Orthopaedic Insights - Cleveland Clinic

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 | [email protected]

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.

OrthOpaedic insights summer 2012 3Visit clevelandclinic.org/ortho

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 [email protected].

Figure 1. Engineered tissue graft for a knee articular cartilage lesion.


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.


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 [email protected].

Figure 2. Lateral (left) and anteroposterior (right) radiographs of a patient with carpal bones fused using the Xpode plate implant.


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.


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 [email protected].

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.


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.


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 [email protected].

Dr. Sferra specializes in foot and ankle reconstructive surgery in the Department of Orthopaedic Surgery. He can be reached at 216.445.8507 or [email protected].

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.


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.


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


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 [email protected].


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 [email protected] or [email protected].


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


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 [email protected].

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


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).


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.


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 [email protected].

Dr. Lietman, Director of the Musculoskeletal Tumor Center, specializes in orthopaedic oncology and adult reconstruction. He can be reached at 216.445.2742 or [email protected].


Resources for PhysiciansREFERRING PHYSICIAN CENTER AND HOTLINE

Cleveland Clinic’s Referring Physician Center has established a 24/7 hotline — 855.REFER.123 (855.733.3712) — to streamline access to our array of medical services. Contact the Referring Physician Hotline for information on our clinical special-ties and services, to schedule and confirm patient appointments, for assistance in resolving service-related issues, and to connect with Cleveland Clinic specialists.

PHYSICIAN DIRECTORY

View all Cleveland Clinic staff online at clevelandclinic.org/staff.

TRACK YOUR PATIENT’S CARE ONLINE

DrConnect is a secure online service providing real-time informa-tion about the treatment your patients receive at Cleveland Clinic. Establish a DrConnect account at clevelandclinic.org/drconnect.

CRITICAL CARE TRANSPORT WORLDWIDE

Cleveland Clinic’s critical care transport teams and fleet of vehicles are available to serve patients across the globe.

• To arrange for a critical care transfer, call 216.448.7000 or 866.547.1467 (see clevelandclinic.org/criticalcaretransport).

• For STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndrome transfers, call 877.379.CODE (2633).

OUTCOMES DATA

View clinical Outcomes books from all Cleveland Clinic institutes at clevelandclinic.org/outcomes.

CLINICAL TRIALS

We offer thousands of clinical trials for qualifying patients. Visit clevelandclinic.org/clinicaltrials.

CME OPPORTUNITIES: LIVE AND ONLINE

The Cleveland Clinic Center for Continuing Education’s website offers convenient, complimentary learning opportunities. Visit ccfcme.org to learn more and use Cleveland Clinic’s myCME portal (available from the site) to manage your CME credits.

EXECUTIVE EDUCATION

Cleveland Clinic has two education programs for healthcare executive leaders — the Executive Visitors’ Program and the two-week Samson Global Leadership Academy immersion program. Visit clevelandclinic.org/executiveeducation.

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.

24/7 Referrals REFERRING PHYSICIAN HOTLINE 855.REFER.123 (855.733.3712)

HOSPITAL TRANSFERS 800.553.5056

ON THE WEB AT:

clevelandclinic.org/refer123

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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 [email protected].

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

October 29-31, 2012 InterContinental Hotel, Cleveland Ohio

The 2012 Medical Innovation Summit will gather 1,000+

senior healthcare executives, investors, entrepreneurs and

clinicians to assess the future of healthcare innovation, with

a focus on the orthopaedics market.

Orthopaedic Insights Summer 2012

A Physician Newsletter from the Department of Orthopaedic Surgery

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