EvEry aspEct of rush’s nEw, statE-of-thE-art hospital ... · spine, foot, and ankle, upper extremity, sports medicine, hip and knee replacement, and orthopedic oncologic surgery

EvEry aspEct of rush’s nEw, statE-of-thE-art hospital, schEdulEd to opEn in January 2012,

will hElp to EnhancE thE patiEnt ExpEriEncE and improvE thE quality of carE.

2 Chairman’sLetter

4 OrthopedicFacultyandFellows(2010)

9 ResearchFacultyandHighlights

14DepartmentofOrthopedicSurgeryResidents

15 HumanUmbilicalCordBlood–DerivedMesenchymal StemCellsforIntervertebralDiskRepair AnA Chee, PhD; YejiA ZhAng, MD, PhD; DessislAvA MArkovA, PhD; BiAgio sAittA, PhD; vlADiMir MArkov, MD; ChAnDer guPtA; howArD s. An, MD

20 AdvancesinAnteriorCruciateLigamentReconstruction: AQuarterCenturyofInnovationatRushUniversity MedicalCenter MiChAel B. ellMAn, MD; riChArD C. MAther iii, MD;

seth l. sherMAn, MD; BernArD r. BACh jr, MD

27 ExtranodalRosai-DorfmanDiseaseWith IsolatedOsseousInvolvement:AnUnusualCase riChArD w. kAng, MD; kevin C. MCgill, MPh; johnnY

lin, MD; MiChelle e. Collier, MD; steven gitelis, MD

32 IdiopathicGlenohumeralChondrolysis:ACaseReport shAne j. nho, MD, Ms; niCole A. Friel, MD, Ms;

BriAn j. Cole, MD, MBA

37 ReducedScapularNotchingFollowingReverseTotalShoulder Arthroplasty:ClinicalResultsofaNewImplantDesign seth l. sherMAn, MD; Brett A. lenArt, MD; eriC strAuss, MD; AMAn DhAwAn, MD; eriC goChAnour, MA; gregorY P. niCholson, MD

42 AnteriorHipPaininanAthleticPopulation:Differential DiagnosisandTreatmentOptions MArk A. slABAugh, MD; rAChel M. FrAnk; MD; roBert C. gruMet, MD; Phil MAlloY, MPt; ChArles A. Bush-josePh, MD; wAlter w. virkus, MD; shAne j. nho, MD, Ms

52 TheTechniqueofAcetabularDistractionforthe ReconstructionofSevereAcetabularDefectsWithan AssociatedChronicPelvicDiscontinuity sCott M. sPorer, MD, Ms; AnDrew MiChAel, MD; wAYne g. PAProskY, MD; MArio MoriC, Ms

58 SelectPublications(2010)

65 SelectResearchGrants(2009-2010)

66 VolumeandQualityData

68 LegacyofExcellence An interview with renowneD sPine surgeon gunnAr B. j. AnDersson, MD, PhD, BY ChristoPher DewAlD, MD

Toviewthe2011Rush Orthopedics Journal online,pleasevisittheRushwebsiteatwww.rush.edu/orthopedicsjournal.

faculty Editors

steven gitelis, MD

Editor in Chief

David Fardon, MD

Brett levine, MD

robert w. wysocki, MD

Chairman’s Letter2011 rush orthoPeDiCs journAl

2

Frommyofficewindow,I’vehadthepleasureofwatchingRush

UniversityMedicalCenter’snewhospitalbuildingtakingshape

overthepast2years.Whenthenewhospital—locatedacross

thestreetfromtheOrthopedicBuilding—opensinJanuary

2012,itwillgreatlyenhanceourabilitytoprovidethehighest

qualityofcareforpatientswithorthopedicconditions.

Thehospitalwillincorporateaconceptcalled“theinterven-

tionalplatform,”with3floorsdevotedtosurgery,imaging,and

specialtyprocedures.It’saconceptdevelopedinrecentyearsfor

academicmedicalcenterswheremultiplemedicalandsurgical

specialistscollaboratetotreatpatientswithcomplexproblems

usingthemostadvancedtechnologiesavailable.Theinterven-

tionalplatformatRushfeaturesoperating-procedurerooms,

associatedprepandrecoveryrooms,andsupportspace.Each

newandlargeroperatingroom—designedbasedonfeedback

fromsurgeonsacrossnumerousspecialties,includingortho-

pedics—willaccommodatemorespecializedequipmentand

technologytoimproveoutcomes.

DevelopmenthasalsocontinuedwithintheOrthopedic

Building.Anewlearningcenterwascompletedtowardtheend

of2010,providingaspacious,state-of-the-artvenueforeduca-

tionalactivitiestocomplementouralreadyimpressiveclinical

andresearchfacilities.

Inthemidstofthesephysicaltransformations,ourphysicians

andresearcherscontinuedtobreaknewgroundinorthopedic

careandresearch.HowardS.An,MD,andcolleaguesinthe

departmentsoforthopedicsurgeryandbiochemistryreceived

theprestigious2011KappaDeltaElizabethWinstonLanier

AwardfromtheAmericanAcademyofOrthopaedicSurgeons

forapaperentitled“IntervertebralDiscRepairorRegeneration

byGrowthFactorand/orCytokineInhibitorProteinInjec-

tion.”CraigJ.DellaValle,MD,wasaco-recipientofthe2011

FrankStinchfieldAwardfromtheHipSocietyforinvestiga-

tionsintodislocationfollowingtotalhipreplacement.And

GunnarB.J.Andersson,MD,PhD,receivedthe2010

FreedomofMovementAwardfromtheArthritisFoundation,

GreaterChicagoChapter.Seepage68foraninterviewwith

Andersson,whoprecededmeasdepartmentchairman,in

whichhelooksbackonhisillustriouscareer.

Membersofthedepartmenthavealsorecentlyascendedto

keynationalleadershippositions.Ijoinedthepresidentialline

oftheAmericanAcademyofOrthopaedicSurgeons,servingas

thesecondvicepresident;HowardS.An,MD,isthecurrent

presidentoftheInternationalSocietyfortheStudyoftheLum-

barSpine;andCharlesA.Bush-Joseph,MD,istheincoming

presidentoftheMajorLeagueBaseballTeamPhysicianAssocia-

tion.Inaddition,StevenGitelis,MD,editorinchiefofthis

journal,wasrecentlyelectedpresidentofthemedicalstaffof

RushUniversityMedicalCenter.

Finally,IwouldberemissifIdidn’tmentionouroutstand-

ingresidentsandfellows,whocametoRushfromacrossthe

UnitedStatesandaroundtheworldtoparticipateinourhighly

competitivetrainingprograms.Ourfacultymembersvalue

thecontributionsofresidentsandfellowstothecareofour

patients,andwearehonoredtobesharingourknowledgeand

skillswiththenextgenerationoforthopedicspecialists.

IinviteyoutoperusethisissueoftheRush Orthopedics

Journalandenjoyasamplingofthestellarworkproducedby

ourdepartmentduringthepastyear.

JoshuaJ.Jacobs,MD

TheWilliamA.Hark,MD/SusanneG.Swift ProfessorofOrthopedicSurgery

Chairman,DepartmentofOrthopedicSurgery

RushUniversityMedicalCenter

Chairman’s Letter 2011 rush orthoPeDiCs journAl 3

Joshua J. Jacobs, MD (right), with Markus A. Wimmer, PhD, director of the Tribology Labo-ratory and co-director of the Motion Analysis Laboratory

“in thE midst of [rush’s] physical transformations, our physicians and rEsEarchErs

continuEd to brEak nEw ground in orthopEdic carE and rEsEarch.”

4

adult rEconstructivE surgEry

fEllows

Daniel Del gaizo, MD

Medicalschool–GeorgeWashingtonUniversitySchoolofMedicineandHealthSciencesResidency–UniversityofNorthCarolina

kurt hirshorn, MD

Medicalschool–UniversityofSouthFloridaCollegeofMedicineResidency–AtlantaMedicalCenter

jeremy kinder, MD

Medicalschool–RushMedicalCollegeResidency–NorthwesternMemorialHospital

trevor Murray, MD

Medicalschool–CaseWesternReserveUniversityMedicalCenterResidency–ClevelandClinic

Brian Pack, MD

Medicalschool–WayneStateUniversitySchoolofMedicineResidency–GrandRapidsMedicalEducationandResearchCenter

Anand srinivasan, MD

Medicalschool–JeffersonMedicalCollegeResidency–BaylorUniversityMedicalCenter

OrthopedicFacultyandFellows(2010)2011 rush orthoPeDiCs journAl

Aaron rosenberg, MD

Director,SectionofAdultReconstruction

Professor,DepartmentofOrthopedicSurgery

richard A. Berger, MD

Assistantprofessor,DepartmentofOrthopedicSurgery

Brett levine, MD


wayne g. Paprosky, MD


scott M. sporer, MD, Ms


jorge o. galante, MD, DMsc

TheGraingerDirectorshipoftheRushArthritisandOrthopedicsInstitute


Craig j. Della valle, MD

Associateprofessor,DepartmentofOrthopedicSurgery

Director,AdultReconstructiveOrthopedicSurgeryFellowshipProgram

joshua j. jacobs, MD

TheWilliamA.Hark,MD/SusanneG.SwiftChairofOrthopedicSurgery

Chairmanandprofessor,DepartmentofOrthopedicSurgery

Orthopedic Faculty and Fellows (2010) 2011 RUSH ORTHOPEDICS JOURNAL 5

Walter W. Virkus, MD

Associate professor, Department of Orthopedic Surgery

Director, Orthopedic Residency Program

Steven Gitelis, MD

Director, Section of Orthopedic Oncology

Rush Medical College Endowed Professor of Orthopedic Oncology

Vice chairman and professor, Department of Orthopedic Surgery

ELBOW, WRIST, AND HAND SURGERY

Mark S. Cohen, MD

Director, Section of Hand and Elbow Surgery

Professor, Department of Orthopedic Surgery

John J. Fernandez, MD

Assistant professor, Department of Orthopedic Surgery

Robert Goldberg, MD

Instructor, Department of Orthopedic Surgery

Robert W. Wysocki, MD


FOOT AND ANKLE SURGERY

Simon Lee, MD


Johnny L. Lin, MD Assistant professor, Department of Orthopedic Surgery

George Holmes Jr, MD

Director, Section of Foot and Ankle Surgery


ONCOLOGY AND TRAUMA

6

pEdiatric surgEry

Monica kogan, MD

Director,SectionofPediatricSurgery


spinE surgEry

howard s. An, MD

Director,DivisionofSpineSurgery

TheMortonInternationalChairofOrthopedicSurgery


Director,SpineSurgeryFellowshipProgram

gunnar B. j. Andersson, MD, PhD

TheRonaldL.DeWald,MD,EndowedChairinSpinalDeformities

Professorandchairmanemeritus,DepartmentofOrthopedicSurgery

kim w. hammerberg, MD


Frank M. Phillips, MD

Director,SectionofMinimallyInvasiveSpineSurgery


kern singh, MD


David Fardon, MD


Christopher Dewald, MD


edward j. goldberg, MD


fEllows

kelley Banagan, MD

Medicalschool–SUNYUpstateMedicalUniversityResidency–UniversityofMarylandMedicalCenter

thomas Cha, MD

Medicalschool–DrexelUniversityCollegeofMedicineResidency–ColumbiaUniversityMedicalCenter

safdar khan, MD

Medicalschool–AgaKhanUniversityMedicalCollegeResidency–HospitalforSpecialSurgery(researchfellowship);UniversityofCaliforniaDavis

isaac Moss, MD Medicalschool–McGillUniversityFacultyofMedicineResidency–UniversityofTorontoAffiliatedHospitals

Orthopedic Faculty and Fellows (2010) 2011 rush orthoPeDiCs journAl 7

sports mEdicinE, surgEry

Bernard r. Bach jr, MD

Director,DivisionofSportsMedicine

TheClaudeN.Lambert,MD/HelenS.ThomsonChairofOrthopedicSurgery


Director,SportsMedicineFellowshipProgram

Charles A. Bush-joseph, MD


Anthony A. romeo, MD

Director,SectionofShoulderandElbowSurgery


nikhil n. verma, MD Assistantprofessor,DepartmentofOrthopedicSurgery

shane j. nho, MD, Ms


Brian j. Cole, MD, MBA

Director,RushCartilageRestorationCenter


gregory nicholson, MD


fEllows

Aman Dhawan, MD

Medicalschool–AlbanyMedicalCollegeResidency–WalterReedArmyMedicalCenter

neil ghodadra, MD Medicalschool–DukeUniversitySchoolofMedicineResidency–RushUniversityMedicalCenter

richard C. Mather iii, MD

Medicalschool–DukeUniversitySchoolofMedicineResidency–DukeUniversityMedicalCenter

seth l. sherman, MD Medicalschool–WeillCornellMedicalCollegeResidency–HospitalforSpecialSurgery

8

sports mEdicinE, primary carE

jeffrey M. Mjaanes, MD

Assistantprofessor,departmentsoforthopedicsurgeryandpediatrics

krystian Bigosinski, MD

Assistantprofessor,departmentsoffamilymedicineandorthopedicsurgery

joshua Blomgren, Do

Assistantprofessor,departmentsoffamilymedicineandorthopedicsurgery

kathleen M. weber, MD

Director,primarycare/sportsmedicineandwomen’ssportsmedicineprograms


fEllow

Anne rettig, MD

Medicalschool–UniversityofVirginiaSchoolofMedicineResidency–TuftsMedicalCenter

Research Faculty and Highlights 2011 rush orthoPeDiCs journAl 9

ResearchFacultyandHighlights2011 rush orthoPeDiCs journAl

thE robbins and Jacobs family biocompatibility and implant pathology laboratory

robert M. urban

Director,theRobbinsandJacobsFamilyBiocompatibilityandImplantPathologyLaboratory


Deborah j. hall

Instructor,DepartmentofOrthopedicSurgery

thomas M. turner, DvM


TheRobbinsandJacobsFamilyBiocompatibilityandImplantPathologyLaboratoryisconcernedwiththebiocompatibilityof

materialsusedinreconstructionofboneandsofttissues,includingmetalalloys,syntheticpolymers,andprocessedallograftsand

xenografts.Thelaboratorydevelopsuniqueanimalmodelstoevaluatetheefficacyofcandidatebiomaterialsforreconstructionsin

spine,foot,andankle,upperextremity,sportsmedicine,hipandkneereplacement,andorthopediconcologicsurgery.Researchers

inthelabalsostudyimplantsandtissuesobtainedfrompatientsatrevisionsurgeryandmaintainarepositoryofmanythousands

ofretrieveddevices;thesedevicesareevaluatedforevidenceofimplantdegradation,wear,andcorrosionproducts,andtheireffects

onhosttissues.Aspartoftheworld’slargestpostmortemretrievalprogramforjointreplacement,thelabfocusesontherelation-

shipbetweenimplantperformanceandtheresponseofdistantorganstosystemicdisseminationofdegradationproducts.The

laboratoryhasreceivednumerousawardsforitsresearchintheseareas.

biomatErials laboratory

not pictured: AnastasiaSkipor,MS,instructor,DepartmentofOrthopedicSurgery

TheBiomaterialsLaboratoryisfocusedonunderstandingimplantdebrisandthebiologiceffectsofthisdebris,includingwhat

typesofimplantdebrisareproducedfromimplantwearandcorrosion,howdifferenttypesofdebrisinteractwithhumanbiol-

ogyandtheimmunesystem,howdebrisproducesanimmuneresponse,andwhyimmunereactivitytodebrisissodifferentfrom

persontoperson.Answeringthesequestionsiscriticaltoimprovingthelong-termperformanceoforthopedicimplantsandis

nadim j. hallab, PhD

Director,BiomaterialsLaboratory


continued on next page

10

motion analysis laboratory

Markus A. wimmer, PhD

Co-director,MotionAnalysisLaboratory

Director,TribologyLaboratory


kharma C. Foucher, MD, PhD



hannah j. lundberg, PhD


TheMotionAnalysisLaboratoryseeks,throughitsresearchandclinicalactivities,toimprovethephysicalcapabilitiesofpatients

withmusculoskeletalailments.Thelabstudiesthefunctionalperformanceofindividualsduringactivitiesofdailyliving,measur-

ingthekinematicsandkineticsofnaturalandartificialjoints.Currentresearchfociinvolveexploringthepathomechanismof

abnormalgaitonosteoarthriticjointsanddevelopingrehabilitationstrategiestoeitherdelayorhalttheprogressionofcartilage

wear.Primaryequipmentincludes12optoelectroniccameras,and5Bertecforceplatestorecordlimbsegmentmovementsand

moments.A16-channelwirelesselectromyographicsystemhelpstoobtaininsightintomuscleactivity.Strength-andbalance-

testingequipmentandfootpressuremeasuringsystemscomplementthestate-of-the-artequipment.

sEction of orthopEdic oncology

Carl Maki, PhD

Associateprofessor,Departmentof

AnatomyandCellBiology

Qiping Zheng, PhD

Assistantprofessor,Departmentof

AnatomyandCellBiology

Along-termresearchgoalintheSectionofOrthopedicOncologyhasbeentoidentifymolecularmechanismsresponsiblefor

therapyresistanceinosteosarcomaandothercancers,andthenusethisinformationtomoreeffectivelytargetresistantcells.Osteo-

sarcomaisthemostcommonmalignantbonecancerinchildren.Currenttreatmentincludesaggressivepreoperativeandpostop-

erativemultidrugchemotherapy.Nonetheless,itisestimatedthat30%ofpatientswithlocalizeddiseaseand80%ofpatientswith

thecentralmissionofthelaboratory.Overthepast10years,thelabhasmadestridesin4areas:establishingthetheoreticalbasis

forengineeringsurfacesforoptimizinganddirectingcellbioreactivity;characterizingimplantdebris,includingmetal-protein

complexesformedfromimplantdegradationandtheirdifferentinflammatorypotentials;developingsuccessfulbench-to-bedside

diagnostictestingofimmunereactivitytoimplantdebris,facilitatingtheevaluationofpatientsanddifferenttypesofimplants;

andcharacterizingdebris-specificeffectsonperi-implantcells—includingestablishinglevelsoftoxicexposurefordifferentcell

types—anddiscoveringnewpathwaysbywhichimplantdebrisexertproinflammatoryeffects(ie,inflammasomepathway).


sEction of molEcular mEdicinE

tibor t. glant, MD, PhD

Director,SectionofMolecularMedicine

TheJorgeO.Galante,MD,DMSc,Chairin

OrthopaedicSurgery


katalin Mikecz, MD, PhD


TheSectionofMolecularMedicineemploysstate-of-the-artstrategiesandtechniquesinbasicmolecularbiology,biochemistry,

genetics,cellbiology,andimmunologytoconductleading-edgeresearch.Currentstudiesfocusontheautoimmunemechanisms

ofrheumatoidarthritis,includingthescreening,identification,andlocalizationof“disease-susceptible”genesthatcontrolauto-

immuneprocessesandinflammatorycellmigrationintothesynovium;theautoimmunemechanismsofankylosingspondylitis,

includingthescreening,identification,andlocalizationof“disease-susceptible”genesinacorrespondinganimalmodel;andthe

immunology/immunopathologyandgeneticsofextracellularmatrixcomponents(specificallycartilagemacromolecules).Research-

ersinthesectionarealsostudyingthefunctionalandpathophysiologicalimportanceofspecificdomainsofcartilageaggrecan,link

protein,andsmallproteoglycansusingtargeteddisruption(knockout)andoverexpressionofthesemoleculesinmice.Basedonthis

work,theyhavedevelopedamousemodelofosteoarthritis.Anotherareaofinterestisthecellularandmolecular(signaling)mecha-

nismsofpathologicalboneresorptioninfailedtotalhiparthroplasties,whichinclude(1)particle-inducedcellularresponsesand

signalingmechanismsofmacrophages,osteoblasts,andperiprostheticfibroblastsand(2)epigenomicalterationsofgeneexpression

involvedinpathologicalboneresorptionandboneremodeling.Researchersarealsolookingatmyeloproliferativediseasesassociated

directlyorindirectlywithpyodermagangrenosumorSweet’ssyndrome,tworelativelyrareskindiseaseswithunknownetiology.

spinE biology laboratory

nozomu inoue, MD, PhD


ThegoalofresearchintheSpineBiologyLaboratoryistoimprovetheunderstandingofintervertebraldiskbiologyandthe

pathophysiologyofintervertebraldiskdegenerationsothatpatientswithlowbackpaincanbebetterdiagnosedandtreatedwith

not pictured:

TiborA.Rauch,PhD,associateprofessor,DepartmentofOrthopedicSurgery

Yejia Zhang, MD, PhD


metastaticdiseaseatdiagnosiswillrelapse.Recurrenttumorsarethoughttoarisefromtherapy-resistantcancercellsthatsurvivethe

initialtreatment.Thetumorsuppressorproteinp53isactivatedandtriggerscelldeathpathwaysinresponsetoDNA-damaging

chemotherapeuticdrugs.Morethan50%ofcancersharborinactivatingmutationsinthep53gene,andinmanycasesmutations

inthep53genehavebeenlinkedtoadiminishedresponsetochemotherapy.Determiningthemolecularbasisforchemotherapy

resistanceshouldalloworthopediconcologiststomoreeffectivelytargetthesetherapy-resistantcells.


moreeffectiveandlessinvasivemethods.Overthepast10-15years,thelabhastestedcandidatetherapeuticagentsusinginvitro

cellculturemodels,organculturemodels,andinvivoanimalmodelsofintervertebraldiskdegenerationtoassesstheirpotentialto

assistinmatrixrestorationandperhapstoreducediskogeniclowbackpain.InjectionofthebonemorphogeneticproteinsBMP-7

andBMP-14inarabbitmodelwasshowntobeeffectiveinrestoringintervertebraldiskheight,MRIsignalsofthedisk,biochem-

icalmatrixcontents,andbiomechanicalproperties.Basedonthesepreclinicaldata,theFDAhasallowedinvestigationalnewdrug

clinicaltrialstobeginintheUnitedStates.Thisgroundbreakingworkwasrecognizedin2011whenHowardS.An,MD,and

colleaguesinthedepartmentsoforthopedicsurgeryandbiochemistryreceivedtheKappaDeltaElizabethWinstonLanierAward

forapaperentitled“IntervertebralDiscRepairorRegenerationbyGrowthFactorand/orCytokineInhibitorProteinInjection.”

Thelab’songoingworkinvolvestestingothercandidatemoleculestoregeneratedegeneratedintervertebraldisks,whilefocusing

onpain-mediatedmoleculesassociatedwithdegeneration.

12

spinE biomEchanics laboratory

raghu n. natarajan, PhD


Alejandro A. espinoza orías, PhD


TheSpineBiomechanicsLaboratoryhasdevelopedanalysissoftwaretodeterminesubtleandcoupledspinalmotionpatternsthat

thefacetjointsanddisksexhibitinvivo.CT/MRIdataarereconstructedintohigh-resolution,3-dimensionalmodelsthatoffera

varietyofgeometriccharacterizationoptions.Invitrovalidationofspinalmotionmodelsiscarriedoutatthelaboratoryusinga

spinetestingframenewlydevelopedinhouseanddrivenbyaservo-hydraulicmaterialstestingmachine.Motionofthecadaveric

specimensiscapturedinrealtimebyinfraredcameras,thusfullycharacterizingthespinalkinematics.Theframeisalsocapable

oftestingtheeffectsofspinalinstrumentationanddevicesonspinalkinematics.Computermodelsofthehumanspinearebe-

ingusedinthelabtounderstandchangesinspinalkinematicsduetosurgicalproceduresperformedonthelumbarandcervical

spines,includingfusionandmotionpreservationsystems.Computermodelsarealsobeingusedtounderstandtheeffectsofvari-

oustearsandcleftsformedduringthediskdegenerationprocess.

sports mEdicinE rEsEarch laboratory

vincent M. wang, PhD

Director,SportsMedicineResearchLaboratory

Assistantprofessor,Departmentof

OrthopedicSurgery

TheprimaryresearchfocusoftheSportsMedicineResearchLaboratoryisthestructure,function,injury,andrepairofsoft

connectiveskeletaltissues(tendon,ligament,cartilage,andmeniscus)anddiarthrodialjoints(particularlykneeandshoulder).

Ongoinginvestigationsincludequantitative,3-dimensionalanatomicstudiesfortherefinementofsurgicaltechniques


tribology laboratory

Alfons Fischer, PhD

Visitingprofessor,Departmentof

OrthopedicSurgery

ThegoaloftheTribologyLaboratoryistocontributetolong-lastingtreatmentsolutionsfortheosteoarthriticjoint.Researchersin

thelabapplythephysicalprinciplesoffriction,wear,andlubricationtonaturalandartificialjointstoimproveboththematerial

propertiesofimplantsandthepatient’swell-being.Althoughtheirmainfocusisartificialimplants,researchersinthelabalsoapply

“tribologicalthinking”tonaturaltissuesinanefforttobetterunderstandtheeffectsofloadingandmotiononlivingstructures.

Thelaboratoryisequippedwithadvancedequipmentthatincludesakneesimulatorandahip/spinesimulatorfortestingpros-

theticjointbearingcouplesunderphysiologicalconditions;acustom-builtbioreactortotestlivecartilage;apin-on-diskapparatus

forscreeningbearingmaterials;andspecificallydedicatedhydraulic,pneumatic,andelectromechanicalmachinestotestbiomate-

rialproperties.Thelaboratoryalsofeaturesaretrievalanalysissuitewithastate-of-the-artinterferometricmicroscopeforsurface

topographicalcharacterization,acoordinatemeasuringmachinewithmicron-rangeprecisionforimplantgeometricalmeasure-

ments,andaccesstoascanningelectronmicroscopewithenvironmentalcapabilities.

Mathew t. Mathew, PhD


not pictured:

MichelLaurent,PhD,scientist,DepartmentofOrthopedicSurgery

Markus A. wimmer, PhD

Director,TribologyLaboratory



(eg,orientationofbonetunnelsforanteriorcruciateligament[ACL]reconstruction);comparativebiomechanicalstudiesofstabil-

ityandstrengthconferredbyvarioussurgicaltechniques(eg,rotatorcuffrepair,ACLreconstruction);assessmentofmicroscopic,

biologic,andbiomechanicalpropertiesofnormal,injured,andhealingmusculoskeletalsofttissues(eg,toassessrolesofspecific

tissuematrixproteins,surgicalrepairtechniques,ortherapeuticsonthequalityofhealing);anddevelopmentandapplicationof

noninvasiveimagingtechniquesforquantitativeassessmentoftissueintegrity.

14

laith M. Al-shihabi, MD

Medicalschool–MedicalCollegeofWisconsin

Christopher Bayne, MD

Medicalschool–HarvardMedicalSchool

sanjeev Bhatia, MD

Medicalschool–NorthwesternUniversityFeinbergSchool

ofMedicine

Debdut Biswas, MD

Medicalschool–YaleUniversitySchoolofMedicine

Brian r. Braaksma, MD

Medicalschool–ColumbiaUniversityCollegeof

PhysiciansandSurgeons

Peter n. Chalmers, MD

Medicalschool–ColumbiaUniversityCollegeof

PhysiciansandSurgeons

Cara A. Cipriano, MD

Medicalschool–UniversityofPennsylvaniaSchool

ofMedicine

Michael ellman, MD

Medicalschool–UniversityofMichigan

MedicalSchool

Amir-kianoosh Fallahi, MD

Medicalschool–WayneStateUniversitySchoolofMedicine

jonathan M. Frank, MD

Medicalschool–UniversityofCaliforniaLosAngelesGeffen

SchoolofMedicine

nickolas g. garbis, MD

Medicalschool–UniversityofIllinoisCollegeofMedicine

atChicago

james gregory, MD

Medicalschool–UniversityofPennsylvaniaSchoolofMedicine

Christopher gross, MD

Medicalschool–HarvardMedicalSchool

Andrew hsu, MD

Medicalschool–StanfordUniversitySchoolofMedicine

richard w. kang, MD

Medicalschool–RushMedicalCollege

Brett A. lenart, MD

Medicalschool–WeillCornellMedicalCollege

Paul B. lewis, MD


sameer j. lodha, MD

Medicalschool–WashingtonUniversitySchool

ofMedicine

samuel A. McArthur, MD

Medicalschool–UniformedServicesUniversityHébert

SchoolofMedicine

kevin Park, MD

Medicalschool–TulaneUniversitySchoolofMedicine

sanjai k. shukla, MD

Medicalschool–DukeUniversitySchoolofMedicine

william slikker iii, MD

Medicalschool–StanfordUniversitySchoolofMedicine

geoffrey s. van thiel, MD

Medicalschool–UniversityofCaliforniaLosAngelesGeffen

SchoolofMedicine

David M. walton, MD

Medicalschool–CaseWesternReserveUniversitySchool

ofMedicine

Adam Yanke, MD


Department of Orthopedic Surgery Residents2011 rush orthoPeDiCs journAl

HumanUmbilicalCordBlood–DerivedMesenchymalStemCellsforIntervertebralDiskRepair

AnA Chee, PhD; YeJiA ZhAng, MD, PhD; DessisLAvA MArkovA, PhD; BiAgio sAiTTA, PhD; vLADiMir MArkov, MD; ChAnDer guPTA; hoWArD s. An, MD

author affiliations

DepartmentofOrthopedicSurgery,RushUniversityMedical

Center,Chicago,Illinois(DrsChee,Zhang,andAn);Department

ofRehabilitationMedicine,ThomasJeffersonUniversity,Phila-

delphia,Pennsylvania(DrsMarkovaandMarkovandMrGupta);

andDepartmentofCellBiology,SchoolofOsteopathicMedicine,

UniversityofMedicineandDentistryofNewJersey,Stratford,

NewJersey(DrSaitta).

corresponding author

AnaChee,PhD;RushUniversityMedicalCenter,1653W

CongressPkwy,Chicago,IL60612([email protected]).

introduction

Scientistsandclinicianshavefoundthatstemcellscandifferentiate

intoavarietyofcelltypesandthereforecanprovidetherapeutic

effectsformanyhumandiseases.Forthelast20years,researchand

clinicaltrialsusingumbilicalcordbloodcellshaveshownpromise

intreatingalargenumberofhematologicdiseasesandasmaller

numberofnonhematologicdiseases.Unlikeembryonicstem

cells,humanneonatalumbilicalcordblood–derivedmesenchy-

malstemcells(hUCB-MSCs)aretakenfromdonatedumbilical

cordtissuesamplesafterbirthwithnoharmtothemotherorthe

newborn,andthereforetheirresearchisnotsubjecttotheethical

andpoliticaldebatesurroundingembryonicstemcellresearch.

Mesenchymalstemcells(MSCs)areself-renewingcellsthatexhibit

multilineagedifferentiationintobone,cartilage,fat,andmuscle.1-5

Studieshaveshownthatclassicmesenchymalstemcellsarecapable

ofdifferentiatingintocellsofconnectivetissuelineagessuchas

osteogenic,adipogenic,andchondrogeniclineages.6-9Human

UCB-MSCscanbeculturedinspecializedmediaandinduced

todifferentiateintoclassicmesenchymallineages(adipogenic,

chondrogenic,andosteogenic)(Figure1).Comparedtoadult

mesenchymalstemcelltransplantation,umbilicalcordbloodstem

celltransplantationallowsformorehumanleukocyteantigen

(HLA)disparity,thusrequiringlessstringentmatchingbetween

donorandrecipient.10,11Umbilicalcordbloodstemcellsareless

maturethanadultbonemarrow–derivedMSCsandthushavea

largercapacitytosurviveandreplicate.Todate,hUCB-MSCshave

becomeawidelyacceptedsourceofhematopoieticstemcells:they

havebeenusedintransplantstotreatanumberofhematopoietic

andmalignantdiseases,12includingBuerger’sdiseaseandchronic

spinalcordinjury.13,14OurlabisexploringtheuseofhUCB-MSCs

asatherapyforlowerlumbarspondylosisandassociateddiseases

bytestingthetherapeuticeffectsofhUCB-MSCsondegenerating

rabbitintervertebraldiskexplantcultures.

Articles2011 rush orthoPeDiCs journAl

“our initial studiEs havE shown that transplantEd stEm cElls survivE and ExprEss

thE human typE ii collagEn gEnE, a markEr showing that thE stEm cElls

arE hElping to rEpair thE disk.“

Articles 2011 rush orthoPeDiCs journAl 15

16

back pain therapy

Backpainandneckpainarecommonclinicalproblems,15and

inmanyaffectedpatients,degenerativediskdiseasehasbeen

identifiedasasignificantcontributingfactor.Theetiologyof

diskdegenerationiscomplex.Amongtheriskfactorsaregenetic

predispositionandbiomechanicalproperties.16Viablediskcells

decreaseinnumberinthedegenerativedisk,mostlikelydueto

apoptosis.17Proteolyticenzymesarefoundathigherconcentrations

indegenerativedisksthaninnormaldisks18-20alongwithincreased

levelsofproinflammatorycytokines,18,19moleculesthatpromote

lossofmatrixhomeostasisbysuppressingmatrixsynthesis/repair

andpromotingmatrixdegradation.Improvedextracellularmatrix

productionordecreasedmatrixdegradationcanbeachievedby

avarietyofmethods,forexample,bystimulatingdiskcellswith

growthfactors,inhibitingproinflammatorycytokines,orinhibit-

ingproteolyticenzymes.However,atlatestagesofdiskdegenera-

tionwhenthenumberofviablecellsislow,repopulatingthedisk

withcellsthatcouldproduceandmaintainextracellularmatrix

maybedesirable.

Asanalternativetothesurgicalremovalofthediseaseddisk,cell

therapymaybeapromisingoptiontohelpreducediskdegenera-

tion,restorefunction,andreducebackpain.Asafirststep,our

researchgrouphasstudiedthetherapeuticeffectsofthetrans-

plantationofdonatedhUCB-MSCsintorabbitdegeneratingdisk

explantcultures.Ourinitialstudieshaveshownthattransplanted

stemcellssurviveandexpressthehumantypeIIcollagengene,a

markershowingthatthestemcellsarehelpingtorepairthedisk.

Also,thestemcellscanstimulatetheresidentdiskcellstohelp

repairthediskbyexpressinghigherlevelsofrabbittypeIIcollagen

geneandlowerlevelsofthematrixmetallopeptidase13gene,a

markerfordiskdegeneration.Withimprovedextracellularmatrix

productionanddecreasedmatrixdegradation,thestemcellshavea

positivetherapeuticeffectonthediskhomeostasis.

results

stem Cell survival in rabbit Disk Culture

HumanumbilicalcordbloodstemcellswerestainedwithCellVue

NIR815Fluorescentdye(LI-COR,Lincoln,Nebraska)sothey

couldbetrackedwithinanintervertebraldiskexplant.Labeled

hUCB-MSCsweretransplantedintoculturedrabbitintervertebral

diskexplantsandcontinuedtofluorescegreenaftera1-month

cultureperiod(Figure2,lowerpanel).Whenanoninjectedrab-

bitdiskisscanned,ittypicallyhasredbackgroundfluorescence.

However,whentheimagesareoverlapped,thecombinationof

thegreenfluorescingstemcellstransplantedinredfluorescing

rabbitdiskhasayellowfluorescentappearance,whichisaclear

indicationthatthestemcellsaretransplanted.Thefluorescent

colorfromthesamedisksdiminishesonlyslightlythroughoutthe

4-weekcultureperiod,whichmayrelatetonaturalfadingofthe

dyeorstemcelldeath(Figure2,upperpanel).

figure 1. Humanumbilicalcordblood–derivedmesenchymalstemcellsundergoadipogenic(B,C;fatstainedred),chondrogenic(E,F;proteoglycanrichmatrixstainedblue),andosteogenicdifferentiation(H,I;calcifiedmatrixstainedblack).Undifferentiatedcontrolcellswerenegativeforstaining(A,D,G).

b ca

E fd

h ig

expression of Disk repair genes After stem

Cell transplantation

Wesubsequentlytested(1)ifhUCB-MSCcandifferentiateinto

chondrocyte-likecellscapableofmakingextracellularmatrix(using

reversetranscriptionPCR)and(2)ifhUCB-MSCcanstimulate

residentdiskcellstoexpresshigherlevelsofextracellularmatrix

genesandlowerlevelsofproteolyticenzymes(usingreal-time

PCR).Aftera1-monthcultureperiod,totalcellularRNAwas

extractedfromdiskexplanttissues.Stemcellsculturedinamono-

layerdonotexpresshumantypeIIcollagenmRNA(Figure3,left

panel,lane1);humantypeIIcollagengenewasexpressedinrabbit

diskexplantstransplantedwithhUCB-MSCs(Figure3,leftpanel,

lane3).TheratiosoftheintensitiesofhumantypeIIcollagen

bandstoglyceraldehyde-3-phosphatedehydrogenase(GAPDH)

bandswerequantifiedandareshownintherightpanelofFigure3.

Usingreal-timePCR,wewereabletodetecta2-foldincreasein

expressionofrabbittypeIIcollagenmRNA(Figure4,leftpanel)

figure 2. Humanumbilicalcordstemcellssurviveaftertransplantationintorabbitintervertebraldiskexplantculturefor1month.Rightpanel,Rabbitdisktransplantedwithfluorescentlylabeledhumanumbilicalcordbloodcellsandculturedandscannedforupto4weeks.Leftpanel,Intensityofthefluorescenceofcellsinthedisk.Errorbarsindicatethestandarddeviation.

infr

ared

flu

ore

scen

ce in

ten

sity

c

ou

nts

per

mm

2

0

50000

100000

150000

200000

250000

300000

day 0 week 2 week 4

figure 3. HumantypeIIcollagengeneexpressioninrabbitorganculturebyreversetranscriptionPCR.Leftpanel,SemiquantitativereversetranscriptionPCRwasperformedwithcustomdesignedprimersforhumantypeIIcollagen,humanglyceraldehyde-3-phosphatedehydrogenase(hGAPDH),andrabbitGAPDH(rGAPDH).Rightpanel,TheratioofintensitiesofhumantypeIIcollagenbandstoGAPDHbands.

rat

io o

f ty

pe

ii c

olla

gen

to

ga

pdh

0

0.1

0.2

0.3

0.4

0.5

0.6

type ii collagen gene Expression

stem Cells

0.7

Disk Disk + stem Cells

stem

Cel

ls

Dis

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Dis

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ells

human type ii Collagen

rgAPDh

hgAPDh


Day 0 week 2 week 4

1 2 3

18

anda3-folddecreaseinexpressionofrabbitmatrixmetallopep-

tidase13mRNA(Figure4,rightpanel)instemcelltransplanted

intervertebraldiskswhencomparedtononinjectedintervertebral

disks.Thisindicatesthattheintervertebraldiskstransplantedwith

stemcellsareundergoingareparativeprocess.

future directions

Ourresearchteamisinauniquepositiontodevelopnovelbiologi-

caltreatmentstrategiesfordiskdegenerationgiventhatwehave

formedclosecollaborationsbetweencliniciansandmolecularand

cellbiologists.Atearlyandintermediatestagesofdiskdegenera-

tion,growthfactortherapymaybesufficienttoinduceresident

cellstorepairtheirownmatrixanddiskstructure.Atadvanced

stagesofdiskdegeneration,diskshaveasmallerpopulationof

residentdiskcells,duetocelldeath,andthereforegrowthfactor

therapiesmaynotbeeffective.Inordertoreversediskdegeneration

andrestorefunction,celltransplantationintotheseverelydegener-

ativediskswouldbeneededtohelprepopulatethediskwithviable

cells.Humanumbilicalcordbloodtransplantationhasbeenused

totreatanumberofhematologicalmalignancies.Ourpreliminary

invitrostudieshaveshownthatcelltherapywithhUCB-MSCsfor

diskdegenerationisverypromising.Wehavetrackedtransplanted

hUCB-MSCsinthediskenvironment,andthesecellshavebeen

abletosurviveanddifferentiate.Cellstransplantedintoarabbit

diskexplantcultureexpressgenestohelprepairthediskandalso

stimulateresidentdiskcellstoexpressgenesthatwillhelprestore

diskfunction.

Beforethistherapycanundergoclinicaltrials,thehUCB-MSCcell

therapywouldneedtobevalidatedinaninvivoanimalmodel.

Ourgrouphasdevelopedarabbitdiskdegenerationmodelto

studythebiologicalmechanismsofdiskdegenerationandtotest

therapeuticsfordiskregeneration,whichhasbecomeastandard

modelinthediskdegenerationfield.Usingourexpertiseinunder-

standingthebiologyofdiskdegenerationandthepromisingtools

ofcelltherapy,wehopethesestudieswilllaythegroundworkto

makehUCB-MSCsapromisingtreatmentoptionforpatientswith

severediskdegenerationandbackpain.

references

1.FriedensteinAJ,GorskajaJF,KulaginaNN.Fibroblastprecursorsinnormalandirradiatedmousehematopoieticorgans.Exp Hematol.1976;4(5):267-274.

2.PittengerMF,MackayAM,BeckSC,etal.Multilineagepotentialofadulthumanmesenchymalstemcells.Science.1999;284(5411):143-147.

3.DeansRJ,MoseleyAB.Mesenchymalstemcells:biologyandpotentialclinicaluses.Exp Hematol.2000;28(8):875-884.

4.BakshD,SongL,TuanRS.Adultmesenchymalstemcells:characterization,differentiation,andapplicationincellandgenetherapy.J Cell Mol Med.2004;8(3):301-316.

5.LinZ,WillersC,XuJ,ZhengMH.Thechondrocyte:biologyandclini-calapplication.Tissue Eng.2006;12(7):1971-1984.

6.LeeOK,KuoTK,ChenWM,LeeKD,HsiehSL,ChenTH.Isolationofmultipotentmesenchymalstemcellsfromumbilicalcordblood.Blood.2004;103(5):1669-1675.

7.KoglerG,SenskenS,AireyJA,etal.Anewhumansomaticstemcellfromplacentalcordbloodwithintrinsicpluripotentdifferentiationpoten-tial.J Exp Med.2004;200(2):123-135.

figure 4. RabbittypeIIcollagenandmatrixmetallopeptidase13(MMP13)geneexpressioninrabbitorganculturebyreal-timePCR.After1monthofculture,RNAwasisolatedfromrabbitdisktransplantedwithstemcellsandcomparedtoRNAfromthenoninjecteddisk.Real-timePCRwasperformedusingTaqmanassaysspecificforrabbittypeIIcollagen(leftpanel)andrabbitmatrixmetallopeptidase13(rightpanel).Errorbarsindicatethestandarddeviation.

fold

dif

fere

nce

0

0.5

1

1.5

2

2.5


rabbit type ii collagen

fold

dif

fere

nce

0

1

2

3

4


rabbit mmp13

0.5

1.5

2.5

3.5

4.5


8.BiebackK,KernS,KlüterH,EichlerH.Criticalparametersfortheisolationofmesenchymalstemcellsfromumbilicalcordblood.Stem Cells.2004;22(4):625-634.

9.LeeMW,ChoiJ,YangMS,etal.Mesenchymalstemcellsfromcryo-preservedhumanumbilicalcordblood.Biochem Biophys Res Commun.2004;320(1):273-278.

10.KurtzbergJ,LaughlinM,GrahamML,etal.Placentalbloodasasourceofhematopoieticstemcellsfortransplantationintounrelatedrecipients.N Engl J Med.1996;335(3):157-166.

11.WagnerJE,RosenthalJ,SweetmanR,etal.SuccessfultransplantationofHLA-matchedandHLA-mismatchedumbilicalcordbloodfromunre-lateddonors:analysisofengraftmentandacutegraft-versus-hostdisease.Blood.1996;88(3):795-802.

12.GluckmanE.Tenyearsofcordbloodtransplantation:frombenchtobedside.Br J Haematol.2009;147(2):192-199.

13.KimSW,HanH,ChaeGT,etal.Successfulstemcelltherapyusingumbilicalcordblood-derivedmultipotentstemcellsforBuerger’sdiseaseandischemiclimbdiseaseanimalmodel.Stem Cells.2006:24(6):1620-1626.

14.KangKS,KimSW,OhYH,etal.A37-year-oldspinalcord-injuredfemalepatient,transplantedofmultipotentstemcellsfromhumanUC

blood,withimprovedsensoryperceptionandmobility,bothfunctionallyandmorphologically:acasestudy.Cytotherapy.2005;7(4):368-373.

15.AmericanAcademyofOrthopaedicSurgeons.Burden of Mus-culoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost.Rosemont,IL:AmericanAcademyofOrthopaedicSurgeons;2008.

16.AndersonDG,TannouryC.Molecularpathogenicfactorsinsymp-tomaticdiscdegeneration.Spine J.2005;5(6)(suppl):260S-266S.

17.GruberHE,HanleyENJr.Analysisofaginganddegenerationofthehumanintervertebraldisc:comparisonofsurgicalspecimenswithnormalcontrols.Spine (Phila Pa 1976).1998;23(7):751-757.

18.KangJD,GeorgescuHI,McIntyre-LarkinL,Stefanovic-RacicM,DonaldsonWFIII,EvansCH.Herniatedlumbarintervertebraldiscsspontaneouslyproducematrixmetalloproteinases,nitricoxide,interleu-kin-6,andprostaglandinE2.Spine (Phila Pa 1976).1996;21(3):271-277.

19.KangJD,GeorgescuHI,McIntyre-LarkinL,Stefanovic-RacicM,EvansCH.Herniatedcervicalintervertebraldiscsspontaneouslyproducematrixmetalloproteinases,nitricoxide,interleukin-6,andprostaglandinE2.Spine (Phila Pa 1976).1995;20(22):2373-2378.

20.GruberHE,IngramJA,HanleyENJr.ImmunolocalizationofMMP-19inthehumanintervertebraldisc:implicationsfordiscaginganddegeneration.Biotech Histochem.2005;80(3-4):157-162.

20

AdvancesinAnteriorCruciateLigamentReconstruction:AQuarterCenturyofInnovationatRushUniversityMedicalCenter

MiChAeL B. eLLMAn, MD; riChArD C. MATher iii, MD; seTh L. sherMAn, MD; BernArD r. BACh Jr, MD

author affiliations

DepartmentofOrthopedicSurgery(DrEllman),andDivision

ofSportsMedicine,DepartmentofOrthopedicSurgery

(DrsMather,Sherman,andBach),RushUniversityMedical

Center,Chicago,Illinois.


BernardR.BachJr,MD;RushUniversityMedicalCenter,

1611WHarrisonSt,Suite300,Chicago,IL60612

([email protected]).

introduction

Anteriorcruciateligament(ACL)reconstructioniswidely

acceptedasthetreatmentofchoiceforpatientswithfunctional

instabilityduetoanACL-deficientknee.Itiscurrentlyestimated

thatmorethan100000primaryACLreconstructions(ACLRs)

areperformedannuallyintheUnitedStates.1Since1986,the

seniorauthor(B.R.B.Jr)hasperformedover2000primaryand

revisionACLreconstructions.Duringthistime,researchatRush

onACLinjuryhasresultedin120peer-reviewedpublications,

46bookchapters,and12monographsandtextbooksauthored

ontopicsspecifictotheACL(Table1).Clinicaldiagnosis,surgical

treatment,andpostoperativemanagementofACLrupturehave

evolvedconsiderably,resultinginpredictablyexcellentclinical

resultsfollowingACLRwithhighpatientsubjective

satisfactionscores.

AtRush,abundantresearchdedicatedtoanimprovedunder-

standingofthebasicanatomy,biomechanics,graftcharacteris-

ticsandfunction(includinggraftfixation,healing,tensioning,

andremodeling),andsurgicaltechniquerelatedtotheACLhas

resultedinimprovedclinicaloutcomesanddecreasedpostoperative

morbidity.Further,agreaterunderstandingoftheoptimaltiming

forsurgery,coupledwithanemphasisonaggressivepostopera-

tiverehabilitationincludingpatellarmobilization,hyperextension

recovery,andfullweightbearing,hashelpedprovidetheframe-

workforACLtreatmenttoday.Whileathoroughoverviewofthe

extensivecontributionsfromRushtotheACLliteratureisbeyond

thescopeofthisreview,wewillsummarizemanyofthemajor

advancesinACLR,emphasizingtheinfluenceofRushduringthe

past25years(Table1).

from the laboratory to clinical practice

AgreaterunderstandingoftheACLatitsmostbasiclevelhas

allowedforsignificantadvancesinclinicaldiagnosisandman-

agement.Anatomically,theACLisanintra-articularstructure

originatingfromthemedialaspectoftheposteriorlateralfemoral

condyleandinsertingontothetibialplateaubetweentheanterior

hornsofthemedialandlateralmenisci.2,3Itiscomposedofan

anteromedialbundleandaposterolateralbundlethatfunction

topreventanteroposteriorandrotatoryinstability,respectively.

EarlybiomechanicalgaitanalysisstudiesatRushdemonstrateda


“ovEr thE past quartEr cEntury at rush, anatomic, biomEchanical, and clinical studiEs

havE pavEd thE way for vast improvEmEnts in diagnosis, surgical trEatmEnt, and

postopErativE rEhabilitation of patiEnts with acl dEficiEncy.”

pivotalroleoftheACLinthegaitcycle,asACL-deficient(ACLD)

patientsdevelop“quadavoidance”and“hamstringoveruse”gait

abnormalities.4,5Thesepatternswerefoundtobeincreasinglytime-

dependentandadoptedbythecontralateralnormalkneeaswell,

significantlyaffectingthepatient’sgaitcycle.AfterACLR,how-

ever,gaitpatternsreturnedtonormal.Otherstudiesevaluatedthe

dynamicaspectsoftheACLDandACL-reconstructedkneeincut-

tingandcrosscuttingmaneuversandhelpedtopredictthenatural

historyofACLruptureovertime.6,7Furthercollaborationwiththe

biomechanicaldepartmentresultedinextensiveresearchanalyzing

table 1. SummaryofRushResearchonACLTreatmentOver25Years


Anatomic Footprint study of the ACl Femoral insertion

Avoiding Complications in ACl surgery

Biomechanical Aspects of hamstring graft Fixation

Biomechanical Aspects of interference screw Diversion

Biomechanical Aspects of interference screw Fixation

Biomechanical Aspects of low-Dose irradiated Allografts

Biomechanical Aspects of Multiple Freeze-thaw Cycles on Bone–Patellar tendon–Bone (BtB) Allografts

Biomechanical Aspects of screw Post versus Free Bone Block Fixation for graft tunnel Mismatch

Biomechanical Comparison of outside-in and inside-out interference screw Fixation

Biomechanical Comparisons of 1-, 2-, and 4-strand hamstring grafts on Fixation

Charge Comparisons of outpatient versus inpatient ACl surgery

Do smaller tibial tunnel sizes impact Ability to Perform Anatomic ACl reconstruction?

Dynamic Function Following ACl surgery: Biomechanical gait Analysis

effects of ACl injury on gait Analysis

effects of Donor Age on Bone Mineral Density in BtB Allografts

Functional gait Adaptation over time

gait Analysis Following ACl reconstruction

illustrated history of ACl surgery

intra-articular Biochemical Markers in ACl injury

kt1000 Assessment of Autografts versus Allografts: Do grafts stretch During the First Year?

kt1000 Comparison of ACl-Deficient Patients Awake versus examination under Anesthesia (euA)

kt1000 Parameters of ACl reconstruction

Management of Partial ACl injuries

Management of tunnel Malposition and expansion in revision ACl surgery

Meta-analysis of Patellar tendon versus hamstring grafts

Magnetic resonance imaging (Mri) Correlation of Patient height and Patellar tendon length: implications for sizing Allografts to reduce graft tunnel Mismatch

neural Anatomy of the ACl

Pearls and Pitfalls of BtB graft harvest

Perioperative Pain and Analgesic usage Following outpatient ACl surgery

Primary Bone grafting of the Distal Patellar Defect

radiographic observations of interference screw Morphologies

recognition of Posterior wall Blowout: techniques for Avoidance, recognition, and treatment

revision ACl surgery: technical Considerations

strategies for successful outpatient surgery

surgical results in the skeletally immature Adolescent using hamstring Allografts

surgical results of ACl reconstruction in Patients over the Age of 35

surgical results of ACl reconstruction in the worker’s Compensation Patient Population

surgical results of ACl reconstruction: gender Comparisons

surgical results of endoscopic ACl reconstruction: Minimum 2-Year Follow-up

surgical results of revision ACl reconstruction

surgical results of 2-incision Arthroscopic ACl reconstruction: Minimum 2-Year Follow-up

surgical technique of ACl reconstruction in the skeletally immature Adolescent

surgical techniques of Arthroscopic-Assisted ACl reconstruction: 2-incision technique

surgical techniques of endoscopic ACl reconstruction

systematic review of single-Bundle ACl reconstruction outcomes

treatment of Arthrofibrosis Following ACl surgery

treatment of Patellar tendon rupture Following ACl BtB reconstruction

22

severalaspectsofACLgraftfixation,includingtheeffectsofinter-

ferencescrewfixationonfailurecharacteristics,8,9outside-inversus

inside-outscrewfixation,10freeboneblockfixationcomparedto

traditionalscrewpostfixation,8graftrotationonultimateand

cyclicloading,11,12theuseof1-,2-,and4-strandedallografts,13the

effectsoffreeze-thawcyclesongrafts,14andtheeffectsofdonorage

onbonemineraldensityinirradiated(1mR)allografts.15

Clinically,itiswidelyrecognizedthatthemostcommonreason

forACLfailurefollowingprimaryACLRistechnicalerrordueto

improperplacementofthetibialorfemoraltunnel.Overthepast

25years,agreateremphasishasbeenplacedonpreciseanatomic

tibialandfemoraltunnelplacement,aswellasonachievingthe

properorientationofthetunnelsinboththecoronalandsagittal

planes.Failuretore-createnativeanatomywithpropertunnelpo-

sitionmayleadtoimpingementorrotationalinstabilityresulting

inlossofmotionand/orsubsequentgraftfailure.Withthehelpof

theanatomydepartment,orthopedicresearchersatRushpublished

severalstudiesthatmorepreciselyidentifiedtheideallocationof

thetibialandfemoralfootprintsforpropertunnelplacement.2,3

Rueetalsuggestedthattheideallocationofthefemoraltunnelis

inthe“overthetop”position,laterallyrotatedwiththetipofthe

aimerat1:30or2o’clockfortheleftkneeand10o’clockor10:30

fortherightknee.Inthisposition,cadavericstudiesrevealed

thata10-mmfemoraltunnelwillfillapproximately50%ofthe

posterolateralbundleand50%oftheanteromedialbundlefoot-

prints,decreasingtheriskofgraftfailure.2,3Morerecently,robotic

technologyhasbeenemployedatRushtostudytheexactanatomic

originandinsertionsoftheACLinthefemurandtibia,assessthe

feasibilityof“anatomic”transtibialtechniques,anddetermineif

smallertibialtunnels(eg,7mm)asusedforhamstringACLRcan

targetthecenterofthefemoralsiteorigin.

advances in diagnosis of acl injury: kt1000

arthrometer observations

TheKT1000arthrometer(MEDmetric,SanDiego,California),

aninstrumenteddeviceforassessinganterior-posteriortranslations

oftheknee,hasbeenusedexclusivelyinACL-injuredandrecon-

structedkneesatRush.Althoughthisdevicedoesnotquantitate

rotation,ithasproveninvaluableinthediagnosisofACLDand

hasobjectifiedourpostoperativeoutcomes.UsingtheKT1000,

wehavedemonstratedthat98%ofnormalkneeshavelessthan10

mmofanteriortranslationandlessthana3mmside-to-sidedif-

ference(STSD)comparedtothecontralateralknee.16Incontrast,

thevastmajorityofACL-injuredpatientshavegreaterthan10

mmoftranslationandmorethana3-mmSTSD,allowingfor

moreaccuratediagnosisofACLinjuryclinically.Further,inclini-

calstudiesfollowingbothautograftandallograftACLRatRush,

highlysignificantreductionsintheseabnormalparameterswere

notedsuchthatatfollow-up,lessthan4%ofpatientshadarthro-

metriccharacteristicsoffailure(>5-mmSTSD).17Wehavealso

demonstratedthatthereisnosignificanttime-relatedattenuation

intranslationsbetween6weeksand1yearpostoperativelyamong

bone–patellartendon–bone(BTB)allograftandautograft.17

graft choice in the acl-deficient patient at rush

Since1986,thecentralthirdofthepatellartendon,orBTBau-

tograft,hasbeenthebenchmarkgraftchoiceforACLRinyoung,

activepatientsatRush.Itisreadilyavailable,allowsstablefixation

withbone-to-bonehealingwithinthegrafttunnelforinterfer-

encescrewfixation,isstrongerthanthenormalACL,andallows

forearlyandmoreaggressivepostoperativerehabilitation.18,19In

addition,allograftshavegainedtremendouslyinpopularityover

thepastdecadeandareusedincertaincircumstances,suchasfor

multipleligamentinjuries,afterpreviousfailedsurgery(revisions),

andinolderpatientswithorwithoutdegenerativejointdisease.20

Improvementsinallograftsafety,availability,anddurableclinical

results,coupledwithminimummorbidityandaquickerrecovery,

ledtothesignificantincreaseinitsusage,particularlyinolderpa-

tients.Despitetheriskofdiseasetransmissionandincreasedcosts,

allograftuseintheelderlyhasincreasedsignificantlyduetohigh

ratesofsatisfaction,decreaseddonorsitemorbidity,andaquicker

postoperativerehabilitationcourse.From1986to1991,1%ofall

primaryACLpatientsreceivedanallograftatRush.Atsubsequent

5-yearintervals,theratesofallograftusagehaveincreasedfrom1%

to3%,13%,34%,andover50%,respectively.20Age,patientsize,

andactivitylevelimpactourgraftrecommendations.Inpatients

under20,thevastmajorityreceiveaBTBautograft,whereasabout

50%ofpatientsintheir20s,65%ofpatientsintheir30s,and

nearlyallpatientsover40yearsofagereceiveanACLallograftfor

reconstruction.Usingautograftsinolderpatientshasresultedin

increaseddonorsitemorbidityandexacerbationofpaininpatients

withpreexistingpatellofemoraldiseaseordegenerativejointdis-

ease,aswellasamoredifficultpostoperativerehabilitationcourse;

therefore,weprefertouseallograftsinthispatientpopulation.

arthroscopic-assisted transtibial approach:

clinical studies

Beginningintheearly1980swiththeadventofarthroscopy,

ACLRsurgicaltechniquesquicklyevolvedfromopenarthrotomies

tolessinvasivearthroscopic-assistedintra-articularACLRutiliz-

ingfreeBTBandhamstringgraftspassedthroughappropriate

bonetunnels.Manyoftheprinciplesthathavebecomestandard

reconstructiontechniquestodayweredevelopedinthe1980s

and1990s,andsurgeonsatRushwereattheforefrontofthis

evolution.Between1986and1991,surgeonsatRushperformed

arthroscopic-assistedACLRsusinga2-incisionapproach.One

incisionwasmadeovertheanteriortibiafordrillingofthetibial

tunnelfromoutsidein,andasecondincisionwasmadeoverthe

lateralaspectofthelateralfemoralcondylefordrillingofthefemo-

raltunnelfromoutsidein.Bachandcolleaguespublishedboth

short-term(2-4years)21andintermediate-term(5-9years)22results

inclinicaloutcomestudiesofpatientswhounderwentACLRwith

thistechnique.Ataminimum5-yearfollow-up,90%ofpatients

hadclinicallystablekneesonexamination(Lachmantest,pivot

shifttest),95%hadobjectivelystableknees(KT1000arthrometer

testing),and94%hadsubjectivesatisfactionwiththeoperative

result.22Functionaltestingdemonstratedlessthan2%difference

comparedtothecontralateralside,witha2%reoperationrate.In-

terestingly,thisgroupofpatientshadareported15%incidenceof

flexioncontracturewithin2-4yearswitha10%reoperationrate,

andthisincidenceincreasedto28%whentheywerereevaluatedat

5-and9-yearfollow-upwitha12%reoperationrate.22

Thehighratesofkneeflexioncontracturesandtheadditional

surgicalmorbidityofasecondincisioninthe2-incisionapproach

ledtothedevelopmentofasingle-incisionarthroscopic-assisted

endoscopictechniqueallowingforintra-articulardrillingofthe

femoraltunnel.Thistechnique,initiallyperformedatRushin

1991,utilizesanobliquelyorientedtranstibialapproachinan

efforttoplacealateralizedfemoraltunnelwithintheintercondylar

notch.23Usingthisnovelapproach,Bachetalreportedagreater

than90%successrateforkneestabilitybyphysicalexamination

and95%byobjectivequantification(KT1000arthrometertesting)

usingpatellartendonautograftwithoutextra-articularaugmenta-

tionafter2years.24Functionaltestsshowed4%to6%differences

inside-to-sidecomparisonsforfunctionaltesting,andtherewasa

5%reoperationrateforminormotionproblems(flexioncontrac-

ture,retears).Mostrecently,withtheemphasisonearlyextension

ofthekneeandaggressivepostoperativemotionprotocols,this

reoperationratedecreasedto2%.1Additionalclinicalfollow-up

studieshaveevaluatedsubgroupsofACLRpatientsincluding

thoseovertheageof35,25maleversusfemalepatients,26skeletally

immaturepatients,27revisionACLpatients,28andprimaryallograft

ACLpatients,29allwithexcellentclinicalresults.Thetranstibial

techniquehasbeenthepreferredapproachtoACLRatRush,as

wellasnationallyandinternationally,fornearly20years.

ResearchersatRushhaveauthoredmyriadmanuscripts,book

chapters,andmonographsfocusingonsurgicaltechniquesof

2-incision,single-incision,andallograftreconstructions,aswellas

ACLRoftheskeletallyimmaturepatient.

the rush influence on acl graft tunnel placement

Anteriorfemoraltunnelplacementrisksimpingementofthegraft

inextension,causinglossofmotionandsubsequentgraftfailure.

Verticalfemoraltunnelplacementprovidesequivalentanterior-

posteriorstabilityonsimulatedLachmantestingbutislessable

tocontrolrotationalstabilitythanthosetunnelsdrilledatamore

obliqueangle.Therefore,wehypothesizedthataposteriorand

obliqueorientationofthegraftinthesagittalandcoronalplanes,

respectively,ispreferable.Toachievethisgoal,wecreatedanacces-

sorytranspatellarportaltoallowforamoreobliquetibialtunnel,

permittingtheplacementofthefemoraltunnelfartherdownon

thelateralwalltoavoidverticaltunnelplacementandcreating

alongertibialtunneltoavoidgraft-tunnelmismatch.30Recent

robotictechnologyhasalsobeenusedtoassessthefeasibilityof

thetranstibialtechniquetoplaceagraftanatomicallyand

revealedthatusingasmallertibialtunnel(eg,hamstring7-mm

tibialtunnel)mayprecludeanatomicplacementwhendrillingin

atranstibialfashion.

Early pioneers in outpatient acl surgery

ResearchersatRushwereamongthefirsttoelucidatewhethersig-

nificanthealthcaresavingscouldresultfromaquickerpostopera-

tiverecoveryperiodenabledwhenusingtheendoscopictranstibial

techniqueinanoutpatientsetting.Novaketal31andNogalski

etal32atRushanalyzedthecorrelationbetweenhospitalcosts,

proceduresetting,andlengthofstayforACLR.Inamatched

comparisonof2patientgroupsassessingtherelationshipbetween

healthcarecostsandproceduresetting,surgeonsatRushreported

asignificantchargedifferencebetweenidenticalproceduresper-

formedin2differentsettings,themainhospitalandtheoutpatient

surgicenter,aschargesforthesurgicentergroupaveraged$7390

(range,$3679to$12202)lessthanthehospitalgroup.Consistent

performanceofACLRonanoutpatientbasisatRushsince1993

hascreatedconsiderablecostsavings,allowingthemedicalcenter

tooptimizesocietalresourceutilization.

postoperative acl rehabilitation at rush

PerhapsthegreatestchangeinthemanagementofACLinjuries

overthepast30yearsinvolvesrehabilitation.Intheearly1980s,

rehabilitationprotocolsafterACLRinvolvedprolongedperiods

ofimmobilizationandlimitedweightbearingontheoperative

extremity.From1986to1993atRush,continuouspassivemo-

tionmachineswerearoutinepartofourrehabilitationprotocol

butresultedinahighincidenceofpostoperativearthrofibrosis.

Beginninginthelate1970sandearly1980s,Noyesetalfirst

recognizedtheadverseeffectsofpostoperativeimmobilizationon

kneeligamentsinhumans.33Inthelate1980s,Shelbourneand


24

Nitzreportedonaprotocolofimmediatefullweightbearingand

unrestrictedrangeofmotion(“acceleratedrehabilitation”),aswell

asreturntosportsbyasearlyas4to6monthspostoperatively.34

Subsequently,Beynnonetalreportedtheresultsofaprospective,

randomized,double-blindtrialofacceleratedversustraditional

postoperativerehabilitationprotocolsfollowingautogenousBTB

ACLR.35Thisstudyshowednodifferencesbetweenthe2groups

atanytimepointregardingKT1000measurements,subjective

outcomescores,orsingle-leggedhoptestanddemonstrateda

statisticallysignificantreductionintimerequiredforunrestricted

returntoplayintheacceleratedgroup.

AtRush,wehaveobservedthatthegreatestpredictorof

postoperativerangeofmotionispreoperativemotion,sosurgery

istypicallydelayeduntilfullpreoperativemotionisachieved.

time period protocol

Preoperative goals: Communicate expectations, normalize range of motion (roM), reduce inflammation and edema, eliminate antalgic gait.

weeks 1-6 weight bearing as tolerated without assist by postoperative day 10. (period of protection) hinged knee braces - BtB or hamstring graft: locked in extension when sleeping/ambulating until week 6. - Allograft: May discontinue immobilizer after 10-14 days.

roM: Progress through passive, active, and resisted roM as tolerated. extension board and prone hang with ankle weights (up to 10 lb) recommended. stationary bike with no resistance for knee flexion (alter set height as roM increases).

goal: Full extension by 2 weeks, 120 degrees of flexion by 6 weeks.

Patellar mobilization: 5-10 minutes daily.

strengthening: Quad sets, straight leg raises (slrs) with knee locked in extension. Begin closed chain work (0-45 degrees) when full weight bearing. no restrictions to ankle/hip strengthening.

weeks 6-12 transition to custom ACl brace if ordered by the physician.

roM: Continue with daily roM exercises.

goal: increase roM as tolerated.

strengthening: increase closed chain activities to 0-90 degrees. Add pulley weights, bands, etc. Monitor for anterior knee pain symptoms. Add core strengthening exercises.

Add side lunges and/or slideboard. Add running around 8 weeks when cleared by physician.

Continue stationary bike and biking outdoors for roM, strengthening, and cardio.

weeks 12-18 Advance strengthening as tolerated, continue closed chain exercises. increase resistance on equipment.

initiate agility training (figure 8s, cutting drills, quick start/stop, etc.).

Begin plyometrics and increase as tolerated.

Begin to wean patient from formal supervised therapy, encouraging independence with home exercise program.

table 2. Authors’ACLRRehabilitationProtocol

Postoperatively,ourpatientsparticipateinanearly,aggressive

rehabilitationprogramthatgraduatespatientsinalogicalfashion

overa4-to6-monthperiod.WhileweunderstandthatanACLR

maytake6monthsto1year(dependentupongraftsource)before

completegraftincorporationandremodeling,wehavealsoshown

thatrigidinitialgraftfixationallowsforimmediate,fullweight

bearing,rangeofmotionastoleratedwithanemphasisoncom-

pletehyperextensionrecovery,andearlyinitiationofclosedkinetic

chainexercisesinsteadofisokineticexercises(Table2).Thistype

ofacceleratedrehabilitationprogramhasprovenbothsafeand

efficacious,returningthemajorityofourathletestounrestricted

playby4-6monthspostoperatively.Wehaverecentlyobserved

thatthepersonalrevisionrateforoursurgeonsperformingACLR

was1.8%(43/2400)overan8-yeartimeperiod.

conclusion

OverthepastquartercenturyatRush,anatomic,biomechanical,

andclinicalstudieshavepavedthewayforvastimprovements

indiagnosis,surgicaltreatment,andpostoperativerehabilitation

ofpatientswithACLdeficiency.Thesechangeshaveresulted

inpredictablyexcellentfunctionalandclinicalresultsthathave

withstoodthetestoftime.Aswetransitionintothenextdecade,

ongoingresearchwillguidesurgeonsatRushasleadersinthe

managementofACLdeficiencyforyearstocome.

references

1.LewisPB,ParameswaranAD,RueJP,BachBRJr.Systematicreviewofsingle-bundleanteriorcruciateligamentreconstructionoutcomes:abaselineassessmentforconsiderationofdouble-bundletechniques.Am J Sports Med.2008;36(10):2028-2036.

2.RueJP,GhodadraN,BachBRJr.Femoraltunnelplacementinsingle-bundleanteriorcruciateligamentreconstruction:acadavericstudyrelatingtranstibiallateralizedfemoraltunnelpositiontotheanteromedialandposterolateralbundlefemoraloriginsoftheanteriorcruciateligament.Am J Sports Med.2008;36(1):73-79.

3.RueJP,GhodadraN,LewisPB,BachBRJr.Femoralandtibialtunnelpositionusingatranstibialdrilledanteriorcruciateligamentreconstruc-tiontechnique.J Knee Surg.2008;21(3):246-249.

4.WexlerG,HurwitzDE,Bush-JosephCA,AndriacchiTP,BachBRJr.Functionalgaitadaptationsinpatientswithanteriorcruciateligamentdeficiencyovertime.Clin Orthop Relat Res.1998;(348):166-175.

5.PatelRR,HurwitzDE,Bush-JosephCA,BachBRJr,AndriacchiTP.Comparisonofclinicalanddynamickneefunctioninpatientswithante-riorcruciateligamentdeficiency.Am J Sports Med.2003;31(1):68-74.

6.HurwitzDE,AndriacchiTP,Bush-JosephCA,BachBRJr.FunctionaladaptationsinpatientswithACL-deficientknees.Exerc Sport Sci Rev.1997;25:1-20.

7.BerchuckM,AndriacchiTP,BachBR,ReiderB.Gaitadaptationsbypatientswhohaveadeficientanteriorcruciateligament.J Bone Joint Surg Am.1990;72(6):871-877.

8.NovakPJ,WexlerGM,WilliamsJSJr,BachBRJr,Bush-JosephCA.Comparisonofscrewpostfixationandfreeboneblockinterferencefixationforanteriorcruciateligamentsofttissuegrafts:biomechanicalconsiderations.Arthroscopy.1996;12(4):470-473.

9.DworskyBD,JewellBF,BachBRJr.Interferencescrewdivergenceinendoscopicanteriorcruciateligamentreconstruction.Arthroscopy.1996;12(1):45-49.

10.BryanJM,BachBRJr,Bush-JosephCA,FisherIM,HsuKY.Comparisonof“inside-out”and“outside-in”interferencescrewfixa-tionforanteriorcruciateligamentsurgeryinabovineknee.Arthroscopy.1996;12(1):76-81.

11.BerksonE,LeeGH,KumarA,VermaN,BachBRJr,HallabN.Theeffectofcyclicloadingonrotatedbone-tendon-boneanteriorcruciateliga-mentgraftconstructs.Am J Sports Med.2006;34(9):1442-1449.

12.VermaN,NoerdlingerMA,HallabN,Bush-JosephCA,BachBRJr.Effectsofgraftrotationoninitialbiomechanicalfailurecharacteristicsofbone-patellartendon-boneconstructs.Am J Sports Med.2003;31(5):708-713.

13.ParkDK,FogelHA,BhatiaS,etal.Tibialfixationofanteriorcruciateligamentallografttendons:comparisonof1-,2-,and4-strandedcon-structs.Am J Sports Med.2009;37(8):1531-1538.

14.LeeGH,KumarA,BerksonE,VermaN,BachBRJr,HallabN.Abiomechanicalanalysisofbone-patellartendon-bonegraftsafterrepeatfreeze-thawcyclesinacyclicloadingmodel.J Knee Surg.2009;22(2):111-113.

15.KangRW,StraussEJ,BarkerJU,BachBRJr.Effectofdonorageonbonemineraldensityinirradiatedbone-patellartendon-boneallograftsoftheanteriorcruciateligament. Am J Sports Med.2011;39(2):380-383.

16.BachBRJr,WarrenRF,FlynnWM,KrollM,WickiewieczTL.Ar-thrometricevaluationofkneesthathaveatornanteriorcruciateligament.J Bone Joint Surg Am.1990;72(9):1299-1306.

17.BachBRJr,JonesGT,HagerCA,SweetFA,LuergansS.Arthrometricresultsofarthroscopicallyassistedanteriorcruciateligamentreconstruc-tionusingautograftpatellartendonsubstitution.Am J Sports Med.1995;23(2):179-185.

18.PiaseckiDP,BachBRJr.Anatomicalsingle-bundleanteriorcruciateligamentreconstructionwithatranstibialtechnique.Am J Orthop(Belle Mead NJ).2010;39(6):302-304.

19.NedeffDD,BachBRJr.Arthroscopicanteriorcruciateligamentreconstructionusingpatellartendonautografts:acomprehensivereviewofcontemporaryliterature.Am J Knee Surg.2001;14(4):243-258.

20.BusamML,RueJP,BachBRJr.Fresh-frozenallograftanteriorcruciateligamentreconstruction.Clin Sports Med.2007;26(4):607-623.

21.BachBRJr,JonesGT,SweetFA,HagerCA.Arthroscopy-assistedan-teriorcruciateligamentreconstructionusingpatellartendonsubstitution:two-tofour-yearfollow-upresults.Am J Sports Med.1994;22(6):758-767.

22.BachBRJr,TradonskyS,BojchukJ,LevyME,Bush-JosephCA,KhanNH.Arthroscopicallyassistedanteriorcruciateligamentreconstruc-tionusingpatellartendonautograft:five-tonine-yearfollow-upevalua-tion.Am J Sports Med.1998;26(1):20-29.

23.HardinGT,BachBRJr,Bush-JosephCA,FarrJ.Endoscopicsingle-incisionanteriorcruciateligamentreconstructionusingpatellartendonautograft:surgicaltechnique.1992[classicalarticle].J Knee Surg.2003;16(3):135,144;discussion145-147.


26

24.BachBRJr,LevyME,BojchukJ,TradonskyS,Bush-JosephCA,KhanNH.Single-incisionendoscopicanteriorcruciateligamentreconstructionusingpatellartendonautograft:minimumtwo-yearfollow-upevaluation.Am J Sports Med.1998;26(1):30-40.

25.NovakPJ,BachBRJr,HagerCA.Clinicalandfunctionaloutcomeofanteriorcruciateligamentreconstructionintherecreationalathleteovertheageof35.Am J Knee Surg.1996;9(3):111-116.

26.FerrariJD,BachBRJr,Bush-JosephCA,WangT,BojchukJ.Anteriorcruciateligamentreconstructioninmenandwomen:anoutcomeanalysiscomparinggender.Arthroscopy.2001;17(6):588-596.

27.PavlovichRJr,GoldbergSH,BachBRJr.AdolescentACLinjury:treatmentconsiderations.J Knee Surg.2004;17(2):79-93.

28.FoxJA,PierceM,BojchukJ,HaydenJ,Bush-JosephCA,BachBRJr.Revisionanteriorcruciateligamentreconstructionwithnonirradiatedfresh-frozenpatellartendonallograft.Arthroscopy.2004;20(8):787-794.

29.BachBRJr,AadalenKJ,DennisMG,etal.Primaryanteriorcruciateligamentreconstructionusingfresh-frozen,nonirradiatedpatellartendonallograft:minimum2-yearfollow-up.Am J Sports Med.2005;33(2):284-292.

30.BachBRJr,AadalenKJ,MazzoccaAD.Anaccessoryportalforposteriorcruciateligamenttibialinsertionvisualization.Arthroscopy.2004;20(suppl2):155-158.

31.NovakPJ,BachBRJr,Bush-JosephCA,BadrinathS.Costcontain-ment:achargecomparisonofanteriorcruciateligamentreconstruction.Arthroscopy.1996;12(2):160-164.

32.NogalskiMP,BachBRJr,Bush-JosephCA,LuergansS.Trendsindecreasedhospitalizationforanteriorcruciateligamentsurgery:double-incisionversussingle-incisionreconstruction.Arthroscopy.1995;11(2):134-138.

33.NoyesFR,MangineRE,BarberS.Earlykneemotionafteropenandarthroscopicanteriorcruciateligamentreconstruction.Am J Sports Med.1987;15(2):149-160.

34.ShelbourneKD,NitzP.Acceleratedrehabilitationafteranteriorcruci-ateligamentreconstruction.Am J Sports Med.1990;18(3):292-299.

35.BeynnonBD,UhBS,JohnsonRJ,etal.Rehabilitationafteranteriorcruciateligamentreconstruction:aprospective,randomized,double-blindcomparisonofprogramsadministeredover2differenttimeintervals.Am J Sports Med.2005;33(3):347-359.

ExtranodalRosai-DorfmanDiseaseWithIsolatedOsseousInvolvement:AnUnusualCase

riChArD W. kAng, MD; kevin C. MCgiLL, MPh; JohnnY Lin, MD;

MiCheLLe e. CoLLier, MD; sTeven giTeLis, MD

author affiliations

SectionofOrthopedicOncology,DepartmentofOrthopedic

Surgery,RushUniversityMedicalCenter,Chicago,Illinois.


RichardW.Kang,MD;RushUniversityMedicalCenter,



introduction

In1969RosaiandDorfmandescribedsinushistiocytosiswith

massivelymphadenopathy(SHML),ararenon-neoplasticdisorder

involvinghistiocytes,ofunknownetiology.1Thetermsinushistio-

cytosisreferstohistiocytosisthatoccursinthedistendedsinuses

oflymphnodes.MostoftheliteraturereferstoSHMLasRosai-

Dorfmandisease(RDD),aconventionwefollowinthispaper.

RDDmostcommonlypresentsasbilateral,nontender,painless

enlargedlymphnodesintheneck,whichmaybeaccompaniedby

fever,elevatedsedimentationrate,weightloss,andimmunologi-

calabnormalitiessuchasleukocytosis,polyclonalhypergamma-

globulinemia,andanemia.Lessfrequentlyinvolvednodalsitesare

mediastinal,hilar,retroperitoneal,axillary,andinguinal(allinthe

30%-50%range).2-5ExtranodalRDDoccursin43%ofpatients,

with23%experiencingisolatedextranodaldisease.6

Oftheapproximately1000patientsreportedintheliterature,2,3,5

lessthan3%presentedwithisolatedosseousinvolvement.6Inthe

registryof423patientsreportedbyFoucaretal,8%hadbone

involvement,2%hadboneinvolvementwithoutlymphadenopa-

thy,andapproximately0.5%hadisolatedboneinvolvement.6The

skullisthemostcommonlocationofasolitarybonelesion.7

Histiocytecells,partoftheimmunesystem,aresometimes

referredtoastissuemacrophages.Theyhaveaneosinophilic

cytoplasmandhaveanumberoflysosomes.Theirmainfunctions

involvephagocytosisandantigenpresentation.Otherdiseasesthat

havehistiocytosisincludeLangerhanscellhistiocytosis(which

mayalsobereferredtoasoneofthefollowingvariants:eosino-

philicgranuloma,Hand-Schüller-Christiandisease,orLetterer-

Siwedisease)andhemophagocyticlymphohistiocytosis.Clinical

manifestationsofLangerhanscellhistiocytosismayincludesingle

ormultiplebonelesion(s),exophthalmos,diabetesinsipidus,

visceralorskinlesions,fever,hepatosplenomegaly,anemia,bacte-

rialinfections,orlymphadenopathy.Thehistologicappearanceof

Langerhanscellhistiocytosisincludesaneosinophiliccytoplasm,

apolymorphousmixofinflammatorycells,andLangerhans

histiocytes(cellswith“bean-shaped”nuclei,crispnuclearmem-

brane,finelystippledchromatinpattern,abundantpale/eosino-


“this is thE only casE in thE litEraturE of [rosai-dorfman disEasE] of thE talus without

involvEmEnt of lymph nodEs and adJacEnt structurEs. it is also thE only casE in thE

litEraturE trEatEd with surgical Excision of thE lEsion.”


28

figure 1. A,Histologicsectionshowssheetsofhistiocyteswithabundantfoamycytoplasmadmixedwithsmalllymphocytes(hematoxylinandeosin).B,S-100proteinimmunostainshowsnumerouspositivelystaininghistiocytes.C,CytologictouchpreparationsstainedwithDiff-Quik.Numeroushistiocytesareintermixedwithlymphocytesandplasmacells.Twohistiocytesdemonstrateemperipolesis(whitearrows).Anosteoclast-likegiantcellisalsopresent.

philiccytoplasm,andBirbeckgranules,whichare“racket-shaped”

inclusionbodiesseeninthecytoplasmwithelectronmicroscopy).

Hemophagocyticlymphohistiocytosisclinicallymanifestsasfever,

splenomegaly,andjaundice.Thehistopathologyofthisdiseasewill

demonstratestromalmacrophageswithnumerousredbloodcells

intheircytoplasm.

AchievingadefinitivediagnosisofRDD,asinitiallydescribedby

Goeletal,8isaccomplishedthroughdetectionofCD68andS-100

protein-positivehistiocytesandbymicroscopicanalysisdemon-

stratingemperipolesis,aphenomenoncharacterizedbyphagocyto-

sisofintactlymphocytesorplasmacellsbyhistiocytes(Figure1).

CD68isastainformonocytesandmacrophages,whileS-100isa

stainforavarietyofcellsincludingneuralcrestcells,chondrocytes,

adipocytes,myoepithelialcells,macrophages,Langerhanscells,

dendriticcells,andkeratinocytes.Comparedtothepresentationin

lymphnodes,osseousRDDhaslesspronouncedlymphophagocy-

tosisandhasmorefibrosis.9

RDDisoftenbenignandhasahighrateofspontaneousremis-

sion;therefore,managementbyconservativemeansisusually

adequate.InareviewbyPulsonietal,1083%ofthecasesnot

involvingorcompressingvitalorganshadcompletespontaneous

remission.Amoreaggressiveapproachmayberecommended

whenthelocationofthelesionthreatensmajorcomplications,

suchascordcompression.Persistentcasesrequiringtherapyhave

beentreatedwithsteroids,surgicalexcision,radiationtherapy,

and/orchemotherapy.11,12

case report

Clinical history

A25-year-oldwomanhadexperiencedanklepainandswellingfor

2months.Sheattemptedanklebracingandanti-inflammatory

medication,whichdecreasedbutdidnoteliminatethepain.She

hadnotbeeninjuredandhadalwaysbeenhealthy.Shewasmark-

edlytenderoverthelateralborderofthetalus.Laboratorystudies

revealedanormalhematocrit,hemoglobin,andplateletcountand

amildlydecreasedconcentrationofwhitebloodcells.Therewas

noevidenceoflymphadenopathyandthusfineneedleaspiration

wasnotperformed.

Herphysicianreferredhertoourorthopediconcologyclinic

becausex-raysofheranklehadrevealedabonelesioninhertalus

(Figure2).HerMRI(Figure3),performedwithandwithoutgad-

oliniumcontrast,showedalargelesioninthelateralaspectofthe

talusextendingtothearticularsurfaceofthelateraltalardome.

Thisheterogeneousmassdemonstratedlowsignalintensityon

T1-weightedimagesandmixedintensityonT2-weightedimages

withmildtomoderateheterogeneouspostcontrastenhancement.

Whiletherewasamildperifocaledemasurroundingthelesion,

weidentifiednoareasoferosionofboneordiscretedestructionof

cortexbyMRI.

Werecommendedcomputedtomography(CT)toassessfor

intralesionalcalcificationandmoresubtleevidenceofbony

destruction.HerCTscan(Figure4)showedanintraosseouslesion

measuring3.2cm×2.5cm×2.0cmoccupyingapproximately

40%ofthetalus.Someofthebordersappearedtobeslightlyir-

regularandsclerotic.

Thedifferentialdiagnosisofasolitarylesionofthetaluscausing

chronicanklepainandswellingmayincludeosteomyelitis,bone

cyst,lymphoma,giantcelltumor,metastaticdisease,plasmacy-

toma,lipoidosis,andRosai-Dorfmandisease.

Althoughosteomyelitiswasapossibility,itwasunlikelygiven

thepatient’suneventfulmedicalhistoryandlackoflocaltrauma

nearthetalus.Althoughtherewasswelling,shedidnothaveany

warmth,erythema,fevers,orchills.Herlaboratoryvalueswere

normal,whichalsowasnotconsistentwithosteomyelitis.

a b c

Aneurysmalandunicameralbonecystswerealsoplausible,given

thelucentappearanceofthelesiononradiographs.However,

thelesionwasnotexpansile.Typically,unicameralbonecystsare

mildlyexpansileandaneurysmalbonecystsaremoreexpansile.

TheMRIofaneurysmalbonecystswillalsohavefluid-fluidlevels,

whichwasnotconsistentwithourfindingsforthispatient.

Lymphomawasunlikelyasitisassociatedwithradiographsthat

consistofapermeativelesionandareasofcorticalthickening,

whichwerenotseeninthispatient.

Giantcelltumorwashigheronthedifferential,giventheage

andsexofthepatient,aswellasthejuxta-articularlocationofthe

lesion.

Metastaticdiseasewasveryunlikelygiventheyoungageofthis

patient.Shealsohadnohistoryofaprimarycancernordidshe

havepainoutsideofherankle.Also,herimagingdemonstrated

alesionthatwaswellmarginated,whichisuncharacteristicof

metastasis.

Plasmacytomaismorecommoninthe50-to60-year-oldage

group.Itusuallypresentsinthevertebra,ribs,orpelvis.Thepa-

tientdeniedanypainintheselocations.Shealsodidnothaveany

systemicmanifestationsassociatedwithplasmacytomaincluding

anemia,renalinsufficiency,hypercalcemia,orperipheralneuropa-

thy.

Lipoidosisisadisorderofmetabolismofaparticulartypeoflip-

idsthatleadstohepatosplenomegaly,lymphadenopathy,anemia,

mentalretardation,andphysicaldeterioration.Someneurologic

manifestationsincludeseizures,ophthalmoplegia,andataxia.The

patientdidnothaveanyofthesemanifestations.

Inourcase,weconsideredRDDasapossibility,buttherewas

uncertaintyasitisararediagnosis.Thenextstepwastobean

intralesionalbiopsy,aprocedurebestdonebyanorthopedic

oncologistsoastomaximizediagnosticaccuracy,minimizemor-

bidity,andprovidecontinuitywiththecaretofollow.

intralesional Biopsy

Afterbeingfullyinformedofthepossibilities,thepatientagreed

tosurgicalbiopsy.Weexposedthetalusthroughananterolateral

incisionandbluntdissection.Withfluoroscopicguidance,we

placedaguidewiredirectlyintothelyticlesion,followedbyacan-

nulateddrillandaCraigneedlesleeve.Withapituitaryrongeur

wesampledtissuefromthelesion.Frozensectionswereequivocal;

therefore,wedecidedtowaitforpermanentsections.

histopathology

Microscopicanalysisofthemassrevealedaheterogeneousinfiltrate

ofhistiocytes,lymphocytes,andplasmacellswithsomehistiocytes

showingintactlymphocyteswithintheircytoplasm(emperipolesis)

(Figure1).Thefindingofemperipolesisisessentiallydiagnosticfor

RDD.ThehistiocytesinRDD,asopposedtoreactivehistiocytes

thatcouldbeseeninaninfectiousprocess,arecharacteristically

positiveforS-100proteinaswasseeninthiscase.TheCD68stain

wasnotperformedasitwasdeemedunnecessaryatthispoint.

operative Debridement

Afterfurtherdiscussion,thepatientconsentedtoarthroscopic

evaluationofherrighttibiotalarjointfollowedbyanopen

intralesionaldebridementandfillingofthetaluswithbonegraft

substitute.Throughastandardanteromedialportaloftheankle,

diagnosticarthroscopyrevealedonlyamoderateamountofreac-

tivesynoviumintheanterioraspectoftheankle,withnoevidence

ofaproliferativesynovialdisease.Theanteriorsynoviumwasthen

sampledusingalateralarthroscopicincision,whichwascreated

throughthepreviousbiopsyincision.Thisspecimenwastakenoff

thefieldandsavedforpathology.


figure 2. Anteroposterior(AP),mortise,andlateralpreoperativeankleradiographsdemonstratingalargecysticlesioninthelateraltalus.

figure 3. Coronal,sagittal,andaxialT2-weightedMRIimagesofankledemonstratinglargemixedsignalintensitylesioninthelateraltalus.

figure 4.Coronal,sagittal,andaxialCTimagesofankledemonstratingalargecysticlesionofthelateraltaluswithscleroticmargins.

figure 2 figure 3 figure 4

30

Oncewefinishedthearthroscopy,weextendedthepriorantero-

lateralskinincisionandexposedthetalus.Withahigh-speedburr

weopenedanonarticularportionofthebone(Figure5).Thetalus

hadadefectfilledwithbrownpigmentedtissue.Wedebulkedthe

lesionandsubmittedthetissuetothepathologist.Themargins

wereextendedwithahigh-speedburrfollowedbyelectrocautery.

Completeexcisionofthetumorwasconfirmedusingthearthro-

scopetovisualizethebordersoftheremainingcavitarydefectin

thetalus(Figure6).Thewoundwaslavagedandpackedwith

bonegraftsubstitute(PRO-DENSEInjectableRegenerativeGraft;

WrightMedicalTechnology,Arlington,Tennessee).

Follow-up

Thepatientdidwellinthepostoperativeperiod,andby24weeks

shehadfullyrecoveredandwasbacktonormalactivities.Radio-

graphsather24-weekfollow-uprevealednearcompletecon-

solidationofthedefectwithbone(Figure7).Givenhermarked

progress,herprognosisisexcellent,andshewillfollowupwith

usonanannualbasis.Wefeltthattheoperativedebridementwas

thoroughandthechancesofrecurrenceareminimal.

discussion

RDDisarareself-limiteddisorderthatcanpresentwithisolated

osseousinvolvement,whichhasbeenreportedintheskull,spine,

femur,radius,ulna,metacarpals,andtalus.1,13Becausepresenta-

tionsoftenincludeenlargedlymphnodesandhistopathologyof

proliferationsoflymphoidcells,butabenignandself-limited

course,RDDissometimescalleda“pseudolymphomatous”

disorder.Theconditionisoftenmisdiagnosed,leadingtodelaysin

treatment.

Thedifferentialdiagnosisofasolitarylesionofthetaluscaus-

ingchronicanklepainandswellingmayincludeosteomyelitis,

aneurysmalbonecyst,unicameralbonecyst,giantcelltumor,

metastaticdisease,plasmacytoma,lymphoma,andlipoidosis.The

histopathologyconfirmedtheexclusionofthepossibilitiesinthe

differentialdiagnosisotherthanRDD.Osteomyelitiswasruled

outbythelackofreactivehistiocytes.Therewerenocysticareas

seenonhistology;thusweeliminatedaneurysmalandunicameral

bonecystsfromthedifferentialdiagnosis.Thehistologyofgiant

celltumorsdemonstratesmultinucleatedgiantcellsdispersed

throughoutaseaofmononuclearcells,whichwedidnotseein

ourpatient’sbiopsy.Metastaticdiseasewouldnothavebenign-

appearinghistologyaswasseeninourpatient.Therewereno

plasmacellsobserved;thusweremovedplasmacytomafromthe

differentialdiagnosis.Also,thepatient’shistologydidnothavea

largeproliferationofblueroundcells,whichistypicallyseenin

lymphoma.Finally,lipoidosiswasdisregardedfromthedifferential

diagnosisbecauseofthelackofanylipidcells.

Inthepublishedliterature,therearenoothercasesofsolitary

osseousRDDinvolvingonlythetalus.Thereare,however,2

similarcasesofextranodalRDDwithprimarylesionslocatedin

thetalusandextendingtoadjacentbones.Thefirstcase,published

byAbdelwahabetal7in2004,involveda63-year-oldwomanwho

complainedofprogressivepaininherleftankleand,afterabiopsy

earlyinthecourseofthedisease,wasmisdiagnosedwithosteomy-

figure 5. Viewofanopeningintothenonarticularportionofthetalusseenviaanterolateralincisionoftheankle.

figure 6.Cleanmarginsobservedinsidethetalusafteraggressivedebridement,high-speedburring,andelectrocautery.

figure 5 figure 6

elitisandgivenantibiotics.Shepresented25yearslateroncrutches

withprogressiveswellingandintermittentflaresofpain.MRI

revealedaheterogeneouslow-intensitysignalonT1-weightedim-

ageofthetaluswithextensionintothecalcaneus,navicularbone,

andsurroundingsofttissue.

Thesecondsimilarcase,reportedbyGuptaetal,14isofa

64-year-oldwomanwitha6-8monthhistoryofleftanklepain

andswellingfollowingarelapsingandremittingcourse.Afterthe

initialevaluation,shewaslosttofollow-upfor4.5yearsandthen

presentedonceagainwithcontinuedpainandswelling.AnMRIat

baseline,4.5years,and7yearsshowedprogressivegrowthofmul-

tiplelesionswithheterogeneouslow-intensitysignalonT1-weight-

edimageseventuallyreplacingthemarrowoftalus,navicularbone,

calcaneus,andportionsofthecuboidandlateralcuneiformwith

extensionintoadjacentsofttissue.

Ourpatient,just25yearsoldwhenshebeganhavingsymptoms,

ismuchyoungerthanmostreportedcases.Thetissuefromher

lesiondemonstratedemperipolesisandanS-100proteinpositive

immunostain,diagnosticofRDD.Thisistheonlycaseinthelit-

eratureofRDDofthetaluswithoutinvolvementoflymphnodes

andadjacentstructures.Itisalsotheonlycaseintheliterature

treatedwithsurgicalexcisionofthelesion.RDD,whilerare,needs

tobeconsideredwhenevaluatingalyticbonelesion.

references

1.RosaiJ,DorfmanRF.Sinushistiocytosiswithmassivelymphadenopa-thy:anewlyrecognizedbenignclinicopathologicalentity.Arch Pathol.1969;87(1):63-70.

2.Bernácer-BorjaM,Blanco-RodríguezM,Sanchez-GranadosJM,Benitez-FuentesR,Cazorla-JimenezA,Rivas-MangaC.Sinushistiocytosiswithmassivelymphadenopathy(Rosai-Dorfmandisease):clinico-patho-logicalstudyofthreecases.Eur J Pediatr.2006;165(8):536-539.

3.ChopraD,SvenssonWE,ForouhiP,PooleS.ArarecaseofextranodalRosai-Dorfmandisease.Br J Radiol.2006;79(946):e117-e119.

4.McAlisterWH,HermanT,DehnerLP.Sinushistiocytosiswithmassivelymphadenopathy(Rosai-Dorfmandisease).Pediatr Radiol.1990;20(6):425-432.

5.SodhiKS,SuriS,NijhawanR,KangM,GautamV.Rosai-Dorfmandisease:unusualcauseofdiffuseandmassiveretroperitoneallymphade-nopathy.Br J Radiol.2005;78(933):845-847.

6.Foucar,E,RosaiJ,DorfmanR.Sinushistiocytosiswithmassivelymph-adenopathy(Rosai-Dorfmandisease):reviewoftheentity.Semin Diagn Pathol.1990;7(1):19-73.

7.AbdelwahabIF,KleinMJ,SpringfieldDS,HermannG.Asolitaryle-sionoftaluswithmixedscleroticandlyticchanges:Rosai-Dorfmandiseaseof25years’duration.Skeletal Radiol.2004;33(4):230-233.

8.GoelMM,AgarwalPK,AgarwalS.PrimaryRosai-Dorfmandiseaseofbonewithoutlymphadenopathydiagnosedbyfineneedleaspirationcytol-ogy:acasereport.Acta Cytol.2003;47(6):1119-1122.

9.WalkerPD,RosaiJ,DorfmanRF.Theosseousmanifestationsofsinushistiocytosiswithmassivelymphadenopathy.Am J Clin Pathol.1981;75(2):131-139.

10.PulsoniA,AnghelG,FalcucciP,etal.Treatmentofsinushistiocytosiswithmassivelymphadenopathy(RosaiDorfmandisease):reportofacaseandliteraturereview.Am J Hematol.2002;69(1):67-71.

11.LasakJM,MikaelianDO,McCueP.Sinushistiocytosis:ararecauseofprogressivepediatriccervicaladenopathy.Otolaryngol Head Neck Surg.1999;120(5):765-769.

12.HorneffG,JürgensH,HortW,KaritzkyD,GöbelU.Sinushistiocy-tosiswithmassivelymphadenopathy(Rosai-Dorfmandisease):responsetomethotrexateandmercaptopurine.Med Pediatr Oncol.1996;27(3):187-192.

13.LehnertM,EisenschenkA,DienemannD,LinnarzM.Sinushistio-cytosiswithmassivelymphadenopathy:skeletalinvolvement.Arch Orthop Trauma Surg.1993;113(1):53-56.

14.GuptaS,FinzelKC,GrubberBL.Rosai-Dorfmandiseasemasquerad-ingaschronicanklearthritis:acasereportandreviewoftheliterature.Rheumatology (Oxford).2004;43(6):811-812.

figure 7. Radiographstakenatthe24-weekfollow-updemonstratingnearcompleteconsolidationofthedefectwithbone.


32

IdiopathicGlenohumeralChondrolysis:ACaseReportshAne J. nho, MD, Ms; niCoLe A. FrieL, MD, Ms; BriAn J. CoLe, MD, MBA

author affiliations

DivisionofSportsMedicine,DepartmentofOrthopedicSurgery,

RushUniversityMedicalCenter,Chicago,Illinois.


BrianJ.Cole,MD,MBA;RushUniversityMedicalCenter,



introduction

Chondrolysisisthedisappearanceofarticularcartilageresulting

fromdissolutionofthecartilagematrixandcells.Itisaccompa-

niedbyprogressivelossofjointspaceandincreasedstiffnessinthe

involvedjoint.1,2Chondrolysishasbeendocumentedinthehip,

knee,ankle,andshoulder.Thecauseisoftenunknown.Recently,

therehavebeenanumberofpublishedreportsofglenohumeral

jointchondrolysis.1,3-13Althoughtheetiologyhasbeenpostulated

tobemultifactorial,associationswitharthroscopy,painpumps,1,7,11

radiofrequencyenergydevices,6,8infection,4,9andsutureanchors3

havebeendocumented.Inthepresentarticle,wedescribethefirst

reportedcaseofidiopathicglenohumeralchondrolysisnotassoci-

atedwithanyknownriskfactor.

case report

A32-year-oldmancomplainedofshoulderpainandstiffness

beginninginhisearlytwenties.Hereportednoinjuryor

traumaticevent.Hisprimarycarephysiciantreatedhimwith3

steroidinjectionsoverthecourseof4years.Theexactlocationof

theinjections,thedrugtypeanddose,andthetimingbetween

injectionsareunknown.Withworseningpain,hewasevaluated

byanorthopedicsurgeonapproximately7yearsaftertheonset.

Hecomplainedofanteriorshoulderpainandalsohadfeelings

ofshoulderinstability.Hisrangeofmotionwas80°offorward

flexion,70°ofabduction,and45°ofexternalrotation.Hedidnot

haveahistoryofsevereacneorotherknownsourcesofpotential

infection.Radiographsdemonstratedaconcentricallylocated

glenohumeraljointwithawell-preservedjointspaceandanormal

acromiohumeralindex.Magneticresonanceimagingrevealed

osteochondriticchangesofthehumeralheadwithbonyerosions

andsynovitisoftheglenohumeraljoint,apartial-thicknesstear

ofthesupraspinatustendon,andfrayingofthesuperiorglenoid

labrum.Laboratoryevaluationincludedcompletebloodcount

(whitebloodcell[WBC]count9.7),C-reactiveprotein(0.13),

rheumatoidfactor(<4),andantinucleotideantibody(<80),all

withinnormallimits.

Hisshoulderpainrequiredchronicpainmanagementwith

narcoticanalgesia.Hislocalorthopedicsurgeonexaminedhim

underanesthesiaandfoundnoinstabilitybutsignificanttightness.

Hispassiverangeofmotionwas90°offorwardflexion,90°of

abduction,30°ofexternalrotation,and25°ofinternalrotation.

Diagnosticarthroscopyrevealedaglobalchondrolysiswitha1.0

cm×1.5cm×3.5cmareaoffull-thicknesscartilagedefect,loose


“glEnohumEral chondrolysis has gainEd intErEst in thE past fEw yEars

and has bEEn rEportEd in multiplE casE rEports and casE sEriEs as

a potEntial postopErativE complication.“


bodies,synovitis,anddegenerativefrayingofthesuperiorlabrum

andlongheadofthebiceps(Figure1).Heunderwentglobalcap-

sularrelease,debridementofthesuperiorlabrumandlonghead

ofthebiceps,chondroplasty,extensivesynovectomy,loosebody

removal,subacromialdecompression,anddistalclavicleexcision.A

painpumpwasinsertedattheconclusionofthesurgery.

Onemonthaftersurgery,hisforwardflexionhadincreasedto

150°,abductionto155°,internalrotationto60°,andexternal

rotationto55°.Hispaindramaticallydecreasedandonlyaffected

himatnightandduringphysicaltherapy.Seventeenmonthsafter

theinitialsurgery,hehadanothersurgeryperformedbythesame

orthopedicsurgeonbecauseofcontinuedactivity-relatedpain.

Arthroscopicevaluationdemonstratedprogressiveglenohumeral

jointchondrolysis,synovitis,andathickenedsubacromialbursitis.

Theoperativeprocedurewaschondroplastyoftheglenohumeral

joint,extensivesynovectomy,andsubacromialbursectomy.After

thesecondsurgery,heexperiencedpersistentpainanddiminished

rangeofmotion.

Subsequently,heconsultedtheseniorauthor(B.J.C.).He

described“asensationthatthereisalwaysaknifeinmyshoul-

der.”Onexam,hehadforwardflexionto60°,abductionto40°,

externalrotationto10°,andinternalrotationtothebuttock.

Radiographsconfirmedjointspacenarrowingwithoutevidence

ofsclerosisorosteophytes(Figure2).Hisactivitiesofdailyliving

wereseverelyrestricted,andhewastaking80mgofOxyContinup

to10timesadayforpainrelief.Repeatsteroidinjectiondidnot

improvesymptoms.

Thepatientunderwentshoulderhemiarthroplastyandbiceps

tenodesis.Theglenoidwaspristineanddidnotrequireaglenoid

component.Thethickenedandflattenedbicepstendonwas

releasedandtenodeseddistally(Figure3).Threemonthsafter

thelastsurgery,hehadanimprovedrangeofmotionwith140°

forwardflexion,140°abduction,and60°externalrotationand

describedminimalpain,occurringonlyatnight.Hewasnolonger

takingpainmedication.Atthetimeofpreparationofthisreport,

20monthsafterhislastsurgery,wehavebeenunable,inspiteof

multipleattempts,tolocatehiminordertodocumenthiscurrent

status.

discussion

Thepresentreportistheonlycaseinthepublishedliterature

ofidiopathicglenohumeralchondrolysis.Thepatientpresented

withinsidiousonsetofprogressiveshoulderpainanddiminished

globalrangeofmotionrefractorytononoperativetreatment.At

theinitialpresentation,themagneticresonanceimagingstudy

demonstratedglenohumeraljointchondrolysisandsynovitis.

Thepatientalsounderwentlaboratoryevaluationforinfectious

orinflammatoryetiologyforhisshoulderpathology,butthese

studieswereunremarkable.Althoughthepatienthad3steroid

injectionsearlyinhisnonoperativemanagement,singleinjections

(asopposedtocontinuousinfusionpainpumps)ofMarcaineor

lidocainehavenotdemonstratedchondrotoxicity.14Theinitial

arthroscopicinspectiondemonstrateddramaticglenohumeraljoint

chondrolysis,andanindwellingpainpumpwasinsertedfollowing

theprocedure.Thesecondarthroscopyalsodemonstratedsevere

glenohumeraljointchondrolysis.

Glenohumeralchondrolysishasgainedinterestinthepastfew

yearsandhasbeenreportedinmultiplecasereportsandcaseseries

asapotentialpostoperativecomplication.Althoughcausesofpost-

operativechondrolysishavenotbeenidentifieddefinitely,potential

associatedfactorsincludethermaltreatment,6,8continuousinfusion

oflocalanesthetics,1,7,11infectionwithPropionibacterium acnes,4,9

higharthroscopicirrigationfluidtemperatures,5,10,15injectionof

gentianviolet,12anchorlooseningandsubsequenttrauma,3and

iatrogenicinjury.

Postoperativeshoulderchondrolysisisararebutdevastating

complication.Patientsareusuallyyoung,presentingwithanun-

figure 1. Arthroscopicimagesfromthepatient’sinitialsurgery,displayingchondrolysisofthehumeralhead.

a b

34

eventfulpostoperativecoursefollowedbyrapidonsetofshoulder

painat6-12monthsaftertheindexsurgery.1,7Therehavebeenno

reliabletreatmentsonceglenohumeralchondrolysisisdiagnosed.

BailieandEllenbeckerreporton23casesofshoulderchondrolysis

thatweretreatedwithoralandintra-articularsteroids,nonsteroi-

dalanti-inflammatorydrugs,debridement,andhyaluronicacid

injections.1Ninepatientsof23underwentshoulderarthroplasty.

Inaseriesof20patientswithglenohumeralchondrolysis,patients

weretreatedwithavarietyofbiologicprocedures,including

microfracture,autologouschondrocyteimplantation,allograftsof

thehumeralhead,concomitanthumeralheadallograftandlateral

meniscalinterposition,andcapsularrelease.11Inbothcaseseries,

patientsdemonstratedimprovementintheshortterm.

Chondrolysishasbeendescribedinmultiplejoints,includ-

ingtheknee,theankle,andmostcommonlythehip(Table1).

Chondrolysisofthehipiswelldocumented,withcausesincluding

sequelaeofuntreatedslippedcapitalfemoralepiphysis(SCFE),13,22-24

penetrationofthearticularsurfacebypinsduringsurgicaltreat-

ment,25extendedimmobilization,exposuretomethacrylate,26and

septicarthritis.Idiopathicchondrolysisofthehip(ICH)ischarac-

terizedbyarapidcourseofprogressivechondrolysisthatcom-

monlyoccursinadolescents.27ICHpresentsaspainandstiffness

inthejoint,withlossofarticularspace.EisensteinandRothschild

suggestthatchondrolysisislinkedwithanimmuneabnormality

thatmakesthecartilagesusceptibletoarticularcartilagedamage.28

Adibetal,inacaseseriesofchildrenpresentingwithpainfulstiff

joints,discuss14patientswithchronichiparthritisinwhichjuve-

nileidiopathicarthritis(JIA),septichip,andreactivearthritishad

beenruledout.29Theauthorssuggestthatthepatients’arthritisis

aresultofchronicinflammatoryarthritisandmayevenrepresenta

separatesubtypeofJIA.

Regardlessofthecause,chondrolysisofthehipinyoungpatients

isdifficulttotreat.Korulaetalpresentacaseseriesofpatients

(averageage,13years)withidiopathicchondrolysisofthehip.23

Patientsweretreatedwithcapsulectomy,andtheresultsreport

aless-than-satisfactoryoutcomeforpatients.Carneyetalfound

chondrolysisin16%ofpatientswithSCFE,andmostpatientshad

pooroutcomes.22

Chondrolysisoftheknee,althoughuncommon,hasbeen

describedfollowingmeniscectomy.16,17Charroisetalstatethat

kneechondrolysisofthelateralcompartmenthadbeenreportedin

youngathletesfollowingmeniscectomy.17Alfordetalpresenttwo

casesofseverechondraldamagewithin1yearofmeniscectomy.16

Therapidpresentationofchondrolysisinthesecasessuggestsa

causeotherthanmechanicalwear.Furthermore,kneechondrolysis

hasbeenassociatedwithradiofrequencyprocedures,18exposureto

chlorhexadine,19andphysicalandsurgicaltrauma.20

InacasereportbyBojesculetal,2theauthorsreportacaseofid-

iopathicanklechondrolysis.Thepatientpresentedwithchronic(5

years)lateralankleinstability,andarthroscopicfindingsincluded

moderatesynovitis,gradeIIanterolateralchondrolysis,andan

anteriortalarosteophyte.Followingreconstructionoftheligament,

thepatientreportedstiffnessandpainat11monthspostopera-

tivelyandhadradiographicevidenceofchondrolysis.Ofnote,this

patienthadapainpumpafterthefirstscope.

conclusions

Wepresentthecaseofayoungpatientwithlong-standingshoulder

painandstiffness.Ourpatienthadnoneofthefactorsreportedas

possibleetiologiesincasesofchondrolysisoftheglenohumeraland

otherjoints.Hehadhad3intra-articularsteroidinjectionspriorto

thediagnosisofchondrolysis,leadingustoconsiderwhethersome

figure 2.Preoperativeanteroposteriorandaxillaryradiographspriortoevaluationforhemiarthroplasty.Thepatienthasjointspacenarrowingbutdoesnotdisplaysclerosisorosteophytes.

figure 3.Postoperativeanteroposteriorandaxillaryradiographs.

a b a b

figure 2 figure 3


idiosyncraticreactiontotheinjectedmaterialorunrecognized

infectionfromtheinjectionscouldhaveoccurredandcausedthe

chondrolysis.However,hehadsymptomspriortotheinjections,

thematerialsinjectedwereshort-acting,shoulderjointinjections

areexceedinglycommonandnotknowntobeassociatedwith

chondrolysis,laboratorytestingshowednoevidenceofinfec-

tion,andthepristineconditionoftheglenoidcartilagefoundat

thelastsurgerysuggestedapathologicprocessoriginatinginthe

humeralheadasopposedtothejointspace.Forallthesereasons,

weconcludedthat,thoughthepossibilityofarelationshipbetween

theinjectionsandthechondrolysiscouldnotbeeliminated,itis

probablethattherewasnocausalrelationship,andthereforethe

etiology,inthiscase,isbestconsideredidiopathic.

references

1.BailieDS,EllenbeckerT.Severechondrolysisaftershoulderarthroscopy:acaseseries.J Shoulder Elbow Surg.2009;18(5):742-747.

2.BojesculJA,WilsonG,TaylorDC.Idiopathicchondrolysisoftheankle.Arthroscopy.2005;21(2):224-227.

3.AthwalGS,ShridharaniSM,O’DriscollSW.Osteolysisandarthropathyoftheshoulderafteruseofbioabsorbableknotlesssutureanchors:areportoffourcases.J Bone Joint Surg Am.2006;88(8):1840-1845.

4.DelyleLG,VittecoqO,BourdelA,DuparcF,MichotC,LeLoëtX.ChronicdestructiveoligoarthritisassociatedwithPropionibacteriumacnesinafemalepatientwithacnevulgaris:septic-reactivearthritis?Arthritis Rheum.2000;43(12):2843-2847.

5.GoodCR,ShindleMK,GriffithMH,WanichT,WarrenRF.Effectofradiofrequencyenergyonglenohumeralfluidtemperatureduringshoulderarthroscopy.J Bone Joint Surg Am.2009;91(2):429-434.

6.GoodCR,ShindleMK,KellyBT,WanichT,WarrenRF.Glenohumeralchondrolysisaftershoulderarthroscopywiththermalcapsulorrhaphy.Arthroscopy.2007;23(7):797.e1-797.e5.

7.HansenBP,BeckCL,BeckEP,TownsleyRW.Postarthroscopicglenohu-meralchondrolysis.Am J Sports Med.2007;35(10):1628-1634.

8.LevineWN,ClarkAMJr,D’AlessandroDF,YamaguchiK.Chondroly-sisfollowingarthroscopicthermalcapsulorrhaphytotreatshoulderinsta-bility:areportoftwocases.J Bone Joint Surg Am.2005;87(3):616-621.

9.LevyPY,FenollarF,SteinA,etal.Propionibacteriumacnespostop-erativeshoulderarthritis:anemergingclinicalentity.Clin Infect Dis.2008;46(12):1884-1886.

10.LuY,EdwardsRBIII,NhoS,ColeBJ,MarkelMD.Lavagesolutiontemperatureinfluencesdepthofchondrocytedeathandsurfacecontour-ingduringthermalchondroplastywithtemperature-controlledmonopolarradiofrequencyenergy.Am J Sports Med.2002;30(5):667-673.

table 1.SummaryofDescribedChondrolysisEtiologies

affected Joint Etiology

knee Following meniscectomy16,17

radiofrequency procedures18

exposure to chlorhexadine19

Physical and surgical trauma20

idiopathic21

shoulder thermal treatment6,8

(glenohumeral) intra-articular pain pumps1,7,11

infection4,9

high-temperature irrigation fluid5,10,15

gentian violet12

Anchor loosening and subsequent trauma3

hip untreated slipped capital femoral epiphysis (sCFe)13,22-24

incorrect pin placement25

extended immobilization

exposure to methacrylate26

septic arthritis

idiopathic23,27

immune abnormality28

36

11.McNickleAG,L’HeureuxDR,ProvencherMT,RomeoAA,ColeBJ.Postsurgicalglenohumeralarthritisinyoungadults.Am J Sports Med.2009;37(9):1784-1791.

12.TamaiK,HigashiA,ChoS,YamaguchiT.Chondrolysisoftheshoul-derfollowinga“colortest”-assistedrotatorcuffrepair:areportof2cases.Acta Orthop Scand.1997;68(4):401-402.

13.WarnerWCJr,BeatyJH,CanaleST.Chondrolysisafterslippedcapitalfemoralepiphysis.J Pediatr Orthop B.1996;5(3):168-172.

14.ChuCR,IzzoNJ,CoyleCH,PapasNE,LogarA.Theinvitroeffectsofbupivacaineonarticularchondrocytes.J Bone Joint Surg Br.2008;90(6):814-820.

15.YangCY,ChengSC,ShenCL.Effectofirrigationfluidsonthearticularcartilage:ascanningelectronmicroscopestudy.Arthroscopy.1993;9(4):425-430.

16.AlfordJW,LewisP,KangRW,ColeBJ.Rapidprogressionofchondraldiseaseinthelateralcompartmentofthekneefollowingmeniscectomy.Arthroscopy.2005;21(12):1505-1509.

17.CharroisO,AyralX,BeaufilsP.Rapidchondrolysisafterarthroscopicexternalmeniscectomy:aproposof4cases[inFrench].Rev Chir Orthop Reparatrice Appar Mot.1998;84(1):88-92.

18.VangsnessCTJr.Radiofrequencyuseonarticularcartilagelesions.Orthop Clin North Am.2005;36(4):427-431.

19.vanHuyssteenAL,BraceyDJ.Chlorhexidineandchondrolysisintheknee. J Bone Joint Surg Br.1999;81(6):995-996.

20.JayGD,ElsaidKA,ChichesterCO.Earlydamagetothearticularcartilagematrixoccursfollowingtraumatickneeinjurieswithoutfracture.Acad Emerg Med.2003;10(5):496.

21.SlabaughMA,FrielNA,ColeBJ.Rapidchondrolysisofthekneeafteranteriorcruciateligamentreconstruction:acasereport.J Bone Joint Surg Am.2010;92(1):186-189.

22.CarneyBT,WeinsteinSL,NobleJ.Long-termfollow-upofslippedcapitalfemoralepiphysis.J Bone Joint Surg Am.1991;73(5):667-674.

23.KorulaRJ,JebarajI,DavidKS.Idiopathicchondrolysisofthehip:medium-tolong-termresults.ANZJ Surg.2005;75(9):750-753.

24.LubickyJP.Chondrolysisandavascularnecrosis:complicationsofslippedcapitalfemoralepiphysis. J Pediatr Orthop B.1996;5(3):162-167.

25.StamboughJL,DavidsonRS,EllisRD,GreggJR.Slippedcapitalfemoralepiphysis:ananalysisof80patientsastopinplacementandnum-ber.J Pediatr Orthop.1986;6(3):265-273.

26.LeclairA,GangiA,LacazeF,etal.Rapidchondrolysisafteranintra-articularleakofbonecementintreatmentofabenignacetabularsubchondralcyst:anunusualcomplicationofpercutaneousinjectionofacryliccement.Skeletal Radiol.2000;29(5):275-278.

27.RachinskyI,BoguslavskyL,CohenE,HertzanuY,LantsbergS.Bilateralidiopathicchondrolysisofthehip:acasereport.Clin Nucl Med.2000;25(12):1007-1009.

28.EisensteinA,RothschildS.Biochemicalabnormalitiesinpatientswithslippedcapitalfemoralepiphysisandchondrolysis.J Bone Joint Surg Am.1976;58(4):459-467.

29.AdibN,OwersKL,WittJD,OwensCM,WooP,MurrayKJ.Isolatedinflammatorycoxitisassociatedwithprotrusioacetabuli:anewformofjuvenileidiopathicarthritis?Rheumatology (Oxford).2005;44(2):219-226.

ReducedScapularNotchingFollowingReverseTotalShoulderArthroplasty:ClinicalResultsofaNewImplantDesign

seTh L. sherMAn, MD; BreTT A. LenArT, MD; eriC sTrAuss, MD; AMAn DhAWAn, MD; eriC goChAnour, MA; gregorY P. niChoLson, MD

author affiliations

DivisionofSportsMedicine,DepartmentofOrthopedicSurgery,

RushUniversityMedicalCenter,Chicago,Illinois.


SethL.Sherman,MD;RushUniversityMedicalCenter,1611

WHarrisonSt,Suite300,Chicago,IL60612(dr.seth.sherman@

gmail.com).

introduction

Totalshoulderarthroplasty(TSA)hasrevolutionizedthetreatment

ofsymptomaticglenohumeralarthritis,significantlydecreasing

painandimprovingshoulderfunctioninpatientswithsevere

disease.However,inpatientswithadeficientrotatorcuff,conven-

tionalTSAhasprovidedsuboptimalresultsleadingtoadecreasein

subjectivepatientsatisfaction,anincreasedcomplicationrate,and

poorradiographicoutcomes.1Thereverseball-and-socketprosthe-

siswasdevelopedinanattempttocompensateforthenonfunc-

tioningrotatorcuffinpatientsrequiringTSA.2Implantdesign,

meticuloussurgicaltechnique,andcarefulpatientselectionhave

ledtosuccessfuloutcomesforthemajorityofpatientsundergoing

reverseTSA.2-4However,theincreaseindemandforandpopularity

ofthistechniquehasledtotherecognitionofnovelcomplications

suchasscapularnotching,inherenttotheuniquedesignof

reverseTSA.

Scapularnotchingisseenradiographicallyinferiortothe

glenosphereandisapotentialcomplicationofreverseTSA.This

entitymostlikelyrepresentsrepetitivemechanicalabutmentofthe

humeralcomponentwiththeinferiorportionoftheneckofthe

scapula,resultinginglenoidneckosseouserosionovertime,and

withitpotentialpolyethylenewearthatcouldcompromiseresults.

Scapularnotchingtypicallyoccurswithinthefirstfewmonths

afterreverseTSA,withareportedincidencerangingfrom44%to

96%.3,5Manyfactorscontributetothedevelopmentofscapular

notching,includingpreoperativediagnosis,prostheticdesign,

surgicalapproach,positioningoftheglenoidcomponent,andthe

patternofglenoidwearinthedegenerativeprocess.6-10Initialshort-

termstudiesdidnotdemonstrateanegativeimpactofscapular

notchingonpostoperativepainandConstantscores.7However,

resultsfromlonger-termstudiessuggestthatscapularnotching

maybeaprogressivefinding,andithasbeenassociatedwithaloss

ofrangeofmotion,lossofstrength,decreasedshoulderoutcome

scores,andincreasedpolyethylenewearwiththepotentialfor

implantloosening.4,9

TheindicationsforreverseTSAcontinuetoexpandandnow

includerotatorcuffarthropathy,rheumatoidarthritis,proximal

humerusfractures,fracturemalunions/nonunions,andrevision

procedures.Thehighreportedratesofscapularnotchingare


“wE strongly bEliEvE that thE combination of implant dEsign modifications, carEful

patiEnt sElEction and prEopErativE workup, and mEticulous surgical tEchniquE havE

lEd to thE low incidEncE of notching in this sEriEs.“


38

figure 1. A,Grade3scapularnotchaccordingtotheNerot/Sirveauxclassification.NotetheextensionofthebonelossoverthelowerfixationscrewonthisAPradiograph.B,Grade4scapularnotchaccordingtotheNerot/Sirveauxclassification.Notetheprogressionofthedefecttotheundersurfaceofthebaseplate.

alarming,especiallyinlightofevidencesuggestingitsnegative

impactonpatientoutcomes.Thisstudypresentsalargeconsecu-

tiveseriesofTrabecularMetalReverse(Zimmer,Inc,Warsaw,In-

diana)totalshoulderarthroplastiesperformedbytwoexperienced

shouldersurgeons.Ourhypothesisisthatscapularnotchingcanbe

minimizedthroughproperpatientselection,meticuloussurgical

technique,andimplantdesignmodifications.

materials and methods

Aconsecutiveseriesof144TrabecularMetalReversetotalshoulder

arthroplastiesperformedby2experiencedshoulderarthroplasty

surgeons(G.P.N.andAnandM.Murthy,MD)providedthe

studypopulation.Thereverseshoulderwasapprovedforusein

theUnitedStatesin2004.TheTrabecularMetalReversewas

introducedinearly2006.Bothsurgeonshad2yearsofexperience

utilizingGrammont-styleimplantspriortousingtheTrabecular

MetalReverse.Allshoulderswereradiographicallyevaluatedwith

trueanteroposterior(AP)andaxillaryviewsduringtheirpost-

operativefollow-upvisits.Eachsurgeonwasblindedtopatient-

specificinformationandevaluatedtheAPandaxillaryradiographs

fromhisowncases.Thefirstevaluationhadaminimumfollow-up

of6monthsandanaverageof14months(range,6-24months).

Asecondevaluationofthesame144shoulderswasperformedby

thesame2surgeonsinanidenticalfashionanaverageof8months

later.Thustheminimumfollow-upbecame14monthsandthe

averagefollow-upwas22months(range,14-32months).

Scapularnotching,whenpresentonthepostoperativeradio-

graphs,wasgradedusingtheNerot/Sirveauxclassification.10,11

Agrade1notchdescribesadefectcontainedwithintheinferior

pillarofthescapularneck.Agrade2notchinvolveserosionof

thescapularnecktotheleveloftheinferiorfixationscrewofthe

glenospherebaseplate.Agrade3scapularnotchindicates

extensionofthebonelossoverthelowerfixationscrew.Agrade4

defectdescribesprogressiontotheundersurfaceofthebaseplate

(Figure1).Althoughtheprimaryendpointofthisstudywasa

radiographicevaluation,instabilityeventsandcomplicationrates

werealsodocumented.

Thisstudywasapprovedbytheinstitutionalreviewboard.

results

Themeanageofpatientsinthisserieswas68years(range,39-

87years).Wehaveradiographicfollow-uponall144patients.

Chartreviewwasalsoperformedonallpatients.Femalepatients

accountedfor58%ofthecases.Allprocedureswereperformed

throughadeltopectoralapproach.Inthisseries,thepreoperative

diagnoseswererotatorcuffarthropathy(50%),failedrotatorcuff

repairs(20%),fracturesequelae(16%),andfailedpriorimplants

(14%).Forty-eightpatients(33%)hadprevioussurgeryonthe

operativeshoulder.In126patients(87.5%),a36-mmglenosphere

wasused,andin18(12.5%)a40-mmglenospherewasused.

Analysisafterthefirstevaluationrevealeda0%scapularnotch

rate.Therewerenoglenoidlucenciesorloosening.Therewere5

(3.5%)instabilityeventsthatoccurredearly(lessthan2months

postoperatively).Tworequiredclosedreduction,and3requireda

revisionwithpolyethylenelinerexchange.Noneofthesepatients

wentontohaveanyevidenceofscapularnotchingorperiosteal

reactiononfinalfollow-up.

Atthesecondevaluation,therewerenoadditionalpatientswith

instabilityevents.Ascapularnotchwasnotedin12of144(8.3%),

alldiagnosedontheAPradiograph.Nineofthe12(75%)were

grade1,2(17%)weregrade2,and1(8%)wasgrade3.There

werenograde4notches(Table1).

Ofthecasesthatwerefoundtohaveapostoperativescapular

notch,8wereforadiagnosisofprimarycuffteararthropathy,

2wererevisioncases,and2werefortreatmentofsurgicalneck

a b


nonunions.Onlyoneoftheglenosphereswasfelttobeplaced

inneutralpositionwithoutaninferiortiltwhenevaluatedbythe

operatingsurgeonanalyzingtheAPradiograph.

Nocasewithanotchorperiostealreactionhaddocumentation

ofclinicalsymptoms,instability,orradiographicevidenceof

glenoidbaseplateloosening.Therewasnoscrewbreakageor

implantdissociation.

discussion

Scapularnotchingisdefinedaserosionofboneofthescapular

necksecondarytomechanicalabutmentofthehumeralimplant

withadductionoftheupperextremity.3,7,8Repetitivemechanical

contactbetweenthepolyethylenecupofthehumeralcomponent

andtheinferiorscapularneckwithsubsequentwearofthepolyeth-

ylenemayinvokeabiologicresponse,leadingtochronicinflam-

mationofthejointcapsule,localosteolysis,andthepotentialfor

implantloosening.8,12Additionally,scapularnotchingmayleadto

lossofjointconstraint,creatingthepotentialforjointinstability.2

TheimplantusedexclusivelyinthisseriesisaTrabecularMetal

Reverseprosthesis(Figure2).Whilemaintaininganinferiorand

medialpositionoftheglenoidcenterofrotation,theprosthesis

hasseveraluniquedesignfeaturesthatmayaidinthepreven-

tionofscapularnotching.Themetallicneck-shaftangleis143

degrees,andthepolyethylenecomponenthasa7-degreeangle,

thuscreatingatotalneck-shaftangleof150degrees.This5-degree

differencefromotherreversearthroplastydesignsallowsforbetter

adductionofthearmwithoutmechanicalabutment.Addition-

ally,thisimplantdesignhasalowprofilewithnometallicmaterial

abovethehumeralosteotomy.Theglenoidbaseplatehasa3-mm

trabecularmetalpadonthebackside.Thiscreatesasmalllateral

offsetwhenimplantedontotheglenoidsurface.Webelievethat

theseuniquedesignparametersare,atleast,partiallyresponsible

forthedecreasedincidenceofnotchingappreciatedinthecurrent

series(Figure3).

Theincidenceofscapularnotchinginthepresentstudyis8.3%,

whichissignificantlydecreasedfromtheincidencefoundin

previousreports.Webelievethatseveralfactorsincludingsurgical

approach,implantposition,andimplantdesignareresponsible

forthereducedincidenceofnotchinginthecurrentseries.These

factorswillbediscussedindetailbelow.Intheliterature,the

incidenceofscapularnotchingrangesfrom44%to96%.2,4,7,9,10,12,13

Simovitchetalnotedpostoperativescapularnotchingin44%of

cases.9Inthatseries,notchingwasradiographicallyevidentata

meanof4.5monthspostoperatively,withnocasesdemonstrating

newonsetscapularerosionafter14monthsoffollow-up.Clini-

calseriespublishedbyLévigneetal,7Sirveauxetal,10andBoileau

etal2reportedscapularnotchingwithaslightlyhigherincidence

of62%,63.6%,and74%respectively.Anotherseries,byWerner

etal,4demonstratednearuniversalpresenceofnotching,finding

evidenceofinferiorscapularneckerosionin96%,with54%ofthe

table 1.DistributionofScapularNotchingbyNerot/SirveauxClassificationatanAverageof22MonthsFollow-up

figure 2. DesignfeaturesoftheZimmerTrabecularMetalReverseprosthesis.Theprosthesisisalow-profilehumeralcomponentwitha3-mmtrabecularmetalglenoidbaseplate.Thehumeralcomponentincorporatesa150-degreeneck-shaftangle,143degreesfromthehumeralcomponentand7degreesfromthepolyethylenecomponent.

grade number (%)

1 9 (75)

2 2 (17)

3 1 (8)

4 0 (0)

total 12 (100)

figure 2table 1

40

notchesclassifiedaseithergrade1orgrade2and46%asgrade3

orgrade4.

Thereremainsnoconsensusintheliteratureregardingthetime

ofonsetofscapularnotching,orthepresenceofradiographic

progression.Scapularnotchingtendstofirstappearearlyinthe

postoperativeperiod,withmostreportsdescribingradiographic

evidenceofscapularneckerosionbetween6weeksand14months

postoperatively.3Simovitchetalreportednonewcasesofscapular

notchingrecognizedpastthe14-monthtimepoint.9Forthisrea-

son,webelievethatthetimecourseusedinthepresentstudywas

sensitiveenoughtocapturethemajorityofpatientswhowould

developscapularnotchinginourseries.StudiesbyWerneretal4

andSimovitchetal9demonstratethattheextentofthescapular

notchingplateausovertimewithstabilizationat2-3years,while

Lévigneetal7reportedprogressionat2and3yearsfollow-upwith

evidenceofworseningofgrade.Thetopicofprogressionremains

controversial.Ourseriesdoesnotcurrentlyaddinsighttothis

debate.Longer-termfollow-upofseveralyearsisnecessarybefore

drawinganymeaningfulconclusions.

Theimpactofscapularnotchingonpostoperativeshoulderfunc-

tion,instability,andimplantsurvivorshipisalsocontroversial.In

thepresentstudy,wedidnotfindanyimpactofscapularnotching

ontheseparametersatameanof22monthspostoperative.The

instabilityrateofthecurrentstudywas3.5%.Theseinstability

eventsoccurredearlywithinthepostoperativeperiod(lessthan

2months)andwerenotassociatedwiththepresenceofor

subsequentdevelopmentofscapularnotching.Inallthecases

inourseries,includingthe12withscapularnotches,therewas

noevidenceofimplantdissociation,glenoidloosening,screw

breakage,orcatastrophicpolyethylenewear.Thedatafromthe

literatureismixedwithregardtotheclinicalimpactofscapular

notching.Delloyeetal14andVanhoveandBeugnies12identified

glenospherelooseninginasmallseriesofpatientswithscapular

notching.Lévigneetal7reportedacorrelationbetweenthepres-

enceandsizeofanotchwiththedevelopmentofradiolucencies

aroundboththehumeralandglenoidcomponentsasfollow-up

timeincreased.Theclinicalrelevanceofthesefindingsremains

unclear.Someauthorsreportedtheabsenceofanycorrelationbe-

tweenthepresenceorgradeofscapularnotchingandanyobjective

orsubjectiveclinicalmeasureorpostoperativecomplication.2,7,4In

contrast,otherstudieshaveshownarelationshipbetweenthepres-

enceandextentofscapularnotchingandlowerConstant-Murley

andsubjectiveshoulderscores.Sirveauxetal10foundthatpatients

withgrade3andgrade4notchinghadlowerpostoperativeCon-

stant-Murleyscores.Similarly,Simovitchetal9foundlowermean

Constant-Murleyscores,lowersubjectiveshoulderscores,inferior

shoulderstrength,andworsepostoperativerangeofmotionin

patientswithscapularnotchescomparedwiththosewithnormal

radiographs.Longerfollow-upstudieswillhelptoshedlighton

thiscontroversialtopic.

Technique-dependentfactorsmayalsoplayaroleinthede-

creasedincidenceofscapularnotchinginourseries.Adeltopec-

toralsurgicalapproachwasusedinallcasesinthisseries.Ahigher

incidenceofscapularnotchinghasbeenshownwiththeanterosu-

periorapproachascomparedwithadeltopectoralapproach(86%

versus56%).7Intraoperatively,duringexposureandpreparation

oftheglenoid,theglenospherebaseplateisimplantedasinferior

onthenativeglenoidaspossibletofosterinferioroverhangofthe

glenospherecomponent.Reamingwasperformedtopromotea

slightinferiortilttotheimplantedglenospherebaseplate(10to

20degrees).Neutralorsuperiorlytiltedbaseplatesincreasethe

riskofscapularnotchingcomparedwithinferiorglenoidtilt.

figure 3. A,InitialpostoperativeAPradiographdemonstratingimplantationoftheZimmerTrabecularMetalReverseprosthesiswiththeap-propriateamountofinferiorization,medialization,andinferiortilt.B,A2-yearfollow-upAPradiographofthesamepatientshowsnoevidenceofscapularnotching.WebelievethattheuniquedesignfeaturesoftheZimmerTrabecularMetalReverseprosthesisandstrictadherencetoGrammontprincipleshaveledtothissuccessfulradiographicoutcome.

a b

Severalstudiesdemonstratethatallowinginferioroverhangofthe

glenosphereimprovedimpingement-freeadductionandabduction

angles.6,8,9,10Ithasalsobeenshownthatbaseplatesimplantedwith

aslight(15-degree)inferiortilthadthemostcompressiveforces

underthebaseplateduringloadingwiththeleastamountoftensile

forcesandthesmallestamountofmicromotion.6,8,9,10Thesenior

author(G.P.N.)useshandreamersontheglenoid,reaminguntila

“subchondralsmile”ofcancellousbonecanbeseenontheinferior

aspectoftheglenoid.Superiordefectsthatremainsubsequent

tohandreamingcanbebonegrafted,ensuringtheglenosphere

baseplateisnotplacedwithasuperiortilt.Theglenospherecanbe

sizedappropriatelytoallowfor2to3mmofinferioroverhang,

whichwillpromotepostoperativerangeofmotion,stability,and

minimizationofnotchdevelopmentwithhumeraladduction.

Theprimaryobjectiveofthisradiographicstudywastodeter-

minetheincidenceofscapularnotchingwiththisuniqueim-

plantdesign.Futurefollow-upofthiscohortwillbenecessaryto

commentonradiographicprogressionanditslong-termimpact

onclinicalstabilityandimplantlongevity.Thiswasnotaclinical

outcomestudy,butwewereabletoreviewandreporton100%of

ourpatients’recordsdocumentingclinicalparametersincluding

instabilityevents;implantlucency,loosening,orfailure;andpres-

enceorabsenceofmajorcomplications.

Inconclusion,thisstudydemonstratesasignificantdecrease

intheincidenceofscapularnotchingwiththeuseofaunique

implantdesignandconsistentsurgicaltechnique.Thisimplant

stillrespectstheprovenGrammontdesignprinciples.Westrongly

believethatthecombinationofimplantdesignmodifications,

carefulpatientselectionandpreoperativeworkup,andmeticulous

surgicaltechniquehaveledtothelowincidenceofnotchinginthis

seriesandtheshifttowardlower-grade(1or2)notcheswhenpres-

ent.Whilethetrueclinicalimpactofscapularnotchingisyetto

berevealed,minimizationofscapularnotchingmayproveessential

inreducingmorbidityandpreventingcomplicationsinpatients

undergoingreverseTSA.

references

1.EdwardsTB,BoulahiaA,KempfJF,BoileauP,NemozC,WalchG.Theinfluenceofrotatorcuffdiseaseontheresultsofshoulderarthroplastyforprimaryosteoarthritis:resultsofamulticenterstudy.J Bone Joint Surg Am.2002;84-A(12):2240-2248.

2.BoileauP,WatkinsonDJ,HatzidakisAM,BalgF.Grammontreverseprosthesis:design,rationale,andbiomechanics.J Shoulder Elbow Surg.2005;14(1)(supplS):147S-161S.

3.GerberC,PenningtonSD,NyffelerRW.Reversetotalshoulderarthroplasty.J Am Acad Orthop Surg.2009;17(5):284-295.

4.WernerCM,SteinmannPA,GilbartM,GerberC.TreatmentofpainfulpseudoparesisduetoirreparablerotatorcuffdysfunctionwiththeDelta

IIIreverse-ball-and-sockettotalshoulderprosthesis.J Bone Joint Surg Am.2005;87(7):1476-1486.

5.RocheC,FlurinPH,WrightT,CrosbyLA,MauldinM,ZuckermanJD.Anevaluationoftherelationshipsbetweenreverseshoulderdesignparametersandrangeofmotion,impingement,andstability.J Shoulder Elbow Surg.2009;18(5):734-741.

6.GutiérrezS,LevyJC,FrankleMA,etal.Evaluationofabductionrangeofmotionandavoidanceofinferiorscapularimpingementinareverseshouldermodel.J Shoulder Elbow Surg.2008;17(4):608-615.

7.LévigneC,BoileauP,FavardL,etal.Scapularnotchinginreverseshoulderarthroplasty.In:WalchG,BoileauP,MoléD,FavardL,LévigneC,SirveauxF,eds.Reverse Shoulder Arthroplasty: Clinical Results, Complica-tions, Revision.Paris,France:SaurampsMédical;2006:353-372.

8.NyffelerRW,WernerCM,SimmenBR,GerberC.AnalysisofaretrievedDeltaIIItotalshoulderprosthesis.J Bone Joint Surg Br.2004;86(8):1187-1191.

9.SimovitchRW,ZumsteinMA,LohriE,HelmyN,GerberC.PredictorsofscapularnotchinginpatientsmanagedwiththeDeltaIIIreversetotalshoulderreplacement.J Bone Joint Surg Am.2007;89(3):588-600.

10.SirveauxF,FavardL,OudetD,HuquetD,WalchG,MoléD.Gram-montinvertedtotalshoulderarthroplastyinthetreatmentofglenohumeralosteoarthritiswithmassiveruptureofthecuff:resultsofamulticentrestudyof80shoulders.J Bone Joint Surg Br.2004;86(3):388-395.

11.SirveauxF.La prothèse de Grammont dans le traitement des arthropathies de l’épaule à coiffe détruite: à propos d’une série multi-centrique de 42 cas[thesis].Nancy,France:FacultédeMédecinedeNancy;1997:245.

12.VanhoveB,BeugniesA.Grammont’sreverseshoulderprosthesisforrotatorcuffarthropathy:aretrospectivestudyof32cases.Acta Orthop Belg.2004;70(3):219-225.

13.BoulahiaA,EdwardsTB,WalchG,BarattaRV.Earlyresultsofareversedesignprosthesisinthetreatmentofarthritisoftheshoulderinelderlypatientswithalargerotatorcufftear.Orthopedics.2002;25(2):129-133.

14.DelloyeC,JorisD,ColetteA,EudierA,DubucJE.Mechanicalcomplicationsoftotalshoulderinvertedprosthesis[inFrench].Rev Chir Orthop Reparatrice Appar Mot.2002;88(4):410-414.


42

AnteriorHipPaininanAthleticPopulation:DifferentialDiagnosisandTreatmentOptionsMArk A. sLABAugh, MD; rACheL M. FrAnk, MD; roBerT C. gruMeT, MD; PhiL MALLoY, MPT;

ChArLes A. Bush-JosePh, MD; WALTer W. virkus, MD; shAne J. nho, MD, Ms

author affiliations

DivisionofSportsMedicine,DepartmentofOrthopedicSurgery

(DrsSlabaugh,Frank,Grumet,Bush-Joseph,Virkus,andNho),

andHealthyHipProgram(DrsBush-Joseph,Virkus,andNho),

RushUniversityMedicalCenter,Chicago,Illinois;andAthletico

PhysicalTherapy,Chicago,Illinois(MrMalloy).


ShaneJ.Nho,MD,MS;RushUniversityMedicalCenter,1611W

HarrisonSt,Suite300,Chicago,IL60612([email protected]).

introduction

Athleticinjuriesaroundthehiphavebeenpoorlyunderstoodand

oftenwerelumpedintothediagnosisof“hippointer.”Patients

withhipinjurieswerefrequentlytreatedconservativelyforlong

periodsoftimeuntilmanyeithergaveuptheirsportofchoiceor

limitedtheiractivities.

Sincetheadventofhiparthroscopy,therehasbeenanincreasing

interestinthediagnosisandtreatmentofpatientswithathletic

hipinjuries.Justinthepast10yearstherehasbeenincreasing

researchinterestandpublicationregardingconditionsthataffect

thehipandtheirtreatment.Advancesinimagingmodalitieshave

allowedphysiciansandsurgeonstobettergraspsoft-tissueinjuries

aroundthehipandtheirnaturalhistory.Additionally,technologic

advancesinhiparthroscopyequipmentandrepairdeviceshave

allowedconditionsthatwerepreviouslytreatedconservativelynow

tobetreatedmoreaggressively,allowingforearlierreturntosports

andresultinginhighpatientsatisfaction.

Withalltheserecentadvances,physiciansaregainingabetter

understandingofthecomplexanatomyandpathologyofthehip

andsurroundingareas.Oftenhipconditionscanbecategorized

intoananatomicallocationdependinguponwherethehippain

predominantlyoccurs.Thisreviewwillfocusonthecausesof

anteriorhippaininanathleticpopulation.

anatomy

Knowledgeofthefunctionalanatomyofthehipanditssur-

roundingstructuresisnecessaryinordertoarriveataconclusive

diagnosisregardinghipconditions.Theanatomyoftheanterior

portionofthehipiscomplex,withseveralmusclegroupscrossing

thehipandmanymorearisingfromthehipareaandthelower

abdominalwall.

Adiscussionofhipanatomyhastoincludekeystructuresinthe

pelvissincethesestructures,wheninjured,oftenradiatepaininto

theanteriorhip.Theanteriorpelvisconsistsofseveralstructures

thatplayaroleinconditionsthataffectthehip.Osseousmorphol-

ogyincludestheanteriorsuperioriliacspine(ASIS),whichserves


“tEchnologic advancEs . . . havE allowEd conditions that wErE prEviously trEatEd

consErvativEly now to bE trEatEd morE aggrEssivEly, allowing for EarliEr rEturn to

sports and rEsulting in high patiEnt satisfaction.“


astheoriginofthesartoriusmuscleandtheilioinguinalligament.

Theanteriorinferioriliacspine(AIIS)servesastheattachment

oftherectusfemoris,oneofthekeyhipflexorsandkneeextend-

ers.Themusclescollectivelyknownastheadductorsofthehip

alloriginateintheanteriorpelvicregion.Thepectineusandthe

adductorlongusoriginateonthesuperiorpubicramus,whilethe

adductormagnus,theadductorbrevis,andthegracilisoriginateon

theinferiorpubicramus.Allthesemusclescollectivelyadductthe

thigh.Therectusabdominisinsertsonthepubicbonejustlateral

tothesymphysis.Finally,theiliopsoas,themajorhipflexor,cross-

esundertheilioinguinalligamenttoinsertonthelessertuberosity

aftercrossingovertheanteriorcapsuleofthehip.Thistendonhas

alargebursasurroundingitthathelpsitglidesmoothlyoverthe

hipwithrangeofmotion.

Theinguinalareaisunfamiliarterritoryformanyorthopedic

surgeonssincegeneralsurgeonstreatthemajorityofconditions

arisinginthisarea.Itishelpfultothinkoftheinguinalcanalasa

boxcomposedofsixsides.Theposterioropeningisthedeepin-

guinalring.Theposteriorwalloftheboxiscomposedofthisring,

thetransversalisfascia,andtheconjointtendonwithCooper’s

ligament.Thesuperiorwall(roof )consistsoftheinternaloblique

andtransversusabdominismuscles.Theanteriorwalliscomposed

oftheaponeurosisoftheinternalandexternalobliquesaswellas

thesuperficialinguinalring.Theinferiorwall(floor)ismadeup

oftheinguinalligament,thelacunarligament,andtheiliopubic

tract.Theinguinalcanalcontainsthespermaticcordinmalesand

theroundligamentinfemalesalongwiththeilioinguinalnerve

(responsibleforradiationofpaintotheanteriorhip).Theclinical

significanceofthesestructureswillbediscussedfurtherunderthe

respectivedisorders.

Thehipitselfisaspheroidaljointcomposedofthefemoral

headandtheacetabulum,whichisdeepenedbythelabrum.

Intra-articularpathologyisoftenmanifestedbyanteriorhipor

groinpainduetotheinnervationofthehipcapsule.Themajor-

ityofthearticularhipisinnervatedbythefemoralandobturator

nerves,bothofwhichhaveanterior/medialinnervationandradia-

tionpatterns.Therefore,mostintra-articularconditionsradiateto

theanteriorgroinorhip.

physical Examination

Knowledgeoftheanatomyoftheanteriorpartofthehipwill

allowtheastutecliniciantofocusthephysicalexaminationto

elucidatethelocationandtypeofpathologyineachpatient.Physi-

calexaminationshouldbeginwithagaitassessment.Patientswho

haveastressfracturewillhavedifficultybearingweightonthe

affectedside,andanantalgicgaitwillbeobserved.Furthermore,

patientswithfemoroacetabularimpingement(FAI)willoftenhave

anincreasedfootprogressionanglewiththeaffectedlimbexhibit-

ingmoreexternalrotation.Patientswithsevereosteoarthritis,in

additiontothosewithavarietyofotherconditions,canhavea

Trendelenburggaitandsigniftheabductorsaresufficientlyweak

tocausepelvictilttotheaffectedsidewhenbearingweightsolely

ontheaffectedextremity.

Carefulexaminationofthehipatrestwiththepatientsitting

overthesideofthebedcanelucidatecausesofhipimpingement.

Inpatientswithacetabularretroversion,theaffectedextrem-

itymustexternallyrotateinorderforthefemoralnecktoavoid

impingementontheanterioracetabularrim.Therangeofmotion

isthenassessedandcomparedwiththatoftheopposite,nonin-

volvedextremity.Thisassessmentincludesflexionandextension,

withrotationassessedat90degreesofhipflexion.Patientswho

havebothFAIandosteoarthritiswilloftenhavelimitedmotion,

especiallyinternalrotation,withpainattheendsoftherangeof

motion.Crepitationcanoccasionallybefeltwithcircumduction

inthispatientpopulation.InpatientswithFAI,theimpingement

figure 1. Femoralneckstressfractureofrightfemur.A,MRI,frontalview.B,Postoperativeradiographshowingpercutaneousscrewfixation.

a b

44

testconsistingofadductionandinternalrotationwillelicitpain.

Thismaneuvercanbetestedstartingat45degreesofhipflexion,

increasingtoaround120degrees.Patientswithmoresevereim-

pingementwillhavemorepainwithlesshipflexion.

Duringtherangeofmotionexamination,thehipisbrought

intomaximalflexion/abductionandexternalrotationandquickly

broughtbacktoneutralrotationwiththehipstraight.Patients

withinternalsnappingofthehipduetobursitisintheiliopsoas

willhavesnappingwiththismaneuverastheiliopsoassnapsover

theiliopectinealeminenceorthefemoralhead.Oftendownward

pressureinthisareaisneededtofeelthesnappingofthistendon.

Alog-rollexaminationisperformedtodetermineifintra-

articularpathologyiscausingsynovitisofthehip.Thisexamination

isperformedbyinternallyandexternallyrotatingthehipwith

thehiprelaxedandthekneefullyextended.Muscularstrength

testingisperformedtoassessthepresenceofanytendinopathyof

thetendonsaroundthehip.Strengthtestingoftheinternaland

externalrotatorsaswellastheadductorsisperformedwiththepa-

tientintheseatedposition.Abductorstrengthtestingisdonewith

thepatientinthelateralposition.Hipflexionstrengthtestingis

performedwiththepatientinthesupineandseatedposition.The

patientwithrectusfemoris/quadricepstendonitiswillhavemuch

morepainwithresistedhipflexioninthesupinepositionthanin

theseatedposition,whereastheoppositewillbetrueiniliopsoas

tendonitis.Whilethepatientisinthesupineposition,astraight

legexaminationisperformedtohelpruleoutanybackconditions

thatmightradiateintotheanteriorhip.Alsoinasupineposition,

thepatientisaskedtoperformasit-upagainstresistancetoascer-

tainwhetheranyabdominalwallpathologyispresent.

Palpationofthehipisextremelyimportantforidentifyingall

hipconditionsbutespeciallythoseintheanteriorhip.Palpation

beginsontheASISandinthinpatientsovertheAIIStodetermine

ifinjurytothesartoriusorrectusfemorishasoccurred.Inpatients

withosteitispubis,palpationjustlateraltothesymphysiswill

revealtenderness.

Theabovestepwisephysicalexaminationwillallowthesurgeon

toformulateadifferentialdiagnosisthatcanbeconfirmedbyplain

radiography,magneticresonanceimaging(MRI),orcomputed

tomography(CT).Thespecificcausesofanteriorhippainare

presentedinthefollowingsection.

specific conditions

stress Fracture

Astressfractureisaninsufficientbonyhealingresponsecausedby

anabnormalamountofforceactingonanormalbone.Thefrac-

tureresultsfromeitherabnormalmuscularforcesorgaitpatterns

thatdistributeexcessivestresstotheunderlyingbone.1Patients

typicallyarelong-distancerunnerswhochangetheirfrequency,

duration,orintensityoftraining.2,3Additionally,militaryrecruits

havetypicallybeenshowntohaveahigherincidenceduetotheir

rapidonsetofintensetraining.Patientswithafemoralneckstress

fracturepresentwithactivity-relatedanteriorgroinpainthatis

relievedbyrestandoftencorrespondstoanincreasingtraining

regimen.Thesepatientswillinitiallybeonlymildlyaffected,butas

theycontinuetoworkthroughthepain,theybecomemuchmore

symptomatic.Patientswhohavedelayedtheirpresentationalmost

alwayshavepainwithweightbearingandanantalgicgait.

Thediagnosisofafemoralneckstressfracturebeginswith

plainradiography,whichfrequentlywillbenegative.However,

withcarefulinspectionincreasedsclerosisattheinferiorneckor

afracturelineatthesuperiorneckcanoccasionallybevisualized.

Inpatientswhereradiographsarenegative,thestudyofchoiceis

MRItodiagnosethestressfracture.4MRIwillrevealdecreased

figure 2.Radiographshowingmilddysplasiaofthehips.

figure 3. A,B,Intraoperativearthroscopicimagesofrighthipshowingahypertrophiclabrumwithcontusion.

a b

figure 2 figure 3


signalintensityonT1images(blackline)orincreasedintensity

onT2images(Figure1A).

Thelocationofpathologicchangesdeterminestheclassification

offemoralneckstressfractures.5Inferiorneckchangesaretermed

compression-sidedstressfractures,whereassuperiorneckchanges

indicateatension-sidedstressfracture.Ifthefracturelineextends

allthewayfromthesuperiortotheinferiorfemoralneck,thefrac-

tureisclassifiedascomplete.Completefracturesportendimpend-

ingdisplacementandrequireemergentevaluation.

Treatmentoffemoralneckstressfracturesisdictatedbythe

fracturelocation.Tension-sidedfracturesarecommonlythoughtto

haveanincreasedriskofpropagationtotheinferiorneckandthus

aretreatedmuchmoreurgentlywithpercutaneousscrewfixation4

(Figure1B).Compression-sidedstressfracturesaretreatedwith

restrictedweightbearingandactivitymodificationuntilsymp-

tomscease.Gradualresumptionofactivityisallowedonlyafter

thepatientiscompletelyasymptomaticforaperiodoftime.Any

recurrentpainindicatesresidualstressreaction,andactivitiesneed

tobeceased.Withbothoftheseregimens,treatmentforstressfrac-

turesisgenerallysuccessful.6

osteonecrosis

Osteonecrosisofthehipcanbecausedbyavarietyofderange-

ments.Theendstateofthehipiscollapseduetolossofthe

structuralintegrityofthesubchondralbonemostlikelythoughtto

befromdecreasedbloodflow.Thisnecrosisofthefemoralheadis

adebilitatingconditionsinceittypicallyisprogressiveandaffects

patientsearlyinlife,between20and50yearsofage.7Manycauses

ofosteonecrosishavebeenelucidated,suchastrauma,steroids,

alcohol,smoking,lupus,sickle-cellanemia,diving,andcoagulopa-

thies;however,around20%ofcaseshavenoapparentcauseand

areidentifiedasidiopathic.8,9

Patientswithosteonecrosisofthehiptypicallypresentwithpain

inthegroin,whichtheyrelateasadeep,intermittentache.Usually

thereisnohistoryoftrauma,andpatientshavepainwithroutine

dailyactivities.Examinationfindingsdependuponthestageof

presentation.Inpatientswithearlydisease,painwillbepresent

onlyattheextremesoftherangeofmotion;however,inpatients

withseveredisease,arestrictedrangeofmotionisevidentand

mostplanesofmotionarepainful.

Plainradiographyisfrequentlydiagnosticofosteonecrosis

becausepatientsfrequentlypresentwithadvanceddisease.Ficat10

classifiedosteonecrosisbaseduponradiographicfindings.StageIis

characterizedbynegativeradiographs;stageII,bycysticchangesin

thefemoralheadnotaffectingitsshape;stageIII,bysubchondral

collapse;andstageIV,bycollapseordeformationofthefemoral

head.MRIisfrequentlybeneficialindeterminingthestageand

extentofosteonecrosis,aswellasthepresenceofsignsofcol-

lapse,sinceitisverysensitiveindetectingsubtleabnormalitiesin

thebone.Steinbergetal11developedaclassificationthatisbased

uponMRIandusesthepercentageofthehipinvolvedtofurther

subclassifyosteonecroticlesions.

Thetreatmentofosteonecrosisiscontroversialsincenosinglein-

terventionhasbeenshowntopreventprogressionofthediseasein

allpatients.9Inaddition,thepoorresultsofmanyinterventionsfor

osteonecrosishavefurthercontributedtothecontroversyregarding

treatmentforthiscondition.Generally,treatmentisdictated

bythestageofthedisease.Watchfulwaitingwithconservative

managementistypicallynotindicatedforprogressivesymptomatic

osteonecrosissincethenaturalhistoryofosteonecrosisisprogres-

siveworseningandultimatecollapsein80%ofpatients.9Patients

intheearlystageswithoutcollapseorcartilagedamagecanbe

treatedwithcoredecompressionwithorwithoutadditional

vascularizedbonegrafting.Effectivenessoftheseproceduresisbet-

terforpatientsintheearlystagesofdiseasewithgoodresultsin

figure 4.A,B,Intraoperativearthroscopicimagesofrighthiplabraldebridement.

a b

46

84%-96%ofcasesinstageIand47%-74%ofcasesinstage

II.12,13PatientsinstageIVofthediseasetypicallyrequiretotalhip

replacementatayoungage.Resultsoftotalhipreplacementin

osteonecrosisaretypicallythoughttobeinferiortothoseofhip

replacementforosteoarthritis,butcomparingresultsinthese2

differentpopulationsisdifficultbecauseofageandactivitydiffer-

ences.14,15

labral tears

Acetabularlabraltearshaverecentlybeenrecognizedasanincreas-

ingcauseofhippaininanactivepopulation.16Initially,labraltears

werethoughttobeisolatedentities17;however,increasinglythey

havebeenassociatedwithstructuralabnormalitiesoneitherthe

acetabularorthefemoralsideofthehipsuchasFAI.18Inisolation,

theyhavebeenassociatedwithathleticparticipationthatrequires

repetitivehipflexionand/orpivoting,suchasinhockey,soccer,

football,andevenrunning.17,19Othercausesoflabraltearsinclude

dysplasia(Figure2),instability,trauma,anddegeneration.

Patientswithlabraltearstypicallypresentwithanteriorhippain

radiatingtothegrointhatisassociatedwithactivitiessuchas

twistingmotions,running,walking,andoftensittingforpro-

longedperiods.Mechanicalsymptomsareoftenvariable.Byrdhas

describedthe“C”signinwhichpatientsgriptheirhipjustabove

thegreatertrochanterwiththeirhandina“C”shapeindicating

thesiteofpathology.20Examinationofthehiprevealsapositive

impingementsignwherethehipistakenintoflexion,adduction,

andinternalrotationandreproducesgroinpain.18Thistestrelies

onthefemoralneckimpingingontheanterosuperiorlabrum,

wheremostlabraltearsoccur.Posteriorlabraltearswillhavepain

reproducedwhenthepatientlieswithbothlegshangingoffthe

tableasthecontralaterallegisbroughttothepatient’schestwhile

theaffectedlimbismaximallyextended.Theexaminerthenforce-

fullyexternallyrotatesthehip,andpainisreferredtotheposterior

hip/buttock.18

Theworkupincludesradiographsandtypicallymagnetic

resonancearthrography(MRA).Radiographswillbehelpfulonly

inthecaseofdysplasiaorFAI.MRAisnearly100%specificfor

labraltearswiththecontrastextendingintothenormallydark

labrumonT2images.21Occasionally,perilabralcystsareseenin

associationwiththelabraltear.

Thetreatmentforlabraltearscontinuestobesurgicalsincecon-

servativetreatmenthasshownpoorresultsinrestoringfunction.

Despitegoodresultswithsurgicalintervention(Figures3and4),

thereexistscontroversyoverwhetherlabraltearsshouldbede-

bridedorrepaired.17Asystematicreviewindicatesthatgoodresults

arepossiblewithlabraldebridementforupto3.5years.22How-

ever,thelong-termresultsoflabraldebridementareunknown,

anditisunclearwhetherthereisanincreasedriskofarthritisin

patientswhohavelabraldebridementonly.Someauthorsprefer

ananatomicrepairoverdebridementinordertorestorenormal

hipkinematicsandhopefullylong-termfunctionofthehip.23,24

Inpatientswhohaveastructuralabnormalityofthehipsuchas

dysplasiaorFAI,thestructuralabnormalityneedstobeaddressed

atthetimeofsurgeryinordertopreventrecurrenttearsorfailure

oftherepair.

Femoral Acetabular impingement

Femoralacetabularimpingementexistswhenthereisabnormal

contactbetweenthefemoralneckandtheacetabularrim.Pathol-

ogycanexistoneitherthefemoralside(camimpingement)orthe

acetabularside(pincerimpingement)25;however,mostcommonly

acombinationofabnormalanatomyonbothsidesisfound

inpatientswithFAI.26Inpurecamimpingement,theanterior

femoralnecklosesitsnormalconcaveanatomyandhasa“bump”

thatimpingesontheanterosuperiorlabrum,withflexioncausing

labraltearsanddelaminationoftheadjacentcartilage.Purepincer

impingementarisesfromaprominentacetabularrimcausingover-

coverageofthefemoralhead.Inpincerimpingement,acetabular

figure 5.A,B,RadiographsofFAI.Thelefthipdemonstratescombinedlesionwithcrossoversignandossifiedlabrumwithcamlesionofthefemoralhead-neckjunction.

a b

labraltearsresultfromtherepetitiveimpactionwithflexionand

internalrotation.

PatientswithFAIreportaninsidiousonsetofgroinpainthatis

exacerbatedbyflexionactivities.Squatting,tyingshoes,driving,

andprolongedsittingallexacerbatethesymptoms.FAIcanbe

foundinathletesinvolvedinsportsthatrequirerepetitiveflexion

andtwisting,suchashockey,football,andgolf.27Inpatientswith

cartilagedamage,evenwalkingorrunningcancausesymptoms

withoutthemechanicalirritationoftheimpingement.Physi-

calexaminationofpatientswithFAIrevealsfindingssimilarto

thosefoundinpatientswithacetabularlabraltears.Severecasesof

abnormallylargecamlesionsorovercoverageresultinrestriction

oftherangeofmotionofthehip,especiallyinternalrotationand

flexion,duetoamechanicalblock.Theimpingementtestisposi-

tiveinpatientswitheithertypeofFAI.

Radiographs(Figure5)areessentialtodiagnoseFAIanddistin-

guishthisconditionfromanisolatedlabraltear.28Camimpinge-

mentisbestdemonstratedonacross-tableradiograph,whichwill

showanasphericityofthefemoralhead/neckjunctionanteriorly.

Pincerimpingementwillshowovercoverageofthefemoralhead

(increasedcenter-edgeangle)orretroversionoftheacetabulum

(cross-oversign)onananteroposterior(AP)radiograph.MRIor

MRAfrequentlyisusedtoquantifytheextentofthepathology,

especiallytodetermineifanycartilagedeteriorationhasoccurred

inassociationwithcamimpingement.CT,andinparticular

3-dimensionalCT,isalsoextremelyhelpfulasitprovidesaclear

evaluationofthefemoralhead/neckandacetabulumosseous

structure(Figure6).

Surgicalintervention(Figure7)isoftenneededsinceFAIis

anabnormalmechanicalabutmentbetweenthefemurandthe

acetabulumandtreatmentisaimedatcorrectingorremoving

theabnormalanatomy.Currently,botharthroscopicandopen

approacheshavebeenrecommendedtotreatbothtypesofFAI.28

Forcamimpingement,bothmethodsrelyonremovingboneby

osteoplastyatthefemoralhead/neckjunctiontoallowthefemoral

necktoclearthelabrumwithflexionandinternalrotation.29Pin-

cerimpingementistreatedwithdetachmentofthelabrumandre-

movaloftheacetabularrimthathangsoverthefemoralhead/neck

junction.Thelabrumisthenfixedbacktothenormallycontoured

acetabularrimwithsutureanchors.30Inbothtypesofimpinge-

ment,labraltearsareaddressedwithfixationordebridement,and

cartilagedamageisaddressedwithdebridementormicrofracture.

Resultsofbothopenandarthroscopicosteoplastyofthefemur

andacetabulumarestillpreliminarywithonlyafewstudiesre-

portingmidtermresults.Philipponetalreportedresultsat2years

afterarthroscopicosteoplasty.30Patientshadanaveragesatisfaction

of9(outof10)withbetterresultsinpatientswithlabralfixation.

Becketalreportedimprovementin13of18patientswithopen

dislocation.31Opensurgeriesareassociatedwithlongerrecovery

timesandrehabilitationperiodsthanarthroscopictreatment,but

advocatesrelatebetterabilitytocontourthefemuroracetabulum.

Itremainstobeseenwhichsurgerywillresultinimprovedresults

and,moreimportantly,lessprogressiontoarthritisandtheneed

forhipreplacement.Bothopenandarthroscopicprocedurescur-

rentlyhavearoundan8%-13%rateofrevisiontohiparthroplasty

inshort-termfollow-up.25

iliopsoas tendonitis

Oftenreferredtoasinternalsnappingofthehiporinternalcoxa

saltans,iliopsoastendonitis/bursitiscanbearecalcitrantcauseof

anteriorhippain.Snappingoftheiliopsoasleadingtobursitisor

tendonitiscanoccurat3differentanatomicsites:theiliopectineal

eminence,thefemoralhead,orthelessertrochanter.32Although

thepresenceofsnappingisnecessarytocausepathology,itspres-

enceisnotindicativeofpathology.Runnersandballetdancers


figure 6.A,B,CTscansoflefthipwithFAIdemonstratingbothcamandpincerpathologies.B,Notetheexcessbonealongthefemoralneck.

a b

48

arefrequentlynotedtohaveissueswithiliopsoastendonitis.33,34

Thechronicityofthesymptomswillindicatewhatpathologyis

present.Inpatientswithrelativelyacutesymptoms,onlyabursitis

willbepresent;however,longerdurationofsymptomswillleadto

tendonitisortendinopathy.35

Patientswhohavesymptomaticiliopsoastendonitisrelateante-

riorpainthatisassociatedwithsnappingofthehip.Theprovoca-

tivemaneuverthatelicitspainistakingthehipfromaflexedand

externallyrotatedpositiontoanextendedandinternalrotated

position.34Mostoften,theexaminercanhearasnaporpop,but

occasionally,pressurewithone’shandovertheiliopsoastendonis

neededtofeeltheinternalsnapping.Tendernessinthissamearea

isalsodiagnosticoftendonitis.

Inpatientsforwhomconservativetreatment(rest,anti-inflam-

matories,andphysicaltherapy)hasfailed,ultrasoundisemployed

toguideatherapeuticandoftendiagnosticinjectionofcortisone.36

Becauseoftheabilityofultrasoundtodetectdynamicdifferences,

thesnappingoftheiliopsoascanbeseenwiththeaboveprovoca-

tivemaneuver.37Ifacortisoneinjectionfails,surgicalfractional

lengtheningoftheiliopsoastendoncanbeperformedtoeliminate

snappingandrelievepainateitherthejointorthelessertrochanter

(Figure8).38

Muscular strains/Avulsion Fractures

Muscularstrainscanoccurinanyoftheanteriorlylocatedmuscles

thatinsertaroundorcrossthehip.Intheadultathleticpopula-

tion,theadductormusclegroupismostcommonlyaffected.

However,inskeletallyimmaturepatients,avulsionfracturesatthe

originofthesartoriusandtherectusfemorisaremorecommon

thanmuscularstrains.

Athleteswhohaveadductorstrainstypicallyareinvolvedin

eitherrotationalorkickingsportssuchassoccer,football,hockey,

andrugby,wherechangesindirectionarefrequentlyseeninsome

positionplayers.39Typically,anincitingeventsuchasafallorex-

cessiveeccentriccontractionduringapivotingmaneuverisrelated

asthebeginningofthepain.Physicalexaminationrevealsquite

focalfindingswithswellingandtendernessconfinedtotheantero-

medialaspectofthehipalongtheadductormusclegroup.The

patienthastendernessalongtheadductorsanddecreasedstrength

withresistedadductioncomparedwiththecontralateralside.Very

rarelywillthepatienthavearuptureoftheadductorsoffofthe

pubis,whereadefectmaybefelt.40Inpatientswhohaveaques-

tionablehistoryoravagueexam,MRIishelpfultodeterminethe

truesiteofpathology.41Treatmentofadductorstrainscontinues

tobenonoperativewithrest,ice,andactivitymodificationuntil

tendonhealingcanoccur.Inthoserarecompletetendonavulsions,

surgicalreattachmentisneededifretractionissignificant;however,

howmuchretractionistoomuchisnotknown.

Avulsionsofthesartoriusorrectusfemoris(Figure9)inskeletal-

lyimmaturepatientsaretypicallyseenafteratraumaticsporting

injury.Sportsthatrequirerapidaccelerationanddecelerationof

thehipinanextendedpositionsuchassoccer,hockey,gymnastics,

andtrackfrequentlyareassociatedwithsuchavulsionfractures.

Adolescentsage14to17aremostfrequentlyatriskduetothe

inherentweaknessoftheapophysisatthemuscularattachments.42

Patientspresentwithatraumatichistoryandpain,swelling,

andtendernessintheaffectedmusculargroup.Stretchingofthe

affectedmusclealsoreproducescharacteristicpain.Radiographs

arediagnosticandwilltypicallyshowminimaldisplacementofthe

apophysisattheASISorAIIS.

Treatmentistypicallyconservativewithrest,ice,anti-inflamma-

tories,andoccasionallyphysicaltherapy.Surgicalinterventionis

rarelyneededandisindicatedonlywithsignificantdisplacement

(>2cm).43Dependinguponthefracturesize,useofeithersuture

anchorsorscrewfixationiswarranted.

figure 7.Intraoperativearthroscopicimagesoflefthipcamosteoplasty.A,Camlesionintheperipheralcompartment.B,Osteoplastyofthecamlesion.

a b


figure 8.Intraoperativearthroscopicimageshowingiliopsoasreleaseatthelessertuberosity.

figure 9.Imageshowingruptureoftheleftrectusfemoris.

osteitis Pubis

Osteitispubisisaninfrequentcauseofanteriorhippainthataf-

fectsmalesmuchmorecommonlythanfemales.Thetermosteitis

pubishasbeenusedtodescribeanumberofconditionsthataffect

theareasurroundingthesymphysispubis.Injuriestotherectus

musclesorpubicsymphysis,infection,andhormonalconditions

thataffectpre-orpostpartumfemaleshavebeenknowntocause

thiscondition.Aswithmostinjuriesaroundthehip,twistingor

rotationsportsarefrequentlyassociatedwiththisconditionin

athletes,makingthediagnosisdifficult.44,45

Patientswithosteitispubispresentwithpainovertheanterior

aspectofthepelvisthatisworsewithsit-ups,risingfromachair,

oranyactivitywherecontractionoftherectusmusclesoccurs.32

Painradiatesintotherectusmuscles,andoccasionallyspasminthe

musclessurroundingthepubisisencountered.Tendernessiselic-

iteddirectlyoverandjustlateraltothesymphysis.Radiographsare

frequentlynegative,butoccasionallychronicdegenerativechanges

atthesymphysisarepresentinadditiontosymphysealnarrowing.

Ifinstabilityispresent,1-leggedstanceimageswillshowdiastasis

orsuperiormigrationofoneramusinrelationshiptotheother.

Additionalimagingisoftennecessaryfordiagnosis;MRIand

bonescansareusedtolocalizethepathologytothesymphysis

pubis.MRIandbonescanswillshowlocalizedpathologytothe

pubisjustadjacenttothesymphysis;however,MRIisfrequently

nonspecific.46

Thetreatmentofosteitispubisisnearlyalwaysnonsurgicalwith

rest,anti-inflammatories,andphysicaltherapytogentlystretch

themusculaturearoundthepelvisandworkoncorestrengthen-

ing.Ifconservativemeasuresfail,alocalizedsteroidinjectioncan

beconsidered.Surgicalmanagementofrefractorycasesincludes

curettage,meshplacement,orstabilization,allofwhichhave

variedresultsandnoneofwhichhasshownsuperiorityover

others.47RadicandAnnearrecentlypublishedresultsshowinga

goodreturntosportinathletestreatedwithcurettage.45

sports hernia

Sportshernia,alsoreferredtoasathleticpubalgia,continuestobe

anenigmaticconditioncausinganteriorhippainintheathlete.

Arrivingatthisdiagnosiscanbechallenging,andpatientscan

havelingeringsymptomsforyearsbeforereceivingthediagnosisof

sportshernia.48Unlikeotherhernias(inguinal,abdominal,etc),a

sportsherniatypicallydoesnotinvolveabulgeoftissueprotruding

throughonebodypartintoanother.Incontrast,asportshernia

occurswhentheobliqueabdominalmusclesstrainorcompletely

tearawayfromtheirattachmenttothepubis.Arecentsystematic

reviewoftheliteraturehasshownthattheunderlyingetiologyof

sportsherniasinvolvesposterioringuinalwallweakening,which

canbearesultofpoorlybalancedhipadductorandabdominal

muscleactivation.49

Patientswithsportsherniawilltypicallypresentwithanterior

hipand/orgroinpain,especiallywithhipextension,twisting,and

turning.Inaddition,patientscanhavepaininthelowerabdomen

and(formales)inthetesticles.Physicalexaminationwillusually

showpubicpointtenderness,whichisexacerbatedbyresistedhip

adduction.50MRIandultrasound49areextremelyhelpfulinassist-

ingwithdiagnosisandformingatreatmentplan.51

Theinitialtreatmentofchoiceforsportsherniasisconserva-

tive,andthefirststepisalwaysactivitymodificationortemporary

absencefromsymptom-producingactivities.Additionalmodali-

tiesincludeanti-inflammatories,ice,andphysicaltherapyto

strengthenthesurroundingmuscles.Whilecontroversyexists

regardingappropriatesurgicaltreatment,52surgicalintervention

withaninternalobliqueflapreinforcedwithmeshhasprovento

besuccessful.50,52

figure 8 figure 9

50

general rehabilitation considerations

Rehabilitationfollowingahipinjurythatresultsinanteriorhip

painwillbedeterminedbyinjurylocation,typeandmechanismof

injury,andseverityofthepathology.Restrictionofweightbearing

throughuseofanassistivedevicemaybeutilizedtopreventexces-

sivestressonbonyandsupportingsoft-tissuestructuresduring

theearlystagesofhealing.Physicaltherapyinitiallyshouldfocus

onearlycontrolledrangeofmotionofthehipjointtoprevent

bothintra-andextra-articularadhesionsandexcessivescartissue

formation.53Postoperatively,tightnessoftheposteriorhipcapsule

aswellastheanteriorandposteriormusculatureisacommon

findinginthispopulation.Soft-tissueandjointmobilizationmay

beutilizedtoaddressareasofsoft-tissuerestrictionandcapsular

tightnessinordertorestoremobilityandsymmetricalrangeof

motion.54Improvementsinmusclefiringpatternshavealsobeen

observedfollowingmanualtherapytechniques.Strengthening

ofthesupportinghipjointmusculatureshouldfocusonthehip

abductorgroup,theanteriorandposteriorthighmusculature,and

thecorestabilizingmuscles.Neuromuscularreeducationshouldbe

utilizedtopromotenormalbiomechanicsandminimizecompensa-

torymovementpatterns.Acardiovasculartrainingprogrammaybe

usedtorestorefitnesstocompetitiveathletes,andareturn-to-sport

programshouldbeimplementedbeforereturntounrestricted

trainingandfullcompetition.53-55

Conclusions

Anteriorhippainisoftenpoorlyunderstoodyetremainsacom-

moncomplaintintheathleticpopulation.Thelocationofpathol-

ogyrangesfromtotheunderlyingbonyanatomyofthehiptothe

supportingsoft-tissuestructuresandcanbedifficulttoassessclini-

cally.Intheathleticpopulation,anteriorhippaincoversabroad

spectrumofconditions,includingstressfractures,osteonecrosis,

labraltears,femoralacetabularimpingement,iliopsoastendonitis,

osteitispubis,musclestrains/avulsionfractures,andsportshernia.

Althoughmanyoftheseconditionscanbealleviatedwithnon-

surgicalmanagement,theclinicianshouldhavealowthresholdto

referathleteswithpersistenthipandgroinpaintoanorthopedic

surgeonspecializinginhipjointpreservationsurgery.Theworkup

shouldbeginwithplainradiographs,butadvancedimagingwith

MRI,MRA,orCTmaybeappropriate.Anintra-articularinjec-

tionwithlocalanestheticsandsteroidcanbebothdiagnosticand

therapeutic.Thetreatmentoptionsdependonthediagnosisand

varyfromactivitymodificationtosurgicalintervention.Withan

improvedunderstandingofathletichippathology,healthcare

providerswillbebetterequippedtohandleanteriorhipand

groininjuries.

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52

TheTechniqueofAcetabularDistractionfortheReconstructionofSevereAcetabularDefectsWith

anAssociatedChronicPelvicDiscontinuitysCoTT M. sPorer, MD, Ms; AnDreW MiChAeL, MD; WAYne g. PAProskY, MD; MArio MoriC, Ms

author affiliations

DepartmentofOrthopedicSurgery,RushUniversityMedicalCen-

ter,Chicago,Illinois(DrsSporerandPaprosky);DrexelUniversity,

Philadelphia,Pennsylvania(DrMichael);RushUniversityMedical

Center,Chicago,Illinois(MrMoric).


AndrewMichael,MD;DrexelUniversity,629CarrollDr,

Hummelstown,PA17036([email protected]).

introduction

Theprevalenceofpelvicdiscontinuity,aconditionresultingin

separationofthesuperiorandinferiorportionsofthepelvis,will

likelyincreaseduetototaljointreplacementbeingutilizedin

youngerandmoreactivepatients.Well-fixedcementlessacetabular

componentscancreateasituationinwhichosteolysisandstress

shieldingcanprogressasymptomatically.1Theseverityofboneloss

canbepronouncedbythetimethecupmigratesorthepatient

beginstohavesymptoms.Similarly,migrationofacemented

acetabularcomponentoveraperiodoftimecanresultinalarge

amountofbonedestruction.2Asuccessfulacetabularreconstruc-

tionrequireseitherastablemechanicalconstructthatgainsits

stabilitysolelythroughsupplementalfixation(screws,spikes,

flange)orabiologicconstructthatwillallowboneingrowthinto

theacetabularcomponent.Inordertoachieveboneingrowthinto

anacetabularcomponent,theinitialreconstructionmustminimize

micromotionandthesurroundingmilieumustremainbiologically

active.

Pelvicdiscontinuityresultsinamorechallengingenvironment

inwhichtoobtaininitialcomponentfixationduetothepossibil-

ityofpersistentmotionbetweenthesuperiorandinferiorhalves

ofthepelvis.Severalauthorshavesuggestedcompressionplating

oftheposteriorcolumnwiththeuseofahemisphericalacetabu-

larcomponent.2-4Thegoalofthissurgicaltechniqueistorigidly

fixthediscontinuityinordertoobtainbonyunionbetweenthe

superiorandinferiorhemipelvisandtominimizemicromotion

ofahemisphericalcomponentinordertoallowboneingrowth.

Adequateposteriorcolumnbonetoallowbothstableplatefixation

aswellasdirectboneappositionisaprerequisiteforthismethod

ofreconstruction.However,incertainsituationswheretheamount

ofbonelossalongtheposteriorcolumnissevere,rigidstability

anddirectbonyappositioncannotbeobtained.Inthesesituations,

anacetabularcagecanbeusedtobridgethedefectandobtain


“pElvic discontinuity rEsults in a morE challEnging EnvironmEnt in which to obtain

initial componEnt fixation duE to thE possibility of pErsistEnt motion bEtwEEn thE

supErior and infErior halvEs of thE pElvis.“


relativefixationalongtheiliacwingandischium.Theresultsof

thismechanicalsolutionforachronicpelvicdiscontinuityarepoor

becauseboneingrowthintotheacetabularcagewillnotoccurand

prolongedmicromotionandstressuponthemechanicalconstruct

persist.5Thepurposeofthisreviewistodescribeatechniqueof

acetabulardistractionusingaporoustantalumacetabularcompo-

nentwithorwithoutaporoustantalumaugmentinpatientswith

achronicpelvicdiscontinuity.Wehypothesizedthatareconstruc-

tionusingporoustantalumcomponentsplacedintoadistracted

acetabularpelviswouldprovideenoughinitialmechanicalstability

forboneingrowthtooccurintotheprosthesisand/oraugment

bothsuperiorlyandinferiorlyinordertobridgeandstabilizethe

pelvicdiscontinuity.

materials and methods

Twenty-eightconsecutivepatientsundergoingrevisiontotalhip

arthroplastytreatedwithaporoustantalumacetabularcompo-

nentwithorwithoutaugmentsinthesettingofachronicpelvic

discontinuitybetween2002and2006wereidentifiedthroughour

institutionaldatarepository.Thesepatients’medicalrecordswere

retrospectivelyreviewedfollowingstudyapprovalbyourinstitu-

tionalreviewboard.Thiscohortofpatientsrepresentsanunselect-

edseriesofpatientstreatedforachronicpelvicdiscontinuityasno

otherpatientduringthistimeunderwentposteriorcolumnplating

orwastreatedwithanacetabularcage.

Atthetimeofmostrecentfollow-up,5patientshadbeenlostto

follow-upand3additionalpatientshaddiedfromcausesunre-

latedtotherevisionprocedurepriortominimum2-yearfollow-

up.These8patientswereexcludedfromthestudycohort.The

remaining20patientshadanaveragefollow-upof54months

(range,24to84months).Ofthesepatients,15werefemalewhile

5weremale.Theaverageageatthetimeoftherevisionprocedure

was67.5years(range,46to86years),andtheaveragenumberof

previoussurgerieswas2.6(range,0to6).Ofthepatientsinthe

follow-upgroup,theoriginaldiagnosiswasosteoarthritisin10

patients,rheumatoidarthritisin9patients,anddevelopmental

dysplasiaofthehipin1patient.Thereasonforrevisioninall

20patientsinthefollow-upgroupwasasepticloosening.The

acetabulardefectswereclassifiedusingthesystemdescribedbyone

oftheseniorauthors(W.P.).6Fouroftheacetabulawereclassified

asPaproskytypeIIC,3weretypeIIIA,andtheremaining13were

typeIIIB.Allpatientshadanassociatedpelvicdiscontinuitythat

wasverifiedintraoperatively.

surgical technique

Thesurgerywasperformedbyoneoftheseniorauthors(W.P.,

S.S.)throughaposteriorapproach.Aftertheacetabularcompo-

nentwasexplanted,thelowerportionoftheischiumwasstressed

withaCobbelevator,andmotionbetweenthesuperiorand

inferiorportionsoftheacetabulumconfirmedthepresenceofa

discontinuity.Allfibroustissueandgranulationtissuewascleared

betweenthediscontinuityinordertouncoverviablehostbone.

Fullhemisphericalreamerswerethenplacedintheacetabular

defectatthelevelofthenativehipcenterinordertodetermine

theanterior-posteriordimensionofthepelvicdefect.Sequentially

largerreamerswereutilizeduntilthereamersengagedtheanterior-

superiorandposterior-inferiormarginsoftheacetabulum.The

typeandpositionoftheaugmentswasdictatedbythelocationand

severityofboneloss.Augmentswerefrequentlyusedtoreconstruct

portionsoftheanterior-superioracetabulumaswellastheposterior-

inferioracetabulumtoprovidesecurepointsoffixationforthe

acetabularcomponentcephaladandcaudaltothediscontinuity

(Figure1).Attemptsweremadetomaximizetheamountofhost

figure 1.Tantalumellipticalcupspanningthepelvicdiscontinuity.Asuperioraugmentwasusedinthiscase.

figure 2.Well-fixedporoustantalummetalcup.Nocupmigrationorhardwarefailurecanbeseenat6yearspostoperatively.

figure 1 figure 2

54

bonecontactwiththeporoustantalumaugmentsandacetabular

component.Thesuperiorandinferiorhemipelviswasdistractedby

placingaporoustantalumacetabularcomponentthatwas6to8

mmlargerthanthehemisphericalreamerthathadpreviouslyen-

gagedtoanteriorandposteriorcolumns.Ligamentotaxiswasused

toprovideinitialstabilitytothecupwhilemultiplescrewswere

placedintotheremainingiliumandischium.Theaugmentswhen

usedweresecuredtotheporoustantalumacetabularcomponent

withtheuseofpolymethylmethacrylate.Apolyethylenelinerwas

cementedintotheacetabularcomponentinallcasesinorderto

providescrewswithafixedangle.7Tantalummetalaugmentswere

usedin11ofthe20hips.In3ofthe11patients,2augmentswere

used.Thefemoralheadsizewasmaximizedinallpatients.Two

patientswithdeficientabductorshadaconstrainedliner,9patients

hadatripolararticulationduetoaretainedfemoralcomponent,

6hada40-mmheadsize,1hada36-mmheadsize,and2hada

32-mmheadsize.

Allpatientswereexaminedclinicallyandradiographicallyat2

weeks,6weeks,3months,6months,andyearlythereafterfora

minimumof2years.Theassessmentofclinicalimprovementwas

donewiththemodifiedPostel–Merled’Aubignéscorebyoneof

theauthors(A.M.,S.S.,W.P.).Clinicaloutcomemeasuresincluded

theMerled’Aubignéwalkingandpainscores.Thepreoperative

andpostoperativescoreswerecomparedusingapairedttesttotest

forasignificantimprovementinambulationandpainscores.

Radiographicreviewconsistedofstandardanteroposterior

(AP)radiographsofthepelvis,APradiographsofthefemur,and

Lowensteinlateralradiographs.Radiographstakenpreoperatively,

immediatelypostoperatively,andatthemostrecentfollow-up

werereviewedandthefindingswereconsensuallyagreeduponby

2reviewers(S.S.andA.M.)(Figure2).TheAPradiographstaken

preoperativelyweregradedaccordingtotheacetabulardefectclas-

sificationdescribedbyBradfordandPaprosky.8Themostrecent

radiographswerecomparedwiththeinitialpostoperativeradio-

graphs.Looseningwasdefinedradiographicallyasachangeinthe

componentabductionangleofgreaterthan10degreesorachange

inthehorizontalorverticalpositionofgreaterthan6mmafter

correctingformagnification(Figure3).Kaplan-Meiercurvesshow-

ingtimetofailureforradiographiclooseningaswellasreoperation

forclinicalfailurewerecreated(Figure4).

results

Amongthe20patientswithaminimumof2-yearfollow-up,1

constructfailed,necessitatingrevisionsurgery(Figure5).Upon

radiographicreviewofthe19clinicallystablepatients,4acetabular

componentswereclassifiedaslooseduetocomponentmigrationat

anaverageof18monthsfollow-up.Alllooseacetabularcompo-

nentswereinpatientswithatypeIIIBacetabulardefect.Allradio-

graphsconsideredtobeloosedemonstratedincreasedverticalin-

clination,superiormigration,andlossoffixationintotheischium.

Tworadiographiccasesdemonstratinglooseningwereidentified

withinthefirstyearoffollow-up,1wasidentifiedwithin2yearsof

follow-up,and1wasnotedatthe4-yearfollow-up.Twoofthese

4alsohadfractureofthescrewsthatwereplacedintheinferior

augmentsorintotheinferiorportionoftheacetabularcomponent

(Figure6).Alltheimplantsclassifiedasloosehavesinceremained

stableoveranaverageperiodof49months,showingwell-ingrown

cupwithnofurthermigration.

figure 3.A,Well-fixedcup39monthsaftersurgery.B,Samepatientseen50monthsaftersurgery;migrationofthecupisnoted.

a b


Clinically,17of19patientsreportedhavingnopainontheop-

erativehip,1patientreportsminimalpainafterwalking6blocks

ormore,and1patientreportspainwithsittingforlongperiods

oftime.Sevenpatientsarewalkingwithoutassistivedevices,5

patientsuseacaneallthetimetoambulate,4patientsuseacane

onlyforlongdistances,and3patientsuseawalkeratalltimes.

Noneofthepatientsinthisstudyusedwheelchairsasofthemost

recentfollow-up.Theaverageimprovementusingthemodified

Merled’Aubignépainandambulationscorewasfrom3.3pre-

operativelyto9.6postoperatively(P<.0001,standarddeviation

1.2).The4patientswithradiographicallyloosecomponentsat

mostrecentfollow-upwerepainfreeandfunctioningwellwithan

averageMerled’Aubignéscoreimprovementof3preoperativelyto

8.75postoperatively(P<.0012,standarddeviation0.96).Associ-

atedperioperativecomplicationsincludedacolonrupturerequir-

inggeneralsurgicalintervention,anintraoperativefemoralartery

injuryrequiringrepairbyavascularsurgeon,agreatertrochanteric

fracturethatwastreatednonoperatively,andasuperficialinfection

successfullytreatedwithirrigationanddebridement.Atthetime

ofmostrecentfollow-up,therewerenopostoperativedislocations.

discussion

Therearefewstudiesevaluatingthetreatmentandoutcomesof

chronicpelvicdiscontinuitiesencounteredatthetimeofrevision

acetabularsurgery.Mostoftheavailableliteratureonthesubject

isintheformofananalysisofthesedifficultcasesasasubsetof

alarge,diverserevisionseries.Berryetalidentifiedpelvicdis-

continuitiesin31of3505patients(0.9%)requiringrevisionhip

surgery.2Theuseofaposteriorcolumnpelvicreconstructionplate

withanassociatedcementlessacetabularcomponentwasshown

toprovidethehighestrateofhealingacrossthediscontinuity

assumingthediscontinuitywasnotaresultofradiationnecrosis.

Morcellizedbonegraftprotectedbyanantiprotrusioncagehasalso

beenshowntoresultinacceptableclinicalandradiographicresults

atshort-termfollow-up.2Egglietalreportedon7casesofpelvic

discontinuitytreatedwithpelvicplatingandacetabularreinforce-

mentrings.Onepatienthadincompletesciaticnervepalsy,1had

recurrentdislocations,and1neededreoperationforasepticloosen-

ing.However,atfinalfollow-upalldiscontinuitieshadhealedand

theacetabularcomponentswerebelievedtobestable.9DeBoeret

alreportedontheuseofacustomtriflangeddevice(DePuy,

figure 4.Kaplan-Meiercurves.A,Timeelapsedfromdateofsurgerytodiagnosisofradiographicloosening.B,Timeelapsedfromdateofsurgerytoreoperationforclinicalfailure.

0 10 20 30 40

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

50 60 70 80 90

20 19 19 18 15 10 8 5 3 0

surv

ival

pro

bab

ility

, %

time to radiographic loosening, months

no. at risk

product-limit survival Estimate

0 10 20 30 40

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

50 60 70 80 90

20 18 16 15 12 7 5 3 2 0

surv

ival

pro

bab

ility

, %time to reoperation, months

no. at risk

product-limit survival Estimate

+ Censored 95% equal Precision Band+ Censored 95% equal Precision Band

a b

56

Warsaw,Indiana)in20hipswithseverepelvicbonelossand

discontinuityatanaveragefollow-upof10years.Definitehealing

wasdemonstratedradiographicallyin18of20hipswithnocases

ofimplantmigration.However,6caseshadnonprogressiveradio-

lucentlines,1casehadpartialsciaticnervepalsy,and5patients

had1ormoredislocations.10HoltandDennisreportedontheuse

ofacustomtriflangeddevicein26hips.Inthisseries,however,

only3ofthe26hipshadapelvicdiscontinuity.Twoofthese3

failedsecondarytolossofinferiorfixationintheischium.The

authorsrecommendedcautionintheuseofthedevicewithout

additionalcolumnplating.11

Currently,moststudiesrecommendedcompressionplatingof

theposteriorcolumntoreduceandstabilizethepelvisinanat-

tempttocreateasolidplatformforacetabularreconstruction.9,11-12

However,theseverityofbonelossencounteredduringacetabular

reconstructionmayresultinlargesegmentalareasofdeficientbone

makingthepossibilityofhealingbetweenthesuperiorandinferior

hemipelvisunlikely.

Wehavepreviouslyreportedpoorintermediateresultswiththe

useofacetabularcagesinthetreatmentofpelvicdiscontinuity

whenbulkacetabularallograftalongwithanacetabularcagewas

usedinpatientswithchronicpelvicdiscontinuities.Inthisseries,

16hipshadbeenfollowedforanaverageof5yearspostopera-

tively.5Fiveofthesehipswererevisedforlooseningwhilean

additional3hipswereradiographicallyloose.Inthesesituations,

itwashypothesizedthatthediscontinuitydidnothealandthat

persistentmicromotionacrossthediscontinuityresultedinfatigue

ofthecageandeventualfailure.Consequently,webelievethat

durableacetabularfixationinapatientwithanassociatedchronic

pelvicdiscontinuitywithsevereposteriorcolumnbonelosscan

occuronlyifthereisbonyhealingofthediscontinuityorifthere

isbonyingrowthintoaporousacetabularcomponentfromboth

thesuperiorandinferiorhemipelvis.Incasesofchronicpelvic

discontinuity,webelievethebiologicpotentialforhealingatthe

discontinuityisdecreasedandthatitisunlikelymostchronicdis-

continuitieswilleventuallyheal.Wedescribeasurgicaltechnique

thatreliesuponpelvicdistractioninanattempttogainrigidinitial

fixationtoanacetabularcomponentbothcaudalandcephaladto

thediscontinuity.Thegoalofthistechniqueistousetheporous

acetabularcomponentasaninternalplatetospanthediscontinu-

ityratherthanrelyonbiologichealingacrossthediscontinuity.

Thissurgicaltechniqueallowsforpotentialbiologicingrowthinto

theacetabularcomponentcephaladandcaudaltothediscontinu-

ity.Wefeelthatcomparedtothepoorresultswithuseofcagecon-

structs,itoffersagreateropportunityforabiologicsolutionthat

couldpotentiallyleadtobetterpatientoutcomesandimproved

componentsurvival.Wepreviouslycompared12patientswith

pelvicdiscontinuitiesthatweretreatedwithaporoustantalum

metalcupwith12patientsinapreviouscohortwhoweretreated

withacageconstruct.13Inour2005studywefoundthattreatment

withaporoustantalummetalshellofferedareproducibleandcon-

sistentimprovementinpainandambulationatanaverageof2.1

figure 5.A,Well-fixedprosthesis.B,Thecuphasmigratedcephaladandhasbecomemorehorizontal.Thepatientwassymptomaticandnecessitatedarevision.

a b

figure 6.Brokenscrewscanbeseenasthiscuphasmigratedfromitspreviouslywell-fixedposition.Thepatientisnow6yearspostoperative,andnofurthercomponentmigrationhasoccurred.Thepatientremainsasymptomatic.

figure 5 figure 6

yearsfollow-up.In2006,weproduceda2.6-yearfollow-upof13

patientswithpelvicdiscontinuitiestreatedwithaporoustantalum

shellwhoshowedimprovedPostel–Merled’Aubignéscoresfrom

6.1to10.3.14Theseresultsshowedpromisingoutcomesinshort-

termfollow-up.

Inourcurrentstudy,15of20hipsremainedclinicallyandradio-

graphicallystableatanaverageof4.5yearspostoperativelywhile

4ofthe20hipsdemonstratedearlysuperiormigrationofthe

acetabularcomponent.However,all4patientsthatdemonstrated

earlycomponentmigrationhaveshownnofurtherchangeinposi-

tionradiographically,andallpatientsremainpainfree.Only1cup

(5%)requiredrevisionforloosening.Thecauseofthisfailurewas

believedtobeinadequatefixationintotheischium,andwenow

strivetoobtainaminimumof2screwsintotheischiumtoavoid

earlyverticaldisplacementoftheacetabularcomponent.Inour

series,wehadnopostoperativedislocationsandonly1superficial

infection.Wehypothesizethatourdecreasedrateofinfection

comparedtoourseriesofpatientswithposteriorcolumnplating

andacetabularcagereconstructionwassecondarytodecreased

surgicaltimeandminimizingtheamountofsoft-tissuestripping.

Extensivebonelossisfrequentlyobservedinthesettingofa

chronicpelvicdiscontinuity.Inordertoachievelong-termsuccess

inthesedifficultcases,eitherthepelvismustbestabilizedtoallow

healingofthediscontinuityoralternativemethodstobridgethe

discontinuitymustbeutilized.Wepresentthemidtermresultsofa

potentialbiologicsolutioninpatientswithachronicpelvicdiscon-

tinuityusingthetechniqueofpelvicdistraction.Thistechnique

appearstohavepromiseforthesedifficultcasesofsevereboneloss

andcompromisedbiologichealingpotential.

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ProvencherMT,ArcieroRA,BurkhartSS,LevineWN,Ritting

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ProvencherMT,GhodadraN,RomeoAA.Arthroscopicmanage-

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Orthop Clin North Am.2010;41(3):325-337.

ProvencherMT,HandfieldK,BoniquitNT,ReiffSN,SekiyaJK,

RomeoAA.Injuriestothepectoralismajormuscle:diagnosisand

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RomeoAA,GhodadraNS,SalataMJ,ProvencherMT.Ar-

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rosenberg, aaron

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femoralcomponentinsertion.Surg Technol Int.2010;20:334-339.

RosenbergA.Encounteringcanceroritssequelaeatthehip.

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singh, kern

ParkDK,LeeMJ,LinEL,SinghK,AnHS,PhillipsFM.The

relationshipofintrapsoasnervesduringatranspsoasapproach

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sporer, scott m.

BerendKR,SporerSM,SierraRJ,GlassmanAH,MorrisMJ.

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SelectResearchGrants(2009-2010)2011 rush orthoPeDiCs journAl

howard s. an, md

LinkageAnalysis,GenMappingandGenome-WideAnalysis

ofDegenerativeDiskDisease

OutcomeofBiactiveFoamGraftWithAutogenousBone

MarrowAspirate

2009-2010ClinicalSpineFellowshipProgram

gunnar b. J. andersson, md, phd

ProgramProjectGrant

charles a. bush-Joseph, md

ClinicalEvaluationBalloonDistractioninHipArthroscopy

brian J. cole, md, mba

ArthroscopicPartialMeniscectomyinOsteoarthritis

FemoralCondyleResurfacingProsthesis

LabralBumperforTreatmentofShoulderInstability

PostMarketStudyofArticularCartilageDefectsoftheKnee

craig J. della valle, md

PostoperativeAnalgesiainSubjectsforTotalKneeArthroplasty

tibor t. glant, md

MappingofArthritisSusceptibilityGenes

nadim J. hallab, phd

BiocompatibilityAssessmentofParticlesInVitro

Joshua J. Jacobs, md

BiotribologicalLayersinMetal-on-MetalHipReplacement

Cartilage-FriendlyMaterials

84MoSerumMetalIonAnalysisofPRESTIGECervicalDisk

48MoSerumMetalIonAnalysisofthePRESTIGELPCervicalDisk

FrettingCorrosionTestingofModularAcetabularComponents

SerumMetalIonAnalysisofMAVERICKTotalDiskReplacement

SerumMetalIonAnalysisoftheA-MAVTotalDiskReplacement

SystemicImplicationsofTotalJointReplacement

WearingDeterminationofOrthopedicPolyethyleneMaterials

UsingaTracer

brett levine, md

RegenerexTibialTrayMulticenterDataCollection

hannah J. lundberg, phd

CalculationofTotalJointReplacementContactForces

DuringWalking

shane J. nho, md, ms

BiomechanicalAnalysisofGluteusMediusRepairsinaCadaveric

HipModel

gregory p. nicholson, md

AssessRotatorCuffRepairUsingConexiaGraftReinforcement

markus a. wimmer, phd

ReducingtheEmissionofWearDebrisinMetal-on-Metal

HipJoints

yejia Zhang, md, phd

CellTherapyforDegeneratingIntervertebralDisks

Select Research Grants (2009-2010) 2011 rush orthoPeDiCs journAl 65

66

about rush univErsity mEdical cEntEr

Rushisanot-for-profithealthcare,education,andresearchen-

terpriselocatedonthewestsideofChicago.Rushencompasses

theacademicmedicalcenterRushUniversityMedicalCenter;

RushOakParkHospital;RushUniversity;andRushHealth,

aclinicallyintegratednetworkofproviderscoveringthefull

spectrumofpatientcare.

quality rEcognition

• TheorthopedicsprogramatRushisconsistentlyranked

amongthebestinthenationbyU.S.News & World Report.

ItwasrankedNo.8in2011.

• Rush’snurseshavebeenawardedMagnetstatus—thehighest

honorahospitalcanreceiveforoutstandingachievement

innursingservices—3times.Rushwasthefirstmedical

centerinIllinoiscaringforadultsandchildrentoreceivethis

prestigiousdesignation,andthefirstinIllinoistoearnathird

4-yeardesignation.

• Rushwasnamedamongthetophospitalsinthecountry

forquality,safety,andefficiencybytheLeapfrogGroup,

anationalorganizationthatpromoteshealthcaresafetyand

qualityimprovement.Rushisoneofonly65hospitalsthat

madethelistoftophospitalsfor2010fromamongnearly

2000hospitalssurveyed.

• UniversityHealthSystemConsortiumhasawardedRush

thehighestpossiblescorefor“equityofcare”ineachofthe

6yearsofitsannualqualityandaccountablitystudy.This

rankingmeasureswhetherpatientsreceivethesamequality

oftreatmentandhavethesameoutcomesregardlessoftheir

gender,race,orsocioeconomicstatus.

• TheorthopedicsprogramatRushhadthesecond-lowest

readmissionrate(3.29%)inthecountrycomparedtothe

orthopedicsprogramsofotherhospitalsratedamongthetop

50byU.S.News & World Reportin2010.*

• Alsoin2010,theorthopedicsprogramatRushhadthe

third-lowestmortalityindex(.51)amongorthopedics

programsfromU.S. News’top50hospitals.Forpatientsof

orthopedicsurgeonsatRush,themortalityratewas49%less

thanexpectedbyUHCriskadjustmentalgorithms.*

VolumeandQualityData2011 rush orthoPeDiCs journAl

total orthopedic surgical cases**

0

2000

4000

6000

8000

10 000

12 000

FY06 FY07 FY08 FY09 FY10Year

8615 87479310

967910434

*Source:UniversityHealthSystemConsortium(2010).RushmetricsincludeattendingphysicianswithintheDepartmentofOrthopedicSurgeryatRush,whilemetricsforthecomparativegroupsutilizetheUHCorthopedicservicelinedefinition.

**VolumesincludesurgeriesperformedatRushUniversityMedicalCenter,RushOakParkHospital,andtheoutpatientRushSurgiCenterforeachfiscalyear,coveringJuly1toJune30.

nu

mb

er o

f c

ases

orthopEdic subspEcialty surgical casEs**

Volume and Quality Data 2011 rush orthoPeDiCs journAl 67

Adult reconstruction volumes

0

500

1000

1500

2000

2500

3000

FY06 FY07 FY08 FY09 FY10

24462299

25152620 2710

Year

nu

mb

er o

f c

ases

hand, wrist, and elbow volumes

0

250

500

750

1000

1250


1224 12021165 1174

1448

Year

1500

nu

mb

er o

f c

ases

Pediatrics volumes

0

25

50

75

100

125


0

77

120

135 137

Year

150

nu

mb

er o

f c

ases

spine surgery volumes

0

250

500

750

1000

1250


910 897

10431128

1230

Year

nu

mb

er o

f c

ases

Foot and Ankle surgery volumes

0

125

250

375

500

625

750


491

546 609 621674

Year

nu

mb

er o

f c

ases

joint/orthopedic oncology & trauma volumes

0

125

250

375

500

625

750


713647

706632 640

Year

nu

mb

er o

f c

ases

sports Medicine volumes

0

600

1200

1800

2400

3000

3600


27472977

31063342

3591

Year

nu

mb

er o

f c

ases

other volumes

0

20

40

60

80

100

120

FY06 FY07 FY08 FY09 FY10Year

84

102

46

274

nu

mb

er o

f c

ases

68

LegacyofExcellence2011 rush orthoPeDiCs journAl

LegacyofExcellenceAn interview with renowneD sPine surgeon

gunnAr B. j. AnDersson, MD, PhD, BY ChristoPher DewAlD, MD

WhenGunnarB.J.Andersson,MD,PhD,movedtotheUnited

StatesfromhisnativeSwedenin1985,healreadyhadastellar

reputationforhisclinicalandresearchendeavors.Butevenso,he

couldnothaveforeseenthephenomenalsuccesshewouldenjoy

atRushasaclinician,aresearcher,aneducator,andaleader.He

servedaschairmanoftheDepartmentofOrthopedicSurgeryfor

14yearsbeforesteppingdownin2008,andheholdstheRonald

L.DeWald,MD,EndowedChairinSpinalDeformities.Hislab’s

researchonintervertebraldiskdegeneration,whichhasbroken

newgroundinthesearchforanswerstolowbackpain,washon-

oredwiththe2011KappaDeltaElizabethWinstonLanierAward

fromtheAmericanAcademyofOrthopaedicSurgeons(AAOS).

Thiscovetedawardwastheculminationof15-plusyearsspent

characterizingdiskdegenerationandstudyingtherapeuticoptions

toreversethedegenerativeprocess.

ChristopherDeWald,MD,whosefatherestablishedtheen-

dowedchairheldbyAndersson,isoneofthemanyspinesurgeons

atRushwhomAnderssonhasmentoredthroughtheyears.The

tworecentlysatdowntotalkaboutAndersson’slife—andhis

lastingcontributionstospinecareandresearch.

dewald: what inspired you to become an

orthopedic surgeon?

andersson:IknewearlyonthatIwantedtobeasurgeon,butI

wasn’tsurewhichsubspecialtyIpreferred.Iwasinspiredbysome

ofmyprofessorsattheUniversityofGothenburginSweden,and

alsobythefactthatthereismechanicaltheorybehindwhatspine

surgeonsdo,whichI’vealwaysliked.Oneofmyprofessorswas

internationallyfamous;hewaswellknownasoneofthefathersof

biomechanics—applyingmechanicalengineeringprinciplestothe

body.ThisappealedtomebecauseIwasinterestedintheengineer-

ingaspectsoftheprofession.

dewald: was your medical school similar to the medical

schools in the united states?

andersson: ItwasdifferentbecauseinEuropeyoudon’thave

thecollegesystem,soyouwenttomedicalschoolandspent6and

ahalfyearsinmedicalschool.Duringthefirst2yearsyoudoa

lotofthestuffthatinAmericastudentsdoincollege.Thenyou

enterintotheclinicalareaand,asintheUnitedStates,yourotate

todifferentspecialties.Idida1-monthrotationinorthopedic

surgery,andIthoughtitwasagreatsubspecialty.Ialwaysthought

medicinewasfascinatinginthatyoudon’thavetomakechoices

aboutyourareaoffocuswhenyoustartmedicalschool;youhave

tomakechoiceswhenyoufinishmedicalschool.

dewald: at the time you completed your training, there

weren’t fellowships like there are now. how did you

decide that spine was your calling?

andersson:Ithinkothersdecidedthatformeinaway,because

Iwasinitiallyreallynotinterestedintheclinicalcareofpatients

withbackpain.Iwasinterestedindeformity,butIwasmore

interestedinjointreplacementsurgeryandintraumaandfracture

care.However,myresearchwasprimarilyinspine,andpeoplekept

sendingmepatientswithbackproblemsbecausetheyidentified

mewiththespine,andIgotmoreandmoreinterestedinthatarea.

Eventuallyitwastoodifficulttojuggleallthesesubspecialties,soI

hadtomakeadecision.AtthattimeIhadbeendevotingsomuch

timetospinethatitwasveryeasytomakeadecision.Ihavenever

regrettedit.

dewald: what was the focus of your research in sweden?

andersson: AlotoftheresearchIdidwasrelatedtobackpain

inindustry,andwaysofreducingtheimpactofworkontheback.

Youcouldcallitoccupationalorthopedicsoroccupational

gunnar B. J. Andersson, MD, PhD (right), and Christopher DeWald, MD

Legacy of Excellence 2011 rush orthoPeDiCs journAl 69

christophEr dEwald, md, whosE fathEr EstablishEd thE EndowEd chair

hEld by andErsson, is onE of thE many spinE surgEons at rush

whom andErsson has mEntorEd through thE yEars.

70

biomechanics.Atthattimeitwasnotaparticularlypopular

subjectintheUnitedStates.Everybodyknewtherewerealotof

worker’scompensationinjuries,buttherewerenotalotofor-

thopedicsurgeonswhowereinterestedintryingtodosomething

fromapreventionpointofvieworinaddressingtheproblems

morespecifically.Thathasclearlychanged.Nowpeoplearemuch

morecognizantaboutwork-relatedorthopedicproblems.

dewald: i’ve heard you also had something to do with

developing the seats in volvos.

andersson: Idid.ItstartedbecauseVolvowaslookingattheseat

designtheyhad,andtheywantedsomeinput.AndatthattimeI

hadjuststartedmyresearchcareerandwasinterestedinlooking

atsitting—notjustfromacarseatperspectivebutinotherways

aswell.Myresearchteamstartedworkingonwaysofmeasuring

loadsonthespinewhenyousit,andweadaptedthatresearch

toVolvo’sinterestinfiguringoutwhattypesofsupportschairs

shouldhaveinordertobeascomfortableandasphysiologically

welldesignedaspossible.IntheprocessIgotconnectedwiththe

researchengineersatVolvoandwiththeinteriordesigners,andwe

startedworkingverycloselyondevelopingseats.Thatcollabora-

tionactuallycontinuedforabout15years.Itwasaverynicecol-

laboration,andVolvosupportedalotoftheresearchIdidduring

thoseyears.

dewald: they still use the same car seat design today,

don’t they?

andersson:Theydo.Interestingly,someofthethingswefelt

wouldenhancetheseats—suchaslowerbacksupport—were

thingsVolvohadthoughtaboutremovingbecausetheycost

money.Youknow,it’sonlyafewdollarsperseat,butifyoumake

millionsofseatseachyear,itaddsuptoalotofmoney.

dewald: you had quite a successful career in sweden.

what made you decide to make the jump across

the pond?

andersson: Thatwasalsochancetosomedegree.Iwasactually

planningtomovewithinSweden.Inthe1970sandearly1980s,I

hadbeenhereintheStatesdoingresearchwithJorgeO.Galante,

MD,DMSc[theGraingerDirectoroftheRushArthritisand

OrthopedicsInstituteandformerchairmanoftheDepartmentof

OrthopedicSurgery],andIhadpeoplefromtheStatesspending

timewithmeinSweden,primarilyontheresearchside.Around

thetimeIwasgettingreadytomovewithinSweden,Ivisitedthe

UnitedStates,andJorgesaid,“Youknow,ifyou’regoingtomove,

youshouldmovetotheUnitedStates.”That’showitstarted.

Ithoughttheopportunityherewastremendous,andatthattime

inmylifeIalsothoughtitwouldbeexcitingtomovetoanew

environmentandexperiencenewchallenges.Ifiguredifitdidn’t

workout,IcouldalwaysgobacktoSweden.Iwas42yearsold

whenImovedtotheUnitedStates—that’sfairlylateinlife—and

IhadbuiltacareerinSweden.ButIthoughtitwouldbeaninter-

estingchallengetotrytobuildacareerintheUnitedStates.

dewald: how was the transition overall for your family

from sweden to the united states?

andersson:Formywifeandmyselfitwasfairlyeasy,butthekids

struggledforacoupleofyears.However,wehaddecidedfromthe

beginningweweregoingtobehereforthreeyears,whetherwe

likeditornot,andthenafterthreeyearswewouldmakeadeci-

sionwhethertostayormove.Afterthreeyears,wehadbreakfast

andmywifeandItoldthekidsthatweneededtodecidewhat

todo.Andthekidslookedatusandsaid,“Well,wedon’treally

carewhatyouguysdo,butwe’regoingtostayhere.”Soitbecame

fairlyeasy.Ihaveneverregrettedthemove.It’sbeenveryreward-

ingpersonallyandprofessionally.

dewald: what type of research were you doing with dr

galante before you moved here?

andersson: Weworkedmostlyonjointreplacements,andalso

onboneingrowthintotheporousmaterialhehaddeveloped,

whichsubsequentlybecamethefixationsystemforalotofjoint

replacementdevices.Iwasheredoingprimarilyresearchinjoint

replacement.Ididsomeworkonthespineaswellwithsomeof

thepeopleoverattheUniversityofIllinois,Chicago.Insubse-

quentyearssomeofthoseresearcherscameoverandspentayear

withmeinSweden.Wecontinuedtoworktogether.Sobythe

timeImovedhereIhadallthesefriends,andChicagofeltlikea

homeawayfromhomeinmanyways.

dewald: you came to rush in 1985; at what point did you

assume the role of department chairman?

andersson:In1994,andthatwasbecausewemadesomemajor

changestothedepartment.TheRushArthritisandOrthopedics

Institutewascreated,andDrGalante,whohadbeendepartment

chairmansincethedepartmentwasfoundedin1972-1973,de-

cidedhewouldratherbeheadoftheinstitutethancontinuetobe

thedepartmentchairman.Itwasanexcitingtimebecauseatthat

timeIwasalsothemanagingpartnerofMidwestOrthopaedicsat

Rush,andwehadstartedgrowingveryrapidlyandwererecruit-

ingalotoftalentednewpeople.Thereweretremendousclinical

opportunitiesbasedonourclinicalexcellenceandthefactthat

wehadbeenabletomarryresearchandclinicalcareinawaythat

wasuniquetoChicagoand,tosomedegree,uniquetotheUnited

Statesatthetime.

dewald: the amount of change that has occurred in the

department since 1994 is dramatic. how were you able

to grow the department as well as you have with all the

different personalities?

andersson:Youhavetoacceptthatpeoplearedifferent.You

havetotakeadvantageofthefactthatmanypeoplewhohave

high-strungpersonalitiesalsoarebrilliant,andifyougivethem

theopportunitytheywillputtheirbrilliancetouse.Youbuild

byrecruitingpeople,andthenyougivethemanopportunityto

excelintheareaswheretheycanexcel.Andyouleavethemalone;

youdon’tmicromanagewhattheydo.Meanwhile,youjustkeepa

directionthatmoveseverythingforward.

We’vebeenblessedatRush.There’snotbeenasinglepersonthat

Iwouldn’thaverecruitedagaintothisdepartment,andallofthe

facultymembershaveshownclinicalexcellenceaswellasadevo-

tiontoresearchandeducation.We’vealsobeenextremelylucky

inrecruitingtherightpeopletoourresearchfaculty.They’vebeen

successfulingettingfundingandinenhancingRush’sreputation.

Onceyouhaveagoodreputation,it’seasytorecruitmore

goodpeople.

dewald: do you see the department continuing to grow?

andersson:Ido.We’venearlytripledinsizesince1994,when

wehadonly10or11surgeons,andthenumbersofpublications

andresearchpapersandpresentationsbyourfacultyhavebeen

absolutelyphenomenal.Oursurgicalvolumehasgrownaswell;

in1994weweredoingabout3000casesayear;nowwe’redoing

morethan10000cases.Therehasbeenexplosivedevelopment

inmanyofthesubspecialties,andIdon’tseeanyreasonwhythat

shouldstop.

Oneofourlimitations,historically,hasbeenspace.Ontheprac-

ticeside,Istartedworkingonconsolidationandincreasingspace

inthe1990s,andnowwehaveourownbuildingoncampus,and

wehavespaceforadditionalgrowth.

dewald: whose idea was the orthopedic building?

andersson:Ibelieveitwasmyidea.Istartedconceptualizingan

orthopedichospitalintheearly1990s,shortlyafterItookoveras

managingpartnerofMidwestOrthopaedicsatRush.Andbythe

timeRushstartedworkingonthetransformationofthecampus

intheearly2000s,itwasobviousthatweneededmoreprofes-

sionalofficespaceforourorthopedicphysicians.AtthattimeI

pushedtheideathatweshouldhaveaseparatebuildingthatwe

wouldbeabletofinanceandrunonourown.Therewasn’talot

ofresistance.Theinstitutionthoughtitwasagoodideabecause

consolidatingourorthopedicpracticeswouldopenupspaceinthe

existingprofessionalofficebuildingsthatRushcoulduseforother

purposes.Anditalsofreedupsomecapitalfortheinstitutionto

spendonthenewhospital,whichwasimportantforthemfroma

businessperspective.SoIthinkitwasfairlywellacceptedfromthe

verybeginning.

dewald: getting back to your research, you’re best

known for your work on intervertebral disk degenera-

tion, but obviously that wasn’t always your area of

interest. what caused you to shift your focus?

andersson:WhenIfirstcametotheStates,Icontinuedtowork

onliftingandotheractivitiesthatarestressfultotheback.Butone

oftheareasI’vedevotedalotoftimetoisepidemiology,andit

becamecleartomethatbackpainisprobablythemostcommon

ofallthechronicpainconditions,notonlyintheUnitedStates,

butinvirtuallyeverycountryintheworld.Italsobecameobvious

tomethatthemajorcauseofbackpainisrelatedtodiskdegenera-

tionandtheconsequencesofdiskdegeneration.Sooverthepast

15-plusyearsthat’sbeentheprimaryfocusofmyresearch.

Asaresultofthatresearch,wehavecharacterizeddiskdegen-

erationatitsvariousstages.Wehavecreatedanimalmodelsto

studydiskdegenerationindetailandhavestudiedavarietyof

products—genes,growthfactors,cells,stemcells—toreversedisk

degeneration.Andwehavecometothepointnowwhere

2ofthoseproductsarebeingtestedinhumansbylarge

implantcompanies.

Legacy of Excellence 2011 rush orthoPeDiCs journAl 71

“most of thE timE what you do in rEsEarch is lay foundations, you lay bricks, and

hopEfully somEbody ElsE will lay thE nExt brick, and rEsEarch advancEs.”

dewald: your lab received a kappa delta award for this

work. would you say that is your crowning research

achievement?

andersson:Idon’tknowthatIcanreallypointtoonething

thatI’mproudestof.Mostofthetimewhatyoudoinresearchis

layfoundations,youlaybricks,andhopefullysomebodyelsewill

laythenextbrick,andresearchadvances.Youlookattheareasin

whichyouhavemadecontributions,andyouaskwhetherthose

contributionshavestimulatedpeopletodomoreinthearea.And

IthinkIhave.Thewholeareaofclinicalresearch,whichIwas

veryinterestedininitially,hasblossomed.Theareaofoccupational

biomechanicshasgrowndramatically.Spineresearchcertainlyis

ataverydifferentleveltodaythanitwaswhenIstarted.Butyou

gothroughphases.Yougothroughphaseswhenyoucontributea

lot,andthenyougothroughphaseswhereyoustimulateothersto

contribute.Andwhenyougettothestagewhereyoulookbackat

yourlife,it’shardtopickcertainthingsoutandsaythisiswhere

yourcontributionsmadeadifference,andthisiswheretheydidn’t.

Ofcourse,theKappaDeltaAwardisahugehonorbecause

it’sgivenforabodyofresearch,overaperiodoftime,thathas

influencedthefield.Interestingly,IwasanauthoronKappaDelta

Awardpaperstwicebefore,andinbothcasesIhadtotakemy

nameoffbecauseIwasstillinSweden,andatthetimetheywould

notallownonmembersoftheAAOStobeonthesepapers.Sothis

ismyoneandonlyKappaDeltaAward,andthat’sfine.Thetrue

awardeeisHowardS.An,MD,withoutwhomtheprogresswould

nothaveoccurredandwho,appropriately,isthefirstauthor.

dewald: what do you think is the future of treatment for

disk degeneration?

andersson:Ithinkbiologicswillplayalargerrolethantheydo

today.There’snoquestionthatyoucanreversediskdegeneration

intheearlystages.Buttheproblemisthatintheearlystagesmost

peopledon’thaveanypainfromdiskdegeneration.Andclini-

callyit’snotpracticaltohaveamethodtotreatsomethingthat

isn’tcausingsymptoms.Soweneedtofindwaysofaffectingdisk

degenerationatalaterstage,awayofstimulatingthecellsinthe

diskstoproducethenormalproductsthatadiskneedstosustain

itsnormalbiologicactivity.Currentlyyoucandothatbyinject-

ingchemicalsthatstimulatethecells,orbyinjectingcellsthat

producesubstances,orbymanipulatingthegenesofthecells.All

thesemethodsarecurrentlyavailableandarecurrentlybeingtested

clinically,buttheyarestillprimarilyinaresearchstage.Inthe

futuretheywillbeclinicallyusefulmethods,althoughIdon’tthink

it’sgoingtohappeninthenextdecade.Maybeitwillhappenin

mylifetime.

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EvEry aspEct of rush’s nEw, statE-of-thE-art hospital ... · spine, foot, and ankle, upper extremity, sports medicine, hip and knee replacement, and orthopedic oncologic surgery