every aspect of rush’s new, state-of-the-art hospital ... · spine, foot, and ankle, upper...
TRANSCRIPT
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
Assistantprofessor,DepartmentofOrthopedicSurgery
wayne g. Paprosky, MD
Professor,DepartmentofOrthopedicSurgery
scott M. sporer, MD, Ms
Assistantprofessor,DepartmentofOrthopedicSurgery
jorge o. galante, MD, DMsc
TheGraingerDirectorshipoftheRushArthritisandOrthopedicsInstitute
Professor,DepartmentofOrthopedicSurgery
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
Assistant professor, Department of Orthopedic Surgery
FOOT AND ANKLE SURGERY
Simon Lee, MD
Assistant professor, Department of Orthopedic Surgery
Johnny L. Lin, MD Assistant professor, Department of Orthopedic Surgery
George Holmes Jr, MD
Director, Section of Foot and Ankle Surgery
Assistant professor, Department of Orthopedic Surgery
ONCOLOGY AND TRAUMA
6
pEdiatric surgEry
Monica kogan, MD
Director,SectionofPediatricSurgery
Assistantprofessor,DepartmentofOrthopedicSurgery
spinE surgEry
howard s. An, MD
Director,DivisionofSpineSurgery
TheMortonInternationalChairofOrthopedicSurgery
Professor,DepartmentofOrthopedicSurgery
Director,SpineSurgeryFellowshipProgram
gunnar B. j. Andersson, MD, PhD
TheRonaldL.DeWald,MD,EndowedChairinSpinalDeformities
Professorandchairmanemeritus,DepartmentofOrthopedicSurgery
kim w. hammerberg, MD
Assistantprofessor,DepartmentofOrthopedicSurgery
Frank M. Phillips, MD
Director,SectionofMinimallyInvasiveSpineSurgery
Professor,DepartmentofOrthopedicSurgery
kern singh, MD
Assistantprofessor,DepartmentofOrthopedicSurgery
David Fardon, MD
Associateprofessor,DepartmentofOrthopedicSurgery
Christopher Dewald, MD
Assistantprofessor,DepartmentofOrthopedicSurgery
edward j. goldberg, MD
Assistantprofessor,DepartmentofOrthopedicSurgery
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
Professor,DepartmentofOrthopedicSurgery
Director,SportsMedicineFellowshipProgram
Charles A. Bush-joseph, MD
Professor,DepartmentofOrthopedicSurgery
Anthony A. romeo, MD
Director,SectionofShoulderandElbowSurgery
Professor,DepartmentofOrthopedicSurgery
nikhil n. verma, MD Assistantprofessor,DepartmentofOrthopedicSurgery
shane j. nho, MD, Ms
Assistantprofessor,DepartmentofOrthopedicSurgery
Brian j. Cole, MD, MBA
Director,RushCartilageRestorationCenter
Professor,DepartmentofOrthopedicSurgery
gregory nicholson, MD
Associateprofessor,DepartmentofOrthopedicSurgery
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
Assistantprofessor,DepartmentofOrthopedicSurgery
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
Associateprofessor,DepartmentofOrthopedicSurgery
Deborah j. hall
Instructor,DepartmentofOrthopedicSurgery
thomas M. turner, DvM
Assistantprofessor,DepartmentofOrthopedicSurgery
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
Associateprofessor,DepartmentofOrthopedicSurgery
continued on next page
10
motion analysis laboratory
Markus A. wimmer, PhD
Co-director,MotionAnalysisLaboratory
Director,TribologyLaboratory
Associateprofessor,DepartmentofOrthopedicSurgery
kharma C. Foucher, MD, PhD
Co-director,MotionAnalysisLaboratory
Assistantprofessor,DepartmentofOrthopedicSurgery
hannah j. lundberg, PhD
Instructor,DepartmentofOrthopedicSurgery
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).
Research Faculty and Highlights 2011 rush orthoPeDiCs journAl 11
sEction of molEcular mEdicinE
tibor t. glant, MD, PhD
Director,SectionofMolecularMedicine
TheJorgeO.Galante,MD,DMSc,Chairin
OrthopaedicSurgery
Professor,DepartmentofOrthopedicSurgery
katalin Mikecz, MD, PhD
Professor,DepartmentofOrthopedicSurgery
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
Professor,DepartmentofOrthopedicSurgery
ThegoalofresearchintheSpineBiologyLaboratoryistoimprovetheunderstandingofintervertebraldiskbiologyandthe
pathophysiologyofintervertebraldiskdegenerationsothatpatientswithlowbackpaincanbebetterdiagnosedandtreatedwith
not pictured:
TiborA.Rauch,PhD,associateprofessor,DepartmentofOrthopedicSurgery
Yejia Zhang, MD, PhD
Assistantprofessor,DepartmentofOrthopedicSurgery
metastaticdiseaseatdiagnosiswillrelapse.Recurrenttumorsarethoughttoarisefromtherapy-resistantcancercellsthatsurvivethe
initialtreatment.Thetumorsuppressorproteinp53isactivatedandtriggerscelldeathpathwaysinresponsetoDNA-damaging
chemotherapeuticdrugs.Morethan50%ofcancersharborinactivatingmutationsinthep53gene,andinmanycasesmutations
inthep53genehavebeenlinkedtoadiminishedresponsetochemotherapy.Determiningthemolecularbasisforchemotherapy
resistanceshouldalloworthopediconcologiststomoreeffectivelytargetthesetherapy-resistantcells.
continued on next page
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
Professor,DepartmentofOrthopedicSurgery
Alejandro A. espinoza orías, PhD
Instructor,DepartmentofOrthopedicSurgery
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
Research Faculty and Highlights 2011 rush orthoPeDiCs journAl 13
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
Instructor,DepartmentofOrthopedicSurgery
not pictured:
MichelLaurent,PhD,scientist,DepartmentofOrthopedicSurgery
Markus A. wimmer, PhD
Director,TribologyLaboratory
Co-director,MotionAnalysisLaboratory
Associateprofessor,DepartmentofOrthopedicSurgery
(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
Medicalschool–RushMedicalCollege
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
Medicalschool–RushMedicalCollege
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
k
Dis
k +
ste
m C
ells
human type ii Collagen
rgAPDh
hgAPDh
Articles 2011 rush orthoPeDiCs journAl 17
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
Disk Disk + stem Cells
rabbit type ii collagen
fold
dif
fere
nce
0
1
2
3
4
Disk Disk + stem Cells
rabbit mmp13
0.5
1.5
2.5
3.5
4.5
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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.
corresponding author
BernardR.BachJr,MD;RushUniversityMedicalCenter,
1611WHarrisonSt,Suite300,Chicago,IL60612
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
Articles2011 rush orthoPeDiCs journAl
“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
Articles 2011 rush orthoPeDiCs journAl 21
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
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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.
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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.
corresponding author
RichardW.Kang,MD;RushUniversityMedicalCenter,
1611WHarrisonSt,Suite300,Chicago,IL60612
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-
Articles2011 rush orthoPeDiCs journAl
“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.”
Articles 2011 rush orthoPeDiCs journAl 27
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.
Articles 2011 rush orthoPeDiCs journAl 29
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.
Articles 2011 rush orthoPeDiCs journAl 31
32
IdiopathicGlenohumeralChondrolysis:ACaseReportshAne J. nho, MD, Ms; niCoLe A. FrieL, MD, Ms; BriAn J. CoLe, MD, MBA
author affiliations
DivisionofSportsMedicine,DepartmentofOrthopedicSurgery,
RushUniversityMedicalCenter,Chicago,Illinois.
corresponding author
BrianJ.Cole,MD,MBA;RushUniversityMedicalCenter,
1611WHarrisonSt,Suite300,Chicago,IL60612
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
Articles2011 rush orthoPeDiCs journAl
“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.“
Articles 2011 rush orthoPeDiCs journAl 33
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
Articles 2011 rush orthoPeDiCs journAl 35
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.
corresponding author
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
Articles2011 rush orthoPeDiCs journAl
“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.“
Articles 2011 rush orthoPeDiCs journAl 37
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
Articles 2011 rush orthoPeDiCs journAl 39
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.
Articles 2011 rush orthoPeDiCs journAl 41
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).
corresponding author
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
Articles2011 rush orthoPeDiCs journAl
“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.“
Articles 2011 rush orthoPeDiCs journAl 43
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
Articles 2011 rush orthoPeDiCs journAl 45
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
Articles 2011 rush orthoPeDiCs journAl 47
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
Articles 2011 rush orthoPeDiCs journAl 49
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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47.ChoiH,McCartneyM,BestTM.Treatmentofosteitispubisandosteomyelitisofthepubicsymphysisinathletes:asystematicreview.Br J Sports Med.2011;45(1):57-64.
48.UnverzagtCA,SchuemannT,MathisenJ.Differentialdiagnosisofasportsherniainahigh-schoolathlete.J Orthop Sports Phys Ther.2008;38(2):63-70.
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Articles 2011 rush orthoPeDiCs journAl 51
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).
corresponding author
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
Articles2011 rush orthoPeDiCs journAl
“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.“
Articles 2011 rush orthoPeDiCs journAl 53
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
Articles 2011 rush orthoPeDiCs journAl 55
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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DunwellT,HessonL,RauchTA,WangL,ClarkRE,Dallol
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RauchTA,PfeiferGP.DNAmethylationprofilingusingthe
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romeo, anthony a.
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BakerCLIII,RomeoAA,BakerCLJr.Osteochondritisdissecans
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FrankRM,VanThielGS,SlabaughMA,RomeoAA,ColeBJ,
VermaNN.Clinicaloutcomesaftermicrofractureoftheglenohu-
meraljoint.Am J Sports Med.2010;38(4):772-781.
GeaneyLE,MillerMD,TickerJB,RomeoAA,GuerraJJ,Bollier
M,ArcieroRA,DeBerardinoTM,MazzoccaA.Managementof
thefailedACjointreconstruction:causationandtreatment.Sports
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GhodadraN,GuptaA,RomeoAA,BachBRJr,VermaN,
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singh, kern
ParkDK,LeeMJ,LinEL,SinghK,AnHS,PhillipsFM.The
relationshipofintrapsoasnervesduringatranspsoasapproach
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BerendKR,SporerSM,SierraRJ,GlassmanAH,MorrisMJ.
Achievingstabilityandlower-limblengthintotalhiparthroplasty.
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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
FY06 FY07 FY08 FY09 FY10
1224 12021165 1174
1448
Year
1500
nu
mb
er o
f c
ases
Pediatrics volumes
0
25
50
75
100
125
FY06 FY07 FY08 FY09 FY10
0
77
120
135 137
Year
150
nu
mb
er o
f c
ases
spine surgery volumes
0
250
500
750
1000
1250
FY06 FY07 FY08 FY09 FY10
910 897
10431128
1230
Year
nu
mb
er o
f c
ases
Foot and Ankle surgery volumes
0
125
250
375
500
625
750
FY06 FY07 FY08 FY09 FY10
491
546 609 621674
Year
nu
mb
er o
f c
ases
joint/orthopedic oncology & trauma volumes
0
125
250
375
500
625
750
FY06 FY07 FY08 FY09 FY10
713647
706632 640
Year
nu
mb
er o
f c
ases
sports Medicine volumes
0
600
1200
1800
2400
3000
3600
FY06 FY07 FY08 FY09 FY10
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.