(Winter) Meeting of The Hip

THE HIP SOCIETY

The Forty-Fourth Open (Winter) Meeting of The Hip Society

The Twenty-Second Combined Open Meeting of The Hip Society and the

American Association of Hip and Knee Surgeons

(AAHKS)

Final Scientific Program

Saturday, March 5, 2016 Orange County Convention Center, West Bldg., Valencia Room A

Orlando, Florida

© 2016 The Hip Society 2

A N N O U N C E M E N T S

AAOS Annual Meetings

March 14-18, 2017 San Diego, California

March 6-10, 2018 New Orleans, Louisiana

AAHKS 26th Annual Meeting

Save the Date - New Location!

November 10-13, 2016

Hilton Anatole, Dallas, Texas

AAHKS 26th Annual Meeting Call for Symposia

Submit proposals by May 2, 2016

covering all aspects of arthroplasty and health policy.

AAHKS 26th Annual Meeting Call for Abstracts

Submit abstracts by June 1, 2016 for consideration

as podium or poster presentations.

Submit symposia and abstracts online at www.AAHKS.org.

AAHKS 27th Annual Meeting

November 2-5, 2017Hilton Anatole, Dallas, Texas

Digital Archives Are Yours For 1 Year!

On-site participants of the 2016 Specialty Day Meeting of

The Hip Society and AAHKS will receive complimentary access to

video archives for one year beginning April 15, 2016.

This program is streaming LIVE via the Internet to participants around the world. Live-streaming and recording services are provided by:

http://www.aahks.org/


WELCOME TO THE TWENTY-SECOND COMBINED

OPEN MEETING OF THE HIP SOCIETY AND

THE AMERICAN ASSOCIATION OF HIP AND KNEE SURGEONS

(AAHKS)

AT THE 2016 AAOS SPECIALTY DAY

GENERAL INFORMATION

The Mission of The Hip Society:

The Mission of The Hip Society is to advance knowledge of hip disorders, promote evidence-based treat-

ment, and refine surgery of the hip in order to improve the lives of patients.

Meeting Objectives:

The objectives of the Open Meeting of The Hip Society and AAHKS are to provide up-to-date information on

the treatment of hip conditions, including non-arthroplasty options, and the latest surgical techniques as

well as the current thinking on bearing surfaces. Other objectives address the difficult primary THA and

complication management and include an update on revision THA.

CME Accreditation:

This activity has been planned and implemented in accordance with the accreditation requirements and

policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint provid-

ership of the American Academy of Orthopaedic Surgeons and the Hip Society. The American Academy

of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physi-

cians.

The American Academy of Orthopaedic Surgeons designates this live activity for a maximum of 7.75 AMA

PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their

participation in the activity.

IMPORTANT Please complete evaluation online at:

https://www.surveymonkey.com/r/16wm or use the QR code here:

Please silence all electronic devices while inside the session room.

Please refrain from unauthorized photography and video recording of presenta-

tions.

Your registration for, and attendance of, this session gives The Hip Society permis-

sion to capture images of session attendees and to use these images for internal

and marketing purposes.

https://www.surveymonkey.com/r/16wm


ACKNOWLEDGMENTS

PAST PRESIDENTS OF THE HIP SOCIETY

1968-1969 William H. Harris, MD., D Sc. 2010-2011 Chitranjan S. Ranawat, MD

1969-1970 Frank E. Stinchfield, MD (Deceased) 2011-2012 Adolph V. Lombardi, Jr., MD, FACS

1970-1971 Walter P. Blount, MD (Deceased) 2012-2013 David G. Lewallen, MD

1971-1972 Albert B. Ferguson, Jr., MD (Deceased) 2013-2014 Vincent D. Pellegrini, Jr., MD

1972-1973 J. Vernon Luck, Sr., MD (Deceased) 2014-2015 Paul F. Lachiewicz, MD

1973-1974 Mark B. Coventry, MD (Deceased)

1974-1975 Emmett M. Lunceford, Jr., MD (Deceased)

1976-1978 Augusto Sarmiento, MD

1978-1979 Marshall R. Urist, MD (Deceased) PAST PRESIDENTS OF AAHKS

1979-1980 Harlan C. Amstutz, MD 1991 J. Phillip Nelson, MD (Deceased)

1980-1981 Philip D. Wilson, Jr., MD 1992-1993 Chitranjan S. Ranawat, MD

1981-1982 Richard C. Johnston, MD, MS 1994 Richard C. Johnston, MD, MS

1982-1983 Clement B. Sledge, MD 1995 Lawrence D. Dorr, MD

1983-1984 Floyd H. Jergesen, MD (Deceased) 1996 Hugh S. Tullos, MD (Deceased)

1984-1985 C. McCollister Evarts, MD 1997 Merrill A. Ritter, MD

1985-1986 Jorge O. Galante, MD, DMSc. 1998 Richard H. Rothman, MD, PhD

1986-1987 Lee H. Riley, Jr., MD (Deceased) 1999 James A. Rand, MD

1987-1988 William R. Murray, MD (Deceased) 2000 Richard B. Welch, MD

1988-1989 Joseph E. Miller, MD (Deceased) 2001 John J. Callaghan, MD

1989-1990 Donald E. McCollum, MD (Deceased) 2002 Douglas A. Dennis, MD

1990-1991 J. Phillip Nelson, MD (Deceased) 2003 Clifford W. Colwell, Jr., MD

1991-1992 Nas S. Eftekhar, MD 2004 Richard F. Santore, MD

1992-1993 William N. Capello, MD 2005 Joseph C. McCarthy, MD

1993-1994 Robert H. Fitzgerald, Jr., MD 2006 William J. Hozack, MD

1994-1995 Mark G. Lazansky, MD 2007 Daniel J. Berry, MD

1995-1996 Richard B. Welch, MD 2008 David G. Lewallen, MD

1996-1997 Dennis K. Collis, MD 2009 William J. Robb, III, MD

1997-1998 Eduardo A. Salvati, MD 2010 Mary I. O’Connor, MD

1998-1999 Robert B. Bourne, MD, FRCSC 2011 Carlos J. Lavernia, MD

1999-2000 Richard D. Coutts, MD 2012 Thomas P. Vail, MD

2000-2001 Leo A. Whiteside, MD 2013 Thomas K. Fehring, MD

2001-2002 Benjamin E. Bierbaum, MD 2014 Brian S. Parsley, MD

2002-2003 Miguel E. Cabanela, MD

2003-2004 Charles A. Engh, Sr., MD

2004-2005 Richard E. White, MD

2005-2006 James A. D'Antonio, MD

2006-2007 John J. Callaghan, MD

2007-2008 Lawrence D. Dorr, MD

2008-2009 Wayne G. Paprosky, MD

2009-2010 William J. Maloney, III, MD


ACKNOWLEDGMENTS

THE HIP SOCIETY BOARD OF DIRECTORS

2015-2016

AAKS BOARD OF DIRECTORS

2015-2016

Daniel J. Berry, MD - President Jay R. Lieberman, MD - President

Harry E. Rubash, MD - 1st Vice President William A. Jiranek, MD - 1st Vice President

Kevin L. Garvin, MD - 2nd Vice President David A. Halsey, MD - 2nd Vice President

Craig J. Della Valle, MD - Secretary Mark I. Froimson, MD - 3rd Vice President

Joshua J. Jacobs, MD - Treasurer Brian S. Parsley, MD –Immediate Past President

Paul F. Lachiewicz, MD - Immediate Past President Michael P. Bolognesi, MD - Secretary

Mark W. Pagnano, MD – Chair, Education Cmte. C. Lowry Barnes, MD - Treasurer

Michael Tanzer, MD - Chair, Membership Committee Joseph T. Moskal, MD – Member-at-Large

Richard D. Iorio, MD – Chair, Research Committee Ryan M. Nunley, MD – Member-at-Large

Christopher L. Peters, MD - Member-At-Large Audrey K. Tsao, MD – Member-at-Large

Adolph V. Lombardi, Jr., MD – Chair, Fellowship &

Mentorship Committee (Ex-Officio)

AAHKS EDUCATION AND

THE HIP SOCETY EDUCATION COMMITTEE COMMUNICATIONS COUNCIL

2015-2016 Craig J. Della Valle, MD -- Chair

Mark W. Pagnano, MD – Chair Bryan D. Springer, MD – Vice Chair

Daniel J. Berry, MD John C. Clohisy, MD

Paul E. Beaulé, MD Gregory G. Polkowski, II, MD

Kevin J. Bozic, MD, MBA Jeffrey A. Geller, MD

C. Anderson Engh, Jr., MD Keith R. Berend, MD

Steven J. MacDonald, MD, FRCSC David F. Dalury, MD

A. Seth Greenwald, D.Phil. (Oxon) William P. Barrett, MD

Scott M. Sporer, MD William A. Jiranek, MD

AAHKS EDUCATION COMMITTEE

2015-2016

William P. Barrett, MD - Chair

Michael R. O’Rourke, MD

Douglas E. Padgett, MD

Gregory J. Golladay, MD

Jay J. Patel, MD

David A. Halsey, MD


CLIVE P. DUNCAN, MD, FRCSC RECIPIENT OF THE 2016 HIP SOCIETY

LIFETIME ACHIEVEMNT AWARD

The Lifetime Achievement Award will be presented at 2:53 pm – 2:57 pm

To say that Dr. Duncan has a deep passion for hip surgery is an

understatement. Ever since becoming an orthopaedic sur-

geon, he has been working on improving hip health. From the

time he moved to British Columbia, Canada from his native Ire-

land, via the United Kingdom, Dr. Duncan has been one of the

leading hip surgeons in Canada. A gifted surgeon, he has ded-

icated his career to improving techniques of revision total hip

arthroplasty. When the rest of the world regarded that an in-

fected hip replacement bed needs to be free of any foreign ma-

terial, Dr. Duncan developed the concept of a mobile spacer,

which revolutionized the treatment of the infected hip replace-

ment. He also established one of Canada’s and North Amer-

ica’s premier arthroplasty units, and has trained young sur-

geons from all over the world. The impact of his wisdom and

knowledge has served to improve lives and mobility of millions

of patients worldwide.

Dr. Duncan’s thoughtfulness and systematic attention to detail

has led to the development for evidence-based algorithms for the

treatment of periprosthetic femoral fractures, and the development of the Vancouver Classification, which

he humbly named not after himself but after his hometown instead.

Dr. Duncan continues to be an active surgeon, educator and academician in Vancouver, where he has spent

his entire professional career. He has been a true leader and a mentor, having made it his mission to inspire

his younger colleagues, associates and students to be their best. The Hip and Knee arthroplasty unit that he

established continues to be one of the most sought-after units in Canada. An inspiration on and off the

podium worldwide, Dr. Duncan continues to be a sought-after speaker at prestigious meetings and confer-

ences around the world.

Dr. Duncan’s vision and dedication has led to the establishment of the Centre for Hip Health and Mobility,

the only center of its kind dedicated to studying and finding solutions to problems around the hip.

Dr. Duncan’s lasting legacy to his students, disciples, and colleagues will always be paying the utmost atten-

tion to detail, generating and following evidence in surgery, and striving for personal and professional excel-

lence.

The Hip Society is honored to present the 2016 Lifetime Achievement Award to Clive P. Duncan, MD.

Congratulations, Dr. Duncan!


PRESIDENTIAL GUEST SPEAKER

The Presidential Guest Speaker presentation is scheduled at 11:34 am – 11:50 am

Michael M. Morlock

University Professor Dr.habil. Ph.D.

Director, Institute for Biomechanics

Speaker of the Board of Directors, Medical Technol-

ogy Research Center Hamburg

Founding Member FSP “Regeneration, Implants and

Medical Technology”

TUHH Hamburg University of Technology

Michael Morlock received his University degrees in

Mathematics and Sport Sciences from the University of

Stuttgart (Germany) in 1985.

In 1990, he completed his PhD-degree in Medical Sci-

ence at the University of Calgary (Alberta, Canada). Af-

ter 3 years as the head of the Biomechanics Laboratory

of novel GmbH (pressure distribution measurement

systems) and a post-doc position at the LMU-Uniersity

(Trauma Surgery, Prof. Lob) in Munich (Germany), he accepted a position as a Senior Research

Associate at the Biomechanics Institute of the TUHH (Director: Prof. Dr.sc.techn. E. Schneider).

In 2000, he was awarded a professorship at the Technical University of Vienna (Austria), in 2003 a

full professorship at the RWTH Aachen (Germany), and in 2004 the position he still holds as a full

Professor of “Biomechanics“ and Director of the Institute of Biomechanics at the TUHH Hamburg

University of Technology.

In 2007 he initiated the research area “Regeneration, Implants and Medical Technology” at TUHH.

Since 2012 he is a member of the Scientific Committee on Health and Environmental Risks of the

European Commission (Working group on metal-on-metal implants). In 2013 he co-founded the

Hamburg Research Center for Medical Technology (FMTHH) in conjunction with the University Hos-

pital.

He has received several international awards and served official functions in national and interna-

tional research organizations. His major scientific interests are in pre-clinical testing, failure analy-

sis, surgeon education, materials in orthopaedics, as well as the interaction between implants and

the human body.


THE HIP SOCIETY 2016

ROTHMAN-RANAWAT TRAVELING FELLOWSHIP

The Hip Society Welcomes

The 2016 Hip Society Rothman-Ranawat Traveling Fellows

Derek F. Amanatullah, MD, PhD

Stanford University

Redwood City, CA, USA

Atul F. Kamath, MD

University of Pennsylvania

Philadelphia, PA, USA

Matthew J. Wilson,

MBBS (Lond) FRCS (Eng) FRCS (Tr&Orth)

Princess Elizabeth Orthopaedic Centre

Royal Devon and Exeter Hospital

Exeter, Devon, UK

Bharath Loganathan,

MBBS, D.Ortho, M.S.(Ortho), FRCS(Edin)

Shalby Hospital

Ahmedabad, Gujarat, India

The deadline to submit applications for the 2017 Hip Society Rothman-Ranawat

Traveling Fellowship is August 15, 2016. For more information, visit www.hipsoc.org.

http://www.hipsoc.org/


THE HIP SOCIETY 2016 AWARDS

The Scientific Awards will be presented from 2:58 pm – 3:15 pm

The 2016 John Charnley Award

The Missing Link: Re-Defining the Natural Progression of

Osteoarthritis in Patients with Hip Dysplasia and Impingement

Presenter: Rafael J. Sierra, MD

Co-Authors: Cody C. Wyles, BS; Mark J. Heidenreich, MD; Jack Jeng, MD; Dirk R. Larson, MD;

Robert T. Trousdale, MD

The 2016 Otto Aufranc Award

A Multi-Center, Prospective, Randomized Study of

Outpatient versus Inpatient Total Hip Arthroplasty

Presenter: Nitin Goyal, MD

Co-Authors: Antonia F. Chen, MD, MBA; Sarah E. Padgett, PA-C; Timothy L. Tan, MD;

Michael M. Kheir, BS; Robert H. Hopper, Jr., PhD; William G. Hamilton, MD;

William J. Hozack, MD

The 2016 Frank Stinchfield Award

Total Hip Arthroplasty for Femoral Neck Fracture is Not a Typical DRG 470:

A Propensity-Matched Cohort Study

Presenter: Alexander S. McLawhorn, MD, MBA

Co-Authors: William A. Schairer, MD; Joseph M. Lane, MD; David A. Halsey, MD;

Richard Iorio, MD; Douglas E. Padgett, MD

The 2016 Young Investigator Presentation

The Young Investigator Presentation will be from 4:16 pm – 4:23 pm

Removal of an Infected Hip Arthroplasty is High-Risk Surgery:

Putting Morbidity into Context with Other Major Non-Orthopaedic Operatons

Presenter: James A. Browne, MD

Co-Authors: Cancienne JM, Novicoff WM, Werner BC

The Hip Society Scientific Awards Manuscripts in consideration for the 2017 Hip Society Scientific Awards may be submitted beginning

in September 2016 through Clinical Orthopaedic and Related Research (CORR).

The deadline to submit is December 1, 2016.


IN THIS BOOK

Page

Detailed Schedule 16

Abstracts 26

Disclosures 103

The Knee Society’s Program On reverse side


PROGRAM


H I P Valencia Room A

8:00 am – 8:04 am WELCOME

Daniel J. Berry, MD (Rochester, MN)

President of The Hip Society

8:05 am – 8:49 am Session I: Direct Anterior THA: Controversies, Data,

Techniques in 2016

Moderator: Steven J. MacDonald, MD, FRCSC (London, ON, Canada)

8:05 am – 8:10 am 26 Perspective of a Convert: Why I Changed to Direct

Anterior Approach and the Associated Learning Curve

Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH)

8:11 am – 8:16 am 28 The Direct Anterior Approach in a Risk Factor for Early Failure

in Cementless Total Hip Arthroplasty: A Multi-Center Study

R. Michael Meneghini, MD (Fishers, IN)

8:17 am – 8:22 am 29 Surgical Tips and Pearls to Maximize Success of Direct Anterior THA

Done with an Orthopedic Table

Joel M. Matta, MD (Santa Monica, CA)

8:23 am – 8:28 am 31 Surgical Tips and Pearls to Maximize Success of Direct Anterior THA

Done without a Fracture Table

William J. Hozack, MD (Philadelphia, PA)

8:29 am – 8:34 am 33 The Accumulated Evidence Supports Posterior Approach THA

as the Gold Standard in 2016

Bryan D. Springer, MD (Charlotte, NC)

8:34 am – 8:49 am DISCUSSION

8:50 am – 9:40 am Session II: Contemporary Insights into Unsolved Problems in THA

Moderator: Clive P. Duncan, MD, FRCSC (Vancouver, BC, Canada)

8:50 am – 8:55 am 35 Abductor Deficiency and THA: Diagnosis and Management

Richard W. McCalden, MD, FRCSC (London, ON, Canada)

8:56 am – 9:01 am 36 Psoas Impingement & Tendinopathies after THA: Diagnosis and Management

William A. Jiranek, MD (Richmond, VA)

9:02 am – 9:07 am 38 THA for the Patient with a BMI over 40: Risk and Reward

David G. Lewallen, MD (Rochester, MN)

9:08 am – 9:13 am 40 Recurrent Dislocation in the Patient with a Constrained Liner or

Dual-Mobility Implant: What Now?

John J. Callaghan, MD (Iowa City, IA)

9:14 am – 9:19 am 41 Pelvic Discontinuity: Newest Knowledge and Technical Tips in Management

Wayne G. Paprosky, MD, FACS (Winfield, IL)

Page


Valencia Room B K N E E

8:00 am – 8:02 am WELCOME

Thomas P. Vail, MD (San Francisco, CA)

President, The Knee Society

8:02 am – 8:04 am Kevin J. Bozic, MD, MBA (Austin, TX)

Chair, Education Committee, The Knee Society

8:05 am – 8:52 am Session I: Minimizing TKA Complications

Moderator: John J. Callaghan, MD (Iowa City, IA)

8:05 am – 8:12 am 22 Periprosthetic Joint Infection: Controversies and Areas in Need of Research

Javad Parvizi, MD (Philadelphia, PA)

8:13 am – 8:20 am 28 Prevention and Management of Instability in TKA

Thomas K. Fehring (Charlotte, NC)

8:21 am – 8:28 am 30 Optimizing Risk Factors

Richard Iorio (New Rochelle, NY)

8:29 am – 8:36 am 33 Venous Thromboembolism

Jay R. Lieberman, MD (Los Angeles, CA)


8:53 am – 10:04 am Session II: TKA Alignment: Mechanical, Anatomic, or Kinematic

Moderator: Thomas P. Schmalzried, MD (Los Angeles, CA)

8:53 am – 9:00 am 34 Mechanical Alignment

Douglas A. Dennis (Denver, CO)

9:01 am – 9:08 am 35 Anatomic Alignment

Michael A. Mont, MD (Baltimore, MD)

9:09 am – 9:16 am

36 Kinematic Alignment

Stephen M. Howell, MD (Sacramento, CA)

9:17 am – 9:24 am 38 Custom Cutting Guides

Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH)

9:25 am – 9:32 am 39 Robotics for UKA and Potential Role in TKA

Jess H. Lonner, MD (Bryn Mawr, PA)

9:33 am – 9:40 am 41 Computer Navigation: Past, Present, Future

S. David Stulberg, MD (Chicago, IL)

Page


H I P

9:20 am – 9:25 am 42 Failed 2-Stage THR

Arlen D. Hanssen, MD (Rochester, MN)

9:25 am – 9:40 am

Discussion

9:40 am – 9:55 am BREAK

9:56 am – 10:34 am Session III: Strategies to Speed Recovery and

Decrease Complications after THA

Moderator: Mark W. Pagnano, MD (Rochester, MN)

9:56 am – 10:01 am 43 Perioperative Management: Get Ahead and Stay Ahead

Mark W. Pagnano, MD (Rochester, MN)

10:02 am – 10:07 am 44 Role of Staphylococcal Screening and Treatment Prior to THA

Scott M. Sporer, MD (Winfield, IL)

10:08 am – 10:13 am 46 Risk Stratified VTE Prophylaxis after THA

Jay R. Lieberman, MD (Los Angeles, CA)

10:14 am – 10:19 am 47 Outpatient Joint Replacement

Michael E. Berend, MD (Indianapolis, IN)


10:35 am – 11:10 am Session IV: Complex Primary THA: Case-Based Discussion on

the State of the Art

Moderator: Daniel J. Berry, MD (Rochester, MN)

10:35 am – 10:55 am Panel: Richard Iorio, MD (New Rochelle, NY); Michael E. Berend, MD (Indianapolis,

IN); Greg G. Polkowski, II, MD (Nashville, TN); Prof. Fares S. Haddad, FRCS (Lon-

don, United Kingdom); Miguel E. Cabanela, MD (Rochester, MN)

10:55 pm – 11:10 am DISCUSSION

11:11 am – 11:33 am Session V: Taper Corrosion in Orthopaedic Devices – Newest Knowledge

Moderator: Joshua J. Jacobs, MD (Chicago, IL)

11:11 am – 11:16 am 48 Dual Modular Necks in THA: How Big is the Problem? What Caused the Problem?

What Have we Learned?

Michael A. Mont, MD (Baltimore, MD)

11:17 am – 11:22 am 49 When to Revise and What to Revise if Trunionosis is Suspected?

Joshua J. Jacobs, MD (Chicago, IL)

11:23 pm – 11:33 am DISCUSSION

Page

Valencia Room A



9:41 am – 9:48 am 43 Mechanical Guides

Robert E. Booth, MD (Philadelphia, PA)


10:05 am – 10:15 am BREAK

10:16 am – 11:03 am Session III: The Painful TKA: Prevention, Evaluation,

and Management

Moderator: Aaron G. Rosenberg, MD, FACS (Chicago, IL)

10:16 am – 10:23 am 45 Managing Expectations

Michael J. Dunbar, MD, FRCSC, PhD (Halifax, NS, Canada)

10:24 am – 10:31 am 47 Optimizing Emotional Health

David C. Ayers, MD (Worcester, MA)

10:32 am – 10:39 am 48 Pre- and Post-Operative Opioid Management

Thomas P. Vail, MD (San Francisco, CA)

10:40 am – 10:47 am 49 The Role of “Pain Management”

Craig J. Della Valle, MD (Chicago, IL)


11:04 am – 12:00 pm Session IV: Transitioning to Value-Based Healthcare

Moderator: Kevin J. Bozic, MD, MBA (Austin, TX)

11:04 am – 11:11 am 50 Bundled Payments and Other Value-Based Payment Strategies

Kevin J. Bozic, MD, MBA (Austin, TX)

11:12 am – 11:19 am 51 The Role of the EMR in Improving Value

Wael K. Barsoum, MD (Cleveland, OH)

11:20 am – 11:27 am 53 The Role of Registries in Improving Value

Colin Howie, ChB, FRCS, FRCS (Ortho) (Edinburgh, United Kingdom)

11:28 am – 11:35 am 54 Integrated Delivery Systems are Key to Value Creation

Mark I. Froimson, MD (Hunting Valley, OH)

11:36 am – 11:43 am 56 Private Practice Models are More Nimble

Daniel B. Murrey, MD, MPP (Charlotte, NC)

11:44 am – 12:00 pm DISCUSSION

12:00 pm – 1:00 pm LUNCH

Page


H I P

11:34 am – 11:50 am Program Highlight: Presidential Guest Speaker

Introduction: Daniel J. Berry, MD (Rochester, MN)

50 Taper Corrosion in THA: What Causes it and Why are We Seeing it Now?

Michael M. Morlock, PhD (Hamburg, Germany)

11:54 am – 12:50 pm LUNCH

12:50 pm – 1:28 pm Session VI: Top 3 New and Impactful Findings from Joint Registries

Around the Globe

Moderator: Kevin J. Bozic, MD, MBA (Austin, TX)

12:50 pm – 12:55 pm 52 Top Findings from Australian National Joint Registry

Richard N. de Steiger, MD (Richmond, Australia)

12:56 pm – 1:01 pm 54 Top Findings from British National Joint Registry

Martyn Porter, MD (Wigan, United Kingdom)

1:02 pm – 1:07 pm 55 Top Findings from Scandinavian Joint Registries

Henrik Malchau, MD, PhD (Boston, MA)

1:08 pm – 1:13 pm 56 American Joint Replacement Registry: High Level Update

Kevin J. Bozic, MD, MBA (Austin, TX)

1:13 pm – 1:28 pm DISCUSSION

1:29 pm – 2:19 pm Session VII: Is Cross-Linked Poly Now the Bearing of Choice?

Moderator: William J. Maloney, III, MD (Redwood City, CA)

1:29 pm – 1:34 pm 58 Results of Cross-Linked Poly at 10 Years or More

Harry E. Rubash, MD (Boston, MA)

1:35 pm – 1:40 pm 59 Highly Cross-Linked Polyethylene Provides Decreased Osteolysis

and Reoperation

Paul F. Lachiewicz, MD (Chapel Hill, NC)

1:41 pm – 1:46 pm 60 Ceramic vs. Metal Femoral Heads: What is the Role for Each in 2016?

Thomas P. Schmalzried, MD (Los Angeles, CA)

1:47 pm – 1:52 pm 62 Ceramic-on-Ceramic Bearings in 2016: A Perspective from Outside

the United States

Carsten Perka, MD (Berlin, Germany)

1:53 pm – 1:58 pm 64 Dual Mobility Implants: What is Their Role in Primary THA?

Jean-Noël Argenson, MD (Marseille, France)

1:59 pm – 2:04 pm 66 Failed Metal-on-Metal: Current Diagnostic Algorithms and Guidelines

Thomas K. Fehring, MD (Charlotte, NC)

Page

Valencia Room A



1:01 PM – 1:33 PM Session Va: The Knee Society’s Scientific Awards

Moderator: Lawrence D. Dorr, MD (Los Angeles, CA)

1:01 pm – 1:11 pm

57 The John N. Insall, MD Award

“Do Injections Increase the Risk of Infection Following TKA?”:

Presenter: Nicholas Bedard, MD (Iowa City, IA)

1:12 pm – 1:22 pm

58 The Chitranjan S. Ranawat, MD Award

“No Difference in Two-Year Functional Outcomes Using

Kinematic Versus Mechanical Alignment in TKA”

Presenter: Simon W. Young, FRACS (Auckland, New Zealand)

1:23 pm – 1:33 pm 59 The Mark Coventry, MD Award

“Oral Antibiotics Reduce Reinfection Following 2-Stage Exchange:

A Multi-Center, Randomized Controlled Trial”

Presenter: Craig J. Della Valle, MD (Chicago, IL)

1:34 pm – 1:45 pm Session Vb: Highlights

1:34 pm – 1:39 pm AAHKS 2015 Annual Meeting

Gregory G. Polkowski, II, MD (Nashville, TN)

1:40 pm – 1:45 pm The John N. Insall, MD Traveling Fellowship

W. Norman Scott, MD (New York, NY)

1:46 pm – 2:31 pm Session VI: Peri-Operative Management—How Do I Do It?

Moderator: Daniel J. Berry, MD (Rochester, MN)

Prof. Fares S. Haddad, BSc MD (Res) FRCS (Orth) (London, United Kingdom); Steven

J. MacDonald, MD, FRCSC (London, ON, Canada); R. Michael Meneghini, MD (Fish-

ers, IN); Michael P. Bolognesi, MD, MS (Durham, NC); C. Lowry Barnes, MD (Little

Rock, AK); Mark W. Pagnano, MD (Rochester, MN)

2:31 pm – 2:50 pm BREAK

2:51 pm – 4:05 pm Session VII: Case Presentations

Moderator: Thomas P. Vail, MD (San Francisco, CA)

2:51 pm – 2:58 pm 60 When is TKA Appropriate?

Ryan M. Nunley, MD (St. Louis, MO)

2:59 pm – 3:06 pm 61 When Enough is Enough?

Michael Ries, MD (Carson City, NV)

3:07 pm – 3:14 pm

62 Peri-Prosthetic Fractures – What to Do?

Bassam A. Masri, MD, FRCSC (Vancouver, BC, Canada)

Page


H I P


2:20 pm – 2:52 pm Session VIII: How Do We Ideally Position the Acetabular Component?

Moderator: Robert T. Trousdale, MD (Rochester, MN)

2:20 pm – 2:25 pm 69 Newest Knowledge on Ideal Component Position

Lawrence D. Dorr, MD (Pasadena, CA)

2:26 pm – 2:31 pm 71 The Impact of Lumbar Spine Pathology on Functional Hip Position

Douglas E. Padgett, MD (New York, NY)

2:32 pm – 2:37 pm 72 Socket Position and the Risk of Dislocation after Revision THA

Robert L. Barrack, MD (St. Louis, MO)


2:53 pm – 2:57 pm Program Highlight:

The Hip Society’s 2016 Lifetime Achievement Award

Introduction: Daniel J. Berry, MD (Rochester, MN)

Recipient: Clive P. Duncan, MD, FRCSC (Vancouver, BC, Canada)

2:58 pm – 3:15 pm Session IX: The Hip Society Scientific Awards

Moderator: Thomas P. Vail, MD (San Francisco, CA)

A. Seth Greenwald, D.Phil (Oxon) (Cleveland, OH)

2:58 pm – 3:03pm 74 The John Charnley Award

The Missing Link: Re-Defining the Natural Progression of Osteoarthritis in Patients

with Hip Dysplasia and Impingement

Rafael J. Sierra, MD (Rochester, MN)

3:04 pm – 3:09 pm 76 The Otto AuFranc Award

A Multi-Center, Prospective, Randomized Study of Outpatient

Versus Inpatient Total Hip Arthroplasty

Nitin Goyal, MD (Alexandria, VA)

3:10 pm – 3:15 pm 78 The Frank Stinchfield Award

Total Hip Arthroplasty For Femoral Neck Fracture Is Not A Typical DRG 470:


Alexander S. McLawhorn, MD, MBA (New York, NY)

3:16 pm – 3:26 pm BREAK

3:27 pm – 4:15 pm Session X: Revision THA Video Technical Tips to Improve Results

Moderator: C. Anderson Engh, MD (Alexandria, VA)

3:27 pm – 3:32 pm 80 Revision THA for Periprosthetic Fracture

George J. Haidukewych, MD (Orlando, FL)

Page

Valencia Room A



3:15 pm – 3:22 pm 65 Dealing with Extensor Mechanism Deficiency

Matthew S. Austin, MD (Philadelphia, PA)

3:23 pm – 3:30 pm 67 Treatment of the Unstable TKA

Robert T. Trousdale, MD (Rochester, MN)

3:31 pm – 3:38 pm 68 Is This Knee Infected?

Kevin L. Garvin, MD (Omaha, NE)

3:39 pm – 3:46 pm 71 Patient is Unhappy, but I Don’t Know Why

Robert L. Barrack, MD (St. Louis, MO)


4:06 pm – 4:35 pm Session VIII: Young Investigator Symposium

Moderator: Mary I. O’Connor, MD (New Haven, CT)

4:07 pm – 4:12 pm 72 Paper I

“Closed Incision Negative Pressure Therapy Versus Antimicrobial Dressings Follow-

ing Revision Hip and Knee Surgery: A Comparative Study”

H. John Cooper, MD (New York, NY)

4:13 pm – 4:18 pm 73 Paper 2

“Discharge Destination after Total Knee Arthroplasty: An Analysis of Post-Discharge

Outcomes and Risk Factors”

Calin S. Moucha, MD (New York, NY)

4:19 pm – 4:24 pm 75 Paper 3

“Thrombogenic Risk of Unicompartmental Knee versus Total Knee

Replacement”

Edwin Philip Su, MD (New York, NY)


4:36 pm – 5:00 pm Session IX: Transitioning to Outpatient TKA

Moderator: Michael E. Berend, MD (Indianapolis, IN)

4:36 pm – 4:43 pm 77 Building an Outpatient TKA Program

Keith R. Berend, MD (New Albany, OH)

4:44 pm – 4:51 pm 78 Outpatient TKA is a Triumph of Knowledge over Reason

Bryan D. Springer, MD (Charlotte, NC)


5:00 pm ADJOURN

Page


H I P

3:33 pm – 3:38 pm 81 Extended Trochanteric Osteomy Tips and Tricks

Craig J. Della Valle, MD (Chicago, IL)

3:39 pm – 3:44 pm 82 Fluted Tapered Stems in Revision THA

Scott M. Sporer, MD (Winfield, IL)

3:45 pm – 3:50 pm 84 Custom Triflange Cup: Planning and Execution

Douglas A. Dennis, MD (Denver, CO)

3:51 pm – 3:56 pm 86 The Cup-Cage Construct

Allen E. Gross, MD, FRCSC (Toronto, ON, Canada)

3:57 pm – 4:02 pm 89 High-Dose Antibiotic Containing Spacers for Infected THA

Kevin L. Garvin, MD (Omaha, NE)


4:16 pm – 4:23 pm Session XIa: Young Investigator Presentation

Timothy M. Wright, PhD (New York, NY)

4:16 pm – 4:21pm 92 Removal of an Infected Hip Arthroplasty is High-Risk Surgery: Putting Morbidity

into Context with other Major Non-Orthopaedic Operations

James A. Browne, MD (Charlottsville, VA)


4:24 pm – 4:32 pm Session Xlb: The Hip Society Rothman-Ranawat Traveling Fellowship

Moderator: Chitranjan S. Ranawat, MD (New York, NY)

4:24 pm – 4:29 pm Highlights of the 2015 Experience

Brian M. Curtin, MD (Charlotte, NC) and Eoin C. Sheehan, MD (Tullamore, Ireland)

4:30 pm – 4:32 pm Introduction of the 2016 Hip Society Rothman-Ranawat Traveling Fellows

Chitranjan S. Ranawat, MD (New York, NY)

4:33 pm – 5:10 pm Session XII: Impingement and Dysplasia

Moderator: Michael B. Millis, MD (Boston, MA)

4:33 pm – 4:38 pm 93 Complications after Hip Arthroscopy: A Prospective Multicenter Trial

Utilizing a Validated Grading Scheme

Christopher M. Larson, MD (Edina, MN)

4:39 pm – 4:44 pm 94 Risks for Conversion to THA after Primary Hip Arthroscopy in a

Healthcare System

Christopher L. Peters, MD (Salt Lake City, UT)

Page

Valencia Room A


H I P Valencia Room A

4:45 pm – 4:50 pm

97 Average 10-Year Clinical Outcomes of the Bernese PAO for the Treatment

of Classic Acetabular Dysplasia

John C. Clohisy, MD (St. Louis, MO)

4:51 pm – 4:56 pm 99 Predictors of Success for Joint Preserving Surgery of the Hip

Paul E. Beaulé, MD, FRCSC (Ottawa, ON, Canada)


5:10 pm ADJOURN

Page


ABSTRACTS AND MEETING MATERIALS

Session I: Direct Anterior THA: Controversies, Data, Techniques in 2016

8:05 am – 8:10 am

Perspective of a Convert:

Why I Changed to Direct Anterior and the Associated Learning Curve

Adolph V. Lombardi, Jr., MD, FACS

I switched from a less invasive direct lateral approach (LIDL) for primary total hip arthroplasty (THA)

to a direct anterior supine intermuscular approach (ASI) for the following reasons: 1) the impression

of our hospital-based physical therapist that patients done via the anterior approach have better

immediate function; 2) speed of recovery; 3) practice harmony, that is, to offer a service consistent

with my partners; 4) to comply with patient requests; and 5) for the challenge after 28 years in

practice of mastering a new technique that may benefit my patients. We perform the direct anterior

approach using a standard radiolucent operative table with extender at the foot, and the assistance

of fluoroscopy. The patient is positioned supine with the pubic symphysis aligned at the table break.

For femoral preparation and stem insertion, the table is “jack-knifed” by lowering the foot of the

table to approximately 45° and placing the bed into approximately 15° of Trendelenburg. A table-

mounted femur elevator with traction hook is attached to the bed and used to lift the proximal femur

out of the wound.

In a 2009 review from our center [1] comparing 258 THA in patients done via ASI with 372 THA in

patients via LIDL, the two groups were similar demographically in terms of age, gender distribution,

height, weight, and underlying diagnosis, but BMI was somewhat higher in LIDL patients (30 vs 29

kg/m2; p=0.004). Mean estimated blood loss was higher in ASI patients (138 mL LIDL vs. 155 ASI,

p<0.001). However, mean operative times and need for transfusion were similar. More ASI patients

were discharged directly to home after surgery, and their Harris hip scores were significantly higher

at 6 weeks postoperative (80 vs. 75, p<0.001). Frequency of perioperative complications and re-

operations was similar.

In a recent review of all patients undergoing primary THA at our center by three surgeons between

2007 and 2014, 3540 were done via ASI and 2162 were done LIDL (Berend KR et al., Hip Society

Members’ Meeting, 2015). The frequency of reoperation related to wound issues or infection was

lower in ASI patients (0.9% [32 of 3540] ASI vs. 1.7% [36 of 2162] LIDL, p=0.01), and the frequency

of deep infection requiring 1- or 2-staged exchange was substantially lower (0.2% [7 of 3540] ASI

vs. 1.0% [21 of 2162] LIDL, p=<0.001).

In an unpublished review of the presenter’s THA experience at an ambulatory surgery center be-

tween June 2013 and December 2014, there were 103 patients done via ASI versus 61 patients

via LIDL. There was a bias by this surgeon to use the LIDL approach in heavier patients with lower

preoperative activity scores. Operative times were longer using the ASI approach (77 vs. 66

minutes) and estimated blood loss was higher (211 vs 144 mL). Need for overnight stay for medical

reasons was similar (2 ASI patients (2%) vs. 1 LIDL patient (2%). There were no differences between

groups in Harris hip or UCLA scores at early follow-up of 6 months.


In a blinded independent radiographic review of all patients undergoing primary THA done by the

presenter in 2014 (Lombardi et al., Hip Society Members’ Meeting, 2015), with 154 done ASI and

138 LIDL, there were no differences in mean abduction or anteversion angles, or frequency of out-

liers between approach groups. However, medialization of the acetabular component was improved

when using the ASI approach.

Suggested Reading

1. Berend KR, Lombardi AV Jr, Seng BE, Adams JB. Enhanced early outcomes with the anterior

supine intermuscular approach in primary total hip arthroplasty. J Bone Joint Surg Am. 2009

Nov;91 Suppl 6:107-20.

2. Seng BE, Berend KR, Ajluni AF, Lombardi AV Jr. Anterior-supine minimally invasive total hip ar-

throplasty: Defining the learning curve. Orthop Clin North Am. 2009 Jul;40(3):343-50.

3. Berend KR, Kavolus JJ, Morris MJ, Lombardi AV Jr. Primary and revision anterior supine total hip

arthroplasty: an analysis of complications and reoperations. Instr Course Lect. 2013;62:251-

63.


8:11 am – 8:16 am

The Direct Anterior Approach is a Risk Factor for

Early Failure in Cementless Total Hip Arthroplasty: A Multi-Center Study

R. Michael Meneghini, MD; Addison S. Elston, BS; Antonia F. Chen, MD, MBA;

Michael M. Kheir, BS; Thomas K. Fehring, MD; Bryan D. Springer, MD

Introduction

The direct anterior approach (DAA) for total hip arthroplasty (THA) continues to be marketed heavily

with claims of superiority over other approaches. Femoral exposure can be technically challenging

and potentially lead to early failure. The purpose of this study was to examine whether surgical

approach is associated with early femoral component failure and revision THA.

Methods

A retrospective review of 478 consecutive early revision THAs at three academic centers from 2010

through 2014 was performed. Exclusion criteria resulted in a final analysis sample of 341 early

failure THAs. Primary surgical approach was documented for each revision THA, along with the time

to revision, and etiology of failure.

Results

44.1% of early failures were originally via the DAA, compared to 32.0% via the direct lateral and

23.6% via the posterior approach (p < 0.001). Early femoral component failure was more common

with the DAA (49.6%) than the direct lateral (36.6%, p = 0.044) and posterior (13.8%, p = 0.001)

approaches. After multivariate regression, the DAA remained a significant predictor of early femoral

failure (p = 0.001). The DAA was significantly less likely to be associated with instability compared

to the posterior approach (37.5% vs. 47.5%. p = 0.034), but was more likely to be associated with

instability than the direct lateral approach (37.5% vs. 15%, p = 0.043).

Conclusion

Despite claims of early recovery and improved outcomes with the direct anterior approach, our find-

ings indicate the DAA likely confers greater risk for early femoral failure and, along with the posterior

approach, a greater risk of early instability compared to the direct lateral approach following THA.

Significance

This study provides evidence concerning the risks of the DAA that should be considered when con-

templating adoption in practice or marketing this surgical approach and should be discussed with

patients. Further study in the longer term is required to determine if improvements in instrumenta-

tion, training and implementation are able to mitigate the risks reported in this study.


8:17 am – 8:22 am

Surgical Tips and Pearls to Maximize Success

of Anterior Approach THA Done with an Orthopedic Table

Joel M. Matta, MD

For learning any new technique the main principle to follow is: learn the technique thoroughly from

start to finish and adopt it as taught, without attempting to modify it until you are very familiar with

it. Orthopedic table enhanced anterior approach THA (ATHA) is at this point a well established

teachable and repeatable technique though its safety and efficacy depends on adherence to de-

tails. These technical details have evolved to become part of the technique since I first taught it at

a course in 2003. The technical details and innovations have utilized the invaluable input from high

volume expert surgeons as well as from less experienced surgeons taking on the challenges of

learning.

Considering Anterior Approach (AA), 3 technical aspects can be a “mental block” for the uninitiated

surgeon: 1) supine position, 2) the orthopedic table, 3) checking cup position, leg length and offset

with the image intensifier/C-arm. Keep in mind that though you may have been initially trained and

experienced with lateral position, a flat table and no x-ray checks, these three technical aspects

greatly facilitate Anterior Approach and enhance its repeatability, safety, accuracy and overall “ease

of use”.

Make the incision over the tensor and parallel to its fibers posterior and lateral to the normal Smith-

Petersen interval to avoid problems with the lateral femoral cutaneous nerve. I believe there are

more problems both superficial and deep by going too medial rather than too lateral. If you are too

lateral and posterior with your approach at worst you enter the Watson-Jones or Harding interval

and you can correct more anterior or proceed with the alternate approach.

Getting comfortable with femoral exposure is the key to confidence and success with anterior ap-

proach. I get most of my femoral exposure and mobility in the first 10 minutes of the procedure

before the neck cut which minimizes the need for later soft tissue releases. The keys to femoral

exposure are: the orthopedic table and its attached femoral hook, proper capsulotomy with expo-

sure from the acetabular rim to the saddle of the neck, dislocation of the hip with full exposure of

intertrochanteric line, medial neck and proximal lesser trochanter, and later release of lateral cap-

sule from medial greater trochanter (GT) with possible release of obturator internus tendon (about

25-30% of cases). Do not release the obturator externus tendon which is the primary “anti-disloca-

tor”. The capsule is mobilized from the femur except for a portion posterior while the capsule re-

mains fully attached to the acetabular rim and preserved for approximation at closure.

Acetabular exposure should be without problems after femoral dislocation and the associated cap-

sular mobilization. Ream somewhat anterior to posterior to avoid excessive anterior wall reaming.

The reamer is directed also somewhat proximal but not aimed as much proximal as the cup inserter.

Consistent reaming in the direction of later cup insertion can result in a cup that is too proximal.

Check with the c-arm to make sure the pelvis is level and has tilt similar to pre-op and insert the

cup with real time guidance from the c-arm. The ellipse projected by the acetabular rim is your

guide to inclination and anteversion. I utilize “software guided imaging” and match the cup rim

ellipse to the ellipse drawn by the software.


For femoral instrumentation the table spar externally rotates, extends, and adducts the extremity

and the hook-lift device attached to the table holds the proximal femur in a more anterior and stable

position for access. Detach the capsule from the medial GT for exposure. If this is not sufficient for

access, expose the medial cortex of the GT by releasing the obturator internus tendon. Be patient

and methodical with femoral exposure. Trying to force femoral instrumentation at this point by too

forceful lifting with the hook or insertion of the broach in a wrong direction can lead to problems

including fracture or perforation of the proximal femur. Your visualization should be good at this

point but if there is any doubt, check the broach position with c-arm.

Prior to a trial reduction your guides for leg length and offset are the pre-op templating, the normal

sound and feel of broach stability and the relationship of the top of the broach to the GT as indicated

by the templating. The neck cut is an approximation and typically will be a little long necessitating

counter sinking the broach and later planning the calcar when final length and offset is determined.

After these steps the trial femoral components are reduced and the c-arm is used to compare length

and offset to the opposite hip. I advocate an “overlay” technique in which permanent prints from

the c-arm are overlaid to assess symmetrical length and offset. Currently, I utilize “software guided

imaging” which graphically superimposes the 2 hip images. Do not add length or offset beyond

what is normal for that patient for the purpose of tensioning soft tissues or the patient will be un-

happy with the too long extremity. Your accurately positioned cup, restoration of normal length and

offset and soft tissue preservation will ensure hip stability.

Blood loss can be a problem while learning AA. Pay attention to hemostasis of the lateral femoral

circumflex vessles, capsular bleeders at the point of attachment of the capsule and femur and the

retinacular branches of the medial femoral circumflex. Bleeding from the retinacular vessels which

lie along the posterior neck can pose the greatest challenge for hemostasis for the new anterior

approach surgeon. I use a bipolar radiofrequency cautery to aid in hemostasis.

Anterior approach technical instruction is available at a number of industry, AAOS, and ICJR spon-

sored venues. Visiting a surgeon who is expert in AA can also provide an effective supplemental

educational experience.


8:23 am – 8:28 am

Surgical Tips and Pearls to Maximize Success

of Direct Anterior THA Done without a Fracture Table

William Hozack, MD

Walter Annenberg Professor of Joint Replacement Surgery

Sidney Kimmel Medical School at Thomas Jefferson University

Rothman Institute Orthopedics

Philadephia, PA

Preoperative planning of the surgical procedure helps with decision making during the procedure.

Template component size and position for all patients and with experience, preoperative templating

becomes very accurate. If the surgical sizing is not close to the template, you need to evaluate for

possible intraoperative problems, such as a varus stem or femoral fracture.

Exposure is paramount. While the DAA can be minimally invasive, any shortcuts taken on exposure

will increase the risk of trauma and complications. Make the incision in the proper place, but extend

the incision as necessary to provide good exposure with minimal trauma. There are several ways to

increase the exposure.

1. Make the incision in the proper place – the flexion crease of the hip is the proximal start-

ing point.

2. Assess the soft tissue (muscle) tension during the exposure to determine the length of

the incision.

3. Make capsular incisions to increase separation of the femur from the acetabulum to get

good exposure of each.

4. Resect anterior capsule to make your exposure easier and less traumatic.

5. Incise the TFL fascia proximally, if necessary, all the way to the ASIS.

Specific instrumentation helps. All exposures to the hip are facilitated by specific instrumentation

designed for the approach. Used properly, specifically designed instrumentation will make the op-

eration easier and less traumatic.

Double osteotomy of the femoral neck eliminates the trauma associated with dislocation of the hip.

Further it allows proper assessment of the final and true neck cut planned preoperatively.

Spend time on acetabular exposure and preparation. Insist upon full exposure and use anatomic

landmarks defined in the OR to confirm component position and orientation. Intraoperative Xray

can be used as an adjunct only. It is important to remove all osteophytes to define the true anatomy

of the acetabulum prior to reaming. Removal of osteophytes also will reduce the change of impinge-

ment and instability.

Femoral exposure requires specific but minimal releases of capsular structures, but not muscles.

The most important release is of the superior capsule – incision of which allows elevation of the


femur without hyperextension of the leg. Release of this area of capsule prior to femoral elevation

will eliminate the possibility of trochanteric fracture. What is not often appreciated is that proper

acetabular exposure (especially osteophyte removal) also assists in increasing femoral exposure.

Femoral preparation requires centralization of the broach. This can be accomplished in a variety of

ways (box osteotome, rongeur, back broaching) but the residual superior femoral neck needs to be

removed to ensure proper broach and final prosthesis position. The final prosthesis should be in-

serted by hand into the bed prepared by the broach, and then impacted into its final position.

Stability, ROM and leg length should be assessed on every case. Small changes in offset and leg

length can substantially improve stability. ROM checks can identify residual osteophytes creating

impingement and instability.

Easy cases – thin, flexible, long valgus neck, good offset

Hard cases – thick, stiff, muscular, short varus neck, low offset


8:29 am – 8:34 am

The Accumulated Evidence Supports

Posterior THA as Gold Standard in THA

Bryan D. Springer, MD

There are many factors associated with the success of total hip arthroplasty. These include: appro-

priate fixation of the implants, recreation of the biomechanics of the hip (leg length and offset), a

durable bearing surface, and a surgical approach that facilitates these goals. Much attention has

been drawn recently to the direct anterior approach (DA) as a differentiating factor in total hip ar-

throplasty, with less blood loss, little risk of dislocation and faster recovery. Much of this attention

however has been based on marketing claims as well as industry and surgeon promotion with little

if any evidence to support superiority of one approach over another1. Emerging data would suggest

that while these surgical approaches can be done safely in expert hands, they are associated with

long and steep learning curve, higher early failures rates and unique sets of complications2-4.

The posterior approach to total hip arthroplasty has several advantages. (1) it preserves the hip

deltoid (2) is extensile in nature (3) suits all comers with no contraindications and is familiar to most

surgeons. Historically, the biggest limitation of the posterior approach was it association with higher

dislocation rates. While numerous studies do demonstrate higher dislocation rates, modern THA

with the use of larger diameter femoral heads and posterior capsular repair consistently demon-

strate dislocation rates less than 1%5. It is a common fallacy that the direct anterior approach THA

has lower or no dislocations. In fact, the early studies showed equivalent or higher dislocation rates

with the DA approach and more recent evidence suggest no difference in dislocation rates between

DA and posterior approaches.

A significant amount of attention has been placed on the benefits of the DA approach on early post

operative recovery. There remains a paucity of good clinical evidence demonstrating those suppo-

sitions particularly in light of modern multimodal pain management and early rehabilitation proto-

cols6,7. Two prospective randomized studies demonstrate minimal early benefit with regards to

walking aids following surgery8,9. Any short term benefits much be weighted however against nu-

merous studies showing higher early and short term complications with regards to fractures, loos-

ening and nerve injury2,10-14.

Any surgical approach done well can yield excellent results. The enthusiasm for the DA surgical

approach should be tempered by the scientific data rather than marketing and promotion. The pos-

terior approach offers a time tested and familiar surgical approach that yields excellent long-term

clinical results.


References

1. Mohan R, Paul HY, Hansen EN. Evaluating Online Information Regarding the Direct Anterior

Approach for Total Hip Arthroplasty. The Journal of arthroplasty. 2015;30(5):803-807.

2. Hartog Yd, Vehmeijer S. High complication rate in the early experience of minimally invasive

total hip arthroplasty by the direct anterior approach. Acta orthopaedica. 2013;84(1):116-

117.

3. Spaans AJ, Hout JAvd, Bolder SB. High complication rate in the early experience of minimally

invasive total hip arthroplasty by the direct anterior approach. Acta orthopaedica.

2012;83(4):342-346.

4. Tamaki T, Oinuma K, Kaneyama R, Shiratsuchi H. Learning Curve of Total Hip Arthroplasty

Using the Direct Anterior Approach. Journal of Bone & Joint Surgery, British Volume.

2012;94(SUPP XL):188-188.

5. Bystrom S, Espehaug B, Furnes O, Havelin L. Norwegian Arthroplasty Register (2003) Femo-

ral head size is a risk factor for total hip luxation: a study of 42,987 primary hip arthroplasties

from the Norwegian Arthroplasty Register. Acta Orthop Scand.74(5):514-524.

6. Rathod PA, Orishimo KF, Kremenic IJ, Deshmukh AJ, Rodriguez JA. Similar improvement in

gait parameters following direct anterior & posterior approach total hip arthroplasty. The

Journal of arthroplasty. 2014;29(6):1261-1264.

7. Rodriguez JA, Deshmukh AJ, Rathod PA, et al. Does the direct anterior approach in THA offer

faster rehabilitation and comparable safety to the posterior approach? Clinical Orthopaedics

and Related Research®. 2014;472(2):455-463.

8. Barrett WP, Turner SE, Leopold JP. Prospective randomized study of direct anterior vs pos-

tero-lateral approach for total hip arthroplasty. The Journal of arthroplasty.

2013;28(9):1634-1638.

9. Taunton MJ, Mason JB, Odum SM, Springer BD. Direct Anterior Total Hip Arthroplasty Yields

More Rapid Voluntary Cessation of All Walking Aids: A Prospective, Randomized Clinical Trial.

The Journal of arthroplasty. 2014;29(9):169-172.

10. Christensen CP, Karthikeyan T, Jacobs CA. Greater prevalence of wound complications re-

quiring reoperation with direct anterior approach total hip arthroplasty. The Journal of ar-

throplasty. 2014;29(9):1839-1841.

11. Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a frac-

ture table. Clinical Orthopaedics and Related Research®. 2011;469(2):503-507.

12. Russo MW, Macdonell JR, Paulus MC, Keller JM, Zawadsky MW. Increased Complications in

Obese Patients Undergoing Direct Anterior Total Hip Arthroplasty. The Journal of arthroplasty.

2015.

13. Tippets DM, Zaryanov AV, Burke WV, et al. Incidence of heterotopic ossification in direct an-

terior total hip arthroplasty: a retrospective radiographic review. The Journal of arthroplasty.

2014;29(9):1835-1838.

14. Watts CD, Houdek MT, Wagner ER, Sculco PK, Chalmers BP, Taunton MJ. High Risk of Wound

Complications Following Direct Anterior Total Hip Arthroplasty in Obese Patients. The Journal

of arthroplasty. 2015.


Session II: Contemporary Insights into Unsolved Problems in THA

8:50 am – 8:55 am

Abductor Deficiency and THA: Diagnosis and Management

Richard W. McCalden, MD, FRCSC

London, Ontario, Canada

Deficiency of the abductor mechanism, while relatively uncommon, can result in gait dysfunction

and pain following total hip replacement (THR). There are multiple causes for abductor deficiency

following THR including: pre-operative abductor dysfunction, damage to the superior gluteal nerve

intra-operatively, mechanical failure of the abductor muscle repair, or detachment of the abductor

muscles and/or loss of the greater trochanter in the setting of the multiply revised THR. The diag-

nosis is based on careful history and clinical examination, assessment of the radiographs and can

be combined with advanced imaging (MARS MRI) and/or EMG studies. The management of this

condition is problematic and remains a challenge for the treating surgeon. In the setting of a supe-

rior gluteal nerve palsy, careful clinical follow-up is acceptable as the majority of cases resolve spon-

taneously by 24 months following THR. In the setting of mechanical abductor deficiency, a number

of surgical strategies have been reported including: direct trans-osseous repair, numerous local

tendon transfers and the use of allograft reconstruction techniques to replace the abductor mech-

anism. The evidence for these surgical treatments remains limited (level IV & V) and demonstrates

generally variable results. As such, abductor deficiency following THR remains an unsolved problem.

References

Odak S1, Ivory J. Management of abductor mechanism deficiency following total hip replacement.

Bone Joint J. 2013 Mar;95-B(3):343-7.

Drexler M1, Abolghasemian M1, Kuzyk PR1, Dwyer T1, Kosashvili Y1, Backstein D1, Gross AE1, Safir

O1.Reconstruction of chronic abductor deficiency after revision hip arthroplasty using an extensor

mechanism allograft. Bone Joint J. 2015 Aug;97-B(8):1050-5.

Fehm MN, Huddleston JI, Burke DW, Geller JA, Malchau H. Repair of a deficient abductor mecha-

nism with Achilles tendon allograft after total hip replacement. J Bone Joint Surg Am. 2010 Oct

6;92(13):2305-11.

Whiteside LA Surgical technique: Gluteus maximus and tensor fascia lata transfer for primary defi-

ciency of the abductors of the hip. Clin Orthop Relat Res. 2014 Feb;472(2):645-53.

Wang K1, Cole S, White DC, Armstrong MS. Vastus lateralis transfer for severe hip abductor defi-

ciency: a salvage procedure. Hip Int. 2014 Mar-Apr;24(2):180-6.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Odak%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23450018

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ivory%20J%5BAuthor%5D&cauthor=true&cauthor_uid=23450018

http://www.ncbi.nlm.nih.gov/pubmed/23450018

http://www.ncbi.nlm.nih.gov/pubmed/?term=Drexler%20M%5BAuthor%5D&cauthor=true&cauthor_uid=26224820

http://www.ncbi.nlm.nih.gov/pubmed/?term=Abolghasemian%20M%5BAuthor%5D&cauthor=true&cauthor_uid=26224820

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kuzyk%20PR%5BAuthor%5D&cauthor=true&cauthor_uid=26224820

http://www.ncbi.nlm.nih.gov/pubmed/?term=Dwyer%20T%5BAuthor%5D&cauthor=true&cauthor_uid=26224820

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kosashvili%20Y%5BAuthor%5D&cauthor=true&cauthor_uid=26224820

http://www.ncbi.nlm.nih.gov/pubmed/?term=Backstein%20D%5BAuthor%5D&cauthor=true&cauthor_uid=26224820

http://www.ncbi.nlm.nih.gov/pubmed/?term=Gross%20AE%5BAuthor%5D&cauthor=true&cauthor_uid=26224820

http://www.ncbi.nlm.nih.gov/pubmed/?term=Safir%20O%5BAuthor%5D&cauthor=true&cauthor_uid=26224820

http://www.ncbi.nlm.nih.gov/pubmed/?term=Safir%20O%5BAuthor%5D&cauthor=true&cauthor_uid=26224820


http://www.ncbi.nlm.nih.gov/pubmed/?term=Fehm%20MN%5BAuthor%5D&cauthor=true&cauthor_uid=20926725

http://www.ncbi.nlm.nih.gov/pubmed/?term=Huddleston%20JI%5BAuthor%5D&cauthor=true&cauthor_uid=20926725

http://www.ncbi.nlm.nih.gov/pubmed/?term=Burke%20DW%5BAuthor%5D&cauthor=true&cauthor_uid=20926725

http://www.ncbi.nlm.nih.gov/pubmed/?term=Geller%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=20926725

http://www.ncbi.nlm.nih.gov/pubmed/?term=Malchau%20H%5BAuthor%5D&cauthor=true&cauthor_uid=20926725


http://www.ncbi.nlm.nih.gov/pubmed/?term=Whiteside%20LA%5BAuthor%5D&cauthor=true&cauthor_uid=23955258


http://www.ncbi.nlm.nih.gov/pubmed/?term=Wang%20K%5BAuthor%5D&cauthor=true&cauthor_uid=24186678

http://www.ncbi.nlm.nih.gov/pubmed/?term=Cole%20S%5BAuthor%5D&cauthor=true&cauthor_uid=24186678

http://www.ncbi.nlm.nih.gov/pubmed/?term=White%20DC%5BAuthor%5D&cauthor=true&cauthor_uid=24186678

http://www.ncbi.nlm.nih.gov/pubmed/?term=Armstrong%20MS%5BAuthor%5D&cauthor=true&cauthor_uid=24186678



8:56 am – 9:01 am

Unsolved Problems in THA : Psoas Impingement/Tendinosis Following THA:

Diagnosis and Management

William Jiranek, MD; Curtis Hayes, MD; Kevin Hoover, MD

Departments of Orthopaedic Surgery and Radiology

Virginia Commonwealth University School of Medicine

Richmond, VA

Introduction

Anterior psoas impingement as a cause of groin pain after THA was first reported in the US literature

in 1995 (1). Trousdale, Cabanela, and Berry suggested the development of this problem was re-

lated to increasing use of rough uncemented acetabular components, combined with decreased

anteversion of the component. Other studies have suggested some psoas irritation is caused by

physical displacement as found in large head THA and resurfacing. Lachiewicz and Kauk suggested

this problem was under recognized and treated (2). The incidence is unknown, but one study re-

ported an incidence of 4% in their series of 280 primary THA (3).

Diagnosis

Psoas impingement/tendinitis should be in the differential diagnosis of groin pain which persists

beyond 6 months after THA. The character of the pain is dull and aching at rest, increased signifi-

cantly with flexion activities, and rarely associated with a click or pop. Physical exam can rule out

other sources of groin pain, such as hernia, but inspection and palpation may help localize the pain

to the anteromedial groin. The finding of groin pain with resisted hip flexion, particularly at 90

degrees of flexion, is suggestive of iliopsoas tendinitis. Those patients suspected of iliopsoas im-

pingement should have plain radiographs, particularly a cross table lateral, to assess for promi-

nence of the anterior rim of the socket beyond the anterior rim of the bony acetabulum. Cross

sectional imaging can confirm acetabular component positioning (more experience with CT), as well

as swelling and displacement of the psoas tendon (CT or perhaps MARS MRI). In the hands of a

skilled musculoskeletal ultrasonographer, ultrasound can show changes in the tendon, particularly

when compared to the contralateral tendon. In cases where the diagnosis is not made by this im-

aging, injection of the tendon sheath (with contrast confirmation) with local anesthetic that pro-

duces relief of symptoms is confimatory.

Treatment

For confirmed cases of psoas tendinitis, there has been no level 1 trial of nonoperative vs operative

treatment. Review of the literature suggests more failures in the nonoperative groups, but these

were small uncontrolled series. Expert opinion suggests that all patients with confirmed IP tendinitis

have a trial of injection of corticosteroid injection (3). Reports of surgical release of the IP tendon

(most at the tendon insertion at the lesser trochanter) have largely been effective in relieving pain,

although few studies have evaluated post release function. Open release has been described via

numerous surgical approaches including posterior, anterolateral, and medial. Arthroscopic release

of the tendon both at the joint and distally has been described in patients without THA (5).


References

1. Trousdale RT, Cabanela ME, and Berry DJ, Case Report: Anterior Iliopsoas Impingement

After

Total Hip Arthroplasty. JOA V.10, p: 546-49, 1995

2. Bartelt RB, Yuan BJ, Trousdale RT, Sierra RJ, The Prevalence of Groin Pain After Metal-on-

Metal Total Hip Arthroplasty and Total Hip Resurfacing, CORR V. 468:2346–2356, 2010

3. Lachiewicz PF and Kauk JR, Anterior Iliopsoas Impingement and Tendinitis After Total Hip

Arthroplasty, JAAOS, Vol 17: p. 337-343, 2009

4. Bricteux S, Beguin L, Fessy MH: Iliopsoas impingement in 12 patients

with a total hip arthroplasty. Rev Chir Orthop Reparatrice Appar Mot, V 87:820-825, 2001

5. Ilizaliturri VM Jr MD et al., Central Compartment Release Versus Lesser Trochanter Release

of the Iliopsoas Tendon for the Treatment of Internal Snapping Hip: A Comparative Study,

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30: pp 790-795, 2014


9:02 am – 9:07 am

THA for the Patient with BMI over 40: Risk and Reward

David G. Lewallen, MD

Obesity and the diseases linked to it such as diabetes have been associated with higher complica-

tion rates and increased medical costs following Total Hip Arthroplasty (THA). Due to the rising

prevalence of obesity and the adverse impact it has on the development of osteoarthritis, there has

been a worldwide surge in the number of obese patients presenting for THA procedures, including

those morbidly obese (BMI > 40) and those who are super-obese (BMI > 50).

The Reward

When THA is successful (as is true for the majority of morbidly obese patients operated) the oper-

ation is just as dramatically effective as it is for other patients. Excellent pain relief and dramatically

improved function is the result, even though obese patients generally achieve a lower overall level

of function than non-obese patients. Morbidly obese patients with a successful THA and without

early complications are some of the most grateful of patients. This is especially true if they have

been denied surgery for prolonged periods due to their weight and have had to bear severe joint

changes and symptoms during a long period of time leading up to arthroplasty.

The Risks

There is a nonlinear increase in complications, reoperations, and especially infection with increas-

ing BMI that begins between a BMI of 25 to 30, and rises thereafter with a relative inflection point

in some incidence curves for complications at around a BMI of 40. This has caused some surgeons

to suggest a BMI of 40 as an upper limit for elective hip arthroplasty. Risks continue to rise after a

BMI of 40 and when the BMI is over 50, in our series 52% of patients had at least one complication.

Of these 24% had at least one major complication and 33% at least one minor complication with

some suffering more than one complication overall. These data make it reasonable to ask whether

the outcomes in some morbidly obese patients might be improved by weight loss, bariatric surgical

intervention and other measures aimed at optimizing the multiple companion comorbidities and

medical conditions (such as diabetes) that often accompany excess weight. Unfortunately there

has been limited information to date on the best means for optimizing of these patients, and as

important the effectiveness of these interventions, so that the timing and performance of the even-

tual arthroplasty procedures might have the highest possible success rate.


The Costs

The adverse impact of obesity on medical resource utilization and costs associated with THA has

been well documented, Due to longer initial length of stay, greater resource utilization, higher early

complication rates and any readmissions and reoperations the costs for even a single individual

patient can climb dramatically. In a review of data on primary THA patients from our institution, even

after adjusting for age, sex, type of surgery, and other comorbidities, for every 5 unit increase in BMI

beyond 30 kg/m2 there was an associated $500 higher cost of hospitalization and an increase of

$900 in 90-day total costs (p=0.0001)

The Future

The numbers of morbidly obese patients with severe osteoarthritis presenting for possible THA will

only continue to increase in the years ahead. Comprehensive multidisciplinary programs are ur-

gently needed to better manage obese patients with weight reduction options, optimization of med-

ical comorbidities, and treatment of any associated issues, such as protein malnutrition. When end

stage joint changes and symptoms occur we must have such help to maximize the benefit and

reduce the complications of hip arthroplasty in this high risk patient population.


9:08 am – 9:13 am

Recurrent Dislocation in the Patients with a Constrained Liner

or Dual-Mobility Implant: What Now?

John J. Callaghan, MD

The Lawrence and Marilyn Dorr Chair

University of Iowa

Failure of Revision for Dislocation has been reported in 15-40 percent of cases. Use of constrained

liners and dual mobility components have definitely helped in reducing the incidence of recurrence

following revision for dislocation. However 10 to 30 percent of constrained liner and as yet unknown

percentage of dual mobility liner constructs fail.

When the surgeon is faced with this scenario what is important in the evaluation of the situation

and what are the options for treatment?

As constrained liners have been available for a longer period of time in this country we have more

experience of treating failures of these devices. The surgeon must try to determine why the com-

ponent failed. One of the most common scenarios is that the liner was placed in a hip with malpo-

sitioned components. Focus is placed on the evaluation of acetabular component positioning but

femoral component malposition can also contribute to failure. It can be helpful to evaluate the pre

revision radiographs taken prior to placing the constrained liner. Next the overall laxity of the joint

needs to be assessed as well as any contributing boney impingement. In addition today we are

gaining a better understanding of the contribution of a stiff spine and hyper mobile spine in dislo-

cation of hip components and this must be evaluated. Finally presence or absence of functional

hip abduction needs to be assessed. Treatment depending upon which of these variables are pre-

sent can include returning to a large head construct, changing to a dual mobility liner or a less

constraining constrained liner or revising one or both of the original hip components to optimize

positioning. In a case with stiff or hypermobile spines this may require non traditional placement

of the components. Finally abductor reconstruction may be warranted.

In the case of a failed dual mobility component it can fail by intraprosthetic dislocation or dislocation

of the liner from the shell. Especially with modular shells some of these can easily be converted to

constrained liner constructs. Otherwise the surgeon must evaluate contributions to the failure in-

cluding component malposition, boney or soft tissue impingement and abductor insufficiency.

References

1. Daly PJ, Morey BF: Operative correction of an unstable total hip arthroplasty. J Bone Joint

Surg Am. 1992;74:1334-1343.

2. Wera DG. Ting NT, Moric M, et al. Classification and management of the unstable hip arthro-

plasty. J Arthroplasty. 2012; 27 (5) : 710-715.

3. Goetz DD, Bremner BR, Callaghan JJ, et al. Salvage of recurrently dislocating hip prosthesis

with use of a constrained acetabular component. J Bone Joint Surg Am. 2004; 86-A:2419-

2423.


9:14 am – 9:19 am

Pelvic Discontinuity: Newest Knowledge and Technical Tips in Management

Wayne G. Paprosky, MD and Neil P. Sheth, MD

Acetabular bone loss is a challenging problem often encountered in the setting of revision

total hip arthroplasty (THA). When a chronic pelvic discontinuity is seen concomitantly with severe

bone loss, achieving adequate fixation and getting the discontinuity to heal further complicates the

operation. The reconstruction of the acetabulum is centered on the presence of anterosuperior and

posteroinferior column support to attain component fixation and construct stability.

The Paprosky classification is most commonly used to determine the location and degree of

acetabular bone loss. The classification utilizes four radiographic elements for pre-operative eval-

uation: (1) superior migration in reference to the superior obturator line, (2) degree of ischial oste-

olysis, (3) degree of teardrop osteolysis, and (4) integrity of Kohler’s line. Typically, a type IIIB ace-

tabular defect, an “UP and OUT” pattern, has unsupportive columns and can be associated with a

chronic pelvic discontinuity.

There are several options which currently exist to address acetabular bone loss with an as-

sociated chronic pelvic discontinuity. Reconstruction options typically include one of the following:

posterior column plating, cage/ring construct, acetabular allograft, cup-cage construct, jumbo cup

+/- porous metal augments, and custom triflange acetabular component. We advocate the use of

the acetabular distraction technique with a jumbo cup and modular porous metal acetabular aug-

ments for the treatment of severe acetabular bone loss and associated chronic pelvic discontinuity.

There are several key points to consider when using the distraction technique. Following

adequate acetabular exposure, the acetabulum should be assessed for the presence of a disconti-

nuity using a Cobb elevator. Once presence of a discontinuity is confirmed, the superficial portion

of the discontinuity is debrided, being careful not to debride too aggressively and create further

instability of the discontinuity. When augments are utilized, their function needs to be determined;

augments either provide primary construct stability (implanted prior to the cup for column recon-

struction) or supplemental fixation (implanted after cup insertion). A 2.4 mm wire is inserted into

each of the columns and an acetabular distractor is placed over the K-wires. The acetabulum is

reamed on reverse with the acetabulum distracted. Once the columns are engaged by the reamer,

it will typically dislodge from the reamer handle. This identifies the cup size; we propose the use of

the Trabecular MetalTM revision shell. During cup insertion, it is important to cement the augments

to the cup and unitize the entire construct. The K-wires are removed following cup implantation,

and a liner is cemented in the proper orientation. Early results have demonstrated 95% success

looking at ew-revision as an end-point (Sporer et al. CORR 2012).


9:20 am – 9:25 am

What to Do When the Two-Stage THA for Infection Fails

Keith A. Fehring, MD; Matthew P. Abdel, MD; Tad M. Mabry, MD; Arlen D. Hanssen, MD

Rochester, MN

Introduction

Failed 2-stage reimplantation with subsequent infection is a devastating outcome and attempts at

further 2-stage reimplantation procedures are fraught with difficulties without clear guidelines for

treatment or prognosis. A staging system to stratify patients according to infection type, host status,

and local soft tissue status may prove useful when developing treatment algorithms for these diffi-

cult patients. The purpose of this study was to report the results of a subsequent 2-stage reimplan-

tation following a failed 2-stage protocol for periprosthetic hip infection, as well as identify risk fac-

tors for failure, and complications associated with these procedures.

Patients and Methods

We retrospectively identified 20 patients who underwent a second 2-stage exchange arthroplasty

for recurrent infection from 2000 - 2013. Minimum follow-up was 2 years (mean 3.5 years). All

patients were treated with high dose antibiotic spacers, received 6 weeks of intravenous antibiotics,

and the mean time to reimplantation was 19 weeks (range: 8-74 weeks). Fourteen patients (70%)

placed on lifelong antibiotic suppression.

Results

The overall rate of infection was 40% but when classified by the staging system the Type C patients

had a recurrence rate 0f 66%. There was no difference in the reinfection rate in patients placed on

antibiotic suppression when compared with those who were not on antibiotic suppression. At failure

with recurrent infection, a new micro-organism was identified in 43% of the patients. The overall

reoperation rate for any reason was 80%. Excluding infection, the most common reasons for reoper-

ation were hip instability (33%), acetabular loosening (17%) and femoral loosening (17%). All pa-

tients required gaits aids for ambulation at last follow-up.

Discussion

This data suggests that expectations following a second two-stage exchange arthroplasty for

periprosthetic hip infection should be tempered and that a staging system may be useful to deter-

mine whether or not to proceed with another attempt at two-stage reimplantation. In the absence

of recurrent infection, the rate of reoperation for hip instability and implant loosening are consider-

able.

References

1. Kalra KP, Lin KK, Bozic KJ, Ries MD. Repeat 2-stage revision for recurrent infection of total

hip arthroplasty. J Arthroplasty. 2010 Sep;25(6):880-4.

2. McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M. Periprosthetic total

hip infection: Outcomes using a staging system. Clin Orthop Relat Res. 2002;(403)(403):8-

15.

3. Mortazavi SM, O'Neil JT, Zmistowski B, Parvizi J, Purtill JJ. Repeat 2-stage exchange for in-

fected total hip arthroplasty: a viable option? J Arthroplasty. 2012 Jun;27(6):923-6.

4. Pagnano MW, Trousdale RT, Hanssen AD. Outcome after reinfection following reimplantation

hip arthroplasty. Clin Orthop Relat Res. 1997;(338)(338):192-204.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Kalra%20KP%5BAuthor%5D&cauthor=true&cauthor_uid=20206469

http://www.ncbi.nlm.nih.gov/pubmed/?term=Lin%20KK%5BAuthor%5D&cauthor=true&cauthor_uid=20206469

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bozic%20KJ%5BAuthor%5D&cauthor=true&cauthor_uid=20206469

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ries%20MD%5BAuthor%5D&cauthor=true&cauthor_uid=20206469


http://www.ncbi.nlm.nih.gov/pubmed/?term=Mortazavi%20SM%5BAuthor%5D&cauthor=true&cauthor_uid=22226613

http://www.ncbi.nlm.nih.gov/pubmed/?term=O%27Neil%20JT%5BAuthor%5D&cauthor=true&cauthor_uid=22226613

http://www.ncbi.nlm.nih.gov/pubmed/?term=Zmistowski%20B%5BAuthor%5D&cauthor=true&cauthor_uid=22226613

http://www.ncbi.nlm.nih.gov/pubmed/?term=Parvizi%20J%5BAuthor%5D&cauthor=true&cauthor_uid=22226613

http://www.ncbi.nlm.nih.gov/pubmed/?term=Purtill%20JJ%5BAuthor%5D&cauthor=true&cauthor_uid=22226613



Session III: Strategies to Speed Recovery and Decrease Complications after THA

9:56 am – 10:01 am

Pain Management after Contemporary THA:

Part of a Comprehensive Strategy to Get Ahead and Stay Ahead

Mark W. Pagnano, MD

The entirety of the patient experience after contemporary total knee and total hip replacements in

2016 is markedly different from that encountered by patients just a decade ago. Ten years ago

most patients were treated in a traditional sick-patient model of care and because they were as-

sumed to require substantial hospital intervention, many cumbersome & costly interventions (e.g.

indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion,

continuous passive motion machines) were a routine part of the early postoperative experience.

Today the paradigm has shifted to a well-patient model with a working assumption that once a

patient has been medically optimized for surgery then the intervention itself, hip or knee replace-

ment, will not typically create a sick-patient. Instead it is expected that most patients can be treated

safely & more effectively with less intensive hospital intervention. While as orthopedic surgeons we

are enamored with the latest surgical techniques or interesting technologies most busy surgeons

recognize that advances in perioperative pain management, blood management, and early-mobili-

zation therapy protocols account for the greatest share of improvements in patient experience over

the past decade.

One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances

that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and

nausea. The modern orthopedic surgeon and his/her care team needs a simple strategy to pro-

actively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those

surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness

faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and

surgeon alike.

Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates

discharge to home. Today’s emphasis is on a multi-modal strategy that minimizes the use of opioids.

Most protocols use preop medications including an NSAID, acetaminophen, an oral opioid and some

include gabapentin. Regional anesthesia is typically preferred over general. Both peripheral nerve

blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in

decreasing early postoperative pain. Postoperative oral medications delivered on a schedule, not

just as needed, often include acetaminophen, an NSAID and some included gabapentin. Oral and

parenteral opioids are reserved for breakthrough pain.

Sculco PK and Pagnano MW: Perioperative Solutions for Rapid Recovery Joint Arthroplasty: Get

Ahead and Stay Ahead. J Arthroplasty: January 2015.


10:02 am – 10:07 am

Role of Staphlococcal Screening and Treatment Prior to THA

Scott M. Sporer, MD

Background

1-2% primary TJA patients will develop a Surgical site infection(1)

Staphylococcus species the most common infecting organism

15-20% of Patients colonized by Methicillin-Susceptible Staphylococcus(2)

5% of Patients colonized by Methicillin-resistant Staphylococcus aureus (MRSA) prior to sur-

gery

Physicians: 1.5% MRSA, 36% MSSA(3)

$1.62 Billion expected cost in 2020(1)

Techniques

Nasal Decolonization with intranasal mupirocin

Chlorhexidine showers/cloth

Addition of Vancomycin preoperatively

Isolation

MRSA Screen ordered

Culture

done?

Staph screen

done in pre-op

holding

Screen

Positive for

Staph ?

MSSA Positive

Complete mupirocin x

10 doses

MRSA Positive

Contact Precautions

Complete mupirocin x

10 doses

YES YES

Discontinue

mupirocin

NO

NO

Culture

positive for

Staph?

Pre Admission nurse notifies

physician and Staph Screening TeamLab completes further analysis

Infection Preventionist enters patient

information in Series

Contact Precautions initiated

Decolonization

completed?

Complete till 10 doses

YES

NO

YES NO

YES YES

Patient MRSA

positive?

YES

NO

Staph Screening Team member

notifies patient and patient

pharmacy

Pre-op holding nurse begins

Mupirocin (and Ancef pre-op as

ordered unless allergic)

Continue mupirocin post-op

Patient instructed to use HibiclensTM

and mupirocin

Routine Care

- Ancef

Staph Screening Process

Laboratory gives CHG*

cloths to patient

Protocol Step 6

02/09/2011 *CHG = Chlorhexadine Gluconate

Patient gets Vancomycin Pre-op

STOP

Routine Care

- Ancef

Protocol Step 7


Results

50-70% Reduction in rates of Surgical site infection(2, 4)

Patients may remain (+) after decolonization(5, 6)

Cost Effective(7)

References

1. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint

infection in the United States. J Arthroplasty. 2012;27(8 Suppl):61-5 e1.

2. Kim DH, Spencer M, Davidson SM, Li L, Shaw JD, Gulczynski D, et al. Institutional

prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in

patients undergoing elective orthopaedic surgery. J Bone Joint Surg Am. 2010;92(9):1820-6.

3. Schwarzkopf R, Takemoto RC, Immerman I, Slover JD, Bosco JA. Prevalence of

Staphylococcus aureus colonization in orthopaedic surgeons and their patients: a prospective

cohort controlled study. J Bone Joint Surg Am. 2010;92(9):1815-9.

4. Rao N, Cannella BA, Crossett LS, Yates AJ, Jr., McGough RL, 3rd, Hamilton CW. Preoperative

screening/decolonization for Staphylococcus aureus to prevent orthopedic surgical site infection:

prospective cohort study with 2-year follow-up. J Arthroplasty. 2011;26(8):1501-7.

5. Baratz MD, Hallmark R, Odum SM, Springer BD. Twenty Percent of Patients May Remain

Colonized With Methicillin-resistant Staphylococcus aureus Despite a Decolonization Protocol in

Patients Undergoing Elective Total Joint Arthroplasty. Clin Orthop Relat Res. 2015;473(7):2283-90.

6. Moroski NM, Woolwine S, Schwarzkopf R. Is preoperative staphylococcal decolonization

efficient in total joint arthroplasty. J Arthroplasty. 2015;30(3):444-6.

7. Slover J, Haas JP, Quirno M, Phillips MS, Bosco JA, 3rd. Cost-effectiveness of a

Staphylococcus aureus screening and decolonization program for high-risk orthopedic patients. J

Arthroplasty. 2011;26(3):360-5.


10:08 am – 10:13 am

Risk Stratified VTE Prophylaxis after Total Hip Arthroplasty

Jay R. Lieberman, MD

Professor and Chairman

Department of Orthopaedic Surgery

Keck School of Medicine of USC

The selection of a prophylaxis agent is a balance between efficacy and safety. Total hip arthroplasty

patients receive DVT prophylaxis because orthopaedic surgeons are concerned about the morbidity

and mortality associated with pulmonary embolism. However, at the same time there is great con-

cern about excessive bleeding. The goal is to provide the appropriate anticoagulation to prevent

symptomatic pulmonary embolism and DVT but at the same time avoid over anticoagulation which

can be associated with bleeding and other wound problems. Therefore, risk stratification is neces-

sary.

Although risk stratification is the ideal way to determine the appropriate prophylaxis agent to use

for a specific patient, there is no validated risk stratification strategy available today. There is gen-

eral agreement at this time that patients who have had a prior PE or symptomatic DVT are at higher

risk for development of a pulmonary embolism. In addition, there is a general belief that patients

who have coagulation abnormalities (i.e. Factor V Leiden, Protein C and S deficiency) have an in-

creased risk of developing a pulmonary embolism. Other factors that have been mentioned as as-

sociated with PE after total hip arthroplasty include age, female gender, and higher body mass in-

dex. The selection of a prophylaxis regimen should be influenced by the ability to mobilize the pa-

tient after surgery.

References

1. Lieberman, J.R., Pensak, M.J. Prevention of Venous Thromboembolic Disease After Total

Hip and Knee Arthroplasty. J Bone Joint Surgery Am. 2013; 95(19):1801-1811.

2. Bohl, D.D., Maltenfort, M.G., Huang, R., Parvizi, J., Lieberman, J.R., DellaValle, C.J. Develop-

ment and Validation of a Risk Stratification System for Pulmonary Embolism Following Elec-

tive Primary Total Joint Arthroplasty. Presented at the Annual Meeting of the American Asso-

ciation of Hip and Knee Surgeons. Dallas, TX. November 7, 2015.

3. Nam, D., Nunley, R.M., Johnson, S.R., Keeney, J.A., Clohisy, J.C., Barrack, R.L. Thromboem-

bolism Prophylaxis in Hip Arthroplasty: Routine and High Risk Patients. J Arthroplasty. 2015

Jul 2. pii:S0883-5403(15)00579-3.

4. Parvizi, J., Huang, R., Raphael, I.J., Arnold, W.V., Rothman, R.H. Symptomatic Pulmonary

Embolus After Total Joint Arthroplasty: Stratification of Risk Factors. Clin Orthop Related Res.

2014 Mar; 472(3):903-12.


10:14 am – 10:19 am

Outpatient Joint Replacement

Michael E. Berend, MD

Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated a

recent transformation to same day discharge for arthroplasty care. The trend for early discharge

has already happened for procedures formerly regarded as “inpatient” procedures such as upper

extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff re-

pair. Our program began focused on Partial Knee Arthroplasty (PKA) and has now expanded to

primary TKA and THA, and select revision cases.

Over the past two-year period we have performed 1,230 Joint Arthroplasty procedures (THA, TKA,

PKA) with no readmissions for pain control. Overall readmission rate was 2% with approximately

half of the readmission being for outpatient manipulation under anesthesia following TKA. Patient

selection is based on medical screening criteria and insurance access. The program centers on the

patient, their family, home recovery, preoperative education, efficient surgery, and represents a

shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anes-

thesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space.

Perhaps the most significant developments in joint replacement surgery in the past decade have

been in the area of multimodal pain management. This has reduced length of stay in the inpatient

hospital environment opening the opportunity for cost savings and even outpatient joint replace-

ment surgery for appropriately selected patients. The hallmark of this program is meticulous proto-

col execution. Preemptive pain control with oral anti-inflammatory agents, gabapentin, regional

anesthetic blocks that preserve quad function for TKA (adductor canal block) and local anesthetic

spinal and pericapsular long acting local anesthetics with the addition of injectable ketorolac and

IV acetaminophen are key adjuncts. Over the past two years utilizing this type of program over 60%

of our joint arthroplasty patients are now returning home the day of surgery.

Concerns over readmission are appropriate. The rates of complications and readmissions are less

than our inpatient cohort in appropriately selected cases with a standardized care map. We believe

this brings the best VALUE to the patients, surgeons, and the arthroplasty system.

References

1. Edwards, et al. Avoiding Readmsisions – Support Systems Required after Discharge to Con-

tinue Rapid Recovery. J Arthoplasty 2015.


Session V: Taper Corrosion in Orthopaedic Devices – Newest Knowledge

11:11 am – 11:16 am

Dual Modular Necks in THA: How Big is the Problem?

What Caused the Problem? What Have we Learned?

Michael A. Mont, MD

Dual modular necks were introduced as a solution to the restrictions imposed by early monoblock

total hip arthroplasty (THA) implants. This allowed for intraoperative adjustment of femoral heads

and necks, better restoration of leg length, and increased control of hip offset. Because they ena-

ble a more customized fit to the patient, modular hip implants have gained popularity among sur-

geons. However, despite these advantages, modularity has recently been highlighted as a poten-

tial source of THA failure. Over time, modular components may exhibit signs of wear, corrosion,

and mechanical insufficiency. This talk will highlight the major issues associated with dual modu-

lar necks in THA. We will detail methods for diagnosis and treatment, updates on outcomes, and

our algorithm for the management of these patients.

1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee

arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4): 780, 2007

2. Shulman RM, Zywiel MG, Gandhi R, Davey JR, Salonen DC. Trunnionosis: the latest culprit in

adverse reactions to metal debris following hip arthroplasty. Skeletal Radiol 44(3): 433, 2015

3. Hernigou P, Queinnec S, Flouzat Lachaniette CH. One hundred and fifty years of history of the

Morse taper: from Stephen A. Morse in 1864 to complications related to modularity in hip

arthroplasty. Int Orthop 37(10): 2081, 2013

4. Gill IP, Webb J, Sloan K, Beaver RJ. Corrosion at the neck-stem junction as a cause of metal ion

release and pseudotumour formation. J Bone Joint Surg Br 94(7): 895, 2012


11:17 am – 11:22 am

When to Revise and What to Revise if Trunnionosis is Suspected?

Joshua J. Jacobs, MD

Department of Orthopaedic Surgery

Rush University Medical Center

Adverse local tissue reactions (ALTR) related to tribocorrosion at the head-neck junction in

metal-on-polyethylene (MOP) bearings have been described with increasing frequency. Diagnosis

and appropriate management, however, is not well understood. Our group has identified 27 patients

who were revised for an ALTR secondary to corrosion at the modular femoral head-neck taper with

a MOP bearing.1 Patients presented at a mean of 4.3 years (range, 0.4 to 25 years) after their index

procedure and were treated with debridement and a modular bearing exchange, with use of a ce-

ramic femoral head with a titanium sleeve in 23 of the 27 cases. Student’s t-test was used to com-

pare pre and postoperative metal levels with significance set at a p-value of < 0.05.

Preoperative serum cobalt levels were elevated to a greater degree than were chromium

levels in all cases, with a mean cobalt of 11.2 ppb (range, 1.1 to 49.8) and chromium of 2.2 ppb

(range, 0.2 to 9.8). Repeat metal levels (measured in 16 of 18 patients with > 2 year follow up)

showed a significant decrease in serum cobalt to a mean of 0.33 ppb (range 0.18 to 0.6) (p =

0.004), and chromium to a mean of 0.51 ppb (range 0.1 to 1.4) (p = 0.001). Recurrent ALTR was

noted in two cases where a metal as opposed to a ceramic head was used.

The diagnosis of ALTR secondary to corrosion at the head-neck taper in patients with a MOP

bearing is associated with serum cobalt levels of > 1 ppb with cobalt levels consistently elevated

above chromium. Retention of a well-fixed stem and modular exchange to a ceramic head leads to

resolution of symptoms and decreases in metal levels.

1. Plummer, D.R., Berger, R.A., Paprosky, W.G., Sporer, S.M., Jacobs, J.J., and Della Valle, C.J.

Diagnosis and Management of Adverse Local Tissue Reactions Secondary to Corrosion at

the Head-Neck Junction in Patients With Metal on Polyethylene Bearings. J Arthop 31:264-

268, 2016.


PROGRAM HIGHLIGHT: Presidential Guest Speaker

11:34 am – 11:50 am

Taper Corrosion in THA:

What Causes it and Why are We Seeing it Now?

Michael M. Morlock

Corrosion of metallic implants due to contact with body fluids is almost unavoidable, especially at

interfaces or in gaps. It has always been there but only anecdotally reported from the early days of

osteosynthesis and arthroplasty in combination with implant failure rather than biological reactions.

Taper corrosion became suddenly clinically relevant with the introduction of large modular metal-

on-metal hip joint articulations (MoM). With the use of large and very large metal heads in MoM

articulations, which have a larger lever arm and can generate high friction in unfavorable situations,

suddenly the taper interface exhibited problems on a previously unknown scale. Due to the higher

mechanical loading, the taper connection was more sensitive with respect to assembly conditions,

contamination, manufacturing tolerances, material choice and other factors such as taper design.

Changes to the taper design (reduction in length and diameter) made in the 1990’s to increase the

range of motion with small heads (28 and 32mm) have possibly reduced the mechanical strength

of this connection, which did ot matter for small heads or low friction situations. Smaller incisions

(less exposure of the taper) or increased patient weight or activity might also play a role in the

etiology of the problem.

Once the problem was identified, everybody started to look for signs of corrosion at tapers in any

kind of endoprosthesis and bearing articulation and such signs were found in nearly every kind of

taper connection. Most studies addressing the issue point out the multi factorial nature of the prob-

lem. Assembly load, head offset, flexural rigidity and contamination appear to be the principal fac-

tors involved in the development of “mechanically induced crevice corrosion”, as Jeremy Gilbert has

called it. The presently available findings for THA can be summarized in a few key statements:

- Taper connections have been used in millions of endoprosthesis and their benefits clearly out-

weigh the associated risks if used sensibly. The call for Monobloc prosthesis is over exaggerated.

- Every taper connection is a potential source of problems and assembly conditions are crucial for

a proper functioning.

- Taper corrosion can occur in any bearing articulation and head size if the assembly strength is

not sufficient.


- Taper design, material and surface morphology are important but the optimal parameters are

not known.

- Taper connections under high bending loads are more endangered (e.g. XL-heads, bi-modular

stem designs or modular revision stems).

- The critical amount of corrosion to produce a clinical relevant problem is yet unknown.

- Taper connections between similar Titanium alloys rather fail mechanically (fracture) than due

to biological reactions.

- Taper connections involving Cobalt-Chromium-Alloys rather fail due to biological reactions than

mechanically.

- Cells play a role in the corrosion process but the clinical relevance of this influence is yet un-

known.

- The use of ceramic heads of the last generation reduces the extent of the problem.

- The clinically observed phenomena cannot yet be fully reproduced in the laboratory setting; such

good results of pre-clinical testing cannot be directly transferred to the clinical reality.


Session VI: Top 3 New and Impactful Findings from Joint Registries Around the Globe

12:50 pm – 12:55 pm

Top 3 Impacts from the Australian Orthopaedic Association

National Joint Replacement Registry

Professor Richard de Steiger, Deputy Director AOANJRR

Introduction

The AOANJRR began data collection on 1st September 1999 and has had full national coverage

since 2002 Procedures reported to the Registry are cross validated with independently collected

state health department data in a sequential multilevel matching process, which enables almost

100% data collection.. The Registry has records of over 1 million hip and knee replacements and

revisions.

1 Outlier Prostheses

Joint Replacement Registries play a significant role in monitoring arthroplasty outcomes by publish-

ing data on survivorship of individual prostheses or combinations of prostheses. Although registry

data indicate that most prostheses have similar outcomes, some have a higher than anticipated

rate of revision when compared to all other prostheses in their class. The AOANJRR has developed

a method to report prostheses with a higher than expected rate of revision and these are referred

to as “outlier” prostheses. Using this process the Registry has identified 103 prostheses or prosthe-

ses combinations that have a higher than expected rate of revision compared to devices in their

own class up to Dec 31st 2013. Of these 95% showed reduced usage the following year and 55%

had no further recorded use.

The AOANJRR was the first registry to report a higher than expected rate of revision for the ASR

resurfacing Hip Arthroplasty in 2007 and the ASR XL Acetabular System in 2008. These prostheses

were withdrawn from the Australian market in 2009. The AOANJRR also identified early problems

with large head metal on metal conventional total hip arthroplasty reducing the exposure of patients

to these devices. The Registry also publishes 10 year outcomes of THA that have more than 350

procedures recorded and in 2014 28 of the 59 femoral and acetabular combinations had a 10

cumulative percent revision < 5%.

2 Surgeon effect on the outcome of Total Hip Arthroplasty

Patient, surgeon and prosthesis factors may affect the outcome of hip and knee replacement and

the relative importance of each of these elements is yet to be established. The Registry has under-

taken an analysis to determine if the rate of revision for THA is related to the number of procedures

a surgeon performs per year or the number of years a surgeon has been in practice. For the volume

of surgery analysis four groups were identified, surgeons who performed ≤10 procedures per year,

>10 ≤25, >25 ≤70 and >70 per year. For the experience analysis surgeons were grouped into those

surgeons who had been operating for < 3 years post fellowship, 3-7 years and ≥ 8 years


Surgeons averaging >70 procedures per year had a lower rate of revision than surgeons performing

less than 70 procedures for all the types of primary THA. However surgeons who do perform a lower

number of procedures can still have a low rate of revision when choosing well performing prosthe-

ses whereas surgeons undertaking a large number of procedures do not improve the outcome of a

prosthesis that has been identified as having a higher than expected rate of revision.

Overall, for all prostheses the most experienced group had a lower rate of revision than the 3-7 year

group and for the less experienced group only for the first 3 months. When a prosthesis specific

analysis was performed using the two most commonly implanted THA recorded in the registry there

was no effect of experience, once again suggesting choice of prosthesis is important.

3 Surgeon Access to AOANJRR

One of the aims of the registry is to provide information to the stakeholders in the form of presen-

tations, publications and the Annual Report. To provide more timely feedback surgeons can access

their own data on a secure WebPortal which provides information as soon as data is logged into the

registry. Surgeons can compare their own results against the overall national data. Surgeons who

have visited the website have a lower rate of revision than surgeons who have never accessed their

data.


12:56 pm – 1:01 pm

Three Important Findings from the National Joint Registry

of England, Wales, Northern Ireland and the Isle of Man

Martyn Porter, MD

1. There has been a secular decline in 90 day mortality following primary total hip replacement

between 2003 and 2011. The 90 day mortality was 0.56% in 2003 which fell to 0.29% in

2011. Factors associated with decreased mortality were: posterior approach, chemical

thromboprophylaxis and spinal anaesthesia. Type of prosthesis was unrelated to mortality.

2. Mix and match describes a situation whereby a surgeon mixes a component from one com-

pany (for example an acetabular component) with another component from another com-

pany (for example a femoral component). Historically this has been done in fairly large num-

bers where surgeons felt this would be of benefit This practise goes against current advise.

Analysis of this mix and match has revealed that in some instances survivorship is better

than non- mix and match and is not significantly worse in other situations. This provides

some reassurance in relation to this component selection.

3. Survivorship analysis at the ten year mark reveals that many difference brands with different

types of fixation have low revision rates and with comparable results. The traditional debate

of cemented versus cementless fixation is becoming less pertinent in that this analysis sug-

gests that it is the total hip construct, ie stem, acetabular component, liner, bearing materi-

als and fixation that are important in combination.


1:02 pm – 1:07 pm

Top Findings from Scandinavian Joint Registries

Henrik Malchau, MD, PhD

Boston, MA

The Nordic countries, including Denmark, Sweden, Finland, and Norway, have all had a long and

successful tradition of arthroplasty registries. Results presented by the Nordic registries have sug-

gested differences exist among the countries related to data collection system, data/variables be-

ing collected, data definition, and statistical methods used. Reports from the Nordic registries have

further shown differences regarding indication for surgery, characteristics of the joint replacement

populations, fixation methods used, and implant survival. Due to these differences, the results from

the different Nordic registries have not been fully comparable. Furthermore, although the Nordic

registries are population- based, the numbers of patients included in specific populations (e.g., pa-

tients that undergone joint replacement due to rheumatoid arthritis or patients operated due to

osteonecrosis) or the number of patients developing specific adverse events after surgery (e.g. re-

vision due to infection or periprosthetic fracture) are relatively small, limiting the statistical precision

of risk estimates and possibility to draw valid conclusions.

The Nordic registries have acknowledged these limitations and the need for collaboration across

national borders. Thus, the NARA was established in 2007 with the overall aim to improve the qual-

ity of their research and their understanding of the clinical course of patients undergoing joint re-

placement surgery, and thereby enhance the possibility for quality improvement of treatment with

joint replacement surgery.

In order to achieve the overall aim of NARA, several specific aims were set. These are summarized

below:

to create one common Nordic minimal dataset, in order to compare demographics and re-

sults regarding total joint replacement surgery among countries, and to study results in pa-

tient groups which are too small to be studied in each separate country.

to hold two yearly NARA meetings including two or more representatives from each register.

to hold an academic seminar at Nordic Orthopaedic Association meeting every other year.

to promote joint Nordic research where it will be of common interest and higher the quality.

to cooperate on methods developing in research and quality work in register studies.

to coordinate a joint Nordic standpoint towards other international register associations.

Relevant results from the NARA annual report for 2015 will be summarized.


1:08 pm – 1:13 pm

American Joint Replacement Registry (AJRR): High Level Update

Kevin J. Bozic, MD, MBA

Introduction

In Fall 2015, AJRR released their second Annual Report. Since that time, AJRR has enrolled more

hospitals and additional hospitals have begun submitting data.

Materials and Methods

Hospitals voluntarily submit data to the registry via secure electronic data file transfer of procedural

metrics extracted from the hospital’s electronic health record (EHR) system. The second Annual

Report included data from 2012-2014 (N=211,721 procedures). The report covered basic metrics

derived from the procedural information contained in the registry database. Each procedure im-

ported into the AJRR was subject to additional data verification prior to inclusion. Additionally, data

from a statistically powered sample (N=12 hospitals) was audited for accuracy (audit agreement

rate = 91.5%).

Results

The second Annual Report included data on N=211,721 procedures from N=236 hospitals (n=

82,841 hips and n=128,880 knees), doubling the number of hospitals submitting data compared

to the previous report. Procedures were performed by more than 2,200 surgeons. Results pertain-

ing to procedure and diagnosis codes were consistent with other registry findings as was the revi-

sion burden (10.0% for hips; 8.1% for knees). Procedural and component data reporting was greatly

enhanced compared to the previous Annual Report. Data demonstrate that femoral neck fracture

accounts for more than one in 10 hip arthroplasties. Surface replacement arthroplasty has fallen

to less than 0.5% of hip procedures. Moreover, there has been an increase in the use of ceramic

femoral heads compared to cobalt chromium (38.7% to 49.0% over the three year period). For knee

arthroplasties, posterior stabilized components were used in over half (57.8%) of all knee proce-

dures while cruciate retaining designs were used in nearly a third (29.6%). Patellar resurfacing

continues to be the predominant practice in the United States in contrast to Scandinavia, with

81.8% of patients receiving a patellar component in 2014. In 2014 AJRR also conducted a pilot

program of its Level II platform. Lab values, prophylaxis and data on beta blockers were not con-


sistently submitted if the element was not a discrete value in the EMR or if data was not originally

captured in the hospital. Submission of comorbidities was straightforward due to ICD-9 coding.

ICD-10 will allow for more granularity with these elements.

Conclusions

AJRR has made great progress throughout 2015 and has enrolled 600 hospitals representing all

50 states. Acquiring more procedures will enhance our ability to generalize data and conduct lon-

gitudinal analyses. Finally, AJRR began acceptance of Level III/Patient Reported Outcomes in 2015

and in 2016 will collect Level II data for risk adjustment of surgical complications.

Learning Objectives

1. After this presentation, learners will be able to describe the development of a national ar-

throplasty registry.

2. Participants will be able to discuss findings from the second AJRR Annual Report.

3. Attendees will have the ability to explain future directions for a national arthroplasty registry.


Session VII: Is Cross-Linked Poly Now the Bearing of Choice?

1:29 pm – 1:34 pm

13-Year Evaluation of Highly Cross-Linked Polyethylene Articulating with Either 28mm or

36mm Femoral Heads Using Radiostereometric Analysis and Computerized Tomography

Audrey K. Nebergall1; Meridith E. Greene1; Henrik Malchau1;

Anders Troelsen1, 2; Ola Rolfson1, 3; Harry Rubash1

1Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA

2Department of Orthopaedics Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark

3Department of Orthopaedics

Institute of Clinical Sciences at Sahlgrenska Academy

University of Gothenburg

Gothenburg, Sweden

Background

The objective of this 13 year prospective evaluation of HXLPE was to (1) assess the long-term wear

of HXLPE articulating with 2 femoral head sizes using radiostereometric analysis (RSA), and to (2)

determine if osteolysis is a concern with this material through the use of plain radiographs and

computerized tomography (CT).

Methods

All patients received a Longevity® HXLPE liner with tantalum beads and either a 28mm or 36mm

femoral head. Twelve patients (6 in each head size group) agreed to return for 13 year RSA, plain

radiograph, and CT follow-up. The 1 year and 13 year plain radiographs as well as the CT scans

were analyzed for the presence of osteolysis.

Results

The 13 year mean ± standard error steady state wear was 0.05 ± 0.02mm with no significant in-

crease over time or between the 2 head size groups. Two patients’ CT scans showed radiolucent

regions in the acetabulum of 4.51cm3 and 11.25cm3, respectively. In one patient, this area corre-

sponded to a partially healed degenerative cyst treated with autograft during surgery. The second

patient had an acetabular protrusio treated with autograft and the CT scan revealed areas of re-

modeling of this graft. One patient’s 13 year plain radiographs showed evidence of cup loosening,

and linear radiolucencies in zones 2 and 3.

Conclusion

There was no evidence of significant wear over time using RSA. The CT scans did not show evidence

of osteolysis due to wear particles. These results suggest that this material has reduced wear com-

pared to conventional polyethylene, irrespective of head size.

Key words: Total hip arthroplasty, highly cross-linked polyethylene, radiostereometic analysis, com-

puterized tomography


1:35 pm – 1:40 pm

Highly Crosslinked Polyethylene Provides Decreased

Osteolysis and Reoperation at Minimum 10 Years Followup

Paul F. Lachiewicz, MD

Chapel Hill, NC

Background

Highly cross-linked polyethylene was introduced to decrease periprosthetic osteolysis and reopera-

tion, but this has not been conclusively proven.

Questions/Purposes

We asked the following questions: (1) What is the long-term survival of a modern, cementless tita-

nium acetabular component with screw fixation? (2) What are the differences in the rate of reoper-

ation and incidence of osteolysis between components with standard and highly cross-linked poly-

ethylene at minimum 10 years follow-up time?

Methods

One surgeon performed 513 consecutive primary total hip arthroplasties (450 patients) using one

modern, cementless, titanium-mesh acetabular component (Trilogy) with screw fixation. Standard

polyethylene was used in 304 hips and highly cross-linked polyethylene (Longevity) in 209 hips.

Survivorship analysis to 20 years was performed using the entire cohort. We analyzed the rate of

reoperation and radiographic osteolysis in two cohorts of hips, 133 with standard polyethylene and

112 with highly cross-linked polyethylene, with a minimum follow-up time of 10 years.

Results

Of the entire cohort of 513 hips, no acetabular component was removed or revised for aseptic

loosening. With a minimum follow-up of 10 years, there were significantly more reoperations in the

cohort with standard polyethylene (11 of 133, 8%) than highly crosslinked polyethylene (1 of 112,

1%; p=0.03). Osteolysis was seen in 24% (32 of 133 hips) with standard polyethylene, compared

to 13% (15 of 112 hips) with highly cross-linked polyethylene (p=0.02). These differences occurred

despite the presence of patients with greater BMI and higher activity in the cohort with highly cross-

linked polyethylene.

Conclusions

We continue to use this acetabular component with highly cross-linked polyethylene. Longer follow-

up is required to determine the progression of osteolysis.


1:41 pm – 1:46 pm

Ceramic vs. Metal Femoral Heads: What is the Role for Each in 2016?

Thomas P. Schmalzried, MD

Compared to cobalt chromium alloy, ceramic femoral heads wear less against UHMWPE,

although the reduction may not be clinically significant when paired with a cross-linked polyethylene.

In the Australian national joint replacement registry, of the five bearing combinations with 14 year

cumulative percent revision (CPR) data, the lowest is metal femoral heads with cross-linked poly-

ethylene (5.4%). Using ceramic or metal femoral heads with non cross-linked polyethylene results

in the highest CPR at 14 years (11.4% and 9.9%, respectively) (1).

The utilization of ceramic heads has increased in recent years. Domestically, more than

50% of femoral heads are now ceramic. This is due, at least in part, to a reduction in patient age

at the time of surgery. A stronger influence, however, may be the concern for an adverse local tissue

reaction (ALTR) due to taper corrosion with a cobalt chromium femoral head (2). Taper corrosion

necessitating revision surgery was recognized decades ago (3-4), and there are concerns that the

incidence is increasing. Variables in design, manufacturing, biomechanics, and modular head as-

sembly have all been implicated (5). While the incidence of clinically significant taper corrosion is

unknown, ALTR does not appear to occur absent a cobalt chromium interface. Ceramic heads have

a small risk of in vivo fracture (6) and cost more. The relative benefit of ceramic heads is greatest

in younger, more active patients, if there is a long-term reduction in wear and osteolysis, and the

fracture risk remains low.

References

1. Australian Orthopaedic Association Annual Joint Replacement Registry 2015 https://ao-

anjrr.dmac.adelaide.edu.au/en/annual-reports-2015

2. Cooper HJ, Della Valle CJ, Berger RA, Tetreault M, Paprosky WG, Sporer SM, Jacobs JJ. Cor-

rosion at the head-neck taper as a cause for adverse local tissue reactions after total hip

arthroplasty. J Bone Joint Surg Am. 2012 Sep 19;94(18):1655-61.

3. Svensson O, Mathiesen EB, Reinholt FP, Blomgren G. Formation of a fulminant soft-tissue

pseudotumor after uncemented hip arthroplasty. A case report. J Bone Joint Surg Am. 1988

Sep;70(8):1238-42.

https://aoanjrr.dmac.adelaide.edu.au/en/annual-reports-2015

https://aoanjrr.dmac.adelaide.edu.au/en/annual-reports-2015







4. Gilbert JL, Buckley CA, Jacobs JJ, Bertin KC, Zernich MR. Intergranular corrosion-fatigue fail-

ure of cobalt-alloy femoral stems. A failure analysis of two implants. J Bone Joint Surg Am.

1994 Jan;76(1):110-5.

5. Goldberg JR1, Gilbert JL, Jacobs JJ, Bauer TW, Paprosky W, Leurgans S. A multicenter retrieval

study of the taper interfaces of modular hip prostheses. Clin Orthop Relat Res. 2002

Aug;(401):149-61.

6. Massin P, Lopes R, Masson B, Mainard D; French Hip & Knee Society (SFHG).

Does Biolox Delta ceramic reduce the rate of component fractures in total hip replacement?

Orthop Traumatol Surg Res. 2014 Oct;100(6 Suppl):S317-21.



http://www.ncbi.nlm.nih.gov/pubmed/?term=Goldberg%20JR%5BAuthor%5D&cauthor=true&cauthor_uid=12151892

http://www.ncbi.nlm.nih.gov/pubmed/?term=Gilbert%20JL%5BAuthor%5D&cauthor=true&cauthor_uid=12151892

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jacobs%20JJ%5BAuthor%5D&cauthor=true&cauthor_uid=12151892

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bauer%20TW%5BAuthor%5D&cauthor=true&cauthor_uid=12151892

http://www.ncbi.nlm.nih.gov/pubmed/?term=Paprosky%20W%5BAuthor%5D&cauthor=true&cauthor_uid=12151892

http://www.ncbi.nlm.nih.gov/pubmed/?term=Leurgans%20S%5BAuthor%5D&cauthor=true&cauthor_uid=12151892

http://www.ncbi.nlm.nih.gov/pubmed/?term=goldberg+jr+2002



1:47 pm – 1:52 pm

Ceramic-on-Ceramic Bearings in 2016:

A Perspective from Outside the United States

Carsten Perka, MD (Berlin, Germany)

The number of young patients needing a total hip arthroplasty (THA) is increasing continuously. Due

to the higher life expectancy of these patients wear-related problems are the most established long

term risk factors for aseptic failure. Particularly the higher activity of young patients leads to high

demands especially the bearings after total hip arthroplasty. Resulting in a current progress of alu-

mina ceramic-on-ceramic bearings and mixed ceramics these materials are an increasingly attrac-

tive bearing solution.

Modern ceramics are extremely hard, scratch-resistant, biocompatible, offer a low coefficient of

friction, have superior lubrication and the lowest wear rates in comparison to all other bearings in

THA.

Concerns regarding the use of ceramics are the risk of fracture, the occurrence of noises and as a

potential long term risk the stress shielding behind the relatively stiff acetabular component.

The data of the newest generation of mixed ceramics (delta ceramic) are showing a reduction of the

risk of head fractures on 0.03-0.05 %, and a risk of liner fractures at about 0.02 %. These fracture

rates are lower than the risk of stem fracture in almost all registries. The causes for noises of ce-

ramic-ceramic bearings (“The squeaking hip”) are not fully understood. The cup and stem design1,

malpositioning of the components with resulting edge loading and impingement2, the loss of lubri-

cation3, a higher BMI and an unstable hip are discussed.

Nevertheless the overwhelming number of papers shows excellent results especially in younger and

more active patients. The correct operative technique resulting in a stable hip without malaligne-

ment of the components and without impingement is certainly more important than in other bear-

ings. In case of a non-impinging component implantation, ceramic-on-ceramic bearings have sub-

stantial advantages over all other bearings in THA. Due to the superior hardness, ceramic bearings

produce less third body wear and are virtually impervious to damage from instruments during the

implantation process4. The increasing number of used ceramic-ceramic bearings in Europe and the

current results in literature show the growing confidence because of excellent clinical results.


1. Hothan A, Huber G, Weiss C, Hoffmann N, Morlock M. The influence of component design, bear-

ing clearance and axial load on the squeaking characteristics of ceramic hip articulations. J Bio-

mech. 15;44(5):837-41, 2011.

2. Restrepo C, Post ZD, Kai B, Hozack WJ. The effect of stem design on the prevalence of squeak-

ing following ceramic-on-ceramic bearing total hip arthroplasty. J Bone Joint Surg Am. 92(3):550-

7, 2010

3. Chevillotte C, Trousdale RT, Chen Q, Guyen O, An KN. The 2009 Frank Stinchfield Award: "Hip

squeaking": a biomechanical study of ceramic-on-ceramic bearing surfaces. Clin Orthop Relat

Res. 468(2):345-50, 2010.

4. Sentuerk U, von Roth P, Perka C. Ceramic on ceramic arthroplasty of the hip: new materials con-

firm appropriate use in young patients. Bone Joint J. ;98-B(1 Suppl A):14-7, 2016.

5. Hu D, Tie K, Yang X, Tan Y, Alaidaros M, Chen L. Comparison of ceramic-on-ceramic to metal-on-

polyethylene bearing surfaces in total hip arthroplasty: a meta-analysis of randomized controlled

trials. J Orthop Surg Res.3;10:22, 2015.


1:53 pm – 1:58 pm

Dual Mobility Implants: What is Their Role in Primary THA?

Jean-Noel Argenson, Remi Philippot, Matthieu Ollivier,

Sebastien Parratte, Xavier Flecher

The Institute for Locomotion, Marseille, France

The Bellevue Hospital, Saint-Etienne, France

Introduction

The main reason for revision following primary Total Hip Arthroplasty (THA) remains dislocation.

The cumulative risk of dislocation in primary THA has been described to be 7% at twenty-five years.1

Dual Mobility (DM) implants have been proposed to reduce the incidence of dislocation both in

primary and revision THA.

The Concept

Dual mobility (DM) THA as described by Bousquet in the seventies, aims to combine two fundamen-

tal principles: large diameter bearings with increased jump distance to provide stability, and low-

friction arthroplasty with smaller-diameter heads to produce less wear. The first generation of DM

implants was associated with two issues: intra-prosthetic dislocation due to cam effect and wear

between the retentive liner and the prosthetic neck, late cup loosening particularly in patients

younger than 65 years. These failures were mainly attributable to delamination of the alumina coat-

ing sintered on a nonporous surface, resulting in third-body wear.

The Results

The series investigating the use of first generation DM implants in primary THA exhibited a very low

dislocation rate (0 to 0.88%) and a 93% to 96% survivorship at ten years.2,3 The early results of

second generation DM implants, as recently described in a prospective series of 100 patients at a

mean follow-up of 6 years did not found any dislocation or revision 4 .

The Indications: Dual-mobility cups are widely used in some countries in both primary and revision

THA. In primary THA the most commonly admitted indications for primary DM implants include: pa-

tients older than 75, patients with constitutional hyperlaxity and/or previous history of dislocation

on a contralateral THA, patients with neurologic disease impairing locomotion such Parkinson or

hemiplegia, patients with cognitive impairment (such Alzheimer’s disease or dementia), and post-

fracture THA. The long-term results of second generation DM implants might condition the expan-

sion of indication to younger patients in primary THA 4, 5.

References

1. Berry DJ, von Knoch M, Schleck CD, Harmsen WS (2004) The cumulative long-term risk of

dislocation after primary Charnley total hip arthroplasty. J Bone Joint Surg Am 86-A:9–14

2. Philippot R, Camilleri JP, Boyer B, Adam P, Farizon F (2009) The use of a dual-articulation

acetabular cup system to prevent dislocation after primary total hip arthroplasty: analysis of

384 cases at a mean follow-up of 15 years. Int Orthop 33(4):927–932


3. Combes A, Migaud H, Girard J, Duhamel A, Fessy MH (2013) Low rate of dislocation of dual-

mobility cups in primary total hip arthroplasty. Clin Orthop Relat Res 471(12):3891–3900

4. Vermersch T, Viste A, Desmarchelier R, Fessy MH (2015) Prospective longitudinal study of

one hundred patients with total hip arthroplasty using a second-generation cementless

dual-mobility cup. Int Orthop Nov;39(11):2097-101

5. Loving LQ, HerreraL, Banerjee S, Heffernan C Nevelos J, Markel DC, Mont MA (2015) Dual

Mobility Bearings Withstand Loading From Steeper Cup-inclinations Without Substantial

Wear. J Orthop Res 33:398–404t





1:59 pm – 2:04 pm

Failed Metal-On-Metal:

Current Diagnostic Algorithms and Guidelines

Thomas K. Fehring, MD

OrthoCarolina Hip and Knee Center

Metal-on-metal total hip arthroplasties were heralded as a solution for hip instability and wear in-

duced periprosthetic osteolysis. Unfortunately the advent of adverse local tissue reactions (ALTRs)

has tempered enthusiasm for this bearing option. Not unlike metal-on-plastic bearings, patients

have a variable response to metal debris and therefore there are variable thresholds for when co-

balt and chromium may lead to ALTRs.

The challenge for arthroplasty surgeons is to diagnose ALTRs before they occur. Unfortunately there

is no single diagnostic test to accurately diagnose ALTR. Similar to the work-up for periprosthetic

infection, multiple clinical and diagnostic variables must be considered when evaluating a patient

presenting with a painful metal-on-metal hip arthroplasty. However regardless of the bearing sur-

face, all diagnostic possibilities must be considered before indicting the bearing surface as the

cause of pain.

The salient clinical signs of a malfunctioning bearing include pain, mechanical symptoms, and ab-

ductor weakness. Implant and design considerations which are concerning include monoblock

cups, surface replacement in small females, acetabular components with a functional arc less than

a hemisphere, modular neck implants, and a cup malpositioned with a high abduction angle or a

version abnormality.

Metal ion levels (cobalt-chromium) and cross-sectional imaging are the main diagnostic tools in

assessing the metal-on-metal patient. While a diagnostic ion level threshold (>7) has been sug-

gested as important, the correlation between ion levels and tissue necrosis has been questioned (1). Cross-sectional imaging in the form of ultrasound and metal artifact suppression MRIs (MARS)

are useful diagnostic tools. However, at this time the presence of pain is insufficient to identify or

rule-out ALTR. Cross-sectional imaging abnormalities have been identified in asymptomatic pa-

tients in both metal-on-metal and metal-on-poly total hips (2,3).

Therefore, decisions on revision surgery should not be made on isolated ion levels or isolated cross

sectional imaging abnormalities. Similar to the algorithm for periprosthetic infection, multiple clin-

ical and diagnostic variables must be taken into account before recommending revision surgery. A

risk stratification strategy has been described to help guide the decision making process (4, 5).


References

1. Griffin WL, Fehring TK, Kudrna JC, Schmidt RH, Christie MJ, Odum SM, Dennos AC: Are metal

Ion Levels a Useful Trigger for Surgical Intervention? J Arthroplasty 27 Suppl 8, 2012, 36-36.

2. Fehring TK, Odum S, Sproul R, Weathersbee J: High Frequency of Adverse Local Tissue Reactions

in Asymptomatic Patients with Metal-on-Metal THA. Clin Orthop Relat Res 472, 2014, 517-522.

3. Fehring TK, Fehring K, Odum SM: Metal Artifact Reduction Sequence MRI Abnormalities Occur

in Metal-on-polyethylene Hips, Clin Orthop Relat Res 473, 2015, 574-580. 4. Kwon YM, Fehring

TK, Lombardi AV, Barnes CL, Cabanela ME, Jacobs JJ: Risk Stratification Algorithm for Management

of Patients with Dual Modular Taper Total Hip Arthroplasty: Consensus Statement of the American

Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons and the

Hip Society. J Arthroplasty 29 (11), 2014, 2060-2064.

5. Kwon YM, Lombardi AV, Jacobs JJ, Fehring TK, Lewis CB, Cabanela ME: Risk Stratification Algo-

rithm for Management of Patients with Metal-on-Metal Hip Arthroplasty: Consensus Statement of

the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Sur-

geons, and the Hip Society. J Bone Joint Surg Am 96:e4 , 2014.


Session VIII: How Do We Ideally Position the Acetabular Component?

2:20 pm – 2:25 pm

Spinopelvic Motion and Cup Placement in THR

Lawrence D. Dorr, MD

Recent research initiated by Lazennec et al [1] has focused attention on the importance of spinopel-

vic balance, and correct cup inclination and anteversion in THR. Our research identified three cat-

egories of spinopelvic balance/imbalance, and correlated these to inclination and anteversion [2].

Our current research extends that knowledge by defining the types of imbalance that create an “at-

risk for impingement” cup position during postural change of sitting and standing. The pelvis nor-

mally shifts from anterior tilt while standing to posterior tilt while sitting (sacral tilt [ST] is 40o stand-

ing to 20o sitting), and with the posterior tilt the acetabulum opens in both inclination and antever-

sion to allow clearance for the flexed femur. This change in cup position from standing to sitting as

seen on the lateral spinopelvic hip x-rays is termed ante-inclination. With spinal imbalance caused

by arthritis or surgical fusion [3], there are 4 distinct patterns which create risks for impingement

and its consequences of dislocation, edge loading and wear, and impingement pain. Most com-

monly imbalance is caused by stiffness of the construct (∆ST from stand-sit < 12o). So, acetabular

opening does not occur. Therefore, cup positions necessary with stiff constructs must provide a

mechanical opening of the acetabulum to compensate for the absent biological opening so that the

sitting ante-inclination is >45o with sacral acetabular angle >65o.

The first pattern is a flat pelvis-stiff in which the ST standing is 30o or less (normal standing is 40o

+/- 5o) with ∆ST <12o. Cup inclination must be 45o-50o, anteversion of 20o-25o, to keep normal

ante-inclination; the hip off-set should be increased 5 mm to prevent bone-bone impingement of

the trochanter/posterior femur against the pelvis with hip extension. If the ∆ST is <10o, the standing

absolute ST is <20o and especially if the patient has a low pelvic incidence (PI) we use a Dual Mo-

bility cup.

The second pattern is flat pelvis-flex and the difference from the first pattern is with sitting the ST

is near 0 with the spine having a reverse tilt (kyphosis). The ∆ST may be in the normal range (13o-

27o is a pathological posterior tilt, with the standing ST <30o) that creates abnormal flexibility. The

cup needs the same position as with flat-stiff.


The third pattern is anterior-stiff in which the spine is stiff in lordosis so the pelvis has anterior tilt

even with sitting. Since there is no posterior tilt of the pelvis the acetabulum remains closed with

sitting, creating a risk of impingement with the flexed femur causing posterior dislocation. The cup

must be mechanically opened with 45o inclination and 20o-25o anteversion. If this imbalance has

∆ST <10o we use a Dual Mobility cup.

A fourth pattern is the excessively flexible hip which has ∆ST of 30o or more with an absolute stand-

ing ST of 45o or more. In these hips the acetabulum opens wide with sitting so cup inclination

should be 35o-40o and anteversion 15o-20o to keep ante-inclination of the cup below 70o. Ante-

inclination of 70o or more creates risk for drop out dislocation.

References

1. Lazennec J-Y, Boyer P, Gorin M, Catonné Y, Rousseau MA. Acetabular anteversion with CT in

supine, simulated standing, and sitting positions in a THA patient population. Clin Orthop

Relat Res. 2011;469(4):1103-1109. doi:10.1007/s11999-010-1732-7.

2. Kanawade V, Dorr LD, Wan Z. Predictability of Acetabular Component Angular Change with

Postural Shift from Standing to Sitting Position. J Bone Joint Surg Am. 2014;96(12):978-986.

doi:10.2106/JBJS.M.00765.

3. Buckland AJ, et al. Acetabular anteversion changes due to spinal deformity correction: Bridg-

ing the gap between hip and spine surgeons. J Bone Joint Surg Am 2015;97:1913-20.


2:26 pm – 2:31 pm

The Impact of Lumbar Spine Pathology

on Functional Hip Position

Douglas E. Padgett, MD; Christina Esposito, PhD; David J. Mayman, MD;

Seth A. Jerabek, MD; Han Jo Kim, MD; Ted Miller, MD; Kaitlin M. Carroll, BS;

Brian Barlow, MD; Joe Lipman, MS; Timothy M. Wright, PhD

Hospital For Special Surgery

New York, NY

Acetabular component position has long been implicated in stability and wear in total hip arthro-

plasty. Optimal position has been elusive. The inability to determine a “safe zone” for stability has

been attributed partly due to failure to include femoral position in the analysis as well as the impact

of pelvic alignment. Work from our center has suggested the importance of determining pelvic tilt

and adjusting acetabular version accordingly1.

Recognizing that pelvic mobility is inherently linked to spinal mobility, we investigated the impact of

lumbar spine degeneration upon pelvic motion in the sagittal plane. 325 consecutive patients un-

dergoing primary THR were evaluated using EOS© imaging. Images were captured in both standing

and sitting. The goal sitting was to align the femur to be parallel to the floor to achieve at close to

“90” as possible using an adjustable stool. Each lumbar disc space was evaluated for facet arthro-

sis, height narrowing, and end plate changes. A spine with 3 or more degenerative segments was

labelled degenerative disc disease (DDD). Measurements included sacral slope, lumbar lordosis,

and femoral angle for both standing and sitting.

Our analysis found that patients with DDD had:

-Stand with less lumbar lordosis resulting in more posterior pelvic tilt

-Sit with more lumbar lordosis and less posterior tilt

-Require more flexion through the femur to achieve 90o

Patients with DDD and limited pelvic posterior tilt may be at risk for impingement and considera-

tion of increased socket anteversion may be warranted.

Maratt et al, Pelvic tilt in patients undergoing total hip arthroplasty: when does it matter? J Arthro-

plasty 2015


2:32 pm – 2:37 pm

Socket Position and the Risk of Dislocation

after Revision Total Hip Arthroplasty

Anita Sadhu, MD; Denis Nam, MD; Benjamin Coobs, MD;

Toby Barrack; Robert L. Barrack, MD

Washington University School of Medicine

Acetabular component positioning is considered a surgeon-controlled variable affecting stability fol-

lowing total hip arthroplasty (THA). Recently, the importance of the traditional Lewinnek “safe zone”

for acetabular alignment (5°-25° of anteversion and 30°-50° of inclination) on dislocation risk has

been questioned following primary THA. The purpose of this study was to compare cup alignment

in revision THAs that have sustained a postoperative dislocation to a group of matched revision

THAs without dislocation.

A database of revision THA’s that subsequently incurred dislocation was compiled from surgical

clinic, emergency room, and operating room medical records. Revision diagnoses were limited to

osteolysis, aseptic loosening, polyethylene wear, and metallosis. This cohort was matched to a

cohort of revision THA controls (non-dislocators) for surgical approach, gender, age (± 2 years), BMI

(± 2 points), and revision diagnosis. Acetabular component position was measured using Martell

Hip Analysis Suite. The percentage of patients in each cohort within the traditional “safe zone” was

compared using Chi-square analyses.

60 revision THAs sustaining a dislocation and 60 revision THAs without dislocation were included

for analysis. All subjects examined had undergone a posterior approach for each hip procedure.

The percentage of dislocating revision THA’s within the safe zone for both inclination and antever-

sion was 47% (28 of 60) versus 66% (40 of 60, p=0.03) in the control cohort. For inclination only,

66% of dislocators (40 of 60) and 88% of non-dislocators (53 of 60, p=0.005) were within the safe

zone. For anteversion only, 70% of dislocators (42 of 60) and 73% of non-dislocators (44 of 60,

p=0.6) were within the safe zone.

While numerous factors affect hip stability, this matched-cohort study suggests that acetabular

component positioning remains an important variable in decreasing the risk of dislocation following

revision THA. As optimal patient-specific component positioning continues to be an area of future

investigation, targeting the traditional safe zone remains a suitable goal to decrease the risk of

dislocation following revision THA.


References

1. Lewinnek, G. E., et al. (1978). "Dislocations after total hip-replacement arthroplasties." J

Bone Joint Surg Am 60(2): 217-220.

2. Danoff, J. R., et al. (2015). "Redefining the Acetabular Component Safe Zone for Posterior

Approach Total Hip Arthroplasty." J Arthroplasty.

3. Abdel, M. P., et al. (2015). "What Safe Zone? The Vast Majority of Dislocated THAs Are Within

the Lewinnek Safe Zone for Acetabular Component Position." Clin Orthop Relat Res.


THE HIP SOCIETY AWARDS

2:58 pm – 3:03 pm

The John Charnley Award

The Missing Link: Re-Defining the Natural Progression of

Osteoarthritis in Patients with Hip Dysplasia and Impingement

Rafael J. Sierra, MD; Cody C. Wyles, BS; Mark J. Heidenreich, MD;

Jack Jeng, MD; Dirk R. Larson, MD; Robert T. Trousdale, MD

Background

Structural hip deformities including developmental dysplasia of the hip (DDH) and femoroacetabu-

lar impingement (FAI) are thought to predispose patients to degenerative joint changes. However,

the natural history of these malformations is not clearly delineated.

Questions/Purposes

Among patients undergoing unilateral THA that have a contralateral hip without any radiographic

evidence of hip disease, what is the natural history and progression of osteoarthritis in the native

hip based on morphological characteristics? Among patients undergoing unilateral THA that have a

contralateral hip without any radiographic evidence of hip disease, what are the radiographic pa-

rameters that predict differential rates of degenerative change?

Methods

Seven-hundred twenty-two patients ≤55 years that received unilateral primary total hip arthroplasty

(THA) from 1980-1989 were identified. Preoperative radiographs were reviewed on the contrala-

teral hip and only hips with Tönnis Grade 0 degenerative change that had minimum 10-year radio-

graphic followup were included. Radiographic metrics in conjunction with the review of two experi-

enced arthroplasty surgeons determined structural hip diagnosis as DDH, FAI, or normal morphol-

ogy. Every available follow-up AP radiograph was reviewed to determine progression from Tönnis

Grade 0–3 until the time of last follow-up or operative intervention with THA. Survivorship was ana-

lyzed by Kaplan-Meier methodology, hazard ratios, and multi-state modeling.

Results

One-hundred sixty-two patients met all eligibility criteria with the following structural diagnoses: 48

DDH, 74 FAI, and 40 normal. Mean age at the time of study inclusion was 47 years (range 18-55),

with 56% females. Mean follow-up was 20 years (range 10 – 35 years). Thirty-five patients eventu-

ally required THA: 16 (33.3%) DDH, 13 (17.6%) FAI, 6 (15.0%) normal. Kaplan-Meier analysis

demonstrated that patients with DDH progressed most rapidly, followed by FAI, with normal hips

progressing the slowest. The mean number of years spent in each Tönnis stage by structural mor-

phology was as follows: Tönnis 0: DDH = 17.0 years, FAI = 14.8 years, normal = 22.9 years; Tönnis

1: DDH = 12.2 years, FAI = 13.3 years, normal = 17.5 years; Tönnis 2: DDH = 6.0 years, FAI = 9.7

years, normal = 8.6 years; Tönnis 3: DDH = 1.6 years, FAI = 2.6 years, normal = 0.2 years.

Analysis of degenerative risk for categorical variables showed that patients with femoral head lat-

eralization >10 mm, femoral head extrusion indices >0.25, acetabular depth-to-width index <0.38,

lateral center-edge angle <25°, and Tönnis angle >10° all had a greater risk of progression from

Tönnis 0 to Tönnis 3 or THA. Among patients with FAI morphology, femoral head extrusion indices


>0.25, lateral center-edge angle <25°, and Tönnis angle >10° all increased the risk of early radi-

ographic progression. Analysis of degenerative risk for continuous variables using smoothing

splines showed that risk was increased for the following: femoral head lateralization >8 mm, femo-

ral head extrusion index >0.20, acetabular depth-to-width index <0.30, lateral center-edge angle

<25°, and Tönnis angle >8°.

Conclusions

This study defines the long-term natural history of DDH and FAI in comparison to structurally normal

young hips with a presumably similar initial prognostic risk (Tönnis Grade 0 degenerative change

and contralateral primary THA). In general, the fastest rates of degenerative change were observed

in patients with DDH. Furthermore, risk of progression based on morphology and current Tönnis

stage were defined, creating a new prognostic guide for surgeons. Lastly, radiographic parameters

were identified that predicted more rapid degenerative change, both in continuous and categorical

fashions, subclassified by hip morphology.

Level of Evidence

Level II prognostic study


3:04 pm – 3:09 pm

The Otto AuFranc Award

A Multi-Center, Prospective, Randomized Study of

Outpatient versus Inpatient Total Hip Arthroplasty

Nitin Goyal, MD; Antonia F. Chen, MD, MBA; Sarah E. Padgett, PA-C; Timothy L. Tan, MD; Michael

M. Kheir, BS; Robert H. Hopper, Jr., PhD; William G. Hamilton, MD; William J. Hozack, MD

Background

Length of stay following total hip arthroplasty (THA) has slowly decreased over the last two decades,

mirroring trends for other procedures commonly performed in many surgical specialties. However,

published studies that have examined same day and “early” discharge protocols after THA are in

highly selected patient groups done by senior surgeons in a nonrandomized fashion without con-

trols.

Questions/Purposes

The first purpose of this prospective, randomized, multi-center study was to evaluate and compare

THA patients who are discharged on the same day as their surgery (“Outpatient,” less than 12 hour

stay) to those who are discharged after an overnight hospital stay (“Inpatient”) with regards to the

following outcomes: (1) patient-reported satisfaction, (2) postoperative pain, (3) peri-operative com-

plications and healthcare provider visits (urgent care/emergency department, readmission, or phy-

sician office) and (4) relative work effort for the surgeon's office staff. A secondary purpose of this

study was to determine if there are specific patient or surgical factors that are associated with dis-

charge on the day of THA surgery, and if these factors can be identified preoperatively.

Methods

A prospective, randomized study was conducted at two high-volume adult reconstruction centers

between September 2014 and June 2015. Among 209 subjects who were all under the age of 75

years at surgery with a body mass index (BMI) less than 40 kg/m2, 106 were randomized to the

Outpatient group and 103 were randomized to the Inpatient group. All subjects had a primary THA

performed by the direct anterior approach with spinal regional anesthesia at a hospital facility.

Results

On the day of surgery, subjects who were discharged the same day had higher VAS satisfaction than

those who remained in the hospital for one or more nights (96 versus 86, p=0.009) but there was

no difference on the day after surgery (90 versus 89, p=0.55). At 4-week follow-up, the subjects

who were discharged the same day had higher VAS satisfaction than those who remained in the

hospital for one or more nights (89 versus 81, p<0.001). On the day of surgery, subjects who were

discharged the same day had lower VAS pain than those who remained in the hospital for one or

more nights (2.3 versus 3.9, p<0.001). This trend was reversed on the first day after surgery when

subjects who were discharged the same day had higher VAS pain (at home) than those who re-

mained in the hospital for one or more nights (4.0 versus 2.8, p<0.001). At 4-week follow-up, there

was no difference in VAS pain among subjects who were discharged the same day and those who

remained in the hospital for one or more nights (1.4 versus 2.0, p=0.26). There was no difference

in reoperations, visits to primary care physicians (PCPs), specialists, urgent care centers, emergency

departments (EDs), or readmission between the two groups (p>0.05). At 4-week follow-up, there

was no difference in the number of phone calls and emails with the surgeon’s office (p=0.13).


Of the 106 subjects randomized to outpatient surgery, 81 (76%) were discharged as planned. The

remaining 25 subjects were discharged after one night in the hospital. There was no difference in

age (59.6 versus 61.5 years, p=0.26) or gender (46% versus 56% female, p=0.25) for the 81 dis-

charged on the day of their surgery compared to the 25 who stayed overnight. Of the 103 subjects

randomized to inpatient surgery with an overnight hospital stay, 79 (77%) were discharged as

planned. Of the remaining 24 subjects, 16 met the discharge criteria on the day of their surgery and

elected to leave the same day while eight subjects stayed more than one night. The 16 subjects

randomized to inpatient surgery who elected to leave the same day were younger (53.9 versus 61.0

years, p=0.003) and predominantly male (94% versus 47%, p=0.001) compared to the 87 who

stayed in hospital one or more nights.

Conclusions

Using a multi-center, prospective, randomized design, the current study demonstrates that outpa-

tient THA can achieve high patient satisfaction in a broad patient population without increasing

complication rates or requiring additional work for the surgeon’s office. Since 24% (25/106) of

patients planning to have outpatient surgery were not able to be discharged the same day, facilities

to accommodate an overnight stay should be available.

Level of Evidence

Level I - Therapeutic Randomized Control Study


3:10 pm – 3:15 pm

The Frank Stinchfield Award

Total Hip Arthroplasty for Femoral Neck Fracture is Not a Typical DRG 470:


Alexander S. McLawhorn, MD, MBA; William A. Schairer, MD; Joseph M. Lane, MD;

David A. Halsey, MD; Richard Iorio, MD; Douglas E. Padgett, MD

Background

Hip fractures are a major public health concern. For displaced femoral neck fractures (FNF), the

episode of care for total hip arthroplasty (THA) is different than one performed for osteoarthritis

(OA). Yet, Medicare Severity Diagnosis Related Groups system does not distinguish between THA

performed for fracture and OA.

Questions/Purposes

What are the differences in in-hospital and 30-day postoperative clinical outcomes for THA per-

formed for FNF versus OA? Is a patient’s fracture status associated with differences in in-hospital

and 30-day postoperative clinical outcomes after THA?

Methods

The National Surgical Quality Improvement Program database contains prospectively collected out-

comes for surgical patients up to 30 days after discharge. THA patients with OA or FNF were com-

pared using two methods, first as an unadjusted cohort, and also as a one-to-one matched cohort

using a propensity score based on age, gender, ASA grade, and medical comorbidities. Outcomes

of interest included complications, transfusion, length of stay (LOS), discharge destination, and re-

admission. There were 42,692 patients identified (41,739 OA; 953 FNF), with 953 patients in each

group for the matched analysis.

Results

For both the cohort comparison and the matched comparisons, operative time was slightly longer

in the FNF group, and FNF patients had higher rates of longer LOS and more complications com-

pared to patients with OA. Transfusions were more common for FNF in the unadjusted comparison,

but the rates were similar in the matched comparison. Both surgical and medical complications

were higher for FNF in both the unadjusted cohort and the matched comparisons. Similarly, for both

comparisons, the FNF group had higher rates of discharge to inpatient facility as well as higher rates

of unplanned readmission.

Fracture status was strongly associated with any postoperative complication (Odds Ratio [OR] 2.80,

95% Confidence Interval [CI] 2.05-3.84], p<0.001), readmission (OR 1.80, 95% CI 1.00- 3.24, p =

0.049), and discharge to an inpatient facility (OR 1.68, 95% CI 1.39-2.02, p<0.001).


Conclusions

Compared to THA for OA, THA for FNF is associated with significantly greater rates of complications,

longer LOS, more likely discharge to continued inpatient care, and higher rates of unplanned read-

mission. This implies higher resource utilization for patients with a fracture. These differences per-

sist after matching of pre-operative risk factors. As healthcare reimbursement move towards bun-

dled payment models, it would seem important to differentiate patients and procedures based upon

the resource utilization they represent to healthcare systems.

These results show different expected resource utilization in these two fundamentally different

groups of hip arthroplasty patients, suggesting a need to modify healthcare policy in order to

maintain access to THA for all patients.

Level of Evidence

Level III Therapeutic study.


Session X: Revision THA Video Technical Tips to Improve Results

3:27 pm – 3:32 pm

Revision THA for Periprosthetic Fracture of the Femur

George J. Haidukewych MD

Orlando, FL

The most common reason for revision for periprosthetic fracture of the femur is the presence of a

fracture around a loose femoral component. These so-called Vancouver B2 or B3 fractures are

much more common than B1 fractures, which occur around a well-fixed implant. Revision strategies

should focus on stable fixation into the distal fragment, while preserving vascularity of proximal

fragments. Both fully coated cylindrical and titanium modular fluted tapered (TMFT) stems can be

used effectively. The author prefers the advantages of modularity that TMFT stems offer. The pa-

tient is positioned laterally and C arm is used. “Connecting” fracture lines in the proximal femur

can facilitate exposure of the acetabulum, and the distal femoral diaphysis. A prophylactic cable is

placed at the mouth of the distal fragment. Reaming is performed referencing the hip center, and

ensuring appropriate distal bypass. In general, the author prefers to obtain 10 cm of bypass of the

stem past the most distal stress riser. The real implant is driven into the distal fragment. Biplanar

C arm views are obtained to ensure adequate bypass, diaphyseal fit, and avoid anterior femoral

cortical perforation. Trialing then proceeds until hip stability and leg length is acceptable. The

proximal body is assembled and the proximal fragments are “wrapped” around the implant with an

economy of cerclage cables. A period of protected weight bearing is recommended.


3:33 pm – 3:38 pm

Extended Trochanteric Osteotomy: Tips and Tricks

Craig J. Della Valle, MD

Rush University Medical Center, Chicago, IL

The extended trochanteric osteotomy (ETO), as popularized by Paprosky, is a versatile exposure that

is useful for complex primary and revision total hip arthroplasty (THA). It is relatively easy to do (once

you have done a few), is easy to repair with 2-3 cables and heals reliably. By opening up the femoral

canal, and mobilizing the greater trochanter, the ETO affords the surgeon the following advantages:

- Direct access to the femoral canal for implant or cement removal

- Improved acetabular exposure and a “straight shot” at the femoral isthmus for machining

and implanting the revision component.

- Correction of femoral remodeling (if present)

An ETO can be done at one of (3) times during the case

- Prior to dislocation of the hip. This is rare and technically difficulty to do, but very helpful if

the hip is very stiff and exposure is challenging (e.g. extensive HO)

- After dislocation of the hip but prior to removal of the stem (most common).

- After removal of the stem. This is the easiest way to learn how to do an ETO as there is no

stem in the way and the surgeon can simply osteotomize the femur from back to front. Useful

if there is a long cement mantle or if the surgeon wants to benefit from one of the above

advantages such as improved exposure.

Preoperative planning is crucial to determine the length of the ETO. It should be long enough to

remove what you need to get out but short enough to preserve enough femoral isthmus for distal

fixation of the revision stem.

Technical tips include

- Great care with preserving the soft tissues of the osteotomized fragment; if you devascularize

the fragment it will not heal.

- Place a prophylactic cerclage wire distal to the ETO to protect the remaining femur.

- Insert the stem first, then repair the ETO around the revision stem; this oftentimes requires

some sculpting of the lateral fragement as the revision stem is larger than the primary stem.

References

Levine BL, Della Valle CJ, Lewis P, Sporer SM, Paprosky WG. Extended trochanteric osteotomy for

the treatment of Vancouver B2/B3 periprosthetic fractures of the femur. J Arthroplasty, 23,

527-533, 2008.

Levine BL, Della Valle CJ, Hamming M, Sporer SM, Berger RA, Paprosky WG. Use of the extended

trochanteric osteotomy in treating periprosthetic infection. J Arthroplasty, 24, 49-55, 2009.

Della Valle CJ, Berger RA, Rosenberg AG, Jacobs JJ, Sheinkop MB, Paprosky WG. Extended trochan-

teric osteotomy in complex primary total hip arthroplasty. J Bone Joint Surg Am, 85;2385-

90,2003.


3:39 pm – 3:44 pm

Fluted Tapered Stems for Femoral Revisions

Scott M. Sporer, MD

Introduction: Cementless fixation remains the standard for most revision surgical procedures. Mon-

oblock extensively porous coated stems have demonstrated excellent long-term results for the ma-

jority of femoral revision procedures.(1) However, the poor results of extensively coated cylindrical

femoral revision stem in larger femoral defects (Paprosky Type IIIB and IV)(2) or in patients with

large femoral canals resulted in the increased utilization of modular tapered fluted stems. (3) Mul-

tiple surgeons have presented excellent mid term results for both implant stability and patient out-

comes using this method of fixation. Due to the success of modular fluted revision femoral stems,

these implants are now used more routinely in all femoral revisions cases by many surgeons. There

are multiple advantages to using tapered fluted stem for all femoral revisions rather than attempt-

ing to obtain stable fixation with an alternative device.(4)

Advantages of Modular Fluted Tapered Stems:

Independent Adjustment of Leg Length

o Leg length adjusted AFTER distal fixation obtained

o Ability to verify distal fixation (e.g. – varus remodeling)

Independent Adjustment of Offset

o Offset can be adjusted independent of leg length

o Minimize impingement decrease instability

Independent Adjustment of Femoral Version

o Unknown femoral retroversion remodeling

o Ability to adjust suboptimal cup position

Ability to be used in All Defect Types

o Able to be utilized on Paprosky Type II-IV defects

o No need to alter reamers midway through surgery

Ability to get “proximal fixation”

o Multiple proximal body sizes

o May minimize risk of implant fracture

o Minimize stress shielding

Advantages of Non-Modular Fluted Tapered Stems:

Potential “Easier” procedure

o Ability to prepare femur and trial component as one unit

o Ability to remove implant and easily re-ream to obtain appropriate level of seating

Possible Lower implant cost

Disadvantages of Modular Fluted Tapered Stems:

Component Fracture

o Uncommon in current generation (Roller-hardening, shot peening, etc.)

Increased Cost

o Institution dependent

Increased Surgical Time


Disadvantages of Non-Modular Fluted Tapered Stems:

Limited Offset Options

o Instability

o Need to waste stem

Higher Incidence of Stem Subsidence

Varying level of component insertion compared to reamer

Remain susceptible to stem fracture in small sizes if unsupported

References

1. Weeden SH, Paprosky WG. Minimal 11-year follow-up of extensively porous-coated stems

in femoral revision total hip arthroplasty. J Arthroplasty. 2002;17(4 Suppl 1):134-7.

2. Sporer SM, Paprosky WG. Revision total hip arthroplasty: the limits of fully coated stems.

Clin Orthop Relat Res. 2003(417):203-9.

3. Van Houwelingen AP, Duncan CP, Masri BA, Greidanus NV, Garbuz DS. High survival of

modular tapered stems for proximal femoral bone defects at 5 to 10 years followup. Clin Orthop

Relat Res. 2013;471(2):454-62.

4. Konan S, Garbuz DS, Masri BA, Duncan CP. Non-modular tapered fluted titanium stems in

hip revision surgery: gaining attention. Bone Joint J. 2014;96-B(11 Supple A):56-9.


3:45 pm – 3:50 pm

Custom Triflanged Cups: Planning and Execution

Douglas A. Dennis, MD

Adjunct Professor of Bioengineering, University of Denver

Adjunct Professor, Dept. of Biomedical Engineering, University of Tennessee

Asst. Clin. Professor, Dept. of Orthopaedics, University of Colorado School of Medicine

Numerous surgical treatment methods have been utilized for treatment of massive periacetabular

bone loss in revision total hip arthroplasty including structural allografting, impaction allografting,

noncustom anti-protrusio cages, jumbo cups with modular acetabular augments, and custom, tri-

flanged acetabular components (CTAC). CTAC are designed from a thin-cut CT scan with subsequent

3-D reconstruction of the pelvis. Metal subtraction software programs minimize metal-induced dis-

tortion. This type of component is typically utilized in Type III defects when little to no osseous

support remains in the acetabulum. Fixation is obtained by creation of a triflanged prosthetic com-

ponent which is anchored to the ilium, ischium, and pubis with multiple fixation screws. Acetabular

defects are grafted with cancellous allograft.

Literature review of clinical results with CTAC use out to 10 years has demonstrated reliable

fixation and survival of the device itself, even in cases with pelvic discontinuity. However, reopera-

tion rates for complications such as dislocation, infection, etc. are substantial in some reports, likely

related to the complexity of cases in which a CTAC is selected (massive bone loss, multiple previous

surgical procedures).

Advantages of CTAC use include obtaining rigid fixation on remaining host bone (ilium, is-

chium, and pubis). Its custom design enhances the precision of fit. Biomechanically, the device is

much stronger than traditional non-custom cages. Finally, its design incorporates use of modular

polyethylene liners (neutral, extended lip, or constrained) that enhances the surgeon’s ability to

achieve hip stability intraoperatively.

Disadvantages include increased cost and delay in surgery pending implant manufacture

(usually 4 to 6 weeks). Substantial exposure of the ilium is required for accurate placement of the

iliac flange of the prosthesis. This risks injury to the superior gluteal nerve. For this reason, a greater

trochanteric osteotomy is considered to relieve tension on the superior gluteal neurovascular pedi-

cle during insertion of a CTAC. Cement augmentation of ischial screws is recommended in cases

with severe ischial osteolysis. Ideally, the CTAC should be designed with two rows of 3-4 iliac screws

and a minimum of four ischial screws. The central dome of the prosthesis should be designed to

contact the remaining ledge of the inferior ilium to reduce shear stresses on the iliac, ischial, and

pubic flange fixation.

Bibliography

1. Christie MJ, Barrington SA, Brinson MF, et al: Bridging massive acetabular defects with the

triflanged cup: 2 to 9 year results. Clin Orthop 393:216-227, 2001.

2. Holt, GE and Dennis, DA: Use of Custom Triflanged Acetabular Components in Revision Total

Hip Arthroplasty. Clin Orthop , 429: 209-214, 2004


3. Berasi CC 4th, Berend KR, Adams JB, Ruh EL, Lombardi AV Jr: Are custom triflange acetabu-

lar components effective for reconstruction of catastrophic bone loss? Clin Orthop 473: 528-

35, 2015.

4. Taunton MJ, Fehring TK, Edwards P, Bernasek T, Holt GE, Christie MJ.

Pelvic discontinuity treated with custom triflange component: a reliable option. Clin Orthop

470:428-34, 2012.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Berasi%20CC%204th%5BAuthor%5D&cauthor=true&cauthor_uid=25315276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Berend%20KR%5BAuthor%5D&cauthor=true&cauthor_uid=25315276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Adams%20JB%5BAuthor%5D&cauthor=true&cauthor_uid=25315276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ruh%20EL%5BAuthor%5D&cauthor=true&cauthor_uid=25315276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Lombardi%20AV%20Jr%5BAuthor%5D&cauthor=true&cauthor_uid=25315276

http://www.ncbi.nlm.nih.gov/pubmed/?term=Taunton%20MJ%5BAuthor%5D&cauthor=true&cauthor_uid=21997785

http://www.ncbi.nlm.nih.gov/pubmed/?term=Fehring%20TK%5BAuthor%5D&cauthor=true&cauthor_uid=21997785

http://www.ncbi.nlm.nih.gov/pubmed/?term=Edwards%20P%5BAuthor%5D&cauthor=true&cauthor_uid=21997785

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bernasek%20T%5BAuthor%5D&cauthor=true&cauthor_uid=21997785

http://www.ncbi.nlm.nih.gov/pubmed/?term=Holt%20GE%5BAuthor%5D&cauthor=true&cauthor_uid=21997785

http://www.ncbi.nlm.nih.gov/pubmed/?term=Christie%20MJ%5BAuthor%5D&cauthor=true&cauthor_uid=21997785


3:51 pm – 3:56 pm

Cup Cage Construct

Allan E. Gross, MD, FRCSC, O.Ont.

The indications for a cup cage reconstruction are massive bone loss with or without pelvic disconti-

nuity where in the past we have utilized a conventional cage (ref 1,2). Although the posterior ap-

proach can be effective, the senior author’s preference is a lateral approach using a modified sliding

trochanteric osteotomy (ref 3). An extended trochanteric osteotomy is employed when an accompa-

nied femoral revision with need to access to the femoral canal distal to the lesser trochanter is

anticipated (ref 4).

Gentle reaming of the acetabulum is carried out. Reaming continues until either bleeding bone is

obtained or it becomes clear that bony support will decrease with further reaming. If the reamer

does not achieve any degree of engagement in the surrounding bone, a conventional cage rather

than a cup-cage may be necessary. The proximal 1 to 2 cm of the ischium should be exposed and

the slot for the ischial flange created. Morsellized allograft mixed with any autograft from reaming

is now packed into defects especially the discontinuity site. Uncontained defects can be recon-

structed by structural allografts or augments. Then trial is performed to find the size of the cup

which fits the acetabulum and the cage which fits into the cup and extends from ischium to ilium.

The cages are specifically sized for the cup diameter. The cup should be press fit as much as pos-

sible to distract and help to stabilize the discontinuity. We insert a cup 2mm larger than our last

reamer. Every attempt should be employed to provide some contact to bleeding bone preparing

the environment for the cup to stabilize the discontinuity after ingrowth occurs. Considering that the

lateral dome of the acetabulum is usually the most deficient part, placing the cup in 45° inclination

does not provide it with the best host bone contact. Therefore, the cup is usually placed in a rela-

tively vertical position. This aIso provides better access to the ilium for the superior flange of the

cage. It should be in a fairly retroverted direction as well, so that the ischial flange of the cage can

be inserted to the ischium.

Once the revision ultra-porous cup is inserted to the actabular defect, it should be fixed with at least

two screws. The direction of the screws is dictated by the location of better bone stock. Although

revision ultra-porous cups come with multiple screw holes, if deemed necessary, creating more

holes is technically possible using the regular bone drill bits. We cover all of the holes even those

containing screws with bone wax to make possible future removal easier and to prevent the cement

from intruding to the bone-cup interface which may impair the bone ingrowth into the cup.

Then, the slot for the ischial flange of the cage is created. The starting point is located in the inside

surface of the acetabular rim, at 7 o’clock in the right and 5 o’clock in the left hip. The direction is

dictated by the exposed lateral surface of the ischium and is confirmed by drilling a hole and using

a depth gauge to make sure that for a distance of 3 cm the flange will be surrounded by bone. The

slot is initiated using a special osteotome but completed by the real flange of the cage to avoid

inadvertent perforation of the ischium by the sharp osteotome and endangering the sciatic nerve.


A helpful practice is to template with a trial cage and to adjust the superior and inferior flanges of

the real cage before insertion. Usually the upper flanges need to be bent downward to the ilium

and the lower ones upward to align with the ischium. The last action before inserting the cage is to

prepare the lateral ilium for the upper flange. Abductor muscles should be gently elevated from an

appropriate length of the ilium. This should be performed carefully to avoid damage to the superior

gluteal neurovascular bundle and resultant lurch. Cage insertion starts with inserting the inferior

flange all the way into the slot. Then the cage is impacted into the cup so that the upper flanges lie

flat on the ilium, slightly towards posterior. The fixation depends on the distal flange and the screws

through the superior flanges to the ilium. A minimum of three bicortical 6.5mm screws should be

used to fix the flanges to the ilium but before that, it is recommended to insert a couple of screws

in the dome of the cage through the cup and ilium. The latter screws will push the cage further into

the concavity of the cup and minimize the gap between the two. Also by following a perpendicular

direction relative to the flange screws, they provide a much stronger construction. From a biome-

chanical point of view, inserting one screw into the ischium just medial to the inferior flange is help-

ful to provide some compression force at the discontinuity site.

A cemented polyethylene liner should be inserted into the cage aiming for about 40° abduction and

20° anteversion, independent from position of the cup cage. We recommend using an elevated-rim

liner to achieve more posterolateral coverage. This is important because the cup cage is in a vertical

and retroverted position that leaves the liner uncovered posterolaterally. Keep the pressure on the

cup until the cement hardens. This results in penetration of some cement through the cage holes

and elimination of the gap between the cup and the cage.

Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross

classification. Sixty-seven cup-cage procedures with an average follow-up of 74 months (range, 24-

135 months; SD, 34.3) months were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67

(61%) were Gross Type V (pelvic discontinuity). Failure was defined as revision surgery for any

cause, including infection (ref 5).

The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95%

confidence interval [CI], 83.1-97.4), and the 10-year survival rate was 85% (95% CI, 67.2-93.8).

The Merle d'Aubigné-Postel score improved significantly from a mean of 6 preoperatively to 13 post-

operatively (p < 0.001). Four cup-cage constructs had non-progressive radiological migration of the

ischial flange and they remain stable.

The cup-cage construct is a reliable option to treat chronic pelvic discontinuity and severe acetabu-

lar bone defects if stable fixation cannot be obtained through the use of a high-porosity metal cup

with or without augments.

References

(1) Goodman S, Saastamoinen H, Shasha N, Gross AE: Complications of ilioischial reconstruc-

tion rings in revision total hip arthroplasty. J Arthroplasty 19 (4):436-446, 2004.


(2) Kosashvili Y, Backstein D, Safir O, Lakstein D, Gross AE: Acetabular revision using an anti-

protrusion (ilio-ischail) cage and trabecular metal acetabular component for severe acetab-

ular bone loss associated with pelvic discontinuity. J Bone Joint Surg B4 91; B: 870-876,

2009.

(3) Lakstein D, Backstein D, Safir O, Kosashvili Y, Gross AE: Modified trochanteric slide for com-

plex hip arthroplasty: Clinical outcomes and complication rates. J Arthroplasty 25:363-368,

2010.

(4) Lakstein D, Kosashvili Y, Backstein D, Safir O, Gross AE.: Modified extended trochanteric

osteotomy with preservation of posterior structures. Hip Int 20:102-108, 2010.

(5) Amendabar T, Rahman WA, Hetamish BM, Safir O, Gross AE: Promising Mid-term

Results with a Cup-cage Construct for Large Acetabular Defects and Pelvic Discontinuity. Clin

Orthop Relat Research. 2015 Feb 25


3:57 pm – 4:02 pm

High-Dose Antibiotic-Containing Spacers for Infected Total Hip Arthroplasty

Kevin L. Garvin, M.D.

University of Nebraska Medical Center

For more than 20 years, high-dose antibiotic-impregnated spacers have been a mainstay for suc-

cessful management of a prosthetic hip infection. The spacer serves two purposes. The first is the

elution of high-dose antibiotics to treat any residual bacteria that remain at the surgical site after

debridement. The second purpose is to facilitate early mobilization of the patient thereby preventing

muscle atrophy and scarring, as well as helping to lessen the complications and risks associated

with prolonged immobilization and bed rest. The selection of antibiotics for use in bone cement

requires that the antibiotics are stable during the exothermic process of cement polymerization, of

low risk for allergy or other side effects, water soluble and effective against the pathogens com-

monly identified as causing a prosthetic joint infection. Aminoglycosides (gentamicin) were the first

to be used followed by vancomycin, colistin, clindamycin, cephalosporin and others. High doses of

antibiotics are safe for the majority of patients because the antibiotics are primarily released locally

with relatively low systemic levels. However, the growing number of patients with renal disease and

the emerging resistance of bacteria to aminoglycosides have encouraged surgeons to consider al-

ternative antibiotics to aminoglycosides. A recent report of prosthetic knee infections included us-

ing high doses of ceftazidime-vancomycin impregnated cement. Comparable success (85%) was

achieved with this antibiotic regimen for a two-stage reimplantation. Mechanical properties of ce-

ment are also affected by the type of antibiotic but this is less of a concern for the temporary spacer

used to deliver high doses of antibiotics.

Manufactured molds or custom-type molds are available to shape the antibiotic-laden polymers.

The material is injected into the mold while the methacrylate is in a doughy state. Once polymerized,

the soft silicone mold is removed and the antibiotic-laden acrylic spacer can be inserted as a tem-

porary prosthesis. Intramedullary dowels also formed from molds can be inserted into the canal to

increase the local antibiotic delivery. In contrast, prefabricated antibiotic-laden bone cement spac-

ers release a very low dose of antibiotics and therefore are not used for the treatment of a prosthetic

joint that is infected. If bone loss is severe and the temporary spacer cannot provide soft tissue

and joint stability then antibiotic-impregnated beads may be necessary to fill the dead space and

provide local antibiotic delivery.

In summary, high-dose antibiotic-impregnated spacers are effective in releasing antibiotics at the

site of infection and facilitating early mobilization of the patient. However, some challenges still

exist. Cases of resistant organisms, immunocompromised hosts and complex surgeries with severe

bone loss will continue to attract our attention as we aim to improve the outcomes of patients with

prosthetic joint infections.


References

1. Balato G, Ascione T, Rosa D, Pagliano P, Solarino G, Moretti B, Mariconda M. Release of gen-

tamicin from cement spacers in two-stage procedures for hip and knee prosthetic infection: An

in vivo pharmacokinetic study with clinical follow-up. J Biol Regul Homeost Agents. 2015;29:63-

72.

2. Berend KR, Turnbull NJ, Howell RE, Morris MJ, Adams JB, Lombardi AV,Jr. Molded articulating

cement spacers for two-stage treatment of infected THA and TKA. Surg Technol Int.

2015;26:343-349.

3. Buchholz HW, Engelbrecht H. Depot effects of various antibiotics mixed with palacos resins.

Chirurg. 1970;41:511-515.

4. Chang Y, Tai CL, Hsieh PH, Ueng SW. Gentamicin in bone cement: A potentially more effective

prophylactic measure of infectionin joint arthroplasty. Bone Joint Res. 2013;2:220-226.

5. Chen AF, Parvizi J. Antibiotic-loaded bone cement and periprosthetic joint infection. J Long Term

Eff Med Implants. 2014;24:89-97.

6. Drexler M, Dwyer T, Kuzyk PR, Kosashvilli Y, Abolghasemian M, Regev GJ, Kadar A, Rutenberg

TF, Backstein D. The results of two-stage revision TKA using ceftazidime-vancomycin-impreg-

nated cement articulating spacers in tsukayama type II periprosthetic joint infections. Knee Surg

Sports Traumatol Arthrosc. 2015.

7. Goltzer O, McLaren A, Overstreet D, Galli C, McLemore R. Antimicrobial release from prefabri-

cated spacers is variable and the dose is low. Clin Orthop Relat Res. 2015;473:2253-2261.

8. Hendriks JG, van Horn JR, van der Mei HC, Busscher HJ. Backgrounds of antibiotic-loaded bone

cement and prosthesis-related infection. Biomaterials. 2004;25:545-556.

9. James A, Larson T. Acute renal failure after high-dose antibiotic bone cement: Case report and

review of the literature. Ren Fail. 2015;37:1061-1066.

10. Jiranek WA, Hanssen AD, Greenwald AS. Antibiotic-loaded bone cement for infection prophylaxis

in total joint replacement. J Bone Joint Surg Am. 2006;88:2487-2500.

11. Klekamp J, Dawson JM, Haas DW, DeBoer D, Christie M. The use of vancomycin and tobramycin

in acrylic bone cement: Biomechanical effects and elution kinetics for use in joint arthroplasty.

J Arthroplasty. 1999;14:339-346.

12. Magnan B, Bondi M, Maluta T, Samaila E, Schirru L, Dall'Oca C. Acrylic bone cement: Current

concept review. Musculoskelet Surg. 2013;97:93-100.

13. Masri BA, Duncan CP, Beauchamp CP. Long-term elution of antibiotics from bone-cement: An in

vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system. J Ar-

throplasty. 1998;13:331-338.

14. Matos AC, Gonçalves LM, Rijo P, Vaz MA, Almeida AJ, Bettencourt AF. A novel modified acrylic

bone cement matrix. A step forward on antibiotic delivery against multiresistant bacteria respon-

sible for prosthetic joint infections. Materials Science and Engineering: C. 2014;38:218-226.

15. Neut D, Hendriks JG, van Horn JR, Kowalski RS, van der Mei HC, Busscher HJ. Antimicrobial

efficacy of gentamicin-loaded acrylic bone cements with fusidic acid or clindamycin added. J

Orthop Res. 2006;24:291-299.

16. Paz E, Sanz-Ruiz P, Abenojar J, Vaquero-Martín J, Forriol F, Del Real JC. Evaluation of elution and

mechanical properties of high-dose antibiotic-loaded bone cement: Comparative “In vitro” study

of the influence of vancomycin and cefazolin. J Arthroplasty. 2015;30:1423-1429.

17. Penner MJ, Masri BA, Duncan CP. Elution characteristics of vancomycin and tobramycin com-

bined in acrylic bone-cement. J Arthroplasty. 1996;11:939-44.


18. Rahaman MN, Bal BS, Huang W. Review: Emerging developments in the use of bioactive glasses

for treating infected prosthetic joints. Mater Sci Eng C Mater Biol Appl. 2014;41:224-231.

19. Sandiford NA, Duncan CP, Garbuz DS, Masri BA. Two-stage management of the infected total

hip arthroplasty. Hip Int. 2015;25:308-315.

20. Springer BD, Lee GC, Osmon D, Haidukewych GJ, Hanssen AD, Jacofsky DJ. Systemic safety of

high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthro-

plasty. Clin Orthop Relat Res. 2004;(427):47-51.

21. Sterling GJ, Crawford S, Potter JH, Koerbin G, Crawford R. The pharmacokinetics of simplex-

tobramycin bone cement. J Bone Joint Surg Br. 2003;85:646-649.

22. Sukeik M, Haddad FS. Two-stage procedure in the treatment of late chronic hip infections--

spacer implantation. Int J Med Sci. 2009;6:253-257.

23. Uchino M, Sugo K, Naruse K, Uchida K, Hirakawa N, Toyama M, Miyajima G, Urabe K. Elution

characteristics of vancomycin, gentamicin, and Vancomycin/Gentamicin combination from cal-

cium phosphate cement. Advances in Orthopedic Surgery. 2015;2015.


Session XIa: Young Investigator Presentation

4:16 pm – 4:21 pm

Removal of an Infected Hip Arthroplasty is High-Risk Surgery:

Putting Morbidity into Context with other Major Non-Orthopaedic Operations

James Browne, Jourdan Cancienne, Wendy Novicoff, Brian Werner

University of Virginia

Introduction

Two-stage revision remains the standard approach for periprosthetic infection (PJI) of total hip ar-

throplasty (THA) in the United States. The postoperative risks associated with removal of an infected

prosthesis and placement of a spacer have not been thoroughly studied.

Methods

Patients who underwent THA implant removal and spacer placement were identified in a large ad-

ministrative database using ICD-9 and CPT codes. Morbidity and mortality rates were assessed for

the 90-day postoperative period whereas readmission rates were assessed at 30-days postopera-

tively to avoid including potential planned readmissions for reimplantation. These outcomes were

then compared to those following coronary artery bypass grafting (CABG), carotid endarterectomy

(CEA), prostatectomy, pancreatoduodenectomy (Whipple procedure), and kidney transplant. Odds

ratios (OR), 95% confidence intervals (CI) and chi square tests were calculated. p< 0.01 was con-

sidered significant.

Results

Implant removal and spacer placement for THA PJI (n=10,458) had a 30-day readmission rate of

11.6% and 90-day mortality rate of 3.7%. Major complications (deep vein thrombosis [DVT], pul-

monary emobolism [PE], myocardial infarct [MI], acute renal failure [ARF], pneumonia [PNA], stroke

[CVA]) were seen in 15.3% of patients. Postoperative morbidity was often higher compared to other

procedures studied. For example, compared to Whipple patients (n=28,446), THA explant patients

had a higher incidence of DVT (OR 1.4, CI 1.2-1.7), PNA (OR 1.2, CI 1.1-1.4), MI (OR 1.6, CI 1.2-2.1),

ARF (OR 2.5, CI 2.3-2.8), transfusion (OR 4.2, CI 3.9-4.4), and CVA (OR 1.4, CI 1.1-1.7), all p-values

<0.001. 90-day mortality rates were significantly higher compared to CEA, prostatectomy, and kid-

ney transplant (odds ratios between 2.9 to 14.0, p<0.0001). Readmission rates at 30-days were

significantly higher when compared to all other groups including CABG and Whipple (odds ratios

between 1.4 to 8.3, p<0.0001).

Discussion and Conclusion

Removal of an infected THA with spacer placement is high-risk surgery. This large study including

over 10,000 patients helps quantify the risks of readmission, morbidity, and mortality. The rates

of adverse outcomes are higher than for many non-orthopaedic operations typically considered to

be major surgery.


Session XII: Impingement and Dysplasia

4:33 pm – 4:38 pm

Complications after Hip Arthroscopy:

A Prospective, Multicenter Trial Utilizing a Validated Grading Scheme

Christopher M. Larson, MD; John Clohisy, MD; Paul Beaule, MD, FRCSC;

Bryan T. Kelly, M. Russell Giveans, Rebecca M. Stone, ATC; Kathryn M. Samuelson

Background: There is limited literature looking at comprehensive complication rates after arthro-

scopic hip procedures.

Hypothesis/Purpose: To prospectively report complication rates for a consecutive series of hips un-

dergoing arthroscopic procedures.

Study Design: Case Series

Methods: Over a twenty-nine month period, 1,615 consecutive hips with a mean age of 30.5 years

underwent arthroscopic hip procedures at four institutions. The diagnosis, demographic infor-

mation, and procedures were recorded, and a validated complications grading classification for hip

joint surgery was utilized prospectively.

Results: There were 1487 primary hip arthroscopies and 128 revision hip arthroscopies. Arthros-

copy femoroacetabular impingement (FAI) correction was performed in 1505 hips (93.2%), and

1273 hips (78.8%) had a labral repair procedure. The most common event was post-operative lat-

eral femoral cutaneous nerve (LFC) disturbance (16.5%), and persisted beyond 6 months in only

1.6%. The incidence of iatrogenic chondral injury was 1.2%, iatrogenic labral puncture (0.9%),

superficial portal infection (1.1%), sensory deficit about the foot (0.8%), deep venous thrombosis

(0.1%), pulmonary embolism (0.1%), perineal numbness (pudendal nerve) (1.4%), heterotopic ossi-

fication (0.8%), and femoral neck stress fracture (0.1%).. There was no iatrogenic instability, AVN,

or extra-abdominal fluid extravasation identified in this cohort. The overall complication rate, not

including temporary LFC periportal and thigh numbness (sequalae) was 8.3% (134 hips). Overall

7.4% had a grade 1, 0.7% Grade 2, 0.4% grade 3, and 0.1% grade 4 complication. There was a

significantly higher rate of complications for greater surgical and traction time (p < 0.01) and for

females as compared to males (p=.017). No differences were found between primary versus revi-

sion cases (p=.123), labral repair versus debridement (p=.209), and BMI had no effect on compli-

cation rate (p= .103).

Conclusions: The overall complication rate after hip arthroscopy at tertiary hip centers was 8.3%

with higher rates reported with greater surgical and traction times and for females. Compared to

surgical hip dislocation using the same classification system, the overall rate of complications was

similar but the rate of higher grade complications was lower for arthroscopic hip procedures.


4:39 pm – 4:44 pm

Risk Factors for Hip Arthroscopy Failure in a Single Healthcare System

R. Presley Swann MD; Jenny Marland PT, DPT; Jackie Lee PhD;

Mike B. Anderson MSc; Hugh West MD; Christopher Peters MD

Background

Over the past 10 to 15 years, the number of hip arthroscopy procedures performed has risen ex-

ponentially, but few data exist to guide clinicians in determining which patients are likely to require

full conversion to total hip arthroplasty (THA) or repeat/revision arthroscopy.

Questions/Purposes

1. What is the rate of conversion from primary hip arthroscopy to THA?

a. What factors are associated with conversion of hip arthroscopy to THA?

2. What is the rate of conversion from primary hip arthroscopy to revision arthroscopy?

a. What factors are associated with the need for revision hip arthroscopy?

Methods

Querying the data warehouse of the Intermountain Healthcare (IHC) system to identify all patients

who underwent hip arthroscopy between 2003 and 2014 we a performed secondary data analysis.

Data were extracted on patient age, gender, body mass index, American Society of Anesthesiolo-

gists (ASA) physical status score, operating surgeon, and hip outcome. Participating surgeons were

categorized as performing either a high volume (≥ 100 per year) or low volume (< 100/year) of hip

arthroscopies.

Results

Of 1058 eligible patients, 94 (9%) progressed to THA at a mean time to conversion of 1.35 years

(range 0.01 – 7.8). Increasing age (p<0.001), higher ASA scores (p=0.011), and low surgeon vol-

ume (p=0.016) were significant predictors of THA conversion. Twenty percent (n=212) underwent

subsequent revision arthroscopy. Younger age (p<0.001), lower body mass index (p=0.040) and

increasing ASA scores (p<0.001) were all associated with an increased risk for revision arthros-

copy.

Conclusions

In this healthcare system, 27% of hip arthroscopy procedures required repeat arthroscopy or con-

version to THA. Surgeon volume less than 100 cases per year, increased patient age and higher

BMI were also associated with an increased risk of revision arthroscopy or THA.

Key Words: hip arthroscopy, total hip arthroplasty, risk factors, outcomes, age, ASA score, procedure

volume

References

1. Bardakos NV, Vasconcelos JC, Villar RN. Early outcome of hip arthroscopy for

femoroacetabular impingement: the role of femoral osteoplasty in symptomatic

improvement. J Bone Joint Surg Br. 2008;90:1570-1575.

2. Bedi A, Chen N, Robertson W, Kelly BT. The management of labral tears and

femoroacetabular impingement of the hip in the young, active patient. Arthroscopy.

2008;24:1135-1145.

3. Bogunovic L, Gottlieb M, Pashos G, Baca G, Clohisy JC. Why do hip arthroscopy procedures

fail? Clin Orthop Relat Res. 2013;471:2523-2529.


4. Bozic KJ, Chan V, Valone FH, 3rd, Feeley BT, Vail TP. Trends in hip arthroscopy utilization in

the United States. J Arthroplasty. 2013;28:140-143.

5. Casscells SW. Arthroscopy of the knee joint. A review of 150 cases. J Bone Joint Surg Am.

1971;53:287-298.

6. Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am.

2012;94:e23.

7. Domb BG, Gui C, Lodhia P. How much arthritis is too much for hip arthroscopy: a systematic

review. Arthroscopy. 2015;31:520-529.

8. Domb BG, Linder D, Finley Z, Botser IB, Chen A, Williamson J, Gupta A. Outcomes of hip

arthroscopy in patients aged 50 years or older compared with a matched-pair control of

patients aged 30 years or younger. Arthroscopy. 2015;31:231-238.

9. Fabricant PD, Heyworth BE, Kelly BT. Hip arthroscopy improves symptoms associated with

FAI in selected adolescent athletes. Clin Orthop Relat Res. 2012;470:261-269.

10. Gupta A, Redmond JM, Stake CE, Dunne KF, Domb BG. Does Primary Hip Arthroscopy Result

in Improved Clinical Outcomes? 2-Year Clinical Follow-up on a Mixed Group of 738

Consecutive Primary Hip Arthroscopies Performed at a High-Volume Referral Center. Am J

Sports Med. 2015.

11. Harris JD, McCormick FM, Abrams GD, Gupta AK, Ellis TJ, Bach BR, Jr., Bush-Joseph CA, Nho

SJ. Complications and reoperations during and after hip arthroscopy: a systematic review of

92 studies and more than 6,000 patients. Arthroscopy. 2013;29:589-595.

12. Haviv B, O'Donnell J. The incidence of total hip arthroplasty after hip arthroscopy in

osteoarthritic patients. Sports Med Arthrosc Rehabil Ther Technol. 2010;2:18.

13. Helenius I, Tanskanen P, Haapala J, Niskanen R, Remes V, Mokka R, Korkala O. Hip

arthroscopy in osteoarthritis. A review of 68 patients. Ann Chir Gynaecol. 2001;90:28-31.

14. Horisberger M, Brunner A, Herzog RF. Arthroscopic treatment of femoral acetabular

impingement in patients with preoperative generalized degenerative changes. Arthroscopy.

2010;26:623-629.

15. Hurter E. [Arthroscopy; a new method of knee examination]. Rev Chir Orthop Reparatrice

Appar Mot. 1955;41:763-766.

16. Jerosch J, Schunck J, Khoja A. Arthroscopic treatment of the hip in early and midstage

degenerative joint disease. Knee Surg Sports Traumatol Arthrosc. 2006;14:641-645.

17. Krych AJ, Kuzma SA, Kovachevich R, Hudgens JL, Stuart MJ, Levy BA. Modest mid-term

outcomes after isolated arthroscopic debridement of acetabular labral tears. Knee Surg

Sports Traumatol Arthrosc. 2014;22:763-767.

18. Lloyd JM, Wainwright T, Middleton RG. What is the role of minimally invasive surgery in a fast

track hip and knee replacement pathway? Ann R Coll Surg Engl. 2012;94:148-151.

19. McCarthy JC, Jarrett BT, Ojeifo O, Lee JA, Bragdon CR. What factors influence long-term

survivorship after hip arthroscopy? Clin Orthop Relat Res. 2011;469:362-371.

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2002;25:947-948.

21. McCarthy JC, Lee JA. Arthroscopic intervention in early hip disease. Clin Orthop Relat Res.

2004:157-162.

22. Nielsen TG, Miller LL, Lund B, Christiansen SE, Lind M. Outcome of arthroscopic treatment

for symptomatic femoroacetabular impingement. BMC Musculoskelet Disord. 2014;15:394.

23. Parvizi J, Bican O, Bender B, Mortazavi SM, Purtill JJ, Erickson J, Peters C. Arthroscopy for

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Arthroplasty. 2009;24:110-113.

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26. Philippon MJ, Schroder ESBG, Briggs KK. Hip arthroscopy for femoroacetabular impingement

in patients aged 50 years or older. Arthroscopy. 2012;28:59-65.

27. Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ. Prevalence of

abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J

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Cross-Sectional Analysis. Arthroscopy. 2015.

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Radiographic Predictors for Worsened Clinical Outcomes After Hip Arthroscopic Labral

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Orthopedics. 2012;35:612-617.

32. Youel MA. Arthroscopy of the knee. Calif Med. 1973;118:36.


4:45 pm – 4:50 pm

Average Ten Year Clinical Outcomes of the Bernese PAO

for the Treatment of Classic Acetabular Dysplasia

Stephen T. Duncan, MD, Lexington, KY; Kayla Thomason, BS, St. Louis, MO;

Geneva Baca, BA, Granite City, IL; Gail Pashos, BS, St. Charles, MO;

Perry L. Schoenecker, MD, St. Louis, MO; John C. Clohisy, MD, St. Louis, MO

Introduction

In patients with symptomatic acetabular dysplasia, the Bernese periacetabular osteotomy (PAO) is

an effective procedure for deformity correction and early relief of pain and hip dysfunction[2-6].

There is a paucity of data regarding the longer term results of this procedure[1]. The purpose of this

study was to analyze the average 10 year clinical, radiographic, and total hip arthroplasty (THA)

conversion results following the PAO for the treatment of symptomatic DDH.

Methods

We performed a retrospective analysis of 186 consecutive hips (159 patients) treated with the PAO

for symptomatic DDH with 10.3 years average followup (range, 6.9 to 17.9). Preoperatively, all pa-

tients had hip pain and sufficient hip joint congruency. Patient demographics, radiographic meas-

urements, and patient reported outcome scores [modified Harris Hip score (MHHS), UCLA, WOMAC]

were analyzed .

Results

Average age was 25 years (range,10 to 60), with 138 females (87%) and 21 males (13%) and BMI

of 25.5 kg/m2. Average lateral center edge angle improved 25.9° (12.0° to 36.2°, p <0.001), and

30.5° (9.5° to 40.0°, p<0.001) in the anterior center edge angle. The Tönnis angle decreased from

22.25° to 4.5° (p< 0.05). Improvements in outcomes included: MHHS [20.8 points; (65.4 to 85.3,

p<0.001)], UCLA [1.4 points (6.8 to 7.1, p<0.05)], and WOMAC subscores which demonstrated

clinically significant improvement.

Table 1. Average 10 year clinical outcome and radiographic measures

Initial Follow-up Average delta p = value

UCLA 6.8 7.1 ↑ 1.4 0.042

mHHS 65.4 85.3 ↑ 20.8 < 0.001

WOMAC Pain 63.9 85.1 ↑ 25.4 0.006

WOMAC Stiffness 72.4 81.0 ↑ 17.0 0.017

WOMAC Function 74.0 88.0 ↑ 18.3 0.042

WOMAC Total 71.7 87.3 ↑ 19.6 0.025

LCEA measure, degrees 12.0 36.2 ↑ 25.9 < 0.001

Tonnis angle, degrees 22.25 4.5 ↓ 17.7 < 0.05

ACEA measure, degrees 9.5 40.0 ↑ 30.5 < 0.001


Ten hips (10.9%) required conversion to THA at 82.3 months (range, 16 to 197 months), 2 hips

(2.2%) required early postoperative revision (1 for overcorrection of the deformity and loss of hip

flexion and 1 for loss of reduction likely due to patient noncompliance), 1 hip (1.1%) required revi-

sion at 11 years for relative overcorrection of the deformity and impingement, and 1 patient (1.3%

of patients) passed away of unrelated causes.

Discussion and Conclusion:

The PAO is an effective technique for surgical correction of symptomatic DDH in adolescents and

young adults. Average ten year results were very good with a low conversion rate to THA and 86%

survivorship.

1. Clohisy JC, Schutz AL, St John L, Schoenecker PL, Wright RW. Periacetabular osteotomy: a

systematic literature review. Clinical orthopaedics and related research. 2009;467:2041-

2052.

2. Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment of hip

dysplasias. Technique and preliminary results. Clinical orthopaedics and related research.

1988:26-36.

3. Hartig-Andreasen C, Troelsen A, Thillemann TM, Soballe K. What factors predict failure 4 to

12 years after periacetabular osteotomy? Clinical orthopaedics and related research.

2012;470:2978-2987.

4. Matheney T, Kim YJ, Zurakowski D, Matero C, Millis M. Intermediate to long-term results

following the Bernese periacetabular osteotomy and predictors of clinical outcome. The Jour-

nal of bone and joint surgery. American volume. 2009;91:2113-2123.

5. Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year followup of Bernese per-

iacetabular osteotomy. Clinical orthopaedics and related research. 2008;466:1633-1644.

6. Troelsen A, Elmengaard B, Soballe K. Medium-term outcome of periacetabular osteotomy

and predictors of conversion to total hip replacement. The Journal of bone and joint surgery.

American volume. 2009;91:2169-2179.


4:51 pm – 4:56 pm

Factors Predicting Success for Joint Preserving Surgery of the Hip

Paul E. Beaulé, MD, FRCSC

Professor of Surgery; Head of Division of Orthopedic Surgery

University of Ottawa, Ontario, Canada

Introduction

Despite the successful outcomes of hip preservation surgery, failures do occur leading onto repeat

surgery or worsening hip function in 10-20% of patients[1-3]. Although improving clinical results can

be done by better patient selection and optimizing of surgical technique the means to achieve this

are not clear as well as how to best focus our efforts. One approach is to categorize failures/repeat

surgeries into failure modes permitting a more in-depth analysis.

When reviewing our overall experience at our center of 1013 cases our overall failure rate was 11%

(109) at a mean time of 2.5 years. However if we then look at separating these failures into three

Modes we gain a bit more insight into where efforts can be directed in improving success after JPSH.

Out of the 1013 hips, 6% (64 hips) had a Mode 1 failure that we define as hips undergoing subse-

quent joint replacement surgery. The mean age of this group was 49 with 33 males @ a mean time

of 3.1 yrs: 55 were following arthroscopy, 8 following surgical dislocation (SD), and 1 following peri-

acetabular osteotomy (PAO); 2% (19 hips) had Mode 2 failure that we define as an incorrect diag-

nosis. The mean age was 29 at a mean time of 2.2 yrs: 10 following arthroscopy; 5 following SD; 2

following PAO. Finally, 2.2%(24 hips) had Mode 3 failures that we define as mal correction with a

mean age 31; @mean time of 2 yrs: 23 following scopes and 1 following SD. Overall complication

rate was less than 4% (40/1013) with only 0.8% (8/1013) altering management.

We will review factors predicting success as function of the 3 failure Modes:

MODE 1- Organ Failure:

If we then look at the factors that can help minimize Mode 1 failures these would be primarily based

on patient selection as a function of health status of the hip joint i.e. degree of arthritis. The current

standard in defining the overall health of the hip joint are patient age and presence or absence of

arthritic changes on plain xrays (sclerosis, joint space narrowing, osteophytes). In general, patients

less than 35 years of age with a Tonnis grade of 1 or less tend to have the best long-term outcome

[3-6]. More recently with the advent of more advanced cartilage imaging techniques such as

dGEMRIC and T1Rho there is capacity for direct quantification of proteoglycan content thus ena-

bling greater sensitivity and specificity in determining arthritic status of the joint. Having said that,

other structures within the hip joint including the labrum, cartilage, synovium and bone, can con-

tribute to hip pain and decreased function and influence the outcome of joint preserving surgery of

the hip. Using hi-resolution 3T MRI a semi quantitative scoring system was developed for compre-

hensive evaluation of the hip joint. Using a regression analysis and correlating to percent change in

the HOOS score, we identified 3 items on MRI that were predictive: Osteophyte in anterior zone of

acetabulum (r=-.411, p=.016); Bone Marrow Edema-supero-lateral acetabulum (r=-.440, p=0.046);

subchondral cyst supero-lateral acetabulum (r=.-391, p=0.022). Presence of these changes could

help counsel the treating physician in regards to expected outcome after joint preserving surgery of

the hip.

Modes 2 –Incorrect Diagnosis:

One of the key underlying issues leading to poor clinical outcome and/or early clinical failures de-

spite surgical expertise is having the correct diagnosis. Clohisy et al7 found that many of the stand-


ard radiographic parameters used to diagnose DDH and/or FAI have poor observer reliability. Ac-

cordingly, a more clear set of definitions and measurements must be developed to allow for more

reliable diagnosis of early hip disease. Methods to improve the reliability of a radiographic evalua-

tion may increase the clinical utility of these parameters8. In addition, some pathology maybe very

difficult to perfectly categorize into one group which brings into play the concept of a transitional

form of hip pathology. It is unclear what percentage of patients fit within that group and more im-

portantly who to best address them surgically remains to be determined.

In order to guide us somewhat better we performed a study asking if soft tissue structures can

differentiate between dysplasia and cam-femoroacetabular impingement of the hip. Fifty-seven pa-

tients who underwent preoperative MRA and corrective hip surgery were retrospectively identified

yielding three groups: 17 with hip dysplasia [DDH] (11F, 6M; mean age 35.1 yrs, range 19.6-53.6);

20 with isolated labral tears [LT] (17F, 3M; mean age 38.4 yrs, range 15.2-62.1) and 20 with cam-

type femoroacetabular impingement [FAI] (11F, 9M; mean age 38.8yrs, range 18.9-51.2). Meas-

urements of the hip labral length, capsule thickness, and psoas, rectus femoris and gluteal muscle

dimensions were performed, with normalization of the values for statistical analysis. We found that

in patients with dysplasia the labrum was longer/hypertrophy associated with a thicker capsule

anteriorly and superiorly compared to the FAI and isolated labral group. In regards to the muscula-

ture the rectus was larger in the transverse plane.

Consequently, in borderline cases these findings may serve as discriminators between the three

main subgroups of FAI, Dysplasia and isolated labral pathology.

Mode 3 – Mal-Correction.

A recent paper by Clohisy et al[12] looking at the most common reasons for revision surgery noted

that both open and arthroscopic technique were almost equally split in regards to previous surgical

approaches. More importantly for both FAI and dysplasia, hip arthroscopy was the most common

previous surgical approach at 86% and 64%, respectively with inadequately corrected structural

disease as the most common reason for secondary surgery: femoral osteochondroplasty and ace-

tabular reorientation.

For example, patients with labral tears due to underlying DDH may expect to have little to no symp-

tomatic benefit from arthroscopy[13;14]. Conversely, overcorrection with PAO can lead to retrover-

sion which can cause FAI, creating a new problem[15]. There is retroversion present in one sixth of

patients with DDH and if not recognised beforehand can be problematic[16].

Head-neck offset deformity may go un-recognised and can cause impingement after PAO[17]. There

may be associated chondral damage with dysplasia which can be a cause of poor outcome after

PAO and doing a hip arthroscopy to deal with intra-articular pathology at the same time might be

more beneficial[2].

In the treatment of FAI, cases of associated retroversion and/or global over coverage, there is still

no consensus as to what magnitude of over-coverage should be the threshold for rim trimming or

PAO. The extent to which acetabular rim trimming is done is also important because over trimming

can cause dysplasia leading to early degeneration of the joint[18]. Similarly there are no clear indi-

cations for labral debridement versus repair. It is generally assumed that preservation and repair

to keep the labrum intact is preferable to labral debridement or excision[19].

More importantly, one underlying issue is that surgeons who are expert in a particular kind of hip

preservation procedure may be inclined to treat everything with the same technique. However, the

pathology and not the surgical armamentarium should dictate the best technique. This is difficult


to assess but certainly in our series this represented just over 2% of our failures and although rela-

tively low, requires attention. This may reflect to some extent a rapidly evolving field as well as the

importance of continued professional development in regards to attendance of meetings as well as

visiting surgeons/centers with particular expertise.

Conclusion

Success of surgical treatment depends on accurate diagnosis with careful selection of the hip

preservation procedure most suited to the pathology and also on the expertise of the surgeon. The

importance of introducing modes of failure will permit to improve the reliability of our treatments as

well as permit effective comparison of surgical techniques in the treatment of pre-arthritic hip dis-

ease. Future work is necessary in achieving consensus in both diagnosis and surgical management

to minimize early failures and improve predictability of surgery.

Reference List

1. Clohisy JC, Schutz AL, St JL, Schoenecker PL, Wright RW: Periacetabular osteotomy: a sys-

tematic literature review. Clin Orthop Relat Res 467(8):2041, 2009

2. Beaulé PE, Dowding C, Parker G, Ryu JJ: What Factors Predict Improvements in Outcomes

Scores and Reoperations After the Bernese Periacetabular Osteotomy? Clin Orthop Relat

Res EPub 2014

3. Matheney T, Kim YJ, Zurakowski D, Matero C, Millis M: Intermediate to long-term results

following the Bernese periacetabular osteotomy and predictors of clinical outcome. J Bone

Joint Surg Am 91(9):2113, 2009

4. Troelsen A, Elmengaard B, Soballe K: Medium-Term Outcome of Periacetabular Osteotomy

and Predictors of Conversion to Total Hip Replacement. J Bone Joint Surg Am 91:2179,

2009

5. Steppacher SD, Tannast M, Ganz R, Siebenrock KA: Mean 20-year Follow up of Bernese

Periacetabular Osteotomy. Clin Orthop Relat Res 466:1633-44, 2008

6. Albers CE, Steppacher SD, Ganz R, Tannast M, Siebenrock KA: Impingement Adversely Af-

fects 10-year Survivorship After Periacetabular Osteotomy for DDH. Clin Orthop Relat Res

2013

7. Clohisy JC, Carlisle JC, Trousdale RT, Kim Y-J, Beaule PE, Morgan P, Steger-May K, Schoe-

necker PE, Millis M: Radiographic evaluation of the hip has limited reliability. Clin Orthop

Relat Res 467(3):666, 2009

8. Nepple JJ, Martell JM, Kim Y-J, Zaltz I, Millis MB, Podeszwa DA, Sucato DJ, Sink EL, Clohisy

JC, ANCHOR Study Group: Interobserver and intraobserver reliability of the radiographic

analysis of femoroacetabular impingement and dysplasia using computer-assisted meas-

urements. Am J Sports Med 42(10):2393, 2014

9. Letournel E, Judet R: Fractures of the Acetabulum. Springer-Verlag, New York, 1993

10. Larson CM, Moreau-Gaudry A, Kelly B.T., Byrd JWT, Tonetti J, Lavallee S, Chabanas L, Bar-

rier G, Bedi A: Are Normal Hips Being Labeled as Pathologic? A CT-based Method for Defin-

ing Normal Acetabular Coverage. Clin Orthop Relat Res EPub 2014


11. Ng KCG, Lamontagne M, Adamczyk AP, Rakhra KS, Beaule PE: Patient-specific anatomical

and functional parameters provide new insights into the pathomechanism of cam FAI. Clin

Orthop Relat Res Epub Oct 2014 2014

12. Clohisy J.C., Nepple JJ, Larson CM, Zaltz I, Millis M, Academic Network of Conservation Hip

Outcome Research (ANCHOR) Members: Persistent structural disease is the most common

cause of repeat hip preservation surgery-Springer. Clin Orthop Relat Res 471:3788, 2013

13. Heyworth BE, Shindle MK, Voos JE, Rudzki JR, Kelly BT. Radiologic and intraoperative find-

ings in revision hip arthroscopy. Arthroscopy 23[12], 1295-1302. 2007.

Ref Type: Journal (Full)

14. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ: Revision

hip arthroscopy. Am J Sports Med 35(11):1918, 2007

15. Myers SR, Eijer H, Ganz R: Anterior femoroacetabular impingement after periacetabular os-

teotomy. Clin Orthop Rel Res 363(June):93, 1999

16. Li PL, Ganz R: The morphology of congenital acetabular dysplasia. One in six is retroverted.

Clin Orthop Rel Res 416(11):245, 2003

17. Albers CE, Steppacher SD, Ganz R, Tannast M, Siebenrock KA: Impingement Adversely Af-

fects 10-year Survivorship After Periacetabular Osteotomy for DDH. Clin Orthop Relat Res

2013

18. Steppacher SD, Huemmer C, Schwab JM, Tannast M, Siebenrock K: Surgical hip disloca-

tion for treatment of femoroacetabular impingement: factors predicting 5-year survivorship.

Clin Orthop Relat Res 472:337, 2014

19. Espinosa N, Rothenfluh D, Beck M, Ganz R: Treatment of femoro-acetabular impingement:

preliminary results of labral refixation. J Bone Joint Surg 88A(5):925, 2006


CME Accreditation Statement This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for

Continuing Medical Education (ACCME) through the joint providership of the American Academy of Orthopaedic Surgeons and the Hip Society. The

American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

Credit Hours The American Academy of Orthopaedic Surgeons designates this live activity for a maximum of 7.75 AMA PRA Category 1 Credits™. Physicians

should claim only the credit commensurate with the extent of their participation in the activity.

Goals and Objectives The objectives of the Open Meeting of The Hip Society are to provide up-to-date information on the treatment of hip problems including

arthroplasty and non-arthroplasty options and surgical techniques. Interactive symposia will be utilized.

Upon completion of this program, participants should be able to:

• Update clinical skills and basic knowledge through research findings and biomechanical studies.

• Discuss the various surgical and non-surgical treatments and management of conditions related to the hip joint. • Determine indications and complications in total hip arthroplasty.

• Critique presentations of surgical techniques and demonstrations of treatment options.

• Evaluate the efficacy of new treatment options through evidence-based data.

FDA Statement Some pharmaceuticals and/or medical devices at the Specialty Day Meeting have not been cleared by the U.S. Food and Drug Administra-

tion (FDA) or have been cleared by the FDA for specific purposes only. The FDA has stated that it is the responsibility of the physician to

determine the FDA status of each pharmaceuticals and/or medical devices he or she wishes to use in clinical practice.

The Hip Society policy provides that “off label” uses of a device or pharmaceutical may be described in The Hip Society’s CME activities so long

as the “off-label” status of the device or pharmaceutical is also specifically disclosed (i.e. that the FDA has not approved labeling the device for

the described purpose). Any device or pharmaceutical is being used “off label” if the described use is not set forth on the product’s approved

label.

To obtain information regarding the clearance status of a device or pharmaceutical refers to the product labeling or call the FDA at 1-800-

638-2041 or visit the FDA internet site at http://www.fda.gov/cdrh/510khome.html

Financial Disclosure Each participant in The Hip Society/AAHKS Meeting has been asked to disclose if he or she has received something of value from a com-

mercial company, which relates directly or indirectly to the subject of their presentation. These responses reflect the answers from a series

of questions submitted by all persons participating in the Academy’s overall online Disclosure Program, which is available to all Academy

members at www.aaos.org/disclosure. The Hip Society does not view the existence of these disclosed interests or commitments as neces-

sarily implying bias or decreasing the value of the author’s participation in the meeting.

Education Committee

Mark W Pagnano, MD, Chair: Submitted on: 01/31/2016; DePuy, A Johnson & Johnson Company: IP royalties;

Hip Society: Board or committee member; Knee Society: Board or committee member; Pacira: Paid consultant;

Stryker: IP royalties

Paul E Beaule, MD: Submitted on: 05/31/2015; Biomet: Paid consultant; Corin U.S.A.: IP royalties; Paid consultant;

Research support; DePuy, A Johnson & Johnson Company: Paid consultant; Research support; Journal of Bone and

Joint Surgery - American: Publishing royalties, financial or material support; MEDACTA: IP royalties; Paid consultant;

Paid presenter or speaker; MicroPORT: Paid presenter or speaker; Research support; MicroPort Orthopedics: IP royal-

ties; Smith & Nephew: Paid consultant; Smith-Nephew: Paid presenter or speaker; Wolters Kluwer Health - Lippincott

Williams & Wilkins: Publishing royalties, financial or material support

Daniel J Berry, MD: Submitted on: 10/12/2015; American Joint Replacement Registry: Board or committee member;

DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Elsevier: Publishing royalties,

financial or material support; Hip Society: Board or committee member; Journal of Bone and Joint Surgery - American:

Editorial or governing board; Mayo Clinic Board of Governors: Board or committee member; Wolters Kluwer Health -

Lippincott Williams & Wilkins: Publishing royalties, financial or material support

Kevin John Bozic, MD, MBA: Submitted on: 11/09/2015; AAOS: Board or committee member; American Joint Re-

placement Registry: Board or committee member; Harvard Business School: Paid consultant; Institute for Healthcare

Improvement: Paid consultant; Orthopaedic Research and Education Foundation: Board or committee member; Yale-

New Haven Center for Outcomes Research: Paid consultant

C Anderson Engh Jr, MD: Submitted on: 11/10/2015; AAOS: Board or committee member; American Association of

Hip and Knee Surgeons: Board or committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid con-

sultant; Research support; Stock or stock Options; Hip Society: Board or committee member; Smith & Nephew: Re-

search support

http://www.fda.gov/cdrh/510khome.html

http://www.aaos.org/disclosure


A Seth Greenwald, DPhil Oxon: Submitted on: 10/06/2015; AAOS: Board or committee member; Aesculap/B.Braun:

Research support; Biomedical Development Corporation: Research support; Biomet: Research support; DePuy, A

Johnson & Johnson Company: Research support; Hospital for Special Surgery Journal: Editorial or governing board;

Iconacy Orthopedics: Research support; ImplantCast: Research support; Intellirod: Research support; Journal of Ar-

throplasty: Editorial or governing board; Journal of Orthopaedic Surgery (APOA): Editorial or governing board; Journal of

the Korean Orthopaedic Association: Editorial or governing board; Lima Corporate: Research support; MatOrtho: Re-

search support; Maxx Orthopedics: Research support; Medacta: Research support; OmniLife Science: Research sup-

port; Orthopaedic Research and Education Foundation: Board or committee member; Orthopedics: Editorial or govern-

ing board; Orthopedics Today: Editorial or governing board; Ranier: Research support; Seminars in Arthroplasty: Pub-

lishing royalties, financial or material support; Smith & Nephew: Research support; Total Joint Orthopedics (TJO): Re-

search support; Video Journal of Orthopaedics: Editorial or governing board; Zimmer: Research support

Steven J MacDonald, MD: Submitted on: 10/29/2015; DePuy, A Johnson & Johnson Company: IP royalties; Paid con-

sultant; Research support; Hip Innovations Technology, JointVue: Stock or stock Options; Knee Society: Board or com-

mittee member; Smith & Nephew: Research support; Stryker: Research support

Scott M Sporer, MD: Submitted on: 10/03/2015; American Joint Replacement Registy: Board or committee member;

Central Dupage Hospital: Research support; Hip Society: Board or committee member; Paciria: Paid consultant;

SLACK Incorporated: Publishing royalties, financial or material support; Smith & Nephew: Paid consultant; Stryker:

Research support; Zimmer: Paid consultant; Research support


Presenters and Moderators

Matthew P Abdel, MD: Submitted on: 10/01/2015; European Journal of Orthopaedic Surgery and Traumatology: Edi-

torial or governing board; Journal of Bone and Joint Surgery - British: Editorial or governing board; Journal of Orthopae-

dic Research: Editorial or governing board; Journal of Orthopaedics and Traumatology: Editorial or governing board;

Minnesota Orthopaedic Society: Board or committee member

Mike Anderson, MS, ATC: Submitted on: 12/18/2015; OrthoGrid Technologies, Inc.: Paid consultant

Jean-Noel A Argenson, MD: Submitted on: 10/01/2015; Adler-Ortho: Research support; Euros: Research support;

Graftys, Convatec, Moximed: Board or committee member; Journal of Bone and Joint Surgery - American: Editorial or

governing board; Orthopedics Today: Editorial or governing board; Symbios: Research support; Zimmer: IP royalties;

Paid consultant; Research support

Geneva Baca: (This individual reported nothing to disclose); Submitted on: 11/02/2015

Brian Barlow, MD: (This individual reported nothing to disclose); Submitted on: 11/03/2015

Robert L Barrack, MD: Submitted on: 10/26/2015; Biomet: Research support; Hip Society: Board or committee mem-

ber; Journal of Bone and Joint Surgery - American: Editorial or governing board; Journal of Bone and Joint Surgery -

British: Editorial or governing board; Knee Society: Board or committee member; Medical Compression Systems: Re-

search support; National Institutes of Health (NIAMS & NICHD): Research support; Smith & Nephew: Research sup-

port; Stryker: IP royalties; Other financial or material support; Paid consultant; Research support; The McGraw-Hill

Companies Inc: Publishing royalties, financial or material support; Wolters Kluwer Health - Lippincott Williams & Wil-

kins: Publishing royalties, financial or material support; Wright Medical Technology, Inc.: Research support

Toby Nathan Barrack, BA: Submitted on: 02/02/2016; Biomet: Research support; Hip Society: Board or committee

member; Journal of Bone and Joint Surgery - American: Editorial or governing board; Journal of Bone and Joint Surgery

- British: Editorial or governing board; Knee Society: Board or committee member; McGraw-Hill Companies: Publishing

royalties, financial or material support; Smith & Nephew: Research support; Stryker: IP royalties; Other financial or

material support; Paid consultant; Research support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing

royalties, financial or material support; Wright Medical Technology, Inc.: Research support

Paul E Beaule, MD: Submitted on: 05/31/2015; Biomet: Paid consultant; Corin U.S.A.: IP royalties; Paid consultant;

Research support; DePuy, A Johnson & Johnson Company: Paid consultant; Research support; Journal of Bone and

Joint Surgery - American: Publishing royalties, financial or material support; MEDACTA: IP royalties; Paid consultant;

Paid presenter or speaker; MicroPORT: Paid presenter or speaker; Research support; MicroPort Orthopedics: IP royal-

ties; Smith & Nephew: Paid consultant; Smith-Nephew: Paid presenter or speaker; Wolters Kluwer Health - Lippincott

Williams & Wilkins: Publishing royalties, financial or material support

Michael E Berend, MD: Submitted on: 02/02/2016; Biomet: IP royalties; Paid consultant; Paid presenter or speaker;

Research support; Johnson & Johnson. Into our 501c3 research foundation: Research support; Journal of Arthro-

plasty: Editorial or governing board; Knee Society: Board or committee member; Stryker: Research support; Zimmer:

IP royalties; Paid consultant; Paid presenter or speaker; Research support

Daniel J Berry, MD: Submitted on: 10/12/2015; American Joint Replacement Registry: Board or committee member;

DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Elsevier: Publishing royalties,

financial or material support; Hip Society: Board or committee member; Journal of Bone and Joint Surgery - American:

Editorial or governing board; Mayo Clinic Board of Governors: Board or committee member; Wolters Kluwer Health -


Kevin John Bozic, MD, MBA: Submitted on: 11/09/2015; AAOS: Board or committee member; American Joint Re-

placement Registry: Board or committee member; Harvard Business School: Paid consultant; Institute for Healthcare

Improvement: Paid consultant; Orthopaedic Research and Education Foundation: Board or committee member; Yale-

New Haven Center for Outcomes Research: Paid consultant

James Andrew Browne, MD: Submitted on: 11/30/2015; American Journal of Orthopedics: Editorial or governing

board; Biocomposites Ltd: Paid consultant; DJ Orthopaedics: Paid consultant; Ethicon: Paid consultant; Journal of Ar-

throplasty: Editorial or governing board

Miguel E Cabanela, MD: Submitted on: 01/12/2016; MidAmerica Orthopedic Society: Board or committee member

John J Callaghan, MD: Submitted on: 10/12/2015; DePuy, A Johnson & Johnson Company: IP royalties; Paid consult-

ant; International Hip Society: Board or committee member; Journal of Arthroplasty: Editorial or governing board; Jour-


nal of Arthroplasty (Deputy Editor): Publishing royalties, financial or material support; Knee Society: Board or commit-

tee member; Orthopaedic Research and Education Foundation: Board or committee member; Wolters Kluwer Health -


Kaitlin M Carroll, BS: (This individual reported nothing to disclose); Submitted on: 02/01/2016

Jourdan Michael Cancienne, MD: (This individual reported nothing to disclose); Submitted on: 10/01/2015

Antonia Chen, MD, MBA: Submitted on: 11/03/2015; 3M: Research support; AAOS: Board or committee member;

ACI: Paid consultant; Joint Purification Systems: Paid consultant; Musculoskeletal Infection Society: Board or commit-

tee member; Myoscience: Research support; SLACK Incorporated: Publishing royalties, financial or material support

John C Clohisy, MD: Submitted on: 11/02/2015; Microport Orthopedics, Inc.: Paid consultant; Pivot Medical: Re-

search support; Smith & Nephew: Paid consultant; Research support; Wolters Kluwer Health - Lippincott Williams &

Wilkins: Publishing royalties, financial or material support; Zimmer: Research support

Benjamin Ray Coobs, MD: (This individual reported nothing to disclose); Submitted on: 11/03/2015

Brian Matthew Curtin, MD: Submitted on: 10/03/2015; American Association of Hip and Knee Surgeons: Board or

committee member; American Joint Replacement Registry Review Commission: Board or committee member; Clinical

Orthopaedics and Related Research: Editorial or governing board; DePuy, A Johnson & Johnson Company: Paid pre-

senter or speaker; European Journal of Orthopaedic Surgery and Traumatology: Editorial or governing board; Interna-

tional Congress for Joint Reconstruction: Board or committee member; Iroko Pharmaceuticals: Paid consultant; John-

son & Johnson: Paid consultant; Journal of Arthroplasty: Editorial or governing board; Orthopedics: Editorial or govern-

ing board

Richard De Steiger, MD: Submitted on: 11/13/2015; Australian Orthopaedic Association National Joint Replacment

Registry: Board or committee member; Enlighten Health: Board or committee member; Journal Of Orthopaedic Sur-

gery: Editorial or governing board

Craig J Della Valle, MD: Submitted on: 10/01/2015; American Association of Hip and Knee Surgeons: Board or com-

mittee member; Arthritis Foundation: Board or committee member; Biomet: IP royalties; Paid consultant; Research

support; CD Diagnostics: Research support; Stock or stock Options; DePuy, A Johnson & Johnson Company: Paid con-

sultant; Hip Society: Board or committee member; Knee Society: Board or committee member; Mid America Orthopae-

dic Association: Board or committee member; Orthopedics Today: Editorial or governing board; SLACK Incorporated:

Editorial or governing board; Publishing royalties, financial or material support; Smith & Nephew: Paid consultant; Re-

search support; Stryker: Research support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties,

financial or material support

Douglas A Dennis, MD: Submitted on: 10/31/2015; Clinical Orthopaedics and Related Research: Editorial or govern-

ing board; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker; DePuy, A

Johnson & Johnson Company, Porter Adventist Hospital: Research support; Innomed: IP royalties; Joint Vue: Stock or

stock Options; Journal of Arthroplasty: Editorial or governing board; Journal of Bone and Joint Surgery - American: Edi-

torial or governing board; Orthopedics Today: Editorial or governing board; Wolters Kluwer Health - Lippincott Williams

& Wilkins: Publishing royalties, financial or material support

Lawrence Douglas Dorr, DMD: Submitted on: 01/31/2016; DJ Orthopaedics: IP royalties; Total Joint Orthopedics:

Stock or stock Options

Clive P Duncan, MD, MSc, FRCSC: Submitted on: 10/22/2015; Zimmer: Paid presenter or speaker

Stephen Thomas Duncan, MD: Submitted on: 01/05/2016; American Association of Hip and Knee Surgeons: Board

or committee member; Biomet: Paid consultant; Journal of Arthroplasty: Editorial or governing board;

Mitek: Paid consultant; Morph: Unpaid consultant; Smith & Nephew: Paid consultant

Addison Elston, BS: (This individual reported nothing to disclose); Submitted on: 06/01/2015

C Anderson Engh Jr, MD: Submitted on: 11/10/2015; AAOS: Board or committee member; American Association of

Hip and Knee Surgeons: Board or committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid con-

sultant; Research support; Stock or stock Options; Hip Society: Board or committee member; Smith & Nephew: Re-

search support

Christina Ilona Esposito, PhD: Submitted on: 05/26/2015; EOS Imaging Inc.: Research support


Keith Fehring, MD: Submitted on: 04/02/2015; American Association of Hip and Knee Surgeons: Board or committee

member; DePuy, A Johnson & Johnson Company: IP royalties; Other financial or material support; Paid consultant;

Paid; presenter or speaker; Resea; Knee Society: Board or committee member

Thomas K Fehring, MD: Submitted on: 11/04/2015; American Association of Hip and Knee Surgeons: Board or com-

mittee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker; Re-

search support; Knee Society: Board or committee member

Xavier Flecher: Submitted on: 06/17/2015; Stryker: Paid consultant; Zimmer: Paid consultant

Kevin L Garvin, MD: Submitted on: 10/20/2015; AAOS: Board or committee member; American Orthopaedic Associa-

tion: Board or committee member; Hip Society: Board or committee member; Wolters Kluwer Health - Lippincott Wil-

liams & Wilkins: Editorial or governing board

M. Russell Giveans, PhD: Submitted on: 05/25/2015; Ortholink Pty Ltd: Paid consultant

Nitin Goyal, MD: Submitted on: 02/01/2016; Cayenne Medical: Paid consultant; Datatrace: Publishing royalties, fi-

nancial or material support; Stryker: Paid consultant

Meridith E Greene: Submitted on: 06/01/2015; Biomet: Other financial or material support; Zimmer: Other financial

or material support

A Seth Greenwald, DPhil Oxon: Submitted on: 10/06/2015; AAOS: Board or committee member; Aesculap/B.Braun:

Research support; Biomedical Development Corporation: Research support; Biomet: Research support; DePuy, A

Johnson & Johnson Company: Research support; Hospital for Special Surgery Journal: Editorial or governing board;

Iconacy Orthopedics: Research support; ImplantCast: Research support; Intellirod: Research support; Journal of Ar-

throplasty: Editorial or governing board; Journal of Orthopaedic Surgery (APOA): Editorial or governing board; Journal of

the Korean Orthopaedic Association: Editorial or governing board; Lima Corporate: Research support; MatOrtho: Re-

search support; Maxx Orthopedics: Research support; Medacta: Research support; OmniLife Science: Research sup-

port; Orthopaedic Research and Education Foundation: Board or committee member; Orthopedics: Editorial or govern-

ing board; Orthopedics Today: Editorial or governing board; Ranier: Research support; Seminars in Arthroplasty: Pub-

lishing royalties, financial or material support; Smith & Nephew: Research support; Total Joint Orthopedics (TJO): Re-

search support; Video Journal of Orthopaedics: Editorial or governing board; Zimmer: Research support

Allan E Gross, MD, FRCSC, Prof: Submitted on: 10/06/2015; Canadian Orthopaedic Association: Board or committee

member; Hip Society: Board or committee member; Intellijoint systtem - device for measuring length and offset after

hip replacement: Stock or stock Options; Journal of Arthroplasty: Editorial or governing board;

Knee Society: Board or committee member; Zimmer: Paid consultant; Paid presenter or speaker

Fares Sami Haddad, FRCS: Submitted on: 10/02/2015; Annals of the Royal College of Surgeons England: Editorial or

governing board; Bone and Joint Journal: Editorial or governing board; corin: IP royalties; Journal of Arthroplasty: Edito-

rial or governing board; matortho: IP royalties; Orthopedics Today: Editorial or governing board; Smith & Nephew: IP

royalties; Paid consultant; Research support; Stryker: Paid consultant

George John Haidukewych, MD: Submitted on: 12/17/2015; AAOS: Board or committee member; Biomet: IP royalties;

Paid consultant; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Journal of Orthopedic Trauma:

Editorial or governing board; Orthopediatrics, Institute for Better Bone Health: Stock or stock Options; Synthes: Other

financial or material support; Paid consultant

David A Halsey, MD: Submitted on: 01/16/2016; AAOS: Board or committee member; American Association of Hip

and Knee Surgeons: Board or committee member; Vermont Medical Society: Board or committee member; Vermont

Orthopaedic Society: Board or committee member

William G Hamilton, MD: Submitted on: 10/01/2015; Biomet: Research support; DePuy, A Johnson & Johnson Com-

pany: Paid consultant; Paid presenter or speaker; Research support; Inova Health Care Services: Research support

Arlen D Hanssen, MD: Submitted on: 12/10/2015; Elsevier: Publishing royalties, financial or material support; Inter-

national Congress for Joint Reconstruction (ICJR): Board or committee member; Stryker: IP royalties

Curtis W Hayes, MD (Richmond, VA) Submitted on: 02/08/2016Up-To-Date: Publishing royalties, financial or material

support

Mark Joseph Heidenreich, MD: (This individual reported nothing to disclose); Submitted on: 12/18/2015

Kevin Hoover, MD, PhD: Submitted on: 02/01/2016; American College of Radiology: Board or committee member

Bioclinica, Inc.: Paid consultant


William J Hozack, MD: Submitted on: 02/01/2016; Journal of Arthroplasty: Editorial or governing board; Stryker: IP

royalties; Paid consultant; Research support

Robert Hopper, PhD: (This individual reported nothing to disclose); Submitted on: 01/15/2016

Richard Iorio, MD: Submitted on: 01/19/2016; American Association of Hip and Knee Surgeons: Board or committee

member; APOS Medical & Sports Technologies Ltd.: Research support; Bioventis: Research support; Clinical Orthopae-

dics and Related Research: Editorial or governing board; DJ Orthopaedics: Paid consultant; Ferring Pharmaceuticals:

Research support; Hip Society: Board or committee member; JBJS Reviews: Editorial or governing board; Journal of

Arthroplasty: Editorial or governing board; Journal of Bone and Joint Surgery - American: Editorial or governing board;

Journal of the American Academy of Orthopaedic Surgeons: Editorial or governing board; Knee Society: Board or com-

mittee member; MCS ActiveCare: Paid consultant; Orthofix, Inc.: Research support; Orthosensor: Research support;

Pacira: Paid consultant; Research support; Vericel: Research support; Wellbe: Stock or stock Options

Joshua J Jacobs, MD: Submitted on: 11/10/2015; Hip Society: Board or committee member; Implant Protection:

Stock or stock Options; Medtronic Sofamor Danek: Research support; Nuvasive: Research support; Zimmer: Research

support

Jack Jeng, MD: (This individual reported nothing to disclose); Submitted on: 12/18/2015

Seth A Jerabek, MD: Submitted on: 10/28/2015; Stryker: Paid consultant; Paid presenter or speaker

William A Jiranek, MD: Submitted on: 10/03/2015; American Association of Hip and Knee Surgeons: Board or com-

mittee member; Cayenne Medical: Paid consultant; DePuy, A Johnson & Johnson Company: IP royalties; Paid consult-

ant; Research support; Johnson & Johnson: Stock or stock Options; Lifenet Health, Inc.: Board or committee member;

OLC Orthopaedic Learning Center: Board or committee member; Stryker: Research support

Bryan T Kelly, MD: Submitted on: 10/30/2015; A-3 Surgical: Stock or stock Options; A3 Surgical: Unpaid consultant;

Arthrex, Inc: Paid consultant

Michael Maher Kheir, BS: (This individual reported nothing to disclose); Submitted on: 01/18/2016

Han Jo Kim, MD: Submitted on: 10/01/2015; Biomet: Paid consultant; HSS Journal, Asian Spine Journal: Editorial or

governing board; K2M, Inc: Paid consultant; Scoliosis Research Society: Board or committee member

Paul F Lachiewicz, MD: Submitted on: 10/01/2015; Gerson Lehrman Group: Paid consultant; Guidepoint Global Advi-

sors: Paid consultant; Hip Society: Board or committee member; Innomed: IP royalties; Journal of Arthroplasty: Edito-

rial or governing board; Journal of Surgical Orthopaedic Advances: Editorial or governing board; Mallinckrodt (formerly

Cadence): Paid presenter or speaker; Orthopaedic Surgery & Trauma Society: Board or committee member;

Pacira: Paid consultant; Paid presenter or speaker; Zimmer: Research support

Joseph M Lane, MD: Submitted on: 10/01/2015; AAOS: Board or committee member; Agnovos: Paid consultant;

Amgen Co: Paid consultant; Association of Bone and Joint Surgeons, AOA, ASBMR: Board or committee member; Bone

Therapeutics, Inc. CollPlant: Paid consultant; CollPlant, Inc: Stock or stock Options; Eli Lilly: Paid consultant; Grafty's:

Paid consultant; Harvest, Inc., ISTO, BiologicsMD: Paid consultant; Kuros: Paid consultant; Merck: Research support;

Musculoskeletal Tumor Society: Board or committee member; Orthopaedic Research Society: Board or committee

member

Christopher M. Larson, MD: Submitted on: 10/01/2015; A3 Surgical: Paid consultant; Stock or stock Options;

Arthroscopy: Editorial or governing board; Educational support: Smith & Nephew: Research support;

Smith & Nephew: Paid consultant

Dirk Larson: (This individual reported nothing to disclose); Submitted on: 12/18/2015

Jacqueline Eve Lee, PhD: (This individual reported nothing to disclose); Submitted on: 02/01/2016

David G Lewallen, MD: Submitted on: 10/01/2015; Acuitive: Stock or stock Options; American Joint Replacement

Registry: Board or committee member; Ketai Medical Devices: Stock or stock Options; Unpaid consultant;

Link Orthopaedics: Paid consultant; Mako/Stryker: IP royalties; Orthopaedic Research and Education Foundation:

Board or committee member; Pipeline: IP royalties; pipeline biomedical holdings: Paid consultant; Zimmer: IP royal-

ties; Paid consultant; Paid presenter or speaker

Jay R Lieberman, MD: Submitted on: 10/09/2015; AAOS: Board or committee member; American Association of Hip

and Knee Surgeons: Editorial or governing board; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant;


Hip Innovation Technology: Stock or stock Options; Journal of Arthroplasty: Editorial or governing board; Saun-

ders/Mosby-Elsevier: Publishing royalties, financial or material support; Western Orthopaedic Association: Board or

committee member

Joseph D Lipman, MS: Submitted on: 02/01/2016; Exactech, Inc: IP royalties; Extremity Medical: Unpaid consultant;

Lima Corporate: IP royalties; Mathys Ltd: IP royalties; Ortho Development Corporation: IP royalties

Adolph V Lombardi Jr, MD: Submitted on: 10/12/2015; Clinical Orthopaedics and Related Research: Editorial or gov-

erning board; Hip Society: Board or committee member; Innomed: IP royalties; Journal of Arthroplasty: Editorial or gov-

erning board; Journal of Bone and Joint Surgery - American: Editorial or governing board; Journal of Orthopaedics and

Traumatology: Editorial or governing board; Journal of the American Academy of Orthopaedic Surgeons: Editorial or

governing board; Kinamed: Research support; Knee: Editorial or governing board; Knee Society: Board or committee

member; Mount Carmel Education Center at New Albany: Board or committee member; Operation Walk USA: Board or

committee member; Orthosensor: IP royalties; Paid consultant; Research support; Pacira Pharmaceuticals, Inc.: Paid

consultant; Research support; Surgical Technology International: Editorial or governing board; Zimmer Biomet: IP roy-

alties; Paid consultant; Research support

Tad M Mabry, MD: Submitted on: 10/05/2015; Mid-America Orthopaedic Association: Board or committee member

Steven J MacDonald, MD: Submitted on: 10/29/2015; DePuy, A Johnson & Johnson Company: IP royalties; Paid con-

sultant; Research support; Hip Innovations Technology, JointVue: Stock or stock Options; Knee Society: Board or com-

mittee member; Smith & Nephew: Research support; Stryker: Research support

Henrik Malchau, MD: Submitted on: 05/11/2015; Biomet: Research support; Unpaid consultant; Ceramtec: Paid con-

sultant; DePuy: Research support; International Hip Society: Board or committee member; ISAR (International Society

for Arthroplasty Registries): Board or committee member; MAKO: Research support; RSA Biomedical: Board or com-

mittee member; RSA Biomedical Inc: Stock or stock Options; Scientific advisor for Biomet in northern Europe: Board or

committee member; Smith & Nephew: Research support; Stryker: IP royalties;

Zimmer: Research support

William J Maloney, MD: Submitted on: 10/07/2015; AAOS: Board or committee member; Abbott: Stock or stock Op-

tions; AJRR: Board or committee member; American Association of Hip and Knee Surgeons: Board or committee mem-

ber; Flexion Therapeutics, Inc.: Board or committee member; Flexion Therapeutics, Inc. - Scientific Advisory Board:

Paid consultant; Flexion Therapeutics, Inc. --: Stock or stock Options; Gillead: Stock or stock Options; ISTO Technolo-

gies (Start up ): Stock or stock Options; ISTO Technologies, Inc - Board of Directors: Paid consultant; ISTO Technolo-

gies, Inc.: Board or committee member; Johnson & Johnson: Stock or stock Options; Journal of Orthopaedic Research:

Editorial or governing board; Journal of Orthopaedic Science: Editorial or governing board; Merck: Stock or stock Op-

tions; Moximed: Stock or stock Options; Pfizer: Stock or stock Options; Pipeline Orthopaedics: Stock or stock Options;

Stemedica: Board or committee member; Stemedica ( Start up): Stock or stock Options; Stryker: IP royalties; TJO:

Stock or stock Options; Western Orthopaedic Association: Board or committee member; Zimmer: IP royalties

Jennifer Marland, PT: (This individual reported nothing to disclose); Submitted on: 02/01/2016

Joel Michael Matta, MD: Submitted on: 10/04/2015; DePuy, A Johnson & Johnson Company: Paid consultant;

Invuity Inc: Paid consultant; Stock or stock Options; Medtronic Sofamor Danek: Paid consultant; MizuhoOSI: IP royal-

ties; Radlink Corp: Stock or stock Options; Stryker: Paid consultant

David Jacob Mayman, MD: Submitted on: 02/01/2016; Knee Society: Board or committee member; OrthAlign: Stock

or stock Options; Smith & Nephew: Paid consultant; Paid presenter or speaker

Richard W McCalden, MD: Submitted on: 10/30/2015; Smith & Nephew: Paid consultant; Paid presenter or speaker;

Smith & NephewJ&J DepuyStryker: Research support

Alexander Stewart McLawhorn, MD, MBA: Submitted on: 11/20/2015; American Association of Hip and Knee Sur-

geons: Board or committee member; HSS Journal: Editorial or governing board

R Michael Meneghini, MD: Submitted on: 09/29/2015; Journal of Arthroplasty: Editorial or governing board;

Knee Society: Board or committee member; Stryker: IP royalties; Paid consultant; Research support

Theodore Miller, MD: (This individual reported nothing to disclose); Submitted on: 01/31/2016

Michael B Millis, MD: Submitted on: 09/24/2015; Saunders/Mosby-Elsevier: Editorial or governing board; Publishing

royalties, financial or material support; Springer: Editorial or governing board


Michael A Mont, MD: Submitted on: 10/22/2015; AAOS: Board or committee member; American Journal of Orthope-

dics: Editorial or governing board; DJ Orthopaedics: Paid consultant; Research support; Johnson & Johnson: Paid con-

sultant; Research support; Journal of Arthroplasty: Editorial or governing board; Journal of Knee Surgery: Editorial or

governing board; Medical Compression Systems: Paid consultant; Merz: Paid consultant; Microport: IP royalties; Na-

tional Institutes of Health (NIAMS & NICHD): Research support; Ongoing Care Solutions: Research support; Orthope-

dics: Editorial or governing board; Orthosensor: Paid consultant; Research support; Pacira: Paid consultant; Sage

Products, Inc.: Paid consultant; Stryker: IP royalties; Paid consultant; Research support; Surgical Techniques Interna-

tional: Editorial or governing board; Tissue Gene: Research support; TissueGene: Paid consultant; U S Medical Innova-

tions: Paid consultant

Michael M Morlock, PhD: Submitted on: 01/04/2016; Aesculap/B.Braun: Paid presenter or speaker; Research sup-

port; Ceramtec: Paid presenter or speaker; Research support; DePuy, A Johnson & Johnson Company: Paid consult-

ant; Paid presenter or speaker; Research support; Smith & Nephew: Paid presenter or speaker; Stryker: Paid pre-

senter or speaker; Zimmer: Paid consultant

Denis Nam, MD, MSc: Submitted on: 10/01/2015; EOS Imaging: Research support; KCI: Paid consultant; OrthAlign

Inc.: Stock or stock Options

Audrey Nebergall: (This individual reported nothing to disclose); Submitted on: 05/19/2015

Wendy Novicoff, PhD: (This individual reported nothing to disclose); Submitted on: 01/30/2016

Matthieu Ollivier, MD, MS: (This individual reported nothing to disclose); Submitted on: 05/15/2015

Douglas E Padgett, MD: Submitted on: 10/01/2015; Hospital For Special Surgery: Board or committee member; Jour-

nal of Arthroplasty: Editorial or governing board; Mako: IP royalties; Paid consultant; Paid presenter or speaker; Medi-

cal Compression Systems: Paid consultant; Stryker: Paid consultant; The Hip Society: Board or committee member

Sarah Padgett, PA-C: Submitted on: 01/15/2016; Abbvie: Stock or stock Options

Mark W Pagnano, MD: Submitted on: 01/31/2016; DePuy, A Johnson & Johnson Company: IP royalties; Hip Society:

Board or committee member; Knee Society: Board or committee member; Pacira: Paid consultant; Stryker: IP royalties

Wayne Gregory Paprosky, MD: Submitted on: 11/03/2015; Cadence Health: Other financial or material support;

DePuy, A Johnson & Johnson Company: Paid consultant; Hip Society: Board or committee member; Intellijoint: IP roy-

alties; Stock or stock Options; Journal of Arthroplasty: Editorial or governing board; Medtronic: Paid consultant;

Stryker: IP royalties; Paid consultant; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, finan-

cial or material support; Zimmer: IP royalties; Paid consultant

Sebastian Parratte, MD: Submitted on: 05/30/2015; Arthrex, Inc: Paid consultant; Euros: IP royalties; Graftys Adler

Orthopaedics: Paid consultant; Smith & NephewMoximed: Paid consultant; Zimmer: Paid consultant

Gail Pashos: Submitted on: 11/02/2015; GlaxoSmithKline: Stock or stock Options

Carsten Perka, MD: Submitted on: 01/08/2016; Aesculap/B.Braun: Paid consultant; Paid presenter or speaker; Bi-

omet: Paid presenter or speaker; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter

or speaker; German Orthopaedic and Trauma Society, Northern German Orthopaedic and Trauma Society, Arbeitsge-

meinschaft; Endoprothetik (German Endoprosthetic Society): Board or committee member; Smith & Nephew: IP royal-

ties; Paid consultant; Paid presenter or speaker; Smith & Nephew, Pluristem, Aesculap/B.Braun: Research support;

Springer: Editorial or governing board; Zimmer: Paid consultant; Paid presenter or speaker

Christopher L Peters, MD: Submitted on: 01/25/2016; AAOS: Board or committee member; American Association of

Hip and Knee Surgeons: Board or committee member; Biomet: IP royalties; Paid consultant; Paid presenter or

speaker; Research support; CoNextions Medical: Stock or stock Options; Hip Society: Board or committee member;

Journal of Arthroplasty: Editorial or governing board; Journal of Hip Preservation: Editorial or governing board; Knee

Society: Board or committee member

Remi Philippot, MD, PhD: Submitted on: 12/14/2015; ceramconcept: IP royalties; eos: Unpaid consultant;

serf: Other financial or material support

Gregory G Polkowski, II MD: Submitted on: 06/11/2015; American Association of Hip and Knee Surgeons: Board or

committee member

Martyn Porter, MD: Submitted on: 02/01/2016; International Society of Arthroplasty Registers: Board or committee

member; National Joint Registry of England and Wales: Board or committee member


Chitranjan S Ranawat, MD: Submitted on: 01/14/2016; Ceramtec (family member): Research support; Conformis

(family member): IP royalties; Conformis (family members): Stock or stock Options; DePuy, A Johnson & Johnson Com-

pany: IP royalties; Eastern Orthopedic Education Foundation: Board or committee member; Hip Society: Board or com-

mittee member; Journal of Arthroplasty: Editorial or governing board; Mako (family member): Paid consultant; Paid

presenter or speaker; Mitek (family member): Paid consultant; Paid presenter or speaker; Stryker (family member): IP

royalties

Ola Rolfson, MD, PhD: Submitted on: 02/01/2016; International Society of Arthroplasty Registers: Board or commit-

tee member; Swedish Hip Arthroplasty Register: Board or committee member

Harry E Rubash, MD: Submitted on: 12/21/2015; Ceramtec: IP royalties; Flexion: Paid consultant; Hip Society: Board

or committee member; Pacira: Paid consultant; Stryker: IP royalties; Wolters Kluwer Health - Lippincott Williams & Wil-

kins: Publishing royalties, financial or material support

Anita Sadhu, MD: (This individual reported nothing to disclose); Submitted on: 02/02/2016

Kathryn Samuelson, BS: (This individual reported nothing to disclose); Submitted on: 11/03/2015

William W. Schairer, MD: (This individual reported nothing to disclose); Submitted on: 10/15/2015

Thomas P Schmalzried, MD: Submitted on: 05/27/2015; DePuy, A Johnson & Johnson Company: IP royalties; Stock

or stock Options; None: Research support; Orthopaedic Research and Education Foundation: Board or committee

member; Orthopedics Today: Editorial or governing board; Stryker: IP royalties; Paid consultant; Paid presenter or

speaker; Stock or stock Options

Perry L Schoenecker, MD: Submitted on: 05/01/2015; Journal of Children's Orthopaedics: Editorial or governing

board; Journal of Pediatric Orthopedics: Editorial or governing board; Pediatric Orthopaedic Society of North America:

Board or committee member

Eoin C Sheehan, MD, FRCS (ORTHO): (This individual reported nothing to disclose); Submitted on: 12/04/2015

Neil P Sheth, MD: Submitted on: 10/05/2015; Smith & Nephew: Paid consultant; Zimmer: Paid consultant

Rafael Jose Sierra, MD: Submitted on: 10/04/2015; American Association of Hip and Knee Surgeons: Board or com-

mittee member; Biomet: IP royalties; Paid consultant; Paid presenter or speaker; DePuy, A Johnson & Johnson Com-

pany: Research support; Journal of Arthroplasty: Editorial or governing board; Link Orthopaedics: Paid consultant;

Stryker, Biomet: Research support; Zimmer: Research support

Scott M Sporer, MD: Submitted on: 10/03/2015; American Joint Replacement Registy: Board or committee member;

Central Dupage Hospital: Research support; Hip Society: Board or committee member; Paciria: Paid consultant;

SLACK Incorporated: Publishing royalties, financial or material support; Smith & Nephew: Paid consultant; Stryker:

Research support; Zimmer: Paid consultant; Research support

Bryan Donald Springer, MD: Submitted on: 10/01/2015; AJRR: Board or committee member; Arthroplasty Today: Edi-

torial or governing board; Convatec, Polaris: Paid consultant; DePuy, A Johnson & Johnson Company, Ceramtec: Paid

presenter or speaker; Joint purifications systems.: Other financial or material support; Journal of Arthroplasty: Editorial

or governing board; Knee Society: Board or committee member; Stryker: Paid consultant

Rebecca M Stone, ATC: (This individual reported nothing to disclose); Submitted on: 09/28/2015

Russell P Swann, MD: (This individual reported nothing to disclose); Submitted on: 02/01/2016

Timothy Tan, MD: (This individual reported nothing to disclose); Submitted on: 10/04/2015

Kayla Mae Thomason, BS: (This individual reported nothing to disclose); Submitted on: 01/05/2016

Anders Troelsen, MD, PhD: Submitted on: 05/28/2015; Biomet: Other financial or material support; Paid consultant;

Paid presenter or speaker; Research support; DOS - Danish Orthopaedic Society (Scientific committee member):

Board or committee member; EKS - European Knee Society (Communication committee member): Board or commit-

tee member; Zimmer: Research support

Robert T Trousdale, MD: Submitted on: 01/26/2016; American Association of Hip and Knee Surgeons: Board or com-

mittee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Hip Society: Board or committee

member’; Journal of Arthroplasty: Editorial or governing board; Knee Society: Board or committee member


Thomas Parker Vail, MD: Submitted on: 10/04/2015; American Board of Orthopaedic Surgery, Inc.: Board or commit-

tee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Knee Society: Board or committee

member

Brian C Werner, MD: (This individual reported nothing to disclose); Submitted on: 10/07/2015

Hugh S West Jr, MD: Submitted on: 10/02/2015; Linvatec: IP royalties; Paid consultant; Mitek: IP royalties; Paid con-

sultant; Research support; Stryker: Paid consultant

Timothy M Wright, PhD: Submitted on: 10/30/2015; Exactech, Inc: IP royalties; Stock or stock Options; Knee Society:

Board or committee member; Lima: IP royalties; Mathys Ltd: IP royalties; Orthobond: Stock or stock Options; Stryker:

Research support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material

support; Zimmer: Paid consultant

Cody Wyles, BS: (This individual reported nothing to disclose); Submitted on: 10/06/2015; Report: CUS7800W

01/30/2016

Staff

Olga Foley: (This individual reported nothing to disclose); Submitted on: 10/05/2015

Lisa DuShane: (This individual reported nothing to disclose); Submitted on: 11/05/2015

The Hip Society American Association of Hip and Knee Surgeons 9400 W. Higgins Road, Suite 500 9400 W. Higgins Road, Suite 230

Rosemont, IL 60018-4976 Rosemont, IL 60018-4976

Phone: (847)698-1638 Phone: (847)698-1200 Fax: (849)268-9540 Fax: (847)698-0704

Email: [email protected] Email: [email protected]

Website: www.hipsoc.org Website: www.aahks.org

Please complete the online evaluation at: https://www.surveymonkey.com/r/16wm or use the

QR code here.

mailto:[email protected]

mailto:[email protected]

http://www.aahks.org/

https://www.surveymonkey.com/r/16wm

(Winter) Meeting of The Hip

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Transcript of (Winter) Meeting of The Hip