G. Lajtai · S.J. Snyder · G. R. Applegate G. Aitzetm O ller · C. Gerber · (Eds.)

Shoulder Arthroscopy and MRI Techniques

Springer-V erlag Berlin Heidelberg GmbH

The Shoulder Robert Schoffmann Oii painting

G. Lajtai · S.J. Snyder G. R.Applegate · G. Aitzetmuller C. Gerber · (Eds.)

SHOULDER AR ROSCOPY

A D MRI TECH IQUES

With 834 Figures and 20 Tables

Springer

ISBN 978-3-642-62771-2 ISBN 978-3-642-55604-3 (eBook) DOI 10.1007/978-3-642-55604-3

Library of Congress Cataloging-in-Publication Data Shoulder arthroscopy and MRI techniques/Lajtai Georg . . . [ et al.]. p.; cm. Includes bibliographical references and index. ISBN 3540431128 (alk. paper) 1. Shoulder joint - Endoscopic surgery. 2. Shoulder joint- Magnetic resonance imaging.l. Laj­tai, G. (Georg) [DNLM: 1. Shoulder Joint- surgery. 2.Arthros­copy - methods. 3· Magnetic Resonance Imaging - methods. WE 810 S5586173 2002] RD557.5 .S5437 2002 617.5'72059-dc21

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Painting frontispiece: Robert Schi:iffmann, Carintia, Austria Email: atelier.schoeffmann@telering.at

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24/3111 - 5 4 3 2 1 SPIN 11019633 Printed on acid-free paper

This publication is a "must have" and now. The shoul­der topic is of great interest to the orthopaedic com­munity. The list of contributors is a proverbial inter­national collection of who's who in shoulder surgery. The information is new, reflecting presentations made at an international congress in Austria only 8 months before publication. This feat must be un­precedented in textbook publication. The content material takes the reader from the fundamentals to the most advanced and sophisticated of shoulder diagnoses and treatment modalities.

As you would expect in such a fine text; the mate­rial is comprehensive, well organized, properly se­quenced, well written, subjected to careful editing, supported by excellent illustrations, and with well­documented references. It succeeds where most pub­lications of this type fail; it provides up to date, state of the art dissertations.

Preface

1

The only thing the reader will miss is the experience of attending this great international congress ISC -www.shoulder.org; the hospitality of the hosts, Georg Lajtai, Franz Unger and Gernot Aitzetmiiller, as well as the ambience of the beautiful setting in the Austri­an mountains.

Congratulations to Georg Lajtai and his co-editors as well as Springer for making this information avail­able in such a t imely way. Only e-mail could have been faster.

Lanny L. Johnson

This book was supported by the

F;,e;;tOr •t..c. fv~.or.Jo~t;c.tl Forchstrasse 340 8oo8 Zurich Switzerland

www.resortho.com

Dedication

'

1 dedicate this book to my parents Elfriede and Ladis­laus, who gave me the time to develop myself, as well as to my familly - Mona, Julian and Nikolaus - for un­derstanding my lifestyle.

1 also dedicate this book to my teachers: L. L. Johnson, S. J. Snyder, and C. Gerber

Georg Laj tai

1 Shoulder Arthroscopy: Struggles and Successes L. L. Johnson

1.1 Struggles . . . . . . . . . . . . . . . . 1.2 The Second MajorArea of Problems. 1.3 Anatomical Landmarks . . 1.4 Anatomical Variations. . . 1.5 Glenohumerallnstability . 1.6 Degenerative Arthritis . . 1.7 Undersurface Rotator CuffTears . 1.8 The Subacromial Space . . . 1.9 The Acromioclavicular Joint 1.1 O Surgical Technique .... 1.11 Diagnostic Arthroscopy. 1.12 Operative Arthroscopy . 1.13 Rotator Cuff Disease. . .

1

3

3.1 1 3.2 2 2 3.3 3 7 9

11 3.4 13 14 14 15 15 17

1.14 Learning Arthroscopic Shoulder Surgery. 19 4 1.15 New Technology . . . . 20 1.16 The Internet . . . . . . . 21 1.17 1.18

1.19

2

2.1

2.2

2.3

Results and Outcomes . . Expanded Applications of Arthroscopic Techniques. Future ............ .

21

21 21

Positioning ofthe Patient . .... ...... 25 G. Lajtai · G. Aitzetmuller D. Meyer · C. Gerber

Lateral Decubitus Position 25 2.1.1 Procedure . . . . . 25 2.1.2 Tips . . . . . . . . . 27 2.1.3 Adva ntages of the

Lateral Decubitus Position. 29 Beach-Chair Position . . . . . . 30 2.2.1 Procedure . . . . . . . . . 30 Comparison of the Advantages and Disadvantages of the

Above-Mentioned Resting Positions . . . . 30

4.1 4.2

4.3

4.4

4.5

4.6

4.7

Contents

lnstrumentation in Shoulder Arthroscopy . 31 N. Espinosa · G. Lajtai · C. Gerber

lntroduction ......... . Equipment ... . ...... . 3.2.1 Operating lnstruments. lrrigation and Pump Systems. 3.3.1 The Reservoir for the Liquid . 3.3.2 Pump Systems . . 3.3.3 Cannula Systems . Optical Equipment. 3.4.1 Light Sau rce 3.4.2 Light Cables .. 3.4.3 Arthroscopes . 3.4.4 Cameras. . . .

31 31 31 38 38 39

. 40

. 42

. 42

. 44

. 45

. 45

Suture Anchors .... . ..... . .... . . 47 D. Meyer · G. Lajtai · C. Gerber

lntroduction . . . . . . . Types of Suture Anchors 4.2.1 Materials . . . . . Types of lnsertion- and Fixation-Mechanisms in Bone 4.3.1 Straight lnsertion . . . 4.3.2 Screw-Type Anchors . 4.3.3 Toggling Anchors . . 4.3.4 Expanding Anchors Fixation of Soft Tissue . . 4.4.1 Suture ...... . 4.4.2 Knotless Anchors . Performance and Failure of Suture Anchors . . . .

4.5.1 Pu llout from Bone 4.5.2 Structural Failure . 4.5.3 Suture Damage Through the Eyelet Hints for Anchor Selection and Deployment . . . . . . .

4.6.1 Anchor lnsertion Site.

4.6.2 Financial Aspects . Summary .......... .

. 47

. 47

. 47

. 49

. 49 50 52 52 53 53 53

54 54 54 54

55 55

58 58

X Contents ,

5 Arthroscopic Knot-Tying Techniques . . . . 59 7 F. Unger · G. Lajtai · D. Meyer · C. Gerber

5.1 lntroduction . . . . . . . . . . 59 5.2

5.3 5.4

5.5

5.6 5.7

Terminology, Suture Material and lnstruments . . . . 5.2.1 Suture Materials . . . . 5.2.2 Cannulas ... . ... . General Guidelines and Technical Hints. Knot Patterns. . . . . . . 5.4.1 Nonsliding Knots .. 5.4.2 Sliding Knots . ... 5.4.2.4 A Very Special Knot:

The Outback Knot (Heinz Hoenecke). . . . . . . . .

Causes and Suggestions for Avoiding Mistakes in Knot Tying . . . . . . . . . 5.5.1 The Knot ls Not Sufficiently Tight

From the Beginning ..... 5.5.2 The Knot Loosens Slowly . . 5.5.3 Solutions, if Knots Are Loose. Tips and Tricks . . . . . . . . . . . . Biomechanical Studies and Discussion .

7.1 59 7.2 59 60 60 61 61

o 63

o 67

71 7.3 7.4

71 7.5 71 71 71 7.6 71

5.8 Summary . . . . . . . . . . . . . . . . . . 72

6 Surgical Approaches ........ ...... 75 G. Lajtai · G. Aitzetmuller D. Meyer · C. Gerber

6.1 lntroduction .... . 75 6.2 Anatomy . . . . . . . . . . . . . . . . . . 77 6.3 Approaches to the Glenohumeral Joint. 77

8

8.1 8.2

6.3.1 Dorsal Approach . . . . . . . . . . 77 8.3 6.3.2 Anterior Approaches. . . . . . . . 80 6.3.3 Cranial Approach (Neviaser Portal) . 89 6.3.4 Changing of Portals . . . . . . . . 90 6.3.5 The Half Pipe . . . . . . . . . . . . 91 8.4

6.4 Approaches to the Subacromial Space . 94 8.5 6.4.1 Dorsal Subacromial Approach 94 6.4.2 Anterior Subacromial Approach 95 6.4.3 Lateral Subacromial Approach . . 96

6.5 Approach to the Acromioclavicular Joint . 96 6.5.1 Superior and Transcutaneous 8.6

Approach . . . . . . . . . . . . . . . 97 6.5.2 Inferior from the Subacromial Space . 97

6.6 lmpaired Visualization . . . . . . . . 98 6.6.1 Blood Pressure Control. . . . . 98 6.6.2 lntra-articular Filling Pressure . 98 6.6.3 Electrocoagulation . 98 6.6.4 Laser . . . . . . . . . . . . . . . 98

Arthroscopic Anatomy and Normal Variants . . o o o o o o o 101 F. Unger · G. Lajtai · C. Gerber

lntroduction. . . . . . . . . . . Anatomy of the Glenohumeral Joint. 7.2.1 Biceps Tendon .. 7.2.2 Rotator Interval . 7.2.3 Humeral Head .. 7.2.4 Glenoid ... . . 7.2.5 Glenoid Labrum. 7.2.6 Joint Capsule and

Glenohumeral Ligaments 7 .2.7 Rotator Cuff . . . . . 7.2.8 Subscapular Recess ... . 7.2.9 Normal Variants .. . .. . Anatomy of the Subacromial Space Acromioclavicular Joint . . Course of Examination. . . 7 .5.1 Glenohumeral Joint. 7.5.2 Subacromial Space . Summary . .. .. . . .. .

MR lmaging of the Shoulder: Basic lntroduction to MRI,

101 101 101 103 103 104 104

105 107 11 o 110 112 114 114 114 115 116

WhatTo look For and Potential Problems 117 G. R. Applegate

lntroduction . . Principles of Magnetic Resonance lmaging .. 8.2.1 Tl- and T2-Weighted lmages Quality ............. . 8.3.1 Equipment .... . ... . 8.3.2 MRI Shoulder Protocol .. 8.3.3 Radiologic lnterpretation lndications . . . . . . . . . . . . Normal Anatomy and Normal Variants 8.5.1 Rotator Cuff . . . . . 8.5.2 Glenoid Labrum. . . 8.5.3 Sublabral Foramen . 8.5.4 Buford Complex. MR Arthrography. 8.6.1 Theory . . . . . . 8.6.2 Technique ... . 8.6.3 Three-Dimensional MRI from an

lntra-articular Perspective ....

117

117 118 118 119 120 121 121 121 121 125 126 126 128 128 128

129

Contents XI

9

9.1 9.2

9.3 9.4

MRI in Shoulder lnstability and SLAP lesions . . . . . . . . . . . . . 131 G. R. Applegate · S. D. Simonich

lndications . . . . . . . . . . . . . . . . . 131 Glenohumeralligaments . . . . . . . . . 131 9.2.1 Superior Glenohumeralligament. 131 9.2.2 Middle Glenohumeral Ligament. 131 9.2.3 Inferior Glenoid Ligament . 131

labral Pathology . . . 131 Specific lnjuries . . . . 131 9.4.1 Bankart lesion 132 9.4.2 HAGllesion. 134 9.4.3 ALPSA Lesion . 136 9.4.4 GLAD Les ion. . 136

10.5 Posterior lnstability-Historical Perspective and Results . 1 0.5.1 Posterior lnstability­

Operative lndications ... 1 0.5.2 Operative Technique

for Posterior lnstability . . 1 0.5.3 Posterior lnstability­

Postoperative Management . 1 0.6 Microinstability-

Historical Perspective and Results . 1 0.6.1 lndications for Surgery . 1 0.6.2 Operative Technique

for Microinstability . . 1 0.7 Summary . . . . . . . . . . .

165

165

166

169

169 173

173 174

9.4.5 Osteochondral Lesion of the Glenoid . . . . .

11 Posterior and Posteroinferior lnstability . . 177

9.4.6 Multidirectionallnstability. 9.5 Recommendations . 9.6 SLAP Lesions . . . . .

9.6.1 Subtypes .... 9.7 labral Degeneration . 9.8 Paralabral Cysts. . . .

10 Arthroscopic Repairs of lnstability: Anterior, Posterior, MuJt,idirectional,

136 J. S. Abrams 138 138 1 1.1 lntroduction. . . . . . . . . 138 1 1.2 Surgical Technique ..... 138 11.2.1 Patient Positioning . 141 11.2.2 Technical Equipment . 141 11.2.3 TipsandTricks ... .

11.2.4 Procedure ...... . 11.2.5 Postoperative Care . .

11.3 Summary . ......... .

177 180 180 180 181 183 189 190

and Microinstability Repairs . . . . . . . . 145 C. K. Jones · F. H. Savoie III 12 Minor Shoulder lnstabilities . . . . . . . . . 193

A. Castagna · A. Grasso · G. Vinanti 10.1 lntroduction . . ... . 10.2 Pathology . . . . . . . 10.3 Anterior lnstability-

Historical Perspective and Results . 1 0.3.1 lndications for Arthroscopic

Anterior Reconstruction . 1 0.3.2 Bankart Reconstruction -

Surgical Technique .... 1 0.3.3 Postoperative Management

145 145 12.1 lntroduction ........ . .

1 2.2 Etiology . . . . . . . . . . . . 1 53 12.3 Traumatic Minor lnstability .

1 2.4 Atraumatic Minor lnstability 1 54 12.5 Anatomicai-Pathological Findings .

12.5.1 Supraspinatus Tendon Lesions. 154 12.5.2 Posterior-Superior Labrum

Lesions . .. . .. .. .. . of Bankart Repair . . . . . . . 160 12.5.3 Superior Labrum Lesions

(SLAP Lesions). . . . . . 12.5.4 Rotator Interval Lesions 12.5.5 Middle Glenohumeral

Ligament Lesions . ...

1 0.4 Multidirectionallnstability-Historical Perspective and Results . 160 10.4.1 MDI- Surgicallndications . 161 1 0.4.2 Technique ofThermal

Capsulorraphy and Rotator lntervaiCiosureforMDI ...... 161

1 0.4.3 Postoperative Management for Capsular Shrinkage and Rotator Interval Closure . . . . . . . 165

12.5.6 Anterior-Inferior Labrum Lesions 12.5.7 Inferior Glenohumeral

Ligament Lesions . . 12.5.8 Posterior-Inferior

Capsule Retraction . . . . . . . . 12.5.9 Axillary Pouch Capsular Stretch .

193 193 194 195 195 195

196

196 196

198

198

199

199 199

XII Contents

12.6 Diagnosis .. . 199 12.6.1 History . 199 15

12.7 Clinica! Exam . 200 12.7.1 Range-of-Movement Evaluation. 200 12.7.2 Clinica! Tests. 200 15.1

12.8 lmaging ............... 201 15.2 12.9 Surgical Technique . . . . . . . . . 201 15.3

12.9.1 Rotator Interval Treatment. 202 15.4 12.9.2 Middle Glenohumeral 15.5

Ligament Treatment 206 15.6 12.1 O Postoperative Treatment 211 15.7 12.11 Summary o o o •••• • • • 211 15.8

13 Pulleylesions ................. 213 16 S. Lichtenberg · P. Habermeyer

13.1 lntroduction. . . . . . . . . . . . . . . . . 213 1 3.1.1 Anatomy of the Pulley System . . . 213 13.1.2 Pathoanatomy and Pathogenesis

of Pulley Lesions . . . 217 13.1.3 Diagnostic Evaluation 219

13.2 Operative Technique . . . . . 219 - 13.2.1 Operative Treatment . 219

13.3 Postoperative Rehabilitation . 226 13.4 Summary . . . . . . . . . . . . 226

14 Arthroscopic Treatment of Superior L~brallesions . . . . . . . . . . 229 T. F. Murray Jr.

14.1 lntroduction ....... . , .. 14.2 Classification of SLAP lesions. 14.3 Diagnosis ... . .. . 14.4 Treatment . . . . . . . . .

14.4.1 Patient Set-up ... 14.4.2 Portal Placement . 14.4.3 Diagnostic Arthroscopy 14.4.4 Arthroscopic Superior

Labral Debridement

. 229

. 231 232 233 233 234 235

235 14.4.5 Superior Labral Repair 236

14.5 Pitfalls . . . . . . . . . . . . . 241 14.5.1 Poor Portal Placement 242 14.5.2 lnadequate Suture Anchor Fixation. 242 14.5.3 Difficult Suture Passage 242 14.5.4 Suture Entanglement. . 242 14.5.5 Sutu re Breakage . . . . 242

14.6 Rehabilitation . . . . . . . . . . . 242 14.6.1 Orthopedic Associates

of Portland SLAP Rehabilitation Protocol . . . . . . . . . . . . . . . . 243

16.1

16.2

16.3 16.4 16.5

17

17.1

Posterosuperior lmpingement . ...... 245 D.Jung

lntroduction. o •• o • • 245 lndications • o ••• o 245 Preoperative Planning. 245 Patient lnformation .. 245 Equipment • o o o •• o 246 Preoperative Preparation . 246 Surgical Technique . .. 246 Postoperative Therapy. . . . 251

MRI Evaluation of the Rotator Cuff, Acromioclavicular Joint and Bursa . . . . . 253 G. R. Applegate · S. D. Simonich

lmpingement . . . . . . . . . . 253 16.1.2 Bursal Changes . . . . . 253 16.1.3 Osseous lmpingement . 253 16.1.4 Secondary 1 mpingement . 255 Rotator CuffTears . . . . . . . 255 16.2.1 Fuii-ThicknessTears. . . 256 16.2.2 Partiai-Thickness Tears . 258 16.2.3 Subscapularis Tears . . . 258 16.2.4 MRI Accuracy . . . . . . 260 Rotator CuffTear Size and Atrophy. 260 Evaluation ofthe Postoperative Cuff. . 260 Other Rotator Cuff lssues . . . . 263 16.5.1 Acromioclavicular Joint. . 263 16.5.2 Biceps Pathology . . . . . 263 16.5.3 Rotator Cuff Arthropathy. 264 16.5.4 GreaterTuberosity Fracture 264 16.5.5 Balanced Tears . . . 264 16.5.6 Calcific Tendinitis . . . 266 16.5.7 Adhesive Capsulitis . . 267 16.5.8 Osteochondromatosis 267

lmpingement Syndromes . . . . . . . . . . 269 C. Gerber · G. Lajtai

Types of lmpingement Recognized To Be of Clinica! Significance . . . . . 270 17.1.1 Extra-articular lmpingement . 270 17.1.2 lntra-articular lmpingement . . 275

Contents XIII

18 Arthroscopic Subacromial Decompression . . . . . . . . . . . . . G. Aitzetmuller · G. Lajtai · C. Gerber

18.1 lntroduction ........ . 18.2 lndications for ASD. . . . . 18.3 Counterindications to ASD 18.4 Radiographic Examination 18.5 Surgical Technique . . . . .

1 8.5.1 Surgicallnstrumentarium 1 8.5.2 Positioning of the Patient 1 8.5.3 Orientat ion Support 1 8.5.4 Visibility . . . . . . . 1 8.5.5 Arthroscopy of the

Glenohumeral Joint. 18.5.6 Bursoscopy . . . .. 18.5.7 Lateral Instrument Portal. 18.5.8 Acromioplasty ..... 18.5.9 Clavicular Osteophyte

18.6 Postoperative Treatment 18.7 Complications. . . . . . . . .

. .. 283

283 284 285 285 287

. 287

. 287 288 288

289

21 Arthroscopic Resection of the Lateral Clavicle . G. Aitzetmuller · G. Lajtai · C. Gerber

21.1 lntroduction ... . . 21.2 lndications .... . 21.3 Counterindications . 21.4 Radiographic Examination 21.5 Operative Technique .

21 .5.1 Positioning ..... 21.5.2 Accesses . . . . . . . 21.5.3 Surgicallnstrumentarium 21 .5.4 Associated Pathologies .. 21.5.5 The Acromioclavicular Joint . 21.5.6 Soft-Tissue Debridement.

289 21.5.7 Bone Resection . . 290 21.6 Radiological Check .... 292 21.7 Postoperative Treatment 295 21.8 Complications ... .. . . 296 296

22 Arthroscopic Management

. .. 339

339 340 340 340 340 340 340 341 341 341 342 342 347 347 347

19 Arthroscopic Treatment of Frozen Shoulders . . . . . . . . . . . . . 349 L. Neumann

of Rotator Cuff Calcific Tendinitis .. . .. . 299 T. F. Murray Jr.

19.1 lntroduction. 19.2 Diagnosis . . 19.3 Treatment . .

1 9.3. 1 Nonoperative Treatment . 19.3.2 Operative Treatment .

19.4 Rehabilitation. 19.5 Summary . . . . . . . . . . .

20 Arthroscopic Treatment of Significant Bursai-Sided

22.1 lntroduction. 22.2 Definition . .

299 22.3 Primary Frozen Shoulder 299 22.3.1 Epidemiology . 300 22.3.2 Pathology . . . . . 300 22.3.3 Pathogenesis . . . 300 22.3.4 Associated Conditions . 304 22.3.5 Clinica! Presentation . 305 22.3.6 Clinica! Diagnosis . ..

22.3.7 Differential Diagnosis. 22.3.8 lnvestigations . . . . .

22.4 Acquired Frozen Shoulder ..

and Fuii-Thickness Rotator CuffTears ... 307 T.J. Tucker · S.J. Snyder

22.4.1 Proxima! Humerus Fractures. 22.4.2 Degenerative Joint Diseases . 22.4.3 Sepsis Sequelae ..

20.1 lntroduction .. ... 20.2 Set-up . . . . . . . . 20.3 Special Equipment . 20.4 Visualization . . . . 20.5 Technique ... .. .

20.5.1 Subacromial Decompression 20.5.2 Arthroscopic Rotator Cuff Repair

Technique for Fuii-Thickness Tears 20.5.3 Significant Bursa i-Sided Tears

and Bursal Flap Tears . 20.6 Postoperative Care . . . . . . . . . . .

307 308 308

22.4.4 Surgical Sequelae .... 22.5 Treatment . . . . . . . . . . . .

22.5.1 Primary and Secondary Frozen Shoulder . .. . .

31 O 22.5.2 The Acquired Frozen Shoulder. 31 1 22.6 Rehabilitation . 312 22.7 Complications.

319

335 337

22.8 Summary . . .

349 349 350 350 351 351 351 352 352 352 352 353 353 353 353 353 354

354 359 361 361 362

XIV Contents

23 Arthroscopic Reconstruction of Glenoid Fractures . . . . . . .. . . 365 G. Lajtai · G. Aitzetmu ller

23.1 lntroduction .. 365 23.2 Classification . 365 23.3 Requirements. 366 23.4 Positioning . . 369 23.5 Surgical Technique . 369 23.6 Condus ion • • • • o 377

Subject Index ...... . .............. 379

Jeffrey S. Abrams Princeton Orthopaedic and Rehabilitation Associates 325 Princeton Avenue Princeton, NJ 08540 USA

Gernot Aitzetmuller Center for Sport Surgery and Pain Management LandstraBe 66/3 4020 Linz Austria

Gregory R. Applegate Valley Presbyterian MRI Center 6855 Noble Avenue Van Nuys, CA 91405 USA

A.Castagna lstituto Clinico Humanitas Via A. Manzoni 20089 Rozzano (Milan) Italy

Norman Espinosa Orthopadische Universitatsklinik Balgrist Forchstrasse 340 8oo8 Ziirich Switzerland

Christian Gerber Orthopadische Universitatsklinik Balgrist Forchstrasse 340 8oo8 Ziirich Switzerland

A.Grasso Casa di Cura Villa Valeria Piazza Carnaro 18 00141 Rome Italy

\ ·: :· .J ~ • • : • 1- • • • • - • :. ' .. -~ 1 • l -

List of Contributors

Peter Habermeyer ATOS Klinik BismarckstraBe 9-15 69115 Heidelberg Germany

lanny l.Johnson 2950 Mount Hope Road Post Office Box 975 Okemos, MI 48864 USA

Christopher K. Jones Mississippi Sports Medicine and Orthopaedic Center 1325 Fortification Street Jackson,MI39202 USA

DirkJung MEOCLINIC FriedrichstraBe 71 Quartier 206 10117 Berlin Germany

Georg lajta · Altis - Center for Sport Surgery Moorweg3o 9330 Althofen Austria

Sven lichtenberg ATOS Klinik BismarckstraBe 9-15 69115 Heidelberg Germany

Dominik Meyer Orthopădische Universitatsklinik Balgrist Forchstrasse 340 8oo8 Ziirich Switzerland

''''''*''''''''''''''''''''''~ "~'I""CC""lr~." F. M"\1"'?)': J•. Sport Medicine Center Orthopedic Associates of Portland 33 Sewall Street Portland, ME 04104-1260 USA

(.a;\ ~:e.'"'•n .. n.r. Nottingham City Hospital Hucknall Road Nottingham, NG5 1PB UK

\l'.:i~ ( t.:i.J\.,I):e. u: Mississippi Sports Medicine and Orthopaedic Center 1325 Fortification Street Jackson,MI39202 USA

)!.t-:phrel'l &).SI!ll.i)OtOO

Tampa Bay Orthopaedic Specialists 4000 Park Street North St. Petersburg, FL 33709 USA

l' ................................................... ·."!rf'·':J< Nrh._. • ._.rh._. • .., ... -...w.-...w.-...-...-.-. . s~~~l 1 s .. ~""" .. 6815 Noble Avenue Van Nuys, CA 91405-3730 USA

'rc~:dTxk:x Tucson Orthopaedic Institute 2424 N. Wyatt Dr. Tucson, AZ 85712 USA

a::l"'aa"'l,•l•r·~r

PollheimerstraBe 15 46oo Wels Austria

!i. \..Î c: o::JI:i lstituto Clinica Humanitas Via A. Manzoni 20089 Rozzano (Milan) Italy