Copyright 1990 by The Journal of Bone and Join: Surge’,.

Incorporated

Clinical and Radiographic Evaluation

of Total Hip Replacement
A STANDARD SYSTEM OF TERMINOLOGY FOR REPORTING RESULTS*

BY RICHARD C. JOHNSTON, M.D.t, DES MOINES, IOWA, ROBERT H. FITZGERALD, JR., M.D4, DETROIT, MICHIGAN,
WiLLIAM H. HARRIS, M.D., ROBERT POSS, M.D.L BOSTON, MAURICE E. MULLER, M.D.#, BERNE, SWITZERLAND,

AND CLEMENT B. SLEDGE, M.DAI, BOSTON, MASSACHUSETTS

Since the 1940’s, technical advances in operative treat- sought to stimulate hip surgeons to address this fundamental
ment of diseases of the hip have stimulated the introduction issue. He believed that ‘ ‘it is urgent that orthopaedic sur-
of several numerical rating systems to express the state of geons agree to a uniform method of evaluating and reporting
the hip before and after treatment4’6’7’9”4’6”9. These sys- the results of hip-replacement surgery’ ‘8#{149}

tems were designed to allow the assessment of various forms The Hip Society responded to these concerns by ap-
Of arthroplasty of the hip, especially those involving the pointing a committee, which was composed of four of us
implantation of a prosthetic device. Both The British Or- (R. C. J.; R. H. F., Jr.; W. H. H.; and R. P.), to prepare
thopaedic Association and The American Academy of Or- a standardized scheme for evaluation of the hip. To obtain
thopaedic Surgeons have attempted to improve
the widest possible consensus, and the deliberations were broad-
standardize these numerical systems2”. In the 1960’s, Lar- ened to include the Commission on Documentation and
son and Hams independently introduced two new rating Evaluation of the Soci#{233}t#{233}
Internationale de Chirurgie Or-
systems, which have since been widely used by North Amer- thop#{233}diqueet de Traumatologie (SICOT) and The Task
ican surgeons. These rating systems enable surgeons to de- Force on Outcome Studies of The American Academy of
scribe the preoperative and postoperative status of a hip with Orthopaedic Surgeons, each of which was chaired by one
a single number. of us (M. E. M. and C. B. S., respectively). The Hip
After the introduction of total hip arthroplasty, Euro- Society, the SICOT Commission on Documentation and
pean surgeons tended to use the system of Merle d’Aubign#{233} Evaluation, and The American Academy of Orthopaedic
and Postel, and Chamley’s modification of that system. As Surgeons’ Task Force have agreed to the system of no-
more surgeons became involved in the operative treatment menclature that is presented in this paper (Fig. 1).
ofthe arthritic hip, and numerous modifications ofthe design None of the current rating systems can improve corn-
of prosthetic devices were introduced, additional systems munication between investigators (by allowing comparison
for evaluation were developed”7. As radiographic evalua- of their results) and still allow them the latitude to express
tion became more sophisticated, it became an integral part their opinions. However, if the components of each rating
of the assessment of the results of hip arthroplasty. This led system included certain basic parameters, individual inves-
to the introduction of a rating system that incorporated ra- tigators could emphasize the parameters that they thought
diographic analysis into the evaluation, resulting in a single to be of major or minor importance by varying the point
value on a scale of 1 to 100 points to express the clinical systems applied to each parameter. The purpose of this
and radiographic result of total hip arthroplasty’3. report was to provide nomenclature in which each term,
Although each of the rating systems has certain ad- whether applying to a functional or a radiographic param-
vantages, the proliferation of these scales without the use eter, is specifically defined so as to have a constant meaning.
of common descriptors or standard nomenclature has made When reporting results, an investigator should use the
comparison of the findings of different investigators diffi- appropriate components from each rating system. These
cult, if not impossible. Galante, responding to the concerns components will vary with the objective or objectives of the
of the Editor of The Journal of Bone and Joint Surgery, specific study. However, when the clinical results of a pro-
* No benefits in any form have been received or will be received from cedure on the hip are described, certain functional param-
a commercial party related directly or indirectly to the subjectofthis article. eters - including, at least, pain, gait, and some activities
No funds were received in support of this study.
t Des Moines Orthopaedic Surgeons, 1440 Pleasant Street, Des
of daily living must be used. Also, the reported
- results
Moines, Iowa 50314. of an operation on the hip are rarely meaningful to the reader
t Department of Orthopedic Surgery, Wayne State University, 4707
unless radiographic data are included. At the very least,
St. Antoine Boulevard, Detroit, Michigan 48201.
§ Suite 433 , Ambulatory Care Center, Massachusetts General Hos- radiographic parameters should include migration of the
pital, Boston, Massachusetts 021 14.
#{182}
Department of Orthopedic Surgery, 75 Francis Street, Boston, Mas-
prosthetic components.
sachuseus 02115. Investigators may include additional factors or corn-
# Maurice E. Muller Foundation for Continuing Education and Re-
search in Orthopaedic Surgery, Murtenstrasse 35, P.O. Box 2016, Ch-
ponents that they think are necessary. As long as each basic
3001 Berne, Switzerland. variable is reported individually and is described using stan-

VOL. 72.A, NO. 2, FEBRUARY 1990 161

162 R. C. JOHNSTON ET AL.

TABLE I
CLINICAL EVALUATION

Pain Time walked

Degree Without support
- None - no pain - Unlimited (>60 mins.)
- Mild - slight and occasional pain; patient has not altered - 31-60 mins.
patterns of activity or work - I 1-30 mins.
- Moderate - patient is active but has had to modify or give - 2-10 mins.
up some activities, or both, because of pain <2 mins. or indoors
- only
- Severe - major pain and serious limitations - Unable to walk
Occurrence With support
- None - Unlimited (>60 mins.)
- With first steps. then dissipates (start-up pain) - 31-60 mins.
- Only after long (30-mm.) walks - 11-30 mins.
- With all walking - 2-10 mins.
- At all times - <2 mins. or indoors only
- Unable to walk
Workllevel of activity
Occupation (specify, Satisfaction of patient
including homemaker): Op. increased your function?
Retired - Yes
- No - No
- Yes Op. decreased your pain?
Nursing home - Yes
- No - No
- Yes (date entered: ________________ Op. decreased your need for pain medication?
Level of activity - Yes
- Bedridden or confined to a wheelchair - No
- Sedentary - minimum capacity for walking or other - Not applicable
activity Satisfied with results?
- Semi-sedentary - white-collar job, bench work, light - Yes
housekeeping - No
- Light labor - heavy house-cleaning, yard work, assembly
Status of hip compared with your last visit?
line, light sports (e.g. , walking 5 km)
- Better
- Moderate manual labor - lifts 23 kg, moderate sports
- Same
(e.g. , walking or bicycling >5 km)
- Worse
- Heavy manual labor - frequently lifts 23-45 kg, vigorous
sports (e.g. , singles tennis or racquetball) Physical examination
Work capacity in last 3 mos. Limp without support
- 100% - None - no limp
- 75% - Slight - detected by trained observer
- 50% - Moderate - detected by patient
- 25%
- Severe - markedly alters or slows gait
_0 Range of motion of hip
Putting on shoes and socks
Fixed flexion
- No difficulty Left: #{176}

- Slight difficulty Right: _#{176}

Further flexion to
- Extreme difficulty
- Unable Left: #{176}

Right: _#{176}
Ascending and descending stairs
Abduction/adduction
- Normal (foot over foot)
Left: _/_
- Foot over foot using banister or assistive device
Right: _/_
- 2 feet on each step
External/internal rotation
- Any other method
(hip in 0#{176}
of flexion or maximum extension)
- Unable
Left: _/_

Sitting to standing Right: 0/0

- Can arise from chair without upper-extremity support

Trendelenburg sign
- Can arise with upper-extremity support
Positive
- Cannot arise independently
_Left
Walking capacity - Right
Usual support needed Negative
- None Left
-

- I cane for long walks Right

-

- 1 cane Unable to test

- 1 crutch Left
- 2 canes - Right
- 2 crutches Trendelenburg lurch (abductor lurch or Duchenne sign)
- Walker - Present
- Unable to walk - Absent
Limb lengths
- Equal
Short left: _ cm
Short right: _ cm
Method of measurement (radiograph, blocks, other):
 CLINICAL AND RADIOGRAPHIC EVALUATION OF TOTAL HIP REPLACEMENT 163

FIG. 1
Diagrammatic representation of the overlapping missions of the three organizations that sponsored the consensus paper.

dard nomenclature, other investigators, surgeons, and read- of clinical results are shown in Table I. These parameters
ers can extract the necessary information to apply any rating include pain, ability to work, level of activity, walking
system to the reported result. In this report, we outline these capacity, satisfaction of the patient, and results of the phys-
specific clinical and radiographic parameters. We encourage ical examination. Investigators who are reporting clinical
investigators to include as many of them as practical. More data are encouraged to do so using the form shown in Table
importantly, we urge investigators to use the specific Ian- I. They are also encouraged to use, combine, or expand the
guage that we suggest for reporting these parameters. data as they choose. Correlation of some parameters with
others, such as pain with limp, is the prerogative of the
Components of a System
individual investigator, as long as the definition of each
for Evaluation of the Hip
term remains constant.
Categorization of Patients In the management of disease involving the hip, the
A system for collection of data must include infor- goal of both the orthopaedic surgeon and the patient is a
mation that will allow appropriate categorization of patients. painless hip that is strong enough and mobile enough to
This information includes age, sex, height, weight, and the allow normal function and activity. The role of evaluation
side on which the operation was performed. The primary ofthe hip is to record a measurement ofthe described factors
diagnosis (that is, the original pathological condition) should at various points in time. Not only should the record be
be recorded, and secondary diagnoses should be included clear, but the record-keeping must be concise, as well as
when appropriate. Any previous operations on the involved brief enough to be compatible with clinical practice.
hip should also be recorded. Abnormalities of the contra- The degree of pain, strength, mobility, and the lengths
lateral hip and other joints, as well as major orthopaedic or of the limbs can be determined directly. In single-limb
medical problems and medications that have been admin- stance, a positive Trendelenburg sign is an expression of
istered, should be detailed. In addition, certain technical unfavorable geometry of the hip or weakness of the abduc-
aspects of the operative procedure should be recorded (for tors, or both. In contrast, a Trendelenburg lurch or abductor
example, the approach, the treatment of the capsule, the lurch (known as the Duchenne sign in the European liter-
type and size of any prosthesis, and the details of fixation). ature), which may or may not be associated with a positive
Trendelenburg sign, represents an attempt by the patient to
Clinical Evaluation
reduce pain by shifting the body weight closer to the center
The parameters that provide a reasonable description of the hip (Fig. 2).

VOL. 72-A, NO. 2. FEBRUARY 1990

164 R. C. JOHNSTON ET AL.

TABLE II
RADIOGRAPHIC EVALUATION: CEMENTED PROSTHESES

Acetabulum Femur

Migration of component Migration of stem Resorption of medial part of neck

(measurement must be related Varus-valgus (calcar)
to teardrop) - No _ No
- No - Yes _ Yes
- Yes - Varus qualitative only; Loss of height (exclusive
Superior: _ mm - Valgus J choose one of rounding): _ mm
Medial: _ mm Subsidence (must be related to fixed Loss of thickness: _ mm
Location of center of rotation of hip landmarks on femur: prox. tip of Resorption or hypertrophy of shaft
relative to teardrop greater trochanter and mid-point of _ No
Superior: _ mm lesser trochanter) Resorption (zones:
Lateral: _ mm - No Hypertrophy (zones:
- Yes ( mm)
Broken cement - Within cement Change in density
- No _ No
- With cement
- Yes Patchy loss (zones:
Zone (specify Broken cement Uniform loss (zones:
1-3): - No Increased trabecular
- Yes bone (zones:
Cement-bone radiolucency
(DeLee and Charnley) Stem Endosteal cavitation
- No - Intact _ No
- Yes - Bent _ Yes
Maximum width - Broken Zones:
Zone 1: _ mm Radiolucency Length: _ mm
Zone 2: _ mm Prosthesis-cement Width: _ mm
Zone 3: _ mm (anteroposterior radiograph) Ectopic ossification
Continuous - No _ Brooker I (none)
- No - Yes _ Brooker II (mild)
- Yes
Cement-bone _ Brooker III (moderate)
Maximum width: _ mm
Anteroposterior radiograph _ Brooker IV (severe)
Radiolucency around screws - No
Position of stem
- No - Yes
_ Neutral
Yes Maximum width
-
_ Valgus l qualitative only;
- Not applicable Zone 1: _ mm
_ Varus J choose one
Zone 2: _ mm
Breakage of screws
Zone 3: mm Greater trochanter
- No
Zone 4: mm _ Not osteotomized
- Yes
Zone 5: _ mm _ Osteotomized
- Not applicable
Zone 6: mm _ Healed
Wear of socket: _ mm Zone 7: mm _ Not healed
Lateral radiograph _ Displaced
Position of component
- No _ Non-displaced
Inclination (abduction):
- Yes
Version of cup
Maximum width
Retroversion:
Zone 8: mm
- Neutral
Zone 9: mm
Anteversion: #{176}
Zone 10: _ mm
Zone 11:_mm
Zone 12: _ mm
Zone 13: _ mm
Zone 14: _ mm

Motion of the hip can be directly measured clinically mates at best, it is useful to make indirect determinations
and recorded in a standard fashion. Fixed flexion is deter- and compare the results. The ability to walk depends on
mined with any lumbar lordosis flattened. We recommend pain, strength, and, to a lesser degree, motion. Walking is
recording “further flexion to” rather than “further flexion also a very important function to the patient. It is recom-
of”. In reporting functional limb-length discrepancy, it is mended that gait be considered in three categories: time
important to specify the method of measurement. walked, support needed, and degree of limp. Use of the
The patient can be questioned concerning the amount specific language for all three categories will create more
of pain that he or she feels. Although we define four cat- uniform reporting. Some investigators may choose to report
egories of pain, this is not a four-point analog scale. Dis- distance walked as well as time walked or to include some
abling pain in the hip is severe, even though some patients estimation of the velocity of gait. The degree of limp both
who have disabling pain may have more pain than others. with and without the use of a support can be reported. It is
Since all of the described parameters involve a certain useful to note when the degree of limp was determined -

amount of subjectivity on the part of the patient or the for instance, during a walk across the examining room or
examiner, or both, and since the categories are gross esti- after the patient walked for sixty minutes.

ThE JOURNAL OF BONE AND JOINT SURGERY

 CLINICAL AND RADIOGRAPHIC EVALUATION OF TOTAL HIP REPLACEMENT I 65

FIG. 2
Trendelenburg sign and Trendelenburg lurch (Duchenne sign). Left: negative Trendelenburg sign and lurch. Center: negative Trendelenburg sign
and positive Trendelenburg lurch. Right: positive Trendelenburg sign and lurch.

Assessment of certain activities of daily living is a capacity. On the other hand, if he quits that job and is now
useful way to determine function of the hip indirectly. An doing bench work without difficulty, caring for his yard
over-all determination of activity can provide information with some trouble, and playing a limited amount of golf
concerning the extent to which the hip is stressed. The level with a cart, function should be recorded as light labor be-
of work or activity that the patient is attempting to achieve cause of the yard work and golf, but with 75 per cent
should be recorded. Then, the patient’s capacity to perform capacity because of the limitations. If, postoperatively, he
this activity should be noted. For example, if a man who kept his new job, but worked in his yard and played golf
normally performs heavy manual labor is so disabled that without difficulty, function should be recorded as light labor
he is just at the point of being unable to work, function with 100 per cent capacity. If he went back to his old job,
should be recorded as heavy manual labor, with a 0 per cent but had some difficulty performing all aspects of it, function
should be recorded as heavy manual labor with 75 per cent
capacity.
Post The ability to reach the foot and to put on and take off
socks and shoes is an indirect determination of motion of
the hip as well as an important function to the patient.
Similarly, the ability to ascend or descend stairs has been
14 included because of its importance to the patient and its
usefulness as an indirect indication ofboth pain and strength.
TABLE III

CORRELATION OF PAIN WITH MIGRATION OF THE

ACETABULAR COMPONENT OR FRACTURE OF THE CEMENT, OR BOTH,
IN A HYPOTHETICAL GROUP OF ONE HUNDRED PATIENTS
AFTER TOTAL HIP ARTHROPLASTY

Migration of the
Acetabular Component or
Fracture of the Cement
Pain No Yes Total

None 76 9 85
Mild 3 7 10
Moderate I 3 4
Severe I 1
FIG. 3-A FIG. 3.B
Total 80 20 100
Zones for radiographic evaluation.

VOL. 72-A, NO. 2. FEBRUARY 1990

I 66 R. C. JOHNSTON ET AL.

TABLE IV

RADIOGRAPHIC EVALUATION: UNCEMENTED PROSTHESES

Acetabulum Femur

Migration of component Migration of stem Resorption of medial part of neck

(measurement must be related Varus-valgus (calcar)
to teardrop) - No _ No
_ No _ Yes _ Yes
_ Yes _ Varus qualitative only; Loss of height (exclusive
Superior: _ mm - Valgus I choose one of rounding): _ mm
Medial: _ mm Subsidence (must be related to fixed Loss of thickness: _ mm

Location of center of rotation of hip landmarks on femur: prox. tip of Resorption or hypertrophy of shaft
relative to teardrop greater trochanter and mid-point of _ No
Superior: _ mm lesser trochanter) Resorption (zones:
Lateral: _ mm - No Hypertrophy (zones:
_ Yes (_ mm)
Prosthesis-bone radiolucency Change in density
(DeLee and Chamley) Porous coating _ No
_ No - Intact Patchy loss (zones:
_ Yes _ Dislodged Uniform loss (zones:
Maximum width _ Progressive loss Increased trabecular
Zone I: _ mm _ Not applicable bone (zones:
Zone 2: _ mm Stem Endosteal cavitation
Zone 3: _ mm _ Intact No

_
_
Continuous - Bent Yes

-
No
Yes
- Broken
_

Zones:
Length:
______
_ mm
Prosthesis-bone radiolucency
Maximum width: _ mm
Anteroposterior radiograph Width: _ mm
Radiolucency around screws No
-
Ectopic ossification
- No - Yes _ Brooker I (none)
_ Yes Maximum width _ Brooker II (mild)
_ Not applicable Zone 1:_mm _ Brooker III (moderate)
Breakage of screws Zone 2: _ mm _ Brooker IV (severe)
_ No Zone 3: _ mm
Zone 4: _ mm Position of stem
_ Yes
_ Neutral
_ Not applicable Zone 5: _ mm
Zone 6: _ mm
_ Valgus 1 qualitative only;
Porous coating
Zone 7: _ mm
_ Varus f choose one
_ Intact
Lateral radiograph Greater trochanter
_ Dislodged No
_ _ Not osteotomized
_ Progressive loss Yes

_
- _ Osteotomized
_ Not applicable Maximum width _ Healed
Wear of socket: mm Zone 8: _ mm _ Not healed
Zone 9: _ mm _ Displaced
Position of component
Zone 10: _ mm _ Non-displaced
Inclination (abduction):
Zone 11:_mm
Version of cup Zone 12: _ mm
Retroversion: J) Zone 13: _ mm
- Neutral Zone 14: _ mm
Anteversion: _

The ability to sit in and rise from a chair is an indirect is an indirect indication that the cement has cracked and the
determination of motion, strength, and, to a lesser extent, prosthesis has moved. Therefore, it is important to record
pain. Obviously, it is also a very important function in this finding.
everyday life. We do not believe that the meaning of radiolucency at
the bone-cement interface is known. However, a radiolucent
Radiographic Evaluation
zone of any size at this interface elicits concern about the
The parameters that are most likely to provide an ac- longevity of fixation. The greater the width and extent of
curate estimate of the success or failure of fixation of a the radiolucency, the greater the concern. Therefore, both
prosthetic component to bone after cemented total hip re- the width and the extent of a cement-bone radiolucency
placement are shown in Table II. These data are extremely should be recorded. On the acetabular side, we suggest the
important. use of the three zones that were delineated by DeLee and
It is generally accepted that migration of a prosthesis Charnley to report the location of the radiolucency and to
or cracks in the cement are definite indications of loosening give some indication of its extent.
of the prosthesis from bone. For practical purposes, ra- It is suggested that radiolucency on the femoral side
diolucency at the prosthesis-cement interface is not consid- be reported as it is seen on an anteroposterior radiograph in
ered to occur on the acetabular side of a total hip arthro- each of the seven zones that Omen et al. described (Fig. 3-
plasty. When it appears on the femoral side, radiolucency A). If a lateral radiograph is used, seven more zones (zones

ThE JOURNAL OF BONE AND JOINT SURGERY

 CLINICAL AND RADIOGRAPHIC EVALUATION OF TOTAL HIP REPLACEMENT 167

FIG. 4-A FIG. 4-B

Figs. 4-A, 4-B, and 4-C: Radiographs ofa healthy seventy-two-year-old woman who had osteoarthrosis ofthe left hip. In 1977, a total hip arttsroplasty
was performed through an anterolateral approach. The patient had no pain in any other joint. She was taking aspirin for pain in the hip.
Fig. 4-A: Preoperative radiograph revealing destruction of the articular cartilage and subluxation of the joint.
Fig. 4-B: Anteroposterior radiograph made eight years postoperatively.

8 through 14) should be considered (Fig. 3-B). Because the

use of all of these zones can generate a huge amount of data
that may be difficult to manage and use, the zones may be
combined innovatively for reporting purposes.
Correlation of radiographic parameters with clinical
parameters, such as degree of pain with migration of the
acetabular component or fracture of the cement, or both,
should provide valuable information (Table III). On the
acetabular side, other parameters that may be useful include
the location of the center of the hip and the wear and position
ofthe socket. On the femoral side, useful parameters include
any resorption or change in the density of the medial part
of the femoral neck, of other parts of the femur, or of the
entire femur; ectopic ossification; the position of the stem;
and the status of the greater trochanter.
At this stage of experience with uncemented pros-
theses, even less is known about the importance of radio-
graphic findings than is known for cemented prostheses
(Table IV). However, it seems rational that migration of a
component or breakage of a porous coating or screw mdi-
cates lack of fixation. The radiographic appearance of the
prosthesis-bone junction may or may not correlate with fix-
ation of the prosthesis. Nevertheless, it seems useful to
report radiolucencies at these locations. The suggested pa-
rameters are very similar to those for cemented prostheses.
However, we believe that lateral radiographs may be much
more important in the assessment of hips that have an unce- Anteroposterior radiograph made ten years postoperatively. The patient
was eighty-two years old. She had no pain, walked for as long as thirty
mented prosthesis than for those that have a cemented pros- minutes at a time, put on shoes and socks with ease, and ascended and
thesis. descended stairs without difficulty. The hip could flex from 0 to 100
degrees, abduct 30 degrees, and adduct 20 degrees. The patient could arise
It is relatively simple to apply these parameters to any from a seated position without difficulty, and she could retrieve objects
from the floor easily. The lengths of the limbs were equal.
of the commonly used systems (Table V). Figures 4-A, 4-
B, and 4-C depict the case of a patient who was followed
for ten years after a total hip arthroplasty with cement. The a description of the patient’s general health, as well as the
legends contain the usual demographic data, diagnosis, and specific parameters pertinent to the hip. Radiographs made

VOL. 72-A, NO. 2. FEBRUARY 1990

168 R. C. JOHNSTON ET AL.

TABLE V

COMPARISON OF HIP SCORES FOR A PATIENT AFTER A TEN-YEAR FOLLOWUP*

Hip Score (Points)

Rating System Pain Function Mobility Motion Radiographic Total

Merle d’Aubign#{233}-Postel 6 4 5 - A665

Harris 44 47 4 3 - 98
Iowa 35 35 20 10 - 100
Mayo Clinic 40 20 20 - 18 98

ten years after the arthroplasty (Fig. 4-C) allowed docu- viewed as building-blocks of information, which can be
mentation ofthe parameters listed in Table II. As is evident, combined in any manner or expanded into subcategories,
one can compute the Merle d’Aubign#{233}-Postel, the Harris, depending on the author’s purpose. The essential feature of
the IowaI4, or the Mayo Clini&3 hip score from this infor- the building-blocks is that each is unalterable in its defini-
mation. tion. Only through use of standardized terminology is an
There is no best way to report the results of an operation international language of comparative results feasible.
on the hip. There is, however, a great need for standardized
terminology so that one can compare the multitude of re- Noir: The Commission on Documentation and
Evaluation of the Soci#{233}t#{233}
Internationale de
Chinirgie Orthop#{233}dique ci de Traumatologie of Maurice E. Muller. M.D. (Chairman);
consisted
ported data. By using the clinical and radiographic termi- Ivan Kempf, M.D.; Robin Ling, M.D. ; Sir Dennis Paterson; Salomon Schachter. M.D.; Jos#{231}ph
Schatzker. M.D. ; and Clement B. Sledge, M.D. The Task Forte on Outcome Studies of The
nology (CART) proposed in this paper, investigators can American Academy of Orthopaedic Surgeons consisted of Clement B. Sledge, M.D. (Chairman);
John Ganiand. M.D.; Robert Keller. M.D.; Matthew Liang. M.D.; Augusto Sarmiento, M.D.;
have a common language. The proposed terms should be David Schurman. M.D. ; and Marvin Steinberg. M.D.

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