Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 466 | Issue 11 | Nov, 2008
Articles

The Classic: Modular Total Knee-Replacement Arthroplasty. A Review of Eighty-nine Patients

Richard S. Laskin MD Fifty-eight osteoarthritic and thirty-one rheumatoid patients underwent modular total knee-replacement arthroplasty. The major indication for the operation was relief of pain. Contraindications to this resurfacing arthroplasty included varus-valgus instability of over 20 degrees, combined varus-valgus instability with flexion contracture of over 40 degrees, marked recurvatum, and predominant patellofemoral symptoms. In 59 per cent of the osteoarthritic and 58 per cent of the rheumatoid patients, complete relief of pain was evident when they were evaluated twenty-four months after surgery, while another 35 per cent of each group had only mild pain related to inclement weather. Their ability to walk long distances without support or limp was increased. Range of motion and ability to climb stairs were not significantly improved.

The Classic: Total Condylar Knee Replacement in Patients Who Have Rheumatoid Arthritis. A Ten-Year Follow-Up Study

Richard S. Laskin MD Eighty knee replacements with a total condylar prosthesis in patients who had rheumatoid arthritis were followed for ten years. At ten years, nineteen knees needed revision and sixty-one prostheses were still functioning. The major reasons for revision were loosening of the tibial component or late bacteremic seeding from another site. Radiolucency at the bone-cement interface adjacent to the tibial component was statistically related to malposition of the tibial component. According to the system of The Hospital for Special Surgery, the mean scores were 64 points preoperatively and 85 points postoperatively. Synovitis recurred in only 3 per cent of the knees. When revision, pain, or radiographic evidence of loosening were considered an indication of failure, the ten-year cumulative survival was 75 per cent.

The Chitranjan Ranawat Award

Patricia D. Franklin MD, Wenjun Li PhD, David C. Ayers MD Total knee replacement effectively relieves arthritis pain but improvement in physical function varies. A clearer understanding of the patient attributes associated with differing levels of functional gain after TKR is critical to surgical decision making. We reviewed 8050 primary, unilateral TKR patients enrolled in a prospective registry between 2000 and 2005 who had complete data. We evaluated associations between 12-month function (SF12/PCS) and preoperative gender, age, BMI, emotional health (MCS), knee diagnosis, quadriceps strength, and physical function (PCS). More than 98% of patients reported pain relief (KS pain score). At 12 months, mean PCS gain was 13.6 points, but the distribution was bimodal. The mean gain in PCS in the 63% of patients with greater improvement was 21 (SD = 7), and 4.1 (SD = 7) in the remaining 37%. Increased likelihood of poor functional gain was associated with older age, body mass index (BMI) over 40, lower MCS, and poor quadriceps strength. While two-thirds of patients reported functional gain well above national average at 12 months post-TKR, 37% reported limited functional improvement. Further understanding of the patient attributes associated with limited improvement will guide the design of innovative strategies to improve functional outcomes.,[object Object]

The Mark Coventry Award: In Vivo Knee Forces During Recreation and Exercise After Knee Arthroplasty

Darryl D. D’Lima MD, PhD, Nikolai Steklov BS, Shantanu Patil MD, Clifford W. Colwell MD Knee forces directly affect arthroplasty component survivorship, wear of articular bearing surfaces, and integrity of the bone-implant interface. It is not known which activities generate forces within a range that is physiologically desirable but not high enough to jeopardize the survivorship of the prosthetic components. We implanted three patients with an instrumented tibial prosthesis and measured knee forces and moments in vivo during exercise and recreational activities. As expected, stationary bicycling generated low tibial forces, whereas jogging and tennis generated high peak forces. On the other hand, the golf swing generated unexpectedly high forces, especially in the leading knee. Exercise on the elliptical trainer generated lower forces than jogging but not lower than treadmill walking. These novel data allow for a more scientific approach to recommending activities after TKA. In addition, these data can be used to develop clinically relevant structural and tribologic testing, which may result in activity-specific knee designs such as a knee design more tolerant of golfing by optimizing the conflicting needs of increased rotational laxity and conformity.

The John Insall Award: Gender-specific Total Knee Replacement: Prospectively Collected Clinical Outcomes

Steven J. MacDonald MD, FRCSC, Kory D. Charron MET, Robert B. Bourne MD, FRCSC, Douglas D. Naudie MD, FRCSC, Richard W. McCalden MD, FRCSC, Cecil H. Rorabeck MD, FRCSC Gender-specific total knee replacement design is a recent and debated topic. We determined the survivorship and clinical outcomes of a large primary total knee arthroplasty cohort, specifically assessing any differences between gender groups. A consecutive cohort of 3817 patients with 5279 primary total knee replacements (3100 female, 2179 male) with a minimum of 2 years followup were evaluated. Preoperative, latest, and change in clinical outcome scores (WOMAC, SF-12, KSCRS) were compared. While men had higher raw scores preoperatively, women had greater improvement in all WOMAC domains including pain (29.87 versus 27.3), joint stiffness (26.78 versus 24.26), function (27.21 versus 23.09), and total scores (28.35 versus 25.09). There were no gender differences in improvements of the SF-12 physical scores. Men had greater improvement in Knee Society function (22.1 versus 18.63) and total scores (70.01 versus 65.42), but not the Knee Society knee score (47.83 versus 46.64). Revision rates were 10.2% for men and 8% for women. Women demonstrated greater implant survivorship, greater improvement in WOMAC scores, equal improvements in SF-12 scores, and less improvement in only the Knee Society function and total scores. The data refute the hypothesis of inferior clinical outcome for women following total knee arthroplasty when using standard components.,[object Object]

In-hospital Complications and Mortality of Unilateral, Bilateral, and Revision TKA: Based on an estimate of 4,159,661 Discharges

Stavros G. Memtsoudis MD, PhD, Alejandro González Della Valle MD, Melanie C. Besculides DrPH, MPH, Licia Gaber BA, Thomas P. Sculco MD Patients undergoing bilateral total knee arthroplasty (BTKA) may have higher complication rates and mortality than those undergoing a unilateral procedure (UTKA). To evaluate this hypothesis, we analyzed nationally representative data collected for the National Hospital Discharge Survey on discharges after BTKA, UTKA, and revision TKA (RTKA) between 1990 and 2004. The demographics, comorbidities, in-hospital stay, complications, and mortality of each procedure were compared. An estimate of 4,159,661 discharges (153,259 BTKAs; 3,672,247 UTKAs; 334,155 RTKAs) were included. Patients undergoing BTKA were younger (1.5 years) and had a lower prevalence of comorbidities for hypertension (versus UTKA), diabetes, pulmonary disease, and coronary artery disease (versus UTKA and RTKA). The length of hospitalization was 5.8 days for BTKA, 5.3 for UTKA, and 5.4 for RTKA. Despite similar length of hospitalization, the prevalence of procedure-related complications was higher for BTKA (12.2%) compared with UTKA (8.2%) and RTKA (8.7%). In-hospital mortality was highest for patients undergoing BTKA (BTKA, 0.5%; UTKA, 0.3%; RTKA, 0.3%). Patients undergoing BTKA had a 1.6 times higher rate of procedure-related complications and mortality compared with those undergoing UTKA. Outcomes for patients undergoing RTKA for most variables were similar to those for UTKA. BTKA, advanced age, and male gender were independent risk factors for complications and mortality after TKA.,[object Object]

Diagnosis of Infected Total Knee: Findings of a Multicenter Database

Javad Parvizi MD, FRCS, Elie Ghanem MD, Peter Sharkey MD, Ajay Aggarwal MD, R. Stephen J. Burnett MD, FRCS(C), Robert L. Barrack MD Although total knee arthroplasty (TKA) is an effective and successful procedure, the outcome is occasionally compromised by complications including periprosthetic joint infection (PJI). Accurate and early diagnosis is the first step in effectively managing patients with PJI. At the present time, diagnosis remains dependent on clinical judgment and reliance on standard clinical tests including serologic tests, analysis of aspirated joint fluid, and interpretation of intraoperative tissue and fluid test results. Although reports regarding sensitivity and specificity of all diagnostic tests in the literature are abundant, the interpretation of the available data has been hampered by the low sample size of these studies. In view of the scope of this important problem and the limitations of previous reports, a large database was assembled of all revision TKA performed at three academic referral centers in order to determine the current status of diagnosis of the infected TKA utilizing commonly available tests. Intraoperative cultures should not be used as a gold standard for PJI owing to high percentages of false-negative and false-positive cases. When combined with clinical judgment, total white cell count and percentage of neutrophils in the synovial fluid more accurately reflects PJI and when combined with hematologic exams safely excludes or confirms infection.,[object Object]

Measuring Tools for Functional Outcomes in Total Knee Arthroplasty

Robert B. Bourne MD, FRCSC Total knee arthroplasty has come under increasing scrutiny attributable to the fact that it is a high-volume, high-cost medical intervention in an era of increasingly scarce medical resources. Health-related quality-of-life outcomes have been developed such that healthcare providers might determine how good an intervention is and whether it is cost-effective. Total knee arthroplasty has been subjected to disease-specific, patient-specific, global health, functional capacity, and cost-to-utility outcome measures. Patient satisfaction is high (90%) after total knee arthroplasty and 93% of patients would have this operative procedure again. Large improvements in preoperative to postoperative WOMAC scores occurred (over 39 of 100 points in 82% of patients). Cost-to-quality outcomes demonstrated total knee arthroplasties are extremely cost-effective. This analysis documents total knee arthroplasty is a highly efficacious procedure that competes favorably with all medical and surgical interventions.

Stemmed Implants Improve Stability in Augmented Constrained Condylar Knees

Jeremy J. Rawlinson PhD, Robert F. Closkey MD, Nicole Davis, Timothy M. Wright PhD, Russell Windsor MD We previously combined experimental and computational measures to ascertain whether tibial stem augmentation reduces bone strains beneath constrained condylar implants. Using these same integrated approaches, we examined the benefit of a stem when a wedge is used. Implants were removed from the eight paired cadaver specimens from our previous experiment, and oblique defects created that were restored with 15° metallic wedges cemented in place. We applied a varus moment and an axial load and monitored relative motion between implant and bone. Specimen-specific 3-D finite element models were constructed from CT scans and radiographs to examine bone stress in the proximal tibia. Implants with a wedge but no stem had greater motion than the previous control with no stem or wedge. Use of a modular stem with a wedge maintained the same level of motion as the primary case, suggesting that a stem is preferable when a wedge is utilized. The computational models confirmed this conclusion with a 30% reduction in bone stress compared to 17% in the primary case without a wedge. The wedge carried more axial load compared to the primary implant due to its support on stiff metaphyseal bone.

Posterior Cruciate-retaining Total Knee Arthroplasty for Valgus Osteoarthritis

James P. McAuley MD, Matthew B. Collier MS, W. G. Hamilton MD, Ehsan Tabaraee MS, G. A. Engh MD The valgus, osteoarthritic knee is challenging technically and it is unknown whether and how technical and implant variables influence outcomes. We therefore determined the influence of surgical technique of soft tissue balancing and patient and implant factors from 100 unselected cruciate-retaining TKAs for valgus osteoarthritis in patients younger than 75 years of age. From 1987 to 1990, lateral soft tissue balancing was done with an outside-in progression in which the lateral collateral ligament and popliteus were typically released from the femur. From 1991 to 1994, an inside-out technique was use in which the lateral collateral ligament and/or popliteus were typically preserved. The minimum followup was 0.1 year (mean, 8.2 years; range, 0.1–18.2 years). Fourteen of 16 revisions were for wear and/or instability. Popliteus release, lateral collateral ligament release, or greater polyethylene shelf age increased the risk of revision. At 10 postoperative years, survival (end point, revision) was 89% (100 knees), 94% when the shelf age was less than 1 year (n = 73 knees), 97% when the popliteus or lateral collateral ligament was not released (n = 57 knees), and 100% when both conditions were met (n = 39 knees). Cruciate-retaining implants can be successfully used in knees with any degree of valgus osteoarthritis and survival is improved when the surgeon preserves at least one of the structures providing lateral stability in flexion and uses polyethylene with a short shelf life.,[object Object]

Tibial Post Wear in Posterior-stabilized Knee Replacements is Design-dependent

Bridgette D. Furman BS, Joseph Lipman MS, Mordechai Kligman MD, Timothy M. Wright PhD, Steven B. Haas MD Polyethylene tibial post wear in posterior-stabilized knee designs is a major problem. The Insall-Burstein II (IB PS II) reportedly has severe anterior wear of the post in retrieved implants. We hypothesized the more anterior placement in the IB PS II would be reflected in greater wear at the anterior face than the IB PS I. We examined 234 retrieved inserts using subjective scales to grade post damage and wear. Of the IB PS II inserts, 38% demonstrated severe wear compared with only 25% of IB PS I inserts. The most prevalent damage location for the IB PS II was the anterior face, whereas the IB PS I sustained wear mainly on the medial face. While the IB PS post was not designed to constrain posterior femoral displacement, our observations confirm contact in hyperextension or other paradoxic anterior tibial translation is common and design-dependent. Minimizing wear and damage through proper post placement and changes in implant design to anticipate contact on the anterior post should be considered for future posterior stabilized knee replacements. These changes cannot occur in isolation, however, because changes in post placement and design also depend on their relation to the shape and location of the tibial bearing surfaces.

Lateral Retinacular Release Rates in Mobile- versus Fixed-bearing TKA

Charles C. Yang MD, Lee A. McFadden LTC, MD, Douglas A. Dennis MD, Raymond H. Kim MD, Adrija Sharma MS Controversy exists as to whether bearing mobility facilitates centralization of the extensor mechanism after TKA. To assess the incidence of lateral retinacular release, we retrospectively reviewed 1318 consecutive primary TKAs (1032 patients) performed by one surgeon using either a rotating-platform bearing (940) or a fixed bearing (378) from the same implant system. The selection of a fixed- versus mobile-bearing TKA was primarily based on age with patients younger than 70 years receiving a mobile-bearing TKA. We performed a lateral release whenever continuous symmetric patellar facet contact with the trochlear groove from 0° to 90° of flexion was not obtained using the rule of no thumb after tourniquet release. One hundred four of 1318 knees (7.9%) had a lateral release. We performed more lateral releases in the fixed-bearing group (14.3% [54 of 378]) than in the mobile-bearing group (5.3% [50 of 940]). Patellar tilt occurred more often in the mobile-bearing group (10% [94 of 940]) than in the fixed-bearing group (6.9% [26 of 378]), although the magnitude of mean patellar tilt was small in both groups (mobile-bearing 3.0°; fixed bearing 2.55°). No patient had patellar subluxation greater than 5 mm. We suspect the fewer lateral releases in the mobile-bearing group is the result of better extensor mechanism centralization provided by bearing rotation.,[object Object]

Lack of Axial Rotation in Mobile-bearing Knee Designs

Ray C. Wasielewski MD, MS, Richard D. Komistek PhD, Sumesh M. Zingde MS, Kate C. Sheridan BS, Mohamed R. Mahfouz PhD It has often been assumed rotational kinematics are improved with mobile-bearing TKA designs as the terms mobile-bearing and rotating platform imply. We tested this assumption by assessing the in vivo axial rotation magnitudes and patterns of 527 knees implanted with 12 different mobile-bearing TKA designs. Implants were grouped and compared by type—posterior stabilized (PS), posterior cruciate retaining (PCR), and posterior cruciate sacrificing (PCS)—and by specific design. We hypothesized all three mobile-bearing types (PS, PCR, and PCS) would achieve greater than 10° average axial rotation and we would find no differences in axial rotation between types. Only 14% of PS knees, 3% of PCS knees, and 17% of PCR knees attained greater than 10° axial rotation when measured from 0° to 90°. The percentage of PCS knees with greater than 10° axial rotation was less compared with the other two groups. Axial rotation averaged 4.3°, 2.5°, and 3.8° for the PS, PCS, and PCR knees, respectively. Incidences of reverse rotation were observed in 17% of PS knees, 32% of PCS knees, and 28% of PCR knees. Compared with the PCS group, the PS group achieved greater average axial rotation and had a lower percentage of knees displaying incidences of reverse rotation. The data refuted the hypotheses.

Patient-reported Outcome Correlates With Knee Function After a Single-design Mobile-bearing TKA

Jean-Noel Argenson MD, Sebastien Parratte MD, Abdullah Ashour MD, Richard D. Komistek PhD, Giles R. Scuderi MD [object Object],[object Object]

Rotating Platform versus Fixed-bearing Total Knees: An In Vitro Study of Wear

Hani Haider PhD, Kevin Garvin MD One of the assumed benefits of mobile bearings is the reduction of UHMWPE wear. However, to date, such benefit has not been categorically proven. To test the hypothesis that rotating platform total knee arthroplasty would have less wear than a fixed-bearing of the same design, this in vitro study compared the wear and kinematics (which influence wear) of one type of mobile with fixed-bearing tibial components of otherwise identical design. We tested four fixed bearing (FB) and four rotating platforms (RP) on force control knee simulators using identical ISO standard force inputs and simulated soft tissue restraint for 6 million walking cycles. The internal/external rotations peaked just before toe off, reaching an average maximum of 7° internal (tibial rotation) in the RP, 1.5 times that of the FB, which peaked at approximately 4.5° internally. Two of the RP specimens showed infrequent and mostly temporary dislocations of the UHMWPE insert. The wear rate for the FB averaged 8.14 ± 2.63 mg/million cycles and the RP averaged 6.78 ± 1.74 mg/million cycles. Both were very low wear rates compared with most other implants tested similarly in the same laboratory. We concluded polyethylene wear was similar for both designs.

Long-term Results With a Lateral Unicondylar Replacement

Jean-Noël A. Argenson MD, Sebastien Parratte MD, Antoine Bertani MD, Xavier Flecher MD, Jean-Manuel Aubaniac MD While the literature suggests lateral unicondylar knee arthroplasty (UKA) improves function in the short- and medium-term, it is less clear on longer-term function. We asked (1) whether lateral UKA improved longer-term Knee Society scores and return to previous activity level); (2) whether there were any concerning longer-term radiographic findings (the Knee Society roentgenographic evaluation and scoring system); and (3) whether lateral UKA was durable as measured by survivorship to revision at 10 and 16 years. We retrospectively reviewed 39 patients with 40 lateral cemented metal-backed UKA. The patients had a mean age of 61 years at surgery. The etiologies were primary osteoarthritis in 24 knees, posttraumatic in 12 cases, and osteonecrosis in four cases. We performed clinical and radiographic evaluations at a minimum followup of 3 years (mean, 12.6 years; range, 3–23 years). Prostheses survivorship was 92% at 10 years and 84% at 16 years. Despite the limited number of indications and technical considerations, our data suggest lateral UKA is a reasonable alternative for isolated lateral femorotibial compartment disease.,[object Object]

Less Invasive TKA

Andrea Baldini MD, Paolo Adravanti MD Femoral intramedullary canal referencing is used by most knee arthroplasty systems. Fat embolism, activation of coagulation, and bleeding may occur from the reamed canal. The purpose of our study was to evaluate a new extramedullary device that relies on templated data. We randomized 100 consecutive patients undergoing primary total knee arthroplasty through a limited parapatellar approach to use of either standard intramedullary femoral instruments (IM group) or a new extramedullary device (EM group). The extramedullary instrument was calibrated using templated data obtained from a preoperative full-limb weightbearing anteroposterior view of the knee. In both groups, an intraoperative double check was performed using an extramedullary rod referring to the anterosuperior iliac spine. Femoral component coronal alignment was within 0° ± 2° of the mechanical axis in 84% of the IM group and 86% of the EM group. Sagittal alignment of the femoral component was 0° ± 2° in 78% of the IM group and 90% of the EM group. We observed no difference in the average operative time between the two groups. The two groups showed similar postoperative blood loss. Extramedullary reference with careful preoperative templating can be safely used during TKA.,[object Object]

Effect of Gender and Preoperative Diagnosis on Results of Revision Total Knee Arthroplasty

Stephanie Y. Pun MD, Michael D. Ries MD Recent studies question an effect of gender on outcome of primary TKA. We questioned whether the results of revision TKA were affected by gender. We separated 67 revision TKAs by gender and preoperative diagnosis into four groups (arthrofibrosis, infection, instability, and wear and loosening). Each revision TKA was individually matched by age and gender to two primary TKAs. Postoperative Knee Society pain and function scores after revision TKA were lower than for primary TKA for both females and males. However, postoperative Knee Society pain and function scores were similar in males and females. Postoperative pain and function scores were lower for all revision groups compared with primary TKA, except for pain and function scores after revision for instability. Postoperative pain and function scores were higher for instability and wear or loosening than for arthrofibrosis. Our data suggest the results of revision TKA are affected by preoperative diagnosis but not gender.,[object Object]

Men versus Women

Roger H. Emerson MD, Jessica Martinez MD The role played by femoral component sizing in the clinical outcome of primary TKA is currently debated. Oversizing the femur in patients with smaller knees could lead to overstuffing the knee capsule with resulting pain and reduced range of motion. We asked whether the distribution of femoral component sizes differed between genders and whether the availability of additional sizes benefited genders differently and led to a measurable improvement in knee flexion and Knee Society scores or pain. We retrospectively examined two groups of consecutive knees of patients who underwent primary TKA using similar techniques and constraint: Group 1 (93 men and 90 women) who had available four original sizes and Group 2 (106 men and 106 women) after the introduction of three new smaller sizes. More than twice as many new smaller sizes were used in women (52.3%, 56 of 106) compared to men (17.9%, 19 of 106). At the scheduled 6-month followup visit (average, 6 months; range, 5–7 months), we found no differences in the knee score, pain score, and knee flexion in men and women before the additional sizes (Group 1) and after the new sizes (Group 2). Additional sizes therefore did not appear to influence short-term outcomes.,[object Object]

Restoration of Femoral Anatomy in TKA With Unisex and Gender-specific Components

Henry D. Clarke MD, Joseph G. Hentz MS Recent modifications in total knee prosthesis design theoretically better accommodate the anatomy of the female femur and thereby have the theoretical potential to improve clinical results in TKA by more accurately restoring femoral posterior condylar offset, reducing femoral notching, reducing femoral component flexion, and reducing component overhang. First, we radiographically evaluated whether a contemporary unisex prosthesis would accommodate female anatomy equally as well as male anatomy. Next, we radiographically evaluated female knees in which a gender-specific prosthesis was used. Pre- and postoperative radiographs of 122 knees (42 female unisex, 41 male unisex, 39 female gender-specific) were reviewed. In the unisex groups, there were no differences in femoral notching or femoral component flexion. Posterior femoral offset increased in both groups. However, femoral component overhang was worse in female knees (17%) than in male knees (0%). In the gender-specific female group, the incidence of component overhang was similar to that in the unisex female group. Unisex femoral components of this specific design do not equally match the native anatomy male and female knees. In some women, a compromise was required in sizing.

The Impact of Gender, Age, and Preoperative Pain Severity on Pain After TKA

Jasvinder A. Singh MBBS, MPH, Sherine Gabriel MD, MSc, David Lewallen MD Do gender and age affect knee arthroplasty outcomes? In a cohort of patients who underwent primary or revision TKA between 1996 and 2004 and responded to a followup questionnaire 2 and 5 years after arthroplasty, we investigated the impact of gender and age on the prevalence of moderate or severe post-TKA knee pain (primary TKA: 2 years, 5290; 5 years, 2602; revision TKA: 2 years, 1109; 5 years, 505). Moderate-severe pain was higher in women than men after primary TKA at 2 and 5 years (9% versus 6.6% and 7.9% versus 6.5%) and post-revision TKA at 2 and 5 years (28.6% versus 22% and 28.9% versus 18.3%). More women compared to men and fewer patients between 61 and 70 years (versus patients ≤ 60) had moderate-severe pain 2 years after primary TKA adjusting for gender, age, and preoperative pain severity. In the post-revision TKA group, the odds of moderate-severe pain were lower in patients older than 80 years (versus those ≤ 60) at 2 years and higher in patients with moderate-severe preoperative pain at 2 and 5 years postoperatively, after adjustment for gender, age, and preoperative pain severity. We conclude female gender, younger age, and worse preoperative pain predict greater risk of moderate-severe pain postoperatively in patients with primary and revision TKA.,[object Object]

Anthropomorphic Differences Between the Distal Femora of Men and Women

Jess H. Lonner MD, Jeff G. Jasko MS, Beverly S. Thomas RN There is debate about whether distinct designs of femoral components for men and women are needed based on morphologic and size differences between genders. We asked whether anthropomorphic differences exist between the distal femoral dimensions in women and men. We measured the distal femora of 100 women and 100 men intraoperatively after preparation for prosthetic implantation. The measured dimensions included the anteroposterior height from the posterior edge of the medial femoral condyle to the flush anterior cut, the mediolateral width at the transepicondylar axis, the anterior and posterior edges of the anterior chamfer, and the medial and lateral trochlear flanges. These measurements were compared between genders using independent-samples t test. The aspect ratio (a measure of the shape of the distal femur), the ratio between the anteroposterior and mediolateral dimensions, was calculated for men and women to determine whether there is a shape difference between genders. The mean aspect ratio was larger for women than for men (0.84 [range, 0.57–1.03] versus 0.81 [range, 0.066–1.34], respectively). The standard deviation and range of each measurement of size and morphology suggest variability not only between genders but also within genders. Whether the aspect ratios and variations will reflect clinically important differences in outcomes after TKA with available prostheses will require additional study.

Navigation Did Not Improve the Precision of Minimally Invasive Knee Arthroplasty

Peter M. Bonutti MD, Daniel A. Dethmers MD, Mike S. McGrath MD, Slif D. Ulrich MD, Michael A. Mont MD Potential advantages of minimally invasive total knee arthroplasty (TKA) include decreased pain, faster recovery, and increased quadriceps muscle strength. Computer-assisted navigation has been associated with more accurate component alignment. We evaluated two groups of 50 patients who had minimally invasive TKAs performed with and without navigation by two surgeons. A comparison of 50 previous TKAs by each of the two surgeons showed similar results. The mean operative times for the navigation and nonnavigation groups were 112 minutes (range, 63–297 minutes) and 54 minutes (range, 35–86 minutes), respectively. The mean estimated blood losses, mean Knee Society pain as well as functional scores and mean component alignments were similar. The number of knees that deviated by more than 3° from the normal anatomic axis was three and one in the navigated and nonnavigated groups, respectively. Complication rates were 6% and 4% in the navigated and nonnavigated groups, respectively. Our data demonstrate no distinct advantage of navigation when combined with a minimally invasive approach.,[object Object]

Radiographic and Navigation Measurements of TKA Limb Alignment Do Not Correlate

Mark A. Yaffe MD, Samuel S. Koo MD, S. David Stulberg MD Precise pre- and postoperative anatomic measurements are necessary to plan, perform, and evaluate total knee arthroplasty (TKA). We evaluated the relationship between radiographic and navigation alignment measurements, identified sources of error in radiographic and navigated alignment assessment, and determined the differences between desired and clinically accepted alignment. Fifty-eight computer-assisted TKAs were performed and limb alignment measurements were recorded both pre- and postoperatively with standard radiographs and with an intraoperative navigation system. Intraoperative navigation produced consistent navigation-generated alignment results that were within 1° of the desired alignment. The difference between preoperative radiographic and navigation measurements varied by as much as 12° and the difference between postoperative radiographic and navigation measurements varied by as much as 8°. This discrepancy depended on the degree of limb deformity. Postoperative radiographic measurements have inherent limitations. Navigation can generate precise, accurate, and reproducible alignment measurements. This technology can function as an effective tool for assessing pre- and postoperative limb alignment and relating intraoperative alignment measurements to clinical and functional outcomes.,[object Object]

Determining Femoral Component Position Using CAS and Measured Resection

James Benjamin MD To evaluate the ability of computer-assisted surgery (CAS) to accurately size and determine rotational alignment of the femoral component in TKA, the author reviewed femoral component position after 50 consecutive primary TKAs using a femur-first, measured resection workflow. The computer software used allowed femoral rotation to be selected based on epicondylar axis, posterior condylar axis, or anteroposterior axis. The final femoral component size and position was determined by the surgeon to avoid anterior notching, match the posterior-medial condyle resection, and flexed to match the plane of the anterior femoral cortex. Femoral sizing was confirmed intraoperatively with a standard sizing guide. The femoral component was downsized in 52% of patients from the size recommended by the computer software. The posterior condylar axis matched the implanted rotational position of the femoral component to within 1° in 64% of patients in contrast to the epicondylar axis (32%) and anteroposterior axis (26%). CAS provides information to make surgical decisions but does not replace clinical judgment. Landmark referencing may be compromised by limited surgical exposures leading to variation in implant positioning by computer software. A clear understanding of the principles of TKA is critical when using CAS to optimize implant sizing and position.

Rotational Position of Femoral and Tibial Components in TKA Using the Femoral Transepicondylar Axis

Paolo Aglietti MD, Lorenzo Sensi MD, Pierluigi Cuomo MD, Antonio Ciardullo MD, PhD Proper femoral and tibial component rotational positioning in TKA is critical for outcomes. Several rotational landmarks are frequently used with different advantages and limitations. We wondered whether coronal axes in the tibia and femur based on the transepicondylar axis in the femur would correlate with anteroposterior deformity. We obtained computed tomography scans of 100 patients with arthritis before they underwent TKA. We measured the posterior condylar angle on the femoral side and the angle between Akagi’s line and perpendicular to the projection of the femoral transepicondylar axis on the tibial side. On the femoral side, we found a linear relationship between the posterior condylar angle and coronal deformity with valgus knees having a larger angle than varus knees, ie, gradual external rotation increased with increased coronal deformity from varus to valgus. On the tibial side, the angle between Akagi’s line and the perpendicular line to the femoral transepicondylar axis was on average approximately 0°, but we observed substantial interindividual variability without any relationship to gender or deformity. A preoperative computed tomography scan was a useful, simple, and relatively inexpensive tool to identify relevant anatomy and to adjust rotational positioning. We do not, however, recommend routine use because on the femoral side, we found a relationship between rotational landmarks and coronal deformity.

Computer Navigation-assisted versus Minimally Invasive TKA

Peter M. Bonutti MD, Daniel Dethmers MD, Slif D. Ulrich MD, Thorsten M. Seyler MD, Michael A. Mont MD Computer-navigated and minimally invasive TKAs are emerging technologies that have distinct strengths and weaknesses. We compared duration of surgery, length of hospitalization, Knee Society scores, radiographic alignments, and complications in two unselected groups of 81 consecutive knees that underwent TKA using either a minimally invasive approach or computer navigation. The two groups were operated on by two different surgeons over differing timeframes. The mean surgical time was longer in the navigated group by 63 minutes. The Knee Society scores and lengths of hospitalization of the two groups were similar. The postoperative component alignments of the two groups were similar; the mean femoral valgus and tibial varus angles of the navigation group changed from 96° and 88° preoperatively to 95° and 89° postoperatively, respectively, and in the minimally invasive group, the mean femoral valgus angles and tibial varus angles changed from 97° and 88° preoperatively to 95° and 89° postoperatively, respectively. There were 11 major and three minor complications in the navigation group, including one revision, two femoral shaft fractures, four reoperations for knee stiffness, and four instances of bleeding from tracker sites. We believe the higher incidence of complications in addition to the longer operative time in the navigated group may outweigh any potential radiographic benefits.,[object Object]

Does Patellar Eversion in Total Knee Arthroplasty Cause Patella Baja?

Vineet Sharma MD, Panagiotis G. Tsailas MD, Aditya V. Maheshwari MD, Amar S. Ranawat MD, Chitranjan S. Ranawat MD Several proponents of minimally invasive surgery-total knee arthroplasty (MIS-TKA) have suggested patellar eversion during a standard exposure of the knee may cause shortening of the patellar tendon and poorer outcomes secondary to acquired patella baja. To explore this suggestion, we retrospectively reviewed 135 consecutive TKAs in 110 patients to ascertain the effect of TKA on the postoperative Insall-Salvati ratio. All surgeries were performed using standard TKA techniques with a midline incision, medial parapatellar arthrotomy, partial excision of the fat pad, and routine eversion of the patella. One patient developed a postoperative patella baja, defined as an Insall-Salvati ratio of less than 0.8. The Knee Society score for knee and function in this patient was 75 and 70, respectively. Five additional patients had a decrease in Insall-Salvati ratio by 10% or more but without patella baja. Mean Knee Society score for knee and function in these five patients was 94 (range, 73–99) and 96 (range, 90–100), respectively, as compared with 93 (range, 37–99) and 94 (range, 40–100) in the remaining 104 patients. Our data suggest the incidence of patella baja is low after TKA despite routine patellar eversion. Furthermore, a 10% or more decrease in the Insall-Salvati ratio without patella baja was not associated with a worse clinical outcome.,[object Object]

Predicting Patellar Failure After Total Knee Arthroplasty

John B. Meding MD, Mark D. Fish DO, Michael E. Berend MD, Merrill A. Ritter MD, E. Michael Keating MD [object Object],[object Object]

To Resurface or Not to Resurface the Patella in Total Knee Arthroplasty

Naeder Helmy MD, Carolyn Anglin PhD, Nelson V. Greidanus MD, FRCS (C), Bassam A. Masri MD, FRCS (C) The management of the patellar articular surface at the time of primary total knee arthroplasty (TKA) is controversial. We used expected-value decision analysis to determine whether the patella should be resurfaced in TKA, and also whether secondary resurfacing on an unresurfaced patella is worthwhile. Outcome probabilities and utility values were derived from randomized controlled trials only. A decision tree was constructed and fold-back analysis was performed to ascertain the best treatment path. Sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities. Our model showed patellar resurfacing is the best management strategy for the patella at the time of primary TKA. This decision is robust to changes in the specific data: the best path would remain the same as long as the incidence of persistent anterior knee pain (AKP) with resurfacing remains less than 29% (current mean, 12%) or the incidence of AKP after nonresurfacing falls below 12% (current mean, 26%). Delayed (ie, secondary) patellar resurfacing for ongoing patellar pain provides inferior results for the majority of patients.,[object Object]

Isolated All-polyethylene Patellar Revisions for Metal-backed Patellar Failure

Ryan M. Garcia MD, Matthew J. Kraay MS, MD, Victor M. Goldberg MD The outcome of isolated patellar component revisions after metal-backed patellar failure is variable with satisfactory results reported from 78% to 100%. To supplement information in the literature we determined the failure rate and the functional outcome based on the Knee Society clinical and roentgenographic evaluation systems of isolated patellar component revisions after metal-backed patellar component failure. We retrospectively reviewed 27 patients with 28 isolated patellar component revisions for metal-backed patellar component failure performed between 1988 and 2005. Twenty-five knees in 24 patients were available for review with a minimum followup of 24 months (mean, 90 months; range, 24–210 months). All knees were revised with a cemented all-polyethylene patellar component and all tibial polyethylene components were routinely exchanged. One failure (4%) occurred 122.6 months after the isolated patellar component revision secondary to femoral and tibial component loosening. The average Knee Society knee score improved from 73 to 89 points, whereas the average Knee Society function score improved from 56 to 65. Our data confirm those in the literature suggesting a successful outcome can be achieved with an isolated patellar component revision for metal-backed patellar component failure.,[object Object]

Management of the Deficient Patella in Revision Total Knee Arthroplasty

Ryan M. Garcia MD, Matthew J. Kraay MS, MD, Patricia A. Conroy-Smith RN, Victor M. Goldberg MD There are a number of options available to manage the patella when revising a failed total knee arthroplasty. If the previous patellar component is well-fixed, undamaged, not worn, and compatible with the femoral revision component, then it can be retained. When a patellar component necessitates revision and is removed with adequate remaining patellar bone stock, an onlay-type all-polyethylene cemented implant can be used. Management of the patella with severe bony deficiency remains controversial. Treatment options for the severely deficient patella include the use of a cemented all-polyethylene biconvex patellar prosthesis, patellar bone grafting and augmentation, patellar resection arthroplasty (patelloplasty), performing a gull-wing osteotomy, patellectomy, or the use of newer technology such as a tantalum (trabecular metal) patellar prosthesis. Severe patellar bone deficiency is a challenging situation because restoration of the extensor mechanism, proper patellar tracking, and satisfactory anatomic relationships with the femoral and tibial components are critical for an optimal clinical outcome.,[object Object]

Polyethylene Wear Is Influenced by Manufacturing Technique in Modular TKA

Adolph V. Lombardi MD, FACS, Bradley S. Ellison MD, Keith R. Berend MD Polyethylene insert backside surface wear is implicated in osteolysis and failure of total knee arthroplasty. Manufacturing and sterilization methods reduce articular-sided wear. We questioned whether manufacturing technique influences the severity of backside wear. We examined 39 explanted tibial bearings in a blinded fashion using visual, stereomicroscopic, and scanning electron microscopic techniques. We examined 26 direct compression molded components and 13 nondirect compression molded components and applied a new backside wear severity score. The score characterized the magnitude of the various modes of wear with severity ranging from 0 (no wear) to 27 (severe wear). Time in vivo, tibial baseplate material, and manufacturing technique were used as variables for comparison. Backside wear was related to polyethylene manufacturing process with direct compression molded implants having a wear score of 2.3 and nondirect compression molded a score of 5.7. Time in vivo influenced backside wear, although direct compression molded predicted decreased backside wear independent of time in vivo. The data suggest manufacturing technique influences backside wear in total knee arthroplasty polyethylene inserts.

Highly Crosslinked Polyethylene is Safe for Use in Total Knee Arthroplasty

Jeffrey T. Hodrick MD, Erik P. Severson MD, Deborah S. McAlister MD, Brian Dahl BS, Aaron A. Hofmann MD Highly cross-linked polyethylene (XLPE) has been used with good initial success in hip arthroplasty to reduce wear. However, the process of crosslinking reduces fracture toughness, raising concerns as to whether it can be safely used in total knee arthroplasty (TKA). We therefore asked whether XLPE can be used safely in TKA. We performed a retrospective review of 100 subjects receiving XLPE and compared them to 100 subjects who received standard polyethylene in the setting of TKA. The standard polyethylene group had a mean age of 70 with a minimum follow up of 82 months. The highly cross-linked polyethylene group had a mean age of 67 and a minimum follow up of 69 months (mean, 75 months; range, 69–82 months). On radiographic review, the standard group demonstrated 20 TKAs with radiolucencies; 4 of these had evidence of a loose tibial component. The standard group required three revisions related to loose tibial components. The XLPE group had 2 subjects that demonstrated radiolucencies on radiograph and no subjects with evidence of tibial loosening. There were no reoperations related to osteolysis. The data suggest XLPE in TKA can be used safely at least short- to midterm. Our study provides an impetus for further long-term investigation.,[object Object]

Clinical Evaluation of the Shoulder Shrug Sign

Xiaofeng Jia MD, PhD, Jong-Hun Ji MD, Steve A. Petersen MD, Jennifer Keefer PA-C, Edward G. McFarland MD The “shrug sign” (inability to lift the arm to 90° abduction without elevating the whole scapula or shoulder girdle) has been associated with a diagnosis of rotator cuff disease. Based on our clinical experience, we hypothesized the shrug sign is not a specific diagnostic sign for this condition, but rather is associated with various shoulder conditions and shoulder weakness and loss of range of motion. We retrospectively reviewed 982 consecutive patients who had been examined preoperatively for the shrug sign. A positive shrug sign was present in 51.3% of the patients, and the average distance lost from the horizontal was 20.5° ± 2.2° (standard error of mean). Increasing age was associated with the presence of a shrug sign. The highest incidence was in patients with adhesive capsulitis (94.7%). The shrug sign was not sensitive for tendinosis, partial rotator cuff tears, or full-thickness or massive rotator cuff tears. The shrug sign was associated with weakness in abduction, night pain, and loss of range of motion, especially passive abduction. Although the shrug sign is useful as a general sign of shoulder abnormality, particularly when associated with stiffness, it was not specific or sensitive for rotator cuff problems.,[object Object]

Disability and Psychologic Distress in Patients with Nonspecific and Specific Arm Pain

Ana-Maria Vranceanu PhD, Steven Safren PhD, Meijuan Zhao MD, James Cowan BA, David Ring MD, PhD Psychological illness influences the experience and expression of pain and disability. We tested three null hypotheses: (1) patients with nonspecific pain (medically unexplained and idiopathic) and patients with specific pain (discrete and verifiable) are equally likely to screen for psychiatric illnesses based on a validated screening questionnaire; (2) the presence of psychiatric illness (from a screening questionnaire) will not predict whether patients have specific or nonspecific pain type; and (3) across all patients and regardless of whether they have specific or nonspecific pain, psychiatric illness will not predict disability as measured by the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire. We rejected all null hypotheses. The 41 patients with nonspecific arm pain were more likely than the 40 patients with specific arm pain to screen for a somatoform disorder (34% versus 7.5%), posttraumatic stress disorder (24% versus 7.5%), and panic disorder (12.2% versus 5%). The presence of anxiety and somatoform disorders predicted pain type (nonspecific versus specific) and arm-specific disability (DASH). Somatoform disorder was the strongest predictor of pain type and DASH scores. Based on a screening questionnaire, a comorbid psychiatric illness, a somatoform disorder in particular, is associated with nonspecific arm pain and arm-specific disability.,[object Object]

Is a Sliding Hip Screw or IM Nail the Preferred Implant for Intertrochanteric Fracture Fixation?

Brian Aros MD, MS, Anna N. A. Tosteson ScD, Daniel J. Gottlieb MS, Kenneth J. Koval MD This study was performed to determine whether patients who sustain an intertrochanteric fracture have better outcomes when stabilized using a sliding hip screw or an intramedullary nail. A 20% sample of Part A and B entitled Medicare beneficiaries 65 years or older was used to generate a cohort of patients who sustained intertrochanteric femur fractures between 1999 and 2001. Two fracture implant groups, intramedullary nail and sliding hip screw, were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. The cohort consisted of 43,659 patients. Patients treated with an intramedullary nail had higher rates of revision surgery during the first year than those treated with a sliding hip screw (7.2% intramedullary nail versus 5.5% sliding hip screw). Mortality rates at 30 days (14.2% intramedullary nail versus 15.8% sliding hip screw) and 1 year (30.7% intramedullary nail versus 32.5% sliding hip screw) were similar. Adjusted secondary outcome measures showed significant increases in the intramedullary nail group relative to the sliding hip screw group for index hospital length of stay, days of rehabilitation services in the first 6 months after discharge, and total expenditures for doctor and hospital services.,[object Object]

E-PASS for Predicting Postoperative Risk with Hip Fracture: A Multicenter Study

Jun Hirose MD, PhD, Hiroshi Mizuta MD, PhD, Junji Ide MD, PhD, Eiichi Nakamura MD, PhD, Koji Takada MD This multicenter study of 813 consecutive patients with hip fracture was performed to estimate the effectiveness and reproducibility of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system to assess postoperative risk in patients with hip fracture. E-PASS is comprised of a preoperative risk score, a surgical stress score, and a comprehensive risk score based on the preoperative risk score and surgical stress score. Postoperative complications developed in 163 patients (20.0%); 13 (1.6%) died. Hospital postoperative morbidity and mortality rates increased linearly with the preoperative risk score and comprehensive risk score; the correlation was significant. The severity of postoperative complications and the incidence of higher grades of complications increased significantly with rising preoperative risk score and comprehensive risk score. Each E-PASS score also was related significantly with the length of postoperative hospitalization and costs. These results suggest E-PASS is useful for predicting postoperative risk, estimating costs, and for comparing the outcome in patients having surgical treatment of hip fractures.,[object Object]

Staphylococcus aureus Nasal Colonization in Preoperative Orthopaedic Outpatients

Connie Savor Price MD, Allison Williams ND, PhD, Giby Philips MD, Michael Dayton MD, Wade Smith MD, Steven Morgan MD [object Object]

Excision of Painful Bipartite Patella: Good Long-term Outcome in Young Adults

Maria Weckström MD, Mickael Parviainen MD, Harri K. Pihlajamäki MD, PhD Excision of the accessory bipartite fragment is widely used, but its long-term outcome is not known. We evaluated the outcome after surgical excision of a symptomatic accessory bipartite or multipartite patella fragment in young adult men performing their compulsory military service and determined the incidence of painful bipartite patellae in this group of skeletally mature adults. We followed 25 of 32 patients for a minimum of 10 years (mean, 15 years; range, 10–22 years). The incidence of painful, surgically treated bipartite patella was 9.2 per 100,000 recruits. Patients’ median age at surgery was 20 years. There were 19 superolateral and six lateral bipartite fragments. Other radiographic findings were rare. At followup, the Kujala score mean was 95 points (range, 75–100 points), and osteoarthrotic changes (Kellgren-Lawrence Grade 1) were seen in two knees. No reoperations related to bipartite patella occurred during the followup. Symptomatic bipartite patella is rare and does not seem primarily associated with anatomic deviations, but when incapacitating pain persists despite nonoperative treatment, surgical excision seems to yield reasonable functional outcome and quick recovery with no apparent adverse sequelae. Our data suggest there is no reason to avoid this technically undemanding procedure for treating persistent symptoms of bipartite patella in young adults.,[object Object]

Accuracy of Posterior Subtalar Joint Injection Without Fluoroscopy

Kevin L. Kirk DO, MAJ, USA, John T. Campbell MD, Gregory P. Guyton MD, Lew C. Schon MD Injection into the posterior subtalar joint has not been validated for accuracy using radiographic end points. We asked whether needle placement into a normal posterior subtalar joint could be performed accurately and selectively by experienced surgeons without fluoroscopic guidance. Three fellowship-trained orthopaedic foot and ankle surgeons each injected the posterior subtalar joint of 20 cadaveric specimens using an anterolateral approach. Fluoroscopic images were obtained by an independent investigator and blinded. A separate fellowship-trained foot and ankle surgeon interpreted the images. Of 60 injections, 58 were accurate and two were extraarticular based on interpretation by an independent foot and ankle surgeon. Extravasation into the ankle occurred in 14 samples and into the peroneal sheath in two samples. Experienced surgeons can place intraarticular injections into a radiographically normal posterior subtalar joint without fluoroscopy with a high degree of accuracy. However, extravasation into the ankle or peroneal tendon sheath occurred in an unpredictable fashion, suggesting selectivity of injection placement is relatively limited without the use of fluoroscopy. Fluoroscopy may not be necessary for injections used solely for therapeutic purposes. However, if the injection is intended for diagnostic purposes or to assist in surgical decision-making or if the joint is abnormal, we recommend fluoroscopy to ensure the subtalar joint is the only anatomic structure impacted by the injection.

Myths and Legends in Orthopaedic Practice: Are We All Guilty?

Nirmal C. Tejwani MD, Igor Immerman MD Over years of practice, many beliefs and practices become entrenched as tried and tested, and we subconsciously believe they are based on scientific evidence. We identified nine such beliefs by interviewing orthopaedic surgeons in which studies (or lack thereof) apparently do not support such practices. These are: changing the scalpel blade after the skin incision to limit contamination; bending the patient’s knee when applying a thigh tourniquet; bed rest for treatment of deep vein thrombosis; antibiotics in irrigation solution; routine use of hip precautions; routine use of antibiotics for the duration of wound drains; routine removal of hardware in children; correlation between operative time and infection; and not changing dressings on the floor before scrubbing. A survey of 186 practicing orthopaedic surgeons in academic and community settings was performed to assess their routine practice patterns. We present the results of the survey along with an in-depth literature review of these topics. Most surgeon practices are based on a combination of knowledge gained during training, reading the literature, and personal experience. The results of this survey hopefully will raise the awareness of the selected literature for common practices.

Case Report: Two-step Malignant Transformation of a Liposclerosing Myxofibrous Tumor of Bone

Kirk Campbell BS, Felasfa Wodajo MD We present the case of a patient with malignant transformation of a liposclerosing myxofibrous tumor. The patient had a histologically confirmed liposclerosing myxofibrous tumor that, during a course of 22 months, spontaneously transformed into a lesion appearing like a benign giant cell reactive lesion and subsequently into a high-grade bone sarcoma. Few such cases of spontaneous malignant transformation of liposclerosing myxofibrous tumor have been reported. We report what we believe to be the first case documenting spontaneous transformation of a liposclerosing myxofibrous tumor into an intermediate lesion with benign-appearing histologic features and then into a high-grade malignant tumor.

Case Reports: Pediatric PCL Insufficiency from Tibial Insertion Osteochondral Avulsions

Nirav K. Pandya MD, Luke Janik BS, Gilbert Chan MD, Lawrence Wells MD Posterior cruciate ligament (PCL) insertion-site osteochondral avulsions in children, particularly from the tibia, are not commonly seen by orthopaedic surgeons. Because of the rarity of these injuries, careful attention to the specific physical examination and imaging findings seen with these injuries is necessary so that the proper diagnosis can be made. Osteochondral avulsions of the PCL can be missed on plain radiographs in skeletally immature patients, and therefore magnetic resonance imaging is necessary for proper diagnosis. With this knowledge, clinicians can formulate treatment plans which can return their patients to activities while avoiding potential morbidity resulting from missed diagnoses or improper treatment. We report two rare cases of PCL insufficiency stemming from tibial insertion osteochondral avulsions. Both patients underwent subsequent open reduction and internal fixation of the avulsion using two different fixation methods (bioabsorbable anchors versus cannulated screw and washer) and have returned to full sporting activities.

A 56-year-old Woman with a Right Arm Mass

Panayiotis J. Papagelopoulos MD, DSc, Andreas F. Mavrogenis MD, Evangelia Skarpidi MD, Irene Nikolaou MD, Panayotis N. Soucacos MD, FACS
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