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Challenges in Treating
Acromioclavicular Separations:
Current Concepts
Abstract
Jay B. Cook, MD Injuries to the acromioclavicular joint constitute approximately 3.2% of
Kevin P. Krul, MD shoulder injuries. Although the overall goal of treatment continues to
be return to activity with a pain-free shoulder, the treatment of
acromioclavicular joint separations has been fraught with conflict
since the earliest reports in both ancient and modern literature.
Accurate diagnosis and classification are important to determine the
optimal treatment. Nonsurgical therapy remains the mainstay for
treatment of low- and most mid-grade injuries, although recent
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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Challenges in Treating Acromioclavicular Separations
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Jay B. Cook, MD and Kevin P. Krul, MD
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Challenges in Treating Acromioclavicular Separations
treatment results in higher complica- or shoulder immobilizer and biologic augmentation, most com-
tion rates, slower return to work, and activity modification.7,14 Patients monly with the use of a tendon graft.
equivalent range of motion.14 Con- undergoing nonsurgical treatment In the low-grade, symptomatic type I
sequently, type III injuries have are removed from sport until and II injuries that have failed non-
largely been treated nonsurgically the symptoms resolve. surgical treatment, an open or
past few decades. However, more Currently, the authors do not arthroscopic distal clavicle excision
recent studies have described altered attempt a reduction when undergo- may be appropriate to provide pain
shoulder mechanics and scapular ing nonsurgical treatment. Patients relief.
dyskinesia with AC separations.15,16 are treated with a sling for 2 to 3 AC fixation has historically involved
weeks until much of the acute pain plates, screws, or wires across the ACJ
resolved, followed by therapy and in the acute setting.7 Most commonly
Type V Injuries
early range of motion. For type I and today, this consists of hook plates,
Type V injuries are treated surgically, II injuries, surgery is considered if which are secured to the clavicle with
although little evidence exists to patients remain symptomatic or screws and span the ACJ maintaining
support this treatment. The only level unable to return to sport after 3 to reduction by hooking under the ac-
I or level II published data on non– 6 months of therapy and rehabilita- romion. The plates are frequently
surgically treated severe Tossy type tion. Patients with a type III injury or removed approximately 3 months
III separations come from Bannis- a type V injury with ,2 cm dis- postoperatively. The hook plate has
ter’s10 randomized controlled trial. placement and without medial- previously been demonstrated to result
These patients had 2 cm of dis- lateral instability with the clavicle in higher outcome scores compared
placement, and, in the authors’ not overriding acromion are brought with nonsurgical treatment, however
opinion, these would be consistent back after 3 to 4 weeks from injury lower scores compared with a modi-
with a Rockwood type V. In the for repeat evaluation. Those who fied Weaver-Dunn technique.20 A
nonsurgical group, four of five report significant improvement in more recent randomized control trial
patients had fair or poor outcomes.10 pain and motion, as well as minimal demonstrated equally good functional
A more recent study examined non- scapular dyskinesia, are counseled to outcome scores between hook plate
surgical management of type V continue nonsurgical management. If fixation and nonsurgical treatment.21
injuries demonstrating that most the patients are noted to have marked CC fixation was traditionally per-
patients will return to work; how- scapular dysfunction and minimal formed with a screw from the clavicle
ever, those with .2 cm of displace- improvement in pain, stability of the to the coracoid; however, modern
ment of the clavicle above the joint is evaluated clinically and techniques have used suspensory
acromion were more likely to fail radiographically, and surgical inter- fixation for CC fixation in place of
nonsurgical therapy.17 One other vention may be offered at this point. the rigid screw, particularly with
review examined type V injuries and Other considerations with regard to acute injuries.22 One study com-
noted that 77% of patients were able work demands and the ability to pared the Bosworth screw with a
to return to work with nonsurgical comply with postoperative restric- suture button for treatment of acute
management, half being manual tions are also taken into account in injuries and noted no difference
laborers, despite modest ASES the treatment algorithm.19 in maintenance of reduction, but
(American Shoulder and Elbow increased patient satisfaction with
Society) and DASH (Disabilities of the suture button.23 Fixation with
the Arm, Shoulder, and Hand) Surgical Treatment one or two suture buttons as an
scores.18 acute repair technique has been
More than 150 techniques for surgi- shown to have high biomechanical
cal treatment of AC injuries have stability.24 This technique is optimal
Author’s Preferred been described.14 These techniques for repair of acutely torn ligaments,
Nonsurgical Treatment have generally fallen into several providing stabilization to allow the
Protocol categories: AC fixation, CC fixation, native ligaments to heal.25
Multiple methods of casting and sling or ligament reconstruction. On Modern techniques have also
wear attempting to externally hold an principle, acute injuries with the moved toward anatomic reconstruc-
AC reduction have been used.7 capacity to heal can do well with tions using tendon grafts with or
Notably, patient compliance is low, techniques that hold the reduction without suspensory devices used in
and no method has been proven to and allow for healing. Typically, conjunction with the graft, particularly
be more effective than a simple sling chronic injuries require some form of for more chronic injuries.19,26-29
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Jay B. Cook, MD and Kevin P. Krul, MD
Multiple biomechanical studies have The counterargument is that de- for bony stability, two recent bio-
shown anatomic CC ligament recon- layed reconstruction better selects mechanical studies have shown that
struction to have biomechanical those patients who require surgery as there does not appear to be a significant
properties similar to the native joint, they have failed nonsurgical man- increase of strain on the graft with a
significantly better than older tech- agement. Despite the aforementioned small excision of the distal clavicle.
niques.30,31 The anatomic recon- literature suggesting that acute Beitzel et al38 showed that with an
struction was first described by repairs have better outcomes, delayed intact posterior-superior AC capsule, a
Mazzocca et al32 over a decade ago. reconstructions improve outcomes 5-mm resection added minimal ante-
Since this description, the technique from preoperative levels without rior or posterior translation, but this
has been modified with regard to subjecting patients to potentially increased with a 10-mm resection.
graft type, graft configuration, graft unnecessary surgery (see Outcomes The authors recommended main-
placement, fixation method, aug- section). Delaying the reconstruction taining the posterior-superior cap-
mentation, and incorporation of maximizes the number of patients sule or considering AC capsule
graft limbs into the AC liga- who can be successfully treated reconstruction if needed in the set-
ments.1,14,19,28,31-34 As of yet, there nonsurgically. ting of an AC separation.38 Beaver
has been no establishment of a single If patients could be identified who et al39 demonstrated no increased
modification of the anatomic tech- would fail nonsurgical management, anterior to posterior or superior to
nique that is superior to the rest, rehabilitation would be expedited if inferior translation with bio-
although anatomic reconstruction early surgery were performed. Sev- mechanical testing of a CC ligament
seems to be preferable to non- eral factors have been identified that reconstruction with and without
anatomic reconstruction, given might suggest which patients will 7 mm of distal clavicle resection.
available data. 14 likely fail nonsurgical management. Two studies have examined the
The first is highly unstable injuries, presence or absence of distal clavicle
types IV and VI specifically.7 The excision as it related to early radio-
Other Controversies in
second is type V injuries, but spe- graphic failure, but did not show any
Surgical Treatments
cifically, if there is .2 cm displace- statistically significant difference
Timing ment at the ACJ as some type V between the two groups with regard to
Early versus delayed treatment con- injuries can do well with nonsurgical loss of reduction postoperatively.36,40
tinues to be a subject of debate. Few treatment.17,18 Finally, dynamically No other study has directly compared
articles have compared early surgery unstable type III injuries will often fail reconstructions with and without a
versus delayed treatment, but the nonsurgical treatment and merit distal clavicle excision with regard to
existing data trend toward improved consideration for surgery as recom- functional outcome scores or revision
patient satisfaction and radiographic mended by International Society of rates. Currently, the authors’ pre-
outcomes with early treatment.35-37 Arthroscopy, Knee Surgery and ferred approach is to attempt a closed
Nevertheless, there is some difficulty Orthopaedic Sports; these can be reduction visualized with fluoroscopy
drawing generalized conclusions identified by a cross-arm AP radio- after the patient is placed under
because the available data include graph noting the clavicle overriding anesthesia prior to prepping the
low-level studies with different defi- the acromion or axillary radiographs shoulder. If the ACJ is unable to be
nitions on “acute.”14 Conceptually, with the arm abducted and adducted reduced fully, the incision will be
acute surgical treatment affords the to evaluate for posterior displace- extended to allow for removal of the
ability to stabilize the ACJ and ment.12,19 However, these factors meniscal homologue or any inter-
allows the native ligaments to heal, have not yet been prospectively posed tissue and then proceed with a
ideal for techniques not including validated. 5-mm distal clavicle resection with an
biologics.25 However, the recom- imbrication of the capsule and pos-
mendation cannot be made to treat sible augmentation with a limb from
all potentially surgical ACJ separa- Distal Clavicle Excision the graft.
tions with an acute repair, given the Reduction of the ACJ can usually be
available data on surgical versus achieved without much difficulty in
nonsurgical treatments. Such an the more acute setting. However, a Graft Type
algorithm would result in a potentially distal clavicle excision is sometimes Most techniques describe the use of
high number of patients undergoing required to obtain reduction of chron- allograft as a tendon source, but auto-
surgery who would otherwise do well ically dislocated ACJs. Although it has graft has also been described.19,26-29,36
nonsurgically. been argued to retain the distal clavicle One study looked at allograft versus
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Challenges in Treating Acromioclavicular Separations
Figure 3 Figure 4
Superior view of 3D CT
reconstruction of a right shoulder
showing an example of the planned
tunnel location of the conoid (red)
and trapezoid (blue) limbs based on
anatomic ratios.
autograft as a risk factor for early Preoperative and postoperative radiographs of a coracoclavicular ligament
radiographic failure, noting a higher reconstruction performed for a chronic ACJ separation. Placement of both
buttons on the clavicle allows vertical compressive force without placing a hole in
failure rate in the allograft group the coracoid. Both the graft and the suture are slung under the coracoid together.
(37.5% versus 16.7%) but was
underpowered to show significance
with regard to radiographic fail- Table 2
ure.36 There are no studies designed Complications
to directly comparing allograft and
Complication Incidence (Source)
autograft for use in biologic aug-
mentation in CC ligament recon- Loss of reduction (early or late) Up to 53%36,40
struction, and it is unknown at this Clavicle fracture Up to 18%34
time what role graft type plays in Coracoid fracture Up to 20%34,a
failure or loss of reduction in CC Infection Up to 6%28,34
ligament reconstruction. Total complication rates Up to 53%33,34,36,40,41
a
In patients with the coracoid tunnel.
Author’s Preferred Surgical
Technique
As stated previously, most patients V injuries who have failed non- same technique is used for both sub-
are given a trial of nonsurgical treat- surgical treatment as mentioned acute and chronic injuries.
ment for Rockwood types I, II, III, above are also indicated for surgi- The clavicle is preoperatively tem-
and V with ,2 cm of ACJ displace- cal intervention. plated to place the conoid tunnel at
ment. Early surgical indications Patients with low-grade injuries 20% to 25% of the clavicular length
include Rockwood types IV, VI, and and persistent pain can often be from the distal clavicle, and the trape-
V with .2 cm of displacement or treated with a simple distal clavicle zoid tunnel is placed 1.5 to 2 cm lateral
with medial-lateral instability re- excision. Those with higher-grade to this (near the anatomic insertion at
sulting in the clavicle overriding the injuries, symptomatic instability, or 17% of clavicular length) (Figure 3).
acromion in a high demand patient. significant deformity who have failed Both the tendon graft and the Dog
Other surgical indications include nonsurgical management undergo Bone (Arthrex) are shuttled from the
open injuries, or injuries with arthroscopically assisted, anatomic medial tunnel, under the coracoid, up
neurologic deficits, or low-grade reconstruction using biologic and the lateral tunnel. The ACJ is reduced
injuries (types I and II) that have synthetic fixation. As surgical inter- and the suture button is secured, then
failed nonsurgical therapy for 3 to vention is rarely undertaken within the graft is secured on top of the
6 months. Patients with types III or the first 2 to 3 weeks from injury, the clavicle. The remaining limbs may be
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Jay B. Cook, MD and Kevin P. Krul, MD
Table 3
Outcomes of Anatomic Reconstructions
Study Patients Follow-up Subjective Satisfaction Objective Scores
ASES = American Shoulder and Elbow Society, DASH = Disabilities of the Arm, Shoulder, and Hand, SANE = Single Assessment Numerical
Evaluation, SST = Simple Shoulder Test, VAS = Visual Analog Scale
a
Only reported on patients without a complication.
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Challenges in Treating Acromioclavicular Separations
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Review Article
Abstract
Matthew V. Smith, MD, MSc Physical examination of the elbow is a critical component in
Joseph D. Lamplot, MD formulating an accurate diagnosis. Various special physical
examinations have been described to improve the clinician’s ability to
Rick W. Wright, MD
establish an accurate diagnosis. A comprehensive approach to the
Robert H. Brophy, MD physical examination of the elbow, including special tests, may
facilitate improved diagnosis of elbow pathology.
Dr. Smith or an immediate family lating an accurate diagnosis. Various bility.5 The examiner should also
member is a member of a speakers’ special physical examinations that know the course of the ulnar, median,
bureau or has made paid
presentations on behalf of Arthrex.
improve the clinician’s ability to and radial nerves because they cross
Dr. Wright or an immediate family establish an accurate diagnosis have the elbow.
member has received research or been described. In this article, we
institutional support from the National present a comprehensive approach
Institutes of Health (NIAMS and
NICHD) and serves as a board
to the physical examination of the
member, owner, officer, or committee elbow, with a focus on special tests Physical Examination
member of the American Board of as described by their original authors.
Orthopaedic Surgery, the American We have included interpretations of The examination begins with inspec-
Orthopaedic Association, and the
each test and statistical information tion of the affected elbow with com-
American Orthopaedic Society for parison with the contralateral side.
Sports Medicine. Dr. Brophy or an regarding the accuracy of each test, if
immediate family member is a available. The examiner should observe the
member of a speakers’ bureau or has resting position of the elbow. In pa-
made paid presentations on behalf of tients with an effusion, the elbow is
Arthrex; has received research or often held in 70° to 80° of flexion, a
institutional support from Orteq Sports
Anatomy and
Medicine; and serves as a board Biomechanics position accommodating the greatest
member, owner, officer, or committee capsular volume.6 The examiner
member of the American Academy of The elbow is a complex hinge joint should also assess the carrying angle
Orthopaedic Surgeons, the American that comprises three bony articu- of the elbow. In full extension, a
Orthopaedic Association, the
American Orthopaedic Society for
lations that provide stability to the normal valgus carrying angle is
Sports Medicine, and the Orthopaedic joint.1,2 The medial ulnar collateral approximately 11° in men and 13° in
Research Society. Neither ligament (MUCL) and the lateral ul- women.7 The carrying angle changes
Dr. Lamplot nor any immediate family nar collateral ligament (LUCL) com- in a linear fashion during flexion,
member has received anything of
value from or has stock or stock
plex provide additional static moving from valgus to varus as the
options held in a commercial company constraints to the elbow.3 The MUCL elbow moves from extension into
or institution related directly or resists valgus stress to the elbow, flexion, making accurate assessment
indirectly to the subject of this article. particularly within the functional of the resting carrying angle difficult
J Am Acad Orthop Surg 2018;26: range of throwing from 20° to 120°,2 in the setting of a flexion contrac-
678-687 and consists of anterior, posterior, ture.8 An increased carrying angle
DOI: 10.5435/JAAOS-D-16-00622 and transverse bundles.4 The LUCL has been observed in professional
complex comprises the LUCL, radial throwing athletes and may indicate
Copyright 2018 by the American
Academy of Orthopaedic Surgeons. collateral ligament, annular ligament, an adaptation to repetitive valgus
and accessory LUCL. Of the struc- stress.9,10
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Matthew V. Smith, MD, MSc, et al
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Comprehensive Review of the Elbow Physical Examination
Epicondylitis
Maudsley Test
Resisted middle finger extension selec-
tively recruits the ECRB tendon and
can reproduce symptoms of lateral
A and B, Clinical photographs demonstrating the milking maneuver. A, The
affected elbow is flexed .90°. B, The examiner pulls on the patient’s thumb with epicondylitis but may also be painful in
the patient’s forearm supinated, the shoulder forward-flexed and elbow flexed the setting of radial tunnel syndrome.20
.90°. The entire course of the ulnar collateral ligament should be palpated Resisted wrist extension with the
during this maneuver. A subjective feeling of apprehension and instability along
elbow in full extension and pronation
with medial elbow pain indicates a positive test result.
stretches the common extensor origin
and can also recreate symptoms of
Figure 3 lateral epicondylitis.1 In patients with
lateral epicondylitis, grip strength de-
creases as the elbow moves from a
position of flexion to extension, with a
29% decrease in grip strength while in
extension compared with flexion.21
Chair Test
The patient is asked to lift a chair with
the shoulder forward-flexed, elbow
extended, and forearm pronated. If
this maneuver provokes lateral elbow
pain, it indicates lateral epicondylitis.22
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Matthew V. Smith, MD, MSc, et al
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Comprehensive Review of the Elbow Physical Examination
Figure 5
A through C, Clinical photographs showing the table-top relocation test. A, The patient is asked to stand in front of a table
with the hand placed around the outer edge of the table. The patient performs a press-up maneuver with the elbow pointing
laterally, maintaining the forearm in supination. B, The patient is asked to push down through the hand onto the edge of the
table, allowing the elbow to flex, and bringing the chest toward the table. C, The maneuver is repeated with the examiner
placing his or her thumb over the radial head while the patient performs the same maneuver.
Prone Push-up Test elbow as he or she raises his or her around the outer edge of the table.
The patient is positioned prone on the body from the chair.31 The patient is asked to perform a
floor with the elbows flexed at 90°, Regan and Lapner31 performed a press-up maneuver with the elbow
the forearms supinated, and the arms prospective evaluation of the prone pointing laterally, maintaining the
abducted to greater than the shoul- push-up test, the chair push-up test, forearm in supination. The patient is
der width. The patient is asked to and the lateral pivot shift test; the then asked to push down through the
perform an active push-up. A test is prone and chair push-up tests hand onto the edge of the table, al-
considered positive if apprehension demonstrated a higher diagnostic lowing the elbow to flex while
and guarding occur as the affected sensitivity compared with the lateral bringing the chest toward the table.
elbow is terminally extended from a pivot shift test. For the prone and The test is considered positive if pain
flexed position.31 chair push-up tests, they reported and apprehension occur at approxi-
87.5% sensitivity for each test, with mately 40° of flexion. Next, the ma-
Chair Push-up Test a combined sensitivity of 100%, neuver is repeated with the examiner
The patient begins seated in a chair compared with 37.5% for the lateral placing his or her thumb over the
with the elbows flexed at 90°, fore- pivot shift test. radial head while the patient per-
arms supinated, and arms abducted forms the same maneuver. Symptoms
to greater than the shoulder width. Table-top Relocation Test of pain and instability should be
The patient is asked to push up from The table-top relocation test com- relieved as the examiner’s thumb
the chair using exclusively upper prises three parts32 (Figure 5). First, prevents posterior subluxation of the
extremity forces. A test is considered the patient is asked to stand in radial head. Finally, the examiner
positive if the patient demonstrates front of a table with the hand of removes his or her supportive thumb
apprehension while extending the the symptomatic extremity placed during mid-elbow flexion of the same
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Matthew V. Smith, MD, MSc, et al
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Comprehensive Review of the Elbow Physical Examination
Figure 7
A through C, Clinical photographs showing the biceps crease interval (BCI). A and B, The main flexion crease (arrow) is
marked. The contour of the distal biceps is palpated along a line parallel to its long axis to identify the point at which the
curve of the distal biceps begins to turn most sharply toward the antecubital fossa (cusp). C, The cusp (arrow) is
marked. The distance between the crease (arrow) and the cusp (arrow) is measured and recorded as the BCI. The
contralateral, unaffected arm is also measured to calculate a biceps crease ratio (BCR). Using a threshold of 6.0 cm for
the BCI or 1.2 for the BCR, sensitivity, specificity, and overall accuracy of 92%, 100%, and 93%, respectively, have
been reported.
examiner moves the patient’s fore- muscle weakness; and diminished entrapment, cubital tunnel syndrome
arm through a passive range of grip strength, pinch strength, and generally demonstrates a motor
supination and pronation, using fatigue.39 Symptoms may be exacer- deficit to ulnar innervated extrinsic
both palpation and visualization to bated with prolonged elbow flexion. muscles and less clawing. Additional
assess for appropriate movement of Careful examination may demon- examination maneuvers include di-
the biceps muscle belly. strate interosseus atrophy in the set- rect compression of the nerve and
Application of the hook test, passive ting of prolonged disease. With the prolonged maximal elbow flexion
forearm pronation test, and BCI test in elbow in full extension, gentle palpa- (ie, elbow flexion test), both of which
sequence result in 100% sensitivity tion and percussion (ie, Tinel sign) of may provoke or exacerbate symp-
and specificity for complete biceps the ulnar nerve along its full course toms in the setting of cubital tunnel
ruptures when the outcomes of each starting at the axilla and moving dis- syndrome. Because of their high false-
test are in agreement.38 tally behind the medial epicondyle positive rates, no tests for cubital tun-
through the cubital tunnel and into the nel syndrome are highly specific.40
FCU muscle may elicit pain or radi- Ulnar nerve hypermobility occurs in
Compressive Neuropathies
ating symptoms into the forearm greater than one third of the adult
About the Elbow and/or ring and little fingers.39 A two- population and does not seem to be
point discrimination test may be associated with an increased inci-
Ulnar Neuritis/Cubital Tunnel abnormal in the setting of both dence of symptomatology.41 Snap-
Syndrome cubital tunnel syndrome and most ping of the medial elbow, often
Ulnar neuritis/cubital tunnel syn- distal ulnar nerve entrapment. How- associated with ulnar nerve symp-
drome can be seen in isolation or ever, an abnormal sensory exami- toms, is not necessarily caused by
concurrently with other medial nation over the ulnar aspect of the dislocation or subluxation of the
elbow conditions, including medial dorsal hand in the distribution of the ulnar nerve.42 Rather, recognizing
epicondylitis and UCL injuries.4,12 dorsal sensory branch of ulnar nerve the possibility of a snapping medial
Patients often present with medial can differentiate cubital tunnel from head of the triceps over the medial
elbow pain; paresthesias of the more distal entrapment because this epicondyle is important. A snapping
small finger, ulnar half of the ring nerve branches approximately 5 cm medial triceps can be elicited with
finger, and ulnar aspect of the hand; proximal to the wrist.39 Furthermore, resisted extension of a fully flexed
hand weakness secondary to intrinsic compared with more distal nerve elbow.
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Matthew V. Smith, MD, MSc, et al
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Comprehensive Review of the Elbow Physical Examination
full supination can be very painful 8. Morrey BF, Chao EY: Passive motion of the treated by a new reconstructive operation.
elbow joint. J Bone Joint Surg Am 1976;58: Clin Orthop Relat Res 1970;72:248-253.
and may be relieved with pronation 501-508.
of the forearm. 23. Verhaar J, Walenkamp G, Kester A, van
9. King GJ, Morrey BF, An KN: Stabilizers of Mameren H, van der Linden T: Lateral
the elbow. J Shoulder Elbow Surg 1993;2: extensor release for tennis elbow: A
165-174. prospective long-term follow-up study.
Summary J Bone Joint Surg Am 1993;75:1034-1043.
10. Wright RW, Steger-May K, Wasserlauf BL,
O’Neal ME, Weinberg BW, Paletta GA: 24. Pienimaki TT, Siira PT, Vanharanta H:
Clinicians must have a thorough Elbow range of motion in professional Chronic medial and lateral epicondylitis:
understanding of the physical exam- baseball pitchers. Am J Sports Med 2006; A comparison of pain, disability, and
34:190-193. function. Arch Phys Med Rehabil 2002;83:
ination of the elbow and the special 317-321.
tests that have been described to 11. Cain EL Jr, Dugas JR, Wolf RS, Andrews
JR: Elbow injuries in throwing athletes: A 25. Keener JD, Sethi PM: Distal triceps tendon
diagnose specific pathologies. The current concepts review. Am J Sports Med injuries. Hand Clin 2015;31:641-650.
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26. Viegas SF: Avulsion of the triceps tendon.
for certain pathologies, including 12. Amin NH, Kumar NS, Schickendantz MS: Orthop Rev 1990;19:533-536.
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27. Wilson FD, Andrews JR, Blackburn TA,
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tive than advanced imaging studies. in the pitching elbow. Am J Sports Med
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29. O’Driscoll SW, Bell DF, Morrey BF:
use this review as a reference con- motion of joints in male subjects. J Bone
Posterolateral rotatory instability of the
Joint Surg Am 1979;61:756-759.
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15. O’Driscoll SW, Lawton RL, Smith AM: The 440-446.
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“moving valgus stress test” for medial
for various elbow pathologies. 30. Anakwenze OA, Kancherla VK, Iyengar J,
collateral ligament tears of the elbow. Am J
Ahmad CS, Levine WN: Posterolateral
Sports Med 2005;33:231-239.
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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Review Article
Management of Bunionette
Deformity
Abstract
Glenn Guangyu Shi, MD Bunionette deformity, historically known as tailor’s bunion, is a
Ammar Humayun, MD forefoot protuberance laterally, dorsolaterally, or plantarlaterally
along the fifth metatarsal head. Although bunionette deformity has
Joseph L. Whalen, MD, PhD
been compared to hallux valgus deformity, it is likely due to a
Harold B. Kitaoka, MD multifactorial, anatomic interplay between fifth metatarsal bony
morphology and forefoot soft-tissue imbalance. Friction generated
between the bony prominence, soft tissue, and associated
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Glenn Guangyu Shi, MD, et al
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Management of Bunionette Deformity
Figure 3
Classification of bunionette deformities using AP weight-bearing radiographs of a foot to identify an enlarged metatarsal
head (type I deformity; A), lateral bowing of fifth metatarsal shaft (type II deformity; B), and large 4 to 5 intermetatarsal angle
(type III deformity; C).
Table 1
prominence and no angular defor- because of shortcomings of the
mity of the metatarsal. Metatarsal study design.
Classification of Bunionette
osteotomies can be used to reduce the
Deformity
width of the forefoot and subsequent
Type Description pain while preserving the fifth meta- Lateral Eminence Resection
I Enlarged fifth metatarsal head tarsal length and joint function. Resection of the lateral condyle is
II Lateral bowing of fifth Similar to hallux valgus correction, typically reserved for patients who
metatarsal shaft proximal osteotomies allow for have an isolated prominent lateral
III Increased IMA larger correction of the IMA com- condyle, but it can also be considered
IV Combination of an enlarged pared with distal osteotomies and for patients who cannot tolerate the
head size and bow or IMA carry a risk of potential injury to the limitations or comply with postoper-
already tenuous proximal fifth ative care (Figure 4). Some surgeons
IMA = intermetatarsal angle
metatarsal blood supply.11-15 Suffi- consider the use of simple resection
ciently powered, prospective, ran- in patients who have symptomatic
domized, controlled trials related to bunionette deformities and in those
bunionette deformity, surgical options surgical bunionette correction are who wish to avoid or are not can-
range from simple lateral eminence not available. Most of the evidence didates for osteotomy. Resection
resection to various distal or proximal related to surgical outcomes is does not correct malalignment but
fifth metatarsal shaft osteotomies. derived from level IV case series rather reduces the mass effect.
Surgical management is mainly that use a wide variety of surgical Recovery is often fast with surgical
dependent on the severity and the techniques, inclusion criteria, out- options that preserve joint mobility
location of pain and correlates with come measures, concomitant sur- and metatarsal length without oste-
clinical and radiographic findings. geries, postoperative protocols, and otomy, avoiding the osteotomy-
Lateral eminence resection is lengths of follow-up. The validity of associated complications of nonunion
reserved for patients with a focal many conclusions is questioned and malunion. A case series of
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Glenn Guangyu Shi, MD, et al
16 patients (21 feet) treated with mity correction. All patients ach- Figure 4
lateral condyle resection reported a ieved radiographic union at 12
71% patient satisfaction rate, with weeks; no nonunion or malunion
no notable correction of angular was reported.
deformity and no relationship be- Techniques for minimally invasive
tween the amount of resection and osteotomy with or without fixation
patient satisfaction.16 Relative contra- continue to emerge, with good to
indications of lateral condylar resec- excellent results.25-30 In a study of in
tion include pes planus deformity and 31 feet, Waizy et al31 described
forefoot pronation because the later- a minimally invasive approach to
ally driven force will continue to pro- distal fifth metatarsal osteotomy
duce pain despite resection because of with Kirschner wire (K-wire) fixa-
the position of the foot during weight tion after oblique medial displace-
bearing. ment osteotomy. The mean four to
five IMA was reduced from 12° to
7.5°, and one patient sustained a pin
Distal Fifth Metatarsal Head tract infection.31 Magnan et al32
Osteotomy reported the case of 30 consecutive
Distal osteotomies have evolved over percutaneous distal osteotomies of
time and have more corrective power the fifth metatarsal for bunionette
than simple lateral condyle resection deformity correction and reported
alone.17-23 Distal osteotomies are improvement of the average Ameri- AP radiograph of the right foot after
lateral eminence resection in an 85-
indicated for painful type II bun- can Orthopaedic Foot and Ankle year-old woman. She had no
ionette deformity. Although trans- Society lesser toe score from 51.9 subluxation or recurrence.
verse and oblique distal osteotomies preoperatively to 98.4 postopera-
have been criticized for the risk of tively at a mean follow-up of
instability, malunion, and the high 96 months. Concerns of inferior the success of long oblique Ludloff
potential of recurrence, Cooper and outcomes after minimally invasive osteotomies combined with lateral
Coughlin24 reported that, in a study correction of type II and III de- condylectomy and soft-tissue bal-
of 14 patients with type I deformity formities are possibly the result of an ancing in 93% of their study pop-
treated with subcapital oblique inability to address the underlying ulation. Several authors modified the
osteotomy, the rate of good or pathology that caused bunionette oblique osteotomy to be more bio-
excellent clinical results was 88% deformity, bowing, and increased mechanically stable with reverse
at a mean follow-up of 2.9 years. IMA. Translation of .50% of the Ludloff and scarf osteotomies with a
Alternatively, chevron osteotomy metatarsal neck width can result in success rate similar to that of the
of distal fifth metatarsal allows for instability, malunion, and unstable standard Ludloff osteotomy.33,35,36
correction with an inherently stable surgical fixation.33 In a recent case series, 16 patients
osteotomy design. In a case series by underwent a reverse Ludloff-type
Kitaoka et al23 with a mean follow- osteotomy for symptomatic type II
up of 7.1 years, the authors reported Diaphyseal Fifth Metatarsal and III bunionette deformities.37
improvement in pain control, IMA, Osteotomy After a mean follow-up of 41.9
forefoot width, and fifth MTPA after In patients with an increased four to months, 15 of 16 patients reported
distal chevron osteotomy. Satisfac- five IMA or substantial lateral bow- satisfactory outcomes, with an
tion was 89.5% in 17 of 19 patients. ing of the metatarsal shaft, diaphy- average final American Orthopaedic
The osteotomy is stable by design; seal fifth metatarsal osteotomy is Foot and Ankle Society lesser toe
however, fixation is recommended indicated.34 Historically, adverse score of 86.6 points. MTPAs and
to prevent transfer metatarsalgia, events, such as malrotation, non- IMAs were considerably reduced
malunion, nonunion, and recur- union, and malunion, have been from 24.9° preoperatively to 4.3°
rence.4 Boyer and Deorio20 re- associated with transverse osteoto- postoperatively and 13.2° preoper-
ported a 90% satisfaction rate in mies. Surgeons favor stable oste- atively to 5.2° postoperatively,
their series on distal chevron oste- otomy constructs adapted from respectively. One patient reported
otomy with single bioabsorbable those used to manage hallux valgus dissatisfaction because of a persistent
pin fixation for bunionette defor- deformity. Coughlin4 demonstrated fifth toe contracture.37
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Bunionette Deformity
Complications
The overall reported complication
rate after surgical bunionette defor-
mity correction is low. Complications
including delayed wound healing,
malunion, nonunion, transfer metatar-
salgia, and recurrence vary depending
on the specific procedure and the im-
plants used. Recurrence can occur
after bunionette deformity correction
regardless of the technique used. When
the procedure chosen does not address
the underlying deformity, the patient is
at a higher risk for recurrence. Sublux-
ation is unique to undercorrection and
poor capsular imbrication, and dislo-
cation can occur with overcorrection or
undercorrection of bunionette defor-
mity (Figure 6). In addition, over-
resection of the lateral condyle can
produce enough instability to cause
immediate or delayed dislocation.
Valgus fifth toe is a poorly tolerated
AP radiograph of a right foot
demonstrating metatarsophalangeal condition in shoe-wearing societies,
AP radiograph of the left foot after
fifth metatarsal head resection for a joint subluxation, which is a when the fifth metatarsal phalangeal
failed symptomatic bunionette complication of lateral eminence joint becomes unstable after osteotomy
correction in a 64-year-old woman. resection. Other complications and medial soft-tissue release. Transfer
include early arthritis and instability.
metatarsalgia can occur when the fifth
Proximal Fifth Metatarsal metatarsal is shortened, elevated, or
Osteotomy address painful bunionette deform- resected. Implant-related complica-
ities (Figure 5). Concerns with this tions are most commonly reported
Proximal or base fifth metatarsal os- with the use of K-wire, which can
procedure are related to MTPJ
teotomies were designed to address cause soft-tissue irritation and pin tract
instability, flail toe deformity, and
increased four to five IMAs. Re- infections.21,25,30,40
transfer metatarsalgia. Kitaoka and
cently, Okuda et al15 reported on a
Holiday38 reported on a series of 11
series of 10 patients who underwent
feet in seven patients who underwent
proximal third osteotomy of the fifth
fifth metatarsal head resection with Authors’ Preferred Surgical
metatarsal for bunionette correction
an average follow-up of 9.1 years. Approach
with sustained correction of a large
Poor results were seen in seven of 11
IMA (12.2° preoperatively to 4.8°
feet, with a 64% complication rate After diagnosis of bunionette defor-
postoperatively). Osteotomies in this
reported. Common complications mity, it is important to determine the
region lost favor because of concerns
included transfer metatarsalgia and exact location of the pain: lateral,
with nonunion, given the tenuous
persistent painful fifth toe. Fifth plantarlateral, or plantar. Radio-
blood supply at 2 cm proximal to the
metatarsal head resection still has a graphs can help the surgeon identify
fifth metatarsal base.
role in rheumatoid forefoot re- and classify the deformity.
constructions and in the management We reserve lateral condyle resec-
Metatarsal Head Resection of failed osteotomies, infections, and tion for a type I bunionette deformity
Metatarsal head resection is often neuropathy in patients with impend- with painful lateral callosity. A 3-cm
considered a salvage option to ing ulceration who cannot adhere to longitudinal incision is made lateral
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Glenn Guangyu Shi, MD, et al
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Bunionette Deformity
Figure 8
A, Preoperative clinical photograph of a foot showing the marking for a lateral incision along the fifth metatarsophalangeal
joint for longitudinal diaphyseal osteotomy to correct a type II deformity. B, Intraoperative photograph showing a
microsagittal saw being used to shave the lateral eminence flush with the fifth metatarsal shaft. C, Intraoperative
photograph showing the diaphyseal osteotomy line, which is made along the fifth metatarsal shaft. D, AP fluoroscopic
image of a foot showing guidewires that are inserted to identify the length of osteotomy. E, Intraoperative photograph
showing the use of a microsagittal saw in plane with the guidewires to avoid elevation or plantar flexion of the metatarsal
head. F, After completion of the proximal half of the metatarsal shaft osteotomy, a temporary Kirschner wire is placed
rather than a 2.0-mm screw to secure the proximal half of the osteotomy before completion of the distal half of the
osteotomy, preventing the surgeon from losing control of bony stability during manipulation. Subsequently, the metatarsal
head is shifted and pinned in place. G, AP fluoroscopic image of the foot demonstrating adequate correction.
Intraoperative photographs of a foot showing insertion of two 2.0-mm screws into the metatarsal shaft (H) and the use of a
microsagittal saw to remove the overhanging edges of the osteotomy (I). Postoperative AP weight-bearing (J) and lateral
(K) radiographs of a foot showing correction and fixation at 12 weeks.
tightened and the correction assessed Careful shaving or smoothing of the the abductor digiti minimi slightly
with fluoroscopy. Overcorrection or sharp edges of the osteotomy may be dorsally. Final AP, lateral, and obli-
undercorrection can be changed by necessary (Figures 8, I). que intraoperative fluoroscopic im-
simply loosening the screw and re- Care should also be taken to avoid ages are obtained. Routine skin
tightening it after the desired align- overpenetration of the plantar cortex closure is then completed with nylon
ment is achieved. with the screws because it could sutures.
A second screw is placed either potentially cause weight-bearing Unlike simple lateral eminence
proximal or distal to the first screw pain. The capsule of the MTPJ is resection or distal osteotomy, feet are
and is angled to provide another bi- then repaired using absorbable su- splinted for 2 weeks after diaphyseal
cortical fixation point, replacing the tures with the toe held at neutral, osteotomies until the skin sutures are
provisional K-wire (Figure 8, H). advancing the plantar capsule with removed, and then, a short leg cast is
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Glenn Guangyu Shi, MD, et al
worn for 2 to 4 more weeks. Patients 6. Steel MW III, Johnson KA, DeWitz MA, cortical screw fixation. J Foot Surg 1989;
Ilstrup DM: Radiographic measurements of 28:237-243.
are allowed to bear weight in a post- the normal adult foot. Foot Ankle 1980;1:
operative shoe at 6 weeks after 151-158. 22. Kitaoka HB, Leventen EO: Medial
displacement metatarsal osteotomy
surgery. The osteotomy may be 7. Shimobayashi M, Tanaka Y, Taniguchi A, for treatment of painful bunionette.
visualized radiographically for 3 to Kurokawa H, Tomiwa K, Higashiyama I: Clin Orthop Relat Res 1989:
Radiographic morphologic characteristics 172-179.
4 months, but the patient may return
of bunionette deformity. Foot Ankle Int
to normal activities in supportive 2016;37:320-326. 23. Kitaoka HB, Holiday AD Jr, Campbell
DC II: Distal Chevron metatarsal
shoes in 8 to 10 weeks. Impact exer- osteotomy for bunionette. Foot Ankle
8. Fallat LM: Pathology of the fifth
cise is usually tolerated by 12 weeks ray, including the Tailor’s bunion 1991;12:80-85.
(Figure 8, J and K). deformity. Clin Podiatr Med Surg 1990;
24. Cooper MT, Coughlin MJ: Subcapital
7:689-715.
oblique osteotomy for correction of
9. Nestor BJ, Kitaoka HB, Ilstrup DM, bunionette deformity: Medium-term
results. Foot Ankle Int 2013;34:
Summary Berquist TH, Bergmann AD: Radiologic
1376-1380.
anatomy of the painful bunionette. Foot
Ankle 1990;11:6-11.
Most painful bunionette deformities 25. Legenstein R, Bonomo J, Huber W,
10. Grice J, Marsland D, Smith G, Calder J: Boesch P: Correction of Tailor’s bunion
respond to nonsurgical management. Efficacy of foot and Ankle with the Boesch technique: A
When initial nonsurgical methods corticosteroid injections. Foot Ankle Int retrospective study. Foot Ankle Int 2007;
2017;38:8-13. 28:799-803.
have failed to relieve the symptoms,
surgical options allow for deformity 11. Shrum DG, Sprandel DC, Marshall H: 26. White DL: Minimal incision approach
Triplanar closing base wedge osteotomy for to osteotomies of the lesser metatarsals:
correction, with low reported com- For treatment of intractable
Tailor’s bunion. J Am Podiatr Med Assoc
plication rates. Clinical and radio- 1989;79:124-127. keratosis, metatarsalgia, and Tailor’s
graphic evaluation guide surgical bunion. Clin Podiatr Med Surg 1991;8:
12. Weitzel S, Trnka HJ, Petroutsas J: 25-39.
intervention. Newer minimally inva- Transverse medial slide osteotomy for
sive techniques with expanded cor- bunionette deformity: Long-term results. 27. Giannini S, Faldini C, Vannini F, Digennaro
Foot Ankle Int 2007;28:794-798. V, Bevoni R, Luciani D: The minimally
rective power have been reported, invasive osteotomy “S.E.R.I.” (simple,
with promising results.27-29 Type I 13. Moran MM, Claridge RJ: Chevron effective, rapid, inexpensive) for correction
osteotomy for bunionette. Foot Ankle Int of bunionette deformity. Foot Ankle Int
deformity is still managed with lat- 1994;15:684-688. 2008;29:282-286.
eral eminence resection with or
14. Shereff MJ, Yang QM, Kummer FJ, Frey 28. Michels F, Van Der Bauwhede J, Guillo S,
without distal osteotomy. Types II CC, Greenidge N: Vascular anatomy of the Oosterlinck D, de Lavigne C: Percutaneous
and III can be managed with either fifth metatarsal. Foot Ankle 1991;11: bunionette correction. Foot Ankle Surg
350-353. 2013;19:9-14.
distal or diaphyseal osteotomy.
15. Okuda R, Kinoshita M, Morikawa J, 29. Laffenetre O, Millet-Barbe B, Darcel V,
Jotoku T, Abe M: Proximal dome- Lucas YHJ, Chauveaux D: Percutaneous
shaped osteotomy for symptomatic bunionette correction: Results of a
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16. Kitaoka HB, Holiday AD Jr: Lateral 179-184.
those published within the past 5 condylar resection for bunionette. Clin
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Windhager R: The modified distal
1. Coughlin MJ: Etiology and treatment of the 17. Sponsel KH: Bunionette correction by horizontal metatarsal osteotomy for
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2. Steinke MS, Boll KL: Hohmann-Thomasen 31. Waizy H, Olender G, Mansouri F,
metatarsal osteotomy for Tailor’s bunion 18. Leach RE, Igou R: Metatarsal osteotomy Floerkemeier T, Stukenborg-Colsman C:
(bunionette). J Bone Joint Surg Am 1989; for bunionette deformity. Clin Orthop Minimally invasive osteotomy for
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not advisable for severe deformities: A
3. Diebold PF: Basal osteotomy of the fifth 19. Haber JH, Kraft J: Crescentic osteotomy for critical retrospective analysis of
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4. Coughlin MJ: Treatment of bunionette 20. Boyer ML, Deorio JK: Bunionette 32. Magnan B, Samaila E, Merlini M, Bondi
deformity with longitudinal diaphyseal deformity correction with distal chevron M, Mezzari S, Bartolozzi P:
osteotomy with distal soft tissue repair. osteotomy and single absorbable pin Percutaneous distal osteotomy of the
Foot Ankle 1991;11: fixation. Foot Ankle Int 2003;24: fifth metatarsal for correction of
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5. Koti M, Maffulli N: Bunionette. J 21. Frankel JP, Turf RM, King BA: Tailor’s
Bone Joint Surg Am 2001;83-A: bunion: Clinical evaluation and correction 33. Maher AJ, Kilmartin TE: Scarf osteotomy
1076-1082. by distal metaphyseal osteotomy with for correction of Tailor’s bunion: Mid- to
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Management of Bunionette Deformity
long-term followup. Foot Ankle Int 2010; technique. Foot Ankle Surg 2012;18: 38. Kitaoka HB, Holiday AD Jr: Metatarsal
31:676-682. 50-54. head resection for bunionette: Long-term
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34. London BP, Stern SF, Quist MA, Lee RK, 36. Glover JP, Weil L Jr, Weil LS Sr: Scarfette
Picklesimer EK: Long oblique distal osteotomy for surgical treatment of 39. Reize P, Leichtle CI, Leichtle UG, Schanbacher
osteotomy of the fifth metatarsal for bunionette deformity. Foot Ankle Spec J: Long-term results after metatarsal head
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Colsman C, Claassen L: The reverse 40. Friend G, Grace K, Stone HA: L-
35. Guha AR, Mukhopadhyay S, Thomas RH: Ludloff osteotomy for bunionette osteotomy with absorbable fixation
“Reverse” scarf osteotomy for bunionette deformity. Foot Ankle Spec 2016;9: for correction of Tailor’s bunion.
correction: Initial results of a new surgical 324-329. J Foot Ankle Surg 1993;32:14-19.
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Review Article
Surgical Management of
Patellofemoral Instability in the
Skeletally Immature Patient
Abstract
Lauren H. Redler, MD Compared with skeletally mature patients, skeletally immature
Margaret L. Wright, MD patients are at a higher risk of acute traumatic patellar dislocation.
Surgical treatment is the standard of care for patients with recurrent
instability and requires important and technically challenging physeal
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Patellofemoral Instability in Skeletally Immature Patient
Figure 1 fragments have not been shown to recognize the features that affect the
benefit from surgical treatment.8,9 risk of failure of surgical intervention
Current standard treatment includes and recurrent instability, including
activity restriction, patellar taping patella alta, elevated TT-TG, and
or bracing, and physical therapy trochlear dysplasia. Although these
focused on stretching the iliotibial factors guide patient counseling, they
band and strengthening the vastus rarely affect surgical planning in this
medialis oblique (VMO), gluteal age group. Surgeons should ensure that
muscles, and core. Osteochondral children have reached skeletal maturity
injuries occur in as many as 75% of and physeal closure before considering
pediatric patients with acute patellar tibial tubercle (TT) osteotomy.
dislocation.10 The osteochondral
lesion is typically on the medial facet
of the patella or lateral femoral con- Surgical Techniques
dyle. Surgery is indicated in patients
with loose osteochondral fractures to Surgical Considerations
avoid a mechanical block to motion In the pediatric population, a thor-
and development of early chondral ough understanding of the distal
wear. Lesions in non–weight-bearing femoral and proximal tibial physes,
portions of the knee or irreparable as well as the TT apophysis, is critical
osteochondral fragments may be when considering the multitude of
excised, but large fragments from available surgical techniques. The
weight-bearing surfaces have high distal femoral physis has a charac-
healing capacity and should be re- teristic undulating structure with
AP radiograph of a skeletally immature paired. There are also reports of large, relatively proximal medial and lateral
knee showing the undulating course of chondral only fragments healing after borders (Figure 1). It is the largest
the distal femoral physis. fixation in adolescent patients, and and fastest growing physis in the
these may benefit from fixation.11 body and contributes 70% of the
Syndromic dislocation occurs in pa- Patellar stabilization is indicated in femoral length and 37% of overall
tients with syndromes associated with patients with recurrent instability; lower limb growth, which amounts
ligamentous laxity or osseous defor- 49% of patients with recurrent to approximately 1 cm per year
mity (eg, Marfan syndrome, Ehlers- instability who are treated non- during skeletal immaturity. This
Danlos, Down syndrome). Allografts surgically will have further instability, growth plate fuses between the ages
should be used for medial patello- as opposed to a 4% of those treated of 14 and 16 years in females and 16
femoral ligament (MPFL) reconstruc- with MPFL reconstruction.3,12 Eighty and 18 years in males. The proximal
tion in this group.7 Obligatory percent of patients return to their tibial physis contributes approxi-
dislocation results from tight lateral preinjury activity level after MPFL mately 55% of the length of the tibia
structures and occurs every time the reconstruction compared to only and 25% of the length of the entire
knee is flexed, but reduces in knee 52% of patients treated nonsurgically limb. On average, the proximal tibial
extension. Fixed dislocation cannot be or with MPFL repair.8,13 Patients physis contributes 0.65 cm of growth
reduced even with knee extension. with recurrent instability have lower per year. This physis fuses between
Obligatory and fixed dislocations may short- and long-term outcome scores the ages of 13 and 15 years in fe-
require additional soft-tissue proce- than those treated with MPFL males and 15 and 19 years in males.
dures for stabilization beyond the lat- reconstruction, as well as increased The TT apophysis fuses between the
eral release and MPFL reconstruction progression of patellofemoral carti- ages of 13 and 15 years in females
techniques described in this review.2 lage erosion compared to those and 15 and 19 years in males. The
without recurrence. 14-16 MPFL patella begins to ossify at age 3 years
reconstruction alone can be per- in females and 4 to 5 years in males.
Surgical Indications formed successfully in pediatric Growth disturbance as a result of
patients who have recurrent insta- injury of the patellar physis after
Skeletally immature patients who bility associated with trochlear MPFL reconstruction has not been
sustain an initial, acute patellar dis- dysplasia and no other structural reported. However, reconstruction
location without loose osteochondral deformities.17 It is important to technique and patellar fixation
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Margaret L. Wright, MD
Figure 2
A, AP intraoperative fluoroscopic image showing drilling of the femoral socket away from the physis. B, Lateral intraoperative
fluoroscopic image showing the drill located at the Schottle point. C, Postoperative coronal magnetic resonance image
showing the location of the interference screw on the distal medial femur distal to the physis. (Courtesy of Beth E. Shubin
Stein, MD, New York, NY.)
should be carefully considered in physeal tunnels remain the location that underwent the procedure, 26
young patients and is discussed in of choice. It is also important to knees had excellent results based on
more detail later. consider the perichondrium of the the Insall criteria21 (Figure 3).
The femoral insertion of the MPFL physis because it is sensitive to in- The Galeazzi semitendinosus
is variable in pediatric patients, jury. Caution must be exercised to tenodesis is performed by harvesting
although radiographic and cadaver avoid violation of the perichondrium the semitendinosus tendon, leaving it
studies have found that in most pa- during both surgical dissection and attached at its distal insertion, and
tients, the midpoint of the femoral tunnel placement. sewing it in an oblique manner to the
attachment is just distal to the inferomedial patella. A 2012 study of
physis.18,19 Grafts placed proximal 34 knees treated with the procedure
to the physis have the unique com- Distal Realignment found that 35% required a second
plication of proximal migration of Procedures surgery and 82% had recurrent sub-
the insertion after reconstruction and Distal realignment procedures include luxation or dislocation, so it has
high tension across the physis. the Modified Roux-Goldthwait, Ga- largely been abandoned for more
Fluoroscopic guidance is mandatory leazzi, and Nietosvaara techniques. effective and anatomic reconstruc-
to avoid physeal violation and to These procedures are often combined tion procedures22 (Figure 4).
determine appropriate tunnel place- with proximal realignments, includ- Nietosvaara et al23 described a
ment. Care should be taken to con- ing medial imbrication and lateral more anatomic modification of
firm that the trajectory of the guide retinacular release. the Galeazzi distal reconstruction,
pin is completely distal to the physis The modified Roux-Goldthwait in which the semitendinosus and
on the AP view, given the concave procedure is performed by detach- gracilis are left attached at the pes
shape of the distal femoral physis20 ing the lateral half of the patellar insertion, passed through a medial
(Figure 2). Although growth of the tendon from the TT and passing it longitudinal patellar bone tunnel
distal femoral epiphysis arises from medially under the patellar tendon. from inferior to superior, and then
the secondary subchondral growth The tendon is sutured to the medial fixed to the femoral insertion of the
plate, and is theoretically at risk of tissues and periosteum at the junction MPFL with an interference screw.
injury during creation of tunnels in of the medial TT and pes anserine Although this technique seems
the epiphysis, the concern for teth- insertion. A lateral release, sometimes promising in the original case series,
ering of the distal femoral physis with medial imbrication, is also per- long-term outcome studies have not
outweighs this issue, and thus, epi- formed. In an early study of 30 knees yet been performed23 (Figure 5).
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Patellofemoral Instability in Skeletally Immature Patient
Figure 3
Schematic drawing of the modified Roux-Goldthwait distal realignment technique. (Reproduced with permission from Weeks
KD III, Fabricant PD, Ladenhauf HN, Green DW: Surgical options for patellar stabilization in the skeletally immature patient.
Sports Med Arthrosc Rev 2012;20[3]:194-202.)
Soft-tissue Procedures tients with an initial dislocation come scores and rates of recurrent
who are undergoing a procedure for instability have been reported in
MPFL Repair
additional injuries (ie, osteochondral both autograft and allograft ham-
The MPFL is the primary restraint
repair). string reconstruction in skeletally
against lateral patellar translation
immature patients.7,20,27
and is stretched or torn in dislocation
Patellar fixation using bone tun-
events, most commonly at the patel- Hamstring MPFL Reconstruction
nels, docking technique, interference
lar origin.19 Direct MPFL repair does MPFL reconstruction is favored in
screw, or suture anchor fixation has
not require patellar bone tunnels patients with recurrent instability
been described.20,28 Creation of a
and poses minimal risk of femoral because the chronically injured
bony sulcus and suture anchor fix-
physeal injury. However, biomechan- medial retinacular structures are
ical tests of MPFL repair show weak- insufficient to prevent recurrent dis- ation are gaining favor because they
ness compared to the native ligament location. Anatomic MPFL recon- avoid the risk of patella fracture
and MPFL reconstruction.24 Pa- struction procedures for skeletally (Figure 6). In addition, if cartilage
tients who undergo MPFL repair immature patients have been de- restoration procedures (eg, osteo-
are more likely than those who scribed, with multiple fixation tech- chondral fracture fixation, OATS
undergo reconstruction to have niques available in the patella and [osteochondral allograft transfer sys-
recurrent dislocation, and they are femur to avoid injury to the physis. A tem], minced chondral allograft) are
nearly as likely as patients who are recent meta-analysis found that anat- concurrently performed on the patella,
treated nonsurgically to have recur- omic grafts have the lowest recur- creation of bone tunnels in the patella
rent dislocation.23,25,26 MPFL repair rence rate when a double-limb graft increases the possibility of the tunnels
is therefore only considered in pa- configuration is used.7 Similar out- communicating and compromising the
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Margaret L. Wright, MD
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Patellofemoral Instability in Skeletally Immature Patient
Sling Procedures
In an effort to maximize the ability
to create an anatomic graft while
minimizing the risk of femoral phys-
Intraoperative photographs demonstrating the placement of suture anchors (A) eal injury, the use of sling procedures
for fixation of the hamstring graft (B) to the medial border of the patella (asterisk) for MPFL reconstruction in pediatric
during medial patellofemoral ligament reconstruction. patients has been described. Monllau
et al36 described a technique using
gracilis autograft, in which the ad-
technique, it is important to consider Adductor Tendon Reconstruction ductor tendon insertion is used for
both the tibial and femoral physes Because of the proximity of the the femoral MPFL attachment point.
when determining the location of the adductor tubercle to the femoral Two tunnels are drilled through the
MPFL and MTFL fixation sites. insertion of the MPFL, the adductor patella in a V shape (Figure 7, E).
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Margaret L. Wright, MD
Figure 7
Schematic drawing of several physeal-sparing medial patellofemoral ligament reconstruction techniques: hemiquadriceps
tendon transfer (A), hemipatellar tendon transfer (B), adductor tendon pedicle graft (C), hamstring graft using MCL as a
pulley (D), hamstring graft using adductor tendon as a pulley (E), and double-limb hamstring allograft using patellar and
femoral sockets (F). (Reproduced with permission from Gausden EB, Green DW: Medial patellofemoral ligament
reconstruction: Hamstring technique, in Cordasco FA, Green DW, eds: Pediatric and Adolescent Knee Surgery.
Philadelphia, PA, Wolters Kluwer, 2015, pp 140-147.)
The gracilis tendon is passed through A free hamstring graft is fixed to the passed behind the femoral attachment
one bone tunnel, under the VMO, patella and then passed medially and of the MCL and sutured to the ante-
around the adductor magnus tendon under the posterior third of the femoral rior patellar retinaculum. When per-
near its femoral insertion, back insertion of the MCL. The graft is then forming the MCL sling techniques,
across the medial knee, and through looped back over the MCL and care should be taken to avoid iatro-
the second patellar tunnel, and the sutured to the anterior patellar reti- genic injury to the MCL, although
ends are sutured together. naculum.37 A variation of this tech- no MCL injuries have been reported
A similar technique has been nique is to leave the semitendinosus in the literature to date (Figure 7, D).
described using the femoral MCL attached to its pes insertion site. The Although these techniques are
(medial collateral ligament) insertion. free end of the graft can then be appealing because they avoid tunnels
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Patellofemoral Instability in Skeletally Immature Patient
Figure 8 MPFL, the medial quadriceps ten- excessive lateral release because
don femoral ligament (MQTFL), medial instability after lateral release
has been identified. It originates has also been described. 42 Lateral
from the deep aspect of the quad- release may also be indicated in
riceps tendon and inserts superior patients with obligatory or fixed
to the MPFL.41 MQTFL recon- patellar dislocation because these
struction is an alternative to MPFL patients have tight lateral restraints
reconstruction that avoids the use that limit the ability to maintain
of patellar tunnels. patellar reduction.2
MQTFL reconstruction is per-
formed with either semitendinosus
autograft or allograft. The graft is Complications
Intraoperative photograph of the
knee demonstrating a combined
fixed just anterior to the adductor Although MPFL reconstruction
MPFL and MQTFL reconstruction. tendon insertion with an interference techniques are currently the standard
MPFL = medial patellofemoral screw or suture anchor. A second of care for pediatric patients with
ligament, MQTFL = medial parallel incision is made over the patellofemoral instability, complica-
quadriceps tendon femoral ligament.
(Courtesy of Mininder S. Kocher,
medial patella and quadriceps ten- tions remain a considerable chal-
MD, MPH, Boston, MA.) don, and the graft is passed ex- lenge. One of the largest series of
tracapsularly. The graft is sutured to young patients (aged ,21 years)
the distal aspect of the medial quad- undergoing MPFL reconstruction
on the medial femur and minimize the riceps tendon, and patellar tracking is reported an overall complication
risk of growth disturbance, results observed throughout range of motion rate of 16.2%.12 The most common
have been mixed. One study found to evaluate graft tension. In a series of complications were loss of complete
a higher risk of patellar instability 17 skeletally mature patients who knee flexion and recurrent patello-
after the adductor sling procedure underwent an MQTFL reconstruc- femoral instability. In the patients
compared to anatomic techniques.38 tion for instability, none had recur- with loss of flexion, all improved
A study of the adductor tendon rence at 1 year postoperatively.41 A with manipulation under anesthesia
reconstruction compared to the combination MPFL-MQTFL recon- and nearly all had anterior place-
adductor sling procedure using struction technique is gaining popu- ment of the femoral insertion point
hamstring autograft found no dif- larity, sparking interest in renaming identified on MRI.12 One study
ference in postoperative instability or it the medial patellofemoral complex found that the primary radiographic
complications, but found that pa- (Figure 8). risk factor for recurrent dislocation
tients who had undergone the sling was the severity of trochlear
procedure were more likely than dysplasia.43
those who underwent reconstruction Lateral Release Although specific methods of fixation
using the adductor magnus tendon Lateral release has not been found to and graft type have not been associated
to return to sports and had subjec- be effective when performed in iso- with complications after anatomic
tively better outcome scores.39 Longer lation, likely because it does not reconstruction, patella fracture is a
follow-up of the same patients found improve patellar tracking. However, known complication of the bone tun-
that 11 of 15 had an excellent outcome in some cases, it may be an effective nels used for patellar fixation. Six cases
with the sling procedure and only one addition to medial soft-tissue proce- of patella fracture (4.3%) were identi-
required further surgery.39 dures. Indications for a lateral release fied in one series, and five of the six
in combination with medial proce- required surgical fixation.44 Although
Medial Quadriceps Tendon dures include abnormal patellar tilt, uncommon, this is an important
Femoral Ligament defined as the inability to evert the consideration when choosing the
Reconstruction patella to neutral, and TT-TG technique of MPFL reconstruction,
Anatomic studies have shown vari- distance .20 mm. It is important especially in younger patients with a
ability in the patellar origin of the to distinguish abnormal patellar tilt, less ossified patella and small margin
MPFL, with some patients having which represents true lateral tightness, for error. This may sway the surgeon
greater attachment to the VMO and from lateral patellar tilt seen on to use techniques that do not require
quadriceps tendon as opposed to imaging in all cases of patellar insta- patellar bone tunnels (quadriceps or
the patella directly.40 A separate bility as a result of injured incompe- patellar tendon autograft or suture
structure just superior to the tent medial tissues. It is vital to avoid anchor fixation).
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Lauren H. Redler, MD and Margaret L. Wright, MD
Indications
Guided growth techniques have been
used for many years to correct genu
valgum in children with open physes.
The goals of these procedures are to
maximize growth potential and to
avoid osteotomies after growth is
complete. Genu valgum is a known
risk factor for patellar instability, and
correction of genu valgum in isola-
tion or in addition to medial soft-
tissue procedures decreases the risk of
recurrent instability.45 Radiographs
should be obtained to confirm bone
age; a three-joint standing radiograph
of the lower extremities should
be obtained to assess remaining
growth and the degree of deformity. A, Preoperative standing AP three-joint radiograph of the lower extremities
Guided growth techniques are typi- showing genu valgum of the left knee. B, Postoperative standing AP three-joint
cally indicated in patients with genu radiograph of the lower extremities showing correction of genu valgum with distal
medial femoral and proximal medial tibial hemiepiphysiodesis.
valgum .10° (defined by the lateral
distal femoral angle ,79°) that is
associated with patellar instability, currently with a medial soft-tissue until skeletal maturity with standing
who have at least 6 months to 1 year procedure. Using blunt dissection, radiographs to confirm that no
of remaining growth. Temporary the periosteum over the physis is overcorrection or other deformity
hemiepiphysiodesis through the identified but not violated. The develops.
application of an extraphyseal ten- figure-of-8 plate is placed and held
sion band plate is a safe, effective, provisionally with a hypodermic
and minimally invasive technique. needle or K-wire fixation. Fluoros- Technical Considerations
However, it should not be used in copy is used to confirm the position of
children aged ,8 years because the plate over the midsagittal line of Physeal stapling and other forms of
spontaneous correction of the the distal femoral physis on the lateral hemiepiphysiodesis have been used to
deformity is likely in children this view, with one hole of the plate on correct genu valgum; however, they
young.46 each side of the physis. When posi- are not reversible and therefore must
tion is confirmed, K-wires are placed be used in older children who will
in each hole, and cannulated screws reach completion of growth before
Technique are placed for definitive fixation. overcorrection. Figure-of-8 plates act
Temporary hemiepiphysiodesis, or Weight bearing as tolerated may be as a tension band across the physis
tension band plating, is most often permitted or weight bearing within and slow growth relative to the lateral
done at the distal medial femur but the limitations of any other proce- physis without creating permanent
can also be applied to the proximal dures that were performed concur- physeal bars or tethers.46 They can
medial tibia in cases in which both the rently.46 Patients are followed at therefore be used for growth modu-
femur and tibia contribute to the 3- to 4-month intervals with stand- lation techniques in younger chil-
deformity. The surgical site is identi- ing three-joint radiographs to mea- dren, allowing for faster correction.
fied with fluoroscopy, and the pro- sure correction of the deformity Correction of approximately 0.7°
cedure is performed through a 2-cm (Figure 9). The plates are removed per month in the femur and 0.5°
skin incision or through the incision when correction is complete, and the per month in the tibia can be ex-
over the femoral insertion of the patient should continue to be fol- pected, for a combined average of
MPFL if the procedure is done con- lowed at 4- to 6-month intervals 1.2° per month if used together.
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Patellofemoral Instability in Skeletally Immature Patient
Valgus alignment can improve an fixation technique should be tai- adolescents: Operative versus nonoperative
treatment. Int Orthop 2011;35:1483-1487.
average 8° per year with a femoral lored to the patient’s anatomy and
hemiepiphysiodesis and an addi- remaining physeal growth. Lower 10. Kramer DE, Pace JL: Acute traumatic and
sports-related osteochondral injury of the
tional 4° per year with tibial hemi- limb alignment is an important pediatric knee. Orthop Clin North Am
epiphysiodesis.46 Faster and greater factor and offers the unique adjunct 2012;43:227-236.
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Research Article
Abstract
Matthew William Christian, MD Introduction: A surgical simulation platform has been developed to
Cullen Griffith, MD simulate fluoroscopically guided surgical procedures by coupling
computer modeling with a force-feedback device as a training tool for
Carrie Schoonover, BS
orthopaedic resident education in an effort to enhance motor skills and
Tim Zerhusen, Jr, BS potentially minimize radiation exposure. The objective of this study
Max Coale, BA was to determine whether the simulation platform can distinguish
Nathan O’Hara, MHA between novice and experienced practitioners of percutaneous
pinning of hip fractures.
Ralph Frank Henn III, MD
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Novel Surgical Simulator for Flouroscopic Procedures
Figure 1 Figure 2
Dr. Christian or an immediate family member serves as a board member, owner, officer, or committee member of the American Orthopaedic
Foot and Ankle Society and the Maryland Orthopaedic Association. Dr. O’Toole or an immediate family member has received royalties from
Coorstek; serves as a paid consultant to Coorstek, Imagen, and Smith & Nephew; has stock or stock options held in Imagen; has received
research or institutional support from DePuy Synthes and Stryker; and serves as a board member, owner, officer, or committee member of
the Orthopaedic Trauma Association. Dr. Sciadini or an immediate family member serves as a paid consultant to and has stock or stock
options held in Stryker. None of the following authors or any immediate family member has received anything of value from or has stock or
stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Griffith, Ms.
Schoonover, Mr. Zerhusen, Mr. Coale, Mr. O’Hara, and Dr. Henn.
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Matthew William Christian, MD, et al
Table 1
Characteristics of Study Participants (n = 50)
Medical Students Residents Fellows and Attendings
Characteristic (n = 15) (n = 17) (n = 18) P value
Years of orthopaedic training, mean (SD) 0 (0) 3.5 (1.2) 10.6 (6.2) ,0.0001
No. of hip fractures treated, mean (SD) 0 (0) 2 (35) 212 (34) ,0.0001
Previous simulator experience, n (%) 0 (0) 15 (88.24) 9 (50) ,0.0001
Previous hip simulator experience, n (%) 0 (0) 1 (5.88) 3 (16.67) 0.20
Experience with computer games, n (%) 10 (66.67) 12 (70.59) 12 (66.67) 0.96
Is simulator appearance sufficient, n (%) 14 (93.33) 16 (94.12) 17 (94.44) 0.99
Is appearance important, n (%) 4 (26.67) 3 (17.65) 5 (27.78) 0.75
one of the two views was available view or complete any of those number of hip fractures treated, and
“live” at any given time, mimicking exercises. previous surgical simulator experience.
the surgical equivalent of transfer- Participants were categorized into No notable difference was shown in
ring fluoroscopic images from the three training levels: medical students experience with computer games or
left to the right screen during pro- (n = 15), orthopaedic residents (n = satisfaction with simulator appearance.
cedures and requiring the clinical 17), and fellows/attending ortho- As shown in Table 2, orthopaedic
motor skill of making biplanar paedic surgeons (n = 18). Responses fellows and attendings significantly
changes in pin position and orienta- to the survey were summarized using outperformed medical students in
tion with uniplanar imaging. counts and proportions for categor- distance to the anterior cortex (P =
Predetermined performance met- ical responses and means with SDs 0.02), distance above the bottom of
rics were anonymously and auto- for continuous variables. Data from the lesser trochanter (P = 0.04),
matically recorded by the simulator the survey were compared by the inferior guidewire tip distance to the
for each attempt by each participant, training level using analysis of vari- center (P = 0.04), and angle between
including time to task completion, ance for continuous variables and posterior guidewire and anterior
total simulated fluoroscopy time, and the chi-square test for categorical guidewire (P = 0.04).
variables. Linear regression was used
distance from predetermined “ideal” Table 3 shows the parameters
to compare the effect of the partic- in which residents, fellows, and
pin positions. All participants were
ipants’ training levels on the simula- attendings significantly outperformed
shown an example of the inverted
tor parameters. The medical student medical students. The residents and
triangle construct with ideally posi- category served as the reference level
tioned pins demonstrated by simu- the fellows and attendings groups
in all of the regression modes. A used significantly fewer radiographs
lated AP and LAT fluoroscopic power analysis demonstrated that a
views before task completion and (P = 0.03 and P = 0.04, respectively),
sample size of 12 in each study group
placed guidewires significantly closer
were instructed to replicate the con- would be required to provide .80%
to the joint surface anteriorly,
struct. However, they were not told power to detect statistically signifi-
posteriorly, and inferiorly (P , 0.001
how the test was scored, nor were cant differences with a one-sided
in all cases), and were significantly
they provided with any clinical alpha level of 0.025. All analyses
closer to the ideal starting point on
rationale behind the “ideal” con- were conducted using JMP Version
the LAT cortex for the inferior pin
struct. Care was taken to ensure that 12 (SAS Institute).
(defined as the mid-sagittal position
no study participants had previous on the LAT fluoroscopic view) (P ,
exposure to or experience with the 0.001). The more experienced groups
simulator. Although a series of 12
Results
also placed the anterior and inferior
training exercises of increasing com- Table 1 presents a summary of the guidewires significantly more parallel
plexity has been developed for survey responses stratified by the (P = 0.04 and P = 0.07, respectively).
this training module, culminating training level. As expected, orthopae- Figure 3 demonstrates the relation-
in the final task of placement of dic residents, fellows, and attendings ship between years of training of the
the three pins, participants in had markedly more experience than participant and surgical precision
this study were not permitted to medical students in years of training, parameters, such as the distance from
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Novel Surgical Simulator for Flouroscopic Procedures
Table 2
Simulator Parameters in Which Fellows and Attending Orthopaedic Surgeons Outperform Medical Students
Training Parameter
Parameter Level Estimate SE P value
SE = standard error
a
Medical student training level served as the reference level; values shown are mean 6 SD.
the posterior guidewire to the joint ticeship model in which trainees Resulting radiation exposure may
surface. participate in surgical procedures on place surgeons, patients, trainees,
As noted in Table 4, a number of patients under the supervision of and operating room personnel at risk,
parameters were not significantly dif- experienced surgeons. This approach particularly if radiation is increased
ferent despite differing levels of training has remained largely unchanged because of the training component
and experience. The amount of time since Halsted16 proposed the tech- on actual patients. The amount of
on the simulator required to place nique in the 1900s. Increasing levels radiation exposure has been shown
the three pins and number of wire of involvement and autonomy are to be higher in cases performed
retries were not markedly different. conferred based on the trainee’s by less-experienced surgeons. This
We noted a trend toward decreased demonstration of mastery of con- phenomenon is thought to be caused
amount of fluoroscopy time for both cepts and techniques and chrono- by lower levels of confidence, less
the residents and the fellows and at- logical progression through surgical experience with surgical procedures,
tendings groups; however, it was not residency training. Much of the and higher level of reliance on fluo-
significantly different (P = 0.28 and assessment of a trainee’s progress is roscopic imaging.17,18
P = 0.13, respectively). In addition, highly subjective and dependent on Percutaneous, fluoroscopically guided
the number of guidewires penetrating the teaching physician’s observations procedures are common in orthopaedic
the joint surface, either transiently or in the operating room. Some surgical surgery. Performing them safely
left in this position, and parallel residents are naturally gifted, and and effectively depends on a thor-
placement of the posterior guidewire others struggle with certain tasks in ough understanding of anatomy, the
relative to the inferior guidewire were the operating room. In either case, pathophysiology of the injury or
not markedly different. the potential exists for adverse ef- condition being treated, and the
fects on patients, ranging from mechanical and biologic implications
Discussion increased surgical times to iatrogenic of the applied treatment. Most of
injury. Additionally, many ortho- these concepts can be taught through
Traditionally, surgical training has paedic trauma procedures involve traditional didactic means. However,
been undertaken using an appren- the use of intraoperative fluoroscopy. equally important to the success of
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Matthew William Christian, MD, et al
Table 3
Simulator Parameters in Which Residents, Fellows, and Attending Orthopaedic Surgeons Outperform Medical
Students
Parameter
Parameter Training Level Estimate SE P value
Radiographs (n)
Medical student, 41.73 6 32.25a
Resident 23.91 10.91 0.03
Fellow/attending 22.66 10.76 0.04
Inferior guidewire distance to the joint surface (mm)
Medical student, 16.21 6 1.41a
Resident 212.5 1.94 ,0.001
Fellow/attending 211.8 1.91 ,0.001
Posterior guidewire distance to the joint surface (mm)
Medical student, 13.5 6 0.74a
Resident 29.26 1.02 ,0.001
Fellow/attending 29.61 1.01 ,0.001
Anterior guidewire distance to the joint surface (mm)
Medical student, 14.54 6 1.09a
Resident 210.76 1.5 ,0.001
Fellow/attending 211.15 1.48 ,0.001
Distance to the center of the lateral cortex (mm)
Medical student, 5.35 6 0.6a
Resident 23.12 0.83 ,0.001
Fellow/attending 23.19 0.82 ,0.001
Angle between inferior guidewire and anterior
guidewire (°)
Medical student, 4.69 6 0.67a
Resident 21.9 0.92 0.04
Fellow/attending 21.69 0.9 0.07
SE = standard error
a
Medical student training level served as the reference level; values shown are mean 6 SD.
these procedures and the safety of risk of patient harm with that that is risk-free for patients and
patients undergoing them is the approach is obvious, particularly trainees is the ultimate goal of sim-
acquisition of specialized motor during a trainee’s learning phase of ulator development.
skills, an understanding of three- technically demanding skills. In the Surgical simulation has been shown
dimensional structures as evaluated case of percutaneous pinning of to be an effective adjunct to tradi-
by two-dimensional images, and the femoral neck fractures, penetration tional clinical training in other dis-
simultaneous processing of didactic of the articular surface, damage to ciplines, with positive effects on
knowledge and visual and tactile the femoral head blood supply, procedural time and intraoperative
feedback received by the surgeon neurologic injury, and prolonged errors.7-10 General surgeons first
while performing the procedure. surgical time leading to increased routinely used surgical simulation
These latter skills are not learned in a infection and anesthesia-related com- training with the development of
classroom. Hands-on practice and plications are all potential hazards laparoscopic surgical procedures in
repetitive exposure are required to encountered when training new the 1990s.6 Because of the inherently
achieve proficiency. Although this surgeons. Developing a tool to allow different skill set required to perform
has traditionally occurred in the beginning practitioners to progress laparoscopic surgical procedures
operating room during surgical pro- through a substantial portion of the compared with traditional open
cedures on live patients, the inherent learning phase in an environment techniques, including triangulation
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Novel Surgical Simulator for Flouroscopic Procedures
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Matthew William Christian, MD, et al
Table 4
Simulator Parameters in Which There Was No Effect of Training on Performance
Training Parameter
Parameter Level Estimate SE P value
SE = standard error
a
Medical student training level served as the reference level; values shown are mean 6 SD.
accurately placing three guidewires students regarding the implications chanter, traversing the femoral neck
in an inverted triangle configura- of incorrect pin placement, causing at the mid-sagittal level, and passing
tion without first completing the them to take less time and care in no closer than 2 mm and no further
sequence of training exercises would positioning the pins. Although the than 3 mm from the inferior cortex of
distinguish between experienced and number of fluoroscopic images ob- the femoral neck. Similar “ideals”
inexperienced users. tained showed a statistically signifi- were defined for the superior anterior
Our results suggest that this simu- cant difference between novice and and superior posterior pins. Pin pen-
lator is capable of distinguishing experienced users, total fluoroscopic etration of the articular surface was
between groups with differing clini- imaging time did not, perhaps re- also critically assessed. As further
cal experience: medical students with flecting an increased propensity of development and validation of the
an interest in orthopaedic surgery but the experienced practitioners to use simulator progresses, adjustments to
no previous experience with percu- longer runs of “live fluoroscopy” but these parameters may be necessary to
taneous pin placement, orthopaedic fewer spot films. The performance more accurately assess clinically rel-
residents with some experience, and metrics assessed by the simulation evant performance. However, this
orthopaedic trauma fellows and at- program were based on certain as- initial investigation seems to confirm
tendings with the most experience. sumptions and parameters defined the ability of the simulator to assess
One of the parameters for which by the investigators and incorpo- and distinguish between performance
performance metrics were similar rated into the computer program. by users with differing amounts of
between the groups was the total time The ideal starting point and trajec- surgical training and experience.
to completion of the exercise. This tory for the inferior pin, for example, Subjective feedback from the more
finding may reflect a lack of under- were defined as being no lower than experienced practitioners (residents,
standing on the part of the medical the inferior border of the lesser tro- fellows, and attendings) regarding
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Novel Surgical Simulator for Flouroscopic Procedures
how accurately the simulator repro- tempted to closely match our control capable of enhancing resident educa-
duced the tactile, visual, and three- group to the resident population by tion and improving clinical perfor-
dimensional elements of percutaneous choosing students from the ortho- mance, once expanded to include
hip pinning was not specifically solic- paedic interest group only, but per- appropriate training modules and
ited as part of the study. However, the haps there is something intrinsically incorporated into residency training.
anecdotal feedback received was uni- different about the groups, such as
versally positive. Most of them com- better hand–eye coordination in those
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Evidence-based Medicine: Levels of
difficult than it is in real life. This would be an alternate explanation for
evidence are described in the table of
phenomenon may reflect the fact that our results; however, other factors
contents. In this article, references
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the task rather than a lack of technical 7. Grantcharov TP, Kristiansen VB, Bendix J,
ability. The study could have been Bardram L, Rosenberg J, Funch-Jensen P:
Randomized clinical trial of virtual reality
strengthened by testing the partic- Conclusions simulation for laparoscopic skills training.
ipants before the task was begun to Br J Surg 2004;91:146-150.
ensure that they actually understood Our study demonstrates preliminary 8. Seymour NE, Gallagher AG, Roman SA,
the proper pin placement. The simu- construct validation of the AAOS/OTA et al: Virtual reality training improves
lator’s most profound differences fluoroscopy simulator—specifically, its operating room performance: Results of a
randomized, double-blinded study. Ann
were found between surgeons with ability to distinguish between novice Surg 2002;236:458-463.
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makes sense if it is measuring a very performance of a simple hip-pinning Proficiency-based virtual reality training
basic skill, such as pin placement, procedure. Further validation is nec- significantly reduces the error rate for residents
during their first 10 laparoscopic
that surgeons pick up relatively essary and ongoing to determine cholecystectomies. Am J Surg 2007;193:
quickly during residency. We at- whether this platform will prove 797-804.
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Matthew William Christian, MD, et al
10. Seymour NE, Gallagher AG, Roman SA, skills training. J Am Acad Orthop Surg affecting factors and reduction by an
O’Brien MK, Andersen DK, Satava RM: 2012;20:410-422. intervention program. J Pediatr Orthop
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Georgiou E: The effect of mixed-task basic 2010;26:832-840. dependence of radiation exposure for the
training in the acquisition of advanced 15. DeMaio M: Giants of orthopaedic surgery: orthopaedic surgeon during interlocking
laparoscopic skills. Surg Innov 2014;22: Masaki Watanabe MD. Clin Orthop Relat nailing of long-bone shaft fractures: A
418-425. Res 2013;471:2443-2448. clinical study. Arch Orthop Trauma Surg
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KA: Surgical simulation in orthopaedic Konen O: Intraoperative C-arm radiation Philadelphia, PA, Saunders, 2003.
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Research Article
Abstract
Harpreet Bawa, MD Introduction: Patients undergoing total hip arthroplasty (THA) and
Jack W. Weick, MD total knee arthroplasty (TKA) are at high risk of deep vein thrombosis
(DVT) postoperatively, necessitating the use of prophylaxis
Douglas R. Dirschl, MD
medications. This investigation used a large claims database to
Hue H. Luu, MD evaluate trends in postoperative DVT prophylaxis and rates of DVT
within 6 months after THA or TKA.
Methods: Truven Health MarketScan Commercial Claims and
Encounters and Medicare Supplemental and Coordination of Benefits
databases were reviewed from 2004 to 2013 for patients who
underwent THA or TKA. Data were collected on patient age, sex,
From the Department of Orthopaedic
Surgery and Rehabilitation Medicine, Charlson Comorbidity Index, and hypercoagulability diagnoses.
University of Chicago Medicine and Postoperative medication claims were reviewed for prescribed aspirin,
Biological Sciences, University of warfarin, enoxaparin, fondaparinux, rivaroxaban, and dabigatran.
Chicago Medical Center, Chicago, IL.
Results: A total of 369,483 patients were included in the analysis, of
Correspondence to Dr. Bawa:
which 239,949 patients had prescription medication claims. Warfarin
harpreetbawa@gmail.com
was the most commonly prescribed anticoagulant. Patients with a
Dr. Dirschl or an immediate family
member serves as a paid consultant
hypercoagulable diagnosis had markedly more DVTs within 6 months
to Bone Support and Stryker and after THA or TKA. More patients with a hypercoagulable diagnosis
serves as a board member, owner, were treated with warfarin or lovenox than other types of
officer, or committee member of the
American Orthopaedic Association,
anticoagulants. A multivariate regression analysis was performed,
the Foundation for Orthopaedic showing that patients prescribed aspirin, fondaparinux, and
Trauma, and the Orthopaedic Trauma rivaroxaban were markedly less likely than those prescribed warfarin
Association. Dr. Luu or an immediate
family member serves as a paid or enoxaparin to have a DVT within 6 months after THA or TKA.
consultant to DePuy Synthes and Conclusion: After THA and TKA, warfarin is the most commonly
Stryker and serves as a board prescribed prophylaxis. Patients with hypercoagulability diagnoses
member, owner, officer, or committee
member of the American Orthopaedic are at a higher risk of postoperative DVT. The likelihood of DVT within
Association and the Musculoskeletal 6 months of THA and TKA was markedly higher in patients treated with
Tumor Society. Neither of the warfarin and lovenox and markedly lower in those treated with aspirin,
following authors nor any immediate
family member has received anything fondaparinux, and rivaroxaban.
of value from or has stock or stock Level of Evidence: Level III
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Bawa and Dr. Weick.
J Am Acad Orthop Surg 2018;00:1-8
DOI: 10.5435/JAAOS-D-17-00235
M ore than 1 million total hip
arthroplasty (THA) and total
knee arthroplasty (TKA) procedures
of thromboembolic complications.2–4
The most common complication is
deep vein thrombosis (DVT) because
are performed in the United States patients are placed at a higher risk
Copyright 2018 by the American
Academy of Orthopaedic Surgeons. each year.1 Patients undergoing these as a result of venous stasis with
procedures are at an increased risk leg positioning, increased risk of
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Trends in Deep Vein Thrombosis Prophylaxis
Methods
Data Source
A retrospective review was conducted
using the Truven Health MarketScan
Commercial Claims and Encounters
(commercial insurance) and Medicare
Supplemental and Coordination of
Benefits (Medicare with commercial
supplement) databases (Truven Health
Analytics). The databases contain
deidentified, integrated, person-specific
Flowchart showing the cohort selection. claims data for approximately 17 to 51
million individuals per year. The com-
mercial insurance database includes
endothelial injury, and aberrant acti- after TKA or THA. In a trial of 13,356 healthcare claims for individuals with
vation of the clotting cascade.4,5 patients undergoing THA, low-dose insurance through a commercial pro-
Prophylaxis after THA and TKA is aspirin reduced the rate of DVT by vider or a self-insuring employer under
recommended by both the American 29%, PE by 43%, and fatal pulmo- fee-for-service, fully capitated, or par-
Academy of Orthopaedic Surgeons nary embolism by 58% compared tially capitated health plans. The
and American College of Chest Physi- with placebo.15 Low-molecular-weight Medicare with commercial supplement
cians; however, no consensus exists on heparin agents, such as enoxaparin, database includes claims information
the optimal prophylactic regimen.6 have also been shown to be effective; for individuals who have both Medi-
Anticoagulation after THA or TKA however, they must be administered care and commercial employer-
can pose unique challenges because through subcutaneous injection.16 sponsored coverage. All claims
anticoagulation medications must bal- Other therapies such as factor Xa from the Medicare with commercial
ance the reduction in blood clot for- and direct thrombin inhibitors are supplement database reflect the coor-
mation, with the risk of postoperative appealing because they can be deliv- dination of benefits between the com-
bleeding, hematoma formation, revi- ered orally, do not require monitor- mercial insurer and Medicare such that
sion surgery, and infection.7-10 The ing, and have constant dosing for all payments made by either entity are
vitamin K antagonist warfarin has been most patients. Unfortunately, this captured within the database. The
shown to be effective in reducing the group of medications is costly and age distribution in the Medicare with
rate of proximal DVTs and pulmonary requires fresh frozen plasma for commercial supplement database is
embolisms.11,12 The major advantage reversal.5,17,18 representative of the overall Medicare
of warfarin is that it can be reversed Although DVT prophylaxis after population. These databases, when
if bleeding complications arise or THA and TKA is assumed to be the combined, constitute approximately
if patients require urgent surgical standard of care, given the high like- 20% of the overall insurance market.
intervention.13,14 Warfarin’s most lihood of thromboembolic events International Classification of Disease
notable disadvantage is that it is only without prophylaxis, a paucity of (ICD-9) diagnoses codes and Current
effective within a narrow therapeutic data exists on surgeon practice pat- Procedure Terminology (CPT) codes
window, necessitating frequent lab- terns and changes over time. In can be identified in individual claims.
oratory monitoring and dose ad- addition, few studies have evaluated The data include claims made from
justments. These drawbacks have led postoperative DVT rates by anti- both inpatient and outpatient clinical
to the use of alternative methods of coagulants at a large-scale pop- encounters and prescription medi-
chemoprophylaxis. ulation level. The purpose of this cations. National Drug Codes (NDCs)
Recent studies have demonstrated the investigation was to use a large claims are used to organize prescription
effectiveness of aspirin prophylaxis database to evaluate trends over time medication claims. The NDCs specify
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Harpreet Bawa, MD, et al
Table 1
Demographics of Patient Deep Vein Thrombosis Prophylaxis After Total Hip Arthroplasty or Total Knee
Arthroplasty Procedures
No
Prescription Anticoagulation
Factor Aspirin Warfarin Enoxaparin Fondaparinux Rivaroxaban Dabigatran Claim
Table 2
Postoperative Deep Vein Thrombosis Prophylaxis Trends by Drug Type
Postoperative Medication 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Prescription aspirin 0.03% 0.02% 0.03% 0.00% 0.03% 0.08% 0.20% 1.04% 1.59% 2.91%
Warfarin 75.02% 72.29% 68.04% 63.18% 61.65% 60.36% 58.92% 54.77% 45.51% 41.17%
Enoxaparin 25.26% 28.46% 30.91% 33.81% 35.65% 37.21% 37.94% 36.88% 26.19% 24.63%
Fondaparinux 2.72% 3.33% 5.21% 7.27% 7.09% 7.14% 7.18% 5.85% 2.98% 2.15%
Rivaroxaban 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 5.30% 27.89% 33.58%
Dabigatran 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.25% 1.39% 1.25% 1.05%
both the type and dosage of the med- agulant, and protein C/S deficiency. for each subject using ICD-9 codes
ication prescribed. Prescription medication claim infor- for comorbidities, as described in
mation was collected based on NDCs previous studies.19
on prescribed aspirin, warfarin, enox-
Study Sample aparin, fondaparinux, rivaroxaban,
The databases were reviewed from and dabigatran. Patients were ex- Statistical Analysis
2004 to 2013 for subjects with a CPT cluded if they were on any prescrip- Mean age, percent female, percent of
code for THA (CPT = 27,130) or TKA tion anticoagulation medications population with the hypercoagulable
(CPT = 27,447). Patients were .2 months before the THA or TKA group, and CCI were calculated for
required to be enrolled in the database procedure. In addition, patients with each type of anticoagulant studied.
continuously for 6 months before and no claims for a prescription antico- Trends of utilization by year for each
6 months immediately after the THA agulant are presented as a separate anticoagulant were compared. Rates
or TKA procedure. Data were col- group. Data were gathered on all of DVT in the 6-month period after
lected on patient age and sex. We anticoagulation prescription claims in THA and TKA were calculated by
identified a group of patients who the 6-month period after THA and each type of prescription anticoagu-
were hypercoagulable, defined as TKA procedures. Postoperative lant using the ICD-9 code for DVT
subjects with a previous DVT (ie, DVTs were identified in the 6 months (ie, 453.40). DVT rates by year were
ICD-9 code 453.40) or who had an after THA and TKA procedures using also calculated over the course of the
ICD-9 code for primary hypercoagu- the ICD-9 code for DVT (453.40). study period to analyze trends in
lable state (ie, ICD-9 289.81, 289.82, We excluded any anticoagulation DVT rates over time. A best fit line
286.53, and 795.79), which includes prescription claims that occurred was used to calculate the R2 value
diagnoses of factor V leiden, anti- after a DVT. Charlson Comorbidity and statistical significance of the
phospholipid antibody, lupus antico- Index (CCI) scores were calculated yearly trend.
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Trends in Deep Vein Thrombosis Prophylaxis
Figure 2
Graph showing yearly trends in deep vein thrombosis prophylaxis after total hip arthroplasty and total knee arthroplasty procedures.
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Harpreet Bawa, MD, et al
Table 4
Deep Vein Thrombosis Rate Within 6 Months After Total Hip Arthroplasty or Total Knee Arthroplasty Procedures by Year
Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Annual DVT rate 3.33% 3.40% 3.39% 3.28% 3.41% 3.21% 3.12% 3.26% 3.27% 3.21%
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Trends in Deep Vein Thrombosis Prophylaxis
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Harpreet Bawa, MD, et al
is possible that these patients counter were also not captured by the thromboembolic disease in patients having a
total hip or knee arthroplasty. J Bone Joint
were taking over-the-counter anti- database. Patient compliance with Surg 2002;84:466-477.
coagulants; however, this cannot be medications could not be determined
5. Falck-Ytter Y, Francis CW, Johanson NA,
confirmed with the available data. from our data because the usual et al: Prevention of VTE in orthopedic
The study found markedly increased course of anticoagulants prescribed surgery patients: Antithrombotic Therapy
DVT rates in the 6 months after THA after a THA or TKA is too brief and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians
and TKA procedures in patients treated to calculate medication possession Evidence-Based Clinical Practice
with warfarin (odds ratio: 3.60, 95% ratios. Guidelines. Chest 2012;141:e278S-e325S.
confidence interval, 3.38–3.84) and Overall, this investigation demon- 6. Eikelboom JW, Karthikeyan G, Fagel N,
enoxaparin (odds ratio: 1.14, 95% strates, at a population level, recent Hirsh J: American Association of
Orthopedic Surgeons and American
confidence interval, 1.09–1.20). The trends in DVT prophylaxis after College of Chest Physicians guidelines for
exact reason for the increased DVT THA and TKA procedures. Although venous thromboembolism prevention in hip
rate in this subgroup cannot be warfarin is still the most commonly and knee arthroplasty differ: What are the
implications for clinicians and patients?
determined from this study and prescribed prophylaxis after THA Chest 2009;135:513-520.
beyond the scope of this investigation. and TKA procedures, use of this
7. Barrack RL: Current guidelines for total
This study focused on claims in- agent is decreasing. Patients with a joint VTE prophylaxis: Dawn of a new day.
formation and did not have any history of DVT or hypercoagulability J Bone Joint Surg Br 2012;94:3-7.
information on INR levels or patient are at a higher risk of postoperative 8. McDougall CJ, Gray HS, Simpson PM,
compliance. Studies have demon- DVT, regardless of the type of Whitehouse SL, Crawford RW, Donnelly WJ:
Complications related to therapeutic
strated that patients are within the prophylaxis prescribed. After ad- anticoagulation in total hip arthroplasty.
therapeutic range only 45.9% of the justing for age, sex, and hypercoag- J Arthroplasty 2013;28:187-192.
time postoperatively.27 Enoxaparin ulability diagnosis, the likelihood 9. Parvizi J, Ghanem E, Joshi A, Sharkey PF,
is administered subcutaneously and of DVT within 6 months of THA Hozack WJ, Rothman RH: Does
provides challenges inherent to peo- and TKA procedures was markedly “excessive” anticoagulation predispose to
periprosthetic infection? J Arthroplasty
ple hesitant to administer the drug increased in patients treated with 2007;22:24-28.
on themselves; however, this has warfarin and lovenox and markedly
10. Pulido L, Ghanem E, Joshi A, Purtill JJ,
not been shown to prevent compli- decreased in those treated with aspi- Parvizi J: Periprosthetic joint infection: The
ance.28 It is unclear whether the in- rin, fondaparinux, and rivaroxaban. incidence, timing, and predisposing factors.
Clin Orthop Relat Res 2008;466:
creased rate of DVT observed is due Given the sample size of the data 1710-1715.
to failure of patient compliance or over a prolonged period in the actual
11. Johanson NA, Lachiewicz PF, Lieberman JR,
another confounding variable unac- observed clinical setting, this infor- et al: American Academy of Orthopaedic
counted for in the regression model. mation is useful for surgeons when Surgeons Clinical Practice guideline on:
Importantly, the results in this counseling their patients on the dif- Prevention of symptomatic pulmonary
embolism in patients undergoing total hip or
study represent the actual observed ferent types of anticoagulants avail- knee arthroplasty. J Bone Joint Surg Am
population-level rates over a decade able before undergoing THA or TKA 2009;91:1756-1757.
of time with the use of various pro- procedures. 12. Francis CW, Pellegrini VD Jr, Marder VJ,
phylactic regimens. Consequently, et al: Comparison of warfarin and external
pneumatic compression in prevention
these findings are informative to of venous thrombosis after total hip
both surgeons and patients as to the References
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expected population rates of DVT. 2911-2915.
References printed in bold type are
This study has limitations inherent 13. Nam D, Sadhu A, Hirsh J, Keeney JA,
those published within the past 5 years. Nunley RM, Barrack RL: The use of
to any retrospective review. The
warfarin for DVT prophylaxis following
database is likely to represent a rep- 1. Maradit Kremers H, Larson DR, Crowson CS,
hip and knee arthroplasty: How often are
et al: Prevalence of total hip and knee
resentative sample of the overall pop- replacement in the United States. J Bone Joint
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Arthroplast 2015;30:315-319.
ulation but does not include patients Surg Am 2015;97:1386-1397.
without insurance or on Medicaid. 2. Visuri T, Pulkkinen P, Paavolainen P, 14. Aynardi M, Brown PB, Post Z, Orozco F,
Ong A: Warfarin for thromboprophylaxis
The information in the database is Koskenvuo M, Turula KB: Causes of death
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3. Harris WH, Sledge CB: Total hip and total
sample size. Patients who did not have knee replacement. N Engl J Med 1990;323: 15. Prevention of pulmonary embolism
medication claims data were also 801-807. and deep vein thrombosis with low
dose aspirin: Pulmonary embolism
excluded from this analysis. Medi- 4. Sculco T, Colwell C, Pellegrini V, Westrich G, prevention (PEP) trial. Lancet 2015;
cations that were obtained over the Bottner F: Prophylaxis against venous 355:1295-1302.
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Trends in Deep Vein Thrombosis Prophylaxis
16. Colwell CW, Hardwick ME: Rationale for 21. Asnis PD. Gardner MJ, Ranawat A, and low-molecular-weight heparin on
low-molecular-weight heparin prophylaxis Leitzes AH, Peterson MGE, Bass AR: The surgical complications following total hip
after total knee arthroplasty. Clin Orthop effectiveness of warfarin dosing from a arthroplasty. Thromb Haemost 2016;115:
Relat Res 2006;452:181-185. nomogram compared with house staff 600-607.
dosing. J Arthroplasty 2007;22:213-218.
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events in orthopedic surgery patients: A et al: Economic burden of long-term Aspirin versus anticoagulation for
comparison of the AAOS and ACCP complications of deep vein thrombosis after prevention of venous thromboembolism
guidelines with review of the evidence. Ann total hip replacement surgery in the United major lower extremity orthopedic
Pharmacother 2013;47:63-74. States. Value Health 2003;6:59-74. surgery: A systematic review and
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risk in hip and knee arthroplasty: State of et al: Comparative effectiveness of low-
the art. Orthopedics 2003;26:S231-S236. molecular-weight heparins versus other 27. Nam D, Nunley RM, Johnson SR, Keeney JA,
anticoagulants in major orthopedic surgery: Clohisy JC, Barrack RL: Thromboembolism
19. Quan H, Sundararajan V, Halfon P, A systematic review and meta-analysis. prophylaxis in hip arthroplasty: Routine and
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Bone Joint Surg Br 1995;77:6-10. Park YS: Effect of oral factor Xa inhibitor 270-279.
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Research Article
Abstract
Robert L. Buly, MD, MS Background: Version abnormalities of the femur can cause pain and
Branden R. Sosa, HS hip joint damage due to impingement or instability. A retrospective
clinical review was conducted on patients undergoing a
Lazaros A. Poultsides, MD, MSc,
PhD subtrochanteric derotation osteotomy for either excessive
anteversion or retroversion of the femur.
Elaine Caldwell, BS, RN
Methods: A total of 55 derotation osteotomies were performed in 43
S. Robert Rozbruch, MD patients: 36 females and 7 males. The average age was 29 years
(range, 14 to 59 years). The osteotomies were performed closed with
an intramedullary saw. Fixation was performed with a variety of
intramedullary nails. Twenty-nine percent of patients had a
retroversion deformity (average, 29° of retroversion; range, 12°
to 223°) and 71% had excessive anteversion of the femur
(average, 137° of anteversion; range, 122° to 153°). The etiology
was posttraumatic in 5 patients (12%), diplegic cerebral palsy in 2
patients (5%), Prader-Willi syndrome in 1 patient (2%), and idiopathic
in 35 patients (81%). Forty-nine percent underwent concomitant
surgery with the index femoral derotation osteotomy, including hip
arthroscopy in 40%, tibial derotation osteotomy in 13%, and a
periacetabular osteotomy in 5%. Tibial osteotomies were performed
to correct a compensatory excessive external tibial torsion that would
be exacerbated in the correction of excessive femoral anteversion.
Results: No patient was lost to follow-up. Failures occurred in three
hips in three patients (5%): two hip arthroplasties and one nonunion
that healed after rerodding. There was one late infection treated
From the Hospital for Special Surgery,
New York, NY.
successfully with implant removal and antibiotics with an excellent
final clinical outcome. At an average follow-up of 6.5 years (range, 2 to
Correspondence to Dr. Buly:
bulyr@hss.edu 19.7 years), the modified Harris Hip Score improved by 29 points in the
remaining 52 cases (P , 0.001, Wilcoxon signed-rank test). The
J Am Acad Orthop Surg 2018;00:1-10
results were rated as excellent in 75%, good in 23%, and fair in 2%.
DOI: 10.5435/JAAOS-D-17-00623
Subsequent surgery was required in 78% of hips, 91% of which were
Copyright © 2018 The Author(s). implant removals.
Published by Wolters Kluwer Health,
Inc. on behalf of the American
Conclusions: A closed, subtrochanteric derotation osteotomy of the
Academy of Orthopaedic femur is a safe and effective procedure to treat either femoral
Surgeons.This is an open access retroversion or excessive anteversion. Excellent or good results were
article distributed under the terms of
the Creative Commons Attribution- obtained in 93%, despite the need for subsequent implant removal in
NonCommercial-NoDerivatives more than two-thirds of the patients.
License 4.0 (CC BY-NC-ND), which
permits downloading and sharing the
work provided it is properly cited. The
work cannot be changed in any way or
used commercially without permission
from the journal. I n the surgical treatment of hip
disorders, a major cause of failure
is either insufficient correction or a
failure to fully recognize the under-
lying deformities causing pain and
joint damage.1-3 One type of femoral
deformity that is still frequently pathogenesis of hip disease, there is et al.28 All readings and measure-
overlooked are rotational defor- little written about the outcomes of ments were performed by board-
mities of the femur, that is, excessive treatment. This article describes the certified musculoskeletal radiologists.
anteversion or femoral retroversion. technique and outcomes of a closed, The osteotomies were performed
These rotational deformities may derotation osteotomy of the femur with the patient in the supine position
occur alone or may coexist with to correct either excessive femoral under regional, hypotensive anes-
acetabular dysplasia4-6 or various anteversion or retroversion as part thesia. The operated leg was draped
types of hip impingement.2,5,7-9 of a hip preservation effort. The free, and traction was not used. An
Rotational deformities may also be question to be answered is whether intramedullary hand saw was used
associated with cerebral palsy10 and hip pain as a result of version abnor- that did not require exposure of the
labral tears11 and are not unusual malities of the femur can be alleviated osteotomy site.14 A small, longitu-
after the fixation of femoral shaft by this type of surgery. dinal skin incision was made just
fractures.12-14 proximal to the greater trochanter.
Excessive femoral anteversion can The isthmus of the femur was over-
cause instability, damage of the artic- Methods reamed by 0.5 mm in accordance
ular cartilage and acetabular labrum, with the nail to be used. The
and eventually osteoarthritis.15-17 Patients selected for the index proce- subtrochanteric region was then
Furthermore, it can cause a decrease dure had hip pain secondary to reamed 0.5 mm larger than the
in the length of the abductor lever increased femoral anteversion or diameter of the proposed intra-
arm, 18 posterior extra-articular femoral retroversion. Surgery was medullary saw. Rotational control
impingement,9 and ischiofemoral offered if the patient had failed all was achieved by placing 1/8-inch
impingement.19 Finally, excessive fem- nonsurgical treatment measures and smooth Steinmann pins into the
oral anteversion may cause increased if the range of motion aberration femur proximal and distal to the
hip and knee adduction moments, an correlated with the version abnor- osteotomy in the desired amount
intoeing gait and patellofemoral mal- mality (ie, excessive hip internal rota- of rotational correction (Figure 1).
tracking, with resultant knee pain and tion with excessive anteversion or a The location and progress of the
arthritis.20-22 lack of internal rotation associated osteotomy were controlled by
Femoral retroversion, on the other with femoral retroversion). Patients fluoroscopy (Figure 2). The angular
hand, causes damage due to impinge- with coxa vara (a neck-shaft angle correction was controlled visually by
ment between the femoral neck and of ,125°) or coxa valga (a neck-shaft using flat, triangular guides from a
acetabulum, which may result in dam- angle of .140°) were excluded, with blade plate instrument set (Figure 3).
age to the labrum and articular carti- the understanding that a varus or The osteotomy was performed
lage, ultimately resulting in valgus derotation intertrochanteric in the subtrochanteric region by
osteoarthritis of the hip.16,23 Other osteotomy would be more appropri- inserting the hand saw, which was
potential retroversion problems in- ate to address the concomitant neck- then rotated in a stepwise fashion with
clude an increased risk of slipped shaft angulation.27 progressive protrusion of the blade
capital femoral epiphysis24 and sus- In addition to plain radiographs, all from the cam. The distal fragment was
ceptibility to a traumatic posterior hip patients underwent preoperative then rotated to align the two pins
dislocation.25,26 Residual, untreated MRI to assess the condition of the parallel, thus effecting the rotational
femoral retroversion may be a reason articular cartilage and labrum and correction. The goal was to achieve
why hip preserving surgeries may fail, three-dimensional CT scans to accu- approximately 15° of femoral ante-
especially after the arthroscopic treat- rately define the anatomic deform- version. Fixation was then achieved
ment of hip impingement.1-3 ities. The measurement of femoral using a variety of trochanteric entry
Despite the important role of fem- version was performed by the CT intramedullary nails that were locked
oral rotational deformity in the technique described by Murphy proximal and distal to the osteotomy.
Dr. Buly or an immediate family member has stock or stock options held in Blue Belt Technology and serves as a board member, owner,
officer, or committee member of the Maurice Mueller Foundation of North America and the International Society for Hip Arthroscopy.
Dr. Rozburch or an immediate family member has received royalties from Stryker; is a member of a speakers’ bureau or has made paid
presentations on behalf of NuVasive, Smith & Nephew, and Stryker; serves as a paid consultant to NuVasive, Smith & Nephew, and Stryker;
and serves as a board member, owner, officer, or committee member of the Limb Lengthening Reconstruction Society. None of the following
authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or
institution related directly or indirectly to the subject of this article: Mr. Sosa, Dr. Poultsides, and Ms. Caldwell.
Figure 1
The intramedullary devices used were sion. The periacetabular osteotomy Postoperatively, epidural patient-
42 TriGen Trochanteric Antegrade was performed first with the same controlled anesthesia was used if a
Nails (Smith & Nephew), five Tro- preparation and drape setup used for tibial osteotomy was not performed.
chanteric Fixation Nails and three both procedures. Intravenous patient-controlled anes-
Intramedullary Femoral Nails (DePuy A concomitant tibial/fibular oste- thesia was used instead with tibial
Synthes), four Gamma Nails (Stryker), otomy was performed if the patient osteotomies to allow monitoring of
and one piriformis fossa entry had a compensatory external tibial the lower leg and vigilance regarding
Phoenix Femoral Nail (Zimmer torsion coexisting with excessive a possible compartment syndrome.
Biomet). femoral anteversion, as described by No braces or casts were used after
Concomitant hip arthroscopy was Tönnis and Heinecke.15 This proce- surgery. There were no range of
performed just prior to the osteotomy dure was done to prevent an exag- motion restrictions. Weight bearing
if the magnetic resonance image re- gerated external foot progression as tolerated was permitted with
vealed labral and/or articular carti- angle that would result from der- crutches unless a concomitant peri-
lage lesions or the presence of a cam otating the excessively anteverted acetabular or tibial osteotomy was
lesion of the femoral neck that would femur in patients with this rotational performed, in which case the weight
impinge if a retroverting derotation deformity. The tibia was either bearing was restricted to 20% for
femoral osteotomy was to be per- internally rotated with gradual cor- 6 weeks. Follow-up examinations
formed for excessive anteversion. rection using an external hexapod with AP and lateral radiographs were
A concomitant periacetabular frame in the supramalleolar or performed at 6 weeks, 3 months,
osteotomy was performed at the proximal tibial regions or corrected 6 months, and 1 year after surgery.
same setting if there was coexisting, acutely over an intramedullary nail, The modified Harris Hip Score
severe dysplasia that required cor- depending on the morphology of the (mHHS) was used, and scores were
rection along with the femoral ver- tibial deformity. documented before surgery and at
Figure 2
A, Photograph showing the Winquist intramedullary saw. B, Photograph showing the saw blade extended from the cam
mechanism. C–E, Intraoperative fluoroscopic images showing gradual transection of the lateral and medial cortices,
followed by osteotomy completion.
the latest follow-up. The minimum and 7 males; the average age was 29.0 range, 12° anteversion to 224°
follow-up time was 24 months. years (range, 14 to 59 years). retroversion). Seventy-one percent
The deformity etiology was post- (39 hips in 29 patients) had excessive
traumatic in 5 patients (12%), diple- anteversion of the femur (average, 1
Results gic cerebral palsy in 2 patients (5%), 37° of anteversion; range, 122°
Prader-Willi syndrome in 1 patient to 153° anteversion). The average
Starting in 1997, a total of 81 femoral (2%), and idiopathic in 35 patients rotational correction was 24° for the
osteotomies have been performed in (81%) (Table 1). All hips had a retroverted hips (range, 18° to 35°)
67 patients. Forty-three patients Tönnis arthritis grade of zero (no and 23° (range, 15° to 40°) for an-
having undergone 55 derotation evidence of arthritis).15 Twenty-nine teverted hips (Table 2). All 16 ret-
osteotomies had a minimum follow- percent of the hips (16 hips in 14 roverted hips were considered to
up of 2 years. All bilateral cases were patients) had a retroversion defor- have “severely diminished ante-
done staged. There were 36 females mity (average, 29° of retroversion; version” by the criteria of Tönnis,
Figure 3
A, Triangles used to set the degree of rotation correction. B, A 20° triangle was used to set the correction between the proximal
and distal pins in a case of excessive anteversion. C, The femoral nail is inserted while maintaining rotational correction.
whereas 37 of 38 excessively ante- Previous surgery had been per- 23%, and fair in 7%, including the
verted hips (97%) were considered formed in 26 hips (47%) (Table 1). revision femoral osteotomy and two
to be “severely increased” (.25° of Twenty-seven hips (49%) underwent total hip replacements.
anteversion), with 1 (3%) being concomitant surgery with the index Failure was defined as conversion to
“moderately increased” (21° to 25° femoral derotation osteotomy, in- total hip arthroplasty, refixation of the
of anteversion).15 cluding hip arthroscopy with labral index osteotomy, or an mHHS of ,70.
The clinical hip range of motion débridement and chondroplasty in Failures occurred in three hips in three
assessment for all patients included 16 (29%), 6 hip arthroscopies with patients (5%): two hip arthroplasties
measuring internal and external ro- an additional femoral osteochon- and one rerodding for a femoral
tations, with the hip flexed to 90°. droplasty (11%), a tibial derotation nonunion. A total hip arthroplasty was
Retroverted hips typically lacked or osteotomy in 7 (13%), and an ipsi- performed 46 months after osteotomy
had diminished internal rotation. lateral periacetabular osteotomy with in a 46-year-old woman with Ehlers-
Conversely, hips with excessive 3 of the femoral osteotomies (5%) Danlos syndrome with only minimal
anteversion had more internal ro- (Table 1). Three of the ipsilateral osteoarthritic change seen on MRI
tation than external rotation. For tibial osteotomies were performed in and a normal joint space on plain
the cases with excessive anteversion, the supramalleolar region and two in radiographs (Tönnis stage zero). The
the preoperative average of internal the proximal tibia, with external frame patient continues to do well with the
rotation at 90° of hip flexion fixation. Two of the tibial osteotomies contralateral osteotomy and has an
was 173° (range, 145° to 110°) and were performed at midshaft with mHHS of 74 points. Another hip
external rotation 122° (range, 25° immediate rotational correction and replacement was performed in an 18-
to 160°). After osteotomy, the fixation with an intramedullary nail. year-old man with Prader-Willi syn-
internal rotation diminished to 126° No patient was lost to follow-up. drome 15 months after the index
(range, 15° to 45°), whereas the One patient died of cancer 12.7 years procedure because of the failure of
external rotation improved to 148° after surgery with a hip score of 85. The the concomitant periacetabular oste-
(range, 115° to 70°). This was average time to femoral osteotomy otomy. The third failure was in a 26-
significant at P , 0.01 (Wilcoxon union was 3.3 months (range, 2 to year-old woman with Ehlers-Danlos
signed-rank test). For the cases of 16 months). All the tibial and pelvic syndrome with a nonunion that
retroversion, the preoperative average osteotomies healed uneventfully. was rerodded successfully. All three
of internal rotation at 90° of hip At an average follow-up of 6.5 years presented initially with excessive
flexion was 21° (range, 220° to (range, 2 to 19.7 years), the mHHS anteversion.
110°) and external rotation 181° improved by 27 points (P , 0.001, Subsequent surgery was required in
(range, 150° to 190°). After oste- Wilcoxon signed-rank test) from 66 78% of hips, 39 of 43 (91%) were
otomy, the internal rotation improved to 93 points. When taken separately, implant removals. The implant was
to 123° (range, 110° to 135°), there was a statistically significant removed in patients with radiographic
whereas the external rotation dimin- improvement in both the groups with evidence of bone union and only if
ished to 142° (range, 130° to 50°). either retroversion or excessive ante- there was notable pain refractory to
This was significant at P , 0.001 version (Table 2). The results were nonsurgical treatment, usually irrita-
(Wilcoxon signed-rank test). rated as excellent in 70%, good in tion from the screw heads or a thigh
Table 2
Comparison of the Anteverted Versus Retroverted Cases
Periacetabular Tibial
Hips Osteotomy Osteotomy Average Average Preoperative Postoperative
Condition (%) (%) (%) Deformity Correction mHHS mHHS
plating, but it requires a much more follow-up, no patient had notable terlocking screws or a thigh ache that
invasive approach.40 The advantage hip abductor weakness or Trende- resolved in most cases after implant
of the described technique is that it lenburg limp or sign. removal. Other than the hip arthro-
allows for a much less invasive It was necessary to perform a con- plasties or osteotomy revisions, the
approach, lessening surgical mor- comitant tibial osteotomy in seven cases remainder of cases were hip arthro-
bidity and theoretically a lower (13%) with excessive femoral ante- scopic débridements in two patients.
chance of infection. In addition, the version and a compensatory external Winquist14 reported the ability to
vastus lateralis is not dissected from tibial torsion instead of the usual perform a closed osteotomy and in-
the femur, maintaining more of the intoeing gait associated with excessive tramedullary nailing to correct sim-
periosteal blood supply to enhance anteversion, dubbed as “miserable ple rotational deformities.
bone union. In all the cases, it was malalignment syndrome.”21 Surgical Chapman et al13 reported closed
not necessary to expose the oste- correction of increased femoral ante- osteotomy nailing performed in 31
otomy site because the transection version requires externally rotating the patients for leg-length inequality and
was performed with an intra- distal fragment. In these patients, there 6 with rotational deformities. Preop-
medullary bone saw. Other advan- would have been a greatly exaggerated erative rotational deformities aver-
tages include the ability to allow external foot progression angle. aged 58° and all were corrected to
weight bearing as tolerated immedi- A concomitant periacetabular oste- within 5° of normal.
ately because the fixation is provided otomy was performed in patients with Stahl et al12 treated 14 patients with
with a locked intramedullary nail. severe acetabular dysplasia and coex- posttraumatic rotational deformities
Placing the distal interlocking screw isting femoral malrotation where it was of the femur that ranged from 26° to
in the dynamic mode allows com- felt that correction of only one or the 63° with a closed technique over an
pression at the osteotomy site with other would leave a notable deformity intramedullary nail. Postoperative CT
weight bearing. In contrast, patients that is often an indication for surgery scans revealed excellent correction of
treated with an intertrochanteric when occurring alone. This procedure the deformity within 4° in all cases.
osteotomy and plating are main- was performed in three patients (5%). Kamath et al40 reported 28 rota-
tained at 20% weight bearing for at Concomitant hip arthroscopy was tional femoral osteotomies in 26
least 6 weeks after surgery. In performed for two reasons: to address patients, 93% for excessive femoral
addition, a pure derotation oste- intra-articular pathology (ie, torn anteversion. Clinical outcomes were
otomy performed in the subtro- acetabular labrum and articular car- not reported. After two initial fail-
chanteric region does not deform the tilage damage) that would ordinarily ures for nonunion, all subsequently
proximal femur. Should a total hip not be accessed during the osteotomy went on to union with refixation.
arthroplasty be required in the and to remove a sizable cam lesion Pailhe et al41 reported nine der-
future, it does not hamper stem that would impinge after a femoral otation osteotomies in six adolescents
insertion as can occur after a previ- retroverting osteotomy. (average age, 13.6 years) for excessive
ous intertrochanteric osteotomy. The failures all occurred in patients anteversion. The technique was done
The disadvantage of the described with excessive anteversion and con- with a distal supracondylar oste-
technique is that bone healing is nective tissue disorders: Ehlers- otomy and fixation with an antegrade
slower, averaging 3 to 4 months, and Danlos or Prader-Willi syndrome. intramedullary nail. The average
in some cases even longer, which may Interestingly, failure did not occur in correction was 19°. Patient-reported
be due to the diminished healing the contralateral osteotomy of the outcome scores were not recorded.
potential of cortical bone versus two Ehlers-Danlos patients. Collagen All patients were satisfied or very
cancellous bone. In addition, there is abnormalities associated with these satisfied and had better foot pro-
much less surface area at the site of conditions may have contributed to gression angles and less internal
the transverse subtrochanteric oste- the problems of instability and poor rotation on range of motion testing.
otomy than with an intertrochanteric bone healing. Putz et al10 performed 96 der-
or supracondylar type. Another dis- Although subsequent surgery was otation femoral osteotomies (proxi-
advantage is potential damage to the required in 78% of hips, 93% of these mal or distal) in 63 adult cerebral
hip abductors because of the reaming were implant removals. Overall, 70% palsy patients with excessive ante-
necessary to insert a nail. Care was of patients underwent removal of the version. Although patient-reported
taken to enter the greater trochanter implant. Although generally better outcome scores were not recorded,
through the posterosuperior “bare tolerated than a blade plate after the group experienced statistical
area” if possible to leave the intertrochanteric osteotomy, most pa- improvement in foot progression
abductors minimally disrupted. At tients had either irritation from the in- angle and passive and stance range of
motion. Tibial rotation osteotomy 1. Ross JR, Larson CM, Adeoye O, Kelly BT, procedures. Clin Orthop Relat Res 1993:
Bedi A: Residual deformity is the most 245-251.
was required in 16.7% of cases to common reason for revision hip
compensate for excessive external arthroscopy: A three-dimensional CT 14. Winquist RA: Closed intramedullary
study. Clin Orthop Relat Res 2015;473: osteotomies of the femur. Clin Orthop
tibial torsion.10 In the present study, a Relat Res.1986:155-164.
1388-1395.
similar need for concomitant tibial
2. Fabricant PD, Fields KG, Taylor SA, 15. Tonnis D, Heinecke A: Acetabular and
derotation osteotomy was noted. femoral anteversion: Relationship with
Magennis E, Bedi A, Kelly BT: The effect of
The limitation of this study is that it femoral and acetabular version on clinical osteoarthritis of the hip. J Bone Joint Surg
outcomes after arthroscopic Am 1999;81:1747-1770.
is a retrospective case series without a
femoroacetabular impingement surgery. J 16. Eckhoff DG: Effect of limb malrotation on
control group. However, it is a single- Bone Joint Surg Am 2015;97:537-543. malalignment and osteoarthritis. Orthop
surgeon series with a consistent Clin North Am 1994;25:405-414.
3. Clohisy JC, Nepple JJ, Larson CM, Zaltz I,
technique over a 20-year period. The Millis M: Persistent structural disease is the 17. Terjesen T, Benum P, Anda S, Svenningsen
present study seems to be the only most common cause of repeat hip S: Increased femoral anteversion and
preservation surgery. Clin Orthop Relat
series in which a patient-recorded out- Res 2013;471:3788-3794.
osteoarthritis of the hip joint. Acta Orthop
Scand 1982;53:571-575.
come score was used. In addition, no
4. Kohno Y, Nakashima Y, Akiyama M, Fujii 18. Scheys L, Spaepen A, Suetens P, Jonkers I:
patients were lost to follow-up. M, Iwamoto Y: Does native combined Calculated moment-arm and muscle-
anteversion influence pain onset in patients tendon lengths during gait differ
with dysplastic hips? Clin Orthop Relat Res substantially using MR based versus
2015;473:3716-3722. rescaled generic lower-limb musculoskeletal
Conclusion 5. Tibor LM, Liebert G, Sutter R,
models. Gait Posture 2008;28:640-648.
Impellizzeri FM, Leunig M: Two or more 19. Gomez-Hoyos J, Schroder R, Reddy M,
In conclusion, hip pain and deterio- impingement and/or instability deformities Palmer IJ, Martin HD: Femoral neck
are often present in patients with hip pain. anteversion and lesser trochanteric
ration can be caused by a variety of Clin Orthop Relat Res 2013;471: retroversion in patients with ischiofemoral
deformities, acting either alone or in 3762-3773. impingement: A case-control magnetic
combination. There can be consider- 6. Thawrani DP, Feldman DS, Sala DA: Not
resonance imaging study. Arthroscopy
2016;32:13-18.
able overlap with acetabular dyspla- all hip dysplasias are the same: Preoperative
sia, hip impingement, and neck-shaft CT version study and the need for reverse 20. Eckhoff DG, Montgomery WK, Kilcoyne
bernese periacetabular osteotomy. J Pediatr RF, Stamm ER: Femoral morphometry and
abnormalities, while femoral version Orthop 2017;37:47-52. anterior knee pain. Clin Orthop Relat Res
may be diminished, normal, or exces- 1994:64-68.
7. Bedi A, Dolan M, Magennis E, Lipman J,
sive. It is important to identify all the Buly R, Kelly BT: Computer-assisted 21. Bruce WD, Stevens PM: Surgical correction
deformities present to ensure the best modeling of osseous impingement and of miserable malalignment syndrome. J
resection in femoroacetabular Pediatr Orthop 2004;24:392-396.
chance of success after hip preserva- impingement. Arthroscopy 2012;28:
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RB, Westberry DE, Baird GO, Stevens PM:
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psoas lengthening: The effect of femoral Posture 2016;49:202-206.
caused by these deformities. A closed, version. Arthroscopy 2012;28:965-971.
subtrochanteric derotation osteotomy 23. Moya LE, Buly RL, Henn RF, Kelly BT, Ma
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anatomic axes of the glenoid aids in placement of the guidewire in the glenoid, which should be inserted in the center of
the neck slightly inferiorly and with some inferior tilt. To achieve optimal baseplate fixation, the screws should be directed
toward the three columns of the scapula. The use of baseplates with variable-angle locking screws should be considered
to freely orientate the screws. The suprascapular nerve must be avoided during posterior screw insertion. Finally, implant
stability is assessed by evaluating shoulder range of motion and tension of the deltoid and conjoint tendons. Watch the
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