Download Indiana Orthopaedic Journal - Department of Orthopaedic Surgery

Indiana Orthopaedic Journal
INDIANA UNIVERSITY DEPARTMENT of ORTHOPAEDIC SURGERY
2009
Synthes is the leader in orthopaedic trauma
devices for internal and external fixation.
Synthes develops, manufactures and markets the AO system of
orthopaedic implants and instruments. Our goal is to provide the
most advanced implants, biomaterials, instruments and technologies
that meet or exceed the highest expectations in safety and quality.
Our products are designed to ensure reliable operating procedures,
rapid recovery and optimal patient outcomes.
Synthes offers a variety of fixation options for orthopaedic trauma
applications.
Indiana Orthopaedic Journal
Volume 3 – 2009
Table of Contents
Annual Reports
1
3
4
5
7
8
9
10
11
12
13
15
16
19
20
21
22
23
Chairman’s Report – Jeff Anglen, MD
Residency Program Director’s Report – Randy Loder, MD
Orthopaedic Research Lab Report – Melissa Kacena, PhD
Faculty of the Department of Orthopaedic Surgery
Volunteer Faculty and Lecturers
PGY-1 through PGY-4 Residents
Graduating Class of 2008 and Incoming Interns
Fellows
Recent Awards, Honors, and Other Accolades
Faculty – Selected Journal Publications
Faculty – International Service Update
Garceau-Wray Lectureship
Event Photos
Residency Alumni List
Alumni News
Alumni – Selected Journal Publications
Supporting the IU Department of Orthopaedic Surgery through IU Foundation Donations
Lindseth Lectureship
Faculty and Alumni Manuscripts
Basic Science
A Novel Treatment for Osteoporosis?
25Megakaryocytes:
Monique Bethel, M.D. and Melissa A. Kacena, Ph.D.
Effects of Preparations of Rat Pulmonary Alveolar Macrophages Challenged with
28Osteogenic
Staphylococcus Aureus
Russell D. Meldrum M.D., Umut A. Gurkan Ph.D., Seema A Kattaya M.S., Ozan Akkus Ph.D.
Spine
Use of Radiographic Measurements at the Craniocervical Junction to Predict Spinal Cord
30The
Compression in Patients with Rheumatoid Arthritis
Creso Bulcao, M.D. and John P. Lubicky, M.D.
34Pedicle Screw Fixation for the Surgical Treatment of Canine Traumatic L7 FractureDislocation: A Clinical Report
Rick C. Sasso, M.D., W. David Min, M.D., and Richard Sasso, D.V.M.
i
Indiana Orthopaedic Journal
Volume 3 – 2009
Shoulder
38
ase Report: Porous Tantalum Augment Used To Address Significant Glenoid Deficiency in
C
Revision Total Shoulder Arthroplasty
Vivek Agrawal, M.D.
Humerus
Complications in the Treatment of Humeral Fractures
41Avoiding
Jeffrey O. Anglen, M.D., Michael T. Archdeacon, M.D., Lisa K. Cannada, M.D., Dolfi Herscovici Jr., D.O.
Wrist
Following Arthroscopic Thermal Ligamentorrhaphy of Partial Tears of the
48Outcomes
Scapholunate Ligament in an Active Population
Arthur C. Rettig, M.D., Kevin M. Marberry M.D., Brady P. Barker, M.D., Lance A. Rettig, M.D.
General Topics
Institute of Medicine Report on Resident Duty Hours
52The
Jeffrey O. Anglen, M.D., Michael J. Bosse, M.D., M.S.E., Timothy J. Bray, M.D., Andrew N. Pollak,
M.D., David C. Templeman, M.D., Paul Tornetta III, M.D., J. Tracy Watson, M.D.
Health
54Hoosier
Stephen B. Trippel, M.D.
Influencing Patient Choice of Hospital and Surgeon for Total Hip or Knee Arthroplasty
55Factors
Robb Weir, M.D., Judy R. Feinberg, Ph.D., William N. Capello, M.D.
Tumor
The Use of the ComPreSs Device for Endoprosthetic Fixation in Orthopaedic Oncology:
58The
Indiana University Experience
®
L. Daniel Wurtz, M.D. and Raymond J. Metz, M.D.
Adriamycin -Impregnated Cement for Treatment of Metastatic Carcinoma to Bone
64Bruce
T. Rougraff, M.D. and Brent Damer, D.O.
®
Femur
Interlocked Nailing of Pediatric Femoral Fractures
67Flexible
Lubica Jencikova-Celerin, MD, PhD, Jonathan H. Phillips, BSc, MB, BS, Lloyd N. Werk, MD,
Hip
MPH, Stacey Armatti Wiltrout, MA, MS, and Ian Nathanson, MD
Combined Use of Simulation and Navigation to Demonstrate Hip Kinematics
77The
By Robert L. Thornberry, M.D. and Andrew J. Hogan
Knee
Occult Knee Dislocation Treated with Patellar Olecranization
84An
Brian H Mullis, M.D. and Janos P Ertl, M.D., Eric M Lindvall, D.O.
Space Narrowing After Partial Medial Meniscectomy in the Anterior Cruciate Ligament –
87Joint
Intact Knee
K. Donald Shelbourne, M.D. and Jonathan F. Dickens, M.D.
Alignment in Total Knee Arthroplasty: Just how important is it?
91Coronal
David M. Fang, M.D., Merrill A. Ritter, M.D., and Ken E. Davis, M.S.
94Information for Authors
Judy R. Feinberg, PhD
[email protected]
Editor
Donna L. Roberts
[email protected]
Assistant
ii
Indiana Orthopaedic Journal
Volume 3 – 2009
Chairman’s Report
After what seemed to be an interminable winter, a glorious spring arrived in
Indianapolis just in time for the residents’ graduation and the Garceau-Wray Lectureship. Our visiting professors this year were Dr. Lee Riley, III, Director of Spine
Surgery at Johns Hopkins Medical Institutions, and Dr. Rick Wright, Co-Director
of Sports Medicine for the Washington University School of Medicine. The PGY-4
residents presented their research projects on Thursday, June 4, and Dr. Megan
Brady won the best resident research project award for her study on wound complications following calcaneal fracture surgery. Dr. Greg Dikos won the George
Alavanja award for orthopaedic professionalism and fellowship. Teaching awards,
selected by the residents, were given to Drs. Alex Mih and Tom Fisher. This year’s
scientific program was composed of the research project presentations of the subspecialty orthopaedic fellows training in Indianapolis. We had presentations from
Hand, Spine, and Sports fellows. This turned out to be a very popular and productive format which we hope to continue and expand.
During the spring of each year, we make an annual report to the School of Medicine, which I presented to the Dean and his staff in April. Some of the highlights
of that report are:
Faculty. Over the time period from 2006 to 2009, we have added nine faculty, and we will add one more (Dr. Ripley Worman) to the faculty in the fall. We now have 17 clinical faculty, including three who are jointly employed by IU and our private
practice group allies (Indiana Hand Center, Methodist Sports Medicine, and Indiana Spine Group). In 2008, there were over 30
volunteer faculty from eight different local orthopaedic groups who served as lecturers, rotation supervisors, or research mentors to orthopaedic residents and medical students. It is our philosophy to view the training and education of the next generation
of orthopaedic surgeons as a responsibility and privilege of the entire profession, not just those of us in full time academic
practice. Each year, we invite alumni and volunteer faculty to participate in the residency interview process, to help select our
residents from the medical student applicants. If you would like to be involved in this process, please let me know.
Our primary recruitment priority now is increasing the Pediatric Orthopaedic Division. As Riley Hospital completes their
major expansion, there is continued need for more pediatric orthopaedists. Our goal is to add at least two more faculty members
to the three outstanding pediatric orthopaedic surgeons currently in our division (Drs. Loder, Lubicky and Caltoum).
Clinical Services. IU Orthopaedics is thriving at all of our hospital venues. Wishard now has two full time orthopaedic surgeons (Drs. Mullis and Ertl) and regular specialty clinics in hand, shoulder and elbow, spine, pediatrics, sports medicine, and
total joint surgery. The quality and volume of orthopaedic activity at Wishard, both clinical and research, is at an all time high,
providing greatly needed services to patients from all walks of life, including the poor and indigent. The orthopaedic service at
the Roudebusch VA Hospital continues to be successful and busy, under the direction of Dr. Mark Webster. We have recently
completed a new contract with the VA and have two full time faculty members with primary VA assignments. The pediatric
orthopaedic service at Riley Children’s Hospital has a long and distinguished history at IU, and that continues. The pediatric
division is seeing more patients and doing more surgery than ever before, and is recognized for excellence on a national and
international level. We have moved much of our adult reconstructive work to Methodist Hospital, where Drs. Parr and Meldrum
run a busy total joint service. At IU Hospital, Dr. Capello continues to provide outstanding hip surgery and great teaching for
the residents, while Drs. Wurtz and Cummings are expanding and further developing the division of orthopaedic oncology.
Additional resident rotations at Clarian West with Dr. Ambrose, at the Hand center, Indiana Spine Group, and with Methodist
Sports Medicine round out our clinical educational activity.
Education. Recently re-accredited by the RRC for five years, our educational program is thriving, under the direction of
Education Chair Dan Wurtz and Program Director Randy Loder. All of our graduates who took ABOS exams last year passed
both Parts I and II. The OITE scores maintained a significantly improved level over the performances of 5+ years ago. In addition to our repeating two-year curriculum of lecture and conference topics, we have added the following teaching forums: a
multidisciplinary spine conference including private practice orthopaedic and neurosurgeons, a revised format for our ortho1
Indiana Orthopaedic Journal
Volume 3 – 2009
Chairman’s Report (continued)
paedic journal club with more articles reviewed, and fresh cadaver anatomy dissection sessions which will be done quarterly at
the new Biomet learning facility in Warsaw.
We provide physical exam instruction for the 2nd year medical students, clinical rotations for the upper level medical students
with both full time and volunteer faculty, research opportunities, and mentorship for those desiring a career in Orthopaedics.
In addition, we are working with selected 3rd and 4th year students to develop a series of problem based orthopaedic learning
cases in PowerPoint format, which can be used as a teaching resource.
We serve as the sponsoring institution for post-graduate fellowships in hand surgery, sports medicine, spine, and orthopaedic
trauma through our affiliated groups. In addition, we have a fellowship in total joint arthroplasty and in academic orthopaedics.
Both the full time and the volunteer faculty have participated in an extensive and impressive array of continuing medical
education programs sponsored by both national and international orthopaedic organizations, such as: AAOS, Orthopaedic
Trauma Association, Pediatric Orthopaedic Society of North America, AO North America, The North American Spine Society,
and others too numerous to mention. The world wide reputation of the faculty is impressive and growing
This year we added a new special educational event to our calendar, The Richard Lindseth Lectureship in Pediatric Orthopaedics. Funded by alumni donations, this event brings to campus one distinguished visiting professor in pediatric orthopaedics
and numerous other pediatric ortho faculty from surrounding institutions. Last year, Dr. Bob Hensinger from Michigan was
the first Lindseth Lecturer. We hosted 14 visiting pediatric orthopaedic faculty, each of whom presented a short talk on their
research or area of clinical interest. Residents from other programs in the region are invited to attend free of charge.
Research. Led by Drs. Turner, Trippel and Kacena, orthopaedic research at IU includes a constellation of laboratories within
Fesler Hall and the Biotechnology Research and Training Center (BRTC). There are five labs in Fesler Hall, including biomaterials, cartilage biology, biomechanics, tissue engineering, and biomolecular engineering. In addition, we conduct research in
skeletal genetics and mechanobiology at the BRTC. The research group includes 20 scientists and clinicians, four of whom have
grants from the National Institutes of Health (NIH). These scientists come from several different departments: Orthopaedic
Surgery, Biomedical Engineering, Anatomy, Physical Therapy, and the Dental School. The primary focus of the science efforts
is the development of molecular therapies for chronic musculoskeletal disease and treatment of bone and cartilage injuries,
including bone healing strategies.
All faculty make some contribution to the research mission of the department, and each resident completes a publishable
project during their residency period. Currently, the Trauma and Pediatric divisions are the most active in clinical research.
The Orthopaedic Trauma division has 14 active projects, and is participating both in commercially sponsored research and in
multicenter, prospective studies organized by the OTA or other international collaborations such as the Clarity Research Group
from McMaster University.
Full time faculty has published nearly 100 papers or book chapters in calendar 2008 and 2009 (so far), and a bibliography of
some of these publications is included in this journal.
Thanks to all the alumni who have supported the Department over the past year through your donations, support, and attendance at our events, such the Garceau-Wray Lectureship and the Indiana Reception at the AAOS meeting. With your help,
IU orthopaedics continues to thrive and meet our goals of advancing orthopaedic knowledge, producing the next generation of
orthopaedic surgeons for our state and nation, and providing excellent musculoskeletal care for all Hoosiers.
Jeffrey O. Anglen, M.D.
Professor and Chairman, Indiana University School of Medicine, Department of Orthopaedic Surgery
2
Indiana Orthopaedic Journal
Volume 3 – 2009
Residency Program Director’s Report
Since the last issue of the Indiana Orthopaedic Journal, the noteworthy
events have occurred regarding our residency program.
Resident Applications
We again used our out-patient clinics as the site of the resident interviews. This also allows more interviews per interviewee, allowing them
to get a complete perspective of the program. This has been very popular
with the applicants. Some comments we have received are: “The residents
and attendings appeared to be a great group of people, and the program is
in a great city”, “Well done, the interview day shed a positive light on the
program.” “ Dr. Anglen’s small group session was worthwhile and made
him seem quite approachable.” “I was impressed with your program. It was
much better than I expected.” “Having the residents there was a very good
thing.” and “I had a great time at the interview. The resident turnout and
enthusiasm was exceptional.” “The interviewers were personable and gave
me a great look at the program.” This year we received 409 applications for
Dr. Loder introducing a speaker at the
the five positions, similar to the 395 last year. Of these 409 applicants, 169
Garceau-Wray Lectureship where the PGY-4
were screened out simply on the basis of USMLE Part I Board Scores; 240
residents present their research projects.
files were then reviewed and 75 applicants were offered interviews. These
interviews took place over three days, two for non IU students and one specifically for IU students. The day for IU students is shorter as they are acquainted with the venue and program. The addition
of this third day reserved for IU students allows us to interview more non IU students on the other two days, thus potentially
increasing the diversity and number of potential residents. We wish to extend our appreciation to all the faculty, both full time
and volunteer/alumni, who participated in the resident interview process this year.
Our five new PGY-1 residents who began their studies July 1, 2009 are: Dr. David Barba from UCLA, Dr. Edgar Fernandez
from the University of Texas at Galveston, Dr. Scott Pepin from the University of Minnesota, Dr. Chad Turner from the University of Utah, and Dr. Jason Watters from Indiana University.
Resident Awards
Dr. Jonathon Wilhite, PGY-3, was awarded a one year grant from the Orthopaedic Trauma Association for his study “Efficacy
and Dose Evaluation of TPO in Healing Critical-Sized Femoral Defects”. This study is to study the hypothesis that TPO, the
main megakaryocyte growth factor, when locally increased will result in a local increase of megakaryocytes. TPO is known to
enhance osteoblast proliferation by direct cell to cell contact, and it is hoped that a local increase in osteoblast proliferation will
result in subsequent bone formation and bone healing in the area of defect.
Dr. Susan McDowell, PGY-2, is one of the co-PIs on a Biomedical Research Grant from the IU School of Medicine entitled
“Structural and Functional Evaluation of Stainless Steel and PMMA Induced Membranes as a Graft Bed for Segmental Bone
Defects.
Dr. David Fang, PGY-3, won the American College of Surgeons Resident Paper Contest for his paper “Coronal Alignment in
Total Knee Arthroplasty” and which has been accepted for publication in The Journal of Arthroplasty. Randall T. Loder, M.D.
George J. Garceau Professor of Pediatric Orthopaedics
Residency Program Director, Department of Orthopaedic Surgery
3
Indiana Orthopaedic Journal
Volume 3 – 2009
Orthopaedic Research Laboratory Report
Orthopaedic research at IU is located in six laboratories within Fesler Hall, Medical Sciences, and the Biotechnology Research and Training
Center under the direction of Drs. Charles Turner, Stephen Trippel, David Burr, Hiroki Yokota, Tien-Min Gabriel Chu, and Melissa Kacena. The
research group includes 25 scientists and clinicians, eight of whom have grants from the NIH, and come from five departments: Orthopaedic
Surgery, Biomedical Engineering, Anatomy and Cell Biology, Physical Therapy, and Restorative Dentistry. Below are brief research updates
from the six research directors as well as a brief update on additional orthopaedic research endeavors.
Research Update
Charles Turner, PhD, Professor and Associate Chair of Biomedical Engineering, Director of Orthopaedic Research. Dr. Turner’s research is
funded by NIH and focuses on understanding genetic influences on bone strength and causes of bone wasting diseases. Dr. Turner was recently
awarded the title of Chancellor’s Professor.
Stephen Trippel, MD, Professor of Orthopaedic Surgery. Dr. Trippel’s research focuses on cartilage-related disorders. His research team
includes Shuiliang Shi PhD, Congrong Wang PhD, Anthony Acton BS and Albert Chan BS. His work is funded by the NIH and VA, and recent
work includes the investigation of gene therapy and regulation of articular cartilage by growth factors.
David Burr, PhD, Professor and Chair of Anatomy and Cell Biology. Dr. Burr’s research focus is on the effects of changes in bone collagen
on the mechanical properties, and increased fracture risk, of bone in osteoporosis and in Type II diabetes. Dr. Burr is currently President of the
American Association of Anatomists and the Orthopaedic Research Society. He recently was awarded the Borelli Award from the American
Society of Biomechanics. Much of his work is funded by NIH and NSBRI.
Hiroki Yokota, PhD, Professor of Biomedical Engineering. Dr. Yokota’s research focuses on bone remodeling in response to mechanical
loading, specifically: (a) application of joint loading for stimulating bone formation and accelerating healing of bone fracture and osteonecrosis;
(b) investigation of load-driven translational regulation and interactions to integrated stress responses; and (c) mathematical and computational
modeling of mineral metabolism. He was elected as a Fellow of American Institute for Medical and Biological Engineering in 2008. His research
has been supported by NIAMS.
Tien-Min Gabriel Chu, DDS, PhD, Associate Professor of Restorative Dentistry. Dr. Chu’s research is focused on the development of tissue
engineering strategies to enhance regeneration in long bones and in craniofacial areas with particular interest in fabrication and characterization
of high strength 3D biodegradable scaffolds capable of carrying mesenchymal stem cells and/or releasing growth factors. In 2008, he received
funding from IU School of Dentistry and Oral and Maxillofacial Surgery Foundation to investigate the use of polymer-reinforced calcium phosphate as novel 3D scaffolds to enhance regeneration in rabbit cranial defects.
Melissa Kacena, PhD, Assistant Professor of Orthopaedic Surgery, Chair, Orthopaedic Research Committee. Dr. Kacena’s research goal is
to improve understanding of the interaction between bone and hematopoietic systems, thereby potentially improving treatment of metabolic bone
disease and fracture healing. Her research will focus in three areas: 1) role of megakaryocytes, megakaryocyte growth factors and their receptors
in bone homeostasis; 2) translational/clinical studies examining the genetic regulation of skeletal homeostasis; and 3) molecular mechanisms underlying bone repair/fracture healing. She has received numerous honors, young investigator awards, and research grants, including NIH funding
and recently served as an ad hoc member on several NIH study sections.
Additional Basic Orthopaedic Research Studies/News:
After 16 years of service to the Department, it is with sorrow and best wishes in retirement, that we said goodbye to our friend and colleague,
Dr. Judy Feinberg. She has published more than 50 peer-reviewed manuscripts and has been a tremendous biostatistics and scientific writing
resource. She will be missed tremendously.
Drs. Brian Mullis, Janos Ertl, Jeffrey Anglen, Matthew Allen, Tien-Min Gabriel Chu, and Melissa Kacena are collaborating on a rabbit
study examining structural and functional evaluation of stainless steel and PMMA induced membranes as a graft bed for segmental bone defects.
Dr. Mullis recently received a Biomedical Research Grant from the IU School of Medicine to support this work. Dr. Susan McDowell, PGY-2
resident, is assisting on this project.
Drs. Brian Mullis, Peter Hoggs, Tien-Min Gabriel Chu, and Mr. Daniel Alge (PhD student in Biomedical Engineering, Purdue University)
are working together to compare the load and mode of failures in fresh-frozen cadaver femurs fixed by sliding hip screws implants with nonlocking plates and locking plates. Dr. Mullis recently received funding from Synthes for this project. Dr. Jonathan Wilhite, PGY-3 resident, was awarded an OTA resident research award to study the ability of thrombopoietin to heal critical-sized femoral defects in rats. Drs. Jeffrey Anglen, Tien-Min Gabriel Chu, and Melissa Kacena are serving as his faculty advisors for this project.
A new osteosarcoma group has been formed by Drs. Daniel Wurtz, Judd Cummings, Melissa Kacena, and Lindsey Mayo. Dr. Katie Peck,
PGY-2 resident, is assisting with this research. This newly formed group meets bimonthly to develop and discuss joint research projects. Recently, their joint pre-proposal was selected as the one proposal to be sent from the IU Simon Cancer Center for the V Foundation Scholar Award.
Dr. Theresa Guise and her research and clinical group will be moving from UVA to IU School of Medicine beginning in the summer, 2009.
Their research primarily focuses on bone cancers. The arrival of her group on campus promises to bring new opportunities for collaborations.
Melissa A. Kacena, Ph.D.
Assistant Professor of Orthopaedic Surgery
Chair, Orthopaedic Research Committee
4
Indiana Orthopaedic Journal
Volume 3 – 2009
Department of Orthopaedic Surgery Faculty
Jeffrey O. Anglen, MD
Professor and Chairman
Clinical Interests: Orthopaedic trauma and post-traumatic complications with
special interest in pelvis and acetabulum fractures, peri-articular fractures of both
upper and lower extremity, bone healing, nonunions, malunions, deformity and
post-traumatic infections.
Richard E. Lindseth, MD
Professor Emeritus
Contact Information: 317-274-7913 (office phone);
[email protected] (e-mail)
Thomas A. Ambrose, MD, FACS
Randall T. Loder, MD
Clinical Interests: Adult reconstruction (total joint replacements), Sports
Medicine and treatment of post-traumatic complications such as non-unions and
malunions. T reatment of severe musculoskeletal injuries, such as pelvic and
acetabular fractures as well as complex long bone fractures.
Clinical Interests: Pediatric orthopaedics with special interest in scoliosis,
pediatric hip disorders (hip dislocation, Perthes’ disease, slipped capital femoral
epiphysis), clubfoot, and cerebral palsy.
Christine B. Caltoum, MD
John P, Lubicky, MD, FAAOS, FAAP
Associate Professor and
Chief of Surgery at Clarian West
Contact Information: 317-278-5492 (office phone);
[email protected] (e-mail)
Assistant Professor
Clinical Interests: Pediatric orthopaedic surgery with special interest in Perthes
disease and shoulder problems secondary to obstetrical brachial plexus palsies
Contact Information: 317-274-1174 (office phone);
[email protected] (e-mail)
Contact Information: 317-278-0961 (office phone);
[email protected] (e-mail)
Professor
Clinical Interests: Pediatric orthopaedics with special interest in spinal
deformities, limb length discrepancies and deformities, and pediatric spinal cord
injury.
Contact Information: 317-274-1174 (office phone);
[email protected] (e-mail)
William N. Capello, MD
Professor Emeritus
Clinical Interests: Hip replacement with special interest in revision hip
replacement
Contact Information: 317-274-8617 (office phone);
[email protected] (e-mail)
Judd E. Cummings, MD
George J. Garceau Professor of
Pediatric Orthopaedics and Vice Chairman
G. Peter Maiers, II, MD
Assistant Professor
Clinical Interests: Sports medicine with a focus on total knee care, adult and
pediatric athletic injuries, ligament reconstruction, cartilage restoration, and hip
arthroscopy
Contact Information: 317-580-3516 (office phone);
[email protected] (e-mail)
Assistant Professor
Clinical Interests: Management of adult and pediatric patients with bone and
soft tissue tumors or tumor-like conditions utilizing a comprehensive and multidisciplinary approach. Operative treatment incorporates contemporary surgical
techniques for removal of extremity, pelvic tumors, and spinal tumors. Reconstructive techniques include limb sparing surgery using both endoprostheses and
structural allografts. Metastatic lesions of bone are managed with prophylactic
stabilization, internal fixation, or resection and reconstruction.
Russell D. Meldrum, MD
Associate Professor and
Adult Reconstruction Fellowship Director
Clinical Interests: Adult reconstruction with special interest in hip and knee
replacement surgery and arthritis.
Contact Information: 317-278-6904 (office phone);
[email protected] (e-mail)
Contact Information: 317- 274-3227 (office phone);
[email protected] (e-mail)
Janos P. Ertl, MD
Assistant Professor, and
Chief of Orthopaedics, Wishard Hospital
Alexander D. Mih, MD
Associate Professor,
and Chief of Upper Extremity Service
Clinical Interests: Bridging orthopaedic trauma and sports medicine including surgical
procedures of arthroscopic assisted periarticular fractures, long bone fractures, non-unions,
minimally invasive fracture treatment arthroscopy, autogenous and allograft chondral
transplantation, ligament reconstruction and amputation reconstruction.
Clinical Interests: Reconstructive surgery of the upper extremity, brachial
plexus reconstruction and repair, pediatric upper extremity disorders,
microsurgery, shoulder reconstruction
Paul E. Kraemer, MD
Brian H. Mullis, MD
Contact Information: 317-630-6192 (office phone);
[email protected] (e-mail)
Assistant Professor
Clinical Interests: General spine surgery, spinal trauma, adult spinal deformity,
and metastatic disease to the spine, adjacent segment disease, and revision /
deformity surgery.
Contact Information: 317- 713 6879 (office phone);
[email protected] (e-mail)
Contact Information: 317-274-3224 (office phone);
[email protected] (e-mail)
Assistant Professor and
Chief of Orthopaedic Trauma Service
Clinical Interests: Orthopaedic trauma and post-traumatic complications with
special interest in pelvic and acetabular fractures, peri-articular fractures of both
upper and lower extremities, bone healing, nonunions, malunions, deformities,
and post-traumatic infections
Contact Information: 317-630-6192 (office phone);
[email protected] (e-mail)
5
Indiana Orthopaedic Journal
Volume 3 – 2009
Department of Orthopaedic Surgery Faculty
J. Andrew Parr, MD
(continued)
Mark D. Webster, MD
Assistant Professor and
Chief of Adult Reconstruction Service
Assistant Professor and
Chief of Orthopaedic Service at VA
Clinical Interests: Minimally invasive total hip and knee surgery, alternative
bearing surfaces and complex revision hip and knee replacement.
Clinical Interests: Sports medicine, fractures, total joints, trauma.
Stephen B. Trippel, MD
L. Daniel Wurtz, MD
Contact Information: 317-278-5789 (office phone);
[email protected] (e-mail)
Contact Information: 317-278-8880 (office phone);
[email protected] (e-mail)
Professor
Clinical Interests: Arthritis treatment, joint preserving and joint replacement
surgery.
Associate Professor and
Chief of Orthopaedic Oncology Service
Clinical Interests: Operative and non-operative treatment of musculoskeletal
tumors
Contact Information: 317-278-6904 (office phone);
[email protected] (e-mail)
Contact Information: 317-278-3227 (office phone);
[email protected] (e-mail)
Research Faculty
David B. Burr, PhD
Melissa A. Kacena, PhD
Contact Information: 317-274-7496 (office phone);
[email protected] (e-mail)
Contact Information: 317-278-3482 (office phone);
[email protected] (e-mail)
Professor and Chair of Anatomy
Professor of Orthopaedic Surgery (Indiana University)
Professor of Biomedical Engineering (Purdue
University, IUPUI)
Assistant Professor of Orthopaedic Surgery (Indiana
University)
Assistant Professor of Biomedical Engineering (Purdue
University, IUPUI)
Charles H. Turner, PhD
Professor of Orthopaedic Surgery and Director of
Research (Indiana University)
Professor of Biomedical Engineering (Purdue
University)
Contact Information: 317-274-3226 (office phone);
[email protected] (e-mail)
Joining Our Faculty in the Coming Year…
Ripley W. Worman, M.D.
Dr. Worman received his medical degree from the Indiana University School of Medicine and completed his
residency training in our program at Indiana University. He will be joining our faculty and will be working
with Dr. Ambrose at Clarian West as a general orthopaedist starting in July, 2009.
6
Indiana Orthopaedic Journal
Volume 3 – 2009
The Indiana University Department of Orthopaedic Surgery
would like to thank the following individuals
for their valuable contributions to our residents’ education
during the 2008-2009 academic year
Volunteer Faculty Chiefs of Service
Thomas J. Fischer, MD
Chief of Hand Service
David A. Porter, MD, PhD
Chief of Foot & Ankle Service
Lance A. Rettig, MD
Chief of Sports Medicine Service
Rick C. Sasso, MD
Chief of Spine Service
Resident Conference Lecturers 2008
Kenneth Buckwalter, MD...................................................................................................... Dept of Radiology
Michael Coscia, MD........................................................................................................................... OrthoIndy
Michael Coughlin, MD............................................................................... Oregon Health Sciences University
Jack Farr, MD..................................................................................................................................... OrthoIndy
David Fisher, MD............................................................................................................................... OrthoIndy
Tinker Gray, MA, ELS.......................................................................................... The Shelbourne Knee Clinic
Jeffrey Greenberg, MD............................................................................................... The Indiana Hand Center
Hill Hastings, MD...................................................................................................... The Indiana Hand Center
Robert Huler, MD............................................................................................................................... OrthoIndy
Richard Idler, MD....................................................................................................... The Indiana Hand Center
Thomas Kaplan, MD.................................................................................................. The Indiana Hand Center
William Kleinman, MD.............................................................................................. The Indiana Hand Center
Thomas Klootwyk, MD................................................................................Methodist Sports Medicine Center
Dr. L.K. Lelei.............................................................................................................................. Moi University
Arthur Lorber, MD....................................................................................................Indianapolis Bone & Joint
Gregory Merrell, MD................................................................................................. The Indiana Hand Center
Alex Meyers, MD.....................................................................................Reconstructive Hand Surgeons of IN
Alexander Mih, MD............................................................................................. Dept of Orthopaedic Surgery
Eric Monesmith, MD.......................................................................................................................... OrthoIndy
Michael Pannunzio, MD...........................................................................Reconstructive Hand Surgeons of IN
Jeffrey Pierson, MD......................................................................................Joint Replacement Surgeons of IN
Nate Prahlow, MD......................................................................................................Dept of Physical Therapy
Kent Remley, MD...............................................................................................Center for Diagnostic Imaging
Arthur Rettig, MD........................................................................................Methodist Sports Medicine Center
Lance Rettig, MD.........................................................................................Methodist Sports Medicine Center
Richard Rodgers, MD............................................................................... University Neurosurgical Associates
Randall Roper, PhD...................................................................................................................Dept of Biology
Rick Sasso, MD................................................................................................................. Indiana Spine Group
David Schwartz, MD.......................................................................................................................... OrthoIndy
K. Donald Shelbourne, MD................................................................................... The Shelbourne Knee Clinic
James Strickland, MD..............................................................................Reconstructive Hand Surgeons of IN
Scott Urch, MD..................................................................................................... The Shelbourne Knee Clinic
Thank You!
7
Indiana Orthopaedic Journal
Volume 3 – 2009
PGY-1 through PGY-4 Residents
PGY-1
Matthew D. Abbott, MD
Indiana University
School of Medicine
Ryan R. Jaggers, MD
Indiana University
School of Medicine
Raymond J. Metz, Jr., MD
Indiana University
School of Medicine
Justin A. Miller, MD
University of Louisville
School of Medicine
W. Lee Richardson, MD
Ohio State University
College of Medicine
Kathryn M. Peck, MD
Indiana University
School of Medicine
Daniel R. Sage, MD
SUNY Downstate College
of Medicine
Tarek A. Taha
Medical University
of South Carolina
David M. Fang, MD
Washington University
School of Medicine
Stephen P. Jacobsen, MD
University of Medicine
& Dentistry of New Jersey
Christopher B. Vincent, MD
University of Colorado
School of Medicine
Jonathan H. Wilhite, MD
Indiana University
School of Medicine
Conor J. Dwyer, MD
Indiana University
School of Medicine
Larry Martin, Jr, MD
Meharry Medical College
Justin W. Miller, MD
Indiana University
School of Medicine
A. Kirk Reichard, MD
University of Louisville
School of Medicine
PGY-2
Scott R. Bassuener, MD
Susan M. McDowell, MD
University of Wisconsin
Indiana University
School of Medicine
School of Medicine
& Public Health
PGY-3
Joseph E. Bellamy, MD
University of Illinois
College of Medicine
PGY-4
Megan A. Brady, MD
Iowa Carver College
of Medicine
8
Indiana Orthopaedic Journal
Volume 3 – 2009
Best of Luck to our PGY-5 Residents
Left To Right:
Matthew D. Welsch, MD
Medical School: Medical College of Wisconsin
Research Project Title: C
omparison of Radiation Exposure in Lumbar Pedicle Screw Placement With Fluoroscopy Versus Computer Assisted Image Guidance with Intraoperative
3-D Imaging (Rick C. Sasso, MD and Matthew D. Welsch, MD)
Fellowship: Hand (Indiana Hand Center, Indianapolis, IN)
Karl D. Shively, MD
Medical School: University of Illinois College of Medicine
Research Project Title: Early Results of the Maestro Wrist Reconstructive System (James Strickland, MD, Lance Rettig, MD and Karl Shively, MD)
Fellowship: Trauma (University of Texas-Southwestern at Parkland Hospital, Dallas, TX)
Ripley W. Worman, MD
Medical School: Indiana University School of Medicine
Research Project Title: Extremity Gunshot Injuries in Children (Ripley W. Worman, MD and Randall T. Loder, MD)
Practice: Indiana University School of Medicine, Department of Orthopaedic Surgery, Indianapolis, IN
Gregory D. Dikos, MD
Medical School: Indiana University School of Medicine
Research Project Title: Axial CT Evaluation of the Distal Tibiofibular Syndesmosis (Gregory D. Dikos, MD, Timothy G. Weber, MD, Eric Westin, MD, and Marcus B. Stone, PhD)
Fellowship: Trauma (Harborview Medical Center, Seattle, WA)
David M. Foulk, MD
Medical School: Wright State University School of Medicine
Research Project Title: Prospective, Randomized Trial of Metal-On-Metal Artificial Lumbar Disc Replacement: Initial Results for Treatment of Discogenic Pain (Rick C. Sasso,
MD, David M. Foulk, MD and Michael Hahn, MD)
Fellowship: Sports (Cincinnati Sports Medicine & Orthopaedic Center, Cincinnati, OH)
Welcome to the New Interns
David Barba, MD
University of California
Los Angeles
Edgar Fernandez, MD
University of Texas
Galveston
Scott Pepin, MD
University of Minnesota
9
Chad Turner, MD
University of Utah
Jason Watters, MD
Indiana University
Indiana Orthopaedic Journal
Volume 3 – 2009
Good Luck to the Fellows
Nick Papakonstantinou, MD
fellowship location Ortho Indy - Spine
practice name, city Rochester Hills Orthopaedics
Rochester, MI
John Douglas Haltom, MD
fellowship location Methodist Sports Medicine
practice name, cityWest Tennessee Bone & Joint Clinic
Jackson, TN
John B Heinrich, MD
fellowship location Methodist Sports Medicine
practice name, cityOrthopedic Associates of Dallas
Dallas, TX
Ian C. Marrero-Amadeo, MD
fellowship location Indiana Hand Center
practice name, cityUniversity of Alabama at Birmingham - Division of Plastic Surgery
Birmingham, AL
Timothy C. Bowlin, MD
fellowship location Indiana Hand Center
practice name, cityBaton Rouge Orthopaedic Clinic
Baton Rouge, LA
Kayvon D. Izadi, MD
fellowship location Indiana Hand Center
practice name, cityMethodist Physicians Clinic - Sports Medicine Center Health West
Omaha, NE
Daniel R. Lewis, MD
fellowship location Indiana Hand Center
practice name, cityOrtho Carolina
Charlotte, NC
Thomas J. McDonald, MD
fellowship location Indiana Hand Center
practice name, cityKaiser Permanente
Sacramento, CA
10
Indiana Orthopaedic Journal
Volume 3 – 2009
Recent Awards, Honors, and Other Accolades
Dr. Alex Mih was selected as a recipient of one of this year’s Trustee Teaching
Awards from the School of Medicine. This prestigious award recognizes Dr.
Mih’s skill, dedication and hard work in teaching students, residents and colleagues
– which he has demonstrated so well over his career at IU. We are lucky to have
many great teachers in our department, and this recognition of Dr. Mih’s success and
commitment makes us all proud.
Dr. Jeff Anglen was elected Secretary of the American Board of Orthopaedic Surgery
and was the Presidential Guest Speaker at the annual meeting of the Ohio Orthopaedic
Society.
Dr. Randy Loder is an ex-officio board member and Chairman of the Communications
Council of the Pediatric Orthopaedic Society of North America (POSNA).
Dr. John Lubicky was the recipient of the Good Will Ambassador Award from the Vilnius University
Children’s Hospital and the Lithuanian-American Medical Society.
Dr. Brian Mullis was elected the IU SOM Teacher of the Year for Surgery Subspecialites by the
medical school class of 2009. He also received a Navy Achievement Medal for service to the Naval
Medical Center Portsmouth as an orthopaedic trauma surgeon and was appointed Battalion Surgeon for
NMCB-28, a battalion of reserve Seabees mostly stationed in the south and southwest. In addition, he was
appointed to the OTA Research Committee, became an ATLS Instructor for the American College of
Surgeons, and was appointed to the Editorial Board of the Journal of Trauma as an associate editor.
Dr. L. Daniel Wurtz was awarded the coveted Trustee Teaching Award for 2008 at the recent medical
school commencement ceremony. This award is the result of nominations by learners or colleagues for
contributions to the IU School of Medicine educational effort. Dr. David Burr is President of the Orthopaedic Research Society.
Dr. Tom Fischer was appointed to serve as Co-Chairman of the AO International Hand Course to
be held in December in Davos, Switzerland, as well as Co-Chairman of the 2010 AO North American
Hand Course. He also serves as the Vice Chairman of the Academic Standards Committee of the
Butler University Board of Trustees.
Dr. David Fang, PGY-3 resident, was one of three winners of the Indiana State Medical Association
Resident Presentation Competition for his presentation entitled “Importance of Alignment in Total Knee
Arthroplasty” at the Annual Meeting of the Indiana Chapter of the American College of Surgeons.
Dr. Jonathan Wilhite, PGY-3 resident, was awarded an OTA Resident Research Grant for his research
with Drs. Anglen, Kacena and Chu on “Efficacy and Dose Evaluation of TPO in Healing Critical-Sized
Femoral Defects”.
Dr. Greg Dikos, PGY-5 resident, was the recipient of this year’s George Alavanja Award for Orthopaedic
Professionalism and Fellowship at the annual Garceau-Wray dinner.
Ms. Kendall Dedinsky has been named the recipient of the Dean’s Council Scholarship sponsored by
the Department of Orthopaedic Surgery. She is a native Hoosier who comes from a family of healthcare
workers. She has applied to go to Kenya as part of our joint academic model program in collaboration with
Moi University as she has an interest in the practice of medicine in developing countries.
11
Indiana Orthopaedic Journal
Volume 3 – 2009
Selected Faculty Journal Publications - 2008
Anglen JO, Baumgaertner MR, Smith WR, Tornetta III P, Ziran BH. Technical tips in fracture care:
fractures of the hip. Instructional Course Lectures. 57:17-24, 2008.
Anglen J. Broken bones and orthopedist groans. Journal of Trauma-Injury Infection & Critical Care.
65(3):743; 2008 Sep.
Burd TA, Hughes MS, Anglen JO. The floating hip: complications and outcomes. Journal of TraumaInjury Infection & Critical Care. 64(2):442-8, 2008 Feb.
Cannada LK, Anglen JO, Archdeacon MT, Herscovici D Jr, Ostrum RF. Avoiding complications in the
care of fractures of the tibia. Journal of Bone and Joint Surgery – American. 90(8):1760-8, 2008 Aug.
Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence? Journal of Bone and Joint Surgery – American.
90(9):1855-61, 2008 Sept.
Ziran BH, Smith WR, Anglen JO, Tornetta III P. External fixation: how to make it work. Instructional Course Lectures. 57:37-49, 2008.
Upasani VV. Caltoum C. Petcharaporn M. Bastrom TP. Pawelek JB. Betz RR. Clements DH. Lenke LG. Lowe TG. Newton PO. Adolescent idiopathic
scoliosis patients report increased pain at five years compared with two years after surgical treatment. Spine. 33(10):1107-12, 2008 May 1.
Upasani VV. Caltoum C. Petcharaporn M. Bastrom T. Pawelek J. Marks M. Betz RR. Lenke LG. Newton PO. Does obesity affect surgical outcomes in
adolescent idiopathic scoliosis? Spine. 33(3):295-300, 2008 Feb 1.
Capello WN. Feinberg JR. Trochanteric excision following persistent nonunion of the greater trochanter. Orthopedics. 31(7):711, 2008 Jul.
Capello WN. D’Antonio JA. Feinberg JR. Manley MT. Naughton M. Ceramic-on-ceramic total hip arthroplasty: update. Journal of Arthroplasty. 23(7
Suppl):39-43, 2008 Oct.
Biau DJ. Halm JA. Ahmadieh H. Capello WN. Jeekel J. Boutron I. Porcher R. Provider and center effect in multicenter randomized controlled trials of
surgical specialties: an analysis on patient-level data. Annals of Surgery. 247(5):892-8, 2008 May.
Loder RT. The demographics of equestrian-related injuries in the United States: injury patterns, orthopedic specific injuries, and avenues for injury
prevention. Journal of Trauma-Injury Infection & Critical Care. 65(2):447-60, 2008 Aug.
Loder RT. Feinberg JR. Emergency department visits secondary to amusement ride injuries in children. Journal of Pediatric Orthopedics. 28(4):423-6,
2008 Jun.
Loder RT. The demographics of playground equipment injuries in children. Journal of Pediatric Surgery. 43(4):691-9, 2008 Apr.
Loder RT. Aronsson DD. Weinstein SL. Breur GJ. Ganz R. Leunig M. Slipped capital femoral epiphysis. Instructional Course Lectures. 57:473-98, 2008.
Loder RT. Correlation of radiographic changes with disease severity and demographic variables in children with stable slipped capital femoral epiphysis.
Journal of Pediatric Orthopedics. 28(3):284-90, 2008 Apr-May.
Samartzis D. Lubicky JP. Shen FH. “Bone block” and congenital spine deformity. Diagnosis: Klippel-Feil syndrome with congenital scoliosis. Annals of
the Academy of Medicine, Singapore. 37(7):624, 2008 Jul.
Lubicky JP. Point of view. Spine. 33(20):2236, 2008 Sep 15.
Samartzis D. Kalluri P. Herman J. Lubicky JP. Shen FH. The extent of fusion within the congenital Klippel-Feil segment. Spine. 33(15):1637-42, 2008 Jul 1.
Samartzis D. Kalluri P. Herman J. Lubicky JP. Shen FH. 2008 Young Investigator Award: The role of congenitally fused cervical segments upon the space
available for the cord and associated symptoms in Klippel-Feil patients. Spine. 33(13):1442-50, 2008 Jun 1.
Meldrum RD. Maiers GP. Feinberg JR. Parr JA. Capello WN. Park JJ. Long-term outcome of surface replacement with comparison to an age- and timematched primary total hip arthroplasty cohort. Journal of Arthroplasty. 23(1):1-9, 2008 Jan.
Mullis BH. Sagi HC. Minimum 1-year follow-up for patients with vertical shear sacroiliac joint dislocations treated with iliosacral screws: does joint
ankylosis or anatomic reduction contribute to functional outcome? Journal of Orthopaedic Trauma. 22(5):293-8, 2008 May-Jun.
Porter DA. May BD. Berney T. Functional outcome after operative treatment for ankle fractures in young athletes: a retrospective case series. Foot &
Ankle International. 29(9):887-94, 2008 Sep.
Webb BG. Rettig LA. Gymnastic wrist injuries. Current Sports Medicine Reports. 7(5):289-95, 2008 Sep-Oct.
Rettig LA. Hastings H 2nd. Feinberg JR. Primary osteoarthritis of the elbow: lack of radiographic evidence for morphologic predisposition, results
of operative debridement at intermediate follow-up, and basis for a new radiographic classification system. Journal of Shoulder & Elbow Surgery.
17(1):97-105, 2008 Jan-Feb.
Smith HE. Welsch MD. Sasso RC. Vaccaro AR. Comparison of radiation exposure in lumbar pedicle screw placement with fluoroscopy vs computerassisted image guidance with intraoperative three-dimensional imaging. Journal of Spinal Cord Medicine. 31(5):532-7, 2008.
Sasso RC. Best NM. Metcalf NH. Anderson PA. Motion analysis of bryan cervical disc arthroplasty versus anterior discectomy and fusion: results from a
prospective, randomized, multicenter, clinical trial. Journal of Spinal Disorders & Techniques. 21(6):393-9, 2008 Aug.
Whang PG. Lim MR. Sasso RC. Skelton A. Brown ZB. Greg Anderson D. Albert TJ. Hilibrand AS. Vaccaro AR. Financial incentives for lumbar surgery: a
critical analysis of physician reimbursement for decompression and fusion procedures. Journal of Spinal Disorders & Techniques. 21(6):381-6, 2008 Aug.
Sasso RC. Foulk DM. Hahn M. Prospective, randomized trial of metal-on-metal artificial lumbar disc replacement: initial results for treatment of discogenic
pain. Spine. 33(2):123-31, 2008 Jan 15.
Sasso RC, Shively RD, Reilly TM. Transvertebral Transsacral strut grafting for high-grade isthmic spondylolithesis L5-S1 with fibular allograft. Journal of
Spinal Disorders & Techniques. 21(5):328-33, 2008 Jul.
Sasso RC. Garrido BJ. Postoperative spinal wound infections. Journal of the American Academy of Orthopaedic Surgeons. 16(6):330-7, 2008 Jun.
Lehman RA Jr. Dmitriev AE. Helgeson MD. Sasso RC. Kuklo TR. Riew KD. Salvage of C2 pedicle and pars screws using the intralaminar technique: a
biomechanical analysis. Spine. 33(9):960-5, 2008 Apr 20.
Sasso RC. Best NM. Cervical kinematics after fusion and bryan disc arthroplasty. Journal of Spinal Disorders & Techniques. 21(1):19-22, 2008 Feb.
Smith MW. Marcus PS. Wurtz LD. Orthopedic issues in pregnancy. Obstetrical & Gynecological Survey. 63(2):103-11, 2008 Feb.
12
Indiana Orthopaedic Journal
Volume 3 – 2009
Orthopaedic Training in Kenya - Update
Our colleagues at the Moi University Teaching
and Referral Hospital (MTRH) in Kenya have
started the first Orthopaedic residency training
program in the country, and one of the few in East
Africa. The training is between 4 and 8 years long,
and there are currently 6 residents in the program
which is in its 2nd year of existence. Four new
residents will start in September. Unlike training
in the United States, post-graduate training in
Kenya is paid for by the trainee in the form of
tuition. This costs 180,000 Kenyan shillings per
year ($2500 US). Students arrange for their own
accommodation and meals. Some are sponsored
by their employing hospital, while others pay their
own way. The program results in a “Masters”
degree in Orthopaedics. Dr. Kibor Lelei is the senior
orthopaedic consultant, and has been responsible
Dr. Lelei teaching SIGN nail technique to fellow Kenyan
surgeons and the KOA meeting.
13
Dr. Lelei, Dr. Anglen and Dr. Christer Anderson from Sweden
at the Sirikwa Hotel in Eldoret, Kenya.
for the development of this program. Dr. Lelei has
visited Indianapolis and our department multiple
times, and has helped to run a SIGN nail workshop
for our residents. In addition to Dr. Lelei, Dr.
Ongaro and Dr. Muteti are formally trained
orthopaedic consultants on the faculty, and there
are 4 additional faculty members.
The primary teaching facility is the MTRH,
although the residents may work with faculty at
other private hospitals in Eldoret. In addition, there
are external rotations in Kijabe, Tenwek and St.
Mary’s Hospital Rift Valley. During the first year,
the residents have rotations in Plastic Surgery, ICU,
Neurosurgery, Accident and Emergency, Radiology,
Thoracic, General and Orthopaedic Surgery. They
also take anatomy, physiology and pathology
courses. In the second year, they do away rotations
including Pediatric Orthopaedics. In the 3rd year,
they have some elective time in sub-specialties, and
in the 4th year, they do subspecialty orthopaedics
rotations such as sports, arthroplasty, hand, spine
and foot/ankle. Orthopaedic residents in Kenya
are bright, talented, hardworking and resourceful –
much like their American counterparts!
Indiana Orthopaedic Journal
Volume 3 – 2009
Drs. Anglen and Shively operate on a Kenyan patient with an
acetabular fracture in the “George Rapp” operating theatre
in Eldoret, Kenya.
Dr. Anglen and Dr. Karl Shively, chief resident,
visited Kenya in March to participate in the Kenya
Orthopaedic Association annual meeting. Dr.
Anglen was the Presidential guest speaker, and
Dr. Shively ran a workshop on arthroscopic ACL
reconstruction, a relatively rare technique in
Kenya. Both participated in clinics, operations,
ward rounds and lectures for the faculty, residents
and students. Moi University orthopaedic residents
presented their research projects, which included:
outcomes of treatment of open fractures with the
SIGN nail, treatment of clubfoot by the Ponseti
method, Osteopetrosis, Madura foot, Impact of
bodaboda accidents, and fibular grafting for long
bone defects.
Dr. Shively and two of the Moi Orthopaedic residents take
tea during a break at the Kenya Orthopaedic Association
meeting.
It is hoped that we can develop a two-way
exchange program for orthopaedic trainees and
faculty in Indianapolis and Eldoret, building on
the success of the IU-Kenya program in other
fields. Such an educational exchange would be
tremendously valuable to both programs. Dr.
Shively’s travel was supported by a generous grant
from the Indiana Orthopaedic Society Foundation.
Orthopaedic alumni who are interested in supporting
resident travel to or from Kenya in the future, or in
helping to raise funding for this program, should
contact Dr. Anglen.
14
Indiana Orthopaedic Journal
Volume 3 – 2009
The Garceau-Wray Lectureship
In 1966, the Riley Memorial Association began the Garceau
Lectureship in honor of Dr. George Garceau, the first Chairman of the
Department of Orthopaedic Surgery at the Indiana University School of
Medicine. The combined Garceau-Wray Lectureship was begun in 1976
in memory of Dr. James B. Wray, the second Chairman of the Department
of Orthopaedic Surgery, following his untimely death.
Dr. Garceau (1896-1977) was recognized around the world as a
both a fine pediatric orthopaedic surgeon and as a true gentleman. He
joined the staff at Riley Hospital in 1928 and rose through the academic
ranks to become Professor and Chairman of Orthopaedic Surgery, then
a section of General Surgery, in 1948. He was instrumental in forming
an independent Department of Orthopaedic Surgery in 1960 and served
as the Chairman until his retirement in 1966. During his career, he
served as Vice President of the American Academy of Orthopaedic
Surgery, President of the American Board of Orthopaedic Surgery, and
President of the Clinical Orthopaedic Society. In addition to being a
skilled surgeon, he was an inspiring and innovative teacher, developing
the model of the residency program still in use at Indiana University.
Dr. Wray (1926-1973) was recruited as the second Chairman of the Department in 1966. He was dedicated to the
investigation and research of metabolic and vascular responses to fracture and to the general metabolic responses to trauma,
and he established the orthopaedic basic science research laboratories in 1967. In addition to multiple scientific publications,
he was the recipient of three research awards for excellence. Like his predecessor, he was an inspiring and dedicated surgeon
and teacher. His sudden and untimely death left a void in the hearts of his colleagues, residents, and medical students by whom
he was liked and respected.
The Garceau-Wray Lectureship is supported by generous donations from our alumni and industry. Each year two
nationally known speakers are invited to address the faculty, residents, alumni, and community surgeons in honor of these two
fine gentlemen. This year’s meeting was held on June 4-5, 2009 at the University Place Conference Center and Hotel on the
IUPUI campus. Keynote speakers were:
Lee H. Riley III, M.D.
The Johns Hopkins University School of Medicine, Baltimore, MD
Dr. Riley is an Associate Professor and Director of both the Division of Spine Surgery and of the
spine fellowship program. He is member of many professional organizations and currently serves on
the AAOS Medical Student, Resident, and Fellow Education Committee, the NIH Orthopaedics and
Skeletal Biology Small Business Review Panel, and the AO Spine North America Complications
Committee. The title of his George J. Garceau Lecture was ‘The Clinical Challenge of Cervical
Myelopathy’.
Rick W. Wright, M.D.
Washington University School of Medicine, St. Louis, MO
Dr. Wright is an Associate Professor, Residency Director, and Co-Chief of Sports Medicine.
He has been an active member of numerous professional organizations and has served on a variety
of committee for the AAOS, American Society of Sports Medicine, Association of Bone & Joint
Surgeons, and the American Orthopaedic Association. The title of his James B. Wray Lecture was
‘Revision ACL Reconstruction: Early Results from the MARS Group’.
15
Indiana Orthopaedic Journal
Volume 3 – 2009
Garceau-Wray
Lectureship &
Graduating Resident
Reception/Dinner
Dr. Rick Wright (center) with residents Drs. Susan
McDowell, RJ Metz, Joe Bellamy, and Tarek Taha
Dr. &
Mrs. Russ
Meldrum
and Dr. Bill
Capello at
the dinner
reception
Drs. Mark
Webster and
Brian Mullis
and the
Chairman’s
wife, Diane
Anglen,
congratulate
graduating
resident, Dr.
Greg Dikos
(second from
left)
Resident
Dr. Kirk
Reichard,
Frank
Purciful, PA,
and Dr. Dan
Wurtz during
coffee break
Dr. Lee Riley (second from left) with residents Drs. Matt
Abbott, Ryan Jaggers, and Justin A. Miller
Lectureship attendees visit with vendors
during a break
Dr. Randy Loder with Dr. and Mrs. George
Rapp at the dinner reception
16
Dr. Jeff Anglen presenting a gift of
appreciation to graduating PGY-5 resident,
Dr. Karl Shively and his wife, Elizabeth
Indiana Orthopaedic Journal
Volume 3 – 2009
Annual Faculty Picnic at Dr. Anglen’s House
to Welcome the New Interns and Residents
Dr. Bill Capello (right) visits with Dr. Loder’s wife, Chris, and Dr.
Christine Caltoum
Dr. Rick Sasso with resident, Dr. Larry
Martin
New intern, Dr. Scott Pepin, takes his turn with the caricaturist
Drs. Jeff Anglen and Brian Mullis
Dr. Pete Maijer’s and his family along
with general orthopaedic fellow, Dr.
Creso Bulcao, enjoying the picnic
Dr. Paul Kraemer (center) with resident, Dr. Justin W. Miller and
his wife, Kaprice
17
Dr. Brian Mullis with residents, Dr. Susan McDowell and Dr.
Joe Bellamy. All three are commissioned officers in the Medical
Corps of the U.S. Navy (inactive status)
Indiana Orthopaedic Journal
Volume 3 – 2009
Indiana Reception at the
AAOS Meeting in Las Vegas
Mark Your Calendar to Join Us at Next Year’s Indiana Reception
at the AAOS Meeting in New Orleans!
18
Indiana Orthopaedic Journal
Volume 3 – 2009
Residency Program Alumni
Class of 1955
Edward V Schaffer, MD
Class of 1958
Gerald H. Weiner, MD
Class of 1962
John M Miller, MD
George F Rapp, MD
John G Suelzer, MD
(Deceased)
Class of 1963
Alois E Gibson, MD
Class of 1974
Colin W Hamilton, MD
Jerry L Mackel, MD
Joseph C Randolph, MD
Richard W Eaton, MD
Gary W Misamore, MD
Robert L Thornberry, MD
Thomas M Trancik, MD
Class of 1975
Ronald G Bennett, MD
Kenneth L Bussey, MD
Milton R Carlson, MD
(Deceased)
William H Couch, MD
Robert L Forste Jr, MD
Alfred E Kristensen, MD
Class of 1984
Steven K Ahlfeld, MD
Frank Johnson, Jr., MD
John K Schneider, MD
Christopher Stack, MD
Phillip L Stiver, MD
Class of 1976
Class of 1964
Walter E Badenhausen, MD James E. Albright, MD
(Deceased)
Ronald M Gilbert, MD
James R. Dashiell, MD
Donald F Hodurski, MD
Class of 1965
John L Reynolds, MD
William O Irvine, MD
Peter C. Weber, MD
Class of 1967
Class of 1977
Peter C Boylan, MD
Robert T Clayton, MD
Class of 1968
Charles E Jordan, MD
Steven R Glock, MD
Stephen G Powell, MD
George E Reisdorf, MD
Wilbur G Sandbulte, MD
James W Strickland, MD John F Showalter, MD
Leo Stelzer, Jr., MD
Class of 1969
Bennett J. Cremer, MD
Class of 1978
Ronald P Pavelka, MD
David L Bankoff, MD
David A Tillema, MD
Philip M Faris, MD
Philip H Ireland, MD
Class of 1970
David F Mackel, MD
Wheeler T Daniels, MD
G Paul DeRosa, MD
Class of 1979
William J Sabo, MD
Larry T Johnson, MD
Philip W Pryor, MD
Class of 1971
Theodore L Stringer, MD
William A Atz, MD
Terry R Trammell, MD
Kyu Sop Cho, MD
Pedro Musa-Ris, MD
Class of 1980
Keith D Sheffer, MD
Michael M Durkee, MD
Willard G Yergler, MD
James P Pemberton, MD
Class of 1972
Anthony J Arnold, MD
Robert E Cravens, MD
Alan J Habansky, MD
Charles J Holland, MD
James B Steichen, MD
John P. Vincent, MD
Class of 1973
John Howard Avery, MD
John M Gossard, MD
John C Klein, MD
William B LaSalle, MD
Wade Rademacher, MD
Class of 1981
George W Lane, MD
K Donald Shelbourne, MD
Franklin D Wilson, MD
David A Yngve, MD
Class of 1985
John M Ambrosia, MD
Vincent L. Fragomeni, MD
John O. Grimm, MD
Gary R Moore, MD
Class of 1986
Jack Farr II, MD
Michael S Green, MD
Richard D Schroeder, MD
Charles D Van Meter, MD
Class of 1987
Joseph Baele, MD
Richard G Buch, MD
Robert A Czarkowski, MD
David A Fisher, MD
Donna P Phillips, MD
Class of 1988
Frederick E Benedict, MD
Gregory Graziano, MD
Michael F Kaveney, MD
Delwin E Quenzer, MD
H Jeffery Whitaker, MD
Class of 1989
Andrew Combs, MD
Paul K Gerth, MD
Robert J Huler, MD
Class of 1990
Jeffrey A Clingman, MD
Dean C Maar, MD
Keith A Miller, MD
Richard Mullins, MD
William B Rozzi, MD
Carlos K Woodward, MD
Class of 1991
Mark J Conklin, MD
Class of 1982
Steven E Fisher, MD
John G Crane, MD
Gregory T Hardin, MD
Eric S Leaming, MD
Bruce T Rougraff, MD
Mohammed R Nekoomaram, MD Jeffrey D Webster, MD
Dennis C Stepro, MD
Class of 1992
Class of 1983
David Brokaw, MD
Karen S Duane, MD
Richard V Davis, MD
19
Norman Mindrebo, MD
Jonathan H Phillips, MD
John C Pritchard, MD
Class of 1993
Paul M Keller, MD
Michael L Kramer, MD
Daniel E Lehman, MD
Lynn M. Nelson, MD
Peter Sallay, MD
Class of 1994
Karl M Baird M.D.
David A Goertzen, MD
Stephen L Kollias, MD
Scott A Lintner, MD
Dean W Ziegler, MD
Class of 1995
Barry S Callahan, MD
Carey A. Clark, MD
James E. Goris, MD
Kosmas J. Kayes, MD
John I. Williams, MD
Class of 1996
James S. Kapotas. MD
Karen J. McRae, MD
P. Andrew Puckett, MD
Nirmal K. Surtani, MD
Peter Tang, MD
Class of 1997
Joseph F. Bellflower, MD
Thomas W. Kiesler, MD
Scott A. Magnes, MD
Paul S. Nourbash, MD
James R. Post, MD
Class of 1998
Rick Ahmad, MD
William P Didelot, MD
Jarvis Earl, MD
David B Fulton, MD
Thomas J Puschak, MD
Class of 1999
Vivek Agrawal, MD
Dale Dellacqua, MD
Mark B Durbin, MD
Colin G Sherrill, MD
Marshall L Trusler, MD
Class of 2000
George Alavanja, MD
(Deceased)
Patrick K Denton, MD
Brett F Gemlick, MD
Steven B Smith, MD
Anton A. Thompkins, MD
Class of 2001
Jamie Kay, MD
Euby Kerr, MD
Kevin E Klingele, MD
Christopher R Price, MD
Kirnjot (KJ) Singh, M.D.
Class of 2002
Robert O Anderson, MD
Timothy G Berney, MD
Joseph G Jerman, MD
Chad E Mathis, MD
Lance A Rettig, MD
Class of 2003
Cary M Guse, MD
Daniel W Hanson, MD
Adelbert (AJ) J Mencias, MD
Mark C Page, MD
Todd R Wurth, MD
Class of 2004
Kevin E Julian, MD
Aaron LeGrand, MD
Kurt Martin, MD
John T Pinnello, MD
Timothy L Walker, MD
Class of 2005
Lonnie D Davis, MD
Jedediah W Jones, MD
Michael J Sukay, MD
Marcus A. Thorne, MD
Class of 2006
C Noel Henley, MD
Ari J Kaz, MD
Brian J. Kerr, MD
G. Peter Maiers, MD
Aaron J Mast, MD
Alex Meyers, MD
Class of 2007
Brady P. Barker, MD
Padraic R. Ohma, MD
Michael P. Rusnak, MD
Bret R. Winter, MD
Jeffrey K. Wu, MD
Class of 2008
Ben Garrido, MD
Sean Garringer, MD
Kevin Lemme, MD
John Powell, MD
Indiana Orthopaedic Journal
Volume 3 – 2009
Alumni News
Class of 1981
Class of 1999
Frank Wilson sent this photo of his son receiving his MBA from IU
in June, 2008 – yet another proud IU grad in the family. From left to
right in the photo, is daughter, Tiffany (age 26), son, John (age 18),
wife, Chris, son and IU graduate, Matthew (age 31), and the proud
father, Frank.
Vivek Agrawal, MD, Director of The
Shoulder Center in Zionsville, has been
chosen by Becker’s Hospital Review as one
of the 10 Shoulder Specialists to Know in
America. More information is available at
www.TheShoulderCenter.com.
Class of 2002
Class of 1988
Gregory Graziano is an Associate Professor
and Chief, Orthopaedic Spine Division, at the
University of Michigan Health System where
he has been practicing in the subspecialty of
spine for the past 20 years. He continues to
teach residents on a daily basis and serves as
a mentor to high school and college students
who are interesting in pursuing a career in
Orthopaedics. He has published abstracts
and manuscripts in multiple orthopaedic
journals as well as written book chapters and presented scientific
exhibits, and he serves on the Editorial Review Boards of Spine, The
American Journal of Orthopaedics, Journal of Spinal Disorders,
Journal of the American Academy of Orthopaedic Surgeons, and is
an Associate Editor of The Spine Journal. In addition he continues
to pursue the science of Orthopaedics through continued research
and the development of new technologies.
Class of 1992
After completing his residency at IU, Dave
Brokaw completed a trauma fellowship
at Harborview Medical Center in Seattle,
WA. Following his fellowship, he joined the
OrthoIndy trauma team where he is actively
involved with fellow and resident education
and where he also feels privileged to have
several IU grads as his partners. He recently
developed an orthopaedic telemedicine
program in conjunction with Clarian Health.
While he continues to take trauma call on a
routine basis, his practice has evolved into treating elective posttraumatic orthopaedic reconstruction problems and the treatment of
acute injuries of the upper and lower extremities. He and his wife,
Chris, have three children. Mattie is a junior at Cathedral High
School and is interested in going to Notre Dame and following that
with medical school. James is a freshman at the same high school,
and is interested in the physical sciences, track and cross country. John is a fifth grader at Holy Spirit Catholic School and enjoys
baseball and is not quite sure what he wants to do. Tim Berney sent us this
family photo of his wife,
Jill, and son, Jamieson,
age 4½, while vacationing
in Hawaii. Tim is
currently practicing sports
medicine and general
orthopaedics in Aberdeen,
WA. He’s in a group of
three orthopaedists and
mentioned they’re looking
for one or two others to
join their practice due to
heavy volume if anyone is
interested in relocating to
Washington state.
Class of 2008 (Fellow)
Robb Weir completed a total joint fellowship at IU last year
and is currently practicing at Henry Ford Hospital in Detroit
subspecializing in total joint replacements. He is pleased to report
that his wife, Susan, and two sons, Andrew (age 3½) and Aaron (age
1½) are all doing well.
20
Indiana Orthopaedic Journal
Volume 3 – 2009
Alumni Journal Publications - 2008
Harner CD. Ranawat AS. Niederle M. Roth AE. Stern PJ. Hurwitz SR. Levine WN. DeRosa GP. Hu SS. AOA symposium.
Current state of fellowship hiring: is a universal match necessary? Is it possible?. Journal of Bone & Joint Surgery American Volume. 90(6):1375-84, 2008 Jun
King S. Berend ME. Ritter MA. Keating EM. Faris PM. Meding JB. Extended femoral osteotomy and proximally coated
prosthesis for hip revision. Orthopedics. 31(1):67, 2008 Jan.
Faris PM. Keating EM. Farris A. Meding JB. Ritter MA. Hybrid total knee arthroplasty: 13-year survivorship of AGC total
knee systems with average 7 years followup. Clinical Orthopaedics & Related Research. 466(5):1204-9, 2008 May.
Aleto TJ. Berend ME. Ritter MA. Faris PM. Meneghini RM. Early failure of unicompartmental knee arthroplasty leading to
revision. Journal of Arthroplasty. 23(2):159-63, 2008 Feb.
Berend ME. Ritter MA. Meding JB. Faris PM. Keating EM. Pierce A. Clinical results of isolated tibial component revisions
with femoral component retention. Journal of Arthroplasty. 23(1):61-4, 2008 Jan.
Rue JP. Colton A. Zare SM. Shewman E. Farr J. Bach BR Jr. Cole BJ. Trochlear contact pressures after straight
anteriorization of the tibial tuberosity. American Journal of Sports Medicine. 36(10):1953-9, 2008 Oct.
Verma NN. Kolb E. Cole BJ. Berkson MB. Garretson R. Farr J. Fregly B. The effects of medial meniscal transplantation
techniques on intra-articular contact pressures. The Journal of Knee Surgery. 21(1):20-6, 2008 Jan.
Sasso RC. Garrido BJ. Postoperative spinal wound infections. Journal of the American Academy of Orthopaedic Surgeons.
16(6):330-7, 2008 Jun.
Choplin RH. Henley CN. Edds EM. Capello W. Rankin JL. Buckwalter KA. Total hip arthroplasty in patients with bone
deficiency of the acetabulum. Radiographics. 28(3):771-86, 2008 May-Jun.
Lee GH. Virkus WW. Kapotas JS. Arthroscopically assisted minimally invasive intraarticular bullet extraction: technique,
indications, and results. Journal of Trauma-Injury Infection & Critical Care. 64(2):512-6, 2008 Feb.
Kerr BJ. McCarty EC. Outcome of arthroscopic debridement is worse for patients with glenohumeral arthritis of both sides
of the joint. Clinical Orthopaedics & Related Research. 466(3):634-8, 2008 Mar.
Pittner DE. Klingele KE. Beebe AC. Treatment of clubfoot with the Ponseti method: a comparison of casting materials.
Journal of Pediatric Orthopedics. 28(2):250-3, 2008 Mar.
Meyers A. Palmer B. Baratz ME. Ulnar collateral ligament reconstruction. Hand Clinics. 24(1):53-67, 2008 Feb.
Jencikova-Celerin L. Phillips JH. Werk LN. Wiltrout SA. Nathanson I. Flexible interlocked nailing of pediatric femoral
fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures. Journal
of Pediatric Orthopedics. 28(8):864-73, 2008 Dec.
Riina J. Patel A. Dietz JW. Hoskins JS. Trammell TR. Schwartz DD. Comparison of single-level cervical fusion and a metal-on-metal cervical
disc replacement device. American Journal of Orthopedics (Chatham, Nj).
37(4):E71-7, 2008 Apr.
Bi LX. Mainous EG. Yngve DA. Buford WL. Cellular isolation, culture and
characterization of the marrow sac cells in human tubular bone. Journal of
Musculoskeletal Neuronal Interactions. 8(1):43-9, 2008 Jan-Mar.
21
Indiana Orthopaedic Journal
Volume 3 – 2009
The Indiana University School of Medicine and the Department of Orthopaedic Surgery
greatly appreciate those alumni and friends who have provided financial support aimed
toward enhancing the education of our medical students, residents, and fellows.
If you are interested in discussing the many options available for providing support to the
Department through a planned or estate gift, please contact:
Joshua B. Lee, JD, at 317-278-2124.
Specific accounts within the IU Foundation that will directly support
the Department of Orthopaedic Surgery are:
James B. Wray Memorial Lectureship (38-MORT-028)
Endowment supports lectureships in orthopaedic surgery
Richard E. Lindseth Lectureship (37-MORT-046)
Endowment supports lectureships specifically in pediatric surgery
Jack Van Kampen Endowment (37-MORT-020)
Endowment supports joint replacement fellowships
James Gordon Kidd, Jr., M.D. Research Fellowship (37-MORT-038)
Endowment supports resident and graduate student research projects
Zimmer Orthopaedic Investments (38-MORT-044)
Funds provide general support for the Department of Orthopaedic Surgery
Orthopaedic Residency Education Fund (38-MORT-051)
Funds provide support to the residency program for the Department of Orthopaedic
Surgery
Please include the account name and number in the memo line of your check made
payable to the Indiana University Foundation-Orthopaedics and mail to:
PO Box 660245
Indianapolis, IN 46266-0245
Website: http://www.iuf.indiana.edu/
22
Indiana Orthopaedic Journal
Volume 3 – 2009
2009 Lindseth Lectureship Information
November 6, 2009
8am-5pm Lectureship
6pm-8pm Dinner
University Place Conference Center & Hotel
850 W. Michigan St., Indianapolis, IN
Registration Fee
50 ($25 for residents) Lectureship (includes lunch)
$
$40 ($20 for residents) Dinner
The Department of Orthopaedics at Indiana University is pleased to present the 2nd Annual Lindseth
Lectureship through the generosity of the Orthopaedic Residency Alumni. The Lectureship will
consist of a full day of talks and case presentations on pediatric orthopaedics presented by the
pediatric orthopaedic faculty of IU and other distinguished academic pediatric orthopaedists.
It is our honor to welcome Dr. Scott J. Mubarek of the University of California-San Diego to give
the second Lindseth Lecture in Pediatric Orthopaedics. Dr. Mubarak is the Director of Children’s
Hospital’s Pediatric Orthopedic Program and Clinical Professor of Orthopedics.
Dr. Mubarak is a member of the POSNA Board of Directors and is past president of that
organization. He is also a member of the AAOS, SRS, and AOA.
Dr. Richard Lindseth with 2008 Lindseth Lectureship speakers,
Dr. Matt Dobbs of Washington University (left), and Dr. Robert
Hensinger of University of Michigan (right).
23
Drs. Jeff Anglen, Christine Caltoum, and Randy Loder with
speaker, Dr. David Stevens, Emeritus Professor, University of
Kentucky.
Indiana Orthopaedic Journal
Volume 3 – 2009
Patient Referral Information
Physicians IMACS OneCall
(Indiana Medical Access & Communication System)
1-800-622-4989 (Toll-Free)
317-916-3500 (Local)
-orwww.clarian.org
Click under the tab ‘Physicians’, and
Complete the on-line patient referral form
University Orthopaedic Associates, Inc.
For Adult Patient Appointments, call 317-274-7372
For Pediatric Patient Appointments, call 317-274-2500
For more information, visit our website at:
www.orthopaedics.iu.edu
24
Indiana Orthopaedic Journal
Volume 3 – 2009
Megakaryocytes: A Novel Treatment for Osteoporosis?
Monique Bethel, M.D. and Melissa A. Kacena, Ph.D.
Department of Orthopaedic Surgery – Indiana University School of Medicine – Indianapolis, Indiana, USA
Corresponding Author:
Melissa Kacena, Ph.D.
Assistant Professor
Indiana University School of Medicine
Department of Orthopaedic Surgery
1120 South Drive, FH 115
Indianapolis, IN 46202
(317) 278-3482 – phone
(317) 278-9568 – fax
[email protected]
Osteoporosis is a growing problem in the United States.
Although not restricted to elderly persons, they bear the brunt
of it. In the US, approximately 55% of individuals over the
age of 50 are at risk of developing osteoporosis (or about 44
million people) and an estimated 10 million persons already
have it.1 To give an idea of the scope of damage done by this
disease, in 2005 over 2 million fractures were the result of
weak bones and the costs are staggering: the medical costs
associated with these fractures were $19 billion, and this is
expected to rise to $25.3 billion by the year 2025.1 Although
osteoporosis is traditionally associated with thin, white females, it can also afflict men as well as other ethnicities At
this point, medicine has few treatments to combat this disease
and they are not without side effects. Several of these treatments will be briefly highlighted here.
There are two main classes of medication available to
treat osteoporosis: anti-resorptives and bone-forming or anabolic agents. With regard to anti-resorptives, bisphosphonates
are the main therapeutic treatment. As a compound, bisphosphonates have been around for over a century but their use
for the treatment of individuals with diseases of bone metabolism has evolved in the past few decades. The basic structure of bisphosphonates involves a carbon surrounded by two
phosphate groups and two other variable sidechains. (Figure
1). Once introduced into the body, bisphosphates bind to
mineral surfaces and during osteoclastic bone resorption the
bisphosphonates are released and taken up by osteoclasts.2
Inside the osteoclast they are incorporated into the cell’s native ATP making it non-hydrolyzable, it can interfere with
cellular signaling or the cytoskeleton of the cell.2 These effects ultimately cause the cell to undergo apoptosis leading to
an over-all decrease in osteoclast number, a decrease in bone
breakdown, and therefore, an increase in bone density.2 The
major side effects of these drugs are esophagitis and gastritis
sometimes severe enough to cause perforations. These complications usually can be avoided by sitting upright for 30-60
minutes after ingesting the drug. Another serious side effect
recently attributed to bisphosphates use is osteonecrosis of
the jaw (ONJ). This was recently defined by Khosla et. al.3
as, “an area of exposed bone in the maxillofacial region that
did not heal within 8 wk after identification by a health care
provider, in a patient who was receiving or had been exposed
to a bisphosphonate and had not had radiation therapy to the
craniofacial region”. The mechanism of this injury is unclear;
however, there are some predisposing factors that have been
found in patients who developed this adverse reaction. These
factors include the following: periodontal disease, prior surgical dental manipulation, an immunocompromised state
(particularly cancer3), and hypercoaguability.4 Furthermore,
it has been posited that the relative decrease in bone remodeling from bisphosphonate use also contributes to this complication. The risk of developing ONJ is increased with duration
of use of the bisphosphate as well as its potentcy.5 Another
serious side effect with IV bisphosphonates is renal insufficiency likely secondary to acute tubular damage. Clinical
trials have estimated the incidence at 9-15% and one paper in
2003 noted kidney damage serious enough to require dialysis, and even death, among some patients.5 Despite the risk of
these adverse reactions, bisphosphonates remain a mainstay
in the treatment of osteoporosis and bone loss diseases such
as metastatic bone disease or multiple myeloma.
Other treatments used for osteoporosis include estrogen, which is believed to increase bone mass via several
mechanisms.6 One of these mechanisms is the inhibition of
receptor activator of NF-__ or RANK, which is the receptor
for RANK-ligand (RANKL) a key component of osteoclast
development and up-regulation of osteoprotegerin, a decoy
RANKL receptor.7 Unfortunately, in a landmark study, estrogen was later discovered to lead to an unacceptable increase
in the risk of breast cancer and cardiovascular sequelae (MI,
stroke, PE/DVT).8 Therefore, estrogen is recommended in
the treatment of osteoporosis only if there is an additional
indication for its use.
Selective estrogen receptor modulators (SERMs) such as
raloxifene act as an estrogen agonist in bone tissue but estrogen antagonist in breast and endometrial tissue.9 Therefore
these agents have the benefit of increasing bone density as
does estrogen, without the concern of increased cancer risk.
It has been shown that as a group these agents have an inhibitory effect on osteoclastic differentiation although their exact
mechanism of action is unknown.9
Finally, daily injections of parathyroid hormone (PTH)
Figure 1. Chemical structure of a bisphosphonate.25
25
Indiana Orthopaedic Journal
Volume 3 – 2009
Megakaryocytes: A Novel Treatment for Osteoporosis? (continued)
are FDA-approved for osteoporosis treatment and are of the
bone-forming, or anabolic, class. As opposed to bisphosphonates, which ultimately only preserve the bone architecture
of the patient by inhibiting bone destruction by osteoclasts,
PTH actually improves bone architecture by increasing the
amount of bone laid down during the remodeling process.10
The drawbacks of this drug include a finding of hypercalcemia and hypercalciuria in some patients as well as a somewhat prohibitive cost and a method of administration some
patients may find difficult. One major concern with this drug
is the possibility of osteosarcoma formation after long-term
use. In a rat study, osteosarcoma was found in approximately
31% of female rats and 22% of male rats receiving doses of
5-, 30-, and 75-µg/kg of PTH after an average of 20 months.9
This has led to requirement that PTH injections not be continued beyond 2 years. Furthermore, current research has not
proven PTH to be superior to bisphosphonates in fracture
prevention.10 Patients for whom PTH should be considered
are those with pre-existing osteoporotic fractures, those with
extremely low bone-mineral density (“T” scores below -3.5),
or those for whom antiresorptive therapies have proven ineffective.10
was elucidated by Shivdasani et. al and was found to involve
several transcription factors including GATA-1 and NF-E2
both of which are needed farther down the line in their development (see Figure 2).16,17 Our laboratory began studying
these mice and then discovered that mice deficient in either
GATA-1 or NF-E2, not only had a phenotype of megakaryocytosis and thrombocytopenia but also developed a high bone
mass phenotype by ~4 months of age.18 In the GATA-1 deficient mice, the numbers of megakaryocytes were increased
from 10-100 fold with an 85% decrease in platelet numbers, while bone volume increased some 3-fold.18 Similarly,
NF-E2 deficient mice have a 2-5 fold increase in the number
of megakaryocytes, 5% of the normal levels of platelets and
a greater than 3-fold increase in bone volume.18 Finally in
2008, mice with a defect in the glycoprotein Ib-IX, which
binds with von Willebrand factor, and lack of which causes a
problem with platelets sticking to damaged endothelium (von
Willebrand’s disease, a bleeding disorder), were also found
to have a phenotype of increased bone mass.19 These murine
models demonstrate an association between megakaryocytosis and increased bone mass, however the question remains:
Does this relationship persist in humans?
Although these therapies have proven to be effective in
increasing bone mass and reducing fractures, there are negative aspects involved with them, leaving room for new treatments as they become available. There exists some exciting
new research revealing an interaction between megakaryocytes and bone density that may lead to novel treatments for
osteoporosis and other diseases of bone metabolism.
Indeed, there are several studies involving humans
showing a similar relationship between megakaryocytes and
increased bone mass. In a study linking osteoporosis with
megakaryocytes, Bord et. al. found that megakaryocyte numbers increased as well as bone mass with high dose estrogen
treatment.20 Similarly, osteosclerosis is observed in myeloproliferative disorders in which megakaryocyte number is
also increased. For example, in idiopathic myelofibrosis,
megakaryocytosis is common and 80% of patients present with osteoslerosis, the remainder usually have findings
of early fibrosis with hypercellularity.21 Although the exact
mechanisms of this interaction are still being ellucidated, research is beginning to reveal some of the details.
Recent research is beginning to reveal a previously unrecognized relationship between megakaryocytes and bone
metabolism that could lead to the development of novel therapeutic options. Consider this: There exist four mouse models
in which increased levels of megakaryocytes and increased
bone density are seen. The first of these is the thrombopoeitin
(TPO, the main megakaryocyte growth factor) over-expressing mouse, discovered in the 1990s.11,12 These mice over-express TPO via either an infection with a retrovirus containing the gene or daily administration of TPO. In addition to
a marked megakaryocytosis, these mice had elevated platelet levels as well as osteosclerosis.13-15 Two of the other four
types of mice have a mutation that disrupts the normal development of megakaryocytes. This pathway of differentiation
from megakaryocyte precursor to terminally differentiated
megakaryocytes with the capability of producing platelets
!"#$%&'$()$%*#
+,'-()%$',
567
!(-*.*,/'0/$(
+,'-()%$',
567
122*$",(
!(-*.*,/'0/$(
In 2004, our laboratory18 and others22 reported on the
interaction between megakaryocytes and osteoblasts. The
results revealed that in vitro, megakaryocytes positively influenced osteoblast development 3-6 fold by a mechanism
requiring cell-to-cell contact.18 As noted earlier, this increase
in osteoblast number was accompanied by a 300% increase
in trabecular bone volume in vivo.18 In short, this data shows
that megakaryocytes have an anabolic effect on bone metabolism. As discussed below, research has revealed that megakaryocytes also act in an anti-resorptive manner.
!*$",(4!(-*.*,/'0/$(
78389:
3(,2%)*##/4!*$",(
!(-*.*,/'0/$(
;59<=
Figure 2. Basic diagram of megakaryocyte development. FOG = friend of GATA, NF-E2 = nuclear factor erythroid 2
26
+#*$(#($>
Indiana Orthopaedic Journal
Volume 3 – 2009
Megakaryocytes: A Novel Treatment for Osteoporosis? (continued)
Evidence has shown that megakaryocytes can affect the
growth and development of osteoclasts by several mechanisms. Megakaryocytes express RANKL, one of the key
factors that promote osteoclastogenesis. In addition, megakaryocytes also express osteoprotegerin (OPG), a decoy protein that binds to RANKL receptors and blocks its activation.
Therefore, megakaryocytes have the potential to inhibit or
promote osteoclast development. In 2006, our laboratory and
others,23,24 reported that megakaryocytes inhibit osteoclast
formation in vitro. In these studies24 we demonstrated that
megakaryocyte conditioned media was able to block osteoclast formation (~10-fold). OPG was also shown not to be
responsible for this inhibition as megakaryocytes from OPGdeficient mice also inhibited osteoclast development. We are
currently working to identify the exact protein causing this
inhibition. It is known not to be among the factors recognized for inhibiting osteoclasts, such as IL-4, IL-10, IL-12,
IL-13, IL-18, interferon gamma (IFN-g), TGFb, GM-CSF,
osteoclast inhibitory lectin (OCIL), calcitonin, amylin, and
calcitonin gene-related peptide.24
In summary, there is growing evidence of the influence
that megakaryocytes have on bone metabolism, an influence
that has both anabolic and anti-resorptive properties (Figure
3). Although the details of this relationship are not yet fully
understood, it is thought that in excess, megakaryocytes can
lead to significantly increased bone mass. The hope is that
one day this research will lead to the development of novel
megakaryocyte-related therapeutic treatment for osteoporosis or other diseases of bone metabolism.
Osteoblast
Osteoblasts
MK
Osteoclast
Osteoclasts
Figure 3. Diagram of the interactions between megakaryocytes and
osteoclasts and osteoblasts demonstrating that the megakaryocyteosteoblast relationship involves cell-to-cell contact while the megakaryocyte-osteoclast relationship involves a secreted protein.
Acknowledgements
The authors wish to thank Dr. Amanda Taylor for reviewing this manuscript. This work was supported in part by
the Department of Orthopaedic Surgery, Indiana University
School of Medicine, by NIH grant AR055269 (MAK), by a
grant from the Ralph W. and Grace M. Showalter Research
Trust Fund, and by a Research Support Funds Grant from
Indiana University Purdue University Indianapolis.
27
References
1.Available at: www.nof.org. Accessed August 12, 2008.
2.Graham RG. Bisphosphonates: Mode of action and pharmacology. Pediatrics. 2007;119:S1
50-S158.
3.Khosla S, Burr D, Cauley J, Dempster DW, Ebeling PR, et al. American Society for Bone and
Mineral Research. Bisphosphonate-associated osteonecrosis of the jaw: Report of a task force of
the American Society for Bone and Mineral Research. J Bone Miner Res. 2007; 22:1479-1491.
4.Mehrotra B, Ruggiero S. Bisphosphonate complications including osteonecrosis of the jaw.
Hematology Am Soc Hematol Educ Program. 2006; 515: 356-60.
5.Chang JT, Green L, Beitz J. Renal failure with the use of zoledronic acid. N Engl J Med. 2003;
349:1676-9.
6.Nasu M, Sugimoto T, Kaji H, Chihara K. Estrogen modulates osteoblast proliferation and
function regulated by parathyroid hormone in osteoblastic SaOS-2 cells: Role of insulin-like
growth factor (IGF)-I and IGF-binding protein-5. J Endocrinol. 2000; 167:305-313.
7.Riggs BL. The mechanisms of estrogen regulation of bone resorption. J Clin Invest. 2000;
106:1203-1204.
8.Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA. 2002; 288:321-333.
9. Vahle JL, Sato M, Long GG, Young JK, Francis PC, Engelhardt JA, Westmore MS, Linda
Y, Nold JB. Skeletal changes in rats given daily subcutaneous injections of recombinant human
parathyroid hormone (1-34) for 2 years and relevance to human safety. Toxicol Pathol. 2002;
30:312-321.
10.Hodsman AB, Bauer DC, Dempster DW, Dian L, Hanley DA, et al. Parathyroid hormone and
teriparatide for the treatment of osteoporosis: A review of the evidence and suggested guidelines
for its use. Endocr Rev. 2005; 26:688-703.
11.Bartley TD, Bogenberger J, Hunt P, Li YS, Lu HS, et al. Identification and cloning of a megakaryocyte growth and development factor that is a ligand for the cytokine receptor mpl. Cell.
1994; 77:1117-1124.
12. de Sauvage FJ, Hass PE, Spencer SD, Malloy BE, Gurney AL, et al. Stimulation of megakaryocytopoiesis and thrombopoiesis by the c-mpl ligand. Nature. 1994; 369:533-538.
13.Villeval JL, Cohen-Solal K, Tulliez M, Giraudier S, Guichard J, et al. High thrombopoietin
production by hematopoietic cells induces a fatal myeloproliferative syndrome in mice. Blood.
1997; 90:4369-4383.
14.Yan XQ, Lacey D, Fletcher F, Hartley C, McElroy P, et al. Chronic exposure to retroviral
vector encoded MGDF (mpl-ligand) induces lineage-specific growth and differentiation of megakaryocytes in mice. Blood. 1995; 86:4025-4033.
15.Yan XQ, Lacey D, Hill D, Chen Y, Fletcher F, et al. A model of myelofibrosis and osteosclerosis in mice induced by overexpressing thrombopoietin (mpl ligand): Reversal of disease by bone
marrow transplantation. Blood. 1996; 88:402-409.
16.Shivdasani RA, Fujiwara Y, McDevitt MA, Orkin SH. A lineage-selective knockout establishes the critical role of transcription factor GATA-1 in megakaryocyte growth and platelet development. EMBO J. 1997; 16:3965-3973.
17.Shivdasani RA, Rosenblatt MF, Zucker-Franklin D, Jackson CW, Hunt P, et al. Transcription factor NF-E2 is required for platelet formation independent of the actions of thrombopoietin/
MGDF in megakaryocyte development. Cell. 1995; 81:695-704.
18.Kacena MA, Shivdasani RA, Wilson K, Xi Y, Troiano N, et al. Megakaryocyte-osteoblast
interaction revealed in mice deficient in transcription factors GATA-1 and NF-E2. J Bone Miner
Res. 2004; 19:652-660.
19.Suva LJ, Hartman E, Dilley JD, Russell S, Akel NS, et al. Platelet dysfunction and a high bone
mass phenotype in a murine model of platelet-type von willebrand disease. Am J Pathol. 2008;
172:430-439.
20.Bord S, Vedi S, Beavan SR, Horner A, Compston JE. Megakaryocyte population in human bone marrow increases with estrogen treatment: A role in bone remodeling? Bone. 2000;
27:397-401.
21.Thiele J, Kvasnicka HM, Fischer R. Histochemistry and morphometry on bone marrow biopsies in chronic myeloproliferative disorders - Aids to diagnosis and classification. Ann Hematol.
1999; 78:495-506.
22.Miao D, Murant S, Scutt N, Genever P, Scutt A. Megakaryocyte-bone marrow stromal cell
aggregates demonstrate increased colony formation and alkaline phosphatase expression in vitro.
Tissue Eng. 2004; 10:807-817.
23.Beeton CA, Bord S, Ireland D, Compston JE. Osteoclast formation and bone resorption are
inhibited by megakaryocytes. Bone. 2006; 39:985-990.
24.Kacena MA, Nelson T, Clough ME, Lee SK, Lorenzo JA, Gundberg CM, Horowitz MC.
Megakaryocyte-mediated inhibition of osteoclast development. Bone. 2006; 39:991-999.
25.“Bisphosphonates”. Available at: http://en.wikipedia.org/wiki/Bisphosphonate. Accessed July
15, 2008.
Indiana Orthopaedic Journal
Volume 3 – 2009
Osteogenic Effects of Preparations of Rat Pulmonary Alveolar
Macrophages Challenged with Staphylococcus Aureus
Russell D. Meldrum M.D., Umut A. Gurkan Ph.D., Seema A Kattaya M.S., Ozan Akkus Ph.D.
Department of Orthopaedic Surgery – Indiana University School of Medicine – Indianapolis, Indiana, USA
Weldon School of Biomedical Engineering — Purdue University – West Lafayette, Indiana, USA
Introduction
Methods
Infection of a surgical or traumatic wound is one of the
most common complications associated with elective and
trauma surgery because of the inherent bacterial skin colonization that may inoculate deep bone and tissue when there is
a break in the skin. Under the right conditions normally docile bacterial whose growth are normally kept in check may
proliferate until there may be damage to the local soft tissues
and bone (even expedite death). This damage can be aided
with the right metabolic requirements for bacterial growth,
the host’s impaired ability to fight infections, impaired vascularity to deliver antibiotics, and the lack of skin coverage
allowing continued colonization. An infection with normal
skin flora, occurring at either a fracture or orthopedic prosthesis, may prevent or impair healing leaving the prosthesis
loose and or the fracture ends atrophic.1 In either case, the
remaining bone will resorb due to a variety of mechanical
and physiologic causes expediting its failure.
Staphylococcus aureus obtained from ATCC (Bacteria:
ATCC 6538PNA Staphylococcus aureus, Manassas, VA) and
Macrophages (ATCC CRL-2192, Manassas, VA). Bacteria
were cultured overnight (tryptic soy broth 12114-05, Mobio,
Carlsbad, CA) ), collected at a concentration of 108 cells/ml,
heat killed at 65˚C, cooled to room temperature and centrifuged at 3000g for 5 minutes. rMSC (ATCC 30-2004 F-12K
Medium [Kaighn’s Modification of Ham’s F-12 Medium], St.
Louis, MO) media was added onto the pellet, sonicated and
vortexed 5 cycles, centrifuged, fresh rMSC media was added
onto the pellet and resuspended preserving the initial concentration. The macrophages were seeded onto 24-well plates
supplemented with modified Ham’s F12K medium and 15%
heat inactivated fetal bovine serum. Half of the macrophage
cultures were supplemented with 50ml/well of the bacterial
preparation explained above and retained for 6 and 72 hours
(Bac/Mac). The other half was not supplemented with bacterial preparation (Mac). After 6 and 72 hours, the media was
removed from the wells, centrifuged at 125g for 5 minutes
and the supernatant was collected and stored at -80˚C before
being applied to the rMSC cultures. rMSCs were obtained
from marrow aspirated from the femurs and tibiae of 60 days
old male Long-Evans rats (Harlan, Indianapolis, IN) and subcultured 4 to 7 times before being used in osteogenic assay.
MSC media was composed of a-MEM supplemented with
10% FBS, 2 mM L-Glutamine, 100 U/ml Pen-strep, 1.5mg/ml
Fungizone, 10 mM b-glycerophosphate and 50mg/ml ascorbic acid. A total of five groups were employed: 1) rMSCs
without any factors, 2&3) rMSC media supplemented with
10% (v/v) Bac/Mac preparation collected after 6 hours or 72
hours, and 4&5) rMSC media supplemented with 10% (v/v)
Mac preparation collected after 6 hours or 72 hours. Alkaline phosphatase assay and Von Kossa (von Kossa: 2% silver
nitrate [sigma 239139] in 1x PBS, St. Louis, MO) mineralization assay were performed in order to test the osteogenic
differentiation of rMSCs and to assess the endpoint mineralization, respectively. Significance of differences was assessed
by Kruskal Wallis followed by post hoc Mann Whitney U test
at (p < 0.050).
However, in some instances, and for an unknown reason,
extra skeletal osseous formation and remodeling may occur.
This change in skeletal geometry is typically a hallmark of a
deep infection or osteomyelitis. Therefore the same organism in on instance will cause new bone to be formed and in
the other old bone will resorb. Though reports demonstrated
that there is a macrophage mediated osteogenic effect which
ceases to exist upon proinflammatory stimulus by way of introduction of bacterial Lipopolysaccharide (LPS), a molecule
typically found in the wall of gram negative bacteria.2 Lipopolysaccharide has limited clinical significance since most
of the infections do not come from gram negative bacteria,
but from gram positive bacteria and mainly the Staph and
Strep species. Because of the questionable utility of previous
studies, further validation is necessary to validate the earlier
reports by bacterial strains that are relatively more clinically
relevant.
The purpose of this study was to measure the effect of
a clinically important infectious agent (staphylococcus aureus) on in vitro ossification by using rat pulmonary alveolar
macrophages and then applying the products to rat marrow
stromal cell cultures (rMSCs) and assessing the osteogenic
response. To do this we measured Von cossa staining and alkaline phosphatase at 6 and 72 hours after a mixture of staph
and inoculation a culture of macrophage and added variables
of nutrition and cell wall.
Results
Alkaline phosphatase assay at day 14 indicated that
MSCs supplemented with the MAC preparation had a sig-
28
Indiana Orthopaedic Journal
Volume 3 – 2009
Osteogenic Effects of Preparations of Rat Pulmonary Alveolar Macrophages
Challenged with Staphylococcus Aureus (continued)
nificantly greater activity than the control group both at 6 hr
and 72 hr time points. (Figure 1) Of the two Bac/Mac groups,
72h group had greater amount of alkaline phosphatase activity. Von Kossa mineralization assay (day 21) indicated that
MSCs supplemented with Mac preparations at both time
points had significantly greater mineralization than the control group. (Figures 2 & 3) The MSC cells supplemented with
Bac/Mac preparation did not induce a statistically significant
osteogenic response on the MSCs as per Von Kossa mineralization assay on day 21. (Figure 2)
Discussion
The results of this preliminary study suggest that rat pulmonary alveolar macrophages induce osteogenic response on
the rat MSCs. However, this osteogenic effect on rat MSCs is
inhibited with the addition of staphylococcus aureus. These
findings validate the previous work by Champagne et al.2
The results also establish a time table for inhibition such that
the osteogenic effect of macrophages emerges as soon as 6
hours and persists for up to 72 hours. While there was a trend
for a temporal reduction in osteogenicity by macrophages,
the number of samples per group did not provide sufficient
power; therefore, current results need to be supplemented
with further samples. It was also observed that Bac/Mac-72hr
group had greater alkaline phosphatase activity than controls,
which suggest that the inflammatory effect subsides by 3
days. It is also likely that Bac/Mac-72hr group had undergone osteoblastic differentiation in a delayed manner and it
may be possible that a time point later than 72hr may display
increased mineralization. Future studies will assess longer
time durations to assess full recovery from this osteogenic
inhibition.
Figure 1. Alkaline phosphatase assay on the 14th day.
Figure 2. Von Kossa mineralization assay on the 21st day.
(Brackets connecting individual groups indicate statistical
significance less than 0.05, n=4)
Conclusion
From the results included here we were able to conclude
that rat pulmonary alveolar macrophages induce osteogenic
response on the rat MSCs. Also, when rat pulmonary alveolar macrophages are challenged by Staphylococcus Aureus,
they fail to induce a statistically significant osteogenic response on rat MSC. Lastly, Staphylococcus aureus inhibits
macrophagemediated osteogenic effects in a time-dependent
fashion.
29
Figure 3. Typical wells with mineralized rat marrow cells.
References
1.Zych GA, Hutson JJ Jr. Diagnosis and management of infection after tibial intramedullary
nailing. Clin Orthop. 1995; 315:153-62.
2. Champagne CM, Takebe J, Offenbacher S, Cooper LF. Macrophage cell lines produce osteoconductive signals that include bone morphogenetic protein-2. Bone. 2002; 30:26-31.
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of Radiographic Measurements at the
Craniocervical Junction to Predict Spinal Cord Compression
in Patients with Rheumatoid Arthritis
Creso Bulcao, M.D. and John P. Lubicky, M.D.
Department of Orthopaedic Surgery – Indiana University School of Medicine – Indianapolis, Indiana, USA
Investigation performed at:
Faculdade de Medicina da USP
Instituto de Ortopedia e Traumatologia
-IOT- FM-HC-FMUSP
Rua Dr. Ovidio Pires de Campos, 333, Setimo Andar,
Sao Paulo- SP- Brasil- CEP: 05403-000
Phone: 55+11+3069-6950
Web site: www.hcnet.usp.br/iot
Corresponding Author:
John P. Lubicky, M.D.
Riley Hospital for Children
702 Barnhill Dr., ROC 4250
Indianapolis, IN 46202
Phone: 317 274-1174
Fax: 317 274-7197
Email: [email protected]
Abstract
Study Design: This is a six year prospective study.
Objective: To determine if the radiographic indices of Ranawat
and Redlund-Johnell as measured on cervical spine radiographs
in patients with rheumatoid arthritis when correlated with clinical assessment were reliable predictors of spinal cord damage and
resultant neurologic impairment.
Background: A number of radiographic measurements have been
used to evaluate and monitor the stability, alignment, space available for the cord and position of the craniocervical junction. MRI
has added additional information about the neural tissues in that
area of the cervical spine.
Method: Clinical assessment of cervical pain, overall function,
neurological status and radiographic analysis of the cervical spine
at the craniocervical and subaxial levels were performed in patients with rheumatoid arthritis. This data was collected prospectively over a period of six years at which point various variables
were compared within and among groups and at different time
periods.
Results: The number of patients as well as the severity of
abnormalities present at the start of the study compared to the end
was noted to be statistically significant. Additionally, a relationship between the neurological deterioration and the radiographic
indices of Ranawat and Redlund-Johnell were also found to be
statistically significant.
Conclusion: Deteriorating functional and neurologic status
and the presence of cervical pain were associated with Rana-
wat and Redlund-Johnell indices of less than or equal to 26.25
mm and 13.25 mm respectively. Prophylactic measures/treatment are indicated, however, only when the clinical and radiographic abnormalities are both present. But critical radiographic
index measures are predictive of future or impending neurologic
abnormalities.
Introduction
The concern that stimulated
this study was that despite close
follow-up, some patients with rheumatoid arthritis and problems at the
craniocervical (C-C) junction, an
anatomic area encompassing very
important skeletal and neurologic
structures (Figure 1), were diagnosed with neurologic compromise
at a point at which cervical stabilization and/or decompression did not
result in neurological improvement.
Axial instability, basilar invaginaFigure 1: Drawing
tion, subaxial subluxation, myelof the anatomy of the
opathy, radiculopathy, and cervical
craniocervial junction
pain are examples of problems that
occur in these patients. Although
not entirely preventable, if these issues could be detected and addressed at an earlier stage using objective measures that indicated
impending neurologic abnormality, then appropriate measures
could be taken to prevent further functional neurologic loss of
function. This study evaluated two radiographic indices measured
at the C-C junction and atlantoaxial (A-A) junction that can be
used as predictors of impending neurologic deficit. The subaxial
region was also evaluated, but the focus was on the C-C area. The
impact of a variety of complications due to the natural course of
the disease, while not preventable, can be minimized through
early diagnosis and the use of a number of medical and surgical
interventions. Serious neurologic complications that occur at the
C-C junction, although rare, are disabling and sometimes life threatening
and require prompt and aggressive
treatment.
Previous studies have addressed
the abnormalities of the C-C junction
and described methods of evaluating
the anatomy and abnormalities of it.
(Figure 2). Rana et al1 studied the
C1-C2 horizontal (atlanto-dens interval, ADI), and using the McGregor
Line as a reference visualized the po30
Figure 2: Drawing of
landmarks for various
measurements
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of Radiographic Measurements at the Craniocervical Junction to Predict
Spinal Cord Compression in Patients with Rheumatoid Arthritis (continued)
sition of the tip of the odontoid process (the vertical subluxation).
Dvorak et al2 used radiographs and MRI to study the upper cervical
spine in the neutral and flexed positions looking for predictors of
neurologic complications based on changes of alignment and also
the ratio between the spinal diameter and the spinal cord. Floyd et
al3 also studied the horizontal and vertical migration of the C1-C2
complex by using the McGregor Line. Barros Filho et al4 studied
the occipital cervical junction and demonstrated a preference for
use of the Ranawat and Redlund-Johnell methods (Figures 1 &
2) in patients with rheumatoid arthritis instead of other methods
because of the difficulty in visualizing certain landmarks, e.g., the
digastric line of Fischgold and Metzer on the transoral view. They
also took issue with the MacRae and Chamberlain lines (Figure
3) for similar reasons. Lastly, Barros Filho et al5 noted difficulties with the MacRae and Chamberlain lines (Figure 3) due to the
difficulty in visualizing the posterior margins of the foramen magnum on the lateral views of the cervical spine. They concluded
that methods that do not require the direct visualization of the tip
of the odontoid process, e.g., Redlund-Johnell and Ranawat are
generally more reliable for the study of patients with rheumatoid
arthritis with cervical spine involvement. Boden6 studied the posterior space between C1 and C2 in a lateral view of the cervical
spine concluded that, when this distance was less than 14 mm, the
likelihood of neurologic compromise was increased. Kuhr et al7
and Sunahar et al8 also made similar observations about the C-C
complex.
Figure 3a: Ranawat
measurement
Figure 3b: RedlundJohnell measurement
The hypotheses of this study is that there are radiographic
measures or indices that could be predictive and/or confirmatory
of neurologic deterioration at the C-C junction due to abnormalities at a time at which cervical intervention could stabilize or improve neurologic function.
sent about the purpose, risks, limitations, and their responsibilities
of commitment to the study and were required to sign the consent
form.
The following methodologies were used in the clinical and
radiographic analyses.
Functional Classification as described by Steinbrocker et
al10: Class I – Normal (perform all daily activities including self
care, housekeeping, transportation, etc. without any limitation or
difficulty); Class II – Adapted (perform activities with limitation
or difficulty); Class III – Limited (incapable of performing some
activities); Class IV – Wheelchair or Bedridden. Neurological status was graded using the system of Ranawat et al11 which was
modified: Grade 0 – Normal; Grade 1 – Slightly increased reflexes
(3+) and/or sensory alternations (paresthesias); Grade 2 – Light
motor paresis (motor strength 3 or 4); Grade 3 – Moderate or serious paresis (motor strength 1 or 2). This neurologic classification
was adopted because of its use in multiple other studies previously
published. The modified version is more easily reproducible and
simpler to apply.
Radiographic examination of the C-C, A-A, and subaxial cervical spine was performed in all patients. With regard to the upper
cervical spine, plain radiography lateral views in neutral and flexion were performed. The flexion view was utilized for the assessment of C1-2 instability. The neutral view demonstrated vertical
subluxation of the C1-2 complex through the use of the Ranawat
and Redlund-Johnell methods.
The actual mechanics of measuring these indices are as follows: (1) Ranawat- In the lateral view of the cervical spine a line
is draw from the center of the sclerotic ring (lateral image of the
pedicles of the Axis) to another line that goes from the midpoint of
the anterior and posterior arches of the Atlas (Figure 3a). (2) Redlund-Johnell- In the lateral view of the cervical spine a line is draw
parallel to the inferior cortical of the body of the Axis. From this
line a perpendicular line should intersect a line drawn between the
inferior aspect of the occiput and the hard palate (Figure 3b). Both
these methods do not rely on the visualization of the tip of the
odontoid process, sometimes very hard to see in osteopenic and
vertically migrated patients. Also the utilization of these methods
makes the measurement feasible with plain radiographs.
Consecutive patients meeting the two inclusion criteria which
were (1) sero-positive evidence of the diagnosis of rheumatoid
arthritis and (2) a complete prospectively collected series of radiographs, compose the basis of this study. They were then all followed for a period of six years at which time final evaluation was
performed. All the patients were followed and treated at one institution by one of us (CB). Clinical examinations were performed in
each and every case personally by that same author. Radiographic
exams were personally supervised by one of us (CB) who assisted
in positioning the patients in a standard manner to ensure that adequate radiographs were obtained at every point of evaluation.
The subaxial region was studied with lateral views in neutral
and flexed position of the cervical spine as well. Other parameters
measured were the interlaminar angle (which should not be greater
than 11 degrees in the adult) and the interlaminar distance (which
should not be greater than 3.5 mm).13 The degenerative changes
present at the lower cervical spine (subaxial levels) were also
studied using guidelines proposed by Rahim and Stambough.14 All
radiographic exams were made in the same institution and under
standardized conditions. The radiographic technique consisted of
60 kv of penetration with 8 miliamperes of contrast. The distance
between the patient and the x-ray source was 1.2 meters and the
equipment had a total potency of 500 miliamperes. All exams
were performed on either one of two similar units in the same
department of radiology.
The study was approved by the Ethics Commission of the
Institution and every patient were provided with an informed con-
Clinical assessment for the presence of cervical pain was performed in all 40 patients at the beginning and the end of the study
Methods
31
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of Radiographic Measurements at the Craniocervical Junction to Predict
Spinal Cord Compression in Patients with Rheumatoid Arthritis (continued)
using a measure where the patient simply indicated whether they
had neck pain or not. Typically pain waxed and waned from day
to day and was worse some days than others but no standardized
metric was used to quantify it.
Statistical analysis was performed by a university-based consultant statistician who assigned a level of significance for all test
as p<0.05. Initially, all variables were evaluated in a descriptive
way. For continuous variables the mean, standard deviation and
median were calculated. The comparison between the initial and
final radiographic indices was done by the Wilcoxon test because
the hypothesis of normality (i.e., that the value would be the same
at the end of the study) was refuted. The comparison between the
number of patients with radiographic subaxial parameters and
axial index as well with laboratory essay for rheumatoid factors
and clinical outcomes like cervical pain was performed with the
Mc Nemar test. The comparison between the Redlund-Johnell
and Ranawat (axial index) in patients with and without neurologic abnormality was done by the ANOVA (analysis of variance)
test. Fisher’s exact test was used when comparison between the
number of patients with radiographic alternations (either axial or
subaxial) were cross examined with those with and without neurological alterations at the end of the study.
Results
Forty patients meeting the two inclusion criteria were enrolled in the study. The study group consisted of 37 females and
3 males. Their ages range from 30 to 74 years with a mean of approximately 50 years.
Functional Status – There was a deterioration of the functional status of the patients over the period of study. At the beginning of the study most of the patients were concentrated in
functional Classes I and II. At the end of the study most study
patients were concentrated in Classes II and III. No patient moved
to functional Class IV. The number of patients in each category
at the start of the study versus the end of study was found to be
statistically significant (p=0.0006). (Table 1)
Table 1
Functional Status — Initial and Final by Class
Time
Class I
Class II
Class III
Class IV
Initial
14/40 (35%) 23/40 (57%) 03/40 (08%) 0
Final
04/40 (10%) 25/40 (63%) 11/40 (27%) 0
Mc Nemar
p = 0.0006
Neurologic Status – No patient had neurologic compromise
at the beginning of the study. At the end of the study 4/40 (10 %)
presented with changes as follows: paresis of the upper limbs (2),
quadriparesis (1), and hyperreflexia (1). These patients were classified according to the Ranawat classification as Grade 1 (1), and
Grade 2 (3). The number of patients with and without neurologic
changes at the beginning versus the end of the study was statistically significant. (p<0.001) (Table 2).
Radiographic – Comparison of radiographic features of the
Table 2
Time
Normal Neurologic Exam
Abnormal Neurologic Exam
Initial
40/40 (100%)
00/40 (0%)
Final
36/40 (90%)
04/40 (10%)
Mc Nemar
p < 0.001
C-C, A-A and subaxial areas of the cervical spine between the
initial and final evaluations demonstrated a statistically significant
change in all parameters studied. (Table 3) Comparing the number
of patients with abnormal radiographic parameters at the beginning and at the end of the study was found to be statistically significance in all parameters. (Table 4)
Table 3
Radiographic Measures
Radiographic
Initial
Final
Parameters
ADI
2.88 +/- 1.92 4.00 +/- 2.11
Interlaminar angle
8.94 +/- 3.40 10.82 +/- 3.51
Interlaminar distance 2.08 +/- 0.91 2.68 +/- 0.90
Ranawat Index
17.27 +/- 2.65 16.12 +/- 2.88
Redlund-Johnell Index 37.80 +/- 5.79 36.10 +/- 5.86
Ref. Values
Male/Female
4.0 mm
< 11˚
< 3.5 mm
> 13 mm
> 34 mm,
> 29 mm
Wilcoxan
p < 0.001
p = 0.013
p < 0.001
p < 0.001
p < 0.001
Table 4
N Patients
with Abnormal Radiographic Changes
Radiographic
Initial
Final
Parameters
ADI
08/40 (20%) 13/40 (33%)
Interlaminar angle
08/40 (20%) 17/40 (43%)
Interlaminar distance 02/40 (5%)
06/40 (15%)
Ranawat Index
02/40 (5%)
03/40 (8%)
Redlund-Johnell Index 04/40 (10%) 06/40 (15%)
Mc Nemar
p = 0.012
p < 0.001
p < 0.001
p < 0.001
p = 0.178
Two additional comparisons were made: functional status
versus radiographic parameters and neurologic status versus radiographic parameters. In the latter there was a statistically significant correlation (p=0.035) for the Ranawat measure and for the
Redlund-Johnell index (p<0.001). (Table 5) When the functional
status at the end of the study was assessed and correlated with
radiographic parameters (A-A indices) it was found that patients
classified as functional Class I had a mean of 16.5 mm and 40.25
mm for the Ranawat and Redlund-Johnell indices, respectively.
Patients with functional Class II had a mean of 15.66 mm and
Table 5
Neurological Exam Results – Final
Ranawat Index
Redlund-Johnell Index
Normal
16.44 mm
37.19 mm
Abnormal
13.25 mm
30.75 mm
ANOVA
p = 0.035
p < 0.001
32
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of Radiographic Measurements at the Craniocervical Junction to Predict
Spinal Cord Compression in Patients with Rheumatoid Arthritis (continued)
ognized that the disease has progressed to reveal these abnormal
radiographic indices, the risk of neurologic compromise is likely
and needs attention.
Table 6
Final Functional Status
Ranawat Index
Redlund-Johnell Index
Class I
16.50 mm
40.25 mm
Class II
15.66 mm
36.50 mm
Class III
11.00 mm
32.00 mm
36.50 mm, respectively. Finally, Class III patients had a mean of
11.00 mm and 32.00 mm, respectively. No patient progressed to
Class IV. (Table 6) These results clearly indicate that as the radiographic indices worsen as indicated by smaller numbers for the
A-A indices indicating vertical subluxation or basilar invagination,
there is also worsening in the functional status of the patients.
Cervical pain was more commonly found at the end of the
study. (Table 7) Initially 17/40 (43%) of patients had complaints
of cervical pain and 23/40 (57%) had no complaints. At final follow-up cervical pain was reported by 33/40 (82%) of the patients
with only 7/40 (18%) free of symptoms.
Table 7
Cervical Pain
Yes
No
Initial
17/40 (43%)
23/40 (57%)
Final
33/40 (82%)
07/40 (18%)
Discussion
This study shows that clinical outcome, i.e., functional and
neurologic status, was consistently related to radiographic changes observed in the cervical spine in patients with rheumatoid arthritis. Assessment of cervical pain indicated an overall progression with time indicated by an overwhelming majority of patients
having pain at the end of the follow-up period. Thus, the results
confirm the importance of follow-up and close observation and
early recognition of radiographic changes and the application of
radiographic indices to predict neurologic outcome. The hypothesis that radiographic indices can be used as an indication for
prophylactic/therapeutic intervention was confirmed. The authors
specifically note that neurologic status along with radiographic
parameters of Redlund-Johnell and Ranawat indices of 26.25 mm
and 13.25 mm or less respectively in association with progressively worsening neurologic examinations should indicate the
need for surgical intervention involving either the C-C junction or
the A-A level or both depending on the specific type of structural
deformity observed before a greater or perhaps permanent neurologic impairment occurred. Comparison of the variables analyzed in this study found both statistical and clinical significance
when examining these measures. The authors want to stress that
the decision for surgical treatment should not necessarily be based
solely upon radiographic parameters. While the radiographic indices and abnormal range should alert the physician to pending
problems they must be viewed in association with clinical findings as well. Surgical procedures have significant potential risk
especially those in the upper cervical spine and the C-C junction,
so the indications for surgery must be very clear. But once it is rec33
In comparison to other publications this study has longer
follow-up than most, however, many other authors have reached
similar conclusions. On the other hand several authors disagree.
Floyd et al3 investigated a large number (N=250) of randomly selected patients and studied the horizontal and vertical subluxation
of the C1-2 complex. They noted no increase in neurologic deterioration in patients with instability at the C1-2 level. The authors
of this study believe that it is based on a reasonable sample with
good follow-up and describes use of radiographic indices which
reflect relevant clinical changes. Additionally, the present study
correlates various data, e.g., functional status versus radiographic
changes; neurological function versus radiographic changes;
etc. and also views this information at different time points. A
limitation of this study is that MRI was not available for all patients when this study was done in the institution where it was
performed, therefore neural tissue changes as well as soft tissue
disease around the odontoid could not be directly visualized. This
data might also be helpful in correlative analyses with the radiographic parameters. (Figure 4) Since the target organ of rheumatoid arthritis is the synovium, pannus, or synovial hyperplasia
around the odontoid could certainly decrease the space available
for the cord at that level. In sumFigure 4:
mary, using the radiographic indices
MRI image of
of Ranawat and Redlund-Johnell are
craniocervical
helpful when combined with clinical
junction
evaluation to confirm the need for
intervention to prevent worsening
neurologic function in rheumatoid
arthritis of the cervical spine.
References
1.Rana NA, Hencock DO, Taylor AR, Hill AGS. Upward dislocation of the dens in rheumatoid
arthritis. J Bone Joint Surg Br. 1973; 55:471-7.
2. Dvorak J, Grob D, Baumgartner H, Gschwend N, Grauer W, Larsson S. Functional evaluation of the spinal cord by magnetic resonance imaging in patients with rheumatoid arthritis and
instability of upper cervical spine. Spine. 1989; 14:1057-64.
3. Floyd AS, Learmonth ID, Meyers OL. Atlantoaxial instability and neurological indicators in
rheumatoid arthritis. Clin Orthop. 1989; 241: 177-82.
4. Barros Filho TEP, Hasegawa OH, Carneiro JF. Parametros para avaliacao das radiografias da
transicao occipitocervical. Fol Ortop Traumatol. 1991; 10:5-8.
5. Barros Filho TEP, Oliveira RP, Rodrigues NR, Greve JMD, Laurindo IMM, Pereira RMR,
Cossermelli W. Alteracoes radiograficas da coluna cervical na artrite reumatoide. Rev Bras
Ortop. 1992; 26: 349-51.
6. Boden SA. Rheumatoid arthritis of the cervical spine. Surgical decision making based on predictors of paralysis and recovery. Spine. 1994; 19: 2275-80.
7. Kuhr M, Hohmann D, Schramm M, Martus P. Radiographic evaluation of upper cervical
spine in rheumatoid arthritis: a retrospective study. Euro Spine. 1996; 5:107-11.
8. Sunahara N, Matsunaga S, Mori T, Jiri K, Sakou T. Clinical course of conservatively managed rheumatoid arthritis patients with myelopathy. Spine. 1997; 22: 2603-07.
9. Yonezawa K, Konyu T, Takahoski HE. Progression of rheumatoid arthritis of the cervical
spine: radiographic and clinical evaluation. Spine. 1999; 20: 208-15.
10. Steinbrocker O, Traeger CH, Battterman RC. Functional classification of patients with rheumatoid arthritis. JAMA. 1949; 140: 659-62.
11. Ranawat CS, Pellicci P, Tsairis P, Bryan WJ. A prospective study of the progression of rheumatoid arthritis of cervical spine. J Bone Joint Surg Am. 1981; 63: 342-50.
12. Redlund-Johnell I, Peterson H. Radiographic measurements of the cranio-vertebral region.
Acta Radiol Diagn. 1984; 25: 23-8.
13. White AA, Panjabi MM. Clinical instability in the lower cervical spine. Spine. 1976; 1:
15-26.
14. Rahim KA, Stambough JL. Radiographic evaluation of degenerative cervical spine. Ortho Clin
N Am. 1992; 23: 395-403.
15. Rosner B. Fundamentals of Biostatistics. Boston, MA: PWS; 1986, ed. 2.
Indiana Orthopaedic Journal
Volume 3 – 2009
Pedicle Screw Fixation for the Surgical Treatment
of Canine Traumatic L7 Fracture-Dislocation:
A Clinical Report
Rick C. Sasso, M.D., W. David Min, M.D., and Richard Sasso, D.V.M.
Sasso Veterinary Hospital — Warsaw, Indiana, USA
• High velocity trauma may cause devastating canine neurologic
injury due to unstable spine fractures.
• Stable internal fixation with a pedicle screw/rod construct can
allow early mobilization and recovery of neurologic function.
Introduction
The use of pedicle screw fixation in the treatment of human spinal
column fracture has been well described in medical literature.1- 3
The primary advantage conferred through the use of pedicle screw
fixation is the ability to obtain extremely strong fixation of each
vertebral segment. The screw passes from the dorsal elements
through the pedicle and anchors into the ventral vertebral body.
The heads of each pedicle screw are connected to a rod, producing extremely rigid constructs with a subsequent higher rate of
successful fusion, while maximizing neurologic recovery. By
stabilizing the spinal fracture the neural structures are protected
while ambulating is allowed. Treatment of canine traumatic spinal injury has revolved around the use of spinous process banding,
Steinman pinning in conjunction with methylmethacrylate, and
percutaneous external stabilization techniques. 4-7 While these
methods have proven to be successful, there is also significant risk
associated with the use of these techniques.8, 9 The application of
pedicle screw fixation in canines is a natural evolution in the treatment of traumatic spinal disorders. However, to our knowledge,
the use of this technique has yet to be described in the literature.
Herein we describe our own experience in the use of pedicle screw
fixation for stabilization of a canine traumatic lumbar fracture.
Case
A one-year-old 43 lb. male Dalmatian was struck by an automobile. The owner noted an immediate inability of the dog to
move his hindquarters. He was taken to a local veterinary hospital
where examination by the senior author revealed a dense cauda
equina injury. The dog was unable to ambulate with profound
weakness of bilateral hind legs. He was able to wag his tail spontaneously, albeit weakly. He had a fair response to deep pain in his
right hind leg with a lesser response in his left hind leg. The dog
had overflow urinary incontinence and had to be assisted to fully
empty his bladder. On palpation, there was a noticeable step‑off
of the spinous processes in the low lumbar region. Examination
revealed no extremity fractures, no intrathoracic or intrabdominal
visceral injuries. He was hemodynamically stable without tachycardia or hypotension.
Plain radiographs of the dog’s lumbar spine revealed a bipedicle fracture of L7 with a traumatic fracture-dislocation of
L6-7 and 100% retrolisthesis of L6. Cephalad displacement of the
L7 vertebral body and pelvis measured approximately 75% of the
Figure 1: Initial x-rays A) Lateral x-ray
of fracture- dislocation of L7. The injury
from ventral to dorsal includes an avulsion fracture of the ventral-caudal body
of L6, the ventral 1/3 of the L6-7 disc,
bipedicle fractures of L7, and continues
through the dorsal element of L7. The L7 vertebral body and attached
sacrum is dislocated ventrally and shortened with the caudal 25% of the
L7 vertebral body at the level of the L6-7 disc. B) Dorsal-ventral x-ray
demonstrating no medial- lateral translation. The pedicles of L6 and L7
are visualized as long and narrow.
length of the L6 vertebral segment. (Figure 1) The mechanism
of injury was likely hyperextension similar to a traumatic spondylolisthesis of C2 (Hangman’s Fracture) in humans. Extension
and distraction of the anterior column causes an avulsion fracture
of the anterior- inferior body of L6 by tension of the anterior annulus of the L6-7 disc. Compression of the posterior elements in
extension results in the pedicle fractures.
A spinal cord injury dose of methylprednisolone was given
for this cauda equina lesion (30mg/kg bolus followed by 5.4 mg/
kg/hr for 23 hours). 10, 11 Minimal improvement of neurologic status occurred by the second post injury week. Due to the dense
cauda equina injury with continued spinal canal compromise secondary to the spinal dislocation, the dog’s owner was given the
option of surgical decompression and stabilization.
The senior author called for the assistance of an orthopaedic
spine surgeon to help with stabilization of the fracture. Given the
nature of the injury, it was felt that adequate reduction of the fracture would be difficult to achieve with conventional canine spinal
surgery techniques due to the degree of dislocation and the amount
of instability present. The orthopaedic surgeon recommended the
use of pedicle screw fixation in conjunction with rods to optimize
stabilization of the fracture. Standard pedicle screw instrumentation systems available for humans would clearly be inadequate,
as the canine pedicle is much narrower than the human pedicle.
As such, 3.5mm titanium with a poly-axial head to attach with
a 3.2-mm rod prototype was chosen. The owners were fully assessed of the difficult and unique unstable fracture with profound
neurologic deficit and the options for treatment. The pedicle offers
the strongest site for anchoring to the vertebrae, but modification
to allow entry into the small canine pedicle was a concern. Based
34
Indiana Orthopaedic Journal
Volume 3 – 2009
Pedicle Screw Fixation for the Surgical Treatment of
Canine Traumatic L7 Fracture-Dislocation: A Clinical Report (continued)
on measurement of the plain x-rays, 3.5mm diameter screws were
found to satisfactorily fit within his L6 & L7 pedicles. The owners
gave informed consent for use of this experimental system.
Procedure
The dog was prepared in sternal recumbency in the standard
fashion. The hair along the dorsal lumbar spine was shaved. The
skin was cleansed using hexachlorophene solution. The animal
was anesthetized using a combination of Ketamine and Rompun
(Xylazine) with maintaince anesthesia including inhaled isoflurane.
The dog’s lumbar spine and sacrum was exposed in the standard fashion through a longitudinal incision. A complete dislocation of the facet complex at L6‑7 was noted. Due to the age of
the injury and the fact that the posterior elements of L7 were not
connected to the vertebral body of L7 due to the bipedicle fracture,
manual reduction of the L7 body was not anatomic. The facet complexes were excised and soft tissue within the facets was removed
in order to allow for better reduction. Furthermore, the ligamentum flavum present within the spinal canal at L7 was removed and
a formal complete dorsal laminectomy of L7 was performed for
decompressive purposes. Profound compression of the dura was
found due to the lamina of L7 as well as the torn, infolded Ligamentum flavum. The dura was not torn. There was no CSF leak.
Excellent cauda equina decompression was obtained. After this
had been completed, manual reduction was again attempted with
better results. However, reduction could not be maintained due
to the tendency of the spine to slip back into a subluxed position.
Gross instability was present.
Figure 2: Intraoperative picture after the dorsal decompression during
insertion of the pedicle screws.
35
The pedicles of L7 and S1 were identified through the
laminectomy defect. 3 The outer cortical bone was removed with
rongeurs until the cancellous bone of the pedicle was identified.
A small hand drill was used to create a pilot hole for the pedicle
screw. The pilot hole was then tapped and a 14mm by 3.5mm titanium poly-axial screw (Vertex reconstruction system: Medtronic
Sofamor-Danek, Memphis TN.) was placed in the bilateral L6
and S1 pedicles. (Figure 2) Similar pedicle screws were placed
in L6 and S2 bilaterally. Longitudinal 3.2mm titanium rods were
placed into the poly-axial screw heads at L6 and L7 and initially
tightened using the locking nut. The lumbar spine was then manually reduced to allow the rod to sit within the screw connectors at
S1and S2. The locking nuts were then applied to the S1 and S2
screws, maintaining reduction of the lumbar spine. (Figure 3)
The surgical field was copiously irrigated and then closed in a
multi-layer fashion. The deep fascia was approximated with 0-Vicryl, the subcutaneous fascia with 00-Vicryl, and the skin with
00-Nylon.
Figure 3: Intraoperative pictures A) after insertion of the right rod.
B) Final construct.
Indiana Orthopaedic Journal
Volume 3 – 2009
Pedicle Screw Fixation for the Surgical Treatment of
Canine Traumatic L7 Fracture-Dislocation: A Clinical Report (continued)
ture dislocation. The popularity of pedicle screw fixation in the
treatment of human thoracolumbar burst fractures is predicated
upon proof of its safety and efficacy with respect to avoidance
of neurologic deterioration and increase in the rate of successful
fusion. The use of similar techniques in canines has not been described in the literature, to the author’s knowledge. Although the
reasons behind the lack of utilization of pedicle screw fixation in
canines are manifold, the primary factors are most likely cost and
lack of instrumentation systems appropriately sized for use in canines. The application of pedicle screw fixation has been used in
several other animal models including sheep and mini-pigs. 12, 13
Figure 4: Postoperative x-rays
A) Lateral x-ray with screws in
the pedicles of L6, the remnants
of the L7 pedicles, and the S1
and S2 pedicles. Direct access
to the L7 body is not possible
through a dorsal approach
due to the bi-pedicle fracture;
however, by manipulating the
sacrum though the S1 and S2
pedicles improved reduction of
the L7 dislocation was accomplished. The cephalad 25% of
the L7 vertebral body is now at
the level of the L6-7 disc.
This is an improvement of
approximately 50 % of the
length of the L7 body.
B) Dorsal-ventral x-ray
demonstrating the final
construct.
Results
Postoperative plain radiographs demonstrate improved sagittal alignment but with continued subluxation present at L6-7.
(Figure 4) The inability to obtain a full reduction at L6-7 was
most likely due to partial healing of the fracture in the subluxed
position and the inability to access the body of L7 through a posterior approach due to fracture at the base of the L7 pedicle-body
junction. Ventral-dorsal radiographs showed normal alignment.
The animal recovered well from surgery and anesthesia.
There were no postoperative complications. The dog had a rapid
improvement in his neurologic status, with significantly improved
strength in his hind legs. At the three-month follow-up from surgery, he was essentially neurologically normal, and completely
regained bladder and bowel control. At six-month follow-up he
had no neurologic deficits and was living a normal life.
Discussion:
This case illustrates the application of a technique commonly
used in treating human thoracolumbar fractures to a canine frac-
In recent years, an advance has been made in human spinal
instrumentation systems with respect to posterior cervical fusions.
That advance has been the development of lateral mass screwrod systems. This technique has been further refined to allow the
placement of poly-axial screws into the cervical lateral mass or
pedicle followed by rigid connection to a rod to achieve a construct strength that is unmatched by other techniques. The screws
provided in these new systems are small enough to be placed within a 4-mm cervical pedicle in humans and are sufficiently small to
be used in dogs. Key features of this system include poly-axial
screws that allow for a greater degree of freedom than uni-axial
screws, in conjunction with a top-loading rod connector. This allows for placement of all screws prior to connection to the rod.
There are three main biomechanical advantages of pedicle
screw fixation over vertebral body fixation. First, the pedicle
screw traverses all columns of the spine allowing for a more rigid
point of fixation than a vertebral body Steinman pin. Second, the
pedicle screws can be rigidly affixed to the longitudinal rod allowing for a much stiffer construct than a Steinman pin/methylmethacrylate construct. Finally, in cases such as the one presented
where alignment is difficult to maintain, the instrumentation system can be used to reduce a fracture manually and to maintain that
reduction.
Studies have previously demonstrated no long-term outcome
difference in canines with spinal fractures and spinal cord injuries that were treated surgically as compared to those treated nonsurgically. However, these same studies also acknowledge that
the surgically treated animals in general had more severe injuries.
Furthermore, the surgically treated animals showed more rapid
return of neurologic function as compared to the non-surgical
cohort. In this case functional neurologic recovery of the cauda
equina injury can be predicted by spinal canal decompression
followed by rigid stabilization to allow protection of the neural
elements. Placing screws into the remnants of the L7 pedicles
and rigidly fixing to L6 above and the sacrum below successfully
instrumented this very unstable fracture- dislocation of L7.
One final factor to consider when choosing a treatment methodology for canine spinal fractures is cost. Most of the fixation
techniques previously described in the literature utilized relatively
inexpensive equipment. The cost of the titanium implants that
were used to treat the described fracture is significantly more
expensive. Ultimately, the difference in cost may prohibit widespread application of this technique. However, in select situations
with select fractures, the use of pedicle screw fixation may be not
just an attractive option but also the only reasonable option.
36
Indiana Orthopaedic Journal
Volume 3 – 2009
Pedicle Screw Fixation for the Surgical Treatment of
Canine Traumatic L7 Fracture-Dislocation: A Clinical Report (continued)
References
Conclusion
Pedicle screw fixation for stabilization of a canine lumbar
fracture- dislocation was a safe and effective technique in this
case. This new type of spinal fixation has advantages over other
methods of stabilization including the ability to reduce and maintain reduction in severely displaced fractures as well as increasing
the overall increased strength of the construct. As more instrumentation systems become available for humans, the cost of the materials should decrease, thereby making widespread use in animals
more feasible. Additional clinical investigation of pedicle screw
fixation for unstable canine fractures is required before routine
utilization.
37
1.Sasso RC, Cotler HB: Posterior instrumentation and fusion for unstable fractures and fracturedislocations of the thoracic and lumbar spine: A comparative study of three fixation devices in 70
patients. Spine. 1993;18:450-460.
2. Sasso RC, Cotler HB, Reuben JD: Posterior fixation of thoracic and lumbar spine fractures using
DC plates and pedicle screws. Spine. 1991; 16:S134-S139.
3. Sasso RC, Cotler HB, Thalgott JS: Transpedicular Fixation with AO Dynamic Compression Plates.
In An HS, Cotler JC, eds: Spinal Instrumentation, pp. 257-280. Williams & Wilkins, Baltimore, MD,
1992.
4. Bagley RS. Spinal fracture subluxation. Vet Clin North Am Small Anim Pract. 2000; 30:33-53.
5. Bruecker KA, Seim HB 3rd. Principles of spinal fracture management: Sem Vet Med Surg (Small
Anim). 1992; 7(1); 71-84.
6. Kirby BM. Spinal fracture/luxation. Vet Clin North Am Small Anim Pract. 1995; 25(5): 1149-74.
7. Selcer RR, Bubb WJ, Walker TL. Management of vertebral column fractures in dogs and cats; 211
cases (1997-1985). J Am Vet Med Assoc. 1991; 198(11); 1965-8.
8. Ludders JW, Ekstrom PM, Linn KA. Anesthesia case of the month. Complications during spinal
surgery for a spinal fracture in a dog. J Am Vet Med Assoc. 1998; 213(5); 612-4.
9. Olmstead Ml. Fracture complications. An overview. Vet Clin North Am Small Anim Pract. 1991; 21(4):
641-6.
10. Bracken MB, et al: A randomized, controlled trial of methylprednisolone or naloxone in the treatment
of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J
Med. 1990; 322: 1405-11.
11. Coleman WP, Benzel E, Cahill DW, Ducker T, Geisler F, Green B, Gropper MR, Goffin J, Madsen
PW, Maiman DJ, Ondra SL, Rosner M, Sasso RC, Trost GR, Zeidman S: A critical appraisal of the
reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute
spinal cord injury. J Spinal Disord. 2000; 13: 185-199.
12. Christensen FB, Dalstra M, Sejling F, Overgaard S, Bunger C: Titanium-alloy enhances bonepedicle screw fixation: Mechanical and histomorphometrical results of titanium-alloy versus stainless
steel. Europ Spine J. 2000; 9: 97-103.
13. Rocca M, Fini M, Greggi T, Parisini P, Carpi A, Giardino R: Biomaterials in spinal fixation. An
experimental animal study to improve the performance. Intl J Artificial Organs. 2000; 23: 824-30.
Indiana Orthopaedic Journal
Volume 3 – 2009
Case Report: Porous Tantalum Augment Used
To Address Significant Glenoid Deficiency in
Revision Total Shoulder Arthroplasty
Vivek Agrawal, M.D.
The Shoulder Center – Zionsville, Indiana, USA
Correspondence:
Vivek Agrawal, MD
The Shoulder Center
10801 N. Michigan Road,
Suite 100
Zionsville, IN 46077
[email protected]
Total shoulder arthroplasty can provide significant pain
relief as well as improvement in function.1 Glenoid component failure is a common mode of failure for unconstrained
total shoulder arthroplasty.2,3 Fixed posterior subluxation
combined with excessive glenoid retroversion may result in
premature loosening of the glenoid component due to asymmetric load distribution in the horizontal plane.4 A clear consensus on the results of corrective measures to address fixed
posterior subluxation is not available.5-7 Multiple options to
address bony deficiency at the time of glenoid component revision exist including allograft and autograft augmentation in
a single or two stage revision.2,8-11 In addition to the potential
morbidity of these graft sources, nonunion, dissolution, and
loss of fixation as mechanisms of failure of both grafts has
also been reported 5,12-14. While structural porous tantalum has
been successfully utilized in other adult reconstruction applications, to our knowledge, the use of a porous tantalum augment to successfully address significant glenoid bone loss has
not been previously reported.15 We present a case of a failed
glenoid component presenting with significant glenoid bone
loss and fixed posterior subluxation managed with a porous
tantalum augment at the time of revision arthroplasty. The
patient was informed that data concerning his case would be
submitted for publication and consented.
Case Report
A 61-year-old right hand dominant male was referred
to our shoulder clinic with debilitating right shoulder pain
of several years duration. He had three previous operations
for this shoulder including an initial Putti-Platt procedure
to address shoulder instability. The second operation was a
total shoulder arthroplasty for debilitating arthritis. The total shoulder replacement provided good pain relief but very
limited functional improvement for several years. With the
recurrent progression of shoulder pain, the patient had several evaluations of his right shoulder and had a diagnostic
shoulder arthroscopy with debridement revealing a grossly
loose glenoid component. He was referred to our tertiary
care shoulder clinic for definitive management. Preoperative radiographs (Fig. 1) revealed a posteriorly subluxated
Figure 1a and 1b
Preoperative images (Axillary and CT scan) show posterior subluxation with significant asymmetrical posterior glenoid wear and
failed glenoid component
total shoulder replacement with a failed glenoid component.
The patient was also noted to have significant weakness of
his subscapularis and supraspinatus on clinical examination. Subsequent EMG/NCV confirmed evidence of chronic
severe demyelinative suprascapular neuropathy. After thoroughly reviewing the risks, benefits, and options of treatment,
we discussed with the patient that revision options included
conversion to a hemiarthroplasty with grafting and resurfacing of his glenoid, reimplantation of a glenoid component,
or conversion to a reverse total shoulder arthroplasty. Given
the constellation of clinical findings, including both soft tissue and bony deficiency combined with instability, and the
38
Indiana Orthopaedic Journal
Volume 3 – 2009
Case Report: Porous Tantalum Augment Used To Address Significant
Glenoid Deficiency in Revision Total Shoulder Arthroplasty (continued)
patient’s goals we also discussed with him that although we
would be prepared for each of these options intraoperatively,
he may have the best chance at meaningful pain relief and
limited function with a reverse total shoulder replacement.
Graft options including the possible use of a porous tantalum
augment and iliac crest autologous graft to address the glenoid deficiency were also discussed with the patient. Given
his debilitating pain and previous operations, he preferred to
avoid iliac crest graft if possible and wished to proceed with
a revision procedure. During the approach, the subscapularis
was intact but significantly attenuated. A lesser tuberosity
osteotomy was performed along with a sub-coracoid and
deep surface release of the subscapularis to preserve as much
function and length of the subscapularis as possible. The subscapularis lesser tuberosity osteotomy was securely repaired
at the end of the procedure. Intraoperatively, after removal of
the glenoid component and loose cement mantle, the patient
was noted to have a large cavitary defect with associated loss
of the posterior wall resulting in significant posterior glenoid
version. Enough native bone remained for excellent purchase
of the long-stem (25mm) baseplate for the reverse prosthesis.
Reconstruction of the posterior defect with a 5mm porous
tantalum augment (Zimmer) allowed us to create a stable
base with neutral version to accept the glenoid baseplate for
the reverse prosthesis. The tantalum augment was a modular implant designed for total knee revision arthroplasty.
The augment is manufactured with a central hole to allow
incorporation to the tibia base plate during revision total knee
arthroplasty. This augment was contoured intraoperatively,
utilizing a high speed metal cutting wheel, to fill the posterior
defect creating a neutral glenoid face for the reverse baseplate. The augment was incorporated and stabilized with the
posterior compression screw in the baseplate. In this fashion,
the augment was compressed to the native glenoid bone and
baseplate to minimize micro-motion at the baseplate tantalum interface. The locking screws were then placed routinely
resulting in excellent capture of the scapula and seating of
the baseplate in native bone. A 42-mm glenosphere component was placed without difficulty. The press fit humeral stem
was then removed via a cortical window which was stabilized
with cerclage wires. A long stem reverse humeral component
that extended at least 2.5 diameters distal to the osteotomy
was cemented into the humeral shaft with excellent stability.
The patient had an uneventful postoperative course, noting
immediate resolution of shoulder pain. At 12 months postop
his active FF = 130 degrees, abduction = 130 degrees, ER
(90) = 60 degrees, IR (90) = 40 degrees. Despite excellent
restoration of external rotation and deltoid strength, his subscapularis strength only returned to Grade +4/5 at 12 months
after surgery. Postoperative radiographs (Figure 2) demonstrate correction of glenoid version to neutral with well fixed
reverse prosthesis and porous tantalum augment. Preoperative Constant Score was 5 and Postoperative Constant Score
(12 months) was 64.
39
Figure 2a and 2b
Postoperative images (AP and
Axillary) show restoration of neutral glenoid version with the posterior porous tantalum augment in
place.
Discussion
Revision total shoulder arthroplasty is a technically demanding procedure. As the rate of total shoulder arthroplasty
continues to increase, a greater number of revision procedures can be expected. Reasons for failure of primary total
shoulder replacement are numerous. The causes for failure
may be broadly categorized into soft tissue deficiencies,
osseous deficiencies, component wear, and infection. The
results of revision also can vary significantly based on the
etiology2. The problem of fixed posterior subluxation combined with significant glenoid bone deficiency is particularly
difficult both in the primary and revision setting. Although
the indications for the Reverse Total Shoulder Replacement
are evolving and long term results are forthcoming, instability of the center of rotation as seen in rotator cuff deficiency
is a well accepted indication. Our patient presented with a
particularly difficult problem - recurrent posterior instability,
glenoid bone loss, failed total shoulder arthroplasty, and rotator cuff compromise. Porous tantalum has a long history of
use in orthopedics particularly to address bone deficiency in
hip and knee arthroplasty. The biomechanics, biocompatibility, and osteoconductivity of porous tantalum have also been
favorable15-20. Aside from the risks of morbidity associated
with use of allograft and autograft, the success of incorporation of these grafts has also been questioned. As the demand
for shoulder replacements continues to increase, the ability to
reliably address revision of failed implants will also continue
to be in demand. Although, we present the utilization of porous tantalum augmentation to address glenoid bone defects
as an option to consider taken as an extension of its success
in hip and knee reconstruction, we also fully recognize the
preliminary nature of our report, and continue to recommend
Indiana Orthopaedic Journal
Volume 3 – 2009
Case Report: Porous Tantalum Augment Used To Address Significant
Glenoid Deficiency in Revision Total Shoulder Arthroplasty (continued)
and primarily utilize autologous bone graft whenever
possible. Longer follow-up and further studies are required
before a modular system as seen in revision knee arthroplasty
is possible for shoulder arthroplasty.
References
1.Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU, Ahmad CS. Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral
osteoarthritis: a systematic review. J Shoulder Elbow Surg. 2007;16:396-402.
2.Dines JS, Fealy S, Strauss EJ, Allen A, Craig EV, Warren RF, Dines DM. Outcomes analysis
of revision total shoulder replacement. J Bone Joint Surg Am. 2006; 88:1494-500.
3. Wirth MA, Rockwood CA, Jr. Complications of total shoulder-replacement arthroplasty. J
Bone Joint Surg Am. 1996; 78:603-16.
4.Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty. 1999; 14:756-60.
5. Hill JM, Norris TR. Long-Term Results of Total Shoulder Arthroplasty Following Bone-Grafting of the Glenoid. J Bone Joint Surg Am. 2001; 83:877-83.
6. Walch G, Ascani C, Boulahia A, Nove-Josserand L, Edwards TB. Static posterior subluxation
of the humeral head: an unrecognized entity responsible for glenohumeral osteoarthritis in the
young adult. J Shoulder Elbow Surg. 2002; 11:309-14.
7. Habermeyer P, Magosch P, Lichtenberg S. Recentering the humeral head for glenoid deficiency in total shoulder arthroplasty. Clin Orthop. 2007; 457:124-32.
8. Cheung EV, Sperling JW, Cofield RH. Reimplantation of a Glenoid Component Following
Component Removal and Allogenic Bone-Grafting. J Bone Joint Surg Am. 2007; 89:1777-83.
9. Peidro L, Segur JM, Poggio D, de Retana PF. Use of freeze-dried bone allograft with platelet-derived growth factor for revision of a glenoid component. J Bone Joint Surg Br. 2006;
88:1228-31.
10. Gerber C, Warner JJ. Management of Glenoid Bone Loss in Shoulder Arthroplasty. Techniques
in Shoulder and Elbow. 2001; 2:255-66.
11. Bell RH, Noble JS. The management of significant glenoid deficiency in total shoulder arthroplasty. J Shoulder Elbow Surg. 2000; 9:248-56.
12. Hou CH, Yang RS, Hou SM. Hospital-based allogenic bone bank--10-year experience. J Hosp
Infect. 2005; 59:41-5.
13. Banwart JC, Asher MA, Hassanein RS. Iliac crest bone graft harvest donor site morbidity. A
statistical evaluation. Spine. 1995; 20:1055-60.
14. Caldwell PE, 3rd, Shelton WR. Indications for allografts. Orthop Clin North Am. 2005;
36:459-67.
15. Bobyn JD, Poggie RA, Krygier JJ, Lewallen DG, Hanssen AD, Lewis RJ, Unger AS,
O’Keefe TJ, Christie MJ, Nasser S, Wood JE, Stulberg SD, Tanzer M. Clinical validation of
a structural porous tantalum biomaterial for adult reconstruction. J Bone Joint Surg Am. 2004; 86
(Suppl 2):123-9.
16. Christie MJ. Clinical applications of Trabecular Metal. Am J Orthop, 2002;31:219-20.
17. Cohen R. A porous tantalum trabecular metal: basic science. Am J Orthop. 2002; 31:216-7.
18. Fujibayashi S, Neo M, Kim HM, Kokubo T, Nakamura T. Osteoinduction of porous bioactive
titanium metal. Biomaterials. 2004; 25:443-50.
19. Ronningen H, Solheim LF, Langeland N. Invasion of bone into porous fiber metal implants in
cats. Acta Orthop Scand. 1984; 55:352-8.
20. Zardiackas LD, Parsell DE, Dillon LD, Mitchell DW, Nunnery LA, Poggie R. Structure,
metallurgy, and mechanical properties of a porous tantalum foam. J Biomed Mater Res. 2001;
58:180-7.
40
Indiana Orthopaedic Journal
Volume 3 – 2009
Avoiding Complications in the Treatment
of Humeral Fractures
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
By Jeffrey O. Anglen, M.D., Department of Orthopaedics – Indiana University School of Medicine – Indianapolis, Indiana, USA
Michael T. Archdeacon, M.D., M.S.E., Department of Orthopaedics – University of Cincinnati Medical Center – Cincinnati, Ohio, USA
Lisa K. Cannada, M.D., Dallas, Texas, USA
Dolfi Herscovici Jr., D.O., Florida Orthopaedic Institute – Temple Terrace, Florida, USA
© 2008 The Journal of Bone and Joint Surgery, Inc. Reprinted from the Journal of
Bone and Joint Surgery American, Volume 90, pp. 1580-1589 with permission.
Most humeral fractures heal uneventfully, but a variety
of complications can occur after both surgical and nonoperative treatment. Three of the most common complications
encountered are nonunion of a humeral shaft fracture, loss
of fixation of a proximal humeral fracture, and radial nerve
palsy. This lecture will focus on these three relatively common complications and will discuss their etiology, risk factors, prevention, detection, and treatment.
Nonunion of a Humeral Shaft Fracture
Nonunion has been reported to occur following approximately 1% to 10% of humeral shaft fractures that have been
treated nonoperatively and after approximately 10% to 15%
of those that have been treated surgically1-3. The difference
in these nonunion rates may represent both the effects of
treatment and a selection effect, as more complex and highenergy fractures may be treated surgically. When a humeral
nonunion occurs after surgical treatment there are additional
treatment considerations because of the presence of hardware
and the risk of infection.
Some risk factors for nonunion of a humeral shaft fracture are an open fracture; a segmental, transverse, or highly
comminuted fracture pattern; bone loss; wide displacement
of the fracture fragments (>100% of the shaft diameter); impaired host healing (due to smoking, diabetes, medications
such as nonsteroidal anti-inflammatory drugs, malnutrition,
and noncompliance with physicians’ instructions); pre-existing shoulder or elbow stiffness; and intervening local infection.
Prevention of nonunion of a humeral shaft fracture is not
always possible, but some measures taken during treatment
of the acute fracture may reduce the risk of the complication. Selection of the appropriate treatment for each patient is
the first step because nonunion can result both from unnecessary surgery as well as from failure to recognize patients
who would benefit from operative care. Most humeral shaft
fractures in reasonably healthy patients heal well when treated without internal fixation. Because of the great mobility
of the shoulder, moderate amounts of angulation, shortening,
and rotational deviation from normal usually cause no functional problems after healing. Nonoperative treatment should
consist of a short period of immobilization in a sling and/or
coaptation splint, followed by active shoulder and elbow motion in a functional brace3. Performing an operation without
41
compelling reasons increases the risk of all complications,
including nonunion.
When the patient has one or more of the risk factors for
nonunion delineated above, when the fracture cannot be adequately reduced, or when the fracture reduction cannot be
controlled with functional bracing because of patient obesity,
head trauma, soft-tissue injuries, or other reasons, surgical
stabilization is indicated. Bilateral humeral fractures and
those occurring in patients with multiple injuries or chest
trauma are usually best managed with internal fixation. Although there are proponents of both nail and plate fixation
for humeral shaft fractures, the risks of nonunion and a reoperation have been reported to be lower with plate fixation
than with nail fixation. The nonunion rate after plate fixation
is approximately 4%, whereas that after nail fixation is approximately 10%4,5.
When internal fixation is selected, it is important to pay
attention to certain technical details to lower the risk of nonunion. The fracture should be reduced well (but not necessarily anatomically), and it is particularly important to avoid
distraction at the fracture site. This can occur during closed
nailing if the nail is tight in the distal part of the canal. If
bone is missing, shortening of as much as 2 to 3 cm (in our
experience) is acceptable in order to achieve bone contact;
larger gaps should be bridged with a bone graft. Because the
humerus is subjected to strong rotational forces as a result of
the weight of the upper extremity, the fixation construct must
adequately neutralize rotational forces to achieve stability for
reliable healing. In our experience, unstable fixation has been
a very common cause of nonunion of the humeral shaft after
operative fixation. To achieve adequate stability with an intramedullary nail, the nail must fill the diaphyseal canal and
be locked with screws on both ends to resist torque. Humeral
intramedullary nails are usually inserted without power reaming because of the small size of the medullary canal and the
risk of tissue damage. Hand reaming is done with T-handled
reamers to open the canal and allow a larger nail to be inserted, but this technique does not permit adequate shaping of
the nail path to provide a tight ‘‘wedge’’ fit that would resist
rotation. In addition, attempting to achieve a very tight fit in
the distal fragment can lead to distraction at the fracture site
or comminution of the distal fragment. Thus, distal interlocking is necessary to stabilize the nail and prevent rotation of
the humerus around it. One interlocking screw on either end
is usually sufficient.
Indiana Orthopaedic Journal
Volume 3 – 2009
Avoiding Complications in the Treatment of Humeral Fractures (continued)
Fig. 1-A Anteroposterior radiograph of the left
humerus of a thirty-five-yearold farmer, made
nine months after intramedullary nail fixation
of an open fracture sustained during a fall.
The patient reported pain when he used the
arm and a sensation of instability and weakness. The radiograph shows a small-diameter
nail, locked only proximally; a malaligned
fracture; and no evidence of fracture-healing.
Fig. 1-B The humerus
healed well after the
fixation was revised to
a long, large plate to
provide adequate stability and alignment.
Excellent bone apposition was achieved, and
autogenous cancellous
bone graft was placed
around the nonunion
site.
Fig. 1-A
Fig. 1-B
For plate fixation to achieve stability, the plate must be
of adequate thickness and length: the thickness should be
>3.5 mm (a large-fragment plate) for most adults, and the
length should be such that at least four screw holes overlie each major proximal and distal fragment. This does not
mean that every screw hole in the plate needs a screw placed
through it, as excessive screw placement can be damaging
(Figs. 1-A through 2-E). The most proximal and distal screw
hole in each fragment should be utilized in order to maximize
resistance to rotational stresses (the socalled near-near, farfar screw pattern), a technique similar to the construction of a
stable external fixator configuration for a diaphyseal fracture.
More screws can be added in each fragment in situations of
suboptimal screw purchase, but they may not be necessary
in good bone if the two end screws are placed well and solidly secured. When a fracture of the distal part of the shaft
involves the metaphysis or epiphysis, bicolumnar fixation
should be achieved with good purchase in the bone of both
columns distally (Figs. 3-A through 3-D). In general, plateand-screw fixation should be ‘‘balanced’’ around the center of
the fracture; that is, there should be an approximately equal
plate length and number of screws on both sides of the center
of the fracture. The construct should appear symmetrical in
terms of the amount of fixation. This becomes more difficult
near the ends of the bone, and metaphyseal fractures may require double-plate fixation to achieve adequate control of the
smaller fragment. The use of locked-plate techniques near the
epiphysis may change this rule, but the effectiveness of that
approach has not yet been clearly established.
Plates should be applied without circumferential softtissue stripping, with gentle tissue handling, and with the
least amount of bone devascularization needed to expose the
radial nerve for its protection and to allow the plate to be
positioned on the bone. Butterfly fragments should not be
stripped of muscular attachments, and cerclage wiring can be
detrimental and often is unnecessary. Excessive stripping of
the soft tissue from the bone can contribute to delayed union
or nonunion. Plates should be applied over the periosteum
after gentle elevation of the muscle from the bone.
Good-quality radiographs in two planes that include
both the shoulder and the elbow should be made in the operating room when the patient is still under anesthesia. These
are made to identify any problems with fixation or distraction
at the fracture site, which are more likely to be missed with
fluoroscopy. These problems can then be addressed before
the patient is awakened from the anesthesia.
Union is expected within sixteen weeks, and a nonunion
of the humerus is usually defined as a failure to heal by twenty-four weeks with no progress toward healing seen on the
most recent radiographs. Obvious loss of stability on clinical
examination or radiographs is clear evidence of a nonunion.
When this is seen, there is no need to wait for an arbitrary
amount of time before initiating treatment for the nonunion.
Pain is usually associated with humeral nonunion, but it is
not as common as it is with nonunions of weight-bearing long
Fig. 2-A
Fig. 2-B
Fig. 2-A This isolated midshaft humeral fracture, sustained by a
healthy forty-year-old woman while skiing, would probably have
healed well if it had been treated with closed means. Fixation with
a long large-fragment plate with an excessive number of screws was
performed through a large incision. Fig. 2-B Nonunion resulted.
Note the loss of screw fixation distally.
42
Indiana Orthopaedic Journal
Volume 3 – 2009
Avoiding Complications in the Treatment of Humeral Fractures (continued)
diction. When nonunion is unexpected, infection should be
considered as a possible cause, and a clinical examination
and blood tests such as measurements of the erythrocyte
sedimentation rate and the C-reactive protein level should be
performed. Any patient with a nonunion that does not have
an obvious cause should be evaluated to rule out diabetes,
hypothyroidism, a problem with calcium metabolism, or another endocrine abnormality6.
Once a humeral nonunion is established, nonoperative
treatment is not likely to be effective as external bone stimulators have not generally been successful in treating these
complications7,8. External fixation has been used temporarily in staged treatment of infected nonunions, but it is rarely
employed as a definitive treatment because patients cannot
tolerate use of this device for long periods.
Fig. 2-C
Fig. 2-D
Fig. 2-C External fixation was applied after hardware removal.
Fig. 2-D When the pin sites became
infected, the external fixator frame
was removed, leading to an unstable,
atrophic, and possibly infected nonunion with substantial bone loss.
Fig. 2-E Union was achieved after
use of a long-double-plate technique
through a posterior approach combined with use of iliac crest bone graft
with bone morphogenetic protein and
implantation of a bone stimulator.
Fig. 2-E
bones of the lower extremities. Instability may be evident
clinically on physical examination. The diagnosis is usually
obvious on radiographs, although if there is hardware obscuring the bone, computed tomography with use of hardwaresubtraction algorithms may help one to evaluate the fracture
site.
Treatment of the nonunion requires careful analysis of
causative factors. One should not forget to address medical
problems, such as diabetes, malnutrition, and tobacco ad43
The surgical procedure should be carefully planned. For
a nonunion that has not been previously treated surgically,
particularly one that shows evidence of bone reaction on radiographs (a hypertrophic type), provision of adequate stability with plate fixation may be all that is necessary. ‘‘Taking
down’’ (debriding) the nonunion to excise the fibrous tissue
between the bone ends is not necessary in this situation.
However, opening the medullary canal proximally and distally is believed to aid healing, when this can be accomplished
without taking down a firm fibrous union, as is possible with
an atrophic nonunion. The fibrous scar tissue connecting the
bone ends of a hypertrophic nonunion has the capacity to turn
into bone and does not inhibit union in a stable milieu. If a
true pseudarthrosis with a synovial cavity exists, the cartilage
covering the ends of the bones and the lining tissue should
be excised, the medullary canal should be opened in both
directions, and good bone apposition should be achieved.
If previous surgery has been performed, hardware removal
will probably be necessary and the correct instruments for
that portion of the procedure must be available. The surgeon
should have a plan for what will be done if an unsuspected
infection or broken or stripped hardware is encountered.
Plate fixation of the humerus can be performed through
a posterior or an anterolateral approach. The choice may be
determined by the need to remove hardware; if not, the posterior approach offers a more cosmetic scar position. Proximal
humeral nonunions are approached through a deltopectoral
incision, and distal humeral intra-articular nonunions typically require a posterior approach, often with an osteotomy
of the olecranon. In the treatment of a diaphyseal nonunion,
caremust be taken to identify, mobilize, and protect the radial nerve. It is useful to warn patients that they may have a
transient radial nerve palsy as a result of just the surgical manipulation and there is a small risk of permanent nerve injury.
At least three samples should be taken from the nonunion site
for culture if a previous operation had been performed.
The use of bone grafts, bone morphogenetic protein, or
shortening may be necessary to treat bone defects. Osteopenic or pathologic bone resulting from previous surgery may
require the use of locking plates, double plates, or allograft
struts, which may be utilized in an intramedullary position9,10.
Unlike the situation in the lower extremity, if the previous hu-
Indiana Orthopaedic Journal
Volume 3 – 2009
Avoiding Complications in the Treatment of Humeral Fractures (continued)
bone around the screw holes. When the plate loosened and
fixation failed, a large amount of bone was lost from around
each screw hole. The use of external fixation with subsequent
pin track infection led to more bone loss. Successful treatment of this difficult situation required removal of all hardware; d´ebridement of the necrotic bone and infected soft tissue; a period of treatment with antibiotics, both systemic and
local (beads); and then refixation with double plates, bonegrafting, and implantation of a stimulator.
Fig. 3-A
Fig. 3-B
Fig. 3-A Anteroposterior radiograph demonstrating a nonunion in a
fifty-three-year-old truck driver who had sustained a fracture of the
distal part of the humerus, and had been treated with open reduction and internal fixation at another hospital, five months previously.
The patient reported pain with any motion of the arm and elbow,
and the fracture site was tender to palpation and manual stress.
Fig. 3-B Lateral radiograph of the elbow before the revision surgery.
meral fixation implant was a nail, exchange nailing is usually
not very successful11,12. Fixation should be achieved with a
long plate (Figs. 2-A through 2-E). Healing of atrophic nonunions can be enhanced with cancellous autograft, demineralized bone matrix, or bone morphogenetic protein2,13,14.
Figures 1-A and 1-B are radiographs of a patient in
whom a nonunion had resulted mostly from inadequate stability provided by the initial fixation. The fracture was stabilized with an intramedullary nail with a relatively thin diameter, which was locked only proximally. The distal fragment,
subjected to high torque forces, was able to rotate around the
nail, and this excessive motion resulted in nonunion. In addition, the fracture was malaligned, most likely as a result
of malreduction at the time of surgery. The lack of any hypertrophic healing response or callus suggests that there was
also a biological component, in addition to the biomechanical
deficit, that caused this nonunion. Multifactorial etiologies
are not uncommon and should be addressed when the nonunion is treated. The treatment in this case was removal of the
nail, balanced stable fixation with a large-fragment plate, and
bone-grafting. Successful healing resulted.
Figures 2-A through 2-E demonstrate a different cause of
nonunion. In this case, a healthy patient initially had a closed
isolated fracture that would most likely have healed uneventfully following closed treatment with a functional fracture
brace. However, the patient was subjected to an operation
with periosteal stripping and application of a large plate with
filling of every screw hole; the biological healing potential
of the bone was compromised, and nonunion resulted. After
plate removal, devascularization was evidenced by sclerotic
Figures 3-A through 3-D show a distal humeral nonunion.
The fracture was fixed with a gap at the junction of the diaphysis and metaphysis, with use of plates that were probably too
flexible (reconstruction plates rather than compression plates)
and definitely too short. Although fixation through nine or ten
cortices was achieved in the proximal fragment, the screws
were all placed in a short segment of the bone. Despite the
large number of screws, the plate length was inadequate to
provide good mechanical stability. The mechanical function
of a plate as a nongliding splint depends more on the length
of the plate than on the number of attachment points to the
bone. Revision to longer bicolumnar plates was performed,
and a more balanced fixation construct resulted. Lag screws
were added. Bone graft and a bone stimulator were used to
stimulate healing. Solid union resulted in two months.
Loss of Fixation of a Proximal Humeral Fracture
Fractures of the proximal part of the humerus are often
complicated by loss of fixation after surgical treatment. A
loss of fixation was reported in approximately 13% of 349
cases reviewed in 199715. The fixation loss is usually, but not
always, the result of loosening of the portion of the construct
in the humeral head. The humeral head comprises mostly
cancellous bone and has very poor holding power for screw
Fig. 3-C
Fig. 3-D
Fig. 3-C Revision fixation was performed with removal of hardware, bicolumnar plate fixation with longer plates to achieve better fixation on the proximal fragment, and use of lag screws distally. Bone graft and an implantable bone stimulator were inserted.
Fig. 3-D Lateral radiograph demonstrating healing after the revision.
44
Indiana Orthopaedic Journal
Volume 3 – 2009
Avoiding Complications in the Treatment of Humeral Fractures (continued)
fixation, particularly in elderly patients. High stresses that exceed the holding power of screws in this cancellous bone may
be applied to the surgical neck with arm motion. Therefore,
elderly patients should not receive overly aggressive physical
therapy in the postoperative period.
Traditionally used plates and screws can loosen quickly
as a result of poor-quality bone, a lack of load sharing when
there is fracture comminution, and the lack of a fixed angle
between the plate and screws. The traditionally used largefragment T-plate allows, at most, three screws to be placed
through its proximal portion and into the humeral head fragment. Interlocking nails likewise allow only one or two screws
to be used in the proximal fragment, providing an inadequate
grip on this fragment. Percutaneous threaded-tipped Kirschner wires often migrate in dangerous directions and may fail
quickly, particularly if too few are placed or if they are positioned poorly. Blade plates, which were initially proposed as
a solution to this problem, have proved to be no panacea16.
Fig. 4-A
Reducing the incidence of fixation failure involves several steps. The first is correct patient selection. Nonoperative
therapy is successful for a large proportion of simple surgical
neck fractures, even in elderly patients. Arthroplasty should
be considered for patients with preexisting arthritis or shoulder stiffness, severe comminution, a head-splitting fracture,
or an associated dislocation. Avoiding an unnecessary or incorrect operation in the initial treatment of the fracture is the
first way to prevent fixation failure.
The use of suture or wire fixation has been preferred by
some surgeons. This sort of fixation into tendons of the rotator cuff or through the bone at the tendon insertion can be
superior to screw fixation in osteopenic bone. Multiple large
nonabsorbable sutures can be placed in a tension-band fashion connecting greater and lesser tuberosities to the head and
shaft fragments17.
Locking plate fixation is a major advance in the treatment of proximal humeral fractures. It can reduce the risk
of lost fixation, but it is not always successful and there are
technical points that must be observed18,19. It is important to
position the plate appropriately to avoid impingement with
shoulder motion. The use of multiple locking screws of adequate length in different planes improves fixation. The optimal number of screws is unknown, but more appears to be
better. Unlike the situation in the diaphysis, where placement
of additional screws that may be unnecessary can have harmful effects on bone biology, extra screws placed in the humeral head do not seem to be detrimental. This may be because
these screws are placed without drilling and in bone that is
very well vascularized. Intraoperative fluoroscopy, especially
the axillary view, is important to ensure that no screws penetrate the head and impinge on the glenoid. Allograft cortical
struts from the fibula or tibia can be used in an intramedullary location to improve fixation both proximally and distally
(Figs. 4-A and 4-B).
Recognition of loss of screw fixation is usually not difficult if radiographs are made early after surgery. Recurrence or persistence of pain and instability should prompt
radiographic evaluation. When loss of fixation is identified,
45
Fig. 4-A Shoulder
radiograph demonstrating a nonunion
of the proximal part
of the humerus in a
thirty-five-year-old
drug abuser with diabetes who had had
three previous operations. The locking
plate lost purchase
in the shaft fragment,
and a retrograde
Ender nail was used
in an attempt to salvage the situation.
The patient still had
pain and clinically
visible instability at the
fracture site.
Fig. 4-B Union was achieved
with double locking plates,
and an intramedullary
fibular allograft was used
to improve fixation in the
shaft portion of the construct. Cancellous autogenous bone graft with bone
morphogenetic protein was
placed in the metaphyseal
defect at the same time.
Fig. 4-B
it usually requires revision surgery. Revision fixation with
bonegrafting is appropriate for young and active patients, after analysis and identification of the reasons for failure. In
elderly patients, patients with severe osteopenia, and those
with articular damage, hemiarthroplasty or total shoulder replacement can achieve pain relief but the functional outcome
is usually poor18.
Nerve Injury
Nerve injury that is evident after treatment of a humeral
fracture can be a result of the injury or of the treatment. During the initial evaluation of any patient with a humeral fracture, it is important to perform a careful neurologic examination and to document sensation and specific motor function
of the radial, median, ulnar, and axillary nerves. In closed
injuries, nerves can be contused or stretched but are rarely
completely disrupted, except in the setting of a scapulothoracic dissociation20. Open injuries can result in nerve laceration and occasionally in segmental nerve loss21.
Radial nerve injury associated with fracture of the humeral shaft is the most common nerve lesion complicating
any long-bone fracture22. In a metaanalysis reviewing thirtyfive studies in the literature that included a total of 1045 patients with radial nerve palsy, the prevalence of this problem
was estimated to be approximately 12% in patients with a hu-
Indiana Orthopaedic Journal
Volume 3 – 2009
Avoiding Complications in the Treatment of Humeral Fractures (continued)
meral fracture. It was more commonly associated with middle and distal third humeral fractures than with proximal third
fractures and more commonly associated with transverse or
spiral patterns than with oblique or comminuted types22. Radial nerve injury occurs in approximately 10% of patients
who have sustained multiple injuries23. In an electromyographic study of 143 proximal humeral fractures, 67% were
found to be associated with evidence of some denervation,
most commonly in the axillary or suprascapular nerve24. During operative treatment, nerves can be stretched, contused,
compressed, or cut. A new or recurrent postoperative nerve
palsy is usually a transient problem, but it is reported to be
permanent in 2% to 3% of patients25.
To prevent nerve injury, the treating physician must be
aware of the location and anatomy of the nerves in the upper extremity. During surgical procedures, the nerves should
be identified, exposed, and protected. The radial nerve lies
in the spiral groove on the posterior aspect of the humeral
shaft. It comes into contact with the bone as it approaches
the lateral supracondylar ridge, more proximally than usually expected26. Gerwin et al. described a modification of the
typical posterior triceps-splitting approach that allows more
exposure of the humeral diaphysis while protecting the radial
nerve27. It involves identifying the nerve as it approaches the
lateral intermuscular septum and retracting the medial and
lateral heads of the triceps in a medial direction. During nail
fixation of a humeral shaft fracture, it is important to be sure
that the nerve is not lying in the fracture site. If the fracture is
oblique, in the distal third of the shaft, and cannot be reduced
anatomically, and particularly if there is a preexisting nerve
palsy, a small incision should be made to expose the fracture
site and ensure that the nerve is not entrapped. Proximal interlocking screws placed from anterior to posterior through a
humeral nail endanger the axillary nerve28. Percutaneous pins
inserted for fixation of proximal fractures may be near the axillary nerve as it wraps around the humerus on the undersurface of the deltoid. To reduce the risk of injury to the nerve,
these pins should be placed through a small incision and, after
spreading of the muscle, a drill guide should be placed directly on the bone29. Fixation of distal humeral fractures places
the ulnar nerve at risk. During open reduction and fixation
of the distal part of the humerus, the ulnar nerve should be
exposed and mobilized. Anterior subcutaneous transposition
is useful if there is a possibility of hardware impinging on the
nerve. The nerve should be mobilized sufficiently to prevent
tension or kinking. During any fixation procedure, the surgeon should minimize, as much as possible, the amount and
duration of tension on both the ulnar and the radial nerve during retraction. For this reason, we believe that self-retaining
retractors should not be used in such cases.
Identification of nerve injury is usually not difficult. The
patient often reports numbness and/or weakness, most commonly a wrist drop. The neurologic examination can be brief
and still thorough enough to identify problems. Scratch or
sharp sensation should be tested in the distributions of the
major nerves—i.e., the first dorsal web space for the radial
nerve, the volar aspect of the long finger for the median nerve,
the ulnar side of the small digit for the ulnar nerve, and the
lateral shoulder area over the deltoid muscle for the axillary
nerve. Motor function should be tested for both active motion
and strength. Thumb and wrist extension should be assessed
to evaluate the radial nerve; grip and the ‘‘OK’’ sign, to evaluate the median and anterior interosseous nerves; spreading
and crossing the fingers, to evaluate the ulnar nerve; and active shoulder abduction, to evaluate the axillary nerve. The
results of the preoperative and postoperative examinations
should be completely documented.
Nerve injury associated with closed fractures can be
managed with observation, as it resolves in almost all patients, usually by four months after the injury30. Shao et al.22
reviewed thirty articles describing management of radial
nerve injury. They found that approximately 70% of patients
treated with expectant management (observation) had spontaneous recovery, and, when they were combined with those
who had delayed exploration after a period of observation,
the overall recovery rate was 88%. Patients treated with early
exploration had a recovery rate of 85%, so there seemed to be
no advantage to early exploration for a primary nerve injury.
The findings with regard to secondary nerve injury were similar: although there were not enough studies for the authors
to make any clear recommendations, it appears that routine
early exploration is not warranted and may cause additional,
iatrogenic nerve damage. Although it has been suggested that
a surgeon should explore any nerve that loses function during
closed treatment, we are not aware of any studies documenting improved outcomes following this strategy and most authors have recommended against it31. When nerve deficits are
recognized, appropriate splinting and range-of-motion exercises should be instituted to prevent contractures. Some surgeons have recommended baseline electromyographic studies at six and twelve weeks after the identification of a nerve
injury, but the effect of such studies on treatment decisions
and ultimate outcomes is unclear. If a fracture-related radial
nerve deficit in an adult has not resolved by six months, a decision should be made about exploration for repair or tendon
transfer. This is controversial, but many believe that tendon
transfer provides better and earlier functional recovery32.
Overview
Although most humeral fractures heal uneventfully,
complications do occur. They cannot be prevented entirely,
but the risk of common complications can be reduced. Humeral shaft nonunion can be due to errors in patient selection for treatment or to technical mistakes. Both excessive
and inadequate surgery can lead to nonunion. A common error is failure to provide adequate stability for the fracture,
which is subjected to large angular and torsional loads. Nails,
if used, should be interlocked on both sides of the fracture.
Plates should be of adequate thickness and length. The risk of
loss of fixation in the humeral head can be reduced (but not
eliminated) with the correct use of locking plates and augmentation with bone grafts or other substances. Nerve palsy
is a common complication, and the risk can be reduced with
proper knowledge of anatomy, protection of the nerves, and
avoidance of excessive retraction during surgery. A radial
nerve palsy after a closed fracture or surgery usually resolves
with observation.
46
Indiana Orthopaedic Journal
Volume 3 – 2009
Avoiding Complications in the Treatment of Humeral Fractures (continued)
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation
of this work. Neither they nor a member of their immediate
families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Stryker Orthopaedics)
paid or directed in any one year, or agreed to pay or direct,
benefits in excess of $10,000 to a research fund, foundation,
division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors,
or a member of his or her immediate family, is affiliated or
associated.
Printed with permission of the American Academy of
Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academy’s Annual Meeting, will be available in February 2009 in Instructional Course Lectures,
Volume 58. The complete volume can be ordered online at
www.aaos.org, or by calling 800-626-6726 (8 A.M.-5 P.M.,
Central time).
47
References
1. Rutgers M, Ring D. Treatment of diaphyseal fractures of the humerus using a functional brace.
J Orthop Trauma. 2006;20:597-601.
2. Hierholzer C, Sama D, Toro JB, Peterson M, Helfet DL. Plate fixation of ununited humeral
shaft fractures: effect of type of bone graft on healing. J Bone Joint Surg Am. 2006;88:1442-7.
3. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82:478-86.
4. Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft
fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14:162-6.
5. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of
fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A
prospective, randomised trial. J Bone Joint Surg Br. 2000;82:336-9.
6. Brinker MR, O’Connor DP, Monla YT, Earthman TP. Metabolic and endocrine abnormalities
in patients with nonunions. J Orthop Trauma. 2007;21:557-70.
7. Bassett CA, Mitchell SN, Gaston SR. Pulsing electromagnetic field treatment in ununited fractures and failed arthrodeses. JAMA. 1982;247:623-8.
8. Anglen JO. Enhancement of fracture healing with bone stimulators. Failed internal fixation. Tech
Orthop. 2002;17:506-14.
9. Van Houwelingen AP, McKee MD. Treatment of osteopenic humeral shaft nonunion with
compression plating, humeral cortical allograft struts, and bone grafting. J Orthop Trauma.
2005;19:36-42.
10. Ring D, Kloen P, Kadzielski J, Helfet D, Jupiter JB. Locking compression plates for osteoporotic nonunions of the diaphyseal humerus. Clin Orthop Relat Res. 2004;425:50-4.
11. Verbruggen JP, Stapert JW. Failure of reamed nailing in humeral non-union: an analysis of 26
patients. Injury. 2005;36:430-8.
12. Ilyas I, Younge DA. Locked intramedullary nailing for difficult nonunions of the humeral diaphysis. Int Orthop. 2003;27:278-81.
13. Flinkkilä T, Ristiniemi J, Hämäläinen M. Nonunion after intramedullary nailing of humeral
shaft fractures. J Trauma. 2001;50:540-4.
14. Bong MR, Capla EL, Egol KA, Sorkin AT, Distefano M, Buckle R, Chandler RW, Koval
KJ. Osteogenic protein-1 (bone morphogenic protein-7) combined with various adjuncts in the
treatment of humeral diaphyseal nonunions. Bull Hosp Jt Dis. 2005;63:20-3.
15. Connor PM, Flatow EL. Complications of internal fixation of proximal humeral fractures. Instr
Course Lect. 1997;46:25-37.
16. Meier RA, Messmer P, Regazzoni P, Rothfischer W, Gross T. Unexpected high complication
rate following internal fixation of unstable proximal humerus fractures with an angled blade
plate. J Orthop Trauma. 2006;20:253-60.
17. Dimakopoulos P, Panagopoulos A, Kasimatis G. Transosseous suture fixation of proximal humeral fractures. J Bone Joint Surg Am. 2007;89:1700-9.
18. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg. 2007;15:12-26.
19. Rose PS, Adams CR, Torchia ME, Jacofsky DJ, Haidukewych GG, Steinmann SP. Locking
plate fixation for proximal humeral fractures: initial results with a new implant. J Shoulder Elbow
Surg. 2007;16:202-7.
20. Brucker PU, Gruen GS, Kaufmann RA. Scapulothoracic dissociation: evaluation and management. Injury. 2005;36:1147-55.
21. Foster RJ, Swiontkowski MF, Bach AW, Sack JT. Radial nerve palsy caused by open humeral
shaft fractures. J Hand Surg [Am]. 1993;18:121-4.
22. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br.
2005;87:1647-52.
23. Noble J, Munro CA, Prasad VS, Midha R. Analysis of upper and lower extremity peripheral
nerve injuries in a population of patients with multiple injuries. J Trauma. 1998;45:116-22.
24. Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg. 2001;10:421-7.
25. Södergård J, Sandelin J, Böstman O. Postoperative complications of distal humeral fractures.
27/96 adults followed up for 6 (2-10) years. Acta Orthop Scand. 1992;63:85-9.
26. Bono CM, Grossman MG, Hochwald N, Tornetta P 3rd. Radial and axillary nerves. Anatomic
considerations for humeral fixation. Clin Orthop Relat Res. 2000;373:259-64.
27. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior
aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am.
1996;78:1690-5.
28. Riemer BL, D’Ambrosia R. The risk of injury to the axillary nerve, artery, and vein from proximal locking screws of humeral intramedullary nails. Orthopedics. 1992;15:697-9.
29. Rowles DJ, McGrory JE. Percutaneous pinning of the proximal part of the humerus. An anatomic study. J Bone Joint Surg Am. 2001;83:1695-9.
30. Mohler LR, Hanel DP. Closed fractures complicated by peripheral nerve injury. J Am Acad
Orthop Surg. 2006;14:32-7.
31. Böstman O, Bakalim G, Vainionpää S, Wilppula E, Pätiälä H, Rokkanen P. Radial palsy in
shaft fracture of the humerus. Acta Orthop Scand. 1986;57:316-9.
32. Kruft S, von Heimburg D, Reill P. Treatment of irreversible lesion of the radial nerve by tendon
transfer: indication and long-term results of the Merle d’Aubigné procedure. Plast Reconstr Surg.
1997;100:610-6;617-8.
Indiana Orthopaedic Journal
Volume 3 – 2009
Outcomes Following Arthroscopic Thermal Ligamentorrhaphy
of Partial Tears of the Scapholunate Ligament
in an Active Population
Arthur C. Rettig, M.D., Methodist Sports Medicine – The Orthopedic Specialists, Indianapolis, Indiana, USA
Kevin M. Marberry M.D., University of Missouri – Columbia School of Medicine,
Department of Orthopaedic Surgery, Columbia, Missouri, USA
Brady P. Barker, M.D., Indiana University School of Medicine, Department of Orthopaedic Surgery, Indianapolis, Indiana, USA
Lance A. Rettig, M.D., Methodist Sports Medicine – The Orthopedic Specialists, Indianapolis, Indiana, USA
Table 1. Geissler Arthroscopic Grading
Scapholunate Ligament Injuries5
Abstract
Purpose: Unlike complete tears of the scapholunate ligament
(SL), partial tears do not have well-defined treatment algorithms. This is particularly true of athletes and active patients,
who place more physical demand on this ligament. The purpose of this study was to evaluate the functional outcome of
thermal ligamentorrhaphy for partial tears of the SL in an active population.
Grade IScapholunate ligament attenuation, normal midcarpal
evaluation
Grade IIScapholunate ligament attenuation, +/- small flap tear,
midcarpal exam: mild step-off, scapholunate diastasis
< width of probe
Grade IIIPartial tearing of the ligament, midcarpal exam: Probe is
able to be advanced into scapholunate interval and rotated
Methods: Ten patients with a diagnosis of Geissler grade I or II
SL instability during arthroscopy underwent thermal ligamentorrhaphy. Grip strength, the Mayo wrist score, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire were measured.
represent significant carpal instability often requiring open reduction and repair with or without augmentation. (Figure 1)
Results: At a mean follow up of 15.8 weeks, average grip
strength was 89.7% of the contralateral side. Seven patients
rated good to excellent on the Mayo scores, and the mean
DASH score was 14.6. Seven of the 10 patients were involved
in athletic activities. Two other patients were able to return to
their activities with little or no difficulty, and the third patient
was not active.
Thermal shrinkage of capsular and ligamentous tissue is
gaining acceptance as a viable treatment option in joints such
as the shoulder, ankle, knee and hip.6,7,8,9,10,11,8 With the emergence of radiofrequency (RF) probes for small-joint arthroscopy, thermal ligamentorrhaphy is being used in the treatment
of injuries to the wrist such as in mid-carpal instability and in
partial scapholunate tears.12,13
Conclusions: Thermal ligamentorraphy of partial tears of the
SL appears to be a safe treatment for active patients in this
small series with short term follow-up.
The purpose of this study was to critically evaluate the
short-term outcome and functional recovery of patients following surgical treatment of scapholunate instability utilizing
arthroscopic thermal ligamentorrhaphy.
Type of Study: Case series, level of evidence IV
Grade IVComplete tearing of the ligament, midcarpal exam:
arthroscope may be advanced into the interval
Key Terms: scapholunate ligament; athlete; thermal shrinkage;
functional outcome
Introduction
Chronic dorsal wrist pain can be debilitating to affected
individuals. Unfortunately, an accurate clinical diagnosis may
be difficult due to limitations of the physical exam and imaging
techniques.1 Patients are often diagnosed with a “wrist sprain”
without a clear understanding of the pathology.2 Recent wrist
arthroscopic techniques have evolved to improve the diagnostic capabilities and treatment of intercarpal ligament injuries.3,4
Geissler and Freeland developed a classification system of
wrist interosseous ligament instability based on arthroscopic
findings.5 (Table 1) Grade I and II injuries represent attenuation or partial tearing of the ligament without significant instability. These types of scapholunate injuries are amenable to
arthroscopic techniques. However, Grade III and IV categories
Figure 1: Arthroscopic image of the midcarpal joint with wide diastasis of the scaphoid and lunate consistent with a Geissler Grade
III/IV.
48
Indiana Orthopaedic Journal
Volume 3 – 2009
Outcomes Following Arthroscopic Thermal Ligamentorrhaphy of Partial Tears
of the Scapholunate Ligament in an Active Population (continued)
Materials and Methods
This study was approved by our Institutional Review
Board and all patients signed informed consents. Between January, 2003 and February, 2006,15 patients were identified who
had undergone thermal ligamentorrhaphy of the scapholunate
ligament. Three patients were excluded from the study because their primary symptoms were ulnar sided wrist pain and
they were primarily treated for triangular fibrocartilage complex (TFCC) tears. Of the remaining patients, 10 consented to
participate and are included in this analysis. There were three
males and seven females. The mean age of the study subjects
was 33.9 years (range 18-52). Nine of these patients were active in the arts, recreational or collegiate level athletics. (Table 2)
Table 2. Avocational Activities of Study Population
Sport
Number of patients Basketball
Golf
Cheerleading
Go Carts
Piano
Working out No sport 2
3
1
1
1
1
1
Level
was achieved and any flaps were debrided with a small shaver.
(Figure 3) Copious irrigation was utilized during thermal application of the ligament. After finishing the arthroscopic portion of the procedure, posterior interosseous nerve (PIN) resection was performed by identifying the PIN on the radial side of
the fourth dorsal compartment and then resecting 1-2 cm of the
nerve. Postoperative Rehabilitation
Postoperatively, patients were immobilized in a short arm
splint for one week and then in a short arm cast for four weeks.
Active and passive range of motion exercises were introduced
with protection in a removable splint when not exercising.
Strengthening and return to activity was allowed over the next
two months with full return to activity and sports occurring
three to six months postoperatively.
Recreational
Collegiate
Collegiate
Recreational
Recreational
Recreational
Clinical Presentation
All patients presented with dorsal wrist pain which had
been present for a minimum of three months. Physical exam
revealed tenderness on the scapholunate interval and exhibited
pain in dorsiflexion. Pain was reproduced with scaphoid shift
test but without carpal instability. Decreased grip strength of
the dominant involved extremity was noted when compared
to the contra-lateral. Grip and static PA wrist radiographs were
negative for widening of the scapholunate interval. Sagittal
wrist radiographs demonstrated neutral posture of the lunate
with normal scapholunate relationships. Magnetic resonance
imaging (MRI) of the wrists was interpreted as either partial
tearing of the SL ligament or no ligamentous pathology.
Figure 2: The arthroscopic image is from the radiocarpal joint with
the RF probe applied to the scapholunate ligament complex.
Surgical Procedure
During arthroscopy the SL ligament was evaluated from
the radiocarpal joint by introducing a 2.7 mm, 25 degree scope
into the 3-4 portal and a probe through the R6 portal. Stability of the SL ligament was evaluated from the midcarpal
joint through the scaphocapitate portal (radial midcarpal). If
the ligament was found to be intact, but redundant (Grade I),
with or without a flap tear (Grade II) the patient was considered a candidate for thermal ligamentorrhaphy. A small joint
Vulcan (Smith & Nephew, Andover, MA) or Oratec (Oratec,
Menlo Park, CA) monopolar radiofrequency probe was introduced through the R6 portal and set at a temperature of 65
– 72 degrees Celsius. (Figure 2) Thermal shrinkage was undertaken until the normal convex appearance of the ligament
49
Figure 3: The arthroscopic image from the radiocarpal joint demonstrates normal appearance of the scapholunate with a covex appearance.
Indiana Orthopaedic Journal
Volume 3 – 2009
Outcomes Following Arthroscopic Thermal Ligamentorrhaphy of Partial Tears
of the Scapholunate Ligament in an Active Population (continued)
Outcome measures included grip strength, the Mayo
wrist score, and the Disabilities of the Arm, Shoulder, and
Hand (DASH) score. The Mayo wrist score is derived from
assessment of pain, function, grip strength, and range of motion. Mayo wrist scores were graded as excellent if 90 points
or higher, good from 80 to 89, fair from 65 to 79, and poor if
less than 65 points. The DASH Outcome Measure is a 30-item,
self-report questionnaire designed to measure physical function and symptoms in patients with musculoskeletal disorders
of the upper limb. Additionally, the DASH contains two optional modules that measure function in work and sports activities. There are four questions on the sports module section and
the patient is asked to rate each one on a scale of one to five
with one being no difficulty in doing the task asked and with
five being unable to do the task asked. Each section of the
DASH is scored from zero to 100, with a lower score indicating higher function.
Results
Mean follow-up time for clinical follow-up was 15.8 weeks
(range 5-38 weeks). The DASH questionnaire was mailed to patients at a later time than their final visit to the clinic and the
mean follow-up time for the return of the completed survey
was 56.6 weeks (range, 22 – 170 weeks). Mean grip strength
was 89.7% (range, 57-110%) of the contralateral side. Seven
of the 10 patients scored good to excellent on the Mayo score.
Mean DASH scores for the Disability/Symptom section were
14.6 (range, zero to 40.8). Nine patients participated in the arts,
recreational or collegiate level athletics and completed the sport/
performing art module of the DASH. The average score for the
sport/performing art module of the DASH was 36.7 with a range
of patients who had no difficulty playing collegiate basketball
to one patient who was unable to participate in collegiate cheerleading. (Table 3) The cheerleader’s course was complicated by
a re-injury and the development of reflex sympathetic dystrophy
(RSD). No other complications were identified.
Discussion
Radiofrequency thermal ligamentorrhaphy is nothing
new to orthopaedic surgery as it has been used to “shrink”
ligaments of the shoulder, hip, knee and ankle. 6,8,7,14,15,9,10,11,16,17
The principle of RF generated heat involves the creation of a
frequency within tissue that causes water molecules to oscillate, and through interstitial friction, generate heat. Joint capsular tissue and ligaments are modified by focal temperatures
reaching 65-70 degrees Celsius. The temperature must be kept
below 100 degrees Celsius degrees to prevent tissue water vaporization and the resultant tissue ablation leading to loss of
tissue integrity.15 The molecular biology of RF capsulorrhaphy
has been well documented.18 The basis of longitudinal shrinkage of collagen fibrils is the unwinding of the triple helix and
maintenance of intermolecular crosslinks.
Radiofrequency thermal shrinkage for treatment of glenohumeral instability has been studied extensively both in
vivo and clinically.7,14,19,20,21,22,23 Hecht et al showed in histologic evaluation the immediate hyalinization and cell necrosis,
followed by an active cellular reparative phase, and finally tissue maturation, regaining its fibrous appearance by 12 weeks.24
Although the response to heat seems to be both temperature
and time dependent, Hayashi et al demonstrated no effect of
tissue region on shrinkage.7 Results of clinical studies have
shown mixed results with treatment for unidirectional traumatic dislocation showing more favorable results than treatment
for patients with multidirectional instability which often result
in high failure rates.17,21,23 One study also showed favorable results in treating overhead athletes with microinstability.20
The natural history and significance of complete tears of
the SL ligament are well understood.2,25 The SL ligament plays
a crucial role in the kinematics of wrist motion 26 allowing
synchronous movement of the scaphoid and lunate during normal wrist motion. Loss of this link leads to a relatively dorsiflexed posture of the lunate which effectively unloads the ra-
Table 3. Patients’ responses to the sport/performing art module of the Disabilities of the Arm, Shoulder, and
Hand (DASH) questionnaire
Patient #
Sport
Using your usual
technique for playing sport
Questions
Playing sport
because of wrist
Playing sport as well as
you would like
Spending your usual time
playing sport
1
Basketball
No difficulty
No difficulty
No difficulty
No difficulty
2
Golf
No difficulty
No difficulty
Mild difficulty
Mild difficulty
3
Cheerleading
Unable
Unable
Unable
Unable
4
Basketball
Mild Difficulty
No Difficulty
Mild Difficulty
Mild Difficulty
5
Go Carts
Unable
Unable
Unable
Unable
6
No sport or activity
7
Golf
Mild Difficulty
Moderate Difficulty
Mild Difficulty
Moderate Difficulty
8
Playing piano
Mild Difficulty
Mild Difficulty
Mild Difficulty
Mild Difficulty
9
Working out
No difficulty
No difficulty
No difficulty
No difficulty
10
Golf
Mild Difficulty
Mild Difficulty
Mild Difficulty
Mild Difficulty
50
Indiana Orthopaedic Journal
Volume 3 – 2009
Outcomes Following Arthroscopic Thermal Ligamentorrhaphy of Partial Tears
of the Scapholunate Ligament in an Active Population (continued)
diolunate joint. This condition is known as a dorsal intercalated
segmental instability (DISI) deformity. In the presence of DISI,
the radioscaphoid joint is overloaded, subsequently leading to
degeneration of this joint and collapse of the wrist in a pattern
of arthritis termed scapholunate advanced collapse (SLAC).
While an isolated injury to the SL ligament does not invariably
result in scapholunate diastasis and a DISI deformity, tears of
the SL ligament (or even partial tears) have been shown to progressively lead to the typical radiographic findings mentioned
previously.2 Treatment of acute complete (Grade III or IV) SL
ligament tears consists of open reduction and internal fixation
of the ligament.27
Controversy exists concerning the treatment of partial
tears of the SL ligament. Some authors have advocated debridement of partial SL tears and have documented up to 85%
improvement.4,28 Recently, surgeons have begun to utilize arthroscopic thermal ligamentorrhaphy for the treatment of partial SL tears.12 Darlis et al presented their results in 16 patients
(mean age of 34 years) with a mean follow up of 19 months.
Fourteen patients in their cohort experienced substantial pain
relief following the procedure while two patients did not. During follow-up, there were no signs of radiographic degenerative joint disease within the wrist and based on the Mayo wrist
score, there were eight excellent, six good, one fair, and one
poor result. Of note, only one patient in this study was considered an elite level athlete and this patient was unable to return
to his previous level of sports activity. The authors recommended viewing these intermediate term results cautiously, but
noted the procedure to be safe and effective in relieving dorsal
wrist pain in selected patients.
Hirsh et al13 reported their results of electrothermal shrinkage in a series of 10 patients, all with Geissler Type II SL ligament tears. At an average follow-up of 28 months average
DASH scores were 20 (range, 11-48). Nine of the 10 patients
were asymptomatic at final follow-up and had returned to their
pre-injury functional level.
Our results, in terms of grip strength, DASH score, and
Mayo score are comparable to those obtained in other studies.
Additionally we more closely examined how our patients were
able to return to their athletic and recreational activities.
One weakness of our study is the small number of patients. Partial symptomatic tears of the scapholunate ligament
are relatively uncommon, and this is reflected in the paucity
of patients in this study. A longer follow-up time would also
strengthen the results of our study. While seven of our 10 patients enjoy good to excellent results at the current mean follow-up of 56.6 weeks, it is unclear whether they will continue
to experience the same level of function and pain relief over
an extended period of time. Finally, the numerous concomitant
procedures performed in conjunction with SL shrinkage lead
one to question how much of the outcome is directly attributable to the surgery in question. Another confounding aspect
is that all of our patients underwent PIN neurectomy whereas
this procedure was not performed in the studies by Hirsch et
al13 and Darlis et al12. A randomized trial comparing ligamentorrhaphy alone would need to be conducted to answer this
question.
51
Conclusion
Pain relief was achieved in the majority of the patients following thermal ligamentorrhaphy for Geissler grades I and II
partial tears of the scapholunate ligament. Results of our study
compare favorably to previous reports. Our series of active patients were able to return to their pre-injury level of activities
which included activities beyond that of work and activities of
daily living. Thermal ligamentorrhaphy appears to be a safe
and effective way to treat active athletes with no known adverse effects in this series of active patients.
References
1.Dautel G, Goudot, B, Merle, M. Arthroscopic diagnosis of scapho-lunate instability in the absence of X-ray abnormalities. J Hand Surg. 1993;18A:213-218.
2.Watson HK, Weinzweig, J, Zeppieri, J. The natural progression of scaphoid instability. Hand
Clinics. 1997;13:39-49.
3. Kozin SH. The role of arthroscopy in scapholunate instability. Hand Clinics. 1999;15:435-444.
4. Weiss AP, Sachar, K, Glowacki, KA. Arthroscopic debridement alone for intercarpal ligament
tears. J Hand Surg. 1997;22A:344-349.
5. Geissler WB, Freeland, AE. Arthroscopically assisted reduction of intraarticular distal radial
fractures. Clin Orthop. 1996;125-134.
6. Philippon MJ. The role of arthroscopic thermal capsulorrhaphy in the hip. Clin Sports Med.
2001;20:817-829.
7. Hayashi K, Markel, MD. Thermal capsulorrhaphy treatment of shoulder instability: basic science. Clin Orthop. 2001;59-72.
8. Maiotti M, Massoni, C, Tarantino, U. The use of arthroscopic thermal shrinkage to treat chronic lateral ankle instability in young athletes. Arthroscopy. 2005;21:751-757.
9. Indelli PF, Dillingham, MF, Fanton, GS, Schurman, DJ. Monopolar thermal treatment of
symptomatic anterior cruciate ligament instability. Clin Orthop. 2003;139-147.
10. Farng E, Hunt, SA, Rose, DJ, Sherman, OH. Anterior cruciate ligament radiofrequency thermal shrinkage: a short-term follow-up. Arthroscopy. 2005;21:1027-1033.
11. Roach R, Roberts, S, Rees, D. The potential benefit of thermal shrinkage for lax anterior cruciate ligaments. Acta Orthopaedica Belgica. 2004;70:247-252.
12. Darlis NA, Weiser, RW, Sotereanos, DG. Partial scapholunate ligament injuries treated with
arthroscopic debridement and thermal shrinkage. J Hand Surg. 2005;30A:908-914.
13. Hirsh L, Sodha, S, Bozentka, D, Monaghan, B, Steinberg, D, Beredjiklian, PK. Arthroscopic
electrothermal collagen shrinkage for symptomatic laxity of the scapholunate interosseous ligament. J Hand Surg. 2005;30B:643-647.
14. Chen S, Haen, PS, Walton, J, Murrell, GA. The effects of thermal capsular shrinkage on the
outcomes of arthroscopic stabilization for primary anterior shoulder instability. Am J Sports Med.
2005;33:705-711.
15. Lu Y, Bogdanske, J, Lopez, M, Cole, BJ, Markel, MD. Effect of simulated shoulder thermal
capsulorrhaphy using radiofrequency energy on glenohumeral fluid temperature. Arthroscopy.
2005;21:592-596.
16. Carter TR, Bailie, DS, Edinger, S. Radiofrequency electrothermal shrinkage of the anterior
cruciate ligament. Am J Sports Med. 2002;30:221-226.
17. D’Alessandro DF, Bradley, JP, Fleischli, JE, Connor, PM. Prospective evaluation of thermal
capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up. Am
J Sports Med. 2004;32:21-33.
18. Medvecky MJ, Ong, BC, Rokito, AS, Sherman, OH. Thermal capsular shrinkage: Basic science and clinical applications. Arthroscopy. 2001;17:624-635.
19. Levy O, Wilson, M, Williams, H, Bruguera, JA, Dodenhoff, R, Sforza, Get al. Thermal capsular shrinkage for shoulder instability. Mid-term longitudinal outcome study. J Bone Joint Surg.
2001;83B:640-645.
20. Reinold MM, Wilk, KE, Hooks, TR, Dugas, JR, Andrews, JR. Thermal-assisted capsular
shrinkage of the glenohumeral joint in overhead athletes: a 15- to 47-month follow-up. J Orthop
Sports Phys Ther. 2003;33:455-467.
21. Noonan TJ, Tokish, JM, Briggs, KK, Hawkins, RJ. Laser-assisted thermal capsulorrhaphy.
Arthroscopy. 2003;19:815-819.
22. Gartsman GM, Roddey, TS, Hammerman, SM. Arthroscopic treatment of anterior-inferior
glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg. 2000;82A:991-1003.
23. Mishra DK, Fanton, GS. Two-year outcome of arthroscopic bankart repair and electrothermal-assisted capsulorrhaphy for recurrent traumatic anterior shoulder instability. Arthroscopy.
2001;17:844-849.
24. Hecht P, Hayashi, K, Cooley, AJ, Lu, Y, Fanton, GS, Thabit, G, III et al. The thermal effect of
monopolar radiofrequency energy on the properties of joint capsule. An in vivo histologic study
using a sheep model. Am J Sports Med. 1998;26:808-814.
25. O’Meeghan CJ, Stuart, W, Mamo, V, Stanley, JK, Trail, IA. The natural history of an untreated isolated scapholunate interosseus ligament injury. J Hand Surg. 2003;28B:307-310.
26. Sokolow C, Saffar, P. Anatomy and histology of the scapholunate ligament. Hand Clinics.
2001;17:77-81.
27. Zarkadas PC, Gropper, PT, White, NJ, Perey, BH. A survey of the surgical management of
acute and chronic scapholunate instability. J Hand Surg. 2004;29A:848-857.
28. Ruch DS, Poehling, GG. Arthroscopic management of partial scapholunate and lunotriquetral
injuries of the wrist. J Hand Surg. 1996;21A:412-417.
Indiana Orthopaedic Journal
Volume 3 – 2009
The Institute of Medicine Report on Resident Duty Hours
Part I: The Orthopaedic Trauma Association Response to the Report
By Jeffrey O. Anglen, M.D., Department of Orthopaedics – Indiana University School of Medicine – Indianapolis, Indiana, USA
Michael J. Bosse, M.D., M.S.E., Department of Orthopaedic Surgery – Carolinas Medical Center – Charlotte, North Carolina, USA
Timothy J. Bray, M.D., Reno Orthopaedic Clinic, Reno, Nevada, USA
Andrew N. Pollak, M.D., Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland, USA
David C. Templeman, M.D., Department of Orthopaedic Surgery, G2, Hennepin County Medical Center, Minneapolis, Minnesota, USA
Paul Tornetta III, M.D., Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts, USA
J. TracyWatson, M.D., Department of Orthopaedic Surgery, Saint Louis University, Saint Louis, Missouri, USA
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member
of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
© 2009 The Journal of Bone and Joint Surgery, Inc. Reprinted from the Journal of
Bone and Joint Surgery American, Volume 91, pp. 720-722 with permission.
The Orthopaedic Trauma Association (OTA) is a professional organization, composed primarily of orthopaedic trauma
surgeons, with the mission of promoting excellence in the care of
injured patients through education, research, and advocacy. The
majority of our membership is from the United States and is involved in training orthopaedic residents. We read with great concern the prepublication draft of the recent report by the Institute
of Medicine (IOM) entitled ‘‘Resident Duty Hours: Enhancing
Sleep, Supervision, and Safety.’’1 We believe that if the recommendations of this IOM committee were adopted by the Accreditation Council for Graduate Medical Education (ACGME), the
result would be detrimental to the care of trauma patients and the
training of orthopaedic residents in the United States.
While it may seem intuitively logical that sleep deprivation
and excessive fatigue might lead to the commission of medical
errors by resident physicians and resultant patient injury, there is
no evidence that this is actually occurring or has occurred to a
substantial degree in the current training environment. The IOM
report acknowledges this lack of evidence in the summary section of Chapter 6, in which they note that the ‘‘data are too limited’’ to determine what proportion of errors or adverse events
are even attributable to residents, much less to resident fatigue
(page 6-23). The report notes that it is ‘‘not possible’’ to determine the extent of patient risk from resident fatigue or whether
further reduction in resident duty hours would improve patient
safety (page 6-24). While this lack of evidence may be due to
inadequate study, we believe it is also true that the current system of supervision and oversight limits the likelihood of patient
injury from resident error.
We agree with the committee that there has been inadequate
time and effort to study the effects of the introduction of the
eighty-hour workweek restrictions instituted in 2003. The report
notes that there has been a ‘‘lack of any comprehensive attempt
to document changes . . . and their impact, if any, on . . . patient
safety’’ (page S-15) and ‘‘the full effects’’ of the 2003 duty-hour
regulations remain unclear (page 4-19)1. Nonetheless, they go
on to recommend further restriction of resident duty hours. We
believe that it is dangerous and imprudent to make disruptive,
expensive, and potentially harmful regulatory changes to correct
a problem that is not documented to exist, particularly without
adequate study of the effects of duty hours on patient safety and
educational efficacy. Changes in resident duty-hour regulations
should be based on the results of such research, in the same man-
ner that changes in medical care should be based clearly on scientific evidence.
We believe the proposed changes would be detrimental for
the following reasons:
1. All regulatory changes involve unintended and unexpected consequences. There are many possible ways in which
increased duty-hour restrictions may actually increase medical errors and worsen patient safety. Other factors in residentassociated medical errors include faulty handover of care, high
patient loads, and cross-covering large numbers of patients2. All
of these are likely to be worsened, at least in the short term, by
the proposed changes. This is acknowledged in the report when
they state ‘‘All . . . agreed that shorter duty hours have resulted
in more handovers of care, which have been associated with increased risks to patient safety’’1 (page 1-11). In addition, further
limitation of duty hours may reduce the number of residents on
duty in some hospitals at one time, reducing resident-resident
supervision and backup. Further study is warranted to ensure
that the increased duty-hour restrictions do not result in more
patient harm and to quantify the associated risk.
2. As detailed in the 2006 IOM report ‘‘Hospital-Based
Emergency Care: At the Breaking Point,’’3 America’s trauma
centers are in a crisis state. Many or most trauma centers are
affiliated with teaching institutions and rely on resident care to
keep up with the ever-increasing load of emergency patients.
As trauma surgeons, we are acutely aware of this problem on a
daily basis. Further restriction of resident duty hours may cripple
trauma centers by forcing perfectly capable, well-trained, and
eager surgical residents to sit on the sidelines, while manpower
shortages result in decreased access for patients.
3. Further limitation of resident duty hours will necessarily
result in reduced resident experience in patient care. This will
produce residents with a lower level of surgical skill and immature ability for independent decision-making. These less skillful, less experienced graduates may place subsequent patients at
risk for errors committed when the surgeons are in independent
practice, without the protective backup of experienced faculty
surgeons. Some effort to study and estimate this risk should be
performed prior to instituting any changes, in order to compare
with the potential risks of the current system. Alternatively, the
duration of surgical training programs may need to be lengthened to achieve adequate experience and skill, which would
52
Indiana Orthopaedic Journal
Volume 3 – 2009
The Institute of Medicine Report on Resident Duty Hours (continued)
worsen the projected manpower shortages in surgical specialties
and reduce patient access to care.
4. While studies have documented that the eighty-hour
workweek has resulted in improvements in self-reported quality
of life for residents, they have also documented a reduction in the
same measures for faculty4,5. Academic physicians, particularly
orthopaedic trauma surgeons, are a group at high risk for career
burnout. Any changes that increase faculty stress and decrease
quality of life will adversely affect our ability to recruit and retain the experienced surgical teachers who provide the final firewall of patient protection through oversight and supervision.
5. The economic burden of these proposed changes, which
is estimated to be $1.7 billion1 (page S-14), will drain resources from teaching programs and/or from patient care. Although
the committee has called on Congress and ‘‘all potential funding sources’’ to consider mechanisms for support, it is unclear
where this money could be found in the current federal budget.
We agree with the authors of the report that ‘‘without the necessary restructuring in resource allocation, attempts to implement
the recommendations will fail to have the desired benefits and
could even reduce patient safety’’1 (page S-5). To make any such
sweeping changes before the funding mechanism is firmly in
place could be disastrous.
6. The infrastructure and mechanisms for monitoring compliance with some of these recommendations, particularly the
five-hour protected sleep period between 10 P.M. and 8 A.M.
(‘‘nap time’’), do not exist and would necessitate a dramatic expansion of the surveillance activities of residency programs. It is
not clear who would be performing bed checks and whether that
cost is included in the above estimate of resources required.
In addition to the reasons we have listed, we have more
general and philosophical concerns with the culture that may be
promoted by the recommendations in this report—that is, a culture in which the needs of the patient are no longer the primary
concern of the physician but take a secondary role to the personal comfort of the physician. This trend would seem to erode
the basis of professionalism underlying the practice of specialty
surgery in the U.S. Although some medical specialties, because
of the nature of their practice, can adopt a ‘‘shiftwork’’ approach
with no reduction in quality of patient care, we do not believe
that is true for orthopaedics nor for the subspecialty of orthopaedic traumatology. Ours is a challenging profession, in which
working long hours and functioning while fatigued are sometimes necessary for successful outcomes. As the report states,
‘‘many physicians work long and unpredictable hours around the
clock once they finish their graduate medical training—longer
hours than most other workers in the United States’’1 (page 1-8).
If potential orthopaedic surgeons do not learn how to recognize,
accommodate to, and work through some level of fatigue within
the relatively protected environment of residency, then they will
have to learn it later, after residency, possibly at great cost to
their patients. There should be some recognition in the regulations for the differences between the specialties. One set of rigid
rules does not fit all specialties and could do a disservice to the
public by producing physicians who may be ill-suited for their
chosen specialty.
We strongly urge the ACGME not to adopt any of the proposed changes contained in the IOM report unless and until further study documents the need for change and a favorable riskbenefit ratio for the proposed restrictions and certainly not until
adequate funding mechanisms are solidly in place.
Part II: A Response to the Orthopaedic Trauma Association Leadership
Regarding Their Position Paper on the Institute of Medicine Report
By Thomas J. Nasca, MD, MACP, Philadelphia, Pennsylvania
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member
of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
The Accreditation Council for Graduate Medical Education (ACGME) has embarked on a comprehensive survey of the
graduate medical education community concerning the elements
contained in the Institute of Medicine (IOM) report.1 This includes a national survey of program directors, faculty, and residents (which was in its fourth week at the time of writing) and
will include requests from organizations (such as the Orthopaedic Trauma Association [OTA]) whose members are involved
in the education of residents and fellows, the next generation of
physician caregivers in the United States. The OTA has anticipated our request for positions regarding this report.
We do not intend merely to respond to the IOM report.
The ACGME has called for formal positions from over 100 organizations, and their response has been requested by May 1.
This information, coupled with an in-depth review of the medical literature on patient safety and resident duty hours, will be
used to inform the Council of Review Committee Chairs and the
ACGME Board of Directors in their deliberations regarding the
53
review and potential revision of ACGME duty-hour standards.
These actions are in keeping with the promise made to the profession in 2003, to review and revise as appropriate our resident
duty-hour standards and key elements of the learning environment.
References
1. Ulmer C, Wolman DM, Johns MME, editors; Committee on Optimizing Graduate Medical
Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Resident duty hours:
enhancing sleep, supervision, and safety. Institute of Medicine of the National Academies. Washington, DC: National Academies Press; 2008.
2. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on
adverse events and their causes. Arch Intern Med. 2005;165:2607-13.
3. Committee on the Future of Emergency Care in the United States Health System. Hospitalbased emergency care: at the breaking point. Washington, DC: National Academies Press; 2007.
4. Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. The impact of the 80-hour
resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243:864-75.
5. Vanderveen K, Chen M, Scherer L. Effects of resident duty-hours restrictions on surgical and
nonsurgical teaching faculty. Arch Surg. 2007;142:759-66.
Indiana Orthopaedic Journal
Volume 3 – 2009
Hoosier Health
Stephen B. Trippel, M.D.
Department of Orthopaedic Surgery – Indiana University School of Medicine – Indianapolis, Indiana, USA
Indiana has an unprecedented opportunity to assume a
national leadership role in health care reform. This is not limited to orthopaedics, for while orthopaedic patients would
be affected by such Indiana leadership, all Hoosiers could benefit. This year, our country is engaged in a renewed discussion on how to simultaneously decrease costs and increase
coverage in the provision of goods and services via a health
care delivery system. The opportunity for Indiana arises from
Washington’s focus for reform on deficiencies in health care,
while the central problem our state and our country faces is
deficiencies in health.
Regarding health care, it is clear that, in orthopaedics, as
well as other disciplines, there are problems in its distribution. In contrast, far from suffering a deficiency in the amount
of health care that we consume, it can be argued that we in the
US are over-utilizers of care. But let us assume, instead, that
we need all of the health care that we use. We then may ask
why we need it. Since our need for treatment increases when
our success at preserving health decreases, the answer is, at
least in part, that we are failing to keep our health.
This gives us a choice. We can choose to focus on achieving and preserving health, or we can choose to focus on
trying to regain our health after it is lost. Indiana’s current
opportunity is to lead the country in implementing methods
to preserve health while Washington developes methods to
control care.
This opportunity is possible only because of a phenomenon observed several years ago by, among others, Dr. Louis
W. Sullivan, Secretary of the US Department of Health and
Human Services. Writing about individual behavior, he noted
“… our physical and emotional well-being is dependent upon
measures that only we, ourselves, can affect.” Through “enlightened behavior”, “we can control our health destinies…”
He chose smoking as one example, noting that it is “the single most preventable cause of death and illness in this country”. As another example he chose AIDS, noting that it “is an
almost entirely preventable disease.” (Healthy People 2000,
DHHS Publication No. (PHS) 91-50212, 1990, p. v). Today,
in Indiana and elsewhere, we would have to add obesity, diabetes, heart disease, and arthritis to the list of diseases that are
at least partly preventable through “enlightened behavior”.
And this is only a small selection from the list of such problems. From this perspective, we are not merely losing our
health, we are discarding it.
Behavior-dependent diseases have a profound effect on
the patients we see in orthopaedic practice. Behaviors can
influence the initial development of a host of orthopaedic disorders ranging from fractures to arthritis to slipped femoral
capital epiphysis. Further, behaviors can adversely affect the
outcome of both the operative and non-operative treatments
that we provide for those disorders. And orthopaedics is not
the only specialty affected by these problems. Indeed, it is
likely that most medical specialties can offer examples of
behavior-dependent diseases.
In addressing the phenomenon that many diseases can be
prevented by our own individual behavior, it is important to
remember that many other diseases are not under our control.
Multiple forms of cancer, many infections, and most genetic
disorders - to list a few - are still imposed upon us rather
than brought upon us by ourselves. More intensive research
into the causes of these diseases and an equitable, sustainable
system of care for them are essential. They help validate the
current national discussions regarding system change.
Our ability to control, in large measure, our own health
implies a responsibility to use that control wisely. This is similar to our other abilities. For example, our ability to drive
automobiles comes with a responsibility to drive wisely. Indiana has formalized this responsibility by providing its citizens with incentives, both legal and financial, to use their
ability to control automobiles wisely.
Indiana plays a role in our decision-making process in
areas other than driving. Indeed, the list of our decisions that
Indiana modulates, through various incentives, is long and
varied. They range from decisions about paying taxes to shooting guns to consuming alcohol to selling cigarettes. Imagine
then, what Indiana could accomplish, should it decide to take
the lead in developing policies that reward individuals for
making decisions that promote and preserve health.
54
Indiana Orthopaedic Journal
Volume 3 – 2009
Factors Influencing Patient Choice of Hospital and Surgeon
forTotal Hip or Knee Arthroplasty
Robb Weir, M.D., Judy R. Feinberg, Ph.D., William N. Capello, M.D.
Department of Orthopaedic Surgery – Indiana University School of Medicine – Indianapolis, Indiana
Healthcare consumers are becoming more savvy as relevant information has become more readily available and as
many are shouldering a greater percentage of their healthcare
costs. There is a body of literature on factors influencing the
doctor-patient relationship, with most of those studies geared
toward primary care providers or specialists in treatment of
chronic diseases.1-3 There is much less information on how
a patient chooses a given health care provider and even less
information on patients’ choice of hospital, perhaps because
patients are more likely select a physician first and then hospital choice is limited to where the physician has admitting
privileges. Hospitals are more likely to gather patient satisfaction information following a given procedure or admission to evaluate consumer preferences than to evaluate patient choice primarily.4,5
Historically, prescription drug and medical device advertising in the United States was directed primarily toward
professionals rather than consumers. However, direct-to-consumer (DTC) advertising has grown exponentially since the
FDA lifted a moratorium on direct marketing of prescription
drugs to patients in 1985.6 This explosion of DTC advertising
is highly controversial with proponents citing research showing its value in educating consumers and increasing public
awareness of various medical conditions and treatment options.7,8 On the other hand, opponents argue that it strains the
doctor-patient relationship because of inappropriate requests
for specific drugs or devices by patients leading to inappropriate or excessive use of healthcare resources.9-10
Recently the orthopaedic community has begun to examine the effect of DTC advertising, particularly related to
a growing number of total hip and knee arthroplasties.11 Results of a survey of 361 surgeons indicated a majority felt
that DTC advertising had an overall negative impact on their
practice and their interaction with patients (74%) and that patients were often confused or misinformed about the appropriate treatment for their condition based on an advertisement
(77%).11 Of the 352 patient respondents, 52% recalled seeing
or hearing advertisements related to hip or knee arthroplasty,
and those patients were more likely to request a specific type
or surgery or brand of implant. Thus, advertising appears to
be playing a substantial role in orthopaedic practice.
Although advertising is clearly having an effect related to
total hip or knee arthroplasty, how advertising has influenced
patient selection of an arthroplasty surgeon or the hospital
where that procedure might take place has not been studied.
Our aim in this study was to begin to examine the various
influences on patient selection of an arthroplasty surgeon and
hospital, including the effect of DTC advertising.
55
Methods
The population for this pilot study was drawn from the
practice of four arthroplasty surgeons at two clinic locations
within a single healthcare system. All patients who were
scheduled for a primary or revision total hip or knee arthroplasty within an eight-month period were asked to complete
the study survey instrument at the time of scheduling a hip
or knee arthroplasty procedure. The survey instrument was
designed to assess the importance of various factors that may
influence patient selection of a hospital or surgeon for total
hip or knee arthroplasty. In addition to demographic information, the study patients were asked to rank each of 15 items
related to their choice of hospital and 16 items related to their
choice of surgeon as to the amount of influence each played.
A Likert-type scale was used with 1 being lowest (no influence) to 10 being highest (most influential). Respondents
were also given the option of marking ‘NA’ if the item was
not applicable to them. This study was approved as exempt
through the IRB, and consent to participate was implied by
completion of the survey. Descriptive statistics were used to
analyze the data, and nonparametric statistics were used to
compare male versus female and age less than 65 years to
65 years and older using CSS:Statistica (StatSoft, Inc, Tulsa,
OK).
Results
A total of 107 patients completed the survey. Demographic characteristics are seen in Table 1. The demographics
Table 1
Study Patient Demographics (N = 107)
Variable
Valid N
Sex
105
Age
91
Marital
104
Status
Race
100
Education
105
Employment
101
Insurance
103
Residence
93
Procedure
101
N (%)
33 male (31%), 72 female (69%)
61.7 ± 11.7 (range, 34 – 96)
53 (51%) married,
51 (49%) divorced/widow/single
82 (82%) Caucasian, 18 (18%) other
57 (54%) high school or less,
48 (46%) some college/degree
34 (33%) full- or part-time, 37 (36%) retired,
30 (31%) disabled/unemployed/homemaker
48 (47%) Medicare, 42 (41%) private,
13 (12%) other
77 (83%) Indianapolis or surrounding area,
13 (14%) state of Indiana, 3 (3%) outside of Indiana
39 (39%) unilateral THA, 57 (56%) unilateral TKA,
5 (5%) bilateral THA or TKA
Indiana Orthopaedic Journal
Volume 3 – 2009
Factors Influencing Patient Choice of Hospital and Surgeon for
Total Hip or Knee Arthroplasty (continued)
reflect a typical total hip or knee arthroplasty population, that
is, about two-thirds female, average age of 62 years, and the
majority Caucasian. Thirty-nine (39%) patients were undergoing unilateral total hip arthroplasty and 57 (56%) were undergoing unilateral total knee arthroplasty. Five patients were
undergoing bilateral hips or knees, and another six patients
did not indicate what procedure they were going to undergo.
Of the 45 patients who indicated that the planned arthroplasty
was not their first hip or knee joint replacement, 20 indicated
that this planned arthroplasty would be performed by the same
surgeon who did their previous arthroplasty, and 21 indicated
that it was to be at the same hospital as the previous arthroplasty. Forty-two (40%) patients indicated that this surgeon
was the second or third surgeon they had consulted for the
needed arthroplasty. When asked how the choice of implant
was decided for the planned arthroplasty, 68 (64%) indicated
that the surgeon told them what implants would be used; 30
(28%) indicated that the decision was mutually agreed upon
after discussing several options, and two patients (2%) indicated that they had suggested a specific type of implant to the
surgeon. The vast majority of patients (101, 95%) indicated
that their reason for seeking out a surgeon was because their
joint pain had become worse or unbearable, with a loss of
functional ability as the second most common reason (73,
69%).
The ranking of the factors influencing patient choice of
surgeon is seen in Table 2. The greatest percentage of respondents (69%) thought that the friendliness and helpfulness of
Table 2
Influence of Factors in Selecting an Arthroplasty Surgeon
Percentages Based on a 10-Point Likert Scale
(1 = least influential 10 = most influential)
Factor
Valid N NA/1-3
4-7
8-10
Friendliness/Helpfulness of Staff
97
25%
6%
69%
Personality of Surgeon
97
23%
10%
67%
Reputation of Surgeon
96
26%
9%
65%
Surgeon is Board-Certified
94
31%
5%
64%
Experience of Surgeon
94
34%
7%
59%
Surgeon was Suggested or Scheduled
by My Primary Doctor
96
40%
3%
57%
Convenience of Office Location
97
38%
11%
51%
Insurance Coverage In-Network
98
45%
7%
48%
Type of Implants Used by Surgeon
(Manufacturer, Design)
92
55%
11%
34%
Previous Experience with This Surgeon
96
63%
6%
31%
Recommended by Friend or Relative
92
73%
2%
25%
Cost/Charges for Service
94
69%
6%
24%
Selected Hospital, Not Surgeon
93
83%
5%
12%
Internet Web-Site Information
92
85%
8%
8%
Radio or TV Advertisement
93
90%
3%
7%
Newspaper or Magazine Advertisement
91
95%
2%
3%
the staff was most influential in their selection of a surgeon.
The next most influential factors were the personality of the
surgeon (67%), the reputation of the surgeon (65%), and
board certification of the surgeon (64%). The least influential
factors were all media-related. Print, radio, and television advertisements as well as internet information were ranked the
lowest by 85% to 95% of respondents.
Table 3
Influence of Factors in Selecting a Hospital
Percentages Based on a 10-Point Likert Scale
(1 = least influential 10 = most influential)
Factor
Valid N NA/1-3
4-7
8-10
9%
68%
Good Reputation
98
22%
Selected Surgeon, Not Hospital
95
40%
5%
55%
Convenient Location of Hospital
98
32%
15%
53%
Insurance Coverage In-Network
101
42%
6%
52%
Convenient Parking
100
39%
14%
37%
Private Rooms
97
50%
10%
40%
Previous Experience with Hospital
99
52%
11%
37%
Restaurant-Style Menu
99
58%
12%
30%
Recommended by Friend or Relative
93
69%
5%
26%
New Building
97
59%
19%
23%
Cost/Charges for Services
94
69%
10%
21%
Did Not Like Previous Hospital
91
82%
5%
12%
Radio or TV Advertisement
95
91%
4%
5%
Internet Web-Site Information
92
92%
4%
3%
Newspaper or Magazine Advertisement
94
93%
5%
2%
The ranking of the factors influencing patient choice of
hospital is seen in Table 3. Sixty-eight per cent of respondents indicated that the reputation of the institution was the
most influential aspect for choosing a hospital. The convenience of location was endorsed as most important by 53%
of respondents, and the hospital being in their insurance network was most important to a similar percentage (52%) of
respondents. However, 55% of respondents indicated that
selection of the surgeon was of greater influence than the
selection of hospital. The least influential factors in hospital
selection were the same as with surgeon selection, that being
all media-related items, with greater than 90% ranking those
items as low influence or not applicable.
There were no differences in preferred influences between males and females or between younger (<65 years old)
or older (54 years or older) patients, however the numbers in
this study are small and statistical power, calculated post-hoc,
was lacking.
Discussion
The aim of this pilot study was to determine what factors most influence a patient’s choice of surgeon and hospital
when undergoing total hip or knee arthroplasty. Interesting,
56
Indiana Orthopaedic Journal
Volume 3 – 2009
Factors Influencing Patient Choice of Hospital and Surgeon for
Total Hip or Knee Arthroplasty (continued)
the item endorsed as most influential to the greatest percentage of patients overall was the friendliness and helpfulness
of the staff, which is neither specific to the surgeon or the
facility. Considering that this study population was drawn
from preoperative patients, one might assume that either this
choice was either based on ‘first impressions’ or was based
on desire, not necessarily actual interactions that had taken
place. However, about 20% of the study participants reported
that this was not their first procedure with this surgeon, and
so those patients had prior encounters with the clinic and hospital staff.
The most influential factors in selecting the surgeon in
this study were personality, reputation, and board-certification
with the least influences coming from media sources. Other
studies of how people choose a doctor are limited. One such
survey conducted in England in 1989 found that, when registering with a new general practitioner, most patients simply
registered with their nearest doctor, and many did not register
until after they were ill, indicating little consumer activism.12
A more recent national survey in the U.S. had somewhat similar findings, confirming that patients tend to be passive consumers of physician services.13 However, the study’s author
also suggested that consumer activism is likely to grow as
access to information with which to compare physicians also
grows. Contrary to the findings in this study of orthopaedic
surgeons, patients selecting a cosmetic surgeon used wordof-mouth and magazine and newspaper articles as important
sources of information.14 However, cosmetic patients also
reported board certification as most influential.
As anticipated, most patients indicated that surgeon selection was more influential than hospital selection, but, the
influential factors were similar to those factors influencing
surgeon selection. The most influential factor for hospital
selection was reputation. Since media-related sources were
rated as having little influence, one might assume that reputation comes from other sources, such as other physicians, family, or friends. The two other most influential factors in hospital selection were quite pragmatic, those being convenience
of location and being in the patient’s insurance network.
As opposed to marketing of drugs, in orthopaedic surgery, physicians and hospitals are responsible for a substantial portion of the DTC advertising.15,16 DTC advertising related to orthopaedic implants through the media is increasing
with over half of patients in a recent study recalling seeing or
hearing advertisements related to hip or knee arthroplasty.11
The effect of advertising was not the focus of this study, however it is worth noting that only two patients in this study indicated that they suggested a specific type of implant to their
surgeon, and the majority (64%) indicated that the surgeon
told them what kind of implant would be used, presumably
without discussing multiple options since that was another
response choice. Over one-half of patients indicated that the
type of implants used by the surgeon had little or no influence
in their choice of surgeon. The results of this study would
suggest that advertising has little influence on a patient’s selection of a surgeon or hospital, and that these study patients
reflect a passive consumerism seen in other studies. However it should be noted that this study has many limitations,
57
including a small sample size drawn from a single practice
group and a single healthcare system, so these results should
not be generalized to the larger total hip and knee arthroplasty
patient population.
In summary, this pilot study examined factors that may
influence choice of surgeon and hospital by patients who
were scheduled to undergo a total hip or knee arthroplasty
within a single practice and healthcare system. The most influential factor in selecting a surgeon was the friendliness and
helpfulness of the staff, and two-thirds of the patients indicated that both the reputation of the surgeon and the reputation of the hospital were most influential. Although hospitals,
surgeons, and implant manufacturers are increasingly using
DTC advertising in an attempt to gain a competitive edge in
the growing joint arthroplasty market, media-related factors
were the least influential factors in choice of surgeon or hospital in this study. Additional, larger studies should be carried
out to determine the efficacy of such advertising as, at least
with this small study, the influence seems much less than the
impact of DTC advertising of the pharmaceutical industry.
Acknowledgements
The authors would like to thank Drs. Thomas Ambrose,
Russell Meldrum, and Drew Parr for allowing their patients
to participate in this study and Suzie Walters and Brandi
Monnett for their assistance with data collection.
References
1. Duberstein P, Meldrum S, Fiscella K, Shields CG, Epstein RM. Influences on patients’
ratings of physicians: Physicians demographics and personality. Patient Educ Couns. 2007;
65:270-274.
2.Kearly KE, Freeman GK, Heath A. An exploration of the value of the personal doctor-patient
relationship in general practice. Br J Gen Pract. 2001; 51:712-718.
3.Koba R, Sooriakumaran P. The evolution of the doctor-patient relationship. Int J Surg. 2007;
5:57-65.
4.Cheng S-H, Yang M-C, Chiang T-L. Patient satisfaction with and recommendation of a
hospital: effects of interpersonal and technical aspects of hospital care. Intl J Qual Health Care.
2003; 15:345-355.
5.Young GJ, Meterko M, Desai KR. Patient satisfaction with hospital care: effects of demographic
and institutional characteristics. Med Care. 2000, 38:325-334.
6.Food and Drug Administration. Direct-to-consumer advertising of prescription drugs:
withdrawal of moratorium. Federal Register. 1985; (Sept 9):36677-8.
7.Bell RA, Kravitz RL, Wilkes MS. Direct-to-consumer prescription drug advertising and the
public. J Gen Intern Med. 1999;14: 651-657.
8.Kravitz RL, Epstein RM, Feldman MD, Franz VE, Azari R, Wilkes MS, Hinton I, Franks
P. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized
controlled trial. JAMA. 2005; 293:1995-2002.
9. Mintzes B, Barer ML, Kravitz RL, Bassett K, Lexchin J, Kazanjian A, Evans RG, Pan R,
Marion SA. How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in
primary care environments with and without legal DTCA. CMAJ. 2003; 169:405-412.
10.Robinson AR, Hohmann KB, Rifkin JI, Topp D, Gilroy CM, Pickard JA, Anderson RJ.
Direct-to-consumer pharmaceutical advertising: physician and public opinion and potential
effects on the physician-patient relationship. Arch Intern Med. 2004; 164:427-432.
11. Bozic KJ, Smith AR, Hariri S, Adeoye S, Gourville J, Maloney WJ, Parsley B, and Rubash
HE. The 2007 ABJS Marshall Urist Award. The impact of direct-to-consumer advertising in
orthopaedics. Clin Orthop. 2007; 458:202-219.
12.Salisbury CJ. How do people choose their doctor? BMJ, 1989; 299:608-610.
13.Harris KM. How do patients choose physicians? Evidence from a national survey of enrollees
in employment-related health plans. Health Serv Res. 2003; 38:711-732.
14.Nowak LI, Washburn JH. Patient sources of information and decision factors in selecting
cosmetic surgeons. Health Marketing Quarterly. 1998; 15:45-54.
15.Labovitch RS, Bozic KJ, Hansen E. An evaluation of information available on the internet
regarding minimally invasive hip arthroplasty. J Arthroplasty. 2006; 21:1-5.
16.Adeoye S, Bozic KJ. Direct to consumer advertising in healthcare. Clin Orthop. 2007;
457:96-104.
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of the ComPreSs® Device for
Endoprosthetic Fixation in Orthopaedic Oncology:
The Indiana University Experience
L. Daniel Wurtz, M.D. and Raymond J. Metz, M.D.
Section of Orthopaedic Oncology —
­ Indiana University Medical Center – Indianapolis, Indiana, USA
Abstract
Implant failure due to aseptic loosening continues to
be a long term problem in patients reconstructed with large
endoprotheses following limb-sparing resections. Most patients who undergo these procedures for treatment of primary
malignant bone tumors are of a young and often skeletally
immature age and currently receive cemented stems as a fixation option. A substantial number of these young patients
will demonstrate early signs of aseptic loosening within five
years of the reconstruction. A need for a more durable, longterm biologic fixation option prompted us to begin using the
Compress Device (CPS) in a number of our patients. We are
reporting the results of our patients undergoing limb-sparing
surgery and reconstruction using the Compress system for
implant-bone fixation over a two year period. Functional and
radiographic results in these patients have been very encouraging.
Introduction
For at least two decades, limb-sparing surgery emerged
as a reasonable alternative to amputation for the surgical
treatment of patients diagnosed with primary malignant bone
tumors and occasional benign, but locally aggressive, bone
disease. In fact a multiinstitutional study published in 1986
by Simon, et al reported that limb-sparing surgery did not
shorten the survival in patients with osteosarcoma of the distal femur.1 The advantage of this approach for resection of
bone tumors of the lower extremity is not only the improved
cosmesis and social acceptance of retaining a limb but also
improved efficiency of energy expenditure for ambulation.2,3
Our ability to perform a limb sparing resection, however, is
constrained by our struggle to reconstruct a limb in a way to
produce a functional and durable result for the patient when
compared to that of an amputation and prosthetic fitting.4
Even with the looming reality that endoprosthetic reconstruction carries a significant complication rate, the vast majority
of patients are considered candidates for a limb-sparing approach to their surgical treatment. (Figure 1) These complications may be categorized as those occurring early in the
perioperative or early postoperative period such as neurovascular injury, tumor contamination, infection, and limb length
inequality and those occurring late such as tumor recurrence,
hematogenously seeded infection, and implant failure.
Whereas significant progress has been made in many
areas of implant design, device failure continues to be a ma-
jor problem. Advances in design,
modularity, and materials used for
implants have been huge. However a continued long term problem
of fixation failure exists. Most
orthopaedic oncologic surgeons
continue to rely upon the use of
polymethylmethacrylate for stem
fixation to host bone. This practice has been viewed as necessary
for immediate stem fixation in the
relatively hostile bone environment present during the weeks or
months of continued chemotherapy for systemic treatment needed
for aggressive bone malignancies. Uncemented, porous coated
“press fit” medullary canal stems
carry a significant incidence of
early loosening in this environment due to poor bone ingrowth
to the porous surface coating of
typical contemporary implants.
As primary malignant bone tumors such as osteosarcoma and
Ewing’s sarcoma have a predilection for the second decade of life,
cement fixation carries the concern for aseptic loosening issues.5
To add to this concern, many of
these skeletally immature patients
have not only had a disruption of
normal longitudinal bone growth
due to the sacrifice of an active
growth plate, but they will have
a continued maturation of the diameter of a bone due to periosteal
new growth. This periosteal appositional growth leads to an increase in the bone diameter and
medullary canal dimension that
continues long after the canal is
filled with a cement mantle of
finite dimension. This loss of
the cement contact as the bone
essentially grows centripetally
away from the static, nonbiologic
58
Figure 1A, B. Anteroposterior and lateral radiographs of an osteosarcoma
of the distal femur.
Figure 1C. Reconstruction
of the distal femur and knee
with a cemented, endoprosthesis with a rotating hinge
knee replacement.
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of the ComPreSs® Device for Endoprosthetic Fixation in
Orthopaedic Oncology: The Indiana University Experience (continued)
fixation, as well as the age
old problem of osteolysis,
have been a continued
nemesis for the orthopaedic surgeon to insure long
term durable fixation.
(Figure 2)
Because of the concerns for long term implant
survival, we selected a recent innovation called the
ComPreSs® (CPS) (Biomet, Warsaw, IN) to be
incorporated as a cementless fixation alternative
for our endoprostheses to
bone. (Figure 3) This device was FDA approved
in 2003 and was designed
to decrease the common
prosthetic implant causes
of failure as we discussed
above including aseptic
loosening. Initial reviews
of this fixation device
have been very encourFigure 2A, B. Plain radiographs
of a 9-year-old female treated for a aging and have demonstrated results equivalent
distal femoral osteosarcoma. Figure A shows a well-cemented stem. to or better than cemented
Figure B, however, shows obvious
medullary stems.6,7,8 We
aseptic loosening only three years
began
using the CPS in
after surgery.
early 2004 with the hope
of achieving better long term implant survival than those patients with cemented stems and subsequently reviewed our
results for this discussion.
tumor. Seventeen of the 19 patients therefore had diagnoses of high grade bone sarcomas and were treated with pre
and postoperative chemotherapy. The remaining two patients
with benign diagnosis underwent surgical resection only for
treatment of their disease. All patients were followed closely
by clinical examination and plain radiographs.
The CPS device consists purely of a unique, noncemented fixation interface between an endoprosthesis and a
transected bone. Immediate fixation results from compressive
forces generated by a series of compressed concave washers
stacked inside of a spindle with a porous surface that contacts
the cut surface of the bone end. This spindle is anchored by a
medullary canal plug with a stem that is seated several centimeters into the medullary bone canal and stabilized with
cross pins. The spindle telescopes over the canal plug stem as
it emerges from the end of the bone. The compressive forces
of the spindle may be varied from 400 to 800 pounds per
square inch and is based upon measurements of the cortical
bone thickness (strength). After the spindle is securely attached and compressed to the bone, the remainder of the endoprothesis may then be coupled to it through a morse taper
mechanism. The surgical technique is illustrated in Figure 4.
Long term fixation is achieved through bone ingrowth to the
porous surface of the spindle. Patients are asked to remain
touch weight bearing and avoid physical activity other than
motion for six weeks postoperatively to minimize stresses
at the spindle-bone interface until sufficient early bone ingrowth further stabilizes the implant.
Materials and Methods
From our prospectively collected data base, we reviewed
all patients who underwent limb-sparing surgery and reconstruction using large endoprotheses for primary bone disease.
Patients with metastatic disease and/or history of external
beam radiation were contraindicated for the CPS and were
excluded from its use. Of these, we found 19 patients who
had a reconstruction using the CPS device for a study cohort.
All procedures were performed by the senior author (LDW)
at the Indiana University Medical Center. The mean patient
age was 18.3 years (range, 7-48 years). All patients were
followed for at least two years or until death from systemic
disease (one patient). Diagnoses included osteosarcoma, Ewing’s sarcoma, desmoplastic fibroma, and recurrent giant cell
59
Figure 3A, B. Photographs of an assembled endoprosthesis attached to the ComPreSs® device proximally. Note in Figure B, the
porous-coated spindle and the canal plate with stem. The spindle
contacts the bone surface with immediate compression provided by
an appropriate load created by the washers.
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of the ComPreSs® Device for Endoprosthetic Fixation in
Orthopaedic Oncology: The Indiana University Experience (continued)
Figure 4A, B. A plain radiograph and
magnetic resonance image of a 14-year-old
with an osteosarcoma of the distal femur.
Figure 4C, D. Intraoperative photos taken during the resection of this distal femoral
tumor leaving a large bone deficit for reconstruction.
Figure 4E-G. The bone canal anchor plug has been placed. The spindle is then telescoped over the stem of the canal plug. Compression
is then applied by tightening the nut with the T-handle wrench to secure the spindle on to the bone resulting in immediate fixation.
Figure 4H, I. The distal femoral prosthesis is connected to the spindle fixation through the
Morse taper connection.
Results
Of the nineteen patients, 17 patients had at least two
years of follow-up with examinations and plain radiographs.
One patient was lost to follow-up and another died of systemic disease at 18 months. Of these 17 patients, there were three
failures: one patient with insulin dependent diabetes with a
wound infection requiring amputation and two patients with
aseptic loosening requiring revision. One of the patients with
aseptic loosening had exceptionally poor nutritional status
while the other began immediate weight bearing and other
activity against advice. The average time to failure of these
two patients with aseptic loosening was 6.3 months and each
was revised to a cemented stem.
Figure 4J, K.
Anteroposterior and
lateral plain
radiographs
of the
implanted
endoprosthesis with
ComPreSs®
fixation to the
distal femur.
Of the 14 patients without implant failure, 10 patients
were diagnosed with high grade malignant bone tumors necessitating systemic chemotherapy pre and postoperatively to
the initial surgery that included CPS fixation. The remaining
four patients were either revisions after completion of chemotherapy (two patients) or diagnoses not requiring chemotherapy (two patients). Anatomic locations included 10 distal
femurs, two proximal femurs, one proximal tibia, and one
proximal humerus. All of these patients were asymptomatic
and demonstrated a typical radiographic pattern of new bone
growth from the edge of the bone cortex to the edge of the
porous coated spindle creating an appearance resembling an
elephant’s foot. (Figure 5) Most of this osseointegration ap60
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of the ComPreSs® Device for Endoprosthetic Fixation in
Orthopaedic Oncology: The Indiana University Experience (continued)
Figure 5A, B. Plain radiographic evidence of the typical appearance of bone ingrowth to the porous coating of the spindle
(elephant’s foot).
peared to occur within the first 12 months following surgical
implantation. (Figure 6)
Discussion
Prosthetic failure related to aseptic loosening remains a
prevalent and yet vexing problem for long term survival of
large endoprosthetic devices despite innovative changes in
implant design over many years. Uncemented fixation with
typical porous-coated intramedullary stems have not been favored in the population of patients requiring chemotherapy
perioperatively because of continued concerns of poor bone
ingrowth from the host in an environment impacted negatively by systemic chemotherapy administered over several
months before and after reconstructive surgery. Unfortunately cement fixation for these large implants has not resulted in
Figure 6. Electron microscopy of a retrieval specimen showing bone
ingrowth to the spindle. (Courtesy of James O. Johnston, M.D.)
61
predictable good long term
results either. For endoprosthetic reconstruction about
the knee, Healey et al reported aseptic loosening of
the femoral component was
the most frequent mode of
failure. The rate of prosthetic survival with the KaplanMeier method was 85, 67
and 48 percent at three, five,
and ten years, respectively.5
Eckardt (UCLA) and Grimer
(UK) reported similar problems with aseptic loosening
of 47 percent at 10 years
and 74 percent at 20 years,
respectively, for all implant
survivors.9,10 (Figure 7)
Figure 7A. Early postoperative
plain radiograph of a cemented
stem of a distal femoral prosthesis in a 17-year-old patient.
A discussion of the problem of
aseptic loosening would not be complete without a brief review of the basic pathophysiology. Aseptic loosening
is a chronic inflammatory reaction. The
pathology is characterized by the slow
growth of an interface tissue between
the bone and the cement or between
the bone and the metal implant surface.
This interface tissue or membrane is
histologically synovial-like in appearance and is granulomatous histiocyticfibrotic tissue.
Figure 7B, C.
This membrane Aseptic loosening is
is associated with evident on these rathe pathological diographs taken four
bone resorption years postoperatively
responsible for in the same patient.
loosening of the
prosthetic components. Bone
resorption
is
triggered by the
release of cytokines, local inflammatory mediators, and bone
matrix degrading
enzymes.
The process of
aseptic loosening seems to follow a continu-
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of the ComPreSs® Device for Endoprosthetic Fixation in
Orthopaedic Oncology: The Indiana University Experience (continued)
ous, cyclic pathway until gross loosening of the implant stem
occurs. Aseptic loosening has been extensively studied and
many aspects of the disease have been elucidated however
much remains unknown and needs further investigation. This
process has been attributed to the formation of the interface
membrane. The particular membrane in each case is likely
related to the biomechanics of the system implanted, i.e. cemented or uncemented stem. Micromotion was identified as
a possible triggering factor of the inflammatory reaction responsible. Other investigators believe the chronic presence of
wear particles is likely responsible for the cyclic inflammatory reaction and subsequent pathologic bone resorption.
In addition to the problems associated with aseptic
loosening (particularly with cemented stems), we are also
frequently presented with the long term problems of stress
shielding in the patients with intramedullary stems (particularly extensively porous-coated stems) used in an effort to
enhance bone ingrowth.11 This problem of progressive bone
demineralization is directly related to the effects described by
Wolff’s Law. This principle states that the internal architecture and external shape of bone is altered by external forces
upon the bone. This modeling of bone often results in a decrease in host bone quantity and quality as a result of reduced
natural stresses “seen” by the host bone splinted internally.
The ComPreSs® system is a unique fixation device for
endoprostheses used to reconstruct skeletal defects in cases
of tumor resection and failed arthroplasty. It uses a high
compression, pre-stress concept and avoids the use of long
intramedullary stems and cement that have been associated
with stress shielding, osteolysis, and ultimate implant failure.
The CPS device provides immediate, rigid fixation resulting in bone hypertrophy in response to compressive forces
(Wolff’s Law). We have several examples of patients in our
study group demonstrating this bone growth or hypertrophy
of bone cortices. (Figure 8) We believe this device will improve the longevity of limb salvage reconstructions especially in young, active individuals and preserve bone stock rather
than further its resorption.
Frequently, patients requiring extensive tumor surgical
resections will have only short segments of host bone remaining to receive a fixation device. Unfortunately many of these
patients will not have adequate bone length to support a cemented or uncemented medullary stem typically of 10 to 15
centimeters in length. This situation necessitates the use of a
short stem leading to less than optimal long term fixation and
likely resulting in early loosening and failure. The CPS typically seats a canal plug only 8 centimeters in length. Additionally this length may be shortened if necessary. The CPS is
therefore more versatile for a short bone situation. (Figure 9)
The results in our cohort of patients using CPS fixation
is encouraging and is similar to other small studies report-
Figure 8A, B. Revision of the loose stem of the 9-year-old shown
in Figure 2 to an implant using the ComPreSs® fixation. At two
years postoperatively, note the substantial bone growth on to the
spindle with thickened cortices of the host bone. The immediate
compression of the device has caused impressive bone remodeling
as a reaction to stresses imparted to the host bone.
Figure 9A, B. The ComPreSs® device may be used in situations
of limited remaining bone length. Note the bone growth and fixation achieved in this patient four years after a large segment of
femur was removed to treat her malignancy.
62
Indiana Orthopaedic Journal
Volume 3 – 2009
The Use of the ComPreSs® Device for Endoprosthetic Fixation in
Orthopaedic Oncology: The Indiana University Experience (continued)
ed recently.12 Our 3 patients with implant failure presented
within 6 months postoperatively. Two of these patients never
produced radiographic evidence of bone growth on to the porous coated spindle. We believe the failures in these patients
are related to exceptionally poor nutritional status resulting
in lack of adequate osseointegration. Our 10 patients who
received chemotherapy with successful osseointegration did
not experience a poor nutritional status during the course of
treatment. The third patient began weight bearing activity immediately and had radiographic evidence of subsidence with
loss of compression. (Figure 10)
The overall good results in this short term study have
encouraged us to continue using the CPS device for fixation
in patients receiving limb sparing procedures. We believe this
novel device will address the continued problems of aseptic
loosening in our oncology patient population. Long term results are not yet available and will likely be obtained with
multiinstitutional participation.
Figure 10. Plain radiographs of
a failed ComPreSs® fixation at six
months postoperatively in this 15-yearold who was noncompliant with his
postoperative restrictions. Note the
lucency between the bone end and the
spindle. The spindle has maximized
the telescoping over the anchor plug
stem and is rotationally unstable.
63
References
1. Simon MA, Aschliman MA, Thomas N, Mankin HJ. Limb-salvage treatment versus amputation
for osteosarcoma of the distal end of the femur. J Bone Joint Surg Am. 1986; 68A:1331-1337
2. Plotz W, Rechl H, Burgkart R, Messmer C, Schelter R, Hipp E, Gradinger R. Limb salvage
with tumor endoprosthesis for malignant tumors of the knee. Clin Orthop. 2002; 405:207-215.
3. Tolbert J, Fox E, Hosalkar H, Ogilvie C, Lackman R. Endoprosthetic reconstructions: results
of long-term followup of 139 patients. Clin Orthop. 2005; 438:51-59.
4. Hillman A, Hoffmann C, Gosheger G, Krakau H, Winkelmann W. Malignant tumor of the
distal part of the femur or the proximal part of the tibia: Endoprosthetic replacement or rotationplasty: Functional outcome and quality of life measurements. J Bone Joint Surg Am. 1999;
81A:462-468.
5. Kawai A, Muschler GF, Lane JM, Otis JC, Healey JH. Prosthetic knee replacement after
resection of a malignant tumor of the distal part of the femur. J Bone Joint Surg Am. 1998;
80:636-647.
6. Bini SA, Johnston JO, Martin DL. Compliant prestress fixation in tumor prostheses: Interface
retrieval data. Orthopedics. 2000; 23:707-712.
7. Cristofolini L, Bini SA, Toni A. Invitro testing of a novel limb salvage prosthesis for the distal
femur. Clin Biomechan. 1998; 13:608-615.
8. Bhangu AA, Kramer MJ, Grimer RJ, O’Donnell RJ. Early distal femoral endoprosthetic survival: cemented stems versus the Compress implant. Internat Orthop. 2006; 30:465-472.
9. Sumner D, Galante J. Determinants of stress shielding: design versus materials versus interface.
Clin Orthop. 1992; 274:202-212.
10. Unwin PS, Canon SR, Grimer RJ, Kemp HBS, Sneath RS, Walker PS. Aseptic loosening in
custom-made prosthetic replacements for bone tumors of the lower limb. J Bone Joint Surg Br.
1996; 78B:5-13
11. Eckhardt J. Long term results of cemented endoprostheses for reconstruction of bone tumors of
the distal femur. Presented at the International Symposium on Limb Salvage, New York, September, 1997.
12. Avedian RS, Goldsby RE, Kramer MJ, O’Donnell RJ. Effects of chemotherapy on initial
compressive osseointegration of tumor endoprotheses. Clin Orthop. 2007; 459:48-53.
Indiana Orthopaedic Journal
Volume 3 – 2009
Adriamycin-Impregnated Cement for Treatment of
Metastatic Carcinoma to Bone
Bruce T. Rougraff, M.D. and Brent Damer, D.O.
OrthoIndy – Indiana Orthopaedic Hospital – Indianapolis, Indiana, USA
Abstract
Purpose: To assess the safety and efficacy of Adriamycin in
the treatment of metastatic carcinoma of bone with methylmethacrylate.
Methods: Eighteen patients with 22 skeletal metastatic lesions were treated with open curettage and Adriamycin cement, with or without internal fixation. The patients were
followed radiographically until final follow-up or death from
disease.
Results: 55% of the patients died of their disease. 96% had
complete local control of their skeletal disease with excellent function. Complications included one local recurrence,
one amputation for progressive disease unrelated to the cement, serous drainage for four weeks, and arthrofibrosis in
a shoulder.
Conclusions: Adriamycin cement is a safe and effective option in the treatment of selected cases of metastatic carcinoma to bone.
Introduction
Treatment of metastatic disease of the bone commonly
involves an intralesional excision with stabilization of the
bone with an endoprosthesis or internal fixation. Bone cement
is commonly used to fill the void after curettage of a lesion
in order to restore continuity of the bone allowing for early
functional recovery. With intralesional excision, the risk of
local recurrence is much higher than with wide resection or
amputation. Local recurrence of disease can ultimately lead
to fatigue and failure of the stabilizing construct leading to
pain, decreased function, hardware failure, decreased quality
of life, and probable re-operation. Currently, local radiotherapy, systemic chemotherapeutics, or combinations of both are
used to assist in preventing tumor recurrence. Despite these
postoperative adjuvant therapies local recurrence rates have
been as high as 48%.1
The use of bone cement as a vehicle for the delivery of
medication to local tissues has stimulated recent studies on
the use of antineoplastic medications.2-11 The elution characteristics of antibiotic impregnated cement have shown that
supratherapeutic doses are attained at a local level without
the systemic side effects and these levels can be maintained
for extended periods of time.12,13 This has lead to further research with the use of antineoplastic-impregnated cement for
the treatment of primary and metastatic bone lesions. Experimental studies have confirmed that Adriamycin® (doxorubicin) is released in a manner similar to the release of antibiotics
and maintains 87% of the compressive and tensile strength.14
Adriamycin was found to have superior cytotoxic effect of
cancer cells in vitro over methotrexate and cisplatin.12 The
cytotoxic effect of Adriamycin is maintained throughout cement polymerization and is released into the surrounding tissues in both in vitro and in vivo experiments.3,12,13 The ability
to attain supratherapeutic levels of drug on a local level is
advantageous to avoid the systemic toxic side-effects typical of systemically delivered chemotherapeutics. Because of
the severe toxicity to soft tissues, there has been concern that
using Adriamycin-impregnated cement would be associated
with significant wound healing problems and a high wound
infection rate.
Only one clinical series15 using Adriamycin-impregnated
methylmethacrylate for the treatment of long bone metastases has been published in the English literature. Katagiri et
al. showed a local recurrence rate of only 4% with use of
Adriamycin cement despite 16 of their 25 patients having
intralesional surgical margins. They also showed no complications such as postoperative infections or delayed wound
healing. Their study included 14 of their 27 procedures being endoprosthesis secured with Adriamycin cement. They
did not limit their study to curettage and cementing, as they
included wide resection and they routinely employed pre-operative embolization of the skeletal lesion. It could be argued
that their aggressive use of resection with endoprostheses and
pre-operative embolization were the reason that they had a
96% local control rate.
The purpose of this paper is to present our results of curettage and cementation with the use of Adriamycin-impregnated bone cement, without pre-operative embolization or
wide resection, for the treatment of metastatic bone lesions.
We hope to address concerns of local control of the metastatic
skeletal lesion and complications related to the intervention.
Materials and Methods
A retrospective review of medical records was performed
on patients treated with curettage and cementation for metastatic bone disease and myeloma/plasmacytoma between the
dates of 4/1/1999 to 5/1/2007. Eighteen patients were referred to the lead author (BTR) for treatment of patients with
metastatic skeletal lesions that either failed previous radiation (eight patients), or had very destructive skeletal lesions
that otherwise would have been candidates for wide resection
or amputation (10 patients). During this same time frame,
119 other patients were treated for metastatic lesions that did
not qualify for Adriamycin cement, or refused this option.
Eighteen patients (22 procedures) were treated with intral64
Indiana Orthopaedic Journal
Volume 3 – 2009
Adriamycin-Impregnated Cement for Treatment of Metastatic Carcinoma to Bone
(continued)
esional excision of the lesion and fixation with Adriamycinimpregnated cement. (Table 1) No patient underwent tumor
embolization.
Myeloma/plasmacytoma was the most common pathology seen in seven patients, kidney (four), melanoma (two),
breast (two), thyroid (one), metastatic paraganglionoma
(one), and lung (one) The indications for surgical treatment
included pathologic fracture or painful impending pathologic
fracture.
The Adriamycin was mixed with the cement early in our
study with all operating room personnel wearing air ventilation suits to avoid breathing Adriamycin particles. Later in
the study, the Adriamycin powder was mixed under sterile
conditions by the pharmacy with the monomer of the Howmedica Simplex™ cement under a ventilation hood and delivered under sterile conditions to the operating room at the
time of surgery. 100 mg of Adriamycin was mixed with each
unit of cement. Only one patient required two units of cement to fill a large proximal humeral defect, with all others
receiving one. Complete open curettage of the bone lesion
was performed and the defect was filled with Adriamycin cement. (Figures 1-4)
Radiation was delivered to the site of disease in 10 of the
18 patients who had not received radiation prior to referral.
Two patients (2/18) refused radiation therapy and six (6/18)
patients could not receive additional radiotherapy. Patients
were followed clinically and radiographically every three
months until disease progression limited their ability to return for follow-up.
Figure 1. This AP radiograph of the proximal
humerus shows a lytic destructive lesion in
a 61-year-old white female with acute onset
of right shoulder pain and a normal SPEP.
Needle biopsy was consistent with myeloma
of the proximal humerus. She had no other
skeletal lesions.
Figure 2. This lateral radiograph shows a
non-displaced pathologic fracture through a
lytic, destructive lesion.
Figure 3. The patient underwent curettage
and Adriamycin cement filling of the defect as
well as radiation (30 gy) to the area. This radiograph is one month after surgery and shows
minimal bone healing around the cement.
Figure 4. This radiograph, taken three months
after the index procedure, shows excellent bone
healing around the cement. The patient was
completely pain-free from six weeks after surgery with full range of motion, until her death
21 months after diagnosis.
Table 1
Metastatic Lesions Treated with Adriamycin Cement
ID# 1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 Age @ sx
61 43 55 58 64 69 75 51 64 70 45 55 32 67 29 73 66 75 Primary Tumor Location
plasmacytoma met lung met renal met breast met thyroid myeloma plasmacytoma met renal myeloma plasmacytoma melanoma myeloma paraganglioma met breast melanoma myeloma met renal met renal Location of Met Tumor
R prox humerus R humerus epicondyle L talus, prox tibia, tibia talus R prox tibia L prox humeurs R scapula-glenoid neck R prox humerus R ulna L prox tibia L med fem condyle Bilateral distal femurs L humeral diaphysis R ulna Prox Femur, Prox humerus R prox hum, l prox hum L prox hum, r distal fem R tibia midshaft Impending/ Procedure Pathologic Fx
Radiation Local
Tx
Control
fx fx Impending fx fx fx Impending fx fx Impending Impending Impending Impending fx Impending Impendingx2 fx, im Impending 30 gy refused 30 gy previous 30 gy 45gy previous 30gy previous previous refused previous 35Gy 30gy 30gy 46Gy previous 30gy curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement curettage, adria cement 65
yes
yes yes yes yes yes yes yes yes yes no yes yes yes yes yes res yes
Complications/
Other Surgery none
none amputation wound healing delay, no surgery delayed union,no surgery none none none none none resection, endoprosthesis none none none none none none none Follow-up Status
in Months
21
12
86 10 52 17 61 27 66 66 16 22 15 21 15 25 6
3
DOD
DOD
AWD
AWD
NED
DOD
AWD
DOD
NED
NED
DOD
DOD
DOD
DOD
DOD
AWD
AWD
DOD
Indiana Orthopaedic Journal
Volume 3 – 2009
Adriamycin-Impregnated Cement for Treatment of Metastatic Carcinoma to Bone
(continued)
Results
Of the 22 skeletal sites of metastatic bone disease treated with Adriamycin cement, only one site had local tumor
failure (4.5%) that required a wide surgical resection and
proximal tibial endoprosthesis reconstruction. The local recurrence occurred in a patient with metastatic melanoma
who presented to our institution after locally recurrent melanoma in the tibia after prior curettage, fixation and radiation.
He then underwent curettage and Adriamycin cement with
a new intramedullary fixation. He refused radiation therapy
against our advice to pursue herbal medical therapy. He locally recurred three months later and underwent resection
and reconstruction. He died of brain metastases a year later.
A second patient with renal carcinoma that metastasized to
several places in his tibia and talus, required an amputation
for recurrent disease in his mid-tibia that was not treated with
Adriamycin cement. The talus and proximal tibia sites with
Adriamycin cement had no pathologic evidence of carcinoma
at the time of amputation. Two other complications included;
serous wound drainage for four weeks after surgery treated
with dressing changes, and adhesive capsulitis in proximal
humeral metastasis. There were no hardware failures, infections, wound dehiscence or fractures.
Ten of the 18 patients (56%) have died of their disease.
Follow-up ranged from 3-85 months, with the average being
47 months in the surviving patients. No patients died of other
causes than their cancer.
Discussion
The goal of surgical treatment for metastatic disease of
bone is attain maximal, painless function as soon as after
surgery to improve the quality of the life without complications or need for further surgeries. This is best accomplished
through local control of the skeletal disease and stabilization
of bony defects. Current local control is attained by curettage
and burring of lesion with adjunctive radiation, chemotherapy
or both. Radical resection and amputation are reserved for the
most difficult cases. Rates of local recurrence after curettage
and radiation have been shown to approach 35%-48%.1
Our experience has shown that melanoma, renal carcinoma, and patients who recurred after prior radiation, are
at significant risk of tumor recurrence with less than wide
resection or amputation. These 18 patients represent those
difficult cases that prompted our attempt to perform less radi-
cal excisions by adding Adriamycin to the cement. Our goal
was to gain local control of the metastasis which we did in
all but one patient who refused post-operative radiation. We
reported four complications, two of which required surgery.
It is probable that none of those complications were related to
the Adriamycin specifically.
The authors uniformly used Howmedica Simplex™ cement in this series. Palacos® cement has been shown to have
superior elution characteristics and may be a better choice
for Adriamycin delivery.13 With 95% of our patients achieving local control, it is unlikely that that a clinically relevant
difference would be seen in a comparison trial between Palacos® and Simplex™ cement.
The authors believe that using Adriamycin cement is a
safe and highly effective option in selected cases of metastatic carcinoma to bone. Good soft tissue coverage should
always be employed.
References
1. Rompe JD, Eysel P, Hopf C, Heine J. Metastatic instability at the proximal end of the femur.
Comparison of endoprosthetic replacement and plate osteosynthesis. Arch Orthop Trauma Surg.
1994; 113:260-4.
2. Decker S, Winkelmann W, Nies B, van Valen F. Cytotoxic effect of methotrexate and its solvent on osteosarcoma cells in vitro. J Bone Joint Surg Br. 1999; 81B:545-551.
3. Greco F, Palma L, Specchia N, Jacobelli S, Gaggini C. Polymethylmethacrylate-antiblastic
drug compounds: An in-vitro study assessing the cytotoxic effect in cancer cell lines – A new
method for local chemotherapy of bone metastasis. Orthopedics. 1992; 15:189-194.
4. Guan WY, Yi WT, Zhi MY, Z SS. Experimental research on the use of an antineoplastic drug
with a bone implant. Int Orthop. 1990; 14:387-391.
5. Hernigou P, Brun B, Astier A, Goutallier D, le Bourgeois JP. Chapter 26. Diffusion of methotrexate from surgical acrylic cement. Humphrey GB (ed). Osteosarcoma in Adolescents and
Young Adults. Boston, Kluwer Academics Publishers, 1993, pp. 231-233.
6. Hernigou PH, Thiery JP, Benoit J, et al. Methotrexate diffusion from acrylic cement: Local
chemotherapy for bone tumours. J Bone Joint Surg Br. 1989; 71B:804-811.
7. Kim HS, Park YB, Oh JH, Yoo KH, Lee SH. The cytotoxic effect of methotrexate loaded bone
cement on osteosarcoma cell lines. Int Orthop. 2001; 25:343-348.
8. Kirchen ME, Menendez LR, Lee JH, Marshall GJ. Methotrexate eluted from bone cement:
Effect on giant cell tumor of bone in vitro. Clin Orthop. 1996; 328:294-303.
9. PazzagliaU, Ceciliani L, Mora R. Reaction to methylmethacrylate in bone metastases treated by surgical curetting and filling with acrylic cement. Arch Orthop Trauma Surg. 1983;
101:145-149.
10. Penner MJ, Duncan CP, Masri BA. The in vitro elution characteristics of antibiotic-loaded
CMW and Palacos-R bone cements. J Arthroplasty. 1999; 14:209-214.
11. Wang HM, Crank S, Oliver G, Galasko CSB. The effect of methotrexate-loaded bone cement
on local destruction by the VX2 tumour. J Bone Joint Surg Br. 1996; 78B:14-17.
12. Rosa MA, Maccauro G, Sgambato A, et al. Acrylic cement added with antiblastics in the
treatment of bone metastases: Ultrastructural and in vitro analysis. J Bone Joint Surg Br. 2003;
85B:712-716.
13. Wasserlauf S, Warshawsky A, Arad-Yelin R, et al. The release of cytotoxic drugs from acrylic
bone cement. Bull Hosp Joint Dis. 1993; 53:68-74.
14. Healey JH, Shannon F, Boland P, DiResta GR. PMMA to stabilize bone and deliver antineoplastic and antiresorptive agents. Clin Orthop. 2003; 415: S263-S275.
15. Katagiri H, Sato K, Takahashi M, et al. Use of Adriamycin-impregnated methylmethacrylate in the treatment of tumor metastases in the long bones. Arch Orthop Trauma Surg. 1997;
116:329-333.
66
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures
Experience With a New Flexible Interlocking Intramedullary Nai
Compared With Other Fixation Procedures
Lubica Jencikova-Celerin, MD, PhD,* Jonathan H. Phillips, BSc, MB, BS,• Lloyd N. Werk, MD, MPH,*
Stacey Armatti Wiltrout, MA, MS,* and Ian Nathanson, MD*
© 2008 Lippincott Williams & Wilkins. Reprinted with permission:
Jencikova-Celerin L, Phillips JH, Werk LN, Wiltrout SA, Nathanson I.
Flexible Interlocked Nailing of Pediatric Femoral Fractures Experience With a
New Flexible Interlocking Intramedullary Nail Compared With Other Fixation Procedures.
J Pediatr Orthop 2008;28:864-873.
Background: The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial.
We hypothe­sized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications
and improves outcomes, including leg-length discrepancy,
time to healing, and time to weight bearing compared with
other fixation procedures (OFPs) including standard elastic
nail implants.
Methods: Using a retrospective cohort study design, we
reviewed medical records and radiographs of children, 7 to
18 years of age, with femoral shaft fractures requiring open
treatment between July 1, 1998, and June 30, 2003. Patients
selected for the study had unilateral fracture sites proximal to
the supracondylar region and distal to the lesser trochanter,
presence of open femoral growth plates, and open surgical
treatment. Analyses compared inpatient measures and patient
outcomes between FIIN and OFP groups.
Results: Of the 160 patients eligible for inclusion, 23 were
lost to follow-up. The remaining 137 patients had a mean
follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was
not statistically significant, complications occurred in 19.0%
of patients in the FIIN group and 30.4% in the OFP group.
Trochanteric heterotopic ossification was the most common
complication (13.8%) noted in the FIIN group and superficial
infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight
From the *Nemours Foundation, Clinical Management Program, and
†Division of Pediatric Orthopaedics, Orlando Regional Healthcare,
Orlando, FL.
This study was conducted and supported by Nemours Clinical Management
Program, which evaluates institutional services.
Drs Jencikova-Celerin and Werk, Ms Wiltrout, and Dr Nathanson declare no
conflict of interest.
Mr Phillips has received royalty payments from BIOMET, Parsippany, NJ,
but no compensation from BIOMET in respect to this study.
Reprints: Lloyd N. Werk, MD, MPH, Nemours Foundation, Clinical Management Program, 4901 Vineland Rd, Suite 300, Orlando, FL 32811.
E-mail: [email protected].
Copyright *2008 by Lippincott Williams & Wilkins
67
bearing (P = 0.001) without disturbance of proximal femoral
geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were
less common with FIIN (3.6%) compared with OFP (24.4%).
A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN.
Conclusions: Older children and adolescents with femoral
shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP.
Level of Evidence: Level III, therapeutic study.
Key Words: femoral shaft fractures, flexible interlocking intramedullary nail
(J Pediatr Orthop 2008;28:864-873)
Femoral shaft fractures in children and adolescents occur
with an incidence of 19 to 45 per 100,000 children,1-5 although
the mechanism of injury resulting in a femoral shaft fracture
differs by age group. Children younger than 12 years experience femoral shaft fractures primarily related to falls and pedestrian versus motor vehicle accidents, whereas adoles­cents
experience femoral shaft fractures primarily when injured as
passengers in motor vehicle accidents.2
Approximately 66% of femoral shaft fractures occur
in the middle third of the shaft,2 with treatment varying by
age, fracture complexity, and associated injuries.6-8 Surgeons’
preference and family considerations play a significant role
in selection of treatment as well. Nonoperative treatment
involving spica casting with or without traction is usually
preferred for children aged 6 years and younger,9-11 whereas
skeletally mature adolescents seem to benefit from internal
fixation.12 However, the treatment of children 7 to 18 years
old remains controversial and varies by surgeons’ preferences
and practice settings.6, 8, 13, 14
Methods for fixation of femoral shaft fractures in chil­
dren and adolescents include early closed reduction and spica
casting,9-11, 15 external fixation,16, 17 elastic titanium or stain­less
steel nailing,18-20 rigid or bridge plate fixation,21-24 and rigid
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
nailing via an antegrade approach.12 Each of these pro­cedures
affects time to mobility and may contribute to patients missing weeks of school as well as parents’ loss of work-days.25
Possible complications of these procedures include pain, infection, limb shortening, malunion of the healed bone, and
refracture.26-30 Rigid reamed intramedullary nailing of femoral shaft fractures has been associated with a vascular necrosis of the femoral head in 2% to 3% of patients and is contraindicated for use in children with open proximal femoral
physes.30-32 Despite concerns about rigid reamed intramedullary fixation, this procedure is associated with a reduction in
other complications such as in situ failure,33 malunion,34-36
non-union,37,38 limb-length discrepancy,39,40 and soft tissue
problems.12,33 Titanium elastic nailing to treat femoral shaft
fractures in children has gained popularity in Europe and
North America during the last decade. However, as many as
10% of children experience complications that occasionally
contribute to unac­ceptable limb shortening. Furthermore, implant failure has been described as more common in heavier
children.41
sion of Orthopaedic Surgery in Orlando and in Jacksonville,
Fla, or the pediatric facilities of 2 partner hospital systems
(Orlando Regional Healthcare, Orlando, and Baptist Medical Center, Jacksonville) between July 1, 1998 and June 30,
2003, for treatment of femoral shaft fractures were identified
for pos­sible inclusion. Inclusion criteria consisted of children
with (1) an age of 7 to 18 years, (2) femoral shaft fractures
proxi­mal to the supracondylar region and distal to the lesser
tro­chanter, (3) presence of open femoral growth plates, and
(4) open surgical treatment. Excluded were children with (1)
underlying pathological bone diseases (eg, unicameral bone
cyst, fibrous dysplasia, and osteogenesis imperfecta), (2) neuromuscular disorders (eg, cerebral palsy and arthrogrypo­sis),
(3) bilateral femoral shaft fractures, and (4) femoral fracture
extending outside the shaft. It was assumed that these conditions would substantially affect outcomes independent of
the operative procedure and limit the generalizability of the
findings to most cases of femoral shaft fracture in children.
Patients who were not re-evaluated in the postoperative period were determined to be lost to follow-up.
The coauthor (J.H.P.) designed a flexible interlocking intramedullary nail (FIIN) (Pediatric Locking Nail; BIOMET,
Parsippany, NJ) to overcome problems of axial and rotational
instability, as well as to avoid anatomical constraints in a
child’s immature femur that may contribute to the poorer out­
comes seen with the standard elastic and rigid intramedullary
nails. The FIIN is inserted with a per-trochanteric approach
to avoid the vascular bed in the piriformis fossa. This subrigid implant manufactured in a titanium alloy allows plastic
deformation of the nail as it is introduced in a curved entry
path into the femoral canal from a portal lateral to the tip of
the greater trochanter. Proximal and distal interlocking areas
accept 4-mm interlocking screws to stabilize unstable and
comminuted femoral shaft fractures. The nail has a precon­
toured 9-degree anterior bow in a neutral coronal plane to
allow universal handedness.
Inpatient and outpatient medical records were abstracted
for patient baseline characteristics, surgical information, and
outcomes data. Refer to the Appendix for specific definitions
and measurement criteria. Abstracted information was verified
by an independent orthopaedic surgeon (L.J.-C.) and transferred into an electronic database. This surgeon performed
none of the surgeries. Duration of observation spanned from
the time of surgery to last recorded follow-up. To minimize
potential bias, J.H.P., who invented the FIIN, did not participate in medical record abstraction, data management, or data
analysis.
Surgeons at Nemours practice sites in Orlando and Jacksonville used a variety of operative techniques for the fixation
of femoral shaft fractures including use of the FIIN. We hypothesized that fixation with a FIIN is associated with better
inpatient measures (operative blood loss, surgery time, and
duration of hospital care) and improved patient outcomes
(leg-length discrepancy, time to healing, and time to weight
bearing) compared with other fixation procedures (OFPs).
Methods
A retrospective, cohort study design was used to inves­
tigate outcomes associated with fixation of femoral shaft
frac­tures in children and adolescents through review of inpatient medical records, outpatient medical records, and radiographs. Patients presenting to surgeons of the Nemours Divi-
Bivariate analyses were performed to confirm baseline
comparability and outcomes of patients in the FIIN and OFP
groups using Student t test for continuous data and contingency table analyses for categorical data.
Two orthopaedic surgeons (L.J.-C., J.H.P.) reviewed independently the available final radiographs for leg length, femoral neck-shaft angle, articulotrochanteric distance, pres­ence
of healing, and presence of complications such as malunion
or refracture. Both reviewers each evaluated three-quarters
of all radiographs (scanograms, whole-leg radio­graphs, and
hip-knee-ankle radiographs). Pearson c2 and intraclass correlation coefficient (ICC), as well as k analyses, compared
interobserver variability on radiographic studies. On the basis of intraclass correlation, there was excel­lent interobserver
agreement for differences in leg length (ICC = 0.639), neckshaft angle (ICC = 0.766), and articulotrochanteric distance
(ICC = 0.678). Because inter-observer agreements for the
radiological parameters were highly significant (P G0.001),
paired measurements were averaged, and a single absolute
value was reported. In addition, there was 100% agreement
on determination of proximal femoral physis status (k= 1.0).
68
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
Logistic regression and analysis of covariance were used
in multivariate analyses. Because weight of more than 45.5
kg (100 lb) was considered to be a potential confounder,41
analyses were planned to stratify on this variable, as well as
fracture pattern and presence of multiple trauma. To compare
the FIIN group with patients receiving comparable devices,
a subgroup analysis comparing standard elastic nail fixation
to the FIIN group was performed. Patients lost to follow-up
and those remaining in the cohort were compared for baseline
characteristics and surgical information. All analyses were
performed using SPSS v12.0.1 (Statistical Packages for the
Social Sciences Inc, Chicago, Ill), and P < 0.05 was considered significant.
Human Subjects and Ethical Considerations
The institutional review boards of Nemours and 2 partner
hospital systems (Orlando Regional Healthcare and Baptist
Medical Center) reviewed and approved the protocol for this
research study. The Nemours and Orlando Regional Healthcare institutional review boards also approved use of the FIIN
(Pediatric Locking Nail; BIOMET) in 1998, and Food and
Drug Administration clearance was granted in 2000.
After appropriate prepping of the femur and adjoining
areas, open wounds of the thigh were debrided and irrigated.
A guide pin for the trochanteric reamer was placed in the center of the greater trochanter under fluoroscopic control using
both anteroposterior and lateral projections to enable percutaneous placement (Fig. 1). Until familiar with the procedure,
creating a small 3-to 4-cm incision in the skin over the trochanter helped the orthopaedic surgeon through direct visualization and palpation to identify the correct starting point
for nail insertion. Unlike other nails, the FIIN was not introduced through the tip of the greater trochanter but lateral to
this point crossing the midportion of the greater trochanteric
epiphysis almost perpendicular to this structure. This position was selected to minimize the chance of fracture medially
into the piriformis fossa and lessen the transmission of heat
from the reamer to the vascular structures here. Only when
the guide pin has been satisfactorily placed should reaming of
the tro­chanteric entry point be performed (Fig. 2).
Techniques
The surgical techniques for insertion of stan­dard elastic nail implants, external fixation, bridge plat­ing, and rigid intramedullary nailing have been described elsewhere.
6,8-11,14,15,22,24,27,28
The FIIN surgical technique was performed as follows.
Preoperative Planning
Fractures distal to the lesser trochanter and at least 4 cm
proximal to the distal femoral physes were amenable to fix­
ation with this device. Determination of the limiting diameter
of the intramedullary canal was based on radiographs of the
affected femur. A femoral shaft canal width of at least 9 mm
accommodated the maximum FIIN diameter of 8.5 mm with­
out reaming the canal. One of two versions of the FIIN was
selected based on patient weight. For children weighing up to
45 kg (100 lb), a FIIN that tapered to a 5.5-mm diameter was
selected. A 6.5-mm-diameter nail was selected for heavier
chil­dren. Both versions of the FIIN had the same 8.5-mm-diameter proximal and distal limiting geometry. A radiolucent
ruler aided the determination of the appropriate nail length.
Figure 1. Percutaneous placement of the trochanteric guide pin.
Surgical Procedure
Standard fluoroscopically aided reduction was per­
formed on a fracture table under general anesthesia and complete muscle blockade. Closed reduction of widely displaced
fractures simplified femoral instrumentation and passage of
the nail. An adducted position of the lower limb aids in the
approach to the greater trochanter.
69
Figure 2. Reaming over the correctly placed guide pin. The entry
point is well below the tip of the trochanter.
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
An incision was made around the guide pin if it was percutaneously placed and deepened down to the lateral cortex
of the trochanter. The guide pin should not cross to the calcar
because this will potentiate the formation of an obstructing
pedestal by the reamer, making passage of the nail difficult.
A 9-mm reamer under fluoroscopic control created an entry
channel, with care taken to avoid the calcar femorale. It was
necessary to open only the lateral aspect of the trochanteric
cortex and not pass deeply into the intertrochanteric area itself. This area can be opened with handheld conical reamers
of various sizes used in a manner akin to proximal femoral
broaches to smooth the curved path of the bent nail tip if necessary. The more distal canal of the femoral shaft was not
reamed, and the isthmus of the canal was left unreamed because preoperative planning determined the limiting diameter
of the nail (8.5 mm) passes this area without this maneuver.
The selected diameter FIIN was mounted on the prox­
imal targeting device. Bends were fashioned in the proximal
and distal ends of the nail using a rod bender (Fig. 3). A proximal bend of approximately 30 degrees allowed easier passage through the intertrochanteric region and shifted the nail
medially in the femoral canal to allow an anatomical trajectory of the device along the canal as if it had been introduced
through the piriformis fossa. This helped to avoid the coronal
plane malreduction that results from straight nails introduced
through the trochanter. The lesser bend of 15 to 20 degrees in
the distal nail both allowed easier passage through the curve
of the intertrochanteric region and created a steerable tip for
the passage of the fracture during nail insertion. The FIIN
is solid and less rigid than an external fixator but more rigid
than an elastic nail made of the same material. Care is needed
to avoid damaging the interlocking screw holes with the an-
Figure 3. Intraoperative bending of the nail. Bends are fashioned
in the proximal and distal ends of the nail using a rod bender. Note
the proximal bending in preparation for fixation of a left femoral
fracture.
vils of the bender, and a trial passage of the drill and drill
sleeves for the proximal interlock is advisable after bending
the nail.
The FIIN was then introduced through the greater trochanteric opening and around the curve of the intertrochan­
teric region, rotating the nail to allow the easiest passage. The
nail was passed with hand pressure or with impaction using
a mallet fluoroscopically monitored. Care must be exercised
when passing the isthmus because overbending of the nail tip
can increase its effective diameter greater than the anticipated
8.5 mm, and the resulting hoop stresses generated can comminute the fracture at the isthmus. If excessive resistance to
passage was felt, then removal of the nail and modification
of the tip bend to a lesser amount improved progress. Upon
controlled passage of the nail across the fracture by steering
and manual reduction of the fragments, the nail was seated
proximally, and its position checked under fluoroscopy so
that its proximal end was just subjacent to the trochanteric
cortex. The nail should not violate the distal femoral physis
or distract the fracture. Proximal interlocking was achieved
with the drill sleeves, depth gauge, and drills, with attention
to achieve passage of the screw just below the distal margin
of the trochanteric physis (Fig. 4).
Traction was released from the limb, axial alignment
confirmed, and distal interlocking performed using the technique of perfect circles. The distal interlock should not be
perpendicular to the femoral shaft because there is a bend at
the nail tip resulting in an obliquity of the nail in the canal
(Fig. 5).
The wounds were closed, and anesthesia was reversed.
Figure 4. Proximal interlocking of the nail. The FIIN’s.
70
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
Figure 6. Preoperative anteroposterior radiograph of marked
proximal bend medializes it in
the femoral canal. midshaft femur fracture in a 13-year-old
boy.
Figure 7. Preoperative lateral
radiograph of midshaft femur
Figure 5. Distal interlocking of the nail. Note the obliquity of the
locking screw to the long axis of the femoral shaft.
Postoperative Care
Distal fractures at risk for further postoperative fracture
motion were stabilized with knee immobilizers for the first 2
to 3 weeks. Otherwise, external immobilization was unnecessary, and touch-down weight bearing using crutches was
allowed initially. Progressive weight bearing was permitted at about 3 weeks with the advent of an early callus seen
on radiograph. Full weight bearing was encouraged once 3
bridging cortices were evident radiographically. The FIIN
was removed at 9 to 12 months after insertion. The progres­
sion from initial femur fracture through healed femoral shaft
is illustrated in Figures 6 to 10.
Results
Children and adolescents (N = 183) 7 to 18 years old
were identified with femoral shaft fractures during the 5-year
period July 1, 1998, to June 30, 2003. Of those patients, 160
met inclusion criteria, with 23 transferring their postoperative care, which resulted in loss to follow-up. The final study
cohort consisted of 137 patients, with 58 in the FIIN group
and 79 in the OFP group (Fig. 11).
The 23 patients lost to follow-up were compared with
those retained in the final cohort. The attrition of patients
from the FIIN group (18.3%) and OFP group (11.2%) was
not significantly different. Also, these 23 patients had baseline characteristics of age at fixation, height, weight, association with multiple trauma, fracture condition, fracture location, and fracture pattern that were not significantly different
from the final cohort.
The mean age of the 137 patients was 11.5 years (SD,
2.5 years) with 73.7% males. Although patients in the FIIN
71
Figure 8. Anteroposterior radiograph of healing femur fracture
7 weeks postoperative.
Figure 9. Lateral radiograph of
healing femur fracture fracture
in a 13-year-old boy. 7 weeks
postoperative.
Figure 10. Anteroposterior radiograph after nail removal 9
months postoperative.
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
Figure 11. Subject enrollment.
group averaged 11 months older than in the OFP group
(P = 0.02), Table 1 shows that there were no significant differences between the 2 groups with respect to weight, fracture
pattern, fracture location, or frequency of multiple trauma.
Days to follow-up and length of stay were similar between
the 2 groups.
58 children (43.1%). Orthopaedic surgeons in both Orlando
and Jacksonville used standard elastic nail im­plants (Enders
or titanium elastic nails) for 32 children (40.5%) with femoral shaft fractures, external fixator in 12 (15.2%), plate in 5
(6.3%), rigid intramedullary nail in 28 (35.4%), and a combination of nail-and-plate fixation in 2 (2.5%).
There was no record of the decision making in the medical record that led an orthopaedic surgeon to select an operative technique and fixation device. Six surgeons in Orlando
used the FIIN in surgical fixation of femoral shaft fractures on
The mean duration of surgery, 166.9 minutes (SD, 74.9
minutes), and length of hospital stay, 5.4 days (SD, 6.6 days),
did not differ significantly between the groups. The volume of
blood loss in patients from the FIIN group was significantly
72
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
less than that in the OFP group (mean difference, 83.2 mL;
P = 0.042) (Table 2). In a multivariable analysis comparing blood loss in the presence of 3 potential confounders,
weight (<45.5 vs >45.5 kg), pattern (comminuted, oblique,
spiral, and transverse), and multiple trauma, the difference in
blood loss between groups remained significant (P = 0.023),
and only weight among the confounders reached statistical
significance (P = 0.013). This relationship of reduced blood
loss in the FIIN group (P = 0.050) persisted in a more parsimonious model controlling for weight alone (P = 0.017).
The overall time to full weight bearing was 71.9 days
(SD, 51.6 days), and this milestone was reached 34.6 days
sooner in the FIIN group (P < 0.001). An analysis of co­
variance was used to evaluate any association in the pres­
ence of the 3 identified potential confounders. In this multivariable analysis, the difference in days to full weight bearing
and an interaction with presence of multiple trauma remained
significant (P < 0.001). Among patients with multiple trauma, those in the FIIN group were full weight bearing in 50.8
days (SD, 20.3 days) compared with the OFP group in 108.6
days (SD, 79.3 days) (P = 0.002). Children having a single
fracture in the FIIN group were full weight bearing in 53.5
days (SD, 21.7 days) versus 75.1 days (SD, 47.7 days) in the
OFP group (P = 0.01). Although not signifi­cant, the time to
radiographic healing trended toward a shorter time period in
the FIIN group. The mean time to implant removal for the
cohort was 294.3 days (SD, 150.1 days) and did not differ
significantly between study groups (Table 2).
Among the 137 patients in the study, 35 (25.5%) had a
total of 43 complications. Eleven patients (19.0%) in the FIIN
group and 24 (30.4%) in the OFP group experienced one or
more of these events. The complications were categorized as
either minor or major. Some patients had multiple complica­
tions (Table 3). None of the reported major complications
occurred in the FIIN group. Complications were seen more
frequently when stabilizing transverse (5 [26.3%] in the FIIN
73
group and 12 [35.3%] in the OFP group) and comminuted
fractures (3 [12.0%] in the FIIN group and 7 [31.8%] in the
OFP group). Furthermore, complications occurred more often in the third quarter of the femoral shaft in the FIIN group
(7 [30.4%]) and in the OFP group (11 [35.5%]).
Patients in the OFP group had a higher percentage of
superficial infection (12.8%), and 1 child in the OFP group developed osteomyelitis. Trochanteric heterotopic ossification
developed in 13.8% of children in the FIIN group. Among
children with weight less than 45.5 kg (100 lb), complications occurred more commonly in the OFP group (10
[24.4%]) than in the FIIN group (1 [3.6%]; P = 0.022). The
rate of complications for children weighing more than 45.5
kg (100 lb) was similar between groups (10 [33.3%] in the
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
FIIN group and 13 [36.1%] in the OFP group). Complication
rates did not significantly differ between the 2 study groups
when stratified on potential confounders: fracture condition,
pre­sence or absence of multiple trauma, fracture location,
or frac­ture pattern. No association between study group and
complications was found when these confounders were accounted for simultaneously in a logistic regression model (P
= 0.152). However, weight persisted as a significant covariate
(P = 0.008).
In the subgroup analysis, patients from the FIIN group
were compared with the 32 patients in the OFP group who
had standard elastic nail implants. At baseline, patients in the
FIIN group were 2.4 years older (P G0.001), 8.0 kg heavier
(P = 0.01), and 10.8 cm taller (P = 0.009) than patients with
standard elastic nail fixation. Whereas approximately half of
the children in the FIIN group were less than 45.5 kg (100
lb), 75% of the 32 children treated with a standard elastic nail
implant were less than 45.5 kg (100 lb). Patients in the FIIN
group experienced more fractures with transverse or oblique
pattern, and most fractures occurred in the middle second
or third quarters of the femoral shaft. A similar proportion
of patients had multiple trauma between the subgroup and
the FIIN group. The time to full weight bearing among the
FIIN group was 16.9 days shorter (P = 0.035) than in patients
with standard elastic nail fixation. Although not statistically
significant, patients in the FIIN group were observed to have
fewer complications (11 [19.0%]) versus those treated with
standard elastic nail implants (12 [37.5%]). Furthermore,
stratification by condition, fracture location, and fracture pattern did not reveal any significant associations between the 2
nail implants and presence of complications. However, patients with standard elastic nail implants who were less than
45.5 kg (100 lb) (7 [29.2%]) had 8.1 times the complications
of patients in the FIIN group (P = 0.018), and those patients
who had multiple trauma (4 [44.4%]) had 4.7 times as many
complications (P = 0.049) as the FIIN group.
In another subgroup analysis, patients from the FIIN
group were compared with the 28 patients in the OFP group
who had rigid intramedullary nailing. At baseline, the patients
in the FIIN group were 0.85 years younger (P = 0.112), 7.35
kg lighter (P = 0.041), and 10.0 cm taller (P = 0.023) than
those patients with rigid intramedullary nail fixation. Where­
as approximately half of the children in the FIIN group were
less than 45.5 kg (100 lb), 28.6% of the 28 children treated
with a rigid nail implant were less than 45.5 kg (100 lb). Patients in the FIIN group experienced similar proportions of
fractures with transverse and comminuted pattern, and most
fractures occurred in the middle second or third quarters of the
femoral shaft. A similar proportion of patients had multiple
trauma between the subgroup (35.7%) and the FIIN group.
The time to full weight bearing among the FIIN group was
nearly 50 days shorter (P = 0.007) than in patients with rigid
nail fixation. The frequency of complications among patients
in the FIIN group (11 [19.0%]) was similar to those with rigid
nail implants (5 [17.9%]). This finding persisted regardless
of condition, fracture location, fracture pattern, weight more
than 45.5 kg, or presence of multiple trauma.
Discussion
Our study indicated that children and adolescents treated
in the FIIN group experienced less blood loss and shorter time
to full weight bearing than those treated in the OFP group.
These findings were not significantly affected by pattern type,
fracture location, or exposure to multiple trauma. In addition,
we observed a trend toward shorter time to radiographic heal­
ing and fewer complications among FIIN patients.
The large variability in duration of surgery, hospital
length of stay, and time to full weight bearing reflects the
effect of some patients experiencing substantial comorbidities as well as the influence of a few outlying values. For
example, duration of surgery ranged from 63 to 448 minutes
(median, 153 minutes) and hospital length of stay from 1 to
54 days (median, 4 days).
Patients in the FIIN group ambulated sooner than did the
OFP group. The relationship between the FIIN group and an
earlier time to full weight bearing persisted even in the presence of multiple trauma. In addition, the time to full weight
bearing in patients in the FIIN group was shorter than in those
with standard elastic nail fixation.
The overall complication rate among patients in the FIIN
group (19.0%) was lower than reported rates in the literature,
which range from 29.5% to 62%.4,12,14,19,27,29,33,39 Further­more,
a minor complication, trochanteric heterotopic ossifica­tion,
was the most common complication (13.8%) found among
the 58 patients with FIIN. The FIIN patients were 1.7 times
more likely than those with OFPs to develop trochanteric heterotopic ossification, which may be the result of its method of
insertion. Whereas the FIIN is inserted with a per-trochanteric approach, standard elastic nail implants are in­serted retrogradely, entering the bone approximately 2.5 cm proximal to
the distal femoral physis.33,39,40 In contrast to reports of pain
and skin erosion among individuals treated with standard
elastic nail implants,27,33,39 the FIIN had none of these complications. In addition, patients treated with a FIIN had no major complications. Children treated with a FIIN and weighing
less than 45.5 kg (100 lb) had the fewest complications.
Some have reported that comminuted and long oblique
femoral shaft fractures may require methods of stabilization
other than standard elastic nail implants because of early loss
of reduction and possible malunion.33,39,40 On the basis of our
experience, the FIIN stabilized these fractures well with a
faster time to full weight bearing and a trend toward lower risk
74
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
of complications than OFPs. Interestingly, children weighing
less than 45.5 kg (100 lb) exhibited better outcomes using a
FIIN than patients receiving OFPs. The higher complication
rate among patients treated with elastic nail implants compared with the FIIN who weighed less than 45.5 kg (100 lb)
was unexpected. This relationship continued even in the presence of multiple trauma.
Study Limitations
In a retrospective, cohort study design, unaccounted
factors could contribute to observed differences in outcome.
However, baseline characteristics of study patients in each
group were similar with respect to sex, weight, fracture pattern, and fracture location. Patient age in each group was normally distributed from 7 to 17 years old. Although patients in
the FIIN group averaged 11 months older, this age dif­ference
is unlikely to have a substantial clinical impact.
The duration of management varied among patients but
was found to be similar between study groups. Also, the ob­
served interval between office visits for patient postoperative
follow-up and re-evaluations varied. However, progress toward radiographic union was evaluated at each office visit
and the ability to bear weight assessed (once 3 bridging cortices formed).
Most patients were followed up for more than a year, but
it is possible that some were not followed up long enough
to detect complications such as leg-length discrepancies and
femoral head avascular necrosis. For example, arrest of tro­
chanteric development may occur as soon as several months
and as long as 3 years postoperatively.42 Because the followup period did not significantly differ between the 2 groups (P
= 0.936), underestimation of the complication rates would
not be biased toward either group.
We abstracted estimates of blood loss from the operative record. We recognize that measurement of intraoperative
blood loss can be variable and imprecise. This limitation will
persist among similar investigations until validated methods
of blood loss estimation are adopted within and across hospitals.
Future research building on the findings of this study
should compare FIIN fixation with a similar single procedure
such as standard elastic nail fixation in a prospective experimental study design. Such a study will require a sample size
sufficiently large to detect major complications and duration
of observation long enough to reveal late complica­tions. In
addition, the role of FIIN fixation, if any, among children
and adolescents with femoral shaft fractures and underlying
pathological bone conditions requires further study.
Conclusions
Flexible interlocking intramedullary nail fixation in children and adolescents with femoral shaft fractures (proximal
75
to the supracondylar region, distal to the lesser trochanter,
and with open proximal femoral physes) is associated with
improved outcomes compared with other common fixation
procedures. Children and adolescents treated with this tech­
nique experience less blood loss in the operating room and
a shorter time to weight bearing without evidence of disturbance of proximal femoral geometry or avascular necrosis
of the femoral head. These findings were more pronounced
among children weighing less than 45.5 kg (100 lb).
Acknowledgments
The authors thank Mary A. Regling, BA, and Michele
Smith, RN, for their efforts in project coordination and data
abstraction. Present and former Nemours orthopaedic surgeons in Jacksonville and Orlando are thanked for their contribution of patient data.
References
1.Hinton RY, Lincoln A, Crockett MM, et al. Fractures of the femoral shaft in children. Incidence,
mechanisms, and sociodemographic risk factors. J Bone Joint Surg Am. 1999;81(4):500-509.
2. Rewers A, Hedegaard H, Lezotte D, et al. Childhood femur fractures, associated injuries, and
sociodemographic risk factors: a population-based study. Pediatrics. 2005;115(5):e543-e552.
3. Landin LA. Epidemiology of children’s fractures. J Pediatr Orthop B. 1997;6(2):79-83.
4. Buess E, Kaelin A. One hundred pediatric femoral fractures: epidemiology, treatment attitudes,
and early complications. J Pediatr Orthop B. 1998;7(3):186-192.
5. Vetti N, Lindtjorn B, Engesaeter LB. 406 Femoral fractures in children [Article in Norwegian].
Tidsskr Nor Laegeforen. 1998;118(22): 3415-3418.
6. Buckley SL. Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res. 1997;338:60-73.
7. Sanders JO, Browne RH, Mooney JF, et al. Treatment of femoral fractures in children by
pediatric orthopedists: results of a 1998 survey. J Pediatr Orthop. 2001;21(4):436-441.
8. Wright JG. The treatment of femoral shaft fractures in children: a systematic overview and critical appraisal of the literature. Can J Surg. 2000;43(3):180-189.
9. Cassinelli EH, Young B, Vogt M, et al. Spica cast application in the emergency room for select
pediatric femur fractures. J Orthop Trauma. 2005;19(10):709-716.
10. Infante AF Jr, Albert MC, Jennings WB, et al. Immediate hip spica casting for femur fractures
in pediatric patients. A review of 175 patients. Clin Orthop Relat Res. 2000;376:106-112.
11. Ferguson J, Nicol RO. Early spica treatment of pediatric femoral shaft fractures. J Pediatr Orthop. 2000;20(2):189-192.
12. Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop
Surg. 2004;12(5):347-359.
13. de Sanctis N, Gambardella A, Pempinello C, et al. The use of external fixators in femur fractures in children. J Pediatr Orthop. 1996; 16(5):613-620.
14. Stans AA, Morrissy RT, Renwick SE. Femoral shaft fracture treatment in patients age 6 to 16
years. J Pediatr Orthop. 1999;19(2):222-228.
15. Irani RN, Nicholson JT, Chung SM. Long-term results in the treatment of femoral shaft fractures in young children by immediate spica immobilization. J Bone Joint Surg Am. 1976;58(7):
945-951.
16. Aronson J, Tursky EA. External fixation of femur fractures in children. J Pediatr Orthop.
1992;12(2):157-163.
17. Blasier RD, Aronson J, Tursky EA. External fixation of pediatric femur fractures. J Pediatr
Orthop. 1997;17(3):342-346.
18. Carey TP, Galpin RD. Flexible intramedullary nail fixation of pediatric femoral fractures. Clin
Orthop Relat Res. 1996;(332):110-118.
19. Bar-On E, Sagiv S, Porat S. External fixation or flexible intramedullary nailing for femoral shaft
fractures in children. A prospective, randomised study [published correction appears in J Bone
Joint Surg Br. 1998;80(4):749]. J Bone Joint Surg Br. 1997;79(6):975-978.
20. Ozdemir HM, Yensel U, Senaran H, et al. Immediate percutaneous intramedullary fixation and
functional bracing for the treatment of pediatric femoral shaft fracture. J Pediatr Orthop. 2003;
23(4):453-457.
21. Eren OT, Kucukkaya M, Kockesen C, et al. Open reduction and plate fixation of femoral shaft
fractures in children aged 4 to 10. J Pediatr Orthop. 2003;23(2):190-193.
22. Agus H, Kalenderer O, Eryanilmaz G, et al. Biological internal fixation of comminuted femur
shaft fractures by bridge plating in children. J Pediatr Orthop. 2003;23(2):184-189.
23. Anglen JO, Choi L. Treatment options in pediatric femoral shaft fractures. J Orthop Trauma.
2005;19(10):724-733.
24. Hedequist DJ, Sink E. Technical aspects of bridge plating for pediatric femur fractures. J Orthop Trauma. 2005;19(4):276-279.
Indiana Orthopaedic Journal
Volume 3 – 2009
Flexible Interlocked Nailing of Pediatric Femoral Fractures (continued)
25. Greisberg J, Bliss MJ, Eberson CP, et al. Social and economic benefits of flexible intramedullary
nails in the treatment of pediatric femoral shaft fractures. Orthopedics. 2002;25(10):1067-1070.
26. Corry IS, Nicol RO. Limb length after fracture of the femoral shaft in children. J Pediatr Orthop. 1995;15(2):217-219.
27. Luhmann SJ, Schootman M, Schoenecker PL, et al. Complications of titanium elastic nails for
pediatric femoral shaft fractures. J Pediatr Orthop. 2003;23(4):443-447.
28. Gregory P, Pevny T, Teague D. Early complications with external fixation of pediatric femoral
shaft fractures. J Orthop Trauma. 1996;10(3):191-198.
29. Hutchins CM, Sponseller PD, Sturm P, et al. Open femur fractures in children: treatment,
complications, and results. J Pediatr Orthop. 2000;20(2):183-188.
30. Beaty JH, Austin SM, Warner WC, et al. Interlocking intramedullary nailing of femoralshaft fractures in adolescents: preliminary results and complications. J Pediatr Orthop.
1994;14(2):178-183.
31. Letts M, Jarvis J, Lawton L, et al. Complications of rigid intramedullary rodding of femoral
shaft fractures in children. J Trauma. 2002; 52(3):504-516.
32. Staheli L. Fractures of the shaft of the femur. In: Rockwood C, Wilkins K, King R, eds. Fractures
in Children. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:941-981.
33. Narayanan UG, Hyman JE, Wainwright AM, et al. Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Pediatr Orthop.
2004;24(4):363-369.
34. Gwyn DT, Olney BW, Dart BR, et al. Rotational control of various pediatric femur fractures
stabilized with titanium elastic intramedullary nails. J Pediatr Orthop. 2004;24(2):172-177.
35. Heinrich SD, Drvaric DM, Darr K, et al. The operative stabilization of pediatric diaphyseal
femur fractures with flexible intramedullary nails: a prospective analysis. J Pediatr Orthop.
1994;14(4):501-507.
36. Linhart WE, Roposch A. Elastic stable intramedullary nailing for unstable femoral fractures in
children: preliminary results of a new method. J Trauma. 1999;47(2):372-378.
37. Buechsenschuetz KE, Mehlman CT, Shaw KJ, et al. Femoral shaft fractures in children: traction and casting versus elastic stable intramedullary nailing. J Trauma. 2002;53(5):914-921.
38. Benirschke SK, Melder I, Henley MB, et al. Closed interlocking nailing of femoral shaft fractures: assessment of technical complications and functional outcomes by comparison of a prospective database with retrospective review. J Orthop Trauma. 1993;7(2):118-122.
39. Sink EL, Gralla J, Repine M. Complications of pediatric femur fractures treated with titanium
elastic nails: a comparison of fracture types. J Pediatr Orthop. 2005;25(5):577-580.
40. Flynn JM, Hresko T, Reynolds RA, et al. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop.
2001;21(1):4-8.
41. Moroz LA, Launay F, Kocher MS, et al. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br.
2006;88(10):1361-1366.
42. Raney EM, Ogden JA, Grogan DP. Premature greater trochanteric epiphysiodesis secondary to
intramedullary femoral rodding. J Pediatr Orthop. 1993;13(4):516-520.
Appendix
Variables were defined as follows:
• Sexual immaturity: Girls < 14 years old and boys < 16 years old
• Weight: Weight in pounds was stratified as either ≥ 45.5 kg (100 lb)
or < 45.5 kg (100 lb)
• Condition: Open or closed femoral shaft fracture
• Location: Proximal, second, third, and distal quarters of the femur
• Pattern: Transverse, oblique, spiral, and comminuted fracture type
• Duration of surgery: Length of surgical procedure in minutes. Duration of
surgery included anesthesia induction, patient positioning, fracture reduction, surgical preparation, operative procedure, and anesthesia reversal
• Length of hospital stay: Number of days from surgical procedure to hospital discharge. Criteria for discharge may include adequate pain control
with oral analgesics, satisfac­tory wound conditions, and ability to ambulate
with assistive devices
• Blood loss: Blood loss in milliliters was abstracted from the anesthesia
record
• Leg-length discrepancy: Difference in length between the affected and
unaffected limbs measured in millimeters based on scanogram, whole-leg
radiographs, or hip-knee-ankle radiographs
• Articulotrochanteric distance difference: Difference between the affected and unaffected joints’ articulotrochan­teric distances measured in
millimeters based on anterior/ posterior pelvis radiograph
•N
eck-shaft angle difference: Difference between the affected and unaffected femoral neck-shaft angles measured in degrees based on anterior/
posterior pelvis radiograph
•T
ime to radiographic healing: The time from surgery to the first radiographic appearance of 3 cortices bridged with fracture callus
•M
ajor complications: Malunion, refracture, deep infection, and avascular
necrosis
alunion: Presence of greater than 10 degrees’ angulation in the fronM
tal plane or 20 degrees in the sagittal plane at the time of radiographic
healing
efracture: Fracture of bone occurring after implant insertion or after
R
its removal
eep infection: Includes infections requiring further treatments, such as
D
oral or intravenous antimicrobials, wound care, and/or further surgical
procedures
•M
inor complications: Superficial infection, trochanteric heterotopic
ossification, delayed union, pain, implant problems
elayed union: Lack of bony union at 6 months based on radiographs
D
Implant problems: Could include a loosened screw, protruding screw
or nail, or bent nail
Dr. Phillips is a 1992 graduate of the Indiana University orthopaedic surgery residency program and may be contacted at the Division of Pediatric
Orthopaedics, Orlando Regional Healthcare, Orlando, FL.
76
Indiana Orthopaedic Journal
Volume 3 – 2009
The Combined Use of Simulation and Navigation
to Demonstrate Hip Kinematics
By Robert L. Thornberry, M.D., and Andrew J. Hogan
Tallahassee Orthopedic Clinic — Tallahassee, FL, USA
© 2009 The Journal of Bone and Joint Surgery, Inc. Reprinted from the Journal of
Bone and Joint Surgery American, Volume 91, pp. 144-152 with permission.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the
authors, or a member of his or her immediate family, received, in any one year,
payments or other benefits in excess of $10,000 or a commitment or agreement
to provide such benefits from a commercial entity (Smith and Nephew). No
commercial entity paid or directed, or agreed to pay or direct, any benefits
to any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the authors, or a member of
their immediate families, are affiliated or associated.
Abstract
Computer navigation of total hip arthroplasty and computer simulation of hip motions based on collision detection
were both introduced more than ten years ago. Neither of these
promising technologies has achieved its full potential to improve patient outcomes. Combining these two technologies
allows the individual strengths of each to more easily demonstrate hip kinematics in a clinically useful way. All normal and
pathologic combined hip motions must be clearly and accurately reported to fully evaluate the kinematics involved in total hip
arthroplasty, femoroacetabular impingement syndrome, and
other hip disorders. The use of three-dimensional data graphs
allows for a rapid and thorough evaluation of the very large
data sets that are required for the purpose of making a complete report of all combined hip motions. Data can be obtained
from simulations made with use of high-resolution computed
tomographic scans and computer-aided implant-design files or
from clinically obtained motion analysis on fresh cadavers or
normal subjects. The use of these methods and graphics allows for the thorough evaluation of the geometries of current
implant designs and will help improve future implant designs.
The pathologic structures in hips with femoroacetabular impingement can be modeled in three dimensions, and surgical
treatment plans can be developed to provide impingement-free
normal hip motion without excessive osseous resection. The
combination of these technologies provides hope for the improved surgical placement of total hip implants by providing
the basis for a kinematic, impingement-based total hip navigation system.
Introduction
In 1996 and 1998, at the Annual Meetings of the American Academy of Orthopaedic Surgeons (AAOS), scientific exhibits were presented on hip navigation, hip range-of-motion
simulations, and small-incision total hip arthroplasty1-4. Each
of these subjects has had an interesting history and development over the last ten years. Small-incision surgery exploded
onto the scene and became both commonplace and controver77
sial5,6. As a promising technology, hip navigation had a surge in
exposure, if not popularity, but it has not been widely accepted
in the United States7,8. The combination of minimally invasive
surgery and computer-assisted orthopaedic surgery spawned a
series of courses around the globe during the last decade.
During this time, hip range-of-motion simulations were
used primarily as marketing tools by industry to drive implant sales9, and their use as a research tool was limited10-12.
The fusion of navigation and simulation technologies has the
potential to improve the understanding of normal and abnormal kinematics of the hip as well as the process capability (Six
Sigma) of total hip arthroplasty. The recent identification of
femoroacetabular impingement syndrome and its relationship
to the etiology of hip arthritis underscores the need for more
thorough and exacting methods to evaluate hip kinematics13.
Materials and Methods
HipNav, a validated computed tomography-based computer navigation and simulation program, was used to model
hip motions from computed tomographic images of normal
hips14. These hips represented an anonymous set of thirty-nine
normal hip scans that were acquired at the New England Baptist Hospital15; in addition, ten normal hips (two hips from each
of five cadavers) came from a cadaver laboratory. All computed tomographic scans were carefully screened to exclude hips
with arthritis, femoroacetabular impingement, and hip dysplasia. Simulations of all available combined hip motions were
calculated after the hips were carefully segmented to allow
manipulation of the solid virtual femora and pelves created in
the software motion simulation program.
It was necessary to remove the femoral head in the simulations to ensure that no intra-articular impingements occurred
due to the normal out-of-round variability of head and acetabular geometry. The soft tissues (labrum and capsule) about the
hip were considered, and, on the basis of observations made
by Tannast et al.15, five degrees were subtracted from hip motions based on collision detection of the bone models. These
simulations created the normal data files of hip motion based
on computed tomography (Fig. 1). Hip scans of patients with
femoroacetabular impingement were compared with these normal scans.
The same process was utilized for the modeling of total
hip motions. A single computed tomographic model was used
to place a total hip computer-assisted design model (stereolithography format) in multiple different orientations with multiple implant types and head sizes. Data were recorded for all
Indiana Orthopaedic Journal
Volume 3 – 2009
The Combined Use of Simulation and Navigation to Demonstrate Hip Kinematics
(continued)
All files were reported as script files, which could cross
computer platforms. The original script files from HipNav
were created in Linux Red Hat (Red Hat, Raleigh, North Carolina), then transferred to a Windows XP computer for statistical
modeling with use of Maple V Release 5.1 (Waterloo Maple,
Waterloo, Ontario, Canada). The Maple graphs lacked clarity
for presentation purposes and were modeled in three-dimensional Studio MAX Autodesk 3ds Max software (Autodesk,
San Rafael, California) and Adobe After Effects 7.0 software
(Adobe Systems, San Jose, California). Very vivid, high-resolution renderings could then be produced, allowing for clear
and unambiguous representation and interpretation.
Figure 1: Data graph of computed tomography-based hip motions
of a normal hip (red) and the implant motions graph of a 28-mm
total hip prosthesis (blue). ER = external rotation; Ext = extension;
Flex = flexion; IR = internal rotation; and AB = abduction.
implant-on-implant impingement and nonimpingement points.
The nonimpingement points were then selected for further
study. Each data set included one to two million data points.
Specialized add-on software was written to allow HipNav to
run sequential simulations in multiple positions, allowing all
potential positions to be modeled.
In order to accurately present all of the data in a single
graph, it was necessary to use a three-dimensional data graph
or point cloud graph (Fig. 1). By convention, the six motions
of the hip were assigned positive or negative values in the Cartesian coordinate system. Flexion was positive and extension
negative on the y-axis; abduction was positive and adduction
negative on the x-axis; and external rotation was positive and
internal rotation negative on the z-axis (Table I). A custom filtering program was written that identified the outer boundary
of the three-dimensional data graph, which was required to
reduce the number of data points to a manageable number, allowing manipulation of the data graphs.
The data collected on normal cadaver hip motions were
obtained by means of one of us (R.L.T.) manually moving a
normal fresh cadaver hip through a range of motion and by
means of reference arrays attached to the femur and pelvis
with use of modified BrainLAB VectorVision (BrainLAB,
Westchester, Illinois) software. All osseous landmarks were
fully exposed, and small screws were placed to reduce registration errors. All hips were evaluated for arthritis, femoroacetabular impingement, and hip dysplasia with use of computed
tomographic scans or through exposure by dissection.
VectorVision software reported ten data points of the hip
position per second relative to the pelvic plane. With use of the
same convention, three-dimensional graphs were created with
use of the Maple software. It usually took about twenty minutes of continuous movement to obtain sufficient data points to
generate a reasonable graph. The graphs then required the application of a wrap-type program for the purpose of surrounding the collected points to provide a solid three-dimensional
graph. These graphs represented all of the possible positions
in which each cadaveric hip could be placed (Fig. 2-A).More
than forty normal cadaveric hips have been studied to date for
the creation of a database of normal hip motion.
Simulations were run for different head sizes, implants,
implant positions, liners (lipped compared with nonlipped),
and lipped liner positions. Results were graphed in Maple and
evaluated by overlaying one graph on another. When a simulation graph demonstrated an important point or insight, a threedimensional Studio MAX animation was made.
Results
Multiple studies have been reported in which these techniques have been used16-19. The combined-motions graphs that
were obtained with use of HipNav show a much more complex
picture of hip range of motion than previously described (Table
II). This method is of particular importance in the evaluation
of femoroacetabular impingement. The ability to graphically
represent the loss of motion and the areas that need to be altered surgically can be a powerful tool in the treatment of this
disorder.
The cadaveric hip range of motion was far greater than
what was expected or had been previously reported (Fig.
2-B)20-26. This necessitated increasing the parameters for the
78
Indiana Orthopaedic Journal
Volume 3 – 2009
The Combined Use of Simulation and Navigation to Demonstrate Hip Kinematics
(continued)
2A
2C
Figure 2-A: Normal, cadaveric combined-motions graph on a standard Cartesian coordinate system. ER = external rotation; Ext =
extension; Flex = flexion; and IR = internal rotation. Figure 2-B:
Normal, cadaveric combinedmotions graph demonstrating the
need for expanded hip-motion parameters. Red = normal cadaveric range of motion; and blue = clinically based range of motion
parameters as reported in the literature. Ext = extension; and Flex
= flexion. Figure 2-C: Alternate view of the necessity for an expansion of hip-motion parameters for accurate cadaveric combinedmotions graphs. Red = normal cadaveric range of motion; and blue
= clinically based range-of-motion parameters as reported in the
literature. Ext = extension; ER = external rotation; IR = internal
rotation; and AB = abduction.
2B
three-dimensional data graphs that were used to model the motions of hip implants (Fig. 2-C). The charted cadaveric hip motions were most closely aligned with the simulated motions
reported in the work of Sugano et al.24 than with the motions
in any of the previous clinical works found in the literature
(Table II).
79
Ten cadaveric hips, with both computed tomographic and
cadaveric motions recorded, showed similarities. However, the
complex nature of the hip capsular ligaments restricted certain hip motions, in addition to osseous impingement, in many
movements. Graphic analyses were most similar during combined flexion and internal rotation. These combined motions
Indiana Orthopaedic Journal
Volume 3 – 2009
The Combined Use of Simulation and Navigation to Demonstrate Hip Kinematics
(continued)
3A
3B
Non-navigated placement of a hip implant, as reported in
the literature, is quite variable when computed tomographic
scans are used to measure placement27. The accuracy of implantation that is needed to ensure the restoration of normal range
of motion of the hip is much more exacting than the accuracies
that have been reported with non-navigated techniques27. Simulations were performed of multiple combined anteversion and
abduction angles. These data were then animated with constant
abduction (Figs. 4-A and 4-B) and constant anteversion (Figs.
4-C and 4-D) of the cup.
The impingement proved greatest when the acetabulum
was over-anteverted, with impingement occurring in extension
and external rotation (Fig. 4-A)28. Placing the cup in a more
vertical orientation decreases the prevalence of impingement
but also increases the stresses to the bearing surfaces and decreases the ‘‘jumping distance’’ for dislocation. Newer, hardonhard bearing surfaces do not tolerate vertical cup placement.
It has been suggested that cups should be placed more horizontally. This horizontal positioning increases impingement in
both flexion and extension (Fig. 4-C).
4A
Figure 3-A: Increase in available range of motion with a 32-mm
head size. Red = native hip computed tomography-based range ofmotion; blue = range of motion from28-mmhead size; and orange =
range ofmotion from32-mm head size. Ext = extension; ER = external rotation; and AB = abduction. Figure 3-B: Additional increases
in available range of motion achieved with a 36-mm head size,
as compared with a 32-mm head size. Red = native hip computed
tomography-based range of motion; blue = range of motion from
28-mm head size; and green = range of motion from 32-mm head
size. Ext = extension; ER = external rotation; and AB = abduction.
4B
appear to be more related to osseous impingement than to ligament restraint.
Whether computed tomographic or cadaveric-determined
range-of-motion standards were used, normal hip motion could
not be restored with a 28-mm head prosthesis, regardless of the
cup orientation. If a lipped liner was used, the range of motion
dropped even more precipitously. Range of motion continued
to improve with use of a 32-mm head (Fig. 3-A), and even
more with use of a 36-mm head (Fig. 3-B). The available motion of the 36-mm head was acceptable at 45 of abduction and
35 of combined anteversion, but accurate placement was still
necessary to avoid loss of the normal motions as was seen in
the cadaver studies.
Figure 4-A: Combined-motions graphs of an over-anteverted acetabular cup. Red = native hip computed tomography-based range
of motion; and blue = range of motion from 28-mm head size. ER
= external rotation; IR = internal rotation; Ext = extension; Flex =
flexion; AB = abduction; and AD = adduction. Figure 4-B: Combined-motions graphs of an under-anteverted acetabular cup. Red =
native hip computed tomography-based range of motion; and blue
= range of motion from 28-mm head size. ER = external rotation;
IR = internal rotation; Ext = extension; Flex = flexion; AB = abduction; and AD = adduction.
80
Indiana Orthopaedic Journal
Volume 3 – 2009
The Combined Use of Simulation and Navigation to Demonstrate Hip Kinematics
(continued)
4C
5A
4D
5B
Figure 4-C: Combined-motions graphs of a horizontally positioned
acetabular cup. Red = native hip computed tomographybased range
of motion; and blue = range of motion from 28-mm head size. ER
= external rotation; IR = internal rotation; Ext = extension; Flex =
flexion; AB = abduction; and AD = adduction. Figure 4-D: Combined-motions graphs of a vertically positioned acetabular cup.
Red = native hip computed tomography-based range of motion; and
blue = range of motion from 28-mm head size. ER = external rotation; IR = internal rotation; Ext = extension; Flex = flexion; AB =
abduction; and AD = adduction.
Augmented liners, which have been shown to decrease
dislocation, are frequently used29. In certain positions, loss
of motion to impingement can be anticipated, although the
prevalence of dislocation may decrease. It has previously been
suggested that the proper placement of the augmented liner is
at the four o’clock position30. Simulations were performed to
evaluate augmentation placement and the effect on available
range of motion on the basis of the cadaveric range-of-motion
data. The simulations did not indicate any significant decrease
in impingement by lowering the center of augmentation to the
four o’clock position from the one o’clock or three o’clock position (Fig. 5-A). Substantial decreases in impingement did not
occur until the six o’clock position (Fig. 5-B). A 20 augmented
liner, specifically optimized to limit impingement and placed
directly posterior, caused a decrease in motion to impingement
in external rotation and extension that was equivalent to overanteverting the acetabular cup by 30. A poorly designed liner
or femoral neck geometry would have fared even worse31.
The most promising application of the combined use
of navigation and simulation has been the development of a
new navigation system based on the forced impingement of
81
Figures 5-A and 5-B: Placement of the hooded liner in the three
o’clock position (Fig. 5-A) and six o’clock position (Fig. 5-B) in the
left hip. Red = native hip cadaveric range of motion; and orange =
additional impingement from hooded insert. ER = external rotation;
IR = internal rotation; AB = abduction; and Ext = extension.
the trial hip with a ‘‘gizmo’’ neck augmentation device (Fig.
6-A). This creates a signature three-dimensional graph or three
dimensional fingerprint (appearing like a funnel cake or tube)
of collision detection points that allows for the solution of the
relative position of the acetabular implant without registration
of the pelvic plane (Fig. 6-B). Every possible position must be
simulated to create a data set that is used to identify the cupstem orientation. Every ‘‘tube’’ graph is related to an implant
graph that identifies the available hip motions in each implant
orientation (Fig. 6-C). By overlaying these data on the normal
hip motions, optimal results can be obtained (Fig. 6-D). This
method requires thousands of simulations and several terabytes
of data-filtering to create a database.
These virtual simulations do not need to allow for the
point acquisition errors and repositioning that have limited the
accuracy and usefulness of computed tomography-free navigation, and thus there is a potential for substantial improvements
in the efficiency and accuracy of hip navigation.
Indiana Orthopaedic Journal
Volume 3 – 2009
The Combined Use of Simulation and Navigation to Demonstrate Hip Kinematics
(continued)
6A
6B
Figure 6-A: Computer-generated, three-dimensional model of the
‘‘gizmo’’ neck augmentation device. Figure 6-B: 60 abduction, 20
anteversion (green) and 30 abduction, 20 anteversion (yellow) tube
graphs demonstrating difference in shape. Figure 6-C: Total hip
combined-motions graph (yellow) with corresponding gizmo tube
graph (blue). ER = external rotation; IR = internal rotation; Ext
= extension; Flex = flexion; AB = abduction; and AD = adduction. Figure 6-D: Combined graph of combined hip implant motions
(yellow), gizmo tube graph (blue), and cadaveric combined motions
(red) for a 28-mm head in ideal position (45 abduction and 35 combined anteversion). Ext = extension; ER = external rotation; IR =
internal rotation; and AB = abduction.
Multiple positions were modeled, both with and without
the gizmo device, and graphs were obtained. The subtle differences, even by only one degree, of the tube or gizmo graphs are
variable enough to allow for clear differentiation of obtained
and simulated data.
Discussion
The ability to view all combined hip motions in a single
graph is a great advantage in the evaluation of hip kinematics.
It takes some time to become comfortable with the three-dimensional graphic technique and to understand the differences
displayed when overlaying one graph on another. The methodology supports the use of data, from any source and in all
computer platforms, that can be displayed relative to the pelvic
plane in script files.
6C
6D
Recent studies have suggested that the pelvic tilt is critical
for correct cup placement32. The cadaveric data to date reveal
that the range of motion of the hip relative to the pelvic plane in
fresh cadavers is quite consistent. Variability of the tilt may be
especially important in radiographic measurements and nonnavigated cup positioning, but it had no noticeable effect on
the maximal normal motions that were measured relative to the
pelvic plane in the cadavers that were studied.
The lack of motion due to impingement that was clearly
demonstrated by 28-mm heads is a cause for concern. Small
acetabular components limit the size of the femoral head that
can be used. Larger bearings have clearly been shown to increase the amount of hip motion possible before impingement
occurs (Figs. 3-A and 3-B)33,34. The use of larger femoral heads
did not obviate the need for accuracy in implant placement,
and the simulations indicate that both an improved geometry
with larger head sizes and an improved accuracy are needed to
improve the process capability of total hip arthroplasty.
With use of these methods, a standard of minimal total hip
implant motion can and should be determined. Sixty percent
of retrieved cups in one study demonstrated signs of impingement35, half with moderate to severe damage. This resulted
in a doubling of polyethylene wear in the hips with moderate to severe damage. The poor motion provided by some earlier modular total hip arthroplasty designs needs to be fully
documented, exposed, and corrected. This methodology can
calculate the anticipated rate of implant-on-implant impingement of any prosthesis, knowing the implant geometry and a
82
Indiana Orthopaedic Journal
Volume 3 – 2009
The Combined Use of Simulation and Navigation to Demonstrate Hip Kinematics
(continued)
given surgeon’s implantation variability. This information can
determine if total hip arthroplasty navigation, although not in
popular use today, may be necessary to achieve adequate postoperative range of motion of the hip.
If the implant selected can achieve acceptable combined motions without impingement, despite the wide range
of expected variability of surgical implantation, it should be
documented. However, if certain implant geometries cannot
provide acceptable motion within the limits of variability of
surgical implantation, they should either not be made available
or should carry a disclaimer stating that the implant is not recommended for use without the accompanying use of navigation or an increased femoral head size.
A higher prevalence of dislocation with certain implant
designs has been reported31. In addition, certain designs have
been shown to have increased impingement at the time of retrieval analysis36.
With respect to limitations, the techniques and concepts
reported are forward-looking and a commercially available
working system is not yet available; when such a system is
introduced, it will likely include further improvements and enhancements. At present, this remains a work in progress. Additional studies on normal subjects and more cadavers must be
done to create a statistically valid normal hip-motion database.
Statistical techniques for determining the means and standard
deviations of the three-dimensional data graphs have not been
completed. Although intuitively reasonable, a working kinematic navigation method has yet to be validated to decrease the
prevalence of dislocation and impingement.
Future Developments
The combined use of computer simulation and computer
navigation of the hip is a fertile field for study and offers the
possibility for improvement in implant design, hip navigation
systems, and the treatment of femoroacetabular impingement
syndrome. Future computer tools will soon be available that
will more accurately diagnose and surgically treat femoroacetabular impingement. Improved total hip arthroplasty implant
designs will result in fewer impingements and dislocations.
Future use of a new method of evaluating intraoperative
implant positions with use of three-dimensional data graphs is
suggested. Graphs of a patient’s normal expected hip motions
(from a navigation-obtained database), the available hip motions from the implant, and the intraoperatively obtained tube
graphs can together confirm intraoperatively that the patient
will have satisfactory impingement-free range of motion of the
hip postoperatively.
References
1. Thornberry RL, Lavernia CJ, Barrack RL, Tozakoglou E. The effects of neck geometry and
acetabular design on the motion to impingement in total hip reconstruction (THR). Presented at
the 65th Annual Meeting of the American Academy of Orthopaedic Surgeons; 1998 Mar 19-23;
New Orleans, LA. SE 046.
2. Lavernia CJ, Barrack RL, Thornberry RL, Tozakoglou E. The effects component position in
motion to impingement and dislocation in total hip reconstruction (THR). Presented at the 65th
Annual Meeting of the American Academy of Orthopaedic Surgeons; 1998 Mar 19-23; New
Orleans, LA. SE 058.
83
3. DiGioia AM 3rd, O’Toole RV, Jaramaz B, Simon D, Blackwell M, Morgan F. A computerassisted planner and intraoperative guidance system for the accurate placement of acetabular
implants. Presented at the 63rd Annual Meeting of the American Academy of Orthopaedic Surgeons; 1996 Feb 22-26; Atlanta, GA. SE 075.
4. Crockett HC, Wright JM, Sculco TP, Bates J. Mini-incision for primary total hip arthroplasty.
Presented at the 65th Annual Meeting of the American Academy of Orthopaedic Surgeons; 1998
Mar 19-23; New Orleans, LA. SE 060.
5. Berry DJ. ‘‘Minimally invasive’’ total hip arthroplasty. J Bone Joint Surg Am. 2005;
87:699-700.
6. Berger RA, Jacobs JJ, Meneghini RM, Della Valle C, Paprosky W, Rosenberg AG. Rapid
rehabilitation and recovery with minimally invasive total hip arthroplasty. Clin Orthop Relat Res.
2004;429:239-47.
7. Haaker RG, Tiedjen K, Ottersbach A, Rubenthaler F, Stockheim M, Stiehl JB. Comparison of conventional versus computer-navigated acetabular component insertion. J Arthroplasty.
2007;22:151-9.
8. Digioia AM 3rd, Jaramaz B, Plakseychuk AY, Moody JE Jr, Nikou C, Labarca RS, Levison
TJ, Picard F. Comparison of a mechanical acetabular alignment guide with computer placement
of the socket. J Arthroplasty. 2002;17:359-64.
9. Paradigm Productions. Hip range of motion comparisons. CD-ROM. Memphis, TN: Smith and
Nephew; 1998.
10. Noble PC, Sugano N, Johnston JD, Thompson MT, Conditt MA, Engh CA Sr, Mathis KB.
Computer simulation: how can it help the surgeon optimize implant position? Clin Orthop Relat
Res. 2003;417:242-52.
11. Otake Y, Suzuki N, Hattori A, Hagio K, Sugano N, Yonenobu K, Ochi T. Four dimensional
model of the lower extremity after total hip arthroplasty. J Biomech. 2005;38:2397-405.
12. Leardini A, Belvedere C, Astolfi L, Fantozzi S, Viceconti M, Taddei F, Ensini A, Benedetti
MG, Catani F. A new software tool for 3D motion analyses of the musculoskeletal system. Clin
Biomech (Bristol, Avon). 2006;21:870-9.
13. Ganz R, Parvizi J, Beck M, Leunig M, N¨otzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112-20.
14. Eckman K, Nikou C, Lattanzi R, Jaramaz B, DiGioia AM 3rd. Experimental validation of hip
range of motion simulator. Presented at the 3rd Annual Meeting of the International Society for
Computer Assisted Orthopaedic Surgery; 2003 Jun 18- 21; Marbella, Spain. Special poster no.
17.
15. Tannast M, Kubiak-Langer M, Langlotz F, Puls M, Murphy SB, Siebenrock KA. Noninvasive three-dimensional assessment of femoroacetabular impingement. J Orthop Res.
2007;25:122-31.
16. Thornberry RL, Nelson LS. CT evaluation of combined native hip ROM using computer simulations. Presented at the 6th Combined Meeting of the Orthopaedic Research Societies; 2007 Oct
21-24; Honolulu, HI. Poster no. 0459.
17. Thornberry RL, Nelson LS. Combined native hip range of motions. Presented at the 6th Combined Meeting of the Orthopaedic Research Societies; 2007 Oct 21- 24; Honolulu, HI. Poster no.
0456.
18. Thornberry RL, Nelson LS. Effect of elevated-rim liner position on motion to impingement in
THA. Presented at the 54th Annual Meeting of the Orthopaedic Research Society; 2008 Mar 2-5;
San Francisco, CA. Poster no. 1761.
19. Thornberry RL, Nelson LS. Effect of femoral head size and implantation variability on reestablishing normal combined hip motions. Presented at the 6th Combined Meeting of the Orthopaedic
Research Societies; 2007 Oct 21-24; Honolulu, HI. Poster no. 0159.
20. Green WBB, Heckman JD, editors. The clinical measurement of joint motion. Rosemont, IL:
American Academy of Orthopaedic Surgeons; 1994. The hip; p 99-114.
21. Ahlberg A, Moussa M, Al-Nahdi M. On geographical variations in the normal range of joint
motion. Clin Orthop Relat Res. 1988;234:229-31.
22. Joint motion: method of measuring and recording. Chicago: American Academy of Orthopaedic
Surgeons; 1965.
23. Range of joint motion and method of measurement. Tokyo: Japanese Orthopaedic Association;
1995.
24. Sugano N, Yamanashi W, Sasama T, Sato Y, Nishii T, Miki H, Yoshikawa H. Ranges of motion in anatomically normal hips using computer collision detection. Read at the 49th Annual
Meeting of the Orthopaedic Research Society; 2003 Feb 2-5; New Orleans, LA. Paper no. 0155.
25. Boone DC, Azen SP. Normal range of motion of joints in male subjects. J Bone Joint Surg Am.
1979;61:756-9.
26. Roaas A, Andersson GB. Normal range of motion of the hip, knee and ankle joints in male
subjects, 30-40 years of age. Acta Orthop Scand. 1982;53:205-8.
27. Minoda Y, Kadowaki T, Kim M. Acetabular component orientation in 834 total hip arthroplasties using a manual technique. Clin Orthop Relat Res. 2006;445:186-91.
28. Yamaguchi M, Akisue T, Bauer TW, Hashimoto Y. The spatial location of impingement in total
hip arthroplasty. J Arthroplasty. 2000;15:305-13.
29. Cobb TK, Morrey BF, Ilstrup DM. The elevated-rim acetabular liner in total hip arthroplasty:
relationship to postoperative dislocation. J Bone Joint Surg Am. 1996;78:80-6.
30. Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement. J Bone Joint Surg
Am. 2007;89:1832-42.
31. Barrack RL. Dislocation after total hip arthroplasty: implant design and orientation. J Am Acad
Orthop Surg. 2003;11:89-99.
32. Babisch JW, Layher F, Amiot LP. The rationale for tilt-adjusted acetabular cup navigation. J
Bone Joint Surg Am. 2008;90:357-65.
33. Crowninshield RD, Maloney WJ, Wentz DH, Humphrey SM, Blanchard CR. Biomechanics
of large femoral heads: what they do and don’t do. Clin Orthop Relat Res. 2004;429:102-7.
34. Burroughs BR, Hallstrom B, Golladay GJ, Hoeffel D, Harris WH. Range of motion and stability in total hip arthroplasty with 28-, 32-, 38-, and 44-mm femoral head sizes. J Arthroplasty.
2005;20:11-9.
35. Usrey MM, Noble PC, Rudner LJ, Conditt MA, Birman MV, Santore RF, Mathis KB. Does
neck/liner impingement increase wear of ultrahigh-molecular-weight polyethylene liners? J Arthroplasty. 2006;21(6 Suppl 2):65-71.
36. Yamaguchi M, Bauer TW, Hashimoto Y. Three-dimensional analysis of multiple wear vectors
in retrieved acetabular cups. J Bone Joint Surg Am. 1997;79: 1539-44.
Indiana Orthopaedic Journal
Volume 3 – 2009
An Occult Knee Dislocation Treated with Patellar Olecranization
Brian H Mullis, M.D. and Janos P Ertl, M.D.
Department of Orthopaedics – Indiana University School of Medicine – Indianapolis, Indiana, USA
Eric M Lindvall, D.O., University of California – San Francisco – Fresno, California, USA
Investigation performed at:
Florida Orthopaedic Institute, Tampa FL
Corresponding Authors:
Brian H Mullis, M.D. (Corresponding Author)
Chief, Orthopaedic Trauma Service
Indiana University School of Medicine
Department of Orthopaedics
541 Clinical Drive, Suite 600
Indianapolis, IN 46202-5111
Fax: 317-630-8868
Office: 317-630-6192
E-mail: [email protected]
Janos P Ertl, M.D.
Assistant Professor
Indiana University School of Medicine
Department of Orthopaedics
541 Clinical Drive, Suite 600
Indianapolis, IN 46202-5111
Fax: 317-630-8868
Office: 317-630-6192
E-mail: [email protected]
Eric M Lindvall, D.O.
Clinical Faculty
University of California, San Francisco – Fresno Center
for Medical Education and Research
University Medical Center
445 S Cedar Avenue
Department of Orthopaedics, 4th Floor
Fresno, CA 93720
Fax: 559-459-5029
Phone: 559-459-4004
E-mail: [email protected]
The authors have no conflicts of interest to report in
association with this manuscript.
Abstract
Ligamentous injury to the knee is commonly seen in
association with long bone fractures of the lower extremity. This case study illustrates an occult knee dislocation that
may have been missed if not for a dedicated examination following fixation of open ipsilateral femur and tibia fractures
(floating knee). In addition there was a significant soft tissue
injury of the right thigh which communicated with the knee.
The knee dislocation was treated with patellar olecranization
to maintain motion, as the patient was not a candidate for
early knee ligament reconstruction.
Introduction
The term “floating knee” was first used by Blake & McBryde
to describe ipsilateral fractures of the femur and tibia.1 Since that
description, multiple authors have noted the presence of ipsilateral
knee ligament injury associated with fractures of the femur, tibia,
or both.2-12 Many of these reports note the late diagnosis of occult
knee ligament injury when not suspected at the time of injury.
Olecranization of the patella was first described by Tavernier
and Guilleminet for genu recurvatum deformities.13, 14 The technique describes placing a pin across the patella into the tibia preventing posterior subluxation of the tibia on the femur. Although
controversial, it has been primarily used following posterior cruciate ligament (PCL) reconstruction,13,15,16 with one report from
the Polish literature describing its use for traumatic knee dislocation.17
This case report illustrates the need for examination of the
knee following fixation of long bone fractures as well as a providing a temporary alternative for knee dislocation stabilization when
acute reconstruction of ligament injuries is contraindicated.
Case Report
A 21-year-old male riding a motorcycle was involved in a
collision with a motor vehicle. He sustained multiple orthopaedic
injuries including a closed comminuted shaft fracture of the left
radius and ulna (OTA 22-C3.3) with an associated compartment
syndrome of the forearm (based on clinical
exam), a Gustilo-Anderson type 3A open diaphyseal right femur fracture (OTA 32-A3.2)
(Figure 1), a 3B open diaphyseal right tibia
fracture (OTA 42-A2.2) (Figures 2 & 3), a
closed segmental diaphyseal left tibia fracture (OTA 42-C2.1) with an associated medial tibia plateau fracture (OTA 41-B1.2), a
degloving injury to the left foot, and a closed
right radial styloid fracture (OTA 23-B1.1).
Additional physical exam findings were significant for a complete peroneal nerve palsy
to the right lower extremity with diminished
pulses to both lower extremities.
On the patient’s presentation to the
emergency department, standard Advanced
Trauma Life Support (ATLS) protocols were
initiated. The patient was given a first generation cephalosporin, an aminoglycoside, and
tetanus toxoid. An abdominal CT scan identified a grade 1 splenic laceration in addition to his orthopaedic injuries as described.
The diminished peripheral lower extremity
pulses led to a CT angiogram demonstrating
bilateral anterior tibial artery occlusion. Vascular surgery assessment felt there was ad84
Figure 1: Initial
AP of the right
knee showing
a right femur
fracture
Indiana Orthopaedic Journal
Volume 3 – 2009
An Occult Knee Dislocation Treated with Patellar Olecranization (continued)
Figure 2: Clinical photograph of the right lower
extremity, note degloving
injury seen in the anterior
thigh which resulted in full
thickness skin loss. The
posterior wound communicating with the open
fracture cannot be seen in
this photograph.
equate distal perfusion and
no vascular intervention
was necessary. The patient
was emergently taken to
surgery in order to address
his multiple orthopaedic
injuries.
A complete dorsal and
volar forearm fasciotomy
was performed on the left
forearm followed by bony
stabilization of the radius and ulna fractures with small fragment plates. Surgical débridement was performed on the open
right femur and tibia fractures and the degloving injury of the
left foot. The contaminated instruments were discarded prior to
fracture fixation. Intraoperative assessment identified a significant
subcutaneous degloving injury of the right thigh which communicated with the knee joint. Following the surgical débridement,
a retrograde femoral nail and tibial nail were inserted through a
single medial peripatellar incision. The left segmental tibia fracture was temporarily stabilized with a bridging knee external fixator. All surgical and traumatic open wounds were treated with
negative pressure wound vacuum dressings (left forearm, left
foot, right thigh and right leg). Following
bony stabilization, an examination under
anesthesia of the right knee was performed
demonstrating a positive Lachman’s and
pivot shift, positive posterior drawer, opening with valgus stress greater than 1 cm
and opening with varus stress less than 1
cm. A comparison examination with the
contralateral left knee was unable to be
performed due to the bridging knee external fixator. An external rotation test at 30
and 90 degrees flexion was performed. This
was difficult to interpret given the lack of a
contralateral exam, although there did not
appear to be a significant injury to the posterolateral corner. The patient was diagnosed
with a complete disruption of the anterior
cruciate ligament (ACL), posterior cruciate
ligament (PCL), and medial collateral ligament (MCL) and a grade 2 tear of the lateral
collateral ligament (LCL). The patient was
Figure 3: Initial AP of right leg showing
tibia fracture
85
temporarily treated with a knee
immobilizer. (Figure 4)
The patient returned to
the operating room for repeated débridement of all open
wounds and a first generation
cephalosporin and aminoglycoside were continued while
the wounds remained open. On
post-injury day 5, the patient
underwent removal of his left
knee external fixator and bony
stabilization of the left segmental tibia fracture was performed
with a proximal tibia locking plate. Following multiple
debridements, the right thigh
wound was covered with a split
thickness skin graft. The Sports
Medicine service was consulted regarding the possibility of
acute intra-articular ligament
reconstruction which was felt
to be contraindicated due to
the contaminated traumatic arthrotomy. Although, it was recommended to perform a PCL
avulsion repair on a delayed
basis. Olecranization of the patella was chosen to stabilize the
knee, rather than external fixation, to allow early limited knee
range of motion. (Figure 5)
Figure 4: Immediate post-op
The olecranization of the films showing AP (4A) and
patella was performed with a lateral (4B) of right knee
large threaded Steinman pin.
The patella was hand stabilized
and the pin placed superiorly
through the longitudinal axis
of the patella, entering the
tibia anterior to the tibia nail
insertion site. The proximal
portion of the Steinman pin
was cut and left subcutaneous. A trial passive range of
motion was completed under
anesthesia which yielded 0-80
degrees ROM.
Postoperatively the patient was allowed active
ROM as tolerated within a
hinged knee brace. Once the
patient had systemically improved 3 weeks post injury,
the PCL bony avulsion was
addressed through a posterior approach with the patient Figure 5: Lateral film showing in
the prone position. Although patella olecranization
Indiana Orthopaedic Journal
Volume 3 – 2009
An Occult Knee Dislocation Treated with Patellar Olecranization (continued)
the patient was allowed ROM postoperatively, a significant
amount of heterotopic bone formed about the knee. At 10 weeks
post injury the patient returned to the OR for removal of the olecranization pin and a manipulation was performed with 0 to 80
degrees of knee motion achieved.
The patient progressed to weight bearing as tolerated three
months post injury. All fractures had healed at the one year follow
up. The patient experienced no instability of the right knee and
the knee examination was stable to varus/valgus stress, the dial
test were negative at 30 and 90 degrees, the Lachman’s and posterior drawer exams were negative and the knee motion was 5-75
degrees. The radiographs of the right lower extremity at one year
showed significant heterotopic ossification of the knee anteriorly
and medially with healed femur and tibia fractures. (Figure 6)
Discussion
Knee ligament injuries are common following long bone
fractures of the lower extremity, but are often missed if the knee
is not examined following fixation of the fracture.5,6,10 There has
been a previous report of a knee dislocation associated with a
floating knee, however the initial radiographs clearly demonstrated the knee dislocation.9 In this case report, careful examination
of initial films revealed a bony sleeve avulsion of the PCL from
its tibia insertion, however ligamentous knee instability was not
identified until a dedicated examination was performed following long bone stabilization while the patient was under anesthesia.
Acute ligamentous knee reconstruction was contraindicated due
to the contaminated traumatic knee arthrotomy. Few treatment options remained for the grossly unstable knee and olecranization of
the patella was chosen, allowing limited early range of motion in
a hinged knee brace while maintaining knee alignment.
To our knowledge, olecranization of the patella for knee
dislocations has not previously been described in the English literature. There is one report from the Polish literature of its use
in four patients with knee dislocations with three patients achieving near normal knee function.17 More commonly, olecranization
has been described to protect PCL reconstructions.13,15,16 This is
Figure 6: Final one-year follow-up showing AP (6A) and lateral
(6B) of right knee
controversial as Rungee et al. showed olecranization may actually induce a posterior drawer force during knee flexion.13 Due
to their poor clinical results recommendation against its use following PCL reconstruction were made. In contrast, Kambic et al.
demonstrated olecranization in cadavers did reduce strain on the
PCL throughout 90 degrees of knee ROM , but there was greater
patellofemoral contact pressures, increasing as the knee achieved
full extension.15 They also noted patella lift-off, i.e., loss of patellofemoral joint contact with flexion greater than 60 degrees,
as well as limitation of knee flexion to 90 degrees secondary to
soft tissue constraints. Based on this cadaveric study their recommendations were to limit knee ROM to 20-80 degrees following
patella olecranization.
In this particular case, acute knee ligamentous reconstruction
was contraindicated due to joint contamination from a traumatic
arthrotomy. Olecranization of the patella maintained tibio-femoral
alignment allowing a limited knee range of motion. Unfortunately,
the patient developed significant heterotopic ossification, which
affected his ROM, but assisted in stabilizing the knee.
Conclusion
Vigilance is needed for clinical exam of the knee immediately
following long bone fixation while the patient is still anesthetized.
This case report also describes a technique that has limited indications. However, when acute reconstruction for a knee dislocation is contraindicated, olecranization of the patella may maintain
tibio-femoral alignment while allowing early limited ROM for a
knee that is otherwise unstable.
References
1.Blake R, McBryde A, Jr., The floating knee: Ipsilateral fractures of the tibia and femur. South
Med J. 1975;68(1):13-16.
2. Fraser RD, Hunter GA, Waddell JP, Ipsilateral fracture of the femur and tibia. J Bone Joint
Surg. 1978;60B(4):510-515.
3. Lakshman K, Scotland T, The Incidence of Knee-Ligament Injuries in 105 Patients with Lowerlimb Fractures. J Bone Joint Surg. 1985;67B(1):151-152.
4.Pedersen HE, Serra JB, Injury to the collateral ligaments of the knee associated with femoral
shaft fractures. Clin Orthop. 1968;60:119-121.
5.Szalay MJ, Hosking OR, Annear P, Injury of knee ligament associated with ipsilateral femoral shaft fractures and with ipsilateral femoral and tibial shaft fractures. Injury.
1990;21(6):398-400.
6.Walker D, Occult Knee Ligament Injuries Associated with Femoral Shaft Fractures. Am J Sports
Med. 1980;8(3):172-174.
7. Paul GR, Sawka MW, Whitelaw GP, Fractures of the ipsilateral femur and tibia: emphasis on
intra-articular and soft tissue injury. J Orthop Trauma. 1990;4(3):309-314.
8.Walling AK, Seradge H, Spiegel PG, Injuries to the knee ligaments with fractures of the femur.
J Bone Joint Surg. 1982;64A(9):1324-1327.
9.Chen CE, Wang JW, Floating knee with ipsilateral knee dislocation: case report. J Trauma.
1998;44(4):735-737.
10. van Raay JJ, Raaymakers EL, Dupree HW, Knee ligament injuries combined with ipsilateral tibial and femoral diaphyseal fractures: the “floating knee”. Arch Orthop Trauma Surg.
1991;110(2):75-77.
11.Giannoudis PV, Roberts CS, Parikh AR, et al., Knee dislocation with ipsilateral femoral shaft
fracture: a report of five cases. J Orthop Trauma. 2005;19(3):205-210.
12.Templeman DC, Marder RA, Injuries of the knee associated with fractures of the tibial
shaft. Detection by examination under anesthesia: a prospective study. J Bone Joint Surg.
1989;71A(9):1392-1395.
13.Rungee JL, Fay MJ, Deberardino TM, Olecranization of the patella. Orthopedics.
1995;18(1):27-34.
14. Tavernier M, Guilleminet P, Butee osseuse pour genu recurvatum par greffe unissant la rotule au
tibia, et donnant a l’appareil rotulien la forme d’un olecrane. Revue d’Ortho. 1932;9:701-702.
15.Kambic HE, Dass AG, Andrish JT, Patella-tibial transfixation for posterior cruciate ligament
repair and reconstruction: a biomechanical analysis. Knee Surg Sports Traumatol Arthrosc.
1997;5(4):245-250.
16. Hermens KA, Hackenbruch W, Olecranization of the patella in posterior instability of the knee.
Orthop Rev. 1986;15(9):596-599.
17.Niedzwiedzki T, Hladki W, Mierniczek W, [Knee dislocation treatment with temporary tibio-patellar fixation (patellar olecranization)]. Chir Narzadow Ruchu Ortop Pol. 1999;64(2):209-213.
86
Indiana Orthopaedic Journal
Volume 3 – 2009
Joint Space Narrowing After Partial Medial Meniscectomy
in the Anterior Cruciate Ligament – Intact Knee
K. Donald Shelbourne, M.D. and Jonathan F. Dickens, M.D.
The Shelbourne Knee Center – Indianapolis, Indiana, USA
© 2007 American Academy of Orthopaedic Surgeons. Reprinted from the Journal of the
American Academy of Orthopaedic Surgeons, Volume 15 (9), pp. 519-524 with permission.
Abstract
Osteoarthritis of the knee is common after total medial
meniscectomy. In anterior cruciate ligament–intact knees,
the reported outcomes of partial medial meniscectomy are
variable. Radiographic assessment using a posteroanterior
weight-bearing view is a reliable tool for detecting minor
medial joint space narrowing, which may be an early sign of
osteoarthritis. Studies that assessed the effect of partial medial meniscectomy found a low percentage of patients with
>50% joint narrowing at 10 to 15 years after surgery. Digital
radiography, using a posteroanterior weight-bearing view, is
a highly sensitive method for observing minor joint space
narrowing in the involved knee. A recent study showed that
88% of patients who underwent partial medial meniscectomy
had joint space narrowing of <2 mm, and none had narrowing
≥2 mm, at a mean follow-up of 12 years. Subjective results
after partial medial meniscectomy are favorable, with 88% to
95% of patients reporting good to excellent results.
Meniscal tears are the most common injury to the knee
joint, and meniscectomy is one of the most commonly performed orthopaedic procedures in the United States.1 Historically, the meniscus was thought to be an unnecessary
remnant within the knee, and orthopaedic surgeons treated
meniscal tears with total meniscectomy. However, in 1936,
King2 observed a direct relationship between the amount of
meniscus removed and the degree of degenerative changes.
In 1948, Fairbank3 compared preoperative and postoperative
radiographs in patients who underwent ­total meniscectomy
and described the triad of degenerative radiographic changes
that occurred: joint space narrowing, femoral condyle flattening, and tibial ridge formation. Numerous studies have
confirmed the poor long-term outcome following total meniscectomy.4,5 Because of the importance of the meniscus in
maintaining knee function and health, the goal of treatment
today is to conserve as much functional meniscus as possible,
with minimal resection of injured tissue.
Partial meniscectomy has been reported to reduce morbidity and the cost of care; it also allows early return of
function and weight bearing. The theory is that partial meniscectomy preserves enough of the meniscal rim to protect
the joint from developing osteoarthritis (OA). The natural
history of OA consists of articular cartilage destruction, with
surface erosions, clefts, and eventu­al loss of cartilage tissue.
Degenera­tive changes in the knee joint are variably reported.6,7
Degenerative changes in the ar­ticular surface following
partial me­niscectomy may be assessed by a va­riety of clinical tools. Magnetic resonance imaging, joint fluid aspi­rate,
and blood biomarkers all have been used to assess the degree
of de­generative changes in the tibiofemo­ral joint.8 Radio87
graphic assessment of joint space width and joint space narrowing, however, remains the simplest, most cost-effective,
and widely used option for evaluating progressive cartilage
destruction.9,10 Joint space width is the measure­ment of the
joint space between the femur and tibia. Joint space narrow­
ing is the measurement of the differ­ence in joint space width
deter­mined by comparing sequential radiographs of the involved knee or by comparing the involved knee with the contralateral knee. Recent advances in digital radiography and
instruments equipped with precise measuring tools, magnification, and image enhancement have resulted in increased
early detection of minor joint space narrowing before clinical
symptoms appear.
Functional Anatomy and Biomechanics
The menisci are wedge-shaped, semilunar, cartilaginous
structures that transmit forces between the convex condyles
of the distal femur and flat tibial plateau. The meniscal peripheral rim is attached to the joint capsule, with the anterior
and posterior horns firmly attached to the tibia. The firm meniscal attach­ment prevents joint subluxation, al­lowing effective load distribution and reduced contact stresses.11
The medial meniscus covers ap­proximately 60% of the
tibial pla­teau12 and has a diameter of 35 mm.13 The medial
meniscus is smaller and less mobile than the lat­eral meniscus,
making the medial meniscus more prone to tears. Me­niscal
tears result in less load distri­bution and increased contact
stress across the tibial plateau, which pro­duces degenerative
bone and causes changes in the cartilage. The princi­pal role
of the meniscus in load transmission and distribution was
first hypothesized by Fairbank.3 This has been confirmed in
numerous biomechanical studies that demon­strate the functional importance of the meniscus and the favorable prog­
nosis associated with rim-conserving partial meniscectomy
in contrast with total meniscectomy.14,15
Radiographic Evaluation
The radiographic progression of knee OA is generally
evaluated with serial measurements of joint space width. Radiographic evaluation of joint space width in the patient with
a normal contralateral knee is a pre­cise technique for assessing joint space narrowing following meniscec­tomy.16 Joint
space narrowing tradi­tionally has been studied with plain
radiographs. Initial research by Ahl­back17 demonstrated that
anteropos­terior (AP) extension weight-bearing radiographs
were more useful than non–weight-bearing radiographs in
detecting joint space narrowing. Rosenberg et al18 observed
that con­ventional AP radiographs did not vi­sualize the region
of the knee that developed the earliest and most fre­quent degenerative changes. When evaluated with posteroanterior
Indiana Orthopaedic Journal
Volume 3 – 2009
Joint Space Narrowing After Partial Medial Meniscectomy in the
Anterior Cruciate Ligament – Intact Knee (continued)
graphs.20 Ana­tomically, joint space width can most closely
be approximated as a measurement from the middle of the
femoral condyle to the middle of the tibial plateau (Figure 2).
Ultimately, compared with AP radiographs, PA radiographs
improve reproducibility and alignment, and they should be
implemented in orthopaedic prac­tice as a primary method to
serially evaluate for progressive OA.
Results After Partial Medial Meniscectomy
A
B
Figure 1: Anteroposterior view (A) demonstrates only mild joint
space narrowing in the medial compartment of the right knee,
whereas the posteroanterior view (B) demonstrates significant narrowing.
Variation in study parameters makes it challenging to
subjectively and ob­jectively compare reports of joint space
narrowing following partial meniscectomy of medial meniscus tears. Different classifications of OA are used from one
study to another. Some authors report only a short-term follow-up using only plain ra­diographs and including unstable
knees.
At a mean 12-year follow-up of patients who underwent
partial me­niscectomy in ACL-intact knees, Hulet et al21 detected joint space narrowing in 16% of patients on plain AP
and PA radiographs. Only 2% of these patients developed
narrowing of >50% of the joint space width in the affected
knee compared with the contralateral, unoperated knee. A
va­riety of meniscal tear types were in­cluded in this study;
although it is not known which type of tear pro­duced narrowing in >50% of the compartment, the authors note that 54%
of the tears in the study popu­lation were bucket-handle tears.
In addition, 82% of patients had no ar­ticular cartilage damage. The authors found no significant differences be­tween the
various meniscal tears and the clinical outcome, the Interna­
tional Knee Documentation Com­mittee final objective grade,
or the incidence of anterior knee pain.21
(PA) radiographs, 85% of patients with grade III or IV articular cartilage damage were observed to have major joint space
narrowing following me­niscectomy. However, in the same
patient population, narrowing was detected in only 25% of
patients when AP radiographs were used.18
When PA radiographs are taken with the knee in 45° of
flexion, how­ever, the femorotibial surfaces that exhibit the
greatest cartilage damage are in direct juxtaposition (Figure
1). Of the two views, only the AP re­quires correction for radiographic magnification; this has been report­ed to be as high
as 34%.19 Thus, the precision and accuracy of detecting joint
space narrowing were notably increased with plain PA radio­
graphs.19
Digital radiography has led to the development of automated programs that measure joint space width. Such techniques were first used for the hip and are now being used to
eval­uate the knee.20 Joint space congru­ence, measured with
digital radio­graphs and automated image analysis systems,
is used to calculate the minimum joint space width. This is
the most reproducible and sensitive parameter for determining the progression of OA with standard­ized serial PA radio-
A
B
Figure 2: Radiographs used to measure joint space width from the
middle of the femoral condyle to the middle of the tibial plateau. The
anteroposterior (A) view shows a wider joint space in the medial
compartment than does the posteroanterior (B) view. Len = distance
between points. (Reproduced with permission from Shelbourne KD,
Dickens JF: Digital radiographic evaluation of medial joint space
narrowing after partial meniscectomy of bucket-handle medial meniscus tears in anterior cruciate ligament–intact knees. Am J Sports
Med 2006;34:1648-1655.)
88
Indiana Orthopaedic Journal
Volume 3 – 2009
Joint Space Narrowing After Partial Medial Meniscectomy in the
Anterior Cruciate Ligament – Intact Knee (continued)
Chatain et al16 used plain AP ra­diographs to analyze
joint space nar­rowing in stable knees at a mini­mum 10-year
follow-up. All types of meniscal tears were included in this
study; 48% were vertical tears. Nar­rowing was observed in
21.5% of pa­tients when the affected knee was compared with
the contralateral control knee. Only 2.3% of patients (5/214)
exhibited narrowing in >50% of the compartment. Young age
(ie, <35 years), an intact meniscal rim, and minimal cartilage
damage after meniscectomy were favorable, independent
prognostic risk factors.16
Burks et al22 reported that 60.4% of patients demonstrated joint space narrowing following partial medial meniscectomy in stable knees after a mean 14.7-year follow-up.
Excel­lent results (ie, Lysholm score >95 points, compartment
narrowing ≤2 mm, no side-to-side radiographic grade difference) were observed in 38 of 64 patients (59%). Twenty
pa­tients had good results (Lysholm score, 85 to 94 points;
joint space narrowing, from 3 to 5 mm; side-to-side grade
change, ≤1). Although Burks et al22 found more instances
of joint space narrowing compared with Chatain et al16 and
Hulet et al,21 the average narrowing was only 0.7 mm. This
suggests that most of the find­ings of this study were of minor joint space narrowing. Many of these me­niscal tears were
bucket-handle tears and were evaluated with flexion weightbearing PA or AP radio­graphs, whichever demonstrated the
most severe radiographic grade.22 Ul­timately, changes were
relatively mi­nor, suggesting that the technique of Burks et
al22 for detecting narrowing was more sensitive than if they
had used AP radiographs.
Subjective results following par­tial medial meniscectomy in stable knees have been consistently favor­able, ranging from 88% to 95% good to excellent results.16,21-23 The
use of various subjective tools, however, makes comparison
between studies difficult. Burks et al22 found no cor­relation
between radiographic and clinical results, whereas others
have found a correlation between objec­tive and subjective
results.16 It is possible that the use of PA radio­graphs allowed
these investigators to detect more cases of minor joint space
narrowing before clinical symptoms developed. In contrast,
Chatain et al16 used plain AP radio­graphs; thus, more joint
space nar­rowing may have been necessary to detect degenerative changes, and it is probable these patients were more
likely to be symptomatic.
A recent study examining joint space narrowing following partial meniscectomy of bucket-handle me­dial meniscus
tears in knees with chondromalacia not greater than grade
II was performed using digital PA radiographs obtained in a
standard orthopaedic clinical practice.23 At a mean 12-year
follow-up, 88% of patients were found to have minor joint
space narrowing (<2 mm). No patient had major narrowing
(≥2 mm). Longitudinal studies sug­gest that more narrowing was ob­served with a longer follow-up inter­val. Clinical
symptoms were unrelated to partial meniscectomy. These
data confirm that digital PA radiographs used with magnifica­
tion, enhancement, and precise mea­suring tools are the most
sensitive method for detecting minor differ­ences in joint
space narrowing. These techniques may be easily ap­plied in
clinical orthopaedic prac­tice. Digital PA radiographs may be
the most effective technique for se­rially monitoring minor
progression of joint space narrowing.
89
Bruyere et al24 showed that joint space narrowing ≥0.7
mm over 3 years is independently associated with a future
need for OA-related surgery. In the follow-up studies of partial medial meniscectomy, pa­tients did not have significant
artic­ular cartilage damage, which is known to be a possible
compound­ing factor of OA. Regardless, it ap­pears that partial
medial men­iscectomy, as an isolated factor, does not have the
deleterious effect that has been reported with total meniscectomy.16,21-23
Although several researchers have observed a correlation between joint space narrowing and OA, oth­ers suggest
that narrowing is not a useful indicator of early degenerative changes. In a rabbit model, Messner et al25 compared
weight-bearing AP radiographs with the histologic changes
of articular cartilage up to 40 weeks after total meniscectomy. Plain radiographs were obtained us­ing a mammography
unit and were scanned into an image-analysis pro­gram. Joint
space narrowing was measured in the medial and periph­eral
halves of the medial tibiofemo­ral joint compartment. Overall,
nar­rowing was greater in the peripheral half of the medial
joint compart­ment, the region that is physiologi­cally supported by the meniscus. Immediately following medial me­
niscectomy, joint space width was reduced on weight-bearing
AP radio­graphs secondary to loss of meniscal tissue. During
the 40-week follow-up, degenerative changes in the car­tilage
developed; however, these changes did not lead to further
joint space narrowing. Consequently, changes in cartilage 40
weeks after meniscectomy were not observed, using radiographic joint space nar­rowing as an indicator. The authors
concluded that narrowing found at short-term follow-up after
total me­niscectomy may be incorrectly in­terpreted as early
OA. Thus, narrow­ing observed at long-term follow-up after
total meniscectomy indicates only that the meniscus was removed, not that there are degenera­tive cartilage changes indicative of OA. The authors suggest that joint space narrowing used to detect OA following total meniscectomy is best
used in longitudinal studies; knees with different meniscal
status (eg, intact, excised) cannot be accurately compared.25
Histologic examination of the ar­ticular cartilage is the
benchmark in detecting OA. However, PA radio­logic evaluation of joint space width and joint space narrowing remains
the least invasive, most cost-effective, most sensitive, best
stud­ied, and most widely accepted meth­od for detecting degenerative joint changes. It is well-documented that joint
space width, measured at the narrowest point on a PA radiograph, is a more sensitive method for de­tecting early joint
space narrowing and degenerative joint changes.18,22,23 Additionally, in the initial postoperative period, narrowing is most
likely to occur in the peripher­al region, the region previously
sup­ported with the greatest meniscal height.
The study by Messner et al25 applies to total meniscectomy; these conclusions are not readily applied to partial
meniscectomy. The pe­ripheral rim is preserved in a buckethandle meniscal tear, which has the greatest meniscal height
and con­veys the largest spacer effect. There­fore, narrowing
immediately follow­ing partial medial meniscectomy may
be less likely to occur. Conse­quently, joint space narrowing
ob­served in long-term longitudinal studies of partial meniscectomy may be more accurately attributed to de­generative
Indiana Orthopaedic Journal
Volume 3 – 2009
Joint Space Narrowing After Partial Medial Meniscectomy in the
Anterior Cruciate Ligament – Intact Knee (continued)
changes in the knee joint than to loss of meniscal height. The
observations by Messner et al25 raise concerns about the reliability of joint space narrowing to detect de­generative changes in the knee. Fu­ture studies should compare joint space narrowing with histologic changes in human knees.
Postoperative Concerns
One advantage of arthroscopic par­tial medial meniscus
resection of de­generative bucket-handle tears is de­creased
morbidity. Immediate return to full range of motion and
early weight-bearing are characteristic of postoperative rehabilitation for par­tial meniscectomy in the patient with stable
knees. Once range of motion has returned, patients may begin
strength training, with the pri­mary goal of near-normal symmetry in both knees.
Although many patients who un­dergo partial medial meniscectomy experience favorable results, resec­tion of a portion
of a degenerative medial meniscus may cause some identifiable problems. A minority of patients have no improvement or
ex­perience worse symptoms following arthroscopy. Approximately 5% of patients are unhappy or dissatisfied16,26 after
partial medial menis­cectomy, and at 10-to 15-year follow-up,
9% to 10% of knees are considered abnormal or severely ab­
normal, using standardized evalua­tion systems.16,22 One year
after par­tial meniscectomy, 91% of patients exhibit excellent
functional re­sults.4 Failure to demonstrate im­provement in
the early postoperative period is unlikely to be the result of
degenerative changes in the articular cartilage. Following total meniscec­tomy, histologic changes in the ar­ticular cartilage
do not begin to develop until 3 months postopera­tively.26
Repeat surgery following partial meniscectomy is uncommon. In one study, 2.2% of patients required an­other surgery in the same compart­ment as the previous partial medial
meniscectomy.16 It was unknown whether the repeat surgery
was for a new tear or for incomplete treatment of the original
tear. Northmore-Ball and Dandy27 found that, after arthro­
scopic partial meniscectomy in sta­ble knees, 91% of patients
required no further treatment, 4% required late physiotherapy, and 4% required revision.
Summary
Although degenerative change is known to follow total medial menis­cectomy, degenerative change after partial
medial meniscectomy is in­frequently reported. Radiographic
assessment of joint space narrowing using PA radiographs is
the most re­producible, sensitive, and widely available technique for detecting mi­nor narrowing. Preliminary research
using this method demonstrates that partial medial meniscectomy in the ACL-intact knee is associated with only minor
narrowing at long-term follow-up.16,21-23 Further research is
needed to evaluate the extent of long-term joint space narrowing caused by partial meniscectomy.
References
11. Klimkiewicz JJ, Shaffer B: Meniscal Surgery 2002 Update: Indications and techniques for
resection, repair, re­generation, and replacement. Arthroscopy 2002;18:14-25.
12. King D: The function of the semilunar cartilage. J Bone Joint Surg Am 1936; 18:1069.
13. Fairbank TJ: Knee joint changes after meniscectomy. J Bone Joint Surg Br 1948;30:664-670.
14. Hede A, Larsen E, Sandberg H: Partial versus total meniscectomy: A pro­spective randomized
study with long-term follow-up. J Bone Joint Surg Br 1992;74:118-121.
15. Northmore-Ball MD, Dandy DJ, Jack­son RW: Arthroscopic, open partial, and total
meniscectomy: A compara­tive study. J Bone Joint Surg Br 1983 65:400-404.
16. McGinity JB, Geuss LF, Marvin RA: Partial or total meniscectomy: A comparative analysis. J
Bone Joint Surg Am 1977;59:763-766.
17. Rockborn P, Gillquist J: Outcome of arthroscopic meniscectomy: A 13­year physical
and radiographic follow-up of 42 patients under 23 years of age. Acta Orthop Scand
1995;66:113-117.
18. Dorsay TA, Helms CA: Bucket-handle meniscal tears of the knee: Sensitivity and specificity of
MRI signs. Skeletal Radiol 2003;32:266-272.
19. Buckland-Wright JC, Wolfe F, Ward RJ, Flowers N, Hayne C: Substantial superiority of
semiflexed (MTP) views in knee osteoarthritis: A comparative radiographic study, without
fluoros­copy, of standing extended, semi-flexed (MTP), and schuss views. J Rheumatol
1999;26:2664-2674.
10. Mazzuca SA, Brandt KD, Buckwalter KA: Detection of radiographic joint space narrowing
in subjects with knee osteoarthritis: Longitudinal comparison of the metatarsophalangeal and
semiflexed anteroposterior views. Arthritis Rheum 2003;48:385-390.
11. Messner K, Gao J: The menisci of the knee joint: Anatomical and functional characteristics, and
a rationale for clinical treatment. Janat 1998;193: 161-178.
12. Clark CR, Ogden JA: Development of the menisci of the human knee joint: Morphological
changes and their po­tential role in childhood meniscal injury. J Bone Joint Surg Am 1983;65:
538-547.
13. Pagnani M, Warren RF, Arnoczky SP, Wickiewics TL: Anatomy of the knee, in Nicholas JA,
Hershman EB (eds): The Lower Extremitiy and Spine in Sports Medicine, ed2. St. Louis, MO: CV
Mosby, 1995, pp 581-614.
14. Ahmed AM: The load-bearing role of the knee menisci, in Mow VC, Arnoc­zky SP, Jackson DW
(eds): Knee Meniscus: Basic and Clinical Foundation. New York, NY: Raven Press, 1992, pp
59-73.
15. Baratz ME, Fu FH, Mengato R: Menis­cal tears: The effect of meniscectomy and of repair on
intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med
1986;14:270-275.
16. Chatain F, Adeleine P, Chambat P, Neyret P, Société Française díArthroscopie: A comparative
study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-year
minimum follow-up. Arthroscopy 2003;19:842-849.
17. Ahlback S: Osteoarthrosis of the knee: A Radiographic Investigation. Acta Radiol Diagn (Stockh)
1968; uppl 277:7-72.
18. Rosenberg TD, Paulos LE, Parker RD, Coward DB, Scott SM: The forty-five degree
posteroanterior flexion weight bearing radiograph of the knee. J Bone Joint Surg Am
1988;70:1479-1483.
19. Buckland-Wright JC, Macfarlane DG, Williams SA, Ward RJ: Accuracy and precision of
joint space width mea­surements in standard macroradiographs of osteoarthritic knees. Ann Rheum
Dis 1995;54:872-880.
20. Vignon E, Piperno M, Le Graverand MPH, et al: Measurement of radio­graphic joint space
width in the tibiofemoral compartment of the os­teoarthritic knee: Comparison of standing
anteroposterior and Lyon shuss views. Arthritis Rheum 2003; 48:378-384.
21. Hulet CH, Locker BG, Schiltz D, Tex­ier A, Tallier E, Vielpeau CH: Arthro­scopic medial
meniscectomy on sta­ble knees. J Bone Joint Surg Br 2001; 83:29-32.
22. Burks RT, Metcalf MH, Metcalf RW: Fifteen-year follow-up of arthroscopic partial
meniscectomy. Arthroscopy 1997;13:673-679.
23. Shelbourne KD, Dickens JF: Digital radiographic evaluation of medial joint space narrowing
after partial me­niscectomy of bucket-handle medial meniscus tears in anterior cruciate ligamentintact knees. Am J Sports Med 2006;34:1648-1655.
24. Bruyere O, Richy F, Reginster JY: Three year joint space narrowing predicts long term incidence
of knee surgery in patients with osteoarthritis: An eight year prospective follow up study. Ann
Rheum Dis 2005;64: 1727-1730.
25. Messner K, Fahlgren A, Persliden J, Andersson BM: Radiologic joint space narrowing and
histologic changes in a rabbit meniscectomy model of early knee osteoarthrosis. Am J Sports Med
2001;29:151-159.
26. Shapiro F, Glimcher MJ: Induction of osteoarthrosis in the rabbit knee joint. Clin Orthop Relat
Res 1980;147:287-295.
27. Northmore-Ball MD, Dandy DJ: Long-term results of arthroscopic par­tial meniscectomy. Clin
Orthop Relat Res 1982;167:34-42.
Acknowledgments
The authors thank Tinker Gray, MA, ELS, for her editorial assistance with the manuscript. They also thank the
Methodist Health Founda­tion for generous financial support
of their research.
90
Indiana Orthopaedic Journal
Volume 3 – 2009
Coronal Alignment in Total Knee Arthroplasty:
Just how important is it?
David M. Fang, M.D., Merrill A. Ritter, M.D., and Ken E. Davis, M.S.
The Center for Hip and Knee Surgery — Mooresville, IN, USA
© 2009 Journal of Arthroplasty. This manuscript has been provisionally accepted for
publication in the Journal of Arthroplasty and is preprinted with permission.
Abstract
A recent study has challenged the premise that wellaligned TKAs have better survival than outliers. This study
examines the importance of overall coronal alignment as a
predictor for revision.
Patients with primary TKAs were stratified into neutral,
varus, and valgus alignment groups based on the postoperative tibiofemoral angle.
In 6,070 knees (3,992 patients), there were 51(0.84%)
failures: 21(0.5%) in the neutral group, 18(1.8%) in the varus
group, and 12(1.5%) in the valgus group. The best survival
was for overall alignment between 2.4-7.2 valgus. Varus
knees failed primarily by medial tibia collapse, while valgus
knees failed from ligament instability.
Outliers in overall alignment have a higher rate of revision than well-aligned knees. The goal of TKA should be to
restore alignment within 2.4-7.2 degrees of valgus.
Introduction
There is surprisingly little evidence to support the widely
held assumption that restoring the coronal alignment in total
knee arthroplasty (TKA) leads to improved function and longevity. Moreover, most of the supporting literature is based
on historic prosthesis designs. Lotke and Ecker showed that
good clinical results were correlated with a well positioned
geometric total knee arthroplasty.7 Moreland believed that
prosthesis malalignment was a major cause of component
loosening and instability.9 Bargren and Blaha found that the
Freeman Swanson (ICLH) knee failed at lower compressive
loads and had a higher rate of clinical failure when aligned
in varus.1 Ritter showed that the posterior cruciate condylar (PCC) TKA should be aligned in neutral or slight valgus
for improved survival.12 Jeffrey demonstrated that restoring
the mechanical axis of the lower extremity through the center of the knee resulted in a more durable implant (Denham
knee).6
A recent study by Pagnano et al examining three modern
knee designs has challenged the premise that restoring the
coronal alignment improves implant durability.10 Although
there was no statistical difference between outliers in mechanical alignment and well aligned knees, the trend was
towards fewer revisions in the outliers (94% vs. 96% at 15
years).
91
The current study is an extension of the study by Berend,
which found that varus positioning of the tibia was associated
with an increase in failure by medial tibial collapse.2 This
study differs in that it contains six years of additional patients
and follow-up to the original study and examines all mechanical failures, and not only tibial sided failures. The purpose
of this retrospective study was to determine, in a large series
of patients with long term follow-up, if correcting the normal
coronal alignment is necessary with modern implants.
Materials and Methods
Between 1983 and 2006, six thousand seventy (6,070)
consecutive primary TKAs in 3,992 patients were performed.
Intraoperative alignment was achieved as previously described.3 The femoral component was aligned to 5 degrees
of valgus using a intramedullary femoral guide. The proximal tibial cut was made perpendicular to the mechanical axis
of the tibia using an extramedullary guide. Final intraoperative confirmation of overall tibial alignment was verified
using a long rod through the center of the tibial insert. All
patients who had a minimum of 2 years follow-up and adequate radiographs were included in the study. The sample
demographics are shown in Table 1. Preoperative and postoperative radiographs were obtained at 2 months, 6 months,
1 year, and every 2-3 years thereafter, with all measurements
made by the attending surgeon using a handheld goniometer.
The overall anatomic tibiofemoral angle and the femoral and
tibial component position were measured on standard length,
standing AP 14” x 17” radiographs of the knee. A cemented
Table 1
Sample Demographics
Mean (+/- Standard Deviation)
Range
Age
70.1 years (+/-8.6) 21 - 93
Female 2,436 (61.0%)
Male 1,556 (39.0%)
BMI 30.0 (+/-5.5)
16.5 - 64.3
Diagnosis
Osteoarthritis
5,803 (95.6%)
Rheumatoid 187 (3.1%)
Osteonecrosis
65 (2.1%) Other
15 (0.3%)
Prosthesis
AGC
100%
Indiana Orthopaedic Journal
Volume 3 – 2009
Coronal Alignment in Total Knee Arthroplasty: Just how important is it? (continued)
cruciate-retaining, metal-backed, non-modular tibial implant
with compression molded polyethylene, Anatomically Graduated Components (AGC, Biomet, Warsaw, IN) was used in
all cases.
was 4.8˚ (+/-2.5˚) valgus. There were 4,236 patients (69%)
in the normal alignment group within one standard deviation
of the mean tibiofemoral angle (2.4-7.2˚ valgus). (See Figure
1) The mean tibial component position was 90.4˚ (+/-2.1˚).
Patients were stratified into three groups based on
the postoperative tibiofemoral angle: a normal alignment
group within one standard deviation of the mean anatomical tibiofemoral angle, a varus group less than one standard
deviation, and a valgus group more than one standard deviation above the mean angle. Patients were similarly stratified
based on tibial component position into neutral, varus, and
valgus groups. Failure was defined as any revision surgery
not related to infection, including medial tibial collapse, progressive radiolucency, and functional instability. Postoperative radiographs and operative notes were reviewed for all
revision cases to determine the mechanism of failure.
There were 51 (0.84%) failures in the 6,070 knees. Of
these revisions, 40 (78%) were on the tibia side only, 7 (14%)
were on the femoral side only, and 4 (8%) were due to failures on both the tibia and femoral side. The average time to
failure was 5.5 (+/-3.7) years [range 0.6, 14.0 years].
All statistical analysis was performed using Statistical
Analysis Software (SAS). Survival probabilities were given
by Kaplan-Meier survivor analysis, with mechanical failure
requiring revision as the end point. Cox regression with forward, backward and stepwise selection procedure was performed on age, gender, body mass index, overall anatomical
alignment angle, and tibial component position. Odds ratios
were reported with corresponding p-values and a significance
level of 0.05.
Results:
The average follow up was 6.6 +/-3.5 years (range 2 –
22.5 years). During the study, 1,118 (28.0%) patients died.
The mean preoperative alignment was 0.1˚ varus (+/-7.7˚)
[range 25˚ varus, 35˚ valgus]; however, there was no difference in survival based on preoperative varus, valgus, or neutral alignment. The mean postoperative tibiofemoral angle
Figure 1: The data shows that the mean overall alignment was 4.
valgus and 1 standard deviation below the mean 2.4 degrees valgus
to 1 std dev above the mean, 7.2 degree, includes the majority of the
knees in this study.
Figure 2
The revision rate for the neutral alignment group was
significantly lower at 0.5% (21/4,029), compared to 1.8%
(18/1,222) for the varus group (p=0.0017) and 1.5% (12/819)
for the valgus group (p=0.0028). The failure rate was equally low for each degree within the neutral alignment group,
which includes a range of approximately 5 degrees (Figure
2). At 20 years, the survival rate was 99%, compared to 95%
for the varus group and 97% for the valgus group during the
same time period (Figure 3). Thirteen of the eighteen of the
varus side failures (72%) were due to medial tibial collapse.
Figure 3: Kaplan Meier Survival by Overall Alignment
92
Indiana Orthopaedic Journal
Volume 3 – 2009
Coronal Alignment in Total Knee Arthroplasty: Just how important is it? (continued)
This corresponded to a 6.9 times increased risk of failure
by medial tibial collapse in varus knees compared to those
that were properly aligned (p<0.0001). Of the twelve valgus sided failures, five were attributed to instability (42%),
with a 3.7 times increased risk compared to normal aligned
knees (p= 0.02). Older age was also a significant factor for
improved prosthesis survival (p<0.0001). Gender and BMI
were not associated with revision surgery.
significant difference between measurements from standard
knee and hip to ankle films.8,11 This result was validated at
our institution in a subset of 188 patients who received both
long leg and standard length films postoperatively, and the
manuscript has been submitted for publication. The correlation coefficient between the tibiofemoral angle and mechanical axis was 0.94 (p<0.01). Therefore, overall alignment can
be accurately evaluated using standard length knee films.
Using Cox regression analysis with forward, backward,
and stepwise selection, varus tibial component position was
not a stronger or more significant predictor for tibial collapse
than overall varus alignment. Varus tibial alignment was
found to be only associated with a 2.8 times increased risk
of failure by medial tibial collapse (Odds Ratio=3.0, p=0.04),
compared to a 6.9 times risk for tibial collapse based on overall varus alignment (p<0.0001). The backward elimination
p-values for varus tibial alignment in favor of overall varus
alignment were p=0.3410 for tibial collapse, p= 0.7054 for
any tibial failure, and p=0.3118 for tibial or femoral failure.
Although the association between tibial collapse and varus
tibial alignment observed by Berend was confirmed in this
study, varus tibial alignment alone did not explain any additional failure beyond that of overall alignment.
This study included approximately six additional years
of data and twice the number of patients to the data presented
in the Berend study. During this time, there were three additional tibial failures. The correlation between tibial collapse
and varus alignment was also observed in the present study;
however, overall tibiofemoral alignment was a stronger predictor of failure than tibial component position alone. Berend
reported that the negative effect of a varus tibia on survival
may be partially compensated for by increasing the femoral
component valgus.2 This finding supports the relative importance of overall coronal alignment over tibial component
position. The effect of femoral component alignment is currently being investigated and appears to be a significant independent predictor of survival; however, further investigation
is needed to determine the relative importance of femoral,
tibial, and overall coronal alignment. The importance of femoral component position is beyond the scope of this study, but
will be addressed in future research and publications.
Discussion:
The function and durability of total knee replacement is
determined by a combination of patient, implant, and surgeon
related factors. One of the important variables controlled by
the surgeon is proper positioning of the individual components and the resulting overall alignment of the lower extremity. Preoperative alignment did not have an impact on
implant survival. Rather, postoperative alignment was the
chief predictor of failure and revision surgery, regardless of
the preoperative alignment in varus, valgus or neutral. The
results from this study reaffirm the fundamental principle that
a well aligned TKA has better longevity than one placed in
varus or valgus.
There is no consensus whether the anatomic or mechanical axis should be used to describe overall coronal alignment.
The “normal” alignment of the knee is generally considered
to be an anatomic tibiofemoral angle of 7-9 degrees of valgus
or a mechanical axis that falls through the middle third of the
knee. Nevertheless, Insall believed that the mechanical axis
should lie lateral to the center of the knee in valgus5, while
Townley believed that the mechanical axis should lie medial
to the center of the knee in varus.13
Standing full length lower extremity radiographs have
been the gold standard for assessing overall limb alignment,
but they are not necessary or routinely obtained because of
the added cost and technical difficulty of obtaining accurate films. Previous studies have shown that the anatomic
and mechanical axes are directly correlated, and there is no
93
The conclusion that a poorly aligned knee is more durable cannot be drawn from the recent study by Pagnano.10 Although their study examined 399 knees with 35 mechanical
failures, the results did not reach statistical significance and
were potentially underpowered. This study included a much
larger series of patients and found that there was a statistically and clinically significant difference in survival based
on overall alignment. The power of this study should also
overcome potential confounding variables and differences in
study design, such as those between surgeons and implants,
as well as measuring the anatomic versus the mechanical
axis.
Postoperative alignment is the most important surgeoncontrolled factor in determining the durability of TKA. Although the difference in revision rate between well-aligned
and poorly-aligned knees may seem small, 99.5% compared
to 98.5%, respectively, given the number of TKAs performed
each year, this would translate into many potentially avoidable revision surgeries. The results of this study show that
there is not a single ideal target degree for coronal alignment,
but rather, a wide range of approximately 5 degrees that
can be achieved without the need for computer navigation.
However, the decision to use navigation ultimately requires
individual scrutiny of post-operative alignment and clinical
outcomes to consistently reproduce the ideal coronal alignment 2.4-7.2 degrees of valgus and the best survival of total
knee implants.
Indiana Orthopaedic Journal
Volume 3 – 2009
Coronal Alignment in Total Knee Arthroplasty: Just how important is it? (continued)
References
1.Bargren JH, Blaha JD, Freeman MAR: Alignment in total knee arthroplasty: Correlated biomechanical and clinical observations. Clin Orthop 173:178-183, 1983.
2. Berend ME, Ritter MA, Meding JB, Faris PM, Keating EM: Tibial component failure mechanisms in total knee arthroplasty. Clin Orthop 428:26-34, 2004.
3. Cates HE, Ritter MA, Keating EM, Faris PM: Intramedullary versus extramedullary femoral
alignment systems in total knee replacement. Clin Orthop 286:32-9, 1993.
4.Fang DM, Ritter MA, Davis K: Are Full Length Knee Films Necessary after TKA? Manuscript
in submission.
5. Insall JN: Total knee arthroplasty. Clin Orthop 192:13, 1985.
6.Jeffrey RS, Morris RW, Denham RA: Coronal alignment after total knee replacement. J Bone
Joint Surg Br 73B: 709-714, 1991.
7.Lotke PA, Ecker ML: Influence of positioning of prosthesis in total knee replacement. J Bone
Joint Surg 59A:77-79, 1977.
8.McGory JE, Trousdale RT, Pagnano MW: Preoperative hip to ankle radiographs in total knee
arthroplasty. Clin Orthop 404: 196-202, 2002.
9.Moreland JR: Mechanisms of failure of total knee arthroplasty. Clin Orthop 226: 6-13, 1988.
10.Parratte S, Pagnano MW, Trousdale R, Berry DJ: The Mechanical Axis may be the wrong
target in CAS TKA: 15-year survival of 399 Modern TKA: somewhat better for so-called outliers, American Association of Hip and Knee Surgeons annual meeting, Dallas, TX 2007.
11.Petersen TL, Engh GA: Radiographic assessment of knee alignment after total knee arthroplasty. J Arthroplasty 3:67-72, 1998.
12.Ritter MA, Faris PM, Keating EM, Meding JB: Postoperative alignment of total knee replacement: its effect on survival. Clin Orthop 299:153-156, 1994.
13. Townley CO: The anatomic total knee resurfacing arthroplasty. Clin Orthop 192:82, 1985.
Author Information
The Indiana Orthopaedic Journal is an annual publication of the Department of Orthopaedic
Surgery. The Journal has a limited paper circulation and may be accessed electronically via the
IU Department of Orthopaedic Surgery website (http://www.orthopaedics.iu.edu/). We invite
original research papers, case studies, and opinion pieces from our core faculty, volunteer faculty,
residents, and alumni. We will also accept for reprint a recent, previously published paper with
written permission to reprint from the publisher.
When preparing your original manuscript for submission, please follow this general format.
An abstract is optional, but, if included, it should be 250 words or less. For research papers,
there should be an Introduction, Methods, Results, and Discussion sections. References
should be listed in order of appearance in the paper. Tables should be in a separate Word file
and not imbedded in the text of the paper. Figures may be submitted in jpg format or within a
PowerPoint file. All figures will appear in black-and-white in the Journal. Each figure should
have a legend, and all references, tables, and figures should be cited in the text. Incomplete
manuscripts will be returned to the submitting author.
Please submit no more than two manuscripts, case studies, or opinion papers per first author per
year. Manuscripts will be solicited via an email call for papers sent out in early January. All
manuscripts must be submitted electronically. Submission deadlines are generally on or about
the end of March with anticipated publication in early September of each year. Due to limited
space, a manuscript may be held for publication in a subsequent issue or rejected.
94
Synthes is the leader in orthopaedic trauma
devices for internal and external fixation.
Synthes develops, manufactures and markets the AO system of
orthopaedic implants and instruments. Our goal is to provide the
most advanced implants, biomaterials, instruments and technologies
that meet or exceed the highest expectations in safety and quality.
Our products are designed to ensure reliable operating procedures,
rapid recovery and optimal patient outcomes.
Synthes offers a variety of fixation options for orthopaedic trauma
applications.
Indiana Orthopaedic Journal
INDIANA UNIVERSITY DEPARTMENT of ORTHOPAEDIC SURGERY
2009