Orthopaedic Insights - Cleveland Clinic · 4 ORTHOPAEDIC INSIGHTS For referrals, please call 216.445.0096 or 800.223.2273, ext.50096 Limitations to Current arthropLasty teChniQue

OrthopaedicInsights

Winter 2011

A Physician’s Newsletter from the Department of Orthopaedic Surgery

In This Issue:

3 Anterior Approach for Hip

Arthroplasty Shows Promising

Early Results

4 Glenoid and

Actebular Positioning

Systems Update

9 Lessons Learned in the

Care of the Elite Athlete

12 Physician Spotlight:

Kenneth Marks, MD

14 Hip Resurfacing:

An Option for Active Patients

16 Maximizing Patient

Satisfaction Following Total

Knee Arthroplasty

18 Meniscal Transplantation

Gains Popularity

20 Osteoarthritis and Obesity

22 Perspectives on Providing

Care at Abu Ghraib

ORTHOPAEDIC INSIGHTS2 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096

U.S.News & World Report Cleveland Clinic’s Orthopaedic Program is

ranked No. 4 in the nation by U.S.News & World

Report – the top ranking in the state of Ohio.

Dear Colleague, I am pleased to share with you the Fall 2010 edition of Orthopaedic Insights, which highlights many of our integrated approaches to clinical care, research and academics here in the Cleveland Clinic’s Department of Orthopaedic Surgery.

The diversity of the expertises of our staff is reflected in this issue of Ortho-paedic Insights. On p. 9, we highlight what lessons Dr. Thomas Graham has learned treating professional athletes with injuries and disorders of the hand and wrist. Drs Preetesh Patel, Juan Suarez and Wael Barsoum share their experience with adopting of the anterior approach for hip arthroplasty (p. 3) and Dr. Ken Greene discusses ways to maximize patient satisfaction follow-ing total knee arthroplasty (p.16). On p. 22, Dr. Mark Berkowitz shares his experiences caring for injured detainees as an orthopaedic surgeon at Abu Ghraib prison with the 115th Field Hospital in Iraq. We also highlight the many career achievements of Dr. Kenneth Marks, who in his 35 years in the field has made significant contributions in advanced limb-sparing surgery and expanding access to health services (p.22). We applaud him for his achieve-ments and thank him for his years of dedication to our organization.

These articles represent just a few of the ways that orthopaedic surgeons at Cleveland Clinic continue to look for innovative ways to improve care for patients today and contemplate the breakthroughs of tomorrow. They also demonstrate the strengths of our institute model here at Cleveland Clinic. Our Orthopaedic & Rheumatology Institute (ORI) effectively blends the strengths of our Orthopaedic and Rheumatology programs, both ranked among the top four nationally by U.S.News & World Report. This collaboration among orthopaedic specialists, musculoskeletal radiologists, biomedical engineers, rheumatologists, immunologists and physiatrists has helped streamline the assessment and management of musculoskeletal diseases and created new opportunities for innovation, investigation and training – ultimately improving the care we can offer your patients.

Thank you for picking up this issue of Orthopaedic Insights. We hope you enjoy these articles showcasing our recent work. Please feel free to contact us if you have any comments, questions or suggestions about this publication or our institute.

Richard D. Parker, MDChairman, Department of Orthopaedic Surgery

Professor, Cleveland Clinic Lerner College of Medicine

216.444.2992

[email protected]

Health Care Quality Innovation Summit Optimizing Value and Securing a Future of Innovation and Quality

May 11 - 13, 2011

InterContinental Hotel and Bank of America

Conference Center, Cleveland, Ohio

Register today! ccfcme.org/Quality11

ORTHOPAEDIC INSIGHTS 2011 3Visit clevelandclinic.org/ortho

At the Cleveland Clinic Florida, we have been performing the

operation with exciting results. The anterior approach is min-

imally invasive, using a true internervous plane with less soft

tissue trauma that makes the recovery faster and less painful

for patients. Typically, patients are being discharged in one

to two days and are off any walking assistive devices in just a

few days to a couple of weeks. Many patients are returning to

work within two weeks.

The direct anterior approach can be performed using a

standard operating room table or specialized tables specifi-

cally designed for the approach. The table allows for optimal

positioning of the extremity during surgery and facilitates

the femoral exposure that can be challenging using this

approach. In our experience, the use of specialized tables

makes the procedure technically easier and applicable to the

vast majority of patients. Having the patient in the supine

position facilitates bilateral surgeries. Revision surgery also

can be accomplished through this approach with predictable

results.

There are some challenges with this approach. Most sur-

geons are not familiar with it and the learning curve can be

quite steep. Performing the operation without a specialized

table is technically demanding and requires more assistance

in the operating room, especially during femoral exposure.

Implant impaction with the patient in the supine position

also is demanding and provides a different tactile feedback

to the surgeon. Blood loss appears to be more than with

traditional approaches and other equipment, such as bipolar

cautery, drains and cell savers are advocated with this ap-

proach.

The direct anterior approach for total hip arthroplasty is

showing promising early results and patient satisfaction.

Precise surgical technique and component positioning can

decrease early complications, such as instability and leg

length discrepancy, minimizing the revision load to our

healthcare system. Faster recovery allows patients to return

to a productive life earlier. More studies are required to deter-

mine the long-term impact of this approach.

About the Authors

Drs. Patel and Suarez practice at Cleveland Clinic Florida in Weston, Fla. and specialize in primary and revision hip and knee replacement surgery. Dr. Barsoum, Vice Chairman of Ortho-paedic Surgery, practices in Cleveland, Ohio and specializes in primary and revision hip and knee replacement. Physicians may contact Drs. Patel and Suarez at 877.463.2010 or [email protected] and [email protected]. Dr. Barsoum can be reached at 216.444.7515 or [email protected].

Anterior Approach for Hip Arthroplasty Shows Promising Early ResultsBy Preetesh D. Patel, MD, Juan C. Suarez, MD, and Wael K. Barsoum, MD

One of the most exciting recent innovations in hip surgery is the adoption of the anterior approach for hip arthroplasty.

Although not a new concept, it recently has been utilized with improved techniques and instruments that allow for

a more precise and safe operation. The approach allows the surgeon to perform the procedure with the patient in the

supine position and facilitates the use of fluoroscopy for precise component position and leg length approximation. In this

era of cost containment in our healthcare system, new techniques that can reduce the revision burden, especially instabil-

ity, will endure the test of time.


Limitations to Current arthropLasty teChniQue

Total joint arthroplasty of the shoulder, hip and knee

has demonstrated high clinical success rates, enabling

the vast majority of patients to resume an active and

independent life.

However, premature implant failure is a frequent limita-

tion of these procedures, most often resulting from poor

implant placement. In fact, malpositioned implants ac-

count for nearly 30 percent of premature implant failures,

costing the health care industry $1.15 billion per year.

Implant placement currently relies exclusively on the

surgeon’s intraoperative assessment of limited anatomic

landmarks at the time of surgery and the use of generic

instruments that do not take into consideration a patient’s

unique anatomy or the differing degrees of pathology.

These methods are most accurate with surgeon experience

and minimal joint pathology, yet are prone to errors with

less experienced hands or more severe pathology.

a CoLLaboratiVe approaCh

to optimize surgiCaL outComes

Cleveland Clinic’s Orthopaedic Surgery and Biomedical

Engineering departments are collaborating to develop

surgeon-friendly products that improve the accuracy and

precision of component placement, reduce surgery time,

enhance patient outcomes and decrease healthcare costs.

Novel technologies have been developed in recent years

to assist the surgeon in bone preparation and implant

positioning that include the use of pre-operative computer-

assisted surgical planning software and the development

of patient-specific instruments (Figure 1). Such technology

currently is available for the knee by a limited number of

implant manufacturers. Yet with more than 200,000 hip

and shoulder replacements annually and a projected 25-

year growth rate of 685 percent in the knee and 429 percent

in the hip, there is increasing demand for expansion of

this technology into other joints.

Our team has developed and validated a computer-based, 3-D

surgical simulator for total shoulder arthroplasty (TSA) and

total hip arthroplasty (THA). Additionally, we have developed

patient-specific instruments from this preoperative software

and have validated the use of these instruments in preclinical

trials of cadavers and sawbones with bone defects (Figure 2).

appLiCation oF new teChnoLogy

to the shouLder and hip

The glenoid positioning system (GPS) and acetabular

positioning system (APS) are comprised of patient-specific

surgical instruments that redefine precision for implant

placement. The new approach involves obtaining a preopera-

tive CT scan for incorporation into the 3-D surgical simula-

tor. The 3-D representation is then virtually implanted by the

surgeon using our simulator, allowing for patient-specific

instruments to be manufactured for the day of surgery. The

GPS has been developed for both the anatomic and reverse

TSA approach and the APS is the first system to permit THA

over a central acetabular guidewire.

Glenoid and Acetabular Positioning Systems UpdateBy Michael D. Hendel, PhD, Leonard T. Buller, BA, Wael K. Barsoum, MD, Joseph P. Iannotti, MD, PhD

Figure 1: Screenshot of 3D Reconstruction Figure 2: Screenshot of isolated scapula with implant


Early preclinical trials of the GPS and APS have produced

results that closely match the optimized presurgical plan

as defined by the software in the measurements of version,

inclination, location on the fossa, and screw location and

trajectory. They also have demonstrated a clinically and sta-

tistically significant improvement in component placement

when compared to the use of standard surgical instruments

by multiple surgeons. Furthermore, the GPS and APS not

only improved a surgeon’s accuracy, but also decreased the

variability within and between surgeons when compared to

the use of standard instruments (Figure 3).

The Cleveland Clinic Department of Orthopaedic surgery

is currently enrolling patients in a prospective, randomized

clinical trial to evaluate the efficacy of this promising new

technology.

About the Authors

Dr. Barsoum, Chair of the Cleveland Clinic Department of Surgi-cal Operations and Vice Chair of the Department of Orthopaedic Surgery, can be reached at 216.444.7515 or [email protected]. Iannotti, Chair of the Cleveland Clinic Orthopaedic and Rheumatologic Institute and Co-Director of the Orthopaedic Research Center, can be reached at 216.445.5151 or [email protected]. Leonard T. Buller, BA, and Michael D. Hendel, PhD, are medical students at the Cleveland Clinic Lerner College of Medicine.

Figure 3a: Visual Representa-tion of GPS Sawbone Trial: The top two rows indicate the final results of the metaglene and screw placement in the sagittal view for the standard place-ment method (white circles) compared to the preoperative virtual plan (blue circles). The bottom two rows indicate the GPS method. Columns represent each surgeon’s Standard and GPS trial results.

Figure 3b: Visual Representa-tion of APS Sawbone Trial: The top two rows indicate the final results of the shell and screw placement in the transverse view for the standard place-ment method (white) com-pared to the pre-operative virtual plan (blue). The bottom two rows indicate the APS method. Columns represent each surgeon’s Standard and APS trial results.


Defining normal bony anatomy and its variability

in a population allows for the evaluation of pathologic

deviations in an individual’s joint, a critical step in the

design of prosthetic joint components. For years,

orthopaedic surgeons have been limited to plain radio-

graphs or computed-tomographic (CT) images for

preoperatively assessing pathologic changes in a joint

and planning a suitable corrective strategy. These

methods are imprecise, subjective assessments that

restrict surgeons to speculation on the changes in a

joint instead of accurate, quantitative measurements.

Custom three-dimensionaL (3-d) simuLator

To address this issue, the Cleveland Clinic’s of Orthopaedic

Surgery and Biomedical Engineering departments devel-

oped a novel 3-D CT-based simulator for visualization of a

patient’s unique osseous anatomy as a free body, indepen-

dent of patient orientation within the gantry. This simulator

accurately measures the surface anatomy of reconstructed

3-D CT images when compared with measurements on

excised cadaver bone. Furthermore, it has been validated in

its use to perform the first 3-D quantitative assessment of

glenoid and acetabular vault shape in a normal population.

QuantiFying a VauLt

Vault shape was defined using CT scans of 60 normal

acetabulae and 61 normal scapulae with an additional 11

scapulae and 20 acetabulae for validation of vault geometry.

Each patient’s vault shape was obtained by manually tracing

predefined borders on 2-D slices of a hemipelvis or scapula

(Figure 1). Each 2-D outline was digitally stitched into a 3-D

triangular mesh model (Figure 2), representing a patient’s

vault. The size of each model was then normalized to allow

for comparison. Variation in vault shape among the study

population was quantified using the Euclidean distance be-

tween nearest neighboring points method. This calculation

measured the distance between every point on the vault’s

Characterization of Scapular and Acetabular Vault Shape with the Use of Novel 3-D Image Processing SoftwareBy Leonard T. Buller, BA, Michael D. Hendel, PhD, Wael K. Barsoum, MD, Joseph P. Iannotti, MD, PhD

Figure 1: Traced frontal image of the right hemipelvis soon after the fusion of the ala of the ilium and the margin of the acetabulum.

Figure 2: Screenshot of a model of the acetabular vault.


surfaces. Comparison of the vaults revealed at least 97

percent of the surface points of the acetabular vaults varied

by less than 3.0 mm and at least 85 percent of the points

defining the glenoid vault varied by less than 2.0 mm.

This suggests a single vault geometry fits an average clinical

population.

Future direCtions

We are optimistic that the use of this technology will

increase our understanding of bony anatomy and enable

surgeons to accurately define both a normal and pathologic

joint, leading to enhanced prosthetic design and improved

patient outcomes. Our team at Cleveland Clinic is currently

developing this technology into a preoperative tool for virtual

execution of the reconstruction, bone graft placement and

component placement in total joint arthroplasty (Figures 3

and 4). Training modules also are being designed to improve

surgical skills and decision making.

About the Authors

Dr. Barsoum, Chair of the Cleveland Clinic Department of Surgi-cal Operations and Vice Chair of the Department of Orthopaedic Surgery, can be reached at 216.444.7515 or [email protected].

Dr. Iannotti, Chair of the Cleveland Clinic Orthopaedic and Rheumatologic Institute and Co-Director of the Orthopaedic Research Center, can be reached at 216.445.5151 or [email protected]. Leonard T. Buller, BA, and Michael D. Hendel, PhD, are medical students at the Cleveland Clinic Lerner College of Medicine.

Figure 3: 2-D representation of glenoid vault model for place-ment of glenoid implant in total shoulder arthroplasty.

Figure 4 – 3-D planning for total shoulder arthroplasty.


Cervical disc degeneration is a normal part of aging that

occurs to some degree in everyone throughout their

lifetime. While most cases of disc degeneration do not be-

come clinically apparent, a minority of people will develop

symptomatic disc disease in the form of neck pain, radicu-

lopathy, myelopathy or myeloradiculopathy. The traditional

surgical treatment for symptomatic disc disease refractory

to nonoperative care is anterior cervical discectomy and

fusion (ACDF), a therapy with a proven record of excel-

lent clinical outcomes. The notion that the elimination of

motion is harmful has become a primary rationale for the

enthusiasm for cervical disc arthroplasty (CDA).

There are two major principles that are espoused by propo-

nents of CDA: 1) Preservation of motion will result in better

clinical outcomes, and 2) CDA will result in a decrease in

adjacent level degeneration and disease. Regarding the latter,

Hilibrand et al1 performed a 10-year survivorship analysis

of 409 anterior decompression and fusion procedures. They

reported a 2.9 percent annual incidence of adjacent level dis-

ease and an overall prevalence of 14 percent (follow-up two to

21 years). Kaplan-Meier survivorship analysis demonstrated a

predicted prevalence of adjacent level disease of 13.6 percent

at five years and 25.6 percent at 10 years. However, whether

or not this represents the natural history of spondylosis or a

result of fusion remains very controversial.

Published results on Food and Drug Administration Investi-

gational Device Exemption (IDE) trials are available for three

artificial discs: Prestige ST Disc, Medtronic Sofamor Danek,

Memphis, Tenn.; ProDisc-C, Synthes Spine, Paoli, Pa.; and

BRYAN Disc, Medtronic, Memphis, Tenn.

In 2007, Mummaneni et al2 compared single-level CDA using

the Prestige ST to ACDF in an IDE randomized controlled

trial. The reported differences in clinical outcome were not

statistically significant at 12 months or 24 months postopera-

tively. That is, both ACDF and CDA were equally efficacious in

treating symptomatic single-level cervical disc disease. Mur-

rey and colleagues3 published two-year results on the ran-

domized, controlled trial that compared one-level ProDisc-C

to ACDF. Like the Prestige trial2, there was

a statistically significant improvement in functional outcome

measures from baseline for both groups, but there was no

statistically significant intergroup difference in validated

outcome measures. The IDE trial results for the BRYAN

Disc were published recently by Heller and associates.4 At

24-month follow-up, there was no statistical difference found

in the Visual Analog Scale (VAS) score for the arm, SF-36,

neurological examination or adverse events. However, there

was a statistically significant intergroup difference found

favoring the Bryan Disc for the VAS neck and Neck Disability

Index scores.

These three studies represent the best literature on cervical

disc arthroplasty, and the two-year results are quite exciting.

Longer-term follow-up is necessary to determine if CDA will

prevent or lessen adjacent level degeneration and the need for

subsequent cervical surgeries. Other important aspects that

remain unanswered regarding this new technology include

long-term clinical and radiographic outcomes, implant wear

characteristics, revision strategies and implant cost.

About the Authors

Dr. Mroz specializes in complex cervical spine surgery and can be reached at 216.445.9232 or [email protected].

References:

1. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 81(4):519-28, 1999.

2. Mummaneni PV, Burkus JK, Haid RW, et al. Clinical and radio-graphic analysis of cervical disc arthoplasty compared with allograft fusion: a randomized controlled clinical trial. J Neurosurg Spine 6; 198-209, 2007.

3. Murrey D, Janssen M, Delamarter R et al. Results of the prospec-tive, randomized, controlled multicenter Food and Drug Adminis-tration investigational device exemption study of the ProDisc-C total disc replacement versus anterior discectomy and fusion for the treat-ment of 1-level symptomatic cervical disc disease. Spine J 9: 275-286, 2009.

4. Heller JG, Sasso RC, Papadopoulos SM, et al. Comparison of Bryan cervical disc arthroplasty with anterior cervical decompres-sion and fusion. Clinical and radiographic results of a randomized, controlled clinical trial. Spine 34: 101-107, 2009.

An Update on Cervical Disc ReplacementBy Thomas E. Mroz, MD


Lessons Learned in the Care of the Elite AthleteBy Thomas Graham, MD

There is no position in any sport that is not influenced by

the function of the hand and wrist. The common vernacular

used to describe those players in selected sports who appear

to have more ball-handling as part of their job description

as being in “skilled positions” is inaccurate as it is insulting

to those who share the field but are supposedly less gifted

in their “specialty.” Watching football linemen maneuver

their opponent with facility or observing the adept basketball

defender is an education in the use of the hands in sport, and

leaves little doubt that there is immense skill involved. Yes,

even soccer players are hampered in many aspects of their

game when they are playing with a hand or wrist disorder.

Accepting these data, there is little doubt that the athlete’s

ability to play after or with a hand or wrist injury is simply

different (usually more realistic) than after an anterior cruci-

ate ligament tear or a catastrophic neck injury. The hand

or wrist problem is almost “demoted,” although realization

that these injuries may be potentially season-ending or even

career-threatening seems to be gaining some recognition.

However, for the foreseeable future, the pressure on the

athlete and the care provider to minimize lost days of service

or return the injured player rapidly after hand problems is

unmistakable.

It was this challenge that really inspired me two decades ago

to start focusing more on the type of injuries sustained by

athletes and developing ways to prevent and minimize them,

while sharpening our surgical and rehabilitation skills to

introduce in-season return potential for many injuries that

once robbed players of their chance to participate. Now that

we have treated hundreds of elite athletes and countless col-

legiate, scholastic and recreational athletes, the information

on treating this special subset of patients and pathologies

has become validated and organized.

We have learned a great deal in this unique “laboratory” of

treating athletes with injuries and disorders of the hand and

wrist, yet I still feel compelled to address the question I get

maybe more than any other, as a physician who attends ap-

proximately 100 professional sports contests per year: “Why

spend so much time, energy and resources on caring for

professional (elite) athletes?” For me, the answers are simple;

this endeavor provides me challenges and opportunities that

are not found in any other facet of hand surgery. The fact

that such incremental differences separate the hall-of-famer

from the minor leaguer puts an unparalleled focus on every

element of your care. Having access to almost unlimited re-

sources (trainers, equipment, etc.) in one of the most compli-

ant populations in the world also gives us a true assessment

of what our treatments really can do.

The last part of the answer may be the most important; I have

learned more about how to care for each patient in my prac-

tice like they were a champion. From office processes that

try to respect the patient’s time to novel surgical techniques

and aggressive rehabilitation protocols that return patients

to “the game of life” faster, we have been able to internalize

and adopt many of the lessons learned in the care of the elite

athlete to care of the homemaker and hog farmer.

Some of the “clinical all-stars” that we have identified or con-

tributed over the years include the following:

• aggressive fixation of the fractured scaphoid

• early excision of hook of the hamate fractures to

accelerate return-to-play

• innovative techniques for treatment of tubular bone

fractures, like “bouquet pinning” for metacarpal fractures

• the use of wrist arthroscopy

• judicious handling of closed tendon injuries about

the hand and wrist

Lastly, being around dedicated athletes and iconic sports

organizations for more than 20 years also has allowed me to

appreciate the characteristics inherent in a “championship

team.” Many of those same characteristics are on display

every day at our institution and leave me humbled and appre-

ciative to be part of the Cleveland Clinic team.

About the Author

Dr. Graham specializes in surgery of the hand and upper ex-tremity, complex elbow disorders and fracture reconstruction, and congenital hand surgery. Physicians may contact him at 216.444.3598 or [email protected].


Rotator cuff tear is one of the most common sources of

shoulder pain and disability. The outcomes of repairing

large, chronic rotator cuff tears remain poor with re-tear

rates as high as 80 percent 1. These high rates have been

associated with fatty degradation of the rotator cuff

muscles, suggesting that accurate assessment of fatty

degeneration plays a crucial role in predicting tendon

healing and post-operative functionality of the rotator cuff

muscle.2,3,4,5 Current clinical evaluation of intramuscular

fat remains subjective and unreliable, and a standardized

non-invasive method to accurately measure intramuscular

fat content does not exist. In recent years, other medical

fields such as neurology have explored the potential of

using magnetic resonance spectroscopy (MRS). Previous

studies even correlated MRS outputs with the Goutallier’s

grading system of fat degeneration on MRI. 6,7

The global objective of our work is to assess the extent to

which proton magnetic resonance spectroscopy (1H-MRS)

can be used as a non-invasive imaging modality to provide

quantitative measures of muscle fat content. We used

1H-MRS and biochemical lipid extraction to analyze the

fat content in canine infraspinatus muscles that had been

mechanically unloaded at various time points to allow

for muscle degeneration. Each muscle was imaged as part

of the entire cadaveric shoulder girdle in both parallel

and perpendicular orientation (Figure 1). The muscles

were subsequently dissected into pieces that corresponded

to the voxels defined by our multi-voxel chemical shift

imaging (CSI) sequences, and their fat contents were

quantified biochemically using the Folch lipid extraction

method.8 For all samples, the sum of the lipid signals from

1H-MRS outputs from each voxel was calibrated by the

H2O signals (Figure 2) and compared against the weight

of the biochemically extracted lipid weight by using a

mixed model (Figure 3).

We did not find a significant relationship between bio-

chemically extract fat content and MRS lipid outputs.

As shown in Figure 3, the mixed model (fat content = 8.30

+ 9.24 (RLipid)) was not significant with p = 0.41, and the

mean residual was -1.32 percent (95 percent CI -2.03 to

-0.60). The effect of scan orientation was also not statisti-

cally significant (p = 0.83) (Figure 3b). Despite previous

correlation between the Goutallier grading system and MRS

outputs, we were unable to translate such relationship to

allow intramuscular lipid quantification from 1H-MRS out-

puts. Interestingly, we were able to find a significant relation-

ship between MRS outputs and fat content in our preliminary

study using isolated tissue samples. Hence, we suspect that

different sample environments in our study may provide

significant MRS noise to affect the signal outputs from the

selected voxels. Due to the sensitive nature of MRS, minor

environmental differences, such as inhomogeneous inter-

phase between the muscle and surrounding air, may produce

MRS noise to affect the signal outcomes.

In this study, we demonstrated that our current knowledge

of 1H-MRS cannot be easily applied clinically to improve

surgical analysis of fat degeneration within the human rota-

tor cuff muscles. Further research and development are still

needed to bridge the gap between MRS experimental use and

Exploring a Non-Invasive Alternative to Quantify Fatty Infiltration in Rotator Cuff MuscleBy Anny Hsu, MS and Kathleen Derwin, PhD

Figure 1: 1H-MR spectroscopy was performed using a 3-tesla unit and boxy matrix/phase array spine coils with spin echo multi-voxel CSI sequence at TR:2000ms TE:30ms, vector size of 1024 points, and bandwidth of 200Hz. The entire cadaveric shoulder girdle was scanned with the multi-voxel CSI sequence. The voxel grids are positioned such that they span the infraspina-tus muscle.


its clinical role. As seen in our preliminary studies, 1H-MRS

may be used to evaluate isolated muscle samples. Hence, we

believe that further research will uncover the full potential of

this powerful tool and its clinical utility in orthopaedics.

About the Authors

Anny Hsu, of Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, can be reached at [email protected].

Dr. Derwin, of the Department of Biological Engineering at Cleveland Clinic’s Lerner Research Institute, can be reached at 216.445.5982 or [email protected].

References:

1. Bishop et al., J Shoulder Elbow Surg 2006; 15(3):290-9. 2. Goutallier et al: J Shoulder Elbow Surg 2003;12:550-43. Nakagaki K et al: J Shoulder Elbow Surg 1996:5:194-2004. Thomazeau H et al: Clin Orthop Relat Res 1997:344:275-83. 5. Iannotti JP et al: JBJS Am 1991:63:17-296. Pfirrmann CWA et al: Radiology. 2004:232(3):709-715. 7. Torriani M et al: Radiology. 2005:236(2):609-614. 8. Folch J et al: J. Biol. Chem. 1957:226(1):497-509.

Figure 3 a,b: To calibrate the lipid signals by the H2O signals, MRS fat ratio (RLipid) was calculated from the H2O and the sum of the lipid signals using the following equations: RLipid = CH2O*ALipid/AH2O where CH2O and AH2O represented the H2O concentra-tion and signal peak integral, respectively. ALipid represented the sum of all three lipid peaks integrals. No significant relationship was found between MRS fat ratio and biochemically extract fat weight. In figure 3a, fat content = 8.30 + 9.24 (RLipid) with p = 0.41, and the mean residual was -1.32 percent (95% CI -2.03 to -0.60). The effect of scan orientation was also not statistically significant (p = 0.83) (Fig. 3b).

Figure 2a,b: The 1H-MR spectrums of each voxel contained two to three lipid resonances in the region 1-2ppm. Additionally, the resonances of creatine and choline were noted in region 2.5-4ppm, whereas the H2O resonance was found at 4.7 ppm.

a

b

ORTHOPAEDIC INSIGHTS12 For referrals, please call 216.445.0096 or 800.223.2273, ext.50096ORTHOPAEDIC INSIGHTS

In 1970, Kenneth Marks, MD, was working as a resident

with legendary Cleveland Clinic surgeon George Crile

Jr., MD, who championed lumpectomy surgical treat-

ment over radical mastectomy, the standard surgical

therapy for breast cancer patients at the time.

“I saw that Dr. Crile’s breast-sparing surgery was mak-

ing a positive difference for many cancer patients,”

recalls Dr. Marks. “That’s what eventually led me to de-

velop limb-sparing surgical techniques to treat patients

with musculoskeletal tumors.”

Since joining Cleveland Clinic as a staff orthopaedic

surgeon in 1975, Dr. Marks has performed approximate-

ly 11,000 surgeries in the specialty areas of orthopaedic

oncology, joint replacement and orthopaedic infec-

tions. In addition to his role in advancing limb-sparing

surgery, Dr. Marks served as Chairman of Orthopaedic

Surgery from 1991 to 2000. Now, more than 35 years

later, Dr. Marks continues to work as a Cleveland Clinic

medical consultant and perform joint replacement sur-

geries at Cleveland Clinic’s Euclid Hospital.

“Dr. Marks is a highly skilled and extraordinarily talented

surgeon,” says Joseph P. Iannotti, MD, PhD, Chair of Cleve-

land Clinic’s Orthopaedic and Rheumatologic Institute. “He

managed very difficult cases that saved many lives, and saved

a lot of limbs that otherwise would have been amputated.”

Dr. Iannotti also notes Dr. Marks’ vision as an administrator

who launched the first of Cleveland Clinic’s Family Health

Centers to deliver patient care and outpatient surgery ser-

vices throughout Northeast Ohio.

deVeLoping Limb-sparing teChniQues

During the 1970s, amputation was the standard surgical

therapy for patients with osteosarcoma, Ewing’s Sarcoma,

chrondrosarcoma, and other primary bone tumors.

Seeing that patients were having a very difficult time adjust-

ing to life after surgery, Dr. Marks collaborated with other

orthopaedic oncology surgeons across North America to

develop limb-sparing techniques to lower amputation rates.

“At the time there were only about 20 orthopaedic oncology

surgeons in North America and we knew we could save a

patient’s limb and maintain its functionality by replacing the

malignant bone or joint with an allograft, endoprothesis or

composite that many times we had to design,” says Dr. Marks.

“When we began limb-sparing surgeries, we were criticized

by some in the medical community who thought we were

risking peoples’ lives by not doing amputation. However, over

time it was proven that limb-sparing surgery’s cure rate was

equal to that of amputation. The other benefit was that limb-

sparing surgery maintained the patient’s quality of life.”

Today, limb-sparing surgery is the standard therapy. The

National Cancer Institute estimates 70 percent to 90 percent

of extremity osteogenic sarcomas can be effectively treated

by limb-sparing surgery.

Physician Spotlight: Looking BackKenneth Marks, MD, Advanced Limb-sparing Surgery and Expanded Access to Health Services

Kenneth Marks, MD

“Today, limb-sparing surgery is the standard therapy.

The National Cancer Institute estimates 70 percent to

90 percent of extremity osteogenic sarcomas can be

effectively treated by limb-sparing surgery.”

ORTHOPAEDIC INSIGHTSORTHOPAEDIC INSIGHTS 2011 13Visit clevelandclinic.org/ortho

CLiniCaL Leadership

Throughout his career, Dr. Marks has served on numer-

ous medical committees. He also was elected President of

the medical staff and in that capacity he was appointed a

member of Cleveland Clinic’s Board of Governors and was

the physicians’ representative for Cleveland Clinic’s Board of

Trustees.

After completing his post-doctoral studies at Oxford Univer-

sity in England in 1977, he returned to Cleveland Clinic where

he initiated and organized the first nurse clinician program

that successfully enhanced patient care and education. Dr.

Marks’ nurse clinician program was adopted as a model to

organize additional nurse clinician programs throughout

Cleveland Clinic.

Dr. Marks also served in various administrative positions

and made significant contributions that advanced patient

care led to Cleveland Clinic’s growth throughout Northeast

Ohio.

For example, when serving as Chairman of Orthpaedics

Surgery, Dr. Marks led the initiative to open an orthopaedics

health center at Independence, a southern Cleveland suburb.

“I recognized there was a need to bring Cleveland Clinic

physicians and their excellent care closer to where patients

live or work,” remembers Dr. Marks. “After we opened the

satellite office, patient visits grew month after month, so it

became a resounding success and helped grow the orthopae-

dics department.”

The Independence health center subsequently expanded, of-

fering additional family healthcare services and was used as

a blueprint model to open 16 additional family health centers

throughout Northeast Ohio.

heLping others

Yet, of all the successes he has seen during the past three de-

cades, Dr. Marks says the most rewarding aspect of his career

to-date has been developing relationships with patients.

“Because of the nature of orthopaedic oncology surgery, I

was treating patients with multiple morbidities and their

coordination of surgical treatment and follow-up care was

complex,” says Dr. Marks.

“As a result, I developed close relationships with patients. I’ve

been seeing some of them for more than 25 years, and they

send me photos of their children. Seeing my patients thrive

has been the most rewarding aspect of my medical career.”

“Because of the nature of orthopaedic oncology

surgery, I was treating patients with multiple morbidi-

ties and their coordination of surgical treatment and

follow-up care was complex.”


Arthritis of the hip is an

increasing problem seen

in younger, more active

patients, and they want

to remain active. For

end-stage arthritis, these

younger patients have the

options of hip replacement

or hip resurfacing.

Hip replacement involves re-

moving several inches of the

upper femur and inserting

a stem into the femoral shaft, with a ball at the upper end.

Apart from the immediate bone removal at surgery, bone

continues to be lost from the upper femur in response to

altered loading, which causes weakening in the femoral neck

and thickening farther down near the end of the stem. Such

“stress shielding” is extremely common after hip replace-

ment. If stem revision is required, the bone loss in the upper

femur commonly requires complex surgery, such as long

stems and bone grafting.

Hip resurfacing has the prime advantage of removing almost

no bone from the upper femur. Instead of inches, only milli-

meters are removed, and the missing cartilage of the femoral

head is resurfaced using a metal cap. Loading of the upper

femur is more normal, and stress shielding is avoided. In

fact, bone in the upper femur actually increases in density for

the first year after resurfacing. In the event of femoral compo-

nent failure, so much normal bone remains that a simple hip

replacement may be all that is needed.

Positive aspects of hip resurfacing also include less likeli-

hood of dislocation, less leg-length discrepancy and better

balance. Importantly for many younger patients, there are no

long-term activity restrictions, and there is better return to

athletics. Our patients play hockey, ski and run marathons.

The overall success rate of hip resurfacing in men under 65

is the same as or better than hip replacement in this high-

demand group. Smaller patients and the elderly do not do as

well, and hip replacement may be a better choice for them.

What was initially thought to be a gender-based difference,

with women doing worse than men, has been shown to be

more related to size than gender. Larger men and women do

better than smaller patients, probably related to improved

lubrication and less wear with larger implants.

There are concerns about the metal-on-metal bearing used

in hip resurfacing. However, the best available devices, when

properly implanted, exhibit extremely low levels of circulat-

ing metal ions. Cobalt and chromium ions, normally present

in humans at less than 0.5 parts per billion (ppb), rise to

about 1 to 3 ppb after hip resurfacing. Longitudinal studies

in Scandinavia over 30 years have shown no increase in can-

cer risk from this bearing, and an increase in life expectancy.

However, poorly designed or poorly implanted devices may

produce much higher ion levels. Local tissue damage may

result, with painful masses or cysts requiring revision to a

non-metal bearing. One device with a higher-than-expected

failure rate was the subject of a world-wide recall in August

2010.

The key predictors of successful hip resurfacing are younger,

larger patients, who have their surgery using a well-per-

forming implant, done at a center with a large experience.

Cleveland Clinic has established a Center for Hip Resurfacing

at Euclid Hospital, where nearly 1,000 resurfacing procedures

have been performed following FDA approval in 2006. This

makes Euclid Hospital one of only a handful of centers in the

U.S. with such substantial experience. Our overall success

rate exceeds 99 percent at two- to four-year follow-up.

Hip Resurfacing: An Option for Active PatientsBy Peter J. Brooks MD, FRCS(C)


For 50-year-old Steve Sheehy, (pictured left) the choice was

obvious. After a lifetime of sports and officiating at college

and high school soccer games, his hips were wearing out,

making even simple walking a painful chore. In 2007, facing

the prospect of hip replacement, Steve opted instead for hip

resurfacing at Cleveland Clinic Euclid Hospital, which he

hoped would allow him to continue his active lifestyle, and

even compete in marathons. His wishes were fulfilled, and

he ran two half-marathons and two full marathons until his

other hip was resurfaced in 2009. By year’s end, he will be in

training again, running on two resurfaced hips.

About the Author

Dr. Brooks is Chief of Surgery at Cleveland Clinic’s Euclid Hospital. He specializes in hip and knee replacement, and hip resurfacing. For inquiries about hip resurfacing, physicians may reach him at 216.444.4284 or [email protected].

“The key predictors of successful hip resurfacing are

younger, larger patients, who have their surgery using

a well-performing implant, done at a center with a

large experience.”


Kurtz, et al, projected an increase in the demand for

total knee arthroplasty in the United States to increase

by 673 percent from 2005 to 2032. If these projections

hold true, there will be a significant increase in unhappy

patients following total knee arthroplasty, as up to 20

percent of patients following total knee remain dissatisfied

with their surgery. Our current methods of measuring

outcome do not necessarily reflect patient satisfaction.

With the current baby boom generation entering the

demographics requiring total knee arthroplasty (Figure 1),

it is critical that physicians not only concentrate on patient

function after surgery, but also patient satisfaction.

Unfortunately, they are not one and the same.

setting expeCtations

The majority of total knee replacement patients will say they

are aware of the fact that their knee is not a normal knee,

although they are significantly improved following surgery.

It is imperative that the physician explain that limitations

may still exist, especially to patients who have multiple joint

involvement, a pre-existing radiculopathy or pre-existing

co-morbidities. Setting expectations prior to surgery is the

single most important factor in achieving patient satisfaction.

A multi-center study investigating the Triathlon Knee System

(Stryker Corporation) in a prospective study has shown

that patients with a preoperative range of motion less than

95 degrees had an average gain of 28 degrees of increased

range of motion. Those patients between 95 and 120 degrees

preoperatively gained 11 degrees postoperatively, and those

patients who had greater than 120 degrees of flexion preop-

eratively, lost an average of 4 degrees of motion postopera-

tively. Is your patient aware that he or she actually may lose

range of motion following surgery? Patients typically exhibit

apprehension prior to their total knee arthroplasty, and

comprehensive preoperative education can alleviate many of

these concerns.

pain management

Recent advances in postoperative pain management have led

to a significant improvement in patient satisfaction and ac-

celerated gains in rehabilitation. Having anesthesia services

that include long-acting blocks and indwelling catheters is

essential.

surgiCaL approaCh & prosthesis seLeCtion

Minimally invasive and muscle sparing techniques have

gained popularity with both patients and surgeons in recent

years. Although these approaches have shown some short-

term benefit, there appears to be no long-term advantage to

their use.

Maximizing Patient Satisfaction Following Total Knee ArthroplastyBy Kenneth A. Greene, MD

Figure 1: U.S. population demographics


Modern imaging techniques have challenged the concept of

the instant center of rotation and a multi-radius knee design

(Figure 2). A single radius knee design is based on the con-

cept of establishing a flexion-extension axis approximated

by the epicondylar axis. This maintains ligament isometry

throughout flexion and extension and reduces the problem of

mid flexion instability, often seen in the multi-radius design.

The addition feature of a shortened posterior condyle, and

attention to removal of posterior osteophytes has led to a

significant increase in postoperative flexion (Figures 3 and 4)

and greater patient satisfaction.

Computerized navigation has decreased the number of align-

ment outliers, but as of yet has not been shown to improve

patient outcomes. In the future, we may find that patient-

specific cutting blocks, based off a preoperative MRI, allow a

much more accurate placement of the implant in regards to

the flexion-extension axis than our current techniques.

measuring suCCess

Patients and surgeons are ultimately seeking the same goal,

predictable satisfaction following total knee arthroplasty.

When our patients do not hesitate to have their other knee

done, we will know that we have succeeded.

About the Author

Dr. Greene is a specialist in hip and knee reconstruction focus-ing on primary and revision replacement. Physicians may reach him at 330.721.5702 or [email protected].

Dr. Greene serves as a paid consultant to Stryker Orthopedics. As one of the developers of the Triathlon Total Knee System he also is entitled to royalties.

References:

Kurtz, et al. J Bone Joint Surg Am. 2007;89:780-785.

2011 AAOS abstract #2907

Greene KA, Schurman JR. Quadriceps muscle function in primary total knee arthroplasty. J Arthroplasty. 2008 Oct; 23(7) suppl 1: 15-19.

Figure 2: Multiradius versus single radius design

Figure 3: Duracon versus Triathlon range of motion Figure 4: Range of motion result with single radius design


The menisci (medial and lateral meniscus) of the knee are

c-shaped fibrocartilagenous structures whose main function

is load (shock) transmission. As “shock transmitters,” the

menisci distribute forces between the femur and tibia over a

larger surface area, which has the net effect of reducing the

point contact forces of the articular cartilage. Additionally,

they aid in joint lubrication, joint nutrition and the medial

meniscus acts as a secondary stabilizer to anterior transla-

tion of the knee when the anterior cruciate ligament has been

injured.

Meniscal injuries can occur at any age, with the greatest

frequency in the third through fifth decade. Younger people

tend to injure (tear) their meniscus in an athletic endeavor,

while older people sustain their tear by minimal insult, such

as twisting while getting out of a chair or golf cart. There is

a spectrum of treatment for symptomatic meniscal tears,

including partial meniscectomy (removal), meniscal repair

and meniscal transplantation. Whenever possible, menis-

cal repair is advocated – especially in the young patient. The

most common procedure for this condition is arthroscopic

partial meniscectomy, which in turn is the most commonly

performed surgical procedure in orthopaedics. This proce-

dure decreases the symptoms (locking, clicking, pain, swell-

ing, etc.) associated with the meniscal tear; however, it does

not alter the usual natural history, which is progressive knee

post-traumatic arthritis.

Meniscal transplantation (replacement or reconstruction),

which I perform here at Cleveland Clinic, is gaining popular-

ity for the treatment of patients under age 50, who have sus-

tained a large (> 50 percent) irreparable meniscus tear and

are beginning to develop early clinical and radiographic evi-

dence of post-traumatic arthritis. Medial meniscal transplan-

tation is more commonly performed than lateral because the

medial meniscus is more frequently injured. However, it has

been my experience that subtotal lateral meniscectomy more

frequently results in deterioration of the knee, requiring con-

sideration for meniscal transplantation. Meniscal transplan-

tation entails removing the remaining meniscal tissue to the

rim and implanting a fresh frozen allograft (cadaver) menis-

cus, which has been sized preoperatively to the patient’s knee

via MRI or plain radiographs.

Appropriate candidates for meniscal transplantation include

patients with stable, well-aligned knees with minimal to

moderate (Outerbridge Grade I – III) symptomatic post-trau-

matic arthritis, as those with advanced changes (Outerbridge

Grade IV) have faired poorly in published clinical outcome

studies. Physical examination allows the experienced clini-

cian to determine stability and alignment of the knee, while

the history provides the details of symptoms and the extent

of past surgery or surgeries. Radiographic studies include

weight bearing (extension and flexion); lateral and patellar

(Mercer-Merchant) views of both knees, as well as a MRI of

the involved knee and sometimes a bone scan to assess the

entire “state of the knee.”

Prior to meniscal transplantation, it is imperative that the

surgeon correct any malalignment and/or pathological lax-

ity to ensure the best outcome. This can be accomplished

Meniscal Transplantation Gains PopularityBy Richard D. Parker, MD

Picture 1: MRI of the right knee reveals absent lateral meniscus in the mid-substance with only the rim remaining, and edema of the lateral tibial plateau with a small near full thickness articular cartilage defect.


with an osteotomy and/or ligamentous reconstruction. The

meniscal transplant is placed into the knee in an arthroscop-

ically guided manner with either a bone trough (lateral) or

bone tunnels (medial) to anchor its boney attachments and

sutured to the native meniscal rim or capsule. The surgery is

performed as an outpatient (23-hour stay) and requires the

patient to use crutches for four to six weeks. Rehabilitation is

necessary to regain motion and strength. Patients are able to

return to heavy labor in three to four months and sports at six

to nine months.

Success is defined as a reduction in pain/swelling, increase

in activity and a delay in the inevitable progression of post-

traumatic arthritis. Clinical studies have demonstrated a

75 to 85 percent success rate; however, long-term studies are

necessary to determine the exact reduction in the progres-

sion of post-traumatic arthritis. For this reason, meniscal

transplantation is still considered a salvage procedure and is

not recommended for the asymptomatic patient.

About the Author

Dr. Parker is Chairman of the Department of Orthopaedic Surgery at Cleveland Clinic. He specializes in sports medicine, sports-related injuries and arthroscopic knee surgery. Physicians can reach him at 216.444.2992 or [email protected].

Picture 2a and b: Arthroscopic views of the lateral compartment in the same right knee:

a. Though the posterior horn of the lateral meniscus seems sufficient, the mid-portion of the me-niscus is quite deficient with only the rim remaining. Note the tibial and femur chondral changes.

b. Post meniscus transplant, the chondral lesion is now covered.

Picture 3: Allograft lateral meniscus transplant prior to implantation. Note the bone block with both the anterior and posterior horns attached. The bone block fit into place via a dove tail technique.


Numerous studies have highlighted the most important

risk factor for developing osteoarthritis is being overweight

or obese. Osteoarthritis (OA) is the most common form of

arthritis, which most commonly affects the knee, hip, spine

and hands.

To this end, researchers at the Cleveland Clinic Orthopedic

and Rheumatologic Institute and the Metabolic and Endo-

crine Institute, including rheumatologist, M. Elaine Husni,

MD, MPH, orthopaedic surgeon Morgan Jones, MD, ortho-

paedic surgeon George Muschler, MD, and endocrinologist

Sangeeta Kashyap, MD, have teamed up together to provide

comprehensive weight loss to patients who are obese with

knee OA and may require a total joint replacement in the

near future. Our goal is to compare the outcomes of standard

preoperative care and intensive weight loss program added

to preoperative care among patients undergoing total knee

replacement surgery.

This area of research is of increasing importance given the

fact that an estimated 27 million Americans have been af-

fected by OA, with expenditures increasing by 22 percent

from $252 billion in 1997 to $353 billion in 2005.

In a first of its kind longitudinal study conducted by the

Centers for Disease Control, more than 3,000 residents age 45

and older were followed, the results demonstrated nearly one

in two Americans, or 46 percent of the cohort, will develop

symptomatic knee OA by age 85. In addition, this lifetime risk

was highest among those patients who were obese. Although

the specific amount of weight loss an individual must lose to

affect improve health outcome is uncertain, studies have sup-

ported that for every 11-pound weight loss (approximately two

BMI units), individuals could reduce their risk of knee OA by

50 percent. Furthermore, it is estimated that persons in the

highest quintile of body weight have up to 10 times the risk of

knee OA than those in the lowest quintile.

Both the CDC and the Arthritis Foundation have created one

of the largest efforts to combat the signs and symptoms of OA

by forming “A National Public Health Agenda for Osteoarthri-

tis,” which is a focused collaborative effort to achieve three

overarching themes in the next three to five years:

• Provide evidence-based intervention strategies – such as

self management education, physical activity, injury pre-

O-O Syndrome: Osteoarthritis and ObesityBy M. Elaine Husni, MD, MPH

what Can heLp your patients?

Your patients can help reduce their risk of developing osteoarthritis by following these three basic tips:

1. Know your bmi (body mass index) This can help your patient to know if they are overweight or obese and may be associated with certain health risks. BMI is calculated by dividing the patient’s weight in kilo-grams and is divided by height in meters, squared.

We recommend that if you check your BMI to assess whether you are overweight and are currently of normal weight, you should reassess at two-year intervals.

bmi VaLue weight Category 25-29.9 Overweight 30 Obese >35 Morbidly Obese

2. Know your waist CirCumFerenCe.

This can be an indicator of health risks, such as metabolic syndrome or an increase in cardiovascular disease. This can correlate with abdominal fat and can be an independent predictor of disease risk. It is considered abnormal for men at > 40 cm and women at > 35 cm and signifies increased risk.

3. partiCipate in moderate physiCaL aCtiVity,

progressing to 30 minutes or more on most (or preferably all) days of the week.

4. dietary modiFiCation, including low-fat, high-fiber, low glycemic index diet, under the guidance of a nutri-tionist and physician.

vention, weight management and healthy nutrition – to all

Americans with OA.

• Establish supportive policies, communication initiatives

and strategic alliances for OA prevention and management.

• Promote research to better understand the burden of OA,

its risk factors and effective strategies for intervention.

About the Author

Dr. Husni is the Director of the Arthritis and Musculoskeletal Center. Physicians may reach her at 216.445.1853 or [email protected].


Welcoming in the Era of Intraoperative Computer-Assisted NavigationBy Thomas Kuivila, MD

Orthopaedic surgeons are many things. Old quarterbacks,

frustrated musicians, cabinetmaker wannabes. But cer-

tainly one thing they are not are low-tech throwbacks. Oh

sure, they’ll regale the young pups with tales of past daring

do armed only with rolls of plaster, silk suture and K-wires,

and some will further eschew the bandwagon of the new and

kvetch about the “triumphs of technology over reason.” How-

ever, deep down they like shiny and new, clever and cool –

especially when it is utilitarian and helps them do something

better and faster than before.

Enter the era of intraoperative computer assisted navigation.

Clever, and definitely very cool. It is not a robot, but some-

thing akin to your automobile navigation system; it helps the

surgeon, but doesn’t do the driving. Readers may recall that

version 1.0 was bulky and inaccurate. It relied on axial scans

done elsewhere and at a different time, then attempted to

combine that data with intraoperative findings. Generation 2

is far more accurate and user friendly. It utilizes images

done with a portable CT scanner a.k.a. an “O-arm” (figure 1)

with markers affixed to bone at the time of the scan. A

three- dimensional infrared array attached to the patient

communicates with an over head scanner which allows the

propriety software to give the surgeon a real-time image

of the bony anatomy. Provided the markers aren’t disturbed

(definitely a potential Achilles heel – no orthopaedic pun

intended) following scan completion, accuracy to the

fraction of a millimeter level is possible.

Cleveland Clinic now has an O-arm available to the orthopae-

dic and neuro spine teams, with plans to purchase more as

user familiarity and need arise.

Having virtual visualization when posterior landmarks are

absent or when pedicles are hopelessly small or askew is a

huge asset to the surgeon doing complex cases with anatomy

that, to quote an old mentor, “Just ain’t natural Vern.” (It

didn’t matter if your name wasn’t Vern.)

The early adapters of this technology are already on board

with developing, if not version 3.0, at least 2.1. Further refine-

ments will make this technology and its use an everyday

affair. The result? Better patient outcomes and a genuine

surgeon appreciation of the assets of high tech, not just being

enamored of it for the sake of the shiny. Alas, some will pine

that we once found pedicles with only a probe, but deep down

they will be cheering the greatest and latest in spinal opera-

tive care.

About the Author

Dr. Kuivila is Head of the Section of Pediatric and Adolescent Spinal Surgery. He can be reached at 216.444.2741 or [email protected].

O-arm with markers affixed to bone at the time of the scan. A three-dimensional infrared array attached to the patient communicates with an over head scanner which allows the propriety software to give the surgeon a real-time image


The medical care that has been provided to American sol-

diers injured in Iraq has been widely and rightly praised. But

significantly fewer people are aware of the high level of care

that has been provided to injured enemy combatants and

detainees of the War on Terror.

The care of enemy injured represents a critical part of the

mission of all medical units in the field. But in 2005, I expe-

rienced this mission more acutely when I served as ortho-

paedic surgeon at Abu Ghraib prison with the 115th Field

Hospital in Iraq. The central and primary mission of this unit

was detainee medical care, ie. saving the lives and limbs of

insurgents injured in the act of trying to kill us.

The complex rationale for providing such care to the enemy

is informed by strategic, tactical, public relations and moral

considerations. But in practice, these complicated issues are

quickly superseded by the challenge of treating severe ortho-

paedic injuries.

Battlefield orthopaedics consists primarily of amputations,

fracture care and wound management, and this was no dif-

ferent in the detainee population of the prison. But certain

challenges were unique to this prison environment. Because

the patients were almost exclusively prisoners, security was

a constant challenge. Surgical procedures were conducted

within specialized metal trailers imported into the prison

rather than hard hospital facilities. Equipment and implants

were significantly limited, particularly compared with the

larger fixed facilities elsewhere in theater.

Yet despite these challenges, the quality of care provided to

the injured detainees was uncompromised. Amputations

were performed with the same emphasis on preserving

residual limb length and function. By contracting with local

prosthetists, all prison amputees were able to be fitted with

appropriate prosthetics to preserve ambulatory capability.

(Figure 1)

Perspectives on Providing Orthopaedic Care at Abu GhraibBy Mark J. Berkowitz, MD

Detainee treated at Abu Ghraib prison with transtibial amputation ambulating with prosthesis.

Detainee with bilateral tibia fractures treated with functional rehabilitation including early weightbearing.


Fractures were treated almost exclusively with external fixa-

tion due to the injury severity and lack of internal fixation

options. But, following the principles learned during the

Vietnam War, early weightbearing and aggressive functional

rehabilitation were instituted to preserve satisfactory func-

tion. (Figure 2)

Massive soft tissue injuries were managed using negative

pressure dressings identical to those used to treat injured

American soldiers back home. This use of state-of-the-art

technology, even in an austere environment, allowed salvage

of many mangled limbs that otherwise would have required

amputation. (Figures 3A, 3B, 3C and 3D)

In addition to emergent care, complex reconstructive pro-

cedures also were made available to detainees with chronic,

debilitating injuries. Chronic nonunions were stabilized and

bone grafted. Posttraumatic deformities were corrected with

osteotomy and stabilization. And paralyzed limbs were again

made useful with tendon transfer procedures.

Providing care for enemy injured can be psychologically chal-

lenging. It can be a distasteful task and often feels contrary

to the ultimate mission. But reduced to its most elemental

level, it represents the best that orthopaedics and America

have to offer – the ability to improve others’ quality of life.

About the Author

Dr. Berkowitz is an orthopaedic surgeon at Cleveland Clinic. He specializes in foot and ankle and lower extremity trauma surgery. Physicians may contact him at 216.444.7607 or [email protected].

Appearance of wound after 45 days of negative pressure VAC therapy.

Initial large soft tissue defect in open proximal femur fracture. Negative pressure VAC dressing applied to wound incorporating adjacent external fixator pins.

Wound after successful application of split-thickness skin graft.


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

reFerring physiCian Center

For help with service-related issues, information about our clinical

specialists and services, details about CME opportunities and more,

contact us at [email protected], at 216.448.0900 or toll-free

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visit clevelandclinic.org/drconnect or email [email protected].

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cme.com, offers convenient, complimentary learning opportunities,

from a virtual textbook of medicine (Disease Management Project)

and a medical newsfeed refreshed daily, to myCME, a system for

physicians to manage their CME portfolios. Many live CME courses

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Orthopaedic Insights is published by Cleveland Clinic’s Department of Orthopaedic Surgery to inform musculoskeletal specialists about advances in diagnosis, medical and surgical management, and research.

Joseph p. iannotti, md, phdChair, Orthopaedic & Rheumatologic Institute

richard d. parker, md, Chair, Orthopaedic Surgeryryan C. goodwin, md, Medical Editorann milanowski, Editorirwin Krieger, Art Directorsteve travarca, tom merce, don gerda, Photographers

For a copy of our Orthopaedic Surgery Staff Directory, please visit clevelandclinic.org/ortho or contact Marketing Manager Beth Lukco at 216.448.1036 or [email protected].

The Orthopaedic & Rheumatologic Institute, one of 26 institutes at Cleveland Clinic,

is staffed by physicians, scientists and engineers who pursue excellence and innova-

tion in the care of patients with joint, bone, muscle, connective tissue and immune

disorders. Cleveland Clinic is a nonprofit, multispecialty academic medical center.

Founded in 1921, it is dedicated to providing quality specialized care and includes

an outpatient clinic, a hospital with more than 1,000 staffed beds, an education

institute and a research institute.

Orthopaedic Insights is written for physicians and should be relied upon for

medical education purposes only. It does not provide a complete overview of the

topics covered, and should not replace a physician’s independent judgment about

the appropriateness or risks of a procedure for a given patient.

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Orthopaedic Insights - Cleveland Clinic · 4 ORTHOPAEDIC INSIGHTS For referrals, please call 216.445.0096 or 800.223.2273, ext.50096 Limitations to Current arthropLasty teChniQue