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Orthopaedic Insights
Summer 2012
A Physician Newsletter from the Department of Orthopaedic Surgery
In This Issue:
3 Biological Solutions for Damaged Articular Cartilage
4 Advances in Limited Carpal Fusion
6 Intraoperative Blood Management in Total Joint Replacement
8 Missed Peritalar Injuries of the Foot and Ankle
10 Reverse Total Shoulder Arthroplasty
13 Image of the Issue: 3-Tesla MRI Reveals Intra-Articular Remnant
14 Allograft Reconstruction of the ACL: Challenges in Young Patients
16 Osteosarcoma: A Case Study in Multidisciplinary Collaboration
OrthOpaedic insights2 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096
Dear Colleague, It is my pleasure to share with you this Summer 2012 issue of Orthopaedic Insights, which profiles some of the most exciting clinical and research activities we have under way in Cleveland Clinic’s Department of Orthopaedic Surgery.
On the research front, we are proud to be able to spotlight efforts across a wide range of orthopaedic practice areas. We lead with a profile by Dr. Paul Saluan (p. 3) of our institution’s participation in a Phase III study of a promising engineered tissue graft for articular cartilage repair and regeneration. Next, Drs. Peter Evans and Noah Raizman provide an update (p. 4) on their investigations using a novel plate made from a polyether compound for limited carpal fusion in wrist arthritis. Then Dr. Wael Barsoum and colleagues (p. 6) review their recent randomized trials aimed at identifying the best patient populations for various intraoperative hemostatic therapies in the setting of joint replacement.
These and other clinical research reports are complemented by even more practical pieces on how we manage a diversity of clinical challenges, from strategies to avoid misdiagnosis of peritalar injuries of the foot and ankle (p. 8) to the imperative for multidisciplinary collaboration to promote optimal outcomes with surgical limb salvage in osteosarcoma (p. 16).
These articles reflect the emphasis we place on innovation in the service of patient care within our department and the broader Orthopaedic & Rheumatologic Institute of which it is part. A number of the articles also illustrate the benefits of the multidisciplinary care model that arises from our institute structure, where orthopaedic specialists, musculoskeletal radiologists, rheumatologists, biomedical engineers and physiatrists collaborate to promote more streamlined and effective diagnosis and management of musculoskeletal diseases.
I hope you enjoy perusing this issue of Orthopaedic Insights as much as we enjoyed producing it. I invite you to contact us anytime with questions about our programs and activities or to explore how we might
partner to advance patient care.
Richard D. Parker, MD Chairman, Department of Orthopaedic Surgery
Professor, Cleveland Clinic Lerner College of Medicine
216.444.2992 | parkerr@ccf.org
U.S.News & World Report Cleveland Clinic’s Orthopaedic Program
is ranked No. 4 in the nation in U.S.News
& World Report’s “America’s Best Hospitals”
survey — the top-ranked program in Ohio.
AwardsTwo Department of Orthopaedic Surgery physicians, Joseph Iannotti, MD, PhD, Chairman, Orthopaedic & Rheumatologic Institute, and Wael Barsoum, MD, were the recipients of Cleveland Clinic’s 2011 Sones Innovation Award. The prize recognizes achievements that reflect the spirit of Dr. Mason Sones, a Cleveland Clinic pioneer whose discoveries gave rise to modern cardiovascular medicine. Drs. Iannotti and Bar-soum were honored for their work over more than a decade developing software and virtual bone modeling techniques that add a new dimension to surgical planning and implant customization.
Jack Andrish, MD, and Richard D. Parker, MD, both of the Department of Orthopaedic Surgery, are part of a multicenter research team that received the 2012 Kappa Delta Ann Doner Vaughan Award from the American Academy of Orthopaedic Surgeons. The prize, which recognizes research in orthopaedic surgery of high significance and impact, was for the paper “Prognosis and Predictors of ACL Reconstruction Using the MOON Cohort: A Model for Comparative Effectiveness Studies” from the NIH-funded Multi-center Orthopaedic Outcomes Network (MOON) project. Drs. Parker and Andrish collaborated with lead author Kurt P. Spindler, MD, of Vanderbilt Uni-versity, who completed a fellowship in orthopaedic surgery at Cleveland Clinic in 1991, along with investigators at five other centers.
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Articular (hyaline) cartilage has a limited capacity for repair
and regeneration. Injury to cartilage often results in scar
formation, leading to a lasting loss of structure and function.
Cleveland Clinic orthopaedic surgeons use several clinical
strategies to promote the recovery of articular cartilage that
has been harmed by acute trauma or repetitive joint damage.
However, repair of cartilage, especially in the knee, remains
a clinical challenge.
BIOLOGICAL TREATMENT STRATEGIES ARE EMERGING
Combinations of surgical techniques with regenerative
medicine approaches to cartilage repair have only begun to
be explored as potential options for returning function,
especially for patients who are young and active. One such
novel treatment involves the development of a cellular ther-
apy for cartilage repair that relies on the superior biological
activity of juvenile chondrocytes to produce a living cartilage
equivalent. The lesions are first debrided and measured.
The engineered tissue graft (Figure 1) is then cut out to the
exact shape of the lesion and secured in place in the defect
with fibrin glue in one surgical procedure. The patient is
followed closely for five years postoperatively.
PHASE III CLINICAL TRIAL UNDER WAY
We are currently participating in a Phase III randomized,
controlled, multicenter study to evaluate the safety and
efficacy of this procedure for grade 3 and 4 articular lesions
of the knee in the femoral condyle or trochlear groove as
Biological Solutions Show Promise for Repair and Regeneration of Damaged Articular CartilageBy Paul M. Saluan, MD
compared with microfracture treatment. Although the graft
used in the procedure is still investigational, initial results
are promising.
For this study, the intended use of this implant is the treat-
ment of up to two unilateral symptomatic articular cartilage
lesions of the knee ranging from 1 to 5 cm2 in size. The
lesions must be in separate compartments of the same knee,
and the total combined area of the two lesions should not
be greater than 6 cm2. Patients will be treated and followed
for five years at Cleveland Clinic’s Center for Sports Health.
Eligible subjects are patients between the ages of 18 and 60
with moderate to severe pain. Lesions to be treated must be
shouldered by surrounding native cartilage. Ipsilateral knees
must have relatively intact menisci and stable ligaments
and need to exhibit normal alignment. Contralateral knees
must be asymptomatic and stable.
Superiority between the treatment and comparator groups is
being assessed in mean Knee injury and Osteoarthritis Out-
come Score (KOOS) pain and ADL scores at 18 and 36 months.
Clinical assessments, including imaging, are done at base-
line, at 6 weeks, and at 6, 12, 18, 24, 36, 48 and 60 months.
CONCLUSION
Although articular cartilage lesions continue to be a
challenge to treat, there is a clear trend toward combining
biological solutions with surgical techniques for their repair
and regeneration, such as the approach being studied at our
Center for Sports Health. We look forward to sharing the
study results as they become available.
ABOUT THE AUTHOR
Dr. Saluan holds joint appointments in the Center for Sports Health and the Center for Pediatric Orthopaedic Surgery within Cleveland Clinic’s Orthopaedic & Rheumatologic Institute. He specializes in pediatric and adolescent sports medicine and arthroscopic surgery. He is certified in orthopaedic surgery and holds a subspecialty certificate in sports medicine from the American Board of Orthopaedic Surgery. He can be contacted at saluanp@ccf.org.
Figure 1. Engineered tissue graft for a knee articular cartilage lesion.
OrthOpaedic insights4 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096
Advances in Limited Carpal Fusion: New Techniques and Innovative ImplantsBy Noah Raizman, MD, and Peter J. Evans, MD, PhD
ISSUES AND OPTIONS IN LIMITED CARPAL ARTHRODESIS
Multiple degenerative and post-traumatic conditions affect-
ing the wrist lead to painful and limiting carpal arthritis.
The patterns of scapholunate advanced collapse (SLAC) and
scaphoid nonunion advanced collapse (SNAC) have been
well-described, and multiple salvage operations have been
devised to treat them. In earlier stages, limited carpal fu-
sions have the potential to decrease pain, maintain func-
tional range of motion and preserve carpal height. While
the literature supports both proximal row carpectomy and
limited carpal fusion for SNAC and SLAC wrists, proximal
row carpectomy is not an option when advanced midcarpal
arthritis exists or when the head of the capitate shows
significant degenerative changes.
A solid capitolunate fusion is the goal of most limited carpal
arthrodeses, creating a stable unit that links the radius and
the distal carpal row. The importance of preserving the
triquetrum or including it in the fusion is unknown. Stud-
ies have examined excising both the scaphoid and trique-
trum, leading to a three-bone fusion, or even just excising
the proximal scaphoid. Other investigators have performed
isolated capitolunate fusions without including the hamate
or triquetrum, all with comparable results in small series.
Biomechanically in the laboratory, excision of the triquetrum
has been shown to lead to better wrist motion. Lunate posi-
tion within the fusion is critical.
HARDWARE EVOLUTION
Traditionally, partial carpal fusions were performed using
K-wire fixation with distal radius bone grafting. More
recently, multiple compression screws, staples and circular
fixation plates have been used to eliminate the need for hard-
ware removal and increase the rate of union. First-generation
circular plates have been shown in some studies to lead to
high nonunion rates, though other studies have shown excel-
lent results. Other complications reported with dorsal plate
or staple fixation include impingement of the hardware on
the radius or extensors. In addition, with metal hardware, the
progression of fusion is often radiographically obscured and
difficult to evaluate.
INVESTIGATIONS OF A NEW RADIOLUCENT PLATE
The Xpode plate (Figure 1) from TriMed is a third-generation
circular locking fusion plate made from PEEK, a radiolucent
polymer with a modulus of elasticity similar to that of corti-
cal bone. It has been used in both the wrist and the foot. Its
titanium screws allow for bony compression and also lock
into the plate at variable angles, enabling multiple screws
to be placed into each bone (Figure 2). The instrumentation
includes a reamer that allows for full recession of the plate
into the carpal fusion mass to avoid any dorsal impingement.
We have been using this plate for more than two years in
limited carpal fusions. Our preferred technique is to resect
both the scaphoid and the triquetrum and perform a three-
bone fusion with at least two screws each in the capitate,
lunate and hamate.
Wrist arthritis is a disabling condition that has many etiologies but commonly affects patients after scaphoid nonunion or scapholunate ligament injuries that remain untreated, often for years. While multiple techniques have been used to salvage degenerative wrists, partial wrist fusions maintain carpal height, preserve motion and reliably improve pain. We have begun using a new, variable-angle, circular locking plate made from polyether ether ketone (PEEK) to optimize results in our patients with this painful condition.
OrthOpaedic insights summer 2012 5Visit clevelandclinic.org/ortho
Our investigations are ongoing, but early results in 19
patients (2 female, 17 male; mean age, 58 years) with a mean
follow-up of 7.8 months demonstrate no nonunions. The
mean visual analog pain scale measurement was 1.9/10. Total
wrist arc of motion was 79 degrees. Complications have been
minimal: One patient was reoperated on for suspected non-
union but was found to have complete fusion on exploration.
While we continue to collect data on these patients, our early
results with this new technique are encouraging. It appears
that the combination of technical modifications to the
original four-corner fusion technique and new implants may
benefit patients with degenerative wrist arthritis.
Figure 1. The Xpode plate implant.
We have been using this new third-generation
circular locking fusion plate for more than
two years in limited carpal fusions.
ABOUT THE AUTHORS
Dr. Raizman is a hand fellow in the Cleveland Combined Hand Fellowship. Dr. Evans is Director of the Upper Extremity Center in the Department of Orthopaedic Surgery. He specializes in surgery of the hand, elbow and shoulder, including joint replace-ment, arthroscopy, and tendon and nerve repair. He can be reached at 216.444.7973 or evansp2@ccf.org.
Figure 2. Lateral (left) and anteroposterior (right) radiographs of a patient with carpal bones fused using the Xpode plate implant.
OrthOpaedic insights6 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096
Intraoperative Blood Management in Total Joint Replacement: Recent Studies Guide Judicious Use of Hemostatic Therapies
By Alison Klika, MS; Michael R. Bloomfield, MD; and Wael K. Barsoum, MD
Total hip arthroplasty (THA) and total knee arthroplasty
(TKA) can cause significant blood loss, with an expected
postoperative hemoglobin drop of 1 to 3 g/dL.1 Excessive
blood loss puts the patient at risk for allogeneic or autologous
blood transfusion, each of which has its own potential for
complications. The prevalence of allogeneic blood transfu-
sion following THA and TKA ranges from 11 to 37 percent,
depending on the nature and extent of the procedure.2
Among the many issues associated with allogeneic transfu-
sions are the potential for disease transmission, immuno-
modulation with the increased susceptibility to infection,
and systemic transfusion reactions.3 In addition, allogeneic
transfusions are costly, adding approximately $700 in direct
costs per case at our institution.4 Preoperative autologous
blood donation has been in decline in recent years, due to
overcollection (35 to 55 percent of donated units go unused),
laboratory mistakes and mislabeling, and high costs (almost
$700 in additional cost per case).
ASSESSING OPTIONS FOR BLOOD MANAGEMENT
These risks and drawbacks of allogeneic and autologous
blood transfusion have fueled the development of a rich
market of products and strategies designed to minimize
perioperative blood loss. Intraoperative options, including
hypotensive anesthesia, topically active hemostatic agents,
antifibrinolytics (tranexamic acid, aprotinin) and blood
salvage strategies, offer the opportunity to reduce the need
for blood transfusion. The gold standard for evaluating these
products and approaches is a randomized controlled trial
(RCT). Our research group at Cleveland Clinic has conducted
recent RCTs of two different intraoperative hemostatic
therapies, a bipolar sealer and a topical hemostatic agent,
in the context of total joint replacement.
BIPOLAR SEALER: PATIENT SELECTION IS KEY
Our study of the bipolar sealer aimed to test its efficacy
in achieving hemostasis in the setting of primary THA.5
Patients were excluded from the study if they had a
hemoglobin below 11.5 g/dL; a history of cardiac, liver or
renal disease; predonated blood; a history of joint infection;
a bleeding disorder; or peripheral vascular disease. Results
from 140 patients showed that in relatively healthy patients
and straightforward cases, the bipolar sealer does not reduce
transfusion requirements compared with the standard
Bovie electrocautery control. However, a separate group
tested this device in revision THA for infection (i.e., greater
morbidity) and found that total blood loss, intraoperative
blood loss and perioperative hemoglobin decline were
significantly reduced in the experimental group.6 We have
discontinued using this device in patients undergoing
primary THA but recognize that it may be useful in different
patient populations.
Figure 1. Use of a collagen/thrombin and autologous platelet topical hemostatic agent during primary total hip arthroplasty.
OrthOpaedic insights summer 2012 7Visit clevelandclinic.org/ortho
TOPICAL HEMOSTATIC AGENT: PROMISING RESULTS IN TKA
Our group has also completed an RCT of a collagen/throm-
bin and autologous platelet topical hemostatic agent in
primary TKA.7 We randomized 100 patients on a 1-to-1 basis
either to the experimental therapy plus standard hemostasis
or to standard hemostasis alone. The primary outcome
measure was transfusion requirements as determined by
a blinded investigator using standardized criteria. Signifi-
cantly fewer transfusions were needed in the treatment
group than in the control group (0 vs. 5; P = 0.007). We are
now in the process of evaluating this product in the setting
of primary THA (see Figure 1).
Given the various blood management products available
and their considerable costs, it is important to first test their
usefulness and determine the patient populations they are
most likely to benefit. Additionally, cost-effectiveness and/
or cost-benefit analyses will further guide hospitals in the
decision-making process regarding these products.
ABOUT THE AUTHORS
Dr. Bloomfield is a chief resident in the Department of Ortho-paedic Surgery. Ms. Klika is a research program manager for the Department of Orthopaedic Surgery and Surgical Operations.
Dr. Barsoum, Vice Chair, Department of Orthopaedic Surgery, and Chair, Surgical Operations, specializes in reconstruction, replacement and arthroscopy of the hip and knee as well as re-vision joint replacements. He can be reached at 216.444.7515 or barsouw@ccf.org.
It’s important to first test the available blood management products to determine the patient populations they are most likely to benefit.
REFERENCES 1. Sculco TP, Baldini A, Keating EM. Blood management in total joint arthroplasty. Instr Course Lect. 2005;54:51-66.
2. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999;81(1):2-10.
3. Innerhofer P, Klingler A, Klimmer C, Fries D, Nussbaumer W. Risk for postoperative infection after transfusion of white blood cell-filtered allogeneic or autologous blood components in orthopedic patients undergoing primary arthroplasty. Transfusion. 2005;45(1):103-110.
4. Krebs VE, Higuera C, Barsoum WK, Helfand R. Blood management in joint replacement surgery: what’s in and what’s out. Orthopedics. 2006;29(9):801-803.
5. Barsoum WK, Klika AK, Murray TG, Higuera C, Lee HH, Krebs VE. Prospective randomized evaluation of the need for blood transfusion during primary total hip arthroplasty with use of a bipolar sealer. J Bone Joint Surg Am. 2011;93(6):513-518.
6. Clement RC, Kamath AF, Derman PB, Garino JP, Lee GC. Bipolar sealing in revision total hip arthroplasty for infection: efficacy and cost analysis. J Arthroplasty. 2012 Jan 21 [Epub ahead of print].
7. Bloomfield MR, Klika AK, Molloy RM, Froimson MI, Krebs VE, Barsoum WK. Prospective randomized evaluation of a collagen/thrombin and autologous platelet hemostatic agent during total knee arthroplasty. J Arthroplasty. 2012;27(5):695-702.
OrthOpaedic insights8 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096
Fractures of the foot and ankle have been reported as the most
commonly missed injuries in the emergency room. There are
many reasons for this, including the rarity of these injuries and
the subtle radiographic findings that accompany them.
Motor vehicle accidents are a major cause of these injuries.
Despite an overall decline in motor vehicle fatalities, the
number of motor vehicle accident survivors who sustain foot
and ankle injuries has increased. Improved survival rates
due to airbags, for example, have increased the number
of patients who are treated for high-energy motor vehicle
trauma. Moreover, studies have shown that overall morbidity
is greater in polytraumatized victims with foot injuries
than in those without foot injuries, which underscores the
importance of proper recognition of these injuries.
THE TOLL OF MISSED PERITALAR INJURIES
Peritalar injuries are defined as fractures or ligamentous dis-
ruption resulting in instability of one or more peritalar joints
(the tibiotalar, subtalar, calcaneocuboid and talonavicular
joints). Of these, the tibiotalar, subtalar and talonavicular are
all essential joints of the lower extremity — i.e., necessary for
normal biomechanical function. Because of the effect on foot
kinematics, missed or delayed diagnosis of peritalar injuries
often results in permanent functional impairment. Patients
with missed injuries often go on to develop significant
morbidity and require complex reconstructive procedures
or salvage procedures due to advanced degeneration of the
peritalar structures.
FACTORS ASSOCIATED WITH MISSED INJURIES
A recently presented study of missed foot and ankle injuries
at a Level I trauma center identified 27 patients with 44
missed injuries over a 10-year span. Of these 44 injuries, talus
fractures were the most commonly missed, followed by cal-
caneus and navicular fractures. Additionally, there were nine
dislocations identified encompassing the peritalar joints.
Of the 17 talus fractures identified, fractures of the lateral
process were most commonly missed. Other identified frac-
tures included those of the posterior talar process, talar head,
talar body, intra-articular calcaneus and navicular bone. This
study demonstrated a correlation between patient sex and
time to diagnosis, with males having a statistically signifi-
cant delay from presentation to diagnosis. Age also appeared
to be correlated with time to diagnosis, with younger patients
having greater delay.
Missed Peritalar Injuries of the Foot and Ankle: Why Timely Detection MattersBy Sean Matuszak, MD, and James J. Sferra, MD
Figure 1. Imaging studies in a patient with trauma from a motor vehicle accident. The initial X-ray (left) was read as negative, but a delayed CT scan (right) shows a displaced talar body fracture.
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While previous reviews have defined the scope of these
missed peritalar injuries, we are only recently coming to
recognize just how common these misdiagnoses are.
STRATEGIES FOR TIMELY DETECTION
Because foot and ankle injuries are the most commonly
missed orthopaedic injuries in the acute setting, it is im-
portant to have a heightened awareness of these injuries. A
fundamental concept to understand is the complex nature
of their diagnosis. Previous authors have tried to simplify
algorithms for diagnosis with the development of the Ottawa
rules, which aim to identify which patients with foot and
ankle injuries should undergo X-ray studies. However, as
described by Wei et al, only one-third of these missed injuries
are due to improper X-ray technique or unidentifiable X-ray
findings; two-thirds of all missed injuries are identifiable on
initial X-rays when these are re-reviewed.
These data underscore how important it is not only to order
X-rays but to scrutinize them carefully — and to have a low
threshold for advanced imaging, as demonstrated by the
cases illustrated in Figures 1 and 2. At Cleveland Clinic, our
practice is often to order a CT scan or MRI in the acute set-
ting for patients who are unable to ambulate, have sustained
high-energy injuries or have exam findings out of proportion
to their X-ray findings. At the very least, these findings in the
acute setting must prompt referral to a specialist.
While it is impossible to completely eliminate the possibility
of missed injuries in the foot and ankle, proper awareness
and education regarding the complexity of diagnosing these
injuries should reduce the frequency of missed and delayed
diagnoses and the resultant morbidity.
ABOUT THE AUTHORS
Dr. Matuszak is a foot and ankle fellow in the Department of Orthopaedic Surgery. He can be reached at matuszs@ccf.org.
Dr. Sferra specializes in foot and ankle reconstructive surgery in the Department of Orthopaedic Surgery. He can be reached at 216.445.8507 or sferraj@ccf.org.
SUGGESTED READING Kou J, Fortin P. Commonly missed peritalar injuries. J Am Acad Orthop Surg. 2009;17:775-786.
Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY. Systemic analy-sis of missed extremity fractures in emergency radiology. Acta Radiol. 2006;47:710-717.
Matuszak SA, Fortin P, Baker E. Missed peritalar injuries: a retrospec-tive review. Paper presented at: 26th Annual Summer Meeting of the American Orthopaedic Foot & Ankle Society; July 9, 2010; National Harbor, MD.
Burgess AR, Dischinger PC, O’Quinn TD, Schmidhauser CB. Lower extremity injuries in drivers of airbag-equipped automobiles: clinical and crash reconstruction correlations. J Trauma. 1995;38:509-516.
Sangeorzan BJ, ed. The Traumatized Foot. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2001.
Figure 2. Imaging studies in a patient following a fall from a high elevation. The initial X-ray (left) was read as negative, but a delayed CT scan (right) demonstrates a missed calcaneal fracture.
Missed or delayed diagnosis of peritalar injuries often results in permanent functional impairment.
OrthOpaedic insights10 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096
PROSTHESIS USE INCREASING
Increasing numbers of reverse total shoulder arthroplasty
procedures have been performed in the United States since
approval of the implant by the Food and Drug Administra-
tion in 2004. Approximately one-third of the 338 shoulder
arthroplasty surgeries performed at Cleveland Clinic in 2011
involved reverse prostheses, with more reverse shoulder re-
placements implanted in 2011 than in the previous five years
combined. Quality outcomes have been maintained with this
rise in volume, with low rates of infection and readmission
following shoulder arthroplasty at our institution.
The growth in use of the reverse prosthesis has led to broader
application of reverse total shoulder arthroplasty when
shoulder replacement is indicated in the presence of signifi-
cant rotator cuff dysfunction. Its primary indication remains
the pseudoparalytic, severely rotator cuff-deficient shoul-
der most commonly seen in patients with rotator cuff tear
arthropathy or a massive, irreparable rotator cuff tear with or
without arthritis (Figure 1). However, reverse total shoulder
arthroplasty is now increasingly used in the setting of failed
or revision shoulder arthroplasty, as well as in the treatment
of complex proximal humerus fractures requiring shoulder
replacement.
Implant failure from aseptic or septic causes is often
associated with development of rotator cuff deficiency,
either from damage to the rotator cuff itself or from bone
loss leading to tuberosity deficiency (Figure 2). Acute or
chronic proximal humerus fractures can also be associated
with tuberosity deficiency due to fracture comminution
or tuberosity nonunion that can lead to significant rota-
tor cuff dysfunction. In both situations, surgical treatment
can be challenging, and the use of anatomic total shoulder
arthroplasty or hemiarthroplasty may provide only modest
functional outcomes with regard to active shoulder elevation.
In contrast, reverse total shoulder arthroplasty has shown
promise in potentially providing more reliable improvement
in shoulder function in these challenging clinical scenarios.
However, more data are needed to determine the optimal
use of the implant in such conditions.
DEVELOPMENTS IN IMPLANT DESIGN
The increasing use of reverse total shoulder arthroplasty
has brought modifications in implant design in an attempt
to improve functioning and longevity of the prosthesis and
reduce complications. A key concept of the initial modern
design of this prosthesis was to medialize and distalize the
center of rotation of the glenohumeral joint, with the objec-
tives of optimizing function of the deltoid to compensate for
the deficient rotator cuff and reducing stresses across the
implant to avoid implant loosening and failure.
Reverse Total Shoulder Arthroplasty: As Prosthesis Use
Grows, So Do Efforts to Optimize Implant Placement and FunctionBy Eric Ricchetti, MD
Figure 1. Postoperative radiograph of a reverse total shoulder arthroplasty prosthesis placed in a patient with rotator cuff tear arthropathy.
We are using computer simulation tools to study the relationship between implant factors and patients’ bony anatomy in determining impingement-free range of motion.
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Figure 2. (Left) Preoperative radiograph of a 70-year-old patient who previously underwent standard total shoulder arthroplasty at an outside facility, with subsequent development of rotator cuff deficiency and superior migration of the humeral prosthesis. (Right) Postoperative radiograph after the patient underwent revision of a reverse total shoulder arthroplasty.
Since the release of this initial design, newer prostheses and
surgical techniques have been developed to place the center
of rotation in a more lateralized position. This lateral offset
can place the implant closer to the shoulder’s native center
of rotation. The design change has shown promising results,
with potentially decreased concern for implant instability
and scapular notching, two commonly reported complica-
tions with reverse total shoulder arthroplasty, and improved
active shoulder function in terms of internal and external
rotation. This and other design modifications, in combina-
tion with further knowledge about optimal component posi-
tioning, such as more inferior positioning of the glenosphere,
will ideally lead to improved clinical function and prosthesis
survival. However, more data are needed to determine the
optimal use and benefits of such changes.
coNtiNUed oN Next page
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EFFORTS TO DETERMINE OPTIMAL
IMPLANT PLACEMENT AND DESIGN
Cleveland Clinic’s Department of Orthopaedic Surgery has
begun to further investigate some of these questions about
optimal implant placement and design. Using computer
simulation tools previously developed in our department, we
are studying the relationship between implant factors and
patients’ bony anatomy in determining impingement-free
range of motion with reverse total shoulder arthroplasty. A
CT study of a patient’s shoulder is uploaded into the com-
puter simulation software, and a three-dimensional recon-
struction of the humerus and scapula is made. A reverse
prosthesis can then be experimentally placed in this three-
dimensional reconstruction, and shoulder movement can be
simulated to determine how implant modifications impact
range of motion and function (Figure 3).
Figure 3. (Left) Three-dimensional reconstruction of a shoulder with placement of a reverse total shoulder arthroplasty implant using computer simulation software. No areas of bony impingement are noted in this abducted position. (Right) As the arm is brought into a position of adduction, an area of bony impingement is identified in red along the neck of the scapula.
This study will help determine how an individual patient’s
native bone anatomy, particularly glenoid and scapular neck
morphology and pathologic bone loss from underlying dis-
ease, affects optimal implant position. This will allow us to
predict, for example, what degree of lateral offset and inferior
positioning of the glenosphere component is necessary to
maximize shoulder range of motion and minimize areas of
bony impingement between the reverse prosthesis and the
native scapula in a given patient.
Our ultimate goal is to use these computer simulation and
preoperative planning tools in clinical practice to more pre-
cisely place reverse total shoulder arthroplasty implants in
an ideal position based on the patient’s anatomy and thereby
limit bony impingement, avoid development of component
loosening and scapular notching, and maximize prosthesis
survival.
ABOUT THE AUTHOR
Dr. Ricchetti is Fellowship Director for Shoulder and Elbow Surgery in the Department of Orthopaedic Surgery and special-izes in all aspects of shoulder and elbow surgery. He can be reached at 216.445.6915 or ricchee@ccf.org.
OrthOpaedic insights summer 2012 13Visit clevelandclinic.org/ortho
Image of the Issue: 3-Tesla MRI Aids Diagnosis of Complete Long Head Biceps Tear With Remnant Intra-Articular FragmentBy Hassana Barazi, MD, and Joshua Polster, MD
A 59-year-old man presented with shoulder pain of two
weeks’ duration. Clinical findings were suggestive of rota-
tor cuff pathology. A routine noncontrast MRI examination
was performed on a 3-tesla MRI machine (Siemens Verio®)
using multichannel surface coils over the affected shoulder.
The images demonstrated absence of the long head biceps
tendon at the level of the bicipital groove without evidence of
tendon dislocation, findings compatible with a complete tear
with distal retraction (Figure 1). A sizable intra-articular rem-
nant of the long head of the biceps tendon was still present
and attached to the supraglenoid tubercle (Figure 2).
The management of biceps tears is generally conservative in
the absence of an intra-articular remnant. Surgical man-
agement may be required when an intra-articular fragment
is present. For this reason, high-quality assessment of the
intra-articular biceps is important diagnostically, as it can
effectively alter the course of treatment. In this case, the
patient was managed conservatively with NSAIDs and physi-
cal therapy and continues to report a gradual decrease in
shoulder pain with time.
Figure 1. MRI showing absence of the long head biceps tendon at the level of the bicipital groove with no evidence of tendon dislocation, which suggests a complete tear of the tendon with distal retraction.
Figure 2. MRI in the same patient demonstrating a large intra-articular remnant of the long head of the biceps tendon attached to the supragle-noid tubercle.
The 3-tesla MRI system has a magnetic field strength two
to three times stronger than that of standard high-field
systems, allowing acquisition of images with much greater
signal-to-noise ratios and at higher speeds. In combination
with multichannel coils, newer software and new imaging
sequences, this allows for images with significantly higher
resolution of small structures. This higher resolution enables
more thorough evaluation of intra-articular structures. The
result is greater diagnostic certainty and ultimately better
patient care.
ABOUT THE AUTHORS
Dr. Barazi is a musculoskeletal radiology fellow in Cleveland Clinic’s Imaging Institute. Dr. Polster is a musculoskeletal radi-ologist and Imaging Director of Cleveland Clinic Sports Health. They can be reached at 216.445.2548 and at barazih@ccf.org or polsterj@ccf.org.
OrthOpaedic insights14 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096
Although surgical reconstruction of anterior cruciate
ligament (ACL) tears generally carries good to excellent
long-term results in more than 90 percent of patients,
higher failure rates have recently been identified following
allograft reconstruction of the ACL in younger, more active
patients. We recently contributed to this evidence base by
presenting (at the 2012 annual meeting of the American
Academy of Orthopaedic Surgeons) long-term outcomes in
a large cohort of patients undergoing allograft ACL recon-
struction. This article reviews our findings in the context of
an overview of options for ACL reconstruction and recom-
mendations for managing young, active patients with this
very common injury.
VARIOUS GRAFT CHOICES
AVAILABLE FOR RECONSTRUCTION
Bone-patellar tendon-bone (BTB) autograft has traditionally
been considered the gold standard for ACL reconstruction.
The advantages of BTB autografts include earlier bone-to-
bone healing compared with soft-tissue autografts (6 vs. 12
weeks), increased stability with BTB grafts, larger graft size
and avoidance of morbidity to the hamstring musculature,
which is an important dynamic stabilizer against anterior
translation of the tibia on the femur.
Over the past few decades, hamstring autograft has become
increasingly popular as a reconstruction option, with more
widespread use of quadruple-stranded semitendinosus and
semitendinosus-gracilis autografts. Proponents of these
all-soft-tissue grafts cite many benefits: hamstring grafts
are biomechanically stronger than BTB grafts, they’ve
demonstrated a lower incidence of anterior knee pain in
some studies, they are highly versatile, and they eliminate
concerns over graft-tunnel mismatch. More recent studies
show that there are no significant differences in objective
measures of stability with hamstring autografts relative to
BTB autografts. This may be due to better options for fixa-
tion of soft-tissue grafts.
INCREASING POPULARITY
OF ALLOGRAFT RECONSTRUCTION
At the same time, allograft reconstruction is an increasingly
popular graft choice, as it can be both versatile and con-
venient. The many tendon options for use in allograft ACL
reconstruction include the gracilis, semitendinosus, Achilles,
patellar, quadriceps, and posterior and anterior tibialis. Pro-
ponents of allograft tissue cite the elimination of donor-site
morbidity, shorter surgical times, smaller incisions, increased
versatility, and faster recovery and rehabilitation. Some of
these factors can be especially important from a comparative
standpoint because donor-site pain can be significant in some
patients following autograft tissue harvest, and some studies
have noted issues with anterior knee pain as well as loss of
terminal extension following BTB autograft surgery. More-
over, allograft tissue can be thawed and prepared prior to the
patient’s arrival in the surgical theater, which markedly de-
creases operative time. For these and other reasons, allograft
tissue has become the tissue of choice for many surgeons.
LONG-TERM OUTCOMES RAISE QUESTIONS
Nevertheless, multiple authors have demonstrated increased
failure rates following allograft ACL reconstruction. In a
study of patients younger than age 40 who underwent ACL
reconstruction, Barrett et al found that those who received
allografts had a failure rate four times higher than that of
control patients who received autografts. In one of the most
notable studies, Singhal et al demonstrated a 55 percent
failure rate following allograft ACL reconstruction in patients
younger than 25 years of age compared with a failure rate of
just 24 percent in those older than 25.
A limitation of many of the studies showing less-than-favor-
able outcomes after allograft ACL reconstruction has been
fairly small cohort sizes. I recently partnered with colleagues
to report long-term outcomes in a large cohort of patients un-
dergoing allograft ACL reconstruction at a single institution.
All procedures were performed between 2000 and 2008 by two
board-certified sports medicine specialists with more than 50
years of combined clinical experience. Ninety-nine allograft
and 24 autograft reconstructions were included. Our findings
are summarized in Tables 1 and 2.
Allograft Reconstruction of the ACL: Further Evidence of Higher
Failure Rates in Young Patients – and What It Means for ManagementBy Lutul D. Farrow, MD
OrthOpaedic insights summer 2012 15Visit clevelandclinic.org/ortho
The principal finding of this study is the substantially higher
reoperation rate among patients younger than 25 years of age
within the group that underwent allograft ACL reconstruc-
tion. We found a 20 percent failure rate in young patients
following allograft reconstruction, whereas there were no
failures in patients under age 25 following autograft recon-
struction. This study also identified 19 Division I National
Collegiate Athletic Association intercollegiate athletes who
underwent ACL reconstruction, 13 with allografts and 6 with
autografts. In this Division I cohort, none of the autograft
reconstructions failed, whereas 62 percent of the allograft
reconstructions did.
CONCLUSIONS AND RECOMMENDATIONS
The failure rate following autograft ACL reconstruction is
reported at approximately 5 to 8 percent in most long-term
studies. Multiple studies have found higher failure rates fol-
lowing allograft ACL reconstruction. There are many theories
why allograft tissue may be inferior to autograft. Some sug-
gest that the method of preservation and storage, along with
allograft exposure to ionizing radiation or certain chemicals
during sterilization/aseptic processing, may alter the al-
lograft’s biomechanical properties and impact the process of
graft ligamentization. Taking this into consideration, return-
to-play guidelines may need to be altered to account for this
longer ligamentization process.
Our study demonstrates high failure rates following allograft
reconstruction, especially in patients younger than age 25, as
well as an alarmingly high failure rate in elite intercollegiate
athletes. Based on available evidence, at Cleveland Clinic we
generally do not recommend allograft reconstruction in the
young, active athlete. We counsel all patients on the higher
risk of failure with allograft reconstruction, and we generally
recommend autograft reconstruction in those younger than
age 50. In less active patients over age 50, allograft reconstruc-
tion becomes a more viable option because the outcomes in
this group are comparable to those with autograft reconstruc-
tion. While autograft reconstruction remains our first-line
option for primary ACL reconstruction in most patients, graft
choice ultimately should be decided on a case-by-case basis.
ABOUT THE AUTHOR
Dr. Farrow specializes in sports medicine surgery, acute sports injuries and arthroscopy of the knee and shoulder in the Depart-ment of Orthopaedic Surgery. He serves as Assistant Team Physician with the National Football League’s Cleveland Browns and can be reached at 216.518.3620 or farrowl@ccf.org.
SUGGESTED READING Lenehan EA, Askam BM, Grana WA, Farrow LD. Long-term outcomes following allograft anterior cruciate ligament reconstruction [abstract P453]. Poster presented at: Annual Meeting of the American Academy of Orthopaedic Surgeons; February 7, 2012; San Francisco, CA.
Barrett GR, Luber K, Repogle WH, Manley JL. Allograft anterior cruciate ligament reconstruction in the young, active patient: Tegner activity level and failure rate. Arthroscopy. 2010;26(12):1593-1601.
Singhal MC, Gardiner JR, Johnson DL. Failure of primary anterior cruciate ligament surgery using anterior tibialis allograft. Arthroscopy. 2007;23(5):469-475.
Table 1. Reoperation rates following allograft ACL reconstruction (percentages)
Revision ACL reconstruction
Meniscus repair
Partial meniscectomy
Hardware removal
Infection Total*
All pts (n = 99) 10.1 4 6.1 2 3 18.2
Pts < 25 years of age (n = 39)
20.5 7.7 12.8 2.6 2.6 30.8
*Some patients underwent multiple procedures at the time of revision surgery
Table 2. Reoperation rates following autograft ACL reconstruction (percentages)
Revision ACL reconstruction
Meniscus repair
Partial meniscectomy
Hardware removal
Infection Total*
All pts (n = 24) 4.2 12.5 12.5 4.2 4.2 29.2
Pts < 25 years of age(n = 13)
0 15.4 15.4 7.7 0 30.8
*Some patients underwent multiple procedures at the time of revision surgery
OrthOpaedic insights16 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096
A SECOND CHANCE
“My quality of life and health are as great as they were before
surgery, if not better. I am able to be just as active and enjoy
working out, swimming, bike riding, and anything from sand
volleyball to golf to jumping on a trampoline. I have nearly no
limitations.”
The above quote is from a patient whose world was rocked in
2006 when he was told, at age 15, that his progressively grow-
ing tibial mass had imaging and biopsy findings consistent
with a high-grade nonmetastatic osteosarcoma (Figure 1).
Rather than allowing the news to end his career hopes and
life aspirations, this young man teamed with specialists in
Cleveland Clinic’s multidisciplinary Musculoskeletal Tumor
Center to treat the high-grade bone sarcoma. The overall
treatment strategy combined a multiagent chemotherapy
regimen with an allograft-prosthetic composite reconstruc-
tion of the proximal tibia-fibula, augmenting the extensor
mechanism using a medial gastrocnemius flap (Figure 2).
Osteosarcoma: A Case Study in Why
Multidisciplinary Collaboration MattersBy Nathan W. Mesko, MD; David Joyce, MD; Michael Joyce, MD; and Steven A. Lietman, MD
Figure 1. Anteroposterior radiograph (left) and MRI (right) showing the bone destruction and soft-tissue mass (arrows) of an aggressive osteosarcoma of the proximal tibia at the time of diagnosis in the 15-year-old case patient (see text).
OrthOpaedic insights summer 2012 17Visit clevelandclinic.org/ortho
Six years later, this patient is now thriving as a 21-year-old
University of Toledo student who is focused on his goal of be-
coming a nurse. He remains free of metastases and is grateful
for what he calls his “second chance” on life.
DRAMATIC EVOLUTION IN TREATMENT
One of the greatest paradigm shifts in bone and joint sur-
gery in the past three decades has been in the treatment of
primary sarcoma of the bone. In the 1960s and ’70s, the gold-
standard treatment of primary osteogenic sarcoma (osteosar-
coma) of bone was rooted in limb amputation, with expected
survivorship hovering at an abysmal 10 to 20 percent despite
heroic surgical efforts to procure clear margins in an attempt
to “cure” the body of the malignant process. Before the advent
of complex imaging modalities, preoperative “mapping” of
tumor margins was difficult, leading physicians to prioritize
patient survivorship (amputation) over functional salvage.
With advances in adjuvant and neoadjuvant chemotherapy
in the 1980s, accompanied by the advent of MRI and CT
imaging, limb salvage procedures began to gain prominence
without sacrificing survivorship. As these multidisciplinary
approaches evolved, five-year survival curves began to show
a significant rise, with current long-term survival rates in
nonmetastatic osteosarcoma approaching 80 percent. Today,
more than 80 percent of bone and soft-tissue sarcomas in the
extremities are managed with surgical limb salvage.
WHY MULTIDISCIPLINARY COLLABORATION IS CRITICAL
Osteosarcoma is the most common primary bone malignan-
cy. The age at diagnosis follows a bimodal distribution, with
most cases occurring between ages 12 and 25 or in the sev-
enth decade of life. While no gender predilection is noted in
earlier childhood, there is a shift toward male preponderance
Today, more than 80 percent of bone and
soft-tissue sarcomas in the extremities
are managed with surgical limb salvage.
Figure 2. Anteroposterior (left) and lateral (right) radiographs showing the case patient’s allograft-prosthetic composite placed after chemotherapy and resection with a negative margin.
OrthOpaedic insights18 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096
in late adolescence. The presence of metastases at diagnosis
or at primary recurrence worsens prognosis, with 10-year
survival rates of only 20 to 30 percent reported in patients
with known metastases. Osteosarcoma subtype also corre-
lates with prognosis, with less-aggressive subtypes such as
parosteal osteosarcoma reported to have long-term survival
rates generally greater than 90 percent.
Neoadjuvant (preoperative) and adjuvant (postoperative)
chemotherapy have become a mainstay in osteosarcoma
treatment. Neoadjuvant therapy serves to guide prognosis
based on histological tumor necrosis response. It also aids
the surgeon by preoperatively “maturing” (and, if possible,
shrinking) the tumor margins to gain more accessible bound-
aries that allow for preservation of muscles and neurovascular
tissues. Given the complexities of advances in adjuvant and
neoadjuvant therapy for sarcoma, multidisciplinary collabo-
ration becomes vital to most patients’ chances for optimal
outcome. It is this philosophy of multidisciplinary care that
invigorates Cleveland Clinic’s approach to musculoskeletal
sarcoma treatment.
A PROGRESSIVE MULTIDISCIPLINARY APPROACH
At our Musculoskeletal Tumor Center, we partner with an ex-
perienced team of Cleveland Clinic pathologists, radiation on-
cologists and medical oncologists to target subtypes of bone
and soft-tissue sarcomas with tailored advanced treatment
regimens. For patients with adolescent osteosarcoma, our
pediatric oncologists help oversee the medical treatments,
orchestrating a 10-week neoadjuvant course of cisplatin, doxo-
rubicin and high-dose methotrexate. At the completion of this
therapy, a resection specimen is studied for tumor response,
and the aforementioned course is continued for 30 weeks
total if there is greater than 90 percent tumor necrosis. If a
less-dramatic response is noted after the index 10 weeks (<90
percent necrosis), then additional agents (ifosfamide and eto-
poside) can be added for a total therapy duration of 40 weeks.
In addition, we are conducting randomized clinical trials at
Cleveland Clinic to help ascertain the role of interferon-alpha
following chemotherapy for reducing the risk of relapse.
After limb salvage surgery, patients are quickly integrated
into an aggressive postoperative physical therapy regimen to
aid with gait training, range-of-motion gains and strengthen-
ing goals. Long-term follow-up with the orthopaedic oncolo-
gist and medical oncologist ensures that the disease process
is monitored closely, establishing a lifelong partnership
between the patient and his or her team of physicians.
Optimal outcomes from bone and soft-tissue sarcomas are
possible only with a coordinated, multidisciplinary approach
that takes advantage of the most advanced medical and surgi-
cal therapies. At Cleveland Clinic, reconstructive options in
limb salvage surgery, such as allograft-prosthetic compos-
ites, intercalary allografts and metallic endoprostheses, are
supplemented with unique resources such as our active bone
bank. Additionally, our use of preoperative three-dimensional
imaging in consultation with our musculoskeletal radiolo-
gists helps to enhance preoperative planning of tumor resec-
tion margins.
Looking ahead, our hope is that trials such as our ongoing
study of post-chemotherapy interferon-alpha therapy will
allow us to continue making advances that both deepen
understanding of the osteosarcoma disease process and help
physician teams improve functionality and quality of life for
patients like the young man with the “second chance” profiled
here.
ABOUT THE AUTHORS
Dr. Mesko is a PGY-4 orthopaedic resident and Dr. David Joyce is a PGY-5 orthopaedic resident at Cleveland Clinic.
Dr. Michael Joyce specializes in trauma, oncology, total joint replacement and musculoskeletal tissue banking. He can be reached at 216.444.4282 or joycem@ccf.org.
Dr. Lietman, Director of the Musculoskeletal Tumor Center, specializes in orthopaedic oncology and adult reconstruction. He can be reached at 216.445.2742 or lietmas@ccf.org.
OrthOpaedic insights summer 2012 19Visit clevelandclinic.org/ortho
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• To arrange for a critical care transfer, call 216.448.7000 or 866.547.1467 (see clevelandclinic.org/criticalcaretransport).
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ABOUT CLEVELAND CLINIC
Cleveland Clinic is an integrated healthcare delivery system with local, national and international reach. At Cleveland Clinic, 2,800 physicians represent 120 medical specialties and subspecialties. We are a main campus, 18 family health centers, eight community hospitals, Cleveland Clinic Florida, the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Cleveland Clinic Canada, Sheikh Khalifa Medical City, and Cleveland Clinic Abu Dhabi.
In 2011, Cleveland Clinic was ranked one of America’s top 4 hospitals in U.S.News & World Report’s annual “America’s Best Hospitals” survey. The survey ranks Cleveland Clinic among the nation’s top 10 hospitals in 13 specialty areas, and among the top 2 in four of those areas.
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Orthopaedic Insights is published by Cleveland Clinic’s Department of Orthopaedic Surgery to inform musculoskeletal specialists about advances in diagnosis, medical and surgical management, and research.
Joseph P. Iannotti, MD, PhD, Chair, Orthopaedic & Rheumatologic Institute
Richard D. Parker, MD, Chair, Orthopaedic Surgery Ryan C. Goodwin, MD, Medical Editor Glenn Campbell, Managing Editor Irwin Krieger, Art Director
For a copy of our Orthopaedic Surgery Staff Directory, please visit clevelandclinic.org/ortho or contact Marketing Manager Beth Lukco at 216.448.1036 or lukcob@ccf.org.
At the Orthopaedic & Rheumatologic Institute, our physicians, scientists and
engineers pursue excellence and innovation in the care of patients with joint, bone,
muscle, connective tissue and immune disorders. The Orthopaedic & Rheumato-
logic Institute is one of 26 institutes at Cleveland Clinic, a not-for-profit academic
medical center ranked among the nation’s top hospitals (U.S.News & World
Report), where nearly 3,000 physicians in 120 specialties collaborate to give every
patient the best outcome and experience.
Orthopaedic Insights is written for physicians and should be relied upon for medi-
cal education purposes only. It does not provide a complete overview of the topics
covered and should not replace a physician’s independent judgment about the
appropriateness or risks of a procedure for a given patient.
© 2012 The Cleveland Clinic Foundation 12-ORT-148
2012 Medical Innovation Summit: Innovative to the Bone: Orthopaedic Technologies
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Orthopaedic Insights Summer 2012
A Physician Newsletter from the Department of Orthopaedic Surgery
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