higher than in a 37-year-old woman. The medial meniscus body is displaced into
Korean adults,25,26 it is likely that the medial gutter. B, Sagittal T2-weighted magnetic resonance image
redemonstrating complete radial tear involving the posterior horn and root of the
North American patients undergoing medial meniscus.
posterior medial meniscus root repair
are heavier. Currently, limited data
exist on the association of BMI with and January 2015 were retrospec- Lawrence grade 2 or higher preop-
outcomes after posterior medial me- tively identified. erative degenerative changes or varus
niscus root repair and outcomes in a All patients indicated for posterior malalignment of greater than 5
North American population.27 The medial meniscus root repair based on were not indicated for meniscus root
purpose of this study was to test the persistent symptoms unresponsive to a repair. Concurrent procedures per-
association of patient-specific factors trial of nonsurgical treatment and preformed on the affected knee at the
with subsequent surgery and clinical operative MRI on which an academic time of posterior medial meniscus
outcome after posterior medial me- fellowship-trained musculoskeletal ra- root repair were recorded. Preopera-
niscus root repair surgery using diologist confirmed the presence of a tive patient demographic information
arthroscopic pullout repair fixed root tear (Figure 1). including age, sex, BMI, race, and
through a tibial tunnel. Preoperative weight-bearing radio- ethnicity were recorded.
graphs including AP, Rosenberg,
Methods lateral, and merchant views were Surgical Technique
evaluated for all patients according Surgery was performed using an
After institutional review board to the Kellgren-Lawrence classifica- arthroscopic pullout repair fixed
approval [IRB ID #201509055] tion28 for OA. Patients returning to through a tibial tunnel with a locking
was obtained from the study insti- the clinic with persistent or recurrent loop stitch29 (Figure 2). A standard
tution, the records of all patients knee pain after posterior medial me- diagnostic arthroscopy was first
who underwent posterior medial niscus root repair were indicated for performed to determine whether the
meniscus root repair using an radiographs, which were reviewed posterior medial meniscus root tear
arthroscopic pullout technique and compared, when available, with was appropriate for repair and to
fixed through a tibial tunnel by a preoperative radiographs for OA evaluate any other intra-articular
single surgeon between June 2012 progression. Patients with Kellgren- pathology. A motorized shaver was
February 1, 2019, Vol 27, No 3 105
Arthroscopic Posterior Medial Meniscus Root Repair
Figure 2
Photographs showing the surgical technique. A, A posterior medial meniscus root avulsion from its posterior tibial
attachment is identified medial to the probe. B, The guide for a retrograde flip-cutting drill is placed at the posterior horn
attachment to the tibia. C, The flip-cutting drill is advanced into the knee joint, deployed, and backed down into the tibia
approximately 5 mm. D, The suture passer has placed a second pass of suture through the more peripheral aspect of the
posterior root in a locked loop fashion. E, A passing suture, which was advanced up the spinal needle and retrieved through
the working portal, is used to pull the two ends of the FiberWire down through the tibial tunnel. F, The sutures are threaded
through and tied over a poly button, securing the posterior root.
used when necessary to débride any place a 2-0 FiberWire suture (Ar- Postoperative Rehabilitation
unstable portion of the meniscus threx) through the posterior menis- After surgery, patients were made non–
root. A guide for a retrograde flip- cus. The suture passer was backed weight bearing for 6 weeks. Super-
cutting drill (Arthrex) was then out of the knee and reloaded with vised physical therapy was started
placed at the posterior horn root the other end of the FiberWire for after the first postoperative visit within
attachment in the joint. The guide a second pass through the more 10 to 14 days of surgery. Weight
was brought flush to the tibia peripheral aspect of the posterior bearing was progressed as tolerated
through a small incision over the root in a locked loop fashion. Then, starting at 6 weeks postoperatively,
anterior proximal tibia. The drill was the passing suture was used to pull with the knee locked in extension for
then advanced into the knee joint, the two ends of the FiberWire down the first 4 weeks of weight bearing.
and the retrograde flip-cutting drill through the tibial tunnel. Tension Patients were then weaned out of the
was deployed and backed down into was applied to bring the meniscus brace and not allowed to run before
the tibia approximately 5 mm. The root down into the posterior horn 4.5 months after surgery.
drill was advanced back into the root attachment. The sutures were
joint, and the flip cutter was closed threaded through and tied over a
before removing the drill through the poly button (Arthrex), securing the Follow-up
tibial tunnel. A long spinal needle posterior root. The stability of the At minimum 2-year follow-up, pa-
was passed up through the tibial repair was assessed with the arthro- tients were contacted and consented
tunnel to maintain access to the scopic probe and with flexion and before asking if they had any subse-
posterior joint. A suture cannula extension of the knee. Any associated quent surgery on the affected knee and
(Arthrex) was placed through the pathology was treated appropriately collecting clinical outcomes using the
working portal, and a passing suture before removing the arthroscopic Knee Injury and Osteoarthritis Out-
was advanced up the spinal needle equipment and closing the wounds. come Score (KOOS), which has been
and retrieved out the cannula. Then, After placing a sterile dressing, the validated for detecting OA.30,31 Pa-
a suture passer (Arthrex) advanced knee was placed in a hinged knee tients were categorized as having
through the cannula was used to brace locked in full extension. clinical OA if they met the clinical
definition of OA based on the Statistical Analysis Table 1

KOOS score as previously de- Two-tailed Mann-Whitney U tests Patient Demographics
scribed30 or if they underwent total were used to assess for differences in
Age (yr) 50.4 6 11.0
knee arthroplasty (TKA).32,33 A age, sex, and BMI for patients meeting (mean 6 SD)
consensus expert panel developed clinical criteria for OA.30 Fisher exact ,50 9
a definition for patients with a tests were used to determine the ef- $50 13
symptomatic knee notable enough to fects of age ($50 years), BMI BMI (kg/m2) 34.4 6 7.3
seek medical attention based on the ($35 kg/m2), and sex on the incidence (mean 6 SD)
threshold level of the KOOS subscale of clinical and radiographic OA. All BMI , 25 1 (4.5%)
scores.30 This definition was based statistical analysis was performed 25 # BMI , 30 5 (22.7%)
on the long-term follow-up of who using SPSS version 12.0 (IBM), and (overweight)
previously underwent isolated par-
statistical significance was accepted 30 # BMI , 35 8 (36.4%)
for P values of less than 0.05. (obesity)
tial meniscectomy with intact cru-
BMI $ 35 8 (36.4%)
ciate ligaments. Clinical OA has (severe
previously been defined as the score Results obesity)
for the KOOS subscale QOL #87.5 Sex
and two of the four additional Patient Demographics Male 8 (36.0%)
subscales equal to or less than the Of the 25 eligible patients, 22 patients Female 14 (64.0%)
score obtained as follows: pain #86.1, (88%) were available for minimum Ethnicity
symptoms #85.7, ADL #86.8, and 2-year follow-up. There were 8 men White/ 21 (95.5%)
(36%) and 14 women (64%). The caucasian
sport/rec #85.0.30,34-37
To identify prognostic factors for mean follow-up time was 2.4 6 0.3 Asian 1 (4.5%)
clinical and/or radiographic OA, years. Patient demographics are

BMI = body mass index
patient-specific factors including age, shown in Table 1.
sex, and BMI were also analyzed for
their association with the incidence of Subsequent Surgery patient demonstrated degenerative
subsequent surgery and clinical and Two patients (9.1%) underwent sub- changes on preoperative radiographs
radiographic OA after surgery. sequent surgery. Although neither (Kellgren-Lawrence grade 0), both
Figure 3
Failure of posterior medial meniscus root repair surgery. A, Preoperative standing PA (Rosenberg) radiographs of a 52-year-old
woman with a BMI of 42.4 kg/m2 and no antecedent knee pain before left knee posterior medial meniscus root injury
demonstrating no degenerative changes of the symptomatic left knee (Kellgren-Lawrence grade 0). B, Postoperative standing
PA (Rosenberg) radiographs obtained 6 months postoperatively demonstrating notable progression of left knee medial
compartment radiographic OA with definite joint space narrowing (Kellgren-Lawrence grade 3). She subsequently underwent
TKA 15 months after posterior medial root repair. BMI = body mass index, OA = osteoarthritis, TKA = total knee arthroplasty
February 1, 2019, Vol 27, No 3 107
Table 2 cantly higher incidence of clinical flecting the greater prevalence of

OA than those with BMI ,35 kg/m2 obesity in our patient population
KOOS Scores
(83.3% versus 28.6%; P = 0.048). compared with earlier reports on
Score No significant association was found posterior medial meniscus root
KOOS Subscale (Mean 6 SD)
between age or sex and the inci- repair.19,22,23,27,39 Although previ-
KOOSpain 86.3 6 14.2 dence of clinical OA. There was ous studies have demonstrated that
KOOSsymptoms 81.6 6 19.7 no significant correlation of age or PMMRTs occur at a higher inci-
KOOSADL 88.8 6 15.1 sex with KOOStotal or any KOOS dence in obese patients,13,38 no
KOOSsport/rec 65.8 6 32.2 subscale. studies have investigated the asso-
KOOSQoL 69.5 6 22.5 ciation between obesity and out-
KOOStotal 392 6 91.0 Radiographic Osteoarthritis comes after posterior medial
meniscus root repair despite a
No. of patients 10 (45) Preoperative radiographs demon-
meeting clinical strated Kellgren-Lawrence grade 1 higher incidence of this injury in
OAa (%) this patient population.19,22,23,27,39
OA in three patients (13.6%). Post-
Male 3 (30) We also demonstrate no revision
operatively, nine patients (40.9%)
Female 7 (70) had clinically indicated radiographs surgeries among patients with
BMI ,35 kg/m2.
ADL = activities of daily living, KOOS = Knee
obtained at a minimum of 6 months
Tears of the posterior horn of the
Injury and Osteoarthritis Outcome Score, after surgery (1.19 6 0.81 years). Of
OA = osteoarthritis, QOL = quality of life those with available radiographic medial meniscus, including root
a
Clinical OA has previously been defined30 tears, are more common in Asian
as the score for the KOOS subscale QOL follow-up, six patients (66.7%)
#87.5 and two of the four additional countries, possibly attributable to
demonstrated radiographic OA
subscales equal to or less than the score
progression by at least two Kellgren- frequent squatting and sitting on the
obtained as follows: pain #86.1, symptoms
#85.7, ADL #86.8, and sport/rec #85.0. floor with knees in deep flexion.8
Lawrence grades. The mean age of
Consequently, many studies have
these patients was 58.7 6 8.3 years,
reported outcomes after meniscus root
and the mean BMI was 36.1 6
underwent TKA because of progres- repair surgery in Korean populations,
5.5 kg/m2. Of these six patients, four
sive radiographic joint degeneration which may not be generalizable to
had Kellgren-Lawrence grade 2 OA
and persistent symptoms and at 1.2 North American patients.19,22,23,39
and two had Kellgren-Lawrence
and 2.0 years postoperatively (Figure To our knowledge, only one report
grade 3 OA (both underwent sub-
3). Both patients were women, with describes outcomes after posterior
sequent TKA) (Figure 3). The three
BMI $35 kg/m2. No other patients meniscus root repair in a North
patients not demonstrating radio-
underwent any subsequent surgeries American population,27 and the
graphic progression of OA had a
on the affected knee after posterior mean BMI of patients in that study
mean age of 53.0 6 6.7 years (P =
medial meniscus root repair at final was 26.6 kg/m2. The average BMI
0.37 compared with patients with
follow-up. Patients with BMI among adult Koreans aged 30 to 95
radiographic progression) and a
$35 kg/m2 (severe obesity) were years is 23.2 kg/m2,25 which is
mean BMI of 29.3 6 2.5 kg/m2 (P =
significantly more likely than those characterized as normal BMI, com-
0.08 compared with patients with
with BMI ,35 kg/m2 to undergo pared with 26.6 kg/m2 in the United
radiographic progression).
subsequent surgery (25.0% versus States, which is categorized as over-
0%; P = 0.049). weight.26 Furthermore, 36% of
Conclusion adults in the United States are obese
(BMI $30 kg/m2), with an increas-
Clinical Osteoarthritis Posterior medial meniscus root repair ing incidence.40 Because PMMRTs
For all patients, the mean KOOS in a North American patient pop- occur at a higher incidence in obese
score was 392 6 91. Ten of these ulation demonstrates a low rate of patients,38 determination of the
patients (45.5%) met the KOOS subsequent surgery but a relatively association between obesity and
criteria for clinical OA30 (Table 2). high incidence of clinical and radio- outcomes after meniscus root repair
Patients with BMI $35 kg/m2 (severe graphic OA associated with increased is important. It is also important to
obesity) had a significantly higher patient BMI. The association of point out that although outcomes
incidence of clinical OA than pa- patient BMI .35 kg/m2 with clin- were worse in patients with an ele-
tients with BMI ,35 kg/m2 (75.0% ical OA after posterior medial vated BMI level, most patients still
versus 28.6%; P = 0.035). Women meniscus root repair is a novel, but did well. One patient actually low-
with BMI $35 kg/m2 had a signifi- not unexpected, finding, likely re- ered his BMI from 43.5 before
surgery to 29.4 kg/m2 at final follow- or laterality of tear. In the present predominantly female cohort with a
up as a result of lifestyle changes study, we demonstrate a similarly low mean age of 55 years who under-
facilitated by the surgery and revision surgery rate of 9.1%. How- went arthroscopic pullout suture
reported KOOStotal of 483 at final ever, whereas LaPrade et al27 reported repair for PMMRT, with only one
follow-up, among the highest in our three failures (9.7%) necessitating patient demonstrating progression of
cohort. Although further investiga- revision medial meniscus root repairs, chondrosis on second-look arthros-
tion is needed, weight reduction these failures occurred in patients aged copy. Patient BMI was not reported
strategies both before and after 18.9 to 27.9 years, we report two in this study. Jung et al22 reported
posterior medial meniscus root treatment failures (9.1%) in older, notable improvements in all clinical
repair may optimize outcomes fol- severely obese (BMI $ 35 kg/m2) outcomes following all-inside using a
lowing this procedure and should be female patients. suture anchor at minimum 2 years,
emphasized for all posterior medial Several other studies have de- but this study excluded patients with
meniscus root patients with an ele- scribed excellent clinical outcomes high BMI (not quantified) and age
vated BMI level. with minimal radiographic progres- older than 60 years. Cho and Song19
Three studies have demonstrated sion of OA after posterior medial reported notable improvement in all
an association between patient- meniscus root repair surgery. How- clinical outcome measures and
specific factors and outcomes after ever, in these studies, BMI is often complete healing in 50% of patients
posterior medial meniscus root re- not reported or obese patients are at second-look arthroscopy after
pair. Moon et al14 reported out- excluded. Lee et al4 reported clinical pullout suture repair for posterior
comes following arthroscopic pullout and radiographic outcomes after PMMRT. This study also excluded
repair following posterior medial arthroscopic pullout suture repair patients with BMI $30 kg/m2.
meniscus root repair. The authors of PMMRT demonstrating notable Chung et al21 compared clinical and
reported notable improvements in improvement in all clinical outcome radiographic outcomes of APM with
all clinical outcome measures, with measures, complete healing in nearly repair of PMMRT at minimum 5-
poor results seen in those with half of the patients based on second- year follow-up in a cohort, with an
Outerbridge grade 3 or 4 chondrosis look arthroscopy, and radiographic overall mean BMI of 27 kg/m2 and
or varus malalignment greater than progression of OA in only one age 55 years, demonstrating mark-
5. The authors did not demon- patient. The authors did not report edly improved clinical outcomes and
strate a notable association between patient BMI. Kim et al39 compared less radiographic progression of OA
BMI and clinical or radiographic outcomes of arthroscopic suture in the repair group. The rate of
outcomes. Chung et al20 investigated anchor repair compared to pullout conversion to TKA was 35% in the
prognostic factors at minimum 5 suture repair for PMMRT, with APM group compared with zero in
years after PMMRT in a predomi- both groups demonstrating notable the repair group.
nantly female cohort with a mean improvements in clinical outcome There are several limitations to the
age of 56 years and a mean BMI measures, complete healing in ap- current study. The study was a ret-
of 26.0 kg/m2, identifying Outer- proximately 50% of patients, and no rospective series and lacked a control
bridge and ICRS grade 3 or higher significant radiographic progression group with alternative treatments.
chondrosis, varus malalignment, and of OA. For the entire cohort, the Because postoperative radiographs
older age as independent risk fac- mean age was 53 years, and the are not routinely obtained, radio-
tors for poor outcome. BMI, which mean BMI was 24 kg/m2; patients graphic follow-up was available only
was much lower than in our patient with BMI greater than 30 kg/m2 in a subset of patients who were more
population, was not found to were excluded. Kim et al23 compared likely to be symptomatic and thus
markedly correlate with outcome in outcomes after pullout repair com- potentially more likely to have
that study. Finally, LaPrade et al27 pared with APM for PMMRT in a developed radiographic OA. How-
compared outcomes after trans- predominantly female cohort with a ever, radiographic progression in
tibial pullout repair for posterior mean age of 56 years and a mean severely obese patients within a 2-
medial and lateral root tears in BMI of 27 kg/m2. The authors year period postoperatively is an
patients younger or older than 50 reported markedly greater improve- important, but not surprising, find-
years, demonstrating a 6.7% revi- ments in clinical outcome measures ing that may have clinical im-
sion surgery rate (ie, all posterior with less radiographic OA progres- plications. There was a relatively
medial root repairs) and no signif- sion in the repair group. Seo et al24 low number of patients, but despite
icant differences in postoperative reported notable improvements in all this low number, we were able to
outcomes based on patient age, BMI, clinical outcomes measures in a report markedly worse outcomes
February 1, 2019, Vol 27, No 3 109
among severely obese patients. of the posterior root of the medial meniscus. adolescent female patient with surgical
Similar to total meniscectomy. J Bone Joint reattachment. Am J Sports Med 2008;36:
Finally, MRI or second-look arthros- Surg Am 2008;90:1922-1931. 789-792.
copy was not available to assess heal-
4. Lee JH, Lim YJ, Kim KB, Kim KH, Song 17. Kim YM, Rhee KJ, Lee JK, Hwang DS,
ing and the status of the articular JH: Arthroscopic pullout suture repair of Yang JY, Kim SJ: Arthroscopic pullout
cartilage. posterior root tear of the medial meniscus: repair of a complete radial tear of the tibial
Radiographic and clinical results with a 2- attachment site of the medial meniscus
Despite these limitations, this series posterior horn. Arthroscopy 2006;22:
year follow-up. Arthroscopy 2009;25:
demonstrates that posterior medial 951-958. 795.e1-795.e4.
meniscus root repair surgery using 5. Marzo JM, Gurske-DePerio J: Effects of 18. Marzo JM, Kumar BA: Primary repair of
arthroscopic pullout repair has good medial meniscus posterior horn avulsion medial meniscal avulsions: 2 case studies.
initial outcomes in patients with and repair on tibiofemoral contact area and Am J Sports Med 2007;35:1380-1383.
peak contact pressure with clinical
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19. Cho JH, Song JG: Second-look
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ulation, with low rates of subsequent 6. Pagnani MJ, Cooper DE, Warren RF: root tear of the medial meniscus. Knee Surg
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Arthroscopy 1991;7:297-300.
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of clinical OA and subsequent sur- 7. Ahn JH, Wang JH, Yoo JC, Noh HK, Park Prognostic factors in the midterm results of
JH: A pull out suture for transection of the pullout fixation for posterior root tears of
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21. Chung KS, Ha JK, Yeom CH, et al:
1510-1513.
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9. Bolano LE, Grana WA: Isolated
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All-inside repair for a root tear of the
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February 1, 2019, Vol 27, No 3 111
Research Article
Reporting the Influence of Sex in

Research: Trends at AAOS Annual
Meetings
Abstract
Ashley Tisosky, MD Background: Several initiatives have urged the inclusion of sex in
Catherine Logan, MD data analysis, but few studies have examined the prevalence of sex-
specific reporting in musculoskeletal research. This study aims at
Emily M. Brook, BA
determining the presence of sex-specific analyses reported in
Jen Xu, BS research at American Academy of Orthopaedic Surgeons Annual
Elizabeth Matzkin, MD Meetings.
Methods: Abstracts listed in the American Academy of Orthopaedic
Surgeons Annual Meeting programs from 2006 to 2013 were
retrospectively reviewed for the presence of research reporting the
results of a sex-specific analysis.
Results: The number of abstracts reporting a sex-specific analysis
increased from 48 (2006) to 117 (2013) but accounts for 5.4% of
research presented from 2006 to 2013. Hip and knee arthroplasty
From Harvard Combined Orthopaedic
Residency Program (Dr. Tisosky and
literature accounted for 37% of included abstracts.
Dr. Logan), the Department of Conclusions: The reporting of sex-specific analyses has improved
Orthopaedic Surgery (Ms. Brook and over time but accounts for 5.4% of research presented at annual
Dr. Matzkin), Brigham and Women’s
Hospital, and Harvard University
meetings from 2006 to 2013. The inclusion of sex-specific analyses
(Ms. Xu), Boston, MA. should be required for future research publications to better
Correspondence to Dr. Matzkin: understand the influence of sex in musculoskeletal medicine.
ematzkin@bwh.harvard.edu
Dr. Matzkin or an immediate family
institutional support from Zimmer
Biomet and serves as a board
H istorically, women and children
were excluded from research
trials to offer them protection from
Control and Prevention developed
similar guidelines.3-5 In 2015, a Gen-
eral Accounting Office audit found
member of the American Academy of any potential negative consequences. that 57% of enrollees in phase III
Orthopaedic Surgeons, the American In 1985, the United States Public clinical trials were females and that
Orthopaedic Society for Sports Health Service Task Force on Women’s greater than 90% of grant proposals
Medicine, and the Arthroscopy
Association of North America. None of
Health Issues concluded that omis- submitted met the standards for in-
the following authors or any sion of women from research studies clusion of female subjects.6
immediate family member has led to a lack of evidence-based Despite the substantial progress that
received anything of value from or has knowledge about women’s health has been made with regard to the equal
and negatively affected their medical inclusion of both sexes as subjects
related directly or indirectly to the care.1 It was not until 1993 that in federally funded research, subse-
subject of this article: Dr. Tisosky, these guidelines were transformed quent sex-specific data analysis and re-
Dr. Logan, Ms. Brook, and Ms. Xu. into law with the passage of the porting of findings remains low.7 The
J Am Acad Orthop Surg 2019;27: National Institutes of Health (NIH) NIH policy on the inclusion of women
e112-e117 Revitalization Act, which mandated and minorities in research states,
DOI: 10.5435/JAAOS-D-17-00366 the inclusion of women and minorities “the inclusion of the results of
in clinical research.2 Shortly after, the sex/gender, race/ethnicity, and rel-
Academy of Orthopaedic Surgeons. FDA, Agency for Health Research and evant subpopulations analyses is
Quality, and Centers for Disease strongly encouraged in all publication
Ashley Tisosky, MD, et al
submissions. If these analyses reveal Figure 1

no differences, a brief statement to that
effect, indicating the groups and/or
subgroups analyzed, will suffice.”2 In
2014, the NIH further developed new
policies requiring researchers to report
their plans for the balance of male and
female cells and animals in preclinical
studies in all future applications.8
Compliance of sex and gender inclu-
sion in research funded by the agency
is then monitored through data-
mining techniques. Although the
NIH cannot directly control the pub-
lication of sex and gender analyses, it
continues to partner with publishers
to promote the publication of such
research results.9,10
In an effort to address this policy,
some journals have modified their
editorial policies to require the re-
porting of sex-specific results.
Sexual dimorphism is well known
in several musculoskeletal conditions.
Schematic showing inclusion and exclusion criteria for research presented at the
Anterior cruciate ligament (ACL) in- 2006 to 2016 AAOS Annual Meetings. AAOS Annual Meeting years of 2014 to
jury is up to 10 times more likely in 2016 could only be evaluated for inclusion in the subgroup because of a change
females and is caused by a multitude in the program format. AAOS = American Academy of Orthopaedic Surgeons
of factors, including hormonal in-
volvement, neuromuscular control,
the results of a sex-specific analysis using the terms “sex,” “gender,”
and anatomic variations.11-13 The
risk of osteoporosis and fragility
at the American Academy of Ortho- “male,” and “female” in each AAOS
paedic Surgeons (AAOS) Annual Annual Meeting program. Histori-
fractures is substantially greater in
Meetings from 2006 to 2013. We cally, publications have incorrectly
females compared to males, attribut-
hypothesize that the number of used the terms “sex” and “gender”
able to hormonal differences.14-16
research abstracts that report the to describe differences between
In addition, several studies have
results of a sex-specific analysis will
demonstrated sex differences in the males and females in research. The
be low, despite NIH and several
development of osteoarthritis and reason for such an inconsistency is
high-impact journal initiatives that
cartilage loss over time.17-19 due to a lack of knowledge about the
encourage the inclusion of sex-
Although several orthopaedic con- difference between the terms sex and
specific analyses in research results.
ditions have been specifically studied gender. Sex is defined as the biologic
with regard to sex differences, a call classification of living things as male
for the inclusion and reporting of sex- or female according to their repro-
specific analyses in all orthopaedic Methods
ductive organs and functions assigned
research has been proposed. A 2014
Sample and Procedure by the chromosomal complement.21
editorial in Clinical Orthopaedics
Gender is defined by a person’s self-
and Related Research recommended Abstracts listed in the AAOS Annual
that studies be sufficiently powered Meeting final program over a 7-year representation as a male or female or
to answer research questions for period (2006 to 2013) were retro- how that person is responded to by
both sexes and that the influence of spectively reviewed to determine the social institutions on the basis of the
sex on study results must be analyzed presence of research reporting a sex- individual’s gender presentation. 21
and reported.20 The primary pur- specific analysis. A key word search Because these terms have been incon-
pose of our study was to determine within paper, poster, and scientific sistently used in the literature, both sex
the presence of research reporting exhibit presentations was performed and gender were used as key words.
Influence of Sex in Research
Table 1 Abstracts from the 2006 to 2016

AAOS Annual Meeting years were
Number of Abstracts That Met the Inclusion Criteria by Each AAOS Annual
Meeting Year further evaluated for inclusion in a
subgroup, which comprised research
AAOS Annual Included Abstracts Abstracts Focused on Sex
with an explicit purpose of evaluating
Meeting Year (n = 590) Differences (n = 101)
the influence of sex on an orthopaedic
2006 48 5 condition (Figure 1). Examples include:
2007 43 8 “Evidence for gender-related differ-
2008 59 10 ences in absolute risk of death after hip
2009 69 14 fracture: meta-analysis” (2008) and
2010 71 11 “Gender differences in human knee
2011 78 11 function during maneuvers associated
2012 105 8 with non-contact ACL injury” (2011).
2013 117 9 The 2014 to 2016 AAOS programs
2014 — 7 were included in this subgroup analysis
2015 — 8 because the primary outcomes that
2016 — 10 were investigated remain clearly stated
in the abbreviated paragraph, regard-
AAOS = American Academy of Orthopaedic Surgeons less of the overall program format
change. Research from 2014 to 2016
was added to provide the most up-
dated data on the topic of sex-specific
Figure 2
analysis in orthopaedic research.
Measures
The abstracts that met the inclusion
criteria were totaled for each AAOS
Annual Meeting year (2006 to 2013)
and divided by the overall number of
research presentations to evaluate the
prevalence of orthopaedic research
reporting the results of a sex-specific
analysis. In addition, research that
had a purpose to evaluate the in-
volvement of sex in an orthopaedic
condition was summed for the 2006
to 2016 AAOS Annual Meeting
years. Included abstracts and ab-
Graph showing included abstracts (blue) and abstracts that specifically
evaluated the involvement of sex in an orthopaedic condition (red) over the 2006 stracts that met the subgroup criteria
to 2013 AAOS Annual Meeting years. AAOS = American Academy of were summed for each meeting year.
Orthopaedic Surgeons In addition, included abstracts were
categorized by subspecialty.
All abstracts from the 2006 to 2013 research from the 2014 to 2016
AAOS Annual Meetings that con- AAOS Annual Meetings was not
Results
tained one or more of the above key able to be included in the primary The key word search for “sex,”
words were reviewed for inclusion group analysis because the data were “gender,” “male,” and “female”
and exclusion criteria (Figure 1). In not comparable to years 2006 to yielded 1,256 items throughout the
2014, the AAOS Annual Meeting 2013, and reporting of sex-specific 2006 to 2013 AAOS Annual Meet-
program format changed from analysis may have been under- ing programs. Of the search items,
including a full structured abstract reported because of length re- 590 abstracts reported a sex-specific
to a single paragraph summary of strictions, particularly if the impact analysis, and 101 abstracts had a
each presentation. Consequently, of sex was not a primary outcome. purpose to evaluate the influence of
Table 2 Figure 3
Number of Included Abstracts and
Abstracts That Had a Purpose to
Examine the Influence of Sex in an
Orthopaedic Condition by
Presentation Format
Included
Presentation Abstracts
Format (n = 615)
Paper 340
Poster 246
Scientific exhibit 29
sex on an orthopaedic condition

(Figure 1). The number of abstracts
that reported the results of a sex-
specific analysis increased over time, Graph showing the distribution of included abstracts based on orthopaedic
from 48 abstracts in 2006 to 117 in subspecialty.
2013 (Table 1; Figure 2). The most
significant increase by Annual Meet-
ing year was from 2011 (n = 78) to literature concluding distinct differ- plasty abstracts were focused on the
2012 (n = 105; Table 1; Figure 2). ences between the sexes in musculo- knee (n = 13). In addition, of the eight
Abstracts included in the subgroup skeletal conditions, the inclusion of abstracts for which the purpose
(n = 101) did not notably increase sex-specific analyses in all orthopaedic- was to investigate the influence of
over time (Figure 2). Only 5.4% of related research is lacking. One previ- sex in an orthopaedic condition, four
the 11,001 papers, posters, and sci- ous study investigated the proportion focused on the gender-specific knee
entific presentations presented at of research reporting sex-specific ana- replacement implant. This increased
AAOS Annual Meetings from 2006 lyses in high-impact orthopaedic jour- trend in sex-specific analyses is likely
to 2013 reported the results of a sex- nals from 2000 to 2010 and found that due to the marketing of a gender-
specific analysis. The categorization although the presence of sex-specific specific total knee arthroplasty
of included abstracts by presentation analyses increased over the study implant first reported in the litera-
format is shown in Table 2. period, less than a third of studies ture in 2007.22 Advocates cited the
By subspecialty, the largest demon- reported a sex-specific analysis in numerous morphologic differences
stration of sex-specific analyses was in 2010.7 Similarly, our study demon- between male and female knees as
hip and knee arthroplasty, represent- strated that the reporting of sex- the driving force for development
ing 37% (n = 218) of included ab- specific analyses has increased over and utilization of sex-specific knee
stracts, followed by sports medicine time, from 48 abstracts in 2006 to arthroplasty components.23 Oppo-
with 19% (n = 113), trauma with 117 abstracts in 2013. Nonetheless, nents highlighted no difference in
11% (n = 63), pediatrics with 9% only 5.4% of the 11,001 abstracts implant survivorship and functional
(n = 54), and spine with 8% (n = 50). presented at the 2006 to 2013 AAOS outcomes between the sexes when
The remaining subspecialties each Annual Meetings reported the results using standard components.24 This
represented less than 5% of abstracts of a sex-specific analysis. debate spurred interest in research-
with sex-specific analyses (Figure 3). By subspecialty, hip and knee ing not only the anatomical varia-
arthroplasty accounted for 37% of tions between males and females but
research reporting the results of a sex- also research focusing on the poten-
Discussion specific analysis. Although the volume tial sex differences in the clinical
of sex-specific arthroplasty research at outcomes of total joint arthroplasty.
Sexual dimorphism has been well AAOS Annual Meetings has increased In 2012, there was another notable
studied in several areas of musculo- steadily over time, the focus of that increase in the number of hip and
skeletal medicine including ACL research and distribution by ana- knee arthroplasty abstracts that
injury, osteoporosis, and osteo- tomic region has varied considerably. reported the results of a sex-specific
arthritis. Despite the growing body of In 2008, 65% of sex-specific arthro- analysis. This increase was likely
Influence of Sex in Research
associated with the rising interest in extremity fractures. Sex-specific re- research. The subgroup encompassed
metal-on-metal (MoM) hip resurfac- porting in pediatric orthopaedics presentations that specifically focused
ing and total hip arthroplasty, as well (9%) was predominantly focused on on the effect of sex on an orthopaedic
as the influence of sex on out- adolescent idiopathic scoliosis. Other condition, which is evident in the title
comes.25,26 The use of MoM artic- topics included cerebral palsy and and summary paragraph regardless of
ulations in total hip arthroplasty trauma. Last, 8% of the abstracts program format change.
was originally favored because of with sex-specific analyses were found
improved postoperative stability in the field of spine surgery, primarily
using large femoral heads and low reporting on degenerative cervical Conclusions
volumetric wear rate. However, and lumbar disease, outcomes after
high short-term failure rates and spinal fusion, and the use of various Although the overall number of
numerous adverse events including fusion adjuncts including bone mor- research abstracts reporting a sex-
development of aseptic lymphocyte- phogenetic protein-2. specific analysis has improved over
dominated vasculitis-associated le- The primary limitation of this study the study period, research that
sions, pseudotumor formation, is that only the abstract was available reported sex-specific analyses ac-
elevated serum cobalt and chromium for review in the AAOS Annual counted for only 5.4% of research
ion levels, and soft-tissue destruction Meeting program. Abstracts that did presented at the 2006 to 2013 AAOS
lead to a sharp decrease in popularity not explicitly state the outcome of a Annual Meetings. Furthermore,
of the MoM bearing. Female sex has sex-specific analysis were excluded, research that focused primarily on
been identified as a risk factor for even if demographic data were col- the effect of sex on an orthopaedic
elevated serum metal ion levels.27 lected, because there was no method condition comprised less than 1%
Elevated chromium ion levels greater to confirm that a sex-specific analysis of the presentations at the AAOS
than 7 parts per billion are associated was actually performed. It is possible Annual Meeting in 2016 (n = 10;
with markedly worse health-related that some presentations did include 0.7%). In line with the NIH policy
quality of life and hip function in the reporting of sex-specific analyses, dictating that all applications must
female patients with MoM bearings, but did not incorporate such findings state how female and male subjects
both hip resurfacing and total hip into the abstract. This may be due to will be balanced, the AAOS should
arthroplasty.28 The surge in sex- the lack of results significant enough require authors to specifically indi-
specific analyses in total hip arthro- to warrant appearance in the ab- cate whether a sex-specific analysis
plasty research at this time is likely stract in conjunction with length re- was performed. Because of limi-
related to investigation of the various strictions. This limitation may have tations on abstract word count, this
adverse effects of MoM bearings and underestimated the number of pre- may be as simple as adding a check
specific risk factors for those com- sentations that performed a sex- box to the application form.
plications, including sex. specific analysis. Nevertheless, our As clinical investigators, we must
Sports medicine contained the primary purpose was to determine include the results of sex-specific
second highest percentage (19%) of the prevalence of sex-specific report- analyses in all studies. It is impera-
sex-specific reporting. Most of this ing in AAOS Annual Meeting ab- tive that we continue to understand
literature focused on sex differences stracts as a proxy for the orthopaedic the importance of sexual dimor-
in ACL injury and outcomes after research community. Including ab- phism in musculoskeletal medicine.
reconstruction.11-13 Trauma repre- stracts that did not specify an analysis The NIH has continued to develop
sented 11% of abstracts with sex- of sex may have resulted in mislead- new policies to further mandate bal-
specific analysis and encompassed ing data. We were unable to review ance of male and female subjects in
the most diverse spread of ortho- complete abstracts for the reporting preclinical studies. As preclinical
paedic topics. Research with sex- of a sex-specific analysis beyond studies continue to advance the in-
specific analyses ranged from 2013 because of a change in the clusion of sex differences analysis,
appropriate management of unique AAOS program format, which printed clinical scientific reporting should
patient populations including poly- only a short summary of the research intuitively follow the same guidelines
trauma and geriatric patients, rec- in place of the full abstract. We chose to provide the most accurate con-
ognition of metabolic bone disorders to include presentations from the clusions. The time has come for
such as vitamin D deficiency, and 2014 to 2016 AAOS Annual Meeting journals and editorial boards to
atypical diphosphonate-related femur programs in the subgroup analysis require the reporting of sex-specific
fractures, as well as the treatment and to provide the most up-to-date infor- analyses in all published research.
outcomes of various upper and lower mation on the topic of sex-specific This will serve to strengthen not only
the musculoskeletal literature but www.gao.gov/assets/680/673276.pdf. without clinical knee osteoarthritis.

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Research Article
Evaluation of US Orthopaedic
Surgery Academic Centers Based
on Measurements of Academic
Achievement
Abstract
Aram A. Namavar, MS Introduction: Although a variety of agencies have attempted to
Amanda H. Loftin, BS evaluate the academic achievements of orthopaedic surgery
Anadjeet S. Khahera, BS academic centers, most use opaque criteria that are difficult to
Alexandra I. Stavrakis, MD interpret and do not provide clear targets for improvement. This study
Vishal Hegde, MD leverages a weighted algorithm using objective measurements that
Daniel Johansen, MD has been linked to academic achievement to attempt to provide a
Stephen Zoller, MD comprehensive assessment of scholarly accomplishment for
Nicholas Bernthal, MD orthopaedic surgery academic centers.
Methods: We examined full-time faculty at 138 US orthopaedic surgery
academic centers; part-time or volunteer faculty were excluded. Five
From the Department of Medicine,
Stritch School of Medicine, Loyola metrics of academic achievement were assessed: National Institutes of
University Chicago, Chicago, IL (Mr. Health funding (2013), number of publications, Hirschberg-index (ie, a
Namavar), the Department of metric of impact of publications), leadership positions held in
Orthopaedic Surgery, David Geffen
School of Medicine, University of orthopaedic surgery societies, and editorial board positions of top
California Los Angeles (UCLA), Santa orthopaedic and subspecialty journals. Academic programs were
Monica, CA (Ms. Loftin, Dr. Stavrakis, given a score for every category, and the algorithm was used to calculate
Dr. Hegde, Dr. Johansen, Dr. Zoller,
Dr. Bernthal), and the Department of an overall score of academic achievement for each program.
Neurological Surgery, University of Results: The five most academically productive programs were
California, Irvine School of Medicine,
Washington University in St. Louis, Hospital for Special Surgery, Mayo
Irvine, CA (Mr. Khahera).
Clinic, University of Pennsylvania, and Thomas Jefferson University.
Correspondence to Dr. Bernthal:
nbernthal@mednet.ucla.edu
Conclusion: This algorithm may provide faculty with an assessment
tool that can establish benchmarks to help focus efforts toward
Dr. Zoller or an immediate family
member has received research or increasing the academic productivity of their respective programs.
institutional support from Synthes.
Dr. Bernthal or an immediate family
member serves as a paid consultant to
Onkos. None of the following authors
nor any immediate family member has
T he academic contributions of an
orthopaedic surgery academic
center are often difficult to evaluate.
recognize those departments that
have invested heavily in this area and
provide a “road map” for depart-
stock or stock options held in a Members of academic centers con- ments who wish to develop their
tribute to the knowledge base in academic practice.
subject of this article: Mr. Namavar, orthopaedics in many ways, includ- Although public ranking agencies
Ms. Loftin, Mr. Khahera, Dr. Stavrakis, ing publishing manuscripts, review- such as U.S. News & World Report
Dr. Hegde, and Dr. Johansen. ing for journals, and organizing use some objective metrics such as
J Am Acad Orthop Surg 2019;27: national and international meetings. peer-reviewed articles, grants, and
e118-e126 In an era where clinical productivity is clinical trials, they also rely heavily on
DOI: 10.5435/JAAOS-D-16-00536 increasingly measured and linked to subjective data such as “reputation
financial incentives for providers, our score” from a survey of physicians.1-4
Academy of Orthopaedic Surgeons. study aims at quantifying academic In addition, these ranking systems use
productivity in an effort to both the productivity of alumni within the
Aram A. Namavar, MS, et al
preceding 15 years (ie, via Doximity further adding to the methodology noted.18 To avoid double counting
user profiles) and therefore may not used by our colleagues in other spe- coauthored publications by separate
accurately reflect the department’s cialties by including a per capita mea- faculty members, collections for
current productivity.3 sure that normalizes the weighted each residency program were created
In the past several years, efforts at metrics based on the number of faculty within PubMed. The orthopaedic
quantifying academic achievement in each department. In this manner, societies chosen by the authors
using publicly available metrics have the cumulative statistic will reflect the include the two largest general
increased. Researchers in the fields of work of large institutions, whereas the orthopaedic societies in the United
urology, ophthalmology, radiology, per capita statistic will reflect faculty States: the American Academy of
and general surgery have evaluated committed to academia. Orthopaedic Surgeons and the
departments based on National In- Orthopaedic Research Society, as
stitutes of Health (NIH) funding, well as what was felt to be the pre-
number of publications, and faculty Methods eminent subspecialty society for
Hirschberg-indices (“h-index”), a each of the nine orthopaedic sub-
metric that considers both the quan- Orthopaedic surgery academic cen- specialties: American Shoulder and
tity and impact of publications.5-12 ters were defined as departments Elbow Surgeons, American Ortho-
The Kaiser Permanente Department with a current accredited residency paedic Society for Sports Medi-
of Dermatology has furthered this training program. One hundred cine, Musculoskeletal Tumor Society,
area of study by proposing a weighted thirty-eight of the 149 academic American Association for Hand Sur-
algorithm of objective data that orthopaedic programs (92%) in the gery, American Association of Hip
could be used to assess the academic United States provided a list of faculty and Knee Surgeons, Orthopaedic
productivity of US dermatology pro- members on their individual depart- Trauma Association, North American
grams.13,14 This group expanded the mental websites. These websites were Spine Society, Pediatric Orthopaedic
definition of scholarly achievement to used to determine and include all full- Society of North America, and
include positions on editorial boards time faculty, while part-time and the American Orthopaedic Foot and
of major journals and roles in major volunteer faculty were excluded. The Ankle Society. Leadership positions
national conferences; however, they following five publicly available cri- of the eleven societies were defined as
weighted these contributions to give teria were evaluated for all full-time members of the board of directors or
more “credit” to achievements of faculty members: NIH funding, total the executive committee. Orthopae-
NIH funding, h-index, and number of number of publications, h-index, lead- dic journals with an impact factor
publications. This methodology has ership positions held in orthopaedic above 2.0 were included for review.
been met with great enthusiasm from surgery societies and orthopaedic These journals are the American
other subspecialties such as neurosur- subspecialty societies, and board Journal of Sports Medicine; Osteo-
gery and urology, in which researchers membership of top orthopaedic and arthritis Cartilage; Journal of Bone
have replicated their approach.15,16 subspecialty journals. NIH funding and Joint Surgery; Arthroscopy;
The current study aims at leverag- for 2013 was obtained for each indi- Journal of Orthopaedic Research;
ing this algorithm to quantify the vidual faculty member from the NIH Clinical Orthopaedics and Related
academic achievement of US ortho- Research Portfolio Online Reporting Research; Knee Surgery, Sports
paedic academic departments in Tools Expenditures and Reports Traumatology, Arthroscopy; The
2013, an effort that has previously (RePORTER).17 NIH RePORTER Bone & Joint Journal; The Spine
not been attempted. We feel that was searched by the first and last Journal; Spine; Journal of the
the use of five objective weighted name of each individual full-time American Academy of Orthopaedic
metrics including NIH funding, total faculty member, affiliated institu- Surgeons; The Journal of Arthro-
PubMed articles, mean h-index for tion, and the year 2013. The search plasty; and the Journal of Shoulder
faculty, leadership in societies, and results were then filtered to only and Elbow Surgery.
number of faculty on editorial boards include NIH funding for full-time Based on the methodology used to
of major journals can sum to provide faculty members listed as the princi- rank universities in the annual
an accurate assessment of ortho- pal investigator, rather than a coin- Academic Ranking of World Uni-
paedic surgery research productivity, vestigator. Using the Scopus database versities,19 each academic center
thereby both acknowledging pro- website, which includes research was assigned a score from zero to
grams making notable contributions published in 1995 or later, each 1 for each of the five outcome
and providing others a path to- faculty member’s total number of measurements. The program with the
ward improvement. Moreover, we are publications and mean h-index were highest score was assigned a score of
Ortho Academic Achievement Assessment
Figure 1 The researchers performed all

quantitative analyses in Excel 2010
(Microsoft).
Results
Of the 138 orthopaedic surgery aca-
demic centers evaluated, 43 pro-
grams (31%) had faculty members
as principal investigators on NIH-
funded research in 2013. These pro-
grams received NIH grant funding
ranging from $6.1 million (ie,
Washington University) to $70,000
(ie, West Virginia University) (Fig-
ure 2). Rochester ($4.9 million),
Johns Hopkins ($3.8 million), Uni-
versity of California–San Francisco
($3.7 million), University of Penn-
sylvania ($3.1 million), and the Uni-
versity of California–Los Angeles
($2.7 million) represent the remaining
Weighted algorithm showing the overall academic achievement: The five criteria five institutions with the largest
used to evaluate each orthopaedic residency program’s contributions are
total dollar amount of principal
shown. Metrics of original academic thought—h-index, publication number, and
NIH funding—were weighted to each represent 25% of the overall score. Metrics investigator–garnered NIH funding
of leadership—editorial positions and society leadership—were weighted to in 2013 (Table 1).
each represent 12.5% of the overall score. Each programs’ individual score in The total number of publications
each category was multiplied by the weight of the criteria and summed to create
for all faculty of an orthopaedic
a score of overall academic achievement. h-index = Hirschberg-index, NIH =
National Institutes of Health department ranged from 9 to more
than 11,000. The Hospital for Special
Surgery represented the institution
1, and the program with the lowest faculty publications, and h-index) with the greatest total number of
score was assigned a score of 0. The that reflect novel contributions to the publications (11,136), with Mayo
programs in between were subse- field were considered high value, Clinic (8,103) and Thomas Jefferson
quently assigned scores from zero to 1 thus given a weight of 1.0. The re- (5,235) as the other two programs
by dividing the specific outcome maining factors—leadership in soci- with more than 5,000 total pub-
measure that program achieved by eties and number of faculty members lications (Table 2).
the outcome measure achieved by on editorial boards of journals— The University of Southern Cal-
the highest achieving department were thought to reflect contributions ifornia had the highest mean h-index
and multiplying by the determined in leadership and direction of the for full-time faculty (27.647),
weight for that metric. For example, field and given a weight of 0.5. Each followed by Mayo Clinic, which had
Rochester’s $4,895,625 NIH fund- program’s score in each category a mean h-index of 22.746 (Table 3).
ing was divided by Washington was multiplied by the weight of There was less disparity between
University in St. Louis’ $6,113,194 that metric, and these results were orthopaedic surgery programs in the
and multiplied by 1.0 (ie, weighting summed. Overall academic achieve- number of full-time faculty members
factor for NIH funding). ment was thus calculated as sum of who held leadership positions in
Adapted from the model used by these weighted results (Figure 1). orthopaedic surgery societies. Hos-
Wu et al,13 a previously published The per capita measurement was pital for Special Surgery faculty gar-
weighted ranking scheme was used calculated by dividing the number nered five leadership positions, the
to get an overall ranking of proof faculty per each program by highest number of all programs
grams based on the relative impor- the total point value accrued (Table 4). Four leadership positions
tance of each factor. The research from the aforementioned objective were held by full-time faculty at
metrics (ie, NIH funding, number of metrics. Washington University in St. Louis.
Figure 2
Graph showing the National Institutes of Health (NIH) dollar amount awarded to each of the 43 NIH-funded orthopaedic
surgery programs: Full-time faculty members were listed as principal investigators on NIH-funded research at 43 of the 138
orthopaedic surgery programs (31%) evaluated. The total amount of NIH funding granted to orthopaedic programs in 2013
was $54,925,833. These programs received NIH grant funding ranged from $6.1 million (ie, Washington University) to
$70,000 (ie, West Virginia University).
Three leadership positions were held Table 1

by full-time faculty Mayo Clinic in
Ten US Orthopaedic Surgery Residency Programs With the Largest Total
Rochester, MN; Duke University; Dollar Amount of NIH Funding Received by Institutional Full-time Faculty,
University of Pennsylvania; Univer- 2013
sity of California, San Francisco; NIH Funding Points
Harvard University; and Rush Med- Institution (Location) (2013) (Weighted)
ical College. One hundred two or-
thopaedic training programs had Washington University in St. Louis $6,113,194 1.000
(St. Louis, MO)
faculty members holding at least
University of Rochester $4,895,625 0.801
one leadership position in a major (Rochester, NY)
orthopaedic surgery societies. Johns Hopkins University $3,815,332 0.624
With 15 full-time faculty members (Baltimore, MD)
holding editorial board positions at University of California, San Francisco $3,695,186 0.604
top orthopaedic and subspecialty (San Francisco, CA)
journals, Thomas Jefferson Univer- University of Pennsylvania $3,063,417 0.501
sity was the highest scoring pro- (Philadelphia, PA)
gram in this category, followed by University of California, Los Angeles $2,707,227 0.443
Washington University, which had (Los Angeles, CA)
13 members holding editorial board University of Iowa (Iowa City, IA) $2,483,016 0.406
positions (Table 5). University of Pittsburgh (Pittsburgh, PA) $2,017,975 0.330
All 138 programs were evaluated University of California, San Diego $2,009,013 0.329
(San Diego, CA)
using the comprehensive weighted
Mount Sinai (New York, NY) $1,769,781 0.290
algorithm. Washington University in
St. Louis was shown to be the most NIH = National Institutes of Health
academically productive orthopaedic
Table 2 aside from NIH funding. The Univer-

sity of Pennsylvania was in the top 10
Ten US Orthopaedic Surgery Residency Programs With the Highest Total
Number of Publications by Institutional Full-time Faculty, 2013 for 4 of 5 measurements of academic
achievement; it was not ranked in the
Points
top 10 for the number of full-time fac-
Institution (Location) Publications (Weighted)
ulty holding editorial board positions.
Hospital for Special Surgery 11,136 1.000 Thomas Jefferson University appeared
(New York, NY) in the top five for editorial board posi-
Mayo Clinic (Rochester, MN) 8,103 0.728 tions and publications in 2013.
Thomas Jefferson University 5,235 0.470 Based on the per capita measure-
(Philadelphia, PA) ment that accounts for the number of
Washington University in St. Louis 4,736 0.425 faculty in each program, the most
(St. Louis, MO)
academically productive orthopaedic
Harvard University (Boston, MA) 4,309 0.387
surgery programs were the University
New York University (New York, NY) 4,225 0.379
of Southern California, Washington
University of Pennsylvania 4,218 0.379
(Philadelphia, PA)
University in St. Louis, Boston Univer-
sity, Orlando Regional, and the Naval
Rush Medical College (Chicago, IL) 4,068 0.365
Medical Center in San Diego. The top
University of Washington (Seattle, WA) 4,039 0.363
20 academically productive programs
University of Pittsburgh (Pittsburgh, PA) 3,765 0.339
based on this per capita measurement
are summarized in Figure 4.
Table 3
Ten US Orthopaedic Surgery Residency Programs With the Highest Mean Conclusion
h-index of Institutional Full-time Faculty, 2013
Mean Points Any system evaluating orthopaedic
Institution (Location) h-index (weighted) academic centers is inherently con-
troversial. Many different criteria can
University of Southern California 27.647 1.000 be used to gauge the “academic suc-
(Los Angeles, CA)
cess” of programs, and the results
Mayo Clinic (Rochester, MN) 22.746 0.823
are highly dependent on the metrics
Washington University in St. Louis 18.655 0.675
(St. Louis, MO)
selected. It is not the authors’ inten-
tion to “rank” training programs or
Hospital for Special Surgery (New York, NY) 18.103 0.655
orthopaedic departments but rather
Harvard University (Boston, MA) 16.225 0.587
attempt to quantify departmental
Rush Medical College (Chicago, IL) 16.210 0.586
academic contributions. In an era
University of Pennsylvania (Philadelphia, PA) 15.870 0.574
where clinical productivity is linked
Boston University (Boston, MA) 15.643 0.566
to financial incentives for providers,
Columbia University (New York, NY) 15.167 0.546
fiscal “bottom line” and clinical
University of California, Los Angeles 15.086 0.546 productivity often supersede aca-
(Los Angeles, CA)
demic achievement, partially because
h-index = Hirschberg-index of the difficulty in quantifying and
demonstrating academic success.
In light of these pressures, it is our
surgery program in the United Each of the five most academically goal to attempt to quantify aca-
States based on this algorithm (Fig- productive programs appeared in demic achievement to (1) acknowl-
ure 3). The remaining four most the top five of at least two of the edge academic centers that are
academically productive orthopae- five outcome measurements. Nota- advancing the field through research
dic surgery programs were Hospi- bly, Washington University in St. contributions, (2) establish a means
tal for Special Surgery; Mayo Clinic Louis appeared in all five categories. to track improvement or growth,
in Rochester, MN; University of Hospital for Special Surgery and and (3) open a discussion as to
Pennsylvania; and Thomas Jeffer- Mayo Clinic in Rochester, MN, ap- how we define academic “success.”
son University. peared in the top five for every category Although many cite the importance
of academic rankings as means to Table 4

increase the influence and reputa-
Eight US Orthopaedic Surgery Residency Programs With the Highest
tion of the department (and thereby Amount of Full-Time Faculty Holding Leadership Positions in the Two
attracting patients, trainees, and Largest General Orthopaedic Surgery Societies in the United States
additional faculty), these byproducts (ie, AAOS and ORS) and a Subspecialty Society for Each of the Nine
of academic productivity are far more Orthopaedic Subspecialties (ie, ASES, AOSSM, MSTS, AAHS, AAHKS,
OTA, NASS, POSNA, and AOFAS), 2013
difficult to quantify.7
It is also important to note that Leadership Points
Institution (Location) Positions (weighted)
different orthopaedic surgery pro-
grams focus on different aspects Hospital for Special Surgery (New York, NY) 5 0.500
of orthopaedics. Although some de- Washington University in St. Louis 4 0.400
partments value and focus on re- (St. Louis, MO)
search, others put far more effort Duke University (Durham, NC) 3 0.300
into clinical training, community Mayo Clinic (Rochester, MN) 3 0.300
outreach, or technical innovation. University of Pennsylvania (Philadelphia, PA) 3 0.300
Academic success as defined by the University of California, San Francisco 3 0.300
metrics in this article may not be as (San Francisco, CA)
relevant for a program whose mission Harvard University (Boston, MA) 3 0.300
is predominantly focused on clinical Rush Medical College (Chicago, IL) 3 0.300
care. Nonetheless, academic con-
tributions remain one of the central AAAHKS = American Association of Hip and Knee Surgeons, AAHS = American Association for
Hand Surgery, AAOS = American Academy of Orthopaedic Surgeons, AOFAS = American
tenets of academic orthopaedic sur- Orthopaedic Foot & Ankle Society, ASES = American Shoulder and Elbow Surgeons, AOSSM =
gery, and we therefore feel that there American Orthopaedic Society for Sports Medicine, MSTS = Musculoskeletal Tumor Society,
NASS = North American Spine Society, ORS = Orthopaedic Research Society, OTA =
is value in a system of evaluation Orthopaedic Trauma Association, POSNA = Pediatric Orthopaedic Society of North America
based purely on these metrics.
This study is not without limi-
tations. The authors relied on pro-
gram websites, databases, and society
websites to gather data and assumed Table 5
that all information contained on Eleven US Orthopaedic Surgery Residency Programs With the Highest
these websites was current. This Amount of Editorial Board Positions Held by Institutional Full-time Faculty
assessment may be influenced if any Editorial Board Points
of these were not up to date at the Institution (Location) Positions (Weighted)
time of data collection. Moreover, as
Thomas Jefferson University 15 0.500
the Scopus database, which was used (Philadelphia, PA)
to gather data on mean h-index, in- Mayo Clinic (Rochester, MN) 13 0.433
cludes research published in 1995 or Washington University in St. Louis 13 0.433
later, some senior faculty members (St. Louis, MO)
who published before this year may Hospital for Special Surgery (New York, NY) 12 0.400
have an inappropriately low h-index. Stanford University (Stanford, CA) 10 0.333
The h-index has been validated in Cleveland Clinic (Cleveland, OH) 7 0.233
numerous surgical fields, including Harvard University (Boston, MA) 7 0.233
orthopaedic surgery, as an accepted Northwestern University (Chicago, IL) 7 0.233
metric of academic productivity, New York University (New York, NY) 7 0.233
providing insight into not only the University of Texas, Southwestern 7 0.233
quantification of a faculty member’s (Dallas, TX)
productivity but also the impact and University of Wisconsin (Madison, WI) 7 0.233
quality of such productivity. As such,
it is an objective metric that allows The journals included were American Journal of Sports Medicine, Osteoarthritis Research
Society International, The Journal of Bone & Joint Surgery, Arthroscopy, Journal of Orthopaedic
evaluators to quantitatively assess Research, Clinical Orthopaedics and Related Research, Knee Surgery, Sports Traumatology,
the impact that a single person is Bone & Joint Research, the Spine Journal, Spine, Journal of the American Academy of
Orthopaedic Surgeons, the Journal of Arthroplasty, and Journal of Shoulder and Elbow Surgery,
having on their field. There are 2013
criticisms of relying on the h-index,
Figure 3 of rank, such as impact factor or

field reputation ranking, take into
account additional subjective ele-
ments, which allow for outliers such
as those listed earlier to be included
in the overall portrayal of a person’s
rank. Thus, our work was an attempt
to include additional metrics beyond
the h-index to capture these other
factors that affect a faculty member’s
overall rank. However, it should be
noted that a novel metric has been
developed that takes into account
the aforementioned limitations. The
NIH recently established the relative
citation ratio as a rigorously validated
metric that normalizes publication
impact to one’s community. This
newly developed relative citation ratio
seems to be a superior metric that will
be used in future analyses.21,22
Graph showing the overall order of academic achievement. A total of 138 US
Furthermore, NIH RePORTER
orthopaedic surgery residency programs received points using a weighted
algorithm. The overall order of the 20 most academically productive programs in lists NIH funding for the lead inves-
2013 is shown. tigator on the project and does not
credit any coinvestigators despite
how large or small of a role they
Figure 4 played in the project design. More-
over, multiple principal investigator
(PI) grants are assigned only to the
corresponding PI institution, despite
the intent of the NIH to define mul-
tiple PIs as equal contributors.
Although the authors (and other
ranking sources like U.S. News and
World Report) considered NIH
funding to be the main source of
funding in academic orthopaedic
surgery, many other sources,
such as Orthopaedic Research
and Education Foundation and
Department of Defense, exist that
markedly contribute; however, NIH
funding is considered to be the
benchmark when considering aca-
Graph showing the normalized order of academic achievement based on faculty
number in each department. A total of 138 US orthopaedic surgery residency demic achievement.
programs received points using a weighted algorithm. The overall order of the 20 There are two other limitations with
most academically productive programs in 2013 normalizing for the number of respect to the evaluation of NIH
faculty per program is shown.
funding. First, NIH funding to ortho-
paedic departments and academic
full discussions of which are outside cation history; thus, it is not affected productivity index fluctuates over
the scope of this article.5,6,20 The by a few extremely successful pub- time, and this study chose a single year
h-index is designed to normalize lications or a large number of poorly (2013) for evaluation. Although a
against outliers in a person’s publi- cited publications. Other measures longer term average of funding over
years may provide a more accurate U.S. News & World Report and in achievement, these departments have
single depiction, that method would other forums. Finally, we feel that the excelled and provide a model of
limit a department’s ability to annu- modern role of the academic ortho- academic productivity for others to
ally evaluate itself with this algorithm paedic program is the productive follow. This algorithm is easily
to demonstrate progress. Second, the contribution of the department as a reproducible annually with publicly
method by which investigators were whole and not necessarily the per available information and therefore
cross-referenced with institutions capita contribution. We feel it to be provides a tool in the future for de-
would have excluded departments beyond us to decide whether a pro- partments to focus efforts toward
that administer their NIH funding gram that focuses on developing increasing academic productivity in a
through an affiliated hospital. For faculty who are pure clinicians longitudinal fashion.
example, Brown University Ortho- in addition to faculty who are clini-
paedic Department administers its cian scientists should be considered
NIH grants through Rhode Island weaker than a program that develops References
Hospital, rather than the University. only faculty as clinician scientists
This would mean that the faculty’s because the clinical program would References printed in bold type are
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nized. This clearly disadvantages ranking system. For these reasons, we years.
departments that administer NIH feel tha our nonnormalized ranking
1. U.S. News and World Reports:
grants outside of the university, and system to be representative of the Best Orthopedic Hospitals. http://
it represents an important challenge total contribution of the modern health.usnews.com/best-hospitals/
in any attempt to use publicly academic orthopaedic program. rankings/orthopedics. Accessed May 22,
2015.
available data, because individual re- In conclusion, this study represents
2. The Active Times: http://www.
lationships between universities, hos- an evaluation of orthopaedic surgery
theactivetimes.com/best-orthopedic-
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Blue Ridge Institute for Medical academically productive orthopaedic 4. The Leapfrog Group: http://www.
Research (BRIMR.org) uses the iden- surgery programs are Washington leapfroggroup.org/cp. Accessed May 25,
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surgical chairperson associated with
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institutional knowledge. Naval Medical Center in San Diego. of surgery. J Surg Res 2013;185:
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tations exist that should be noted in ranking of the “best” orthopaedic among academic otolaryngologists?
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JA, Jackson-Rosario I: Is there a
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Research Article
Cost Comparison of Surgically

Treated Ankle Fractures Managed
in an Inpatient Versus Outpatient
Setting
Abstract
'RZQORDGHG IURP KWWSVMRXUQDOVOZZFRPMDDRV E\ %K'0IH3+.DY](RXPW4I1DN-/K(=JEV,+R;0LK&\Z&;$:Q<4S,O4U+'U/0L2:Z0O%'%Z&EZE==]3V\29.E: RQ
Clayton Bettin, MD Introduction: Although choices physicians make profoundly affect

Richard Nelson, PhD the cost of health care, few surgeons know relative costs associated
with the setting in which care is provided. Without valid cost
David Rothberg, MD
information, surgeons cannot understand how their choices affect the
Alexej Barg, MD total cost of care.
Mikayla Lyman, BS Methods: Actual costs for all isolated, surgically treated ankle
Charles Saltzman, MD fractures at a level I trauma hospital and affiliated outpatient surgery
center were determined using a validated episode of care costing
system and analyzed using multivariate regression analysis in this
retrospective cohort study.
Results: One hundred forty-eight patients (ie, 61 inpatients and 87
outpatients) with isolated, surgically treated ankle fractures were
From the Department of Orthopaedic included. After controlling for confounding variables, outpatient care
Surgery, Campbell Clinic, Memphis,
TN (Dr. Bettin), and the Department of was associated with 31.6% lower costs compared with inpatient care.
Orthopaedic Surgery, University of Obese patients had 21.6% higher costs compared with patients who
Utah Hospital, Salt Lake City, UT were not obese. No difference was noted in revision surgery,
(Dr. Nelson, Dr. Rothberg, Dr. Barg,
Ms. Lyman, and Dr. Saltzman). readmission, or return visits to the emergency department for patients
Correspondence to Dr. Bettin:
treated on an inpatient or outpatient basis.
cbettin@campbellclinic.com Conclusion: Where medically/socially appropriate, this analysis
Dr. Saltzman or an immediate family
suggests that ankle fracture surgery should be provided in an
member has received royalties from outpatient surgical facility to provide the greatest value to the patient
Smith & Nephew, Wright Medical and society.
Group, and Zimmer Biomet and
serves as a board member, owner, Level of evidence: Level III
American Board of Orthopaedic
Surgery and the Association of Bone
and Joint Surgeons. None of the
following authors nor any immediate
family member has received anything
I n 2013, the United States spent
approximately 16.4% of the gross
domestic product on health care,
focus on the value of care being
provided.
Healthcare value is typically defined
of value from or has stock or stock approximately $9,000 per citizen, as quality of outcomes received by a
and more than 2.5 times the average patient divided by the cost of deliver-
indirectly to the subject of this article: expenditure of other industrialized ing that care.5 A central difficulty in
Dr. Bettin, Dr. Nelson, Dr. Rothberg, nations.1,2 A lack of correlation determining value is calculating the
Dr. Barg, and Ms. Lyman. between spending and outcomes actual cost of a patient encounter due
J Am Acad Orthop Surg 2019;27: exists because US adults receive less to a complex, variable, and frag-
e127-e134 than half of recommended care and mented delivery system.6 Charges
DOI: 10.5435/JAAOS-D-16-00897 ranked 42nd in life expectancy billed are not an accurate estimate of
compared with other developed na- the actual cost of delivering care
Academy of Orthopaedic Surgeons. tions.3,4 This discrepancy between because of markups to allow cross-
spending and outcomes has led to a subsidization of services.7
Surgically Treated Ankle Fractures
As the US healthcare system tran- search in this retrospective cohort (ie, medicine, cardiology) was re-
sitions to value-based care, economic study. Current Procedural Termi- corded, as was the American Society
and quality analyses are needed. nology codes used were 27792, 27814, of Anesthesiology (ASA) score.
Some have been completed examin- 27822, 28723, and 27829 for open The hospital costs for each
ing common orthopaedic procedures reduction internal fixation of lateral encounter were obtained using the
including anterior cruciate ligament malleolus, bimalleolar, trimalleolar Value Driven Outcome (VDO)
reconstruction8-11 and total knee with and without fixation of the pos- tool.18 VDO is a validated value
arthroplasty.12 However, most of terior lip, and syndesmotic fixation, analytics framework developed by a
these studies have relied on hospital respectively. Patients with open, bilat- multidisciplinary team at our insti-
billing charges. Accurate data on eral, and/or other injuries (polytrauma) tution in 2012 to efficiently allocate
cost of delivery are necessary to were excluded from the study. This clinical care costs to individual
evaluate future interventions aimed study was approved by the Institutional patient encounters in a pragmatic,
at increasing healthcare value and Review Board at the University of Utah. modular, transparent, and extensible
before adopting value-based reim- Patients were grouped based on manner.18 This framework supports
bursement systems. whether they were surgically treated both direct and indirect care costs
Ankle fracture is one of the most as an inpatient or outpatient, and and encompasses facility and pro-
common orthopaedic injuries in the medical records were reviewed. The fessional costs. VDO takes all costs
United States currently representing decision to treat the patient as an recorded in the general ledger of the
over half of all fractures of the foot inpatient or outpatient was made by healthcare system, identifies costs
and ankle and increasing in annual the treating physician’s best judg- directly related to patient care, and
incidence.13,14 Surgery for ankle ment, considering individual patient allocates these costs to each indi-
fractures may be performed on an factors at the time of evaluation. vidual patient encounter. It accounts
inpatient or outpatient basis, de- Patients who were discharged on the for virtually all costs. The operating
pending on the presence of other same day of surgery were considered room cost is calculated on a per-
injuries, medical comorbidities, and outpatients regardless of whether the minute basis, and the cost of a
surgeon preference.15,16 Evidence to surgery was performed at the tertiary hospital unit’s personnel is allocated
support outpatient ankle fracture referral hospital or hospital-owned to each patient encounter based on
management is anecdotal, with just surgery center. Demographic infor- the patient’s actual usage of that
one study to our knowledge that mation collected included patient resource. In addition, direct costs
compares inpatient and outpatient age, sex, and body mass index (BMI) such as medicines provided or im-
management. Weckbach et al17 using BMI $ 30 kg/m2 to define plants used are accounted for within
showed outpatient ankle fracture obesity, insurance status, and home 0.5% of the general ledger.18 Costs
care to be a safe and efficient method zip code. Hospital encounter infor- were allocated to categories including
without increased complication rates. mation collected included length of charges for facility and labor (eg,
We present our data on the actual stay, time to surgery, treating sur- facility fees, operating room time,
cost of care for ankle fractures treated geon, fracture pattern, manufacturer recovery room and floor nursing
on an inpatient and outpatient basis, of implants used, and readmission labor, physical therapy), imaging,
with the hypothesis that outpatient and ED visits within 90 days after implants and supplies, laboratory,
care would have a markedly lower surgery. All preoperative and post- and pharmacy. To better compare the
cost without an increased rate of operative radiographs were reviewed inpatient and outpatient groups, all
revision surgery, readmission, or to determine the fracture pattern (eg, fees associated with the ED visit were
emergency department (ED) visits lateral malleolus, bimalleolar, tri- deducted because many outpatients
at 90 days. malleolar), presence of any disloca- were seen in an outside facility ED or
tion pattern, and to confirm the not seen in an ED at all.
number of plates and screws used. In We used univariate and multivari-
Methods an effort to determine the overall able regression analyses to estimate
health of the patient, medical co- the difference in healthcare costs
All cases of isolated closed ankle frac- morbidities including the presence of associated with surgical ankle frac-
tures treated surgically at a single diabetes, rheumatoid arthritis, ture repair in an outpatient setting
tertiary referral hospital and hospital- chronic obstructive pulmonary dis- relative to an inpatient setting.
owned surgery center from July 2013 ease (COPD), and sleep apnea were Because healthcare cost data are
to July 2015 were identified using a recorded. The number of preopera- often not normally distributed, we
Current Procedural Terminology code tive consultations from other services used a generalized linear model
Clayton Bettin, MD, et al
with a gamma distribution and a log lower facility and labor cost with
link, as determined by the modified outpatient care. Table 2 shows the
Discussion
Park test. To control for confounding results of the multivariate regression
As value plays a larger role in how
in the relationship between the loca- analysis. Variables with a rate ratio
health care is delivered, it is impera-
tion of service and healthcare costs where the upper and lower limits of
tive that physicians have an accurate
and utilization, we included a num- the 95% CIs cross 1.0 were not
understanding of the actual cost of
ber of covariates in our regression found to have a statistically signifi-
care being provided and identify
including characteristics of the pa- cant effect on cost. After controlling
sources of increased burden to the
tient, the fracture, and the surgery for confounding variables, outpa-
healthcare system.19 At our institu-
performed. tient care was associated with
tion, surgical intervention for 61
31.6% (95% CI, 19.8% to 41.8%)
inpatient and 87 outpatient ankle
lower costs compared with inpatient
fractures showed that, after multiple
Results care. Obese patients had 21.6%
regression analysis for confounding
(95% CI, 5.8% to 39.8%) higher
factors, outpatient treatment was
Between July 2013 and July 2014, costs compared with patients who
associated with a 31.6% reduction
148 patients met the study inclusion were not obese. No significant dif-
in total facility related costs. The
criteria. Sixty-one patients were ference was noted in revision sur-
primary driver of higher costs for
treated on an inpatient basis, whereas gery, readmission, or return visits to
inpatient treatment was higher
87 patients were treated as an out- the emergency department for pa-
patient by nine surgeons. Table 1 tients treated on an inpatient (0/61; facility and labor charges. Shorter
shows the descriptive statistics for zero) or outpatient (2/87; 2.2%) surgical times with outpatient pro-
the inpatient and outpatient groups. basis. Both patients readmitted from cedures would lead to lower facility
No significant differences were the outpatient group were for pul- and labor charges. Patients admitted
noted between groups with regard monary emboli that were nonfatal for care consumed more resources
to sex, distance to home location, and resolved with medical manage- and were more likely to have more
BMI, or the presence of rheuma- ment. Review of available medical medical comorbidities, more severe
toid arthritis, COPD, or obstructive records during the 90-day postop- fracture patterns, and decreased
sleep apnea. Patients treated as erative period showed no other mobility, and to require more plates
an inpatient were markedly more documented complications encoun- and screws during fracture fixation.
likely to be older; to have federal or tered during routine follow-up. Although the two cohorts are dif-
no insurance, higher ASA scores, a Distance from home, insurance sta- ferent with regard to these con-
history of smoking and diabetes, tus, ASA score, smoking history, founding variables, these variables
preoperative consultations from comorbidities, and implant used did are controlled through the multi-
other services, more severe fracture not have a significant effect on total variate analysis. This is evident by
patterns; and to require a larger cost after multiple regression anal- noting the change in reduction of
number of plates and screws during ysis. Figure 1 shows the similarity of cost from 50% (95% CI, 42.9% to
fracture fixation. breakdown of costs for both inpa- 56.1%) when univariate analysis
Because of the proprietary nature tient and outpatient care reflective of was performed with outpatient care
of the cost data, the regression results the same supply, implant, and labor as the predictor variable compared
are presented in terms of rate costs at the hospital and hospital- with 31.6% (95% CI, 19.8% to
ratios as opposed to being converted owned outpatient surgery center. No 41.8%) after multivariate analysis.
to the original dollar scale. Univari- significant differences were noted in Unmeasured confounding may affect
ate analysis was performed to convey cost between outpatients treated at the data because variables outside of
the unadjusted relative difference the tertiary referral hospital com- those listed Table 2, such as baseline
between the cost of inpatient and pared with the hospital-owned sur- mobility and bone density, are not
outpatient care. With only outpa- gery center. Although univariate accounted for in the multivariate
tient care as the predictor variable, analysis showed that facility and analysis. No significant differences
outpatient surgery was associated labor costs were 46.9% lower with were noted in readmission rates for
with a 50% (95% confidence inter- outpatient care, no significant dif- patients treated on an inpatient and
val [CI], 42.9% to 56.1%) lower cost ference was noted between facility outpatient basis. This is similar to
than inpatient surgery. The primary and labor costs as a percentage of the findings of Weckbach et al17
driver of this cost difference was a totals between inpatient and outpa- who found no increased risk of
46.9% (95% CI, 47.3% to 58.2%) tient care. postoperative complications with
Table 1
Descriptive Statistics
Inpatient (N = 61) Outpatient (N = 87)
Variable N/Mean %SD N/Mean %SD P Value
Age 52.8 19.5 42.5 17.0 ,0.0001

Distance 0.289
,10 miles 32 52.5 42 48.3 —
102100 miles 19 31.2 36 41.4 —
1001 miles 9 14.8 6 6.9 —
Missing 1 1.6 3 3.5 —
BMI 0.192
Normal 14 23.0 29 33.3 —
Overweight 24 39.3 34 39.1 —
Obese 21 34.4 24 27.6 —
Missing 2 3.3 0 0.0 —
Insurance 0.003
No insurance 4 6.6 1 1.2 —
Medicare 12 19.7 4 4.6 —
Medicaid 4 6.6 3 3.5 —
Private/other 41 67.2 79 90.8 —
ASA 0.000
1/1E 12 19.7 43 49.4 —
2/2E 28 45.9 34 39.1 —
3/3E/4 20 32.8 9 10.3 —
Missing 1 1.6 1 1.2 —
Preoperative consultants 13 21.3 0 0.0 ,0.0001
Smoking 0.041
No 36 59.0 66 75.9 —
Yes 12 19.7 14 16.1 —
Former smoker 13 21.3 7 8.1 —
Diabetes 12 19.7 2 2.3 0.000
RA 2 3.3 1 1.2 0.366
COPD and obstructive sleep apnea 8 13.1 5 5.8 0.119
Fracture classification 0.000
Fibula 17 27.9 56 64.4 —
Bimalleolar 17 27.9 13 14.9 —
Trimalleolar 26 42.6 16 18.4 —
Other 1 1.6 2 2.3 —
Dislocation 20 32.8 3 3.5 ,0.0001
Syndesmotic injury 23 37.7 20 23.0 0.052
Implant
No. of 1/3 tubular plates ,0.0001
0 18 29.5 8 9.2 —
1 33 54.1 75 86.2 —
.1 10 16.4 4 4.6 —
Locking plate 18 29.5 3 3.5 ,0.0001
Recon plate 5 8.2 2 2.3 0.096
2.0/2.4 plate 4 6.6 0 0.0 0.016
ASA = American Society of Anesthesiology, BMI = body mass index, COPD = chronic obstructive pulmonary disease
Table 2
Results From Multivariable Generalized Linear Regression Model
95% Confidence Interval
Variable Rate Ratio LL UL
Outpatient 0.684 0.582 0.802

Age 1.002 0.998 1.006
Distance
,10 miles (reference) — — —
10-100 miles 1.077 0.959 1.209
1001 miles 1.060 0.856 1.313
Missing 0.944 0.697 1.277
BMI
Normal (reference) — — —
Overweight 1.083 0.951 1.232
Obese 1.216 1.058 1.398
Missing 0.941 0.566 1.565
Insurance
No insurance (reference) — — —
Medicare 0.795 0.541 1.167
Medicaid 0.671 0.450 1.002
Private/other 0.777 0.560 1.078
ASA
1/1E (reference) — — —
2/2E 0.966 0.850 1.098
3/3E/4 1.059 0.860 1.303
Missing 0.742 0.485 1.135
Preoperative days until surgery .1 1.039 0.877 1.232
Smoking
No (reference) — — —
Yes 1.001 0.861 1.164
Former smoker 1.129 0.948 1.344
Diabetes 1.032 0.859 1.241
COPD and obstructive sleep apnea 1.050 0.853 1.291
Fracture classification
Fibula (reference) — — —
Bimalleolar 1.138 0.976 1.328
Trimalleolar 1.344 1.155 1.564
Other 1.087 0.658 1.795
Dislocation pattern 1.099 0.928 1.301
Syndesmotic injury 1.106 0.975 1.256
Implant
No. of 1/3T plates — — —
0 (reference) — — —
1 0.942 0.722 1.228
.1 0.852 0.619 1.172
Locking plate 1.177 0.879 1.575
Recon plate 1.180 0.916 1.521
ASA = American Society of Anesthesiology, BMI = body mass index, COPD = chronic obstructive pulmonary disease, LL = lower limit, UL = upper limit
Figure 1 Nationwide Inpatient Sample study;

however, these data reflect hospital
charges rather than the actual cost of
care. Determining the cause of this
increase in cost is the subject of
further research.
Kleweno et al24 studied the profit-
ability of common fractures treated
at their tertiary referral system in
Maryland and noted an average
inpatient cost of $10,612 per ankle.
The study included direct variable
expenses (eg, length of stay, supplies,
pharmacy, odds ratio time, labora-
tory, radiology, therapy) and direct
fixed expenses (eg, physician and
managerial expenses), with the
largest components of cost being
length of stay (26%), implants
(29%), and odds ratio time (24%).
Graph showing the cost distribution of surgically treated ankle fractures. Indirect costs were not included, and
only inpatient costs were examined.
Readmission rates and outcome
outpatient management of ankle have a significant effect on total costs scores were not reported. True cost
fractures. after regression analysis. comparison to our inpatient group is
Nine surgeons were included in the One particular implant manu- not possible because of contractual
study, with five surgeons fixing facturer’s products were used in 87% and regulatory reasons pertaining to
141/148 (95.2%) of the fractures. of the total cases. When these prod- the sensitivity of actual cost data to
After multiple regression analysis, no ucts were used, a 45% reduction in the market competitiveness of the
significant differences were noted total costs was noted, which may be hospital. The normalized implant
with regard to operative surgeon and due to alternative manufacturers being costs (ie, 17.5% inpatient and
implant/supply costs. Nor was there a used for more severe fracture patterns 19.1% outpatient) in our experience
significant cost difference in outpa- and/or significant difference in the were lower than those reported by
tient surgeries when performed at the hospital-negotiated contracts with Kleweno et al.24
hospital setting or in the hospital- the different manufacturers. A study by Murray et al25 in 2011
owned surgery center. The hospital An additional finding was that out of the United Kingdom showed
system pools resources between lo- although no significant differences an average length of stay of 10 days
cations (ie, personnel may work at were noted between the inpatient for patients undergoing open reduc-
both locations, both use the same and outpatient groups with regard tion internal fixation and a cost of
laboratory), which may explain the to BMI, obese patients (BMI $ $7,000. The average time to surgery
lack of difference in cost between 30 kg/m2) had a 21.6% higher total for our inpatient group was 0.8 days,
outpatient surgeries performed in the cost than patients who were not with a postoperative length of stay of
hospital or in the hospital-owned obese. This finding is consistent 1.7 days.
surgery center. with the findings in other published Lovald et al12 demonstrated that
Insurance status did not markedly literature showing higher direct outpatient arthroplasty has been
affect the total hospital cost or the medical costs in obese patients shown to lower total medicare pay-
cost of implants used. More in- undergoing total knee arthroplasty ments over a 2-year period by
patients had Medicare as primary or trauma surgery reflected in the $8,527 with less pain and stiffness
insurance, which is consistent, with additional equipment and personnel than a traditional 3- to 4-day hos-
the inpatient group being older and required for obese patient care.19-22 pital stay. Our study demonstrates a
having more medical comorbidities. Cavo et al23 showed a 9% higher 31.6% reduction in costs with out-
ASA score, smoking history, and the cost of care for obese patients with patient fracture management. Not
presence of comorbidities did not ankle fractures as part of a large all patients are best treated on an
outpatient basis. Those with multiple patients who had inpatient surgery Expenditure and Financing. http://stats.
oecd.org/index.aspx?
medical problems requiring preop- were first seen in our ED than pa- DataSetCode=HEALTH_STAT. Accessed
erative optimization may be better tients who had outpatient surgery. August 17, 2015.
treated on an inpatient basis to allow Patients evaluated at an outside 3. McGlynn EA, Asch SM, Adams J, et al: The
for expeditious optimization and institution ED or Urgent Care before quality of health care delivered to adults in
the United States. N Engl J Med 2003;348:
treatment before the onset of signif- treatment at our institution would
2635-2345.
icant soft-tissue swelling that may have artificially lower costs com-
4. Central Intelligence Agency: The World
delay treatment. Patients with poor pared with those treated wholly Factbook: Country Comparison—Life
mobility may be better treated as within our institution had ED costs Expectancy at Birth. 2014. https://www.cia.
inpatients to take advantage of phys- been included. gov/library/publications/the-world-
factbook/rankorder/2102rank.html.
ical therapy and case management Accessed August 17, 2015.
resources postoperatively to assure
Conclusion 5. Porter M: What is value in health care? N
safety before discharge. Physician Engl J Med 2010;363:2477-2481.
judgment is critical to determining
We found that in the surgical treat- 6. Kaplan R, Porter M: How to solve the cost
whether an individual patient is crisis in health care. Harv Bus Rev 2011;89:
ment of closed ankle fractures, con-
better suited to inpatient or out- 46-61.
trolling for the major confounding
patient care. However, unnecessary 7. Porter M, Lee T: Why health care is stuck–
variables, outpatient treatment was
admission of a patient for surgery and how to fix it. https://hbr.org/2013/09/
associated with a 32% reduction in why-health-care -is-stuck-and-how-to-fix-
does come with significant cost as it. Accessed August 18, 2015.
facility related costs compared with
demonstrated in this study.
inpatient care. Additional studies are 8. Saltzman B, Cvetanovich G, Nwachukwu
A potential limitation to the study is B, Mall N, Bush-Joseph C, Bach B:
necessary to determine what admis-
that we report only the results from Economic analysis in anterior cruciate
sion criteria would most efficiently ligament reconstruction. Am J Sports Med
a single institution. However, this
allow inpatient versus outpatient 2016;44:1329-1335.
approach has several strong attributes:
management without any reduction 9. Nagda SH, Altobelli GG, Bowdry KA,
we are confident of (1) the integrity of Brewster CE, Lombardo SJ: Cost analysis
in quality of care provided. On the
the cost data, (2) the low variation in of outpatient anterior cruciate ligament
basis of this study, we conclude that reconstruction. Clin Orthop Relat Res
decision making by the surgeons
if medically/socially appropriate, 2010;468:1418-1422.
regarding surgical indications and
closed ankle fracture surgery should 10. Kao J, Giangarra C, Singer G, Martin S:
approaches, and (3) that all episodes of
be provided in an outpatient surgical A comparison of outpatient and
care—whether in the outpatient or inpatient anterior cruciate ligament
facility to provide the greatest value
inpatient setting were subjected to the reconstruction. Arthroscopy 1995;11:
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Although it may be generalizable to 11. Kumar A, Bickerstaff D, Johnson T,
Appleton D: Day surgery anterior cruciate
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hospitals are needed to draw broader experiences. Knee 2001;8:25-27.
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patient-reported outcomes was not evidence are described in the table of Complications, mortality, and costs for
possible because of the limited avail- outpatient and short-stay total knee
contents. In this article, reference 1 is a arthroplasty patients in comparison to
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Outcomes Measurement Information level II studies. References 8, 10, 12, 2014;29:510-515.
System scores from this period and 20 are level III studies. Reference 13. Shibuya N, Davis M, Jupiter D:
(ie, 10/61 inpatients and 10/87 out- 17 is a level IV study. References 5-7 Epidemiology of foot and ankle fractures
in the United States: An analysis of the
patients) but is an area of future are level V report or expert opinion. national trauma data bank (2007 to
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Research Article
A Comparison of Geriatric Hip

Fracture Databases
Abstract
Trevor Shelton, MD, MS Introduction: The National Surgical Quality Improvement Project
Garin Hecht, MD (NSQIP) and the Trauma Quality Improvement Project (TQIP)
collect data on geriatric hip fractures (GHFs) that could be used to
Christina Slee, MPH, CPHQ
generate risk-adjusted metrics for care of these patients. We

Philip Wolinsky, MD examined differences between GHFs reported by our own trauma
center to the NSQIP and TQIP and those vetted through an internal
GHF list.
Methods: We reviewed charts of GHFs treated between January 1
and December 31, 2015, and compared patients in an internal GHF
database and/or reported to the NSQIP and/or TQIP and determined
differences between databases.
Results: We identified 89 “true” GHFs, of which 96% were identified
by our institutional database, 70% by NSQIP, and 9% by the TQIP.
No differences were found in outcomes and total costs. The net
From the Department of Orthopaedic revenue/patient in the NSQIP database was $24,373 more than
Surgery (Dr. Shelton and Dr. Wolinsky), those in the institutional database.
University of California, Sacramento,
CA, the Department of Orthopaedic Conclusion: Caution should be taken when using NSQIP/TQIP
Surgery and Rehabilitation (Dr. Hecht), databases to evaluate the care of GHFs.
Loyola University, Chicago, IL, and the
Level of Evidence: Level III
Department of Quality and Safety (Ms.
Slee), University of California,
Sacramento, CA.
Dr. Wolinsky or an immediate family
presentations on behalf of Zimmer
I t is estimated that by 2040, more
than 500,000 geriatric hip frac-
tures (GHFs)/year will occur in the
hospital readmission rates, and costs.3
CMS announced the Surgical Hip
and Femur Fracture Treatment model
Biomet and serves as a board
member, owner, officer, or committee United States, nearly doubling the in 2016,4 which expanded bundled
member of the American Academy of number of hip fractures in 1990.1 As payment from elective surgical care
Orthopaedic Surgeons, the American
College of Surgeons, the California many as 47% of hospital admissions (ie, total hip replacements) to the
Orthopaedic Association, and the for traumatic injuries for patients older acute care setting (ie, hip fractures
Orthopaedic Trauma Association. than 65 years are related to hip frac- and other low-energy femur frac-
None of the following authors nor any
tures.2 The burden of hip fracture tures including midshaft and distal
received anything of value from or has management in Medicare-aged patients femur fractures). The plan includes
stock or stock options held in a has prompted Centers for Medicare calculating costs based on census-
and Medicaid Services (CMS) to region pricing, holding hospitals
subject of this article: Dr. Shelton, streamline care and payments. responsible for the cost and quality
Dr. Hecht, and Ms. Slee. In 2011, the CMS introduced the of care, and increasing coordination
J Am Acad Orthop Surg 2019;27: Bundled Payment for Care Improve- between hospitals, physicians, and
e135-e141 ment and instituted it for total joint re- postacute care providers. Quality of
DOI: 10.5435/JAAOS-D-17-00696 placement patients. It was championed care will be judged based on the same
as a path to increase the quality and hospital-level risk-standardized com-
Academy of Orthopaedic Surgeons. value of care. Early results showed plication rate used after total hip and
a decrease in length of stay (LOS), knee arthroplasty (ie, total joint
Hip Fracture Databases
replacement) and the Hospital Con- the patients from an institution are were vetted by the orthopaedic trauma
sumer Assessment of Healthcare Pro- not reported, or if the wrong patients surgeon, orthopaedic resident, and
viders and Systems survey measure. are reported, the data will be skewed. nurse practitioner who are part of the
One reason that total joint outcome We initially sought to use the NSQIP multidisciplinary Geriatric Fracture
measures may have been selected is the and TQIP data from our institution to Program Team. All patients were
absence of any risk-adjusted outcome simplify chart review of complications discussed at the weekly GHF team
metrics for the care of hip fractures. It and adverse events for GHF patients meeting. The criteria for inclusion
would seem that large national data- in our institutional hip fracture data- into the NSQIP database include all
bases would be a logical resource to base but found little overlap in the patients who (1) do not meet the
develop these risk-adjusted outcome “hip fracture patients” that were criteria of a trauma patient estab-
metrics. Bundled payment systems are being abstracted by the NSQIP and lished by NSQIP trauma criteria (eg,
challenging when applied to acute TQIP programs at our institution. fall from height higher than a bed,
nonelective surgeries because the Therefore, the purposes of this study penetrating trauma, high-velocity
treating physician and/or institution were to determine the following: (1) collisions, sports injuries that in-
do not have the option of choosing the are the GHFs reported by our insti- volve multiple limb/multiple systems
patients, their comorbid conditions, or tution to the NSQIP and TQIP the injuries, crush/burn/blast type in-
the timing of surgery. Bundled pay- same as those in a vetted, internal juries, blunt force trauma other than
ment models for patients with trau- GHF database at our level-I trauma falls), (2) fell less than three stairs or
matic injures must take into account center? (2) if they are not, why are had a sports injury involving only
the fact that fractures occur in a patient they different? and (3) are there dif- single system or bone, and (3) whose
population that cannot always be risk ferences in inpatient outcomes and treatment had one of the following
optimized or have nonsurgical treat- costs between the sets of patients in Current Procedural Terminology
ment options and may have multiple each database? The null hypothesis of (CPT) codes: 27226, 27227, 27228,
medical comorbidities.5-7 A bundled this study is that there would be 27236, 27244, 27245, 27248,
payment system for fracture care must no differences between the three 27254, and 27269 (these include
be representative of a medically databases. open treatment of acetabular, femo-
diverse population that is difficult to ral neck/head, intertrochanteric, peri-
risk optimize. In addition, reim- trochanteric, and subtrochanteric
bursement must be based on a large Methods fractures). The TQIP database inclu-
representative cohort by which these sion criteria do not require reporting
“blends of historic hospital specific After institutional review board all GHF patients who present to an
spending”4 can accurately calculate approval (1016282-1) was obtained, institution, but the inclusion criteria
the cost of treating these patients. If a retrospective chart review was perfor those that are reported are (1)
bundled payments are not represen- formed for all patients who were age $ 65 years, (2) had a GLF, and (3)
tative of an “average” patient for a included in our own institutional Abbreviated Injury Scale codes
given region and hospital system, they database for GHFs and/or those 851810.3 (ie, intertrochanteric femur
may actually decrease access to care reported to the NSQIP and/or TQIP as fracture), 851812.3 (ie, neck femur
and make caring for these patients GHFs at our level-I trauma center fracture), and 851818.3 (ie, subtro-
economically unfeasible.8 from January 1, 2015, to December chanteric femur fracture).
There are two risk-adjusted national 31, 2015. This time frame was selected We reviewed all the patients in all
databases housed within the American because 2015 was the first year that all three databases and created a list of
College of Surgeons—the National patients meeting NSQIP criteria were “true” GHF patients who fulfilled our
Surgical Quality Improvement Project required to be vetted, not just a selec- definition of a GHF: (1) age $ 65
(NSQIP) and the Trauma Quality tion of patients. Patients who fit the years, (2) injured in a GLF, and (3)
Improvement Project (TQIP)—that following inclusion criteria were pro- had an isolated hip fracture (ie,
would be logical candidates to spectively enrolled into our institu- proximal femur fractures), without
develop risk-adjusted quality of care tional database: (1) age $ 65 years, (2) other notable injuries (ie, multiple
of metrics for GHF patients. These injured in a ground level fall (GLF), fractures). Then, we determined why a
databases contain large numbers of and (3) had an isolated hip fracture (ie, patient was in a database when they
patients because of the number of intracapsular femoral neck or inter- should not have been and why a
hospitals mandated to report data. trochanteric proximal femur fractures) patient was not in one when they
However, the quality of the data without other notable injuries. The should have been. The sensitivity,
being reported must be accurate. If all patients who were added to the list specificity, positive predictive value
Trevor Shelton, MD, MS, et al
(PPV), and negative predictive value Figure 1

(NPV) for identifying true GHF patients
were determined for each database.
We also recorded the rate of cardio-
pulmonary complications (ie, cardio-
vascular and/or cerebrovascular events,
pneumonia, and ventricular thrombo-
embolism), the hospital LOS, direct and
indirect costs, total costs, and net reve-
nue for each patient.
The mean 6 SD was reported for
continuous variables (ie, age), and
categoric variables were reported as a
percentage. Categoric data (ie, com-
plication rates) were analyzed for
statistical differences between data-
bases using the Fisher exact test.
Differences in continuous variables
(ie, hospital LOS and cost) between Venn diagram depicting the number and percentage of all patients identified in
databases were compared using a our study that were included in each database, as well as the overlap for patients
Kruskal-Wallis Test. Where statistical included in one or more of them. NSQIP = National Surgical Quality
differences were detected using the Improvement Project, TQIP = Trauma Quality Improvement Project
Kruskal-Wallis test, a post hoc Dunn
multiple comparison test was used to and specificity and the highest PPV reported to NSQIP that should not
determine which databases were and NPV (Table 1) and identified 85 have been (ie, they were not true
actually different from one another. of 89 (96%) true GHFs. The insti- GHFs) for the following reasons (some
Computations were performed using tutional database missed four true patients had more than one reason):
statistical software (JMP Pro, 13.0, GHFs and included four patients that 24 of 34 (71%) were aged ,65 years,
http://www.jmp.com). Significance should not have been included because 5 of 34 (15%) were polytrauma pa-
was set at P , 0.05. they were polytrauma patients with tients, 5 of 34 (15%) had peri-
multiple fractures (Table 2). prosthetic femur fractures, 5 of 34
(15%) had an impending or complete
Results pathologic fracture, and 4 of 34 (12%)
National Surgical Quality patients were hospitalized for a
Eighty-nine patients were identified as Improvement Project revision of a fracture nonunion or
true GHFs. A total of 131 patients
The NSQIP database contained 62 of malunion.
were included in at least one of the
89 (70%) true GHFs. Twenty-seven However, if patients aged ,65 years
databases: 89 patients were in our
true GHFs were missed: for 8 of the 27 are excluded from our analysis of the
registry, 96 patients were reported to
(30%), we could not determine why NSQIP database (we could easily
NSQIP, and 13 patients were reported
they were missed (no other explana- exclude them when preforming an
to the TQIP (Figure 1). Poor overlap
tion), 9 of 27 (33%) were missed analysis based on NSQIP data), only
was found between the three data-
because of the NSQIP nurse coder 10 patients were included that should
bases: there were 28 patients (21%)
being on vacation, and 10 of 27 (37%) not have been the following: 3 of 10
who were only in our database, 33
were missed because the wrong CPT (30%) were polytrauma patients, 2 of
patients (25%) who were only in the
code was assigned to the patient (ie, 10 (20%) had periprosthetic femur
NSQIP, and 2 patients (2%) who
CPT codes 27240—closed treatment fractures, 2 of 10 (20%) had an im-
were only in the TQIP. Only two
of intertrochanteric, peritrochanteric, pending or complete pathologic
patients (2%) were included in all
or subtrochanteric femur fracture, fracture, and 3 of 10 (30%) patients
three registries.
with manipulation, with or without were hospitalized for a revision of a
skin or skeletal traction; 27235— fracture nonunion or malunion. This
Internal Database percutaneous skeletal fixation of phenomenon did not change the
Our internal institutional database femoral fracture, proximal end, neck) sensitivity (0.70) of the NSQIP data
had the highest balance of sensitivity (Table 2). Thirty-four patients were but increased the specificity (from
Table 1
Sensitivity, Specificity, and Positive/Negative Predictive Value for Each Database to Correctly Identify a True
Geriatric Hip Fracture Patient
Statistical Measure Institution NSQIP Modified NSQIPa TQIP
Sensitivity 0.96 0.70 0.70 0.09

Specificity 0.90 0.19 0.76 0.88
Positive predictive value 0.96 0.65 0.76 0.61
Negative predictive value 0.90 0.23 0.54 0.31
NSQIP = National Surgical Quality Improvement Project, TQIP = Trauma Quality Improvement Project
a
The modified NSQIP data set does not include patients aged ,65 years.
Table 2
(A) Reasons Why Patients Should Have Been Included as a GHF but Were Not and (B) Reasons Why Patients Were
Incorrectly Included in Each Database: Some Patients Had Multiple Reasons
Factor Institution NSQIP TQIP
A) Reasons GHFs were missed

Missed (no other explanation) 4/4 (100%) 8/27 (30%) 12/81 (15%)
NSQIP nurse on leave/vacation during NA 9/27 (33%) NA
patient admission
Coded using a CPT code that is not a NA 10/27 (37%) NA
NSQIP hip fracture inclusion CPT codes
Not admitted to general surgery trauma service None None 69/81 (85%)
B) Reasons patients were incorrectly included
as a true GHF
Polytrauma 4/4 (100%) 5/34 (15%) 1/5 (20%)
Age ,65 years None 24/34 (71%) None
Periprosthetic fracture None 5/34 (15%) 2/5 (40%)
Impending or pathologic fracture None 5/34 (15%) 2/5 (40%)
CPT = Current Procedural Terminology, GHF = geriatric hip fracture, NA = not applicable, NSQIP = National Surgical Quality Improvement Project,
TQIP = Trauma Quality Improvement Project
0.19 to 0.76), PPV (from 0.65 to that should not have been the fol- the three databases (P = 0.3133);
0.76), and NPV (from 0.23 to 0.54). lowing: one of five (20%) were however, the net revenue for the
polytrauma patients with multiple NSQIP database patients ($14,556 6
fractures, two of five (40%) had a $46,174) was $24,373 more than for
Trauma Quality Improvement periprosthetic fracture, and two of the patients included in our institu-
Project five (40%) had an impending or tional database (2$9,817 6 $15,120)
The TQIP database contained only 8 complete pathologic fracture. (P , 0.0001).
of 89 (9%) of our true GHFs, mean- There was a trend toward significant
ing 81 true GHFs were not reported as there were more cardiopulmonary
to the TQIP: 12 of 81 (15%) were complications in our institutional Conclusion
“missed,” and the remaining 69 of database (P = 0.0835) (Table 3) and
81 (85%) were not reported because with a larger sample size, may become Databases with large numbers of pa-
they were not admitted to the general significant. No difference was found tients are a logical resource for
surgery trauma service (a prerequi- in hospital LOS between the three developing risk-adjusted quality and
site for our institution reporting pa- databases (P = 0.3126). No differ- cost metrics for GHFs. However, the
tients to the TQIP) (Table 2). Five ences were found between patient data reported to these databases need
patients were reported to the TQIP direct, indirect, and total costs for to be representative of actual GHF
Table 3
Cardiopulmonary Complications, Hospital LOS, Costs, and Net Revenue for Each Database
Complication, LOS, or Cost Institution NSQIP TQIP P Valuea
Cardiopulmonary complications 10/89 (11%) 3/96 (3%) 0/13 (0%) 0.0835

Hospital LOS 66 3 76 8 86 6 0.3126
Direct costs $24,839 6 $9,236 $27,627 6 $20,847 $30,345 6 $16,094 0.2989
Indirect costs $10,185 6 $3,886 $12,230 6 $10,848 $12,111 6 $6,618 0.2441
Total costs $35,024 6 $12,966 $39,856 6 $31,570 $42,456 6 $22,552 0.3133
Net revenue 2$9,817 6 $15,120A $14,556 6 $46,174B 2$4,325 6 $25,812A,B ,0.0001
LOS = length of stay, NSQIP = National Surgical Quality Improvement Project, TQIP = Trauma Quality Improvement Project
a
P values reported using the Fisher exact test for categoric variables and the Kruskal-Wallis test. Superscript letters (A and B) indicate where
statistical differences exist between the groups using a post hoc Dunn multiple comparison test.
patients to be accurate. If patients Our study has limitations; our data femur fractures as these injuries are
who should be included are not or if are from patients treated at an aca- highly variable sometimes arthro-
patients who are not actual GHF are, demic Level-1 trauma center, and the plasty surgeon in the periprosthetic
the data will be skewed. If care data from other types of hospitals fractures, multiple surgeons or surger-
guidelines, reimbursement decisions, may be different. However, the data ies in the polytrauma patients, or have
or quality of care ratings are gener- being reported to the NSQIP and different weight-bearing restriction
ated from the database, they may TQIP should be standardized, and (many distal femur and some peri-
be inaccurate. The most important the same from each institution, so prosthetics) and more associated in-
findings of our study are the follow- that like patients can be compared juries (femoral shaft fractures) that
ing: (1) there were major differences to like to generate accurate risk- very much change the care pathway
between the patient populations in- adjusted data from large national for these geriatric trauma patients
cluded in our institution’s GHF da- data samples. Although it is possible compared with true GHFs.
tabase (the “benchmark”) and those that the NSQIP and TQIP data from The challenges of instituting a
reported to the NSQIP or TQIP; (2) every other hospital are perfect, that bundled payment model for acute
the most common reasons that pa- seems unlikely, and it is more plausi- care surgeries have been described.
tients reported to the NSQIP and/or ble that the database dissimilarities Mahure et al7 showed that difference
TQIP were not true GHF patients is reported by our institution are rep- in the cost-to-treat between patients
that they were too young (aged ,65 resentative of the challenge of stan- treated for surgical fractures with
years), and/or had other injuries in dardizing data collection. Second, the minor or severe Severity of Illness
addition to their hip fracture, and/or TQIP database does not require re- Profiles was as high as 489% and
did not sustain their injuries as a porting all patients who fit their def- that the patients are not a homoge-
result of a GLF, and/or had other inition of a GHF patient that present nous population. Each potentially
injuries that were miscoded as a to an institution. Rather, this is has different and unique comorbid-
GHF; and (3) there were no differ- largely dependent on the specific ities; accordingly, treating physicians
ences in complications, hospital LOS, trauma center to decide which pa- may be wary to take on this patient
or total costs between databases. tients get reported (unlike our insti- population because their cost of care
However, our study was underpow- tutional database and the NSQIP is more unpredictable than primary
ered to detect differences in infre- database), meaning there is a poten- joint arthroplasties.7 Similarly, the
quent complications, and despite no tially marked difference from the GHF patient population ranges
difference in total costs, the net rev- NSQIP and institutional databases widely from patients who are fully
enue for the NSQIP database was because of sampling bias criteria. A independent in their activities of
markedly more for patients reported third limitation of this study is that the daily living and are active outside the
to NSQIP than GHFs identified by findings may not be generalizable to home to those patients who are
our institution. Given these differ- those with multiple fractures or other home-ridden with assistive devices or
ences, the null hypothesis of no dif- femur fractures. We excluded patients who reside in nursing homes. The
ference between the databases was with multiple fractures, femoral shaft diversity of GHF patients creates
rejected. fractures, periprosthetic, and distal challenges in streamlining them into
care pathways, and their varied dis- trate this trend, because the TQIP did the patients included need to be the
positions after their acute hospitali- not have any complications, one correct patients. If not, inaccurate
zation only add to the logistical could directly compare the institu- conclusions will occur when there are
challenge of caring for this population tional database and the NSQIP, patients missing from the database
in the hospital. Perhaps as a product which shows that there is a difference who should be included (if there is
of the patient complexity and diver- between the two databases (P = inappropriate sampling) and, more
sity, Gomez et al5 found that trauma 0.0426). All three of the complica- importantly, when patients are in-
centers reported between zero and tions captured in the NSQIP database cluded who should have been ex-
31% of all GHF patients to the were also captured by the institutional cluded. Error in reporting is a known
National Trauma Data Base. When database. However, the NSQIP data- risk in database collection; however,
examining the effect of including GHF base missed capturing seven true GHF assuring that the correct patients are
patients in external benchmarking for patients, which had complications. being reported on is an essential
trauma centers, they recommended This further demonstrates the dif- starting point. We cannot know
not including those patients because ference in the patient populations whether our institution is the only
these inaccurate data affected the risk- between these databases. one that had these issues, but, based
adjusted ranking of trauma centers. Any national database used for on our information, caution should
To establish quality of care bench- studies on the complications, co- be taken when interpreting the results
marks or cost of care averages for morbidities, and costs of hip fracture of studies that use the NSQIP and
GHF patients, it is fundamental that care assumes accurate patient inclu- TQIP databases to report on GHF
only true GHF patients be included in sion and exclusion for these data- patients.
databases or the data generated will bases14-16 Bohl et al17 reported
not be right. The average direct costs substantial variation in comorbid-
for a GHF patient reviewed in our ities and adverse events reported in References
study ranged from $24,389 for those hip fracture patients from the NSQIP
in our database to $30,345 in the and Nationwide Inpatient Sample References printed in bold type are
TQIP database, which is comparable databases. They conclude that the those published within the past 5
to values in previous studies that used most obvious reason is that the years.
patient data from national data- two commonly cited databases have 1. Cummings SR, Rubin SM, Black D: The
bases.9,10 There is a high variability in different reporting criteria for co- future of hip fractures in the United States:
Numbers, costs, and potential effects of
the net revenue generated from the morbidities and different definitions postmenopausal estrogen. Clin Orthop
treatment of GHF from institution for adverse events.18 Multicenter Relat Res 1990;252:163-166.
to institution.11-13 Some of this might benchmark databases for specific or- 2. Clark DE, DeLorenzo MA, Lucas FL,
be due to varying complications or thopaedic diseases have been com- Wennberg DE: Epidemiology and short-
complexities between patients. The pared to national databases as well. term outcomes of injured medicare patients.
J Am Geriatr Soc 2004;52:2023-2030.
higher net revenue for patients in In the adult spinal deformity litera-
3. Zuckerman DM, Jury NJ, Silcox CE: 21st
the NSQIP database is likely due to ture, complication rates for the same
Century Cures Act and similar policy
the differences in the population cohort of 255 patients were reported efforts: At what cost? BMJ 2015;351:h6122.
bases. Even when patient’s younger as 26% in the NSQIP and 68% in the
4. Centers for Medicare & Medicaid Services:
than 65 years are excluded from the multicenter surgeon-run database Surgical Hip and Femur Fracture Treatment
NSQIP database, the net revenue is from the International Spine Study (SHFFT) model. https://innovation.cms.
gov/initiatives/shfft-model. Accessed June
higher than the institutional database, Group.19 Our study highlights the 7, 2017.
which further illustrates that these are benefit of our own institutional re-
5. Gomez D, Haas B, Hemmila M, et al: Hips
different population groups due to the porting hip fracture patients to the can lie: Impact of excluding isolated hip
NSQIP including polytrauma patients TQIP and NSQIP databases. We have fractures on external benchmarking of
and including periprosthetic fractures found that variations in inclusion and trauma center performance. J Trauma
2010;69:1037-1041.
and impending fractures. Although exclusion criteria create doubt that
6. Johnson DJ, Greenberg SE, Sathiyakumar
there was no statistical difference de- the two national databases housed
V, et al: Relationship between the Charlson
tected in cardiopulmonary complica- within the American College of Sur- Comorbidity Index and cost of treating hip
tions between databases, there was a geons can be used to make accurate fractures: Implications for bundled
payment. J Orthop Traumatol 2015;16:
trend to a higher complication rate conclusions about GHF patients. 209-213.
among our own institutional data- Although large, risk-adjusted da-
7. Mahure SA, Hutzler L, Yoon RS, Bosco JA:
base and a larger sample size may tabases are a logical resource for Economic impact of nonmodifiable risk
show a difference. To further illus- developing quality and cost metrics, factors in orthopaedic fracture care: Is
bundled payment feasible? J Orthop 12. Clement RC, Ahn J, Mehta S, Bernstein J: of the NSQIP data. Injury 2015;46:
Trauma 2017;31:175-179. Economic viability of geriatric hip fracture 703-708.
centers. Orthopedics 2013;36:
8. Bosco JA III, Karkenny AJ, Hutzler LH, 17. Bohl DD, Basques BA, Golinvaux NS,
e1509-e1514.
Slover JD, Iorio R: Cost burden of 30-day Baumgaertner MR, Grauer JN:
readmissions following Medicare total hip 13. Kates SL, Blake D, Bingham KW, Kates OS, Nationwide Inpatient Sample and
and knee arthroplasty. J Arthroplasty 2014; Mendelson DA, Friedman SM: Comparison National Surgical Quality Improvement
29:903-905. of an organized geriatric fracture program Program give different results in hip
fracture studies. Clin Orthop Relat Res
to United States government data. Geriatr
9. Burns ER, Stevens JA, Lee R: The direct 2014;472:1672-1680.
Orthop Surg Rehabil 2010;1:15-21.
costs of fatal and non-fatal falls among
18. Bohl DD, Russo GS, Basques BA, et al:
older adults: United States. J Saf Res 2016; 14. Aldebeyan S, Nooh A, Aoude A, Weber
Variations in data collection methods
58:99-103. MH, Harvey EJ: Hypoalbuminaemia—a
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marker of malnutrition and predictor of results: A comparison of the Nationwide
10. Gu Q, Koenig L, Mather RC III, Tongue J: postoperative complications and mortality Inpatient Sample And National Surgical
Surgery for hip fracture yields societal after hip fractures. Injury 2017;48: Quality Improvement Program databases
benefits that exceed the direct medical costs. 436-440. for lumbar spine fusion procedures. J Bone
Joint Surg Am 2014;96:e193.
3536-3546. 15. Sathiyakumar V, Avilucea FR, Whiting PS,
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Sutherland JM, Skinner JS: Medicare NSQIP data. Int Orthop 2016;40:439-445. operative outcomes using nationally
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Letters to the Editor
Letter to the Editor: Costs and Radiographic
Outcomes of Rotational Ankle Fractures
Treated by Orthopaedic Surgeons With or
Without Trauma Fellowship Training
To the Editor: We read with great implication of an underlying bias,
interest the article entitled, “Costs and given the subspecialty practices of the
Radiographic Outcomes of Rota- investigation’s authors, which may
tional Ankle Fractures Treated by have influenced study methodology.

Orthopaedic Surgeons With or With- The authors conclude that “advanced
out Trauma Fellowship Training.”1 technologies had no effect on radio-
The authors should be commended graphic outcomes.” The seemingly
for examining this topic in an effort logical conclusion drawn from this
to decrease costs and healthcare statement is that non–trauma-trained
expenditure. However, we think that orthopaedic surgeons use more ex-
this is a methodologically flawed pensive implants frivolously with no
study with an underreporting of data added benefit and that radiographic
making conclusions drawn of ques- outcomes would be similar with a
tionable validity. cheaper implant. However, a reason-
Although the authors concluded able assumption based on specialty
that a surgeon attribute (ie, trauma- practice is that the trauma-trained
fellowship training) leads to decreased orthopaedic surgeon group treated
implant costs, they neglected to report more ankle fractures than the non–
any data on the surgeon cohort, trauma-trained orthopaedic surgeon
even in its most basic form. How group. Surgeons who frequently treat
many surgeons were involved? What ankle fractures may be more com-
percentage had trauma-fellowship fortable using simpler, less expensive
training and what percentage did constructs based on clinical experience.
not? Whereas statistical results based In contrast, surgeons who may only
on large numbers would strengthen treat several a year may require more
their argument, sparse data obtained advanced implants to achieve the
from a handful of surgeons could same radiographic result. The
easily result in a type I error. Fur- study’s flawed conclusion supposes
thermore, the only surgeon-based that all surgeons are of the same
variable examined was fellowship skill set when treating ankle frac-
training. Additional demographic tures and are equally facile with
information would have been impor- all implants, and that fellowship
tant to truly determine the cause of training accounts for the differential
cost discrepancies if that variable use of implants. The limited data
could be attributed to the surgeons. presented do not support this con-
Could surgeon age, experience, sex, clusion and only support that with
number of ankle fractures treated per the implants used by each cohort,
year, hospital, industry relationships, the radiographic outcomes were
and institutional implant availability similar. Furthermore, advanced
J Am Acad Orthop Surg 2019;27: have led to differential implant utili- technologies may have an effect on
e142-e143
zation and not fellowship-training? radiographic outcomes because less
DOI: 10.5435/JAAOS-D-18-00508 The fact that this investigation experienced surgeons (regardless
Copyright 2018 by the American examined only trauma fellowship of fellowship training) may have
Academy of Orthopaedic Surgeons. training (or the lack thereof) raises the benefited from the aid of anatomic,
fracture-specific fixation to achieve orthopaedic surgeons are all in this conclusion that non-trauma trained
the desired radiographic result. fight to help decrease costs yet orthopedic surgeons (NTTOS) used
The true cause of increased expen- retain the ability to use the specific more expensive implants without
diture is a large and complex issue. implants we think are best for our clinical benefit, and (5) the possibil-
Unfortunately, implant usage, whether patients. ity that using more expensive im-
for a particular patient or a particu- plants may lead to overall savings to
lar condition, may be driven by John Y. Kwon, MD a healthcare system in some cir-
many factors aside from the fracture Boston, MA cumstances. The assertion that our
itself. Although we agree with study has “methodological flaws”
the methodology used to convert J. Kent Ellington, MD (also commonly referred to as “lim-
implant costs to list price for analy- Charlotte, NC itations”) is certainly true as it is with
sis, in real clinical practice the loca- any study, and they must be con-
tion of the surgery may have more Christopher P. Miller, MD sidered by readers when drawing
to do with total costs than fellow- Boston, MA conclusions. Because of this asser-
ship training. More often, surgeons tion, we were very careful with the
are hospital-employed physicians conclusions stated in our discussion
at large trauma centers and mega- Reference section and avoided over interpre-
hospital systems. These large sys- 1. Virkus WW, Wetzel RJ, McKinley TO, tation of our findings. We feel that
tems often have single vendor et al: Costs and radiographic outcomes all our explicitly stated conclusions
contracts with associated volume of rotational ankle fractures treated remain valid and did not intend for
by orthopaedic surgeons with or
price discounts and savings tied to without trauma fellowship training. J readers to infer any additional im-
total spend and milestones achieved. Am Acad Orthop Surg 2018;26: plied conclusions. One example of a
e261-e268.
In contrast, surgeons operating at conclusion that you inferred from
smaller community hospitals or our manuscript was that trauma
ambulatory surgical centers, where fellowship training “led to decreased
such contracts may not be in place, Response to Letter to the implant costs.” Because our study
may have limited or no ability to Editor: Costs and design was retrospective, we were
choose the implant they use. Either Radiographic Outcomes of careful in our conclusions to avoid
way, in an effort to decrease costs, Rotational Ankle Fractures language to suggest a cause-and-
surgeons are being increasingly lim- effect relationship between fellow-
Treated by Orthopaedic
ited in their ability to choose an ship training and implant cost. It
implant and/or vendor. As we undergo
Surgeons With or Without certainly may have been helpful for us
the process of cost containment at our Trauma Fellowship Training to describe this limitation of our study
respective institutions, it is clear that The Authors’ Reply: Thank you for design to avoid confusion; however,
defining and measuring “cost” of care your comments regarding our arti- we felt that detailing the well-known
can be difficult and time-intensive. cle.1 It appears that there are multi- limitations inherent to all retrospec-
Somewhat paradoxically, the use of ple concerns raised in your letter: (1) tive study designs would be unnec-
more expensive individual implants the alleged implied conclusion that essary for this journal’s readership.
may result in total cost savings to the trauma fellowship training caused We regret not being able to include
hospital system, which illustrates the surgeons to use less expensive im- all the data you wished to see regarding
complexities of analyzing implant plants, (2) insufficient information all possible surgeon characteristics.
costs. regarding the group of treating sur- Given the constraints on the manu-
Cost containment efforts are geons leading to the possibility that script size and the vast number of fac-
important and everyone from sur- fellowship training was not the only tors that may influence implant use, it
geons to hospital systems and ad- difference between the groups, (3) would be impossible to include all these
ministrators should be involved in investigator bias due to having factors. We attempted to have similar
this process. However, we must be trauma fellowship training, (4) the surgeon groups with the exception of
careful to measure all variables subspecialty training. Although the
and acknowledge the complexity of J Am Acad Orthop Surg 2019;27: group numbers were simply a result
e143-e145
examining implant costs before of the hospitals included in the study,
attributing increased costs to a DOI: 10.5435/JAAOS-D-18-00509 this resulted with two even groups
lack of trauma fellowship training. Copyright 2018 by the American with seven surgeons in each group.
Regardless of training, we as Academy of Orthopaedic Surgeons. Although we agree that many
fracture-specific fixation to achieve orthopaedic surgeons are all in this conclusion that non-trauma trained
the desired radiographic result. fight to help decrease costs yet orthopedic surgeons (NTTOS) used
The true cause of increased expen- retain the ability to use the specific more expensive implants without
diture is a large and complex issue. implants we think are best for our clinical benefit, and (5) the possibil-
Unfortunately, implant usage, whether patients. ity that using more expensive im-
for a particular patient or a particu- plants may lead to overall savings to
lar condition, may be driven by John Y. Kwon, MD a healthcare system in some cir-
many factors aside from the fracture Boston, MA cumstances. The assertion that our
itself. Although we agree with study has “methodological flaws”
the methodology used to convert J. Kent Ellington, MD (also commonly referred to as “lim-
implant costs to list price for analy- Charlotte, NC itations”) is certainly true as it is with
sis, in real clinical practice the loca- any study, and they must be con-
tion of the surgery may have more Christopher P. Miller, MD sidered by readers when drawing
to do with total costs than fellow- Boston, MA conclusions. Because of this asser-
ship training. More often, surgeons tion, we were very careful with the
are hospital-employed physicians conclusions stated in our discussion
at large trauma centers and mega- Reference section and avoided over interpre-
hospital systems. These large sys- 1. Virkus WW, Wetzel RJ, McKinley TO, tation of our findings. We feel that
tems often have single vendor et al: Costs and radiographic outcomes all our explicitly stated conclusions
contracts with associated volume of rotational ankle fractures treated remain valid and did not intend for
by orthopaedic surgeons with or
price discounts and savings tied to without trauma fellowship training. J readers to infer any additional im-
total spend and milestones achieved. Am Acad Orthop Surg 2018;26: plied conclusions. One example of a
e261-e268.
In contrast, surgeons operating at conclusion that you inferred from
smaller community hospitals or our manuscript was that trauma
ambulatory surgical centers, where fellowship training “led to decreased
such contracts may not be in place, Response to Letter to the implant costs.” Because our study
may have limited or no ability to Editor: Costs and design was retrospective, we were
choose the implant they use. Either Radiographic Outcomes of careful in our conclusions to avoid
way, in an effort to decrease costs, Rotational Ankle Fractures language to suggest a cause-and-
surgeons are being increasingly lim- effect relationship between fellow-
Treated by Orthopaedic
ited in their ability to choose an ship training and implant cost. It
implant and/or vendor. As we undergo
Surgeons With or Without certainly may have been helpful for us
the process of cost containment at our Trauma Fellowship Training to describe this limitation of our study
respective institutions, it is clear that The Authors’ Reply: Thank you for design to avoid confusion; however,
defining and measuring “cost” of care your comments regarding our arti- we felt that detailing the well-known
can be difficult and time-intensive. cle.1 It appears that there are multi- limitations inherent to all retrospec-
Somewhat paradoxically, the use of ple concerns raised in your letter: (1) tive study designs would be unnec-
more expensive individual implants the alleged implied conclusion that essary for this journal’s readership.
may result in total cost savings to the trauma fellowship training caused We regret not being able to include
hospital system, which illustrates the surgeons to use less expensive im- all the data you wished to see regarding
complexities of analyzing implant plants, (2) insufficient information all possible surgeon characteristics.
costs. regarding the group of treating sur- Given the constraints on the manu-
Cost containment efforts are geons leading to the possibility that script size and the vast number of fac-
important and everyone from sur- fellowship training was not the only tors that may influence implant use, it
geons to hospital systems and ad- difference between the groups, (3) would be impossible to include all these
ministrators should be involved in investigator bias due to having factors. We attempted to have similar
this process. However, we must be trauma fellowship training, (4) the surgeon groups with the exception of
careful to measure all variables subspecialty training. Although the
and acknowledge the complexity of J Am Acad Orthop Surg 2019;27: group numbers were simply a result
e143-e145
examining implant costs before of the hospitals included in the study,
attributing increased costs to a DOI: 10.5435/JAAOS-D-18-00509 this resulted with two even groups
lack of trauma fellowship training. Copyright 2018 by the American with seven surgeons in each group.
Regardless of training, we as Academy of Orthopaedic Surgeons. Although we agree that many
variables that could influence utili- plants do not improve outcomes in fortable using simpler, less expensive
zation, none of the variables included ankle fracture surgery. In contrast, constructs . . .,” and surgeon comfort
in your list were different between the statement “advanced technologies level is likely an important factor in
cohorts (statistical analysis not per- may have an effect on radiographic implant selection. However, your
formed). We appreciate the oppor- outcomes as less experienced sur- next statement, “Surgeons who only
tunity here to clarify these details of geons (regardless of fellowship train- treat several [ankle fractures] per
the surgeon groups. ing) may have benefited from the aid year may require more advanced
The fact that the study used sub- of anatomic, fracture-specific fixation implants in order to achieve the same
specialty training to define surgeon to achieve the desired radiographic radiographic result,” does not logi-
groups was generated by an observa- result” is pure speculation without any cally follow the first. These state-
tion, rather than a bias. The groups evidence-based support. Given the ments equate surgeon comfort with
were not generated randomly or with available evidence against the use of treatment requirement. Surgeon dis-
an underlying motive to suggest locking technology in rotational comfort with a nonlocking implant
superiority of trauma trained ortho- ankle fracture surgery, it seems (despite literature support for its use)
pedic surgeons (TTOS). Perhaps, we implausible to suppose that placing does not mean that the surgeon re-
could have better described the back- a precontoured locking plate on the quires a locking implant to perform a
ground leading to this study in the fibula somehow makes it easier to technically sound surgery and to
original manuscript. As part of system obtain and maintain a reduction achieve the desired patient outcome.
utilization review, we were surprised than a nonlocking one-third tubular Therefore, surgeon comfort influ-
to find that many ankle locking plates plate. In other words, for rotational ences implant use, but based on the
and cannulated screws were being ankle fractures, a locking plate is evidence from our study and litera-
used across the health care system. not likely to rescue an inexperienced ture search, it does not appear to
More detailed inspection revealed that surgeon from a poor technical affect clinical outcomes. Whether
all the NTTOS often used these im- outcome. it is acceptable to provide more ex-
plants, and the TTOS rarely if ever We disagree with your assertion that pensive treatment with a rationale of
used them. The correlation between our conclusions must assume that surgeon comfort and no evidence of
subspecialty training and implant use “all surgeons are of the same skill set patient benefit or harm is a philo-
prompted an obvious research ques- when treating ankle fractures [and] sophical question that we did not
tion: Can we quantify the difference in are equally facile with all implants.” attempt to answer with this study.
ankle fracture, implant costs, and All surgeons do not need to be equally Therefore, we cannot necessarily
outcomes between two groups of skilled at treating ankle fractures to conclude whether some surgeons
surgeons who clearly have different have similar radiographic outcomes. should or should not use locking
implant use strategies? Instead, all surgeons must meet a implants for ankle fractures. We can
We feel that the characterization minimum skill level to reduce the only provide support for the asser-
that we suggest that nontrauma sur- fracture and apply fixation, and any tion that locking plates increase cost
geons use locking plates “frivolously” range of skills beyond the minimum without evidence of clinical benefits.
is unfair. We showed that NTTOS likely only provides additional benefit To our knowledge, the later state-
in our series of patients used more in particularly unusual or complex ment “Somewhat paradoxically, use
expensive implants, but their results cases. This explanation is likely the of more expensive individual implants
were no different: no difference in underlying reason that outcomes of may result in a total cost savings to the
reduction quality and no difference in ankle fractures are generally uniform hospital system” is also without evi-
fixation failures. In addition to no regardless of surgeon’s experience dence in ankle surgery. Certainly, we
difference between cohorts, we also rather than the possibility that some acknowledge that there are many
found no difference within each surgeons are better with locking plates factors that go into the cost of care,
cohort based on the implants used and other surgeons are better with including location of care, patient
although numbers are small in these nonlocking plates. Again, the data in factors, and postacute care. However,
subgroups. Regardless of the rea- our study do not alone prove this vendor contracts typically have cost
soning behind implant choice, this explanation, but our data combined savings based on use of their com-
decision had no apparent effect on with previous evidence against lock- pany’s implants but do not require use
clinical outcome. This conclusion is ing plate use support it. of locking implants versus nonlocking
strengthened by the literature review We agree with your statement, implants. Even if a surgeon only has
in our discussion section, outlining “Surgeons who frequently treat access to a single company’s implants
scientific evidence that locking im- ankle fractures may be more com- (which was not the case for any of the
surgeons in this series), most com- importance of papers like this is Walter W. Virkus, MD
panies provide a variety of implants summarized in the last sentence of Robert J. Wetzel, MD
that include both locking and the Letter to the Editor: “. . . retain Todd O. McKinley, MD
nonlocking plates. And even if a the ability to use the specific implants Anthony T. Sorkin, MD
preferred vendor only offers pre- we think are best for our patients.” Jeffery S. Cheeseman, BA
contoured locking plates, the sur- Little evidence exists to guide what Lauren C. Hill, BS, CCRC
geon does not have to spend 3 to 5 we think are the best implants, and Laurence B. Kempton, MD
times the cost on locking screws thus decisions are made based on Indianapolis, IN
versus nonlocking screws. The perceptions of value, marketing by
surgeon still can modulate cost implant companies, conflicts of in- Reference
even in these rare cases. terest as a result of industry rela-
1. Kwon JY, Ellington JK, Miller CP: Letter to
The goal of our investigation was tionships, or personal preferences. the Editor: Costs and radiographic
to focus on an easily measured var- These decisions have a notable effect outcomes of rotational ankle fractures
treated by orthopaedic surgeons with
iable that is directly controlled by on the cost of care both locally and or without trauma fellowship training. J Am
the treating surgeon. We feel the nationally. Acad Orthop Surg 2019;27:e142-e143.
Review Article
Latissimus Dorsi Tendon Rupture
Abstract
Michael S. George, MD Isolated injury to the latissimus dorsi is rare. Partial tendon tears may
Michael Khazzam, MD be successfully treated nonsurgically. Complete tendon ruptures
require surgical repair. Tendon repair can be approached either
through an anterior deltopectoral incision with a secondary small
posterior axillary incision or through a long posterior axillary incision.
Suture anchors can be used to repair the latissimus dorsi to the
humeral attachment. Although the literature is limited to single-patient
case series, most patients have returned to full athletic activity after
surgical repair.
I solated injury to the latissimus dorsi

is rare. Tendon rupture is uncom-
monly seen in high-velocity overhead
latissimus is approximately 8.4 cm
(range, 6.3 to 10.1 cm), and the
average width of the tendon at its
athletes. This article describes the insertion of the humerus is approxi-
anatomy, modes of injury, and surgical mately 3.1 cm (range, 2.4 to 4.8 cm).2
management of complete latissimus The blood supply is primarily from
dorsi tendon rupture. the thoracodorsal artery.
The latissimus dorsi receives its
From KSF Orthopaedic Center, innervation from the thoracodorsal
Houston, TX (Dr. George), and the nerve (C5-7). This nerve originates
Department of Orthopaedic Surgery,
Anatomy of Latissimus
the University of Texas Southwestern Dorsi from the posterior cord of the brachial
Medical School, Dallas, TX plexus and inserts into the anterior
(Dr. Khazzam). The latissimus dorsi originates at the latissimus muscle belly approximately
Dr. George or an immediate family iliac crest, thoracolumbar fascia, and 13.1 cm (range, 11.0 to 15.3 cm)
member has received royalties from inferior thoracic and lumbar spinous medial to the humeral insertion of the
Innomed and serves as a paid processes.1 This broad large muscle tendon.2 In addition, it is important
consultant to KCI. Dr. Khazzam or an
immediate family member is a
is fan shaped and overlies the teres to recognize the relation of the radial
member of a speakers’ bureau or has major. The tendon inserts at the in- nerve. The radial nerve lies over the
made paid presentations on behalf of tertubercular groove at the medial lip anterior surface of the latissimus
Wright Medical Technology; serves and floor. The insertion lies medial dorsi tendon and travels in a proxi-
as a paid consultant to Wright Medical
Technology; has received research or
to the pectoralis major insertion on mal medial to a distal lateral direc-
institutional support from Wright the humerus and lateral and proxi- tion toward the spiral groove of the
Medical Technology; and serves as a mal to the teres major insertion2,3 humerus. The radial nerve passes
board member, owner, officer, or (Figure 1). The muscle tendon unit directly anterior to the tendons at an
Orthopaedic Society for Sports
starts at the midline medially, travels average of 2.9 cm medial to the
Medicine, the American Shoulder and superolaterally, externally rotates superior aspect and 2.3 cm medial to
Elbow Surgeons, and the Arthroscopy 90, and continues laterally to insert the inferior aspect of the humeral
Association of North America. on the humerus. The superior aspect insertions.2
J Am Acad Orthop Surg 2019;27: of the tendon is in continuity with The function of the latissimus dorsi
113-118 the distal aspect of the muscle, and muscle tendon unit is to aid in de-
DOI: 10.5435/JAAOS-D-17-00581 conversely, the lower aspect of the pressing the arm in conjunction with
tendon is continuous with the proxi- the teres major and pectoralis major.
Academy of Orthopaedic Surgeons. mal aspect of the muscle. The average It functions to adduct, extend, and
length of the tendinous portion of the internally rotate the shoulder. In
February 15, 2019, Vol 27, No 4 113
Figure 1 Figure 2 Overhead Throwing Athletes

Overhead throwing athletes, specifi-
cally baseball pitchers, are at signifi-
cant risk of latissimus injury. The
latissimus dorsi is a strong internal
rotator of the shoulder and serves
several functions during the phases of
pitching. Jobe et al17 performed elec-
tromyography analysis of the lat-
issimus through the entire mechanism
and found it to be one of the
highest power generators during
the acceleration phase. In addition,
the latissimus sustains an eccentric
contraction during other phases of
the pitching cycle. This eccentric
contraction coupled with forceful
concentric contraction during accel-
eration, followed by a rapid return to
The latissimus dorsi tendon (a) Anterior incision is marked in the skin eccentric contraction, puts this mus-
inserts on the medial border of the crease on the anterior aspect of the
cle tendon unit at significant risk of
bicipital groove. The pectoralis major axilla. Secondary posterior incision is
tendon (b) is retracted superiorly, marked on the posterior aspect of the injury. Pitchers who sustain this type
and the short head of the biceps latissimus muscle in the axilla. of injury will typically describe a
muscle (c) is retracted medially. sudden onset of severe pain localized
to the posterior axilla during either
and golf.16 These injuries typically late cocking or acceleration phases
addition, the latissimus dorsi muscle
occur in younger patients and are with or without a “pop.” There can
assists in pulling the trunk upward
more common in male than female be an accompanying prodrome of
and forward when the arms are in the
athletes, but no specific demo- symptoms for several days to weeks
fixed overhead position, which puts it
graphic data have been reported in before the injury.
at risk of injury during climbing.4
the literature, given how rare this
The latissimus dorsi muscle also
injury occurs.
makes up the posterior axillary fold,
which is important, as disruption of Diagnosis
the contour to this area can be a clin- Injury Patterns
ical indication of tendon disruption. Injuries can occur at several locations Physical Examination
anywhere along the course of the Patient symptoms after an injury to
latissimus dorsi muscle tendon unit. the latissimus dorsi can range from
Mechanism of Injury Direct tendon avulsion, tendon mid- posterior shoulder pain to complete
substance, musculotendinous junc- loss of the posterior axillary fold
Demographics tion, muscle belly, and costal muscle contour. There can be the presence of
Injuries to the latissimus dorsi are rare origin have all been reported as sites swelling, soft-tissue prominence, or
and typically isolated to athletes of injury. Friedman et al1 provide a mass located on the posterior lateral
involved in overhead activities or active summary to characterize injury pat- chest wall. In addition, there can be
military population. The mechanism terns including (1) avulsion or injury ecchymosis involving the postero-
of injury involves resisted contraction isolated to the tendon, (2) tendon lateral chest wall depending on the
with the arm in the hyperabducted, injury associated with injury to ad- severity of the injury. Resisted ad-
externally rotated, and/or hyper- jacent anatomy such as the rotator duction of the shoulder can further
extended position. These injuries cuff, pectoralis major, or teres major, define the muscle tendon deformity in
have been reported to occur in pro- (3) myotendinous injury, and (4) the setting of complete tendon avul-
fessional baseball pitchers,3,5-10 active intramuscular injury. Muscle bell sion. Physical examination findings
duty military,11 cross fit,1 waterski- strains are the most commonly en- can be nonspecific but may include
ing,4,12 rock climbing,13 tennis,14,15 countered injury pattern.3 limited active glenohumeral joint
Michael S. George, MD and Michael Khazzam, MD
The short head of the biceps (a) is The torn latissimus dorsi tendon is The secondary incision can be used
seen on the medial aspect of the retrieved through the anterior to retrieve the latissimus dorsi
humerus as the pectoralis major incision. tendon if it is retracted too deep to
tendon (b) is retracted superiorly. retrieve it from the anterior incision.
ing as a hypointense stripe on T1- and

range of motion in flexion, external T2-weighted images as it travels to Complete rupture of the humeral
rotation, internal rotation, or ab- its attachment on the humerus.18,19 attachment of the latissimus dorsi re-
duction. It is also possible that pa- Rarely, there may be an associated quires surgical repair.
tients can present with full shoulder bony fragment with avulsion injuries
range of motion. Commonly, there is on plain radiographs of the shoulder,
Nonsurgical Management
tenderness to palpation along the so treating physicians must be suspi-
tendon insertion on the humerus, and cious if cortical defect in the proximal Conservative treatment of acute and
again, in the setting of complete dis- humerus is visualized. This has been subacute latissimus dorsi injuries is
ruption, there can be a palpable described by Spinner et al16 following an option depending on the patient’s
defect in this area. Neurovascular a golf injury resulting in a latissimus activity level. Overhead athletes, in
examination will be normal. dorsi tendon avulsion. Ultrasonogra- particular, seem to do well with
phy can be used in a similar fashion. conservative treatment with a high
Ultrasonography findings can range return to their preinjury activity
Imaging level. Several studies4,9,12-14 have
from hypo or hyperechogenicity to
Use of imaging to diagnose a latissimus fluid-filled clefts and myofibril dis- demonstrated the success and out-
dorsi injury can be difficult because ruption.19 The main utility of MRI or comes of nonsurgical management
commonly used MRI sequences of the ultrasonography is to not only con- of these injuries. Although these
shoulder may miss the area of injury. firm clinical findings of the diagnosis studies consist of case reports/small
MRI and ultrasonography are the but also aid in the extent of the latis- case series (Tables 1 and 2, Supple-
useful tools to visualize the severity and simus injury to help guide treatment mental Digital Content 1 and 2,
location of the injury. If there is a sus- recommendations. http://links.lww.com/JAAOS/A167
picion of a latissimus injury, MRI and http://links.lww.com/JAAOS/
sequences to include the upper thorax A168), these demonstrate that
and bilateral shoulder girdles are rec- Treatment athletes can return to overhead
ommended. MRI can demonstrate the throwing sports such as baseball
tendon disruption, as well as degree Partial latissimus dorsi tendon tears pitching and cricket and compen-
of retraction. The muscle belly has can be successfully treated non- sate with this injury. Conservative
a biconvex shape on axial MRI surgically with a period of rest, fol- treatment should consist of a short
sequences,18 with the tendon appear- lowed by progressive return to activity. period of rest with use of cryotherapy
February 15, 2019, Vol 27, No 4 115
A long posterior incision can be used Suture anchors are placed on the Completed latissimus dorsi repair
to access the latissimus dorsi. The medial aspect of the bicipital groove with sutures in place.
retracted muscle (a) and tendon (b) for attachment of the latissimus dorsi
can be reached from this incision. tendon.
thors’ preferred approach is through
and nonsteroidal anti-inflammatories. in 6 weeks. Only one athlete had an anterior deltopectoral incision.9,10
Goals should be to initiate restoration continued shoulder symptoms and The patient is positioned in the beach
of shoulder range of motion with retired but completed the season. On chair position. The incision is placed
physical therapy. Once full shoulder the basis of these results, the authors anteriorly in line with axillary fold
range of motion has been achieved, a recommended conservative manage- (Figure 2). Subcutaneous tissue is
program of isometric latissimus dorsi ment of these injuries in overhead dissected down to the pectoralis
and teres major strengthening is star- throwing athletes. The results of this major tendon (Figure 3). The fascia
ted, followed by resistance training. study are encouraging but are biased on the inferior aspect of the pectoralis
Attention needs to also be focused on because these athletes have access to major tendon is incised to allow
core and lower-body strengthening notable amount of resources because superior retraction. The pectoralis
and cardiovascular conditioning. Once of the participation in professional major tendon is retracted superiorly,
range of motion and strength have sports. It is unknown whether these and the short head of the biceps is
been restored, it is appropriate to results can be translated to the gen- bluntly elevated medially off the
begin an interval throwing program eral population who are also at risk medial aspect of the humerus. Medial
depending on player position and of latissimus dorsi injuries who are retraction of the short head of the
sports participation. not involved in professional sports biceps exposes the latissimus dorsi
Schickendantz et al6 in the largest such as waterskiing, golf, and tendon insertion site on the medial
case series reported the results of weightlifting. Unfortunately, the re- aspect of the bicipital groove (Figure 4).
conservative management of latissimus mainder of the date in the current The insertion site may be bare or with
dorsi injuries in 10 professional base- literature are case reports providing limited tendinous tissue remaining.9
ball pitchers. Over the course of 10 minimal high-level clinical out- The latissimus dorsi tendon is iden-
seasons, the authors found that all comes data to aid in an evidence- tifying by palpating the teres major
athletes returned to pitching within based decision to guide treatment tendon and finding the latissimus dorsi
3 months of the injury during the same recommendations. tendon anterior to it and retracted into
season. Only one recurrence was the axilla. If the tendon is severely
found 6 months after returning to retracted or scarred down, the radial
throwing. This patient returned to Surgical Technique nerve may need to be identified and
competition with continued non- Two approaches have been described carefully protected. If the tendon can-
surgical treatment at the same level for latissimus dorsi repair. The au- not be easily retrieved from the
Michael S. George, MD and Michael Khazzam, MD
deltopectoral incision, an addi- to bring the tendon to the bone while number of incisions used or method
tional posterior incision is made tying. The arm is adducted and of repair. All the patients in the case
along the posterior axillary border of internally rotated during suture tying reports demonstrated good out-
the latissimus dorsi tendon while the to reduce the tendon to the humerus8 comes, with most returning to full
arm is held in abduction.9 This inci- (Figure 8). activity and return to their preinjury
sion can still be accessed from the Postoperatively, the patient uses a activity levels within 6 to 8 months.
anterior aspect without having to sling for 6 weeks. Passive range of Most studies did not report any
reposition the patient. Through the motion is allowed in physical ther- functional deficits at final follow-
secondary incision, the latissimus apy immediately but limited to up.
dorsi tendon can be found anterior 90 of abduction. Active adduction
to the teres major. The tendon is and internal rotation is started at
tagged with a grasping suture and 6 weeks postoperatively. Full sports
Summary
passed through a subcutaneous tun- participation is allowed 4 months
Results of suture anchor repair have
nel from the posterior to the anterior postoperatively.
been excellent, with most patients re-
wound (Figure 5).
turning to full sports activity. Future
Alternatively, a long posterior inci-
studies are needed to determine the
sion along the axillary border of the Results potential functional limitations after
latissimus dorsi can be used in latis-
latissimus dorsi repair.
simus dorsi repair8,12 (Figure 6). This Because complete latissimus dorsi
approach is similar to the approach rupture is a rare injury, the literature
for latissimus dorsi transfer for rotator is limited to case reports8-13,20-24 References
cuff deficiency.2 The patient is posi- (see Tables 1 and 2, Supplemental
tioned in the lateral decubitus posi- Digital Content 1 and 2, http:// Evidence-based Medicine: Levels of
tion. The incision should be cheated links.lww.com/JAAOS/A167 and evidence are described in the table of
posteriorly away from the axilla to http://links.lww.com/JAAOS/A168). contents. In this article, references 1,
avoid contractures from scarring in As with the nonsurgical data, there 4-16, and 18-21 are level IV studies.
the axilla. The overlying fascia is are only case reports and small case
incised. The infraspinatus, teres, minor series with short clinical follow-up
and teres major tendons are retracted to guide decision making and out-
medially to gain access to the latis- comes to guide treatment decision 1. Friedman MV, Stensby JD, Hillen TJ,
Demertzis JL, Keener JD: Traumatic tear of
simus dorsi footprint on the medial making on this injury. This paucity the latissimus dorsi myotendinous junction:
aspect of the humerus. The tendon of data is due to the infrequent Case report of a crossfit-related injury.
footprint can be visualized with nature of injury to the latissimus Sports Health 2015;7:548-552.
shoulder forward flexion, internal dorsi. A variety of surgical methods 2. Pearle AD, Kelley BT, Voos JE, Chehab EL,
Warren RF: Surgical technique and
rotation, and abduction.2 have been described including both
anatomic study of latissimus dorsi and teres
The tendon is repaired to its inser- single1,2,5,7,10 and two-incision major transfer. J Bone Joint Surg Am 2006;
tion site in a similar fashion for both techniques.3,6,8,11 The decision for 88:1524-1531.
approaches. Once the latissimus one versus two incision techniques 3. Donohue BF, Lubitz MG, Kremcheck TE:
dorsi insertion is identified, the cor- is based on the retraction of the Sports injuries to the latissimus dorsi and
teres major. Am J Sports Med 2016;45:
tical bone is prepared with a high- latissimus tendon and safety of 2428-2435.
speed burr being careful to maintain mobilization of the tendon back to the
4. Henry JC, Scerpella TA: Acute traumatic
the integrity of the cortical bone. Two humerus without causing injury to the tear of the latissimus dorsi tendon from its
or three suture anchors are placed in radial nerve. Repair techniques as to insertion: A case report. Am J Sports Med
2000;28:577-579.
the medial aspect of the humerus methods for reattaching the tendon is
at the latissimus dorsi tendon inser- currently based on surgeon preference 5. Leland JM, Ciccotti MG, Cohen SB, Zoga AC,
Frederick RJ: Teres major injuries in two
tion site (Figure 7). Drill-in anchors and include the use of suture anchors professional baseball pitchers. J Shoulder
are preferable to avoid fracturing or bone tunnel. In chronic tears, an Elbow Surg 2009;18:e1-e5.
the humerus during suture anchor Achilles tendon allograft has been 6. Schickendantz MS, Kaar SG, Meister K,
placement. A pulley-type suture re- described with good results.25 Cur- Lund P, Beverly L: Latissimus dorsi and
teres major tears in professional baseball
pair is performed by placing one rently, with only case reports, there pitchers: A case series. Am J Sports Med
limb of suture in a locking fashion in has not been any difference in tendon 2009;37:2016-2020.
the tendon. The other limb of suture to bone healing rates or outcomes 7. Nagda SH, Cohen SB, Noonan TJ,
is used to slide in the suture anchor based on the technique either with Raasch WG, Ciccotti MG, Yocum LA:
February 15, 2019, Vol 27, No 4 117
Management and outcomes of latissimus 13. Livesey JP, Brownson P, Wallace WA: elite athletes. Skeletal Radiol 2011;40:
dorsi and teres major injuries in Traumatic latissimus dorsi tendon 603-608.
professional baseball pitchers. Am J Sports rupture. J Shoulder Elbow Surg 2002;11:
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outcomes of 2 cases. J Shoulder Elbow Surg traumatic latissimus dorsi avulsion: A case
2010;19:e16-e19. 15. Park JY, Lhee SH, Keum JS: Rupture of report. Am J Orthop (Belle Mead NJ) 2000;
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9. Ellman MB, Yanke A, Juhan T, et al: Open Orthopedics 2008;31.
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2013;42:280-285. Avulsion injury to the conjoined latissimus dorsi tendon rupture. Tech
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10. Ellman MB, Yanke A, Juhan T, et al: Open major muscles. Am J Sports Med 26:
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avulsion in a Major League Baseball Surgical reconstruction of chronic latissimus
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chronic latissimus dorsi rupture: A case report 18. Le HBQ, Lee ST, Lane MD, Munk PL, major tendon avulsions in cricketers: A case
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12. Lim JK, Tilford ME, Hamersly SF, Sallay PI: tear. Skeletal Radiol 2009;38: 25. Sabzevari S, Chao T, Kalawadia J, Lin A:
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2006;34:1351-1355. MRI of latissimus dorsi strain injury in four Sports Traumatol Arthosc 2018;26:63-66.
Review Article
Cemented Femoral Component

Use in Hip Arthroplasty
Abstract
John A. Scanelli, MD Elderly patients undergoing both elective and nonelective hip
Geoffrey R. Reiser, MD arthroplasty contribute markedly to health care spending, and the
current aging population is likely to require even more resources.
John F. Sloboda, MD
Several national joint replacement registries show a lower risk of
Joseph T. Moskal, MD, FACS revision surgery in patients older than 75 years who received
cemented femoral components compared with cementless implants
for primary total hip arthroplasty. Despite a higher incidence of early

periprosthetic femoral fracture, noncemented femoral components
are being used with increasing frequency in elderly patients
worldwide. Improvements in cementing technique and modifications
From Dunedin School of Medicine, to cemented stem design over several decades allow surgeons to
University of Otago, Dunedin, New obtain femoral component fixation in poor-quality bone with a
Zealand (Dr. Scanelli), the relatively low risk of complications. Achieving durable cemented stem
Shenandoah Valley Orthopedics,
Fishersville, VA (Dr. Reiser), fixation requires the surgeon to understand the basic handling
Riverside Orthopedics, Williamsburg, properties of cement, how to prepare the femoral bone, and
VA (Dr. Sloboda), and Virginia Tech differences in stem design and surface finish.
Carilion School of Medicine, Roanoke,
VA (Dr. Moskal).
Dr. Sloboda or an immediate family

member has stock or stock options
held in Pacira Pharmaceutical.
Dr. Moskal or an immediate family
P eriprosthetic femoral fracture is a
leading cause of early revision
surgery after primary total hip arthro-
Cemented femoral components pro-
vide value by reducing perioperative
complications, improving functional
DePuy Synthes; is a member of a
plasty (THA).1 Risk factors for early recovery, and reducing pain in elderly
speakers’ bureau or has made paid femoral fracture include age greater patients or those with poor bone
presentations on behalf of Medtronic than 65, female sex, cementless stem quality who undergo hemiarthroplasty
and Stryker; serves as a paid fixation, and metabolic conditions or THA.11 A large national database
consultant to Corin USA, Medtronic,
and Stryker; has stock or stock
that result in relatively poor bone from England compared 30,424 pa-
options held in Invuity; and serves quality such as osteoporosis, poly- tients treated with either a non-
as a board member, owner, officer, or neuropathy, or rheumatoid arthri- cemented stem or a cemented stem for
committee member of the American tis.2-6 Periprosthetic fractures requiring intracapsular femoral neck fractures
Academy of Orthopaedic Surgeons
and the American Association of Hip
revision surgery are associated with controlling for age, sex, and Charlson
and Knee Surgeons. Neither of the a delayed recovery, increased risk of comorbidity score and found a sig-
following authors nor any immediate deep periprosthetic infection, increased nificantly higher 18-month revision,
family member has received anything mortality, and notable health care 4-year revision, and 30-day chest
costs.7-9 Many elderly patients have infection rate in the noncemented
or institution related directly or persistent functional limitations with group.12 A 2010 Cochrane review of
indirectly to the subject of this article: their ability to ambulate after revi- the method of femoral component
Dr. Scanelli and Dr. Rieser. sion hip surgery.7 These findings fixation in the management of native
J Am Acad Orthop Surg 2019;27: collectively emphasize the impor- hip fractures reported a reduced risk
119-127 tance of the surgeon choosing a of intraoperative fracture in cases
DOI: 10.5435/JAAOS-D-17-00245 suitable method of implant fixation where cement fixation (0/291 versus
for each patient and optimizing 17/306) was used. Using this data to
Academy of Orthopaedic Surgeons. surgical technique to minimize the calculate the number needed to treat
risk of complications.10 suggests one intraoperative femoral
February 15, 2019, Vol 27, No 4 119
Figure 1 the cancellous bone that have been

washed free of fat and marrow con-
tents to create an interlock which al-
lows it to transfer load-bearing forces
from the stem to host bone.
Bone cement forms when a powder
polymer is mixed with a liquid
monomer. The powder consists of
polymethyl methacrylate, an initiator
that starts the polymerization process
when mixed with the liquid and an
opacifier, which allows cement to
be visualized on radiographs. Anti-
biotics and coloring such as chloro-
phyll may also be added to the
powder. The liquid consists of methyl
methacrylate, an activator that reacts
with the initiator in the powder re-
sulting in the production of free rad-
icals, and an inhibitor which slows
the rate of the chemical reaction
enough to allow the surgeon time to
work with the cement. When the
Cumulative percent revision for three major registry reports. AOA = Australian
Orthopaedic Association Joint Registry; NJR = National Joint Registry; RIPO = powder and liquid are mixed, the
Register of Orthopaedic Prosthetic Implants. (Photo courtesy of Joseph T. polymerization process creates an
Moskal, MD, FACS.) exothermic reaction.
The practical phases to consider
fracture can be prevented for every Multiple national joint registries from a surgeon’s perspective are mix-
18 patients who receive a cemented show a lower risk of revision with ing, waiting, working, and setting
implant for management of a dis- cemented femoral component fixa- because bone cement transforms
placed femoral neck fracture.13 tion in patients older than 75 years from a liquid mixture into a solid
A large case-series of 32,644 primary who undergo primary THA15-19 material. The duration of time in each
total hip replacements performed (Figure 1). Noncemented stem use phase varies depending on tempera-
over a 40-year period reported a 14- however prevails throughout much ture in the operating theatre, humidity,
time higher incidence of intraoperative of the world despite compelling data storage temperature of the polymer
fracture with noncemented stems that cement performs best in the and monomer, mixing speed, ratio of
(3.0% [529/17,427]) compared with elderly population.1,15,17,20 polymer to monomer, and the vis-
cemented stems (0.23% [35/15,217]).6 Cemented femoral component fix- cosity of the cement.22 The surgeon’s
Female patients older than 65 years ation is becoming a lost art for many understanding of how these variables
were the highest risk group for this surgeons in North America, which influence the working time is vital to
complication.6 Using this data to cal- also results in reduced exposure for the safe handling and effective use
culate the number needed to treat orthopaedic trainees.21 The need for of bone cement. One of the most
suggests it requires 36 cemented stems cemented stem use is increasing with important variables to appreciate is
to be implanted to prevent one intra- the aging population and the demand when the operating room temperature
operative femoral fracture during pri- for both elective and nonelective hip is relatively warm or humid, the
mary THA. The Swedish arthroplasty arthroplasty in older and medically cement sets quicker.22
registry evaluated 170,413 total hip comorbid patients. The art of cementing lies in the sur-
replacements and found a higher rate geon understanding the optimal time
of postoperative periprosthetic fracture to inject the cement into the femoral
leading to revision surgery within two Bone Cement canal and when to insert the stem
years from the primary operation: (Table 1). The stem must be inserted
17% with noncemented stems com- Bone cement functions as a grout or at the desired height, alignment, and
pared with 6% for cemented stems.14 space filler. It moves into the voids of anteversion before the cement cures.
John A. Scanelli, MD, et al
Table 1 Figure 2
Major Advancements in Cemented
Femoral Component Fixation
Major improvements: technique
Hypotensive anesthesia
Pulsatile lavage removes marrow
contents
Vacuum mixing cement
reduces porosity
Preheating stem speeds cement
setting
Distal cement plug and stem
centralizer
Cement gun—retrograde fill
Pressurize doughy cement
Major improvements: stem
Awareness of surface finish
mechanics
Highly polished stem
Collarless
Tapered
Smooth corners Illustrative viscosity time curves for low-, medium-, and high-viscosity cements.
Cobalt-chrome or stainless steel (Photo courtesy of Exeter Hip Unit.)
cancellous bone surface, wet instead greater than 4.5 g of antibiotic per
The goal is to achieve sustained of doughy. This typically results in a 40 g bag of cement) are used in cement
pressurization of doughy cement poor-quality cement mantle that does spacers as part of the management of
into a dry bed of supportive cancel- not effectively transfer load from the active periprosthetic infection. Con-
lous bone that has been washed and femoral component to host bone. centrations of 3 or 4 g of antibiotic per
dried from marrow contents and Medium-viscosity cement provides bag of cement or higher weaken the
blood.23 Only 3% failure because of more flexibility to the surgeon than mechanical strength of the cement and
aseptic loosening of the femoral low-viscosity cement because of its are not recommended at these dosages
component at 20-year follow-up is predictable transition between phases for prophylactic use in hip or knee
achievable with finger packing cement and its ability to be applied to the arthroplasty.26
into the femoral canal by adhering to bony surfaces and pressurized. High- Bone cement is a viscoelastic poly-
the basic principles of inserting bone viscosity cement can be difficult to mer that is affected by the long-term
cement in a doughy state and pres- extrude through a cement gun. Ulti- properties of creep, stress relaxation,
surizing it.24 mately, the surgeon’s understand- and fatigue. Bone cement functions
The working times and set times for ing and comfort level with the well in compression and poorly in
bone cement are variable (Figure 2); handling properties of the cement tension.22 Fatigue failure of bone
for example, at 20C (68F) the should determine which one to use. cement typically originates in areas
working time for a medium-viscosity Only antibiotics that are heat stable of high tensile stress and is reduced
cement is approximately 4 to 7.5 mi- and in powder form should be added to by stress relaxation during periods of
nutes with a set time of 10.5 minutes, bone cement in appropriate concen- relative unloading (ie, when a patient
whereas a high-viscosity cement has a trations when clinically indicated.26 sleeps at night).22 Both the femoral
working time of 1.5 to 5.5 minutes When additional powder is added to component and bone cement must
with a set time of 8 minutes. Low- the mixture without changing the ratio be effective conduits in transmitting
viscosity cements can be difficult of monomer, the cement takes longer load to host bone and withstand
to use in clinical practice and are to set. Prophylactic antibiotic con- repetitive axial and rotational forces
associated with early loosening.25 centration in bone cement used for without loosening over long periods.
Low-viscosity cement has a relatively joint replacement typically consists of The axial load on the stem is con-
short working time, which usually 1 g of antibiotic per 40 g bag of verted into radial compressive forces
results in it being applied to the cement. High doses of antibiotics (ie, across the cement and transferred
February 15, 2019, Vol 27, No 4 121
Figure 3 2 mm over the first year is commonly

noted around the shoulder of col-
larless polished tapered stems on
radiographs and does not suggest
aseptic loosening or impending fail-
ure of the femoral reconstruction.29
Cemented stem cross-sectional shape
influences the cement mantle thickness
surrounding it and stress transfer from
the stem to the cement mantle.33
Rectangular and oval cross-sectional
shapes are the most commonly used
in clinical practice. Although a rect-
angular cross-sectional stem offers
Theories of stem fixation. (Image courtesy of Matthew Wilson, MBBS, FRCS,
and the Exeter Hip Unit.) more rotational stability than an
oval shape, the edges can create
stress risers.33 The increased stress
to the bone as hoop stress.27 This nent, it would be for one that relies on concentrations at the corners can
phenomenon helps preserve proxi- composite beam fixation. The theory lead to microfractures of the cement
mal femoral bone loss by minimizing that collars improve proximal loading mantle.29 Rounded edges are favoured
proximal stress shielding.28 of the cement mantle has not proven over sharp corners that occur at
necessary for long-term clinical suc-
transition points along the length of
cess.30 The collar also does not pre-
the stem which are less likely to
Stem Design vent stress shielding of the femoral
produce stress risers that could
neck, micromotion, or wear debris.30
adversely affect the durability of the
Cemented stem geometry, material, A collar is counterproductive for pol-
cement mantle.
and surface finish all affect clinical ished tapered stems in which con-
Cemented stems that require a line-
survivorship.29 Philosophies of ce- trolled subsidence is advantageous to
to-line femoral preparation are sized
mented stem fixation can be classified optimize the proximal load on the
to fill most of the femoral canal
according to Shen and Huiskes et al cement mantle because it wedges into
producing a thin (ie, less than 2 mm)
as taper slip or force-closed fixation the cement mantle over time achieving
cement mantle and have performed
and composite beam or shape-closed secondary stability.30
well with long-term follow-up.34 This
fixation27,29 (Figure 3). The taper slip The risk of micromotion between
concept uses a dual- or triple-tapered the stem and the cement mantle in- type of cemented stem challenges the
stem geometry typically with a smooth creases with repetitive axial and concept that a circumferential cement
or highly polished surface finish al- rotational forces over time. This risk mantle of 2 to 4 mm that interdigitates
lowing the implant to wedge into the is relatively well tolerated in polished with cancellous bone is necessary for
cement mantle over the course of the tapered designs but can result in cat- durable long-term fixation and is
first year. This concept improves astrophic failure with roughened referred to as the “French paradox.”34
proximal loading of the cement man- or precoated stems.31 If the bond The surgical technique to prepare the
tle. The composite beam concept relies between the stem and the cement femur with a line-to-line implant with
on a strong bond between the stem breaks with a roughened stem and an oval cross section differs from a
and the cement, so the two different micromotion occurs, the roughened tapered stem design with a rectangular
materials function as one unit during stem surface causes abrasive wear of cross section that is undersized relative
load transmission. Implants relying the cement mantle and generates to the last broach used.
on a composite beam principle are wear debris that induces an inflam- Cemented stems made from tita-
typically roughened or precoated with matory response resulting in osteolysis nium are more flexible than stainless
cement to maximize the mechanical and aseptic loosening.32 For this steel or cobalt-chrome and have not
strength of the bond between the reason, polished stems generally performed well in vivo.35 Titanium
cement mantle and the stem. have better clinical survivorship than stems are more likely to bend than
If a collar will have any positive stems of the same geometry with a the other stems within the cement
effect in improving implant survivor- roughened, precoated, or matte sur- mantle causing areas of high tensile
ship for a cemented femoral compo- face finish.31 Stem subsidence of 1 to stress that can result in early cement
fracture or cement mantle abrasion The surgical technique description Figure 4

ultimately leading to clinical failure. that follows is broadly applicable
In summary, a variety of cemented to any polished tapered collarless
stems with good long-term survivor- cemented stem. This implant design
ship that use either a taper slip method is the most frequently implanted
or a composite beam method of fix- worldwide and has been used for
ation exist. A collarless, polished, over 30 years with excellent survi-
tapered stem with round edges and a vorship reported from multiple
rectangular cross-section functions national joint replacement regis-
well in clinical practice.15,18,19,36 tries.15,18,19 Cemented fixation for
this type of stem relies on the surgeon
establishing a strong interlock be- Supportive metaphyseal cancellous
bone washed free of fat and marrow
tween cement and supportive can-
Surgical Technique contents. The bone has been well
cellous bone. dried and is ready for cement
The surgical indications for cemented Modern cementing technique uses interdigitation. (Photo courtesy of
cement restrictors, pulsatile lavage, a Exeter Hip Unit.)
femoral component use include dis-
placed intracapsular femoral neck cement gun with long nozzle, foam
fractures or primary THA in patients pressurizer, and distal stem central- Preoperative templating helps choose
with poor bone quality, age 70 or izers to help achieve this. Although an appropriately sized femoral com-
greater, and diagnosis of osteoporo- these devices can improve the quality ponent with the desired offset for each
sis or osteopenia. In patients younger of the cement mantle and position of patient. When a cemented stem is used
the implant, adhering to the basic for the management of a displaced
than 55 years, noncemented femoral
principles of how to prepare the bone femoral neck fracture, the contralateral
components tend to have better sur-
for a particular implant and when to hip is used to template the desired
vivorship,15 although satisfactory
insert the cement and the stem remain height, offset, and size of the stem.
performance can be achieved with a
the most important aspects of ce- Templates have cement lines that
tried and true implant with good
menting technique that are universal extend beyond the size of the selected
cementing technique.37
to any femoral component or practice stem to plan for a 2- to 4-mm cement
Identifying patients at risk for
setting. mantle within the outer 3 to 4 mm of
cardiopulmonary collapse (eg, increas-
Ensuring supportive cancellous bone supportive cancellous bone of the
ing age, notable cardiopulmonary
has been exposed but not removed, femoral metaphysis. The distance from
disease, male sex, diuretic use) preop-
the bone washed and dried before in- the tip of the greater trochanter to the
eratively and a coordinated effort and
serting cement in the doughy phase shoulder of the femoral component is
good communication between the
(Figure 4), and providing sustained measured preoperatively and repro-
anesthesiologist and the surgeon are pressurization until the cement sets duced intraoperatively to restore the
essential. The anesthetist should ensure encompasses the key elements of desired leg length (Figure 5).
the patient is adequately fluid resusci- producing a well-fixed cement mantle The level of the femoral neck
tated, and the surgeon should notify the to support the femoral component.22 It osteotomy allows more operative
anesthetic team approximately 10 mi- cannot be overstated that knowing flexibility when a collarless cemented
nutes before inserting cement, so Fio2 when to insert the cement into the stem is used. For example, during the
can be increased. An arterial line is femoral canal and when to insert the trial reduction if the leg is too long, the
helpful in high-risk patients to detect a stem captures the fundamental art final implant can be inserted further
sudden drop in blood pressure. Vaso- of cementing technique. These time into the canal by approximately 1 cm
pressors should be readily available to points are influenced by room tem- without requiring the neck to be re-cut
help maintain intravascular volume if perature, humidity, the temperature and planed or the broach impacted
necessary. To reduce the embolic load at which the cement and monomer further. The neck cut exits at the level
in these high-risk patients, the surgeon are stored, mixing speed and dura- of the saddle laterally and usually one
can frequently irrigate the femoral tion, and the ratio of cement to fingerbreadth above the lesser tro-
canal during preparation of the femur, monomer. A working knowledge of chanter to permit enough metaphyseal
use a cement restrictor, suction cathe- how quickly or slowly the cement is bone to support the implant.
ter, retrograde fill the canal with setting during an operation allows the A straight reamer is used to ensure
cement and avoid excessive cement surgeon to optimize both cement and that appropriate orientation within the
pressurization. stem insertion. femoral canal is achieved. Next, the
February 15, 2019, Vol 27, No 4 123
Figure 5
For orientation, the pictures show a right hip through a posterior approach. The patient’s feet are to the right of the image and
the head to the left. A, Mark on broach handle corresponding with measured distance from the tip of the greater trochanter to
the shoulder of the stem on the preoperative template to reproduce desired leg length intraoperatively. B, Stem at appropriate
height relative to tip of great trochanter. C, Mark on femur parallel to the broach corresponding with stem alignment. (Photos
courtesy of Exeter Hip Unit.)
femur is sequentially broached until the quantify changes in stem position plunging past the isthmus by forcibly
outer 3 to 4 mm of supportive cancel- when referenced against the proxi- inserting it completely by hand. The
lous bone within the metaphysis is mal femoral bone. These marks also femoral canal is then extensively irri-
reached and enough axial and rota- provide reference lines to ensure that gated with pulse lavage with the goal
tional stability of the broach is the final implant is inserted to the of clearing out fat, blood, and marrow
achieved to permit a trial reduction. appropriate depth and the desired contents from the cancellous bone.
Simply cementing the smallest size stem alignment and allow for correction The bone is dried with long ribbon
for all patients is not advised because of varus or valgus malalignment be- gauze packed into the canal. This
this approach risks obtaining a non- fore the stem is completely inserted to ribbon gauze is removed just before
supportive cement mantle in weak the desired height. Cemented stems inserting the cement.
cancellous bone. Irrigating and suc- allow more control over stem version A wall-mounted timer is started once
tioning the femoral canal between than do noncemented implants that the powder and liquid are mixed and
broach sizes helps reduce the risk of rely on proximal metaphyseal fixa- can provide helpful information about
pulmonary emboli. tion. Given the wide variability in the rate at which the bone cement is
Once the desired position of the native femoral anteversion, the addi- setting. Attempting to achieve consis-
broach is achieved within the femur, tional freedom to adjust the femoral tency across all variables that affect the
three marks are made on the femur component version within the cement handling time of cement is encouraged.
relative to the broach to help guide the mantle allows the surgeon to control Two batches of cement are sufficient
final placement of the cemented stem an additional parameter to minimize for most patients, and three batches are
within the cement mantle. The height the risk of dislocation. It is vital when used in large ectatic femoral canals.
of the shoulder of the broach is marked the final stem is implanted within the Vaccum mixing cement minimizes
on the greater trochanter to reproduce cement mantle that soft tissue or toxic fumes from circulating through
leg length. A second mark is made on retractors do not contact the neck of the operating theatre and reduces the
the anterior or posterior surface of the the prosthesis until the cement sets risk of air bubbles from forming within
greater trochanter relative to a refer- because this can retrovert or over- the cement, which theoretically com-
ence mark on the femoral broach to antevert the stem. promises its mechanical strength.
provide feedback about alignment, A cement restrictor of appropriate Cement is typically mixed for 1 minute
and lastly a mark is made along the cut size relative to the femoral canal is by hand or attached to a handheld
surface of the femoral neck to denote placed to permit a 1-cm cement mantle power source on ream setting. It is
the desired anteversion of the stem. distal to the tip of the stem. Starting then loaded into a cement gun with a
Most femoral components have the cement restrictor by hand until long cement nozzle. To minimize the
marks spaced a known distance from resistance is met and then advancing it risk of cement extruding into the
each other on their outer surface with gentle mallet taps until it reaches acetabulum, this space is temporarily
proximally that allow the surgeon to the desired height reduces the risk of filled with surgical gauze.
Figure 6
For orientation, the pictures show a right hip through a posterior approach. A, Retrograde cement fill of canal. B, Doughy
cement visible with canal completely back filled. C, Cement pressurizer now ready for use with long nozzle removed. D,
Cement pressurization with firm pressure applied to proximal femur. 3) Stem insertion with thumb over calcar permitting
improved cement pressurization and pushes stem out of various. E, Cemented stem with supportive cement mantle. (Photos
courtesy of Exeter Hip Unit.)
Familiarity with the practical phases it provides the best chance of being pending on how quickly the cement
of cement and a working knowledge able to overpower the opposing force is setting. Fat and marrow contents
of the factors that influence the setting of back bleeding through cancellous can be seen extruding from the
time of cement allows the surgeon bone.23 The cement is inserted into the femoral cortex during this process.
to anticipate whether the cement will femur in a retrograde fashion after In patients with notable cardiac or
set quite rapidly or late relative to removing the ribbon gauze and suc- pulmonary comorbidities or in cases
conventional working times. This tioning the canal. A small catheter of geriatric femoral neck fractures,
understanding minimizes the risk of suction tip helps minimize the risk of the cement is not pressurized as
inserting the cement too soon while fluid or air being trapped within the vigorously as in primary THA
runny and mixing with blood in the cement mantle because it is removed to minimize the embolic load to these
cancellous bone or too late which can from the canal after it is filled with already metabolically compromised
prevent the stem from being fully cement. The long cement nozzle is patients. Sustained pressurization of
seated and left proud resulting in leg removed after the canal is filled with bone cement once it is placed into the
lengthening or an irreducible hip. cement, and firm pulses of pressure femur until it sets is vital to prevent
When a piece of cement can be easily on the gun with the foam nozzle back bleeding from compromising the
molded in the surgeon’s hand without buried within the proximal femur fixation of cement to host bone.23 If
sticking to the glove, the cement is allows sustained pressurization and the surgeon is not experienced with
ready to be inserted into the femur enhances interdigitation of bone cement, practicing on dry foam saw-
retrograde through a long cement cement with the cancellous bone. bones is recommended.
nozzle (Figure 6). When the cement Ideally, the foam pressurizer is used Some collarless polished stems use a
becomes doughy enough to work with, for at least 30 to 60 seconds de- hollow tipped stem centralizer that is
February 15, 2019, Vol 27, No 4 125
manually attached to the tip of the stem depends on to support the prosthe- 3. Katz JN, Wright EA, Polaris JJ, Harris
MB, Losina E: Prevalence and risk factors
and facilitates optimal position distally sis.23 If the cement is inserted too late for periprosthetic fracture in older
within the cement mantle. Stem cen- and is unable to be molded, the stem recipients of total hip replacement: A
tralizers can also protect the distal will be left proud and could result in a Cohort Study. BMC Musculoskelet Disord
2014;15:168.
cement mantle from stress risers and notable leg length discrepancy.
4. Cook RE, Jenkins PJ, Walmsley PJ, Patton JT,
ultimately fracturing when the stem
Robinson CM: Risk factors for periprosthetic
subsides over time.38 If the centralizer fractures of the hip: A survivorship analysis.
has prongs, orienting one of the prongs Summary Clin Orthop Relat Res 2008;466:1652-1656.
so it is parallel to the lateral border of 5. Beals RK, Tower SS: Periprosthetic
the stem will help reduce the risk of the Cemented femoral component use fractures of the femur: An analysis of 93
stem ending up in varus. When the for hip arthroplasty in the elective fractures. Clin Orthop Relat Res 1996:
238-246.
femoral component is ready to and nonelective setting is a safe and
effective technique for achieving 6. Abdel MP, Watts CD, Houdek MT,
be inserted, it is vital that enough Lewallen DG, Berry DJ: Epidemiology of
working space around the proximal durable implant fixation in relatively periprosthetic fracture of the femur in 32
femur is created, so soft tissue or re- poor-quality bone. Surgeons who 644 primary total hip arthroplasties: A 40-
use modern cementing techniques year experience. Bone Joint J 2016;98-B:
tractors do not contact the neck of 461-467.
the femoral component which can and an implant with favorable design
7. Mardian S, Schaser KD, Gruner J:
adversely affect stem anteversion. The features position their patients for Adequate surgical treatment of peri-
stem is inserted by hand with a long being able to safely weightbear as prosthetic femoral fractures following hip
tolerated after surgery with a lower arthroplasty does not correlate with
handle attachment with the surgeon’s functional outcome and quality of life. Int
thumb holding pressure over the risk of femoral fracture compared Orthop 2015;39:1701.
medial calcar which helps push the with noncemented stems. Clinical
8. Kurtz SM, Ong KL, Schmier J: Future
stem out of varus and also maintains outcome data supports the use of ce- clinical and economic impact of revision
pressure within the cement mantle mented stems in elderly patients and total hip and knee arthroplasty. J Bone
Joint Surg Am 2007;89(suppl 3):144-151.
while the stem is advanced into the those with poor bone quality under-
canal. Resistance should be felt while going hip replacement. 9. Zuurmond EG, van Wijhe W, van Raay JJ,
Bulstra SK: High incidence of complications
the stem is advanced into the cement and poor clinical outcome in the operative
treatment of periprosthetic femoral
mantle if the cement is in the doughy References fractures: An analysis of 71 cases. Injury
state. The stem is initially advanced 2010;41:629-633.
two thirds of its length into the canal, Evidence-based Medicine: Levels of 10. Ng Man Sun S, Gillott E, Bhamra J, Briggs T:
excess cement is then cleared around evidence are described in the table of Implant use for primary hip and knee
the component, and the position arthroplasty: Are we getting it right first
contents. In this article, reference 1 is time? J Arthroplasty 2013;28:908-912.
of the stem is checked with respect a level I study. References 3, 4, 6, 12,
to alignment and anteversion. This 11. Pennington M, Grieve R, Sekhon JS:
16, 26, and 31 are level II studies. Cemented, cementless, and hybrid prostheses
approach allows any final correction References 1, 2, 8, 10, 11, 14, 15, 17- for total hip replacement: Cost effectiveness
to be made before the stem is fully 20, 25, 29, 30, and 35 are level III analysis. BMJ 2013;346:f1026.
seated to the desired position and also studies. References 5, 7, 9, 22-24, 12. Jameson SS, Jensen CD, Elson DW, et al:
further pressurizes the cement with Cemented versus cementless
28, 32-34, and 36-38 are level IV hemiarthroplasty for intracapsular neck of
the last push. After the cement has set, studies. References 21 and 27 are femur fracture - A comparison of 60, 848
care must be taken to ensure that no level V reports or expert opinions. matched patients using national data.
Injury 2013;44:730-734.
free floating fragments of cement
have been left in the wound (see Video, References printed in bold type are 13. Parker MJ, Gurusamy KS, Azegami S:
those published within the past 5 Arthroplasties (with and without bone
Supplemental Digital Content 1, http:// cement) for proximal femoral fractures in
links.lww.com/JAAOS/A183). years. adults. Cochrane Database Syst Rev 2010:
Complications of poor cementing CD001706.
1. American Joint Replacement Registry: 3rd
technique are mostly attributed to in- Annual Report: 2016. Available at: http:// 14. Hailer NP, Garellick G, Kärrholm J:
serting the cement “too early” or “too www.ajrr.net/publications-data/annual- Uncemented and cemented primary total
reports/393-2016-annual-report Accessed hip arthroplasty in the Swedish Hip
late.” If the cement is inserted too early November 11, 2016. Arthroplasty Register. Acta Orthop 2010;
in a relatively runny state, back 81:34-41.
2. Singh JA, Jensen MR, Harmsen SW,
bleeding will overpower the cement Lewallen DG: Are gender, comorbidity, and 15. Australian Orthopaedic Association
and prevent the cement from inter- obesity risk factors for postoperative National Joint Replacement Registry: 2016
periprosthetic fractures after primary total Annual Report—Hip, Knee & Shoulder
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cancellous bone which cement fixation 126–131. National Joint Replacement Registry. 2016.
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Arthroplasty Today 2016;2:211-218. hip prosthesis: A review of 8,579 primary 33. Crowninshield RD, Brand RA, Johnston
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17. Canadian Joint Replacement Registry Arthroplasty Register. J Bone Joint Surg cross-sectional geometry on cement stresses
Annual Report. 2014-2015. Am 1995;77:1543-1550. in total hip reconstruction. Clin Orthop
Relat Res 1980;146:71-77.
18. The New Zealand Joint Registry Sixteen
26. Postak PD, Greenwald AS: The influence of
Year Report. 2014. 34. Langlais F, Kerboull M, Sedel L, Ling RS:
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Northern Ireland: 12th Annual Report. 2015.
27. Shen G: Femoral stem fixation: An 35. Emerson RH, Head WC, Emerson CB,
20. Troelsen A, Malchau E, Sillesen N,
engineering interpretation of the long-term Rosenfeldt W, Higgins LL: A comparison of
Malchau H: A review of current fixation
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Bone Joint Surg Br 1998;80-B:754-756. components used for primary total hip
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February 15, 2019, Vol 27, No 4 127
Review Article
Sideline Management of
Nonmusculoskeletal Injuries by the
Orthopaedic Team Physician
Abstract
Austin W. Chen, MD Although recognized as the most well-trained providers to address
Cortney S. Archbold, DDS musculoskeletal injuries, many orthopaedic surgeons do not routinely
treat patients with nonmusculoskeletal issues in their clinical practice.
Mark Hutchinson, MD
Nonetheless, when serving as a team physician, an orthopaedic
Benjamin G. Domb, MD surgeon may need to initiate management of or manage many
nonmusculoskeletal issues. Knowing how to accurately diagnose and
initiate management of sports-related medical and surgical conditions
is an important facet of being an orthopaedic team physician.
Common systems that may be involved include the cerebral/
neurologic, ocular, dental, respiratory/pulmonary, cardiac, abdominal,
and genitourinary systems. Each of these systems has specific
pathologic processes and risks related to athletic or sporting
participation. Orthopaedic team physicians must have a baseline
familiarity with the most common nonmusculoskeletal issues to
provide comprehensive quality care to athletes and patients.
T he athletic sideline is a unique

clinical setting. The physician
has the advantage of witnessing the
are well equipped to triage them
quickly and accurately; however, ur-
gent nonmusculoskeletal issues are less
mechanism of injury but faces the po- commonly encountered by orthopaedic
tential disadvantage of patients who surgeons in everyday practice. Ortho-
might consciously ignore or withhold paedic surgeons who serve as athletic
information and symptoms in hopes of team physicians must be aware of the
returning to play. Orthopaedic sur- most commonly encountered non-
geons commonly provide sideline musculoskeletal conditions and their
From the Boulder Centre for medical services as team physicians in sideline management. Systems com-
Orthopedics, Boulder, CO (Dr. Chen),
the American Hip Institute, Chicago, IL
all types of sports and levels of commonly affected by athletic injuries
(Dr. Chen and Dr. Domb), the Lake petition. In the analyses of sports- include the cerebral/neurologic, ocular,
Erie College of Osteopathic Medicine, related emergency department visits, dental, respiratory/pulmonary, car-
School of Dental Medicine, Erie, PA 45% of diagnoses were either fracture diac, gastrointestinal, and genitouri-
(Dr. Archbold), and the Department
of Orthopaedic Surgery, University of
or sprain/strain, and the upper and nary systems. Heat- and cold-induced
Illinois at Chicago College of lower extremities accounted for 57.9% injuries are not included in this review
Medicine, Chicago, IL of involved body regions, making the because their evaluation and manage-
(Dr. Hutchinson). orthopaedic surgeon an ideal team ment was well covered by Noonan
J Am Acad Orthop Surg 2019;27: physician.1,2 Orthopaedic surgeons et al.3 Lack of familiarity with
e146-e155 manage these musculoskeletal con- nonmusculoskeletal injuries, com-
DOI: 10.5435/JAAOS-D-17-00237 ditions daily and are well equipped to bined with the confounding varia-
triage them quickly and accurately. bles of the sideline setting, can
Academy of Orthopaedic Surgeons. Orthopaedic surgeons manage these make these situations challenging.
musculoskeletal conditions daily and Team physicians must stay current
Austin W. Chen, MD, et al
on nonmusculoskeletal pathologies Figure 1

because accurate diagnosis and
early initiation of treatment can
make a dramatic difference in care
and outcome.
Preparation for Sideline Care

Preparation for sideline patient care is
vital. A collaborative consensus state-
ment by six major professional associ-
ations (including the American
and the American Orthopaedic Society
for Sports Medicine) defines sideline
preparedness as “the identification of
and planning for medical services to
promote the safety of the athlete, to
limit injury, and to provide medical
care at the site of practice or compe-
tition.”4 The statement outlines goals,
preseason and game-day planning,
and necessary medical supplies. The Photograph showing the contents of a trauma pack carried by team physicians
for the United States Ski and Snowboard teams. (Courtesy of Gillian Bower, PT,
essential elements include knowledge SCS, and Kyle Wilkens, MS, PA-C, ATC-L, for the United States Ski and
of evacuation routes, emergency pro- Snowboard Association, Park City, UT.)
tocols, on-call consultants, environ-
mental and playing conditions, and
breathing/ventilation, circulation/
the location and contents of the Anatomic-specific Concerns
hemorrhage control, disability/
medical supply bag (Figure 1). This
statement should be reviewed before neurologic status, exposures/envi- Nonmusculoskeletal athletic injuries
providing medical coverage at any ronment) and, if pertinent, a rapid can affect the cerebral/neurologic,
athletic event. trauma assessment evaluating the ocular, dental, respiratory, cardiac,
head, neck, upper extremities, chest, gastrointestinal, and genitourinary
back, abdomen, pelvis, and lower systems.
Initial Evaluation/Primary
extremities. Patients should be trans-
Survey
ferred to an emergency department if
they have prolonged loss of con- Cerebral/Neurologic
Standard emergency management
protocols should always be fol- sciousness; Glasgow Coma Scale Hemorrhage
lowed before any focused physical score ,15; deteriorating mental sta- The overall incidence of sports-
examination is conducted. The tus; progressive, worsening, or new related traumatic brain injury (TBI)
initial evaluation includes a pri- neurologic signs (eg, repetitive eme- is 7.8% of the emergency department
mary survey of the ABCDEs (ie, sis, extremity numbness, or sei- visits.7 TBI can result in intracranial
airway/cervical spine protection, zure); or potential spinal injury.5,6 bleeding. Hemorrhage into different
Dr. Hutchinson or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy
of Orthopaedic Surgeons, the American Board of Orthopaedic Surgery, the American College of Sports Medicine, the American Orthopaedic
Society for Sports Medicine, and the Arthroscopy Association of North America. Dr. Domb or an immediate family member has received
royalties from Arthrex, DJO Global, and Orthomerica; is a member of a speakers’ bureau or has made paid presentations on behalf of
Arthrex; serves as a paid consultant to Amplitude, Arthrex, Medacta, Pacira Pharmaceuticals, and Stryker; has received research or
institutional support from Adventist Hinsdale Hospital, Arthrex, Athletic and Therapeutic Institute Physical Therapy, Breg, Medacta, Pacira
Pharmaceuticals, and Stryker; and serves as a board member, owner, officer, or committee member of Arthroscopy Association of North
America and the American Hip Institute. Neither of the following authors nor any immediate family member has received anything of value
from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article:
Dr. Chen and Dr. Archbold.
February 15, 2019, Vol 27, No 4 e147
Sideline Management of Nonmusculoskeletal Injuries by the Orthopaedic Team Physician
intracranial spaces affects the clinical ture spotlight.10 Approximately 1.6 to Coma Scale score, as well as a neck
presentation, prognosis, and urgency 3.8 million sports-related concussions examination. Additional steps include
of the situation. Bleeding can occur in occur in the United States annually.5 symptom evaluation, the Standard-
the following spaces, from superficial The recent abundance of medical lit- ized Assessment of Concussion (SAC),
to deep: epidural, subdural, intrace- erature reflects the awareness of this neurologic screening, the Modified
rebral. Epidural hematomas are no- sports medicine epidemic. Team Balance Error Scoring System, exam-
torious for involving a so-called lucid physicians must stay current with the ination of coordination, and the SAC
interval. This interval is a period of guidelines and consensus statements Delayed Recall score. Memory
relative mental clarity, conscious- from the Concussion in Sport Group assessment is more reliable than
ness, and responsiveness after the because the evolving knowledge and standard orientation questions (eg,
traumatic event, followed by quick understanding of concussion man- time, place, person) are.11 A modified
and extreme neurologic decompen- agement affects important decisions, SCAT5 is available for use in children
sation.8 Subdural hematomas are the such as return to play. aged #12 years. Additionally, the
deadliest head injury in high school A concussion is a clinical manifesta- King-Devick test, which assesses rapid
and college football players, action of a functional brain injury caused eye movement, can be used in com-
counting for 79% of brain injury– by physical forces acting on the brain. bination with portions of the SCAT5
related deaths.9 At the pathophysiologic level, neuro- (Modified Balance Error Scoring
The signs and symptoms of severe nal dysfunction is the result of the System and SAC) to accurately diag-
TBI coincide with many of the afore- brain’s high demand for energy to nose 100% of concussions.6 The
mentioned indications for transfer to restore normal cell resting potentials algorithm in Figure 2 provides a
the emergency department. In the mismatched with restricted cerebral guideline for sideline concussion
event of loss of consciousness, cervi- blood flow and thus low energy sup- diagnosis and management.
cal spine precautions should be taken ply.6 The onset and types of symptoms Any athlete in whom concussion is
until a spine injury can be ruled out. are both important when evaluating suspected should be removed from
An efficient yet thorough neurologic for concussion; however, the diagnosis further participation. Immediate ces-
examination should include assess- may be clouded by minimal trauma, sation of play hastens the initiation of
ment of cranial nerve function; sen- rapidly changing signs and symptoms, the recovery period and reduces the
sation, reflexes, and strength of the and delayed onset. Patients may have risk of second-impact syndrome, in
upper and lower extremities; balance headache, dizziness, imbalance, which rapid cerebral swelling from a
and coordination; and cognitive pro- nausea/vomiting, photophobia, pho- closely timed subsequent head injury
cessing. Cranial nerve assessments nophobia, and/or blurry vision. Cog- can result in death.6 Most mild con-
include facial symmetry and sensa- nition, affect, and sleeping patterns cussions will resolve with observa-
tion, hearing, palate and tongue sym- can also be disrupted. tion; however, more severe cases
metry, and shoulder shrug. A detailed Concussion evaluation should may require neurologic consultation.
eye examination requires an evalua- include a full neurologic evaluation, The 2016 Berlin consensus statement
tion of pupillary response, visual as described in the workup for TBI, includes graded return-to-sport and
fields, and eye movement. Coordi- and evaluation with a specific con- return-to-school strategies.11 This
nation can be assessed with the cussion diagnostic tool, such as the process may last days to months and
finger-to-nose test. Vital signs should Sports Concussion Assessment Tool is beyond the scope of this review.
be monitored because an increase in version 5 (SCAT5), developed by the
blood pressure and decrease in ex- Fifth International Conference on
pected pulse rate can be evidence of Concussion in Sport, held in Berlin in Ocular
an increase in intracranial pressure.8 2016.11 Many athletes have pre- More than 600,000 sports-related
Neurologically intact athletes should season baseline evaluation scores that eye injuries occur each year,
continue to be closely monitored on can be used as a reference for post- accounting for 20% of all eye in-
the sidelines every 30 minutes to injury testing. The SCAT5 assess- juries.12 Most of these patients are
ensure no delayed deterioration of ment has multiple sections and male (81.3%), and .50% of all
their neurologic status occurs. incorporates several verified tools. patients are aged #18 years. From
The “Immediate or On-Field As- 2010 to 2013, basketball accounted
Concussion sessment” section includes the iden- for the most eye injuries (22.6%),
In recent years, Hollywood, high- tification of red flags, such as followed by baseball/softball (14.3%)
profile athletes, and the media have assessment of observable signs, the and air gun shooting (11.8%).13
placed concussions in the popular cul- Maddocks score, and the Glasgow Ocular injuries include a wide gamut
of complications ranging from simple Figure 2

abrasions to complete globe ruptures.
Open adnexal (eyelid, eyelashes, eye-
brow, lacrimal apparatus, conjunc-
tiva) wounds are the most common
type (33.5%), followed by ocular and
adnexal contusions (30.1%).
Sideline examination of an ocular
injury must be thorough. Visual
acuity of each eye can be quickly
evaluated separately by testing the
athlete’s ability to count fingers or
read print. However, a standard
Snellen visual acuity card provides a
more formal evaluation and is avail-
able as a free application download
to a smartphone. Vision loss is a
consistent sign of more severe ocular
injury.14 Pupillary examination is
Algorithm for the approach to concussion diagnosis and management.
conducted with a light source (eg, (Adapted with permission from Kutcher J: Management of concussion.
pen light) to evaluate size, reactivity, Presented at the United States Ski and Snowboard Association Medical
and shape. A relative afferent Emergencies in Skiing and Snowboarding Course, Beaver Creek, CO,
pupillary defect (paradoxical pupil- December 8-10, 2016.)
lary dilation with light in the affected
eye) with the swinging flashlight test wore appropriate eye protection; the Many of the sports often thought of
could be a sign of optic nerve or main deterrents reported were dis- as associated with trauma to the
retinal injury. An efferent defect (ie, comfort and vision restriction.15 dentition, such as hockey, have had
loss of both direct and consensual Regular eyeglasses and contact their dental trauma rates mitigated
constrictions) is seen in patients with lenses are not appropriate and could by the adoption of a mouth guard
anisocoria (unequal pupils) and cause more harm than wearing no policy.
could indicate an oculomotor nerve glasses at all. Polycarbonate lenses Although team physicians depend
lesion or Horner syndrome. The are thinner, lighter, and stronger on dental professionals to definitively
remainder of the examination should than typical eyeglass lenses and manage dental trauma, many imme-
include assessment of the extraocular block most ultraviolet radiation.12 diate steps can be taken to aid in
muscles, eyelids (especially lacer- recovery if a dentist is unavailable.
ations involving the medial tear duct Treatment is often determined by
system), conjunctiva, and cornea. If Dental whether the primary or permanent
available, proparacaine, a topical Oral trauma is very common in ath- dentition is affected. Table 1 contains
anesthetic drop, can aid in the letics. Participation in sports ac- the most common dental injuries and
examination of an uncomfortable or counts for a reported 0.8% to 26% of their sideline treatment.20,21
photophobic patient.15 Appendix 1 all dental injuries, although this esti- Of these injuries, avulsion may
depicts the most commonly en- mation may be low.17,18 Known risk benefit most from timely sideline
countered ocular injuries in sports factors include having a short upper management. Any tooth dislocated
and their sideline management14-16 lip and having an overjet of from its socket has limited time for
(see Appendix 1, Supplemental Digital .3 mm.17 Sports with the highest survival. Preservation of the peri-
Content 1, Sideline Management of risk of oral trauma include basket- odontal ligament cells is vital for a
Ocular Injuries, http://links.lww.com/ ball, football, hockey, martial arts, successful outcome of dental trauma.21
JAAOS/A184). and boxing. Compared with football The immediate reimplantation of a
More than 90% of sports-related athletes, intercollegiate basketball tooth greatly increases its chance of
eye injuries are preventable with athletes are five times more likely to survival. If a tooth cannot be re-
protective eyewear.15 However, few sustain dental trauma. Mouth guard implanted within 5 minutes of
regulations mandate its use. In one protection has decreased dental avulsion, a storage medium should be
survey, as few as 15% of children trauma in sports such as football.19 used. Hanks’ Balanced Salt Solution
February 15, 2019, Vol 27, No 4 e149
Table 1
Sideline Management of Dental Injuries
Injurya Definition Sideline Management Return to Play
Infraction An incomplete crack of the outer tooth Monitor. As tolerated

structure.
Crown fracture, A small fracture of the tooth which does Ensure fracture has not displaced into As tolerated
uncomplicated not involve the pulp. No blood will lips, gingiva, etc; if so, remove
appear at the fracture site. fragment digitally. Refer to dentist at
earliest convenience.
Crown fracture, Fracture of the tooth which involves the Ensure fragment has not displaced into No
complicated pulp. lips or gingiva; if so, remove fragment
digitally.
Crown root Fracture occurring in dentin, enamel, Do not attempt treatment. No
fracture and cementum. Can only be diagnosed
radiographically. Top portion of the
tooth may be mobile or slightly
displaced.
Root fracture Dentin and cementum fracture involving If permanent tooth, attempt to reposition No
the pulp. in correct anatomic position.
Lateral luxation Tooth is displaced laterally. Periodontal Primary: do not attempt to reposition. No
ligament and alveolar bone are
damaged.
— Permanent: reposition with digital force —
to correct anatomic position.
Intrusion Apical displacement; tooth appears Do not attempt to reposition. No
short.
Extrusion Tooth partially displaced from socket in Primary: if displacement is ,3 mm, No
axial direction. Periodontal ligament reposition in correct anatomic position.
has sustained tear.
— Permanent: reposition immediately to —
correct anatomic position.
Avulsion Tooth is completely displaced from Primary tooth: do not reimplant; No
mouth. Periodontal ligament is reimplantation may cause damage to
severed. successional tooth.
— Permanent tooth: pick up by the crown of —
the tooth, rinse for 10 sec, and
reimplant immediately. If unable to
reimplant, store in Hanks’ Balanced
Salt Solution, milk, saline, or saliva. If
no other medium is available, store in
water.
a
All injuries require immediate referral to a dentist unless otherwise indicated.
is a cell and tissue culture solution available, water or saliva can be when teeth are placed back in socket
that is considered the best choice in used, but these choices have the within the designated amount of
this scenario.22 Whole milk has a poorest prognosis for tooth survival. time, pulpal considerations should
similar pH and physiologic osmo- If saliva or water is used, it is always be assessed.23
lality as the mouth and is often imperative that the tooth be re-
available if the injury is sustained implanted within 20 minutes.20 If the
in a home environment.23 Saline is tooth is dry for .20 minutes, the Respiratory/Pulmonary
frequently available as a trans- likelihood of ankylosis is much Acute respiratory disorders are
portation medium; however, it lacks higher. If the time extends beyond some of the most common non-
many essential ions and glucose, 60 minutes, the chance of saving the musculoskeletal issues in athletes.
which are necessary for cell sur- tooth is small because of death of the Among these disorders, the most
vival.22 If none of these mediums are periodontal ligament cells. Even common are upper respiratory
Figure 3 Figure 4
Illustration depicting anatomic

locations for needle thoracostomy
decompression. The letter A
indicates the second intercostal
space at the midclavicular line (ICS2-
MCL). Note that this location is below
the first palpable rib; the first rib is
beneath the clavicle and not
generally palpable. The letter B
indicates the fourth and fifth
intercostal spaces at the midaxillary
line (ICS4/5-MAL). The letter C
indicates the fourth and fifth intercostal
spaces at the anterior axillary line
(ICS4/5-AAL). A 14- or 16-gauge 5-cm
angiocatheter should be inserted at
any of these locations. (Reproduced
with permission from the Mayo
Foundation for Medical Education and
Flowchart for the sideline management of acute EIA and exercise-induced
Research, Rochester, MN.)
bronchoconstriction (EIB). EIA = exercise-induced asthma, MDI = metered-dose
inhaler, PEF = peak expiratory flow rate27
infection, asthma/exercise-induced
bronchospasm (EIB), and vocal cord pressure gradients can develop Preventive therapy for asthma and
dysfunction.24 Less common but life- during scuba diving and Valsalva EIB can help avoid the need for urgent
threatening entities include blunt maneuvers while weight lifting, re- sideline management (Figure 4). The
lung trauma (eg, pneumothorax, sulting in barotrauma.25 The rec- most commonly used preventive
hemothorax, pneumomediastinum, ognition and management of medication is an inhaled short-acting
pulmonary contusion) and anaphy- emergent respiratory conditions is b2-agonist, such as an albuterol
laxis. Anaphylaxis is a rapid onset vital as delayed or mismanaged metered-dose inhaler, two puffs
disorder involving the skin and/or treatment could have disastrous 15 minutes before exercise. Long-
mucosa. Symptoms may involve consequences. Figure 3 depicts acting b2-agonists are ineffective in
itching, flushing, respiratory com- possible locations for needle thor- treating patients with exercise-
promise (eg, dyspnea, wheeze/ acostomy or decompression of induced asthma or EIB.27 Mast cell
bronchospasm, stridor, hypoxemia) a pneumothorax. Appendix 2 con- stabilizers, such as cromolyn sodium
and/or hypotension, or signs of end- tains pulmonary conditions and and nedocromil sodium, can be
organ dysfunction (eg, hypotonia, injuries and their sideline manage- helpful in preventing symptoms;
syncope, incontinence). Blunt lung ment, as well as return-to-play however, they are not as effective as
trauma is rare but has been guidelines24-29 (see Appendix 2, short-acting b2-agonists.24,27 Leu-
described in downhill skiing/ Supplemental Digital Content 2, kotriene antagonists (montelukast
snowboarding, road/mountain bik- Sideline Management of Pulmonary and zafirlukast) can also help pre-
ing, equestrianism, ice hockey, Conditions and Injuries, http:// vent symptoms in athletes with mild-
football, rugby, and soccer. High- links.lww.com/JAAOS/A185). to-moderate asthma but are not
February 15, 2019, Vol 27, No 4 e151
effective in athletes with acute treatment is necessary because de- chest wall recoil between com-
bronchospasm because they are lays, measured in minutes, portend pressions, and a limitation of chest
administered orally.24,27 Induction disastrous outcomes. compression interruptions to ,10
of a relative refractory period of EIB The diagnosis of cardiac arrest can seconds. An algorithm from the 2015
45 to 60 minutes before exertion can be delayed because of its unantici- update is seen in Figure 5.
weaken any airway response during pated occurrence in a healthy athletic In the event of stable tachyar-
actual competition.24 Cool dry air population and confusion with other rhythmias (ie, supraventricular tachy-
exacerbates symptoms and should be causes of nontraumatic collapse, such cardia), vagal maneuvers can slow the
avoided when possible. To combat as exertional heatstroke, heat ex- heart rate. These maneuvers include
unavoidable outside environments, haustion, seizures, and exercise- the Valsalva maneuver, carotid mas-
nasal breathing and the use of a related syncope.31 Myoclonic or sage, rubbing the eyes, ice to the face,
surgical mask or scarf reduce water seizure-like activity may be present and quickly lying down to a supine
loss and warms inspired air.24 in 20% to 30% of athletes with position. Success rates of these tech-
Reduced sodium intake and the use cardiac arrest. Furthermore, agonal niques vary from 19.4% to 54.3%.34
of fish oil, ascorbic acid, and vitamin breathing may be misinterpreted as However, the Valsalva maneuver
D supplementation may have bene- normal, and difficulty in assessing may be unsuccessful with an unco-
fits in reducing EIB, but their effects pulse may further delay the diagnosis operative patient, and carotid mas-
have not been proven.24,30 and treatment. To prevent delayed sage should be used with caution
implementation of an emergency in patients with a suspected carotid
action plan and to decrease the plaque because cerebrovascular ac-
Cardiac chances of catastrophic outcomes, cidents have been reported.34
Cardiac conditions are rare but cardiac arrest should be presumed in Although prevention and prepara-
potentially fatal athletic event occur- any athlete who collapses and is tion are key to minimizing and suc-
rences. Sudden cardiac death occurs unresponsive. cessfully managing cardiac arrest,
in approximately 1 in 100,000 to Although many conditions can they are beyond the scope of this
200,000 high school athletes and in 1 result in cardiac arrest, most are review. The Interassociation Con-
in 65,000 college athletes annually.31 managed similarly with basic life sensus Statement on Cardiovascular
The most common causes of cardiac support techniques/cardiopulmonary Care of College Student-Athletes
death in athletes aged ,35 years are resuscitation (CPR) and with the use should be consulted for more infor-
hypertrophic cardiomyopathy (26%), of an automated external defibrilla- mation on this topic.35
commotio cordis (20%), and anom- tor. A victim’s chances of survival
alous coronary arteries (14%).31,32 In from cardiac arrest increase two- or
athletes aged .35 years, most deaths threefold with CPR.31 However, for Abdominal Injuries
are the result of acquired athero- every minute that defibrillation is Severe abdominal sports-related in-
sclerotic coronary artery disease.32 delayed after cardiac arrest occurs, juries are rare; however, sports par-
Many other conditions, congenital survival decreases by approximately ticipation results in an estimated 10%
or acquired, may predispose athletes 10%. This decline in survival is of all abdominal injuries. The activi-
to or result in arrhythmias or cardiac mitigated to 3% to 4% per minute ties most often implicated in abdomi-
arrest.32 Congenital conditions in- with effective CPR.31 Guidelines nal trauma are collision sports (eg,
clude hypertrophic cardiomyopathy, for CPR were updated by the Amer- hockey, football, soccer) and sports
aortopathy (eg, Marfan syndrome), ican Heart Association in 2015.33 with high velocity/energy potential
anomalies of the coronary arteries These updates include encouraging (eg, cycling, skiing/snowboarding,
and valves, and arrhythmias (eg healthcare professionals to simulta- surfing). Abdominal trauma from
long QT and Wolff-Parkinson-White neously check for breathing and a ball impact (in baseball or lacrosse)
syndromes). Acquired conditions in- pulse to more quickly initiate chest has also been reported. Injuries can
clude atherosclerotic coronary artery compressions and increasing the affect the abdominal contents as well
disease, Kawasaki disease, myocar- emphasis on the quality of the CPR as the abdominal wall and diaphragm.
ditis, commotion cordis, drug- being performed. Updated perfor- Life-threatening scenarios can de-
induced long QT syndrome, and mance targets for CPR include a velop and result in abdominal organ
environmental factors (eg, hypo- compression rate of 100 to 120 compromise and must be identified
thermia, hyperthermia, ingested compressions per minute, compres- rapidly by the team physician.
substances.) Prompt recognition is sion depth of 2 to 2.4 inches (5 to Many abdominal injuries result in
not always easy, but immediate 6 cm) for adults, allowance of full similar signs and symptoms. These
signs and symptoms include persis- Figure 5

tent abdominal pain, nausea and
vomiting, guarding, rebound tender-
ness, distension, and loss of normal
bowel sounds. Referred pain to the
shoulder may occur from diaphrag-
matic irritation. If a delay in presen-
tation occurs or substantial time has
elapsed from the time of injury, signs
of chemical or bacterial peritonitis,
including fever, may be present with
hollow organ (gastrointestinal tract)
injury.
Sideline management should be
focused on the diagnosis of severe or
life-threatening abdominal trauma
and prompt transportation to an
emergency department. Identifying
specific organ involvement is sec-
ondary to recognizing an acute
abdominal injury and often requires
blood work, advanced imaging, and/or
surgery. After a working diagnosis is
made, a decision can be made regarding
return to play, removal from competi-
tion, or transfer to an emergency
department. Specifics of each injury can
be found in Appendix 336,37 (see Sup-
plemental Digital Content 3, Sideline
Management of Abdominal and
Genitourinary Injuries, http://links.
lww.com/JAAOS/A186).
Genitourinary Injuries
Sports participation is the most
common cause of genitourinary in-
juries. These injuries include those
affecting the kidneys, ureters, blad-
der, urethra, and external genitalia.
According to data from the National Adult cardiac arrest algorithm based on the American Heart Association’s 2015
Electronic Injury Surveillance Sys- updated guidelines.33 AED = automated external defibrillator, ALS = advanced
tem, an estimated 137,525 patients life support, CPR = cardiopulmonary resuscitation
with sports-related genitourinary in-
juries were seen in emergency de- tion in football, baseball or softball, use may be beneficial in high-risk
partments between 2002 and 2010.38 basketball, and soccer was also sports (eg, football, hockey, soccer,
The pediatric population accounted common. The external genitalia ac- baseball, softball). Sperm banking can
for nearly 75% of these injuries. As counted for 60% of the injuries. be considered for adults who have
age increased, the incidence of geni- No standards for protective genito- only one viable testicle.39 Appendix 3
tourinary injury decreased. Among urinary equipment have been estab- (see Supplemental Digital Content 1,
adult patients, .80% were men. lished, and no data are available to http://links.lww.com/JAAOS/A186)
Approximately one-third of the in- support use of an athletic cup. How- presents genitourinary injuries and
juries involved a bicycle. Participa- ever, common sense suggests that cup their sideline management.39-41
February 15, 2019, Vol 27, No 4 e153
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Summary for sports-related injuries. Ann Emerg Med CA: Epidemiology of facial injuries in sport.
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28. Sicherer SH, Simons FE; Section on Allergy
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12. Goldstein MH, Wee D: Sports injuries: An
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Schneider EB: Epidemiology of sports-
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5-10, 12-28, 30-32, 34, and 36-41 JAMA Ophthalmol 2016;134:1382-1390. sideline and event preparation for
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33, and 35 are level V reports or catastrophes. Emerg Med Clin North Am 170-176.
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32. Wasfy MM, Hutter AM, Weiner RB:
15. Cass SP: Ocular injuries in sports. Curr Sudden cardiac death in athletes. Methodist
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those published within the past 5 16. Aerni GA: Blunt visual trauma. Clin Sports 33. American Heart Association: Highlights of
years. Med 2013;32:289-301. the 2015 American Heart Association
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February 15, 2019, Vol 27, No 4 e155
Research Article
Optimal Management of Tethered

Surgical Drains: A Cadaver Study
Abstract
Joseph L. Laratta, MD Background: Tethered drains are a complication of drain usage and may
Joseph M. Lombardi, MD result in unintentional retained broken drains, as well as anxiety and uncertainty
for the surgeon and the patient. To date, no study has examined the optimal
Jamal N. Shillingford, MD approach for management and removal of tethered drains.
Matthew J. Grosso, MD Methods: The study design sought to identify suture size, mechanism of
drain fixation (through versus around), points of constriction (one versus
Ronald A. Lehman, MD
multiple) and the efficacy of weighted traction as potential sources of

Lawrence G. Lenke, MD tethered drains by means of four study arms. (1) Arm one compared drains
William N. Levine, MD sutured through the tubing versus a tight closure of the surrounding fascia,
which were then subjected to weighted suspension. (2) Arm two compared
K. Daniel Riew, MD
drains sutured into the fascia using eight each of 4–0, 2–0 and 0 vicryl and
then subject to manual traction. (3) Arm three compared drains sutured to
the fascia through the tubing versus local tissue incarceration followed by
manual traction. (4) Lastly, group four examined drains tethered at two
distinct points after which they were subject to manual traction.
Results: Our results showed a 25% drain retention rate when manual
traction was applied to 0 vicryl and 2–0 vicryl suture. In contrast, there were
no instances of drain retention when suture was closed with 4–0 vicryl.
When evaluating for multiple points of fixation, drains tethered in two
locations were retained in 87.5% of trials versus drains with a single tether
point (25%) representing a statistical significance (P = 0.041). There was
no difference in rates of drain retention when pierced through the tubing
versus incarcerated in local fascia. Only one of the 16 drains was
successfully removed by weighted suspension (8.3%). Attempts at
manual traction following weighted suspension resulted in a 50% drain
retention rate which was higher than the rates of immediate manual
From Norton Leatherman Spine traction (18.8%).
Center, University of Louisville
Medical Center, Louisville, KY Conclusion: Our results found that manual traction is a reasonable first line
(Dr. Laratta, Dr. Shillingford), the approach to address drains tethered by all methods and suture sizes. The use
Department of Orthopaedic Surgery, of weighted traction for the management of tethered drains is less effective than
The Daniel and Jane Och Spine manual traction and may result in more retained drain fragments.
Hospital at New York–Presbyterian
(Dr. Lombardi, Dr. Lenke, Dr. Riew, Level of Evidence: Level IV.
Dr. Lehman), and Department of
Orthopaedic Surgery New York–
Presbyterian/Columbia University
Medical Center, New York, NY
(Dr. Grosso, Dr. Levine).
Correspondence to Dr. Lombardi:

W ound drainage systems are used
in orthopaedic surgery to allow
for removal of blood and other fluids
epidural hematomas in the immediate
postoperative period.2
Tethered drains are a complication
jml2285@columbia.edu from the surgical wounds in the of drain usage and may result in unin-
J Am Acad Orthop Surg 2019;27: postoperative period.1 The common tentional retained broken drains, as
129-135 goal with the usage of closed wound well as anxiety and uncertainty for the
DOI: 10.5435/JAAOS-D-17-00122 drains is to reduce the rate of hema- surgeon and the patient.3-7 The pri-
tomas and surgical site infections. mary culprit for a retained drain is
Academy of Orthopaedic Surgeons. Drains are of particular importance inadvertent suture fixation that occurs
in spine surgery because of the risk of during closure of the wound. Often,
February 15, 2019, Vol 27, No 4 129
Tethered Drain Management
the suture fixation is not identified Therefore, the primary purpose of was incised longitudinally with a
until drain removal occurs in the the current study was to determine 10-blade scalpel. Subperiosteal dissec-
postoperative period. Manual removal whether an optimal method exists for tion was performed with electro-
of a tethered drain may result in removing a tethered drain through cautery to the medial aspect of the facet
drain breakage and retention of a weighted traction. In addition, we joints. Medium polyvinyl chloride
drain fragment within the surgical sought to determine whether the suture (PVC) closed wound suction drains
site. The surgeon and patient must size, method of tethering, and number with a 1/8-inch diameter (10 French;
evaluate the need for drain retrieval of tether points affect the ability to 3.2 mm) and a 12.5-inch (31.7 cm) hole
and the associated risks of a second successfully remove a tethered drain. pattern (Bard Medical) were placed
procedure versus drain retention and below the fascia in a standard deep
the risks of possible adverse reactions drain fashion. Drain tips were colored
with a retained foreign body.3-5 Methods with a black marker to allow for iden-
Although precautions may minimize tification (Figure 1). The drain was
the risk of tethered and subsequently Patients tethered to the fascia in one of three
retained drains, cases still occur and A single cadaver was donated from manners: suturing through the existing
may be underreported in the literature Fusion Solutions. The identity of the drain holes, piercing the drain tubing,
because of the concern of legal im- cadaver was protected, and the Bio- and suturing around or incarcerating
plications.6,8 When a drain is tethered, Skills Laboratory policy for handling the drain (Figure 2). The remainder of
the goal is to remove the drain in its donor specimens was strictly followed. the fascia was closed in an interrupted
entirety without any retained broken The specimen was an 80-year-old male figure-of-8 suture technique. Five
fragment. There are a few small case cadaver. The specimen was un- knots were used to secure the drains
series that describe anecdotal methods embalmed and freshly frozen to pre- to the fascia in an alternating square
for tethered drain removal, including a serve tissue quality and consistency. knot fashion. The subcutaneous tis-
technical report describing applying The current experiment was the first sue and skin were closed in layers.
constant traction to the drain with and only freeze-thaw cycle for the To minimize variability, a single sur-
weights until successful removal.9-12 specimen, preventing any further tis- geon (J.L.L.) performed all suturing,
If successful, weighted traction may sue degradation. and a second surgeon (J.M.L.) per-
allow for a safe and cost-effective formed all drain removal. The manual
technique for preventing an unto- drain removal technique was stan-
ward complication. Unfortunately, no Preparation of Specimens dardized. After the release of suction
studies exist that rigorously examine The specimen was placed prone on a from the drainage canisters, a sustained
the management of tethered drains standard operating room table. A pulling force was applied to the drain
and systematically evaluate the effi- midline incision was made from T12 to tubing. If the drain was still unable to
cacy of weighted traction, which the sacrum based on palpable ana- be removed after 5 seconds, a quick
may be applicable to all surgical tomic landmarks. Subcutaneous tissue jerk was applied to the drain tubing.
subspecialties that use closed wound was sharply dissected until the level of Drain removal was considered suc-
drainage systems. the thoracolumbar fascia. The fascia cessful if the drain was removed in its
Dr. Grosso or an immediate family member has received research or institutional support from Stryker. Dr. Lehman or an immediate family
member is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy Synthes, Medtronic, and Stryker; serves
as a paid consultant to Medtronic; and serves as a board member, owner, officer, or committee member of AOSpine, the Cervical Spine
Research Society, the North American Spine Society, and the Scoliosis Research Society. Dr. Lenke or an immediate family member has
received royalties from Medtronic; serves as a paid consultant to DePuy Synthes, K2M, and Medtronic; has received research or institutional
support from AOSpine, DePuy Synthes, EOS, the Scoliosis Research Society, and the Setting Scoliosis Straight Foundation; has received
nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid
travel) from the Evans Family Donation and the Fox Family Foundation; and serves as a board member, owner, officer, or committee
member of Global Spine Outreach and the Orthopaedic Research and Education Foundation. Dr. Levine or an immediate family member
serves as an unpaid consultant to Zimmer Biomet and has received royalties from Zimmer Biomet and Medtronic. Dr. Riew or an immediate
family member is a member of a speakers’ bureau or has made paid presentations on behalf of Zimmer Biomet, Medtronic, and Zeiss; serves
as a paid consultant to Zimmer Biomet and Medtronic; has stock or stock options held in Amedica, Benvenue, Expanding Orthopaedics,
PSD, NexGen Spine, Osprey, Paradigm Spine, Spinal Kinetics, Spineology, and Vertiflex; has received research or institutional support
from AOSpine; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-
related funding (such as paid travel) from Advanced Medical, AOSpine, and Zeiss; and serves as a board member, owner, officer, or
committee member of AOSpine. None of the following authors or any immediate family member has received anything of value from or has
stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Laratta,
Dr. Lombardi, and Dr. Shillingford.
Joseph L. Laratta, MD, et al
entirety without any retained broken layered fashion, the drains were man- Figure 1
fragment in the wound. ually removed. Wound re-exploration
and analysis proceeded in a similar
Suture Size fashion as previously described.
To evaluate the effect of suture caliber

on successful drain removal, 24 closed Weighted Traction
wound suction drains were sutured to To systematically examine the efficacy
the fascia through existing tube holes of weighted traction on tethered
in the following manner: 8 with 4-0 drains, 12 closed wound suction drains
vicryl, 8 with 2-0 vicryl, and 8 with were tethered to the fascia with a
0 vicryl sutures. After closure of the 0 vicryl suture. Six drains were tethered
remainder of the wound in a layered to the fascia through existing holes in
fashion, the drains were manually the tube, and six drains were incarcer-
removed. The wound was reexplored ated around the fascia with a suture.
for evaluation of drain retention and After closure of the remainder of the
failure point (drain versus suture). wound in a layered fashion, 2 L of
Drain failure was defined as a breakage lactated Ringer intravenous solution
in the drain tube with an intact suture. (2 kg) was hung from each of the drain
Drain failure includes both partial tubes for 6 hours (Figure 4). Six hours
Photograph showing the distal ends
(Figure 3) and complete drain break- was determined based on the feasi- of drains colored black to aid in
age. Suture failure was defined as bility of this technique in clinical intrawound identification.
either breakage in the suture itself or practice. After 6 hours, all failures that
sufficient loosening in the suture or remained tethered to the specimen groups (Table 1). In the 4-0 vicryl
knot to allow for drain removal with- underwent manual drain removal. The group, no drain retentions were
out breakage. delayed manual removal attempted to noted (P = 0.301). In the 0 vicryl and
assess the effect of removal of creep 2-0 groups, the drain failed in 87.5%
Double Tether from the system by the weighted of trials, whereas the suture failed in
traction. Wound re-exploration and 12.5%. The 4-0 vicryl group had
To evaluate the effect of an additional analysis proceeded in a similar fashion
point of fixation on successful drain significantly more suture failures
as previously described. (62.5%) than drain failures (37.5%)
removal, eight closed wound suction
drains were sutured to the fascia compared with the 2-0 and 0 vicryl
through the tube holes with a 0 vicryl Statistical Analysis groups (P = 0.040).
suture. At a more distal location on Unadjusted univariate analysis was When evaluating the effect of an
the tube, the fascia was incarcerated performed to determine the mean additional point of fixation on suc-
around the drain with a 0 vicryl differences between measurements cessful drain removal, drains tethered
suture. After closure of the remainder using the chi-squared or Fisher exact in two locations were retained in
of the wound in a layered fashion, test for categoric variables. Findings 87.5% of trials (Table 2). Drains teth-
the drains were manually removed. were considered statistically signifi- ered in a single location were retained
Wound re-exploration and analysis cant when the P value was ,0.05. significantly less often (25%; P =
proceeded in a similar fashion as Analysis was conducted using IBM 0.041). No difference was noted in the
previously described. SPSS Statistics Version 24. rate of drain failure in the double
tether versus single tether group
(87.5% versus 100%; P = 1.000).
Tethering Method Results In the trials evaluating the method
To evaluate the method of suture of tethering drains to the fascia,
tethering on successful drain removal, In the trials evaluating the effect of the drains were either pierced through
16 closed wound suction drains were suture size, three different sizes were the drain tubing or sutured around
tethered to the fascia with a 0 vicryl threaded through the existing holes in the drain tubing (Table 3). The drain
suture. Eight were pierced through the the drain tubing tethering it to the failed significantly more often in the
drain tubing, and eight were sutured fascia. There was a 25% drain re- pierced group than in the sutured
around the drain tubing. After closure tention rate with standard manual around group (87.5% versus 25%;
of the remainder of the wound in a removal in the 0 vicryl and 2-0 vicryl P = 0.041). No difference was noted
February 15, 2019, Vol 27, No 4 131
Figure 2
Photographs showing methods of drain tethering: suturing around the drain (A), suturing through existing drain holes (B),
and piercing the drain (C).
Figure 3 Figure 4 0.001). At the end of the weighted

traction period, the 11 remaining
drains were manually removed. Six
drains (50%) were successfully re-
moved, and five drains (41.7%) were
retained. Overall, there were more
retained drains with manual removal
after weighted traction compared
with manual removal, although this
was not statistically significant (50%
versus 18.8%; P = 0.114).
Conclusion
The use of closed suction drainage is
associated with presumed risks includ-
ing retrograde infection, increased
postoperative bleeding, and the need
Photograph showing an example of Photograph showing 2 L of lactated for transfusion.13 Inadvertent sutur-
drain failure where manual traction Ringer intravenous solution applied ing of a drain during wound closure is
caused the suture to result in drain to drain tubing as constant traction an underreported but not uncommon
breakage. for 6 hours. complication in orthopaedic surgery.
Retained broken drain fragments
in the rate of drain retention in either (8.3%) was successfully removed after after removal pose a treatment chal-
the pierced group or sutured around 2 hours and 17 minutes by drain fail- lenge for the surgeon often resulting
group (0% versus 12.5%; P = 1.000). ure. By the end of the study period in repeat trips to the operating room
The effect of weighted traction on (6 hours), 11 drains (91.7%) were for retrieval, increasing morbidity to
successful drain removal was evaluated unsuccessfully removed and remained the patient, and incurring additional
in two situations: when the drain was tethered to the fascia (Table 4). The costs to the healthcare system. To
tethered through the existing drain weighted traction method was less date, only a few studies have exam-
holes and when the drain is incar- successful at removing drains com- ined the incidence of retained drains
cerated around by a suture. One drain pared with manual removal (P # after posterior spinal surgery.
Table 1
Suture Size Trials
Outcome 0 Suture (n = 8) 2-0 Suture (n = 8) 4-0 Suture (n = 8) P value
Suture failure 1 (12.5) 1 (12.5) 5 (62.5) 0.040

Drain failure 7 (87.5) 7 (87.5) 3 (37.5) —
Retention 2 (25.0) 2 (25.0) 0 (0.0) 0.301
Successful removal 6 (75.0) 6 (75.0) 8 (100.0) 0.301
Stawicki et al6 reported 0.03% to Table 2

0.1% incidence of retained surgical
Double Tether Trials
foreign bodies in abdominal surgery
and presented practical measures, Outcome Tethered ·1 (n = 8) Tethered ·2 (n = 8) P value
including an emphasis on education Suture failure 1 (12.5) 0 (0.0) 1.000
in early recognition, prevention, and
Drain failure 7 (87.5) 8 (100.0) —
focus on team-oriented training strat-
Retention 2 (25.0) 7 (87.5) 0.041
egies, to avoid this complication.
Successful removal 6 (75.0) 1 (12.5) 0.041
Other authors have reported the nat-
ural history of retained drains in ret-
rospective long-term studies.3 To our
knowledge, this is the first study of its Table 3
kind to evaluate the different methods
Tethering Method Trials
of removing retained spinal drains,
including the previously anecdotal Outcome Incarcerated (n = 8) Pierced (n = 8) P value
management of tethered drains with Suture failure 6 (75.0) 1 (12.5) 0.041
constant weighted traction. We eval- Drain failure 2 (25.0) 7 (87.5) —
uated the effect of suture type, teth-
Retention 1 (12.5) 0 (0.0) 1.000
ering method, and number of tether
Successful removal 7 (87.5) 8 (100.0) 1.000
locations.
The current study demonstrates that
the suture size and number of tether
points are important in the clinical Table 4
management of tethered drains. As
Weighted Traction Trials
expected, drains tethered in a single
location were retained significantly Manual Removal Weighted Traction
Outcome (%) (n = 16) (%) (n = 12) P value
less often than drains tethered in two
locations (P = 0.041). In terms of the Suture failure 7 (43.8) 4 (33.3) 0.705
suture size, no instances of drain Drain failure 9 (56.3) 8 (66.7) —
retention were found with a 4-0 vicryl Retention 3 (18.8) 11 (91.7) ,0.001
closure. When the 4-0 suture failed Successful removal 13 (81.3) 1 (8.3) ,0.001
(62.5%), the drain was delivered
completely intact, representing a sig-
nificant difference from the 2-0 and
0 vicryl trials, which had suture fail- and most effective when removing tion is a reasonable first-line approach
ure rates of only 12.5%, respectively drains tethered by a suture of smaller to drains tethered by 2-0 and 0 vicryl
(P = 0.040). In addition, the drain caliber. Although the larger suture sutures.
was damaged but not retained in only test groups had lower instances of Incarceration of drains in the fascial
37.5% of trials when using 4-0 vicryl suture failure (12.5%), overall drain closure and direct piercing of the
compared with 87.5% of trials in retention rates continued to remain drain tubing or through existing drain
both the 2-0 and 0 groups. The data low at 25%. We conclude from our holes are notable causes of tethering in
support that manual traction is safest data that an attempt at manual trac- the clinical setting. Not surprisingly,
February 15, 2019, Vol 27, No 4 133
Figure 5 0.001). Attempts at manual trac- manual removal. Last, this study used
tion on the drains that remained fresh frozen cadavers with a single
tethered after weighted traction freeze-thaw cycle. Despite similar
resulted in 50% drain retention properties, cadaver tissue may respond
rates. It is therefore our current to mechanical stress differently than
recommendation to avoid hanging live patient tissue.
weights from tethered drains because The current study is not without
it does not improve successful drain certain limitations. In this series,
removal and may in fact lead to only a single type of drain was eval-
increased overall rates of drain uated, which may have different
retention. mechanical properties than those
We hypothesize that this effect is due used in other clinical settings. Because
Photograph showing exposure of the to the smaller modulus of elasticity of the medium PVC closed wound suc-
fascial layer in a patient undergoing PVC tubing versus braided suture. tion drain, colloquially termed a
constant weighted traction. The
fascial deformity evident with Because the drain tubing and braided medium Hemovac drain, is the most
weighted traction may lead to suture are in series, the two entities common drain type used in ortho-
unnecessary patient discomfort and experience similar stress; however, paedic surgery, it was chosen for this
impaired wound healing in the acute given the decreased modulus of elas- study to provide the maximum utility
postoperative period.
ticity for PVC, the drain experiences for orthopaedic surgeons. Similarly,
greater strain than the suture. The although the use of vicryl suture in an
drains that were pierced by suture constant weighted traction and sub- interrupted figure-of-8 pattern is
broke in most of the instances sequent strain across the PVC drain likely considered the benchmark fas-
(87.5%), whereas the suture failed in may lead to plastic deformation and cial closure, different suture material
75% of tissue-incarcerated drains. decreased mechanical properties of or patterns of closure may be used for
Suture failure in this setting was not the drain at a greater magnitude than fascial closure at other institutions,
due to suture breakage observed in the braided suture, which is designed and the results of this study may not
the 4-0 trials but due to sufficient to withstand normal physiologic strain be directly applicable.
loosening of the suture to allow for of the human body. It is evident The three drain types commonly
successful drain removal. Regardless, that weighted traction weakens the used in orthopaedic procedures include
there remained no statistically sig- mechanical properties of the tubing Hemovac, Penrose, and Jackson-Pratt
nificant difference in drain reten- accounting for the high rates of drain drains. Each drain type is produced by
tion rates whether the drain tubing breakage and retention. Moreover, different manufacturers, and similarly,
was pierced, sutured through exist- from a patient perspective, the hang- different manufacturers produce mul-
ing drain holes, or incarcerated ing of weights from a drain site is tiple drain types. In an evaluation of a
(P = 1.000). likely uncomfortable and may serve single company’s Hemovac, Penrose,
In the past, anecdotal trials have as an additional source of stress and and Jackson-Pratt drains, there were
advocated for the hanging of weight impaired wound healing in the imme- more than 50 different and unique
from drains that were tethered in situ. diate postoperative period (Figure 5). tubing options, varying in length,
These teachings often call for hanging Our study protocol attempted to shape, thickness, composition, chan-
2 to 5 lbs of weight from the drain limit variation in the surgical technique neling, and perforation pattern.14
tubing for a period of 2 to 3 hours. Per by having a single investigator surgi- Thus, the results of the current study
report, this design helped to facilitate cally tether the drains and another must be evaluated in the context of
suture failure and subsequent suc- investigator perform all manual trac- medium Hemovac drains and may
cessful drain removal (personal tion maneuvers. Even still, it is impos- not be applicable for other drain
communication with Joseph M. sible to quantify and standardize the types or different suture closure
Lombardi, MD, September 5, degree to which a drain was tethered or methods (running/continuous and
2018). The current study does not the force used during manual removal. barbed suture closure). For true
support this practice. After 6 hours, In addition, the thoracodorsal fascia is generalizability, future studies are
only one drain (8.3%) was suc- among the strongest fascial layers in necessary to evaluate the methods of
cessfully removed by weighted the body. It is quite possible that drains removal within each drain option.
traction alone, which was signifi- tethered in areas of the body with less In conclusion, tethered drains are
cantly inferior to the standard robust fascia may produce different likely a more common complication
manual removal technique (P , results after weighted traction and in orthopaedic surgery than previously
reported.6 Although any tethered after orthopaedic surgery. Cochrane 8. Tammelleo A. Penrose drain left in
Database Syst Rev 2007:CD001825. patient: Continuing tort. Case in point:
drain may result in retained broken Jumper v. Healthone Corp (699 F. Supp.
drain fragments after attempted 2. Mirzai H, Eminoglu M, Orguc S: Are drains 220—SD (1988)). Regan Rep Nurs L
useful for lumbar disc surgery? A 1989;29:4.
removal, the phenomenon is observed prospective, randomized clinical study. J
at a higher rate when the drain is Spinal Disord Tech 2006;19:171-177. 9. Tong A, Orpen N: Removal of surgical
tethered in more than one location. drains. Ann R Coll Surg Engl 2007;89:
3. Zeide MS, Robbins H: Retained wound 73-81.
Regardless, manual traction is a rea- suction-drain fragment: Report of 7 cases.
sonable first-line approach to address Bull Hosp Joint Dis 1975;36:163-169. 10. Jurim O, Verstandig A, Katz E, Kluger Y:
Non-operative removal of a retained
tethered drains. In a medium Hemovac 4. Gausden EB, Sama AA, Taher F, surgical drain. Eur J Plast Surg 1991;
drain cadaver model, the use of Pumberger M, Cammisa FP, Hughes AP: 14:42.
Long-term sequelae of patients with
weighted traction for the manage- retained drains in spine surgery. J Spinal 11. Leonovicz PF, Uehling DT: Removal of
ment of tethered drains is less effective Disord Tech 2015;28:37-39. retained Penrose drain under fluoroscopic
guidance. Urology 1999;53:1221.
than manual traction and may result 5. Liu KS, Huang KC, Wong CH: A neglected
in more retained drain fragments. retained penrose drain mimicking an 12. Namyslowski J, Halin NJ, Greenfield AJ:
amputation stump neuroma. J Trauma Percutaneous retrieval of a retained
2007;62:1051-1052. Jackson-Pratt drain fragment. Cardiovasc
Intervent Radiol 1996;19:446-448.
6. Stawicki SP, Evans DC, Cipolla J, et al:
References Retained surgical foreign bodies: A 13. Chen ZY, Gao Y, Chen W, Li X, Zhang YZ: Is
comprehensive review of risks and preventive wound drainage necessary in hip arthroplasty?
strategies. Scand J Surg 2009;98:8-17. A meta-analysis of randomized controlled
trials. Eur J Orthop Surg Traumatol 2014;24:
those published within the past 5 years. 7. Gheorghiu D, Cowan C, Teanby D: 939-946.
Retained surgical drain after total knee
1. Parker MJ, Livingstone V, Clifton R, McKee arthroplasty: An eight-year follow-up. JBJS 14. Wound Drainage Products [Brochure].
A: Closed suction surgical wound drainage Case Connect 2015;5:e63. Waukegan, IL, Cardinal Health, 2016.
February 15, 2019, Vol 27, No 4 135
Research Article
Hemolysis Is a Diagnostic Adjuvant

for Propionibacterium acnes
Orthopaedic Shoulder Infections
Abstract
K. Keely Boyle, MD Introduction: The purpose of this study was to further evaluate the
Scott R. Nodzo, MD pathogenicity of hemolytic and nonhemolytic phenotypes of
Propionibacterium acnes (P acnes) isolates from shoulders of
Travis E. Wright, BA
orthopaedic patients.
John K. Crane, MD, PhD Methods: Thirty-one patient records were reviewed, which had a
Thomas R. Duquin, MD positive P acnes shoulder culture from joint aspiration fluid and/or
intraoperative tissues for demographics, clinical course, culture, and
laboratory data. Patients were categorized as definite infection,
probable infection, or probable contaminant. Antibiotic resistance
patterns and hemolysis characteristics were subsequently analyzed.
Results: Hemolysis demonstrated 100% specificity with a positive
From the Department of Orthopaedics predictive value of 100% and 80% sensitivity with a negative predictive
(Dr. Boyle, Mr. Wright, and value of 73% for determining definite and probable infections.
Dr. Duquin), State University of New
York at Buffalo, the Department of
Hundred percent of the patients in the hemolytic group and only 27%
Microbiology and Immunology of patients in the nonhemolytic group were classified as infected.
(Dr. Crane), State University of New Presenting inflammatory markers were markedly higher in the
York at Buffalo, Buffalo, NY, and the
Division of Adult Reconstruction and
hemolytic group. Clindamycin resistance was found in 31% of the
Joint Replacement, Hospital for hemolytic strains, whereas no antibiotic resistance was observed in
Special Surgery, New York, NY the nonhemolytic group.
(Dr. Nodzo).
Conclusion: Hemolytic strains of P acnes exhibit enhanced
Correspondence to Dr. Boyle: pathogenicity to their host by eliciting a more prominent systemic
kkboyle@buffalo.edu
inflammatory response, increased antibiotic resistance, and a more
Dr. Duquin or an immediate family
challenging clinical course. Hemolysis may serve as a specific
bureau or has made paid marker for assisting in diagnosing true infection with P acnes.
presentations on behalf of Zimmer Level of Evidence: Level III retrospective comparative study.
Zimmer Biomet; and has received
research or institutional support from
Zimmer Biomet. None of the following
authors nor any immediate family
I nfection after orthopaedic shoul-
der procedures is a devastating
complication with notable diagnostic
nostic and treatment algorithms to
optimize successful patient outcomes
after periprosthetic shoulder infection.
value from or has stock or stock and therapeutic challenges. Treat- The accurate diagnosis of infection
ment often requires prolonged intra- and identification of the offending
indirectly to the subject of this article: venous antibiotics and the potential organism(s) continues to be a chal-
Dr. Boyle, Dr. Nodzo, Mr. Wright, and for multiple surgical procedures. lenge. This statement is particularly
Dr. Crane. There has been a rapid increase in the true for Propionibacterium acnes (P
J Am Acad Orthop Surg 2019;27: number of orthopaedic shoulder pro- acnes), which is one of the most
136-144 cedures performed in the United States, common infecting organisms after
DOI: 10.5435/JAAOS-D-17-00394 with total shoulder arthroplasty rates orthopaedic shoulder procedures.4-7
projected to increase by more than The prevalence of P acnes in peri-
Academy of Orthopaedic Surgeons. 150% by the year 2020.1-3 There is a prosthetic shoulder infections has
considerable need for improved diag- been shown to be equal or exceed that
K. Keely Boyle, MD, et al
of other common offending organ- flammatory response, form biofilms demographics, clinical course, preop-
isms.5,8 Diagnosing infection with P on orthopaedic implants, and dem- erative and operative culture data, and
acnes remains a challenge because of onstrate antibiotic resistance.17-19 laboratory data at the time of sus-
the indolent clinical presentation, and Beta-hemolytic activity has been noted pected diagnosis of infection.
unreliable utility of classically used in certain strains of P acnes and may
markers of infection such as serum be directly correlated with the bac- Skin Preparation, Culture
erythrocyte sedimentation rate (ESR) teria’s pathogenicity.20 The cohemo- Collection, and Analysis
and C-reactive protein (CRP).9 Syno- lytic Christie-Atkins-Munch-Peterson
Skin preparation and culture sam-
vial fluid aspirations are less reliable in factor is found in the P acnes genome
pling was surgeon dependent and
diagnosing infection because cell and functions as a toxin to host cells,
occurred before development of our
counts may not be elevated, anaerobic which may be responsible for this
current protocol for revision surgery,
cultures may be negative, and aspira- observed beta-hemolytic activity.19,21
which includes preoperative aspira-
tions of the shoulder may produce Although antibiotic susceptibilities
tion, at least four intraoperative cul-
scant amounts of synovial fluid.10 to P acnes have been well described
tures and intraoperative frozen section
Diagnosing true infection with P acnes in the dermatologic literature, few
to evaluate for acute inflammation
relies largely on intraoperative find- reports have assessed the suscepti-
(see Table, Supplemental Digital Con-
ings and culture results.11-14 In the bilities in upper extremity ortho-
tent 1, http://links.lww.com/JAAOS/
setting of positive intraoperative cul- paedic procedures.22,23
A136). Most patients had multiple
tures, there continues to be contro- The purpose of this study was to
aerobic and anaerobic tissue cultures
versy on distinguishing true infection further evaluate orthopaedic patients
taken; however, some patients had
from contamination. Some patients with and without hemolytic strains
only synovial fluid aspiration cultures
with positive culture results present of P acnes. We hypothesized that
or two tissue cultures, and frozen
with obvious infection, whereas others patients identified with hemolytic
section was performed on a limited
present with no clinical signs of in- strains of P acnes would demonstrate a
basis. Preoperative aspirations were
fection and may be of little or no more prominent systemic inflamma-
performed by an interventional radi-
clinical importance. Gram stain is tory response and greater antibiotic
ologist using fluoroscopic guidance
usually negative for these gram- resistance and exhibit a higher rate of
and standard sterile techniques. No
positive, facultative, anaerobic rods. definite clinical infection than nonhe-
contrast was used for aspirations; the
Cultures need to be held for two to molytic strains of P acnes.
saline used was preservative-free, and
three times longer than normal for
ChloraPrep (Becton, Dickinson and
successful growth and identification
Methods Company) was used for skin prepa-
of the organism. However, a recent
ration. Intraoperative cultures
report demonstrated that culture
Patient Selection included both synovial fluid and
incubation extending beyond 14 days
tissue samples that were harvested
may be associated with an increase in Our institutional microbiology labo-
from multiple sites using sterile
nondiagnostic or contaminated sam- ratory has been collecting all clinical P
instruments. The tissue samples
ple.15 Determining true infection ver- acnes isolates since September 2010.
were included from the following
sus contamination with P acnes is From this collection, 48 patients who
locations: deep capsule or pseuo-
critical to establishing the appropriate had a positive P acnes shoulder culture
docapsule, surface of glenoid and
treatment, including revision surgery from either an aspiration or intra-
humeral components, intramedullary
and proper selection of antibacterial operative culture during revision sur-
tissue, tissue off the glenoid osseous
therapy. gery were identified. Of those 48
surface, and glenoids holes.13 Per
Genomic studies have identified patients, 17 were excluded: 11 super-
standard protocol at our institution,
distinct phylotypes (ie, IA, IB, II, ficial wound cultures, 5 coinfections
all cultures were incubated for up to
and III) of P acnes associated with with Staphylococcus species, and 1
21 days on anaerobic and aerobic
orthopaedic implants, with type IB mislabeled isolate. The remaining 31
mediums, then identified using the
being most commonly isolated from patients with positive P acnes cultures
MicroScan rapid anaerobe identifica-
infected prostheses.16 These phylo- after orthopaedic shoulder procedures
tion method (Siemens Healthcare).
types have varying adaptive viru- were included in the study and
lence properties that may influence included arthroplasty (n = 19) and
pathogenic potential including the nonarthroplasty patients (n = 12). Infection Criteria
ability to degrade and invade host After appropriate IRB approval, The definition of what is infection
cells, produce an enhanced host inpatient records were reviewed for versus contamination is still debated
February 15, 2019, Vol 27, No 4 137
Hemolysis in Propionibacterium acnes shoulder infections
Figure 1 Figure 2
Photograph showing hemolytic strain

77 versus nonhemolytic strain 78 of
Propionibacterium acnes.
Propionibacterium acnes inocula were spread onto Brucella Blood agar plates.
in the shoulder literature. Our group Etest antibiotic strips were then applied to the center of the plates. Minimum
uses a multimodal diagnostic crite- inhibitory concentrations were determined for each strain of P acnes against
routine antibiotics.
rion that is reflective of the current
literature, including subjective and
objective clinical presentation find- (see Table, Supplemental Digital and incubated at 37C for 48 to 96
ings, preoperative laboratory mark- Content 2, http://links.lww.com/ hours under anaerobic conditions
ers of infection, culture results from JAAOS/A137). The postoperative using the GasPak EZ anaerobe pouch
joint synovial fluid aspiration, and course was followed for each patient. system (Becton, Dickinson and Com-
intraoperative tissue and fluid speci- The postoperative course of thera- pany). Hemolysis was analyzed at this
mens.9,12,20,24 Using a constellation peutic antibiotic treatment was com- time and defined as clearance around
of previously described diagnostic pared with previous and current the bacterial colonies greater than
criteria, including the periprosthetic recommended clinical practice guide- 2 mm (Figure 1). Inocula were then
shoulder infection criteria described lines for the management of peri- prepared to a 0.5 McFarland stan-
by Frangiamore et al,13 patients were prosthetic joint infection (PJI).26-28 dard, which is equivalent to an OD600
categorized as having one of the Each patient’s postoperative course of 0.13 using a spectrophotometer.
following based on their preopera- was identified in a binary manner as Using a cross-hatch method, inocula
tive, intraoperative, and postopera- to whether a therapeutic course of were spread onto Brucella Blood agar
tive findings as outlined in Table (see intravenous or highly bioavailable plates. Etest antibiotic strips (Bio-
Supplemental Digital Content 2, oral antibacterial treatment was Mérieux) were then applied to the
http://links.lww.com/JAAOS/A137): completed (see Tables, Supple- center of the plates (Figure 2). Anti-
definite infection, probable infection, mental Digital Content 2, http:// biotics were chosen based on clinical
or probable contaminant.20,25 The links.lww.com/JAAOS/A137 and practice and previous work by our
surgeon or consultants classifying Supplemental Digital Content 3, group and included penicillin G,
patients were masked to the hemo- http://links.lww.com/JAAOS/A138). vancomycin, clindamycin, cipro-
lytic pattern of the bacteria. To floxacin, and cephalothin.22 All
facilitate the analysis of hemolysis plates were subsequently incubated
as a diagnostic tool, the patients Antibiotic Susceptibility and at 37C for 48 to 72 hours under
were further categorized into two Hemolysis anaerobic conditions.20,22 Minimum
groups: (1) infected and (2) not in- Antibiotic susceptibility and presence inhibitory concentration (MIC) was
fected. The infected group included of hemolysis was analyzed on the 31 then determined from the Etest strips
patients who met the criteria for P acnes strains. The isolates were (Figure 3). MICs correlated well
definite infection and probable stored on CryoCare Beads (Key Sci- with results obtained using the agar
infection. However, the noninfected entific) at 270C, grown on Brucella dilution method.15,29,30 Antibiotic
group included patients who met the Blood agar plates (Anaerobe Sys- breakpoints were determined from
criteria for probable contaminant tems) using three-quadrant streaking the Clinical Laboratory Standards
Institute and European Committee on Figure 3

Antimicrobial Susceptibility Testing.31
Statistical Analysis
A post hoc sample size calculation
was performed using a 100% inci-
dence of infection in the hemolytic
group and a 27% incidence of infec-
tion in the nonhemolytic group, re-
sulting in a necessary sample size of
seven patients in each group and P
value of 0.05 and 80% power.
Nonparametric Mann-Whitney U
tests were performed for continuous
data when comparing the hemolytic
group with the nonhemolytic group.
Continuous data are reported as
Image on the left shows Propionibacterium acnes stain 45 that is susceptible to
means with associated SDs and me- Penicillin depicted in the image on your right is the same P acnes strain that is
dians with associated interquartile resistant to clindamycin.
ranges (IQRs). The Fisher exact test
was used to analyze categorical
variables. A P value less than 0.05 tients in the nonhemolytic group (12.5%). In the nonhemolytic group,
was considered statistically signifi- were active tobacco users. No pa- 11 of the 15 patients were categorized
cant. Descriptive statistics were used tients had inflammatory arthritis in as a probable contaminant (73.3%),
to analyze the patients’ demographic either group. No patients in either three were categorized as definite in-
data and to represent the patients group were markedly immunocom- fections (20%), and one patient was
classified into the diagnostic criteria promised. The mean Charlson Co- categorized as a probable infection
categories of definite infection, morbidity Index in the hemolytic and (6.7%).
probable infection, and probable nonhemolytic groups was 1.56 6
contaminant. The sensitivity, speci- 1.67 and 1.50 6 1.15, respectively Demographics
ficity, positive predictive value (P = 0.90).
The hemolytic group comprised 13
(PPV), and negative predictive value males and 3 females, and the nonhe-
were calculated for the ability of the Predictive Values of molytic group comprised 7 males and
hemolytic phenotype to predict true Hemolysis 8 females (P = 0.04) with a similar
infection.32,33 mean follow-up from the initial revi-
Hemolytic strains of P acnes were
sion surgery (40.0 6 9.7 versus
identified in 16/31 (52%) patients,
41.0 6 10.3 months, respectively; P =
Results and nonhemolytic strains in the re-
0.91). Mean age was 60.3 6 12.2 and
maining 15/31 (48%) patients.
63.4 6 13.2, respectively (P = 0.33),
Patient characteristics; preoperative, Hemolysis had 100% specificity and
with a mean body mass index of
intraoperative, and postoperative 80% sensitivity, with a PPV of 100%
30.6 6 7.4 and 29.8 6 6.5 (P = 0.93).
findings; index procedure, initial re- and a negative predictive value of
operation procedure; and culture 73% for determining definite and
data for the hemolytic and nonhe- probable infections. All 16 (100%) Preoperative Findings
molytic strains are outlined in Tables of the patients in the hemolytic Decisions on the type of initial revi-
(see Supplemental Digital Content 3, group were categorized as infected. sion surgery procedure were surgeon
http://links.lww.com/JAAOS/A138 In contrast, 73% (11/15) of patients dependent. Time from the index
and Supplemental Digital Content 4, in the nonhemolytic group were clas- procedure to the initial revision sur-
http://links.lww.com/JAAOS/A139). sified as noninfected. In the hemolytic gery procedure was on average
Two patients in the hemolytic group group, 14 of the 16 patients were 12.4 months (range, 1 to 69 months) in
and three patients in the nonhemo- categorized with a definite infection the hemolytic group and 22.1 months
lytic group had diabetes. One patient (87.5%), and two patients were clas- (range, 1 to 138 months) in the non-
in the hemolytic group and two pa- sified with a probable infection hemolytic group (P = 0.07). Presenting
February 15, 2019, Vol 27, No 4 139
Figure 4 lytic group, 94% (15/16) underwent a

complete therapeutic course of intra-
venous or highly bioavailable oral
antibacterial treatment, compared
with only 33% (5/15) in the nonhe-
molytic group (P = 0.002). The one
patient who did not receive a thera-
peutic course of antimicrobial therapy
in the hemolytic group refused ad-
ministration of antibiotics (see Table,
Supplemental Digital Content 3,
Antibiotic Susceptibility
The average MICs of the hemolytic
and nonhemolytic groups for each
antibiotic tested are outlined in Table
Preoperative ESR and CRP of patients with hemolytic versus nonhemolytic (see Supplemental Digital Content 5,
strains of Propionibacterium acnes. Hemolytic group: presenting median ESR http://links.lww.com/JAAOS/A145).
and CRP were 10.0 mm/hr (IQR, 7.5 to 49.5) and 17.9 mg/L (IQR, 5.0 to 32.8),
respectively. Nonhemolytic group: presenting median ESR and CRP were All strains were susceptible to peni-
9.0 mm/hr (IQR, 3.5 to 12.0; P = 0.04) and 3.5 mg/L (IQR, 0.7 to 5.8; P = 0.01), cillin G. The activity of vancomycin
respectively. CRP = C-reactive protein, ESR = erythrocyte sedimentation rate, against P acnes was fair with an
IQR = interquartile range, WBC = white blood cell. MIC50 of 0.38 and MIC90 of 0.5.
The average MIC90 for clindamycin
in the hemolytic group was 144,
median ESR was 19.0 mm/hr in the hemolytic group, had cultures that which was markedly higher than the
hemolytic group (IQR, 7.5 to 49.5); became positive within the 14- to 21- average MIC90 in the nonhemolytic
compared with a median of 9.0 mm/hr day period. Of these eight, true infec- group of 0.762. Clindamycin resis-
in the nonhemolytic group (IQR, 3.5 tion was present in all of the hemolytic tance was found in 31% (5/16) of the
to 12.0; P = 0.05). Similarly, median strains (3/3), whereas all five of the hemolytic strains versus zero (0/15)
CRP was 17.9 mg/L in the hemolytic nonhemolytic strains were classified as in the nonhemolytic group. One of
group (IQR, 4.97 to 32.8); compared probable contaminants. these clindamycin resistant strains
with a median of 3.5 mg/L in the was also resistant to vancomycin and
nonhemolytic group (IQR, 0.7 to 5.8) Postoperative Course ciprofloxacin. There were no resis-
(P = 0.02). No significant differences tant strains to any of the antibiotics
were found in the white blood cell In the hemolytic group, all 16 (100%)
tested in the nonhemolytic group.
count between groups (7.9 · 109/L; of the patients underwent a revision
IQR, 7.8 to 10.7 · 109/L versus 7.5 · surgery procedure for infection,
109/L; IQR, 6.2 to 9.4 · 109/L; P = compared with 9 of 15 (60%) pa- Discussion
0.38) (Figure 4). tients in the nonhemolytic group (P =
0.01). Nine (56%) patients in the P acnes recognition is rapidly grow-
hemolytic group compared to 2 ing as the leading infecting pathogen
Intraoperative Cultures (13%) patients in the nonhemolytic after orthopaedic procedures of the
The mean positive intraoperative group presented with wound com- shoulder.34,35 In a recent review of 30
culture rate was 77.1% in the hemo- plications before revision surgery patients who underwent revision
lytic group, compared with 41% (P = 0.02). Failure of management of shoulder arthroplasty by Ricchetti
in the nonhemolytic group (P = infection was determined as neces- and colleagues, P acnes was the most
0.0002). Mean time to growth was sitating any further operation for commonly isolated offending organ-
9.9 6 4.1 days in the hemolytic infection. Overall, 44% (7/16) of ism.25 Accurate identification of in-
group compared with 11.6 6 4.1 days patients in the hemolytic group failed fection with P acnes is challenging
in the nonhemolytic group (P = 0.27). initial management of infection. No because of the bacterium’s indolent
A total of eight patients, three in the patients in the nonhemolytic group nature and low virulence. Classic
hemolytic group and five in the non- failed initial treatment. In the hemo- markers of infection such as ESR and
CRP, especially when compared with almost twice as long in the nonhe- cultures were streaked only on
the hip and knee, have poor predic- molytic group. A substantial percent- anaerobic plates because none of our
tive capabilities for diagnosing true age of patients in the hemolytic group isolates grew on aerobic media. This
infection in the shoulder.9,36 P acnes (44%) compared with the nonhemo- study also denotes the optimal
has an array of pathogenic properties lytic group (0%) failed initial treat- recovery time for identifying clini-
that differ between strains, which ment requiring a revision procedure cally important strains of P acnes to
may elicit a stronger inflammatory for persistent infection. These findings be within 13 days. Limiting cultures
response from the host and manifest indicate that the hemolytic strains of to 13 days in our series would have
in a more pronounced clinical course. P acnes have increased pathogenic missed 17% (3/18) of patients with
A number of virulence factors have potential and elicit more pronounced infections. Our data do correlate
been identified in recent years that and noticeable clinical presentation with a recent study of P acnes
contribute to clinical disease from than the nonhemolytic strains. The culture-positive shoulder arthro-
bacterial seeding and biofilm forma- presence or absence of hemolysis is plasty revisions in which 45% were
tion, to modification and manipula- easily identified by standard microbi- positive at 1 week, 86% at 2 weeks,
tion of the host immune response.19 ology laboratory techniques and pro- 97% at 3 weeks, and 100% at
McDowell and colleagues identified vides additional information to help 4 weeks.35 The results of our study
two virulence genes, hemolysin and clinicians determine whether a patient support a 14- to 21-day culture hold
Christie-Atkins-Munch-Peterson factor with a positive P acnes culture should protocol and indicate that hemolysis
homolog, that are likely related to more be treated as a true infection or may be useful in determining infec-
pathogenic strains of P acnes.18-20,37 contaminant. tion versus contamination in positive
We conducted this study to expand Aspiration of synovial fluid during cultures with delayed growth.
upon previous work and further the diagnostic workup was unreliable There remains a paucity of data
define the pathogenic nature of for identifying a positive P acnes on P acnes antibiotic susceptibility
hemolytic strains of P acnes from the culture and showed poor correlation patterns in patients who have un-
shoulder after orthopaedic proce- with true clinical infection, which dergone an orthopaedic shoulder
dures.20 Most patients analyzed in confirms the results of previous studies procedure.22,39,40 The antibiotic sus-
previous work had to be excluded (see Tables, Supplemental Digital ceptibility patterns found within this
because of polymicrobial culture re- Content 2, http://links.lww.com/ study largely correlate with the find-
sults, retrievals from native shoulders, JAAOS/A137 and Supplemental Dig- ings of previous work from our insti-
and insufficient preoperative, intra- ital Content 3, http://links.lww.com/ tution.22 Penicillin G showed strong
operative, or postoperative data to JAAOS/A138).10 This phenomenon activity against P acnes, with many
determine a diagnostic category. can likely be explained by the bac- isolates demonstrating MICs lower
Hemolysis had a high PPV of a true teria’s properties of cell adhesion and than the lowest antibiotic concentra-
infection with P acnes versus the biofilm formation, decreasing the tion on the E-test strip. The activity of
nonhemolytic strains that were sug- synovial fluid burden and establishing vancomycin against P acnes was fair
gestive of contamination. Our results immunoavoidance.19 with a MIC50 of 0.38 and MIC90 of
showed that hemolytic strains dem- The mean time to growth of P acnes 0.5 and one of the hemolytic strains
onstrate greater pathogenic potential was similar between the hemolytic showing resistance. Thirty-one percent
than nonhemolytic strains of P acnes. and nonhemolytic groups (9.9 and of the strains were resistant to clin-
Patients with a hemolytic P acnes 11.6 days, respectively). Although damycin, which is a nearly three times
infection had a markedly higher no current consensus exists on how higher rate of resistance than reported
CRP, presented with greater inci- long to incubate cultures, many in the literature.20,22 No resistance in
dence of wound complications and microbiology laboratories hold cul- the nonhemolytic strains was iden-
were more likely to have a positive tures for 14 to 21 days. The current tified. However, a substantial increase
intraoperative culture than were literature suggests that the mean time in the resistance pattern was observed
patients identified with nonhemo- to growth is anywhere from 5 to within the hemolytic P acnes isolates,
lytic strains. Ninety-three percent of 12 days.15,38 Our findings support indicating that hemolysis is a feature
patients in the hemolytic group the work of Butler-Wu et al,15 who of the bacterium’s pathogenicity. This
had .50% of specimens that were determined the need for a minimum is a critical finding because there are
positive for P acnes with 8 patients culture incubation period of 13 days. only anecdotal reports and no opti-
having all positive cultures. Time However, our work does contrast mal guideline for antibiotic admin-
from index surgery to the initial their conclusion in that 29.4% of istration in patients with suspected
treatment or revision procedure was true infections were missed when P acnes orthopaedic-implant-associated
February 15, 2019, Vol 27, No 4 141
infections of the shoulder.41 Further The Musculoskeletal Infection tive P acnes culture.35 Finally, some
evidence of clindamycin resistance Society criteria for diagnosing PJI are of the antibiotics currently being
was reported in a recent P acnes largely based on lower extremity co- evaluated to manage P acnes
animal implant infection model in horts. Although similarities exist, orthopaedic-implant-associated in-
which clindamycin was found to periprosthetic shoulder infections fections, including biofilm eradi-
have the highest minimal bactericidal differ because many of the diagnostic cation, were not examined in our
concentration and minimal biofilm tests, such as ESR/CRP, synovial fluid study. Despite these limitations,
eradication concentration.42 Our aspiration, Gram staining, and frozen our results add to the current lit-
results show that hemolysis is not section, are unreliable.9,43,44 The clin- erature because they provide an
only correlated with the clinical ical presentation of shoulder infection additional diagnostic tool to assist
outcome but also linked to clinda- with P acnes is unique because many in identifying true infection and
mycin resistance. These correlations do not present with overt signs of further clarify the antibiotic resis-
reinforce the importance of micro- infection, including wound dehis- tance patterns of P acnes.
bial identification, proper prophy- cence, drainage, or a draining sinus.
lactic antibiotic administration, and This scenario presents a challenge to
accurate sensitivity profiling. the treating surgeon when attempting Conclusion
The variability of culture samples to use the Musculoskeletal Infec-
obtained is a limitation of this study. tion Society criteria for diagnosing Hemolytic strains of P acnes dem-
In addition, a specific negative con- shoulder infections.45 Our study was onstrate enhanced pathogenicity in
trol was not performed for this study; powered to determine hemolysis as a their host and hemolysis serves as a
however, our institution has previ- marker for infection but was not marker for true P acnes infection.
ously internally validated the identi- powered to show a significant dif- This finding suggests that hemolysis
fication and growth protocols of P ference in serum ESR and CRP. can be used as a diagnostic adjuvant,
acnes with masked samples. Many of Although the analysis of ESR did not especially in the setting of equivocal
the samples were collected before the show statistical significance, the anal- clinical findings, and potentially
development of standard protocols ysis of CRP was significant. CRP is improves decision-making regarding
for the evaluation of infection after a more sensitive serum marker for treatment. The increased antibiotic
shoulder procedures at our institution, inflammation. Although this is one of resistance profiles observed in hemo-
which includes preoperative aspira- the largest collections of orthopaedic lytic strains is concerning and should
tion, at least four intraoperative cul- shoulder isolates reviewed in a single be carefully considered when choosing
tures and frozen section. Patients with study, a larger series would increase antibacterial therapy for prophylactic
less than four intraoperative cultures the validity of our results and would and therapeutic courses of treatment.
may have been incorrectly classified be indicated in the future.
as a probable contaminant. Based on It may be viewed as a limitation that
our criteria, if additional cultures were limited intraoperative frozen sections
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acnes biofilm in vitro and in an 44. Ricchetti ET, Frangiamore SJ, Grosso musculoskeletal infection society. Clin Orthop
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Research Article
Elective Total Shoulder

Arthroplasty in Octogenarians:
A Safe Procedure
Abstract
Patawut Bovonratwet, BS Introduction: There has been a lack of studies investigating the
Rohil Malpani, BS perioperative course of total shoulder arthroplasty (TSA) performed in
the increasingly octogenarian ($80 years old) population in a large
Nathaniel T. Ondeck, BS
sample size. The purpose of this study was to compare perioperative
Vineet Tyagi, MD complications between primary TSA performed in octogenarians and

Jonathan N. Grauer, MD that performed in younger populations (,70 and 70 to 79 years old)
from the National Surgical Quality Improvement Program database.
Methods: Patients who underwent primary TSA between January
2005 and December 2015 were identified from the National Surgical
Quality Improvement Program database and stratified into three age
groups: ,70, 70 to 79, and $80 years old. Patient characteristics and
comorbidities were compared between the three groups. Propensity
score-matched comparisons were then performed for length of
hospital stay, 30-day perioperative complications, and readmissions.
Risk factors and reasons for readmission in the octogenarians were
From the Department of Orthopaedics characterized.
and Rehabilitation, Yale School of
Medicine, New Haven, CT.
Results: This study included 3,007 patients who were ,70 years old,
2,155 patients who were 70 to 79 years old, and 900 octogenarian
Correspondence to Dr. Grauer:
jonathan.grauer@yale.edu patients. Statistical analysis was carried out after matching for
propensity score. While no significant differences in perioperative
Dr. Grauer or an immediate family
member serves as a paid consultant complications were observed between the octogenarians and 70- to
to Bioventus, Medtronic, and Stryker; 79-year-olds, significantly higher rates of readmission (4.2% versus
and serves as a board member,
1.7%; P = 0.002), pneumonia (1.1% versus 0.0%; P = 0.002), and
of the American Academy of urinary tract infection (1.8% versus 0.2%; P = 0.001) were found in
Orthopaedic Surgeons, the Cervical the octogenarians compared with ,70-year-olds. In addition,
Spine Research Society, the Lumbar
Spine Research Society, and the
the octogenarians also had a slightly longer length of hospital
North American Spine Society. None stay compared with the younger populations (0.6 days longer
of the following authors or any than ,70-year-olds and 0.4 days longer than 70- to 79-year-olds;
both P , 0.001).
stock or stock options held in a Conclusion: These data suggest that primary TSA can safely be
commercial company or institution considered for octogenarians with only mildly increased morbidities.
subject of this article: Mr.
However, greater preoperative optimization or post-discharge care for
Bovonratwet, Mr. Malpani, Mr. octogenarians may be warranted to reduce the rates of readmission.
Ondeck, and Dr. Tyagi.

145-154
DOI: 10.5435/JAAOS-D-17-00364 O ctogenarians in general have
been shown to have a greater
number of comorbid conditions and
total hip arthroplasty, age has been
associated with an increased risk for
major perioperative complications
Academy of Orthopaedic Surgeons. are at higher risk for complications and mortality.2-4 However, despite
during surgery.1 In total knee and this association, the overall adverse
February 15, 2019, Vol 27, No 4 145
Shoulder Arthroplasty in Octogenarians
event rate following lower extremity population. We hypothesized that 6,062 patients remained for further
arthroplasty in octogenarians re- octogenarians would experience analysis. Patients were then strati-
mains relatively low. As a result, higher postoperative complication fied into three age groups: ,70
multiple studies have concluded rates following primary TSA com- years old, 70 to 79 years old,
that these procedures should still pared with younger populations. and $80 years old. Following the
be offered to octogenarians due to methods of Ricchetti et al,8 ,70-
improvements in quality outcome year-olds served as a younger
measures, clinical outcomes, and Methods comparison group. However, to
cost-effectiveness.5-7 provide a more comprehensive
With regard to total shoulder Patient Cohort analysis, the current study also
arthroplasty (TSA) in the octoge- The NSQIP database collects over used 70- to 79-year-olds as another
narians, there has been a lack of 150 patient variables, which include younger comparison group.
studies investigating complications patient demographics, intraoperative Patient characteristics such as age,
and functional outcomes. While one variables, and 30-day postoperative sex, height, weight, functional sta-
study reported no differences in adverse events regardless of discharge tus before surgery, American Soci-
complication rates between octoge- status. Data are collected from over ety of Anesthesiologists (ASA)
narians and a younger population,8 500 participating institutions in the classification, and diabetes mellitus
another study reported a higher United States.11,12 Trained clinical status were directly extracted from
mortality rate in the octogenarian and surgical reviewers abstract NSQIP. Body mass index, defined as
population.9 However, one of these patient information through a vari- weight (kg)/height2 (m2), was cal-
previous studies included only a ety of sources including medical culated from patient height and
small sample size,8 while the other records and patient interviews.11 weight. The ASA score has been
study lacked post-discharge data.9 Inter-rater disagreement has been found to correlate well with patient
The current mandatory bundled reported to be below 2% based on comorbidities and used as a marker
payment for total hip or knee arthro- routine auditing.11 Over the past of comorbidity in the current
plasty, Medicare’s Comprehensive several years, the number of ortho- investigation.14,15
Care for Joint Replacement model, paedic studies using NSQIP has Operative time and hospital length
has been instituted, and future bundles greatly increased.13 Our institutional of stay (LOS) were also directly ex-
for other major orthopaedic proce- review board granted an exemption tracted from the NSQIP database.
dures such as TSA are likely to for studies using this dataset. Operative time is defined as the total
follow suit.10 Since octogenarians are Patients who underwent primary operation time in minutes.11 LOS is
thought to be at higher risk for com- TSA procedures between January defined as the length of hospital stay
plications, detailed information on 2005 and December 2015 were after operation until discharge.
comorbidities, postoperative adverse identified using the Current Proce- While most variables in the NSQIP
events, and readmission in this dural Terminology (CPT) code database are recorded only for the
potentially vulnerable but increasing 23472, which includes anatomic TSA first 30 postoperative days, LOS is
patient population may be helpful to and reverse TSA procedures. Our reported beyond 30 days. However,
guide future risk adjustment.1 study considered only patients who to limit the influence of outliers on
The purpose of the current study had International Classification of the analysis, the current study con-
was to utilize a large national data- Disease, 9th Revision code for os- sidered patients with an LOS longer
base with post-discharge follow-up teoarthrosis and allied disorders of than 30 days (n = 5) to have an LOS
data, the National Surgical Quality the shoulder region (715.11, 715.21, equal to 30 days.
Improvement Program (NSQIP), to 715.31, and 715.91) and underwent
(1) compare complications following surgery recorded as elective. Patients
primary TSA between octogenarians who underwent hemiarthroplasty Perioperative Complications
and a younger patient population (n = 5), revision TSA (n = 15), or and Readmission
(,70 years old), (2) compare com- procedures recorded as emergent The NSQIP database tracks patients
plications following primary TSA (n = 44) were excluded. The CPT code for the occurrence of individual
between octogenarians and a geri- used to identify hemiarthroplasty complications through the 30th
atric patient population (70 to 79 was 23470, while the CPT codes postoperative day, regardless of hos-
years old), and (3) determine the used to identify revision TSA were pital discharge. These individual
risk factors and reasons for 30-day 23331, 23332, 23473, and 23474. complications were used to generate
readmission in the octogenarian Based on these exclusion criteria, three groups of adverse events.
Patawut Bovonratwet, BS, et al
The occurrence of a minor adverse included in this study. Reasons for After the three age groups were
event (MAE) was defined as the readmission were recorded for cases matched with propensity scores,
occurrence of any of the following: from 2012 to 2015; therefore, the patient characteristics, operative time,
urinary tract infection (UTI), pneu- analysis of reasons for readmission individual adverse events, 30-day
monia, blood transfusion, wound includes only 4,802 of 6,062 cases, readmissions, aggregated adverse
dehiscence, and renal insufficiency. but this represents 79.2% of all cases events, and postoperative LOS were
The occurrence of a serious adverse included in this study. again compared between the ,70-
event (SAE) was defined as the year-old group versus $80-year-old
occurrence of any of the following: group and the 70 to 79-year-old
death, return to the operating room, Data Analysis group versus $80-year-old group.
wound-related infection, thrombo- For comparisons of patient charac-
Unadjusted Analysis
embolic event, cardiac arrest, myo- teristics, operative time, LOS, and
The first set of statistical analyses
cardial infarction, renal failure, reasons for readmission, statistical
involved unadjusted comparisons of
stroke/cerebrovascular accident, on significance was set at a = 0.05.
patient characteristics, operative
ventilator for .48 hours, unplanned However, for comparisons of adverse
time, individual adverse events, 30-
intubation, and sepsis/septic shock. events, since 20 tests were performed
day readmissions, reasons for read-
The occurrence of any adverse event on both individual and aggregate
mission, aggregated adverse events,
(AAE) was defined as the occurrence groupings of adverse events, statisti-
and postoperative LOS between
of an MAE or SAE, as defined by cal significance was set at a = 0.003
the ,70- and $80-year-old groups
Bovonratwet and colleagues and due to Bonferroni’s correction.22
and between the 70- to 79-year-old
Leroux et al.16-18 Accordingly, 99.70% confidence in-
group and $80-year-old groups.
For comparison of grouped adverse tervals (CIs) are reported.
Chi-squared tests or Fisher exact
events between two age groups, cer-
tests were used for categorical vari-
tain individual complications that
ables, and 2-tailed Student t-tests Relative Risks for Postoperative
have already been shown to be sig-
were used for continuous variables. Complications
nificantly different between these two
For the third set of statistical analyses,
groups were not included as part of
Poisson regressions with robust error
the grouped adverse events (MAE, Propensity Score-matched
variance were used to calculate
SAE, or AAE). This allowed other Analysis
the relative risks (RRs) of AAEs,
aggregated complications to be sta- For the second set of statistical ana-
SAEs, and MAEs between the $80-
tistically analyzed between the two lyses, propensity score matching was
year-olds relative to the matched
age groups when significant differ- used to account for potential selec-
,70-year-olds and between the $80-
ences in individual complications tion bias between the different age
year-olds relative to the matched 70-
were excluded. For example, in the groups compared.19,20 Propensity
to 79-year-olds.23 The multivariate
comparison of grouped adverse score matching is commonly used to
regressions controlled for all patient
events between the matched ,70- create matched cohorts for compar-
and intraoperative characteristics
and $80-year-olds, pneumonia and ison of orthopaedic procedures.21
listed in Table 1. Statistical signifi-
UTI were not counted as an MAE, First, propensity scores were gener-
cance was set at a = 0.003 due to
SAE, or AAE, as pneumonia and UTI ated for every patient using their sex,
Bonferroni’s correction, and 99.70%
have already been shown to be sig- body mass index, functional status
CI are reported.
nificantly different between these before surgery, ASA classification,
two groups. diabetes mellitus status, and opera-
The number of readmissions and tive time. Patients with similar pro- Risk Factors for 30-day
reasons for readmission are recorded pensity scores were considered to Readmission in the
in the later years of the NSQIP data- have similar distribution of selected Octogenarians
base. Occurrence of readmission preoperative and intraoperative fac- Occurrence of 30-day readmission
within 30 days of operation is tors. Second, patients from the three was tested for association with each
reported in the NSQIP database for age groups with similar propensity patient and intraoperative charac-
cases that occurred from 2011 scores were matched. Each patient in teristics shown in Table 1 using
to 2015, but not for earlier cases. the octogenarian group was matched Pearson’s chi-squared test (bivariate)
Hence, the analysis of readmission to one patient from the , 70-year- and Poisson regression with robust
includes only 5,314 of 6,062 cases, old group and one patient from the error variance (multivariate). The
but this represents 87.7% of all cases 70- to 79-year-old group. final multivariate Poisson model was
February 15, 2019, Vol 27, No 4 147
Table 1
Demographics of Patients in Different Age Groups Undergoing Primary Total Shoulder Arthroplasty
Age Groups (yr)
,70 70–79 $80 P Valuea Before P Valuea After
Propensity Propensity
Total Number = 3,007 Number = 2,155 Number = 900 Matching Matching
Age (yr) Average: 61.5 Average: 74.2 Average: 83.1 ,0.001 ,0.001
Sex ,0.001 0.254
Male 1,597 53.11% 888 41.21% 305 33.89% — —
Female 1,410 46.89% 1,267 58.79% 595 66.11% — —
BMI (kg/m2) Average: 32.3 Average: 30.9 Average: 28.2 ,0.001 0.751
18-25 376 12.50% 358 16.61% 248 27.56% — —
25-30 874 29.07% 726 33.69% 380 42.22% — —
30-35 867 28.83% 562 26.08% 184 20.44% — —
.35 890 29.60% 509 23.62% 88 9.78% — —
Functional status 0.001 0.460
before surgery
Independent 2,923 98.19% 2,085 97.61% 858 95.97% — —
Partially dependent 53 1.78% 50 2.34% 33 3.69% — —
Totally dependent 1 0.03% 1 0.05% 3 0.34% — —
ASA Average: 2.4 Average: 2.6 Average: 2.7 ,0.001 0.571
1-2 1,760 58.63% 950 44.12% 330 36.67% — —
3 1,191 39.67% 1,142 53.04% 549 61.00% — —
$4 51 1.70% 61 2.83% 21 2.33% — —
Diabetes mellitus 0.006 0.676
No diabetes mellitus 2,560 85.13% 1,793 83.20% 787 87.44% — —
Non-insulin-dependent 310 10.31% 253 11.74% 91 10.11% — —
diabetes mellitus
Insulin-dependent 137 4.56% 109 5.06% 22 2.44% — —
diabetes mellitus
Operative time (min) Average: 119.6 Average: 111.6 Average: 107.6 ,0.001 0.913
#89 755 25.16% 700 32.53% 347 38.64% — —
90-119 918 30.59% 653 30.34% 247 27.51% — —
$120 1,328 44.25% 799 37.13% 304 33.85% — —
ASA = American Society of Anesthesiologists

a
Chi-squared tests were used to compare these variables (significant at P , 0.05)
Boldface indicates statistical significance.
Italic rows refer to the median group.
selected using a backward stepwise (14.8%) were in the age group $80
approach, where all variables in
Results years old (Table 1).
Table 1 were initially included in the
model and variables with the highest Patient Population
P values were eliminated one by one A total of 6,062 patients who under- Preoperative and
until only variables with P , 0.05 went primary elective TSA for osteo- Intraoperative
remained in the model. The level of arthrosis were identified for analysis Characteristics
significance was set at a = 0.05 for the based on the inclusion/exclusion cri- Compared with patients in the ,70-
risk factors multivariate analysis.24 teria defined. Of these cases, 3,007 and 70- to 79-year-old groups, oc-
All statistical analyses were per- (49.6%) were in the age group ,70 togenarians who underwent primary
formed using STATA version 13 years old, 2,155 (35.5%) were in the TSA had a significantly higher
(StataCorp LP). age group 70 to 79 years old, and 900 percentage of females (P , 0.001),
Table 2
Matched Comparisons of Adverse Event Rates Between the ,70-Year-Old and $80-Year-Old Age Groups
Before
Propensity Matched After Propensity
,70 yr $80 yr Matching , 70 yr Matching
Total Number = 3,007 Number = 900 P Valuea Number = 892 P Valuea
Blood transfusion 51 1.70% 46 5.11% ,0.001 24 2.69% 0.018

Readmission 41 1.57% 32 4.23% ,0.001 13 1.65% 0.002
Return to the operating room 25 0.83% 11 1.22% 0.282 11 1.23% 1.000
Urinary tract infection 14 0.47% 16 1.78% ,0.001 2 0.22% 0.001
Thromboembolic event 13 0.43% 4 0.44% 1.000 4 0.45% 1.000
Wound-related infection 8 0.27% 1 0.11% 0.694 2 0.22% 1.000
Pneumonia 4 0.13% 10 1.11% ,0.001 0 0.00% 0.002
Sepsis/septic shock 3 0.10% 2 0.22% 0.326 1 0.11% 1.000
Death 3 0.10% 2 0.22% 0.326 3 0.34% 1.000
Myocardial infarction 2 0.07% 6 0.67% 0.003 1 0.11% 0.124
Unplanned intubation 2 0.07% 3 0.33% 0.084 1 0.11% 0.625
Wound dehiscence 2 0.07% 1 0.11% 0.544 1 0.11% 1.000
On ventilator .48 hr 1 0.03% 2 0.22% 0.135 1 0.11% 1.000
Renal insufficiency 1 0.03% 1 0.11% 0.408 0 0.00% 1.000
Cardiac arrest 1 0.03% 1 0.11% 0.408 0 0.00% 1.000
Stroke/cerebrovascular accident 0 0.00% 2 0.22% 0.053 0 0.00% 0.500
Renal failure 0 0.00% 1 0.11% 0.230 0 0.00% 1.000
a
Chi-squared tests were used to compare these variables (significant at P , 0.003 due to Bonferroni).
Ordered from the highest to lowest frequency of occurrence in the ,70-year-old cohort.
lower percentage of obese patients (4.2% versus 1.7%; P = 0.002), UTI (RR, 1.49; 99.70% CI, 0.85 to 2.63;
(P , 0.001), higher percentage of (1.8% versus 0.2%; P = 0.001), and P = 0.037) (Figure 1).
patients with dependent functional pneumonia (1.1% versus 0.0%; P =
status (P = 0.001), higher percentage 0.002) (Table 2). There were no
of patients with $3 ASA (P , 0.001), significant differences between the
Comparison of Age Groups
lower percentage of diabetes mellitus rates of other AAE (P = 0.028), SAE 70 to 79 Years Old
(P = 0.006), and shorter operative (P = 0.232), or MAE (P = 0.015) versus $80 Years Old
time (P , 0.001). Once patients were between the two age groups (Table After matching for propensity score,
propensity score-matched, there were 3). However, the $80-year-old no significant differences in individ-
no longer significant differences in group had a significantly longer ual adverse events could be found
patient characteristics/comorbidities postoperative LOS (2.4 days versus between these two age groups (all P $
and operative time between the age 1.8 days; P , 0.001) (Table 3). 0.003; see Table 4 in the Appendix,
groups (P . 0.05 for all) (Table 1). After separating the occurrence of Supplemental Digital Content 1,
pneumonia and UTI, Poisson re- http://links.lww.com/JAAOS/A146).
gressions with robust error variances Similarly, there were no significant
Comparison of ,70- between propensity score-matched differences in AAE (P = 0.003), SAE
versus $80-Year-Old Age populations, $80-year-olds relative (P = 0.127), or MAE (P = 0.003)
Groups to matched ,70-year-olds, revealed between these two age groups (see
After matching for propensity score, no significant differences in risk for Table 5 in the Appendix, Supple-
in the comparison of $80-year-old occurrence of other MAEs (RR, mental Digital Content 1, http://
group versus ,70-year-old group, 1.71; 99.70% CI, 0.84 to 3.52; P = links.lww.com/JAAOS/A146). How-
the $80-year-old group had signifi- 0.026), SAEs (RR, 1.43; 99.70% CI, ever, the $80-year-old group had
cantly higher rates of readmission 0.60 to 3.44; P = 0.223), or AAEs a significantly longer postoperative
February 15, 2019, Vol 27, No 4 149
Table 3
Matched Comparisons of Aggregate Group of Adverse Events and Length of Hospital Stay Between the ,70-Year-
old and $80-Year-Old Age Groups
Matched
,70 yr $80 yr P Value ,70 yr P Value
Number = Number = Before Propensity Number = After Propensity
Total 3,007 900 Matching 892 Matching
AAEa 50 1.66% 29 3.22% 0.004 42 4.71% 0.028

MAEa 3 0.10% 2 0.22% 0.367 25 2.80% 0.015
SAEa 49 1.63% 27 3.00% 0.009 19 2.13% 0.232
Length of hospital stayb — — — — ,0.001 — — ,0.001
Mean (SD) 1.7 d (1.5 d) 2.4 d (1.7 d) — 1.8 d (1.3 d) —
AAE = any adverse event, MAE = minor adverse event, SAE = serious adverse event
a
Chi-squared tests were used to compare these variables (significant at P , 0.003 due to Bonferroni), urinary tract infection, pneumonia, and blood
transfusion were not counted as an AAE, MAE, or SAE (before propensity matching) Urinary tract infection and pneumonia were not counted as an
AAE, MAE, or SAE (after propensity matching).
b
T-test was used to compare this variable (significant at P , 0.05).
Figure 1 Risk Factors for 30-day

Readmission in the
Octogenarians
Based on the multivariate analysis
(see Table 6 in the Appendix, Sup-
plemental Digital Content 1, http://
links.lww.com/JAAOS/A146), the
only independent risk factor for 30-
day readmission in the octogenarian
population was a high ASA classifi-
cation versus ASA = 1 to 2 (ASA, 3;
RR, 3.68; 95% CI, 1.30 to 10.44;
ASA $ 4; RR, 6.95; 95% CI, 1.36 to
35.58; P = 0.025).
Plot showing the relative risk of adverse events following primary elective Reasons for 30-day
shoulder arthroplasty for the octogenarian patients versus the ,70-year-old Readmission
age group. The adverse events are listed on the left. Diamonds indicate
relative risks (RRs). Horizontal lines denote the 99.70% confidence intervals Categorization of reasons for read-
of these RRs, per Bonferroni’s correction. The vertical line indicates a RR of 1. mission revealed that the major
Therefore, horizontal lines that cross the vertical line indicate RRs that are not reason for 30-day readmission in the
statistically significant. *Pneumonia and urinary tract infections were not
counted as a minor adverse event, serious adverse event, or any adverse octogenarian population was non-
event. surgical site related (59.4% non-
surgical site related, 18.7% surgical
site related, and 21.9% unspecified).
LOS (2.4 versus 2.0 days; P , 0.001) revealed no significant differences in The percentages of nonsurgical site-
(see Table 5 in the Appendix, Sup- risk for occurrence of MAEs (RR, related reasons for readmission were
plemental Digital Content 1, http:// 1.80; 99.70% CI, 0.99 to 3.27; P = lower for the 70 to 79-year-old
links.lww.com/JAAOS/A146). 0.004), SAEs (RR, 1.59; 99.70% CI, group (53.8% nonsurgical site related,
Poisson regressions with robust 0.64 to 3.95; P = 0.132), or AAEs 21.2% surgical site related, and
error variances between these two (RR, 1.66; 99.70% CI, 0.99 to 2.80; 25.0% unspecified) and the ,70-year-
propensity score-matched populations P = 0.004) (Figure 2). old group (48.8% nonsurgical site
related, 26.8% surgical site related, Figure 2

and 24.4% unspecified) (Figure 3).
However, these differences were not
statistically significant: P = 0.62 and
P = 0.37, respectively.
Conclusion
Despite the increasing frequency of

octogenarians undergoing arthro-
plasties of various kinds,6 research
studying postoperative complications
and readmission rates following TSA
in octogenarians has been lacking.
The current study analyzed a large
patient population and demonstrated Plot showing the relative risk of adverse events following primary elective
that octogenarians who underwent shoulder arthroplasty for the octogenarian patients versus the 70- to 79-year-old
primary elective TSA have signifi- age group. Adverse events are listed on the left. Diamonds indicate relative risks
cantly higher rates of readmission, (RRs). Horizontal lines denote the 99.70% confidence intervals of these RRs,
per Bonferroni’s correction. The vertical line indicates a RR of 1. Therefore,
pneumonia, and UTI compared horizontal lines that cross the vertical line indicate RRs that are not statistically
with a younger population (,70 significant. *All individual complications were counted as a minor adverse event,
years old) but that there were serious adverse event, or any adverse event.
no significant differences in peri-
operative complications compared
with a geriatric population (70 to remained significantly higher for in adverse events compared with
79 years old). octogenarians compared with those a younger population, the overall
The octogenarians in the current of a younger population (,70 years event rates in the octogenarian
study tended to be female, have lower old). In addition, the average hospi- population are still low. Based on
body mass index, have dependent tal LOS for the octogenarian pop- these results, it is believed that TSA
functional status, have a higher ASA ulation is 0.6 days longer (P , should still continue to be offered to
score, and have lower incidence of 0.001) than that of the younger octogenarians because of improve-
diabetes mellitus compared with patient group. The increase in mor- ments in functionality and pain
younger populations. Previous stud- bidity in the octogenarian pop- relief.9,33
ies have shown that body mass tends ulation is supported by several other The results of the current study
to decrease toward the latter part of studies in different patient pop- share some similarities to those from
life, a trend that is observed in our ulations.28,29 Specifically, a positive previous studies; there are several dif-
patient cohort.19,25 Further, other relationship was found between ferences too. Similar to the results of
published studies have found a pos- increasing age and occurrence of the study by Ricchetti et al,8 the cur-
itive relationship between age and postoperative pneumonia and UTI in rent study did not find differences in
higher average ASA score, lower other studies, which agrees with major complications, such as mor-
functional status, and lower rates of our findings.24,30,31 Although the tality, between octogenarians and a
diabetes mellitus, which are compa- increased rate of readmission in the younger population. However, in
rable in our patient series.19,26,27 To octogenarian population undergoing contrast, the current study was able
control for these differences in primary TSA is a novel finding of to identify higher rates of 30-day re-
patient demographics and overall this study, another study has shown admission, UTI, and pneumonia in
health between the different age that octogenarians undergoing total octogenarians. This difference most
groups, propensity score matching hip arthroplasty are also more likely likely stems from the higher statistical
was applied. to be readmitted.6 Lastly, the power in the current study due to a
After matching for propensity increased length of hospital stay in much larger patient population.
score, only the rates of pneumonia the octogenarian population in this Another previous study on the same
(P = 0.002), UTI (P = 0.001), and study is supported by several previ- topic by Griffin et al9 identified higher
30-day readmission (P = 0.002) ous studies.29,32 Despite the increase rates of postoperative anemia and
February 15, 2019, Vol 27, No 4 151
Figure 3 narian group. Further analysis to

determine the risk factors for 30-day
readmission in the octogenarian
population revealed ASA scores of 3
or higher to be the only independent
risk factor. ASA has been shown to
correlate well with 30-day read-
mission in other patient populations
as well.35,36 We further aimed to
characterize the reasons for these
readmissions. After categorization,
octogenarians had a higher percent-
age of non-surgical site-related rea-
sons for readmission than the other
two populations. However, these
differences were not statistically sig-
nificant. These results suggest that
greater preoperative medical opti-
mization and postdischarge care may
be able to reduce the rate of read-
missions in this group since most of
the reasons for readmission were not
related to the surgical site. A detailed
risk profile for readmission is par-
ticularly important for risk adjust-
ment models and bundled payment
Bar chart showing the percentage of and reasons for 30-day readmission in the models, which may soon be consid-
three different age groups (,70 years old, 70 to 79 years old, and $80 years ered for TSA procedures.37
old). Each bar represents the percentage of total readmissions in that age The strengths of the current study
group. Each bar is further subdivided into three categories of reasons for
readmission (nonsurgical site related, surgical site related, and unspecified) by include the large number of cases
percentage. and the high-quality data provided
by the NSQIP database. Addition-
ally, with the potential of bundled
mortality in octogenarians who two age groups. Stemming from this payments for TSA, the current study
underwent shoulder arthroplasty. similarity and the limited lifespan of offers unique insights into the risk
However, the current study could not the shoulder prosthesis,34 it appears profile for complications and read-
identify these differences. The reason that borderline cases for primary missions in the growing octogenar-
for this discrepancy is most likely due TSA in patients aged 70 to 79 years ian population. The limitations of
to the difference in patient inclusion can be postponed and performed this study closely follow the limi-
criteria. While the current study later in life if necessary without a tations of the NSQIP database. Most
included only primary elective TSA significant increase in postoperative importantly, since the database
patients diagnosed with osteo- complications. In terms of hospital contains only follow-up data for up
arthrosis of the shoulder, the study by stay, the octogenarian population, to 30 days after a procedure, adverse
Griffin et al9 included hemiarthro- on average, had a longer stay by events beyond this period cannot be
plasty procedures and patients with 0.4 days. However, this may not be recorded. Additionally, the lack of
proximal humeral fractures as well. clinically significant. Our results of data specific to TSA somewhat hin-
After matching for propensity age-segregated complication profiles ders the assessment of postoperative
score, none of the rates of adverse may provide direction for the complications. Absence of patient-
events were statistically different establishment of a dynamic appro- reported follow-up data, such as
between octogenarians and the geri- priateness criterion for TSA proce- pain and change in quality of life, is
atric population (70 to 79 years). dures, which is currently lacking.9 also another limitation. Further, the
These findings suggest a similar Notably, readmission was found to definitions of MAE, SAE, and AAE
complication profile between these have higher incidence in the octoge- used in the current study, although
commonly used, may not be the most Total shoulder arthroplasty in older 19. Miric A, Inacio MC, Kelly MP, Namba RS:
patients: Increased perioperative Are nonagenarians too old for total hip
rigorous. Lastly, patients who had a morbidity? Clin Orthop Relat Res 2011; arthroplasty? An evaluation of morbidity
history of periprosthetic infection 469:1042-1049. and mortality within a total joint
could not be excluded from the study replacement registry. J Arthroplasty 2015;
9. Griffin JW, Hadeed MM, Novicoff WM, 30:1324-1327.
since NSQIP does not record this Browne JA, Brockmeier SF: Patient age is a
factor in early outcomes after shoulder 20. Giordano S, Schaverien M, Garvey PB,
variable.
arthroplasty. J Shoulder Elbow Surg 2014; Baumann DP, Liu J, Butler CE: Advanced
In conclusion, this study suggests 23:1867-1871. age does not affect abdominal wall
that primary TSA can safely be offered reconstruction outcomes using acellular
10. Lovy AJ, Keswani A, Beck C, Dowdell JE, dermal matrix: A comparative study using
to the octogenarian population due to Parsons BO: Risk factors for and timing of propensity score analysis. Am J Surg 2017;
higher rates of relatively minor com- adverse events after total shoulder 213:1046-1052.
arthroplasty. J Shoulder Elbow Surg 2017;
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readmissions compared with a youn- Lattes S: Thirty-day morbidity after
11. ACS-NSQIP: User Guide for the 2015 ACS single-level anterior cervical discectomy,
ger cohort (,70 years old) and no NSQIP Participant Use Data File (PUF). fusion: Identification of risk factors and
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12. Bovonratwet P, Bohl DD, Malpani R, Nam means. J Am Stat Assoc 1961;56:52-64.
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Research Article
Reliability of Proxy-reported Patient-

reported Outcomes Measurement
Information System Physical
Function and Pain Interference
Responses for Elderly Patients With
Musculoskeletal Injury
Abstract
M. Loreto Alvarez-Nebreda, MD, Background: Patient-reported Outcomes Measurement Information
PhD System (PROMIS) instruments are useful to evaluate health status, but
Marilyn Heng, MD, MPH, its use can be challenging for some vulnerable elderly patients, requiring
FRCSC aid from their proxies. Whether the proxies could be accurate informants
Bernard Rosner, PhD is unknown. The goal of this study was to compare elderly patients’ and
Michael McTague, MPH
their proxies’ answers with PROMIS physical function (PF) and pain
interference (PI) computer adaptive test for the evaluation of patients’
Houman Javedan, MD
outcomes after musculoskeletal injury. In addition, to correlate patients’
Mitchel B. Harris, MD reported PF with the Timed Up and Go (TUG) test.
Michael J. Weaver, MD Methods: This prospective cohort study, from February to September
2016, in the Orthopaedic trauma clinic of two level I Trauma centers,
included 273 patients aged 65 years or older, ambulatory, cognitively
intact, with a discernible proxy. PROMIS PF and PI, TUG, and the “FRAIL”
Questionnaire screening tool were performed. The correlation of
PROMIS scores between patients and proxies, and also with the TUG
From the Harvard Orthopedic Trauma score, was assessed using Spearman rank correlation. The Bland-
Initiative, Brigham & Women’s
Hospital, Boston, MA (Dr. Alvarez-
Altman analysis served to check agreement and bias. Subgroup
Nebreda, Mr. McTague, Dr. Harris, comparison was tested using probit transformations.
and Dr. Weaver), the Servicio de Results: The mean age of patients was 75.7 years, SD 7.5 (62.2 years;
Geriatría, Hospital Universitario
Ramón y Cajal (IRICYS), Madrid,
SD, 13.8 for proxies), 66.7% women, 57.1% married, and 34% with
Spain (Dr. Alvarez-Nebreda), the femoral fractures. A significant correlation and agreement of PROMIS PF
Harvard Orthopedic Trauma Initiative, and PI scores were found between patients and proxies (Spearman rho
Massachusetts General Hospital,
Boston, MA (Dr. Heng), the Brigham & for both, PF and PI = 0.73), although proxies tended to overestimate the
Women’s Hospital (Dr. Rosner), and interference of pain on patient’s performance (median difference, 21.7;
the Division of Aging, Department of P , 0.001). The correlation was markedly stronger in nonfrail patients
Medicine, Brigham & Women’s
Hospital, Boston, MA (Dr. Javedan). and in those with faster TUG scores. There was also a correlation
between patients’ PROMIS PF and TUG test (Spearman rho = 2 0.58).
Correspondence to Dr. Alvarez-
Nebreda: Conclusions: Proxies are good informants of the PF of ambulatory,
loreto.alvarez@salud.madrid.org cognitively intact elderly patients, as evaluated by the PROMIS PF
J Am Acad Orthop Surg 2019;27: instrument, after musculoskeletal injury, although they tend to slightly
e156-e165 overestimate PI. The use of proxy-reported PROs might better
DOI: 10.5435/JAAOS-D-17-00644 characterize functional impairment and pain in a vulnerable patient
Copyright 2018 by the American population, and it could decrease selection bias in outcomes research.
Academy of Orthopaedic Surgeons. Level of Evidence: Diagnostic level II
M. Loreto Alvarez-Nebreda, MD, PhD, et al
P atient-reported outcome (PRO)

measurement instruments have
been increasingly used to evaluate
patients’ age, sex, educational level,
or cognitive impairment. This is not
without other challenges: a reliable
Methods
health status.1,2 They are helpful in informant is not always available, Participants
assessing the effectiveness of clinical and there could be potential corre- We performed a prospective cohort
interventions and guiding treatment lations of ratings with proxies’ feel- study of 273 patients aged 65 years
decisions.3 The Patient-reported ing of burden or affective disorders. or older presented for follow-up to
Outcomes Measurement Informa- It has been suggested that proxies the orthopaedic trauma outpatient
tion System (PROMIS) initiative was tend to rate disability to be more clinic of two American College of
launched in 2004 by the National extensive than patients do and that Surgeons’–verified level I Trauma
Institutes of Health with the goal of effect is even greater when speaking Centers. The study was designed to
developing a set of validated, psycho- about caregivers.2 have 98% of power to detect an
metrically robust, PRO instruments. The Timed Up and Go (TUG) test is effect size of 0.25 for the mean dif-
They use item response theory and an effective method to assess mobility ference between the patient and
computer adaptive testing (CAT) and to quantify locomotor perfor- proxy on PF using a two-sided test
to decrease patient response bur- mance in geriatric patients. It shows with alpha = 0.05, with an expected
den while maintaining measure- significant correlation with gait speed dropout rate of 10%. Patients were
ment accuracy.3,4 (r = 20.61) and the Barthel Index (r = recruited between February and
The resultant PROMIS CAT tools 0.78). Community-dwelling elderly September 2016. Patients were in-
have shown many desirable psycho- women aged between 65 and 85 cluded if they were aged at least 65
metric properties, such as high reliabil- years should complete the TUG test years, they were able to walk with or
ity, validity, responsiveness, improved in less than 12 seconds.23 A TUG without aids, and they had no
precision, and acceptability, using cutoff point of 24 seconds at dis- dementia diagnosis. The PROMIS
fewer questions than legacy scores, charge in elderly patients with a hip CATs available were in English;
and decreasing the floor and ceiling fracture was used to predict falls at therefore, only English-speaking pa-
effects.3,5-7 The PROMIS physical 6 months.24 tients or proxies were included. Pa-
function (PF) item bank was devel- Only one study has considered the tients were recruited during the
oped through a rigorous process, use of proxies for PRO assessment in recovery from their injury at a time
and it has been increasingly used in the setting of trauma, and it tested the when they were able to complete the
the study of orthopaedic patients agreement between patient and proxy TUG. Proxy was defined as any
over the past several years.3,8-18 estimates of preinjury PF.2 Whether relative/significant other who had
PROMIS CAT instruments, there- proxies are good informants of been in touch with the patient in the
fore, represent an opportunity to patients’ PF and pain interference last month to the extent of being
have reliable and complete informa- (PI) during their recovery remains aware of the patient’s level of func-
tion about patients’ symptoms to unknown. tioning. Participants without a dis-
facilitate more timely and appropri- The primary goal of this study was cernible proxy and those who could
ate interventions. The geriatric pop- to evaluate the correlation between not answer patient-reported ques-
ulation is one of the most interesting patients and proxies’ responses to the tionnaires because they were delirious
targets of this initiative. However, PROMIS PF and PI after musculo- or they had cognitive impairment
PROMIS CAT tests could be chal- skeletal trauma. In addition, we seek (Confusion Assessment Method–
lenging for some vulnerable elderly to correlate patients’ reported PF with short form25 or Mini-Cog26 posi-
patients, requiring aid from their an objective measure of mobility, the tive, respectively) were excluded. In
proxies. TUG test. Finally, we evaluated fac- an effort to include all patients
The use of proxy-based assessment tors, such as age, frailty, and fre- and minimize selection bias, if the
scales in the geriatric population is quency of contact between the patient proxy was not present in clinic with
extensive.19-22 Some of them are and proxy or impaired mobility that an otherwise eligible patient, an
quick and economical questionnaires, may influence the agreement between attempt was made to contact and
and the answers are not influenced by patients and their proxies. interview the proxy within 1 week to
Dr. Heng or an immediate family member serves as a board member, owner, officer, or committee member of the New England Orthopaedic
Society. None of the following authors or any immediate family member has received anything of value from or has stock or stock options
held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Alvarez-Nebreda, Dr. Rosner,
Mr. McTague, Dr. Javedan, Dr. Harris, and Dr. Weaver.
February 15, 2019, Vol 27, No 4 e157
Proxy-reported Patient-reported Outcomes Measurement Information System in Elderly Patients
complete the questionnaire. This Comorbidity Index,29 the “FRAIL” coefficient was used to measure in-
study was approved by the institu- Questionnaire screening tool (FRAIL terrater agreement for ambulatory
tional review board. scale),30 ambulatory aid used at home aids. Statistical significance was as-
and out of the home, type of sessed at the 0.05 level. Analyses
injury/condition, treatment method, were conducted using SAS 9.3 and
Outcomes and Data and the frequency of contact between SPSS Statistics for Macintosh, Ver-
Collection patients and their proxies. sion 20 (IBM).
Patients and their proxies were ap-
proached in a clinic by a geriatrician
(M.L.A.-N.) to participate in the study. Statistical Analyses Results
After informed consent was obtained, Quantitative variables were described
demographic and injury data were by mean/SD or median/interquartile Four hundred twenty-five patients
collected. The patient and proxy were range and compared using the met the inclusion criteria and were
then independently administered the t-test, analysis of variance, and approached to participate in the
PROMIS PF and PI CAT. Proxies were the Wilcoxon signed-rank test. study. At least one exclusion criterion
instructed to answer for the patient to Qualitative variables were de- was present in 55 patients—31 of
the best of their knowledge. The scribed by percentages and com- which did not have a proxy and 24
patient then completed the TUG test. pared using the chi-square or Fisher had cognitive impairment; 70 pa-
All measures were administered elec- exact test. tients declined to participate. Of 300
tronically through an iPad accessing The relationship between patients patients, 76% came to the clinic
Research Electronic Data Capture, an and proxies’ PROMIS CAT PF and accompanied by a proxy. The
online HIPAA-compliant data man- PI scores was evaluated in three proxies who were not present in the
agement tool hosted by Harvard Cat- ways. First, comparing patients and visit were either phoned or sent
alyst–Partners HealthCare Research proxies’ scores using the Wilcoxon the questionnaire by e-mail, resulting
Computing, Enterprise Research signed-rank test. Second, the agree- in complete data from 273 proxies
Infrastructure & Services (ERIS).27 ment and bias were studied using a (91%) (Figure 1).
The primary goal of the study was Bland-Altman analysis, in which the The baseline characteristics of pa-
to determine the correlation and distribution of the score difference tients and proxies are described in
agreement of the PROMIS PF and PI between the patients and the prox- Table (see Supplemental Digital Con-
scores between patients and proxies. ies’ PF and PI were plotted versus tent 1, http://links.lww.com/JAAOS/
PROMIS measures use a T-score the mean of patient and proxy score, A140). Most of the patients were
metric in which 50 is the mean of the and linear regression was performed married women, mean age 75.7 years
general US population, and 10 is the to detect proportional bias. Third, (SD, 7.5), with a postsecondary
SD, with higher scores representing Spearman rank correlation was used degree, living with their spouses.
more of the concept being measured to assess the association between Almost half of the patients were
(eg, better PF, more PI).28 When PF/PI scores reported by patients and walking with no aid at home, and
administered using a CAT, the min- by proxies. The same method was 32% of them were using no aid out-
imum number of items asked is four. used to assess the correlation be- side. A correlation was found between
The CAT algorithm will ask addi- tween patients’ PF scores and TUG the description of the ambulatory aid
tional questions as required to scores. reported by patients and proxies
achieve a standard error of 0.33, up In addition, we evaluated differ- (kappa coefficient: 0.84 and 0.85,
to a maximum of 12 questions. ences in Spearman correlations respectively). Fractures of the femur
The TUG was conducted using a between patients and proxies when were the most prevalent (34%), fol-
chair with arms placed on a flat surface comparing subgroups, and each lowed by humerus fractures (9.9%).
with a line marking the 3-m turning comparison was represented graphi- Proxies were younger (mean age,
point. Subjects were instructed on the cally. Four subgroups were analyzed 62.2 years; SD, 13.8), half of them
word “go” to get up and walk to cross based on age, frequency of contact were patients’ spouses, with a slightly
the line marked on the path, then turn with proxy, frailty (as measured by higher level of education. Many pa-
around, walk back to the chair, and sit the FRAIL scale), and mobility (as tients and proxies had a close rela-
down again, and they were timed. measured by the TUG test). Correla- tionship: 74.7% of the proxies were
Additional data collected included tions between subgroups were com- in contact with the patient on a daily
sociodemographic information, edu- pared using probit transformation basis, and 50.2% of the total for
cational attainment, Charlson Age- methods.31,32 The Cohen kappa more than 12 hours per day.
Correlation of Patient- Figure 1

reported Outcomes
Measurement Information
System Physical Function
and Pain Interference Scores
Between Patients and
Proxies
A statistically significant correlation
of PF scores was found between pa-
tients and proxies (Spearman rho,
0.73; P , 0.001). On average, both
patients and proxies answered 4.3
questions (SD, 0.7). The median
PROMIS PF score was 33.1, being
the same for patients and for
proxies, P = 0.09 (Table 1). The
Bland-Altman analysis showed a
good agreement, with no systematic
bias (mean difference, 0.3), some
outliers in higher categories, and
slightly more agreement in lower Algorithm showing patient inclusion in the study
categories of PF but without pro-
portional bias (linear regression,
P = 0.35) (Figure 2).
The median PROMIS PI score was 0.001). However, proxies tended to (Table 1). Overall it took patients
58.5 for patients and 60.2, P , report a slightly higher degree of PI. 86.6 (SD, 55.1) seconds and proxies
0.001, for proxies. There was also a Patients required more questions on 70.7 (SD, 38.7) seconds to complete
positive and significant correlation average (5.4 6 2.9) compared with the PROMIS PI CAT (P = 0.001).
of PI scores between patients and proxies (4.9 6 2.4; P = 0.04) to The Bland-Altman analysis demon-
proxies (Spearman rho, 0.73; P , complete the PROMIS PI CAT strated the presence of a small
Table 1
PROMIS Physical Function (A) and Pain Interference (B): Score Comparison Between the Patient and Proxy
Difference PF Scores
Factor Patient PROMIS PF Proxy PROMIS PF (Patient PF-proxy PF) P Valuea
(A) PROMIS PF
Mean (SD) 34.2 (8.2) 33.9 (8.5) 0.3 (6.3) —
Median 33.1 33.1 0 0.09
Minimum–maximum 20 to 61.7 15.4 to 59.7 233.6 to 17.9 —
Interquartile range 27.2 to 40.7 26.8 to 39.4 22.0 to 3.7 —
Total no. of questions, mean (SD) 4.3 (0.7) 4.3 (0.7) — 0.88
(B) PROMIS PI
Mean (SD) 56.8 (10.2) 58.6 (9.5) 21.7 (7.1) —
Median 58.5 60.2 21.7 ,0.001
Minimum–maximum 38.7 to 76.4 38.7 to 80.1 231.8 to 31.6 —
Interquartile range 50.3 to 64.3 52.6 to 65.7 25.7 to 1.8 —
Total no. of questions, mean (SD) 5.4 (2.9) 4.9 (2.4) — 0.04
PF = physical function, PI = pain interference, PROMIS = Patient-reported Outcomes Measurement Information System
a
Wilcoxon signed-rank test.
February 15, 2019, Vol 27, No 4 e159
Figure 2 Correlation of the Patient-

reported Outcomes
Measurement Information
System Physical Function
Score With the Timed Up
and Go Score
The mean time for the patients to
perform the TUG was 25.3 seconds
(SD, 21.8; range, 4.9 to 230). The
percentage of patients who per-
formed the TUG in more than 24
seconds was 34.9%. A moderate
correlation was found between the
PROMIS PF and the TUG test
(Spearman rho, 20.58; P , 0.001).
The relationship between the scores
is shown in Table 2. The correlation
was higher in the group of patients
with lower extremity injuries
(Spearman rho, 20.65) than in those
with upper extremity injuries
(Spearman rho, 20.41).
Correlation of the
Patient-reported
Outcomes Measurement
Information System
Physical Function and Pain
Interference Scores
Between Patients and
Proxies by Subgroups
The correlation between patients
and proxies’ PF scores was signif-
icantly higher in nonfrail (as mea-
sured by the FRAIL scale) patients
(P , 0.001) and in those who
performed the TUG test in less
than 24 seconds (P , 0.001; Table
3; Figure 3). Older patients (.80
years) had a similar degree of
correlation of PF between the
patient and proxy as younger pa-
tients (aged 60 to 79 years) (P =
Bland-Altman plots showing the difference in PF scores (A) and PI scores (B) 0.22). Furthermore, proxies who
between patients and proxies against the mean of the two measurements. PF = have daily contact with the patient
physical function, PI = pain interference have a similar degree of correlation
between both PROMIS PF as
systematic bias (mean difference, statistically significant proportional proxies with less contact (P =
21.7); it showed some outliers in bias (linear regression, P = 0.09) 0.86). None of those variables
lower categories, and more agreement (Figure 2). No floor or ceiling effects markedly affected the correlation
in higher categories of PI, without were identified. between patients and their proxies
with respect to the PROMIS PI Table 2

questionnaire.
Relationship Between TUG Groups by Quartiles and the PROMIS PF Score
Discussion PROMIS PF Score

TUG Groups by Quartilesa n Mean 6 SD P Valueb
This study shows that good agreement
exists between ambulatory, cognitively Quartile 1 68 42.5 6 7.8 ,0.001
intact elderly patients’ and their prox- Quartile 2 69 36.4 6 6.8 —
ies’ perceptions of their PF and PI Quartile 3 68 33.6 6 6.3 —
during the recovery from musculo- Quartile 4 69 29.1 6 5.2 —
skeletal injury. Consequently, in that
PF = physical function, PROMIS = Patient-reported Outcomes Measurement Information
population, PROMIS PF and PI can be System, TUG = Timed Up and Go
a
administered to a proxy if the patient is b
25th percentile = 13.1; 50th percentile = 18.2; 75th percentile = 28.8.
ANOVA analysis.
unable to complete the questionnaire
during the appointment.
The conclusions of this study would
be applicable to a considerable num- because of the Affordable Care over time is unknown. A previous
ber of vulnerable patients coming to Act.33 Although the future of this study found how proxies’ percep-
the orthopaedic trauma clinic for legislation is still unclear, PROs are tions of patients’ function, measured
follow-up. It is worth to note that the being adopted more and more by using basic and instrumental activi-
use of technology by elderly patients both insurance companies as a ties of daily living, changed over
is sometimes challenging. Thus, measure of value and by clinicians to 6 months.37 It demonstrated that
visually impaired patients, as well as help gauge the results of treatment.34 proxy assessment showed less
those who lack experience in using The PF and PI instruments are of improvement and more deteriora-
tablets or filling online questionnaires, particular importance in patients with tion compared with the patients’
would indeed need the help of their musculoskeletal trauma, especially in own perceptions.
proxies. Patients with mild cognitive their CAT form. The PROMIS PF CAT Similarly, the patients’ mean PI
impairment or with focal neurologic has demonstrated to be highly reliable score was higher (56.8) than the
problems but without dementia may while very much shorter than the Short mean score of people within the
find themselves in the same predica- Musculoskeletal Function Assess- same age range in the US general
ment. Finally, there is the case of some ment3 or the Disabilities of the Arm,
population, which is 49.9 for people
particularly frail patients who feel Shoulder, and Hand (DASH and
aged 65 to 74 years and 49.7 for
exhausted before completing the QuickDASH) questionnaires.18
those aged 75 years or older.28 We
questionnaires. In our daily practice, This study confirms the results of
found good correlation between pa-
we often see proxies helping patients Stuart et al2 who found a similar level
tients and their proxies, although a
to answer the PRO assessments, or of agreement between patients and
small and likely clinically unimpor-
even providing answers on their their proxies with regard to the
preinjury level of function. Similar tant bias existed toward the proxies
behalf, but before the present study,
results were found in two more indicating a greater degree of PI.
no publications existed showing the
studies testing other proxy-based Although our study shows a gener-
reliability of proxies’ answers.
scales to measure PF in patients ally good correlation between pa-
Allowing proxies to complete these
questionnaires can help provide after stroke.35,36 tients’ and proxies with regard to
clinicians with useful information The mean PROMIS PF score for measuring pain, others have cautioned
regarding patients’ progress after patients was 34.2 and is over one SD that because pain can be a more
injury and surgery. It can also help lower than the mean score for people subjective experience, it may be less
reduce selection bias in research if within the same age range on the US amenable to proxy assessment.35,38
these patients would be otherwise general population, which is 47.2 in We also found a moderate correla-
excluded from studies. people aged 65 to 74 years and 45.6 tion between PF scores and the TUG.
PROs and the PROMIS instru- in those aged 75 years or older.28 In It is likely that a higher degree of
ments in particular are becoming this project, we studied single time correlation was not seen because the
more commonplace both in clinical points during patients’ recovery, but patient population we selected included
practice and in research.3,8-18 The use how patients and proxies differ in both upper and lower extremity in-
of PROs has increased, particularly their evaluation of their progress juries. When analyzed separately, the
February 15, 2019, Vol 27, No 4 e161
Table 3
Spearman Correlation Between Patients’ and Proxies’ PROMIS PF and PI Scores, by Subgroups
Correlation PROMIS PF Scores Correlation PROMIS PI Scores
Subgroups n Spearman Rho P Valuea Spearman Rho P Valuea
Age group, yr
60–79 181 0.72 0.22 0.70 0.26
.80 92 0.74 — 0.79 —
Frequency of contact group —
Nondaily 69 0.79 0.86 0.82 0.19
Daily 204 0.72 — 0.71 —
Frailty group —
Frail 92 0.55 ,0.001 0.71 0.62
Nonfrail 180 0.75 — 0.68 —
TUG group —
,24 s 162 0.76 ,0.001 0.77 0.11
$24 s 87 0.55 — 0.68 —
PF = physical function, PI = pain interference, PROMIS = Patient-reported Outcomes Measurement Information System, TUG = Timed Up and Go
a
Probit transformation analysis
correlation in the lower extremity in- TUG while in the clinic, which in turn with a physical test performed by the
juries group was higher. enables us to establish a link between patients could address that issue. We
Finally, the subgroup analysis the new PROMIS instruments and included ambulatory patients who
demonstrated that proxies are more the TUG test. were able to perform the TUG. The
accurate when informing about the correlation of elderly patients and
fittest patients (eg, nonfrail and fast their proxies’ answers to PROMIS
performers of TUG). That exem- Limitations PF in patients who are not able to
plifies, once again,39,40 how frailty The results of this study should be walk at all and who rely completely
and functionality—and not chrono- interpreted considering its limi- on the help of their proxies is ex-
logical age—are key features, which tations. First, we studied a selected pected to be high, but that should be
could determine different outcomes population of patients, and the con- demonstrated in future studies.
in elderly patients. This information clusions apply only to them. The Second, only patients who pre-
should be considered when using inclusion of English-speaking, cog- sented to the clinic were enrolled.
proxy’s answers in clinical practice nitively intact patients was manda- Data from a related study in progress
and for the design of future studies. tory to be able to use the PROMIS also conducted by our group show
CAT questionnaires. The same that patients who could not come to
approach was chosen in the only the clinic were the frailest ones, many
Strengths study published before about the of them living in long-term in-
To our knowledge, this is the first topic.2 The PROMIS CAT translated stitutions. It would be interesting to
prospective, large, cohort study that to other languages will probably be analyze the patient-proxy agreement
succeeds in demonstrating an agree- available soon. We could anticipate in the institutionalized population.
ment in patient and proxy correlates that caregivers of patients with Finally, TUG is a limited measure-
about PF and PI in elderly orthopae- dementia would be even better in- ment of PF, more related to lower
dic patients after injury and surgery, formants of patients’ PF. However, extremity PF than to upper extremity
and it will let us offer the PROMIS other caregiver-related factors, such function. Thus, the construct val-
instruments to the proxy in cases in as their feeling of burden or affective idity of TUG to measure PF, and
which ambulatory cognitively intact disorders, could affect their accuracy therefore its adequacy to be com-
patients cannot complete them. The as informants. Only a study compared with the PROMIS PF CAT,
prospective design of this study al- paring caregivers’ PROMIS PF an- could be limited too. Still, the corre-
lowed the patients to perform the swers about patients with dementia lation between TUG and PROMIS
Figure 3
Dispersion graphs showing the correlation of patients and proxies’ PF by subgroups: (A1) Nonfrail; (A2) Frail; (B1) Timed Up
and Go (TUG) , 24 seconds; (B2) TUG $ 24 seconds. PF = physical function
PF CAT found in this study was PROMIS PF and PI instruments. In tional impairment and pain in a
moderately good. situations in which some of those timely manner, and it will also
patients have difficulty complet- serve to include more vulnerable
ing questionnaires, proxies can be elderly patients in future studies
Conclusion used to obtain reliable information
measuring those important out-
about a patient’s PF and PI. This
Additional study of the PROMIS incomes. Further research about
information can be useful to better
struments in the geriatric population other potentially frail subgroups is
understand the patient’s clinical
is crucial. This study demonstrates picture, as well as for clinical out- needed to extend the conclusions to
that elderly ambulatory, cognitively comes research. The use of PROs the whole elderly population com-
intact orthopaedic trauma patients and proxy-reported PROs will ing to the orthopaedic trauma
and their proxies agree well on allow us to detect and treat func- clinic.
February 15, 2019, Vol 27, No 4 e163
4. Cella D, Riley W, Stone A, et al: The 16. Papuga MO, Mesfin A, Molinari R, Rubery
Acknowledgment Patient-reported Outcomes Measurement PT: Correlation of PROMIS physical
Information System (PROMIS) developed function and pain CAT instruments with
and tested its first wave of adult self- Oswestry Disability Index and Neck
The authors thank Madeline reported health outcome item banks: Disability Index in spine patients. Spine
McGovern for her assistance in data 2005-2008. J Clin Epidemiol 2010;63: 2016;41:1153–1159.
acquisition. This work was con- 1179-1194.
17. Morgan JH, Kallen MA, Okike K, Lee
ducted with support from Harvard 5. Bruce B, Fries J, Lingala B, et al: OC, Vrahas MS: PROMIS physical
Development and assessment of floor and function computer adaptive test compared
Catalyst/The Harvard Clinical and with other upper extremity outcome
ceiling items for the PROMIS physical
Translational Science Center (National function item bank. Arthritis Res Ther measures in the evaluation of proximal
Center for Research Resources and the 2013;15:R144. humerus fractures in patients older than
60 years. J Orthop Trauma 2015;29:
National Center for Advancing Trans- 6. Fries JF, Krishnan E, Rose M, et al: 257-263.
lational Sciences, and National In- Improved responsiveness and reduced
sample size requirements of PROMIS 18. Döring AC, Nota SP, Hageman MG,
stitutes of Health Award UL1 et al: Measurement of upper extremity
physical function scales with item response
TR001102) and financial con- theory. Arthritis Res Ther 2011;13:R147.
disability using the Patient-reported
Outcomes Measurement Information
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7. Fries JF, Witter J, Rose M, et al: Item
and its affiliated academic healthcare response theory, computerized adaptive 1160-1165.
centers. The content is solely the testing, and PROMIS: Assessment of
19. Jones C, Feeny D: Agreement between
responsibility of the authors and does physical function. J Rheumatol 2014;41: patient and proxy responses during
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not necessarily represent the official
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9. Hung M, Baumhauer JF, Brodsky JW, et al:
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February 15, 2019, Vol 27, No 4 e165
Research Article
Opioid Prescribing Practices of

Orthopaedic Surgeons: Results
of a National Survey
Abstract
Eli Raneses, MPH Introduction: Opioids are widely used after orthopaedic procedures.
Eric S. Secrist, MD Nonmedical opioid use is a growing public health issue.

Methods: An anonymous online survey was distributed by e-mail to
Kevin B. Freedman, MD, MSCE
the orthopaedic societies of all 50 states and several large private
David H. Sohn, MD, JD practices to assess practicing orthopaedic surgeons’ opioid
Thomas B. Fleeter, MD prescribing practices.
Christopher M. Aland, MD Results: A total of 555 orthopaedic surgeons practicing in 37 states
responded. The most commonly prescribed opioid for both teenagers
and adults was hydrocodone/acetaminophen. Of note, 42.3%
reported that a patient they have prescribed opioids for developed an
From the Rothman Institute
opioid dependency, whereas 35.3% do not believe that opioid use is a
Orthopaedics (Mr. Raneses,
Dr. Freedman, and Dr. Aland), problem in their practice. Of note, 30.3% reported prescribing refills,
Thomas Jefferson University, Atrium and factors significantly associated with increased prescribing of refills
Health, Charlotte, NC (Dr. Secrist), the
University of Toledo Medical Center,
included a greater number of years in practice (P , 0.001) and
Toledo, OH (Dr. Sohn), and the Town practicing in a suburban rather than an urban or rural environment
Center Orthopaedic Associates, (P = 0.03).
Reston, VA (Dr. Fleeter).
Conclusion: Orthopaedic surgeons rarely prescribe any refills, tend
Correspondence to Dr. Aland: to prescribe less opioids to teenagers than adults, and prescribe fairly
Chris.Aland@rothmaninstitute.com
uniformly for patients who are treated nonsurgically or undergo minor
Dr. Freedman or an immediate family or arthroscopic surgery. They exhibit considerable variation in
bureau or has made paid prescribing for fractures and major procedures.
presentations on behalf of Genzyme
and serves as a paid consultant to
DePuy. Dr. Aland or an immediate
family member has stock or stock
options held in ArthroCare and
Johnson & Johnson and serves as a
O pioid-based analgesia is widely
used and is effective in the
management of pain after orthopae-
heroin users increased from 106,000
to 178,000 between 2007 and 2011,
and according to one survey, 79.5%
board member, owner, officer, or dic procedures.1 The nonmedical use of individuals who began using heroin
committee member of the Arthroscopy
Association of North America. None of
of prescription opioids is an in- within the past year had previously
the following authors or any creasing public health issue in the abused prescription opioids.5 Ortho-
immediate family member has United States, though. Twelve mil- paedic surgeons are the fifth highest
received anything of value from or has lion people used prescription pain prescribers of opioids in patients aged
medication for nonmedical purposes 30 to 39 years and the third highest
related directly or indirectly to the in 2010,2 and other than marijuana, prescribers in patients older than 40
subject of this article: Mr. Raneses, no drug is more commonly abused years.6
Mr. Secrist, Dr. Sohn, and Dr. Fleeter. by Americans.3,4 This causes more Prescription opioid use is particu-
J Am Acad Orthop Surg 2019;27: deaths annually than cocaine and larly concerning among teenagers,
e166-e172 heroin combined,4 and heroin use is who are vulnerable to substance
DOI: 10.5435/JAAOS-D-16-00750 19 times higher among individuals abuse issues.5 In one survey, 17.6% of
who have abused prescription high school seniors had used pre-
Academy of Orthopaedic Surgeons. opioids than among those who have scription opioids medically and
not.5 The number of estimated new 12.9% had used them nonmedically.7
Eli Raneses, MPH, et al
Table 1
Defined Daily Dose Range and Equianalgesic Ratio for Various Opioids and Formulations
Drug Adm. DDD (mg) Range Equianalgesic Ratio
Morphine PO 100 1 1
Morphine PA 30 — 3
Oxycodone PO 75 1.3–2.0 1.5
Buprenorphine TD 1.2 110 110
Buprenorphine SL 1.2 33.3-60 50
Fentanyl TD 1.2 68-150 100
Fentanyl SL 0.6 50 50
Hydromorphone PO 20 3.6-8.0 6
Ketobemidone PA 50 3.0 3
Ketobemidone PO 50 1 1
Pethidine PO 400 0.03-0.13 0.1
Codeine PO 90/120a 0.05-0.15 0.1
Tramadol PO 300 0.1-0.2 0.2
Dihydrocodeine PO 150 0.1-0.16 0.13
Dextropropoxyphene PO 140a 0.15 0.15
DDD = defined daily dose, PA = parenteral, PO = per oral, SL = sublingual, TD = transdermal

a
The DDD for these compounds is based on combinations with paracetamol.
Equianalgesic ratio: potency of respective opioid/opioid formulations compared with oral morphine.
Adapted with permission from Svendsen, K, Borchgrevink, P, Fredheim, O, Hamunen, K, Mellbye, A, Dale, O: Choosing the unit of measurement
counts: The use of oral morphine equivalents in studies of opioid consumption is a useful addition to defined daily doses. Palliat Med
2011;25:725-732.
Orthopaedic surgeons are common focusing on opioid prescribing paedic surgeries and conditions in
care providers for this population, as practices among this group. both teenagers and adults. We
2 million high school athletic injuries The relative strength of opioid hypothesized that there would be
occur each year,8,9 and approxi- medications is an important consid- wide variation in opioid prescribing
mately one in four emergency eration when prescribing these med- practices for any given orthopaedic
department visits by children and ications for pain control. Previous procedure and that some orthopaedic
adolescents are related to sports in- studies have attempted to determine surgeons would overprescribe rela-
juries.10 In one study, males who equianalgesic ratios between various tive to their peers.
participated in high-injury sports (eg, opioids and morphine (Table 1, re-
wrestling, football) had 50% higher printed with permission).19 A pa-
odds of nonmedical use of prescrip- tient’s height and weight influence Methods
tion opioids than adolescents who the volume of distribution of stan-
did not participate in those sports,11 dard dosages of these medications, Surveying
and opioid prescriptions nearly and genetic variations in pharmaco- An anonymous online survey (see
doubled among adolescents from kinetics and pharmacodynamics can Appendix, Supplemental Digital
1994 to 2007.3 This underscores the influence an individual patient’s Content 1, http://links.lww.com/
importance of safe prescription response to one medication relative JAAOS/A157) was used to assess
practices, and several studies have to another,20 but these equianalgesic practicing orthopaedic surgeons’
surveyed physicians to determine ratios can provide a baseline under- opioid prescribing practices. The
what prescription practices are cur- standing of the relative amount of survey was developed based on other
rently being used.12-16 Despite pre- opioid activation provided by vary- published prescribing practices sur-
scribing prescription opioids at a ing dosages of medications com- veys, as well as expert opinion.21,22
higher rate relative to other physi- monly used in this setting. The survey was initially piloted at
cians17,18 and treating adolescents This study surveyed orthopaedic our institution and modified for
with a high frequency, we are surgeons on current opioid prescrip- length and phrasing before wider
unaware of any previous study tion practices for common ortho- distribution.
February 15, 2019, Vol 27, No 4 e167
Opioid Prescribing Practices of Orthopaedic Surgeons
Figure 1 0.05. Because this is a pilot study

on prescription practices, a power
analysis was not preformed.
Results
Surgeon Demographics
A total of 555 orthopaedic surgeons
practicing in 37 states and the District
of Columbia responded to the survey,
with a response rate of 15%. The
state with the most respondents was
California (36.6%), followed by
Pennsylvania (15.3%), Texas (8.1%),
Michigan (3.6%), and New York
(3.6%). Eighteen of the responding
states had fewer than 5 responses. Of
the respondents, 93% were men,
with an average of 28.6 (SD, 12.6)
years in practice. The most re-
spondents reported primarily prac-
ticing in an urban location (46.7%),
Pie chart showing the distribution of subspecialties within orthopaedic surgery followed by suburban (39.3%) and
among surgeons who completed the questionnaire. rural (14.1%) locations. The propor-
tion of surgeons practicing in each
subspecialty is shown in Figure 1.
We first distributed the survey Society sampling because it was the Most surgeons (57.5%) operated on
through the Pennsylvania Orthopae- only state society that we have seven or more patients per week, with
dic Society, via both mass e-mail and accurate survey distribution and 25.8% reporting that they operated
physical distribution at their fall denominator data for. on two or more teenagers per week.
2015 annual meeting. We then dis- The survey asked which opioid
tributed the survey through e-mail to medications surgeons would typically
the orthopaedic societies of all 50 prescribe to an adult or teenager for a Surgeon Prescribing
states, as well as several large private given procedure, how many tablets Practices
practices. The e-mails were not all they would provide, how many refills The typical opioid prescriptions
sent at once and were distributed they would authorize, the surgeons’ reported by survey respondents for
around the time of the orthopaedic backgrounds, and whether practice adult and teenage patients undergo-
societies’ annual meetings. Because protocols were in place for opioid ing nonsurgical treatment, minor or
some societies did not wish to share prescribing at their clinic. arthroscopic procedures, reconstruc-
their mailing lists, we provided the tive surgery, and fracture repair are
survey and its link to the leadership detailed in Tables 2 and 3. A subset
of the societies for them to distribute. Statistical Analysis of the sample (18.6%) did not report
Surveys were distributed digitally Statistical analysis was performed performing major or reconstructive
from October 2015 until January using the R statistical package (R procedures on teenage patients. When
2016, and we collected responses to Foundation for Statistical Comput- all procedures were analyzed as a
the survey from October 2015 until ing). Demographics were assessed whole, the most commonly prescribed
March 2016, giving respondents descriptively, and associations were opioid for both teenagers and adults
2 months to respond to the survey analyzed using the Fishers exact test was hydrocodone/acetaminophen.
after it was distributed to them. We for categoric variables and the Mann- Forty-six percent of surgeons re-
have estimated our overall response Whitney U test for continuous vari- ported that they typically stop pre-
rate based on our response rates ables. Associations were considered scribing narcotic medications at
from the Pennsylvania Orthopaedic significant at a P value less than 4 weeks or less postoperatively,
Table 2
Reported Prescribing to Adults
Minor
Nonsurgical Surgery Reconstructive Fractures
Drug (n = 542) (n = 538) Surgery (n = 539) (n = 528)
Hydrocodone/acetaminophen 22.10% 59.70% 33.60% 47.00%

Oxycodone/acetaminophen 5 3.30% 16.50% 39.90% 31.60%
Acetaminophen/codeine 10.10% 13.80% 3.50% 7.20%
None 64.20% 5.90% 2.80% 4.20%
Oxycodone 0.20% 2.00% 8.00% 3.60%
Oxycodone/acetaminophen 7.5 — 1.90% 9.80% 5.90%
Hydromorphone — 0.20% 1.30% 0.20%
Morphine — — 1.10% 0.40%
Table 3
Reported Prescribing to Teens
Minor Reconstructive
Nonsurgical Surgery Surgery Fractures
Drug (n = 539) (n = 535) (n = 507) (n = 516)
Hydrocodone/acetaminophen 8.20% 47.30% 42.20% 45.70%

Oxycodone/acetaminophen 5 1.10% 10.80% 26.00% 17.80%
Acetaminophen/codeine 13.20% 29.00% 11.80% 21.10%
None 77.40% 10.80% 10.80% 10.10%
Oxycodone 0.20% 1.70% 4.30% 2.90%
Oxycodone/acetaminophen 7.5 — 0.20% 3.90% 2.10%
Hydromorphone — 0.20% — —
Morphine — — 0.80% 0.20%
whereas 40% reported typically ated with prescribing any refill (P =

Table 4
stopping between 4 and 8 weeks 0.03), with suburban practitioners re-
postoperatively, and 14.4% reported porting higher refill prescribing than Percentage of Respondents Who
Reported Prescribing Refills
typically stopping at greater than expected and urban and rural practi- (n = 555)
8 weeks postoperatively. tioners prescribing less than expected.
To To
Overall, only 30.3% of surgeons Prescribing any refills was not associ- Factor Adults Teens
prescribed any refills. Most refills were ated with physician subspecialty or the
prescribed for reconstructive proce- number of surgeries performed weekly Nonsurgical 5.6 4.9
dures and fractures for both teenage (P = 0.33 and P = 0.33, respectively). Minor surgery 10.1 7.9
patients and adults (Table 4). A smaller Prescribing any refill was also not Fractures 19.6 14.6
proportion of surgeons prescribed re- associated with whether the physician Reconstructive 23.2 15.0
fills to teenagers than adults (20.7% had a patient in the past who devel-
versus 27.9%), and prescribing refills oped an opioid addiction (P = 0.71),
to adults was significantly associated whether the physician discussed opioid Among respondents to this survey,
with prescribing refills to teenagers use with their patients (P = 0.24), 42.3% reported that they had knowl-
(P , 0.0001). A greater number of whether their office used a pain man- edge of a patient that they have pre-
years in practice (30.5 versus 27.8 agement protocol (P = 0.64), and scribed to who developed an opioid
years) was significantly associated with whether they believed opioid depen- dependency. Forty-six percent reported
prescribing any refill (P , 0.001). dence was an issue in their practice that they agreed that opioid use was an
Location of practice was also associ- (P = 0.91). issue in their practice, 35.3% did not
February 15, 2019, Vol 27, No 4 e169
believe that opioid use was an issue in sitivity analysis to analyze whether oid medication to teenagers than
their practice, and 18.6% were neutral. there was an undue effect of their re- adult patients, 42.3% reported that
In a survey of primary care physicians sponses on the average prescriptions. they were aware of a previous patient
published in JAMA in 2015, mean- Overall, the respondents from Cal- who had developed an opioid addic-
while, 90% reported that they believed ifornia had more practice years on tion, 85.2% reported that they dis-
that prescription drug abuse was a average (31.7 versus 26.8), and a higher cuss opioid use with their patients
“big” or “moderate” issue in their proportion practiced in an urban set- before surgery, and 46.7% reported
communities.23 Surgeons’ beliefs re- ting than respondents from the other that their office uses a pain manage-
garding whether opioid use was an states (57.6% versus 40.3%). Re- ment protocol. Importantly, physi-
issue in their practice was not spondents from California tended to cians who reported working in a
associated with a surgeon’s number of prescribe similarly to other states, clinic using an opioid prescription
years of practice (P = 0.42), practice except for adult fractures and adult protocol were more likely to discuss
location (P = 0.21), use of a pain reconstructive procedures, where the these medications with their patients
management protocol (P = 0.11), or most commonly prescribed medication preoperatively, indicating that
whether they discussed previous opi- was hydrocodone/acetaminophen increased utilization of these may be a
oid use with their patient (P = 0.47). instead of oxycodone/acetaminophen way to spur better physician-patient
Of the respondents to this survey, 5/325. communication.
85.2% of surgeons reported discussing In this study, less than a third of
previous opioid use with their pa- surgeons reported prescribing refills
tient before surgery, whereas 46.7% Conclusion for opioids, and most of these refills
reported that their office uses a pain were prescribed for major procedures
management or prescribing protocol Although opioids are widely used for and fractures. A recent study in
for narcotics. Meanwhile, in a survey postoperative pain control after pediatric patients undergoing spinal
of primary care physicians published in orthopaedic procedures,1 issues related fusion found that 72% did not
2007, 56% reported that they had a to the nonmedical use of prescription require any refills.24 At least one
system established in their clinic to opioids have been described as an study has shown that less than 10%
track patients who are prescribed epidemic in the United States. The of their patients needed a refill on
chronic narcotics, and 75% reported nonmedical use of opioid medication their prescription and that 89% of
having a policy established for after- causes more deaths annually than the patients used less than 20 hy-
hour narcotic replacement.15 Knowl- cocaine and heroin combined,4 and drocodone after common sports
edge of a previous patient who had heroin abuse is 19 times higher medicine procedures.25 In this con-
developed an opioid dependency was among individuals who have abused text, the practice of typically provid-
not associated with whether a surgeon prescription opioids than among ing refills needs closer examination.
would discuss previous use (P = 0.18) those who have not.5 To better Most surgeons (65.2%) reported
or with reporting that their office define the role of orthopaedic sur- that they believed that the most
used a pain management protocol geons in fueling this issue, we common way for teenagers to obtain
(P = 0.23). Those working in a prac- endeavored to define the current narcotics was through their parent’s
tice using a pain management proto- practices of orthopaedic surgeons in medication supplies, followed by
col reported discussing previous use the United States. purchasing from a friend (17.3%).
more often than those who do not To our knowledge, this is the only The 2013 and 2014 National Survey
use a protocol (P , 0.005). published survey of orthopaedic sur- on Drug Use and Health from the
Most surgeons (65.2%) reported geon opioid prescribing practices to Substance Abuse26 and Mental Health
that they believed that the most date. It demonstrates that orthopae- Services Administration reported that
common way for teenagers to dic surgeons tend to prescribe fairly most of those who misused prescrip-
obtain narcotics was through their uniformly for patients who are treated tion painkillers got them from a
parent’s medication supplies, fol- nonsurgically or undergo minor or friend or relative, in line with what
lowed by purchasing from a friend arthroscopic surgery but exhibit most surgeons reported. However,
(17.3%). considerable variation in prescribing the second most commonly reported
for fractures and major procedures. means of obtaining narcotics ac-
Most surgeons do not prescribe any cording to the 2013 and 2014
Subgroup Analysis refills, and morphine, hydromorphone, National Survey on Drug Use and
As a large subset of our sample reported and oxycodone are rarely prescribed. Health was from a doctor. These
from California, we performed a sen- Surgeons report prescribing less opi- data show that most surgeons seem
to have some understanding of surgeons who are members of their iations in prescribing practices
where their patients or nonprescrip- local and state medical societies or between states with different laws
tion opioid abusers are most likely to those who are a part of large ortho- regarding opioid prescriptions would
obtain narcotics for nonmedical use paedic practices were solicited to help decipher the effects this legisla-
but may underestimate the role that participate. It also meant that we tion has on prescribing practices, and
they play in contributing to this could not obtain an accurate overall additional research is needed regard-
issue. It also highlights the impor- response rate. We estimated our ing the amount of these medications
tance of proper disposal of opioids response rate from the Pennsylvania that patients use postoperatively. To
following cessation of usage after an Orthopaedic Society sampling be- date, we are aware of only a few
orthopaedic procedure, and a recent cause it was the only group in which studies, which have analyzed patient-
study in pediatric patients found that we could obtain both an accurate reported postoperative opioid use in
only 59% planned to dispose of their gauge of the distribution and an the orthopaedic setting.24,30 These
unused medications in a manner accurate denominator. Our response studies have demonstrated that pa-
recommended by the US Food and rate from the Pennsylvania Ortho- tients typically have leftover pills
Drug Administration.24 paedic Society was approximately after they stop taking opioids post-
Because this is the first nationwide 15%. Finally, as this issue has rapidly operatively, and every unused pill
study on the opioid prescribing habits gained the attention of the general that is not disposed of carries some
of orthopaedic surgeons, it provides a public, many state laws, or specific degree of risk that it will eventually
barometer for groups interested in policy guidelines have been enacted. be taken for nonmedical purposes. It
assessing their opioid prescription This includes policies aimed at the is absolutely vital that every effort be
practices. Medical practices, state establishment of pain clinics, policies made to limit excessive prescriptions.
orthopaedic associations, hospital requiring physicians to use and Whereas this study documents how
systems, or other groups could use review Prescription Drug Monitoring many orthopaedic surgeons currently
these results to conduct internal sur- Programs, and guidelines directly prescribe, additional research into
veys of their practitioners to assess aimed at prescription practices such how many of these medications pa-
their prescription practices relative to as those in use in Washington state, tients actually take after various
nationwide trends. To aid in this those proposed by Medical Board of surgeries would provide an evidence
process, we have provided the origi- California, among others.22,27-29 We base for physicians to use in deter-
nal text of our survey in the supple- were not able to analyze the influ- mining how much they should
mental section of this article. This ence these may have had on pre- prescribe.
study may also encourage surgeons scribing practices in various states.
and their practices to begin to develop Because this is a descriptive study,
their own pain management protocol these findings should not be consid-
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Research Article
Hip Arthroscopy for

Femoroacetabular Impingement
and Labral Tears in Patients
Younger than 50 Years: Minimum
Five-year Outcomes, Survivorship,
and Risk Factors for Reoperations
Abstract
Itay Perets, MD Introduction: There is a paucity of literature on mid-term outcomes
Edwin O. Chaharbakhshi, BS for hip arthroscopy for femoroacetabular impingement and labral
tears.
Jackob Shapira, MD
Methods: Inclusion criteria were age at surgery ,50 years and
Lyall Ashberg, MD documented preoperative patient-reported outcomes. Patients with a
Brian H. Mu, BA Tönnis grade .0 or previous ipsilateral hip conditions were excluded.
Benjamin G. Domb, MD Results: Of 407 eligible cases, 327 hips (295 patients) had minimum
5-year follow-up. Mean age was 32.4 years. All mean patient-reported
outcomes and visual analog scale improved at follow-up (P , 0.001).
Mean satisfaction was 7.9. Thirty-eight hips (11.6%) required
secondary arthroscopy at a mean of 25.1 months. Survivorship
at minimum 5 years was 92.4%. The complication rate was 7.0%.
Conclusions: Hip arthroscopy for management of femoroacetabular
impingement and labral tears in patients aged ,50 demonstrates
favorable and safe mid-term outcomes. Several risk factors for
conversion to total hip arthroplasty in this age group warrant cautious
patient selection for arthroscopy.

Orthopaedics, Hadassah Hebrew
H ip arthroscopy for management
of femoroacetabular impinge-
ment (FAI) and labral tears is a rela-
literature for a variety of demo-
graphics and conditions, mid-term
outcomes are limited. Furthermore,
University Hospital, Jerusalem, Israel tively new surgical procedure that has the question as to whether or not
(Dr. Perets), American Hip Institute in
Chicago (Dr. Perets, Dr. Shapira, been well documented in the litera- outcomes of hip arthroscopy deteri-
Mr. Mu, Mr. Chaharbakhshi, and ture as safe and effective for those orate between the short and mid-
Dr. Domb), Chicago, IL, and Atlantis who failed to improve with conser- term remains unclear.
Orthopaedics, Atlantis, FL. vative treatment.1-5 In the context of The purpose of this study was to
Correspondence to Dr. Domb: the rapid expansion and continued report minimum 5-year outcomes,
DrDomb@AmericanHipInstitute.org improvements in hip arthroscopy, it survivorship, risk factors for future
J Am Acad Orthop Surg 2019;27: is vital to delineate guidelines for reoperation, and complications for
e173-e183 appropriate patient selection based patients younger than 50 years
DOI: 10.5435/JAAOS-D-17-00258 on risk factors, survivorship, and undergoing hip arthroscopy for man-
trends in outcomes over time. agement of FAI and labral tears. We
Academy of Orthopaedic Surgeons. Although short-term outcomes have hypothesized that this cohort of pa-
been well reported throughout the tients would demonstrate favorable
February 15, 2019, Vol 27, No 4 e173
Hip Arthroscopy Outcomes
Figure 1 tears and FAI between April 2008 mentous laxity and positive appre-
and October 2011. During this study hension were also evaluated for
period, a total of 913 hip arthroscopies during the examination.6 To diag-
were performed. To generate the nose FAI, anterior, lateral, and pos-
cohort for this study, the following terior hip impingement tests were
inclusion criteria were applied: patients performed. As previously described
aged ,50 years, preoperative diag- by Byrd,7 anterior impingement was
nosis of FAI and labral tear, under- tested for using forced flexion and
went hip arthroscopy for management IR. Lateral impingement was tested
of FAI and labral tear, and had pre- for using forced abduction and ER.
operative baselines for the modified Posterior impingement was tested for
Harris Hip Score (mHHS), the Non- by positioning the afflicted leg in
arthritic Hip Score (NAHS), Hip extension and ER.8 All examinations
Outcome Score–Sports Specific Sub- were performed by the senior
scale (HOS-SSS), and visual analog author, a sport medicine fellowship-
scale (VAS). Patients with arthritic trained orthopaedic surgeon.
changes (Tönnis osteoarthritis grade
. 0), previous hip conditions includ- Preoperative Radiographic
ing hip fractures, slipped capital fem- Measurements
oral epiphysis, osteonecrosis of the
femoral head, hip dysplasia (lateral We obtained a series of preoperative
center-edge angle ,18), and previous radiographs for all patients who
ipsilateral surgical intervention were underwent hip arthroscopy at our
excluded. The details of our patient institution. The radiographs used were
selection process are summarized in as follows: AP pelvis, false profile,
Figure 1. All patients participated in Dunn view, and cross-table lateral. The
the American Hip Institute Hip Pres- AP radiograph was used to measure
ervation Registry. While the present each hip’s lateral center-edge angle
study represents a unique analysis, (LCEA) of the Wiberg9 and Tönnis
data on some patients in this study angle. The false profile view was used
may have been reported in other to measure the anterior center-edge
A flow-chart of the patient selection studies. All data collection received angle of Lequesne.10 The Dunn view
process. was used to measure the alpha angle
Institutional Review Board approval.
of each hip.11 A hip with an alpha
angle $60 was identified as having a
mid-term outcomes and that the Preoperative Physical cam lesion. Pincer deformities were
results would not deteriorate from Examination identified by identifying, protrusio
2-year outcomes. Patients undergoing hip arthroscopy acetabuli,12 ischial spine sign,13
at our institution undergo routine crossover sign,14 LCEA . 40,15 or
physical examinations of the hip. The anterior center-edge angle .40.16 All
Methods range of motion of each symptomatic patients underwent MRI to identify
hip was measured by examining labral tears, assess the integrity of the
Patient Selection Criteria internal rotation (IR), external rota- cartilage, and identify other patholo-
Data points were prospectively col- tion (ER), and flexion. Both IR and gies. All radiographic measurements
lected and retrospectively reviewed ER were measured with the patient were performed using GE Health-
on all patients who underwent hip positioned supinely and both the hip care’s Picture Archiving and Com-
arthroscopy for management of labral and the knee flexed to 90. Liga- munication System.
Dr. Domb or an immediate family member has received royalties from Arthrex, DJO Global, MAKO, Stryker, and Orthomerica; is a member
of a speakers’ bureau or has made paid presentations on behalf of Arthrex and Pacira Pharmaceuticals; serves as a paid consultant to
Adventist Hinsdale Hospital, Amplitude, Arthrex, MAKO, Medacta, Pacira Pharmaceuticals, and Stryker; and has received research or
institutional support from Arthrex, ATI, Breg, Kaufman Foundation, Medacta, Pacira Pharmaceuticals, and Stryker. None of the following
authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or
institution related directly or indirectly to the subject of this article: Dr. Perets, Mr. Chaharbakhski, Dr. Shapira, Dr. Ashberg, and Mr. Mu.
Itay Perets, MD, et al
Hip Arthroscopy Surgical performed using a beaver blade in distributed before comparative anal-
Technique patients presenting with painful ysis. For comparing preoperative
internal snapping. The ligamentum and minimum 5-year scores, the
All hip arthroscopies were performed
teres was débrided in cases pre- 2-tailed paired t-test or Wilcoxon
by the senior author (B.G.D.). The
senting with partial or complete signed-rank test were used for nor-
indications for surgical intervention
tears. The capsule was either mally and nonnormally distributed
primarily included clinical and
released, repaired, or plicated at the data, respectively. Patients with
radiographic evidence of labral tears
end of the procedure based on scores at the 2-year and minimum
and FAI as well as failure to improve
whether the patient demonstrated 5-year time points were also com-
with conservative treatment. Patients
ligamentous laxity and/or borderline pared for score change using the
were positioned on a well-padded
dysplasia on radiographs (18 # aforementioned tests. The chi-squared
perineal post in the modified supine
LCEA # 25). and Fisher exact tests were performed
position. Traction was applied
to identify risk factors for requiring
to the nonsurgical leg and to the future secondary arthroscopy and
surgical leg as needed. A minimum
Patient-reported Outcomes
Tools converting to THA. All data analyses
of two portals were used: the were performed using Microsoft
standard anterolateral and mid- Consenting patients who underwent
Excel (Microsoft Corporation).
anterior accessory portals. Inter- hip arthroscopy at our institution
portal capsulotomy was performed completed preoperative questionnaires
using a beaver blade to access the to document baseline scores for
joint. The hip joint was vented, mHHS, NAHS, HOS-SSS, and VAS. A Results
followed by diagnostic arthroscopy VAS of 0 indicated no pain, and 10
to evaluate the conditions of the indicated the highest pain possible. Patient Demographics
labrum, intra-articular cartilage, Patient-reported outcomes (PROs),
Of 407 hip arthroscopies eligible for
and ligamentum teres. Labral tears VAS, and satisfaction were routinely
inclusion, 327 cases (295 patients)
were intraoperatively classified using collected each year postoperatively.
had minimum 5-year follow-up
the classification by Seldes et al.17 The Satisfaction was scored on a scale
(80.3%) and were therefore in-
Acetabular Labrum Articular Dis- from zero to 10, with zero being
cluded for analysis. The mean follow-
ruption (ALAD) and Outerbridge completely unsatisfied and 10 being
up time was 68.7 months (range, 60.0
classifications were used to define the highest satisfaction possible. All $
to 102.9). Of the 327 cases, 108
acetabular and femoral head carti- 5-year mHHS were analyzed regard-
(33.0%) were male and 219 (67.0%)
lage defects.18,19 Ligamentum teres ing patient acceptable symptomatic
were female. The mean age at surgery
defects were defined using the Domb state and minimal important change,
was 32.4 years (range, 14.2 to 49.9),
and Gray and Villar20 classifications. mHHS $ 74 and DmHHS $ 8,
which was approximately 2 years
Bony deformities were corrected respectively.21,22 Questionnaires were
after the mean age at onset of
using a burr under fluoroscopic completed during clinic appointments,
hip symptoms. Thirty-eight hips
guidance. Cam lesions were corrected through e-mail or telephone interview.
(11.6%) in 37 patients required sec-
by performing femoroplasty, and Patients with preoperative baseline
ondary arthroscopy at a mean of
pincer lesions were corrected by per- scores that had complete documenta-
25.1 (range, 0.9 to 82.7). Twenty-
forming acetabuloplasty. Labral tion of PROs, VAS, and satisfaction
five hips (7.6%) converted to THA
tears were either repaired, resected, at a minimum of 5 years or had
at a mean of 37.0 months postoper-
or selectively débrided to achieve converted to total hip arthroplasty
atively (92.4% survivorship). Surgi-
stability. In cases of selective (THA) were considered to have
cal complications included 16 cases
débridement, the labrum was pre- had minimum 5-year follow-up. Pa-
(4.9%) of numbness and/or tingling
served as much as possible while tients missing any of the aforemen-
of the lower extremity, three cases
fully treating any defects. In cases tioned scores were considered lost to
(0.9%) of heterotopic ossification,
follow-up.
with irreparable labra, a labral three cases (0.9%) of infection that
reconstruction was performed using resolved with antibiotics treatment,
hamstring allograft. An acetabu- Statistical Analysis and one case (0.3%) of femoral
lar or femoral head microfracture The threshold for statistical signifi- neck stress fracture that was man-
was performed in hips presenting cance was set to 0.05. The Shapiro- aged with in situ pinning. Patient
with full-thickness chondral defects. Wilk test was performed to determine demographics are summarized in
Iliopsoas fractional lengthening was whether data points were normally Table 1.
February 15, 2019, Vol 27, No 4 e175
Table 1 To determine whether outcomes

were markedly changed at mid-term
Demographics for Patients Aged , 50 Years Who Underwent Hip
Arthroscopy for the Management of Femoroacetabular Impingement and follow-up, minimum 5-year out-
Labral Tears With Minimum 5-year Follow-up comes were compared with 2-year
outcomes. Mean scores at 2 years and
Patients 295
at a minimum of 5 years postopera-
Hips 327
tively were as follows: mHHS (83.1
Left 157 (48.0%)
to 83.3), NAHS (82.2 to 83.2),
Right 170 (52.0%)
HOS-SSS (72.3 to 72.3), VAS (2.7 to
Sex
2.4), and satisfaction (8.1 to 7.9).
Male 108 (33.0%)
Among the 306 patients who did not
Female 219 (67.0%) convert to THA, 231 (75.5%) sur-
Age at onset of symptoms (yr, mean, SD, 30.2 6 10.9 (8.4–49.2) passed the patient acceptable symptom-
range)
atic state cutoff (mHHS $ 74) and
Age at surgery (yr, mean, SD, range) 32.4 6 10.9 (14.2–49.9)
230 (75.2%) had an MCID at lat-
BMI (mean, SD) 24.6 6 4.9 (16.3–43.6)
est follow-up. All PROs demon-
Follow-up time (mo, range) 68.7 6 8.0 (60.0–102.9)
strated no deterioration from
Follow-up percentage 80.3 2 years to minimum 5 years follow-
Future reoperation and end points up (Figure 2).
Required future secondary arthroscopy 38 (11.6) A subgroup analysis based on the
(n, %)
duration of symptoms before surgery
Time to secondary arthroscopy (mo, mean, 25.1 6 20.0 (0.9–82.7)
SD, range) (,1 versus $1 year) demonstrated
no notable differences or trends in
Converted to hip resurfacing (n, %) 5 (1.5)
mean preoperative or follow-up
Converted to total hip replacement (n, %) 20 (6.1)
outcomes scores. A second sub-
Total conversion to THA (n, %) 25 (7.6)
group analysis was performed based
Time to THA (mo, mean, SD, range) 37.0 6 24.1 (4.1–95.2)
on the clockface labral tear size from
BMI = body mass index, THA = total hip arthroplasty anterior to posterior (,2 versus $2).
No differences or trends were ob-
served based on mean preoperative
Arthroscopic Findings and decortication performed in the cases scores. Follow-up scores were sta-
Procedures without pincer deformities. Femoral tistically significantly inferior in pa-
head osteoplasty was performed in tients with clockface tears $ 2: mean
All hips had a Seldes-defined labral
217 hips (66.4%). More patients mHHS (86.5 versus 82.3; P = 0.04),
tear. In regard to chondral defects,
underwent capsular repair/plication mean international hip outcome
197 hips (60.2%) had an ALAD (52.9%) as opposed to release. tool-12 (78.2 versus 70.0; P = 0.01),
grade $ 2, 189 (57.8%) had an mean HOS-SSS (78.1 versus 70.2;
acetabular Outerbridge grade $ 2, P = 0.02), and mean VAS (1.9 versus
and 69 (21.1%) had a femoral head Patient-reported Outcomes 2.5; P = 0.04). Mean NAHS (86.2
Outerbridge grade $ 2. There were at $ 5 Years Postoperatively versus 82.1; P = 0.06) and mean
162 hips (49.5%) with a ligamentum Mean mHHS, NAHS, HOS-SSS, and patient satisfaction (8.3 versus
teres tear. These findings are sum- VAS demonstrated significant im- 7.8; P = 0.12) also trended lower
marized in Table 2. provements from preoperatively to in this group, but statistically sig-
The primary arthroscopic proce- minimum 5 years postoperatively nificant differences could not be
dures performed in this cohort are (P , 0.001). These findings are identified.
summarized in Table 3. All 327 summarized in Table 4. The mean
labral tears were managed with improvements for the aforemen-
labral repair (69.7%), selective tioned PROs and VAS were as fol- Secondary Arthroscopies
débridement (26.3%), resection lows: mHHS (62.4 to 83.3), NAHS The 38 hips that required future sec-
(1.8%), or reconstruction (2.1%). (58.8 to 83.2), HOS-SSS (43.1 to ondary arthroscopy were compared
Acetabular osteoplasty was per- 72.3), and VAS (5.9 to 2.4). Mean with the 267 hips that did not require
formed in 255 hips (77.7%) to satisfaction at latest follow-up was any future operations to identify
manage pincer lesions, with minimal 7.9. potential risk factors for secondary
Table 2 Table 3
Hip Arthroscopic Intraoperative Hip Arthroscopic Procedures Performed in Patients Aged , 50 Years
Findings in Patients Aged , 50
Years Factor n (%)
Factor n (%) Labral treatment 327 (100)

Repair 228 (69.7)
Labral tear 327 (100)
Débridement 86 (26.3)
Seldes I 165 (50.5)
Resection 6 (1.8)
Seldes II 84 (25.7)
Reconstruction 7 (2.1)
Combined Seldes I 78 (23.9)
and II Acetabular osteoplasty 254 (77.7)
ALAD Femoral head osteoplasty 217 (66.4)
0 37 (11.3) Capsular repair/plication 173 (52.9)
1 93 (28.4) Ligamentum teres débridement 146 (44.6)
2 102 (31.2) Capsular release 151 (46.2)
3 76 (23.2) Acetabular chondroplasty 104 (31.8)
4 19 (5.8) Iliopsoas fractional lengthening 148 (45.3)
Acetabular Outerbridge Synovectomy 47 (14.4)
grade Femoral head chondroplasty 36 (11.0)
0 26 (8.0) Loose body removal 37 (11.3)
1 112 (34.3) Acetabular microfracture 28 (8.5)
2 99 (30.3) Femoral head microfracture 4 (1.2)
3 65 (19.9) Gluteus medius/minimus repair 4 (1.2)
4 25 (7.6)
Femoral head
Outerbridge grade
the first 2 years after primary hip Additionally, the patients who con-
0 249 (76.1)
arthroscopy. The survivorship among verted had significantly higher pre-
1 9 (2.8)
this subcohort was 92.1%. Among operative alpha angles (P = 0.049).
2 24 (7.3)
the 40 hips, 25 had recurrence of The conversion group was signifi-
3 23 (7.0)
symptoms, 11 had reinjured their hip, cantly more likely to have undergone
4 22 (6.7) three had heterotopic ossification, capsular release (P = 0.039) and
Ligamentum teres tear 162 (49.5) and one had a femoral neck stress labral débridement (P = 0.020)
Partial 156 (47.7) fracture. rather than repair (P = 0.026).
Complete 6 (1.8) Finally, the converting group had
Conversion to Total Hip lower preoperative mean mHHS (P =
ALAD = Acetabular Labrum Articular
Disruption Arthroplasty 0.002), NAHS (P = 0.002), and
HOS-SSS (P = 0.007). Preoperative
The 25 hips that converted to THA
VAS trended higher for the THA
arthroscopy (Table 5). Patients were compared with 306 hips that
group, but the mean difference was
who underwent future secondary did not convert to THA to identify
not significant. The results of a
arthroscopy had a higher body mass risk factors in an identical fashion
Kaplan-Meier analysis for survival
index (BMI) (P = 0.036) and were (Table 6). Notably, the patients who
of conversion to THA can be found
more likely to be female (P , 0.001). converted to THA were significantly
in Figure 3.
They were also significantly less older (P , 0.001) and had a higher
likely to have undergone capsular BMI (P , 0.001). Chondral damage
release (P = 0.042). Additionally, the was another risk factor for conver- Conclusions
hips that required secondary sion because these patients were
arthroscopy demonstrated signifi- significantly more likely to have The purpose of this study was to
cantly lower preoperative mean Outerbridge grades $ 2 in the ace- report minimum 5-year outcomes,
mHHS (P , 0.001), NAHS (P = tabulum (P = 0.006) and femoral survivorship, and risk factors for re-
0.033), and HOS-SSS (P = 0.012). head (P = 0.007), and a difference operation in patients ,50 years who
Thirteen (4.0%) of those secondary approaching significance for ALAD underwent hip arthroscopy for the
arthroscopies were performed within $ 2 (P = 0.059) was observed. management of labral tears and FAI.
February 15, 2019, Vol 27, No 4 e177
Table 4
Mean Patient-reported Outcomes, Pain, and Satisfaction With Minimum 5-year Follow-up
Factor Preoperative $ 5-yr Follow-up P Value
mHHS 62.4 6 16.0 83.3 6 15.8 ,0.001

NAHS 58.8 6 18.9 83.2 6 16.0 ,0.001
HOS-SSS 43.1 6 24.8 72.3 6 25.2 ,0.001
VAS 5.9 6 2.2 2.4 6 2.2 ,0.001
Satisfaction — 7.9 6 2.3 —
mHHS = modified Harris Hip Score, NAHS = Non-Arthritic Hip Score, HOS-SSS = Hip Outcome Score–Sports Specific Subscale, VAS = visual
analog scale
Figure 2
Scores collected preoperatively and postoperatively at 2 years and minimum 5 years for the subcohort of patients who had
all of these scores. A, PROs. B, VAS and satisfaction. PROs = preoperative patient-reported outcomes, VAS = visual analog
scale.
Our cohort consisted of 327 hips in PROs. Risk factors for conversion to THA within 2 years postoperatively,
295 patients with minimum 5-year THA included older age, higher BMI, compared with 35% in the 60- to
follow-up. We found notable im- chondral damage, higher preopera- 69-year-old age group.24 Our study
provements for all PRO scores and tive alpha angle, undergoing capsular supports the lower conversion rate to
VAS at latest follow-up with a mean release and labral débridement, and THA in younger patients, with a
satisfaction of 7.9. No notable dif- lower preoperative PROs. This study 5-year survivorship of 92.4%. In
ferences could be detected regarding found a complications rate of 7.0%. addition, in this group (age , 50),
outcomes at 2 years postoperatively Patient age is a particularly impor- older age was found to be one of the
versus minimum 5-year follow-up. tant consideration when considering a risk factors for conversion to THA.
Survivorship at follow-up was patient’s candidacy for hip arthros- Hip arthroscopy in young patients
92.4%, with 25 patients undergoing copy. Byrd and Jones previously has demonstrated favorable and safe
THA at a mean of 37.0 months reported that hip arthroscopy in outcomes in the short term. In addi-
postoperatively. In our cohort, younger patients tended to prolong tion, older age has been shown to be a
11.6% of all hips required a sec- the need for THA at the short term.23 risk factor for inferior improvement
ondary arthroscopy at a mean of Additionally, a recent population- and higher rates of conversion to
24.7 months from the index proce- based analysis of 7,351 patients THA after hip arthroscopy. Further-
dure. Risk factors for secondary who underwent hip arthroscopy more, several studies have demon-
arthroscopy included higher BMI, reported that 3% of patients aged strated the advantages of hip
female sex, and lower preoperative younger than 40 years converted to arthroscopy over open surgeries for
Table 5
Risk Factors for requiring a Future Secondary Arthroscopy Arthroscopy in Patients Aged , 50 Years
Factor Future Secondary Arthroscopy No Future Surgery P Value
Hips 38 267 —
Age at surgery (yr, mean, SD) 29.2 6 9.2 32.2 6 11.0 0.115
BMI (mean, SD) 22.7 6 3.1 24.5 6 5.0 0.036
Female sex (n hips, %) 35 (92.1) 174 (65.2) ,0.001
Ligamentum teres tear (n, %) 18 (47.4) 132 (49.4) 0.948
ALAD $ 2 (n, %) 23 (60.5) 156 (58.4) 0.944
Acetabular outerbridge $ 2 (n, %) 20 (52.6) 150 (56.2) 0.812
Femoral head outerbridge $ 2 (n, %) 5 (13.2) 53 (19.9) 0.446
Preoperative alpha angle (, mean, SD) 56.2 6 8.0 58.8 6 11.4 0.312
Preoperative LCEA (, mean, SD) 31.7 6 6.1 30.2 6 5.7 0.119
Preoperative ACEA (, mean, SD) 30.3 6 6.9 32.0 6 8.4 0.242
Preoperative Tönnis angle (, mean, SD) 3.2 6 3.8 3.7 6 4.3 0.487
Underwent labral repair (n, %) 30 (78.9) 188 (70.4) 0.807
Underwent labral débridement (n, %) 5 (13.2) 70 (26.2) 0.122
Underwent labral resection (n, %) 2 (5.3) 3 (1.1) 0.119
Underwent microfracture (n, %) 3 (7.9) 20 (7.5) .0.999
Underwent capsular release (n, %) 10 (26.3) 121 (45.3) 0.042
Preoperative mHHS (mean, SD) 54.8 6 14.3 63.4 6 16.0 ,0.001
Preoperative NAHS (mean, SD) 52.8 6 16.8 59.4 6 19.1 0.033
Preoperative HOS-SSS (mean, SD) 33.7 6 20.1 44.3 6 25.0 0.012
Preoperative VAS (mean, SD) 6.2 6 2.2 5.9 6 2.2 0.317
ALAD = Acetabular Labrum Articular Disruption, BMI = body mass index, mHHS = modified Harris Hip Score, NAHS = Non-Arthritic Hip Score,
HOS-SSS = Hip Outcome Score–Sports Specific Subscale, VAS = visual analog scale, LCEA = lateral center-edge angle
Bold indicates a statistically significant difference
FAI in this age group.4,25,26 In a ret- NAHS ,10 points. Domb et al2 repair in particular. However, young
rospective case-control outcome compared hip arthroscopy outcomes age seems to also be a good prog-
analysis at minimum 2-year follow- in patients older than 50 with those nostic factor in the mid-term.
up, McCormick et al27 evaluated in patients younger than 30 Recently, our group looked at mid-
whether age and arthritis are pre- at minimum 2-year follow-up. The term outcomes of specific patient
dictive of outcomes after hip survivorship rate was 98.1% for the populations that underwent hip
arthroscopy for labral pathology. younger control group and 82.7% arthroscopy, and part of them are
They reviewed 125 patients with a for the older group. Among the included in this data. We found that
mean age of 40.9 (17.3 to 62.8). The survivors, both groups demonstrated mid-term outcomes of hip arthros-
results showed that age below 40 similar improvement in mHHS, copy, in general, are favorable,
years was predictive of good to HOS-ADL, VAS, and satisfaction durable, and safe.28-35 The current
excellent results (odds ratio, 7; 95% scores. Our study, with minimum study presents the mid-term follow
confidence interval, 2.9 to 16.9; P , 5-year follow-up, demonstrates up on our previously published
0.0001). Gupta et al3 performed 92.4% survivorship, satisfaction of short-term study of a similar patient
a minimum 2-year clinical follow-up 7.9, and notable improvement in cohort.36 In a retrospective review
of 738 hip arthroscopies. The mean multiple PROs. These results support of patients who underwent hip
age was 38 (13.2 to 76.4) years. The the literature portraying hip arthros- arthroscopy, McCarthy et al37 re-
multivariate regression analysis copy as a favorable procedure in ported on 111 hips with a mean age
demonstrated that increased age at younger patients. of 39 (613) with minimum 10-year
the time of surgery was a notable risk There is a paucity of literature follow-up. Their results showed
factor for conversion to THA, sec- regarding mid-term results of hip that patients elder than 40 years
ondary arthroscopy, and change in arthroscopy in general and labral had a 3.6 times higher odds ratio for
February 15, 2019, Vol 27, No 4 e179
Table 6
Risk Factors for Converting to Total Hip Arthroplasty in Patients Aged ,50 Years
Converted to
Factor THA Did Not Convert P Value
Hips 25 302 —
Age at surgery (yr, mean, SD) 40.4 6 7.7 31.8 6 10.9 ,0.001
BMI (mean, SD) 27.8 6 4.1 24.3 6 4.8 ,0.001
Male sex (n hips, %) 12 (48.0) 96 (31.8) 0.151
Required secondary arthroscopy (n, %) 3 (12.0) 35 (11.9) .0.999
Ligamentum teres tear (n, %) 13 (52.0) 149 (49.3) 0.962
ALAD $ 2 (n, %) 20 (80.0) 177 (58.6) 0.059
Acetabular outerbridge $ 2 (n, %) 21 (84.0) 168 (55.6) 0.006
Femoral head outerbridge $ 2 (n, %) 11 (44.0) 58 (19.2) 0.008
Preoperative alpha angle (degrees, mean, SD) 63.2 6 10.8 58.6 6 11.1 0.049
Preoperative LCEA (degrees, mean, SD) 31.5 6 7.6 30.4 6 5.8 0.363
Preoperative ACEA (degrees, mean, SD) 31.0 6 6.9 31.9 6 8.2 0.679
Preoperative Tönnis angle (degrees, 4.3 6 3.7 3.6 6 4.4 0.458
mean, SD)
Underwent labral repair (n, %) 12 (48.0) 216 (71.5) 0.026
Underwent labral débridement (n, %) 12 (48.0) 74 (24.5) 0.020
Underwent labral resection (n, %) 1 (4.0) 5 (1.6) 0.382
Underwent microfracture (n, %) 5 (20.0) 23 (7.6) 0.079
Underwent capsular release (n, %) 17 (68.0) 134 (44.4) 0.039
Preoperative mHHS (mean, SD) 53.3 6 13.6 62.4 6 16.0 0.002
Preoperative NAHS (mean, SD) 47.5 6 16.5 58.8 6 18.9 0.002
Preoperative HOS-SSS (mean, SD) 29.4 6 22.7 43.1 6 24.8 0.007
Preoperative VAS (mean, SD) 6.3 6 1.8 5.9 6 2.2 0.470
ALAD = Acetabular Labrum Articular Disruption, BMI = body mass index, mHHS = modified Harris Hip Score, NAHS = Non-Arthritic Hip Score, HOS-
SSS = Hip Outcome Score–Sports Specific Subscale, VAS = visual analog scale, LCEA = lateral center-edge angle, THA = total hip arthroplasty
Bold indicates a statistically significant difference
conversion to THA in 10 years. They

Figure 3
demonstrated 90% survivorship of
hip arthroscopy in 10 years in pa-
tients younger than 40 with Tonnis
0. In a retrospective study of 44 hip
arthroscopies for the management of
FAI, Hufeland et al38 found persis-
tent clinical improvement without
notable progression of degenerative
changes at a mean follow-up of 5.5
years. The mean age was 34.3 (17 to
65) years. Survivorship was 88.6%,
and the five patients who converted
to THA were markedly older with a
mean age of 49.8. In a minimum
5-year follow-up study, Skendzel
et al39 evaluated 466 patients who
underwent hip arthroscopy for the
Kaplan-Meier curve for the conversion to total hip arthroplasty end-point.
management of FAI. They concluded
that hip arthroscopy for FAI resulted HOS-SSS, and international hip patients who converted to THA
in markedly better outcomes and outcome tool 33. They demonstrated were markedly older and had higher
activity level. The survivorship rate that the most common risk factor for BMI, more chondral damage, more
was 84%, and the mean age was failure of the primary procedure was labral débridements and capsular
39.6 (18 to 77) years. The group that residual intra-articular impingement. releases, and lower preoperative
converted to THA was markedly This finding is also supported by mHHS, NAHS, and HOS-SSS.
older (50.2 versus 37.3), and most other studies.42,43 Our study re- These findings are consistent with
patients who converted to THA were inforces the aforementioned results the literature.
elder than 50 (44/63) years. How- and demonstrates that secondary This study has several strengths.
ever, Palmer et al40 evaluated 201 arthroscopies were performed more First, there is a paucity of the liter-
hips with cam-type FAI that under- commonly in females, in patients ature regarding mid-term results of
went hip arthroscopy. The mean age with higher BMI, and in patients hip arthroscopy, and this is one of
was 40.2 (14 to 87) years, and the who demonstrated lower preopera- the first studies investigating this
mean follow-up was 46 months. All tive mHHS, NAHS, and HOS-SSS. patient population, in one of the
age groups separated by decade were In our study, we reported an 11.6% largest cohorts in the literature.
compared with the rest of the group, secondary arthroscopy rate, which Second, we used three PROs, VAS,
and no statistically significant dif- can be attributed to several factors. and satisfaction to evaluate the
ferences in NAHS were found. They Within 2 years after the primary patients.
also found no statistical difference surgery, we demonstrated 4.0% The study also has a number of
when comparing the younger-than- secondary surgeries; the additional limitations. First, despite the large
20 group with the older-than-60 7.6% could be attributed to the sample size, it has the inherent limi-
group. They did not report on con- longer length of follow-up. Another tations of retrospective case series.
version to THA according to age. As potential explanation for the sec- However, as a prospectively collected
one of the first studies of mid-term ondary arthroscopy rate could be data, it eliminates recall bias and
outcomes of hip arthroscopy for the suture material. All of these limits selection bias. Second, the
labral treatment, our study continues surgeries were performed before our study results would be strengthened
the trend in the literature and shows institution revised our capsular by a control group. Nevertheless, hip
safety, favorable outcomes, and a closure/plication technique to use arthroscopy has been well indicated
low rate of conversion to THA in only absorbable sutures to pre- for management of FAI and labral
this age group. Comparing our vent suture granulomas sometimes tears in the current literature and has
2-year with minimum 5-year out- found in the capsule when using shown good short-term results.
comes, all PROs, VAS, and satis- nonabsorbable sutures. Hence, in our opinion, it would be
faction showed no deterioration. Older age, higher BMI, and higher inappropriate to have a control group
Although the literature indicates level of osteoarthritis are well es- of patients who would not undergo
favorable outcomes for hip arthros- tablished risk factors for conversion hip arthroscopy when indicated sim-
copy in this age group, patient selec- to THA. In a review of 792 patients, ply for the purpose of this study.
tion is still important. There are Redmond et al44 did a bivariate and Third, because each patient under-
several notable risk factors for sec- multivariate analysis in search of went several procedures within their
ondary arthroscopy or conversion to variables that could be associated operation, defining which specific
THA. In a retrospective review of with conversion to THA. The vari- procedures led to our results is diffi-
1898 procedures, Ricciardi et al41 ables that were found to have cult. However, to reduce the rate of
found that patients who underwent association with conversion to THA future procedures, we manage any
revision after hip preservation sur- in this model were higher age, pathology that could be the source of
gery tended to be younger in age, lower reoperative mHHS, decreased pain as indicated by the diagnostic
were female, and had worse preop- femoral anteversion, revision sur- arthroscopy.
erative hip functional outcomes than gery, femoral Outerbridge grade 2 In conclusion, hip arthroscopy for
those in the primary cohort. Of the to 4, performance of acetabulo- management of FAI and labral tears
1746 primary procedures, 1,631 plasty, lack of performance of fem- in patients aged ,50 demonstrates
(93.4%) were hip arthroscopies. The oroplasty, and lower LCEA. In favorable and safe mid-term out-
PROs that were used to evaluate the addition, Gupta et al3 showed that comes. Several risk factors for con-
patients and showed markedly lower apart from older age, the need for version to THA in this age group
preoperative scores in the revision acetabuloplasty was also a risk warrant cautious patient selection
group were mHHS, HOS-ADL, factor for THA. In our study, the for arthroscopy.
February 15, 2019, Vol 27, No 4 e181
9. Wiberg G: Shelf operation in congenital 22. Kemp JL, Collins NJ, Roos EM, Crossley
References dysplasia of the acetabulum and in KM: Psychometric properties of patient-
subluxation and dislocation of the hip. J reported outcome measures for hip
Bone Joint Surg Am 1953;35-A:65-80. arthroscopic surgery. Am J Sports Med
Evidence-based Medicine: Levels of 2013;41:2065-2073.
evidence are described in the table of 10. Lequesne M, de Seze: False profile of the
pelvis: A new radiographic incidence for 23. Byrd JW, Jones KS: Prospective analysis of
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11. Harris MD, Kapron AL, Peters CL, of hip arthroscopy and risk of conversion to
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those published within the past 5 The bony landmarks. Radiology 1978;128:
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1. Byrd JWT, Jones KS: Hip arthroscopy for Leunig M: Ischial spine projection into the prospective matched-pair study with
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February 15, 2019, Vol 27, No 4 e183
Research Article
Incidence of Posteromedial
Meniscocapsular Separation and
the Biomechanical Implications on
the Anterior Cruciate Ligament
Abstract
Cory Edgar, MD, PhD Purpose: To report the incidence of posterior medial meniscocapsular
Neil Kumar, MD, MBA junction (PMCJ) separation in patients with anterior cruciate
ligament (ACL) injury and to evaluate its biomechanical effect on
James K. Ware, MD
the ACL.
Connor Ziegler, MD Methods: Three hundred thirty-seven consecutive patients
Dale N. Reed, MD undergoing isolated primary ACL reconstruction were retrospectively
Jessica DiVenere, BS analyzed for PMCJ lesion. Forty-four patients were identified with
PMCJ lesion and studied. Eight cadaver knees underwent
Elifho Obopilwe, MS
biomechanical testing to determine anterior tibial displacement and
Mark P. Cote, DPT anteromedial bundle ACL strain in the intact, PMCJ lesion, and PMCJ
Robert A. Arciero, MD repair states at 0, 30, 60, and 90 of flexion. Mixed-effects linear
regression with Bonferroni correction was used for statistical
analysis.
Results: PMCJ tear incidence with ACL disruption was 13.1%.
Specimen with PMCJ tears had statistically increased anterior tibial
translation at 30 (1.2 mm; P , 0.01) and statistically increased ACL
strain at 30 (24%; P , 0.01) and 90 (50%; P , 0.01). With PMCJ
repair, translation reduced (P . 0.05) by 12%, 18%, and 10% at 0,
30, and 90 of flexion, respectively. PMCJ repair reduced (P , 0.05)
ACL strain by 40%, 39%, 43%, and 31% at 0, 30, 60, and 90 of
flexion, respectively.
Conclusions: A PMCJ lesion was observed in 13% of ACL injuries.
This injury contributes to increased ACL strain, and PMCJ repair
markedly reduces ACL strain to preinjury levels.

Surgery, University of Connecticut
M eniscal injuries in the setting of
anterior cruciate ligament
(ACL) disruption are a common
medial meniscus, placing this struc-
ture at particular risk of traumatic
injury.1,9 This mechanism may explain
Health Center, Farmington, CT.
occurrence.1-3 In the acute setting, the why the reported rate of peripheral
Correspondence to Dr. Kumar: incidence of concomitant meniscal posterior horn medial meniscal tears
neilskumar1@gmail.com tears after ACL injury is 41% to 82% range from 20% to 40%.1,2,9,10
J Am Acad Orthop Surg 2019;27: and can approach 100% with chronic A unique variant of the peripheral
e184-e192 ACL insufficiency.1-8 The supra- posterior horn medial meniscus injury
DOI: 10.5435/JAAOS-D-17-00327 physiologic anterior tibial translation is the separation of the posterior
associated with ACL tear results in meniscocapsular (PMCJ) junction. Such
Academy of Orthopaedic Surgeons. abutment of the medial femoral con- lesions have been defined as “ramp le-
dyle on the posterior horn of the sions”; however this terminology has
Cory Edgar, MD, PhD, et al
Figure 1 Figure 2
A, A lesion of the posterior medial meniscocapsular junction (*) is seen in a left

knee. B, Two simple vertical sutures with #2 Orthocord (DePuy Synthes) are
used to repair the lesion.
An 18-gauge spinal needle is

introduced into the posteromedial meniscocapsular junction separation ment is evaluated in all patients
compartment of the left knee and in a group of patients with ACL injury undergoing ACL reconstruction. With
used as a probe. Here, the posterior and to evaluate the biomechanical effect the knee at 90 flexion, a 70 arthro-
horn medial meniscus has a double- of missed and repaired lesions on the scope is placed into the posteromedial
bucket tear, including a tear at the
meniscocapsular junction (*). MFC = ACL. We suspected that .10% of our compartment via the Gillquist et al18
medial femoral condyle, PHMM = cohort had a PMCJ lesion identified maneuver to visualize the posterior
posterior horn medial meniscus arthroscopically. We further hypothe- meniscocapsular junction. An 18-
sized that with biomechanical testing gauge spinal needle (Figure 1),
in a cadaver model, PMCJ lesions lead introduced into the posteromedial
also been used to describe disruption
to increased anterior tibial translation compartment of the knee, is used to
of the meniscotibial ligament and
and greater strain on the anteromedial probe the junction and identify the
tears in the red-red zone of the pos-
bundle of the ACL, both of which can tear site.
terior horn.11-14 Despite its recogni-
be reduced with PMCJ repair. All lesions, regardless of size or
tion over 30 years ago,15,16 PMCJ
injury is currently under renewed perceived instability, were repaired
investigation. Smith and Barrett1 using an all-inside technique. A
found PMCJ tears in 3.1% of pa- Methods posteromedial portal (“Metcalf por-
tients with ACL deficiency, 73.3% of tal”) is created, and an 8 · 25 mm
whom underwent reconstruction Incidence cannula is placed.19 Through the
within 6 weeks of injury. However, To establish the incidence of PMCJ posteromedial portal, a Spectrum
other authors have found rates three separation, 339 consecutive patients hook (ConMed) first pierces the
to five times greater.12,17 who underwent isolated primary capsular tissue and then pierces the
Despite the recent increased recog- ACL reconstruction by the senior posterior meniscus to create a verti-
nition of PMCJ separation, much re- author from October 2006 to March cal simple stitch. A zero PDS shuttle
mains unknown regarding the 2013 were analyzed retrospectively. suture is deployed through the hook
incidence of these lesions. Further- Surgical reports and arthroscopic and retrieved from the posteromedial
more, the implications of missed and images were reviewed to identify all portal. A #2 Orthocord (DePuy
repaired lesions on the ligamentous patients with a tear involving the Synthes) is shuttled through the
stability and chondral health of meniscocapsular junction at the pos- capsular and meniscal tissue and tied
the knee are yet to be fully elucidated. terior horn of the medial meniscus. arthroscopically (Figure 2).
The purpose of this study was to re- In the practice of the senior sur- For each patient with this injury,
port the incidence of posteromedial geon, the posteromedial compart- variables such as age, sex, side,
Dr. Edgar or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of and serves as a
paid consultant to DePuy Synthes Mitek. Dr. Arciero or an immediate family member has stock or stock options held in Biorez; has received
research or institutional support from Arthrex; and serves as a board member, owner, officer, or committee member of the American
Orthopaedic Society for Sports Medicine. None of the following authors nor any immediate family member has received anything of value
from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article:
Dr. Kumar, Dr. Ware, Dr. Ziegler, Dr. Reed, Ms. DiVenere, Mr. Obopilwe, and Mr. Cote.
February 15, 2019, Vol 27, No 4 e185
Posteromedial Meniscocapsular Separation
Figure 3 steel self-drilling and self-tapping

Schantz pins (Synthes) were inserted
in an anterior-posterior direction
along the midsagittal plane in both
the femur and tibia approximately 5,
10, and 15 cm from the joint line. A
lateral parapatellar arthrotomy was
performed, taking care to preserve the
anterior meniscal horns and inter-
meniscal ligament to prevent desta-
bilization of the medial meniscus
anterior horn.20
Testing System
The testing fixture followed the primary
principles of knee and cruciate ligament
testing described by Beynnon and
The Materials Testing System is fixed to the tibia with three external fixation pins,
and the tibia is translated anteriorly in relation to the femur within the cylinder. Amis.21 Three large external fixator
The testing system is shown with the knee in (A) 0 and (B) 30 flexion. clamps (Synthes) were used to secure
an 11-mm-diameter carbon fiber bar
(Synthes) to the tibial Schantz pins. The
Figure 4 Biomechanical Study tibia was then secured in neutral
Specimen Preparation rotation directly to the actuator of the
Materials Testing System (model 858;
To determine the biomechanical ef-
Materials Testing Systems) (Figure 3)
fects of PMCJ injury and repair, eight
using three more identical external
fresh-frozen human cadaver knees,
fixator clamps such that it was per-
two males and six females, were used.
pendicular to the actuator’s axis of
All specimens had no evidence of
movement. The actuator was centered
previous knee surgery, injury, or
inferior to the tibiofemoral joint line
degenerative disease. Arthroscopic
and central to the long axis of the tibia.
examination of the specimens verified
The actuator was free to rotate during
the lack of intra-articular pathology.
testing. Anterior-posterior loads were
Specimens ranged from 36 to 49 years
applied perpendicular to the tibia,
in age, with a mean age of ,45 years. whereas the combined fixtures allowed
The knees were stored in a 220C unconstrained superior-inferior and
freezer and thawed overnight before medial-lateral translation of the femur,
testing. Adequate amounts of soft internal-external rotation of the femur,
For strain testing, the differential tissues were removed to allow for and varus-valgus movement of the
variable reluctance transducer is mounting and testing while preserv- tibia. The femur was mounted in an
placed within the midsubstance of ing the soft tissue around the joint.
the anterior cruciate ligament, and a aluminum cylinder and secured with
limited notchplasty is performed to The capsular and ligamentous struc- six screws positioned equidistant
prevent transducer impingement. tures in and around the knee joint, around the cylinder, which allowed
including the cruciate and collateral free rotation about the long axis of
ligaments, the popliteus, and the the femur.
mechanism of injury, time from injury, oblique popliteal ligament, were A differential variable reluctance
time of MRI, and associated injuries carefully preserved. The femur and transducer (DVRT) (2.0 mm ultra-
identified at the time of surgery were tibia were cut approximately 20 cm microminiature sensor; MicroStrain)
recorded. All patients had obtained proximal and distal to the joint line, was positioned collinear with the
preoperative MRI. All patients who respectively. The femur and tibia ACL anteromedial bundle and
underwent isolated bundle ACL or were potted in a cylindrical poly- pressed into its midsubstance before
patients without surgical records vinylchloride mold using polymethyl securing the specimen to the actuator
available for review were excluded. methacrylate. Three 5-mm stainless (Figure 4). To prevent impingement
against the sensor with knee Figure 5

extension, a limited notchplasty, as
previously reported by Spang et al,22
was performed. The knee was taken
through a range of motion to ensure
that DVRT output remained in the
readable range. The DVRT was
subsequently secured at its inferior
aspect with a single stitch.
Testing Protocol
Preconditioning was performed with
anterior-posterior directed loads of A, Cadaver dissection of the posteromedial knee showing a meniscocapsular
lesion. B, Meniscocapsular separation repaired anatomically with three sutures.
100 N applied for 10 cycles at 0.25 Hz.
Subsequently, anterior-posterior loads
of 150 N were applied perpendicular Table 1
to the tibia for 10 cycles, during which Demographics and Associated Lesions in Patients With Posterior
time DVRT output was recorded for Meniscocapsular Lesion
anterior tibial displacement and ante- Demographics Associated Lesions
romedial bundle ACL strain. The tibia
was allowed to “relax” to a resting Sex Chondral lesions 14
position at the desired flexion angle Male 28 (64%) MFC 8
being tested between each cycle while Female 16 LFC 1
no posterior loads were applied and Age (yr) Trochlea 2
was reconfigured as PMCJ state was Mean 23.0 Patella 3
altered. Data generated were based Range 12-52 Lateral meniscus tear 9
on a previously described standard Side
curve, with strain calculated as a Right 25 (57%)
percent change in strain from a Left 19
baseline resting position.22
Each knee was tested in the intact, LFC = lateral femoral condyle, MFC = medial femoral condyle
PMCJ tear, and PMCJ repair states.

First, anterior tibial translation and state. The lesion was repaired ar- Health Center’s Human Subjects
ACL strain were tested in the intact throscopically using the previously Protection Office Institutional Review
knee at 0, 30, 60, and 90 of flexion. created posteromedial cannulated Board. Statistical analysis used a
A posterior meniscocapsular defect portal. A curved suture passer was first mixed-effects linear regression with
was then generated in each specimen. passed through the capsule and then Bonferroni correction to determine
Using dry arthroscopy, a postero- taken through the posterior horn of the changes in translation and strain
medial cannulated portal was created medial meniscus. A #2 FiberWire with the progression of various
under direct visualization. This tech- (Arthrex) was passed through the PMCJ conditions. Statistical sig-
nique ensured adequate localization of capsule and meniscus using a zero PDS nificance was determined at P ,
the portal to form the capsular lesion. suture shuttle and tied using arthro- 0.05. Stata Statistical Software
A No. 11 surgical scalpel was intro- scopic technique. Each cadaver knee Release 14 (StataCorp) was used for
duced intra-articularly through the was repaired using three vertical sim- evaluation.
cannula and used to separate the ple sutures placed approximately
posterior horn of the medial meniscus 3 mm apart (Figure 5). The PMCJ
from the posterior joint capsule for a Results
repair specimens were retested for
length of approximately 1 cm. A translation and ACL strain from 0 to
probe verified separation of the 90 of flexion.
Incidence
meniscocapsular attachment. At this A total of 337 patients ultimately
point, the specimens were tested for Statistical Analysis met our inclusion criteria; 44 were
translation and ACL strain from 0 The study was reviewed and approved found to have a posteromedial
to 90 of flexion in the PMCJ tear by the University of Connecticut meniscocapsular separation, an
February 15, 2019, Vol 27, No 4 e187
Table 2
Mechanism of Injury for Patients Sustaining Anterior Cruciate Ligament Disruption and Meniscocapsular
Separation
Sports Nonsports
Soccer 11 Plant/twist 7
Basketball 6 Jump 2
Football 6 Trip 1
Lacrosse 3 Unspecified 2
Skiing 2 Contact
Ultimate 2 Football 5
frisbee
Field hockey 1 Basketball 1
Baseball 1
incidence of 13.1%. Most patients 1.23 mm), PMCJ tear (4.56 6 Anterior Cruciate Ligament
were men (64%), with a mean age of 0.69 mm), and PMCJ repair Strain
23 years (Table 1). The time of (4.03 6 1.25 mm) testing states
With the resting position in full
injury was not available in the (Figure 6). At 0 flexion, no statis-
extension, strain on the anteromedial
clinical notes for 3 of the 44 pa- tically significant difference was
bundle of the ACL increased by 2.4%
tients. Of the remaining 41, the found in tibial translation in knees
in intact knees, 3.5% with PMCJ
average time from injury to surgery with PMCJ lesion (P = 0.68) or tears, and 2.1% after PMCJ repair
was 7.6 months, with a range of PMCJ repair (P = 1.00) compared to after an anterior tibial translational
0.25 to 72 months. The median intact knees. At 30 flexion, anterior force. However, differences in ACL
duration from injury to confirma- translation measured 3.25 6 strain were not statistically signifi-
tion of the posteromedial me- 0.67 mm in the intact knee, 4.43 6 cant after PMCJ tear (P = 0.11) or
niscocapsular separation was 0.82 mm with PMCJ tear, and 3.65 PMCJ repair (P = 1.00) compared
3 months. The PMCJ lesion was 6 0.86 mm with repair. At 30 with intact specimen (Figure 7).
found arthroscopically within flexion, compared with intact spec- From the resting position at 30
6 months of injury in 76% of imen, anterior tibial translation was flexion, ACL strain increased by
patients. statistically different (P , 0.01) 3.7% in intact knees, 4.6% with
The most frequent cause of injury with PMCJ lesion, but not statisti- PMCJ tears, and 2.8% after PMCJ
was sports participation (73%), with cally different after PMCJ repair repair. Compared with the native
soccer accounting for a third of sports (P = 0.72). At 60 flexion, anterior knee, ACL strain in knees with
injuries (Table 2). Twenty-six (81%) tibial translation was 2.66 6 PMCJ lesions were statistically
of the 32 sports injuries were due to a 0.70 mm in intact specimen, 2.70 6 different (P , 0.01), but similar
noncontact mechanism, whereas six 0.42 mm after PMCJ tear, and 2.98 after repair (P = 1.00) With the
(19%) were contact injuries. Of the 6 0.67 mm after repair. No statis- resting position at 60 flexion, ACL
nonsports injuries, most were due tically significant differences were strain increased by 3.5% in intact
to a planting or twisting mechanism. found in translation after PMCJ tear knees, 5.1% with PMCJ tears, and
Eighteen patients (41%) were found (P = 1.00) or PMCJ repair (P = 0.47) 2.9% after PMCJ repair. ACL
to have additional intra-articular compared with intact specimen at strain increased was not statisti-
pathology at the time of surgery. 60 flexion. At 90 flexion, anterior cally different after PMCJ tear (P =
Thirty-two percent of patients had translation measured 2.34 6 0.06) or PMCJ repair (P = 1.00)
concomitant chondral injury, and 0.57 mm in the intact knee, 2.6 6 compared with intact specimen.
21% had evidence of lateral me- 0.44 mm with PMCJ tear, and 2.30 From the resting position at 90
niscal tear.
6 60.59 mm with repair. No sta- flexion, ACL strain increased by
tistically significant differences were 3.2% in intact knees, 4.8% with
Anterior Tibial Translation found in translation after PMCJ tear PMCJ tears, and 3.3% after PMCJ
Anterior displacement of the tibia (P = 0.56) or PMCJ repair (P = 1.00) repair. Compared with the native
was greatest with the knee in full compared with intact knees at 90 knee, ACL strain in knees with
extension for the intact (4.12 6 flexion. PMCJ lesions were statistically
Figure 6
Magnitude of anterior tibial translation at 0, 30, 60, and 90 of flexion.
different (P = 0.01), but similar was 13.1% in patients who under- medial lesions, but their reported
after repair (P = 1.00). went primary ACL reconstruction. incidence was much lower than the
One of the difficulties when deter- results of this study. This phenom-
Summary mining the true incidence of PMCJ enon could be due to injury chro-
disruption is the variable definition nicity, which may increase the risk
Compared with intact knees, speci-
of “ramp lesion.”11 Strobel23 and of posterior horn medial meniscal
men with PMCJ tears had statistically
Woods and Chapman15 originally and meniscotibial injury.12,14 Most
increased anterior tibial translation
described ramp lesions specifi- (76%) of our patients were diag-
at 30 and statistically increased
cally referring to injuries to the nosed with PMCJ tear arthroscopi-
ACL strain at 30 and 90. Com-
meniscocapsular junction of the cally within 6 months of injury,
pared with knees with PMCJ tears,
posterior horn of the medial menis- whereas a similar percentage (73.3%)
PMCJ repair resulted in a statisti-
cus. In a prospective investigation, of their patients were identified
cally significant reduction of ACL
Bollen17 reported a PMCJ incidence within 6 weeks.
strain at 0, 30, 60, and 90 of
of 9.3% in 183 consecutive patients The detection of PMCJ injuries
flexion.
undergoing ACL reconstruction and can be difficult to identify whether
zero in 700 patients without ACL by MRI or arthroscopically. De
Discussion deficiency who underwent knee Maeseneer and colleagues24,25 corre-
arthroscopy. Smith and Barrett1 lated MRI of PMCJ tears in cadavers
The clinical arm of this study aimed at investigated 575 patients with con- with radiologic findings in patients with
determining the incidence of poste- comitant ACL and meniscal tears and a knee MRI and found perimeniscal
rior meniscocapsular separation after found only 3.1% had meniscocapsular fluid and an irregular meniscal outline
ACL disruption. Over a 7-year lesions. The authors did not note to correlate best; however, the au-
period, the incidence of PMCJ lesion how many of these tears were thors cautioned that even these
February 15, 2019, Vol 27, No 4 e189
Figure 7
Percent change in anterior cruciate ligament strain at 0, 30, 60, and 90 of flexion.
Figure 8 findings could be confused with 77% sensitive and 84% specific for
normal anatomy. In 23 patients with arthroscopically identified PMCJ
known medial PMCJ separation, tears. Previous reports indicate that
Rubin et al26 examined preoperative without viewing or probing the
MRI for various parameters indi- medial posterior meniscocapsular
cating injury. Positive predictive junction through a posteromedial
values for meniscal displacement portal, 15.4% to 16.8% of lesions
(8%), meniscocapsular signal change may be missed.13,28 In our opinion,
(10%), fluid deep to the MCL (6%), utilization of the 18-gauge spinal
and fluid superficial to the MCL needle technique to probe this area
(11%) were quite poor. Because reduces the risk of missing such
MRI is performed with the knee lesions.
extended, the lesion may reduce, A missed PMCJ lesion can alter the
making detection more difficult.17 In natural mechanics of the knee. Ahn
our study, the attending orthopaedic et al29 noted that peripheral longi-
surgeon identified a continuous tudinal tears of the posterior horn of
superior to inferior fluid outline the medial meniscus immediately
A T2-weighted sagittal through the peripheral posterior adjacent to the capsular attachment
magnetic resonance image of
the right knee showing fluid horn of the medial meniscus on resulted in an increased anterior
extending around the posterior T2-weighted sagittal magnetic reso- translation with ACL deficiency.
border of the medial meniscus nance images, which specifically in- Anterior tibial translation increased
indicating meniscocapsular dicates PMCJ pathology27 (Figure by 87% to 101% from 0 to 60 of
separation.
8). In our cohort, this technique was knee flexion, with the lowest at 90
(48%). Our study found that ante- 43%, which may help with graft PMCJ lesion on an ACL graft could
rior laxity increased by 1.5% to survival. Our study may indicate be greater. The study examined
36% from 0 to 90 flexion; how- that repair of PMCJ lesions could only a specific repair technique, and
ever, we tested only with an anterior confer a degree of biomechanical various PMCJ repair methods may
translation force, whereas Ahn protection with regard to strain seen affect knee mechanics differently.
et al29 included an axial compressive by the anteromedial bundle of the Finally, the clinical implications of
force. Repair in both studies reduced ACL. However, the clinical im- the biomechanical findings were not
anterior laxity by 10% to 18% at all plications of these findings are yet investigated.
flexion angles, except at 60. Stephen unknown, and further investigation
et al30 reported a 42% and 33% is warranted.
reduction in anterior tibial transla-
Conclusion
tion at 30 and 90 flexion, respec-
Posterior medial meniscocapsular
tively, with PMCJ repair after ACL Limitations separation is not an unusual con-
reconstruction. Similar to our study,
comitant injury with ACL disruption,
PMCJ repair corrected a greater Retrospective reviews involve several
with an incidence of 13.1% in our
amount of laxity at 30 flexion; limitations. Patients with PMCJ le-
cohort. PMCJ tears can lead to
however, our investigation examined sions may have been missed during
increased strain on the native ACL.
the knee with the native ACL rather record review, and some records may
PMCJ repair can reduce ACL strain
than a reconstructed ligament. not have included imaging of the
to magnitudes more reflective of the
We hypothesized that PMCJ tears meniscocapsular junction. Such er-
preinjury state.
would increase both anterior tibial rors would be greatly reduced with
translation and strain of the ante- a prospective examination and may
romedial bundle of the ACL. In the provide a truer indicated of lesion References
PMCJ tear state, ACL strain incidence. Patients who had missed
increased by 24% to 50% up to 90 PMCJ lesions would also not have Evidence-based Medicine: Levels of
flexion. These results were statisti- been included; however, we suspect evidence are described in the table of
cally significant at 30 and 90 and this group to be small because contents. In this article, references 3
trending toward significance at 60. the senior author examines the are level I studies. References 1 and
PMCJ repair reduced ACL strain by meniscocapsular junction on all 26 are level II studies. Reference 12
31% to 43%; all reductions in strain patients with ACL injuries. is a level III studies. References 2, 7,
were statistically significant for every Limitations also include those 13, 14, 15, 16, and 28 are level IV
flexion angle. In fact, PMCJ repair inherent with cadaver study. The studies. Reference 4 is a level V
reduced ACL strain by 12.5% to testing protocol did not include report or expert opinion.
24% compared with the intact knees multiplanar forces and flexion only
up to 60 of flexion. At 90, ACL to 90, which may be different from
strain after PMCJ repair state was knee mechanics seen clinically. Ca-
years.
3% greater than the intact state. davers were approximately 20 years
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Research Article
Patient Outcomes After Revision of

Anatomic Total Shoulder
Arthroplasty to Reverse Shoulder
Arthroplasty for Rotator Cuff Failure
or Component Loosening: A
Matched Cohort Study
Abstract
Edward Shields, MD Purpose: To compare outcomes after conversion of anatomic total
J. Michael Wiater, MD shoulder arthroplasty (aTSA) to reverse total shoulder arthroplasty
(RTSA) and a matched cohort.
Methods: Patients converted from aTSA to RTSA for rotator cuff
failure or component loosening and a primary RTSA matched cohort
were retrospectively identified from a prospective database.
Demographics and preoperative and postoperative outcomes were
obtained and compared.
From The Department of Orthopaedic Results: Age, sex, body mass index, follow-up length, and
Surgery, Beaumont Health, Royal
Oak, MI. preoperative function were similar between revision (n = 35) and
primary (n = 70) groups. At final follow-up, visual analog scale pain
Correspondence to Dr. Wiater:
J.Michael.Wiater@beaumont.edu (2.4 6 2.8 versus 1.7 6 2.8; P = 0.24) and American Shoulder and
Dr. Wiater or an immediate family
Elbow Surgeons (68 6 26 versus 76 6 24; P = 0.14) scores were
member has received royalties from similar. The revision group had worse subjective shoulder value
Smith & Nephew; is a member of a scores (63 6 30 versus 79 6 21; P = 0.002), satisfaction (74%
presentations on behalf of DePuy
versus 90%; P = 0.03), and more complications (31% versus 13%;
Synthes and Zimmer Biomet; has P = 0.02).
stock or stock options held in Catalyst Conclusion: Revision of aTSA to RTSA for component loosening or
OrthoScience, Hoolux Medical, and
Mpirik; has received research or rotator cuff failure results in function comparable to primary RTSA;
institutional support from Zimmer however, more complications, worse subjective shoulder value
Biomet, DJO Global, and Tornier; and scores, and lower patient satisfaction should be expected.
officer, or committee member of the Level of Evidence: Level III, retrospective comparative
American Academy of Orthopaedic
Surgeons and the American Shoulder
and Elbow Surgeons. Neither
I
Dr. Shields nor any immediate family n patients with degenerative gleno- proximal humeral fractures, RTSA
humeral arthritis and irreparable is also used for proximal humeral
options held in a commercial company rotator cuff defects, reverse total nonunions, irreparable rotator cuff
or institution related directly or shoulder arthroplasty (RTSA) can reli- tears, immunologic GH arthrosis,
indirectly to the subject of this article. ably reduce pain and lead to markedly severe glenoid bone loss, dysplastic
J Am Acad Orthop Surg 2019;27: improved function.1-7 The widespread glenoids, and even chronic fixed
e193-e198 success of RTSA for rotator cuff tear dislocation.8-10 Many reports have
DOI: 10.5435/JAAOS-D-17-00350 arthropathy has subsequently resulted also cited RTSA as an option for
in the expansion of indications.8,9 Not revision shoulder surgery.7,11-25
Academy of Orthopaedic Surgeons. only have successful outcomes been Utilization of RTSA has grown
published for the management of acute exponentially since it was approved
February 15, 2019, Vol 27, No 4 e193
Patient Outcomes After Revision of Anatomic Total Shoulder Arthroplasty
for use in the United States more than patients undergoing primary reverse sedimentation rate, C-reactive pro-
10 years ago.26-28 The RTSA now shoulder arthroplasty for rotator cuff tein, and white blood cell values. If
makes up approximately one third of tear arthropathy. On the basis of the elevated, preoperative aspiration is
all GH arthroplasty procedures and previous literature suggesting that performed to evaluate for infection.
an estimated 25% of arthroplasty- surgery before shoulder arthroplasty In addition, at the time of surgery,
treated proximal humerus frac- increases the risk of inferior out- frozen sections and cultures are sent.
tures.29 With the increasing numbers comes,31 the study hypothesis was No patient was infected at the time
of RTSA procedures being performed, that patients undergoing revision of revision surgery based on these
the number of revision shoulder surgery would have inferior out- tests. Preoperative imaging consisted
arthroplasty cases has also increased comes compared with the cohort of plain radiographs, with CT scan
exponentially.28 undergoing primary RTSA. on an as-needed basis. No tendon
Using RTSA is an attractive option transfers were performed on any
for revision shoulder arthroplasty, patient. Forty-two patients met the
and satisfactory outcomes have Methods inclusion and exclusion criteria. Of
been demonstrated after revision these patients, 2 were deceased, and
to RTSA for instability, rotator All patients who provide informed 5 were lost to follow-up before their
cuff deficiency, component loosen- consent are enrolled into an institu- 2-year postoperative evaluation,
ing, glenoid bone loss, and infec- tional, review board–approved, pro- leaving a final study cohort of 35
tion.7,11-13,15-21,23-25 However, most spective database that monitors patient patients (83%).
studies reporting on outcomes for outcomes before surgery, at 2 weeks, A matched cohort of patients who
revision shoulder arthroplasty 3 months, 1 year, and then yearly had undergone primary RTSA for
to RTSA have lumped together after RTSA. A trained, independent rotator cuff tear arthropathy or irrep-
anatomic total shoulders, hemi- clinical research nurse examines pa- arable rotator cuff tears was established
arthroplasties, fractures, and patients tients before surgery and at all post- in a two control:one revision patient
with infections,7,11-13,15-18,20,21,23,24 operative visits. Patients who do not ratio, based on age, sex, body mass
whereas those specifically focusing on return are contacted by phone to index, and final follow-up length. The
revision of anatomic total shoulder obtain outcome scores. Outcomes author who selected these patients was
arthroplasty (aTSA) have been case collected include the American blinded to their preoperative and post-
series without control groups for ref- Shoulder and Elbow Surgeons (ASES) operative outcomes during selection.
erence.19 This is important to note score, subjective shoulder value
because several studies that included (SSV), visual analog scale (VAS)
mixed cohorts (eg, aTSA, hemi- score for pain (range, 0 [no pain] Surgical Technique
arthroplasty, infections) reported that to 10 [max pain]), and patient All procedures were performed, with
revisions had worse outcomes than satisfaction. Medical records are the patient in the beach chair posi-
typically seen in primary RTSA also searched for postoperative tion with a standard deltopectoral
patients,13,15 whereas others have complications, including revision approach. A subscapularis tenot-
reported similar outcomes between surgeries, and general patient omy was performed with subse-
revision and primary RTSA.7,12 demographics. quent repair at the end of the
These discrepancies may be explained This database was retrospectively procedure, unless the subscapularis
in part by variable distributions of queried for patients between the tendon was deficient preoperatively.
aTSA, hemiarthroplasty, and infection years 2008 to 2014 for patients All components were implanted
patients being revised to RTSA in these undergoing RTSA for failed aTSA. based on the manufacturer’s recom-
studies because patients undergoing Inclusion criteria included conver- mendations. In the revision surgery
revision shoulder surgery for post- sion of aTSA to RTSA for component group, 20 patients received a DJO
traumatic indications and infections loosening or rotator cuff failure Encore baseplate and Zimmer Tra-
may have markedly worse outcomes and minimum 24-month follow-up. becular Metal humeral component,
compared with other indications.30 Exclusion criteria were revisions for 11 received all Zimmer Trabecular
The purpose of this study was to infection, neurologic disorders, chronic Metal components, 2 received
compare patients who underwent dislocations, previous revision arthro- Encore baseplates with retained
revision of an aTSA to RTSA, for plasty surgery, age .95 years at the Biomet Comprehensive Shoulder
component loosening or rotator cuff time of surgery, and any traumatic System stems, and 2 received Encore
failure only, and to compare their indication. All patients were worked baseplates with retained Tornier
outcomes to a matched cohort of up before surgery with erythrocyte Aequalis stems. For the controls, 69
Edward Shields, MD and J. Michael Wiater, MD
received all Zimmer Trabecular Table 1

Metal components, and 1 received a
Demographic Information for Revision and Matched Control Groups
Trabecular Metal stem with Encore
baseplate. The use of different Revision Group Matched Controls
Variable (n = 35) (n = 70) P Value
implant systems reflects the senior
author’s preference for using the Age 64 6 10 67 6 9 0.09
Encore baseplate in situations with Sex (female) 54% 59% 0.67
glenoid bone loss. Seventeen glenoid BMI 31.5 6 8 32 6 7 0.85
defects underwent cancellous bone Side of procedure (right) 69% 66% 0.48
grafting. One humeral osteotomy Follow-up length (mo) 50 6 22 47 6 14 0.32
was performed and repaired with
cerclage cables. Because of a large BMI = body mass index
number of patients not having
radiographs at final study follow-up,
imaging analysis was not performed. Table 2
Sixteen glenoid components were
Preoperative and Postoperative Functional and Subjective Outcomes for
loose and two humeral components Revision and Matched Control Patient Groups
at the time of conversion.
Revision Matched
Group Controls
Statistical Analysis Factor (n = 35) (n = 70) P Value
All statistical analyses were per- Preoperative values
formed using SPSS (v22; IBM). First, Pain score 7.2 6 2.5 7.2 6 2.6 0.97
the equal variance and normality as- ASES score 30.4 6 17 30.6 6 17 0.96
sumptions of continuous data were ASES ADL score 9.7 6 4.9 10.3 6 5.1 0.59
assessed using the Levene test and the SSV score 30 6 28 23 6 21 0.17
Shapiro-Wilk test, respectively. Stu- Postoperative values
dent t-tests and Mann-Whitney U Pain score 2.4 6 2.8 1.7 6 2.8 0.24
tests were used to assess differences
ASES score 68 6 26 76 6 24 0.14
in normally distributed and non-
ASES ADL score 26 6 13 21 6 7.6 0.01a
normally distributed independent
SSV score 63 6 30 79 6 21 0.002a
outcome variables, respectively. The
Patient satisfaction (percent satisfied) 74 90 0.03a
chi-square test was used to compare
categoric variables. Statistical sig- ADL = activities of daily living, ASES = American Shoulder and Elbow Surgeons,
nificance was defined as P , 0.05. SSV = subjective shoulder value
a
P , 0.05.
Values are presented as mean 6 SD.
Results follow-up, VAS pain (2.4 6 2.8 16 months after conversion, one
versus 1.7 6 2.8; P = 0.24) and ASES patient had two additional surgeries
The average age (64 6 10 versus scores (68 6 26 versus 76 6 24; P = for scar excision, one conversion to
67 6 9 years; P = 0.09), sex distri- 0.14) were similar between revision hemiarthroplasty, and one infection
bution (54% versus 59% women; and primary patients (Table 2). The ultimately treated with resection ar-
P = 0.67), body mass index (31.5 6 8 revision group had better ASES throplasty) required revision surgery
versus 32 6 7 kg/m2; P = 0.85), activities of daily living scores (26 6 in the revision group. In addition, four
surgical side (69% right versus 66% 13 versus 21 6 7.6; P = 0.01), but patients (ie, three tuberosity fractures
right; P = 0.48), and follow-up worse SSV scores (63 6 30 versus 79 and one nondisplaced humeral split)
length (50 6 22 versus 47 6 6 21; P = 0.002), and a lower rate of sustained minor intraoperative frac-
14 months; P = 0.32) were similar patient satisfaction (74% versus tures, one sustained a lower trunk
between the revision (n = 35) and 90%; P = 0.03) compared with the brachial plexopathy that resolved,
primary (n = 70) RTSA groups matched control group (Table 2). and one acromial stress fracture was
(Table 1). All preoperative outcome Five patients (ie, one loose base- treated with sling immobilization. In
measures were similar between the plate revised 3 years from conversion, all, 11 patients (31%) experienced
two groups (Table 2). At final one loose humeral component at some complications.
February 15, 2019, Vol 27, No 4 e195
The matched control group patients tients who received an aTSA that RTSA patients, whereas the revision
experienced two revision surgeries (ie, subsequently failed by rotator cuff patients had worse SSV scores, all
one polyethylene dissociation 3 years failure or component loosening, with similar to the observations in our
after index procedure and one recur- subsequent conversion to an RTSA. study.
rent dislocator), two minor intra- These patients had similar functional Many have reported higher com-
operative fractures (ie, one anterior outcomes based on the ASES and plication rates after revision shoulder
glenoid and one humeral split), one VAS pain scores compared with a surgery.7,16,22,24,25,32 In their litera-
postoperative periprosthetic humeral matched cohort of patients undergo- ture review, Randelli et al22 reported
fracture from a fall, one ulnar nerve ing primary RTSA but did have lower complication rates as high as 62%
palsy that resolved, and one myocar- subjective value scores and an overall and a mean revision surgery rate of
dial infarction on postoperative day 2; lower rate of satisfaction compared 27% after revision shoulder arthro-
one patient developed Clostridium with primary patients, despite nota- plasty. Flury et al16 reported 43%
difficile colitis, and there was one ble gains in function. intraoperative complications, 38%
broken drill tip left in a scapula. In Managing patient expectations postoperative complications, and a
all, nine patients (13%) experienced and selecting a procedure that max- 10% infection rate. Another study
some complications compared with imizes a patient’s chances for a sat- also showed that not only were
31% in the revision group (P = 0.02). isfactory outcome can be challenging complications more frequent in the
Significantly more patients required when confronted with a failed to- revision group but the complications
revision surgery in the revision group tal shoulder arthroplasty. Although of revision patients are more likely to
(14%) compared with the matched many authors have reported out- be surgical compared with primary
control group undergoing primary comes after conversion of aTSA to RTSA patients, which tend to have
RTSA (3%; P = 0.03). RTSA, many of these studies include more medical complications.32 Wall
Subgroup analysis was performed to fractures, infections, or various et al reported a 37% complication
determine the effect of complications types of arthroplasty (ie, hemi and rate in revision surgery compared
on SSV and patient satisfaction. In the total).7,11-18,20-25 Revision surgery with 13% for primary, whereas
revision group, patients without a for infection and trauma have been Werner et al reported a 38% revision
complication had better SSV scores (68 shown to result in worse outcomes surgery rate in revision surgery
6 28 veresus 51 6 33; P = 0.12) and relative to other indications.30 Com- compared with 18% for primary
overall satisfaction (83% versus 55%; bining multiple revision indications surgery.7,25 In contrast, patients
P = 0.07), but neither reached statis- together may be necessary with small younger than 65 years may experi-
tical significance. In addition, for the sample sizes but may lead to mis- ence similar complication rates
revision group, patients who under- leading results if certain groups of between the revision and primary
went a revision surgery had much patients do better or worse. Our procedures according to Black
worse SSV scores (68 6 28 versus study attempted to specifically focus et al,12 who observed a 19% com-
26 6 31; P = 0.004) and satisfaction only aTSA patients who required plication rate in revisions and 15%
(83% versus 20%; P = 0.004) com- revision for mechanical reasons. The in primary RTSA (P . 0.05). Data
pared with all revision patients with no results from our data suggest that from our study are in line with most
complications or revision surgeries. overall, pain and function in this previous literature, suggesting that
Controls without any complication subset of revision patients are simi- revision shoulder arthroplasty sur-
still had better average SSV scores lar to primary RTSA outcomes, and gery results in a higher complication
(control, 79 6 21 versus revision, 68 6 these results echo several earlier and revision surgery rates compared
28; P = 0.05) and patient satisfaction reports.7,12 The previous studies with primary arthroplasty.
(control, 90% versus revision, 83%; that found a difference in functional The data from this study, using 35
P = 0.38) compared with revision pa- outcomes between revision and revision patients and 70 matched
tients without complications; however, primary RTSA included fracture controls, may be underpowered to
the differences were not statistically sequelae, infections, failed hemi- detect a difference between the groups
significant. arthroplasty, and failed aTSA pa- regarding the final ASES and pain
tients in their revision group, which scores. However, the difference in the
could account for the differences average ASES score between the revi-
Discussion observed in our study.13,15 Interest- sion and control patients was only
ingly, Black et al12 also found that eight points. Several recent pub-
This study reports outcomes on a reported outcome scores and pain lications have investigated the mini-
relatively homogenous group of pa- were similar in revision and primary mal clinically important difference
Edward Shields, MD and J. Michael Wiater, MD
(MCID) for the ASES score specifi- group, the overall size of the cohort is 4. Shi LL, Cahill KE, Ek ET, et al: Latissimus
dorsi and teres major transfer with reverse
cally after shoulder arthroplasty. One relatively small. The database con- shoulder arthroplasty restores active
study found the ASES MCID to be tains extensive information on these motion and reduces pain for
13.5 points,33 whereas the other patients; however, factors such as posterosuperior cuff dysfunction. Clin
Orthop Relat Res 2015;473:3212-3217.
concluded that a 21-point difference workers compensation, mental health,
5. Simovitch RW, Helmy N, Zumstein MA,
was needed.34 Even if the difference socioeconomic status, or other factors Gerber C: Impact of fatty infiltration of the
observed in our study reached sta- that can markedly influence outcomes teres minor muscle on the outcome of
tistical significance, it is below all are not documented. Differences in reverse total shoulder arthroplasty. J Bone
Joint Surg Am 2007;89:934-939.
reported shoulder arthroplasty– attending preference for revision
specific ASES MCID values. The cases resulted in a larger variation of 6. Sirveaux F, Favard L, Oudet D, Huquet D,
Walch G, Molé D: Grammont inverted
final difference in VAS pain scores implant utilization in the revision total shoulder arthroplasty in the treatment
between the two cohorts in this study group compared with a relatively of glenohumeral osteoarthritis with massive
rupture of the cuff: Results of a multicentre
was 0.7 points, which is well below homogenous control group. Although study of 80 shoulders. J Bone Joint Surg Br
the reported 1.4 point MCID for never clearly shown, differences be- 2004;86:388-395.
shoulder arthroplasty.34 To our tween these implant designs could 7. Werner CML, Steinmann PA, Gilbart M,
knowledge, the MCID for the SSV potentially affect patient outcomes. Gerber C: Treatment of painful
has not been determined, and it is With only 83% of the eligible revi- pseudoparesis due to irreparable rotator
cuff dysfunction with the delta III reverse-
thus unclear whether the statistically sion patients having 2-year follow- ball-and-socket total shoulder prosthesis. J
lower SSV score in the revision group up, it is possible that the 17% not Bone Joint Surg Am 2005;87:1476-1486.
by 16 points is clinically meaningful. included could have had a notable 8. Chalmers PN, Keener JD: Expanding roles
It remains unclear why the revision effect on final average outcomes. for reverse shoulder arthroplasty. Curr Rev
Musculoskelet Med 2016;9:40-48.
group, despite similar pain and ASES
scores, and actually better ASES ADL 9. Hyun YS, Huri G, Garbis NG, McFarland
Conclusion EG: Uncommon indications for reverse
scores, would have worse SSV scores total shoulder arthroplasty. Clin Orthop
(63 6 30 versus 79 6 21; P = 0.002) Revision of aTSA to RTSA for com-
Surg 2013;5:243-255.
and overall satisfaction (74% versus ponent loosening or rotator cuff 10. Hussey MM, Hussey SE, Mighell MA:
90%; P = 0.03) compared with the Reverse shoulder arthroplasty as a salvage
failure results in function comparable procedure after failed internal fixation of
primary group. This may be a result to primary RTSA; however, more fractures of the proximal humerus:
from a higher revision surgery rate complications and worse SSV scores Outcomes and complications. Bone Joint J
2015;97-B:967-972.
(14% versus 3%; P = 0.03) in the and patient satisfaction should be
revision group because it was the expected.
11. Abdel MP, Hattrup SJ, Sperling JW, Cofield
RH, Kreofsky CR, Sanchez-Sotelo J:
only real objective difference be- Revision of an unstable hemiarthroplasty or
tween the groups identified, and anatomical total shoulder replacement
these patients had much worse final References using a reverse design prosthesis. Bone Joint
J 2013;95-B:668-672.
outcomes than the rest of the group.
Additional explanations may be that References printed in bold type are 12. Black EM, Roberts SM, Siegel E,
those published within the past 5 Yannopoulos P, Higgins LD, Warner JJP:
these patients have either higher ex- Reverse shoulder arthroplasty as salvage
pectations or are more pessimistic years. for failed prior arthroplasty in patients 65
years of age or younger. J Shoulder Elbow
about their function after having 1. Boulahia A, Edwards TB, Walch G, Baratta Surg 2014;23:1036-1042.
failed at least one surgery already. RV: Early results of a reverse design
prosthesis in the treatment of arthritis of the 13. Boileau P, Watkinson D, Hatzidakis AM,
Interestingly, a study by Black et al12 shoulder in elderly patients with a large Hovorka I: Neer Award 2005: The
also found patients converted to rotator cuff tear. Orthopedics 2002;25: Grammont reverse shoulder prosthesis:
129-133. Results in cuff tear arthritis, fracture
RTSA from aTSA had similar func- sequelae, and revision arthroplasty. J
tional outcomes compared with pri- 2. Gerber C, Pennington SD, Lingenfelter EJ, Shoulder Elbow Surg 2006;15:527-540.
Sukthankar A: Reverse delta-III total
mary RTSA patients, yet revision shoulder replacement combined with 14. Budge MD, Moravek JE, Zimel MN, Nolan
patients had worse subjective scores latissimus dorsi transfer: A preliminary EM, Wiater JM: Reverse total shoulder
similar to our findings. report. J Bone Joint Surg Am 2007;89: arthroplasty for the management of failed
940-947. shoulder arthroplasty with proximal
This study has a number of inherent humeral bone loss: Is allograft
3. Puskas GJ, Catanzaro S, Gerber C: Clinical
weaknesses. Although the data were augmentation necessary? J Shoulder Elbow
outcome of reverse total shoulder Surg 2013;22:739-744.
collected prospectively, the retro- arthroplasty combined with latissimus dorsi
spective design introduces the risk transfer for the treatment of chronic 15. Cuff D, Pupello D, Virani N, Levy J,
combined pseudoparesis of elevation and Frankle M: Reverse shoulder arthroplasty
to a number of biases. Because of our external rotation of the shoulder. J for the treatment of rotator cuff deficiency.
specific criteria for the revision Shoulder Elbow Surg 2014;23:49-57. J Bone Joint Surg Am 2008;90:1244-1251.
February 15, 2019, Vol 27, No 4 e197
16. Flury MP, Frey P, Goldhahn J, Schwyzer H- in failed shoulder arthroplasties for rotator 29. Schairer WW, Nwachukwu BU, Lyman S,
K, Simmen BR: Reverse shoulder cuff deficiency. Joints 2015;3:31-37. et al: National utilization of reverse total
arthroplasty as a salvage procedure for shoulder arthroplasty in the United States. J
failed conventional shoulder replacement 23. Valenti P, Kilinc AS, Sauzières P, Katz D: Shoulder Elbow Surg 2015;24:91-97.
due to cuff failure: Midterm results. Int Results of 30 reverse shoulder prostheses
Orthop 2011;35:53-60. for revision of failed hemi- or total shoulder 30. Dines JS, Fealy S, Strauss EJ, et al:
arthroplasty. Eur J Orthop Surg Traumatol Outcomes analysis of revision total
17. Kelly JD, Zhao JX, Hobgood ER, Norris 2014;24:1375-1382. shoulder replacement. J Bone Joint Surg
TR: Clinical results of revision shoulder Am 2006;88:1494-1500.
arthroplasty using the reverse prosthesis. J 24. Walker M, Willis MP, Brooks JP, Pupello
Shoulder Elbow Surg 2012;21:1516-1525. D, Mulieri PJ, Frankle MA: The use of the 31. Matsen FA, Russ SM, Vu PT, Hsu JE,
reverse shoulder arthroplasty for treatment Lucas RM, Comstock BA: What factors are
18. Levy J, Frankle M, Mighell M, Pupello D: of failed total shoulder arthroplasty. J predictive of patient-reported outcomes? A
The use of the reverse shoulder prosthesis Shoulder Elbow Surg 2012;21:514-522. prospective study of 337 shoulder
for the treatment of failed hemiarthroplasty arthroplasties. Clin Orthop Relat Res 2016;
for proximal humeral fracture. J Bone Joint 25. Wall B, Nové-Josserand L, O’Connor DP,
474:2496-2510.
Surg Am 2007;89:292-300. Edwards TB, Walch G: Reverse total
shoulder arthroplasty: A review of results 32. Saltzman BM, Chalmers PN, Gupta AK,
19. Melis B, Bonnevialle N, Neyton L, et al: according to etiology. J Bone Joint Surg Am Romeo AA, Nicholson GP: Complication
Glenoid loosening and failure in anatomical 2007;89:1476-1485. rates comparing primary with revision
total shoulder arthroplasty: Is revision reverse total shoulder arthroplasty. J
with a reverse shoulder arthroplasty a 26. Kim SH, Wise BL, Zhang Y, Szabo RM:
Increasing incidence of shoulder Shoulder Elbow Surg 2014;23:1647-1654.
reliable option? J Shoulder Elbow Surg
2012;21:342-349. arthroplasty in the United States. J Bone
33. Werner BC, Chang B, Nguyen JT, Dines
Joint Surg Am 2011;93:2249-2254.
DM, Gulotta LV: What change in American
20. Ortmaier R, Resch H, Matis N, et al:
27. Rosas S, Law TY, Kurowicki J, et al: Shoulder and Elbow Surgeons score
Reverse shoulder arthroplasty in revision of
Trends in surgical management of proximal represents a clinically important change
failed shoulder arthroplasty: Outcome and
humeral fractures in the Medicare after shoulder arthroplasty? Clin Orthop
follow-up. Int Orthop 2013;37:67-75.
population: A nationwide study of records Relat Res 2016;474:2672-2681.
21. Patel DN, Young B, Onyekwelu I, from 2009 to 2012. J Shoulder Elbow Surg
34. Tashjian RZ, Hung M, Keener JD, et al:
Zuckerman JD, Kwon YW: Reverse total 2016;25:608-613.
Determining the minimal clinically
shoulder arthroplasty for failed shoulder
28. Schwartz BE, Savin DD, Youderian AR, important difference for the American
arthroplasty. J Shoulder Elbow Surg 2012;
Mossad D, Goldberg BA: National trends Shoulder and Elbow Surgeons score, Simple
21:1478-1483.
and perioperative outcomes in primary and Shoulder Test, and visual analog scale (VAS)
22. Randelli P, Randelli F, Compagnoni R, revision total shoulder arthroplasty. Int measuring pain after shoulder arthroplasty. J
et al: Revision reverse shoulder arthroplasty Orthop 2015;39:271-276. Shoulder Elbow Surg 2017;26:144-148.
Editorial
JAAOS Serving the Orthopaedic
Community Even Better
William N. Levine, MD As many of you head to the Annual bined editorial boards for reviews
Meeting in Las Vegas, I wanted to and research that made this happen.
draw your attention to some impor- So, be prepared for your next article
tant improvements we have made submission to speed through the
over the past 12 months to serve review process toward a decision,
you better and make The Yellow and once accepted, see it online and
Journal even more competitive.We in an issue much more quickly than
have processed a notable backlog of in the past. I would also like to
accepted articles last year and were thank our many reviewers (see list at
able to clear this out and publish all http://links.lww.com/JAAOS/A315)
those articles online still in 2018 who have helped JAAOS to become
ahead of the print issues. Some articles the most read orthopaedic journal
could not be assigned to issues last in the world (based on the most
year, so these will all be part of JAAOS recent Kantar Media Medical/
issues throughout March 2019. We Surgical Readership Study in Or-
have accelerated the entire publi- thopaedic Surgery). In January, we
cation process markedly, so if you have introduced a new feature–
ever wonder where your accepted podcasts, “JAAOS Unplugged”:
article is after you returned your https://journals.lww.com/jaaos/Pages/
author proofs, you can go to the podcasts.aspx. These audio tidbits
Advanced Access (PAP) section on are intended for your commute,
the JAAOS menu and find your workout, or anywhere you want to
article published online already: listen in, and are based on
https://journals.lww.com/jaaos/toc/ a selection of JAAOS articles of the
publishahead. Lastly, and this will current month and a discussion
please you as you submit your next between authors of a selected article
review proposal or article to JAAOS: being led by Andrew Jensen, MD,
we have been able to markedly recurrent Chair of the AAOS Resi-
duce the time from submission of an dent Assembly and Chair of
article to the first decision, be it ac- the Resident Assembly Executive
ceptance, request for revisions, rec- Committee. Enjoy and let us know
ommendation to cascade an article what you think!
to JAAOS Global, or a rejection.
Jointly with Jeffrey Fischgrund, MD,
Dr. Levine is Editor-in-Chief of the JAAOS Editor, Research, I am
Journal of the American Academy of thankful for the efforts of the com-
Orthopaedic Surgeons, Rosemont, IL,
and the Frank E. Stinchfield Professor
and Chairman, Department of
Orthopedic Surgery, Columbia
University Medical Center, New York,
NY.
Dr. Levine or an immediate family

member serves as an unpaid
consultant to Zimmer Biomet.
DOI: 10.5435/JAAOS-D-18-00809
March 1, 2019, Vol 27, No 5 155
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Review Article
Degenerative Rotator Cuff Tears:

Refining Surgical Indications
Based on Natural History Data
Abstract
Jay D. Keener, MD Degenerative rotator cuff tears are the most common cause of
Brendan M. Patterson, MD shoulder pain and have a strong association with advanced aging.
Considerable variation exists in surgeons’ perceptions on the
Nathan Orvets, MD
recommended treatment of patients with painful rotator cuff tears.
Aaron M. Chamberlain, MD Natural history studies have better outlined the risks of tear
enlargement, progression of muscle degeneration, and decline in the
function over time. This information combined with the known factors
potentially influencing the rate of successful tendon healing such as
age, tear size, and severity of muscle degenerative changes can be
used to better refine appropriate surgical indications. Although
conservative treatment can be successful in the management of
many of these tears, risks to nonsurgical treatment also exist. The
application of natural history data can stratify atraumatic
From the Shoulder and Elbow
Service, Department of Orthopaedic
degenerative tears according to the risk of nonsurgical treatment and
Surgery, Washington University, St. better identify tears where early surgical intervention should be
Louis, MO. considered.
Dr. Keener or an immediate family
Genesis, Shoulder Innovations, and
Imascap; serves as a paid consultant
to Arthrex; and has received research
or institutional support from the
R otator cuff disease is the most
common cause of shoulder dis-
ability and is especially prevalent in
Additionally, male sex, dominant
arm, history of heavy labor, certain
acromial characteristics, and genetic
National Institutes of Health (NIAMS
and NICHD) and Zimmer Biomet. the aging population.1 Many authors factors correlate with rotator cuff
Dr. Patterson or an immediate family suggested that rotator cuff disease tears.9,10
member is an employee of Disk- is a natural aging phenomenon, Although the natural history of
Criminator. Dr. Chamberlain or an given the strong association with age degenerative rotator cuff tears has
immediate family member serves as a
paid consultant to Arthrex, DePuy, and the fact that most tears are recently been better defined, many
and Zimmer Biomet and has received asymptomatic.2,3 Cadaveric and in unanswered questions remain re-
research or institutional support from vivo imaging studies have shown the garding the risk factors for disease
Zimmer Biomet. Neither Dr. Orvets nor rates of asymptomatic rotator cuff progression, in particular pain de-
received anything of value from or has tears to increase proportionally with velopment. Natural history studies
stock or stock options held in a age, with 20% of patients in their are fundamental for developing
commercial company or institution sixties and up to 80% of patients appropriate treatment algorithms.
related directly or indirectly to the older than 80 years having tears.2 Despite the high prevalence of rotator
subject of this article.
Yamaguchi et al4 found that patients cuff pathology, substantial contro-
Supported by NIH grant: R01-051026. with a painful cuff tear at the age of versy exists regarding the optimal
J Am Acad Orthop Surg 2019;27: 66 years or older have a 50% chance management of symptomatic rotator
156-165 of having a contralateral rotator cuff cuff disease.11 Trends in nonsurgical
DOI: 10.5435/JAAOS-D-17-00480 tear that is often unknown to the management and rotator cuff repair
patient. Asymptomatic tears develop have varied markedly over time.12
Academy of Orthopaedic Surgeons. pain in approximately 30% to 40% Further complicating the matters, the
of patients within 2 to 5 years.5-8 symptom duration does not correlate
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Jay D. Keener, MD, et al
Figure 1 Figure 2
A, Anterior cable intact tear. Typical appearance of degenerative rotator cuff

tear. Tear involves the supraspinatus and anterior infraspinatus within the rotator
crescent. The anterior attachment of the supraspinatus is intact, preventing
severe retraction of the supraspinatus tendon. * = biceps tendon. B, Anterior
Insertional rotator cuff anatomy cable disrupted tear. This degenerative cuff tear involves the anterior
according to Mochizuki in an supraspinatus tendon uncovering the biceps tendon. More severe retraction of
illustration of the superior right the supraspinatus muscle is seen. * = biceps tendon.
proximal humerus. GT = greater
tuberosity, HH = humeral head, ISP-I
= infraspinatus insertion, LT = lesser than previously thought. The inser- search. Kim et al16 mapped the
tuberosity, SSP-I = supraspinatus tion extends a mean of 12.6 mm in common locations of asymptomatic
insertion. (Reproduced with
permission from Mochizuki, T,
the anterior to posterior direction and symptomatic full-thickness de-
Sugaya, H, Uomizu, M, et al: into a tapered insertion that is much generative cuff tears in 272 patients
Humeral insertion of the smaller laterally than medially. The using ultrasonography, measuring
supraspinatus and infraspinatus: infraspinatus tendon curves anteri- the distance from the anterior tear
New anatomical findings regarding
the footprint of the rotator cuff. J
orly covering a mean of 32.7 mm of margin to the biceps tendon. Only
Bone Joint Surg Am 2008;90: the superior and posterior greater 33% of tears involved the most
962-969.) tuberosity in the sagittal plan (Figure anterior aspect of the supraspinatus
1). Previous studies of the infra- tendon (Figure 2). The most com-
spinatus tendon footprint cited a mon location of tears involved an
with the rotator cuff tear severity or
range of 16 to 29 mm in the anterior area 13 to 17 mm posterior to the
other patient factors.13 Clinical
to posterior dimension. Mochizuki biceps tendon. Small full-thickness
guidelines provided by the American
et al highlighted the morphology tears most commonly involved an
of infraspinatus tendon as curving area 15 mm posterior to the biceps
on the management of rotator cuff
superiorly onto the greater tuberosity tendon, suggesting that degenerative
disease are largely weak or inconclu-
sweeping lateral the supraspinatus tears most commonly originate here.
sive because of lack of high-quality
insertion. These findings are clinically This region correlates with the in-
evidence. Their recommendations
relevant in that many tears classified fraspinatus and supraspinatus junc-
highlight the need for further research
as isolated to the supraspinatus tention commonly described as the
to better define the natural history of
don based on previous anatomic rotator crescent that is bordered by
rotator cuff disease and the results of
definitions actually also involve the the rotator cable.15 Isolated small-
both surgical and nonsurgical inter-
infraspinatus tendon. and medium-sized tears with or
vention to further refine treatment
Degenerative rotator cuff tears without disruption of the anterior
recommendations.14
develop from age-related changes supraspinatus tendon were compared
that may be directly related to the by Namdari et al.17 They found that
Tear Characteristics— poor vascularity of the rotator cres- anterior supraspinatus disrupted tears
Degenerative Cuff Disease cent. Along a continuum, tears likely had a larger tear size and possessed
progress from tendinopathy to par- greater supraspinatus muscle degen-
The insertional anatomy of the rota- tial to full-thickness tears over time. eration. However, no differences in
tor cuff must be considered when Previous theories suggesting that baseline or postsurgical functional
discussing degenerative rotator cuff degenerative tears begin at the ante- outcomes (ASES; 92 versus 93) or
tears. Mochizuki et al15 showed that rior supraspinatus tendon insertion healing rates (93% versus 86%) for
the supraspinatus footprint on the adjacent to the biceps tendon have anterior supraspinatus intact versus
greater tuberosity was much smaller been challenged by prospective re- disrupted tears were seen.17
March 1, 2019, Vol 27, No 5 157
Rotator Cuff Surgical Indications
Disruption of the rotator cuff ten- versus partial thickness) and hand Multiple other studies with variable
don is felt to lead to muscular fatty dominance were associated with a methodologies have attempted to
infiltration (FI) and atrophy, sec- greater enlargement risks; however, define the tear enlargement risks in
ondary to tendon retraction and subject age, sex, and baseline tear size both asymptomatic and painful
impaired force transmission. Rotator were not. The risks of tear enlargement shoulders. Moosmayer et al6 pro-
cuff tear size and location are directly at 2 and 5 years were 22% and 50%, spectively followed 50 full-thickness
related to the patterns of fatty muscle respectively, for full-thickness tears degenerative rotator cuff tears for 3
degeneration. Kim et al18 demon- and 11% and 35%, respectively, for years and showed that symptoms
strated that fatty degeneration was partial-thickness tears. This data sug- developed in 36% of patients. The
nearly exclusive to full-thickness tears. gest that although tear progression is symptomatic group had a larger
Thirty-five percent of the shoulders common, the timeline is relatively increase in tear size, a greater pro-
had evidence of fatty degeneration on slow. Keener et al20 investigated gression of muscle degeneration, and
ultrasonography, and tears with fatty tear progression in anterior supra- more frequent biceps pathology on
degeneration had a greater width and spinatus intact compared with that follow-up imaging compared with
length than those without. In this in disrupted tears in 139 patients the asymptomatic group. In patients
cohort, disruption of the anterior with minimum 2-year follow-up. They with symptomatic full-thickness tears
supraspinatus insertion (anterior cable) found no statistical difference in the managed nonsurgically, using ultra-
was the most important predictor of risk of enlargement, time to enlarge- sonography, Safran et al7 demon-
supraspinatus muscle degeneration, ment, or magnitude of enlargement strated that 49% of tears increased in
whereas larger tear size was the best between groups. However, a trend size within 2 years. The only variable
predictor of infraspinatus muscle exists towards greater enlargement associated with increased pain was
degeneration. risks in the cable-disrupted tears (67% tear enlargement at the time of follow-
vs. 52%, P = 0.09) versus intact tears. up. Using MRI, Maman et al8 retro-
The factors important for pain spectively reviewed 59 patients with
Natural History development in shoulders with rotator cuff tears, with imaging
asymptomatic tears are not clearly a different time points. They found
Tear Enlargement and Pain defined.21 Interestingly, in patients that age greater than 60 years, full-
Progression presenting with a painful rotator cuff thickness tears, and FI were all
Defining the risks of tear progression tear, disease severity does not cor- associated with tear progression. Tear
and symptom development is critical relate well with VAS pain scores. enlargement occurred in 19% at 18
in developing treatment algorithms Both Mall et al19 and Keener et al20 months and at 48% with follow-up
and can be best understood by look- have prospectively demonstrated beyond 18 months. Moosmayer
ing at natural history studies. The that tear enlargement is a risk factor et al22 reported the findings of a
natural history of degenerative rota- for pain development; however, selected subgroup of 49 subjects with
tor cuff tears has been recently absolute correlations do not exist. In small- and medium-sized full-
defined in asymptomatic patients the study by Keener et al,20 46% of thickness tears, who were followed
followed prospectively. Given that asymptomatic shoulders developed for a mean of 8.8 years and managed
rotator cuff disease is often bilateral, pain over a 5-year period. Although nonsurgically. The authors excluded
screening the contralateral shoulder the risk of pain development was 23 shoulders requiring surgery dur-
in patients with a painful rotator cuff approximately 70% more likely if ing the study period. This study
tear provides a valuable study group enlargement occurred, 37% of the demonstrated great variability in
where no treatment intervention is newly painful shoulders did not the magnitude of tear enlarge-
needed.4,19 Keener et al5 examined the enlarge and 38% of enlarged tears ment (mean tear width increase was
risks of cuff tear enlargement and pain remained asymptomatic. Pain de- 8.3 mm). One-third of the tears in-
development in 224 asymptomatic velopment was associated with clin- creased greater than 10 mm (half of
shoulders with known full-thickness ically notable decline in shoulder these were greater than 20 mm).
tears (118), partial-thickness tears (56), function. There are clearly factors Progression of degenerative muscle
and intact rotator cuffs (50) followed other than tear enlargement that changes was noted in half the sub-
annually with ultrasonography and play a role in pain development in jects. Shoulder function remained
clinical examination (Table 1). At 5 shoulders with degenerative tears, stable if the tear size increase was
years of follow-up, the risk of tear and it is important to remember that less than 10 mm. Declining ASES
enlargement of 5 mm or greater was other potential pain generators may and Constant scores were noted
49%. Tear severity (full thickness play a role in symptom onset. with tear enlargement greater than
Table 1
Natural History Studies of Untreated Rotator Cuff Tears
Imaging
Study Study Group Duration of F/U Modality Results
Moosmayer 50 asymptomatic full- 3 yr Ultrasonography 36% of shoulders developed pain.

et al6 thickness tears and MRI Painful shoulders had greater enlargement
(10.6 mm versus 3.3 mm).
Increased rate of progression of advanced
atrophy in the symptomatic group (35% versus
12%).
Increased rate of fatty muscle degeneration in the
symptomatic group (35% versus 4%).
Maman 49 nonsurgically Minimum 6 mo, MRI F/U longer than 18 mo associated with greater tear
et al8 managed with range of progression (48% versus 19%).
symptomatic 7–58 mo Age .60 years associated with tear progression
rotator cuff tears (54% versus 17%).
24% of full-thickness tears and zero partial-
thickness tears developed muscle atrophy.
Risk of tear enlargement associated with the
presence of fatty muscle infiltration.
Keener Asymptomatic Mean 5.1 yr Ultrasonography 46% developed pain (50% full-thickness tears,
et al5 patients with 118 46% partial-thickness tears, and 28% controls).
full-thickness tears, Tear enlargement occurred in 61% of full-
56 partial-thickness thickness tears, 44% of partial-thickness tears,
tears, and 50 and 14% of controls.
controls Tear enlargement associated with hand
dominance.
Tear enlargement associated with pain
development.
Tear enlargement associated with cuff muscle
degeneration.
Tear size, age, and sex not correlated with
enlargement.
Safran et al7 61 symptomatic full- 2-3 yr Ultrasonography 49% of tears enlarged, 43% of tears were stable,
thickness rotator 8% of tears decreased in size.
cuff tears in 51 Correlation of tear enlargement and pain
patients aged development.
,60 yr Age, prior trauma, initial tear size. and bilateral
tears were not associated with tear
enlargement.
Fucentese 24 symptomatic full- Mean 42 mo Initial MR Mean Constant score was 75 at F/U.
et al24 thickness rotator arthrogram, 11 patients had no tear or smaller tear at F/U.
cuff tears in F/U MRI 9 patients had no change in tear size.
patients aged 6 patients (25%) had increased tear size.
,65 yr who Progression of FI from zero to 14% of cohort, but
declined surgery none were advanced.
FI = fatty infiltration, F/U = follow-up
20 mm and progression of muscle of advanced fatty muscle degenera- outcomes and lower tendon healing
degeneration. tion compared with smaller tears. rates following surgery (Figure 3). A
However, the timeline for the pro- recent report prospectively examined
gression of muscle degeneration and the risks of fatty muscle degenera-
Progression of Muscle the risk factors for these changes have tion progression using ultrasonogra-
Degeneration not been well-defined. Muscle de- phy.23 In a cohort of 156 full-thickness
It has been well recognized that larger generative changes are thought to tears (the majority being small or
and more chronic rotator tears are be clinically relevant because they medium sized), 55% of tears had some
associated with a greater likelihood have been linked to poorer clinical degree of fatty muscle degeneration
March 1, 2019, Vol 27, No 5 159
Figure 3
T1-weighted parasagittal MRI images demonstrating rotator cuff muscle health. A, Right shoulder. All cuff muscles healthy.
B, Right shoulder. Supraspinatus (thin arrow) with Goutallier grade II changes (fatty change noted but more muscle than fat).
Infraspinatus (thick arrow) with grade III changes (equal muscle and fat). Teres minor (*) with advanced fatty infiltration. C,
Left shoulder. Supraspinatus (thin arrow) and infraspinatus (thick arrow) with grade IV changes (more fat than muscle).
during a follow-up period of 6.0 years. outcomes is debated, it is generally scopic cuff repair. They reported
The presence of muscle degeneration felt that better and more consistent complete healing in 71% of patients,
was linked to older age and larger tear clinical results are obtained follow- noting age to be strongly correlated
size at baseline. Progression of muscle ing a successful tendon healing. with tendon healing. Patients with a
degeneration was more common in Therefore, identification of factors healed repair were on average 10
tears that enlarged (43% versus 20%). that better predict and surgical strat- years younger (57.8 6 9.4 years)
Progression of fatty muscle changes in egies that improve tendon healing is than those with a failed repair (68 6
enlarged tears was more common in important in identifying the optimal 7.6 years). Furthermore, for patients
tears that were larger at enrollment surgical candidates. Park et al25 younger than 55 years, the healing
(13.0 versus 10.0 mm) and in tears reported on 339 patients undergoing rate was 95%, and for patients older
with a greater magnitude of enlarge- arthroscopic rotator cuff repair for than 65 years the healing rate
ment (9.0 versus 5.0 mm), and when small- and medium-sized tears. They dropped to 43%.27 Oh et al28
the anterior supraspinatus was torn found patient age, tear size, and FI reported on 187 patients undergoing
(53% versus 17%). Although con- of the cuff muscles to be important arthroscopic or mini-open rotator
siderable variability exists in temporal risk factors in the development of cuff repair with a minimum follow-
progression of muscle changes com- recurrent rotator cuff tears. Multi- up of 1 year. The average age of
pared with enlargement events, the ple other studies have consistently patients with an intact repair CT
median time from an enlargement shown that patient age, tear size, arthrogram was 58 years compared
event to the progression of muscle and fatty muscle infiltration are key with 63 years for patients with a
degeneration was 1.0 and 1.1 years factors in predicting tendon healing retear. They also found that tendon
for the supraspinatus and infra- following rotator cuff repair. retraction and FI of the infraspinatus
spinatus, respectively. Patient age plays an important role were risk factors for poor healing.
in cuff tendon healing following sur- This finding highlights the influence
gery. Early literature from Harryman of age and other intrinsic tear char-
Factors Affecting Rotator et al26 revealed a strong correlation acteristics on rotator cuff healing.
Cuff Healing with rotator cuff healing and patient In multiple studies, tear size has
age, with older patients more likely been shown to influence healing rates
When considering surgical treatment, demonstrating recurrent defects. after repair. Galatz et al29 reported
it is paramount to understand factors Boileau et al27 reviewed the healing on the structural integrity of large
that influence rotator cuff healing. rates and functional outcome of and massive rotator cuff tears after
Although the correlation between 65 consecutive patients with full- arthroscopic cuff repair. Recurrent
successful tendon healing and clinical thickness tears treated with arthro- tendon defects were identified in
94% of shoulders. Although ad- Similar to tendon injuries elsewhere, for the patients undergoing surgical
vances in surgical techniques have it makes biologic sense that the heal- treatment. Long-term follow-up con-
improved the healing rates of ing environment is optimal in the tinued to demonstrate statistically
arthroscopic cuff repair, tear size acute setting before chronic degener- significant improvements in ASES
continues to be one of the primary ative changes have occurred. While and Constant scores for patients
determinants of successful tendon this concept is common dogma, undergoing surgery; however, these
healing. Park et al25 studied a large research supporting this notion is improvements were not considered
cohort of patients with small- to limited. Tan et al33 studied the effects clinically relevant at 5-year follow-up
medium-sized rotator cuff tears and of recent trauma and tendon healing because the differences failed to reach
found that patients with tears .2 cm in 1,300 patients undergoing arthro- the minimal clinically important dif-
had a healing rate of 65% compared scopic cuff repair. No notable differ- ference threshold.38 The crossover rate
with a healing rate of 89% in pa- ence was observed in the healing increased to 24% by 2 years, with 12
tients with tears #2 cm. More recent rates between patients who reported of 51 patients initially randomized to
literature from Tashjian et al30 has shoulder pain secondary to a specific physical therapy undergoing surgical
shown that tear retraction plays an event compared with tears with a repair. The authors found that 37% of
important role in tendon healing more insidious pain onset. In pa- the patients treated with physical
following repair of degenerative cuff tients reporting traumatic event, de- therapy had greater than 5 mm
tears. They investigated 42 patients laying surgery by more than 24 increase in tear size on 5-year follow-
undergoing arthroscopic rotator cuff months correlated with decreased up ultrasonography. The authors
repair and reported an overall heal- tendon healing. Other studies have supported an initial trial of physical
ing rate of 86%. Tendon healing was demonstrated a benefit of earlier therapy for small- to medium-sized
seen in 92% of tears when the surgical management of traumatic rotator cuff tears; however, they cau-
musculotendinous junction was lat- rotator cuff tears. Petersen and tioned that without surgery, many
eral to the glenoid compared with a Murphy34 investigated 36 shoulders tears have an increased risk of
healing of 56% in tears with with acute rotator cuff tears and enlargement and decreased function.
retraction of the musculotendinous found improved functional out- Kukkonen et al39 performed a ran-
junction medial to the glenoid. comes for patients who underwent domized controlled trial comparing the
Both FI and muscular atrophy are surgery in less than 4 months after outcomes of physical therapy, acro-
well-established risk factors influencing injury compared with those who mioplasty and physical therapy, or
tendon healing following rotator cuff underwent surgery after 4 months. rotator cuff repair for 160 patients
repair. Park et al25 found grade 2 and with full-thickness, degenerative rota-
higher fatty degeneration of the infra- tor cuff tears. They found no notable
spinatus to be an independent risk Clinical Outcomes—Higher difference in the functional scores or
factor for recurrent tears. Chung et al31 Level Evidence patient satisfaction between groups at
reviewed the results of 272 patients 2 years. The authors recommend
undergoing arthroscopic cuff repair. Multiple prospective studies have physical therapy as the preferred initial
Increased FI of the supraspinatus, in- documented excellent outcomes fol- treatment for isolated supraspinatus
fraspinatus, and subscapularis was lowing surgical repair of degenerative tears, with a caveat that many tears
associated with decreased tendon rotator cuff tears.35,36 More recently, treated without repair increase in size
healing. Furthermore, with multivari- several prospective randomized trials at short-term follow-up. Lambers
ate analysis, increased FI of the infra- have compared surgical versus non- Heerspink et al40 conducted a pro-
spinatus was an independent risk surgical management of rotator cuff spective randomized trial investigating
factor for recurrent tendon defects tears. Moosmayer et al37 performed a surgical versus nonsurgical treatment
following repair. Kim et al32 also randomized trial comparing physical in 56 patients with degenerative
found FI of the infraspinatus to be an therapy with surgical management of rotator cuff tears. At 1-year follow-
independent risk factor for a recurrent traumatic and degenerative rotator up, a notable improvement was
cuff tear with multivariate analysis of cuff tears. The authors originally observed in VAS pain scores for pa-
132 patients following repair of full- reported the outcomes of 103 patients treated with cuff repair; how-
thickness cuff tears. tients with a minimum follow-up of ever, no notable difference was seen
Rotator cuff tears resulting from 1 year. In patients with small- to in Constant scores between groups. A
acute injuries are thought to be more medium-sized rotator cuff tears, they subgroup analysis of healing data
likely to heal than degenerative rota- found markedly greater improve- within revealed that patients with
tor cuff tears after surgical repair. ments in ASES and Constant scores intact repairs demonstrated notable
March 1, 2019, Vol 27, No 5 161
Table 2
Treatment Recommendations Based on Patient and Tear Characteristics
Risks of Tear
Enlargement/
Muscle
Degeneration
Progression Patient and Tear Characteristics Treatment Recommendation
Low risk Partial-thickness tears Maximize conservative treatment, surgery if

Large tears with advanced muscle changes persistently asymptomatic.
Degenerative tears in patients aged .65–70 yr
Atraumatic full-thickness tears less than 15 mm in size
with an intact anterior cable
Medium risk Age under 62-65 years Informed discussion of surgical and
Atraumatic full-thickness tears .15 mm nonsurgical options warranted.
Anterior cable disruption Consider surveillance exams with successful
Acute on chronic tears–preserved function conservative treatment.
High risk Acute traumatic full-thickness tears Strong consideration for early surgical repair.
Acute on chronic tears with new pseudoparalysis or
profound external rotation weakness
Minimal muscle degenerative changes
Age compatible with healing
improvements in pain and functional discussion of the risks and benefits of progression of arthritic changes in
outcome compared with patients both surgical and nonsurgical treat- patients with degenerative rotator
treated nonsurgically. ment. Conservative treatment is a cuff tears followed prospectively.
Although these studies suggest an well-accepted treatment method for Certain tear characteristics warrant
advantage of surgery over conservative atraumatic full-thickness rotator cuff consideration for either close sur-
management of rotator cuff tears at tears in the short term.41 In many veillance or recommendation for
short-term follow-up when patients are patients with notable medical co- early surgical intervention. Based on
randomized at baseline presentation, morbidities or advanced age, this the natural history data, tears can be
the magnitude of the clinical relevance may well be the preferred treatment. stratified according to the short-term
of these findings is challenged by However, we are faced with a chal- risks of developing features previ-
defined minimal clinically important lenge when deciding the best treat- ously shown to adversely affect the
difference thresholds. Importantly, ment for younger patients with healing rates and clinical outcomes of
these studies do not make a distinction full-thickness tears that possess a surgery (Table 2). These risks must
between tears with varying risk factors high likelihood of disease progres- be taken in the context of specific
for progression and do not adequately sion. Natural history studies have patient (age) and tear-related factors
address the potential downsides of better clarified tears with a higher (size, cable integrity, and fatty mus-
nonsurgical treatment over time. These risk of progression, highlighting an cle degeneration) already present at
include the tear enlargement risks, opportunity to refine surgical in- the time of clinical presentation.
degenerative muscle change progres- dications. Delayed surgical inter- Shoulder pain severity is highly
sion, and the subsequent deleterious vention in higher risk tears may variable across tear sizes, and pain
effects of cuff repair healing seen with allow tear enlargement and/or the can often be managed, at least short
advancing age. development of irreversible muscle term, conservatively. We suggest
changes, which, when combined that anatomic and patient-related
with the deleterious effects of aging, features that affect surgical results
Redefining Surgical will decrease the rate of successful are better objective criteria than pain
Indications Based on tendon healing.42 Many studies have severity for consideration for early
Natural History Data demonstrated both increased tear surgical intervention.
size and progression of muscle Low-risk tears include those with
Informed decision making for the degeneration within 2 years. Addi- low risk of tear enlargement and
management of degenerative rotator tionally, Chalmers et al43 have progression of muscle degeneration
cuff tears should entail a complete documented increased radiographic or tears with poor healing capacity.
In these tears, there are lower risks of Figure 4

short-term tear progression or the
optimal window for surgery has been
missed. These include tears at both
ends of the disease spectrum: partial-
thickness rotator cuff tears and larger
tears with advanced fatty muscle
degeneration (grade III/IV Goutallier
changes) and/or proximal humeral
migration. Atraumatic tears in pa-
tients older than 65 to 70 years,
although still reasonable surgical
candidates, have a lower healing rate
and consideration for initial conser-
vative treatment is warranted.
Included in this group are atraumatic
full-thickness tears up to 15 mm in
size with an intact anterior supra-
spinatus tendon and healthy muscles
because the short-term risks of tear
progression are relatively low. There
is time to maximize conservative
treatment without affecting the re-
sults of later surgery if conservative
treatment fails.
Medium-risk tears include those
with moderate risk of short-term tear
progression in individuals with good
healing capacity (age under 62-65
years). These include atraumatic full- Acute on chronic rotator cuff tear, right shoulder. A, Coronal T2-weighted MRI
thickness tears 15 mm or larger and image. Large retracted tear of the supraspinatus tendon (thin arrow). B, Coronal
tears with disruption of the anterior T2-weighted MRI image. Retracted and kinked infraspinatus tendon (thin arrow).
Intramuscular edema noted within the infraspinatus (thick arrow). C, Parasagittal
supraspinatus tendon, as well as T2-weighted MRI image. Perimuscular edema noted within the supraspinatus
previously painful shoulders with and infraspinatus muscles. D, Parasagittal T1-weighted MRI image. Grade III
recent trauma (acute on chronic Goutallier fatty changes within the supraspinatus (thin arrow). Grade I/II
tears). These risks are amplified if Goutallier fatty changes within the infraspinatus (thick arrow).
there is already early fatty muscle
degeneration because these tears tendon retraction was not reliable in of tendon healing because of their
possess a greater risk of progression distinguishing between acute and acuity. In these shoulders, surgical
of muscle degeneration over time. chronic tears. For medium-risk tears, intervention has the greatest poten-
Acute on chronic rotator cuff tears an informed discussion of treatment tial to interrupt the natural history of
represent a unique challenge in dis- options with the patient is warranted. an untreated cuff tear. Included are
tinguishing whether a preexisting Surveillance physical or imaging ex- acute traumatic full-thickness tears,
tear was present, and if so, how much aminations, such as ultrasonography, especially those 15 mm or larger, in a
of the tear represents acute enlarge- should be considered to assess po- previously healthy shoulder. Also
ment (Figure 4). One study suggested tential tear progression with success- included are acute on chronic tears
MRI features that may distinguish ful conservative treatment. Patients with a dramatic loss of function such
acute from chronic tears.44 Acute should be counseled not to ignore an as pseudoparalysis and/or profound
tears have less muscle fatty degen- increase in shoulder weakness because external rotation weakness. An impor-
eration, often possessed a wavy or this may herald tear enlargement. tant consideration for these tears
kinked appearing central tendon, High-risk tears represent those with is the quality of the involved mus-
and are often associated with peri- the greatest risk of disease progres- cles, which should possess minimal
muscular edema. The amount of sion or tears that possess a high rate fatty degenerative changes. Strong
March 1, 2019, Vol 27, No 5 163
consideration for surgical repair is asymptomatic and symptomatic shoulders. 17. Namdari S, Donegan RP, Dahiya N, Galatz
J Bone Joint Surg Am 2006;88:1699-1704. LM, Yamaguchi K, Keener JD:
warranted for tears such as these in Characteristics of small to medium-sized
patients aged 65 years or younger. 5. Keener JD, Galatz LM, Teefey SA, et al: A rotator cuff tears with and without
prospective evaluation of survivorship of disruption of the anterior supraspinatus
asymptomatic degenerative rotator cuff tendon. J Shoulder Elbow Surg 2014;23:
tears. J Bone Joint Surg Am 2015;97:89-98. 20-27.
Summary
6. Moosmayer S, Tariq R, Stiris M, Smith HJ: 18. Kim HM, Dahiya N, Teefey SA, Keener JD,
The natural history of asymptomatic Galatz LM, Yamaguchi K: Relationship of
In recent years, an improved knowl- rotator cuff tears. J Bone Joint Surg Am tear size and location to fatty degeneration
edge of the natural history of de- 2013;95:1249-1255. of the rotator cuff. J Bone Joint Surg Am
generative rotator cuff tears has 2010;92:829-839.
7. Safran O, Schroeder J, Bloom R, Weil Y,
strengthened our understanding of Milgrom C: Natural history of nonoperatively 19. Mall NA, Kim HM, Keener JD, et al:
treated symptomatic rotator cuff tears in Symptomatic progression of asymptomatic
this disease process. When the risks of patients 60 years old or younger. Am J Sports rotator cuff tears: A prospective study of
disease progression are coupled with Med 2011;39:710-714. clinical and sonographic variables. J Bone
the known factors that influence 8. Maman E, Harris C, White L, Tomlinson
Joint Surg Am 2010;92:2623-2633.
tendon healing following rotator cuff G, Shashank M, Boynton E: Outcome of 20. Keener JD, Hsu JE, Steger-May K, Teefey
repair, we can better refine surgical nonoperative treatment of symptomatic SA, Chamberlain AM, Yamaguchi K:
rotator cuff tears monitored by magnetic Patterns of tear progression for
indications. The optimal manage- resonance imaging. J Bone Joint Surg Am asymptomatic degenerative rotator cuff
ment of tears must be individualized 2009;91:1898-1906. tears. J Shoulder Elbow Surg 2015;24:
based on the clinical presentation 1845-1851.
9. Yamamoto A, Takagishi K, Osawa T, et al:
and various patient- and tear-related Prevalence and risk factors of a rotator cuff 21. Dunn WR, Kuhn JE, Sanders R, et al:
tear in the general population. J Shoulder Symptoms of pain do not correlate with
factors. Elbow Surg 2010;19:116-120. rotator cuff tear severity: A cross-sectional
study of 393 patients with a symptomatic
10. Tashjian RZ, Farnham JM, Albright FS, atraumatic full-thickness rotator cuff tear. J
Teerlink CC, Cannon-Albright LA:
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Greis PE: Influence of preoperative Yum JK, Iannotti JP: Functional outcome 41. Kuhn JE, Dunn WR, Sanders R, et al:
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March 1, 2019, Vol 27, No 5 165
Review Article
Medial Unicompartmental
Arthroplasty of the Knee
Abstract
Jason M. Jennings, MD, DPT Indications for medial unicompartmental knee arthroplasty (UKA)
Lindsay T. Kleeman-Forsthuber, have expanded over the past two decades. Proposed advantages
MD include faster recovery, improved kinematics, and better functional
Michael P. Bolognesi, MD outcomes compared with total knee arthroplasty (TKA) in age-
matched control subjects. A focused preoperative examination and
imaging is essential to identify appropriate surgical candidates. No
difference has been demonstrated between fixed- and mobile-bearing

From Colorado Joint Replacement
(Dr. Jennings), Denver, CO, and the
implants for implant survivorship or patient-reported outcomes. The
Department of Orthopaedic Surgery most common reasons for conversion to a TKA are aseptic loosening
(Dr. Kleeman-Forsthuber and and progression of osteoarthritis. Ten-year survival for UKA in cohort
Dr. Bolognesi), Duke University
Medical Center, Durham, NC. studies has shown to be .90% with outcomes after conversion to
TKA being similar to outcomes for revision TKA. Registries have
Dr. Jennings or an immediate family
member is a member of a speakers’ consistently shown lower implant survival for UKA compared with
bureau or has made paid that for TKA, which is likely secondary to use of several different
presentations on behalf of Xenex;
implants by surgeons of varying levels of experience. UKA has the
serves as a paid consultant to Total
Joint Orthopedics; and has received potential to be a cost-effective alternative to TKA in certain patient
research or institutional support from populations when performed at high-volume centers with advanced
DePuy Synthes. Dr. Kleeman-
Forsthuber or an immediate family
surgical techniques.
member is an employee of Arthrex.
Dr. Bolognesi or an immediate family
U
member has received royalties from nicompartmental knee arthro- improved surgical technique and
Total Joint Orthopedics and Zimmer
Biomet; is a member of a speakers’
plasty (UKA) is an attractive promising midterm outcomes, UKA
bureau or has made paid alternative to total knee arthroplasty use has great potential to increase
presentations on behalf of Zimmer (TKA) for patients with isolated over the next few decades.
Biomet; serves as a paid consultant to medial knee arthritis. UKA offers
Total Joint Orthopedics; serves as an
unpaid consultant to Amedica and
several potential advantages over
Total Joint Orthopedics; has received TKA including less-invasive surgical Traditional Indications
research or institutional support from exposure, preservation of native bone
Zimmer Biomet and DePuy Synthes; stock, retention of cruciate ligaments, The primary indications for UKA
has received nonincome support
(such as equipment or services),
lower perioperative morbidity,1 en- are isolated anteromedial osteo-
commercially derived honoraria, or hanced postoperative recovery,1,2 arthritis or spontaneous osteonec-
other non–research-related funding and improved patient satisfaction.2,3 rosis of the knee. When UKA was
(such as paid travel) from AOA In addition, biomechanics of UKA first introduced in the 1970s, it
Omega; and serves as a board
more closely resembles native knee was associated with high rates of
member of the American Association function with improved dynamic early failure.6 In 1989, Kozinn and
of Hip and Knee Surgeons and the proprioception and postural control Scott7 established indications for
Eastern Orthopaedic Association. compared with that of TKA.4 Recent patient selection which included
J Am Acad Orthop Surg 2019;27: studies have demonstrated the cost- age lower than 60 years, weight
166-176 effectiveness when UKA is per- under 180 pounds, avoidance of
DOI: 10.5435/JAAOS-D-17-00690 formed in the appropriate patient heavy labor, minimal baseline pain,
population.5 In addition, UKA is preoperative arc of motion of 90
Academy of Orthopaedic Surgeons. associated with less morbidity and with less than a 5 flexion con-
mortality compared with TKA.2 With tracture, and angular deformity
Jason M. Jennings, MD, DPT, et al
under 15. Contraindications in- Patient Age implants. Berger et al11 found pro-
cluded osteoarthritis of the patello- Younger patients tend to be more gression of PFJ arthritis as the pri-
femoral joint (PFJ) or contralateral active at baseline and have higher mary mode of failure at 15-year
condyle, inflammatory arthropathy, expectations for their function after follow-up in their series of patients
presence of chondrocalcinosis, and surgery, potentially predisposing with an FB implant; however, further
cruciate ligament insufficiency.7 them to higher implant wear and evidence on this subject is limited at
Adherence to traditional indications loosening. In a meta-analysis of this time.
limited the pool of eligible patients, registries and clinical studies, age
with one study finding only 6% lower than 60 years was associ-
of patients meeting all parameters.8
Anterior Cruciate Ligament
ated with a higher likelihood of Insufficiency
Others have argued that over 50% revision; however, younger patients
of patients undergoing TKA should Absence of a functioning anterior cru-
had much better functional out-
be considered for UKA.9 Hamilton ciate ligament (ACL) has historically
come scores.10 Hamilton et al9 found
et al9 found that 68% of their 1,000 been considered a contraindication
conflicting results with no notable
patients who underwent UKA had to UKA, given high rates of failure
difference in the 15-year survival,
one or more of the previously cited observed in ACL-deficient patients.12
including time or indication for re-
contraindications. No differences This dogma has recently been chal-
vision, for patients younger than 60
were noted in pain or functional lenged with several studies showing
years compared with that for pa-
scores at 10 years between those acceptable outcomes in ACL-deficient
tients older than 60 years. The role
with one or more contraindications patients. Boissonneault et al13 com-
of bias should be considered when
and “ideal” candidates.9 Interest- evaluating patient age, because re-
pared outcomes of ACL-deficient pa-
ingly, more patients in the “ideal” vision may be pursued earlier in
tients with those of ACL-intact patients
candidate group had poor functional and found better functional scores in
young patients who fail to achieve
scores at 10 years compared with the ACL-deficient group at 5-year
their expected activity level. Ulti-
those with contraindications (18% follow-up with only one revision for
mately, an earlier time to revision
versus 7%). Implant survival at 15 lateral compartment arthritis progres-
may be acceptable for younger pa-
years was 90.7% in the “contra- tients as long as functional scores are
sion. A recent meta-analysis failed to
indicated” group and 88.5% in the find a higher incidence of revision in
consistently high.
“ideal” group, with no difference in ACL-deficient patients.10 Some have
mechanism of failure or time to argued that better outcomes can be
revision.9 Presence of Patellofemoral achieved for medial UKA when
Joint Osteoarthritis simultaneous ACL reconstruction is
Some have proposed that PFJ arthri- performed.14 Mancuso et al14 com-
Emerging Indications tis is indicative of knee malalignment pared outcomes of UKA between
and that correction of this defor- ACL-deficient patients and those
High Body Mass Index and mity with UKA will offload the PFJ with simultaneous ACL reconstruc-
Weight from further articular damage and tion and found higher implant
Traditional weight restrictions for pain. van der List et al10 identified survival in the ACL-reconstructed
UKA are based on the notion that five cohort studies assessing out- group (97%) compared with
heavier patients place excess load on comes of UKA with PFJ arthritis that in the ACL-deficient group
implants that increases the risk of and found no difference in func- (88%). Patients with an MB im-
aseptic loosening. Recent studies tional outcomes or risk for revision plant demonstrated higher revision
suggest that this dogma may not be compared with those without evi- rates than those with FB implants,
true. Hamilton et al9 compared pa- dence of PFJ arthritis. Similarly, with the most common reason
tients with weight over 180 lbs with Hamilton et al9 found similar func- for revision being tibial compo-
those under 180 lbs and found tional scores in those with and nent loosening. 14 Longer follow-
no difference in functional scores without exposed bone of the PFJ up studies are needed to determine
between groups and implant survival when a mobile-bearing (MB) im- whether ACL reconstruction im-
at 15 years. In a meta-analysis of 6 plant was used, and no difference in proves long-term survival, but col-
national registries and 31 clinical revision at 10-year follow-up. The lectively these studies demonstrate
studies, no increased risk for poor acceptance of UKA for patients with promising early outcomes and sur-
outcomes or revision was noted in PFJ disease may not be applicable for vivorship for UKA in ACL-deficient
patients with a BMI over 30.10 both fixed-bearing (FB) and MB patients.
March 1, 2019, Vol 27, No 5 167
Medial Unicompartmental Arthroplasty of the Knee
Figure 1 Valgus stress views have been used to

determine whether a patient’s varus
deformity is correctable and to assess
the lateral compartment cartilage in-
tegrity.16 The stress view is performed
by flexing the knee 20 and applying
a valgus force with the x-ray beam
perpendicular to the knee joint (Figure
1). If the lateral joint space maintains a
width of 5 mm or more and if the
mechanical varus alignment can be
corrected to within 3 of neutral,
then the UKA can be considered.16
Waldstein et al16 studied the efficacy of
valgus stress views in predicting lateral
compartment degenerative changes
and found no correlation between
lateral joint space width on stress view
and Outerbridge grade of the lateral
cartilage intraoperatively. They found
gross variations in measurements
based on age and gender with males
Radiographs showing an example of standing AP (A) and valgus stress (B) and younger patients having a
of the knee in the preoperative work-up of the patient being considered for
unicompartmental knee arthroplasty. Stress radiograph is performed with the markedly wider joint space. Over-
knee in slight flexion with x-ray beam perpendicular to the knee joint. A all, stress radiographs have not
valgus force is placed on the knee joint to compress the lateral compartment demonstrated a clear benefit in
soft tissue. Narrowing greater than 5 mm of the lateral joint space with valgus determining the severity of lateral
stress is considered indicative of lateral compartment degenerative
changes.16 compartment arthritis but are still
useful for determining whether the
mechanical alignment is correctable.
drawer can be used to evaluate
Patient Evaluation collateral ligament sufficiency Cross-sectional Imaging
preoperatively, but ultimately in- Evaluation
Patients with isolated anteromedial
traoperative evaluation of these MRI can be a poor indicator of knee
knee arthritis may report pain localized
structures will determine whether pathology severity and even falsely
to the medial joint line, but this finding
UKA can be performed. overestimate the extent of cartilage
is not reliable. Pain may be localized to
any compartment or diffuse in the knee damage or ACL deficiency.17 Hurst
secondary to reactive synovitis. Pres- et al17 studied outcomes of UKA in
ence of anterior knee pain should not be Preoperative Imaging patients with abnormal and normal
considered a contraindication to UKA preoperative MRIs and found no
because this finding has not shown to Radiographic Evaluation difference in pain or functional
correlate with outcomes after medial Evaluation begins with standard scores between groups with only
UKA.15 Patients with medial arthritis radiographic views of the knee, in- one failure in the abnormal MRI
typically have a varus knee deformity, cluding standing AP, lateral, mer- group compared with four failures
which should be passively correctable chant, and Rosenberg. The lateral in the normal/no MRI group. Other
to neutral on valgus stress at 20 of view can indicate ACL insufficiency studies have demonstrated similar
flexion.16 The integrity of the patient’s if evidence of posterior tibial ero- findings with MRI providing over
collateral ligaments should be evalu- sion or posterior femoral subluxa- exaggerated severity of knee pa-
ated both preoperatively and intra- tion exists. The merchant view thology and not being associated
operatively. Physical examination tests assesses the PFJ and should not with increased risk of failure after
such as Lachman test, pivot shift demonstrate lateral patella sublux- UKA.18 For patients with suspected
test, anterior drawer, and/or posterior ation or lateral patella erosion. spontaneous osteonecrosis of the
knee, MRI can be used to confirm Figure 2

the diagnosis and assess the extent of
the disease.
CT is primarily used for patients
undergoing robotic-assisted UKA.
A three-dimensional model of the
patient’s knee is generated to guide
implant positioning and soft-tissue
balancing.
Surgical Technique
Surgical exposure of the knee for UKA
should be large enough to allow ade-
quate visualization of the knee joint
while minimizing medial soft-tissue
release. The horizontal tibial bone
resection should be minimal, just
enough to remove the arthritic sur-
face and be in line with native slope of
the tibia. The sagittal tibial cut should
be as close as possible to the tibial Photograph showing an example of lateral fixed-tibia unicompartmental knee
spine to maximize tibial surface area arthroplasty (UKA) bearing (top) and medial mobile-tibial UKA bearing
disassembled (bottom).
for the tibial implant without desta-
bilizing the ACL. Penetration of the
posterior cortex and making too deep Figure 3
of a tibial cut should be avoided
because these errors can result in
fracture of the medial tibial plateau.
The patient’s varus deformity should
not be overcorrected because this
approach will place excess stress on
medial soft-tissue structures resulting
in pain and increase contact forces in
the contralateral compartment pre-
disposing to increased wear. The
tibial component should be sized to
maximize the tibial surface area
because undersizing can place excess
load on the tibial component pre-
disposing to tibial fracture or
implant subsidence. Excessive force
should be avoided with tibial
implant impaction to avoid iatro-
genic fracture. Femoral component
Photographs showing the example of mobile-bearing unicompartmental knee
placement should be in the center (or arthroplasty (UKA) implant (A) and fixed-bearing UKA implant (B) demonstrating
slightly lateral) on the medial femo- difference in congruency between fixed and mobile constructs.
ral condyle to optimize tracking with
the tibial component. Special care
should be taken during cementation quate drying time with the knee oughly inspected for presence of re-
to optimize interdigitation of the immobilized. Once cement has tained debris or cement in the
cement in the bone and allow ade- hardened, the joint should be thor- posterior aspect of the knee.
March 1, 2019, Vol 27, No 5 169
Figure 4 a comparative analysis of FB and

MB UKAs at 15-year follow-up and
found comparable clinical scores
between groups with similar revision
rates. A meta-analysis of cohort studies
showed lower revision rates attribut-
able to wear for MB implants at 5- and
10-year follow-up; however, no nota-
ble difference was found in clinical
outcomes, patient-reported outcomes,
or overall revision rates between MB
and FB implants.24 A recent systematic
review of cohort and registry studies
found higher rates of aseptic loosening
as a mode of failure in MB implants
compared with that in FB implants,
but higher rates of osteoarthritis pro-
gression in FB implants.25 Polyethylene
wear accounted for 12% of revisions
in the FB group and zero in the MB
group, whereas dislocation accounted
for 11% of failures in the MB group.
Overall, the long-term survival seems
to be similar between groups, but more
focused analysis is needed to identify
whether patient factors increase the
risk of failure with certain bearings.
Cemented Versus
Postoperative radiographs of well-functioning left medial mobile-bearing Uncemented Bearings
unicompartmental knee arthroplasty, including full-length standing AP (A) and
lateral (B) radiographic views. Cementation of UKA implants can be
challenging because of limited visibility
and smaller surface area. Aseptic loos-
backside wear.22 Conflicting data exist ening remains the primary indica-
Implant Options for Medial on whether FB or MB implants have tion for revision of UKA. Despite high
Unicompartmental lower wear rates. One in vitro study failure rates with early uncemented
Arthroplasty demonstrated superior wear rates for UKA designs, renewed interest has
FB designs with linear wear rates of been found in uncemented fixation.
Mobile- Versus Fixed-bearing 0.018 mm/million cycles compared Kendrick et al26 randomized patients
Implants with 0.032 mm/million cycles for MB to either uncemented or cemented
Metal-backed MB implants were in- implants.22 Use of highly cross-linked Oxford (Zimmer Biomet) implants
troduced in the 1980s and designed to polyethylene improved wear rates by and found higher incidence of subsi-
be fully congruent with distribution of 68%, but the difference in wear per- dence with uncemented components
contact forces over a large surface area formance between bearing types re- at 2-year follow-up. The incidence of
to lower polyethylene wear rates (Fig- mained consistent.22 partial and complete radiolucencies
ures 2–4).19 MB implants carry the In vivo data on MB and FB implants was higher in the cemented group at
unique complication of bearing dislo- have not demonstrated a clear differ- 62% compared with 29% in the
cation, which has a variable cited ence in clinical performance between uncemented group. At final follow-
incidence between 0.3% and 4.2%.19- bearings (Table 1). One cohort study up, 24% of cemented implants had
21 Modern metal-backed FB implant by Whittaker et al23 found higher complete radiolucency of the tibial
designs have low conformity between 5-year survival in the FB group at component, but all were ,1 mm
the femoral and tibial components to 96% compared with 89% for the MB and nonprogressive.26 Studies have
allow for greater ROM and lower group. Parratte et al19 performed shown no correlation between stable
Table 1
Mobile-bearing Versus Fixed-bearing Cohort Studies Survival Data
No. of
Knees Mean Follow-
Study Study Type (Patients) up (yr) Survival Indications for Revision
Emerson et al44 Level III FB: 51 (45) 6.1 to 6.8 FB: 92% (11 yr) FB: polyethylene wear (7.8%),
tibial subsidence (4%), OA
progression (2%), pain (2%)
— MB: 50 (43) — MB: 92% (11 yr) MB: OA progression (8%), aseptic
loosening (2%), impingement
(2%), pain (2%)
Confalonieri et al45 Level I FB: 20 (20) 5.7 FB: 95% (5 yr) FB: pain (5%)
— MB: 20 (20) — MB: 100% (5 yr) MB: none
Whittaker et al23 Level III FB: 150 (117) 3.6 to 8.1 FB: 96% (5 yr) FB: OA progression (5%),
polyethylene wear (4.7%),
aseptic loosening (2%)
— MB: 79 (62) — MB: 89% (5 yr) MB: aseptic loosening (5%), OA
progression (2.5%), bearing
dislocation (1.3%)
Parratte et al19 Level III FB: 79 (75) 17.2 FB: 83% (20 yr) FB: polyethylene wear (5.1%), OA
progression (3.8%), aseptic
loosening (2.5%)
— MB: 77 (72) — MB: 80% (20 yr) MB: OA progression (6.5%),
aseptic loosening (3.9%),
dislocation (3.9%)
Bhattacharya et al46 Level III FB: 91 (79)a 3.7-5.6 FB: 91.2% (6 yr) FB: aseptic loosening (2.2%), OA
progression (2.2%), pain (2.2%),
others (2.2%)
— MB: 49 (44) — MB: 98% (10 yr) MB: OA progression (2%)
Biau et al47 Level III FB: 67 (57) 3.25-5.25 FB: 98.6% (2 yr) FB: infection (1.4%)
— MB: 37 (33) — MB: 97% (2 yr) MB: dislocation (2.7%)
FB = fixed-bearing, MB = mobile-bearing, OA = osteoarthritis

a
Fixed-bearing implants in this study were all-polyethylene tibial bearings.
radiolucencies ,1 mm and aseptic with registries consistently showing Cohort Survival Data of
loosening;27 however, in the presence worse outcomes.29 One explanation is Unicompartmental Knee
of pain, many surgeons would be that registries include multiple differ- Arthroplasty
pressed to revise these implants.26 ent implants performed by surgeons
Overall, cohort studies have shown
Midterm survival for cemented and with varying levels of clinical expe-
promising long-term results for UKA
uncemented implants has shown to rience. In addition, many of the
implants (Table 2). In a cohort study,
be comparable between groups with clinical outcome studies have been
one study showing 95.4% 10-year performed by design surgeons. A Pandit et al30 showed 10-year survival
survival for cemented UKA and systematic review of cohort and of 94% and 15-year survival of 91%
97.4% for uncemented implants.28 registry studies found that the aver- in their series of 1,000 medial UKAs
These results are promising for un- age 10-year survival for UKA was with an MB implant. Similarly,
cemented UKA, but more long-term 90.5% in cohort studies but only Lisowski et al27 showed 15-year
follow-up is needed. 84.1% in registries.29 The 15-year survival of 90.6% with revision
survival was 87% and 69.6%, occurring at mean of 5.7 years.
Survival Data and respectively. While registries provide Another study by Foran et al48
Outcomes critical information on trends over demonstrated 20-year survival of
time, cohort studies may allow better 90% in their series of 62 FB im-
Considerable discrepancy exists be- understanding of how specific implants. Several other studies have
tween cohort and registry studies on plants perform at single-center in- shown high 10-year survival
UKA survival and clinical outcomes, stitutions by higher volume surgeons. ranging from 90.6% to 96% with
March 1, 2019, Vol 27, No 5 171
Table 2
Cohort Studies on Unicompartmental Knee Arthroplasty With $10 Years of Follow-up
No. of
Study Knees Implant Mean
Study Type (Patients) Type Follow-up Survival Indications for Revision
Foran et al48 Level IV 62 (51) Fixed 10 98% (10 yr) OA progression (4%)
— — — — 93% (15 yr) Pain (4%)
— — — — 90% (20 yr) —
Faour-Martin et al20 Level IV 511 (402) Mobile 10.4 94.5% (10 yr) Infection (2.9%)
— MISa — — — Pain (1.6%)
— — — — — Aseptic loosening (0.8%)
— — — — — Dislocation (0.3%)
Kim et al (2015)21 Level IV 166 (128) NR 10 90.4% (10 yr) Bearing dislocation (4.2%)
— MISa — — — Aseptic loosening (2.4%)
— — — — — Polyethylene fracture (0.6%)
— — — — — Tibial fracture (0.6%)
— — — — — Infection (0.6%)
Pandit et al (2015)30 Level IV 1,000 Mobile 10.3 94% (10 yr) OA progression (2.5%)
(818)
— MISa — — 91% (15 yr) Bearing dislocation (0.7%)
— — — — — Unexplained pain (0.7%)
— — — — — Infection (0.6%)
Emerson et al (2016)49 Level IV 213 (173) Mobile 10 90.6% (10 yr) OA progression (4.2%)
— MISa — — — Aseptic loosening (1.9%)
— — — — — Hemarthrosis related (1.4%)
— — — — — Bearing dislocation (0.5%)
Lisowski et al (2016)27 Level IV 138 (129) Mobile 11.7 91.6% (10 yr) OA progression (4.3%)
— MISa — — 90.6% (15 yr) Pain (2.9%)
— — — — — Bearing dislocation (0.7%)
Total: six studies Average, 10-year survival: 93.2%; 15-year survival: 91.5%
MIS = minimally invasive surgery, NR = not reported

a
MIS = minimally invasive approach used.
wide variability in the indications Lim et al1 demonstrated comparable compare long-term clinical outcomes
for revision (Table 2). results in their series of UKA and TKA between UKA and TKA.
patients with better functional scores
in the UKA group, but higher overall
Cohort Survival Data of Registry Survival Data
revision rate of 6.3% for UKA com-
Unicompartmental Knee pared with 3% for TKA. The UKA National registries vary widely in how
Arthroplasty Versus Total group experienced lower medical UKA outcomes are reported with some
Knee Arthroplasty complications and had lower incidence providing more specific information
There is great interest in outcomes of of infection and wound complications than others (Table 3). The Australian
UKA compared with those of TKA than the TKA group.1 Lombardi et al2 database with 46,094 UKAs contains
because TKA is often the alternative also reviewed their series of UKA and the largest population of UKAs with
surgical procedure considered for TKA patients and found better early some of the longest follow-up.31 They
patients. Lyons et al3 compared knee range of motion, shorter hospital report 14.6% UKA revision rate at 10
5,606 TKAs with 279 UKAs and stay (1.4 days versus 2.2 days), and years and 21% revision at 15 years,
found higher clinical outcome scores higher Knee Society functional scores with the most common indications
in UKA patients at 2-year follow-up. in the UKA group. No difference for revision being aseptic loosen-
Survival was slightly higher in the between groups was found in regard to ing (43.5%), progression of osteo-
TKA group with 5-year survival of return to work or recreational activi- arthritis (29.4%), and unexplained
98% and 95% for TKA and UKA, ties at final follow-up.2 Although these pain (9.5%).31 Risk factors for earlier
respectively, and 10-year survival of studies demonstrate short- and mid- revision include female gender and
95% and 90%.3 Another study by term benefits with UKA, few studies younger age. The lowest revision rate
Table 3
National Registry Data on Unicompartmental Knee Arthroplasty Survival and Indications for Revision
No. of Longest Indications for Group with Higher
Registry UKAs Follow-up Survival Data Revision Revision Rate
National Joint Registry 75,719 13 yr 88.2% (FB); 87.6% Others Younger age
(England and Wales)32 (MB) (10 yr)
FB: — 86.4% (FB); 84.5% Aseptic —
23,721 (MB) (12 yr) loosening
MB: — — Pain —
51,140
Australian31 46,094 15 yr 91.1% (5 yr) Loosening/lysis Female (HR 1.14)
(43.5%)
— — 85.4% (10 yr) OA progression Age ,55 yr (HR 4.99)
(29.4%)
— — 79% (15 yr) Pain (9.5%) —
— — — Bearing —
dislocation
(2%)
— — — Wear (1.2%) —
Sweden 50
30,147 30 yr NR Loosening (NR) Age ,65 yr (CRR 2.3)
— — — OA progression —
(NR)
— — — Others (NR) —
— — — Wear (NR) —
New Zealand33 9,635 17 yr 89% (10 yr) Pain (46%) Age ,65 yr
— — 83.3% (14 yr) Loosening (44%) Cemented UKA
— — — Infection (5.3%) Non-MIS approach
— — — Fracture (4.8%) —
Norwegian34 7,648 12 yr 79% (10 yr) Pain (32.8%) Age ,60 yr
— — 72% (20 yr) Aseptic —
loosening
(25%)
— — — OA progression —
(12.6%)
CRR = cumulative revision rate, FB = fixed-bearing, HR = hazard ratio, MB = mobile-bearing, MIS = minimally invasive surgery, NR = not reported,
UKA = unicompartmental knee arthroplasty
was seen in patients aged 65 to 74 Oxford (Zimmer Biomet) with 10- Revision rate for the UKA group was
years with the 10-year survival of year survival of 96%. The Norwe- 4.7% at 5 years compared with 2.0%
87%.31 The National Joint Registry gian database reports very low UKA for TKA, with no improvement in risk
(NJR) for England, Wales and survival of 79% at 10 years and after controlling for covariates.36 As
Northern Ireland database reports 72% at 20 years.34 registry reporting continues to im-
data on FB (31.3% of UKAs) and MB In a review of the Finnish registry, prove, there will hopefully be better
(67.5%) implants separately.32 The Niinimäki et al35 compared 4,713 insight into the reason for these high
10-year survival for FB implant is UKAs with 83,511 cemented TKAs. failure rates and how UKA compares
slightly higher at 89.2% compared They found lower survival in the UKA with TKA outcomes long-term.
with 87.6% for MB implant.32 The group at all time points with the 5-year
overall risk for revision of UKAs is 2.9 survival of 89.4% and the 15-year
times higher than what is observed for survival of 69.6% compared with
Understanding Failure in
TKA. The New Zealand registry re- those in TKA at 96.3% and 88.7%, Unicompartmental Knee
ports UKA survival of 89% at 10 respectively. The higher risk for revi- Arthroplasty
years and 83.3% at 15 years.33 They sion in the UKA group remained ele-
recognized better performance for vated even after controlling for age and Caseload and Experience
certain implants with the lowest gender.35 The US Medicare database Analysis of the National Joint Regis-
revision rate seen in the uncemented has demonstrated similar results.36 try showed that optimal results were
March 1, 2019, Vol 27, No 5 173
obtained by surgeons performing performed primarily for osteo- years from conversion surgery.40
UKAs in 40% to 60% of their pa- arthritis progression (38 to 40%), Complication rates after UKA con-
tients, with poorest results in those aseptic loosening (29%), and poly- version were similar to those after
performing UKA ,5% of the time.32 ethylene wear (10%).25 Dyrhovden primary TKA and better compared
Survival rates for high-volume sur- et al38 reviewed mechanisms for UKA with revision of a failed TKA.40
geons were 96% at 5 years compared failure in the Norwegian database Other studies have shown worse
with 90% in low-volume surgeons.32 between early and later periods (1992 outcomes of UKA conversion com-
Performing UKA through a minimally to 2004 and 2005 to 2015) with a pared with those of primary TKA.
invasive surgery (MIS) approach adds decrease in failures from aseptic Pearse et al41 reviewed 236 failed
another level of complexity, but with loosening, polyethylene wear, and UKAs from the New Zealand regis-
the potential benefit of earlier recov- periprosthetic fractures from early to try and found fourfold higher risk of
ery. Some centers have experienced later time points but more revisions re-revision in the failed UKA group
high failure rates with MIS, with for osteoarthritis progression. Unlike compared with that in the primary
revision rates as high as 11% at 2-year TKA that experienced an improve- TKA group. Furthermore, the age at
follow-up.37 Reasons for revision in- ment in the 10-year survival between re-revision of a failed UKA was 7
cluded retained cement, contralateral time periods (91% to 94%), UKA years younger than those who
compartment chondral pathology or survival remained stable (80% to underwent revision of a primary
meniscal defects, and wound compli- 81%).38 These findings suggest that TKA. Functional scores for con-
cations. Hamilton et al37 reviewed despite advances in UKA implant verted UKAs were markedly lower
their series of 445 MIS UKAs and technology and technique, osteo- than for primary TKA but were
found minimal improvement in reop- arthritis progression is a consistent similar to scores for revised TKAs.41
eration surgery and revision rates mode of UKA failure. Unexplained Another study by Leta et al42 of the
over a 2-year period, suggesting pain is another major factor con- Norwegian database compared out-
absence of a learning curve. This tributing to the discrepancy in revi- comes after conversion of 578 failed
finding highlights that even at high- sion rates between UKA and TKA, UKAs and revision of 768 failed
volume institutions, complication rates because it accounts for 1.6% to 11% TKAs with similar 10-year survival
for MIS UKA are notable and perhaps of UKA revision.20,25 The threshold between groups (82% versus 81%)
longer follow-up and higher volume to revise a painful UKA is much lower and found no difference in re-
are needed to detect improvement in than for TKA, because UKA can be revision rates or patient-reported
the surgical technique. converted to a TKA, while revision outcome scores. They found a
of a TKA tends to be a more extensive markedly higher risk of deep infec-
surgery.39 tion in the revised TKA group with
Mechanisms of Failure longer surgical duration and
The primary mechanisms for UKA increased need for stems and/or
failure have remained consistent since Outcomes for Conversion augmentation than in the conver-
early clinical reports in the 1980s. of Failed Unicompartmental sion UKA group. Collectively, these
Goodfellow et al12 cited aseptic Knee Arthroplasty to Total results indicate that outcomes after
loosening as the primary reason for Knee Arthroplasty conversion of a UKA may not be as
revision (incidence 6.6%) in their optimal as previously suggested but
series of 103 patients with an MB One of the supporting arguments for still show comparable or better
implant at mean follow-up of 3 years. UKA is that conversion to TKA is outcomes than revision TKA.
A recent systematic review found that technically less challenging and mor-
the most common reasons for UKA bid than TKA revision. Conflicting
failure were aseptic loosening (36%), literature exists on the validity of this Cost-effectiveness of
progression of osteoarthritis (20%), argument. Sierra et al40 reviewed Unicompartmental Knee
unexplained pain (11%), instability their series of failed UKAs who Arthroplasty
(6%), infection (5%), and poly- underwent conversion to TKA. The
ethylene wear (4%).25 The majority postconversion complication rate Ghomrawi et al5 performed a Mar-
of early failures (,5 years) were from was 13% overall with 4.4% inci- kov decision analysis using the
aseptic loosening (25%), osteo- dence of aseptic loosening, 3.3% of Swedish registry and found lower
arthritis progression (20%), and stiffness, and 1.2% of deep infection. life-time costs and higher lifetime
bearing dislocation (17%), whereas The re-revision rate after conversion quality-adjusted life years for UKA
midterm and later revisions were was 4.5% performed at average of 2 compared with those for TKA in all
age groups older than 65 year (life- contents. In this article, References meta-analysis critique. J Arthroplasty 2016;
31:2617-2627.
time costs ranging from $35,000 to 26, 43 and 45 are level I studies.
$46,600 for UKA and from $42,000 References 1-4, 10, 13, 19, 23-25, 11. Berger RA, Meneghini RM, Sheinkop
MB, et al: The progression of
to $47,600 for TKA). UKA was no 35, 38, 41, 42, 44, and 47 are level patellofemoral arthrosis after medial
longer cost-effective when rehabili- III studies. References 6, 9, 11, 12, unicompartmental replacement: Results
at 11 to 15 years. Clin Orthop Relat Res
tation costs for TKA decreased by 15, 16, 17, 20, 21, 27-30, 37, 40, 46,
2004;92-99.
two thirds or when 45% of UKA 48 and 49 are level IV studies.
12. Goodfellow JW, Kershaw CJ, Benson MK,
patients required rehabilitation ad- O’Connor JJ: The Oxford Knee for
mission.5 A recent meta-analysis References printed in bold type are
unicompartmental osteoarthritis: The first
found similar results with patients those published within the past 5 103 cases. J Bone Joint Surg Br 1988;70:
over 75 years old consistently reach- years. 692-701.
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1. Lim JW, Cousins GR, Clift BA, Ridley D,
difference in survivorship after
performing a UKA instead of TKA, Johnston LR: Oxford unicompartmental
unicompartmental knee arthroplasty with
knee arthroplasty versus age and gender
but patients younger than 65 years matched total knee arthroplasty:
or without an intact anterior cruciate
ligament. Knee Surg Sports Traumatol
not being economically favorable Functional outcome and survivorship
Arthrosc 2013;21:2480-2486.
analysis. J Arthroplasty 2014;29:
candidates for UKA.43 The major 1779-1783. 14. Mancuso F, Dodd CA, Murray DW,
limiting factor in younger patients Pandit H: Medial unicompartmental knee
2. Lombardi AV, Berend KR, Walter CA,
was implant survivorship, suggesting Aziz-Jacobo J, Cheney NA: Is recovery
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faster for mobile-bearing unicompartmental
would make younger patients better than total knee arthroplasty? Clin Orthop 15. Hamilton TW, Pandit HG, Maurer DG,
Relat Res 2009;467:1450-1457. et al: Anterior knee pain and evidence of
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3. Lyons MC, Macdonald SJ, Somerville
should not be considered contraindications
LE, Naudie DD, Mccalden RW: to mobile-bearing unicompartmental knee
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unicompartmental arthritis. Clin Orthop
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total and unicompartmental arthroplasty. 17. Hurst JM, Berend KR, Morris MJ,
traditional indications for UKA can Knee 2007;14:212-217. Lombardi AV: Abnormal preoperative
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advantages associated with each de- 396-402. limited role. Knee 2001;8:213-218.
sign type. Although conversion to 19. Parratte S, Pauly V, Aubaniac J-M,
6. Insall J, Aglietti P: A five to seven-year
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unicompartmental arthroplasty. Clin
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71:145-150. 20. Faour-Martín O, Valverde-García JA,
tinue to be scrutinized and take both Martín-Ferrero MA, et al: Oxford phase
patient factors and functional out- 8. Stern SH, Becker MW, Insall JN: 3 unicondylar knee arthroplasty through
Unicondylar knee arthroplasty: An a minimally invasive approach: Long-
comes into careful consideration. As evaluation of selection criteria. Clin Orthop term results. Int Orthop 2013;37:
more long-term data on UKA become Relat Res 1993;143-148. 833-838.
available, it will further guide clini- 9. Hamilton TW, Pandit HG, Jenkins C, 21. Kim KT, Lee S, Kim JH, Hong SW,
cians in counseling patients on Mellon SJ, Dodd CAF, Murray DW: Jung WS, Shin WS: The survivorship and
Evidence-based indications for mobile- clinical results of minimally invasive
whether UKA should be performed.
bearing unicompartmental knee unicompartmental knee arthroplasty at 10-
arthroplasty in a consecutive cohort of year follow-up. Clin Orthop Surg 2015;7:
thousand knees. J Arthroplasty 2017;32: 199.
1779-1785.
References 22. Netter J, Hermida JC, D’Alessio J, Kester M,
10. van der List JP, Chawla H, Zuiderbaan HA, D’Lima DD: Effect of polyethylene
Pearle AD: The role of preoperative patient crosslinking and bearing design on wear of
Evidence-based Medicine: Levels of characteristics on outcomes of unicompartmental arthroplasty. J
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23. Whittaker J-P, Naudie DDR, McAuley JP, 33. Rothwell Chairman A; Supervisor Peter unicompartmental to a total knee
McCalden RW, MacDonald SJ, Bourne RB: Devane Orthopaedic Surgeon Simon Young replacement: The New Zealand National
Does bearing design influence midterm Orthopaedic Surgeon Dawson Muir Joint Registry. J Bone Joint Surg Br 2010;
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arthroplasty? Clin Orthop Relat Res 2010; Griffin H, Pettett A; Hobbs Registry
468:73-81. Coordinator T, Rothwell Registry Supervisor 42. Leta TH, Lygre SHL, Skredderstuen A,
Toni Hobbs Registry Coordinator Chris et al: Outcomes of unicompartmental knee
24. van der Voort P, Pijls BG, Nouta KA, Frampton Statistician James Taylor Hip A, arthroplasty after aseptic revision to total
Valstar ER, Jacobs WCH, Nelissen RGHH: Dawson Muir K: The New Zealand Joint knee arthroplasty. J Bone Joint Surg Am
A systematic review and meta-regression of Registry. Seventeen Year Report: January 2016;98:431-440.
mobile-bearing versus fixed-bearing total 1999 to December 2015. 1999. www.nzoa.
knee replacement in 41 studies. Bone Joint J 43. Chawla H, Ghomrawi HM, van der List JP,
org.nz/nz-joint-registry. Accessed September Eggman AA, Zuiderbaan HA, Pearle AD:
2013;95-B:1209-1216. 28, 2018. Establishing age-specific cost-effective
25. van der List JP, Zuiderbaan HA, Pearle AD: annual revision rates for unicompartmental
34. Norwegian Arthroplasty Register Annual
Why do medial unicompartmental knee knee arthroplasty: A meta-analysis. J
Report 2016. 2016. http://nrlweb.ihelse.
arthroplasties fail today? J Arthroplasty Arthroplasty 2017;32:326-335.
net. Accessed September 28, 2018.
2016;31:1016-1021.
44. Emerson RH, Hansborough T, Reitman RD,
35. Niinimäki T, Eskelinen A, Mäkelä K,
26. Kendrick BJL, Kaptein BL, Valstar ER, Rosenfeldt W, Higgins LL: Comparison
Ohtonen P, Puhto A-P, Remes V:
et al: Cemented versus cementless Oxford of a mobile with a fixed-bearing
Unicompartmental knee arthroplasty
unicompartmental knee arthroplasty using unicompartmental knee implant. Clin
survivorship is lower than TKA
radiostereometric analysis: A randomised Orthop Relat Res 2002;62-70.
survivorship: A 27 year Finnish registry
controlled trial. Bone Joint J 2015;97-B:
study. Clin Orthop Relat Res 2014;472: 45. Confalonieri N, Manzotti A, Pullen C:
185-191.
1496-1501. Comparison of a mobile with a fixed tibial
27. Lisowski LA, Meijer LI, van den Bekerom MP, bearing unicompartmental knee prosthesis: A
36. Curtin B, Malkani A, Lau E, Kurtz S, Ong prospective randomized trial using a dedicated
Pilot P, Lisowski AE: Ten- to 15-year
K: Revision after total knee arthroplasty outcome score. Knee 2004;11:357-362.
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and unicompartmental knee arthroplasty in
unicompartmental knee arthroplasty: A
the Medicare population. J Arthroplasty 46. Bhattacharya R, Scott CEH, Morris HE,
prospective study from a non-designer group.
2012;27:1480-1486. Wade F, Nutton RW: Survivorship and
Bone Joint J 2016;98-B:41-47.
patient satisfaction of a fixed bearing
28. Schlueter-Brust K, Kugland K, Stein G, et al: 37. Hamilton WG, Ammeen D, Engh CA, Engh unicompartmental knee arthroplasty
Ten year survivorship after cemented and GA: Learning curve with minimally incorporating an all-polyethylene tibial
uncemented medial Uniglide® invasive unicompartmental knee component. Knee 2012;19:348-351.
unicompartmental knee arthroplasties. arthroplasty. J Arthroplasty 2010;25:
Knee 2014;21:964-970. 735-740. 47. Biau DJ, Greidanus NV, Garbuz DS, Masri
BA: No difference in quality-of-life
29. van der List JP, McDonald LS, Pearle AD: 38. Dyrhovden GS, Lygre SHL, Badawy M, outcomes after mobile and fixed-bearing
Systematic review of medial versus lateral Gøthesen Ø, Furnes O: Have the causes of medial unicompartmental knee
survivorship in unicompartmental knee revision for total and unicompartmental replacement. J Arthroplasty 2013;28:
arthroplasty. Knee 2015;22:454-460. knee arthroplasties changed during the past 220-226.e1.
two decades? Clin Orthop Relat Res 2017;
30. Pandit H, Hamilton TW, Jenkins C, 475:1874-1886. 48. Foran JRH, Brown NM, Della Valle CJ,
Mellon SJ, Dodd CAF, Murray DW: The Berger RA, Galante JO: Long-term
clinical outcome of minimally invasive 39. Murray DW, Liddle AD, Dodd CAF, survivorship and failure modes of
phase 3 Oxford unicompartmental knee Pandit H, Pandit H: Unicompartmental unicompartmental knee arthroplasty. Clin
arthroplasty: A 15 year follow-up of 1000 knee arthroplasty: Is the glass half Orthop Relat Res 2013;471:102-108.
UKAs. Bone Joint J 2015;97-B:1493-1500. full or half empty? Bone Joint J 2015;
97-B:3-8. 49. Emerson RH, Alnachoukati O,
31. The Australian National Joint Replacement Barrington J, Ennin K: The results of
Registry. Annual Report 2015. https:// 40. Sierra RJ, Kassel CA, Wetters NG, Berend Oxford unicompartmental knee
aoanjrr.sahmri.com/documents/10180/ KR, Della Valle CJ, Lombardi AV: arthroplasty in the United States: A mean
217745/Hip and Knee Arthroplasty. Revision of unicompartmental ten-year survival analysis. Bone Joint J
Accessed September 28, 2018. arthroplasty to total knee arthroplasty: 2016;98-B:34-40.
Not always a slam dunk! J Arthroplasty
32. National Joint Registry for England Wales 2013;28:128-132. 50. Swedish Knee Arthroplasty Register
and Northern Ireland 13th Annual Report. Annual Report 2016. Annu Rep (2016).
2016. http://www.njrcentre.org.uk/ 41. Pearse AJ, Hooper GJ, Rothwell A, http://www.myknee.se/pdf/
njrcentre/Home/tabid/36/Default.aspx. Frampton C: Survival and functional SVK_2016_Eng_1.0.pdf. Accessed
Accessed September 28, 2018. outcome after revision of a September 28, 2018.
Review Article
Necrotizing Soft-tissue Infections:

An Orthopaedic Emergency
Abstract
Adam Lee, MD Necrotizing soft-tissue infections are caused by a variety of bacterial
Addison May, MD, FACS, pathogens that may affect patients at any age or health status. This
FCCM orthopaedic emergency initially presents with nonspecific signs such
William T. Obremskey, MD, as erythema and edema. As the disease progresses, classic signs
MPH such as bullae, cutaneous anesthesia, ecchymosis, tense edema,
and gas can be seen. A high level of suspicion is needed to properly
identify and treat in a timely manner. Pain out of proportion to
presentation and rapid progression even with appropriate antibiotic
treatment should heighten suspicion of a necrotizing soft-tissue
infection. The mainstay of management is extensive débridement and
decompression of all necrotic tissue and broad-spectrum antibiotics.
From the Department of Orthopaedic Débridements are repeated to ensure that disease progression has
Surgery (Dr. Lee), Keck Medical been halted. Early surgical débridements should take precedent over
Center of USC, Los Angeles, CA, the
Surgical Critical Care (Dr. May), transfer because of the high rate of limb loss and mortality as a result
Surgical Critical Care and Acute Care of surgical delay.
Surgery Fellowship (Dr. May), Surgery
and Anesthesiology (Dr. May),
Surgical Science (Dr. May), Vanderbilt
University Medical Center, Nashville,
TN, and the Orthopedic Surgery
(Dr. Obremskey), Vanderbilt Medical
H ippocrates astutely described
what we now know as necro-
tizing soft-tissue infection (NSTI).
and make a decisive move to treat
once a diagnosis of NSTI is confirmed
or highly suspected.
Center, Nashville, TN.
He called it a “malignant case of ery- NSTIs are not uniform in presenta-
Dr. May or an immediate family
sipelas” where “fatal cases were tion or extent of involvement. NSTIs
to Atox Bio; has received research or many.” He noted a precipitating event include any or all soft-tissue layers (ie,
institutional support from Atox Bio and as a “trivial accident or very small skin, subcutaneous fat, fascia, mus-
Fresenius Kabi; and serves as a board wound” that progressed to “ab- cle). Necrotizing fasciitis, a subset
member of the Surgical Infection
scessions ending in suppurations” or of this broad disease entity, is the
Society. Dr. Obremskey or an where “flesh, sinews and bones fell most common manifestation of NSTI;
immediate family member serves as a away in large quantities.” In addition, however, one must be aware of other
board member, owner, officer, or the hallmark dishwater purulence presentations as well (ie, necrotizing
committee member of the
Orthopaedic Trauma Association and
was described as “flux . . . not like pus adipositis, pyomyositis). The general
the Southeastern Fracture but . . . a different sort of putrefaction diagnosis and management principles
Consortium. Neither Dr. Lee nor any with a copious and varied flux.” He for necrotizing fasciitis and other
immediate family member has saw that in cases that did not have specific forms hold true for all NSTIs
discrete abscess formation with frank and therefore will be discussed
commercial company or institution drainage “there were many deaths.”1 broadly in the context of this review.
related directly or indirectly to the This account describes the common Unfortunately, NSTIs fall on a
subject of this article. presentation, progression, and natural spectrum of clinical severity. Unlike
J Am Acad Orthop Surg 2019;27: history of untreated NSTIs. For rea- nonnecrotizing soft-tissue infections,
e199-e206 sons that are not agreed on, this dis- NSTIs cannot be managed with anti-
DOI: 10.5435/JAAOS-D-17-00616 ease process has a high morbidity and biotics alone because these infections
mortality despite medical advances commonly occur in the extremities.
Academy of Orthopaedic Surgeons. and necessitates that surgeons have a Orthopaedic surgeons are often
high degree of suspicion to diagnose involved in the early management of
March 1, 2019, Vol 27, No 5 e199
Necrotizing Infections
Table 1 chronic source such as a diabetic foot

ulcer.18 Table 1 lists common organ-
Common Bacteria in Necrotizing Soft-tissue Infections
isms cultured in the polymicrobial
Polymicrobial subtype. The remainder of infections
Anaerobes Bacteroides, Clostridium, Other anaerobes are monomicrobial in nature.
These monomicrobial infections are
Enterobacteriaceae Escherichia coli, Enterobacter, Klebsiella, Proteus
primarily caused by group A strepto-
Monomicrobial Predominantly group A Streptococcus
coccal infection, other b-hemolytic
Other b-hemolytic Streptococcus
strep, MRSA, and in the fresh
Community-acquired MRSA
water setting Aeromonas hydrophila.
Vibrio (with exposure)
Clostridial species are the most prev-
Aeromonas (with exposure)
alent single organism infecting agents
Prevotella and account for a higher incidence
Fungal of limb loss and mortality.16 In cases
MRSA = methicillin-resistant Staphylococcus aureus
of saltwater or consumption of
oysters/cirrhosis Vibrio vulnificans.19
These patients presenting with mon-
this pathology as consultants and Intravenous drug abuse is another omicrobial infections may not have
therefore have a critical role in raising common predisposing factor in as the same identifiable risk factors as
the possibility of and potentially many as 43% of patients with those described with polymicrobial
diagnosing NSTI.2 In its most viru- NSTI.11 Other associations include infections. In the setting of the mon-
lent form, an NSTI can be rapidly smoking, trauma, prior methicillin- omicrobial infection, group A strepto-
progressive and quickly fatal without resistant Staphylococcus aureus coccal infection is likely related to skin
intervention. Awareness is crucial in (MRSA) infection, chronic hepatitis injury or hematogenous strep from
preventing this outcome, and a cur- C, HIV/AIDS, chronic illness, pharyngeal infection or colonization.
rent review of the relevant literature increasing age, NSAID use, and All NSTIs begin with an inoculum of
is presented to raise awareness. exposure to persons infected with bacteria at the site of infection. Bacteria
invasive group A Streptococ- may be transferred from direct contacts
cus.6,8,11-14 Using the National Sur- or via skin or nasopharyngeal coloni-
Epidemiology and Risk gical Quality Improvement Program zation.6,14 Wounds ranging from small
Factors data, a risk calculator found that skin abrasions to large traumatic lac-
seven independent variables corre- erations may serve as a point of entry.
NSTIs are a heterogeneous group of lated with mortality including age Individuals can be asymptomatic car-
rare, limb, and life-threatening pro- greater than 60 years, functional riers on the skin or mucosal surfaces
cesses caused by a variety of bacterial status, requiring dialysis, American where transient bacteremia distributes
pathogens that may affect patients at Society of Anesthesiologists class 4 the pathogen to a source of tissue
any age or health status. An estimated or higher, emergent surgery, septic damage to initiate an infection. Cases
1,000 cases per year occur with an shock, and low platelet count.15 of NSTI being caused by skin break-
increasing incidence in the United The infections can be grouped down in a poorly padded splint,
States.3 In an analysis of Centers for broadly into polymicrobial and mono- external-fixation pin sites, and IV sites
Disease Control and Prevention data microbial subtypes. Polymicrobial are reported.12,13 Once the infecting
of invasive group A Streptococcus, a NSTIs account for approximately 75% agent has gained access into the host,
common infecting agent in NSTIs, an of cases making it the most common the disease is perpetuated by bacterial
estimated 10 to 13,000 cases occur presentation.16,17 These polymicrobial virulence factors that facilitate rapid
each year with a mortality of 29% in infections are commonly associated spread and systemic toxicity. Although
cases that involve NSTI.4 NSTI has a with risk factors such as diabetes, the exact mechanisms of rapid spread
predilection for the aging, infirm peripheral vascular disease, recent and tissues destruction likely vary
population, but all age ranges can surgery, trauma, or immunocompro- between species and are not fully
be infected. However, up to 40% of mised hosts. These infections tend to characterized, these factors are theo-
patients have no known risk fac- be a combination of aerobic and rized to contribute to local tissue pro-
tors.5,6 Diabetes mellitus is the anaerobic bacteria. A variety of bac- gression through tissue ischemia,
most prevalent risk factor and is terial isolates have been cultured from enzymatic degradation, cell lysis, and a
present in up to 71% of infections.6-11 this type, which tends to arise from a systemic response by the release of
Adam Lee, MD, et al
Figure 1 Figure 2
Radiograph showing gas in the soft

tissue.
Photographs showing the (A) nonspecific erythema and (B) edema presentation
of necrotizing fasciitis in a patient with no erythema or proximal edema on
physical examination just 6 hours before. subcutaneous vessels are effaced and
then to blue gray as superficial lay-
toxins into the circulation.18,20,21 nondescriptive. There may be no fea- ers begin to necrose. As the disease
Bacterial inoculation causes the secre- tures that initially distinguish necro- progresses, the pain may abate
tion of local cytokines which activates tizing soft-tissue infections from because cutaneous nerves are oblit-
platelets. In the presence of activated nonnecrotizing soft-tissue infections. erated by the infection resulting in
white cells, the platelets clump leading Close monitoring with interval exam- anesthesia of the skin. Bullae may
to microvascular occlusion. This ination is necessary because NSTIs appear signifying tissue loss and
occlusion in turn disrupts the cutane- can progress quickly, and seemingly are highly specific for an NSTI.
ous blood supply and lymphatic benign presentations may become (Figure 2) Finally, palpable crepitance
channels inciting a local hypoxia and clearly defined over interval examina- in the tissues around the focus of
cytokine release resulting in cellular tions (Figure 1, A and B). infection, indicative of subcutaneous
dysfunction and death. The local A thorough history should be per- gas formation, is highly suggestive of
ischemia and subsequent necrosis formed assessing for risk factors dis- an NSTI because of anaerobic bacte-
limits access of antibiotics and cussed earlier. In addition, potential ria. These so-called hard signs (ie,
humoral response to the affected sources of exposure and sites of anesthesia, ecchymosis/bullae, gas in
region and leads to progressive cuta- inoculation should be elicited. In tissue) are present up to 44% of the
neous nerve damage causing severe approximately 50% of cases, no site time.7,18,24 Importantly, the presence
pain early in the disease to local of entry is found. Exposure to of gas in tissue that is identified with
anesthesia when nerve endings have household cohabitants infected with clinical examination or radiograph
died.21 Invasive group A Streptococ- (Figure 2) is found only in infections
group A Streptococcus raises the risk
cus has a high expression of one such from species that can grow under
of infection to 2000 times that of the
factor called exotoxin that is seen in anaerobic conditions producing non–
general public, and such exposures
most strains that produce invasive carbon dioxide gases, and these
should be determined.6,22 Health-
infections.20,21 Another common in- gases are present in less than 50%
care workers caring for patients with
fecting pathogen, MRSA, produces of cases. Up to 83% of patients pre-
these highly virulent infections are at
panton-valentine leukocidin, a toxin sent in clinical duress with signs
increased risk as well.14 Pain out of
commonly seen in necrotizing inconsistent with a systemic inflamma-
proportion to examination is the
fections that causes muscle necrosis.8 tory response syndrome, sepsis, or
most common finding and should
Toxin production and the host’s septic shock.23
raise one’s suspicion for a more
response to the toxins are potential aggressive process.
targets for intervention in patients Physical examination findings can Diagnosis
with these difficult infections. be initially benign. The most common
findings are erythema, edema/swelling/ Early diagnosis confirmation is often
Presentation induration, and pain, although delayed because of the underestima-
skin changes may not be present tion or confusion with cellulitis. As
Presenting features of necrotizing early.7,10,18,23 Erythema can pro- mentioned previously, hard signs of
soft-tissues injuries can be vague and gress from red to purple/red as NSTI are present in a minority of
March 1, 2019, Vol 27, No 5 e201
Table 2 hemoglobin, sodium, creatinine, may delay time to surgical débride-

blood glucose, albumin, and C-reac- ment and it should be used judicially
Laboratory Risk Indicator for
Necrotizing Fasciitis Score tive protein (CRP) levels. Blood cul- in evaluation of equivocal cases. Gas
(Scoring System to Predict tures should be obtained when dissecting in facial planes on plain
Necrotizing Soft-tissue Infections) concern for systemic involvement is radiograph (in the absence of an
Laboratory LRINEC raised because this can direct early open wound) is a hard sign indicative
Parameter, Units Points antibiotic therapy and confirm pres- of NSTI although this finding is pres-
ence of virulent pathogens. Studies ent in a minority of cases. CT and
CRP, mg/L
have shown low sodium level, ele- MRI are advanced imaging tech-
,150 0
vated creatinine level, and high white niques that may be considered in the
$150 4 blood cell count were sensitive at stable patient with nonfocal disease to
Total WBC, k/mm3 predicting NSTI.24,26 These findings assess for signs of necrotizing fasciitis
,15 0 were used along with laboratory (thickening of deep fascia) or deep
15-25 1 values found to be predictive of abscess or necrotic area.30 MRI is
.25 2 NTSI in a multivariate regression to more sensitive at detecting subtle
Hb, g/dL develop a scoring system for pre- changes in the fascia and deep edema,
.13.5 0 diction of necrotizing infections27 but acquisition time in most hospitals
11-13.5 1 (Table 2). Although this Laboratory is longer than that of a CT scan; so
,11 2 Risk Indicator for Necrotizing Fas- again, a thoughtful approach is
Sodium, mmol/L ciitis (LRINEC) score has not been needed to optimize data gathering
$135 0 validated in a prospective trial, the while preventing lengthy delay in
,135 2 components of the score are still definitive management. Advanced
Creatinine, mg/dL useful in addition to the overall imaging can be useful to direct sur-
#1.6 0 assessment and as a prognostic gical approach if no superficial man-
.1.6 2 tool.9,19,28 A study retrospectively ifestations are present.
Glucose, mg/dL comparing a cohort of patients with Presence of hard signs of NSTI
#180 0 severe erysipelas subsequently diag- makes diagnosis more certain. Clini-
.180 1 nosed with either cellulitis or NSTI cal decompensation or progression of
found that the overall clinical pre- infection despite broad antibiotic
LRINEC = Laboratory Risk Indicator for sentation for each was similar; how- management with increasing serum
Necrotizing Fasciitis ever, NSTI patients were more likely lactate, CRP .150 mg/L, or
to have higher pain scores, a higher leukocytosis .25,000/mm3 are in-
CRP level, and a higher LRINEC dications for urgent surgical inter-
patients, and thus a high index of score29 (Table 2). Another series vention. Diagnosis is formally
suspicion and ongoing vigilance are analyzing vibrio NSTI found severe confirmed with growth of microor-
needed to prevent potentially fatal hypoalbuminemia, thrombocytope- ganism from cultures taken from
progression.3 No one finding or a nia, and bandemia as a predictor of deep tissue intraoperatively as dis-
group of findings has been prospec- mortality and suggested that these cussed later. Diagnosis is confirmed
tively validated as a highly sensitive values be used to direct early surgical on intraoperative inspection of deep
and specific means of confirming the intervention.19 Because of the vari- structures. These findings include
presence or lack of NSTI, and ability of laboratory data indicative of necrotic tissue and dusky gray
therefore, all objective findings must NSTIs, the use of the LRINEC is appearance of fascia. Microbiologic
be considered in the context of the surgeon dependent and has never diagnosis is confirmed with deep tis-
patient’s clinical course.25 been prospectively validated. sue cultures with deep tissue samples
being submitted to histopathology to
aid in confirmation of diagnosis and
Laboratory Evaluation Imaging focused antibiotic management.
Additional laboratory evaluation is Radiographic evaluation may or may
useful to stratify presenting findings. not assist in diagnosis of NSTI.
Initial workup of a suspected necro- Imaging findings are often nonspe- Management
tizing infection should include a cific and may not manifest until sub-
measure of white blood cell count stantial disease progression has Management of NSTIs is best carried
with differential, platelet count and occurred. Further, advanced imaging out by a multidisciplinary team with
Adam Lee, MD, et al
experience treating large soft-tissue Figure 3

wounds. However, initial manage-
ment should be done by the first sur-
geon who recognizes and diagnoses
this potentially lethal infection. The
mainstay of management is expedi-
tious, soft-tissue decompression and
débridement of the necrotic tissue
with first broad-spectrum antibiotic
management and then focused
systemic antibiotic management.31
Repeat débridements are done to
ensure disease progression has halted
and to remove unviable tissue. As Photograph showing (A and B) extensive dual incision fasciotomy with negative
many patients present with a sys- pressure wound therapy placement. Immediately after fasciotomy, notable
decrease in erythema is seen.
temic response or progress to sys-
temic toxicity, intensive care unit
admission with critical-care team ensure adequate decompression is early when frequent débridements
resuscitative support is mandatory. attained as in compartment syn- are ongoing. Vacuum-assisted clo-
Adjunctive management may be drome. Devitalized tissue should be sure can be used and aids in pre-
considered in special cases. removed in all affected layers (eg, paring wounds for subsequent
skin, subcutaneous fat, fascia, mus- closure, graft, or flap.33 Early sur-
cle, bone) until healthy tissue mar- gical débridement is so important to
Surgical Débridement gins are reached (Figure 3, A and B). limb salvage and patient survival in
When NSTI is diagnosed or is sus- Multiple deep tissue cultures should which initial débridement should be
pected based on the progression be collected for microbiologic anal- considered before transferring a
of symptoms in spite of antibiotic ysis. Débridement should proceed patient to a higher level of care for
management, surgical intervention with no regard for late reconstruc- intensive care and reconstruction.
should take precedence. Surgery tion because this may bias a surgeon The initial débridement is not com-
should not be delayed for imaging to leave disease-burdened tissue. plicated or technically difficult and
assessment, and resuscitation and Amputation is required if the pro- should be treated similarly to com-
antibiotic administration should be gression of the infection is so rapid partment syndrome where initial
ongoing concomitantly in prepara- that débridement alone would not be surgical débridement can be done
tion for surgery.32 Broad decom- adequate, the limb is not salvageable by any surgeon and then transfer
pression and débridement of the because of notable tissue loss or if the the patient if needed for extended
infected tissue helps to halt pro- condition of the patient does not care.
gression and allows for antibiotics to allow repetitive débridements. Guil- The reason for the success of a
take effect and for the host’s immune lotine amputations above the level of simple incision over the area involved
system to respond.3 Débridement progression are the most direct form is not completely clear. Surgical inci-
should begin with a longitudinal of amputation and should be con- sion and débridement decreases the
incision over the nidus of infection sidered at the extreme end of the source and bacterial load, but the
(ie, entry site, site of abscess, site of surgical algorithm. In less progres- condition of the skin and subcuta-
original erythema/necrosis). In the sive cases, small ladder incisions may neous tissue improves quickly after
early phase, a simple skin and be used to assess more proximal the skin incision is extended proxi-
subcutaneous incision down to fas- sites of progression. If diagnosis is mally into healthy tissue. The
cia and extended proximally until equivocal, a smaller incision can be decompression seems to halt the
uninvolved tissue is encountered is made to assess for deep fluid or tissue bacteria that spread in the fascial
required. If the underlying muscle is plane disruption (finger test). Once a layers and lymphatic system. The
involved or notable muscle swelling thorough débridement is complete, incision may allow decompression
is present, the underlying fascia wounds are dressed according to and abort the cycle of local tissue
should be incised as in a compart- their location and practical applica- inflammation and edema that drive
ment release. Often, dual incisions tion. Moist gauze packing is the the proximal spread of the disease
are required on the extremities to simplest dressing and may be useful process.
March 1, 2019, Vol 27, No 5 e203
Early surgical re-exploration is scope.31,33 Blood cultures and tissue outcomes.22,37 This change may be
recommended within 24 hours of cultures further direct bacteria-specific because not all IVIG infusions contain
initial débridement and has been treatment based on susceptibilities and the same proportion of antitoxin im-
shown to decrease mortality and rate local policies. Antiribosomal agents munoglobulins. In a similar pursuit of
of acute kidney injury compared are recommended to (1) limit toxin immunomodulation, the only ran-
with repeat débridements done at production and (2) enhance the domized controlled trial involving
greater than 48 hours.17 The same effectiveness of cell wall antimicrobial NSTIs evaluated the drug AB103, a
principles apply to subsequent dé- agents in setting of high bacterial substance that acts on T cells to
bridements as to the initial débride- burden. For gram-positive pathogens, decrease the immune response to
ment. The average number of the antiribosomal agent is most com- toxins. Unfortunately, the authors
surgical procedures in the manage- monly clindamycin.22 Linezolid may found no changes when the novel
ment of NSTI in large series ranges have similar effects on protein syn- therapeutic was compared with the
from 2 to 5 times.10,26,28,34,35 thesis and has been reported as an placebo.35 Corticosteroids have a
When the clinical course has antibiotic supplement in the manage- similar, albeit less specific effect on the
improved and no signs of progression ment of NSTI.36 immune response to bacterial toxins
of disease have manifested for If gram stains of the excised tissue have been used as an adjunct in pa-
several days, reconstruction proce- demonstrate the presence of gram- tients with NSTI and toxic shock
dures can be pursued. The sooner the negative pathogens such as Tulare- syndrome.38
decompression is done, the less the mia, agents in the tetracycline class Hyperbaric oxygen treatment is
necrotic tissue needs to be removed should be considered. theorized to aid in the prevention of
and allows wounds to undergo No specific, evidence-based guide- the progression of tissue loss and
primary closure or skin grafting lines directing antibiotic selection, therefore morbidity and mortality.
although occasional local or free soft- mode of delivery, or duration are However, in a Cochrane review, no
tissue transfers are necessary, and available. Consultation with an literature worth of analysis was
nearly half of all patients will need infectious disease specialist with found, and no summation of data
some form of coverage.32-34 One experience in treating soft-tissue in- was suggested.39 Hyperbaric oxygen
large retrospective study reported an fections may aid in directing long- treatment may be considered if it
average of 1.2 reconstructive proce- term antibiotic management.31 does not interfere with access to
dures in each case of NSTI.26 surgical and antibiotic treatment.
Adjuncts
Antibiotics A number of adjunctive management Outcomes
Antibiotic administration comple- have been attempted to supplement
ments the surgical débridement as a management of these devastating The morbidity and mortality associ-
means to further decrease infective NSTIs. Given the heterogeneity of ated with NSTIs are substantial.
load. Broad-spectrum empiric anti- this disease process and the relatively Mortality caused by this disease has
biotics should be administered on rare occurrences, high-quality evi- been reported in as many as 33% of
presentation based on the presenting dence of therapies used in addition cases with an average mortality of
history, patient risk factors, and to débridement and antibiotics is 22.6%.2,4,5,10,11,16,22,23,26,28,34,40,41
possible exposures. Most hospitals limited. Risk factors for increased mortality
will have an infectious disease pro- Adjuncts have been sought to atten- are similar to risk factors for
tocol for empiric antibiotic treatment uate the systemic response to disease. acquiring an NSTI. Surgical delay or
in the critically ill based on local Intravenous immunoglobulin (IVIG) factors indirectly resulting in surgical
virulence patterns and antibiogram. offers theoretical benefit in blunting delay such as transfer from an outside
A broad-spectrum, synergistic peni- the host’s response to bacterial tox- hospital is the single most important
cillin (ie, piperacillin/tazobactam, ins.20 Pooled immunoglobulins from modifiable factor contributing to
ampicillin/sulbactam) with clinda- donors previously infected with toxin- mortality.5,10 Nonmodifiable risk
mycin or carbapenem is included in producing bacteria are thought to factors include increasing age, multi-
most recommendations for empiric neutralize circulating toxins and lessen ple comorbidities, chronic illness, and
coverage. Because of the possibility the systemic response. However, data immunosuppression.4,5,9,18,23,31,41,42
of community acquired MRSA, are conflicting on the utility of this Other predictors of mortality are
vancomycin or linezolid should be treatment with studies showing related to the systemic effect, how far
added to broaden the antibiotic no change and notable change in the disease has progressed, at the time
Adam Lee, MD, et al
of admission (ie, creatinine, sepsis 13. Jauregui JJ, Bor N, Thakral R, Standard
status, elevated lactate, amount of
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Robotic-assisted Medial
Unicompartmental Knee
Arthroplasty: Options and
Outcomes
Abstract
Jess H. Lonner, MD Medial unicompartmental knee arthroplasty (UKA) has several

Mitchell R. Klement, MD benefits over total knee arthroplasty for the surgical treatment of
isolated medial compartmental arthritis in the knee, including reduced
surgical risk and postoperative morbidity, rapid recovery, more normal
kinematics, greater patient satisfaction, and shorter hospitalization.
Nonetheless, there is substantial concern about the higher revision
rates and lower survivorship in UKA compared to those in total knee
arthroplasty. Robotic assistance has been advanced to improve the
precision of bone preparation, component alignment, and quantified
ligament balance in UKA, with the ultimate goal of improving
kinematics and implant survivorship. Two currently available
From Rothman Institute, Department semiautonomous robotic platforms have demonstrated improved
of Orthopaedic Surgery, Sidney
Kimmel Medical College at Thomas accuracy, and emerging short-term follow-up has demonstrated
Jefferson University, Philadelphia, PA satisfactory functional outcomes. Further studies will be needed to
(Dr. Lonner and Dr. Klement), and
determine if these technologies indeed have a meaningful impact on
Orthopaedic Associates of Wisconsin,
Pewaukee, WI (Dr. Klement). patient outcomes and survivorship in the mid- to long term.
Dr. Lonner or an immediate family
Zimmer Biomet and Smith & Nephew;
is a member of a speakers’ bureau or
has made paid presentations on
behalf of Zimmer Biomet and Smith &
U nicompartmental knee arthro-
plasty (UKA) is a highly effective
treatment for medial compartment
Joint Replacement Registry [https://
aoanjrr.dmac.adelaide.edu.au/en] and
New Zealand Joint Registry [http://
Nephew; serves as a paid consultant
to Zimmer Biomet, Smith & Nephew,
osteoarthritis or focal osteonecrosis www.nzoa.org.nz/news/new-zealand-
Force Therapeutics, and Muvr Labs; in appropriately selected patients.1 joint-registry-thirteen-year-report]).
has stock or stock options held in UKA has potential advantages com- These failures commonly result from
Force Therapeutics and Muvr Labs; pared to their total knee arthroplasty component malposition and limb
has received research or institutional
support from Zimmer Biomet, Force
(TKA) counterparts, including im- malalignment.3
Therapeutics, Smith & Nephew, and proved postoperative function, shorter Robotic technologies have been
Muvr Labs. Neither Dr. Klement nor hospital stay, less blood loss, fewer advanced to increase surgical preci-
any immediate family member has transfusions, less postoperative mor- sion, and improve component align-
bidity, and lower perioperative ment and soft-tissue balance, with the
commercial company or institution costs.1,2 However, despite reports expectation that revision rates from
related directly or indirectly to the from high-volume centers that show technical errors may be mitigated.4
subject of this article. excellent outcomes and durability, In a recent statewide database study,
J Am Acad Orthop Surg 2019;27: these advantages are offset by the surgeon utilization of robotic-assisted
e207-e214 higher revision rate of UKA com- technology was 17.1% and hospital
DOI: 10.5435/JAAOS-D-17-00710 pared to that of TKA and de- utilization 29.2%, with the numbers
creased 10-year survivorship among increasing annually.5 Furthermore,
Academy of Orthopaedic Surgeons. lower volume surgeons (Australian patent activity and peer-reviewed
Orthopaedic Association National publications related to robotic
March 1, 2019, Vol 27, No 5 e207
Robotic Medial Unicompartmental Knee Arthroplasty: Options and Outcomes
Figure 1
With the Mako system, a preoperative CT scan is used to map the patient’s anatomy. This allows the surgeon to select the
most appropriate size and position of the implants (preoperative plan).
technology in UKA—surrogate mea- incorporate an algorithm of three- inadvertent bone preparation (Figure
sures of interest in and evolving dimensional (3D) mapping of the 3, A–D)—one by providing haptic
development and experience with hemi-condylar surfaces and reg- constraint beyond which movement of
robotic technologies—have increased istration of various surface and the burr is limited (Mako); the other by
dramatically over the past few years.6,7 alignment parameters from which modulating the exposure or speed of
This article reviews the robotic the volume and orientation of bone the handheld robotic burr (Navio).
technologies currently approved by to be removed are determined and These systems also provide real-time
the United States FDA for UKA and input into the system. In the case quantification of soft-tissue balancing
examines published data regarding of Mako, a CT scan is needed for which may contribute to the reported
the outcomes of UKAs performed preoperative mapping, whereas Navio successful clinical and functional out-
with these systems. relies entirely on intraoperative as- comes with semiautonomous systems9
sessments without the need for addi- (Figure 2, C).
tional advanced imaging (Figures 1
Robotic Systems FDA- and 2, A–C).4,8
approved for Although the robotic tools remove Clinical Outcomes
Unicompartmental Knee bone and cartilage within the preestab-
Arthroplasty lished parameters, they are controlled Compared to conventional UKA, most
and manipulated by the surgeon, mini- studies have found that robotic assis-
Currently, there are two semiauton- mizing the risk of soft-tissue injuries tance consistently improves surgical
omous systems approved by the FDA that have been reported with autono- accuracy, with substantial reduction
for robotic-assisted UKA in the mous robotic technologies.4 The cur- in variability and error of component
United States—Mako (Stryker) and rent semiautonomous systems use positioning.10 Although there have
Navio (Smith & Nephew). Both different methods to safeguard against been no direct comparisons of the two
Jess H. Lonner, MD and Mitchell R. Klement, MD
available robotic systems, precision underwent UKAs with conventional Figure 2

appears to be comparable regardless instrumentation. The average root
of whether the image-free system or mean squared errors (RMSEs) used
one requiring a preoperative CT scan to judge postoperative component
is used (Table 1; Figure 4). placement compared to the preop-
When evaluating advanced and erative plan demonstrated signifi-
novel technologies, there is undoubt- cantly improved tibial slope accuracy
edly concern that there will be (RMSE, 1.9 robotic; 3.1 conven-
increased surgical time and a sub- tional) with 2.6 times less variance in
stantial learning curve with those the Mako cohort (P = 0.02). In
technologies. Karia et al15 found that addition, with conventional methods,
when inexperienced surgeons per- the tibial component was regularly
formed UKA on synthetic bone placed in more varus (2.7) compared
models using robotics, the mean to that using the robot-assisted cohort
compound rotational and transla- (0.2; P , 0.001).11 Dunbar et al12
tional errors were lower than those and Citak et al8 corroborated the
associated with using conventional significantly higher degree of accu-
techniques. In that study, among racy of component placement in
those using conventional techniques, multiple planes of both the femoral
although surgical times improved and tibial components using robotic
during the learning period, posi- techniques and compared the out-
tional inaccuracies persisted. Con- come to that using manual techniques
trarily, robotic assistance enabled by obtaining postoperative CT scans
surgeons to achieve precision and to accurately measure 3D implant
accuracy when positioning UKA positions. Bell et al10 performed the
components, irrespective of their first prospective, randomized con-
learning experience.15 Other than the trolled study, comparing 62 Mako-
potential for measured improvements assisted UKAs and 58 conventional
in component alignment, robotic UKAs. Using postoperative CT scans
assistance commonly achieves a more to assess component positioning, the
conservative tibial resection than authors found that the use of robotic
conventional methods.16 This may assistance resulted in lower RMSEs
eventually prove to enhance dura- and significantly lower median errors Image of intraoperative “painting” of the
bility because placing the tibial insert in all component parameters for both articular surface (an efficient process
on a stronger bone has been shown the tibial and femoral components.10 with no preoperative CT required) used
to be biomechanically advantageous. Contrarily, not all studies have in the Navio system to register the
condylar anatomy with the surgical
In addition, using smaller tibial in- favored robotic assistance. Hansen software (tibial free collection shown).
serts makes ultimate revision to TKA et al17 compared 32 Mako-assisted Once this has been completed, the
easier and minimizes the need for UKAs to 32 conventional UKAs with implant’s size and position are planned
augments and stems.16 2-year minimum follow-up. The virtually (prosthesis placement). Data
from a dynamic soft-tissue balancing
authors reported improved ability of algorithm are incorporated into the plan
the robotic techniques to reproduce and a graphic representation of gap
Mako the preoperative femoral axis (P = spacing through an entire range of
To date, most studies investigating 0.013) but found no difference in re- flexion is created. At that time,
determination is made regarding
robotic-assisted UKA have reported creation of the planned tibial slope whether the planned position of the
on accuracy of component placement (P = 0.409). Furthermore, the use of femoral and tibial components is
compared to those of conventional the Mako system added a mean adequate or adjustments can be made
techniques (Table 1). Lonner et al11 20 minutes (P = 0.010) of tourniquet to achieve the desired soft-tissue
balance. By adjusting the implant
compared postoperative radiographic time compared to the use of con- positions—including tibial slope, depth
measurements of tibial component ventional UKA. Robotic-assisted of resection, and anteriorization or
positioning in 31 patients who patients in that study achieved distalization of the femoral component—
underwent Mako-assisted medial physical therapy clearance 10.3 hours virtual dynamic soft-tissue balance can
be achieved (gap planning).
UKAs to those of 27 patients who sooner and had 8 hours shorter
March 1, 2019, Vol 27, No 5 e209
Figure 3
Image and photographs of an example of surgical bone removal before implantation using the Navio system, which
safeguards against inadvertent bone removal by modulating the exposure or speed of the handheld robotic bur. A, Image
showing real-time virtual preparation of the femoral surface. B, Photograph showing the actual process of bone removal.
After surface preparation is completed, accuracy is assessed (C) and osteophytes and the meniscus are removed. Final
implantation is performed manually (D).
length of stay than those using con- Currently, mid- and long-term patients were either very satisfied or
ventional UKA, although the former outcome studies are lacking on satisfied with their knee function.
was not statistically significant and robotic-UKA, given the infancy of the The study found no differences in the
the basis for those differences is technologies. However, Pearle et al18 various surgeons first 30 cases
unclear.17 Finally, MacCallum et al14 conducted a prospective, multicenter (ie, those done during a theoretical
found that although precision of review of 1,135 Mako-assisted learning curve) compared to subse-
tibial coronal alignment was sig- UKAs followed up for a minimum quent operations.18 In addition, now
nificantly improved in the Mako of 22 months. In the study period, 11 that robotic technology has demon-
cohort (P , 0.001), there was more UKAs were revised, resulting in a strated superiority in component
accuracy in achieving sagittal align- 98.8% survivorship. In a worst-case accuracy, studies are starting to
ment when using conventional scenario analysis, including patients examine what effect this might have
techniques (P , 0.001) and a 16.6- lost to follow-up, the survivorship on clinical outcomes. Blyth et al20
minute increase in surgical time for was reduced to 96%. In addition, at recently reported a secondary anal-
the robotic cohort. 2.5 years postoperatively 92% of ysis of a randomized controlled trial
Table 1
Summary of Current Literature Evaluating Accuracy of Component Placement in Robotic-assisted Versus
Conventional Unicompartmental Knee Arthroplasty
Results in RMSE,
Postoperative RA Versus
Year, Design, Measurement Conventional
Study Model, System Comparison Components Modality When Present
Lonner et al11 2010, retrospective, 31 RA Tibia only Radiographs Tibia

patients, Mako
— 27 Conv — — Sagittal: 1.9 versus 3.9
— — — — Coronal: 1.8 versus 3.8
Dunbar et al12 2012, retrospective, 20 RA Tibia and CT scan Tibia
patients, Mako femur
— 0 Conv — — Sagittal: 1.9
— — — — Coronal: 1.5
— — — — Axial: 3.0
— — — — Femur
— — — — Sagittal: 2.3
— — — — Coronal: 2.6
— — — — Axial: 3.0
Citak et al8 2013, —, cadaver, 6 RA Tibia and CT scan Tibia
Mako femur
— — — — Axial: 4.0 versus 19.2
— — — — Femur
— — — — Sagittal: 3.2 versus 8.9
— — — — Axial: 1.6 versus 7.4
Mofidi et al19 2014, retrospective, 232 RA Tibia and Radiographs Tibia
— — — — Coronal: 2.2
— — — — Axial: NA
— — — — Femur
— — — — Sagittal: 3.6
— — — — Coronal: 2.8
Smith et al13 2014, —, synthetic 20 RA Tibia and Probe-registering Tibia
bone, Navio femur software
— — — — Coronal: 1.24
— — — — Axial: 1.32
— — — — Femur
— — — — Sagittal: 1.05
— — — — Coronal: 1.52
(continued )
Conv = conventional unicompartmental knee arthroplasty, RA = robotic-assisted unicompartmental knee arthroplasty, RMSE = root mean squared
error, NA = not available
This describes the difference seen between the desired component position (plan) before implantation and the actual results of implantation. The
differences are measured in degrees and are reported as “error.” The errors studied by the authors may be positive or negative depending on the
direction; hence, RMS is used to avoid diluting the average and creating a reproducible measure to compare study to study. Plans may be generated
preoperatively (Mako) or intraoperatively (Navio).
March 1, 2019, Vol 27, No 5 e211
Summary of Current Literature Evaluating Accuracy of Component Placement in Robotic-assisted Versus
Conventional Unicompartmental Knee Arthroplasty
Results in RMSE,
Postoperative RA Versus
Year, Design, Measurement Conventional
Study Model, System Comparison Components Modality When Present
— — — — Axial: 1.30
Lonner et al7 2015, —, cadaver, 25 RA Tibia and Probe-registering Tibia
Navio femur software
— — — — Coronal: 2.43
— — — — Axial: 1.87
— — — — Femur
— — — — Sagittal: 1.31
— — — — Coronal: 2.27
— — — — Axial: 1.61
MacCallum 2016, retrospective, 87 RA Tibia only Radiographs Tibia
et al14 patients, Mako
Bell et al10 2016, prospective, 62 RA Tibia and CT scan Tibia
— 58 Conv — — Sagittal: 1.64 versus
7.98
— — — — Coronal: 2.58 versus
3.71
— — — — Axial: 2.97 versus 7.95
— — — — Femur
— — — — Sagittal: 3.35 versus
6.87
— — — — Coronal: 2.09 versus
5.09
— — — — Axial: 2.70 versus 5.78
Conv = conventional unicompartmental knee arthroplasty, RA = robotic-assisted unicompartmental knee arthroplasty, RMSE = root mean squared
error, NA = not available
This describes the difference seen between the desired component position (plan) before implantation and the actual results of implantation. The
differences are measured in degrees and are reported as “error.” The errors studied by the authors may be positive or negative depending on the
direction; hence, RMS is used to avoid diluting the average and creating a reproducible measure to compare study to study. Plans may be generated
preoperatively (Mako) or intraoperatively (Navio).
using Mako robotic assistance versus Oxford Knee Score (P = 0.0106) and currently in progress. However,
conventional instrumentation in 139 Forgotten Joint Score (P = 0.0346). early studies on Navio demonstrate a
patients. From the first postoperative Finally, robotic-assisted surgery was high degree of accuracy. Smith et al13
day through to week 8 postopera- independently associated with achiev- used the Navio procedure on 20 syn-
tively, the median pain scores for the ing “excellent” Knee Society scores.20 thetic knees using 3D software to
Mako group were 55.4% lower than register the final position of the im-
those observed in the conventional plants in comparison to the planned
group (P = 0.040). In addition, and Navio placement. The authors found a
high activity patients had signifi- Clinical studies examining the satisfac- maximum rotational error of 3.2 and
cantly better outcomes with robotic tion and short-term survivorship on an RMSE of 1.46 across all ori-
assistance in the KSS (P = 0.0064), the Navio system are limited but are entations, for both the tibia and
femoral implants. The maximum

translational error was 1.18 mm and Figure 4
the RMS translational error in all
directions was 0.61 mm.13 Lonner
et al7 studied UKA performed by
four novice surgeons using Navio in
25 cadaveric specimens. The final
positions of the implants were com-
pared to the preoperative plan
using a sophisticated 3D model. The
femoral implant rotational mean
error was 1.04 to 1.88 and the
mean translational error was 0.72
to 1.29 mm across the three planes.
The tibial implant rotational mean
error was 1.48 to 1.98 and the
mean translational error 0.79 to
1.27 mm across the three planes,
similar to the results by Smith et al.13
These levels of precision were similar
to those described by Dunbar et al12
using the Mako system (Table 1).
Postoperative AP radiograph of a patient with bilateral robotic-assisted
unicompartmental knee arthroplasties, on the right using the image-free Navio
system (1 year prior) and on the left using the CT-based Mako system (8 years prior).
Limitations of Robotic
Assistance
analysis further demonstrated that the radiation risk.23 Ponzio and Lonner23
Certainly, the implementation of any cost-effectiveness was very sensitive to recently reported that each preoper-
new technology has its limitations. case volume, with lower costs realized ative CT scan for robotic-assisted
Perhaps the greatest deterrent to early once volumes surpassed 94 cases per knee arthroplasty (using one proto-
adoption of robotic-assisted technol- year.21 Contrarily, costs (and thus col) is associated with a mean effec-
ogy is the cost of implementation. value) will also obviously vary de- tive dose of radiation of 4.8 mSv,
Capital and maintenance costs, as well pending on the capital costs, annual which is approximately equivalent to
as per-case disposable costs for these service charges, and avoidance of 48 chest radiographs. Furthermore,
systems can be high, and those that unnecessary preoperative scans.4 For in that study at least 25% of patients
require additional nonreimbursed instance, assuming a cost of $500,000 had been subjected to multiple scans,
advanced imaging, such as CT scans, for the image-free Navio robotic sys- with some being exposed to cumu-
further challenge the return on invest- tem, return on investment is achiev- lative effective doses of up to 103
ment, particularly in a bundled care able within 25 cases annually, roughly mSv. This risk should not be con-
arrangement. In a Markov analysis of one quarter of the cases necessary with sidered completely negligible, given
one robotic system (Mako), Moschetti the image-based system.4 Swank that 10 mSv may be associated with
et al21 found that if one assumes a et al22 looked at implementing robotic an increase in the possibility of fatal
system cost of $1.362 million, value technology in a hospital setting with a cancer and an estimated 29,000
can be attained because of slightly high-volume surgeon and found that excess cancer cases in the United
better outcomes despite the method the capital needed for the robot could States annually are reportedly caused
being more expensive than traditional potentially be recouped in 2 years with by CT scans. However, this increased
methods. Nonetheless, their analysis increased revenues. However, that radiation risk is not inherent to
of the Mako system estimated that model assumed reimbursement for CT all robotic systems. Image-free sys-
each robot-assisted UKA case cost planning, which is often no longer tems do not require CT scans and
$19,219, compared to $16,476 with done in most markets, particularly are, thus, not associated with this
traditional UKA, and was associated with bundled care arrangements. potential disadvantage, and newer
with an incremental cost of $47,180 Finally, systems that require a pre- CT technologies will emit lower
per quality-adjusted life-years. Their operative CT scan pose an increased radiation doses.
March 1, 2019, Vol 27, No 5 e213
3. Epinette JA, Brunschweiler B, Mertl P, 14. MacCallum KP, Danoff JR, Geller JA: Tibial
Summary Mole D, Cazenave A: Unicompartmental baseplate positioning in robotic-assisted and
knee arthroplasty modes of failure: Wear is conventional unicompartmental knee
not the main reason for failure: A arthroplasty. Eur J Orthop Surg Traumatol
Compared to conventional tech- multicentre study of 418 failed knees. 2016;26:93-98.
niques, robotic technology has been Orthop Traumatol Surg Res 2012;98:
S124-S130. 15. Karia M, Masjedi M, Andrews B, Jaffry Z,
shown to optimize the precision of Cobb J: Robotic assistance enables
bone preparation and component 4. Lonner JH: Robotically assisted inexperienced surgeons to perform
unicompartmental knee arthroplasty with a unicompartmental knee arthroplasties on
alignment. In addition, the ability to dry bone models with accuracy superior to
handheld image-free sculpting tool. Orthop
quantitatively balance the soft tissues Clin North Am 2016;47:29-40. conventional methods. Adv Orthop 2013;
through a range of motion in UKA 2013:481039.
5. Boylan M, Suchman K, Vigdorchik J,
using the various robotic technolo- Slover J, Bosco J: Technology-assisted hip 16. Ponzio DY, Lonner JH: Robotic technology
gies available may further optimize and knee arthroplasties: An analysis of produces more conservative tibial resection
utilization trends. J Arthroplasty 2018;33: than conventional techniques in UKA. Am J
kinematics, functional recovery, and 1019-1023. Orthop (Belle Mead NJ) 2016;45:
durability. To be clear, however, E465-e468.
6. Dalton DM, Burke TP, Kelly EG, Curtin
although we rely on component PD: Quantitative analysis of technological 17. Hansen DC, Kusuma SK, Palmer RM,
alignment and position as surrogate innovation in knee arthroplasty: Using Harris KB: Robotic guidance does not
patent and publication metrics to identify improve component position or short-term
determinants of the benefit of robotic developments and trends. J Arthroplasty outcome in medial unicompartmental knee
technology, further study is needed to 2016;31:1366-1372. arthroplasty. J Arthroplasty 2014;29:
determine whether there is a mea- 1784-1789.
7. Lonner JH, Smith JR, Picard F, Hamlin B,
surable influence on clinical out- Rowe PJ, Riches PE: High degree of 18. Pearle AD, van der List JP, Lee L, Coon TM,
accuracy of a novel image-free handheld Borus TA, Roche MW: Survivorship and
comes and durability with robotics, patient satisfaction of robotic-assisted medial
robot for unicondylar knee arthroplasty
particularly in select subgroups of in a cadaveric study. Clin Orthop Relat Res unicompartmental knee arthroplasty at
patients, such as those who are 2015;473:206-212. a minimum two-year follow-up. Knee 2017;
24:419-428.
younger, with high preoperative 8. Citak M, Suero EM, Citak M, et al:
activity levels. Unicompartmental knee arthroplasty: Is 19. Mofidi A, Plate JF, Lu B, Conditt MA,
robotic technology more accurate than Lang JE, Poehling GG, Jinnah RH:
The field of robotics continues conventional technique? Knee 2013;20: Assessment of accuracy of robotically
to expand in arthroplasty surgery. 268-271. assisted unicompartmental arthroplasty.
Knee Surg Sports Traumatol Arthrosc
Time will tell whether the application 9. Plate JF, Mofidi A, Mannava S, et al: 2014;22:1918-1925.
of robotics will continue to grow Achieving accurate ligament balancing
using robotic-assisted unicompartmental 20. Blyth MJG, Anthony I, Rowe P, Banger
in a meaningful way. For that to MS, MacLean A, Jones B: Robotic
knee arthroplasty. Adv Orthop 2013;2013:
happen, more data will need to be 837167. arm-assisted versus conventional
analyzed, surgical efficiencies im- unicompartmental knee arthroplasty:
10. Bell SW, Anthony I, Jones B, MacLean A, Exploratory secondary analysis of a
proved, and pricing and economies of Rowe P, Blyth M: Improved accuracy of randomised controlled trial. Bone Joint Res
scale optimized. component positioning with robotic- 2017;6:631-639.
assisted unicompartmental knee
arthroplasty: Data from a prospective, 21. Moschetti WE, Konopka JF, Rubash HE,
randomized controlled study. J Bone Joint Genuario JW: Can robot-assisted
References Surg Am 2016;98:627-635. unicompartmental knee arthroplasty be
cost-effective? A Markov decision
11. Lonner JH, John TK, Conditt MA: Robotic analysis. J Arthroplasty 2016;31:
References printed in bold type are arm-assisted UKA improves tibial 759-765.
those published within the past 5 years. component alignment: A pilot study. Clin
Orthop Relat Res 2010;468:141-146. 22. Swank ML, Alkire M, Conditt M, Lonner JH:
1. Lum ZC, Lombardi AV, Hurst JM, Technology and cost-effectiveness in knee
Morris MJ, Adams JB, Berend KR: Early 12. Dunbar NJ, Roche MW, Park BH, arthroplasty: Computer navigation and
outcomes of twin-peg mobile-bearing Branch SH, Conditt MA, Banks SA: robotics. Am J Orthop (Belle Mead NJ)
unicompartmental knee arthroplasty Accuracy of dynamic tactile-guided 2009;38:32-36.
compared with primary total knee unicompartmental knee arthroplasty. J
arthroplasty. Bone Joint J 2016;98-B:28-33. Arthroplasty 2012;27:803-808.e1. 23. Ponzio DY, Lonner JH: Preoperative
mapping in unicompartmental knee
2. Shankar S, Tetreault MW, Jegier BJ, 13. Smith JR, Riches PE, Rowe PJ: Accuracy arthroplasty using computed tomography
Andersson GB, Della Valle CJ: A cost of a freehand sculpting tool for unicondylar scans is associated with radiation exposure
comparison of unicompartmental and total knee replacement. Int J Med Robot 2014; and carries high cost. J Arthroplasty 2015;
knee arthroplasty. Knee 2016;23:1016-1019. 10:162-169. 30:964-967.
Three-dimensional Bioprinting for

Bone and Cartilage Restoration in
Orthopaedic Surgery
Abstract
Aman Dhawan, MD Notable shortcomings exist in the currently available surgical options
Patrick Merrill Kennedy, MD for reconstruction of bone and articular cartilage defects. Three-
dimensional (3D) printing incorporating viable cells and extracellular
Elias B. Rizk, MD
matrix, or 3D bioprinting, is an additive manufacturing tissue
Ibrahim T. Ozbolat, PhD engineering technique that can be used for layer-by-layer fabrication of
highly complex tissues such as bone and cartilage. Because of the
scalability of 3D bioprinting, this technology has the ability to fabricate
tissues in clinically relevant volumes and addresses the defects of
varying sizes and geometries. To date, most of our in vitro and in vivo
success with cartilage and bone tissue bioprinting has been with
extrusion-based bioprinting using alginate carriers and scaffold free
bioinks. Fabrication of composite tissues has been achieved, including
bone which includes vascularity, a necessary requisite to tissue
viability. As this technology evolves, and we are able to integrate high-
quality radiographic imaging, computer-assisted design, computer-
assisted manufacturing, with real-time 3D bioprinting and ultimately
in situ surgical printing, this additive manufacturing technique can be
used to reconstruct both bone and articular cartilage and has the
potential to succeed where our currently available clinical technologies
and tissue manufacturing strategies fail.
away until the desired shape or form

Introduction of Three- is obtained. Although subtractive
dimensional Bioprinting manufacturing is more efficient and
From the Department of Orthopaedics
and Rehabilitation (Dr. Dhawan and and Additive Manufacturing economical for mass-produced, indus-
Dr. Kennedy), Penn State Bone and trial scale manufacturing, subtractive
Joint Institute, Penn State Health, Definitions manufacturing is unable to re-create
Penn State College of Medicine, the
Department of Neurosurgery Three-dimensional (3D) bioprinting is a the complex microarchitecture of bio-
(Dr. Rizk), Penn State Health, Penn tissue engineering fabrication method logic tissues. This architecture is critical
State College of Medicine, and the that uses spatial patterning of living cells to the function of biologic tissues and
Biomedical Engineering Department
(Dr. Ozbolat), The Huck Institutes of
and other biologic materials assembling organs. Bioinks are the medium for
the Life Sciences, Materials Research them in a layer-by-layer deposition printing and are available in a number
Institute, Penn State University, approach for construction of living of forms including hydrogels, micro-
Hershey, PA. tissues and organ analogs. In this carriers, tissue spheroids, cell pellet,
J Am Acad Orthop Surg 2019;27: way, precise control of the micro and tissue strands, and decellularized
e215-e226 microarchitecture can be controlled. matrix components and are used
DOI: 10.5435/JAAOS-D-17-00632 Bioprinting is an additive manufactur- with a variety of bioprinting processes
ing technique, as opposed to more including droplet-, extrusion-, and
Academy of Orthopaedic Surgeons. common subtractive manufacturing laser-based bioprinters. These differ-
whereby a large block of material is cut ent types of inks and techniques each
March 1, 2019, Vol 27, No 5 e215
3D Bioprinting of Bone and Cartilage
Table 1
Types of Bioprinters and Their Respective Characteristics
Factor DBB EBB LBB
Cost Lowa Medium High

Viscosity ,15 mPa/s ,6 · 107 mPa/sa ,300 mPa/s
Cell density ,106 cells/mL High, spheroidsa ,108 cells/mL
Print speed Medium Slow Fasta
Resolution 50-100 mm 100 mm 20 mma
Common Agarose, alginate, collagen, fibrin, Alginate, hyaluronic acid, polyethylene Alginate, collagen, gelatin,
bioinks methacrylated gelatin, polyethylene glycol, agarose, collagen, gelatin, matrigel
glycol pluronic, matrigel, fibrina
Cell viability .85% 80% 95%a
DBB = droplet-based bioprinting, EBB = extrusion-based bioprinting

a
Denotes best for that characteristic.
Reproduced with permission from Leberfinger AN, Moncal KK, Ravnic, DJ et al: 3D Printing for Cell Therapy Applications, in Emerich DF, Orive G,
eds: Cell Therapy: Current Status and Future Directions. Basel, Switzerland, Springer Nature, 2017, pp 227-248.3
have their own advantages and diameter nozzle, and the ability to can be affected by the dehydration
disadvantages and allow for the extrude bioink in a near solid state, and the lack of nutrients.1,2
customization of a range of com- bioinks, such as hydrogels, micro-
plex tissues required for orthopaedic carriers, tissue spheroids, and tissue
Droplet/Inkjet-based Printing
applications.1,2 stands can all be used. This technique
Droplet-based bioprinting is an um-
has demonstrated success with brella term that encompasses inkjet,
Three-dimensional printing a number of different tissues acoustic-droplet-ejection, and micro-
Bioprinting Methods including cartilage, lipid bilayers, valve bioprinting.1 Development of
lungs, and liver tissue deposition this printing can be done by modifi-
Extrusion-based Printing
among others.4-6 While comparing cation on a traditional printer by the
Extrusion-based bioprinting is a
extrusion-based bioprinting to other addition of a controller to the print
pressure-based bioprinting method
methods, this printing method has the head for creation of a two-dimensional
that has grown in use over the last
advantage of greater deposition and bioprinter.7 The bioink is then added
decade (Table 1). Using a robotic
system linked to a fluid-dispensing printing speed as well as anatomically to the printer via a storing cartridge.
array, cells can be deposited in a 3D- correct porous construct generation. Inkjet printing is further subclassified
shaped structures based on computer- Fiscally, this printing method is into continuous, drop-on-demand,
aided design modeling. This process commercially available and has high and electrohydrodynamic printing
is done by using the shear-thinning versatility allowing for the use of methods.1 This method uses gravity,
behavior of the bioink and is gener- various different bioinks. Finally, the atmospheric pressure, and fluid me-
ally plotted in cylindrical lines. This technology remains navigable by a chanics to generate droplets that are
system is run by pneumatic, solenoid, novice user. Disadvantages include delivered to a substrate. Continuous
or mechanical control. Each system limited resolution which decreases inkjet printing forces the bioink under
has its own benefits and drawbacks the precision of patterning and or- pressure through a nozzle which then
depending on the spatial construct to ganization of the cells, hydrogel use breaks into droplets as the potential
be printed or bioink to be used.1,2 is complicated by the gelation and energy is diminished. Drop-on-demand
Because of the flexible and larger solidification requirements, and cells printing works to deliver single drops
Dr. Dhawan or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Biomet and
Smith & Nephew; serves as a paid consultant to Avenue Therapeutics, Zimmer Biomet, and Smith & Nephew; has received research or
institutional support from Revotek and Smith & Nephew; and serves as a board member, owner, officer, or committee member of the
American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America. Dr. Ozbolat or an immediate family
member serves as a paid consultant to BioLife4D and has stock or stock options held in Virtual Systems Engineering. Neither of the following
authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company
or institution related directly or indirectly to the subject of this article: Dr. Kennedy and Dr. Rizk.
Aman Dhawan, MD, et al
on demand by using a pressure pulses Figure 1

to push a drop through a nozzle that is
held into place by surface tension.
These pressure pulses are variable
based on the system and can be pie-
zoelectric, electrostatic, or thermal in
nature. Electrohydrodynamic jet bio-
printing uses an electric field to pull the
bioink droplets onto the substrate,
which again creates the droplet by
disrupting the surface tension at the
nozzle tip. When the generation of
the electric field overcomes the sur-
face tension, the droplet is ejected.
Acoustic bioprinting eject droplets
from a pool by generation of an
acoustic field. This process helps
to minimize exposure to excess pres-
sure, voltage, heat, or shear. When
the central focal point from a circu- Schematics showing a laser printing setup based on laser-induced forward transfer:
lar wave exceeds surface tension, the the upper donor slide is coated underneath with a thin laser energy absorbing layer
droplet is ejected. Finally, microwave and a layer of biologic material to be transferred. The donor slide is placed above a
second collector slide. Laser pulses are focused on the donor slide, evaporate the
bioprinting uses an electromechani- absorbing layer, and generate vapor pressure propelling the cell containing hydrogel
cal valve to control droplet release. toward the collector slide.2 CCD = charged coupled device (Reproduced with
This process occurs by the generation permission from Leberfinger AN, Moncal KK, Ravnic, DJ et al: 3D Printing for Cell
of a magnetic field with the use of a Therapy Applications, in Emerich DF, Orive G, eds: Cell Therapy: Current Status
and Future Directions. Basel, Switzerland, Springer Nature, 2017, pp 227-248.)
solenoid coil that ejects bioink drop-
lets from the gated microvalve.
cision are important factors in lular arrangement can recapitulate
Laser-based Printing bioprinting, a number of disadvantages native anatomy. However, this alone is
Laser-based bioprinting is a form of exist associated with the laser-based insufficient for successful bioprinting.
bioprinting that uses laser-based modality. The most formidable is the The subsequent extracellular matrix
modalities to initiate a droplet release. cost of laser-based systems. The (ECM) formation, the digestion and
This process occurs by a two-layer equipment is large and complex, thus degradation of the hydrogel matrix,
approach. The top layer comprises an limiting its applicability in a stan- and the interactions and proliferation
energy absorbing donor layer, whereas dard research setting. Secondary to of encapsulated cells are all equally
the bottom layer is the selected bioink this, research applications have been critical to the viability and functional
(Figure 1). The release of the bioink somewhat more limited. Cellular ef- success of the printed tissues. Limi-
droplet occurs when a laser pulse is fects on the viable components of the tations of tissue strand/spheroid for-
emitted onto the top donor surface bioinks are also largely unknown. mation using hydrogels include
layer. This process creates a bubble at restricted cell interactions, proliferation,
the interface when the top layer is and colonization of immobilized cells
vaporized, propelling the droplet onto Additive Manufacturing within the hydrogel matrix, as well as
the substrate. Laser-based bioprinting Concepts the inability of cells to spread, stretch,
provides a number of advantages over and migrate to successfully generate the
Three fundamental principles of bio-
other bioprinting methods. The first is new tissue, particularly at high hydrogel
printing exist, including biomimicry,
the ability to avoid mechanical stress concentrations. Bioinks fabricated with
biologic self-assembly, and mini-
by eliminating the direct contact with cell aggregates, without hydrogels, ex-
tissue units as building blocks.
the printer. Other advantages include hibit better biomimetic characteristics
high resolution and increased preci- facilitating both homo- and hetero-
sion, which allows droplets to be Biomimicry cellular interactions because of the high
printed more accurately to the tem- Hydrogels seeded with viable cells cell densities and the lack of exogenous
plate. Although resolution and pre- allow for patterning of cells. This cel- matrix immobilization seen when
March 1, 2019, Vol 27, No 5 e217
encapsulated in hydrogels. These tissue of cells are seeded into an array of notable shortcomings to include cost,
constructs closely resemble the native microwells and cultured for 24 to 48 durability, potential disease transmis-
tissue and preserve cell phenotype and hours to facilitate cell aggregation. sion, and most notably the inability
functionality for extended periods. Cells will sediment to the bottom of to re-create native articular cartilage
the microwells and settle in close architecture often resulting in a short-
Biologic Self-assembly contact with each other, driving the term solution that lacks durability.11-13
cells to spontaneously adhere to one The structure and composition of
Organ and complex tissue develop-
another to minimize free energy and healthy articular cartilage is integral to
ment evolution is fundamentally based
develop into a neo-tissue.8 Because of its function.12-14 This complex struc-
on cellular self-assembly mechanisms.
intracellular cytoskeletal reorganiza- ture varies along the osteochondral
The tissue construct environment of
tion from cadherin mediated cell axis, and many of the limitations of
the cells needs to resemble its native
binding, tissue spheroids will dimin- current techniques can be attributed to
counterpart for cells to maintain their
ish in size because of radial contrac- the lack of the native spatiotemporal
phenotype, establish appropriate cell-
tion.9 Other approaches which have control of biologic signals for guiding
cell interactions, and express tissue-
also demonstrated success in tissue cell differentiation, hyaline cartilage
specific proteins along with ECM.
spheroid fabrication include the formation, specific zonal biomechani-
Three-dimensional cell aggregate con-
hanging drop method, microfluidic- cal properties, and integration with the
figurations allow for a more hospitable
assisted technology, and acoustic underlying bone.11-14 The heteroge-
and more native anatomic environ-
wave-assisted cell assembly. neous and anisotropic cartilage is
ment for tissue self-assembly to occur
Tissue strands are cylindrical neo- composed of anatomic zones that
compared with monolayer cell cul-
tissue building blocks that are used for possess zone-specific mechanical and
tures. Tissue morphogenesis is depen-
bioprinting scale-up tissues like ink in biologic properties reflecting each
dent on the formation of multicellular
an ink-jet printer.9,10 To fabricate the zone’s composition and architecture,
aggregates. These aggregates are
tissue strands for bioprinting, cells at which to date current clinical treat-
bound by cadherin molecules which
very high density are injected and ment technologies and tissue engi-
facilitate strong intercellular adhesion.
packed into hollow alginate tubules.10 neering strategies have been unable
This cadherin mediated aggregates
Semipermeable alginate tubules are to recapitulate. Current cell-based
enable signal transduction, an increase
used as these allow for exchange of techniques result in a disorganized
in integrin expression as well as bind-
nutrition and oxygen. The cells that repair tissue that has poor durabil-
ing to arginyl-glycyl-aspartic acid mo-
are placed into the tubules will form ity.13 Currently, osteoarticular allo-
tifs in the deposited ECM components.
into cylindrical neo-tissue strands graft is the clinical strategy most
as the cells self-adhere and pull away often used for reconstruction of large
Mini-tissue Units as Building from the tubule walls. As with tissue osteochondral defects and injury.15
Blocks spheroids, tissue strands will not Though this can yield good results,
To bioprint scalable tissue, “mini- bind to the alginate luminal surface. there remains a limited supply of these
tissues” which represent the smallest After cells have aggregated into the live osteoarticular allografts, with wait
composite tissue units can and should neotissue strand, the tube is dissolved times often of a year or longer for graft
be used as building blocks. Such using a decrosslinker solution. The matching, during which time signifi-
building blocks can be in spheroid or formed tissue strand is then loaded cant detriment to the adjacent joint
cylindrical form. Both the forms have into a custom-made bioprinter head surfaces and global environment of
been used in bioprinting. and mechanically extrusion printed. the knee occurs, not to mention addi-
Tissue spheroids represent a scaffold- tional pain and suffering, with lost
free bioink-type, where the cells are work time/wages. Furthermore, as
organized spherically into 200- to 400- Cartilage Restoration and with all allograft tissues, disease
mm-diameter cell conglomerations. A Reconstruction transmission remains an issue and
number of different fabrication tech- especially so with osteoarticular al-
niques have been used for fabrication Injury to the articular cartilage of joints lografts as this involves live bone and
of tissue spheroids including cultur- is common. Current clinical restorative cartilage transplants. Given the lim-
ing cells in microwells with rounded options for articular cartilage injury ited clinical success of current scaf-
ends on a cell adhesion inert mold include marrow stimulating tech- fold- and cell-based strategies, there
made of hydrogels such as agarose, niques, osteochondral grafting (auto remains an unmet need for chondral
methacrylated hyaluronic acid, and and allogeneic), and cell-based tech- and osteochondral constructs that
alginate. In this approach, millions niques.11-13 These options all have recapitulate anatomy, histology, and
Figure 2
Scaffold-based and scaffold-free bioprinting technologies: Diagrams showing (A) extrusion-based bioprinting, (B) droplet-
based bioprinting, (C) laser-based bioprinting, (D) bioprinting tissue spheroids, and (E) bioprinting cell pellet.2 (Reproduced
with permission from Ozbolat IT: Scaffold-based or scaffold-free bioprinting: Competing or complementing approaches? J
Nanotechnol Eng Med 2015;6:24701.)
biology, which promote rapid inte- of living cells to create biologic con- tissues.16 These bioinks have also been
gration, and provide a durable clinical structs. The ideal bioink is printable; shown to be biocompatible for carti-
solution to articular cartilage injury. has high mechanical integrity, high lage growth.17 Two major types have
The additive manufacturing strategy of stability, insoluble in cell culture me- been developed, which include scaf-
3D bioprinting provides a potential dium, nontoxic, and nonimmunogenic; fold and scaffold-free techniques.
solution. and can promote cell adhesion. For the Their implications in cartilage res-
bioink to be effective, it must maintain toration are discussed later.
Bioinks its design strength and integrity for im-
The foundation of biologic printing re- plementation in vivo. Several studies Scaffold and Scaffold-free
volves around the use of bioinks. Bio- have evaluated various bioinks for their In Vitro Work
inks are the combination of inert effectiveness in cartilage restoration. Bioprinting can be performed with or
printing medium seeded with living Alginate and agarose may better without a scaffold. Scaffolds used for
cells. Together these components form support hyaline-cartilage whereas gel- fabrication of articular cartilage refers
the raw material which are deposited atin methacryloyl- and poly(ethylene to biomaterials, either synthetic or
onto the collection substrate. The de- glycol) methacrylate-based bioinks naturally occurring, that are used to
velopment has allowed manipulation may support more fibrocartilaginous support the cartilage construct or may
March 1, 2019, Vol 27, No 5 e219
Table 2
Various Natural and Synthetic Hydrogels With Their Types, Advantages, and Disadvantages
Hydrogel Type Advantages Disadvantages
Agarose Natural High mechanical strength, low cost Low cell adhesion
Alginate Natural Fast gelation, low cost, good stability Poor cell attachment, easily clogs at high
concentrations
Chitosan Natural Antibacterial and antifungal Slow gelation, poor mechanical properties
Collagen I Natural Promotes cell attachment, good printing Poor mechanical stability, slow gelation, easily
abilities, have RGD sequencea clogs
Fibrin Natural Promotes angiogenesis, fast gelation Poor mechanical stability, easily clogs
Gelatin Natural Reversible, promotes cell adhesion Unstable/fragile, poor abilities without
modification
Hyaluronic Natural Promotes proliferation and angiogenesis, Rapid degradation, poor mechanical stability
acid fast gelation
GelMA Synthetic Easily degradable, high mechanical Slow gelation, requires UV light which causes
strength cell damage
PEG Synthetic Good when combined with other Low cell proliferation & adhesion, poor
components mechanical strength, UV causes cell
damage
GelMA = methacrylated gelatin/gelatin methacryloyl, PEG = polyethylene glycol, UV = ultraviolet

a
RGD = tripeptide Arg-Gly-Asp sequence which mediates cell attachment.
Reproduced with permission from Leberfinger AN, Moncal KK, Ravnic, DJ et al: 3D Printing for Cell Therapy Applications, in Emerich DF, Orive G,
eds: Cell Therapy: Current Status and Future Directions. Basel, Switzerland, Springer Nature, 2017, pp 227-248.
be used to assist in inducing repair from gradients in composition and/or various components of the scaffolds
native host cells (Figure 2). Scaffold- architecture to mimic the mechanical to optimize cartilage cell growth.
based bioprinting involved the loading properties of native cartilage and Scaffold-free techniques use neo-
of cells into hydrogels or other carrier allow the distribution of appropriate tissues and deposit them in specific
that can be deposited onto prior mechanical and biologic cues to cells patterns on a substrate. These tissues
construct designs. These hydrogels throughout the different zonal archi- are then fused and mature over time
can facilitate the generation of tissues tecture. Total porosity and inter- into larger functional tissues by the
via cell proliferation and growth. connectivity of the pores also play a concept of mini-tissue units as build-
Hydrogels come in a wide variety large role in effectivity of a scaffold. ing blocks. Scaffold-free techniques
of substrates and types, all with vari- This characteristic assists with cell allow a high-density deposition of
ous advantages and disadvantages adhesion and seeding as well as cells on initial print without the need
(Table 2). Scaffolds are attractive in maintaining proximity to blood sup- for biomaterials, which was accom-
tissue engineering as they allow for ply for efficient oxygen and nutrient plished prior by the use of tissue
immediate structural integrity and delivery.18 A number of studies have spheroids that are printed in close
can be used to control the spatio- looked at in vitro bioprinting using a proximity and fuse over time. Spher-
temporal structure, development, and scaffold. Abbadessa et al19 tested oids do have several issues, however.
interactions of the cells and the hydrogels containing polyethylene They require a delivery medium for
developing ECM. Several criteria can glycol and partially (10%) methacry- extrusion which complicates the
be used in deciding the appropriate lated poly(N-(2-hydroxypropyl) meth- printing process. Since fusion occurs by
scaffold. Considerations include bio- acrylamide mono/dilactate) (M10P10) proximity, premature fusion can cause
capability, porosity, pore size, and methacrylated hyaluronic acid nozzle clogging. Finally, gaps between
mechanical strength, biodegradabil- which increased storage modulus, printed spheroids have been shown
ity, and ability to promote cartilage slowed degradation, and improved from tissues with gaps which can leak.1
tissue formation.15 The scaffold also printability versus M10P10 alone. These Yu et al10 developed a novel technique
offers “Time Zero” mechanical load- authors demonstrated chondrocyte which allowed the printing of bio-
bearing properties, a characteristic growth at 42 days of culture. This strands (Figures 3 and 4), which
that bioprinted tissues often initially knowledge base continues to grow as leads to a number of advantages
lack. Scaffolds can be fabricated with various laboratories examine the which included facilitation of rapid
Figure 3
Diagrams showing scaffold free printing of tissue strands as new Bioink.10 (Reproduced with permission from Yu Y, Moncal
K, Li J, et al: Three-dimensional bioprinting using self-assembling scalable scaffold-free “tissue strands” as a new bioink. Sci
Rep 2016;6:28714.)
fusion and maturation through self- present, allowing biomechanical may limit the size of the printable con-
assembly, bioprinting in solid form, testing of the product. The Young’s structs. Scaffold-free techniques may
removal of the liquid delivery medium modulus of the printed cartilage was provide a way for printing of larger
and do not require a support molding tested in compression and found to implantable cartilage patches with
structure during bioprinting for cell be 1,094 6 26.33 kPa similar to similar biomechanical and histological
aggregation and fusion. In their study, native cartilage. The authors postu- properties to that of native cartilage.
the strands were deposited and cul- lated that the Young’s modulus
tured in vitro. Similar to in vitro, would be more similar if strands
cells demonstrated good survivability. were cultured for longer. In Vivo Work
After 2 weeks, histological staining The unique ability of bioprinting al- As we continue to work to find the ideal
was completed demonstrating sub- lows the development of precise pat- parameters and environment for the
stantial proteoglycan deposition with terning of cartilage cells with the bioprinting of chondrocytes, a number
positive staining for Safranin-O, sim- complex structure of the cartilage lay- of researchers have begun to work on
ilar to native cartilage control (Figure ers to produce mimicry of the native in vivo transplantation of these cells.
4). Aggrecan and type II collagen were structure of cartilage. The scaffold-free Both rat or mouse and rabbit models
also present on immunohistological technique has allowed printing of near have been used with the transplanta-
staining further characterizing the solid state tissue which does not tion of cartilage constructs to evaluate
cartilage material. Self-assembly was require a liquid medium for cell facili- in vivo survivability.20,21 Two different
tested and demonstrated as early as 12 tation, viability, or fusion. Current types of in vivo studies have been at-
hours post printing. On day 7, an scaffold-based bioprinting mechanisms tempted thus far. Most work has been
almost complete tissue patch was require a mold to host the cells which on survivability of the 3D bioprinted
March 1, 2019, Vol 27, No 5 e221
Figure 4
Functional and transcriptional characterization of tissue strands. A and B, Images showing a nearly 8-cm-long tissue
strand after decrosslinking the capsule. C, Image showing the well-defined cylindrical morphology achieved as shown
with SEM. Functional evaluations of cartilage tissue strands showing positive staining of Safranin-O compared with
native cartilage (positive control). D, Chart showing the sGAG content measurement by DMMB assay type in
comparison to native cartilage (control). E, Charts showing the positive type II collagen and Aggrecan staining
compared with isotype IgG antibody (negative control). Real-time PCR analysis of tissue strands demonstrating
notable expression of cartilage-specific genes including Sox9, COL2A, and ACAN compared with monolayer-cultured
bovine articular chondrocytes (n = 3). All data are presented as average 6 SD unless otherwise stated.10 ACAN =
Aggrecan, DMMB = dimethylmethylene blue assay, IgG = immunoglobulin G, PCR = polymerase chain reaction, SEM =
scanning electron microscope, sGAG: sulfated glycosaminoglycan (Reproduced with permission from Yu Y, Moncal K,
Li J, et al: Three-dimensional bioprinting using self-assembling scalable scaffold-free “tissue strands” as a new bioink.
Sci Rep 2016;6:28714.)
Figure 5
Diagrams showing the hybrid bioprinting of scaffold-based vascular constructs in tandem with scaffold-free parenchyma tissue,
where fusion, tissue remodeling, and self-assembly of tissue strands take place and sprouting can take place between the
macrovascular network and capillaries in tissue strands. This concept generalizes the tissue used; however, for different tissue
types, modifications on the system would be essential.40 (Reproduced with permission from Ozbolat IT: Scaffold-based or
scaffold-free bioprinting: Competing or complementing approaches? J Nanotechnol Eng Med 2015;6:24701.)
cells implanted subcutaneously in frequently but has the major draw- properties of the scaffold over other
mice. These constructs were then re- back of donor site morbidity. Allo- previously described techniques
tained for varying periods and the cells graft bone has been used extensively, including gas foaming, salt leaching,
histologically evaluated upon removal. but disease transmission, lack of os- and freeze drying. Furthermore, 3D
Work has been promising showing teogenicity, cost, and an already bioprinting allows for better cell-cell
development of vascular membranes, limited supply despite rapidly grow- interconnection, improved oxygen
chondrocyte proliferation, and lacunae ing demand are all notable concerns. diffusion, and nutrient transportation
development without loss of cell The field of bone tissue engineering and provides cells with the necessary
integrity.21 Shim et al20 implanted 3D seeks to reconcile these challenges attachment, proliferation, and tissue
printed cartilage cells into rabbit knee and the growing unmet need for a formation factors.22
joints. Upon evaluation, the test group viable bone grafting alternative by Bone grafts have been created using
showed evidence of neocartilage for- combining (1) a biocompatible scaf- natural hydrogels such as fibrin or
mation, osteochondral integration, fold that recapitulates the natural alginate.23 However, the scaffolds
lacuna formation, and a smooth car- bone ECM niche, (2) inclusion of created in vitro have poor compressive
tilage cap in the area of the defect. osteogenic cells to secrete the neces- modulus making them inadequate for
Early evidence demonstrates both sary ECM, (3) morphogenic signals bone tissue engineering.23 Alterna-
survivability and integration of bio- that spatiotemporally biodirect the tively, 3D bioprinting using synthetic
printed cartilage cells with the use of a cells to the phenotypically desirable polymeric polyethylene glycol dime-
scaffold hydrogel in vivo. This finding type, and (4) sufficient vasculariza- thacrylate hydrogel provides com-
may aid in the development of future tion to meet the growing tissue pressive modulus that can exceed
cartilage tissue engineering techniques nutrient supply and metabolic needs. 500 kPa.24,25 This process approx-
and possible treatment alternatives. Three-dimensional bioprinting al- imates human tissue compressive
lows for additive manufacturing of moduli.26 Furthermore, the use of
this dynamic tissue that includes a polyethylene glycol hydrogel will
Bone Restoration and highly complex microarchitecture provide better cell viability and pro-
Reconstruction integral to its function. Though a mote ECM production.24,27,28 Addi-
number of tissue engineering strategies tion of human mesenchymal stem cells
Notable shortcomings remain with may be employed to tackle the chal- (hMSCs) can regenerate bone tissues
bone grafting options for bone res- lenges of bone tissue engineering, 3D when stimulated by a ceramic scaf-
toration and reconstruction. Auto- bioprinting offers a better control fold.29 Bioactive glass and hydroxy-
graft bone continues to be used over the structural and mechanical apatite (HA) have both been shown to
March 1, 2019, Vol 27, No 5 e223
promote bone tissue formation.23,30 stromal cell-derived factor-1 beta

Collectively, HA in polyethylene gly- (SDF-1b) on 5-mm-diameter acellu-
Clinical Application and
col hydrogel is able to maintain lar DermaMatrix disks, which the Future Direction
hMSCs viability and promotes hMSC authors then implanted into osseous
A key advancement in clinical bio-
osteogenic differentiation and biosyn- defects in mice. The co-delivery of
printing of orthopaedic tissues, whether
thetic function.31 Qi et al32 demon- BMP-2 and SDF-1 was superior to
bone or cartilage, will be integration
strated that using hBMSCs in BMP-2-only and SDF-b-only groups
with computer-aided design, where
conjunction with calcium sulfate in bone formation.35 The addition
medical images acquired by CT, MRI,
hydrate/mesoporous bioactive glass of a bioink carrier to the mixture
positron emission tomography, and
scaffolds stimulated the adhesion, allows for solidification by polymer-
ultrasonography can be directly fed
proliferation, alkaline phosphatase ization to ensure the maintenance of
into a processor, which can rapidly
activity and osteogenesis-related gene the construct. MSCs co-printed with
produce the design through image
expression of hBMSCs. The authors HA can create scaffolds with Young’s
reconstruction algorithms. This step
also demonstrated that calcium sul- modulus values of 1 to 2 MPa.36
involves image segmentation and
fate hydrate/mesoporous bioactive These constructs also were shown to
mesh generation followed by mesh
glass scaffolds could markedly enhance produce substantial bone tissues.
new bone formation in in vivo osseous Another important element to the optimization re-creating highly intri-
defects compared with controls.32 bone formation process was the cate irregular geometric models. The
As in cartilage, bioprinting without incorporation of type I collagen with mesh is then converted into a path
a scaffold provides the advantage of thermo-responsive agarose hydro- plan for 3D bioprinting which can be
avoiding cytotoxic or otherwise bio- gels bioinks. This combination with directly fed into a bioprinter. These
logically deleterious breakdown by- high-collagen ratios optimizes the designs would be patient-specific
products of the scaffold. This approach mechanical stiffness required for with respect to not only the geome-
leads to preservation of cell phenotypes differentiation and provides precise try of implant but also the level of
and function through a facilitation of contours for the constructs.36 tissue insufficiency and the anatomy
cell-cell interactions and a more robust Das et al37 demonstrated osteogenic of the composite tissue as well as the
deposition of ECM. Evinger et al33 differentiation of mesenchymal stem vascular network. Several advances
demonstrated the use of NovoGen cells encapsulated in silk fibroin– in tissue segmentation algorithms from
bioprinting platform with adipose- gelatin which was cross-linked either different imaging modalities have
derived mesenchymal stem cells by the enzyme tyrosinase during recently emerged that may eventually
and/or endothelial cells to produce bioprinting or by sonication post- be used for bioprinting of composite
osteopontin and alkaline phosphatase bioprinting.37 The authors also vascularized tissues.
positive cells after 5 days post bio- demonstrated that by changing the
printing. Osteogenesis was also con- culture media, they were able to dif-
firmed by measuring bone modeling ferentiate cells with a construct that Summary
biochemical markers including inter- varies in mechanical properties and
leulin (IL)-1a, IL-6, IL-8, C-C motif function.38 Raja and Yun39 also used Notable shortcomings exist in the cur-
chemokine ligand 2, and chemokine this technique by depositing in a rently available surgical options for
(C-X-C motif) ligand 1.33 coaxial manner calcium-deficient HA reconstruction of bone and articular
Keriquel et al34 have recently and alginate laden with pre-osteoblast cartilage defects. Three-dimensional
demonstrated that laser-assisted bio- MC3T3-E1 cells,39 leading to the bioprinting as an additive manufactur-
printing is an attractive tool for the engineering of bone tissue compo- ing tissue engineering technique in-
in situ printing of a bone substitute. sites with the compressive modu- corporates viable cells and ECM for
These authors successfully used the lus of 7.01 6 0.82 MPa. Additive layer-by-layer fabrication of highly
laser-assisted bioprinting technique manufacturing of bone using 3D bio- complex tissues such as bone and car-
to bioprint mesenchymal stromal printing offers the advantage of cre- tilage. Because of the scalability of 3D
cells, associated with collagen and ating composite tissues including the bioprinting, this technology has the
nano-HA in a calvarial defect model ability to integrate essential vascularity ability to fabricate tissues in clinically
in mice.34 Using droplet-based bio- to the bone tissue fabrication (Figure relevant volumes and addresses the de-
printing, Herberg et al35 added 5). Kolesky et al38 have demonstrated fects of varying sizes and geometries.
growth factors, including bone this with the ability to create a 1-cm- Adhering to the principles of bio-
morphogenetic protein (BMP)-2, thick tissue with embedded vascula- mimicry, biologic self-assembly, and
transforming growth factor-b1, and ture for tissue perfusion. the use of mini-tissues as building
blocks, notable success has already 6. Durmus N, Tasoglu S, Demirci U: stromal cells for osteochondral tissue
Bioprinting: Functional droplet networks. regeneration in the rabbit knee joint.
been achieved with cartilage and bone Nat Mater 2013;12:478-479. Biofabrication 2016;8:14102.
tissue bioprinting using extrusion-
7. Mattimore JP, Groff RE, Burg T, Pepper 21. Xu T, Binder K, Albanna M, et al: Hybrid
based bioprinting using alginate ME: A general purpose driver board for the printing of mechanically and biologically
carriers and scaffold-free bioinks. HP26 ink-jet cartridge with applications to improved constructs for cartilage tissue
bioprinting. In: Conference Proceedings: engineering applications. Biofabrication
Fabrication of composite tissues has IEEE SoutheastCon, 2010, pp 510-513. 2013;5:15001.
been achieved which includes vas-
8. Athanasiou K, Eswaramoorthy R, Hadidi 22. Bose S, Vahabzadeh S, Bandyopadhyay A:
cularity, a necessary requisite to P, Hu J: Self-organization and the self- Bone tissue engineering using 3D printing.
tissue viability. As this technology assembling process in tissue engineering. Mater Today 2013;16:496-504.
evolves, and we are able to integrate Annu Rev Biomed Eng 2013;15:115-136.
23. Khanarian NT, Jiang J, Wan LQ, Mow VC,
high-quality radiographic imaging, 9. Akkouch A, Yu Y, Ozbolat I: Lu HH: A hydrogel-mineral composite
Microfabrication of scaffold-free tissue scaffold for osteochondral interface tissue
computer-assisted design, computer- strands for three-dimensional tissue engineering. Tissue Eng Part A 2012;18:
assisted manufacturing, with real- engineering. Biofabrication 2015;7:31002. 533-545.
time 3D bioprinting and ultimately 10. Yu Y, Moncal K, Li J, et al: Three- 24. Cui X, Breitenkamp K, Finn MG, Lotz M,
in situ surgical printing, this additive dimensional bioprinting using self- D’Lima D: Direct human cartilage repair
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12. Farr J, Cole B, Dhawan A, Kercher J, enhances mechanical properties of scaffold-
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Research Article
Preoperative Narcotic Use and

Inferior Outcomes After Anatomic
Total Shoulder Arthroplasty:
A Clinical and Radiographic
Analysis
Abstract
Kirk M. Thompson, MD Introduction: Our purpose was to determine whether the chronic use
Justin D. Hallock, MD of preoperative narcotics adversely affected clinical and/or

radiographic outcomes.
Richard A. Smith, PhD
Methods: Seventy-three patients (79 shoulders) with primary total
Tyler J. Brolin, MD shoulder arthroplasty for osteoarthritis were evaluated clinically and
Frederick M. Azar, MD radiographically at preoperative visits and postoperatively at
Thomas W. Throckmorton, MD a minimum follow-up of 2 years: 26 patients (28 shoulders) taking
chronic narcotic pain medication for at least 3 months before surgery
and 47 patients (51 shoulders) who were not taking narcotics
preoperatively.
Results: Postoperatively, significant differences were noted between
the narcotic and nonnarcotic groups regarding American Shoulder
and Elbow Surgeons scores and visual analog scale scores, as well as
forward elevation, external rotation, and all strength measurements
(P , 0.01). The nonnarcotic group had markedly higher American
Shoulder and Elbow Surgeons scores, better overall range of motion
and strength, and markedly lower visual analog scale scores than the
narcotic group.
Conclusion: Chronic preoperative narcotic use seems to be a
notable indicator of poor outcomes of anatomic total shoulder
arthroplasty for glenohumeral osteoarthritis.

Surgery and Biomedical Engineering,
T otal shoulder arthroplasty (TSA)
is a common procedure with an
established track record for manage-
effort to better predict complication
rates and outcomes. Preoperative
narcotic use has been suggested
University of Tennessee-Campbell
Clinic, University of Tennessee Health ment of symptomatic glenohumeral as a possible cause of poor patient
Science Center College of Medicine, arthritis. Over the past 20 years, outcomes, and links between preop-
Memphis, TN.
the number of TSA procedures per- erative narcotic use and increased
Correspondence to Dr. Throckmorton: formed has increased rapidly.1 With postoperative narcotic requirements
tthrockmorton@campbellclinic.com recent changes to the healthcare and long-term dependence have
J Am Acad Orthop Surg 2019;27: system, attention has been directed been established for other ortho-
177-182 toward value-based investigation of paedic procedures.3-8 In particular,
DOI: 10.5435/JAAOS-D-16-00808 surgical procedures in addition to several studies have investigated the
patient outcomes.2 With this shift in use of preoperative narcotics and its
Academy of Orthopaedic Surgeons. attention, patient-specific character- effect on patient outcomes, narcotic
istics have been examined in an usage, and overall satisfaction in
March 1, 2019, Vol 27, No 5 177
Preoperative Narcotic Use and Inferior Outcomes After Anatomic Total Shoulder Arthroplasty
patients with total joint and spine Patient demographic forms were
surgery.3-6,9-17
Methods used during initial visit intake to
Although a number of studies exist determine medical comorbidities,
A search of our institutional shoulder
regarding total hip and knee arthro- smoking history, surgical history,
arthroplasty database was conducted
plasty, there is a paucity of infor- and current medications. Review of
to identify primary anatomic TSAs
mation regarding the effect of medical records identified surgical
performed for primary glenohumeral
preoperative narcotic use on postop- side, hand dominance, implants used,
osteoarthritis by a single surgeon.
erative outcomes after primary ana- complications, and indications for
tomic TSA. One recent study showed Retrospective chart review assessed surgery. Narcotic usage was defined
that opiate-naive patients had better completeness with regard to the as opiate use within the preceding
outcomes after primary TSA than a duration of follow-up, demographic 3 months before surgery and ex-
similar group of patients who were data, visual analog scale (VAS) score, cluded atypical opioid medication
taking narcotics preoperatively;18 American Shoulder and Elbow (eg, tramadol). This information
however, this study relied on patient Surgeons (ASES) scores, and physical was supplemented and confirmed
self-reporting and did not use a examination outcomes including range by query of a statewide narcotics-
prescribing database to track pre- of motion (ROM) and strength. tracking database.7,20
operative narcotic use. In addition, After institutional review board Patients were clinically evaluated
the authors noted significant differ- approval was obtained, our institu- using ASES scores, VAS scores, active
ences in their study groups with tional TSA database was searched for shoulder ROM, and strength testing.
regard to depression, which has patients who had primary anatomic Complications data were also com-
been shown to affect the outcomes TSA done by the senior author from piled. Radiographs from the most
of patients undergoing total joint 2010 to 2014. Patients were excluded recent follow-up at a minimum of 2
surgery. 3,19 Differences were also from the study if TSA was done for years were analyzed for radio-
noted in body mass index (BMI) and conditions other than primary gleno- lucencies and evidence of mechanical
back pain, which are additional humeral osteoarthritis. In addition, failure.
possible confounding factors. Fur- patients who had a revision procedure The procedures were performed
thermore, no assessment of postop- and patients who did not have 2-year with the patient in the beach chair
erative radiographic outcomes or follow-up because of the timing of position; a deltopectoral approach
complication rates was made. their surgery relative to data collection and muscular paralysis were used.
The purpose of this study was The subscapularis was managed with
were excluded. Of 180 anatomic
to evaluate a patient population tenotomy and transosseous repair.
TSAs eligible for 2-year follow-up, 65
undergoing primary anatomic TSA Humeral stems were noncemented,
were excluded for a diagnosis other
for osteoarthritis to determine whether and glenoid components used a cen-
than primary glenohumeral osteo-
the chronic use of preoperative tral post with cementing of the
narcotics adversely affected clinical arthritis (including inflammatory peripheral pegs.
and/or radiographic outcomes at arthritis, revision arthroplasty, post- Statistical analysis was performed
a minimum follow-up of 2 years. traumatic arthritis, and osteonecrosis). using independent samples Mann-
By analyzing prescribing records, Of the remaining 115 TSA procedures Whitney U tests to compare preop-
we also sought to establish a dose- performed, 79 shoulders (73 patients) erative ASES and VAS scores and
dependent effect of preoperative met the inclusion criteria (69%). Pa- strength and ROM measurements
narcotic use while controlling tients were evaluated clinically and between narcotic and nonnarcotic
for mood disorders, chronic pain radiographically at preoperative visits patient groups. The same analysis
syndromes, and other potential and postoperatively at a minimum was performed for postoperative
confounders. follow-up of 2 years. values. Within both the narcotic and
Dr. Azar or an immediate family member serves as a paid consultant to 98point6, Lovera, and Zimmer Biomet; has stock or stock options
held in Pfizer; and serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery, the
Campbell Foundation, and St. Jude Children’s Research Hospital. Dr. Throckmorton or an immediate family member has received royalties
from Zimmer Biomet; is a member of a speakers’ bureau or has made paid presentations on behalf of Zimmer Biomet; serves as a paid
consultant to Zimmer Biomet; has stock or stock options held in Gilead; has received research or institutional support from Zimmer Biomet;
and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American
Shoulder and Elbow Surgeons, and the MAOA. None of the following authors nor any immediate family member has received anything of
value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article:
Dr. Thompson, Dr. Hallock, Dr. Smith, and Dr. Brolin.
Kirk M. Thompson, MD, et al
nonnarcotic groups, independent Table 1

samples Mann-Whitney U tests were
Demographic Data Comparing Narcotic and Nonnarcotic Groups
performed to compare preoperative
to postoperative ASES and VAS Narcotic Nonnarcotic
Factor Group (26) Group (47) P Value
scores and strength and ROM
measurements. Independent samples Laterality R-14, L-14 (n = 28) R-33, L-18 (n = 51) 0.23
T-tests were used to compare age, Sex F-15, M-11 F-21, M-26 0.33
BMI, and the duration of follow-up Smoking history 11 18 0.82
between the narcotic and non- Mood disorders 9 10 0.27
narcotic groups. Fisher exact tests Diabetes mellitus 6 9 0.77
were used to compare the narcotic Chronic artery disease 4 7 1.00
and nonnarcotic groups with respect
to the presence of radiolucencies, Fisher exact tests were used for each category. Mood disorders include a history of depression,
sex, surgical indication, comorbid- anxiety, schizophrenia, or bipolar disorder. Chronic pain syndromes include complex regional
pain syndrome, fibromyalgia, and chronic back pain.
ities, smoking history, and laterality.
Differences with P , 0.05 were
considered statistically significant.
5.6 kg/m2 in the narcotic group scores and VAS scores and forward
(P = 0.93). The mean age was 63.4 6 elevation (FE) strength and ROM
Results 10.2 years in the nonnarcotic group measurements (Table 2). No signif-
and 58.6 6 13.4 years in the narcotic icant differences were noted in
The study cohort comprised 26 group (P = 0.11). No significant external rotation (ER), internal
patients (28 shoulders) taking chronic differences were noted between the rotation (IR) ROM, or strength
narcotic pain medication for a groups with respect to sex, co- measurements between the groups
minimum period of 3 months before morbidities, or laterality (Table 1). (Table 2). The nonnarcotic group at
surgery and 47 patients (51 should- Specifically, no differences were baseline had higher ASES scores,
ers) who were not taking narcotics noted in BMI, worker’s compen- better overall ROM and strength,
preoperatively. The average duration sation, chronic pain syndromes and lower VAS scores than the nar-
of follow-up was 31.5 6 9.8 months (including back pain), or mood dis- cotic group (Table 2).
for the nonnarcotic group and orders (including depression and Postoperatively, significant differ-
34.0 6 10.8 months for the narcotic anxiety). ences were noted between the narcotic
group (P = 0.32). The mean (6SD) Preoperatively, significant differ- and nonnarcotic groups regarding
BMI was 32.3 6 6.7 kg/m2 in the ences were noted in the narcotic and ASES scores, VAS scores, FE, ER, and
nonnarcotic group and 32.1 6 nonnarcotic groups comparing ASES all strength measurements (Table 3).
Table 2
Comparison of Preoperative Scores in the Narcotic and Nonnarcotic Groups
Narcotic Group Nonnarcotic Group
Preoperative P
Score Median Range Minimum Maximum Median Range Minimum Maximum Value
ASES 32 61 0 61 42 75 5 80 0.006
VAS 6 8 2 10 5 9 1 10 0.02
FE ROM 90 130 20 150 110 170 0 170 0.002
ER ROM 30 90 210 80 30 80 0 80 0.302
IR ROM 30 85 0 85 45 120 0 120 0.097
FE strength 4 2 3 5 5 3 2 5 0.017
ER strength 5 1 4 5 5 2 3 5 0.117
IR strength 5 1 4 5 5 1 4 5 0.082
ASES = American Shoulder and Elbow Surgeons, ER = external rotation, FE = forward elevation, IR = internal rotation, ROM = range of motion, VAS
= visual analog scale
P values were generated using Mann-Whitney U tests with the hypothesis that the distribution of scores was the same across both groups.
Bold numbers indicate statistical significance.
March 1, 2019, Vol 27, No 5 179
Table 3
Comparison of Postoperative Scores in the Narcotic and Nonnarcotic Groups
Narcotic Group Nonnarcotic Group
Postoperative P
Score Median Range Minimum Maximum Median Range Minimum Maximum Value
ASES 61 96 0 96 91.7 43.4 56.6 100 0.001

VAS 2 20 0 20 0 3 0 3 0.001
FE ROM 135 130 50 180 160 185 85 270 0.001
ER ROM 45 60 0 60 45 60 25 85 0.04
IR ROM 60 150 0 150 60 60 30 90 0.677
FE strength 5 2 3 5 5 1 4 5 0.001
ER strength 5 1 4 5 5 0 5 5 0.001
IR strength 5 1 4 5 5 0 5 5 0.001
ASES = American Shoulder and Elbow Surgeons, ER = external rotation, FE = forward elevation, IR = internal rotation, ROM = range of motion, VAS
= visual analog scale
P values were generated using Mann-Whitney U tests with the hypothesis that the distribution of scores was the same across both groups.
Table 4 group. Analysis revealed no signifi-

cant differences in overall improve-
Treatment Effect
ment between the groups when
Postoperative Score Narcotic Group Nonnarcotic Group comparing VAS, ROM, or strength
ASES 0.001 0.001 measurements.
Radiographic analysis found no dif-
VAS 0.001 0.001
ference between the narcotic and non-
FE ROM 0.001 0.001
narcotic groups with regard to the
ER ROM 0.004 0.001
number of humeral, glenoid, or com-
IR ROM 0.001 0.002
bined radiolucencies. There were no
FE strength 0.155 0.003
instances of mechanical failure in either
ER strength 0.417 0.001
group. There were four (14%) com-
IR strength 0.778 0.007 plications in the narcotic group and
ASES = American Shoulder and Elbow Surgeons, ER = external rotation, FE = forward elevation,
one (2%) in the nonnarcotic group (P =
IR = internal rotation, ROM = range of motion, VAS = visual analog scale 0.05). These included one instance
Comparison of the preoperative and postoperative scores in the narcotic and the nonnarcotic groups. each of inferior positioning of the
P values were generated using Mann-Whitney U tests with the hypothesis that the distribution of
scores was the same across both preoperative and postoperative values for each group. Median, humeral head, arthrofibrosis (defined
range, and minimum and maximum values for each score are shown in Tables 1 and 2. as active and passive FE less than 90
Bold numbers indicate statistical significance.
with a firm end point), rotator cuff
decompensation (defined as loss of
The nonnarcotic group had markedly state (Table 4); however, strength active FE), and subscapularis failure
higher ASES scores, better overall measurements were not markedly (defined as anterior glenohumeral
ROM and strength, and markedly improved in the narcotic group. subluxation on radiographs with ac-
lower VAS scores than the narcotic Comparing the overall amount of companying loss of active FE) in the
group (Table 3). improvement after TSA between the narcotic group. In the nonnarcotic
Within the nonnarcotic group, groups, significant differences were group, one patient developed ar-
significant postoperative improve- noted as well. The median ASES throfibrosis. There were no revision
ments were noted in the average score improved 29 points (32 to 61; surgeries in either group.
ASES score, VAS score, and all ROM P , 0.001) in the narcotic group and
and strength measurements (Table 4). 49.7 points (42 to 91.7; P , 0.001)
Within the narcotic use group, there in the nonnarcotic group. This dif- Conclusion
also were significant improvements ference in overall improvement was
in the ASES score, VAS score, FE, statistically significant (P = 0.01), Our study suggests that chronic pre-
ER, and IR from the preoperative with inferior results in the narcotic operative narcotic use is a notable
Kirk M. Thompson, MD, et al
independent negative prognostic comorbidities, conditions known to the complication rate of the two
indicator for outcomes of anatomic increase acute and chronic pain and groups (P = 0.14). No surgical
TSA for primary glenohumeral prolonged opioid use postopera- intervention was performed for any
osteoarthritis. Our study is the first to tively.3,22,23 They also relied on complication encountered.
use a narcotic tracking database to patient self-reporting of narcotic use, We acknowledge limitations in our
quantify narcotic use and examine which in a recent series of patients study. First, this remains a retro-
its effects on function after TSA with spine surgery was associated spective comparative case series with
while controlling for confounding with an inaccurate reporting rate of all of the attendant biases. However,
variables, such as age, BMI, sex, 28%,20 and did not include an we note that other confounding var-
chronic pain syndromes, psychiatric analysis of complications or radio- iables were not markedly different
conditions, and comorbidities, and graphic outcomes. between the groups. In addition,
incorporating a radiographic analy- In this study, patient demographics although we used a combined analy-
sis. Evaluation of complications also did not markedly differ in any cate- sis using a statewide prescribing
indicates that preoperative narcotic gory examined. After controlling for database and patient-reported nar-
use is a predictor of inferior results this, we found significant differences cotic use, patients may have used
after TSA. in outcomes between the two groups. out-of-state physicians to obtain
Opiates are commonly prescribed Before intervention, patients tak- additional pain medication. Never-
to treat chronic pain in many ortho- ing narcotics had inferior subjective theless, this technique has been
paedic conditions. Indeed, opiates are functional measurements compared used in other studies.3,7,8,14,19 In
more widely prescribed and more with patients not taking narcotics. addition, although we controlled
readily available in the United States After intervention, these patients did for some variables known to affect
than in other countries around the markedly worse by every outcome outcomes, a covariance analysis was
world.21 The effects of this practice measured except IR. Although both not performed.
on joint replacement surgery are groups experienced substantial clini- In conclusion, we found chronic
currently a topic of intense scrutiny; cal benefit exceeding the minimum preoperative narcotic use to be a
this has been termed the opioid clinically important difference23,24 notable negative prognostic indicator
epidemic. from the intervention as measured in in anatomic TSA for primary gleno-
Narcotic use before total knee and this study, the data also show that humeral osteoarthritis. In addition,
hip arthroplasty procedures has narcotic consumption predicts less we found that patients using chronic
long been linked to decreased re- overall improvement in both sub- narcotics did not improve to the same
turn to work status, increased pain jective functional and objective out- degree as patients who were not using
and postoperative narcotic consump- comes. This indicates that, although chronic narcotics regarding func-
tion, and longer hospital stays.4,10,11 patients using chronic opiate pain tional outcomes and had a higher
Recent studies have shown similar medication can improve after ana- complication rate with the surgery.
links in patients undergoing reverse tomic TSA, it is not to the same Certainly, there is a psychological
TSA and primary TSA.16,18 degree as patients who were not component associated with patient
Morris et al compared outcomes in using narcotics before surgery. outcomes and chronic opioid use. We
60 patients who were taking nar- Four complications occurred in the also speculate that preoperative nar-
cotics before primary TSA to a con- narcotic group (14%) and one (2%) cotic use diminishes the patient’s
trol group of 164 patients and found in the control group (P = 0.05). One ability to tolerate postoperative pain
decreased patient satisfaction and of these complications was related to and increases pain inhibition re-
lower preoperative and postopera- the surgical technique (ie, inferior sponses. These combined forces then
tive Constant scores in those taking positioning of the humeral head). impede the patient from successful
narcotics before surgery.18 They also There was one instance of postop- advancement in the rehabilitation
reported that the percent change erative arthrofibrosis in each group. protocol. Because the focus in health
between the narcotic and non- Two complications in the narcotic care turns toward value-based
narcotic groups was similar; how- group were related to the rotator measures, surgeons and patients
ever, they acknowledged limitations cuff, with none in the control group. should be aware that chronic pre-
of their study in that the narcotic Overall, we noted 5 complications in operative narcotic use adversely af-
group contained more men (ie, 5 separate patients of a total of 79 fects outcomes and increases the
potentially confounding strength surgical procedures (6%). If the complication rate in anatomic TSA,
data), as well as more patients with surgical complication is removed, no although some improvement can be
chronic back pain and psychiatric significant difference was noted in expected. We now attempt to wean
March 1, 2019, Vol 27, No 5 181
patients from narcotics as much as primary total knee arthroplasty and affect outcomes of anterior cervical
association with patient pain relief and procedures: A post hoc analysis of 2
possible before TSA. If this is not satisfaction. J Arthroplasty 2010;25(6 prospective, randomized trials. J Neurosurg
possible, we suggest surgeons coun- suppl):12-16. Spine 2015;23:484-489.
sel these patients that results of sur- 6. Rapp SE, Ready LB, Nessly ML: Acute pain 16. Morris BJ, Laughlin MS, Elkousy HA,
gery will likely be inferior to their management in patients with prior opioid Gartsman GM, Edwards TB: Preoperative
consumption: A case-controlled opioid use and outcomes after reverse
peers. retrospective review. Pain 1995;61: shoulder arthroplasty. J Shoulder Elbow
195-201. Surg 2015;24:11-16.
References 7. Roberson T, Throckmorton TW: Pain after 17. Zywiel MG, Stroh DA, Lee SY, Bonutti
rotator cuff repair. Curr Orthop Prac 2016; PM, Mont MA: Chronic opioid use prior to
27:156-160. total knee arthroplasty. J Bone Joint Surg
Evidence-based Medicine: Levels of Am 2011;93:1988-1993.
8. Roberson T, Azar FM, Miller RH,
evidence are described in the table of Throckmorton TW: Predictors of early 18. Morris BJ, Sciascia AD, Jacobs CA,
contents. In this article, references 3, complications following rotator cuff repair. Edwards TB: Preoperative opioid use
9, 14, 19, 20, and 21 are level II Tech Shoulder Elbow Surg 2016;17:88-92. associated with worse outcomes after
studies. References 4, 5, 6, 12, 13, anatomic shoulder arthroplasty. J Shoulder
9. Hansen LE, Stone GL, Matson CA, Tybor
Elbow Surg 2016;25:619-623.
15, 16, 17, 18, and 25 are level III DJ, Pevear ME, Smith EL: Total joint
arthroplasty in patients taking methadone 19. Armaghani SJ, Lee DS, Bible JE, et al:
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are level IV studies. References 2, 7, for prior heroin addiction: A prospective depression and anxiety in patients
matched cohort study. J Arthroplasty 2016;
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Prolonged preoperative opioid therapy
those published within the past 5 associated with poor return to work rates
K, Elboghdady IM, Singh K: Preoperative
narcotic utilization: Accuracy of patient
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radiculopathy for patients receiving postoperative narcotic consumption. J
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Yian EH, Navarro RA: Yearly trends in Neurosurg Spine 2016;24:206-214.
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Postoperative pain management among
(Hoboken) 2017;69:1574-1581. preoperative opioid use on acute pain and
Dominican and American health-care
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2. Parker VT: Preoperative pain management providers: A qualitative analysis. J Bone
arthroplasty. Acta Anaesthesiol Scand
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22. Roth ML, Tripp DA, Harrison MH,
Commentary on an article by Michael G. 12. Zarling BJ, Yokhana SS, Herzog DT,
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Preoperative opioid use and its association Preoperative reduction of opioid use before
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5. Franklin PD, Karbassi JA, Li W, Yang W, 15. Kelly MP, Anderson PA, Sasso RC, Riew Clin Orthop Relat Res 2016;474:
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Research Article
Perioperative Protocol for Elective

Spine Surgery Is Associated With
Reduced Length of Stay and
Complications
Abstract
Ahilan Sivaganesan, MD Introduction: Healthcare reform places emphasis on maximizing the
Joseph B. Wick, BA value of care.
Methods: A prospective registry was used to analyze outcomes

Silky Chotai, MD
before (1,596 patients) and after (151 patients) implementation
Christy Cherkesky, ACNP-BC of standardized, evidence-based order sets for six high-
Byron F. Stephens, MD impact dimensions of perioperative care for all patients who
Clinton J. Devin, MD underwent elective surgery for degenerative spine disease after
July 1, 2015.
Results: Apart from symptom duration, chronic obstructive
pulmonary disease prevalence, estimated blood loss, and baseline
Oswestry Disability Index, no significant differences existed between
pre- and post-protocol cohorts. No differences in readmissions,
discharge status, or 3-month patient-reported outcomes were seen.
Multivariate regression analyses demonstrated reduced length of stay
(P = 0.013) and odds of 90-day complications (P = 0.009) for
postprotocol patients.
Conclusion: Length of stay and 90-day complications for elective
spine surgery improved after implementation of an evidence-based
perioperative protocol. Standardization efforts can improve quality
and reduce costs, thereby improving the value of spine care.
Level of Evidence: Level III (retrospective review of prospectively
collected data)
From the Department of Neurological

Surgery (Dr. Sivaganesan, Dr. Chotai,
C urrent healthcare reform em-
phasizes quality and value.1
Postoperative outcomes including
Standardization protocols have
improved outcomes in joint replace-
ment4 and specific dimensions of
Ms. Cherkesky, and Dr. Devin), and
the Department of Orthopaedic length of stay (LOS) and complica- spine care, including deformity sur-
Surgery (Mr. Wick, Dr. Chotai, tions markedly affect the value of gery, 5-7 perioperative analgesia, 8
Dr. Stephens, and Dr. Devin), spine surgery by influencing quality thromboembolism prophylaxis,9 and
Vanderbilt University, Nashville, TN. and cost.2 Perioperative practices may infection control.10 A multidimen-
Correspondence to Dr. Devin: be an important determinant of sional perioperative protocol for
clintondevin@gmail.com postoperative spine surgery outcomes. elective lumbar fusion has also
J Am Acad Orthop Surg 2019;27: At present, perioperative practices been reported, which markedly
183-189 vary widely, presenting an opportu- improved LOS, discharge disposi-
DOI: 10.5435/JAAOS-D-17-00274 nity for quality improvement through tion, and other 30-day postopera-
development and implementation tive quality metrics.3
Academy of Orthopaedic Surgeons. of standardized perioperative care A paucity of outcome data exists
protocols.3 for perioperative protocols involving
March 1, 2019, Vol 27, No 5 183
Perioperative Spine Surgery Protocol
elective surgery for degenerative sent at the time of registry enrollment. isfaction questionnaire was used to
spine disease. This includes patient- Patients were included in this study if assess satisfaction with surgery.14
reported outcomes (PROs), which (1) they were older than 18 years; (2) Satisfaction with inpatient care was
are an important metric of spine sur- they had correlative imaging findings assessed with a 5-item Likert scale.
gery quality, and 90-day complica- for the diagnosis of stenosis, disc Patients answering “very satisfied”
tions, which are important, given herniation, spondylolisthesis, adja- or “satisfied” were considered to be
bundled care initiatives encompass- cent segment disease, or pseud- satisfied with the care they received.
ing the 90-day postacute care period. arthrosis; (3) they failed 3 months of
To address this need, we report a multimodal nonsurgical care; (4) they
multidimensional, evidence-based underwent elective surgery for cervi- Protocol Development and
perioperative protocol that was im- cal or lumbar degenerative pathol- Implementation
plemented in July 2015 across our ogy; (5) the number of levels operated A multidisciplinary team of surgi-
institution’s entire elective spine on was #4; and (6) they had com- cal and nonsurgical specialists de-
surgery practice. Perioperative prac- plete postoperative 90-day follow-up veloped the perioperative protocol,
tices, including deep vein thrombosis data. shown in Table 1, by assessing
(DVT) prophylaxis, postoperative Patient demographics, comorbid- studies and practice guidelines for
bracing treatment, bed rest after dur- ities, clinical variables, and surgical DVT prophylaxis;15-17 postopera-
otomy, drain removal, pain control, variables were captured via EMR- tive bracing treatment including
antibiotic use, postoperative imaging, based chart review and are listed in lumbar18-20 and single-level ante-
patient mobilization, and discharge Supplemental Digital Content 1, rior cervical diskectomy and fusion
planning, varied widely before proto- http://links.lww.com/JAAOS/A147. (ACDF21; no literature was avail-
col implementation. We hypothesized Postoperative LOS, discharge to able for cervical corpectomy); bed
that standardizing these dimensions of home or postacute care facility, and rest after incidental durotomy22-25;
care would improve outcomes leading 90-day complications, including re- Jackson-Pratt drain removal using
to increased value of spine care. The admission, cerebrospinal fluid leak, studies from total joint arthro-
purpose of this study was to compare implant failure, new neurologic defi- plasty26 and major breast surgery27
90-day outcomes and complications cit, pneumonia, surgical site infection, (no spine-specific literature was
before and after implementation of urinary tract infection, myocardial available); multimodal pain control
our perioperative elective spine sur- infarction, pulmonary embolism, and with extensive review of NSAID-
gery protocol. DVT, were also obtained from the related evidence;28-35 and antibiotic
EMR. use.36 The protocol also addressed
Baseline and 3-month follow-up discharge planning, postoperative
PROs were collected at clinic visits mobilization, and postoperative
Methods
or by phone interview. Validated imaging. Physician and nurse edu-
PROs collected included the EQ-5D cation sessions were used to intro-
Study Population, for quality of life,11 the Oswestry duce the protocol. Periodic review
Covariates, and Surgical Disability Index for back-related was performed by a nurse practi-
Characteristics disability12 or the Neck Disability tioner to ensure protocol adherence.
All patients undergoing elective spine Index for neck-related disability,13 The protocol was introduced in July
surgery at our institution are enrolled and numeric rating scales for back 2015. For this analysis, the patients
into a prospective, web-based, longi- and leg pain in patients with lumbar were dichotomized into preprotocol
tudinal registry. The registry has pathology and neck and arm pain in (October 2010 to June 30, 2015)
institutional review board approval, patients with cervical pathology. The and postprotocol (July 1, 2015, to
and all patients provide verbal con- North American Spine Society sat- April 30, 2016) cohorts.
Dr. Stephens or an immediate family member has received nonincome support (such as equipment or services), commercially derived
honoraria, or other non–research-related funding (such as paid travel) from Stryker and serves as a board member, owner, officer, or
committee member of AO Spine. Dr. Devin or an immediate family member serves as a paid consultant to DePuy, Exparel, and Stryker; has
received research or institutional support from DePuy and Stryker; has received nonincome support (such as equipment or services),
commercially derived honoraria, or other non–research-related funding (such as paid travel) from Medtronic Sofamor Danek; and serves
as a board member, owner, officer, or committee member of the Cervical Spine Research Society and the North American Spine Society.
None of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a
commercial company or institution related directly or indirectly to the subject of this article: Dr. Sivaganesan, Mr. Wick, Dr. Chotai, and Ms.
Cherkesky.
Ahilan Sivaganesan, MD, et al
Table 1
Evidence-based Perioperative Protocol for Elective Spine Surgery Patients
Dimension of Care Standardized Practice
Thromboembolism prophylaxis • Common elective cases: mechanical DVT prophylaxis only with sequential
compression devices or graduated compression stockings
• Chemoprophylaxis reserved for combined anterior and posterior surgeries, trauma,
spinal cord injury, tumor, and hypercoagulable state
• Encourage early and frequent ambulation
Postoperative bracing treatment • Lumbar fusion: no bracing treatment
• Single-level ACDF: No routine use of collar, soft collars for comfort
• Cervical corpectomy: hard collar until follow-up
Bed rest after durotomy • Immediate mobilization if water-tight primary closure achieved
• 24-hour bed rest only if primary repair is poor
• Patients should lay flat only if symptoms arise
Drain removal • When output ,100 mL/shift or postoperative day #2, whichever comes first
• Exception if large estimated blood loss, coagulopathy, or infection
Pain control • Multimodal preoperative and postoperative regimens use acetaminophen,
gabapentin, celecoxib, as needed, and long-acting narcotics, as needed
antispasmodic
• Specific multimodal regimens for opioid-naive and opioid-tolerant patients
Antibiotics • Single preoperative dose; intraoperative redosing after 3–4 hr
• Patients with comorbidities or undergoing complex surgery receive gram-negative
coverage, intrawound vancomycin powder, and postoperative regimen
• Drains not used to reduce infection rates after single-level surgery
Discharge planning • Begin before surgery
Patient mobilization • Begin on postoperative day 1
Postoperative imaging • Surgeons encouraged to limit the number of postoperative radiographs
ACDF = anterior cervical diskectomy and fusion, DVT = deep vein thrombosis
Statistical Analysis cervical spine surgery. Multivariable separate multivariable linear regres-
Mean and standard deviation were analysis was conducted for the out- sion model was fitted for LOS. All
calculated for continuous variables. comes that were markedly different the independent variables included
Frequency and percentage were cal- on bivariate analysis. in model for complications were
culated for categoric variables. A multivariable logistic regression included in the LOS model. Surgical
Nominal data between preprotocol model was fitted for 90-day com- approach, which may have a sub-
and postprotocol cohorts were complications. The independent vari- stantial effect on complications and
pared using the chi-square test, and ables included in the model were LOS, was included in the models as a
the Student t-test was used to determined a priori, including age, covariate. We did not include inter-
compare continuous variables. Var- American Society of Anesthesiolo- action terms for surgical approach
iables included in the bivariate gists grade, BMI, duration of pre- because this would have underpow-
analysis were selected based on operative narcotic use, sex, race (eg, ered the overall study. All analyses
known associations with postopera- white, African American, other), were performed using SPSS version
tive complications and outcomes. hypertension, diabetes, coronary 23.0 (SPSS, IBM), with level of sig-
Preoperative employment status, artery disease, congestive heart fail- nificance set at P , 0.05.
smoking status, body mass index ure, chronic obstructive pulmonary
(BMI), and race represent socioeco- disease, atrial fibrillation, location
(eg, lumbar, cervical spine present-
Results
nomic status,37 which has been
associated with increased rates of ing with radiculopathy, cervical
complications and LOS.38 The out- spine presenting with myelopathy), Study Population,
comes were compared between presurgical approach (eg, ACDF, Covariates, and Surgical
and post-protocol cohorts for all microdiskectomy, laminectomy alone, Characteristics
the patients and for subgroups of laminectomy and fusion), and A total of 1,747 patients, including
patients undergoing lumbar and preprotocol versus postprotocol. A 1,596 in the preprotocol cohort and
March 1, 2019, Vol 27, No 5 185
Table 2 The postprotocol cohort had a signif-

icantly greater proportion of patients
Satisfaction After Lumbar and Cervical Spine Surgery
with symptom duration for .12
NASS Surgery Preprotocol Postprotocol months before surgery (P = 0.015),
Satisfaction (N = 1,579) (N = 151) P Value
a higher rate of chronic obstructive
Satisfied (NASS 1 and 2) 1,391 (88.1%) 136 (90.1%) 0.285 pulmonary disease (P = 0.024),
Less satisfied (NASS 3 and 4) 188 (11.9%) 15 (9.9%) — lower mean estimated blood loss
(EBL; P = 0.012), and lower base-
Satisfaction With Preprotocol Postprotocol line Oswestry Disability Index
Inpatient Care (N = 1,409) (N = 149) P Value (P = 0.014). No other significant
Satisfaction with provider 1,335 (94.7%) 142 (95.3%) 0.567
differences in baseline demographics,
comorbidities, or surgical character-
Satisfaction with nursing staff 1,279 (90.1%) 138 (92.6%) 0.283
istics were observed.
NASS = North American Spine Society
P = 0.05 is significant.
Outcomes
Table 3 The 90-day complications for the
preprotocol and postprotocol co-
Subanalysis of 90-day Outcomes for Lumbar Surgery Patients
horts are summarized in Table (see
Preprotocol Postprotocol Supplemental Digital Content 2,
Outcome Measure (N = 1,132) (N = 106) P Value
LOS 2.9 6 2.2 2.5 6 1.7 0.021 The overall complication rate was
Discharge to postacute care facility 143 (12.6%) 13 (12.3%) 0.473 significantly lower in the post-
Complications 145 (12.8%) 4 (3.8%) 0.002 protocol cohort (4.6% versus
Readmission rate 64 (5.6%) 3 (2.8%) 0.157 11.3%; P = 0.005); however, the
EuroQol-5 dimensions 0.77 6 0.21 0.76 6 0.22 0.488 frequency of each individual com-
Oswestry Disability Index 26.7 6 18.1 25.7 6 19.1 0.561 plication was too low to derive any
Numeric rating scale–leg pain 2.7 6 3.1 2.8 6 3.2 0.653 meaningful comparisons. No differ-
Numeric rating scale–back pain 3.2 6 2.5 3.3 6 3.1 0.523
ence was noted in satisfaction with
outcomes of the North American
LOS = length of stay Spine Society satisfaction question-
P # 0.05 is significant. naire or satisfaction with care
between the preprotocol and post-
Table 4 protocol cohorts, as shown in Table
2. There was also no significant
Subanalysis of 90-day Outcomes for Cervical Surgery Patients
difference in the readmissions rate,
Preprotocol Postprotocol with a total of 75 patients (4.7%)
Outcome Measure (N = 464) (N = 45) P Value
readmitted before protocol im-
LOS 1.9 6 1.7 1.8 6 1.6 0.124 plementation and 5 patients (2.3%)
Discharge to postacute care facility 29 (6.3%) 5 (11.1%) 0.187 readmitted after protocol im-
Complications 35 (7.5%) 3 (6.7%) 0.561 plementation (P = 0.295).
Readmission 11 (2.4%) 2 (4.4%) 0.322 Tables 3 and 4 summarize out-
EuroQol-5 dimensions 0.75 6 0.19 0.73 6 0.16 0.496 comes among lumbar and cervical
Neck Disability Index 25.8 6 19.4 25.8 6 16.2 0.988 patients within the preprotocol and
Numeric rating scale–arm pain 2.2 6 3.1 2.0 6 2.8 0.693
postprotocol cohorts. Patients un-
dergoing lumbar surgery had signif-
Numeric rating scale–neck pain 3.4 6 2.8 3.5 6 2.7 0.915
icantly shorter LOS (2.5 6 1.7 days
LOS = length of stay versus 2.9 6 2.2 days; P = 0.021)
P # 0.05 is significant. and lower complication rates (3.8%,
versus 12.8%; P = 0.002) after pro-
151 in the postprotocol cohort, were teristics are summarized in Table (see tocol implementation. No signifi-
analyzed. Baseline demographics, Supplemental Digital Content 1, cant changes were noted in PROs
comorbidities, and surgical charac- http://links.lww.com/JAAOS/A147). between the preprotocol and
postprotocol lumbar subgroups. For implementation had significantly LOS were markedly lower in patients
the cervical spine subgroup, no lower LOS compared with the pre- undergoing surgery after protocol
significant differences in LOS, dis- protocol cohort (P = 0.013). implementation, confirming our
charge disposition, complications, hypothesis that standardizing peri-
readmissions, or PROs were noted operative care would improve out-
between the preprotocol and post- Conclusion comes and increase value of spine care.
protocol cohorts. To date, standardized protocols
Quality improvement initiatives have have demonstrated efficacy in
driven the implementation of several improving value of care for patients
Multivariable Logistic bundles and protocols to improve undergoing knee arthroplasty and
Regression Analysis for 90- the overall value of spine care.3,5-10 cardiac surgery.4 Similarly, consis-
day Complications We introduced a multidimensional tent adherence to the best practices
Supplemental Digital Content 3, institution-wide standardized proto- for perioperative spine care has the
http://links.lww.com/JAAOS/A149 col focusing on perioperative care for potential to reduce costs related to
summarizes the odds ratios (OR) and patients undergoing elective surgery unnecessary procedures, rates of
P values for variables associated for degenerative spine disease. This complications, and prolonged hos-
with 90-day complications. Patients study includes bivariate and multi- pital stays. Using an evidence-based
with a history of diabetes had higher variate analyses to compare 90-day best practice protocol, we success-
odds of 90-day complications (OR = outcomes between patients under- fully reduced LOS and complica-
1.455; P = 0.046). Males (OR = going surgery before and after im- tions, which are crucial determinants
0.675; P = 0.018) and patients plementation of the protocol. In of quality and cost of care.2 Specifi-
undergoing surgery after protocol bivariate analyses, no differences cally, LOS among the cohort of pa-
implementation had significantly between the pre- and post-protocol tients undergoing lumbar surgery
lower odds of having 90-day com- cohorts were noted in socioeconomic was reduced by a mean of 0.4 days,
plications (OR = 0.327; P = 0.009). status, represented by preoperative or 9.6 hours, after protocol im-
employment, smoking status, BMI, plementation. Although seemingly
and race, or in level of surgical small, this significant decrease in LOS
Multivariable Linear invasiveness, represented by primary may nonetheless reduce patients’ risks
Regression Analysis for diagnosis and surgical approach. This of adverse outcomes including expo-
Length of Stay phenomenon suggests that socioeco- sure to antibiotic resistant organisms,
The model constant, beta coefficient, nomic status and level of surgical nosocomial infections, pressure ulcers,
and P value for variables associated invasiveness did not influence study in-hospital falls, and delirium. In
with increased LOS are provided in results. An additional important result addition, our results are significant
Supplemental Digital Content 3, is found in the comparison of pre- and because they highlight the feasibility
http://links.lww.com/JAAOS/A149. post-protocol LOS among lumbar and safety of introducing standardi-
Older age (P , 0.0001), higher patients and comparison of EBLs zation protocols within spine surgery.
American Society of Anesthesiologists between pre- and post-protocol co- For example, our results can help allay
grades (P = 0.006), higher BMI (P = horts. For both of these variables, the concerns that standardizing drain
0.01), increased duration of preoper- standard deviation was smaller in removal practices could lead to in-
ative opioid use (P , 0.0001), and the postprotocol group. This finding creased rates of hematoma formation
comorbidities including atrial fibrilla- is surprising because the post- with subsequent neurologic deficits or
tion (P , 0.0001) and coronary artery protocol group had a much smaller that early mobilization or restriction of
disease (P = 0.039) were associated patient population and therefore postoperative bracing treatment may
with increased LOS. With regard to would be expected to have a larger result in increased rates of implant
surgical variables, patients undergoing standard deviation for LOS and failure. Moreover, the markedly lower
lumbar surgery had longer LOS EBL. The smaller standard devia- overall incidence of complications
compared with those undergoing cer- tions among the postprotocol group among the postprotocol cohort proves
vical spine surgery. Furthermore, compared with the preprotocol that a standardization protocol using
laminectomy and fusion was associ- group suggest that the protocol evidence-based practices may help
ated with longer LOS, followed by had a positive influence on reducing reduce complications that are linked to
laminectomy alone, microdiskectomy, variation between providers. In the increased costs, subsequently increas-
and ACDF (P , 0.0001). Patients multivariable analyses, the risking the value of surgery for degenera-
undergoing surgery after protocol adjusted 90-day complications and tive spine pathology.
March 1, 2019, Vol 27, No 5 187
Our protocol is unique in that it are intended to encompass all costs, protocol to standardize perioperative
addresses aspects of perioperative including those related to complica- care in elective surgery for degenera-
care throughout the patient’s hospital tions, within the 90-day postacute tive spine disease was associated with
admission. In contrast, most previ- care period.1 maintained clinical effectiveness,
ously reported spine surgery proto- This study is based on data from a decreased LOS, and fewer overall
cols have focused on specific single institution, which may limit 90-day complications.
dimensions of care, including peri- generalizability. We do not have data In conclusion, we report improve-
operative analgesia,8 thromboembo- quantifying protocol adherence; ments in length of stay and compli-
lism prophylaxis,9 and perioperative however, a designated nurse practi- cation rates, as well as maintained
infection control.10 In addition, our tioner regularly reviewed protocol PROs and satisfaction scores for
study provides an important contri- adherence. We did not account for elective spine surgery after the launch
bution to the literature by reporting surgeon-level variability, but this is of an evidence-based perioperative
on a protocol for patients undergoing less likely to have influenced our re- protocol at our institution. PROs and
elective surgery for degenerative sults because a recent study has shown satisfaction represent quality, and
disease, whereas most previously surgeon-level variability to have no complications are linked to costs.
reported multidimensional spine significant effect on outcomes or Therefore, because healthcare value
surgery protocols have been specific complication rates among a pop- equals quality divided by costs, our
for deformity and other high-risk ulation of patients undergoing elective results demonstrate that standardi-
spine surgeries.5-7,39 We are aware lumbar decompression and fusion.40 zation efforts can improve the overall
of only one other report of a multi- Another limitation is that we did not value of surgery for degenerative
dimensional perioperative protocol perform a subgroup analysis based spine disease.
for patients undergoing elective sur- on surgical approach. Although we
gery for degenerative spine disease. In included surgical approach as a co-
this study, Bradywood et al com- variate in our multivariate regression References
pared 30-day outcomes for lumbar models, we did not include interac-
fusion between 214 patients treated tion terms to avoid underpowering Evidence-based Medicine: Levels of
before and 244 patients treated after the analysis. A randomized trial of a evidence are described in the table of
implementation of an evidence-based protocol such as ours, designed from contents. In this article, reference 13
protocol that included multimodal the outset for subgroup analyses is a level I study. References 15-16
analgesia, postoperative bracing treat- based on the surgery type, will and 27 are level II studies. References
ment, postoperative imaging, and be a next step for our group. A ran- 5-6, 8-10, 14, 18, 20-22, 30-35, and
discharge planning. Patients treated domized trial may also allow us to 39 are level III studies. References
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March 1, 2019, Vol 27, No 5 189
Research Article
Objective Predictors of Grit, Self-

Control, and Conscientiousness in
Orthopaedic Surgery Residency
Applicants
Abstract
Christopher L. Camp, MD Introduction: The purpose of this study was to identify objective
Dean Wang, MD predictors of grit, self-control, and conscientiousness in orthopaedic
surgery residency applicants.
Norman S. Turner, MD
Methods: The following attributes were assessed in 455 applicants:
Brian M. Grawe, MD grit, self-control, conscientiousness, consistency of interest,
Monica Kogan, MD perseverance of effort, and ambition. These measures were
Anne M. Kelly, MD correlated with standard, objective demographics obtained during the
application process.
Results: Alpha Omega Alpha status, additional degrees, and number
of publications did not predict any of the studied attributes. Grit
increased with age (P , 0.001) but decreased with increasing board
scores (P = 0.004). Former collegiate athletes demonstrated greater
From the Department of Orthopedic grit (P , 0.001), consistency of interest (P = 0.007), perseverance
Surgery and Sports Medicine, Mayo
Clinic, Rochester, MN (Dr. Camp), the (P = 0.006), and self-control (P = 0.019). Female applicants
Sports Medicine and Shoulder demonstrated more grit (P = 0.044), consistency of interest
Service, Hospital for Special Surgery, (P = 0.003), and conscientiousness (P = 0.029) than males.
New York, NY (Dr. Wang and
Dr. Kelly), the Department of Applicants with military experience had increased ambition
Orthopedic Surgery, Mayo Clinic, (P = 0.033) and conscientiousness (P = 0.001).
Rochester, MN (Dr. Turner), the
Conclusion: Overall, orthopaedics applicants possess increased grit
Department of Orthopedics,
University of Cincinnati, Cincinnati, compared with the general public, and a number of objective variables
OH (Dr. Grawe), and the Department reliably predicted the studied attributes.
of Orthopedic Surgery, Rush
University Medical Center, Chicago,
Level of Evidence: Level III, Cross-sectional study
IL (Dr. Kogan).
Correspondence to Dr. Camp:

camp.christopher@mayo.edu

I n recent years, particularly since
the introduction of the 80-hour
workweek, the number of applicants
tivity (number of publications) of
applicants are on the rise.5 Concur-
rent with this trend of heightened
received anything of value from or has for orthopaedic surgery residency has academic qualifications of applicants,
stock or stock options held in a increased annually.1 During this a great deal of effort has been dedi-
time, the number of available posi- cated to identifying other factors that
subject of this article: Dr. Camp, tions has remained relatively stable, may predict future success in ortho-
Dr. Wang, Dr. Turner, Dr. Grawe, which has resulted in an increasingly paedic surgery residency. These fac-
Dr. Kogan, and Dr. Kelly. competitive application process for tors include, but are not limited to,
J Am Acad Orthop Surg 2019;27: medial students in which 28% (287 Alpha Omega Alpha (AOA) honor
e227-e234 of 1,013) of orthopaedic applicants society status, class rank, clinical grades,
DOI: 10.5435/JAAOS-D-17-00545 went unmatched in 2017.1-4 As a military status, athletic achievement,
result, the mean United States Med- letters of recommendation, orthopaedic
Academy of Orthopaedic Surgeons. ical Licensing Examination (USMLE) clerkship evaluations, and performance
Step 1 scores and academic produc- on interview day.3,6-10 Although many
March 1, 2019, Vol 27, No 5 e227
Objective Predictors of Grit, Self-Control, and Conscientiousness
of these provide objective measures decisiveness, competence, and self- Grit Scale, 10 item Self-Control Scale,
of applicant aptitude, most fall short of discipline.25 The traits are clearly and the 9-item Conscientiousness
reliably predicting future resident desirable in orthopaedic residents, Scale were electronically adminis-
and surgeon success. Although the and deficiencies in these areas can tered to all students applying for
cognitive, academic measures (eg, place resident education and patient orthopaedic surgery positions at one
USMLE scores, grades, AOA status) care at risk. Short questionnaires have of the four participating study in-
reliably predict future academic and been developed and validated to stitutions (eg, Mayo Clinic, Hospital
testing performance,8,11,12 these quantify each of these personality for Special Surgery, Rush University
data points tell us very little about characteristics.15,24,25 Medical Center, University of Cin-
critical, “noncognitive” variables such Although these traits seem desir- cinnati) during the 2017 National
as interpersonal skills, self-control, able in applicants to orthopaedic Resident Matching Program. These
moral reasoning, and conscientious- surgery residency programs, very lit- were administered after applications
ness.3,13,14 These variables are often tle is known about baseline levels of were submitted but before match day.
termed psychometric and can be very grit, self-control, and conscientious- Each of these scales has been previ-
difficult to quantify. ness in this population. One method ously published and validated.15,24,25
One noncognitive variable that has for assessing these qualities would be Each is based on a five-point scale in
gained notable attention recently is to administer the questionnaires to which five represents the highest
“grit,” which is defined by Duckworth applicants during the interview or possible score (eg, most grit, self-
et al15 as steadfast passion and per- application process. However, if an control, conscientiousness) and one
severance for long-term goals, par- applicant knows that a questionnaire represents the lowest possible score
ticularly in the setting of hardship will be used to determine their suit- (eg, minimal grit, self-control, con-
and setbacks. Outside of the medical ability as a potential resident, notable scientiousness). Only questionnaires
community, grit scores (ie, compiled desirability bias is introduced. Ap- that were answered in their entirety
from a grit scale questionnaire) have plicants may knowingly or unknow- were included in the analysis. All
demonstrated a consistent ability to ingly inflate their responses to appear scales were administered and ana-
predict graduation rates for cadets in more favorable in the eyes of the lyzed in a completely anonymous and
the US Military Academy, advance- programs to which they are applying. deidentified fashion. Applicants were
ment to the final rounds of the To overcome this potential limita- made aware that the information was
Scripps National Spelling Bee, grad- tion, objective measures of these being collected anonymously and
uation rates for at-risk students in traits that are less subject to bias are that their answers would have no
inner-city high schools, and pro- needed. Accordingly, the purposes of bearing on their application or status
ductivity for individuals in the sales this multicenter study were to (1) at any of the participating institutions.
industry.15-18 Within the medical quantify and characterize grit, self- Accordingly, they were encouraged to
community, higher grit scores have control, and conscientiousness in answer all questions in a truthful and
correlated with greater surgical resi- orthopaedic surgery applicants and accurate manner.
dent well-being,19 lower surgical res- (2) correlate these scores with objec- In addition to the previously vali-
ident attrition rates,20,21 decreased tive measures commonly obtained dated scales, a number of personal
burn-out for attending surgeons,22 through the standard application and academic applicant demographics
and higher rates of career satisfaction process such as applicant demo- were assessed. Personal demographics
for rural physicians.23 Along with graphics, USMLE scores, and AOA included age, sex, current or previous
grit, two other traits known to cor- status. It is our hope that this work military experience, previous partici-
relate with future academic and per- will allow program directors and ed- pation in varsity collegiate athletics,
sonal success are self-control and ucators to better objectively identify desired future practice setting, de-
conscientiousness.24,25 Previous work desirable personality traits in appli- sired future fellowship, and whether
has demonstrated that learners with cants and assign appropriate weight the applicant felt that the 80-hour
greater degrees of self-control obtain to the standard applications mea- work week restriction was reason-
higher grades, display more profes- sures already in widespread use. able and appropriate. Academic var-
sional behavior, are less likely to iables included USMLE Step 1 score,
abuse alcohol, have better interper- AOA status, additional graduate
sonal relationships, and react with Methods degrees, and the number of peer-
more optimal emotional responses.24 reviewed publications in print.
Similarly, conscientiousness has been After approval of the institutional The 17-item Grit scale was used to
correlated with orderliness, reliability, review boards at all sites, the 17-item calculate scores for overall grit and
Christopher L. Camp, MD, et al
the following three subscales: Con- Figure 1

sistency of Interest, Perseverance, and
Ambition. Self-control and conscien-
tiousness were calculated from their
respective full scales. For each mea-
sure, the highest possible score was 5,
and the lowest possible score was 1.
Scores were then compared across the
different demographic and academic
variables studied.
Descriptive statistics are used to
report basic measures such as number,
mean (6SD), range, and median. As age increased, a significant increase was noted in the grit score (P , 0.001;
Pairwise comparisons of continuous adjusted R2 = 0.03) (A); however, as USMLE Step 1 Scores increased, grit score
decreased (P = 0.004; adjusted R2 = 0.02) (B). USMLE = United States Medical
variables were performed using a two- Licensing Examination
tailed Student t test. These results are
reported with their corresponding
mean differences (MD), 95% confi- AOA, and 96 (21.1%) had obtained for every 20 point decrease in the
dence intervals (CIs), and P values. To at least one graduate degree in addi- board score. Age did not correlate
compare the mean values of continu- tion to their medical degree. Three with self-control (P = 0.067) or
ous variables across three or more hundred eighty-six applicants (84.8%) conscientiousness (P = 0.706); and
groups, analysis of variance was per- agreed with the statement that the the same was observed for USMLE
formed. When analysis of variance “current 80-hour work week restric- scores (P = 0.332 for self-control and
demonstrated statistical significance, tion was appropriate and reasonable.” P = 0.676 for conscientiousness).
post hoc Tukey testing was performed Regarding desired future practice type, A detailed analysis of grit based on
to assess for pairwise differences. To 124 (27.3%) desired an academic applicant demographics is provided
understand the relationship of out- practice, 135 (29.7%) wanted a pri- in Table 1. Women demonstrated
comes across continuous variables vate practice, 185 (41.7%) desired a increased grit compared with men
such as age and USMLE scores, linear hybrid between the two, and 11 (4.20 versus 4.11; MD, 0.09; 95%
regression analyses was performed. (2.4%) wanted a hospital-employed CI, 0.01 to 0.18; P = 0.004), and they
These results are reported with their position. The average number of peer- had less variability in their grit scores
corresponding P values. Only P , reviewed publications for this cohort (range, 3.33 to 4.83) compared with
0.05 were considered to represent was 3.9 6 7.6 (median, 2), but the men (range, 2.50 to 4.92) (Figure 2,
statistical significance. range was broad (zero to 93). A). For the grit subscales, females
Overall, the mean grit score was had greater consistency of interest
4.12 6 0.38, which places the (3.90 versus 3.72; P = 0.003) and
Results applicant pool in the 70th percentile conscientiousness (4.58 versus 4.48;
for grit compared with the general, P = 0.029) than their male counter-
A total of 455 applicants completed adult population.15 A statistically parts, but no differences were noted
the scales in their entirety, for an significant relationship was noted in perseverance of effort or ambition.
overall completion rate of 50.8% between age and grit, with older Self-control was similar between the
(455 of 895). Of these, 92 (20.2%) applicants possessing more grit than sexes (Table 2; Figure 2, A), but
were women, and 363 (79.8%) were younger applicants (estimate, 0.028; females scored higher in conscien-
men. The mean age was 27.3 6 2.4 P , 0.001) (Figure 1, A). Grit in- tiousness (4.58 versus 4.48; MD,
years, and the range was 23 to 46 creased by 0.14 points (ie, approxi- 0.10; 95% CI, 0.01 to 0.20; P =
years (median, 27 years). The aver- mately 7 percentile points) for every 0.029) (Table 3; Figure 2, A).
age USMLE Step 1 score was 244 6 5-year increase in age. The opposite Former collegiate varsity athletes
13.8 (range, 194 to 276). A total of was seen for USMLE Step 1 scores as were grittier than nonathletes (4.21
171 applicants (37.6%) participated higher scores actually correlated with versus 4.08; MD, 0.13; 95% CI, 0.06
in varsity athletics while in college, and lower grit scores (estimate, 20.004; to 0.20; P , 0.001) (Table 1; Figure
17 (3.7%) had previous or current P = 0.004) (Figure 1, B). This corre- 2, B). In addition, they demonstrated
military experience. A total of 167 lated to a 0.07 point (approximately increased consistency of interest (3.8
applicants (40.5%) were members of 3.5 percentile points) increase in grit versus 3.70; P = 0.007), perseverance
March 1, 2019, Vol 27, No 5 e229
Table 1
Comparison of Grit Scores Based on Different Applicant Characteristics
Variable N % Mean SD Range Median MD 95% CI P Value
Overall 455 100.0 4.12 60.38 2.50-4.92 4.17 — — —

Sex
Female 92 20.2 4.20 60.35 3.33-4.83 4.25 0.09 0.01 to 0.18 0.044
Male 363 79.8 4.11 60.39 2.50-4.92 4.17 — — —
Varsity college sports ,0.001
Yes 171 37.6 4.21 60.39 2.67-4.92 4.25 0.13 0.06 to 0.20 —
No 284 62.4 4.08 60.37 2.50-4.83 4.17 — — —
AOA status 0.166
Yes 167 40.5 4.09 60.39 2.58-4.92 4.17 0.05 20.02 to 0.13 —
No 245 59.5 4.14 60.38 2.50-4.92 4.17 — — —
Military experience 0.957
Yes 17 3.7 4.12 60.50 3.00-4.83 4.25 0.01 20.17 to 0.19 —
No 438 96.3 4.13 60.37 2.50-4.92 4.17 — — —
No. of publications 0.732
0 103 22.6 4.10 60.36 3.08-4.92 4.17 — — —
1-3 225 49.5 4.13 60.38 2.67-4.92 4.17 — — —
3 or more 127 27.9 4.14 60.40 2.50-4.83 4.17 — — —
AOA = Alpha Omega Alpha, CI = confidence interval, MD = mean difference

Bold and italicized P values indicate statistical significance (P , 0.05).
Figure 2
Comparison of grit, self-control, and conscientiousness between females and males (A), college athletes and nonathletes
(B), and applicants with and without military experience (C). *Statistically significant differences were P , 0.05. For each
plot, the horizontal line represents the mean, the box represents the 25th to 75th percentiles, and the bars
represent minimum and maximum scores.
of effort (4.56 versus 4.46; P = They were also more ambitious (4.44 experience had greater ambition (4.59
0.006), and self-control (3.97 versus versus 4.29; P = 0.019) and had versus 4.37; P = 0.033) and were more
3.85; P = 0.019) (Table 2). greater self-control (4.00 versus 3.81; conscientious (4.73 versus 4.49; P =
Those desiring an academic prac- P = 0.006) than those wanting to 0.001) (Table 3).
tice had more consistency of interest enter private practice. No significant correlations were
(3.88) than applicants desiring hy- Finally, military status did not cor- found for any of the scales (eg, grit,
brid (3.71; P = 0.029) or private relate with grit (Table 1; Figure 2, C); self-control, conscientiousness) or
practice settings (3.71; P = 0.025). however, applicants with military subscales (eg, consistency of interest,
Table 2
Comparison of Self-control Scores Based on Different Applicant Characteristics
Overall 455 100.0 3.9 60.52 2.1-5.0 3.90 — — —

Sex 0.529
Female 92 20.2 3.93 60.58 2.2-5.0 3.95 0.04 20.08 to 0.16 —
Male 363 79.8 3.89 60.51 2.1-5.0 3.90 — — —
Varsity college sports 0.019
Yes 171 37.6 3.97 60.52 2.2-5.0 4.00 0.12 0.02 to 0.22 —
No 284 62.4 3.85 60.52 2.1-5.0 3.90 — — —
AOA status 0.157
Yes 167 40.5 3.93 60.50 2.2-5.0 4.00 0.07 20.03 to 0.17 —
No 245 59.5 3.86 60.53 2.1-5.0 3.90 — — —
Yes 17 3.7 3.93 60.59 3.1-5.0 3.80 0.04 20.21 to 0.29 —
No 438 96.3 3.89 60.52 2.1-5.0 3.90 — — —
0 103 22.6 3.90 60.51 2.2-4.9 3.90 — — —
1-3 225 49.5 3.87 60.53 2.2-5.0 3.90 — — —
3 or more 127 27.9 3.93 60.51 2.1-5.0 4.00 — — —

Table 3
Comparison of Conscientiousness Scores Based on Different Applicant Attributes
Overall 455 100.0 4.50 60.44 1.1-5.0 4.56 — — —

Sex 0.029
Female 92 20.2 4.58 60.36 3.2-5.0 4.67 0.10 0.01 to 0.20 —
Male 363 79.8 4.48 60.46 1.1-5.0 4.56 — — —
Varsity college sports 0.222
Yes 171 37.6 4.54 60.51 1.1-5.0 4.56 0.06 20.02 to 0.14 —
No 284 62.4 4.48 60.40 3.2-5.0 4.56 — — —
AOA status 0.754
Yes 167 40.5 4.51 60.46 1.1-5.0 4.56 0.01 20.08 to 0.10 —
No 245 59.5 4.50 60.43 1.2-5.0 4.56 — — —
Yes 17 3.7 4.73 60.24 4.2-5.0 4.78 0.24 0.24 to 0.46 —
No 438 96.3 4.49 60.45 1.1-5.0 4.56 — — —
0 103 22.6 4.53 60.39 3.2-5.0 4.56 — — —
1-3 225 49.5 4.51 60.43 1.1-5.0 4.56 — — —
3 or more 127 27.9 4.47 60.50 1.2-5.0 4.56 — — —

March 1, 2019, Vol 27, No 5 e231
perseverance of effort, ambition) is a term used to describe learners This relationship is one that has long
with the following variables: addi- who “desire to learn and develop been suspected anecdotally; however,
tional graduate degrees, AOA their abilities, pursue challenges, it has never been quantified in this
status, number of publications, or value effort, and are resilient to set- population of applicants. Regardless,
agreement/disagreement with the backs.”26 Clearly, possession of a it is a criterion that is commonly used
80-hour workweek restriction. growth mindset and high levels of in the evaluation and ranking of ap-
grit are desirable characteristics in plicants,3,8,9,30,31 and the current
orthopaedic surgery residents; how- study supports this practice. On a
Discussion ever, these are certainly not the only similar note, applicants with military
factors to be considered. This is experience were more ambitious and
Although a number of objective particularly true for applicants with conscientious than those without, and
measures exist that programs can use decidedly low USMLE scores. Even this was the greatest MD (0.24) of
to assess the academic and test-taking if they have higher levels of grit, a any comparison in the study. These
potential of orthopaedic applicants, number of studies have demonstrated qualities in athletes and military per-
much less is known about critical, that low USMLE scores are predictive sonnel are intuitive because these
noncognitive domains such as of grit, of poor performance on the Ortho- processes generally require discipline,
self-control, and conscientiousness. paedic In-Training Examination and strong interpersonal skills, a mental-
Each of these qualities is desirable in higher failure rates for the American ity of teamwork, and sustained effort
orthopaedic residents, but reliable Board of Orthopaedic Surgeons Part I for long-term goals.
predictors of these traits have not yet Board Examination.11,27,28 There are a number of limitations to
been identified. In this work, appli- When applicants were compared this work that merit discussion.
cants to orthopaedic surgery resi- based on sex, females outscored males Although the completion rate of
dency programs were found to have a in three of the six scales/subscales 50.8% is higher than many similar
mean grit score of 4.12, which would tested. These included grit, consis- cross-sectional studies, there is a
place them in the 70th percentile of the tency of interest, and conscientious- potential for selection bias among the
general population. The factors that ness. Although the difference in grit applicants who were willing and able
were most predictive of high levels of between the sexes was small at 0.1 to complete the assessment in its
grit were increasing age, lower board points, this represents a change of 5 entirety. This may have potential to
scores, female sex, and a history of percentile points compared with the artificially inflate the mean scores of
participation in collegiate athletics. general public (ie, 75th percentile for the outcomes measures. In addition,
Although current or former military females and 70th percentile for males). this work is limited in that it does not
experience was not associated with It is also worth noting that the range of follow these applicants longitudinally
increased grit, it did correlate with grit was tighter for females (Figure 2, to see which ultimately were success-
higher levels of conscientiousness and A). Ultimately, 18% (67 of 363) of fully able to match. Similarly, it does
ambition. male applicants were below the 50th not measure future performance in
One of the more notable findings of percentile for grit (compared with the residency or beyond. Instead, this
this work was the relationship of grit general population) versus 12% (11 work provides predictors for impor-
to age (ie, reciprocative) and USMLE of 92) of females who fell below that tant noncognitive variables at the time
Step 1 scores (ie, inverse). Most ap- mark. The increased grit observed in of application. Finally, it is important
plicants to orthopaedic programs female applicants may be a key to point out that although many vari-
were aged 25 to 29 years, and their influence in their decision to enter ables (eg, AOA status, number of
board scores ranged from 230 to 258. into a field that has historically been publications, additional graduate de-
Accordingly, applicants older than comprised a male majority.29 grees) did not correlate with the
30 years or those with board scores The single variable that was pre- desired attributes, these factors can still
under 230, tend to be outliers from dictive of increased scores across the have an important role in the selection
the majority because they are outside most scales/subscales was participa- process. An area of further exploration
the standard deviation. Their will- tion in collegiate varsity athletics (ie, may reside in publication status of
ingness to pursue the same goal as markedly increased scores in four of the applicant, considering how broad
more traditional applicants may be a the six scales/subscales). Those with the range was within this study. Future
direct reflection of their higher levels an athletic background demonstrated work can hone in on whether grittier
of grit. This finding may be an indi- greater grit, consistency of interest, applicants trend toward more ortho-
cator that these outlying applicants perseverance of effort, and self-control paedic publications while in medical
may posses a growth mindset, which compared with all other applicants. school, rather than those that have
published in other fields or during 1. Anakwenze OA, Kancherla V, Baldwin K, surgery resident applicant. J Bone Joint
Levine WN, Mehta S: Orthopaedic Surg Am 2014;96:e151.
their undergraduate years. residency applications increase after
implementation of 80-hour workweek. Clin 14. Ranasinghe P, Ellawela A, Gunatilake SB:
Orthop Relat Res 2013;471:1720-1724. Non-cognitive characteristics predicting
academic success among medical students
Conclusions 2. Camp CL, Sousa PL, Hanssen AD, et al: in Sri Lanka. BMC Med Educ 2012;12:66.
The cost of getting into orthopedic
15. Duckworth AL, Peterson C, Matthews MD,
Ultimately, a number of objective residency: Analysis of applicant
Kelly DR: Grit: Perseverance and passion
demographics, expenditures, and the value
characteristics and demographics of away rotations. J Surg Educ 2016;73:
for long-term goals. J Pers Soc Psychol
2007;92:1087-1101.
were identified as predictors of grit, 886-891.
self-control, and conscientiousness 16. Eskreis-Winkler L, Shulman EP, Beal SA,
3. Schenker ML, Baldwin KD, Israelite CL,
Duckworth AL: The grit effect: Predicting
among a large cohort of applicants to Levin LS, Mehta S, Ahn J: Selecting the best
retention in the military, the workplace,
and brightest: A structured approach to
US orthopaedic surgery residency orthopedic resident selection. J Surg Educ
school and marriage. Front Psychol 2014;5:
programs. The mean grit score of all 1-12.
2016;73:879-885.
respondents placed them in the 70th 4. Results and Data: 2017 Main Residency
17. Duckworth AL, Quinn PD: Development
and validation of the Short Grit
percentile of all adults, and even Match. Match National Resident Scale (Grit–S). J Pers Assess 2009;91:
higher levels of grit were observed in Matching Program, 2017;4. http://www. 166-174.
nrmp.org/wp-content/uploads/2017/04/
females and collegiate athletes, older Main-Match-Results-and-Data-2017. 18. Robertson-Kraft C, Duckworth AL: True
applicants, and those with lower pdf. Accessed November 1, 2017. Grit: Trait-level perserverance and
USMLE Step 1 scores. Former par- passion for long-term goals predicts
5. DePasse JM, Palumbo MA, Eberson CP, effectiveness and retention among novice
ticipation in varsity collegiate sports Daniels AH: Academic characteristics of teachers. Teach Coll Rec (1970) 2014;
was correlated with higher scores in orthopaedic surgery residency applicants 116:1-27.
from 2007 to 2014. J Bone Joint Surg Am
four of the six scales/subscales as- 2016;98:788-795. 19. Salles A, Cohen GL, Mueller CM: The
sessed. Females outscored males in relationship between grit and resident well-
6. Camp CL, Sousa PL, Hanssen AD, et al: being. Am J Surg 2014;207:251-254.
three of the six categories, and no Orthopedic surgery applicants: What they
significant differences were noted for want in an interview and how they are 20. Salles A, Lin D, Liebert C, et al: Grit
influenced by post-interview contact. J Surg as a predictor of risk of attrition in
the other three categories based on Educ 2016;73:709-714. surgical residency. Am J Surg 2017;213:
sex. Other factors that resulted in 288-291.
7. Orr JD, Hoffmann JD, Arrington ED,
higher scores on these noncognitive Gerlinger TL, Devine JG, Belmont PJ: 21. Burkhart RA, Tholey RM, Guinto D, Yeo
domains included previous or current Army orthopaedic surgery residency CJ, Chojnacki KA: Grit: A marker of
program directors’ selection criteria. J Surg residents at risk for attrition? Surgery 2014;
military experience and a desire to 155:1014-1022.
Orthop Adv 2015;24:120-124.
eventually practice orthopaedics in
22. Walker A, Hines J, Brecknell J: Survival
an academic setting. These data may 8. Turner NS, Shaughnessy WJ, Berg EJ,
of the grittiest? Consultant surgeons
Larson DR, Hanssen AD: A quantitative
help program directors and selection composite scoring tool for orthopaedic
are significantly grittier than their
junior trainees. J Surg Educ 2016;73:
committee identify applicants with residency screening and selection.
730-734.
Clin Orthop Relat Res 2006;449:50-55.
these desirable characteristics with-
23. Reed AJ, Schmitz D, Baker E, Nukui A,
out having to administer additional 9. Egol KA, Dirschl DR, Levine WN,
Epperly T: Association of “grit” and
Zuckerman JD: Orthopaedic residency
tests or surveys that are subject to education: A practical guide to selection,
satisfaction in rural and nonrural doctors.
desirability bias. J Am Board Fam Med 2012;25:832-839.
training, and education. Instr Course Lect
2013;62:553-564. 24. Tangney JP, Baumeister RF, Boone AL:
High self-control predicts good adjustment,
10. Dirschl DR, Campion ER, Gilliam K: less pathology, better grades, and
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RT, Weinhoeft AL, Idusuyi OB: Predictive taxonomy: History, measurement,
contents. In this article, references 2, measures of a resident’s performance on and conceptual issues, in John OP, Robins
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studies. References 1, 3, 5, 8, 10-12, Orthop J 2011;31:238-243. of Personality: Theory and Research. New
York, NY, Guilford Press, 2008.
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USMLE Step 1 score a valid predictor of Leveraging mindsets to promote
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13. Bohm KC, Van Heest T, Gioe TJ, Agel J,
those published within the past 5 Johnson TC, Van Heest A: Assessment of 27. Dougherty PJ, Walter N, Schilling P,
years. moral reasoning skills in the orthopaedic Najibi S, Herkowitz H: Do scores of the
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Research Article
Tendon Transfer Options for

Trapezius Paralysis: A
Biomechanical Study
Abstract
Jean-David Werthel, MD Introduction: The purpose of this study was to evaluate the
Eric R. Wagner, MD biomechanical effectiveness regarding scapulothoracic (ST) upward

rotation of two different tendon transfer procedures involving the
John W. Sperling, MD
levator scapulae, rhomboid major, and rhomboid minor to restore the
Bassem Elhassan, MD function of the paralyzed trapezius.
Methods: Six fresh frozen hemithoraces were mounted on a custom-
built apparatus. A three-dimensional electromagnetic tracking system
was used to record ST upward/downward rotation of the (1) normal
trapezius, levator scapulae, rhomboid minor, and rhomboid major; (2)
Eden-Lange (EL) transferl and (3) a modified EL transfer (triple
transfer).
Results: The normal trapezius was found to be an upward rotator of
the scapula and led to a mean ST rotation angle of 26.98. Similarly,
the modified triple transfer led to an upward rotation of the scapula,
with a mean ST rotation angle of 22.23, whereas the EL led to an
initial downward rotation of the scapula to 26.69, with a mean
scapulothoracic displacement angle of 1.13.
Discussion: The upward rotation of the scapula from the modified
From the Department of Orthopedic transfer mimicked the function of the normal trapezius better than did
Surgery, Mayo Clinic, Rochester, MN.
the traditional EL transfer.
Correspondence to Dr. Elhassan: Level of Evidence: Level V, biomechanical study
Elhassan.Bassem@mayo.edu
Dr. Sperling or an immediate family
Zimmer Biomet, DJO Global, and
Wright Medical Group; serves as a
paid consultant to Exactech, Wright
N ormal shoulder motion de-
pends on the combined func-
tion of the glenohumeral (GH) joint
by maintaining the acromiohumeral
distance and the deltoid resting
length.2 Loss of trapezius function
Medical Group, and Zimmer Biomet; and scapulothoracic (ST) articula- leads to drooping of the shoulder,
and has stock or stock options held in
Responsive Arthroscopy. None of the
tion. It was estimated that the motion loss of scapula external rotation with
following authors or any immediate is approximately divided into 2/3 secondary loss of abduction (and
family member has received anything originating from the GH joint and later flexion), and possible sub-
of value from nor has stock or stock 1/3 from the ST articulation.1,2 The acromial bursitis because of scapula
ST motion depends mainly on the internal rotation and winging.2,3
indirectly to the subject of this article: serratus anterior (AT) muscle that Limited described surgical op-
Dr. Werthel, Dr. Wagner, and stabilizes the scapula on the chest tions exist for patients with chronic
Dr. Elhassan. wall and the trapezius muscle that symptomatic trapezius paralysis. The
J Am Acad Orthop Surg 2019;27: suspends the scapula on the chest most commonly reported procedure
e235-e241 wall and plays a major role in the ST described for the management of this
DOI: 10.5435/JAAOS-D-16-00731 motion, specifically during shoulder condition is the Eden-Lange (EL)
abduction. This is achieved by scap- procedure that entails transfer of the
Academy of Orthopaedic Surgeons. ular upward rotation that in turns levator scapulae (LS) to the lateral
allows a more complete abduction spine of the scapula and rhomboid
March 1, 2019, Vol 27, No 5 e235
Tendon Transfer Options for Trapezius Paralysis
Figure 1 used the right hemithoraces and

shoulder girdles for each specimen.
Fluoroscopy was used before dis-
section, and specimens were ex-
cluded if any GH joint pathology
was found. After dissection, the
shoulder joint, capsule, and muscles
were carefully examined, and speci-
mens were excluded if any gross
abnormality, including arthritis or
rotator cuff tear, was found.
The cadaver specimens were pre-
pared as follows. The upper (UT)
extremities were cut at the proximal
humerus. The cadaver heads were
removed, while sparing the cervical
vertebrae to preserve most of the
proximal origin of the trapezius and
LS muscles. The pelvis was also
removed, and the thorax and abdo-
A and B, Photographs showing a hemitorso mounted on a custom-made men were eviscerated. The spine,
apparatus. The contour lines of the scapula and of the trapezius muscles are sternum, rib cage, and all other mus-
represented. A, Four cords simulate the lines of pull of the anterior, upper, cles of the thorax, back, and shoulder
middle, and lower trapezius. B, The trapezius muscle has been removed, and girdle were preserved.
three cords simulate the lines of pull of the levator scapulae, rhomboid major,
and rhomboid minor. The skin and subcutaneous tissues
were carefully dissected away, and the
origins and insertions of the trapezius,
major (RM) and minor (Rm) to the and LS to different locations on the LS, RM, and Rm were identified.
infraspinatus fossa to reconstruct the posterior aspect of the scapula to Each specimen was mounted on a
function of the lost trapezius.4-8 reconstruct a paralyzed trapezius has custom-built apparatus (Figure 1).
However, the reported outcomes of not been previously performed. The The spinal column was fixed to the
this procedure, including its modified purpose of this study was to evaluate testing apparatus with screws, and
version (in which the RM is transferred and compare the biomechanical ef- the anatomic lordotic and kyphotic
to the infraspinatus fossa and the Rm fectiveness regarding ST upward curvatures were maintained.
to the supraspinatus fossa), showed rotation of LS, RM, and Rm transfers
variable results with inconsistently when performed to different loca-
positive outcomes.3,9-14 This variabil- tions around the posterior scapula to Assessment of the
ity in the outcome could be related to try to restore the upward rotation of Scapulothoracic Rotation
abnormal ST motion and shoulder the paralyzed trapezius. A three-dimensional electromagnetic
biomechanics created by the described tracking system, Polhemus Fastrak,
tendon transfers. Recently, a triple was used to record raw kinematic
Methods
muscle transfer (ie, a modification of data. The Fastrak system tracks the
the EL in which the LS was transferred position and orientation (ie, 6 of
to the spine of the scapula just medial
Preparation of the Cadaver freedom) of several sensors as they
to the acromion; the Rm was trans- Specimens and Creation of move through space in relation to a
ferred to the spine of the scapula just the Shoulder Model transmitter. Sensors were attached to
medial to the LS insertion, and the The study used six fresh frozen the thorax and scapula, and coor-
RM was transferred to the spine of the cadaver specimens (four men and two dinate systems were established ac-
scapula just medial to the Rm inser- women; mean age, 86 years [67.71]), cording to the International Society
tion.) has been described with excel- which were thawed a few hours of Biomechanics recommendations
lent outcomes.15 before testing. We used a novel for the bones.17 ST joint angles were
To our knowledge, biomechanical shoulder model that we published calculated using Euler angles to
evaluation of transfer of the RM, Rm, about previously.16 In this model, we measure the upward and downward
Jean-David Werthel, MD, et al
rotation of the lateral part of the Each condition was tested three Figure 2
scapula in the coronal plane. By times. The force was equally applied
convention, upward rotation was in each muscle segment. The differ-
formulated as a positive angle, and ence between the final and the initial
downward rotation as a negative rotations of the scapula was recorded
angle. to obtain the ST rotation of each trial.
The mean ST rotation of the three
Modeling of the Muscles and trials was recorded. The goal was to
of the Tendon Transfers simplify the experimental setup to
focus only on the effect of the line of
Cords attached to the anatomic ori-
pull of different muscles on upward
gins and insertions of muscles were
rotation of the scapula on the chest
used to model their lines of action.
wall. Therefore, we intentionally did
Briefly, transosseous sutures were
not load other ST or scapulohumeral
placed in the insertions, whereas the
muscles (eg, pectoralis minor, latis-
origins were marked and fitted to
simus dorsi, serratus AT). Although
accept the passage of the cord
these ST muscles are important sta-
through an eye screw. The trapezius
bilizers of the scapula, their role in
muscle was divided into four parts (ie,
scapular upward rotation is minimal.
AT, UT, middle [MT], and lower
In addition, we intentionally did not
[LT]), each replicated by one cord
apply physiologic loads because
(Figure 1). It is worth noting that the Diagrams showing lines of action of
based on our past experience, the
UT trapezius was divided into two the Eden-Lange transfer (left)
application of physiologic forces led
parts because the line of pull of the compared to the lines of action of the
to complete tears of the muscles different subregions of the trapezius
AT (ie, clavicular) portion is differ-
(because no internal tension exists in (upper right). (Reproduced with
ent from that of the rest of the UT. permission from the Mayo Education
the cadaver muscles).
After testing of the trapezius, it was Foundation for Medical Education
carefully excised to expose the and Research, Rochester, MN.)
underlying muscles. The LS, RM, and Eden-Lange Procedure
Rm were each modeled by one cord The EL transfer1,4,18 was reproduced
(Figure 1). as follows: the LS was inserted to Results
To replicate the lines of action of the superior surface of the lateral
the tendon transfers, the anatomic part of the scapular spine before it Intact Muscles
origins of the muscles were main- becomes the acromion.4-7 The RM
When the normal trapezius function
tained, whereas their insertion sites and Rm were transferred laterally
was replicated, it was found to be an
were modified to replicate the differ- together to the posterior body of the
upward rotator of the scapula and led
ent transfers. Each cord was passed scapula in the infraspinatus fossa
to a mean ST upward rotation of 27
from the insertion site (ie, anatomic (Figure 2).
(range, 23 to 32) (Figures 4 and 5).
or transferred), through the origin of
The mean initial resting position of
the muscle, and finally attached sep- Modification of the Eden- the scapula was 5.87. The mean
arately to pneumatic pistons. Lange Transfer final resting position of the scapula
To reproduce more accurately the was 32.85. When loading the dif-
Motion line of action of the trapezius ferent parts of the trapezius indi-
For each trial, the motion was per- muscle, a modification of the EL vidually, the UT was found to be the
formed by increasing the pressure to transfer was included15 (Figure 3). In main upward rotator (ie, external
all the pneumatic actuators simulta- this modification, the LS was trans- rotator) of the scapula (31; range,
neously at a steady rhythm of 1 N ferred to the spine of the scapula just 30 to 34), whereas the MT and
every 5 seconds, until the full scapular medial to the acromion. The Rm was LT were found to also externally
motion (upward rotation) had been transferred to the spine of the scap- rotate the scapula, but to a lesser
achieved. We defined the terminal ula just medial to the LS insertion, extent than the UT, with a mean ST
extent of scapular motion to be the and the RM was transferred to spine upward rotation of 21 (range, 20
point when additional pressure in the of the scapula just medial to the Rm to 22) and 12 (range, 11 to 14),
actuators did not lead to any motion. insertion. respectively.
March 1, 2019, Vol 27, No 5 e237
Figure 3 enables optimal function of the

shoulder joint. It positions the gle-
noid for optimal alignment with
the moving humeral head to allow
maximum efficiency of the deltoid
and rotator cuff muscles,2,9,19,20 and
it lifts the acromion away from the
rotator cuff to prevent coraco-
acromial impingement.19 Lockhart21
in 1930 reported that it is impossible
to abduct the humerus beyond the
horizontal with the scapula fixed on
the chest wall. Furthermore, he
observed in a 19-year-old patient
with trapezius paralysis that the
deltoid could only move the humerus
until it was at right angle to the
scapula. This shows the importance
of the ST motion in achieving over-
head activities.1,2 The relationship
between abduction of the GH angle
and upward rotation of the scapula
Diagrams showing lines of action of the modified Eden-Lange transfer (left)
enables optimal positioning of the
compared to the lines of action of the different subregions of the trapezius
(right). The levator scapulae (LS) is transferred medial to the acromion, joint throughout abduction.
the rhomboid minor (Rm) to the spine of the scapula just medial to the LS, Although the ST motion is not per-
and the rhomboid major medial to the Rm. (Reproduced with permission from fectly homogeneous among different
the Mayo Education Foundation for Medical Education and Research,
subjects for the first 30 of humer-
Rochester, MN.)
othoracic abduction, once this posi-
tion is reached, the scapula and
The LS was found to rotate the rotators. The mean final upward humerus follow a coordinate pattern
scapula downward to 26 (range, 24 rotation of the scapula was 1 with a scapulohumeral rhythm of
to 28). The loading of the rhomboids (range, 27 to 10). The mean initial 2.3.1
led initially to a downward rotation resting position of the scapula was The main muscle involved in the
of the scapula of 24 (range, 23 4.87. The mean final resting posi- upward rotation of the scapula is the
to 25), which, as the scapula was tion of the scapula was 6.02. trapezius as our study has confirmed.
translated medially and superiorly, This was true for every subdivision of
was followed by an upward rotation Modified Eden-Lange the trapezius muscle (ie, AT, UT, MT,
of 14 (range, 12 to 15). Transfer and LT). In the setting of loss of tra-
pezius function, mostly secondary to
The activation of the transferred
paralysis from nerve injury, and
Eden-Lange Transfer muscles in the modified EL setting led
uncommonly secondary to injury or
to an upward rotation of the scapula,
The activation of the transferred detachment of the trapezius muscle,
with a mean upward rotation angle of
muscles in the EL setting led to a the absence of upward rotation of the
22 (range, 13 to 29) (Figures 4 and
downward rotation of the scapula scapula leads to painful limitation of
5). The mean initial resting position
of a mean 27 (range, 23 to 214) abduction. Nerve surgery can be
of the scapula was 0.57. The mean
at the beginning of the motion performed with variable results.18,22-27
final resting position of the scapula
(Figures 4 and 5). In all six speci- When nerve repair or muscle repair is
was 22.91.
mens, the initial medial and proxi- not possible or unsuccessful, tendon
mal translation of the scapula over transfer remains the main treatment
the thorax altered of the center of Discussion option for the absent trapezius func-
rotation of the scapula relative to the tion.3,9,14,18 The most commonly
tendon transfer insertions, eventu- By upwardly rotating the scapula described transfer include isolated
ally leading them to become upward during overhead activities, the trapezius transfer of the LS18 or combined LS
Figure 4
Photographs showing the starting (A) and ending (B) positions of the scapula when loading the trapezius alone. Photographs
showing the starting (C) and ending (D) positions of the scapula when loading the levator scapulae (LS) and rhomboids in the
setting of an Eden-Lange transfer. Photographs showing the starting (E) and ending (F) positions of the scapula when loading
the LS and rhomboids in the setting of a modified Eden-Lange transfer (triple transfer). The scapula rotates in an upward
direction in conditions B and F as opposed to condition D where the scapula is seen to rotate downwardly.
March 1, 2019, Vol 27, No 5 e239
Figure 5
Graphs showing average scapulothoracic angles when progressively loading the trapezius (A), the levator scapulae and
rhomboids in the setting of an Eden-Lange transfer (B), and in the setting of a modified Eden-Lange transfer (C). As opposed
to what is seen in conditions A and C, the scapula starts by rotating downward in condition B.
transfer with the rhomboid muscles rotation of the scapula that was could be related to the abnormal
(ie, EL procedure).4-8 These have caused by the EL transfer was com- biomechanics created by the EL
been shown to provide various bined with medial and proximal transfer.
results throughout the literature. translation of the scapula over the In contrast, the modified transfer
Bigliani et al9,18 and Romero and thorax leading to a modification of did replicate the mechanics of normal
Gerber12 described the restoration the center of rotation of the scapula trapezius, and its activation led to
of a painless functional shoulder relative to the muscular insertions. upward rotation of the scapula in a
after EL transfer, whereas Teboul This change of the center of rotation reproducible fashion. These results
et al3 reported poor results after this explains the upward rotation ob- are consistent with a recently
procedure. served later in the motion. When reported clinical retrospective study
The results in this study showed these findings are translated into the of 22 cases,15 which showed that the
that the LS and the rhomboidei were clinical setup, it would be expected modified technique provided notable
downward rotators of the scapula. that as the patient initiates an over- improvement in pain and range of
When the LS is transferred to the head movement of the shoulder, the motion at an average 35-month
lateral spine of the scapula, it changes EL transfer is activated, and the follow-up. However, there are no
into an upward rotator of the scap- scapula is pulled into downward clinical comparison studies to date
ula. However, the insertions of the rotation. This contradictory down- between the traditional EL transfer
RM and Rm are then lateralized by ward rotation of the scapula places and the modified transfer.
performing the transfer to the body of the supraspinatus and MT deltoid Our study has three main limi-
the scapula. This in turn magnifies the at a disadvantage for optimal func- tations. First, we analyzed only one
downward rotation moment arm of tion. The variability in outcome motion of the scapula (ie, upward-
the transferred muscles. The results in reported after the EL procedure downward rotation) without con-
our study showed that the downward observed in the literature3,9-14,18 sidering variations in translation,
anteroposterior and mediolateral case report. J Bone Joint Surg Am 2011;93:

rotation, or glenohumeral motion.
References e131(1-5).
However, the trapezius is almost an 14. Wiater JM, Bigliani LU: Spinal accessory nerve
References printed in bold type are injury. Clin Orthop Relat Res 1999:5-16.
exclusive upward rotator of the
scapula, so this is the main movement 15. Elhassan BT, Wagner ER: Outcome of
triple-tendon transfer, an Eden-Lange
a palliative transfer should repro- 1. Braman JP, Engel SC, Laprade RF, Ludewig
variant, to reconstruct trapezius paralysis. J
PM: In vivo assessment of scapulohumeral
duce. Second, the loads we applied rhythm during unconstrained overhead Shoulder Elbow Surg 2015;24:1307-1313.
were equally distributed among the reaching in asymptomatic subjects. J 16. Hartzler RU, Barlow JD, An K-N,
different muscles or muscle subre- Shoulder Elbow Surg 2009;18:960-967. Elhassan BT: Biomechanical effectiveness
gion, regardless of the muscle size 2. Inman VT, Saunders JB, Abbott LC: of different types of tendon transfers to the
Observations of the function of the shoulder shoulder for external rotation. J Shoulder
and force-generating capacity of the Elbow Surg 2012;21:1370-1376.
joint (1944). Clin Orthop Relat Res 1996;
different muscles. This, however, 330:3-12. 17. Wu G, van der Helm FCT, Veeger HEJD,
enabled us to have a standardized 3. Teboul F, Bizot P, Kakkar R, Sedel L: et al: ISB recommendation on definitions of
reproducible method for each trial. Surgical management of trapezius palsy. J joint coordinate systems of various joints
Bone Joint Surg Am 2004;86-A:1884-1890. for the reporting of human joint motion—
Finally, important scapular muscles Part II: Shoulder, elbow, wrist and hand. J
such as the serratus AT were not 4. Eden R: Zur Behandlung der Biomech 2005;38:981-992.
loaded. The function of the serratus is Trapeziuslähmung mittelst Muskelplastik.
Dtsch Z Chir 1924;184:387-397. 18. Bigliani LU, Perez-Sanz JR, Wolfe IN:
important in stabilizing the scapula Treatment of trapezius paralysis. J Bone
on the chest wall. In the current model, 5. Lange M: Treatment of paralysis of the Joint Surg Am 1985;67:871-877.
trapezius. Langenbecks Arch Klin Chir Ver
we chose to focus on the upward Dtsch Z Chir 1951;270:437-439. 19. Kibler WB: The role of the scapula in
rotation of the scapula. In this move- athletic shoulder function. Am J Sports Med
6. Lange M: The operative treatment of 1998;26:325-337.
ment, the function of the serratus be- irreparable trapezius paralysis [German].
comes less important. In addition, this Tip Fak Mecm 1959;22:137-141. 20. Pink M: Biomechanics. St. Louis, MO,
Mosby, 1996.
potential variable should not affect the 7. Langenskiöld A, Ryöppy S: Treatment of
results because the same exact exper- paralysis of the trapezius muscle by the 21. Lockhart RD: Movements of the normal
Eden-Lange operation. Acta Orthop Scand shoulder joint and of a case with trapezius
imental setup and values were applied 1973;44:383-388. paralysis studied by radiogram and experiment
equally on all trials. in the living. J Anat 1930;64:288-302.
8. Teinturier P, Vergote T, Terver S: Treatment
of trapezius paralysis by transfer of the 22. Anderson R, Flowers RS: Free grafts of
levator scapulae [French]. Rev Chir Orthop the spinal accessory nerve during radical
Conclusion Reparatrice Appar Mot 1990;76:297-302. neck dissection. Am J Surg 1969;118:
796-799.
9. Bigliani LU, Compito CA, Duralde XA,
In conclusion, the findings of this Wolfe IN: Transfer of the levator scapulae, 23. Harris HH, Dickey JR: Nerve grafting to
study showed that the modified rhomboid major, and rhomboid minor for restore function of the trapezius muscle
transfer of the LS, Rm, and RM did paralysis of the trapezius. J Bone Joint Surg after radical neck dissection: A preliminary
Am 1996;78:1534-1540. report. Ann Otol Rhinol Laryngol 1965;
lead to an ST upward rotation that 74:880-886.
replicated that of the normal trape- 10. Guettler JH, Basamania CJ: Muscle
transfers involving the shoulder. J Surg 24. Norden A: Peripheral injuries to the spinal
zius. In contrast, the EL transfer Orthop Adv 2006;15:27-37. accessory nerve. Acta Chir Scand 1946;94:
showed a contradictory abnormal ST 515-532.
11. Kuhn JE, Plancher KD, Hawkins RJ:
rotation compared with a normal Scapular winging. J Am Acad Orthop Surg 25. Olarte M, Adams D: Accessory nerve palsy.
trapezius rotation. These findings 1995;3:319-325. J Neurol Neurosurg Psychiatry 1977;40:
1113-1116.
indicate that in the clinical setting, the 12. Romero J, Gerber C: Levator scapulae and
modified transfer when performed to rhomboid transfer for paralysis of 26. Woodhall B: Trapezius paralysis following
trapezius: The Eden-Lange procedure. J minor surgical procedures in the posterior
treat trapezius paralysis may poten- Bone Joint Surg Br 2003;85:1141-1145. cervical triangle; results following cranial
tially lead to better functional out- nerve suture. Ann Surg 1952;136:375-380.
13. Skedros JG, Kiser CJ: Modified Eden-Lange
come because it better replicates the procedure for trapezius paralysis with 27. Wright TA: Accessory spinal nerve injury.
normal trapezius function. ipsilateral rotator cuff-tear arthropathy: A Clin Orthop Relat Res 1975:15-18.
March 1, 2019, Vol 27, No 5 e241
Research Article
The Healing Rate of Type II

Odontoid Fractures Treated With
Posterior Atlantoaxial Screw-rod
Fixation: A Retrospective Review of
77 Patients
Abstract
Da-Geng Huang, MD Background: In theory, temporary posterior atlantoaxial screw-rod
Xin-Liang Zhang, MD fixation for type II odontoid fractures is a way to preserve rotatory
motion. However, the healing rate of type II odontoid fractures treated
Ding-Jun Hao, MD
in this way is unknown; that is, the risk associated with conducting a
Bao-Rong He, MD temporary screw-rod fixation for type II odontoid fractures is unknown.
Xiao-Dong Wang, MD This study investigates the healing rate of type II odontoid fractures
Tuan-Jiang Liu, MD treated with posterior atlantoaxial screw-rod fixation by CT imaging
and evaluates the feasibility of conducting a temporary screw-rod
fixation for type II odontoid fractures.
Methods: Patients with type II odontoid fracture who underwent
posterior atlantoaxial screw-rod fixation in our spine center from
January 2011 to December 2014 were identified. Patients older
than 65 years or younger than 18 years were excluded. Those
who were confirmed to have healing odontoid fractures on CT imaging
were included. Those in whom fracture healing was not confirmed
were asked to undergo a CT examination. Fracture healing was
confirmed on the basis of the presence of bridging bone across the
odontoid fracture site on CT imaging.
Results: Seventy-seven patients (56 men and 21 women) were
From the Department of Spine included in the study. The average age of the patients was 40.7 6 11.6
Surgery, Honghui Hospital, Xi’an years (range, 18 to 64 years). The mean duration of follow-up was
Jiaotong University, Shaanxi, China.
26.4 6 4.6 months (range, 24 to 40 months). Fracture healing was
Correspondence to Dr. Hao:
observed in 73 patients (94.8%).
haodingjun_xjtu@sina.com
Discussion: The healing rate of type II odontoid fractures (with an age
range of 18 to 64 years) treated with modern posterior atlantoaxial
received anything of value from or has fixation is relatively high. For patients at that age range, posterior
stock or stock options held in a atlantoaxial temporary screw-rod fixation for type II odontoid fractures
can be conducted with a low risk of nonunion.
subject of this article: Dr. Huang, Level of Evidence: Level IV, therapeutic
Dr. Zhang, Dr. Hao, Dr. He, Dr. Wang,
and Dr. Liu.

e242-e248
DOI: 10.5435/JAAOS-D-17-00277
T ype II odontoid fracture is the
most common type of odontoid
fracture.1,2 In contrast to the healing
surgically is relatively low.3-5 There-
fore, many surgeons treat this kind
of fracture surgically. Posterior
rate of other types of odontoid frac- atlantoaxial fusion is a common
Academy of Orthopaedic Surgeons. tures, the healing rate of type II method used to manage such cases,
odontoid fractures treated non- but this sacrifices the mobility of the
Da-Geng Huang, MD, et al
C1-C2 segment.6-8 In 2001, Harms Surgical Technique obtained at the final follow-up visit
and Melcher9 introduced a screw-rod After general endotracheal anes- to access atlantoaxial stability. Frac-
system for atlantoaxial fixation. In thesia, all patients were placed in the ture non-healing was defined as an
theory, temporary posterior atlan- prone position and the posterior ele- absence of bridging bone across the
toaxial screw-rod fixation for type II ments of C1-C3 were exposed by a fracture site on CT images obtained
odontoid fractures is a way to preserve standard posterior approach. The 24 months after surgery or later.
rotatory motion. However, the heal- medial and lateral margins of the Neurologic deficits were measured by
ing rate of type II odontoid fractures lateral mass of the axis and the pos- the American Spinal Injury Associa-
treated with posterior atlantoaxial terior surface of the posterior lamina tion (ASIA) grades. Neck pain was
screw-rod fixation is unknown; that is, of the atlas were dissected. Screws assessed by Visual Analogue Scale
the risk associated with conducting a were placed in accordance with Tan’s (VAS) score. The patients who un-
temporary screw-rod fixation for type technique,13 which has been shown derwent an internal fixation con-
II odontoid fractures is unknown. A to achieve the highest screw place- struct removal surgery were asked to
few studies, based on small case series, ment success rate compared with a begin practicing cervical rotation
have investigated the healing rate of variety of published techniques for from 2 weeks after surgery. Thus, in
type II odontoid fractures treated with atlas pedicle screw placement. If our opinion, they may return to the
posterior atlantoaxial screw-rod fixa- the C1 pedicle was too narrow to maximum cervical rotation at the time
tion.10-12 However, most of the au- accommodate a screw, we used the of 12 months after fixation construct
thors assessed fracture healing using C1 lateral mass screw technique removal surgery. Therefore, their cer-
radiographs, which is not reliable.10,11 described by Harms and Melcher9 vical range of motion was measured by
In the current study, we investigate the instead. The C2 pedicle screws were the cervical range of motion device
healing rate of type II odontoid frac- inserted regularly.7,9 The ipsilateral (Performance Attainment Associates)
tures treated with posterior atlan- C1 and C2 screws were connected 12 months after surgery.
toaxial screw-rod fixation using CT by a rod. After atlantoaxial fixation
imaging, based on a relatively large by the screw-rod system, the bone Statistical Analysis
number of patients, to evaluate the graft bed was prepared using a high- The fracture healing rate and the at-
feasibility of conducting a temporary speed burr. An autograft or allograft lantoaxial fusion rate were calcu-
screw-rod fixation for type II odontoid was used for fusion. lated. Wilcoxon Signed Ranks Test
fractures. Five patients underwent an internal was used to compare ASIA grades
fixation construct removal surgery before surgery and at the final follow-
Methods 12 months after fusion surgery; a CT up and the VAS scores before surgery
scan indicated that the posterior and at the final follow-up. SPSS ver-
Patients fusion failed, though the odontoid sion 18.0 statistical software (SPSS)
fracture healed. was used for data entry and analysis.
Consecutive patients with type II
A P value of less than 0.05 was
odontoid fracture who underwent
posterior atlantoaxial screw-rod
Evaluation of Fracture considered statistically significant.
fixation in our spine center from Healing, Atlantoaxial Fusion,
January 2011 to December 2014 and Functional Outcomes Results
were identified. Patients older than Fracture healing and posterior at-
65 years or younger than 18 years lantoaxial fusion were confirmed on Seventy-seven patients (56 men and 21
were excluded. Those who were the basis of the presence of bridging women) were included in the study.
confirmed to have healing of the bone on CT imaging. If bridging bone The general information is shown in
odontoid fracture on CT imaging was not found across the fracture site Table 1. The average age of the pa-
were included. Those in whom frac- or between the C1 and C2 laminas on tients was 40.7 6 11.6 years (range,
ture healing had not been confirmed CT images, the patient was asked to 18 to 64 years). The cause of fracture
were asked to undergo a CT exami- undergo a CT scan again 12 months was motor vehicle accidents in 48
nation. The medical records and the after surgery and for every 12 months patients (62.3%) and falls from
imaging data of the included patients thereafter until the end of the study or height in 29 patients (37.7%). The
were reviewed. The study protocol until both fracture healing and at- mean time interval between injury
was approved by the local institution lantoaxial fusion were confirmed. and surgery was 5.6 6 2.7 days (range,
review board at the author’s affiliated For patients with atlantoaxial fusion 3 to 18 days). All the patients were
institution. failure, dynamic radiographs were followed up for at least 24 months,
March 1, 2019, Vol 27, No 5 e243
Healing Rate of Odontoid Fractures
Table 1 through the upper portion of the

odontoid process, type II fractures
General Information on Patients (n = 77)
run across the base of the odontoid
Age, yr process near the junction with the
Mean 6 SD 40.7 6 11.6 axis body, and type III fractures
Range 18-64 include the odontoid and extend into
Sex, n (%) the body of the axis. The healing
Male 56 (72.7) rate of type II odontoid fractures
Female 21 (27.3) treated nonsurgically is relatively low
Cause of fracture, n (%) (range, 43% to 72%).3-5 Hence,
Motor vehicle accidents 48 (62.3) many surgeons tend to treat such
Falls from height 29 (37.7) fractures surgically.6-8 Classic sur-
Time interval between injury and surgery, d gery options are the anterior
Mean 6 SD 5.6 6 2.7 odontoid screw fixation and the
Range 3-18 posterior atlantoaxial fusion. Both
Duration of follow-up, mo methods are subject to advantages
Mean 6 SD 26.4 6 4.6 and disadvantages. Anterior odon-
Range 24-40 toid screw fixation is one treatment
option that maintains atlantoaxial
mobility. However, such fixation is
highly technically demanding, with
with a mean follow-up period of 26.4 procedure 12 months after fusion the risk of secondary spinal cord
6 4.6 months (range, 24 to surgery when the CT scan indicated injury, and is hard to accomplish in
40 months). Fracture healing was that the posterior fusion had failed patients with a barrel chest, short
observed in 73 patients (94.8%) (Fig- even though the fracture healed (Fig- neck, subaxial cervical spondylosis,
ure 1). Fracture healing was confirmed ure 1). Cervical rotatory motion was or thoracic kyphosis.20-22 In addi-
by a CT scan taken at 6 months after preserved mostly in these five patients tion, postoperative dysphagia and
surgery in 62 patients, 12 months (Table 3). Preoperative ASIA grades pneumonia have been reported
after surgery in 4 patients, 18 months were C in 2 patients, D in 14 patients, after anterior odontoid screw fix-
after surgery in 2 patients, 24 and E in 61 patients. At the final ation.23 Posterior atlantoaxial
months after surgery in 2 patients, follow-up visit, ASIA grades were D in fusion is less technically demand-
28 months after surgery in 1 3 patients and E in 74 patients (P , ing and more familiar to most spinal
patient, 38 months after surgery in 0.05). The mean preoperative VAS surgeons. However, such a fusion
1 patient, and 40 months surgery in score was 7.1 6 0.7 (range, 6 to 8). At technique will sacrifice the mobil-
1 patient (Table 2). For the patients the final visit, it decreased to 0.9 6 0.7 ity of the atlantoaxial segment,
who did not heal at the fracture site, (range, 0 to 2) (P , 0.05) (Table 4). accounting for approximately
they all had a fracture gap of more 60% of the total rotation of the
than 5 mm (Figure 2), whereas none neck.24 The loss of atlantoaxial
of the patients with fracture healing Discussion mobility may also increase the
demonstrated this finding in preop- incidence of lower cervical spine
erative CT imaging. Posterior graft Odontoid fractures are usually caused degeneration. 25
bone fusion was observed in 46 by high-energy trauma, such as falls In 2001, Harms and Melcher9
patients (59.7%) by CT imaging. from height and traffic accidents12,15,16; introduced a screw-rod fixation tech-
However, all of the patients with at- they account for 9% to 18% of all nique for atlantoaxial fixation and
lantoaxial fusion failure show no cervical fractures.15,17-19 Such in- pointed out that this technique could
movement on dynamic radiographs. juries are thought to be extremely be used to obtain temporary stabili-
None of the patients with atlantoaxial dangerous owing to the potential zation without definitive fusion, be-
fusion failure consented to additional risk of upper cervical cord injury cause it could avoid damage to the
surgery because they were asymp- following traumatic instability. atlantoaxial articulation. Nevertheless,
tomatic, with the exception of five Anderson and D’Alonzo1 defined a few reports are available on the
patients who hoped to preserve C1-C2 the following three types of such application of this temporary fixation
mobility and who underwent an in- injuries: type I fractures were technique.9,12 In fact, the C1-C2
ternal fixation construct removal described as oblique fractures screw fixation technique was first
Figure 1
Imaging of a 24-year-old male patient diagnosed with odontoid fracture. A, Preoperative CT images showed that the patient
had type II odontoid fracture with a transversal displacement of more than 2 mm, which was reported as a risk factor for
failure of halo immobilization.14 Besides, the fracture gap was more than 2 mm (red arrow), which was also negative for
fracture healing according to our experience. Thus, surgery was considered for this patient. Because the bone quality of the
screw path was affected by trauma (yellow arrow), anterior odontoid screw fixation was not feasible for this patient.
Therefore, he underwent posterior C1-C2 screw-rod fixation and fusion surgery with allograft. B, Fracture healing and
posterior fusion failure were confirmed by CT images obtained 12 months after surgery. Then he underwent an internal
fixation construct removal surgery. C, CT image obtained after construct removal surgery showed that internal fixation
construct had been removed.
described by Goel and Laheri in treated with posterior atlantoaxial Table 2

1994.26 However, they used a screw- screw-rod fixation is still unknown; The Time When Fracture Healing
plate fixation system and not the that is, the risk associated with Was Confirmed (n = 73)
screw-rod fixation system, nor did conducting a temporary screw-rod
Fracture Healing No. of
they mention the possibility of ob- fixation for type II odontoid frac- Confirmed, mo Cases
taining temporary stabilization by tures is unknown. In the current
their fixation system. The healing study, we investigated the healing 6 62
rate of type II odontoid fractures rate of type II odontoid fractures 12 4
should be investigated before de- treated with posterior atlantoaxial .12 7
ciding to do a temporary fixation screw-rod fixation using CT imag-
without fusion for patients with this ing, which is considered the
type of fracture. Maiman and “benchmark” imaging modality for patients.14,28 Therefore, from the
Larson8 reported the management of assessment of fracture healing and results of the current study, we
odontoid fractures with posterior fusion,27 based on a relatively large cannot draw the risk associated with
cervical fixation and fusion. A fusion number of patients. Fracture healing conducting a temporary screw-rod
rate of 100% at the posterior surgi- was observed in 73 of 77 patients, fixation for type II odontoid frac-
cal site was gained, whereas the with a healing rate of 94.8%, indi- tures in patients older than 65 years.
healing rate at the fracture site was cating that a high healing rate of In theory, for patients with an age
only 35%. However, the instrument type II odontoid fractures could be range of 18 to 64 years and without
they used for atlantoaxial fixation achieved by posterior atlantoaxial other concomitant injuries, the tem-
was not a screw-rod system but a screw-rod fixation. Our study provides porary posterior C1-C2 screw-rod
wire or cable that offered much less supportive data for the application of fixation can be considered as a
stability than the modern atlantoaxial the posterior atlantoaxial temporary treatment option for all patients with
screw-rod fixation system. screw-rod fixation technique for the acute type II odontoid fracture,
A few studies, based on small case management of type II odontoid frac- except for those who have a fracture
series, have investigated the healing tures. However, it is important to note gap of more than 5 mm. However,
rate of type II odontoid fractures that the results of the current study compared with this technique, an-
treated with posterior atlantoaxial were based on a case series with an age terior odontoid screw fixation is
screw-rod fixation.10-12 However, range of 18 to 64 years. The geriatric cheaper and requires only one sur-
most of the authors assessed fracture odontoid fractures are a different gery without the need to do internal
healing using radiographs, which is entity. Previous study has showed fixation construct removal. There-
not reliable.10,11 Therefore, the heal- that the healing rate of odontoid fore, anterior odontoid screw fix-
ing rate of type II odontoid fractures fractures is much lower in elderly ation may be a better treatment
March 1, 2019, Vol 27, No 5 e245
Figure 2
A, Preoperative CT images showed the wide fracture gap of more than 5 mm. B, CT image obtained immediately after
surgery showed that the fracture gap was still more than 5 mm. C, CT image obtained 24 months after surgery showed
nonunion at the fracture site.
Table 3
Cervical ROM Measurements of the Five Patients 12 Months After Instrumentation Removal
Cervical ROM
Case No. Age (yr), Sex Flexion (°) Extension (°) Left Rotation (°) Right Rotation (°)
1 24, M 60 70 42 41
2 26, M 52 48 45 40
3 36, M 35 58 50 49
4 38, M 55 67 45 38
5 28, M 53 47 49 40
M = Male, ROM = range of motion
Table 4 option for those in whom ideal

odontoid screw placement can be
Functional Outcomes Before Surgery and at Last Follow-up
done. In our opinion, we prefer rec-
Factor Before Surgery At Last Follow-up ommending the use of temporary
ASIA gradea posterior C1-C2 screw-rod fixation
A 0 0 in patients who have risk factors for
B 0 0 failure of nonsurgical treatment and
C 2 0 are not feasible for anterior odontoid
D 14 3 screw fixation. According to the ex-
E 61 74 isting literature14,16,29,30 and our
VAS scoreb experience, at least, the risk factors
Mean 6 SD 7.1 6 0.7 0.9 6 0.7 for failure of nonsurgical treatment
Range 6-8 0-2 include the following: (1) aged older
than 50 years, (2) fracture displace-
ASIA = American Spinal Injury Association; VAS = Visual Analogue Scale ment of more than 2 mm, (3) fracture
a
P value ,0.05; the comparison of ASIA grade between “before surgery” and “at last follow-up.”
b
P value ,0.05; the comparison of VAS score between “before surgery” and “at least follow-up.”
gap of more than 2 mm, (4) angula-
tion of more than 11, (5) secondary
loss of reduction, and (6) a fracture atively high. For patients at that age really a limitation of C1 pedicle screw
insertion? Eur Spine J 2014;23:
with comminution. Situations not range, posterior atlantoaxial tempo- 1109-1114.
feasible for anterior odontoid screw rary screw-rod fixation for type II
8. Maiman DJ, Larson SJ: Management of
fixation include a fracture line from odontoid fractures can be conducted odontoid fractures. Neurosurgery 1982;11:
posterosuperior to anterior inferior, with a low risk of nonunion. 471-476.
comminuted fractures, poor bone 9. Harms J, Melcher RP: Posterior C1-C2
quality at the fracture site, failure of fusion with polyaxial screw and rod
Acknowledgments fixation. Spine (Phila Pa 1976) 2001;26:
achieving satisfactory fracture reduc- 2467-2471.
tion, body habitus that prevent proper Preliminary report of this study has 10. Molinari RW, Dahl J, Gruhn WL,
trajectory for odontoid screw place- been presented as an oral presentation Molinari WJ: Functional outcomes,
ment, such as barrel chest, short neck, at the 2016 AAOS Annual Meeting in morbidity, mortality, and fracture healing
subaxial cervical spondylosis, severe in 26 consecutive geriatric odontoid
Orlando, Florida. fracture patients treated with posterior
thoracic kyphosis.16,20-22 In our case fusion. J Spinal Disord Tech 2013;26:
series, all the 4 patients with a 119-126.
fracture gap of more than 5 mm failed References 11. Molinari WR, Molinari RW, Khera OA,
to heal at the fracture site even though Gruhn WL: Functional outcomes,
they were treated via the rigid C1-C2 Evidence-based Medicine: Levels of morbidity, mortality, and fracture healing
in 58 consecutive patients with geriatric
screw-rod fixation. Therefore, we evidence are described in the table of
odontoid fracture treated with cervical
consider a fracture gap of more than contents. In this article, reference 10 collar or posterior fusion. Global Spine J
5 mm as a contraindication to this is a level Ⅲ study. References 1-4, 2013;3:21-32.
temporary fixation technique. It is also 6-9, 11, 12, 14, 15, 17, 19, 21-26, 12. Ni B, Guo Q, Lu X, et al: Posterior
important to note that we discuss only and 28-30 are level Ⅳ studies. Ref- reduction and temporary fixation for
odontoid fracture: A salvage maneuver to
the situation of patients (with an age erence 19 is a level Ⅴ expert opinion. anterior screw fixation. Spine (Phila Pa
range of 18 to 64 years) with acute Reference 13 is an anatomy study. 1976) 2015;40:E168-E174.
type II odontoid fracture without other References 5, 16, 18, and 27 are 13. Tan M, Wang H, Wang Y, et al:
concomitant injuries in the current review studies. Morphometric evaluation of screw
fixation in atlas via posterior arch and
study, because geriatric odontoid References printed in bold type are lateral mass. Spine (Phila Pa 1976) 2003;
fractures or remote odontoid fractures 28:888-895.
are a different entity, and some con- years. 14. Platzer P, Thalhammer G, Sarahrudi K,
comitant injuries such as disruption of et al: Nonoperative management of
1. Anderson LD, D’Alonzo RT: Fractures of odontoid fractures using a halothoracic
the transverse atlantal ligament and the odontoid process of the axis. J Bone vest. Neurosurgery 2007,61:522-529.
injury to the C1-C2 joints are contra- Joint Surg Am 1974;56:1663-1674. 15. Hadley MN, Dickman CA, Browner CM,
indication to temporary fixation. 2. Greene KA, Dickman CA, Marciano FF, Sonntag VK: Acute axis fractures: A review
The limitations of the current study Drabier JB, Hadley MN, Sonntag VK: of 229 cases. J Neurosurg 1989;71:
Acute axis fractures: Analysis of 642-647.
include its retrospective nature and the
management and outcome in 340
small number of patients included in 16. Ryken TC, Hadley MN, Aarabi B, et al:
consecutive cases. Spine (Phila Pa 1976)
Management of isolated fractures of the
the study. We did not document when 1997;22:1843-1852.
axis in adults. Neurosurgery 2013;72(suppl
the fracture healed, because the time at 3. Polin RS, Szabo T, Bogaev CA, Replogle RE, 2):132-150.
which patients underwent CT scan Jane JA: Nonoperative management of
17. Subach BR, Morone MA, Haid RJ,
types II and III odontoid fractures: The
varied: some underwent CT scan at Philadelphia collar versus the halo vest.
McLaughlin MR, Rodts GR, Comey CH:
Management of acute odontoid
6 months after surgery, whereas others Neurosurgery 1996,38:450-456.
fractures with single-screw anterior
underwent at 12, 18, or 24 months, etc. 4. Wang GJ, Mabie KN, Whitehill R, fixation. Neurosurgery 1999,45:
A prospective study involving a larger Stamp WG: The nonsurgical management 812-819.
of odontoid fractures in adults. Spine
patient population is needed in the (Phila Pa 1976) 1984;9:229-230.
18. Vaccaro AR, Madigan L, Ehrler DM:
future. Contemporary management of adult
5. Julien TD, Frankel B, Traynelis VC, cervical odontoid fractures. Orthopedics
Ryken TC: Evidence-based analysis of 2000;23:1109-1113.
odontoid fracture management.
Neurosurg Focus 2000;8:e1. 19. Lee PC, Chun SY, Leong JC: Experience of
Conclusions posterior surgery in atlanto-axial
6. Frangen TM, Zilkens C, Muhr G, Schinkel C: instability. Spine (Phila Pa 1976) 1984;9:
Odontoid fractures in the elderly: Dorsal 231-239.
The healing rate of type II odontoid C1/C2 fusion is superior to halo-vest
fractures (with an age range of 18 immobilization. J Trauma 2007;63:83-89. 20. Mazur MD, Mumert ML, Bisson EF,
Schmidt MH: Avoiding pitfalls in anterior
to 64 years) treated with modern 7. Huang DG, He SM, Pan JW, et al: Is the screw fixation for type II odontoid
posterior atlantoaxial fixation is rel- 4 mm height of the vertebral artery groove fractures. Neurosurg Focus 2011;31:E7.
March 1, 2019, Vol 27, No 5 e247
21. Agrillo A, Russo N, Marotta N, Delfini R: 24. Pang D: Atlantoaxial rotatory fixation. 28. Butler JS, Dolan RT, Burbridge M, et al:
Treatment of remote type II axis fractures in Neurosurgery 2010;66:161-183. The long-term functional outcome of type II
the elderly: Feasibility of anterior odontoid odontoid fractures managed non-
screw fixation. Neurosurgery 2008;63: 25. Hilibrand AS, Carlson GD, Palumbo MA, operatively. Eur Spine J 2010;19:
1145-1150. Jones PK, Bohlman HH: Radiculopathy and 1635-1642.
myelopathy at segments adjacent to the site
22. Dailey AT, Hart D, Finn MA, Schmidt MH, of a previous anterior cervical arthrodesis. J 29. Lennarson PJ, Mostafavi H, Traynelis
Apfelbaum RI: Anterior fixation of odontoid Bone Joint Surg Am 1999;81:519-528. VC, Walters BC: Management of type II
fractures in an elderly population. J dens fractures: A case-control study.
Neurosurg Spine 2010;12:1-8. 26. Goel A, Laheri V: Plate and screw fixation Spine (Phila Pa 1976) 2000;25:
for atlanto-axial subluxation. Acta 1234-1237.
23. Vasudevan K, Grossberg JA, Spader HS, Neurochir (Wien) 1994;129:47-53.
Torabi R, Oyelese AA: Age increases the risk 30. Muller EJ, Schwinnen I, Fischer K, Wick M,
of immediate postoperative dysphagia and 27. Gruskay JA, Webb ML, Grauer JN: Muhr G: Non-rigid immobilisation of
pneumonia after odontoid screw fixation. Methods of evaluating lumbar and cervical odontoid fractures. Eur Spine J 2003;12:
Clin Neurol Neurosurg 2014;126:185-189. fusion. Spine J 2014;14:531-539. 522-525.
Review Article
Aquatic Orthopaedic Injuries
Abstract
Robert H. Brophy, MD Extremity injuries sustained in aquatic environments require unique
David L. Bernholt, MD considerations compared with injuries sustained on land. Knowledge of
these considerations is becoming more important as aquatic
recreational activities increase in popularity. Aquatic injuries may occur
through mechanical contact with a variety of different objects or surfaces,
such as a recreational device or watercraft part, or may occur through
contact with marine animals. Marine animal injuries can be further
categorized into bites, stings, or blunt contact, as well as venomous or

nonvenomous, distinctions that should be used to guide clinical
management. Numerous instances of retained foreign bodies after
marine animal stings exist, which can result in infection and prolonged
envenomization; thus, radiographic examination should be routinely
performed in aquatic sting injuries to prevent these harmful sequelae.
Any aquatic injury resulting in an open wound has an increased risk for
infection, and prophylactic antibiotics must be given with consideration
for the unique microbiologic flora of the aquatic environment.
S ince the mid-20th century, a sub-

stantial increase in water-based
sport and recreational experiences
which may place the airway at risk.
Aspiration may occur, but use of the
Heimlich maneuver to remove aspi-
was noticed.1 From 1980 to 2014, a rated liquid is not recommended.3
37.6% increase was observed in the Oxygen (100%) should be delivered
From the Washington University number of registered recreational in all submersion injuries.4 Even
School of Medicine in St. Louis, St. watercraft in the United States. well-appearing patients who have
Louis, MO. Worldwide participation in surfing sustained a near-drowning episode
Dr. Brophy or an immediate family has nearly tripled from 13 to 37 are at increased risk for delayed
member is a member of a speakers’ million between 2002 and 2013.2 cerebral and pulmonary edema and
bureau or has made paid Increasing participation in water-based
presentations on behalf of Arthrex and require monitoring for at least 6
activities unfortunately brings a con- hours after the incident.5 Compared
officer, or committee member of the comitant increase in aquatic injuries, with individuals suffering terrestrial
American Academy of Orthopaedic which have unique considerations that injuries, individuals suffering aquatic
Surgeons and the American must be taken into account to ensure
Orthopaedic Association. Neither injuries have a higher rate of injury
Dr. Bernholt nor any immediate family
optimal management. to the cervical spinal column, so
member has received anything of cervical spine precautions should be
options held in a commercial company Initial Management followed when addressing the pa-
or institution related directly or tient’s airway.6 In addition to spinal
indirectly to the subject of this article. Initial management should be guided column injuries, spinal cord injuries
J Am Acad Orthop Surg 2019;27: by advanced trauma life support also occur more frequently in aquatic
191-199 (ATLS) principles; however, aquatic injuries, so circulation can be com-
DOI: 10.5435/JAAOS-D-16-00702 injuries may present unique chal- promised because of neurogenic
lenges to airway and circulation shock.6 As with terrestrial injuries,
Academy of Orthopaedic Surgeons. management. Injuries occurring in hypovolemic shock may result from
water present risk for submersion, hemorrhage by way of blunt
March 15, 2019, Vol 27, No 6 191
Table 1
Recommended Prophylaxis Based on the Type of Aquatic Exposure
Exposure Type Pathogens of Concern Recommended Prophylaxis
Any aquatic Staphylococcus aureus, A first-generation cephalosporin (cephalexin 500 mg PO q6 h or

exposure Streptococcus pyogenes, cefazolin 1 g IV q8 h) or fluoroquinolone (Levofloxacin 750 mg PO or
Pseudomonas aeruginosa IV daily); aminoglycoside for pseudomonas prophylaxis.
Freshwater Aeromonas hydrophila Fluoroquinolone (Levofloxacin 750 mg PO or IV daily) or a third-
generation cephalosporin (Ceftazidime 2 g IV q8 h).
Saltwater Vibrio vulnificus Doxycycline (100 mg IV or PO q12 hr) in addition to prophylaxis from
row 1. Ceftazidime (2 g IV q8 h) plus doxycycline (100 mg IV q8 h) for
suspected Vibrio infection before culture.
IV = intravenous, PO = by mouth, q = every
or penetrating trauma. Injuries microbiologic milieu compared with vacuum therapy or saline dressings
occurring in divers may also be terrestrial open wounds. Given the between débridements.9,11,12 These
complicated by decompression ill- increased risk for SSTIs, early consul- aggressive necrotizing infections can
ness, caused by gas bubbles forming tation with an infectious disease spe- also result in compartment syndrome,
within blood in arteries or veins cialist is recommended. Although so close monitoring is required to
after a rapid ascent from a depth, staphylococcal and streptococcal infec- determine whether fasciotomies are
which in rare cases can cause car- tions remain common,10 Aeromonas needed.11 Because SSTI in aquatic
diovascular compromise and hydrophila, Edwardsiella tarda, injuries can be caused by gram-
hypotension.7 Erysipelothrix rhusiopathiae, positive, gram-negative, or myco-
After the patient has been stabilized, Mycobacterium marinum, and bacteria, broad-spectrum antibiotic
attention may turn to the patient’s Vibrio vulnificus are often impli- therapies are needed.11 Prophylaxis
orthopaedic injuries. The types of in- cated in SSTIs, and less frequently should be based on the type of
juries seen vary depending on the Chromobacterium violaceum, aquatic exposure (Table 1). Patients
specific mechanism of aquatic injury. Shewanella species, Streptococcus with wounds exposed to saltwater
High-energy long bone and pelvic iniae, and Mycobacterium fortuitum should be given ceftazidime plus
fractures, closed head injuries, and are involved.11 doxycycline as prophylaxis to cover
spinal column or cord injuries com- In freshwater exposures, there Vibrio species, whereas prophylaxis
monly occur in patients involved in should be heightened concern for for patients with wounds exposed to
motorboat and personal watercraft Aeromonas infections, which can freshwater should be given either a
(PWC) accidents, because these are cause rapidly progressive necrotizing fluoroquinolone or a third-generation
high-speed aquatic vessels and typi- infection. Associated infections for cephalosporin to cover Aeromonas
cally the passengers are without safety saltwater exposure can vary by species, with the possible addition of
belts or protective equipment aside region but include V vulnificus in the an aminoglycoside.9,11,12
from life vests.8 The skin of injured Gulf of Mexico, C violaceum in the
extremities should be thoroughly as- Western Pacific, and Shewanella in-
sessed to identify any open wounds fections in the Mediterranean and Motorboats and Personal
that may be present. Skin and soft- Western Pacific.11 Vibrio infections Watercraft Injuries
tissue infections (SSTIs) are common can be very aggressive, with the
with open wounds with either fresh- ability to cause sepsis within 24 to 48 According to US Coast Guard data
water or saltwater exposure, even hours. In addition to systemic anti- from 2006 to 2015, an average of
with small wounds, and when present biotics, necrotizing SSTI caused by 4,567 accidents and 672 fatalities
can result in substantial morbidity.9 Vibrio or Aeromonas species should have occurred annually involving
be treated promptly with aggressive motorized watercraft. Motorized
surgical débridement, consisting of watercraft accounted for most of the
Infectious Considerations serial débridements at 24-hour in- reported watercraft injuries in 2015,
tervals, with excision of all infected with 63% of injuries occurring by
Wounds occurring in freshwater or and nonviable tissue including fascia motorboat and 23% occurring by
saltwater are exposed to a different and use of either negative pressure PWC, such as jet-skis.13 Injuries
Robert H. Brophy, MD and David L. Bernholt, MD
involving motorboats and PWC are ing until the wound is stable with Figure 1
varied, with the most common types healthy tissue.8,17 Limited data exist
of reported injuries being lacerations in the literature regarding propeller
(22.7%); sprains, strains, or con- injuries, but in the largest published
tusions (19.7%); fractures (18.6%); case series, 6 of 13 propeller injuries
and concussions (9.1%).14 Whereas were complicated by infection. Am-
most of the deaths from motorboat putations may occur from the pro-
accidents are because of drowning, peller strike itself or may be required
most of the deaths in PWC accidents as treatment in cases of major neu-
are caused by blunt trauma in- rovascular injuries, extensive soft-
juries.15 PWC accidents often occur tissue loss, or severe secondary
via collision with other PWCs or infection.8
fixed objects, thus resulting in rapid
deceleration with riders often ejected
from the watercraft or affecting the Towed Water Sports
handlebars.15 In these accidents, com-
mon injuries include lower extremity Based on data from the National
fractures (25.8%) and blunt chest in- Electronic Injury Surveillance System
juries (27.4%), with pneumothorax from 2000 to 2007, the estimated
present in one of three of these in- incidence of injuries from tubing, Clinical photograph demonstrating
juries.16 Loss of consciousness is wakeboarding, and waterskiing was motorboat propeller injury of lower
common, occurring in 38.7% of 0.47/100,000; 0.81/100,000; and extremity with hallmark parallel
lacerations.
patients, with 12.9% having closed 2.24/100,000, respectively.18 An
head injuries. estimated 23,460 waterskiing in-
Propeller injuries are particularly juries and 4,810 wakeboarding in- twice as likely to lead to severe in-
devastating motorboat-related injuries were seen in US emergency juries.18 Children and adolescents
juries, resulting in death in about departments from 2001 to 2003.19 are more likely to sustain head and
10% to 15% of incidents10 (Figure Lacerations to the face and closed neck injuries because of contact with
1). The hallmark wound of a pro- head injury were the most common another rider in the tube, whereas
peller injury is deep parallel lacer- injuries to wakeboarders, whereas adults are more likely to sustain
ations, which can result in delayed water-skiers most commonly were sprains or strains of the upper and
wound necrosis because of compro- diagnosed with strains or sprains of lower extremities and to be injured
mise of local vasculature. Addition- the lower extremity.19 Fractures because of impact with the water.23
ally, the pressure differential between were seen in about 10% of injured In any towed water sport, high-
the front and the back sides of a water-skiers and wakeboarders. energy blunt trauma can occur by
propeller can drive water and par- Anterior cruciate ligament (ACL) way of collision with either the boat
ticles deep into a wound, increasing tears and shoulder dislocations are or the objects in the environment,
the depth of wound contamination common and account, among wake- shearing or avulsion injuries can
and posing a greater risk of second- boarders, for about half of all office happen by contact or entanglement
ary infection.10 Because of the risk of visits with an orthopaedic surgeon.20 with the tow rope, and propeller
delayed wound necrosis and the high Furthermore, one study found that injuries can occur.
risk of infection, propeller wounds competitive wakeboarders have a
require multiple débridements with 42.4% prevalence of an ACL tear,
delayed closure. Even propeller with most of it occurring after Surfing
wounds that appear clean with mini- landing a jump of high amplitude.21
mal soft-tissue injury should be con- Tight foot and ankle bindings may Surfing is relatively a safe sport but
sidered for delayed closure because contribute to the high incidence of has been found to have a higher risk
of the driving of contaminated water ACL tears in wakeboarders; how- of notable injury than waterboarding
and debris deep into the wound that ever, no data exist to substantiate or waterskiing, with approximately
occurs at the time of injury.17 this finding.20,22 6.6 injuries per 1,000 hours of surfing
Débridement should continue every Although generally regarded as a among competitive surfers.24 Ap-
48 hours with the use of either saline safer alternative to waterskiing or proximately half of the injuries sus-
dressing or negative pressure dress- wakeboarding, tubing is more than tained are because of contact with
March 15, 2019, Vol 27, No 6 193
Figure 2 aquatic wounds should be obtained results in inflammatory infiltration

because many spines or teeth from of CD31 and CD41 lymphocytes
aquatic animals, as well as aquatic and eosinophils and may lead to
debris such as shells, are radi- delayed healing, wound necrosis,
opaque.28 If radiographs are nega- and granuloma formation, which
tive but still concern exists for a may in turn lead to infectious com-
retained foreign body, then ultraso- plications such as gangrene, osteo-
nography or MRI can evaluate myelitis, necrotizing fasciitis, and
radiolucent foreign bodies because septicemia.22,29,32 Local inflamma-
not all spines are radiopaque.3 tion and tissue necrosis can continue
Puncture wounds should raise sus- weeks after the injury.33 When in-
picion for envenomization. Hot fections occur, they may require weeks
water immersion with 45°C water to months to eradicate; thus, prophy-
Clinical photograph displaying should be performed for envemoni- lactic antibiotics that cover Vibrio
retroserrated stingray tail spine zation wounds because the venom of species and staphylococcus and
fragments removed from a patient’s stingrays, scorpionfish, stonefish, streptococcus should be routinely
knee after intra-articular injury.
lionfish, sea urchins, catfish, and used.24,28,34
weever fish are all heat labile.28 This Because of the severe complications
either the board or the ocean floor, immersion should be done for 30 to that may occur from a retained tail
whereas the other half are noncon- 90 minutes or until pain and symp- spine, any deep wound resulting
tact injuries occurring either while toms subside, with care taken to from a suspected stingray injury
paddling or while riding the board. avoid thermal injury. Intense pain should be surgically explored and
Among competitive surfers, the knee from envenomization may some- débrided,28 although more superfi-
is the most often injured body part, times require regional anesthesia for cial wounds can be treated without
accounting for 19.7% of injuries. pain control.28 surgical intervention.32 Because the
Competitive surfers have an in- tail spine consists of cartilaginous
creased risk of a ligamentous knee vasodentin, it may not be radi-
Stingrays opaque in all cases, but multiple
compared with recreational surfers,
and these injuries typically occur as Although docile, stingrays are com- cases in the literature have demon-
competitive surfers perform aggres- mon culprits in aquatic injuries in the strated the use of routine radiogra-
sive turning on the board or during United States, with as many as 2,000 phy in identifying retained stingray
landing of aerial maneuvers.24,25 A injuries occurring annually.29,30 These tail spines.22,35 For example, we
recent study reported two high ankle injuries often occur when a stingray treated a patient from whom tail
sprains occurring during the same is stepped on, causing it to reflexively spine fragments were retained intra-
competitive surfing event in 2013.26 whip its tail upward. Stingray tails articularly within the knee (Figures 3
The mechanism for both of these are equipped with one to four and 4). In the case of a negative
injuries was landing on the surf- retroserrated spines made of carti- radiograph, ultrasonography may be
board from an aerial maneuver, laginous vasodentin that may inflict able to identify radiolucent material
with likely mechanism axial loading damage mechanically or by enven- from the tail spine.
through a dorsiflexed foot, possibly omization28-30 (Figure 2). Typically,
with external rotation occurring on the injuries resulting from stingray
spines are minor injuries affecting Catfish
impact.26
the lower extremity or hands; how- Catfish inhabit both freshwater and
ever, serious injuries and even death saltwater habitats, and like stingrays,
Aquatic Animal Injuries can occur.28-30 Stingray venom within they also have retroserrated spines on
the spines typically causes intense their dorsal and pectoral fins, which
Marine animal injuries can be catego- local pain but rarely may cause can cause mechanical injury and are
rized as either venomous bites/stings or weakness, vertigo, paresthesias, fas- associated with venom-producing
wounds caused by mechanical trauma ciculations, seizures, paralysis, hypo- glands.36 Venom varies by species but
from nonvenomous animals.27 A tension, and arrhythmias, but it is can have hemolytic, dermonecrotic,
detailed history should be obtained heat labile and hot water immersion inflammatory, or vasoconstrictive
to help determine the etiology of any is effective, providing local pain re- effects, although symptoms are usu-
wound present. Radiographs of all lief.28,31 The envenomization also ally limited to intense pain and
Figure 3 Figure 4
AP (A) and lateral (B) radiographs of left knee on initial presentation to our clinic.
Small linear radiodensity can be seen just superior to lateral tibial spine on the Three-dimensional CT
AP, and multiple, radiodense foreign bodies are visualized in the posterior knee reconstructions of left knee. Three
on the lateral radiograph. separate foreign bodies are identified
in the posterior joint.
swelling, with systemic symptoms spines can be removed with gentle

being exceedingly rare.37 Hot water traction; however, if the spine is can cause mild local injury via punc-
immersion can help mitigate symp- unable to be removed or is not able ture wound, but the resultant enven-
toms of envenomization. Typically, to be removed in entirety, surgical omization causes near-immediate
the wounds are minor and affect the excision is necessary.36,37 All wounds onset of severe pain, lymphedema, and
hands of those handling catfish or should be examined in the outpatient erythema, which often affects the
feet of those who inadvertently step setting within a week because local entirety of the affected extremity.
on them. Noodling, a type of fishing necrosis or infection can occur. As Pain and swelling peak after about
in which a fisherman uses his or her outlined previously,37 antibiotic 90 minutes and typically persist 6 to
hands to find and catch fish in prophylaxis should be given based 12 hours but may last as long as a
underwater holes or enclosures, on saltwater or freshwater exposure. few days. Impending compartment
presents an increased risk of injury. syndrome and acute carpal tunnel
Tendon and major arterial lacer- syndrome after a stonefish enven-
ations have been reported to be re- Stonefish, Scorpionfish, and omization have been reported.40,41
sulting from catfish noodling.37,38 Lionfish Reports of systemic symptoms from
Management should consist of irri- Stonefish, scorpionfish, and lionfish scorpaenid envenomization are
gation, exploration, and débride- are categories of venomous stinging rare but can include hypotension,
ment of the wound. These can often fish within the family Scorpaeni- myotoxicity, neurotoxicity, and even
be safely performed in the emergency dae.39 Scorpaenids are nonaggres- death in very rare cases.39 Skin mani-
department with local anesthetic; sive, bottom-dwelling fish that cause festation of envenomization occurs in
however, larger wounds with greater injury when stepped on by swimmers three grades of severity, with grade 1
soft-tissue injury may require surgi- or handled by fisherman, aquarists, being erythema, grade 2 including
cal management of exploration and or chefs. The potency of venom does bullae formation, and grade 3 being
débridement of any devitalized tis- vary between scorpaenids, with necrotic ulceration at the puncture
sues. In all cases, wounds should be stonefish having the most potent site.9
allowed to heal by secondary inten- venom and lionfish having the least. Hot water immersion (45°C) is the
tion or undergo delayed wound Scorpaenids are most often found in mainstay of treatment as the toxin is
closure with multiple débride- the Indo-Pacific region but can also heat labile. Research has shown that
ments.36,37 All wounds, especially be found off the coast of North fluid within bullae formed after
puncture wounds, should be radio- Carolina, Florida, and California, as envenomization contains a high con-
graphed to assess for retained spine well as in the Caribbean.39 The fish centration of venom, and thus, evac-
fragment or other debris. Retained have dorsal, anal, or pelvic spines that uation of the bullae by sterile
March 15, 2019, Vol 27, No 6 195
Figure 5 tissue, formal surgical débridement

may be necessary.43 Sea urchin spines
can be radiolucent and may require
ultrasonography for identification.41
Nonvenomous Marine
Animals
Sharks
Although highly publicized when
they occur, shark attacks are rare
occurrences, with 50 to 100 occur-
A and B, Clinical photographs of a shark bite wound. (Courtesy of Bert R. ring worldwide annually, having
Mandelbaum, MD, Santa Monica, CA.)
a mortality rate of approximately
10%.44-46 There were a record high
98 shark attacks in 2015.44 The
aspiration or decompression to pre- are venomous, but many sea urchins great white, tiger, and bull sharks
vent further effects of the venom is have venom-containing pedicellariae are the species most often implicated
recommended.28,39 Antivenin is and small pincer-like appendages, in serious attacks.34 Surfers are the
available for stonefish venom and has interspersed among the spines, which most at risk, making up about half
cross-reactivity with the venom of may also contain venom. Sea urchins of all victims, whereas the other half
some species of scorpionfish.42 In are slow-moving, nonaggressive bot- is made up mostly of divers and
cases of severe swelling, the involved tom dwellers and can be found in swimmers.44
extremity should be elevated and any tropical and temperate waters, in Sharks possess powerful crescent-
constrictive clothing or jewelry deep water, and along rocky shores. shaped jaws capable of generating
should be removed. All puncture They cause injury to humans when tremendous compressive force that
wounds should be irrigated with stepped on or grasped, with the can cause crush injury, which result in
sterile solution and carefully in- numerous spines causing puncture bony fractures and neurovascular in-
spected for retained scorpaenid spines wounds with associated envenom- juries. Furthermore, sharks perform a
or integumentary sheaths. Ultraso- ization. The envenomization causes side-to-side shaking motion when
nography or MRI may be needed immediate pain, swelling, erythema, biting, which can result in extensive
because sometimes the spine or and myalgia. Severe symptoms such soft-tissue injury and loss30 (Figure 5).
sheath is radiolucent. When these as hypotension, muscular weakness, Despite this, most shark attacks result
foreign bodies are not removed, dyspnea, aphonia, deafness, and even in minor lacerations.45,47 Attacks
foreign body granulomas or sec- death may occur with greater loads of most often involve the lower ex-
ondary infection can develop. toxin,43 requiring greater than 15 tremity. In the more severe injuries,
Additionally, wounds with necrotic spines to penetrate into the extrem- complex lacerations may involve
ulceration are often slow healing ity.28,43 The toxin is heat labile, so muscle, tendon, and bone, requiring
and may be further complicated by hot water immersion is effective. The extensive débridement along with
secondary infections. Thus, all long, thin spines do present risk for repair or reconstruction of damaged
scorpaenid-inflicted wounds should retained foreign bodies because they structures. Because of soft-tissue loss
be given prophylactic antibiotics of can penetrate deep within tissue and and a large zone of injury, repair of
either a third- or fourth-generation break off. If they penetrate into a damaged neurovascular structures is
cephalosporin or trimethoprim- joint, they can cause intense synovi- sometimes not possible and primary
sulfamethoxazole.42 tis, and if not removed, they can amputation may be necessary.47
cause chronic arthropathy.43 Sec- Involvement of a major vessel oc-
ondary infection and formation of curred in 25% of patients in Lentz
Sea Urchins granuloma may also result from re- et al’s cohort, with one-third of these
Sea urchins are marine organisms tained spines.43 Radiographs should patients dying, whereas Woolgar
belonging to the Echinoderm phy- be obtained to assess for any sea urchin et al’s cohort showed a 15% inci-
lum. They have oval bodies covered spines, and if spines are revealed dence of major arterial injury with a
in numerous thin spines. Not all species within a joint space or deep within mortality rate of 62%.45,47
Treatment of shark attack victims and crocodiles perform a “death teeth that can shear through flesh and
requires expeditious control of blood roll” in which they roll their body bone.50 Although nonaggressive,
loss and resuscitation with blood and head over, tearing the seized they have a tendency to attack hands
products and fluid. Compressive limb off of its prey or pulling its prey with shiny metallic jewelry on.12
dressings and direct pressure should into water to drown it.49 The fatality Because of the razor sharp teeth and
be used to control blood loss, but rate reported in the United States is biting mechanics of the barracuda,
when these methods fail, a tourniquet 4.2%, but this figure includes affected extremities typically have
should be used.47 Patients should reported attacks in which no medical well-defined lacerations without
be transported to a trauma center treatment was required. The extrem- notable soft-tissue loss.34 Because of
as quickly as possible. Thorough ities are affected in more than 90% of saltwater exposure, these wounds
débridement of wounds should be attacks, with the upper extremity should be treated with delayed clo-
performed, and tetanus and antibi- being affected approximately twice as sure or be allowed to heal by sec-
otic prophylaxis for saltwater expo- often as the lower extremity.48 Most ondary intention, and prophylactic
sure should be given because these wounds were minor, but traumatic antibiotics for saltwater exposure
wounds have a high rate of second- amputations of extremities, fractures, should be given.
ary infection.34 Radiographs should or death may occur. Moray eels are generally passive
be obtained to assess for fractures in Management of alligator and bottom dwellers but can be impli-
the involved extremity and for re- crocodile attack injuries is largely the cated in marine bite wounds, typi-
tained foreign bodies, such as shark same as for shark attack wounds; cally when a diver reaches his or her
teeth, and if present, these should be however, unique considerations must hand into a hole or cave where the eel
removed. be made in terms of secondary infec- resides. Moray eels are found in
tion risk. A wide variety of pathogens tropical and subtropical areas of the
has been cultured from the mouths of Indian, Pacific, and Atlantic oceans.
Alligators/Crocodiles alligators, including A hydrophila, They are nonvenomous but possess
Alligators and crocodiles belong to Acinetobacter, Citrobacter, Enter- fang-like teeth and a strong, muscular
the order Crocodylia. Like sharks, obacter, Yersinia, Proteus, Pseudo- jaw that will lock down on prey. In
they infrequently attack humans; monas, Bacteroides, Clostridium, some cases, the eel must be killed to
however, when these attacks occur, Fusobacterium, and Peptococcus, in get it to open its jaw.30 The strength
they are highly publicized. Over an addition to fungi such as Candida, of the moray eel’s jaw can result in a
81-year span from 1928 to 2009, a Aspergillus, and Torulopsis.12,34 A notable crush avulsion injury with
total of 567 adverse encounters with hydrophila is a gram-negative bac- extensive soft-tissue loss. Because the
alligators have occurred, resulting in terium found in fresh and brackish upper extremity is most often af-
24 deaths in the United States.48 The waters and in soil and has frequently fected, involvement of tendinous or
amount of encounters has been been cultured in wound infections neurovascular structures is common
increasing over recent years as the resulting from an alligator or a and amputation of digits or a more
alligator population in the United crocodile bite.12 Infection with this substantial portion of the extremity
States continues to grow. The Amer- organism can occur within 24 to 48 is possible. One case has been
ican alligator is responsible for most hours after the initial injury and can reported in which transections of the
of these attacks. It can be found in be rapidly progressive with associ- ulnar, median, and radial sensory
swamps, lakes, rivers, and canals ated cellulitis or bullae that may nerves, as well as the ulnar artery
in the states of Florida, Georgia, evolve into areas of necrosis. Pro- and all musculature of the flexor
South Carolina, North Carolina, phylactic antibiotics should include a compartment were sustained from a
Louisiana, Alabama, Arkansas, fluoroquinolone or third-generation moray eel bite.51
Mississippi, Texas, Oklahoma, and cephalosporin.48
Tennessee. They are found sparingly
outside of these southern states as Summary
they become dormant below 55°F.48 Other Animals
An average-sized adult is capable of Additional rare bite wounds can be Aquatic injuries will continue to occur
generating 1,000 kg of force with its sustained from barracuda or moray with increasing frequency as aquatic
strong jaws.49 This large amount of eels. Barracudas are long-finned, fast- recreational activities continue to
force on biting causes crush injury to swimming fish that can be found become more prevalent. Management
tissue and results in extensive soft- adjacent to Florida, California, and of aquatic injuries should initially fol-
tissue loss. After biting, alligators Hawaii. They have sharp cutting low ATLS protocols, with particular
March 15, 2019, Vol 27, No 6 197
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March 15, 2019, Vol 27, No 6 199
Review Article
Scapular Notching in Reverse Total

Shoulder Arthroplasty
Abstract
Richard Joel Friedman, MD, Scapular notching is a common radiographic finding occurring after
FRCSC reverse total shoulder arthroplasty, and it refers to an erosive lesion of
David Anthony Barcel, MD the inferior scapular neck because of the impingement of the humeral
Josef Karl Eichinger, MD implant during adduction. The clinical importance of notching is unclear,
and the optimal treatment of severe notching is unknown. The
incidence and severity of scapular notching is related to prosthetic
design and surgical technique. Implant design factors include size,

shape, and position of the glenosphere, inclination of the humeral neck-
shaft angle, implant offset, and native scapular anatomy. Scapular
notching may lead to deterioration of functional outcomes and glenoid
implant loosening and failure. Lateral offset, inferior glenosphere
overhang, and careful consideration of the presurgical glenoid
morphology may help prevent scapular notching. Currently, there is
From the Department of Orthopaedics limited evidence to direct the management of scapular notching, and
and Physical Medicine, Medical further research is needed to elucidate optimal prevention and
University of South Carolina, treatment strategies.
Charleston, SC.
Dr. Friedman or an immediate family
presentations on behalf of Exactech;
serves as a paid consultant to
S capular notching is a radio-
graphic finding, which may occur
following reverse total shoulder ar-
prosthesis.3 One of the distinguish-
ing biomechanical characteristics
of Grammont’s design included
Exactech and Johnson & Johnson;
has received research or institutional
throplasty (rTSA). The term is used to medialization of the center of rota-
support from Exactech; and serves describe an erosive lesion of the axil- tion of the glenoid implant. This
as a board member, owner, officer, or lary border of the scapular neck that decreased the shear force and le-
committee member of the American occurs when the medial rim of the ver arm across the glenoid bone-
Academy of Orthopaedic Surgeons,
the American Orthopaedic
humeral implant contacts the scapula implant interface. Distalization of
Association, and the Association of during shoulder adduction.1 The the glenoid implant served to ten-
Bone and Joint Surgeons. clinical effect of notching was unclear sion the deltoid. The combination
Dr. Eichinger or an immediate family until recently. Currently, several re- of these factors resulted in a lower
member, serves as a board member,
ports suggest a correlation between rate of glenoid implant failure seen
of the American Academy of the radiographic appearance of scap- in previous designs. However, the
Orthopaedic Surgeons. Neither ular notching and functional out- design frequently resulted in con-
Dr. Barcel nor any immediate family comes.1-5 This review discusses the tact between the superior-medial
pathogenesis, radiographic staging, rim of the humeral implant poly-
options held in a commercial company implant design implications, surgical ethylene and the scapular neck3
or institution related directly or technique, and prevention strategies with arm adduction. Mechanical
indirectly to the subject of this article. of scapular notching. engagement of the humeral cup
J Am Acad Orthop Surg 2019;27: with the scapular neck has been
200-209 linked to the development of bone
DOI: 10.5435/JAAOS-D-17-00026 Pathogenesis loss, polyethylene wear, osteolysis,
and glenoid implant loosening and
Academy of Orthopaedic Surgeons. In 1985, Grammont introduced the failure associated with a decline in
first successful reverse shoulder clinical outcomes.1-5
Richard Joel Friedman, MD, FRCSC, et al
Figure 1 Figure 2
A Grashey AP radiograph
demonstrating the scapular neck Grashey AP radiographs demonstrating an erosive lesion of the glenoid with
length, which is defined by the significant bone loss superiorly (A) and reverse total shoulder arthroplasty
distance between the lateral column placed on the same shoulder (B).
of the scapula and the articular
surface of the glenoid.
body with three lateral promontories, (P = 0.0012).18 This suggested that
which include the acromion, cora- those with smaller than average SNL
Incidence coid process, and glenoid. The ori- are at an increased risk of notching.
entation of the mature glenoid Shorter neck lengths result in a smaller
The reported incidence of scapular articular surface is variable, with re- adduction arc, increasing the likeli-
notching varies widely, ranging from ports of normal anatomy ranging hood of impingement between the
4.6% to 96%. A 2015 systematic from 2° of anteversion to 7° of ret- humeral implant and inferior scapular
review of 37 studies and 3,150 patients roversion relative to the plane of the neck. When performing rTSA on pa-
revealed notching rates between 4.6% scapular body.14,15 The tilt of the tients with SNL less than 9.0 mm,
and 50.8%.6 Recent studies evaluating glenoid is angled 40° to 50° cephalad glenoid augmentation should be con-
the effect of implant design and posi- based on the intersection of lines sidered, or an implant with increased
tion report notching rates as low as drawn between the inferior glenoid lateral offset can be used.
10% to 30%, indicating that these neck and the lateral border of the Patients with rotator cuff arthrop-
two factors may play an important scapula.16 athy or inflammatory arthropathy
role.4,7,8 By contrast, other studies Several studies have demonstrated have a loss of rotator cuff function and
have found notching rates in excess of that decreased scapular neck length balance, and this condition results in
50%2,9 and reaching as high as 80% (SNL) leads to increased rates of superior-medial migration of the hum-
to 96% in some scenarios.10,11 Some notching17,18 (Figure 1). In general, eral head against the glenoid, leading to
of the variability in reported inci- SNL is measured as the distance glenoid bone loss and a shorter SNL.
dence is attributable to the length of between the lateral column of the Significant glenoid deformity can re-
follow-up,4,9 and higher grades have scapula and the articular surface of sult, and one must be careful not to
been associated with longer follow- the glenoid on a Grashey AP radio- place the glenoid implant too superior,
up.4 For example, in 2008, Cuff and graph. A cadaver study of 442 scap- with superior tilt, or both (Figure 2)
colleagues12,13 reported that zero out ulae from 221 cadavers revealed a because this may increase the risk of
of 96 patients showed radiographic mean SNL of 10.6 6 3.3 mm.17 Male nothching.1,3
signs of notching at 2 years, but a subjects trended toward a larger SNL
subsequent follow-up of the same than female subjects, and Caucasians
cohort at 5 years revealed an increase had significantly larger SNLs com- Radiographic Analysis
in scapular notching to 9%. pared with African Americans. In a
2014 analysis of 50 rTSA patients, Presurgical Imaging
Anatomic Considerations those with notching were found to Presurgical glenoid morphology can
have a mean SNL of 8.9 mm as influence the outcome of rTSA,
The scapula is roughly triangular in compared with those without notch- including the occurrence of notching.19
shape and is composed of a flattened ing who had a mean SNL of 12.1 mm Therefore, when considering rTSA,
March 15, 2019, Vol 27, No 6 201
Scapular Notching
presurgical radiographs should be Postsurgical Imaging deltopectoral approach was used (P ,

obtained with or without the supple- Careful observation should be made 0.0001).9 Another study from 2011
mentation of a two-dimensional or for the development of notching fol- found that scapular notching occurred
three-dimensional (3D) CT scan. lowing rTSA. When a diagnosis of 74% of the time using the ante-
Typically, standard Grashey AP scapular notching has been made, rosuperior approach and 63% of the
views in external and internal rota- grading the lesion allows the clinician time using the deltopectoral approach;
tion and an axillary lateral view are to observe for progression, readily however, these differences were not
obtained. A CT scan is recommended communicate the severity of notching, statically significant.22 The ante-
when abnormal glenoid anatomy is and make treatment recommendations. rosuperior approach has been linked
suspected. Although two-dimensional Scapular notching was originally clas- with lower rates of postsurgical in-
CT scans are helpful in identifying sified by Sirveaux et al1 in 2004 stability and decreased risk of scap-
lesions of the glenoid, angles on a (Figure 3). Grade 1 describes a defect ular spine and acromion fractures.
given CT image are influenced by the confined to the pillar, grade 2 repre- During an anterosuperior approach,
gantry angle, or angle of the x-ray sents a defect confluent with the infe- one may misjudge the true inferior
beam relative to the patient, which rior most screw, grade 3 represents a border of the glenoid. This situation
may vary considerably with changes defect extended above the inferior most may result in superior placement or
in patient position inside the CT screw, and grade 4 represents a defect superior tilt of the glenosphere or both,
scanner. This can lead to incomplete that involves the central post. Grades 1 which is known to increase the risk
views of scapular anatomy on single and 2 are considered to be the limit by of notching and would explain the
image panes. which purely mechanical erosion may increased rates of notching reported
When 3D CT scans are used, occur. Grades 3 and 4 are likely the with the anterosuperior approach.
intraobserver and interobserver reli- result of a biologic response to poly- Currently, the most common approach
ability is improved, particularly when ethylene particles and osteolysis. for rTSA is deltopectoral; however,
identifying and quantifying aberrant Radiographic evaluation in the setting careful exposure of the inferior
glenoid morphology.19 Abnormali- of notching may be performed using glenoid, including the removal of
ties in presurgical glenoid morphol- standard radiographs. It is important labrum, capsule, and long head of
ogy may lead to technical errors that for grading the lesion that a true triceps origin can help minimize
can result in notching, such as supe- Grashey AP view is obtained with the inadvertent superior tilt regardless
rior tilt of the glenoid implant. x-ray beam tangential to the glenoid of surgical approach.
Therefore, the prevention of notch- baseplate to view it in profile. Addi-
ing starts with adequate presurgical tionally, it is recommended that lat-
imaging. When an abnormality of Glenosphere Tilt
eral and axillary lateral views be
the glenoid is suspected, CT scan obtained.1,3,21 In biomechanical models, inferior
with 3D reconstruction should be glenoid tilt affords a greater arc of
considered when planning rTSA. impingement free motion with a
Additional consideration may be more even distribution of force at
given to CT-guided templating and
Surgical Techniques to the bone-glenoid implant inter-
instrumentation. This technology has Minimize Notching face.23,24 However, optimal glenoid
been used in knee and hip arthroplasty tilt is dependent on other design and
with some success, and it is now in use Surgical Approach anatomic factors, such as lateraliza-
for both anatomic and rTSA. The tech- Surgical approach may also play a role tion of the glenosphere and humeral
nique may add time to presurgical in the development of scapular notch- prosthesis neck shaft angle. Therefore,
planning; however, it may also help ing. The anterosuperior approach (or achieving inferior glenoid tilt is more
prevent scapular notching by decreasing deltoid splitting approach) has been important in standard Grammont-
variability in implant positioning. Pre- associated with an increased risk of style prosthesis with a nonlateralized
liminary results using this technology notching. In one series, a total of 337 glenosphere and a 155° neck shaft
have demonstrated reduced variability shoulders undergoing rTSA were eval- angle (Figure 4).
and placement errors in glenoid posi- uated using either an anterosuperior or Nyffeler et al25 in 2005 examined
tioning.20 Further studies are needed to deltopectoral approach. Approxi- eight cadaver scapulae in four sepa-
determine the cost benefit and clinical mately 86% of patients developed rate positions. They found that
outcomes using presurgical planning notching when an anterosuperior glenospheres placed in 15° of inferior
software and CT-guided instrumenta- approach was used, whereas only 56% tilt had improved range of motion
tion in shoulder arthroplasty. of patients developed notching when a (ROM), including impingement-free
Figure 3 Figure 4
Diagram of the Sirveaux

classification of scapular notching.
adduction. However, glenospheres

placed in neutral position with inferior
overhang demonstrated the greatest
improvement in adduction and overall Diagram demonstrating contact between the humeral polyethylene and the
ROM (P , 0.001). inferior scapular neck when a glenosphere is placed in neutral tilt (A) and without
Conversely, in a sawbones model, contact when a glenosphere is placed with inferior tilt (B).
Gutiérrez et al23 found that inferior
glenosphere tilt resulted in the least All humeral implants were placed glenoid augmentation should be con-
amount of inferior scapular impinge- with a humeral resection angle of sidered to avoid over medialization
ment followed by inferior glenosphere 155°. Inferior translation was deter- during reaming to achieve neutral or
placement and lateral offset. Later, mined using a referencing guide off of slight inferior tilt.
the same group found that concen- the inferior osseous glenoid. Glenoid
tric glenospheres placed in neutral reaming was controlled using a
tilt had a greater discrepancy in joint computer navigation system, which Glenosphere Placement
reactive force at varying degrees of measures glenoid inclination accu- Placing the glenosphere with inferior
abduction than those placed with rately to within 1.5°. No differences overhang appears to confer the
15° of inferior tilt.24 However, in notching or clinical outcomes were greatest reduction in scapular notch-
when a glenosphere was placed observed at 1-year follow-up between ing with the least adverse con-
eccentrically in the inferior position, a the inferior tilt group and the neutral sequence.3,23-28 Nyffeler et al25
neutral tilt actually improved the dis- tilt group.10 performed an in vitro study of
tribution of load. Superior tilt pro- Inferior tilt of the glenosphere is cadaver scapulae to determine opti-
vided the most uneven distribution of thought to increase ROM, result mal glenosphere placement. They
load overall. Discrepancies in load in impingement-free adduction, and measured adduction angles in the
distribution result in implant “rock- provide a more even distribution of scapular plane in the four scenarios as
ing,” which could lead to notching load in some models. Optimal glenoid follows: (1) superior placement with
and early mechanical failure. tilt is unknown and likely dependent exposed inferior glenoid, (2) neutral
Finally, a controlled clinical trial of on multiple factors. However, no sig- placement with the glenosphere flush
52 consecutive rTSA was performed nificant detrimental effects of 10° of with the inferior glenoid rim, (3)
in 2012 whereby shoulders were ran- inferior glenoid tilt exist. Aiming for glenosphere extension below the
domized to either neutral or 10° infe- slight inferior glenoid tilt can help inferior glenoid rim, and (4) with the
rior tilt.10 All glenospheres were sized avoid inadvertent superior tilt, which glenosphere tilted inferiorly 15° and
to 36 mm and placed with 3 mm of has been shown to result in increased flush with the inferior scapular neck.
inferior translation by a single sur- failure rates for nearly all designs and Position 3 provided the greatest
geon. A single glenoid design with a clinical scenarios. In scenarios where impingement-free adduction angle
standard center of rotation was used. significant bone loss is reported, (P , 0.001). Inferior glenosphere
March 15, 2019, Vol 27, No 6 203
Scapular Notching
placement and a reduced incidence offset, whereas nearly 45% of pa- and 0 mm offset (P , 0.05).35 Addi-
of scapular notching corroborated tients with Grammont-style pros- tionally, the benefit of larger diameter
the clinical studies by Simovitch theses developed scapular notching glenospheres was demonstrated in a
et al3 in 2007 and de Wilde et al26 in (P , 0.001).29 2016 prospective randomized study of
2010. Lateral offset can be achieved in a 81 patients with a minimum of 2-year
Limitations exist on the amount of variety of ways, including bone or follow-up. Patients undergoing rTSA
overhang achieved with concentric metal augmentation of the glenoid. were randomized to either a 42-mm
designs before purchase is lost along Autograft or allograft bone augmen- glenosphere or a 38-mm glenosphere.
the inferior border of the glenoid. tation effectively increases the SNL. Notching was found in 48.8% of
Eccentric glenospheres have been de- The advantage of lateralization with a the patients receiving a 38-mm
signed in an effort to increase inferior biologic implant is that the center of glenosphere compared with only
overhang while maintaining screw rotation is maintained at the bone- 12.1% of the patients receiving a
fixation within the glenoid. In 2014, implant interface while simulta- 42-mm glenosphere (P , 0.001).
Poon et al27 compared notching rates neously restoring offset. Concerns No difference was found in the Con-
between concentric implants and exist regarding incorporation of the stant scores between the two groups.36
eccentric implants designed to increase intercalary bone graft positioned
inferior overhang. No notching was between the native glenoid and the
observed with an overhang of baseplate prosthesis. In a 2011 study Humeral Implant Design
.3.5 mm regardless of concentric of 42 patients with cuff-deficient
versus eccentric design. Glenospheres shoulders who underwent rTSA As prosthesis neck shaft angle de-
designed with inferior eccentricity did with bony lateralization, notching creases, the humeral cup becomes more
not decrease notching rates or im- rates were found in 19% at a mean vertical, and the humeral cup is posi-
prove clinical outcomes as compared follow-up of 28 months.30 The graft tioned in more abduction relative to
with concentric glenospheres with was fully incorporated in 41 of the the humeral shaft. In a cadaver model,
a minimum of 3.5 mm overhang. 42 patients (98%). There was no this has been shown to improve
Consequences of excessive inferior evidence of graft resorption, glenoid the impingement-free adduction angle
placement of the glenosphere include loosening, or clinical instability. while providing more lateral offset.34
excessive deltoid tension, the need These latter findings are supported However, as the neck shaft angle
for increased humeral resection, in a recent study by Greiner et al,31 is decreased, contact stresses are
compromised glenoid fixation, and which demonstrated no evidence of increased and tend to shift inferiorly
potential inability for humeral stem radiographic lucency, implant loos- along the polyethylene onlay. This
retention during revision arthroplasty. ening, or graft failure using the bony situation could potentially lead to
offset technique. Also in 2015, edge loading with increased genera-
Athwal et al32 found notching rates of tion of polyethylene wear particles,
Glenosphere Design 40% in those who underwent rTSA which may generate glenoid osteol-
using the bony increased offset tech- ysis, and contribute to notching in the
Similar to glenospheres with an infe- nique compared with 75% in those absence of mechanical impingement
rior overhang, those with a lateral- who received a standard Grammont- with the scapula. Similarly, decreased
ized offset appear to be protective style prosthesis (P , 0.05). Although polyethylene depth appears to im-
against scapular notching.28 Stan- no differences were observed in clin- prove the adduction angle.26,34 How-
dard Grammont glenospheres have a ical outcomes among these patients, ever, there is an increased risk for
medialized center of rotation at the follow-up was short at only 2 years. dislocation because the contact area
glenoid border and a predisposition Finally, it is recommended that large decreases, resistance to shear forces is
toward notching.3 A lateralized center diameter glenospheres be used when decreased, and constraint is dimin-
of rotation more closely replicates a possible. Larger glenospheres are ished. Some evidence exist that the
physiologic center of rotation, and it more stable, improve impingement- maximum contact stress is increased
is thought to decrease the risk for free ROM, and decrease notching.33-36 while onlay depth is decreased, which
notching.29 A systematic review of 13 In a study of 40 cadaver shoulders, again may lead to an increase in
studies was performed in 2015 com- when used in combination with 10 mm instability and polyethylene wear.34
paring standard Grammont-style lateral offset, those with gleno- A recent systematic review of 38
prostheses with those with lateral off- sphere diameters of 42 mm had studies including more than 2,000
set.29 Scapular notching occurred in greater impingement-free ROM rTSAs performed with either 155°
only 5.4% of patients with lateral than those with 36 mm diameters or 135° of humeral neck shaft
Figure 5
Diagram of the various combinations of offset used in reverse total shoulder arthroplasty.
inclination found that implants with prosthesis is used, deltoid and rota-
155° of inclination produced signif- tor cuff tensioning are improved, and
Clinical Outcomes
icantly higher rates of scapular notching is decreased.3,29,32 How-
Mechanical impingement along the
notching.7 Scapular notching was ever, deltoid moment arm is de-
scapular pillar decreases active shoul-
found in only 2.8% in the 135° creased, potentially adversely affecting
der ROM by decreasing one’s ad-
group versus 16.8% in the 155° the clinical performance.
duction angle, leading to increased
group (P , 0.0001). No difference A medial glenoid with lateral hu-
pain and decreased performance.1,3,5
in the dislocation rate was observed merus center of rotation prosthesis
Additionally, as the humeral poly-
between the two groups. will medialize the center of rotation,
ethylene cup comes into contact with
Each of the individual parameters thus improving the deltoid moment
the scapula, wear particle generation
discussed with regard to glenoid and arm. The lateralized humerus im-
increases. Wear particles cause an
humeral prosthesis design, offset, and proves muscle tension in both the
placement are believed to contribute deltoid and remaining rotator cuff immunologic response leading to os-
to notching. Ultimately, it is the com- muscles. Increasing humeral offset teolysis, likely accelerating notching-
bination of these parameters that will via polyethylene depth would likely related bone loss on the glenoid and
have the greatest effect on notching result in continued contact between possibly the humerus. Despite several
rates and clinical outcomes. Similar to the polyethylene and the scapular early studies, which did not observe
the early Grammont-style prostheses, neck during adduction. However, any negative clinical effects, evidence
when a medial glenoid with medial lateralizing the humerus via de- now exists demonstrating that
humerus center of rotation prosthesis creased humeral neck shaft angle notching, and increasing grade of
is used (Figure 5), the deltoid moment (Figure 6), in combination with an notching, is associated with worse
arm is improved as a result of a more appropriately placed glenoid may clinical outcomes.38-40 For example,
medial center of rotation.37 However, decrease the risk for notching.7,34 A in 2007, Wall et al39 evaluated 152
as discussed previously, this situation lateral glenoid with lateral humerus patients undergoing rTSA and found
leads to mechanical impingement and center of rotation prosthesis will that 50% had evidence of notching
notching. It also results in less deltoid improve the mechanical risk of at that time. No differences were
and rotator cuff tensioning, thus notching. But the deltoid moment found in mean Constant scores,
decreasing the stability and perfor- arm is again decreased, and the active ROM, or glenoid loosening
mance. When a lateral glenoid with deltoid and rotator cuff muscles are between patients with notching and
medial humerus center of rotation at the risk for overtensioning. those without.
March 15, 2019, Vol 27, No 6 205
Scapular Notching
Figure 6 Currently, guidelines do not exist to

determine when revision surgery is
indicated. Patient symptoms should
be the guiding force. The decision to
proceed with revision surgery is much
more difficult in the asymptomatic
patient with radiographic evidence of
high-grade notching. In asymptom-
atic patients, radiographic staging
may help determine when to proceed
with revision surgery. When plan-
ning revision surgery, obtaining a CT
scan can be helpful in evaluating
glenoid bone stock to determine the
need for bone grafting. When per-
forming revision surgery for scapular
notching, the surgeon is recom-
mended to revise the glenosphere to
one with more inferior overhang
and slight inferior tilt, use a larger
diameter glenosphere, and improve
lateral offset of either the humeral or
the glenoid implants.
Diagram demonstrating a medialized humerus (left) with a neck shaft angle of

155° and inset liner, and a lateralized humerus (right) achieved with the use of a
Summary
neck shaft angle of 132.5° and an onset liner.
The use of rTSA continues to grow as
indications expand, and long-term
By contrast, reports by Sirveaux results are validated. Scapular notch-
et al1 in 2004, Simovitch et al3 in
Treatment ing is a frequently reported complica-
2007, Wellmann et al5 in 2013, and Recommendations tion and results in negative clinical
Mollon et al4 in 2017 all demon- outcomes. When performing rTSA,
Surgical options to minimize the risk of
strated inferior Constant scores in surgeons should refrain from superior
scapular notching have been discussed
association with scapular notching placement or superior tilt of the
earlier in detail. Currently, techniques
(Table 1). Furthermore, a significant glenosphere or both. A deltopectoral
for the management of scapular
negative correlation has been found approach is most frequently used and
notching have not been reported.
between notching severity and func- appears to improve glenoid posi-
tional outcomes.1,3 Mollon et al4 A minimum follow-up of 24 months
tioning, thereby reducing the risk for
examined 476 shoulders following has been recommended to determine notching. Lateral offset with inferior
rTSA and found a notching rate of the presence of notching. However, overhang of the glenosphere provides
approximately 10%, a rate lower as noted previously, one group found the greatest reduction in notching.
than most previous reports. They no notching at a minimum 2-year The use of glenoid bone augmenta-
found significantly lower postsurgical follow-up on 96 patients following tion to restore offset, and the use
American Shoulder and Elbow Sur- rTSA. But the same study reported a of a glenosphere with a lateral center
geons (P , 0.05), Constant (P , notching rate of 9% at 4 years on of rotation or lateralized humeral
0.01), Simple Shoulder Test (P , the same cohort of patients.12,13 implant and optimal glenoid tilt are
0.05), and University of California- Although no specific guidelines exist emerging areas of interest to minimize
Los Angeles (P , 0.05) shoulder for rTSA follow-up, annual or the risk of notching. Decreasing the
scores in patients with scapular biannual clinical examinations and humeral neck shaft angle also de-
notching as compared with those radiographs are warranted for those creases the tendency for mechanical
without scapular notching at a mean patients demonstrating notching or impingement. The efficacy of these
follow-up of 38 months. progression of notching. techniques in the prevention of
Table 1
Comparison of Studies Evaluating Notching and Functional Outcomes
Average Humeral Notching Effect
Follow-up Patient Neck Shaft Notching Grade of on Clinical
Study (mo) Age (yr) Angle (°) Lateralization Incidence Notching Outcome
Sirveaux et al1 44 72.8 NA Yes—via 63.60% 53.1% grade 1 Only notching grades
humeral cup 3 or 4 correlated
with significant
decline in constant
scorea
— — — — — 20.4% grade 2 —
— — — — — 14.3% grade 3 —
— — — — — 12.2% grade 4 —
Werner et al38 38 68 155 Yes—via 96% 54% grades 1-2 No correlation
humeral cup
— — — — — 46% grades —
3-4
Wall et al39 39.9 72.7 155 NA 51% NA No correlation
Simovitch at al3 44 71 155 Yes—via 44% 17.6% grade 1 Notching, as well as
humeral cup increasing notching
grade, correlated
with significant
decline in constant,a
subjective
shoulder,a active
flexionb and
abduction scoresa
— — — — — 41.1% grade 2 —
— — — — — 35.3% grade 3 —
— — — — — 5.8% grade 4 —
Wellman et al5 23 72 155 NA 43% 63.6% grade 1 Notching correlated
with a significant
decline in constant
scorea
— — — — — 9.1% grade 2 —
— — — — — 15.2% grade 3 —
— — — — — 12.1% grade 4 —
Mollon et al4 38 72.5 145 Yes—via 10.10% 79% grade 1 Notching correlated
glenoid with a significant
decline in constant
score,b ASES,a
SST,a UCLA,a
abduction,b and
strength scoresb
— — — — — 13% grade 2 —
— — — — — 8% grade 3 —
— — — — — 0% grade 4 —
ASES = American Shoulder and Elbow Surgeons, NA = information not available, SST = Simple Shoulder Test, UCLA = University of California-Los Angeles
a
P , 0.05.
b
P , 0.01.
scapular notching should become tial complications to reduce the risk Not all reverse shoulder arthro-
clearer over time. These strategies of stress fracture, instability, glenoid plasty implants are the same, and it is
must be balanced with other poten- loosening, and failure. the responsibility of the surgeon to
March 15, 2019, Vol 27, No 6 207
Scapular Notching
understand the biomechanics and References 14, 16, 37, and 40 are cementless reverse total shoulder
arthroplasty: A comparative study with 2 to
design of the implant they choose to level V reports or expert opinions. 5 years of follow-up. J Shoulder Elbow Surg
use to minimize the risk of notching in 2014;23:1208-1214.
each individual patient. There are References printed in bold type are
12. Cuff D, Pupello D, Virani N, Levy J,
many combinations of offset and those published within the past 5 years. Frankle M: Reverse shoulder arthroplasty
for the treatment of rotator cuff deficiency.
eccentricity of implants available on 1. Sirveaux F, Favard L, Oudet D, Huquet D,
J Bone Joint Surg Am 2008;90:
the market today, and no one single Walch G, Mole D: Grammont inverted
1244-1251.
total shoulder arthroplasty in the treatment
factor appears to contribute solely to of glenohumeral osteoarthritis with massive 13. Cuff D, Clark R, Pupello D, Frankle M:
scapular notching. No clinical out- rupture of the cuff: Results of a multicentre Reverse shoulder arthroplasty for the
study of 80 shoulders. J Bone Joint Surg Br treatment of rotator cuff deficiency: A
comes studies exist that directly 2004;86:388-395. concise follow-up, at a minimum of five
compare the various types of im- years, of a previous report. J Bone Joint
2. Lévigne C, Garret J, Boileau P, Alami G,
plants available for clinical use. Favard L, Walch G: Scapular notching in
Surg Am 2012;94:1996-2000.
Using a medial glenoid with lateral reverse shoulder arthroplasty: Is it 14. Eichinger JK, Galvin JW, Grassbaugh JA,
humerus center of rotation prosthesis important to avoid it and how? Clin Parada SA, Li X: Glenoid dysplasia:
Orthop Relat Res 2011;469:2512-2520. Pathophysiology, diagnosis, and
improves the deltoid moment arm management. J Bone Joint Surg Am 2016;
while maintaining tension on the 3. Simovitch RW, Zumstein MA, Lohri E,
98:958-968.
Helmy N, Gerber C: Predictors of scapular
rotator cuff muscles and simulta- notching in patients managed with the delta 15. Friedman RJ, Hawthorne KB, Genez BM:
neously reduces the risk of notching. III reverse total shoulder replacement. J The use of computerized tomography in the
Bone Joint Surg Am 2007;89:588-600. measurement of glenoid version. J Bone
A lateral glenoid with medial hu-
Joint Surg Am 1992;74:1032-1037.
merus center of rotation prosthesis 4. Mollon B, Mahure SA, Roche CP,
Zuckerman JD: Impact of scapular 16. Abboud JA, Bateman DK, Barlow J:
also decreases the risk of notching, notching on clinical outcomes after reverse Glenoid dysplasia. J Am Acad Orthop Surg
but it does not benefit from the same total shoulder arthroplasty: An analysis of 2016;24:327-336.
improvement in center of rotation 476 shoulders. J Shoulder Elbow Surg
2017;7:1253-1261. 17. Fortun CM, Streit JJ, Horton SA, Muh SJ,
and deltoid moment arm. Gillespie RJ, Gobezie R: Scapular neck
5. Wellmann M, Struck M, Pastor MF, length and implications for reverse total
Very little specific information exists
Gettmann A, Windhagen H, Smith T: Short shoulder arthroplasty: An anatomic study
to direct the surgeon in the manage- and midterm results of reverse shoulder of 442 cadaveric specimens. Int J Shoulder
ment of scapular notching when it arthroplasty according to the preoperative Surg 2015;9:38-42.
etiology. Arch Orthop Trauma Surg 2013;
occurs. Evidence now suggests that 133:463-471. 18. Paisley KC, Kraeutler MJ, Lazarus MD,
scapular notching affects functional Ramsey ML, Williams GR, Smith MJ:
6. Alentorn-Geli E, Samitier G, Torrens C, Relationship of scapular neck length to
outcomes and may result in clinical Wright TW: Reverse shoulder arthroplasty. scapular notching after reverse total
failure and the need for revision sur- Part 2: Systematic review of reoperations, shoulder arthroplasty by use of plain
revisions, problems, and complications. radiographs. J Shoulder Elbow Surg 2014;
gery. Therefore, surgeons should
Int J Shoulder Surg 2015;9:60-67. 23:882-887.
consider following patients with
7. Erickson BJ, Frank RM, Harris JD, Mall N, 19. Frankle MA, Teramoto A, Luo ZP, Levy JC,
progressive notching, even when Romeo AA: The influence of humeral head Pupello D: Glenoid morphology in reverse
asymptomatic, with clinical exami- inclination in reverse total shoulder shoulder arthroplasty: Classification and
nation and radiographic follow-up. arthroplasty: A systematic review. J surgical implications. J Shoulder Elbow Surg
Shoulder Elbow Surg 2015;24:988-993. 2009;18:874-885.
Because the rate of rTSA continues
to increase, scapular notching and 8. Feeley B, Zhang A, Barry J, et al: Decreased 20. Heylen S, Van Haver A, Vuylsteke K,
scapular notching with lateralization and Declercq G, Verborgt O: Patient-specific
its consequences will become more inferior baseplate placement in reverse instrument guidance of glenoid component
significant. shoulder arthroplasty with high humeral implantation reduces inclination variability
inclination. Int J Shoulder Surg 2014;8: in total and reverse shoulder arthroplasty. J
65-71. Shoulder Elbow Surg 2016;25:186-192.
9. Lévigne C, Boileau P, Favard L, et al: 21. Kempton LB, Balasubramaniam M,
References Scapular notching in reverse shoulder Ankerson E, Wiater JM: A radiographic
arthroplasty. J Shoulder Elbow Surg 2008; analysis of the effects of glenosphere
Evidence-based Medicine: Levels of 17:925-935. position on scapular notching following
reverse total shoulder arthroplasty. J
evidence are described in the table of 10. Edwards TB, Trappey GJ, Riley C, Shoulder Elbow Surg 2011;20:968-974.
contents. In this article, references 10, O’Connor DP, Elkousy HA, Gartsman
GM: Inferior tilt of the glenoid component 22. Mole D, Wein F, Dezaly C, Valenti P,
27, 31, and 36 are level I studies. does not decrease scapular notching in Sirveaux F: Surgical technique: The
References 3 and 39 are level II reverse shoulder arthroplasty: Results of a anterosuperior approach for reverse
prospective randomized study. J Shoulder shoulder arthroplasty. Clin Orthop Relat
studies. References 4, 8, 11, 20, 21, Elbow Surg 2012;21:641-646. Res 2011;469:2461-2468.
32, and 33 are level III studies. Ref-
11. Wiater JM, Moravek JE Jr, Budge MD, 23. Gutiérrez S, Levy JC, Frankle MA, et al:
erences 1, 2, 5-7, 9, 12, 13, 15, 22, Koueiter DM, Marcantonio D, Wiater BP: Evaluation of abduction range of motion
28-30, and 38 are level IV studies. Clinical and radiographic results of and avoidance of inferior scapular
impingement in a reverse shoulder model. J arthroplasty: A systematic review. Clin 35. Berhouet J, Garaud P, Favard L: Evaluation
Shoulder Elbow Surg 2008;17:608-615. Orthop Surg 2016;8:288-297. of the role of glenosphere design and
humeral component retroversion in
24. Gutierrez S, Walker M, Willis M, Pupello DR, 30. Boileau P, Moineau G, Roussanne Y, avoiding scapular notching during reverse
Frankle MA: Effects of tilt and glenosphere O’Shea K: Bony increased-offset reversed shoulder arthroplasty. J Shoulder Elbow
eccentricity on baseplate/bone interface forces shoulder arthroplasty: Minimizing scapular Surg 2014;23:151-158.
in a computational model, validated by a impingement while maximizing glenoid
mechanical model, of reverse shoulder fixation. Clin Orthop Relat Res 2011;469: 36. Torrens C, Guirro P, Miquel J, Santana F:
arthroplasty. J Shoulder Elbow Surg 2011;20: 2558-2567. Influence of glenosphere size on the
732-739. development of scapular notching: A
31. Greiner S, Schmidt C, Herrmann S, Pauly S, prospective randomized study. J Shoulder
25. Nyffeler RW, Werner CM, Gerber C: Perka C: Clinical performance of lateralized Elbow Surg 2016;25:1735-1741.
Biomechanical relevance of glenoid versus non-lateralized reverse shoulder
component positioning in the reverse Delta arthroplasty: A prospective randomized 37. Routman HD, Flurin PH, Wright TW,
III total shoulder prosthesis. J Shoulder study. J Shoulder Elbow Surg 2015;24: Zuckerman JD, Hamilton MA, Roche CP:
Elbow Surg 2005;14:524-528. 1397-1404. Reverse shoulder arthroplasty prosthesis
design classification system. Bull Hosp Jt
26. de Wilde LF, Poncet D, Middernacht B, 32. Athwal GS, MacDermid JC, Reddy KM, Dis (2013) 2015;73(suppl 1):S5-S14.
Ekelund A: Prosthetic overhang is the most Marsh JP, Faber KJ, Drosdowech D: Does
effective way to prevent scapular conflict bony increased-offset reverse shoulder 38. Werner CM, Steinmann PA, Gilbart M,
in a reverse total shoulder prosthesis. Acta arthroplasty decrease scapular notching? J Gerber C: Treatment of painful
Orthop 2010;81:719-726. Shoulder Elbow Surg 2015;24:468-473. pseudoparesis due to irreparable rotator
27. Poon PC, Chou J, Young SW, Astley T: A cuff dysfunction with the delta III reverse-
33. Mollon B, Mahure SA, Roche CP, ball-and-socket total shoulder prosthesis. J
comparison of concentric and eccentric
Zuckerman JD: Impact of glenosphere size Bone Joint Surg Am 2005;87:1476-1486.
glenospheres in reverse shoulder
on clinical outcomes after reverse total
arthroplasty: A randomized controlled trial.
shoulder arthroplasty: An analysis of 297 39. Wall B, Nove-Josserand L, O’Connor DP,
J Bone Joint Surg Am 2014;96:e138.
shoulders. J Shoulder Elbow Surg 2016;25: Edwards TB, Walch G: Reverse total
131-e138.137.
763-771. shoulder arthroplasty: A review of results
28. Roche CP, Stroud NJ, Martin BL, et al: The according to etiology. J Bone Joint Surg Am
34. Langohr GD, Willing R, Medley JB, 2007;89:1476-1485.
impact of scapular notching on reverse
Athwal GS, Johnson JA: Contact
shoulder glenoid fixation. J Shoulder Elbow
mechanics of reverse total shoulder 40. Boileau P, Watkinson DJ, Hatzidakis AM,
Surg 2013;22:963-970.
arthroplasty during abduction: The effect Balg F: Grammont reverse prosthesis:
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March 15, 2019, Vol 27, No 6 209
Review Article
Perioperative Management of the

Orthopaedic Patient and Alcohol
Use, Abuse, and Withdrawal
Abstract
David P. Zamorano, MD Alcohol is one of most commonly abused substances in the United
Philip K. Lim, MD States, and it has contributed to a growing epidemic of medical

ailments, including cirrhosis, neurologic and psychosocial disorders,
Brandon A. Haghverdian, MD
impairment to fertility, and cancer. Moreover, acute and chronic
Ranjan Gupta, MD alcohol use represent a significant risk factor for orthopaedic injury and
postoperative complications. Yet, relatively little is known about the
clinical implications of alcohol abuse in common orthopaedic
procedures. Acute withdrawal from alcohol is potentially fatal,
particularly in the orthopaedic inpatient whose abstinence is
mandated by the hospital setting. The aim of this review is to address
the screening, diagnostic, and therapeutic tools available to
appropriately manage acute alcohol withdrawal in the orthopaedic
inpatient. The influence of chronic alcohol consumption on bone
metabolism, fracture healing, and surgical fixation will also be
From the UC Irvine Department of reviewed because this information may guide surgical decision
Orthopaedic Surgery, Irvine, CA
(Dr. Lim and Dr. Gupta), the
making.
Department of Orthopaedic Trauma,
Saint Alphonsus Health System,
Boise, ID (Dr. Zamorano), and the
University of Pennsylvania,
Philadelphia, PA (Dr. Haghverdian).
T he World Health Organization
estimates that an average Ameri-
can consumes more than 9 L of alcohol
tears.7 Notably, orthopaedic patients
undergoing elective procedures may
exhibit relatively lower rates of alcohol
Dr. Zamorano or an immediate family annually.1 Approximately 7% of dependence. Best et al8 determined
member serves as a paid consultant emergency department visits and that 0.6% of patients undergoing
to Smith & Nephew. Dr. Gupta or an
immediate family member serves as a
5% of primary care visits are alco- primary total joint arthroplasty have
board member, owner, officer, or hol related in nature.2 Furthermore, an established diagnosis of alcohol
committee member of the American patients with recidivism are more misuse. However, despite the lack of
Academy of Orthopaedic Surgeons, likely to have used alcohol or be medical comorbidities, this cohort
The American Society for Surgery of
the Hand, and the American Shoulder
intoxicated.3 Approximately 25% exhibited significantly longer hospital
and Elbow Surgeons. None of the of patients admitted to the ortho- stay and an increased risk for peri-
following authors nor any immediate paedic trauma service test positive operative complications (eg, pneumo-
family member have received for alcohol via toxicology screening.4-6 nia, blood transfusion, postoperative
anything of value from or have stock
or stock options held in a commercial
These patients most commonly sustain infection).
company or institution related directly low-energy injuries such as ground- Therefore, the widespread preva-
or indirectly to the subject of this level falls, and they present more fre- lence of alcohol use, abuse, and
article: Dr. Lim and Dr. Haghverdian. quently with lower extremity fractures dependence poses a substantial risk
J Am Acad Orthop Surg 2019;27: particularly at the ankle, hip, and for poorer outcomes in the peri-
e249-e257 tibia.5 Upper extremity injuries pri- operative setting. A thorough and com-
DOI: 10.5435/JAAOS-D-17-00708 marily involve the proximal humerus prehensive understanding of alcohol
and distal radius. Long-term alcohol dependence and withdrawal may
Academy of Orthopaedic Surgeons. intake is also a risk factor for less ameliorate some of the downstream
emergent injuries, such as rotator cuff negative consequences of acute and
March 15, 2019, Vol 27, No 6 e249
Management of Patients With Alcohol Use
chronic intoxication. This article ingestion of alcohol. The rate of alco-

comprehensively reviews the clinical hol metabolism by the liver begins to
Diagnosis and Screening
tools available for screening, diag- increase within weeks of heavy alco-
Orthopaedic patients should be evalu-
nosis, preoperative planning, and hol use ($2 drinks per day). Motor
ated for alcohol use disorder in both
postoperative management of and cognitive signs may be subtle and
the ambulatory and the hospital envi-
orthopaedic patients who misuse difficult to detect in such patients;
ronments (Table 1). Screening begins
alcohol. We aim to provide simple however, the end-organ effects of daily
with a comprehensive social history,
and clinically practical information drinking are often clinically apparent.
including: (1) the quantity, frequency,
to assist the surgeon in managing this These include alterations in the func-
and type of alcohol consumption, (2)
highly prevalent spectrum of disease. tion of cardiovascular, gastrointestinal,
co-usage of other substances, (3) his-
hepatic, male gonadal, psychiatric,
nervous, and hematopoietic organ tory and frequency of episodes of
Definition and systems. The proximal gastrointes- transient amnesia (blackouts), (4)
Pharmacology tinal tract, notably the esophagus history of treatments for alcohol mis-
and stomach, is vulnerable to Mallory- use, and (5) a detailed family history of
A standard alcoholic beverage con- substance abuse. A nonjudgmental
Weiss tears and transmural lesions
tains 12 to 14 g of ethanol, as found approach should be adopted in ob-
(Boerhaave syndrome). Transmural
in 12 ounces of beer (5% alcohol taining this history through a direct
lesions may lead to rapid volume loss
content), 4 ounces of wine (12% patient-physician interview, rather
and potentially fatal hypovolemic
alcohol content), and 1.5 ounces of than a paper survey. Such measures
shock. Moreover, alcohol is also a
80-proof (40% alcohol content) minimize the influence of social
leading contributor of acute and
distilled spirits or liquor. Ethanol desirability bias in patient’s responses.
chronic pancreatitis. 10 Alcohol-
has a predominantly activating influ- A variety of screening instruments
associated hepatic disease, includes
ence on the inhibitory g-aminobutyric have been developed to predict the
acute hepatitis, fatty changes, and
acid (GABA) receptor with subsequent likelihood of abuse in patients who
end-stage cirrhosis. A linear corre-
depressive effects in the central nervous admit to consuming alcohol. Among
lation between chronic alcohol use,
system. Its depressant profile is these are the CAGE questionnaire
levels of testosterone in men, and
further reinforced by the inhibition (Cutting down, Annoyance by criti-
developmental anomalies in their
of postsynaptic excitatory N-methyl- cism, Guilty feeling, and Eye-openers)
children has also been suggested.11
d-aspartate glutamate receptors. and the 10-item Alcohol Use Disorders
Chronic abuse can increase the risk
Benzodiazepines, barbiturates, and Identification Test (AUDIT). Although
of malignancies, including cancers of
short-acting, oral, nonbenzodiazepine both screening tools have been well
the mouth, esophagus, throat, liver,
hypnotics, such as zolpidem, zaleplon, validated, AUDIT has demonstrated
and pancreas. Neurologic injury
and eszopiclone, also potentiate superior sensitivity, specificity, and
associated with chronic alcohol
the g-aminobutyric acid receptor positive predictive value compared
consumption includes peripheral
at all levels of the neuraxis.9 Con- with CAGE, particularly in elderly
neuropathy, cerebellar deterioration,
vergence of these agents on an patients.12,13 Our preference is the
cerebral atrophy, Wernicke-Korsakoff
identical receptor is responsible AUDIT-PC, an abridged version of
syndrome, and alcoholic dementia.
for the cross-efficacy and cross- the AUDIT questionnaire, which
Neuropathic changes present in a
tolerance observed with simultaneous appears to have the best combination
similar fashion as diabetic neurop-
use. Therefore, vigilant monitoring of sensitivity, specificity, positive pre-
athy, with a stocking-glove distri-
against respiratory and cardiovas- dictive value, and area under the
bution of numbness, paresthesia,
cular depression should follow the receiver operating characteristic
and pain. Fortunately, relatively a
administration of these agents, par- curve. 14 However, it should be
few patients with alcoholism ex-
ticularly those administered intra- emphasized that these screening tools
hibit the classic triad of Wernicke
venously (IV) (eg, benzodiazepines, are designed to provoke a more
encephalopathy (WE)—ataxia, con-
barbiturates). meaningful, face-to-face interview.
fusion, ophthalmoplegia—which re-
sults from the depletion of thiamine. A series of predictable, consistent
Effects of Chronic Use on Korsakoff syndrome represents the alterations in serologic markers with
Organ Systems pernicious extension of this condi- sustained heavy alcohol consumption
tion; its clinical manifestations include exist; these alterations are most evident
Metabolic and pharmacokinetic tol- both retro- and anterograde amnesia in patients who consume eight or more
erance is acquired through the chronic and testimonial confabulations. drinks daily (Table 2).15 Elevated levels
David P. Zamorano, MD, et al
of gamma-glutamyl transferase and Table 1

carbohydrate-deficient transferrin are
Relevant Components of Medical History in the Alcoholic Patient
consistent with current, ongoing alco-
hol use; however, their levels may Medical history
normalize after several weeks following (1) Prior history of alcohol withdrawal symptoms
desistance. An elevated carbohydrate- (2) Prior hospitalizations for acute withdrawal symptoms
deficient transferrin may be an indica- (3) Prior attendance or participation in alcohol/drug rehabilitation centers and
tor of chronic alcohol use. Patients may program
also demonstrate macrocytosis (ele- Medication history
vated Mean Corpuscular Volume (1) Current and recent use of GABA-ergic agents (eg, benzodiazepines,
barbiturates, zolpidem, zaleplon, eszopiclone)
[MCV]), with or without associated
vitamin or mineral deficiencies. Pro- (2) Pharmacologic treatments for alcohol use disorder (eg, naltrexone,
acamprosate, disulfiram, topiramate)
gressive hepatic injury provokes serum
Surgical history
elevations in the liver-specific enzymes,
(1) Liver transplantation for alcoholic cirrhosis
aspartate transaminase/serum glutamic
Family history
oxaloacetic transaminase and alanine
(1) Alcohol use disorder or drug abuse
aminotransferase/serum glutamate-
pyruvate transaminase, classically Review of systems
in a .2:1 ratio. (1) Cardiovascular: chest pain, palpitations, lightheadedness, dizziness
Alcohol has broad effects on both (2) Gastrointestinal: abdominal pain, hematemesis, melena/hematochezia,
jaundice
motor and cognitive functions. The
(3) Neurological: numbness, paresthesias, vision changes, confusion, gait
signs and symptoms of acute intoxi- instability, tremor, amnesia
cation are largely dependent on
(4) Psychiatric: anxiety, depression, suicidality, poor focus and energy
blood alcohol levels, ranging from
Social history
mildly decreased inhibition to coma,
(1) Average number of drinksa per day or per week
cardiorespiratory depression, and
(2) CAGE and/or AUDIT-PC questionnaire
finally, death. Other signs of alcohol-
(3) Frequency of episodes of binge drinking ($five drinks on single occasion
induced impairment include slurred for men, $four for women)
speech, incoordination, unstable gait,
(4) Alcohol use before 21 years or during pregnancy
memory impairment, lethargy, and
(5) Prior attempts of sobriety and history of relapse
stupor. Alcohol may also induce
peripheral vasodilation of cutane- AUDIT = Alcohol Use Disorders Identification Test; CAGE = Cutting down, Annoyance by
ous and muscular arteries, even at criticism, Guilty feeling, and Eye-openers; GABA = g-aminobutyric acid
a
Defined as 12 ounces of beer (5% alcohol content), 8 ounces of malt liquor (7% alcohol
low concentrations. In combination content), 5 ounces of wine (12% alcohol content), and 1.5 ounces of 80-proof distilled spirits or
with ethanol-induced diuresis, dia- liquor.
phoresis, and emesis, this phenom-
enon could result in substantial
volume depletion and concordant who are withdrawing from heavy
use. Psychotic symptoms are rela-
Spectrum of Alcohol
alterations in blood pressure, heart
rate, and respiration rate. tively rare. But these symptoms Withdrawal Symptoms
Patients who abuse alcohol are at may include hallucinations, delu-
Patients with alcohol withdrawal may
the risk of a wide spectrum of psy- sions, or both. Nearly two thirds of
exhibit a variety of symptoms ranging
chosocial distress, including depres- patients with alcohol use disorder
from minor to life threatening (Table
sion, anxiety, and inability to maintain also meet diagnostic criteria for
3). Minor withdrawal symptoms (eg,
social-occupational responsibili- another psychiatric disorder, includ-
insomnia, tremulousness, mild anxiety,
ties.16 Depressive symptoms are ing antisocial personality disorder,
schizophrenia, affective disorders, and headache, diaphoresis) are the result of
common in nearly half of all patients
with heavy alcohol use; however, disorders of abuse (of tobacco or il- central nervous system hyperactivity,
these symptoms usually subside licit substances). Therefore, patients and these symptoms may begin as
within weeks of maintained absti- who abuse alcohol should receive soon as 6 hours after the patient’s last
nence. Similarly, transient anxiety appropriate referrals for psychiatric alcoholic drink. Patients exhibiting
is present in nearly one third of evaluation, pharmacotherapy, and minor withdrawal maintain normal
alcoholic patients, particularly those behavioral therapy. mentation, and if symptoms do not
March 15, 2019, Vol 27, No 6 e251
Table 2 time, prolonged, withdrawal seizures

a or a seizure that is different from
Laboratory Findings Suggestive of Chronic Alcohol Use
prior seizures should have a CT head
Basic metabolic Hypoglycemia, hypokalemia, to rule out other etiologies.
panel hypomagnesemia,
Alcoholic hallucinosis peaks at 12
hypophosphatemia, elevated
creatinine, elevated blood urea nitrogen to 48 hours after the last drink, and
Complete blood Leukopenia, macrocytosis (MCV . patients most often endorse visual
count 90 mm3), thrombocytopenia, hallucinations. These symptoms usu-
reticulocytopenia ally resolve in 24 to 48 hours, and
Liver function tests Transaminitis (elevated AST:ALT in 2:1 patients do not have any abnormal
ratio) sensorium or autonomic instability as
GGT .35 U opposed to DT. Hallucinations may
Serum uric acid .416 mol/L (7 mg/dL) prompt the addition of antipsychotics
CDT .20 U/L or .2.6% (eg, haloperidol), which can inadver-
Blood alcohol level Elevated (0.01-0.40 mg/dL) tently decrease the seizure threshold
Coagulation Increased PT/INR/PTT and inhibit physiologic thermoregu-
studies lation. Therefore, their routine use is
ALT = alanine aminotransferase, AST = aspartate transaminase, CDT = carbohydrate deficient
discouraged for the treatment of
transferrin, GGT = gamma-glutamyl transferase, INR = international normalized ratio, MCV = alcoholic hallucinosis.
mean corpuscular volume, PT = prothrombin time, PTT = partial thromboplastin time Typically, DT begins 48 to 96 hours
a
Values and ranges may differ from institution to institution.
after the last drink, may last multiple
days, and represents the most severe
Table 3 form of withdrawal. It occurs in
Symptoms of Alcohol Withdrawal
approximately 5% of patients, but it
is often associated with older patients
Hours Since Last with a history of chronic, heavy alco-
Alcoholic Beverage Clinical Manifestations
hol consumption. The constellation of
6-24 Minor withdrawal symptoms: insomnia, tremors, symptoms of DT includes hallucina-
irritability, anxiety, anorexia, headache, diaphoresis, tions, abnormal mentation, agitation,
palpitations, normal mental status, no autonomic
and seizures in the setting of auto-
instability
Postacute withdrawal syndrome (PAWS): persistence nomic instability (eg, tachycardia,
of minor withdrawal symptoms for 3-6 mo hypertension, hyperthermia, tach-
12-48 Alcoholic hallucinosis (visual, auditory, tactile ypnea, and diaphoresis). It is the
hallucinations) with normal mental status presence of autonomic instability and
Alcoholic withdrawal seizures (brief, unsustained), no altered sensorium that distinguishes
autonomic instability
DT from minor withdrawal symp-
48-96 DT: delirium (fluctuating cognition with impaired
attention), agitation, autonomic hyperactivity toms. Risk of mortality is increased in
(tachycardia, hypertension, tachypnea, the setting of DT secondary to elec-
hyperthermia, diaphoresis), seizures trolyte imbalance, which may pre-
dispose the patient to arrhythmias.
DT = delirium tremens
Before the advent of intensive care,
mortality caused by DT approached
35%, although the contemporary
progress, they will usually resolve in period, and status epilepticus is not rate with appropriate treatment is
24 to 36 hours. Postacute withdrawal consistent with withdrawal seizures. between 1% and 4%.17
syndrome (PAWS) is the persistence Management is achieved with low-dose
of these mild, non–life-threatening benzodiazepines, and the lack of sei-
symptoms for 3 to 6 months. zure resolution should trigger prompt Medical Management
Alcohol-withdrawal seizures usu- transfer to the intensive care unit
ally occur 12 to 24 hours after the last because of the risk of progression to Acute Intoxication
alcoholic drink, but these seizures delirium tremens (DT). Suggestions It is not uncommon to encounter the
may occur as soon as within 2 hours. for intensive care unit admission are acutely intoxicated patient in a post-
They usually occur over a short listed in Table 4. Patients with a first- traumatic condition. In this scenario,
the clinician should prioritize car- Table 4

diorespiratory and hemodynamic
Suggested Criteria for Transfer to Intensive Care Unit
stability, in addition to behavioral
management. Volume depletion and Cardiac disease (heart failure, arrhythmia, angina, myocardial ischemia, recent
myocardial infarction)
blood pressure lability should be ap-
propriately managed with vitamin Hemodynamic instability
and glucose supplemented fluids IV. Significant acid-base disturbance or electrolyte abnormalities
Particular attention should be paid to Respiratory distress or need for intubation
the administration of thiamine before Persistent hyperthermia (T . 39°C)
glucose to prevent progression to or Rhabdomyolysis
worsening of WE. The first dose of Renal insufficiency or increased fluid requirements
thiamine should be given IV with an Need for frequent or high-dose sedatives
additional four daily doses adminis- Withdrawal despite elevated ethanol concentration
tered orally. Patients with WE should History of alcohol withdrawal complications (DT, withdrawal seizures)
be given a prolonged course of high-
DT = delirium tremens
dose thiamine. Belligerent behavior is
best addressed with gentle reassur-
ance, although the use of physical
restraints may be implemented to
However, chlordiazepoxide is hep- turbances, auditory disturbances,
prevent self-harm or injury to others.
atically metabolized and should be tactile disturbances, tremor, and
Low-dose benzodiazepines (eg, lor-
used cautiously in patients with disorientation. Serial assessment and
azepam 1 to 2 mg orally or IV) should
hepatic impairment. ratings are best performed by the same
be used judiciously because they may
For patients older than 50 years or provider to limit interrater variability.
acutely jeopardize cardiac and respi-
with significant cardiac history or Scores of .20 are suggestive of severe
ratory stability.
tachycardia, one should consider withdrawal.
obtaining an electrocardiogram. It is
Acute Withdrawal also important to consider differen-
tial diagnoses for tachycardia (eg, Effects of Alcohol on Soft
In the hours and days following the
patient’s last drink, close observation pulmonary embolism, sepsis, acute Tissue, Bone, and Fracture
should be maintained for the signs blood loss anemia, hyperthyroidism, Healing
and symptoms of alcohol with- beta blocker withdrawal) if the diag- Soft tissue healing may be impaired in
drawal. Minor withdrawal symptoms nosis of alcohol withdrawal is in the patient with alcohol exposure.
generally begin 6 to 24 hours after the doubt. Even acute intoxication is associated
patient’s last drink. Initial manage- with the suppressed production of
ment of these patients includes plac- proinflammatory cytokines involved
ing them in a quiet room to minimize
Perioperative in the acute stages of wound healing.
environmental stimuli. Pharmaco- Considerations In animal models, acute intoxication
logic treatment should be symptom Nursing supervision during the was associated with poor angiogen-
triggered during this phase (Table 5); perioperative period should include esis, epithelialization, and wound
we recommend frequent administra- systematic assessments for the signs healing.19 Deep connective tissue
tion of low-dose lorazepam (eg, 1 to and symptoms of withdrawal. The repair may be faulty owing to the
2 mg every 20 to 30 minutes) until most commonly used assessment diminished collagen production and
symptoms improve. Lorazepam is a method is the Clinical Institute impaired remodeling to mature col-
short-acting benzodiazepine that for- Withdrawal Assessment for Alcohol lagen. This effect is more pronounced
tuitously bypasses liver metabolism, revised scale.18 It is a well-validated in patients with other risk factors,
and therefore, it may be used in instrument to objectively assess with- such as diabetes, tobacco use, and
alcoholic patients with hepatic insuf- drawal symptom severity and monitor corticosteroid use.
ficiency. Alternatively, some clinicians for changes in the autonomic and Chronic alcohol exposure has well-
prefer benzodiazepines with longer physiologic states of the patient.18 The established effects on the musculo-
half-lives, such as chlordiazepoxide domains tested include nausea or skeletal system. It is the most common
(eg, 25 to 50 mg every 4 to 6 hours), vomiting, paroxysmal sweats, anxi- etiology of idiopathic avascular
to minimize blood-level fluctuations. ety, agitation, headache, visual dis- necrosis of the femoral head.20
March 15, 2019, Vol 27, No 6 e253
Table 5 findings have been poorly translated

to investigations in humans. The
Treatment of Alcohol Withdrawal Symptoms
limited data that are available suggest
First-line therapy Protected, quiet environment with low light and that there is an increase in healing
noise stimuli
time for fracture in patients with
IV thiamine (500 mg) before glucose
administration alcohol use disorders.
IV (or PO, if tolerated) thiamine (250 mg) daily
for the following 4 d
IV hydration (glucose-supplemented, Surgical Management
electrolyte and vitamin repletion)
Benzodiazepines IV diazepam 10 mg initially, then 5-10 mg IV or A history of alcohol abuse may have
PO every 3-4 hr significant influence on the surgical
Or lorazepam 1, 2, or 4 mg PO or IV every 10-
15 min until calm, then every 1-2 hr treatment plan and eventual clinical
Or chlordiazepoxide 25-50 mg PO every 4- outcome. In these patients, poor
6 hr (maximum 300 mg/d) patient compliance, diminished over-
Continue until clinically stable and CIWA-A ,8 all host status, and decreased bone
Monitor for respiratory depression; consider
intubation quality can have a deleterious effect on
the maintenance of fracture reduc-
Barbiturates (if refractory to Phenobarbital 260 mg IV initially, then 130 mg
benzodiazepines) as needed tion.28,32 The risk of perioperative
Consider intubation, but discontinue as soon complications, such as infection and
as patient is clinically stable mortality, are also increased in the
alcoholic patient.28,33-35 Therefore,
CIWA-A = Clinical Institute Withdrawal Assessment for Alcohol revised, PO = orally,
IV = intravenously general considerations for all surgical
procedures in these patients should
include appropriate handling of soft
tissues and minimization of unneces-
Alcohol also induces a state of net osteoprotegerin, and relatively nor-
sary dissection. Fracture management
bone loss resulting in osteopenia and mal markers of bone resorp-
and fixation constructs should be
increased fracture risk. Alcohol- tion.21,22,26-28 Overall malnutrition,
similar to those used in osteoporotic
induced osteopenia is an insidious muscular atrophy, and diminished
fractures, but the overall manage-
process. It remains asymptomatic for weight bearing are also thought to
ment of fractures in alcoholic patients
decades before the first alcohol- accentuate the detrimental effects of
can be more challenging because
related pathologic fracture occurs, alcohol on net bone formation.22
there is often significantly diminished
and any abnormalities are uncovered Various hormonal changes may also
patient compliance concomitant with
on bone density scans.21-23 The contribute to alcohol-induced os-
the poorer quality of bone and soft
current consensus regarding alcohol- teopathy; in particular, decreased
tissues. When surgical management
induced bone loss is that chronic production of gonadal testosterone
of a fracture is indicated, it is imper-
alcohol use suppresses normal osse- and increased synthesis of cortisol.
ative that the surgeon considers the
ous turnover activity, thereby lead- This reduced ability of bone forma-
likelihood of noncompliance when
ing to net skeletal demineralization. tion portends a fourfold increased risk
determining the optimal surgical and
Histopathologic analysis of bone of fracture in alcoholic patients when
postoperative treatment plans.
tissue in patients with alcohol abuse compared with age-matched control
has demonstrated the widespread subjects.23,28-30 The ability of fractures
loss of bone area, osteoid density, to achieve union in the chronic alcohol Ankle Fractures
and osteoblast number.21,24,25 The user may be jeopardized, although the Ankle fractures are one of the most
effect of alcohol on bone resorption studies supporting this finding are common fracture seen in alcohol abuse
is less clear, although it appears that limited to mostly animal models. patients. Poor bone mineralization and
alcohol-induced osteopenia is not Rodent studies have consistently quality in these patients result in a
associated with increased osteoclas- demonstrated significant decreases reduction of overall bone stiffness,
tic activity. These findings are sup- in the production and mechanical thereby increasing their risk of de-
ported by changes in biochemical properties of fracture callus be- veloping an ankle fracture from low-
markers of bone remodeling: de- fore and after femoral and tibial energy mechanisms. This is akin
creased markers of bone formation osteotomies in animals fed diets to elderly osteoporotic fractures,
(eg, plasma osteocalcin), increased containing ethanol.31 However, these and fracture fixation can follow a
corresponding treatment plan. There the alcoholic patient, a variety of ad- Just as implant choices must be
should be consideration for the use juncts exist to augment laterally altered when caring for alcoholic
of locking plates and the placement based locked plates, which are typi- patients, reduction and provision
of syndesmotic screws even in the cally used when these fractures do not fixation techniques should be altered.
absence of syndesmotic disruption to necessitate arthroplasty. Additional The use of heavy sutures placed into
increase the overall stability in these surface implants, bone void fillers, the rotator cuff can assist with frac-
patients. and medial cortical struts can be ture reduction. Appropriate choice
The handling of soft tissues should useful tools to increase the strength of and placement of clamps can reduce
include techniques to minimize the construct. Fragment-specific fix- the risk of perforation or cutout from
wound-healing complications because ation with minifragment plates, or the cortex and iatrogenic fractures.
of poor nutrition and subsequent in- the placement of a 2.7-mm plate Additionally, the use of K-wires (eg,
creased risk of infection. In the setting along the medial calcar of the proxi- acromion to head, head to glenoid)
of significant soft tissue compromise mal humerus can enhance construct can be used for provisional fracture
such as the presence of large fracture stability. Ideally, this surface implant reduction.
blisters, one can consider the use of an is placed after the medial calcar has For displaced or comminuted two-
intermedullary implant into the fibula been reduced. However, the plate can part surgical neck fractures in osteo-
through a percutaneous incision. also be used as a reduction tool. The porotic bone, the use of an antegrade
However, this incision can only be broader “footprint” of the plate can intramedullary nail is a consideration.
performed in select fracture patterns increase the reduction surface area Modern proximal humerus intra-
without significant displacement or and may prevent iatrogenic commi- medullary implants have several inter-
angulation because fibular fracture nution of the fracture that may locking options into the head and neck
reduction is indirect. In addition, otherwise happen with standard bone to increase construct rigidity. Further-
in very low demand patients with clamps. more, intramedullary nailing carries the
concerns about the soft tissue and Augmentation with drillable bone advantage of minimal soft tissue dis-
noncompliance, a calcaneotalotibial void fillers (eg, calcium phosphate ce- section; however, a discussion should
nail or ring external fixator can be ments) may also enhance fracture sta- be had with the patient regarding the
used to stabilize the ankle. bility. These bone fillers can be injected possibility of rotator cuff violation and
Special attention should be paid to before or after inserting screws. Intra- the risk of chronic shoulder pain.
the postoperative management of medullary cortical strut allografts and
ankle fractures in these patients. intramedullary plates can also be used
Although there have been studies that to augment fixation. These techniques Proximal Femur Fractures
advocate for early weight bearing in are most useful in providing additional Faroug et al28 reported increased
nonalcoholic patients after fixation support when the medial cortex or occurrence of proximal femur frac-
of uncomplicated bimalleolar ankle calcar or both cannot be adequately tures in younger patients with chronic
fractures, caution should be exercised reconstructed. Typically, the plate or alcohol use compared with non–
in the alcoholic patient. Prolonged allograft is passed anterograde through alcohol abuse patients, possibly sec-
non–weight bearing for at least the fracture site, down the intra- ondary to the increased involvement
6 weeks may be a prudent decision to medullary canal, and then passed ret- of these alcoholic patients in traumatic
allow for sufficient healing of both rograde into the humeral head with a accidents. Hip sparing procedures
soft and bony tissues. However, Kocher clamp. It is important to ensure should be performed in younger
despite weight-bearing precautions, that the strut is long enough so that individuals. But careful evaluation
poor patient compliance can ulti- there is sufficient purchase with screws of radiographs should be per-
mately result in wound breakdown proximal and distal to the fracture. formed because these procedures
and eventual postoperative infection. When using a plate as an intra- require healthy bone. Low-energy
A ring external fixator can be used medullary device, a stout, 3.5-mm, extracapsular hip fractures in the
for patients who develop an infection dynamic, compression plate should alcoholic patient can be treated simi-
and need hardware removed before be considered. However, capturing larly to geriatric extracapsular hip
complete fracture healing. the intramedullary plate with the fractures with appropriate fixation
laterally based implant is challenging. construct depending on the fracture
Removing the plate can also be diffi- pattern. One can consider augmented
Proximal Humerus Fractures cult. Therefore, the use of a cortical fixation with polymethylmeth-
When considering surgery for fixa- strut is the authors’ preferred method acrylate or calcium phosphate ce-
tion of proximal humerus fractures in of intramedullary adjunct fixation. ments, or additional surface implants
March 15, 2019, Vol 27, No 6 e255
such as fracture specific mini frag- increased adherence to postoperative from alcohol. However, further study
ment plates. However, low-energy instructions. Such behavioral changes is needed before this protocol can be
intracapsular hip fractures in patients have also demonstrated a biologic routinely recommended.38
whose bone quality and compliance effect with an improvement in bone Surgical complications are a signifi-
are compromised by ethanol abuse mineral density following adherence cant concern in patients with alcohol
are probably best suited for hemi- to a lifestyle modification plan in heavy use disorder, including infection,
arthroplasty with cementation into consumers of alcohol.36 Avenues bleeding, poor wound and bony
the femoral canal. Arthroplasty should should exist for patients to be referred healing, and mortality. Surgical man-
also be a consideration for patients to alcohol or substance abuse reha- agement of these fractures should fol-
with any signs of avascular necrosis. bilitation centers to assist with absti- low principles similar to those used in
Because of the risk of blood loss in hip nence and maintenance of sobriety. osteoporotic fractures and with the
procedures and hematologic abnor- use of adjuncts such as cements or
malities often associated with chronic fragment-specific plates as needed.
alcohol consumption, it is critical to Summary Postoperative management may ne-
review and monitor patient’s labo- cessitate extended durations of re-
ratory results before surgery to Management of the surgical patient stricted weight bearing to allow for
prepare for adequate perioperative with alcohol use disorder is multifac- adequate healing of soft and bony
resuscitation. eted, and it requires an acute aware- tissues. Although alcohol use disorder
ness of the special needs of these in the orthopaedic patient remains
patients in all phases of care. All a significant clinical challenge, the
Postoperative Care members of the treatment team should information provided herein may
For this challenging subset of be attentive to the clinical parameters equip the orthopaedic surgeon and
patients, postoperative care should and surgical considerations of this other providers with the knowledge to
be tailored to accommodate for the subset of patients. This begins with an properly identify, diagnose, and treat
increased risk of complications stem- appropriate identification of the risks the patient with excellent clinical care.
ming from decreased compliance to involved with surgery in these pa-
postoperative instructions. This is tients, as well as a comprehensive
particularly important for lower discussion about the benefits of absti- References
extremity fractures where noncom- nence before the surgery. For patients
pliance to weight-bearing restrictions involved in traumatic accidents, such
can lead to wound complications and preoperative efforts are not always
contents. In this article, reference 37
fixation failure. In addition to other possible. But nevertheless, it is still
is a level I study. References 7, 8, 17,
adjuncts, such as the application of a imperative to evaluate and monitor
23, 29, 30, 34, 35, and 38 are level III
flexed long leg cast after ankle frac- patients vigilantly. In the acute with-
studies. References 3-6, 12-14, 22,
ture fixation, reinforcement and drawal phase, these patients should be
27, 28, 30, 33, and 36 are level IV
extension of limited weight bearing observed closely for withdrawal
studies. Reference 32 is a level V study.
should be considered. Prolonged symptoms with benzodiazepine treat-
admission in the hospital may be ment as the benchmark therapy for References printed in bold type are
warranted to provide sufficient time signs or symptoms of withdrawal. those published within the past 5 years.
for evaluation by psychiatric and Notably, therapy should be symptom
1. Global Status Report on Alcohol and Health:
behavioral services, in addition to triggered because this has been shown Individual Country Profiles (United States
physical therapy to determine patients’ to decrease the duration of with- of America). World Health Organization.
ability to safely mobilize indepen- drawal symptoms and quantity of 2014. http://www.who.int/substance_abuse/
publications/global_alcohol_report/profiles/
dently. If patients are unable to benzodiazepine administered com- usa.pdf?ua=1. Accessed May 2017.
comply or are deemed unsafe, then pared with scheduled benzodiazepine
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March 15, 2019, Vol 27, No 6 e257
Review Article
Evaluation and Treatment of

Patients With Acetabular Osteolysis
After Total Hip Arthroplasty
Abstract
Neil P. Sheth, MD As the demand for total hip arthroplasty (THA) continues to increase,
Joshua C. Rozell, MD the burden of revision THA is also expected to increase. Although the
quality of polyethylene has improved markedly, osteolysis continues
Wayne G. Paprosky, MD
to be a risk for older designs and younger, active patients. Although
progressive but typically asymptomatic in early stages, osteolysis can
result in component failure and complicate revision surgery. Serial
radiographs are paramount for monitoring progression. Although
select cases may be treated with observation, surgery should be
considered based on age, activity level, and projected life span. Well-
fixed, noncemented modular acetabular components may be treated
Surgery, University of Pennsylvania, with curettage and bone grafting, as well as having to bear liner
Perelman School of Medicine, exchange with retention of the acetabular shell. However, in the
Philadelphia, PA (Dr. Sheth and
Dr. Rozell), and the Department of
setting of osteolysis, it is controversial whether bone grafting and
Orthopaedic Surgery, Rush University component retention is superior to cup revision. This review explores
Medical Center, Chicago, IL the pathophysiology of osteolysis after THA and provides a
(Dr. Paprosky).
comprehensive analysis of the evaluation and treatment of patients
Dr. Sheth or an immediate family with osteolysis.
to Smith & Nephew and Zimmer
Biomet. Dr. Paprosky or an immediate
family member has received royalties
from Intellijoint, Stryker, and Zimmer
DePuy Synthes, Medtronic, Stryker,
O steolysis after total hip arthro-
plasty (THA) continues to be a
common cause of revision surgery.1
the surgical findings during revision
of cemented implants; areas of bone
loss were associated with polymethyl
and Zimmer Biomet; has stock or As such, bearing surface wear has led methacrylate cement–filled granulo-
stock options held in Intellijoint; has
received nonincome support (such as
to contemporary THA prosthesis mas, introducing the term cement
equipment or services), commercially designs. With the exponential in- disease. Somewhat of a misnomer, it
derived honoraria, or other non– crease in THA procedures being was later discovered that not only
research-related funding (such as performed and the number of pa- cement but any foreign particles in-
paid travel) from Cadence Health; and
tients with older designs and concluding metal, polyethylene, or cement
officer, or committee member of The ventional polyethylene, surgeons may induce an osteolytic reaction.2
Hip Society. Neither Dr. Rozell nor any must understand implant properties Older cup designs in conjunction with
immediate family member has to achieve the most favorable clinical conventional polyethylene and gamma
stock or stock options held in a com-
outcomes. irradiated in air have led to an
mercial company or institution related increased generation of free radicals,
directly or indirectly to the subject of which has been a long-term issue in
this article. 3% to 4% of THAs. These free
Background and
J Am Acad Orthop Surg 2019;27: Epidemiology radicals induce more wear particles,
e258-e267 osteolysis, and eventual component
DOI: 10.5435/JAAOS-D-16-00685 Osteolysis is a progressive, active, loosening.3,4
biologic cascade induced in response Periprosthetic osteolysis and asep-
Academy of Orthopaedic Surgeons. to particulate wear debris. The term tic loosening have been reported in
osteolysis was initially used to describe 5% to 78% of patients5,6 and are
Neil P. Sheth, MD, et al
leading causes of revision THA in considered methods to improve osteolysis.5 The activation of macro-
patients with conventional, non– polyethylene wear properties. phages and osteoblasts cause the
cross-linked polyethylene.7 Approxi- release of the receptor activator of
mately 10% of all revision THAs can nuclear factor kb ligand, which then
be attributed to osteolysis, accounting Pathophysiology of binds to its osteoclast receptor, stim-
for a projected 9,700 revisions by the Osteolysis ulating bone resorption and granu-
year 2030.8 Before the year 2000, the loma formation (Figure 1). In a
reported incidence of osteolysis The underlying stimulus for osteol- cadaver study of 17 specimens har-
ranged from 10% to 70% at 7- to 14- ysis is the generation of wear par- vested over a mean of 11 years,
year follow-up, mainly as a result of ticles. Micromotion at the THA particle-induced granulomas were
polyethylene processing.9 The advent bearing surface and the bone-implant present in the porous coating and
of highly cross-linked polyethylene interface allows for the production of along the acetabular implant-bone
(HXLPE) has exhibited improved particle-laden joint fluid. This fluid interface and progressed through
long-term survivorship of THA im- follows the path of least resistance screw holes, ballooning into the ret-
plants.1,2,8,10-15 In one study using through the effective joint space,18 roacetabular bone.19 Most of the
CT with an average 7.2-year follow- any area of bone in contact with the material within the granulomas was
up, Mall et al12 reported osteolysis in prosthesis that is accessible by joint polyethylene. Although polyethylene
12 of 50 hips (24%) with conven- fluid. For cemented prostheses, it is particles lead in the generation of
tional liners and only 1 of 48 hips the cement-bone interface or implant- mode 1 wear, or intended wear oc-
(2%) with HXLPE, representing a cement interface in a loose implant, curring between primary bearing
92% reduction in the incidence of resulting in a linear or balloon type surfaces, smaller but more numerous
appreciable osteolysis. Similarly, a pattern of radiolucency; for non- metal particles incite a milder
prospective, randomized study of cemented implants, any areas with- immune response.5,20
conventional and HXLPE poly- out bony ingrowth provide access to
ethylene at 10-year follow-up showed joint fluid and can result in osteolysis.
that the mean linear wear rate was Many cell types have been impli- Clinical Presentation
0.22 mm/yr for conventional and cated in osteolysis, namely, the
0.04 mm/yr for HXLPE. The inci- macrophage, osteoclast, osteoblast, Many patients with early osteolysis
dence of clinically important osteol- and fibroblast. However, the most are asymptomatic, which is typically
ysis was zero in the HXLPE group important cellular target is the macro- seen in patients 10 or more years
(lesions . 1.5 cm2).16 phage. The process begins with postoperatively.5,9,13,21 In a study of
Improvements in sterilization and macrophage-mediated phagocytosis 104 patients evaluating silent osteol-
processing have allowed for im- of foreign debris. Size rather than ysis after THA, 16.3% met the cri-
proved wear properties. Differences particle type has the greatest effect teria for loosening and 19.2% of
in doses of cross-linking radiation, on the biologic response, although patients were completely asymptom-
radiation techniques (ie, gamma ver- shape, composition, and surface also atic.10 In patients who do present
sus electron beam), thermal treat- alter the magnitude of the response.5 with symptoms, groin, low back, and
ments to quench free radicals (ie, Particles ,7 mm are recognized and buttock pain are common. If the
melting versus annealing), and ter- ingested by the macrophage, lead- components are loose, the patient
minal sterilization packaging (ie, gas ing to a release of cytokines may also experience start-up pain.
plasma, ethylene oxide, or gamma including tumor necrosis factor a Pain not resulting from implant
irradiation) all contribute to the sta- and interleukins 1 and 6. Matrix loosening is usually generated from
bility of ultra-high-molecular-weight metalloproteinases have also been particle-induced synovitis (Figure 2).
polyethylene.17 Whereas irradiated implicated in the process and have If the process is more advanced, pa-
and melted polyethylene has lower been found in periprosthetic tissues.2 tients can experience subluxation or
crystallinity (ie, lower mechanical The downstream effects of these dislocation events as a result of cap-
strength) but no oxidation potential, cytokines induce bone resorption. sular and soft-tissue laxity caused by
annealed polyethylene has higher The most notable transcription fac- recurrent effusions and a no longer
crystallinity but a greater potential tor implicated as an alternative path- concentric reduction of the femoral
for oxidation and osteolysis. Further way for osteolysis activation is nuclear head within the acetabular liner.
modifications such as mechanical factor kb. In vivo evidence shows that Patients with more advanced os-
compression, vitamin E enrichment, mice lacking this factor are protected teolysis may present with micro-
and sequential processing are being against titanium-induced calvarial trabecular fractures or fractures
March 15, 2019, Vol 27, No 6 e259
Evaluation and Treatment of Acetabular Osteolysis Following Total Hip Arthroplasty
Figure 1 Figure 2
Clinical photograph showing

particulate debris-related synovitis in
excised capsular soft tissues.
time elapsed since the index surgery

and knowledge of the bearing sur-
faces used can help guide the treatment
algorithm. For example, a patient with
evidence of osteolysis only 2 years
Illustration showing the cellular mechanisms of osteolysis. (Reproduced with
permission from Goodman SB, Gibon E, Yao Z: The basic science of after THA should increase the suspi-
periprosthetic osteolysis. Instr Course Lect 2013;62:201-206.) cion for periprosthetic infection.
Similarly, early osteolysis in patients
with metal-on-polyethylene bearing
through osteolytic areas, especially polyethylene edge loading, decreas-
surfaces should raise concern for
the greater trochanter. Finally, late ing wear. Accounting for each pa-
trunnionosis. In patients with MOM
implant loosening occurs in patient’s native anatomy and soft-tissue
articulations, cobalt and chromium
tients with long-standing osteolysis. tension mitigates the stresses across
levels must be obtained, and, if ele-
Importantly, patients who present the implant and limits impingement
vated, metal subtraction MRI or
asymptomatically usually have early and eccentric wear.
ultrasonography is performed to
wear because of polyethylene or Implant-related factors include
evaluate for pseudotumor formation.
early metal-on-metal (MOM) wear, bearing surfaces and modularity, as
Regardless of time since surgery,
but all others (ie, trunnionosis, infec- well as polyethylene-related sterili-
however, infection must always be
tion, and loose implants) usually pre- zation, shelf life, and thickness.9
ruled out with an erythrocyte sedi-
sent with some degree of pain. Although earlier wear was seen in
mentation rate and C-reactive pro-
older polyethylene designs with im-
tein. If elevated, aspiration of the hip
proper component positioning, ap-
Risk Factors is indicated before making any treat-
propriate component abduction and
ment decisions.4
anteversion will limit wear with
Risks of osteolysis may be divided Imaging modalities offer further
newer, cross-linked designs. Com-
into patient, surgical, and implant insights into the degree of osteolysis.
ponent positioning and soft-tissue
factors. The typical patient who de- Serial radiographs are often used to
balancing synergistically optimize
velops osteolysis is a young, active assess the disease progression. When
the wear profile in THA.
male with a high body mass index22 notable wear has occurred, the most
who places high loads across the obvious finding is relative eccentric-
joint and demands more from the Diagnosis and Evaluation ity of the femoral head within the
prosthesis, resulting in an accelerated acetabular shell (Figure 3). This can
wear profile. Unless patients present with osteolysis- be calculated by comparing the dis-
From the surgical perspective, related complications such as syno- tances from the superior and inferior
proper acetabular abduction and vitis, fracture, and implant loosening, edges of the femoral head to the
version angle decreases the amount of most are asymptomatic. However, superior and inferior aspects of the
Figure 3 Figure 4
AP radiograph of the hip showing

eccentric wear of the polyethylene
liner, resulting in superior migration
of the femoral head and edge
loading.
shell, respectively. These measure-

ments should be equal in the absence AP radiograph of the hip (A) and selected axial CT cut (B) showing a better
of eccentric wear. Comparing im- appreciation of the volume and severity of osteolysis on advanced imaging.
mediate postoperative and 6-week
radiographs to preoperative radio-
graphs will identify the presence of evidence of bone loss was on average lesion directly correlated with Harris
subchondral cysts, which should not 5.7 years. Even when lesions are pre- Hip Scores and inversely with patient
be mistaken for the development of sent, surgeon reliability in detection is age. Patient age was the sole factor in
osteolytic lesions. poor. In an independent assessment influencing the lesion size. Thus, CT
The Martell method uses a computer- of 60 patient radiographs by four ar- scans should be used in the younger,
assisted vector wear technique to throplasty surgeons, Engh et al6 agreed more active population earlier in the
determine linear polyethylene wear only on 57% of lesions. Agreement postoperative period to assess for le-
on digital radiographs. The direction increased when serial radiographs in sions; these patients should be moni-
of wear is determined by the center of orthogonal planes (ie, Judet views) tored with radiographs every 5 to 10
the femoral head with respect to the were used, emphasizing the impor- years for progression in the absence
center of the cup. In their study, tance of this temporospatial analysis of symptoms, and CT scans if they
Martell and Berdia23 found their tech- during patient follow-up. become symptomatic.13,24
nique to be 10 times more reproduc- To further assess osteolysis pro-
ible than with the use of calipers gression, use of three-dimensional
or a digitizing tablet. On autopsy of imaging has been advocated. CT Methods for Calculating
the specimens, the computer-assisted scans offer more precise information Wear
technique demonstrated three times about periacetabular osteolysis in terms
better accuracy than the manual of location (ie, whether the ischium is Several methods have been described
methods. involved21), volume, and associated for determining wear using plain
Plain radiographs typically under- bony defects (Figure 4). Scans may radiographs (Table 1). In a study that
estimate the size of osteolytic lesions provide more accurate assessment of compared these methods with digital
and may not detect small lesions.7,9,14 femoral and acetabular anteversion calipers, Pollock et al28 showed the
The sensitivity of radiographs in iden- and may be obtained in follow-up if wear template method to be the most
tifying osteolysis has been reported to component exchange is intended for accurate. The Dorr method consis-
be as low as 60%, with a specificity of suspected malposition.14,24 tently overestimated the true mea-
70% to 90%.24 Kitamura et al25 Appearance on a CT scan can also surement. By comparison, the wear
showed that despite lesions likely first correlate with patient function. In a template method does not require
appearing approximately 1.3 years retrospective study of 63 THAs using immediate postoperative films for
after surgery, time to radiographic CT, the total size of the osteolytic comparison.
March 15, 2019, Vol 27, No 6 e261
Table 1 pausal women who refused surgery for

osteolysis were treated with ner-
Commonly Used Methods for Calculating Acetabular Wear
idronate.33 After treatment, improve-
Method Measurement ment was observed in both Harris Hip
Dorr26 Measures the distance from the inferior and Scores and pain scores. Bone density
superior edges of the cup to the edge of the scores increased up to 7%.
femoral head. Half of the difference between Surgeon preference usually dictates
these two measurements defines femoral head when to operate on asymptomatic
penetration
patients. Although no concrete rules
Livermore27 Compares a measurement of the distance
between the femoral head and the shortest
exist as to when to trigger surgical
distance to the edge of the acetabular shell on an intervention for surveillance of os-
AP radiograph (on most recent radiograph). That teolysis, treatment should be used
measurement is then compared against the when there are worsening clinical
immediate postoperative film. Linear wear can
symptoms, appearance of implant
be calculated from this difference.
loosening, or more severe bone loss.
Wear template28 Relies on acetate templates provided by the
implant company that are calibrated to 20% Symptomatic patients with MOM
radiograph magnification. If the magnification is articulations or trunnionosis and
correct, the shortest distance between the edge high metal levels require earlier sur-
of the femoral head and the inner aspect of the gical intervention to prevent cardiac
acetabular component can be measured.
or neurologic complications and fur-
ther soft-tissue damage. Any change
in the patient’s clinical presentation
may require advanced imaging for
involving ,50% of the acetabulum
Classification of Osteolysis further delineation of the osteolytic
affecting one column, type IV is
lesions. The surgeon must have an
segmental and involves .50% loss
Many classification schemes have informed discussion with the patient
in both columns, and type V is
been developed to characterize ace- identifying the risks and benefits of
associated with pelvic discontinuity.7
tabular osteolytic lesions, allowing proceeding with revision versus
The Maloney classification was
standardization and guiding treat- continued observation. Because os-
devised to guide treatment based on
ment. Hozack et al29 characterized teolysis will not improve on its own,
the stability of the acetabular com-
three stages of osteolysis to dictate the patient must understand the risk
ponent and retention of the poly-
treatment. Stage I involves asymp- of lesion progression and the po-
ethylene liner.32 Importantly, certain
tomatic but radiographic wear. Stage tential for component loosening,
criteria were described to guide
IIa describes clinical symptoms associ- which may necessitate a larger, more
retention versus revision of the
ated with wear. Stages IIb and III complex revision surgery.
components (discussed later).
describe wear in the presence of os-
teolysis for patients who are asymp-
tomatic or symptomatic, respectively. Treatment Preoperative Planning
Advancing stage is associated with a Formulating a preoperative plan is
higher degree of surgical difficulty The treatment algorithm for acetabu- paramount to a successful surgery
because of bone loss. lar osteolysis begins with an assessment and can be thought of in the following
The Saleh et al30 and Gross classi- of the patient’s symptoms, activity sequence: radiographic review, sur-
fication similarly provides logical level, and medical comorbidities. gical approach, implant require-
reconstructive options with good Unless the patient presents with ments, instability concerns, and defect
interobserver reliability. The system symptoms, observation and activity treatment. One must keep in mind
distinguishes between cavitary and modification is usually appropriate. that a shell or femoral component that
segmental defects based on the Follow-up with serial imaging stud- appears well fixed radiographically
anticipated remaining bone stock ies every 6 months to assess osteolysis may be determined to be loose intra-
after implant removal.31 Type I has progression and medical treatment operatively. Thus, even when planning
no notable loss of bone stock (ie, a with the use of NSAIDs, diphospho- for an isolated polyethylene liner
well-fixed cup with osteolysis), type nates, or interleukin 1b antagonists exchange, the surgeon should always
II has contained (cavitary) loss, type have been recommended by some.8 be prepared to revise the shell. In-
III has uncontained (segmental) loss In one small series, four postmeno- dications for cup revision include
malposition, instability after screw Table 2

removal, minimal bony ingrowth, the
Items to Consider When Preoperatively Planning for Revision Total Hip
inability to cement a new liner Arthroplasty for Acetabular Osteolysis
because of the small shell size or old
Acetabular Component Evaluation Checklist
acetabular component design, and
shell erosion by the femoral head.34 1. Component manufacturer
2. Shell size
Surgical Approach 3. Modular versus monoblock component
Exposure is influenced by the number 4. Presence of screws/screw holes
of components needing revision and 5. Shape of the shell (hemisphere versus elliptical)
requires a systematic approach. The 6. Shell thickness
use of previous incisions may or may 7. Type of locking mechanism (ie, extraction device)
not be possible depending on the need 8. Acetabular shell track record
for an extensile exposure. Intra- 9. Potential for shell to accept constrained liners
operative assessment of the compo-
nents is the definitive method to assess
loosening. Circumferential acetabular
exposure must be obtained with femoral head, the size heads avail- consider using a constrained or dual
removal of all fibrous tissue to able, whether a liner can be cemented mobility liner. However, a new cup
prevent a false sense of cup stability. in place if the locking mechanism is with a constrained liner will not be
After all screws are removed, the shell not intact, and whether a constrained able to withstand the stresses of
should be assessed for stability by liner or dual mobility articulation motion and is likely to fail. Similarly,
applying manual force with a rongeur may be necessary. Acquisition of the large bipolar heads may allow for
or pliers or applying an axial force to outside hospital surgical report is increased range of motion but have
the cup with the inserter handle while beneficial in identifying the approach been shown to have an increased rate
looking for egress of blood or fluid at and exposure used previously and the (4%) of intraprosthetic dislocation
the bone-implant interface.7,35,36 The implants currently in place. Obtain- because of the higher torque on the
areas of osteolysis should be identified, ing implant stickers may also be nec- articulation interface.38 A preopera-
specifically in the dome, medial wall, essary. Equipment including revision tive CT scan enables the surgeon to
ischium, anterior and posterior col- components, head and liner trials, evaluate the acetabular position
umns, and pubic ramus. allograft, porous-coated implants, more accurately and can aid in sur-
Several criteria should be met to and cementable liners should be gical planning. Table 2 outlines
retain the acetabular shell. First, the available. Evaluation of the stem is important parameters that should be
implant should have a good track also critical. Not only is the type of used to evaluate the acetabular shell
record (ie, has the cup been associated stem important but also the taper size preoperatively.
with delamination? What mode of (ie, is there more than one taper Modular femoral heads and vari-
sterilization is used? What is the shelf option for each stem?) and the ability ous neck lengths should be available
life of the liner?).3 Second, the cup of the revision head to fit that stem in the setting of revision surgery and
should be (1) well fixed after manual and taper. Furthermore, to address previously violated soft-tissue planes
testing, with all screws removed, (2) possible trunnion corrosion, ceramic to increase offset, given the potential
large enough to accommodate a new heads with titanium sleeves should for increased abductor laxity. For a
liner with the appropriate femoral also be available. nonmodular stem, offset acetabular
head size, and (3) positioned liners with increased lateralization
appropriately, the new liner stable options should be available.
Instability
and contained within the cup, and
For concern of potential intra-
the hip stable during intraoperative Defect Treatment Options
operative and postoperative instabil-
testing.7,14,34,37
ity, constrained liners and dual If after intraoperative assessment, the
mobility should be available for acetabular component is found to
Implant Requirements use.7,14,21 Constrained liners are be well fixed, management strategies
Before surgery, the surgeon must indicated for abductor insufficiency. to address polyethylene wear in-
determine what size polyethylene is If a cup is well fixed and the ab- clude débridement of osteolytic le-
available to allow for the largest ductors damaged, it is reasonable to sions and modular liner exchange or
March 15, 2019, Vol 27, No 6 e263
Figure 5 cation between the lesion and the

joint space. At this time, no clear
data exist to suggest the superiority
of one graft over another. Moreover,
even without grafting, some lesions
decrease in size after débride-
ment14,32 (Figure 5). Allograft may
also lose some osteoinductive prop-
erties as well after tissue processing
and irradiation.
The primary purpose of a head and
liner exchange is to address the wear
generator.21 In comparison with
acetabular revision, the advantages
A, AP hip radiograph showing severe osteolysis of the dome and retroacetabular
region and mild osteolysis of the ischium. The cup appears to be well fixed. B, of this procedure are decreased sur-
Postoperative AP hip radiograph obtained 8 years after isolated head and liner gical time and blood loss, more rapid
exchange without bone grafting. patient recovery, lower morbidity,
and minimization of bone loss4,36,39
(Figure 6). If the liner locking
Figure 6 requiring the use of a reconstruction mechanism is damaged or nonfunc-
cage may make inferior fixation tional, or has a poor clinical record
more difficult. Today, debate con- with regard to longevity, the new
tinues as to whether the removal of liner may be cemented in place.
a well-fixed acetabular component Ideally, the new liner should be
should be required and if it is safe to HXLPE and have a shelf life ,5
do so to effectively to treat the years.21 During cementation, careful
osteolysis.1 technique to ensure centralization of
Acetabular component removal the liner within the shell is para-
facilitates débridement of osteolytic mount, creating a 2- to 4-mm uni-
lesions. Rim and dome lesions may form cement mantle for stable
be curetted or débrided under direct fixation.4,36,37,40 The shell and liner
visualization or via a bone window are textured with a metal-cutting burr
posteriorly and superiorly if the to provide for increased stability
acetabular component is found to be and interdigitation at the cement-
well fixed. Through this window, polyethylene and cement-shell inter-
wear debris, granulation tissue, and face. Placing grooves in a spider web
Intraoperative photograph of the
explanted acetabular shell showing areas of metallosis may be removed arrangement creates the greatest tor-
excess bone loss after implant and packed with a supplemental sional and lever-out construct
removal. graft.1,34 If the lesion is retro- strength.4,7,37,39 Before the compo-
acetabular, the senior author prefers nents are cured, all cement extruded
cementation of a new liner into a to use a metal-cutting burr to con- from the interface should be meticu-
well-fixed shell. The goals of treat- nect two to three screw holes of a lously removed to decrease third-
ment are to débride the lesions, well-fixed cup, thereby removing a body wear and provide a congruous
restore bone stock, and halt proportion of the shell and grafting the articulation.41
gression of the osteolytic process.14 lesion in the retroacetabular space. The most common complication
Before the introduction of special- Graft may be in the form of alloge- after head and liner exchange is
ized explant osteotomes and porous neic cancellous bone chips, calcium instability or dislocation, ranging
foam metal cups, removal of a well- phosphate, or calcium sulfate bone from zero to 22%.14,32,40 This risk
fixed cup in the setting of osteolysis cement. These materials are chosen has increased the appeal of acetab-
created more bone loss and even the because of their ease of use, ability to ular revision. Advantages of revision
potential for pelvic fracture.32 In fill large volume defects, radiolu- include more complete access to
cases in which ischial osteolysis is cency, and adequate working time to débride osteolytic lesions, improve-
also present, excessive bone loss fill defects and then seal communi- ment in cup positioning, allowance
Table 3
Selected Outcomes of Isolated Acetabular Liner Exchange for Osteolysis
Average Age Mean Rerevision
at the Time of Follow-up Dislocation or Failures Average Harris
Study No. of Patients Revision (yr) (yr) (%) (%) Hip Score
Boucher et al43 24 65 4.7 25 12.5% —

Restrepo et al42 36 65.5 2.8 — 8.3% (at 5 yr) —
Khanuja et al36 22 48.9 5.8 9 18.1% 89 (range, 72-93)
Callaghan et al4 30 (28 hips) 51 5.3 6 0 76.8 (range, 40.7-100)
Lim et al40 35 (36 hips) 57.6 6.1 — 2.8 91.3 (range, 45-100)
Rivkin et al41 33 (36 hips) 61 11 16.6 11.1 84.1 (range, 34-100)
of increased femoral head size de- four rerevisions (15%). Similarly, progression of osteolysis. Moderate
pending on the cup size chosen, Mallory et al45 reported the outcome success rates for the bone graft fill
and a new locking mechanism for of 47 revisions with an average of a rate were also seen by Engh et al,1
the liner. The most notable dis- 41-month follow-up. Thirty-nine who treated 18 lesions with an
advantages include a longer surgi- percent of shells were loose. They average fill rate of 49%. They
cal time and blood loss, as well as argue that shell revision avoids com- attributed the result to extravasation
bone loss associated with shell plications such as particulate debris, of the graft material through the
explantation.14,34,35 component malposition, and non- cortical window, screw hole, or
conformity, citing that complete other bone defects, suggesting that
débridement, impaction grafting, and the grafting technique is challenging,
Clinical Outcomes of revision are essential for eliminating and improved techniques are
Reconstructive Options the osteolytic nidus. In their view, required to increase the fill rate
cups may only be retained if the cup consistently. Given that many CT
Several studies have reported short- is well fixed in radiostereometric studies show incomplete incorpora-
to medium-term outcomes for isolated studies using serial radiographs. tion of graft into the osteolytic de-
acetabular liner exchange4,36,40-43 Bone grafting has had variable fects, the surgeon must take into
(Table 3). Hamilton et al3 evaluated success quantitatively,1,35 and the consideration the efficacy, safety,
187 cases of acetabular revision, in use of calcium phosphate ceramics in cost, and convenience of each
which 25 retained the old shell. Of revision THA has not been well material used in revision surgery.46 If
the 10 patients who sustained epi- studied. Many formulations, such as bone grafting is undertaken in cases
sodes of postoperative instability, all ProOsteon, Osteoset (calcium sulfate of noncemented components, how-
were noted to have been revised with ceramic), and Vitoss (tricalcium ever, grafting should by no means
the same or smaller femoral head phosphate scaffold), are available; limit the intimate contact of the
compared with their index proce- although they may be effective at component with host bone because
dure. Therefore, increasing the head least in the short term for smaller this will lead to failure of ingrowth.
size can potentially reduce the rate of lesions, the efficacy of these materi-
instability. als is still largely unknown.46 In
Some have advocated performing addition, concerns exist that if this Summary
acetabular revision in the setting of material migrated into the joint
osteolysis. Talmo et al44 evaluated 57 space, it could lead to third-body Despite the use of HXLPE and better
hips that underwent modular liner wear.47 Stamenkov et al35 used high- implants, wear and osteolysis after
exchange. Of those, 25% required resolution CT to follow up 22 os- THA are still a function of selecting
rerevision, the majority (57%) for teolytic lesions in six patients over the appropriate polyethylene thick-
liner dislodgement. Of 22 hips in the approximately 4 years. Despite no ness and proper positioning of com-
cemented liner revision group, 27% lesions progressing in volume and no ponents. Patients diagnosed with
were rerevised for dislocation or new lesions found, only a 44% bone osteolysis require a thorough evalu-
loosening. In the same series, 27 graft fill rate was observed, sug- ation and preoperative workup
patients underwent revision of the gesting that the liner revision alone before proceeding with revision sur-
acetabular shell, resulting in only may play a larger role in preventing gery. The choice between isolated
March 15, 2019, Vol 27, No 6 e265
polyethylene liner exchange and 7. Hall A, Eilers M, Hansen R, et al: Advances Successful long-term fixation and
in acetabular reconstruction in revision progression of osteolysis associated with
acetabular revision is based on sev- total hip arthroplasty: Maximizing function first-generation cementless acetabular
eral factors related to the position and and outcomes after treatment of components retrieved post mortem. J Bone
functionality of the cup and liner, the periacetabular osteolysis around the well- Joint Surg Am 2012;94:1877-1885.
fixed shell. J Bone Joint Surg Am 2013;95:
integrity of the locking mechanism, 1709-1718. 20. Saleh KJ, Thongtrangan I, Schwarz EM:
Osteolysis: Medical and surgical
and the track record of the implants.
8. Beck RT, Illingworth KD, Saleh KJ: Review approaches. Clin Orthop Relat Res 2004;
Although medium-term data show of periprosthetic osteolysis in total joint 427:138-147.
benefits to both surgeries, longer term arthroplasty: An emphasis on host factors
and future directions. J Orthop Res 2012; 21. Lombardi AV Jr, Berend KR: Isolated
data are still required. Surgeons must 30:541-546. acetabular liner exchange. J Am Acad
weigh the risks and benefits of os- Orthop Surg 2008;16:243-248.
9. Siram G, Goyal N, Engh CA: The
teolysis progression and surgical evaluation and management of peri- 22. Ries MD, Link TM: Monitoring and risk of
morbidity before choosing the acetabular osteolysis. Semin Arthroplasty progression of osteolysis after total hip
2013;24:99-105. arthroplasty. J Bone Joint Surg Am 2012;
appropriate option for each patient. 94:2097-2105.
10. Patel AR, Sweeney P, Ochenjele G, Wixson
R, Stulberg SD, Puri LM: Radiographically 23. Martell JM, Berdia S: Determination of
silent loosening of the acetabular polyethylene wear in total hip replacements
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470:3142-3147. 17. Lachiewicz PF, Soileau ES, Martell JM: preoperative assessment of standardized
Wear and osteolysis of highly crosslinked plain radiographs in predicting bone loss at
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variability in radiographic assessment Rubash HE, Engh CA: Treatment of pelvic
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CG: Bisphosphonate treatment for 38. Boyer B, Philippot R, Geringer J, Farizon F: CA Jr, Engh C Sr: Dislocation after
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Shim JW, Park YS: Complete acetabular 39. Yoon TR, Seon JK, Song EK, Chung JY, Rubash HE, Malchau H: Management of
cup revision versus isolated liner Seo HY, Park YB: Cementation of a metal- polyethylene wear associated with a well-
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Medium-term results of cementation of a Adams JB, Kefauver CA, Eberle RW:
35. Stamenkov R, Neale SD, Kane T, Findlay highly cross-linked polyethylene liner into a Noncemented acetabular component
DM, Taylor DJ, Howie DW: Cemented well-fixed acetabular shell in revision hip removal in the presence of osteolysis: The
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41. Rivkin G, Kandel L, Qutteineh B, 46. Callaghan JJ, Liu SS, Phruetthiphat OA:
36. Khanuja HS, Aggarwal A, Hungerford Liebergall M, Mattan Y: Long term The revision acetabulum—allograft and
MW, Hungerford DS, Jones LC, Mont MA: results of liner polyethylene cementation bone substitutes: Vestigial organs for bone
Cementing polyethylene liners into non- technique in revision for peri-acetabular deficiency. Bone Joint J 2014;96-B(11 suppl
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March 15, 2019, Vol 27, No 6 e267
Review Article
Congenital Tibial Deficiency
Abstract
Jody Litrenta, MD Congenital tibial deficiency is a rare condition characterized by partial
Megan Young, MD to complete absence of the tibia, an intact but frequently overgrown
fibula, variable degrees of knee deformity and function, and an
John G. Birch, MD
abnormal equinovarus foot. It can occur in isolation but also presents
Matthew E. Oetgen, MD, MBA concurrently with other orthopaedic anomalies and syndromic
conditions. Among these, congenital abnormalities of the hand and

femur are most commonly observed. Many theories exist regarding its
etiology and some genetic mutations have been identified; however, the
underlying mechanism remains unknown. The prognosis and treatment
differ based on the clinical severity. The goal of treatment is always to
create a stable, functional limb, most commonly with amputation and
use of prosthetics. Controversy exists over the level of amputation
and the usefulness of reconstructive procedures to preserve the foot and
limb length. Current investigation on this complex disorder is focused on
identifying its origins and further developing a classification-based
treatment algorithm to improve patient outcomes.
From the Children’s National Health

System, Division or Orthopaedic
Surgery and Sports Medicine,
Washington, DC (Dr. Oetgen,
C ongenital tibial deficiency oc-
curs in 1 in 1 million live births.1
It exhibits a spectrum of disease,
ectodermal ridge, the zone of polar-
izing activity (ZPA), and the Wnt
signaling pathway. Cell-mediated in-
Dr. Young), NYULMC Hospital for Joint with varying amounts of tibia absence teractions among these centers occur
Diseases, New York, NY (Dr. Litrenta),
contributing to a range of associated between the 4th and 7th week of ges-
and Texas Scottish Rite Hospital for
Children, Dallas, TX (Dr. Birch). knee and foot abnormalities. Knee tation. The apical ectodermal ridge
instability is frequently present, with modulates the proximal to distal
Dr. Oetgen or an immediate family
the most severe forms of deficiency development. The ZPA produces sonic
owner, officer, or committee member lacking a patella and a knee extensor hedgehog (Shh) protein, which directs
of the American Academy of mechanism. Very severe forms also anterior versus posterior orientation;
Orthopaedic Surgeons, the Pediatric often have a skin dimple overlying the
Orthopaedic Society of North this becomes radioulnar in the upper
America, and the Scoliosis Research
proximal tibia and accompanying limb and the tibia and fibula in the
Society. Dr. Birch or an immediate knee flexion contracture. In less severe lower limb. The dorsal limb bud se-
family member has received royalties cases, the proximal tibia and knee cretes Wnt protein, which distinguishes
from Orthofix. Neither of the following extensor mechanism are present and
authors nor any immediate family dorsoventral development.6
the knee is stable. The fibula is typi- Most limb deficiencies are present
value from or has stock or stock cally intact, and the foot position by the 7th week of gestation. The
options held in a commercial company varies in relation to the knee, with upper limb develops after day 28 and
or institution related directly or supination and rigid equinovarus of
indirectly to the subject of this article: the lower limb by day 31, and both
the foot most commonly observed.1-5
Dr. Litrenta and Dr. Young. progress proximal to distal. Upper
J Am Acad Orthop Surg 2019;27: and lower limb abnormalities appear
e268-e279
Embryology after days 35 and 37, respectively.
DOI: 10.5435/JAAOS-D-16-00838 Although the exact cause and timing
In normal embryologic development, of tibial deficiency remain unknown,
Academy of Orthopaedic Surgeons. limb bud orientation progresses the responsible insult likely occurs
under three influences: the apical during this phase.7
Jody Litrenta, MD, et al
One theory for the cause of limb Table 1

deficiency is vascular insufficiency.
Percentage of Observed Associated Pathology in the Two Largest Series
Levinsohn et al8 reported on tibial of Congenital Tibial Deficiency
and fibular deficiency and clubfoot.
Schoenecker et al2 Clinton and Birch5
In all cases, they found similar pat-
Associated Pathologies (57 pts) (%) (95 pts) (%)
terns of arterial deficiencies, involv-
ing the anterior tibial and dorsalis Overall 60 78
pedis artery. Vascular insufficiency can Bilateral 25 32
create either pre- or post-specification Upper extremity 30 33
defects, depending on the timing in Cleft hand 9 16
relation to mesenchymal differentia- Radial deficiency 1 8
tion. Post-specification defects leave a Other 20 9
rudimentary structure, which, the au- Lower extremity 48 96
thors postulate, explains tibial defi- Deficient lateral rays 9 21
ciency given the presence of a partially Medial ray/great toe duplication — 14
formed proximal tibia. However, Hip dysplasia or dislocation 18 11
others speculate a pre-specification Congenital femoral deficiency 9 11
cause, because the limb bud starts off
Coxa valga 12 —
in close proximity to the mesenchyme
Other — 40
of other vital organs, providing an
Visceral NAa 43
explanation for the coexistence of other
Cardiac — 21
systemic developmental anomalies.3
Gastrointestinal — 15
Genitourinary — 7
Spine 21 12
Genetic Basis
a
Visceral organ involvement not reported by Schoenecker et al.
No specific gene mutation has been
identified as the cause of congenital
tibial deficiency. The Shh pathway and foot syndrome, and tibial hemimelia- most common hip abnormality was
has been implicated in syndromic micromelia-trigonobrachycephaly congenital dislocation (10 patients),
forms.9 Recent research has identified syndrome. Among these disorders, a followed by coxa valga and proxi-
a 5 kb deletion within the DNA of the wide range of clinical expression ex- mal focal femoral deficiency. Hand
Shh repressor Gli3 protein in two ists, supporting variable penetrance. deformities were also prevalent,
patients with bilateral tibial defi- For example, in a series of 37 patients occurring in 17 patients (30%).
ciency, resulting in unrestricted Shh with tibial hemimelia–split hand and Spine abnormalities were present in
activity outside the ZPA.10 This study foot syndrome, severity ranged from 12 patients (21%), including 5 with
also noted that the genetic deletion isolated digit hypoplasia or syndac- hemivertebrae, as well as hypoplastic
occurred only on the maternal allele, tyly to complete bilateral tibia agen- vertebrae, scoliosis, and spina bifida.
suggesting autosomal-dominant inher- esis with split hands.15 Interestingly, 20 patients (35%)
itance with incomplete penetrance.10 reported a family history of con-
However, both autosomal-dominant genital anomalies ranging from hand
and autosomal-recessive inheritance Associated Pathology deformities (10 patients) to congen-
models have been described,11-13 and ital tibial deficiency (5 patients).
case reports of additional chromo- Other congenital abnormalities are Most of these were in first-degree
somal abnormalities exist.14 There observed with high frequency. Con- relatives.
are likely multiple genetic alterations genital hip dislocation, vertebral A more recent study by Clinton and
and inheritance patterns responsible malformations, bifurcation of the Birch5 details a longitudinal series of
for tibial deficiency. femur, imperforate anus, and hypo- 95 patients spanning 37 years at
Syndromic forms of tibial deficiency spadias have been reported.2,3,16 In Texas Scottish Rite Hospital. Among
also exist, with four known associated an older series of 57 patients studied these patients, 79% had other
autosomal-dominant types: Warner’s by Schoenecker et al,2 34 patients abnormalities, consistent with pre-
Syndrome, tibial hemimelia diplopodia (60%) had an associated abnormal- vious reports. These were mostly
syndrome, tibial hemimelia–split hand ity of the hip, hand, or spine. The other lower extremity anomalies,
March 15, 2019, Vol 27, No 6 e269
Table 2 cation based on their experience.

They simplified the Jones classifica-
Number of Observed Additional Upper Extremity, Lower Extremity, and
Spine Abnormalities, Organized by Jones Type in 71 Limbs Described by tion into three groups, omitting
Schoenecker et al2 Jones type 3 patients because this
form was never encountered at their
Upper Extremity, Lower Extremity, Spine,
Type No. (%) No. (%) No. (%) Total Limbs institution. Arguing that 15% of
patients could not be described ac-
1A 6 (18) 12 (36) 5 (15) 33 cording to the Jones method, Weber
1B 1 (17) 3 (50) 2 (33) 6 created a more elaborate classifica-
2 2 (12) 6 (37) 3 (19) 16 tion, incorporating seven categories
3 3 (43) 1 (14) 1 (14) 7 from “best” to “worst” and 5 sub-
4 4 (44) 1 (11) 1 (11) 9 categories based on the presence or
Totals 16 (23) 22 (31) 12 (17) 71 absence of a tibia cartilaginous
anlage, which affects reconstruction.
Type 1 is hypoplastic, type 2 is distal
Table 3 diastasis, type 3 is distal aplasia,
Number of Observed Additional Upper Extremity, Lower Extremity, type 4 is proximal aplasia, type 5
Visceral Organ, and Spine Abnormalities, Organized by Jones Type in 125 is bifocal aplasia, type 6 is agenesis
Extremities Described by Clinton and Birch5 with a double fibula, and type 7 is
Upper Lower agenesis with a single fibula (Figure 3).
Extremity, Extremity, Visceral, Spine, Total A final classification system, first
Type No. (%) No. (%) No. (%) No. (%) Limbs
proposed by Paley21 in 2003 and later
1A 23 (32) 44 (60) 23 (32) 12 (16) 73 modified, describes both the progres-
1B 1 (17) 1 (17) 1 (17) 1 (17) 6 sive spectrum of deficiency and the
2 6 (33) 11 (61) 5 (28) 4 (22) 18 treatment algorithm for each type20,21
3 1 (50) 2 (100) 0 (0) 0 (0) 2 (Figure 4). Type 1 represents a con-
4 4 (33) 5 (42) 2 (17) 0 (0) 12 genitally short tibia with relative fibula
5 2 (14) 12 (86) 2 (14) 1 (7) 14 overgrowth. In type 2, the proximal
Totals 37 (30) 75 (60) 33 (26) 18 (14) 125
and distal epiphyses are present with a
dysplastic ankle. The tibia plafond is
absent or deficient in type 3 with distal
such as absent lateral rays and hip “worst” to “best,” based on the diastasis. Only the proximal tibia is
dislocation. Upper extremity anom- skeletal morphology of radiographs present in type 4. Type 5 represents
alies, such as cleft hand, radial defi- of affected infants.17 Type 1, which the most severe with complete absence
ciency, and congenital scoliosis, also lacks any tibial ossification, has two of the tibia (Table 4).
occurred. Congenital tibial deficiency, distinct clinically relevant subgroups.
unlike other longitudinal deficiencies, Type 1b contains a cartilaginous
is particularly notable for associated anlage, whereas type 1a has no carti- Epidemiology Based on the
visceral organ involvement. This series lagenous anlage and further has a Jones Classification
noted that 20 patients had an hypoplastic distal femoral epiphysis.
associated cardiac malformation, 14 Type 2 demonstrates ossification of Schoenecker et al2 presented in their
had a gastrointestinal malformation, the proximal tibia. In type 3, the least report a distribution of commonly
and 7 had a genitourinary congenital common form, isolated ossification of encountered forms. Type 1a and 2
abnormality. These two studies are the distal tibia is seen. Type 4 is short deficiencies were the most common,
the largest reports of observed con- tibia with an absent distal articular representing 46% and 21% of the
genital anomalies (Tables 1–3). surface and distal tibiofibular diastasis series, respectively. Type 4 occurred
(Figures 1 and 2). Although this clas- in 14%, and type 3 and 1b were the
sification scheme remains the most least common, affecting 9% and 8%
Classification Systems widely adopted, limitations exist of limbs, respectively. In this series,
owing to the broad clinical spectrum no limbs were described that did not
The Jones classification is the most of the condition. fit the Jones classification.
commonly used system, dividing tib- Kalamchi and Dawe18 and Consistent with Schoenecker et al,
ial deficiency into four groups, from Weber19 modified the Jones classifi- Clinton and Birch5 reported a similar
epidemiologic pattern of tibial defi- Figure 1

ciency. Among them, type 1a was
the most common, occurring in 58%
of limbs. Type 2 was the second
most common, occurring in 14%.
No limb was truly type 3, because all
eventually developed a proximal tibia
epiphysis on radiographs. Fourteen of
95 limbs (11%) were characterized
by more global tibial deficiency and
deemed not classifiable by Jones cri-
teria. All patients had similar radio-
graphic appearance, with proximal
and distal tibia epiphyses, and prox-
imal and distal fibula overgrowth
leading the authors to propose a
distinct “Jones 5” group. Of note, a
wide range of deformity coexisted
with this group which affected
management. Table 5 details the
relative frequency of Jones types
observed in these two large series.
Clinical Features
A broad spectrum of clinical pathol-
ogy exists in congenital tibial defi-
ciency. Physical examination of the
affected limb follows the Jones clas-
sification. In Jones type 1a, with
complete tibial aplasia, hamstring
function is present and quadriceps
function is deficient, causing knee
flexion contracture. The patella does
not form, and the foot is in rigid
equinovarus. In Jones type 1b and 2,
the knee extensor mechanism is
formed, producing a functional knee Jones classification of congenital tibial deficiency. (Reproduced with permission
without contracture. The fibula dis- from Jones D, Barnes J, Lloyd-Roberts GC: Congenital aplasia and dysplasia of
places proximally and laterally, and the tibia with intact fibula: Classification and management. J Bone Joint Surg Br
an equinovarus foot is noted. In Jones 1978;60:31-39.)
type 3, with isolated distal tibia ossi-
fication, the knee is unstable, with for initial orthopaedic referral. An the treatment and prognosis are
varus positioning of the overall limb. atypically rigid clubfoot, absent vastly different (Figure 5).
Jones type 4 patients have a stable lateral rays, or medial ray duplica- In addition to the characteristic
knee and a rigid equinovarus foot tion should alert the orthopaedic clinical findings, congenital tibial
positioned in the diastasis between surgeon to investigate for tibial deficiency is distinctive for frequent
the tibia and fibula. deficiency. We stress the importance associated congenital abnormalities,
The equinovarus foot position of fully evaluating the entire lower which do not correlate well with any
akin to all types of congenital tibial extremity for clues that the equi- classification system. Other orthopae-
deficiency can be confused with an novarus foot may be a manifestation dic anomalies are commonly encoun-
isolated clubfoot, a common reason of a longitudinal deficiency, because tered in all forms, and a thorough
March 15, 2019, Vol 27, No 6 e271
Figure 2 physical examination of all extremities,

hips, and the spine is essential with a low
threshold to obtain additional imaging.
Because of the risk of associated visceral
organ abnormalities, we recommend a
genetics consultation and advanced
imaging to evaluate for other organ
dysfunction.
Surgical Intervention
The most fundamental treatment

principle is to determine whether the
knee is stable with a functional
extensor mechanism. Type 1a defi-
ciencies lack any tibia. Hamstring
function but not quad function is
present, creating a nonfunctional
contracted and displaced knee joint
proximal and lateral to the femoral
condyles. For this reason, the stan-
dard management of Jones type 1a
tibia deficiency is knee disarticu-
lation. In all other types of tibial
deficiency, with a theoretically func-
tional knee, an attempt is made to
reconstruct the proximal tibia and
fibula and preserve the knee joint.
Because of the severity of foot and
ankle deformity and instability, the
distal limb is often managed with a
Syme amputation and prosthetic fit-
ting. For Jones type 1b and 2 limbs in
which varying ossification of the
proximal tibia is present, traditional
management consists of proximal ti-
biofibular synostosis and distal Syme
amputation.
It is vitally important to differenti-
ate type 1a and 1b deficiencies
because these types distinguish a
nonfunctional and functional knee
and extensor mechanism. Though
less commonly encountered, in type
1b deficiency, the cartilaginous anlage
of the proximal tibia will ossify, al-
lowing the knee joint to be preserved.
Ultrasonography is a simple method
that can identify a cartilaginous tibial
anlage predictive of future ossifica-
tion. Additionally, ultrasonography
Radiographic examples of each Jones type of congenital tibial deficiency.
elucidates the presence of other
important components of knee stabil- Figure 3

ity, including an intact patella tendon
and functioning quadriceps mech-
anism.22 Advanced imaging with MRI
provides more precise detail, and in
some cases, it may be helpful in
determining whether knee recon-
struction options are possible and
aid in surgical preparation.23
The rare Jones type 3 deficiencies are
commonly managed with a Syme or
Chopart amputation, assuming even-
tual ossification of a proximal tibial
cartilaginous anlage and a functional
quadriceps mechanism. Similarly, the
modified Syme ankle disarticulation
has been the standard management of
type 4 deficiencies associated with dis-
tal diastasis. Alternatively, lengthening
and reconstruction options that repo-
sition and achieve a plantigrade foot
may be possible. Foot preservation
techniques are often hindered by the Weber classification of congenital tibial deficiency. (Reproduced with permission
absent distal tibia and notable de- from Weber M: New classification and score for tibial hemimelia. J Child Orthop
2008;2:169-175.)
formities of the talus and calcaneus.
ization procedure. Epps et al26 function, despite the fact that one
Brown Procedure published a series of 14 patients with had a knee flexion contraction and
complete tibial deficiency treated another had a limited range of
In 1965, Brown24 described a fibular within the first year of life. All pa- motion. Similarly, Simmons et al28
centralization procedure for congenital tients developed severe flexion defor- reviewed seven patients followed an
tibial deficiency. In this procedure, a mity of the knee which impaired gait average of 7 years after Brown pro-
U-shaped incision was made at the and interfered with prosthetic wear, cedure and also documented good
level of the knee joint and the fibula and they underwent secondary sur- results. The average arc of motion
was dissected from the surrounding geries to manage either the flexion was 57°, and all were ambulating
soft tissues through a lateral para- deformity or knee disarticulation. The with patellar tendon–bearing pros-
patellar arthrotomy. The proximal 3/8 seven patients who underwent knee theses and thigh extensions for col-
inch of the fibular epiphysis was os- disarticulation obtained a satisfactory lateral support. Both Christini and
teotomized to make a flat surface and result, whereas the others remained Simmons found that the Brown
was then centralized and fixed with limited by their knee flexion contrac- procedure may lead to subjectively
K-wires underneath the femoral con- ture at final follow-up. Clinton and reported acceptable function in
dyles. The soft tissues were imbricated Birch5 also noted a high rate of knee patients with complete tibial defi-
to centralize the patella and tighten the disarticulation after the Brown pro- ciency, as long as they had a func-
capsule; distally, the patellar tendon cedure and knee flexion contractures tioning quadriceps of at least grade 3
was reattached to the centralized fib- in a small number of patients who did strength preoperatively. Other
ula. This procedure was largely un- not have further revision surgery. important criteria for a functional
dertaken in Jones type 1a patients. Although a high rate of conversion outcome included the absence of
Although initial enthusiasm was pre- to knee disarticulation is present, the fibular bowing and pterygium folds
sent, a 15-year follow-up study re- Brown procedure has been successful in the popliteus fossa which lead to
vealed that most of these patients went in patients who meet certain in- progressive flexion contractures,
on to have a knee disarticulation.25 dications. Christini et al27 found that and age less than 1 year so the
Other series similarly reported poor 5 of 13 patients who underwent the fibula has adequate time to hyper-
outcomes after the Brown central- Brown procedure had acceptable trophy with growth.27,28
March 15, 2019, Vol 27, No 6 e273
Figure 4 distal femur, but long-term functional

outcome studies are unavailable.
Reconstruction Principles
Advances in technology, our knowl-
edge of biology, and better under-
standing of the pathology of all types
of tibial deficiency may lend alterna-
tive treatments to amputation in the
future even for the most severe types.
Certain principles apply for recon-
structive surgery to successfully
create a functional limb in the hands
of an experienced surgeon. No single
intervention can address the com-
plexity of the limb deficiency. Multi-
ple staged procedures to realign,
recreate and stabilize the joints, and
lengthen the leg must be anticipated.
A plantigrade foot and stable ankle
must be achieved. Reconstruction of
the knee, restoration of a functional
extensor mechanism, and elimination
of the flexion contracture must be
Paley classification of congenital tibial deficiency. (Reproduced with permission addressed. Repeated lengthenings
from Paley D: Tibia hemimelia: New classification and reconstructive options. of the tibia or centralized fibula
J Child Orthop 2016;10:529-555.)
may be required and the adjacent
joints must be stabilized. Paley21
elaborately described reconstruc-
Notable advantages exist in selecting functional knee mechanism. In 2002,
tion options that correspond to his
a more distal level of amputation to Weber29 proposed a technique in
classification of tibial deficiency
preserve the native knee joint. Pa- which the patella anlage is trans-
(Table 4). Functional outcome
tients benefit from improved energy posed to articulate with the distal
studies of these new and modified
expenditure, gait efficiency, and femur. To facilitate the transposi-
techniques are unavailable.
proprioception. Although fibular tion, the quadriceps tendon is
centralization appears to be unsuc- Z-lengthened and stabilized by the
cessful for many patients with com- creation of two visor flaps made Distal Amputation Versus
plete tibial deficiency, those who from the surrounding capsular tissue Reconstruction
demonstrate some preoperative active and crossed to provide medial and
knee function may be candidates. lateral support. The fibula can then Less controversy exists over the
Identifying these patients by thorough be centralized below the patella and management of partial tibial defi-
physical examination and adjunct attached to the patella tendon. The ciency (Jones Ib-Jones 2). A tibio-
ultrasonography will help select construct is supported with a ringed fibular synostosis can be performed
appropriate patients for the Brown fixator, which gradually increases by first osteotomizing the fibula at the
centralization procedure. the range of motion of the new knee neck and fusing the distal portion of
joint. In theory, this surgical tech- the fibula to the remnant tibia in an
nique improves on the Brown cen- end-to-end or side-to-side fashion
Knee Reconstruction tralization by adding better knee with supplemental screw or plate and
stability through the creation of screw fixation (Figure 6). Because
Given the mixed results of the Brown the capsular visor flaps and by using the fibula typically is migrated
procedure, other surgical techniques the patella to provide a larger, more proximally, the technique involves
have been developed to recreate a stable articulating surface for the resecting the proximal fibula to
Table 4
Paley Classification and Reconstruction Principles
Paley Classification Features Reconstruction Options
1 Congenitally short tibia overgrown fibula Correction of valgus deformity and lengthening
Proximal valgus
Normal distal plafond
2 Deficient tibia plafond with diastasis of tibia and Reconstruction of ankle joint
fibula
Foot follows the fibula Correction of any tibia deformity 1 lengthening
3a Distal tibia physis formed but separate from Reconstruction of ankle joint
proximal physis
Plafond dysplastic Correction of tibia deformity 1 lengtheninga
Overgrown fibula Fibula management:(1) resection of diaphysis to
create non-union and (2) distraction of tibia
without fibula fixation
3b Delta tibia representing proximal and distal physis Excision of bracket
connected through bracket epiphysis
Malorientation of knee and ankle Acute correction of tibia deformity 1 partial
resection fibula
Overgrown fibula Lengtheninga
4a Delayed ossification of tibia Creation of plantigrade foot with stable ankle
Absent distal physis Correction of tibia deformity
Ankle joint present but nonfunctional Lengthening after anlage ossifiesa
Overgrown fibula
4b Complete absence of distal tibia Correct foot deformity
Overgrown fibula Fuse talus to distal fibula
Transfer fibula diaphysis to distal end of proximal
tibia
Future lengthening of single bone lega
4c Proximal epiphysis present but absent physis Correct foot deformity and knee contracture
Knee joint present Fuse talus to distal fibula
Notable overgrown fibula Fibula fixed to tibia epiphysis
Repeated future lengtheningsa
5a Complete absence of tibia Patella converted to a tibia plateau
Patella present Fibula centralized to patella (Weber procedure)
Knee flexion contracture
5b (i) Complete absence of tibia Correction of knee contracture
No patella Centralize foot to distal fibula
Knee flexion contracture Reconstruction of knee ligaments and transfer
quad to fibula
Fibula autocentralized Fuse talus to fibula
5b (ii) Same as 5b (i) Centralize fibula to femur
Fibula dislocated Correction of knee contracture
Centralize foot to distal fibula
a
Recommends extending the external fixator to the femur to stabilize the knee.
avoid prosthetic fit problems from maintains the heel pad, or Boyd ostosis in 8 of them. Christini
the protruded fibular head. Re- amputation, which differs because recommended the Boyd procedure
growth of the resected proximal the calcaneus is retained, centralized, instead of a Syme amputation if the
fibula may be prevented by removing and fused to the proximal limb. calcaneus can be centralized, and
the periosteum. Schoenecker et al2 used distal Syme some surgeons suggest that retaining
Distally, the limb is traditionally amputation in 12 patients with type the calcaneus better maintains the
managed with either a Syme ampu- 2 deficiency and successfully com- heel pad position.27 The Boyd pro-
tation, an ankle disarticulation that bined this with tibiofibular syn- cedure is technically more difficult
March 15, 2019, Vol 27, No 6 e275
Table 5 Figure 5
Relative Frequency of Observed Forms of Congenital Tibial Deficiency in
the Two Largest Series, Organized by Jones Type
Schoenecker et al2 Clinton and Birch5
Type (71 Limbs) (%) (125 Limbs) (%)
1a 46 58
1b 8 5
2 23 14
3 10 2
4 13 10
Unclassifiable 0 11
Clinical photograph of an extremity
affected by congenital tibial
deficiency.
than the Syme, and good functional The goals of this procedure are to
outcome is achieved through the use obtain a plantigrade foot, a stable Another long-term study evaluated
of a prosthetic with either amputa- and functional knee joint, and a sta- the outcomes between patients with
tion. However, some surgeons ad- ble ankle joint with arthrodesis, as primary amputation and those with
vocate for distal reconstruction, well as to equalize leg lengths. The use distal foot reconstruction using the
which depends on the length of the of distraction osteogenesis provides Pediatric Quality of Life question-
affected limb and the amount of gradual centralization of the foot and naire. Although the scores were not
deformity present in the foot. Dif- eventual lengthening of the extrem- statistically different, in many areas
ferent combinations of limb leng- ity. Although successful in achieving patients with reconstruction scored
thening and foot centralization and these goals, this approach requires slightly higher. However, it should be
reconstruction have varying success. multiple surgeries and has a high rate noted that the amputation group
The first report of foot centraliza- of complications. On average, pa- was a much smaller group of patients
tion was by Hosny.30 In addition to tients underwent an average of 6.4 and had proportionately more bilat-
performing fibular centralization, an surgeries, spent 17 months in an eral cases than the reconstruction
Ilizarov frame was used to center the external fixator, and experienced 5.5 group. Although distal reconstructive
foot underneath the fibula. Since complications. The severity of these procedures require long treatment
then, several series have detailed the complications varied, including knee times in a frame and high rates of
results.31-33 In a recent publication, subluxation or dislocation, knee complications, many patients and
Balci et al32 presented a clear protocol flexion contracture, equinus defor- families select this option and report
for foot centralization and the results mity, fracture through the regenerate, good satisfaction rates.33
in 17 patients with partial tibial revision of the circular fixator, and
deficiency. Their protocol involved pin tract infections. It is also impor-
initially addressing the ankle, fol- tant to note that the functional Timing of Surgical
lowed by centralization of the fibula outcomes after this reconstructive Intervention
under the remaining tibia. Achilles procedure compared with knee dis-
tenotomy and posteromedial release articulation in Jones 1a deficiency The optimal time to proceed with
were performed first to mobilize the were not different. Furthermore, surgical intervention may be individ-
foot. Next, the posterior facet of 13 of 23 patients who underwent ualized. Amputation is best performed
the calcaneus was centralized under reconstruction required bracing treat- between the ages of 6 months and 1
the fibula with a circular external ment or crutches at long-term year to allow early prosthetic fitting at
fixation. Finally, the fibula was os- follow-up, including all of Jones type the onset of walking. Patients with an
teotomized and centralized beneath 1 patients.32 Finally, neither report additional upper extremity deficiency
the tibia and held with a Steinman specifically discusses the outcomes of present an exception to this rule. De-
wire. Distraction osteogenesis for feet with or without deficient lateral laying lower limb amputation is
limb lengthening in a staged fashion rays. It is logical to consider that the appropriate until surrogate use of the
was performed, once the distal fibula status of the foot may in part dictate lower extremity to replace the upper
had healed to the proximal tibia and the success of centralization, but this extremity is established. For manage-
had expanded to its width. has not been reported. ment of partial tibia hemimelia, a
proximal tibiofibular synostosis can Figure 6

be performed when sufficient ossifica-
tion of the upper tibia develops to
permit successful union, but Jones
argued that stability can be achieved
with fusion to the cartilaginous anlage
that will eventually ossify.17 The sur-
gical plan may vary considerably with
multiple staged procedures antici-
pated to achieve a functional limb for
patients suitable for more complex
reconstruction procedures. Brown24
initially recommended fibular cen-
tralization surgery by 1 year of age to
maximize early ambulation, fibular
articulation, and hypertrophy poten-
tial. Similarly, the Weber29 procedure
was first described in a 15-month-old
child. Paley recommends achieving a
stable ankle and plantigrade foot,
followed by secondary procedures to
create a one-bone leg and recon-
struct the knee.20,21 The timing of
additional lengthening procedures is
driven by the projected discrepancy,
expected number of procedures, the
child’s functional needs, and pre-
paredness of the family for leng-
thening surgery. In general, the
discrepancy should be addressed
with as few surgeries as possible to Radiographic example of a patient after tibiofibular synostosis.
achieve acceptable alignment, a
plantigrade foot, a stable knee, and
equal limb lengths by the time of the day. Although most of them do reference values. However, adoles-
skeletal maturity. Serial lengthenings not have problems with pain, in one cents reported less diversity in the
can be spaced throughout childhood survey, 16% reported having at activities they participated in and less
to allow sufficient time without least moderate pain.34 Pediatric involvement in social and skill-based
surgery. We suggest engaging the patients with prosthetics may struggle activities. None of these findings
parents in a discussion of treatment compared with their peers. Their correlated with the degree of limb
options at the initial consultation different appearance and physical deficiency.35
and beginning reconstruction within limitations compared with typically This research does highlight the fact
the first few years of life. developing children may predispose that children with limb deficiencies
them to difficulty with psychosocial and prosthetics are a highly adaptive
adjustment. group who enjoy participation in
Psychosocial Outcomes Michielsen et al evaluated a group leisure activities. It is notable that
of 56 Dutch children and adoles- adolescents did struggle in a few
Children with limb deficiencies cents with lower limb deficiencies. areas. It would be worthwhile to
experience a high level of function. In this assessment, 8- to 18 year olds examine the transition from child-
Overall, they are better equipped reported their participation in lei- hood to adolescence in this pop-
than the adult population to deal sure activities and their health- ulation and better understand what
with a prosthetic limb. Most pa- related quality of life. Their general contributes to their differences.
tients are able to wear their pros- participation and health-related qual- Furthermore, comparisons between
thetic for long intervals during ity of life were not different from patients with limb reconstruction
March 15, 2019, Vol 27, No 6 e277
and those with amputation may other syndromes and organ dysfunc- 10. Deimling S, Sotiropoulos C, Lau K, et al:
Tibial hemimelia associated with GLI3
better describe how these procedures tion, it is important for each patient to truncation. J Hum Genet 2016;61:443-446.
affect childhood. be thoroughly evaluated for coexist-
11. Clark MW: Autosomal dominant
ing congenital anomalies. Addition- inheritance of tibial meromelia: Report of a
ally, more clearly understanding the kindred. J Bone Joint Surg Am 1975;57:262.
Summary psychosocial needs of affected chil- 12. Leite JA, Lima LC, Sampaio ML: Tibial
dren may in turn allow healthcare hemimelia in one of the identical twins. J
Pediatr Orthop 2010;30:742-745.
Congenital tibial deficiency is an professionals to provide better sup-
uncommon and complex condition, port and adaptive strategies for pa- 13. McKay M, Clarren SK, Zorn R: Isolated
tibial hemimelia in sibs: An autosomal-
with a wide spectrum of clinical pre- tients and families. Finally, further recessive disorder? Am J Med Genet 1984;
sentations. The main goal of treat- research aimed to determine the 17:603-607.
ment underlying all types is to create a underlying etiology may help identify 14. Carvalho DR, Santos SC, Oliveira MD,
stable and functional limb. The sur- and counsel at-risk families in the Speck-Martins CE: Tibial hemimelia in
gical options to achieve the best prenatal period. Langer-Giedion syndrome with 8q23.1-
q24.12 interstitial deletion. Am J Med
functional outcome vary based on the Genet A 2011;155A:2784-2787.
amount of deficiency present. In 15. Richieri-Costa A, Ferrareto I, Masiero D,
complete absence of the tibia, early References da Silva CR: Tibial hemimelia: Report on
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16. Ugras AA, Sungur I, Akyildiz MF, Ercin E:
joint, reconstructive procedures and 1. Fernandez-Palazzi F, Bendahan J, Rivas S: Tibial hemimelia and femoral bifurcation.
Congenital deficiency of the tibia: A report on
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2. Schoenecker PL, Capelli AM, Millar EA,
that reconstruct the knee joint, such et al: Congenital longitudinal deficiency of
Congenital aplasia and dysplasia of the
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18. Kalamchi A, Dawe RV: Congenital
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JP: Anatomic considerations of the foot and 20. Paley D, Chong D: Tibial hemimelia, in
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6. Johnson RL, Tabin C: Molecular models 22. Grissom LE, Harcke HT, Kumar SJ:
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9. Cho TJ, Baek GH, Lee HR, Moon HJ, Yoo
In addition to developing the sur- knee joint in meromelia tibia (congenital
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Owing to its known association with 219-221. centralization of the fibula for congenital
longitudinal deficiency of the tibia. J Bone 30. Hosny GA: Treatment of tibial 33. Shahcheraghi GH, Javid M: Functional
Joint Surg Am 1991;73:858-867. hemimelia without amputation: assessment in tibial hemimelia (can we also
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the tibia. J Pediatr Orthop 1993;13:378-381. 31. Wada A, Nakamura T, Urano N, et al: Foot 34. Vannah WM, Davids JR, Drvaric DM: A
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_ Sa
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Kocaoglu M, Eralp L: Preliminary report 35. Michielsen A, van Wijk I, Ketelaar M:
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March 15, 2019, Vol 27, No 6 e279
Research Article
Revision Metacarpophalangeal
Arthroplasty: A Longitudinal Study
of 128 Cases
Abstract
Eric R. Wagner, MD, MS Purpose: The objective was to examine outcomes associated with a
Matthew T. Houdek, MD, MS large cohort of revision metacarpophalangeal (MCP) arthroplasties.
Methods: A review of 128 revision MCP arthroplasties performed in
Benjamin Packard, MD
64 patients was performed. The mean age at surgery was 62 years.
Steven L. Moran, MD Fifty nonconstrained (31 pyrocarbon and 19 surface-replacing

Marco Rizzo, MD arthroplasty) and 78 constrained silicone implants were used for
revisions.
Results: At a follow-up of 6 years (2 to 16), 20 (16%) implants
required a secondary revision surgery. The 5- and 10-year
survival rates were 81% and 79%, respectively. Postoperative
dislocation occurred in 17 (13%) MCP joints. Subgroup analysis
From the Department of Orthopedic demonstrated a 5-year survival rate of 67% in surface-replacing
Surgery, Division of Hand Surgery, arthroplasties, compared with 83% for both pyrocarbon and
Mayo Clinic, Rochester, MN.
silicone implants (hazard ratio, 2.60; P = 0.09). Clinical improvements
Correspondence to Dr. Rizzo: in pain and MCP range of motion were noted in most patients
rizzo.marco@mayo.edu
postoperatively.
Dr. Moran or an immediate family Conclusions: Revision MCP arthroplasty is a challenging procedure
and serves as a paid consultant to with one in five patients requiring a revision procedure at 5 years and a
Integra LifeSciences; has stock or relatively high rate of postoperative dislocations. However, most
stock options held in AxoGen; and patients who did not undergo a secondary revision surgery
officer, or committee member of the experienced improvements in pain and range of motion. Worse
American Society for Surgery of the outcomes are seen in patients with a history of MCP dislocations.
Hand. Dr. Rizzo or an immediate
Level of Evidence: Level IV
consultant to Zimmer Biomet and
P
American Association for Hand rimary metacarpophalangeal As these primary implants fail, the
Surgery and the American Society for
Surgery of the Hand. None of the
(MCP) arthroplasty is an estab- need for revision MCP arthroplasty
following authors nor any immediate lished treatment of MCP arthritis, will remain critical for restoring
family member has received anything with proven short-term survival motion and decreasing pain in these
of value from or has stock or stock rates, durable pain relief, and pres- patients. As in any revision arthro-
ervation of joint range of motion.1-8 plasty procedure, the long-term suc-
indirectly to the subject of this article: However, little is known regarding cess is largely dependent on the
Dr. Wagner, Dr. Houdek, and the long-term survivorship of these remaining ligamentous and soft-
Dr. Packard. implants, and some studies report a tissue stabilizers, which is especially
J Am Acad Orthop Surg 2019;27: relatively high revision rate when important when using noncon-
211-218 compared to other joint replacement strained implants. In the revision set-
DOI: 10.5435/JAAOS-D-17-00042 procedures.3,5,9 Furthermore, a rel- ting, soft-tissue constraints can be
atively high number of postoperative compromised, affecting the out-
Academy of Orthopaedic Surgeons. complications exist, including im- comes. There is a paucity of literature
plant fractures and dislocations.2,3 examining incidence, prognosis, and
March 15, 2019, Vol 27, No 6 211
Revision Metacarpophalangeal Arthroplasty
Table 1 and subsequently at 5-year intervals,

with in-person clinic visits, radio-
Preoperative and Surgical Considerations
graphs, and questionnaires.11 All
Patients (fingers) 64 (128) revision surgeries or future oper-
Dominant extremity 88 (68%) ations done at our institution or at
involved (fingers) an outside institution are captured in
Male:Female 20:108 the registry. Furthermore, additional
Age (yr, mean 6 SD) 62 6 11 patient information was collected
Smokers 10 (15%) using validated automated digital
Diabetes mellitus 10 (8%) algorithms to identify comorbidities
Inflammatory arthritis 109 (85%) and perioperative factors from the
Posttraumatic arthritis 10 (8%) electronic medical records of patients
OA 9 (7%) who underwent MCP arthroplasties.12
Prednisone use 46 (36%)
Methotrexate use 31 (24%) Demographics
Preoperative instability 31 (24%)
Over a 14-year period from January
Finger
1, 1998, to December 31, 2012, 128
Index 52
revision MCP arthroplasties were
Middle 41 performed in 64 patients at our
Ring 15 institution by nine different surgeons.
Little 20 The demographics are summarized in
Previous implant Table 1. Fifty (39%) nonconstrained
Prior pyrocarbon 23 (31 pyrocarbon and 19 surface-
Prior silicone 87 replacing arthroplasties [SRAs,
Prior SRA 18 Avanta]) and 78 (61%) constrained
Dorsal approach 123 (96%) silicone implants were reported. Of
Implant those with 109 inflammatory ar-
Pyrocarbon 31 thritis, 16 pyrocarbon, 17 SRA, and
SRA 19 76 silicone implants were reported.
Silicone 78 The decision to use different im-
Bone graft 9 (7%) plants was determined by the treat-
Cemented implant 20 (16%) ing surgeon at the time of the index
revision surgery. Cement was used in
OA = osteoarthritis, SRA = surface-replacing arthroplasty 18 (14%) implants (5 pyrocarbon, 13
SRA). Thirty-one (24%) implants had
MCP instability associated with their
outcomes after revision MCP arthro- bination of the prospectively col- primary arthroplasty. Every patient
plasty. The objective of this study was lected institutional Joint Registry underwent the institution’s stan-
to examine a large group of patients Database10 and electronic medical dardized postoperative therapy pro-
undergoing revision MCP arthro- record of all patients who underwent tocol focusing on early range of motion.
plasty with medium-term follow- revision MCP arthroplasty. Briefly,
up, assessing the secondary revision this registry is maintained by trained Clinical Evaluation
surgery, rate of common complica- abstractors who prospectively collect Medical record reviews and the total
tions, and factors that influence these numerous variables, including pa- joints registry data were then used to
outcomes, as well as the postoperative tient demographics, surgical details, assess complications and subsequent
MCP pain and function. complications, revision surgeries, surgeries. The electronic medical re-
arthroplasty revisions, and clinical cords were examined to obtain other
Methods outcome scores on patients who variables, including demographics,
have undergone a total joint arthro- comorbidities, surgical indications/
After approval by the institutional plasty at our institution. Patients findings, joint survivorship, and post-
review board, a clinical retrospective routinely follow up with the surgeon operative complications. The results
review was performed using a com- at 1, 2, and 5 postoperative years from patients’ last clinic visit were
Eric R. Wagner, MD, MS, et al
Figure 1 Table 2
HRs for Implant Failure After Revision MCP Arthroplasty
Risk Factor HR 95% CI P Value
History of instability 3.50 1.45-8.67 0.006a

Diabetes mellitus ,0.01 0.89-0.89 0.04a
Inflammatory arthritis 0.31 0.12-0.97 0.045a
Posttraumatic arthritis 3.59 0.83-10.80 0.08
SRA 2.60 0.84-6.73 0.09
Bone graft ,0.01 1.22-1.22 0.09
Index finger 2.11 0.87-5.25 0.10
Graph showing the Kaplan-Meier
survival analysis of all revision Silicone implant 0.61 0.25-1.52 0.28
metacarpophalangeal arthroplasties. Methotrexate use 0.38 0.06-1.32 0.38
Cemented implant 2.10 0.60-5.73 0.22
Prednisone use 0.66 0.23-1.66 0.39
combined through questionnaires from BMI 0.99 0.94-1.01 0.42
the total joints registry to assess pre- Dominant extremity 1.69 0.48-10.68 0.46
operative and postoperative pain and OA 2.19 0.34-7.62 0.46
hand function. Postoperative clinical Prior pyrocarbon 0.60 0.10-2.09 0.47
outcomes were recorded at patients’ Prior silicone 1.39 0.54-4.27 0.52
last clinical visit. Pain was graded as Smoker 0.60 0.03-3.29 0.61
none, mild, moderate, or severe Age at surgery 0.99 0.95-1.03 0.68
within a standardized questionnaire Dorsal approach 0.68 0.14-12.30 0.73
filled out during the clinic visit while Female 0.86 0.29-3.67 0.81
range of motion was expressed as Pyrocarbon implant 0.89 0.25-2.42 0.83
total arc of motion for the MCP joint Prior SRA 0.92 0.22-2.76 0.90
using a goniometer by the operative
a
surgeon. Pain, range of motion, and Statistically significant
BMI = body mass index, CI = confidence interval, HR = hazard ratio, MCP =
grip and pinch strengths were mea- metacarpophalangeal, OA = Osteoarthritis, SRA = surface-replacing arthroplasty
sured and recorded during patients’
last clinic visit. Repeat revision surgery
was defined as the removal of any comparisons) or unpaired Student followed by pain with limited motion
implant. MCP instability was defined t-tests for continuous variables. All (n = 4), silicone synovitis and bone
as either clinical or radiographic evi- analyses were carried out using resorption (n = 2), infection (n = 1),
dence of a dislocation requiring eval- the JMP statistical software pack- metacarpal component loosening
uation by the treating surgeon. age (version 8; SAS Institute). A (n = 1), and dorsally subluxated and
P-value , 0.05 was considered sta- fractured silicone implant (n = 1).
tistically significant. The Kaplan-Meier survival analysis
Statistical Analysis demonstrated a secondary revision-
Implant survival was examined using free survival at 2, 5, and 10 years of
Results
the Kaplan-Meier method, with Cox 90%, 81%, and 79%, respectively
proportional hazard univariate (Figure 1). Cox proportional hazard
Implant Survival and
analysis to examine the impact of univariate analysis demonstrated
different variables on implant sur-
Complications After Revision that patients with a history of pre-
vival. Pain and functional outcomes Metacarpophalangeal operative MCP joint instability had
and the influence of different var- Arthroplasty an increased risk of implant failure
iables (all variables included in Of the 128 index revision MCP joint (HR, 3.50; P = 0.006) (Table 2).
the hazard ratio [HR] analysis) on arthroplasties within the 14-year Improved implant survival was seen
these outcomes were assessed using period, 20 (16%) underwent a sec- in patients with inflammatory ar-
chi-square test (or Fisher exact test) for ondary revision surgery. The eti- thritis (HR, 0.31; P = 0.045), and
categorical variables as well as paired ologies underlying the secondary while posttraumatic arthritis had
(for preoperative and postoperative revisions were dislocations (n = 11), inferior implant survival rates, it was
March 15, 2019, Vol 27, No 6 213
Figure 2
Radiographs (AP, oblique, and lateral) of a 55-year-old woman with posttraumatic arthritis whose silicone implant of third
finger fractured leading to metacarpophalangeal joint instability and revision surgery.
not statistically significant (HR, 3.59; (one pyrocarbon implant during pri- sion surgery, the SRAs had a higher
P = 0.08). The use of an SRA implant or component removal). Only one of rate of secondary revision surgery
(HR, 2.60; P = 0.09) and the sec- the fractures required intervention, (n = 11 of 19; 58%), when compared
ondary revision surgery performed on which included circumferential su- with silicone (n = 5 of 78; 6%) or
the index finger (HR, 2.11; P = 0.10) ture stabilization. In the postopera- pyrocarbon (n = 4 of 31; 13%) im-
also negatively affected the implant tive period, 17 MCP prosthetic plants. The use of the SRA prosthesis
survival rate but were not statistically dislocations (13%) (Figures 2 and in revision surgery decreased implant
significant (see Appendix 1, Supple- 3), 1 periprosthetic fracture, and 1 repeat revision-free survivorship, but
mental Digital Content 1, http:// periprosthetic joint infection were this was not statistically significant
links.lww.com/JAAOS/A161). reported. Given the high rate of (HR, 2.60; P = 0.09). The 2-, 5-, and
In addition to the 20 secondary postoperative MCP instability, the 10-year implant survival rates for the
revision arthroplasty surgeries, an influence of multiple variables on the SRA implants were 75%, 67%, and
additional eight patients underwent rates of MCP dislocation was exam- 67%, compared with 88%, 83%,
revision surgeries for other reasons in ined. Univariate analysis demon- and 83% for pyrocarbon implants
the postoperative period. These strated that the rates of postoperative and 94%, 83%, and 81% for silicone
included soft-tissue balancing for dislocation were higher in patients implants, respectively (Figure 4).
instability for ulnar deviation (n = 5), with a prior dislocation (P , 0.001).
extensor mechanism centralization In addition, an association between
for subluxation (n = 1), rheumatoid increased rates of instability and the Subgroup Analysis: Prior
nodule excision (n = 2), flexor use of SRA implants approached but Implant Type
digitorum profundus repair for flexor did not reach significance (P = 0.06). The prior and revision prosthesis
digitorum profundus rupture (n = 1). types are summarized in Table 3.
Three intraoperative periprosthetic Among the 87 fingers whose primary
fractures were reported, including Implant Outcomes: MCP arthroplasty involved a silicone
two in the proximal phalanx (one Prosthesis Type implant, the implants used in their
pyrocarbon during implant insertion When subgrouping the secondary index revision surgeries were silicone
and one SRA implant during revision-free survival and results by implants (n = 59), pyrocarbon im-
broaching) and one in the metacarpal implant type used in the index revi- plants (n = 18), and SRA implants
Figure 3 Figure 4
Graph showing the Kaplan-Meier

survival comparison between implants.
Comparison of pyrocarbon (blue),
silicone (red), and surface-replacing
arthroplasty (SRA, green) medium-
term survival rates. The use of an SRA
prosthesis decreased implant revision-
free survivorship (P = 0.09).
90%, respectively. Two (9%) second-

ary revision surgeries were performed,
both in patients who received a
pyrocarbon implant. Revision of a
primary pyrocarbon implant had
lower subsequent secondary revision
rates when the implant type was
switched to a silicone prosthesis at the
time of their revision surgery, in com-
parison to the patients who underwent
the placement of another pyrocarbon
component (HR , 0.01; P = 0.15).
The digit involved and surgical ap-
proach did not have a notable impact
Radiographs (AP, oblique, and lateral) of a 73-year-old woman with rheumatoid
arthritis whose silicone implants of the second to fifth fingers fractured leading to on implant survival rates.
metacarpophalangeal joint instability and revision surgery. Of the 18 fingers whose initial
(primary) MCP arthroplasty was
with an SRA component, half were
(n = 10). The 2-, 5-, and 10-year note, higher rates of secondary revised (index revision) to a silicone
survival rates for revision of a pri- revision surgery were found from a prosthesis (n = 9) and the other half
mary silicone implant were 91%, history of prior instability (HR, were revised to another SRA implant
79%, and 76%, respectively. Fifteen 4.35; P = 0.006) and trended (n = 9). The 2- and 5-year survival
(17%) secondary revision surgeries toward significance regarding revi- rates for revision of a primary sili-
were performed: 10 (17%) in pa- sion of the index finger (HR, 2.20; cone implant were 88% and 83%,
tients with silicone implants, 2 P = 0.13). respectively. Three (17%) second-
(11%) in those with pyrocarbon Twenty-three fingers were treated ary revision surgeries were per-
implants, and 3 (30%) in those with with a pyrocarbon implant for their formed: two in patients with an SRA
SRA implants. Revision of a prior first (primary) MCP arthroplasty. prosthesis and one in a patient
silicone implant using a pyrocarbon Thirteen patients were revised (index with a silicone implant. The use of
or a silicone prosthesis had lower revision) to another pyrocarbon im- silicone (HR, 0.44; P = 0.48) had
rates of secondary revision surgery plant while 10 patients received silicone improved survival rates when com-
than when using an SRA (HR, 4.32; prosthesis. The 2- and 5-year sur- pared with the use of SRA (HR,
P = 0.054) implant, but this did not vival rates for revision of a primary 2.29; P = 0.48) but did not reach
reach statistical significance. Of pyrocarbon implant were 90% and statistical significance.
March 15, 2019, Vol 27, No 6 215
Table 3
Revision Arthroplasty Breakdown
Primary arthroplasty Silicone (n = 87) Pyrocarbon (n = 23) SRA (n = 18)
Index revision arthroplasty Silicone (n = 59) Pyrocarbon (n = 13) SRA (n = 9)
Pyrocarbon (n = 18) Silicone (n = 10) Silicone (n = 9)
SRA (n = 10) — —
SRA = surface-replacing arthroplasty
Subgroup Analysis: had greater than 2 years of index

clinical follow-up. At a mean follow-up Conclusions
Diagnosis
of 6 years (range, 2 to 16), patients
The analysis by surgical diagnosis Revision MCP arthroplasty presents
who underwent index revision MCP a difficult challenge to the hand
(osteoarthritis [OA]/posttraumatic
arthritis and inflammatory arthritis) arthroplasty had improved postopera- surgeon. Oftentimes these joints have
is seen in Figure 5 (Appendix 2, Sup- tive pain levels, with 95% reporting no diminished bone stock or quality,
plemental Digital Content 2, http:// or mild pain compared with 54% deformities, and soft-tissue deficiency.
links.lww.com/JAAOS/A162). Of preoperatively (P , 0.001) (Table 4). As with lower extremity arthroplasty,
note, within inflammatory arthritis No differences were found between deficient soft tissue in the revision
patients, a history of instability (HR, preoperative and postoperative oppo- setting has the potential to increase
3.11; P = 0.03) and index revision of a sitional pinch strength (P = 0.13), joint instability.
prior silicone arthroplasty (HR, 5.27; appositional pinch (P = 0.40), and grip Very little data exist in the literature
P = 0.04) increased the secondary re- strength (P = 0.23). Mean MCP arc of examining incidence, prognosis, and
vision rates, whereas in patients with motion improved from 33° preopera- outcomes of revision MCP. Burgess
OA or posttraumatic arthritis, a his- tively to 40° postoperatively (P = 0.04); et al4 reported on revision surgery for
tory of instability (HR, 4.39; P = 0.10) however, the clinical importance of this 62 MCP silicone arthroplasties per-
and older age at surgery (HR, 0.88; change is unclear. formed in 18 patients. Although
P = 0.045) increased the implant failure
risks. Implant choice did not affect the
rate of implant failure in either subgroup. Table 4
Clinical Outcomes (n = 88)
Clinical Outcomes Outcome Measure Rating P Value
We analyzed the clinical outcomes in all
Follow-up (yr) 6.0 (range, 2-16) —
(n = 88) fingers that were unrevised and
Grip strength (kg)a 0.23
Preoperative 9.1 6 1 —
Figure 5
Postoperative 7.6 6 1 —
Oppositional pinch (kg)a 0.13
Preoperative 1.4 6 0.1 —
Postoperative 1.8 6 0.1 —
Appositional pinch (kg)a 0.40
Preoperative 2.5 6 0.1 —
Postoperative 2.2 6 0.1 —
MCP arc of motion (°)a 0.04a
Preoperative 33° 6 2° —
Postoperative 40° 6 2° —
Graph showing the Kaplan-Meier Pain- none or mild (%) ,0.001a
survival comparison between
Preoperative 54 —
diagnoses. Comparison of
inflammatory arthritis (blue) and Postoperative 95 —
osteoarthritis/posttraumatic arthritis
a
(red) medium-term survival rates Statistically significant
(P = 0.045). MCP = metacarpophalangeal
patients had improved postoperative canals and extension of the dorsal these patients, but no other factors
pain relief, no change was found in surface to prevent volar subluxa- had a notable impact, including pros-
arc of motion, a relatively high tion.16 In addition, with an elastic thesis choice. The history of instability
implant fracture rate (34%), and 12 modulus similar to cortical bone was also associated with an increase in
(20%) fingers required revision sur- and an unconstrained design,17,18 the the rate of failure in patients with OA or
gery. Although the authors did not pyrocarbon implants potentially op- posttraumatic arthritis.
report on the rates of MCP dis- timize the stress transfer through the The findings of these studies high-
locations, the patients in their series bone-implant interface.19 In one of light the importance of the soft-tissue
did have a high rate of ulnar drift, the largest series of pyrocarbon im- envelope in maintaining MCP stabil-
which was associated with a high level plants, Parker et al7 reviewed 142 ity and implant longevity. Swanson20
of patient dissatisfaction. These re- MCP arthroplasties at a 17-month has first reported this highlight in
sults examining silicone arthroplasty average follow-up. Despite substan- 1972 regarding silicone implants,
are comparable to our series, with a 5- tially having most patients with emphasizing that ultimate joint sta-
year survival rate of 81%, but with rheumatoid arthritis in this series, bility was not from the implant itself,
good pain relief with the maintenance the authors noted improved motion but from the encapsulation of the
of the patients’ total arc of motion. and an overall 14% complication soft tissues around the joint. This
Our series of 128 revision MCP rate. Wall and Stern1 examined 11 finding could explain why there were
arthroplasties demonstrates that re- pyrocarbon arthroplasties in patients inferior outcomes in patients with
vision MCP arthroplasty is a chal- treated for OA over a slightly longer prior MCP instability in our series.
lenging procedure with nearly one in follow-up period, demonstrating It appears that previous MCP dis-
five patients requiring further revision a low rate of revision surgery (1/11) locations are associated with in-
surgery at an intermediate follow-up and complications. In this article, creased likelihood of continued joint
of 6 years. Increased rates of revision the authors suggest that although instability. This is especially more
surgery were seen in patients with a pyrolytic carbon arthroplasties might relevant when using the noncon-
history of diabetes mellitus and pre- not be the solution for all osteoar- strained designs.
operative joint instability. In our thritic joints of hands, we recommend The inherent nature of a revision
cohort, a relatively high rate postop- these implants for osteoarthritic MCP arthroplasty can compromise the
erative instability was found with 13% joints. soft-tissue envelope and contribute to
of patients experiencing a dislocation. Since Swanson’s report on silicone the relatively high rate of MCP dis-
In addition, patients who sustained a arthroplasties in 1972, multiple long- location. Revision surgery is often
dislocation were noted to have higher term studies have demonstrated performed in the setting of distorted
rates of secondary revision surgery. slightly poorer results than the shorter anatomy, with increased scar forma-
The use of silicone prosthesis had term pyrocarbon studies. Trail et al8 tion and deformities associated with
slightly better survival in the revision demonstrated a 63% survival at 17 the compromise of ligamentous and
of a prior pyrocarbon or SRA im- years after 1,336 silicone arthro- soft-tissue stability. These are further
plant, whereas both pyrocarbon and plasties, with generally good patient exacerbated by preoperative factors
silicone implants had improved sur- function and satisfaction. Goldfarb or patient comorbidities, as seen by
vival rates when revising a prior sili- and Stern14 reviewed 208 silicone the worse outcomes in our series for
cone MCP arthroplasty. Despite the arthroplasties in 52 hands over a 14- patients with preoperative instability.
relatively high revision rates and need year follow-up period and noted a Increasing implant constraint is often
for further surgery, patients who 38% rate of satisfaction and only a used to compensate for soft-tissue
undergo revision MCP arthroplasty 27% rate of pain relief. incompetency. Traditionally, uncon-
still have improvements in their pain The patient factors that had an strained pyrocarbon or SRA implants
and range of motion postoperatively. impact on outcomes included dia- are reserved for joints with rela-
In the primary setting, both betes mellitus and inflammatory tively preserved soft-tissue stabilizers,
pyrocarbon and silicone arthroplasty arthritis, with a lower risk of implant whereas constrained silicone im-
have demonstrated reasonable rates of failure in both. The etiology behind plants are used for more advanced
implant survival with good clinical these two findings is unclear. We bony and ligamentous loss.3 In our
outcomes.1-3,5,7-9,13-15 One possible further analyzed the outcomes within series, no notable difference was
explanation could deal with the fact only inflammatory arthritis and found appreciated between silicone and
that all pyrocarbon implants used in that prior silicone arthroplasties and a pyrocarbon implants used in the
this study were new generation, with history of implant instability were revision setting. However, we also
wider stems to match the metaphyseal associated with lower rates of failure in appreciate that selection bias may
March 15, 2019, Vol 27, No 6 217
be a factor as patients with silicone ative outcomes, although the smaller replacement. J Bone Joint Surg Br 2004;86:
1002-1006.
implants may have had inferior soft- cohort of patients who received the
tissue competence at the time of SRA implants did have higher rates of 9. Cook SD, Beckenbaugh RD, Redondo J,
Popich LS, Klawitter JJ, Linscheid RL:
revision surgery. Interestingly, the MCP dislocations and further revi- Long-term follow-up of pyrolytic
use of the unconstrained SRA im- sion surgery. Overall, patients had carbon metacarpophalangeal implants. J
Bone Joint Surg Am Vol 1999;81:
plants did increase the risk of MCP very good rates of pain relief and 635-648.
instability and rates of repeat oper- maintenance in their arc of motion.
10. Berry DJ, Kessler M, Morrey BF:
ations, although this was not statis- These encouraging clinical results Maintaining a hip registry for 25 years:
tically significant. demonstrate that despite the chal- Mayo Clinic experience. Clin Orthop
The findings of this study should be lenges faced by the surgeon in the Relat Res 1997;344:61-68.
interpreted in light of its limitations. revision setting, reasonable medium- 11. McGrory BJ, Morrey BF, Rand JA, Ilstrup
DM: Correlation of patient questionnaire
Our series is a retrospective review of term results can be achieved through responses and physician history in grading
patients in a prospectively collected proper implant and joint stabiliza- clinical outcome following hip and knee
total registry. Therefore, we are tion. However, given the increased arthroplasty: A prospective study of 201
joint arthroplasties. J Arthroplasty 1996;
limited on our final outcome mea- risk for joint instability and further 11:47-57.
sures and analysis and are not able to surgery, there continues to be a need
12. Singh B, Singh A, Ahmed A, et al:
obtain patient-validated outcome for innovative strategies to optimize Derivation and validation of automated
measures. For example, we are not long-term outcomes and joint stabil- electronic search strategies to extract
Charlson comorbidities from electronic
able to examine the effect of dorsal ity in the revision setting. medical records. Mayo Clin Proc 2012;87:
bone loss on implant outcomes. 817-824.
However, the fact that the patients 13. Delaney R, Trail IA, Nuttall D: A
are followed prospectively through References comparative study of outcome between the
the institution’s total joints registry Neuflex and Swanson metacarpophalangeal
References printed in bold type are joint replacements. J Hand Surg 2005;30:
adds to the strength of our study, 3-7.
with a comprehensive and complete
years. 14. Goldfarb CA, Stern PJ: Metacarpophalangeal
patient follow-up and hard outcome joint arthroplasty in rheumatoid arthritis: A
analysis. Furthermore, our small 1. Wall LB, Stern PJ: Clinical and radiographic long-term assessment. J Bone Joint Surg Am
outcomes of metacarpophalangeal joint 2003;85-A:1869-1878.
sample size and low number of re- pyrolytic carbon arthroplasty for
visions and complications limit our 15. Chung KC, Kotsis SV, Kim HM: A
osteoarthritis. J Hand Surg 2013;38:
prospective outcomes study of Swanson
ability to perform multivariate anal- 537-543.
metacarpophalangeal joint arthroplasty for
ysis or any further in-depth analysis of 2. Drake ML, Segalman KA: Complications of the rheumatoid hand. J Hand Surg 2004;
small joint arthroplasty. Hand Clin 2010; 29:646-653.
factors associated with outcomes
26:205-212.
beyond a simple univariate model. 16. Simpson-White RW, Chojnowski AJ:
3. Rizzo M: Metacarpophalangeal joint Pyrocarbon metacarpophalangeal joint
Given this is a single institution, arthritis. J Hand Surg 2011;36:345-353. replacement in primary osteoarthritis.
referral bias is introduced into our J Hand Surg Eur Vol 2014;39:575-581.
4. Burgess SD, Kono M, Stern PJ: Results of
cohort as well. Finally, there is revision metacarpophalangeal joint surgery 17. Cook SD, Klawitter JJ, Weinstein AM:
potentially a selection bias, given sili- in rheumatoid patients following previous The influence of implant elastic modulus
silicone arthroplasty. J Hand Surg 2007;32: on the stress distribution around LTI
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1506-1512.
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5. Kimani BM, Trail IA, Hearnden A, Delaney 879-887.
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R, Nuttall D: Survivorship of the Neuflex
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J Hand Surg Eur Vol 2009;34:25-28. Klawitter JJ: The influence of the bone-
This series serves as a comprehen- implant interface stiffness on stress profiles
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7. Parker WL, Rizzo M, Moran SL, Hormel influence of implant elastic modulus on the
vival rate of 81%, with a relatively KB, Beckenbaugh RD: Preliminary results stress distribution around LTI carbon and
high rate of MCP instability. Worse of nonconstrained pyrolytic carbon aluminum oxide dental implants. J Biomed
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Research Article
Quality Measures in Total Hip and

Total Knee Arthroplasty
Abstract
Derek F. Amanatullah, MD, PhD Introduction: Total joint arthroplasty represents the largest expense
Thomas McQuillan, MD for a single condition among Medicare beneficiaries. Payment models
exist, such as bundled payments, where physicians and hospitals are
Robin N. Kamal, MD
reimbursed based on providing cost-efficient, high-quality care. There is a
need to explicitly define “quality” relevant to hip and knee arthroplasty.
Based on prior quality measure research, we hypothesized that less
than 20% of developed quality measures are outcome measures.

Methods: This study systematically reviewed current and candidate
quality measures relevant to total hip and knee arthroplasty using
several quality measure databases and an Internet library search.
Results: We found a total of 35 quality measures and 81 candidate
measures, most of which were process measures (N = 21, 60%), and
represented the National Quality Strategy priorities of patient- and
From the Department of Orthopaedic caregiver-centered experience and outcomes (31%), effective
Surgery, Stanford University
School of Medicine, Stanford, CA clinical care (28%), or patient safety (19%).
(Dr. Amanatullah and Dr. Kamal), and Conclusion: Various stakeholders have developed quality measures
Harvard Combined Orthopaedic in total joint arthroplasty, with increasing focus on developing outcome
Residency Program, Massachusetts
General Hospital, Boston, MA measures. The results of this review inform orthopaedic surgeons on
(Dr. McQuillan). quality measures that payers could use value-based payment models
Correspondence to Dr. Kamal: like the Merit-based Incentive Payment System and Comprehensive
rnkamal@stanford.edu Care for Joint Replacement.
Dr. Amanatullah or an immediate Level of Evidence: Level I, systematic review of level I evidence
consultant to BlueJay Mobile Health,
Exactech, Omni, Sanofi-Aventis,
Stryker, and Zimmer Biomet; has
received research or institutional
support from Acumed, BlueJay Mobile
Health, Stryker, and Zimmer Biomet;
T otal joint arthroplasty is a com-
mon orthopaedic procedure
performed in the elective setting,
Given the notable cost of total joint
arthroplasty to the United States
health system, these procedures are
and serves as a board member, making expenditures on arthritis becoming increasingly regulated
of the American Academy of
the largest for a single condition through payment models that reim-
Orthopaedic Surgeons. Neither of the among Medicare beneficiaries.1 In burse based on providing high-quality
following authors nor any immediate 2014, more than 400,000 total hip care.10 For example, in 2015, the
family member has received anything arthroplasties (THAs) or total knee Centers for Medicare & Medicaid
arthroplasties (TKAs) were performed, Services (CMS) organized a pilot
or institution related directly or with the average Medicare expendi- program for the Comprehensive Care
indirectly to the subject of this article: ture for surgery, hospitalization, and for Joint Replacement. This bundled
Dr. McQuillan and Dr. Kamal. recovery ranging from $16,500 to payment program for THA and TKA
J Am Acad Orthop Surg 2019;27: $33,000 across different geographic reimburses hospitals and surgeons
219-226 areas.2-4 Despite decreasing length of based on their ability to provide
DOI: 10.5435/JAAOS-D-17-00283 hospital stays and improved out- high-quality, cost-efficient services.2
comes,5,6 the total expense of these In value-based models, payers hold
Academy of Orthopaedic Surgeons. procedures will continue to rise with participant hospitals and surgeons
an increase in surgical volume.7-9 financially accountable for an episode
March 15, 2019, Vol 27, No 6 219
Quality Measures in Total Hip and Total Knee Arthroplasty
of care to incentivize higher quality identify gaps in measurement to dence) or “consensus” approval
care.11,12 inform future measure development. from an AAOS expert panel. We
The utilization of a bundled pay- We hypothesized that less than 20% included guidelines for the manage-
ment model is predicated on appro- of current and candidate quality ment of hip and knee osteoarthritis
priate definitions of quality. Quality measures would be outcome mea- from the AAOS but excluded non-
improvement ensures resources are sures, despite evidence suggesting that specific osteoarthritis guidelines
appropriately allocated toward im- patient outcomes may be the most from other professional societies. We
proving care for the patient, and not important indicators of quality.15,18 reviewed the AAOS clinical practice
an aspect of care that is unimportant Prior quality measure research has guidelines on Venous Thrombo-
or not patient-centered. For example, demonstrated a relative paucity of embolic Disease, Periprosthetic Joint
defining “quality” as improvement outcome measures operationalized by Infections of the Hip and Knee,
on a patient-reported function out- payers and regulatory organizations Surgical Management of Osteo-
come measure would shift resources (eg, CMS),19–21 with approximately arthritis of the Knee, Non-Surgical
toward ensuring a patient’s function 60% to 98% of measures being Management of Knee Osteoarthritis,
improved after surgery. The National process measures. These findings led and Dental Procedures. During this
Quality Strategy (NQS) was created to our hypothesis that a minority of review, candidate quality measures
to guide transitions in the healthcare quality measures would be outcome were identified based on high-level
system and to serve as a blueprint for measures. scientific evidence and professional
developing patient-centered quality recommendations but were yet to be
measures.13,14 quantified into measures with a
Quality measures are used to track Methods numerator (the eligible number of
the performance of providers and patients/procedures) and a denom-
health systems and aim to provide We used the methodology of the inator (the total number of
an objective assessment of healthcare Preferred Reporting Items for Sys- patients/procedures).
quality. These measures function as tematic Reviews and Meta-Analysis We performed a PubMed/
tools to assess multiple domains Statement for our review.22 We MEDLINE search using customized
of health care: (1) organizational searched for quality measures in the search criteria with words such as
structures that may facilitate care, (2) Physician Quality Reporting System “hip,” “knee,” “replacement,” and
processes associated with care deliv- (now incorporated in Medicare’s “joint” in addition to words such as
ery, and (3) outcomes associated with Quality Payment Program23), Na- “quality,” “measure,” and “im-
high-quality care.15,16 Payers and tional Quality Forum’s Quality provement” and an EMBASE search
regulatory organizations like the Positioning System, and the Agency using Scopus with identical terms. We
American Academy of Orthopaedic for Healthcare Research and Quality also performed a Google Scholar
Surgeons (AAOS) or CMS act as National Quality Measures Clear- search using these terms and screened
stewards that develop and maintain inghouse (Table 1). We searched for the first 20 results of each term for
quality measures. Quality measures the terms “knee,” “hip,” “replace- additional quality measures.
are important as they guide value- ment,” and “arthroplasty” in these One fellowship trained arthro-
based payment models, such as the databases. We next searched the plasty orthopaedic surgeon (D.F.A.)
Merit-based Incentive Payment Sys- AAOS website for clinical practice and one quality measure expert
tem (MIPS) from CMS, with the goal guidelines that could be considered (R.N.K.) reviewed each of the quality
of reducing costs and improving candidate quality measures. Clinical measures after the initial screening.
quality. practice guidelines were included as These methods included iterative
Quality measures are becoming candidate quality measures if their rounds of independent evaluations by
increasingly important in total joint development was consistent with the the two reviewers, with intermittent
arthroplasty as they guide resource Institute of Medicine criteria for the face-to-face discussions to resolve dis-
allocation, physician and health system development of quality measures, agreement.20 English-language docu-
reimbursement, and quality improve- specifically with respect to the level ments, articles, and measures were
ment efforts.17 We completed a sys- of evidence and the strength of rec- included if they were related directly
tematic review of the quality measures ommendation. We thus included all to the practice of THA/TKA; general
and candidate quality measures in AAOS clinical practice guidelines orthopaedic surgery quality mea-
THA and TKA (1) to identify and that had achieved “strong” or sures were excluded.
categorize measures that address “moderate” endorsement based on Exclusion criteria comprised any
total joint arthroplasty and (2) to high-level (level I and level II evi- guidelines without a description of
Derek F. Amanatullah, MD, PhD, et al
Table 1
Quality Measure Databases and Search Engines
Source Name Organization Details
CMS-PQRS/QPP: Center for Medicare Agency within the US Department of Contains quality measures endorsed by
& Medicaid Services—Physician Health and Human Services that the US government used in quality
Quality Reporting System, Quality administers Medicaid and Medicare reporting for physicians
Payment Program programs
AHRQ—NQMC: Agency for Healthcare Agency that is part of the US Department Database that includes quality
Research and Quality—National of Health and Human Services created measures endorsed by private groups
Quality Measures Clearinghouse specifically to address quality as well as other US government
improvement agencies
NQF—QPS: National Quality Forum— Nonprofit organization that endorses Database of “benchmark” quality
Quality Positioning System quality measures from multiple measures currently endorsed; also
sources searchable for older quality measures
AAOS—CPG: AAOS—Clinical Practice US professional society representing Evidence-based guidelines based on
Guidelines orthopaedic surgeons the current literature specific to
orthopaedic surgery
PubMed/MEDLINE US National Library of Medicine Database of life science and biomedical
references
EMBASE Elsevier, for-profit corporation Database of life science and
pharmacological references
Google Scholar Google, for-profit corporation Search engine for articles from
academic publishers and peer-
reviewed and non–peer-reviewed
sources
AAOS = American Academy of Orthopaedic Surgeons, AHRQ = Agency for Healthcare Research and Quality, CMS = Centers for Medicare &
Medicaid Services, CPG = Clinical Practice Guidelines, NQF = National Quality Forum, NQMC = National Quality Measure Clearinghouse, QPP =
Quality Payment Program, QPS = Quality Positioning System, PQRS = Physician Quality Reporting System
pertinent levels of evidence and ther classified using Donabedian’s15 30-day readmission rate after THA.
approach, recommendations made domains of structure, process, and We further categorized these quality
without level I and II evidence, or outcome. We classified structural measures by the NQS priorities.13,32
statements that were recapitulations quality measures as those that refer These priorities, developed annually
of other previously published guide- to the context in which health care is by the Department of Health and
lines (eg, the American College of delivered, including setting, location, Human Services, include (1) person-
Chest Physicians) based on recom- and material resources. An example and caregiver-centered experience
mendations from the Institute of of a structural measure is volume of and outcomes, (2) patient safety, (3)
Medicine.14,24 AAOS Appropriate care, such as the rate of unilateral or communication and care coordina-
Use Criteria were excluded,25 as bilateral knee arthroplasties per- tion, (4) community and population-
these did not meet an operational formed per 100,000 inpatients at a based health, (5) efficiency and cost
definition of quality measures of the given hospital. Process quality reduction, and (6) effective clinical
Institute of Medicine.14,26 Expert measures involved the management, care.
consensus recommendations by sequence, and best practices in
groups other than the AAOS were healthcare delivery for patients
also excluded from this study.27-29 undergoing THA or TKA: venous Results
We excluded guidelines with more thromboembolism prophylaxis in the
updated versions available in the lit- perioperative period is an appropri- With our initial search strategy, we
erature at the time of this review.30,31 ate example. Outcome quality meas- found 3,253 articles and quality
We also excluded guidelines that were ures ascertained the effect of measures (Figure 1) and reviewed a
specific to hip fracture surgery and treatment from the patient perspec- total of 718 articles and quality
not generalizable to elective THA. tive or measured aspects of clinical measures. One thousand six hundred
After screening and full-text performance. A typical outcome twenty-seven results were excluded
review, quality measures were fur- measure is the age-standardized, due to insufficient description of the
March 15, 2019, Vol 27, No 6 221
Figure 1 of a medical history regarding pain

and function; or percentages of pa-
tients receiving preoperative anti-
biotics, physical examinations, or
medical optimization. Structural
measures discovered during this review
were primarily related to the surgical
volume of arthroplasty for specific
health centers.
Conclusion
Quality measures are the backbone
of value-based payment models.
Payers, orthopaedic surgeons, and
other stakeholders will benefit from
knowing the quality measures ad-
dressing THA and TKA to (1) un-
Illustration of search algorithm and quality measure extraction. AHRQ = Agency
derstand how quality of care is
for Healthcare Research and Quality, NQF = National Quality Forum, PQRS =
Physician Quality Reporting System, QM = Quality Measure, THA = total hip assessed and (2) assume leadership
arthroplasty, TKA = total knee arthroplasty in the development future quality
measures. We find that greater than
50% of all quality measures in to-
level of evidence used to issuing (n = 18; 50%), medical aspects of tal joint arthroplasty are process
recommendations, use of low level perioperative treatment (n = 1; 3%), measures; this finding does not dif-
(level III/IV) evidence in formulating and surgical aspects of treatment (n = fer markedly from our hypothesis as
recommendations. From the re- 16; 32%). well as the findings in other sub-
maining 718 results, 116 quality Most current quality measures specialties of orthopaedics, where
measures specific to THA and TKA were process measures (n = 21, 60%), prior research has noted a relative
met our inclusion criteria: 35 of these in addition to 12 outcome measures scarcity of quantifiable outcome
met criteria as quality measures (see (33%) and 2 structural measures measures to evaluate quality.20
Appendix 1, Supplemental Digital (6%). A review of current quality The relative abundance of outcome
Content 1, http://links.lww.com/ measures, described in Appendix 1 measures identified in this research for
JAAOS/A163) and 81 were defined (see Supplemental Digital Content 1, total joint arthroplasty (34% vs 20%
as candidate quality measures (see http://links.lww.com/JAAOS/A163), in other specialties) re-emphasizes
Appendix 2, Supplemental Digital demonstrates a relative increase in that this THA and TKA have already
Content 2, http://links.lww.com/ these outcome-oriented quality been the target of continued innova-
JAAOS/A164). measures in total joint arthroplasty tion with respect to value-based pay-
Of the 35 current quality measures, that have been operationalized by ment models, with prior measure
9 were obtained from the Physician stakeholders like CMS in recent development attempting to quantify
Quality Reporting System/Quality years. Key outcome measures inpatient outcomes to assess the qual-
Payment Program database (25%), cluded pre- and postoperative ity of care. The development of pay-
16 from the Agency for Healthcare Oxford Knee or Hip Disability ment models like Comprehensive
Research and Quality database and Osteoarthritis Outcome Score Care for Joint Replacement and
(44%), 10 from the NQF database assessments and calculation of age- MIPS represents two examples of
(28%), and 11 from another litera- standardized readmission and com- evolving quality improvement in-
ture source (31%) (Table 2). The six plication rates. Process measures centives in THA and TKA, which
NQS priorities for quality measures typically assessed the elements of the may be driving creation of these
were not represented equally and are healthcare delivery process not quality measures.17,33,34 CMS will
broken down by source in Table 2. related to a specific clinical outcome, continue to emphasize the use of
Quality measures were also stratified such as the screening for cardiovas- patient-reported outcome measures
by relevance to preoperative care cular risk factors or documentation specific to joint arthroplasty for
Table 2
Current Quality Measure Developers and Measurement Domains
Structure, Preoperative,
Development Process, or NQS No. of Medical, or
Source Developer Methodology Outcome Domains Measures Surgical
CMS PQRS/QPP CMS, AAOS, AAHKS, Unknown Process (7) PS (3) 9 Preoperative (5)
NCQA, PCPI/AMA, Outcome (2)
Focus on Therapeutic
Outcomes
— — Process (4) CCC (3) — Medical (1)
— — — PCCEO — Surgical (3)
(3)
AHRQ NQMC AAOS, AAHKS, PCPI/ LR and EC Process (8) ECC (5) 16 Preoperative (8)
AMA, MN Community Outcome (6)
Measurement, CIHI Structure (2)
— — Process (5) PS (3) — Medical (1)
— — Structure (2) PCCEO — Surgical (7)
(3)
— — — CCC (3) — —
— — — C/PH (2) — —
NQF QPS CMS, Optum, MN Unknown Outcome (10) ECC (7) 10 Preoperative (2)
Community
Measurement, Focus
on Therapeutic
Outcomes
— — Process (1) CCC (2) — Medical (0)
— — Structure (1) ERC (1) — Surgical (8)
PubMed, Google AAOS, AMA, CMS, LR, EC, Process (10) PCCEO 11 Preoperative (9)
Scholar, EMBASE ACCP, AAHKS unknown Outcome (1) (5)
— — Outcome (7) PS (4) — Medical (0)
— — — CCC (1) — Surgical (2)
— — — ECC (1) — —
Total Quality As above As above Process (21) PCCEO 35 Preoperative (18)
Measures (without Outcome (12) (11)
duplicates) Structure (2)
— — Process (12) ECC (10) — Medical (1)
— — Structure (3) PS (7) — Surgical (16)
— — — CCC (4) — —
— — — C/PH (2) — —
— — — ECR (1) — —
AAOS = American Academy of Orthopaedic Surgeons, AAHKS = American Association of Hip and Knee Surgeons, ACCP = American College of
Chest Physicians, AHRQ = Agency for Healthcare Research and Quality, AMA = American Medical Association, CCC = communication and care
coordination, CMS = Centers for Medicare and Medicaid Services, C/PH = Community/Population Health, CIHI = Canadian Institute for Health
Information, EC = expert consensus, ECC = effective clinical care, ECR = efficiency and cost reduction, QPP = Quality Payment Program, QPS =
Quality Positioning System, LR = literature review, NCQA = National Committee on Quality Assurance, NQMC = National Quality Measure
Clearinghouse, NQS = National Quality Strategy, PCCEO = patient- and caregiver-centered experiences and outcomes, PCPI = Physician
Consortium for Physician Improvement, PQRS = Physician Quality Reporting System, PS = patient safety
quality assessment.17,34 Other efforts Replacement may also provide defining and codifying candidate
like total joint registry efforts such opportunities for quality assessment quality measures (Table 3). This
as the California Joint Replace- by collecting and sharing provider- review evaluates many candidate
ment Registry and the Function and level quality measures.33 measures, developed by institutions
Outcomes Research for Compara- Second, these results suggest a such as the AAOS, which serve to
tive Effectiveness in Total Joint role for orthopaedic stewardship in guide practice in medical aspects of
March 15, 2019, Vol 27, No 6 223
Table 3
Candidate Quality Measure Developers and Measurement Domains
Structure, Preoperative,
Development Process, or NQS No. of Medical, or
Source Developer Methodology Outcome Domains Measures Surgical
AAOS Clinical AAOS LR and EC Process (57) ECC (33) 60 Preoperative (13)
Practice Guidelines Outcome (3)
— — — CCC (15) — Medical (26)
— — — PS (11) — Surgical (21)
— — — PCCEO — —
(1)
PubMed, Google ACCP, Korean Knee LR, EC, Process (21) PS (10) 21 Preoperative (1)
Scholar, EMBASE Society, PCPI/AMA, unknown
AAHKS
— — — CCC (10) — Medical (20)
— — — PCCEO — Surgical (0)
(1)
Total Quality As above As above Process (78) ECC (33) 81 Preoperative (14)
Measures (without Outcome (3)
duplicates)
— — — CCC (25) — Medical (46)
— — — PS (21) — Surgical (21)
— — — PCCEO — —
(2)
AAOS = American Academy of Orthopaedic Surgeons, AAHKS = American Association of Hip and Knee Surgeons, ACCP = American College of
Chest Physicians, AMA = American Medical Association, CCC = communication and care coordination, EC = expert consensus, ECC = effective
clinical care, LR = literature review, NQS = National Quality Strategy, PCCEO = patient- and caregiver-centered experiences and outcomes, PCPI =
Physician Consortium for Physician Improvement, PS = patient safety
orthopaedic care, most notably in Limitations of this review include new outcome measures may aim to
the assessment, management, and distinguishing overlapping or con- encompass the NQS priorities that
treatment of periprosthetic infections tradictory quality measures, so the rigorously assess patient safety,
and thromboembolism prophylaxis. scope of quality measurement in total coordination of care, and effective
Fewer existing quality measures joint arthroplasty may be smaller surgical treatments in the hospital
assess functional outcomes in the than it originally appears. Examples setting. Qualitative research that
postoperative setting, and an even such as conflicting recommendations assesses patients’ preferences and
smaller number describe the efficient for venous thromboembolism pro- values may be useful in defining
use of resources. The AAOS has phylaxis by the AAOS and Amer- patient-centered outcomes, espe-
prioritized quality measure develop- ican College of Chest Physicians cially in defining these system-wide
ment in the transition to the MIPS, highlight the need for well-defined process objectives.32
and the AAOS Performance Mea- methodologies to achieve scientific The importance of new measure
sures Committee has already identi- consensus. Without consistent defi- development cannot be overstated;
fied MIPS quality measures that are nitions of quality, it will be difficult quality measures are not only linked
most relevant to orthopaedic sur- for regulatory agencies to hold pro- to payments in value-based health-
geons.35,36 The successful evolution viders and health systems fiscally care models but are also ultimately
of a value-based healthcare system accountable for the care they provide. used by health systems to guide
is predicated on appropriate meas- Another limitation of this review is resource allocation and care em-
ures for payers, providers, and pa- that many candidate measures are phasis to improve patient-centered
tients to assess the quality of care; still process measures rather than outcomes. Ensuring that quality
orthopaedic surgeons will play a outcome measures. Although stan- measures evolve with new evidence
vital role in clarifying and defining dardized processes may drive better and are informed by patient values
this agenda. outcomes at high volume centers,37 and expectations can help safeguard
against shifting resources and energy 2002. J Bone Joint Surg Am 2005;87: 22. Moher D, Liberati A, Tetzlaff J, Altman
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Research Article
Factors Predictive of Orthopaedic

In-training Examination
Performance and Research
Productivity Among Orthopaedic
Residents
Abstract
Tyler Kreitz, MD Introduction: Selection of qualified candidates for orthopaedic
Satyendra Verma, PhD residency is necessary for growth and innovation. The purpose of this
study was to determine predictors of Orthopaedic In-training Exam
Alexei Adan, MD
(OITE) performance and research productivity.
Kushagra Verma, MD Methods: A survey was distributed to 13 residency programs
collecting demographics, United States Medical Licensing
Examination (USMLE) and OITE scores, and authored publications.
Associations between preresidency qualifications and OITE scores
and publications were determined.
Results: A total of 274 of 294 surveys were returned (93.2%). We
found a positive correlation between USMLE step 1 and 2 scores with
recent OITE percentile (P , 0.001). Preresidency authorship (P ,
0.001) and postgraduate training year (P , 0.001) were independent
predictors of authorship during residency, whereas USMLE step 1
From the Department of Orthopaedic score was not (P = 0.094).
Surgery, Thomas Jefferson University
Hospitals, Philadelphia, PA
Conclusion: Candidates who perform well on the USMLE are likely to
(Dr. Kreitz), the Department of perform well on the OITE, whereas those with greater authored
Economics, University of Maryland, publications are likely to continue research during residency.
College Park, MD (Dr. S. Verma), the
Temple University, Philadelphia, PA
(Dr. Adan), and the Department of
Orthopaedics, University of
Washington, Seattle, WA (Dr. K.
Verma).
Correspondence to Dr. Kreitz:
O rthopaedic surgery remains one
of the most competitive sub-
specialties that medical students apply
quality of care, patient outcomes, and
cost control. One survey of program
directors noted that the top three
tyler.m.kreitz@gmail.com for. In 2015, a total of 1,062 appli- factors influencing orthopaedic resi-
None of the following authors or any cants competed for 703 orthopaedic dent selection were clinical clerkship
immediate family member has residency-training positions, a match performance at their institution, United
received anything of value from or has rate of 66.2%.1 Competition for States Medical Licensing Examination
limited training positions is intense, (USMLE) step 1 score, and medical
related directly or indirectly to the with approximately one-third of ap- school ranking.2,3 However, whether
subject of this article: Dr. Kreitz, Dr. S. plicants not matching. Programs are these factors are predictive of perfor-
Verma, Dr. Adan, and Dr. K. Verma. able to choose well-qualified appli- mance during orthopaedic training
J Am Acad Orthop Surg 2019;27: cants from an ever-expanding and and future clinical practice is not clear.
e286-e292 competitive pool. Selection of well- Performance during orthopaedic
DOI: 10.5435/JAAOS-D-17-00257 qualified candidates is necessary for residency training is difficult to assess
the growth of the subspecialty. This and is often quantified by objective
Academy of Orthopaedic Surgeons. statement is especially true in a data; Orthopaedic In-training Exam-
healthcare environment defined by ination (OITE) scores and American
Tyler Kreitz, MD, et al
Board of Orthopaedic Surgery (ABOS) developed and distributed to 13 resi- 2. These models were used to evaluate
passage rates.4-8 Several studies have dents at 13 orthopaedic training the influence multiple independent
evaluated preresidency qualifications programs across the country. These variables—step 1 and 2 scores,
as predictors OITE and ABOS scores. programs were individually ap- undergraduate study, preresidency
These studies are limited to single or proached for participation in the publications, and first-authorship
regional training programs and have study. At any given institution, a publications, number of clinical
demonstrated inconsistent correla- designated resident was selected clerkship honors, and postgraduate
tions between step 1 and 2 scores with to explain the study to residents, training year (PGY)—as predictors
OITE performance and ABOS Part I distribute, and collect the surveys of resident research productivity.
passage rates.4-8 Over the last several during a single academic conference. An outside funding source was not
years, increasing competition has Participation in the survey was necessary for this study.
driven the standard for USMLE step 1 voluntary (see Appendix, Supple-
performance to higher levels.1,9 It is mental Digital Content 1, http://
clear that preresidency academic per- links.lww.com/JAAOS/A169). Sur- Results
formance may correlate with resi- veys were completed anonymously
dency performance as measured by and returned during the same con- Thirteen orthopaedic residency pro-
standardized test results, but no conference. At the conclusion of confer- grams were surveyed nationwide. A
sensus exists as to which measures are ence, the assigned resident returned total of 274 survey responses were re-
most predictive.10 Furthermore, the all surveys to the principal investiga- turned of 294 total surveys adminis-
role of orthopaedic resident research tor through certified mail. Institu- tered for a response rate of 93.2%. The
productivity has not been previously tional review board approval was not responders were well distributed by
evaluated as a contributor of residency required because of the anonymous PGY, with the majority being PGY-2
performance. Literature evaluating and voluntary nature of the survey (23.7%), followed by PGY-5 (20.8%),
factors associated with residency administered only to group health- PGY-1 and -4 (18.6%), PGY-3
research productivity is limited, none care professionals. (17.9%), and a single PGY-6 respon-
of which is specific to orthopaedic dent (Table 1). Most respondents were
residents. Factors influencing resident science majors at their undergraduate
research productivity include resi- Statistical Analysis institutions (57.9%) (Table 1). Over
dency research requirement, faculty All aggregate deidentified survey data half (55.64%) of residents took at least
size, and amount of designated aca- were collected and analyzed accord- one gap year between undergraduate
demic time including programs with a ingly. Baseline demographic data were and medical school or medical school
designated research year.11-14 To our determined from the aggregate results. and residency training. Thirty-one
knowledge, no study has evaluated The influence of step 1 and step 2 percent (31.4%) had Alpha Omega
predictors of residency research pro- critical knowledge (CK) scores on Alpha honors, 36.5% were athletes,
ductivity among orthopaedic residents. preresidency and residency research, and 45.3% played a musical instru-
The purpose of the study was to total authored and first-author pub- ment (Table 1). Most respondents had
determine which preresidency factors lications, was determined by the two- step 1 and step 2 CK scores between
are predictive of research productiv- tailed Pearson correlation. 245 and 260, 38.5% and 42.2%,
ity during residency. In addition, Logistic regression was used to respectively (Table 1).
the influence of USMLE and OITE analyze multiple independent factors Most respondents (77%) were
scores—if any—on research pro- as predictors of research productivity involved in at least one authored pub-
ductivity is correlated among a cross- during residency. Resident research lication before residency, with 53%
section of nationwide orthopaedic productivity was measured by two having a first authorship before resi-
training programs. variables: the number of authored dency training (Table 2). Residents
publications and first-author pub- had an average 2.4 authored pub-
lications. Two logistic models were lications and 1.83 first authorships.
Methods developed setting the Y-axis for As expected, respondents reported
comparison with 65% (65% of re- increasing numbers of total pub-
Survey spondents reported an authored lications and first-authorship pub-
A multifaceted anonymous resident publication during residency) for lications by the PGY training level
survey (see Appendix, Supple- model 1, and 49% (49% of re- (Table 2). Most respondents scored
mental Digital Content 1, http:// spondents reported first-author pub- between the 41 and 60th percentile
links.lww.com/JAAOS/A169) was lications during residency) for model on their best OITE performance
March 15, 2019, Vol 27, No 6 e287
Orthopaedic In-training Examination Performance and Research Productivity Among Orthopaedic Residents
Table 1 (28.4%), followed by 61 and 80th

(26.9%), and .80th percentile
Characteristics of Residents Responding to the Survey Shows
Demographic Information Including Distribution of Survey Responses by (25.1%) (Table 1).
PGY, Preresidency Qualifications, Undergraduate Major, Step 1 and Step 2 A significant positive correlation
CK Score, and Most Recent OITE Score Distribution was found between the USMLE step
PGY Percentage 1 score and the most recent OITE
performance percentile (P , 0.001).
PGY-1 18.6 We also found a significant positive
PGY-2 23.7 correlation between the USMLE step
PGY-3 17.9 2 CK score and OITE performance
PGY-4 18.6 (P , 0.001). In addition, a positive
PGY-5 20.8 correlation existed between USMLE
PGY-6 0.4 step 1 and step 2 CK scores, P ,
0.001 (Table 3).
Preresidency Qualifications Percentage Respondents A logistic regression model, as
Gap year 55.6 described above, was performed with
Previous job 50.4
baseline probabilities of authored
publication (model 1, 65%) and first
Musical instrument 45.3
authorship (model 2, 49%). For model
Athlete 36.5
1, the step 1 scores were categorized as
AOA 31.4
follows: low (,215), medium (215 to
Preresidency Qualifications Mean
245), and high (.245). We observed
an inverse relationship between the
Clerkship honors 3.9 step 1 score and the probability of
Authored publications 2.6 having authored publications: low
First-authorship publications 1.8 (65%), medium (25%), and high
(21%) holding other variables con-
Percentage Respondents stant. The difference between the low
and high groups was statistically sig-
Major
nificant. Also, the odds of authored
Sciences 57.9
publications during residency were
Nonscience 42.1
high (67%) when undergraduate sci-
Step 1 score
ence majors are compared with other
,200 0.7
nonscience majors. The probability of
200-214 4.8
authored publications increased to
215-229 9.9 70% if one had a first-author publi-
230-244 35.5 cation during the preresidency period.
245-259 38.5 Five of more clerkship honors
.260 10.6 increased the probability of authored
Step 2 CK score publications to 82%. Probability of
,200 0.4 authored publication increased with
200-214 3.3 each PGY; 82% in the second year
215-229 10.4 (PGY-2) to 99% in the fifth year
230-244 25.2 (PGY-5) (Figure 1).
245-259 42.2 Model 2 presents the logistic regres-
.260 18.5 sion results of first-author publications.
OITE score percentile Initially, the probability of first-author
,20 3.3 publications was 49% based on survey
21-40 16.3 response data. Similar to model 1, a
(continued ) medium or high step 1 score reduced
AOA = Alpha Omega Alpha, CK = critical knowledge, OITE = Orthopaedic In-training the probability of first-authored pub-
Examination, PGY = postgraduate training year lications to 37% (medium) and 31%
(high) holding other variables constant.
Table 1 (continued ) tion with previous studies.6-8 Second,

research productivity increases as res-
Characteristics of Residents Responding to the Survey Shows
Demographic Information Including Distribution of Survey Responses by idents advance in the training level.
PGY, Preresidency Qualifications, Undergraduate Major, Step 1 and Step 2 Finally, previous research experience
CK Score, and Most Recent OITE Score Distribution is a greater predictor of orthopaedic
Percentage Respondents resident research productivity than
standardized test performance.
41-60 28.4 Performance on standardized ex-
61-80 26.9 aminations, particularly the step 1
.80 25.1 score, is an often-cited determinant in
resident selection.3,15,16 This practice
AOA = Alpha Omega Alpha, CK = critical knowledge, OITE = Orthopaedic In-training
Examination, PGY = postgraduate training year remains controversial, although sev-
eral studies have demonstrated a
correlation between step 1 and 2
scores with OITE performance and
However, the following were inde- cants is necessary for the growth of the ABOS part I passage rates.5,17-19 One
pendent notable predictors of first- orthopaedics. Previous studies have retrospective study of two regional
author publications; undergraduate demonstrated a correlation between programs demonstrated a notable
science major (up to 63%), greater USMLE step 1 and 2 scores and OITE correlation between the USMLE step
than five clerkship honors (up to and ABOS performance,4-8 but no 1 score and OITE performance.7
75%), and having a first-author consensus exists as to which measures Spitzer et al5 performed a large ret-
publication before residency (up to are most predictive.10 In addition, no rospective review of 147 residents
76%). Again, as with model 1, the previous studies have examined fac- demonstrating a correlation be-
probability of a first-author publica- tors predictive of research productivity tween the USMLE step 1 score and
tion increased with PGY; from 82% among orthopeadic residents. In this OITE scores. Although two single-
in the second year to 98% in the fifth large multiprogram survey study, we institution retrospective evaluations
year (Figure 2). demonstrate several important find- demonstrated a correlation between
ings regarding predictors of resident USMLE step 2 scores, not USMLE
OITE performance and research pro- step 1 scores, and OITE perfor-
Conclusion ductivity. First, we demonstrated a mance6 with the ABOS part I passage
notable positive correlation between rate.8 Our multicenter retrospective
Selection of competent residents from both USMLE step 1 and step 2 CK evaluation supports these previous
an increasing pool of qualified appli- with OITE performance, in conjunc- findings and demonstrates correlation
Table 2
Percent Distribution of Authorship
Percent Distribution of Authored Articles in Preresidency and During Residency
Preresidency (%) Residency (%)
Authored First-author Authored First-author
No. of Articles Publications Publications Publications Publications
None 23 47 35 51
1-2 38 36 32 28
3-4 16 11 15 15
5-6 8 3 6 3
7-8 6 2 7 1
9-10 1 0 1 1
More than 10 6 1 5 1
Total 100 100 100 100
Data indicate the percent distribution of residents with authored and first-author publications both before and during residency.
March 15, 2019, Vol 27, No 6 e289
Table 3
Correlation Coefficients of United States Medical Licensing Examination With OITE Scores
Factor Step 1 Score Step 2 Score OITE Score
Step 1 score — 0.530a 0.367a

Step 2 score 0.530a — 0.320a
OITE score 0.367a 0.320a —
OITE = Orthopaedic In-training Examination

a
Indicates statistical significance (P ,0.01).
The Pearson correlation between step 1, step 2 CK, and most recent OITE scores is shown.
Figure 1 ductivity may motivate students to

continue research in the future.
Another notable finding from this
study is that a higher number of
medical school clerkship honors were
more likely to perform research dur-
ing resident training. In fact, medical
clerkship performance was a positive
predictor of research productivity,
whereas standardized test perfor-
mance was a negative predictor. This
finding is supported by other studies
suggesting a role for medical student
clerkship and subinternship perfor-
mance in resident selection.3,8,20,21 A
single-institution study demonstrated
Predictive factors for publishing with any authorship during residency. For each
independent variable above, the predicative probability of any authored that medical student clerkship honors
publication is shown by percentage. The probability of any given resident were the single best predictor of
publishing during residency is 65%. This value is determined by a logistic orthopaedic resident success as mea-
regression of notable correlations listed in Table 1. sured by OITE and ABOS perfor-
mance and faculty evaluations.22 A
between both step 1 and 2 CK per- words, those with higher test scores recent single-institution retrospective
formances with OITE performance. It before residency did less research dur- study demonstrated a correlation
is likely that higher performance on ing residency than did their peers. between the number of student
standardized tests as a medical stu- In the same manner, respondents clerkship honors and residency suc-
dent predicts continued performance with lower USMLE scores also cess defined by OITE, ABOS, and
on standardized tests as a resident. demonstrated more preresidency re- clinical performance.8 Our study
We think that research productivity search experience. A few possibilities confirms that clerkship performance
in addition to performance on the can explain this finding. First, stu- is important and is an independent
OITE and ABOS examination should dents who fair worse on the USMLE predictor of research productivity.
be considered when evaluating ortho- examination may turn to research to Medical student clerkship and sub-
paedic residency training. We dem- boost their preresidency application. internship performance should be
onstrate that preresidency research However, this does not explain the given adequate weight in residency
productivity, undergraduate science observation that step 1 and 2 scores selection. Clerkship performance may
major, performance on clinical clerk- are inversely correlated with research offer more qualitative insight into an
ships, and training level are positive productivity even during residency. applicant’s academic performance in
predictors of residency research pro- As a third possibility, early exposure addition to performance in the oft-
ductivity. Step 1 and 2 scores were to research as a medical student is cited quantitative step 1 score.
markedly negative predictors of resi- likely to have a longer-term effect. It is intuitive that undergraduate sci-
dent research productivity. In other Early research exposure and pro- ence majors and those with notable
preresidency research experiences were Figure 2

more likely to perform research as
residents. Science majors may be
introduced earlier to the scientific
research processes and may have a
longer-term effect. Early research
experience may foster a sense of con-
fidence and familiarity with research
and be a motivating factor during
residency. Similar studies in other
subspecialties have demonstrated a
similar effect. Finkelstein et al12
showed that urology residents with
dedicated research time had more
publications than those without
dedicated research time. Similarly,
Gutovich et al13 showed that desig-
nated research time during residency
was an independent predictor of
overall research productivity and Predictive factors for publishing with first authorship during residency. For each
independent variable above, the predicative probability of a first-authored
authored publications among radia- publication is shown by percentage. The probability of any given resident having
tion oncology residents. Access to a first-author publication during residency is 50%. This value is determined by a
research time was the sole predictor logistic regression of notable correlations listed in Table 1.
of research productivity among ra-
diation oncology residents.13 How-
ever, in a retrospective study of 73 any previous orthopaedic surgery resi- tion of surveys to respective residents.
radiology residents at a single pro- dent survey study. This is the largest Ten of the 13 programs surveyed
gram, Patterson et al23 reported no study evaluating predictors of ortho- have dedicated research time, whereas
correlation between preresidency paedic resident OITE performance in two have an optional clinical re-
and residency publications. Our terms of training programs and sub- search year. Nonetheless, we con-
study demonstrates increased re- jects included. In addition, this study is sider the data to be representative of
search productivity among senior the first of its kind to evaluate pre- most orthopaedic residency training
level residents compared with their dictors of research productivity among programs. The distribution of step 1
junior counterparts. Residents of orthopaedic residents. This retrospec- and step 2 scores and proportion
increasing training level have pre- tive survey study is limited by recall of of respondents with Alpha Omega
sumably had access to more aca- respondents. Because responses were Alpha honors is similar to nationwide
demic time, research exposure, and anonymous, it is not possible to verify match results.9 Finally, this study
resources. Additionally, preresidency publications or standardized exami- evaluated only objective measures of
research productivity was a positive nation scores. Further studies may resident success, which are by no
predictor of continued research dur- cross-reference the number and tim- means the only factors necessary in
ing residency. Increasing research ing of publications and include the training of capable residents and
exposure during medical school, ear- respondent-provided USMLE and surgeons. Subjective factors includ-
lier training levels, and throughout OITE score reports; however, this ing professionalism, bedside manner,
residency is likely to increase re- required documentation may reduce technical and communication skills,
search productivity. Orthopaedic the number of overall responses. In and clinical acumen are all necessary
residents with greater research pro- addition, reported OITE scores repre- components of a surgeons training.
ductivity may be more likely to sent most recent test results and may Measurement and evaluation of these
pursue a career in academics.24 not represent the trainee’s typical per- intangible variables are difficult but
The strength of our study lies in formance. Selection bias also exists in should not be overlooked in the
having almost 300 residents partici- the choice of 13 residency programs selection and training of orthopaedic
pate in the survey across 13 institutions included in this study. Residency residents.
with a response rate of 93%, which to programs were chosen based on Selection of qualified orthopaedic
our knowledge is higher than that of familiarity and reliability in distribu- residency candidates is vital to
March 15, 2019, Vol 27, No 6 e291
continued advancement of the sub- contents. In this article, references 5, urology programs. Urology 2015;86:
220-222.
specialty. Although research produc- 6, 8, 14, and 16-24 are level III
tivity is by no means the main goal of studies. References 2, 4, 7, and 11-13 13. Gutovich JM, Den RB, Werner-Wasik M,
Dicker AP, Lawrence YR: Predictors of
residency training, it remains an are level IV studies. radiation oncology resident research
impressionable period. Early expo- productivity. J Am Coll Radiol 2013;10:
sure and encouragement are likely to References printed in bold type are 185-189.
have an effect during residency and those published within the past 5 years. 14. Henderson SO, Brestky P: Predictors of
academic productivity in emergency
perhaps in the long term. Previous 1. The Match. Results and Data: 2015 Main
medicine. Acad Emerg Med 2003;10:
selection criteria may overly empha- Residency Match. 2015. http://www.nrmp.
1009-1011.
org. Accessed February 8, 2016.
size standardized test performance as 15. Prober CG, Kolars JC, First LR, Melnick DE:
predictors of residency performance. 2. Bernstein AD, Jazrawi LM, Elbeshbeshy B, A plea to reassess the role of United States
Della Valle CJ, Zuckerman JD: An analysis Medical Licensing Examination step 1 scores
Progress through research in- of orthopaedic residency selection criteria. in residency selection. Acad Med 2016;91:
novations is necessary for orthopae- Bull Hosp Joint Dis 2002;61:49-57. 12-15.
dics to remain at the forefront of 3. Bernstein AD, Jazrawi LM, Elbeshbeshy B, 16. Sutton E, Richardson JD, Ziegler C, Bond J,
medical advances. Previous research Della Valle CJ, Zuckerman JD: Orthopaedic Burke-Poole M, McMasters KM: Is
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USMLE step 1 score a valid predictor of
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4. Thordarson DB, Ebramzadeh E,
dent research productivity, whereas
Sangiorgio SN, Schnall SB, Patzakis MJ: 17. Herndon JH, Allan BJ, Dyer G, Jawa A,
standardized test performance is a Resident selection: How we are doing and Zurakowski D: Predictors of success on the
negative predictor. These factors why? Clin Orthop Relat Res 2007;459: American Board of Orthopaedic Surgery
255-259. Examination. Clin Orthop Relat Res 2009;
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Zuckerman JD, Egol KA: Factors 18. Dougherty PJ, Walter N, Schilling P, Najibi
candidates. Earlier exposure to associated with successful performance in S, Herkowitz H: Do scores of the USMLE
research and greater access to an orthopaedic surgery residency. J Bone step 1 and OITE correlate with the ABOS
research opportunities will likely Joint Surg Am 2009;91:2750-2755. part I certifying examination?: A
multicenter study. Clin Orthop Relat Res
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2010;468:2797-2802.
orthopaedic residents. This associa- Orthopaedic in-training examination
scores: A correlation with USMLE results. J 19. Case SM, Swanson DB: Validity of NBME
tion may translate into more graduat- Bone Joint Surg Am 2006;88:671-676. part I and part II scores for selection of
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This retrospective survey study residency selection factors to subsequent
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demonstrates that residency candi- performance. South Med J 2005;98:528-532. Resident selection and predictors of
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8. Raman T, Alrabaa RG, Sood A, Maloof P, Clin Orthop Relat Res 2006;449:44-49.
examinations are likely to continue Benevenia J, Berberian W: Does residency
to perform well as residents on selection criteria predict performance in 21. Turner NS, Shaughnessy WJ, Berg EJ,
the OITE. Although, preresidency orthopaedic surgery residency? Clin Larson DR, Hanssen AD: A quantitative
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greater preresidency research ex- Main Residency Match. 2014. http://www. Crouch JH, Wilson FC: Correlating
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What is the relationship between number of
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Research Article
Predictive Modeling for Geriatric

Hip Fracture Patients: Early
Surgery and Delirium Have the
Largest Influence on Length of Stay
Abstract
Garin Hecht, MD Background: Averaging length of stay (LOS) ignores patient

Christina A. Slee, MPH complexity and is a poor metric for quality control in geriatric hip
fracture programs. We developed a predictive model of LOS that
Parker B. Goodell, MD
compares patient complexity to the logistic effects of our institution’s
Sandra L. Taylor, PhD hip fracture care pathway.
Philip R. Wolinsky, MD Methods: A retrospective analysis was performed on patients enrolled
into a hip fracture co-management pathway at an academic level I
trauma center from 2014 to 2015. Patient complexity was approximated
using the Charlson Comorbidity Index and ASA score. A predictive
model of LOS was developed from patient-specific and system-specific
variables using a multivariate linear regression analysis; it was tested
against a sample of patients from 2016.
Results: LOS averaged 5.95 days. Avoidance of delirium and
reduced time to surgery were found to be notable predictors of
reduced LOS. The Charlson Comorbidity Index was not a strong
predictor of LOS, but the ASA score was. Our predictive LOS model
From the Department of Orthopaedic worked well for 63% of patients from the 2016 group; for those it did not
Surgery and Rehabilitation, Loyola work well for, 80% had postoperative complications.
University Medical Center, Maywood,
Discussion: Predictive LOS modeling accounting for patient
IL (Dr. Hecht), the Quality and Safety
Department, University of California, complexity was effective for identifying (1) reasons for outliers to the
Davis, Sacramento, CA (Ms. Slee), the expected LOS and (2) effective measures to target for improving our
UCSF-Fresno, Fresno, CA
hip fracture program.
(Dr. Goodell), the Clinical and Level of Evidence: III
Translational Science Center,
University of California, Davis
(Dr. Taylor), and the Department of
Orthopedics, University of California,
Davis, Sacramento, CA (Dr. Wolinsky). E ach year, more than 300,000
geriatric hip fractures occur in
the United States.1,2 Patients with hip
stay (LOS), and lower hospitalization
costs.10-13
As dedicated hip fracture co-
This investigation was performed at
the University of California, Davis, fractures face reduced mobility and management programs have evolved,
Medical Center by the UC Davis independence after their injury and inpatient outcome metrics have im-
Geriatric Fracture Program. have an increased 1-year mortality proved.3,14 The most effective model,
Correspondence to Dr. Hecht: rate.3,4 Early surgery and a prompt though, has yet to be determined.7
garin.hecht@lumc.edu medical evaluation/optimization have Each hospital and health care system
J Am Acad Orthop Surg 2019;27: been shown to reduce perioperative has unique nuances and logistic chal-
e293-e300 morbidity and mortality rates and lenges that create barriers to im-
DOI: 10.5435/JAAOS-D-17-00447 improve outcomes.5-9 Furthermore, plementing and improving hip fracture
Geriatrics-Orthopedics Co-Manage- programs.15-18 In addition, variance
Academy of Orthopaedic Surgeons. ment models have been shown to among patient populations may pre-
reduce morbidity, decrease length of vent established models of co-managed
March 15, 2019, Vol 27, No 6 e293
Predicting Hip Fracture Length of Stay
care from being transferrable predictive model, we aimed at further the staff—including nurses, physical
between similar types of institutions. understanding what positively and and occupational therapists, discharge
Predictive modeling of care path- adversely affected our care pathway coordinators, and the managers of the
ways can help health care systems to improve patient outcomes and care unit—have been educated about their
better understand how variability efficiency. role in the GFP and participate
affects patient throughput and out- in weekly multidisciplinary meetings.
comes.19 However, the effect of Geriatric pain protocols and a delir-
hospital-specific predictive modeling
Methods ium detection/prevention program
in the hip fracture population has are used throughout the hospitaliza-
After institutional review board
not been explored. tion. Internal fixation or arthroplasty
approval was obtained, a retrospec-
A multidisciplinary care pathway is performed based on the fracture
tive review of the geriatric hip frac-
for geriatric hip fracture patients was pattern, and all patients are weight
ture database at the University of
started in January 2014 at the bearing as tolerated postoperatively
California, Davis, Medical Center
University of California, Davis, Med- on the injured extremity. Discharge
was performed. To be included in our
ical Center, an academic level I adult planning and an evaluation by the
hip fracture database, patients had to
and pediatric trauma center and ter- acute rehabilitation service take place
be aged 65 years or older and have
tiary care center. Before the im- as soon as possible after admission.
isolated hip fractures (AO/OTA 31
plementation of our geriatric fracture A-C) sustained after a ground-level
pathway (GFP), there were no de- fall. Patients meeting these criteria Model Development
fined guidelines or pathways for the were eligible for participation in our Patients who had their hip fracture
care of this fragile patient population. GFP. The GFP is a hip fracture path- surgically treated during calendar
Accordingly, our LOS averaged way that begins in the emergency years 2014 and 2015 were used to
8 days, well above published means in department (ED). After the diagnosis develop our LOS predictive model.
the United States. Since the start of our of a hip fracture, patients enter the Our hip fracture database is pro-
hip fracture program, we have made GFP pathway that guides the workup spectively collected and maintained
substantial, metric-proven improve- and care of the patients. It includes using data automatically extracted
ments in our care of these patients. pain control centered on acetamino- from our hospital’s electronic medi-
Interim analyses of our care metrics phen and an iliofascial nerve block, cal record system (Epic Systems) and
found multiple positive effects of our specific imaging and laboratory tests, supplemented with retrospective
pathway, which include Orthopedic- and family/patient education regard- chart reviews for data that cannot be
Geriatric co-management, cohorting ing hip fractures. An on-call hospi- automatically extracted. In this
patients on an orthopaedic surgery talist reviews the patient’s chart study, we excluded patients who
floor whenever possible, guidelines and determines whether the patient had a fall while already admitted to
for pain control and delirium should be admitted to the orthopae- the hospital, patients who had higher
prevention/detection, early discharge dic service or an internal medicine energy mechanisms of injury, and
planning, and delineating what is service based on clearly defined and patients with any other notable
supposed to happen to patients dur- mutually agreed-upon criteria. Re- injury (more than a soft-tissue con-
ing their hospital stay. After 2 years of gardless of the admitting service, tusion). Patients who refused surgery
data collection, we developed a pre- Orthopedic-Geriatric co-managed care or who were deemed too high risk of
dictive model of LOS and used it to ensues throughout the hospitalization. surgery were also excluded. After the
try to understand the effect of patient Early medical optimization and early model was developed using patients
medical complexity and delays to surgery are the initial goals of care. from 2014 to 2015, data from the
surgery on the actual LOS (aLOS) Patients are cohorted on the ortho- first 30 consecutive patients treated
versus predicted LOS. Using our paedic floor whenever possible, where in early 2016 were used to test our
Dr. Wolinsky or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Zimmer Biomet
and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American
College of Surgeons, the California Orthopaedic Association, and the Orthopaedic Trauma Association. None of the following authors or any
immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution
related directly or indirectly to the subject of this article: Dr. Hecht, Ms. Slee, Dr. Goodell, and Dr. Taylor.
Statistical analysis of the project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health,
through grant number UL1 TR001860. The content is solely the responsibility of the authors and does not necessarily represent the official
views of the NIH.
Garin Hecht, MD, et al
predictive model and assess whether the LOS of each patient. Accordingly, at Supplemental Digital Content 1
it is a valuable tool to use for future we included covariates that were both (http://links.lww.com/JAAOS/A208).
quality improvement analyses. controllable and uncontrollable, as
well as covariates that occur at different
Metrics time points during hospitalization and Results
may not be determinable on admission.
Core hip fracture data/metrics ex-
Delirium was included in our predictive Between January 2014 and Decem-
tracted automatically from electronic
modeling because of its substantial rate ber 2015, 196 patients were entered
medical record reports included de-
of occurrence. All other in-hospital in our hip fracture database. Of these,
mographics, timing of care inter-
complications were excluded as a sep- 177 patients fit the inclusion criteria
ventions, LOS, discharge disposition,
arate variable when we developed our for this study. Nineteen patients were
admitting service and location,
model because they are much less excluded: 11 patients underwent non-
American Society of Anaesthesiolo-
common and have a widely varying surgical management and 8 patients
gists (ASA) score, and laboratory val-
effect on patients’ outcomes and LOS. either had fracture patterns that were
ues. Cost data were obtained from
Therefore, our model assumes a 19% not AO/OTA 31A-C types or they by-
another data system and merged into
complication rate (other than delirium) passed the GFP pathway because of a
our registry. A delay to surgery (DTS)
for each patient based on our average delayed diagnosis of their hip fracture.
was defined as going to the operating
complication rate. Supplemental Table 1 (see Supple-
room two or more midnights after
mental Digital Content 2, http://
presentation to our ED. We defined
links.lww.com/JAAOS/A209) depicts
DTS this way because we do not rou- Statistical Analysis the demographic and clinical profile of
tinely operate on hip fracture patients
Data were used to describe the char- the patients included in this study.
overnight and the time it takes for
acteristics of our patient population Most patients (66.7%) were admitted
their medical evaluation and optimi-
and guide the linear regression anal- to the orthopaedic trauma surgery
zation makes surgery on the day
ysis that explored potential associa- service, and 52.5% of patients were
of presentation nearly impossible.
tions between clinical parameters and cohorted on the orthopaedic floor.
Therefore, one missed full daytime
LOS. The variables that showed a Fifty-four patients (30.5%) had a
surgical block represents a DTS. The
statistically significant relationship to DTS. The mean LOS was 5.95 days,
Charlson Comorbidity Index (CCI)
LOS and key demographic variables and the median LOS was 5.19 days,
was used to score patients’ preexist-
were added to the linear regression which reflects the 7% of patients who
ing comorbidities. The complica-
model to predict LOS. Although had 10-plus-day hospitalizations be-
tions we recorded were those defined
successfully cohorting patients to our cause of complications and/or refus-
by Liem et al20 and the AO Trauma
orthopaedic unit did not meet statis- ing discharge to a skilled nursing
Network. Delirium was assessed
tical significance in our unadjusted facility. Eighty-three percent of pa-
using the Confusion Assessment
regression analysis, we chose to tients had Medicare Part A as their
Method instrument, performed every
include this factor into our modeling payer for the hospitalization, and
12 hours or whenever the patients’
because of its trend toward signifi- 13% had either an HMO-contracted
nurse detected a mental status change.
cance and essential role in our GFP. Medicare or an HMO/PPO as their
For this study, any positive Confusion
The dependent variable, LOS, was payer. Four patients (2.3%) died dur-
Assessment Method was considered to
skewed to the right owing to the ing their hospitalization.
indicate the presence of delirium. All
influence of outliers, so we log trans- The results of the unadjusted
other complications were identified
formed the values to meet normality regression analysis are shown in
by a chart review and verified to have
assumptions of linear regression. We Table 1. Developing a complication
occurred during the hospitalization
predicted log LOS for selected pre- or delirium during the hospitaliza-
rather than being present on admission.
dictor values using the fitted regres- tion and the time to surgery were
sion equation. For ease of predictive of an increased LOS. An
Building a Predictive Model understanding clinical relevance, we INR ,1.5 on admission, ASA, and a
of Length of Stay exponentiated these values to yield CCI score ,4 were also statistically
The primary purpose of creating a the predicted geometric mean of LOS significant and were predictive of a
predictive LOS calculator was to in days. Our statistical model was shorter LOS. Although not statisti-
improve our hip fracture care pathway created using SAS statistical software cally significant, admission to our
and understand which controllable (version 9.3; SAS). The predictive orthopaedic unit—regardless of pri-
and/or uncontrollable factors influence calculator is available for download mary service—trended to lower LOS.
March 15, 2019, Vol 27, No 6 e295
Table 1 significant. Age, sex, and CCI were

poor predictors of LOS. Table 2
Unadjusted Regression Analysis of LOS by Patient Demographics and
Clinical Characteristics shows an example of the applied
predictive model to a theoretical
Variable Point Estimate SE P Value Average LOS
“average” patient, as defined by the
No complication 20.4530 0.084 ,0.001a 2.94 median LOS (5.19 days) in our
Midnights to surgery 0.1581 0.042 ,0.001a 4.75 cohort of patients.
(base = 1)
ASA score (base = 3) 0.1971 0.062 0.002a 4.93
No delirium 20.1890 0.070 0.007a 4.52 Testing the Model
INR , 1.5 20.2651 0.101 0.010a 4.85 To assess the utility of our predictive
CCI , 4 20.1673 0.082 0.042a 4.84 LOS modeling, we compared the
Cohorted to ortho floor 20.1141 0.070 0.104 4.77 aLOS to the expected LOS for 30 pa-
Age (base = 82 y) 0.0046 0.004 0.300 5.03 tients who entered the GFP between
Sex (female) 20.0738 0.075 0.327 4.91 January and May 2016. One patient
was excluded because of an inap-
CCI = Charlson Comorbidity Index, LOS = length of stay
a
propriate diagnosis for inclusion
Statistically significant P value.
(ie, diphosphonate-associated femo-
ral shaft fracture), and two had
incomplete data. The aLOS was
Table 2 within the 95% confidence interval
Example of a Predictive Calculator Showing the Effect of Covariates on the for 89% of patients. However,
Expected LOS because of the wide range on the 95%
Variable Effect on LOS (d) P Value
confidence intervals, which averaged
close to 10 days, we reanalyzed our
Age (each decade older than 82 y) 10.14 0.56 results using the more clinically
Sex (male) 10.23 0.55 relevant LOS range of 61.5 days
Elevated INR (.1.5 on admission) 10.99 0.08 (Figure 1). Using this criterion, 13
CCI score (4 or more) 10.11 0.81 patients (48%) had an accurate
Not cohorted to orthopaedic floor 10.46 0.23 prediction of their LOS, and 4 (15%)
ASA score (one point increase) 10.65 0.07 had a smaller than predicted LOS.
Time to surgery (each midnight) 10.75 ,0.01a In sum, the model made reasonable
Delirium (ever during hospitalization) 11.07 ,0.01a predictions for 63% our patients.
None of these patients had a post-
CCI = Charlson Comorbidity Index, LOS = length of stay
a
operative complication other than
Statistically significant P value.
delirium. Of the 10 patients (37%)
who had a longer aLOS than
predicted LOS 61.5 days, all
Multivariate Analysis time to surgery (P , 0.01) and the
but 2 had a postoperative compli-
A multivariate analysis was per- occurrence of even one episode of
cation other than delirium (80%).
formed to assess the independent delirium (P , 0.01) were indepen-
This illustrated the substantial
effect of each covariate chosen for dent predictors of an increased LOS positive effect (ie, increasing in
our predictive model. The variables (see Supplemental Table 2, Sup- value) on the LOS of any com-
chosen were age, sex, time to surgery, plemental Digital Content 3, http:// plication developing during the
ASA score, CCI score, INR on links.lww.com/JAAOS/A210 for hospitalization.
admission, admission to the ortho- point estimates derived from the of
paedic unit (eg, cohorting patients multivariate multiple linear regres-
successfully), and occurrence of sion). An elevated INR on admis- Subanalysis of
delirium during the hospitalization. sion, the effect of cohorting patients Comorbidities (Charlson
The model had an R2 of 0.20, indi- onto our orthopaedic floor, and the Index) and Delays to Surgery
cating that 20% of variation in aLOS ASA score also had trends showing A stratified analysis using the reason
could be measured by the variables an effect on the expected LOS cal- for any DTS and the effect of preex-
included in the model. Nonetheless, culation but were not statistically isting comorbidities was performed
for our 2014 to 2015 patients. The Figure 1

CCI in isolation was a poor predictor
of LOS in our model. However, pa-
tients with a CCI of 4 or greater
averaged $3,966 more for their total
cost of the hospitalization despite not
having an increased postoperative
complication rate.
DTS was associated with an increased
complication rate and cost of hospital-
ization. When we analyzed the reasons
for the DTS, we found that the reason
for the delay mattered (Table 3). Delays
due to medical evaluation/optimization
or a patient initially refusing surgery
had an increase in LOS, hospital cost,
and complication rate. A delay due to
lack of operating room time was not Graph showing the actual LOS of consecutive 2016 patients plotted against the
associated with an increase in LOS, predicted LOS value. The gray zone is 61.5 days from the predicted LOS,
cost, or complication rate. chosen as a clinically relevant accuracy of our predicted modeling. LOS = length
of stay
Discussion
pected LOS for specific patients at an Our study has many limitations.
LOS can be used as a metric to eval- institution would help hip fracture First, the statistical power for our
uate the success of a geriatric hip centers improve patient care and multivariate modeling is low because
fracture program because it may re- provide more patient-specific quality of the heterogeneity of the hip frac-
flect the cost-effectiveness of care and control by allowing for accurate ture patient population that ranges
the in-hospital complication rate. detection and analysis of outliers. from high-functioning patients to
Simply averaging the LOS can mask We created a predictive calculator minimally ambulatory nursing home
the expected variability in this het- that estimates the expected LOS for a residents. We realized this while
erogeneous patient population and patient in our hip fracture pathway. designing this study, but the value of
has been found to be an ineffective It allowed us to identify which fac- using the results to focus our efforts
measure for determining successful tors place patients at risk of pro- made it worthwhile to pursue and use
patient management.19,21 A tool that longed hospitalizations, as well as this predictive calculator. Although
could be used to calculate an ex- those that predict a shorter LOS. the accuracy of our model is high, the
Table 3
Analysis of Patients Who Had a Delay to Surgery by Reason
Delay due to Patient
Delay due to Medical Delay due to OR Initially Refusing
All Patients Clearance Availability Surgery
No. of patients 177 25 16 5

CCI = 4 or more 42 (24%) 10/25 (40%); P # 0.05a 2/16 (13%); P = 0.27 1/5 (20%); P = 0.84
Postoperative complication 33 (19%) 8/25 (32%); P = 0.06 0/16 (0%); P , 0.05a 3/5 (60%); P , 0.05a
rate (excluding delirium)
LOS (d) 6.0 6 3.1 7.0 6 2.9; P , 0.05a 5.3 6 1.6; P = 0.36 9.2 6 3.1; P , 0.01a
Average total cost of $33,495 $40,264; P , 0.01a $31,443; P = 0.48 $44,882; P , 0.05a
hospitalization
CCI = Charlson Comorbidity Index, LOS = length of stay, OR = operating room

a
Statistically significant.
March 15, 2019, Vol 27, No 6 e297
precision of our expected LOS is low. patients. First, it can provide patients fying the effect of hospital logistics on
To improve the clinical utility, we and families with more specific ex- hip fracture patients. Factors including
set a clinically relevant cutoff of pectations for the hospitalization. admissions on a weekend,18 availabil-
within 1.5 days of our prediction as a For example, a patient with an ele- ity of arthroplasty surgeons,24 admis-
“success.” This calculation enabled vated INR on admission and an ASA sion to orthopaedic versus general
us to measure the effect of a post- score of 4 is expected to have an medicine services,17 and admission
operative complication on increasing increased LOS; however, cohorting to a geriatric unit25 have all been
the LOS in our 2016 group. the patient to our orthopaedic floor shown to affect the LOS at various
Additional limitations of our study and taking the patient to the operative institutions. These conclusions rep-
include the retrospective data collec- room before the second midnight will resent hospital-specific findings and
tion and the subjectivity in interpret- improve the patient-specific predicted therefore may or may not be gener-
ing the cause of any delay to surgery. LOS. If patients and families ask alizable to other hospital systems.
We attempted to mitigate the in- about delirium, we can tell them not For example, the patients who pre-
accuracies of retrospective data col- only our rate of patients who become sent to our institution with elevated
lection by confirming that all medical delirious at some point in the hospi- INRs (14%) are not routinely given
comorbidities were diagnosed before talization but quantify how that may rapid reversal agents. Obviously, a
or at the time of admission for the hip change their predictive LOS. rapid reversal agent can change the
fracture. All the complications we Uncontrollable patient-specific effect of elevated INR on expected
included in our analysis had to occur variables set the initial framework LOS.
during the hospitalization, and any for our LOS predictions when they In developing our GFP, we identi-
that were present at the time of present to the ED. Several of these fied that a DTS and failure to cohort
admission were excluded. A DTS was variables have been previously re- patients onto our orthopaedic ward
most often caused by the need for ported to be associated with an as important logistic targets for
medical optimization clearance or increased LOS for hip fracture pa- improvement. Interestingly, a subgroup
availability of an operating room. It tients including the ASA score,22 analysis of the DTS group showed a
was easy to determine the reason for medical comorbidities,5 and the difference between patients with oper-
the delay via a chart review because fracture pattern.23 We did not in- ative delays due to medical clearance
the daily orthopaedic and medicine clude the fracture pattern in our versus operating room availability
team progress notes discuss the delay modeling because all patients are (Table 3). Although some reasons for
since the implementation of our GFP. treated with immediate weight bear- delayed medical evaluation and opti-
Finally, in creating a model to predict ing, and there was no delay to care for mization may be unsolvable, man-
LOS, we realize that there may be arthroplasties compared with inter- dates for hastened medical evaluations
other variables we did not include nal fixation at our institution. When have been shown to reduce the time to
included that can affect the predictive we analyzed comorbidity scoring surgery and overall LOS.9,26
values. Specifically, hospital disposi- systems, the ASA score was an Our study showed a trend that a
tion is inherently tied to the LOS, and important predictor of LOS, but the patient with an otherwise-average
insurers differ in authorization pro- CCI was not. This phenomenon re- expected LOS successfully cohorted
cesses for skilled nursing facilities. flects the intent of the CCI to capture on our orthopaedic floor, irrespective
Our cohort, however, had Medicare long-term consequences of medical of what service admitted the patient,
Part A as the payor in 83% of pa- conditions while the ASA score rep- can expect a half-day decrease in the
tients. Because there was no other resents the immediate acuity of co- LOS. To our knowledge, this finding
substantially common insurer, we did morbid conditions. Previous studies has not been reported for hospitals
not include the patient’s insurance determining that comorbidities are a in the United States, which separate
status in our modeling. Although we risk factor for a longer LOS have not the acute hospitalization from the
do not anticipate this distribution of made this distinction.5 The CCI is a subacute rehabilitation period.25 Our
insurers to change, it is important worthwhile metric to describe pa- orthopaedic floor offers better care to
to note that this variable may sub- tient complexity that has cost im- geriatric fracture patients because the
stantially alter results in states and plications and affects Medicare nursing and physical/occupational
communities with different payor reimbursement, but it is a poor pre- therapy staff are trained and used
mixes. dictor of LOS and postoperative to taking care of orthopaedic pa-
There are very practical applica- complications. tients. In addition, the staff have
tions to institution-specific predictive Another important application of received extra training in geriatric
modeling in geriatric hip fracture predictive modeling is better quanti- fracture patient care, and their
managers take part in weekly quality comings at a single-site Orthopedic- Has anything changed? Eur J Orthop Surg
Traumatol 2016;26:365-370.
improvement meetings in which all Geriatric co-management hip fracture
the geriatric hip fracture patients pathway. Our model is imprecise, but 7. Khan SK, Kalra S, Khanna A,
Thiruvengada MM, Parker MJ: Timing of
from the past week are discussed. it allows us to identify and analyze surgery for hip fractures: A systematic
This serves as a forum to improve patients whose aLOS deviates sub- review of 52 published studies involving
291,413 patients. Injury 2009;40:
communication, review patients with stantially from their expected LOS. It
692-697.
excessive delays to some aspect of their also lets us communicate better with
8. McGuire KJ, Bernstein J, Polsky D, Silber
care, and discuss complications—it patients and families when they ask JH: The 2004 Marshall Urist Award:
has also created “buy in” from this how long they will be in the hospital Delays until surgery after hip fracture
multidisciplinary group. Because our and with hospital administrators increases mortality. Clin Orthop Relat Res
2004;294-301.
orthopaedic floor has a limited num- when we show the value of additional
ber of beds and admits patients from resources for our hip fracture pathway. 9. Uzoigwe CE, Burnand HGF, Cheesman CL,
Aghedo DO, Faizi M, Middleton RG: Early
other services and departments, we are Most importantly, by understanding and ultra-early surgery in hip fracture
competing for a finite resource. Our the individual “predictors” for longer patients improves survival. Injury 2013;44:
726-729.
findings suggest that hip fracture or shorter LOS, we can target areas for
patients would benefit from our improvement in our hip fracture pro- 10. Kates SL, Mendelson DA, Friedman SM:
Co-managed care for fragility hip fractures
hospital expanding the orthopae- gram. We are not advocating that (Rochester model). Osteoporos Int 2010;
dic floor and/or being prioritized for other centers to use our exact model; 21(suppl 4):S621-S625.
admission to the unit. Predictive rather, our model serves as a prototype 11. Lau TW, Fang C, Leung F: The
modeling can display how the entire for other institution-specific predictive effectiveness of a geriatric hip fracture
clinical pathway in reducing hospital and
distribution of LOS would be expected calculators that would allow similar rehabilitation length of stay and improving
to shift to the left if all of our patients targeted analyses to be performed. short-term mortality rates. Geriatr Orthop
were able to be cohorted to our Future work will aim at improving the Surg Rehabil 2013;4:3-9.
orthopaedic ward—a powerful tool to precision of our modeling and 12. Swart E, Vasudeva E, Makhni EC,
bring to hospital administrators. exploring the relationship to risk ad- Macaulay W, Bozic KJ: Dedicated
perioperative hip fracture comanagement
Our predictive model was devel- justments that affect reimbursement as programs are cost-effective in high-
oped to focus our quality improve- our geriatric hip fracture pathway volume centers: An economic analysis.
ment efforts. When we applied our continues to improve. 222-233.
model to the first 30 patients of our
13. Dy CJ, McCollister KE, Lubarsky DA, Lane
2016 cohort, we found that the effect JM: An economic evaluation of a systems-
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Updates on and Controversies

Related to Management of Radial
Nerve Injuries
Abstract
Sonia Chaudhry, MD Radial nerve injuries are among the most common major traumatic
Kyros R. Ipaktchi, MD peripheral nerve injuries. Recent literature has updated our
knowledge of aspects ranging from radial nerve anatomy to treatment
Ashley Ignatiuk, MD, MSC,
FRCSC options. Observation and tendon transfers were, and still are, the
mainstays of management. However, the improved outcomes of
nerve repair even 5 months after injury have changed the treatment
algorithm. Nerve repair techniques using conduits, wraps, autograft,
and allograft allow tension-free coaptations to improve success.
Nerve transfers have evolved to allow a more anatomic recovery of
function if used in a timely manner. This review offers an update on
radial nerve injuries that reflects recent advances.
T he radial nerve is commonly in-

jured in both traumatic and iatro-
genic settings. Although management
tum, more proximally than previously
thought, 16 cm from the distal humerus
or 47% of the shaft length.1
principles of peripheral nerve injuries Interposed between the brachialis
apply, continuing advances in the and brachioradialis, the radial nerve
literature warrant periodic re- becomes increasingly anteriorly posi-
examination of this injury. Pre- tioned as it travels distally and bi-
Orthopaedics, Connecticut Children’s sented here is an overview of the furcates into the posterior interosseus
Medical Center, Hartford, CT anatomy, epidemiology, and man- nerve (PIN) and superficial radial nerve
(Dr. Chaudhry), the Department of agement of radial nerve injuries (SRN) just distal and anterior to the
Orthopaedics, University of Colorado,
with a focus on recent literature. radiocapitellar joint. The extensor carpi
Denver, CO (Dr. Ipaktchi), and
Department of Surgery, Rutgers New radialis longus (ECRL) is innervated
Jersey Medical School, Newark, NJ proximal to the elbow, whereas the
(Dr. Ignatiuk). Anatomy
extensor carpi radialis brevis (ECRB) is
Dr. Ipaktchi or an immediate family The posterior cord of the brachial innervated distal to the elbow, more
plexus terminally divides into the radial often from the SRN than the PIN.
institutional support from Acumed. The SRN provides sensation to the
Neither of the following authors nor and axillary nerves behind the pector-
any immediate family member has alis minor, atop the subscapularis anatomic snuffbox, first web space,
received anything of value from or has muscle. A common misconception is and dorsal aspect of the thumb, index,
that the radial nerve descends along the and long fingers. Because of the overlap
commercial company or institution between the SRN and lateral ante-
related directly or indirectly to the spiral groove after traversing the trian-
subject of this article: Dr. Chaudhry gular interval. The spiral groove con- brachial cutaneous nerve, loss of SRN
and Dr. Ignatiuk. tains fibers of the brachialis origin that function is well tolerated, but only
J Am Acad Orthop Surg 2019;27: separate the nerve from the bone. symptomatic with neuroma formation.
e280-e284 Direct contact instead occurs about the
DOI: 10.5435/JAAOS-D-17-00325 deltoid tuberosity proximally and Classification
along the lateral metaphyseal flare dis-
Academy of Orthopaedic Surgeons. tally. The radial nerve is tethered where Radial nerve injuries are often simply
it pierces the lateral intermuscular sep- labeled high or low in relation to
Sonia Chaudhry, MD, et al
nerve bifurcation. Injuries can also be Figure 1

divided into four levels with func-
tional implications,2 with all levels
involving loss of thumb and finger
extension with variable levels of
more proximal paralysis. Level I
is infraclavicular, proximal to
the brachioaxillary inlet at the be-
ginning of the spiral groove. Injuries
at this level affect elbow extension.
Level II injuries occur at the level of
the spiral groove, proximal to the
brachioaxillary outlet where the nerve Photograph showing lipoma just distal to the antecubital fossa, with the posterior
interosseous nerve (overlying pickups) running through the lesion while the
pierces the lateral intermuscular sep- superficial radial nerve is lying atop the mass more radially (A). Top radial, right
tum. Elbow extension is spared; proximal. Post-resection, the nerve has been preserved (B).
however, wrist extension is not. Level
III injuries are between the septum and
still recommended.6 In addition, the continuity. Study is recommended
elbow joint, and wrist extension is
radial nerve is the most commonly around 3 to 4 months after injury.
variable. Physical examination cannot
injured nerve during medial epi- Larger polyphasic motor action po-
reliably differentiate loss of the ECRB
condyle fracture fixation, put at tentials of longer duration may be
if the ECRL is intact, although isolated
risk with bicortical penetration. seen before clinical recovery, al-
ECRL function could put the wrist
In addition to traumatic iatrogenic though the degree of recovery is
into exaggerated radial deviation given
causes, intramuscular and intrave- unclear. If the amplitude of motor
its insertion. The loss of one wrist
nous injections have been shown to nerve conduction velocity is low, less
extensor is enough to weaken grip
cause nerve injuries. In one study, than 0.3 mV, exploration can be
strength. Level IV injuries are distal to
radial nerve injection injuries, only undertaken, with repair remaining a
the ECRB motor branch.
7 of 24, at the level of the arm viable option even 5 to 6 months after
recovered spontaneously.7 Symp- injury.2
tom onset is delayed in 10%
Epidemiology because the agent injected can take
time to penetrate the nerve’s pro- Management and
The radial nerve is the most com-
tective layers. Last, the differential Outcomes
monly injured motor nerve. The
should include compressive causes
incidence with humerus fractures is
because of inflammation and neo- Nonsurgical
12%. Small studies have shown
plastic processes (Figure 1).
trends toward higher incidence in the With few exceptions, an initial ob-
presence of skin wounds and major servation period is warranted, during
fracture displacement.3 Most of the Evaluation which extension bracing of the fin-
palsies, 50% to 68%, present as gers and wrist and motion to keep
complete motor loss.4 Other injuries, A thorough history should elucidate joints supple should be instituted. In
such as shoulder dislocations, hu- both the cause and probable injury the setting of humeral shaft fractures,
meral neck injuries, and Monteggia location. One should assess motor 70% of radial nerve palsies demon-
fractures, can also be associated with and sensory deficits, strength of poten- strate spontaneous recovery around
radial nerve injuries. tial donor muscles, and passive joint 7 weeks, ranging from 2 weeks to
Iatrogenic injuries are not motion. A migrating Tinel’s phenome- 6.5 months.8 Early exploration has
uncommon. The incidence of injury non is a good prognostic indicator. been shown not to improve the
for each humeral shaft approach is Objective measures are limited be- outcome except in the case of open
as follows: lateral 1/5, posterior 1/9, cause MRI and ultrasound have been fracture or concomitant forearm in-
and anterolateral 1/25.5 External of limited use. Electromyography and juries.9 Humerus fracture manage-
fixation puts the nerve at risk dur- nerve conduction velocity studies are ment is generally unchanged by the
ing lateral pin placement, and rarely helpful acutely except when presence of the radial nerve injury. A
despite anatomic studies detailing continuity is unknown because slowed study of unreamed intramedullary
safe zones, open pin placement is but intact conduction indicates some nail fixation with a 40% rate of
March 15, 2019, Vol 27, No 6 e281
Radial Nerve Injuries
Figure 2 matic radial nerve injuries demon-

strated good outcomes with repair,
neurolysis, or grafting an average of
3 months after injury compared with
unsuccessful outcomes an average of
5 to 6 months after injury, although
repairs performed within 5 months
were still superior to muscle or ten-
don transfers.2
Nerve Repair
All nerve repairs/reconstructions
Photograph showing stab injury to the posterior arm with acute radial nerve deficit should be performed tension free.
manifested by lack of elbow, wrist, and digital extension along with lack of sensation Adjacent joints should be stretched
in the superficial radial nerve distribution. Stab wound irrigated and closed in the for the repair to allow free limb
emergency department in preparation for formal exploration in the operating room
excursion without traction on the
next day (A). Early exploration within 24 hours and direct epineural suture repair (B).
coaptation. Bone shortening, nerve
mobilization, and transposition all
primary radial nerve injury demon- an extensive zone of injury, a
reduce tension on the repair. A series
strated that the injury resolved spon- reliable minimally invasive approach
of 27 penetrating injuries between the
taneously 93%,10 indicating that to finding the nerve without damage
brachial inlet and elbow joint pri-
nerve exploration was not warranted to the triceps is with an incision along
marily repaired by 6 months demon-
even with operative cases, unless the lateral bicipital groove, where the
strated recovery of extension at the
nerve visualization was required for posterior antebrachial cutaneous nerve
wrist in 93%, fingers in 74%, and
an open approach. Secondary palsy is found posterior to the septum and
thumb in 52%.13 Nerve grafting can
during functional bracing was an traced proximally to where it joins the
be used for residual gap manage-
indication for early exploration in the radial nerve and penetrates the inter-
ment. In Pan’s study, all injuries
past; however, these have also been muscular septum.12 A decision analy-
above the brachial outlet required
shown to resolve spontaneously.11 sis model integrating 37 years of
grafting, with longer grafts at the
studies demonstrated early surgery to
spiral groove level averaging 10.3 cm,
Early Exploration provide an 85% chance of nerve
compared to more distal grafts aver-
recovery in the setting of humeral shaft
Past indications for early exploration aging 6.4 cm. Shorter grafts were
fracture.9 The downside of early ex-
have included secondary palsy after associated with better outcomes.
ploration is potentially unnecessary
closed reduction, open fractures, distal Overall motor recovery was 95% at
surgery if the nerve is found to be in
third fractures including Holstein– the elbow, 80% at the wrist, and 30%
continuity.
Lewis fractures, penetrating injury in the digits.2
(Figure 2), associated vascular injury, The sural nerve is the most com-
high-velocity gun-shot wounds, and Late Exploration monly chosen autograft. Harvest
severe soft-tissue injuries. Both sec- Late exploration is the most common sequelae include sensory loss, neu-
ondary palsies and distal third frac- strategy for persistent palsies. Late roma, deep venous thrombosis, and
tures are no longer considered surgery gives a 69% chance of hematoma. There may be hesitation
definite indications for early explo- recovery in the setting of humeral to incur this morbidity in the setting
ration, with larger studies showing shaft fracture, with a 31% risk of no of guarded prognosis, in which case
higher rates of spontaneous recovery recovery at the end of treatment.9 As allografts can be considered. A report
than indicated by initial reports. The the radial nerve innervates extrinsic of 71 upper extremity nerve repairs
arguments for early exploration are muscles, the distance from the level using processed nerve allograft,
high rates of nerve entrapment, seen of injury to the motor end plates is including 2 radial nerve repairs,
in 6% to 25% of cases, and nerve shorter than that for the median and demonstrated functional results
lacerations reported in 20% to 42% ulnar nerves. Nerve repair can, comparable to those of repairs using
of humerus fractures4,8 that can be therefore, be successfully performed autografts for gaps measuring 5 to
repaired before scarring when the later, although timing may affect 50 mm.14 Synthetic conduits are al-
nerve is maximally mobile. If there is recovery. One study of 244 trau- ternatives to grafts for small gaps or
Sonia Chaudhry, MD, et al
can supplement direct repairs and and connected at a proximal end of Although lack of radial nerve sen-
grafts. They contain fluid leaking from the recipient branch, releasing re- sation tends not to be functionally
nerve ends to help form the fibrin cipient nerve sites of entrapment, disabling, painful neuromas can
matrix and support cell migration. motor reeducation when M1 recov- cause significant allodynia. Options
ery is present, and concomitant ten- include desensitization with occupa-
don transfers when appropriate. tional therapy, anesthetic injection,
Nerve Transfers sympathectomy, or proximal tran-
Nerve transfers from the median to Tendon Transfers section, or cauterizing and burying
the radial nerve are among the most the end within muscle or other soft
technically difficult, but carry the Tendon transfers are a tried and true
tissue.19
best quality of results. Ray and treatment option. Functional improve-
Mackinnon15 reported on 19 patients ment is such that many choose this
treated an average of 5.7 months after option without even exploring the Summary
injury with transfer of redundant nerve for potential repair. Principles
median nerve branches to the flexor include ensuring the presence of Knowledge of radial nerve anatomy,
carpi radialis (FCR) and flexor dig- supple joints, expendable donors physiology, injury mechanisms, and
itorum superficialis (FDS) to the PIN with adequate strength and excur- potential for recovery after insult
and ECRB branches, respectively, sion, straight line of pull, synergism, continues to be updated. As larger
with a few variations. Medical soft-tissue coverage with minimal studies demonstrate higher sponta-
research council muscle strength at 12- scar tissue, and one tendon per func- neous recovery rates and longer
month follow-up was M4 or higher tion. The most common transfer for windows for successful late repair,
for wrist extension in 18 patients and wrist extension is PT to ECRB. Finger early nonsurgical management for up
finger/thumb extension in 12 patients. extension is with FCR to extensor to 6 months in adults and 9 months in
Good results have been reproduced digitorum communis, although the children has expanded from closed
in a similar study of the pronator teres flexor carpi ulnaris or FDS to the ring humeral shaft fractures to include
(PT) branch to ECRL, FCR branch to or long fingers is an option. Thumb operative fractures that do not re-
PIN, and FDS branch to ECRB in six extension is with palmaris longus or quire nerve exposure, secondary
patients with complete radial nerve an FDS tendon transferred to the palsies, and distal third humerus
palsy. All achieved independent finger extensor pollicis longus. Repairs can fractures. Early exploration con-
function with 93% grip strength.16 be performed end to end for a tinues to be the recommendation
It should be noted that nine patients straighter line of pull, or end to side when the probability of recovery
in Mackinnon’s series had concomi- when done early or in combination after observation is less than 40%,
tant PT to ECRB tendon transfers as with nerve repair and some degree of such as with penetrating injuries and
an internal splint. A supercharged nerve recovery is expected. high-energy open fractures. Treatment
end-to-side transfer is another option High levels of patient satisfaction options include tendon transfers,
to “babysit” motor end plates while and good range of motion are gener- direct repair with or without grafting,
awaiting spontaneous nerve recovery ally reported. Neuroplasticity is re- nerve transfers, or combination pro-
or regeneration of a nerve transfer.17 quired and, therefore, younger and cedures. Further study is needed to
Mackinnon18 notes that despite motivated patients tend to do better. determine the long-term outcomes of
her success with nerve transfers, she Sequelae include under- or over- nerve repairs with modern techniques
still performs five tendon transfers tensioning, loss of power grip, unnatu- that emphasize tension-free repair and
for every nerve transfer when treat- ral movement of the wrist and fingers, compare the use of allografts with that
ing radial nerve palsies. Nerve limited wrist flexion, and lack of indi- of autografts.
transfers offer high-demand patients vidual finger movement.2
increased finger dexterity without References
nerve grafting and reduce the risk of Salvage
sensory/motor bundle malalignment; Stiff or painful joints will not function Evidence-based Medicine: Levels of
however, the recovery time frame is well with either tendon transfers or evidence are described in the table of
significantly longer at 1 year compared late recovery of muscles. In these cases, contents. In this article, references 2,
to that for tendon transfers which offer wrist fusion provides a durable solu- 5, 8, 10, and 11 are level III studies.
immediate motor function. Technical tion that places the wrist in a position References 3, 7, and 13-17 are level
pearls include tension-free repair of power so that remaining finger and IV studies. References 1, 4, 6, 9, 12,
with the donor branch taken distal thumb function can be optimized. and 18 are level V studies.
March 15, 2019, Vol 27, No 6 e283
Radial Nerve Injuries
References printed in bold type are of rotation of the elbow: the need for a 13. Laubscher M, Held M, Maree M,
rational safe zone for lateral pin Solomons M: Radial nerve lacerations: The
those published within the past 5 placement. J Hand Surg Am 2014;39: outcome of end-to-end repairs in
years. 1136-1140. penetrating trauma. Hand Surg 2015;20:
67-72.
1. Bono CM, Grossman MG, Hochwald N, 7. Esquenazi Y, Park SH, Kline DG, Kim DH:
Tornetta P: Radial and axillary nerves: Surgical management and outcome of 14. Cho MS, Rinker BD, Weber RV, et al:
Anatomic considerations for humeral fixation. iatrogenic radial nerve injection injuries. Functional outcome following nerve repair
Clin Orthop Relat Res 2000:259-264. Clin Neurol Neurosurg 2016;142:98-103. in the upper extremity using processed
nerve allograft. J Hand Surg Am 2012;37:
2. Pan C-H, Chuang DC-C, Rodríguez- 8. Shao YC, Harwood P, Grotz MRW, Limb 2340-2349.
Lorenzo A: Outcomes of nerve D, Giannoudis PV: Radial nerve palsy
reconstruction for radial nerve injuries based associated with fractures of the shaft of the 15. Ray WZ, Mackinnon SE: Clinical outcomes
on the level of injury in 244 operative cases. J humerus: A systematic review. J Bone Joint following median to radial nerve transfers. J
Hand Surg Eur Vol 2010;35:385-391. Surg Br 2005;87:1647-1652. Hand Surg Am 2011;36:201-208.
3. Nachef N, Bariatinsky V, Sulimovic S, 9. Bishop J, Ring D: Management of radial 16. García-López A, Navarro R, Martinez F,
Fontaine C, Chantelot C: Predictors of nerve palsy associated with humeral shaft Rojas A: Nerve transfers from branches to
radial nerve palsy recovery in humeral shaft fracture: A decision analysis model. J Hand the flexor carpi radialis and pronator teres
fractures: A retrospective review of 17 Surg Am 2016;34:991-996.e1. to reconstruct the radial nerve. J Hand Surg
patients. Orthop Traumatol Surg Res 2017; Am 2014;39:50-56.
103:177-182. 10. Grass G, Kabir K, Ohse J, Rangger C, Besch
L, Mathiak G: Primary exploration of 17. Barbour J, Yee A, Kahn LC, Mackinnon SE:
4. DeFranco MJ, Lawton JN: Radial nerve radial nerve is not required for radial nerve Supercharged end-to-side anterior
injuries associated with humeral fractures. J palsy while treating humerus shaft fractures interosseous to ulnar motor nerve transfer
Hand Surg Am 2006;31:655-663. with unreamed humerus nails (UHN). for intrinsic musculature reinnervation. J
Open Orthop J 2011;5:319-323. Hand Surg Am 2012;37:2150-2159.
5. Claessen FM, Peters RM, Verbeek DO,
Helfet DL, Ring D: Factors associated 11. Koch PP, Gross DFL, Gerber C: The results 18. Mackinnon SE: Donor distal, recipient
with radial nerve palsy after operative of functional (Sarmiento) bracing of proximal and other personal perspectives
treatment of diaphyseal humeral shaft humeral shaft fractures. J Shoulder Elbow on nerve transfers. Hand Clin 2016;32:
fractures. J Shoulder Elbow Surg 2015; Surg 2002;11:143-150. 141-151.
24:e307-e311.
12. Matzi V, Hörlesberger N, Hohenberger 19. Wolfe SW, Pederson WC, Hotchkiss RN,
6. Wegmann K, Lappen S, Pfau DB, Neiss GM, et al: Minimally invasive approach to Kozin SH, Cohen MS: Green’s Operative
WF, Müller LP, Burkhart KJ: Course of the radial nerve: A new technique. Injury Hand Surgery. Philadelphia, PA, Elsevier
the radial nerve in relation to the Center 2015;46:2374-2378. Health Sciences, 2016, pp 1.
Extremity War Injuries XII: Homeland Defense as a Translation of War
Lessons Learned: Erratum
In the July 15, 2018 issue for the article “Extremity War Injuries XII: Homeland Defense as a
Translation of War Lessons Learned” appearing on page e288, the authors state the list of
authors was incomplete. Below is a complete list of all authors for this article.
LTC Daniel J. Stinner, MD
Andrew H. Schmidt, MD
David Teague, MD
COL (Ret) Roman Hayda, MD
Christopher LeBrun, MD
Christopher Born, MD
David Teuscher, MD
Ellen MacKenzie, PhD
MAJ Jonathan Dickens, MD
Mark McAndrew, MD
LCDR Christopher Smith, MD
MAJ Jean Claude D’Alleyrand, MD
LT Scott Tintle, MD
LTC Benjamin K. Potter, MD
COL (Ret) Andrea Crunkhorn, PhD
COL (Ret) James Ficke, MD, FACS
LTC Anthony Johnson, MD
COL Kirby Gross, MD
Reference
Stinner DJ, Schmidt AH: Extremity War Injuries XII: Homeland defense as a translation of war lessons learned. J Am Acad Orthop
Surg 2018;26:e288-e301.
March 15, 2019, Vol 27, No 6 e285

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Review Article

Value-based Total Hip and Knee

literature. Research efforts toward quality improvement are likely to be

January 1, 2019, Vol 27, No 1 1

Figure 1 Structure of Total Joint

2 Journal of the American Academy of Orthopaedic Surgeons

January 1, 2019, Vol 27, No 1 3

4 Journal of the American Academy of Orthopaedic Surgeons

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6 Journal of the American Academy of Orthopaedic Surgeons

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8 Journal of the American Academy of Orthopaedic Surgeons

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10 Journal of the American Academy of Orthopaedic Surgeons

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Microinstability of the Hip—Gaining

identify microinstability patients preoperatively. Initial management

12 Journal of the American Academy of Orthopaedic Surgeons

Bony Stability Figure 1

January 1, 2019, Vol 27, No 1 13

14 Journal of the American Academy of Orthopaedic Surgeons

have demonstrated that the center of Figure 2

January 1, 2019, Vol 27, No 1 15

Figure 3 hip arthroscopy, making a capsu-

16 Journal of the American Academy of Orthopaedic Surgeons

addition to having a high index of Figure 4

January 1, 2019, Vol 27, No 1 17

Figure 5 assessed on AP pelvis radiographs,

18 Journal of the American Academy of Orthopaedic Surgeons

AP pelvis radiograph of a patient

January 1, 2019, Vol 27, No 1 19

Figure 9 Figure 10 lent intra-articular visualization with

20 Journal of the American Academy of Orthopaedic Surgeons

chondrolysis and thermal necrosis of traumatic and atraumatic instability. Clin

and acceptance of arthroscopic hip 2. Tan V, Seldes R, Katz M, et al:

January 1, 2019, Vol 27, No 1 21

22 Journal of the American Academy of Orthopaedic Surgeons

Electrical Injuries of the Hand and

the skeletal muscle secondary to its large volume in the upper

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e2 Journal of the American Academy of Orthopaedic Surgeons

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e4 Journal of the American Academy of Orthopaedic Surgeons

of current flow from the source to the Figure 2 Figure 3

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e6 Journal of the American Academy of Orthopaedic Surgeons

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e8 Journal of the American Academy of Orthopaedic Surgeons

From the Department of

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Figure 1 Emerging Educational and

e10 Journal of the American Academy of Orthopaedic Surgeons

students, engineering students, busi- Figure 2

January 1, 2019, Vol 27, No 1 e11

e12 Journal of the American Academy of Orthopaedic Surgeons

whereby capitalization can result in Figure 3

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e14 Journal of the American Academy of Orthopaedic Surgeons

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e16 Journal of the American Academy of Orthopaedic Surgeons

A jump park, or trampoline park,

January 1, 2019, Vol 27, No 1 23

Figure 1 variables include sex, age, diagnosis,

24 Journal of the American Academy of Orthopaedic Surgeons