2018 Hip Program FINAL

General Program Information
The Mission of The Hip Society
The Mission of The Hip Society is to advance the knowledge and treatment of hip disorders to
improve the lives of our patients.
Meeting Objectives
The objectives of the Open (Winter) 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 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. The American Academy of Orthopaedic Surgeons designates
this live activity for a maximum of 7.5 AMA PRA Category 1 Credits™. Physicians should claim
only the credit commensurate with the extent of their participation in the activity.
Evaluation
Your opinion matters! Please complete your evaluation online at:

https://www.surveymonkey.com/r/HSWM2018 or use the QR code to access with your handheld
smart device:
Photography
Please refrain from unauthorized photography and video recording of presentations. Your
registration for, and attendance of, this session gives The Hip Society permission to capture
images of session attendees and to use these images for internal and marketing purposes.
Table of Contents
• Detailed session schedule 15
• The Hip Society’s abstracts 25
• Faculty disclosures 112
• The Knee Society’s program Reverse side
Save the Date and Join Us In Las Vegas!
The AAOS 2019 Annual Meeting and Specialty Day
March 12-16, 2019
© 2018 The Hip Society / AAHKS 2

Acknowledgements
Past Presidents of The Hip Society
1968-1969 William H. Harris, MD, DSc. 2007-2008 Lawrence D. Dorr, MD
1969-1970 Frank E. Stinchfield, MD  2008-2009 Wayne G. Paprosky, MD
1970-1971 Walter P. Blount, MD  2009-2010 William J. Maloney, III, MD
1971-1972 Albert B. Ferguson, Jr., MD  2010-2011 Chitranjan S. Ranawat, MD
1972-1973 J. Vernon Luck, Sr., MD  2011-2012 Adolph V. Lombardi, Jr., MD
1973-1974 Mark B. Coventry, MD  2012-2013 David G. Lewallen, MD
1974-1975 Emmett M. Lunceford, Jr., MD  2013-2014 Vincent D. Pellegrini, Jr., MD
1976-1978 Augusto Sarmiento, MD 2014-2015 Paul F. Lachiewicz, MD
1978-1979 Marshall R. Urist, MD  2015-2016 Daniel J. Berry, MD
1979-1980 Harlan C. Amstutz, MD 2016-2017 Harry E. Rubash, MD
1980-1981 Philip D. Wilson, Jr., MD 
1981-1982 Richard C. Johnston, MD, MS Past Presidents of AAHKS
1982-1983 Clement B. Sledge, MD 1991 J. Phillip Nelson, MD 
1983-1984 Floyd H. Jergesen, MD  1992-1993 Chitranjan S. Ranawat, MD
1984-1985 C. McCollister Evarts, MD 1994 Richard C. Johnston, MD, MS
1985-1986 Jorge O. Galante, MD, DMSc.  1995 Lawrence D. Dorr, MD
1986-1987 Lee H. Riley, Jr., MD  1996 Hugh S. Tullos, MD 
1987-1988 William R. Murray, MD  1997 Merrill A. Ritter, MD
1988-1989 Joseph E. Miller, MD  1998 Richard H. Rothman, MD, PhD
1989-1990 Donald E. McCollum, MD  1999 James A. Rand, MD
1990-1991 J. Phillip Nelson, MD  2000 Richard B. Welch, MD
1991-1992 Nas S. Eftekhar, MD  2001 John J. Callaghan, MD
1992-1993 William N. Capello, MD 2002 Douglas A. Dennis, MD
1993-1994 Robert H. Fitzgerald, Jr., MD  2003 Clifford W. Colwell, Jr., MD
1994-1995 Mark G. Lazansky, MD 2004 Richard F. Santore, MD
1995-1996 Richard B. Welch, MD 2005 Joseph C. McCarthy, MD
1996-1997 Dennis K. Collis, MD 2006 William J. Hozack, MD
1997-1998 Eduardo A. Salvati, MD 2007 Daniel J. Berry, MD
1998-1999 Robert B. Bourne, MD, FRCSC 2008 David G. Lewallen, MD
1999-2000 Richard D. Coutts, MD 2009 William J. Robb, III, MD
2000-2001 Leo A. Whiteside, MD 2010 Mary I. O’Connor, MD
2001-2002 Benjamin E. Bierbaum, MD 2011 Carlos J. Lavernia, MD
2002-2003 Miguel E. Cabanela, MD 2012 Thomas P. Vail, MD
2003-2004 Charles A. Engh, Sr., MD 2013 Thomas K. Fehring, MD
2004-2005 Richard E. White, MD 2014 Brian S. Parsley, MD
2005-2006 James A. D'Antonio, MD 2015 Jay R. Lieberman, MD
2006-2007 John J. Callaghan, MD 2016 William A. Jiranek, MD, FACS

Acknowledgements
The Hip Society Board of Directors AAHKS Board of Directors
Kevin L. Garvin, MD – President Mark I. Froimson, MD, MBA – President
Douglas E. Padgett, MD – 1st Vice President Craig J. Della Valle, MD – 1st Vice President
Joshua J. Jacobs, MD – 2nd Vice President Michael P. Bolognesi, MD – 2nd Vice President
Craig J. Della Valle, MD – Secretary C. Lowry Barnes, MD – 3rd Vice President
Jay R. Lieberman, MD – Treasurer William A. Jiranek, MD – Immediate Past President
Harry E. Rubash, MD – Immediate Past President Gregory G. Polkowski, II, MD, MSc – Secretary
Scott M. Sporer, MD – Chair, Education Cmte. Ryan M. Nunley, MD – Treasurer
John C. Clohisy, MD – Chair, Membership J. Bohannon Mason, MD – Member-at-Large
Richard Iorio, MD – Chair, Research Committee R. Michael Meneghini, MD – Member-at-Large
C. Anderson Engh, Jr., MD – Member-At-Large Javad Parvizi, MD – Member-at-Large
Adolph V. Lombardi, Jr., MD – Chair, Fellowship & Scott M. Sporer, MD – Member-at-Large
Mentorship Committee (Ex-Officio)
AAHKS Education and Communications
The Hip Society Education Committee Council
Scott M. Sporer, MD – Chair Bryan D. Springer, MD – Chair
Paul E. Beaulé, MD Joseph T. Moskal, MD, FACS – Vice Chair
Mathias P.G. Bostrom, MD Craig J. Della Valle, MD – Past Chair
Craig J. Della Valle, MD Robert M. Molloy, MD – 2017 Program Chair
Edward Ebramzadeh, PhD Matthew P. Abdel, MD – 2018 Program Chair
Kevin L. Garvin, MD Jeffery A. Geller, MD – Web & Social Media
Harpal S. Khanuja, MD – Publications
David F. Dalury, MD – Patient & Public Relations
William P. Barrett, MD -- Education
AAHKS Education Committee

William P. Barrett, MD -- Chair
Joseph T. Moskal, MD, FACS – Vice Chair
Ronald E. Delanois, MD -- Member
Adam A. Sassoon, MD, MS -- Member
Michael P. Bolognesi, MD – Presidential Line
Mentor
As The Hip Society celebrates its 50th Anniversary, we would like to

acknowledge the wisdom and the foresight of our founding members, the
contributions of many who served and continue to serve as leaders,
educators, and mentors to the future of our profession, and thank all for
your dedication to excellence in patient care and research.

A Tribute to The Hip Society: 50 Years!
Session V (11:15 am – 12:05 pm)
Lawrence D.Dorr, MD William H. Harris, MD, D.Sc.

President of The Hip Society (2007-2008) Founding Member, President of The Hip Society (1968-1969)
David G. Lewallen, MD Vincent D. Pellegrini, Jr., MD

President of The Hip Society (2012-2013) President of The Hip Society (2013-2014)
Session moderated by:
Daniel J. Berry, MD
President of The Hip Society (2015-2016)

Congratulations: The 2018 Hip Society
Lifetime Achievement Award Recipient
Session V (11:15 am – 12:05 pm)
Reinhold Ganz, MD, Professor Emeritus
Zurich, Switzerland
Reinhold Ganz graduated from medical school in Freiburg, Germany.

His early postgraduate training was focusing on bone physiology and
biomechanics at the University of Basel and the AO Research Institute
in Davos, Switzerland. He pursued the orthopaedic training under the
guidance of Maurice Muller in Berne, who engaged his interest in hip
surgery. Succeeding Muller as chief of the department, he decided to
give more attention to preservation of the native hip.
All research projects were based on detailed cadaver studies of the

vascular supply of the involved area.
The goal of a first undertaking was to optimize reorientation surgery of

the dysplastic acetabulum and make the procedure more versatile.
While the available techniques approached the acetabulum from the
pelvic outside and as such were interfering with the main blood
suppliers, a technique was developed to execute the osteotomy
entirely from inside to spare not only the abductors but also the blood
vessels to the acetabular bone. The technique allows large correction and provides sufficient fragment
perfusion even after extensive capsulotomy for additional intra-articular surgery. Meanwhile, the Bernese
Periacetabular Osteotomy (PAO) has gained worldwide acceptance.
Surgical dislocation of the hip joint was tainted for a long time with the risk of avascular head necrosis.
Detailed injection studies of the supplying vessels showed the way to perform a safe and reproducible
dislocation without such risks. Rather unexpected, routine surgical hip dislocation allowed to observe
impingement and to formulate the concept explaining one important initiation of osteoarthritis of the hip.
Furthermore, the extension of surgical hip dislocation with a retinacular flap opened the door for a new class of
intraarticular joint preserving procedures, notably, relative neck lengthening, subcapital realignment, true
femoral neck osteotomy and head osteotomy to reduce its size.
Such work was only possible with a dedicated team: Katharina Leunig and Morteza Kalhor have provided
substantial and specific knowledge of the vascular supply of the hip area. Kaj Klaue and Jeffrey W. Mast have
contributed basic facts to concept and technical execution of the PAO technique. Michael Leunig, Klaus A.
Siebenrock and Martin Beck have given essential input to the impingement concept and to further specify
indication and technical execution of the new procedures.

Congratulations: The 2018 Hip Society
Scientific Award Winners
Session V (11:15 am to 12:05 pm)
The 2018 John Charnley Award

Analysis of US Hip Replacement Bundled Payments: Physician-initiated Episodes Outperform
Hospital-initiated Episodes
Presenter: William S. Murphy, AB
Co-Authors: Ahmed Siddiqu, DO; Tony Cheng, MBA; Ben Lin, BA; David Terry, MBA; Carl T. Talmo, MD;
Stephen B. Murphy, MD
The 2018 Otto Aufranc Award

The Genetics of Osteolysis After Total Hip Arthroplasty
Presenter: J. Mark Wilkinson, PhD, FRCS
Co-Authors: Scott J. Macinnes, PhD; Konstantinos Hatzikotoulas, PhD; Anne Marie Fenstad, MSc; Karan
Shan, PhD; Lorraine Southam, PhD; Ioanna Tachmazidou, PhD, Geir Hallan, PhD; Harvard Dale, PhD;
Kalliope Panoutsopoulou, PhD, Ove Furnes, PhD; Eleftheria Zeggini, PhD
The 2018 Frank Stinchfield Award

Spino-pelvic Hypermobility is Associated with Inferior Outcome Post-THA: Examining the Effect of
Spinal Arthrodesis
Presenter: George Grammatopoulous, BSc, MBBS, D.Phil (Oxon)
Co-Authors: Wade Gofton, MD, FRCSC, Med; Zaid Jibri, MBCHb, MRCSEd, FRCR; Matthew Coyle, MD;
Johanna Dobransky, MHK, BSc; Cheryl Kreviazuk, BA; Paul R. Kim, MD, FRCSC; Paul E. Beaulé, MD,
FRCSC

The Hip Society’s Traveling Fellowships
The Hip Society’s Rothman-Ranawat Traveling Fellowship
At the core of the mission of The Hip Society is the promotion of the science of disease of the hip.
Fundamental to science are the basic tenets of education and research. The ultimate benefactors of our
knowledge are the patients. The Hip Society Rothman-Ranawat Traveling Fellowship is open to four (4)
young orthopaedic surgeons, from North America, and throughout the world. The traveling Fellows will visit up
to twelve (12) sites in North America as identified by The Hip Society. The ultimate goal of the fellowship is to
offer the young surgeons an inspirational tour of state-of-the-art facilities providing exemplary surgical care of
the hip joint throughout North America.
Congratulations, 2018 Rothman-Ranawat Traveling Fellows!
Elie S. Ghanem, MD Chris R. Gooding, MBBS BSc (Hons), MD, MRCS,

Birmingham, AL, USA FRCS, Tr and Orth
Cambridge, United Kingdom
S.M. Javad Mortazavi, MD Benjamin M. Stronach, MD

Tehran, Iran Jackson, MS, USA
Those interested in applying for the 2019 Rothman-Ranawat Traveling Fellowship,

please visit The Hip Society’s website www.hipsoc.org, click on the Education tab.
The deadline to apply for the 2019 Fellowship is August 15, 2018.
The Hip Society-British Hip Society Traveling Fellowship

The Hip Society is proud to partner with the British Hip Society to provide an exceptional exchange opportunity
to two (2) outstanding North American candidates. Successful candidates will travel throughout the United
Kingdom for a period of three-four weeks and will be hosted by world-renowned experts in adult hip
reconstruction. The program will include opportunities for scientific exchange, OR observations, close
interaction with faculty, as well as social and cultural events.
The 2018 Hip Society-British Hip Society Traveling Fellowship
Those interested in applying for the 2018 Fellowship, please visit The Hip Society’s
website www.hipsoc.org, and click on the Education tab.
The extended deadline to apply is April 1, 2018.
To read about the 2016 Fellows’ adventures, learnings, and experiences, go here:
https://2016bhsfellowship.wordpress.com/

Notes:

H I P La Nouvelle Ballroom B
7:55 am – 8:00 am WELCOME
Kevin L. Garvin, MD (Omaha, NE) – President, The Hip Society
8:00 am – 8:45 am Session I: Primary Surgical Approach/Technique and Implant

Selection: Tips and Tricks to Maximize Outcomes (Video-Based)
Moderator: Steven J. MacDonald, MD, FRCSC (London, ON, Canada)
8:00 am – 8:06 am ABMS Approach in the Lateral Decubitus Position 25

Christopher L. Peters (Salt Lake City, UT)
8:06 am – 8:12 am Direct Anterior Approach Including Tips to Improve Exposure 27

Paul E. Beaulé (Ottawa, ON, Canada)
8:12 am – 8:18 am Dysplastic Hip 31

John C. Clohisy, MD (St. Louis, MO)
8:18 am – 8:24 am Previous Surgery/Retained Hardware 33

Michael J. Archibeck, MD (Albuquerque, NM)
8:24 am – 8:30 am Previous Lumbar Fusion 35

Gwo-Chin Lee, MD (Philadelphia, PA)
8:30 am – 8:45 am DISCUSSION
8:45 am – 9:30 am Session II: Intraoperative and Early Postoperative Complications:

Surgical Exposure and How to Manage (Video-Based)
Moderator: C. Anderson Engh, Jr., MD (Alexandria, VA)
8:45 am – 8:51 am Intraoperative Acetabular Fracture: How to Gain Exposure and Manage 36
Through an Posterior Approach
James I. Huddleston, III, MD (Redwood City, CA)
8:51 am – 8:57 am Failed Acetabular Fixation: How to Gain Exposure and Manage Through an 37
Anterior Approach
Joseph T. Moskal, MD (Roanoke, VA)
8:57 am – 9:03 am Management of Early Step Subsidence/Calcar Fracture (Using Either 41

Anterior or Posterior Approach)
Paul J. Duwelius, MD (Portland, OR)
9:03 am – 9:09 am Management of Trochanter Fracture (Intra-Op and Early Post-Op) 44

Rafael J. Sierra, MD (Rochester, MN)
9:09 am – 9:15 am Component Malposition and Leg Length Inequality: When Should I Go 46
Back and What Should I Do?
Robert L. Barrack, MD (St. Louis, MO)

La Nouvelle Ballroom C K N E E
7:55 am – 8:00 am WELCOME
Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH) – President, The
Knee Society
8:00 am – 8:45 am Session I: The Difficult Primary TKA (Video-Based)

Moderator: Mathias P.G. Bostrom, MD, FACS (New York, NY)
8:00 am – 8:06 am Fixed Valgus Knee 25

Douglas A. Dennis, MD (Denver, CO)
8:06 am – 8:12 am The Terrible Varus Knee 28

Arun B. Mullaji, MD (Mumbai, India)
8:12 am – 8:18 am The Obese Patient 29

David G. Lewallen, MD (Rochester, MN)
8:18 am – 8:24 am The Stiff Knee 31

Wael K. Barsoum, MD (Weston, FL)
8:24 am – 8:30 am Previous Incisions/Compromised Soft-Tissue 32

Henry D. Clarke, MD (Phoenix, AZ)
8:45 am – 9:30 am Session II: Current Trends in Knee Arthroplasty

Moderator: Thomas S. Thornhill (Boston, MA)
8:45 am – 8:51 am Can a Bicruciate Retaining TKA Be Successful? 34

Alfred J. Tria, MD (Princeton, NJ)
8:51 am – 8:57 am When Is It Safe to Perform TKA after Steroid/HA Injection? 36

Thomas P. Sculco, MD (New York, NY)
8:57 am – 9:03 am Patient Specific Implants and Instruments 37

Tom Minas, MD, MS (Chestnut Hill, MA)
9:03 am – 9:09 am Alternative Bearing Surfaces 39

Steven B. Haas, MD (New York, NY)
9:09 am – 9:15 am The Pocket Rocket: Handheld Navigation 40

David J. Mayman, MD (New York, NY)

9:30 am – 10:15 am Session III: Lumbopelvic/Instability: Patient Identification and
Methods to Minimize
Moderator: Wayne G. Paprosky, MD, FACS (Winfield, IL)
9:30 am – 9:36 am Who is at Risk of Instability? 47

Arthur L. Malkani, MD (Louisville, KY)
9:36 am – 9:42 am What is the “Safe Zone” for an Individual Patient? 49

Lawrence D. Dorr, MD (Los Angeles, CA)
9:42 am – 9:48 am What Implants and Approach Should We Use to Optimize 51

Outcomes: Is It Patient-Specific?
James D. Slover, MD, MS (New York, NY)
9:48 am – 9:54 am Is There a Role for Computer Navigation? 52

Douglas E. Padgett, MD (New York, NY)
9:54 am – 10:00 am When Should I Revise the Hip for Postop Instability and What Should I Do? 54
R. Michael Meneghini, MD (Fishers, IN)
10:15 am – 10:30 am COFFEE / REFRESHMENT BREAK
10:30 am – 11:15 am Session IV: Bearing Surface and Taper Corrosion

Moderator: Thomas P. Schmalzried, MD (Los Angeles, CA)
10:30 am – 10:36 am Who is at Risk? Should Everybody Be Screened? 56

Henrik Malchau, MD, PhD (Boston, MA)
10:36 am – 10:42 am What is the Current Understanding of the Problem? 59

Joshua J. Jacobs, MD (Chicago, IL)
10:42 am – 10:48 am What is the Clinical Presentation and How Do I Work Up a Painful Hip? 61
Don S. Garbuz, MD, MHSc, FRCSC (Vancouver, BC, Canada)
10:48 am – 10:54 am How Should I Treat This Problem and What are the Outcomes? 63
William L. Griffin, MD (Charlotte, NC)
10:54 am – 11:00 am Should We All Be Going to Ceramic? 65

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

9:30 am – 10:15 am Session III: Special Highlights
The Knee Society’s Scientific Awards

Moderator: Harry E. Rubash, MD (Boston, MA)
9:30 am – 9:35 am The John N. Insall Award 41

“Unsupervised Home Exercise Equivalent to Traditional Outpatient Therapy
After Primary TKA: A Randomized Controlled Trial”
Antonia F. Chen, MD, MBA (Philadelphia, PA)
9:35 am – 9:40 am The Chitranjan S. Ranawat Award 42

“Developing and Implementing a Novel Guideline Strategy Reduced
Postoperative Opioid Prescribing Following TKA and THA”
Cody C. Wyles, MD (Rochester, MN)
9:40 am – 9:45 am The Mark Coventry Award 44

“Does Ceramic Bearing Articulation Improve the Clinical Outcomes of Total
Knee Arthroplasty in Younger Patients?”
Young-Hoo Kim, MD (Seoul, Republic of Korea)
9:45 am – 9:50 am The Insall Travelling Fellowship Update

W. Norman Scott, MD, FACS (New York, NY)
9:50 am – 10:10 am What’s Keeping Knee Surgeon’s Up at Night: A Global Perspective

Moderator: Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH)
Panel: Keith R. Berend, MD (New Albany, OH); Fabio Catani, MD (Modena,
Italy); Scott M. Sporer, MD, MS (Winfield, IL); Emmanuel Thienpont, MD
(Brussels, Belgium)
The Knee Society’s 2018 Lifetime Achievement Award

10:10 am – 10:11 am About the Award: Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH)
10:11 am – 10:12 am Introduction: A Seth Greenwald, D.Phil (Oxon) (Cleveland, OH)
10:12 am – 10:14 am 2018 Lifetime Achievement Award Recipient: Peter S. Walker, PhD
(New York, NY)
10:14 am – 10:15 am on behalf of the 2018 Lifetime Achievement Award Recipient Richard S.
Laskin, MD (Posthumously), Steven B. Haas, MD (New York, NY)
10:30 am – 11:15am Session IV: Lessons Learned from Difficult Cases

Moderator: Aaron A. Hofmann, MD (Salt Lake City, UT)
10:30 am – 11:00 am Panel Discussion

William B. Macaulay, MD (New York, NY); Geoffrey H. Westrich, MD (New
York, NY); Peter F. Sharkey, MD (Media, PA); Nicholas J. Giori, MD (Palo
Alto, CA)

11:15 am – 12:00 pm Session V: Special Highlights
Moderator: Kevin L. Garvin, MD (Omaha, NE)
11:15 am – 11:20 am The Hip Society’s Scientific Awards

The John Charnley Award 66
“Analysis of US Hip Replacement Bundled Payments: Physician-initiated
Episodes Out Perform Hospital-initiated Episodes”
William S. Murphy, AB (Boston, MA)
11:20 am – 11:25 am The Otto Aufranc Award 68

“The Genetics of Osteolysis After Total Hip Arthroplasty”
J. Mark Wilkinson, PhD, FRCS (Sheffield, UK)
11:25 am – 11:30 am The Frank Stinchfield Award 69

“Spino-pelvic Hypermobility is Associated with Inferior Outcome Post-THA:
Examining the Effect of Spinal Arthrodesis”
George Grammatopoulos, MD, FRCS, PhD (Ottawa, ON, Canada)
The Hip Society’s Rothman-Ranawat Traveling Fellowship

11:30 am – 11:35 am Recap of the 2017 Rothman-Ranawat Traveling Fellowship
Carlos A. Higuera-Rueda, MD (Cleveland, OH); Christopher E. Pelt, MD
(Salt Lake City, UT)
11:35 am – 11:38 am Introduction of the 2018 Rothman-Ranawat Traveling Fellows

Moderator: Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH)
11:38 am – 12:00 pm The 50th Anniversary of The Hip Society: A Tribute

Moderator: Daniel J. Berry, MD (Rochester, MN)
Lawrence D. Dorr, MD (Los Angeles, CA); William H. Harris, MD, MS
(Lexington, MA); David G. Lewallen, MD (Rochester, MN); Vincent D.
Pellegrini, Jr., MD (Charleston, SC)
12:00 pm – 12:05 pm The Hip Society’s 2018 Lifetime Achievement Award

Presented by: Kevin L. Garvin, MD (Omaha, NE)
12:05 pm – 1:00 pm LUNCH – Box lunches provided to all participants
1:00 pm – 1:45 pm Session VI: Lessons Learned from Difficult Cases

Moderator: Robert T. Trousdale, MD (Rochester, MN)
1:00 pm – 1:30 pm Panel Discussion

Clive P. Duncan, MD (Vancouver, BC, Canada); Richard W. McCalden, MD
(London, ON, Canada); Aaron G. Rosenberg, MD (Deerfield, IL); Ran
Schwarzkopf, MD, MSc (New York, NY); Thomas P. Vail, MD (San
Francisco, CA)
1:30 pm – 1:45 pm DISCUSSION

11:15 am – 12:00 pm Session V: New Research We Should Know About
Moderator: Mary I. O’Connor, MD (New Haven, CT)
11:15 am – 11:21 am What Activity Should I Recommend for My Patients? 46

Philip C. Noble, PhD (Houston, TX)
11:21 am – 11:27 am Highly Crosslinked and Antioxidant Poly: What Does the Data Show? 49
Timothy M. Wright, PhD (New York, NY)
11:27 am – 11:33 am Kinematic Alignment 51

David W. Murray, MD, FRCS (Oxford, UK)
11:33 am – 11:39 am RSA Data: What Does It Mean to Me? 52

Michael J. Dunbar, MD, PhD, FRCSC (Halifax, NS, Canada)
11:39 am – 11:45 am The Role of Tranexamic Acid 54

Fred D. Cushner, MD (New York, NY)
11:45 am – 12:00 pm DISCUSSION
12:00 pm – 1:00 pm LUNCH – Box lunches provided to all participants
1:00 pm – 1:45 pm Session VI: Partial Knee Arthroplasty

Moderator: Andrew A. Freiberg, MD (Boston, MA)
1:00 pm – 1:06 pm Medial Compartment UKA: Indications/Contraindications 57

David F. Dalury, MD (Towson, MD)
1:06 pm – 1:12 pm Lateral Compartment UKA 59

William A. Jiranek, MD (Durham, NC)
1:12 pm – 1:18 pm Make It Right the First Time: Robot Wars 60

Jess H. Lonner, MD (Bryn Mawr, PA)
1:18 pm – 1:24 pm Without the Grout: Cementless UKA 63

Christopher A.F. Dodd, MB, ChB, FRCS (Oxford, UK)
1:24 pm – 1:30 pm Do Them Both: Bicompartmental TKA 64

Jean-Noël Argenson, MD (Marseille, France)

1:45 pm – 2:30 pm Session VII: Revision THA: Surgical Options for Success (Case-Based)
Moderator: Allan E. Gross, MD, FRCSC, O.Ont (Toronto, ON, Canada)
1:45 pm – 1:49 pm Safe Removal of Femoral and Acetabular Components 70

John Antoniou, MD, FRCSC, PhD (Montreal, QC, Canada)
1:49 pm – 1:53 pm Acetabular Reconstruction: When Do I Need to Use Augments? 74

Wayne G. Paprosky, MD, FACS (Winfield, IL)
1:53 pm – 1:57 pm Femoral Revision: What is the Best Stem to Use? 76

Matthew S. Austin, MD (Philadelphia, PA)
1:57 pm – 2:01 pm Management of Periprosthetic Femur Fractures 77

George J. Haidukewych, MD (Orlando, FL)
2:01 pm – 2:05 pm What Do I Do if the Abductors are Deficient? 78

Michael D. Ries, MD (Reno, NV)
2:05 pm – 2:30 pm DISCUSSION and Additional Cases
2:30 pm – 3:15 pm Session VIII: Infection

Moderator: Arlen D. Hanssen, MD (Rochester, MN)
2:30 pm – 2:36 pm Making the Diagnosis: What is the Gold Standard? 80

Stephen J. Incavo, MD (Houston, TX)
2:36 pm – 2:42 pm Indication for I&D: Is There Ever a Role?

Ryan M. Nunley, MD (St. Louis, MO)
2:42 pm – 2:48 pm One-Stage vs. Two-Stage vs. Partial Resection 82

Craig J. Della Valle, MD (Chicago, IL)
2:48 pm – 2:54 pm When Do I Replant and What Do I Need to Worry About? 83

Bassam A. Masri, MD, FRCSC (Vancouver, BC, Canada)
2:54 pm – 3:00 pm Postoperative Antibiotics: How Long Are They Needed? 89

Michael A. Mont, MD (Cleveland, OH)

1:45 pm – 2:30 pm Session VII: Infection
Moderator: Charles L. Nelson, MD (Philadelphia, PA)
1:45 pm – 1:51 pm Step One: Is this Infected?

Javad Parvizi, MD, FRCS (Philadelphia, PA)
1:51 pm – 1:57 pm Should I Just Wash It Out? 66

Bryan D. Springer, MD (Charlotte, NC)
1:57 pm – 2:03 pm Articulating Spacers: What Works? 70

Michael P. Bolognesi, MD, MS (Durham, NC)
2:03 pm – 2:09 pm One-Stage vs. Two-Stage Treatment of PJI 72

Thomas K. Fehring, MD (Charlotte, NC)
2:09 pm – 2:15 pm The Burden of Infection 73

Kelly G. Vince, MD, FRCSC (Kamo, New Zealand)
2:30 pm – 3:15 pm Session VIII: Revision TKA: What Matters Most (Video-Based)
Moderator: John J. Callaghan, MD (Iowa City, IA)
2:30 pm – 2:36 pm First Things First: Exposure in Total Knee Revision 76

Daniel J. Berry, MD (Rochester, MN)
2:36 pm – 2:42 pm Fixation Strategies: Stems/Cones/Sleeves 78

Paul F. Lachiewicz, MD (Chapel Hill, NC)
2:42 pm – 2:48 pm Supracondylar Periprosthetic Femur Fracture 79

David Backstein, MD, MEd, FRCSC (Toronto, ON, Canada)
2:48 pm – 2:54 pm Constraint in Total Knee Revision 82

William J. Maloney, III, MD (Redwood City, CA)
2:54 pm – 3:00 pm Extensor Mechanism Reconstruction: Cadavers and Mesh 84

James A. Browne, MD (Charlottesville, VA)
3:15 pm – 3:30 pm COFFEE/REFRESHMENT BREAK
Sessions IX and X are combined

with The Hip Society and will be held in
La Nouvelle Ballroom B

C O M B I N E D S E S S I O N S
La Nouvelle Ballroom B
3:30 pm – 4:15 pm COMBINED SESSION IX: Outpatient TJA
Moderator: Adolph V. Lombardi, Jr., MD, FACS (New Albany, OH), President
of The Knee Society
3:30 pm – 3:36 pm Outpatient Arthroplasty: The Time is Now 94

Richard Iorio, MD (New York, NY)
3:36 pm – 3:42 pm Identifying the Optimal Patient 95

Michael E. Berend, MD (Indianapolis, IN)
3:42 pm – 3:48 pm Management of Blood Loss 97

William G. Hamilton, MD (Alexandria, VA)
3:48 pm – 3:54 pm Perioperative Pain Management 100

Mark W. Pagnano, MD (Rochester, MN)
3:54 pm – 4:00 pm The International Perspective 101

Fares S. Haddadd, BSc, MCh (Orth), FRCS (Orth), FRCS (Ed) Dip, Sports
Med FFSEM (London, UK)
4:15 pm – 4:20 pm Update from the AAHKS 2017 Annual Meeting

Mark I. Froimson, MD, MBA (Hunting Valley, OH), President of AAHKS
4:20 pm – 5:00 pm COMBINED SESSION X: Value and Economics in TJA

Moderator: Kevin L. Garvin, MD (Omaha, NE), President of The Hip Society
4:20 pm – 4:26 pm Bundled Payments in Total Joint Arthroplasty: How Does Risk and 103
Readmission Impact Cost of Care
Giles R. Scuderi, MD (New York, NY)
4:26 pm – 4:32 pm Where Do We Stand with Value-Based Payments? A Washington Update 104
Kevin J. Bozic, MD, MBA (Austin, TX)
4:32 pm – 4:38 pm Patient-Reported Outcomes Measures Made Easy 107

David C. Ayers, MD (Worcester, MA)
4:38 pm – 4:44 pm Hospital-Physician Alignment 109

C. Lowry Barnes, MD (Little Rock, AR)
4:44 pm – 4:50 pm Surgical Centers, Consulting and Implant Recall: What You Should Do to 110
Protect Yourself
Mark I. Froimson, MD, MBA (Hunting Valley, OH)
5:00 pm – 5:05 pm Closing Remarks / Meeting Adjourned

Notes:

Session I: Primary Surgical Approach/Technique and Implant Selection: Tips and
Tricks to Maximize Outcomes (Video-Based)
8:00 am – 8:06 am
ABMS Approach in the Lateral Decubitus Position

Christopher L. Peters, MD
Introduction: Traditional posterior approach (PA) for total hip arthroplasty (THA) is considered the gold
standard. Recently, there has been increasing enthusiasm for anterior based approaches, including the
anterior based muscle sparing (ABMS) approach. There has also been concern for surgeons when considering
changing their practice due to the potential for increased complications during the learning curve period. The
purpose of this study was to evaluate the learning curve of a single surgeon when switching from a posterior
approach to an ABMS approach.
Methods: We retrospectively reviewed secondary data on 169 patients that underwent primary THA by a
single surgeon from July 2015 to April 2017. In August of 2016, the surgeon began using an ABMS approach.
All ABMS THA patients (n=80) were compared to PA THA patients in the previous year (n=89). Perioperative
variables and complications were collected. Multivariable linear regression was used to evaluate the
relationship between surgical approach and the continuous variables while controlling for age, sex, body mass
index (BMI), and ASA score. Mediation analysis was used to evaluate the estimated blood loss between the
groups while accounting for surgical duration. Finally, Exact Poisson Regression was used to compare
complications between the groups.
Results: There was no difference in age, sex, BMI, ASA score, or preoperative PROs (all, p>0.05). The
adjusted mean surgical time in ABMS THA was 99 minutes (95% CI, 93 – 105) compared to 90 minutes (95%
CI, 85 – 94) in the PA THA (p=0.025). Length of stay was slightly shorter in ABMS THA with an adjusted mean
LOS of 1.53 days (95% CI, 1.3 – 1.7) compared to 1.87 days (95% CI, 1.7 – 2.1) in PA THA (p=0.012). There
was no difference in EBL between the groups (p=0.355). The adjusted mean abduction angle was 42° (95%
CI, 40° – 44°) in ABMS THA and 43° (95% CI, 41° – 45°, p=0.800) in PA THA. There was no difference in
anteversion angle between the groups (p=0.512) with an adjusted mean anteversion angle of 29° (95% CI, 24°
– 35°) in ABMS THA and 32° (95% CI, 27° – 37°) in PA THA. There was no difference in intraoperative
(p=0.829) or postoperative complications (p>0.99).
Conclusion: Our study demonstrates that during the learning curve for this single surgeon there was no
difference in the outcome measures or perioperative complications. This is early evidence indicating that there
is no learning curve effect for transitioning from a mini-posterior approach to using the ABMS approach in
patients with primary osteoarthritis.
The most common reasons for revision after total hip arthroplasty (THA) historically have been aseptic
loosening, bearing wear, hip instability, and infection.
As the methods of implant fixation, bearing surfaces, femoral head diameter, operative approaches and the
most commonly used implant technologies have changed, the frequency of specific types of revision after THA
are also changing.
Overall the rate of revision after primary THA has fallen over the last decade, mainly as a consequence of
improved implant fixation and common use of cross-linked polyethylene (PE) bearings.

Wide use of uncemented implant fixation is leading to fewer late revisions for implant loosening. However, the
widespread use of uncemented fixation has led to more early revisions for femoral periprosthetic fracture.
Crosslinked PE use is notably reducing revisions for PE wear, especially in younger patients. There are still
some patients with metal-metal bearings requiring revision surgery, but this is mainly a “tail” from more
frequent use in the mid 2000’s.
Dislocation remains the second most common reason for revision after mechanical failure, but larger diameter
heads have reduced the absolute rate of revision for this indication. Dual-mobility implant use in selected
patients may also reduce the overall rate as time goes on.
Use of the direct anterior approach by some surgeons has been associated with lower rates of early revision
for dislocation, but a higher risk of early revision for femoral component loosening.
Infection has not declined and remains a major unsolved problem.

8:06 am – 8:12 am
Direct Anterior Approach Including Tips to Improve Exposure

Paul E. Beaulé, MD, FRCSC
Introduction:
Between 2006 and 2016 (5562 hips), of which 1087 hips (937 patients) were primary elective THA were done
using the anterior approach in the supine position at our Institution. There were a variety of ‘standard’ length
stems 566 (52.1%) and a number of ‘short’ stems 521 (47.9%) that are frequently utilized in the anterior
approach. The positioning table was used in 889 hips (81.8%) and 198 hips (18.22%) were operated on the
regular table. Since 2006 our center’s use of the anterior approach has increased from 1.5% to 53.2% of all
annual THA.
Intra-operative events were reported in 49 hips (4.5%), included calcar crack in 29 hips (2.7%), chip fracture in
the greater trochanter in 9 hips (0.82%). Canal perforations or shaft fractures in 5 hips (0.45%), 4 hips (0.36%)
had displaced greater trochanter fractures, had acetabular insufficiency fractures in 2 hips (0.18%).
-Higher incidence of intra-operative events with using the regular table and the regular stems 5.1% and
5.7%, respectively versus 4.4% with the positioning table and 3.3% with the short stems, not statistically
significant (p-value = 0.68 and 0.058, respectively).
Rate of intra-operative complications was higher in surgeons with less than 100-cases experience: (5.8%
versus 3.9%), not statistically significant (p-value 0.175).
Wound complications were reported in 25 hips (2.3%). The rate of infection and wound complications was
significantly higher for surgeons who had performed less than 100-cases, 3.7% versus 1.7% (p-value 0.048).
Dislocation was reported in 8 hips (0.73%).
Post-operative periprosthetic fractures were reported in 7 hips (0.64%). Implant failure in 3 hips (0.27%),
fractured ceramic linear, fracture of modular neck and polyethylene liner disengagement.
Thirty hips (2.7%) showed HO: only 2 hips required resection. Incidence of HO was significantly higher with the
regular table than positioning table 6.1% vs. 2.2% respectively (p-value= 0.004). Other risk factors of HO
including male gender: 4.7% vs 1.8% in female (p-value 0.007).
Re-operation was required in 60 hips (5.5%), slightly higher for surgeons who had performed less than 100-
cases (6.7% versus 5.1%), not statistically significant (p-value 0.294).
Key Steps for the Anterior Approach in Supine Position
Positioning –Supine position:
-Patient is placed on positioning table with slight counter-traction to non-surgical leg to keep pelvis
level.
-Patients with a large pannus, tape can be used to retract it from the surgical site.

Incision:
-Can be classic in line with the Tensor muscle or Bikini(1) but regardless will be centered over the
greater trochanter
-With the classic incision, it is lateral to the ASIS which can vary based on body habitus but around 2-
4cm.
-Branches of the Lateral Femoral Cutaneous Nerve are at risk(2) with 3 types of distributions(3):
-Medial to the ASIS
-Posterior direction at level of ASIS
-Fan-type with multiple branches
-Use a sponge to mobilize the fat over the tensor fascia further helping to avoid
some of its branches.
Fascial layers:
-TENSOR: tensor muscle is peeled off the medial aspect which is then retracted laterally.
-RECTUS: incising it will then permit retraction of the rectus muscle medially.
-INNOMINATE-LETOURNEL: Branches of lateral femoral circumflex are located here just proximal to
the vastus lateralis. Careful attention is needed to properly cauterize.
Capsular Exposure:
-Iliocapsularis is often adherent to the capsule requiring sharp dissection.
-Reflected head of rectus can be released to provide exposure of the antero-lateral
acetabular rim.
-A blunt Hohlman retractor is placed around the infero-medial neck-extra-capsular.
-The antero-lateral third of the capsule is resected.
Femoral Neck cut: (The neck cut is performed in-situ.)
-Level of the calcar cut is performed according to the preoperative planning, the stem design.
-A sharp Hohman is placed in the lateral shoulder between lateral based of neck and greater trochanter
dictating level of cut proximal to distal. A blunt Hohman is placed intracapsularly and medially protecting the
soft-tissues.
-In regards to level of cut from the lesser trochanter, this will be dictated by the degree of obliquity of
saw. Prior to proceeding with the saw, the cut is marked with cautery.
-The cut is done with slight traction applied to the leg and head is excised with a cork screw with the
femur externally rotated while one levers the engaged cork screw proximally and releasing the inferomedical
capsule off the femoral head using cautery.

-With the traction released, the level of calcar cut is checked palpating the LT with external rotation of
the femur. To facilitate femoral exposure, the pubo-femoral ligament and the medial capsule are released
from the calcar.
Pitfalls:
• High cut might lead to increased risk of calcar crack, version alteration and difficult acetabular
exposure.
• Low calcar cut might lead to stem varus alignment.
• Never complete neck cut with an osteotome as this can lead to calcar propagation.
Acetabular Exposure/Preparation:
-Anterior wall retractor is placed at the 4 O’clock for a right hip and at the 8 O’clock position for the left
hip.
-Tensor and posterior capsule are retracted using a small COBRA on the posterior wall.
-Labrum is excised as well as the inferomedial osteophyte.
-Reaming is then began in the standard fashion lifting hand slightly anteriorly to avoid reaming the
anterior wall
-Acetabular component is then implanted in 15-20 degrees of anteversion and 40 degrees of abduction.
-As the patients is not lying on their side, secondary impaction can be important in patients with good
quality bone as there is no counter force on the pelvis during reaming and impacting.
Proximal femur exposure: (Aiming anterior displacement of the proximal femur till at least the middle of the
acetabulum.)
-With the leg in extension, a hooked in placed to elevate the femur after which the leg is locked into
external rotation of 80 to 90 degrees. This ensures that the greater trochanter remains anterior to the
ischium.
-The leg is then brought in extension of about 30-40 degrees ensuring no traction is applied to the leg.
-External rotation of the femur is adjusted so that posterior femoral cortex is parallel to the wall.
In patients with femoral retro-torsion or large muscle mass this may not be achievable.
-The leg is adduction to facilitate clearing of the broach passing the ilac wing.
-We have two different positing tables: Delacroix-Judet (Maquet, France) using a posterior bump or
HANA© table (Mizuho OSI) with femoral bone hook to stabilize femur during broaching.
Access to femoral canal:
The box cut is performed using a rongeur or offset box osteotome, then the femoral canal is accessed using a
canal finder (curved canal finder) by applying axial pressure starting hugging the calcar simultaneously with
anterior to posterior movement.

Femoral Broaching:
The femur is broached sequentially to a final size that yielded excellent axial and rotational stability. A trial
reduction was performed to ensure restoration of leg lengths and good stability before implanting the definitive
stem.
Tips:
• It is helpful to decide using either the single or double offset broach handle to clear the iliac crest
(double offset used with excessively retro-verted femur).
• Posterior pressure should be applied during broaching to push the stem into valgus.
• Always try one size above before deciding the final size due to tendency of under-sizing with the
anterior approach.
• Stability and range of motion (impingement) checked by disengaging the boots from the positioning
table, carried out by the help of the circulating nurse.
• In most cases, an intra-operative radiograph was obtained to ensure adequate leg length and offset
and identify any under-sizing, mal-alignment, bony perforation or fracture.
Check the calcar:
-The calcar should be checked all around for any hairline cracks or fractures before reduction. Calcar
cracks are treated using a bicortical 3.5mm screw.
Greater trochanter (tip/chip)
-Because of the intact sling with the vastus and abductors, those are most commonly treated with
restricted weight bearing.
Hip is then reduced with the leg in extension. Range of motion check is done in every case by
disengaging the booth to ensure proper implant positioning and stability. This is the followed by an
AP pelvis to verify leg lengths and implant positioning.
1. Leunig M, Faas M, von Knoch F, Naal FD. Skin crease 'bikini' incision for anterior approach total hip
arthroplasty: surgical technique and preliminary results. Clin Orthop Relat Res. 2013;471(7):2245-52.
2. Goulding K, Beaule PE, Kim PR, Fazekas A. Incidence of lateral femoral cutaneous nerve neuropraxia
after anterior approach hip arthroplasty. Clin Orthop Relat Res. 2010;468(9):2397-404.
3. Rudin D, Manestar M, Ullrich O, Erhardt J, Grob K. The Anatomical Course of the Lateral Femoral
Cutaneous Nerve with Special Attention to the Anterior Approach to the Hip Joint. J Bone Joint Surg Am.
2016;98(7):561-7.

8:12 am – 8:18 am
Dysplastic Hip
John C. Clohisy, MD
Developmental dysplasia of the hip (DDH) is a common etiology of hip pain, dysfunction and progressive joint
degeneration. Patients with endstage OA secondary to DDH commonly require total hip arthroplasty, and can
be challenging to treat surgically. These patients tend to be young at the time of presentation, can have
previous failed procedures, and can have substantial deformities on both the femoral and acetabular sides.
THA clinical outcomes can be excellent, but an increased risk of complications has been documented
especially in more severe deformities. The Crowe and Hartofilakidis classification schemes are most commonly
used for DDH and focus primarily on acetabular deformity and proximal displacement of the femoral head.
Various disease characteristics of DDH can make THA more challenging and should be considered when
contemplating THA.
General DDH disease characteristics (variable)

Disuse osteoporosis
Compromised muscularity (previous surgery)
Soft tissue laxity
Previous surgery- scar, retained hardware, iatrogenic deformity (acetabulum and femur)
DDH structural disease characteristics (variable)
Femur- coxa valga, torsional deformities, canal stenosis, dislocation

Acetabulum- anterolateral insufficiency, increased acetabular inclination, lateralized hip center, version
abnormalities, small true acetabulum
Technical considerations
-Acetabulum
medialize, optimize host coverage, posterior bone stock, minimize rim overhang (anteriorly), avoid excessive
anteversion and abduction
severe deformity (dislocation)- identify true acetabulum for placement at true hip center, augment/graft to
supplement host coverage if needed.
-Femur
assess and know version, avoid excessive anteversion, recreate offset, length, different stem options
severe deformity (dislocation/osteotomy deformity)- consider subtrochanteric shortening osteotomy or angular

correction if needed
Summary
The DDH hip can present substantial challenges to the reconstructive hip surgeon. Careful preoperative
planning, understanding of the hip pathomorphologies, awareness of potential technical pitfalls and availability
of appropriate equipment/implants can optimize total hip arthroplasty in this patient population.

References
[1] Crowe, J. F., Mani, V. J. and Ranawat, C. S. 1979 "Total hip replacement in congenital dislocation and dysplasia of the
hip." J Bone Joint Surg Am. 61(1): 15-23. DOI:
[2] Hartofilakidis, G., Stamos, K., Karachalios, T., Ioannidis, T. T. and Zacharakis, N. 1996 "Congenital hip disease in
adults. Classification of acetabular deficiencies and operative treatment with acetabuloplasty combined with total hip
arthroplasty." J Bone Joint Surg Am. 78(5): 683-692. DOI:
[3] Rogers, B. A., Garbedian, S., Kuchinad, R. A., Backstein, D., Safir, O. and Gross, A. E. 2012 "Total hip arthroplasty for
adult hip dysplasia." J Bone Joint Surg Am. 94(19): 1809-1821. DOI: 10.2106/JBJS.K.00779

8:18 am – 8:24 am
Previous Surgery/Retained Hardware

Michael J. Archibeck, MD
Total hip arthroplasty following prior hip surgery can dramatically complicate the procedure and increase the
rate of complications. Studies have shown a higher dislocation rate, infection rate, fracture rate, a longer
surgical duration, and higher blood loss. The surgeon should be aware of these issues and educate the patient
about them as well.
The task of this presentation is to provide a systematic method for preoperative evaluation of such patients,
discuss surgical techniques to assist in minimizing the risk of complications, and review implant selection in
cases of deformity or defects from hardware removal.
At initial presentation, the history and physical examination can provide valuable information regarding
potential concerns that may need to be addressed. Beyond the typical history of hip pain and OA, the surgeon
should ask about the prior procedure and any postoperative complications (infection, DVT, nerve injury, HO,
prolonged drainage or antibiotic use). Examination should include an assessment of the neurovascular status
of the limb, a measurement of LLD, examination of prior scars, abductor function and ROM of the hip.
Studies should include preoperative radiographs. In cases of prior trauma, the presence of heterotopic
ossification should be identified and perioperative prophylactic radiation should be considered. In the case of
prior injury and retained hardware, infection needs to be ruled out. CRP and ESR should routinely be obtained
in such cases. If elevated, or any clinical history that would raise suspicion is present, aspiration and additional
studies (leukocyte scan, PET scan) may be needed to rule out infection. In cases of acetabular hardware or
fracture, a CT scan can be helpful to confirm bony union of the fracture and identify areas of defect and
potential hardware encroachment on reaming or implant. Vascular studies should be obtained if pulses are
diminished. Nutrition panel may be needed in cases of potential malnutrition.
Preoperative planning should include obtaining old operative notes if possible – especially in cases of failed
ORIF of hip fracture. This will aid in extraction with minimal trauma. Metal cutting burrs and hardware removal
sets should be available especially if retained acetabular plates/screws are present. Proximal femoral deformity
or overgrown hardware may require an extended trochanteric osteotomy. Implant selection should generally
include a primary plan and at least one back up plan. On the acetabular side, the need for enhanced ingrowth
surfaces and augments should be considered. Supplemental screws should generally be used. Anticipate the
potential need for augmentation, cages, bone grafting, dual mobility, etc. On the femoral side, depending on
several factors, cemented fixation or cementless fixation should be planned. In either case, the femoral
component should bypass any stress risers (screw holes) if possible. If it is not possible, prophylactic fixation
should be considered (plate or struts). If concerned about the presence of possible infection, consider having
spacers available. In complex cases, consider the use of blood salvage procedures such as intraoperative cell
saver.
Intraoperative considerations include the approach. Generally, old scars can be ignored about the hip. If it is
within the surgeon’s armamentarium, consideration should be given to an approach that mitigates against the
elevated risk of dislocation (eg. modified Hardinge, etc). Approach the hip joint and dislocate the hip with any
retained femoral hardware in situ. Resist the temptation to remove the hardware first. Once a nontraumatic
dislocation is easily obtained, re-reduce the hip and remove the hardware. This will minimize the risk of
iatrogenic fracture through screw hole with a forced dislocation. On the acetabular side, ream until screws are
encountered and remove with a burr from within. In cases of disuse osteopenia, such as following a failed hip
fracture ORIF, ream cautiously as the bone deep to the thin subchondral layer can be very soft and lead to
overpenetration. Use supplemental screws. Consider the use of a dual mobility in high risk patients. On the
femoral side consider prophylactic cerclage cables in cementless cases if significant stress risers are present.
Consider sending cultures if infection is a concern. Consider intraoperative radiographs or C-arm if needed.
Postoperatively, consider radiation therapy if at risk for heterotopic ossification. Consider more aggressive
anticoagulation for DVT prophylaxis if relatively restricted mobility is present. Consider restricted weight
bearing if fixation tenuous.
References:
1. Tetsunaga T, Fujiwara K, Endo H, Noda T, Tetsunaga T, Sato T, Shiota N, Ozaki T. Total hip arthroplasty after failed treatment of proximal femur
fracture. Arch Orthop Trauma Surg. 2017 Mar; 137(3): 417-424.
2. Mahmoud SS, Pearse EO, Smith TO, Hing CB. Outcomes of total hip arthroplasty, as a salvage procedure, following failed internal fixation of
intracapsular fractures of the femoral neck: a systematic review and meta-analysis. Bone Joint J. 2016 Apr; 98-B(4): 452-60.
3. Archibeck MJ, Carothers JT, Tripuraneni KR, White RE. Total hip arthroplasty after failed internal fixation of proximal femoral fractures. J Arthrop. 2013
Jan; 28(1):168-171.
4. Exaltacion JJ, Incavo SJ, Mathews V, Parsley B, Noble P. Hip Arthroplasty After Intramedullary Hip Screw Fixation: A Perioperative Evaluation. Journal
of orthopaedic trauma, 2011
5. Exaltacion JJ, Incavo SJ, Mathews V, Parsley B, Noble P. Hip Arthroplasty After Intramedullary Hip Screw Fixation: A Perioperative Evaluation. Journal
of orthopaedic trauma, 2011
6. D'Arrigo C, Perugia D, Carcangiu A, Monaco E, Speranza A, Ferretti A. Hip arthroplasty for failed treatment of proximal femoral fractures. International
orthopaedics 34(7): 939, 2010
7. McKinley JC, Robinson CM. Treatment of displaced intracapsular hip fractures with total hip arthroplasty: comparison of primary arthroplasty with early
salvage arthroplasty after failed internal fixation. The Journal of bone and joint surgery American volume 84-A(11): 2010
8. D'Arrigo C, Perugia D, Carcangiu A, Monaco E, Speranza A, Ferretti A. Hip arthroplasty for failed treatment of proximal femoral fractures. International
orthopaedics 34(7): 939, 2010
9. Hopley C, Stengel D, Ekkernkamp A, Wich M. Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older
patients: systematic review. BMJ 340: c2332, 2010
10. Leonardsson O, Rogmark C, Karrholm J, Akesson K, Garellick G. Outcome after primary and secondary replacement for subcapital fracture of the hip
in 10 264 patients. The Journal of bone and joint surgery British volume 91(5): 595, 2009
11. Leonardsson O, Rogmark C, Karrholm J, Akesson K, Garellick G. Outcome after primary and secondary replacement for subcapital fracture of the hip
in 10 264 patients. The Journal of bone and joint surgery British volume 91(5): 595, 2009
12. Schmidt AH, Leighton R, Parvizi J, Sems A, Berry DJ. Optimal arthroplasty for femoral neck fractures: is total hip arthroplasty the answer? Journal of
orthopaedic trauma 23(6): 428, 2009
13. Hammad A, Abdel-Aal A, Said HG, Bakr H. Total hip arthroplasty following failure of dynamic hip screw fixation of fractures of the proximal femur.
Acta orthopaedica Belgica 74(6): 788, 2008
14. Gjertsen JE, Lie SA, Fevang JM, Havelin LI, Engesaeter LB, Vinje T, Furnes O. Total hip replacement after femoral neck fractures in elderly patients
: results of 8,577 fractures reported to the Norwegian Arthroplasty Register. Acta orthopaedica 78(4): 491, 2007
15. Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced
intracapsular fracture of the femoral neck. A randomized, controlled trial. The Journal of bone and joint surgery American volume 88(12): 2583, 2006
16. Schmidt AH, Asnis SE, Haidukewych G, Koval KJ, Thorngren KG. Femoral neck fractures. Instructional course lectures 54: 417, 2005
17. Utrilla AL, Reig JS, Munoz FM, Tufanisco CB. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized,
prospective, comparative study in 210 elderly patients with a new design of the gamma nail. Journal of orthopaedic trauma 19(4): 229, 2005
18. Zhang B, Chiu KY, Wang M. Hip arthroplasty for failed internal fixation of intertrochanteric fractures. The Journal of arthroplasty 19(3): 329, 2004
19. Haidukewych GJ, Berry DJ. Salvage of failed internal fixation of intertrochanteric hip fractures. Clinical orthopaedics and related research (412): 184,
2003
20. Haidukewych GJ, Berry DJ. Hip arthroplasty for salvage of failed treatment of intertrochanteric hip fractures. The Journal of bone and joint surgery
American volume 85-A(5): 899, 2003
21. Hardy DC, Descamps PY, Krallis P, Fabeck L, Smets P, Bertens CL, Delince PE. Use of an intramedullary hip-screw compared with a compression
hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. The Journal of bone and joint
surgery American volume 80(5): 618, 1998
22. Tabsh I, Waddell JP, Morton J. Total hip arthroplasty for complications of proximal femoral fractures. Journal of orthopaedic trauma 11(3): 166, 1997
23. Haentjens P, Casteleyn PP, Opdecam P. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly
patient. Archives of orthopaedic and trauma surgery 113(4): 222, 1994
24. Haentjens P, Casteleyn PP, Opdecam P. Hip arthroplasty for failed internal fixation of intertrochanteric and subtrochanteric fractures in the elderly
patient. Archives of orthopaedic and trauma surgery 113(4): 222, 1994
25. Franzen H, Nilsson LT, Stromqvist B, Johnsson R, Herrlin K. Secondary total hip replacement after fractures of the femoral neck. The Journal of bone
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26. Mehlhoff T, Landon GC, Tullos HS. Total hip arthroplasty following failed internal fixation of hip fractures. Clinical orthopaedics and related research
(269): 32, 1991

8:24 am – 8:30 am
Previous Lumbar Fusion

Gwo-Chin Lee, MD
Instability following primary total hip arthroplasty remains a leading cause of revision surgery [1]. While
avoiding extremes in acetabular and femoral component positioning can reduce the risk for dislocation, the
safe zones for each individual remains unknown [2]. In recent years, the contributions of the spine and spino-
pelvic motions to hip implant stability has been recognized [3]. Additionally, there has been increased
awareness that prior lumbar surgery places the hip patient at higher risk for postoperative instability [4].
Therefore, we explore potential strategies to minimize complications in this patient population.
Impingement is the root cause for most dislocations. In patients with spinal pathology, the acetabular opening
angle and the functional arc of motion is decreased leading to greater risk for impingement [5]. In the stiff
spine (i.e. prior fusion), there is a relative decrease in acetabular anteversion because there is a relative lack of
pelvic extension leading to relative acetabular retroversion in a seated position. In cases where the spine is
rigid and unbalanced in the sagittal plane, the risk of impingement is further magnified. In a flat back deformity,
the pelvis is fixed in extension thus leading to risk for posterior impingement and anterior dislocation [6].
Careful preoperative planning and implant selection can reduce the risk for postoperative instability in this
patient population. The use of additional imaging such as sitting to standing radiographs or dynamic imaging
such as EOS imaging can preoperatively define the relation between the hip and the spine and prompt
adjustments in the target for hip implants. Careful templating and restoration of offset will help restore
appropriate soft tissue tensions. Increasing the acetabular component anteversion and abduction can reduce
the risk for impingement in some patients [7]. Finally, the use of larger heads and selective use of dual mobility
articulation can further effectively enlarge the safe zone for these patients.
In summary, patients with prior lumbar fusion undergoing THA are at increased risk for postoperatively hip
instability. Preoperative planning, intraoperative adjustments for acetabular positioning, and maximizing head
size and offset can help reduce the risk for dislocation.
References
1. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the
United States. J Bone Joint Surg Am. 2009 Jan;91(1):128-33.
2. Abdel MP, von Roth P, Jennings MT, Hanssen AD, Pagnano MW. What Safe Zone? The Vast Majority of Dislocated
THAs Are Within the Lewinnek Safe Zone for Acetabular Component Position. Clin Orthop Relat Res. 2016
Feb;474(2):386-91.
3. Sultan AA, Khlopas A, Piuzzi NS, Chughtai M, Sodhi N, Mont MA. The Impact of Spino-Pelvic Alignment on Total
Hip Arthroplasty Outcomes: A Critical Analysis of Current Evidence. J Arthroplasty. 2017 Nov 22. pii: S0883-
5403(17)31026-4.
4. Malkani AL, Garber AT, Ong KL, Dimar JR, Baykal D, Glassman SD, Cochran AR, Berry DJ. Total Hip Arthroplasty
in Patients With Previous Lumbar Fusion Surgery: Are There More Dislocations and Revisions? J Arthroplasty.
2017 Oct 31. pii: S0883-5403(17)30953-1. doi: 10.1016/j.arth.2017.10.041. [Epub ahead of print]
5. Lazennec JY, Clark IC, Folinais D, Tahar IN, Pour AE. What is the Impact of a Spinal Fusion on Acetabular Implant
Orientation in Functional Standing and Sitting Positions? J Arthroplasty. 2017 Oct;32(10):3184-3190.
6. Phan D, Bederman SS, Schwarzkopf R. The influence of sagittal spinal deformity on anteversion of the acetabular
component in total hip arthroplasty. Bone Joint J. 2015 Aug;97-B(8):1017-23.
7. 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 Jun 18;96(12):978-986.

Session II: Intraoperative and Early Postoperative Complications: Surgical
Exposure and How to Manage (Video-Based)
8:45 am – 8:51 am
Intraoperative Acetabular Fracture: How to Gain Exposure

and Manage Through a Posterior Approach
James I. Huddleston, III, MD
Intraoperative fracture of the acetabulum is a rare complication associated most commonly with insertion of a
cementless acetabular component. In a series of 7,121 primary total hip arthroplasties (THA) from 1990-2000,
the rate of intraoperative acetabulum fracture was 0.4% (21 of 5,359 cementless THAs). There weren’t any
fractures in the 1,762 cemented sockets. Seventeen of the 21 fractures were deemed stable and four were
treated successfully with supplemental screw fixation.1 In a case series of 13 hips, only nine were diagnosed
intraoperatively. Four of these cases required reoperation.2 Another case series of 32 hips reported a 66%
failure of cases with posterior column instability.3 The most recent case series reports 16 fractures in 21,519
THAs (0.0007%) performed from 1997-2015.4 Intraoperative fractures associated with cemented sockets (1 of
5,400)5 and cup removal are even less common.
Several classification systems have been developed to assist with diagnosis and management of
intraoperative acetabulum fractures. The initial classification was based on in vitro fracture patterns: anterior
wall, transverse, posterior wall, and inferior lip.6,7 Another system distinguishes between stable and unstable
fracture patterns.8 A third classification scheme differentiates between a non-displaced fracture with a stable
shell (type I), a non-displaced fracture that threatens the stability of the shell (type II), and a displaced fracture
(type III). Lastly, the Unified Classification System (UCS) is the most recent and has been endorsed by the AO
and Orthopaedic Trauma Association.9
Successful management of these fractures requires prompt intraoperative detection (cup seats deeper than
final reamer), achievement of adequate exposure (superior gluteal neurovascular bundle and sciatic nerve),
stable fracture fixation, maintenance of satisfactory alignment and stability of the prosthetic socket, and
achievement of fracture union and osseointegration. Risk factors for this complication include excessive press-
fit, poor bone quality, small sockets, and over-reaming. Stable fractures should be treated with screws through
the cup. Unstable fractures should be treated with posterior column plating and screws through the cup. Cup-
cage constructs and anterior column screws may be needed, in addition to posterior column plating, in the
most unstable fracture patterns. Weight-bearing should be limited postoperatively for at least 6-12 weeks.
1. Haidukewych GJ, Jacofsky DJ, Hanssen AD, et al. Intraoperative fractures of the acetabulum during primary total hip arthroplasty. J Bone
Joint Surg Am 2006.
2. Sharkey PF, Hozack WJ, Callaghan JJ, et al. Acetabular fracture associated with cementless acetabular component insertion: A report of 13
cases. J Arthroplasty 1999.
3. Laflamme GY, Belzile EL, Fernandes JC et al. Periprosthetic fractures of the acetabulum during cup insertion: posterior column stability is
crucial. J Arthroplasty 2015.
4. Brown JM, Borchard KS, Robbins CE, Ward DM, Talmo CT, Bono JV. Management and prevention of intraoperative acetabular fracture in
primary THA. AM J Orthop 2017.
5. McElfresh EC, Coventry MB. Femoral and pelvic fractures after total hip arthroplasty. J Bone Joint Surg Am 1974.
6. Callaghan JJ. Periprosthetic. fractures of the acetabulum during and following total hip arthroplasty. Instr Course Lect 1999.
7. Callaghan JJ, Kim YS, Pederson DR, et al. Periprosthetic fractures of the acetabulum. Orthop Clin North Am 1999.
8. Della Valle CJ, Momberger NG, Paprosky WG. Periprosthetic fractures of the acetabulum associated with a total hip arthroplasty. Instr Course
Lect 2003.
9. Duncan CP, Haddad FS. Periprosthetic fractures after joint replacement: A unified classification system. In: Schutz M, Perka C, Ruedi TP, ed.
Periprosthetic Fracture Management. Vol 1. New York, NY: Thieme 2014.

8:51 am – 8:57 am
Failed Acetabular Fixation: How to Gain Exposure

and Manage Through an Anterior Approach
Joseph T. Moskal, MD
In this technique, the patient is positioned in supine position on either a regular operating room table or a
specialized table depending on surgeon preference, and a spinal or general anaesthesia is administered. A
modified Smith-Petersen approach to the hip is used for exposure (1,2). The incision is started along the iliac
crest, over the ASIS and directed distally over the tensor fascia lata (TFL) (Figure 1). Subcutaneous flaps are
raised medially and laterally, care is taken to try and avoid injuring the lateral femoral cutaneous nerve. The
TFL fascia is incised and peeled off the TFL fibers. The interval between the TFL and the rectus femoris is
identified and the lateral circumflex vessels are coagulated. Proximally, the aponeurosis of the external oblique
muscle is sub-periosteally peeled of the iliac crest and reflected medially along with the oblique abdominal
muscles. The aponeurosis of the sartorius and the inguinal ligament is then peeled off the anterior superior iliac
spine (ASIS). The hip is slightly flexed and the medial muscle envelope is lifted off the inner iliac table with a
Hohmann retractor that sub-periosteally rests on the pelvic brim, and in cases of an extensive medial defect on
the inner surface of the sciatic spine. The iliopsoas muscle is thus retracted medially. The anterior inferior iliac
spine (AIIS) and the rectus femoris are identified (Figure 1). The interval between the iliopsoas medially and
the insertion of the rectus femoris and iliocapsularis laterally is identified and opened. A Langenbeck retractor
is used to lift the iliopsoas off the ileopectineal eminence and a sharp tipped Hohmann retractor is put medially
to the eminence. The tip of this retractor is fixed into to the pubic bone in order to safely retract the psoas
medially (Figure 2). If the view on the anterior column is insufficient, the rectus femoris tendon can be
tenotomized as originally described by Ganz et al.(1,2). In some cases the rectus femoris tendon can be
tenotomized to improve exposure and allow the desired reconstruction, in these cases the tendon was sutured
back at the end of the procedure. The hip capsule is then incised. The superior part of the capsule can be
removed if hindering visualization. The pubo-femoral ligament (i.e. the inferior capsule) is tagged and retracted
inferiorly by a postero-inferior retractor. The superior capsular release is done with the hip located. The femur
is then dislocated followed by dislodging of the femoral head component in isolated acetabular revisions,
extraction of the femoral component in reconstructions requiring revising both the femoral and acetabular
components or performing the femoral neck cut at the desired level in a primary arthroplasty. The femur is then
lifted to the level of the TFL. A superior retractor is placed at the level of the superior release just in front of the
gluteus minimus. Attention is then placed towards socket removal and debridment of the bony defects.
Overall reconstruction constructs can consist of highly porous hemispherical acetabular components, along
with particulate graft and/or titanium augments if needed. If a cage is required, a slot is created into the
ischium for anchorage of the distal flange of the cage and the anterior insertion of the gluteus minimus was
sub-periosteally peeled off the outer table of the ilium to allow fixation of the proximal flange of the cage to the
ilium (Figure 3). The polyethylene liner is cemented in either the revision shell or the cage, which is put over
the revision shell. (Figure 4).
Testing for stability or impingement is performed in deep flexion with 30° internal/external rotation as well as
hyperextension with external rotation. In cases were the rectus femoris tendon had a suture repair performed
at the end of the procedure this is followed by trans-osseous suturing of the muscle insertions at the level of
the AIIS. The oblique abdominal muscle is sutured onto the conjoined fascia of the TFL and the maximus at
the level of the iliac crest. The TFL fascia is then closed. A drain is placed and subsequently removed within 24
to 48 hours. Patients are immediately mobilized, partial weight bearing (50 to 75%) for 6 weeks. Open chain
exercises were prohibited to allow the rectus femoris tendon to heal.
Legend
Figure 1. The Modified extensile Smith-Petersen approach to the anterior column of a right hip is shown on a
cadaver specimen. (a) The iliac crest and anterior superior iliac spine (ASIS) (¶) are identified. The incision
runs over the lateral side of the crest towards the ASIS and then distally over the muscle belly of the tensor
fascia lata (°). (b) The ASIS is identified after the abdominal muscles have been peeled off sub-periosteally.
Similarly, the insertion of the inguinal ligament is sub-periosteally peeled off. (c) With the hip flexed, a
Hohmann retractor is put at the inner table of the ileum underneath the iliacus muscle (★). (d) The retractor is
put at the pelvic brim and the interval between the iliacus-iliopsoas medially and the rectus femoris direct head
laterally is opened (blue arrow).
Figure 2. (a) The ASIS (¶) and the anterior inferior iliac spine (AIIS) (^) is identified. The iliopsoas (blue arrow)
is retracted medially. The hip remains flexed. (b) The pubic eminence (★) is identified and marks the medial
extension of the acetabulum. (c) A sharp retractor is fixed in the pubic bone, just medial to the eminence. The
psoas and the neurovascular structures are retracted medially.

Figure 3. (a) A 83-year old female patient presented with a severe acetabular defect and a peri-Vancouver
type B3 peri-prosthetic femoral fracture 20 years following a cemented hip replacement. (b) A retractor was put
at the ischial spine and one at the pubis. The posterior column was intact but the anterior column and medial
wall were completely disrupted. (c) A lateral augment was applied to provide support to the trabecular revision
shell was inserted. (d) A cage was applied to provide support and (e) a liner was cemented in. (f) The incision
was extended distally, cerclage wires were applied around the femur and a modular revision stem was inserted
(g).

Figure 4. (a) A 45-year old female presented with a Paprosky type 2 lateral defect of the left hip (b). (c) The
intra-operative view of the cup-augment trials was excellent. (d) The lateral augment was inserted and loosely
fixed. (e) The revision shell was inserted and the augment was fixed. (f) A trial reduction was done and allowed
for extensive stability testing. (g) Radiograph 4 years post-operatively.
References
1. Ganz R, Klaue K, Vinh TS, Mast JW. A new periacetabular osteotomy for the treatment- of hip dysplasias.
Technique and preliminary results. Clin Orthop Relat Res. 1988;232:26-36.
2. Leunig M, Siebenrock KA, Ganz R. Rationale of periacetabular osteotomy and background work. J Bone
Joint Surg Am. 2001;83:438-48.

8:57 am – 9:03 am
Management of Early Stem Subsidence/Calcar Fracture

(Using Either Anterior or Posterior Approach)
Paul J. Duwelius, MD
I. Introduction
• Epidemiology: 0.5-1% incidence in primary THA

• However, one study found a 5.4% incidence in primary THA with cementless stem versus 0.3% incidence
when cemented stem used.
• Another study revealed 1.2% incidence with a cemented stem versus 3% with a cementless stem
• Problems with these studies include variability due to sample size or use of different femoral stems or
insertion techniques
• Risk factors for periprosthetic fracture:
o Cementless stems versus cemented stems
o Recent reports of present day dual tapered stems decrease incidence
o Small incision surgery
o Female gender
o Previous surgery on the affected hip
o Increased age
o Osteoporosis
o Altered bone morphology or deformity such as Paget’s disease
o Surgical approach (Anterior approach higher risk)
• Diagnosis and Treatment
o Surgeon must have high index of suspicion intraoperatively
o Broach technique very important in uncemented technique
▪ Listen for pitch change
▪ Sudden change in resistance highly suggestive of fracture
▪ Stop and let bone expand due to viscoelastic properties of bone during broaching
▪ Intraoperative radiograph if fracture suspected
▪ Insure stem stability prior to closure
▪ Revise stem versus cable and continue if fracture discovered
II. Identification of the Problem
• High risk patient with poor bone quality:

o Cemented stem
o Cementless stem with cable
o Care with rapid mobilization: 50% of patients with postoperative periprosthetic fracture report
no mechanism of injury
o High-risk patients should be advised not to come off assisted weight bearing too soon.
III. Fracture Occurs: Now What?
• Classifications exist but reliability and validity not tested

• Don’t miss the fracture
• Intraoperative fracture easily treated with cerclage wiring
• Fractures occur in classical pattern intraoperatively: calcar crack or triangular fragment of proximal
medial femur
• Trochanteric fracture usually requires cable with tension band technique; plating associated with high
rate of trochanteric escape
o Careful attention to protection of trochanter with anterior retractor
o Maybe indication to prepare femur first and leave broach in femoral canal so retractor pressure
is on broach and not the GT
• Postoperative fracture with stem subsidence
o Usually fracture unstable due to shortening and retroversion
o Stem revision rather than ORIF with plate or cable preferable
o Revision to standard or mid length stem with some diaphyseal fixation (Taper fluted modular
or non-modular stem or extensively coated stem).
o Fracture can be treated with cerclage wire and standard stem if excellent stability and good
bone quality
o Realize risk of complications with early revision especially infection
IV. Conclusions
• Anterior versus posterior: Where are we with calcar fractures?

o All approaches have problems
o Ease of making approach extensile?
o Consider the learning curve
o What’s the “bail out”
o Consider the next operation if revision required?
o What’s the problem? (32 or 36 femoral heads)
o Do what works best in your hands
o Long term results good if periprosthetic fracture recognized and treated properly

Periprosthetic Femur Fracture References
• Intraoperative Periprosthetic Fractures During Total Hip Arthroplasty. Evaluation and Management: Davidson,
D, Pike, J, Garbuz, D, Duncan, C, Masri, B: JBJS, Am. 2008; 90, 2000-2012.
• Intraoperative Proximal Femoral Fracture in Primary Cementless Total Hip Arthroplasty: Ponzio, D, Shahi, A,
Park, A, Purtill, J: JOA: Vol.#30, pp. 1418-1422. 2015.
• Frequency and Treatment for Periprosthetic Fractures about Total Hip Arhtroplasty in the United States: Cox,
J, Kowalik, T, Gehling, H, DeHart, M, Duwelius, P, Mirza, A: JOA: http://dx.doi.org/10.1016/j.arth.2016.01.062
• Cerclage Wires or Cables for the Management of Intraoperative Fracture Associated With a Cementless,
Tapered Femoral Prosthesis: Berend, K., Lombardi, A, Mallory, T, Chonko, D, Doods, K, Adams, J: JOA, Vol.
#10, pp. 17-21. 2004.
• The Effect of Prophylactic Wires in Primary Total Hip Arthroplasty: A Biomechanical Study: Waligora, A,
Owen, J, Wayne, J, Hess, S, Golladay, W, Jiranek, W.: JOA, Vol. #32, pp. 2023-2027, 2017.
• Intraoperative Periprosthetic Femur Fracture: A Biomechamical Analysis of Cerclage Fixation: Frisch, N,
Charters, M, Sikora-Klak, J, Banglmaier, R, Oraver, D, Silverton, C: JOA: Vol. #30, pp. 1449-1457, 2015.
• Reduced Incidence of Intraoperative Fracture With a Second-Generation Tapered Wedge Stem: Fleischman,
A, Schubert, M, Restrepo, C, Chen, A, Rothman, R.: JOA, http://dx.doi.org/10.1016/j.arth.2017.06.018
• Total Intraoperative Femur Fracture: Do the Design Enhancements of a Second- Generation Tapered-Wedge
Stem Reduce the Incidence? Colacchio, N, Robbins, C, Aghazadeh, M, Talma, C, Bono, J: JOA: pp 1-6,
2017.
• Direct Anterior Approach: Risk Factor for Early Femoral Failure of Cementless Total Hip Arthroplasty: A
Multicenter Study: Meneghini, M, Elston, A, Chen, A, Fehring, T., Springer, B: JBJS, Am: Vol. 99-A, pp. 99-
105, 2017.
• Risk Factors for Perioperative Femoral Fractures: Cementless Femoral Implants and the Direct Anterior
Approach Using the Fracture Table: Hartford, J, Knowles, S: JOA: Vol. #30, pp. 2013-2018, 2016.
• Risk of Periprosthetic Fractures with Direct Anterior Total Hip Arthroplasty: Berend, K, Mirza, A, Morris, M,
Lombardi, A; JOA: Vol.#31: pp. 2295-2298.
• Intraoperative Femur Fracture Risk During Primary Direct Anterior Approach Cementless Total Hip
Arthroplasty With and Without a Fracture Table: Cohen, E, Vaughn, J, Ritterman, S, Eisenson, D, Rubin, L:
JOA: http://dx.doi.org/10.1016/j.arth.2017.04.020

9:03 am – 9:09 am
Management of Trochanter Fracture (Intra-Op and Early Post-Op)

Rafael J. Sierra, MD
• Intraoperative GT fractures:
o Incidence: 132 of 32644 Primary THA (0.4%) Mayo Data
o Classification:
▪ Intraoperative: Vancouver A2 or A3: crack vs displaced fractures.
o Occurrence most likely during femoral component placement or preparation (Table: From Abdel
et al BJJ 2017) See below.
o 70% nondisplaced/ 30% displaced
o 50% treated with ORIF
• Postoperative:
o Incidence: 135 of 32644 Primary THA (0.4%) Mayo Data
o Classification:
▪ Vancouver Ag: Postoperative Fractures
o Occurrence: No known trauma 47%, 83% tip avulsions that are treated nonoperatively (90%)
(Table from Abdel et al BJJ 2017)
• Results of Treatment of Trochanteric Fractures

o Intraoperative: most treated with suture or cable fixation if minimally displaced.
o Postoperative: Most are treated nonoperatively.
▪ Fixation may be an option if displacement greater than 2 cm, significant pain,
trendelenburg and/ or associated with dislocation. See options below.
o Pritchett (CORR 2001): 30 GT fractures, 6 intraop, 5 seen on initial radiograph. Average time to
fracture was 8 months. 90% had less than 2.5 cm of displacement.
▪ 6 Intraop fractures treated with Dall Miles cables, or suturing No. 5 ethibond.
▪ No other fracture was treated surgically during first year
▪ NO bracing, activity restriction or restricted weightbearing was used as treatment.
• Results:
o No dislocations occurred
o 6 of 30 had trendelenburg sign at 1 year
o 8 patients had displacement of > 2 cm

o > 1/3 of patients had pain or limp and in half of persisted into final follow-
up.
o Hendel et al.(Acta Orthop Scand 2002):

▪ 21 intraop fx.
▪ 15 treated with wire fixation at the time of surgery
• All healed, 1 with minimal displacement
▪ 6 treated nonoperatively
• 1 did not unite > 2 cm displacement
▪ All together 8 patients slightly limped postoperatively and had pain.
o Fixation options:
▪ Sutures and Wires: good option intraop fractures with minimal displacement.
▪ Dall Miles Claw and Cables: has been used in the past for fixation of trochanter after
trochanter osteotomy. Breakage ranges from 3% (Dall and Miles JBJS Br 1983) to 32 %
(Ritter JBJS Br 1991) Not the preferred method for postoperative fractures. Maybe
option in intraop fractures if additional fixation other than wires or sutures is needed.
▪ Claw-plates (Gavanier et al Injury 2017: 1 of 8 did not heal) (Min-Wook Kim et al : Hip
and Pelvis 2015: 1/5 did not heal). Good option in postoperative fractures. Bony
apposition necessary for healing. Potential risk of nonunion, and some concern for
infection.
▪ Dual Locked Plating: May be most stable construct (biomechanical studies Sariyilmaz et
al: Acta Orthop Traum Turk 2016). Bony apposition required for adequate healing.
Locked plating an option as well. (LaFlamme et al, J of Arthroplasty 2012). Option for
salvage of nonunions after failure of cable fixation devices.
o Special circumstances:
▪ Comminuted fractures: Best to treat nonop initially then fix if displaced.
▪ Fractures associated with osteolysis. Best allow some healing, then revise hip and bone
graft lytic trochanteric lesions.
▪ Fractures associated with Dislocation: operative fixation with cable plate or locked plates
if displaced and revision of implants if needed.
▪ Marked displacement of the trochanter that cannot be reduced. Allograft interposition
has been used with poor results. Subperiosteal Elevation of gluteus medius and minimus
on vascular pedicle off the iliac crest has been reported with decent reports. (Chin et al
JBJS Am 2000) I have not done this procedure.

9:09 am – 9:15 am
Component Malposition and Leg Length Inequality:

When Should I Go Back and What Should I Do?
Robert L. Barrack, MD
Instability and limb lengthening are two of the most common complications leading to patient morbidity,
dissatisfaction, and lawsuits. The indications for early return to the operating room are not clear in part
because some degree of component malposition and limb length discrepancy is relatively common while
acutely returning to the operating room is extremely rare. To get some sense of the incidence of this
occurrence, the registry of cases of a small group of arthroplasty surgeons at the single university center of
primary hip arthroplasty cases. In only 11 of almost 8,000 cases (0.14%) was a patient returned to the
operating on the same day as surgery or during the index hospitalization. Seven cases involved component
malposition, three fractures and one mismatch pair of components. There were no cases of return to the O.R.
for limb length inequality.
The indications for return to the O.R. for limb length inequality are not established. Lengthening associated
with nerve deficit is one possible indication. One such case successfully treated with modular neck shortening
has been reported. [1] Lengthening of >1cm which is noticeable and bothersome to the patient is another
possible indication. The clinical significance of such a discrepancy is controversial. The incidence has been
reported to be over 20%. in some series. [2] Some studies have reported worse outcomes associated with
lengthening of this degree, [3] while others have not found such a correlation. [2] The indications for return to
the O.R. for malposition are also not clear. The most common indication is malposition associated with
instability (subluxation or dislocation). Other cases of malposition are most often treated with watchful waiting
since most malposition components do not go on to dislocate and the risk of acute reoperation can be daunting
with a risk of over 30% reported. [4]
Given the enormous risk of missing over lengthening and component malposition, avoiding these occurrences
at all reasonable costs is warranted. One successful approach is the use of modern intraoperative imaging.
Outliers for length and cup position have been avoided in virtually all cases in studies from a number of centers
reported recently. [5-7]
References:
1. Silbey, M. B. and J. J. Callaghan (1991). "Sciatic nerve palsy after total hip arthroplasty: treatment by modular neck
shortening." Orthopedics 14(3): 351-352.
2. Whitehouse, M. R., et al. (2013). "The impact of leg length discrepancy on patient satisfaction and functional outcome
following total hip arthroplasty." J Arthroplasty 28(8): 1408-1414.
3. Mahmood, S. S., et al. (2015). "The Influence of Leg Length Discrepancy after Total Hip Arthroplasty on Function and
Quality of Life: A Prospective Cohort Study." J Arthroplasty 30(9): 1638-1642.
4. Darwiche, H., et al. (2010). "Retrospective analysis of infection rate after early reoperation in total hip arthroplasty." Clin
Orthop Relat Res 468(9): 2392-2396.
5. Ezzet, K. A. and J. C. McCauley (2014). "Use of intraoperative X-rays to optimize component position and leg length
during total hip arthroplasty." J Arthroplasty 29(3): 580-585.
6. Hambright, D., et al. (2018). "Intra-operative digital imaging: assuring the alignment of components when undertaking total
hip arthroplasty." Bone Joint J 100-B(1 Supple A): 36-43.
7. Penenberg, B. L., et al. (2018). "Digital Radiography in Total Hip Arthroplasty: Technique and Radiographic Results." J
Bone Joint Surg Am 100(3): 226-235.

Session III: Lumbopelvic/Instability: Patient Identification and Methods to
Minimize
9:30 am – 9:36 am
Who is at Risk of Instability?

Arthur L. Malkani, MD
Dislocation continues to be one of the most common etiologies of failure leading to revision surgery following
primary total hip arthroplasty. Over the past several years, dislocation rates have plateaued to approximately
2% and all the gains from use of large femoral head sizes have now been realized.(1) To make any further
gains, attention needs to focus on patients at high risk for dislocation. There are several patient related factors
that have been implicated leading to increased risk of dislocation following primary THA such as increased
age, extent of co-morbid conditions, prior hip surgery, and patients with neuromuscular and cognitive
disorders. (2) More recently the presence of lumbosacral disease in patients undergoing THA has also been
implicated as a risk factor for dislocation. In a medicare database study following THA patients over a decade,
the number of patients with prior lumbar spine fusion undergoing primary THA had increased by 293%. The
incidence of hip dislocation in patients undergoing primary THA with prior lumbar spine fusion was 7.4%
compared to 4.8% without fusion, p<.001. There was an 80% increased incidence of dislocation in the fusion
group at 6 months, 71% at 1 year.(3) In another medicare database study using PearlDiver Technologies, the
incidence of dislocation at 2 years following primary THA was 2.36% in the group without lumbar fusion,
whereas the dislocation incidence increased to 4.26% in a short lumbar fusion segment group and 7.5% in a
group with more than 3 lumbar segments fused.(4)
In a recent study, evaluating EOS images in the standing and sitting position in 1000 primary THA’s, patients
with fixed spino-pelvic alignment (lumbar spine DJD and lumbar fusion) were at increased risk of dislocation.(5)
The group that dislocated had decreased compensatory spine/pelvic flexion and functional acetabular
inclination / anteversion compared to the non-dislocators. Lumbar spine fusion alters the dynamic relationship
between the pelvis and the lumbosacral spine which leads to less flexible spino-pelvic junction during standing
and sitting.(6) In another study the timing of THA and lumbar fusion was addressed. There was a 72%
increased risk of dislocation in the prior lumbar spine group compared to those with hip arthroplasty first
followed by a lumbar spine fusion within 2 years and 130% increased risk of dislocation in the lumbar spine
fusion group compared to those with THA first and lumbar spine fusion within 5 years.(7) Patients with a
history of lumbosacral pathology are at increased risk of hip dislocation leading to revision surgery following
primary THA. Identifying patients at increased risk of dislocation due to fixed spino-pelvic alignment along with
a treatment strategy to include a thorough evaluation of intra-operative functional cup position and possible use
of dual mobility cups may help minimize the incidence of post-operative hip dislocation following primary THA.
Additional studies are required to determine the ideal or best functional acetabular cup position for the specific
fixed spino-pelvic alignment or pathology being addressed in patients undergoing primary THA.

References:
1) Goel A, Lau E, Ong, K, Berry D, Malkani A. Dislocation rates following primary total hip arthroplasty have plateaued
in the Medicare population. J Arthroplasty. 2015 May;30(5):743-6. doi: 10.1016/j.arth.2014.11.012. Epub 2014 Nov
26.
2) Soong M, Rubash H, Macaulay W. Dislocation after total hip arthroplasty. J Am Acad Orthop Surg. 2004 Sep-
Oct;12(5):314-21.
3) Garber A, Cochran A, Ong K, Baykal D, Glassman S, Dimar J, Berry D, Malkani A. THA in Patients with Previous
Lumbar Fusion Surgery: Are there more Dislocations and Revisions? J Arthroplasty. 2017 Oct 31. pii: S0883-
5403(17)30953-1. doi: 10.1016/j.arth.2017.10.041.
4) Sing D, Barry J, Aguilar T, Theologis A, Patterson J, Tay B, Vail T, Hansen E. Prior Lumbar Spinal Arthrodesis
Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty. J Arthroplasty. 2016 Sep;31(9
Suppl):227-232.e1. doi: 10.1016/j.arth.2016.02.069. Epub 2016 Mar 15.
5) Jerabek S, Esposito C, Carroll K, Sculco P, Padgett D, Mayman D. THA patients with fixed spinopelvic alignment
from standing to sitting are at higher risk of hip dislocation. Presented at AAHKS 2017, Dallas.
6) Phan D, Bederman S, Schwarzkopf R. The influence of sagittal spinal deformity on anteversion of the acetabular
component in total hip arthroplasty. Bone Joint J. 2015 Aug;97-B(8):1017-23. doi: 10.1302/0301-620X.97B8.35700.
7) Malkani A, Himschoot K, Ong K, Lau E, Baykal D, Dimar J, Glassman S, Berry D. Does Timing of Primary Total Hip
Arthroplasty Prior to or After Lumbar Spine Fusion Have an Effect on Dislocation and Revision Rates? Paper
presentation AAOS New Orleans 2018.

9:36 am – 9:42 am
What is the “Safe Zone” for an Individual Patient?

Lawrence D. Dorr, MD
Background: The Lewinnek safe zone has not proven to be a reliable guide for surgeons in cup placement in
total hip replacement. Recent knowledge about acetabular position change in the Sagittal plane as the pelvis
rotates may be one clue for this unreliability. A second reason can be the failure of Lewinnek et al to include
the femoral side of the joint in establishing the ideal acetabular component position. We considered these
anatomical factors in researching whether the spatial motion of the acetabulum provided a key to determine a
“safe zone” for the cup placement.
Questions/purpose: We asked three questions: 1) Can a sagittal functional hip mobility be defined and is it a
sagittal “safe zone”?; 2) Can the sagittal functional hip mobility be translated into a coronal “safe zone”? 3) Are
there hips which have no “safe zone”?
Methods: 220 hips (213 patients) were prospectively studied with AP pelvis and stand and sit lateral spine-
pelvis-hip radiographs, as well as the computer numbers for cup inclination and anteversion, and the stem
anteversion achieved intraoperatively. Measurements of the biomechanical reconstruction of the hip, and the
cup angles of anteversion and inclination, were done on the AP pelvis X-ray.The measurements from the
spinopelvic X-rays focused on the dynamic motion of the posterior lumbosacral hinge (sacral slope) and the
anterior hip hinge (ante-inclination and pelvic femoral angle). Stiffness of the lumbosacral hinge translated into
a stiff pelvic gear so that it could not rotate during standing and sitting. The compensation is increased motion
of the anterior hinge (the hip) which increases risk for impingement. This imbalance cannot be factored into the
Lewinnek angles. So we identified a sagittal measurement of the hip joint which is a combination of the
acetabular and femoral angles both standing and sitting (the Combined Sagittal Index, CSI) which could be
predicted by the mobility of the lumbosacral hinge (sacral slope, dSS) and the maximum hip flexion sitting or
standing (pelvic femoral angle, PFA). The sacral slope mobility affects the pelvic mobility which affects the
acetabular angle/mobility because it is part of the pelvis.
Results: 207 of 220 hips (94%) were within Combined Anteversion of 25o-45o; 193/220 hips had inclination of
35o-50o. All 13 of the hips outside the normal Combined Anteversion range could have been within that range
with different intraoperative decisions because they were in retroverted hips. 203/207 hips (99%) with normal
combined anteversion also had 90% coverage of their femoral head sitting. Therefore we considered
Combined Anteversion of 25o-45o, and inclination of 35o-50o as a coronal safe zone. To be truly classified as a
safe zone meant that hips within these ranges must also keep the sagittal mobility in its normal range. 203 of
220 hips had normal range for CSI sitting, and 206 were within the normal range standing, and 94% of these
hips also were in the coronal safe zone. There were 17 hips which could never be classified within a safe zone
because their spinopelvic stiffness did not allow normal sagittal mobility even with correct coronal safe zone
values.

Conclusions: The Lewinnek safe zone failed in its intent because it considered only one side of the hip joint.
Combined anteversion of 25o-45o can be used as an anteversion safe zone with inclination of 35o-50o with
confidence that it keeps the sagittal functional hip mobility inside its normal Combined Sagittal Index range for
94% of hips. There were 17 hips which were not able to be classified within a safe zone because their
spinopelvic stiffness increased their risk for impingement even with normal coronal safe zone numbers. This
combination safe zone for functional cup position will need to be subjected to the same clinical tests performed
with the Lewinnek safe zones, but we conclude that the clinical correlation in this study of the coronal hip
position of both sides of the joint to the sagittal functional position of both sides of the joint warrants further
study and clinical validation by other researchers. If it performs well in these additional studies it provides a
guideline for surgeons that is not difficult to accomplish in the operating room.

9:42 am – 9:48 am
What Implants and Approach Should We Use to Optimize Outcomes:

Is It Patient-Specific?
James D. Slover, MD, MS
The goal of any hip surgery is to improve function and relieve pain by implanting or revising an implant with a
construct that will achieve these goals, while surviving over the long term and simultaneously minimizing
complications. When considering the implant and surgical approach to the hip you will employ to achieve these
goals for a specific patient several important considerations are needed. First, a firm understanding of the
goals of the surgery is needed. This includes needed anatomic access and obstacles that need to be
overcome or addressed to achieve the required reconstruction. In certain situations, an approach that provides
more direct ability to deal with these challenges can be employed. For example, if a reconstruction requires
removal of hardware in the posterior hip, a posterior approach may be chosen over an anterior approach,
where this would be more difficult to accomplish. In contrast, a hip with significant anteversion or anterior
pathology may be more easily dealt with using an anteriorly based approach. Previous incisions, though not
mandatory for re-use, may be used to guide the approach as long as the other aforementioned goals can be
achieved.
Secondary goals of hip reconstruction surgery include ease and speed of recovery. This typically involves
rapid early mobilization. The ultimate goal is full functional recovery of muscles and other soft tissues
surrounding the hip joint. These goals can be achieved using almost all approaches to the hip in the vast
majority of cases, and this has been demonstrated for numerous approaches and implants in the literature. In
addition, provided surgeons are experienced with the approach, this should not limit implant selection. Most
implants will work well with the majority of primary hip reconstruction cases.
Patient characteristics may also be an important factor when selecting the surgical approach for a hip
reconstruction. In select situations, patient anatomy and any deformity or pathology present may dictate a
certain implant for reconstruction. For example, excessive anteversion or retroversion of the femur may
require a modular implant, or an elderly osteoporotic patient with a stovepipe femur may require a cemented
femoral stem. In most cases these can be anticipated during pre-operative templating for the case, but
surgeons should ensure appropriate training and understanding of the implant before using it in a patient
reconstruction.
Another important factor to consider is surgeon experience and comfort with the approach. As almost all cases
can ultimately be reconstructed safely and effectively using any of the common approaches to the hip,
surgeons need to ensure they are confident in their ability to perform the surgical approach chosen. Numerous
studies have documented the impact of the learning curve for various surgical approaches, and surgeons
should take appropriate steps to minimize these effects through education and collaboration during the
learning phase. In addition surgeons should select cases carefully, particularly during the early phases of
adoption of a new surgical approach or implant, or when choosing an approach or implant not used frequently,
in order to optimize outcome sand minimize complications.
In conclusion, the vast majority of hip reconstructive cases can be completed safely and effectively through any of
the common surgical approaches to the hip using most implant systems. However, select cases, pathology and
patient characteristics may make one approach or implant system preferred for a particular situation and surgeons
can anticipate this through careful planning. Attention to training and preparation can allow experienced surgeons to
use these alternate approaches when necessary and to achieve optimal patient outcomes.

9:48 am – 9:54 am
Is There a Role for Computer Navigation?

Douglas E. Padgett, MD
The 2 most concerning issues following THR remain:
-short term: instability
-long term: bearing wear
Both of these concerns are impacted by component position. Historically, we have used static 2-D metrics to
guage the accuracy of implant position: “The safe zone of Lewinnek”. This classic paper focusing on roughly
100 THR’s of which 9 dislocated, has been the standard by which we have measured “ideal implant position”.
The limitations of the Lewinnek zone have been borne out recently by work at both our institution and that of
the Mayo clinic. It appears that there is no safe zone! Why? It appears that:
1. Pelvic position and by default, functional acetabular position may change dramatically from
standing, sitting to squatting positions.
2. The vast majority of studies ignore the femoral side of the equation: the other “half” of the hip story
which certainly can impact combined orientation of the articulation.
Based upon computational analysis, clinical studies assessing change from standing to sitting as well as the
impact of deeper flexion, I believe we are getting closer to understanding the optimal position of implants to
achieve the desired short term and long-term effects.
Assuming we can identify optimal 3-D placement of implants on an individualized basis, it seems logical that
we use enabling technology to aid in executing this plan. The limitations and wide variability of implant position
using manual guides enabling technologies include:
-navigation
-smart tools
-robotic assistance
These technologies can be either image based (CT, MRI or ultrasound) or imageless using anatomic
landmarks. Many of the criticisms of the outcomes of studies using these technologies are that the typical
metrics such as reduction in dislocation, increase in patient satisfaction, or a reduction in bearing wear have
not justified their use. However, given that optimal implant position was frankly “guessed at”, these criticisms
do not appear justified.
In summary, I believe we are entering a new phase of total hip arthroplasty: not one based upon improvement
in design or bearing but an era of “customized / individualized” implant delivery. Based upon the patients
unique anatomy and spino-pelvic alignment, hip arthroplasty will be placed utilizing these enhancing
technologies to optimize function and longevity.

References:
Pelvic Tilt in Patients Undergoing Total Hip Arthroplasty: When Does it Matter?
Joseph D. Maratt, Christina I. Esposito, Alexander S. McLawhorn, Seth A. Jerabek, Douglas E. Padgett, David J. Mayman
J Arthroplasty. 2015 Mar; 30(3): 387–391. Published online 2014 Oct 23. doi: 10.1016/j.arth.2014.
Cup Position Alone Does Not Predict Risk of Dislocation after Hip Arthroplasty
Christina I. Esposito, Brian P. Gladnick, Yuo-yu Lee, Stephen Lyman, Timothy M. Wright, David J. Mayman, Douglas E.
Padgett J Arthroplasty. 2015 Jan; 30(1): 109–113. Published online 2014 Jul 11. doi: 10.1016/j.arth.2014.07.009
Does CT-Based Navigation Improve the Long-Term Survival in Ceramic-on-Ceramic THA?

Nobuhiko Sugano, Masaki Takao, Takashi Sakai, Takashi Nishii, Hidenobu Miki
Clin Orthop Relat Res. 2012 Nov; 470(11): 3054–3059. Published online 2012 May 9. doi: 10.1007/s11999-012-2378-4
Hip–spine relations and sagittal balance clinical consequences Jean-Yves Lazennec, Adrien Brusson, Marc-Antoine
Rousseau. Eur Spine J. 2011 Sep; 20(Suppl 5): 686–698. Published online 2011 Jul 28. doi: 10.1007/s00586-011-1937-9
What Safe Zone? The Vast Majority of Dislocated THAs Are Within the Lewinnek Safe Zone for Acetabular Component
Position Matthew P. Abdel, Philipp von Roth, Matthew T. Jennings, Arlen D. Hanssen, Mark W. Pagnano Clin Orthop
Relat Res. 2016 Feb; 474(2): 386–391. Published online 2015 Jul 7. doi: 10.1007/s11999-015-443

9:54 am – 10:00 am
When Should I Revise the Hip for Postop Instability and What Should I Do?
R. Michael Meneghini, MD
There are multiple causes of recurrent dislocation after total hip arthroplasty (THA) and include component
malposition, extra-prosthetic impingement, polyethylene wear, abductor muscle incompetence, altered
neurologic function about the hip from neurologic or spinal disease and less commonly adverse local tissue
reaction from metal hypersensitivity or infection. Successful treatment of recurrent instability after THA
requires an assessment of potential causal factors, identification of the etiology and treatment targeting the
specific etiology of instability.
When To Revise?
The decision of when to revise a patient with instability after THA is based on the clinical scenario and whether
the instability can be predicted to be recurrent. If the hip dislocation is an isolated occurrence either in the early
postoperative period or from a traumatic event with well-positioned implants, then continued observation is
warranted. In this scenario, the surgeon and patient can expect a reasonable chance of closed reduction
rendering the hip stable without surgical intervention. Studies show a success rate of 67-81% for closed
reduction of an early dislocation after a THA.1,2 Conversely, if more than one dislocation has occurred remote
from the original surgery, the chance of closed reduction rendering the hip stable without further surgery is less
likely. Further, if an isolated dislocation in the immediate postoperative period or in a previously well-
functioning THA is the result of an identifiable and correctable etiology that is known to render the hip unstable
surgical correction should be considered.
What Should I Do? – Surgically Correct the Underlying Etiology of Instability
The Rush University group published a system of classifying recurrent instability into 6 etiology groups, which
guides the surgical treatment strategy.3 Type 1 instability is characterized by an acetabular component outside
the “safe zone”. This instability type is treated with revision of the acetabular component. It should be noted,
however, that the “safe zone” as reported by Lewinnek has recently been refuted and it is acknowledged that
the ideal position is likely patient specific.4-7 Type 2 instability is characterized by femoral component
malposition and the recommended treatment is revision of the femoral component. Type 3 instability is
compromise or complete absence of the abductor-trochanteric complex. The recommended treatment is
optimization of implant position and insertion of a constrained liner, while some would propose avoiding a
constrained liner in favor of a dual-mobility bearing.8,9 Type 4 instability is intra-prosthetic impingement or
impingement caused by extra-prosthetic bone or soft-tissues. The recommended treatment is removal of the
offending impingement and optimization of femoral head diameter. This may include use of a dual-mobility
bearing in some cases, particularly in smaller cup sizes. Type 5 instability is eccentric polyethylene wear in
well-functioning THA with appropriately positioned components and treatment is a head and liner exchange
with optimization of femoral head diameter. Type 6 is a diagnosis of exclusion, where no identifiable etiology is
found and the treatment is with a constrained liner3, or more recently a consideration would be given to a dual-
mobility articulation.8,9
While this classification system is useful to provide guidance for treatment, other factors may contribute to
instability. There is emerging evidence that alterations in the lumbopelvic alignment can adversely affect THA
stability by creating a “dynamic” acetabular component malposition. This is most commonly seen in patients
with lumbar spine disease or instrumented lumbar spinal fusion surgery.10-21 Further research is warranted to
provide more specific guidance on the exact implant position that is optimal in these particular patients.

References
1. Joshi A, Lee CM, Markovic L, Vlatis G, Murphy JC. Prognosis of dislocation after total hip arthroplasty. J Arthroplasty.
1998;13(1):17-21.
2. Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg Am. 1982;64(9):1295-1306.
3. Wera GD, Ting NT, Moric M, Paprosky WG, Sporer SM, Della Valle CJ. Classification and management of the unstable
total hip arthroplasty. J Arthroplasty. 2012;27(5):710-715.
4. Lazennec JY, Thauront F, Robbins CB, Pour AE. Acetabular and Femoral Anteversions in Standing Position are Outside
the Proposed Safe Zone After Total Hip Arthroplasty. The Journal of arthroplasty. 2017;32(11):3550-3556.
5. DelSole EM, Vigdorchik JM, Schwarzkopf R, Errico TJ, Buckland AJ. Total Hip Arthroplasty in the Spinal Deformity
Population: Does Degree of Sagittal Deformity Affect Rates of Safe Zone Placement, Instability, or Revision? The
Journal of arthroplasty. 2017;32(6):1910-1917.
6. Danoff JR, Bobman JT, Cunn G, et al. Redefining the Acetabular Component Safe Zone for Posterior Approach Total Hip
Arthroplasty. The Journal of arthroplasty. 2016;31(2):506-511.
7. McLawhorn AS, Sculco PK, Weeks KD, Nam D, Mayman DJ. Targeting a New Safe Zone: A Step in the Development of
Patient-Specific Component Positioning for Total Hip Arthroplasty. Am J Orthop (Belle Mead NJ). 2015;44(6):270-276.
8. Plummer DR, Christy JM, Sporer SM, Paprosky WG, Della Valle CJ. Dual-Mobility Articulations for Patients at High Risk
for Dislocation. J Arthroplasty. 2016;31(9 Suppl):131-135.
9. Stucinskas J, Kalvaitis T, Smailys A, Robertsson O, Tarasevicius S. Comparison of dual mobility cup and other surgical
construts used for three hundred and sixty two first time hip revisions due to recurrent dislocations: five year results
from Lithuanian arthroplasty register. Int Orthop. 2017.
10. An VVG, Phan K, Sivakumar BS, Mobbs RJ, Bruce WJ. Prior Lumbar Spinal Fusion is Associated With an Increased Risk
of Dislocation and Revision in Total Hip Arthroplasty: A Meta-Analysis. J Arthroplasty. 2018;33(1):297-300.
11. Barry JJ, Sing DC, Vail TP, Hansen EN. Early Outcomes of Primary Total Hip Arthroplasty After Prior Lumbar Spinal
Fusion. J Arthroplasty. 2017;32(2):470-474.
12. Bedard NA, Martin CT, Slaven SE, Pugely AJ, Mendoza-Lattes SA, Callaghan JJ. Abnormally High Dislocation Rates of
Total Hip Arthroplasty After Spinal Deformity Surgery. J Arthroplasty. 2016;31(12):2884-2885.
13. Buckland AJ, Puvanesarajah V, Vigdorchik J, et al. Dislocation of a primary total hip arthroplasty is more common in
patients with a lumbar spinal fusion. Bone Joint J. 2017;99-B(5):585-591.
14. Esposito CI, Carroll KM, Sculco PK, Padgett DE, Jerabek SA, Mayman DJ. Total Hip Arthroplasty Patients With Fixed
Spinopelvic Alignment Are at Higher Risk of Hip Dislocation. J Arthroplasty. 2017.
15. Furuhashi H, Togawa D, Koyama H, Hoshino H, Yasuda T, Matsuyama Y. Repeated posterior dislocation of total hip
arthroplasty after spinal corrective long fusion with pelvic fixation. Eur Spine J. 2017;26(Suppl 1):100-106.
16. 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.
17. Lazennec JY, Clark IC, Folinais D, Tahar IN, Pour AE. What is the Impact of a Spinal Fusion on Acetabular Implant
Orientation in Functional Standing and Sitting Positions? J Arthroplasty. 2017;32(10):3184-3190.
18. Malkani AL, Garber AT, Ong KL, et al. Total Hip Arthroplasty in Patients With Previous Lumbar Fusion Surgery: Are
There More Dislocations and Revisions? J Arthroplasty. 2017.
19. Mudrick CA, Melvin JS, Springer BD. Late posterior hip instability after lumbar spinopelvic fusion. Arthroplast Today.
2015;1(2):25-29.
20. Shah SM, Munir S, Walter WL. Changes in spinopelvic indices after hip arthroplasty and its influence on acetabular
component orientation. J Orthop. 2017;14(4):434-437.
21. Sultan AA, Khlopas A, Piuzzi NS, Chughtai M, Sodhi N, Mont MA. The Impact of Spino-Pelvic Alignment on Total Hip
Arthroplasty Outcomes: A Critical Analysis of Current Evidence. J Arthroplasty. 2017.

Session IV: Bearing Surface and Taper Corrosion
10:30 am – 10:36 am
Who is at Risk? Should Everybody Be Screened?

Henrik Malchau, MD, PhD
Introduction: Many metal-on-metal (MoM) implants fail due to adverse local tissue reactions (ALTRs)
secondary to implant wear. There is little consensus regarding the relationship between symptomaticity and
ALTR presence, as several studies have shown similar pseudotumor incidence between symptomatic and
asymptomatic patient cohorts.
The primary objective of this study was to determine if ALTR prevalence differs between asymptomatic and
symptomatic patients treated with MoM HRA and MoM THA implants. The secondary objective of this study
was to evaluate the association between ATLR severity and symptomaticity among patients diagnosed with
ALTR.
Methods: The study cohort consisted of 327 patients treated with a unilateral hip replacement (145 MoM THA
and 182 MoM HRA). The study patients were selected from a prospective, multicenter, follow-up study of a
recalled hip system from sites performing annual metal artifact reduction sequence magnetic resonance
imaging (MARS-MRI) irrespective of patient symptoms. Follow-up also consisted of three patient-reported
outcome measures (PROMs), the Harris Hip Score (HHS), VAS Satisfaction score, and VAS Pain score, and
whole blood cobalt and chromium ion levels. The presence of ALTR of MARS-MRI was graded using the
Anderson classification system. The maximal diameter and synovial thickness of the ALTR were determined
for hips in which ALTR was found. MoM THA and MoM HRA patients were considered separately for all
analyses. We used univariate tests and a multivariable binary logistic regression to determine predictors of
ALTR.
Results: Overall, 33.8% of our MoM THA patients developed a moderate or severe ALTR by the time of their
follow-up. Symptoms were observed in 38.6% of patients, and 46.2% had elevated metal ion levels (Table 1).
During our univariate analyses of the MoM THA patient cohort, we found that ALTR presence was associated
with symptomaticity (p = 0.015) but not with elevated blood metal ion levels (p = 0.870) (Figure 1). More than
half (51.2%) of the symptomatic patients had ALTRs, while only 28.2% of the asymptomatic patients had
ALTRs. This association was highlighted in our multivariable model, as symptomaticity was the only variable
that proved significant when assessing moderate or severe ALTR presence (OR = 2.6; p = 0.019) (Table 2).
For patients with an ALTR, the ALTR diameter did not vary between symptomatic and asymptomatic patients
(p = 0.077), but synovial thickness did (p = 0.037) (Figure 2).
In the MoM HRA patients, we found a 15.9% prevalence of moderate or severe ALTR. Elevated metal ion
levels were seen in 21.4% of patients, and 22.5% were symptomatic (Table 1). We found a univariate
association between ALTR and metal ion levels (p < 0.001), but none between ALTR and symptomaticity (p =
0.796) (Figure 1). These findings were reinforced in the multivariable model, as only elevated metal ion levels
were found to be predictive of ALTR (OR = 9.2; p < 0.001) (Table 2). When considering patients with an ALTR
only, we found that neither ALTR diameter (p = 0.330) nor synovial thickness (p = 0.535) (Figure 2) were
associated with the presence of symptoms.

Conclusion: We found that symptomaticity was associated with an increased risk of having ALTR in patients
who had MoM THA, but not for those with MoM HRA. Furthermore, ALTR severity (quantified by synovial
thickness) in MoM THA patients is associated with increased risk of having symptoms. For patients treated
with the MoM HRA, we found that although elevated blood metal ion levels may be used to screen for ALTR,
there was no association between symptoms and ALTR.

10:36 am – 10:42 am
What is the Current Understanding of the Problem?

Joshua J. Jacobs, MD
The science of tribocorrosion addresses the synergistic effects of mechanical and electrochemical degradation
processes of metal interfaces including bearing surfaces and modular junctions. Mechanically assisted crevice
corrosion (MACC) is a well-described tribocorrosion phenomenon that was first reported in the early 1990s1,2
after the introduction of modular heads in total hip arthroplasty. While many retrieval studies conducted during
that era documented the presence of corrosion in cobalt alloy/cobalt alloy, cobalt alloy/titanium alloy and
alumina ceramic/cobalt alloy combinations, there were a very limited number of reports indicating that there
were clinical sequelae associated with MACC. Gilbert et al.2 described the mechanistic basis of MACC
whereby the inciting event was fretting at the head-neck coupling leading to disruption of the passivating oxide
layer, re-passivation, depletion of oxygen, change in the local solution chemistry (decrease in pH and increase
in chloride ion concentration) resulting in instability of the oxide and subsequent attack of the underlying metal.
This sequence of events can lead to the release of large quantities of metal degradation products.
In retrospect, as we consider cases of osteolysis from that era, some of the local tissue reactions that were
attributed to polyethylene were likely a reaction to corrosion debris which has subsequently been shown to be
capable of causing osteolysis in experimental animal models3 and in humans with corroded modular stainless
steel intramedullary femoral nails4. Furthermore, in some cases histological analysis of periprosthetic tissue
associated with failed corroded devices from that area demonstrated a perivascular lymphocytic infiltrate akin
to what was later reported as ALVAL (aseptic lymphocyte-dominated vasculitis-associated lesion) in
association with failed metal-on-metal devices.5
Subsequent to this early experience with head/neck modularity, the concern regarding MACC seemed to have
virtually disappeared from our literature, presumably because the orthopaedic implant industry responded by
producing head-neck couplings with better performance. However, this issue has re-emerged over the last few
years and has taken on a new significance since MACC has been associated with adverse local tissue
reactions (ALTR) and clinical failure6 at a prevalence rate reported to be 3.2% or greater depending on the
design and year of manufacture7,8. The central question is: Why is this happening now? In this presentation,
five possibilities are considered: i) the implants have changed9; ii) the operation has changed; iii) the patients
have changed; iv) the surgeon’s awareness has changed; and 5) the patients are being over- or misdiagnosed.
While MACC-associated ALTR is incompletely understood at this juncture, important insights are emerging
from in vitro tribocorrosion testing and implant retrieval studies pointing to the importance of metallurgical
characteristics of Co-based implant alloys10-11.

REFERENCES
1. Collier JP, Suprenant VA, Jensen RE, Mayor MB. Corrosion at the interface of cobalt-alloy heads on titanium-alloy
stems. Clin Orthop 271:305-312, 1991.
2. Gilbert JL, Buckley CA, Jacobs JJ. In vivo corrosion of modular hip prosthesis components in mixed and similar
metal combinations. The effect of crevice, stress, motion, and alloy coupling. J Biomed Mater Res 27:1533–1544, 1993.
3. Lee, S.H., Brennan, F.R., Jacobs, J.J., Urban, R.M., Ragasa, D.R., and Glant, T.T. Human Mononcyte/Macrophage
Response to Cobalt-Chromium Corrosion Products and Titanium Particles in Patients with Total Joint Replacements. J
Ortho Res 15:40-49, 1997.
4. Jones, D.M., Marsh, J.L., Nepola, J.V., Jacobs, J.J., Skipor, A.K., Urban, R.M., Gilbert, J.L. and Buckwalter, J.A.
Focal Osteolysis At The Junctions Of A Modular Stainless-Steel Femoral Intramedullary Nail. J Bone Jt Surg 83-A:537-548,
2001.
5. Willert H-G, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, Lohmann CH. Metal-on-metal bearings and
hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am 87-A:28-
36, 2005.
6. 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 Arthrop 31:264-268, 2016.
7. McGrory, B.J., MacKenzie, J and Babikian, G. A High Prevalence of Corrosion at the Head-Neck Taper with
Contemporary Zimmer Non-Cemented Femoral Hip Components. J Arthroplasty. 30:1265-8, 2015.
8. Hussey, D.K. and McGrory, B.J. Ten-Year Cross-Sectional Study of Mechanically Assisted Crevice Corrosion in
1352 Consecutive Patients With Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty 32:2546-2551, 2017.
9. Pourzal, R., Hall, D.J., Ha, N.Q., Urban, R.M., Levine, B.R., Jacobs, J.J. and Lundberg, H.J. Does Surface
Topography Play a Role in Taper Damage in Head-neck Modular Junctions? Clin Orthop 474:2232-2242, 2016.
10. Hall, D.J., Pourzal, R., Lundberg, H.J., Mathew, M.T., Jacobs, J.J. and Urban, R.M. Mechanical, Chemical and
Biological Damage Modes within Head-Neck Tapers of CoCrMo and Ti6Al4V Contemporary Hip Replacements. J Biomed
Mater Res Part B 2015:00B:000-000.
11. Pourzal, R., Hall, D.J., Ehrich, J., McCarthy, S.M., Mathew, M.T., Jacobs, J.J., Urban, R.M. Alloy Microstructure
Dictates Corrosion Modes in THA Modular Junctions. Clin Orthop 475:3026-3043, 2017.

10:42 am – 10:48 am
What is the Clinical Presentation and How Do I Work Up a Painful Hip?

Don S. Garbuz, MD, MHSc, FRCSC
Taper corrosion (trunionosis) is a clinical problem in both metal on metal (MOM) and metal on poly (MOP) total
hip replacements. It is a problem first identified in MOM total hips. In a RCT from our center MOM total hips
were found to have significantly elevated serum cobalt and chromium levels compared to resurfacing.
Subsequent studies have shown a high rate of adverse local tissue reactions secondary to trunionosis in
patients with MOM total hips.
More recently it has been recognized that MOP total hips can also have ALTRs secondary to taper corrosion.
This is much less frequent than in MOM THAs. Patients will present with new onset pain, stiffness and
instability. Be suspicious in patients with previously well positioned hip implants who present with dislocation
between 2-6 years post surgery.
In patients with MOM or MOP THAs who present with pain one must be suspicious of an ALTRs. However, first
infection must be ruled out. Standard tests are done however diagnosis can be difficult. Often ESR/CRP are
elevated. For cell count one must ask for a manual cell count. Once infection is ruled out workup now focuses
on ALTR
In MOM THAs metal ions are not very useful as even well-functioning THAs with no ALTR can have elevated
cobalt and chromium levels. To R/O ALTR in these patients’ cross-sectional imaging is needed. This can be
ultrasound or metal reduction MRI. The choice will depend on your centers expertise in these areas. A study
from our center has shown that both tests are excellent, however due to its cheaper cost and high sensitivity
we have favoured ultrasound. However, one must have an ultra-sonographer who has experience with hip
ultrasound.
In patients with MOP THAs workup for infection includes x-rays, metal ions and cross-sectional imaging. On
plain x-rays rounding of the calcar will often be the first subtle clue. However, the majority of the time plain x-
rays are normal. Serum cobalt above 1 part per billion is an indication of a problem with taper corrosion. In any
patient with this number additional cross sectional imaging should be obtained. Again this can be ultrasound or
MARS MRI.
In summary taper corrosion is very common in MOM THA and less frequent in MOP THAs. In MOP THAs be
suspicious in patients who present with new pain, stiffness or instability. IN MOP THAs certain implants seem
to be at higher risk than others. Workup in both groups include plain x-rays and cross sectional imaging.IN
MOP THAs cobalt levels are very useful and a value greater than 1 part per billion.

References
1. Garbuz DS, Tanzer M, Greidanus NV, Masri BA, Duncan CP. The John Charnley Award: Metal-On-
Metal Hip Resurfacing versus Large-Diameter Metal on Metal Total Hip Arthroplasty: A Randomized
Clinical Trial. Clinical Orthopaedic and Related Research 468:318-325, 2010
2. Garbuz DS, Hargreaves BA, Duncan CP, Masri BA, Wilson DR, Forster BB. The John Charnley Award:
Diagnostic Accuracy of MRI Versus Ultrasound for Detecting Pseudotumors in Asymptomatic Metal-on-
Metal THA. Clin Orthop Relat Res. 2014 Feb;472(2):417-23.
3. Lash NJ, Whitehouse MR, Greidanus NV, Garbuz DS, Masri BA, Duncan CP. Delayed Dislocation
Following Metal-on-Polyethylene Arthroplasty of the Hip due to ‘Silent’ Trunnion Corrosion. Bone Joint
J. Feb 2016; 98-B(2) 187-93.
4. Cooper JH, Della Valle CJ, Berger RA, Tetreault M, Paprosky WG, Sporer SM, Jacobs JJ. Corrosion at
the Head-Neck Taper as a Cause for Adverse Local Tissue Reactions After Total Hip Arthroplasty. The
Journal of Bone and Joint Surgery 2012. American Volume, 94(18), 1655–1661.
5. Plummer DR, Berger RA, Paprosky WG, Sporer SM, Jacobs JJ, Della Valle CJ.Diagnosis and
Management of Adverse Local Tissue Reactions Secondary to Corrosion at the Head-Neck Junction in
Patients With Metal on Polyethylene Bearings. J Arthroplasty 2016 Jan 31(1):264-268

10:48 am – 10:54 am
How Should I Treat This Problem and What are the Outcomes?
William L. Griffin, MD
Modular heads, necks, and stems allow for intra-operative optimization of offset, anteversion, leg lengths, and
soft tissue tension. However, modularity comes with a cost. All modular junctions are subject to interface
motion which can lead to mechanically assisted crevice corrosion (MACC). Fretting and the metal debris
generated from trunnion corrosion can cause adverse local tissue reactions (ALTR) as seen with metal on
metal bearings and corrosion can occasionally lead to implant fracture.
Implant retrievals and FEA studies have identified a number of mechanical factors associated with fretting and
corrosion. Taper angle, taper diameter, surface area and finish, neck length, flexural rigidity, and mixed alloys
(Ti and CoCr) can all affect the degree of corrosion. Increasing head size, evaluated in several studies, did not
correlate with the development of taper corrosion.
Dual modular stems with CoCr necks and Ti stems are subject to loads that can exceed the elastic limits of the
Ti stems and have led to fretting and ALTR, high revision rates, and subsequent implant recalls from two
manufacturers.
The incidence of taper corrosion at the modular head-neck junction in a metal-on-poly THA is relatively rare (1-
2%), making the diagnosis more difficult. It is more commonly seen in dual modular stems at the neck-stem
junction and in cases of metallosis with metal-metal bearings at the head-neck trunnion.
Evaluation of these patients requires a high index of suspicion in a painful MOP THA. If MOP patients have
even mildly elevated Co and Cr ion levels (>1.0), then a cross sectional study such as a MARS-MRI is
indicated to help identify ALTR.
Isolated head-neck taper corrosion with minimal damage to the soft tissues and bone can be successfully
treated with exchange of the CoCr metal head to a ceramic head with a Ti sleeve. Recurrence of taper
corrosion with a retained stem is rare, but has been reported. For those cases with more severe adverse local
tissue reactions, there is an increased postoperative risk of instability, and infection. In these cases large
heads, MDMs, or constrained liners may be indicated.
For recalled dual modularity stems with revision rates ranging from 25-48%, stem revision is recommended.
There is insufficient data on all of the dual modular stems to make definitive recommendations regarding the
need for stem removal.
Further study will help to better delineate who is at risk for taper corrosion and which patients are better treated
with stem revision vs head exchange.

References:
1) Gross Trunnion Failure After Primary Total Hip Arthroplasty. Banerjee S, Cherian JJ, Bono JV, Kurtz SM, Geesink R,
Meneghini RM, Delanois RE, Mont MA. J Arthroplasty. 2014 Nov 26. pii: S0883-5403(14)00899-7.
2) High Early Major Complication Rate After Revision for Mechanically Assisted Crevice Corrosion in Metal-on-
Polyethylene Total Hip Arthroplasty. McGrory BJ, Jorgensen AH. J Arthroplasty. 2017 Dec;32(12):3704-3710.
3) Ten-Year Cross-Sectional Study of Mechanically Assisted Crevice Corrosion in 1352 Consecutive Patients With Metal-
on-Polyethylene Total Hip Arthroplasty. Hussey DK, McGrory BJ. J Arthroplasty. 2017 Aug;32(8):2546-2551.
4) Serum Metal Levels for Diagnosis of Adverse Local Tissue Reactions Secondary to Corrosion in Metal-on-
Polyethylene Total Hip Arthroplasty. Fillingham YA, Della Valle CJ, Bohl DD, Kelly MP, Hall DJ, Pourzal R, Jacobs JJ J
Arthroplasty. 2017 Sep;32(9S):S272-S277.
5) Diagnosis and Management of Adverse Local Tissue Reactions Secondary to Corrosion at the Head-Neck Junction in
Patients With Metal on Polyethylene Bearings. Plummer DR, Berger RA, Paprosky WG, Sporer SM, Jacobs JJ, Della
Valle CJ J Arthroplasty. 2016 Jan;31(1):264-8.
6) Total hip arthroplasty head-neck contact mechanics: a stochastic investigation of key parameters. Donaldson FE,
Coburn JC, Siegel KL. J Biomech. 2014 May 7;47(7):1634-41.
7) What do we know about taper corrosion in total hip arthroplasty? Jacobs JJ, Cooper HJ, Urban RM, Wixson RL, Della
Valle CJ. J Arthroplasty. 2014 Apr;29(4):668-9
8) Correlation of corrosion and biomechanics in the retrieval of a single modular neck total hip arthroplasty design:
modular neck total hip arthroplasty system. Lanting BA, Teeter MG, Vasarhelyi EM, Ivanov TG, Howard JL, Naudie DD. J
Arthroplasty. 2015 Jan;30(1):135-40.

10:54 am – 11:00 am
Should We All Be Going to Ceramic?

Jay R. Lieberman, MD
Bearing surface utilization has undergone significant change over the past decade. The rise of ceramic heads
has increased for a number of different reasons including: low reported revision rates from registry data;
decreased frequency in femoral head fractures; and reduced costs. However, the most important reason for
the increase in use of ceramic femoral heads are the reports beginning in 2010 of femoral neck taper corrosion
associated with cobalt chrome heads.
The question is should we all just be using ceramic heads? At this point it does not appear that the data is
strong enough to recommend that ceramic femoral heads should be used in all patients. Taper corrosion has
been associated with ceramic heads in the past. We need to determine the etiology of taper corrosion before
completely switching to the use of ceramic heads. In younger patients, it seems reasonable to switch to
ceramic heads in the hopes of having decreased wear. The data is not clear for elderly patients. If there is no
difference in price between metal and ceramic heads at a particular institution then it may seem reasonable to
use a ceramic head. However, we really cannot say that this will completely solve the taper corrosion problem.

Session V: Special Highlights
11:15 am – 11:20 am
THE JOHN CHARNLEY AWARD
Analysis of US Hip Replacement Bundled Payments: Physician-initiated

Episodes Out Perform Hospital-initiated Episodes
William S. Murphy, AB; Ahmed Siddiqu, DO; Tony Cheng, MBA; Ben Lin, BA;
David Terry, MBA; Carl T. Talmo, MD; Stephen B. Murphy, MD
Background: The Center for Medicare and Medicaid Services (CMS) launched the Bundled Payment for Care
Improvement (BPCI) Initiative in 2013 to create incentives to improve outcomes and reduce costs in various
clinical settings, including total hip arthroplasty (THA). This study seeks to quantify BPCI initiative outcomes for
THA and determine the optimal party (e.g. Hospital vs Physician Group Practice [PGP]) to manage the
program.
Questions/purposes: (1) Is BPCI associated with lower 90-day costs, readmissions, or mortality for elective
THA? (2) Is there a difference in 90-day payments, readmissions, or mortality between episodes initiated by
PGPs and hospitals for elective THA? (3) Is BPCI associated with reduced total Elixhauser comorbidity index
or age for elective THA?
Methods: We performed a retrospective analysis on the CMS Limited Data Set (LDS) on all Medicare primary
elective THAs without major comorbidity (DRG 470) performed in the United States (except Maryland) between
January 2013 and March 2016, totaling more than $7.1 billion in payments. Episodes were grouped into
hospital-run BPCI (n = 43,922), PGP-run BPCI (n = 44,662), and THA performed outside of BPCI (n =
284,002). All Medicare Part A payments were calculated over a 90-day period after surgery and adjusted for
inflation and regional variation. For each episode, age, sex, race, geographic location, background trend, and
Elixhauser comorbidities were calculated to control for major confounding variables. Total payments,
readmissions, and mortality were compared among the groups with linear regression.
Results: When controlling for age, sex, race, background trend, geographic variation in spending, and total
Elixhauser comorbidities, BPCI was associated with a 4.44% (95% CI, -4.58% to -4.30%; p < 0.001) cost
decrease for all participants ($1,244 decrease from baseline of $18,802) ; however, odds ratios (ORs) for 90-
day mortality and readmissions were unchanged in elective, DRG 470 THA episodes. PGP-run episodes
achieved a 4.81% decrease in cost (95% CI, -5.01% to -4.61%; p < 0.001) after enrolling in BPCI ($1,335
decrease from baseline of $17,841). Hospital-run episodes achieved a 4.04% decrease in cost (95% CI, -
4.24% to 3.84%; p < 0.01) after enrolling in BPCI ($1,138 decrease from baseline of $19,799). The decrease in
cost of PGP-run episodes was greater than the decrease in cost of hospital-run episodes (p < 0.001). ORs for
90-day mortality and readmission remained unchanged after BPCI for PGP- and hospital-run BPCI programs.
The average Elixhauser comorbidity index rose by 0.21 for hospital-run after BPCI (95% CI, 0.03–0.38; p =
0.02) and by 0.19 for BPCI overall (95% CI, 0.02–0.037; p = 0.03), while there was no change in PGP-run
programs (p = 0.21). Patient age did not change after BPCI for PGP-run (p = 0.97), hospital-run (p = 0.62), or
overall BPCI episodes (p = 0.73).

Conclusion: This study demonstrates that at risk physician leadership in BPCI is more effective than hospital
leadership in reducing cost while maintaining patient outcomes; physicians may be a more logical group in
which to entrust further healthcare reform. Even when controlling for decreasing costs in traditional fee-for-
service care, BPCI is associated with a further cost reduction without increased adverse events, and this is not
due to the selection of younger patients or those with fewer comorbidities.

11:20 am – 11:25 am
THE OTTO AUFRANC AWARD
The Genetics of Osteolysis After Total Hip Arthroplasty

Scott J. Macinnes, PhD; Konstantinos Hatzikotoulas, PhD; Anne Marie Fenstad, MSc;
Karan Shah, PhD; Lorraine Southam, PhD; Ioanna Tachmazidou, PhD; Geir Hallan, PhD;
Harvard Dale, PhD; Kalliope Panoutsopoulou, PhD; Ove Furnes, PhD; Eleftheria Zeggini, PhD;
J. Mark Wilkinson, PhD, FRCS
Background: Periprosthetic osteolysis resulting in aseptic loosening is a leading cause for total hip
arthroplasty (THA) failure. Individuals vary in their susceptibility to osteolysis. Heritable factors are thought to
contribute to this variation. We conducted two genome-wide association studies to identify genetic risk loci
associated with osteolysis susceptibility and with time to prosthesis failure due to osteolysis.
Methods: The Norway cohort comprised 2,624 subjects after THA recruited from the Norwegian Arthroplasty
Registry, 779 with revision surgery for osteolysis. The UK cohort comprised 890 subjects recruited from
hospitals in the north of England, 317 with radiographic evidence or revision surgery for osteolysis. Osteolysis
susceptibility case-control analyses and quantitative trait analyses for time to prosthesis failure were
undertaken after genome-wide genotyping. Finally, a meta-analysis of the discovery datasets was undertaken.
Results: Genome-wide association analysis identified 4 and 11 independent suggestive genetic signals for
osteolysis susceptibility at P≤5x10-6 in the Norwegian and UK cohorts, respectively. Following meta-analysis, 5
independent genetic signals showed suggestive association with osteolysis at P≤5x10-6, with the strongest
comprising 18 correlated variants on chromosome 7 (lead signal rs850092, P=1.13x10-6). Genome-wide
quantitative trait analysis in cases only showed a total of 5 and 9 independent genetic signals for time to
prosthesis failure at P≤5x10-6, respectively. Following meta-analysis, 11 independent genetic signals showed
suggestive evidence of association with time to failure at P≤5x10-6, with the largest association block
comprising 174 correlated variants in chromosome 15 (lead signal rs10507055, P=1.40x10-7).
Conclusions: These studies provide the first genome-wide insights into the heritable biology of osteolysis.
Although there were no signals of genome-wide significance, we find replicating evidence for several
independent genetic loci both for osteolysis susceptibility and time to prosthesis failure at P≤5x10-6, consistent
with the complex aetiology of the disease.

11:25 am – 11:30 am
THE FRANK STINCHFIELD AWARD
Spino-pelvic Hypermobility is Associated with Inferior Outcome Post-THA:

Examining the Effect of Spinal Arthrodesis
George Grammatopoulos, BSc, MBBS, D.Phil (Oxon); Wade Gofton, MD, FRCSC, Med;
Zaid Jibri, MBCHb, MRCSEd, FRCR; Matthew Coyle, MD; Johanna Dobransky, MHK, BSc;
Cheryl Kreviazuk, BA; Paul R. Kim, MD, FRCSC; Paul E. Beaulé, MD, FRCSC
Background: The mechanisms of how spinal arthrodesis (SA) affects patient function after total hip
replacement remain unclear.
Purposes: a) Determine how outcome post-THA compares between patients with- and without-SA, b)
Characterize sagittal pelvic changes that occur when moving between different functional positions, and test
for differences between patients with- and without-SA, and c) Assess whether differences in sagittal pelvic
dynamics are associated with outcome post-THA.
Methods: Forty-two patients with THA-SA (60 hips) were case-control matched for age, gender, BMI with 42
THA-only patients (60 hips). All presented for review where outcome, PROMs [including Oxford-Hip-Score
(OHS)] and 4 radiographs of the pelvis and spino-pelvic complex in 3 positions (supine, standing, deep-seated)
were obtained. Cup orientation and various spino-pelvic parameters [including pelvic tilt (PT) and Pelvic-
Femoral-Angle (PFA)] were measured. The difference in PT between standing and seated allowed for patient
classification based on spino-pelvic mobility into normal (±10–30°), stiff (<±10°) or hypermobile (>±30°).
Results: The THA-SA group had inferior PROMs (OHS: 33vs.43; p<0.001) and more complications (12vs.3;
p=0.01), especially dislocation (5vs.0) than the THA-only group. No difference in change of PT between supine
and standing positions was detected between groups. When standing THA-SA patients had greater PT
(24°vs.17°; p=0.01) and the hip was more extended (194°vs.185°; p<0.001). THA-SA patients were 4x more
likely to have spino-pelvic hypermobility with anteriorly tilting of their pelvis. Of all biomechanical parameters,
only spino-pelvic hypermobility was associated with significant inferior PROMs (OHS:35; p=0.04) and was also
present in dislocating hips that required revision despite optimum cup orientation.
Conclusion: In patients with SA who have undergone a THA, the presence of spino-pelvic hypermobility is
associated with an inferior outcome and leads to hip instability secondary to anterior impingement when deep
seated (anterior tilt functionally retroverting cup). For those patients, current implant positioning may not be
sufficient to avoid dislocation.

Session VII: Revision THA: Surgical Options for Success (Case-Based)
1:45 pm – 1:49 pm
Safe Removal of Femoral and Acetabular Components

John Antoniou, MD, FRCSC, PhD
Component removal, both on the femoral and acetabular sides, during revision total hip arthroplasty (THA)
requires careful planning in order to minimize bone loss. If successfully performed, reconstruction options are
maintained and a successful revision operation is more easily achieved.
Surgeon experience and familiarity with different techniques is of the utmost importance in order to remove the
components safely and expeditiously while preserving as much bone as possible. Access to specialized tools
is often essential. Different surgeons have a variety of preferences for tools and techniques.
In this talk, we will present you with an overview of various tips and techniques that are described in the
literature. A logical and stepwise method for dealing with implant removal that works best in our hands will be
demonstrated.
As witnessed by the attached reference list, the many different techniques described indicate that a single
safe, reproducible ideal method doesn’t exist. We will highlight a few of the systems that we have found to be
useful and versatile in our hands over the years: the extended trochanteric osteotomy for femoral revisions,
the Explant system on the acetabular side and the OSCAR on both the femoral and acetabular sides.
Although some may prefer other techniques, we recommend that surgeons use an approach with which they
are familiar and that works well in their hands. Generally, use of careful preoperative planning, use of an
extensile approach, patience and a stepwise logical progression are always recommended.
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2004;53(119-30.
52. Burstein G, Yoon P, and Saleh KJ. Component removal in revision total hip arthroplasty. Clin Orthop Relat Res. 2004420):48-54.
53. Mitchell PA, Masri BA, Garbuz DS, Greidanus NV, Wilson D, and Duncan CP. Removal of well-fixed, cementless, acetabular components in revision hip
arthroplasty. J Bone Joint Surg Br. 2003;85(7):949-52.
54. MacDonald SJ, Cole C, Guerin J, Rorabeck CH, Bourne RB, and McCalden RW. Extended trochanteric osteotomy via the direct lateral approach in revision hip
arthroplasty. Clin Orthop Relat Res. 2003417):210-6.
55. Langlais F, Lambotte JC, Collin P, Langlois F, Fontaine JW, and Thomazeau H. Trochanteric slide osteotomy in revision total hip arthroplasty for loosening. J
Bone Joint Surg Br. 2003;85(4):510-6.
56. Kim YM, Lim ST, Yoo JJ, and Kim HJ. Removal of a well-fixed cementless femoral stem using a microsagittal saw. J Arthroplasty. 2003;18(4):511-2.
57. Huffman GR, and Ries MD. Combined vertical and horizontal cable fixation of an extended trochanteric osteotomy site. J Bone Joint Surg Am. 2003;85-A(2):273-7.
58. Berry DJ. Removal of cementless stems. Instr Course Lect. 2003;52(331-6.
59. Archibeck MJ, Rosenberg AG, Berger RA, and Silverton CD. Trochanteric osteotomy and fixation during total hip arthroplasty. J Am Acad Orthop Surg.
2003;11(3):163-73.
60. Schmidt J, Porsch M, Sulk C, Hillekamp J, and Schneider T. Removal of well-fixed or porous-coated cementless stems in total hip revision arthroplasty. Arch
Orthop Trauma Surg. 2002;122(1):48-50.
61. Paprosky WG, and Martin EL. Removal of well-fixed femoral and acetabular components. Am J Orthop (Belle Mead NJ). 2002;31(8):476-8.
62. Nozawa M, Shitoto K, Mastuda K, Maezawa K, Yasuma M, and Kurosawa H. Transfemoral approach for revision total hip arthroplasty. Arch Orthop Trauma Surg.
2002;122(5):288-90.
63. Laing AJ, Mullett H, and Curtin W. Segmental femoral cement extraction at revision hip arthroplasty - a safe technique. Eur J Orthop Surg Traumatol.
2002;12(3):132-6.
64. Glassman AH. The removal of cementless total hip femoral components. Instr Course Lect. 2002;51(93-101.
65. Farrington WJ, Dunlop DG, and Timperley AJ. Cup removal in revision hip arthroplasty. J R Coll Surg Edinb. 2002;47(2):500-1.

66. Porsch M, and Schmidt J. Cement removal with an endoscopically controlled ballistically driven chiselling system. A new device for cement removal and
preliminary clinical results. Arch Orthop Trauma Surg. 2001;121(5):274-7.
67. Paprosky WG, Weeden SH, and Bowling JW, Jr. Component removal in revision total hip arthroplasty. Clin Orthop Relat Res. 2001393):181-93.
68. Della Valle CJ, and Stuchin SA. A novel technique for the removal of well-fixed, porous-coated acetabular components with spike fixation. J Arthroplasty.
2001;16(8):1081-3.
69. de Thomasson E, Mazel C, Gagna G, and Guingand O. A simple technique to remove well-fixed, all-polyethylene cemented acetabular component in revision hip
arthroplasty. J Arthroplasty. 2001;16(4):538-40.
70. Jingushi S, Noguchi Y, Shuto T, Nakashima T, and Iwamoto Y. A device for removal of femoral distal cement plug during hip revision arthroplasty: a high-powered
drill equipped with a centralizer. J Arthroplasty. 2000;15(2):231-3.
71. Chen WM, McAuley JP, Engh CA, Jr., Hopper RH, Jr., and Engh CA. Extended slide trochanteric osteotomy for revision total hip arthroplasty. J Bone Joint Surg
Am. 2000;82(9):1215-9.
72. Taylor JW, and Rorabeck CH. Hip revision arthroplasty. Approach to the femoral side. Clin Orthop Relat Res. 1999369):208-22.
73. Smith PN, and Eyres KS. Safe removal of massive intrapelvic cement using ultrasonic instruments. J Arthroplasty. 1999;14(2):235-8.
74. Markovich GD, Banks SA, and Hodge WA. A new technique for removing noncemented acetabular components in revision total hip arthroplasty. Am J Orthop
(Belle Mead NJ). 1999;28(1):35-7.
75. Younger TI, Bradford MS, and Paprosky WG. Removal of a well-fixed cementless femoral component with an extended proximal femoral osteotomy. Contemp
Orthop. 1995;30(5):375-80.
76. Younger TI, Bradford MS, Magnus RE, and Paprosky WG. Extended proximal femoral osteotomy. A new technique for femoral revision arthroplasty. J
Arthroplasty. 1995;10(3):329-38.

1:49 pm – 1:53 pm
Acetabular Reconstruction: When Do I Need to Use Arguments?

Wayne G. Paprosky, MD, FACS
Acetabular reconstruction in revision total hip arthroplasty can be complicated by the presence of acetabular
bone loss. In severe cases of acetabular bone deficiency with segmental bone defects or pelvic discontinuity,
obtaining a stable, well-fixed acetabular component can be very challenging. The anatomic location and
degree of bone loss is important in determining the treatment algorithm for acetabular revision. Porous coated
uncemented hemispherical cups have been successful and are indicated in the majority of patients. As the
severity of acetabular deficiencies increases, more complex alternitives are needed for revision. Antiprotrusio
cages traditionally have been used but higher failure rates necessitated the development of alternatives.
Porous coated acetabular augments have become an attractive alternative to structural allograft and oblong
components in the setting of severe bone loss.
Radiographic Parameters for Paprosky Acetabular Bone Loss Classification
a. Superior Migration of the hip center

i. Referenced off of the superior obturator line
ii. > 3 cm signifies severe bone loss
iii. Assessment of acetabular dome bone stock
b. Teardrop osteolysis
i. Assessment of inferomedial and medial wall bone loss
c. Ischial osteolysis
i. Assessment of posterior column bone stock
d. Violation of Kohler’s line
i. Represents the ilioischial line
ii. Medial migration of the acetabular component
iii. Assessment of anterosuperior and medial wall bone loss
e. Type III
i. Severe bone loss
ii. Distorted oblong shaped acetabulum
iii. Columns NOT supportive
1. IIIA
a. UP and OUT defect
b. Superior migration > 3 cm
c. 30-60% acetabular bone loss
2. III B
a. UP and IN defect
b. Superior migration > 3 cm
c. 60%+ acetabular bone loss
d. Violation of Kohler’s line
e. Possible pelvic discontinuity present
f. Type of Augment Secondary Support
i. Intra cavitary
ii. Extra cavitary

g. Type of Augment Primary Support
i. Intra cavitary
ii. Anterior or posterior column or both
iii. Intra cavitary footing severe anterior support medial defect
iv. Primary supportive extra cavitary
Summary for use of porous metal AUGMENTS for reconstruction

a. Augments are NOT only bone void fillers
b. What is the purpose of the augment
i. Primary stability
ii. Supplemental fixation
c. ALL augments MUST BE unitized to the cup with cement

1:53 pm – 1:57 pm
Femoral Revision: What is the Best Stem to Use?

Matthew S. Austin, MD
What is the best stem to use in femoral revision arthroplasty? The answer to this question depends primarily
upon the degree of femoral bone loss encountered after removal of the prior component. Proper preoperative
planning is an essential component to success in revision femoral arthroplasty. A dependable classification
method to define bone loss can aid in surgical decision making. The Paprosky classification also helps to
determine treatment:
Type I: Minimal loss of metaphyseal cancellous bone and an intact diaphysis
Revisions with type I bone loss can be treated like a primary total hip arthroplasty with either cemented
or uncemented fixation.
Type II: Extensive loss of metaphyseal cancellous bone and an intact diaphysis
Revisions with type II bone loss in the femur require extensively porous coated diaphyseal fitting
implants as much of the cancellous bone in the metaphysis in lost or unreliable.
Type IIIA: Metaphysis is severely damaged and nonsupportive and there is >4cm of intact diaphyseal bone
available for distal fixation
Revisions with type IIIA bone loss have extensive metaphyseal deficiency and require an extensively
coated stem that must obtain greater than 4cm of scratch fit to ensure proper fixation.
Type IIIB: Metaphysis is severely damaged and nonsupportive and there is <4cm of intact diaphyseal bone
available for distal fixation
Revisions with type IIIB bone loss are challenging due to the diaphyseal compromise. Current
recommendations for this type of scenario include cementless, tapered stem with flutes to aid in
rotational stability.
Type IV: Extensive metaphyseal and diaphyseal damage in conjunction with a nonsupportive isthmus and
widened femoral canal
Revisions with type IV bone loss are a significant challenge during revision hip arthroplasty. The
widened femoral canal makes the use of traditional cementless stems difficult. Alternative techniques
such as impaction grafting, allograft-prosthetic composites and mega-prostheses are part of the
armamentarium when dealing with type IV bone loss.
Utilizing the Paprosky classification system and following the basic principles of revision surgery (gentle and
adequate surgical exposure, use of extensile exposures when necessary, careful removal of the prior
component, and anatomic reconstruction of the femur) can lead to reproducible and successful reconstruction
of the femur in total hip revision surgery.

1:57 pm – 2:01 pm
Management of Periprosthetic Femur Fractures

George J. Haidukewych, MD
Proximal fractures of the greater trochanter (Vancouver A) are typically result from osteolysis. Bearing
exchange and grafting of the trochanteric defect is recommended. If fixation is needed typically suture fixation
is preferred. Fractures around a well fixed stem (Vancouver B1) are typically treated with ORIF. Balancing the
fixation and optimizing proximal fixation with a combination of locked screws and cerclage is recommended.
Fractures around loose stems (Vancouver B2-3) are treated with revision. Modular, fluted, tapered titanium
stems are very effective for this indication. The technique involves obtaining solid distal fixation, assembling
the appropriate proximal body to restore hip stability and leg length, then obtaining proximal fragment fixation
with an economy of cerclage. Maintaining vascularity with minimal soft tissue dissection from the proximal
bony fragments is recommended. Distal fractures (Vancouver C) are treated with long laterally based locking
plates. Obtaining good bypass of the hip stem is preferred. Careful attention to technical details and soft
tissue viability will minimize complications.

2:01 pm – 2:05 pm
What Do I Do if the Abductors are Deficient?

Michael D. Ries, MD
Abductor deficiency after THA can result from proximal femoral bone loss, trochanteric avulsion, muscle
destruction associated with infection, pseudotumor, adverse local tissue reaction (ALTR) to metal debris,
abductor paralysis from surgical trauma, or other causes (1,2). Constrained acetabular components are
generally indicated to control instability after THA with deficient abductors. However, the added implant
constraint also results in greater stresses at the modular liner-locking mechanism of the constrained
component and bone-implant fixation interface, which can contribute to mechanical failure of the constrained
implant or mechanical loosening (3).
Use of large heads has been effective in reducing the rate of dislocation after primary THA. However,
relatively large (36mm heads) were not found to be effective in controlling dislocation in patients with abductor
deficiency (4). Dual mobility implants which can provide considerably larger head diameters than 36mm may
offer an advantage in improving stability in patients with abductor deficiency (5). However the utility of these
devices in controlling instability after THA with deficient abductors has not been established,
Direct repair of abductor avulsion may restore some abductor function, but results are variable (6,7).
Augmentation using achilles tendon allograft has also been described (8). However allograft tendon can
attenuate over time in vivo (9). Whiteside utilized a transfer of the anterior gluteus maximus and subsequently
described combined transfer of the tensor muscle and anterior gluteus maximus to the greater trochanter for
treatment of absent abductors after THA (10,11). The transposed tensor muscle also provides muscle
coverage over the greater trochanter, which may be beneficial in controlling lateral hip pain. Whiteside
reported satisfactory results in five patients treated with the combined muscle transfer. Preoperatively all
patients had severe or moderate pain, severe abductor limp, and a positive Trendelenburg sign. At three
months after surgery, all patients could actively abduct and at 1 year postoperatively, three patients had no hip
pain, two had mild pain that did not limit their activity, three had no limp, and one had mild limp.
Treatment of patients with hip instability and abductor deficiency has generally required use of a constrained
acetabular component. Transfer of the tensor muscle and anterior gluteus maximus to the greater trochanter
can improve abductor strength and also reduce lateral hip pain. The combination of a large head and tensor
muscle transposition may be a viable alternative to use of a fully constrained component in patients with
deficient abductors after THA. However the need for implant constraint should also be individualized and
based on factors such as the viability of the transposed muscle, patient compliance with post-operative activity
restrictions, femoral head/neck ratio, and cup position.

1. Cooper HJ, Della Valle CJ, Berger RA, Tetreault M, Paprosky WG, Sporer SM, Jacobs JJ. Corrosion at the Head-
Neck Taper as a Cause for Adverse Local Tissue Reactions After Total Hip Arthroplasty. J Bone Joint Surg, 94A: 1655
-1661, 2012.
2. DeFrancesco CJ, Kamat AF. Abductor muscle necrosis due to iliopsoas bursal mass after total hip arthroplasty. J Clin
Ortho Trauma, 6: 288-292, 2015.
3. Guyen O, Lewallen DG, Cabanela ME. Modes of Failure of Osteonics Constrained Tripolar Implants: A Retrospective
Analysis of Forty-three Failed Implants. J Bone Joint Surg, 90A: 1553 -1556, 2008.
4. Kung P, Ries MD. Effect of Femoral Head size and Abductor Mechanism on Dislocation Rate After Revision Total Hip
Arthroplasty. Clin Orthop. 465: 170-174, 2007.
5. Ko LM, Hozack WJ. The dual mobility cup: what problems does it solve? Bone Joint J. 2016 Jan;98-B(1 Suppl A):60-
3.
6. Lübbeke A, Kampfen S, Stern R, Hoffmeyer P. Results of Surgical Repair of Abductor Avulsion After Primary Total
Hip Arthroplasty. J Arthroplasty, 23: 694-698, 2008.
7. Miozzari HH, Dora C, Clark JM, Nötz HP. Late Repair of Abductor Avulsion After the Transgluteal Approach for Hip
Arthroplasty. J Arthroplasty, 25: 450-457, 2010.
8. Fehm MN, Huddleston JI, Burke DW, Geller JA, Malchau H. Repair of a Deficient Abductor Mechanism with Achilles
Tendon Allograft After Total Hip Replacement. J Bone Joint Surg, 92A: 2305 -2311, 2010.
9. Brown NM, Murray T, Sporer SM, Wetters N, Berger RA, MD; Della Valle CJ. Extensor Mechanism Allograft
Reconstruction for Extensor Mechanism Failure Following Total Knee Arthroplasty. J Bone Joint Surg, 97A: 279 -283,
2015.
10. Whiteside LA. Surgical technique: Transfer of the anterior portion of the gluteus maximus muscle for abductor
deficiency of the hip. Clin Orthop Relat Res; 470: 503-510, 2012.
11. Whiteside LA. Surgical technique: Gluteus maximus and tensor fascia lata transfer for primary deficiency of the
abductors of the hip. Clin Orthop Relat Res, 472:645-53, 2014.

Session VIII: Infection
2:30 pm – 2:36 pm
Making the Diagnosis: What is the Gold Standard?

Stephen J. Incavo, MD
The diagnoses of infection complicating total hip replacement (THR) can be straightforward in many, if not
most, cases. However, some cases may be difficult to diagnose, and misdiagnosis can lead to unnecessary
surgical procedures, increased pain and morbidity, or bone and soft tissue destruction. The diagnosis of an
infected THR can be compromised if antibiotics have been administered, if the infection is caused by a less
virulent or a hard to culture organism, or in the case of a culture–negative infection which may be seen in 10-
20% of infection cases.
Accurate and timely diagnosis of infection is important for multiple reasons: Avoiding inappropriate or casual
antibiotic use, preventing revision of unsuspected infected components, and differentiating infection from
trunionosis or metallosis. In addition to the diagnosis of infection, identification of the organism(s) is very
important for several reasons. The safest, easiest, and least expensive antibiotic can then be used for the
infecting organism. Consideration of one-stage revision may be best suited for certain organisms. Some
organisms are considered easier to eradicate and carry a better prognosis.
Goals of the orthopaedic surgeon include properly diagnosing periprosthetic joint infection (PJI) and ruling out
infection before further implant surgery is performed. Patient history and physical exam, serum ESR and CRP,
and joint aspiration for cell count and culture remaining the mainstay of diagnosis. Because there is no gold
standard for the diagnosis of PJI diagnostic criteria have been adopted.
Major Criteria • Two positive periprosthetic cultures

• A sinus tract communicating with the
(one) joint.
• Elevated serum CRP and ESR.

Minor Criteria • Elevated synovial fluid WBC count or
(3 of 5 necessary) changes in the leukocyte esterase strip.
• Elevated synovial fluid PMN percentage.
• Positive histological analysis of
periprosthetic tissue.
• Single positive culture.

Criterion Chronic PJI (>90 DAYS)
Erythrocyte Sedimentation Rate >30
(mm/hr)
C-reactive protein (mg/L) >10
Synovial Fluid WBC count (cell/µl) >3,000

Synovial Fluid PMN (%) >80
Leukocyte Esterase + OR ++
Histological Analysis of Tissue Greater than 5 neutrophils/ HPF
Serum and synovial fluid markers are the focus of recent attention. Alpha-defensin testing is commercially
available and is rapidly gaining acceptance. It has been reported to be unaffected by antibiotic use. A partial
list of other markers include IL-6, IL-2, TNF, ELA-2, and NGAL. These markers have been reported to have
sensitivity and specificity in the 90% - 100% range for the presence of infection but have no ability to identify
organisms. These may prove most useful in the diagnosis of difficult to diagnose infections or in the timing of
re-implant surgery. These synovial fluid markers require ELISA testing. D-Dimer, a product of fibrin breakdown
that accompanies inflammation, has recently been identified as a promising, readily available serum marker.
New techniques are emerging that may significantly impact the diagnosis of PJI, especially in culture negative
cases. Next Generation Sequencing involves sequencing pathogen DNA in a given sample. Metagenomic
Shotgun Sequencing is a process based on extraction of microbe DNA, gene amplification and sequencing.
Both of these techniques may identify polymicrobial infections that were not apparent using conventional
culture.
To date, the “best” test for PJI diagnosis and treatment has not been established. Serum and synovial fluid
markers and microbial DNA analysis have the potential to enhance our understanding and treatment of PJI.

2:42 pm – 2:48 pm
One-Stage vs. Two-Stage vs. Partial Resection

Craig J. Della Valle, MD
A “two-stage exchange” remains the gold standard for treatment of the infected THA in North America.
Although there is interest in “one-stage exchange” this technique is not as familiar to many US surgeons and it
is unclear if the reported results of Europe can be translated to North American practice. Specific concerns
include the “radicalness” of the debridement required and the use of cemented revision components, which are
not used commonly in North America. Thus while the idea of a one stage exchange is attractive to many North
American surgeons, careful study will be required to determine if success can be achieved with a more
“conservative” debridement and the use of cementless revision components which are preferred by some
surgeons. Generally agreed upon indications for a one-stage exchange include a culture positive infection with
a sensitive organism, a good soft tissue envelope and simple bony defects.
The basic principles of a two-stage exchange include:

- Thorough debridement of all infected appearing foreign material and all cement
- Placement of an interval antibiotic loaded spacer (note that the addition of antibiotics to bone cement is
NOT FDA approved)
o 4-6g of antibiotics per pkg of cement; typically vancomycin + tobramycin
o Higher viscosity cement may be associated with higher elution
o The combination of antibiotics also leads to higher elution
Antibiotic spacers can be “articulating” or “static”. Potential advantages of an articulating spacer include greater
patient comfort and an easier approach at the second stage exchange as soft tissue tension and range of
motion is maintained. However, these spacers are oftentimes more costly and can break or dislocate.
The first stage is followed by approximately 6 weeks of organism specific IV antibiotics. An interdisciplinary
approach with an infectious disease specialist, internal medicine and a nutritionist optimizes outcomes.Our
protocol then includes weekly ESR and CRP to monitor their trend. These labs are re-checked two weeks after
cessation of antibiotics to ensure the trend has not changed. We have found that while the ESR and CRP are
significantly lower than prior to removal of the infected implant, they often times DO NOT normalize and there
is no specific cut-off value that predicts persistent infection.
Partial resection has been reported from some specialized centers as a solution for patients where removal of
their present femoral or acetabular implant would lead to a situation that as NOT RECONSTRUCTABLE. This
technique should be used VERY SPARINGLY.
References:
Shukla S, Ward JP, Jacofsky MC, Sporer SM, Paprosky WG, Della Valle C. Perioperative testing for persistent sepsis
following resection arthroplasty of the hip for periprosthetic infection. J Arthroplasty, 25: 87-91, 2010.
Lombardi AV Jr, Berend KR, Adams JB. Partial two-stage exchange of the infected total hip replacement using disposable
spacer moulds. Bone Joint J. 2014 Nov;96-B(11 Supple A):66-9.

2:48 pm – 2:54 pm
When Do I Replant and What Do I Need to Worry About?

Bassam A. Masri, MD, FRCSC
The timing of reimplantation during two-stage exchange arthroplasty for an infected hip replacement remains
difficult to predict. There are no standardized or well-agreed upon algorithms for when to reimplant. The
purpose of the two-stage exchange arthroplasty is to allow infection eradication in the first stage, where
implants removed so that when the implants are re-inserted at the second stage, the surgical field is ideally
perfectly sterile, so that the risk of recurrent infection is minimized.
The surgeon, therefore, must balance the patient’s needs for a permanent implant to minimize the morbidity of
the procedure, with the risk of recurrent infection. It is widely accepted that parenteral antibiotics are required
between stages. Most but not all experts, also, recommend an antibiotic holiday during which patients are
monitored off antibiotics to ensure that the hip is not re-infected, and to ensure safety of the reimplantation.
During the interval between stages, patients are monitored with serological markers, most often ESR and CRP.
Also, prior to reimplantation, it is possible to aspirate the joint for cell count and differential and to culture the
fluid to see if bacteria can be grown. More sophisticated tests such as measurement of a-defensin-1 levels
may be done on the aspirated synovial fluid. Also it is possible to obtain a frozen section of the synovial tissue
to look for the number of PMN’s per high power field, as an indicator of infection.
Shukla et al reported on 87 hips revised for periprosthetic joint infection [1]. They reported 7 hips with
persistent infection. The area under the cure (AUC) for receiver operator characteristics (ROC) curves of the
markers studied in their study ranged between 0.55 and 0.91. With lowest AUC value attributed to the CRP
and highest attributed to aspirated joint fluid WBC counts.
Janz et al studied 69 patients after resection hip arthroplasty prior to reimplantation [2]. They concluded that
aspiration WBC counts and CRP had a PPV of 75% and 36%, respectively and NPV of 70% and 90%,
respectively. They did not report the AUC of the ROC curves. These values do not provide any diagnostic
value.
Bori et al studied 21 patients prior to reimplantation [3]. They studied WBC per HPF microscopy during
reimplantation. They concluded that using WBC above 5 per HPF yielded positive and negative predictive
values of 100% and 73.6%, respectively. However, their sample size was small. They did not report the AUC
of the ROC curves of WBC count and they did not use any statistical means to choose optimal cut-off values.
Some authors considered the use of sonication of antibiotic spacers in order to identify residual infection prior
to reimplantation [4,5]. However, sonication of the antibiotic spacers can only be used for cultures during
reimplantation and not pre-stage 2 for the diagnosis of residual infection.
Another option gaining popularity is the use of Alpha Defensin-1 to diagnose residual infection [4]. It has been
shown that it is a good diagnostic tool for a wide range of bacteria and even in patients already treated with
antibiotics [6,7]. The Alpha Defensin -1 has shown promising results with close to 100% sensitivity and
specificity for identifying periprosthetic joint infection [8] outperforming all available markers for the diagnosis of
periprosthetic joint infection. However, only one study included 6 patients (out of 61) that had Alpha Defensin-1
tested before reimplantation [9]. In that study the authors did not analyze these patients separately.

Based on the available evidence to date, the mainstay of judging when to reimplant remains carefully clinical
monitoring of the patient to make sure that the wound is well-healed and that the patients’ symptoms are not
suggestive of ongoing infection. Serial monitoring of the ESR and the CRP to ensure that they continue to
decline and do not suddenly spike is important. There is no validated cut-point for the ESR and CRP above
which reimplantaiton should be delayed. In many patients who do not become reinfected the ESR and the CRP
do not necessarily retunt to normal levels, but plateau at significantly lower levels than they were
preoperatively.
In an effort to identify if we can refine the diagnostic criteria that are predictive of a successful reimplantation,
prior to riemplantation, we reviewed 182 patients with infected hip and knee replacement who underwent two-
stage exchange arthroplasty. Of these 107 (58.8%) were male and 75 (41.2%) were female. Mean age was
66.6 (SD=11.1, range=31-90). Mean body mass index of the patients was 30.25 (SD=6.99, range=18.3-46.6).
The study population included 73 (40.1%) knee and 109 (59.9%) hip replacements revised for infection.
There were 144 (79.2%) patients in which two stage revision due to infection resulted in infection free
arthroplasty. In 38 (20.8%) patients persistent infection was diagnosed after the second stage operation. (see
Table 1) Of these patients 8 (21.1%) patients had additional irrigation and debridement, 10 (26.3%) patients
were on antibiotic suppression, 4 (10.5%) had an amputation, 11 (28.9%) had a new two stage revision, 3
(7.9%) had a resection arthroplasty, 1 (2.6%) had an arthrodesis and one (2.6%) patient had multiple plastic
surgery procedures for wound closure.
Markers prior to reimplantation included CRP, WBC and Neut% in aspiration. During reimplantation, histologic
count of WBC per HPF microscopy (×400) in the final (not frozen) sections was also included. There was no
statistically significant difference in markers’ value in the infected and non-infected patients between
arthroplasty sites (hip or knee). Of all the markers examined only the CRP had a statistically significant higher
values for residual infection prior to reimplantation (p value=0.002). However, for the CRP, the AUC of the
ROC curve was 0.677 indicating that this marker has poor accuracy in diagnosing residual infection prior to
reimplantation (see Table 2).
Cultures during the second stage were also highly unreliable. Out of 37 patients who were infected after the
second stage and had intraoperative culture results, 26 (70.2%) patients had negative cultures. Only 11
patients (29.8%) out of the aforementioned 37 had positive intraoperative cultures at the time of reimplantation
(see Table 2). While negative cultures predicted lack of infection with a p-value of 0.001, the AUC was 0.634
indicating poor performance. This is highlighted by the fact that 70.2% of ultimate failures had negative cultures
at the time of the second stage procedure.
Using optimal cutoff values as determined by the Youden’s index, the positive predictive values for residual
infection ranged between 26.3% and 57.1%, and negative predictive values ranged between 78.3% and 85.2%
(see Table 3).
Combining the results of the infection markers yielded positive predictive values between 50% and 80% and
negative predictive values between 77% and 90%. The best combination of markers was CRP above 15mg/L
and Neut% above 80% in aspiration. This combination yielded positive predictive value of 80% and negative
predictive value of 85.4% (see Table 4).
Examinations of monthly CRP values at one to four months after the first stage had AUC of ROC curves of
0.581, 0.647, 0.591 and 0.603, respectively (Figure 1). Although CRP at four months after the first stage was
higher in patients with residual infection, its diagnostic value is limited due to the fact that about half of the
infected cases had CRP values below the cut-off of 15mg/Liter.
In summary, we are no further ahead at having an ideal test for predicting whether the reimplantation will be
successful. It remains to be seen whether tests such at Alph-Defensin-1 will allow us to better prognosticate
and to determine when it is appropriate to reimplant. In the meantime, we generally give 6 weeks of IV
antibiotics, and wait another 6 weeks off antibiotics while monitoring the ESR and CPR weekly, in collaboration
with the infectious disease consultant. Once the ESR and CRP have dropped to near normal levels, and once
the surgeon and the infectious disease consultant agree that the clinical features do not suggest ongoing
infection, the hip is reimplanted.
Table 1: Demographic and clinical data
Total No residual infection Residual infection P value

(N=38, 20.8%)
N=182 (N=144, 79.2%)
Gender
Male 107 (58.8%) 84 (78.5%) 23 (21.5%)
Female 75 (41.2%) 60 (80.0%) 15 (20.0%) 0.807
Age 66.6 (±11.1) 67.5 (±10.5) 63.4 (±12.8) 0.106
Site
Knee 73 (40.1%) 52 (71.2%) 21 (28.8%)
Hip 109 (59.9%) 92 (84.4%) 17 (15.6%) 0.032
Side
Left 90 (49.5%) 69 (76.6%) 21 (23.4%)
Right 92 (50.5%) 75 (81.5%) 17 (18.5%) 0.533
Body Mass 30.25 29.62 (±6.09) 32.91 (±9.66) 0.154

Index (±6.99)
ASA score 2.45 (±0.58) 2.39 (±0.56) 2.66 (±0.58) 0.018
ASA = American society of Anesthesiologists

Table 2: Values of diagnostic parameters
No residual Residual AUC of

Total P val
infection infection ROC
CRP prior to
reimplantation 14.07 (±32.0) 10.51 (±22.15) 27.79 (±53.95) 0.677 0.002
(mg/L)
WBC in aspiration 3572.00 2950.5 5303.1

0.506 0.944
(cells/L) (±14,381.5) (±13,768.2) (±16,395.6)
Neutrophils % in 48.33% 45.76% 56.91%

0.623 0.200
aspiration (±31.46%) (±31.23%) (±32.04%)
Neutrophils in
histology HPF at
reimplantation
<5
5-10 136 (87.7%) 110 (80.9%) 26 (19.1%)
11-30 7 (4.5%) 5 (71.4%) 2 (28.6%)
>30 11 (7.1%) 8 (72.7% %) 3 (27.3%)
1 (0.6%) 1 (100%) 0 (0%) 0.524 0.801
Cultures at
reimplantation
Negative
160 (91.4%) 134 (83.8%) 26 (16.3%)
Positive
15 (8.6%) 4 (26.7%) 11 (73.3%) 0.634 0.001
HPF= High power field; AUC= Area under the curve for the Receiver Operator Characteristic (ROC) curve.

Table 3: Diagnostic properties of infection markers
Sensitivity Specificity PPV NPV LR+ LR-

CRP (mg/L)>15 43.8% 84.6% 42.4% 85.2% 2.83 0.67
Asp WBC 28.6% 92.3% 57.1% 78.3% 3.71 0.77

(cells/Liter) >1100
Asp Neut% >80% 41.7% 85.0% 45.5% 82.9% 2.78 0.69
WBC per HPF ≥ 5 16.1% 88.7% 26.3% 80.9% 1.43 0.95

cells
CRP=C reactive protein, Asp = Aspiration, WBC=White blood cells, Neut%= Neutrophil percent, HPF = high
power field, PPV=positive predictive value, NPV= Negative predictive value, LR+ = positive likelihood ratio, LR-
= negative likelihood ratio.
Table 4: Combining infection markers.
Sen Spec PPV NPV LR+ LR-

CRP (mg/L)>15 and 16.7% 97.1% 66.7% 77.3% 5.83 0.86
Asp WBC (cells/Liter) >1100
CRP (mg/L)>15 or 66.7% 82.9% 57.1% 87.9% 3.89 0.40
Asp WBC (cells/Liter) >1100
CRP (mg/L)>15 and 40.0% 97.2% 80.0% 85.4% 14.40 0.62
Asp Neut% >80%
CRP (mg/L)>15 or 70.0% 77.8% 46.7% 90.3% 3.15 0.39
Asp Neut% >80%
Asp WBC (cells/Liter) >1100 and 33.3% 92.3% 50.0% 85.7% 4.33 0.72
Asp Neut% >80%
Asp WBC (cells/Liter) >1100 or 50.0% 84.6% 50.0% 84.6% 3.25 0.59
Asp Neut% >80%
CRP>15 and Asp WBC >1100 and 20.0% 97.1% 66.7% 81.0% 7.00 0.82
Asp Neut% > 80%
Sen= Sensitivity; Spec=Specificity; CRP=C reactive protein, Asp = Aspiration, WBC=White blood cells,
Neut%= Neutrophil percent, HPF = high power field, PPV=positive predictive value, NPV= Negative predictive
value, LR+ = positive likelihood ratio, LR- = negative likelihood ratio.

REFERENCES
1. Shukla S, Ward JP, Jacofsky MC, Sporer SM, Paprosky WG, Della Valle C. Perioperative testing for persistent
sepsis following resection arthroplasty of the hip for periprosthetic infection. J Arthroplasty. 2010;25 (6 supp) :87–
91.
2. Janz V, Bartek B, Wassilew GI, Stuhlert M, Perka CF, Winkler T. Validation of Synovial Aspiration in Girdlestone
Hips for Detection of Infection Persistence in Patients Undergoing 2-Stage Revision Total Hip Arthroplasty. The
Journal of Arthroplasty, 2016; 31: 684–687.
3. Bori G, Soriano A, Garcı´a S, Mallofre , Riba J, Mensa J. Usefulness of histological analysis for predicting the
presence of microorganisms at the time of reimplantation after hip resection arthroplasty for the treatment of
infection. J Bone Joint Surg Am. 2007;89:1232–1237.
4. Mariconda M, Ascione T, Balato G, et al. Sonication of antibiotic-loaded cement spacers in a two-stage revision
protocol for infected joint arthroplasty. BMC Musculoskelet Disord 2013;14:193.
5. Nelson CL, Jones RB, Wingert NC, et al. Sonication of antibiotic spacers predicts failure during two-stage revision
for prosthetic knee and hip infections. Clin Orthop Relat Res 2014;472(7):2208.
6. Deirmengian C, Kardos K, Kilmartin P, Gulati S, Citrano P, Booth RE. The Alpha-defensin Test for Periprosthetic
Joint Infection Responds to a Wide Spectrum of Organisms. Clin Orthop Relat Res, 2015; 473: 2229–2235.
7. Shahi A, Parvizi J, Kazarian GS, Higuera C, Frangiamore S, Bingham J, Beauchamp C, Della Valle CJ,
Deirmengian C. The Alpha-defensin Test for Periprosthetic Joint Infections Is Not Affected by Prior Antibiotic
Administration. Clin Orthop Relat Res, 2016; 474:1610–1615.
8. Wyatt MC, Beswick AD, Kunutsor SK, Wilson MJ, Whitehouse MR, Blom AW. The Alpha-Defensin Immunoassay
and Leukocyte Esterase Colorimetric Strip Test for the Diagnosis of Periprosthetic Infection. A Systematic Review
and Meta-Analysis. J Bone Joint Surg Am. 2016;98:992-1000.
9. Bingham J, Clarke H, Spangehl M, Schwartz A, Beauchamp C, Goldberg B. The Alpha Defensin-1 Biomarker
Assay can be Used to Evaluate the Potentially Infected Total Joint Arthroplasty. Clin Orthop Relat Res (2014)
472:4006–4009.

2:54 pm – 3:00 pm
Postoperative Antibiotics: How Long Are They Needed?

Michael A. Mont, MD
The treatment of infected total hip arthroplasty involves much morbidity including surgical and medical
techniques with the use of prolonged intravenous antibiotic administration. The surgical treatment may involve
a débridement with polyethylene replacement and implant retention, a one stage, or most commonly a 2-stage
re-implantation procedure. Intravenous antibiotics are usually started in the hospital setting and are continued
on the out-patient basis. Although treatment is shifting towards out-patient management, some insurance plans
disallow out-patient administration of antibiotics and patients are required to stay at the hospital for a prolonged
duration of time [1]. The adverse effects of intravenous antibiotics combined with the increased hospital costs
incentivize providers to administer these medications for a minimal duration of time which is required to
achieve the clearance of infection [1]. However, there is no clear consensus on how long this therapy is
needed. Furthermore, some orthopaedists prescribe prophylactic oral antibiotics to be taken for a specific
duration of time or indefinitely. Due to the differences in duration and route of antibiotic administration, we have
conducted a literature review of this topic in: 1) débridement with polyethylene exchange and implant retention;
2) one-stage; and 3) two-stage re-implantation procedures. We have identified 28 reports on implant retention
(See Table 1), 3 reports on one-stage (See Table 2), and 4 reports on two-stage re-implantation (See Table
3). The highest success rate of infection eradication was in two-stage (approximately 93%), followed by one-
stage re-implantation (approximately 90%), and implant retention (approximately 75%). A total of 12 of the 28
studies on implant retention administered antibiotics for less than 12 weeks and had a mean success rate of
74%. The remaining studies (n=16) administered antibiotics for at least 12 weeks and had a mean success
rate of 82%. The mean success rate in one-stage re-implantation cohort was approximately 90% and there
was no association between duration of the antibiotic treatment (range, 2 weeks to 6 months) and infection
eradication. The mean success rate of two-stage re-implantation was 93% and there was no difference
between antibiotic administration duration (range, 0 to 6 weeks) and infection eradication. Two-stage re-
implantation appears to provide the highest success of infection eradication, followed by only slightly lower
success rates of one-stage re-implantation. Débridement with polyethylene replacement and implant retention
has lower success rate. Two weeks may be a sufficient duration of antibiotic therapy for one-stage and two-
stage procedures. Débridement with polyethylene replacement and implant retention may be considered for
some patients, however, a longer antibiotic regimen of at least 12 weeks may be needed. Although some
studies have used as little as 2 weeks of postoperative antibiotics, the majority do 6 weeks or longer and this
duration needs further study.

Table 1. Débridement with polyethylene exchange and implant retention.
Author Year N Duration of Antibiotic Follow-up (months) Success

(months) Rate
Veltman et al. [2] 2015 8 12 weeks 36 88

Moojen et al. [3] 2015 35 12 weeks N/A 71
Betz et al. [4] 2015 38 12 weeks 42 82
Moojen et al. [5] 2014 33 12 weeks 48 88
Konigsberg et al. [6] 2014 20 42 weeks 56 80
Aboltins et al. [7] 2013 19 52 weeks 24 89
Geurts et al. [8] 2013 69 13 weeks 27 83
Kuiper et al. [9] 2013 34 18 weeks 35 74
Westberg et al. [10] 2012 38 7 weeks 48 71
Perez-Cardona et al. 2012 5 11 weeks 15 100
[11]
Choi et al. [12] 2012 28 6 weeks N/A 68
Sukeik et al. [13] 2012 26 6 weeks 79 77
Buller et al. [14] 2012 62 6 weeks 34 56
Klouche et al. [15] 2011 12 12 weeks 30 25
Puhto et al. [16] 2011 32 THA 4 weeks of IV followed by 26 90
4 weeks of PO
Cobo et al. [17] 2011 57 12 weeks 26 53
Vilchez et al. [19] 2011 53 (18 THA) IV 11 days, oral 88 days 24 76
Bernard et al. [20] 2010 144 (62 1.5 or 3 months 36 (median) 80
THA)
Martinez-Pastor et al. 2009 47 (15 THA) Median 2.6 months 15.4 75
[21]
Tintle et al. [22] 2009 3 6 weeks 39 100
Byren et al. [23] 2009 52 52 weeks 28 87
Soriano et al. [25] 2006 39 (10 THA) 2.7 months 24 77
Berdal et al. [26] 2005 29 (12 THA) 3 months 22.5 83
Giulieri et al. [27] 2004 11 100 weeks 28 64
Krasin et al. [28] 2001 7 6 weeks 30 29
Tsukayama et al. [29] 1996 41 6 weeks 46 68

Table 2. One-stage re-implantation.
Author Year N Duration of Follow- Success

Antibiotic up Rate
(months) (months)
Yoo et al. 2009 12 8 weeks 3.6 years 83
[30]
Winkler et al. 2008 37 2 weeks 4 years 92
[31]
Rudelli et al. 2008 32 6 months 103 94
[32]
Table 3. Two-stage re-implantation.
Author Year N Duration of Follow- Success

Antibiotic up Rate
(months) (months)
Whittaker 2009 44 2 weeks 49 93
Stockley et 2008 114 0 74 88
al. [33]
McKenna et 2009 30 5 days IV, ? 35 100
al. [34] PO
Hsieh et al. 2005 99 1 week IV vs. 43 89% 1
[35] 4 weeks IV + 2 week IV;
weeks PO 91% other
cohort
p=0.67

References
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[2] Veltman ES, Vos FJ, Meis JF, Goosen JHM. Debridement, antibiotics and implant retention in early postoperative
infection with Pseudomonas aeruginosa. J Infect 2015;70:307–9. doi:10.1016/j.jinf.2014.10.002.
[3] Moojen DJF. Similar success rates for single and multiple debridement surgery for acute hip arthroplasty infection--
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[4] Betz M, Abrassart S, Vaudaux P, Gjika E, Schindler M, Billières J, et al. Increased risk of joint failure in hip prostheses
infected with Staphylococcus aureus treated with debridement, antibiotics and implant retention compared to
Streptococcus. Int Orthop 2015;39:397–401. doi:10.1007/s00264-014-2510-z.
[5] Moojen DJF, Zwiers JH, Scholtes VA, Verheyen CC, Poolman RW. Similar success rates for single and multiple
debridement surgery for acute hip arthroplasty infection. Acta Orthop 2014;85:383–8.
doi:10.3109/17453674.2014.927729.
[6] Konigsberg BS, Valle CJ Della, Ting NT, Qiu F, Sporer SM. Acute Hematogenous Infection Following Total Hip and
Knee Arthroplasty. J Arthroplasty 2014;29:469–72. doi:10.1016/j.arth.2013.07.021.
[7] Aboltins C, Dowsey MM, Peel T, Lim WK, Parikh S, Stanley P, et al. Early prosthetic hip joint infection treated with
debridement, prosthesis retention and biofilm-active antibiotics: functional outcomes, quality of life and
complications. Intern Med J 2013;43:810–5. doi:10.1111/imj.12174.
[8] Geurts JAP, Janssen DMC, Kessels AGH, Walenkamp GHIM. Good results in postoperative and hematogenous
deep infections of 89 stable total hip and knee replacements with retention of prosthesis and local antibiotics. Acta
Orthop 2013;84:509–16. doi:10.3109/17453674.2013.858288.
[9] Kuiper JWP, Brohet RM, Wassink S, van den Bekerom MPJ, Nolte PA, Vergroesen DA. Implantation of resorbable
gentamicin sponges in addition to irrigation and debridement in 34 patients with infection complicating total hip
arthroplasty. Hip Int 2013;23:173–80. doi:10.5301/HIP.2013.10612.
[10] Westberg M, Grøgaard B, Snorrason F. Early prosthetic joint infections treated with debridement and implant
retention: 38 primary hip arthroplasties prospectively recorded and followed for median 4 years. Acta Orthop
2012;83:227–32. doi:10.3109/17453674.2012.678801.
[11] Corona Pérez-Cardona PS, Barro Ojeda V, Rodriguez Pardo D, Pigrau Serrallach C, Guerra Farfán E, Amat Mateu
C, et al. Clinical experience with daptomycin for the treatment of patients with knee and hip periprosthetic joint
infections. J Antimicrob Chemother 2012;67:1749–54. doi:10.1093/jac/dks119.
[12] Choi H-R, von Knoch F, Kandil AO, Zurakowski D, Moore S, Malchau H. Retention treatment after periprosthetic
total hip arthroplasty infection. Int Orthop 2012;36:723–9. doi:10.1007/s00264-011-1324-5.
[13] Sukeik M, Patel S, Haddad FS. Aggressive early débridement for treatment of acutely infected cemented total hip
arthroplasty. Clin Orthop Relat Res 2012;470:3164–70. doi:10.1007/s11999-012-2500-7.
[14] Buller LT, Sabry FY, Easton RW, Klika AK, Barsoum WK. The preoperative prediction of success following irrigation
and debridement with polyethylene exchange for hip and knee prosthetic joint infections. J Arthroplasty 2012;27:857-
64-4. doi:10.1016/j.arth.2012.01.003.
[15] Klouche S, Lhotellier L, Mamoudy P. Infected total hip arthroplasty treated by an irrigation-debridement/component
retention protocol. A prospective study in a 12-case series with minimum 2 years’ follow-up. Orthop Traumatol Surg
Res 2011;97:134–8. doi:10.1016/j.otsr.2011.01.002.
[16] Puhto A-P, Puhto T, Syrjala H. Short-course antibiotics for prosthetic joint infections treated with prosthesis retention.
Clin Microbiol Infect 2012;18:1143–8. doi:10.1111/j.1469-0691.2011.03693.x.
[17] Cobo J, Miguel LGS, Euba G, Rodríguez D, García-Lechuz JM, Riera M, et al. Early prosthetic joint infection:
outcomes with debridement and implant retention followed by antibiotic therapy. Clin Microbiol Infect 2011;17:1632–
7. doi:10.1111/j.1469-0691.2010.03333.x.

[18] Aboltins CA, Dowsey MM, Buising KL, Peel TN, Daffy JR, Choong PFM, et al. Gram-negative prosthetic joint infection
treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clin Microbiol
Infect 2011;17:862–7. doi:10.1111/j.1469-0691.2010.03361.x.
[19] Vilchez F, Martínez-Pastor JC, García-Ramiro S, Bori G, Maculé F, Sierra J, et al. Outcome and predictors of
treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with
debridement. Clin Microbiol Infect 2011;17:439–44. doi:10.1111/j.1469-0691.2010.03244.x.
[20] Bernard L, Legout L, Zürcher-Pfund L, Stern R, Rohner P, Peter R, et al. Six weeks of antibiotic treatment is sufficient
following surgery for septic arthroplasty. J Infect 2010;61:125–32. doi:10.1016/j.jinf.2010.05.005.
[21] Martinez-Pastor JC, Munoz-Mahamud E, Vilchez F, Garcia-Ramiro S, Bori G, Sierra J, et al. Outcome of Acute
Prosthetic Joint Infections Due to Gram-Negative Bacilli Treated with Open Debridement and Retention of the
Prosthesis. Antimicrob Agents Chemother 2009;53:4772–7. doi:10.1128/AAC.00188-09.
[22] Tintle SM, Forsberg JA, Potter BK, Islinger RB, Andersen RC. Prosthesis retention, serial debridement, and antibiotic
bead use for the treatment of infection following total joint arthroplasty. Orthopedics 2009;32:87.
[23] Byren I, Bejon P, Atkins BL, Angus B, Masters S, McLardy-Smith P, et al. One hundred and twelve infected
arthroplasties treated with “DAIR” (debridement, antibiotics and implant retention): antibiotic duration and outcome.
J Antimicrob Chemother 2009;63:1264–71. doi:10.1093/jac/dkp107.
[24] Aboltins CA, Page MA, Buising KL, Jenney AWJ, Daffy JR, Choong PFM, et al. Treatment of staphylococcal
prosthetic joint infections with debridement, prosthesis retention and oral rifampicin and fusidic acid. Clin Microbiol
Infect 2007;13:586–91. doi:10.1111/j.1469-0691.2007.01691.x.
[25] Soriano A, García S, Bori G, Almela M, Gallart X, Macule F, et al. Treatment of acute post-surgical infection of joint
arthroplasty. Clin Microbiol Infect 2006;12:930–3. doi:10.1111/j.1469-0691.2006.01463.x.
[26] Berdal J-E, Skråmm I, Mowinckel P, Gulbrandsen P, Bjørnholt J V. Use of rifampicin and ciprofloxacin combination
therapy after surgical debridement in the treatment of early manifestation prosthetic joint infections. Clin Microbiol
Infect 2005;11:843–5. doi:10.1111/j.1469-0691.2005.01230.x.
[27] Giulieri SG, Graber P, Ochsner PE, Zimmerli W. Management of Infection Associated with Total Hip Arthroplasty
according to a Treatment Algorithm. Infection 2004;32:222–8. doi:10.1007/s15010-004-4020-1.
[28] Krasin E, Goldwirth M, Hemo Y, Gold A, Herling G, Otremski I. Could irrigation, debridement and antibiotic therapy
cure an infection of a total hip arthroplasty? J Hosp Infect 2001;47:235–8. doi:10.1053/jhin.2000.0809.
[29] Tsukayama DT, Estrada R, Gustilo RB. Infection after total hip arthroplasty. A study of the treatment of one hundred
and six infections. J Bone Joint Surg Am 1996;78:512–23.
[30] Yoo JJ, Kwon YS, Koo K-H, Yoon KS, Kim Y-M, Kim HJ. One-stage cementless revision arthroplasty for infected hip
replacements. Int Orthop 2009;33:1195–201. doi:10.1007/s00264-008-0640-x.
[31] Winkler H, Stoiber A, Kaudela K, Winter F, Menschik F. One stage uncemented revision of infected total hip
replacement using cancellous allograft bone impregnated with antibiotics. J Bone Joint Surg Br 2008;90:1580–4.
doi:10.1302/0301-620X.90B12.20742.
[32] Rudelli S, Uip D, Honda E, Lima ALLM. One-Stage Revision of Infected Total Hip Arthroplasty with Bone Graft. J
Arthroplasty 2008;23:1165–77. doi:10.1016/j.arth.2007.08.010.
[33] Stockley I, Mockford BJ, Hoad-Reddick A, Norman P. The use of two-stage exchange arthroplasty with depot
antibiotics in the absence of long-term antibiotic therapy in infected total hip replacement. J Bone Joint Surg Br
2008;90:145–8. doi:10.1302/0301-620X.90B2.19855.
[34] McKenna PB, O’Shea K, Masterson EL. Two-stage revision of infected hip arthroplasty using a shortened post-
operative course of antibiotics. Arch Orthop Trauma Surg 2009;129:489–94. doi:10.1007/s00402-008-0683-x.
[35] Hsieh P-H, Shih C-H, Chang Y-H, Lee MS, Yang W-E, Shih H-N. Treatment of deep infection of the hip associated
with massive bone loss: two-stage revision with an antibiotic-loaded interim cement prosthesis followed by
reconstruction with allograft. J Bone Joint Surg Br 2005;87:770–5. doi:10.1302/0301-620X.87B6.15411.

COMBINED Session IX: Outpatient TJA
3:30 pm – 3:36 pm
Outpatient Arthroplasty: The Time is Now

Richard Iorio, MD
Traditionally, the vast majority of hip and knee joint replacement procedures have been performed in an
inpatient hospital setting and required a hospital stay of 3 days or longer. Improved anesthesia and surgical
techniques, advances in postoperative care management, and growing patient demand for elective outpatient
procedures are combining with healthcare economic factors to drive these operations to hospital outpatient
departments, orthopaedic surgical specialty facilities and ambulatory surgery centers (ASC) at an accelerated
rate. Over the next 10 years, it has been forecast that inpatient joint replacement volumes will remain relatively
flat while outpatient primary joint replacement volumes will experience triple-digit growth.
Surgeons, payers, hospitals and independent facilities are fostering an increasingly favorable environment for
total joint replacement (TJR) in the outpatient setting. As the transition to the outpatient setting begins to take
hold, facilites must shift their strategic focus to maintain market share and margin. Orthopedic service line
leaders can prepare their programs with an assessment of expected demand, competitive pressure and the
payer landscape to assess market feasibility. Collaboration among providers, point of service facilities,
insurers, and patients will facilitate more outpatient arthroplasty in the years ahead.
CMS believes (1) that most outpatient departments are equipped to perform TKA for Medicare beneficiaries;
(2) most outpatient departments may perform TKA; and (3) the procedure is already being performed in
numerous hospitals on an outpatient basis. CMS is looking for data to support the belief as to whether these
criteria have been satisfied. CMS has allowed that TKA (CPT code 27447 will be assigned to C-APC 5115
(Level 5 Musculoskeletal Procedures) with status indicator “J1”. CMS expects providers will “carefully develop
evidence-based patient selection criteria to identify patients who are appropriate candidates for an outpatient
TKA procedure as well as exclusionary criteria that would disqualify a patient from receiving an outpatient TKA
procedure.” Further, while CMS is not adding TKA to the ASC covered surgical procedures list for CY 2018, it
appears that CMS is moving toward to allowing TKA at outpatient and ambulatory surgery centers.
While CMS believes that some less medically complex TKA cases could be appropriately and safely performed
on an outpatient basis, CMS does not expect to create or endorse specific guidelines or content for the
establishment of providers’ patient selection protocols. CMS acknowledges the importance of deferring to
patients and providers to decide the appropriate site of service for a particular patient. It is anticipated that
total hip arthroplasty will be removed from the in-patient only list in the future.

3:36 pm – 3:42 pm
Identifying the Optimal Patient

Michael E. Berend, MD
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 paved the way for outpatient joint replacement surgery in
appropriately selected patients either in free standing ASC’s or hospital environments. The synergy and
implementation of the knowledge gained over the past two decades of arthroplasty care make outpatient joint
replacement possible and effective.1,2
Refinement of surgical techniques, anesthesia protocols, and patient selection has facilitated a transformation
to same day discharge for arthroplasty care in our practice.13-15 This initially began in September of 2011 with
selected Partial Knee Replacement (PKR) cases. The surgical procedures included in the outpatient program
have expanded to include primary TKA (Total Knee Arthroplasty), primary THA (Total Hip Arthroplasty), and
selected revision cases.
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 repair. These cases are now routinely performed in free standing ASC’s. ASC’s afford surgeon
flexibility and ownership opportunities. They also allow a “white board” approach to new innovations in
outpatient care such as joint replacement surgery of the hip, knee, and shoulder.
The outpatient program centers on the patient needs, family engagement, essentials of home recovery,
preoperative education, efficient surgery, and a surgeon controlled environment with highly standardized care.
This is a distinct shift in today’s healthcare environment, which has seen the expansion of regulatory demands;
focus on Electronic Health Record (EHR), and discussions of potential future value creation.
The hallmark of this program is meticulous protocol execution and surgeon directed care pathways.
Preemptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that
preserve quad function for TKA (adductor canal block) 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 the majority of our partial knee replacement patients are now returning home the day of
surgery.13-15
Since 2011 we helped develop and implement an outpatient program as part of 76 participating physician-
owned ambulatory facilities in 19 states. 19,415 joint replacements have been performed. The cohort included
6,146 TKA, 5,102 THA, 7,227 partial knee replacements, and 940 revisions and TSA. Patients had a mean
age of 58 years and 50% of the patients were female. 97% of patients were discharged same day, the deep
infection rate was 0.2%, and the readmission rate was 0.3%.
Interestingly we have had no readmissions for pain control since the programs inception. The majority of
readmissions were for manipulation done as an outpatient with the remainder being known complications
following inpatient or outpatient arthroplasty care and not unique to their outpatient care. 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, anesthesia, facility costs,
and payors as arthroplasty procedures shift to the outpatient space. We believe this brings the best VALUE to
the patients, surgeons, and the arthroplasty system.

The outpatient program centers on the patient needs, family engagement, essentials of home recovery,
preoperative education, efficient surgery, and a surgeon controlled environment with highly standardized care.
This is a distinct shift in today’s healthcare environment, which has seen the expansion of regulatory demands;
focus on Electronic Health Record (EHR), and distractions from real discussions of demonstrated value
creation. The future is bright for both ASC and hospital development of successful outpatient joint replacement
program for patients and surgeons alike.
Patient Satisfaction scores were outstanding with this program achieving 98% Great/Good for 2014-15. We
believe this brings the best VALUE to the patients, surgeons, and the arthroplasty system and represents the
future of arthroplasty care with future growth of both partial knee replacements and outpatient arthroplasty.
The future is bright for both ASC and hospital development of successful outpatient joint replacement program
for patients and surgeons alike.

3:42 pm – 3:48 pm
Management of Blood Loss

William G. Hamilton, MD
1. Introduction:
a. Total joint arthroplasties have well known significant average blood loss
i. Total Hip 4.0 gm/dl
ii. Total Knee 3.8 gm/dl (1)
b. Historical transfusion rates are as high as 70% (2)
c. Despite years of work to optimize blood management, some published data suggests that
transfusion rates (especially with allogeneic blood) are rising (3, 4)
d. There is wide variability between surgeons as well, suggesting that varying protocols can
influence transfusion rates
e. Multiple studies now associate blood transfusions with negative outcomes
i. Increased surgical site infection (5)
ii. Increased costs
iii. Increased length of stay
2. Preoperative
a. Identify patients that are at increased risk of blood transfusion (6)
i. Pre-op anemia (Hgb less than 13.0 gm/dl)
ii. Female patients
1. Especially smaller stature female patients with lower blood volume
iii. Revision surgery

iv. Bilateral surgery
v. Elderly
b. Check Hgb prior to surgery (finger monitor in clinic is non-invasive)
c. For pre-operative anemia, consider tactics to raise hgb
i. Iron supplement
ii. Epogen
iii. IV Iron infusion
3. Intraoperative
a. Anesthesia
i. Regional anesthesia- linked to reduced postoperative transfusions (7)
ii. Hypotension (Mean arterial pressure <60 mm/hg) (8, 9)
b. Lower operative time
i. Efficient, organized, quality surgery, leave a dry field
c. Bipolar sealer
i. Initial enthusiasm for maintaining a dry surgical field, level 1 studies did not show benefit
to using expensive device (10,11)
4. Tranexemic acid
a. Antifibrinolytic agent
b. Reduces average blood loss by 300 cc
c. Multiple different administration protocols
i. IV (12-18)
1. Weight based dosing 10-20 mg/kg
2. Standardized dosing for all patients
a. Our current regimen: 1 gm IV pre-op, 1 gm IV in PACU
ii. Topical (19-22)
1. Usually 2-3 gm mixed in 50-100 cc of saline, spray in wound and allow to soak
for 3-5 minutes
iii. Oral (23, 24)
1. 1950 mg PO 2 hrs prior to surgery
d. Clinical practice Guideline: AAHKS/AAOS/ASRA/Hip & Knee Society
i. All individual formulations are effective at reducing blood loss- strong
ii. No method of administration is clearly superior at reducing blood loss and the risk of
transfusion
iii. The dose of IV or topical TXA does not significantly affect the drug’s ability to reduce
blood loss and risk of transfusion
iv. Multiple doses of IV or oral TXA compared to a single dose does not significantly alter
the risk of blood transfusion
v. Pre-incision IV TXA administration potentially reduces blood loss and risk of transfusion
compared to post-incision administration
vi. Administration of all TXA formulations in patients without history of VTE does not
increase the risk of VTE
vii. Administration of all TXA formulations in patients with a history of VTE, MI, CVA, TIA, or
vascular stent does not appear to increase the risk of VTE
viii. Administration of all TXA formulations does not appear to increase the risk of arterial
thrombotic events
5. Postoperative
a. Change transfusion triggers
b. Do not treat a “number”, safe algorithms established (1)
• Discuss with patient

< 7 gm/dl • Transfuse 1 U PRBC
• Volume crystalloid vs colloid,

7-8 with symptoms evaluate meds
• Reevaluate
• Transfuse 1 U PRBC (rare)

Persistent orthostasis,
dizziness, fatigue
6. Summary
a. A comprehensive blood management program can reduce transfusion rates to less than 3%
for THA and 1% for TKA can facilitate outpatient total joint arthroplasty

References:
1. Pierson, JL, Hannon, TJ, Earles, DR: A blood-conservation algorithm to reduce blood transfusions after total
hip and knee arthroplasty. JBJS-A, Jul; 86-A: 1512-8. 2004
2. Beirbaum, et, al, JBJS-A, 1998
3. Browne, J , Adib, F, Brown, TE, Novicoff, WM: Transfusion rates are increasing following total hip
arthroplasty: risk factors and outcomes. J Arthroplasty Sep 28(supp) 34-7, 2013
4. Yoshihara, H, Yoneoka, D: National Trends in the Utilization of Blood Transfusions in Total Hip and Knee
Arthroplasty, J Arthroplasty, 29 (2014) 1932-1937
5. Hill, et al: Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis.
J of Trauma, 2003
6. Rosencher, N, Kerkkamp, HE, Macheras, G, Munuera, LM, Minchella, G, Barton, DM, Cremers, S, Abraham,
IL; OSTHEO Investigation. Transfusion, 2003, Apr, 43(4), 459-69.
7. Juelsgaard, Larsen, UT, Sorensen, JV, et al: Hypotensive epidural anesthesia in total knee replacement
without tourniquet: reduced blood loss and transfusion. Reg Anesth Pain Med, 2001, Mar-Apr: 105-10.
8. Sharrock, N, Salvati, E. Hypotensive epidural anesthesia for total hip arthroplasty: a review: Acta Orthop
Scand, 1996, Feb: 67 (1): 91-107.
9. Eroglu, A, Uzunlar, H, Ericyes, N. Comparison of hypotensive epidural anesthesia and hypotensive total
intravenous anesthesia on intraoperative blood loss during total hip replacement: J Clin anesth, 2005, Sep,
420-5
10. Morris, MJ, Barret, M, Lombardi, AV, Tucker, TL, Berend, KR. Randomized blinded study comparing a bipolar
sealer and standard electrocautery in reducing transfusion in THA. J Arthroplasty 2013
11. Barsoum, W, Kilika, Murray, TG, et al. Prospective randomized evaluation of the need for blood transfusion
during primary total hip arthroplasty with use of a bipolar sealer. JBJS-A, 2011, Mar, 513-8
12. Zhou, et al, Acta Orthop Trauma, 2013
13. Lee, YC Park, SJ, Kim JS, Cho, CH. Effect of tranexemic acid on reducing postoperative blood loss in
combined hypotensive epidural anesthesia and general anesthesia for toal hip replacement. J Clin Anesth,
Aug (25) 2013, 393-8
14. Hourlier, H, Fennema, P. Single tranexemic acid dose to reduce perioperative morbidity in primary total hip
replacement: a randomized clinical trial. Hip Int Jan-Feb 2014 24(1): 63-8
15. Gandhi, Evans, HM, Mahomed, SR, Mahomed, NN. Tranexemic acid and the reduction of blood loss in total
knee and hip arthroplasty: a meta-analysis. BMC Res Notes, May 7; 6:184. 2013
16. Alshryda, S, Sarda, P, Skeik, M, Nargol, A, Blenkinsopp, J, Mason, JM. Tranexemic acid in total knee
replacement: a systematic review and meta-analysis. JBJS-Br, Dec; 93(12) 2011: 1577-85.
17. Ralley, FE, Berta, D, Binnis, V, Howard, J, Naudie, DD. One intraoperative dose of tranexemic acid for
patients having primary hip or knee arthroplasty. CORR, 2010, Jul;468: 1905-11
18. Rajesparan, K, Biant, LC, Ahmad, M, Field, RE. The effect of an intravenous bolus on tranexamic acid on
blood loss in total hip replacement. JBJS-Br, 2009, Jun: 776-83
19. Konig, G, Hamlin, BR, Waters, JH. Topical tranexemic acid reduces blood loss and transfusion rates in total
hip and total knee arthroplasty. J Arthroplasty 2013, Oct, 28(9): 1473-6.
20. Gilbody, J, Dhotar, HS, Perruccio, AV, Davey, JR. Topical tranexemic acid reduces transfusion rates in total
hip and knee arthroplasty. J Arthroplasty 2014 Apr; 29(4): 681-4
21. Wong, H, Abrishami, A, Beheiry, HE, et al. Topical Application of Tranexamic Acid reduces Poatoperative
Blood Loss in Total Knee Arthroplasty. JBJS-A, 2010. Nov 92(15): 2503-2513.
22. Molloy, DO, Archbold, HA, Ogonda, L, McConway, J, Wilson, RK, Beverland, DE. Compariosn of topical
fibrin spray and tranexamic acid on blood loss after total knee replacement: a prospective randomized
controlled trial. JBJS-Br, Mar 2007 89(3): 306-9
23. Irwin, A, Khan, SK, Jameson, SS, Tate, RC, Copeland, C, Reed, MR. Oral versus intravenous tranexamic
acid in enhanced-recovery primary total hip and knee replacement: result of 3000 procedures. Bone Joint J,
Nov 95-B. 2013:1556-61.
24. Oral and Intravenous Tranexamic Acid are Equivalent at Reducing Blood Loss Following Total Hip
Arthroplasty. J Bone Joint Surg Am. 2017;99:373-8.

3:48 pm – 3:54 pm
Perioperative Pain Management

Mark W. Pagnano, MD
The entirety of the patient experience after contemporary total knee and total hip replacements in 2017 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 assumed 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 replacement, 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-mobilization 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
include 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.

3:54 pm – 4:00 pm
The International Perspective

Fares S. Haddad, BSc, MCh (Orth), FRCS (Orth), FRCS (Ed) Dip, Sports Med FFSEM
Improved pain management techniques, surgical practices and the introduction of novel interventions have
enhanced patients’ post-operative experience after total joint arthroplasty (TJA). Enhanced recovery pathways
require a multidisciplinary team to manage pre-operative education, multimodal pain control and accelerated
rehabilitation. The current economic climate and restricted budgets favour brief hospitalisation while minimising
costs. This has put considerable pressure on hospitals to combine excellent results, early functional recovery
and shorter admissions.
In this session, others will have covered some common interventions and methods that shorten lengthen of
stay and make outpatient TJA possible. These include pre-operative patient education, pre-emptive analgesia,
local infiltration analgesia, pre-operative nutrition, , peri-operative rehabilitation, wound dressings, different
surgical techniques, minimally invasive surgery and fast-track joint replacement units.
The concept of enhanced recovery has been widely implemented by orthopaedic centres worldwide. The
adoption of multimodal pathways and accelerated rehabilitation programmes appear to improve patient care
and function while reducing length of stay. The introduction of day-case / outpatient TJA at leading centres has
been achieved for a selected subgroup of patients with low morbidity and mortality.
There are undoubted advantages to a robust pathway through which patients can learn about their procedure,
optimise their nutritional and physical status, learn what to expect from surgery and the peri-operative period,
reduce the risks of surgery and speed up recovery and discharge. Although a number of pathways have been
described, there has been a paucity of multicentre randomised trials comparing outcomes from these
dedicated centres to those of conventional services. So far the evidence is largely circumstantial.
Implementation of ERPs in each hospital needs to be tailored to the services and expertise available at each
centre.
The shift towards day-case or outpatient arthroplasty has resulted from a number of drivers. The desire to limit
the morbidity, mortality and cost of surgery has generated an enhanced a recovery programme which has
been extremely successful in limiting pain and smoothing the patient pathway around the time of surgery. This
in turn has had economic benefits in terms of reducing length of stay. Ultimately, the reduction in length of stay
increased risks for some patients, whilst it potentially benefitted others. That threshold remains unclear. Other
drivers, however, have intervened and, in particular, the push towards generating hospital and surgeon profits
by reducing length of stay and transferring the resulting savings into a hospital or surgical budget/ profit have
led to a push to discharge patients on the same day. This has been shown to be possible and indeed safe for a
selected subset of patients in the United States and is being applied in certain centres in Europe. There is a
cohort of young, medically fit, healthy and highly-motivated patients with a good support network in whom this
can be applied. The resource saving in terms of hospital stay has to be balanced against extra resources that
have to be put in preoperatively and immediately postoperatively to ensure that this pathway is smooth but,
ultimately, it may well be to the benefit of that group of patients to have a shorter time in hospital.

The adoption across the world has been much slower and is much less surgically driven than it is in the United
States, and that may well relate to the different economic models outside the United States. Current United
Kingdom regulations are that surgeons can only have a maximum 5% stake in any surgical unit or SurgiCentre.
The motivation, therefore, to shift patients from an inpatient to an outpatient setting is much smaller. Like many
innovations, it can be driven by the need to get market share, and hence competitive advertising, and also by
patients who see a shortened length of stay as a surrogate for an earlier return to work and to activity.
The international perspective on outpatient arthroplasty is that it is the natural endpoint of enhanced recovery
protocols but that it has not yet found its happy medium/equilibrium. It can be applied to a select group of
patients. The resulting preoperative and postoperative care pathways created will benefit all patients. The
belief in most large institutions is that the trend towards decreasing length of stay will continue and will be of
benefit of patients and to society as a whole in terms of the overall cost of healthcare. We have yet, however,
to define the exact population of patients who could be compromised by this and it, therefore, will continue to
be introduced slowly and carefully.

COMBINED Session X: Value and Economics in TJA
4:20 pm – 4:26 pm
Bundled Payments in Total Joint Arthroplasty: How Does Risk and Readmission
Impact Cost of Care?
Giles R. Scuderi, MD
Introduction: This study aims to better understand the impact of patient specific variables on the total cost of
care in the total joint arthroplasty population. The impact that these patient specific variables including
discharge disposition, comorbidities, and readmissions have on total cost of care will better allow physicians to
modify the way care is bundled into episodes, and alleviate excessive financial risk.
Methods: All payment data was retrospectively reviewed for 1,092 (617 Total Knee Arthroplasty and 475 Total
Hip Arthroplasty) patients who underwent a procedure during the initiation of a bundled payment model at a
single academic center in a major city (January 2014 to November 2016). The LACE index was used to stratify
patients as low (0-4), moderate (5-9) or high risk (10+). Discharge disposition, and readmissions were
analyzed to understand their financial impact on total cost.
Results: After classifying patients into low, moderate and high risk groups we found a significant increase in
total cost per episode of care between the low and moderate risk group in our TJA population. The significant
difference between the two cohorts was $5,507.00 (p-value < 0.001) with the low risk cohort displaying a lower
total cost of care. The mean difference in cost between cohorts remained significant when comparing the low
risk cohort against the high-risk cohort, seeing patients categorized as high risk paying on average $10,604.00
more than those classified as low risk (p-value < 0.001). Patients discharged to a Skilled Nursing Facility and
Acute Rehabilitation Facility had the highest total cost, with similar averages of total cost per episode of care.
Patients discharged home had the least total cost across discharge disposition groups. Those discharged to a
SNF/ Acute Rehabilitation Facility paid on average $11, 623.00 more than those discharged home (p< 0.001).
There were 34 hospital readmissions consisting of 19 surgical and 15 medical readmissions. A hospital
readmission adds on average $17,629.00 to the total cost per episode of care. It was determined that surgical
readmissions cost on average $15,313.00 more than medical readmissions (p= 0.001). A high percentage of
the total cost per episode of care was attributed to post-discharge fees and services, which seems to increase
considerably per LACE group, and is in agreement with results found in similar literature.
Conclusion: It is important for surgeons to modify bundled episodes of care to account for various factors of a
patient’s care. Total cost per episode of care for Total Joint Arthroplasty increases linearly alongside patient
risk, classified by LACE Score. Hospital readmissions and post discharge destination have a significant impact
on total cost. A significant difference in cost was found between medical and surgical readmissions. While
medical readmissions may be unavoidable, surgical readmissions are costly, and often preventable.

4:26 pm – 4:32 pm
Where Do We Stand with Value-Based Payments? A Washington Update

Kevin J. Bozic, MD, MBA
There continues to be ongoing discussions revolving around the transition from a fee-for-service (FFS)
payment system to one focused on value – defined as health outcomes achieved per dollar spent.1 Indeed,
regardless of political ideology, it is accepted that current healthcare spending is problematic for America’s
economy and the future of the country’s health and wellbeing. Over half of the increase in healthcare spending
can be attributed to rising service prices and intensity, and currently, healthcare represents 17.9% of the
United States’ Gross Domestic Product (GDP).2,3 Part of the solution to curtail unsustainable healthcare
spending involves the implementation of value-based medicine initiatives.
In Washington, DC, there continues to be support for a shift to value-based payment models, beginning in
2013 with the implementation of the Bundled Payments for Care Improvement (BPCI) program by the CMS
Innovation Center. This voluntary program offered or currently offers participants four innovative value-based
payment models:4
• Model 1) An episode of care was defined as the acute hospital stay only – reimbursement included a
discounted fee to the hospital based on historical Medicare rates plus FFS reimbursement to physicians
[discontinued in December 2016]
• Model 2) An episode of care included the acute inpatient care plus post-acute care services rendered
related to the arthroplasty procedure – reimbursement is provided in a FFS manner but then reconciled
against a target CMS price
• Model 3) An episode of care begins immediately following acute in-hospital arthroplasty care with post-
acute care services (e.g., skilled nursing facility) – reimbursement is provided in a FFS manner for the
post-acute care services but then reconciled against a target CMS price
• Model 4) An episode of care includes all inpatient services related to an arthroplasty procedure, as well
as any related readmissions – reimbursement is provided by CMS in a single, prospective manner and
the hospital reimburses care providers using such funds.
While BPCI Model 1 is no longer offered, the remaining models are currently being utilized. As of October 1,
2017, 514, 675 and 2 participants were active using Models 2, 3 and 4, respectively.4 Further, the BPCI
initiative will continue through Fall 2018 for all participants in the three models extending their involvement for
two additional years. Such a program is an important step in transitioning payment incentives from quantity to
quality.
In addition to the BPCI program, the Centers for Medicare & Medicaid Services (CMS) have also implemented
the Comprehensive Care for Joint Replacement (CJR) model; this bundled payment structure provides a lump
sum to cover all related lower extremity joint replacement care within 90 days, including both in-hospital and
post-acute care services rendered (similar to BPCI Model 2).5 The two MS-DRGs covered under this program
are: 1) 469 (Major joint replacement or reattachment of lower extremity with major complications or
comorbidities); and 2) 470 (Major joint replacement or reattachment of lower extremity without major
complications or comorbidities).6 This program was mandatory for many hospitals not participating in the BPCI
initiative, including those that were 1) paid under the Inpatient Prospective Payment System (IPPS), and 2)
located in the Metropolitan Statistical Areas (MSAs) – counties with an urban area that has a population of at

least 50,000 citizens – selected by CMS.6 Currently, hospitals in 67 designated MSAs participate in the
program, although 33 MSAs, low volume hospitals and rural hospitals are doing so voluntarily.6 These
volunteer care centers can elect to opt-in to continue participating in January 2018 or withdraw. Similar to the
BPCI program, the CJR model represents the changing payment landscape; indeed, the focus with the CJR
model is on financially rewarding healthcare value, which provides benefit to both the provider and the patient.
In 2014, over $7 billion in hospitalization costs alone were spent on greater than 400,000 lower extremity
arthroplasty cases covered by Medicare across the United States.6 In addition, there was a variation in the cost
of care up to $16,500.6 These facts, coupled with the unsustainable increase in American healthcare spending,
have led to the development of the federal value-based payment programs discussed in detail above. These
initiatives attempt to incentivize quality, not quantity, in the healthcare marketplace. As private insurers follow
CMS’ lead, more value-based payment options are likely to be introduced, including reimbursement models
that incorporate patient-reported outcomes (PROs).
The shift to value-based reimbursement is not without continued challenges, as more initiatives aimed at
promoting quality, not quantity, are introduced and heavily debated. Recently, the Medicare Payment Advisory
Commission (MedPAC), the committee the advises Congress on appropriate Medicare policy, has recommended
the elimination of the Merit-Based Incentive Payment System (MIPS).7 The main goal of MIPS is to apply a
bonus-type scheme to the traditional FFS model by rewarding physicians for improves outcomes and meaningful
EHR use.7 Unfortunately, the burden appears to be quite high on physicians, as MedPAC suggests that MIPS
reporting requirements cost clinicians over $1 billion in 2017.7 Instead of MIPS, MedPAC has suggested that
clinicians be offered the opportunity “opt in” to a voluntary rewards program focused on claims data; this would
eliminate a significant portion of the reporting burden felt under MIPS.8 In this proposed program, Medicare would
withhold a small portion of reimbursement dollars from all doctors and allow physicians to “recoup” this money by
meeting predetermined quality targets; those who opt not to participate would not be able to recover the withheld
funds.8 While a final policy decision has yet to be made, this ongoing discussion further reinforces the challenges,
yet potential, seen in the shift towards value-based reimbursement and improved healthcare quality across the
United States.
In general, it is recognized at the highest levels of the federal government that the shift to value-based payments
is a necessity for the health of our country moving forward. Many challenges remain but problems continue to be
solved on a daily basis. Recently, current Administrator of CMS, Seema Verma, gave a speech stressing ongoing
projects at CMS aimed to assist this movement to a value-based healthcare system focused on patients. She
discussed an initiative entitled “Patients Over Paperwork”, which aims to review all regulations at CMS and
improve or only keep those that truly put patients first.9 Additionally, she introduced “Meaningful Measures”, a
collaborative initiative involving a number of healthcare stakeholders aimed to ensure that “measure sets are
streamlined, outcomes-based, and meaningful to doctors and patients.”9 Lastly, she stated that the Center for
Medicare and Medicaid Innovation (CMMI) would be collecting ideas via a “Request for Information”, shifting
the idea generation from Washington to the communities that serve patients.9 Administrator Verma’s ultimate
goal is to have competition lead to improved patient-centered healthcare focused on quality, not quantity,
Currently, there are a number of exciting initiatives in Washington, DC focused on the ongoing shift from a FFS
model to a value-based payment structure. As we continue to learn more through both the successes and
failures of current proposals and projects, a more concrete formula for longitudinal success will develop. An
exciting future within healthcare is on the horizon.

References
1. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481.

2. Dieleman JL, Squires E, Bui AL, et al. Factors Associated With Increases in US Health Care Spending, 1996-
2013. Jama. 2017;318(17):1668-1678.
3. Centers for Medicare & Medicaid Services (CMS). National Health Expenditure Data: Historical. 2017;
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Accessed December 8, 2017.
4. Centers for Medicare & Medicaid Services (CMS). Bundled Payments for Care Improvement (BPCI) Initiative:
General Information. 2017; https://innovation.cms.gov/initiatives/bundled-payments/. Accessed December 8,
2017.
5. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals
Furnishing Lower Extremity Joint Replacement Services. Final rule. Fed Regist. 2015;80(226):73273-73554.
6. Centers for Medicare & Medicaid Services (CMS). Comprehensive Care for Joint Replacement Model. 2017;
https://innovation.cms.gov/initiatives/cjr/index.html. Accessed December 8, 2017.
7. Morse S. MedPAC recommends Congress eliminate MIPS payment track in MACRA: Medicare advisory
commission recommends voluntary physician participation in a program with measures more similar to APMs.
2017; http://www.healthcarefinancenews.com/news/medpac-recommends-congress-eliminate-mips-payment-
track-macra. Accessed December 20, 2017.
8. PWC. HRI as we see it: This week's regulatory and legislative news. 2017; https://www.pwc.com/us/en/health-
industries/health-research-institute/weekly-regulatory-legislative-news/week-of-12-11-2017.html - section-06.
Accessed December 20, 2017.
9. Verma S. Remarks by Administrator Seema Verma at the Health Care Payment Learning and Action Network
(LAN) Fall Summit (As prepared for delivery - October 30, 2017). 2017;
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-10-30.html.
Accessed December 20, 2017.

4:32 pm – 4:38 pm
Patient-Reported Outcomes Measures Made Easy

David C. Ayers, MD
• PROs support the IOM vision for 21st Century to use information technology to support patient-
centered, evidence based decisions
• As healthcare moves to a value based reimbursement system PROs are used to define outcomes and
quality and therefore are the numerator of the value equation
• PROs have moved into clinical Practice In TJR
o Ayers, Bozic. The Importance of Outcome Measurement in Orthopedics
CORR 471: 3409-3411, 2013
o Orthopedic surgeon reimbursement in US increased by PRO reporting in PQRS
through FORCE-TJR
o Pay for Performance Quality Reporting; CJR; Pilot project by BC of MA
o PROs used for negotiations with insurance companies, ACOs and referring MDs as a
measure of quality
• PROs can be collected in a busy practice with >85% follow-up at 1 year
o Collect joint specific PRO scores; include pain, function, quality of life (12 questions)
o General Health PRO from which PCS and MCS can be calculated (10-12 questions)
o Ayers, Franklin. Integrating PRO into Ortho.Practice; Proof of Concept from FORCE-TJR
CORR: 471(11) 3482-3488, 2013
• PRO must bring value to visit ; real time scoring; CAT enabled
• PRO used for Shared Decision Making and part of routine clinical care , not “research”
o Ayers. Patient-Reported Outcomes Move into Clinical Practice.
Orthopedics Today. August 2014
• FORCE-TJR has collected >35,000 patients PROs (Pre-op, 6M and 1 Yr Post-op with 86% collection
rate).
1. Franklin, Allison, Ayers. Beyond Implant Registries; a Patient-Centered Approach to TJR.
JAMA: 308(12)1217-18, 2012.
2. Ayers, Franklin. Joint Replacement Registries in US; A New Paradigm.
JBJS-A. 2014; 96:1567-9
o National TJR research registry and Comparative effectiveness consortium based at University
of Massachusetts Medical School
o Currently includes >225 sites in >28 states in the US
o Established by a $12 Million P50 Grant from AHRQ
o Currently collects and measures Level 1,2,3, and 4 data
o Establish PRO standards at the surgeon and hospital level
o FORCE members now using FORCE platform and FORCE infra-structure to manage
bundled payment programs with CMS (BPCI and CJR) and private payers
o FORCE –TJR feedback to surgeons/hospitals for quality improvement and real-time
operational data to manage bundle payment programs
▪ Patient characteristics/mix/ Charlson co-morbidity index
▪ Patient selection (timing of surgery)
▪ Medical and ortho co-morbid conditions
▪Discharge location/ use of ancillaries
▪TJR outcomes including post-TJR pain and function
▪TJR outcomes also including adverse events/ readmissions/return to surgery/ revision
surgery
o FORCE-TJR Now open to new member enrollment
• PROs used to evaluate patient mix at the hospital/surgeon level for medical and MSK co-morbidities
o Used to answer how do my patients compare to FORCE-TJR cohort on key risk-adjustment
factors
o Ayers, et al. Patient Reported Outcomes After TKR; Need for MSK Co-Morbidity Index
JBJS-A: 95(20)1833-7, 2013
• Patient Selection and Timing of Surgery; Appropriateness
o How do my patients compare to other sites on pre-TJR pain and function?
o Ayers, Franklin. Pre-Op Pain and Function Profiles Reflect Consistent TKA Patient
Selection
Among US Surgeons. CORR: Jan 2015, 473(1) p76-81
• TJR patient reported outcomes;
o How does my risk adjusted 1 year pain and function scores compare to FORCE-TJR national
cohort?
o Surgeons/hospitals want to improve!
• PROs improve risk adjustment models for readmissions
o FORCE-TJR and AAHKS showed that adding pre-op function (PCS), BMI as continuous
variable, smoking, modified Charlson co-morbidity score, Orthopedic co-morbidities improve
readmission model from CMS C=.62 to FORCE-TJR C=.78
o Ayers, et al. Using FORCE-TJR Data to Improve Risk Adjusted Readmission Prediction
Models.
JBJS-A: 97(88) 668-71, 2015
• PROs used to evaluate Cemented vs. Cemented TKRs; risk adjustment for PROs based on patient
characteristics
o Ayers, Li, Zheng, Franklin. Does Pain and Function Differ After TKR with Cementless vs.
Cemented Fixation? Proceeding of the Knee Society. September 2015
• PROs already play an important role in clinical practice in TJR and will play an increasingly vital role in
assessing quality and value in the future; look for a turn-key internet based option that provides you
with real-time scoring of PROs and access to PRO national norms to benchmark your practice

4:38 pm – 4:44 pm
Hospital-Physician Alignment
C. Lowry Barnes, MD
The current healthcare environment allows numerous opportunities for physicians and hospitals to align
incentives. Opportunities such as co-management, gain-sharing, as well as partnering in CJR, BPCI, and
BPCI-Advanced will be discussed. Large numbers of surgeons are now being employed by hospitals, and
models of employment will be shared. As total joints move to out-patient settings, partnerships in ASC's may
become more viable for joint replacement surgeons. Additionally, lower level alignments such as flip rooms,
support of third-parties to help with patient engagement, research relationships, and hospital employment of
mid-level providers to assist with in-patient care will be reviewed also.

4:44 pm – 4:50 pm
Surgical Centers, Consulting and Implant Recall:

What You Should Do to Protect Yourself
Mark I. Froimson, MD, MBA
Today’s rapidly changing medical and health care environment provides both opportunity and risk for
surgeons. As surgeons are the prime advocate for the welfare of their patients, they are constantly and
justifiably seeking ways to improve care delivery. Among an array of rapidly evolving issues, three stand out as
particularly impactful: the site of care delivery, the adoption of new technology, and the business and financial
relationships that are often associated with these. Patient care is rapidly moving to outpatient centers,
implants have been introduced and recalled at a blistering pace and physician consulting relationships
continue to be seen as both essential and concerning. An important legal and regulatory framework has been
developed intended to safeguard patients. But, as with any oversight, there are both beneficial elements and
unintended consequences. The surgeon who is actively seeking to test the boundaries of existing practice
must do so with a thorough understanding of how to navigate these elements. Innovation and progress must
be accompanied by an appropriate measure of prudence and circumspection. By understanding a wide array
of stakeholder and environmental perspectives, the proper course and cadence can be set.

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 7.5 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 Administration (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 commercial 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 necessarily implying bias or decreasing the value of the author’s
participation in the meeting.

Education Committee
Scott M Sporer, MD Submitted on: 01/18/2018; American Association of Hip and Knee Surgeons: Board or committee member;
American Joint Replacement Registy: Board or committee member; DJO Surgical: IP royalties; Paid consultant; Hip Society: Board or
committee member; Myoscience: Paid consultant; Stock or stock Options; Osteoremedies: IP royalties; Paid consultant
SLACK Incorporated: Publishing royalties, financial or material support; Stryker: Research support; Zimmer: IP royalties; Research
support
Paul E Beaule, MD (Canada) Submitted on: 05/09/2017; 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 royalties; Smith & Nephew: Paid consultant; Smith-Nephew: Paid presenter or
speaker; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support; Zimmer: Paid
consultant
Mathias P G Bostrom, MD (New York, NY) Submitted on: 05/19/2017; Orthopaedic Research Society: Board or committee member;
Smith & Nephew: Paid consultant; Research support; Springer: Editorial or governing board
Kevin John Bozic, MD, MBA (Austin, TX) Submitted on: 01/17/2018; American Joint Replacement Registry: Board or committee
member; Centers for Medicare and Medicaid Services: Paid consultant; Harvard Business School: Paid consultant; Hip Society: Board
or committee member
Craig J Della Valle, MD (Chicago, IL) Submitted on: 09/27/2017; American Association of Hip and Knee Surgeons: Board or committee
member; Arthritis Foundation: Board or committee member; CD Diagnostics: Stock or stock Options; DePuy, A Johnson & Johnson
Company: Paid consultant; Hip Society: Board or committee member; Knee Society: Board or committee member; Mid America
Orthopaedic 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; Research support; Stryker:
Research support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support; Zimmer: IP
royalties; Paid consultant; Research support
Edward Ebramzadeh, PhD (Los Angeles, CA) Submitted on: 09/28/2017; Amgen Co: Research support; AOS: Research support;
Arthrex, Inc: Research support; Biomet: Research support; Corin U.S.A.: Paid consultant; DePuy, A Johnson & Johnson Company:
Research support; Extremity Medical: Research support; I-Spine: Research support; Journal of Bone and Joint Surgery - American:
Editorial or governing board; Journal of of Applied Biomaterials and Functional Materials: Editorial or governing board; Journal of
Orthopaedic Trauma: Editorial or governing board; Synthes: Research support; Tri-Med: Research support; Zimmer: Research support
C Anderson Engh Jr, MD Submitted on: 10/08/2017; AAOS: Board or committee member; DePuy, A Johnson & Johnson Company: IP
royalties; Research support; Stock or stock Options; Hip Society: Board or committee member; Smith & Nephew: Research support
Kevin L Garvin, MD (Omaha, NE) Submitted on: 10/06/2017; AAOS: Board or committee member; American Orthopaedic Association:
Board or committee member; Hip Society: Board or committee member; Knee Society: Board or committee member; Wolters Kluwer
Health - Lippincott Williams & Wilkins: Editorial or governing board

Presenters and Moderators
John Antoniou, MD, FRCSC, PhD Submitted on: 10/06/2017; AAOS: Board or committee member; Canadian Orthopaedic
Association, Canadian orthopaedic research society: Board or committee member; Zimmer: Research support
Michael J Archibeck, MD (This individual reported nothing to disclose); Submitted on: 05/23/2017
Matthew Austin, MD (Philadelphia, PA) Submitted on: 01/21/2018; AAOS: Board or committee member; American Association of Hip
and Knee Surgeons: Board or committee member; Corin U.S.A.: Paid consultant; JayPee: Publishing royalties, financial or material
support; Journal of Arthroplasty: Editorial or governing board; Journal of the American Academy of Orthopaedic Surgeons: Editorial or
governing board; Link Orthopaedics: Paid consultant; Stryker: Paid consultant; Zimmer: IP royalties; Paid consultant; Research support
David Christopher Ayers, MD (Worcester, MA) Submitted on: 06/01/2017; AAOS: Board or committee member; American
Orthopaedic Association: Board or committee member; Journal of Bone and Joint Surgery - American: Editorial or governing board
C Lowry Barnes, MD (Little Rock, AR) Submitted on: 06/01/2017; American Association of Hip and Knee Surgeons: Board or
committee member; AR Orthopaedic Society: Board or committee member; Clinical Orthopaedics and Related Research: Editorial or
governing board; ConforMIS: Research support; DJO: IP royalties; HealthTrust: Paid consultant; HipKnee Arkansas Foundation: Board
or committee member; Journal of Arthroplasty: Editorial or governing board; JSOA: Editorial or governing board; Liventa: Stock or stock
Options; Medtronic: IP royalties; Paid consultant; Mid American Orthopaedic Association: Board or committee member; None: Unpaid
consultant; Responsive Orthopaedics: Stock or stock Options; Responsive Risk Solutions: Paid consultant; Stock or stock Options;
Southern Orthopaedic Association: Board or committee member; Zimmer: IP royalties; Paid consultant
Robert L Barrack, MD (Saint Louis, MO) Submitted on: 01/16/2018; Biomet: Research support; EOS Imaging: Research support
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: Research support; Smith & Nephew:
Research support; 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 & Wilkins: Publishing
royalties, financial or material support; Wright Medical Technology, Inc.: Research support
Paul E Beaule, MD (Canada) Submitted on: 05/09/2017; 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 royalties; Smith & Nephew: Paid consultant; Smith-Nephew: Paid presenter or
speaker; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support; Zimmer: Paid
consultant
Michael E Berend, MD (Indianapolis, IN) Submitted on: 05/31/2017; Biomet: IP royalties; Paid consultant; Paid presenter or speaker;
Research support; Hip Society: Board or committee member; Johnson & Johnson. Into our 501c3 research foundation.: Research
support; Journal of Arthroplasty: 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 (Rochester, MN) Submitted on: 05/23/2017; American Joint Replacement Registry: Board or committee member
Bodycad: Paid consultant; Stock or stock Options; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research
support; Elsevier: Publishing royalties, financial or material support; Hip Society: Board or committee member; International 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 (Austin, TX) Submitted on: 01/17/2018; American Joint Replacement Registry: Board or committee
member; Centers for Medicare and Medicaid Services: Paid consultant; Harvard Business School: Paid consultant; Hip Society: Board
or committee member
Tony Cheng, MBA (Watertown, MA) (This individual reported nothing to disclose); Submitted on: 06/01/2017
John C Clohisy, MD (Saint Louis, MO) Submitted on: 10/17/2017; Microport Orthopedics, Inc.: Paid consultant; Wolters Kluwer Health
- Lippincott Williams & Wilkins: Publishing royalties, financial or material support; Zimmer: Paid consultant; Research support
Matthew Coyle, MD, MSc (Canada) (This individual reported nothing to disclose); Submitted on: 02/15/2018
Havard Dale, MD, PhD (Norway) (This individual reported nothing to disclose); Submitted on: 01/08/2018
Craig J Della Valle, MD (Chicago, IL) Submitted on: 09/27/2017; American Association of Hip and Knee Surgeons: Board or committee
member; Arthritis Foundation: Board or committee member; CD Diagnostics: Stock or stock Options; DePuy, A Johnson & Johnson
Company: Paid consultant; Hip Society: Board or committee member; Knee Society: Board or committee member; Mid America
Orthopaedic 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; Research support; Stryker:

Research support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support; Zimmer: IP
royalties; Paid consultant; Research support
Johanna Dobransky, MA (Canada) (This individual reported nothing to disclose); Submitted on: 05/25/2017
Lawrence D Dorr, MD Submitted on: 07/05/2017; DJ Orthopaedics: IP royalties; Encore Medical: Paid consultant; Joint Development,
Inc.: Stock or stock Options; Operation Walk: Board or committee member; Total Joint Orthopedics: Unpaid consultant; Zimmer: IP
royalties
Clive P Duncan, MD, MSc, FRCSC (Canada) Submitted on: 06/03/2017; DePuy, A Johnson & Johnson Company: Paid consultant;
Zimmer: Paid presenter or speaker
Paul J Duwelius, MD (Portland, OR) Submitted on: 01/11/2018; AAOS: Board or committee member; Clinical Orthopaedics and
Related Research: Editorial or governing board; Journal of Bone and Joint Surgery - American: Publishing royalties, financial or material
support; Operation Walk-Freedom to Move CEO: Board or committee member; Providence Orthopedic Foundation & Director of
Providence Orthopedic Institute: Research support; Signature Health Care: Paid presenter or speaker; UniteOR: Stock or stock
Options; Zimmer: IP royalties; Paid consultant; Research support
C Anderson Engh Jr, MD Submitted on: 10/08/2017; AAOS: Board or committee member; DePuy, A Johnson & Johnson Company: IP
royalties; Research support; Stock or stock Options; Hip Society: Board or committee member; Smith & Nephew: Research support
Anne Marie Fenstad, MSc (Norway) (This individual reported nothing to disclose); Submitted on: 01/08/2018
Mark I Froimson, MD Submitted on: 09/27/2017; American Association of Hip and Knee Surgeons: Board or committee member;
American Journal of Orthopedics: Editorial or governing board; American Orthopaedic Association: Board or committee member; Clarify
Health, LLC: Stock or stock Options; Johnson & Johnson: Paid consultant; Journal of Arthroplasty: Editorial or governing board; Journal
of Bone and Joint Surgery - American: Editorial or governing board; Mid American Orthopaedic Association: Board or committee
member; Pacira: Employee; Stock or stock Options
Ove Nord Furnes, MD (Norway) Submitted on: 10/05/2017; Nordic Artrhoplasty Register Association: Board or committee member;
The Norwegian Arthroplasty Register: Board or committee member
Donald S Garbuz, MD, MHSc, FRCSC (Canada) Submitted on: 10/09/2017; DePuy, A Johnson & Johnson Company: Research
support; Mueller Foundation of North America: Board or committee member; Stryker: Paid consultant; Zimmer: Paid consultant;
Research support
Kevin L Garvin, MD (Omaha, NE) Submitted on: 10/06/2017; AAOS: Board or committee member; American Orthopaedic Association:
Board or committee member; Hip Society: Board or committee member; Knee Society: Board or committee member; Wolters Kluwer
Health - Lippincott Williams & Wilkins: Editorial or governing board
Wade Travis Gofton, BSCH, MD, Med, FRCSC (Canada) Submitted on: 06/05/2017; Microport: Paid consultant; Paid presenter or
speaker; Synthes - institutional research support: Other financial or material support; Zimmer: Paid consultant; Paid presenter or
speaker
George A Grammatopoulos, MRCS (This individual reported nothing to disclose); Submitted on: 02/12/2018
William L Griffin, MD Submitted on: 10/06/2017; American Association of Hip and Knee Surgeons: Board or committee member
DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Journal of
Arthroplasty,CORR: Editorial or governing board; Knee Society, AAOS: Board or committee member; Zimmer: Research support
Allan E Gross, MD, FRCSC, Prof (Canada) Submitted on: 06/05/2017; Intellijoint systtem - device for measuring length and offset after
hip replacement: Stock or stock Options; Journal of Arthroplasty: Editorial or governing board; Zimmer: IP royalties; Paid consultant;
Paid presenter or speaker
Fares Sami Haddad, FRCS Submitted on: 10/06/2017; 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: Editorial or governing board; matortho:
IP royalties; Orthopedics Today: Editorial or governing board; Smith & Nephew: IP royalties; Paid consultant; Research support;
Stryker: IP royalties; Paid consultant
George John Haidukewych, MD Submitted on: 02/04/2018; AAOS: Board or committee member; Biomet: IP royalties; Paid
consultant; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Hip Society: Board or committee member; Journal of
Orthopedic Trauma: Editorial or governing board; Revision Technologies, Orthopediatrics: Stock or stock Options; Synthes: Other
financial or material support; Paid consultant
Geir Hallan, MD (Norway) Submitted on: 06/26/2017; DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Research
support; Link Orthopaedics: Paid presenter or speaker

William G Hamilton, MD Submitted on: 05/20/2017; Biomet: Research support; DePuy, A Johnson & Johnson Company: IP royalties;
Paid consultant; Paid presenter or speaker; Research support; Inova Health Care Services: Research support; Total Joint Orthopedics:
IP royalties; Paid consultant
Arlen D Hanssen, MD (Rochester, MN) Submitted on: 05/24/2017; Elsevier: Publishing royalties, financial or material support;
International Congress for Joint Reconstruction (ICJR): Board or committee member; Stryker: IP royalties
William H Harris, MD Submitted on: 05/30/2017; Zimmer: IP royalties
Konstantinos Hatzikotoulas, PhD (United Kingdom) (This individual reported nothing to disclose); Submitted on: 01/08/2018
Carlos A Higuera Rueda, MD Submitted on: 10/18/2017; 3M: Research support; American Association of Hip and Knee Surgeons:
Board or committee member; American Journal of Orthopedics: Editorial or governing board; CD Diagnostics: Research support;
Cempra: Research support; Cymedica: Research support; Ferring Pharmaceuticals: Research support; Journal of Hip Surgery: Editorial
or governing board; Journal of Knee Surgery: Editorial or governing board; KCI: Paid consultant; Paid presenter or speaker; Research
support; Mid-American Orthopaedic Association: Board or committee member; Musculoskeletal Infection Society: Board or committee
member; Myoscience: Research support; National Quality Forum: Board or committee member; OREF: Research support; Orthofix,
Inc.: Research support; Pacira: Research support; Pfizer: Paid consultant; Stryker: Research support; TenNor Therapeutics Limited:
Paid consultant; The Academy of Medicine of Cleveland & Northern Ohio (AMCNO): Board or committee member; Zimmer: Other
financial or material support; Paid consultant
James I Huddleston, III MD (Redwood City, CA) Submitted on: 05/26/2017; AAOS: Board or committee member; American
Association of Hip and Knee Surgeons: Board or committee member; American Knee Society: Research support; Biomet: Paid
consultant; Research support; California Joint Replacement Registry: Board or committee member; Paid consultant; Exactech, Inc: IP
royalties; Paid consultant; Paid presenter or speaker; Hip Society: Board or committee member; Journal of Arthroplasty: Editorial or
governing board; Knee Society: Board or committee member; Porosteon: Paid consultant; Stock or stock Options; Robert Wood
Johnson Foundation: Research support; Zimmer: Paid consultant; Paid presenter or speaker
Stephen J Incavo, MD (Houston, TX) Submitted on: 05/31/2017; Innomed: IP royalties; Journal of Arthroplasty: Editorial or governing
board; Knee Society: Board or committee member; Kyocera: IP royalties; Nimbic Systems: Stock or stock Options; Osteoremedies: IP
royalties; Smith & Nephew: IP royalties; Wright Medical Technology, Inc.: IP royalties; Zimmer: IP royalties; Paid consultant
Richard Iorio, MD Submitted on: 12/09/2017; American Association of Hip and Knee Surgeons: Board or committee member;
Bioventis: Research support; Bulletin of the Hospital for Joint Disease: Editorial or governing board; Clinical Orthopaedics and Related
Research: Editorial or governing board; DJ Orthopaedics: Paid consultant; Ferring Pharmaceuticals: Research support; Force
Therapeutics: Stock or stock Options; Hip Society: Board or committee member; JBJS Reviews: Editorial or governing board; Johnson
& Johnson: Paid consultant; 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 committee member; MCS ActiveCare: Paid consultant; Stock or stock Options; Medtronic: Paid consultant; Muve Health: Paid
consultant; Stock or stock Options; Orthofix, Inc.: Research support; Orthosensor: Research support; Pacira: Paid consultant; Research
support; URX Mobile: Stock or stock Options; Vericel: Research support; Wellbe: Stock or stock Options; Zimmer: Paid consultant
Joshua J Jacobs, MD (Chicago, IL) Submitted on: 12/21/2017; American Board of Orthopaedic Surgery, Inc.: Board or committee
member; Hip Society: Board or committee member; Implant Protection: Stock or stock Options; Journal of Bone and Joint Surgery -
American: Publishing royalties, financial or material support; Medtronic Sofamor Danek: Paid consultant; Research support; Nuvasive:
Research support; Orthopaedic Research and Education Foundation: Board or committee member; The Journal of Bone and Joint
Surgery: Board or committee member; Zimmer: Research support
Zaid Jibri (This individual reported nothing to disclose); Submitted on: 02/15/2018
Paul R Kim, MD Submitted on: 04/10/2017; Biomet: Paid consultant; Zimmer: Paid consultant
Cheryl Kreviazuk, BA (Canada) (This individual reported nothing to disclose); Submitted on: 06/01/2017
Gwo-Chin Lee, MD (Philadelphia, PA) Submitted on: 05/31/2017; AAOS: Board or committee member; CD Diagnostics: Research
support; Ceramtec: Paid presenter or speaker; Clinical Orthopaedics and Related Research: Editorial or governing board; DePuy, A
Johnson & Johnson Company: Paid consultant; Paid presenter or speaker; Journal of Arthroplasty: Editorial or governing board
Journal of Bone and Joint Surgery: Editorial or governing board; Orthopedics: Editorial or governing board; Pacira: Paid consultant;
SLACK Incorporated: Editorial or governing board; Smith and Nephew: Research support; Stryker: Paid consultant; Zimmer: Research
support
David G Lewallen, MD (Rochester, MN) Submitted on: 10/11/2017; Acuitive Technologies: Paid consultant; Stock or stock Options
American Joint Replacement Registry: Board or committee member; Ketai Medical Devices: Stock or stock Options; Mako/Stryker: IP
royalties; Orthopaedic Research and Education Foundation: Board or committee member; Zimmer Biomet: IP royalties; Paid consultant
Jay R Lieberman, MD (Los Angeles, CA) Submitted on: 10/09/2017; AAOS: Board or committee member; American Association of Hip
and Knee Surgeons: Board or committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant

Hip Innovation Technology: Stock or stock Options; Musculoskeletal Transplant Foundation: Board or committee member
Saunders/Mosby-Elsevier: Publishing royalties, financial or material support; Western Orthopaedic Association: Board or committee
member
Benjamin Lin, BA (New York, NY) Submitted on: 02/15/2018; GE Healthcare: Stock or stock Options; Gilead: Stock or stock Options
Adolph V Lombardi Jr, MD (New Albany, OH) Submitted on: 10/13/2017; Clinical Orthopaedics and Related Research: Editorial or
governing board; Elute, Inc.: Stock or stock Options; Hip Society: Board or committee member; Innomed: IP royalties; Joint
Development Corporation: Stock or stock Options; Journal of Arthroplasty: Editorial or governing 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; 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; SPR Therapeutics, LLC: Research support; Stock or stock Options; Surgical Technology International: Editorial or
governing board; Zimmer Biomet: IP royalties; Paid consultant; Research support
Steven J MacDonald, MD (Canada) Submitted on: 11/11/2017; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant;
Research support; Hip Innovations Technology, JointVue: Stock or stock Options; Smith & Nephew: Research support; Stryker:
Research support
Scott John Macinnes, MBChB, PhD Submitted on: 01/10/2018; DePuy, A Johnson & Johnson Company: Other financial or material
support
Henrik Malchau, MD (Cambridge, MA) Submitted on: 05/30/2017; Biomet: Research support; Ceramtec: Paid consultant; 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 committee 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: Paid consultant; Research support
Arthur L Malkani, MD Submitted on: 01/03/2018; AAOS: Board or committee member; Journal of Arthroplasty: Editorial or governing
board; Stryker: IP royalties; Paid consultant; Paid presenter or speaker; Research support
Bassam A Masri, MD, FRCSC (Canada) Submitted on: 10/09/2017; Canadian Orthopaedic Association: Board or committee member;
DePuy, A Johnson & Johnson Company: Research support; Journal of Arthroplasty: Editorial or governing board
Richard W McCalden, MD (Canada) Submitted on: 10/11/2017; Smith & Nephew: Paid consultant; Paid presenter or speaker; Smith &
NephewJ&J DepuyStryker: Research support
R Michael Meneghini, MD (Fishers, IN) Submitted on: 05/07/2017; American Association of Hip and Knee Surgeons: Board or
committee member; DJ Orthopaedics: IP royalties; Paid consultant; Research support; Emovi: Stock or stock Options; International
Congress for Joint Reconstruction: Board or committee member; Journal of Arthroplasty: Editorial or governing board; Knee Society:
Board or committee member; MuveHealth: Stock or stock Options; Osteoremedies: IP royalties; Paid consultant; PixarBio: Stock or
stock Options
Michael A Mont, MD (Cleveland, OH) Submitted on: 10/16/2017; AAOS: Board or committee member; Abbott: Paid consultant;
Cymedica: Paid consultant; DJ Orthopaedics: Paid consultant; Research support; Johnson & Johnson: Paid consultant; Research
support; Journal of Arthroplasty: Editorial or governing board; Journal of Knee Surgery: Editorial or governing board; Mallinckrodt
Pharmaceuticals: Paid consultant; Microport: IP royalties; National Institutes of Health (NIAMS & NICHD): Research support; Ongoing
Care Solutions: Paid consultant; Research support; Orthopedics: Editorial or governing board; Orthosensor: Paid consultant; Research
support; Pacira: Paid consultant; Peerwell: Stock or stock Options; Performance Dynamics Inc.: Paid consultant; Sage: Paid consultant;
Stryker: IP royalties; Paid consultant; Research support; Surgical Techniques International: Editorial or governing board; TissueGene:
Paid consultant; Research support
Joseph T Moskal, MD (Roanoke, VA) Submitted on: 06/10/2017; AAOS: Board or committee member; American Association of Hip
and Knee Surgeons: Board or committee member; Corin U.S.A.: Paid consultant; DePuy, A Johnson & Johnson Company: IP royalties;
Invuity: Stock or stock Options; Medtronic: Paid consultant; Paid presenter or speaker; Stryker: Paid consultant; Paid presenter or
speaker
Stephen B Murphy, MD (Boston, MA) Submitted on: 06/01/2017; International Society for Technology in Arthroplasty: Board or
committee member; International Society of Computer Assisted Orthopedic Surgery: Board or committee member; MicroPort
Orthopedics Inc.: IP royalties; Surgical Planning Associates, Inc.: Stock or stock Options
William Murphy, BA Submitted on: 02/12/2018; Archway Health Advisors LLC: Paid consultant; International Society for Computer
Assisted Orthopedic Surgery: Board or committee member; International Society for Technology in Arthroplasty: Board or committee
member; MicroPort Orthopedics Inc.: IP royalties; Paid consultant; Surgical Planning Associates, Inc: Stock or stock Options
Ryan M Nunley, MD (Saint Louis, MO) Submitted on: 10/19/2017; AAOS: Board or committee member; American Association of Hip
and Knee Surgeons, Board of Directors and Treasurer: Board or committee member; Biocomposites: Paid consultant; Biomet:
Research support; Cardinal Health: Paid consultant; DePuy, A Johnson & Johnson Company: Paid consultant; Research support;
Halyard: Paid consultant; Hip Society: Board or committee member; Medical Compression System Inc: Paid consultant; Medical
Compression Systems, Inc.: Research support; Medtronic: Paid consultant; Microport: IP royalties; Paid consultant; Mid-America
Orthopaedic Association, Program Committee Chair, 2018 Program Chair: Board or committee member; Mirus: Paid consultant;
Missouri State Orthopaedic Association, Board Member and President: Board or committee member; Smith & Nephew: Paid consultant;
Research support; Southern Orthopaedic Association, 2nd Vice President, President Elect: Board or committee member; Stryker:
Research support; The Knee Society, Education Committee, 2018 Program Chair: Board or committee member
Douglas E Padgett, MD (New York, NY) Submitted on: 10/06/2017; American Joint Replacement Registry: Board or committee
member; DJ Orthopaedics: IP royalties; Paid consultant; Paid presenter or speaker; Journal of Arthroplasty: Editorial or governing
board; PixarBio: Paid consultant; Stock or stock Options; The Hip Society: Board or committee member
Mark W Pagnano, MD (Rochester, MN) Submitted on: 04/21/2017; DePuy, A Johnson & Johnson Company: IP royalties; Hip Society:
Board or committee member; Knee Society: Board or committee member; Stryker: IP royalties
Kalliope Panoutsopoulou, PhD (United Kingdom) (This individual reported nothing to disclose); Submitted on: 01/08/2018
Wayne Gregory Paprosky, MD Submitted on: 01/17/2018; Innomed: IP royalties; Intellijoint: IP royalties; Stock or stock Options
Journal of Arthroplasty: Editorial or governing board; Medtronic: Paid consultant; Nothwestern Medicine CDH: Other financial or material
support; Stryker: IP royalties; Wolters Kluwer Health - Lippincott Williams & Wilkins: Publishing royalties, financial or material support;
Zimmer: IP royalties; Paid consultant
Vincent D Pellegrini, Jr, MD (Charleston, SC) Submitted on: 01/27/2018; American Orthopaedic Association: Board or committee
member; Association of American Medical Colleges, Board of Directors: Board or committee member; Chair, Council of Faculty and
Academic Societies, AAMC: Board or committee member; Health Volunteers Overseas/Orthopaedics Overseas, Board of Directors:
Board or committee member; South Carolina Orthopaedic Association, Board of Directors: Board or committee member; Synthes:
Research support
Christopher Earl Pelt, MD (Salt Lake City, UT) Submitted on: 04/19/2017; AAOS: Board or committee member; American Association
of Hip and Knee Surgeons: Board or committee member; Biomet: Research support; Pacira: Research support; Unpaid consultant; TJO
(Total Joint Orthopedics): Paid consultant; Zimmer Biomet: Paid consultant; Paid presenter or speaker
Christopher L Peters, MD (Salt Lake City, UT) Submitted on: 05/24/2017; 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; Journal of Arthroplasty: Editorial or governing board; Journal of Hip Preservation: Editorial or governing board; Knee
Society: Board or committee member; Muve Health: Stock or stock Options
Michael D Ries, MD Submitted on: 05/24/2017; OrthAlign: Stock or stock Options; Smith & Nephew: IP royalties; Paid consultant;
Stryker: IP royalties; Paid consultant
Aaron Glen Rosenberg, MD, FACS (Chicago, IL) Submitted on: 04/04/2017; Wolters Kluwer Health - Lippincott: Publishing royalties,
financial or material support; Wolters Kluwer Health - Lippincott Williams & Wilkins: Editorial or governing board; Zimmer: IP royalties;
Paid consultant; Paid presenter or speaker; Stock or stock Options
Thomas P Schmalzried, MD (Los Angeles, CA) Submitted on: 04/05/2017; DePuy, A Johnson & Johnson Company: IP royalties;
Stock or stock Options; Unpaid consultant; None: Research support; Orthopedics Today: Editorial or governing board; Stryker: Stock or
stock Options
Ran Schwarzkopf, MD (New York, NY) Submitted on: 10/02/2017; AAOS: Board or committee member; American Association of Hip
and Knee Surgeons: Board or committee member; Arthroplasty Today: Editorial or governing board; Gauss surgical: Stock or stock
Options; Intelijoint: Paid consultant; Stock or stock Options; Journal of Arthroplasty: Editorial or governing board; Smith & Nephew: Paid
consultant; Research support
Giles R Scuderi, MD (New York, NY) Submitted on: 05/18/2017; Biomet: IP royalties; Paid consultant; Paid presenter or speaker;
Convatec: Paid presenter or speaker; Medtronic: Paid consultant; Paid presenter or speaker; MERZ Pharmaceutical: Paid consultant;
Operation Walk USA: Board or committee member; Pacira: Paid consultant; Paid presenter or speaker; Research support;
SpringerElsevierThiemeWorld Scientific: Publishing royalties, financial or material support; Zimmer: IP royalties; Paid consultant; Paid
presenter or speaker
Karan M Shah, PhD (United Kingdom) (This individual reported nothing to disclose); Submitted on: 01/08/2018
Ahmed Siddiqi, DO (Philadelphia, PA) (This individual reported nothing to disclose); Submitted on: 02/14/2018
Rafael Jose Sierra, MD (Rochester, MN) Submitted on: 10/11/2017; American Association of Hip and Knee Surgeons: Board or
committee member; Biomet: Paid consultant; Paid presenter or speaker; DePuy, A Johnson & Johnson Company: Research support
Journal of Arthroplasty: Editorial or governing board; Link Orthopaedics: IP royalties; Paid consultant; Midamerica orthopedic society:
Board or committee member; Springer: Publishing royalties, financial or material support; Stryker, Biomet: Research support; Zimmer:
IP royalties; Research support

James D Slover, MD Submitted on: 04/10/2017; American Association of Hip and Knee Surgeons: Board or committee member;
Biomet: Research support; REcent Advances in Arthroplasty: Editorial or governing board
Lorraine Southam (United Kingdom) (This individual reported nothing to disclose); Submitted on: 01/10/2018
Ioanna Tachmazidou (United Kingdom) Submitted on: 02/15/2018; GlaxoSmithKline: Employee
Carl T Talmo, MD (Boston, MA) Submitted on: 05/22/2017; Astra-Zeneca: Employee; Journal of Arthroplasty: Editorial or governing
board
David Terry (Watertown, MA) (This individual reported nothing to disclose); Submitted on: 06/01/2017
Robert T Trousdale, MD Submitted on: 10/06/2017; American Association of Hip and Knee Surgeons: Board or committee 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; Medtronic: IP royalties
Thomas Parker Vail, MD (San Francisco, CA) Submitted on: 10/06/2017; American Board of Orthopaedic Surgery, Inc.: Board or
committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Knee Society: Board or committee member
J Mark Wilkinson, MB, ChB, PhD, FRCS (Ortho) Submitted on: 01/07/2018; Amgen Co: Research support; British Orthopaedic
Research Society: Board or committee member; National Joint Registry for England, Wales, and Northern Ireland: Board or committee
member; Orthopaedic Research Society: Board or committee member
Eleftheria Zeggini, PhD (United Kingdom) (This individual reported nothing to disclose); Submitted on: 09/28/2016
Staff
Olga Foley (Rosemont, IL) (This individual reported nothing to disclose); Submitted on: 10/06/2017
Austin Lugar (Rosemont, IL) (This individual reported nothing to disclose); Submitted on: 01/08/2018
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: hip@aaos.org Email: helpdesk@aahks.org
Website: www.hipsoc.org Website: www.aahks.org
Please complete the online evaluation at: https://www.surveymonkey.com/r/HSWM2018 or use

the QR code here.

2018 Hip Program FINAL

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2018 Hip Program FINAL

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General Program Information

The Mission of The Hip Society

Your opinion matters! Please complete your evaluation online at:

Save the Date and Join Us In Las Vegas!

The AAOS 2019 Annual Meeting and Specialty Day

March 12-16, 2019

© 2018 The Hip Society / AAHKS 2

© 2018 The Hip Society / AAHKS 3

AAHKS Education Committee

As The Hip Society celebrates its 50th Anniversary, we would like to

© 2018 The Hip Society / AAHKS 4

Lawrence D.Dorr, MD William H. Harris, MD, D.Sc.

David G. Lewallen, MD Vincent D. Pellegrini, Jr., MD

Session moderated by:

© 2018 The Hip Society / AAHKS 5

Reinhold Ganz graduated from medical school in Freiburg, Germany.

All research projects were based on detailed cadaver studies of the

The goal of a first undertaking was to optimize reorientation surgery of

© 2018 The Hip Society / AAHKS 7

The 2018 John Charnley Award

Presenter: William S. Murphy, AB

The 2018 Otto Aufranc Award

Presenter: J. Mark Wilkinson, PhD, FRCS

The 2018 Frank Stinchfield Award

Presenter: George Grammatopoulous, BSc, MBBS, D.Phil (Oxon)

© 2018 The Hip Society / AAHKS 10

Congratulations, 2018 Rothman-Ranawat Traveling Fellows!

Elie S. Ghanem, MD Chris R. Gooding, MBBS BSc (Hons), MD, MRCS,

S.M. Javad Mortazavi, MD Benjamin M. Stronach, MD

Those interested in applying for the 2019 Rothman-Ranawat Traveling Fellowship,

The Hip Society-British Hip Society Traveling Fellowship

The 2018 Hip Society-British Hip Society Traveling Fellowship

The extended deadline to apply is April 1, 2018.

© 2018 The Hip Society / AAHKS 11

© 2018 The Hip Society / AAHKS 14

8:00 am – 8:45 am Session I: Primary Surgical Approach/Technique and Implant

8:00 am – 8:06 am ABMS Approach in the Lateral Decubitus Position 25

8:06 am – 8:12 am Direct Anterior Approach Including Tips to Improve Exposure 27

8:12 am – 8:18 am Dysplastic Hip 31

8:18 am – 8:24 am Previous Surgery/Retained Hardware 33

8:24 am – 8:30 am Previous Lumbar Fusion 35

8:30 am – 8:45 am DISCUSSION

8:45 am – 9:30 am Session II: Intraoperative and Early Postoperative Complications:

8:57 am – 9:03 am Management of Early Step Subsidence/Calcar Fracture (Using Either 41

9:03 am – 9:09 am Management of Trochanter Fracture (Intra-Op and Early Post-Op) 44

9:15 am – 9:30 am DISCUSSION

© 2018 The Hip Society / AAHKS 15

8:00 am – 8:45 am Session I: The Difficult Primary TKA (Video-Based)

8:00 am – 8:06 am Fixed Valgus Knee 25

8:06 am – 8:12 am The Terrible Varus Knee 28

8:12 am – 8:18 am The Obese Patient 29

8:18 am – 8:24 am The Stiff Knee 31

8:24 am – 8:30 am Previous Incisions/Compromised Soft-Tissue 32

8:30 am – 8:45 am DISCUSSION

8:45 am – 9:30 am Session II: Current Trends in Knee Arthroplasty

8:45 am – 8:51 am Can a Bicruciate Retaining TKA Be Successful? 34

8:51 am – 8:57 am When Is It Safe to Perform TKA after Steroid/HA Injection? 36

8:57 am – 9:03 am Patient Specific Implants and Instruments 37

9:03 am – 9:09 am Alternative Bearing Surfaces 39

9:09 am – 9:15 am The Pocket Rocket: Handheld Navigation 40

9:13 am – 9:30 am DISCUSSION

© 2018 The Hip Society / AAHKS 16

9:30 am – 9:36 am Who is at Risk of Instability? 47

9:36 am – 9:42 am What is the “Safe Zone” for an Individual Patient? 49